Dr.

AmeerAboMokh
1. The adrenal is a frequent site for chronic granulomatous diseases, predominantly tuberculosis but also
histoplasmosis, coccidioidomycosis, and cryptococcosis → Addison’s disease → ACTH stimulation test.
Now the most frequent cause is ideopathic atrophy, related to an autoimmune mechanism.
Asthenia: abnormal physical weakness or lack of energy.
The diagnosis of adrenal insufficiency is made with the ACTH stimulation testing to assess adrenal
reserve capacity for steroid production. The best screening test is the cortisol response 60 minutes after
cosyntropin ”man-made ACTH” is given intramuscularly or intravenously. Cortisol levels should increase
appropriately. If the response is abnormal, then primary and secondary adrenal insufficiency can be
distinguished by measuring aldosterone levels from the same blood samples. In secondary, but not
primary, adrenal insufficiency, the aldosterone level is normal.
In primary adrenal insufficiency, plasma ACTH and associated peptides are elevated because of loss
of the usual cortisol–hypothalamic–pituitary feedback loop, whereas in secondary adrenal insufficiency,
plasma ACTH values are low or “inappropriately” normal.
2. Primary adrenal insuf.: adrenal cortex destruction #secondary adrenal insuf.: ACTH deficiency
The most useful test to distinguish is measurement of the circulating plasma ACTH level. ACTH levels
greater than normal define primary disease; values in the normal range or below define secondary disease.
Primary: Rx= Fludrocortisone + Hydrocortisone
Secondary: Rx= Hydrocortisone only
3. Cushing $: violaceous striae and incidental bruising, hirsutism, and menstrual irregularity, unprovoked
hypokalemia, proximal muscle weakness, signs of hyperandrogenism (acne, hirsutism), and psychological
disturbances (depression, mania, and psychoses).
Dx: 24-hour urinary free cortisol level.
# The high-dose (8 mg) dexamethasone suppression test is used to determine the possible cause of
Cushing syndrome.
4. Propylthiouracil often causes a mild leukopenia that does not require discontinuation of the drug. Drug-
induced agranulocytosis, however, is a life-threatening complication occurring in 0.1% to 0.2% of patients on
antithyroid medications and requires immediate discontinuation of the drug→CBC.
5. Gynecomastia in older men can result from medication use (e.g., omeprazole and cimetidine, INH, digitalis,
phenothiazine, testosterone), substance abuse (e.g., alcohol; illegal drugs, including marijuana and heroin),
endocrine disorders (e.g., hypogonadism, hyperthyroidism), Klinefelter’s syndrome, liver disease, and
neoplasm.
6. Primary Hyperaldosteronism (Conn Syndrome). This is most commonly due to a unilateral adenoma.
→ HTN+hypokalemia
7. The most common causes of secondary hyperaldosteronism are congestive heart failure and cirrhosis with
ascites.
In secondary hyperaldosteronism, the renin-aldosterone axis responds normally to chronic intravascular
volume deficiency. Secondary hyperaldosteronism is a collective term for a diverse group of disorders
characterized by physiologic activation of the renin-angiotensin-aldosterone (R-A-A) axis as a homeostatic
mechanism designed to maintain serum electrolyte concentrations or fluid volume.
8. Paracentesis is required to evaluate new-onset ascites.
9. JAK2 → Polycythemia vera\ Essential thrombocythemia → Budd–Chiari syndrome.
# erythromelalgia: Paroxysmal throbbing and burning pain in the skin often precipitated by exertion or heat,
affecting the hands and feet, accompanied by a dusky mottled redness of the parts with increased skin
temperature; may be associated with myeloproliferative disorders.
10. When is reflux alarming,and when is Endoscopy used in GERD? - : when the following symptoms are present: 1-
Weight loss 2-Anemia 3-Blood in the stool 4-Dysphagia
11. Patients with small amounts of ascites can usually be managed with dietary sodium restriction alone.
<2g OF SODIUM PER DAY
12. A serum-ascites albumin gradient (SAAG) greater than 1.1 suggests portal hypertension as the cause of
the ascites. SAAG less than 1.1 suggests alternative causes for ascites, including malignancy, pancreatitis,
spontaneous bacterial peritonitis, and tuberculosis.
 Dr.AmeerAboMokh
A SAAG ≥1.1 g/dL reflects the presence of portal hypertension and indicates that the ascites is due to
increased pressure in the hepatic sinusoids.
13. Asymptomatic cholelithiasis does not require cholecystectomy unless: porcelain gallbladder, sickle cell anemia, stone
> 2 to 3 cm, pediatric patient.
14. Patients with hematochezia and hemodynamic instability should have upper endoscopy to rule out an
upper GI source before evaluation of the lower GI tract.
15. Testing for autoimmune hepatitis usually includes an antinuclear antibody [ANA assay(!) and measurement
of specific immunoglobulins.
Many patients with autoimmune hepatitis: Serum AST and ALT levels are increased and fluctuate in the
range of 100−1000 units.
AMA is related to the duct not to the hepatocyte, so LFT will stay normal ,while alkaline phosphatese
will increase.
Anti-mitochondrial autoantibodies(AMA) are a signature autoantibody of primary biliary cholangitis
(PBC), formally known as primary biliary cirrhosis, and detected in 95% of patients.
16. Safety concerns about selected ANTIEMETICS have been emphasized. Centrally acting
antidopaminergics, especially METOCLOPRAMIDE, can CAUSE IRREVERSIBLE MOVEMENT DISORDERS
SUCH AS TARDIVE DYSKINESIA, PARTICULARLY IN OLDER PATIENTS. This complication should be
carefully explained and documented in the medical record.
17. Autoimmune hepatitis: *antinuclear antibody (ANA) *anti-smooth muscle antibody (SMA) *anti-liver kidney
microsomal antibodies (LKM-1, LKM-2, LKM-3) *anti soluble liver antigen (SLA) *liver–pancreas antigen (LP),
and
***anti-mitochondrial antibody (AMA)). The presence of anti-mitochondrial antibody is more suggestive of
primary biliary cholangitis.
18. Patients with small amounts of ascites can usually be managed with dietary sodium restriction alone...
When a moderate amount of ascites is present, DIURETIC THERAPY is usually NECESSARY. Traditionally,
SPIRONOLACTONE at 100–200 mg/d as a single dose is started, and furosemide may be added at 40–80
mg/d, particularly in patients who have peripheral edema.
19. For suspected pancreatic carcinoma → Endoscopic ultrasonography is the best screening tool.
20. Following the detection of an ADENOMATOUS POLYP, the entire large bowel should be visualized
endoscopically because synchronous lesions are noted in about one-third of cases. COLONOSCOPY should
then be repeated periodically, even in the absence of a previously documented malignancy, because such
patients have a 30–50% probability of developing another adenoma and are at a higher-than-average risk for
DEVELOPING A COLORECTAL CARCINOMA. ADENOMATOUS POLYPS are thought to require >5 years
of growth before becoming clinically significant; COLONOSCOPY (!!!) NEED NOT BE CARRIED OUT MORE
FREQUENTLY THAN EVERY 3 YEARS FOR THE VAST MAJORITY OF PATIENTS.
21. Hereditary nonpolyposis colon cancer (HNPCC), or Lynch syndrome: 3-2-1 rule to perform screening.
(3 affected members, 2 generations, 1 under age 50).
22. Daily intake of aspirin has been demonstrated to decrease the risk of colorectal cancer in multiple cohort
and case-control studies.
23. UP TO 25%(!!!) OF PATIENTS WITH COLORECTAL CANCER HAVE A FAMILY HISTORY(!!!) OF THE DISEASE,
suggesting a hereditary predisposition.
24. Although esophageal masses and cancer can lead to several types of dysphagia, the most common
complaint is solid food dysphagia that worsens to the point that liquids are also hard to swallow.
Liquid phase dysphagia often implies a functional disorder of the esophagus rather than a mass-like
obstruction.
Early satiety is often due to gastric obstruction or extrinsic compression of the stomach (splenomegaly
is a common reason for this), or to a functional gastric disorder such as gastroparesis.
25. Esophageal squamous cell carcinoma risk factors are all of: Smoking, Alcohol and Achalasia.
26. rituximab “R-CHOP” activates hepatitis B in hep B carrier pts.
27. Hepatitis A: There is neither an associated chronic state nor a carrier state. The diagnosis is made by the
detection of elevated levels of IgM antibodies, which indicate active disease, and IgG antibodies, which
 Dr.AmeerAboMokh
indicate previous disease. Immunization, especially for travelers, is recommended to specifically prevent
hepatitis A
28. Patients who have Crohn disease with ileal disease or ileal resection are also likely to form calcium oxalate
kidney stones → Hematuria
29. Hepatic encephalopathy presents as a change of consciousness, behavior, and neuromuscular function
associated with liver disease. Hyperreflexia and asterixis (flapping tremor) are clinical manifestations of the
disease process that result from toxins in the systemic circulation as a result of impaired hepatic clearance.
Fever, gastrointestinal bleeding, and sedation are all potential precipitating factors in a patient with liver
disease.
30. ONCE THE PRESENCE OF ASCITES HAS BEEN CONFIRMED, THE ETIOLOGY OF THE ASCITES IS
BEST(!!!) DETERMINED BY PARACENTESIS(!!!).
31. Schistosomiasis [Schistosoma mansoni] liver disease: hepatosplenomegaly, hypersplenism, and
esophageal varices develop quite commonly, and is usually associated with eosinophilia.
It causes cirrhosis from vascular obstruction resulting from periportal fibrosis but relatively little
hepatocellular injury.
32. Spontaneous bacterial peritonitis → Diagnostic peritoneocentesis
33. Hepatic transplantation is contraindicated in a patient who is actively drinking.
34. Propanolol effect on varices → Decrease hematemesis
35. Pancreatitis - Which of the following laboratory values suggests a poor prognosis? Ranson criteria!
36. acute pancreatitis etiology: Gallstone, Acute and chronic alcoholism, Hypertriglyceridemia, Acute trauma or
following ERCP
37. Localized epigastric burning pain relieved by eating requires evaluation for peptic ulcer disease. Upper
gastrointestinal endoscopy provides the best sensitivity and specificity.
38. The TREATMENT of H. PYLORI–positive peptic duodenal ulcer disease is TRIPLE THERAPY aimed at
the ERADICATION OF H. PYLORI, along with acid suppression. This TRIPLE THERAPY includes a PPI and
two antibiotics, usually amoxicillin (1 g BID) with clarithromycin (500 mg twice daily). In patients with
PENICILLIN ALLERGIES, metronidazole (500 mg twice daily) is SUSBSTITUTED for amoxicillin.
39. Diagnosis is made by the detection of C. difficile toxin in the stool and sigmoidoscopy or colonoscopy
findings consisting of yellowish-white plaques of exudate with alternating areas of normal bowel mucosa. If
the exudate is removed, bleeding often occurs from the affected mucosa.
Metronidazole is an alternative agent for use if oral vancomycin and oral fidaxomicin are not available.
40. Trauma → A peripheral smear showing Howell-Jolly bodies implies loss of splenic function. This is
important as asplenic patients are at considerably higher risk of overwhelming sepsis and warrant vaccination
against encapsulated pathogens.
41. Overwhelming post-splenectomy infection (OPSI) treatment: vancomycin with ceftriaxone
42. spontaneous bacterial peritonitis (SBP). It is recommended to start antibiotic treatment for SBP if the
neutrophil count is greater than 250 cells/mm3: 3rd generation= cefotaxime or ceftriaxone.
43. subacute bacterial endocarditis (SBE): - Fewer than 5% of patients are afebrile - blood cultures will be
positive in the absence of previous antibiotic use.
44. Which of the following makes the diagnosis of spontaneous bacterial peritonitis (SBP) unlikely? PMN count
in the ascitic fluid < 250 cells/mm3.
45. MALIGNANCY-RELATED HYPERCALCEMIA: LEVELS OF PTH measured by the double-antibody technique are
UNDERDETECTABLE OR EXTREMELY LOW IN TUMOR HYPERCALCEMIA.
In a patient with minimal symptoms referred for hypercalcemia, LOW OR UNDETECTABLE PTH
LEVELS would focus attention on a possible occult MALIGNANCY!
46. Hyperparathyroidism: Medical treatment, used if surgery is contraindicated or if serum calcium ≤11.5 mg/dL
and patient is asymptomatic, includes bisphosphonates (pamidronate).
47. In a patient with T-score less than -2.5, and age post-menopause, having hypercalcemia, you must fist rule
out primary hyperparathyroidism before starting treatment. So further measure two-site immunoradiometric
assay (IRMA,or so-called intact PTH) and assess 24-hour urinary calcium output.
 Dr.AmeerAboMokh
48. Most common cause of hypercalcemia: Parathyroid adenoma.
49. Thyroid storm Rx: Treat with the 4 P’s: β-blockers (eg, Propranolol), Propylthiouracil, corticosteroids (eg,
Prednisolone”stop peri. Conversion”), Potassium iodide (Lugol iodine) ”aka Supersaturated potassium iodine”.
Other measures involve fluid replacement and control of fever with acetaminophen and cooling
blankets. Avoid aspirin because it may increase T3and T4by reducing protein binding.
50. Men, like women, are at risk of developing osteoporosis that may lead to increased risk of fractures.
Hypogonadism is an independent risk factor for osteoporosis.
51. In order to distinguish myxedema ”severe hypothyroidism” from other causes of coma: hypothermia,
periorbital edema, delayed deep tendon reflexes.
52. Cushing disease and hypothyroidism are more common in females.
53. Patients with hypothyroidism frequently have elevations of cholesterol and triglycerides.
54. If you take a thiazide diuretic, your potassium level can drop too low (hypokalemia).
55. Unexplained, persistent hyponatremia should be considered a marker for an underlying malignancy.
SIADH is a mechanism for developing hyponatremia, not a diagnosis. In all patients with SIADH, a specific
etiology for inappropriate vasopressin secretion should be sought.
The workup should include a careful search for malignancy and central nervous system pathology and an
endocrine evaluation to exclude hypothyroidism and hypocortisolism. In patients with asymptomatic
hyponatremia secondary to SIADH, the treatment of choice is fluid restriction.
Tumors with neuroendocrine features, such as SCLC and carcinoids, are the MOST COMMON
SOURCES OF ECTOPIC VASOPRESSIN PRODUCTION” SIADH”, but it also occurs in other forms of
LUNG CANCER and with CNS lesions, head and neck cancer, and genitourinary, gastrointestinal, and
ovarian cancers.
56. Tumors that elaborate PTHrP are most commonly squamous cell carcinomas, such as those of the lung,
esophagus, and head and neck.
57. Indications for surgical intervention for asymptomatic primary hyperparathyroidism include: age less than
50 years, markedly elevated urine calcium excretion, kidney stones on radiography, decreased creatinine
clearance, markedly elevated calcium or 1 episode of life-threatening hypercalcemia, and substantially
decreased bone mass.
58. Pheochromocytoma: Patients should be treated with α-blockade (typically phenoxybenzamine) for 10 to 14
days prior to surgery as well as β-blockade (i.e., propranolol) for 2 to 3 days prior to surgery. The α-blockade
is used to control BP, and the β-blockade is used to decrease tachycardia.
The incidence of pheochromocytoma is markedly increased in several genetic syndromes: multiple
endocrine neoplasia type 2a and type 2b; and the phakomatoses, including neurofibromatosis,
cerebelloretinal hemangioblastosis, tuberous sclerosis, and Sturge-Weber syndrome.
59. HEADACHES are COMMON FEATURES of small intrasellar tumors. Because of the confined nature of the
pituitary, small changes in intrasellar pressure stretch the dural plate; however, headache severity correlates
poorly with adenoma size or extension... Sellar masses are encountered commonly as incidental findings on
MRI, and most of them are PITUITARY ADENOMAS (INCIDENTALOMAS). In the ABSENCE OF HORMONE
HYPERSECRETION, these small intrasellar lesions CAN BE MONITORED(!!!) SAFELY WITH MRI, which is
PERFORMED ANNUALLY and then less often if there is no evidence of further growth.
60. The RLN has mixed motor, sensory, and autonomic functions and innervates the intrinsic laryngeal
muscles. DAMAGE TO A RLN(!!!) results in mixed pathology, the most important of which is PARALYSIS OF
THE VOCAL CORD on the affected side. SUCH DAMAGE MIGHT RESULT IN A MIDLINE POSITION OR
PARAMEDIAN POSITION (Sabiston,20e,883).
61. FNAB has become the single most important test in the evaluation of thyroid masses and can be
performed with or without ultrasound guidance – i.e start with it !!!
62. SUBACUTE THYROIDITIS... The peak incidence occurs at 30–50 years, and WOMEN are AFFECTED
three times ,MORE frequently than men... During the initial phase of follicular destruction, there is release of
Tg and thyroid hormones, leading to increased circulating T4 and T3 and SUPPRESSION OF TSH. During
this destructive phase, RADIOACTIVE IODINE UPTAKE IS LOW OR UNDETECTABLE.
 Dr.AmeerAboMokh
Examination reveals a small goiter that is exquisitely TENDER. PAIN is often referred to the jaw or
ear... thyroid function tests characteristically evolve through three distinct phases over about 6 months: (1)
thyrotoxic phase, (2) hypothyroid phase, and (3) recovery phase. In the thyrotoxic phase, T4 and T3 levels
are increased, reflecting their discharge from the damaged thyroid cells, and TSH IS SUPPRESSED... The
diagnosis is confirmed by a HIGH ESR and LOW UPTAKE OF RADIOIODINE (<5%).
63. Empty Sella: A partial or apparently totally empty sella is often an incidental MRI finding, and may be
associated with intracranial hypertension. These patients usually have normal pituitary function, implying that
the surrounding rim of pituitary tissue is fully functional.
64. enteral nutrition is less likely to cause infection than parenteral nutrition.
65. There are inactivated and live, attenuated forms of influenza vaccine. The intranasal spray, marketed as
“Flu-mist,” is a live, attenuated virus and is not recommended for the elderly or immunocompromised patients.
This vaccine has similar efficacy to the intramuscular vaccine, which is an inactivated, or “killed,” preparation
of the previous year’s strains of influenza A and B. The intramuscular vaccine is manufactured using egg
products; patients with true egg hypersensitivity should not receive it. It is safe for elderly and
immunocompromised patients. In the past, influenza vaccines have been associated with Guillain-Barré
syndrome. This association has not been demonstrated in the past decade, despite close surveillance.
Patients do not need to be warned of this side effect.
66. Niacin (nicotinic acid) is used to treat hyperlipidemia. It lowers LDL cholesterol and triglyceride levels and
increases HDL cholesterol levels.
67. Delirium old age (start attacking people verbally in hospital) → classic anti-psychotic drug (e.g. Halidol).
68. IV drug abuse having sepsis → suspect MRSA → Rx: Vancomycin
The only cephalosporins that cover MRSA: CEFTAROLINE, CEFTAZIDIME.
69. Migrane: Unilateral, throbbing headache.
70. The 23-valent pneumococcal vaccine is recommended for all patients over age 65 and for high risk
individuals of other ages (e.g., those with asplenia, diabetes, asthma, or COPD).
71. Haldol side effect: - Neuroleptic malignant syndrome: the symptoms include high fever (102°F to 104°F),
tachycardia, tachypnea, diaphoresis, autonomic dysfunction, mental status changes, hypertension and
hypotension, tremors, seizures, muscle rigidity, and leukocytosis.
Rx: IV dantrolene (also used for malignant hyperthermia).
72. For beta blocker toxicity → antidote is Glucagon, which does not require beta-adrenergic receptors to
exert its positive inotropic effect( but by increasing cAMP & cardiac contractility)..
& use Epinephrine, that works through alpha-adrenergic receptors.
The two drugs will reverse the bradycardia & the hypotensive effect of beta blocker, respectively.
73. This patient presents with rhabdomyolysis related to alcohol intoxication and prolonged immobilization.
Myoglobin released from the breakdown of skeletal muscle is an endogenous nephrotoxin that can induce
acute renal failure (ARF) by direct injury to tubular epithelial cells.
Both myoglobin and hemoglobin (released from the breakdown of red cells in hemolytic processes) will
react with the urine dipstick test for blood. The presence of pigments in the urine should be suspected
when the results of dipstick testing are strongly positive for blood in the absence of red cells on microscopic
examination.
 Dr.AmeerAboMokh
1. Treatment consists of stopping the transfusion as soon as possible, vigorous diuresis with furosemide or
mannitol, and possible dialysis if renal failure occurs. With multiple transfusions, the patient may develop
antibodies to WBC antigens, which cause febrile reactions that are manifested by chills and temperatures
higher than 38°C. Using washed RBCs helps prevent these reactions.
2. Haemochromatosis: hepatomegaly, weakness, hyperpigmentation, atypical arthritis, diabetes, impotence,
unexplained chronic abdominal pain, or cardiomyopathy.
3. Asplenic adult patients succumb to sepsis at 58 times the rate of the general population.
Adults are at lower risk than children because they are more likely to have antibody to these organisms.
STREPTOCOCCUS PNEUMONIAE is the MOST COMMON isolate, causing 50–70% of cases, but the
risk of infection with Haemophilus influenzae or Neisseria meningitidis is also high.
4. Neutropenic fever: Rx is to give broad spectrum antibiotics until neutrophil count is above 500!
Empiric antimicrobial therapy is a standard part of the management of neutropenic fever. Patients may
present after chemotherapy treatment for cancer.
5. Neutropenia is usually defined as an absolute neutrophil count (ANC) <1500 or 1000 cells/microL, severe
neutropenia as an ANC <500 cells/microL, and profound neutropenia as an ANC <100 cells/microL.
(WBC) x total neutrophils (segmented neutrophils% + segmented bands%) x 10 = ANC
6. In patients receiving ace inhibitor treatment there may be problems while using a white cell filter when
transfusing blood.
In the patients who have had an unusual reaction to blood transfusion blood should be irradiated.
7. TTP Rx: Plasma exchange for 6 session.
8. MGUS <10% mononucleal plasma cells, IgG spike <3.0g
Smoldring myloma>10% mononucleal plasma cells but asymptomatic ptx ( no back pain ) .
Multiple myloma >10% with symptoms (back pain and hypercalcemia).
9. Use of whole blood has now been almost completely supplanted by therapy employing specific blood
components.
Red cells are further processed by leukocyte reduction or washing to remove plasma proteins. Current
filter technology reduces white cell counts to less than 5 × 106 cells per unit, a concentration that is sufficient
to reduce febrile transfusion reactions and delay alloimmunization and platelet refractoriness → Leukocyte
transfusion reduces febrile transfusion reactions.
With single-donor platelet therapy, there is a reduction in the risk of blood-borne infection and antigen
exposure, because the product is from one donor rather than four to six; disadvantages are a longer
collection time, greater cost, and often limited supply.
Fresh frozen plasma (FFP) have to be frozen within 8 hours of collection→100% perfect
Cryoprecipitate consists of the cryoproteins recovered from FFP when it is rapidly frozen and then
allowed to thaw at 2° to 6° C. These cryoproteins include fibrinogen(F1), factor VIII, von Willebrand factor,
factor XIII, and fibronectin.
10. Hemolytic transfusion reactions are classified as immediate or delayed:
-1. Immediate hemolytic reactions are the result of a preexisting antibody in the recipient that was not
detected during pretransfusion testing.
-2. Delayed hemolytic reactions are the result of an anamnestic response to an antigen to which the recipient
is already sensitized.
- Until the antibody causing the immune hemolysis is identified, only type O red cells and AB plasma should
be used.
- Febrile non-hemolytic transfusion reaction (FNHTR) is a type of transfusion reaction that is associated with
fever but not directly with hemolysis. It is most commonly caused by antibodies directed against donor
leukocytes and HLA antigens. Alternatively, FNHTR can be mediated by pre-formed cytokines in the donor
plasma as a consequence of white blood cell breakdown. These inflammatory mediators accumulate during
the storage of the donated blood “Length of stay” → stop the infusion immediately, Leukoreduction may help
next time, drawing blood for culturing to rule out sepsis, Acetaminophen.
11. About 50% of patients with acute lukemia have a mild to moderate ELEVATION OF SERUM URIC
ACID at presentation. Only 10% have marked elevations, but renal precipitation of URIC ACID and the
 Dr.AmeerAboMokh
nephropathy that may result is a serious but uncommon complication. The initiation of chemotherapy may
aggravate HYPERURICEMIA, and patients are usually STARTED IMMEDIATELY ON ALLOPURINOL AND
HYDRATION AT DIAGNOSIS.
12. Apheresis platelets are collected from a single donor by using an apheresis machine with an
integrated leucoreduction system (removing ≥ 99% white cells). The machine draws blood from the donor,
isolates the platelets and some plasma by centrifugation and returns the remaining blood back to the donor.
One apheresis product is equivalent to 6 to 8 random donor platelet concentrates and therefore should
increase the platelet count by 30,000/uL to 40,000/uL in a 70 kg patient.
One random donor platelet concentrate(1 unti pooled platelets) is expected to increase the platelet
count by 5000 to 10, 000/uL in a 70 kg patient who is not refractory.
13. t(15;17) acute promyelocytic leukemia: All-trans-retinoic acid (ATRA, or triretinoin).
14. Increased homocystein can be seen in both (b12) and folate deficiency.
Increased methyl malonic acid is only seen in b12 deficiency.
15. The STIMULATED ERYTHROPOIESIS is reflected in the blood smear by the appearance of increased
numbers of POLYCHROMATOPHILIC MACROCYTES→marrow stress\defect
If the reticulocyte production index is <2 in the face of established anemia, A DEFECT IN ERYTHROID
MARROW PROLIFERATION(!!!) or maturation MUST BE PRESENT
16. Clues for extravascular hemolysis include an elevated lactate dehydrogenase, spherocytes on the
peripheral blood smear, and hepatosplenomegaly. Intravascular hemolysis (disseminated intravascular
coagulation, mechanical heart valve, thrombotic thrombocytopenic purpura) will show schistocytes on
peripheral smear.
17. In an anaemic patient cyanosis will appear later , and thus the patient may be hypoxic even in the
absence of central cyanosis.
18. Normocytic normochromic anemias can be: 1. Hemolytic 2. Hemorrhage 3. CKD 4. Cancer.

19. Microangiopathic hemolytic anemia(MAHA): Schistocytes.

20. Serum recombinant erythropoietin is used to treat refractory anemia in patients with chronic renal
disease. The major side effect is hypertension, which must be monitored at regular intervals. Other side
effects include polycythemia, with the possible development of thromboembolism, stroke, and MI. Iron
supplementation must be given to achieve an adequate erythropoietin response.
21. biopsy of temporal artrey can show changes after 14 days even with therapy , so no role to wait biopsy
without interfferance (High Dose Steroid).
22. CLL: the diagnosis is made by peripheral blood smear, as mature small lymphocytes constitute almost
all the white blood cells seen. The leukemic cells in acute leukemia are immature blast cells that are easily
distinguished from the normal-appearing mature lymphocytes of CLL.
23. A patient diagnosed to suffer from chronic lympocytic leucemia will require chemotherapy: To control
anemia or thrombocytopenia.
For stage 0(elevated WBC), stage1(Lymphoadenopathy), and stage II (hepatosplenomegaly)=there is
NO TREATMENT.
stage III (anemia) and stage IV (thrombocytopenia) are treated with
=FLUDARABINE,CYCLOPHOSPHAMIDE,AND RITUXIMAB.
24. leukocytosis with an absolute lymphocyte count of 7.5X109/L (normal 1-3X109/20-40%), Flow
cytometry reveals a monoclonal B cell population→ Chronic lymphocytic lekemia (CLL).
25. What is required to make the diagnosis of CLL? Identification of a monoclonal B cell population with
characteristic phenotype by flow cytometny.
26. richter transformation:- CLL transformation into an aggressive lymphoma, most commonly diffuse large
B-cell lymphoma (DLBCL)→ Excision biopsy to diagnose.
27. Pt and ptt pronogled, bleeding, sepsis gram negative, platelets 40k, fragmented RBC, reduced
fibrinogen level → DIC → Rx is to treat the underlying cause.
TTP: pt, ptt, and plasma fibrinogen levels will be normal.
 Dr.AmeerAboMokh
28. Methemoglobin is oxidized hemoglobin that is locked into the ferric state. Oxidized hemoglobin is brown
and will not carry oxygen. Methemoglobinemia occurs from an idiosyncratic reaction of hemoglobin to certain
drugs such as: Benzocaine and other anesthetics, Nitrites and nitroglycerin, Dapsone.
G6PD deficiency can induce methemoglobinemia by inhibiting NADPH-flavine reductase, which
prevents the reduction of methemoglobin.
29. This patient’s lupus and her rapid development of truly life-threatening hemolytic anemia are both very
suggestive of autoimmune hemolytic anemia. Diagnosis is made by a positive Coombs test documenting
antibodies to the red cell membrane, but smear will often show microspherocytes, indicative of the damage
incurred to the red cells in the spleen. Schistocytes are typical for microangiopathic hemolytic anemias such
as hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura. The lack of
thrombocytopenia makes these diagnoses considerably less plausible.
Small red cells without the central pallor are SPHEROCYTES(‫ ;)!!!نفسها‬they can be seen in hereditary
spherocytosis, HEMOLYTIC ANEMIAS of other causes, and clostridial sepsis
30. Schistocytes : HUS , TTP
Microspherocytes : SLE
Target cells : thalassemia , liver disease
31. Autoimmune hemolytic anemia may be idiopathic or secondary to disorders such as systemic lupus
erythematosus, chronic lymphocytic leukemia (CLL), HIV infection, or hepatitis C infection.
32. most appropriate anticoagulation for duration pregnancy: Prophylactic dose LMWH.
33. For a patient with family hx of hypercoagulable state that presented with a DVT: Start heparin and warfarin
immediately, discontinue heparin after 5 days’ overlap, and evaluate for the hypercoagulable state after warfarin
therapy is completed. But antiphospholipid syndrome and factor V leidin tests would be accurate at any time.
34. Heparin is the commonest cause of drug-induced thrombocytopenia.
The drop in platelet count is due to the production of an antibody against a complex of heparin and platelet
factor 4.
Low-molecular-weight heparin can also cause thrombocytopenia, although less frequently than
unfractionated heparin.
Bone marrow examination would not be necessary
35. Heparin-induced thrombocytopenia causes a white clot syndrome rather than bleeding (which is
uncommon in HIT). The patient develops platelet aggregation and excess clotting, which can be either
venous or arterial.
Patients may develop stroke, myocardial infarction, digital gangrene, and so on.
Although HIT usually resolves spontaneously after 7 to 10 days, the development of thrombosis due to HIT
requires therapy with alternative anticoagulants.
Rx immediately: Lepirudin, danaparoid. Long term: warfarin
36. Drug-induced thrombocytopenia due to heparin differs from that seen with other drugs in two major
ways. (1) The thrombocytopenia is NOT USUALLY SEVERE, with nadir counts RARELY <20,000/μL. (2)
Heparin-induced thrombocytopenia (HIT) is not associated with bleeding and, in fact, markedly increases the
risk of THROMBOSIS.
MOST PATIENTS DEVELOP HIT AFTER EXPOSURE TO HEPARIN FOR 5–14(!!!) DAYS
37. HIT purpura: It’s nonpalpable and caused by thrombosis.
38. The presentation of ITP as a chronic illness with a mild bleeding diathesis is not uncommon in adults.
In most adult patients (90%), ITP will follow a course characterized by chronic thrombocytopenia; in most
children, platelet counts will return to normal within 3 months.
ITP is infrequently associated with splenomegaly.!!!!!!
Although most cases of ITP are idiopathic, it is well known that ITP can be associated with a number of
underlying conditions, including HIV, viral illnesses (e.g., Epstein-Barr virus [EBV] infection), and
autoimmune disease, most notably SLE.
In adults, in contrast to children, ITP can present as a smoldering (relatively benign) disease. Therapy is
recommended for asymptomatic patients whose platelet counts are persistently lower than 20,000 to
 Dr.AmeerAboMokh
30,000/μl and for patients with significant bleeding complications→ most commonly fatal by intracranial
bleeding.
#case scenario: petechiae on her shins, bleeding after dental work, thrombocytopenia, heavier
menstrual period, 25yrs old.
39. (MGUS):
M PROTEIN IN SERUM <30 g/L(!!!), BONE MARROW CLONAL PLASMA CELLS <10%(!!!)
NO(!!!) evidence of other B cell proliferative disorders, NO(!!!) myeloma-related organ or tissue impairment
(NO(!!!) end organ damage, including bone lesions.
40. Paroxysmal nocturnal hemoglobinuria (PNH): The triad of portal vein thrombosis, hemolysis, and
pancytopenia.
PNH results from an acquired mutation in stem cells
41. Both vitamin B12 and folate deficiencies may cause megaloblastic anemia; however, only B12
deficiency causes neurologic symptoms.
42. Absorption of cobalamin in the small intestine is dependent on proteins prod uced in the mouth and
stomach.
Megaloblastic erythropoiesis is characterized by defective DNA synthesis a nd arrest at the G2 phase, with
impaired maturation and a buildup of cells that do not synthesize DNA and that contain anomalous DNA.
Patients with severe cobalamin deficiency mostly will have abnormal neuro exam.
43. TTP: daily plasmapheresis until platelet count normalizes is the current initial treatment of choice.
All patients with TTP should be admitted to an ICU for close monitoring of acute bleeds.
Patients tend to be females who are 10 to 45 years of age. Risk factors include pregnancy, autoimmune
disorders (eg, SLE), infection, allogenic bone marrow transplantation, malignancy, and medications (such as
quinine, clopidogrel, and ticlopidine).
Platelets should only be administered in patients with a life-threatening bleed.

44. Bleeding of the oral mucosa and urine, thrombocytopenia, fragmented red blood cells →TTP
45. A normal urine sediment is possible in TTP.

1. escitalopram (cipralex) is a SSRI for depression → a cause of SIADH → Rx: fluid restriction.
2. Cardiogenic shock: low venous o2 sat, SVR may be low/normal/elevated, high CVP.
3. Hypomagnesemia (due to sepsis for e.g.): if mild → oral Mg Severe→ parenteral MgCl2
4. Regarding hypovolemic shock: Oliguria is a crucial prognostic sign of impending vascular collapse.
5. Metabolic acidosis in patients with chronic renal failure can be associated with normal or wide anion gap and
requires the use of bicarbonate when its level is lower than 20-22 mmol/l.
6. Hypomagnesemia affects (makes worse) hypokalemia. So if patient doesn’t respond to oral K+ check his
Mg+ levels.
7. For septic shock in an I.V user: Vancomycin.
8. For severe hyponatremia: give hypertonic saline (ex: 3%).
9. The relation between hypertonic saline volume and serum sodium increase rate is complex and
individualized. Therefore you need to monitor serum sodium levels closely.

1. KAPOSI'S SARCOMA is a soft tissue sarcoma of vascular origin that is INDUCED BY HUMAN
HERPESVIRUS 8.
2. The most common scenario for the development of extended-spectrum β-lactamase (ESBL)-gram negatives
in the hospital is prevalent use of third-generation cephalosporins.
 Dr.AmeerAboMokh
3. INJECTION DRUG USE–ASSOCIATED ENDOCARDITIS, especially that involving the tricuspid valve, is
commonly caused by S. AUREUS(!!!), which in many cases is RESISTANT TO METHICILLIN(!!!) (2012).
4. TTP suspected, THE PERIPHERAL SMEAR(!!!) SHOULD BE EXAMINED(!!!) FOR EVIDENCE OF
SCHISTOCYTES.
5. In the majority of sinusitis cases the patient will recover without antibiotic therapy.
6. Disinfectant only removes transient hand flora (not permanent flora).
7. Contact with blood fluids and an obvious contamination of the hands require washing with an antiseptic
solution.
8. Necrotizing fasciitis: Severe pain, leukocytosis and fever. But there is no local swelling or erythema of the
skin (for those presenting with the type of presentation called “with no portal of entry” and they are in early
stages of the disease..
Early diagnosis may be difficult when PAIN or unexplained FEVER is the only presenting manifestation.
Swelling then develops and is followed by brawny edema and tenderness. With progression, dark-red induration of the epidermis appears, along
with bullae filled with blue or purple fluid.
Rapid spread occurs along fascial planes,through venous channels and lymphatics. Patients in the later stagesare toxic and frequently manifest
shock and multiorgan failure. In 20–40% of cases, myositis occurs concomitantly, and, as in gas gangrene, serum creatine phosphokinase levels
may be markedly elevated. Necrotizing fasciitis due to mixed aerobic-anaerobic bacteria may be associated with gas in deep tissue, but gas usually
is not present when the cause is S. pyogenes or MRSA. Prompt surgical exploration down to the deep fascia and muscle is essential. Necrotic
tissue must be surgically removed, and Gram’s staining and culture of excised tissue are useful in establishing whether group A streptococci, mixed
aerobic-anaerobic bacteria, MRSA, or Clostridium species are present
9. Healthy patient with sudden urinary irritation with urgency and increased frequency: dx and rx as usual UTI.
Uncomplicated UTI refers to acute cystitis or pyelonephritis in NONPREGNANT outpatient women
WITHOUT anatomic abnormalities or instrumentation of the urinary tract... Uncomplicated cystitis in women
can be treated on the basis of history alone.
10. High fever, headaches, and a rash on his trunk and limbs. He has recently been in contact with dogs:
Rickettsia conorii. Aka: Mediterranean spotted fever, Israeli tick typhus. Comes from the brown dog tick,
Rhipicephalus sanguineus.
If recognized in a timely fashion, rickettsial disease is very responsive to treatment. DOXYCYCLINE
“tetracycline-based treatment” is the treatment of choice for both adults and children.
11. Treatment of Mucocutaneous Candidal Infections” skin candidiasis”: Cutaneous Topical azole.
12. Prerenal Azotemia: Urine sodium “Una” <20 meq/L.
13. Brucellosis: classic triad of fever, arthralgia/arthritis, and hepatosplenomegaly can be demonstrated in most
patients. A common constellation of symptoms in children is refusal to eat, lassitude ‫سل‬ َ ‫ك‬
َ , refusal to bear
weight, and failure to thrive.
14. The diagnosis of pseudomembranous colitis is made by demonstration at sigmoidoscopy of yellowish
plaques (pseudomembranes) that cover the colonic mucosa or by detection of C difficile toxin in the
stool.
15. Chronic diarrhea can be categorized as watery (secretory vs. osmotic vs. functional), fatty, or inflammatory. Watery diarrhea may be
subdivided into osmotic (water retention due to poorly absorbed substances), secretory (reduced water absorption), and functional
(hypermotility) types. Osmotic laxatives, such as sorbitol, induce osmotic diarrhea.
16. DIARRHEA, the leading cause of illness in TRAVELERS, is usually a SHORT-LIVED(!!!), SELF-
LIMITED(!!!) condition... The MOST(!) frequently identified pathogens causing TRAVELERS' DIARRHEA
are enterotoxigenic and enteroaggregative ESCHERICHIA COLI(!)
If neither high fever nor blood in the stool accompanies the diarrhea, LOPERAMIDE(!) should(!) be taken(!)
in combination with the antibiotic...The standard regimen is a 3-day course of a quinolone(!) taken twice
daily
17. Traveler’s diarrhea Rx (Harrison 20th):
-Watery diarrhea no distressing symptoms: oral fluids
-Watery diarrhea with distressing enteric symptoms: Bismuth subsalicylate or loperamide
-Dysentery (passage of bloody stools) or fever (>37.8°C): fluoroquinolone(such as ciprofloxacin) or
Azithromycin
18. Several species of bacteria, such as S. aureus, C. perfringens, and Bacillus cereus, can produce toxins
that produce so-called food poisoning (i.e., vomiting and diarrhea) within 4 hours of ingestion. In such
cases, the bacteria do not need to establish an intraluminal infection; ingestion of the toxin alone can
 Dr.AmeerAboMokh
produce the disease. Symptoms subside after the toxin is cleared, usually by the next day; evidence of
toxicity (e.g., fever) is minimal.
19. More than 90% of cases of ACUTE DIARRHEA are CAUSED BY INFECTIOUS AGENTS; these cases are
often accompanied by vomiting, fever, and abdominal pain. The remaining 10% or so are caused by
medications, toxic ingestions, ischemia, food indiscretions, and other conditions (Harrison,19e,265).
20. Erysipelas: needs hospital admission and antibiotics (oral or IV if severe.
The classic presentation is a well-demarcated, fiery‫ملتهب‬ ُ red, painful lesion, most commonly on the lower
extremities and the face. High fever and chills may be present.
21. Erysipelas is caused by Streptococcus group A(GROUP A β-hemolytic STREPTOCOCCI).
22. The initial blood test of FUO workup panel include tuberculin skin test and protein electrophoresis.
One of the first steps as well is to rule out FACTITIOUS(!!!) or fraudulent FEVER.
23. Giardia lamblia is one of the most common parasitic diseases, with worldwide distribution.
Infection follows ingestion of environmental cysts, which excyst in the small intestine releasing flagellated
trophozoites. As few as 10 cysts can cause human disease.
24. herpes zoster is pain associated with acute neuritis and POSTHERPETIC NEURALGIA treatment:
ANTICONVULSANTS (GABAPENTIN [GABANTIN(!!!)] or pregabalin) or antidepressants (nortriptyline,
desipramine, duloxetine, or venlafaxine) can be used as FIRST-LINE DRUGS for patients with
NEUROPATHIC PAIN.
25. Herpes simplex virus (HSV) infection is best confirmed by isolation of the virus in tissue culture “ Viral
culture” gold standard for definitive diagnosis; results available in 48 hours
26. EBV infectious mononucleosis is associated with ATYPICAL LYMPHOCYTOSIS “Over 10% atypical
lymphocytes are demonstrated in peripheral blood smear”, not eosinophils!
27. Listeria gastroenteritis: Antibiotic treatment is not necessary for uncomplicated cases (2010‫)ש‬.
28. All patients who have had recent head trauma, are immunocompromised, have known malignant lesions or
central nervous system (CNS) neoplasms, or have focal neurologic findings, papilledema, or a depressed
level of consciousness should undergo computed tomography (CT) or magnetic resonance imaging (MRI)
of the brain prior to lumbar puncture (LP). In these cases EMPIRICAL ANTIBIOTIC THERAPY(!!!) SHOULD
NOT(!!!) BE DELAYED(!!!) PENDING TEST RESULTS BUT SHOULD BE ADMINISTERED PRIOR(!!!) TO
NEUROIMAGING(!!!) AND LP (Harrison,19e,883).
29. COMPLEMENT DEFICIENCIES, especially of the components involved in the assembly of the membrane
attack complex (C5 THROUGH C9) “deficiency of late components of the complement system”, predispose
to NEISSERIAL(!!!) BACTEREMIA, and persons with more than one episode of DGI [DISSEMINATED
GONOCOCCAL INFECTION](!!!) should be screened with an assay for total hemolytic complement activity
(Harrison,19e,1006).
30. #Typically, in acute bacterial meningitis (e.g., meningitis caused by S. pneumoniae), the CSF glucose level
is decreased, the total protein level is elevated, and the WBC count is elevated and has a neutrophilic
predominance.
# (normal glucose level, increased total protein level, increased number of lymphocytes) is typical of viral
meningitis.
# (decreased glucose level, elevated protein level, increased number of lymphocytes) can be seen in
meningitis caused by syphilis, Lyme disease, or Mycobacterium tuberculosis.
# (normal glucose level, elevated protein level, increased number of RBCs) may be seen after trauma or
subarachnoid hemorrhage.
31. Meningitis: Initiate antibiotics treatment with Rocephin, fundus examination and lumbar puncture.
32. Typical CSF Profiles for Meningitis and Encephalitis: BACTERIAL MENINGITIS:
GLUCOSE (mg/dL)<40, Protein (mg/dL)>100, Gram’s stain Positive (in >60% of cases).
33. High fever after > 48 hours hospital stay: hospital acquired infection “nosocomial”.
34. The demonstration of organisms in BRONCHOALVEOLAR LAVAGE(!!!) FLUID is almost 100% sensitive
and specific for PCP in patients with either HIV infection or IMMUNOSUPPRESSION “e.g. a patient on long
term corticosteroid” (!!!) of other etiologies (Harrison,19e,1360).
 Dr.AmeerAboMokh
35. Schistosoma mansoni infection causes cirrhosis from vascular obstruction resulting from periportal fibrosis
but relatively little hepatocellular injury. Hepatosplenomegaly, hypersplenism, and esophageal varices
develop quite commonly, and eosinophilia. (2010‫)ש‬.
36. The presence of WBCs and blood in the stool is consistent with an inflammatory process: Shigellosis.
37. Trichomoniasis can only be spread sexually. Trichomoniasis resistant to metronidazole has been reported.
Partner has to be treated as well.
38. Back from Thailand (southeast Asia) with fever, rash (rose spots), abdominal pain, headache: enteric
typhoid fever (Salmonella).
# Dengue fever(!)---Headache, musculoskeletal pain (“breakbone fever”); leukopenia; occasionally biphasic
(“saddleback”) fever.
# Leptospirosis(!)---Myalgias; aseptic meningitis(!); fulminant form: icterohemorrhagic fever (Weil’s
disease)
39. Back from India with abdominal pain and general maculopapular rash on the chest & abdomen:
Salmonella typhi(same as previous question).
ROSE SPOTS make up a faint, salmon-colored, blanching, MACULOPAPULAR RASH located primarily on
the TRUNK AND CHEST.
40. For ENTEROCOCCUS FAECALIS UTI: Ampicillin, AMOXICILLIN.
41. Pseudomembranous colitis: it is important to initiate treatment with ORAL VANCOMYCIN for patients who
appear seriously ill, particularly if they have A HIGH WBC COUNT(>15,000/μL) OR A CREATININE LEVEL
THAT IS ≥1.5 TIMES HIGHER than the premorbid value (Harrison,19e,860).
42. VZV rash appeared on the face of a man due to being immunocopromised as he was treated for 3 weeks
with prednisolone. Rx: Initiating drug therapy for varicella zoster virus (VZV).
VARICELLA-ZOSTER VIRUS(!!!) Virus... Localized zoster can SPREAD RAPIDLY in an
IMMUNOSUPPRESSED(!!!) patient (Harrison,19e,921)
43. Man screen urine culture for insurance policy grows more then 10⁵ colony forming ut/mL E coli → No Rx!
This is asymptomatic bacteriuria: is defined as a positive urine cultures and negative signs and
symptoms, mainly no treatment is required , except for pregnancy.

44. Urinary catheter that grew pseudomonas aeruginosa→ Rx: IV tazocin (piperacillin tazobactam).
45. Urinary Tract Obstruction complicated by infection requires immediate relief of obstruction to prevent
development of generalized sepsis and progressive renal damage. Sepsis necessitates prompt urologic
intervention. DRAINAGE may be achieved by NEPHROSTOMY, ureterostomy, or ureteral, urethral, or
suprapubic CATHETERIZATION.
46. Young woman with UTI, Rx: Trimethoprim/sulfamethoxazole (TMP/SMX) aka co-trimoxazole.
+ If Gram’s stain does not reveal gonococci, urethritis is treated with a regimen effective for NGU “non-
gonococcal urethritis”, such as azithromycin or doxycycline.
47. Penicillin (or other drugs) may cause acute interstitial renal disease. Eosinophils attack the cells lining
the tubules as a reaction to drugs (70%) → urinalysis with blood cells and eosinophils (Eosinophils=
Interstitial).
48. The FINDING OF EOSINOPHILS IN THE URINE is suggestive of allergic interstitial nephritis or
ATHEROEMBOLIC RENAL DISEASE(!!!) and is optimally observed with Hansel staining. The absence of
EOSINOPHILURIA, however, does not exclude these etiologies (Harrison,19e,292).
ATHEROEMBOLIC DISEASE(!!!)---Hypocomplementemia, EOSINOPHILURIA(variable), variable amounts
of proteinuria (Harrison,19e,1806)
49. Target hemoglobin value in a patient with chronic renal insufficiency treated with recombinant
erythropoietin and iron: 10-11,5 gr/dl at the most.
50. AKI secondary to ACUTE INTERSTITIAL NEPHRITIS can occur as a consequence of exposure to MANY
ANTIBIOTICS, including penicillins, cephalosporins, quinolones, sulfonamides, and rifampin... EXTREMELY
HEAVY PROTEINURIA (“NEPHROTIC RANGE,” >3.5 g/d) can occasionally be seen in glomerulonephritis,
vasculitis, or INTERSTITIAL NEPHRITIS (PARTICULARLY FROM NSAIDs) (Harrison,19e,1804).
To confirm the diagnosis of renal failure due to antibiotic treatment: biopsy!
 Dr.AmeerAboMokh
51. To rule out renal injury from contrast media: Renal function 3-5 days post exposure.
52. PRERENAL AZOTEMIA: BUN/creatinine ratio above 20, urine specific gravity>1.018, FeNa <1%,
hyaline casts in urine sediment, Urine osmolality>500 mOsm/kg.
53. Proteinuria is often the first sign of amyloidosis.
54. acute bacterial epididymitis: Concurrent urethral discharge (2010‫)ש‬
55. Glucocorticoids “prednisone” represent the key initial medical therapy for patients diagnosed with FSGS.
However, it doesn't respond well to steroids. (Medexams).
56. Fournier gangrene is a form of necrotizing fasciitis occurring in the male genitals. It is a life-threatening
infection with mortality ranging from 13% to 22%. Predisposing factors include diabetes mellitus, local
trauma, paraphimosis, periurethral extravasation of urine, perirectal or perianal infections, and surgery in
the area. surgery should be performed urgently to define the nature and extent of the infectious process,
with resection of the involved tissue. Antibiotics are an important adjunct to surgery. “Immediate surgical
exploration and resection without regard to reconstruction”. (2013‫)ש‬.
57. Goodpasture's syndrome is associated with: Pulmonary hemorrhage and glomerulonephritis(2010‫)ש‬.
58. Patient on dialysis catheter had febrile illness:PROMPT REMOVAL AND CULTURE OF THE CATHETER+
AB Rx.
59. NEPHRITIS is usually the most serious manifestation of SLE... Because NEPHRITIS is asymptomatic in
most LUPUS patients, urinalysis should be ordered in any person suspected of having SLE... Patients with
dangerous PROLIFERATIVE forms of GLOMERULAR DAMAGE (ISN III and IV) usually have
MICROSCOPIC HEMATURIA AND PROTEINURIA (>500 mg per 24 h). (Blood&Protein!!!).
60. Type 1 membranoproliferative glomerulonephritis is caused by immune complex deposition in the
subendothelium, most commonly immune deposits from hepatitis C virus (HCV) antigens or cryoglobulins.
It may present as nephrotic or nephritic or both. Hypertension is a very common as well.
The question may give you HTN, raised ALT & AST, with protein & blood in urinalysis→ Test for hepC AB.
61. urinary sediment is the most typical of glomerulonephritis: Red blood cell casts.
Hematuria with dysmorphic RBCs, RBC CASTS, and protein excretion >500 mg/d is virtually DIAGNOSTIC
OF GLOMERULONEPHRITIS (Harrison,19e,294).
62. A patient with Hx of nephrotic $ who presents with acute onset of flank pain and hematuria → suspect
thrombosis of the renal vein → Renal ultrasound and duplex scan (Doppler ultrasonography) !!!
63. Nonseminimatous testicular cancer: α-fetoprotein (AFP).
64. Constipation could accompany patient having overflow ”not overactive!!” urinary incontinence, because
both indicate neural problems. Moreover, when this type of incontinence may find so many urine when
catheterizing the patient. Also, it is not the same as urge incontinence. Patient has no urge. But high urinary
frequency. (2013‫)ש‬
65. 50 y man with diffuse bone pain for 6 weeks now. dialysis for 15 year: Renal osteodystrophy.
66. Possible long-term side effects of chemotherapy: Leukemia.
67. The MAINSTAYS OF DRUG THERAPY FOR OAB [OVERACTIVE BLADDER] include OXYBUTYNIN
CHLORIDE(!!!) and tolterodine. OXYBUTYNIN CHLORIDE(!!!) has been shown in randomized placebo-controlled trials to be
EFFECTIVE in increasing bladder capacity, decreasing the frequency of detrusor contractions, and IMPROVING SYMPTOMS OF URINARY
URGENCY in approximately 70% of patients. It is effective for both idiopathic and neuropathic etiologies of detrusor instability (Lange,11e,1763).

1. Doxorubicin-based cardiac toxicity is does-dependent. (2010‫)ש‬

Anthracycline-induced (drugs like Doxorubicin) congestive heart failure is irreversible.
Mediastinal irradiation often results in acute peri-carditis 9 months after the treatment.
Chronic constrictive pericarditis often manifests symptomatically up to 10 years after treatment.
Radiation may result in acute and chronic pericarditis, myocardial fibrosis, and accelerated atherosclerosis.
2. FOBT has a high false-positive rate; 2–10% of those with a positive result have colon cancer, and ~25%
have adenomas.
Sigmoidoscopy carries a perforation risk of 1/1000, while the risk with colonoscopy is three times greater.
 Dr.AmeerAboMokh
One-time colonoscopy detects more advanced lesions than one-time fecal occult blood testing with
sigmoidoscopy. (2010‫)ש‬
3. Sjögren’s syndrome :dry mouth, dry eyes (keratoconjunctivitis sicca), dryness of other mucous membranes,
and joint pain. Link with the HLA-DR3. Signs include parotid gland enlargement and loss of taste and smell. Other complications
include alopecia, increased risk of pulmonary infections, pancreatitis, pericarditis, sensory neuropathies, interstitial nephritis, and RTA. Laboratory
findings include positive rheumatoid factor (seen in 70% of affected patients), elevated ESR (70% of affected patients), anemia (33% of affected
patients), and leukopenia and eosinophilia (25% of affected patients). Diagnosis is accomplished with the Schirmer’s test, which measures the
quantity of tears secreted in 5 minutes in response to irritation from a filter paper strip placed under each lower eyelid. There is increased risk for
(2010‫)ש‬
lymphoma and Waldenstrom’s macroglobulinemia.
4. Podagra: gout of the foot, especially the big toe. Maybe caused by thiazide drugs (S.E.).
Treatment of gout involves the use of ice, rest, NSAIDs (e.g., indomethacin, naproxen, ibuprofen),
colchicine (which may provide dramatic relief in the acute phase), and allopurinol (xanthine oxidase
inhibitor) for patients who have chronically elevated uric acid levels after the acute attack has resolved (low-
dose colchicine can also be used). In addition, uricosuric agents, including probenecid and sulfinpyrazone,
may be helpful but should be used with caution in patients with renal problems. Prednisone may also be
helpful in patients who cannot tolerate other medications.
Absolute confirmation involves joint aspiration with the detection of needle-shaped urate crystals that are
negatively birefringent under a polarizing microscope.
5. Complaints of diffuse proximal muscle pain (Hip and shoulder), low-grade fevers, and generalized fatigue.
Laboratory findings include an elevated ESR and mild anemia (of chronic disease)→ Polymyalgia
rheumatica.
More common in women, older than 50 years, associated with giant cell arteritis, morning stiffness (mimics
RA). Rx is steroids until it resolves by itself in about 1-2 years. (Step-up p.261).
6. Pseudogout: Calcium pyrophosphate crystal deposition in the large joints” positive birefringent, rod shaped
and rhomboidal crystals” in the large joints (principally the knees). [in contrast to a negative birefringence
seen with urate crystals in gout]
7. Lead time bias refers to the phenomenon where early diagnosis of a disease(b\c of screening) falsely
makes it look like people are surviving longer.
A test does not influence the natural history of the disease; patients are merely diagnosed at an earlier date.
(2010‫)ש‬
8. Father, paternal aunt, and paternal cousin with colon cancer with ages of diagnosis of 54, 68, and 37 years,
respectively →Amsterdam II criteria → hereditary nonpolyposis colon cancer (2010‫)ש‬.
9. CRC: One-time colonoscopy detects more advanced lesions than one-time fecal occult blood testing with
sigmoidoscopy. (2010‫)ש‬
10. construction worker presents with pain over the lateral elbow. He reports that he has been using a hammer
more often → Lateral epicondylitis (2010‫)ש‬.
11. Reduce the risk of colon cancer: Aspirin. (2010‫)ש‬.
12. Diagnose the cause of vertebral osteomyelitis with blood cultures. Because the infection is often
hematogenous, blood cultures should be obtained initially in all patients. Cultures are positive in up to 75%
of patients, and identification of Staphylococcus aureus, which is the most frequent cause of vertebral
osteomyelitis, may obviate the need for a bone biopsy. (2010‫)ש‬
13. CRC screening- Adults ≥50 years: Screen every 10 years.
14. Osteoarthritis: in addition to acetaminophen ask the patient to do physiotherapy.
15. For ankylosing spondylitis (which is an axial disease), we start with anti-TNF (etanercept, infliximab) after
NSAIDs and physiotherapy. Where in RA we start with DMARDs (methotrexate).
16. Presents with a painful, swollen right knee and a low-grade temperature. The most useful test for this
individual is: Joint fluid analysis {to determine whether this patient has a septic joint, detect uric acid
crystals (gout) or calcium pyrophosphate crystals (pseudogout)}.
17. Osteoporosis management: Ca 1000mg daily, doing weight-bearing exercise, smoking cessation, ERT,
bisphosphonates must be taken on an empty stomach with at least an 8-oz glass of water while the patient
remains upright without eating for at least 30 minutes
 Dr.AmeerAboMokh
18. #Low-risk adenomas – If only one or two small (≤1 cm) tubular adenomas -> first surveillance colonoscopy
should be performed in 5 to 10 years.
#Advanced adenomas - ≥1 cm, villous histology or high-grade dysplasia or more than 3 adenomas -> first
surveillance colonoscopy in 3 years. (2011‫ ש‬Harrison 18e)
19. RA: we check the RF(sensitive) first, then anti-CCP which is more specific.
20. RA + splenomegaly + neutropenia (low leukocytes) → Felty syndrome.
21. Pale conjunctiva (anemia) + synovitis + malar rash + arthritis → think: SLE .
22. To confirm the diagnosis of acute gout: Arthrocentesis.
23. Scleroderma renal crisis occurs in 10–15% of cases of diffuse SSc (include: Malignant hypertension):
Treatment: ACE inhibitors
24. Glucocorticoids “Dexamethasone” should be administered to patients with newly diagnosed
intraparenchymal metastases.
25. Step-up to medicine: Hypercalcemia Rx: first step in management is IV fliuds "NS 0.9%"
26. Diagnosis of Sjogren syndrome is by Schrimmer test and misurament of antibodies “anti-Ro (SSA)”.
27. Temporal arteritis: ESR is high in almost all cases.
28. Hx of long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal
extremities+10-lb weightloss+ bilateral clubbing → suggests hypertrophic osteoarthropathy → order CXR.
Clinical features: clubbing of digits, periosteal new bone formation, and arthritis. Hypertrophic
osteoarthropathy is associated with intrathoracic malignancy, suppurative lung disease, and congenital
heart problems. While x-rays may suggest osteomyelitis, the process is usually bilateral and easily distinguishable from osteomyelitis.
29. Preexisting arthritis (osteoarthritis or rheumatoid arthritis), immunocompromised states (alcoholism,
diabetes, or cancer), and risky sexual behavior are risk factors for the development of septic arthritis.
Patients present with a warm, tender, erythematous, swollen joint and pain with passive range of motion.
Fever and chills are common. Arthrocentesis is diagnostic with joint fluid demonstrating a WBC count
>50,000/μL with > 75% granulocytes. Staphylococcus aureus remains the predominant pathogen.
Patients with septic arthritis should receive a first dose of antibiotics in the ED prior to admission.
30. ACUTE RENAL FAILURE (general weakness + decrease urine output+high creatinine) occurs in patients
with TUMOR LYSIS SYNDROME(!!!) and prevents spontaneous correction of the electrolyte abnormalities;
emergency dialysis may be the only way to comprehensively correct the abnormalities (Sabiston,20e,90).
31. METHOTREXATE(!!!) IS THE DMARD OF CHOICE(!!!) FOR THE TREATMENT OF RA AND IS THE
ANCHOR DRUG(!!!) FOR MOST COMBINATION THERAPIES.
32. colorectal cancer: There is family history in about 25% of patient & there is NO value for Fiber rich diet in
its prevention.
33. Most common tumor causing fever of unknown origin? Lymphoma.
34. Self-examination at monthly intervals may enhance the likelihood of detecting change. Although the
35. #U.S. Preventive Services Task Force states that evidence is insufficient to recommend for or against skin
cancer screening, a full-body skin exam seems to be a simple, practical way to approach reducing the
mortality rate for skin cancer (Harrison 20 524)
Chest x-ray for early detection of lung cancer were not shown to be effective as far(to the extent that)
decreasing mortality.
#In contrast to CXR ,low-dose, noncontrast, thin-slice spiral chest computed tomography (LDCT) has
emerged as an effective tool to screen for lung cancer. (Harrison 20 540).
#Early detection of prostate cancer is not effective in prolonging life expectancy in all age groups.
36. CBC demostrating leukopnia less than 400 wbc: SLE diagnosis criteria.
37. Typical side effect of corticosteroids: Hypokalemia on blood tests.
38. High percentage of antiphospholipid syndrome will also have SLE.
39. Patients with underlying joint disease (e.g., rheumatoid arthritis) are at increased risk of septic (bacterial)
arthritis. In the majority of cases, bacteria are presumed to reach the joint space via the bloodstream rather
than by direct inoculation. The knee and hip are the most commonly involved joints. Only 10% to 15% of
cases of septic arthritis are polyarticular.
40. Esophageal malignancy: difficulty swallowing solids that progresses to liquids and lymphadenopathy.
 Dr.AmeerAboMokh
41. SLE: facial rash may not involve the bridge of the nose! ANA found in 90% of patients!
42. SLE treatment: Hydroxychloroquine(plaquenil) &/or NSAID’s.
43. A - MCPs, PIPs, of the wrist = rheumatoid arthritis
B - DIPs of the wrist = OsteoArthritis
C - sacroiliac joint and the right knee (DIFFUSION) = Ankylosis Spondilytis
D - PIP of the right finger and a ''sausage" toe = Psoriatic arthritis
44. CT abdomen revealed 12cm mass and around it there are several smaller masses: The growth rate of the
tumor is lower compared to the growth rate several weeks ago.
45. Sjogren syndrome: Anti SSA/Ro
46. Weak right radial pulse and murmur over right subclavian artery → Takayasu arteritis
It is MOST PREVALENT IN adolescent girls and YOUNG WOMEN. PULSES ARE COMMONLY ABSENT
in the involved vessels, particularly the SUBCLAVIAN ARTERY... The diagnosis of TAKAYASU
ARTERITIS(!!!) should be suspected strongly in a YOUNG WOMAN who develops a DECREASE OR
ABSENCE OF PERIPHERAL PULSES, discrepancies in blood pressure, and arterial bruits
(Harrison,19e,2189).
47. history of renal failure + acute gout attack → Rx: Local steroid injection to aching joint.
Gout: The METATARSOPHALANGEAL JOINT OF THE FIRST TOE often is involved... The MAINSTAY OF TREATMENT during an acute attack is
the administration of anti inflammatory drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs(!)), COLCHICINE(!), or GLUCOCORTICOIDS.
NSAIDs are used most often in individuals without(!) complicating comorbid conditions. Both COLCHICINE(!) and NSAIDs(!) may be POORLY
TOLERATED(!) and DANGEROUS(!) in the ELDERLY and in the presence of RENAL INSUFFICIENCY(!) and gastrointestinal disorders... For a
single joint or a few involved joints, INTRAARTICULAR(!!!) TRIAMCINOLONE ACETONIDE(!!!), 20–40 mg, or METHYLPREDNISOLONE(!!!), 25–50
mg, have been EFFECTIVE(!!!) and well TOLERATED(!!!) (Harrison,19e,2233).
48. most appropriate first line of treatment for symptomatic RA patient: Methotrexate.
49. DIFFUSE LARGE B-CELL LYMPHOMA is the MOST COMMON TYPE OF NON-HODGKIN'S
LYMPHOMA, representing approximately one-third of all cases.(Harrison 19e).
50. Malignant LYMPHOMA is a well-known manifestation of SJOGREN'S SYNDROME that usually presents
later in the illness (Harrison,19e,2166).
51. Polymyalgia rheumatica: age>50 years, ESR>50, anemia, fever.
It is not found in small joints usually (non-articular condition).
52. Brain meningioma: The most common brain tumor.
They are now the most common primary brain tumor, accounting for approximately 35% of the total. Their
incidence increases with age. They tend to be more common in women and in patients with
neurofibromatosis type 2. They also occur more commonly in patients with a past history of cranial
irradiation (Harrison, 19e, 602).
53. #Bacterial cystitis(!) is usually(!) caused by Escherichia coli(!) (Harrison,19e,60e-1).
#Multiple myeloma associated with Streptococcus pneumoniae, HAEMOPHILUS INFLUENZAE, Neisseria
meningitidis (Harrison,19e,486).
Bone pain is the most common symptom in myeloma... The next most common clinical problem in patients with myeloma is susceptibility to bacterial
infections... and >75% of patients will have a serious infection at some time in their course (Harrison,19e,713).
54. OSTEOARTHRITIS (OA) is the most common type of arthritis... OA affects certain joints, yet spares others.
COMMONLY AFFECTED JOINTS INCLUDE the cervical and lumbosacral spine, hip, knee, and FIRST
METATARSAL PHALANGEAL JOINT (MTP)... Age is the most potent risk factor for OA. Radiographic
evidence of OA is RARE in individuals UNDER AGE 40 (Harrison,19e,2226).
55. In addition to the back pain ankylosing spondylitis causes anterior uveitis.
56. CISPLATIN requires administration with adequate hydration, including forced diuresis with mannitol to
prevent kidney damage; even with the use of hydration, gradual decrease in kidney function is common,
along with noteworthy anemia. Hypomagnesemia frequently attends CISPLASTIN use and can lead to
hypocalcemia and tetany. Other COMMON TOXICITIES include neurotoxocity with STOCKING-AND-
GLOVE SENSORIMOTOR NEUROPATHY. Hearing loss occurs in 50% of patients treated with
conventional doses (Harrison,19e,103e-12).
57. acute episode of Gout disease+ Hx of renal failure → Rx: Prednisolone.
58. The FIRST EPISODE OF ACUTE GOUTY ARTHRITIS frequently begins at night with dramatic joint pain
and swelling. Joints rapidly become warm, red, and tender, with a CLINICAL APPEARANCE that often
MIMICS that of CELLULITIS. (Harrison 19e).
 Dr.AmeerAboMokh
59. fever and severe left knee pain. Synovial fluid revealed Neisseria Gonorrhoeae. → Immediate antibiotics
therapy with ceftriaxone.
GONOCOCCAL ARTHRITIS has accounted for up to 70% of episodes of infectious arthritis IN PERSONS <40 YEARS OD AGE... WOMEN are at
greatest risk during menses and during pregnancy and overall ARE TWO TO THREE TIMES MORE LIKELY than men TO DEVELOP
DISSEMINATED GONOCOCCAL INFECTION (DGI) AND ARTHRITIS... INITIAL TREATMENT consists of CEFTRIAXONE (Harrison,19e,835)
60. hepatocellular carcinoma: Alpha fetoprotein.
61. tumor markers such as PSA (prostate cancer), CA-125(!)(ovarian(!) cancer), CEA (colon cancer), and
CA-19–9 (!)(pancreatic(!) cancer) (Harrison,19e,480e-2).
62. #The positivity for anti-ds DNA correlates directly with kidney injury severity in SLE.
#Positive serology for anti RO “Anti-SSA” is specific for (neonatal)-SLE.
63. ANKYLOSING SPONDYLITIS can cause neck pain and less commonly atlantoaxial subluxation; surgery may be required to
prevent spinal cord compression (Harrison,19e,122).
ANTERIOR UVEITIS develops in sarcoidosis, ANKYLOSING SPONDYLITIS, juvenile rheumatoid arthritis, inflammatory bowel
disease, psoriasis, reactive arthritis, and Behçet’s disease (Harrison,19e,200).
The seronegative arthropathies, including ANKYLOSING SPONDYLITIS, reactive arthritis, psoriatic arthritis, and the
arthritides associated with ulcerative colitis and regional enteritis, are all STRONGLY ASSOCIATED WITH THE HLA-B27
HISTOCOMPATIBILITY ANTIGEN and may be accompanied by a pancarditis and proximal aortitis (Harrison,19e,290e-3).
The symptoms of the disease are usually first noticed in LATE ADOLESCENCE OR EARLY ADULTHOOD; the median age in
Western countries is APPROXIMATELY 23 YEARS (Age of onset less than 45 years!!).
characteristic features: (1) AGE OF ONSET<40 YEARS OLD; (2) insidious onset; (3) IMPROVEMENT WITH EXERCISE; (4)
no improvement with rest; and (5) pain at night with improvement upon getting up (Harrison,19e,2169).
64. At presentation, patients with Fibromyalgia most commonly report “PAIN ALL OVER.” These patients have pain that is typically
BOTH ABOVE AND BELOW THE WAIST ON BOTH SIDES OF THE BODY(occiput, neck, shoulder, ribs, elbows, buttoks, knees)
and involves the axial skeleton (NECK, back, or chest). The pain attributable to FM is poorly localized, difficult to ignore, severe in
its intensity, and associated with a reduced functional capacity. For a diagnosis of FM, PAIN should have been present most of the
day on most days FOR AT LEAST 3 MONTHS. The clinical pain of FM is associated with increased evoked pain sensitivity. In
addition to widespread pain, FM patients typically report FATIGUE, stiffness, SLEEP DISTURBANCE, COGNITIVE
DYSFUNCTION, anxiety, and depression... The sleep complaints include difficulty falling asleep, difficulty staying asleep, and early-
morning awakening... Cognitive issues are characterized as slowness in processing, DIFFICULTIES with attention or
CONCENTRATION, problems with word retrieval, and short-term memory loss... Symptoms of anxiety and depression are
common... Thus diagnostic testing is focused on EXCLUSION OF OTHER DIAGNOSES and evaluation for pain generators or
comorbid conditions (Harrison,19e,2238).
65. Even when the results of tests for latent Mycobacterium tuberculosis infection are negative, active
tuberculosis can develop in patients receiving anti-TNF therapy (Harrison,19e,125).
It is recommended that patients have a purified protein derivative (PPD) or a QuantiFERON-TB gold
test as well as a chest x-ray before initiation of anti-TNF therapy. (Harrison,19e).
Patients receiving treatment that eliminates B cells (e.g., with anti-CD20 antibodies or rituximab) are
especially vulnerable to intercurrent viral infections. The incidence of progressive multifocal
leukoencephalopathy (caused by JC virus) is elevated in these patients (Harrison,19e,490).
66. osteoporosis FRAx questionnaire: In addition to bone density, there are A NUMBER OF RISK FACTORS
for fracture; the common ones are... Age, prior fractures (especially recent fractures), a family history of
osteoporosis-related fractures, low body weight, smoking, and excessive alcohol use are all independent
predictors of fracture. Chronic diseases with inflammatory components that increase skeletal remodeling
such as RHEUMATOID ARTHRITIS, increase the risk of osteoporosis, as do diseases associated with
malabsorption. Chronic diseases that increase the risk of falling or frailty, including dementia, Parkinson’s
disease, and multiple sclerosis, also increase fracture risk (Harrison,19e,2488).
The Fracture Risk Assessment (FRAX ) score, an algorithm that combines an individual’s bone-density score with age and other risk factors to
predict her 10-year risk of hip and major osteoporotic fracture.
In the United States, it has been estimated that it is cost-effective to treat a patient if the 10-year major fracture risk (including hip, clinical spine,
proximal humerus, and tibia) from FRAX is ≥20% and/or the 10-year risk of hip fracture is ≥3% (These are the 2 values practically measured by
FRAX).

1. Homeless man intoxicated + Right lower lobe infiltrates + fever: Broad spectrum with anaerobic coverage.
 Dr.AmeerAboMokh
2. Old age + Difficulty breathing after a morning jog+ occasionally uses an inhaler → next? Peak Exspiratory
flow (PEF).
3. Evaluation of hemoptysis
Hemoptysis with no risk factors:
1. CXR 2. If CXR is not revealing - obtain a CT 3. If both are unrevealing - Bronchoscopy
Hemoptysis with risk factors (= age > 40/ smoking/ recurrent bleedings): CT is indicated directly!!!
4. Smoking: annual screening with low-dose CT in adults aged 55-80 who have a 30-pack-year smoking
history. (2011‫)ש‬
5. Heavy smoker + Rt sided exudate pleural effusion + no fever→ Suspected malignancy (not pneumonia).
6. Clubbing may be associated with the patients liver disease “cirrhosis” but not with COPD.
7. The pleural effusion in lupus is EXUDATIVE, with an ↑ lactate dehydrogenase level.
8. Residual volume is elevated in conditions that result in premature airway closure with expiration or due to
inability to fully exhale due to muscle weakness or chest wall stiffness. Other disorders that lead to increased
residual volume include Emphysema, asthma, diaphragmatic weakness, and kyphoscoliosis. Idiopathic
pulmonary fibrosis usually causes a decrease in residual volume due to airway stiffness. Obesity should not
affect residual volume. (2010‫)ש‬
9. Severe kyphoscoliosis causes pulmonary symptoms in up to 3% of patients with this condition. The physical
abnormalities caused by the forward and lateral curvature of the spine result in abnormal pulmonary
mechanics. This is manifested primarily as restrictive lung disease” not obstructive” with chronic alveolar
hypoventilation. This in turn leads to ventilation-perfusion imbalances that result in hypoxic vasoconstriction
and may cause the eventual development of pulmonary hypertension. (2010‫)ש‬
10. right sided infective endocarditis on the tricuspid valve --> septic pulmonary emboli (especially in drug
abuser).
11. Patient had GI bleeding after clexane treatment of DVT → Stop clexane and use IVC filter.
IVC indications: high risk of bleeding or real bleeding from GI, GU, GYN, CNS…
12. A diminished-forced expiratory volume in 1 sec (FEV1)/forced vital capacity (FVC) (often defined as <70%
of the predicted value) is diagnostic of OBSTRUCTION... A TOTAL LUNG CAPACITY <80% of the predicted
value for a patient’s age, race, sex, and height defines RESTRICTIVE pathophysiology. (Harrison,19e,1662).
13. The DECISION TO WEAN: It is important to consider discontinuation of mechanical ventilation once the
underlying respiratory disease begins to reverse (ex: fever returns to normal temp) … the following
conditions indicate amenability to weaning: (1) Lung injury is STABLE or RESOLVING. (2) Gas exchange is
adequate, with LOW PEEP/Fio2 (<8 cmH2O) and Fio2(<0.5). (3) HEMODYNAMIC variables are STABLE,
and the patient is no longer receiving vasopressors). (4) The patient is CAPABLE OF INITIATING
SPONTANEOUS BREATHS (Harrison,19e,1743).
14. Diagnostic Criteria for ARDS: ABSENCE of Left Atrial Hypertension: PCWP ≤18(!!!) mmHg or NO clinical
evidence of increased left atrial pressure (Harrison,19e,1736)
15. Moderate persistent asthma: Daily symptoms, Nighttime symptoms 5or more/month
60< FEV1 <80% Tx_start with low dose ICS and LABA
16. Mild persistent asthma: SABA + low dose ICS
17. Antibiotics are not component of the treatment of an acute asthma exacerbation unless there is evidence of
pneumonia.
18. Decrease FEV1 evaluates disease severity of asthma.
19. asthma attack: PCO2 not elevated until severe, and there is lack of infiltration on chest X-rays.
20. Clinical picture of asthma, bronchiectasis (proximal) and eosinophilia --> Allergic bronchopulmonary
aspergillosis.
The mainstay of the treatment ABPA is a systemic glucocorticoid (oral) such as prednisolone.
21. COPD patient with raised PCO2 → Intubate and begin mechanical ventilation.
22. COPD can cause prolonged expiratory phase and diminished breath sounds bilaterally.
23. Chronic obstructive pulmonary disease (COPD) per se does not cause clubbing. So, if clubbing is present
in COPD, underlying lung cancer and bronchiectasis must be ruled out.
 Dr.AmeerAboMokh
24. Ventilation-perfusion mismatching accounts for essentially all of the reduction in Pao2 that occurs in COPD; shunting is minimal. This finding
explains the effectiveness of modest elevations of inspired oxygen in treating hypoxemia due to COPD and therefore the need to consider problems
other than COPD when hypoxemia is difficult to correct with modest levels of supplemental oxygen (Harrison,19e,1702).
Only three interventions—smoking cessation, OXYGEN THERAPY IN CHRONICALLY HYPOXEMIC
PATIENT, and lung volume reduction surgery in selected patients with emphysema—have been
demonstrated to INFLUENCE the natural history-aka change course- of patients with COPD.
All other current therapies are directed at improving symptoms and decreasing the frequency and severity
of exacerbations.
25. Reduce the number of acute COPD exacerbation: Inhaled corticosteroids.
26. low-grade fever and weight loss with decreased fremitus, flatness to percussion, and decreased breath
sounds all on the right → Malignancy that caused massive pleural effusion.
27. Massive pleural effusion--> tracheal deviation away from the lesion.
28. Given this patient’s longstanding history of tobacco use and having not seen a doctor for annual
examinations, it is likely that the pleural effusion ”on one side” is exudative as a result of an underlying
malignancy.
Other causes of exudative effusions include the following: infection, connective tissue diseases, neoplasm, pulmonary emboli,
uremia, pancreatitis, esophageal rupture—postsurgical, trauma, and drug induced.
Causes of transudative effusions include CHF, hypoalbuminemia, cirrhosis, myxedema, nephrotic syndrome, superior vena cava
syndrome, and peritoneal dialysis.
29. THE SECOND GENERATION (cefamandole, CEFUROXIME, cefaclor, cefprozil, cefuroxime axetil,
cefoxitin, cefotetan) has additional activity against H. INFLUENZAE and Moraxella catarrhalis. Cefoxitin and
cefotetan have potent activity against anaerobes as well. SECOND-GENERATION CEPHALOSPORINS
ARE USED TO TREAT COMMUNITY-ACQUIRED PNEUMONIA because of their activity against S.
PNEUMONIAE, H. INFLUENZAE, and M. catarrhalis. They are also used for other mild or moderate
infections, such as acute otitis media and sinusitis (Harrison,19e,941).
They don’t cover the atypical pneumonia organisms (ex: chlamydia pneumoniae).
#Typical pneumonia: S.pneumonia, Haemophilus influenza, aerobic (Klebsiella/Enterobacteriaceae),
S.aureus, Moraxella catarrhalis
#Atypical pneumonia: M.pneumonia, Chlamydia, Coxiella burnetiid (Q-fever), Legionella, Viruses(influenza..)
30. AN UPPER-LOBE CAVITATING LESION SUGGESTS TUBERCULOSIS(!!!).
#To be adequate for culture, a sputum sample must have >25(!) neutrophils and <10(!) squamous epithelial
cells per low-power field. The sensitivity and specificity of the sputum Gram’s stain and culture are highly
variable. Even in cases of proven bacteremic pneumococcal pneumonia, the yield of positive cultures from
sputum samples is ≤50%(!)... The yield from blood cultures(!), even when samples are collected before
antibiotic therapy, is disappointingly low(!)
# The two currently in use are C-reactive protein (CRP) and procalcitonin (PCT(!)). Levels of these acute-
phase reactants increase in the presence of an inflammatory response, particularly to bacterial(!) pathogens.
CRP may be of use in the identification of worsening disease or treatment failure, and PCT(!) may play a role
in determining the need for antibacterial(!) therapy(Harrison,19e,805).
31. Factors that increase the likelihood that tube thoracostomy will have to be performed for parapneumonic
effusion include loculated pleural fluid, pH below 7.20, pleural fluid glucose below 60 mg/ dL, positive Gram
stain or culture of pleural fluid, and presence of gross pus on aspiration.
32. Patients with structural lung disease, such as cystic fibrosis or bronchiectasis, are at risk for a unique
group of organisms including P. aeruginosa and S. aureus. (2010‫)ש‬
Alcohol use predisposes patients to anaerobic infection, likely due to aspiration, as well as S. pneumoniae
(Klebsiella rarely seen).
Poor dental hygiene is associated with anaerobic infections.
33. In real sputum there will be at least 25 neutrophils and no more than 10 squamous cells, but even in such
cases the rate of positive sputum culture does not exceed 50%.
34. Risk Factors for Early Deterioration in CAP (poor prognosis): HYPONATREMIA, Hypoglycemia,
Thrombocytopenia, Severe acidosis (pH <7.30), Severe hypoxemia (arterial saturation<90%),
Hypoalbuminemia, And patients who are old or requiring hospitalization. Multilobar infiltrates, Mental
confusion or comorbidities as well.
 Dr.AmeerAboMokh
35. If Pseudomonas is a consideration: An antipseudomonal β-lactam (e.g., piperacillin/tazobactam
(Harriosn,19e,808).
36. community acceured pneumonia: Empiric treatment should be initiated without need to identify the
organism.
Since the etiology of CAP is rarely known at the outset of treatment, INITIAL THERAPY IS USUALLY EMPIRICAL|(!!!), designed to cover the most
likely pathogens. In all cases, ANTIBIOTIC TREATMENT SHOULD BE INITIATED AS EXPEDITIOUSLY AS POSSIBLE(!!!)... Once the etiologic
agent(s) and susceptibilities are known, therapy may be altered to target the specific pathogen(s) (Harrison,19e,807).
37. Pseudomembranous colitis after pneumonia treatment: Switch antibiotic to Vancomycin.
38. Alcoholic has pulmonary abscess in the right lower lobe with an air-fluid level. This is characteristic of an
anaerobic infection. These are usually associated with a period of loss of consciousness and with poor oral
hygiene. The location of the infiltrate(superior segment Rt lower lobe) suggests aspiration, also making
anaerobic infection most likely. The superior segment of the right lower lobe is the segment most likely
to develop aspiration pneumonia. Lung abscess indicates a necrotizing process, which is uncommon with
the “typical” bacterial pathogens pneumococci and H influenzae, and very rare in the usually patchy
“atypical” pneumonias caused by Legionella and Mycoplasma.
39. Clinical manifestations may initially be similar to those of pneumonia, with FEVERS, cough, SPUTUM
PRODUCTION, and chest pain; a more chronic and indolent presentation that includes night sweats, fatigue,
and anemia is often observed with anaerobic lung abscesses. A subset of patients with PUTRID lung
abscesses may report discolored phlegm and FOUL-TASTING OR FOUL-SMELLING SPUTUM. Patients
with lung abscesses due to non-anaerobic organisms, such as S. aureus, may present with a more fulminant
course characterized by high fevers and rapid progression. Findings on physical examination may include
FEVERS, poor dentition, and/or gingival disease as well as amphoric and/or cavernous breath sounds on
lung auscultation. Additional findings may include digital clubbing and the absence of a gag reflex
(Harrison,19e,814).
40. Furosemide is given IV and action begins even before it affects the kidneys. Dose: 40mg
41. However, the d-dimer assay is not specific. Levels increase in patients with myocardial infarction,
pneumonia, sepsis, cancer, and the postoperative state and those in the second or third trimester of
pregnancy. Therefore, d-dimer rarely has a useful role among hospitalized patients, because levels are
frequently elevated due to systemic illness.
42. Because acute bacterial sinusitis is uncommon in patients whose symptoms have lasted <10 days, expert
panels now recommend reserving this diagnosis for patients with “persistent” symptoms (i.e., symptoms
lasting >10 days in adults or >10–14 days in children) accompanied by the three cardinal signs of purulent
nasal discharge, nasal obstruction, and facial pain “ (Harrison 20th) → less than 10 days: Symptomatic
treatment.
43. Pneumocystis jiroveci (formerly P. carinii) is an opportunistic pulmonary infection that often affects
patients with AIDS. As many as 30% of patients with AIDS present with this initial infection. Symptoms
include a fever; dry, nonproductive cough; tachypnea; and hypoxia. Chest radiograph usually shows bilateral
perihilar infiltrates.
Treatment involves TMP-SMX. ‫بجيك مريض هوموسيكشوال بقحقح بدك تشك في جيروفيسي مباشرة‬
44. . Chest x-ray revealed pronounced hilum and laboratory results were significant for mildly elevated liver
function test (sarcoidosis) → Many sarcoidosis patients do not require any treatment. Systemic steroid
therapy is unnecessary in this case. The patient with ASYMPTOMATIC(!!!) elevated(!) liver(!) function(!) tests or AN ABNORMAL
CHEST ROENTGENOGRAM(!!!) PROBABLY DOES NOT(!!!) BENEFIT FROM TREATMENT(!!!). However, these patients should be monitored for
evidence of progressive, symptomatic disease (Harrison,19e,2205).
45. Breast cancer patient with backpain spinal cord compression until proven otherwise high dose
injection dexamethasone + urgent full vertebral column MRI (steroid before imaging!!!)
46. POSTSTREPTOCOCCAL GLOMERULONEPHRITIS is prototypical for acute endocapillary proliferative
glomerulonephritis... It is more common in MALES... Poststreptococcal glomerulonephritis due to impetigo
develops 2–6 weeks after skin infection and 1–3 WEEKS AFTER STREPTOCOCCAL PHARYNGITIS... The
CLASSIC PRESENTATION is an acute nephritic picture with HEMATURIA, pyuria, red blood cell casts,
EDEMA, HYPERTENSION, and oliguric renal failure, which may be severe enough to appear as RPGN.
Systemic symptoms of HEADACHE, malaise, anorexia, and flank pain (due to swelling of the renal capsule)
are reported in as many as 50% of cases... TREATMENT IS SUPPORTIVE(!!!), with control of hypertension,
 Dr.AmeerAboMokh
edema, and dialysis as needed. ANTIBIOTIC TREATMENT FOR STREPTOCOCCAL INFECTION SHOULD
BE GIVEN(!!!) to all patients and their cohabitants (Harrison,19e,1837).
47. TB is usually localized to the apical and posterior segments of the UPPER LOBES, where the substantially
higher mean oxygen tension (compared with that in the lower zones) favors mycobacterial growth. The
superior segments of the lower lobes are also more frequently involved (Harrison,19e,1108).
48. Legionella urine antigen is detectable within 3 days of symptoms and will remain positive for 2 months. It
is not affected by antibiotic use. (2010‫)ש‬
49. Legionella pneumonia Rx: Azithromycin or Levofluxacin.
50. If the causative agent is strep pneumonia (pneumococcus)→ Blood cultures are positive in less than 30%
of the cases
51. PE and VTE: Low-molecular-weight heparin (LMWH) is safe and effective for the treatment of pulmonary
thromboembolism
52. For suspected thrombophilia in a person with family Hx who had DVT and is currently on 6 months of
warfarin → Thrombophilia-screening at least two weeks after therapy cesassion.
53. 3 weeks after recovery from pneumonia, the mycobacterial cultures groves 2 colonies of mycobacterium
avium complex. Which is the most appropriate next step in management? No further treatment (Because
there is no previous medical condition in the lungs to promote MAC disease).
54. normal PaO2 75-105, normal PCO2 33-45.
55. SCLC is a highly aggressive disease characterized by... DRAMATIC RESPONSE(!!!) TO FIRST-LINE
CHEMOTHERAPY(!!!) and radiation... If the histologic diagnosis of SCLC is made in patients on review of a
resected surgical specimen, such patients should receive standard SCLC CHEMOTHERAPY as well...
CHEMOTHERAPY SIGNIFICANTLY PROLONGS SURVIVAL IN PATIENTS WITH SCLC... DESPITE
response rates to first-line therapy as high as 80%, the MEDIAN SURVIVAL is about 1-1.5 years.
56. Small cell lung carcinoma: the most recent American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines recommend surgical resection over nonsurgical treatment in SCLC patients with
clinical stage I disease after a thorough evaluation for distant metastases. After resection, these patients
should receive platinum-based adjuvant chemotherapy. Prophylactic cranial irradiation (PCI) should be
considered in all patients.
57. Everyone with a reactive PPD or Interferon Gamma Release Assay (IGRA) test should have a chest x-
ray to exclude active disease (master the boards).
58. What is the induration diameter that will justify prophylactic treatment for latent tuberculosis? At least 5 mm.
59. MASSIVE PE accounts for 5–10% of cases, and is characterized by extensive thrombosis affecting at least
half of the pulmonary vasculature. DYSPNEA, SYNCOPE, HYPOTENSION(systolic), and CYANOSIS are
HALLMARKS of MASSIVE PE. Patients with MASSIVE PE may present in CARDIOENIC SHOCK and can
die from multisystem organ failure.
The ONLY(!!!) Food and Drug Administration–approved indication for PE fibrinolysis is MASSIVE(!!!) PE. For
patients with submassive(!) PE, who have preserved systolic blood pressure but moderate or severe
RV dysfunction, use of fibrinolysis remains controversial(!)(Harrison,19e,1636).
PULMONARY EMBOLI (PE) SHOULD BE TREATED with FIBRINOLYTIC AGENTS if MASSIVE and in
some cases if SUBMASSIVE (Harrison,19e,296e-5).

1. HEADACHE: Raised CSF pressure is well recognized as a cause of HEADACHE. Brain imaging can often
reveal the cause, such as a space-occupying lesion. New daily persistent headache (NDPH) due to raised
CSF pressure can be the presenting symptom for patients with IDIOPHATIC INTRACRANIAL
HYPERTENSION (PSEUDOTUMOR CEREBRI) without visual problems, particularly when the fundi are
normal. Persistently raised intracranial pressure can trigger CHRONIC MIGRAINE. These patients typically
present with a history of generalized HEADACHE that is present on waking and improves as the day goes
on. It is generally worse with recumbency. Visual obscurations are frequent. The diagnosis is relatively
straightforward when papilledema is present, but the possibility must be considered even in patients
 Dr.AmeerAboMokh
without funduscopic changes. Formal visual field testing should be performed even in the absence of overt
ophthalmic involvement (Harrison,19e,110).
An elevated pressure, with normal cerebrospinal fluid, points by exclusion to the diagnosis of
PSEUDOTUMOR CEREBRI (IDIOPHATIC INTRACRANIAL HYPERTENSION). The MAJORITY OF
PATIENTS are YOUNG, FEMALE, AND OBESE. Treatment with a carbonic anhydrase inhibitor such as
acetazolamide lowers
Intracranial pressure by reducing the production of cerebrospinal fluid. Weight reduction is vital: bariatric
surgery should be considered in patients who cannot lose weight by diet control (Harrison,19e,203).
Excessive vitamin ingestion can lead to disease; examples include VITAMIN A and PSEUDOTUMOR
CEREBRI (Harrison,19e,2536).
2. After stroke you start a preventive management with ASA and CLOPIDOGREL. BUT(!!) if the patient suffers
from ATRIAL FIBRILLATION, in this case you give ANTICOAGULATION. (First Aid, step 2ck 2018, p. 261)
3. DEMENTIAS associated with PARKINSON'S DISEASE (PD) are common and may develop years after
onset of a parkinsonian disorder, as seen with PD-related dementia (PDD), or can occur concurrently with
or preceding the motor syndrome, as in DEMENTIA WITH LEWY BODIES (DLB) (Harrison,19e,171).
The diagnosis of DLB is suggested by early visual hallucinations; PARKINSONISM (Harrison,19e,172).
In DLB, the initial symptoms may include the new onset of a PARKINSONIAN SYNDROME (resting tremor,
COGWHEEL RIGIDITY, bradykinesia, festinating gait), but DLB often starts with visual hallucinations or
dementia(Harrison,19e).
COGWHEEL RIGIDITY, in which passive motion elicits jerky interruptions in resistance, is seen in
PARKINSONISM (Harrison,19e,2538).
Pathologically, the hallmark features of PD are degeneration of DOPAMINERGIC neurons in the
SUBSTANTIA NIGRA pars compacta (SNc), reduced striatal dopamine, and intracytoplasmic
proteinaceous inclusions known as LEWY BODIES that primarily contain the protein alpha synuclein
(Harrison,19e,2609).
4. The ROMBERG SIGN is positive, which means that the patient sways markedly or topples when asked to
stand with feet close together and eyes closed. In severe states of deafferentation involving deep sensation,
the patient cannot walk or stand unaided or even sit unsupported. Continuous involuntary movements
(pseudoathetosis) of the outstretched hands and fingers occur, particularly with eyes closed
(Harrison,19e,158).
5. Charcot-Marie-Tooth syndrome: foot drop. autosomal dominant, affecting the peripheral nervous system.
Manifestations include weakness and atrophy of the peroneal and distal leg muscles. The condition affects
motor and sensory nerves. Other features include impaired sensation and absent or hypoactive deep
tendon reflexes.
6. Gullian Barre syndrome: #Campylobacter enteritis is the most common disease associated with GBS
#Cytomegalovirus is the most common virus associated with GBS
Ascending paralysis: Bilateral flaccid paralysis spreads from the lower to the upper limbs in a
“stocking‑glove” distribution. Reduced or absent muscle reflexes. The presenting complaint is usually
weakness associated with the proximal muscles in a symmetric distribution.
Laboratory findings include elevated protein levels in CSF samples, altered EMG findings, and evidence of demyelination on nerve biopsies.
Mortality is approximately 10%. Up to 20% of patients may be left with persisting deficits. Approximately 3% may develop relapses, sometimes years
later.
7. MS: Charcot’s neurological triad → Dysarthria (+eating/swallowing/speech articulation) + nystagmus(+optic
neuritis/loss of vision/double vision) + Intention tremor(+muscle weakness\paralysis\ataxia).
Also sensory: paresthesia, numbness, burning sensation
Lhermitte’s sign: electrical shock
Autonomic nerves: bladder (incontinence), intestine (constipation), sexual dysfunction
Depression\anxiety\poor concentration
#Suspected when time(over several flare ups) and space (spread over CNS): It is characterized by remissions and
exacerbations that are separated in time and involve different areas of the CNS. A second form identified is progressive.
Dx: MRI (white matter plaques), cerebral spinal fluid shows oligoclonal bands of immunoglobulin G
(IgG) “autoimmune process”, visual evoked potential
 Dr.AmeerAboMokh
8. Acute Ischemic STROKE :After the clinical diagnosis of STROKE is made, an orderly process of evaluation
and treatment should follow... Perform an emergency noncontrast HEAD CT scan TO DIFFERENTIATE
BETWEEN ISCHEMIC STROKE AND HEMORRHAGIC STROKE; there are no reliable clinical findings that
conclusively separate ischemia from hemorrhage, although a more depressed level of consciousness,
higher initial blood pressure, or worsening of symptoms after onset favor hemorrhage, and a deficit that is
maximal at onset, or remits, suggests ischemia (Harrison,19e,2561).
9. Symptoms such as DOUBLE VISION, numbness, and limb ATAXIA suggest a brainstem or CEREBELLAR
LESION (Harrison,19e,149).
10. The patient presents with a clinical history that is consistent with a SAH(headache that started 2 days ago. He states the
headache began suddenly with peak intensity while he was defecating. The pain is continuous particularly in the occipital region and is associated
with mild nuchal rigidity and mild photophobia. He denies having a recent fever. A noncontrast head CT is obtained and is normal.).
Brain CT
without contrast is the procedure of choice for diagnosing SAH and should be done in any individual with a
new onset of a severe or persistent headache. It has a sensitivity of 95% for detecting SAH. If the CT is
negative, an LP should be performed because some patients with SAH have a normal CT scan. A yellow
supernatant liquid (xanthochromia), obtained by centrifuging a bloody CSF sample, can help distinguish
SAH from a traumatic tap. If the diagnosis is still in question, an angiography may be required. Treatment of
meningitis with IV antibiotics should not be delayed if the diagnosis is suspected. However, the patient’s
clinical history is inconsistent with this diagnosis (he is afebrile and without constitutional symptoms).
11. SUBARACHNOID HEMORRHAGE (SAH)... In ~45% of cases, SEVERE HEADACHE associated with
exertion is the presenting complaint. THE PATIENT OFTEN CALLS THE HEADACHE “THE WORST
HEADACHE OF MY LIFE”; however, the most important characteristic is sudden onset. Thunderclap
headache is a variant of migraine that simulates an SAH. Before concluding that a patient with sudden,
SEVERE HEADACHE has thunderclap migraine, a DEFINITIVE WORKUP(!!!) for aneurysm or other
intracranial pathology IS REQUIRED(!!!) (Harrison,19e,1784).
12. Sudden onset of a severe headache, especially the “worst headache of my life,” should elicit concern about
subarachnoid hemorrhage (SAH). Diagnostic steps include an emergent CT scan of the head. Because the
CT scan will identify only 90% of all SAH, a negative scan should be followed up by a lumbar puncture to
avoid missing 1 out of every 10 subarachnoid hemorrhages.
13. TRIGEMINAL NEURALGIA is characterized by excruciating paroxysms of pain in the lips, gums, cheek, or
chin and, very rarely, in the distribution of the ophthalmic division of the fifth nerve... DRUG THERAPY
WITH CARBAMAZEPINE(!!!) IS EFFECTIVE IN ~50–75% OF PATIENTS (Harrison,19e,2646).
14. Spinal abscesses are most commonly found in immunocompromised patients, IV drug users, and the
elderly. Signs and symptoms of epidural abscess usually develop over a week or two and include fever,
localized pain, and progressive weakness. An elevated WBC count is also commonly seen. MRI is the most
useful diagnostic test. Staphylococcus aureus is the most common causative organism.
15. MYASTHENIA GRAVIS (MG):
About 30% of patients with THYMOMA have MYASTHENIA GRAVIS... Among patients with MYASTHENIA
GRAVIS, ~10–15% have a THYMOMA (Harrison,19e,123e-1).
History:
Diplopia, ptosis, dysarthria, dysphagia, dyspnea
Weakness in characteristic distribution: proximal limbs, neck extensors, generalized
Fluctuation and fatigue: worse with repeated activity, improved by rest
Physical examination:
Ptosis, diplopia, Motor power survey, FORWARD ARM ABDUCTION TIME (5 min), Vital capacity
measurement, Absence of other neurologic signs (Harrison,19e,2702)

1. Non-ST-segment elevation acute coronary syndrome (NSTE-ACS): include patients with non-ST-segment
elevation myocardial infarction (NSTEMI), who, by definition, have evidence of myocyte necrosis, and those
with UNSTABLE ANGINA (UA), WHO DO NOT... Medical therapy involves simultaneous anti-ischemic and
 Dr.AmeerAboMokh
antithrombotic treatments and consideration of coronary revascularization... intravenous NITROGLYCERIN
(5–10 μg/min using nonabsorbing tubing) is recommended... BETA BLOCKERS are the other mainstay of
anti-ischemic treatmen... INITIAL TREATMENT should begin with the platelet cyclooxygenase inhibitor
ASPIRIN... benefit of intravenous GLYCOPROTEIN IIb/ IIIa INHIBITORS... unfractionated HEPARIN (UFH),
long the mainstay of therapy (Harrison,19e,1593).
Unstable angina is defined as angina or ischemic discomfort with at least one of three factors: pain at rest lasting >10 min, severe recent pain (within
4–6 weeks), or crescendo angina. NSTEMI is diagnosed when a patient with unstable angina has positive cardiac biomarkers.
2. Patient with bilateral edema and pain at exercise → Cath directly and not exercise stress test.
3. Exercise-induced falls in blood pressure or the development of an exercise-induced S3 heart sound are
strongly suggestive of ischemic left ventricular dysfunction. Specific exercise-induced ECG changes include
changes ≥ 1 mm horizontal or downward-sloping ST segment depression or elevation during or after exercise.
Exercise-induced changes in lead V5 are most reliable for the diagnosis of IHD.
The ISCHEMIC ST-SEGMENT RESPONSE generally is defined as flat or downsloping DEPRESSION OF THE ST SEGMENT >0.1 mV BELOW
BASELINE. The development of angina and/or SEVERE (>0.2 mV) ST-SEGMENT DEPRESSION AT A LOW WORKLOAD, i.e., before completion of
stage II of the Bruce protocol, and/or ST-segment depression that persists >5 min after the termination of exercise INCREASES the SPECIFITY of the
test and SUGGESTS SEVERE IHD and a HIGH RISK of future adverse events (Harrison,19e,1582).
4. Best treatment for AS → Aortic valve replacement surgery (not Aortic balloon valvuplasty).
OPERATION IS INDICATED(!!!) in patients with SEVERE AS (VALVE AREA <1 cm2 or 0.6 cm2/m2 body
surface area) WHO ARE SYMPTOMATIC, those who exhibit LV systolic dysfunction (EF <50%), and those
with Bicuspid aortic valve(BAV disease) and an aneurysmal root or ascending aorta (maximal dimension >5.5
cm (Harrison,19e,1532).
In asymptomatic children or adolescents or young adults with critical aortic stenosis without valvular calcification or these features, aortic
balloon valvuloplasty is often useful. If SURGERY is contraindicated in older patients because of a complicating medical problem such as malignancy
or renal or hepatic failure, balloon valvuloplasty may provide short-term improvement...
5. NEW-ONSET AFib(!!!) that produces severe hypotension, PULMONARY EDEMA [CRACKLES(NCBI)], or
ANGINA should be ELECTRICALLY CARDIOVERTED starting with a QRS SYNCHRONOUS(!!!) SHOCK of
200 J, ideally after sedation or anesthesia is achieved (Harrison,19e,1487).
6. pain and numbness of the right foot. She has chronic atrial fibrillation → Doppler of the arteries in order to
rule out an arterial clot originating in the heart.
7. For patients with CHF, progressive heart failure accounts for the majority of deaths. !!! ‫على مدة زمنية وليس فجأة‬
Sudden cardiac death caused by ventricular tachycardia, fibrillation, bradycardia, or electromechanical
dissociation occurs in 20% to 40% of patients with CHF.
Syncope, a persistent third heart sound, signs of chronic right-sided heart failure, extensive conduction
system disease, and ventricular tachyarrhythmias portend a poor prognosis.
Annual mortality is 10% to 20% for patients with mild to moderate symptoms (NYHA class II or III symptoms);
it often exceeds 40% for patients with advanced class IV symptoms.
Overall, female sex is associated with a better prognosis than male sex in CHF.
8. Case of Old age+CHF+Afib → b-blocker.
9. Although any valvular vegetation can embolize, vegetations located on the mitral valve and vegetations
larger than 10 mm are greatest risk of embolizing.
10. Harrison: prophylaxis for endocarditis for high risk lesions: Amoxicillin (2 g PO 1 h before procedure). If
allergic to penicillin, then Clarithromycin or Azithromycin (500 mg PO 1 h before procedure).
Prophylaxis recommended when there is gingival manipulation or perforation of the oral mucosa (including
surgery on the respiratory tract). Prophylaxis is not advised for patients undergoing gastrointestinal or
genitourinary tract procedures.
High risk lesions: 1. Prosthetic heart valves 2. Prior endocarditis 3. Unrepaired cyanotic congenital heart
disease, including palliative shunts or conduits 4. Completely repaired congenital heart defects during the 6
months after repair
5. Incompletely repaired congenital heart disease with residual defects adjacent to prosthetic material
11. Remember that MVP is not a high risk lesion for endocarditis, but still it is a moderate risk. However, no
antibiotic prophylaxis is needed.
12. CONTRAINDICATIONS FOR NONINVASIVE VENTILATION: (2016‫)ש‬
Cardiac or respiratory arrest(!) Severe encephalopathy
Severe gastrointestinal bleed HEMODYNAMIC INSTABILITY (Ex: low BP) (!!!)
 Dr.AmeerAboMokh
Unstable angina and MYOCARDIAL INFARCTION(!!!) Facial surgery or trauma
Upper airway obstruction High-risk aspiration and/or inability to protect airways
Inability to clear secretions (Harrison,19e,1741)
13. Percutaneous aortic valve replacement (TAVR) “cardiac catheterization” has been shown to be an effective
treatment for HIGH-RISK and inoperable patients with aortic stenosis. This is in comparison to survival after
surgical valve replacement. (2016‫)ש‬
14. The NCEP:ATPIII(!!!) HAS FOCUSED ON NON-HDL(!!!) CHOLESTEROL rather than on triglycerides
(Harrison,19e,2453). This is for directing the management. (2011‫)ש‬
15. Ninety-five percent of patients with a diagnosis of hypertension have primary or essential hypertension.
Evaluation for secondary causes is generally reserved for those refractory to medical therapy or those
presenting with hypertensive crisis.
Testing is recommended to detect the secondary effects of hypertension, evaluate other cardiovascular risk
factors, and help in choosing medical therapy. Recommended testing includes an ECG, chest x-ray, CBC,
glucose, cholesterol, electrolytes, creatinine, calcium, uric acid, and urinalysis. (2011‫)ש‬
16. Case of patient with very high BP of 220/125 mm Hg, but NO end organ damage → Administer atenolol, 50
mg, and follow up in 24 hours (No need for ICU admission!!!)
Malignant HTN “(e.g. >200/130 mmHg)” management: Atenolol
17. Mitral valve prolapse (MVP): The condition is common and associated with myxomatous transformation
of the valve leaflet.
18. STEMI old man: Thrombolytic therapy and aspirin.
Many elderly patients, of course, will have contraindications to thrombolytics, particularly gastrointestinal bleeding, recent stroke, head injury, or
surgery.
19. ATRIAL FIBRILLATION(!!!)... DIGOXIN may be added, particularly in HEART FAILURE patients, because
it does not have negative inotropic effects (Harrison,19e,1487).
Digoxin treatment does not improve survival of patients with acute heart failure, however it is a therapeutic
option in patient with atrial fibrillation(2016‫)ש‬
20. The natural progression of ECG changes seen with MI include peaked hyperacute T-waves to ST-segment
elevation, to Q-wave development, and to T-wave inversion.
21. Case of ECG shows normal sinus rhythm with occasional premature ventricular contractions and ST
segment elevations of 0.2 mV in leads II, III, and aVF → We give classic treatment for MI, including
streptokinase if needed, but without anti-arrhythmic drug like Lidocaine!!!
22. Pericarditis: there is a relative contraindication for anticoagulation as it increase the risk for cardiac
tamponade.
23. We give NSAIDs. If unresponsive, give colchicine. Colchicine (0.5 mg bid, given for 4–8 weeks) has been
found to be effective, not only in acute pericarditis, but also in reducing the risk of recurrent pericarditis.
24. Monomorphic ventricular tachycardia + Hypotension → synchronized defibrillation !!!
Sustained Monomorphic VT... If HYPOTENSION, impaired consciousness, or pulmonary edema is present,
QRS SYNCHRONOUS(!!!) ELECTRICAL CARDIOVERSION should be performed, ideally after sedation if the
patient is conscious. For stable(!) tachycardia, a trial of adenosine(!) is reasonable (Harrison,19e,1494).
An unsynchronized(!) discharge of 200–300 J (monophasic waveform; approximately 50% of these energies
with biphasic waveforms) is used immediately in patients with ventricular fibrillation(!) or when ventricular
tachycardia(!) causes hemodynamic deterioration(!) (Harrison,19e,1608).
Pulseless(!) electrical activity and asystole(!) are not(!) amenable to cardioversion, but [unsynchronized]
cardioversion(!) is indicated(!) in ventricular fibrillation(!) and pulseless ventricular tachycardia(!)... If the QRS
complex is narrow, and the PATIENT IS HEMODYNAMICALLY UNSTABLE from tachycardia,
SYNCHRONIZED(!!!) CARDIOVERSION is warranted (Sabiston,20e,553).
#Ventricular tachycardia & SVT when patient is not stable: Synchronous cardioversion!!!!
25. Hypertriglyceridemia, which is enhanced by poorly controlled diabetes, estrogen, and alcohol,
predisposes to pancreatitis.
26. Unstable angina\NSTEMI: admit patient and start heparin (LMWH is superior to UFH).
27. Compared with fibrinolysis, PRIMARY PCI(!!!) is generally PREFERRED when the diagnosis is in doubt,
cardiogenic shock is present, bleeding risk is increased, or SYMPTOMS HAVE BEEN PRESENT FOR AT
 Dr.AmeerAboMokh
LEAST 2–3 h(!!!) when the clot is more mature and less easily lysed by fibrinolytic drugs... If no
contraindications are present, FIBRINOLYTIC(!) therapy should ideally be initiated WITHIN 30 MIN(!) of
presentation (i.e.,door to needle time ≤30 min) (Harrison,19e,1599).
28. Based on Harrison 20 picture:
–You have 30 min to give fibrinolytic agent
-90 min to do cath
-120 min to move to PCI capable facility, else you do fibrinolysis.
-DIDO (door-in-door-out) time is 30 min.
The diagnosis of NSTE-ACS is based largely on the clinical presentation. Typically, chest discomfort is severe
and has at least one of three features: (1) it occurs at REST (or with minimal exertion), lasting >10 minutes...
DIAGNOSTIC EVALUATION... In addition to the clinical examination, three major noninvasive tools are used in
the evaluation of NSTEMI-ACS: the electrocardiogram (ECG), cardiac biomarkers, and STRESS TESTING.
CCTA IS ADDITIONAL EMERGING OPTION. The goals are to: (1) recognize or exclude myocardial infarction
(MI) using cardiac biomarkers, preferably cTn; (2) detect rest ischemia (using serial or continuous ECGs); and
(3) detect significant coronary obstruction at rest with CCTA and myocardial ischemia using STRESS
TESTING “i.e. Nuclear perfusion imaging stress test “(Harrison,19e,1594).
29. NITRATES(!!!): These should first be given sublingually or by buccal spray (0.3–0.6 mg) if the patient is
experiencing ischemic pain... The ONLY ABSOLUTE CONTRAINDICATIONS(!!!) TO THE USE OF
NITRATES(!!!) ARE HYPOTENSION(!!!) or the use of sildenafil or other phosphodiesterase- 5 inhibitors within
the previous 24–48 h (Harrison,19e,1595).
30. Unstable ischemic heart disease is classified as UNSTABLE ANGINA when there is NO DETECTABLE
myocardial injury and as non–ST elevation MI (NSTEMI) when there is evidence of myocardial necrosis
(Harrison,19e,96).
ISCHEMIA also causes characteristic changes in the electrocardiogram (ECG) such as repolarization
abnormalities, as evidenced by INVERSION OF T WAVES (Harrison,19e,1580).
Serum cardiac biomarkers are obtained to distinguish UNSTABLE ANGINA (UA) from non-ST-segment
elevation myocardial infarction (NSTEMI) (Harrison,19e,1599).
T-WAVE CHANGES that accompany episodes of ANGINA PECTORIS and disappear thereafter
(Harrison,19e,1582).
31. The Valsalva maneuver results in an increase in intrathoracic pressure, followed by a decrease in venous
return, ventricular filling, and cardiac output. The majority of murmurs decrease in intensity during the strain
phase of the maneuver. Two notable exceptions are the murmurs associated with MVP and obstructive
HOCM, both of which become louder during the Valsalva maneuver (Harrison,19e,51e-7).
32. SYNCOPE AND SUDDEN DEATH in patients with LONG QT SYNDROME(!!!) result from a unique
POLYMORPHIC VENTRICULAR TACHYCARDIA called torsades des pointes that degenerates into
ventricular fibrillation (Harrison,19e,147).
33. CHOLESTEROL EMBOLI(!!!): AGING patients with clinical complications from atherosclerosis sometimes
shower CHOLESTEROL crystals into the circulation... Depending on the location of the atherosclerotic
plaques releasing these cholesterol fragments, one may see cerebral transient ischemic attacks; livedo
reticularis in the lower extremities; Hollenhorst plaques in the retina with visual field cuts; NECROSIS OF THE
TOES; and ACUTE GLOMERULAR CAPILLARY INJURY LEADING TO FOCAL SEGMENTAL
GLOMERULOSCLEROSIS sometimes associated with hematuria, mild proteinuria, and loss of renal function,
which typically progresses over a few years. Occasional patients have fever, eosinophilia, or eosinophiluria. A
skin biopsy of an involved area may be diagnostic... THERE IS NO THERAPY TO REVERSE EMBOLIC
OCCLUSIONS, AND STEROIDS SO NOT HELP. Controlling blood pressure and lipids and cessation of
smoking are usually recommended for prevention (Harrison,19e,1848).
34. Afib+thyrotoxicosis → Propranolol
35. AF is occasionally ASSOCIATED WITH AN ACUTE PRECIPITATING FACTOR AS hyperthyroidism,
ACUTE ALCOHOL INTOXICATION, or an acute illness (Harrison,19e,1485).
 Dr.AmeerAboMokh
36. New-onset AF that produces SEVERE HYPOTENSION, pulmonary edema, or angina should be
ELECTRICALLY CARDIOVERTED starting with a QRS SYNCHRONOUS(!!!) SHOCK of 200 J, ideally after
sedation or anesthesia is achieved (Harrison,19e,1487).
37. The most common current reason for THYROID ABNORMALITIES in the cardiac population is the
treatment of tachyarrhythmias with AMIODARONE(!!!), a drug with substantial iodine content
(Harrison,19e,1563).
38. AMIODARONE S.E(!!!)---Tremor, peripheral neuropathy, pulmonary fibrosis or inflammation, HYPO- AND
HYPERTHYROIDISM, hepatitis, photosensitivity.
39. ANTICOAGULATION IS WARRANTED prior to conversion for episodes more than 48 h in duration and
chronically for patients at increased risk of thromboembolic stroke based on the CHA2DS2-VASc SCORING
SYSTEM (Harrison,19e,1485).
Anticoagulation with a vitamin K antagonist (warfarin) or the newer oral anticoagulants is warranted for
patients who have had more than 48 h of AF and are undergoing cardioversion, for patients who have a prior
history of stroke, or FOR PATIENTS WITH A CHA2DS2-VASc SCORE OF ≥2(!!!)... THE ANTIPLATELET
GENTS ASPIRIN AND CLOPIDOGREL ARE INFERIOR TO WARFARIN(!!!) FOR STROKE PREVENTION IN
AF and do not reduce the risk of bleeding (Harrison,19e,1488).
40. In randomized trials, administration of antiarrhythmic medications TO MAINTAIN SINUS RHYTHM DID
NOT IMPROVE SURVIVAL(!!!) or symptoms compared to a rate control strategy, and the drug therapy group
had more hospitalizations (Harrison,19e,1488).
41. Initial management of atrial flutter is similar to that for ATRIAL FIBRILLATION... ELECTRICAL
CARDIOVERSION(!!!) is warranted for HEMODYNAMIC INSTABILITY [HYPOTENSION(!!!)] OR SEVERE
SYMPTOMS (Harrison,19e,1485).
42. Carotid sinus massage can distinguish atrial flutter from sinus tachycardia.
43. If asymptomatic need no treatment
Mobitz 1 if symptomatic —> pacemaker
Mobitz 2 symptomatic—-> pacemaker
Mibitz 2 asymptomatic BUT QRS wide —-> pacemaker
44. When syncope occurs in an older patient as a result of head turning, wearing a tight shirt collar, or shaving
over the neck area, carotid sinus hypersensitivity should be considered. It usually occurs in men above the
age of 50 → Dx by Carotid massage with ECG monitoring.
45. B-natriuretic peptide (BNP) is secreted by the heart's ventricles and is sensitive to changes in left
ventricular function. Elevated levels are associated with elevated levels of enddiastolic pressure. BNP can be
helpful in determining whether shortness of breath is due to cardiac versus a pulmonary etiology. A value 400
pg/dL represents a >95% chance of congestive heart failure. ‫ب عالي معناها فشل قلب‬-‫ن‬-‫ب‬
46. B blocker is indicated in CHF with low EF, but CI in NYHA class 4.
47. If possible, surgery should be delayed 7 days after stopping the patients clopidogrel.
48. Dressler $ occurs up to 6 weeks after cardiac procedure → Rx: NSAIDs
49. best treatment for hypotension and bradycardia caused by acute beta-blocker toxicity: Glucagon.
50. Clopidogrel: Irreversibly blocks P2Y12 to prevent adenosine diphosphate (ADP)–induced platelet
aggregation.
51. LMWH does not require laboratory monitoring.
52. Case 45 year-old male with an idiopatic DVT → a comprehensive evaluation necessary.
53. The most common cause of inherited thrombophilia associated with DVT is activated protein C resistance
(factor V Leiden).
54. Case of DVT 68yrs old → Careful history, physical examination, routine blood counts and chemistries,
chest x-ray (CXR), fecal occult blood testing (FOBT), and prostate-specific antigen (PSA); if these are not
revealing, no further evaluation is necessary.
55. Each small square is 0.04 seconds and each large square has 5 small square (0.2 seconds).
56. Indication for Surgical Intervention in Patients with ENDOCARDITIS: EMERGENT (SAME DAY):
-Acute aortic regurgitation plus preclosure of mitral valve
-SINUS OF VALSALVA ABSCESS RUPTURED INTO RIGHT HEART(!!!)
 Dr.AmeerAboMokh
-Rupture into pericardial sac (Harrison,19e,825)
57. TRANSESOPHAGEAL ECHOCARDIOFGRAPHY(!!!) has become the test of choice for assessment of
small lesions in the heart such as VALVULAR VEGETATIONS, especially in the setting of a PROSTHETIC
VALVE DISEASE (Harrison,19e,270e-2).
58. 4-6 weeks antibiotics for IV drug abuser endocarditis.
59. Clinical settings in which ACUTE,SEVERE MR occur include (1) papillary muscle rupture complicating
acute myocardial infarction (MI), (2) rupture of chordae tendineae in the setting of myxomatous mitral valve
disease (MVP), (3) INFECTIVE ENDOCARDITIS, and (4) blunt chest wall trauma... ACUTE,SEVERE MR as
a consequence of INFECTIVE ENDOCARDITIS results from destruction of leaflet tissue, chordal rupture, or
both. (Harrison,19e,51e-2).
60. Infective Endocarditis: Elevated C-reactive protein level >90% of patients (Harrison,19e,817).
61. Macroalbuminuria is considered a cardiovascular risk factor in diabetes mellitus patient.
62. The symptoms of septic cavernous sinus thrombosis are fever, headache, frontal and retroorbital pain,
and DIPLOPIA. The classic signs are ptosis, proptosis, chemosis, and EXTRAOCULAR DYSMOTILITY due
to deficits of cranial nerves III, IV, and VI; hyperesthesia of the ophthalmic and maxillary divisions of the fifth
cranial nerve and a decreased corneal reflex may be detected. There may be evidence of dilated, tortuous
retinal veins and papilledema (Harrison,19e,906).
63. Migraine +uncomplicated HTN → GIVE Beta blocker. (‫ש‬2010).
64. Very high HTN + ischemic stroke → IV labetalol to lower the bp to below 185\110 MMHQ and then
thrombolytic therapy.
65. Cyclosporine A: used for prevention of transplant of kidney, causes paradoxically renal function injury and
exacerbation of arterial hypertension.
Calcineurin inhibitors (CYCLOSPORINE and tacrolimus) have an afferent arteriolar constrictor effect on the
kidney and MAY PRODUCE PERMANENT VASCULAR AND INTERSTITIAL INJURY(!!!) AFTER
SUSTAINED HIGH-DOSE THERAPY.This action will lead to a DETERIORATION IN RENAL FUNCTION(!!!)
difficult to distinguish from rejection without a renal biopsy (Harrison,19e,1829).
66. Renovascular hypertension: stenosing lesions of the renal circulation cause hypertension through
ischemia-mediated activation of the renin-angiotensin-aldosterone system.
67. Hypotension after meal: Diagnosis is confirmed by monitoring blood pressure after eating.
68. Dizziness rise about half an hour after breakfast and is accompanied by palpitations+Falls→Orthostatic
hypotension.
69. Implantable cardioverter defibrillator (ICD):
ALGORITHM FOR CARDIOVERTER/DEFIBRILLATOR IMPLANTATION:
ICD Implantation After STEMI At Least 40 Days After STEMI;
Assess LVEF and NYHA Functional Status
LVEF < 30-40%, NHYA Class II-III
LVEF < 30-35%, NHYA Class I (Harrison,19e,1609)
70. Patient’s presentation is consistent with acute mitral valve regurgitation because of a ruptured papillary
muscle in the setting of an AMI. Patients usually present with pulmonary edema in the setting of an AMI.
Chest x-ray characteristically reveals pulmonary edema with a normal heart size. The characteristic murmur
of mitral regurgitation is a holosystolic murmur that is loudest at the apex.
71. Order of ECG changes seen in an MI: Hyperacute T wave, ST-segment elevation, Q wave.
72. Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease and a
history of rheumatic fever (Chap. 381). In other patients with rheumatic heart disease, lesser degrees of MS
may accompany mitral regurgitation (MR) and aortic valve disease (Harrison,19e,1539).‫الثنتين معا‬
Many acquired and congenital cardiac lesions may result in stenosis and/or regurgitation of one or more heart valves. For example, rheumatic heart
disease can involve the mitral (mitral stenosis [MS], mitral regurgitation [MR], or MS and MR), aortic (aortic stenosis [AS], aortic regurgitation [AR], or
AS and AR), and/or tricuspid (tricuspid stenosis [TS], tricuspid regurgitation [TR], or TS and TR) valve, alone or in combination (Harrison,19e,1550).
73. MITRAL STENOSIS... The FIRST HEART SOUND (S1) IS USUALLY ACCENTUATED in the early stages
of the disease and slightly delayed... The OS is followed by a low-pitched, rumbling, DIASTOLIC MURMUR,
HEARD BEST AT THE APEX... Unless there is a contraindication, MITRAL VALVOTOMY [PRECAUTIOUS
VALVE DILATATION(!!!) is indicated in SYMPTOMATIC (New York Heart Association [NYHA] Functional
 Dr.AmeerAboMokh
Class II–IV) patients with isolated SEVERE MS, whose effective orifice (valve area) is < ~1 cm2/m2 body
surface area, or <1.5 cm2 in normal-sized adults. MITRAL VALVOTOMY can be carried out by two
techniques: PMBV and surgical VALVOTOMY... Successful VALVOTOMY is defined by a 50% reduction in
the mean mitral valve gradient and a doubling of the mitral valve area. Successful VALVOTOMY, whether
balloon or surgical, usually results in striking symptomatic and hemodynamic IMPROVEMENT and
PROLONGS SURVIVAL...
MITRAL VALVE REPLACEMENT(!!!) (MVR) is necessary in patients with MS and significant associated MR,
those in whom the valve has been severely distorted by previous transcatheter or operative manipulation, or
those in whom the surgeon does not find it possible to improve valve function significantly with VALVOTOMY
(Harrison,19e,1542).
74. ECHOCARDIOGRAPHY is indicated for the evaluation of patients with EARLY, LATE, OR
HOLOSYSTOLIC MURMURS and patients with GRADE 3 OR LOUDER MID-SYSTOLIC MURMURS.
Patients with grade 1 or 2 MID-SYSTOLIC MURMURS BUT OTHER SYMPTOMS OR SIGNS OF
CARDIOVASCULAR DISEASE, including those from ECG or chest x-ray, SHOULD ALSO undergo
ECHOCARDIOGRAPHY. ECHOCARDIOGRAPHY(!!!) is also indicated for the evaluation of ANY(!!!)
PATIENT WITH A DIASTOLIC(!!!) MURMUR and for patients with CONTINUOUS MURMURS NOT DUE TO
VENOUS HUM OR MAMMARY SOUFFLE (Harrison,19e,51e-8).
75. PCI is performed with adrug eluting stent. How long should this patient be treated with clopidogrel? At least
one year.
76. Troponin I: begins to rise within 3 to 6 hours of chest pain onset, peaks at 12 to 24 hours, and returns to
baseline in 7 to 10 days.
77. LVEF < 30-40%, NHYA Class II-III : (Harrison,19e,1609)
78. Orthostatic hypotension, defined as a reduction in systolic blood pressure of at least 20 mmhg or diastolic
blood pressure of at least 10 mmhg within 3 min of standing orhead-up tilt on a tilt table, is a manifestation of
sympathetic vasoconstrictor (autonomic) failure. (Harrison,19e,145).
79. Scleroderma renal crisis is the most severe manifestation of renal involvement, and is characterized by
accelerated hypertension, a rapid decline in renal function, nephrotic proteinuria, and hematuria. Retinopathy
and encephalopathy may accompany the hypertension. Salt and water retention with microvascular injury can
lead to pulmonary edema. Cardiac manifestations, including myocarditis, pericarditis, and arrhythmias, denote
an especially poor prognosis. Although MAHA is present in more half of patients, coagulopathy is rare
(Harrison,19e,1864).
80. Prevention of sudden cardiac death in patients with ischemic cardiomyopathy? Implantable cardioverter
defibrillator (ICD).
81. Shingles: Rash can be contagious on contact.
82. Case nurse latex allergy: The patient should evaluate for latex allergy with skin test or specific IgE
antibody.
83. Dermatomyositis is associated with Underlying malignancy.
84. Treatment of choice for pyoderma gangrenosum: Steroid therapy.
85. Early and aggressive SURGICAL EXPLORATION is essential in cases of suspected NECROTIZING
FASCIITIS, myositis, or gangrene in order to (1) visualize the deep structures, (2) remove necrotic tissue, (3)
reduce compartment pressure, and (4) obtain suitable material for Gram’s staining and for aerobic and
anaerobic cultures (Harrison,19e,831).
86. In any patient in whom WHIPPLE'S TRIAD is documented, further evaluation is necessary to determine the
underlying cause and guide appropriate management... The GOLD STANDARD for diagnosis of
INSULINOMA is the 72-HOUR(!!!) MONITORED FAST (Sabiston,20e,952).
87. Urine analysis for microalbumineuria should be performed yearly in DM.
88. Most reasonable approach for evaluating DM renal status is Screening for microalbuminuria can be done
with a 24-hour urine collection, an overnight collection, a 4-hour timed collection, or a spot collection with
determination of albumin-creatinine ratio. (Not measure of total protein clearance).
89. Best diagnostic test in order to differentiate central from nephrogenic diabetes insipidus? Serum
vasopressin levels.
 Dr.AmeerAboMokh
90. Metabolic syndrome: THREE OR MORE of the following:
• Central obesity: WAIST CIRCUMFERENCE >102 cm (M)(!!!), >88 cm (F)
• Hypertriglyceridemia: triglyceride level ≥150 mg/dL or specific medication
• Low HDL cholesterol: <40 mg/dL and <50 mg/dL for men and women, respectively, or specific medication
• HYPERTENSION: BLOOD PRESSURE ≥130 mmHg SYSTOLIC(!!!)or ≥85 mmHg diastolic or specific
medication
• Fasting plasma glucose level ≥100 mg/dL or specific medication or PREVIOUSLY DIAGNOSED DM2(!!!)
(Harrison,19e,2450)
91. Mucormycosis (phycomycosis) is a fungal infection that can be fulminant and lethal. It affects the nose,
sinus, and orbit and is seen in patients with poorly controlled diabetes, diabetic ketoacidosis, or
immunodeficiency. Symptoms include dull sinus pain, fever, cellulitis, proptosis, nasal congestion and purulent or bloody nasal discharge, and
gangrenous destruction of the nasal septum, orbits, or palate. In many cases, a black eschar is formed in the nasal area. If the fungus invades the
cerebral vessels, then convulsions, blindness, and death can result. Diagnosis almost always involves biopsy. CT or MRI can help evaluate the extent
of the disease. Treatment is accomplished with diabetic control, amphotericin B, and surgical debridement. The prognosis is poor, with up to a 50%
mortality rate in disseminated cases.
92. It is currently recommended to test patients with type 1 disease for microalbuminuria 5 years after
diagnosis of diabetes and yearly thereafter and, because the time of onset of type 2 diabetes is often
unknown, to test type 2 patients at the time of diagnosis of diabetes and yearly thereafter (Harrison, 20e)
93. TREATMENT GOALS for Adults with Diabetes:
HbA1c--- <7.0(!!!)%, Preprandial capillary plasma glucose--- (80–130 mg/dL)
Peak postprandial capillary plasma glucose--- (<180 mg/dL)
Low-density lipoprotein--- <100mg/dL Triglycerides--- <150 mg/dL

1. Contraindications of fibrinolysis – absolute and relative. (Picture)

2. The recommended treatment in case of atrial fibrillation in patients who suffer from WPW is IV
procainamide.
3. RAAS- this system contribute to the regulation of the arterial blood pressure through angiotensin II and
aldosterone. There are 3 stimuli for renin secretion: decrease NaCl transport to the loop of Henle;
decreased pressure within the renal afferent arteriole; stimulation of beta 1 receptor via sympathetic
nervous system.
4. Treatment for non-ST elevation ACS includes: dual aggregation therapy (Clopidogrel + aspirin),
anticoagulation (Heparin/Enoxaparin), anti-ischemic (b-blocker) and pain management (NGT).
pain managment (such as nitrates which also reduce preload) - if serial nitrates treatements fail consider morphine.
5. Treatment of choice in case of cardiac tamponade is pericardiocentesis.
6. Treatment of Raynaud phenomena is with dihydropyridines calcium channel blockers” Nifedipine”.
7. Familial etiology is the most common cause for dilated cardiomyopathy.
8. Stress test: decrease of more than 10mmhg will lead to cessation of the test, positive stress test is >0.1mm
decrease and lasting more than 0.08s, there is high false positive probability, Involvement of the circumflex
artery can lead to false negative result.
9. X-ray is the best initial diagnostic image for detecting aortic dissection. Widened mediastinum is seen on
imaging.
10. Indications for AVR: Symptomatic patients or asymptomatic patients with LVEF <50%/ LVESD >50mm/
LVEDD >65mm/ previous cardiac surgery will benefit from AVR surgery.
 Dr.AmeerAboMokh
11. Indication for AVR in asymptomatic patient with AS include: abnormal stress test, rapid progression of AS,
jet flow of >5 m/s or mean gradient >60, LV hypertrophy in absence of systemic hypertension
12. Fibrinolysis is done in case PCI can't be done within 120 minutes.
13. Pulsus paradoxus is more than 10 mmhg decline in systolic blood pressure. It is seen in patients with
cardiac tamponade.
14. Chemotherapeutic agents that cause cardiomyopathy include: doxorubicin and danurubicin as well as
trastuzumab.
15. Contraindications for stress test: rest angina within 48h, unstable rhythm, severe aortic stenosis, acute
myocarditis, uncontrolled heart failure, severe pulmonary hypertension, and active infective endocarditis.
16. Aortic regurgitation causes: aortic root disease (syphilis, Marfan…), HTN, valvular (Ankylosing spondylitis,
rhematic fever..), aortitis (Takayasu..). Note: Radiation causes AS not AR (!!!).
17. WPW Afib: If the patient will present with hemodynamic instability the treatment will be cardioversion like in
other tachycardia, but when the patient is stable pharmacological therapy is indicated, and in case of WPW
the treatment is with ibutilide or procainamide.
In WPW there is an accessory pathway between the atria and ventricle that isn't affected by adenosine, digoxin or verapamil which exert their effect
on the AV node. Thus treatment to decrease the rate with verapamil, adenosine or digoxin can worsen the patient's condition due to slowing AV node.
These can facilitate accessory pathway conduction and lead to increased ventricular rate.
18. Abnormal ECG tracing at baseline (like when there's LBBB) limits the utility of any exam that relies on
ECG.
➔ Cardiac scan with thallium or 99m technetium is suggested in this patient and should be done with
exercise (such as treadmill) or pharmacological stress (with dipyridamole or adenosine).
19. Unsynchronized cardioversion is done in case of VF and pulseless VT.
20. 163\60 here there is a high pulse pressure → Think about stiff arteries because of arteriosclerosis.
Diseases that are associated with systolic hypertension and wide pulse pressure: Systolic hypertension
with wide pulse pressure can be seen in: 1. Arteriosclerosis 2. Aortic regurgitation 3. Thyrotoxicosis 4. Patent
ductus arteriosus 5. Fever 6. Arteriovenous fistula 7. Hyperkinetic heart syndrome.
21. The pathophysiologic changes in AR include: 1) Increased total stroke volume 2) Increased LV end
diastolic volume 3) Dilation and eccentric hypertrophy of the LV 4) Increased preload and afterload in
chronic AR.
22. Stent in-thrombosis most commonly in the first month, and could be prevented by dual antiplatelet
therapy (Aspirin + Clopidogrel).
It is called “In-stent” thrombosis, so there is a subacute occlusion at the stent area.
Restenosis is due arterial proliferation (neointima hyperplasia) and most commonly after 3-6 months, it could
be prevented by drug eluting stent. (So suspect when there is bare metal stent.)
Presents as anginal pain
23. Nitrate, beta blockers and calcium channel blockers are given to angina pectoris among other drugs.
24. Malignant hypertension can lead to encephalopathy due to loss of autoregulation. Symptoms include:
vomiting, headache, dizziness, papilledema, stupor, coma, seizures and death in case there is no therapy.
25. Amyloidosis is the most common cause of restrictive cardiomyopathy.
26. Patients with new onset AF or AF with hypotension, angina or pulmonary edema should be treated with
cardioversion. (!!!?)
27. Eisenmenger's syndrome is the result of uncorrected left to right shunt. It presents with cyanosis,
erythrocytosis and clubbing.
28. AS will present with paradoxical splitting of S2 sound due to prolongation of left ventricular systole.
29. Pulsus alternans is when the upstroke of the pulse alternatives between strong and weak. It indicates
systolic dysfunction and is seen in patients with heart failure.
Bisferiens pulse occurs when there are two sharp upstrokes during systole → mixed aortic valve disease
30. Secondary hypertension should be suspected in patient with high blood pressure and hypokalemia. →
Measure the Renin: aldosterone ration. It will help to differentiate between primary and secondary
hyperaldosteronism. In case of renovascular hypertension there is increase in both renin and aldosterone
thus the ratio will be normal.
 Dr.AmeerAboMokh
31. Accelerated idioventricular rhythm is a type of ventricular tachycardia. In the ECG there is wide QRS
>120ms. It is common after reperfusion in patients with STEMI. AIVR may show ventricular complexes,
capture beat, fusion beat.
32. When there is unsustained VT after STEMI, we don’t treat the VT, but treat STEMI with urgent cath.
Sustained VT (persists in the absence of intervention): Lasts longer than 30 seconds and is almost always
symptomatic.
Rx of sustained VT: stable- amiodarone unstable- synchronous DC (see p30 step-up)
33. NYHA class III: less than ordinary causes fatigue/dyspnea/palpitations.
NYHA class II: ordinary activity causes fatigue/dyspnea/palpitations (ex: walking for 200m/climbing stairs).
NYHA class I: Nothing NYHA class IV: problematic at rest
34. Primary renal disease(Renovascular) is the leading cause of secondary hypertension.
Mechanism by which primary renal disease causes hypertension involves: 1. Diminished capacity to excrete sodium 2. Excessive renin secretion in
relation to the volume state 3. increase activity of the sympathetic system.
35. holo-systolic crescendo-decrescendo murmur that increases with Valsalva and standing with a mid-
systolic click → MVP → Treat with beta blockers if there are symptoms (chest pain, dyspnea and
palpitations).
36. Prostanoids(Iloprost), PDE-5 inhibitors(Sildenafil), endothelin inhibitors(Bosentan) and guanylyl cyclase
stimulator(Riociguat) are used in the treatment of PAH.
37. Ventricular arrhythmias are cause of death in approximately 50% of patients with HF. Thus implantable
cardioverter defibrillator (ICD) is recommended as prophylactic treatment in patients with EF <35% and
NYHA III-IV.(This will decrease mortality and not propranolol).
38. Etiology of constrictive pericarditis: idiopathic, viral and tuberculosis. Clinical manifestations
include: dyspnea, kussmaul sign- venous pressure fail to decline during inspiration, paradoxical pulse, S3
sound and pericardial knock.
39. Chronic administration of 75-325mg per day decrease coronary events in asymptomatic men over 50
years.
Aspirin is irreversible COX inhibitor.
40. In monomorphic VT with pulse synchronized cardioversion is indicated (even when hemodynamic
instability).
In case of VF and pulseless VT the treatment is with unsynchronized cardioversion.
41. Case: ST elevation in lead I, II, V2-V6; high pitch, scratching sound is heard at the left sternal border →
Pericarditis.
42. Statins should be given for: (1) all patients with CVD (2) All patients with diabetes aged 40-75 with LDL
above 70 and (3) Primary hypercholesterolemia with LDL > 190.
If the target cannot be met by statin alone, ezetimibe shoulld be added. In the next step, PCSK9 inhibitors
should be considered. Ezetimibe: should be added to statin and not given by itself.
43. The most common cause of resistant hypertension in adults (not elderly) is non-adherence to medications.
Resistant hypertension is defined as blood pressure > 140/90 that does not respond to 3 or more anti-
hypertensive drugs that one of them is a diuretic. The reasons for this resistance are: non-adherence, pseudoresistance (high blood
pressure in clinic and low BP at home), obesity and alcohol consumption and medications that increase BP such as: estrogen, steroids, NSAID and
EPO.
44. Pericarditis, is treated first with aspirin. In case aspirin is ineffective non-steroidal anti-inflammatory drugs (NSAID) such as indomethacin should be
given. Colchicine is given in case the first 2 drugs are ineffective. Contraindication for colchicine is hepatic or renal failure. Steroids are given in case
the previous drugs are contraindicated or the patient is unresponsive.
45. Medications used in treatment of NSTEMI: nitrates, morphine, beta blockers, antiplatelet and anticoagulant.
Combination of nitroglycerin and sildenafil in patient with NSTEMI is contraindicated. This combination can
lead to severe hypotension.
46. The most common cause of AS is degenerative calcification.
47. Heart disease is the leading cause of death in essential hypertension. Secondary hypertension is caused
by renovascular disease.
48. In patients who are normotensive initial treatment of PE is with anticoagulants (LMWH). Treatment with
Coumadin is after initial treatment with heparin based anticoagulant.
 Dr.AmeerAboMokh
49. Patients with chest pain (angina) and LV dysfunction (Low EF) → There is an indication for coronary
angiography.
50. Immediate invasive (within 2 hours) PCI is indicated in non ST elevation ACS in the presence of refractory
angina, signs or symptoms of heart failure or worsening mitral regurgitation, hemodynamic instability, or life
threatening arrhythmia.
51. Primary PAH presents with RV hypertrophy, p pulmonale and right axis deviation.
52. Contraindications of spironolactone include hyperkalemia and renal insufficiency. Spironolactone is a non-
selective aldosterone antagonist.
53. -Pulsus alternans is when the upstroke of the pulse alternatives between strong and weak. It indicates
systolic dysfunction and is seen in patients with Heart failure.
-Bisferiens pulse occurs when there are two sharp upstrokes during systole a AR or Mixed aortic valve
disease.
-pulsus paradoxsus is seen in patients with pericardial tamponade, asthma, superior vena cava
obstruction and chronic obstructive airway disease.
-Pulsus parvus et tardus is a carotid arterial pulse that rises slowly to a delayed peak AS.
54. Patients with CHA2DS2VASc > 2 points are treated with anticoagulants (Warfarin).
55. In case of ventricular tachycardia with change in consciousness, hypotension or pulmonary edema,
synchronous cardioversion is indicated. Antiarrhythmic drugs are used in stable patients.
56. Acute MR is caused by myocardial infarction, infective endocarditis and blunt chest trauma.
57. Most common cause of death in patients with PAH is decompensated right heart failure.
58. NSTEMI with angina at rest, ST depression and elevated troponin → PCI within 24 hours.
59. Acute decompensated heart failure (ADHF) treatment is composed of diuretics (furosemide), vasodilator
(nitrates and nesirtide” ”) and ionotropic (dobutamine).
recombinant human B-type natriuretic peptide ACEi is not part of the treatment.
60. When there are elective surgeries in patient with DEStent within the first year after placement it is suggested
to postpone the surgery. After a year it is possible to discontinue clopidogrel/ticagrelor/ prasugrel and to
continure only with aspirin for indefinite time.
61. Heart failure with preserved ejection fraction (HFpEF) is defined as ejection fraction>40-50%. It is caused
by stiffness of the left ventricular (LV) wall and decrease in relaxation of the LV during diastole. Ex: HOCM,
restrictive cardiomyopathy (ex: due to amyloidosis).
Beriberi and anemia cause high output HF, while chagas disease (dilated cardiomyopathy) causes low EF.
62. Raynaud:the blanching part is due to ischemia as a result of vasospasm of the digital arteries. During the
ischemic part the capillaries and small veins dilate leading to cyanosis from deoxygenated blood. When
rewarming happens, vasospasm resolves and there is reactive hyperemia leading to red color of the digits.
63. Aortic root dilatation (ARD) has long been recognized to cause functional aortic regurgitation (AR) with
anatomically normal aortic valve (AV) cusps that are stretched by the dilated root and, therefore, fail to close.
ECG shows ST depression and T wave inversion, plus LEFT axis deviation (!!!).
64. PCI is indicated in case of 1 vessel disease (but not >50% Lt main artery). Or 2 vessel disease (but LAD is
not one of them). Otherwise, CABG is indicated. (Note: EF has nothing to do with the indications for CABG)
65. When the T wave ends in the second half of the RR interval or in the middle of it, QT prolongation should
be suspected. Then the cause maybe Hypocalcemia (Hypoparathyroidism for e.g.).
66. MR is associated with: 1. Holosystolic murmur 2. At least III/VI intensity of the murmur 3. S4 sound in acute
MR 4. Increase intensity of the murmur with handgrip 5. Decrease intensity of the murmur with Valsalva
maneuver.
67. Calcium channel blocker side effects include: flushing, headaches and peripheral edema in case of
dihydropyridines (nifedipine) use, due to their ability to dilate arterioles.
68. Patients with MS will benefit from warfarin in case of AF, history of thromboembolism and in case of left
atrial enlargement with sinus rhythm.
69. Etiologies of AS: 1) congenital (bicuspid or unicuspid) 2) degenerative calcific 3) rheumatic fever 4)
radiation.
Etiologies of AR: 1) Valvular (bicuspidal valve, endocarditis, rheumatic fever, syphilis) 2) Root disease (aortic
dissection, Marfan's syndrome) 3) Aortitis 4) Hypertension.
 Dr.AmeerAboMokh
70. ACEI, beta blockers (metoprolol, bisoprolol and carvedilol) aldosterone antagonist and hydralazine(!!!) in
combination with nitrates have beneficial effect on mortality in HFrEF.
71. Antiplatelet(aspirin), anticoagulant(Heparin) and PCI are the immediate therapy to STEMI.
72. Atherosclerosis is the most common cause of IHD.
73. Pump failure is the most common in-hospital cause of mortality in patients with STEMI (not arrhythmia).
74. Beta blockers and RAAS drugs (such as ACE inhibitors, ARB and aldosterone antagonists) are indicated in
the treatment of dilated cardiomyopathy. NGT is not!
75. Splitting of S2 is characteristic of AS, the only valvular murmur associated with splitting. Fixed splitting
with AS, and even reversed splitting when severe AS.
76. Poor prognosis factors: 1. Elevated LVEDP (left ventricular end diastolic pressure) 2. Elevated LVEDV
(left ventricular end diastolic volume) 3. Reduced EF.
77. Echocardiographic follow up is indicated in AR patients who do not have any of the indications for surgery.
Follow up is in 6-12 months intervals. (Ex: LVEDD less than 65 needs echo follow up & not surgery).
78. Dipyridamole and adenosine test is recommended in case of: with peripheral vascular disease, exertional
dyspnea(COPD) or deconditioning. Case: COPD with chest pain → do this test
79. ECG presents with tachycardia, no clear P wave and prolonged QT interval. These changes are typical of
anti-depressants (TCA) toxicity.
Drugs that prolong QT interval: 1. Antiarrhythmic drugs: Class Ia and II: sotalol, quindine, procainamide,
ibutilide, dobutilide. 2. Antipsychotics: tricyclic antidepressants 3. Antibiotics: macrolides and quinolones
80. Drugs that should be avoided in IHD are NSAID. (Give lowest dose possible if must be given).
81. Ultrasound is the test of choice for infrarenal AAA in patients 65 or older with a history of smoking. CT is
used for preoperative planning. Both are 100% sensitive.
82. Thiamine (B1) deficiency can cause beriberi disease (wet) and present with high output heart failure.
83. Peripartum cardiomyopathy occurs between the 3rd trimester to 6 months after pregnancy. Risk factors
include: increased maternal age, increased parity, multiple gestation, malnutrition, preelcampsia and use of
tocolytics for premature labor.
84. Beta blockers side effects: Impaired AV conduction, Nightmares, Intensification of the hypoglycemia
produced by hypoglycemic agents (insulin and oral antiglycemics), Impotence, Worsening claudication.
85. Restenosis is due arterial proliferation (neointima hyperplasia) and most commonly after 3-6 months, it
could be prevented by drug eluting stent. → MOA of DES is Inhibition neointimal proliferation.
86. ACE inhibitors (ex:captopril) decrease LV remodeling in STEMI.
87. Mitral valve - (MS):
*Mitral valvotomy [PRECAUTIOUS VALVE DILATATION- which includes either surgical valvotomy or
percutaneous mitral balloon valvuloplasty (PMBV)] is carried out when 1)Symptomatic "NYHA II-IV" 2)
Mitral valve area "MVA"<1.5 cm2.
*Mitral valve replacement(MVR): When there is concomitant MR (MS+MR) or other causes that make valve
has to be replaced and not just reparied.
88. Acute MR (due to infarction for e.g.) treatment options: diuretics, vasodilators (Nitroprusside) and
surgery.
89. When a patient presents with high likelihood of PE: In this case imaging is the test of choice and not D-
dimer which is used in case of low and moderate likelihood for DVT or PE. The image of choice in case of
renal failure is lung scanning (ventilation/perfusion). Patients with renal failure do not tolerate contrast
material as given in CT angiography and can worsen the renal function.
90. Renal insufficiency is a side effect of ACEi due to dilation of the renal efferent arteriole.
91. TAVR is associated with risk for stroke, paravalvular AR and postprocedural heart block, arrhythmia.
92. Heart failure with preserved ejection fraction (HFpEF): Diuretics are the drug of choice in case of volume
overload(edema\crackled..). Furosemide is used. Not Spironolactone.
93. D-dimer is best used in case of low clinical likelihood of DVT.
94. In case of pul. HTN, Lung scanning (ventilation/perfusion) is better than CTA in diagnosing chronic PE.
95. Alcohol is the most common cause of chronic dilated cardiomyopathy.
96. 2nd degree or worse AV block with bradycardia need to be treated with pacemaker implantation.
 Dr.AmeerAboMokh
97. Ablation of foci in the atrial muscle along the pulmonary veins can abolish AF (Atrial fibrillation originates
from along the pul. veins).
98. Beta blockers treatment can be divided into acute therapy and secondary prevention. Acute therapy with
beta blockers decreases the myocardial oxygen demand in case of STEMI. Contraindication for beta
blockers include: severely compromised left ventricular function (acutely deterioration to low EF),
asthma, heart block, orthostatic hypotension and others. However in case of chronic heart failure, beta
blockers take important part in the treatment. In summary, beta blockers are contraindicated in case of heart
failure which isn't controlled.
99. Acromegaly can cause high output heart failure due to ventricular hypertrophy and diastolic dysfunction.
100. Indications for surgery in patient with AAA: onset of symptoms, mass size >5.5cm or mass that expands
>0.5 cm over 6 months. Ultrasound follow up is recommended in patients with mass size less than 5.5cm.
101. Beta blockers IV are the immediate treatment in case of aortic dissection. The goal is to decrease
BP<120 and to achieve pulse of approximately 60 BPM.
102. The most common condition associated with aneurysm of the descending thoracic aorta is
atherosclerosis.
103. Chagas disease present with megacolon or megaesophagous in the history of the patient. Another
complication of Chagas disease is dilated cardiomyopathy. Chagas disease is due to a paraitic organism.
104. Relative contraindication of beta blockers: 1. Asthma 2. Reversible airway obstruction in patients with
chronic lung disease 3. Severe bradycardia 4. Raynaud phenomena 5. Mental depression.
105. Arterial thrombi originate from the LV. Signs and symptoms of thromboembolism include hemiparesis in
case of cerebral vasculature involvment or hypertension in case the renal system is involved.
Echocardiography is used in order to reveal thrombi. After that we initiate anticoagulation.
106. PAH presents with RVH and p pulmonale. Screening test is done with echocardiography and
confirmation is done with right heart catheterization.
107. HCM is treated primarily with beta blockers (metoprolol) and calcium channel blockers (verapamil).
108. Statins should be given for: (1) all patients with CVD (2) All patients with diabetes aged 40-75 with LDL
above 70 and (3) Primary hypercholesterolemia with LDL > 190
Case: diabetic patient → Give statin because he has CVD risk.
109. S1Q3T3 can be seen on ECG in case of PE. T wave inversion in V1-V4 is the most common finding.
110. Patients with aortic stenosis or hypertrophic cardiomyopathy have to undergo coronary arteriography
!!
111. Pericarditis treatment: Laaaaaast thing give steroids (increase the recurrence).
112. Patient present with AFib to office, stable → Anti-coagulation (cardioversion not given to stable patients).
113. Unsynchronized cardioversion is indicated in VF and pulseless VT.
114. Thallium stress test is indicated in: chest pain with ECG showing LBBB.
115. Smoking is not a direct risk factor of atrial fibrillation.
116. Atrial fibrillation (AF) can be symptomatic or asymptomatic, but every atrial fibrillation needs to be
evaluated. Transesophageal echocardiography (TEE) is indicated in stable patient with AF in which the
beginning of the symptoms is unknown or patient with AF with symptoms more than 48 hours.
117. Treatment of PAD in patients with claudication includes smoking cessation and regular exercise(!!!).
118. Rheumatic fever is the most common cause of MS.
119. Effects of nitrates: Systemic venodilation, Reduction of left ventricular end diastolic volume and pressure,
Increased blood flow in the collateral vessels, Antithrombotic effect.
120. Sinus bradycardia needs treatment if hemodynamic compromise results from the bradycardia
(Hypotension). In this case atropine is the first drug to be given as it is most useful to increase heart rate. In
case of persistent bradycardia despite atropine treatment, electrical pacing is used.
121. Bidirectional ventricular tachycardia (VT) on ECG is a rare manifestation of digoxin. The QRS axis
fluctuates (positive / negative) in most leads hence the name bi-directional. Because of its mechanism (binding to K site of
the Na/K ATPase), in case of hypokalemia there is less competition on this binding site and we are more likely to have digoxin toxicity.
Digoxin is mainly eliminated by P glycoprotein. Drugs that compete on P glycoprotein can lead to digoxin toxicity (such as quinidine).
Digoxin has a negative chronotropic and positive inotropic effects. Therefore, in toxicity, we would expect bradycardia and normotension. Other side
effects include: neurological, ophthalmological (coloured vision) and gastrointestinal symptoms. The main risk of toxicity is development of life-
threatening arrhythmias. Rx of toxicity is anti-FAb against digoxin.
 Dr.AmeerAboMokh
ECG changes of hypothermia include bradycardia, QT prolongation and Osborne waves(after QRS: up-
slope).
122. AVR is indicated in patients with class I criteria. 1) Symptomatic patients with mean gradient of >40 mmhg
or Vmax >4m/s 2) Asymptomatic patients with mean gradient of >40 mmhg or Vmax >4m/s and left
ventricular ejection fraction < 50% or previous cardiac surgery.
123. ACEI, beta blockers (metoprolol, bisoprolol and carvedilol) and aldosterone antagonists have beneficial
effect on mortality in HFrEF. Furosemide doesn’t !!!!
124. PE in admitted patient for intracranial hemorrhage → Rx: IVC filter.
125. When ECG shows inferior MI this can indicate right ventricular infarction. Also reciprocal changes
maybe seen in the anterior and lateral leads. One third of the inferior MI will be accompanied by right
ventricular infarction. Signs and symptoms of right ventricular dysfunction- raised JVP and bradycardia. The
treatment for RV MI is volume expansion maintaining RV preload and there absolute contraindication for
treatment with nitrates.
126. Chronic thromboembolic disease is one of the causes for PAH (dyspnea, ankle edema..). Diagnosis
with V/Q scan is better than CT angiography in chronic thromboembolism. Treatment with surgical
thrombectomy is common practice in case of chronic PE that causes symptoms as a result of secondary
hypertension, in these cases thrombectomy can decrease PAH and even lead to full recovery.
Thrombolytics can be used in case of massive PE when there are no contraindications.
127. Carvallo sign is systolic murmur that increases with inspiration. This is common in patients with tricuspid
regurgitation. (Right sided murmurs increase with inspiration)
128. Heart failure after developing cold can suggest viral etiology of dilated cardiomyopathy.
129. PVCs are treated, even if post MI, only when they are symptomatic.
130. Cardiac tamponade presents with beck's triad: hypotension, jugular venous distention and distant heart
sounds.
131. Troponin increases in PE because of RV microinfarction.
132. Contraindications for stress test: rest angina within 48h, unstable rhythm, severe aortic stenosis, acute
myocarditis, uncontrolled heart failure, severe pulmonary hypertension, and active infective endocarditis.
LBBB doesn't make the ECG readable.
133. Life style modifications can reduce blood pressure. Regular exercise and appropriate diet are
recommended.
134. ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II, leading to increase in angiotensin
I and decreased levels of angiotensin II.
135. Most helpful in risk stratification for sudden cardiac death in this patient? Cardiac MRI
136. Hypertensive urgency: systolic blood pressure > 180 or diastolic >120 with no target organ damage.
Hypertensive emergency: high blood pressure with end organ damage such as: papilledema, myocardial
infarction, microangiopathic hemolytic anemia, eclampsia, aortic dissection, stroke and encephalopathy.
Treatment of hypertensive emergency: nitroprusside, labetalol, captopril.
137. Drugs that prolong QT interval include class IA and class III antiarrhythmics, antibiotics (macrolides),
antipsychotics (haloperidol, Tricyclic antidepressants), antiemetics (ondansetron).
138. Constrictive pericarditis clinical manifestations: Kussmaul sign, pericardial knock, S3, dyspnea and
paradoxical pulse.
139. Heart failure is excluded when BNP is within normal range.
BNP and NT-proBNP are elevated in the following cases: 1) age 2) women 3) renal impairment 4) heart
failure
140. Pheochromocytoma is one of the causes of secondary hypertension. It is diagnosed initially with urine
metanephrines followed by CT.
141. Takotsubo cardiomyopathy is caused by stress such as intense emotion (passing away of a loved
husband)
142. In case of hypertensive crisis it is recommended to decrease BP by 25% or values of 160/100.
 Dr.AmeerAboMokh
143. Indications for surgical repair of TAA: symptomatic TAA; aneurysm >5.5 in asymptomatic patient;
patients with Marfan syndrome or bicuspid aortic valve with aneurysm >4 cm; aneurysm expending by more
than 1 cm per year.
144. ASD of primum type is associated with atrioventricular septal defect including ASD and VSD: T21.
145. Surgical procedure should be indicated in patients with AS if: 1) Patient with valve are <1cm2 or
0.6cm2/m2 who are symptomatic 2) Patient with left ventricular systolic dysfunction, EF<50% 3) Patient with
bicuspid aortic valve disease and an aneurysmal root or ascending aorta.
146. Pericarditis: not only diffuse ST elevation, but also PR depression!!! (to differentiate from MI)
147. Wide complex tachycardia differential diagnosis include: 1) ventricular tachycardia 2) SVT such as AF
with aberrant conduction 3) tachycardia with pre-excitation such as antidromic wolff Parkinson white
(orthodromic is narrow complex!!!)
148. horizontal ST depression or downsloping ST depression → positive stress test
149. Positive stress test is >0.1mm decrease and lasting more than 0.08s.
150. AS Patients with congestive heart failure have the worst prognosis.
151. Patient with LL ischemia picture (pale, pain at rest, no pulse..): stent placement “revascularization”.
152. Acute AR Rx: vasodilators like Nitroprusside.
153. More than 48 hours Afib → anticoagulate with WARFARIN to do cardioversion or if CHAD>1.
154. In patients with suspicion of HF, echocardiography should be done in order to evaluate the left and right
ventricle size, function and pulmonary pressure.
155. Patients with NYHA III-IV, QRS >149 and LBBB will benefit from CRT.
CRT is a dual chamber pacemaker which is implanted in patients with HF and a wide QRS complex which indicates ventricular desynchronization.
The aim is to improve the synchronization between the ventricular contraction and therefore reduce the septal paradoxical movement and improve the
filing and contraction of the left ventricle. CRT has been proven to reduce mortality in HFrEF patients with EF <35% and NYHA III-IV. Recent studies
found benefit in patients with NYHA II and a QRS wider than 149 milliseconds and a LBBB.
156. IgA nephropathy presents with episodic macroscopic hematuria or asymptomatic persistent microscopic
hematuria.
Goodpasture's disease: Immunofluorescent shows linear deposits.
157. FSGS is responsible to one-third of the cases of nephrotic syndrome. It may be primary or secondary to
infections, sickle cell disease, lymphoma, etc. African-American has worse prognosis. Doesn't respond well
to steroids.
158. The pathological picture of diabetic nephropathy includes nodular glomerulosclerosis (Kimmelstiel-
Wilson).
#Congo red is used for amyloidosis.
#Minimal change disease presents with effacement of the podocytes.
#Crescents are characteristic for rapid progressive glomerulonephritis.
# Membranous glomerulonephritis presents with subepithelial deposits.
159. Contrast induced nephropathy is an intrinsic etiology of acute kidney injury (AKI). The leading cause of
contrast nephropathy is iodine used in CT scan. The risk is increased in patients with patients with chronic
kidney disease and especially those with diabetic nephropathy. Patients with multiple myeloma or congestive
heart failure are also susceptible to AKI. Creatinine increases 1-2 days after exposure to contrast material,
peaks at the 5th day and resolves after a week. Most often the injury is transient and leaves no irreversible
damage. It is rare that this type of injury leaves a patient with a need for dialysis. Labs show a pre-renal injury
with normal urine precipitation (but it is intrarenal injury).
160. After establishing persistent hematuria, collection of protein in the urine is needed.
161. Poststeptococcal glomerulonephritis (PSGN) laboratory findings: decreased CH50 and C3 levels,
normal C4 levels and increased titers of ASO and anti-DNAse.
Biopsy: Subendothelial and subepithelial deposits of IgG, IgM and C3.
162. Analgesic nephropathy: Radiographic results show small kidneys with scarring and calcification in the
papilla.
163. Dialysis is indicated in AKI in the following cases: pulmonary edema, hyperkalemia, metabolic acidosis,
uremic pericarditis, encephalopathy and in some cases of nephrotoxicity.
 Dr.AmeerAboMokh
164. Patient with CKD stage 3 or above with anemia should be treated with EPO. If EPO is not effective then
iron supplementation is given (even if MCV is within normal range).
165. Renal vein thrombosis is a complication of MGN due to loss of anticoagulation factor in the urine.
166. Brown muddy casts are seen in ATN, which maybe caused by ischemia or toxins.
Ischemic AKI (like recent surgery/hypotension) is an established cause of ATN [Step up, p272].
167. Allergic interstitial nephritis (AIN) presents with fever, rash, peripheral eosinophilia, WBC casts and
oliguric renal failure that occurs usually 7 to 10 days after treatment with beta lactam antibiotic or
methacillin. Other causative agents are NSAIDs, diuretics, anticonvulsants, etc.
168. Hyperphosphatemia is one of the most common metabolic disturbances in CKD. It is associated with
increased risk of cardiovascular complications. It forms complexes with calcium that deposits within vessels
and tissues (calcification of the vessels).
169. 25-30% of patients with IgA nephropathy develop renal failure over 20-25 years, and this is associated
with: male gender, older age, absence of macrohematuria(!!!), proteinuria, hypertension.
Asymptomatic patients require only follow up.
For patients with RPGN treatment is with steroids, cytotoxic agents and plasmapheresis.
170. Urease positive bacteria (proteus, klebsiella) increase pH usually above 8. Lead to struvite stones -
Staghorn nephrolithiasis.
171. Aminoglycosides AKI presents with acute tubular necrosis (ATN), hypomagnesemia and non-oliguric
AKI.
172. In order to prevent continuous polyuria in patient with hydronephrosis (post-renal azotemia), fluids (NS)
should be given in lower amount than urine output.
173. When there is nephrotic (no RBC), think about one of: MCD, membranous and FSGS.
174. Etiologies of pre-renal disease: hypovolemia- decreased cardiac output, congestive heart failure, liver
failure, impaired renal autoregulation (NSAIDs, ACE-I).
175. Multiple myeloma (MM) can injure the kidney in multiple ways but the classic injury is tubular and is
referred as cast nephropathy. Light chains aggregates with Tamm-Horsfall protein in the distal tubule.
Clinical findings will include anemia, bone pain, hypercalcemia and hypergammaglobulinemia. Laboratory
findings include: increased amount of protein and a negative dipstick.
176. NSAIDs & ACE-I cause impaired renal autoregulation → Pre-renal AKI.
177. PPI can cause allergic interstitial nephritis (AIN).
178. When given Cr and BUN in the question → calculate the BUN/Cr ratio and easily determine if it is more
than 20:1 that you have a pre-renal failure.
179. Multiple myeloma is a risk factor of contrast nephropathy.
180. RTA-1 presents with urine pH above 5.5 and hypokalemic, hyperchloremic metabolic acidosis. Normal
anion gap. There is failure to excrete H+.
Fanconi syndrome is associated with RTA type 2.
Barrter syndrome and Gitelman syndrome present with hypokalemia and metabolic alkalosis.
Diarrhea: urinary anion gap is NEGATIVE. Blood anion gap is NORMAL.
181. Nephrotic syndrome: hyperlipidemia/ hypercholesterolemia.
182. Membranous glomerulonephritis (MGN) accounts for one-third of the cases of nephrotic syndrome and is
the most common cause among elderly. Microscopy: subepithelial deposits.
183. IgA with HTN: Treatment with ACEi.
184. Goodpasture's disease present with hematuria and hemoptysis. Immunofluorescent shows linear
deposits of IgG in the basement membrane.
185. ADPKD present during adulthood and presents with hypertension, renal cysts, hepatic cysts, mitral valve
prolapse and berry (not aortic!) aneurysm. 60% of the patients will develop ESRD.
186. The most common cancer in patients after renal transplantation (under immunosuppressive Rx): skin.
187. Sepsis will cause acute tubular necrosis and will lead to intrinsic renal failure.
188. CKD only presents with small kidneys on US. CKD & AKI may present with anemia.
189. The most common cause of mortality in patients with CKD is cardiovascular diseases.
 Dr.AmeerAboMokh
190. BPH is a cause of post-renal acute kidney injury. It presents with elevated creatinine and BUN:Cr above
15.
191. Amphotericin B may cause AKI in the form of acute tubular necrosis. Amphotericin B presents with
polyuria, hypomagnesemia, hypocalcemia and non-anion gap metabolic acidosis.
192. Treatment of rhabdomyolysis is with hydration and forced alkaline diuresis.
193. Patients with Behcet's syndrome + uveitis should be treated with systemic steroids and azathioprine.
Treatment of mucosal symptoms is with topical steroids. Thrombophlebitis is treated with aspirin. Arthritis and
mucocutaneous symptoms are treated with colchicine.
Diagnosis is clinical and based on the following criteria: Recurrent oral ulceration plus two of the following: 1)
recurrent genital ulceration 2) eye lesions 3) skin lesion 4) Pathergy test.
194. Fibromyalgia is diagnosis of exclusion. Laboratory tests that need to be taken are: ESR, CRP, CBC and
TSH.
195. Conventional DMARDs: methotrexate, hydroxychloroquine, sulfasalazine and leflunomide. Their action is
effective within 6-12 weeks. If methotrexate monotherapy is inadequate then combination of conventional
DMARDs are used.
Anti-TNF is contraindicated in case of active infections, hypersensitivity, chronic hepatitis B, congestive heart
failure stage III/IV. Specific attention should be given to reactivation of latent tuberculosis.
Note that RA in pregnancy has different treatment protocol. MTX and leflunomide are contraindicated and
instead hydroxychloroquine or sulfasalazine are used.
196. RA: Steroids are used in order to treat acute flare and to control the disease until MTX is effective.
197. Renal crisis in scleroderma (diffuse) is a life-threatening complication which presents with hypertension,
thrombocytopenia and microangiopathic hemolytic anemia (schistocytes). Treatment is with ACE inhibitors.
198. Therapy of chronic gout is with uricosuric agents such as probenecid or with xanthine oxidase inhibitors
such as allopurinol and febuxostat. They prevent recurrent attacks (used for long term)!
Colchicine is used as alternative for NSAIDs in acute gout attack.
199. FMF: associated with erysipelas, can cause lung disease and treated with colchicine.
200. The most common pulmonary manifestation of SLE is pleuritis.
The most common cardiac manifestation is pericarditis.
201. Temporal arteritis is associated with polymyalgia rheumatica in up to 50% of the patients. Headache is the
presenting symptom. Other manifestations include claudication of the jaw and ischemic optic neuropathy.
High ESR.
202. PAN is associated with HBV.
203. Drug induced lupus is a syndrome that present with ANA positive and clinical manifestations of SLE such
as myalgia, arthritis, malaise, etc. Anti-histone antibodies positive. Drugs: Hydralazine, Procainamide.
204. Ankylosing spondylitis: Extraarticular manifestations include acute uveitis (most common) and aortic
insufficiency. Improvement with exercise\no improvement with rest\pain at night with improvement upon
getting up. Treatment of ankylosing spondylitis is with exercise program and NSAIDs (1st line therapy). Anti-
TNFs are given when NSAID treatment is inadequate. Uveitis is the most common extra-articular
manifestation of ankylosing spondylitis.
205. Diagnosis of Behcet's syndrome include: oral ulcers plus two of the following: 1) recurrent genital
ulceration 2) eye lesions 3) skin lesion(erythema nodosum) 4) Pathergy test.
Presentation may include venous thrombosis and abdominal pain!
206. C1-C2 instability is an important consideration that should be taken in patients with RA.
207. The diagnostic test of choice for Interstitial lung disease in a patient with CREST is High Resolution CT.
Note: Complications of limited cutaneous scleroderma include: pulmonary hypertension, interstitial lung
disease, hypothyroidism and primary biliary cirrhosis.
208. Pseudogout is characterized by deposition of calcium pyrophosphate within the articular tissues.
Pseudogout presents with chondrocalcinosis (cartilage calcification) on x-ray. Arthrocentesis reveals
rhomboid crystals, weakly positive birefringent crystal with polarized light and WBC within ranging from 2000-
100000micro/L in the synovial fluid. Treatment is with rest, NSAID or intra-articular glucocorticoids.
Prophylaxis with colchicine is indicated in case of frequent attacks.
 Dr.AmeerAboMokh
209. SLE patients with positive anti-dsDNA have higher risk of developing lupus nephritis.
210. Interstitial lung disease is seen in up to 90% of the autopsies of scleroderma patients. It presents clinically
in up to 43% of the patients. Pulmonary involvement is the most common cause of death in scleroderma.
211. Diffuse systemic sclerosis is characterized by skin induration and visceral involvement including interstitial
lung disease and renal crisis. It is not associated with pul. HTN like CREST.
212. Diagnosis is based on chest X-ray showing bilateral hilar adenopathy, biopsy showing non-caseating
granuloma and clinical presentation. Laboratory findings are elevated ACE and CD4:CD8 ratio.
213. There is a risk for MI in SLE patients and it is due to accelerated atherosclerosis.
214. Reactive arthritis is a clinical diagnosis.
215. Patients with RA who is pregnant should discontinue methotrexate due to its teratogenic characteristics
and use hydroxychloroquine instead.
216. The autoantibodies which are associated with APS are: anti-cardiolipin, lupus anticoagulant, beta 2
glycoprotein.
217. In all patients with SLE urinalysis should be done at the time of diagnosis in order to detect nephritis. Most
of the lupus nephritis patients are asymptomatic and have anti-dsDNA in high titers and low complement
levels which correlate with the disease progression. Up to 20% will develop ESRD. Lupus nephritis is
asymptomatic at the time of diagnosis.
218. Nail involvement is unique to psoriatic arthritis and appear in up to 90% of the patients. It is
characterized by either: pitting, horizontal ridging, yellowish discoloration or onycholysis. Further
manifestations are dystrophic hyperkeratosis and "pencil in the cup" deformation.
219. Vitamin D levels are elevated in sarcoidosis.
220. Churg-Strauss: asthma, peripheral blood eosinophilia (with increased WBC), mononeuritis multiplex (e.g.
foot drop), sinusitis and allergic rhinitis, purpura, cutaneous and subcutaneous nodules.
221. Polyarteritis nodosa (PAN): affects renal and visceral arteries but not the pulmonary arteries. It has
been associated with hepatitis B and in patients with hairy cell leukemia. Renal manifestations are the most
common and present as hypertension, renal insufficiency and hemorrhage due to microaneurysms.
Treatment is with steroids and cyclophosphamide.
222. c-ANCA is seen in patients with Wegner's granulomatosis. p-ANCA is seen in patients with Churg-
Strauss, microscopic polyangitis and IBD.
223. FMF: The most common cutaneous manifestation is erysipelas.
224. ACE is elevated in sarcoidosis.
225. Wegner's granulomatosis also known as granulomatosis with polyangitis is a necrotizing vasculitis of
the small vessels. It is characterized by glomerulonephritis and upper and lower respiratory tract symptoms.
Lung biopsy offers the highest diagnostic yield, revealing granulomatosis with vasculitis.
226. In case rash on cheeks and RBC in urine but not meet SLE criteria→ Reassure only.
227. Pseudogout is associated with hyperparathyroidism, hemochromatosis and hypomagnesemia.
WBC ranging from 2000-100000micro/L in the synovial fluid. May present as pain and swelling of the first
metacarpophalangeal joint.
228. SLE patient with pain in single joint(e.g. knee) should be evaluated. The prevalence of avascular
necrosis in SLE patient who were treated with systemic steroids with no other manifestation of SLE is high.
229. OA involves the DIP. X-ray shows loss of cartilage, sclerosis of the subchondral bony plate, osteophytes
and narrowing of the joint space. Morning stiffness lasting less than 30 minutes
230. Gonococcal arthritis can lead to disseminated arthritis.
231. Erythema nodosum can be seen in patients with sarcoidosis.
232. APS prolongs aPTT in vitro although in vivo it causes thrombosis.
233. Arthrocentesis is the diagnostic test of choice in gout.
234. ILD (pul. Disease) is seen in 90% of the autopsies of patients with scleroderma.
235. Non-Hodjkin lymphoma presents later in the course of Sjogren syndrome.
236. Hydroxychloroquine can lead to retinal damage and thus should be monitored by ophthalmologic
examination once a year.
 Dr.AmeerAboMokh
237. The treatment of SLE depends on the severity of the disease and the organs that are damaged. Severe
SLE presents as lupus nephritis or CNS lupus. These cases will be treated with high dose steroids and
cyclophosphamide or mycophenolate mofetil. Mild presentation of the disease such as arthritis or dermatitis
may respond to NSAID or anti-malaria drugs or low dose steroids. Hydroxychloroquine in useful in preventing
flares and prevent tissue damage.
238. Sjogren disease presents with anti-Ro and/or anti-La. May have dyspareunia, corneal ulceration.
239. Pulmonary arteries are not involved in PAN.
240. PAN affects the renal arteries and characteristic findings are microaneurysms.
241. Patients with scleroderma have pulmonary involvement which most commonly present as ILD →
Decreased DLco.
242. Pulmonary nodules are one of the extraarticular manifestations of RA. They develop in correlation to
smoking.
243. APS: Diagnosis is based on at least 1 clinical and 1 laboratory criteria. Laboratory antibody has to be
positive twice (after 12 weeks).
244. Treatment of dermatomyositis: oral steroids.
245. Secondary prevention of RF is based on 1.2 million units of benzathine penicillin G, every 4 weeks.
246. Eye involvement in Behcet disease (uveitis) needs follow-up by fundoscopy, it may lead to blindness.
247. Limited cutaneous scleroderma is most commonly associated with CREST syndrome. Diffuse cutaneous
visceral manifestations include interstitial lung disease and renal crisis.
248. OA Rx: non-pharmacological treatment should be started first (splint the joints) followed by
pharmacological treatment with acetaminophen or NSAIDs.
249. HSP presents with purpura on the lower extremities, arthralgia, GI symptoms and leukoctoclstic vasculitis
with IgA and C3 deposits on biopsy.
250. Fibromyalgia is treated with exercise followed by TCA(Amitriptyline ), SNRI or gabapentin.
251. Pseudogout presenting to the ER is treated like gout with NSAIDs, unless there is high creatinine (renal
failure), we give intra-articular steroids.
252. Anti-TNF drugs used if NSAIDs are not enough for Ankylosing spondylitis: Remicade (infliximab),
Enbrel (etanercept), Humira (adalimumab).
253. Ankylosing spondylitis extra-articular complications are uveitis and aortic insufficiency (AR).
254. Inclusion Body Myositis presents in elderly men with distal asymmetric muscle weakness, dysphagia,
facial weakness. All immunosuppressive treatment is ineffective (disappointing) in IBM patients.
255. Polymyalgia rheumatica is characterized by muscular pain (but no weakness), high ESR and anemia on
laboratory testing. Presents in very old women. It is more common in females and over the age of 50. First
line of treatment is prednisone. Resolves by 1-2 years.
256. Treatment of SLE patient who is pregnant should be done carefully. Steroids are not teratogenic and can
be used. Cyclophosphamide should be discontinued if possible. MTX is teratogenic. Hydroxychloroquine is
teratogenic but isn't contraindicated.
257. Wegner's granulomatosis induction therapy: steroids+ cyclophosphamide.
258. Treatment of lupus nephritis is with steroids+ cyclophosphamide/mycophenolate mofetil. Untreated, they
may develop ESRD.
259. Anti-TNFs improve both the cutaneous and the joint symptoms in psoriatic arthritis. It is given in case
other treatments are resistant. In psoriatic arthritis the uveitis is bilateral, posterior and chronic. Uric acid in
the blood is elevated in case of extensive psoriasis.
260. Specific antibodies of SLE are anti-Sm and anti-dsDNA.
261. Exercise proved to be effective treatment for fibromyalgia. Anti-depressants are use as well.
262. PPD test for latent tuberculosis is indicated in patients who are supposed to starts treatment with anti –
TNF (e.g. Infliximab).
263. Renal crisis is a life-threatening complication of scleroderma (especially the diffuse form) and in the first
years of the disease. ACE inhibitors decreased the mortality rate from 90% to 30%. Steroids increase the
risk of renal crisis in scleroderma patients. Presentation could be: Headache, high BP, blurred vision, high
creatinine, hemolytic anemia (low hemoglobin) in a scleroderma patient.
 Dr.AmeerAboMokh
264. Drug-induced lupus is seen with ANA and anti-histone antibodies positivity. A patient treated with RA
drugs (sulfasalazine, anti-TNF) can develop it, presenting with new SLE manifestation.
265. Hereditary hemochromatosis (HH) Rx: is with weekly phlebotomy and oral chelator (deferoxamine).
266. SAAG is calculated as the difference between ascetic and serum albumin. SAAG<1.1 can be due to
biliary leak, nephrotic syndrome, pancreatitis, peritoneal carcinomatosis and tuberculosis.
267. Beta blockers are used as prophylactic therapy of variceal bleeding.
268. Hepatopulmonary syndrome is characterized by: hypoxemia, liver disease and pulmonary AV shunt.
The mechanism is pulmonary vasodilation due to lack of nitric oxide breakdown which leads to hypoxemia
and desaturation. Clinical manifestations include: shortness of breath and oxygen desaturation that occur
when going from sitting to standing position. Diagnosis using pulse oximetry is a reliable screening test.
269. Alcoholic hepatitis is characterized by ratio of 2:1 of AST: ALT. Both pancreatic cancer and
obstruction of the ampulla of Vater's will increase GGT and ALK-P much more than ALT and AST. NASH
AST/ALT <1.
GGT maybe increased in alcoholic hepatitis.
270. Tenofovir and entacavir are used as treatment of choice in patients with cirrhosis and chronic HBV.
271. Nowadays IV drug injection is the most common cause of HCV infection.
272. Increase in ALT and AST will be seen in hepatocellular disease while ALK-P and GGT will be seen in
cholestatic disease. Anti-smooth muscle antibody (ASMA) is used to evaluate autoimmune hepatitis.
273. Negative HBV DNA excludes HBV reactivation. HDV is a virus that must have HBV in order to cause
infection. HDV replication tends to suppress HBV replication, thus we usually will see low levels of HBV DNA.
Treatment for chronic HDV includes interferon.
274. HAV patients will recover completely without complications. There is no carrier state for HAV.
275. Primary sclerosing cholangitis (PSC): increased alkaline phosphatase, prolonged PT, decreased
albumin, and in 65% of patients positive p-ANCA. ALT and AST are not increased usually. 50% of PSC have
UC.
276. Steroids are used in severe alcoholic hepatitis where MELD score>20 or discriminate function>32.
277. Absolute contraindications include: life-threatening diseases such as infection, cardiopulmonary
disease, AIDS, alcohol use, malignancies, metastasis to the liver, cholangiocarcinoma, etc.
Relative contraindications: HIV with CD 4<100, age >70, hypoxemia, pulmonary hypertension, previous
hepatobiliary surgeries, portal vein thrombosis, malnutrition, obesity, poor compliance, renal insufficiency,
psychiatric disease, etc.
Milan criteria: Solitary HCC less than 5cm or 3 small lesions of HCC less than 3cm (Milan criteria), without
involvement of blood vessel, are OK for transplantation.
Another indication is PSC with recurrent ascending cholangitis.
278. In case of ascending cholangitis the treatment is with antibiotics and ERCP.
279. Acetaminophen intoxication: Protocol of treatment starts with charcoal and cholestyramine within 30
minutes from ingestion (after 30 minutes it has been shown to be ineffective). N-acetylcysteine (NAC) is
given orally or IV to patients with high acetaminophen blood levels >200μg/mL after 4 hours and
>100μg/mL after 8 hours. NAC reduces the hepatic necrosis.
280. Lactulose is the mainstay therapy of hepatic encephalopathy.( with adjunct neomycin/rifaximin).
Hepatic encephalopathy is a severe complication of cirrhosis. Patients present with altered mental status,
decline in cognitive function and asterixis (flapping of the hands).
281. High levels of HBeAg 3 months after initial disease increase the risk of chronic HBV.
282. The patient presents with SAAG > 1.1 and protein >2.5 which is suspicious for CHF, early udd chiari
syndrome, IVC obstruction etc.
When SAAG > 1.1 it implies portal hypertension but in order to narrow the options must look at total
protein in ascites fluid.
283. SBP: Diagnosis with paracentesis showing >250 neutrophils. Treatment is with cefotaxime.
284. Increase GGT and ALK-P together with direct hyperbilirubinemia indicate further investigation with US (to
biliary ducts).
 Dr.AmeerAboMokh
285. Patients that presents with "bronze diabetes" (skin discoloration and diabetes mellitus) is suspected for
HH. Other manifestation should also be remembered such as testicular atrophy and dilated cardiomyopathy.
286. HAV vaccination is important before travelling to endemic countries. Active vaccination is effective for up
to 20 years. There are active and passive forms of the vaccine. India is an endemic country. 4 weeks are
required between the vaccination and travelling.
287. PBC: positive anti-mithochondrial antibodies (AMA). Treated with ursodeoxycholic acid.
Xanthomata and xanthelasmata may be found.
288. Serology markers that are seen in AIH are: anti-smooth muscle, anti LKM, anti-nuclear antibodies,
moreover abnormal elevation of liver enzymes (ALT and AST between 100-1000 units). Main treatment is
with steroids (with or without azathioprine).
289. Child-Pugh score was used to assess patient before liver transplantation and to predict their prognosis.
Recently MELD score has replaced Child-Pugh score.
290. PSC is associated with UC and p-ANCA.
Cholangiocarcinoma is a complication of PSC which contraindicates liver transplantation.
291. Variceal bleeding presenting to the ER, treated with antibiotics in addition to other drugs(sepsis risk).
Nevertheless, b-blockers are not used in the acute management. It is only prophylaxis for portal HTN.
292. History of recurrent spontaneous bacterial peritonitis: need antibiotics prophylaxis.
293. During "window" phase of HBV, IgM anti-HBc is usually the only marker that indicates HBV infection.
294. Treatment is generally indicated in chronic hepatitis B patients with HBV DNA >2000 IU/mL.
295. HEV increases the risk of mortality in pregnant women.
296. HBV with no replication (HBeAG -ve): treat when ALT > reference & HBV DNA >2,000 IU/mL.
When HBV is replicating (HBeAG +ve): treat when ALT>2xreference & HBV DNA >20,000 IU/mL.
297. Acute HBV markers: HBeAg, HBsAg and anti HBc IgM.
298. Precipitating factors that contribute for the development of hepatic encephalopathy: hypokalemia,
infection, increased dietary protein load or other electrolyte disturbances.
299. Whipple diease “tropheryma whipplei”: Clinical manifestation: diarrhea, steatorrhea, weight loss, cardiac
and central nervous system abnormalities, arthralgia, eye oscillation and mastication muscle contraction.
Diagnosis is done using small intestine biopsy showing PAS positive macrophage. Treated with TMP-SMX.
300. HTN, severe sweeting, pale skin, tachycardia to ER → Pheochromocytoma → Rx: phenoxybenzamine.
301. Ulcer with clean base is a low-risk for re-bleeding, these patients often discharged home.
302. SIADH: decrease plasma osmolarity and increased urine osmolarity and hyponatremia.
Treatment is with water restriction and 3% saline infusion. Careful correction of sodium should be done to
avoid central pontine myeliolysis. Treatment of chronic SIADH is with oral vaptan (tolvaptan). Other
approaches include demeclocycline or fludocortisone.
303. Patients with secondary hyperparathyroidism will develop bone disease called renal osteodystrophy.
Osteitis fibrosa cystica presents with cystic bone spaces filled with brown fibrous tissue. It is complication
of primary hyperparathyroidism.
304. Nontoxic multinodular goiter (MNG) is common in areas of iodine deficiency. However, if exposed to
contrast material containing iodine that will lead to reactivation of one of the nodules.
305. Toxic megacolon is a complication of UC which manifests with abdominal distention, fever, tachycardia
and hypotension. X-ray shows transverse or right colon diameter > 6 cm.
306. Thyroid nodule on US: when TSH is suppressed diagnosis is ensued with radionuclide scan. "Hot" nodule
is almost never malignant, "cold" nodules require FNA.
307. Increased PTH will increase calcium levels and decrease phosphate levels. Diagnosis is a combination of
characteristic laboratory findings and 99 technicium sestamibi scan with SPECT.
308. In unstable patients with hematochezia EGD is first test done.
309. Increased titers of ASCA have been associated with CD, whereas increased levels of pANCA are more
commonly seen in UC, though these serologic markers have low sensitivity and specificity. Granulomas on
biopsy is typical of CD. Aphthous ulcerations are an endoscopic feature of CD (and the earliest
macroscopic finding). Palpation of an inflammatory abdominal mass on physical exam is a feature of CD.
 Dr.AmeerAboMokh
310. Low dose dexamethasone test: is done for screening for a possible Cushing problem. It suppresses the
hypothalamus and ultimately cortisol will be low (negative test and no problem in the body).
311. In equivocal cases of high dose dexamethasone, inferior petrosal sinus sampling is done. If it is positive
then trans-sphenoidal surgery is done. If it is negative then locating and removing of ectopic ACTH source is
needed.
312. Cushing syndrome (hypercortisolism) divides into 3: ACTH dependent (pituitary adenoma also known as
Cushing disease, ectopic secretion, etc) ACTH-independent (adrenal adenoma, adrenal carcinoma, etc) and
iatrogenic (steroid treatment).
313. In case of perforation after colonoscopy with hemodynamic instability, laparotomy is needed.
314. After measuring TSH and thyroid hormones, anti TPO “Anti Thyroperoxidase Antibodies” needs to be
measured before continuing treatment.
315. Hypercalcemia is defined as calcium levels above 10.2mg/dL. It is mainly due to hyperparathyroidism
and cancer. Clinical manifestations range from asymptomatic patient to fatigue, anorexia, constipation,
altered mental status, vomiting, nephrolithiasis, short QT interval and cardiac arrhythmias.
316. Treatment of DKA starts with IV fluids followed by insulin and potassium (when needed). Bicarbonate is
added in case pH is less than 7.
317. GERD: are retrosternal pain at night and cough.
318. Cancer related hypercalcemia is associated with PTHrP which is common in lung cancer (squamous cell
carcinoma). Hypercalcemia is usually severe and presents with high calcium levels. It will present with low
PTH and phosphate levels and with high calcium levels due to suppression of PTH.
319. Sulfasalazine, Azathioprine, Infliximab, Prednisone: safe in pregnancy.
320. Maintenance treatment in crohn's disease (CD) patients is with azathioprine or 6-MP.
321. Dysphagia can be due to anatomical or functional abnormalities of the esophagus. Usually dysphagia only
to solids inclines on anatomical dysfunction(malignancies, diverticulum, food impaction, schatzki ring).
Dysphagia to both solids and liquids inclines on functional disorder: achalasia, diffuse esophageal spasm,
scleroderma.
Schatzki ring ( fibrous ring in the distal esophagus).
Episodic dysphagia for long time (years) can indicate on benign disease such as Schatzki ring Vs.
Esophageal cancer presents usually with progressive dysphagia to solids, liquids and weight loss.
322. Bisphosphonates are given more commonly to cancer patients as chronic treatment for hypercalcemia.
Bisphosphonates are powerful inhibitors of bone resorption primarily by inhibiting osteoclast activity and thus are a good treatment for hypercalcemia.
323. SIADH treatment is with water restriction and 3% saline infusion. Careful correction of sodium should
be done to avoid central pontine myeliolysis. Treatment of chronic SIADH is with oral vaptan (tolvaptan).
324. After low dose dexamethasone(overnight), we proceed to ACTH levels (in the morning) test.
325. All asymptomatic persons above the age of 50 should have a colonoscopy.
326. Overnight dexamethasone high → ACTH high → Next: Pituitary MRI.
327. Pregnant patient in her first trimester with Grave's disease should be treated with PTU.
328. P-ANCA presents in both primary sclerosing cholangitis and ulcerative colitis.
329. Weight loss, regurgitation, halitosis, (no dysphagia) → Suspect Zinker diverticulum.
Diagnosis of suspected oral-pharyngeal dysphagia is done with a rapid sequence fluoroscopic swallow study
(barium swallowing) due to the fast phase of swallowing which occurs in less than 1 second.
330. PTU/methimazole is the initial therapy of Grave's disease.
Radioiodine causes destruction of the thyroid cells and is used in case of recurrence after treatment with anti-
thyroid drugs. It is contraindicated in pregnancy and breast-feeding.
Thyroidectomy is done in case anti-thyroid drugs fail and the patient can't or wouldn't want to have
radioiodine, it is also recommended to young patients with large goiter.
331. ZES diagnosis starts with measuring gastrin levels. In inconclusive cases secretin stimulation is done.
332. Suspicion for ZES is raised when there is ulcer accompanied by diarrhea.
333. Growth hormone (GH) deficiency presents differently in children and adults.
In children GH deficiency leads to short stature (more than 3 standard deviations below the mean),
micropenis, increased fat, high pitched voice and propensity to hypoglycemia due to increased insulin action.
 Dr.AmeerAboMokh
In adults GH deficiency presents as fatigue, decreased concentration, reduced lean body mass, increased
fat mass (increased weight), increased waist to hip ratio, hyperlipidemia, left ventricular dysfunction,
hypertension. Diagnosis is made by stimulation test using insulin (insulin tolerance test) that should
increase GH normally and fails to do so in GH deficiency.
334. In case of penicillin allergy the treatment is: PPI+ clarithromycin+ metronidazole (Triple therapy).
335. High fiber diet is important in reliving symptoms of diverticulosis.
336. Patients who have suspicious IBS needs further diagnostic tests, such as colonoscopy or barium enema
to exclude other causes.
337. Prolactinoma is the most common hormone secreting disease of the pituitary gland. Etiologies leading to
prolactin hypersecretion include: pituitary adenoma, chronic renal failure, primary hypothyroidism and anti-
dopaminergic drugs. Prolactin inhibits GnRH and is stimulated by TSH. Dopamine inhibits prolactin.
Pharmacological treatment is with dopamine agonists (bromocriptine and cabergoline).
338. In case of HHS there is need to correct sodium levels (1.6mEq for every 100mg/dL increase in serum
glucose) with normal saline. In case sodium level is above 150 then 0.45% saline is given.
339. Carcinoid syndrome presents with right heart valvular dysfunction (Tricuspid insufficiency).
340. In bleeding peptic ulcer, it is possible to evaluate the risk of re-bleeding from the appearance of the ulcer.
The highest risk is with visible blood vessel or active bleeding. In this case there is need to treat with IV PPI
and endoscopy (Epinephrine injection).
341. US is preferred over CT for the diagnosis of appendicitis during pregnancy.
342. Primary polydipsia presents similarly to diabetes insipidus. It is differentiated from DI by water
deprivation test which leads to increase urine osmolarity. Moreover, DI presents with hypernatremia (in
nephrogenic it can be normal) while primary polydipsia present with hyponatremia.
343. Sick euthyroid syndrome (SES) most common presentation is decreased T3 levels and normal TSH\T4
levels. In very severe cases there may be decrease in total T4 and T3 levels. The mechanism leading to this
disturbance is secretion of interleukin 6. It is suggested the low T3 levels decrease the catabolism and
protect the patient. In case SES is suspected in severe acute illness, it is recommended to repeat the test
after recovery.
344. Domperidone is a peripheral dopamine antagonist which is devoid of CNS side effects. It is useful
antiemetic in case of gastroparesis.
345. Amiodarone is an anti-arrhythmic drug that can lead to hypo and hyperthyroidism.
346. In ill or medicated individual the most common cause of hypoglycemia is treatment of DM with insulin or
insulin secretagogues.
347. Sulfonylurea (e.g. Glyburide) side effects are hypoglycemia and weight gain.
348. Primary hyperaldosteronism also known as Conn's syndrome is the most common cause of
mineralocorticoids excess. Conn's syndrome is a result of bilateral micronodular hyperplasia or unilateral
adrenal adenoma.
Clinical manifestations include hypokalemic hypertension, hypernatremia, muscle weakness and proximal
myopathy, metabolic alkalosis which leads to muscle cramps.
Diagnosis of hyperaldosteronism is with aldosterone: renin ratio (ARR). High ratio means Aldosterone is
high and renin is low. Confirmation is done with saline infusion test, oral sodium loading or fludrocortisone
suppression test.
Following establishment of the diagnosis, CT scan is done in order to detect the cause of
hyperaldosteronism. Adrenal vein sampling is done in surgical candidates with no obvious lesion on CT or
in unilateral lesion in patients over the age of 40.
Treatment divides into surgical and pharmacological. The latter is with spironolactone.
349. The etiology of chronic mesenteric ischemia is atherosclerosis. Clinical manifestation present with
weight loss (food-fear) due to abdominal pain with eating. Diagnosis is done using CT angiography or
duplex of the mesenteric vessels. Treatment is with risk reduction such as smoking cessation and with
revascularization with stent placement.
350. Gallstones are the leading cause of acute pancreatitis.
 Dr.AmeerAboMokh
351. Etiology of PUD: H.pylori, NSAIDs, COPD, chronic renal failure, cirrhosis, nephrolithiasis, alpha 1 anti-
trypsin deficiency, current tobacco use, former tobacco use, older age, three or more doctor visits per year,
CAD, former alcohol use, African American, obesity, diabeted mellitus, etc.
352. Due to the high risk of colon cancer in UC patients it is recommended to have colonoscopies every 1-2
years if: pancolitis for 8-10 years or proctosigmiditis over 12-15 years.
353. Prediabetes (impaired fasting glucose or impaired glucose intolerance): fasting glucose (100-
125mg/dL), 2 hours plasma glucose 7.8-11.0mmol/L (140-199mg/dL) and HbA1C- 5.7-6.4%.
354. Associated diseases with celiac disease: 1) Dermatitis herpetiformis 2) Diabetes mellitus type I 3) IgA
deficiency 4) Down syndrome 5) Turner syndrome.
355. Colorectal cancer is the second leading cause for mortality in the western world (after lung cancer). Its
incidence is decreasing in the last 20 years due to early screening tests (colonoscopy, fecal occult blood
test). The origin of the disease starts with an adenomatous polyp seen in colonoscopy in majority of the
cases. Less than 1% of the colon adenomas will go malignant transformation and it takes about 10 years.
356. Statins are HMG-CoA reducatase inhibitors. Statins leads to decreased LDL and triglyceride levels. Their
side effects include hepatitis, myopathy, dyspepsia, fatigue, headache, etc. the risk of myopathy increase
with age, renal failure and drugs such as antibiotics, antifungal, immunosuprresives and
fibrates(gemfibrozil). AST and ALT should be measured before treatment and then annually.
357. DM type2 screening test will be done in:
1.All people above 45 years, every 3 years.
2.In younger individuals with BMI >25 and additional risk factor for DM (physical inactivity, family history,
macrosomic baby, gestational diabetes, hypertension, etc.)
358. Esophageal cancer manifests with progressive weight loss and dysphagia first to solids then to liquids. It
is diagnosed using endoscopy.
359. Initial treatment of DKA is IV Fluids with short acting insulin.
360. Thyrotoxicosis is seen with altered mental status, fever and tachycardia, mostly with Grave’s in the
background.
361. Pharmacological agents. Drugs that are used include: bisphosphonates, selective estrogen receptor
modulator, progestin, calcitonin and denosumab.
Side effects of bisphosphonates include: atypical femor fracture, jaw osteonecrosis and esophageal irritation.
Alendronate should be taken with a glass of water due to its poor absorption.
362. CMV esophagitis appears most often in immunocompromised patients after transplantation. Endoscopic
examination reveal deep and linear ulcer in the distal esophagus. Treatment is with ganciclovir.
363. Acute pancreatitis: US is the best initial diagnostic step in the emergency room (to detect the etiology
such as gallstones) while CT scan maybe done later.
364. Diarrhea with increased fecal fat and decreased D-xylose absorption→ Celiac disease.
365. Amylase and lipase both increase in less than a day (and at the same time) in acute pancreatitis. Increase
of more than 3 fold in their levels are suggestive of acute pancreatitis. In chronic pancreatitis amylase and
lipase are normal in many cases. From both markers lipase has higher specificity.
366. Treatment for acute adrenal insufficiency (hypotension, hyponatremia, hyperkalemia) is with fluid and
hydrocortisone, followed by fludrocortisone (mineralocorticoid).
367. Gold standard for diagnosis of acute mesenteric ischemia is with CT angiography and treatment is with
laparotomy (Take the patient to the OR!!!).
Duplex US isn't indicated in acute mesenteric ischemia, duplex of the mesenteric vessels is used in case of
chronic mesenteric ischemia.
368. Pill esophagitis is caused when swallowed pill lodges in the esophageal lumen and can't proceed
further. It occurs when inadequate fluid is taken with the pill. Medications associated with pill esophagitis:
doxycycline, tetracycline, quinidine, phenytoin, potassium chloride, ferrous sulfate, NSAID and
bisphosphonates. Clinical manifestations are sudden onset of chest pain and odynophagia.
369. Pituitary adenoma is one of the many causes of hypopituitarism. In patients with hypopituitarism levels
of GH, LH, FSH, ACTH, prolactin and TSH are reduced. This can lead to clinical manifestations related to a
decrease in the end products of these hormones.
 Dr.AmeerAboMokh
370. Microscopic changes of Crohn's disease include non-caseating granulomas, transmural inflammation
and lymphoid aggregates.
371. Erythema nodosum and peripheral arthritis are usually correlated with bowel activity. They occur in
flares of IBD.
372. OGTT is used to diagnose acromegaly.
373. Primary hypothyroidism is associated with increased prolactin due to increase in TSH and TRH.
374. Thyroid gland surgery → PTH glands removed → Hypocalcemia → It manifest with muscle spasm,
carpopedal spasm, facial grimacing, depression and prolonged QT interval.
375. GLP-1 analogs are one of the treatments of T2DM. Their major side effect is nausea and they are
contraindicated in renal disease and medullary carcinoma of the thyroid. Don’t cause hypoglycemia.
376. DM2 insulin dosage: 0.2-0.3 U/kg/day DM1 insulin dosage: 0.5-1.0 U/kg/day
377. In subclinical hypothyroidism pregnancy should be evaluated before treatment is started. Measure b-hcg.
In subclinical hypothyroidism only TSH is elevated while the patient is asymptomatic. Treatment with
levothyroxine is indicated if TSH is higher than 10, TPO is positive, pregnancy and heart disease.
378. Quadruple therapy in case of resistance with triple therapy: clarithromycin/metronidazole + PPI+ bismuth+
tetracyclin.
379. In pregnant women with levothyroxine treated hypothyroidism the requirement for thyroid hormone are
increased by 50%.
During pregnancy total T4 increases, free T4 is unchanged and TSH decreases.
380. Case: old man has IDA, so colonoscopy and capsule done and were free →oral iron and follow-up
enough.
381. Hydrogen breath test or lactose exclusion trial are used to diagnose lactose intolerance.
382. Lithium causes nephrogenic DI.
383. Prolactin inhibits GnRH and is stimulated by TSH. Dopamine inhibits prolactin.
Diagnosis of prolactinoma is clinical and by measuring prolactin levels. In macroadenoma (tumor more than
1cm) it is important to check visual fields.
Treatment is divided into pharmacological and surgical. Pharmacological treatment is with dopamine agonists
(bromocriptine and cabergoline). Surgery is suggested when there is resistance to pharmacological therapy.
In case of asymptomatic patient no treatment is needed.
384. Patient less than 50 with primary hyperparathyroidism will have parathyroidectomy.
385. Patient who can't discontinue NSAIDs need to have PPI in order to treat peptic ulcer disease.
386. Primary hyperparathyroidism presents with high PTH and calcium and low phosphate.
387. Insulin and insulin secretagogues(either sulfa or non sulfa like Repaglinide) can cause hypoglycemia.
388. Treatment of gastric ulcer is with PPI and repeated endoscopy within 8-12 weeks(to confirm
eradication).
389. 1st degree relative with cancer age >60 → screening every 10 yrs starting at age 40.
2x 1st degree relative with cancer age >60 or 1 relative <60yrs → screening every 5 yrs starting at age 40
390. HHNC: If serum sodium is above 150mEq/L (after correction ”1.6 for each 100 glucose increase”) then
0.45% saline is used.
Also use 0.45% for hemodynamic stable patient (even without hypernatremia after correction). NS is used in hemodynamic unstable patient.
Treatment starts with fluid replacement (normal saline) in order to achieve stable hemodynamic state. If serum sodium is above 150mEq/L then 0.45%
saline is used in order to prevent fast correction of the sodium. After hemodynamics are stable 0.45% saline is used and then D5W (5% dextrose in
water). Insulin is added at rate of 0.1unit/kg/hour until glucose levels decrease to 250mg/dL.
391. Subacute thyroiditis (also named de Quervain’s thyroiditis or viral thyroiditis):
The disease usually affects middle aged women and is characterized by 3 phases that span over
approximately 6 months:
-A thyrotoxic phase with inflammation and disruption of the thyroid gland follicles leading to increased
serum thyroid hormones (with thyrotoxicosis symptoms) and decreased TSH. Radioactive uptake in this
phase is low (due to the inflammation and disruption of the thyroid gland follicles).
-A hypothyroid phase which usually begins weeks after the initiation of symptoms and is characterized by
low circulating thyroid hormones and increased TSH levels. Radioactive uptake in this phase is normal or
elevated.
-A recovery phase in which thyroid hormones and TSH return to normal serum levels.
 Dr.AmeerAboMokh
392. Patient who presents with hypokalemic hypertension should be evaluated for primary hyperaldosteronism
with aldosterone: renin ratio.
393. Osmotic diarrhea occurs due to osmotic component that isn't absorbed from the intestine and as a result
there is water flow into the intestine. Lactase deficiency leads to osmotic diarrhea. Osmotic diarrhea usually
disappears with fasting. Important diagnostic method to differentiate between chronic diarrhea types is
osmotic gap. Osmotic gap above 50 is suspicious for osmotic diarrhea.
394. Candina albicans is the most common causative agent of infectious esophagitis. It is treated with oral
fluconazole.
395. Patients with vitamin D deficiency will have concurrent hypophosphatemia and hypocalcemia and
hypomagnesemia.
Vitamin D deficiency presents as osteomalacia in adults. Vitamin D function is to increase calcium and phosphate absorption from the intestine.
396. IBS-Constipation dominant treatment: increase fiber intake, osmotic agent as polyethylene glycol,
lubiprostone, linaclotide.
397. Chronic pancreatitis is initially diagnosed with CT scan (may show calcifications).
398. IBS-D treatment includes antispasmodics, antidiarrhea, bile acid binders and newer gut serotonin
modulator.
399. PTHrP is elevated in squamous cell carcinoma of the lung leading to increased calcium and decreased
PTH and phosphate.
400. IBD CRC screening: Crohn’s disease\pancolitis UC → Yearly(every 1-2yrs) after 8 years.
Lt-sided UC → Yearly(every 1-2yrs) after 15 years
401. Vitamin D deficiency presents with hypocalcemia, hypophosphatemia and hypomagnesemia.
Hypoparathyroidism presents with increased phosphrous.
402. 3-9 adenomas, or any high-risk adenoma (e.g. high grade tubulovilluos adenoma polyp) --> Repeat
colonoscopy in 3 years
403. UC: mucous+WBC+RBC in stool, crypt abscess, deep ulcerations that appear as "collar button" ulcers
and haustra thickening (lead pipe appearance).
404. Chronic mesenteric ischemia (food fear) is due to atherosclerosis (not Afib).
405. Treatment of hypoparathyroidism is with calcium and vitamin D. Thiazide is added to prevent
nephrocalcinosis.
406. Acute gastritis most common etiology is infection. Other causes are associated with stress such as: burns
(Curling ulcer), brain injury (cushing ulcer) and others.
Chronic gastritis is divided into Type A and Type B according to the location of involvement. When type A
involve the body and it is as a result of autoimmunity (pernicious anemia), Type B involve the antrum and is
associated with H.pylori.
407. The treatment goals for DM are:
Glycemic control: HbA1C<7% ; fasting glucose 80-130mg/dL ; postprandial glucose <180mg/dL.
Blood pressure control <140/90.
Lipids: LDL <100mg/dL ; HDL >40 in men and >50mg/dL in women; triglyceride <150mg/dL.
408. HSV esophagitis appears with vesicles and punched out ulceration on endoscopy. Treatment is with
acyclovir.
409. Treatment of achalasia includes pharmacological therapy which is relatively ineffective when compared to
Heller myotomy or balloon dilatation.
410. Primary hyperparathyroidism adenoma diagnosis is composed of characteristic laboratory values and
nuclear scan (99 technicium sestamibi scan with SPECT).
411. Celiac disease is associated with GI and non-GI malignancies. Among them lymphoma is frequently
seen in celiac patients.
412. Patients with minor GI bleeding who are less than 40 years old can have sigmoidoscopy as diagnostic
test. (colonoscopy is done in stable patient, over the age of 40 with lower GI bleeding\\anoscopy is not used
to detect lower GI bleeding)
413. Treatment of acute pancreatitis: aggressive fluid resuscitation, intravenous analgesics and NPO.
414. Asymptomatic patients with subclinical hypothyroidism should be followed up annually (and TSH<10).
 Dr.AmeerAboMokh
415. Adrenal insufficiency is either primary (adrenal defect) or secondary (due to a defect in the hypothalamus or pituitary). In primary insufficiency
(also known as Addison’s disease) there is a deficiency of both mineralocorticoids and glucocorticoids, whereas in secondary insufficiency there is
glucocorticoid deficiency. Androgen secretion is disrupted in both.
Chronic adrenal insufficiency present as fatigue, hyperpigmentation in areas of friction (due to stimulation of melanocytes by ACTH in primary
insufficiency). Labs show hyponatremia and hyperkalemia.
Acute adrenal insufficiency (“adrenal crisis”) is usually associated with Addison’s disease and presents as postural hypotension, abdominal
tenderness, fever, nausea and vomiting. There is usually a prodrome of nonspecific complaints for a long period. It may be triggered by an illness,
stress (i.e. surgery), hyperthyroidism. Dx by ACTH stimulation (co-syntropin test)
Adrenal crisis typically presents as low blood pressure, fever, fatigue, abdominal pain, hyponatremia and
hyperkalemia. It is an emergency which requires immediate treatment with rehydration and hydrocortisone.
416. Kallmann syndrome occurs when the synthesis of GnRH is defective. It is associated with decrease in
the smelling sensation (anosmia). Other manifestations include: color blindness, optic atrophy, nerve
deafness, cleft palate, renal abnormalities, etc. The absence of GnRH leads to delayed puberty and
hypogonadism in males. Females presents with primary amenorrhea and failure of secondary sexual
development.
417. Least common complication of endoscopic procedures: Infection (perforation, res. depression,
pancreatitis occur more).
418. On Synacthen test: Secondary adrenal insufficiency has low ACTH vs. Primary adrenal insufficiency has
high ACTH (absent feedback).
We can measure cortisol level only and see it is low although ACTH was give → primary adrenal insuff.
419. In ulcerative colitis (UC) treatment is divided into remission and maintenance.
Remission drugs: 5-ASA and steroids
Maintenance: anti TNF(infliximab), MTX, Azathioprin, 6-MP. (If 6-MP is not useful → move to Infliximab)
420. Agranulocytosis is a major and dangerous side effect of anti-thyroid drugs(like PTU).
421. Before FNA is done in patient with incidentaloma and history of malignancy, screening for
pheochromocytoma is needed.
Generally, incidentaloma masses ≥4.0 cm should be removed. ... ‫احفظ هاي وخلص‬
422. Community acquired pneumonia, clostridium difficile diseases, inhibition of IF production, inhibition of
CYP450 (warfarin, phenytoin..) are potential side effects of PPI.
423. Women after the age of 65 should have bone density scan to evaluate osteoporosis.
424. H.pylori is a common etiology of both gastric and duodenal ulcers. It is also associated with MALT
lymphoma, gastritis and gastric adenomcarcinoma.
425. Cimetidine “H2 blocker”: it has several side effects associated with anti-androgen activity such as
gynecomastia and impotence. Moreover it affects cytochrome P450 and monitoring of theophylline, warfarin
and phenytoin is needed with long term use.
426. Fecal osmotic gap over 50 indicate osmotic diarrhea. This means that there is an osmotic metabolite
which is not sodium or potassium in the intestinal lumen such as carbohydrates, which is not breaking down
due to lactase deficiency.
Fecal osmotic gap= fecal osmolarity- 2(fecal Na+ fecal K).
Addison disease leads to secretory diarrhea. IBD is a cause of inflammatory diarrhea.
427. The appropriate initial evaluation for suspected esophageal dysphagia (even if achalasia is suspected) is
the performance of an upper endoscopy which allows visualization of the mucosa and gives the ability to
perform biopsies from suspicious lesions.
428. Tropical sprue occurs in tropical area: southern India, Philippines and Caribbean islands.
Clinical manifestations: diarrhea, steatorrhea, weight loss and nutritional deficiencies including folate and
vitamin B12. There is increased osmotic gap in stool.
Diagnosis is based on biopsy from the small intestine showing similar changes as in celiac disease (less
flattening and atrophy of the villi and more infiltration of lymphocytes into the lamina propria). Gluten free diet
doesn't improve the disease.
Treatment starts with antibiotics and folic acid. Tetracycline is used for up to 6 months and show
improvement within 1-2 weeks.
429. H.pylori: when symptoms of dyspepsia remain or recur (after treatment), endoscopic evaluation is
needed.
 Dr.AmeerAboMokh
430. Patients with GERD above the age of 55 and with more than 5 years of heartburn need gastroscopy also
if there are no alarm symptoms.
431. The fact that there is no blood in the nasogastric tube dose not exclude an upper GI bleed.
432. UC screening: colonoscopy every 1-2 years after 8 years of disease.
433. Celiac disease can present anytime throughout life (from age of 1 to the eighth decade). Etiology is
unknown but there are several genetic, immunological and environmental factors. Clear association was
established with gluten consumption.
Diagnosis of celiac disease starts with serological measurement of antibodies.
434. Silent thyroiditis is characterized by initial hyperthyroidism (low TSH and high FT4). Silent thyroiditis is
common with other autoimmune disease, mainly diabetes mellitus type 1. The condition also occurs in
pregnant women 3-6 months postpartum. The clinical course of the disease starts with hyperthyroid state for
2-4 weeks followed by hypothyroidism for 4-12 weeks and returning to normal state. Anti-TPO is commonly
seen in silent thyroiditis antepartum. RAIU scan will show no uptake of radioiodine. Clinically there is no pain
and no increased ESR (differentiates from subacute thyroiditis). Treatment in symptomatic patients is with
propranolol. In all other cases annual follow up is acceptable.
435. Hypoglycemia is considered as glucose level below 70mg/dL.
436. DES appears with corkscrew esophagus and is diagnosed with barium swallowing followed by
manometry. Treatment include: nitrates, CCB (Nifedipine), hydralazine, botulinum toxin and anxiolytics.
437. Thiazolidinedoines “rosiglitazone” side effects include: peripheral edema, congestive heart failure, weight
gain, fractures and macular edema.
438. "Cold" nodules are suspicious for cancer, thus US guided FNA is needed (Whatever the TSH is).
439. When gastrin levels are inconclusive in determining ZES, secretin stimulation test is needed.
440. Increased vitamin D due to increased ingestion or abnormal metabolism of the vitamin leads to increased
1,25(OH)2D metabolite, that increases in turn the levels of calcium and phosphate absorption.
441. Increased vitamin D (Excess) due to increased ingestion or abnormal metabolism of the vitamin leads to
increased 1,25(OH)2D metabolite, that increases in turn the levels of calcium and phosphate absorption.
Excess vitamin D will have negative feedback on PTH leading to decreased PTH levels.
442. Plummer-Vinson syndrome presents with esophageal web, esophageal ring, iron deficiency, atrophic
glossitis and other symptoms in middle aged women.
443. Nephrolithiasis in CD patients is due to calcium oxalate stone that develop as a result of hyperoxaluria
from increased absorption of dietary oxalate.
444. Prediabetes is defined as fasting glucose (100-125mg/dL), 2 hours plasma glucose (140-199mg/dL) and
HbA1C- 5.7-6.4%.
445. Treatment of gastric ulcer (H.pylori -ve) is with PPI and repeated endoscopy within 8-12 weeks.
446. Asbestosis and drug-induced (amiodarone, bleomycin, methotrexate) fibrosis: affect the lower zones.
Exposure to asbestos is a risk factor for bronchial carcinoma (more common) as well as mesothelioma.
Pleural plaques are benign and do not undergo malignant change. They are the most common form of
asbestos related lung disease and generally occur after a latent period of 20-40 years.
The severity of asbestosis is related to the length of exposure. This is in contrast to mesothelioma where
even very limited exposure can cause disease.
447. The diagnosis of MM is with electrophoresis showing M-spike and bence jones protein, and with bone
marrow biopsy presenting more than 10% plasma cells.
448. Criteria of MGUS include M protein in serum <30g/L, bone marrow clonal plasma cells <10%, no evidence
of other B cell proliferative disorders and no myeloma related organ or tissue impairment.
449. First line of treatment is imatinib (Glivec) which is a tyrosine kinase inhibitor(even better than bone
marrow transplant). Laboratory findings include leukocytosis (>50,000), anemia in one third of the patients,
thrombocytosis and basophilia. Peripheral blood presents with left shift including band cells, myelocytes,
metamyelocytes, promyelocytes and blast cells (<5%). Leukocyte alkaline phosphatase score is low and
LDH is high. BM examination shows hypercellularity with high myeloid:erythroid ratio and blast cells <5%.
450. In bacterial overgrowth folate levels are usually normal or even elevated due to synthesis of folate by
small bowel bacteria. However, it is typical to find B12 deficiency.
 Dr.AmeerAboMokh
Among causes of Folate deficiency are: Alcohol, Tropical sprue, Excess utilization or loss (anemia,
lymphoma, anticonvulsant, CHF, liver disease..).
451. Thoracostomy is indicated in case thoracentesis shows loculated pleural fluid, pH <7.2, glucose level in
the fluid <60mg/dL, positive gram stain and presence of gross pus in the pleural space. A thoracostomy is a
small incision of the chest wall, with maintenance of the opening for drainage. It is most commonly used for
the treatment of a pneumothorax.
452. Patient with VF is treated with defibrillation then if VF is still present amiodarone is given, and if not
sufficient lidocaine are given.
453. Heart failure is a contraindication for treatment with doxorubicin and thus R-CHOP protocol isn't used.
454. Asthma: Diagnosis starts with spirometry showing decreased FEV1/FVC. Reversibility is seen using short
beta 2 agonist which increases FEV1 by more than 12% or 200mL or with methacholine test which reduces
FEV1 by 20%.
455. In case of pleural fluid which is more than 1cm (>10mm) in size on X-ray, there is need for diagnostic
thoracentesis, except of cases of CHF which is bilateral and without pleuritic chest pain or fever.
456. Diagnosis of PNH: flow cytometry showing CD55 and CD59 negative cells.
457. Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by a triad of intravascular hemolytic anemia,
pancytopenia and tendency to venous thrombosis. Treatment include transfusion of filtered RBC when necessary, folic acid
supplementation are mandatory and eculizumab which binds the C5 complement component and will activate the membrane attack complex.
Definitive cure can be reached with allogenic bone marrow transplantation.
458. Myasthenia gravis: treatment is with pyridostigmine and removing the thymus. Removal of thymus will
result in clinical improvement in approximately 85% of myasthenia gravis even in the absence of thymoma.
459. Cardiogenic shock is characterized by increased CVP and systemic vascular resistance and decreased
cardiac output.
460. Acute promyelocytic leukemia (AML) is associated with DIC.
461. Hemophilia presents with prolonged aPTT and normal PT, bleeding time and platelets count (&Male).
462. The typical findings in bacterial meningitis are high opening pressure, 10-10,000 WBC (neutrophilic
pleocytosis), low glucose (<40), high protein (>45), positive gram stain (in 60% of cases) and culture (in
80%), and bacterial DNA on PCR.
463. Complications of SCD include splenic infarction, renal papillary necrosis, occlusion of the retinal vessels,
aseptic necrosis, osteomyelitis, dactylitis, stroke, priapism, acute chest syndrome.
464. CLL: Diagnosis with blood smear will show smudge cells and further diagnosis is done with flow
cytometry showing CD5+ cells. Lymph node biopsy will show small lymphocytes. Bone marrow biopsy shows
monoclonal B-lymphocytes. Blood count reveals lymphocytosis.
If treatment is indicated in CLL (advanced disease “III, IV”):
Below 65 years old: Rituximab + Cyclophosphamide + Fludarabine
Above 65 years old: Chlorambucil + Obinutuzumab OR Bendamustine + Rituximab
465. After initiating successful antiretroviral therapy in patients with HIV, especially in patients with CD4 under
50, up to 30% of patients develop a chain immune reaction called IRIS due to a sharp decrease in HIV RNA.
Immune reconstitution inflammatory syndrome (IRIS) is a condition seen in some cases of AIDS or
immunosuppression, in which the immune system begins to recover, but then responds to a previously
acquired opportunistic infection(e.g. TB) with an overwhelming inflammatory response that paradoxically
makes the symptoms of infection worse.
466. Blood smear must be part of the primary assessment in every thrombocytopenia and especially when it is
asymptomatic, in order to rule out pseudothrombocytopenia due to agglutination of the platelets with EDTA in
the test tube. In case of suspicion of pseudothrombocytopenia, blood should be collected into a test tube with
heparin or citrate.
467. Amyloid is an insoluble protein that deposits extracellularly. Diagnosis of amyloidosis is done with biopsy
of fat tissue followed by immunohistochemistry with congo red staining.
468. Hypernatremia is a life-threatening condition and warrants treatment with fluids, ideally free water by
mouth or nasogastric tube, or intravenous solutions such as D5W, 0.45% NaCl or 0.225% NaCl.
 Dr.AmeerAboMokh
469. Idiopathic pulmonary fibrosis (IPF) has characteristics of restrictive lung disease which shows FEV1/FVC
>80% (because FVC is reduced), reduced lung volumes (RV, TLC, FRC) and DLco. CT scan will show
patchy, basilar, subpleural reticular opacities with honeycombing and traction bronchiectasis.
470. Streptococcus pneumoniae is the most common cause of meningitis- accounting for approximately 50%
of cases in adults.
471. Aquagenic pruritus and eryhtromelalgia together with increased hemoglobin are suspicious for PV.
472. Hodgkin: Treatment in stage I and II is with short course chemotherapy with localized radiation. Treatment
for stages III/IV is with full course chemotherapy with ABVD. Patients that have relapse after remission with
chemotherapy will need autologous bone marrow transplantation in order to cure from the disease.
473. In order to start therapy the diagnosis must be confirmed. In order to confirm the diagnosis of interstitial
lung disease (ILD) the test of choice is lung biopsy. Biopsy is done by fibro-optic bronchoscopy with
multiple biopsies. In case diagnosis can't be established open thoracotomy is indicated.
474. Classical appearance on CT scan of resectable pancreatic cancer is enough in order to have surgery (no
need to know pathology by a biopsy).
475. Lungs are the most common primary origin of brain metastasis. Melanoma is the cancer most likely to send metastases to
the brain.
476. Cystic fibrosis (CF): fat soluble vitamin deficiency, malabsorption (steatorrhea).
477. ET patients who have platelets count over 1.5 million/uL or are over the age of 60 should receive
hydroxyurea and aspirin.
478. Treatment of aplastic anemia is with hematopoietic stem cell transplantation (HSCT) when compatible
sibling donor is available. In other cases antithymocyte globulin and cyclosporine are given.
479. Immune thrombocytopenic purpura (ITP) is characterized by immune mediated destruction of
thrombocytes. While in children it is acute disease in adults it is chronic disease with spontaneous remission
within months. ITP can be also secondary to autoimmune disease or infections. First line treatment of
patients without bleeding or severe thrombocytopenia is with steroids or IVIg. In patient with bleeding or
severe thrombocytopenia (<5000) hospitalization is needed together with steroids and IVIg. Anti D is useful in
patient in patients with Rh+ who haven't had splenectomy. Rituximab is used in refractory cases of ITP.
Splenectomy is done in patients who relapse after steroids tapering. TPO agonists are used in case of
relapse after splenectomy or unresponsiveness to at least one other therapy.
480. When INR is above 10 and there is no bleeding then vitamin K is given. If there is serious bleeding then
vitamin K and FFP are given.
481. Q fever (Coxiella burnetii): a zoonotic disease and the main sources that can transmit are cattle, sheep
and goats. The people who are at risk are farmers, veterinarians, ranchers and in fact everyone who comes
in contact with the animals and especially with their puppies and placenta. Clinical features include fever, dry
cough, mild thrombocytopenia, lymphadenopathy and rash. The diagnosis is based on serological tests. The
usual treatment for acute Q fever is doxycycline at 100 mg twice daily for two weeks.
482. Chylothorax is a form of pleural effusion which occurs due to disruption to the thoracic duct. The most
common etiology is trauma but also malignancies of the mediastinum can lead to this. Thoracentesis
reveals milky fluid and triglycerides are above 110mg/dL.
483. Liddle's syndrome is a rare autosomal dominant condition that causes hypertension and
hypokalaemic alkalosis. It is thought to be caused by disordered sodium channels in the distal tubules
leading to increased reabsorption of sodium. Plasma aldosterone and renin levels are low.
Liddle syndrome is a tubular syndrome caused by ENaC hyperactivity resulting in a hyperaldosteronism-like state: hypertension, hypokalemia and
metabolic alkalosis.
484. Treatment of moderate persistent asthma is with SABA+ICS+LABA.
485. Hypertension has the highest relative risk for stroke.
486. Aplastic anemia Blood smear shows large RBC and low to absent thromobocytes, granulocytes and
reticulocytes. Bone marrow biopsy shows fatty specimen and hypocellularity.
487. Unfractioned heparin works by activation of antithrombin and by this accelerates inhibition of clotting
factor, mainly thrombin and factor Xa. LMWH work similarly to heparin, however it inhibits factor Xa more
than thrombin.
 Dr.AmeerAboMokh
488. Heparin induced thrombocytopenia (HIT)occurs due to antibodies that target platelet factor 4 (PF4). HIT
occurs within 5-14 days. The reduction in platelets level is more than 50%.
489. vWD will present with prolonged aPTT, decreased factor VIII activity and normal platelet count.
490. Patients with bleeding who are treated with warfarin should be treated with vitamin K and FFP
(cryoprecipitate is only given in life threatening bleeding).
491. In case INR is 3.5-10 warfarin should be withheld until it returns to the therapeutic range. If INR is
above 10 then vitamin K and FFP are administered.
492. First step in treatment of acute asthma exacerbation (e.g. with dyspnea) is with oxygen. This is followed
by SABA and ICS. In severe cases OCS is given.
493. Dabigatran is a new oral anticoagulant which inhibits thrombin directly. It is approved for stroke
prevention in non-valvular atrial fibrillation. It causes less intracranial bleeding than warfarin and is
effective in prevention of recurrent VTE. It is contraindicated in renal failure if creatinine clearance is below
15.
Other NOACs (rivaroxaban,apixaban,edoxaban) work on factor Xa.
494. MM: treatment in patients who can't undergo transplantation is with thalidomide, lenalidomide or
bortezomib combined with dexamethasone. (Use one or two drugs of these with dexamethasone).
495. Hypotension, high fever and erythroderma are very suspicious of TSS as a result of Staph aureus.
Treatment first and foremost must include fluids and vasopressors to increase blood pressure. The
recommended antibiotic treatment today is a combination of clindamycin(because it is a protein synthesis
inhibitor which lowers the toxin synthesis) with penicillin. TSS can develop from any infected site, e.g. from
dermal infection like a bite.
496. Mechanical ventilation is used in case of respiratory failure. One of the side effects of invasive mechanical
ventilation is respiratory alkalosis → Decrease respiratory rate.
497. The clotting factors in the liver are mostly dependent on vitamin K for their metabolism. Factor V is
produced in the hepatocytes and isn't dependent on vitamin K. Low factor V levels differentiates between
hepatocyte failure and vitamin K deficiency. Following factor V activity is part of the evaluation of fulminant
hepatitis.
498. Reversible causes of dementia: depression, hydrocephalus and alcoholism. Other causes include
infection, endocrine disorders, vitamin deficiencies (Vit. B12), etc.
499. The cornerstone of botulism treatment is ICU and botulinum anti toxin.
Botulism: most commonly it occurs after eating home-canned food. Clinical manifestation includes paralysis
of cranial nerves that may cause diplopia, dysarthria, ptosis, ophthalmoplegia, depressed pupil reflex, dilated
pupils, respiratory depression, dizziness, dry mouth and sore throat, flaccid paralysis of voluntary muscles
and even death. Patients are usually fully conscious, but dysarthria, ptosis and paralysis may mislead that
there is a change in their state of consciousness.
500. Waldenstrom macroglobulinemia (WM) is a lymphoplasmacytic lymphoma that secretes monoclonal
IgM. It is most commonly known due to its hyperviscosity syndrome but other manifestations such as
lymphadenopathy and hepatosplenomegaly also appear. Hyperviscosity syndrome is characterized by blurry
vision, headaches, dizziness, altered mental status and cardiopulmonary disorders such as congestive heart
failure. Diagnosis with bone marrow biopsy will show increased plasmacytoid lymphocytes. Serum
electrophoresis show increase IgM . Treatment for hyperviscosity is with plasmapheresis.
501. Thalassemia presents with Mentzer index <13.
Sideroblastic anemia presents with high Iron and Ferritin.
502. Bronchiectasis: productive cough which is tenacious and thick. Clubbing.
CT scan is the diagnostic imaging of choice. It shows airway dilatation known as "tram track" or "signet ring
sign" and bronchial wall thickening in the dilated airways.
503. Thrombosis is seen more commonly (than bleeding) in patients with HIT.
504. AA amyloidosis is associated with chronic inflammatory diseases (ex: RA).
505. Allergic bronchopulmonary aspergillosis (ABPA) is caused by aspergillus infection. It presents with
eosinophilia and asthma symptoms. Diagnosis is determined by increased eosinophils and by skin sensitivity
 Dr.AmeerAboMokh
test showing positive serum precipitins for aspergillus. Other signs include central bronchiectasis and
brown plugs of mucus. IgE is increased..
506. Primary myelofibrosis (PMF) is a myeloproliferative disorder (JAK2) characterized by marrow fibrosis,
extramedullary hematopoiesis and splenomegaly. The disease is usually discovered due to splenomegaly,
weight loss, fatigue and night sweats. Blood smear will show characteristic teardrop shaped RBC
"dacrocyte". LDH and alkaline phosphatase can be elevated. Bone marrow aspiration presents with dry tap.
507. Vitamin A poisoning can cause increased intracranial pressure, diplopia, seizures, dermatitis, acne and
even death. Chronic poisoning is manifested with cheilosis, glossitis, hypercalcemia, etc.
508. Moderate persistent asthma is characterized by daily daytime symptoms and night time symptoms more
than once a week and FEV1 is 60-80. The treatment of moderate persistent asthma is with SABA + ICS low
dose + LABA.
509. Treatment of PNH include eclizumab, folic acid and filtered RBC transfusion. Definitive cure can be
reached with allogenic bone marrow transplantation.
510. Diagnosis of OSA is based on symptoms of nocturnal breathing disturbances + >5 episodes of apnea per
hour of sleep each lasting for at least 10 seconds each.
511. HRT is contraindicated in factor V leidin.
512. Neutropenia due to chemotherapy needs continuous follow up (No need to treat).
513. Bone pain is the most common symptoms of multiple myeloma.
514. UFH is monitored by aPTT.
Heparin is an anticoagulant which can be administered intravenously or subcutaneously. Subcutaneous treatment is given in order to prevent
thromboembolic events (such as surgeries or hospitalized patients). It doesn't need to be monitored. When UFH is given intravenously its action is
unpredictable and necessitates monitoring.
515. Mild intermittent asthma is characterized by daytime symptoms less than two days a week, night time
symptoms less than 2 times per months, FEV1/FVC =80.
Mild intermittent asthma Rx: short acting beta agonist (SABA).
516. Localized Hodgkin lymphoma (Stage I) has more than 90% cure rate. Treatment in stage I and II is with
short course chemotherapy with localized radiation. Treatment for stages III/IV is with full course
chemotherapy with ABVD.
517. Treatment of PV is based on phlebotomy, anticoagulants after first episode of thrombosis, ruxolitinib
(Jack2 inhibitor), anagrelide and antihistamines.
518. Anemia of chronic disease present with high ferritin, low iron and low TIBC.
519. The treatment of thrombosis in patients with HIT is with direct thrombin inhibitors such as argatroban or
lepirudin.
520. Leptospirosis is a zoonotic infection caused by a spirochete. Humans are infected upon direct contact
with animal secretions or tissue. An additional option for transferring this disease is via polluted water.
Possible risk factors for this infection include: working in close proximity with animals(farmers), exposure to
water ( sailing, swimming in freshwater), travelers.
In most cases the infection is asymptomatic. Only 1% of those who are infected develop a severe disease.
Weil syndrome is a severe manifestation of leptospirosis, and its manifestations are: jaundice,
thrombophilias, hematomas and kidney failure. It can be life threatening, and can deteriorate to full blown
sepsis with multi organ failure. Meningitis with impaired consciousness can also occur. Definitive diagnosis of
leptospirosis is achieved via PCR or seroconversion. In mild cases, patients can be treated with either
amoxicillin or doxycycline PO. Once severe disease is suspected, patients should be treated with penicillin
IV.
521. Treatment of bacterial meningitis is with ceftriaxone and vancomycin.
522. Low platelets, petechiae and normal blood smear → No further tests needed (ITP).
While in children it is acute disease in adults it is chronic disease with spontaneous remission within months.
First line treatment of patients without bleeding or severe thrombocytopenia is with steroids or IVIg. In
patient with bleeding or severe thrombocytopenia (<5000) hospitalization is needed together with steroids
and IVIg. Anti D is useful in patient in patients with Rh+ who haven't had splenectomy. Rituximab is used in
refractory cases of ITP. Splenectomy is done in patients who relapse after steroids tapering. TPO agonists
are used in case of relapse after splenectomy or unresponsiveness to at least one other therapy.
 Dr.AmeerAboMokh
523. Hypersensitivity pneumonitis (HP) is an alveolar inflammation in response to extrinsic allergen.
Etiologies is varies and include birds, coffee beans, grain, moldy hay, etc. It presents with acute, subacute
and chronic presentations. Acute and subacute clinical presentation is with fever, chills and malaise. Chronic
presentation starts with gradual symptoms such as cough, fatigue, weight loss, dyspnea and clubbing of the
fingers.
X-ray examination shows micronodular opacities or hazy ground glass appearance in acute and subacute
cases. In chronic cases more fibrotic characteristic are seen. Spirometry shows obstructive or restrictive
characteristics. Lung biopsy shows non caseating granulomas.
Treatment is with avoidance of the underlying cause and in chronic cases with steroids.
524. AL- amyloid composed of immunoglobulin light chains. It is associated with myeloma or lymphoma.
AL amyloidosis manifest with renal symptoms: proteinuria, hypoalbuminemia, hypercholesterolemia,
hypertriglyceridemia and edema. Cardiac symptoms: diastolic dysfunction and thickened ventricles.
Neurological symptoms: autonomic dysfunction and sensorimotor neuropathy. Other signs include
macroglossia, cholestasis, factor X deficiency and hepatosplenomegaly.
525. Diagnostic imaging of choice in bronchiectasis is CT scan.
526. SCD is treated with hydroxyurea (Enhances Hb F levels, which interferes with the sickling process). In
acute chest syndrome the treatment is with hydration, transfusion and exchange transfusion.
527. Steroids, IVIg or anti D are first line therapies for patients with ITP.
528. Cisplatin causes renal impairment and peripheral neuropathy (hearing impairment).
Carboplatin has same side effects as Cisplatin but it is less nephrotoxic and neurotoxic.
Bleomycin causes bone marrow suppression, mucositis, alopecia and lung fibrosis.
Cyclophosphamide causes hemorrhagic cystitis and myocarditis.
Alkylating agents cause bone marrow suppression, hair loss, infertility, mucositis and they are teratogenic. In addition they increase the risk of secondary tumors such as
acute leukemia and myelodysplastic syndrome. Cyclophosphamide, Melphalan, Chlorambucil and Carboplatin are alkylating agents.
529. GERD and post nasal drip can cause chronic cough. Pneumonia may cause acute and subacute cough
that last less than 8 weeks.
530. Left ventricular failure is the most common cause of pleural effusion.
531. Diagnostic tests of hereditary spherocytosis are: osmotic fragility test, eosin-5 maleimide binding test and
SDS gel electrophoresis.
532. Diagnosis of Hodgkin lymphoma is done by complete lymph node excision and biopsy. On specimen
Reed-Sternberg cell are characteristic finding.
533. Myelodysplastic syndrome (MDS) is a hematological disease divided into five entities which are characterized by: cytopenia and dysmorphic blood
cells and precursors due to bone marrow failure and by high risk of acute myeloid leukemia transformation.
Etiology of MDS is associated with either idiopathic reasons or secondary causes such as radiation, chemicals (benzene) and chemotherapeutics
(especially alkylating agents). Cytogentics abnormalities are also been found to be associated with MDS (defects in chromosomes 5, 7, 20,trisomy of
8).
Clinically anemia is seen early in the course of the disease with typical complains of fatigue, weakness, dyspnea and pallor. However some of the
patients are asymptomatic. Laboratory results show pancytopenia and macrocytosis. Blood smears show hypogranulated neutrophils with
hyposegmented, ringed or abnormally segmented nuclei. Bone marrow biopsy is hypercellular, but in up to 20% of the cases it can be hypocellular.
Curative treatment is only possible with hematopoietic stem cell transplantation (HSCT). Lenalidomide is effective treatment in MDS patients with 5q-
syndrome.
534. Cardiogenic pulmonary edema is treated with: oxygen, morphine, furosemide, nitrates and vasopressors
(if needed). It presents with dyspnea, LV low EF, tachycardia, tachypnea, diffuse crackles...
535. Differential diagnosis of lymphocytosis (>50%) in pleural fluid: cancer, TB or rheumatologic disease.
Differential diagnosis of high neutrophils count: parapneumonia, PE and pancreatitis.
Case: a patient presents with exudative fluid which contains high lymphocyte count. These findings are
suspicious for malignancy and thus cytology should be done.
536. Prognosis of patients with AML is classified into favorable, intermediate and poor. Patients with
translocation (15,17), t(8,21) and inversion (16) have good prognosis, patients without cytogentic
abnormalities have intermediate outcome risk and patients with t(6,9) , inversion (3) or -7 have very poor
prognosis.
537. In all patients with INR> 3.5 warfarin needs to be stopped (and not to reduce the dose!!!).
538. Patient with AL type amyloidosis will present with factor X deficiency.
539. Nodule up to 6-8 mm will be checked again by CT scan after 6-12 months.
 Dr.AmeerAboMokh
540. In case of asymptomatic patients with low stage CLL follow up alone is enough. In more advanced stage
(such as bone marrow failure) treatment is initiated.
541. Peripheral lung cancer should be sampled with CT guided needle biopsy. If there is suspected mets in
the body, PET-CT is indicated after the biopsy confirms the diagnosis.
Central mass can be sampled with bronchoscopy if there is a bronchus that allows sampling of the tumor.
542. Lung cancers “Bronchogenic carcinoma” are most commonly associated with asbestosis (more than
mesothelioma).
543. Bone marrow failure (thrombocytopenia), splenomegaly >6cm, LN >10cm, Immune anemia or
thrombocytopenia, constitutional symptoms: are indications to treat CLL.
544. Silicosis is an occupational induced disease. It presents with restrictive lung pattern "RV decreased, TLC
decreased and FEV1/FVC >80%" and hilar lymph node calcifications "eggshell appearance". X-ray shows
opacities affecting the upper lobes of the lungs.
545. Erysipelas is a superficial skin infection syndrome characterized by clear borderline inflammation. The
typical contaminant is GAS and the treatment of choice is penicillin (e.g. Dicloxacillin). A common source
of penetration is damaged skin due to mycosis"e.g. fungus in the legs", injuries, stings and more.
546. Occupational exposure to Asbestos during mining, construction (pipe fitters and boilermakers) or ship
repair imposes increased risk for developing asbestosis.
Asbestosis is characterized by chest X-ray showing pleural thickening or calcification, especially in the lower
lung fields. Spirometry will show restrictive pattern (reduced lung volumes and diffusing capacity).
547. The patient in this question has clinical and radiological evidence of COPD with emphysema. COPD is
associated with smoking, and pulmonary function test will reveal decreased FEV1/FVC and decrease FVC
with increase in RV and FRC.
Diseases which are associated with COPD are chronic bronchitis, asthma, emphysema and bronchiectasis.
548. The most common side effect of transfusion of cellular blood components is febrile non hemolytic
reaction.
549. Urinary tract infection is a common infectious syndrome. Generators are usually gram-negative bacilli
bacteria. It is common to divide the infections into complicated and uncomplicated. Urinary tract infection,
which is not complicated, is an inflammation of a healthy, non-pregnant woman, without suspicion of resistant
bacteria. All other infections are considered to be complicated UTI. Recent consumption of antibiotics makes
us suspect infection of resistant bacteria or fungal infection.
First step in diagnosis: Urinalysis.
550. Assay for ADAMTS 13 can diagnose TTP.
551. Methylmalonate is used to differentiate between vitamin B12 deficiency and folate deficiency.
552. Increased fibrin degradation product (FDP) is the most sensitive test for diagnosing DIC. In addition
platelets count is decreased, fibrinogen is decreased and PT and aPTT are prolonged. Blood smear will
show schistocytes (due to microangiopathic hemolytic anemia). Treatment with fresh frozen plasma (FFP) and/or platelets is
indicated in case of active bleeding or high risk of bleeding. Cryoprecipitate is given in case of low fibrinogen level, <100mg/dL.
553. Hyperkalemia Rx: calcium gluconate, insulin IV, Ventolin inhalation, diuretics and Kayexalate. Dialysis is
done only if the mentioned pharmacological therapy fails (even if there is ECG changes).
Hyperkalemia is defined as potassium level above 5.5 mMOL / L. Severe hyperkalemia is defined as a level above 6 mMOL / L. There are 2 main
causes of hyperkalemia - the first is the transfer of intracellular potassium into extracellular fluid, and the second is a decrease in the potassium
secretion in the kidney, which is the most common cause (another cause is pseudohyperkalemia, which is not true hyperkalemia).
The physiological response of nephron to the GFR decrease is prostaglandin-mediated vasodilatation of afferent artery, angiotensin II mediated
efferent artery vasodilation, and thus preserves glomerular perfusion pressure. Thus, concomitant administration of NSAIDS and ACE-I, which result
in a decrease in the production of these substances, will result in a decrease in glomerular perfusion pressure, a decrease in GFR, and in the end a
decrease in potassium secretion in the kidney. Another effect that contributes to hyperkalemia in the administration of ACE-I is in an indirect
mechanism through disturbing aldosterone secretion.
Hyperkalemia is a life-threatening condition due to conduction disorders - bradycardia, asystole, sinus arrest, and arrhythmias such as VT and VF.
The first change to be seen in hyperkalemia is peaked T waves caused by changes in myocardial repolarization; Another increase cause conduction
disorders that manifest as prolonged PR interval and QRS segment expansion. In severe hyperkalemia, P waves disappear and the QRS segment
appears very wide until a rhythm called sine wave, which subsequently leads to VF and asystole.
Hyperkalemia above 6.5 mMOL, with or without the presence of ECG changes, requires aggressive treatment including cardiac monitoring and drug
therapy.
554. Patients with COPD will present with hypercapnia (High PCO2 levels), hypoxia and decreased pH.
 Dr.AmeerAboMokh
555. Trousseau sign (peripheral thrombophlebitis in presence of visceral cancer) is associated mainly with
pancreatic cancer. Migratory thrombophlebitis is the classic presentation of Trousseau sign. CA19-9 is
elevated in pancreatic cancer.
CA 15-3 is elevated in breast cancer. CA-125 is elevated in ovarian cancer.
556. During acute exacerbation of bronchiectasis antibiotics are recommended "targeted against
H.influenzae and P.aeruginosa." Dornase (rhDNase) is only used for CF associated bronchiectasis.
557. Treatment of APL [t(15,17)] is with Tretinoin.
558. Frequency of COPD exacerbation is decreased by: LABA, inhaled corticosteroids, anticholinergics
and influenza vaccination.
559. ITP: patients who relapse after splenectomy or are unresponsive to at least one other therapy should be
treated with TPO agonists (Eltrombopag).
560. ARDS etiologies divide into direct and indirect lung injuries. Among the direct lung injuries aspiration of
gastric content (e.g. due to drug overdose) can lead to ARDS.
561. When evaluating mediastinal mass the first step is to localize the mass into one of the three mediastinal
compartments. The most common anterior masses are teratoma, thymoma, thyroid mass and lymphoma.
Middle compartment mass is most commonly due to bronchogenic cyst, enlarged lymph nodes due to
metastasis and vascular mass. Posterior mediastinal mass are due to neurologic tumor, meningocele,
gastroenteric cyst,etc. Diagnosis is done first by CT scan but definitive diagnosis is done by
mediastinoscopy.
Mediastinoscopy will give definitive diagnosis to masses in the anterior or middle mediastinum.
562. A1AT should be suspected in young patients (e.g. 4th decade of life) with signs of COPD, as a cause of
emphysema, rather than smoking.
563. Pleural biopsy is done in case preliminary diagnostic tests for pleural effusion are negative.
564. Steroids are the first line of therapy in case of AIHA.
565. Heparin inhibits factor thrombin and factor X. It can cause elevated liver enzymes or osteoporosis.
566. Diarrhea may cause hypokalemia, metabolic acidosis, evidence of elevated urinary potassium (not the
source of lost) and negative UAG (vs RTA that causes +ve Urine AG).
Case: patient with weight issues has hypokalemia and metabolic acidosis → suspect laxative abuse that
causes diarrhea. Vomiting is not really associated with hypokalemia and it causes metabolic alkalosis.
567. Hodgkin lymphoma: pain in LNs following alcohol consumption.
568. "GOLD" criteria: staging system for severity of the disease. It is based on FEV1 levels. Mild disease is
FEV1 >80%, moderated disease is FEV1 between 50-80%, severe is between 30-50% and very severe is
below 30%.
So, FEV1 is the criterion that determines the severity of COPD as can be seen in the "GOLD" staging.
569. DIC: Rx with fresh frozen plasma (FFP) and/or platelets is indicated in case of active bleeding or high risk
of bleeding. Cryoprecipitate is given in case of low fibrinogen level, <100mg/dL.
570. When bacterial meningitis is suspected, blood cultures should be immediately obtained and empirical
antimicrobial and adjunctive dexamethasone therapy initiated without delay. In stable patient without
increased ICP, you can then proceed to LP without a CT scan. If, however, elevated ICP is suspected, CT
should be performed before LP.
Suspicion of elevated ICP requiring a CT scan before LP include: recent head trauma, papilledema on
fundus exam, changes in level of consciousness, focal neurologic deficits.
571. TLS manifestations: hyperuricemia, hypocalcemia, hyperkalemia, hyperphosphatemia, metabolic acidosis and acute renal failure.
Preventive treatments of TLS is effective and include allopurinol, hydration and alkalization of the urine. In refractory cases rasburicase, which is
recombinant urate oxidase, is used. Febuxostat is another xanthine oxidase inhibitor like allopurinol and better than allopurinol in reducing uric acid in
blood of patients with hematologic cancer.
572. Waldenstrom macroglobulinemia (WM) is a lymphoplasmacytic lymphoma which secretes IgM.
573. The presence of gram-positive rods in CSF indicates that the bacterium is Listeria and therefore
treatment should include only Ampicillin. Because in this case we know the pathogen, we do not need to
cover other typical pathogens.
#Note: Pneumococcus is treated with ceftriaxone and vancomycin is added to cover resistant strains.
#Note: Pneumococcus is cocci. Listeria is rods (bacilli).
 Dr.AmeerAboMokh
574. Anemia of chronic disease (ACD) laboratory findings will show high ferritin levels, low iron and low
TIBC. Ferritin levels increase due to pro-inflammatory cytokines. It first presents as a normocytic anemia and
overtime it becomes microcytic.
575. CML: Leukocytes>50k, Basophilia, t(9,22), splenomegaly.
576. DIC presents with high FDP, prolonged PT and aPTT, low fibrinogen and thrombocytopenia.
577. Hemolytic anemia +dark urine +thrombocytopenia → suspect: PNH.
578. In acute asthma exacerbation arterial blood gas will show hypoxemia and low PCO2 first. In severe
disease PCO2 will be high.
579. Silicosis: 'egg-shell' calcification of the hilar lymph nodes (upper lobes).
seen in patients that worked in the foundries, glass and cement manufacturing and sandblasting industry.
It is a risk factor for developing TB (silica is toxic to macrophages), RA and scleroderma.
580. Bacterial meningitis: patients above the age of 55, infants, pregnant women or immunocompromised
should receive ampicillin (covers listeria) in addition to ceftriaxone and steroids.
581. Increased MCHC is characteristic of hereditary spherocytosis. Gallstones in early age triggers diagnostic
investigation.
582. Hypercalcemia is characteristic paraneoplastic phenomenon of squamous cell carcinoma (usually
caused by PTHrP secretion).
Small cell and squamous cell tumors are highly associated with smoking, and are usually centrally located,
compared to adenocarcinomas which are more peripheral.
583. Surgery is recommended for NSCLC when the tumor can be removed totally (ipsilateral involvement “if
there is LNs they have to be in the same lung. No mets).
584. In a patient with atypical pneumonia, mycoplasma should be suspected when there are extrapulmonary
manifestations such as hematologic, neurological, cutaneous manifestations and even glomerulonephritis,
hepatitis. Hemolytic anemia (high LDH, bilirubin) and lack of leukocytosis are characteristic.
585. Septic shock is sepsis plus hypotension that doesn't respond to fluids for 1 hour.
586. Amiodarone may inhibit warfarin clearance and thus you have to lower the dose of warfarin when both
drugs are given together.
587. Clopidogrel is an ADP antagonist. It inhibits platelet aggregation.
588. The immediate treatment of anaphylaxis (e.g. after CT contrast administration) is with adrenaline. It
includes dyspnea, laryngospasm and hypotension.
589. Obesity hypoventilation syndrome (OHS) is defined as BMI >30kg/m2 and chronic daytime alveolar
hypoventilation (PaCO2 >45mmhg). In almost 90% OHS is due to obstructive sleep apnea. Laboratory
findings will show high PCO2 and normal alveolar-arterial PO2 gradient. Treatment is with weight reduction
and nocturnal non-invasive positive pressure ventilation.
590. Cardiogenic shock is characterized by increased CVP (preload) and systemic vascular resistance
(afterload) and decreased cardiac output.
591. Allergic bronchopulmonary aspergillosis is caused by aspergillus infection. It presents with
eosinophilia and asthma symptoms. Diagnosis is determined by increased eosinophils and by skin sensitivity
test showing positive serum precipitins for aspergillus. Other signs include central bronchiectasis and brown
plugs of mucus. Treatment: Steroids and anti-asthma drugs (antifungals maybe added if resistant to initial
Rx).
592. Etiologies of cold agglutinin (IgM) AIHA include EBV, mycoplasma and lymphoma.
593. Treatment of acute chest syndrome (of SCD) include: hydration, transfusion is given to keep hematocrit
above 30% and exchange transfusion if arterial saturation decreases below 90%. Hydroxyurea is the
mainstay of therapy.
594. In case of exudate several diagnostic tests are done: measuring pleural fluid glucose, cytology, culture
and staining of pleural fluid, marker (adenosine deaminase) for tuberculosis. If glucose is less than 60mg/dl
then malignancy, bacterial infections and rheumatoid pleuritis is more likely. If glucose is more than 60mg/dL
than PE and TB are suspected.
When PE or TB are suspected, a CT scan should be done to exclude or verify the diagnosis.
595. Exudative pleural effusion second most common cause is malignancy (most commonly breast cancer).
 Dr.AmeerAboMokh
596. Mucormycosis is classically represented in diabetic patients (black eschar) and most commonly with
rhino-orbito-cerebral involvement. The treatment of choice is amphotericin B.
597. Renal failure in MM is most often due to hypercalcemia.
598. Hyposegmentation of neutrophils and macrocytosis should raise the suspicion for Myelodysplastic
syndrome (MDS).
599. TTP blood smear: helmet cell, aka schistocyte.
600. Ventricular free wall rupture is a complication that occurs in up to 10% of the patients that die during
hospitalization after MI. It occurs during the first week after MI onset and it is more common among elderly
and anterolateral MI which didn't revascularized efficiently. Clinical presentation: loss of consciousness, loss
of pulse and blood pressure. ECG shows pulseless electrical activity (sinus rhythm) due to cardiac
tamponade. Treatment is with CPR and surgery in case of tamponade.
601. Celiac disease may present with iron deficiency anemia (weakness and IDA labs).
602. At the beginning of treatment of vitamin B12 deficiency there is increased production of progenitor cells.
These progenitor cells increase the consumption of potassium leading to hypokalemia. Thus treatment with
potassium supplements have been recommended in order to avoid the danger of hypokalemia.
603. Patient with neutropenic fever is a patient with severe infection until proven otherwise and thus the
treatment is with empiric antibiotics. Patients with neutropenia are in increased risk of invasive fungal
infections (candida and aspergillus). It is common to add empiric antifungal drugs if the fever lasts more than
7 days. Empiric therapy includes caspofungin or amphotericin B.
604. Coumadin skin necrosis is due inherited or acquired deficiency of protein C or protein S. it presents with
erythematous lesions on the thighs, buttocks, breast or toes. It occurs 2-5 days after initiation of treatment
with warfarin.
605. 70 years old patients presents with macrocytic anemia and thrombocytopenia (part of the disease
pancytopenia). On bone marrow biopsy ringed sideroblasts and dysmorphic blood cell. Which of the following
is the most likely diagnosis? Myelodysplastic syndrome.
606. Patients with COPD exacerbation and PaCO2 >45 should receive Mechanical ventilator support with
non-invasive positive pressure ventilation (NIPPV).
607. Treatment of life threatening AIHA is blood transfusion.

1. above 95% of DU occurs in the 1st part of the duodenum.

2. Contrast nephropathy peaks at the 5th day and resolves after a week.
3. Every traveler returning from an endemic malaria region (e.g. Africa) who presents with fever is suspected
of malaria until proven otherwise. Malaria must be ruled out actively by performing thick and thin drop
tests.
4. SBP most common organism: E.coli.
5. Functional abdominal pain is characterized by non specific periumbilical pain, with normal history,
physical exam and blood tests. No further evaluation is required, and follow up in the clinic is advisable.
6. Mucormycosis afflicts disease mainly in immunosuppressive patients- patients with uncontrolled diabetes,
neutropenia, chronically treated with steroids, solid organ or hematopoietic stem cell transplantation. The
first symptoms are usually nasal or conjunctival secretions and eye or facial paraesthesia and pain. In
advanced disease, damage to the muscles of the eyes may occur, manifested by proptosis and even
ophthalmoplegia. A biopsy remains the most sensitive and specific test to diagnose the fungus and the
agent of choice is the anti-fungal drug amphotericin B in its various forms.
7. In order to diagnose SLE, we need fulfillment of at least four criteria, with at least one clinical criterion AND
one immunologic criterion.
8. The most common cause of chronic hypercalcemia is primary hyperparathyroidism (PHPT). In the
asymptomatic ambulatory patient usually the cause of hypercalcemia is PHPT whereas in the older and
hospitalized patient the cause is usually malignancy.
 Dr.AmeerAboMokh
9. Contraindications of the use of Nitrates include Decreased SBP (<90 bpm), Clinical suspicion of a right
sided MI (inferior MI, jugular venous distention, clear lungs and hypotension) and Patients who have taken
phosphodiesterase-5iinhibitors in the past 24 h.
10. The most important side effects of alpha blockers (Doxazosin) are orthostatic hypotension and
dizziness which can be potentiated with concomitant use of PDE-5 inhibitors. Other side effects include
ejaculation dysfunction, headaches and nasal congestion.
11. Treatment of acute pericarditis includes aspirin or NSAIDs for 1-2 weeks alongside PPIs for gastric
protection. In addition, colchicine should be added for 3 months, which aids in reducing recurrence and
may enhance the patient's response to NSAIDs.
12. Gout: fluid aspiration leukocyte count is usually elevated (2000 to 60,000/μL).
13. Drug-Induced Hypersensitivity Syndrome (DIHS) is a systemic drug reaction which can present with A
prodrome of fever and catarrhal symptoms followed by the appearance of a diffuse rash, typically 2–8
weeks after the drug is started. Eosinophilia is a common lab finding. Lymphadenopathy, leukocytosis with
eosinophilia, hepatitis, nephritis, pneumonitis, myositis and gastroenteritis. Fascial, hand and foot swelling
may appear. Treatment of DIHS begins with immediate cessation of the suspected offending agent.
Systemic PO prednisone is an appropriate treatment and should be tapered slowly over 8–12 weeks.
14. HF patients in volume overload should be in a sodium restricted diet and should be treated with diuretics-
usually furosemide. It is recommended that all patients with HFrEF, regardless of their symptoms, will
receive treatment with ACEI and BB. Neurohormonal blockade with these agents has been proven to
reduce mortality and slow the progression of the disease. Spironolactone is an aldosterone receptor antagonist and has been
proven to reduce mortality in EF patients with NYHA II-IV. It is usually used as a second line treatment if BB or ACEI are contraindicated or not
tolerated.
15. Acyclovir inhibits the replication in part of the herpes virus family including HSV 1, HSV 2, VZV and EBV.
VZV is less sensitive to acyclovir and therefore higher doses of the drug are used in the treatment of VZV.
Renal failure (most common side effect). This side effect is due to drug crystallization in the kidney which
can impair renal function, and is most common when the drug is administered rapidly (i.e IV administration)
or when the patient is dehydrated.
16. SBE prophylaxis is recommended only when there is penetration of the gums, oral mucosa infected GU
tract or infected skin(not only procedure there but infected!!), but not only, there has to be an indication of
the “heart related problems list” as well.
17. Imparied glucose tolerance (IGT) is diagnosed when glucose after OGTT is more than 140 mg/dL but less
than 200 mg/dL. Imparied fasting glucose (IFG) is diagnosed when fasting glucose is 100-125 mg/dL.
Prediabetes is defined by imparied glucose tolerance, imparied fasting tolerance, or Hb A1C is 5.7-6.4%.
According to his lab results, this kid has prediabetes.
18. In immunocompetent patients between the ages of 3 months to 55 years the proper treatment is a third or
fourth generation cephalosporin (Ceftriaxone or Cefotaxime or Cefepime) + Vancomycin. It is important to
remember that today, an integral part of the treatment is addition of Dexamethasone (preferred 20 min
before antibiotics) which reduces production of inflammatory cytokines.
19. Reticulocyte count indicating active BM RBC production: >2.5.
20. There are several predisposing factors for infective endocarditis. IE in IVDU, especially when there is
involvement of the TC valve (right sided), is most commonly caused by S. aureus.
21. Clubbing of the digits is not a sign of chronic obstructive pulmonary disease (COPD). The presence of this
sign on physical exam, especially in the COPD type-cast patients, should prompt further medical
evaluations with particular focus on lung cancer which is most likely to be the cause of new onset digital
clubbing in an old smoking patient → CT scan needed to rule out lung CA.
DDx of digital clubbing: infective endocarditis, cyanotic congenital heart disease, lung cancer,
bronchiectasis, asbestosis, sarcoidosis, lung abscess, cystic fibrosis, tuberculosis, mesothelioma, IBD and
hepatic cirrhosis.
22. Best treatment for AS → Aortic valve replacement surgery (not Aortic balloon valvuplasty).
There are 3 Class 1 recommendations for aortic valve replacement (AVR) in severe AS- severe AS that is
symptomatic, Asymptomatic severe AS with a LVEF <50%, Asymptomatic severe AS in a patient that is
undergoing other cardiac surgery.
 Dr.AmeerAboMokh
Notice that Balloon is done for Mitral Stenosis(aka: Mitral valvotomy) and not for aortic stenosis.
23. The recommended therapy of CDI includes oral vancomycin, fidaxomicin or metronidazole. Metronidazole
is less effective than the others and recommended only if the others are not accessible. Treatment is
usually given to 10-14 days.
24. Quinolones (like Ciprofloxacin) side effects: Achilles tendon tendinitis and tear, QT prolongation,
myasthenia gravis exacerbation, convulsions, hyperglycemia.
25. Steroids are used in severe alcoholic hepatitis where MELD score>20 or discriminate function>32.
26. The most commonly occurring side effects of TMP-SMX are associated with the GI tract and include
nausea, vomiting and diarrhea. If the drug is used for a long period of time, leukopenia, thrombocytopenia
and granulocytopenia may develop (aplastic anemia).
27. Alcohol withdrawal may be a serious condition and should be in mind when a known alcoholist is
admitted to the hospital. The classic sign of alcohol withdrawal syndrome is the appearance of a tremor,
yet may include additional signs and symptoms such as delusions, hallucination, seizures and symptoms of
delirium tremens (DT). The medication of choice for the treatment of alcohol withdrawal symptoms are
benzodiazepines (BZDs) like Lorazepam.
28. The pathogens causing uncomplicated pyelonephritis and cystitis are similar and are dominated by E.coli.
29. The most common aetiology of nephrotic syndrome in adults is membranous glomerulonephritis (MGN). In
70-80% of cases the reason is idiopathic whereas in 20% of cases it is secondary to an underlying disease.
Treatment of MGN includes Treatment of edema, dyslipidemia, hypertension (ACE inhibitors and
statins).
30. A patient presenting with thyrotoxicosis, sore throat, neck pain and fever, with diffuse decreased iodine
uptake → This is the thyrotoxic phase of subacute thyroiditis → high dose aspirin or NSAIDs.
A thyrotoxic phase with inflammation and disruption of the thyroid gland follicles leading to increased
serum thyroid hormones and decreased TSH. Radioactive uptake in this phase is low(‫)بسبب الديسربشن‬.
31. When PSGN presents with renal failure → next is to give penicillin. Later we control blood pressure by
other drugs.
32. TTP is life threatening and should be treated early with plasma exchange until platelet count is normal and
signs of hemolysis are resolved for at least 2 days. Glucocorticoids are usually added as an adjunct.
Characteristic labs show increased LDH, increased indirect bilirubin, decreased haptoglobin, increased
reticulocyte count, negative direct coombs test (MAHA).
33. ZES: most commonly originates in the pancreas. In all cases of ZES testing, PPI needs to be discontinued
a week before.
34. The patient in the question is suspected of giant cell (temporal) arteritis with polymyalgia rheumatica.
Treatment begins with prednisone 40–60 mg/d for approximately 1 month and then gradually tapered
down. 81 mg per day of aspirin is added for it was found to reduce cranial ischemic complications.
35. Among connective tissue diseases, the occurrence of PAH has been recognised only in systemic sclerosis,
particularly in those with limited cutaneous scleroderma. Cardiac auscultation may reveal a fixed\narrow
splitting of S2 with a prominent P2 sound. S3 or S4 may be present. In addition, a holosystolic TR murmur
can be found.
36. The spirometry results expected in advanced pulmonary fibrosis are of a restrictive pattern. We expect to
see a decrease in the TLC, FRC, RV and FVC. The FEV1 is usually normal and the DLCO is markedly
decreased.
37. Coumadin should be stopped 5 days prior to surgery Bridging therapy using LMWH or heparin is
recommended in patients at high risk for thromboembolic events → Discontinue coumadin for 5 days prior
to surgery and cover with clexane (LMWH).
NOACs are easier to manage as they have a shorter half life and can be discontinued and continued quite quickly. In moderate to high risk cardiac
patients receiving aspirin, continuing aspirin around surgery is suggested, rather than stopping 7-10 days prior. IVC filter should be considered in
patients with a high perioperative bleeding risk or very recent DVT or PE. Surgery should be postponed after BMS (6 weeks) or DES (6 months)
placement and if that is not a feasible option, dual antiplatelets should be continued perioperatively.
38. A serum acetaminophen level should be measured 4 hours after the reported time of ingestion, and
decisions should be taken according to the results. So Never give N-acetylcysteine before 4 hours have
 Dr.AmeerAboMokh
passed since the intake accident, because you need to act based on its level. If the time is unknow, we
give.

1. Lorazepam, Oxazepam and Midazolam are considered short acting, whereas Diazepam, clonazepam is an
example of a long acting agent. The side effects of long-acting benzodiazepines include increased risk of
daytime psychomotor impairment and higher risk of daytime sedation. But they tend to have less-severe
withdrawal phenomena.
2. Streptococcus gallolyticus group (formerly Streptococcus bovis).
3. Don’t wait for troponin when there is ST elevation → PCI if accessible.
4. Diagnosis of multiple myeloma requires demonstration of bone marrow plasmacytosis >10% or M
component on protein electrophoresis, together with evidence of end-organ damage (CRAB or malignancy
biomarkers).
5. Thalassemia minor – The anemia is very mild (not below 8). Low MCV. Ferritin levels should be normal.
Sideroblastic anemia – Ferritin levels are high not low. IDA: high RDW.
6. Presence of visible pus in the pleural space is the strongest indication for chest tube insertion (more than
pH<7.2).
7. Sarcoma is a neoplasm that originates from mesenchyme. Tissue types include skeletal muscle, adipose
cells, blood and lymphatic vessels, and connective tissue or those cells with a common mesoderm origin.
Epithelium-derived neoplasms are known as carcinomas.
8. If you have poor response to appropriate antibiotics, think about either the resistance of the pathogen, or a
sequestered focus (lung abscess or empyema). → a chest x-ray is needed or even chest CT
9. It is estimated that 80-95% of duodenal ulcers and approximately 75% of gastric ulcers are associated with
Helicobacter Pylori infection. (More common than NSAIDs).
10. Lorazepam is a short acting benzodiazepine, therefore it will most probably has withdrawal symtoms.
11. The main treatment of lymphangitis is cephalexin plus warm compressors. The most common aetiology of
lymphangitis is strepcoccus pyogens (Group A strep).
12. The Lethal Triad is a term that refer to the presence of hypothermia, acidosis and coagulopathy in patients
who are bleeding or in shock from various factors. The hypothermia should be managed in order to restore
proper function of the coagulation system.
13. Hyperkalemia Rx: IV 10% calcium gluconate 10 mL over 2-3 minutes, repeat dose if ECG still
pathologic.
14. The preoperative testing of a healthy patient above 70 years of age include ECG, CBC + platelets,
electrolytes, BUN/creatinine and glucose levels. (echo is not needed).
15. IgA nephropathy in adults: The most common presentations are asymptomatic micro-hematuria and
episodic macro-hematuria.
16. Ankylosing spondylitis: pain improves with movement and worsened with rest. The disease usually
develops in the second or third decade of life.
17. Systolic murmur 2/6 at the upper middle-right sternum and a wide, permanent split of the second heart
(S2) → ASD.
Pulmonic stenosis- Wide split of second sound. Systolic murmur is located upper-left sternum.
18. Topiramate is an anticonvulsant drug, used in the treatment of PTSD, Epilepsy, migraines, smoking
cessation, Obesity and Bulimia. Topiramate was found to provide little or no benefit in the treatment of
psychotic disorders.
19. Nosocomial pneumonia occurs after the first 72 hours of hospitalization until 4 weeks post discharge. The
most common bacterial pathogens causing nosocomial pneumonia are gram-negative rods (Escherichia
coli, Pseudomonas) and Staphylococcus aureus. IV clavulanate/Ticarcillin should be started immediately.
20. The main etiology of tamponade is pericarditis which can be triggered by different etiologies including:
rheumatologic inflammatory conditions such as SLE, idiopathic, neoplastic, infectious etc.. other common
etiologies for tamponade include post cardiac surgery and trauma.
 Dr.AmeerAboMokh
ECG: usually shows tachycardia and a low voltage. Sometimes might also see “electrical alternans”-
changes in P, QRS or T wave amplitude from beat to beat. Becks triad and pulsus paradoxus.
21. The leading cause for chronic kidney disease in north America and Europe is diabetic nephropathy.
22. Pneumonia: microorganisms reaches the lower respiratory tract in several ways. The most common is by
aspiration from the oropharynx.
Common cold, influenza, pertussis and rubella are examples of infections, which are transmitted through
droplets.
23. In elderly patients, especially those with known coronary artery disease, the starting dose of levothyroxine
is 12.5–25 μg/day (We lower the dose!!!).
24. Unilateral aldosterone-producing adenomas were considered to be accountable for about 60% of cases,
but this number has decreased substantially as nonselective screening has been applied, with aldosterone-
to-renin ratio method. Nowadays, the most common cause is considered to be bilateral adrenal
hyperplasia.
Hyperplasia is characterized by milder hypokalemia compared with adenoma.
25. Beta blockers decrease pain (by improving oxygen demand and supply in the myocardium), infarct size
and incidence of ventricular arrhythmia in patients with myocardial infarction.
26. 5-ASA agents are the first line treatments for mild-moderate UC.
27. A 19 years old male presents with hypertension 190/120 mmHg, headache, myalgia, arthralgia and
abdominal pain. He is also noted to have livedo reticularis as well as pain and swelling in left testis. He
reports losing 6 kg in weight over the last 6 months. His blood tests reveals: WBC 15,000 HB 10 gr/dL,
ESR 100 mm/hr. Urinalysis: negative protein, positive RBC, negative WBC → Polyarteritis nodosa.
Specific organ systems can cause more specific symptoms. In 60% of patients there is renal involvement,
with renal failure and hypertension. Another common system involved is musculoskeletal, in 64% of cases,
causing arthritis, arthralgia, and myalgia. In 50% there is involvement of the peripheral nervous system,
presenting as peripheral neuropathy and mononeuritis multiplex. Other common system are the GI
tract(abdominal pain, nausea, vomiting, bowel infarction and more..), the skin (rash, purpura, nodules,
livedo reticularis, Raynaud’s phenomenon, cutaneous infarcts), cardiac, genitourinary (namely testicular
involvement), and CNS. The disease is associated with hepatitis B and hairy cell leukemia.
28. APS patients should be placed on warfarin for life, aiming to achieve an international normalized ratio (INR)
ranging from 2.5 to 3.5, alone or in combination with 80 mg of aspirin daily. In pregnancy, warfrain is
contraindicated (mainly in 1st trimester) and therfore low-molecular-weight heparin with aspirin 80 mg daily
are given instead.
29. Lab tests that are considered routine in diagnosis of acute abdomen include complete blood count, blood
chemistry, liver and pancreatic function tests.
30. Scarlet fever: 10-day Amoxicillin (Moxypen) PO.
31. Bone marrow transplantation is the only curable therapy for b-thalassemia.
Hydroxyurea is an antineoplastic agent that increases the fetal haemoglobin. It is used for sickle cell disease and beta thalassemia patients.
Hydroxyurea will decrease the incidence of haemolysis.
32. Anemia of chronic disease “normocytic normochromic anemia” is a common manifestation in
active Rheumatoid arthritis. Other acute phase reactants might be present and therefore might also find
leukocytosis and thrombocytosis. Kidneys are usually not affected in RA and hemolytic anemia is not a
feature.
33. Of all the types of rejection, acute rejection is considered to be the only one which may be successfully
reversed with the proper treatment.
34. Bacterial meningitis: WBC count is 100-10000, usually> 1000. The empirical antibiotic treatment for
suspected bacterial meningitis Rocephin + Vancomycin. If Listeria is suspected, ampicillin should be added.
35. Spironolactone (aldosterone antagonist) is proven effective only for more advanced stages of CHF - EF <35% and NYHA 3-4. The automatic
implantable cardiac defibrillator (AICD) is indicated for patients with EF <35%, and class II or III symptoms despite optimal medical treatment.
Cardiac resynchronization therapy (CRT) is indicated when having prolonged QRS duration >149 msec and LBBB.
36. Abdominal pain, respiratory symptoms with neutrophilia with no detected organism in sputum analysis
makes Legionella the most likely cause. The macrolides (especially azithromycin) and the quinolones
(especially levofloxacin or ciprofloxacin) are the antibiotics of choice and are effective as monotherapy.
 Dr.AmeerAboMokh
37. Most asthma exacerbations are mild and do not require blood gases. At the beginning you would expect
hyperventilation leading to low PCO2 levels and high PaO2 levels and oxygen saturation.
In severe asthma, patients may become tired, and they are unable to hyperventilate and starts
decompensating, so a normal or rising PaCO2 signals impending respiratory failure and warrants
immediate therapy, and possibly prophylactic intubation and ventilation.
So, a normal PaCO2 indicates a more severe disease. Another indicator for severity is pulsus paradoxus.
38. APL is highly curable subtype of AML now treated mainly with ATRA +/- ATO for low-risk patients. APL
often presents with DIC-like manifestations.

1. Afib stable patient more than 48h: Decrease heart rate with beta blockers.
2. HOCM + Systolic B.P is 90 mmHg: I.V fluids with monitoring B.P.
3. Atorvastatin: The aim of the treatment is to elevate the life expectancy following MI.
4. Doxazocin (alpha Blocker): orthostatic hypotension [not b-blocker].
5. COPD exacerbation with bad patient vitals: Bronchodilatation inhalations.
6. Acute Ischemic STROKE :After the clinical diagnosis of STROKE is made, an orderly process of evaluation
and treatment should follow... Perform an emergency noncontrast HEAD CT scan TO DIFFERENTIATE
BETWEEN ISCHEMIC STROKE AND HEMORRHAGIC STROKE; there are no reliable clinical findings
that conclusively separate ischemia from hemorrhage, although a more depressed level of consciousness,
higher initial blood pressure, or worsening of symptoms after onset favor hemorrhage, and a deficit that is
maximal at onset, or remits, suggests ischemia (Harrison,19e,2561).
7. E. coli ESBLs (Extended Spectrum Beta-Lactamases): Treat with Carbapenems “meropenem”.
8. Paronychia can cause septic arthritis so need anti-staphylococcal antibiotics: First generation
cephalosporine (e.g cefazolin).
9. When there is solid lesion on x-ray with dyspnea and cough for a week: order Chest CT.
10. Homless, AST/ALT>2, Liver biopsy reveals hepatocyte ballooning, neutrophil infiltration, Mallory-Denk
bodies, steatosis, and intrasinusoidal fibrosis → Acute alcoholic hepatitis.
11. pyoderma gangernosum is a complication of uncontrolled ulcerative colitis, once the flare (cause) is treated
with steroids, pyoderma will also be treated.
12. HCV treatment: Direct acting antiviral agent.
13. Drug induced lupus: Procainamide
14. Pseudogout presents with chondrocalcinosis (cartilage calcification) on x-ray. WBC within ranging from
2000-100,000micro/L in the synovial fluid.
15. SlE diffuse proliferative glomeronephritis (WHOclass IV) Rx: Prednisolone and IV cyclosporine.
16. Nodular sclerosing classical HL (NSHL): most common subtype with good prognosis.
17. AA- amyloid composed of serum amyloid A and is associated with chronic inflammatory or infectious
diseases (RA, FMF, IBD).
18. antiphospholipid antibodies (APLA) syndrome after flight with hemoptysis → Angio CT to rule out PE.
19. Blurred consciousness\altered mental status are contraindication for the use of BiPaP for NIV.
20. Rickettsia conorii: high fever , sever headache and a rash on the trunk and the palms of the hands. If
recognized in a timely fashion, rickettsial disease is very responsive to treatment. DOXYCYCLINE
“tetracycline-based treatment” is the treatment of choice for both adults and children.
21. SCLC positive for epidermal growth factor receptor (EGFR): treated with tyrosine kinase inhibitors (TKIs).
Better prognosis.
22. CA19-9 is used for disease recurrence follow up for cholangiocarcinoma.
23. Dual antiplatelet therapy (DAPT), defined as the use of a P2Y12 receptor inhibitor (clopidogrel, ticagrelor or
prasugrel) and aspirin, is required after percutaneous coronary intervention (PCI) with drug-eluting stents
(DES).
24. pleural effusion: Dullness to percussion+ decreased fremitus+ decreased breath sounds.
25. Preferred treatment approach to correct hypernatremia with normal blood pressure: Drinking water via
nasogastric tube (Better than normal saline and 0.45%).
 Dr.AmeerAboMokh

1. COPD exacerpation, during admition (MAT) is noted→ Rx:Improve breathing and control COPD
exacerbation.
2. The most common cause of pleural effusion is left ventricular failure. (Harrison,20e,2007). Although
pleural effusions are often bilateral in HF, when they are unilateral, they occur more frequently in the right
pleural space. (p.1776).
3. In elderly patients with iron deficiency anemia, you must rule out colon cancer → Do colonoscopy and not
endoscopy.
4. New visual field deficit may compose the neurological part of the TTP pentad. For dx: check Peripheral
blood smear.
5. Staging of CLL: Rai Staging System: High risk (stage III/IV) Lymphocytosis with anemia or
thrombocytopenia due to bone marrow involvement. Binet Staging System: C Hemoglobin ≤10 g/dL and/or
platelets.
6. Enterococcus fecalis is a gram-positive cocci that may cause UTI.
7. Catheter related infections should be treated with vancomycin due to its ability to treat MRSA.
8. Immigrant, bilateral consolidation, necrotic lymph nodes are identified on CT, dyspnea weight loss night
sweats productive cough → Suspected TB → Sputum microscopy with acid-fast stain (Ziehl-Neelsen
stain).
9. Decrased level of conciousness indicates increased ICP, LP may cause herniation in this case → LP after
CT. Never do Lumbar Puncture before obtaining CT if neuroimaging is indicated.
10. Membranous nephropathy maybe caused by: Autoimmune diseases (SLE, RA..), Cancer, Infection
(Hepatitis B and C, syphilis..).
11. Alport's syndrome: defect of type IV collagen.
12. Retroperitoneal fibrosis: lower back pain, hydronephrosis (compression of ureters), history of radiation.
13. Painless hematuria+smoking+older then 50= think bladder cancer.
14. GGT is elevated in alcohol consumption and fatty liver, beside biliary disease.
15. Whipple Disease (Tropheryma whipplei): damages villi in the small intestine, Weight loss, diarrhea, joint
pain, fever and arthritis, diagnosis by periodic acid-Schiff stain (PAS)–positive macrophages in the
lamina propria containing non–acid-fast gram-positive bacilli.
16. If an acute mesenteric ischemia is suspected, quickly initiating imaging studies (CT angiography, color
Doppler sonography) is essential. In cases with peritonitis or risk of shock, however, emergency surgery
without prior imaging is indicated!
17. Acute Mesenteric Ischemia: Mesenteric angiography (CT angio) is the definitive diagnostic test. [Step-up].
18. Enterotoxigenic/ aggressive E. coli (ETEC) is the most common pathogen causing traveler's diarrhea
(watery).
19. Osteonecrosis (Avascular Necrosis) is a side effect of steroids. More common in the hip. Pain aggravated
by motion. Diagnosed by hip MRI.
20. hypomagnesemia lead to 1)hypocalcemia 2)hypokalemia.
21. Sotalol Antiarrhythmic potassium channel blockers (class Ill) and b-blocker (class II): one side effect is QT
segment prolongation, so needs follow up on ECG.
22. Erythema nodosum maybe caused by OCPs.
23. After taking an antibiotic and sudden increase in liver transaminases→ Drug Induced Liver Injury / toxicity
“DILT”.
24. Primary Hyperparathyroidism: Note that in the presence of hypercalcemia, a normal PTH level is
“abnormal” (i.e., high) because high calcium levels suppress PTH secretion. [Step-up,4e]
In a nutshell, in primary hyperparathyroidism PTH maybe high or normal!
25. Esophageal cancers: Endoscopy is the primary diagnostic test, enabling direct visualization and biopsy of
the lesion for histopathological confirmation.
 Dr.AmeerAboMokh

1. CA-125 --- OVARIAN CANCER, some lymphomas --- Menstruation, PERITONITIS, pregnancy
(Harrison,19e,473)
2.