Stomach

Hematemesis

Causes:

Peptic Ulcer……most common cause

Reflux Esophagitis

Esophageal Varices

Mallory Weis $

Esophageal and gastric cancer)

Investigation ……… Upper Endoscopy

First step……….fluid resuscitation

If you need to give blood…………….PACKED RBCS IS THE BEST

Congenital hypertrophic pyloric stenosis (CHPS)

Pathology…..hypertrophy of pyloric muscles

Sex………usually boy (first born)

Age…….symptoms start at 2-6 weeks…..vvv imp

Clinical picture;

NON BILIOUS vomiting

Dehydration and loss of weight

Exam…………..olive like mass

Test……..feeding test……….visible
peristalsis

If feeding test positive……….no further tests

Inv…………..ULTRASONOGRAPHY

RISK………..HYPOKALEMIA AND DEHYDRATION

TTT…..

First step…….correct dehydration and electrolyte disturbances

Then…………..surgery

CHPS VS GERD:

CHPS ……occurs only at 2-6 weeks after birth

Severe loss of weight and dehydration

GERD…..occurs at any time

Weight gain NOT affected and NO marked dehydration

Acquired pyloric stenosis:

Cause……fibrosed peptic ulcer is most common cause

Cp……….recurrent vomiting

Timing of vomiting ……1 hour after meals ….vvvvvvvv imp

Important sign……succession splash

X-ray…….dilated stomach

TTT………surgery
Peptic ulcer

Site……Duodenum more than gastric…..imp

Risk factors;

Helicobacter pylori…………main cause (70%)

Others……….smoking, alcohol, stress, NSAIDS

CLINICAL PICTURE;

Epigastric pain

Nausea and vomiting

Iron deficiency anemia

Investigation……..endoscopy and biopsy

TTT……….ERADICATION OF H.PYLORI
Triple therapy……….amoxicillin, omeprazole and metronidazole

Very high resistance nowadays to ………..metronidazole

So give…………amoxicillin, clarithromycin and omeprazole

Most common cause of failure of triple therapy….short course

Optimum course of therapy………….3-6 months

Follow up………urea breath test

Best advice to avoid Peptic ulcer………avoid smoking

Complications of peptic ulcer

1-bleeding
CP……..VOMITING OF BLOOD
MANAGEMENT;
Confused patient…………..intubate first
Not confused……………..fluid resuscitation first priority
Type of fluid given…….normal saline

If you need to give blood…………….PACKED RBCS IS THE BEST

Then……………iv omeprazole
Then……………endoscopy
If bleeding ulcer visible…………adrenaline or HEAT PROBE
If not controlled medically ……..surgery

2- Perforated peptic ulcer…….emergency

Clinical picture;
Severe abd. Pain referred to the back
Nausea and vomiting
Hypotension
First step……….erect x-ray……..free air under diaphragm
TTT………RESUSCITATION FIRST
SURGERY
 COMPLICATION OF GASTRIC SURGERY;

Dumping syndrome ….vvvvvvvvvvvvvv imp

‫بعد االكل بنص ساعة انتفاخ و هبوط و اسهال‬

Vasomotor and GIT symptoms following meals

GIT………FULLNESS, pain, nausea and diarrhea

Vasomotor……flushing

Mechanism:

Early dumping within 1st hour of eating >> hypovolemia

Late dumping within 1-3 hours of eating>> hypoglycemia

TTT…….frequent small meals rich in protein and fat and less in

carbohydrate…..vvvv imp
band slip
One of the complications of
GASTRIC BAND COMPLICATIONS
A “slip” occurs when the stomach that is
below the band “slips” up or prolapses
through the band

Symptoms :
1. Severe heartburn or reflux (GERD)
2. Pain when eating solid food
3. Vomiting with solid foods
4. Night cough
5. Chest pain or pressure

Inv:……. Barium meal………vvvvv imp

TTT:……..surgery is the defnitive management

Esophageal varices

If not bleeding………….BB

If bleeding…………ligation

Inv…………endoscopy

Priority………fluid resus

To stop bleeding……….fresh frozen plasma

Very low Hb……………packed RBCS

 .

Anus

1-Piles

PF………. Constipation and pregnancy

Cp…………bleeding but NOOOO PAIN

Inv…….colonoscopy with old age….to exclude cancer

TTT…
Mild…..diet and band ligation
Severe …..surgery
2-Perianal hematoma
Cp ………..painful anus….vvvvvvv imp

Management;

First 24 hs……….simple aspiration

24hs-5 days……incision under local anesthesia

More than 5 days………leave it resolve spontaneously

N;B:

Piles and perianal hematoma similar in images so look at the

clinical scenario for pain;

Painful ……..perianal hematoma

Painless ……piles
Pilonidal sinus

Cp…….young male with dark dense hair

Usually asymptomatic or
discharge

TTT…….radical excision……vvvvvvvv imp

Anal fistula:

Most common cause of :

Perianal fistula……..abscess

Low lying fistula…..crohn's

Recurrent or multiple fistulae……crohn's

Rectovesical……malignancy

Rectovaginal …..iatrogenic

Cp:

Persistent purulent discharge

Inv:

Proctoscopy is the main inv

Fistulography

TTT:

STAGED OPERATION
Anal fissure:

Etiology:

Constipation

Chron's causes multiple fissures…vvvvvv imp

CP:

.PAIN with slight bleeding

How to examine ?? ……just inspection ….vvvvvv imp

DRE ……….contraindicated in acute anal fissure…..imp

TTT;

Diet….increase fluid and vegetables

Local Anesthesia + corticosteroid cream 

Local Glyceride Trinitrates ointment 

If CHRONIC……….surgery(LATERAL SPHINTERECTOMY) 

N:B:

The commonest causes of bleeding per rectum

INFANCY……….ANAL FISSURE

TTT OF ANAL FISSURE OR FISTULA SECONDARY TO

CHRONS…..INFLIXIMAB

BLEEDING PER RECTUM

CAUSES"

MOST COMMON over all………. PILES AND FISSURE

Most common cause in infancy………anal fissure

Most common cause in adult…….upper GIT bleeding

MOST COMMON IN OLD AGE………. DIVERTICULOSIS

Cancer colon………MUST BE EXCLUDED IN elederly

Bleeding per rectum +AF……….Ischemic colitis

TTT:

First step………fluid resuscitation

Type of fluid…..normal saline

If you need blood………Packed RBC'S (O- RH-)

Inv ……colonoscopy

Isotope scan……..helps asses site of bleeding

N.B:

If patient with melena …colonoscopy and endoscopy did not

reveal source of bleeding next step…capsule endoscopy…vvv
imp

OLD AGE + BLEEDING PER RECTUM……..COLON CANCER UNTIL

PROVED OTHERWISE…….FIRST STEP IS COLONOSCOPY

MOST RECTAL BLEEDING WILL STOP SPONTANEOUSLY BY THE

TIME OF RESUSCITATION

HERNIA

Protrusion of viscus through a defect

Main predisposing factors……constipation and chronic cough

Types:

1- Femoral hernia
Sex………multiparous females

Site…….below inguinal ligaments medial to femoral vessel and

lateral to pubic tubercle

MOST COMMON HERNIA TO COMPLICATE….vvvvvvvvv imp

N:B:

HERNIA………most common cause of intestinal obstruction

Most common type of hernia causing complication…femoral

How to suspect complicated hernia???

1-NO impulse of cough…vvvvvv imp
2-Symptoms of IO……..vomiting, constipation, distention
Inv of choice if IO………..X-ray
TTT of choice……surgery
Incisional hernia:

Hernia caused by an incompletely-healed surgical wound

Most common PF………..hematoma……vvvvvvv imp
CP……..swelling with scar……vvvvvvv imp
how to exam the patient……standing and coughing…vvvvv imp
TTT………..surgery

HERNIA IN PEDIATRIC

1- Inguinal hernia
Management;
If obstruction or strangulation……immediate surgery

If Irreducible…………surgery as soon as possible

If reducible…… Rule of 6-2:

Birth -6 weeks……………Surgery in 2 days

6weeks – 6 months………… in 2 weeks

> 6 months ……………… in 2 months

Congenital hypothyroidism should be excluded in infants with

Inguinal Hernia
2-Umbilical hernia
Less than 4 years……….observation

More than 4 years……..surgery

Divarication of recti: (Diastasis recti)

How to see it??.....raising up without support

TTT:

PREGNANCY AND KIDS…….no ttt

Mild cases…..physiotherapy…..

Severe cases……surgery
 Esophagus

Corrosive injury of the esophagus:

First aid management:

First step……. Glass of milk……….NOT USED ANY MORE

Gastric lavage is contraindicated

Analgesic, cortisone and antibiotics

INV:

ENDOSCOPY ……very important

Timing of the endoscopy…….1st 24 hours

Long term ttt……..DILATORS

Achalasia:

Cause…… no relaxation of lower esophageal sphincter

Cp:

More in females

Dysphagia…..more to fluids

Reguirgitation….foul smelling

Aspiration pneumonia

Inv:

Manometric studies…… the best…. Weak peristaltic waves

Barium enema……. Marked dilated esophagus

Endoscopy
TTT:

HELLER'S OPERATION ( myotomy)……of choice

Dilators………elderly not able to tolerate operations.

Botulinum toxin injection

Esophageal spasm

Retrosternal pain increased by hot and cold

drinks

dysphagia

If barium………. Cork screw appearance

TTT…….nitroglycerine, Ca channel blockers,

proton pump inhibitors

Eosinophilic esophagitis:

Also known as allergic oesophagitis

Allergic inflammatory condition of the esophagus caused by
food allergy
Symptoms :
swallowing difficulty
food impaction and heartburn
Associations:
Autoimmune and allergic disease. This
includes asthma and celiac disease.
Pathophysiology
Infiltrate with the eosinophil into the esophagus.
INV:
Endoscopically………….ridges, furrows, or rings
Treatment:
Dietary modification to exclude food allergens
First-line medical therapy is corticosteroids and other anti-
inflammatories
Mechanical dilatation in severe cases

HIATUS HERNIA:

Sliding ………the most common

Cp……. The same as GERD

Retrosternal discomfort with

regurgitation

Aspiration

Dysphagia and bleeding

Inv:

24 hs PH monitoring……the best

Endoscopy…..in severe cases

TTT……..MAINLY CONSERVATIVE

Reduction of body weight

Elevation of the head of the bed

Frequent small meals

Drugs:……..PPI is the best

H2 blockers and antacid

Surgery in severe cases

Para esophageal hernia:

Intermittent dysphagia

Post prandial pain

Pressure on the heart……cardiac

symptoms

Inv…..barium enema

TTT……..surgery

N:B:

Most common type of esophageal hernia…….sliding

Main ttt of sliding hernia………conservative

Main ttt of paraesophageal hernia……..surgery

Best ttt of GERD……..PPI

Best medical ttt of sliding hernia……PPI

Esophageal stricture:

History of prolonged GERD Syndrome

Now……dysphagia but no longer GERD

picture……vvvvimp
Loss of weight

Inv…….endoscopy

Small……PPI

Severe….surgery

BARRET'S ESOPHAGUS: VVVVVVVVV IMP

Cause …….long standing GERD

RISK………adenocarcinoma of the esophagus

Inv……….endoscopy

IF metaplasia……..biopsy

If low grade dysplasia…..repeat the endoscopy every 6 months

If high grade dysplasia……….ablation or surgery

Best ttt…….PPI……vvvv imp

Cancer esophagus:

Type…….SCC…. majority

PF…..smoking and alcohol

Site…..middle third

Cp…..OLD AGE

dysphagia, LOSING WEIGHT

Type of malignancy:

SCC…….most common

Columnar………lower one third

TTT : palliative

Surgery in early cases

Mallory Weiss syndrome:

Gastro-esophageal laceration ……partial tears

Causes:

Severe alcoholism, retching, coughing, or vomiting.

Cp…..vomiting up blood after violent retching or vomiting

Definitive diagnosis ………. endoscopy.

Treatment:
Supportive
Cauterization or injection of epinephrine to
stop the bleeding

Boerhaave syndrome:
Full-thickness tear ……rupture of the esophageal wall

History…….. Severe alcoholism, retching, coughing, or vomiting.

Cp,inv and ttt……..look at esophageal rupture

Premalignant lesions of cancer colon:

1-Familial polyposis coli:

Genetics…….Autosomal dominant •

Colon and rectum are full of polyps •

Fate……100% develop cancer •

Timing of polyps….usually by age of •

10-15 ys

TTT…..surgery once polyps start to appear •

Screening……colnoscopy •

Starting age of conoscopy……12 ys •

2-Gardner syndrome:

Variant of FPC •

FAP+ •

Desmoid tumours •

Osteoma + •

Epidermoid Cyst •

3-Peutz jegher’s syndrome:

Mucocutanous pigmentation •

Future risk: cancer colon •

4-Juvenile Polyposis : •

Solitary Polyp= no risk of cancer + bleeding •

Multiple Polyp > 5 =10% risk of cancer •

N:B: •

Most common type of adenoma causing electrolyte •

disturbances……villous adenoma

Most common polyp with malignant potential…..villous •

Least polyp with malignant potential…..tubular •

Colon Cancer •

Male > female •

Risk factors: •

Ulcerative Colitis , Familial Adenomatous Hyperplasia , •

Colonic Adenomata , low fiber Diet

Clinical picture" •

Rt Colon Lt Colon Sigmoid rectum

Iron Altered Complete Bleeding
deficiency bowel habit Bowl
Anemia Obstruction
Dyspepsia Partial Altered bowl Abdominal
Obstruction Habits Mass
Abdominal pain Rectal Tenesmus
mass bleeding
Most common symptom of cancer cecum……….anemia, pallor
and fatigue

Most common symptom of cancer rectum…..bleeding per

annus
Most common symptom of cancer left colon….alteration in
bowel habits

Investigation

1-X-ray…………apple core apperance

2-Colonoscopy……..investigation of choice

3-Fecal Occult Blood test ( FOBT)

If any patient above 50 with iron deficiency anemia…….,colon

cancer until proved otherwise

First step…….FOBT

If FOBT (+)……COLNOSCOPY

If high risk……..COLNOSCOPY from the beginning

Cancer colon what to give:…..VVVVVVVVVVV IMP

Preoperative………chemo and radio

Post operative…..chemo only

Screening for recurrence after colon cancer operation:

Colnoscopy…the most imp…..EVERY YEAR •

CEA •
Diverticular disease:

Site……sigmoid colon

Rectum……never affected

Not premalignant…..vvv imp

Cp:

Old age male constipating

acute stage…..fever, pain in the left ilac fossa, bleeding per

rectum

chronic….mass in the left iliac fossa

complications:……IO, perforation, Fistula

INV:

BARIUM ENEMA……screw toothed appearance

CT…….the best in the acute stage

TTT:

HIGH FIBER DIET AND LAXATIVES

Acute stage……conservative ttt

If perforation………surgery

N:B:

diverticulosis is the most common cause of rectal bleeding in

the elderly
Intestinal fistula:

Causes….mainly post operative

Others…… crohn's

Complication……electrolyte disturbances

Skin irritation

TTT:

Mainly conservative…….vvvvv imp

Surgery….rarely

Irritable bowel syndrome:

cp:
age…..more in young people
personality……more in pt under stress
Chronic abdominal pain
Alternating constipation with diarrhea
Stool…..ribbon shaped
Diagnosis…..clinically
TTT:
high fiber diet……main line of ttt
Laxatives
Spasmolytics for the pain….vvvvimp
SSRI….drug of choice….takes at least 2-4 weeks to work
Dyspepsia:
Functional pain
No organic lesion
Any abdominal discomfort with no organic lesion
Epigastric pain , fullness, bloating,heart burn, nausea
Diarrhea:
Most common cause of bloody diarrhea….campylobacter
Second most common cause of bloody diarrhea…shigella
Most common cause of traveler diarrhea….E-coli
Most common cause of diarrhea in pediatrics…viral
Most common virus causing diarrhea in kids……rotavirus
Diarrhea followed by weakness and areflexia…GBS
Diarrhea followed by renal impairement….HUS
Bloody diarrhea followed by RUQ pain….ameba
Diarrhea after camping…..Giardia
Chronic bloody diarrhea in young male…..IBS
Diarrhea after long term antibiotics....clostridium difficile
Antibiotic causing clostridium difficle….clindamycin
TTT of clostridium difficile ….metronidazole or vancomycin
Diarrhea after eggs or chicken…..salmonella
Diarrhea just hours after meal…..staph toxin
Diarrhea in bed ridden with constipation...fecal impaction
Main ttt of diarrhea…..fluid
TTT of traveler diarrhea…..fluid only
TTT of staph toxin…..fluid only
TTT of shigella or campylobacter….antibiotics
TTT of ameba or giardia….metronidazole

Pseudomembranous colitis:
Organism………………Clostridium difficile
Cause...............prolonged use of antibiotics..........key word
Most common causative antibiotic............clindamycin

Signs and symptoms:

Signs and symptoms of CDI range from mild diarrhea to severe
life-threatening
Inv:
Stool analysis

Treatment:
Mild cases ...........no treatment.
 Metronidazole ….. initial drug of choice for mild to moderate
disease
 Oral vancomycin is preferred for more severe disease or
diarrhea persists after a course of metronidazole
 Hematology
:

Anemia:

:ANEMIA presentations .

.Mild -> Fatigue - loss of energy - tiredness - malaise .

.Severe -> Shortness of breath - lightheadedness - confusion .

.Pallor - flow murmur - pale conjunctiva .

Causes of microcytic hypochromic anemia:

1-iron deficiency anemia

2-thalassemia

3-sideroblastic anemia

4-anemia of chronic disease

MCV:

NORMAL….80-100

MICRO……LESS THAN 80

MACRO…..MORE THAN 100

IRON DEFIENCY ANEMIA:

CAUSES:

Infants:
Most common cause……diet…prolonged breast feeding without
supplementation

Adult:

Most common cause…….GIT bleeding….peptic ulceration

Elderly:

Most serious cause…….cancer colon

Specific manifestation of iron deficiency:

Appetite…..PICA ( strange appetite)

Mouth…….angular stomatitis

Investigations:

CBC:

Decreased Hb, decreased hematocrite, decreased RBC'S

Decreased MCV and MCHC

Iron studies..

Serum iron, ferritin, transferring……decreased

TIBC…….increased

For diagnosis of the cause:

Stool exam……ancylostoma, occult blood

Endoscopy……peptic ulcer

Colonoscopy…colon cancer….vvvvv imp in elderly

Treatment:

Replacement therapy:

How:

Iron rich diet….beef, chicken, leafy greens

Oral iron…..ferrous sulphate, ferrous gluconate

Side effect of iron:

Black stool….. imp

Abdominal pain, vomiting, constipation

Parentral iron:

Indication: intolerable to oral iron e.g:peptic ulcer

Side effect,… anaphylaxis

Transfusion therapy:

How?.....packed RBC's

When:

Hemoglobin less than 7 gm…….vvvvvvvvvvvvv imp

Marked symptoms of the anemia

Hemolytic anemia:

Causes:

Hereditary spherocytosis

Paroxysmal nocturnal hemoglobinuria

Thalassemia
Sickle cell anemia

G6PD deficiency

General manifestations:

Jaundice

Hepatosplemegaly

Gall stones

Leg ulceration

Investigations:

CBC:

Normocytic normochromic anemia

Reticulocytic count…..high….vvvv imp

Serum bilirubin….. increased

Serum LDH…..increased

Haptoglobin…..decreased….vvvvvvvvvvvvvvvv imp

Hereditary spherocytosis vvvvvvvvvvvvvvvvvvvv imp

Defect…..membrane of the RBC's

Cp:

Same as hemolytic anemia

Since birth……vvvvvvvvvvvvvvvvvvvvv imp

Marked splenomegaly……vvvvvvvvvvv imp

Complications….aplastic crisis ( parvovirus)….v imp

Investigations:

Specific test…….increased osmotic fragility..vvvv imp

Blood film…..spherocytes

TTT:>

Splenectomy….vvvv imp

ttt of aplastic crisis…transfusion…..vvvvvvv imp

Paroxysmal nocturnal hemoglobinuria:

Complications:

Aplastic anemia

Thrombosis

Pancytopenia

Acute leukemia

Investigations:

Specific test…..Ham test

Most confirmatory test….flow cytometry CD55, CD58

Thalassemia:

Disease…..Autosomal recessive……vvvv imp

Defect……beta chain

Types:

Major…..both chromosomes are affected

Minor…..one chromosome affected

Cp:

POSITIVE FAMILY HISTORY

Onset .. not before 6 months

Symptoms of iron overload e.g:cirrhosis

Thalassemic facies:

Depressed nasal bridge

Prominent maxilla

Protruding upper incisor

Pallor

jaundice

investigations:

Most confirmatory test…….Hemoglobin electrophoresis

Blood film……target cells

Serum studies…. Increased serum iron

TTT:

Repeated blood transfusion

Iron chelation…..deferoxamine

Folic acid

Splenectomy

Prevention:…… DNA analysis for the parents

Sickle cell anemia:

Genetics……..Autosomal recessive

Complications:

Vasoocclusive crisis:

Bone infarction……aseptic necrosis of the hip

CNS…..stroke

Lung infarction….acute chest syndrome

Splenic infarction

Priapism

Hand foot syndrome

How to prevent crisis:?..avoid cold,

dehydration,stress

TTT of crisis:

Analgesic……first step….vvvvvvvvvv imp

Oxygen…..second step

Antibiotics, Hydration

Exchange transfusion with acute chest syndrome, stroke

2-aplastic crisis:

Cause…..parvovirus

Cp……pallor

Inv…..low hemotocrite and low reticulocytes

TTT……..transfusion
3-hemolytic crisis:

Cp: pallor, jaundice and red urine

Inv….low hematocrite but increased reticulocytes

TTT…..transfusion

4-sequestration crisis:

Cp: pallor with marked enlargement of the spleen

TTT….splenectomy

Investigations:

Confirmatory test…..Hb electrophoresis….Hb S

Blood film……sickle cells

TTT:

Repeated blood transfusion

Type of blood,……packed RBC's

Iron chelation…..deferoxamine

Folic acid

How to prevent crisis?......hydroxyurea

G6PD deficiency:…..oxidative hemolysis:

Clinical picture:

Same hemolytic anemia….sudden pallor, jaundice, red urine

Causes:
Drugs…..most common

Aspirin, antimalarial, sulpha drugs

Infections

Meals…..fava beans

Inveatigations:

Same as hemolytic anemia

Specific test…. Asses G6PD enzyme activity

Take care…..after attack G6PD activity is normal but decreased

after one month

TTT:

Avoid oxidative stress

Autoimmune hemolytic anemia:

Occurs with SLE, CLL lymphoma , EBV

Specific test……positive Comb's test

TTT:

Cortisone, Immunosuppressive drugs

Cold agglutinin antibody:

Most common cause….mycoplasma pneumonia

Direct comb's test

TTT:

Avoid exposure to cold

Aplastic anemia:

Most common cause…..idiopathic

Most common drug causing aplastic anemia….diclofenac

viral infections, including viral hepatitis B, parvovirus B19

Clinical picture:
Decreased RBC'S…….anemia
Decreased WBC'S …...infections
Decreased platelets…..bleeding

Investigations:
CBC……pancytopenia
Bone marrow examination….hypocellular fatty tissue…vvvimp
TTT:
The best…..BMT
Supportive….blood transfusion
Megaloblastic anemia:

Causes:

1-vitamin B12 deficiency

Most common cause……vegetarian

Pernicious anemia

Gastrectomy

Organism…..diphyllobothrium latum

2-folic acid deficiency:

Alcoholic…….most common

Drugs: methotrexate, phenytoin cotrimoxazale

Clinical picture:.

Anemia

GIT manifestation…

Atrophic gastritis

Neurological manifestations..only B12 deficiency:

Peripheral neuropathy

Sub acute combined degeneration:

Loss of posterior column functions e.g: position and vibration

CBC's:

RBC's…...large MCV …..imp

WBC'S…..large neutrophils and

hypersegmented

Platelets….large and decreased

Serology:

Antiparietal cell antibody … only B12

Schilling test…..only B12 deficiency

TTT:

Replacement therapy

Vit B12 deficiency….IM cyanocobolamine

Folic acid deficiency…oral folic acid

Transfusion….packed RBC'S….only severe cases

:PERINICIOUS ANEMIA

Auto-antibodies against the gastric intrinsic factor required .

.for B12 absorption ………vitamin B12 deficiency

Associated other auto-immune diseases e.g. Autoimmune .

.thyroiditis & Vitiligo

Peripheral blood smear -> Macro-ovalocytes, megaloblasts & .

.hyper-segmented neutrophils

Dx -> Detection of Anti-intrinsic factor Abs .

.Risk……CANCER STOMACH….VVVVVVV IMP

Anemia of chronic disease:

Specific test….increased ferritin

Anemia of renal failure:

Main cause…..erythropoeitin deficiency

TTT….erythropeitin replacement

Purpura:

Causes:

Decreased platelet production

Increased platelet destruction….ITP, SLE

Decreased platelet functions: uremia

Vessel …..vasculitis….HSP…vvvvvvvvvv imp

Scurvy….vitamin c deficiency…old age

Senile purpura
Immune thrombocytopenic purpura:

History……URTI 1-2 weeks before attack

Bleeding:

Skin….petechial hge

Generalized

Not raised above the surface

Do not blanch on pressure

Mucous membranes:

Epistaxis, bleeding gums

Hematuria

Intracranial bleeding….in severe cases

Investigation:

Platelets…..decreased

Bleeding time….increased

Bone marrow exam….increased megakaryocytes with

defective budding

Antiplatelets antibodies

TTT:

Majority of cases……nooooooooo ttt

Mild cases….no ttt….avoid trauma and NSAIDs..vvv imp

Moderate cases:

Prednisone…..drug of choice…..first line

IVIG…..second line

Platelet transfusion ….not done only with intracranial bleeding

Chronic cases……splenectomy

Prognosis….excellent

Hemophilia…..coagulation disorder:

Genetics……..X-LINKED

So boys are the majority of cases

Type:

Hemophilia A….factor 8 deficiency

Hemophilia B…..factor 9 deficiency

Clinical picture:

Bleeding:

Onset….prolonged bleeding after circumcision

Skin….ecchymosis

Joints…..hemoarthrosis….most common site

Repeated hge in the joints….joint damage

Muscle….muscle hematoma

Excessive hemorrhage after minor trauma….vvvvvv imp

Investigations:

Bleeding time….normal

APTT….increased

PT….normal

Factor 8…..decreased with hemophilia A

Factor 9 ….decreased with hemophilia B

TTT:

General measures:

Avoid trauma

Avoid NSAIDs

Specific ttt:

Factor 8 replacement

Fresh frozen plasma

Desmopressin….increases factor 8 production

Von-Willebrand disease:

Autosomal dominant

Most common hereditary coagulable status

Bleeding prolonged

Investigation:

Bleeding time….prolonged

APTT…..increased
Take care:

Girl with prolonged bleeding……Von Willebrand

Boy with prolonged bleeding…..hemophilia Or von willebrand

Purpura….increased bleeding time

Hemophilia….increased APTT

Von willebrand…..increased both

Confirmatory test for:

Thalasssemia….hemoglobin electrophoresis

Sickle cell……..hemoglobin electrophoresis

Hereditary spherocytosis….osmotic fragility

Autoimmune……comb's test

ITP…….increased megakarycytes

Bleeding after URTI……ITP

:)POLYCYATHEMIA VERA (P.vera(

.Plethoric face .

.Headache - Blurring of vision - dizziness - fatigue .

Pruritis happening after a hot bath or shower .

.Splenomegaly…..huge size

.Hypertension .

peptic ulcerations ++ .

.
Dx -> CBC "MARKEDLY HIGH HEMATOCRITE & low MCV

Increased red cell mass

."Dx -> ABG " Absence of hypoxia…vvvvv imp .

.)Dx -> -- Erythropoietin…. Normal or low ….vvvv imp .

.WBCs & ++ Platelets ++ .

.)Tx -> PHLEBOTOMY. (HCT < 45% .

.Tx -> Hydroxyurea – drug of choice .

Tx -> Give daily Aspirin to prevent Thrombosis .

Polycythemia rubra vera vs secondary polycythemia:

Polycythemia rubra secondary

vera polycythemia
Oxygen saturation normal hypoxia
erythropoeitin Normal or low increased
.

Myelofibrosis:

Cp……..pancytopenia

Bone marrow examination:

Aspiration…….tear drop …vvvvvvv imp

Biopsy….the best…. Fibrotic BM

Thrombophilia ( hypercoagulable status):

Causes:

Congenital:

Factor 5 leiden deficiency…..most common…vvv imp

Homocystiniemia

Deficiency of factor C

Deficiency of factor S

Deficiency of antithrombin 3

Acquired:

SLE

Antiphospholipid syndrome

PNH

DIC

Malignancy

OCP

Pregnancy

Nephrotic syndrome

TTT:

Aspirin ( low dose ) and warfarin

If pregnant….low dose aspirin and low dose heparin

Lymphoma:

Hodgkin lymphoma:

Age….either 15-35 or over 50 ys

Cp: painless enlargement of the lymph nodes

Most common affected lymph nodes…..cervical

Enlarged, discrete, non tender and rubbery

Pain induced by alcohol

Splenohepatomegaly

General manifestation:

Fever, night seating, pruiritis, weight loss and anemia

Intermittenet fever…..pel Ebstein fever

Microscopy …..reed Sternberg cells

Associated with …..HTLN virus

Non-hodgkin lymphoma:

Associated sometimes with sjogren syndrome

Cp:

Progressive enlargement of the lymph nodes

Gastric lymphoma

Investigation:

Biopsy…..excisional ….. is the best

CBC……anemia, eosinophilia

TTT:

Early stages…….chemo and radio

Advanced stages………chemotherapy
Burkitt's lymphoma:…… imp

Cause……Ebstein Bar virus

Age…..kids

Cp….progressive enlargement of the LN

TTT……chemo

GASTRIC MALT = MUCOSA ASSOCIATED LYMPHOID TISSUE .

:MANAGEMENT

! ERADICATION OF HELICOBACTER-PYLORI .

TRIPLE THERAPY (OMEPRAZOLE - CLARITHROMYCIN - .

.)AMOXICILLIN

:TUMOR LYSIS $YNDROME .

.Ass. with tumors with high cell turn-over .

.}HYPER {phosphatemia - kalemia - uricemia( .

.}HYPO {Calcemia .

.TL$ may lead to fatal arrhythmias, ARF & sudden death .

Tx -> Allopurinol .

:DIC = DISSEMINATED INTRAVASCULAR COAGULATION

.Doesn't occur in healthy pts .

Ass. with sepsis - burns - snake bites - cancer - Abruptio .

.placenta or AF Embolism

BLEEDING related to CLOTTING FACTORS DEFECIENCY & .

!! THROMBOCYTOPENIA
D-dimer & FDP (fibrin degradation products(…… ++ .

Fibrinogen level…..decreased

.Platelet count…….decreased

.)Tx -> REPLACEMENT by FFP FRESH FROZEN PLASMA .

Complications of blood transfusion:

1-pyrogenic reaction:

Cp…..chills, fever, nausea and vomiting

Cause…..minor bacterial contamination or some pyrogens

2- allergic reaction:

Cp…mild itching, to urticaria

Cause….allergens

TTT: antihistamins, cortisone

3-CHF:

Cause…..adminstration of blood too rapidly to elderly

Prevention: give packed RBC'S instead of whole blood

4- hemolytic reaction:

Cp:

Fever, chest pain and dyspnea

Tachycardia and hypotension

Hemoglobinuria and jaundice

TTT:

Stop the transfusion immediately

Normal saline

Iv cortisone

6- hyperkalemia

Due to storage of blood

7-citrate intoxication:

Excess citrate….hypocalcemia

TTT : iv ca gluconate

Most common component that is decreased in stored

blood….platelets (short half life)……VVVV imp

:FEBRILE NEUTROPENIA .

.Temperature > 38.3c or sustained temp .

.Neutropenia = neutrophil count < 1500 cells/ml .

The most common invading organism is PSEUDOMNAS .

.AERUGINOSA

BLOOD CULTURES followed by IV CEFEPIME or PIPERACILLIN .

.TAZOBACTAM
:METASTATIC BRAIN CANCER .

.Incidence -> Lung > Breast > Melanoma > Colon .

Primary solitary brain metastases -> BREAST - COLON - RENAL .

.CELL CARCINOMA

Multiple brain metastasis -> LUNG - MALIGNANT .

.MELANOMA

Brain metastasis are the most common intracranial tumors .

TTT:

SOLITARY -> SURGICAL RESECTION followed by whole brain .

.radiation

.Multiple -> Palliative whole brain radiation .

:PAIN CONTROL IN CANCER PATIENTS .

.Use SHORT ACING IV MORPHINE .

MANAGEMENT OF CHEMOTHERAPY INDUCED NAUSEA & .

:VOMITING

 . SEROTONIN ANTAGONIST Ondansetron

 

general manifestation: 
fever, fatigue, weight loss 
night sweating, loss of appetite 

easy bruising, 
recurrent infections 
pain in the joints, muscles 
lymphadenopathy 
hepatosplenomegaly 



important notes: 
Most common leukemia in kids…acute lymphoblastic 
leukemia
Most common type of leukemia in the elderly….chronic 
lymphatic leukemia
Main cp of chronic myeloid leukemia….splenomegaly 
Main CP of chronic lymphatic leukemia lymphadenopathy 
Old age + marked lymphadenopathy….. chronic lymphatic 
leukemia or lymphoma
Most common virus causing leukemia….RETROVIRUSES ( 
HTLV)
Blast cells…..acute leukemia 
Decreased leukocyte alkaline phosphatase…..chronic 
myelgenous leukemia
Philadelphia chromosome….. chronic myelgenous 
leukemia
Most common complication of chronic myeloid 
leukemia….blastic crisis


Chronic lymphatic leukemia: 

‫ مش مستاهلة عالج‬-‫ اللوكيميا الطيبة‬-‫لوكيميا العواجيز‬ 

Age….elderly 
Main cp…..marked lymphadenopathy 
DD…..lymphoma 
Association…..autoimmune hemolytic anemia 
Prognosis……good 
Usually no ttt 
If you have to ttt……..chemotherapy is the first line 
If marked drop in the platelets….steroid 



 HEPATOLOGY

TYPES OF VIRAL HEPATITIS:

HEPATITIS B DIAGNOSIS -> SEROLOGY

.
First marker appears in the blood……surface antigen

Marker detected only by liver biopsy……Hbc

Marker of highly infectivity……….. e-Antigen

How to follow up……….PCR

Acute cases……….NO TTT

.Tx -> Anti-viral therapy -> LAMIVUDINE + INTERFERON .

HEPATITIS C: .

Main route of transmission…..blood contact

.Best initial test -> Hepatitis C antibody .

Most accurate……….. Hepatitis C PCR for RNA

.Liver biopsy……determine the seriousness of the disease

TREATMENT:

Acute cases……….NO TTT

CHRONIC CASES…….. RIBAVIRIN + INTERFERON .

Breast feeding……continue

Delivery……normal vaginal

.Sex…….continue

.No vaccine & No post-exposure prophylaxis for hepatitis C .

 Hepatitis A:

History………travel to a developing country (Thailand)

Cp:

 fever, pain at right upper quadrant area

 Nausea, Vomiting, Tiredness, fatigue, Loss of appetite
 Pale or gray-colored stools
 Jaundice
 Urine is dark brownish in color, like cola or strong tea.

Investigations:

Liver enzymes………markedly increased

D etection of HAV -s pecific IgM and IgG

Prophylaxis against hepatitis A …….VVVVVV IMP

When………both pre and post exposure

For who??........Travellers

How??..........IVIG and inactivated vaccine

When?...........4 weeks before travel

If will travel very soon ……give IVIG

:CIRRHOSIS:

:GENERAL FEATURES OF CIRRHOSIS .

Edema -> from low oncotic pressure -> Tx: Spironolactone - 1

.Gynecomastia - 2

.Palamar erythema - 3

.Splenomegaly - 4
.)Thrombocytopenia - 5

.)Encephalopathy ..……Tx: lactulose - 6

.)Ascites …….Tx: spironolactone - 7

Esophageal varices ……Tx: propranolol will prevent - 8

bleeding - Banding if rebleed

:HYPER-ESTROGENISM : .

Gynecomastia – .

Testicular atrophy –

Spider angiomata –

palmar erhtema

:ASCITES

TTT

Paracentesis .

Diuretics……..spironolactone

Refractory………TIPS

:SPONTANEOUS BACTERIAL PERITONITIS vvvvvvv imp .

Pt with cirrhosis & ascites >-

low grade fever……..key word

abd. Pain…..key word

Dx -> Best test -> paracentesis…… Cell count > 250 neutrophils

.Tx -> IV CEFOTAXIME >-

Primary biliary cirrhosis:

Middle-aged woman

ITCHING .

XANTHELASMA .

Jaundice

hepatosplenomegaly

.H/O of other autoimmune diseases .

.IgM ++ .

Most accurate test -> Anti-mitochondrial antibody vvvv imp .

.Liver biopsy

.Tx -> Ursodeoxycholic acid .

PRIMARY SCLEROSING CHOLANGITIS

.)Inflammatory bowel disease (UC ) .

! ITCHING .

.Most accurate test -> ERCP -> BEADING of the biliary system .

.Tx -> Ursodeoxycholic acid .

:WILSON's DISEASE = HEPATO-LENTICULAR DEGENERATION

.-- Ceruloplasmin -> ++ Copper .

.Abnormal Copper deposition in liver, basal ganglia & cornea .

.Young pt < 30 ys .

LIVER……Cirrhosis .
BRAIN……. Choreiform movement disorder

Neuropsychiatric abnormalities

.Eye………… Keiser Fleischer rings vvvvv imp

Best initial test -> Slit lamp (Keiser Fleischer .

rings) & -- Ceruloplasmin level

.Most accurate test -> Liver biopsy .

.Tx -> Penicillamine .

HEMOCHROMATOSIS

:AUTOSOMAL RECESSIVE

.Genetic disorder -> over-absorption of IRON .

.Iron deposits in various body tissues .

.Heart -> Restrictive cardiomyopathy .

.Skin -> Darkening & pigmentation .

.Joint -> Psedogout & CPPD .

.Pancreas -> Bronze Diabetes .

.Pituitary -> Panhypopituitarism .

.Genitalia -> Infertility .

.Infections -> LISTERIA, VIBRIO VULNIFICUS & YERSINIA .

Liver -> HEPATOMA & cirrhosis -> HEPATOCELLULAR .

.)CARCINOMA (Most common cause of death

.Dx -> Best initial test -> transferrin levels vvvvvvv IMP .

.Dx -> Most accurate test -> Liver biopsy .

 .Tx -> Phlebotomy .

PRONOSIS:…..WORST WITH C282Y gene mutation

Screening for hemochromatosis:

 WHO IS AT RISK?????
 All first-degree relatives of patients with haemochromatosis,
known mutation in HFE gene

 HOW TO DO SCREENING ????

First step :

Transferring saturation and serum ferritin concentration

when to say (+)????

Fasting transferrin saturation >45%

Fasting ferritin >250 µg/L on more than one occasion,

How to confirm???????

HFE mutations ……if (+)……referral for genetic counselling

when to test Children of C282Y heterozygotes ????

1- Should only be tested if the other parent has the C282Y

mutation.
2-until age 18 years unless symptomatic

Other first-degree relatives of C282Y heterozygotes should be

tested with iron studies. If these are positive…… referral for
genetic counselling
)NON-ALCOHOLIC STEATOHEPATITIS (

.Associated with obesity - DM - Hyperlipidemia .

.)Dx-> Most accurate test -> Liver biopsy (Fatty infiltration .

.Tx -> No specific therapy ….control body weight and DM

:ALPHA - 1 ANTI-TRYPSIN DEFECIENCY vvvvvvvvvv imp

.PAN-ACINAR EMPHYSEMA + CIRRHOSIS .

Young patient with emphysema

:VARICEAL BLEEDING MANAGEMENT .

The 1st step ……….RESUSCITATION .

,If you need blood ……packed RBC'S ( O- RH- low hemolysis)

Then .. Control the bleeding itself …….ENDOSCOPY

If failed……..TIPS

:HEPATIC ENCEPHALOPATHY : .

.Due to ++ AMMONIA level .

PPT factors -> hypovolemia - GIT bleeding - infection .

.TTT:

.(LACTULOSE) -> .

.)NEOMYCIN -> .

! )Lower protein in diet (BUT .. NOT PTN FREE DIET xxxx .

:ALCOHOLIC LIVER DISEASES .

.H/O of heavy alcohol use .

Stages -> .

1. Fatty liver "steatosis" –

2. Hepatitis –

."3. Fibrosis "Cirrhosis

:On CESSATION of alcohol intake .

.Steatosis & hepatitis & early fibrosis are REVERSIBLE >-

.True cirrhosis (with generation nodules) are IRREVERSIBLE, >-

:EMPHYSEMATOUS CHOLECYSTITIS .

Due to 2ry infection of the gall bladder with gas forming .

.bacteria e.g. Clostridium

.diabetic male .

.Crepitus .

.Complications -> Gangrene & perforation .

.Dx -> Abdominal radiograph -> Air fluid level .

Tx -> fluid & electrolyte resuscitation, & antibiotics .

.cholycystectomy
Very important statistics: VVVVVVV IMP

Most common cause of cirrhosis in australia……..alcohol

Most common virus causing chronicity in adult…..C

Most common virus causing chronicity in kids…..B

Most common virus causing liver cancer……..B

Most common virus to be transmitted after needle abrasion...B

Most common virus transmitted by food…..A

Virus that can kill adult while very begnin in kids….A

Viruses transmitted by food….A and E

Virus that can kill pregnant women……E

Virus that is associated with hepatitis B……D

Most common route of hepatitis B transmission…perinatal

Best inv for CHRONIC HEPATITIS -> Liver biopsy

 Orthopedics:
Anterior shoulder dislocation:

Joint affected ……..glenohumeral joint

Cp……. Inability to raise arm above head

Nerve affected……..axillary……deltoid muscle affection

and loss of sensation over shoulder

TTT………closed reduction followed by sling

Reduction is done by using fentanly and midazolam

Posterior shoulder dislocation:

Not common

Occurs in epileptics, electrical shock or eclampsia

Cp: ………adduction and internal rotation

Fracture surgical neck of the humerus:

Nerve affected …….axillary nerve

TTT…..triangular sling

FRACTURE SHAFT HUMERUS :

Risk………radial nerve injury…….wrist drop

TTT…….HANGING ARM CAST

When to suspect child abuse…… spiral fracture

DISLOCATED ELBOW:

Vascular impairement…..brachial artery

TTT……reduction under anesthesia

 Fracture radius and ulna:

Risk…..compartment syndrome

TTT of compartment syndrome……fasciotomy

Management:

Green fracture……splint

Adult……plaster cast involving the wrist and elbow

Colle's fracture:

Age………old age post menopausal female

Risk factor………osteoporosis

Cause……..fall on outstretched hand

Shape……….Posterolateral displacement , impaction and

angulation

Management:

If stable:

Closed reduction followed by a cast

How reduction is done……. Disimpaction then traction the hand in the

flexed position with ulnar deviation

Cast……. Below elbow with pronated semi flexed

hand with ulnar deviation

If unstable……. Surgery

Second look………. After 2 weeks by X-ray

 Complication……….malunion ,,,,,, dinner fork

deformity
Scaphoid fracture:

Most common fractured carpal bone

Cause…….fall on the outstretched hand

Cp…….tenderness in the anatomical snuff box

Radiological changes appear only after 2 weeks ……. Vvvvv imp

Risk…………avascular necrosis……proximal necrosis…..non union

TTT……….. stable…..thumb spica cast

Unstable………. OR+IF

Clavicular fracture:

Cause…….. Fall on outstretched hand

Birth related

Common site…….. Middle third

TTT:

Figure of eight sling

Complication:

Malunion…….most common complication

If vessels injury suspected or with marked

displacement……. Surgery

Cp of birth related fracture………deformity, fullness

and crepitation

TTT of birth related fracture……… none

Nurse maid elbow (radial head dislocation)

Cause……. Strong pulling of the child arm

Age……….. Toddlers

Cp…….. Crying baby not allowed you to touch his

arm in the Dad's lap

TTT……. Manual reduction by supination in 90 degree flexion

Supracondylar fracture:

Risk……….. Brachial artery injury……….

In acute stage……… acute ischemia ( 5 Ps)…….immediate

removal of the cast……. Vvv imp

Chronic stage……Volkmann contracture

Nerve injury……… median nerve

TTT…….. Cast immobilization…

If you suspect tight cast……….remove the cast

If vessel suspected…….immediate exploration

Mallet finger":

Cause……… trauma

TTT…….. Hyperextension of DIP joint for 6 weeks

How…….. non adhesive tape

When to do surgery?..

Instability

Subluxation

Avulsed bony fragment

Tennis elbow (lateral epicondylitis)

Inflammation at the point of the attachment of the Extensor muscles at

the outer part of the elbow.

Cause……..repeated bending and twisting movements.

Risk factor ……..excessive use of the wrist especially when unfit.

Clinical picture;

Job………tennis players, carpenters or

violinists.

Complaint……pain at the outer bony

projection of the elbow

Treatment………..rest and NSAIDS

Golvers elbow (medial epicondylitis)…….

flexor group

The same but less common and less severe

Hip dislocation:

Posterior dislocation:>

Most common form of hip dislocation

Cause………car accidents

Cp…….short leg with internal rotation

Nerve affected……… sciatica

TTT……..closed reduction

Femoral fracture:

It is emergency in elederly

Shape…… short leg with external rotation

Risk…….. Fat embolism

TTT……. Intramedulary nail fixation

Tibial fracture:

Cause….. Direct trauma

Risk compartmental syndrome

TTT….casting

Fracture fibula:

Nerve affected……..common peroneal

TTT…….no ttt….. Just NSAIDs

Stress fracture:

Sites:

Second metatarsal bone…….most common

Proximal tibia……very common

Navicular bone

Risk factors…….runners and jumbers

Cp.. pain increases with activity and decreases with rest

Localized tenderness

X-ray………usually normal

TTT…… rest and analgesic are the main TTT

Cast helps rapid healing

Surgery is rarely needed

Osgood-schlatter disorder

Age ………adolescence

Sex……….boys more than girls

Risk factor……..sports esp. running and jumbing

Mechanism……….traction on the immature tibial

tubercle by the patellar tendon.

Cp……….. Pain at the knee joint or at the patella

Exam……..prominence of the tibial tubercle

Prognosis……….self limited, usually resolve within 12-18 months

Treatment………rest

Restriction of the activities

NSAIDS
Multiple myeloma;
Cancer of plasma cells

 Age. Old age

 Sex. Men more than women.
 Obesity.


Clinical picture

 Bone pain especially the back

 Anemia

Weight loss

 Symptoms of hypercalcemia…..constipation, polyuria, excessive

thirst, nausea

 Kidney (renal) failure. High levels of abnormal monoclonal proteins

(M proteins), which are called Bence Jones proteins, damage the
kidneys.
 Impaired immunity. such as pneumonia, sinusitis, or kidney
infections, skin infections, and shingles

 Weakness or numbness in legs



 .investigations;
 Calcium level…………..increased
 Plasma cells…………..increased
 M proteins…………….increased
 Rouleux cells……..vvvv imp
 X-ay:…………..osteolytic leisions
 Treatment……………chemotherapy
Monoclonal gammopathy of undetermined significance

Diagnosis:

1. A monoclonal paraprotein band lesser than 30 g/L (< 3g/dL);

2. Plasma cells less than 10%.....vvvvvvvv imp
3. No evidence of bone lesions, anemia, hypercalcemia, or renal
insufficiency
4. No evidence of another B-cell proliferative disorder

Prognosis:
May transform into multiple myeloma

Management:
protein electrophoresis should be repeated annually…vv imp
skeletal survey

N:B:
Plasma cells level in:
Multiple myeloma…………more than 10%
MGUS…………….less than 10%
Main management of MGUS……….annual FU by serum electrophoresis

MM vs prostate cancer:
Both of them…………old age male with back pain
Multiple myeloma………..hypercalcemia is a must
Prostate cancer…………….calcium level can be normal
 Carpal tunnel syndrome

Painful disorder of the hand caused by pressure on

the median nerve

Incidence……..Common

Age ………….middle age

Sex ………….more at females

PF…………..pregnancy, RA, hypothyroidism

Symptoms……..pain and numbness at the thumb ,

index and middle finger

Timing ………more at the night

Complication…….permanent weakness and numbness of the hand

Inv…………Nerve conduction velocity and EMG

Tests………phalen test

Treatment……

First line….analgesic and splint

Cortisone injection

Surgery

Plantar fasciitis:

Pain in the foot …….increase with start of walking then subsides

X-ray……..bony spur

TTT…….NSAIDs

No surgery

Prognosis…..heal within 12-18 months

Superior vena cava syndrome:

Cause…….obstruction of superior vena cava

Lung cancer is the usually the main cause

Cp:

Congestion of the face and neck……increased by elevation of the

arm….pemperton sign

INV: CT

TTT:

IRRADIATION………….FIRST STEP

SURGERY……DEFNITIVE TTT
Paget disease:

Remodeling disorder

Cp……….usually asymptomatic

More in females

Bony pain increased at night

Skull deformities…….deafness

Inv:

Alkaline phosphatase……increased

Serum calcium……normal

X-ray……lytic lesions

TTT……biphosphonate

Spinal cord compression:

Causes:

Acute trauma

Metastasis of cancer e.g: breast

C/P:

Mid Throacic Pain

UMNL below level of compression

Investigations:

MRI…………investigation of choice.
Treatment:

Dexamethazone ……… vvvvvv imp ( first step)

LONG TERM TTT……..irradiation

Osteosarcoma:

Age:

Up to 15 years old

Site:long bones

Thigh near Knee

C/P: painful movement

Investigations;

X- ray Subcortical bone formation

Biopsy

Bone Scan

CT Chest

Treatment

Osteoclastoma(Giant cell Tumor)

Site:

Age:

30 – 40 years old

C/P :

Investigations:

Biopsy : (golden standard)

X-ray: Soap bubble appearance

Knee injury vvvvvvvvvv imp
Knee menisci :
Cause ……..trauma
Locking=meniscus ( cannot straighten
knee fully)
Give away=meniscus (unable to support
you)

Cruciate ligament:
Anterior is much more common than posterior:
Cp:
1-"pop" sound during a twisting movement…..key word
2-Followed by inability to continue participation
3- Followed by severe swelling
Inv:
MRI……..investigation of choice
Tests for cruciate ligament:
Anterior:
Anterior drawer test……..(+)
Lachman test
Pivot shift test
posteoir:
Posterior drawer test……(+)
TTT:
Meniscus:
If small…….conservative
If severe…..surgery
Cruciate:
When to do surgery????
1-young active
2-athelete
3-complete tear

Rupture achillis tendon:

Partial:
History of running or jumping
Sudden severe pain
On exam……nooo gap
If gap………complete rupture
TTT:
No gap……conservative ttt
Gap……….emergent surgery less than 3 hs:
Sprained ankle:
Ankle fracture:

: Conservative treatment

 cast for 4-6 weeks

 cast considered for non-displaced fractures

 Serial radiographs ……. at 48 hours, at 7 days, and

then at two-weekly intervals

Operative treatment

 Displaced unstable fractures.

 Vessels injury…loss of distal pulse

Complications

 Compartment syndrome.
 Vascular compromise and foot ischaemia.

N:B:

If you do not feel pulsation in fracture ankle ……first step

is reduction ……. If still no pulse…..exploration

Fracture pelvis:

Causes:

Fall in old age

Trauma

Most common complications…..bleeding….tie the pelvis

Management
Stable :

 Analgesia and early mobilization (usually after 3 to 6

weeks)……vvvvvv imp
 Avulsion fractures…….. rest and pain relief.
 Larger avulsions…….internal fixation

Unstable type:

 resuscitate
 Do not catheterize if urethral injury is suspected.
 surgery

Prophylaxis after orthopedic surgery:vvvvvv imp 

1-Aspirin………..NOT recommended

2-Heparin …….of choice

Type……..LMWH

3-warfarin…..in history of DVT

Target INR…..2-3

Sequence of management after fracture or orthopedic

operations in elederly:…vvvvvvvvvvvvvvvvvvvvvv imp

1st priority..;..LMWH (prophylactic dose) up to 6 weeks

imp

2nd priority……….dexa scan for osteoporosis

Most important ttt of osteoporosis…………bophosphanate

Orbital floor fracture:
Enopthamos
Horizontal diplopia
Pain with limited eye movement
Cheek numbness…due to injury of inferior orbital
nerve…vvimp

Zygomatic Fracture:
C/p: •
Vertical Diplopia (Upward gazing)
Difficult in mastication
Enophthalmoses
Investigation:
X ray
 paresthetica meralgia :
Numbness or pain in the outer thigh
Nerve affected……… lateral cutaneous nerve of thigh
Causes:
Aging
Compress against underwear, outer clothing,
and by belting.
Long periods of standing.

Trendelenburg sign:
Weak or paralyzed abductor muscles of the hip, namely gluteus
medius and gluteus minimus

TTT………..weight bearing over hip muscles …vvvvvvvvvvv imp

Nerve lesions:
Upper limb:
Cranial nerves affection:
Optic:
Ipsilateral loss of vision
Loss of direct and consensual light reflex

Occulomotor:
Ptosis
Mydriasis
Diplopia
Divergent paralytic squint
ipsilateral loss of light reflex
Trochlear:
Vertical diplopia ( on looking downward)
abducent:
Horizontal diplopia ( on looking to the Rt or the Lt)
Facial nerve:
UMNL:
Affect pyramidal tract above facial nucleus
Affect voluntary muscles
Spare emotional movements
Hypertonia
Hyperreflexia
Hemiplegia on the same side
Affection of lower half of the face on the opposite side
Drop angle of the mouth
Deviation of the mouth to the opposite side
Dribbling saliva
Inability to blow cheek
LMNL:
LOST emotional movements
Hypotonia
Hyporeflexia
Hemiplegia on opposite side
Paralysis of all muscles on the same side
No raising of the eyebrow
No closure of the eye
No wrinkles of the forehead
Hypoglossal nerve:
Deviation of the tongue to the same side of the lesion

Important reflexes:
Knee………l4
Foot drop……l5
Ankle………..s1
Biceps and brachioradialis…….c5,6
Triceps……..C6,7
Elbow……..C6,7
Fingers…….c8

nerve affection with fracture:

Anterior dislocation of shoulder…….axillary
Fracture neck humerus……..axillary
Fracture shaft humerus…….radial
Fracture medial epicondyle……..ulnar
supracondylar fracture…….brachial artery first then
median nerve
Saturday nerve pasy…….radial
Fracture at snuff box…….radius
Dislocated elbow……bracial artery and median N
Posterior dislocation of hip…….sciatica
Fracture fibula……..common peroneal
posteoir dislocation of knee…….popliteal artery

Clinical deformity with nerve lesion:

axillary:……..C5 lesion….vvvvvvvvvvv imp
Motor…….lost abduction
Sensory……lost sensation over lateral aspect of arm

Radial:
Motor…….wrist drop
Weak extension
Lost triceps reflex
Ulnar:
at elbow:
Claw hand (complete)
Paralysis of small muscles of hand…..lost abduction and
adduction
Loss of adduction of thumb
Flattening of hypothenar muscles
Sensation……medial one third of palm and medial one
and half fingers
At wrist:
Partial claw hand:
Lost abduction and adduction
Lost adduction of thumb
Flattening of hypothenar eminence
Sensation ……the same

Median nerve:
Loss opposition of thumb
Wasting of thenar eminence
Ape's hand
Loss pronation
Weak flexion of wrist
No flexion of thumb
Sensory……
loss sensation over lateral three and half fingers and
lateral two third of the palm
 Lower limb nerve lesions:
Common peroneal nerve:
Supplies anterior compartment of the leg

Causes:
1-lithotomy position
2-Long time, Hyper flexion of Knee
3- Ballet dancer
4- Fracture fibula 4-
Muscle affected………..extensor hallucius longus
FOOT DROP
Lost eversion
Lost dorsiflexion

Tipial nerve: ( TIP)

Lost………..inversion and plantar flexion
 Salivary gland disorders:

ACUTE PAROTITIS:…vvvvvv imp

Cause…..bad oral hygiene and dehydration..vvvv imp

Organism……staph

Cp……. Painful swelling and pus from the duct

Preverntion………..hydration and oral hygiene

TTT……antibiotic

If fulminant…..decompression by incision

Do not wait for flactuation

salivary gland stones:

Site:

submandibular……..most common

Parotid…….. rare

Cp:

Swelling and pain increased by eating

Pain referred to the ear

Exam…..enlarged and tender gland

INV:

Intraoral X-ray…………vvvvvv imp

Sialogram…..if x-ray doesnot reveal stones…vvvvvvvvv imp

TTT……
If stone in the duct…… cutting directly over it

If the gland…….removal of the gland

Salivary gland tumours:

Most common begnin………pleomorphic adenoma

Most common malignant……….mucoepidermoid carcinoma

Type bilateral or with hot spots……..warthin tumour

Cp:

If begnin…….painless, slowly growing, well defined not affected

facial nerve

If malignant…… painful, rapid growing , affecting facial nerve

So if a patient with swelling in front of the ear with facial nerve

paralysis……… malignant leision

Inv:

BIOPSY………..the main INV ……vvvv imp

Type of biopsy as breast cancer….the best is core biopsy

CT…..for metastasis

If in superficial…. Superficial parotidectomy

If the deep part…… total conservative

Main problem with pleomorphic adenoma…….recurrence

Main nerve affected during surgery…….…facial

nerve…vvvv imp
Sequence of investigations in salivary gland swelling:..vvvvimp

If solid mass:

1st inv…………..CT

Inv of choice………..Biopsy…..most accurate biopsy is excisional

If inflammation:

1st inv…………US

If stones:

1st inv…………X-Ray

Inv of choice………..sialogram
 Soft tissue disorders:

Glomus tumour

A-V shunt in the distal extremities with

neural and smooth muscle fiber

Site…….nail

Cp……pain

Ttt……removal

Keloid and hypertrophic scar:

Keloid ….extend beyond the scar

Hypertrophic scar…..limited to the scar

TTT……..surgery for both of them

In keloid……,cortisone can be used

Acute paronychia:

Infection of the nail bed

Cp…… localized pain and tenderness

TTT….. antifungal

Pulp space infection:

Cause….. staph

Main route…..direct inoculation

Cp…… localized pain and tenderness

TTT….. donot wait for fluctuation….do incision

Tenosynovitis:

inflammation of the fluid-filled sheath

Cp……… pain and swelling with limited movement

Risk factor …….repeated use of the hand

TTT:

Mild……NSAIDs and rest

Brace is recommended

Resistant cases….cortisone injection

Surgery rarely needed

Dupyturen's contracture vvvvvvvvvvvvvvvvvvvvvvvvvvvvv imp

Middle aged men with + family history

Causes…… alcoholism is the most common cause

Trauma

DM……check blood glucose

Cp……flexed fingers

Most common fingers….. little and the ring

Exam……nodules at the palmar fascia

Recurrence rate …..high

INV……blood glucose level………vvvvvvvvvvvvvvvvvvvv imp

US…most imp inv and initial inv and must be done before
surgery….vvvv imp
TTT:…… Early cases…..radiation

Late…..surgery

Volkmann's ischemic contracture:

Ischemia……fibrosis of the muscle…… permanent shortening of

the muscles

causes:

Supracondylar fracture……. Most common cause

Fracture tibia and fibula

Early signs if ischemia…… pain, pallor, parathesia and

pulselessness

Late…..flexion deformity

TTT:

EARLY…….immediate removal of the cast

If no response…. Immediate exploration

Late…. Physiotherapy and surgery

Ingrowing toe nail:…vvvvvvvvvvvvv imp

Age …… young male with tight shoes

Faulty nail trimming

TTT:

Mild:

Piece of gauze soaked with antiseptic

Wearing proper size of shoes……….vvvvvvvvvvvvv imp

Resistant and severe cases…. Wedge resection…VVV IMP

Nail hematomas:

Management:

Small and painless……. NO TTT

If large……. Nail drilling or removal of the whole nail

Simple ganglia:

Cystic swelling related to the tendon

Translucent not attached to the skin

TTT:

Puncture followed by surgery

excision
 Thyroid disorders :

Thyroglossal cyst :…vvvvvvvvvvvvvvvvvvvvvv imp

Congenital due to persisting part of thyroglossal duct

Time of appearing…….. Since childhood

Content…..mucoid fluid

Site….commonly subhyoid at the midline

Cp…..swelling at midline moves up with

protrusion of the tongue

Most common fate…… infection….vvvvvvvvvvvv imp

TTT….. Removal

Removal of the cyst with the body of the hyoid bone with the
remenants of the thyroglossal duct

Solitary thyroid nodule:

Most common site…..junction of isthmus with lateral lobe

Types……..majority are simple

Inv:

FNAB……most accurate and sensitive

Scan:

If hot……… toxic nodule

If cold…….malignancy high possibility

TTT: if suspicious……… surgery

Thyroid cancers:

Risk factors:

Radiation…..children are very susceptible

Genetic…….medullary carcinoma

Hashimoto's…..lymphoma

Endemic goiter….. follicular carcinoma

Anaplastic……de novo

Cp:

Sex…….mainly females

Types:

1-Papillary carcinoma

Most common type

Affecting young females

psammoma bodies…..characteristic

2-follicular carcinoma

Differentiated from adenoma by infiltration of the capsule

So if you find follicular cells in FNAB……next step is core

biopsy to asses capsular infiltration…vvvvvvvvv imp
3-anaplastic

Most fatal

Elderly male

Hard with rapid growth

Lateral aberrant thyroid……. Enlarged deep cervical LN with
normal thyroid gland

Bad sign in cancer thyroid……… Hoarseness of voice (

infiltration of RLN)

TTT:

Main line of ttt…… total thyrodiectomy

Removal of LN…… only if affected

Thyrodiectomy:

Main complications:

1-stridor

Cause…….blood collect under fascia

TTT…….. immediate removal of all stitches and open the wound

in the yard…vvvvvvvv imp

2-thyroid crisis……. Acute hyperthyroidism

Timing …… immediately after operation

Cp:

Hyperpyrexia

Tachycardia

Hypertension

Dyspnea and convulsions

Prevention………good preparation of the patient before surgery

TTT:
FEVER………iv fluid and ice backs

Dyspnea……O2 and sedation

Tachycardia…..propranolol

Carbimazole and cortisone

3-injury of RLN:

UNILATERAL………..hoarseness of voice

Bilateral complete……..aphonia and dyspnea

Bilateral incomplete…..aphonia and stridor

4-laryngeal edema…….. intubate

5-hypoparathyrodism:…vvvvvvv imp

Cause ……removal of the 4 parathyroid glands

Cp……..perioral numbness and tetany

TTT……..

Emergency… Ca gluconate 10% iv slowly….vvvvvvvvvvvvv imp

Maintenance…. Calcium+ vit D

6-Progressive exophthalmos:

TTT:

Tarsorrhaphy to protect the eye

Sleeping semi setting and cortisone

Orbital decompression in severe cases

Special cases of thyrotoxicosis:

1-pregnancy:

Radioactive iodine…….contraindicated

Drugs…….. Causes fetal hypothyroidism

So the best is ….. Short course on antithyroid and propranolol

till becomes euthyroid then surgery

Timing of the surgery…….second trimester

N:B:

SECOND TRIMESTER…….is the best timing to do any operation

in females during pregnancy

2-Thyrotoxicosis in children:

Radioactive iodine……..induce cancer

Surgery…….. High recurrence rate

Anti thyroid……… the best

3-Thyrotoxicosis in cardiac patient:

Surgery……… is the best

4-proptosis of recent onset:

Abruption of toxic status suddenly……. Malignant exophthalmos

So antithyroid 1st till euthyroid then surgery

Post operative fever= post operative agitation:…vvvvvv imp

Causes:

1st day -2nd day………atelectasis

2-3 days………endometritis or UTI or pneumonia

5-7 days…….PE, DVT

5-7 days……wound infection

After 10 days……abscess

After 2 weeks……mastitis

1-ATELECTASIS:

Timing……usually first day •

Cp…….fever , agitation and dyspnea •

PF……..inhibiting cough reflex ( •

anesthesia)

Predisposed patients.....old age, COPD, smokers •

Inv: •

First step………pulse oximetry…..hypoxia •

Second inv………ABG …….THEN………X-ray •

TTT: •

First step……..oxygen •

Physical exercise ( breathing •

exercise)…of choice.

Best prevention……incentive spirometry •

2-UTI:

Urgency, frequency and dysuria

Most common organism…….e-coli

Inv…..urine analysis then urine culture

TTT…….trimethoprim sulpha is the best

How to collect urine samples in pediatrics???

If more than 4 years……mid stream collection

If younger esp, less than 1 year…..suprapubic aspiration is the

best

If failed….catheterization

When to say (+) sample:

Wbc's ( pus cells)…..more than 10

e-coli……..more than 100.000

Further investigation to children…..US is a must

If recurrent UTI…..micturiting cystourethrography

3-Endometritis:

Fever…………high grade

Foul smelling lochia

Uterine tenderness

TTT…..antibiotics
4-Pneumonia:

Fever, cough, dyspnea, secretion

5-Pulmonary Embolism:

SINUS TACHYCARDIA

CHEST PAIN with dyspnea, hemoptysis

Best inv…….CTPA

WHEN to do VQ SCAN?

ALLERGY

RENAL IMPAIREMENT (increased creat, decreased GFR)vv imp

PREGNANCY

If mismatch…….LMWH ( New guidelines)

Warfarin for 3-6 months

6-Wound infection:

Pain, redness, swelling and discharge

TTT…..ANTIBIOTICS

7-MASTITIS:

Breast pain and redness

Breast feeding……continue

Start breast feeding from the affected side

If can not breast feed…..evacuate the breast with a pump

 shock:

Main clinical picture of shock:

Tachycardia

Hypotension

Only type of shock causing bradycardia……..neurogenic

Only type of shock with increased CVP………cardiogenic

Only type of shock increased CO………septic

Most common cause of cardiogenic shock……MI

Most common cause of hypovolemic shock……hemorrhage

Main ttt of neurogenic shock……iv pressors and fluid

Main ttt of septic shock……fluid and antibiotics

Main ttt of cardiogenic shock…….Inotropes

Main ttt of hypovolemic shock……….fluid resuscitation

Type of saline used in resuscitation……normal saline

If you need blood……….packed RBC'S ( O – low hemolysis)

First parameter changes with hge………pulse ( tachycardia)

When pulse increases with hge………losing 10-15% of blood

When blood pressure falls………losing at least 25% of blood

Fluid management:.vvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvv imp

Solution of choice for:

1-Intestinal operations…….Hartman solution

TIMING to give Hartman…….before operation

Main contraindication to Hartman ……….metabolic alkalosis

Intestinal obstruction+ metabolic alkalosis…..Normal saline of

choice….vvvvvvvvvvvvvvvv imp

2-other operations……normal saline 250-500 CC ( maintenance) +

deficit

Post operative fluid management:

Daily requirements………

3 liters ( 2 liters dextrose 5% +1 liter normal saline)

Deficit therapy……….given as normal saline

Potassium supplement………20mmol/liter vvvvvvvvvv imp

So minimum K requirements per day….60mmol/day

In case of hypovolemia due to vomiting:

Normal saline+20mmol K

Note: Urine output should be greater than 0.5-1.0ml/kg/hour

Old age + dehydration …….give normal saline to make urine output
more than 2ml/kg/hour

Most common cause that calculation shows input doesnot equal

output…..Error

Most common cause that output more than input in the fifth day
……resolution of paralytic ileus

Post operative oliguria:vvvvvvvvvvvvvvvvvvvvvvv imp

Most common cause…….post renal obstruction ( functional)

Second most common cause……..dehydration

So the first step in ttt……..catheterization

First inv ……………US …..VVVVVVVVVimp

If no urine after catheterization……iv fluid

 Burn:

Rule of 9 in burn:vvvvv imp

Head and neck……9%

Whole arm…………9%

Front of arm……..4.5%

Front of chest and abdomen…..18%

Back of chest and abdomen…..18%

The whole leg……..18%

Front of the leg only…….9%

Perineum……1%

Types:

First degree…..only epidermis

Second degree…..epidermis and part of the dermis

Third degree…..the whole skin

Most painful burn……first

Painless and white burn……full thickness

Complications:

Early:

1-Asphyxia due to inhalation

Best ttt…….intubation

If you find soot……..intubation

2-hypovolemic and neurogenic shock

3-stomach and duodenal ulcer ( curling ulcer)

due to stress…….acute erosive gastritis

Late complications:

1- Infection:

Most common cause of death

Timing……..5-7 days

Most common organism….pseudomonas

2-eschars:

Immediate step …..escharotomy ( not fasciotomy)

3-laryngeal edema

TTT…….intubation

4-malignant transformation……marjolin ulcer

MANAGENT OF BURN:

FIRST STEPS:

AIRWAYS

Soot in the airway……intubation

Burn of the head and neck……intubation

RESUSCITATION:

TWO FORMULA'S

1 ml/kg/% normal saline + 1 ml/kg/% colloid+ 2000 ml glucose

Or

Lactated ringer 4 ml /kg%....... half the amount the first 8th hs

and the other half for the next 16th hs

prognosis:

1-surface area……most important vvvvvvvimp

2- Depth

3-.site…..face is very serious

4-age….elderly and children are most susceptible

Complications of the central venous catheter:

1-INFECTION

Most common complication

Organism…..staph

Cp…..pain and pus around the catheter

TTT…..removal of the catheter vvv imp

Antibiotics

2-pneumothorax

3-thrombosis

Site……upper limb thrombosis

Inv………duplex

TTT…..iv heparin

Complications during CVP removal?????

1-Dislodgment of thrombus 2-vessel injury

Cp:………marked swelling of face and neck

Inv………..CT with contrast……….vvvvvvvvvvvvvvvvvvvimp

 Miscellaneous topics:

Necrotizing fasciitis:

Risk factor…..DM

After surgery

Organism…streptococcus pyogenes

Skin coloration

Main ttt……debridement

antibiotics

Gas gangrene :

Organism….clostridium perfringens

Source…infected wound

Cp:

Lacerated wound

Swollen wound with gas pain and

numbness

Black muscle

Offensive odor

TTT:

Debridement…most imp

Oxygen, antibiotics
Spenectomy:

Indication :

1- Chronic ITP

2- Hereditary Spherocytosis

3- Hypersplenism

4- Lymphoma

Complication:

Infection….. Pneumococcal , Meningecoccal and hemophilus

Infleunza….most common

Prophylaxis •

1-Pneumococcus vaccine……..most important vaccine •

Timing……..2-3 weeks after surgery and every 5 ys •

2-Influenza…….annualy •

3-Meningococcus…..every 5 •

Antibiotics…..long acting penicillin •

IN AMC 3 types of patients must be given influenza vaccine:

Pregnant……any timing

Old age……annually

Splenectomy……annually
Dehiscence of abdominal incision:

Complication……evisceration

Timing…..7th-8th day after surgery

Cp….. serosanguinous discharge

Blood stained fluid comes in dressing

TTT……emergency

No evisceration……conservative ( abd.
Strapping)

Evisceration………urgent surgery

How to deal with lacerated deep wound?

First step…….debridement

Antibiotics

Tetanus toxoid and IVIG according to the schedule:

N:B:
If patient received tetanus toxoid within past 4 weeks and now presents
with lacerated wound…………DONOT give another dose
Cancer tongue:vvvvvvvvvvvvvvvvvv imp

Old age male smoker…..vvvvvvvvvv imp

Type of cancer………SCC

Premalignant lesion…….leukoplakia

Cp……. Bloody stained saliva VVVVVVVV IMP

Dysphagia with enlarged cervical LN

INV:

BIOPSY……….main inv

CT …..for metastasis

TTT…..SURGERY AND RADIO

Cancer larynx:

Cp:

Middle aged male smoker with hoarseness of voice

Most common risk factor……smoking

Exam……swelling in the neck

Type…….scc

Main inv…….indirect laryngoscopy

CT…..for metastasis

TTT…..surgery and irradiation

Insulinoma:……whipple's triad

Attack of hypoglycemia

If you measure blood glucose level……low

Symptoms relieved by glucose

TTT……surgery

RECTUS SHEATH HEMATOMA

Cp: hypovolemic shock with weakness,
confusion, pallor
Inv…………CT with contrast

TTT……….Evacuation of the hematoma

If patient on warfarin…………immediate fresh

frozen plasma

Zenker ( pharyngeal ) diverticulum:

Old age male

Site….. More in the left side

Cp……dysphagia, regurgitaion

Swelling in the neck

Inv… Barium swallow

TTT……myotomy with excision of the

diverticulum
N:B:

Timing to give antibiotics before the operation…….one hour

Most imp sign after head injury…..level of consciousness

Least cancer causing metastasis to the brain….prostate

Most imp inv in preoperative staging of gastric
adenocarcinoma is …….. PET scan
Pt returned from Thailand 7-10 ds ago develops diarrhea, abdominal pain…. Dx:
giardiasis

TTT of giardiasis: metronidazole OR albendazole

Pt returned from Thailand 1-2 ds ago now develops diarrhea, abdominal pain….
Dx: E-coli (MCC of traveler diarrhea)

TTT: supportive (fluid replacement)

Giardiasis… long incubation period (manifestations after 1-2 Ws)

E-coli………. Short incubation period (manifestations after 1-2 Ds)

Pt returned from Thailand develops headache, rash, join and muscle pain, lab
shows low platelets… Dx: dengue fever

Pt returned from Thailand develops headache, rash, join and muscle pain, lab
shows normal platelets, low RBCs… Dx: malaria

Jaundice………..exclude rash

Malaria: after weeks + normal platelets

Dengue: after few days + decrease platelets

Most imp inv of malaria: thick and thin blood film

High clinical suspicion of malaria& -ve test… Next step: repeat the test

Chemical prophylaxis against malaria:

1st line/ DOC for prophylaxis…………….…….. doxycycline

DOC in pregnancy……………………………......... choloroquine OR quinine+ clindamycin

MC complication of malaria in pregnancy: low birth wt

MCC of low birth wt……………………. Smoking

MCC of teratogenicity………………… Alcohol

Pt returned from Thailand develops bloody diarrhea… Dx: entamoeba histolytica

Young Pt with prolonged H/O bloody diarrhea… Dx: UC

Pt returned from Thailand develops bloody diarrhea. One month later, he

develops fever, RUQ pain… Dx: amoebic liver abscess

Pt with prolonged H/O GB disease develops fever, RUQ pain… Dx: acute
cholecystitis

Pt with prolonged H/O GB disease develops fever, RUQ pain& jaundice… Dx:
acute cholangitis

Amebic liver abscess vs Clonorchiasis…..vvvvvv imp

Both of them ………………… Fever, jaundice and Rt upper quadrant pain

Amebic abscess ……………. GIT symptoms 1st then hepatic symptoms

Clonorchiasis ……………….. Hepatic symptoms only

Inv of choice of typhoid: Widal test; sample from

First week……..blood culture (+)………..it is the inv of choice

Second week…..stool culture(+)

Third week……..urine culture

You suspect typhoid in pt and asked for stool culture which came –ve… Next step:
blood culture.

Most imp measure to prevent typhoid infection: hand washing

1st line TTT of typhoid: ciprofloxacin

Pt < 18 ys: TMP-SMX

MCC of death during travelling: accidents

MCC of traveler diarrhea: E-coli

Vaccines recommended to travelers:

Hepatitis A, HEPATITIS B, BCG, Typhoid & Malaria.

Female will travel to china and will stay in five stars hotel, which vaccine is most
imp to be given to her: BCG

Only vaccine that is compulsory before hajj………meningococcus

Vaccines recommended to pregnant:

Influenza inactivated …………….most imp

Hepatitis B & TdaP.

Pregnant Female will travel to china and will stay in five stars hotel, which vaccine
is most imp to be given to her: influenza

Vaccines to be avoided in pregnancy:

MMR, Human-papillomavirus& varicella.

Vaccines recommended to elderly:

1-influenza……every year

2-pneumococcus

Vaccine to elderly to adult to protect newly born……dtap

Fever of malaria……..paroxysmal ( NOT daily )

Severe colicky flank pain radiate to scrotum, labia, groin with nausea& vomiting
and may be hematuria… Dx: renal colic (kidney stones).

Best inv of kidney stones: CT scan.

Renal stones in pregnancy: US.

Inv should be done before surgery: x-ray “KUB”.

MC type of renal stones: Ca oxalate.

TTT of kidney stones according to its size:

- <5mm ………………… conservative TTT (good hydration).

- 5mm- 2.5Cm ……… ESWL.
- >2.5Cm ……………… surgery.

Best analgesic outside hospital: NSAIDs.

Young pt complains of flank pain asking for strong analgesic ……….first step drug
screen by urine analysis ……take sample in front of you

Do u need to decrease Ca level in diet with Ca Oxalate stones………….nooooooo

Recurrence rate………50%-70% within 1-2 years

Definitive treatment of:

1. ureteric stones : First line of ttt…………….Ureteroscopic laser lithotripsy for

stones at any level.
2. Kidney stones:
- If less than 2 cm………ESWL
- More than 2 cm……… Percutaneous nephrolithotripsy
- Staghorn stone………………….. Open nephro- or pyelo-lithotomy

MC absolute indication of surgery in renal stones: obstruction& infection.

Most common cause of fever after urology procedure…bacteremia

Empirical antibiotics……….amoxycillin and gentamycin

2nd MCC of painless hematuria in adult: cancer kidney.

Hematuria+ flank pain+ renal mass in old age… Dx: cancer kidney.

Old male with Varicocele that don’t empty in recumbency: cancer kidney.

Inv of choice of cancer kidney: CT.

Incidentally discovered renal mass management:

1.If old age:

- First step……….active surveillance
- Imaging of choice for surveillence………CT
- TTT of choice………Total nephrectomy
- When laparoscopic partial nephrectomy can be done??????
 small tumour in one kidney (less than 4cm)
 Cancer in both kidneys
 Only one working kidney.
- What if metastasis????
 Total nephrectomy followed by immunotherapy

2. If young age :

- Active surveillance is NOT generally recommended for young patients

Hematuria &flank pain in trauma pt… Dx: kidney injury.

Inv of choice: CT with contrast.

TTT: conservative (most cases heal spontaneously), laparotomy for unstable pt.

Blood at urethral meatus in trauma pt… Dx: rupture of urethra.

1st step: retrograde urethrography. (catheter is a super wrong answer).

Pt with HTN, hematuria, bilateral flank mass… Dx: PKD.

1st inv: US. Best inv: CT.

Sudden severe headache in pt with PKD… brain CT (risk of rupture berry
aneurysm= SAH).

MCC of death in pt with PKD: renal failure.

Fever, chills, ++WBC, Urinary urgency and dysuria + Tender prostate on exam…
Dx: acute bacterial prostatitis.

Best inv…………..mid stream urine collection

TTT…………ANTIBIOTICS.

1st symptom of BPH……………………. nocturia.

Most imp inv. Of BPH…………………. US.

Most imp medical TTT of BPH…………..… Alpha blockers.

TTT of severe cases of BPH…………………. TURP surgery.

MC complication of TURP surgery……… Bleeding.

Most serious complication of TURP surgery: TURP $ (water intoxication&

hyponatremia).

Enlarged prostate with cancer suspicion… 1st step: PSA, 2ND: TRUS with biopsy.

Old pt with prostate cancer not fit for surgery: watchful waiting.

TTT of prostate cancer:

1. Focal………………………………..………………….. Radical prostatectomy.

2. Local metastases…………………………………. Radiation.
3. Gleason score less than or equal 6……… Radical prostatectomy.
4. Gleason score of 7………………………………. Radiation.
5. Gleason score 8……………………………………androgen ablation

Pt ask for screening of prostate cancer:

1st step: counseling that it is not recommended

If pt persist: do it. ( only PSA ) …..DRE not recommended any more

Old male with back pain and mild anemia +

1. High Ca level………………… Dx: MM

2. Normal Ca level…………… Dx: prostate cancer with bone metastases.

Pt feel dragging pain at upper pole of testis,u felt bag of worm while palpating
pampiniform plexus of vein…..Dx: VARICOCELE.

Most imp inv of varicocele: semen analysis.

Young pt, long standing H/O varicocele which empty on scrotum elevation:

Dx: 1ry varicocele. Confirmatory Inv of 1ry varicocele: US.

Old pt, short standing H/O varicocele which doesn’t empty on scrotum elevation:

Dx: 2ry varicocele. Inv of 2ry varicocele: CT scan.

1st inv of Infant with scrotal swelling: transillumination test.. +ve.

Inv of choice of hydrocele: US.

TTT of hydrocele: observation (no TTT before the 1st year).

Kid with painless edema affecting penis and scrotum………idiopathic edema

Fever+ pain, swelling, redness of scrotum… Dx: epididimo-orchitis.

MC organism causing epididimo-orchitis: E-coli is the MC overall, Chlamydia in

pt<35 ys.

Inv of epididimo-orchitis: UA & culture.

Painless swelling in young adult, you can get above it with +ve transillumination
test… next step: US. (Cystic dilation; image of US in exam)…..Dx: epididymal cyst.

1st step in management: Tumor marker: you must exclude cancer in young pts…
VVV imp.
2nd step: Review after 3-6 ms.

If u decided to do surgery: trans-scrotal approach.

Pt with transverse testis (photo on exam not clearly mentioned) is at risk of:
testicular torsion.

Young male with sudden severe testicular pain= testicular torsion until proven
otherwise.

TTT of testicular torsion: urgent surgery in < 6hs without investigations.

Infant with undescended testis: surgery before 12 ms (risk of malignancy).

MC association with undescended testis: inguinal hernia.

Painless enlargement of testis in young adult= testicular cancer until proven

otherwise.

Inv of choice of testicular cancer: US (biopsy is contra-indicated).

Most imp inv for pt with confirmed testicular cancer: abdominal CT (para-aortic
LNs).

First tumour to look for in testicular cancer ……….alpha feto protein

If you decide surgery………transinguinal

TTT of seminoma: radiation (very radio-sensitive)& surgery.

TTT of metastatic testicular cancer: chemo& surgery.

1st MCC of painless hematuria: cancer bladder.

Inv of choice of cancer bladder: cystoscopy& biopsy.

2nd MCC of painless hematuria: cancer kidney.

Inv of choice of cancer kidney: CT scan.

MCC of painful hematuria: kidney stones.

Inv of choice of kidney stones: CT scan.

Inv of choice of kidney stones in pt with PKD: US.

If immigrant from sudan, somal with painful hematuria: bilharziasis.

If immigrant from sudan, somal with painless hematuria: cancer bladder.

Sequence in painless hematuria???

1st step ………urine Analysis and culture

If normal……….then CT
Pt with H/O MI presents with acute severe pain in his leg… Dx: acute limb
ischemia.

1st symptom……………. pain.

1st sign………………………. pallor

Last symptom…………. paresis.

MC source………………. heart.

MC site…………………… bifurcation of aorta.

1st step in management/ 1st inv to be done: duplex scan.

1st medication to be given/ 1st step in TTT: IV heparin immediately.

Definitive TTT: embolectomy.

Severe swelling of lib after embolectomy… Dx: compartment $.

TTT of compartment $: emergent fasciotomy.

After embolectomy, EKG shows hyperacute T-wave... Dx: hyperkalemia.

TTT of hyperkalemia with significant EKG changes: immediate Ca gluconate.

Pt with bleeding after arterial catheter… Dx: arterial injury.

1st step in TTT of arterial injury: pressure to stop bleeding.

Definitive TTT of arterial injury: surgery…. …VVV IMP.

Pt with intermittent claudication (pain with walking relieved by rest)… Dx: chronic
limb ischemia.

1st step in management of pt with chronic limb ischemia: Ankle Brachial Index
(ABI)… normal ABI: >1.

ABI<0.5= urgent refer; absolute indication of arteriograpghy.

Most serious symptom of pt with chronic limb ischemia: rest pain.

Most imp TTT of chronic limb ischemia: gradual exercise program.

TTT of acute limb ischemia: angioplasty& stent.

MC complication after bypass graft: restenosis.

MC risk factor of PAD: DM.

Mechanism of PAD caused by DM: microangiopathy.

Limb ischemia + intact pulsation= small vessel thrombosis.

Most imp cp of abdominal aneurysm……..pulsatile abdominal mass

Serious signs in aortic aneurysm……..hypotension or pain referred to back

Initial Inv of abdominal aortic aneurysm or If unstable: US.

Inv of choice of abdominal aortic aneurysm……..CT

MCC of foot ulceration with diabetes…..neuropathy

Most common sites……pressure areas (MC site: head of 1st metatarsal & 2nd MC
site: heel).

Most effective way to protect from risk of amputation in smoker pt with DM,
HTN, hyperlipidemia: leg caring

Sequence of ttt in diabetic ulcer:

1st and most important step…….debridement

2nd step………..antibiotics

If clear ulcer with clear discharge………just dressing

Best inv to exclude marjolin ulcer or malignancy….biopsy

Most imp inv to exclude osteomyletitis…..MRI

Young smoker healthy male need leg amputation: buger’s disease.

TTT of choice of Pt with recurrent TIA caused by carotid stenosis: surgery carotid
endarterectomy (not stent)

Indications of surgery for pt with carotid stenosis:

1. Symptomatic pt with >50% stenosis.

2. Asymptomatic pt with ≥70% stenosis.

Pt with red, hot tender, swollen superficial v. which felt cord-like on exam=
superficial thrombophlebitis.

TTT of superficial thrombophlebitis: compression by elastic stocking.

Pt with superficial thrombophlebitis is at risk of DVT (give LMWH; proph. Dose).

1st step in management of Pt with RF of DVT presented with swelling, pain&

tenderness: duplex scan.

Most reliable sign of DVT………..swelling

1st step in TTT of DVT: LMWH immediately.

Long term TTT after LMWH: warfarin for 3-6 ms with target INR of 2-3.

Pt on warfarin, no bleeding, INR>9…… Give FFP.

Pt on warfarin, major bleeding………… Give FFP.

Pt on warfarin, emergent surgery……. Give FFP.

Pt on warfarin, elective surgery………. stop warfaring 5ds before surgery.

Pt on aspirin, emergent surgery….. Give platelets.

Pt on aspirin, elective surgery….. stop aspirin 5ds before surgery.

LL Swelling, pain, tendress +

1. High grade fever……………………………………………..cellulitis

2. Low grade fever+ H/O DVT…………………………….. DVT
3. High INR in pt on warfarin……………………………. Hematoma
Most common site for ischemic ulcer……….tip of fingers

Most common site for neuropathic ulcer……head of 1st metatarsal

Most common site for venous ulcer……against medial malleolus

Is ischemic ulcer painful………..yesssssssssss

Is neuropathic ulcer painful……..nooooooooooo

Is venous ulcer painful…………..noooooooooo

Main ttt of venous ulcer……..compression stoking and elevation of leg

Are antibiotics being used for venous ulcer??….noooooo

Most imp to prevent complication in foot of diabetic patient …..well care of the
foot and well glycemic control

Classification of foot ulcer:

Mild……erythema less than 2 cm

Moderate…….whole erythema at leg or pus at the ulcer
Severe………systemic manifestation like fever

Management:

Mild………..outpatient oral antibiotics

Moderate……outpatient intravenous antibiotics

Severe………inpatient intravenous antibiotics

Drugs need to be stopped before operations:

Warfarin........5-7 days

Aspirin and clopidogrel and NSAIDs........5-7 days

Amitryptillin.....5-7 days

Metformin.......1 day
Substance Abuse/Dependence

Substance abuse:
1-Failure to fulfill responsibilities at work, school, or home.
Use in physically hazardous situations (e.g., driving while
intoxicated).
Legal problems during the time of substance use.
Continued substance use despite recurrent social or
interpersonal problems

Substance dependence:

Failed attempts to cut down use or abstain from the substance.

Significant time spent obtaining the substance (e.g., visiting

many doctors to obtain a prescription for pain pills).
■ Isolation from life activities.
■ Taking greater amounts of the substance than intended.
■ Continued substance abuse despite recurrent physical or
psychological problems 2° to the effect of the substance use.

Tolerance and use of progressively larger amounts to obtain

the same desired effect.

Withdrawal symptoms when not taking the substance.

■

Types:
Stimulants …….amphetamine, methyamphetamine, cocaine, ectasy
Hallucinogens…….LSD
Opioid………HEROIN AND MORPHINE
Phenycyclidine
cannabis

14
 Morphine:
Intoxication:
CNS depression,
Constipation,
pupillary constriction,
Respiratory depression

Antidote:……Naloxone/naltrexone
For rehabilitation………..methodone

Morphine withdrawal:
Lacrimation
rhinorrhea,
Yawning
Diaphoresis,
Dilated pupils,
piloerection
myalgias
Nausea, vomiting, stomach cramps,
diarrhea,
ttt………methadone

Benzodiazepines intoxication
Interactions with alcohol
Amnesia, ataxia, somnolence
Respiratory depression
Paradoxical agitation

Benzodiazepines withdrawal…..with long term

benzodiazepines
Rebound anxiety,
Seizures,
Tremor,
Insomnia,

15
Amphetamines Intoxication:
Psychomotor agitation
Hypertension,
pupillary dilation
Tachycardia
Fever
Most common sign…….. Psychosis followed by hallucination.
Best management for amphetamine psychosis..benzodiazepine

AMPHETAMINE WITHDRAWAL:
Most important sign of amphetamine withdrawal……paranoia

Cocaine toxicity:
Psychomotor agitation
Euphoria, impaired judgment,
Tachycardia,
pupillary dilation,
Hypertension,
Paranoia,
Hallucinations,
Sudden death.
ECG changes from ischemia (“cocaine chest pain”)

N:B:
Effect of cocaine oh brain…..stroke
Effect of cocaine on nose…..septal perforation
Effect of cocaine on heart…….MI
Effect of cocaine on skin…..bugs under skin
Effect of cocaine on placenta…..abruptio placenta
Effect of cocaine on fetus…..teratogenic
Effect of cocaine on fetus…..low birth weight.

16
Phencyclidine hydrochloride (PCP):
Same as cocaine and amphetamine +
Vertical/horizontal nystagmus

LSD
Marked anxiety or depression,
Delusions, visual hallucinations,
pupillary dilatation
Tachycardia,
Hypertension,
Heightened senses (e.g., colors become more intense).

Marijuana
Euphoria,
Slowed sense of time,
increased appetite
Dry mouth,
conjunctival injection,

ACTIVE FORM……..tetra hydro cannabinoid

THERE ARE SPECIAL RECEPTORS FOR CANNABINOIDS IN THE
BRAIN

N:B:
Cannabis induced psychosis>>>……..
If any patient addicted on cannabis developed
psychosis…….first step stop cannabis intake

Cannabis induced akathesia:

First step……………stop marijuana

Most common drug used in parties ………. Ecstasy (MDMA)

17
1st step in management of trauma pt.. Secure airway.

Trauma pt with GCS <8: intubation.

Pt with Trauma of head & neck develop hoarseness of voice: intubation.

Burn at face of the pt: intubation.

Trauma pt with soot at airway: intubation.

Pt with sever status asthmaticus not controlled by medications: intubation.

In all above cases if intubation failed, next step: cricothyroidotomy.

Tracheostomy is only done at the OR (never anywhere else).

Pt with severe head& neck injury: suspect cervical neck injury.

1st step in suspected cervical neck injury: cervical collar.

How to maintain airway in cervical neck injury: ETT.

1st indicator of hypovolemia: pulse change

1st step in management of hypovolemia in trauma pt: IV line& normal saline.

2nd step: packed RBCs “after cross matching”.

IV line> saline> cross matching> RBCs.

N.B. RBCs 1st for hypotension if it is ready

Change in blood pressure in trauma pt indicates z pt lost at least 20-25% of IVV.

Trauma pt with hypotension, congested neck Vs, distant heart

sound……………...Dx: cardiac tamponade.

X-ray of tamponade: enlarged cardiac shadow.

TTT of tamponade: emergent pericardiocentesis.

18
Trauma pt with dyspnea, absent breath sound and hyperresonance in one side of
lung with tracheal deviation to the other side.. Dx: tension pneumothorax.

1st line in management of tension pneumothorax: needle thoracotomy.

N.B. 2 imp wrong answers about 1st line TTT on are O2, tube thoracotomy.

Pt with chest trauma, wide mediastinum in CXR: aortic rupture.

TTT of aortic rupture: emergent surgery.

1st step TTT of pt with rib fracture, severe pain, can’t breathe: IV morphine.

Pt with chest trauma, paradoxical movement of segment of thoracic wall, CXR

show multiple contiguous rib fractured ribs… Dx: flail chest.

TTT of flail chest: pain control, strapping of chest, mechanical ventilation.

Head trauma pt with echymosis around eye, behind ear& clear fluid drippling
from ear, nose….Dx: basal skull fracture.

TTT of basal skull fracture: conservative (no abs, no packing, advice not to sniff).

Head trauma pt loses consciousness& then awake and appear normal then
mentally activity is gradually deteriorated.. Dx: epidural hematoma.

Most imp inv of epidural hematoma: CT (biconvex shaped hematoma).

TTT of epidural hematoma: emergent craniotomy.

Most imp n. to be affected in epidural hematoma: occulomotor n.

Head trauma pt (old or alcoholic pts who frequently falls) with chronic headache,
personality changes, gradual memory loss…….Dx: subdural hematoma.

TTT of subdural hematoma: conservative.

Inv of choice of subdural hematoma: CT (lens shaped hematoma).

Deep coma pt after acceleration-deceleration trauma, CT show diffuse small

bleeding at junction between gray& white matter: diffuse axonal injury.

19
1st step in management of any pt with increase ICT: CT scan.

Pt with signs of meningitis+ vomiting, papilledema.. CT before lumbar tap.

1st step in Pt with penetrating abdominal trauma: control site of bleeding.

2nd step: IV line and normal saline, then packed RBCs if needed.

Last step: exploratory laparotomy (removal of object only in OR).

“Pt with knife at chest”:

Low O2 saturation + hemothorax: intubation 1st.

Low O2 saturation + hypotension: intubation 1st.

Low O2 saturation + pneumothorax: needle thoracotomy 1st.

Normal O2 saturation + hemothax: chest tube 1st.

Normal O2 saturation + hypotension: IV line, normal saline 1st.

Remove the knife only in OR.

Failure of peripheral line in Infant, child with hypotension: intraosseous
cannulation in proximal tibia.

Blunt abdominal trauma “BAT”…….. VVV IMP”

1st step in management of BAT pt with H. instability: FAST exam.

1st step in management of BAT pt with H. stability: CT scan without contrast.

If FAST or CT scan show internal bleeding: laparotomy.

BAT pt with LUQ pain radiate to shoulder: splenic injury.

BAT pt with delayed hypotension: splenic injury.

BAT pt, H. stable with liver injury: conservative TTT.

BAT pt, H. stable with kidney injury: conservative TTT.

20
BAT at epigastrium: risk of stomach injury.

Pain of spleen, liver& GB pathology radiates to shoulder because of irritation of

diaphragm (phernic n. & supraclavicular n. have the same cervical nerve origin;
C 3,4).

1st step in acute abdomen with suspected perforated abdominal viscera:

abdominal X-ray (air under diaghram).

Air under diaphragm in x-ray = emergent laparotomy.

Inv of choice of esophageal rupture: gastrographin contrast esophagography.

Pt with colicky abdominal pain, persistent vomiting, absolute constipation (no

stool, no flatus)…. Dx: intestinal obstruction “IO”.

Abdominal exam in IO: distension, diffuse tenderness, hyperactive bowel sound.

1st inv of suspected IO: abdominal x-ray (multiple air-fluid level).

1st step of management of IO: NGT, IV fluid and abs (conservative TTT).

If no improvement after conservative TTT: surgery.

MCC of IO overall: hernia.

IO+ H/O recent abdominal surgery= post-operative adhesions.

IO+ sudden onset abdominal pain in old age= volvulus.

IO+ old age pt with anemia, wt loss = colon cancer.

IO+ chronic constipation in old age, recurrent LLQ abdominal pain: diverticulitis.

HO chronic constipation in nursing home resident old pt + intermittent SOILING +

full rectum in DRE…..Dx: fecal impaction.

TTT of fecal impaction: Enema.

IO+ sudden onset abdominal pain in old age, empty rectum in DRE… Dx: volvulus.

21
Abdominal x-ray in pt with volvulus: omega loop

1st step in management of sigmoid volvulus: endoscopic decompression.

If endoscopic decompression failed or perforation occurs: surgery.

1st step in management of cecal volvulus: surgery.

Attacks of abdominal pain during which child draws his leg toward abdomen + red
currant jelly stool… Dx: intususception.

Inv of coice of intususception: abdominal US.

Management of intususception: hydrostatic reduction (barium or air

enema)……….diagnostic and theraoeutic.

IO+ absent bowel sound (silent abdomen) & NO abdominal pain occurs acutely
after abd. surgery+ marked dilated intestinal loops in x-ray. Dx: paralytic ileus.

Imp causes of paralytic ileus: hypokalemia, spine fracture.

TTT of paralytic ileus: conservative.

Pt on antiparkinsonian medications develop sigs of IO.. Dx: pseudoobstruction.

Old pt with H/O chronic constipation develops fever, LLQ abdominal pain, faver,
tavhycardia…..Dx: diverticulitis.

Inv of choice of diverticulitis: CT scan.

Low grade Fever, anorexia, tachycardia, pain at rt iliac fossa= acute appendicitis.

Most specific sign of acute appendicitis: localized pain at Rt iliac fossa.

Inv of choice in appendicitis: CT scan.

TTT of choice of appendicitis: laparoscopic appendectomy

Pregnant pt with RUQ abdominal pain, normal LFTs, viral serology= appendicitis

TTT of appendicitis in pregnancy: laparoscopic: appendectomy.

22
MCC after appendix rupture: pelvic abscess.

10 ds after appendicitis, pt presents with painful defecation, fluctuant tender

mass in DRE…Dx: pelvic abscess.

10 ds after appendicitis, pt will +ve psoas sign… Dx: psoas abscess.

Young pt with chronic abd. Pain & bloody diarrhea..Dx: ulcerative colitis.

Long standing H/O Ulcerative colitis+ fever+ x-ray showing massive distended
transverse colon… Dx: toxic megacolon.

1st step in management of toxic megacolon: decompression, IV fluid& IV abs.

If failed: surgery.

Pt with Chronic AF& now has acute severe abdominal Pain and bloody
diarrhea……………… Dx: ischemic colitis.

Female, Fatty, Forty/fifty and Fertile pt with recurrent RUQ abdominal Pain
radiate to shoulder: biliary colic (GB stone).

Asymptomatic GB stone found accidently in US: NO TTT.

MC type of GB stone: cholesterol stone.

MC type of GB stone in pt with hemolysis: pigment stone.

Inv of choice of GB stone: US.

Asymptomatic GB stone found accidently in US BUT CBD is markedly dilated; next

step: ERCP.

Chronic GB stone& NOW severe RUQ pain, fever & leukocytosis: acute
cholecystitis.

Most imp inv of acute cholecystitis: US.

23
Most specific sign of cholecystitis in US: pericholecystic fluid,
GB wall thickness (GB stone is the most common wrong answer
for this Q).
TTT of acute cholecystitis: IV fluid, abs then cholecystectomy within 72hs.

Chronic GB stone+ severe RUQ pain, fever, chills & jaundice: acute cholangitis.

Best initial inv for acute cholangitis: US (show dilated CBD).

TTT of acute cholangitis: 1st>>IV fluid, 2nd>>abs, 3rd>> ERCP decompression then
cholecystectomy.

1st step in TTT of acute cholangitis: IV fluid.

Pt with H/O MI from 1-2ms, now cholecystitis: conservative TTT.. if failed:

pecutaneous cholecystectomy.

Best time of cholecystectomy in pregnancy: 2nd trimester. (there is increase risk

of cholestasis in pregnancy).

1st step in management of priapism: repeated saline flushing.

Management of fracture penis: immediate surgery.

24
 STATISTICS
__________________

INCIDENCE:
___________________________
. It is the frequency of new cases of a disease arising in a
population

. PREVALENCE: is the measure of all cases ( old and new) in the

population at a particular point in time.

Prevalence = (incidence) × (time)

,
Drug or measures prolong survival e.g. improved quality of
care………..increased prevalence but no effect on the incidence

. TYPES OF EPIDEMOLOGICAL STUDIES: vvvvvvvvimp

. CASE CONTROL STUDY (Retrospective study):

_______________________________________
. The cases and controls are assessed retrospectively to for the
presence of risk factor

. The researcher begins with a population with a certain disease

. Is very popular in exploring an exposure - disease association.

. group with the disease of interest are compared with an
similar group that is disease free.
25
Can incidence be measured……..no
Can prevalence be measured……no

. A Prospective COHORT STUDY:

__________________________________________
. Divides the study group into "exposed" and "non exposed" to the
risk factors.
. Each subject is then follow prospectively till the presence of the
disease.
. Is a prospective observational study in which groups are chosen
based upon the presence or absence of one or more risk factors.
. All subjects are then observed over time for the development of the
disease of interest.

Incidence can be measured……….yes

. CROSS SECTIONAL STUDY:

______________________
. Both the exposure and the outcome are studied at one point of time
(at one cross section of time).

. It allows determination of disease prevalence (the total number

of cases in a population at a given time).
. Disease incidence………. can't be determined.
.
.
RANDOMIZED CONTROL TRIALS:
. Type of experimental study.
. It is considered as the gold standard for studying the efficacy of a
treatment or a procedure.
26
AS you asses efficacy of a new drug or new procedure.

. A CASE SERIES OR CASE REPORT:

_____________
. A study involving only patients already diagnosed with the condition
of interest.
. It is helpful in determining the natural history of uncommon
conditions.
LEAST EFFECTIVE STUDY……….CASE REPORT OR SERIES

. A Retrospective cohort study:

_________________________
. Starts at some point between the exposure and the outcome.
. The researcher reviews the past records and classify subjects into
"exposed" and "none exposed" and then follow them until the
outcome.
. In a cohort study, the study subjects are free of the outcome at the
time a study begins.

CLINICAL TRIALS:
_______________
. Compare the therapeutic benefit of different interventions in
patient already diagnosed with a particular disease.
. Can't be used to determine disease incidence.

27
IN CASE OF NORMAL DISTRIBUTION: …………VVVVVVVVVVIMP
______________________________
. 68% of data --> within 1 Standard deviation from the mean ( mean
+/- 1 SD).
. 95% of data -->within 2 standard deviation from the mean (mean +/-
2 SD).
. 99.7% of data -->within 3 standard deviation from the mean (mean
+/- 3 SD).

Case Fatality Rate = no. of deaths(disease)/ tot no of

cases(diseases) * 100

What are absolute and relative risks?

Absolute risk of a disease is your risk of developing the disease over a time period

1 in 10 risk of developing a certain disease in your life. This can also be said to be
a 10%

Relative risk is used to compare the risk in two different groups of people.

28
How to calculate absolute risk from relative risk????

Say the absolute risk of developing a disease is 4 in 100 in non-smokers. Say the
relative risk of the disease is increased by 50% in smokers. The 50% relates to the
4 - so the absolute increase in the risk is 50% of 4, which is 2. So, the absolute risk
of smokers developing this disease is 6 in 100.

Say men have a 2 in 20 risk of developing a certain disease. Then, if a new

treatment reduces the relative risk of getting this disease by 50%. The 50% is the
relative risk reduction, and is referring to the effect on the 2. 50% of 2 is 1. So this
means that the absolute risk is reduced from from 2 in 20, to 1 in 20.

Absolute risk reduction (ARR)

Absolute risk reduction (ARR) is a way of measuring the size of a difference
between two treatments.
An example of absolute risk reduction
In a clinical trial of a drug to prevent migraines, 2 of 100 people taking the drug
experience a migraine (2%), compared with 4 of 100 people taking a placebo (4%).
The absolute risk reduction is 2%, because 4% − 2% = 2%

.
Q.Absolute risk of a disease is 6 in 100 ppl....relative risk for the disease is 50 %...a
new drug is introduced which will lower the risk by one third...what is absolute
risk with new medicine...
a-4%
b-6%
c-12%
d-33%
…………………aaaaaaaaaa

29
Number needed to treat (NNT)
This is the number of people who need to take the treatment for one person to
benefit from the treatment.

NNT= 1/ RATE IN UNTREATED- RATE in TRAETED

NNT = 1/ARR

Say the absolute risk of developing complications from a certain disease is 4 in 20.
Say a medicine reduces the risk of getting these complications by 50%. This
reduces the absolute risk from 4 in 20, to 2 in 20. In percentage terms, 4 in 20 is
20%, and, 2 in 20 is 10%. Therefore, the reduction in absolute risk in taking this
medicine is from 20% to 10% - a reduction of 10 percentage points. The NNT is 10.
That is, 10 people would need to take the medicine for one to benefit.

A medical condition is present in 12 out of 100 in one population. Relative risk is

25 %. A new drug is under investigation & desired to decrease the condition by
1/3. How many patients are needed for the study?

a. 200

b. 100

c. 33

D. 25…………………………… dddddddddddddddddddddddd

A medical condition is present in 8 out of 100 in one population. A new drug is

under investigation & desired to decrease the condition by 25% . How
many patients are needed for the study

1.25
2.50
3.100
4.200……………… bbbbbbbbbbbbbbbbbbbbbb

30
. META-ANALYSIS:
________________
. Is an epidemiologic method for pooling of the data from several
studies to do an analysis having a relatively big statistical power.
P-VALUE:

. For the study to be statistically significant:

The "p" value should be less than 0.05 (i.e< 5% chance the result
obtained were due to chance alone).

- e.g. "P" value is 0.01 means that (the probability of obtaining the
result by chance alone is 1%).

What does it asses…….efficacy

Important curve:

A……………..highest sensitivity
E……………..highest specificity
C………………highest accuracy

31
N:B: VVVVVVVVVVVVVVVVVVIMP
New cases in the community…..incidence
All cases in the community……..prevalence
Study asses incidence……..cohort
Study asses prevalence…..cross sectional
Neither incidence nor prevalence……case control
Least effective study……..case report
Experimental study for new drug…….RCT
Best place to get a sample for study………GP clinic

MOST IMPORTANT STEPS IN STUDY:

1-Double blind……neither the investigator nor the patient know
2-randomization…………for validity
Observational prospective study…….cohort
Compare 2 groups retrospectively…….case control
Study for disease in whole community…….cross sectional
Most important to asses with RCT……efficacy
. 68% of data --> within 1 Standard deviation from the mean ( mean +/- 1
SD).
. 95% of data -->within 2 standard deviation from the mean (mean +/- 2
SD).
. 99.7% of data -->within 3 standard deviation from the mean (mean +/- 3
SD).
Pooling of the data from several studies…... META-ANALYSIS
how to asses efficacy……p value
The best test for screening……..highly sensitive
The best test for confirmation……highly specific
The most accurate test…….high sensitivity and high specificity

Case Fatality Rate = no. of deaths(disease)/ tot no of

cases(diseases) * 100
- Raising the cutoff point of a diagnostic test --> decrease it's
sensitivity but increase it's specificity.
32
 - Lowering the cutoff point of a diagnostic test --> increase it's
sensitivity but decrease it's specificity.

Screening test should have ……….higher sensitivity

Confirmatory test should have……..higher specificity

Most important in effectiveness of study……..randomization

Most important in comparative study……..2 groups take the same
dose of the drugs

Point prevalence………number of patients divided by number of

population in certain time

LEAST IMPORTANT PART IN STATISTICS:

BIAS

. SELECTION BIAS:
_______________
. Results from the manner in which the subjects are selected for the
study
HOW TO OVERCOME……RANDOMIZATION

. OBSERVER'S BIAS
_____________________________________________________
. when the observer maybe influenced by prior knowledge or details
of the study that can affect the results.
HOW TO OVER COME……..DOUBLE BLINDING

. RECALL BIAS:

33
______________
POOR MEMORY OF THE RESPONDANT
. This is more common in case-control studies

RESPONDENT BIAS:
_________________
. Occurs when the outcome of the test is obtained by the patient's
response not by objective diagnostic methods (e.g. migraine
headache).

. MEASUREMENT BIAS:
___________________
. Occurs from poor data collection with inaccurate results.

. LEAD-TIME BIAS:
_________________
. Lead-time bias should be considered while evaluating any screening
test.
. It happens when two interventions are compared to diagnose a
disease, and one of them diagnose the disease earlier than the other
without an effect on the outcome (survival).
:
. Think of LEAD BIAS when you see " a new screening test" for poor
prognosis diseases like lung cancer or pancreatic cancer.

. CONFOUNDING:
______________
. Due to presence of one or more RISK FACTORS associated
independently with both the exposure and the outcome.
. For example: cigarette smoking can be confounding factor in
studying the association between maternal alcohol drinking and low
birth weight babies.
34
. Hawthorne effect:
________________
. It is the tendency of a study population to affect the outcome
because these people are aware that they are being studied.

. In order to minimize the Hawthorne effect, the studied subjects can

be kept unaware that they are being studied.

- Randomization is commonly employed in clinical trials its purpose is

to balance various factors (confounders) that can influence the
estimate of association between the treatment and placebo groups so
that the un-confounded effect of the exposure can be isolated.

. SENSITIVITY:
___________
. Sensitivity --> …the proportion of true +ve cases among all +ve cases
. Indicates the ability of a test to detect those patient with disease.

. SPECIFICITY:
___________
. Specificity --> the proportion of true -ve cases among all -ve cases
(Specificity = true -ve by the test/all-ve that are actually free).
. The higher the specificity the more likely that most healthy patients
will have a -ve test results.

- Raising the cutoff point of a diagnostic test --> decrease it's

sensitivity but increase it's specificity.
- Lowering the cutoff point of a diagnostic test --> increase it's
sensitivity but decrease it's specificity.

35
A. Positive predictive value (ppv) test:
--------------------------------------------------
. Describes the probability of having the disease if the test result is
+ve.
. The post-test probability of having the disease is directly related to
the PPv.
. If the PPV is 25% i.e low, consequently if the test result is positive,
then the post-test probability of having the disease is low.

B. Negative predictive value (NPV) test:

-----------------------------------------------------
. describes the probability of not having the disease if the test result
is -ve.
. A patient with high probability of having a disease will have a low
NPV.
. And a patient with a low probability of having a disease will have a
high NPV.
. If the NPV is 96 % this means that if the test result is -ve, the
chances of the patient to not have the disease is high (96%).
. And the chances of the patient to have the disease is low (100 - 96 =
4%).

. High cutoff --> Decrease sensitivity and Increase specificity.

. Low cutoff --> High Sensitivity --> higher negative predictive value
(NPV) --> decrease false -ve results (Ruling out probability).

. High cutoff --> Higher Specificity --> higher positive predictive value
(PPV) --> decrease false +ve results (Ruling in probability).

36
N.B:

. Increase sensitivity --> increase -ve predictive value (NPV) due to

(decrease false -ve results).
. Increase specificity --> increase +ve predictive value (PPV) due to
(decrease false +ve results).

.
test + a(TP) b(FP)
test - c(FN) d(TN)
SENSITIVITY = TP/ TP+ FN

SPECIFICITY = TN/TN+ FP

PPV - POSITIVE PREDICTIVE VALUE = TP/TP+FP

NPV- NEGATIVE PREDICTIVE VALUE = TN/TN+FN

ODDS RATIO = ad/bc

37
 Screening for hereditary hemochromatosis ( new guidelines) :

 WHO IS AT RISK?????

 All first-degree relatives of patients with haemochromatosis,
known mutation in HFE gene

 HOW TO DO SCREENING ????

Test for HFE mutations, transferrin saturation and serum

ferritin simultaneously

TO assess future and current risk of iron overload

When to start screening???

Only after 18 ys

What if genetic test is (+) ???

Test for HFE mutation in all the 1st degree relatives of this patient

what about the other relatives ( NOT 1st degree)????

First step :

Transferring saturation and serum ferritin concentration

When to say (+)????

Fasting transferrin saturation >45%

Fasting ferritin >250 µg/L on more than one occasion,

How to confirm???????

HFE mutations ……if (+)……referral for genetic counselling

when to test patient less than 18 ys one partent has mutation????

Should only be tested if the other parent has the C282Y mutation.

38
 Screening

Prostate cancer

How?........PSA

Is it recommended?......noooooo

When to do it?......only on demand

First step…..counselling about risks and benefits of screening

Second step…..do the screening

Most common complication after radical prostatectomy….erectile

dysfunction

Testicular cancer
For who?........history of cryptochidism, orchipexy

How?..............testicular examination

Recommended?.....nooooooooo

Colorectal cancer (CRC)

For who?

1-General population…..every 2 ys ……FOBT……..after 50ys

If FOBT (+)………….COLNOSCOPY

2-High risk??

HOW?........colnoscopy

When?.......after 50ys or 10 years younger than affected relative

How often? Every 2 -5 ys

39
Special cases:

Hereditary non polyposis colorectal cancer and lynch syndrome:

When to start?...... 25 ys

How ?......colnoscopy

How often?.....every 2 ys

Once abnormal leisions…….resection

Familial adenomatous polyps:

When?......12 ys

How?......colnoscopy

How often?.....1-2 ys

Genetic screening needs to be done after counseling

once polyps appear…..surgery

N:B

Consider offering FOBT till you start colonoscopy

PR is not recommended as screening tool for cancer colon

Two types of FOBT: guaiac and faecal immunochemical tests.

Immunochemical tests are preferred
Two or three serial stools should be tested
It is essential that any positive FOBT (including just one of the
samples,,,,,,,,COLNOSCOPY
Melanoma

Advice to the patient???

Avoid sun exposure

40
Skin examination+- photography………only in very risky pt

Self examination

Oral cancer
Not recommended

Do oral exam for high risk

Chlamydia screening:….depends largely on opportunistic screening

For who ???

All sexually active females aged 15–29 years

how often?

Every 12 months

how???

PCR ( FIRST CATCH URINE)

NAATs are highly sensitive and specific for chlamydia and

gonorrhoe

When Screening for men ??

Unprotected anal sex

Screening for cervical cancer: vvvvvvvv imp

How??........pap smear

A sample of the ectocervix – using an extended tip spatula – then

the endocervix, using a cytobrush

How often??.......every 2 years

For who?........18-20 years

Or 2 years after first sexual life

41
 Till when…….70ys who have had two normal Pap tests within the
last 5 years. or hysterectomy

Female over 70 asked for screening…screen her

Female over 70 have never screened before…screen her

Do lesbian females need screening…..yessssssss

Female with HPV vaccination needs screening…yess

Pap smear interpretations..vvvvvvvvvv imp

1- Atypical cells with infection...repeat after ttt of the

infection
Low-grade squamous intraepithelial lesions (LSIL)

 repeat Pap test in 12 months

 If the repeat test at 12 months shows LSIL….colposcopy.
 A woman aged 30 years or more with a Pap test report of LSIL,
without a history of negative smears in the preceding
2–3 years, should be offered either colposcopy or a repeat Pap
smear at 6 months

High-grade squamous intraepithelial lesion (HSIL)

 colposcopy

DYSPLAIA………COLPOSCOPY

Vaccination against HPV VVVVVVVVVVV IMP

HOW?.......Gardasil vaccine

Value …..protect against types 6,11,16,18

42
How many doses……..3

For who…..females 9-26

males 9 -26

women over age 26 years…….not recommended

Maximum benefit…..before starting sexual life

continue pap smear after vaccine??......yessssss vaccine doesnot

protect against all types of HPV

Sexually active female can receive vaccine…yessss

females with previous genital warts …..yesssssssss

Females with previous abnormal cytology….yessss

Lactating females……..yessssssssssss

Pregnant females?......nooooooooo

Immunocompromised females……nooooooo

Serology for HPV………..not recommended

Screening for ovarian cancer??

How??....CA125 AND US
For who??
. Lower risk………No screening

US and CA 125……NO longer recommended even in high risk 

……vvv imp

43
 Screening of breast cancer

When to do BRCA1 OR BRCA2 test? 

First step…….counselling about the test 
Positive family history (less than 50 years) breast or ovarian 

Breast and ovarian cancer in the same female 

Family history of male breast cancer 
Ashkenazi jewish 
Is breast self exam routinely advised??....noooo

Has no effect on mortality rate

Best diagnostic screening tool decreasing mortality in whole

preventive medicine……mammography

Screening for breast cancer:VVVVVVVVV IMP

Tool……..MAMMOGRAPHY

Routine:

All females from 50-74 every 2 years

Age 40-49…….only if she asked

Age more than 74…..only if she asked

When to screen at young age??

One first degree relative with breast cancer in age younger -1

than 50 years
2- two first degree relatives with breast cancer at any age -2
3- two second degree relatives less than 50 -3
2 first or second degree with the following: -4
Breast cancer less than 40 years
44
Bilateral breast cancer

Breast and ovarian cancer in the same female

Male breast cancer

Ashkenazi jewish

Blood pressure

For who???.............all population

Starting age?...........18 years

Frequency?...........every 2 years

Hypercholostoleremia:

For who?........all population

When?...........from 45 years

How?.........fasting blood lipid

Frequency?.......every 5 years

DM

For who ?........all population

Starting age?.......40 years

How?.................fasting blood glucose level

Frequency?.........every 3 years

Special groups?

1-aboroginal people………. high risk

Starting age?.......18 years

How?.................fasting blood glucose level

45
 Frequency?.........every 3 years

 2 - women with a history of gestational diabetes mellitus

 Or women with polycystic ovary syndrome
How?.................fasting blood glucose level 
Frequency?.........every 3 years 
 3- patient with impaired glucose tolerance test or impaired
fasting glucose

How?.................fasting blood glucose level 

Frequency?.........every 1 year 

4- if (+) family history:

FBG or HbA1c every 3 ys

Interpretation:

Fasting blood  <5.5 mmol/L: diabetes unlikely

sugar  5.5–6.9 mmol/L fasting: perform an oral glucose
tolerance test VVVV IMP
 7.0 mmol/L or more fasting (>11.1 non-fasting): diabetes
likely, repeat fasting blood sugar to confirm on a separate
day.

Oral glucose Before and 2 hours after a 75 gram oral glucose

tolerance test . If more than 11.1 mmol/L, diabetes is likely.
If between 7.8 and 11.0 mmol/L, there is impaired glucose
tolerance.
If it is less than 7.8 mmol/L, diabetes is unlikely.439
Glycated HbA1c of 6.5% is the diagnostic cut-off
haemoglobin
(HbA1c)

Screening for DM complications:

BP……….each visit
46
 Target……….vvvvvvv imp

Strict BP control is NO longer recommended

If no renal affection……….target BP less than 140/90

If renal affection or albuminuria……target BP less than 130/80.

DRUG OF CHOICE………ACEI

Foot…….. Daily self check….six monthly GP

HbA1c………..3-6 months

Gums…………6 m

LIPID……..every year

kFTs……….every year

Eye…………1-2 years

Medications review and self management education….yearly

Prevention of TIA AND STROKE:

If the source is the heart………..warfarin

If the source is the carotid……. aspirin

Hereditary haemochromatosis (HFE)

 WHO IS AT RISK?????

47
 All first-degree relatives of patients with haemochromatosis,
known mutation in HFE gene

 HOW TO DO SCREENING ????

First step :

Transferring saturation and serum ferritin concentration

When to say (+)????

Fasting transferrin saturation >45%

Fasting ferritin >250 µg/L on more than one occasion,

How to confirm???????

HFE mutations ……if (+)……referral for genetic counselling

when to test Children of C282Y heterozygotes ????

1- Should only be tested if the other parent has the C282Y

mutation.
2-until age 18 years unless symptomatic

Other first-degree relatives of C282Y heterozygotes should be

tested with iron studies. If these are positive…… referral for genetic
counselling

Screening for Glucoma????.....not v imp

For who???

 Family history of glaucoma (first-degree relatives)

Patients aged ≥50 years with:

 diabetes
 myopia
 long-term steroid use

48
 migraine and peripheral vasospasm
 abnormal BP
 history of eye trauma

Frequency?????

Ocular examination 5–10 years earlier than the age of onset of

glaucoma in the affected relative (A).

Inv of choice……. indirect ophthalmoscopy with a slit lamp

49
 PEDIATRIC KEY WORDS- SMART NOTES

KEYWORD RESPONSE KEYWORD RESPONSE

JAUNDICE DAY 1 HAEMOLYTIC ANEMIA Pertussis Give AbCS to all family members
ABO –RH - IX choice PCR NP swap to 3 wks\>3wks Serology
School 3 wks after cough 5 days after ABCS
H.SPHEROCYTOSIS
TX of choice (Erythro \ Azithro)
Prevention DTP
st
CI to DTPa encephalitis after 1 dose
All family members all ages DTPa \ABCS Erythro
JAUNDICE DAY 3 PHYSIOLOGICAL petechiae &bruises in child IX Factor 8
JAUNDICE DAY 7 DIRECT BIL > 20% TOT >3mth fever and grunts Acute bronchiolitis
(BILIARY ATRESIA ) (RSV- Infl A or B – Adenovirus)
JAUNDICE DAY 8 BREAST FEEDING low Sudani give Vit D & ca
st
( Tx increase Frequency) If seizures CT Head (exclude serious things 1 )
st
JAUNDICE DAY 8 BREAST MILK (D-Gluc.) Mom refused to vaccinate baby 1 counseling
(Tx hold then resume) Then REPORT
JAUNDICE DAY 8 HYPOTONIA –SMALL HEAD Preg.HIV mom refused HRRT Do nothing
(CONG.HYPOTHYRODISM)
>340MICMOL\DL BIL EXCHANGE Grunting or Class III or IV IV penicillins (or)
TRANSFUSION ceftriaxone/cefotaxime+\-
Doxycycline – Clarithro-ROXi
CAP if C.Pneum\M.pneum suspected
Pneumonia Mod Iv penicillin
Pneumonia Severe iv Flucloxacillin
>270micmol\dl PHOTOTHERAPY Head injury No DLC – 1 V Discharge
Head Injury –DLC- H- 1>V Observe 4 Hours
Head injury Severe CT urgent
BRONZE BABY S PHOTOTHERAPY SE Vomiting Of 4Wk to <6mth GERD
15 Eosinophils eosinophilic oesophagitis
Vomiting of 4wks of Cow milk CMPA
Vomit of cow milk<1h IgE mediated Food allergy

Jaundice – starvation GILBERT Salbutamol dose: 6 puffs if < 6 years old,

Bil < 100micmol\dl 12 puffs if >6 years old
GLUCURONIDE Decreased GILBERT Wheezy – Creps- fever 2y Bronchiolitis
TRANSFERASE Absent CRIGER NAJAR TX inhaled Salbutamol if >1y & oral
Unconj.BIL (TYPE I AR = DEATH) fluid > 50%
(TYPEII AD =MILD)
MRP2 DEF DUBIN JOHNSON >7mth cries at night w juices Inc solid food
(Age of weaning)
GLUT.TRANSFERASE ROTORS SYNDROME Somalian with OPV give IPV
NEONATAL SEPSIS G B STREPTOCOCCUS For missed Vaccine\ Overdue give now & Catchup
NEONATAL HYPOGLYCEMIA MATERNAL DM2 Whitish discharge around glans Ballanitis
TX Topical betamethasone
st nd
RX OF NEON.HYPOGLYCEMIA IV GLUCOSE Aboriginal Ear discharge 1 Aural Toillet 2 Cipro
rd
THEN IM GLUCAGON Ear drops 3 Surgery if T.M perfpration IX CT
Pull ear\Loss of Ear drum motion O.Media
Ix of choice Autoscopy ( for TM motion)

50
 CT if W aurical swelling (strept.Meningitis ?)
Tx 1-Paracetamol 2- Amox -3- Amoxclav After
th
recovery 4 Hearing assess after 2 mth
Choanal Atresia 1st step keep mouth open Altered M status from last night Check RBS
Choanal Atresia Test Failure to pass nasal cath Cleft lip – palate cc Genetics
Choanal Atresia IX CT WITH CONTRAST Cleft lip – palate SE Poor suckling
With crying Cyanosis improved Choanal Atresia No wheeze cough fever strep Pneumonia

Microcephaly- Pigmented CMV 12 mth cant sit Gross development delay

Retina –Hearing loss gross motor skills, such as crawling or walking, or
fine motor skills, such as using fingers to grasp a spoon
CMV IX OF CHOICE URINE AG IN BABY Wandering child in garden Ketone 3+ Ketotic
IGM IN MOTHER Hypoglycemia
White lesion in tongue baby (pull easily ) candida Steatorrhea- RTI Cystic fibrosis
Adult (not pulled) Rectal prolapse- RTI IX sweat test – Stool Analys
Leukoplakia Constipation- RTI
Cc constipation Diet
Compl. Of constipation Rectal prolapse TX Pelvic
Enema bowel trainig
Positional murmur in child innocent Cleft lip baby mother wants give up Call social
RX of innocent murmur Reassure – Refer If recurrent UTI… 1st US-..micturitingcystourethrography
RX umbilical granuloma Silver nitrate UTI Trimethoprim- T+S- Cephalexin 10d till2ys 7dif
older
Cc Inflammation umbilicus Staph DM 1 follow up Hba1c \6m – BMI \3m- Lipid\1y
Herniation of Umblical Viscera omphalocele Bark cough + fever IX Nasopharyngeal aspirate
Hern of Umblical Viscera W\o Sac Gastroschiasis Bark cough +no fever IX CXR
RX omphalocele NG air suction \gauze cover Contact with measles bfr rash MMR vaccine
Tongue tie SE Dec .SUCKLING not SPEECH Inv urination >5Y ENeuresis
Tongue tie TX window 2-3mth – 1-2ys Cc of Eneuresis Regeression –UTI
Cc of Cleft palate \Lip Genetics IX NXt of Eneuresis Urine C\S not Analysis
Fusion of baby Labia do nothing! Immediate TX Decompression spray Alarm clock
Cc Club foot Postural position TX of Choice of Eneuresis Alarm Clock
Int.Tibial\ med Femoral torsion TX observe Leg click w change Diapers+\- limbing Cong hip dis
3 dys Fever then RASH Roseola infantum( Test of cong hip dis Barlow\ Ortolani test
HSV6)
Koplic spots Measles Ix the best \>4mth US \Xray Frog Lat position
Koplic spots in GP clinic Notify TX of Cong hip Dis Pavlok Harness Maneuver
Slapped Cheek Erythema Infectiousum (5th) Pain long Duration morning improve Growing pain
th
5 disease in Sickle Aplastic (parvo B19) APGAR SCORE
th
SE Preg F in 5 disease Hydops fetalis Epistaxis by hot weather give vit K
Screening 5th disease IgG (IgM infected) Milk drinking abd pain –diahrea Lactose intoleran.
th
5 disease US baby Nxt Blood sample (severity) IX of Lac,intolerance Hydrogen breath test
School exclusion Parvo B19 NO Advice avoid Lactose contain product give Soy
based formula
Klinefilter s Genetics 47XXY BPPV episodes of Vertigo by head spinning
‫طويل صغير ال يخلف و متخلف‬ Inner ear problem
st
1 Audiology and ENT referral then Reassure
Turner genetics 45 XO Initial UTI ECOLI in child Nitrofurantoin-

51
 AmoxCLAV- Ceftriaxone- Genta 98- Cephalexin 97-
trimetho 86 – Sulpha 65
Turners IX FSH Laryngitis more with Viral than Bacterial tonsilitis
Turners TX HRT after Puberity To c renal scaring in VUR DMSA scan
Fetal Alcohol S &S Thin upper lip\absent short Labia fusion Reassure
Plithrum – MR If w\ Dusuria Estrogen cream \ surgery
Screen FAS in Preg. US Wheezy baby (grunt-tug) Bronchiolitis
Fever not more than 40 yes for 2-3 dys
Risk \ cc asthma \ RSV
TX O2+ NGF don’t use B.D \ Steroid \ABCS\adren
Cc CVS ANOMALY In FAS VSD Earache\fever\HL OM w Effusion
Safe Alcohol amount in preg unknown F8\F9 Haemophilia A\B (X-linked) M
diseased and Female carriers
Fibrillin gene –Eye lens subluxation Missed 12m vaccine Give now & catchup at 15m
Marfan
Marfan Genetics AD Missed MMR at 18m MMR now – MMRV aftr4wk
Blue sclera – elastic skin AD Ehlor Danlos Vomiting since birth +bilious duodenal atresia
Blue conj – multiple # Osteogenesis Vomiting Non bilous 2-6 wk CHPS by US
imperfecta
Dd of O.imperfecta child abuse Vomiting only GERD
Lip pigmentation-GIT S&S Peutz Jegher s http://www.racgp.org.au/afp/2012/may/gastro-
oesophageal-reflux-in-children/
P-J s screen and Genetics Colon C. \ AD Grandmother vaccinated dTAp- influ\y -V- CP-p-B
Obese Hypotonic ‫ابن ابوه‬ Prader Willi (ch15) Runny nose seizure fever Dx paracetamol F.Conv
‫ابن امه‬ Angleman S (CH15)
Vertebrae loss\Meninges Spina bifida occulta Hematuria proteinuria –URTI 10-14d
\spinal cord herniation Meningiocele- PSGN
M.myelocele School exclusion No School exclusion
,just restriction of protein & physical activty
IX AntiDNAse – ASOT – C3 – UA
TX Penicillin for 3-5d- Hydralazine- Lasix – CST
Abdomen mass in baby Wilms Tumor Floppy 4 month Prader Villi
UNIL- not cross midline
IX CT
Painfull Abd mass cross midline Croup – stridor –tracheal tug prednisolone oral
With periorbital echymosis Neuroblastoma Grunt-minor acssess.ms 1mg\kg review in1h
VMA best CT – Croup – stridor marked TT- G- C w retrac. =severe=
Surgery + RADIO Adrenaline neub 1:1000 via O2 then Prednisolone
1mg\kg 0r dexmethasonea 0.6mg\kg
Sign of severity restlessness and not
settling down
Baby flat head 6wks flat head syndrome or CSF with Hi Lymph- N Glu 1- HSV2 (hypodense
(positional plagiocephaly) both temporal – hi opening P 28cm)
2-Mumps HX of Mumps DX buccal 7d or PCR)
3-If adult -- Enterovirus
4-TB hi protein – Polymorph mainly lymph – Low
Csf\G ratio but brucellosis G normal

52
thalassemia minor trait ( AR) 50% have trait Meningitis+HypoNa dx SIADH
Recurrent Abd pain – V 2ys UPJ th
Advanced bone age ht +Wt 97 % +insulinemia
obstruction If CA > BA reassure
6puffs not relieved 12 puffs of salbutamol Dehydration 1st NGF
Molluscum no school exclusion Migraine 1st Paracetamol
Subconjunctival& epistaxis - rash Asthma prevention Fluticasone after advice
Diahrea after meal Stool Cs PCRl For awayfrom smoke- mould
E.coli
Hydrocephalus DX CT (FH\ID> 50%) best MRI Neonatal abstinence syn Fluctuating APGAR
Hyperreflexes – sweating

Delay 12mth cant stand unsupport,cant Long term TX asthma 1-SABA

understand no cant sit unsupported(check (Ventoline)
Gross Motor) ,rolled over at 6 months but 2-SABA + low dose CST < 800 (Fluticasone) inhaler
cant walk by himself. He cant play peek a boo. = Flunasa – Flixotide
Cant take His name, says dada n mama. cant 3-SABA + Mod dose CST <2000 (
say No. Cant sift object from one hand to Or LABA ( SERETIDE = salmetrol +Fluticasone) or
another. (Symbicort= Budesonide +FOrmetrol)
24mth SAY 2 Pronouns 4-LABA + CST 2000
Delay at 4 ys Milestone Cant hoop on one foot 5-LABA + Hi CST +\- oral pred – Anti IGE –
then Cant draw Montelucast
aface
Delay at 5 ys Milestone Skip and 2 bicycle spirometery before
IX of choice in Asthma
and after bronchodialators
Preventer FLuticasone inhaler
6 puff add 12 puff
SABA and not improved add oral steroid
Febrile conv risk Epilepsy in future ,white patch upper lobe of right lung
TX paracetamol
School exclusion in rash Until blister dry Stridor on lying back Tracheomalacia
Ist Q in Seizures . First attack?? Breast of mother engorged squeeze then proceed
At 6mth with breast milk iron fortified cereals
Juices obesity then dental cares
Chocking baby Slap on back no Hemlich maneuver
Removal of insect from ear Oil
If battery ingestion rapid removal by
oesophageoscope (fear of perforation)
Rash in buttock HSP 1st U analysis Microcephaly in premature CMV
Microcephaly in child +cataract +Maldev.Lmb
Varicella
multiple absc. since birth Check Neutrophils DKA complications Most common HypoG
Most Serious Cerebral Edema
Soft swelling in Umblicus Umblical hernia sudden red swollen scrotum Testes Torsion
Close by itself 1.5 cm in diam
Sudden cessation of motion staring eyes for 15 sec : Bilious vomi since 1st day Duodenal
+\- hand motion or spasm return to N Petit Atresia or stenosis
mal seizures ( Absence ) TX Ethux.V-a)
L Delay passage of meconium

53
 Hirschsprung’s disease

Limbing +Fat long HX SCFE Newborn After 1 minute suddenly stopped

compl Avascular necrosis TX surgery breathing, HR decreased, cyanosed No
URTI + limbing Tenosynovitis response on stimulation PPV Intubation
IX US not X ray TX NSAID & JT traction not NP Asp
Limbing + inc Jt space on XRAy Perthe s apgar 7 and 10 in 1 and 5 minutes
X ray frog Lat position Perthe s – SCFE respectively, after 1 hr he is cyanosed
and resp distress REsp. D. S.
Occipital deformity in skull change sleep postiton Child <10y DTPa not IVIG
Child >10y dTPA
Child>10y wound tetanus prone not vaccinated or
Uncertain IVIG
Varicella rash TX supportive No vertical transmission in Hep C Start breast feed
IGA nephropathy Ix of Choice biopsy Don’t start solid food <4mth Night breast feed
Bow legs (genu varum) Normal off at 2-3y Stress incontinence Pelvic ms training
DOWN s risk maternal age Non Accidental head injury must excluded in
Genetics triosmy 21 non Dysjunction Haemophilia scenarios
Recurrent rate 1% cc death ALL
Compl CVS endocardial cushion – VSD
GIT duod atresia \ endocrine Hypothyrodism
CNS Atlantoaxial jt subluxatioin
going surgery ?? explain to her procedures
DX during pregnancy by Amniocentesis
Nephrotic afebrile and HTN Renal A stenosis For DPT received 2 doses and coming Wounded
5 doses of DTPa- vaccine 4 children <10 years of age; 3
doses primary schedule for infants (recommended at 2, 4
and 6 months of age) and 2 booster doses (recommended
at 18 months and 4 years of age); . If the 1st booster
dose recommended at 18 months of age (dose 4) is
given after the child is 3.5 years of age, the 2nd
booster dose recommended at age 4 years (dose 5) is
not required
Other adult household contacts and carers of infants
<6 months of age
Adult household contacts and carers (e.g. fathers,
grandparents) of infants <6 months of age should
ideally receive a dTpa vaccine at least 2 weeks
before beginning close contact with the infant. A
booster dose of dTpa is recommended if 10 years
have elapsed since a previous dose.40,41

CREAM +fever Kawasaki Supracellar calcification – Panhypopituitirism

IX ECHO Craniopharyngeoma IX MRI
TX ASA for CAD (aneurysm) Infratentorial midline from Cerebellum
IVIG for Myocarditis Medulloblastoma
Drooling of saliva –thumb sign on Xray Old housing –Child memory loss – constipation

54
Epiglottitis TX admission intubation cricothyrod. >5MU\dl in child -10Mu\dl in adult Lead poisoning
Itchy anus E.vermicularis Cherry red Co TX hyperO2
Tx albendazole single dose Adhesive tape at
night
GTC SHW (Gala- Thales- Cystic- Sickle- Haemoc- Child paracetamol Acetamenophen Toxicity
Wlson) IX Level after 4 hr
A.recessive TX ,200mg\kg discharge >200mg\kg =paracetamol
25% healthy 50% carrier 25 % diseased level .blot on Nanogram – NAC TX
Strawberry tangue sand and pepper rash circumoral
pallor Scarlet fever ( Strept GA) –PSGN- TX
Penicillin
Vesicles in hand and foot oral Hand foot mouth
disease (COX v)
School exclusion till it dry
MMR vaccine 12 – 18 –school Vesicles in mouth \lip Herpes
If bring her son now missed give now Vesicles Post mouth spare lip Herpangina
Infection now no CI + IX for measles Measles vaccine No CI to egg allergy
Ascaris \ Ankylostoma TX Albendazole Vesicles all body crops Chicken POX
IO \ iron def School Exclusion till dried (5d after rash)
Tx Acyclovir Analgesics
Allergic rhinitis Night cortisone
Rash after drug + wheezness(resp) Anaphylxis
Rash after drug + Vomiting(GIT) Anaphylaxis
Rash after drug + hypotension(CVS) Anaphylaxis
TX Adrenaline IM
<6y 6-12ys adult >12ys
0.15 0.3 O.5 mg (1:1000)
If rash only ANtihistaminics

Recurrent Gingival abscess Chr G>disease Foreskin of oenus retracted and swollen
CBC Inc Neutrophilia Paraohimosis
TX urgent manual reduction \ Incision (circumcision)
Indicator of wt in baby BMI % chart Breast development bfr 3y Premature thelarche
>95 obese Cake eat then anaphylaxis NUTS
>80-95 Overweight CI to Influenza Egg allergy \Neomycin
Recurrent infection No IG Xlinked Brutons Premature babies NO CI to Vaccination

55
 :Emergency of surgery

:AIRWAY

____________

Establishing & securing the airway is always the 1st step in .

.management

Altered mental status is the most common indication for .

.intubation in a trauma pt

If GCS less than 8 …………intubate

In case of burn of the face first step………..intubation

In case of hoarseness of voice because of allergy or

burn……intubation

Case of severe asthma not controlled by medication first step

…….. Intubation

…………..intubationSoot in the airway

IF you failed to do intubation……..cricothyrodotomy

Tracheostomy is done only in the OR not the ER

Cervical neck injury:

First step………..cervical collar

How to maintain airway………..Endotracheal intubation

56
Hemodynamics changes with bleeding:

PULSE CHANGE IS THE FIRST INDICATOR FOR HYPOVOLEMIA .

Blood pressure occurs after at least loss of 20-25% of blood

First step ……………….iv lines (peripheral and central)

First fluid given to patient ……………normal saline

If you need to give blood……packed RBC'S is of choice

Drop of BP is an absolute indicate for blood transfusion

Pericardial tamponade

Cause distended neck veins & high central venous pressure .

Cp………… hypotension,

Distant heart sounds

Distended neck veins

.X-RAY………..Enlarged cardiac show (FLASK SHAPE) .

ECG………Electrical alternans .

.Pulsus paradoxus on vital signs .

.Tx -> immediate pericardiocentesis .

57
 :Tension pneumothorax

Distended neck veins & high central venous pressure

Respiratory distress .

Tracheal deviation,

.Absent breath sounds

.Percussion …………Hyperresonance .

Tx -> immediate placing of a large-bore needle or IV catheter .

into second intercostals space….VVVVVVVVV IMP
IF Sudden chest pain during pericardiocentesis…..pneumothorax….
do immediate chest x-ray

58
59
.

60
Traumatic aortic rupture

Cause ………….severe trauma to the chest wall

Site ………………usually at the descending aorta

Mortality rate ………..very high

X-ray…………….WIDENING OF MEDIASTINUM….VVVVV imp

TTT…………SURGERY

FLAIL CHEST.

____________________

61
Rib fracture:

Cp……..chest pain and dyspnea

TTT……..analgesic.......morphine is of choice ….vvvvvvimp.

If old age + rib fracture……..local nerve block

Flail chest:

.Major thoracic trauma

.Multiple contigious ribs are fracutred .

The pt takes shallow breaths due to severe pain .

.PARADOXICAL THORACIC WALL MOVEMENTS….vvvvvvvvimp .

Tx -> Pain control & supplemental oxygen are the most .

important steps……morphine is of choice

.Strap the chest…..vvvvvvv imp

.Positive pressure mechanical ventillation .

62
 :HEAD TRAUMA

CLOSED FRACTURE + NO SYMPTOMS……..NO TTT

COMMINUTED or DEPRESSED SKULL ………SURGERY .

.The 1st step …………HEAD & NECK CT with "OUT" contrast .

:# BASAL SKULL *
Ecchymosis around both eyes (Racoon eyes( .

Ecchymosis behind the ear (Battle's sign( .

Clear fluid drippling from the ear or nose (CSF leak) .

INV:……..CT scan of head & neck .

Fate... Most cases heal by themselves& requires no specific

ttt

NOOO Antibiotics

NOOO packing

NOOO sniffing

63
:EPI-DURAL HEMATOMA

Side head trauma .

Rupture of……… middle meningeal artery

CP:

1- H/O of head trauma & SUDDEN LOSS OF CONSCIOUSNESS. .

2- Honeymoon period (The period when the pt immediately

awakes & appears normal)

3- Pt typically has ipsilateral pupil dilatation due to oculomotor

nerve compression

(Cushing's reflex) = ++ ICP: VVVVVV IMP

Hypertension .

bradycardia

Respiratory depression

Complication ………..herniation of tentorium

First cranial nerve affected ………occulomotor nerve…..mydriasis

and ptosis

.Dx -> CT scan -> BICONVEX LENS shaped hematoma .

.Tx -> EMERGENCY CRANIOTOMY .

64
SUB-DURAL HEMATOMA

."bleeding from the "VENOUS SYSTEM……….bridging veins.

Head trauma with FLUCTUATING CONSCIOUSNESS i.e .

Gradual headaches,.

Memory loss,

personality changes,

Dementia, confusion & drowsiness

High risk groups :

Alcoholics………repeated falls

Old age………….brain atrophy

Typical scenario in AMC exam ……….old age with abnormal

behavior and personality changes with history of
fall………subdural hematoma

.Dx -> CT scan ->, concave CRESCENT .

.Tx -> CONSERVATIVE management with STEROIDS .

Emergency craniotomy ………..IF lateralizing signs & midline .

.displacement

65
*

66
:DIFFUSE AXONAL INJURY
Results from ACCELERATION-DECELERATION injuries to the
head

.The pt will be deeply unconscious .

Dx -> CT -> Normal or diffuse small bleeds at the junctions of .

.the grey & white matter

.CT -> Numerous punctuate hemorrhages .

!Prognosis is terrible .

.Surgery can't help .

)ELEVATED INTRACRANIAL PRESSURE (++ ICP ):

medical emergency ++

.Dx -> Head CT -> Midline shift or dilated ventricles .

Don't perform a lumbar tap in any pt before getting a head .

! CT 1st VVVVVV IMP

If you perform a lumbar puncture on a person with ++ ICT, .

! you will herniate the brain

Tx -> Head elevation……45 degree .

- Hyperventillation

. - Avoid fluid overload

.)Mannitol & furosemide )

.-> Sedation & hypothermia .

67
 ABDOMINAL TRAUMA

1-Penetrating:
1st step………….control the site of bleeding .

Apply direct pressure >-

Blind clamping & the use of tourniquet is NEVER >-

If an object embedded in the pt…….. NEVER to remove it .

Never remove it in the ER Only in the operating room under

.general anesthesia …vvvvvvvvvv imp

The next priority is………. FLUID RESUSCITATION

Type of fluid……normal saline

If you need to transfer blood the best is……packed RBC'S

if suspect organ rupture or severe internal bleeding ………

exploratory laparotomy

.Set up 2 large gauge IV lines >-

.Give fluids & blood >-

.Insert Foley catheter >-

What is the first step with knife at the chest???

Low O2 saturation….intubation then removal under GA

Low O2 saturation with tension pneumothorax….needle

thoracotomy 1st
Low O2 saturation with hemothorax……intubation 1st
Low saturation with low blood pressure……intubation 1st

68
Normal saturation with hemothorax…….chest tube 1st
Normal saturation with low BP……IV fluid followed by
cross matching
If low BP and blood is ready ……give blood immediately
Remove the knife only at the OPERATION ROOM
Donot remove the knife except after:
1-intubation
2-chest tube
1- General anesthesia
.N.B

Intraosseous cannulation in the proximal tibia is used in .

children

.Give an initial bolus of Ringer's lactate at 20 ml/kg .

2- BLUNT ABDOMINAL TRAUMA:

After a car accident of a restrained driver .

Most commonly affected organs…. spleen & liver and kidney

.CP of internal bleeding:

Hypotension .

Tachycardia

Abdominal wall ecchymosis

.Abdominal rigidity and tenderness

69
INV:

1-FAST exam -> (Focused assessment with sonography for .

trauma)…VVVVVVVV IMP

When to do it?.........unstable patient

value?? .

Detect hemoperitoneum, pericardial effusion or intraperitoneal

.fluid

If FAST is limited or equivocal -> A diagnostic peritoneal .

.lavage (DPL)

.DPL is done to evaluate for hemoperitoneum .

If +ve findings on either FAST or DPL -> exploratory .

.laparotomy

2-CT WITH CONTRAST:

When to use it?............stable patient

Value ?........the best to detect liver, splenic or kidney injury

Spleen injury: .

.Most common injured organ ……vvvv imp

.Left upper quadrant abdominal pain .

Abdominal wall contusion .

Lt Lower chest wall tendrness

Lt shoulder pain referred from splenic hemorrhage irritating .

phrenic nerve & diaphragm…..vvvvvv imp

70
Delayed hypotension may result due to Dislodged thrombus ..
….vvvv imp

.Dx -> Abdominal CT with IV contrast .

LIVER TRAUMA……….

MOST OF CASES HEAL BY CONSERVATIVE TREATMENT

If unstable patient……..laparotomy

KIDENRY INJURY:

Cause……….usually blunt trauma

Cp…….hematuria and flank pain

Inv……..CT with contrast is the best

If Unstable……..FAST

If ( +) fast …….laparotomy

TTT…….most cases heal spontaneously

N:B

Blunt trauma to epigastrium causes rupture of which

organ………….stomach

Bunt trauma to chest causes rupture of ….aorta and esophagus

Stable patient………CT with contrast

Unstable patient………FAST

If (+) FINDING ……….LAPAROTOMY

PENETRATING WOUND + UNSTABILITY…..LAPAROTOMY

71
 ACUTE ABDOMEN

PERFORATION:

GASTRO-INTESTINAL PERFORATION )1(

Acute abdominal pain that is sudden, severe, constant & .

.generalized

Most common causes of GIT perforations . :

a) Diverticulitis: Elderly pt with lower abdominal pain & fever

b) Perforated peptic ulcer: Epigastric pain waking up the pt at
night

c) Chron's disease

Dx -> Supine & erect abdominal x-ray (free air under .

.)diaphragm VVVVVVVVVVV IMP

.Tx -> Nothing by mouth (NPO) & IV fluid hydration .

Tx -> IV antibiotics .

.Tx -> Emergency surgery .

N:B:

Most absolute indication for immediate surgery in severe

abdominal pain……..Air under diaphragm

72
73
74
:ESOPHAGEAL PERFORATION )2(

Most common cause is IATROGENIC

Common cause at exam…….trauma

Pain in chest or upper abdomen .

Dysphagia or odynophagia .

S.C. emphysema shortly after endoscopy .

.It is a surgical emergency .

Dx -> GASTROGRAFFIN CONTRAST ESOPHAGOGRAM is the .

best (Do NOT use Barium xx) …….vvvvvvimp

75
 Intestinal obstruction:

MOST COMMON CAUSE OVER ALL……..HERNIA

Most common hernia to complicate……femoral

If H/O of prior surgery ………….adhesions .

If H/O of hernia …………….incarcerated hernia

If H/O of sudden abdominal pain in elderly pt ……… volvulus .

If H/O of elderly pt with anemia, weight loss & melanotic

stools…………….tumor

If H/O of old age recuurent lower left abdominal pain….

Diverticulitis

If patient on antiparkisonian drugs…..pseudoobstruction

Cp:

Colicky abdominal pain .

Vomiting

Constipation

Abd. distension & diffuse tendernesss

Hyperactive bowel sounds due to peristaltic rush .

Dx -> Abd. x-ray -> DILATED BOWEL LOOPS with MULTIPLE .

AIR FLUID LEVELS

Investigation of choice of intestinal obs…. CT

Tx -> Complete bowel rest – .

Decompression e' nasogastric tube....vvvvvimp

76
.If no improvement -> Surgery .

Strangulation signs (fever - tachycardia - leukocytosis - .

Metabolic acidosis

.)Bad sign………..pain referred to the back….vvvvvv imp

Fecal impaction:

Age……………eldery

Cause………..bedridden, nursing home

Cp:……………..long history of constipation

Common symptoms include:

 Abdominal cramping and

bloating
 Leakage of liquid or sudden episodes of
watery diarrhea in someone who(soiling)
has chronic constipation

 Lower back pain

DRE…………….full rectum

Exams and Tests

colonoscopy to exclude colon or rectal cancer.
Treatment
Enema ……. Main ttt
Manual removal
Surgery is rarely needed

77
Volvulus:

Twisting of loop

Site……..sigmoid colon is the commonest

PF………….old age male with constipation

Cp……same as IO……SUDDEN ONSET

….VVVVVVVVVVVV IMP

DRE…….empty rectum

INV……..x-ray…….omega loop

Definitive inv….CT …vvvimp

TTT……

First step……..IV fluid, Iv antibiotics and catheterization

Endoscopic Decompression…….vvvvvvv imp

Rectal tube

If failed or complications occurred……surgery

Caecal volvulus
TTT:
Colnoscopy decompression….NOT effective
Surgery ………main ttt
N:B:

1st line of ttt for sigmoid volvulous……..decompression

1st line of ttt for cecal volvulous…………surgery

78
Volvulous vs fecal impaction ......vvvvvimp

Fecal impaction is much more common than volvulous

Key word of fecal impaction…..bed ridden or nusing home

Key word of fecal impaction…….constipation with fecal soiling

Key word of volvulous……………sudden onset symptoms of IO

DRE of fecal impaction……….full rectum

DRE of volvulous………………..empty rectum

X-ray of volvulous………….omega loop

First step in ttt of fecal impaction…….Enema

First step in volvulous……….decompression

Intussception:

Most common type…….ileocecal

Age…….maximum 3 months- 2years

Predisposing factor……..URTI

Cp:

Pain……….colicky with screaming

Drawing the legs toward the abdomen

Associated with vomiting and pallor

Red current jelly stool

Exam………sausage shaped mass

Investigation of choice…..US

79
Management:

Hydrostatic reduction…..VVVV IMP:

Barium (or air) enema is the procedure of choice……..diagnostic

and therapeutic

Paralytic ileus:

Causes:

Abdominal operations

Spine fracture

Hypokalemia, uremia, DKA

Peritonitis

Cp:

Marked abdominal distention

Vomiting and constipation

NOOO pain …… silent abdomen

x-ray……….marked distended loop

TTT…

Correction of the cause

Conservative ttt is the main management

Surgery is rarely done

80
Intestinal pseudoobstruction:
impairment in the ability of the intestines to push food
Clinical features :
Abdominal pain, nausea, severe distension,
vomiting, dysphagia, diarrhea and constipation
Causes:
Injury to the smooth muscle or the nervous system of the GIT.
Kawasaki disease
Parkinson's disease..........vvvvvvvvvvvv imp
Hirschsprung's disease
ACUTE DIVERTICULITIS:

Cp:

Old age male

Acute abdominal pain in the LT lower quadrant

fever, leukocytosis .

.Palpable tender mass in the LLQ .

.Dx -> CT . …..…….vvvvvvvv imp

.Never order contrast studies or endoscopy in acute phase .

Tx -> If there is no peritoneal signs …….. antibiotics and fluid

Localized peritoneal signs -> - NPO - IV fluids - IV antibiotics .

if Generalized peritonitis or perforation -> Emergency surgery .

:Abscess >-

.Often appears 10 days after onset with persistent fever .

.Surgical drainage is the ttt .

81
ACUTE APPENDICITIS

Age …….. young age

Begins with anorexia

Followed by vague peri-umbilical pain .

Several hours later, it becomes sharp, severe, constant & .

.localized to RLQ of abdomen

Fever, leukocytosis .

Most imp sign..........tenderness at right iliac fossa...VVVIMP

.Investigation of choice……. CT scan……vvvv imp

Tx -> IV antibiotics before appendectomy .

82
 Complications of appendiceal perforations:

1-PSOAS ABSCESS:

Localized Rt lower quadrant findings > 10days after onset of .

.appendicitis

Psoas sign ……..Flexion of the hip against

resistance

Tx -> IV hydration - Antibiotics - Bowel rest - Interval .

appendectomy after 6-8 weeks
.

2- Pelvic abscess formation :

.Drainage of fluid into the recto-vesical pouch .

Tender, fluctuant mass palpable e' the tip of finger .

.Inv of choice………..CT

.painful defecation & diarrhea

Tx -> Abscess drainage .

.N:B:

Take care……in pregnant woman the appendix takes an

abnormal position upward toward the liver

TTT of choice for appendicitis with pregnancy….laparoscopic

Most common complication after appendix rupture…. pelvic

abscess

Most imp sign in appendicitis..........local tenderness at right

iliac fossa

83
CHRONIC ULCERATIVE COLITIS :

:Elective surgery is done in the following conditions .

-1"Disease is present > 10 ys…….malignant risk

2-Multiple hospitalizations >-

3-Failure of medical ttt

Toxic megacolon:. Vvvv imp

Emergent complication of ulcerative colitis

CP:

Abd. Pain and epigastric tenderness

fever

leukocytosis

X-Ray…….Massively distended transverse

colon ……vvvvv imp

First step……..Decompression and fluid …..vvvvvvvvv imp

If failed.…..surgery

84
Ischemic colitis:

.Acute mesenteric ischemia in elderly pts .

History: .

Arrhythmia (Af) -> vvvvvvvvvvvvvvv imp

Recent MI

Cp:

.Severe acute abdominal pain , BLOODY DIARRHEA .

Go straight to surgery or order angiography .

Inv……..angiography

TTT………heparin first step

Embolectomy .

Revascularization or resection

:SURGICAL JAUNDICE

:1-OBSTRUCTIVE JAUNDICE CAUSED BY TUMOR

OLD AGE

Progressive symptoms

.Weight loss

.Adenocarcinoma at the head of pancreas .

.Dx -> CT scan ……..investigation of choice…

.Tx -> Surgical resection .

85
2-choledocholithiasis:

.Obese, fecund woman in her 40s .

.Recurrent episodes of RT UPPER QUADRANT pain .

.Dilated bile duct on sonogram ………..VVVVVIMP .

.$/Dx -> Abdominal US .

.Tx -> Cholecystectomy .

:BILIARY COLIC :
.Colicky pain in the upper right quadrant RUQ .

.Radiating to the right shoulder & back .

.Often triggered by fatty food .

.$/Dx -> U S

.Tx -> Elective cholecystectomy .

:ACUTE CHOLECYSTITIS

.cause………… occlusion of the CYSTIC DUCT By a stone

CP: .

Constant pain in the RUQ

Fever .

.leukocytosis & peritoneal irritation

MOST IMP INV……………US…. Thick walled gall bladder -

Pericholecystic fluid…..vvvvvvv imp

IF US IS EQUIVOCAL………..HIDA SCAN
86
.Tx -> NG suction - NPO - IV fluids - IV antibiotics .

.Tx -> Followed by elective cholecystectomy .

:Tx -> Emergency cholecystectomy……… if there is

Generalized peritonitis or ephysematous cholecystitis (i.e. .

perforation or gangrene)

ACUTE ASCENDING CHOLANGITIS :

medical emergency.

Obstruction of the COMMON BILE DUCT causes obstruction &

ASCENDING INFECTION

.Most common organism……….E-coli

.High fever & very high WBC count .

.High levels of alkaline phosphatase .

.High levels of total & DIRECT bilirubin .

Clinical picture : pain

Fever

Jaundice

Chills

confusion

.-Tx -> IV antibiotics and iv fluid .……….VVVVVVV IMP

Tx -> Emergency decompression of the common bile duct is .

! life saving ……..ERCP

.Tx -> Cholecystectomy must follow .

87
US AND GALL BLADDER STONES: VVVVVVVV IMP

Most imp inv for gall bladder stones……US

Most imp to asses on US……bladder duct dilatation

If the duct is markedly dilated next step……ERCP

Pain only……………biliary cholic

Pain and fever……….cholecystitis

Pain and jaundice………….choledicolithiasis

Pain, fever, chillis and confusion………cholangitis

Cholecystitis and mypcardial infacrtion:

First step………conservative management

Second step……….delay operation to 6 months after MI

If severe symptoms………percutanous cholecystectomy

Most common type of gall stones………cholestrol

Type of stone with hemolysis…………..pigmented (black)

Gall bladder stones:

No symptoms = No ttt

Once symptomatic = surgery

Gall bladder stones and pregnancy:

Best time to remove……….2nd trimester

Why necessary to remove………….increase risk of cholestasis

88
Postcholecystectomy syndrome:
Presence of abdominal symptoms after (cholecystectomy).

 Dyspepsia, nausea, and vomiting.

 Flatulence, bloating, and diarrhea.
 Persistent pain in the upper right abdomen.[2]
CAUSES:
sphincter of Oddi dysfunction
post-surgical adhesions.[6]
biliary microlithiasis.
Inv:

1st inv.........US

Inv of choice........ERCP

N:B:

Most imp indication to do ERCP before

cholecystectomy…..dilated common bile duct

Normal bile duct dilataion…………6 mm

Obstructive Jaundice:
1st inv……….US
Inv of choice,…..ERCP

89
Priapism:……emergency

Painful persistent erection

Cause…..engorged corpora cavernosa usually due to venous

disorder

Causes:

Intracavernosal injection ( PGs or papaverine)

IV drug abuse

Sickle cell

Spinal injuries

TTT:

Repeated saline flushing……..first step

Aspiration

Surgery…..last option

Fracture penis:………emergency

Cause……hard sex (usually prostitute)

Cp……… snapping sound and severe pain

Ttt……..immediate surgery

90
Normal Na level………………………………………………………. 135-145.

Main organ affected by Na level changes………………… CNS.

Main CNS manifestation………………………………………….confusion, convulsion, coma.

MCC of hypernatremia…………………………………………..………. Diabetes Insipidus.

MCC of hyponatremia…………………………………………….………. SIADH.

Best fluid for hyponatremia…………………………………………….. normal saline (0.9%).

Hyponatremia+ confusion or seizure……………………………… Hypertonic saline (3%).

Hyponatremia+ any severe neurological manifestations... Hypertonic saline (3%).

Rapid correction of hyponatremia…central pontine myelinolysis> quadriplegia.

Hyperglycemia>> hyper-osmolarity>> fluid retention>> pseudo-hyponatremia.

Normal K level: 3.5-5

EKG in hyperkalemia: hyper acute T-wave (tall T-wave), wide QRS, prolonged PR.

Hyperkalemia+ EKG changes……………………………………………….... Ca gluconate 1st

Hyperkalemia+ Severe chest pain, dyspnea or palpitation….… Ca gluconate 1st

Hyperkalemia+ K> 7……………………………………………………………… Ca gluconate 1st

Hyperkalemia<7 + NO EKG changes, no manifestation… TTT: insulin+ glucose.

Fastest way to decrease K level………..insulin and glucose

Only drug removing K from body……. Kayexalate ( resonium)
Hyperkalemia in ESRD pt…………..…… dialysis

If K less than 6 ………stop offending drug only

TTT of emergency hypercalcemia: IV fluid& diuretics.

1st presentation of hypocalcemia………………………. Peri-oral numbness.
Cause of Hypocalcemia after total thyroidectomy… hypoparathyroidism (removal
of 4 glands).

Patient after surgery develop perioral numbness but total ca normal….anxiety

Pt will undergo elective surgery in 24 hs, labs shows hypocalcemia… TTT: IV

calcium (rapid correction is needed before surgery)

Long term TTT of hypocalcemia: Ca + vit D

Hyperventilation>> CO2 wash>> alkalosis>> decrease ionized Ca>> tetany... 1ST

STEP: breathing in bag… if persists: Ca gluconate.

Hypoalbuminemia causes decrease in total Ca not ionized Ca… NO tetany.

Post-operative pt on TPN develops skin problem… Dx: zinc deficiency.

MCC of zinc deficiency: TPN.

Pt with hyponatremia, increase in urine Na, osmolarity… Dx: SIADH.

MC drug causing SIADH: carbamazipine.

MC cancer causing SIADH: small cell lung cancer.

Any neurological insult (meningitis, brain tumor… ETC) can cause SIADH.

In SIADH:

 Serum osmolarity…..decreased
 Urine osmolality ……increased
 Urine sodium concentration ……increased

In Diabetes insipidus:

Serum osmolarity……increased

Urine osmolarity……..decreased

Urine sodium concentration…..decreased

In psychogenic polydipesia>?

Serum osmolarity……decreased

Urine osmolarity……..decreased

Urine sodium concentration…..decreased

TTT of hyponatremia in SIADH:

Mild………………………………………………………………………. Fluid restriction.

Moderate……………………………………………………………... Normal saline+ diuretics.

Severe or CNS manifestation (confusion, seizure)… Hypertonic saline (3%).

Child with meningitis develops seizure, lab shows hyponatremia… 1st step:
hypertonic saline (3%).

Pt with hypernatremia, decrease in urine Na, osmolarity… Dx: DI.

MC drug causing DI: lithium.

Pt with hyponatremia, decrease in urine Na, osmolarity… Dx: psychogenic

polydipsia.

How to differentiate DI from psychogenic polydipsia: H2O deprivation test.

Normalization of lab after test ……………………………. Psychogenic polydipsia.

No normalization of lab after test “urine osm. Still low” ………………………. DI.

Again, pay attention please:

Pt with hyponatremia, increase in urine Na, osmolarity..… Dx: SIADH.

Pt with hypernatremia, decrease in urine Na, osmolarity… Dx: DI.

Pt with hyponatremia, decrease in urine Na, osmolarity…. Dx: psychogenic

polydipsia.
ASSESSMENT OF ACID – BASE BALANCE:

1st step: assess Ph:

Normal pH: 7.35 : 7.45

pH< 7.34 = acidosis

pH> 7.46 = alkalosis.

2nd step: assess 2 parameters CO2 & HCO:

Marked change in CO2= respiratory

Marked change in HCO3= metabolic

Acidosis:

 Increase in CO2……………. Respiratory acidosis

 Decrease in HCO3……….. metabolic acidosis

Alkalosis:

 Decrease in CO2…………….. respiratory alkalosis

 Increase in HCO3…………… metabolic alkalosis

3rd step: assess presence of compensation:

Mild increase in the other parameter indicates presence of compensation.

When to give IV calcium???...

1-symptomatic
2- Serum calcium below 1.9 mmol/L
3-rapid correction is needed as before operation

URINE OSMOLARITY………..500-800 mOsm/kg

SERUM OSMOLARITY……. 280 - 295 mOsm/kg water

Pt with lightheadedness, dizziness, Pulse<50… 1st step: atropine

If no response after 3 doses of atropine… trans-coetaneous pacing

If no improvement…. Trans-venous pacing (never in the ER)

Pt with palpitation; ECG shows Regular Narrow-complex tach… Dx: SVT

SVT pt with H. instability (hypotension, chest pain)… cardioversion (DC shock)

SVT pt with H. stability… 1st step: vagal stimulation (e.g. carotid massage)

If no response ………. IV adenosine

If still no response … CCBs or BB

Pt with palpitation; ECG shows Regular Wide-complex tach… Dx: VT

VT pt with H. instability (hypotension, chest pain)… cardioversion (DC shock)

VT pt with NO pulse (pulseless VT)…………………..…… defibrillation

VT pt with H. stability… Amiodarone

Management of VF…….. immediate defibrillation

Pt with palpitation, ECG shows polymorphic VT… Tosade De Point

MC drug causing torsade de point… Erythromycin

1st step in TTT …………….. Mg sulphate

DOC …………………………… Amiodarone

If the pt is H. unstable … Defibrillation

Pt with palpitation, ECG shows short PR, Delta wave (slurred initial portion of
QRS) & wide QRS… Wolf Parkinsonian White $ (WPW $)

svt with WPW… adenosine

Best ttt………catheter ablation

Pt with palpitation, ECG shows irregular, narrow complex tach… AF

MCC of AF………………………………………………. Hyperthyroidism

Pt with AF, the most imp inv to be done….. TSH, T4

DOC of AF…………………………………………………. BB

Pt with palpitation, ECG show extra QRS complex with no preceding P-wave… PVC

MCC of PVC…… hyperkalemia

Most dangerous cause… Ischemia (post-MI)

PCV pt with NO symtoms…. NO TTT

PCV pt with symtoms…….. BB

Pt with dizziness, ECG shows 1st degree HB (PR>0.2 sec & each P wave is followed
by QRS complex)… NO TTT

Pt with dizziness, ECG shows progressive PR interval prolongation followed by

dropped QRS complex… 2nd degree AV block typeI (Mobitz type I)

Pt with dizziness, ECG shows regular PR interval followed by dropped QRS

complex… 2nd degree AV block typeII (Mobitz type II)

Pt with dizziness, ECG shows no relation between P wave & QRS complex… 3rd
degree AV block.

1st degree AV block……………………………….. no TTT

2nd degree AV block type I ………………..….. no TTT (even if symptomatic)

2nd degree AV block type II ………………….. pacemaker (even if asymptomatic)

3rd degree AV block ………………………..…….. pacemaker

Imp drugs causing hyperkalemia: ACE-IS, BB, NSAID, spironolactone

Hyperkalemia with significant ECG changes (wide QRS)… 1st step: Ca gluconate

Imp drugs causing hypokalemia: loop diuretics, amiodarone

ECG with M-shaped in V1, V2…………………….. RBBB

ECG with M-shaped in V5, V6…………………….. LBBB

Dealing with cardiac arrest………. VVVVVV imp

Best step to maintain the airway……head lift jaw thrust

First step………………CPR

First drug to be given…………IV adrenaline

Shockable rhythm… pulseless V.Tac and V.fibrillation… immediate cardioversion

Non-shockable rhytm… asystole and pulseless electrical activity… CPR, drugs

Step has the best long term effect after cardiac arrest…..defibrilator….vvvvv imp

TTT of asystole and pulseless electrical activity……CPR and epinephrine

To have the best neurological outcome after recovery from arrest… induced
hypothermia

How to deal with ventricular fibrillation?????

1st step………………………….……DC shock

If still VF ……………………………CPR for 2 minu

If return to sinus rhythm……continues CPR

Inv of choice for arrhythmia…………….holter

First line for AF with hyperhyrodism………BB

First line for mitral valve prolapsed……BB

First line ttt for HOCM……….BB

First line ttt for angina………BB

First medical ttt for aortic dissection…….BB

TTT of essential tremors……….BB

TTT of panic ……BB ( SECOND LINE) ….FIRST IS Benzodiazepine

TTT of leg restless syndrome…….levo dopa BB SECOND LINE

First drug for premature ventriculat beat……..BB ( only if Ṥ)

First drug for SVT……adenosine then CCB OR BB

First line for WPW ……AMIODARONE

First line for torsade de points………Mg so4

First line stable vent. Tachycardia………amiodarone

First line unstable vent. Tachycardia…….cardioversion

First line V. Fibrillarion……defibrillator

First line for symptomatic bradycardia……..atropine

First line for COPD…….O2

First line for pericarditis…….NSAIDs

First line for percardiac tamponade…….percardiocentesis

First line for STEMI……....angioplasty

First line for non STEMI…….heparin

First line for unstable angina…….heparin

First line for variant angina……CCB

First line for cocaine induced angina……CCB

First line for hyperlipidemia…….statin

Best life style for asthma……avoid smoking

Best life style for HTN……..loss weight

Best life style for OA………Loss weight

First drug for aortic regurge……ACEI

First drug for DM With HTN……ACEI

First line for DM + Protenuria…….ACEI

HTN + unilateral renal artery stenosis…….ACEI

Best ttt for renal artery stenosis…..stent

HTN + DM……..ACEI

HTN + osteoporosis…….THIAZIDES ( hypercalcemia)

HTN + Hyperthrodism…….BB

HTN + BPH……..Alpha blockers

HTN + ESSENTIAL TRMORS……..BB

HEART BLOCK:

First degree……,no ttt

Mobitz 1……..no ttt

Mobitz 2…….pace maker

Third degree (cannon waves)……pace maker

MCC of death following MI…………… ventricular arrythmias

1st step in management of pt with hematemesis: IV line& normal saline.

If pt needs blood: packed RBCs.

Inv of choice of hematemesis: upper GI endoscopy.

Infant with persistent non- bilious vomiting starting at 2-6 Ws, marked
dehydration and wt loss…….Dx: CHPS.

Inv of choice of CHPS: US.

TTT of CHPS: 1st: correct dehydration& electrolyte imbalance and then: surgery.

- Vomiting at 2-6 Ws+ marked dehydration, bad general condition: CHPS.

- Vomiting at 2-6 Ws+ NO dehydration, good general condition: GERD.

Pt with long standing H/O PUD presents with recurrent vomiting occurs 1h after
meal, succession splash on physical exam… Dx: acquired pyloric stenosis.

1st MCC of PUD: H. pylori.

2nd MCC of PUD: smoking (other causes: stress, alcohol, NSAIDs).

Inv of choice of PUD: upper GI endoscopy (biopsy only from gastric cancer).

Regimen for eradication of H. pylori: amoxicillin, calrithromycin, PPI.

Why metronidazole is removed from regimen: DT bacterial resistance.

MCC of failure of TTT of H. pylori: short course of TTT

Follow up of TTT: urea breath test.

Best advice to pt with PUD: stop smoking.

TTT of Pt with PUD develops hematemesis:

1st step: IV line& normal saline. If need blood: packed RBCs.

Then: endoscopy& injection of adrenaline or heat probe if visible bleeding.

Pt with PUD develops severe abdominal pain referred to back: perforation.

1st step in suspected perforation: erect x-ray (air under diaphragm).

TTT of perforation: resuscitation 1st & then surgery.

Nausea, abdominal pain& fullness, diarrhea and flushing within 1 h after meal in
pt undergone partial gastrectomy… Dx: dumping $.

Symptoms within 1 h after eating: Early dumping. Mechanism: hypovolemia.

Symptoms within 1-3 Hs after eating: Late dumping. Mechanism: hypoglycemia.

TTT of dumping $: diet modification (light frequent meals with decrease CHO
content).

TTT of choice of morbid obesity “BMI>35”: SURGERY (gastric band ligation).

Pt with H/O gastric band ligation develops severe vomiting… Dx: band slip.

Inv of choice of band slip: barium meal.

TTT of band slip: surgery.

Prophylaxis of bleeding of esophageal varices: BBs.

TTT of rupture esophageal varices: same as upper GI bleeding+ FFP.

At exam, picture of peri-anal swelling in a pt with bleeding per rectum:

- If painless bleeding: piles.

- If painful bleeding: peri-anal hematoma.

Old pt with bleeding per rectum DT piles: colonoscopy is a MUST.

Best management of recurrent pilo-nidal sinus: radical excision.

MCC of peri-anal fistula: anal abscess.

MCC of recurrent peri-anal fistula: chrone’s disease.

MCC of multiple anal fissures: chrone’s disease.

Most imp exam of pt with anal fissure: just inspection (NOOOOO DRE)
Most imp TTT of anal fissure: local glyceride trinitrate cream.

TTT of anal fissure in chrone’s disease: infliximab.

Mother tells u she found blood in her infant diaper, MCC: anal fissure.

Bleeding per rectum (BPR):

MCC overall: piles and fissure.

MCC in infants: Anal fissure.

MCC in adult: upper GIT bleeding (peptic ulcer).

MCC in adult: diverticulosis (cancer must be excluded).

BPR in pt with AF: ischemic colitis.

1st episode of BPR in old pt: colonoscopy is a MUST.

TTT of bleeding per rectum: IV line& normal saline. Give packed RBCs if pt need
blood.

Next step if upper GIT endoscopy and colonoscopy failed to reveal site of
bleeding>>>>>>>>>>> capsule endoscopy.

MC hernia to complicate: femoral hernia.

Most imp sign indicating complication of hernia: NO impulse on cough.

Pt with hernia develops vomiting, absolute constipation, abdominal

distension…Dx: IO.

1st step in suspected IO: abdominal x-ray then surgery.

Abdominal swelling below scar of previous surgery: incisional hernia.

MC PF of incisional: hematoma.

Examination of incisional hernia: ask pt to stand and cough.

TTT of inguinal hernia in infants:

 1. If obstruction or strangulation: immediate surgery.
2. If irreducible: surgery as soon as possible.
3. If reducible: “rule of 6-2”
- Birth to 6 ws: surgery in 2 ds
- 6 ws to 6 ms: in 2 ws.
- >6 ms: in 2 ms.

Umbilical hernia in pediatric: observe if< 4 ys & surgery if > 4 ys.

How to diagnose pt with divarication of recti: Rising up without support.

TTT of divarication of recti: physiotherapy.

Most imp step in TTT of child who ingests corrosive: endoscopy within 24hs.

Long term TTT of corrosive injury: dilators.

1st inv of achalasia: barium study.

Best inv of achalasia: manometry.

TTT of choice of achalasia: surgery “ heller myotomy”.

TTT of achalasia in old not fit for surgery: dilators.

Attacks of Dysphagia& chest pain in young femal… Dx: diffuse esophageal spasm.

Barium study of esophageal spasm: corkscrew appearance.

TTT of esophageal spasm: nitroglycerine, CCBs.

Dysphagia, heart burn and food impaction with certain food in pt with H/O atopic
disease (e.g. BA) or AI disease (e.g. celiac disease)… Dx: esinophilic esophagitis.

Inv of choice: upper GIT endoscopy.

TTT: diet modification. Cortisone is the 1st line medical TTT

Heart burn, regurgitation and retro-sternal discomfort…Dx: GERD.

Best inv of GERD: 24 hs PH monitoring.

main TTT of GERD: conservative.

1st line medical TTT of GERD: PPI.

Inv of choice of severe cases of GERD: upper GI endoscopy.

Intermittent dysphagia, post-prandial pain+ palpitation… Dx: Hiatal Hernia (para-

esophageal).

Inv of choice: barium study.

TTT of choice:surgery.

Pt with prolonged GERD develops dysphagia& heart burn is relieved… Dx:

esophageal stricture.

Inv of choice: upper GI endoscopy.

Pt with long standing GERD is at risk of: barrett’s esophagus

(precancerous; risk adenocarcinoma of the esophagus)

Inv of choice……….endoscopy

IF metaplasia……..biopsy

If low grade dysplasia…..repeat the endoscopy every 6 months

If high grade dysplasia……….ablation or surgery

Best ttt…….PPI……vvvv imp

Old male smoker, alcoholic with recent dysphagia, wt loss… Dx: cancer esophagus.

MC type of cancer esophagus: SCC.

Most imp RF of Adenocarcinoma: barrett’s esophagus.

Alcoholic vomit up blood after violent retchingor vomiting… Dx: Mallory weiss $.

Definitive Dx: endoscopy.

Main TTT: conservative… if bleeding persist: cauterization or epinephrine
injection.

Alcoholic with severe chest pain,pleural effusion after violent retchingor

vomiting… Dx: boerhaave $.

Main TTT: emergent surgery.

Screening of FAP: colonoscopy starting at 12 ys.

Fate of FAP: 100% develop cancer.

Main TTT: surgery once polyps start to appear.

FAP+ epidermoid cyst+ desmoids tumor+ osteoma= gardner’s $.

Hamartomatous polyp of colon+ pigmentation of lip+ peutz’s jegher $.

MC pre-malignant colonic adenoma: villous adenoma.

MC type of colonic adenoma causing electrolyte disturbance: villous adenoma.

Least colonic polyp with malignant potential: tubular.

MC symptom of cancer cecum: anemia, pallor& fatigue.

MC symptom of cancer rectum: bleeding per rectum.

MC symptom of cancer left colon: altered bowel habbit.

Inv of choice of cancer colon: colonoscopy.

Old male with iron deficiency anemia… cancer colon until proven otherwise.

1st step: FOBT… if +ve finding: colonoscopy.

1st step in high risk pt: colonoscopy from beginning.

Give Colon cancer pt chemo& radio pre-operative and chemo

only post-operative.
After surgery of colon cancer: colonoscopy every year and
CEA.
Old age with prolonged constipation develops painless bleeding per rectum… Dx:
diverticulosis.

MC site: sigmoid colon.

Main TTT: increase fiber diet.

Pt with diverticulosis develops fever, LLQ pain… Dx: acute diverticulitis.

Inv of choice of acute diverticulitis: CT scan.

TTT: conservative mainly (IV fluids, abs)… if perforation: surgery.

MCC of painless bleeding per rectum in old age: diverticulosis.

Chronic abdominal pain and distension that relieved after defecation+ alternating
diarrhea and constipation in nervous pt… Dx: irritable bowel $.

DOC of TTT of irritable bowel $: SSRI.

Most common cause of bloody diarrhea….campylobacter

Second most common cause of bloody diarrhea…shigella
Most common cause of traveler diarrhea….E-coli
Most common cause of diarrhea in pediatrics…viral
Most common virus causing diarrhea in kids……rotavirus
Diarrhea followed by weakness and areflexia…GBS
Diarrhea followed by renal impairement….HUS
Bloody diarrhea followed by RUQ pain….ameba
Diarrhea after camping…..Giardia
Chronic bloody diarrhea in young male…..IBS
Diarrhea after long term antibiotics....clostridium difficile
Antibiotic causing clostridium difficle….clindamycin
TTT of clostridium difficile ….metronidazole or vancomycin
Diarrhea after eggs or chicken…..salmonella
Diarrhea just hours after meal…..staph toxin
Diarrhea in bed ridden with constipation...fecal impaction
Main ttt of diarrhea…..fluid
TTT of traveler diarrhea…..fluid only
TTT of staph toxin…..fluid only
TTT of shigella or campylobacter….antibiotics
TTT of ameba or giardia … metronidazole.

Severe watery diarrhea in pt with prolonged use of abs… Dx: pseudomembranous

colitis.

CO: CLOSTRIDIUM DIFFICILE.

MC antibiotic: clindamycin.

If mild diarrhea………..just fluid

1st medical TTT: metronidazole.

If diarrhea persists after metronidazole: oral vancomycin.

STDs in children, injury non-compatible with the parent’s history.. suspect child
abuse; 1st: photography…. Then: contact child protective service.

MC type of child abuse, MCC of malnutrition in kids: emotional.

Manchausen by proxy = child abuse… report.

Vaginal, penile or rectal discharge, pain or any STDs= sexual abuse.

1st step: photography .. then: admission and report.

MC offender: father (N.B. brother-sister incest is not sexual abuse).

MC type of elder abuse: neglect.. MC offender: caretaker.

MC type of spouse abuse: physical. Nooooo report.

1st step if u suspect spouse abuse: encourage her to talk about the bruises

Pregnant with bruises on her body……….encourage her to report NOT reporting.

Pt with seizure disorder, vision impairment, syncope: encourage to tell RTA & if he
refuse: tell RTA yourself.

Accept gifts of pharmaceuticals if educational, scientific.

Accept gifts from individuals if simple, cheap.

U must respect patient autonomy as long as the patient is mature (14ys) and
competent.

Pt with severe depression refuses TTT.. next step: MMSE test.

If MMSE is normal: respect pt decision… if not: give TTT against will.

Pt with schiz. Controlled on medication refuse TTT: respect.autonomy

Consent for minors: only parents or legal guardians.

Consent for minor in emergency situations: NO consent is needed (TTT them even
if parents refuse TTT as appendectomy for acute appendicitis).
All suicidal pts lack capacity (have no right to refuse TTT).

Pt doesn’t understand or speak English: call translator ‫ ساعة في‬24 ‫خدمة متاحة‬
.‫المستشفيات‬

Pregnant female has the whole rights in the world to harm herself/her fetus.

After delivery, the woman has no rights to harm the neonate.

e.g. HIV pregnant woman can refuse to take medication, have vaginal delivery
BUT if she lactate the baby or refuse to give him TTT: report.

U can only break confidentiality in the following cases: court order, portable
disease (e.g. meningitis) and those who are harmful to others.

Psychiatric pt intends to kill: inform police+ victim. (Victim 1st if both in choices).

Respect pt wishes as long as he/she the capacity to understand even if refusal of

TTT will end pt life (e.g. pt with ESRD refuse dialysis).

Advance directive= living will + health care proxy.

Coma Pt has a written will of DNR, his family ask for ventilation: don’t ventilate.

Coma pt with no living will, encourage consensus.. request discussion.. talk with
involved parties.. In case of split family: ethics committee or court order.

If the pt will is clear (verbal or written living will), it overrule everyone (always
follow it).

Alzeheimer patient no relatives need urgent surgery….1st step….look for advanced

directives

DNR= no chest compression, cardioversion, acute anti-arrhythmic medications.

Stable Pt has respiratory disease who is on DNR… intubate BUT, if the pt is

unstable: don’t intubate (here, intubation is part of resuscitation).

Euthanasia is wrong in all states (don’t give lethal drug to kill pt upon his request.
U have to give morphine to terminal cancer pt even if it may kills him BUT you
can’t give him morphine with intention to kill.

Brain stem death= actual death.

Consent of Abortion: only from mother, allowed in all trimesters.

The physician is the only one who has the right to do abortion.

You as a Physician have the right to refuse to do abortion. Physician must refer pt
to another physician who don’t share your belief.

Abortion Consent for minor: parents or legal guardians.

Sperm donation, egg donation: completely ethical.

Only pt consent is required for sterilization. Spouse consent is not required.

The only authority that has the right to ask 4 donation: Organ donor office
network.

Pt has will with organ donation, family refuse after his death: follow family will.

All reportable diseases MUST be reported. U can also isolate pt with TB.

All STDs: 1st encourage pt to tell partner if refuse: inform health authorities

No 1 can force u to TTT HIV pts BUT, it is unethical to refuse to treat him.

Malpractice = Error in medical care + harm to the patient.

Doctor patient sexual relationship is unethical (if indicated, they should terminate
doctor patient relationship).

Psychiatrist can have sexual relationship with neither current nor former pts.

Physician can ONLY have sexual relationship with former pts.

Any colleague physician with psychiatric illness, substance abuse, alcohol abuse or
even emotional disturbance: report to medical board.
If nurse: report to nurse medical board.

The pt has the right to withdraw from experimental studies at any time.
1st
inv in 1ry amenorrhea:………vvvvvvvvvvvv imp
1. If secondary sexual characteristics exist…………..US
2. If NO 2ry sexual characteristics………….FSH and LH

If XX>>> mullerian agenesis. Manag:elongation of vagina.

If XY>>> androgen insensitivity $. Manag: removal of testis after
puberty.
1ry amenorrhea, +ve uterus, no breast.. next step: karyotyping.
If XX>>> HPO failure. TTT: GnRH; pulsatile form.
If XO>> turner $(gonadal dysgenesis). Manag: hormonal replacement
after puberty.
1ry amenorrhea, abd. Pain at the middle of the month>> imperforate
hymen.
Physical findings in imperforate hymen>> bluish discoloration.
TTT of imperforate hymen>>> surgery under anesthesia.
1st step with 2ry amenorrhea: pregnancy test.
MC site of fibroid: intra-mural
Fibroid cause subfertility& recurrent abortion: submucosal
TTT of fibroid: myomectomy… give GnRH 3-6ms b4 operation.
Pregnant with H/O fibroid has abd. Pain & fever……… Dx: red
degeneration of the fibroid…. TTT: analgesic.
Pain with menstruation with no underlying pathology= 1ry
dysmenorrhea.
TTT of 1ry dysmenorrhea: 1st line: NSAIDs & 2nd line: OCPs.
Infertility+ dysmenorrheal, dysurea, dyschezia, dyspareunia…
Dx:endometriosis.
MC site of endometriosis: ovary (chocolate cyst)… the cause of
infertility.
Inv. Of choice of endometriosis: laparoscopy.
TTT of endometriosis: OCPs or encourage pregnancy.
TTT of severe cases of endometriosis: GnRH analogue or leuprolide
(androgen).
TTT of severe cases of endometriosis in old age: TAH, BSO.
Endometrial gland in myometrium= adenomyosis.
CP of adenomyosis……..menorrhagia and dysmenorrhea
TTT of adenomyosis: OCPs.. if failed: TAH, BSO.
Obese female with infertility, irregular bleeding, acne&
hirsutism..Dx:PCO.
Cause of infertility in PCO: anovulation.
Most imp. Inv. Of PCO: testosterone (free& total).
TTT of PCO: clomiphene citrate for infertility, OCPs for irregular
bleeding.
The most imp. Advice for PCO pts: Wt loss.
MCC of hirsutism: idiopathic hirsutism. TTT: aldosterone.
Female in 3rd decade with signs of menopause; Dx: premature ovarian
failure.
Most imp inv. Of premature ovarian failure: increased FSH.
TTT of premature ovarian failre:
1. OCPs>> for sexually active& those who don’t need kids.
2. HRT>> for those who aren’t sexually active& want kids.
3. IVF with egg donation>>for those who want to get pregnant.
Foul smelling vaginal discharge, clue Cells under nicroscope; Dx:
B.vaginosis.
CO of B. vaginosis: gardenella vaginalis.
TTT of B. vaginosis:oral metronidazole (safe in pregnancy)+ no need
for partner TTT.
strawberry cervix, motile flagellated organism under microscope;
Dx: trichomonas vaginalis.
TTT of trichomans vaginalis: oral metronidazole(u must treat
partner as well)
Thick, cheesy, odorless, pseudohyphae under microscope, Dx:
candida vaginalis.
TTT of candida vaginalis: oral fluconazole(if pregnant: fluconazole
cream)& no need for partner TTT.
Cause of cyclic vulvo-vaginitis……….candida.
TTT of recurrent vulvovaginitis………..oral fluconazole
Post-menopause with long standing H/O of vulvar itching; 1 st step:
punch biopsy.
TTT of lichen sclerosis: cortisone cream(but, bunch biopsy 1 st to
exclude malignancy).
Screening test of Chlamydia: all sexually active female from 15-29 ys
every year.
Offer the girl “opportunistic screening” in each visit…vvvv imp
MCC of cervical muco-purulent discharge in female: chlamydia.
Recurrent subclinical cervicitis DT Chlamydia> adhesion> infertility
TTT of Chlamydia>> azithromycin+ ceftriaxone (treat both
Chlamydia&gonorrhea)
Partner tracing is very important.
After TTTof Chlamydia: search for other STDs(e.g. ELISA for HIV,
VLDL for syph.).
Chlamydia outbreak(e.g. in high school).. give condoms(recently,
lecture about safe sex is the right answer even if condom is found in
answers).

Screening of cervical cancer (pap smear):

1. Start 2 Ys after starting intercourse or >18Ys regardless of
sexual activity.
2. Do pap smear every 2Ys.
3. Stop it in those>70Ys with previous normal test& those
undergone hysterectomy.
4. Lesbians, HPV vaccine>> screen.
5. Virgin……. No screening.
Pap smear interpretation:
1. Abnormal result in presence of infection: repeat screening
after TTT of inf.
2. LSIL: repeat after 12ms; if still LSIL: colposcy.
3. LSIL for those >3o ys old: colposcopy.
4. HSIL: colposcopy.
Give HPV to all female from 9-45 Ys.(max. benefit: b4 starting
intercourse).
Vaccine can be given for those; sexually active females, previous
genital warts,
Previous abnormal cytology & lactating females.
Vaccine can’t be given to immuocompromised & pregnant females.
MC risk factor of endometrial cancer: obesity.
Best inv. For suspected endometrial cancer: hystrescopy & biopsy.
Female with +ve BRCA1, BRCA2 mutation are liable to ovarian&
breast cancer.
Screening of ovarian cancer is no longer recommended even in high
risk Pts.
Ovarian cyst in US of an old female; next step: CA125 even if the cyst
is simple.
Urinary incontinence with increase intra-abdominal pressure (e.g.
coughing, laughing) = stress incontinence (MCC of incontinence in
females).
Inv. Of choice of stress incontinence: urodynamics.
TTT of stress incontinence;
1. 1st line: kegel exercise.
2. If no response to exercise: surgery(TAH or vaginal
hysterectomy).
3. If old pt (can do neither exercise nor operation): pessaries.
Urinary incontinence in all the time, position.. Dx: Total incontinence.
MCC of total incontinence: fistula… TTT: surgery.
Strong unexpected urge to void not related to position= urge
incontinence.
Inv of choice of urge: urine analysis.
TTT of urge; 1st line: bladder training. If failed: anticholenergic or
TCA.
Urinary incontinence in pt with long standing DM>> overflow
incontinence.
TTT of overflow incontinence: intermittent cath.
Main ligament supporting the uterus is: utero-sacral ligament.
2nd MC site of endometriosis: utero-sacral ligament.
MCC of PID: Chlamydia & 2nd MC organism: gonorrhea.
Adult with painful ulcer on genitalia has HSV until proven otherwise.
Adult with painless ulcer on genitalia has syph. until proven otherwise.
MC type of ovarian cyst: follicular cyst.
Ovarian cyst>6cm: laparoscopical removal.
Ovarian cyst<6cm: OCPs & repeat US in 6-8Ws.. if persist:
laparoscopy.
Most imp to be evaluated for female puberty assessment: breast
budding.
Mother worry as her daughter have no menses yet: look for breast
budding.
Time from breast budding to menarche: about 2 Ys.
2ry sexual characteristic<8 Ys in females= precocious puberty.
1st step in manag. Of precocious puberty: x-ray to determine bone
age.
Breast development<3ys only with no other 2ry sexual
characteristics..Dx: premature thelarche… management: reassure
only.
Ethics of abortion in Australia:
1. Process of abortion: 1st: counseling, 2nd: get informed consent&
then do the abortion
2. Who can give informed consent:
a. Competent pt are those >16 ys and those who are>14 but
independent.
b. Parents or guardian…. For those who are <14.
c. Sexual assault authorities… for those<14 who exposed to rape.
3. Who should do the abortion: only the physician.
4. Where the abortion should be done: only in 3ry hospital whatever
far is it.
5. Abortion is legally allowed at any time during pregnancy.
6. U can refuse to do abortion… u should refer to another
physician.
Inv. Of choice for Dx of osteoporosis: DEXA scan.
DEXA scan interpretation: a. (-1:-2.5): osteopenia. b. (<-2.5):
osteoporosis.
When to say osteoporosis??....1-T-score less than 2.5 2-
minimatrauma fracture
Inv. Of choice for suspected osteoprotic bone fracture: X-ray.
Prevention of osteoporosis: Ca & vit.D.
TTT of osteoporosis: bisphosphonate (even if ca&vit.D are present in
MCQ)
TTT of osteoporosis in pt with H/O breast cancer: raloxifen (SERM).
Inv. Of choice for menopause: FSH (increased).
MC symptom of menopause, MC indication for HRT in menopause:
hot flushing.
MC symptom to be improved after HRT: hot flushing.
Depression is neither a part of normal menopause nor responds
to HRT.
MCC of dysfunction bleeding at the beginning of puberty: anovulation.
MCC of dysfunction bleeding near menopause: anovulation.
Menopause + irregular bleeding = cancer endometrium until proven
otherwise……….. next step: hysteroscopy & biopsy.
MCC of post- menopausal bleeding: atrophic vaginitis.
Menopause + bleeding in the 1st year……follicular activation
Menopause+ bleeding+ pain during sex= vaginal atrophy
Menopause+ bleeding+ no pain during sex= endometrial cancer.
Menopause+ brownish discharge= endometrial cancer.
Menopause+ green, yellow or gray discharge= infection.
Indication of HRT: hot flushes, osteoporosis.
Duration of HRT: not >5 Ys
Types of HRT:
Continous……….for menopausal women
Cyclic……for perimenopause.
Female on HRT develop unpredictable bleeding.. mode of HRT:
continuous form.
Post-menopausal with H/O hysterectomy: give estrogen only.
Post-menopause with H/O DVT need HRT: no estrogen should be
given & if you have to give estrogen: give estrogen patches.
Post-menopausal with H/O breast cancer: give paroxitine(SSRI).then
clonidine
Post-menopausal with atrophic vaginitis only: give estrogen cream.
Post-menopausal on HRT for 5Ys: trial of stoppage.
Pt on anti-epileptic need OCPs: give high dose estrogen (microgynon
30-50).
Pt on OCPs, recently started anti-epileptic mededications…. next step:
increase estrogen dos.
Other than DVT& estrogen-dependent tumor; migraine with aura is
an absolute contra-indication of OCPs use.
2 imp. Indications of POPs: Lactating pt & pt with migraine.
Wt to give for emergency contraception: levonorgestrel 750mg.
When to give emergency contraception: condom rupture, unplanned
pregnancy.
Complications of IUCD: bleeding, infection.
Most sensitive method of natural contraception: increase cervical
secretions.
Tubal ligation consent is taken from the female only.
OCPs with lactation: POP is the best, start 6 Ws after delivery, never
estrogen.
Pt on OCPs develops chloasma: stop estrogen.
Pt on OCPs develops HTN; next step: stop OCPs 1st & then check
response.
Pt on OCPs develops headache; next step: stop OCPs 1st & then
check response.
MC indication of OCPs after delivery: low frequency of breast feeding.
Most benefit of jasmine: wt loss.
1st step in evaluation of infertile couple: semen analysis.
MCC of decreased sperm count: alcohol.
+ve progesterone withdrawal test (i.e. withdrawal bleeding) =
anovulation.
Infertile couple, male has no offspring& female in 40s with 2 offspring..
cause of infertility in this couple: female (anovulation DT aging).
Old female not easy to get pregnant…….bad quality and quantity of
the ova
Female near menopause want to get pregnant: IVF.
Cause of infertility in male with CF: absence of vas deference.
Cause of infertility in those undergone any uterine procedure:
Asherman’s $
Metastasis from GIT to ovary; 1st MC: stomach& 2nd MC: colon.
Physical & psychological distress few Ds b4 menstruation:
premenstrual $.
Best way to diagnose premenstrual $: menstrual dairy.
1st line TTT of premenstrual $: relaxation therapy.
2nd line TTT of premenstrual b$: SSRI.
1st line TTT of severe menstrual $ affecting, pt relations: SSRI.
1st step in management of excessive menstrual bleeding: TSH.
If TSH is normal; next step: TVS.
Young female with solid & cystic mass in US.. Dx: dermoid cyst.
Most common site………ovary
MC site of dermoid cyst: ovary.
9 ys kid started menstruation……….normal puberty

2 ys kid started menstruation……….precocious puberty

2 ys kid with breast enlargement only…..thelarche

Main site of action of pop( low dose).........cervix

Main site of action of pop ( normal dose).......ovary
Main site of action of combined oral contraceptive.....hypothalamo
pituitary ovarian axis

Site of sample in female with vaginal discharge …..endocervical

Most common cause of infertility in female with normal examination

………….tube adhesion

Most common cause of infertility in couple with normal

investigations………tube adhesion

Most common cause of infertility in couple who had a kid before……tube

adhesion

Imp Inv for Old age + fracture before discharge from the
hospital……bone scan

Best inv for Chlamydia.....PCR 1st catch urine

Most common malignancy in PCO………breast

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ENDOCRINOLOGY

Thyrotoxicosis ‫ بنت عصبية وبتخس ال تطيق الحر ومش بتنام كويس‬, Pretibial myxedema

Peri-orbital lymphocytic infiltration ……Exophthalmos

MC Cause ….. Grave's MC Arrhythmia is AF

First investigation to any patient with AF…..thyroid functions

1ry thyrotoxicosis : ↑T3 , T4 ↓ TSH

2ry thyrotoxicosis: ↑TSH ↑T3 , T4 (Pit adenoma)

Pt with Thyroid nodule: (goiter, mass, multiple nodules)… 1st TFT --- If ↑ --→ U/S

Hoarsness of voice → suspect ₵ → FNAB guided by U/S

TTT: Most common ttt in Australia….. Radioactive iodine (SE hypothyrosim)

Irradiation to children…..carcinogenic

Surgery ---- Total thyrodiectomy (SE hypothyrodism and recurrence, recurrent

nerve injury)

contraindicated………….in children - recurrence after surgery

If recurrence after surgery??? Radioactive iodine is the best ‫ماتفتحش الرقبة مرتين‬

Antithyroid drugs……carbimazole ---- (SE Agranulocytosis, # with Pregnancy)

Best Drug for pregnant …. Propyuracil + propranol……for palpitations

Definitive ttt………..surgery in 2nd trimester

Drugs for pregnant woman -----→ fetal hypothyroidism

Best test for follow up in pregnancy ………T4

Hypothyroidism and pregnancy: Thyroxine…..safe, ↑requirements

Children…….drugs

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thyrocardiac patient…..surgery

Cancer………total thyrodectomy

With exophthalmos …. make the patient euthyroid first…vvv imp

Sub-acute thyroiditis = De QUERVAIN's THYROIDITIS: ‫التهاب بالغدة‬

Viral etiology, Thyroid TENDRNESS (only type(

RAIU -> LOW……..vimp. All thyrotoxicosis high….

Tx -> ASPIRIN to relieve pain…..vv imp.

Pituitary adenoma: only cause of hyperthyroidism with ++ T4 & ++ TSH

Dx -> Brain MRI ..

Tx -> Surgical removal…. Route……transsphenoidal…..vvvvvvvv imp.

Exogenous thyroid hormone abuse:

↑T4 ……. ↓TSH……… The gland will atrophy ………key word.

Sick euthyroid $yndrome = low t3 syndrome

Acute severe illness… ICU Pt ………key word

↓T3 …… vvvvvvvvvv imp …..High, low or normal T4 & TSH

Hypothyroidism (myxedema): MCC…. Hashimoto's

Eye brows…..loss outer 2/3 //// Thyrotoxicosis ….. exophthalmos

Myxedema coma:

old patients + Predisposing factors…..infections or cold weather

Hypothermia, Hypoventilation, Hypoglycemia, HF

TTT: Iv hydrocortisone + iv thyroxine (by order ff adesonian crisis)

↓T3 and T4

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TSH: 1ry……increased --- 2ry…..decreased ---- Iodine uptake…..decreased

TTT… L-THYROXIN Start with 50 MG/day Average maintenance..200 MG / day

In old patient and CVD patients; Start with 25 and increase gradually 25 per time

Monitoring by TSH … When ?.....4 weeks after starating the ttt..vvvv imp

Pregnant with hypothyroidism….increase dose of thyroxine

Hashimoto's thyroiditis: Hypothyroidism symptoms.

Thyroid peroxidase antibodies….. ↓T4 …… ↑TSH

TTT: thyroxine replacement

MCC hypothyrodismin in Newly born…….congenital dysgenesis

Children / Adult……………..hashimoto's

Developing countries…..iodine deficiency

Most imp thyroid marker in pregnant…..T4

Most imp marker to follow patients with thyroid disorders….TSH

Most imp marker in euthyroid sick syndrome……….T3

Hypothyroidism vs depression and dementia????

How to differentiate???.. Other manifestation of hypothyrosim esp. constipation

Subclinical hypothyroidism vs subclinical thyrotoxicosis:

Both of them……..normal T3 and T4 …… NO symptoms

Subclinical hypothyroidism……High TSH

Subclinical thyrotoxocisis……low TSH

Retrosternal goiter: Neck swelling + obstructive symptoms (pemberton sign)

Inv of choice…..CT chest TTT……….surgery

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Diabetes mellitus: FBS >7 mmol/l …. PP/RBS >11mmol/l…. Hb1c >6.5

Best test for follow up…………HbA1c / 3-6 M

First step………lose weight and diet

Type of carbohydrate……complex not simple

First step in diabetic thin patient……metformin

First line……metformin ( esp in obese patients )

MC SE …….lactic acidosis…….check RFTs

Stop metformin 1-2 days before surgical operations

Insulin dose….start with 20 units per day then increase gradually

Comp: Hypoglycemia, Weight gain, Allergic reaction (change position of the inj)

Wrong dose……usually over dose….nocturnal sweating

If morning hypoglycemia…………decrease long acting at night

If morning hyperglycemia………increase long acting at night

Statin and DM: in type 2 DM with:

1-any CVS risk factors ( smoker, hyperlipidemia, HTN, obesity)

2- absolute CVS risk more than 15%

Diabetic ketoacidosis:

MCC 1st… infection 2nd… Missed insulin 3rd… Newly diagnosed

Cl/P: Abdominal pain, kussmul's breath, N, V, dehydration, confusion then coma

First step……..ABG then…. Urine: glucose and acetone

hyperglycemia and hyperkalemia

TTT: First step……IV fluid (dehydration/Acidosis), normal saline, 4-8 liters

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Second step…..insulin (regular short acting)

Acidosis: self corrected after giving the fluid

Why hypokalemia occurs?.....intracelluar shift after giving insulin

When to give K ??? ………Only after passing urine……

When to give glucose??? If glucose is less than 250 mg/dl…..give glucose 5%

Most common complication during ttt of DKA…..hypoglycemia

Most serious complication/ cause mortality during ttt of DKA…..cerebral edema

Hypoglycemia:

MCC: Overdose of the insulin

Cp………sympathetic overactivity:

TTT…….iv or oral glucose (impaired consciousness …only IV glucose)

In severe cases….IM glucagon

Acathosis nigricans: DM / PCO

Hyperpigmented velvety patches over neck, axilla dt….insulin resistance

-------------------------------------------------------------------------------------------------------------

Acromegaly: Increased growth hormone, pituitary adenoma.

Coarse facial features…..

Best screening test…………insulin like growth factor

Best confirmatory test…….GH suppression by glucose

MRI -> Pituitary lesion.

TTT: Surgical resection with trans-sphenoidal removal.

MCC of death….. CHF Cancer with acromegaly….. colon cancer

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Primary hypo-parathyroidism

MCC: Post-surgical……….. after thyroidectomy & removal of of 4 parathyroids

↓Ca -> perioral Numbness (1st sign), carpopedal spasms , Seizures.

TTT: First step ---→ Ca+2 gluconate…. Long term ----→ vitamin D and Ca

Primary hyper-para-thyroidism: MCC Parathyroid adenoma (90%)

Cp: Abdominal groans, renal stones, bones #s & psychic moans.

First inv for hyperparathyrosim ……parathyroid scan (MCC of ↑Ca ---→ ↑PTH)

↑Ca ……. ↓ PO4……. ↑PTH……

Dexa scan…..osteoporosis

Only type of hyperpathyrosim with low ca+2 level…..secondary to RF

Only type of hyperpara with low PTH ...pseudo( malignancy)

TTT: Parathyroidectomy

TTT of asymptomatic hypercalcemia…..none

hyeperparathyrosim vs familial hypercalcemia hypocacuria:

S. calcium……..…↑ ↑

Urin calcium…….↑ ↓

PTH……………….…↑ ↓

Mother with ↑Ca, son presented with ↑Ca: 1st inv: urin Ca (the ↑Ca not 1st PTH)

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Cushing $yndrome = hyper-corticolism:

Fat redistribution -> Truncal obesity, moon face, buffalo hump, thin arms & legs.

Hypertension -> From salt & water retention.

Hirsutism, pigmentation of the skin

Hyperglycemia - Hyperlipidemia -

DD Of cushing…. Sources of Cushing $ …vvvvvvv imp

1-MMC Pituitary tumor 70% – 2-Ectopic – 3-ACTH Adrenal adenoma

Pituitary tumor Ectopic adrenal

adenoma
ACTH HIGH HIGH LOW
Dexa Suppresion yes no no
Specific test MRI CT CT

.Tx ------------> Removal - Removal - Removal.

Cause of striae…..rupture of subcutaneous tissue

Only type of cushing with low ACTH…..adrenal

Inv of choice for cushing…..suppresion test

Only type that is suppressed by dexamethasone…pituitary

Cushing vs PCO???? Both ………obese, hirsutism, and menstrual disorders

Cushing…+……causes psychiatric manifestations

Adrenal insuffeciency = addison disease :

Mcc….. Auto immune….. TB in developing countries

Cl/P: Pigmentation←----- key word + ‫همدان بيرجع‬

Scars (only recent only) ……vvvvvvv imp

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TTT…..oral cortisone

Addisonian crisis: Hypotensive + Pigmentation + ‫همدان بيرجع‬

Aggressive iv fluid…N saline if not improve… nest step/ DOC iv hydrocortisone

Any pt with vomiting --- ↓K…. the only one ↑K is adisson

Patient with lung cavitation now complaining of weakness and pigmentation…..TB

affected adrenal gland

How to deal with accidental discovery of suprarenal mass???

If less than 4 cm…follow up (if no other hormonal changes-no Hormonal activity)

If more than 4 cm………..biopsy/adrenalectomy

Metabolic syndrome: ↑FBS, abd obesity, ↑Tri LDL ↓HDL, HTN

Pheochromocytoma: panic attack + Headache + HTN.

BEST INITIAL -> VMA levels.

MOST ACCURATE/ of chioce -> MIBG scan of the adrenal glands.

TTT: PHENOXYBENZAMINE (Alpha blocker) "FIRST" to control blood pressure.

Surgical resection.

Erectile dysfunction: Failure of spontaneous erection.

MCC…. Anxiety (psychiatric)

Nocturnal penile tumescence:.Differentiate psychogenic from organic causes:.

(+) ve …………… psychogenic causes (-)ve …………… organic causes

Erectile dysfunction in D.M Due to vascular complications & neuropathy.

1st line of ttt. Sildenafil (SE PRIAPISM)… # with nitrate ---→ sever hypotension

Most common cause in diabetics……anxiety

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Most common organic cause in diabetics….neuropathy

Most common cause after MI…..anxiety

Most common cause after pelvic injury….nerve lesion

Most common drug causing it……alcohol

Most imp question in history…..night erection

Most imp investigation…… nocturnal penile tumescene

Elderly with cancer developed constipation….check Ca level

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Medical ethics
Doctor and Society

Child abuse:

-:
First step……..photography for documentation

.Child Abuse = Always report……….. to Child Protective Services

Report even if its just suspected

Which kids at high risk for being abused????

1-premature

2-low birth weight

3-baby with congenital anomalies

When to suspect????

Delay in seeking the medical care

Unexplained injury

Injury not compatible with the history

STDs in prepubertal child

Types:

1- Emotional ………..most common…..most common cause of

malnutrition in kids

2- Neglect 12nd most common

3-physical ….examples:

1-bruises….of different colors

2-fractures…..esp. spiral fracture of the humerus

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3- Cigarette burns

4-head trauma……CT is a must

5-retinal hge……do a fundoscopy

6- Abdominal injuries

Maunchausen syndrome by proxy:

The parent (usually the mother) fabricates or induces illness in the child

4- sexual abuse:

Most common offender……….the father

Most common type of incest……..brother-sister

How to suspect??

Vaginal, penile or rectal pain, discharge, bruising, erythema or bleeding

ANY STDs in prepubertal child

Bite marks on the genitals or inner thigh

First step…….photography

Then………admission for protection and report

Then…….complete body exam and search for the other STDs

Elder Abuse = Report to…..Adult Protective Services…..even if the

competent adult refuses

Types:

Neglect………most common

Physical

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Psychological

Financial

Offender………caretaker is the most common

Report ……….is a must

Who is at high risk????

Male more than female

 Has memory problems (such as dementia)

 Has physical disabilities
 Has depression, loneliness, or lack of social support
 Abuses alcohol or other substances
 Is verbally or physically combative with the caregiver
 Has a shared living situation
risk factors increase the likelihood that a caregiver will participate
in elder abuse

 Has a history of substance abuse or a history of abusing others

 Is dependent on the older person for housing, finances
 Has mental health problems
 Is unemployed
 Has a criminal history
 Has a shared living situation

Spouse violence:( domestic violence)= intimate violence

Types:

Physical……….most common ((‫بيضربها‬

Psychological

Financial

Sexual

Reporting……….NOOOOOOOOOOOOOOOOOOO
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Who is at high risk????

Pregnant……..most risky……..highest in last trimester

Dependent personality disorder

Married at young age

Aboriginal females

Disability

First step….encourage the woman to talk more about her bruises

Second step……tell her that domestic violence is not acceptable

Third step ……encourage her to access specialist support

services (eg woman’s health centre, social worker, counselor

Encourage her to report by her self but you as PHYSICIAN

never report
Discuss options for safe temporary accommodation if needed and available (eg
safe house, family or friends, hospital)

:Impaired Drivers

)Can’t Drive = Seizure Disorder / Vision Impairment / Syncope

.You can’t suspend or give Driving Licence………The Dept. RTA will

If Found Impaired Driver = Encourage Self Refraining from Driving >

> Using Alternate Transportation

)Encourage to Tell RTA…..if he refuses…..tell yourself

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Gifts from Pharmaceuticals

Accept if………..+ Educational/Medical -

They Can Sponsor Educational Presentation……..if they don’t interfere -

.with content

.Can Accept meals on those Educational Conferences -

Can’t Accept………if hidden agenda / Entertainment things like Movie -

.ticket, Sports Ticket

-:Autonomy

Operation without consent = Assault-

Only case where no consent needed = Emergency Situation-

Freedom to choose one’s own form of health care-

Follow patient pre-planned wishes……..Even if he lose consciousness & -

capacity to make decisions

Autonomy is more imp and takes precedence over Beneficence (Things -

.for patient’s own good). Patient can refuse Rx even it is better for him

Autonomy gives patient right to even make wrong choice for their -
.health care

-:Competence and Capacity to Understand

Only Court can decide = Competence = All Adults are considered

Competent

All Physicians can decide = Ability to Understand………………if difficult

.only then Psychiatrist

Under 16 Year = Minor

Immature Minor = <14 year

Mature Minor = >14 to <16 year

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Consent for Minor = Only Parent………..or…….. Legal Guardian. (No one

)else, whether relative/brother/neighbor

Only Exception = Emergency Situation

Partial Emancipation = Can Give Consent themselves = STD, Prenatal

Care, Contraception, Substance abuse

Minor Comes for Abortion = Encourage him to notify parents /

Encourage Discussion / Family Meeting Emancipated

Minors = Can Give consent for everything If They are…. Independent,

,Military, Married or Living Alone

Adult= Can refuse whatever Rx

Parents = Can’t refuse Life Saving Rx for child……Provide even if they

refuse e.g. Blood Transfusion to

.All Suicidal Patients = considered……..to LACK capacity to understand

-:Informed Consent

..……Inform patient about

All Rx options

what happens by disease if no Rx is done

If patient loses capacity to understand or to communicate…….follow his

last known wish (verbal or written).

Consent is taken by the person who knows all this….e.g. U don’t know
anything about procedure and Ur resident calls & asks u to take consent.
U will refuse and will ask the resident to take himself as u don’t have
.info, so u can’t inform the patients everything

Consent on Phone is Valid……even it is heart surgery……

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Just have 1 health care worker/nurse as ur witness + U take from

appropriate surrogate e.g. Family member or health care proxy + Who
.knows patient wishes

Pregnant Mother = Can refuse or allow whatever she wants………if that

harms her fetus

Fetus = not individual person = no separate rights

.e.g

Mother + 34 week Intrauterine Fetus = Do whatever mother says

Mother + 34 week born Child = Child has emergency = Do ur Rx, even if

.mother refuses

Maternal Consent = Enough……Father has no right over pregnancy

.related issue

Patient never had Capacity to understand e.g. Down Syndrome….now

?What

Whole Life…..Consent by = Parent or Guardian

Not Available = Substituted Judgment = Person who knows Patient….can

.decide what patient would have wished

Weakest Consent Method = Best Interest of Patient. = Best Method for

= .those who never had Capacity

.Court appoints a guardian or Medical Director to make the choice

,So Normally

Consent from Patient himself > Can’t give Then Advance Directive
(Health Care Proxy or Durable Power of Attorney) > Substituted
Judgment by Family Member or Guardian >

-:Best Interest Method CONFIDENTIALITY

Always Maintain Patient Info Confidential…….Except =

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1-Harm to 3rd Part -1

2- Court Order/subpoena/search warrant -2
3- Patient gives consent -3

)From Everyone = Friends, Family (Even if patient has good relations

.If someone asks = I’m sorry, I’m not authorized to give this info

Patient had MI, now admitted & awake…..wife came now & asks = Take
.permission from patient first

If everyone is awaiting result of a test (e.g. biopsy) = Always inform

.Patient first, ask permission, then you can tell family

.If family members comes first = Say I will tell to the patient first

Only 1 exception = Psychiatric Disorder + New medical illness may cause

.Suicidal Attack = Tell family immediately to protect patient

If Government Employee comes & asks = Tell info. Only if he

has……….Subpoena, Court Order or Search Warrant…..Otherwise =
.refuse

= Harm to 3rd Party

i- Psychiatric Patient with Intent to Kill……….Inform Police + Victim

-:End Of Life Issues

If Patient has capacity to understand = Patient can refuse Rx at start….or

any time even after starting of Rx. E.g. after getting that Rx for 1 week or
month etc…………….even they will die without it

.e.g

Renal Failure………Patient can refuse Dialysis from

.Start………….or………..can refuse any further after having it for 6 months

.COPD…Now Mechanical Ventilation = Patient can refuse

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Quadriplegia + Wants to have mechanical ventilation for whole life =

.honour his wishes, Don’t say u will never improve

Aplastic Anemia + Now no more Transfusions = Explain the consequence

.that she’ll die, and stop Rx and honour wish

But…. If Patient has Depression = Means No Capacity to understand =

.Psychiatric Consultation/ Trial of Behavior Rx / Anti-Depressants

Advance Directive = Patient communicates in advance of becoming

.unable to communicate his wishes

.Methods = Living Will …………….&………………….Health Care Proxy 2

Health Care Proxy = Medical Power of Attorney = Durable Proxy =

Proxy Speaks for the Patient…… A messenger of patient………Proxy over

.)Family, wife etc(rules all other decision makers

Proxy Says = What were patient directed instructions or what patient

would have wanted. If No Advanced Directive…….

Now Sequence of Decision makers is Normal Family = Wife > Parents >
Adult Children > Siblings > Friends

Split Family = …..family meeting…..then Ethics Committee or Court

.Order

Living Will

a- If Specific Details = Useful = Overrule everyone

b- If vague like no heroic care = Useless = Difficult to understand and

follow

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if Patient + no Advanced Directive

)i- Family Agrees = Follow it ( Oral Advanced Directive )

ii- If Disagrees = Encourage Consensus/ Request Discussion/Talk with

involved parties……………if not possible = Refer to Ethics Committee…….

Last Step = Court Order / Judicial Intervention

So Order is = Patient Decision himself > Advanced Directive (Proxy,

United Family Decision > Family >Living will) > Oral Advanced Directive
Disagreement Resolved with Discussion > Resolved with ethics
.committee > Court Order

DNR = Donot Resuscitate = Chest Compression, Cardioversion, Acute

Anti-Arrhythmics only………….can do everything else

Can do Surgery, biopsy, Rx etc etc….just no CPR if patient loses pulse,BP

.or breath

Healthy Person can also sign DNR, he doesn’t have to be a terminal

.patient to sign that

DNR doesn’t mean you let the patient die by other means or be less
.careful

?..What about Intubation in DNR

If Patient is Normal…..but has respiratory disease = intubate

If Patient is Unstable = Don’t Intubate (as here Intubation is part of

.)resuscitation

?..What about Artificial Nutrition

Capacity to understand = Artificial Nutrition (NG, Jejunostomy etc) and

TPN (Hyperalimentation) also with consent
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Euthanasia = U yourself give lethal drug and kill the patient on his
.request = Super Duper Wrong….in every State

Law Of Double Effect = Same Drug……can be doing good but at same

time killing the patient

a- If Intention is to do good = Do it………..even if it kills

.b- If intention is to kill = Never do it

.e.g

Metastatic Cancer + COPD + Intense Pain = Pain Killers relieve pain +

Decrease Respiratory drive = Give

the required amount of Opiod Pain Killer….even if he later dies due to

.COPD………..You can’t keep patient suffering

-:Futile Care

If Clear that it is futile = Don’t do it………..even if Patient….or……Family is

.demanding it

e.g. Cirrhosis + Varices + Encephalopathy not responding to

Lactulose………..You suspect death in a few days due to liver
disease………Now develops Hepatorenal Syndrome and Uremia = Don’t
Place Fistula for Dialysis as no change in outcome.Death

.Brain Death = Actual or Legal Death………….even if the heart is beating

.e.g

Man robbed a female and hit her in head…………She is Brain

Dead…….Court asks ur opinion = Tell him She is Legally dead, charge that
man with murder

.Loss of Brainstem Reflexes i.e

Light Reflex, Corneal Reflex, Doll’s Eye (Occulocephalic), Caloric

Response to Ice Water Stimulation to Tympanic Membrane,
.Spontaneous Respiration

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-:Reproductive Issues

:Abortion

1st Trimester = Clearly Available………Do whatever patient says

.2nd Trimester = Less Clear…..But Still do as patient wishes

3rd Trimester = Clearly Restricted for some states…..for exam abortion is

.allowed in all trimesters

Consent = Only from Mother in all Trimesters…………Nothing from

.Father

Physician has right to deny doing it………..Patient can’t force you to do

.it…..Refer to another physician

Gender Selection = Unethical

Getting Fetus Gender Checked….& Later abortion due to it = Unethical

Contraception = Freely available…….from Minors to Adults……..No

Parental Consent required.

Sterilization = Freely Available……..Only Patients consent required…..No

.Consent from Spouse

Prenatal Care/Abortion = No consent from Parents…..but always

.Encourage patient to tell parents

Sperm Donation or Selling = Completely Ethical

Egg Donation or Selling = Completely Ethical

.Fertilized Egg = Can only be donated…..but can’t be sold

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-:Organ Donation

.Autonomy Rules

Patient need Liver + Brother exactly HLA Matched + Don’t want to give =
.No one can force him……..not even court

Who can ask for Donation ? =

Only Organ Donor office Network……or……….Uniform Network for

Organ

.Sharing………..Physician treating the patient can’t ask for donation

only the donor network dr can come ask for their consent.…………

Why…? = Because Organ Donor Netwrok……… are trained to do

so……..their success rate of obtaining consent is greater + if care giver
physician takes consent, family thinks they are not doing everything to
.save him

Payment for Donation = Only for Renewable Tissues = Sperm,

.Unfertilized Egg, Blood

All Other = Unethical

.If In business of selling organs = Unethical

Give Organ to = Person who needs the most…………not a preferably to

rich.Organ Donor Card = Means if he dies……..donate organs……..but Still
.Family Consent required

.e.g

Organ Donor Card + Family says don’t donate = You will not donate any
.organ………vvvvvv imp

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Reportable Diseases

Always Report = To interrupt spread

If e.g. Meningococcemia Patient comes = Always Report………..otherwise

.Epidemic………….but Don’t reveal name of Source Pateint

If STD e.g AIDS, Syphillis, Gonorrhea = Encourage patient to tell

.partner……….if doesn’t……….Tell yourself

In Case of TB = Not only report……….but can isolate/incarcerate patient

for 2 weeks…….to avoid spread….as in 2 weeks of ATT….Sputum
.becomes Negative

..So Autonomy Ends…….where Safety of other begins Sequence is

TB Patient = Give ATT + Isolate for 2 weeks ……..If Refuses

Drugs…..Discuss with Patient…..still refuses….Offer DOT (Directly
Observed Therapy at Home)…..Still refuses………Don’t give ATT without
.consent but to avoid spread, incarcerate/isolate patient in hospital

-:HIV Related Issues

.If Patient gives consent for routine tests……that doesn’t include HIV

Separate Consent = Even for Testing HIV…………if he says No……U cant

.Test for HIV

.e.g

Pregnant Lady with STDs + U offer HIV Testing + She refuses = U will not
.do it

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HIV +ve Pregnant Lady + U offer Anti-Retrovirals + She Refuses = U will

.not give them………….even though this will transmit virus to her baby

)Autonomy of Mother > Safety of Child(

HIV +ve Pregnant + Refuse C Section = Do vaginal delivery….U can’t

forcefully do C Section

Do Notify the Partner = To interrupt spread and Treat him

HIV +ve Patient + Doesn’t want to tell partner = Discuss with

him/Encourage to tell partner…………..still refuses……Inform Health
Department…..Which will make list of partners from patient and notify
them…….if patient refuses to give name of partner = No penalty or
incarceration for patient + If u have

Any idea about partner, notify by yourself, u r protected

Refusal to Treat HIV +ve Patient = Unethical……………but no one can

force a Dr to treat him… so Best choice = Refer the patient to another
.physician

-:STDs

ii- STDs……. 1

First Encourage Patient to tell partner himself…..if he doesn’t… Then Do

.it yourself

!..Trace Contact……..Report…….and Notify

But only those = Can be Treated/Eradicated = HIV, Gonorrhea, Syphilis

Not for those = Can’t be Eradicated = Herpes Simplex

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e.g

Syphillis Patient = Next Step = Ask have you told your partner ?
……..No………Encourage him to tell………..Refuses…… Tell him That Health
Dept. will make a list of all at risk persons + will invite to hospital + then
will inform them + will not tell about u (Source Patient)….. Still refuses ….
Discuss….. Still refuses… You say I will notify………..he threatens to sue….
.U r legally protected, go notify

Malpractice

Rules = 3

1- Error in Care

2- Evidence for error

3- Harm done to patient

If 1,2 are still there…..but no harm done patient = Its not malpractice

e.g.Osteomyelitis + U gave oral drug = Patient became fine but found out
that Biopsy & IV drug is standard

.care + files suit = No Malpractice as no harm done

Patient had Surgery + U forgot to give DVT Prophylaxis + He didn’t

develop it = No malpractice

-:Doctor Patient Relationship

Both Patient and Dr…………can choose their Dr / Patient………..No one can

.force anyone

Gifts = If some intent behind it or Large……don’t accept

Dr/Patient Sexual Contact = Unethical……No matter who initiates

it………..If Indication…..Both should mutually terminate Dr/Patient
.Relationship

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Physician = No Sexual Contact with Present Patients……………..but can for

.Previous Patients

Psychiatrist = Can’t Have not only with Present….but also not with all
.past previous patients

-:Doctor Doctor Relationship

Impaired Doctor = Alzheimers/Substance Abuse/Psychiatric

Disorder/Emotional Disturbance/alcohol or drugs = Report to medical
borad

If nurse……….nurse medical borad

If No Patient Care affected e.g. just Wild Parties, bad language,

Motorcycle gangs on weekends, tattoos=Don’t report

:Physician Disagreement

If Attending….disagree….with Resident = Follow Attending as he is

senior.If Resident….Disagrees = Discuss/Confer/Try to reach consensus
with evidence based medicine……if not resolved…………go to Higher Local
.Authority like PD

)Don’t answer………..inform the patient(

-:Experimentation

.Voluntary + Only with Informed Consent……….Everyone can refuse

If Child = Then consent from parent/guardian

.Same Rules for Prisoners…..no changes

If Study does definite harm to patient = Unethical….not Approved

.e.g

.Not giving Abx to Pneumonia………..just to see what Placebo will do

Does the patient has the right to withdraw from the study ??.........yes.

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Ethics of abortion in Australia:

FIRST STEP ……..ASSES COMPETENCY

More than 16ys……….competent

Less than 14 ys……….immature

14-16 ys and independent……..cempetent

If less than 14 ys…….inform parents or guardian

If less than 14 ys and raped…sexual assult authorities

Process of abortion

1-counselling about abortion

2-informed consent from patient or guardian if immature

3-do abortion

Who is allowed to do the abortion??......only the physician

can the physician refuse to do abortion?....Yes…..refer the

patient

Where is it done?...........only tertiatry hospital

Till which time of pregnancy abortion is legally allowed??

At any time during pregnancy

Less than 12 weeks……the safest time

If more than 20th weeks…….ask for approval of health act

Girl over 16 years but unable to give informed consent????

Get it from the guardian

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Osteoporosis:

Causes:

Female (white)

(+) family history

Postmenauposal

Thin……..BMI LESS THAN 19

Alcohol

Smoking

Caffeine

Cortisone

Decreased exercise

Decreased Ca intake

Anorexia nervosa

Renal failure

Celiac

Hyperthyroidism

RF

C/p:

Fracture (femur, Vertebrae)

Vertebral Collapse

Posterior humping

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Classification:

Osteopenia : -1 to -2.5 (T score)

Osteoprosis : < -2.5 (T score)

When to say osteoporosis??

1-T score………less than -2.5

2-minimal trauma fracture

Investigation………. DEXA scan…..INVESTIGATION OF CHOICE

If you suspect fracture………….X-RAY..vvvvvvvvvvv imp

Prevention………..vvv imp

Ca and vitamin D supplement

Treatment:

Bisphosphanate (all cause Oesophagitis except Zoledronic )

Raloxifen (SERM)……….patient with breast cancer history

Sertonium Ranelate

HRT,Cacitroil

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Menopause:

 Hot flashes
 Migraine
 Rapid heartbeat
 Dysfunctional
bleeding ………..anovulation

Urogenital atrophy

 Itching
 Dryness

 Watery discharge

 Urinary frequency

 Urinary incontinence

 Urinary urgency

 Increased infection,

Skeletal

 Back pain
 Joint pain, Muscle pain

 Osteopenia and the risk of osteoporosis gradually

developing over time
Psychological

 Depression and/or anxiety[10]

 Fatigue
 Irritability
 Mood disturbance
 Sleep disturbances
 Sexual

 Dyspareunia or painful intercourse

 Decreased libido


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 N:B:

Most imp inv…………increased FSH

Most common symptoms……..flushing

Most common indication for HRT in menopause….flushing

Immediate benefit after giving HRT……..decreased flushing

Most common cause of dysfunctional bleeding near

menopause……..anovulation

Most common cause of dysfunctional bleeding at the beginning

of puberty……..Anovulation

Menopause+ irregular bleeding…..cancer endometrium

First step in cancer endometrium……hysteroscopy and biopsy

Bleeding after sex……consider atrophic vaginitis

Most common cause of postmenopausal bleeding….atrophic

vaginitis

Why increase risk of infections in elderly?.....atrophic vaginitis

Most common cause of infection…..bacterial vaginosis

Least symptom to consider normal at menopause….depression

Least symptom to improve with HRT ……..depression

Important differential diagnosis: …vvvvvvvvvvv imp

Bleeding within first year after menopause..follicular activation

Menopause + greenish, grayish or yellowish

discharge…infection

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Menopause + brownish discharge………….cancer endometrium

Menopause + pain during sex + bleeding…..vaginal atrophy

Menopause + no pain during sex + bleeding…cancer

endometrium

Hormonal Replacement Therapy

Indications:

Distressing symptoms of menopause

Osteoprosis

Duration ……..not more than 5 years…..vvvvvvvvvv imp

Mode of administration :…..vvvvvvvvvvv imp

Cyclic ………….. perimenopausal

Continuous……….. postmenopausal ……unpredictable bleeding

Complications:

Breast Cancer if used > 5 years

Endometrial Cancer

Coronary disease

Stroke

PE,DVT…………especially with estrogen

Contraindications:

Oestrogen dependent tumor(Breast ,Endometrial)

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Special cases with HRT:……….vvvvvvvvvvvvvv imp

1- Woman with history of DVT

Best ………NOT to give estrogen at all

If you have to give estrogen….estrogen patch

2-woman with H/O hysterectomy:

Estrogen alone ……NO progesterone

3- Woman with history of breast cancer:

1st line………….paroxetine

2nd line………..clonidine

4-woman complains of only atrophic vaginitis:

Estrogen cream is the best

5- Woman on HRT for 5 years

Trial of stoppage

Contraception :

Combined oral contraceptive pills:

Ethynil estradiol 30-50 (estrogen used)

Levonorgestrol (progesterone used)

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Indications for high dose estrogen (Microgynon 30-50)

enzyme inducer drug…..vvvvvvvvvvvvv imp

Main site of action of pop (low dose).........cervix

Main site of action of pop (normal dose).......ovary
Main site of action of COC...hypothalamo pituitary ovarian axis

Non contraceptive advantages of ocp:

Decrease all the following:

Dysmenorrhea

Functional Ovarian Cyst

PID

Ovarian and Endometrial Cancer

Benign Breast Diseases

OCP and cancers:

• It decreases the risk of :

• 1-endometrial cancer
• 2-ovarian cancer
• 3-colon cancer
• 4-begnin breast disorders
•
•
• It increases the risk of:
• 1-cervical cancer

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• 2-breast cancer
•
• Contraindications of COC:

• Absolute: Relative :
• Pregnancy 1-3 weeks Smoking
• Breast Feeding
• CV and Coronary Diseases HTN,DM
• Thromboembolic and Polycythemia
• Focal Migraine with aura
• Liver Failure
• Estrogen Dependent Tumor
•
•

Missed Pills:

• If the missed pill in Week3………. omit the pill free interval

• The 7 Day Rule :
• Take the forgotten pill as soon as possible
• If time > 12 hours……………………. use condom for 7 days
• If these 7 days runs beyond the last hormone No pill
free interval
• Just Keep Going
•
• Progesterone only Contraceptive Pills :
• Indications : Contraindications:
• Ages>45 pregnancy
• CI for Estrogen Bleeding
• DM ,HTN Ectopic Pregnancy
• Migraine Enzyme Inducer Drugs
• Chlosma
• Lactation
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•
• Injectable Contraception
• Depoprovera
• The least Failure Rate 1/1000
• Side Effect :Delay Fertility for 6 months
• WT gain
•
• Implanon (etonorgetrel implant )
• Sub dermal implant for 3 years
•
•
•
• Emergency Contraception:
• When u need it????
• 1-Rupture of condom
• 2-Unplanned sex
• 3-rape
• 4-missed pill in the 1st week
• How?????..........Postinor
• Levenogestel 750 gm tablet followed by another tablet
after 12 hs
• Limited to the first 72th hours:
• Failure rate 2-3%

IUCD

• Types:
• Copper , Mirena
• Absolute Contraindications:
• Pregnancy Bleeding
• PID Cervical Distortion
• previous ectopic
• Complications:
• Pregnancy ectopic

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• Bleeding
• PID
• Perforation………..do x-ray
• Pain
•
• Barrier method…………… The Highest Failure Rate
• Diaphragm……..highest failure rate
• condom
• Spermicidal
•
• Natural method
• Basal Body Temperature
• Coitus interruptus
• Increase cervical secretions …..most sensitive method

Sterilization:

Vasectomy:

It takes 2-3 months to confirm absence of spermatozoa

TUBAL LIGATION:

Done by laparoscopy……clips

OCP with lactation………vvvv imp:

Best is………..POP

Timing to start…….6 weeks

Never estrogen…….risk of thrombosis

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N:B:

Epilepsy……………………………High Dose pill vvvvv imp

Amenorrhea………increase estrogen

Decrease libido……increase estrogen

Breakthrough bleeding……..increase estrogen

Fullness/tenderness…………decrease estrogen

Chloasma…….stop estrogen

Dysmenorrhea or Menorrhagia………..increase progesterone

Focal migraine……stop bill……vvvvv imp

Most common used method in Australia…..OCP

Most common used contraceptive in Australia in young

females…….OCP

Best method for young couple……OCP

Least used method…….diaphgram

Highest failure rate…….diaphragm followed by condom

Least failure rate………. Injection

Female started OCP and now hypertensive first step…..stop

OCP and check response

Most absolute indication to give OCP to female after

labor…..low frequency of breast feeding

Main benefit of Jasmin …………..no WT gain

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Infertility:

Inability to achieve pregnancy after 12 months of unprotected

& frequent intercourse.

1 -> The 1st step is SEMEN ANALYSIS.

2 -> If normal -> ANOVULATION work up.
3 -> FALLOPIAN TUBE work up

First step……..semen analysis

Volume…….2-5 ml

Sperm concentration…..at least 15 millions/ml

Total sperm count……….at least 39 millions

Mobility……40% mobile

Ph……more than 7.2

Most common drug affecting sperm count…….alcohol….vvimp

{2} ANOVULATION:

. Dx -> Basal body temperature (BBT) chart -> NO midcycle

temperature elevation.
. Dx -> Progesterone -> LOW.
. Dx -> Endometrial biopsy -> Proliferative stage.

Progesterone withdrawal test indicative of anovulation

…vvvvimp
. Tx -> INDUCTION OF OVULATION -> CLOMIPHENE CITRATE

Most common side effect -> OVARIAN HYPERSTIMULATION

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{3} TUBE ABNORMALITIES:……

. Dx -> Chlamydia…………….induce tubal adhesions.

Inv -> HYSTEROSALPINGOGRAM (HSG)

. Tx -> LAPAROSCOPY ->
. Tx -> If tubal damage is severe -> IVF.
N:B:

If female near menopause wants to get pregnant……IVF

Spermatic count less than 20 millions + female problems…..IVF

Cause of male infertility in cystic fibrosis…..absence vas

deferens

Marked decreased in sperm count + decreased mobility +

marked abnormality……..semen donor

Most common cause of infertility in female ≥40 ys…..her age

Why it is so hard for elderly females to get pregnant

……anovulatory cycles( decrease quantity and quality of ova)

 Asherman’s syndrome:

Adhesions inside the uterus

Cause…..any intrauterine procedures e.g: curettage
Symptom……..oligo or amenorrhea
Test…..no withdrawal bleeding after progesterone intake
Inv……HYSTEROSCOPY or hysterosalpingography
TTT: …REMOVAL OF THE ADHESIONS




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 krukenburg tumour:

 METASTASIS ON THE OVARY
 SOURCE………GIT CANCER ( STAOMACH OR COLON)
Ascites of ovarian cancer vs LCF:

Ovarian cancer:

Central dullness with peripheral resonance

LCF:

Central resonance with peripheral dullness

Premenstrual syndrome:

Age……30-40ys

Timing…….maximum before menstruation

 Psychological :
 tension, irritability, tiredness,
 feelings of aggression or anger,
 low mood, anxiety,
 change in sleep pattern,and sexual feelings

 Physical :
 breast swelling and/or pain,
 abdominal bloating,
 swelling of the feet or hands,
weight gain
 migraine

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TTT:

Noting in a diary………..vvvvvvvvvvvvvimp

TTT of choice for premenstrual disorder:

First step……….relaxation
If failed…………SSRI
If severe symptoms………..SSRI
N:B: Dealing with excessive menstrual bleeding:
Guidelines:
First step………..TSH
If normal………..TVS
If normal………look for other systemic causes

Dermoid cyst( teratoma)

Consistency……….solid and cystic
Skin, hair follicles, sweat
glands. hair, sebum, blood, fat, bone,nails, teeth, eyes, car
tilage, and thyroid tissue.

Sites:
Ovary….most common
Periorbital
Spinal
US…….solid and cystic
TTT…..removal

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Eating disorders
Anorexia nervosa
Incidence………….vvv common
Sex …………FEMALE
Age…………adolescent
Affected by culture and modern fashion
Clinical picture;
Body dysmorphic disorder……….unrealistic self valuation
as overweight.
Restricted food intake and low food caloric intake
Great concern with appearance
Denial of emaciated conditions
Self induced vomiting laxatives and diuretics abuse
Strenuous exercise
Scarred or Scratched hand from self gagging to induce
vomiting
Lanugo hair………fine hair on the trunk
Body weight…….very low BMI …..vvvvvvv imp
FSH and LH ……..decrease
Estrogen and progesterone………. decrease………..breast
atrophy and amenorrhea
Bone mass……..decrease……..osteoporosis and
stress fracture

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CBC………..normocytic normochromic anemia

Liver enzymes………abnormal
Brain mass…….decrease………abnormal EEG
PULSE……….bradycardia
Bp……….hypotension
Lower limb edema…….Ankle edema
Electrolytes imbalance……….hypokalemia
……….cardiac arrhythmia…vvvvvvv imp
Complication……….death 15-20%
Inv NOT routine in anorexia nervosa………gonadotropins
If become pregnant………low birth weight …vvvvv imp
Treatment;
Hospitalization
Electrolytes correction
Hydration and parentral nutrition
Behavioral therapy

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Bulimia nervosa

Two types
Purging………..self induced vomiting or using of laxatives
or diuretics
Non purging……..fasting or exercise

Age……….early adulthood
Sex ……..female
Body weight ………normal
Recurrent episodes of binge eating especially after high
caloric diet.
Feeling of guilt and low self esteem
dental enamel erosion, enlarged parotid glands, Erosions on
the hand
Association…………depression
Personality disorders ……….borderline personality
disorder
Treatment;
Cognitive behavioral therapy
SSRI…………for depression
Psychodynamic behavioral therapy…….for borderline
personality disorder

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Dental erosion Hand erosions

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Body dysmorphic disorder

Sex……… females
Belief that a part of the body is abnormal or defective
Usually the patient concerned about her face
Constant mirror checking
Multiple visits to dermatologists and plastic surgeons.
Attempt to hide the deformity
Avoid social situations
House bound
Impairment social functions
TTT……….psychotherapy

Most important risk factor for:

Anorexia nervosa........ family history of atheletism
Bulimia nervosa ....... history of child abuse
Binge eating...... family history of obesity

Causes of body dysmorphic disorder? Vvvvvvvv imp

1-bulimia nervosa

2-anorexia nervosa

3-amputated limb

4-acromegaly

5- Neglect syndrome

N:B: Hypochondriasis is NOT body dysmorphic disorder

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Personality disorders;

Paranoid
Distrustful, suspicious; interpret others’
Usually isolated
Emotionally cold and odd

Schizoid
Isolated, detached “loners.” Restricted
Emotionally sufficient
Disinterested in people and others
Disinterested in sex
Disinterested in criticism
Odd behavior, perceptions, and appearance
.

Schizotypal
Isolated, detached “loners.” Restricted
Emotionally sufficient
Disinterested in people and others
Magical thinking; ideas of reference and persecution.
Patients are suspicious and distrustful of psychiatrists,
making it difficult to form therapeutic relationships between
patient

Avoidant
Socially inhibited
Rejection sensitive.
Fear being disliked or ridiculed
Feel lonely
Very sensitive the criticism

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Borderline……..vvvvv imp
female
Unstable affect
Mood swing
Marked impulsivity
Unstable relationship
suicidal ideation
Feeling of emptiness
Inappropriate anger
Common defense mechanism ……..splitting
Complication……….psychosis
ttt………….psychodynamic _ dialectal therapy

Narcissistic
Self importance
Grandiosity
Preoccupation with success
Very sensitive to criticism
Lack of empathy
Unstable mood

Antisocial
Male
Recurrent criminal acts
Cannot follow social rules
Impulsivity
Doesn't respect the others rights
Aggressiveness and lack of remors
Begins in childhood as conduct disorder..

Obsessive compulsive
Female
Preoccupied with perfectionism, order,

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And control at the expense of efficiency.

Inflexible morals, values
Details of everything
Indecisiveness.

Dependent
Female
Need to be taken care of.
Difficulty making decisions
Feel helpless.
Worry unrealistically about
abandment
Depend totally on husband or family member

Historionic
FEMALE

 Exhibitionist behavior
 Inappropriately seductive appearance or behavior of a sexual
nature
 Constant seeking of reassurance or approval
 Excessive sensitivity to criticism or disapproval

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 Pride of own personality and unwillingness to change, viewing

any change as a threat
 A need to be the center of attention
 Low tolerance for frustration or delayed gratification
 Rapidly shifting emotional states that may appear superficial or
exaggerated to others
 Tendency to believe that relationships are more intimate than
they actually are
 Blaming personal failures or disappointments on others
 Being easily influenced by others, especially those who treat
them approvingly
 Being overly dramatic and emotional

7

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Child hood disorders:

Attention deficit hyperactivity disorder;( ADHD )

Age : 5-7 years
Male more than female
Inattention
Hyperactivity in more than one occasion

Poor academic performance

Impulsivity
Inability to wait in line
Inability to follow orders
Inability to follow the rules
Prognosis; usually persist to adulthood
DD………DEAFNESS……
The same scenario+ speech delay…..do hearing tests
Management;

First step……… call teacher and ask for the

child school record
Treatment; methyphenidate

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Autism
Male than female

Age: before 3 years

Decrease communication; verbal and non verbal …..no
eye contact
Decrease sociability …. Lack of relationship…..no
playing with his friends
Speech and language………delayed

Repetitive behavior and fascination with certain toys

Outburst if you try to change his routine
Mental retardation in 75%
Association …….seizures
Treatment …family counseling and special education

Asperger’s syndrome:

An autism-like disorder of social impairment and repetitive

activities, behaviors, and interests
without marked language or cognitive delays.

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Rett’s disorder:
A genetic neurodegenerative disorder of females with
progressive impairment (e.g., language, head growth,
coordination) after five months of normal development.

Tourette’s Syndrome

Sex…….. males
Age…….. 7 years
Genetics……..autosomal dominant
Associations……….ADHD, learning disorders, and
OCD.
 
Hx/PE:

Motor (e.g., blinking, grimacing, trunk movements)

Vocal (e.g., grunting, coprolalia)
Tics occurring many times per day, recurrently,
Prognosis……..usually life long with exacerbations and
remissions

 Tx:
Antipsychotics (haloperidol, risperidone)....ttt of
choice

. Behavioral therapy

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Oppositional deficient disorder:

 Have temper tantrums

 Be argumentative with adults
 Feel anger and resentment
 Be spiteful or vindictive
 Act aggressively toward peers
 Have difficulty maintaining
friendships
 Have academic problems
 Blame others for their own mistakes
 Extreme negativism

Conduct disorder:

Symptoms:

 Breaking rules without clear reason

 Cruel or aggressive behavior toward
people or animals
 bullying, fighting, using dangerous
weapons, forcing sexual activity
 Not going to school (truancy --
beginning before age 13)
 Heavy drinking and/or heavy drug abuse and stealing
 Intentionally setting fires
 Lying to get a favor
 Vandalizing or destroying property

Causes:

 Child abuse
 Drug or alcohol abuse in the parents
 Family conflicts
 Genetic defects

Long term prognosis…………antisocial personality

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Selective Mutism…………. where children will speak freely

in somesettings (usually at home) but not in others (such as
at school)

Sexuality disorders
Masturbation
Normal human action
All men and women masturbate
More frequent in males
Abnormal only…….if interferes with daily functioning
Homosexuality
Normal variant of human sexuality vvvvvvvvvv imp
Gays less stable than lesbians

Sexual dysfunctions:

Anorgasm………..self stimulation is the ttt of choice

Premature ejaculation……….squeeze technique

Vaginismus…………vaginal dilators

Paraphilias;
Exhibitionism …..Sexual arousal from exposing one’s
genitals to a stranger.
Pedophilia ………… sexual activities with children…..
…….commonest.

Voyeurism………… Observing unsuspecting persons

unclothed or involved in sex……
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Fetishism…………. Use of nonliving objects for sexual

arousal.

Transvestic fetishism ……..Cross-dressing for sexual

arousal.

Frotteurism……….. Touching or rubbing one’s genitalia

against a nonconsenting person (common in subways)
.
Sexual sadism ………. inflicting suffering on sexual
partner.

Sexual masochism ……….being hurt, humiliated, bound,

or threatened.

Transvestic fetism: Transvestism

Type of paraphilia

Sexual satisfaction up to orgasm by wearing

the other gender clothes

Usually MALES

He is male and he knows that he is a male and he enjoys being

a male

Gender identity disorder( transexualism)

Men more than women

Persistent discomfort about his sex

Feeling as trapped in the wrong sex

Children have preference for friends from the opposite sex

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Wearing the opposite gender clothes

Refuse to urinate as sitting down if a girl or standing up if a boy

Believe they were born with the wrong body

Frequently asking for medications or surgeries to change their

physical appearance

Men have operations to remove penis, create a vagina, remove

the hair with laser and take estrogen to change their voices

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Somatization disorder
Female
Age….usually before 30
Underlying psychological stress

Multiple, chronic somatic symptoms from different organ

systems
2 GI, one sexual, and one neurologic

Frequent clinical contacts and/or surgeries

TTT………..One physician ……..psychotherapy

Conversion disorder

Young FEMALE
SUDDEN SEVERE PSYCHIC STRESS
NEUROLOGIC SYMPTOM……blindness, deafness,
paralysis seizure-like
La belle indifference………patient does not care about
her condition
Identification………model their behavior on someone
who is important to them
Low socioeconomic and less educated groups.
Usually resolves spontaneously
Psychotherapy

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Hypochondriasis
Men and women are equally affected.
Preoccupation with or fear of having a serious disease
despite medical reassurance
significant distress/impairment.
Often involves a history of prior physical disease.

TTT……..PSYCHOTHERAY

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Gynecology
Uterine Fibroid ( leiomyoma )
Most common risk
factor……..race (black)
Most common site
………….intramural
Cp:
Asymptomatic….majority of cases
Bleeding…….most common symptom
Complications:
Infertility and recurrent abortion…….submucosal type
Torsion …….subserosal type
Severe pain during pregnancy…ischemic necrosis…imp
prognosis:
It is affected mainly by estrogen level
So it is rare before puberty and degenerates after
menopause
investigation:
us
laparoscopy……subserous type
hysteroscopy…..submucosal type
TTT……
If young female and still seeks kids……MYOMECTOMY

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Give GNRH 3-6 months before operation….decrease tumour

size
If Old age patients and doesn't want any kids: Hysterectomy

Red degeneration of the fibroid:….vvvvv imp

Timing………..with pregnancy
Cp………abdominal pain and fever
TTT……….analgescics

dysmenorrhea
Primary dysmenorrhea:
Young female
Cause…….increased prostaglandins
Timing…..during menstruation
Lower crampy abdominal pain that ends by the end of
menstruation
Nausea and vomiting
First line TTT………NSAIDS
Second line TTT………OCP

Endometriosis

Most common site………ovary (chocolate cyst)

Second most common site…….. ( utero-sacral ligament)

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Cp: young patient

Infertility
dysmenorrhea
dyspareunia
dyschezia
Exam……..nodularity and tenderness
investigation:
CA 125…..increased
LAPAROSCOPY……..investigation of choice….vvvvvv imp
TTT….. Induce pregnancy or menopause
If young patient……..encourage pregnancy
Psudopregnancy………ocp
Severer cases.:……. psudomenopause
Danazol or GHRH ANALOGS (lupron or leuprolide|)
Side effects of danazol……menopausal symptoms:
Acne, hirsutims, hot flushes
Old patient…….TAH and BSO
N;B:
Most common site of endometrisis……..ovary
Most common symptoms …….pain and infertility
Investigation of choive……laparoscopy

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ADENOMYOSIS:
Age …..around 40
Symmetrical enlarged uterus
Dysmenorrhea
menorrhagia
TTT :
Young patient……ocp

Old or no longer want kids……..TAH and BSO

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Primary amenorrhea
No menses at age 14 without secondary sexual
development
Or Age 16 with sexual development
Probabilities
1-(+) breast and(+) uterus:
imperforate hymen
2-(+) breast and(–) uterus:
a- androgen insensitivity syndrome
b-mullerian agenesis
3-(-)breast and(+)uterus..
a-turner syndrome(gonadal dysgenesis)
b-hypothalamic pituitary ovarian failure

1st inv in 1ry amenorrhea:………vvvvvvvvvvvv imp

If secondary sexual characteristics exist…………..US
If NO 2ry sexual characteristics………….FSH and LH

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Mullerian agenesis
Normal female secondary development
Normal estrogen and progesterone
No uterus……..no menstruation
No tubes
Blind end vagina
TTT……….elongation of vagina

Androgen insensitivity syndrome

Defect………androgen receptors
Kayrotyping…..XY 46
Androgen convert to estrogen
Cp:
No uterus…….no menstruation
No androgen receptors……on pubic
hair, no axillary hair
TTT…….. removal of testis after puberty

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Turner syndrome
45 xo
Non functioning ovary….no estrogen and no
progesterone…….no breast, no menstruation
Short stature…vvvvvvvvvvvvvvvvvvvvvv imp
Low IQ
Webbed neck
Wide spaced nipples
CHD……..coarctation of aorta and bicuspid aortic valve
Horse shoe kidney
Cubitus valgus
Congenital lymphedema
MOST IMPORTANT TEST………INCREASED FSH
TTT…….
ESTROGEN AND PROGESTERONE REPLACEMENT only after
puberty

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Hypothalamic pituitary failure:

Causes:
Anorexia
Strenuous exercise
Severe Stress
Congenital…….kallman syndrome
Cp:
Normal uterus
No breast
Low GNRH…..low FSH AND LH……low estrogen and
progesterone
TTT…….pulsatile GNRH

KALLMAN SYNDROME
Low GNRH…..low FSH AND LH ,,,….. PRIMARY
AMENORRHEA
ANSOMIA

IMPERFORATE HYMEN:( hematocolpos)

CP:
CYCLIC abdominal pain
……ovulation occurs normally
No menstruation
Normal breast

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Progressively distended abdomen

Exam……bulging bluish hymen
Us………vagina, uterus and blood full of blood
TTT…….surgery under anaesthesia

Secondary amenorrhea
Causes:

 Obese……..pco
 Exercise too much and for long periods of time
 Have very low body fat (less than 15% - 17%)
 Have severe anxiety or emotional distress

Other causes include

hyperprolactinemia:

 Brain (pituitary) tumors

 Chemotherapy drugs for cancer
 Drugs used to treat schizophrenia or psychosis
 Overactive thyroid gland
 Polycystic ovarian syndrome
 Reduced function of the ovaries

Any female in reproductive age with secondary

amenorrhea ia pregnant untill proved otherwise

First test with secondary amenorrhea……B-hcg

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PCO

CLINICAL PICTURE:

Irregular bleeding

Obesity

Acne and hirsutism

Infertility

Acanthosis nigricans…..dark pigmentation in the neck

and axilla….secondary to insulin resistance

Why infertility……….anovulation

Investigation:

Androgen……increased

Testosterone …..Increased (free and total)….vvvvvimp

LH…….INCREASED

LH: FSH ratio…….reversed (more than 2)

Us:

Thickened ovarian cortex

Stromal hyperplasia

Multiple small peripheral cysts (necklace appearance)

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TTT…….
Advise…………lose weight
Irregular bleeding and hirsutim……..OCP
Infertility…..clomiphene or human menopausal
gonadotropin……1st line ….vvvvvvvvvvvvvv imp
Insulin resistance…….metformin……not routine

N:B:
Most common malignancy in premature ovarian
failure….endometrial

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Congenital adrenal hyperplasia

Most common cause…….21 hydroxylase deficiency

Genetics……..AR
LEVELS OF HORMONES:
Cortisone…….decreased
Aldosterone…….decreased
Androgen………increased
17 Hydroxyprogesterone….increased
CP:
AT INFANCY:
Loss weight, vomiting and dehydration
Salt losing….hyponatremia, hyperkalemia and hypoglycemia
Female…….musculinized external genitalia

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Male………normal genitalia at birth

Adult female……hirsutism, acne, anovulation and irregular
cycles
Investigation:
Bolus ACTH……marked increased 17
HYDROXYPROGESTERONE
TTT…….CORTISONE

IDIOPATHIC HIRSUTISM
Most common cause of hirsutism
No virilization
TTT………..spironolactone….drug of choice

Premature ovarian failure…vvvvvvvvvvvvvvvvv imp

Age……before 30
Family history……positive
Cp……similar to menopause
Most important test……..increased FSH
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TTT:………..vvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvv imp
If wants kids………….HRT
Doesnot want kids…………OCP
If sexually active………….OCP
NOT sexually active………HRT
If wants to get pregnant……IVF with ova donor

Vaginal discharge
Bloody discharge at female neonate
Timing……few days after delivery
Cause…..estrogen passage to fetus through placenta
TTT……….REASSURE

Vulvovaginitis in pediatrics
Most common cause…non specific
Cause….low estrogen…thin epithelium
TTT…..USUALLY NONE
Irrigation with warm water
Foreign body
Most common cause of foul smelling or bloody discharge
in children
DD……..sexual abuse
TTT…..irrigation with warm water
Removal under anesthesia

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Physiologic leucorrhea
Clear or thin whitish discharge
No offensive odor and no itching
TTT…..reassure

Bacterial vaginosis:
Not sexually transmitted
Most common vaginal infection
Cause……..gardenella vaginalis
Clinical picture:
Discharge……..thin, grayish-white
Fishy odor
Wet amount test……clue cells
TTT…..
Metronidazole…….drug of choice
Second line……….clindamycin
During pregnancy………metronidazole safe
Do you need to TTT partner??......noooooo

Trichomonas vaginalis
Sexually transmitted infection
Cause…..motile protozoon
Cp:
Itching and burning

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Profuse, offensive and frothy

discharge
Strawberry cervix

Saline wet preparation…….motile protozoon

TTT……metronidazole
During pregnancy…….metronidazole
Do you need to ttt partner?? Yessssss it is a must

Candida:
Not sexually transmitted
Risk factors:
DM
immunodeficiency
Prolonged antibiotic use
Pregnancy
Cp:
Itching
Vaginal discharge…..thick, scanty, cheesy and odorless
Microscopy…….pseudohyphae
TTT……..oral fluconazole (single dose)

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Pregnancy……….vaginal azole cream

TTT of recurrent vulvovaginitis……oral fluconazole
TTT of the partner……nooo

N:B:
TTT partner with bacterial vaginosis….noo
TTT partner with candida…..noooo
TTT partner with tichomonisis….yess
Bacterial vaginosis and pregnancy….metronidazole
Trichominiasis and pregnancy,,,,,metronidazole
Candida………..oral fluconazole
Candida and pregnancy….azole vaginal cream
Microscopy of bacterial vaginosis……clue cells
Microscopy of trichomonas…..motile flagellated organism
Microscopy of candida …..pseudohyphae
Cause of cyclic vulvovaginitis…..candida

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Lichen sclerosus:
Age……postmenopausal
Cp……itching
Area affected…..ano-genital area
First step…..punch biopsy
Risk……..malignancy
TTT……..,cortisone cream

N:B:
Any itching or lesion at the vulva of old age women…TAKE
BIPOSY…to exclude cancer vulva
TTT of cancer vulva…….radical vulvectomy

Cervical polyp
Shape……finger like projection
Cp………bleeding after sexual
intercourse
TTT…….twisting

Cervical ectropion
Cervical erosion
Cp………post coital bleeding
No ttt

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Cervicitis
CP……….mucopurulent cervical discharge
Causative organism…….chlamydia and gonorrhea are most
common
TTT………. You should ttt both of Chlamydia and gonorrhea
at the same time
Gonorrhea………single dose cefotriaxone
Chlamydia……..azithromycin

CHLAMYDIA:
Most common STD in Australia……..chlamydia
Cp…….majority are asymptomatic
Mucopurulent cervical discharge
Complications: Acute PID, Infertility, ectopic pregnancy
Drug of choice……azithromycin

Chlamydia and gonorrhea:…….usually come together

All patients who are (+) for Chlamydia should be ttt for both
Chlamydia and gonorrhea….cefotriaxone and
azithromycin
Patients was treated for Chlamydia now comes back with the
same symptoms……ttt for gonorrhea
Patients was treated for gonorrhea now comes back with
same symptoms……ttt for Chlamydia

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Chlamydia and the partners:

All partners should be traced, tested and treated against
Chlamydia
Chlamydia and other STDs:
Once patient is + for Chlamydia……..test for other STDs:
HIV…….ELISA
Syphilis……RPR and VDRL
Hepatitis B…..If (-) ……. Give vaccine
Rubella titre ….if ( - )…..give vaccine

Screening for chlamydia..vvvvvvvvvvvvvv imp

For who ???
All sexually active females aged 15–29 years
Why screen Chlamydia??
To avoid infertility
how often?
Every 12 months
Opportunistic screening…..vvvv imp
how???
PCR ( FIRST CATCH URINE)
When Screening for men ??
Unprotected anal sex

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Cervical neoplasia:
Age….30-40
Risk factors….
HPV….16, 18, 31, 33, 35
Early sexual life
Multiple partners
Prostitutes
Smoking
Most common site…….transformation zone
Cp….irregular bleeding and postcoital bleeding

Cervical cancer and pregnancy:

Pregnancy….no effect on progression of the cancer
CIN:
Pap smear and colposcopy every 3 months
Then ttt months after delivery
Microinvasion:
Cone biopsy to exclude frank invasion
TTT….2 months after delivery
Invasive cancer:
Less than 28 wks……radical hysterectomy or irradiation
More than 28 wks…..conservative till 32 wks then ttt

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Screening for cervical cancer: vvvvvvvv imp

How??........pap smear
A sample of the ectocervix then the endocervix
What if Pap smear revealed no cervical canal cells??....and
patient is NOT risky ….DONOT repeat the pap…vvvvvv imp
How often??.......every 2 years
For who......18-20 years
Or 2 years after first sexual life
Till when…….70ys who have had two normal Pap tests
within the last 5 years. or hysterectomy

Female over 70 asked for screening…screen her

Female over 70 have never screened before…screen her
Do lesbian females need screening…..yessssssss
Female with HPV vaccination needs screening…yess
Virgin female………..NOOOO screening

Pap smear interpretations..vvvvvvvvvv imp

1- Atypical cells with infection...repeat after ttt of the
infection

2-Low-grade squamous intraepithelial lesions (LSIL)

 repeat Pap test in 12 months

 If the repeat test at 12 months shows LSIL….colposcopy.
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 A woman aged 30 years or more with a Pap test report of

LSIL, without a history of negative smears in the preceding
2–3 years, should be offered either colposcopy or a repeat
Pap smear at 6 months

3-High-grade squamous intraepithelial lesion (HSIL)

 colposcopy

4-DYSPLAIA………COLPOSCOPY

How to deal with Cervical intraepithelial neoplasia (CIN):

CIN 1 and 2………….repeat test after 1 year

CIN 3………..colposcopy and biopsy

Vaccination against HPV VVVVVVVVVVV IMP

HOW?.......Gardasil vaccine
Value …..Protect against types 6,11,16,18
How many doses……..3
For who…..females 9-45
Males 9 -26
Maximum benefit…..before starting sexual life
Continue Pap smear after vaccine??......yessssss vaccine does
not protect against all types of HPV
Sexually active female can receive vaccine…yessss
Females with previous genital warts …..yesssssssss
Females with previous abnormal cytology….yessss
Pregnant females….....NOOOOOO

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Lactating females……..YESSSSSS
Immunocompromised females……nooooooo
Serology for HPV………..not recommended

Diethystillbesteriol
Side effects:
T- Shaped uterus
Cervical insufficiency
Sarcoma botyroid

Endometrial cancer:
Most common gynecological cancer
Age…around 60
Risk factors…unopposed estrogen
Obesity……most common risk factor
HTN and DM
Nullipara
Late menopause
PCO
Chronic anovulation
Cp…….post menopausal bleeding
Inv:
Us……endometrial thickness normally less than 5mm
Hysteroscopy and biopsy …best

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TTT…… TAH and BSO

N:B:
Post menopausal bleeding is cancer endometrium until
proved otherwise
Most common cause of post menopausal bleeding….vaginal
atrophy

Ovarian Cancer

Most ovarian tumors are benign,

Risk factors :
Age
Low parity
Infertility
Delayed childbearing.
Family history
The BRCA1 and BRCA2 mutation ■

Lynch II syndrome or hereditary nonpolyposis colorectal

cancer (HNPCC) …….. increase risk of colon, ovarian,
endometrial, and breast cancer.

HISTORY/PE
■
Asymptomatic……majority.
Majority present with advanced malignant disease
Palpable abdominal mass, Ascites.
■
DIAGNOSIS
■Tumor markers ↑CA-125
Transvaginal ultrasound
Main TTT of ovarian caner……debulking operation

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N:B:
Frequency of female genital tract cancers: endometrial >
ovarian > cervical.
Number of deaths: ovarian > endometrial > cervical
Most common cause of death with ovarian cancer….IO
Most common cause of death with cervical cancer..uremia

Old age female with simple ovarian cyst first

step…..tumour markers
Screening for ovarian cancer??......imp

Lower risk………No screening

Higher risk ?????
US and CA 125……NO longer recommended even in high risk
……vvvvvvvvvvvvvv imp

Pelvic organ prolapse:MMM_ PE

LVIC ORGAN PROLAPS E

Risk factors:
Vaginal birth
Advancing age
Pelvic surgery
HISTORY/PE
■Presents with the sensation of a bulge or protrusion in the
vagina.
■Urinary or fecal incontinence, a sense of incomplete bladder
emptying, dyspareunia
DIAGNOSIS
Valsalva maneuver while in the lithotomy position.
TREATMENT
■weight reduction in obese patients
kegel exercise…….old age as first line ttt

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■Pessaries ……very old age can neither do operation nor do

kegel exercise
■The most common surgical procedure is vaginal or
abdominal hysterectomy

Incontinence

1-Total
Uncontrolled loss at all times and in all positions.
Most common cause………..fistula
Previous surgery
Nerve damage
Cancer
TTT…….Surgery.

2-Stress incontinence……..MOST COMMON

After ↑ intra-abdominal pressure (coughing, sneezing)
Causes:…. multiparous women or after pelvic Surgery
Inv of choice ………..urodynamics ….vvvvvv imp
.TTT…….same as pelvic prolapse
Kegel exercises
pessary.
Uretheral suspension

3-Detrusor hyperreflexia (urge incontinence)

Strong, unexpected urge to void that is unrelated to position
Most common cause………Inflammatory conditions or
neurogenic disorders of the bladder.
Inv…………urine analysis
TTT……… bladder training ……first line…vvvvvvvv imp
IF bladder training failed……. Anticholinergic or TCA

4-Overflow
Chronic urinary retention.

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Chronically distended bladder

intravesical pressure that just exceeds with ↑ the outlet
resistance, allowing a small amount of urine to dribble out.
TTT…… intermittent CATHETER

N:B:
Main ligament supporting the uterus…..uterosacral
Inv of choice of stress incontinence……….urodynamics
Inv of choice of urge incontinence………….urine analysis

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Pelvic inflammatory disease:

Most common organism…..chlamydia and gonorrhea
Age ……usually young age
Risk factors…..multiple sexual partners, IUD
Clinical picture:
Mucopurulent cervical discharge
Severe lower abdominal pain and tenderness
Fever, nausea and vomiting and chills
Exam….tenderness and guarding
Cervical motion tenderness and bilateral adnexal
tenderness
Inv…..+ culture for Chlamydia or gonorrhea
Complications…..abscess
Infertility secondary to adhesions
Ectopic pregnancy
RUQ pain (Fitz-Hugh–Curtis
syndrome) may indicate an associated perihepatitis
(abnormal liver function, shoulder pain)

TTT…..
If IUD is there…..remove IUD
Usually needs admission
Antibiotics…..cefotriaxone and doxycyclin or gentamicin

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Types of STDs:
Bacterial -1
Chancre
Chancroid
Gonorrhea
Granuloma venerum
Lymphgranuloma inguinale
Viral:
Herpes simplex
Hepatitis B
HIV
HPV
Fungal…….trichomons
Which STDs causing ulcerations??
Syphilis….chancre…..painless
Hemophilus ducreyi…..chanchroid……painful
Herpes simplex….painful
Gonorrhea
Granuloma inguinale and LGV

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Bartholin cyst:
Shape….cystic swelling
Site………..posterior part of labia major
 Cp….
 A painless lump in the vulva area.
 Discomfort with walking, sitting, or having sex.
Complication….infection …abscess
TTT……
Small……leave it
Larger or bothering patient…… Marsupialization
Abscess…..antibiotics and drainage and leave a
catheter

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Fuctional ovarian cysts:

, the most common type of ovarian cystFollicular cyst
Thecal lutein cysts most common with vesicular mole
Cp:

 Abdominal pain.
 Uterine bleeding.
 Fullness, pressure, swelling, or bloating in the abdomen

 Complications……..torsion……severe abdominal pain
 Rupture……acute abdomen

 Management:vvvvvvvvvvv imp

Less than 6 cm………rescan after 6-8 weeks

Give OCP

When laparoscopy???

More than 6 cm

Persistence after 2 months

Old age…..suspect cancer

Complex cyst

When laparotomy???......if ruptured

Toxic Shock Syndrome (TSS)

S. aureus toxin (TSST-1)

Within five days of the onset of a menstrual period

Cause…….tampons.

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HISTORY/PE
Abrupt onset of fever, vomiting,
Watery diarrhea,
Diffuse macular erythematous rash
Desquamation, especially of the palms and soles

. TREATMENT
■Rapid rehydration.

Normal stages of puberty: vvvvvvimp

1- Female:
Breast Development (Thelarche),…..breast budding(
first stage)
Pubic Hair (Pubarche)
Increase growth velocity
Menstruation (Menses/Menarche)

Most important question to female with delayed

menstruation????
Timing of breast budding ……..as menstruation usually
occurs 2 ys after breast budding…vvvvvvvvvv imp

2- Males
Enlargement of The Testicles and Scrotum…..first step
Pubic Hair (Pubarche)
Growth velocity
Penis Growth

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Precocious Puberty

2° sexual characteristics before 8 ys in females

■Central precocious puberty: Results from early activation of

hypothalamic GnRH production

■Peripheral precocious puberty: (pseudo-precocious).

Results from nonhypothalamic GnRH production.
HISTORY/PE
■Signs of estrogen excess (breast development and possibly
vaginal bleeding)
Cause……..ovarian cysts or tumors.

■Signs of androgen excess (pubic and/or axillary hair, body

odor) enlarged clitoris, acne, and/or ↑
Causes: adrenal tumors or congenital adrenal hyperplasia

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DIAGNOSIS
■First step: Obtain a x-ray of the wrist and hand to
determine bone Age….vvvvv imp
.

■Next step: Conduct a GnRH agonist (leuprolide) stimulation

test.
■Central precocious puberty: If LH response is +, obtain a
cranial MRI to look for CNS tumors.

■If CNS tumors are ruled out, constitutional precocious

puberty is the likely etiology.

■Peripheral precocious puberty: If LH response is -……. order

the following:
■Ultrasound of the ovaries and/or adrenals…… for ovarian
or adrenal /tumors.

■Estradiol: …… will be ↑ WITH ovarian tumors.

.
Androgen (DHEAS): …..increased with adrenal androgen

TREATMENT
■Central precocious puberty: Leuprolide….. first-line.
■Peripheral precocious puberty: Treat the cause.
■Ovarian cysts: No intervention is necessary
■CAH: Treat with glucocorticoids.
■Adrenal or ovarian tumors: SURGERY
■McCune-Albright syndrome: Antiestrogens (tamoxifen

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Premature thelarche
Breast development in girls aged <3 years,

Caused by maternal oestrogens in the early months.

Absence of any other signs of puberty.

 Normal growth with appropriate bone

age (ie no growth spurt).

TTT…….reassure

N:B:
9 ys kid started menstruation……….normal puberty
7 ys kid started menstruation……….precocious puberty
2 ys kid with breast enlargement only…..thelarche

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Pt with anemia (any type), Hb level< 7 ……………………….…. Packed RBCs.

Pt with anemia (any type) develops severe symptoms …. Packed RBCs.

MCV 80-100…………………………. Normal

MCV <80 ………………………….. microcytic anemia

MCV >100 ……………………….. macrocytic anemia

MCC of iron deficiency anemia in infant: prolonged breast feeding (start weaning
at 4 ms with iron- fortified cereal).

MCC of iron deficiency anemia in adult: GIT bleeding (PUD)… Upper GI endoscopy

MCC of iron deficiency anemia in old: cancer colon… colonoscopy.

Specific manifestation of iron deficiency anemia: Pica.

Side effect of oral iron sulphate: black stool, abdominal pain.

Imp lab findings in hemolytic anemia: ++ reticulocyte count& -- haptoglobin.

Other lab findings in hemolytic anemia: ++ billirubin, ++ LDH.

Anemia since birth…………………. Hereditary spherocytosis (HS)

MC affected organ in HS>>> marked splenomegaly>>> splenectomy is a must

pt with HS develops severe symptoms, lab shows hemolytic anemia& --

reticulocyte count… Dx: aplastic crisis DT parvo-virus inf… TTT: packed RBCs

Inv of choice of HS: osmotic fragility test

Thalassemia: AR disease

Confirmatory test of thalassemia: Hb electrophoresis.

1st step in TTT of hand- foot $ in pt with sickle cell anemia: strong analgesic.

1st step in TTT of priapism in pt with sickle cell anemia: strong analgesic.
Definitive TT of hand- foot $, priapism or any presentation of vaso-occlusive crisis
in pt with sickle cell anemia: exchange transfusion.

pt with SCA develops severe symptoms, lab shows hemolytic anemia& --

reticulocyte count… Dx: aplastic crisis DT parvo-virus inf… TTT: packed RBCs

pt with SCA develops severe symptoms, lab shows hemolytic anemia& ++

reticulocyte count… Dx: hyperhemolytic crisis … TTT: packed RBCs

sickle cell anemia + marked pallor + marked spleen enlargement……sequestration

crisis….TTT>>>>splenectomy

Confirmatory test of SCA: Hb electrophoresis.

Child with attacks of hemolytic anemia occurs only after oxidative stress (e.g.
infection, sulfa ingestion… etc)… Dx: G6PD deficiency.

Inv of choice of G6PD deficiency: G6PD enzyme activity one month after the
attack (it is normal directly after the attack).

Inv of choice of AIHA: coomb’s test.

MC drug causing iron deficiency anemia: aspirin.

MC drug causing aplastic anemia: diclofenac.

BM biopsy in aplastic anemia: hypocellular fatty tissue.

MC of vitamin B12 deficiency: vegetarian

MC of folic acid deficiency: alcohol

CBC of megaloblastic anemia: large RBCs, MCV>100& large WBCs

(hypersegmented neutrophils)

Anemia + neurological manifestation… Dx: vit B12 deficiency.

MC neurological manifestation in vit B12 deficiency: loss of posterior column

function (loss of vibration& position sensation).
Schilling test: used only for Dx of the cause of vit B12 deficiency.

TTT of megaloblastic anemia: replacement of vitamin B12, folic acid.

Dx of pernicious anemia: detection of anti-intrinsic factor antibodies.

Specific test of anemia of chronic disease: increase ferittin.

Cause of anemia in ESRD: decrease erythropoietin.

Child with H/O URTI 1-2 Ws develops generalized petechial Hge… Dx: ITP.

Inv of choice of ITP: BM biopsy (++ megakaryocyte with defective budding)

Other inv of ITP: -- platelets count, ++ Bleeding Time.

TTT of choice of mild cases: observation.

TTT of choice of moderate cases: cortisone as 1st line

Child with ecchymotic patches, hemo-arthrosis, muscle hematoma… Dx:

hemophilia.

MCC of hemophilia: factor 8 deficiency (Hemophilia A).

Type of hereditary in hemophilia: X-linked.

TTT of hemophilia: factor 8 replacement (FFP if factor 8 isn’t available).

Kid with bruises…..>>>>>>>>>child abuse shouldbe excluded 1st even if scenario is

very clear to be hemophilia

Child with bruises and petechiae………FBC is the 1st step

Hemophilia will do a surgery………..factor 8 before the surgery

Von-willebrand will do a surgery……….factor 8 before the surgery

Child with bleeding disorder, lab shows ++BT& ++aPTT… Dx: Von-Willbrad
Disease.

++ BT, normal aPTT……………. ITP

Normal BT, ++ aPTT…………… hemophilia

++ BT, ++ aPTT…………………… Von-Willbrand Disease

Girl with bleeding tendency>>>>>mostlyvon-willebrand

Pt with Von- Willbrad Disease undergoes emergent operation, which is important

to give… answer: coagulation factors (not platelets).

Pt headache, blurring of vision, severe pruritis after bathing… Dx: P-vera.>>>>TTT

is phlebotomy

Lab of P-vera: ++RBCs, marked high hematocrit.

P-vera…………………. Normal O2 saturation, normal or low erythropoietin.

2ry polycythemia… Decrease O2 saturation, increase erythropoietin.

BM aspiration in myelofibrosis: fibrotic BM, tear-dropped shaped cells.

MCC of hereditary hypercoagulooathy: factor 5 leiden deficiency.

MC affected LN in Hodgkin lymphoma: cervical LN.

MC virus related to Hodgkin lymphoma: HTLN virus.

MC organ affected in non-Hodgkin lymphoma: intestine.

TTT of choice of Hodgkin lymphoma is chemo , non-Hodgkin lymphoma: chemo,

radio

Inv of choice of Hodgkin lymphoma, non-Hodgkin lymphoma: excisional biopsy

Pt with enlarged LN not relieved after abs TTT… next step: excisional biopsy

TTT of Gastric Mucosa Associated Lymphoid Tissue: eradication of H.pylori

Pt undergone chemotherapy develops arrhythmia, lab shows ++ K, phosphate,

uric acid& -- Ca… Dx: tumor lysis $ (TLS)

TTT of tumor lysis $: allopurinol.

Pt with sepsis/severe burn develops bleeding from peripheral line, lab shows –
platelet, -- fibrinogen, ++PT, ++aPTT … Dx: DIC

TTT of DIC: FFP

Pt received blood develops peri-oral numbness, muscle twitches… cause: citrate

intoxication

Patient afer blood transfusion developed tachycardia, hypotension and chest

pain………..hemolytic reaction>>>>1st step is normal saline

MC component that is decreased in stored blood: platelets (shortest half life)

Pt with neutrophils< 1500, evidence of infection… Dx: febrile neutropenia.

Cause of infection in febrile neutropenia: ps. Auruginosa.

Old Alcoholic, smoker pt with enlarged cervical LV… next step: biopsy.

Most common cancer with brain metastases: LUNG cancer (breast is the 2nd MC)

TTT of choice of pain in terminal cancer: short acting morphine

TTT of choice of nausea, vomiting caused by chemotherapy: ondansetron

Chronic lymphocytic leukemia:

MC clinical picture ………. Marked lymphadenopathy

MC complication ………… Auto- Immune Hemolytic Anemia (give cortisone)

Prognosis……………………. Very good (usually need NO TTT)

TTT of choice……………… chemotherapy only (no radio)

MC leukemia in old: Chronic lymphocyastic leukemia

MC leukemia in children: Acute lymphoblastic leukemia

MC CP of chronic myelogenous leukemia: spleenomegaly

Most important in acute leukemia>>>>>blast cells

Decreased leukocyte alkaline phosphatase…..chronic myelgenous leukemia

Philadelphia chromosome….. chronic myelgenous leukemia

Mode of transmission of HAV, HEV: feco-oral (food transmitted).

Mode of transmission of HBV, HCV: blood derived.

Pt with +ve anti-HBs and -ve all other HBV serology…………….. Vaccination

Pt with +ve anti-HBs, anti-HBc and -ve all other HBV serology… Chronic HBV Inf

First marker appears in the blood……..…surface antigen

Marker detected only by liver biopsy……Hbc-Ag

Marker of highly infectivity………………….. e-Antigen

How to follow up………………………………….PCR

Acute cases……………………………………….….NO TTT

CHRONIC HEPATITIS: More than 6 months with +ve serology.

TTT of chronic HBV: lamivudin, interferon.

Post- exposure prophylaxis of HBV:

History of previous vaccination….reassure

Wash hand is the 1st step if needle puncture

First step:

If history of vaccination……..reassure

If not vaccinated……….. check immune status

If (+) for antibodies……..reassure

If (-) for antibodies = susceptible……vaccine and IVIG

If in the exam no option for checking the immune status…..go for vaccine and
IVIG
Baby born to HBV mother………………. Vaccine and IVIG immediately to the newly
born.

Chronicity of hepatitis B in adult…..10-15%

Chronicity of hepatitis B in newly born….over 75 %

TTT of hepatitis B…….INTERFERON AND LAMIVUDINE

Main SE of interferon……depression and fatigue

If depression occurred…..stop interferon

Post- exposure prophylaxis of Hepatitis C:

First step…….check base line immune status

Second step……serial labs for 6 months

If (+) for HCV antibodies…….NEXT STEP HCV RNA

IF HCV RNA (+)……start ttt

TTT of hepatitis C…….interferon and ribavirin

Chronicity of hepatitis C ……over 75%

Counseling Q for pts with HCV inf:

Vaginal delivery…… Available

Lactation ………….… Available.

Sex……………………... Available but preferred to use condom.

Best way to avoid hepatitis C….avoid sharing razors.. imp

Alcoholic + gynaecomastia + bilateral parotid swelling+ scrotal swelling. ........

Alcoholic liver disease

Best way to avoid neonatal infection..........avoid scalp electrodes

when to screen for hepatitis C in neonate...18 months ( antibody)

Pt returned from Thailand presents with fever, jaundice, RUQ abdominal pain. His
lab shows increase in ALT, AST, normal AP… Dx: HAV infection.

Pt returned from Thailand presents with fever, jaundice, RUQ abdominal pain. His
lab shows increase in ALT, AST, marked increase AP… Dx: acute cholangitis.

Pt returned from Thailand presents with fever, RUQ abdominal pain. His lab
shows ++WBCs& normal ALT, AST, AP… Dx: acute cholecystitis.

Prophylaxis against HAV: inactivated vaccine “4 Ws before travel”

Most effective measure to control HAV epidemic at school: control of food source

And vaccination

Pt with liver cirrhosis, ascites develops abdominal pain, fever… Dx: SPB.

Inv of choice: paracentesis (++ WBCs, >250 neutrophil)

TTT of choice: IV cefotaxime

Prevention of recurrence: TMP-SMX.

Most accurate test of 1ry biliary cirrhosis: AMA.

Definitive TTT of 1ry biliary cirrhosis: liver transplant.

Pt with cirrhosis, choriform movement, personality changes: Dx: wilson’s disease

Best initial test: -- ceruplasmin level& slit lamp exam of eye (kayser flischer ring)

Most accurate test: liver biopsy

TTT of choice: penicillamine

Best initial test of hemochromatosis: trans-ferritin level or ferritin level… If both

found in choice: transferritin level.

If ferritin or transferrin high…………next step is gene analysis …vvvvvv imp

Most accurate test: liver biopsy.

TTT: phlebotomy.

Screening of hemochromatosi:

Normal population:

1st step………..serum ferritin or better transferrin

2nd step……..if any of the above high do gene analysis

Who: those with 1st degree relative with hemochromatosis.

1nd step of screening: HFE gene mutation

When to test kids ???

If both parents are carrier

Pt with hemochromatosis known to have cirrhosis came with fever, abdominal

pain… Dx: SBP.

Pt with obesity, DM, hyperlipidemia develops hepatomegally... Dx: NASH.

Young non-smoker with emphysema, liver cirrhosis… Dx: A1AT deficiency.

Young non-smoker with pan-acinar emphysema… U must survey his liver.

Cause of hepatic encephalopathy in pt with cirhhosis: increase ammonia

level……next step is lactulose and enema

MCC of liver cirrhosis in Australia: alcoholic liver disease.

TTT of emphysematous cholecystitis: IV fluid, abs& emergent surgery.

VVV imp notes:

Common cause of cirrhosis in Australia …….…..alcohol

Most common virus causing chronicity in adult…………………......C

Most common virus causing chronicity in kids………………………..B

Most common virus causing liver cancer………………………….…....B

Most common virus to be transmitted after needle abrasion...B

Most common virus transmitted by food……………..A

Virus that can kill adult while very begnin in kids….A

Viruses transmitted by food……………………………..….A and E

Virus that can kill pregnant women…………………..….E

Virus that is associated with hepatitis B……D

MC route of HBV transmission …. Perinatal

Best inv of chronic hepatitis… liver biopsy.

MCC for the need of liver transplantation: cirrhosis

MCC disease cause need of liver transplant in Australia: alcoholic liver disease

Pt on list for transplant, MCC that this pt may not be given the live: pt say he
can’t stop drinking.

HBV: vaccine available& post- exposure prophylaxis also available.

HCV: NO vaccine available& NO post- exposure prophylaxis.

Take care:

Most common virus causing Hepatic cancer…..B

Most common toxin causing hepatic cancer ……aflatoxin

Most common cause of hepatic cancer over all……cirrhosis

If bleeding varices:
.VARICEAL BLEEDING MANAGEMENT:
.The 1st step ……….RESUSCITATION (nomal saline )

If you need blood ……packed RBC'S ( O- RH- low hemolysis),

1st step to control bleeding………sungestaken tube

Defnitive ttt……….band ligation

If failed……..TIPS

Pain in RT upper quadrant area, fever, jaundice + air fluid level in the bilary
tree…..colostridium cholecystitis

Next step……..iv fluid and antibiotics

Defnitive ttt……….surgery
Child with recent H/O OM develop neck stiffness, MC CO: Strep. pneumonia

Child with recent URTI develop neck stiffness, MC CO: Strep. pneumonia

Most common cause of meningitis in these age groups:

Newly born up to 1 month…….Group B streptococcus

Children…… Strep. Pneumonia (MC overall)

Adult………….. Nisseria meningitides (MC serious organism)

Eldery……….. strep. Pneumonia

Most imp sign in meningitis… Neck stiffness

First step in kid with signs of meningitis….blood culture then Iv cefotriaxone or iv

penicillin

If you have to choose one of them……Iv cefotriaxone

If you suspect meningitis:….vvvvvvvvvvv imp

First step……….blood culture
Second step………empirical antibiotics
Third step……….brain CT
Fourth step……..lumbar puncture

Bacterial meningitis…..marked increased neutrophils

Viral meningitis……..lymphocytosis

Herpes encephalitis…… high RBC's in CSF

TB meningitis……..increased protein

Most common neurological sequale after meningitis….deafness

Marked drop of blood pressure after meningitis…..acute adrenal crisis( water

house friedreichson's syndrome)

Main line of TTT of:

Viral meningitis…….supportive

Herpes………iv acyclovie

TB meningitis……steroid and antituberculous drugs

Acute adrenal crisis……steroid

Prophylaxis to close contact:

1st line ……………………….. Rifampin

2nd line ………………………. Ciprofloxacin

MC symptom of herpes encephalitis: Confusion

CSF analysis of herpes encephalitis: ++ lymphocytes & ++ RBCs

TTT of herpes encephalitis: IV acyclovir

Child with fever, headache, pain and tenderness at sinus: acute sinusitis.

MC affected sinus: maxillary sinus.

TTT: Amox- clav for 10 ds.

URTI, good general condition, just red swollen throat &tonsil… viral pharyngitis

URTI, bad general condition, red swollen throat & tonsil with white spots and
cervical lymphadenopathy… bacterial pharyngitis

MCC of bacterial pharyngitis: strep pneumonia.

Best 1st inv: rapid strep test

Best confirmatory test: throat culture

TTT of choice: amox clav

Bacterial URTI, deviated uvula in exam… Dx: peri- tonsillar abscess

1st step in TTT of peri- tonsillar abscess: aspiration (tonsillectomy after 4 ms)
1st step in with peri- tonsillar abscess with severe respiratory distress: intubation

Child with symptoms of Viral URTI for 48 hs, u suspect influenza… next step: test
for influenza (not medication; medications r given only in the 1st 48 hs).

Inv of influenza… Fast test> naso-pharyngeal swap/ confirmatory> viral culture

TTT of Influenza after 48 hs: only symptomatic

Pt recently returned from Thailand presents with any symptom= HIV until proven
otherwise.

Best screening test for HIV: ELISA

Best confirmatory test for HIV: Western Blot

MCC of +ve ELISA AND -ve Western Blot… false +ve ELISA

MCC of pneumonia in HIV pt: PCP

TTT of PCP pneumonia: TMP-SMX.

HIV and pregnancy:

During pregnancy…….mom takes antiretroviral therapy

During labor……..CS

After labor……give baby zidovudine for 6 weeks

Breast feeding …….nooooooo

Most effective way to prevent perinatal transmission at all…mom receives

antiretroviral during pregnancy

Second most common route of HIV transmission…perinatal

Post exposure prophylaxis…..start therapy till the results are back

Most common route of HIV in Australia…..sex

Most common type of sex liable to HIV…..anal followed by oral

Hardest type of sex to transmit HIV…….vaginal

Does kissing transmits HIV………… NOOOOOOOO

Patient after travel to Thailand developed rash, sore throat and lymphadenopathy
with atypical lymphocytosis………HIV

Pt recently returned from Thailand develops neurological symptoms: malaria

Pt recently returned from Thailand develops neurological symptoms and lesions

on brain CT : HIV

Pt recently returned from Thailand develops neurological symptoms& Q includes

CT scan with any whitish lesion… Dx: HIV (not malaria).

Pt with painless ulcer on genitalia= syphilis until proven otherwise

Inv of choice of 1ry syph: biopsy (not blood test)

CO of syph: tryponema pallidum

TTT of choice of syph: IV penicillin single dose

Pt with H/O painless ulcer on genitalia develops macuo-papular rash& generalized

lymphadenopathy… Dx: 2ry syphilis.

Pt with H/O painless ulcer on genitalia develops macuo-papular rash& alopecia…

Dx: 2ry syphilis.

Painful ulcer on genitalia…………Herpes simplex

Inv of choice for herpes simplex…….PCR

TTT of choice for herpes …….oral acyclovir even in pregnancy

Key word for primary syphilis……chancre

Condyloma lata……syphilis

Condyloma accuminata……HPV
What is jarish-Herxheimer reaction???

Fever and headache after giving penicillin

TTT: aspirin, anti-pyretic (will pass)

TTT of choice of syph in pt with penicillin allergy: doxycycline

Most common organism of UTI……E-COLI

Key word of cystitis……suprapubic pain with no fever

Key word of pyelonephritis….very high fever, chills, flank pain

What you will see in urine analysis….WBC'S more than 10

What you will see in urine culture….E-COLI more than 100.000

Why female is at higher risk of UTI….short urethra

Why pregnancy at high risk…..progesterone relax ligaments

How to collect urine samples in Adult…..mid stream collection

How to collect urine samples in pediatrics???

If more than 4 years……mid stream collection

If younger esp, less than 1 year…..suprapubic aspiration

If failed….catheterization

When to say (+) sample:

WBCs ( pus cells)…..more than 10

E-coli……..more than 100.000

Further investigation to children…..US is a must

If recurrent UTI…..micturiting cystourethrography

TTT of cystitis……………. 1st line: TMP-SMX & 2nd line: amox

TTT of pyelonephritis… Cefotriaxone OR amox+gentamicin OR
piperacillin+tazobactam

TTT of UTI in pt with ESRD… 1st line: ciprofloxacin, 2nd line: cephalosporin& 3rd
line: TMP-SMX

TTT of UTI in pregnancy:

Cystitis: 1st line: nitrofurantoin, 2nd line: cephalexin& 3rd line: amox-clav

Asymptomatic bacteruria: nitrofurantoin (1st line)

Pyelonephritis: IV cephalosporin

MCC of fever after urological procedure: bacteremia

TTT: amox + gentamicin.

Pt undergone urological procedure develops fever, he received amox before the

procedure… Next step: gentamicin.

Pt with URTI takes ampicillin develops rash after 24 hs… Dx: Infectious
Mononucleosis (IMN)

CO of IMN: Ebstein Bar Virus (EBV)

Pt with URTI+ HSM… Dx: IMN

Most imp inv of EBV: atypical lymphocytes& +ve heterophil antibody test

Most specific inv of IMN: EBV antigen

Pt with URTI, HSM, atypical lymphocyte& -ve heterophil antibody test … Dx: CMV
(mononucleosis – like $)

TTT of IMN: supportive

Most imp advice to pt with IMN: avoid contact sport for 3-4 weeks

Pt with recent H/O URTI 6 ms ago& since then he has fatigue that is neither
related to exertion nor relieved by rest… Dx: chronic fatigue $.
TTT of chronic fatigue $: PSYCHOTHERAPY “CBT”

Pt returned from Thailand develops headache, rash, join and muscle pain, lab
shows low platelets… Dx: dengue fever

Pt returned from Thailand develops headache, rash,jaundice, join and muscle

pain, lab shows normal platelets, low RBCs… Dx: malaria

Malaria: after weeks to months + normal platelets

Dengue: after few days + decrease platelets

Diabetic Pt with ear discharge develops facial palsy… Dx: malignant OE

CO of malignant OE: pseudomonas aeruginosa

Diabetic Pt with painful vesicular rash in & around ear develops facial palsy… Dx:
ramsy hunt $

CO of ramsay hunt $: HZV (VARICELLA)

Pt returned from abroad develops any respiratory symptoms+ any hepatic

symptoms… Dx: Q-fever

Pt returned from camping at west Australia develops fever, rash or any other
presentation… Dx: ross river fever.

Source of infection of lyme disease: Tick bite

Major Depressive Disorder

The male-to-female ratio is 1:2;

Age 20 -30 and the elderly
Duration………2 weeks at least
Most common timing……..winter

Symptoms :
Sleep (hypersomnia or insomnia)
Interest (loss of interest or pleasure in activities)
Guilt (feelings of worthlessness or inappropriate guilt)
Decrease Energy or fatigue
Decrease Concentration
Decrease Appetite
Decrease weight
Psychomotor agitation or retardation
Suicidal ideation
Anhedonia……loss of interest of all pleasant activities

Dysthymic disorder……..depression for at least 2 years

Cyclothymic disorder….depression with episodes of hypomania

Seasonal affective disorder……depression during winter only

Atypical depression………..increased appetite, increased

weight and sleep a lot

Mood …….most imp to check in suspected depressed patient

TREATMENT
■ Pharmacotherapy:
Drug of choice………..SSRI
Effect appears at least ………2-6 weeks
Duration of TTT…………..at least 6 months
Duration of TTT in suicidal patients……2 ys
Withdraw over at least 2 weeks…..vvvvvvvv imp
20
N:B :

Old age + severe depression…………..ECT

Depression+smoker………..bupropion

Depression+insomnia……..mirtazapine

Depression + decreased appetite……….mirtazapine

Most common season for depression………..winter

Most common season for suicide……………spring

Most common season for SIDS……………..winter

Depression+ memory impairement…………pseudodementia

Depression and suicide

Highest risk of suicide……………. first two

weeks after leaving hospital

Most important question to depressed patient……..suicial

thoughts??

Highest probability of suicide……..history of previous suicidal

attempt

Once you discover suicidal thoughts……involuntary admission

Most risky patients……have a plan of suicide

21
Bipolar Disorders

Age……is 20

Male equal female

Symptoms of mania—

Distractibility
Insomnia (no need for sleep)
Grandiosity (high self esteem)

More Goal directed

Flight of ideas
Activities/psychomotor
Agitation
Sexual indiscretions/
Other pleasurable
Activities
Talkativeness/pressured Speech

Hypomania:

The episode is not severe enough to cause marked

impairment in functioning, or to necessitate hospitalization,
and there are no psychotic features

MANAGEMENT:
Acute and marked psychosis……involuntary admission
First line drug…….lithium
Second line drug…..valproic acid
Others…………….carbamazepine
If pregnant or lactating………..carbamazepine
Resistant and severe cases…….ECT
If marked psychotic symptoms……antipsychotic drugs

22
Schizophrenia

Males (ages 18–25) than in

Male equal females
Males earlier than females

Epidemiology ………vvvvvvvvvvv imp

General population………1%
First degree relative………12%
Second degree relative……6%
Single parent……………..12%
Two parents………………40%
Monozygotic twins………47%
dizygotic twins…………..12%

grand father…………..…6%

CT……… (enlarged ventricles and decrease cortical volume

Chemistry……abnormal serotonin and dopamine levels

Types:

■ Paranoid: Delusions and/or hallucinations

■ Disorganized: Speech and behavior patterns are highly
disordered
■ Catatonic: immobility, extreme negativism, mutism, waxy
flexibility, echolalia, or echopraxia.

Causes of death with schizophrenia: VVVVVVVVV IMP

1- CVS………most common cause

2- SUICIDE

23
HISTORY/PE

The differential includes the following:

Duration less than one month…….brief psychotic disorder

Duration 1- 6 months………Schizophreniform disorder
Duration more than 6 months……schizophrenia
.
Schizoaffective disorder:
Schizophrenia+depression or bipolar disorder

Schizoid personality disorder…..withdrawal + ignorance of

people
Shizotypal personality disorder…..withdrawal +magical thining

24
TREATMENT
Acute and marked psychosis……involuntary admission

Antipsychotics drugs
Severe and resistant cases…….ECT

Good prognostic indicators in schizophrenia: vvvimp

Family history…… (-)

Sex………female

Onset………acute (first attack)

Precipitating factors……yes

Catatonic symptoms…..yes

Positive symptoms……yes

Negative symptoms….noo

Normal CT

Stable family relationship

Stable work

Stable personality

Immediate TTT

25
N:B:

Drug of choice for catatonic schizophrenia…..benzodiazepine

People at very high risk to be hurt by schizophrenic

patient……..parents

Most specific sign for schizophrenic …… impaired insight

People who are living close to the airports…….insomnia

What is mannerism?..... abnormal repetitive behavior

TTT of weight gain secondary to antipsychotic drug……orlistat

First step in ttt of any psychiatric patient……establish good

relationship with the patient

DD of teenager developed drop of academic performance:

1-schizophrenia
2-depression
3-drug abuse
Derailment….. Loosening of association

 "The next day when I'd be going out you know, I took
control, like uh, I put bleach on my hair in California
 "The traffic is rumbling along the main road. They are going
to the north. Why do girls always play pantomime
heroes?"—
Autotrophic asphyxia: 
It is a hypoxophilia 
Type of sexual satisfaction by causing self asphyxia 
Example: tying a robe a round the neck 


26
 suicide 

Most likely…………. 

Single male Homeless

Least likely ………… Married 
High Risk Group ……. Immigrant 
Recent loss of Employment 
Early Dementia 
PHYSICIANS 
In Australia , Suicide 2nd most common cause of Death 
No evidence of increase risk act if the doctor ask suicidal 

ideation
Risk Factor s: 
Male ,Previous attempts ,Major depression , availability of 

guns etc
Females more attempts but males more successful 


First step ……….involuntary hospitalization 

27
 Miscellaneous topics

Most common cause of death in the following groups:

Less than 1 year……….congenital anomalies

1-14 ys…….Non accidental injuries

14-25………suicide

25-44………suicide

44-65……..CVS

More than 65……cardiac disorders

Most common cause of death over all……….CVS……vvvvvvv imp

Very soon will be the 1st cause of death in Australia…..dementia

Most common causes of death according to 2016 statistics:

First…………….CVS

Second………..dementia and Alzeheimer disease

Third…………..cerebrovascular disease

Fourth……….lung cancer

Fifth…………COPD

Lumbar puncture:

Indications:

 Suspected meningitis
 Suspected intracranial bleeding To establish diagnosis:
 GBS…..cytoalbuminous dissociation
 Multiple sclerosis….oligoclonal bands.

Contra-indications to lumbar puncture

 1- Signs suggesting raised intracranial pressure:

28
  A reduced level of consciousness
 bradycardia
 hypertension
 Unequal, dilated or poorly responsive pupils
 Papilloedema

 2- Superficial infection at the lumbar puncture site

Complications of lumbar puncture

 Post-LP headache……most common

 Precautions with lumbar puncture:

 Coagulations factors and platelets levels are very important to
asses ………..vvvvvvvvvvvvvvv imp

CAT BITE VS CAT SCRATCH DISEASE ???? 

Cat scratch: 
Organism…….bartonella hernesale 
Cp……just skin scratches 
Lymphadenopathy……key word 
TTT…..generally self limiting 
Azithromycin in severe cases 
Cat bite: 
Organism…….pasterulla multocoida 
Cp………cellulitis like ( marked swelling, 
redness and pain)
No lympadenopathy ….vvvvvvv imp 
TTT………..penicillin


Snake bite:

Majority of snakes are…..non poisonous

Do not:
 Cut a bite wound
 Attempt to suck out venom
 Apply tourniquet, No ice, no water
 Give the person alcohol or caffeinated drinks

29
Cp: Just minor pain and redness in over 90% of cases
 nausea and vomiting, diarrhea
 anaphylaxis
 ,necrosis, severe internal bleeding, kidney failure, and respiratory
failure
 coagulopathy …..
……
 neurotoxicity… vision blurriness and parathesia
investigation:
Best……..biopsy from the bite…vvvvvvv imp
Second …..Urine
First aid in snake bites……….bandage

TTT….antivenom…..only if symptoms appear…vvv imp

Risk of antivenom…..severe anaphylaxis and death
Staph causing food toxicity:
Abdominal pain, nausea and vomiting within 6 hs after meal
Cause….toxins not bacteria
Type of food.….usually sugary food such as cakes
Inv…..none
TTT….just conservative

Human bites:

Much worse than animal bites

1-clean and debride the wound

2-give prophylactic penicillin and tetanus toxoid

3-hepatitis B and HIV infection prophylaxis

4-3-NO suturing……….vvvvvvvvvvvvvv imp

5-if infection occurred…..take a swap and give metronidazole and

cefotaxime

Malignant hyperthermia:

30
cause:………….inhalational anesthetic agents and succinylcholine
cp:
tachycardia
rigidity FEVER
Rhabdomyeolysis and DIC

TTT………………Dantrolene and Supportive Care

Pituitary Apoplexy :

Sudden neurologic impairment, usually due to a vascular

process……………. Acute hemorrhage or infarction of a pituitary
gland

SUDDEN ONSET Headache

 Nausea and vomiting
 Diplopia
 Visual blurring

INV:
Initial………. ……… CT
inv of choice…………MRI
if pregnant……………MRI

TTT………………….transsphenoidal surgical decompression

Subphrenic abscess

Fluid between diaphragm, liver, and spleen.

After surgical operations like splenectomy.
Cp:
Cough, dypnea
diminished or absent breath sounds,
hiccups
dullness in percussion

31
inv............CT is of choice
TTT..........drainage

Jelly fish stinges:

Types:

1-Blue bottle:

Most common

Common to most southeastern Australian beaches

Very painful but very begnin

First aid:

 Wash sting site and remove tentacles

 Hot water immersion (45°C for 20 minutes*)
 Avoid vinegar as it may worsen the pain

Need of hospital transfer…..noooo

2-major box:

First aid:

 Apply vinegar and remove tentacles

Transport to hospital for:

 Analgesia (oral and IV)

 Consider antivenom in patients with cardiovascular collapse

Epigastric hernia in kids:

32
Cp……swelling above umbilicus

Course…..spontaneous resolution in the majority

TTT……none

Prolactinoma:

Types:

microprolactinoma (< 10 mm diameter)

macroprolactinoma (>10 mm diameter).

Cp:

 females
 infertilityThe usual
 oligomenorrhea, amenorrhea
 Galactorrhea

 Men
 decreased libido, erectile dysfunction
 infertility
 Gynecomastia

 Inv:

1st step…………(prolactin level)

2nd step……….MRI ( imaging of choice )

Medical ttt is the 1st line regardeless the tumour size

Dopamine-agonist (bromocriptine or cabergoline) is first-line

Surgery:

Approach…………Trans-sphenoidal

When???.................intolerant of dopamine-agonists, or inadequate

control of tumour growth

33
 Cervical lymphadenopathy in kids:
Cause…… usually after viral infections.

Management of acute adenitis:

oral antibiotics for 10 days, review in 48

hours

 Flucloxacillin.

 Investigations
Acute adenitis Persisting adenitis (>2 weeks)

 No blood investigations  FBE/film

 Serology - EBV, CMV, HIV
 Mantoux test
 CXR
 CT may be required preoperatively
 Excision biopsy

Bell's palsy:

Acute unilateral LMNL weakness of the facial

nerve
Fate…. complete recovery within three months.
Inv………NOT required
TTT:
Care of eye….vvv imp
Steroid…..drug of choice

Imaginary friends

It is common in kids

a part of normal development

TTT…..reassure

34
Incarcerated uterus:

Growing retroverted uterus becomes wedged into the pelvis

cp:
Urinary retention…..most common cause of presentation at ER
Back pain

Management:

If urine retention ……..Foley catheter

The obstetrician may attempt to manipulate the uterus

hirschsprung disease:

Absence of ganglia in the distal colon →functional obstruction

CP:

Newborn with delayed passage of meconium

History of chronic constipation since birth
Bowel obstruction with bilious vomiting
Failure to thrive.

35
Inv:

Barium enema

Biopsy…..of choice

TTT:…..RESECTION

Mesenteric adenitis:

Swollen (inflamed) lymph nodes in the abdomen

Cause:…………… viral infection.

The symptoms ::

 Mild abdominal pain

 mild diarrhoea.
 HIGH fever

NO treatment is necessary other than pain killer

36
 flat head syndrome :

Types:

 Plagiocephaly - flattening on one side of a baby’s head.

 Brachycephaly – the baby’s head is disproportionately wide
compared to its depth.

 Cause:

 It can happen when babies lie for long
periods on their backs.

Symptoms
 Flat area on back or one side of the head.
 Bulging on one side of the head.
 One ear more forward than the other.
 Unbalanced look to the face.

Treatment

Will correct itself by their first birthday.

 Changing the position of the baby during sleep


Tracheomalacia :
Weakness of the walls of the trachea.

Symptoms
 Breathing noises that may change with position
 Breathing problems that get worse with coughing, crying, feeding
 High-pitched breathing

Exams and Tests

laryngoscope ……of choice

Treatment
Humidified air, careful feedings, and antibiotics for infections.

37
 What is Red Man Syndrome?

Rapid infusion of vancomycin

Symptoms
 Flushing
 Erythema
 Pruritus
How to avoid?
Slow infusion of diluted vancomycin………….vvvvvvvvvvvvvvv imp

lidocaine toxicity: (and all local anesthetic toxicity)

Signs and Symptoms

circumoral numbness, facial tingling, restlessness, vertigo, tinnitus,

slurred speech, and tonic-clonic seizures

Causes:

high dose or wrong injection

Breaking bad news:

"Bad news" ….. any information which adversely and seriously affects an
individual's view of his or her future Setting up the interview.

 Assessing the patient's Perception.

 Giving Knowledge and information to the patient.
 Addressing the patient's Emotions with empathy.
 Having a Strategy and Summarising.

Prepare for the consultation

 Ideally, bad news should be given in person and not over the
telephone.
 The patient may like to be accompanied by a spouse or someone
close to them…….vvvvvvvvvvvv imp
38
Gallstone ileus:

Small bowel obstruction caused by an impaction of a gallstone within the

lumen of the small intestine.

pneumobilia (air within the biliary tree)

 Evidence of small bowel obstruction

 radiopaque gallstone on abdominal radiograph

Treatment:
Initial management ….. fluid resuscitation and nasogastric
suctioning
If failed……………surgical emergency

Deafness:

N:B:

Most common cause of deafness in kids….conductive

Most common cause of deafness in elderly…

Sensorineural

Any kid with delayed language first test….hearing test

39
 Any kid after otitis media must do …hearing test

Most common cause of conductive deafness….wax

Most common cause of sensorineural in kids.. Pneumococcal meningitis

presbycusis:

Age-related hearing loss

sensorineural hearing loss.

The hearing loss is most marked at higher frequencies

Nasopharyngeal angiofibroma:
Benign but locally aggressive vascular tumor

cp:

 chronic epistaxis
 Nasal obstruction
 facial dysmorphism
 Conductive hearing loss
 Diplopia
 proptosis when having intraorbital extension.



 Investigation:

Best……. CT or MRI

Biopsy ……..noooooo ….. extensive bleeding

Fracture nose:

Symptoms
 pain
 swelling
 bleeding
 deformity

40
 First Aid Treatment
 closed reduction surgery…..main ttt
 If deformity persists….. rhinoplasty

Closed reduction, rhinoplasty are not usually performed until three to 10

days after your injury, after swelling goes down.
Retro-pharyngeal abscess:

. Fever & sore throat.

. Dysphagia & Odynophagia.

. Trismus

. Pain on neck EXTENSION

. H/O of local trauma to the pharynx e.g. FISH BONE.

Inv …CT

TTT…drainage

Nasopharyneal carcinoma:

Most common virus causing it……EBV

Cp:

Cervical lymphadenopathy

Trismus, pain, otitis media

INV….biopsy

viruses and cancer:

Lymphoma….EBV

Nasopharyngeal carcinoma….EBV

Cervical cancer….HPV

Cancer larynx…….HPV

41
Hypothermia

Body core temperature below 35.0 °C

Risk factors…………old age exposed to cold weather

Mild:
shivering, hypertension, tachycardia, tachypnea, and vasoconstriction
Severe:
stupor, blood pressure, Pulse and respiration rates decrease significantly
TTT…………. Rewarming

Quick points regarding smoking cessation??

Types of smokers???

1-Nicotine dependent….more than 10 cigarettes or withdrawal

symptoms

2-Non nicotine dependent

Management of nicotine dependent????

Counseling……..is never enough

Pharmacotherapy……should be use:

1- nicotine replacement………first line….most safe

Safe in kids, pregnant and cardiac patients

Should be given in high doses

Should be given weeks before smoking cessation

2-vareniciline….most effective ….but side effects…..not safe in

pregnancy and Cardiac patients

3-bupropion……not in patients with H/O seizures

Management of non nicotine dependent????.... Counseling

42
points regarding BMI????

Most accurate way to asses development of kids …..BMI on centile chart

BMI is NOT accurate in elderly and athelets

Main TTT if BMI more than 35......surgery

New points in vaccinations???

Vaccine that should be given immediately after birth……hepatitis B

2 routine vaccines to elderly:

Influenza………..yearly

Pneumococcal……once if after 65 ys

dTap to the elderly????

Booster dose every 10 years

Should be given to all people after age of 50 ys

How to provide maximum protection to the newly born from

pertussis????.... by dTap vaccine.

For who?????

1-Mom……………. In third trimester

2-Baby…………. immediately after birth

3-Carers of the infants especially if above 50ys

4-Grandparents

43
HTN, tea colored urine, massive proteinuria and edema in Young pt with H/O URTI
1-2 Weeks ago… Dx: PSGN.

Initial inv………ASOT

Inv of choice: renal biopsy.

Most imp step in TTT: anti-hypertensive drugs and fluid restriction.

Diet in PSGN: increase CHO, decrease protein.

Fate: complete recovery in >95% of pts.

HTN, tea colored urine, massive proteinuria and edema in Young pt with H/O URTI
1-2 days ago… Dx: IgA nephropathy.

MCC of renal failure in pediatric …….. IgA NEPHROPATHY.

MC type of GN ………………………………… IgA NEPHROPATHY.

URTI and GN at the same time= IgA NEPHROPATHY.

URTI from 1-2 Ws then GN at the same time= PSGN.

Blood in UA of a child discovered accidently, normal BP, RFTs, NO proteinuria=

basement membrane nephropathy (benign hematuria).

TTT of basement membrane nephropathy: reassurance.

Recurrent painless Hematuria+ deafness… Dx: alport’s $.

Child with renal failure few weeks after attack of bloody diarrhea… Dx: HU$.

HU$= renal failure, anemia, thrombocytopenia& schistocytes after an attack of

bloody diarrhea caused by E-coli O157-H7 infection.

TTT of HU$: plasmapheresis.

The same scenario in adult in addition to fever, neurological manifestation= TTP.

TTT of TTP: plasampheresis.

44
Child with H/O recent VURTI then develops: hematuria, rash in buttocks,
abdominal pain& joint pain… Dx: HSP.

Most imp complication of HSP: intussusceptions.

Protenuria in a child fall from with completely normal physical exam and normal
lab… Dx: orthostatic proteinuria.

Management: repeat the test… if still +ve: 24 hs urine collection.

Proteinuria occurs with fever, VURTI, dehydration… Dx: transient proteinuria…

management: reassure.

Proteinuria+ hematuria in a child with VURTI but BP is normal, physical exam is

normal, lab is normal… repeat test after recovery from inf.

Child with marked proteinuria (+3), hypoalbuminemia, hyperlipidemia&

generalized edema… Dx: NEPHROTIC $.

TTT: cortisone, diet (increase protein).

Recurrent UTI in children………. Vesico- ureteric reflux (VUR).

Inv of choice: VCUG.

Complications of Recurrent UTI: renal scarring and renal failure.

Inv of choice of renal scarring: DMSA scan.

TTT of choice: continuous prophylactic abs (TMP-SMX).

1st attack of UTI in children: US is a MUST.

Recurrent attacks of UTI in children: VCUG.

Child/adult with UTI on abs TTT, no improvement after 3 ds: CT scan.

Inv of choice of posterior Urethral valve: VCUG.

45
Child with recurrent attack of abdominal pain and fever, you find renal mass on
exam… Dx: uretro- pelvic junction obstruction.

Inv of choice: VCUG.

Accidently discovered renal mass in child… Dx: wilm’s tumor.

Pt undergone cardiac catheterization develops rash (livedo reticularis, blue or

purple lesions in fingers, toes)… Dx: cholesterol embolization (athero-emboli).

Pt with H/O radiological procedure with contrast develops edema, increase

creatinine… Dx: contrast- induced nephropathy.

Prevention: hydration.

Pt with hematuria+ pulmonary manifestations (hemoptysis, dyspnea or

cough)………………………………………………………Dx: GOOD PASTURE $.

Inv of choice/ most accurate test …………….kidney biopsy.

Screening test ………………………………………. anti- basement membrane antibodies.

TTT………………………………..plasmapheresis, immunosuppressive and cortisone.

Pt with triad of hematuria, lung manifestation (LRT) & recurrent

epistaxis/sinusitis/OM (URT) and (+) C-ANCA… Dx: wegner granulomatosis.

Type of anemia in ESRD: iron deficiency anemia… TTT: erythropoietin then iron.

Pt with ESRD is at risk of osteoprosis…………………. TTT: Ca& vitamin D.

Pt with ESRD is at risk of bleeding DT: platelets dysfunction.

TTT of hyper-phosphatemia in ESRD: diet phosphate restriction+ oral phosphate

binder.

Pt with ESRD develops severe chest pain improves with leaning forward, EKG
show ST segment elevation in all leads… Dx: uremic pericarditis.

TTT of uremic pericarditis: immediate dialysis.

46
Pt with ESRD, EKG shows tall T-wave…Dx: hyperkalemia.

1st step in TTT: immediate Ca gluconate.

Definitive TTT: dialysis.

Pt with ESRD came for his dialysis session which will be in 3hs, EKG shows tall T-
wave… next step: immediate Ca gluconate till dialysis is ready.

MC complication during dialysis: hypotesion… cause: over removal of fluid… TTT:

IV bolus fluid.

MC type of rejection after renal transplant: acute rejection (Occurs Ds to Ms).

MC pathology in acute rejection: Acute Tubular Necrosis.

TTT of acute rejection: IV steroid.

Rejection on table after renal transplant: hyperacute rejection.

Best way to assess pt with renal failure: body wt.

Best TTT of ESRD: renal transplantation (best from living related donor).

MCC of death in ESRD: cardiovascular disease.

Anti-hypertensive contra-indicated in pt with ESRD: ACE-Is.

MCC of HTN in young adult: renal artery stenosis.

Inv of choice of renal artery stenosis: angiography.

TTT of choice of renal artery stenosis: angioplasty & stent.

TTT of HTN in unilateral cases: ACE-Is (still need stent).

ACEI is contraindicated in patients with BILATERAL renal artery stenosis

Imp lab in renal artery stenosis: increase rennin (DT activation of RAAS).

UA shows pus but no organism… Dx: sterile pyuria.

47
MCC of sterile pyuyria: TB.
MCC of fluid overload in pt with ESRD: missed dialysis session.

MC symptom of overload in pt with ESRD: dyspnea.

Most imp inv of overload in pt with ESRD: ABG.

Pt with ESRD develops dyspnea, ABG shows acidosis… next step: urgent dialysis.

Rash after URTI after receiving antibiotics???

Raised above surface and non blanching…….vasculitis

Raised above surface+joint pain + abd pain+hematuria…….HSP

Maculopapular rash after ampicillin………EBV

Rash+wheezy chest +vomiting, hypotension………anaphylaxis

Most accurate way to asses fluid input and output in renal failure and
cardiac patients……weight followed by 24 h urine

HIV patient on antiretrovial drugs developed painful hematuria and

renal colic…..CT without contrast (renal stones).
Most nephrotoxic abs combination: gentamicin+ cephalexin.

48
Paroxysmal attacks of severe intense burning pain in the trigeminal distribution…
Dx: trigeminal neuralgia

1st line medical TTT of trigeminal neuralgia: carbamazipine

2nd line medical TTT of trigeminal neuralgia: amitryptiline

MC virus causing trigeminal neuralgia: HZV (varicella)

2 VVVVVVVVVVV imp case scenario:

Pt with paroxysmal attacks of pain at face + redness (vesicles usually not

mentioned in exam) = varicella neuralgia

Pt with paroxysmal attacks of pain at face + H/O redness at face = post- herpetic
neuralgia

1st line of TTT of trigeminal neuralgia………………. carbamazipine

1st line of TTT of bipolar in pregnancy………….….. carbamazipine

1st line of TTT of epilepdy in pregnancy…..……….. carbamazipine

1st line of TTT of complex partial seizure………….. carbamazipine

MCC/ MC RF of intra-cranial Hge… HTN

Weakness started at LL ms then ascends upward in pt with H/O of GIT infection or

vaccination...................................................................... Guillian Barre $

Most imp sign in pt with GB$............................................. Areflexia

CSF findings in GB$............................................ cyto- albuminous dissociation

TTT of GB$........................................................... plasmapheresis or IVIG

TTT of GB$ with affected respiratory ms…………. plasmapheresis

Most imp monitoring of pt with GB$ .................... lung vital capacity (spirometry)

49
Pt with ptosis, diplopia & muscle weakness after periods of activity which
improves with rest……… Dx: myasthenia gravis

Imp notes in myasthenia gravis

Most common association……thyrotoxicosis

Most common cp………drooping eyelid

Most common tumour associated …… thymoma

Most imp inv……..edrophonium test

Drug of choice……physostigmine and neostigmine

Most serious complication……respiratory impairement

First step if O2 drop……intubation

Most imp to assess in acute attack… respiration

pt with prolonged use of cortisone develops ms weakness… Dx: steroid- induced

myopathy

Pt with sudden severe headache then develops nausea& vomiting… Dx: Sub-
Arachnoid Hge (SAH)

1st step in management: CT without contrst

If CT finding in equivocal/ best diagnostic test: lumbar puncture (CSF analysis)

CSF findings in SAH: ++RBCs and xanthochromia

Pt with bilateral renal mass develops sudden severe headache… Dx: SAH DT berry
aneurysm rupture

TTT: coiling or restenting (Endo-vascular therapy)

After TTT of SAH, pt develops hypo-natremia… Dx: SIADH

Imp medication to be given to Pt with SAH: nimodipine (to decrease vasospasm)

50
Young female with optic neuritis= multiple sclerosis (ms) until proven otherwise

Young female with acute onset blindness, no H/O ophthalmological disorder=

multiple sclerosis (MS) until proven otherwise

Young female with patchy neurological manifestations … DD: multiple sclerosis OR

conversion disorder

1st step in diagnosis: brain MRI (demyelination) with OR without gadolinium

If MRI is non-equivocal:

2nd choice…………… CSF analysis (Oligo-clonal IgG bands)

3rd choice…………… Visual evoked response

Young female with optic neuritis… next step: MRI (not visual evoked response)

TTT of choice of MS: IV cortisone high dose

Pt shaves his Pt side of face only; comb his hair in the Rt side only… Dx: hemi-
neglect $

Dx: ask pt to fill in the number of a clock

Cause of hemi-neglect $: lesion of non-dominant (Rt) parietal lobe

Pt came with T> 40. He worked for prolonged time under sun rays in a hot
day……… Dx: heat stroke…. TTT: evaporation cooling.

Most imp way of prevention of decubitus ulcer: pt repositioning every 2 Hs

2nd most imp way of prevention of decubitus ulcer: air matress

Old pt with irresistible urge to move legs when at bed before or during
sleeping…… Dx: restless leg $

TTT: levodopa

MC association of restless leg $: iron deficiency anemia

51
Pt with hand tremor only (no other presentation of parkinsonism or
ataxia)…………. Dx: essential tremor

TTT………………. BB (DOC)

Pt with rapid progressive dementia+ myoclonus… Dx: CJD… CO: prion.

Brain death must be confirmed by 2 physicians.

Weakness & loss of P&T affecting UL only… Dx: syringomyelia (cord cavitation)

Inv of choice: MRI (cavity in the spinal cord)

DM pt with ptosis, down and out gaze… Dx: occulomotor neuropathy

Cause of neuropathy in pt with DM………… ischemic

Young female with attacks of unilateral pulsating headache with or without

aura….. Dx: migraine

1st line of TTT: NSAIDs

If failed: sumatriptan

If failed: ergotamine

1st line of TTT in pregnant & children: paracetamol

1st line of prevention: BB

2nd line of prevention: amitryptiline

MCC of headache in children: migraine headache

OCPs is contra-indicated in pts with migraine with aura

Pt complains of severe band-like headache… Dx: tension headache

TTT: 1st line…….. massage & relaxation & 2nd line…….. NSAIDs

Headache + severe unilateral retro-orbital pain… cluster headache

52
TTT of acute attack of cluster headache: 100% O2

Young female with H/O of OCPs or vitamin A intake complains of severe

headache, diplopia, exam shows papilledema… Dx: peudo-tumor cerebri (IIH)

1st step in management: CT…. NORMAL

2nd step: LP… increase opening pressure& normal Cs

MC complication: blindness

TTT: stop offending medication, Wt loss

Pt with resting tremor, bradkinesia, rigidity, narrow- based shuffling gait&

postural instability… Dx: Parkinsonism

TTT of choice: levodopa

Pt with Parkinsonism develops nausea, vomiting, abd distension& constipation…

Dx: pseudo-obstruction

Child with recurrent episodes of staring (as if dreaming) that lasts 5-15 seconds
after which he resumes activity as nothing happened... Dx: absence seizure

TTT of choice: esuthoxamide

Child with 1st attack of generalized convulsion with fever and evidence of extra-
cranial infection… febrile seizure (benign seizure)

TTT: control of fever; (1st line: paracetamol. If very high: ice packs then
paracetamol)

Risk of future epilepsy in pt with febrile seizure is> normal population

Risk of future BA in pt with bronchiolitis is> normal population

First attack seizure: vvvvvvvvvvvvvvv imp

First step ………….ask a witness ….vvvvvvvvvvvv imp

Inv……..CT without contrast is the first inv

53
If normal……do EEG

Most imp questions to kid with seizure ....is this 1st attack???

Seizures and driving .…the most recent updates:….vvvvvv imp

Isolated seizures…….6 months

Single seizure on withdrawal of the medication……3 months

Non-compliant patient, Chronic seizure or Recurrent seizure….2 years

Other illness and driving:

Hemianopia……never drive

TIA or stroke……..1 month

When to stop anti-epileptic medication… pt free of seizure for 2 Ys

Female on anti-epileptic medication decided to be pregnant… next step: stop

medication (even if cabamazipine is found in choices)

Most safe drug in pregnancy…………. Carbamazipine

Single attack of seizure lasting> 30 min… status epilepticus

TTT: ABC then IV diazepam

MCC of status epilepticus/ MCC of recurrent seizures… non-compliance

Sudden onset vertigo with NO other manifestation…... vestibular neuritis

Sudden onset vertigo+ hearing loss………………………...... labyrinthitis

Paroxysmal attacks of vertigo, tinnitus, ear fullness….. minier’s disease

Vertigo related to position……………………………………..… BPPV

Vertigo, tinnitus, neurological manifestation………….. Acoustic neuroma

Test of choice of BPPV………………………….. Dix- Hallpike maneuver

54
Test of choice of Acoustic neuroma….. MRI

1st step in management of suspected stroke………………...… aspirin

1st step in management of suspected stroke in PUD pt….. aspirin

Pt with ischemic stroke presented in the 1st 3 hs………….….. TPA (best outcome)

Most imp medication in hemorrhagic stroke… anti-hypertensive (oral ACE-Is)

Long term management of stroke………………………….. aspirin & dipyridamole

1st inv in suspected stroke………………………………….………………. CT

Best inv of stroke……………………………………………….………………. MRI

Inv on choice in embolic stroke ………………………………………. Echo, EKG

MC RF of stroke…………………………………..……….. HTN

Stroke pt with hemiplegia affecting LL>UL with marked personality changes… ACA

Stroke pt with hemiplegia affecting UL>LL with homonymous hemianopia…. MCA

Stroke pt with deep coma/OR/ fall attacks…………….. Vertebra – basilar artery

Stroke pt with contralateral hemiplegia, ipsilateral blindness……….. ICA

Stroke pt with ipsilateral horner $, ataxia and contralateral loss of P, T… PICA

Stroke pt with uncrossed hemiplegia (paralysis of face& body at the same

side)………….… INTERNAL CAPSULE

Lesions of the optic pathway:

Optic nerve…….unilateral blindness

Optic chiasma…..bitemporal hemianopia

Optic radiation….contralateral homononymous hemianopia

Occipital lobe…… contralateral homononymous hemianopia

55
Temporal lobe…..contralateral upper quadrantic field defect

Parietal lobe……. contralateral lower quadrantic field defect

MC affected reflex in pt with sciatica…... Ankle reflex

Area of lower limb affected by sciatica… the whole leg except the medial side

Inv of choice of sciatica…………………………. MRI

1st line TTT of sciatica …………………………… paracetamol

1st inv in Duchene muscle dystrophy….. CK

Best inv in Duchene muscle dystrophy…. Muscle biopsy

VITAMIN DEFICIENCY:
Vitamin A ………….. NIGHT blindness and impaired growth

Vitamin D …………. Adult: osteomalacia. Kids: rickets

Vitamin E….anemia

Vitamin K….Bleeding

Vitamin C ( ascorbic acid)…most common cause of bleeding in elderly (scurvy)

Thiamine(B1)…..wernike enceplalopathy and beriberi

Riboflavin…..cheilosis and dermatitis

Niacin……pellagra( dermatitis, diarrhea and dementia)

Vitamin B6…..peripheral neuropathy

Folic acid……megaloblastic anemia

B12(cyanocobalamines)… megaloblastic anemia, peripheral neuropathy

Pt with cervical injury develops severe -- pulse &-- BP… Dx: Neurogenic shock

56
Pt on labor receive epidural anathesia develops severe -- pulse &-- BP… Dx:
Neurogenic shock

Neurogenic shock is the only type of shock causing bradycardia

1st step in TTT of Neurogenic shock… IV fluid (then, atropine, vaso-pressor)

Old pt with AF need anti-coagulation TTT with…… Warfarin with target INR 2-3
EXCEPT for those with prosthetic valve (target INR> 2-3)

57
 Obstetrics

Diabetes in Pregnancy:

Two categories:
1-gestational DM…….. Occurs in late pregnancy.
2-chronic DM

DIAGNOSIS
single step testing with a 75g OGTT at 24-28 weeks

TREATMENT
■ Mother:
■ First step: Start with the diet
■ Next step: Add insulin if dietary control is insufficient.
Oral hypoglycemic drugs…..contraindicated
■ Fetus:
■ It may be necessary to induce labor at 39–40 weeks
.
COMPLICATIONS
More than 50% of patients go on to develop glucose
intolerance and/or type2 DM later in life.

Fetal complications:

Cardiac and renal defects……most common

Neural tube defects
Sacral agenesis)
Hypocalcemia
Polycythemia
Hyperbilirubinemia
Hypoglycemia from hyperinsulinemia
Respiratory distress syndrome (RDS)
Birth injury (e.g., shoulder dystocia)

58
Screening for gestational DM??

Timing……24-28 weeks

How……single test with a 75g OGTT

If(+)….do fasting blood glucose

BMI >30 kg/m2, family history of diabetes, previous gestational
diabetes..do FBS in 1st antenatal check up

Follow up after labor ……FBS every 3 YEARS

Gestational and Chronic Hypertension

1- Gestational hypertension

Timing ……….> 20 weeks’ gestation

Risk…… preeclampsia.

2- Chronic hypertension:
Before conception and at < 20 weeks’ Gestation
Tx: antihypertensives (e.g., methyldopa, labetalol, nifedipine)

N:B:
Drug of choice for HTN with pregnancy…..methyldopa
ACEI must be avoided with pregnancy….. …..TERATOGENIC

Preeclampsia and Eclampsia

■ Preeclampsia: at > 20 weeks’ gestation.

1- Hypertension
2- proteinuria (> 5 gm of protein in a 24-hour period)
3- Edema

59
 Eclampsia: New-onset grand mal seizures in women with
preeclampsia.

Signs of severe preeclampsia

1- persistent headache
2- visual disturbances
3- epigastric pain or RUQ pain
4- Vaginal bleeding
5- Hyperreflexia

6- HELLP syndrome:
Hemolysis
Elevated LFTs
Low Platelets

The only cure for preeclampsia/eclampsia is delivery of the

fetus.

■ Preeclampsia:

■ If the patient is close to term …… induce delivery

If far from term……….… expectant management.

■ Severe preeclampsia:

■ First step: Control BP with labetalol or hydralazine

Goal < 160/110 with a DBP of 90–100 to maintain fetal blood
flow
■ Second step: Prevent seizures with magnesium sulfate
Third step: Deliver by induction or C-section

Eclampsia:
■ First step: ABCs with supplemental O2.

60
■ Second step: Seizure control/prophylaxis with magnesium. If
seizures recur, give IV diazepam
Third step……. delivery

Toxicity of magnesium sulfate:

First sign…….loss of deep tendon reflexes
Serious sign……respiratory depression, coma
TTT……… IV calcium gluconate.
_ OBSTETRIC COMPLICATIONS OF PREGNANCY

Ectopic Pregnancy

The classic triad of ectopic pregnancy

Pain (abdominal)
Amenorrhea
Vaginal bleeding

Most common site…….ampulla of falopian tube

Recurrence rate……… 10-15 %

Predisposing factors:….. scarring to the fallopian tubes

History of PID…….most common cause
IUD
Pelvic surgery
Surgical abdomen

DIAGNOSIS
Woman of reproductive age presenting with abdominal pain
and vaginal bleeding is a ruptured ectopic pregnancy until
proven otherwise

First step: _ pregnancy test

If(-)……..no pregnancy
If (+)…….transvaginal ultrasound

61
If you find a sac in the uterus……..normal pregnancy
Empty uterus………do serial B-hcg
Doubling……..normal pregnancy
No doubling…….ectopic

TREATMENT
■ Medical treatment (methotrexate)

Endoscopic management:…..laparoscopy
When?...............Unruptured
Stable patient

Laparotomy:
When?................Ruptured
Unstable patient

Most serious sign in ectopic pregnancy….pain referred to left

shoulder…..immediate laparotomy

Antepartum Hemorrhage
■ Defined as any bleeding that occurs after 20 weeks’.

■ The most common causes are placental abruption and

placenta previa

62
Abnormal placental implantation:
■ Total: Placenta covers the cervical os.
■ Marginal: Placenta extends to the margin of the os
■ Low-lying: Placenta is in close proximity to the os

PLACNETA PREVIA:

Risk factors:
Prior C-sections……most common
Grand multiparity
Multiple gestation,
Prior placenta previa.

CP:
Painless, bright red bleeding that ceases in 1-2 hours

PLACENTA ABRUPTION:
Risk factors:
Hypertension,………..most common
Cocaine…….vvv imp
Smoking
Abdominal/pelvic trauma
63
Cp:
Painful, dark vaginal
Abdominal pain,
On exam……….uterine tenderness
Shock out of proportion to the bleeding.
.
Diagnosis :
No vaginal exam!
Ultrasound …….. retroplacental clot

. Management:
Stabilize patients …….. Manage expectantly
Hospitalize
Start IV fluid
Fetal monitoring
Moderate to severe cases:…………….. C-section

Complications
Hemorrhagic shock.
Coagulopathy: DIC more with placental separation
Recurrence risk is 5–10%
Vasa previa:
(Fetal vessels crossing the internal os).
Cp……vaginal bleeding when rupture of membranes with
marked fetal distress
Main management……CS

64
N:B: VVVVVVVVVVVVV IMP

Most common risk factor for placental abruption….HTN

Most common risk factor for placenta previa…previous CS

Bleeding with placental abruption……painful

Bleeding with placenta previa……painless

Most imp sign with placental abruption ……….uterine

tenderness
Main inv with placenta previa……US

Main inv with placental separation….US

Drug causing placental infarction……cocaine

Main complication with placental separation….DIC

Main risk factor for stroke……HTN

Main risk factor for MI………HTN

Main risk factor for placental separation…..HTN

Main factor causing damage of kidney in diabetic

patients…..HTN

Round ligament pain:……….vvvvvvvvvvvvvvvv imp

Most common cause of abd pain with pregnancy
Timing.............2ND trimester
Site........usually RT side
DD...... appendicitis
TTT........analgesic and rest

65
Umbilical cord prolapse:

Causes:
Premature rupture of the membranes …..Most common
management:imp
Initial step…..asses pulsation of umbilical cord to see if fetus is
alive or not
Second step…….. Put patient in the knee – chest position (
trendelenberg)
Third step………. Push the presenting part back ward to
decrease pressure
Fourth step………CS
Never to try to push umbilical cord backward

66
Cholestasis of pregnancy

Timing ……third trimester

cp……. Jaundice and itching

Inv…… bilirubin and ALT elevated

CTG…..for fetal distress

Risk….…..fetal distress and mortality

TTT…..ursodeoxycolic acid

Early delivery of fetus at 35-37 weeks

Asymptomatic bactuiria:

No symptoms

Bacteria level………. at least 100,000 colony

Most common bacteria……..E-COLI

Most common risk factor…….short urethra

Risk…………..pyeolonephritis 30%

Investigation:…… midstream clean-catch urine

TTT :

NITROFURANTOIN…….1st line

Cephalexin………………..2nd line

Amoxicillin- clavulanate

67
N:B:…….WHEN TO TTT ASYMTOMATIC BACTURIA??

Adult………noooooo

Non-pregnant women……noooooo

Eldery……nooooo

DM……..noooooo

Patient with renal transplantation…….noooooo

Spinal cord injuries…….noooooo

Patient on catheter……nooooooo

Children………..nooooooo

Pregnant……….yesssssss

Vesicouretral reflux……..yessss

Pyelonephritis with pregnancy

High fever,

Chills

Pain in the flank.

Nausea and vomiting

Complication………..preterm delivery

TTT

HOSPITALIZATION

IV cefotiaxone and gentamycin

68
 Gestational Trophoblastic Disease (GTD)
( vesicular mole)
■
Complete moles: Sperm fertilization of an empty ovum; 46,XX
■ Incomplete (partial) moles: normal ovum is fertilized by two
sperm 69,XXY and contain fetal tissue.

HISTORY/PE
First-trimester uterine bleeding (most common),
Uterine size greater than dates.
Hyperemesis gravidarum
Preeclampsia/eclampsia at < 24 weeks,
■
Risk factors include:
Extremes of age (< 20 or > 40 years)

DIAGNOSIS
No fetal heartbeat is detected.

69
Pelvic exam …… enlarged ovaries (bilateral theca-lutein cysts)
Expulsion of grapelike molar clusters (vesicles)

Labs………markedly ↑serum -hCG (usually > 100,000 mIU/mL),

Pelvic ultrasound …… “snowstorm” appearance
No gestational sac or fetus present
D&C……………….. “cluster-of-grapes” tissue
CXR ………. lung metastases;

TREATMENT
1- Evacuate the uterus
2- Follow with weekly with B-hCG.
3- Treat malignant disease with chemotherapy
(methotrexate)
4- If metastases……Chemo, radio and hysterectomy
5- OCP for at least 1-2 years

COMPLICATIONS
Molar pregnancy may progress to malignant GTD
choriocarcinoma (2–5%) with pulmonary or CNS metastases.

70
N:B:
Key words for vesicular mole…….vesicles with bloody vaginal
discharge , snow storm appearance
Most common site for metastasis…….lung
Most common risk factor…….extremities of age
Most common associated ovarian cyst...theca lutein cyst
When to suspect vesicular mole ?? 1- rapidly enlarging uterus
2- severe vomiting
1st step with severe vomiting…..exclude vesicular mole ( level
of B-hcg)

Multiple Gestations

■ Hx/PE: Characterized by rapid uterine growth,

Excessive maternal weight
Exam……. palpation of three or more large fetal parts
■
■ Maternal complications—e.g., preeclampsia, preterm labor,
preterm PROM(PPROM), placental abruption
■ Fetal: Complications include twin-to-twin transfusion
syndrome, IUGR, and preterm labor
In case of twins …After delivery of the first baby next
step……assessing position of the second baby

. Fetal Macrosomia
Most common cause…..DM
■ Tx: Planned cesarean delivery if EFW > 4500 g
■ Cx:
Polyhydramnios
■ Defined as an AFI > 20 on ultrasound.
■ Etiologies:
Fetal anomalies (e.g., duodenal atresia,
tracheoesophageal fistula)
■ Dx: Fundal height greater than expected.
1st inv……….US
71
Oligohydramnios
■ An AFI < 5 cm on ultrasound.

Etiologies :
Fetal urinary tract abnormalities (e.g., renal agenesis, GU
obstruction),……..most common cause
.
■ Tx: Rule out inaccurate gestational dates. AND DE LIVE RY

Shoulder Dystocia

Risk factors:
Obesity
diabetes,

DIAGNOSIS
Recoil of the perineum (“turtle sign)

TREATMENT
■ Leg elevated (first step) (McRoberts’ maneuver)…….
■ Pressure (suprapubic)……second most important
■ Episiotomy.

COMPLICATIONS
Clavicle fracture
Brachial plexus injury

N:B:
Most important risk factor for shoulder dystocia….DM
First step in shoulder dystocia…..elevation of patient legs
Second step……….suprapubic pressure
Signs of clavicle fracture….fullness, crepitus or deformity
TTT of clavicle fracture with shoulder dystocia ….none
Most common nerve injury with shoulder dystocia…..brachial
plexus

72
Erb palsy :

Root affected…….C5 and C6

Cp…..internally rotated arm, adduction,( waiter tip) hand
Association……..diaphragmatic paralysis
Fate….resolve in 3 months

Klumpls palsy:

Root affected……C7,8 and T1

Cp……hand and wrist paralysis
Association…..Horner syndrome

N:B:
Patient after labor with hypotension + contracted uterus + deviated
uterus ………..broad ligament hematoma

73
Rupture of Membranes (ROM)

■ PPROM: Rupture of membranes occurring at < 37 weeks’

gestation.
■ Prolonged ROM: Defined as rupture > 18 hours prior to
delivery.

HISTORY/PE
Patients often report a “gush” of clear or blood-tinged
amniotic fluid.
.
DIAGNOSIS
■ First step:
■ A sterile speculum exam …… pooling of amniotic fluid
in the vagina
■ Nitrazine paper test is _ (paper turns blue, indicating
alkaline pH of amniotic fluid).
■ Second step: Ultrasound

Never perform digital vaginal exams

Test for premature rupture of membrane…….fibronectin

TREATMENT
■ Depends on GA and fetal lung maturity.
■ Term. ………INDUCE LABOR
■ < 32 weeks’ gestation: Expectant management with bed rest
■ Antenatal corticosteroids (e.g., betamethasone or
dexamethasone for 48 hours): …. promote fetal lung maturity
■ If signs of infection or fetal distress develop…… give
antibiotics and induce labor.
Preterm Labor
■ Onset of labor between 20 and 37 weeks’ gestation.
HISTORY/PE
Menstrual-like cramps
Low back pain, pelvic pressure,

74
Or new vaginal discharge or bleeding.

DIAGNOSIS
■ Requires regular uterine contractions
Concurrent cervical change

■ Sterile speculum exam to rule out PROM.

■ Ultrasound

. TREATMENT
■ 1st step ……Unless contraindicated, begin tocolytic
therapy (B- AGONIST, MgSO4, CCBs, PGIs)

Steroids to accelerate fetal lung maturation.

penicillin or ampicillin for GBS prophylaxis

contraindications to tocolysis:

 Infection, nonreassuring fetal testing, placental abruption

 Fetus is older than 34 weeks gestation
 Fetus weighs less than 2500 grams or has intrauterine
growth restriction (IUGR) or placental insufficiency
 Lethal congenital or chromosomal abnormalities

 Cervical dilation is greater than 4 centimeters

 Chorioamnionitis or intrauterine infection is present

 Other cause of fetal distress or fetal death

N:B:
Key word of PROM…..sudden gush of fluid
Key word of preterm labor….uterine contraction and
dilatation of cervix
Most imp drug to the PROM………dexamethasone
Most imp drug to Preterm labor……tocolytics
Most absolute contraindication to tocolytics….
chorioamnionitis

75
Key word of chorioamnionitis……maternal fever
Once chorioamnionitis occurred...sampling and antibiotics

Fetal Malpresentation and malposition

Any presentation other than vertex
Risk factors:
Prematurity……….MOST COMMON
Most common malpresentation…..breech
Most common malposition………occipito posterior

Breech presentations
Subtypes include the following:
■ Frank breech (50–75%): The thighs are flexed and extended
knees
■ Footling breech (20%): One or both legs are extended below
the buttocks.
Complete breech (5–10%): The thighs and knees are flexed.
TREATMENT
■ Up to 75% spontaneously change to vertex by week 38.
■ External version: only after 36th weeks

76
Indications for Cesarean Section:

Most common indication for CS… previous CS

Most common cause of 1° C-section…. Cephalopelvic
disproportion
Prior classical C-section……….never to try vaginal delivery……..
uterine rupture
Transverse Lie……..equal CS
Shoulder presentation…….equal cs
Face presentation……..equal CS
Previous classic section ……equal CS
Cord compression…………equal cs
Active Herpes on genitalia…….Equal CS
HIV in mother……equal CS
Placenta previa/placental abruption…… If Failed operative
vaginal delivery
N:B:
Women with previous just one CS you may try vaginal delivery
provided that appropriate circumstances

77
Episiotomy

■ Two types: median (midline) and mediolateral.

■ Routine use of episiotomy is not recommended.

_ PUE RPE RIUM

78
 Inverted uterus:

More in the Primigravida

Causes:

Traction on the Placenta without waiting for uterine

contraction

C/P:

Postpartum bleeding
Circulatory collapse

Management :

Return the uterus manually

Hydrostatic replacement

Surgical intervention

Uterine rupture:

Occurs in early labor or late pregnancy

Causes :

Previous CS

Grand Multipara

Myomectomy ,Labor augmentation

C/P:

Old CS scare +

Fetus ascends upward

Abdominal pain +

79
Fetal stress +

Palpation of fetus outside uterus

Management:

Emergent laparotomy + Blood Transfusion

Repair or remove the uterus

Postpartum Hemorrhage
■ Loss of > 500 mL of blood for vaginal delivery or > 1000 mL
for C-section

Causes of Postpartum Hemorrhage:

UTERINE ATONY………..most common
Genital tract trauma
Retained placental tissue

Uterine Atony:
Most common cause of postpartum hemorrhage (90%)

Risk factors:
1- Uterine overdistention (multiple gestation, macrosomia,
polyhydramnios).
2- Exhausted myometrium (rapid or prolonged labor, oxytocin)
Diagnosis…….. Palpation of a soft, enlarged, “boggy” uterus.

TTT:
Bimanual uterine massage……1ST STEP
Oxytocin infusion……2nd step
Methergine (methylergonovine)
Prostaglandin (PGF2a).
Uterine/internal iliac artery ligation
Hysterectomy ……severe cases

80
Postpartum Infections (endometritis)
■ Characterized by 1- 38°C
2-Uterine tenderness
■ 3- Malodorous lochia

Timing…….usually 2nd day-3rd day

■ C-section,……..most most risk factor

TTT:
Hospitalization
First step………….culture
Broad-spectrum empiric IV antibiotics (e.g., clindamycin and
gentamicin)
Sheehan’s Syndrome (Postpartum Pituitary Necrosis)

Anterior pituitary insufficiency 2° to massive obstetric

hemorrhage and shock
.
■ Hx/PE:
The most common presenting syndrome is failure to lactate
(due to ↓ prolactin levels).

■ Other Symptoms :
Decreased TSH……… weakness, lethargy, cold insensitivity,
Decreased FSH and LH ……genital atrophy, and menstrual
disorders.
■ Dx:
Hormonal testing
MRI of the pituitary
■ Tx: replacement therapy. ( CORTISONE FIRST THEN
THYROXINE)
Colostrum:
(“early breast milk”) …..very rich protein, fat, secretory IgA and
minerals
Timing…..first 3 days

81
The 6 W’s of postpartum fever:
Wind (atelectasis,)…..first day
Water (UTI)…………..2nd – 3rd day
Womb(endomyometritis)….2nd – 3rd
Walk (DVT, pulmonary embolism)….after 5 days
Wound (incision, episiotomy) after one week
Weaning (breast engorgement, mastitis)….. more than 10 days

contraindicated in Breastfeeding

 Maternal Drugs –
 Chemotherapy agents –
 Radioactive isotope –
 Primaquine and Quinine – contraindicated if either infant
or mother has G6PD
 Sulfa drugs
 Metronidazole –

 Local breast conditions:
 Mastitis…….YESSSSS
 Breast abscess…..YESSSSS
 Advanced breast cancer…..NOOOO
Active herpes viral infection (vesicles)…….NOOO

82
Normal labor :vvvvvvvvvvvvv imp

Onset of Labor

 Painful Uterine Contractions

Painful, intermittent, involuntary and co-ordinated

uterine contractions

false labor pains'

Uterine contractions in late pregnancy which they often

mistake for onset of labor.

But the contractions are usually not regular, does not

increase gradually in intensity

Expulsion of Show or Mucus Plug

Mucus with small amount of blood

 Rupture of Membranes

a sudden gush of waters,

Childbirth occurs in three stages:

First stage: The time of the onset of true labor until the
cervix is completely dilated to 10 cm.
Second stage: The period after the cervix is dilated to 10
cm until the baby is delivered.

83
Third stage: Delivery of the placenta.

First Stage
The first stage of labor is the longest and involves two
phases:

 Latent Phase -The time of the onset of labor until the

cervix is dilated to 4 cm.
 Active Labor Phase - Continues from 4 cm. until the
cervix is dilated to 10 cm.

84
Early Labor Phase
What to expect:

 Early labor will last approximately 8-12 hours

 Your cervix will efface and dilate to 4 cm
 Contractions will last about 30-45 seconds, giving you 5-
30 minutes of rest between contractions


Active Labor Phase:

What to expect:

 Active labor will last about 3-5 hours

 Your cervix will dilate from 4 cm to 10 cm
 Contractions during this phase will last about 45-60
seconds with 3-5 minutes rest in between

Second stage:
Start with……complete cervical dilatation
Ends with…….baby delivery
Duration………1-3 hours

Third stage:
Start with……..delivery of the baby
Ends with…….delivery of the placenta
Duration………half an hour

85
 Abnormal labor :

Prolonged latent phase:

Contraction…….regular
Cervix……..around 2 cm
No cervical change in 14 hs
TTT…….sedation and rest

Prolonged active phase:

Contraction………regular
Cervix………dilated around 7 cm
2 cm change in 4 hs

Arrested active phase

Contraction………regular
Cervix………dilated around 7 cm
No change in 3 hs

Management?
Asses contractility":
If hypotonic……..oxytocin
Hypertonic……….sedation
Adequate…………CS

Second stage arrest:

Regular contraction
Fully dilated cervix
No descent in 3 h

86
Management :
If weak contraction…….oxytocin
Asses head engagement:
Not engaged……..CS
Engaged……..forceps (non rotating)

Acceleration:
Increase FHR above base line
Less than 2 minutes
Not related to contraction
Always reassure

Variability:
Fluctuation in the FHR
NORMALLY OCCURS ( 6-25 / min)
If absent ……..abnormal
If marked variability……fetal distress

Normal range of fetal heart rate….. 110-160

If less than 110……..bradycardia
If more than 160……tachycardia

Most common cause of fetal bradycardia……sleeping baby

Most common cause of fetal tachycardia……maternal fever
Normal fetal PH…….7.25 – 7.35

Types of Fetal Deceleration

Early deceleration:
Gradual drop in the FHR
Gradual increase in the FHR
Mirror image of the contraction
Cause…….fetal head compression

87
Late deceleration
Gradual drop in FHR
Gradual increase in the FHR
Delay in relation to contraction
Cause…….fetal hypoxia or fetal acidosis
FIRST STEP……….FETAL SCALP PH

Variable deceleration
Sudden drop in FHR
Sudden increase FHR
Severe if FHR less than 60 ……..CS
Cause…….cord compression
Management???......First step give fluid and change maternal
position…..vvvvvvvvvvvvvvvvv imp
If still no response……….CS

WHEN TO SAY NORMAL LABOR????? VVVVVVVVIMP

Base line………110-160
Acceleration……present
Variability………present
Deceleration……absent

WHEN TO SAY ABNORMAL LABOR????? VVVVVVIMP

Base line…..less than 110 or more than 160
Acceleration…….absent
Variability……….absent
Late or variable deceleration……..present

ON (SAB)
Early acceleration Late deceleration

88
Variable deceleration ►

89
Fetal movement assessment:…….. at 32–34 weeks

Normally……….. 10 or more fetal movements in 2 hours

Abnormal fetal movements:

First step……..history and examination

First inv……….fetal heart Doppler
If fetal heart rate detected……CTG
If not detected……..immediate US
If normal CTG……reassure
If abnormal CTG……immediate US
If CTG not available ….refer to hospital
If recurrent abnormal FHM:
Near term…….induction of labor
A way from term……continuous CTG

90
. ■ Nonstress test (NST):
Performed with the mother resting in the lateral tilt position
FHR is monitored externally by Doppler

Acoustic stimulation may be used.

■ “Reactive” (normal response): 15
bpm above baseline lasting for at least 15 seconds over a 20-
minute
■ “Nonreactive”: Fewer than two accelerations over a 20-
minute period.

91
■ Biophysical profile (BPP): Uses real-time ultrasound to
assign a score of
2 (normal) or 0 (abnormal) to five parameters:
Fetal tone
Breathing
Movement,
Amniotic fluid volume
NST
. Scoring is as follows:
■ 8–10: Reassuring for fetal well-being.
■ 6: Considered equivocal. Term pregnancies are usually
delivered
■ 0–4: strong consideration should be given to immediate
delivery

SYSTEM PARAMETER PATTERN

Cardiovascular
Heart rate………. Gradually increases 20%.
Blood pressure………. Gradually decreases 10% by
Stroke volume……..increased
Cardiac output..Increased especially in LT lateral position

Pulmonary
Respiratory rate…….increased

Blood
Volume…..increased
Hematocrit…..decreased
Fibrinogen……increased

Gastrointestinal
Sphincter tone…….. Decreases.
Gastric emptying…... Increases.

Blood gases……..respiratory alkosis

92
Renal
Blood flow……increased
GFR…………..increased
Creatinine clearance……increased
Urine glucose……..increased
Ureter……dilated (progesterone effect)….increased UTI

ENDOCRINE :
Pituitary…..increased in size but not blood supply…..Sheehan
syndrome
Thyroid:
Total T3 and T4……..increased
Free T3 and T4……..normal

Abortion

Loss of products of conception (POC) before 20th week of

pregnancy
More than 80% will occur in the first trimester.

Risk factors:
■ Chromosomal abnormalities: ……most common
■ Inherited thrombophilias: Factor V Leiden
■ Immunologic issues: Antiphospholipid antibodies,
■ Anatomic issues: Uterine abnormalities, incompetent cervix

DIAGNOSIS
■ Ultrasound…… Can identify the gestational sac 5–6 weeks
from the LMP and fetal cardiac activity at 6–7 weeks.
■
■ Maternal Rh type should be determined and RhoGAM
given if the type is Rh –

93
Types of abortion:

Threatened:
No POC is expelled.
Uterine bleeding +/– abdominal pain.
Closed os +
Intact membranes + fetal cardiac motion on ultrasound

.TTT:
Pelvic rest for 24–48 hours
No sexual relationships
Progesterone
Fate: 50% ends with abortion

Complete abortion:
POC …….Completely expelled.
Pain ……no
Bleeding…..no
Closed os.
Ultrasound ….. Empty Uterus
.
Incomplete
Some POC ….. Expelled.
Bleeding……yes
Pain……yes
Open os.
Ultrasound shows retained fetal tissue.
Manual uterine aspiration or D&C.

Inevitable
No POC is expelled.
Uterine bleeding
pain.
Open os
MUA, D&C, misoprostol, or expectant management.

94
Missed
No POC is expelled.
No fetal cardiac motion.
No uterine bleeding.
No pain
Closed os.
No fetal cardiac activity;
retained fetal tissue on ultrasound.
TTT: MUA, D&C, or misoprostol.

Septic
Endometritis leading to septicemia
Main TTT…….antibiotics then curettage
Main risk with curettage……….perforation of uterus.

N:B:
Fate of threatened abortion…..50 % LOSS OF FETUS
Main route of delivery with missed abortion….vaginal as long as
no affection of her labs
Main ttt of threatened abortion……rest
Most common cause of abortion……chromosomal
Timing of abortion with chromosomal disorders….first
trimester
TTT of abortion in first trimester…….Dilatation and curettage
TTT of abortion in second trimester……dilatation and
evacuatuion
Best way to assess the gestational age in first trimester……US

95
 Fetal demise

Fetal death after 20th weeks

Cp…….NO fetal movement and NO FHR
MOST common cause……idiopathic
Risk……..DIC
TTT…..VVVVIMP
First step…….check hematology labs
If NO DIC………WAIT FOR SPONTANOUS DELIVERY
IF DIC………….induction of labor
Main route of delivery……..vaginal
CS…….is never the first option

SLE WITH PREGNANCY:

Risk……….recurrent abortion
Timing……..second trimester
Types of antibodies……antiphospholipid, anticardiolipin
Most common congenital abnormality…….heart block ( anti RO
and anti La)…….vvvv imp
TTT…….
Low dose ASPIRIN
Low dose HEPARIN ( LMWH)

96
 Incompetent cervix

Painless dilation of the cervix

Delivery of normal baby who quickly dies
Timing………second trimester

CAUSES:

 history of conization (cervical biopsy),

 LEEP
 diethylstilbestrol exposure

INVESTIGATIONS:

US……….SHORTENING OF CERVIX

HERNIATION OF FETAL MEMBRANES

TTT……..CERCLAGE

When to do ??...........13-16 weeks

When to remove??......36-37 weeks

COMPLICATIONS OF PREGNANCY

97
 Hyperemesis Gravidarum

Persistent vomiting …… acute starvation

Main cause……related to B-hcg hormone
Cp:
Timing……mostly in first pregnancy
Large ketonuria
Weight loss
Electrolytes disturbances

Risk factors :
Molar pregnancies……vvvvvvvv imp
Multiple gestations

DIAGNOSIS
■ Rule out molar pregnancy:
Check B-hCG level and ultrasound…….first step
.
Management:
Hospitalization
IV fluid …..TPN with severe cases
Vitamin B 6
Antiemetics………..metoclopramide( 1st line), codeine and
antihistamincs
Induce abortion with resistant cases

N:B:
First step in hyperemesis gravidarum…..exclude molar
pregnancy
Hormone causing hyperemesis gravidarum……B-hcg
Antiemetics,,,,,,metoclopramide, codeine and antihistamincs

98
 Anesthesia and Analgesia

1-Opioids

Side effect……neonatal depression

TTT……….naloxone

2-Epidural
Side effect…… hypotension
Limited duration
postdural puncture headache
TTT……vasopressors and fluids

3-General …. Emergent cesarean

Side effect……Maternal aspiration

4-Local block (lidocaine)

Drugs should be avoided in pregnancy :

Alcohol……fetal alcohol syndrome

Cocaine……congenital abnormality

Phenytoin…….fetal hydantoin syndrome

Carbamazepine……neural tube defect

Fetal hydantoin syndrome

Tetracycline…… yellow-brown discoloration of teeth

Isotretinoin,
Warfarin….facial abnormalities

ACEI

Diethylstilbestrol……vaginal adenosis, T- shape uterus

Lithium …….. (Ebstein’s anomaly).

99
Methotrexate
Radiation
Streptomycin ……. Hearing loss
Valproic acid…… Neural tube defects
Vitamin A in high doses
High risk pregnancy:

1- Anemia:

Iron deficiency…….ferrous sulphate

Megaloblastic…….folic acid

2-DM:

OGTT…….ROUTINE TO ALL PREGNANTS

Timing…….24-26th weeks

If (+)…..follow up after pregnancy by FBG every 3 ys

3-Thyroid:

Best ttt…….surgery

Timing…….second trimester

Anthyroid drugs……..fetal hypothyroidism

Best antithyroid drug……..propyuracil

Radioactive iodine…….contraindicated

4-Cardiac:

Most common disease…….mitral stenosis

Fetus affection……..low birth weight

Best way of delivery…….vaginal

100
5-SLE:

Most common fetal affection……congenital heart block

Affection on the mother……abortion ( antiphospholipid

syndrome)

TTT………LOW DOSE ASIRIN+LOW DOSE HEPARIN

Warfarin……..contraindicated

6-Gestational thrombocytopenia:

Common in late pregnancy

TTT…….usually none

If bleeding……cortisone and IVIG

7-Epilepsy:

Pregnancy exacerbates the epileptic attacks

All antiepileptic drugs are teratogenic

Phenytoin…….cleft lip and palate

Sodium valproate……spina bifida

Carbamazepine…….spina bifida

So the target is……single drug with the lowest dose

The best is ……….carbamazepine…..imp

Guidelines for post term labor……vvvv imp

Normal timing of delivery…….37-40weeks

If after 42th weeks…………induce labor

If between 40th-42th weeks:

101
First step………CTG

If normal…….wait

If distressed…….induce labor

N:B:

Causes of free floating head during labor ( not engaged):

1- malpresentation( occipitiposteroior position)…most

common
2-small pelvis………second most common

N:B:
Other than paracetamol………..most pain killers are NOT
safe in pregnancy
Rh Isoimmunization
Fetal RBCs leak into the maternal circulation
anti-Rh IgG antibodies form that can cross the placenta,
leading to hemolysis of fetal Rh RBCs (erythroblastosis fetalis)

Most common cause of maternal sensitization……hidden feto-

maternal hemorrhage

DIAGNOSIS

Serial ultrasound and amniocentesis for evidence of fetal

hemolysis
. Best way to asses fetal severity…..fetal blood sampling
TREATMENT
In severe cases……… preterm delivery when fetal lungs are
mature
Intrauterine blood transfusions.
COMPLICATIONS
■ Hydrops fetalis Infections
infections in pregnancy
102
■ Toxoplasmosis
Source………………….Raw meat
Cat feces.
Cp….. Hydrocephalus,
Intracranial calcifications

Rubella:
More than 95% of the women are immunized
Transplacental transmission in the first trimester
Cp:
“blueberry muffin” rash,
Cataracts,
Deafness
Patent ductus arteriosus (PDA).

How to prevent??......vaccination
Timing to give vaccine?....before pregnancy or after delivery

■ Syphilis:
maculopapular skin rash,
lymphadenopathy,
hepatomegaly,
In childhood, late congenital syphilis is characterized by saber
shins, saddle nose, CNS involvement, and Hutchinson’s triad:
peg-shaped upper central incisors, deafness, and interstitial
keratitis

CMV:
The most common congenital infection;
periventricular calcifications.

■
Herpes:

103
Intrapartum transmission if the mother has active lesions.
How to prevent?........CS

■ HIV
Transmission can occur in utero, at the time of delivery, or via
breast feeding

104
Prevention in OBS/GYN:

Example of primary prevention…….vaccination

Examples of secondary prevention…….screening (colonoscopy,

mammography, pap smear)

105
 Preventive activities prior to pregnancy
Guidelines for nutritional supplementation:
■ Folic acid
■ Iron
■ Calcium
■ Vitamin D………..the most important vitamin
■ Vitamin B12
■ Iodine

Further vitamin A, C or E supplements may in fact cause harm and so

these are not recommended for use in pregnancy

Vaccinations
MMR and varicella should be advised against becoming
pregnant within 28 days of vaccination. Recommended
vaccinations are:

 MMR
 varicella (in those without a clear history of chickenpox )
 influenza (recommended during pregnancy in second
trimester)
 diphtheria, tetanus, pertussis (DTap)
 Rubella.

Folic acid supplementation vvvvv imp

Dose…..0.5 mg
When to start……..1 month prior to pregnancy, and for the first
3 months after conception.
women at high risk …………increase dose to 5 mg
1- history of NTD
2- women on anti-epileptics
3- women who have diabetes)

106
Healthy weight, nutrition and exercise
Recommend regular, moderate-intensity exercise
Smoking, alcohol and illegal drug cessation (as indicated)
Smoking………nooooooo
Illegal drug …….noooooooo
Alcohol ……….nooooooo ( not even one cup).
Healthy environments

Table 1.1 Pre-conception: preventive

interventions

Intervention Technique

Folate High-risk women: 5 mg/day

supplementation
Most women: 0.5 mg/day
beginning at least 1 month
prior to conception and for
first trimester

Iodine All women who are

supplementation pregnant, breastfeeding or
considering pregnancy
should take an iodine
supplement

Smoking Not allowed

107
Table 1.1 Pre-conception: preventive
interventions

Intervention Technique

Alcohol and illicit For women who are

drug use pregnant or planning a
pregnancy, no drinking is
allowed
The risk of harm to the
foetus is highest when there
is high, frequent, maternal
alcohol intake.
The risk of harm to the
foetus is likely to be low if a
woman has consumed only
small amounts of alcohol
before she knew she was
pregnant.

Interpregnancy Should be more than 18

interval months
Preterm birth, low birth
weight and small for
gestational age.

N:B:

Normal increase in weight during pregnancy….10-12 kgs

108
 How to prevent Down syndrome???

Who is at risk?......all pregnant women

How???

First trimester……

1- Us…… nuchal translucency……at 11 weeks

2- Free beta human chorionic gonadotrophin (HCG), at 10-12

weeks

Second trimester :

 beta HCG,…….increased
 inhibin A………increased
 oestriol,……….decreased
 alpha-fetoprotein……decreased
 ideally at 15–20 weeks

Or you can use the diagnostic tools?

Chorionic villus sampling:

Timing (10-12 weeks)

More sensitive

Risk……1 %

Amniocentesis:

Timing……15-16 weeks

Less sensitive

Risk……….0.5 %

109
Neural tube defect:

How to prevent??.......folate supplementation 0.5 gm

If women with past history of NTD……5 gm

Recurrence rate ……..1-5 %

Screening????

Amniocentesis:

Timing……15-16 weeks

What to find?........increased AFP

Most common cause of increased AFP…….dating error

Risk……….0.5 %

How to screen in 2nd trimester…..US

110
 Prevention of infection:

 Toxoplasmosis…… avoid cat litter, raw/undercooked meat

and unpasteurised milk products
 Ttt…….spiramycin and pyrimethamine


 Listeriosis: …..avoid paté, soft cheeses (feta, brie, blue vein),

Parvovirus:

History of contact with a child with slapped cheek

First step………IGg

If (+)………reassure

111
If (-)………..IGM

IF (-)……..reassure

If (+)……..us to exclude hydrops fetalis

If hydrops…….amniocentesis and umbilical sample

If woman with IGg (-) and IGM(-) BUT she is at high

risk……..repeat test after 2-4 weeks

112
RUBELLA:

How to prevent…………….VACCINATION:

Timing………… 1-3 months before pregnancy

After delivery

Never during pregnancy

What if exposed to infection during pregnancy?....same as

parvovirus

Eptein bar virus:

Reassure the mother
No tests to be done

113
Hepatitis B:

Chronicity with hepatitis B ……..85%

Once baby is delivered…………give him hep B vaccine AND
immunoglobulins
Breast feeding ………..allowed
Vaginal delivery……….allowed
CS……..not required

Genital herpes:
Active infection…………CS
If vaginal delivery done…….give acyclovir to the neonate

HIV
ONCE MOTHER IS DIAGNOSED……..initiate antiviral therapy
Most important drug to baby………zidovudine
How to deliver the baby…….CS
Breast feeding…………not allowed
Give zidovudine to the baby for the first 6 weeks

Chlamydia and gonorrhea:

Chlamydia……….azithromycin
Gonorrhea………..cefotriaxone
Syphilis:
TTT of choice………single dose IM benzathine penicillin

Candida:
Avoid oral preparations
The best is………vaginal clotrimazole

114
CMV in pregnancy:

Primary CMV during pregnancy is associated with the

highest risk of transmission
Anti CMV IgM is an appropriate screening antibody in
pregnancy
CMV IgM can persist for months after primary infection or
reappear with reactivation or re-infection.
CMV IgG avidity assist in timing of CMV infection.
Low avidity of igG indicates a recent infection, with
progression to high avidity with time

115
116
117
PREVENTION of isoimmunization:

Routine screening………(24- 28) weeks

■ If the mother is Rh(-)and the father is Rh + or unknown, give
RhoGAM (Rh immune globulin )

Most common cause of maternal sensitization……hidden fetal

hemorrhage

Indications for RhoGAM vvvvvvvvvvvvvv imp

1- Normal pregnancy at 24-28 weeks

2- After delivery within 72 hours
2-If the baby is Rh _, give RhoGAM postpartum.
3-abortion
4-ectopic pregnancy,
5- amniocentesis,
6- chorionic villus sampling
7-vaginal bleeding
8-placenta previa/
9-placental abruption.
Routine screening tests in pregnancy:

Complete blood count

Rubella antibody status
Syphilis serology
Hepatitis B serology
HIV
Blood group and antibody screen….24th-28 wks
OGTT……..24th-28th weeks
Group B- streptococcus at 36th weeks

118
Screening for group B streptococcus in pregnancy???
Why to screen???
10-30% of females are infected with the bacteria
When to screen??
36th -37th weeks
What if positive????
Give intrapartum penicillin….vvvvvv imp
When to give the antibiotics even if the swab is negative??
If labor starts before 37th weeks
Membranes ruptured more than 18 hours
Temperature during labor more than 38
The woman has ever tested positive for the organism
Previous baby was affected with the organism

Bishop score:

If bishop score less than 2…….induction with

prostaglandin and reassess after 6-12 hs……vvvvimp

119
N:B:
What will reduce the risk of transmission of hep C to her
baby…… avoid Fetal scalp electrodes
Best test for prevalence of HCV in child born to HCV
positive mother…. HCV AB at 18 month
Test for premature rupture of membrane…….fibronectin

120
Screening test for DM for all pop.>> FBS at age of 40

Screening test for GDM>> a 75g OGTT at 24-28 weeks

BMI >30 kg/m2, FH of DM, previous GDM..do FBS in 1st antenatal visit.

TTT of GDM>> 1st line:diet, exercise.. 2nd line:insulin

Female with H/O GDM, after delivery recommendation>> FBS/3Ys.

Most Common fetal compl. of GDM>> cardiac defect

Most uniqe fetal compl. Of GDM>> Sacral agenesis.

DOC for TTT of Gest. HTN>>> methyldopa

Preeclampsia (HTN, proteinuria) + any of the following(persistence headache,

visual disturbance, epigastric or RUQ pain, vaginal bleeding, hyperreflrxia).. Dx;
severe pre-eclampsia.

TTT of severe pre-eclampsia: 1st: control BP2nd: mg sulfat& 3rd; delivery.

Medications to control BP is severe pre-eclampsia: (labetolol, hydralazine,

nifedipine).

Pregnant with pre-eclampsia& (Hemolysis, Elevated Liver enzymes, Low

Platelets)…..Dx:HELLP $.

TTT of HELLP $: delivery

pregnant with severe pre-eclampsia develop seizure.. Dx; eclampsia.

TTT of eclampsia>> ABC+diazepam then as severe pre-eclampsia.

1st sign of mg sulfate toxicity>> depressed DTR

TTT of mg sulfate toxicity>>> Ca gluconate.

The only cure for severe pre-eclampsia is delivery.

Amenorrhea for 2 weeks…1st step/or/next step>> pregnancy test

121
Amenorrhea for 2 weeks, abdominal pain& vaginal bleeding..next step>>
pregnancy test.

-ve urine pregnancy test… next step>> blood B-HCG.

If B-HCG is –ve……….. no pregnancy

If B-HCG is +ve……….. next step>> trans-vaginal US>> normal VS ectopic

pregnancy.

If no sac in trans-vaginal US…. Next step>>> check B-HCG for doubling;

Doubling>>> normal pregnancy…… no doubling>>> ectopic pregnancy.

MCC of ectopic pregnancy>> PID(Chlamydia inf.)

MC RF of ectopic pregnancy>> previous ectopic.

MC site of ectopic pregnancy: ampula.

Ectopic preg.. pt stable, non-ruptured sac………ttt>>>> lapraroscopy

Ectopic preg.. pt unstable or ruptured sac………ttt>>>> laprarotomy.

Pregnant female with vaginal bleeding+pla pla pla…. 1st Next step>> US; BUT,
never to 4get that ABC always 1st in emergency.

Most common risk factor for placental abruption….HTN

Most common risk factor for placenta previa…previous CS

Bleeding with placental abruption……painful

Bleeding with placenta previa……painless

Most imp sign with placental abruption ……….uterine tenderness

Main inv with placenta previa……US

Main inv with placental separation….US

Drug causing placental infarction……cocaine

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Main complication with placental separation….DIC

During labor, fetal vessels cross the internal os… dx>> vasa previa.

TTT of vasa previa>> CS.

MCC of abdominal pain with no other complain in pregnancy>>> round lig. Strain.
DD: appendicitis>> fever only with appendicitis.

MC risk factor of umbilical cord prolapse>> PROM.

management:1st>> assess cord pulsation; 2nd>> put pt in knee-chest position&

3rd>> CS.

Pregnant female with asymptomatic GB stone need cholecystectomt..why? DT

increased risk of cholestasis of pregnancy.

Pregnant female with asymptomatic bacteruria…ttt:nitrofurantoin, amox-calv,

cephalexdin. nitrofurantoin is DOC if the 3 choices are found.

asymptomatic bacteruria in children, adult, old, those with DM, spinal cord injury,
those who undergone renal transplant or those who need intermittent cath……
NO prophylactic TTT with Abs.

asymptomatic bacteruria is only treated in pregnant and those with VUR.

TTT of Pyelonephritis in pregnancy>> hosp. + IV Abs

When to suspect vesicular mole ?? 1- rapidly enlarging uterus 2- severe vomiting

Key words for vesicular mole…….vesicles with bloody vaginal discharge , snow
storm appearance
Most common risk factor…….extremities of age
Most common site for metastasis…….lung
Most common associated ovarian cyst...theca lutein cyst
1st step with severe vomiting…..exclude vesicular mole ( level of B-hcg)
The most imp. Dx of GTD>>> B-HCG
The most imp. Follow up after evacuation of mole>>> B-HCG
Female with vesicularmole should avoid pregnancy for at least 2 ys

123
In case of twins; After delivery of the 1st baby next step>> assessing position of
the second baby

MCC of polyhydramnios>>> GIT obstruction (e.g. TEF, Duedenal atresia)

MCC of oligohydramnios>>> Urinary tract obstruction.
MCC of fetal macrosomia>>>> Maternal DM
MCC of shoulder dystocia>> maternal DM
The most imp sign of shoulder dystocia>> turtle sign(fetal head goes out& in).
the 1st step in management of shoulder dystocia>> leg elevation(Mcrobert’s
maneuver).
The most imp bone 2 b fractured in shoulder dystocia>> clavicle… NO TTT of
clav. Fracture.
After delivery of shoulder dystocia, baby with adduction, internally rotated
arm& waiter tip hand; Dx>> Erb’s palsy.…association>> diaphragmatic
paralysis… no ttt.
After delivery of shoulder dystocia, baby with 2HS (Hand paralysis& Horner’s
$); Dx>> klumpke’s palsy… no ttt.
Patient after labor with hypotension + contracted uterus + deviated uterus
………..broad ligament hematoma.

Key word of PROM…..sudden gush of fluid

Key word of preterm labor….uterine contraction and dilatation of cervix
Most imp drug to the PROM(1st step in manag.)………dexamethasone
Most imp drug to Preterm labor(1st step in manag.)……tocolytics
Most absolute contraindication to tocolytics…. chorioamnionitis
Key word of chorioamnionitis……maternal fever
Once chorioamnionitis occurred...sampling and antibiotics

Pt with PROM, after initial manag.& reusc; next step is>>> transfer to 1ry care
hosp. at 50kms far or 3ry care hosp. at 150 km far??? A: 3ry hospital whatever
far it is.

Time of external cephalic version>>> week 36.

Most common indication for CS… previous CS

Most common cause of 1° C-section…. Cephalopelvic disproportion

124
Prior classic CS, transverse lie, shoulder presentation, face presentation, cord
compression, active herpes in genitalia, maternal HIV, placenta
previa/abruption>>>>>>>>>> CS.
Female in labor has sudden abdominal pain, fetus ascend upward… Dx>> uterine
rupture… the most common RF>> previous CS…. Next step>>> resusc&
laparotomy.
Post-partm Hge; the uterus is soft& enlarged on palpation(boggy uterus)..Dx>>
uterine atony.
1st step in manag. Of uterine atony>> uterine massage.
1st line medication of uterine massage>> oxytocin.
Post-partum fever, uterine tenderness& foul smelling lochia… Dx>> endometritis.
MC RF of endometritis>> CS.
TTT of endometritis>> IV Abs for gram +ve & gram –ve organisms.
Post-partum failure to lactation…. Dx>> sheehan $ (post-partum pituitary
necrosis).
TTT of Sheehan $>>> cortisone 1st then thyroxine (to avoid adrenal crisis).
Colostrum is rich in>>> protein& secretory Ig.
HIV>>>>>>>>>>>>> >>>> NO lactation.
HBV, HCV>>>>>>>>>>>>>>>>>>>>> lactation is allowed.
Metronidazole… allowed in pregnancy
Metronidazole…. Contra-indicated in lactation.
Slow cervical dilation=Prolonged active phase(MCC:weak contraction)…manag>>>
oxytocin.
No cervical dilation for>3hs in active phase=arrested active phase.. manag>> CS.
Arrested labor after Engagement= arrested 2nd stage of labour.. manag>>>
forceps.
Normal CTG during labor>> fetal HR: 110-160, acceleration, variability, no
deceleration.
HR>160= fetal tachycardia….. MCC: maternal fever.
HR<110= fetal bradycardia…. MCC: sleeping baby.
Fetal HR -- with contraction= Early deceleration… cause>> fetal head
compression.
Fetal HR -- at the end of contraction=late dec.. cause>> fetal hypoxia.

Fetal HR -- with no relation to contraction= variable dec.. cause: umb. Cord

compression.

125
Normal fetal HR, variability, no deceleration BUT acceleration absent= “NOT”
abnormal labor.

BE FAMILIAR WITH CTG FINDING… CHECK IMAGES!!!

Abnormal fetal movement… 1st step>> fetal HR detection by Doppler..
if not detected>> immediate US
if detected>> CTG… normal CTG>> reassure… abnormal CTG>> immediate US.
If CTG is not available>>> refer to hospital.
If CTG is normal& pt come again with decreased fetal movement; if pt is near
term>> induction of labor…….. if pt away from term>> cont. CTG.
MCC of abortion in 1st trimester>>> chromosomal abn.
MCC of abortion in 2nd trimester>>> APL $, cervical incompetence.
Best way to monitor IU fetal growth>> US
Best way to monitor fetal growth in alcoholic pregnant>>> US
Uterine bleeding<20 ws, closed OS, no POC is expelled…Dx>> threatened
abortion.
POC is fully expelled, bleeding stop, closed OS, US show empty uterus.. Dx>>
complete ab.
Bleeding <20ws, bleeding continues, open OS, some POC is expelled.. Dx>>
incomplete ab.
Bleeding<20ws, bleeding continues, open OS, no POC is expelled.. Dx>> inevetible
ab.
Decreased symptoms of pregnancy(e.g. – N&V), no bleeding, closed OS, US show
no fetal cardiac activity.. Dx>> missed ab.
Manag. Of missed ab.>> D&C
Most serious complication of missed ab.>>> DIC
Monitoring of IUFD>>> coagulopathy profile….
If normal>> monitor…… If abnormal>> delivery.
Manag. Of IUFD>>> delivery (CS is never ur 1st option).
SLE in Pregnancy… 1.APL antibodies>> coagulopathy… TTT>> LMWH, aspirin.
MC congenital abnormalities with SLE>>> heart block (anti-RO/anti-LA
antibodies).
Painless loss of pregnancy in 2nd trimester, no contraction>>> cervical
incompetence.
MC RF of cervical incompetence>>> H/O any cervical procedure(e.g. conization)
Dx of cervical incompetence>>> US (shortening of cervix)
TTT of cervical incompetence>>> cerclage (to be done at 13-14 W & removed at
36-37 W)
126
Pregnant with severe vomiting.. most imp. Inv./next step>>> B-hcg
TTT of hyperemesis gravidarum>>> anti-emetic
Antiemetic of choice in pregnancy.>>>>>metoclopramide
Best way of delivery in cardiac pts>>>> vaginal delivery.
Thrombocytopenia in late pregnancy with no bleeding>> no TTT.
if bleeding occur>> cortisone.
The most safe anti-epileptic drug in pregnancy>>> carbamazipne
If pregnant continue to 42 W.>> induction of labor.(normal labor:37-41 W.)
MCC of free floating head (non-engaged)>>> occipito-post. Position.
2nd MCC of free floating head: small pelvis.
The only safe analgesic in pregnancy>>> paracetamol.>>>>>other analgesics NOT
safe in pregnancy……..>>>>try to avoid all analgesics
MCC of maternal sensitization (Rh -ve pregnant) >>> hidden feto-maternal Hge.
Best way 2 assess severity of fetal affection in Rh isoimmunization>> fetal blood
sampling.
Supplementation during pregnancy>> iron, folic acid, Ca& iodine.
Vitamins needed in pregnancy>> vit. D& B12.
Vitamins NOT needed in pregnancy>> A,C&E.
Vaccination needed/safe in pregnancy>> influenza, DTaP
Vaccination NOT SAFE in pregnancy>> all live attenuated vaccines(e.g. MMR,
varicella..etc).
Increase folic acid supplementation for those with DM, H/O NTD those on anti-
epileptic.
During pregnancy; NO alcohol, smoking, illegal drugs.
Screening of Down $ in 1st trimester>> US or B-hcg… if both>> choose US.
Screening of down $ in 2nd trimester>> quadriple test.
Confirmatory (diagnostic) test of down $ in 1st trimester>> chorionic villous
sampling.
Confirmatory (diagnostic) test of down $ in 2nd trimester>> amniocentesis.
Prevention of toxoplasmosis in pregnancy>>> avoid cats
Prevention of listeria in pregnancy>>> avoid cheeses.
Pregnant exposed to child with parvovirus infection.. 1st step>> check igG.
If igG is +ve>>> reassure…….. if igG is –ve>>> check igM.
If igM is +ve>> US to detect fetal infection(hydrops fetalis)& UC sampling (i.e.
cordiocentesis) to assess severity of fetal affection.
If igM is –ve>> repeat test in 2-4 Ws.

127
Pregnant sexposed to rubella during pregnancy… 1st step>>> check igG.. then;
same as parvovirus.
Prevention of rubella>>> vaccination
Pregnant exposed to EBV during pregnancy>>> reassure
Baby delivered to HBV infected woman>> give vaccine & immunoglobulin.
Pregnant with HBV, HCV>>> normal vaginal delivery, breast feeding allowed.
Pregnant with HIV, genital herpes>> CS, NO breast feeding.
Pregnant with HIV>>> HAART therapy.
Child born to woman with HIV>>> zidovudine.
Pregnant has +ve igM to CMV during screening.. next step>>> igG
Routine Rh screening during pregnancy>> 24-28 Ws; to prevent isoimmunization.
Rh –ve female exposed to any Rh +ve blood>>> give RhoGAM at 48 Ws& post-
partum.
Pregnant with +ve group B strept early in pregnancy.. next step>> intra-partum IV
penicillin.
Pregnant with +ve H/O group B stept. In previous pregnancy.. now –ve… next
step>> intra-partum IV penicillin.
If bishop score less than 2…….induction with prostaglandin and reassess after
6-12 hs

What will reduce the risk of transmission of hep C to her baby…… avoid
Fetal scalp electrodes

Best test for prevalence of HCV in child born to HCV positive mother….
HCV AB at 18 month

Test for premature rupture of membrane…….fibronectin

128
129
 Ophthalmology:

Pediatric ophthalmology:

Leucokoria:

Cp…..white pupil

DD……congenital cataract

Retinoblastoma

First step……refer vvvvvvvvvvvvvimp

Retionopathy of prematurity:

Risk factor…….prematurity

High flow oxygen…….vasoproliferative scarring and blindness

TTT………laser

Retinoblastoma:

Incidence……..rare

The most common malignant intraocular tumour

Cp……..leucokoria

Strabismus

Inv…….CT ( NO BIOPSY…SPREAD)

TTT…..surgery good prognosis

Corneal abrasion:

Pain, tearing, photophobia and decreased vision

Inv……fluroscein

130
TTT……pain relief and antibiotics

Foreign body: imp

First step……….excessive irrigation with saline

Metal foreign body……..emergent removal under anesthesia

If deeply embedded……refer

Penetrating eye injury:

Urgent referral

X-ray

Tetanus vaccine

antibiotics

Orbital versus periorbital cellulitis:

Most common organism……..staph

Cp:

Erythema

Edema

Chemosis

How to differentiate?????
Vvvvvvvvvvv imp

Orbital cellulitis…….cannot move eye ball and diplopia

Periorbital cellulitis……..normal eye movements no diplopia

131
Inv:

Orbital cellulitis……….CT……vvvvvvvvvvv imp

Periorbital cellulitis…………FBC and blood culture

TTT:

ORBITAL CELLULITIS:

ADMISSION and IV cefotiaxone and iv flucloxacillin

Periorbital Cellulitis:
Mild Amoxycillin/Clavulanate

Moderate Flucloxacillin

Severe, Flucloxacillin
or <5y & not Hib and
immunised Ceftriaxone 50 mg/kg/

132
ANIRIDIA:

Defect of the iris

Check for Wilm's tumour

WAGR syndrome:

Wilms tumour

Aniridia

Genitourinary malformation

Retardation

congenital cataract:

most common causes:

rubella ( cataract, deafness and PDA)

Galactossemia

Strabismus:

Transient……common up to 4 months

Time to correct…..1-2ys

Must be corrected before 7 ys

133
Neonatal conjunctivitis: (ophthamia neonatorum) vvvvvvvimp

First day…….chemical (silver nitrate)

Up to 2- 5 days……..gonococcal infection

TTT…….single dose iv cefotriaxone

5-14 days……..chlamydia

TTT…….oral erythromycin

Nasolacrimal duct obstruction

Cp……excessive watery secretions

TTT…….message

Prognosis……majority heal spontaneously

Children conjunctivitis:

Most common cause……viral

Most common virus…….adenovirus

DD of photophobia: vvvvvvvvvvv imp

Look at the pubil

Normal……..keratitis

Constricted…..iritis/uveitis

Dilated fixed, no light reflex……acute glaucoma

No photophobia……….. Conjunctivitis ( bacterial or viral)

134
HERPES SIMPLEX INFECTION:

CP……..dendritic ulcer

Pain, photophobia, lacrimation

TTT……..acyclovir

Herpes zoster ophthamicus:

Cp…..rash involving trigeminal nerve distribution

Dendritiform ulcer

TTT…… acyclovir

Subconjuctival hge:

Causes…..trauma, severe cough

TTT……..usually none

Acute glaucoma:

Closed angle:

PF:

OLD AGE

FEMALE

HYPERMETROPIA

PROLONGED TIME IN DARK AREA

Sudden severe unilateral pain……..key word

Halos around lights…….key word

Dilated fixed pupil…….key word

135
Photophobia, lacrimation and blurring of vision, EYE
INJECTION

Inv….tonometery

TTT:

Emergency room……1st line…….iv Acetazolamide

LONG TERM…..IRIDOTOMY

DRUG MUST BE AVOIDED…….ATROPINE

Open angle glaucoma:

Bilateral loss of peripheral vision

Risk factors:

DM

Myopia

Elderly

Fundus exam…..cupping of optic disc

Tonometery….increased IOP

TTT:
136
Timolol

Long term…..trabeculectomy

DD OF sudden UNILATERAL loss of vision:VVVVVVVVVVV IMP

1-CRAO

2-CRVO

3- Amurosis fugax

4-RETINAL DETACHMENT

Central retinal artery occlusion:

Cause……..emboli

Source…..ipsilateral carotid artery

Cp:

Sudden painless unilateral loss

Ophthalmoscopy…..cherry red spot

FIRST STEP:

BREATHING IN A BAG……..INCREASED CO2

MESSAGE…..only first 90 minutes

Then……high flow oxygen

If more than 3 hours………iv acetazolamide….vvvvvvvv imp

137
Central retinal vein occlusion:

Sudden unilateral painless loss of vision

Funduscopy….disk swelling and venous dilatation

TTT……no specific ttt

Retinal detachment:

Main risk factors:

Myopia

DM

Macular degeneration

Cp:

Flashes of light……..key word

Curtain coming down…….vvvvvvv imp

Floaters

Loss of vision

First aid ……….. tilt the head back….vvvv imp

TTT……..laser photocoagulation

Amurosis fugax:

Cause……emboli

Source……ipsilateral carotid artery

Sign if impending stoke

Cp……..sudden painless unilateral loss of vision

138
 Curtain falls down

Then the patient sees well again

Exam……murmur over carotid

Inv……..US for carotid

Drug of choice……..aspirin

DD of curtain falling down:"

1-retinal detachment……….flashes of light

2-retinal emboli…………murmur over carotid

Macular degeneration:

Most common cause of blindness in eldery

Cp:

Slowly bilateral loss of central vision

See the lines wavy

TTT:………..better to refer

Dry……No ttt

Wet….laser

Diabetic retinopathy:

One of DD of eye floaters

Stages:

Non-proliferative……control DM

Proliferative…………Laser photocoagulation

139
Screening of DM retinopathy…….. Every 1-2 years

Cataract:

Most imp risk factor……..age

Others,…..DM, smoking, trauma

Cp……can not read well at night………key word

Cannot see well at day light……vvvvvvvv imp

TTT……phacoemulsion…imp

DD of eye floaters:

1-Retinal detachment

2-trauma……bleeding

3-DM………..most common cause

Cp……black dots moving in front of him

Inv……fundoscopy

TTT:

Usually none

DD OF PUPIL ABNOMALITIES:

CONSTRICTED:
Morphine……..give naloxone
Heroin toxicity
Organophosphorus……atropine and oximes
Intracranial hge(pontine)……..CT is a must
Iritis and uveitis…….associated with photophobia

140
Dilated:
Amphetamine toxicity
Ectasy toxicity
Cocaine toxicity
LSD toxicity
Alcohol withdrawal……iv diazepam
DD of Dilated fixed:
.acute glaucoma
3rd cranial nerve palsy
Trachoma:

Organism………….chlamydia

Most common cause of blindness in the aboriginal people

Cp……inflammation and scarring of the eye

Best prophylaxis…………wash hands

TTT:

AZithromycin……DOC

Surgery

Dacryocystitis:

of the lacrimal sacInfection

It causes pain, redness, and swelling over the inner aspect of

the lower eyelid

141
TTT:

Oral antibiotics, warm compresses

If abscess………incision and drainage

Hypopyon:

Pus in the anterior chamber

Cause………post operative

Hyphema:

Blood in the anterior chamber

Episcleritis and scleritis

Cp:

 Both conditions present with a red eye

which may be painful.

Management:[8]
topical corticosteroids or oral anti-inflammatory medications.

N:B:

Sudden loss of vision in elderly:

1st inv ………….ESR……….vvvvvvvvvvvvvvv imp (even before CT )

142
143
 Post exposure prophylaxis:

1-hepatitis B :
History of previous vaccination….reassure
First step……..check immune status
If (+) for antibodies……..reassure
If (+) for antigens………ttt
If (-) for antibodies …..susceptible……vaccine and IVIG
If in the exam no option for checking the immune
status…..go for vaccine and IVIG

Baby born to Hb B mother………………. Vaccine and IVIG

immediately to the newly born

Chronicity of hepatitis B in adult…..10-15%

Chronicity of hepatitis B in newly born….over 75 %
TTT of hepatitis B…….INTERFERON AND LAMIVUDINE
Main SE of interferon……depression and fatigue
If depression occurred…..stop interferon

Hepatitis C:
First step…….check base line immune status
Second step……serial labs for 6 months
If (+) for HCV antibodies…….NEXT STEP HCV RNA ( PCR )
IF HCV RNA (+)……start ttt
TTT of hepatitis C…….interferon and ribavirin
Chronicity of hepatitis C ……over 75%
Counseling:
Lactation…….continue
Sex………continue but preferred to use condoms
HIV:
First step…….start immediate therapy before the labs results
If (-)…….stop ttt
If (+)……continue ttt

Prophylaxis of the newly born :

First step……start immediate ttt
Drug…….zidovudine
Duration…….6 weeks
Counseling:
Take the retroviral therapy during pregnancy…..yesss
Delivery………CS
Lactation…….NOOOO
Sex…….with protection

Post-exposure prophylaxis for measles:

Within 3 days (72 hours) of first exposure to infectious case:

birth to 5 months Normal Human

Immunoglobulin only if
mother has had <2
doses MMR and no
history of past measles
infection or negative
maternal IgG
(otherwise, no NHIG)

6 to 8 months IVIG

More than 9 months MMR

What if after 3 days to within 6 days??????

IVIG

What if immunocompromised????
IVIG only
What if pregnant????
First step …….check IgG
If (+)………none
If (-)………IVIG
In settings with large numbers of individuals with uncertain vaccination
histories and immunity (e.g. in high schools, adult workplaces)
…….prompt MMR vaccination, even if it is >72 hours after the exposure.

Varicella:
Children:
How?……..by vaccine ( Live attenuated vaccine)
If vaccinated before…….no prophylaxis
If immune compromised…….. IVIG

If pregnant??
Vaccinated before……NOOO prophylaxis
Not vaccinated:
First step……serology
(+) IgG…..NOO prophylaxis
(-) IgG…..IVIG 5 days and 2 days after delivery
MC affected nerve in Anterior Shoulder Dislocation (ASD): axillary n.

MC affected muscle in ASD: deltoid m. (pt can’t raise hand above head).

Senory defect in ASD: loss of sensation above shoulder.

TTT of ASD: closed reduction under anesthesia (fentanyl, midazolam).

Nerve affected in fracture surgical neck of humerus: axillary n.

Nerve affected in fracture shaft of humerus: radial n.

Radial n. injury: wrist drop, fingers drop.

Suspect child abuse in spiral fracture of shaft of humerus.

Vascular injury in Elbow dislocation: brachial artery.

MC complication in fracture both ulna & radius: compartment $.

TTT of compartment $: emergent fasciotomy.

Post- menopausal pt fall on outstretched hand causing postero-lateral

displacement of distal end of radius… Dx: colle’s fracture.

MC risk factor of colle’s fracture: opsteoprosis (MC in post-menopausal female).

Reduction of colle’s fracture: Disimpaction then traction the hand in the flexed
position with ulnar deviation then cast application (Below elbow with pronated
semi flexed hand with ulnar deviation).

Follow up of colle’s fracture: x- ray after 2 weeks.

MC complication of colle’s fracture: malunion.

Pt fall on outstretched hand then complain of pain & tenderness at anatomical

snuff box… Dx: scaphoid fracture.

TTT of scaphoid fracture: thumb spica cast.

Follow up of scaphoid fracture: x-ray after 2 weeks.

Complication of scaphoid fracture: avascular necrosis of proximal part.

TTT of clavicular fracture: sling.

Most common site of clavicle fracture……….middle one third

Fracture lateral or medial third of clavicle and displaced ,,,,urgent refer

Fracture clavicle in neonate……..no ttt

Strong pulling of child’s hand then child persistently cries& refuses any touch to
his arm… Dx: nurse maid elbow.

TTT of nurse maid elbow: manual reduction by supination & flexion.

After casting of Pt with supra-condylar fracture of humerus, he develop pain,

pallor, parasthesia…... Dx: acute ischemia.

1st step in management of acute ischemia: immediate removal of the cast… If

symptoms of persist after cast removal: immediate exploration.

MC affected vessel in supracondylar fracture: brachial a.

MC affected nerve in supracondylar fracture: median n.

Pain or parathesia after elbow dislocation……immediate reduction

If you have to choose between brachial a & median n (e.g. MC neurovascular

complication: brachial a).

Pain at lateral surface of elbow: lateral epicondylitis (tennis elbow).

Muscle affected in tennis elbow: extensor muscles(extensor carpi radialis brevis.

TTT of tennis elbow: rest, analgesic…….1st step………..brace ( 2nd step)

Medial epicondylitis (golver’s elbow): same as tennis elbow but the lateral
surface& flexor muscles are affected.

Trauma pt, leg affected became short& internally rotated: post. Hip dislocation.
Nerve may be affected with pot hip dislocation……sciatica

Trauma pt, leg affected became short& externally rotated: fracture femur shaft.

Fracture femur shaft in old age is a surgical emergency.

MC complication of fracture tibia: compartment $.

MC nerve injury in fibular fracture: common peroneal n.

Marathon runner with pain at tibia= stress fracture until proven otherwise.

MC site of stress fracture: 2nd metatarsal bone (tibia is the 2nd MC wrong).

TTT of stress fracture: rest& analgesics.

Cause of stress fracture in ballet dancer: decrease of BMI as they may develop
anorexia nervosa (not ballet itself).

Young runner with knee pain= Osgood schlatter disease until proved otherwise.

TTT of Osgood schlatter diseases: rest, analgesics.

Prognosis of Osgood schlatter diseases: complete healing within 12-16 ms.

Old pt with back pain + anemia= multiple myeloma (MM) until proven otherwise.

Lab findings in MM:

1. Increase in M protein in serum protein electrophoresis & bence jones

protein in urine protein electrophoresis.
2. Decrease in RBCs (anemia) & WBCs (recurrent infection).
3. Ca level: MUST be increased
- Typical scenario of MM + normal Ca level: the answer is NOT MM.
- Typical scenario of MM + high Ca level or Ca level isn’t mentioned: the
answer is MM.
X-ray of MM: osteolytic bone lesion.

Blood smear of MM: rouleux appearance.

TTT of MM: chemotherapy.( thalidomide )

Old pt with anemia, back pain and increase in plasma cells BUT <10%......Dx:
monoclonal gammopathy of undetermined significance (MGUS).

Management of MGUS: annual protein electrophoresis (risk of MM).

Old male pt with back pain & normal Ca level.. Dx: prostate cancer with bone
metastases.

Pain, numbness at lateral 3& ½ fingers of hand in pregnant pt, pt with RA, pt with
hypothyroidism… Dx: carpal tunnel $ (CTS).

Nerve affected in CTS: median nerve.

Most imp inv of CTS: nerve conduction velocity.

TTT: analgesic& splint; if failed: intra-articular cortisone; if failed: surgery.

Pain in foot that relieved after walking… Dx: planter fasciitis.

TTT of planter fasciitis: analgesic (subside in 12-16 ms).

Pt with lung cancer develop severe congestion of face & neck which increase
when pt elevate his arm… Dx: superior vena cava $.

Inv of choice of superior vena cava $: chest CT scan.

1st step in management of superior vena cava $: radiation.

Pt with H/O cancer (esp. breast& lung) presents with back pain: spinal cord
compression from metastases.

Inv of choice of spinal cord compression: MRI.

1st step in management of spinal cord compression: IV cortisone.

Skull deformity + deafness………..paget disease

Most imp inv in paget……….increased ALP

Main ttt of paget……….biphosphanate

Long term TTT of spinal cord compression DT metastases: radiation.

Knee trauma in Football player then locking (can’t straight knee fully) & his knee
gave away (can no longer support him)…. Dx: meniscal injury.

Medial meniscus injury more common than lateral meniscus

Medial collateral ligament injury more common than lateral

Knee trauma in football player + popping sound= cruciate ligament injury.

Knee trauma in football player with +ve anterior drawer sign, +ve lachman’s test
or +ve pivot shift test = cruciate ligament test.

Most imp inv in all knee injury: MRI.

Q of a typical scenario of meniscal injury gives 2 choices: A.meniscal injury only

& B.meniscal injury and medial collateral ligament? Answer: B.

Meniscus injury or ACL injury……….urgent refer

Running or jumping followed by popping sound and severe pain at tendo-

achilis…….. Dx: rupture tendo- achillis.

TTT: if no gap>> conservative. If gap: emergent surgery in <3 hs.

Most common drug causing rupture tendon achillis…..quinolones

Pt with ankle fracture, no pulsation or 5Ps of ischemia…… 1st step in management:

reduction. If still no pulsation: exploration.

Most imp advice to Old pt with fracture pelvis: early mobilization (risk of DVT).

Steps of management of old pt after orthopedic surgery:

1st priority: LMWH prophylactic dose (up to 6 weeks)… high risk of DVT.

2nd priority: DEXA scan (for assessment of osteoporosis).

Most imp TTT of osteoprotic bone fracture: bisphosphonate.

TTT of DVT: LMWH therapeutic dose + warfarin with target INR of 2-3.

Trauma to face, vertical diplopia + numbness of check= orbital floor fracture.

Most consistent sign in fracture orbital floor……diplopia

Cause of numbness of check: injury of inferior orbital n.

Trauma to face, vertical diplopia (upward gaze)= zygomatic fracture.

Pt with numbness at the outer part of the thigh: parathetica meralgia.

n. affected in parathetica meralgia: lateral cutaneous n. of the thigh.

Cause of +ve trndlenburg’s sign: weakness or paralysis of abductor ms of the

thigh (gluteus medius& gluteus minimus).

TTT: weight bearing over hip ms.

Occulomotor neuropathy: affected in pt with DM, epidural hematoma.

Signs: ptosis, down and our gaze, diplopia and loss of light reflex.

pt with facial n. palsy, how to differentiate between UMNL& LMNL?? Ask the pt
to close his eye: A. UMNL: pt can close his eyes. B.LMNL: pt can’t.

pt with hypoglossal n lesion: tongue deviate to the side of lesion.

Imp reflexes: -knee: L4, foot drop: L5.ankle: S1.

C5 injury (vvvvvvvvvvvvv imp)

1. Loss of sensation over lateral aspect of arm

2. Loss of arm abduction.

Radial n. injury: wrist drop, very weak extension of elbow.

Ulnar n. injury: claw hand.

Median n. injury: Ape hand.

MC affected n in Pt lying in lithotomy position for a long time: common peroneal.

MC affected m. in Pt lying in lithotomy position for a long time: ext. hall. Longus.

MC affected compartment in Pt lying in lithotomy position for a long time:

anterior Compartment of the leg.

MC affected m. in fracture fibula: ext. hall. Longus.

Main cp of peroneal nerve affection…..foot drop, lost eversion and dorsiflexion

Tibial n. injury: loss of Inversion & Planter flexion (TIP).

Initial step after football injury......standing X-RAY

Locked knee after truma.......,medial meniscus injury

Best to visualize dental disorder……. Orthopartogarm

Supracondylar # swelling elbow and numbness fingers….1st step….. reduction

• ACL rupture – Anterior drawer, Lachman and pivot shift tests

• PCL injury – posterior draw test

• Collateral ligament injury – varus and valgus stress tests

• meniscal injury – McMurray test

• patella dislocation – patella apprehension test

Duration of prophylaxis against DVT after surgeries:

HIP…………35 days

Knee………14 days

Lower leg…..until mobilization

Abdomen………10 days
General, cardiac, gynecological, spinal……one week or fully mobile

Cesarean but risky female……….6 weeks

Cancer………10 days

Cancer with major surgery…….28 days

Cancer with H/O DVT………..28 days

Painful 3rd cranial nerve palsy……..posterior communicationg artery

aneurysm

Important reflexes:

Knee………l4

Foot drop……l5

Ankle………..s1

Biceps and brachioradialis…….c5,6

Triceps……..C6,7

Elbow……..C6,7

Fingers…….c8

nerve affection with fracture:

Anterior dislocation of shoulder…….axillary

Fracture neck humerus……..axillary

Fracture shaft humerus…….radial

Fracture medial epicondyle……..ulnar

supracondylar fracture…….brachial artery first then median nerve

Saturday nerve pasy…….radial

Fracture at snuff box…….radius

Dislocated elbow……bracial artery and median N

Posterior dislocation of hip…….sciatica

Fracture fibula……..common peroneal

posteoir dislocation of knee…….popliteal artery

Neonatal jaundice with breast feeding< 6 times/d: breastfeeding jaundice.

TTT Of breast feeding jaundice: increase frequency of breast feeding.

Neonatal jaundice with breast feeding>8 times/d: breast milk jaundice.

TTT of breast milk jaundice: temporary cessation of breast feeding for 2ds then
resume breast feeding.

Jaundice at 1st day: hemolytic disease of new born(DT Rh incompatability).

Jaundice at 3rd day: physiological jaundice.

Direct Jaundice after 7th day: biliary atresia.

1st step in management Of neonatal jaundice: total& direct billirubin.

Bilirubin> 270 micromol/L : phototherapy.

Bilirubin> 340 micromol/L : exchange transfusion.

Asymptomatic Indirect hyperbilirubinemia in healthy adult: gilbert $.

TTT of neonatal hypoglycemia… 1st line: IV glucose.. if failed: IM glucagon.

Cyanosis with feeding which improve with crying… Dx: choanal atresia.

Test of choice if choanal atresia suspected: catheter test.

Inv. Of choice for Dx of choanal atresia: CT scan with contrast.

1st step in management of choanal atresia: airway to keep mouth open.

Neonate with microcephaly, pigmented retina: congenital CMV infection.

Inv of choice of congenital CMV infection….urine antigen

innocent murmur management: reassure; BUT, refer to pediatrician is the right

answer if found.

MCC of omphalitis : staph. Aureus.

MC source of infection in omphalitis: umbilicus.

MCC of cleft lip, cleft palate: genetic.

Fused labia: leave it alone (if DOC is asked: estrogen cream)… never to pull them
apart.

MCC of club foot: postural (esp. in primigravida).

3 days of fever followed by maculopapular rash.. Dx: roseola infantum.

VURTI+ koplik spot on buccal mucosa then maculopapular rash.. Dx: measeles.

After Dx of measles, you must notify.

Most imp. Complication of measles: OM.

Most imp. Vitamin to be given in measles: vit. A.

VURTI+ slapped check… Dx: erythema infectiosum. CO: parvovirus B19.

Parvovirus B19 infection in pt with SCA or HS: aplastic anemia.

Parvovirus B19 infection in pregnancy: hydrobs fetalis in fetus.

No school exclusion for pt with parvovirus B19 inf. (pregnant teacher shouldn’t go
to school).

Strawberry tongue+ circumoral pallor+ sandpaper rash= scarlet fever.

Ulceration on post. Pharynx, uvula, palate only: herpangina.

The same+ ulceration on hand and foot= hand foot mouth disease.

School exclusion in hand, foot and mouth disease….till all lesions crust

CO of herpangina & hand foot mouth diseases: coxsakie virus.

Ulceration on lips only: HSV infection.

Wheezes in child<2ys with URTI… Dx: bronchiolitis …… CO: RSV.

Child with bronchiolitis is at greater risk of bronchial asthma.

TTT of bronchiolitis: only supportive (O2 by nasal cannula& fluid)…. No abs.

Inspiratory stridor worse on lying down+ barking cough = croup.

CO of croup: para-influenza virus.

TTT of Mild to moderate croup: inhaled cortisone.

TTT of severe croup: inhaled “nebulized” adrenaline.

Very high fever, expiratory stridor, drooling of saliva..Dx: epiglottitis.

CO of epiglottitis: H.influenza.

TTT of epiglottitis: admission& intubation.

Fever for 5ds+ 4 of the following (CREAM; Conjunctivitis, Rash, Erythema,

Adenopathy& MM involvement) = Kawasaki disease.

Most imp. Inv: echo

Most serious complication: myocarditis, coronary aneurysm.

1st line of TTT of Kawasaki: IVIG and 2nd line: aspirin.

Child with fever, crying& pulling on his ear… Dx: OM.

MCC of OM: stept. Pneumonia.

Most specific finding on otoscopy: loss of mobility of ear drum.

Drug of choice of otitis media ( current updates)………paracetamol only

If no response……….amox

If still no response,………amox-clav

Most imp test after recovery : hearing assessment.

Swelling behind the ear after PM.. Dx: mostoiditis.. inv of choice: CT scan.
TTT of chronic OM: aural toilet.

Druf of choice for chronic OM……ciprofloxacin drops

Varicella post-exposure proph: vaccine for immune-competent within 72 hs &

IVIG for pregnant& immune-compromised.

School exclusion for avricella: until blisters dried or at least 5 ds after the rash.

MC compl of mumps in children: encephalitis.

MC compl of mumps in adult: orchitis.

30 ys old Pt on sulfasalazine with H/O mumps when he was a child. now he has
abnormal semen analysis.. cause: sulfasalazine.

Long standing H/O dry cough esp. at night : BA

Long standing H/O dry cough with fever: pertussis.

Inv of choice at 1st 3 Ws of pertussis presentation: PCR of nasopharyngeal swab.

Inv of choice after 3 Ws: seology.

Prevention of pertussis: vaccine.

School exclusion for pertussis: at least 3Ws of cough or 5ds of Abs TTT.

Regardless of age or immunization status, all close contact to a case of pertussis

must receive erythromycin.

Give vaccine to non-immunized& those who received last dose in >10 ys.

Accidently discovering of abdominal mass in a child: nephroblastoma.

INV. Of choice of nephroblatoma: CT scan.

Painful mass which may crosses midline+ peri-orbital ecchymosis..

neuroblastoma.

Uneven thigh skin folds, discrepancy of leg length… Dx: DDH.

Diagnostic tests of DDH: barlow test, ortolani test.

Inv of choice of DDH: <4 ms: US …. >4 ms: x-ray.

TTT of DDH: pavlik- harness maneuver.

Painless limp with collapsed femur head in x-ray: perthe’s disease.

Painful limp in obese male teenager with limitation of movement: SCFE.

x-ray of SCFE: displaced femoral head medially& posteriorly.

TTT of SCFE: emergently surgery. (DT fear of avascular necrosis).

Limitation of movement in perthe’s& SCFE: abduction and internal rotation.

1st step in management of any child with limping: x-ray EXEPT in clear cases of
transient synovitis; 1st step: US.

H/O camping then malabsorption $... Dx: giardiasis TTT: meronidazole.

Best inv. Of giardiasis: intetstinal biopsy.

Newborn with frothy saliva& milk regurge.. Dx: esophageal atresia.

1st step: passage of wide bore catheter following by x-ray.

TTT of esophageal atresia: surgery.

Inflammation of penis+ inability to retract in backward= phimosis.

TTT of phimosis: cortisone cream.

Inflammation of penis+ inability to retract in forward= para-phimosis.

TTT of para-phimosis: urgent manual reduction… if failed: incision.

Whitish discharge on glans penis in a child= balanitis; TTT: cortisone.

From medical point of view: circumcision is NOT recommended.

Urethral opening at the ventral surface of penis: hypospadius… next step: never
to do circumcision (the foreskin will be used in the surgery).

Child with Difficulty in initiation of micturition+ H/O urinary cath.= urethral

stenosis.

Inv. Of choice for Dx of urethral stenosis: urethroscopy.

TTT : repeated dilation…. If failed: surgery.

Diarrhea in a complete healthy child<5ys old with normal inv: toddler diarrhea.

Excessive fruit juice: tooth caries, obesity, and diarrhea.

MCC of constipation in pediatric…….diet

Maximum timing of constipation….after weaning
Constipation since birth…..Meconium ileus or hirshpring
Cp……in functional constipation…..full rectum with stool
MCC of anal fissure in infancy.constipation

MCC of rectal prolapse in kids.constipation

TTT of acute constipation…..enema
Most effective…….bowel training
MCC of rectal prolapse in children: constipation.

Rectal prolapse+ recurrent chest inf.+ FTT = CF.

Most imp Q to be asked in a child with rectal prolapse: bowel habit.

Abdominal cramping + diarrhea after lactation/dairy products = lactose

intolerance.

Inv. Of choice of lactase intolerance: hydrogen breath test.

TTT of lactase intolerance: lactose free diet (lactose free formula in infants).eg:
soy based formula

MCC of epistaxis in children : hot wather.

Healthy Child with leg pain that may awaken the pt from sleep, all inv. Are
normal….. Dx: growing pain… management: reassure.

Healthy child crying& pull his leg to his abdomen, all inv are normal.. Dx: infantile
colic…. Management: reassure and diet modification.

Crying followed by cyanosis and then convulsion.. Dx: breath holding spells.

Convulsion then cyanosis: epilepsy.

Involuntary passage of stool> 4ys = encopresis.

TTT: toilet training… if failed: diet modification… if failed: laxatives.

Involuntary passage of urine> 5ys = enuresis.

MCC of enuresis: psychological BUT, urine culture MUST be done 1st.

MC organic cause of enuresis: UTI.

Most imp inv. To be done in enuresis: urine culture.

Pt with enuresis, ‘ll go camping after 1-2 ds, best management: desmopressin.

Best long term TTT of enuresis: alarm clock.

Inv of choice of hydrocephalus: CT scan (not US) “MRI>CT>US”.

Limping after VURTI or with the onset of URTI = TRANSIENT SYNOVITIS.

Most common cause of limping in kids………. TRANSIENT SYNOVITIS

Inv of choice of transient tenosynovitis: US.

TTT: analgesics, joint traction.

N.B. 1st inv of choice of limping child: X-ray.

And kid with limping should be referred

N.B. 1ST inv of choice of limping after VURTI: US.

Fluid the child need every day: 150mg/ kg.

4 Ws infant with excessive vomiting, good general condition… Dx: GERD.

4 Ws infant withexcessive vomiting, bad general condition.. Dx: CHPS.

Best inv of GERD: 24 Hs ph monitoring.

Best advice to mother with an infant with GERD: upright position after feeding.

Mother lose consciousness in daughter wedding, normal physical exam, normal

test.. most imp Q to ask: H/O separation anxiety while child.

Separation anxiety in children is NOT part of normal development; need psych

TTT.

MCC of painless bleeding in child<2ys old: meckel’s diverticulum.

TTT of mickel’s diverticulum: surgery.

TTT of choice of allergic rhinitis: intra-nasal cortisone at night.

Chronic cough + rhinorrhea which improve with antihistaminic: post-nasal drip.

Hives, Hypotension, wheezy chest+/- lip and tongue swelling after bee sting/
peanut ingestion= anaphylaxis.

Hives, pruritis, flushing after bee sting/peanut ingestion= urticaria (allergy).

MCC of anaphylaxis: food> bee sting> drugs.

MC components of cake causing anaphylaxis: nuts> sugar, egg.. etc.

TTT of anaphylaxis: IM epinephrine at the thigh.

Epinephrine dose:

1. Adult>12 ys: 0.5mg IM

2. Child 6-12 ys: 0.3mg IM

3. Child <6 ys: 0.15mg IM

Pt with recurrent anaphylaxis: epinephrine pin.

Sudden onset respiratory distress+ localized wheezes in children: FB inhalation.

Most serious cause of localized wheezes in adult: tumor.

Male child with recurrent chest, GIT infection >6ms of age + decrease in all ig and
lymphoid tissue.. Dx: X-linked agammaglobulinemia.

TTT of x-linked agammaglobulinemia: IVIG.

Recurrent infection+ recurrent suppurative lymphadenitis and multiple gingival

abscesses= CGD.

MC affected Cs in CGD: neutrophils. (enlarged LNs that may ooze pus with
neutrophils And bacteria inside).

MC organism causing infection in CGD: staph aureus.

Which Enzyme is affected in CGD? NADPH oxidase.

Specific test to diagnose CGD: nitroblue tetrazolium test.

1st step in head injury in kids: flow chart.

Head trauma Child with skull fracture (open, depressed or basal) develop
convulsion, recurrent vomiting or altered mental status… CT is a must.

Head trauma child with no loss of consc. &only 1 episode of vomiting.. reassure.

Head trauma child with persistent headache& 2 episodes of vomiting.. observe

for 4 hours.

If GCS less than 8……immediate intubation

AR diseases: pt MUST have both chromosomes in order to be affected.

AD diseases: pt need only one chromosome in order to be affected.

Assessment of child growth: always follow growth chart (not given percentage).

1tst: between 5th-85th percentile= normal growth.

2nd: between 85th-95th percentile= overweight.

3rd: >95th percentile= obese.

4th: <5th percentile= underweight.

Most affected parameter by acute malnutrition: weight.

Period of accelerated growth that follow periods of arrested growth: catch up

growth.

Best clinical indicator for overwt & underwt in children: BMI growth chart (not
numbers).

MCC of obesity overall: over feeding.

Failure To Thrive (FTT):

Most common cause…….psychological

FTT + constipation only……..hirschprung disease

FTT + constipation + recurrent chest infection….cystic fibrosis

FTT+ steatorrhea + recurrent chest infection……cystic fibrosis

FTT + steatorrhea……..celiac
If FTT is DT neglect…. Report to child protective authority.

Vaccination schedule for premature infants: the same schedule & dose as mature
infants.
Child with VURTI, now time of vaccination: give as schedule.

Child missed vaccination dose: catch up vaccine schedule (give him missed
vaccines now).

“Imp. Ex.” MMR vaccine: 1st dose at 12 m& 2nd dose at 18 m.

Egg allergy is NOT a contra-indication to MMR vaccine.

Somalian kid previously received doses of OPV comes to u, WT NEXT?? Give IPV.

Mam refused to give vaccines to her kid. 1st step: talk 2 her, if refused: refer for
counseling, if still refused: report to child protective authority?????????.

MCC of short stature: normal variant “constitutional”.

1st step in assessment of short stature, delayed puberty, precocious puberty: x-

ray to detect bona age (BA).

If CA> BA: REASSURE… if BA>CA: very bad.

TTT of Obese child: exercise prog (NOT diet as food is vital 4 development).

MCC of iron deficiency anemia in infants: prolonged exclusive breast feeding.

Start weaning at 4 ms (very imp. To start give iron fortified cereals).

MCC of decreased breast milk: decreased frequency.

Frequency of breast feeding: at least 8 times/ day.

Chocking in infants……… slapping on the back.

Chocking in adults…… hemlick maneuver.

Sudden onset cough, dyspnea+ localized wheezes= FB aspiration (1st step: x-ray).

Unilateral offensive nasal discharge in mentally retarded kid= FB in the nose.

TTT of FB in the nose: removal under anesthesia.

Infant with an insect in ear.. 1st step: kill it by oil.. then removal with forceps or
ear toilet.

Child with fish bone in larynx: laryngoscopy.

Child ingests battery; x-ray shows it at the esophagus: remove it by endoscope.

MCC of bloody vaginal discharge in infants: FB in the vagina.

TTT of FB in the vagina: removal under general anesthesia.

Immigrant infant from Sudan; most imp to check: Ca& vit. D (high risk of rickets).

Cause of neonatal gynecomastia: passage of maternal hormones.

Management of neonatal gynecomastia: observe (never squeeze).

Best way to asses fetal IUG: US.

Defect in both BPD, abdominal width= Symmetrical IUGR (MCC: chromosomal

abnormalities, congenital infection).

Defect in abdominal width, normal BPD= asymmetrical IUGR (MCC: placental

problems as preeclampsia).

MCC of RDS: prematurity.

Risk of high flow O2 to premature: 1.Retinopathy of prematurity. 2. Lung

dysplasia.

1st step in management of Meconium stained amniotic fluid: CTG & scalp pH
monitoring

suction NOT recommended any more in cases with meconium staining

1st step in meconium stating………mask ventilation

If very low apgar score with no response : intubation.

IM vitamin K is given routinely to all neonates (to avoid neonatal bleeding).

Tachypnea in neonate delivered by CS with normal CXR: transient tachypnea of
neonate……. TTT: O2.

Subconjunctival Hge in neonate: reassure.

MCC of facial n. palsy in neonates: forceps delivery.

Bluish discolouration on buttocks since birth= Mongolian spots.

Management of Mongolian spot: reassure.

Red strawberry mass raising above surface of face of neonate= hemangioma.

TTT of hemangioma: reassure (‘ll spontaneously disappear at 7-8 ys)… if not:

cortisone is the 1st line TTT.

Dark purple color at face of neonate (at trigeminal distribution) not raising above
the skin= port wine stain= capillary malformation.

Most imp inv to be done for pt with port wine stain: brain CT (to exclude sturge-
weber $).

Translucent cyst since birth= cystic hygroma.

MC site of cystic hygroma: face.

Cyst at neck side= branchial cyst…. TTT: remove by surgery.

Most common fate of brachial cyst….infection

Firm painless swelling at birth & later, head tilt to one side= congenital torticollis.

Excessive watery diarrhea in infants.. Dx: blocked naso-lacrimal duct.

Most imp advice: massage of the duct several times/day (improvement occurs at
6-12 ms).

Dyspnea, cyanosis at birth with scaphiod abdomen, intestinal sound at chest,

intestinal shadow IN THE CHEST at X-ray… Dx: Congenital diaphragmatic hernia.

TTT: decompression, resuscitation and immediate surgery.

MC complication in infant of diabetic mother: hypoglycemia.

Neonate to mother with DM.1st: good apgar score then: depressed……………..MCC:

hypoglycemia.

MCC of neonatal RDS: prematurity.

Prevention of RDS: antenatal cortisone.

TTT of RDS: surfactant.

Persistent non-bilious vomiting at 2-6 Ws of age: CHPS.

Persistent Bilious vomiting since birth.. Dx: duodenal atresia.

Inv of choice in duodenal atresia: abdominal x-ray (double bubble sign).

TTT of duodenal atresia: surgery.

No passing of stool since birth, no anal opening..Dx: imperforate anus.

Inv of choice of imperforate anus: x-ray with the pt upside down.

Neonate with High pitched cry, sweating, tremor, vomiting, diarrhea and may be
convulsion….Dx: neonatal abstinence $ (neonate to opoid abusing mother).

TTT of neonatal abstinence $: opoids.

Neonate with low apgar score, confusion, decrease in RR, BP, PR and may be
pinpoint pupil. cause: passage of opoid to fetus during labor (maternal
anesthesia)……TTT: naloxone.

School exclusion:
Chicken pox………………………………………… until vesicles dried.

Hand foot mouth disease…………………… until vesicles dried.

Impetig……………………………………………… until 24hs from starting abs TTT.

Measles……………………………………………. for 4 ds after rash appearance.

Pertussis………………………………………….. for 5 ds after abs TTT or 3 Ws of cough.

Eryhema infctiosum………………………….exclusion of pregnant teacher not the

infected kid.

Child living in low socioeconomic status environment develop abdominal pain,

constipation & change in bahaviour…Dx: lead poisoning.

When u suspect paracetamol toxicity; assessment of paracetamol level in blood 4

hs after ingestion:

- If paracetamol ingested is <200mg/kg… no TTT.

- If paracetamol ingested is >200mg/kg… give antidote.
- Antidote for paracetamol toxicity: IV N-acetyl cysteine.
Pt presented with symptoms of Paracetamol toxicity, time of ingestion is not
known…. Next step: give antidote.

Vomiting, tinnitus, hyperventilation after ingestion of large dose of

medication………..Dx: aspirin toxicity.

Metabolic changes in Aspirin toxicity:

1st>> respiratory alkalosis DT hyperventilation

Then>> metabolic alkalosis DT defect in metabolism.

Pt work in close garage, BBQ party with geadache, irritability, lethargy and cherry
red skin color…Dx: CO poisoning…. TTT: high flow O2.

Farmer presented with lacrimation, salivation, urination, defecation, rhinorrhea,

bronchorrhea/wheezy chest, decrease in BP, PR and may be pin point
pupil……………….Dx: OPC poisoning.

1st step in TTT of OPC poisoning: remove pt clothes.

Antidote of OPC poisoning: oximes.

Child ingested pills which appear opaque in abdominal x-ray.. iron poisoning.

TTT of iron poisoning: deferoxamine.

Child ingest white pills develop arrhythmia….1st step: ECG… then if ECG changes:
give NAHCO3.

Genetics of important diseases:

Hemophilia…….x-linked

G6PD…………….x-linked

Duchenne…….x-linked

Huntington…….AD

Gilbert…………AD

Spherocytosis……..AD

Essential tremors……AD

Ehler-danlos…….AD

Marfan syndrome……AD

Adult Polycystic kidney disease……..AD

Familial adenomatous polyps……AD

Peutz-jehers……..AD

HOCM……..AD

Tourrete syndrome…….AD

CYTIC FIBROSIS……AR

Thalassemia……AR

Galactossemia……AR
 Sickle cell anemia……AR

Wilson…….AR

Hemochromatosis……AR

Type of toothpaste used under 17 ys old ………..low fluoride

Preferred type of milk in lactose intolerance…..soy based milk

Most common cause of delayed milestones is prematurity.

Delayed milestones + H/O prolonged jaundice or prolonged stay in the

ICU……consider neurological problem

First step in dehydrated in kid ….oral feeding if failed then Iv feeding

When to say direct hyperbilirubinemia……..when direct is more than 20% of the

total

Direct hyperbilirubinemia after 1st week………biliary atresia

prolonged jaundice, constipation, hypotonia, enlarged tongue, umbilical

or inguinal hernia, mental retardation…..congenital hypothyrodism

Most common cause of delayed milestones is prematurity.

After sting bite if the child develops?????

Rash only or limited swelling…………oral antihistamine(oral promethazine)

Rash+wheezy chest+hypotension or vomiting……IM adrenaline

Most imp inv with a drowsy kid in the morning ….blood sugar

9 ys kid started menstruation……….normal puberty

2 ys kid started menstruation……….precocious puberty

2 ys kid with breast enlargement only…..thelarche

Head increased rapidly in size in a baby …..hydrocephalus

Tall boy, infertile, gynecomastia with mental retardation…..klienfelter SYNDROME

1ST inv in infertility in this boy………testosterone level

Neonatal jaundice with breast feeding< 6 times/d: breastfeeding jaundice.

TTT Of breast feeding jaundice: increase frequency of breast feeding.

Neonatal jaundice with breast feeding>8 times/d: breast milk jaundice.

TTT of breast milk jaundice: temporary cessation of breast feeding for 2ds then
resume breast feeding.

Jaundice at 1st day: hemolytic disease of new born(DT Rh incompatability).

Jaundice at 3rd day: physiological jaundice.

Direct Jaundice after 7th day: biliary atresia.

1st step in management Of neonatal jaundice: total& direct billirubin.

Bilirubin> 270 micromol/L : phototherapy.

Bilirubin> 340 micromol/L : exchange transfusion.

Asymptomatic Indirect hyperbilirubinemia in healthy adult: gilbert $.

TTT of neonatal hypoglycemia… 1st line: IV glucose.. if failed: IM glucagon.

Cyanosis with feeding which improve with crying… Dx: choanal atresia.

Test of choice if choanal atresia suspected: catheter test.

Inv. Of choice for Dx of choanal atresia: CT scan with contrast.

1st step in management of choanal atresia: airway to keep mouth open.

Neonate with microcephaly, pigmented retina: congenital CMV infection.

Inv of choice of congenital CMV infection….urine antigen

innocent murmur management: reassure; BUT, refer to pediatrician is the right

answer if found.

MCC of omphalitis : staph. Aureus.

MC source of infection in omphalitis: umbilicus.

MCC of cleft lip, cleft palate: genetic.

Fused labia: leave it alone (if DOC is asked: estrogen cream)… never to pull them
apart.

MCC of club foot: postural (esp. in primigravida).

3 days of fever followed by maculopapular rash.. Dx: roseola infantum.

VURTI+ koplik spot on buccal mucosa then maculopapular rash.. Dx: measeles.

After Dx of measles, you must notify.

Most imp. Complication of measles: OM.

Most imp. Vitamin to be given in measles: vit. A.

VURTI+ slapped check… Dx: erythema infectiosum. CO: parvovirus B19.

Parvovirus B19 infection in pt with SCA or HS: aplastic anemia.

Parvovirus B19 infection in pregnancy: hydrobs fetalis in fetus.

No school exclusion for pt with parvovirus B19 inf. (pregnant teacher shouldn’t go
to school).

Strawberry tongue+ circumoral pallor+ sandpaper rash= scarlet fever.

Ulceration on post. Pharynx, uvula, palate only: herpangina.

The same+ ulceration on hand and foot= hand foot mouth disease.

School exclusion in hand, foot and mouth disease….till all lesions crust

CO of herpangina & hand foot mouth diseases: coxsakie virus.

Ulceration on lips only: HSV infection.

Wheezes in child<2ys with URTI… Dx: bronchiolitis …… CO: RSV.

Child with bronchiolitis is at greater risk of bronchial asthma.

TTT of bronchiolitis: only supportive (O2 by nasal cannula& fluid)…. No abs.

Inspiratory stridor worse on lying down+ barking cough = croup.

CO of croup: para-influenza virus.

TTT of Mild to moderate croup: inhaled cortisone.

TTT of severe croup: inhaled “nebulized” adrenaline.

Very high fever, expiratory stridor, drooling of saliva..Dx: epiglottitis.

CO of epiglottitis: H.influenza.

TTT of epiglottitis: admission& intubation.

Fever for 5ds+ 4 of the following (CREAM; Conjunctivitis, Rash, Erythema,

Adenopathy& MM involvement) = Kawasaki disease.

Most imp. Inv: echo

Most serious complication: myocarditis, coronary aneurysm.

1st line of TTT of Kawasaki: IVIG and 2nd line: aspirin.

Child with fever, crying& pulling on his ear… Dx: OM.

MCC of OM: stept. Pneumonia.

Most specific finding on otoscopy: loss of mobility of ear drum.

Drug of choice of otitis media ( current updates)………paracetamol only

If no response……….amox

If still no response,………amox-clav

Most imp test after recovery : hearing assessment.

Swelling behind the ear after PM.. Dx: mostoiditis.. inv of choice: CT scan.
TTT of chronic OM: aural toilet.

Druf of choice for chronic OM……ciprofloxacin drops

Varicella post-exposure proph: vaccine for immune-competent within 72 hs &

IVIG for pregnant& immune-compromised.

School exclusion for avricella: until blisters dried or at least 5 ds after the rash.

MC compl of mumps in children: encephalitis.

MC compl of mumps in adult: orchitis.

30 ys old Pt on sulfasalazine with H/O mumps when he was a child. now he has
abnormal semen analysis.. cause: sulfasalazine.

Long standing H/O dry cough esp. at night : BA

Long standing H/O dry cough with fever: pertussis.

Inv of choice at 1st 3 Ws of pertussis presentation: PCR of nasopharyngeal swab.

Inv of choice after 3 Ws: seology.

Prevention of pertussis: vaccine.

School exclusion for pertussis: at least 3Ws of cough or 5ds of Abs TTT.

Regardless of age or immunization status, all close contact to a case of pertussis

must receive erythromycin.

Give vaccine to non-immunized& those who received last dose in >10 ys.

Accidently discovering of abdominal mass in a child: nephroblastoma.

INV. Of choice of nephroblatoma: CT scan.

Painful mass which may crosses midline+ peri-orbital ecchymosis..

neuroblastoma.

Uneven thigh skin folds, discrepancy of leg length… Dx: DDH.

Diagnostic tests of DDH: barlow test, ortolani test.

Inv of choice of DDH: <4 ms: US …. >4 ms: x-ray.

TTT of DDH: pavlik- harness maneuver.

Painless limp with collapsed femur head in x-ray: perthe’s disease.

Painful limp in obese male teenager with limitation of movement: SCFE.

x-ray of SCFE: displaced femoral head medially& posteriorly.

TTT of SCFE: emergently surgery. (DT fear of avascular necrosis).

Limitation of movement in perthe’s& SCFE: abduction and internal rotation.

1st step in management of any child with limping: x-ray EXEPT in clear cases of
transient synovitis; 1st step: US.

H/O camping then malabsorption $... Dx: giardiasis TTT: meronidazole.

Best inv. Of giardiasis: intetstinal biopsy.

Newborn with frothy saliva& milk regurge.. Dx: esophageal atresia.

1st step: passage of wide bore catheter following by x-ray.

TTT of esophageal atresia: surgery.

Inflammation of penis+ inability to retract in backward= phimosis.

TTT of phimosis: cortisone cream.

Inflammation of penis+ inability to retract in forward= para-phimosis.

TTT of para-phimosis: urgent manual reduction… if failed: incision.

Whitish discharge on glans penis in a child= balanitis; TTT: cortisone.

From medical point of view: circumcision is NOT recommended.

Urethral opening at the ventral surface of penis: hypospadius… next step: never
to do circumcision (the foreskin will be used in the surgery).

Child with Difficulty in initiation of micturition+ H/O urinary cath.= urethral

stenosis.

Inv. Of choice for Dx of urethral stenosis: urethroscopy.

TTT : repeated dilation…. If failed: surgery.

Diarrhea in a complete healthy child<5ys old with normal inv: toddler diarrhea.

Excessive fruit juice: tooth caries, obesity, and diarrhea.

MCC of constipation in pediatric…….diet

Maximum timing of constipation….after weaning
Constipation since birth…..Meconium ileus or hirshpring
Cp……in functional constipation…..full rectum with stool
MCC of anal fissure in infancy.constipation

MCC of rectal prolapse in kids.constipation

TTT of acute constipation…..enema
Most effective…….bowel training
MCC of rectal prolapse in children: constipation.

Rectal prolapse+ recurrent chest inf.+ FTT = CF.

Most imp Q to be asked in a child with rectal prolapse: bowel habit.

Abdominal cramping + diarrhea after lactation/dairy products = lactose

intolerance.

Inv. Of choice of lactase intolerance: hydrogen breath test.

TTT of lactase intolerance: lactose free diet (lactose free formula in infants).eg:
soy based formula

MCC of epistaxis in children : hot wather.

Healthy Child with leg pain that may awaken the pt from sleep, all inv. Are
normal….. Dx: growing pain… management: reassure.

Healthy child crying& pull his leg to his abdomen, all inv are normal.. Dx: infantile
colic…. Management: reassure and diet modification.

Crying followed by cyanosis and then convulsion.. Dx: breath holding spells.

Convulsion then cyanosis: epilepsy.

Involuntary passage of stool> 4ys = encopresis.

TTT: toilet training… if failed: diet modification… if failed: laxatives.

Involuntary passage of urine> 5ys = enuresis.

MCC of enuresis: psychological BUT, urine culture MUST be done 1st.

MC organic cause of enuresis: UTI.

Most imp inv. To be done in enuresis: urine culture.

Pt with enuresis, ‘ll go camping after 1-2 ds, best management: desmopressin.

Best long term TTT of enuresis: alarm clock.

Inv of choice of hydrocephalus: CT scan (not US) “MRI>CT>US”.

Limping after VURTI or with the onset of URTI = TRANSIENT SYNOVITIS.

Most common cause of limping in kids………. TRANSIENT SYNOVITIS

Inv of choice of transient tenosynovitis: US.

TTT: analgesics, joint traction.

N.B. 1st inv of choice of limping child: X-ray.

And kid with limping should be referred

N.B. 1ST inv of choice of limping after VURTI: US.

Fluid the child need every day: 150mg/ kg.

4 Ws infant with excessive vomiting, good general condition… Dx: GERD.

4 Ws infant withexcessive vomiting, bad general condition.. Dx: CHPS.

Best inv of GERD: 24 Hs ph monitoring.

Best advice to mother with an infant with GERD: upright position after feeding.

Mother lose consciousness in daughter wedding, normal physical exam, normal

test.. most imp Q to ask: H/O separation anxiety while child.

Separation anxiety in children is NOT part of normal development; need psych

TTT.

MCC of painless bleeding in child<2ys old: meckel’s diverticulum.

TTT of mickel’s diverticulum: surgery.

TTT of choice of allergic rhinitis: intra-nasal cortisone at night.

Chronic cough + rhinorrhea which improve with antihistaminic: post-nasal drip.

Hives, Hypotension, wheezy chest+/- lip and tongue swelling after bee sting/
peanut ingestion= anaphylaxis.

Hives, pruritis, flushing after bee sting/peanut ingestion= urticaria (allergy).

MCC of anaphylaxis: food> bee sting> drugs.

MC components of cake causing anaphylaxis: nuts> sugar, egg.. etc.

TTT of anaphylaxis: IM epinephrine at the thigh.

Epinephrine dose:

1. Adult>12 ys: 0.5mg IM

2. Child 6-12 ys: 0.3mg IM

3. Child <6 ys: 0.15mg IM

Pt with recurrent anaphylaxis: epinephrine pin.

Sudden onset respiratory distress+ localized wheezes in children: FB inhalation.

Most serious cause of localized wheezes in adult: tumor.

Male child with recurrent chest, GIT infection >6ms of age + decrease in all ig and
lymphoid tissue.. Dx: X-linked agammaglobulinemia.

TTT of x-linked agammaglobulinemia: IVIG.

Recurrent infection+ recurrent suppurative lymphadenitis and multiple gingival

abscesses= CGD.

MC affected Cs in CGD: neutrophils. (enlarged LNs that may ooze pus with
neutrophils And bacteria inside).

MC organism causing infection in CGD: staph aureus.

Which Enzyme is affected in CGD? NADPH oxidase.

Specific test to diagnose CGD: nitroblue tetrazolium test.

1st step in head injury in kids: flow chart.

Head trauma Child with skull fracture (open, depressed or basal) develop
convulsion, recurrent vomiting or altered mental status… CT is a must.

Head trauma child with no loss of consc. &only 1 episode of vomiting.. reassure.

Head trauma child with persistent headache& 2 episodes of vomiting.. observe

for 4 hours.

If GCS less than 8……immediate intubation

AR diseases: pt MUST have both chromosomes in order to be affected.

AD diseases: pt need only one chromosome in order to be affected.

Assessment of child growth: always follow growth chart (not given percentage).

1tst: between 5th-85th percentile= normal growth.

2nd: between 85th-95th percentile= overweight.

3rd: >95th percentile= obese.

4th: <5th percentile= underweight.

Most affected parameter by acute malnutrition: weight.

Period of accelerated growth that follow periods of arrested growth: catch up

growth.

Best clinical indicator for overwt & underwt in children: BMI growth chart (not
numbers).

MCC of obesity overall: over feeding.

Failure To Thrive (FTT):

Most common cause…….psychological

FTT + constipation only……..hirschprung disease

FTT + constipation + recurrent chest infection….cystic fibrosis

FTT+ steatorrhea + recurrent chest infection……cystic fibrosis

FTT + steatorrhea……..celiac
If FTT is DT neglect…. Report to child protective authority.

Vaccination schedule for premature infants: the same schedule & dose as mature
infants.
Child with VURTI, now time of vaccination: give as schedule.

Child missed vaccination dose: catch up vaccine schedule (give him missed
vaccines now).

“Imp. Ex.” MMR vaccine: 1st dose at 12 m& 2nd dose at 18 m.

Egg allergy is NOT a contra-indication to MMR vaccine.

Somalian kid previously received doses of OPV comes to u, WT NEXT?? Give IPV.

Mam refused to give vaccines to her kid. 1st step: talk 2 her, if refused: refer for
counseling, if still refused: report to child protective authority?????????.

MCC of short stature: normal variant “constitutional”.

1st step in assessment of short stature, delayed puberty, precocious puberty: x-

ray to detect bona age (BA).

If CA> BA: REASSURE… if BA>CA: very bad.

TTT of Obese child: exercise prog (NOT diet as food is vital 4 development).

MCC of iron deficiency anemia in infants: prolonged exclusive breast feeding.

Start weaning at 4 ms (very imp. To start give iron fortified cereals).

MCC of decreased breast milk: decreased frequency.

Frequency of breast feeding: at least 8 times/ day.

Chocking in infants……… slapping on the back.

Chocking in adults…… hemlick maneuver.

Sudden onset cough, dyspnea+ localized wheezes= FB aspiration (1st step: x-ray).

Unilateral offensive nasal discharge in mentally retarded kid= FB in the nose.

TTT of FB in the nose: removal under anesthesia.

Infant with an insect in ear.. 1st step: kill it by oil.. then removal with forceps or
ear toilet.

Child with fish bone in larynx: laryngoscopy.

Child ingests battery; x-ray shows it at the esophagus: remove it by endoscope.

MCC of bloody vaginal discharge in infants: FB in the vagina.

TTT of FB in the vagina: removal under general anesthesia.

Immigrant infant from Sudan; most imp to check: Ca& vit. D (high risk of rickets).

Cause of neonatal gynecomastia: passage of maternal hormones.

Management of neonatal gynecomastia: observe (never squeeze).

Best way to asses fetal IUG: US.

Defect in both BPD, abdominal width= Symmetrical IUGR (MCC: chromosomal

abnormalities, congenital infection).

Defect in abdominal width, normal BPD= asymmetrical IUGR (MCC: placental

problems as preeclampsia).

MCC of RDS: prematurity.

Risk of high flow O2 to premature: 1.Retinopathy of prematurity. 2. Lung

dysplasia.

1st step in management of Meconium stained amniotic fluid: CTG & scalp pH
monitoring

suction NOT recommended any more in cases with meconium staining

1st step in meconium stating………mask ventilation

If very low apgar score with no response : intubation.

IM vitamin K is given routinely to all neonates (to avoid neonatal bleeding).

Tachypnea in neonate delivered by CS with normal CXR: transient tachypnea of
neonate……. TTT: O2.

Subconjunctival Hge in neonate: reassure.

MCC of facial n. palsy in neonates: forceps delivery.

Bluish discolouration on buttocks since birth= Mongolian spots.

Management of Mongolian spot: reassure.

Red strawberry mass raising above surface of face of neonate= hemangioma.

TTT of hemangioma: reassure (‘ll spontaneously disappear at 7-8 ys)… if not:

cortisone is the 1st line TTT.

Dark purple color at face of neonate (at trigeminal distribution) not raising above
the skin= port wine stain= capillary malformation.

Most imp inv to be done for pt with port wine stain: brain CT (to exclude sturge-
weber $).

Translucent cyst since birth= cystic hygroma.

MC site of cystic hygroma: face.

Cyst at neck side= branchial cyst…. TTT: remove by surgery.

Most common fate of brachial cyst….infection

Firm painless swelling at birth & later, head tilt to one side= congenital torticollis.

Excessive watery diarrhea in infants.. Dx: blocked naso-lacrimal duct.

Most imp advice: massage of the duct several times/day (improvement occurs at
6-12 ms).

Dyspnea, cyanosis at birth with scaphiod abdomen, intestinal sound at chest,

intestinal shadow IN THE CHEST at X-ray… Dx: Congenital diaphragmatic hernia.

TTT: decompression, resuscitation and immediate surgery.

MC complication in infant of diabetic mother: hypoglycemia.

Neonate to mother with DM.1st: good apgar score then: depressed……………..MCC:

hypoglycemia.

MCC of neonatal RDS: prematurity.

Prevention of RDS: antenatal cortisone.

TTT of RDS: surfactant.

Persistent non-bilious vomiting at 2-6 Ws of age: CHPS.

Persistent Bilious vomiting since birth.. Dx: duodenal atresia.

Inv of choice in duodenal atresia: abdominal x-ray (double bubble sign).

TTT of duodenal atresia: surgery.

No passing of stool since birth, no anal opening..Dx: imperforate anus.

Inv of choice of imperforate anus: x-ray with the pt upside down.

Neonate with High pitched cry, sweating, tremor, vomiting, diarrhea and may be
convulsion….Dx: neonatal abstinence $ (neonate to opoid abusing mother).

TTT of neonatal abstinence $: opoids.

Neonate with low apgar score, confusion, decrease in RR, BP, PR and may be
pinpoint pupil. cause: passage of opoid to fetus during labor (maternal
anesthesia)……TTT: naloxone.

School exclusion:
Chicken pox………………………………………… until vesicles dried.

Hand foot mouth disease…………………… until vesicles dried.

Impetig……………………………………………… until 24hs from starting abs TTT.

Measles……………………………………………. for 4 ds after rash appearance.

Pertussis………………………………………….. for 5 ds after abs TTT or 3 Ws of cough.

Eryhema infctiosum………………………….exclusion of pregnant teacher not the

infected kid.

Child living in low socioeconomic status environment develop abdominal pain,

constipation & change in bahaviour…Dx: lead poisoning.

When u suspect paracetamol toxicity; assessment of paracetamol level in blood 4

hs after ingestion:

- If paracetamol ingested is <200mg/kg… no TTT.

- If paracetamol ingested is >200mg/kg… give antidote.
- Antidote for paracetamol toxicity: IV N-acetyl cysteine.
Pt presented with symptoms of Paracetamol toxicity, time of ingestion is not
known…. Next step: give antidote.

Vomiting, tinnitus, hyperventilation after ingestion of large dose of

medication………..Dx: aspirin toxicity.

Metabolic changes in Aspirin toxicity:

1st>> respiratory alkalosis DT hyperventilation

Then>> metabolic alkalosis DT defect in metabolism.

Pt work in close garage, BBQ party with geadache, irritability, lethargy and cherry
red skin color…Dx: CO poisoning…. TTT: high flow O2.

Farmer presented with lacrimation, salivation, urination, defecation, rhinorrhea,

bronchorrhea/wheezy chest, decrease in BP, PR and may be pin point
pupil……………….Dx: OPC poisoning.

1st step in TTT of OPC poisoning: remove pt clothes.

Antidote of OPC poisoning: oximes.

Child ingested pills which appear opaque in abdominal x-ray.. iron poisoning.

TTT of iron poisoning: deferoxamine.

Child ingest white pills develop arrhythmia….1st step: ECG… then if ECG changes:
give NAHCO3.

Genetics of important diseases:

Hemophilia…….x-linked

G6PD…………….x-linked

Duchenne…….x-linked

Huntington…….AD

Gilbert…………AD

Spherocytosis……..AD

Essential tremors……AD

Ehler-danlos…….AD

Marfan syndrome……AD

Adult Polycystic kidney disease……..AD

Familial adenomatous polyps……AD

Peutz-jehers……..AD

HOCM……..AD

Tourrete syndrome…….AD

CYTIC FIBROSIS……AR

Thalassemia……AR

Galactossemia……AR
 Sickle cell anemia……AR

Wilson…….AR

Hemochromatosis……AR

Type of toothpaste used under 17 ys old ………..low fluoride

Preferred type of milk in lactose intolerance…..soy based milk

Most common cause of delayed milestones is prematurity.

Delayed milestones + H/O prolonged jaundice or prolonged stay in the

ICU……consider neurological problem

First step in dehydrated in kid ….oral feeding if failed then Iv feeding

When to say direct hyperbilirubinemia……..when direct is more than 20% of the

total

Direct hyperbilirubinemia after 1st week………biliary atresia

prolonged jaundice, constipation, hypotonia, enlarged tongue, umbilical

or inguinal hernia, mental retardation…..congenital hypothyrodism

Most common cause of delayed milestones is prematurity.

After sting bite if the child develops?????

Rash only or limited swelling…………oral antihistamine(oral promethazine)

Rash+wheezy chest+hypotension or vomiting……IM adrenaline

Most imp inv with a drowsy kid in the morning ….blood sugar

9 ys kid started menstruation……….normal puberty

2 ys kid started menstruation……….precocious puberty

2 ys kid with breast enlargement only…..thelarche

Head increased rapidly in size in a baby …..hydrocephalus

Tall boy, infertile, gynecomastia with mental retardation…..klienfelter SYNDROME

1ST inv in infertility in this boy………testosterone level

Most imp findings in x-ray of pt with OA… narrow joint space, osteophytes

Most common risk factor….obesity

Most imp step in life style….lose weight

Sequence of ttt in osteoarthritis:

First line…………..paracetamol

If failed…………..NSAIDs

If failed……………opioid

If failed…………..intraarticular steroid

Marked impairment of daily activities……..replace the joint

Where to hold the stick……..the opposite side with the diseased leg on the
ground

All labs of OA….. Normal

Old pt with chronic neck pain, sensory deficit… cervical spondylosis

X-ray findings… bony spurs & sclerotic facet joint

TTT……………… paracetamol 1st

Pt with acute pain, swelling, redness at 1st MTP joint… Dx: acute gouty arthritis
(podagra)

Most imp test… Synovial fluid analysis = arthrocentesis = aspiration of joint fluid

Findings in arthrocentesis: WBCs 2000-50000, NEEDLE shaped, NEGATIVELY

bireferingent crystals

NEGATIVE gram stain & culture

GOUT X-ray ---> PUNCHED OUT EROSIONS

++serum Uric acid is neither sensitive nor specific

Management:

Most imp in life style prevention of gout…….stop alcohol

OTHERS…….LOW PURINE DIET AND LOSE WEIGHT .

1st line TTT of acute attack…..………. INDOMETHACIN (NOT in RF or GIT bleeding)

2nd line TTT of acute attack……………..COLCHICINE

Acute attack in pt with renal failure….steroid……..vvvvvvvv imp ( colchicine may

e used with half dose )

PREVENTION ---> Allopurinol & probenicid

TTT of tophacous gout………allopurinol (NOT surgery)

Tophacous gout no responding to TTT next step………increase the dose

Main side effect of colchicine……….diarrhea

Main side effect of allopurinol………rash

If acute attack occurred while the pt is on allopurinol……indomethacin and

continue the allopurinol .vvvvvvvvv imp

Most common drug causing attack of gout……..Thiazide.VVVVVVV IMP

Main indication for long term use of medications in gout……renal failure

Starting dose of allopurinol….. 50-100 mg

SIDE EFFECTS OF THIAZIDE…….VVVVVVVVVVVVVVVVVVV IMP:

Hyponatremia

Hypokalemia

Hyperglycemia……induce DM ……………………..vvvvvvvv imp

Hyperurecemia…..contra-indicated in gout……vvvvvvv imp

Hypercalcemia….hypocalcuria….vvvvvvv imp (prophylaxis against renal stones)

Hyperlipidemia (cause disturbance in lipid profile)

Old Pt with hyper-calcemia develops acute knee joint pain… Dx: pseudo-gout

Arthrocentesis in pseudo-gout… rhomboid- shaped crystals, +ve berferingent

TTT… 1st line: NSAIDs. If no response: intra-articular steroid

Low Back Pain (LBP)

Pt with LBP not radiating to LL, exam shows para-vertebral ms spasm………. Dx:
lumbo- sacral sprain (lumbago).

TTT…. Analgesic & activity BUT no bed rest

Pt with LBP radiating to LL, exam shows +ve straight leg test…Dx: herniated disc

Inv of choice… MRI

TTT… 1st line: analgesic and continue movement. If no improvement: surgery

Pt with LBP with severe radicular LL pain, LMNL and urine& stool incontinence…
Dx: Cauda Equina $

Pt with LBP with severe radicular LL pain, UMNL and urine& stool incontinence…
Dx: Conus meddularis $

Inv of choice of both: MRI

TTT of choice of both: surgery

Post- menopausal pt with severe LBP, exam shows localized pain& tenderness to
one vertebra… Dx: vertebral fracture (osteoprotic fracture)

Inv of choice: X- RAY

If no fracture appears: DEXA scan

LBP ++ with leaning forward and walking up hill & -- with standing up… Dx: spinal
stenosis
Inv of choice: MRI. TTT of choice: surgery

Pt with H/O come with back pain… metastases until proven otherwise

1st step in management………….. IV steroid

Inv of choice…………………………. MRI

Long term TTT……………………… Radiation

Old age male with back pain, anemia& ++ Ca… Multiple Myeloma (MM)

Young male with chronic LBP… Ankylosing Spondylitis (AS) until proven otherwise

Inv of choice… X-ray (bamboo spine)

Imp Lab. of AS……………………… +ve HLA-B27& -ve RF

Imp. Eye affection in AS……… Anterior uveitis

Imp chest affection in AS….. Chest wall movement restriction

Management:
Non pharmacological ttt……….physiotherapy and hydrotherapy
First line medications………..NSAIDs ( naproxen)
Second line…..…….infliximab
Third line………....sulphasalazine
fourh line………….methotrexate
If failed…………… infliximab (risk of TB reactivation)

Diseases with pain referred to the back

1-perforated peptic ulcer

X-ray……air under diaphragm
TTT……..immediate laparotomy

2-acute pancreatitis:
Inv……amylase and lipase, US, CT
TTT……analgesic, IV fluid and NPO
3-aorta( dissection-ruptured)
TTT……surgery:
4-acute cholecystitis:
Female with severe RUQ pain
Inv……US…….stone at cystic duct and
TTT……conservative then scheduled cholecystectomy
5- others: renal colic, pyelonephritis.

Young male cannot see, pee or climb a tree after history of diarrhea,,…..reiter (
reactive )

DD of shoulder pain

Pt with shoulder pain, exams show limitation of passive movement BUT no

limitation of active movement. After intra-articular lidocaine injection, the pain is
markedly relieved…..Dx: rotator cuff tendonitis

Inv of choice: MRI

TTT of choice: NSAIDs

Pt with shoulder pain, exams show limitation of passive movement BUT no

limitation of active movement. After intra-articular lidocaine injection, the pain is
NOT relieved…..Dx: rotator cuff tear

Inv of choice: MRI

TTT of choice: arthroscopic repair

MC injured muscle in shoulder: supra-spinatus

Pt with chronic shoulder pain, exam shows limitation of both active& passive
movement… Dx: adhesive capsulitis… TTT: physiotherapy

Pt with shoulder pain, exam shows NO limitation of active or passive movement…

Dx: sub-acromial bursitis… TTT: NSAIDs

DD of muscle pain
Pt with generalized musculo- skeletal pain, disturbed sleep, normal
lab……………….Dx: fibro- myalgia

TTT of choice…. Amitryptiline

Pt with pain at shoulder& pelvic girdle and morning stiffness> 1h… Dx:
polymyalgia rheumatic (PMR)

TTT of choice: low dose steroid.

If PMR associated with giant cell arteritis: give high dose steroid (risk of blindness)

If u suspect giant cell arteritis…

1st step: ESR… if increases: Give high dose steroid

2nd step: confirm diagnosis by temporal a biopsy

Pt with muscle weakness, ++ CK& ++ aldolase… Dx: polymyositis

Inv of choice: muscle biopsy

TTT of choice: cortisone

Pt with muscle weakness, ++ CK& ++ aldolase, heliotrope rash and gotron

papule… Dx: dermato- myositis

Pt with kerato-conjunctivitis, difficult swallowing, dyspareunia and enlaged

parotid gland… Dx: Sjogren’s $

Pt with Sjogren $ presented with marked enlarged parotis… Biopsy

Most imp inv: anti-SSA (RO) anti-SSB (LA) antibodies

TTT: Symptomatic

Young pt with fever, arthritis, abdominal pain, foot drop& +ve C-ANCA… Dx: PAN

Inv of choice: sural nerve biopsy

Imp Inv to be done in pt with PAN: HBV serology

TTT of choice: cortisone, cyclophosphamide

Young female with rash over face and arthralgia………SLE

Inv of choice………..anti-DNA or anti-smith

Mild joint affection……….. hydroxycholoroquine…..vvvvvvvvv imp

Only skin manifestation……..hydroxycholoroquine……..vvvvvvv imp

Young female with chronic dry cough and bilateral hilar

lymphadenopathy………sarcoidosis……..next inv,….CT chest

Inv of choice ………biopsy ( lung or skin )

Ca level and ACE………increased

TTT of sarcoidosis …….oral steroid

Patient with rheumatoid arthritis now swelling at back of knee……backer cyst …..if
rupture……severe pain at calf

Young male with severe selling at knee, with redness and fever…….septic arthritis
until proved otherwise: immediate aspiration

Most commonorganism of septic arthritis ……staph aureus

Old age female with rheumatoid arthritis now severe selling and pain at knee joint
: ,,…next step aspiration to exclude septic arthritis

Female with joint pain and morning stiffness that decreases with activity ……
rheumatoid arthritis

Female with rheumatoid arthritis now elevated liver enzymes…….methorexate

induced hepatitis

For symptomatic control In acute attack..…….NSAIDS and splinting

Most imp inv for a RA pt will do operation……..X-RAY CERVICAL
vertebrae……exclude C1-C2 vertebrae

Pt with RA died on table while intubation……..C1-C2 fracture

Most common cause of death with RA…….CVS

Best drug for RA………methotrexate

FELTY'S SYNDROME……..RA + Splenomegaly + neutropenia

. methotrexate shouldn't be used in pregnant

DO u do surgery to sc nodules……..noooooooo

Drugs that can be used safely in pregnancy:…..vvvvvvvvvv imp

Prednisone

Sulphasalazine

Hydroxycholoroquine

Drugs that affect male fertility????...vvvvvvvvvvvvvvv imp

Methotrexate

sulphasalazine

Test should be done before giving azathioprine:

Thiopurine methyltransferase Genotype

Hydroxycholoroquine….safe in pregnancy and doesNOT affect male fertility

Female with basal crepitations over back, colored fingers with some fingers
amputated and difficulty in swallowing……..sclerderma…..anti-scl antibody…..most
common cause of death is pulmonary HTN

TTT of renal crisis with scleroderma…….ACEI

CREST $ = LIMITED scleroderma

. Calcinosis cutis.

. Raynaud's phenomenon.

. Esophageal dysmotility.

. Sclerodactyly.

. Telangiectasia.

+ . ve Anti-Centromere

Old age male on large dose of cortisone now limping………avascular necrosis

….MRI OF CHOICE

Patient patient with peripheral neuropathy manifestations now marked swelling

and redness at mid foot ……..charcoat joint ….next step is cast and immobilization

Drug of choice”

Rheumatoid arthritis --------------> Methotrxate.

. Osteoarthritis --------------------> Weight loss & Acetaminophen.

. Gout acute attack -----------------> NSAIDs, Indomethacin.

. Gout prevent. of new attack -------> allopurinol.

. CPPD ------------------------------> NSAIDs.

. Disk herniation -------------------> paracetamol.

. Epidural abscess ------------------> Abs "Vancomycin."

. Cord compression ------------------> Steroids.

. Spinal stenosis -------------------> Weight loss & Steroid injection .

. Fibromyalgia ----------------------> Amitriptyline.

. Carpal Tunnel. $ ------------------> Wrist splint & NSAIDs.

. Polymyositis ----------------------> high dose steroids.

. Rotator cuff injury ---------------> NSAIDs.

. SLE -------------------------------> High dose steroids.

. Sjogren $ -------------------------> Water the mouth & atrificial tears.

. Polymyalgia Rheumatica ------------> LOW dose steroids.

. Temporal "Giant cell" arteritis ---> HIGH dose steroids.

. Ankylosing Spondylitis ------------> NSAIDs.

. Psoriatic arthritis ---------------> NSAIDs.

. Reactive arthritis "Reiter's $" ---> NSAIDs.

. Septic arthritis ------------------> CEFTRIAXONE & VANCOMYCIN.

. Gonococcal arthritis --------------> Ceftriaxone or cefotaxime

Rhematoid Arthritis "RA" ------------> Anti-Cyclic Citrulinated Peptide "CCP."

. Systemic Lupus Erythematosus "SLE" --> Anti-Double Stranded DNA "DS DNA

Connective tissue disease………….anti ribonucleo protein

. Scleroderma -------------------------> Anti-topoisomerase "Scl 70."

. CREST $ -----------------------------> Anti-centromere.

. Sjogren $ ---------------------------> SS-A "Ro" & SS-B "La."

. Wegener's granulomatosis --> Anti-neutrophil cytoplasmic Antibody "C-ANCA."

. Chrug-Strauss -----------------------> Anti-myeloperoxidase antibody "P-ANCA

 psychpharmacology
SSRIs
Fluoxetine,
sertraline,
paroxetine,
citalopram
FLuvoxamine

INDICATIONS:
Depression and anxiety.

SIDE EFFECTS:
Sexual side effects, GI distress, agitation, insomnia,

Serotonin syndrome……………vvvvvvv imp

SSRI+ LSD, Ecstasy, cocaine , amphetamine and MAOI

 CLINICAL PICTURE:
 Confusion
 Agitation or restlessness
 Dilated pupils
 Headache
 Changes in blood pressure and/or temperature
 Nausea and/or vomiting
 Diarrhea
 Rapid heart rate
 Loss of muscle coordination or twitching muscles
 Shivering and goose bumps
 Heavy sweating

 MANAGEMENT:………EMERGENCY
 Hospitalization
 Stop offending drugs first
 Symptomatic TTT……..e.g: benzodiazepine for agitations
 N:B
 SSRI takes at least 2-6 weeks to be effective
Patient on SSRI comes back to you complaining that there
is no improvement……….just continue the medications
Patient on SSRI still have symptoms first step…..increase
dose
Patient on SSRI developed side effects…..shift to
another SSRI
Most common side effect of SSRI….abdominal pain and
agitation
Patient on SSRI after taking tramadol developed serotonin
syndromes first step……….stop both of them

TCAs
Nortriptyline
desipramine
amitriptyline,
imipramine

Indications:
Depression, anxiety
Chronic pain( fibromyalgia)
Migraine headaches,
Enuresis (imipramine)

Side effects:
Anticholinergic effects (dry mouth, constipation,
Urinary retention, sedation, diplopia)
hyperprolactinemia
Sexual problems.
Toxicity: vvvvvvvvvv imp
Cp………….seizures and arrhythmia
ECG……….prolongation of QRS
TTT………..IV NaHCO3
MAOIs …….Phenelzine, tranylcypromine, selegiline

Hypertensive crisis if taken with high-tyramine foods

cheese, red wine)

Most imp to check in patient on MAOI….Blood

pressure……….vvvvvvvvvvvvvvvv imp

Lithium …….first line mood stabilizer

Indications:
Acute mania
Prophylaxis in bipolar disorders

Side effects:
nephrogenuc diabetes insipidus………, Thirst, polyuria,
acne,
hypothyroidism,…… weight gain
nausea, diarrhea, seizures,
teratogenicity
Tremor
.
Narrow therapeutic window
Lithium toxicity:
ataxia,
dysarthria,
delirium, and
acute renal failure.
Avoid lithium in patients with impairedrenal function.

TTT……dialysis…..vvvvvvvvvvvvvvvvv imp
Carbamazepine
Second-line mood stabilizer; anticonvulsant;
Trigeminal neuralgia……….drug of choice
Skin rash, leukopenia

Lamotrigine ………rash
Antipsychotics

Typical antipsychotics

Haloperidol, droperidol, fluphenazine, thioridazine

chlorpromazine

Indications:
Psychotic disorders,
Acute mania,
Tourette’s syndrome.

Side effects:
1-Extrapyramidal symptoms
2-hyperprolactinemia.
3-Anticholinergic effects (dry mouth,constipation,urine
retention, diploapia)

Extrapyramidal symptoms

1- Neuroleptic malignant syndrome:

Fever,
Muscle rigidity,
Autonomic instability
Impaired conscious level
Elevated CK
TTT:
Stop medication
dantrolene or
bromocriptine

2-Acute dystonia
Involuntary muscle contraction or spasm (e.g. torticollis,
oculogyric crisis).
TTT……….. benztropine or diphenhydramine
DECREASE DOSE RE CHANGE DRUG
3-Akathisia
Restlessness in the legs…..continous walking
decrease the dose+
-blockers (propranolol).
Benzodiazepines or anticholinergics may help.

4- Tardive Dyskinesia
Involuntary movements ……especially tongue
Irreversible……..50%
Discontinue or decreasethe dose of neuroleptic

5-Pseudoparkinsonism (e.g., shuffling gait, rigidity).

anticholinergic (benztropine)
dopamine agonist (amantadine).
decreasethe dose of neuroleptic or discontinue (if
tolerated).

Antipsychotics…atypical
Clozapine, risperidone , olanzapine,

Clozapine
Weight gain,
Type 2 DM,
Agranulocytosis …….CBC MONITOR

Olanzapine:
Marked sedation……1st side effect
Weight gain

Respiridone:
insomnia
weight gain
acne and rash
N:B:

First line therapy for schizophrenia……..olanzapine

schizophrenia + insomnia…….olanzapine
drug with the least side effects…..olanzapine
schizophrenia+ oversleeping…..respiridone
Most common antipsychotic to cause
palpitations….clozapine
Most imp to monitor in patient on antipsychotic
medications…..blood sugar and lipid profile

Least effective antipsychotic drug……..quetiapine

ECT
Indications;
Severe cases, no response to medical TTT,
Suicidal patients and contraindication to medical ttt
Postpartum psychosis
Side effects:
Transient memory disturbance
Transient increase intracranial pressure
From who you get the consent?........mental health
tribunal …..vvvvv imp
Value of ECT….give immediate response …..vvvvvvvvv
imp

Olanzapine vs respiridone??

Which of them is used for first attack of psychosis??

Both of them
But olanzapine is prefered ……less side effects

Psychosis + insomnia…….give olanzapine

Psychosis+ sedation……give respiridone

Akathesia with Marijuana:

First step in management……..stop marijuana

Psychosis and marijuana:

First step……stop marujuana

Donepezil and SSRIs

Synergistic effect

First step……..stop both of them

Police brings to you homeless psychotic patient :

First step………….collateral history from the police

If agitated………antipsychotic then admission

If not agitated………….admission

Where to admit……….psychiatric unit

DD of sudden withdrawal manifestation in teenagers??

1-drug abuse……..need to be excluded first

2-depression…..associated with decreased appetite, enegery,

and sleep and suicidal thoughts

3-prodrome of schizophrenia……associated with delusions and

hallucinations
N;B:

Delusion with pregnancy…………olanzapine

Drug causing teratogenicity in first trimester…..anticonvulsant

Drug causing teratogenicity in last trimester…..antipsychotic

First step if mom complains of behaviouir of her son

…..interview with the son

Currently ttt of choice in agitated person if:

Psychotic patient………..antipsychotic medications

Delirious patient………..antipsychotic medications

Postoperative……………..antipsychotic medications

Amphetamine toxicity…………………benzodiazepine

Alcoholic………diazepam

Alcoholic and liver impairment……..lorazepam

Mental retarded kid….respiridone

Overvalued idea

An unreasonable, strongly held belief or idea.

This idea is acceptable to the patient
The idea is beyond the bounds of reason

Obsessions
Persistent, unwanted, and intrusive ideas, thoughts, impulses,
or images
N:B:
Patient with dementia needs urgent surgery first
step….ask for advanced directive
Panic Disorder

Female in her 20th

Agoraphobia is present in 30–50% of cases

 Hx/PE:
 
Periods of intense fear or discomfort
:
Tachypnea, chest pain, palpitations, diaphoresis,
Nausea, trembling, dizziness,
Fear of dying or “going crazy,”
Depersonalization.
Perioral and/or acral paresthesias
.
 
DD;
 Medical conditions: Angina, MI, arrhythmias,
hyperthyroidism, pheochromocytoma
.

Labs of panic attack…….labs of hyperventilation ( alkalosis,

hypocapnea and increased O2)
 Tx:
 CBT,
Benzodiazepines (e.g., clonazepam) ……… immediate relief
BB…….SECOND LINE,

AGORAPHOBIA:
Avoid places or situations make you feel trapped, helpless
or embarrassed.
Public transportation, being in open or enclosed spaces,
standing in line or being in a crowd




Social phobia: marked fear provoked by social or
performance situations e.g., public speaking.

 Specific phobia: feared object or situation (e.g., animals,

heights, airplanes).

 
 Tx:
 Specific phobias:
EXPOSURE IS THE BEST THERAPY

 Social phobias:
CBT,
SSRIs,
low-dose benzodiazepines, ……..acute attack
-blockers …………acute attack

Dementia
An impairment in cognitive functioning with global deficits.
Level of consciousness is stable

What is cognition? Mental processes of perceptions,

memory, judgment, thinking and reasoning

.
Age……. highest among those > 85 years of age.
course ……. persistent and progressive.
The most common causes are
Alzheimer’s disease (50%)
multi-infarct dementia (25%)

HISTORY/PE
Diagnostic criteria include memory impairment and one or
more of the following:
 Aphasia: Language impairment.
 Apraxia: Inability to perform motor activities.
 Agnosia: Inability to recognize previously known objects.
 Impaired executive function (problems with planning,
organizing
 Personality, mood, and behavior changes are common (e.g.,
wandering and aggression).
Delusions and hallucinations

DIAGNOSIS

 A careful history and physical are critical

.
Mini–mental state examination
It takes about 10 minutes and examines functions
including arithmetic, memory and orientation.

Maximal score of 30 points
Severe (≤9 points),
Moderate (10–18 points)
Mild (19–24 points) cognitive impairment.
Can never rule out dementia.
Low to very low scores correlate closely with the presence
of dementia

Alzheimer
Not preventable nor curable
Most common type of dementia
Risk factors………….female
Family history
Head trauma
Down syndrome (fall down with down)
Age……….usually after 65
CT………..BRAIN ATROPHY AND ENLARGED
VENTRICLES
.
.
TREATMENT
Provide environmental cues and a rigid structure for the
patient’s daily life.

 Cholinesterase inhibitors…..TACRINE AND

DONEPEZIL

N:B
There is no definitive investigation for Alzheimer
Alzheimer is neither preventable nor curable
First to be affected in Alzheimer…….memory
Least likely to be affected with Alzheimer is face recognition
Memory affection with normal aging sometimes very similar to
Alzheimer except that there is no impairment of normal
function…….. he lives independently
Best ttt for Alzeheimer + cadiac patient….memantine…vvimp

Lewy body dementia

Dementia+
Parkinsonism (rigidity bradykinesia, mask face and static
tremors) +
visual hallucination

PICK DISEASE

Atrophy of frontal and temporal lobe

Dementia+
Severe personality changes and very strange behavior
Huntington disease
Autosomal dominant
Atrophy of caudate nucleus
Familial
Triad (dementia, personality changes and chorea)
Age start at 40
Prognosis……death within 20 years after diagnosis
Parkinsonism
Age……..above 50
Resting tremors
Bradykinesia
Rigidity
Mask face
Dementia……40% of cases
Treatment……levodopa

Normal pressure hydrocephalus

Enlarged ventricle
Normal pressure
Triad (dementia, urine incontinence and gait ataxia)
TTT……..SHUNT

VASCULAR DEMENTIA (MULTI INFARCT)

SEX……usually male
Age…….younger than ALzeheimer
Course…….patchy or step wise
Risk factor……hypertension
Association…….focal deficit
TTT,,,,,,,,treat underlying condition
PSEUDODEMENTIA = DEPRESSION
Delirium
An acute disturbance of consciousness with altered cognition
Age……… Children and the elderly
Risk factor……..hospitalized patients (e.g., ICU psychosis)
Reversible if the underlying cause can be treated.

HISTORY
Acute onset of waxing and waning consciousness
(hallucinations, illusions, delusions).
Patients may be combative, anxious, paranoid, or stuporous.
Sleep-wake cycle
Symptoms at night (sun downing).

Causes:
UTI……….MOST COMMON
Medications
Surgery
Medical problems
Substance abuse
Organ failure
 
Occult UTI is common in the elderly….urine analysis
 
TREATMENT
 Treat underlying causes (delirium is often reversible).
 Normalize fluids and electrolytes.

Violent patient……..
Antipsychotics (e.g., haloperidol)…….IM
 Physical restraints may be necessary
N;B:
Most common 2 causes for agitation after admission to the
hospital:
1-delerium…….IM Haloperidol
2-alcohol withdrawal…… diazepam
Post traumatic stress disorder;

Etiology……….severe traumatic or psychological events

Clinical picture;

Experiencing of the traumatic events………..flash backs, dreams

or recollection

Avoidance of all stimuli associated with the trauma

Increase arousal, anxiety, sleeps disturbances

Survivor's guilt and depression

Durations………..within one month of the trauma diagnosed as

acute stress disorder

If lasted more than one month it is diagnosed as PTSD

TTT,……………...psychotherapy

Depression……SSRI

Factitious disorder( maunchusen syndrome)

sex ……………..usually male

job………………health care workers

Underlying psychological etiology…………….the patient want

people to take care of him

clinical picture;

Long history of hospital admissions and scars of surgeries

If tests return negative……….accuse doctors and threaten

litigation

Become angry when confronted

mauchusen syndrome by proxy

Symptoms and signs are faked for another person

Usually mother and their children

malingering

Fake symptoms for an obvious gain (money , avoidance of

work, or drugs)

sex……………usually male

Common in drug addicts, prisoners, and the military

Common scenario in the AMC exam…………young male

complains of severe colic pain asking for strong analgesic as
morphine……….first step DRUG SCREEN ( collect the sample in
front of you )

Wernike encephalopathy

Etiology………….chronic alcoholism………thiamine deficiency

Clinical picture..

Ataxia and nystagmus,

Confusion

Confabulation

Association………….hypoglycemia

Treatment…………thiamine first then glucose

dissociative fugue

Underlying stressful event

Sudden travel

Assumption of new personality and new name

Resolution is usually rapid

Duration from days to months

Dissociative identity disorders

More at females

Usually related to childhood sexual abuse

Multiple personalities controlling the person

Commonest personality disorder ………..borderline personality

disorder

Suicidal attempts, impulsivity and substance abuse

adjustment disorder

Within 3 months of the stressful event

cp;

Depression and anxiety

Withdrawn behavior

Erratic behavior
IMPULSE CONTROL DISORDER:

1-KLEPTOMANIA

2-PYROMANIA

3-TRICHILLOMANIA

4-PATHOLOGICAL GAMBLING

KLEPTOMANIA

Sex ……….females

Failure to resist impulse to steal even if she doesn't need these

stolen objects

The goal is the stealing not the objects

Increased anxiety before act followed by release of

anxiety after act.

Feeling guilty or ashamed of their act

Depression

Pyromania

Male

Mild mental retardation

Fire setting on more than one occasions

Increased anxiety before act followed by release of anxiety

after act.
Gratification and satisfaction after act

Lack of remors

Become sexually aroused by fire

Trichillomania

Sex……….female

Pulling her own hair

Hair loss all over body especially scalp

May eat hair………..obstruction

Associated with nail bitting and gnawing

What is grief?
Grief is a natural response to loss.:
 Divorce or  Death of a pet
relationship breakup  Loss of a cherished
 Loss of health dream
 Losing a job  A loved one’s serious
 Loss of financial illness
stability  Loss of a friendship
 A miscarriage  Loss of safety after a
 Retirement trauma
 Selling the family
home
What Are there stages of grief?.

The five stages of grief:

 Denial: “This can’t be happening to me.”
 Anger: “Why is this happening? Who is to
blame?”
 Bargaining: “Make this not happen, and in
return I will ____.”
 Depression: “I’m too sad to do anything.”
 Acceptance: “I’m at peace with what
happened.”
.”

Common symptoms of grief

 Shock and disbelief –
 Sadness –
 Guilt –
 Anger –
 Fear –
 Physical symptoms –, including fatigue,
nausea, lowered immunity, weight loss or
weight gain, aches and pains, and insomnia.

Complicated grief (abnormal grief)

Symptoms of complicated grief include:
 Intense longing and  Searching for the
yearning for the person in familiar
deceased places
 Intrusive thoughts or  Avoiding things that
images of your loved remind you of your
 one loved one
 Denial of the death  Extreme anger or
or sense of disbelief bitterness over the
 Imagining that loss
your loved one is  Feeling that life is
alive empty
The difference between grief and depression
Other symptoms that suggest depression, not just
grief:
 Intense, pervasive  Slow speech and
sense of guilt body movements
 Thoughts of suicide  Inability to function
or a preoccupation at work, home,
with dying and/or school
 Feelings of
hopelessness or
worthlessness

Role of GP in grief;

Counseling about the grief

Support the patient:

Drugs only for":
depression ….SSRI
You should ask the mother if she have any feeling of hurting
herself or her baby which is common with postpartum
psychosis

Main risk factor for postpartum psychosis……….primipara

Important steps for mild postpartum blue……family

involvement and continue breast feeding

Treatment of resistant cases of postpartum

psychosis…involuntary admission and .ECT
 Cirumstantiality vs tangetiality:

 Circumstantiality– An inability to answer a question
without giving excessive, unnecessary detail.. but
eventually will answer the question


Tangentiality is that the patient will talk

irrelevant and will never answer the question

Déjà vu :
is the phenomenon of having the strong sensation
that an event or experience currently being
experienced has been experienced in the past

Jamais vu
is a term in psychology which is used to describe any
familiar situation which is not recognized by the observer.
impression of seeing the situation for the first time, despite
rationally knowing that he or she has been in the situation
before. Appears with……. aphasia, amnesia,
and epilepsy.
Depersonalization disorder

The individual may feel detached from his or her entire being

he feels as if he is dreaming or flashing

(e.g., “I am no one,” “I have no self”).

(:“I know I have feelings but I don’t feel them”),

( “My thoughts don’t feel like my own,)

(e.g., feeling robotic, like an automaton; lacking control of
one’s speech or movements).

Derealization are characterized by a feeling of unreality or

detachment from, or unfamiliarity with, the world, be it
individuals,

 Delusions;………false fixed belief


 Delusion of control
 Cotard delusion: he is dead
 Delusional jealousy:
 Delusion of guilt
 Delusion of mind being read:
 Delusion of thought insertion
 Delusion of reference
 Erotomania
 Grandiose religious delusion:
 Somatic delusion
Grandiose delusions
Persecutory delusions

Anti-psychotic medication is the preferred

medication

Folie à deux
shared psychotic disorder
usually 2 members of the family
delusional belief are transmitted from one individual
to another
Capgras syndrome
disorder in which a person holds a delusion that a friend,
spouse, parent, or other close family member has been
replaced by an identical-looking impostor

ANXIETY DISORDERS

Generalized Anxiety Disorder

 Uncontrollable, excessive anxiety or worry about

activities or events in life

Female
Age……….. Early 20s.
 
Hx/PE:
Presents with anxiety on most days (six or more months)
three or more somatic symptoms (restlessness, fatigue,
difficulty concentrating,
Irritability, muscle tension, disturbed sleep).

Long term prognosis……… depression

 
Tx:
 Lifestyle changes, psychotherapy
Medication…………. SSRIs, venlafaxine
. Benzodiazepines may be used for immediate symptom relief.

Obsessive-Compulsive Disorder (OCD)

 
Age………. adolescence or early adulthood
Sex…………. males and females
Long term prognosis;……….. Psychosis
Hx/PE:

Obsessions: Persistent, unwanted, and intrusive ideas,

thoughts, impulses, or images 

Compulsions: Repeated mental acts or behaviors

(e.g., hand washing, elaborate rituals for ordinary

tasks, counting, excessive checking).

 Patients recognize these behaviors as excessive and

irrational products of their own minds

Patients wish they could get rid of the obsessions

 Tx:
SSRIs ………..drug of choice….in kids use( fluvoxamine)
BEST PSYCHOTHERAPY……exposure and prevention
cognitive-behavioral therapy

Sleep disorders
Sleep consists of 4 stages
Stage 3 and 4 ……….hardest to arouse
REM………easiest to arouse and more and second half of
the sleep
Sleep changes at elderly;
Total sleep decreases
REM decreases
Stages 3 and 4 tend to vanish
 Narcolepsy
Age………young
Sex…….usually male
CP;
SLEEP ATTACK………..commonest symptom.
Cataplexy…….pathgnomonic
Sudden onset of loss of muscle tone precipitated by
intense emotion or loud noise if short the patient will
remain awake and if prolonged he will sleep
Hypnagogic hallucination………hallucinations as going
to sleep
Hypnopompic hallucinations…….hallucinations while
walking up
Sleep paralysis……..awake but unable to sleep
Falling asleep quickly at night
Treatment;
Forced naps at regular time ……… of choice
Psycho stimulant
Antidepressants
 Sleep apnea
Type:
Obstructive……muscle atonia in oropharynx, nasal or
tongue
Central……….lack of respiratory efforts
Age………..middle age
Sex ……….male
Obese
Snoring during night
Headache in the morning
Tired during the day
Day time sleepiness
Associations…………depressions and mood changes
Complications..
Arrhythmia
Hypertension
Sudden death
Investigation………polysomonography…….of choice
Treatment;
Weight loss……..first step….best for long term
Continuous Positive airway pressure (CPAP)………ttt of
choice
Surgery
 1° INSOMNIA

Bad quality of the sleep

 Affects up to 30% of the general population

 Dx: nonrestorative sleep or

Difficulty initiating or maintaining sleep
 Tx:
 First-line therapy includes the initiation of good sleep
hygiene measures,
which include the following:
 Establishment of a regular sleep schedule
 Limiting of caffeine intake
 Avoidance of daytime naps
 Warm baths in the evening
 Use of the bedroom for sleep and sexual activity only
 Exercising early in the day
 Relaxation techniques
 Avoidance of large meals near bedtime
 Pharmacotherapy is considered second-line therapy and
should be initiated
With care for short periods of time (< 2 weeks).
Benzodiazepines…...the drug of choice
Melatonin ………………
 Pediatric orthopedic:

Developmental dysplasia of the hip joint: ( congenital hip

dislocation)

Female, first born, breech with + family history

Cp:

 Legs of different lengths

 Uneven skin folds on the thigh
 The mother notices it during
change of the diaper
 Limping

 Physical exam:

Barlow test

Ortolani test

The above tests are (+) and the

physician can feel or listen a click

Investigation:…….. ultrasonography is the best

If after 4 months…… x-ray in the frog lateral view

TTT:

Pavlik harness maneuver

Casting and surgery

Complication….. avascular necrosis

Legg calve perthes disease

Age……..4-8

Limp………..painless

Limited movement…….abduction
and internal rotation

X-ray( frog and lateral view)……… increased joint space,

collapse and deformity

TTT………mainly conservative

Surgery with deformity

Slipped capital femoral epiphysis

Obese adolescent boy (10-15 ys)

Cp:

Painful limp

Limited movement……..abduction and

internal rotation

X-ray (frog lateral view)…….displaced femoral head medial and

posterior

TTT:….mainly surgery

Complication…………..avascular necrosis

N:B:

First inv in a child with limping……X-Ray

Except if scenario is clear to be tensosynovitis…..US

Most imp step in child with chronic limping….Refer

Osteomyelitis:

Organism………staph ( most common)_

If sickle cell…….salmonella

Cp….pain

Fever, redness, swollen

Site…….metaphysis of long bone

Exam……localized tenderness

X-ray…..normal at first

Best test….MRI

TTT……antibiotics

DD of malabsorption in kids. vvvvvvvvvvvvv imp

1-giardiasis
History of camping
Inv….stool analysis
Best inv….intestinal biopsy
TTT…..oral metronidazole
2-celiac disease:
FTT
Iron deficiency, folic acid deficiency
Association….IDDM, thyroditid, vitiligo
Best inv….biopsy….atrophy of villi
Skin association……dermatitis herpitiformis
TTT.…gluten free diet
3-cystic fibrosis:
Recurrent chest infections
Nasal polyps, recurrent sinusitis
FTT
Inv…..sweat choloride test
4-short bowel syndrome

Miscellaneous topics

Esophageal atresia:

Most common type….. proximal atresia with distal

tracheoesophageal fistula

Cp:

Antenatal……..polyhydraminos

After birth:

Frothy saliva

Reguirgitation of milk

Attacks of cyanosis

Inv:…

Passage of wide bore catheter down the

esophagus followed by x ray

TTT…….surgery
Phimosis:

Tightness of the foreskin preventing

its free traction over glans penis

Paraphimosis:

Foreskin is retracted, swollen and

painful

Management:

Phimosis…….cortisone cream

Paraphimosis:

First step …….urgent manual

reduction

If failed…….incision

Circumcision few days after the

inflammation subsides

Never to use ice

Balanitis:

Inflammation of the glans penis

CP……. Discharge usually whitish

TTT………cortisone cream…..main TTT in

majority of the cases

If you find yeast…….. miconazole

If cellulitis or pus………ANTIBIOTICS
 Circumcision:

Is it recommended in Australia?........nooooo

Its incidence………decreasing

Contraindications?

Hypospadius……vvvvv imp

Buried penis

Chordee

Sick infant and inadequate experience

BURIED PENIS:

Causes:

Excessive fat at the base or excessive skin

TTT……….. refer to pediatric surgeon

Hypospadius:

Urethral opening in the ventral surface of the penis

Most common site …….glanular

TTT……..surgery

NEVER TO DO CIRCUMCISION……as the foreskin is used for the

surgery

Urethral stenosis:

Causes:

Adult…….catheter trauma

Kids…..congenital or after circumcision

CP……DIFFICULTY IN INITIATING THE MICTURITION

Inv………urethroscopy

TTT:

Mild…… repeated dilatation

Severe……surgery

Toddler diarrhea:

Age……..before 5 ys
Cp…….just diarrhea with normal exam
Major cause……diet
TTT…..increase fluid, fiber in diet
Avoid excessive fruit juice
Avoid too high fatty diet

Constipation in pediatrics:
Most common cause…….diet
Maximum timing of constipation….after weaning
Constipation since birth…..Meconium ileus or hirshpring
Cp……in functional constipation…..full rectum with stool
Most common cause of anal fissure in infancy. constipation

Most common cause of rectal prolapse in kids. constipation

TTT of acute constipation…..enema
Most effective…….bowel training
Other lines of ttt…..increase fluid, fiber and laxatives
Rectal prolapsed in kids:
Most common cause……constipation…..vvvv imp
Rectal prolapsed + recurrent chest infection +
FTT….cystic fibrosis
TTT……mainly dietary modification
Surgery…..rarely done….spontaneous resolution

Lactose intolerance:
Inability of adults to digest lactose,
Congenital lactase deficiency prevents babies from
drinking even human milk

Symptoms:
Abdominal bloating
cramps, flatulence, diarrhea, nausea, borborygmi,
and vomiting
investigations:
Hydrogen breath test……….(+)….inv of choice
Stool sugar test
Stool pH in lactose intolerance is less than 5.5.
Intestinal biopsy

Management:
Lactose free formula………..soy based formula
Avoiding lactose-containing products
Dairy products:
Milk
Butter, Yogurt, Cheeses, Sour cream
Epistaxis in kids:
Most common in kids……hot weather
Most common in adult……HTN
First step……compress nares
Head forward and cold compress, Anterior nasal packing
If bleeding site identifies…..cautery

Infantile colic:

Age……..around 10 weeks

Cp……prolonged crying at least 3 hs

Timing of crying……….afternoon and

early evening

Posture of infant…..flexing legs and clenching fists

Exam……..normal baby

Causes:

GERD, lactose intolerance, cow's milk intolerance

TTT:

REASSURE , NO DRUGS

Dietary modification

Growing pain ( begnin nocturnal limb pain)

Typical age…..3- 7 ys

Positive family history

Cp…..pain awakes the child

Site……usually Lower limb

Duration…..about half an hour

Exam…….normal and active child

TTT……..

Reassure

messsage

FUCTIONAL ( NON- ORGANIC) abdominal pain:

More than 90% of kids with recurrent abd. Pain

Cp:…..recurrent abdominal pain with or without vomiting

Severity……not severe

Duration…..subside spontaneously in less than 20 minutes

Site…..usually no abnormality

Association…….no diarrhea, no constipation, no dysuria

Exam……completely normal

Inv……..norma

Underlying cause……stress, child abuse. Family problems

TTT…….reassure

Breath holding attacks:

Age……peak 2-3 years

Cp: Severe crying……..cyanosis……loss

consciousness…….fits if prolonged
DD… epilepsy

In epilepsy… convulsions first then cyanosis

TTT'';

Reassure parents

Avoid frustrating the kid

Encopresis:

Involuntary passage of stool

When to consider it ?......after 4 years

More in boys

Exam…..fecal retention

TTT:

Toilet training……..vvvvvvvvvvvvvvv imp

If failed……diet modification and increase fluid

If failed……laxatives

Enuresis: vvvvvvvvvvv imp

(+) family history

Male more than females

Nocturnal more than diurnal

When to consider?.....after 5 ys……vvvvvvvvvv imp

Most common cause……psychological

Most common organic cause……UTI

Inv……….urine analysis and culture

TTT:

Toilet training

ALARM CLOCK………..VVVVVVVV IMP

DESMOPRESSIN……….RAPID EFFECT ( BOY GOING TO CAMP)

IMIPRAMINE

Cerebral palsy:

What is this?......persistent posture and movement disorder

Most common type……..spastic

Most common cause…….unknown

Most common association…….seizures

Perinatal hypoxia…….causes about 10% of the cases

Hydrocephalus:
Most common cause…obstruction
Cp:
Rapidly enlarged head
Sun downing of the eye
Delayed closure of fontanel
Investigation of choice…..CT ….vvvvv imp
TTT….shunt
Transient tenosynovitis :

Main cause……viral infection

Painful limb with mild restriction of movement

Site of pain…..hip, knee or groin

X-ray…..normal

US…..the best ( mild effusion)

TTT:

BED REST WITH NSAID

JOINT TRACTION VVVVVVV IMP

Temper tantrum:

Age ….from 1 year up to 4 ys

Cp:

Kicking, shouting, screaming, breath holding

or throwing

TTT:

REASSURE

Ignore the baby

Stay calm, move away and say nothing

Try to avoid the trigger

Praise appropriate behavior

Make sure that the child is ok

Stuttering and stammering:

Boys more common

Positive family history

Age… usually begins under age of 6 ys

Prognosis…….usually improves by adulthood

Best age to ttt….before 5 ys

Very important numbers in pediatrics:

Endotracheal tube:

Size….(age÷4)+4

Length……(age ÷ 2) + 12

Fluid the child needs every day….150 ml/kg……vvvv imp

When to introduce solid food?..... 5-6 months

Treatment of dehydration:

Shock therapy……….20 ml/kg lactated ringer

Deficit therapy …… % of dehydration×10×body weight

Maintenance therapy….

First 4 months…..120 ml/ kg

4-12 months……100 ml/ kg

More than 12 months…….80 ml/ kg

Type of fluid in shock therapy…..lactated ringer

Type of fluid in deficit therapy… glucose 5% + saline ( 1:1)

Type of fluid in maintenance theterapy… glucose 5% + saline
( 4:1)

GERD:

Common in the first year of life

Cp:

Excessive vomiting

Recurrent aspiration

Failure to thrive in severe cases

Sudden infant death syndrome

Inv:

24 hs esophageal monitor……the best

Endoscopy….in severe cases

TTT……VVVV IMP

 small, frequent feeds thickened with cereal

 Upright positioning after feeding
 Elevating the head of the bed
 Prone positioning (infants >6 months)
 Drugs…… H-2 blocker such as ranitidine
 PPI ( OMEPRAZOLE)
Separation anxiety:

Separation anxiety disorder is NOT a normal stage of

development

Common symptoms of separation anxiety disorder:

 Fear that something terrible will happen to

a loved one.
 Worry OF permanent separation.

 Nightmares about separation

 Refuse to go to school vvvvvv imp
 Display reluctance to go to sleep.
 Complain of physical sickness like a
headache or stomachache Cling to the
caregiver.
causes of separation anxiety disorder in
children:

 Change in environment
 Stress.
 Over-protective parent.

Adult Separation Anxiety Disorder?

Women more than men
 History of childhood separation anxiety

TTT:

 Listen to and respect your child’s

feelings.
 Talk about the issue
 Anticipate separation difficulty.

Nasal polyps in kids:

Most common cause in kids…..cystic
fibrosis…vvvv imp
Most common in adult……allergic rhinitis
TTT…..intranasal steroid

Meckle diverticulum:
2% of population- 2 ys of age -2 cm in size – 2 feet
from ileocecal valve
Most common cause of painless bleeding per
rectum in kids
Cp…..asymptomatic in majority of cases
Rectal bleeding, abdominal pain
Inv….radionucleotide scan
TTT…..surgery in kids
ALLERGIC RHINITIS
Watery rhinorrhea .
sneezing
prominent eye symptoms
.Early age of onset .
Identifiable trigger: .
animals - environmental exposure
.Usually seasonal .
.Nasal mucosa ,……..pale blue or pale on exam .
association…….. with allergic disorders e.g. .
.eczema & asthma
.Tx -> Allergen avoidance .
.Tx -> Topical intra-nasal cortisone At night

The 3 most common causes of CHRONIC .

COUGH
Post-nasal drip
.BRONCHIAL ASTHMA .
.GERD .

:POST-NASAL DRIP.
.chronic rhino-sinusitis .
.Dry cough .
Dx -> Confirmed by improvement of the nasal .
.discharge & cough with H1 Anti-histaminics
ANAPHYLAXIS
causes: .
Food….most common cause….imp
Bee stings
Medications
Component in cake causing anaphylaxis………..nuts….vvvv imp

cp:
CVS…………hypotension & tachycardia
Cutaneous ………hives - flushing - pruritis .
GIT ……….. Lip / tongue swelling - vomiting .
Respiratory ……..Dyspnea - wheezing - stridor - .
hypoxia
Tx -> .
INTRA-MUSCULAR EPINEPHRINE
Site………..THIGH
If recurrent anaphylaxis………adrenaline pen

dose :

 Adult IM dose 0.5 mg IM of 1:1000)

 Child IM :
 >12 years (0.5 mL of 1:1000 )
 >6-12 years: IM (0.3 mL of 1:1000 ).
 <6 years: IM (0.15 mL of 1:1000 ).
Localized wheezes:
Causes:
Secretions……most common cause
Foreign body….sudden onset
Tumour……most serious
First step…..ask the patient to cough….if wheezes
decreased….secretions

X-linked agammaglobulinemia ( Bruton agammaglobulinemia

X-linked genetic disorder

Patients do not generate mature B cells,…….. a complete lack of
antibodies in their bloodstream.
Patients with untreated XLA are prone to develop serious and
even fatal infections.
Diagnosis:
Sex……young boy
History of recurrent infections, mostly in the respiratory tract,
through childhood.
Marked lymph node hypoplasia
Tonsils and adenoid tissue markedly small
Labs……….drop all immunoglobulins
Treatment
Intravenous infusion of immunoglobulin
 Chronic granulomatous disease:
Pathology:
mutations nicotinamide adenine dinucleotide phosphate
(NADPH) oxidase in phagocytes……causing defect in
oxidation …… causing defect in intracellular killing of
pathogens by phagocytes.
History
Symptoms become apparent in the first 2 years of life
 Pneumonias
 Otitis
 Adenitis
 Skin infections
 Septicemia
 Diarrhea
 Spleen and/or liver abscesses
 Gingival abscesses
 Suppurative lymphadenitis
 Causes:
Most common organism………..staph
Most common fungal ………… Aspergillus species.
Laboratory Studies:
nitroblue tetrazolium dye test
Flow cytometry
Complete blood cell counts:
increased neutrophils
microcytic hypochromic anemia.
Medical Care
prolonged administration of antibiotics and prednisone.
Head Injury in kids:
First step………… flowchart

Initial Management Flowchart:

Neuroimaging:


 Definitive indications:
 basal skull fracture
 open or depressed skull fracture
  Unresponsive or only responding non-purposefully to
pain
 GCS persistently < 8
 Respiratory irregularity

 Relative indications:
 Loss of consciousness lasting more than 5 minutes
 Amnesia
 Persistent vomiting
 Clinical suspicion of non-accidental injury
 Post-traumatic seizures
 GCS persistently less than 14, or for a baby under
1 year GCS persistently less than 15
 Dangerous mechanism of injury (high-speed road
traffic)

How to assess severity of head injury:

Minor –  No loss of consciousness
jump to  Up to one episode of vomiting
Management  Stable, alert conscious state
 May have scalp bruising or laceration
 Normal examination

Moderate  Brief loss of consciousness

 Currently alert or responds to voice
 drowsy
 Two or more episodes of vomiting
 Persistent headache
 Up to one single brief ( <2min)
convulsion
 scalp bruise, haematoma or laceration

Severe  Decreased conscious level

 Localizing neurological signs
 Signs of increased intracranial pressure:
  Uncal herniation: Ipsilateral
dilated non-reactive pupil due
to compression of the
oculomotor nerve
 Central herniation
 Irregular respirations
 Penetrating head injury
 CSF leak from nose or ears

Management

 Minor head truam:

discharge
 Moderate Head Injury:
 observation at ER for a period of up to 4 hours
 Severe head injury:
 Urgent CT head

 When to do intubation and mechanical

ventilation:
 Child unresponsive or not responding purposefully to
pain
 GCS persistently <8
 Loss of protective laryngeal reflexes
 Respiratory irregularity

 How to decrease ICP:
 20-30 degrees head up
 Increase pCO2
 mannitol or hypertonic saline

Discharge requireme
Head injury information sheet - to be given to all
parents.
Genetics of important diseases:

Hemophilia…….x-linked

G6PD…………….x-linked

Duchenne…….x-linked

Huntington…….AD

Gilbert…………AD

Spherocytosis……..AD

Essential tremors……AD

Ehler-danlos…….AD

Marfan syndrome……AD

Adult Polycystic kidney disease……..AD

Familial adenomatous polyps……AD

Peutz-jehers……..AD

HOCM……..AD

Tourrete syndrome…….AD

CYTIC FIBROSIS……AR

Thalassemia……AR

Galactossemia……AR

Sickle cell anemia……AR

Wilson…….AR
Hemochromatosis……AR

Vvvvvv important dates in pediatrics:

Squint…….absolutely before 7 ys ( best 1-2 ys)

Undescended testis……….6-12 months

Inguinal hernia:

If obstruction……immediate operation

If irreducible……ASAP

If reducible ( 6-2 rule):

Birth-6 weeks……surgery within 2 days

6 weeks-6 months…..within 2 weeks

After 6 months……within 2 months

Femoral hernia…… ASAP

Umbilical hernia…after 4 years

Never tape down

Paraumbilical hernia…… best after 6 months

Epigastric hernia…….best after 6 months

Torsion testis….less than 6 hours

Hydrocele……reassess after 1 year

Varicocele…..leave and review

Developmental dysplasia of hip…….pavilk maneuver (

abductor splinting)

Genu varum……normal up to 3 years

Refer if ICS more than 6 cm

Knock knee…..normal up to 8 years

Refer if IMS more than 8 cm

Flat foot………..NO TTT unless stiff

Metatarsus adductus……refer 3 months after presentation

Internal tibial torsion……refer 6 months after presentation

Medial femoral torsion……normal up to 8 years

Tongue tie……3-4 months or 2-6 years

Ear deformity…..after 6 years

Cleft lip……. Less than 3 months

Cleft palate……6-12 months

Strawberry hemangioma…… spontaneous resolution up to

7 ys

Port wine stain…………. No resolution

Bed wetting……..normal up to 5 ys

Encopresis……normal up to 4 ys

Precocious puberty:

Girls………before 8 ys

Boys……..before 9 ys

Delayed puberty:

After 14 ys without secondary sexual characteristics

After 16 ys with secondary sexual characteristics

ADHD………5-7 YS

Autism…….before 3 ys

Tourette……… 7ys

Name of the organismS:…………..VVVV IMP

Syphilis……..treponema pallidum
Molluscum contagiosum……….pox virua

Genital warts……..Human papilloma virus

Genital herpes…….herpes simplex

Vaginal thrush……….candida

Scabies…….sarcoptes scabeii

Bacterial vaginosis…….gardenella vaginalis

Pediculosis pubis………phtirus pubis

N:B:

Most common cause of delayed milestones is prematurity.

After sting bite if the child develops?????

Rash only or limited swelling…………oral antihistamine(oral

promethazine)

Rash+wheezy chest+hypotension or vomiting……IM adrenaline

Most imp inv with a drowsy kid in the morning ….blood

sugar
9 ys kid started menstruation……….normal puberty
2 ys kid started menstruation……….precocious puberty
2 ys kid with breast enlargement only…..thelarche
 Growth curves

when to say normal???

1-lie between 5th and 95th percentile

2-follow his own percentile

3-all the parameters should be at the same percentile level

When to say abnormal?

1-less than 5th

2-more than 95th

3-marked deviation from his percentile curve

Catch up growth….period of accelerated growth following

period of growth arrest…..good indicator

Principles of growth:

Newborn loses 10% of their weight after birth

Infants double after 6 months, triple after 12 months

Best way to asses growth of the kid….growth chart

Best way to asses the growth….weight/height ratio

The parameter that markedly affected by acute

malnutrition…..weight

Best clinical indicator for overweight and under weight…BMI

Best way to asses bone age……..x-ray hand and wrist

First step if you suspect precocious puberty….x-ray hands

Amount of iron stores in kids enough for…….only 6 months

Most common cause of undernutrition in kids….psychological

Most common cause of obesity in kids….parentral obesity(over

feeding)

When to say obese in kids……BMI more than 95%

When to say overweight in kids……BMI 85-95%

Failure to thrive FTT

Most common cause…….psychological

FTT + constipation only……..hirschprung disease

FTT + constipation + recurrent chest infection….cystic fibrosis

FTT+ steatorrhea + recurrent chest infection……cystic fibrosis

FTT + steatorrhea……..celiac

If FTT due to neglect……report to child protection authority

VERY IMORTANT NOTES FOR VACCINATION:

These conditions are not contraindication to vaccination:

Reaction to previous DPT (fever, soreness, swelling)

Prematurity

Low birth weight

Current URTI or current antibiotics course

Family history of seizures

Family history of sudden infant death syndrome

Vaccines and prematurity:

Same schedule exactly as mature baby

Do not reduce the dose

If a child missed a dose of his scheduled doses of

immunization……catch up
Timing of MMR vaccine????
First dose is given…….. 12 months
Second dose is given …….. 18 months

MMR vaccine and allergy:

Egg allergy is not contraindication to MMR

Egg allergy is contraindication to influenza vaccine

Neomycin allergy is contraindicated to MMR vaccine

DTap vaccine:

Currently contains pertussis toxoid not whole cell vaccine

Only contraindication……encephalitis after previous dose

Polio vaccine:

2 types:

Oral……more effective but more complications

IPV…….Less effective less spread to population but less

complications

What is used in Australia?........only IPV ( ORAL IS RARE)

VERY IMP CASE SCENARIO IN AMC:

Somalian kid comes to you previous vaccinated with OPV your

next step?.........give him IPV
Mum refuses to vaccinates her baby???

First step…….COUNSELLING and try to persuade her

Still refuse……report

HIV positive mom want to breast feed her baby ?

First step…….tell her not to do that

If refused……..REPORT

Most common cause…..normal variant

Most common organic cause…..psychological

familial constitutional
Family history (+) (-)
Growth velocity normal delayed
Bone age normal delayed
puberty Short adult height Normal adult height
TTT GH may be useful reassure

Bone age and chronological age : vvvvvvv imp

BA=CA………ideal

BA more than CA…….VERY BAD

CA more than BA……reassure

First step…..x-ray of hands and wrist

Obesity in kids ……vvvvvvvvv imp

Most imp step……exercise

Second step………..diet……NOT recommended

Breast feeding :

Frequency…..at least 8 per day

How long exclusive breast feeding…..4-6 months

Most common cause of decreased breast milk…..decreased

frequency

Problems with breast feeding.:

Sore nipples (cracked)

Most common cause…..poor attachment

TTT:

IF candida infection…..nystatin

Breast pumping may be required

Weaning:

Timing……4-6 months

Problems with prolonged breast feeding:

1-iron deficiency anemia

2-rickets

3-under nutrition

General rules:

Start with small amount of only one type

Add new addition only after 2-3 weeks

Give the food by spoon and plate

Give before breast feeding and at fixed times

If dislike omit and try again later

Schedule"

4-6 months….iron rich cereals, fruit juices

6 months…….yogurt, fruit

7 months……egg yolk

8-9 months….share ordinary food

Hazards of excessive fruit juice??

1-obesity

2-dental caries

3-diarrhea, failure to thrive

Chocking in pediatrics????

Slap on his back

Chocking in adult????

Hemlich maneuver
 foreign body in pediatrics:

Inhalation of foreign body

Key word…..sudden onset cough and dyspnea

Exam…………localized wheezes

Most common site….RT main bronchus

First step……X-RAY

TTT……rigid bronchoscopy

Foreign body in the nose:

Key word…….unilateral offensive discharge in mentally

retarded kid

TTT…….removal under anesthesia

Foreign body in the ear:

Pain, deafness or discharge

Tinnitus if insect

Management:

Ear scope:

If battery……..remove immediately

Insects………..kill first using oil

Methods usually used in removal…….ear toilet or forceps

Foreign body in the laryngx:

Most common…….fish bone

Cp…….chocking, cough

TTT……laryngoscopy

Ingestion of foreign body:

First step……x-ray

Management:

If in the esophagus:

If battery……immediate removal….perforation

How to remove…..esophagoscopy

If beyond the esophagus:

Small and blunt...weekly x-ray and check the stool

If large object ….

Before pylorus ………..try to remove it

Beyond pylorus…..weekly x-ray with checking the

stool

If sharp object:

Before pylorus…..remove

Beyond pylorus…..daily x-ray with checking the

stool

If donot pass after 3 days…..removal

Kwashiorkor:

Very rare in Australia

Cause..Deficiency in protein diet with excessive carbohydrate

Rickets:

Very rare in Australia

Risk factors:

Immigrant….vvvvv imp

No exposure to the sun

Diet low in ca2 and vit D

Cp:

Head….frontal bossing, delayed closure of fontanel

Limbs….deformities, genu varum, genu valgum

Marfan sign….transferse groove at the medial malleolus

Chest….rosary beads, pigeon chest, Harrison sulcus

Spine….kyphoscoliosis

Muscles….weak and hypotonia

Neurology….tetany. irritability

Labs….decreased ca, decreased phosphorus, increased ALP

TTT:

Sin exposure

Vitamin D and Ca…VVVVV IMP

Neonatal gynecomastia:

Cause….passage of maternal hormones or infection

Most imp….do not squeeze

Neonatal reflexes:
Significance of Moro Reflex:

A-Absent:

1-marked prematurity

2-CNS depression

B-asymmetrical response:

Fracture clavicle, Erb's palsy

c- Persistent Moro:

Cerebral palsy, mental retardation

CLASSIFICATIONS OF NEWLY BORN:

Preterm……before 37 weeks

Term………..37-42 weeks

Post term….more than 42 weeks

According to the weight:

Normal weight…..2.5-4 kg

macrosomia………..more than 4 kg

Low birth weight….less than 2.5 kg

Neonatal bleeding:
Most common cause…….Vit K deficiency
First step……..IM Vitamin K

Risk with high flow o2 to premature:

1-Retinopathy of prematurity….new vessels formation..blindness

2-Dysplasia of the lung

Intrauterine growth restriction:

Prematurity:

Before 37 weeks

Excessive laungo hair

CNS….respiratory distress syndrome

GIT….necrotizing enterocolitis Infection….sepsis

Vision…..retinopathy of prematurity

Metabolic….hypoglycemia, hypocalcemia, hypothermia

Meconium aspiration syndrome:

Cp:

Meconium stained amniotic fluid

Respiratory distress

Chest exam…decreased air entry and wheezes

x-ray….patchy infiltrate and hyperventilation with atelectasis

TTT:

According to 2015 algorithm:

Nasopharyngeal aspirations is NO longer recommended
So 1st step......mask ventilation
If failed or marked acidosis or drop of heart rate below 100
or apnea.....intubation

Transient tachypnea of the newlyborn:

Risk factor…….CS…..delayed absorption of lung fluid

Cp…respiratory distress
TTT….O2.. usually resolved within 72 hours after birth.
Facial nerve palsy:
Cause…..forceps delivery
Fate …..full recovery within one week

cephalohematoma
Caput succedanum
Milia:
Firm white paplules inclusion cysts
TTT……reassure (spontaneous
resolution)

Mongolian spots:
Skin…..bluish discoloration
Site…..mostly on buttock
DD……child abuse
How to differentiate?.... Since birth vvvvvvv
imp
TTT……reassure

Hemangioma:

Red in color mainly in the face

Raised above surface

Fate……involution by the age of 7 to 8

Complication……..bleeding

TTT:

Spontaneous resolution…vvv imp

Cortisone……….. First option for TTT

propranolol

Laser, Surgery
Capillary malformation (Port wine stain)

Dark purple in color not raised above surface

If pressure……blanching

Site……distribution of trigeminal nerve

Fate………… no involution

INV………CT………vvvvvvvv imp

Why CT?....exclude struge weber syndrome (affection of

meninges)

TTT:

LASER………main TTT

Surgery and graft……. Not preferred

Cystic hygroma:
Timing……since birth (vvvvvvvvv imp)
Can cause obstructed labor
Sites:
Face…..most common site
Axilla……second most common
Site……lower part of the neck
Transillumination…..translucent
TTT…..remove
Branchial cyst:
Site….high in the neck deep to the stenomastoid
Content…..mucous and cholesterol
Edge…..well edge
Consistency…..well-defined
Transillumination…..opaque
Complication……infection
Fistula formation
TTT…..remove

Congenital torticollis ( sternomastoid

tumour)
Cause….interruption of blood supply
At birth…..firm painless swelling
Later….head tilt to one side
TTT:
Early…..physiotherapy
Later….division of sternomastoid

Premature thelarche:;
Breast development before age of 3 ys
No other sexual characteristics
TTT….reassure
Blocked nasolacrimal duct:

Cp…….. excessive watery secretion

Prognosis…… majority improves by age of 6 months

TTT:

Message of the duct several times per day

How is it done?...tip of the little finger in the inside

corner of the eye and stroking firmly downward to
the tip of the nose

If infection occurred?...... warm cottonwool soaks

If no healing after 12 months…… dilators

Congenital diaphragmatic hernia:

Cp:

Dyspnea and cyanosis

Intestinal sounds may be heard in the chest

Schaphoid abdomen

Lung hypoplasia

INV:

X-RAY…… intestinal shadow in the chest

TTT:

First step……. orogastric tube….decompression of the intestine

Second step………..intubation

Extracorporeal membrane oxygenation

IMMEDIATE SURGERY
Galactosemia:
Cause:G1P uridy transferase deficiency
Cp:
Cataract
Hepatosplenomegaly
Jaundice
Hypoglycemia
Mental retardation
TTT…no lactose in diet

Phenyketonuria:
Cause…..phenylalanine
hydroxylase deficiency
Cp:
Fair hair
Fair skin
Blue eyes
Microcephaly
Mental retardation
TTT…..low phenylalanine in diet
Infant of diabetic mother:
Cp:
Macrosomia
Hypoglycemia, Hypothermia
Hypocalcemia, Hypomagnecemia
Hyperbilirubinemia
Hyperinsulinemia…..hypoglycemia
Polycythemia…..plethoric face
Respiratory……fetal distress syndrome
CVS…..congenital anomaly
Spine….sacral agenesis – spina bifida
Most common anomaly….VSD

RESPIRATORY DISTRESS SYNDROME:

Cause….surfactant deficiency
Risk factors….prematurity
DM
CP……respiratory distress
Initial test…..X-ray….ground glass appearance
Most accurate….lecithin/sphingomyelin ratio
First step…..O2
Best ttt……surfactant
How to prevent……antenatal betamethasone
meconium ileus:
Main risk factor…..cystic fibrosis
Cp….IO
X-ray….distention of the bowel loop
TTT….high gastrografin enema

Duodenal atresia:
Bilious vomiting
Timing…..since birth
x-ray….double bubble sign
TTT….surgery

Duodenal atresia CHPS:

Since birth 3-6 weeks
Bilious vomiting non bilious
Imperforated anus:
Cp….no passing of stool
No anal opening
TTT…surgery
X-ray….
Position…..upside-down
Put a marker on the anus
Draw a line between the symphisis pubis and the sacrum
You will see a shadow of gas of the rectum:
If above pubococcygeal line….low anomaly
Below pubococcygeal kine…..high anomaly
 Neonatal abstinence syndrome (NAS):
a newborn of addictive mom
Signs and symptoms:
Withdrawal symptoms in the newborn
 High-pitched cry
 Tremors
 convulsions
 Sweating
 Excessive sucking
 Poor feeding
 Vomiting
 Diarrhea
Management
Opioids …………. first-line therapy.
N;B:
Type of toothpaste used under 17 ys old ………..low
fluoride….vvvvv imp
Preferred type of milk in lactose intolerance…..soy based
milk
Most common cause of delayed milestones is prematurity.
Delayed milestones + H/O prolonged jaundice or prolonged
stay in the ICU……consider neurological problem
First step in dehydrated in kid ….oral feeding if failed then
Iv feeding
 ‫‪neonatal jaundice:‬‬

‫‪breast feeding jaundice vs breast milk jaundice: vvimp‬‬

‫المرض االوالنى سببه االساسى االم مش بترضع الولد كمية لبن كفاية علشان كده‬
‫عالجه االساسى هو نزود كمية اللبن فى الرضاعة و الصفرة هتختفى بالكامل‬
‫المرض التانى سببه مش واضح اوى اللبن هو اللى بيعمل المشكلة الحل نوقف‬
‫الرضاعة شوية ‪.....‬و بعدين نرجع ترضع تانى مهم جدا جدا جدا االم ترجع تانى‬
‫طبيعى بعد فترة‬
Physiological hyperbilirubinemia:
Timing……3rd day

When it start to appear ?????

 appears in the sclera 35-40 micromol

 appears in the skin 70 - 100 micromol/L


Prevention of jaundice

 Early and frequent breastfeeding (8-12 times per day

for the first few days)

Pathological jaundice:
Causes:
1- Hemolytic disease of the newly born:
Cause…..Rh (-) mom and Rh(+) baby
Most common cause of sensitization of the mom…..hidden
feta-maternal hge bleeding
How to prevent…….anti-D after any maternal bleeding
2-ABO incomptability:
If mom is O and the baby is A, B or AB
Can occur if first baby born
Mild hemolysis
3-Sepsis:
Fever, bad general condition and jaundice
4-: Choledecal cyst
Cystic dilatation of extrahepatic biliary
system
TTT…..surgery
Classification of hyperbilirubinemia according to
dates:vvvvvv imp
First day:VVVVVVVV IMP
1-TORCH infection
2-Rh and ABO incomptability
3-Hemolytic anemia……..hereditary spherocytosis
2nd-3rd day:
Physiological
Cephalohematoma
More than 7 days
Breast milk jaundice
Hypothyroidism
1-2 weeks…….biliray atresia

Complications of pathological jaundice:

Kernicterus":
Organ affected…….basal ganglia
Cp….lethargy, seizures and hypotonia
TTT…..exchange transfusion
Investigation:
Bilirubin….direct and indirect….1st step .…vvvv imp


 When to do phototherapy????

 bilirubin >270micromol/L

When to do exchange transfusion????:

 bilirubin >340 micromol/L

Comb's test……for hemolysis

Management:
1-Phototherapy…..blue green light
Side effects……hyperthermia, dehydration, skin rash, bronze
baby syndrome corneal damage
Precautions::
Cover the eye and the genitalia
Frequent change of the position
Increase fluid intake

2-Exchange tansfusion:
Indications:
Symptoms of kernicterus
Marked elevation of bilirubin
 Blood used……fresh, warm , irradiated, Group O Rh(-)

3-Phenobarbital
N:B:
When to say direct hyperbilirubinemia……..when direct is
more than 20% of the total
Direct hyperbilirubinemia after 1st week………biliary atresia

Congenital hypothyrodism:

Most common cause…….thyroid dysgenesis

Cp…..prolonged jaundice, constipation, hypotonia, enlarged
tongue, umbilical or inguinal hernia, mental retardation
 prevention:
Screening……..2nd and 7th day of life
Technique………blood sample from the heel
TTT…..thyroxine

Gilbert syndrome:
Most common cause of hyperbilirubinemia
Genetics…..AD
Cause….low glucuronyl transferase
Cp…..jaundice
Type…..indirect hyperbilirubinemia
TTT…..none
Crilger Najar:
Same as Gilbert
But more severe ….needs ttt
Dubin Johonson and Rotor syndrome:
Conjugated hyperbilirubinemia
No ttt
With Dubin Johonson…..green colored liver biopsy

Neonatal seizures:

Most common cause….hypoxic ischemic encephalopathy

TTT:

First step….airway and o2……. Diazepam, Phenobarbital

Neonatal hypoglycemia:

Most common cause….DM

Cp:….tachycardia, pallor, sweating, lethargy, convulsions, coma

Inv….blood glucose level

TTT:

IV glucose….if hypoglycemia persist give IM Glucagon…vvv imp

Neonatal hypothermia:

Cp…low temperature, facial erythema, bradycardia,

hypotension, apnea

TTT….gradual warming

:choanal atresia…

Cp:

RDS

Cyanosis…improves with crying..key

word

Test…failure to pass a catheter

through the nose

Inv of choice….CT with contrast

TTT:

First step…..airway to keep the mouth open

Surgery

Cytomegalovirus in neonate:

Most common cause of congenital neonatal infection

Most common cause of birth defect
Cp:

 Hearing loss
 Vision loss…..pigmented
retina
 Mental disability
  Small head size………microcephaly
 Seizures
 Death
 Inv of choice……urine antigen
TTT…….ganicyclovir

Routine screening……not done

How to asses acute infection…..IgM
Best way to asses fetal infection….amniotic
fluid sampling
Neonatal sepsis:

cp: fever, poor suckling, hypotension

Most common organism………Group B- steroptococcus

Oral candidiasis:

Cp….difficult suckling,

Exam….whitish lesion removed easily

TTT…..oral nystatin

Innocent murmur:

Characteristics:

Age……less than 12 months

Absence of any cardiac symptoms…..as cyanosis or dyspnea

NO other congenital abnormalities

Site…..best between left sternal edge and the apex

Changes with change in posture or respiration

Decreases by sitting up

Systolic never diastolic, Soft

MANAGEMENT…………reassure and refer to pediatrician…..imp

Umbilical Granuloma:

Cause…..remnants of the umbilical cord

TTT…… silver nitrate

Complication…….infection

Omphalitis :

Inflammation of umbilical cord stump

Organism……staph (most common)

Most common source of infection…umbilicus

Cp….pain, redness, swelling, pus

Fever

Omphalocele vs Gastroschisis

Both of them ……. Herniation of

abdominal viscera

Omphalocele……….there is a sac

Gastroschiasis……….nooooo sac

TTT:

Gastroschisis…….emergency surgery

Omphalocele:

First step….. cover contents with a gauze

Then……NG suction….Then surgery

Tongue tie:

Family history usually positive

Does it affect speech?....noooo

Does it affect suckling?...Yesss

Timing of repair:

3-4 months or

1-2 years
Cleft lip and palate:

Usually unilateral

Most common cause…genetic

Complications of cleft palate?

1- affect feeding

2-affect speech

3- repeated ear infection…..deafness

4-aspiration pneumonia

Timing of surgery:

Cleft lip……Less than 3 months

Cleft palate …..6- 12 months

Fused labia in babies:

Most common cause….adhesion secondary to inflammation

Timing……majority after 3 months

Do not try to pull them apart

TTT:

The most safe ttt……….leave it alone….vvvvvvvv imp

Medical treatment, massage or cream is not usually needed.
Labial fusion does not have any effect on future fertility

Key points to remember

 Labial fusion is common.

 It does not usually cause any other symptoms.
 It is not related to other problems.
 The fusion will normally separate naturally by the time your
daughter has her first period.
 The safest, most effective and least stressful thing to do is no
treatment.

Metatarsus adductus:

Cp…..adducted foot

Bean shaped sole of foot

On exam….. the heel can go flat on the surface

Resolution…..usually by 3 years

Referral……3 months after surgery

Main ttt…..serial cast

Surgery if no resolution after 3 years

CLUB FOOT ( talipes equinovarus):

Common esp. in males

Majority of cases……just postural ( esp. primigravida) or
congenital

Heel cannot go flat on the surface

TTT:

Usually NO ttt

CORRECTIVE SHOES

SERIAL CASTING

IF NOT…..SURGERY

INTERNAL TIBIAL TORSION:

AGE…….toddler

Site of the lesion……tibia

TTT:

OBSERVE

Resolution by 3-4 years

Refer after 6 months of presentation

Medial femoral torsion:

Site …..femur

TTT:

Reassure and just observe

Resolution….by 8-9 ys

Refer after 8 ys of presentation

 Pediatrics infections:

Types of skin rashes:

1-maculopapular:

Measles

Mumps

Roseola infantum

Scarlet fever

Infectious mononucleosis

SLE

Juvenile rheumatoid arthritis

Sweat rash

Vesicular rash………chicken pox, herpes zoster, herpes simplex

Roseola infantum:

Cause…..herpes simplex virus 6

Cp……3 day fever followed by

maculopapular rash

Complications……febrile convulsions

TTT…….symptomatic

Rubella:

Cp….fever

Marked posterior lymphadenopathy….key word

Measles:

IT IS A NOTIFIABLE DISEASE

Cp:

Cough, conjunctivitis, coryza

Koplik's spots

Maculopapular rash after the Koplik's

Most common complication……otitis media

Most imp vitamin to give,,……vitamin A

Main TTT …….support

Erythema infectiousm: (fifth's disease)

Cause……….parvovirus B19

Cp:

Slapped cheek

Maculopapular rash

School exclusion…….none

TTT……symptomatic

Parvovirus in normal kids………..slapped

cheek

Parvovirus in sickle cell patients…….aplastic anemia

Parvovirus in pregnancy………hydrops fetalis

Scarlet fever:

Cause…..group A streptococcus

Cp:

Strawberry tongue

Circumoral pallor

Sand paper rash

Complication…….glomerulonephritis

TTT……penicillin

Hand, foot, mouth disease:

Cause……. coxsackie virus

Cp:

Mouth………ulcer

Hands and foot …..maculopapular rash

then vesicles

School exclusion…… Exclude until all

blisters have dried
herpangina:

Organism…… coxsackie

Cp…..vesicles and ulcers in the mouth, palate and uvula

Herpangia vs herpes gingivostamatitis:

Both of them………vesicles

Herpangia………….affecting mainly posteroir part of the mouth

Herpes…………….affecting mainly lips and anteroir part of the

mouth

Bronchiolitis:

Cause……RSV

Age…….2 weeks up to 2 years

Cp……wheezes and respiratory distress……..key word

Risk……asthma in the future higher risk

X-ray……hyperinflation

TTT,……supportive only (O2 and fluid)……via nasal prong

Hospitalization only if complicated

No antibiotics

Croup:( acute laryngotracheo bronchitis)

Cause…….parainfluenza virus

Cp:

fever
Inspiratory stridor worse in night

Harsh voice

Barking cough

Symptoms increase by lying on the back

TTT……
Mild to Moderate Croup…………… Prednisolone

Severe croup………nebulized adrenaline

Epiglottitis

Cause…….hemophilus influenza

Cp:

Very high fever

Toxic look

DROLLLLLLLLING of saliva

Expiratory stridor with soft voice

Donot examine the throat

X-ray……thumb print sign

Management/:

First step……admission

Intubation

If cannot intubate…….cricothyrodectomy

Antibiotics
KAWAZAKI disease:

Inv…..ECHO….VVVVVVVIMP

First line of ttt………..IVIG

2nd line of ttt………….Aspirin

ACUTE OTITIS MEDIA:

CAUSE……..step. pneumonia…….most commo::

Fever, Crying and Pull their ears

Vomiting and feeding troubles

Signs:

Loss mobility OF EAR DRUM ……..vvvvvvvvvvvvv imp

TTT:

Drug of choice………paracetamol only

If no response……….amox

If still no response,………amox-clav
Most imp test to be done to the baby after recovery……hearing
assessment vvvvvvvvvvvvvvvv imp

Complications of otitis media:

1-Effusion……….usually resolve spontansouly

2: Mastoiditis

Cp…..swelling behind the ear

Inv……CT

3-MENINGITIS:

Organism……strep.pneumoniae

Cp……stiffness of the neck and rash

Inv……..CT

4-Cholesteatoma…..whitish mass…..bone erosion

Chronic otitis media:

Persistent drainage from the middle ear lasting >6-12 wk

Inv……..CT
TTT……aural toilet ….main management
antibiotics

Worm infections:
Ascaris lumbricoides:
Most common worm …..very long worm
Complications….intestinal obstruction, lung affection
TTT….albendazole
Hook worm( ankylostoma)
Abdominal pain and diarrhea
Most common worm causing iron deficiency anemia in
kids
Hypoalbuminemia
Inv….stool analysis
TTT…..albendazole and iron
Enterobius vermicularis…vvvvv imp
Most common cp…….itchy anus
Inv of choice…….adhesive tape at night
TTT….single dose albendazole and repeat after 2 wks
Trichinella spiralis:
Undercooked meat
Most common cp…….muscle pain
Inv of choice……larva in muscle biopsy
TTT….mebendazole

Trichuris trichura:
Most common complication….rectal prolapsed
Cp….periumbilical pain
TTT….albendazole
Chicken pox ( varicella)

Cp:

Fever

Vesicular rash….different morphology( crops)

Post exposure prophylaxis:

1-Vaccine….live attenuated

…..only 1st 72 hours

2-IVIG…if pregnant or immunocompromised

Exclusion from school…vvvvvvvvvv imp

Exclude until all blisters have dried

At least 5 days after the rash
TTT….acyclovir, analgesics

MUMPS:

Cp….fever, fatigue

Enlarged parotid, tender, bilateral in 25%

Commonest complication in kids……encephalitis

Commonest complication in adult…..orchitis…testicular

atrophy….infertility

Pancreatitis, deafness, myocarditis, arthritis

TTT….supportive

School exclusion….. Exclude for 9 days or until swelling goes

down
Pertussis (whooping cough)….vvvvvvvvvvvv imp
Organism….bortedella pertussis

Infectivity period:

During catarrhal and paroxysmal stages

Up to 5 days after starting antibiotics

Stages:

Catarrhal stage(1-2 weeks)

Fever, mild cough, sneezing

Paroxysmal stage (2-4 weeks)

Severe paroxysmal spasmodic cough

The cough ends by characteristic whoop (sudden inspiratory crow)

Convalescent stage(2 weeks)

Decrease frequency and severity

Complications:

Subconjuctival hge….very common due to severe cough

CNS…..convulsions

Otitis media, pneumonia, pneumothorax

Inv of choice …. PCR of nasopharyngeal swap (-) after 3 wks

Serology…..low value

Prevention….DTP vaccine

TTT:

Erythromycin or azithromycin ….drug of choice

School exclusion:…vvvvvvv imp

Exclude the child for 3 weeks after the onset of cough

or until they have completed 5 days of antibiotic.
Protection of the contacts:……VVVVVV IMP
1-antibiotics prophylaxis:

 Most school-aged children who are fully vaccinated and

do not have symptoms do not require prophylaxis.

All the family members should receive erythromycin

regardless of their age or immunization status

2- Vaccination prophylaxis:

 Close contacts that are not up to date with their pertussis

immunisation should be given DTPa or dTpa as soon
after exposure as possible.
 dTpa for adults who have not had pertussis-containing
vaccine in the last 10 years.
 IMPORTANT PEDIATRICS SYNDROMES:

Down syndrome:
Cause…..Triosomy 21
CP:
upward slanting palbebral fissure
inner epicanthal fold
open mouth with tongue protrusion
hypotonia
Hearing loss
Simian crease
Gonadal deficiency
Hypothyroidism
Antanto-axial instability
Very important tips for down:
Most common genetic disorder…..non-dysjunction
Most common risk factor……maternal age
Most common cause of death…..leukemia (acute
lymphoblastic)
Mentally…..early onset alzeheimer
Most common CVS abnormality….endocardial cushion
defect followed by VSD
Most common GIT abnormality……duodenal atresia
Most common endocrine abnormality…..hypothyrosim
Most common spine abnormality….. Antanto-axial
instability
Recurrence rate with Down…..1%
risk of down syndrome by age chart Australia: vvvimp
20……1/870
30…….1/500
35…….1/200
40…….1/100
45……1/25
49……1/10

Klienfelter syndrome:
Genetics…..47XXY
Cp:
Tall man
Long limbs
Slim
Hypogonadism….small testis
Decreased testosterone hormone
gynecomastia
Low IQ
Behavioural problems
Turner syndrome: ( 45X0)

Most imp inv……FSH….increased

TTT…..hormonal replacement after puberty

FETAL ALCOHOL SYNDROME:

Most imp cp:
Thin upper lip
Absent or short philthrum
Mental retardation
When grow up???
Irritability and hyperactivity
Safe amount of alcohol during pregnancy….not known
Most common cause of MR in Australia….FAS
How do u screen during pregnancy?....US
Most common CVS anomaly…..VSD

Marfan syndrome:
Genetics….AD
Mutation in fibrillin gene
Tall stature
Long slim limbs
Decreased U:L limb ratio
Arachnodactyly
Joint laxity and subluxation
Eye…..upward subluxation of the
lens
Heart….AR
Aortic dissection
Spine…..scoliosis
Pectus excavatum
Ehler-Danlos syndrome:
Genetics….AD
Hyperextensible skin
Easily fragile

Joint laxity
MVP
AR
Aortic dissection
Blue sclera

:Osteogenesis imperfecta
Genetics….AD
Blue conjunctiva

Scoliosis
Recurrent multiple fracture
DD….child abuse
:

:Peutz-jeghers syndrome….
VVVVVVVV IMP
Genetics……AD
Lips……pigmentation
Colon…..polyps
Risk:
1-intussception
2-colon cancer….SCREEN
Fetal hydantoin syndromes:…..
Causes:
Drugs….valproic acid, phynetoin, carbamazepine

Fragile x-syndrome:
Genetics:…x-linked
‫كل حاجة كبيرة اال عقلة صغير‬
Large ears
Large skull
Large testis
Mental retardation
 Not important syndromes:

Edward syndrome : triosomy 18…. Not imp

patau syndrome….not imp

Waldenburg syndrome….not imp

Albinism
Blue eyes
Premature graying

Prader-willi syndrome … not imp

Marked obesity
Marked hypotonia

Angelman syndrome….not imp

Marked laughter
MR
 Pediatric oncology:

SPINA BIFIDA vs MENINGOCELE vs MENINGOMYELOCELE:

Recurrence rate……2-5 %

How to diagnose?.....amniocentesis at 15 weeks

How to prevent?.......Folic acid supplementation

Spina bifida occulta:

No herniation covered by tuft of hair

Asymptomatic……..no ttt

Meningocele:

Herniation…..meninges but not the spinal cord

Covered by skin

Do ct ……exclude hydrocephalus

TTT……surgery

Meningomyelocele:

Herniation….meninges and spinal cord

No skin covering (thin membrane)

Cp……paraplegia and spincteric disturbances

Inv….CT….exclude hydrocephalus

TTT……surgery
Wilms tumour:

Age……2-5 ys

Usually unilateral

Association:

Hemi hypertrophy

Aniridia

Urinary tract abnormalities

Cp…….asymptomatic abdominal pain does not cross midline

Hypertension and hematuria

Inv……CT is the best

TTT:

Nephrectomy IS THE MAIN TTT

Then chemotherapy
If both kidneys affected…….unilateral nephrectomy and partial
contralateral nephractomy

Prognosis…..excellent

Neuroblastoma:

Origin……neural cells

Cp:…..age usually less than 2 ys

Painful abdominal mass crosses the midline

Nausea, vomiting and fever

Periorbital ecchymosis

Inv:

Vanillymanillic acid……increased

The best inv…………..CT

TTT…..SURGERY and radio

N:B:

Wilms tumour is much more common than neuroblastoma….in

the exam if you are confused go to wilm's.

Craniopharyngioma:

Suprecellar calcification…….vvvvv imp

Cp:

Increased ICP

Growth failure and loss vision

Panhypopituitarism
The best…..MRI

x-ray……calcification

TTT…..surgery

Infratentorial tumours:

Astrocyroma:…….most common

Medulloblastoma……second most common

Both of the arise from cerebellum

Medulloblastoma…….midline infratentorial
 Pediatrics toxicology:

Lead poisoning:

...key word………….Old housing

Low socioeconomic status

Cp:

Behavioral….hyperactivity, aggression, irritability

GIT….abd. pain , vomiting and constipation

CNS…..affect memory, seizures and lethargy

Confirmatory test…..venous sampling…..ivn of choice

Confirmed with an elevated BLL (>0.48 µmol/L or 10 µg/dL).
Un Safe amount of lead in if more than 5 µg/dL.
Overt clinical toxicity from lead may not become apparent until BLL
exceed 40 µg/dL.
X-ray of long bone…..dense lead line

CBC….microcytic hypochromic anemia with basophilic stippling

TTT……chelation

Acetaminophen:

Nausea and vomiting

RUQ pain

Labs:

Acetaminophen level after 4 hs……..vvvvvvvv imp

Check Liver functions test and renal fuctions

TTT:……. N- acetylcystine
How is it given……..iv

Duration …..for 21 hours

Side effect of NAC infusion?

Anaphylactoid reactions
Management of this reaction????
Cease the infusion for 30 minutes, give promethazine then
recommence the infusion at half the previous rate
Aspirin:

First symptom……hyperventilation

Cp:

Vomiting

Lethargy, seizures and dehydration

TINNITUS

ABG:

First stage……respiratory alkalosis

Then…..metabolic acidosis

TTT…….alkalinization of urine

Carbon monoxide:

Cause…..fire, sleeping in the garage

Cp……cherry red color

Headache, irritability and lethargy

Complications…..rhabdomyelosis……renal failure

TTT……..high flow O2

Organophosphorus:……….PESTICIDES

Increased all body secretions:

Diarrhea

Urination
Lacrimation and salivation

Bradycardia

Miosis

Twitching and fasciculation

Exposure………..insecticide and fertilizers

FIRST STEP……..REMOVAL OF ALL CLOTHES

imp

Atropine…….ttt the symptoms

Pralidoxime……the definitive ttt

Iron:

Main source……multivitamins pills

Cp:

Abd. Pain, nausea and vomiting

Liver dysfunction

Inv:

X-ray……radioopaque tablets in the staomach….imp

TTT……deferoxamine

TCA:

WHITE TABLETS

CP……SEIZURES WITH ARRYTHMIA

First step…….ECG…….wide QRS

TTT…….sodium bicarbonate
 Vascular surgery

Acute limb ischemia;

Most common cause…………embolism

Most common source of emboli…...heart.

Most common site……bifurcation of femoral artery

Most common complaint………pain

Earliest sign…………pallor

Latest sign………..paresis

Clinical picture;

Age……….usually old age male

Onset………….sudden

6 ps ( pallor, pain, pulselessness, parathesia, paresis,

poikilothermia)

Clinical scenario in the exam……..patient with previous history

of MI coming to you with sudden severe pain in his leg
Investigation

Duplex………..fast

Angiography……the best but delay diagnosis

TTT

Morphine and hydration

Iv heparin ……….immediately….vvv imp

Embolectomy

Complication of treatment;

Acute compartment syndrome;

Marked swelling of the limb…….compression of the

vessels….ischemia

TTT……..IMMEDIATE FASCIOTOMY

HYPERKALEMIA

ECG……….HYPERACUTE T WAVE

TTT……….Ca gluconate immediately

Arterial injuries

Causes……..

Penetrating injury

Fracture

Following canulation

First step………..pressure to stop bleeding…..vvvvv imp

Definitive ttt………..Surgery….vvvvvv imp

Patient with swelling at femoral area with history of recent

catheterization first step………pressure

Chronic ischemia:

Atheroscelorosis is the most common risk factor

Cp:

Most early symptom……Intermittent claudication

Most serious symptom……Rest pain

Rest pain……increase with elevation of legs

Decrease by hanging of the legs

Maximum at night

Ulceration and gangrene

Others…..loss hair, loss nail , cold limbs, and color changes

Most imp sign……….Rubor on

dependence….vvvvvvvvvv imp
 First test……..ankle brachial pressure index…vvvvvvvvvv imp

Normally more than 1

If less than 0.5….urgent refer

Duplex………mild cases

Arteriography…….if ABI below 0.5

TTT…

MILD CASES;

Conservative:

Stop smoking

Gradual exercise program….vvvvvvvvvvvvvvvvv imp

Aspirin

Surgical intervention??????

 rest pain, ischaemic ulceration, or gangrene

 claudication symptoms limit work or lifestyle

Types of the operation?????

 Endovascular angioplasty or stenting, or open surgical reconstruction


 The choice of procedure will depend on the anatomic location of the
stenotic/occlusive disease, its extent, and the patient’s comorbidities.


Small segment…….thromboendarterectomy 

Big segment……..by bass graft 

Gangrene……amputation 
N:B:

Most common complication after bypass graft ……restenosis

Severity of the symptoms depends mainly on the collaterls

DM and PAD????

Most common risk factor for PAD…………DM

Main mechanism of DM to cause PAD……microangiopathy

Limb ischemia + intact pulsations………..small vessel thrombosis

ABDOMINAL AORTIC ANEURYSM;

Most common site……..below renal arteries

Most common cause…….atherosclerosis

Most common cause of aortic aneurysm in

young age …trauma

Most common symptom……pain

Clinical picture;

Usually asymptomatic

Expansile abdominal mass

Risk……..rupture…….emergency

Clinical picture of ruptured aneurysm:

Severe abdominal pain referred to back

Hypotension

Inv……………us
TTT…….IMMEDIATE SURGERY if

N:B;

Indication of surgery with abdominal aneurysm (elective

surgery):

Size………more than 5 cm

Rapidly enlargement

Symptomatic

Most common causes of severe abdominal pain referred to

back:

Perforated peptic ulcer- 1

Acute cholecystitis- 2
Acute pancreatitis- 3
Aorta ( rupture or dissection) - 4

A-V fistula:

Connection between artery and vein

Types;

Congenital………local gigantism

Acquired ………trauma or surgery for dialysis

Cp………increase CO, TACHYCARDIA, water hammer pulse,

Compression of fistula leads to bradycardia

TTT:…… CONGENITAL……..NO TTT

Aquired……surgery
Diabetic foot…vvvvv imp

Most common cause of ulceration with diabetes…..neuropathy

Most common sites……pressure areas (heel and head of 1st

metatarsal)

Most effective way to prevent diabetic foot…….leg caring

Sequence of ttt in diabetic ulcer:

1st and most important step…….debridement

2nd step………..antibiotics

If clear ulcer with clear discharge………just dressing

Best inv to exclude marjolin ulcer or malignancy….biopsy

Most imp inv to exclude osteomyletitis…..MRI followed by x-ray

If gangrene…….amputation

Buerger disease

Young male smoker

Cause…….neurovascular inflammation

Cp……..recurrent claudicating
 Superficial thrombophlebitis

Raynauds phenomenon

TTT…….stop smoking, sympathectomy, and amputation with

severe cases

CAROTID ARTERY SUGERY:

INDICATIONS:
1-asymptomatic carotid stenosis with ≥70% carotid stenosis…..best
candidate

2-symptomatic patients with greater than 50% stenosis

Contraindications:
 Patients with a severe neurologic deficit following a cerebral infarction
 Patients with an occluded carotid artery
 Concurrent medical illness that would significantly limit the patient’s
life expectancy
TTT of choice of carotid stenosis is end arterectomy NOT stent
….vvvvvvvvvv imp

Superficial thrombophlebitis

Veins become red, tender, and cord like

Fever

If recurrent….suspect visceral cancer

Risk………DVT

Prophylaxis against
DVT…………LMWH….vvvvvvvvvvvvvvvv imp

TTT……… compression by elastic stoking…vvvvvvv imp

 DVT
Predisposing factors:
Virchow triad:
1-Damage of especial lining of epithelium of vessels- 1
2- venous stasis…..prolonged stasis, long trip- 2
3- hypercoagulability:
Antithrombin 3 deficiency, protein C and S - 3
deficiency
Others…….malignancy, OCP, obesity

Clinical picture:- 4
Pain
Swelling
Tenderness
Investigation…….duplex
Treatment:

LMWH…….immediately

Warfarin
Duration…….at least 3- 6 months……..vvvvvvvvv imp

Target……..INR 2-3

Managing haemorrhage and/or a high INR

1-If the patient has life-threatening bleeding (eg intracranial or

gastrointestinal haemorrhage):

Hospital management
vitamin K1 IV
Fresh frozen plasma:…….VVVVVVVV IMP


 INR above 9 without bleeding or with only a minor bleed
(eg haematuria or epistaxis) - stop warfarin, administer
vitamin K1,

INR of 5-8, no bleeding - stop warfarin.
INR 4.5-5……….switch one dose
INR 3-4.5……….decrease dose

Managing a low INR

 Consider increasing the dose temporarily
q
+WARFARIN AND SURGERY
:VVVVVVVVVV IMP

ELECTIVE SURGERY……. warfarin is withheld

for 5 days
EMERGENCY SURGERY……Infusions of fresh-
frozen plasma

When bridging therapy is needed……. LMWH

Anticoagulation therapy should usually be restarted on the

day after surgery

BRIDGE THERAPY:

WHO NEEDS BRIDGE THERAPY ??

1-AF

2- Artificial valve

3-recent thromboembolism

Type of heparin used……..LMWH

Timing:
•Before surgery……, stop the heparin 24 hours before surgery
After surgery ……., wait at least 24 hours after surgery

ASPIRIN AND SURGERY…vvvvvvvvvv imp

Elective surgery……..stop aspirin at least 5 days before surgery

Emergency…….stop aspirin now and give platelets

When to stop NSAIDs before operations……5 days before

surgery

N:B:…..heparin with renal impairement (unfractionated

heparin)

Unfractionted heparin is given via iv route …..causes more

complication and needs monitor while LMWH doesnot need
monitor so it can be given at home)

Cellulitis vs DVT vs hematoma???

All of them,………..swelling, pain and tenderness

Cellulitis………..high grade fever

DVT………….low grade fever, past H/O DVT

Hematoma………..patient on warfarin, High INR

HEPARIN INDUCED THROMBOCYTOPENIA:

CAUSE,……..ANTIBODIES activating the platelets

Cp……thrombosis venous or arterial

Thrombocytopenia

TTT…….. stop heparin

Plasmapharesis

Never give platelets….worse condition

Warfarin induced thrombosis

Timing…….maximum 3-4 days after start warfarin

Site………….skin most common affected organ ( thigh, breast

and abdomen)

TTT…….STOP WARFARIN

Give vitamin k

LMWH:
Types of LL ulcerations????

Ischemic ulcer venous ulcer

Neuropathic ulcer………………→

important notes:

Most common site for ischemic ulcer……….tip of fingers

Most common site for neuropathic ulcer……pressure sites

Most common site for venous ulcer……against medial

malleolus

Is ischemic ulcer painful………..yesssssssssss

Is neuropathic ulcer painful……..nooooooooooo

Is venous ulcer painful…………..noooooooooo

Main ttt of venous ulcer……..compression stoking and

elevation of leg

Are antibiotics being used for venous ulcer??….noooooo

Most imp to prevent complication in foot of diabetic patient

…..well care of the foot and well glycemic control