M 01 PULMONOLOGY

 Spirometry

 RESTRICTIVE LUNG DISEASE

UPPER lobe fibrosis LOWER lobe fibrosis

Silicosis IPF
EAA Drug-induced fibrosis
Ankylosing spondylitis Asbestosis
TB Connective tissue disorder
Sarcoidosis

 CLUBBING
SYSTEM CAUSES
Cardiac - Congenital heart defects
- Endocarditis
- Atrial myxoma
Respiratory - Lung cancers (the MC cause)
- Bronchiectasis
- Lung abscess
- Cystic fibrosis
- Interstitial lung disease
- Mesothelioma
GI and liver - Celiac disease
- Liver cirrhosis
- Liver cancer
- GI cancer
- IBD
Thyroid - Thyrotoxicosis
others - Hodgkin lymphoma
- Aortic aneurism
M 09 CARDIOLOGY

 Rheumatic Fever
 Diagnostic: - Evidence Streptococcal + (2 major or 1 major with 2 minor)

Major Minor
Erythema marginatum Raised ESR or CRP
Chorea Fever
Polyarthritis Arthralgia
Carditis Prolonged PR
Subcutaneous nodules

 Valvular Heart Disease

.

 Maneuvers of Murmur

Maneuver effect MVP/HOCM AS AR MS MR

Squatting + venous return - + + + +
Valsalva - venous return + - - - -
Handgrip - ventricular emptying - - + = +
Nitrates + ventricular emptying + + - = -
M 08 CARDIOLOGY

 HTN

One reading ≥180/110

Two reading ≥140/90

Primary Secondary

Life style
modification  Renal artery stenosis
 Chronic Kidney disease
Stage 2 Stage 1  Glomerulonephritis
 OSA
Start with 2 Start with  Hormonal
drugs, one is One drug - Cushing’s Syndrome
diuretic - Pheochromocytoma
- Hyperaldosteronism
- Hyperparathyroidism
 Liddle Syndrome: mutation
<65 or >65 or
on aldosterone receptors
DM black

ACEI/ CCB
ARB

ACEI + CCB

Add thiazide
DM ACEI/ ARB
CAD BB, CCB
K+ > 4.5 K+ < 4.5 Pregnancy Mythyldopa
increase add Labetalol
thiazide aldactone Hydralazin
BPH Alpha Blockers
M 07 CARDIOLOGY

Irregular Bradycardia Tachycardia

 Ventricular extrasystole:  3rd degree AV Block:  Ventricular Tachycardia:
(Premature Ventricular (infra Hiss) No P or T wave
contractions PVC’s) Idioventricular rhythm
PP interval ≠ RR interval
Wide QRS

 Ventricular Bigeminy or
Trigeminy
 RBBB : Normal HR, RSR’ in V1
 LBBB: Normal HR, M shape pattern in V6
 Wolff-Parkinson-White: normal HR, Λ wave, short PR interval
 Ventricular fibrillation: Type A: left side, Type B: Right side
No clear P, QRS or T wave
 Atrial fibrillation:  Med junctional Rhythm:  Supraventricular tachycardia:
P replaced by F wave, maybe (nodal Rhythm) (nodal rhythm)
Absent P

coars, fine or absent

wave

 Supraventricular extrasystole:  Sinus Bradycardia:  Supraventricular tachycardia:

(PAC’s) Can be associated with Fixed (atrial rhythm), P wave
Crowded Q-Q interval prolonged PR interval (1st superimposed on T wave, and HR
AV block) > 160

 Variable 2nd AV Block:

Normal Q-Q interval
- Mobtiz T 1: PR progressive  Med junctional Rhythm:
Single P wave

prolongation (nodal Rhythm)  Sinus Tachycardia:

inverted P wave HR 100- 160

- Mobtiz T 2: PR without
prolongation

 Sick sinus syndrome (SSS):

Tachy-Brady alternance
 Multifocal Atrial Tachycardia
≥ 3 different P wave
morphologies
 Atrial flutter with variable 2nd AV Block: Fixed block  Atrial flutter
blocks, unstable R-R interval 3rd AV Block: supraHiss
Multi P
wave

Atrial rate 300 PM Stable R-R interval, 3:1 block

M 06 CARDIOLOGY

 NORMAL ECG
 Rate – Rhythm – axis – intervals
 P: 2.5 * 2.5 ss
 QRS: <3ss, V1+V5/6 < 35 ss
 Q: <1 ss, <2mm /<25% of R wave
 PR: 3-5 ss
 QTc (QT/√RR): 9.5-11 ss

 ATRIAL FIBRILATION

A.F / A. flutter/ MAT

unstable stable

DC cardioversion Young Elderly

< 48 H Rate control:

Elective Rhythm Digoxin, BB
control: cardioversion CCB
+ Anticoagulant, TEE Rhythm control:
Medical cardioversion If failed
 M 05 CARDIOLOGY

Acute Coronary
Syndrome
Management at ER

STEMI NSTEMI Unstable Angina

Inferior Others

MOFA-B MONA-B

--------------------------------------------------------------------------------------------------------
Thrombolysis

STEMI NSTEMI and UA

TIMI ≥ 3 TIMI < 3

Thrombolysis

If Contraindications
Primary PCI Thrombolytics
If impossible (>90 min)

Rescue PCI If failed

--------------------------------------------------------------------------------------------------------
After reperfusion TIMI score: (UA / NSTEMI)
- Age ≥ 65 years
After reperfusion

ACE - RF ≥3 present
unless CI - Know case of CAD (>50 %)
- Aspirin using in last week
- Severe angina
- ST deviation ≥ 0.5 mm
- Positive cardiac enzymes
M 04 CARDIOLOGY

 ISCHEMIC HEART DISEASE (IHD)

Type Clinical ECG Cardiac enzyme
Stable angina Typical chest pain: Normal -
- Retrosternal, central
Unstable angina - Radiation: neck, jaw, ST depression -
epigastrium, back Or T inversion
NSTEMI - Heavy, dull, squeezing, ST depression +
ACS

pressure like Or T inversion

STEMI - Increased with Exercise ST elevation +
- decreased with nitrate Or LBBB

 Stable angina
 Treatment:
SOCRAD
- 1st: Control RF +Aspirin + statin + BB + Nitrates- Site
- 2nd: stop (BB) and give (CCB) - Severity
- 3rd: PCI + previous medical treatment - Onset
- Offset
onset offset Sensibility/specificity - Character
Myoglobin 1h 24 h Sn + , Sp - - Radiation
CK-MB 4-6 h 2-3 days Sn + , Sp - - Relieving
Troponin 4-6 h 10-14 days Sn + , Sp - Aggravation
 {CPK= CK-MB + CK-MM + CK-BB} CK-MB >25% of CPK - Duration
 STEMI

Leads ST+ Artery affected

Inferior II + III + avF Right Coronary artery
Septal V1 + V2
Anterior V3 + V4 Left Anterior descending artery
Lateral V5 + V6 + I + avL Left Circumflex artery
posterior ST-: at anterior and septal Associated with inferior or lateral MI
M 03 PULMONOLOGY

Pneumonia

outpatient inpatient

Using ATB in
the last 3 months

- Macrolides: Respiratory Ceftriaxone with

Azithromycin or Fluoroquinolones Azithromycin
Clarithromycin (Levofloxacin or
- Doxycycline Moxifloxacin)

 RESPIRATORY NEOPLASMS

Type Small cell Non-small cell

or (Oat cell) Squamous cell Adenocarcinoma Large cell
Central from central peripheral peripheral
site

APUD cells
Early  surgery strongly with MC in non-smokers Poorly
Chemotherapy Clubbing, Majority are smokers differentiated
+

Radiotherapy cavitary lesion Poor Prognosis

Gynecomastia
Lambert-Eaton-myasthenic Sd
ACTH Cushing Syndrome

HPOA
Paraneoplastic features

TSH  Hyperthyroidism
Hypertrophic pulmonary
PTH  Hypercalcemia

osteo-arthropathy
ADH SIADH
M 02 PULMONOLOGY

 RESPIRATORY INFECTION

Pneumonia

CAP HAP

Typical (sputum) Atypical (no sputum)

 Sputum Cough  No Sputum

Staphylococcus aureus is MC
 High fever  Mild symptom
 Unwell Toxic patient  Not detectable germ

It’s started after 48 H

 CXR: Lobar consolidation  Not culturable germ
 CXR: Diffuse Patchy
infiltration
 Strep. pneumonia (the MC)  Mycoplasma (the MC)
 HIP  Virus (RSV, CMV, adenoV)
 Staphylococcus  Fungi
 Pseudomonas  Legionella
 E. coli  Chlamydia
 Klebsiella

Pathogen association
Strepto. pneumonia 80% Typical pneumonia, Rusty Sputum, Herpes labialis
H. influenza COPD exacerbation
Staphylococcus aureus Recent influenza
Klebsiella pneumonia Alcoholism, DM, Red-current jelly sputum, lung abscess
Anaerobes Poor dentition, (aspiration: right middle or lower lobe)
Mycoplasma pneumonia young and healthy patient, associated with SPM, Cold
agglutinin hemolytic anemia and erythema multiform
Legionella Contaminated water source, Air condition system,
ventilation system workers, Diarrhea, HypoNa+ ,HypoP
Pneumocystis pneumonia HIV positive
Pseudomonas aeruginosa The MC cause in Bronchiectasis, CF and VAP

CURB65: - Confusion - Urea > 7 - RR>30 - BP <90/60 - age >65

M 17 NEPHROLOGY

 Acute Renal Failure

ARF

Proteinuria <1 g/l

Serum (urea/crea)

> 20 ≤ 20

Liver disease Hypotension Hypoperfusion

Nephrotoxicity
Hepatorenal $ Pre-renal ARF
ATN

Renal obstruction - Allergic Drugs NSAID with:

- Systemic disease DM, alcoholism, SCA,
Hematuria, Pain - Strep, TB, CMV chronic UT obstruction

Fever, arthralgia, Fever, hematuria,

Rash, No oliguria flank pain, Olig-anuria

Post-renal ARF AIN Papillary necrosis

Acute Tubular Necrosis (ATN)

Drugs Dose dependent, Need 5-10 days : Aminoglycoside, amphotericin,
vancomycin, cisplatin, acyclovir, cyclosporine
NSAID’s
Contraste Only one present with low urine Na+ , FENa <1%, High specific gravity
Others Hemoglobin, myoglobin, hyperuricemia (tumor lysis syndrome),
Bence-Johns protein (MM)
M 16 NEPHROLOGY

Transporter Hormones action Diuretic action

Na+- Glucose co-trans

Na+- Amin acid co-trans

Na+- Phosphate co-trans

↓ PTH
Early PT ↓ Carbonic anhydrase
Na+- H+ ex ↑ Angiotensin II
inhibitors
K+ channel

Water

Ca+2

Na+ - Cl- co-trans

Late PT K+ channel

Ca+2

Na+ - K+ - 2Cl- co-trans ↑ ADH ↓ Loop diuretic

Thick ALLH
Ca+2 , Mg+2 ↓ Loop diuretic

Na+ - Cl- co-trans ↓ Thiazide

Early DT
Ca+2 ↑ PTH ↑ Thiazide

Na+ + Cl- Channels ↑Aldosterone ↓ K+ sparing diuretics

Late DT +
Collecting duct K+ channels ↑ Aldosterone ↓ K+ sparing diuretics
(principal cell)
Water ↑ ADH

K+ - H+ ex
Late DT +
Collecting duct H+ ATPase ↑ Aldosterone ↓ K+ sparing diuretics
(α-intercalated cell)
Water

Ion blood level Na+ K+ Ca+2

Loop diuretics ↓ ↓ ↓
Thiazides ↓ ↓ ↑
K+ sparing diuretics ↓ ↑

BP  aldosterone FENa:
Blood volume  ADH (urine Na/ plasma Na) / (urine crea/ plasma crea) *100

Mg+2: necessary to PTH release, so hypomagnesemia lead to urinary loss of calcium

and potassium
M 15 HEMATOLOGY

 HEMATOPOISIS

 HEMOSTASIS
Disease BT Plt vWF PTT F8 PT F9 Note

ITP,TTP, HUS ↑ ↓ = = = = =
vWFD ↑ = ↓ ↑ ↓ = = The MC inherited
Bleeding Disease
HIT ↑ ↓ = ↑↑ = ↑ = Onset on 5-15 Days
Hyper-uremia ↑ = = = = = = Reversible
Aspirin ↑ = = = = = = Irreversible
APAS = ↓ ↑ = Recurrent thrombus
Warfarin = = = = = ↑↑ =
Hemophilia A = = = ↑ ↓ = = Dg +6 months
Hemophilia B = = = = = ↑ ↓ Type B: Christmas
DIC ↑ ↓ ↓ ↑ ↓ ↑ ↓
M 14 HEMATOLOGY

 BLOOD SMEAR
Forma Disease
Target cell “Codocyte” - SCA
- Thalassemia
- IDA
- Hyposplenism
- Liver disease
- Sideroblastic anemia
“Tear-drop” poikilocyte - Myelofibrosis
Spherocytes - Hereditary Spherocytosis
- Autoimmun Hemolytic anemia
Basophilic stippling - Lead poisoning
- Thalassemia
- Sideroplastic anemia
- Myelodysplasia
Howell jolly body - Hyposplenism
Heinz body - G6PD
- αThalassemia
Bite cells - G6PD
Schistocytes “helmet cells” - Intravascular hemolysis
- Mechanical heart valve
- MAHA: DIC, HUS, ITP, TTP, vasculitis
“Pencil” Poikilocyte - IDA
Burr cells “ Echinocyte” - Uremia
- Pyruvate kinase deficiency

 BLOOD PRODUCTS

Volum Tempreture time Incresing/unit Crossmatch

PRBC 450 ml 1-6 co 35 Days 1 mg/dl Yes
Platelets 300 cc 22-24 co 5 Days 5000-10000 No
FFP 300 cc -25 co 36 months Yes
Cryoprecipitate 50 cc -25 co 36 months Better to do

 Autoimmune Hemolytic Anemia

AIHA Type Site Treatment Most acccurate test
Warm IgG Extra-vas Splenectomy with steroid Coombs test
Cold IgM Intra-vas No Splenectomy or steroid Cold agglutinin titer
M 13 HEMATOLOGY

ANEMIA

Microcytic Normocytic Macrocytic

Iron study Reticulocytes Physiological

IDA Pregnancy
spherocytosis newborn

Electrophorese B12, B9 study

β Thalassemia B12, B9 DA
α Thal Hb H

Serum ferritin Megaloblasts

Chronic. D Methotrexate
𝜶 Thal (trait) sulfa, chemo

- Sideroblastic anemia - Liver disease

- Lead poisoning - Alcoholism
- Hypothyroidism
- Myelodysplasia
- Reticulocytosis
Bleeding

SCA, G6PD
- Chronic Disease
- Liver disease
Acquired Hemolysis
- Renal disease
- PNH, MAHA - Aplastic anemia
- Mechanical, burn - MDS
Coomb’s test
- Hypersplenism - Myelofibrosis
- march Hb_uria - Leukemia
- malaria, sepsis - Drugs (chemo)
Allo-immune - renal/ liver failure - Hypothyroidism
Auto-immune - Drugs, chemicals - Mixed (iron +B12)
M 12 HEPATOLOGY

 VIRAL HEPITITIS

Type transmission incubation Form Vaccine Others

A RNA Fecal-oral 15-45 Acute Yes In small children <5 Y

B DNA 45-160 Mix Yes Chronic: Lamivudine

- Blood + Tenofovir
C RNA - saliva 15-180 Chronic No Less in sex, MC in
- sex blood
D RNA - vertical Mix Yes Prevention by HBV
vaccine
E RNA Fecal-oral Acute No

HBV

HBs Ag
Not infected Infected

Anti-HBs Anti-HBc
IgM IgG

Anti-HBc
immune Not immune acute Chronic
IgM

Anti-HBc Anti-HBe

Vaccine Recovered Active Inactive

M 11 GI

Crohn’s disease Ulcerative colitis

M/F ratio M=F M>F
Involvement Full thickness Mucosa and submucosa
Features Usually non bloody diarrhea Usually bloody diarrhea
Weight loss more prominent Less Weight loss
RIF mass LIF pain
Vit D and B12 malabsorption No Vit malabsorption
Crypt abscess Crypt abscess
MC site Terminal ileum Rectum
Biopsy Non caseating granuloma Absent Non caseating granuloma
Pathology Increased globlet cells Depleted globlet cells
Cobble stone appearance Pseudopolyps
Extra-GI Erythema nodosum Erythema nodosum
Pyoderma gangrenosum Pyoderma gangrenosum
Osteoporosis Osteoporosis
Seronegative arthritis Seronegative arthritis
Gallstone Primary sclerosing cholangitis
Liver cirrhosis Ankylosing spondalytis
Pericarditis
Episcleritis , uveitis
Complication Obstruction Toxic colon
Fistula Cholangitis
Malabsorption Pyoderma gangrenosum
Col-rec cancer Less risk More risk
smoking Increased by smoking decreased by smoking
marker ASCA pANCA

ALP AST ALT Other

MI, intestinal infarction = ↑↑ =
Tumor , bone disease ↑↑↑ = =
Obstructive liver disease ↑↑↑ ↑ ↑
Alcohol liver disease 1 ↑↑ ↓ AST / ALT >2
Alcoholic Fatty liver 2 ↑↑ ↑ <500 AST / ALT >2
Alcoholic hepatitis ↑ ↑↑ >1000 ↑ AST / ALT >2
Alcoholic cirrhosis 3 ↓ ↓ AST / ALT >2
Steatosis 4 ↑ ↑ ALT > AST
Hepatitis ↑ ↑↑ >1000 ↑↑ >1000 ALT > AST
Liver necrosis 6 ↑↑↑ >5000 ↑↑↑ >5000
M 10 GI

Stomach Duodenum Jejunum Ileum Colon

Alcohol
Ion+2 (Ca, Mg, Fe, Cu)
Ion+1 (K, Na, Cl)
Water soluble Vitamins
fat soluble Vitamins
Fatty acid
Fat
Glucose
Sucrose/ lactose
Protein/ Amino acid
Water

 DIARRHEA
Infection

- Cholera - Enterohemorrhagic E. coli

- Bacillus cereus - Salmonella, Shigella
- Clostridium difficile (>18 hours) - Yersinia
- Staph aureus (4-6 hours) - Campylobacter
- Viral: Rotavirus (the MC cause - Clostridium difficile (less often)
of diarrhea) - Viral: CMV
- Systemic: sepsis, PID, malaria, - Parasite: entamoeba histolitica
meningitis, pneumonia (>5 days), Schistosomiasis

Watery Bloody

- Zollinger-Ellison syndrome
- Metabolic: DKA, DM, uremia, - Ischemic Colitis
thyrotoxicosis, VIPoma - GI bleeding
Non infection

- Drugs: PPI, cytotoxic, ATB, - Medication (NSAIDs, Chemo)

laxatives - IBD
- Carcinoid syndrome - Diverticulitis
- Cancer
- Giardiasis (>5 days)
- Radiation
M 21 ENDOCRINOLOGY

Diabetes Insipidus
Type Causes
Central stroke, tumor, trauma, hypoxia, infection, histiocytosis
Nephrogenic Lithium, demeclocycline, CKD, hypokalemia, hypercalcemia,
pyelonephritis, renal amyloidosis, Sjögren’s syndrome

MEN I MEN IIa MEN IIb

(Wermer syndrome) (Sipple’s syndrome)
Pancreatic tumor Pheochromocytoma Pheochromocytoma
Pituitary tumor Medullary thyroid cancer Medullary thyroid cancer
Parathyroid tumor (MC) Parathyroid tumor Neuroma, Marfanoid feature

 Adrenal gland
Renin Zona glomerulosa aldosterone Cushing Hyper corticolism
ACTH Zona fasciculate cortisone Addison Hypo adrenalism
FSH, LH Zona reticularis androgen Conn Hyper aldosterone

Associations Hypo-adrenalism
TSH – PRL ACTH – MSH Low High
Sodium, BP Urea
Blood sugar Potassium
Spironolactone is an anti-androgen and anti- Serum Cortisol Calcium
aldosterone drug aldosterone ACTH
PH

Cushing

Low Low dose Dexa 1mg High

 urinary cortisol

Normal ACTH

High dose Dexa Adrenal or

8mg suppression exogenic steroid
test

Low ACTH High ACTH MRI, CT scan

Small cells Pituitary

lung cancer Adenoma
sulfa, chemo
M 20 NEPHROLOGY

Acidosis Alkalosis
Wide anion gap (MUD PILES) - GI loss of acid
- Methanol overdose - Hyperaldosterone: Conn’s, Cushing’s
- Uremia: renal failure - Diuretics and hypokalemia
- DKA - Milk-alkali syndrome
- Phosphate, Paraldehyde
- Ischemia
- Lactate, hypotension
Metabolic

- Starvation, Salicylate overdose

Normal anion gap (HARD UP)

- Hyper alimentation
- Addison’s disease
- RTA (+ urine gap)
- Diarrhea, ileostomie, fistula
- Urethral diversion
- Pancreatico-enterostomy

- COPD - Anemia
respiratory

- Drowning - Anxiety, pain and Fever

- Opiate overdose - Interstitial lung disease
- Kyphoscoliosis - PE
- Sleep apnea - Mild asthma
- Life-threating asthma
M 19 NEPHROLOGY

Ions effect on ECG

+
Hyper- K - Low or absent P wave Hypo- K+ - High P wave
- Prolonged PR - Depressed ST
- Wide QRS - Broad or Flat T wave
- Peaked T wave - U wave
- Sine wave - Long QT
Hyper- Ca+2 - Short QT (ST) Hypo- Ca+2 - Long QT
- AV Block
- wide or flat T wave

Causes
Hyper-K+ - Pseudo hyperkalemia
- Oliguric renal failure
- Drugs: K+ sparing, ACEI/ARB, NSAID’s, cyclosporine, BB,
Digoxin, Heparin
- Type IV RTA
- Addison’s disease
- acidosis, Rhabdomyolysis, chemo, insulin deficiency
Hypo-K+ - alkalosis, High insulin, B-agonist, Barium intoxication, Hypo-Mg+2
- Diuretic therapy
- Type I and II RTA
- Conn’s syndrome, Cushing syndrome, Barter’s syndrome
- Vomiting, diarrhea, poor intake, GI loss

 RTA: Hyperchloremic metabolic acidosis with normal anion gap

Type Diagnosis Causes
I - Distal - Idiopathic
- Failure of H+ secretion, HCO3- reabsorption - Drugs
- low serum K+ - RA, SLE
- Urine PH not less than 5.5 (renal stone) - Sjögren’s syndrome
II - Proximal - Idiopathic
- Failure of NaHCO3 reabsorption - Fanconi syndrome
- low serum K+ - Wilson’s syndrome
- Urine PH variable ±5.5 (osteomalacia) - amyloidosis
III - Mixed between type I and II
- Normal serum K+
- Urine PH less than 5.5
IV - Hyporeninemic hypoaldosteronism - Decrease amount or effect
- High serum K+ of aldosterone
- Urine PH less than 5.5 (salt loss)
M 18 NEPHROLOGY

 Allergic drugs
Diseases Drugs
- Acute interstitial nephritis - Penicillin, Cephalosporin, Quinolones
- Drug allergy and rash - PPI (the MC), NSAID’s
- Stevens-Johnson syndrome - Phenytoin
- Toxic epidermal necrolysis - Sulfa drugs
- Hemolysis (G6PD) - Rifampicin, Streptomycin
- Furosemide
- Allopurinol

 Glomerular diseases

Nephritic syndrome
Post- streptococcal Glomerulonephritis After 1-3 weeks of URTI
IgA Nephropathy ( Berger’s disease) After 1-2 Days of URTI
Henoch Schonlein purpura Children
Good pasture syndrome Hemoptysis, Hematuria
Granulomatosis with polyangiitis Hemoptysis, Hematuria, URT symptoms,
(Wegner’s disease) cANCA (+)
Polyarteritis nodosa Chronic HBV, HCV, No respiratory sign
Alport’s syndrome Sensori-neural with visual disturbances
proliferative glomerulonephritis (Lupus)
Nephrotic syndrome
Minimal Change disease MCC in children
Membranous glomerulonephritis MCC in adults
Focal segmental glomerulosclerosis MCC in IV drug users with AIDS
DM nephropathy MCC of 2nd nephrotic syndrome
Amyloidosis Idiopathic, Myeloma, FMF, chronic
inflammation, IBD, RA
Drugs Penicillamine, gold, mercury, cadmium
Allergic reaction
M 22 ENDOCRINOLOGY

 DM

Type 1 DM Type 2

Hb A1C

>9 <9

Life style
modifications

Insulin Oral agent

Acting Type Onset Peak Duration

Rapid Lispro, Aspart, Glulisine 5-20 min 0.5-3 h 3-8 h
short Regular insulin (± I.V) 30 min 2-4 h 5-8 h
intermediate NPH 2-4 h 6-10 h 18-28 h
long Detemir, Levemir, Glargine 2 h none 20-24 h
Premixed insulin: rapid or short acting combined with intermediate acting insulin
Serum Osmolarity = 2(Na+) + serum glucose + serum urea ((in mmol/L))

Diabetic Retinopathy (5 years after DM)

Microaneurysm Dot and blot hemorrhage
Cotton-wool appearance Pre-proliferative
Angiogenesis May lead to retinal detachment
Macular edema May occur at any stage, the mcc of vision loss in DM
More angiogenesis Lead to Glaucoma

Diabetic Neuropathy (15 years after DM)

Symmetrical sensory polyneuropathy Gloves and stocking, loss of legs reflexes
Asymmetrical motor neuropathy Acute infarction in lumbosacral plexus
Mononeuropathy Motor or sensory, rapid dysfunction of
single peripheral or cranial nerve
MC: 3rd and 6th CN, sciatic, femoral nerve
Autonomic neuropathy Postural hypotension, bradycardia, urinary
incontinence, gastric atony, constipation...
M 25 RHEUMATOLOGY

Seropositive arthritis Seronegative arthritis

F>M M>F
RF (+), HLA DR4,3,1 RF (-), HLA B27
symmetric asymmetric
Poly arthritis Oligo arthritis
Morning stiffness >60 min <60 min
Upper limb more affected Lower limb more affected
Steroid using in treatment No Steroid using in treatment
Rheumatoid arthritis Ankylosing spondylitis
SLE Reactive arthritis
Scleroderma Psoriatic arthritis
Sjögren’s syndrome Enteropathic arthritis
Mixed connective tissue disease Juvenile chronic arthritis

Disease Features
RA, SLE Previously explained
Skin changes, muscle weakness, GERD, malabsorption,
Scleroderma lung fibrosis, cardiomyopathy, aortic regurgitation, RF,
malignant HTN
Dry mouth, Dysphagia, parotid enlargement, Dry eyes,
Sjögren’s Syndrome
vasculitis, RTA, pancreatitis
Mixed Connective RA, SLE, scleroderma, fibromyositis
tissue disease
Chronic inflammation of Sacroiliac joint and spine, pain
Ankylosing arthritis worse at rest, Heel pain, AV block, uveitis, aortic
regurgitation
Sexually transmitted: (salmonella, Shigella, Campylobacter,
Reactive arthritis
Chlamydia), conjunctivitis, Urethritis, Fever, weight loss
(Reiter’s)
carditis, Aortic regurgitation
Psoriatic arthritis History, Psoriasis ok skin, Nail pitting, Sausage digits, iritis
Gonococcal arthritis Sexually active, Polyarticular, Tenosynovitis, Petechial rash
Nodal or erosive: DIP and PID, Non nodal: DIP, knee OA,
Osteoarthritis morning stiffness, limitation of movement, swelling,
crepitus
MC: Knee and wrist, in I.V drug: spine and sacroiliac,
Infective arthritis
MC: Staph aureus, in artificial joint: Staph. epidermidis
Young: man, monoarthritis, 1st metatarsophalangeal joint,
Gout Elderly: women, polyarthritis, small joint of hand, Tophi
History: diuretic, alcohol, + protein intake, surgery, trauma
± hemochromatosis, hyperparathyroidism, hypothyroidism,
Pseudo gout
gout, mc site in knee, don’t affect DIP or PIP
M 24 RHEUMATOLOGY

Rheumatoid Psoriatic Ankylosing osteoarthritis

arthritis arthritis spondylitis

Rheumatic arthritis SLE

Systemic Fever, fatigue, weight loss
myocarditis, endocarditis coronary Pericarditis, Libman-sacks
Cardio vasculitis endocarditis “sterile endocarditis”
Pericarditis
Nodule Alveolitis, pleuritis
pulmonary
Pleural effusion, fibrosis
Eosinophilia, SPM,Thrombocytosis Lymphopenia, thrombocytopenia
Hemato
Anemia, Neutropenia
Mononeuritis multiplex, visceral Raynaud’s phenomenon
vascular
Vasculitis
Cervical cord compession, Carpel tunnel syndrome, Chorea,
Neuoro
peripheral neuropathy, amyloidosis Lymphatic meningitis
Oculo- Epi-scleritis, keratoconjonctivitis Malar butterfly rash, Discoid
dermo lupus rash , oral ulcer
Muscle wasting, Bursitis, Serositis, proliferative GN
Others osteoporosis
tenosynovitis
ESR High Assess the progression of disease
CRP High Only if Infection or serositis
Most. Sp Anti-CCP Anti-Smith
Most. Sn ANA
M 23 RHEUMATOLOGY

 HYPERSENSITIVIY
Type Form Cause Example
I Anaphylaxis, immediate IgE Anaphylaxis, atopy, asthma
II Cytotoxic, cell- mediated IgG or IgM AIHA, ITP, RF
III Immune complex Free Ag and Ab SLE, PSGN, EAA
IV Delayed T-cell-mediated GBS, MS, EAA, RVHD
V New type Ab Grave’s d, myasthenia gravis

 ERYTHEMA
Erythema nodosum Erythema marginatum
 No cause (idiopathic)  RF
 Drugs (penicillin, sulfa, NSAID’s)  mild myocarditis
 Oral contraceptives  allergic drug reactions
 Steroides  sepsis
 UC/ CD, sarcoidosis, Behcet’s  glomerulonephritis
 Malignancy/ lymphoma
 Infection: streptococci, TB, Brucellosis
 Pregnancy

Erythema multiforme Erythema migrans

 Stevens-Johnson Syndrome (SJS):  Lyme disease
Sulfa, penicillin, NSAID’s, steroids,
quinolones, cephalosporines ….
 infections
 Sarcoidosis, SLE,
 Pregnancy, Malignancy, Radiotherapy
M 26 RHEUMATOLOGY

 VASCULITIS
 Fever, fatigue, Weight loss, arthralgia, myalgia
Disease Features
Giant cell (temporal) Severe headache, scalp tenderness, Jaw claudication,
arteritis associated with PMR, ±sudden painless vision loss
large

Polymyalgia Sudden onset, severe pain, stiffness in shoulder, neck,

Rheumatica (PMR) pelvic muscles
Takayasu’s arteritis Affect aorta and its branch, asymmetric limb pulse
Chidren with high grade fever > 5 days with 4/5 of:
Medium

Kawasaki’s arteritis conjunctivitis, red cracked lips, strawberry tongue,

cervical APD, red palms and soles
More in male, Chronic hepatitis B or C, hematuria, RF,
drop foot, mononeuritis multiplex, sensorimotor
Polyarteritis nodosa
polyneuropathy, post prandial angina, GI bleeding, skin
ulcer, purpura, nodules, (no lung involvement),
URT: sinusitis, nasal septal perforation, saddle nose
Granulomatosis with LRT: cough, hemoptysis, dyspnea, cavitary lesion
polyangiitis “wegner” Hemato-protienura, conjunctivitis, scleritis, skin rash,
ulcer and nodules, cANCA
Small

Churg-strauss Pulmonary-renal syndrome, Eosinophilia, asthma,

syndrome paranasal sinusitis, mononeuritis multiplex, pANCA +
Oral and Genital ulcers, inflammatory arthritis, acne,
Behcet’s disease erythema nodosum, uveitis, retinal vasculitis, iritis,
aseptic meningitis, SVC obstruction
Henoch-Schönlein Purpura
Essential cryglobulinemia
Microscopic polyangiitis

High ESR >100 Low ESR = 00

 Infection  Afibrinogenemia
 Giant cell arteritis  Agammaglobulinemia
 PMR  Extreme polycythemia
 SLE (Hct >65%)
 Vasculitis  Increased plasma
 Lymphoma viscosity
 Multiple Myeloma
M 27 NEUROLOGY

CN Type Function
I Sensory Olfactory nerve
II Sensory Optic nerve
III Motor Oculomotor  latero-inferior deviation + ptosis + mydriasis
IV motor Trochlear nerve: innervates superior oblique muscle of the eye
V Mixed Trigeminal sensation of the face, motor by mastication
VI Motor The abducent nerve: palsy  inward deviation and diplopia
VII Mixed Facial nerve: facial expression, taste sensation 2/3 of the tongue
VIII Sensory Vestibulocochlear nerve
IX Mixed Glossopharyngeal nerve
X autonomic Vagus nerve
XI Motor Accessory nerve: sternocleidomastoid and trapezius
XII Motor Hypoglossal nerve: muscles of tongue

Aphasia
Type Sens Speech
Wernicke’s (receptive) No sense and word fluent
substitution
Broca’s (expressive) sense what he want to say Non fluent
Conduction Speech fluent but patient say word he doesn’t mean it
Global Severe receptive and expression aphasia

LMNL UMNL
Hypotonia Hypertonia
Muscle wasting No muscle wasting
Hyporeflexia Hyperreflexia
No clonus ± Clonus
Planter flexion or no response Upward Planter reflex Babinski +

Thunderclap headache
SAH Usually occipital, neck rigidity, photophobia, vomiting, suspected
berry aneurysm (PKD, Tabaco, HTN, alcohol, hyperlipidemia)
Carotid artery Frontal, visual symptoms (amaurosis fugax, diplopia, Horner’s
dissection syndrome)
Vertebral artery Occipital, nausea, vomiting, brain stem finding (vertigo, ataxia,
dissection diplopia, tinnitus, dysarthria)
Cerebral venous Hypercoagulability, sign of increased ICP, focal finding like 6th
thrombosis CN palsy
M 30 INFECTIONS

Cocci Bacilli
Staphylococci Listeria monocytogenes
+ Streptococci Clostridium
Enterococci diphtheria
Neisseria meningitidis E. coli
Neisseria gonorrhea Klebsiella pneumonia
Moraxella catarrhalis Proteus
- Enterobacter , H.pylori
Salmonella, Shigella, Yersinia
Vibrio cholera
Pseudomonas aeruginosa

Germ Treatment
Pneumonia  Macrolides – Doxycycline – Amoxicillin
 Fluoroquinolone (if ATB use in the past 3 month) - (inpatient)
 Ceftriaxone + Azithromycin (inpatient)
Mycoplasma Macrolides
Legionella Macrolides
Klebsiella
Pseudomonas Carbapenems (except Ertapenem) - Tigecycline – Cefepime (4GC)
– Aminoglycosides – Fluoroquinolones (except Moxifloxacin)
Lung abscess
H. pylori 2 of : amoxicillin – clarithromycin – metronidazole
Meningitis  Cefotaxime (+ Amoxicillin if <3 month or >50 years)
 Cefotaxime or Benzylpenicillin if meningococci
 Acyclovir if viral
Encephalitis Acyclovir
Brucellosis Doxycycline + Rifampicin
Staph.tox.shk Flucloxacillin – Vancomycin
Strep.tox.shk Clindamycin – Benzylpenicillin
Lyme disease Doxycycline – Amoxicillin
Typhoid fever Chloramphenicol – Amoxicillin – Cefixime – Cotrimoxazole –
Ceftriaxone – Azithromycin
Syphilis Penicillin - Doxycycline
Gonorrhea Ceftriaxone
Chlamydia Azithromycin
MRSA Minor: TMP/SMX – Doxycycline – Clindamycin – Linezolid
Major: Vancomycin
M 28 NEUROLOGY

Type Features
Migraines Unilateral, Aura, photophobia, visual disturbances, menses-
headache related, associated with chocolate, wine and cheese
≥ 3 criteria (POUND): Pulsatile, One day duration, Unilateral,
Nausea and vomiting, Disability
Cluster headache Around one eye, Frequent, Short duration, High intensity,
associated with red and tearing eye with rhinorrhea
Giant cell arteritis >50 years, Jaw claudication, visual symptoms, tenderness at the
temporal area, very high ESR
Benign IC HTN Obesity, OCP, Vitamin A toxicity, venous sinus thrombosis,
mimic brain tumor with nausea and vomiting, visual
disturbance, papilledema with diplopia from 6th CN palsy,
worsen in the morning, and Valsalva maneuver
Tension headache The MC type, Bilateral, non-throbbing, radiate forward from the
occipital region
Sinusitis periocular pain, Fever, tenderness, cough, increased by forward
decline,
Trigeminal 5th CN compression, unilateral lancinating facial pain,
neuralgia precipitated by touching the face, mastication

CVA
Middle  Weakness and sensory loss in the opposite side
 Loss of visual field on the opposite side (Homonymous hemianopsia)
 Aphasia: speech center present on the left side in 90%
Anterior  Cognitive defect
 Urine incontinence
 Weakness in leg more than arm
Posterior  Ipsilateral sensory loss of face
 Contralateral sensory loss of limbs
 Limb ataxia
M 28 NEUROLOGY

Type Features
Migraines Unilateral, Aura, photophobia, visual disturbances, menses-
headache related, associated with chocolate, wine and cheese
≥ 3 criteria (POUND): Pulsatile, One day duration, Unilateral,
Nausea and vomiting, Disability
Cluster headache Around one eye, Frequent, Short duration, High intensity,
associated with red and tearing eye with rhinorrhea
Giant cell arteritis >50 years, Jaw claudication, visual symptoms, tenderness at the
temporal area, very high ESR
Benign IC HTN Obesity, OCP, Vitamin A toxicity, venous sinus thrombosis,
mimic brain tumor with nausea and vomiting, visual
disturbance, papilledema with diplopia from 6th CN palsy,
worsen in the morning, and Valsalva maneuver
Tension headache The MC type, Bilateral, non-throbbing, radiate forward from the
occipital region
Sinusitis periocular pain, Fever, tenderness, cough, increased by forward
decline,
Trigeminal 5th CN compression, unilateral lancinating facial pain,
neuralgia precipitated by touching the face, mastication

CVA
Middle  Weakness and sensory loss in the opposite side
 Loss of visual field on the opposite side (Homonymous hemianopsia)
 Aphasia: speech center present on the left side in 90%
Anterior  Cognitive defect
 Urine incontinence
 Weakness in leg more than arm
Posterior  Ipsilateral sensory loss of face
 Contralateral sensory loss of limbs
 Limb ataxia
M 31 PHARMACOLOGY

Antibiotic Examples
Penicillin Amoxicillin – Ampicillin – Dicloxacillin – Naficillin – Peni G.V
Cephalosporins 1st : Cephalexin – Cefazolin
2nd: Cefaclor – Cefuroxime – Cefoxitin
3rd: Ceftriaxone – Cefotaxime – Ceftazidime
4th: Cefepime
Macrolides Erythromycin – Azithromycin – Clarithromycin
Carbapenems Imipenem – Meropenem – Ertapenem – Doripenem
Fluoroquinolones Ciprofloxacin – Levofloxacin – Moxifloxacin
Aminoglycosides Gentamycin – Tobromycin – Amikacin
TMP/SMX
Doxycycline

Medicament Examples
ACEI Enalapril – Perindopril – Ramipril – Lisinopril
ARB Valsartan – Candesartan - Irbesartan
B. blockers Selective B1: Atenolol – Metoprolol – Bisoprolol
Non Selective: Propanolol – Labetalol – Carvedilol
CCB Peripheral: Amlodipine – Nifedipine – Felodipine
Central : Diltiazem – verapamil
Loop diuretics Furosemide – Bumetanide – Torsemide
K+ sparing Spironolactone – eplerenone – amiloride

Vit deficiency Disease

A Poor wound healing
B1 (Thiamin) Wet Beriberi: SOB – lower limb edema – HF
Dry Beriberi: Paralysis – confusion – Nystagmus
B3 (Niacin) Pellagra: dementia – diarrhea – dermatitis – depression – death
B6 (Pyridoxine) Anemia – dermatitis – atrophic glossitis with ulceration –
angular cheilitis – conjunctivitis – confusion – neuropathy
B9 (folic acid) Anemia
B12 (Cobalamin) Anemia – Neurological manefistation
C (ascorbic acid) Scurvy: Sore arms – sore legs – gum bleeding
Poor wound healing
D Rickets – osteomalacia
K Bleeding – prolonged PT
Zink Skin rash – dermatitis – alopecia – poor wound healing
Copper Microcytic Hypochromic anemia
Chromium, Mg Insulin resistance