SMLE INTERNAL MEDICINE

SUMMARY
Diseases in table according to the system
Notes taken from Dr. Amer Zahrallayali 2022 Course

Done by: Dr. Huda Meshikhes, Twitter: @HMeshikhes

Table of Contents
RHEUMATOLOGY ......................................................................................................................................................................................... 2
NEPHROLOGY ................................................................................................................................................................................................ 9
CARDIOLOGY ................................................................................................................................................................................................ 15
PULMONOLOGY ........................................................................................................................................................................................... 24
HEPATOLOGY ............................................................................................................................................................................................... 32
GASTROENTEROLOGY ............................................................................................................................................................................... 40
ENDOCRINE ................................................................................................................................................................................................... 44
INFECTIOUS DISEASE .................................................................................................................................................................................. 52
HEMATOLOGY AND ONCOLOGY .............................................................................................................................................................. 58
NEUROLOGY ................................................................................................................................................................................................. 64

Discipline Number of pages

1 Rheumatology 6 pages
2 Nephrology 5 pages
3 Cardiology 8 pages
4 Pulmonology 7 pages
5 Hepatology 7 pages
6 Gastroenterology 3 pages
7 Endocrine 7 pages
8 Infectious Disease 5 pages
9 Hematology and Oncology 5 pages
10 Neurology 6 pages

1
Rheumatology

2
 Hints Diagnosis Treatment Extra
- Newly diagnosed methotrexate + steroid
Poor prognostic
- Newly diagnosed + very mild (negative RF, low
features:
ESR/CRP) hydroxychloroquine
- Joint erosion
- Not improved on methotrexate + poor prognostic
- >20 small joints
features add anti-TNF (infliximab)
involved
- Morning stiffness >1 - Not improved on methotrexate + no poor
- Poor functional
hour prognostic features add hydroxychloroquine
status
- Increase with rest, and sulfasalazine
- Initial/Next: RF - Smoker
decrease with - ove in all medications give
Rheumatoid - Diagnostic: anti-CPP - Late presentation
movement methotrexate and rituximab
arthritis - X-ray: osteopenia - High RF, high ESR
- Most common in wrist - Patient taking methotrexate +
sclerosis pannus and CRP, high anti-
- hydroxychloroquine + no improvement + no poor
CCP
Spine (except C1/C2), prognostic features add biologic (infliximab)
- Subcutaneous
Hip - If pregnant:
nodules
o Low activity (only joint symptoms)
hydroxychloroquine + steroid
- RA
o High activity (deformity subcutaneous nodule,
- Splenomegaly
extra-articular) hydroxychloroquine +
- Low neutrophils
sulfasalazine + steroid OR anti-TNF + steroid
- Arthritis + Fever - NSAIDs
Adult-onset
- Rash (salmon patch) - - No improvement or severe (multi-joint) steroid
- HIGH ferritin - Refractory methotrexate
- Lifestyle modification
- Morning stiffness <30 - All labs normal
- Topical diclofenac
minutes - X-ray (late findings):
- If no improvement:
- Decrease with rest, joint space
o Patient with CKD, hypertension, PUD, CHF oral paracetamol or
Osteoarthritis increase with narrowing
tramadol
movement subchondral
o Healthy short course NASAIDs (ibuprofen or celecoxib)
- sclerosis
- If no improvement with oral medication intra-articular injection steroids
wrist, ankle, elbow osteophytes
- If no improvement codeine (last resort)
3
 Indications of urate
- Initial/Next: joint lowering agent
- Diuretics (furosemide,
aspiration - First attack: (allopurinol OR
thiazide)
(monosodium urate o Medically free indomethacin + misoprostol febuxostat OR IV
- Diabetes
crystals, needle OR colchicine pegloticase if
- CKD
Gout shaped, negative o CKD, CVD, HF, PUD Colchicine refractory tophi)
- CHF
birefringent, yellow) - After 2 weeks, start prevention colchicine for - Tophi
- Pyrazinamide
- Specific sign on 6 months + urate lowering agents (only if - 2 or more
- High turnover disease
ultrasound: double indicated) attacks/year
(psoriatic arthritis, RA)
contour sign - Erosion on x-ray
- GFR <60
- Initial/Next: joint
aspiration (calcium
- Hyperglycemia
pyrophosphate,
- Hypercalcemia
rhomboid shaped, - NSAIDs + colchicine
Pseudo-gout - Hypomagnesemia
positive birefringent, - Treat underlying cause
- Hypothyroidism
blue)
- Hemochromatosis
- X-ray:
chondrocalcinosis
- If gonorrhea, they - Gonococcal gonorrhea (gram -ve) ceftriaxone 2 weeks + 1 dose of
- Joint fluid analysis
have to do cervical + doxycycline or azithromycin
Septic arthritis >50,000 cell count
urethra + pharyngeal - Staph oxacillin or cloxacillin, if resistant vancomycin
(PMN >75%)
PCR for chlamydia - Strep penicillin OR ceftriaxone OR ampicillin
- Male > female
- <40 years old
- Back pain - NSAIDs
Ankylosing - Diagnostic: MRI hip
- Anterior uveitis, aortic - If no improvement + spine affected infliximab
spondylitis and spine
regurgitation, apical - If no improvement + peripheral (knee, ankle) affected sulfasalazine
lung fibrosis, IgA
nephropathy

4
 - GU infection
- NSAIDs
(chlamydia)
- Post infection (2-4 - No improvement or another attack stop NSAIDs + give steroids
- GI infection (shigella,
weeks of GI/GU - No improvement (recurrent or severe symptoms) stop steroids + give
Reactive arthritis clostridium difficile,
infection) sulfasalazine OR methotrexate
salmonella,
- 20-40 years - Antibiotics (doxycycline or azithromycin) given if only active infection, with
campylobacter
NSAIDs
jejuni)
- More common with - If spine affected anti-TNF
IBD arthritis -
- If peripheral (knee) affected IBD medications
- Upper limb
involvement
- Sausage digit
- NSAIDs
(dactylitis)
Psoriatic arthritis - X-ray: pencil in cup - If mild add sulfasalazine
- Nail pitting
- If severe add anti-TNF
- Silver erythematous
scaly plaque
- 45-54 years old
- Tight skin in trunk
Sclerodermic renal
- Involvement of heart
- No steroids crisis:
(MI or restrictive
Diffused - Initial/Next: ANA - If pulmonary fibrosis IV cyclophosphamide OR - Sudden
cardiomyopathy
systemic - Diagnostic: anti-SCL mycophenolate mofetil hypertension
leading to right heart
sclerosis 70 (topoisomerase I) - Renal crisis ACE inhibitor (even if pregnant or - Increase creatinine
failure), lung (ILD),
high creatinine) - Microangiopathic
kidney (sclerodermic
hemolytic anemia
renal crisis)
- Tight skin in face, hand
- Calcinosis
- Initial/Next: ANA
Limited systemic - Raynaud phenomena - Raynaud CCB (nifedipine) topical nitrate
- Diagnostic: anti-
sclerosis - Esophageal dysmotility improve Viagra aspirin SSRI
centromere
- Sclerodactyly
- Telangiectasia
5
 - Painless, proximal
muscle weakness
- Purple rash:
o Eye: Heliotrope rash
o - High creatinine - Must do both
papules kinase - Mild disease (no organ involvement) steroid upper and lower GI
o Upper back: shawl - Initial/Next: ANA - Severe disease azathioprine OR methotrexate endoscopy and in
Dermatomyositis
sign - Specific: anti-jo, OR rituximab OR IVIG (if refractory) female pelvic
o Neck: V-sign anti-m1 - Life threatening (low O2, hypoxia, respiratory ultrasound to rule
o Hip: holster sign - Diagnostic: muscle failure) cyclophosphamide out GI/Gyne
- Organ involvement biopsy malignancy
(cardiomyopathy, ILD,
pulmonary
hypertension)
Polymyositis - No rash only weakness
- Mild (only joint or skin symptoms)
- Malar rash
hydroxychloroquine + PO steroid - No live vaccine
- Alopecia
o If in the question only given hydroxychloroquine (MMR, zoster)
- Nonpainful oral ulcer
give steroid - Only killed vaccine
- Seizure, psychosis
o If no improvement add methotrexate or (pneumococcal,
- Episcleritis, sicca - Initial/Next: ANA
azathioprine influenza)
- Pericarditis (>1:60)
- Moderate/non-life threatening (pleurisy, - Neonatal lupus
- Liebman-sac - Specific:
pericarditis, pleura effusion, platelet 20-50) (bradycardia +
SLE endocarditis o Anti-smith
hydroxychloroquine + IV steroid complete heart
- Pulmonary (diagnostic)
o If no improvement add methotrexate or block) from anti-Ro
hypertension o Anti-dsDNA
azathioprine or mycophenolate mofetil - If SLE + RA
- Pleurisy (disease activity)
- Severe/life threatening (affects brain, spine, hydroxychloroquine
- Pleural effusion
kidney, or pulmonary hemorrhage) IV + methotrexate
- Raynaud phenomena
cyclophosphamide + IV steroid - Anti-La is least
- Ascites
o Give maintenance hydroxychloroquine + autoantibody
- Mesenteric vasculitis
mycophenolate mofetil
6
 - Stop (methotrexate, cyclophosphamide, mycophenolate mofetil) 3 months before conception
- Safe in pregnancy: hydroxychloroquine, steroid, azathioprine, cyclosporine, tacrolimus
Pregnancy and - Start with hydroxychloroquine + low dose steroid
SLE - Presented with attack:
o Life threatening IV steroid + mycophenolate mofetil (save the mother even if contraindicated) OR rituximab
o Non-life threatening IV steroid + hydroxychloroquine no improvement increase dose of steroid OR give cyclosporine
- First step to diagnose is renal biopsy (guides the management):
o I (minimal mesangial) + II (mesangioproliferative) no treatment
Lupus nephritis o III (focal proliferative) + IV (diffuse proliferative) IV steroid + IV cyclophosphamide OR IV mycophenolate mofetil
o V (membranous) IV steroid + IV cyclophosphamide OR IV mycophenolate mofetil AND add ACE inhibitor (for proteinuria)
o VI (sclerosis) dialysis
- Infliximab
- Sulfasalazine
Drug-induced - Initial/Next: ANA
- Hydralazine - Stop medication
lupus - Specific: anti-histone
- Procainamide
- Quinin + Methyl dopa
- SLE + multiple
miscarriages + DVT
- Lupus anticoagulant
- Livedo reticularis - Low molecular weight heparin (enoxaparin) + low dose aspirin
Antiphospholipid - Anticardiolipin
- Liebman-sac - If only antibodies positive with no symptoms or miscarriage only low
syndrome - Low platelets
endocarditis dose aspirin given
- Long PTT
- Fetal loss (x1 >10 wks
OR x3 <10 wks)
- Initial/Next: ANA
- Specific: anti-Ro
- Ocular symptoms tear drops or drops of cyclosporin (if severe)
(SSA), anti-La (SSB)
- Oral symptoms PO pilocarpine
Sjogren - Rose-Bengal stain
- Dry eyes and mouth - Extra-glandular (arthritis, lung fibrosis, renal tubular acidosis type 1):
syndrome and Schirmer test
o Mild (arthritis) NSAIDs
- Diagnostic: parotid
o Severe Steroid
or salivary gland
biopsy
7
 - Diagnostic: CT
Takayasu - Young, Asian female
angiography of aorta - IV steroid
arteritis - No radial pulse
and aortic arch
- Unilateral headache
- Jaw claudication - Best to diagnose: CT
- Decrease eye vision angiography of
Giant cell
- Tender scalp temporal artery - Give high dose prednisone without delay
arteritis
- Associated with - Gold standard:
polymyalgia temporal biopsy
rheumatica
- Male >50 years
- Abdominal pain
- Diagnostic: CT
- History of HBV
Polyarteritis angiography
- No effect on lungs - IV steroid
nodosa (microaneurysms in
- Livedo reticularis +
mesentery)
mononeuritis
multiplex
- Recurrent sinusitis
- URTI
Wegner
- Saddle nose - IV steroid + IV cyclophosphamide
(Granulomatous - C-ANCA
- Hemoptysis - If no improvement plasma exchange (plasmapheresis)
polyangiitis)
- Renal involvement
(RBC casts)
Shurg-straus
- Noncontrolled asthma
(Eosinophilic - Steroid
- Recurrent rash + - P-ANCA
granulomatous - If cardiac manifestation IV steroid + IV cyclophosphamide
eosinophils >10%
polyangiitis)
- Episodic fever + Pain in
Familial - High ESR, CRP, WBC - Colchicine
joint + Peritonitis pain
Mediterranean - High levels of IL-1 - If only arthritis aspirin and steroid
+ Pleuritis
fever - Have pyrin gene - No antibiotic (amoxicillin or macrolide)
- Lebanon or Turkey
8
Nephrology

9
 Hints Diagnosis Treatment Extra
- Refractory acidosis to NaHCO3
- Refractory hyperkalemia and hypercalcemia
- Intoxication by (salicylate, methanol, ethylene glycol, isopropyl alcohol)
Indication of
- Refractory volume overload to diuretics
urgent dialysis
- Uremia:
o Uremic pericarditis, Uremic encephalopathy, Refractory bleeding to desmopressin, Refractory uremic neuropathy
- If ESRD and on dialysis came with hyperkalemia start hemodialysis
- Initial: cardiac stabilizer (IV Ca gluconate) - If refractory
Tall T wave - Next: cell shifter (IV insulin with IV dextrose, (tried for 3 times)
- K >6.5 in ECG albuterol nebulizer, NaHCO3 only if low pH) hemodialysis
Hyperkalemia - Tall, tented T - Next step: ECG - Last: clearance (Ca resonium OR furosemide) - Treatment of
wave in V3-V4 hypokalemia is
No ECG - Start cell shifters (IV insulin + IV glucose)
potassium
finding - NaHCO3 only if low pH
replacement (KCl)
- Urine Na: - In SIADH rule out
- Na <135 o >30 renal loss (diuretics) hypothyroidism
- Stupor Hypovolemia o <30 extra-renal (vomiting, diarrhea, NGT, and adrenal
- Coma dehydration) insufficiency to
- Anorexia - Give isotonic saline make the
- Lethargy - Serum - Urine osmolarity: diagnosis
- Hyporeflexia osmolarity o <100 (diluted urine) psychogenic polydipsia - Hyponatremia +
Euvolemia
- Weakness - Assess volume o >100 (dark urine) SIADH CNS symptoms
Hyponatremia
- Orthostatic status - Restrict water IV hypertonic
hypotension - Urine Na: saline with rate
- Seizure o >30 renal loss (CKD or nephrotic syndrome) of correction Na
- Headache Hypervolemia o <30 extra-renal (CHF, cirrhosis, secondary level 4-6 in first 4
- Stomach cramp hyperaldosteronism) hours, <12 in first
- Give diuretics 24 hours
- Osmotic demyelination syndrome paraplegia, diplopia, dysarthria from rapid correction diagnosed by MRI
- Over correction + no signs of osmotic demyelination syndrome (central pontine myelinosis) stop normal saline + give D5W
10
 - Dysuria without
- 3-5 days of:
fever
Uncomplicated o Nitrofurantoin OR Trimethoprim first line
- Female
cystitis o Amoxicillin OR Ciprofloxacin OR Augmentin second line
- Nonpregnant
- Trimethoprim not given in G6PD
- Medically free
- Dysuria without
- 5-7 days:
fever
- Urine analysis o Amoxicillin OR Ciprofloxacin first line
- Male
- Urine culture: o Nitrofurantoin OR Trimethoprim second line
Complicated - Pregnant
o Klebsiella - Pregnant:
cystitis - Renal transplant
o E. coli o Trimethoprim in second trimester OR Nitrofurantoin (stops last 30 days before
- Renal stones
o Enterobacter delivery) OR Beta lactam (Amoxicillin OR cephalexin)
- Anomalies
o Proteus o Not given in pregnancy (Metronidazole, Ciprofloxacin, Aminoglycoside, Tetracyclines)
- DM
o Pseudomonas
- Fever + flank
o Serratia
pain + dysuria - 10 days:
Uncomplicated o Staphylococcus
- Normal kidney o Ciprofloxacin
pyelonephritis saprophyticus
function o If pregnant IV ceftriaxone or IV meropenem
(honeymoon
- Normal US
cystitis
- Fever + flank
pain + dysuria
- 14 days:
- High creatinine
Complicated o IV meropenem OR IV ceftriaxone with IV aminoglycosides (gentamycin) OR IV
- Low blood
pyelonephritis ciprofloxacin
pressure
o If pregnant IV meropenem
- Perinephric
abscess on US
Acute tubular - Severe prolonged ischemia from hypotension or hypovolemia
necrosis - Contrast induced nephropathy (prevented by giving pre and post isotonic IV fluid)
(Granular or - Gout
muddy cast) - Toxins (aminoglycosides, vancomycin, acyclovir, methotrexate)
causes - Pigments: rhabdomyolysis, hyperbilirubinemia

11
 Acute - Allergy to drug (B-lactam or sulfa drugs)
interstitial - Autoimmune (SLE, Sjogren)
nephritis
- Infections (TB, pyelonephritis)
(WBC Cast)
causes - Infiltration (lymphoma, leukemia)
- Statins for cardiovascular complication protection
- ACE inhibitor to decrease albumin level
- CKD + hypertension decrease Na
- CKD + oliguria decrease K
CKD - CKD + volume overload diuretics (lasixs)
(Waxy cast) - CKD + uremic pericarditis or uremic encephalopathy or uremic neuropathy dialysis
- CKD + metabolic acidosis PO NaCHO3
- CKD + hyperkalemia management of hyperkalemia above
- CKD + anemia of chronic disease erythropoietin injections (target Hb level until 10, treat IDA before giving erythropoietin)
- CKD + secondary hyperparathyroidism calcitriol + phosphate binder
- Proteinuria >3.5 gram (+4), Hypoalbuminemia, Hyperlipidemia, Edema
- Cast: fat/oval
- Diabetic nephropathy
Systemic causes
- Autoimmune + proteinuria + high Ca + rash amyloidosis
- Pediatrics, Leukemia, or lymphoma
Minimal change GN - Pudding (podocyte effacement)
- Management: Prednisone
Nephrotic - Malaria, HBV
syndrome - Solid malignancy (lung, breast, colon)
Membranous GN - SLE
- Medications (gold, NSAIDs)
- Management: ACE inhibitor + prednisone + treat the cause
- Sickle cell disease
Focal segmental - Heroin, anabolic steroids
glomerulosclerosis - HIV, chronic pyelonephritis
- Management: ACE inhibitor + prednisone + treat the cause

12
 - RBC casts or dysmorphic RBCs
- Proteinuria <3.5 grams, Hematuria (dark urine or Coca-Cola), Hypertension, Azotemia (high BUN and creatinine)
- Hemolytic uremic syndrome
Normal C3/C4 - Henoch-Schoenlein purpura
- Goodpasture syndrome
Systemic causes
- SLE
Nephritic
Low C3/C4 - Endocarditis
syndrome
- Cryoglobunemia
- Young + history of URTI within days
IgA nephropathy - Normal C3/C4
- Treatment: Steroid + ACE inhibitor
- Young + history of URTI or skin infection within weeks
Post infectious GN
- Low C3/C4
- Crescent shaped (Comes with Wegner and good pasture syndromes)
Goodpasture Wegner (granulomatous polyangiitis)
Rapidly - IgG linear deposits (anti-basement membrane antibodies)
progressive - C-ANCA
- Hemoptysis + hematuria + high creatinine
GN - Hemoptysis + hematuria + high creatinine + sinusitis
o Anti-GBM disease only hematuria, no hemoptysis
- Management: cyclophosphamide + steroid +/- plasmapheresis
Features of renal tubular acidosis:
- Hyperchloremic metabolic acidosis (non-anion gap)
- Hypokalemia
Type I (distal) Type II (proximal) Type IV (distal)
- Bicarbonate wasting - High K (unique)
Renal tubular - Decrease secretion of H ions
- Causes: - Hormonal effect by aldosterone
acidosis - Stones formation
o Multiple myeloma (from principal cells in distal)
- Causes:
o Gold, mercury - Causes:
o Autoimmune (SLE, Sjogren, RA)
o Acetazolamide o Diabetic nephropathy
o Drugs (lithium)
o Fanconi syndrome (low bicarbonate, low Na, o CKD
o Hyperglycemia
low K, low glucose) o Obstructive uropathy

13
 Steps in ABG
Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Step 1: arrows Same way Opposite ways
compare pH with PaCO2 pH PaCO2 pH PaCO2 pH PaCO2 pH PaCO2
Step 2: compensation
(±2)
HCO3: 24 PaCO2: 40
Anion gap = Na (HCO3 + Cl)
Step 3: Anion gap - High >12 high anion gap metabolic acidosis
- Normal (8-12) non-anion gap metabolic acidosis
1. Delta anion gap = (step 3) 12
2. Delta HCO3 = 24 patient HCO3
Step 4: delta delta (if 3. Delta delta = delta anion gap delta HCO3:
high anion gap >0 0 <0
metabolic acidosis) High anion gap High anion gap metabolic
metabolic acidosis + Pure acidosis + non anion gap
metabolic alkalosis metabolic acidosis
- Methanol
- Uremia
- DKA
- Paraldehyde - CNS depression
Anion - Isoniazid - Airway
- - Anxiety
gap - Ethanol obstruction
syndrome - Mechanical
- Lactic acidosis - Pulmonary
- Cushing ventilation
- Renal failure edema
Examples syndrome - Progesterone
- Rhabdomyolysis - Pneumonia
- Vomiting (pregnancy)
- Salicylates - Hemothorax
- Loop diuretics - Salicylates
- Renal tubular acidosis - Pneumothorax
- Thiazide - Sepsis
- Diarrhea - Neuromuscular
Non - Acetazolamide disease
anion
- Spironolactone
gap
- Fistula
-
14
Cardiology

15
 Hints Diagnosis Treatment Extra
- Lasix, morphine (if chest pain or
anxiety), nitrates, O2 (if sat
- Acute
<92%), C-PAP
Acute presentation:
- If BP <90/60 add dobutamine
- Left side: pulmonary edema o Orthopnea +
- if BP >160/100 add IV
(bilateral basal crackles) = PND
- Sensitive: BNP >100 nitroglycerine
cough, wheeze o Bilateral basal
- Chest X-ray: first - ACE inhibitor (+/- PO Lasix as
- Right side: ascites, lower crackles
cephalization then reliever) BB
Heart failure limb edema, hepatomegaly, o S3
Kerly B line then
Kussmaul sign, distended o Edema
pleural effusion spironolactone
jugular veins o High BNP
- Diagnostic: Echo digoxin (last resort)
- Both: fatigue, exercise Chronic - Antidiabetic that
- In preserved ejection fraction
intolerance decreases
BB +/- Lasix
mortality in CHF
- Preventive measure: if ejection
SGLT-2
fraction <35% intracardiac
defibrillator
- Chest x-ray:
cardiomegaly +
- Familial pulmonary edema
- Infection (post URTI) - ECG: A. fib) - Same management of chronic HF
Dilated
- Myocarditis (SOB, HF, chest - Echo: decreased - Peripartum or postpartum bromocriptine
cardiomyopathy
pain, ECG normal) ejection fraction - Definitive transplant
- Lateral displaced apex - Diagnostic:
endomyocardial biopsy
myocarditis
- Diseases with -osis - Chest x-ray:
(amyloidosis, sarcoidosis, pulmonary edema - Treat underlying cause
Restrictive
hemochromatosis, systemic - ECG: low voltage - Control HR beta blocker
cardiomyopathy
sclerosis) - Diagnostic: - Definitive transplant
- Kussmal sign endomyocardial biopsy
16
 - Beta blocker no improvement calcium channel blocker no
- Autosomal dominant - Chest x-ray: improvement surgical myomectomy
Hypertrophic - Young + exercise + family cardiomegaly - Insert intracardiac defibrillator if:
obstructive history of sudden death - ECG: left ventricular o Has syncope
cardiomyopathy - Syncope, angina, arrythmia, hypertrophy o Family history of sudden cardiac death
dyspnea - Normal Echo o Ventricular tachycardia or V. fib
- Avoid digoxin and nitrate
- Early diastolic murmur
- Lt upper sternal boarder
- Mild or moderate: ACE inhibitor + CCB + nitrate
- Wide pulse pressure
Aortic - Surgery (replacement):
- Increase with expiration and
regurgitation o Ejection fraction <50
leaning forward
o Severe symptoms (HF)
- Increase with hand grip and
squatting
- Asymptomatic:
o Avoid exercise
- Mid-diastolic murmur
o Antibiotics prophylaxis if RHD
- At apex
o Anticoagulation + BB + Diuretics
- Low pitched
- Diagnosis: - Balloon valvoplasty: - Worst outcome in
Mitral stenosis - Loud S1
transthoracic echo o Symptomatic (HF) pregnancy
- Opening snap
o Mitral valve area <1.5 (severe mitral
- Decrease with hand grip
stenosis)
- Increase with squatting
- Pregnancy percutaneous mitral balloon
commissurotomy
- Ejection systolic murmur - Surgery (replacement):
(crescendo-decrescendo) o Symptomatic (HF)
- Rt upper sternal boarder o Asymptomatic + echo <50 + severe (valve area <1, or pressure
Aortic stenosis - Radiate to carotid gradient >40)
- Slow rising pulse - Severe + echo >50 observe + stress test
- Decrease with hand grip - Old not fit for replacement transcatheter aortic valve
- Increase with squatting implantation
17
 - High pitched holo-systolic - Medical: normal BP + acute (ischemia or IE)
murmur - Surgery (repair):
Mitral
- Radiate to axilla o Low BP + acute
regurgitation
- Increase with hand grip and o Symptomatic chronic
squatting o Asymptomatic + ejection fraction <60
Unstable (BP <90) - Urgent synchronized cardioversion (50-100 J)
Duration of - Rhythm control ONLY by:
symptoms o Non-urgent electrical synchronized cardioversion - ECG A. fib (no P
<48 hours o Pharmacological cardioversion: IV heparin then amiodarone wave, irregular)
- Rate control: - Atrial flutter (Saw
o Decompensated CHF amiodarone tooth): rate
o Chronic CHF metoprolol (better option) OR digoxin control no
o Bronchial asthma diltiazem or verapamil (CCB) improvement
- Anticoagulant: radiofrequency
A. fib
Stable o Warfarin (if positive transesophageal echo) ablation
Duration of
o Empirical warfarin for 3 weeks (if refused transesophageal echo) - CHADS2 score:
symptoms
- Rhythm control (ONLY if young OR first time OR CHF): o CHF
>48 hours
o Synchronized electrical cardioversion o Hypertension
o Pharmacological cardioversion: Sotalol OR Flecainide OR Amiodarone o Age >75
- Stroke prevention: o DM
o CHADS2 score: o Stroke or TIA
0 aspirin
1 anticoagulation
- Unstable (BP <90) synchronized cardioversion
- ECG:
- Female, stress, caffeine, - Stable carotid massage (first line) + Valsalva no improvement
o Narrow
Supraventricular smoking, sepsis adenosine no improvement metoprolol OR verapamil/diltiazem OR
complex
tachycardia - Skip beat, regular, high synchronized cardioversion
o No P wave
heart rate - If bronchial asthma CCB, cardioversion (NO BB or adenosine)
o Regular
- If CHF adenosine, BB (if not decompensated), cardioversion (NO CCB)
Wolf-Parkinson- - Procainamide OR Sotalol Radiofrequency
- ECG: wide QRS + short PR interval + delta wave
White ablation
18
 Premature - Symptomatic beta blocker
ventricular - ECG: one QRS is wide the rest are normal
- Asymptomatic Holter monitor for 48-72 hours
contraction
Ventricular - Monomorphic DC shock (non-synchronized)
tachycardia - Polymorphic (torsade de point) stop offending drugs (antibiotics, antidepressants, antipsychotics) + IV Mg sulfate (No shock)
- HR <60 + symptoms (low BP, loss of consciousness, HF, after MI, chest pain) IV atropine 3 options:
o Transcutaneous/temporary pacing (best)
Bradyarrhythmia o Dopamine (alternative)
o Epinephrine (alternative)
- HR <60 + No symptoms find the cause (no medications needed)
- No drop beat + constant prolonged interval - If typical vasovagal OR situational syncope +
First degree (no
- Symptomatic pacemaker normal ECG reassurance and education
drop beat)
- Asymptomatic reassurance - Syncope + murmur OR abnormal ECG ECHO
- Drop beat + nonconstant prolonged - If recurrent unexplained vasovagal attack:
Mobits I interval o ECG normal do head tilt test if negative
- Treatment: like first degree CT brain
AV block
o ECG abnormal do Holter monitor
Second degree
- Bundle branch block on ECG (look at V1):
(drop beat)
- Drop beat + constant prolonged interval o QRS going down LBBB think of acute
Mobits II
- Treatment: pacemaker anterior wall MI
o QRS going up or rabbit ears RBBB problem
in lung like PE
- Idiopathic (URTI) colchicine + NSAID no
improvement steroid
- Pleuritic chest pain relieved - SLE/RA steroid +
- ECG: diffuse ST segment elevation with
by leaning forward hydroxychloroquine/methotrexate
PR depression
Pericarditis - Pericardial rub - TB steroid + antiTB
- Diagnostic: Cardiac MRI (if not in
- Pericardial effusion - Post MI:
choices choose CT)
- Kussmal sign o <1 week (post MI pericarditis) aspirin
o >2 weeks + fever + high ESR = Dressler syndrome
NSAIDs

19
 - Right sided IE (tricuspid regurgitation):
- Fever + murmur - Most common organism in all infective o MRSA vancomycin, MSSA oxacillin
- Shortness of breath endocarditis: staph aureus - Strep Viridans ceftriaxone + gentamicin 2 weeks
- - Tricuspid + IV drug abuser staph - Prosthetic valve:
- Janeway lesions (erythema in aureus o <60 days vancomycin + gentamycin + rifampin
palm and soles) - Native valve (VSD, ASD, rheumatic o >60 days ceftriaxone + gentamycin
- Splenomegaly heart disease) + tooth extraction - Surgery CHF, persistent fever >72 hours, rupture
Infective
- Duke criteria: strep viridans aneurysm, recurrent septic emboli, fungal infection
endocarditis
o Positive blood culture (2 - Prosthetic valve (look at time of - Prophylaxis (give amoxicillin 1 hour before any
separate occasions) surgery): surgery above diaphragm) + one of the following:
o Positive blood culture in o <60 days staph epidermidis or o Cyanotic heart disease
first 12 hours staph aureus (if patient unstable with o Prior IE
o Positive echo vegetations severe symptoms) o Prosthetic valve
o Positive new regurgitation o >60 days strep viridans o Cyanotic heart disease repair
o Heart transplant
- Jones criteria (2 major or 1
major + 2 minors):
o Major: - Primary prevention penicillin for 10 days for
Migratory arthritis (pain) acute pharyngitis
Carditis (murmur) - Secondary prevention penicillin injection every
Subcutaneous nodules 4 weeks to prevent re-infection and re-attack:
Erythema marginatum o Rheumatic fever + no heart disease for 5
- High ASO titer
Rheumatic fever Sydenham chorea years OR until 21 years old (which ever longer)
- +ve throat culture (group A strep)
o Minor: o Rheumatic fever + heart disease for 10 years
High CRP, ESR OR until 40 years old (which ever longer)
Fever - Arthritis Aspirin
Arthralgia - Carditis Cortisone
ECG: prolonged PR - Chorea Haloperidol
interval
Leukocytosis
20
 - Aspirin + Plavix/clopidogrel - If stable angina (normal
- ECG: ST depression, T - ACE inhibitor (given post MI) ECG and cardiac enzyme)
Unstable angina wave inversion - BB do stress ECG test
- Cardiac enzymes: normal - Heparin o Treatment: BB +
- High intensity statin nitrate + ACE inhibitor
- Nitrate (only if diabetic) no
- O2 therapy only if hypoxia improvement BB +
- ECG: ST depression, T
- Low risk CT angio in 48-72 hours CCB no
wave inversion
Non-STEMI - High risk CT angio urgent vessel improvement PCI
- Cardiac enzymes: high
anatomy: - Leads:
(troponin, CK, CK-mB)
- Chest pain o <3 vessels PCI o V1-V2 = septal
(central + o vessels OR DM + 2 vessels CABG o V3-V4 = anterior
radiating to jaw o V5-V6, I, aVL = lateral
and neck) o II, III, AVF = inferior
- Aspirin + Plavix/clopidogrel
- Most o Inferior MI + V2-3 (ST
- ACE inhibitor (given post MI)
considerable risk depression) = posterior
- BB
factor in MI: - CK-mB used for re-
- Heparin
o First infarction
- High intensity statin
hypertension - Cardiac enzyme order:
- Nitrate
o Second CK-mB (3 days)
- O2 therapy only if hypoxia
smoking - ECG: ST elevation troponin (5 days) AST
- PCI within 90 minutes No alteplase
STEMI - Cardiac enzymes: high (7 days) LDH
repeat ECG no improvement (still ST
(troponin, CK, CK-mB) - Repeat troponin when
elevation) repeat thrombolytics
negative after 2-3 hours
improved (low ST by 50% + no pain) send
- Goal levels:
to PCI center
o LDL <70
- PCI within 90 minutes Yes CT angio
o BP <130/80
urgent vessel anatomy:
o Aspirin for life
o <3 vessels PCI
- If inferior wall MI + right
o vessels OR DM + 2 vessels CABG
ventricular infarction
NO nitrate
21
 - Medications used (in order): ACE inhibitor, BB, CCB, Diuretic
- If patient is black start with CCB or thiazide
- Patient with comorbidity (regardless of ethnicity): start with ACE inhibitor
add CCB (EXCEPT in HF)
o ACE inhibitor + developed cough change to ARB
o ACE inhibitor + developed angioedema change to CCB
- If GFR <40 ACE inhibitor + loop diuretic
- 140-179 systolic
- Ambulatory blood - Patient healthy:
Hypertension - Pregnant: 140-
pressure monitoring o >60 years old: CCB or thiazide (first line) add ACE
159 systolic
inhibitor
o <60 years old: ACE inhibitor add CCB
improve add thiazide
- In pregnancy (in order):
o Labetalol
o Nifedipine
o Methyl dopa
- Hypertension urgency: Labetalol or Captopril or Hydralazine
- Hypertension emergency:
o Stroke (treat ONLY when BP >220/110) and papilledema Nicardipine
- >180/>110 alone (CCB) OR Labetalol (BB)
- >180/>110 hypertension urgency o AKI Hydralazine OR Nicardipine
Emergency
- Pregnant: - >180/>110 + end organ o MI Nitroprusside OR Nitroglycerin AND BB
hypertension
>160/110 damage hypertension o HF Nitroglycerin AND Loop diuretic
emergency - In pregnancy (in order):
o Labetalol
o Hydralazine
o Nifedipine

22
 Amiodarone toxicity Digoxin toxicity
Cytochrome P450
(Class 3 broad spectrum antiarrhythmic) (Toxic level >2)
Side effect Action to detect - Causes of toxicity (increase digoxin Inhibitors Inducers
Prolonged QT binding):
interval (leading ECG at baseline + every o Hypokalemia
to torsade de 3-6 months o Hypomagnesemia
pointes) - Benign finding in ECG slopping ST
Photosensitivity Routine use of sunscreen depression (a digoxin effect not an
Blue-man adverse effect) - Increase P450 effect:
Routine skin exam
syndrome - Side effects: decrease drug level
o Hyperkalemia - Decrease P450 effect:
Peripheral action done: increase dose
- increase drug level
neuropathy o Paroxysmal atrial tachycardia of drug affected
action done: decrease
Corneal deposits Ophthalmic exam (most common) o Carbamazepine
o Nausea and vomiting dose of drug affected
Thyroid function test: o Rifampicin (antiTB)
Hypothyroidism o Sodium valproate
Prior to use, every 4 o Dizziness, Confusion Lowers everything
+ o Isoniazid (antiTB)
months until 1 year o Arrythmia: Bradycardia, AV block, except:
hyperthyroidism o Fluconazole (antifungal)
after stopping the drug Ventricular tachycardia Clopidogrel (increase)
o Amiodarone
Pulmonary o Visual disturbance (xanthopsia = Thiazide (no effect)
PFT yellow vision) o Acute alcohol drinking
fibrosis Nifedipine (change, it
o Erythromycin
Liver fibrosis LFT every 3-5 months o Gynecomastia is contraindicated)
o Ciprofloxacin (UTI)
- Treatment when: o Chronic alcohol
o Metronidazole (C. diff)
o Asymptomatic + acute ingestion o Phenytoin
- Amiodarone induced hypothyroidism - Most antibiotics are
(for suicide) + level 10 - All antiepileptics are
stop the drug + give thyroxine inhibitors
o Asymptomatic + chronic ingestion inducers except valproic
- Amiodarone induced hyperthyroidism
(for treatment) + level >6 acid
(low radioiodine uptake on thyroid scan):
o Symptomatic regardless of digoxin
o Type 1 stop amiodarone only
level
o Type 2 stop amiodarone + give
- Antidote:
steroids
o Digibind or Digifab
o If not available hemodialysis

23
Pulmonology

24
 Pulmonary hypertension
- Risk factors + chronic dyspnea developed right sided heart failure
Symptoms
- Right ventricular heave + tricuspid regurgitation + prominent P2
Group 1 Group 2 Group 3 Group 5
Group 4
(Primary pulmonary artery hypertension) (Cardiac) (Lung) (Miscellaneous)
- Familial - Chronic
- Chronic hypoxia:
Risk - Idiopathic - Left sided heart thromboembolism
o COPD - Sarcoidosis
factors - Connective tissue disease (RA, SLE, failure (most recurrent PE
o Interstitial lung - Sickle cell
(Groups) Sjogren, Systemic sclerosis, common cause of chronic
disease disease
Dermatomyositis) right sided heart thromboembolism
o Neuromuscular -
- HIV failure) pulmonary
disease
- Portal hypertension (Schistosomiasis) hypertension
- Gold standard: right side heart
Diagnosis catheterization
- Connective tissue disease Echo
Echo -
-
Specific test: V/Q scan
Echo
- Echo

- Supportive:
o Keep O2 saturation >90%
o Diuretics for symptoms of right sided heart failure
o Digoxin if there is A. fib
Treatment
- Vasodilation:
- ACE inhibitor
o CCB (nifedipine) - Pulmonary
- BB - Treat the cause - Treat the cause
o Phosphodiesterase inhibitors endarterectomy
- Spironolactone
(sildenafil/Viagra)

25
 Hints Diagnosis Treatment Extra
- ECG: sinus tachycardia +
ST depression in S1Q3T3
(specific sign)
- If unstable thrombolytics
- Thromboprophylaxis
then surgical thrombectomy
CT angio - Low risk + medical admission
- Risk factors of PE + sudden o If there is contraindication to
- ambulation
SoB + pleuritic chest pain thrombolytic go surgery
Pulmonary D-dimer (if high do CT - Low risk + surgical admission
- If symptoms came with low - Stable:
embolism angio) mechanical prophylaxis
BP or bradycardia o LMWH for 3 days until INR 2-
- CKD V/Q scan (decompressive devices)
massive PE 3 then warfarin OR novel
- Pregnant ultrasound - High risk + medical admission
oral anticoagulant
of leg (if negative V/Q + CKD unfractionated
(rivaroxaban, apixaban)
scan) heparin (if medically free
o Provoked duration 3-6
- Gold standard LMWH)
months
pulmonary angiography - High risk + major surgery or
o Unprovoked duration 3
- trauma LMWH +
months for first attack, for
Doppler ultrasound mechanical prophylaxis
life for second attack
- Calf pain + unilateral swelling - D- - Orthopedic surgery
- CKD unfractionated heparin
DVT + venous distension + dimer (if high do doppler fondaparinux or LMWH
- Pregnant LMWH
erythema ultrasound)
- Gold standard
venography
- First check previous CT scan
- If <8 mm + no malignant features follow up with CT 6-12 months
- <3 cm round - If malignant features regardless of size PET scan
Solitary lung
- Single o Malignant features: Spiculated, Upper lobe, Female, Age >60, Smoking
nodule
- Normal lung parenchyma - If >8mm PET scan
- If PET scan positive biopsy
- If PET scan negative follow up with CT scan every 6-12 months

26
 - Aspirin + nasal polyps +
- Acute exacerbation: oxygen if asthma
low SaO2 SABA + SAMA stop aspirin + give LTRA
no improvement steroids - Asthma + high eosinophils +
no improvement Mg vasculitis Churg
sulfate no improvement Straus/EGPA (p-ANCA)
intubate - Asthma + atopy (atopic
- Nocturnal cough or wheeze - Depends on peak flow - Chronic: SABA (intermittent) dermatitis) allergic rhinitis
Asthma
- Dry, white sputum (PEF) inhaled corticosteroid (mild (high IgE) give LTRA
persistent) LABA (moderate - Bronchial asthma not
persistent) LTRA or LAMA improved on bronchodilators
(severe persistent) do IgE levels showed
- Refractory oral steroids very high IgE allergic
- Exercise induced SABA 1 bronchopulmonary
hour before exercise aspergillosis (no atopy) give
oral steroids
- Acute exacerbation: SAMA +
SABA steroids PO
antibiotics Oxygen (88-92%)
- First venturi or low flow
Indications of long term O2:
oxygen nasal cannula
- PaO2 <55
- Bipap if: no improvement, RR
- PaO2 <60 + cor pulmonale
>25, pH 7.25-7.35, PaCO2 >45
- SaO2 <89 + cor pulmonale
COPD - Chronic productive cough - Depends on FEV1 - Mechanical intubation if: no
- SaO2 <89 at rest in 2 or more
improvement on Bipap,
occasions
confused, low BP, RR >30,
Indication of Bipap at home:
PaO2 <55-60, pH <7.25
- PaCO2 >53
- Chronic: LAMA + SABA as
needed no improvement
add LABA no improvement
add inhaled corticosteroids
27
 - Airborne isolation until resolution sputum negative
- 2 months of rifampicin, isoniazid, pyrazinamide, ethambutol
- Fever
- 4 months of rifampicin, isoniazid
- Night sweats - Active: AFB smear
- Latent:
- Weight loss - Latent: Interferon
TB o First line: rifampicin for 4 months
- Cough dry or productive gamma release assay or
o Second line: isoniazid + vitamin B6, general population for 6
- Pleuritic chest pain PPD test
months, and healthcare workers for 9 months
- +/- hemoptysis
- Stop all medications when: AST/ALT 5x UNL + asymptomatic OR
AST/ALT 3x UNL + jaundice, abdominal pain (symptomatic)
- If diagnosed with strep pneumoniae amoxicillin
- Smoker or COPD + Hemophilus influenzae
cefuroxime CURB-65:
- Must do sputum culture
- CURB-65 (0-1) + healthy azithromycin for 5 days - Confusion
- Productive cough and gram stain
Typical - CURB-65 (0-1) + comorbidity levofloxacin OR - Urea >6.5
- Fever - Specific test for strep
pneumonia cefuroxime + azithromycin for 5 days - RR >30
- Consolidation on x-ray pneumoniae urinary
- CURB-65 (2) levofloxacin OR ceftriaxone + - BP <90
antigen
azithromycin - Age 65
- CURB-65 (3 or more) levofloxacin + vancomycin
+ cefepime/meropenem/tazocin for 7-10 days
- Dry cough
- Bilateral chest x-ray
infiltration - Must do sputum culture
- Healthy, male, crowded area, and gram stain
low hemoglobin, rash - Mycoplasma: IgM cold
Atypical (erythema multiforme) agglutination test
- Azithromycin OR doxycycline
pneumonia Mycoplasma pneumoniae - Legionella: urinary
- Old, water source or AC, antigen on buffered
abdominal pain, diarrhea, charcoal yeast extract
high LFT, low hemoglobin, agar
low Na Legionella
pneumophila
28
 - Hospitalized - E. coli
Hospital - Vancomycin + cefepime
- After 2-3 days developed - Pseudomonas
acquired - Vancomycin + piperacillin-tazobactam
fever, productive cough, - Klebsiella
pneumonia - Vancomycin + meropenem
pneumonia on x-ray - MRSA
- ICU + mechanical ventilation
- After 3-4 days developed
Ventilation fever, change color of
acquired - Pseudomonas - Same as above with or without levofloxacin
secretion, increase tube
pneumonia
secretion
- Bilateral + severe
- Alcoholic + unconscious
- Acute stroke
- Post seizure
- Foreign body ingestion
Lung abscess - Fever - X-ray: air-fluid level - Clindamycin OR Augmentin
- Purulent foul-smelling
sputum
- +/- hemoptysis
- +/- clubbing

- Unstable patient + Bilateral

infiltration + Critical low O2 - High flow O2
- Pneumonia - Prone positioning
- Pancreatitis - Fluid balance
ARDS - Diagnosis of exclusion
- Shock - PEEP (positive end respiratory pressure)
- Sepsis - Pulmonary vasodilator (inhaled NO)
- Aspiration - ECMO (extracorporeal membrane oxygenation if refractory)
- Near drowning

29
 - Older age - First PFT (low TLC, RV,
- Chronic shortness of breath FVC, DLCO)
Interstitial - Progressive - Next Chest x-ray
-
lung disease - Dry cough - Diagnostic: high
- Finger clubbing resolution CT (ground
- Bilateral fine crackles glass appearance)
- X-ray: hilar LAP
- Female (30 50)
- Labs: ACE level (80%
- Red eye + ILD symptoms
specific)
- Raised erythematous painful
- Diagnostic: high
Sarcoidosis nodules (erythema - Steroids
resolution CT
nodosum)
- Gold standard:
- Lupus pernio (facial rash)
endobronchial US (LN
- Hypercalcemia
biopsy)
- Acute:
- Male + Fever + Foul smelling o Levofloxacin + inhaler SABA +
Causes:
productive cough - Chest x-ray: tram track SAMA
- Cystic fibrosis
- Dyspnea appearance o O2 if less than 92%
- Primary ciliary dysfunction
- Clubbing - Diagnostic: high - Chronic:
Kartagener
Bronchiectasis - +/- hemoptysis resolution CT (cystic o Inhaler SABA + LAMA
- TB
- Diffuse rhonchi ground glass appearance o Chest rehabilitation +
- Malignancy
- Mid-inspiratory crackles + honeycomb postural drainage (chest
- Repetitive pneumonia
- History of smoking, TB, or appearance) physiotherapy)
- Alpha 1 anti-trypsin
cystic fibrosis o Prophylactic antibiotic
(azithromycin)

30
 - Smoker + dyspnea + cough + occasional hemoptysis + finger clubbing + weight loss + No fever, best modality for diagnosis:
o Peripheral: CT guided biopsy
o Central: Video assisted thoracoscopy, endoscopic bronchial ultrasound
- Miosis + ptosis + anhidrosis (apical tumor)
- Facial plethora (redness) + SOB + dilated chest veins in chest superior vena cava obstruction (oncological emergency)
o Diagnosis: CT venogram
o Treatment: steroids + radiation
Small cell lung cancer Non-small cell lung cancer
- 30%
- Smoker, Cavitary lesion, Central lesion
Squamous - Hemoptysis and clubbing more than small cell
- Neuroendocrine tumor (high grade), 15%
- Lung mass + increase Ca high PTH related
Lung cancer - Smokers, Central lesion, Blue cells, Fast growing
peptide
- Responsive to chemo, but recurring disease
- Most common (40%)
- Paraneoplastic syndrome:
- Smoker and non-smoker. Peripheral lesion,
o Lung mass + hyponatremia SIADH
Clubbing
o Lung mass + puffy face, plethora, central obesity, striae Adenocarcinoma
- Case: Women +/- Asian + never smoked +
(Cushing features) Ectopic ACTH
peripheral lung mass on chest x-ray
o Lung mass + weakness in arms and shoulders that
- Hypertrophic pulmonary osteoarthropathy
improves with repetition + no diplopia Lambert Eaton
- Stage I and II surgery then radiation then
syndrome (the opposite of myasthenia gravis) affects
chemotherapy (adjuvant)
presynaptic Ca channel in neuromuscular junction
Treatment - Stage III combination (concurrent chemo +
radiation) then target therapy
- Stage IV chemotherapy

31
Hepatology

32
 Hints Diagnosis Treatment Extra
- NPO - Causes:
- Aggressive hydration with o Stone (most common)
ringer lactate (goal: reduce o Alcohol
- Lipase/amylase >3 times
CRP, Hct, BUN in 12-24 hours) o Hypercalcemia, Triglyceride
upper normal limit
- Feeding: o Neoplasia
- Lipase >10,000 rules out
o Early enteral feeding o Infection (mumps,
alcohol
prompted after 24 hours mycoplasma, TB, CMV, HIV)
- ALT >3x upper normal limit
(NGT) o Autoimmune
rules in gallstones
o Low fat low residue within o Injury or ERCP (prevented
- Abdominal pain - US:
72 hours if no nausea or by PR indomethacin)
radiating to the o Wide CBD
Acute pancreatitis vomiting (oral) o Drugs (furosemide, aspirin,
back (band like) o CBD stone
- IV opioids (pethidine or statin, sulfa drugs,
- Nausea and - CT done in ER if:
morphine) azathioprine, ACEI)
vomiting o Acute severe (AKI,
- Gallstones ERCP within 24 o Steroids or scorpion sting
- Jaundice Respiratory failure, Shock, GI
hours next elective - Determine severity:
- Decreased bowel bleeding)
cholecystectomy o ER: procalcitonin
sound o Persistent severe (not
- Infected necrosis (febrile) o 48 hours: CRP
- Signs of improving after 48 hours
Imipenem + debridement - Poor prognostic factors
retroperitoneal with treatment)
- Sterile necrosis (nonfebrile) (hyperglycemia,
hemorrhage
if symptomatic hypocalcemia, DIC, ARDS,
(Cullen, Grey-
debridement metabolic acidosis)
Turner)
- Initial high amylase and lipase
then normalizes
- Causes:
- +ve fecal fat stool + decrease - Pancreatic enzyme
o Alcohol (most common)
stool elastase (steatorrhea) replacement
o Idiopathic
Chronic pancreatitis - CT calcification - Pain control:
o Autoimmune
- Diagnostic: MRCP o If not improving on opiate
o Associated with cystic
- Endoscopic US: celiac nerve plexus block
fibrosis
o Biopsy from a mass
o Dilated duct with stricture
33
 - Young, female
Autoimmune - ANA, IgG
- Other autoimmune - Steroids
pancreatitis - CT: fibrosis (sausage pancreas)
disease
- CBC:
o Anemia of chronic disease
- White nails, palmar o Macrocytic anemia (folate
- Child Pugh score:
erythema, deficiency)
o Ascites
o Low platelet, Neutropenia
o Hepatic encephalopathy
contracture, - LFT:
o Bilirubin
clubbing, asterixis o Synthesis:
- Lactulose for constipation o INR
- Hepatic fetor, Bilirubin (high)
(prevent hepatic o A 5-6
Chronic liver enlarged parotids PT/PTT (high) PT has
encephalopathy) o B 7-9
disease - Gynecomastia, greatest prognostic value
- BB for varices (prevent GI o C 10-15 (survival <45%)
spider angioma Albumin (low)
bleeding) - Poor prognostic factors:
- Testicular atrophy o Enzymes:
o Ascites
- Cuput medusa, ALT/AST hepatocellular
o High PT
splenomegaly, ALP/GGT biliary
o Hypoglycemia
variceal bleeding, - All results -ve Liver biopsy
o Hyponatremia <130
ascites, jaundice by percutaneous or
transjugular (when there is
ascites or coagulopathy)
- Paracentesis >1.1 (portal hypertension): - General:
o Perisinusoidal: Schistosoma, Portal vein thrombosis o Reduce Na intake
o Sinusoidal: Cirrhosis (ascitic protein <2.5), HCC o Spironolactone no improvement add furosemide
o Post sinusoidal: Right CHF (ascitic protein >2.5), Budd - Symptomatic (tense ascites) albumin + paracentesis
Chiari syndrome - Refractory (AKI from diuretics OR no improvement on
Ascites
- Paracentesis <1.1 (non-portal hypertension): medication):
o Nephrotic syndrome o Large volume paracentesis + albumin OR TIPS
o Malignancy - Other conditions:
o TB o Ascites + hyponatremia free water restriction
o Pancreatitis o CLD dehydrated + ascites give 0.45 NS
34
 - Ascites + cell count of peritoneal fluid (PMN >250)
Spontaneous - Cefotaxime OR ceftriaxone (for 5 days) + IV albumin
- Organism: E. coli, Klebsiella, Streptococcus pneumoniae
bacterial peritonitis - Prophylactic antibiotic (fluroquinolone)
- History of current upper GI bleeding or previous SBP
- Precipitating factors:
o Bleeding
o Constipation
- Treat the cause
Hepatic o Infections, SBP
- CLD + disorientation, insomnia, asterixis, confusion - Lactulose enema in ER
encephalopathy o Medication (sedative)
- Oral lactulose (prevention)
o Non-adherence to meds
o Dehydration, Low Na or K
o TIPS in refractory ascites
- All patients with CLD should do EGD to look for varices:
Gastroesophageal o Not present no need BB
varices o Present propranolol or nadolol
- Upper GI bleeding present give BB and do endoscopic variceal ligation
- Diagnosis of exclusion
- Criteria:
o Cirrhosis + ascites + high creatinine (AKI) - Not ill octreotide + midodrine
Hepato-renal
o No improvement on creatinine after discontinuation of - Critically ill vasopressor + albumin
syndrome
diuretics - Consider renal and liver transplant
o No signs of shock
o No nephrotoxic medication, No intrinsic kidney disease
Budd Chiari - Female + OCP or DVT
syndrome (hepatic - Anticoagulation
- Jaundice + abdominal pain + ascites (CLD)
vein thrombosis)
- Female - ANA, ASMA
- Abdominal pain, - Anti-LKM, Anti-SLA
Autoimmune ascites, jaundice - Anti-actin
- Steroids +/- azathioprine
hepatitis (CLD) - Anti-LC
- Other autoimmune - Diagnosis: biopsy (bridging
disease fibrosis)

35
 Ischemic hepatitis - ICU + low BP + septic shock + sudden high AST and ALT - Correct blood pressure
- AST>ALT 2:1 + agitated, delirium, hyperthermia, high HR
Alcohol hepatitis - ICU + benzodiazepine in delirium termens
= delirium termens
- ALT>AST 2:1 infectious hepatitis
Hepatitis A Hepatitis B Hepatitis C Hepatitis E
NA RNA DNA RNA RNA
IP <2 weeks 8 12 weeks 8 12 weeks <2 weeks
- Needle stick injury:
o 30% if not vaccinated - Needle stick injury 2-7%
o 5-10% if vaccinated - Body fluids except for saliva (only if
- IV drug abuser, sexual, contaminated by blood)
Spread Fecal oral transfusion - Breast feeding recommended (no Fecal oral
- Breast milk if cracked nipple or transmission)
bleeding and baby not - If exposed monitor LFT and
vaccinated antiHCV (no treatment)
- If exposed hepatitis B Ig
Infectious
- Acute: Anti-hepatitis C IgM (ELISA)
hepatitis Hep B interpretation (see diagram
HCV RNA viral load HCV genotype
Dx IgM hepatitis A below) + HBV DNA viral load IgM hepatitis E
(6 genotype)
(>20K)
- Chronic: Anti-HCV IgG
- Tenofovir OR entecavir
(nucleotide inhibitor) - Sofosbuvir OR ribavirin
Mx Supportive supportive
- PEG interferon alpha (non- - PEG interferon alpha
nucleotide inhibitor)
- No vaccine
- CLD > HCC - Non-contagious
- HCC > chronicity
- Non-contagious - Genotype 3 most common in HCC - South Asia
Extra - Has vaccine
- Has vaccine - Genotype 4 most common in KSA - In pregnant
- Co-infection with hepatitis D
- Recovery or resolution -ve HCV fulminant hepatitis
RNA viral load + anti-HCV IgM (-ve)

36
Non-alcoholic fatty - Obese, DM II - Vitamin E + metformin (diabetic or non-diabetic)
- Diagnostic: biopsy
liver disease - Rapid weight loss - Weight reduction if obese
- Male + jaundice,
- Transferrin saturation (high)
abdominal pain
specific
(CLD) +
- Iron level (high)
hyperpigmentation - Venesection + iron chelating (deferoxamine)
Hemochromatosis - Hct (high)
+ hypogonadism + - No improvement transplant
- Biopsy: pearl stain +ve
arthritis
- Genetics: autosomal recessive
(pseudogout) + DM
(HFEC282Y)
+ cardiomyopathy
- Copper (high)
- Female + jaundice, - Ceruloplasmin (low)
abdominal pain - Urine copper (high)
(CLD) + abnormal - Pathognomic: Kayser Fleischer
movement + ring (grey ring cornea) - Penicillamine + zinc
Wilson disease
psychiatric disease - MRI brain (if abnormal - No improvement transplant
+ family history of movement): panda sign
liver disease + - CSF: copper
tremor - Genetics: autosomal recessive
(ATP7B gene)
- Female, 40 years
old
- AMA
- Osteoporosis,
Primary biliary - Diagnostic: MRCP + biopsy - Ursodeoxycholic acid
pruritis, high
cholangitis - Diagnostic and therapeutic: - Cholestyramine (for pruritis)
cholesterol
ERCP
(xanthelasma) +
SLE/Sjogren/RA
- ANCA or ASCA
Primary sclerosing - Male +/- pruritis - MRCP (beading stricture) if - Ursodeoxycholic acid
- Do colonoscopy for UC
cholangitis - Associated with UC negative biopsy - Treat IBD flare up
- ERCP after MRCP
37
 - Screening: ultrasound every 6 months - Single liver lesion <2-3 cm surgery
Hepatocellular
- Diagnostic: CT triphasic in CLD - Multiple liver lesions tyrosine inhibitor (-nib)
cancer
- Diagnostic: biopsy in non-CLD - Single liver lesion >4 cm radiofrequency ablation or transplant
- Pharmacological:
o Octreotide for 2-3 days OR
Telipressin
- Resuscitation:
o Ceftriaxone OR cefotaxime
o ABC + NPO
for 5 days (to prevent SBP)
o Transfusion:
Variceal bleeding o BB after discharge
If <7 + no CAD
- Endoscopy:
transfusion
o Esophageal band ligation OR
If 8 + CAD transfusion - Only tachycardia 10%
esophageal sclerotherapy
- Hematemesis or until Hb level 10 blood loss
balloon
coffee ground In variceal bleeding - Orthostatic hypotension
TIPS
vomitus exceed Hb 10 or above 20% blood loss
- Pharmacological:
- Melena (dark stool) o Unstable (no endoscopy) - Hypotension 30% blood
o PPI IV then infusion for at
ICU loos
least 72 hours then give oral
Interventional Radiology
o If low risk PPI for 24 hours
(embolization)
Non-variceal - Endoscopy:
Surgery
bleeding o Erythromycin before
o Stable urgent endoscopy
endoscopy
within 12-24 hours
o Epinephrine injection +
cautery
o Ulcer found biopsy
- No source of bleeding on endoscopy
- Bleeding endoscopy negative source push enteroscopy (large endoscopy tube) negative capsule enteroscopy
negative admit and wait until active bleeding CT angio
Obscure GI
- Causes:
bleeding
o Dieulafoy lesion (direct spurting of blood)
o Angiodysplasia
o Gastric antral vascular ectasia (watermelon stomach) systemic sclerosis
38
 Hep B
interpretation

Window peroid
Infected Not infected
(before infection)

Hbs AB/Anti-HbsAg
1- HbsAg +ve
HbsAg -ve Anti HBc (IgM) +ve +ve (antibody = no
(antigen = infection)
infection)

2- Anti HBc Ab 3- HbEAg

Anti HBc Ab
(acute vs chronic) (infectivity)

+ve -> highly

IgG +ve -> chronic +ve -> previously
infectious -ve -> vaccinated
infection infected
(contagious)

IgM +ve -> acute -ve -> non-

infection infectious (inactive)

39
Gastroenterology

40
 Hints Diagnosis Treatment
- Upper 2/3 Endoscopy + biopsy
- Risk factors: Smoking + alcohol
Squamous
- Dysphagia to solid - Esophageal web/ring Without
esophageal cancer - Endoscopy screening every 3-5 years
then liquid + weight (anatomical problem) + female + dysplasia
loss IDA Plummer Vinson disease
- +/- nausea and - Lower 1/3 Low grad
- Endoscopy screening every 6-12 months
vomiting or - Most common type dysplasia
Adenocarcinoma hematemesis -
esophageal cancer High grade - Endoscopic ablation or resection
metaplasia) from GERD
dysplasia - If not treated adenocarcinoma
- Obesity most common cause
- Odynophagia > - Candida (white spots) Fluconazole
Infectious
dysphagia - CMV Ganciclovir
esophagitis
- Immunocompromised - HSV Acyclovir
- Odynophagia > - Causes: NSAIDs, KCl, Bisphosphonate, Doxycycline
Pill esophagitis
dysphagia - Treatment: stop the drug
- Young or middle age
Eosinophilic - Endoscopy and biopsy - Modify diet swallow inhaled steroid
- Male, Dysphagia
esophagitis eosinophils dilation
- History of atopy
- <50 years old + no alarming features:
- GI: Heart burn, regurgitation, metallic taste, dysphagia o 8 weeks PPI trial + lifestyle modification
endoscopy normal esophageal 24-hour pH
GERD - Extra-GI: Cough, wheeze, atypical chest pain
monitor (diagnostic) normal functional heartburn
- Alarming features: Vomiting, anemia, weight loss, dysphagia
- <50 years old + alarming feature OR >50 years old:
o Endoscopy PPI surgery
- If taking antibiotic and PPI - Triple therapy for 10-14 days:
stop for 2-4 weeks o Clarithromycin + Amoxicillin + PPI (BID)
PUD - Epigastric pain that - Urea breath test, stool antigen, - After 4 weeks test for eradication by:
(H. pylori) radiates to the back endoscopy + rapid urea test o Urea breath test (specific and accurate)
- Gold standard: biopsy (gram o Endoscopy (diagnostic)
negative, comma shaped motile) o Stool antigen
41
 Extracolonic Feature
Related to disease activity Not related to disease activity
Inflammatory - Peripheral arthritis
bowel disease - Erythema nodosum (raised in lower limb and painful) - Pyoderma gangrenosum (ulcer deep in lower limb)
- treated with steroids
- Orofacial lesion (oral ulcers), Episcleritis
- P-ANCA - ALL patients given LMWH
- Mostly in female - Colonoscopy and biopsy: - Mild disease 5-ASA (sulfasalazine or mesalamine)
- Pancolitis + Proctitis o Continuous inflammation o UC:
involving the rectum Left colon oral + enema
- Left sided colon (most
o Erosion Proctitis enema or suppository
common)
o Crypt abscess o CD:
- Grossly bloody Colonic oral
Ulcerative colitis o Pseudopolyps
diarrhea o Diffuse ulceration Extra-colonic no 5-ASA, give steroids
- Lower abdominal pain - Barium: lead pipe appearance Fistulizing or perianal disease add antibiotics
(before defecation) - CRP for monitoring (ciprofloxacin + metronidazole)
- Tenesmus - Moderate disease add Budesonide PO or enema
- Screening 8-10 years from
- Nocturnal diarrhea - Moderate severe disease:
diagnosis (has risk of colon
o Stop budesonide
cancer)
o Add prednisone + azathioprine (OR methotrexate in CD)
Order thiopurine methyltransferase before starting
- ASCA azathioprine
- Smoking - Colonoscopy and biopsy: - Severe disease:
- Mouth to anus sparing o Transmural inflammation, o Rule out infection (C. difficile) by toxin assay
the rectum Skip lesions by extending o Give IV steroids (methylprednisone or hydrocortisone) for
- Ilium (most common) ileocolonoscopy 3 days add direct agent (Infliximab or
o Non-caseating granuloma adalimumab)
- B12 deficiency
(pathognomic) - Surgery:
- Abdominal pain o Cobble stone, Aphthous o Toxic megacolon UC (abdominal pain, colon >6 cm):
- Fever ulcer No shock IV steroid + antibiotic
- Mucus, nongrossly - MR enterography for small surgery
bloody, diarrhea bowel assessment Shock surgery
- CRP for monitoring o Perianal disease or fistulizing CD first line is
infliximab
42
 - Young + female - Diet: Low-FODMAP diet
- Stress - Diarrhea predominant:
- Abdominal pain o Rule out celiac
Irritable bowel
- Diarrhea or constipation o Loperamide or cholestyramine
syndrome
- Pain improves with defecation antispasmodics
- Features of early depression o Give rifaximin (antibiotics)
- -ve fecal calprotectin, normal osmotic gap - Constipation predominant give laxative
- Anxiety
- Depression,
- Chronic abdominal - Approach in diagnosis:
- Isolated high AST
o Symptomatic and on same diet AND positive IgA tissue
pain - Antibodies: transglutaminase + IgA level NO biopsy
- Diarrhea o IgA tissue transglutaminase + o Asymptomatic and on same diet OR negative IgA tissue
- Bloating IgA level specific transglutaminase biopsy
- IDA o IgA antigliadin o Symptomatic + stopped gluten HLA DR2/DQ8 if
Celiac disease o IgA antiendomysial
- Dermatitis positive do biopsy
herpetiformis - Definitive: duodenal biopsy o If diagnosed and symptomatic check food diary if
- Fatty stool lymphocyte infiltration + compliant do endoscopy and biopsy
atrophic villi - Management:
(steatorrhea)
- Genetic: HLA-DR2/DQ8 o Gluten free diet (wheat, rye, barely)
- Symptoms present
o Can eat rice, potato, lentil
after eating bread,
wheat, pastry
- Antibiotics use
(Ceftriaxone,
clindamycin,
- Sensitive: stool PCR for C. diff - Initial (first) episode vancomycin oral for 10 days
ciprofloxacin,
- Specific: stool toxin assay - Second or subsequent fidaxomicin oral for 10 days
Clostridium difficile ampicillin)
- Colonoscopy: - Severe vancomycin oral + metronidazole IV
diarrhea - Watery diarrhea +/-
o Pseudomembranous colitis + - Prevention washing with water and soap
blood or mucus
bowel thickening - Toxic megacolon surgery
- Lower abdominal pain
- Fever
- Very high WBC
43
Endocrine

44
 Hints Diagnosis Treatment Extra
- Bolus insulin with
- HLA +ve - Post prandial high blood sugar
meals rapid
- AntiGAD and fasting is normal increase
acting (Lispro)
- Anti-islet cell the bolus and keep basal same
Diabetes type 1 - Basal insulin at
- Anti-insulin antibody - Prediabetes: - Post prandial normal blood sugar
nigh long
- Young <20 years + thin + o HbA1C 5.7-6.4 (normal + high fasting blood sugar
acting (Lantos or
autoimmune disease <5.7) keep rapid same + increase basal
Glargine)
o Impaired fasting glucose
- Obese with high BMI + diabetic bariatric surgery
100-125 mg/dL
o Post OGTT >2 (140-190)
- Patient admitted for any cause other than diabetes give
- Diabetes:
insulin sliding scale
o HbA1C >6.5 (2 readings)
- Best insulin regimen in pregnant NPH BID
o Fasting glucose >126 (2
- All give metformin + lifestyle modification
reading)
- If >40 years old give Statin
- >40 years old o Random glucose (>200) +
- If HbA1c >9 give basal insulin (long acting)
Diabetes type 2 - Obesity symptoms (no need to
- If not improved on metformin and diet modification:
- Family history +ve repeat)
o If CVD (stroke or IHD) 1st option: GLP-1 (-tide), 2nd
o Oral glucose tolerance test
option: SGLT-2 (-glifozin)
after 2 hours (best for
o If HF or CKD 1st option: SGLT-2, 2nd option: GLP-1
pregnancy) >200
o Medically free + obese 1st option: GLP-1 (-tide), 2nd
option: SGLT-2 (-glifozin)
o Medically free + risk of hypoglycemia DDP-4 (-gliptin)
o Medically free completely SU (gli-)
- Increase in glucose >200 - Hyponatremia from vomiting - Insulin + Hydration + potassium (only if 3.5 4.5)
- Ketones in serum - Hyperkalemia - With-hold insulin and give potassium if <3
Diabetic ketoacidosis
- Low pH, low HCO3, high - Hypophosphatemia - If anion gap high despite insulin give IV dextrose + NS
anion gap - High WBC, High amylase and lower insulin
- Dehydration - >600 glucose
Hyperosmolar - Same as DKA with more aggressive fluid
- Hypotension - No ketones
hyperglycemic state - Monitor by serum osmolarity and symptoms
- Altered mental status - High serum osmolarity (>320)
45
 - (diffuse homogenous uptake):
- High FT4 + low TSH o Beta blocker + Methimazole or Propylthiouracil
- Thyroid stimulating antibody o If not improved on medication or high risk for CAD
radioactive iodine
- Post viral, tender, high ESR o Obstructive goiter or Severe ophthalmoplegia surgery
thyroiditis o In pregnancy: PTU (1st trimester), methimazole (2nd and
- Sweating
- Normal FT4 + low TSH 3rd trimesters)
- Tremor
subclinical hyperthyroidism - Thyroiditis (no uptake) beta blocker
- Weight loss
- Delirium, fever, high HR, high - Subclinical hyperthyroidism treat when TSH <0.1
- A. Fib
BP thyroid storm - Toxic multinodular goiter beta blocker then radioactive
Hyperthyroidism - Warm skin
- Malignant features do FNA: iodine
- Heat intolerance
o >20 mm o Surgery (near total or total thyroidectomy) if obstructive
- Ophthalmoplegia
o <20 mm + hypoechoic or - Sick euthyroid syndrome (nonthyroidal illness):
- High reflex
solid or microcalcification or o ICU + low TSH, T3 and T4 (all low)
- Diarrhea
LN or taller than wider o Recovery: high TSH high T4 high T3
- <20 mm + benign do TSH o Confirm by reverse T3
level: o No treatment only labs after weeks
o Normal/high FNA - Thyroid storm:
o Low thyroid uptake scan o Beta blocker IV + iodide IV
o Methimazole or PTU
- Hashimoto thyroiditis:
- Weakness - Low FT4 + high TSH
o L-thyroxine
- Fatigue - AntiTPO antibody +
o Check TSH every 6 weeks
- Depression antithyroglobulin
o If pregnant 30% in thyroxine
- Weight gain Hashimoto thyroiditis
- Subclinical hypothyroidism treat when:
- Cold intolerance - Normal FT4 + high TSH
Hypothyroidism o TSH >10
- Constipation subclinical hypothyroidism
o AntiTPO +ve
- Menorrhagia - Low BP, hypothermia, change
o Pregnant
- Hyperlipidemia mental status, low Na,
- Myxedema coma:
- Diastolic hypertension hypoglycemia Myxedema
o Warm blanket + IV fluid + IV hydrocortisone
- Delayed tendon reflex coma
o
46
 - Steroid use
- Normal Ca, PO4, vitamin D
- Smoking
- Dexa scan >-2.5
- Female, hormones
osteoporosis
- Old age
Osteoporosis - Dexa scan -1 to <-2.5 - Bisphosphonate
-
osteopenia do FRAX test
- Celiac disease
- Osteopenia + fragility fracture
- Primary biliary cholangitis
osteoporosis
- Heparin
- Dizziness - High PTH + high Ca + low PO4
- Management of hypercalcemia aggressive hydration
- Polyurea primary
with NS failed, options:
- Constipation hyperparathyroidism
o IV zoledronic acid (bisphosphonate)
- Renal stones - High PTH + low Ca + high PO4
Hypercalcemia o Denosumab
- Nausea and vomiting secondary
(Hyperparathyroid) o Calcitonin
- Pancreatitis hyperparathyroidism
o Steroids
- PUD - High PTH + high Ca + high PO4
o IV Lasix
- ECG with narrow QRS tertiary
o Dialysis (last resort)
complex hyperparathyroidism
- >1 cm (macroadenoma): cabergoline failed
- Next step: pregnancy test +
- Female transsphenoidal surgery
TSH (rule out pregnancy and
- Galactorrhea - <1 cm (microadenoma): follow up MRI developed
hypothyroidism)
Prolactinoma - Amenorrhea symptoms (headache only) cabergoline failed
- Confirmatory: Fasting
- Decrease libido transsphenoidal surgery
prolactin level
- Infertility - Symptomatic (diplopia, signs of optic chiasm
- Pituitary MRI
compression): Transsphenoidal surgery
- Change in voice and - Nest step: Insulin like growth
shoes size factor (screening)
- Increase in length and jaw - Confirmatory: oral glucose
- Surgery
Acromegaly - Carpal tunnel tolerance test, after 2 hours
- octreotide
- Headache check growth hormone level
- Sleep apnea, DM, HF (high)
- Acanthosis nigricans - Pituitary MRI
47
 - Rotterdam 2 of 3:
o Androgen excess
- Young female
(hirsutism/acne)
- Obese - Metformin all
o Ovary (ovulatory dysfunction)
- Acne - Childbearing clomiphene (fertility drugs) or IVF
by labs or clinical:
PCOS - Oligo or amenorrhea - Non-childbearing OCP
High LH:FSH
- Hirsutism - Acne topical or isotretinoin (if non-childbearing)
Increase free testosterone
- Alopecia - Hirsutism OCP or spironolactone
Increase estradiol
- Acanthosis nigricans
o Ultrasound evidence of
polycystic ovaries
- Whipple triad:
o Symptoms of
hypoglycemia (sweating, - Labs: high C-peptide + high
Insulinoma dizziness, palpitation) insulin - Surgery
o Glucose <3 (<54) in non- - CT pancreases
diabetic, <3.5 in diabetic
o Improves with glucose
- Abdominal pain, Diarrhea
Carcinoid syndrome - Facial flush, Wheeze - Urine 5HIAA - Octreotide
- Tricuspid regurgitation
- >4 cm surgery
- <4 cm:
Adrenal - Patient did CT abdomen
o Functional: +ve surgery
incidentaloma and found adrenal mass
o Non-function: CT adrenal Benign (do follow up), Malignant (do surgery after ruling out
pheochromocytoma by 24 hours urine metanephrines)
- Young <40 years - Screening: Aldosterone:renin
- Unilateral adrenal adenoma:
- Hypokalemia ratio (>20:1)
o >4 cm surgery
Primary - High BP refractory to - Confirmatory: Saline
o <4 cm spironolactone
hyperaldosteronism medication suppression test
-
- Metabolic alkalosis - Location: CT adrenal (size and
o Spironolactone
- PE normal location)
48
 - high cortisol + low
ACTH
- Acne Primary - Next: CT adrenal
- Screening (high cortisol):
- Moon face - Treatment: surgery + PO hydrocortisone
o 24-hour urine free cortisol
- Plethora and fludrocortisone for life
o Low dose overnight
- Truncal obesity - Cushing disease high cortisol + high
dexamethasone (not used in
- Fat pad ACTH + suppressed (ACTH became low)
liver disease)
- Striae - Next: MRI pituitary
Hypercortisolism o 11 pm salivary cortisol (best
- Hyperpigmentation - Treatment: mitotane OR cabergoline OR
for pregnant)
- Hypokalemia metyrapone OR ketoconazole
- Confirmatory: ACTH level
- Hypertension Secondary improve transsphenoidal surgery
- High dose dexamethasone
- Metabolic alkalosis - Ectopic high cortisol + high ACTH + not
suppression test for secondary
- Hyperglycemia suppressed (ACTH still high)
hypercortisolism
- Lymphopenia - Next: CT chest, abdomen, and pelvis (rule
out malignancy)
- Treatment: treat the cancer
- Screening (low), confirmation (low)
- Next: CT adrenal for etiology
- Abdominal pain o Autoimmune = Addison disease
- Nausea and vomiting o Adrenal hemorrhage
- Hyperkalemia o TB, metastatic deposit
- Metabolic acidosis - Screening: morning serum o Hemochromatosis, sarcoidosis
Primary
- Hyperpigmentation cortisol o Rifampin, Septic shock
Adrenal insufficiency (buccal mucosa and - Confirmation: ACTH injection - Treatment:
palmar crease) (cosyntropin test) and check o Acute (adrenal crisis): 0.9 NS + IV
- Orthostatic hypotension cortisol level hydrocortisone
- Dizziness o Chronic: PO hydrocortisone 3 times per
- Hypoglycemia day + fludrocortisone for life
- Hyponatremia - Screening (low), confirmation (high)
Secondary - Next step: MRI pituitary
- Treatment: PO hydrocortisone for life
49
 - Screening: 24-hour urine
- Headache metanephrine OR
- 1- IV hydration
- Pallor venylmandilic acid (VMA)
- 2- Alpha blocker (phenoxybenzamine)
Pheochromocytoma - Diaphoresis - Confirmation: serum free
- 3- After 2 weeks add BB
- Episodic high BP metanephrine
- 4- Surgery
- Paroxysmal palpitation - Location: CT adrenal (size and
location)
Polyurea + normal Na + urine osmolarity <100 Polyurea + hypernatremia
- Initial water deprivation test and check urine osmolarity:
- Next: MRI brain
o High >800 (concentrated) primary polydipsia
- +ve central diabetes insipidus (treatment:
o Low <800 (diluted) ADH problem
Diabetes insipidus Desmopressin)
- Confirmatory desmopressin test:
- -ve Nephrogenic diabetes insipidus (treatment:
o Improved urine osmolarity >50% central diabetes insipidus
amiloride)
o nephrogenic diabetes insipidus
- Note: if polyurea + hyponatremia + urine osmolarity <100 = primary polydipsia

50
 Screening for
Osteoporosis - >65 years old
(Dexa scan) - <65 + high risk (steroid or hormonal replacement therapy)
Hypertension - >18 years old
Lipid - Men 35 and above - Women 45 and above
- PCOS
DM II - Normal BP at 45 years old
- High BP any age
Start Repeat
General population - 50 years old and above - Every 10 years
IBD (UC) - 10 years from diagnosis - Annual
Polyp - 10 yeas old (pediatric)
Colon cancer - Annual
(Familial polyposis) - At age 20 years old start upper GI scope with colonoscopy
(Colonoscopy)
Non-polyps - 20 years old
- Every 5 years
(HNPCC /Lynch syndrome) - At age 40 years old start upper GI scope with colonoscopy
1st degree relative with colon - 40 years old
- Annual
cancer - 10 years earlier from start of relative with colon cancer
Lung cancer - From 55 to 80 if active smoker (20 pack per year)
(Low dose CT - Ex-smoker and quit 15 years ago
chest) - All patients (smoker) and >65 years old do abdominal ultrasound (for abdominal aortic aneurysm)
Brest cancer - >40 years old (Saudi) or >45 (American)

51
Infectious Disease

52
Organism/Disease Diagnosis Treatment
- Purulent (pus):
- Dermal lymphatics (deeper) o Septic shock (low BP) vancomycin
- Ill-defined boarders, Acute onset S/E: Red man syndrome (itching + redness)
Cellulitis
- More systemic symptoms slow infusion rate + antihistamine
Streptococcus - Tender o Non-septic clindamycin
pyogenes
- Non-purulent clindamycin OR dicloxacillin
- Dermal and subdermal (superficial)
- Mild amoxicillin
Erysipelas - Well-demarcated, Indolent
- Septic shock IV ceftriaxone
- Less systemic symptoms
- Painless genital ulcer
Syphilis - Painless inguinal lymph nodes - Penicillin G
- Maculopapular rash in palms and soles
STD - Painless genital ulcer
- Doxycycline
Genital ulcer (Chlamydia trachomatis) - Painful inguinal lymph nodes
Chancroid - Painful genital ulcer
- Doxycycline
(Hemophilus ducry) - Unilateral inguinal lymph node involvement
- Painful genital ulcer
HSV-2 - Acyclovir
- Bilateral inguinal lymph node involvement
- Painless genital ulcer (chancre)
Primary - Penicillin G
- Diagnostic test: Dark field microscopy
- Healed ulcer with scar
Secondary - Maculopapular rash in palms and soles - Penicillin G (even in pregnancy)
Syphilis - Diagnostic test: FTA-AB, VDRL +ve, PEP +ve
(Treponema - Neurosyphilis (personality changes, Argyle
Pallidum) Robertson pupil)
- Penicillin G IM weekly over 3 weeks
Tertiary - Foot drop
- Neurosyphilis: IV penicillin G for 10-14 days
- Aortitis
- Diagnostic test: FTA-AB
- Fever + chills + tachycardia + syphilis started on penicillin Jarish-Herxidemer reaction

53
 - Post auricular lymphadenopathy
Rubella
- Rash: face then trunk
(German measles)
- Droplet transmission
Maculopapular - Cough + coryza + conjunctivitis
- Supportive
rash Rubeola - Kolpik spots in buccal mucosa
(Measles) - Rash: face then trunk
- Droplet transmission
Roseola (HHS-6) - Trunk rash
- Non-localized (fever, back pain, high titer, low
WBC, raw mild ingestion):
o Doxycycline + rifampicin OR streptomycin OR
- Raw milk ingestion then develops gentamicin for 6 weeks
o Back pain - Localized (lower back pain):
o Fever o Pregnant: rifampicin + trimethoprim
o Hepatomegaly sulfamoxazole for 4 weeks
Brucella meltiness
- Sensitive test: serum agglutination test (>1:640) o Joint/osteomyelitis: doxycycline + rifampicin
- Gold standard: blood culture + gentamycin for 3 months
o If blood culture negative and there is high suspicion do bone marrow o CNS: doxycycline + rifampicin + ceftriaxone
culture until CSF normalized (up to 6 months)
o Endocarditis: doxycycline + rifampicin +
gentamycin + trimethoprim sulfamoxazole
for 6 weeks 6 months
- Came from Jeddah, Jizan
- Febrile illness: fever, severe headache, myalgia, periorbital pain, petechial
rash
- Critical phase: acute hemorrhagic phase (low BP, pleural effusion, GI bleeding) - Supportive (paracetamol + IV fluids)
Dengue fever - Recovery phase (dangerous): seizure, bradycardia, low platelet - Avoid NSAIDs or aspirin (they cause low
- Testing: platelet)
o Duration of illness <3 days do PCR or ELISA
If negative IgM detection
o Duration of illness >3 days do IgM detection
54
 - Traveling + (IV drug abuse OR sexual contact with multiple partners)
- After 3-6 weeks post exposure:
- Prophylaxis:
o Mononucleosis like symptoms:
o Adult or healthcare worker with needle stick
Sore throat, fever, lymphadenopathy, rash, fatigue, myalgia, jaundice =
injury:
acute retroviral infection
2 hours 72 hours of exposure (window
- Transmission:
to give post-exposure medication) 2
o Body fluids except for saliva (only if contaminated by blood)
nucleoside reverse transcriptase inhibitor
o 0.2-0.3% through needle stick injury
+ integrase inhibitor for at least 4 weeks
o Breast milk (contraindicated to breast feed)
o Pregnant with HIV not on medication and she
- Tests:
is in labor:
o Screening: ELISA (HIV AB 1 and 2)
Mother and child zidovudine (NRTI) OR
o Confirmatory: Western blot
nevirapine
o Measure:
- Treatment: 2 nucleoside reverse transcriptase
Viral load by PCR determines treatment (anti-retroviral)
inhibitor + integrase inhibitor
CD4 count (<500) determine the needs of prophylactic against
HIV opportunistic infection
1- HIV patient + multiple ring enhancement on brain CT + fever + 7- HIV + eye symptoms + CD <50 CMV retinitis
confusion + meningitis + CD <100 toxoplasma: 8- HIV + meningitis + CD <50 CMV encephalitis
o Diagnosis: CSF toxoplasma IgG 9- HIV + eye symptoms + CD <100 toxoplasmosis
o Treatment: pyrimethamine + sulfadiazine 10- HIV + meningitis + CD <100 toxoplasma OR
2- HIV patient + single ring enhancement in brain + CD <50 HIV cryptococcus:
lymphoma o Diagnosis: +ve Indian ink
3- HIV patient + temporal area lesion + seizure + confused HSV o Treatment: amphotericin + flucytosine OR only
encephalitis liposomal amphotericin
4- HIV patient + hypoxia + SOB + dry cough + fever + bilateral 11- HIV + raised purple skin or buccal mucosa + CD <400
infiltration + high LDH + CD <200 pneumocystis Jiroveci Kaposi sarcoma (HHV-8)
pneumonia: 12- HIV + diarrhea + CD <100 cryptosporidium
o Diagnosis: broncho-alveolar lavage 13- HIV + diarrhea + any CD giardia
o Treatment: trimethoprim + sulfamoxazole 14- HIV + odynophagia + white patch esophagus + CD <200
5- HIV + pneumonia + patch + any CD streptococcus pneumonia candida esophagitis
6- HIV + Cavitary lesion + any CD TB 15- HIV + odynophagia + ulcer in esophagus HSV or CMV
55
 - Prophylaxis (travelling):
- #1 cause of FUO in returned travels
o Chloroquine sensitive area give
- Fever of unknown origin: Fever >38.3 for 21 days (3 weeks) + 1 week of
chloroquine once weekly (2 weeks before +
inpatient investigation
throughout + 4 weeks after)
- Sub-Saharan Africa or Sudan or Jizan (Southern Saudi) + fever + abdominal
o Chloroquine resistant area (KSA):
pain + jaundice + splenomegaly
First line: atovaquone (malarone) daily (2
- Features of severe malaria:
days before + throughout + 5 days after)
o Labs:
Second line: doxycycline (2 days before +
Parasitemia >5% (CDC) OR >2% (WHO)
throughout + 28 days after)
Severe anemia
Pregnant mefloquine once weekly (2
Lactic acidosis
weeks before + throughout + 4 weeks
Hypoglycemia
after)
o Clinical:
- Treatment:
Malaria Cerebral malaria (seizures, confusion)
o Non-complicated (no severe features):
Respiratory distress (ARDS)
P. falciparum PO artesunate +
Renal failure (high creatinine, decrease urine output)
sulfadoxine/pyrimethamine + primaquine
DIC
one dose
- Species: anopheles (peak: late night or pre-dawn)
Non-P. falciparum PO chloroquine +
- Most common type in Saudi p. vivax then p. falciparum
primaquine one dose
- Most common malaria that causes chronic disease p. malaria
o Severe (Regardless of malaria type):
- Most common malaria causes fatal or severe disease p. falciparum
IV artesunate
- Hypnozytes in liver p. vivax + p. ovale
o Pregnant (Regardless of malaria type):
- Diagnosis:
Non-complicated:
o Screening: Rapid diagnostic test in blood banks
1st trimester clindamycin + quinine
o Confirmation: blood smear + light microscopy (Geimsa stain, thin-thick film)
2nd + 3rd trimester artesunate + sulfa
If smear negative repeat smear (thin-thick) every 12 hours for total of 3
Severe:
sets (CDC) OR repeat smear (thin-thick) every 8 hours for 2 days (WHO)
IV artesunate + clindamycin

56
 Vaginitis
Bacterial vaginosis
Normal Trichomonas (STD) Candida
(Gardnella vaginalis)
Itching
Symptoms X Itching Itching
dysuria
Frothy green Thick white
Discharge Clear Foul fishy
Musty green grey Cheese
Cervical petechiae
Clinical findings X Erythema X
(strawberry cervix)
Vaginal pH 3.8 4.2 >4.5 4.5 >4.5
KOH (whiff test) Negative Positive Negative Positive
Clue cells (coccobacilli)
NaCl (wet mount) Lactobacilli Motile flagellated protozoa X
20%
KOH (wet mount) X X Pseudo-hyphae X
Metronidazole + treat the Topical clotrimazole or Metronidazole + no
Treatment -
partner miconazole or fluconazole treatment for partner

57
Hematology and
Oncology

58
 Diagnosis Treatment
- General:
o Adequate hydration
o Adequate analgesia
- Urgent blood transfusion:
- Pain vaso-occlusive crisis o Hb <6
- Pain + very low BP + low Hb + splenomegaly spleen o Reticulocytes 4%
sequestration o Major surgery (keep Hb at least above 10)
- Low WBC, low Hb, low reticulocytes, low platelets o Pregnant going for CS
Sickle cell disease
Aplastic crisis (parvovirus B19) - Urgent blood exchange:
- Jaundice, low Hb, high reticulocyte hemolytic crisis o Microinfarction (stroke)
- Low O2, SOB, chest x-ray with high interstitial markings, o Acute chest syndrome
fever Acute chest syndrome o Spleen sequestration
o Priapism
- Hydroxyurea (prevention):
o Severe acute chest syndrome
o Frequent painful crises 3/year
- Petechiae, epistaxis, gum bleeding, ecchymosis,
menorrhagia, GI bleeding
Von Willebrand - Desmopressin
- Normal platelet count
deficiency - If bleeding Cryoprecipitate
- High bleeding time
- Slight increase in PTT
- Young + post URTI - >30 years old + asymptomatic observe
Immune - Petechiae or purpura - >30 years old + bleeding IVIG and platelet
thrombocytopenic
- Low platelet - <30 years old steroids no improvement splenectomy or
purpura
- High bleeding time rituximab

- Pregnant
Thrombotic - Confusion (CNS) + petechiae and low platelet - Plasma exchange
thrombocytopenic
(thrombocytopenia) + low Hb and peripheral blood smear - FFP if no plasma exchange
purpura
shows schistocytes (MAHA) + high creatinine (AKI) + fever

59
 Hemophilia A - Male + Hematoma +Hemarthrosis - Factor 8 replacement or cryoprecipitate
- Isolate patient to +ve pressure room
- Do septic work up (blood culture, sputum culture, urine culture
and examination, chest x-ray)
- Main treatment: Cefepime or tazocin or imipenem covers gram
Febrile - Single fever 38.3 OR persistent fever 38 over 3 hours
negative (E. coli, pseudomonas, klebsiella)
neutropenia - Neutropenia (absolute neutrophil count <0.5)
o Porta cath or IV line or pneumonia (MRSA) add vancomycin
o No improvement in 5-7 days of antibiotics add antifungal (-
fungin)
- Ceftazidime covers pseudomonas only
- IV dexamethasone MRI spine with contrast for confirmation
- If came with only pain emergency radiotherapy
Cord compression - Cancer + sever back pain and numbness
- If came with pain and neurological symptoms (numbness, urinary
incontinence) surgical decompression
- High RBC, Hb >16.5, high HCT >49%
- Headache, dizziness, blurred vision, tinnitus, plethora,
Polycythemia vera splenomegaly, bleeding, thrombosis (Budd Chiari - Phlebotomy (helps reduce HCT to <45%) + aspirin
syndrome), pruritis
- EPO level low then do mutation test (JAK 2 mutation)
- Young, Fatigue, Bleeding, Recurrent infection
- Anemia, low platelet, Low WBC
- No palpable lymphadenopathy
Acute myeloid
- No splenomegaly - Trans-retinoic acid
leukemia
- Acute promyelocytic leukemia M3
- Translocation 15:17 (PML-RAR)
- Auer rod, myeloperoxidase +ve on cytochemistry
- Old, Fatigue
- High WBC, high basophils
Chronic myeloid
- Splenomegaly - Tyrosine kinase inhibitors (-nib)
leukemia
- Palpable lymphadenopathy
- Translocation 9:22 (Philadelphia chromosome)
60
 - Lymphadenopathy, Large spleen
- Asymptomatic (even if there is lymphadenopathy or
Chronic - High WBC
splenomegaly) watchful waiting
lymphocytic - Peripheral smear: smudge cell, CD5 +ve
- Symptomatic (anemia or thrombocytopenia) fludarabine,
leukemia - Associated with autoimmune hemolytic anemia (warm
cyclophosphamide, rituximab
IgG) and ITP
- Non-tender - Bimodal age (young and
- Adriamycin
lymphadenopathy very old)
Hodgkin - Bleomycin
- Night sweats, fever, - With EBV or HIV
lymphoma - Vincristine
weight loss >10% (B- - Patholognomic: Reed
- Dacarbazine
symptoms) Sternberg cell
- Lymphocytosis + very - Autoimmune (SLE, RA, - R-CHOP:
high LDH autoimmune hemolytic o Rituximab
- Diagnosis: First lymph anemia warm IgG type) o Cyclophosphamide
Non-Hodgkin node excisional biopsy - o Adriamycin
lymphoma
then PET-CT for - Infections (EBV, H. pylori) o Oncovin
staging (Ann Arbor) - Decrease immunity (HIV, o Prednisone
post-transplant) - If H. pylori lymphoma (MALToma) H. pylori eradication
- Elderly and smoker, Back pain, Repeated infections
- Hypercalcemia and anemia (due to bone infiltration)
Multiple myeloma - High creatinine (acute tubular necrosis) - Autologous stem cell transplant
- Diagnosis: urine protein electrophoresis or serum protein
electrophoresis
Stage I Stage II Stage III Stage IV
- Lymph node surgery + - Chemo + target therapy
Colon - Subserosa surgery - Serosa surgery + chemo
chemo (palliative)
- Radiation + hormonal - Same as stage II but
Solid Prostate - Radiation - Radiation + GHRH + chemo
therapy (GHRH) longer
tumors
- ER/PR hormonal
- Surgery + radiotherapy + - Neoadjuvant chemo +
Breast - Surgery + radiotherapy - HER2 trastuzumab
chemo surgery + radiotherapy
- Triple negative chemotherapy

61
 Anemia
Iron studies
Peripheral smear
Ferritin TIBC Transferrin saturation
Anemia of chronic disease High Low High Microcytic hypochromic or normocytic normochromic
Iron deficiency anemia Low High Low Microcytic hypochromic
Labs -
Sideroblastic anemia Microcytic hypochromic
-
(Lead poisoning) Basophilic stippling
Bata major HbF >90%
Thalassemia Microcytic hypochromic
Beta minor HbF 2-3%, HbA2 3-10%
HbA 0%
HbS present
Sickle cell disease Normocytic normochromic
HbA2 <3.5%
HbF 1-8%
Normocytic normochromic
Myelofibrosis - Tear drop
Dry tap
Aplastic anemia Parvovirus B19 Normocytic normochromic
High methylmalonic acid
B12
Megaloblastic High homocysteine
Macrocytic hyperchromic
anemia Normal methylmalonic acid
Folate
High homocysteine
Autoimmune Direct Coombs test +ve
hemolytic Cold (IgM): mycoplasma, CMV, HIV
anemia Warm (IgG): CLL, NHL, SLE Spherocytes
Hemolytic Hereditary
Direct Coombs test -ve
anemia spherocytosis
Bite cells
G6PD Enzyme activity assay
Heinze body
MAHA Direct Coombs test -ve Hamlet cell or Schistocytes

62
 Transfusion
Indication Reaction
- Mild urticaria (rash)
- Within minutes
Plasma pheresis
- Good pasture syndrome - In mild Stop transfusion + antihistamine
(Therapeutic Allergic reaction
- TTP (diphenhydramine) then gradually start again
apheresis)
- In severe (SOB, low BP, rash) stop
transfusion + epinephrine +/- steroid
- NO rash
Low platelet leads to ICH:
- Fever + symptoms (chest pain, SOB, pain at
- < 50,000 + active bleeding
site of cannula, bleeding from cannula)
- < 20,000 + infection Acute hemolytic
Platelet - Within hours
- < 10,000 + asymptomatic reaction
- From ABO incompatibility
- Contraindications: HELLP, HUS, TTP,
- Management: stop transfusion + ICU +
heparin induced thrombocytopenia)
dopamine + IV fluid
- NO rash
Contains Von Willebrand + factor 8:
- Fever (+/- chills) + no other symptoms
- Bleeding in Von Willebrand deficiency Febrile nonhemolytic
Cryoprecipitate - Most common reaction
- Factor 8 deficiency reaction
- Due to donor WBC
- DIC (low fibrinogen)
- Management: acetaminophen
No WBC:
Irradiated - Hematological malignancy
- Stem cell transplant
- Active bleeding due to warfarin
- DIC with bleeding
- NO rash + NO fever + SOB + high RR + chest x-
FFP - Liver disease (cirrhosis)
ray non cardiogenic edema (ARDS)
- INR >2 before going to procedure (helps Transfusion related
- Within 6 hours
reduce quickly) acute lung injury
- Management: treat as ARDS (supportive) in
- Post exposure (pregnant exposed to
ICU
measles <72 hours)
- Autoimmune disease (Idiopathic
IVIG
thrombocytopenic purpura)
- Guillain barre syndrome
- Myasthenia gravis

63
Neurology

64
 Hints Diagnosis Treatment Extra
- Fever + progressive headache at
night (+/- frontal)
- Increase ICP (vomiting, confusion, - CT brain with contrast ring
- Headache at
seizure, blurred vision) enhancement - Metronidazole +
Brain abscess morning and frontal
- Focal neurological deficit (weakness) - Best modality: MRI brain with contrast ceftriaxone
= brain tumor
- Risk factors (chronic sinusitis, dental - Definitive (gold standard): brain biopsy
infection, chronic mastoiditis, otitis
media, IV drug abuser, fracture)
- 18 50 years:
- Start empirical antibiotics with
o Strep. pneumoniae (most common)
- Presentation: dexamethasone:
o N. meningitidis
o 2 out of 4 (fever, headache, neck o 18 50 years ceftriaxone + vancomycin
- >50 years:
stiffness, change in mental status) o >50 years ceftriaxone + vancomycin +
o Strep. Pneumoniae (most common)
o Knee flexion ampicillin
o N. meningitides
o Passive neck flexion Brudzinski o If listeria suspected no dexamethasone
o Listeria monocytogenes (elderly,
sign - Droplet isolation for N. meningitidis and
alcoholics, immunocompromised in
o Atypical presentation in elderly discontinue after 24 hours of starting
early age)
(confusion) treatment
- Blood culture then CT brain, Only if:
- Special presentation: - After culture result, if:
Bacterial o Immunocompromised
o Fever + headache + petechial rash o N. meningitidis ceftriaxone 7 days
meningitis o Change mental status
+ low BP + hyperkalemia o Streptococcus vancomycin 10 days
o >60 years old
meningococcemia o Listeria ampicillin
o Seizure
Causes adrenal hemorrhage - Prophylaxis for N. meningitidis:
o Space occupying lesion
(water house syndrome) o Ciprofloxacin once PO OR rifampin 2 days OR
o Focal neurological deficit
- Complications: ceftriaxone once IM
- LP if no space occupying lesion (tumor,
o Seizure (acute) o In pregnant IM ceftriaxone
abscess):
o Hearing loss (most common late - Immunization (A, C, Y, W 135 + B):
o Bacterial high protein, low glucose,
complication) o SCD
high PMN
o Stroke o Asplenic patients
o TB high protein, low glucose
o Hajj
lymphocyte
65
 - Most common viral
- Herpes simplex (most common):
meningitis
o All ages HSV-1
enterovirus
o Elderly varicella zoster virus
Viral - Fever + change in mental status and o LP: low protein,
(vesicular rash) - IV acyclovir
encephalitis personality high glucose, high
- LP + PCR for HSV-1
lymphocyte
- Best modality for diagnosis: MRI with
o Treatment:
contrast (temporal area enhancement)
supportive
- Bilateral pressure, band-like pain - Acute attack (episodes) NSAIDs or Acetaminophen
(mild moderate intensity) o Both at risk of medication overuse headache
Tension - Increase with activity, stress, sleep Occurs with use of simple analgesia for 15 day/month OR combination for 10
headache deprivation, dehydration days/month
- Associated with photophobia and Avoided by gradual wean off medication
phonophobia - Chronic attack tricyclic antidepressant (amitriptyline)
- Unilateral headache starts at night, - Trigeminal neuralgia
sudden, severe, several times per shock-like pain in
- Acute attack high flow O2 100% OR hyperbaric O2 chamber +
Cluster day (>8 times per day) face when eating or
sumatriptan (adjuvant)
headache - Male + tearing + red eye + shaving
- Prophylaxis: CBB (verapamil)
rhinorrhea + miosis + ptosis + lid o Treatment:
edema carbamazepine
- Unilateral headache pulsating, - Acute sumatriptan (5-HT1 agonist) + NSAIDs
painful (moderate severe) o Never give nitrates with sumatriptan
- Without aura (last 4 72 hours, o Contraindication to sumatriptan (CAD or prior stroke) give one of the following:
nausea and vomiting) Metoclopramide
- With aura (last for minutes and Valproic acid
Migraine comes before the headache, visual Magnesium IV
spots, numbness, speech Steroids
disturbance, photophobia or Ergotamine
phonophobia) - Prophylaxis:
- Aggravated by activity o First line: BB
- +ve family history o Second line: CCB OR amitriptyline OR valproic acid OR topiramate
66
 1- Severe headache in occiput suddenly happening after lifting an object intracranial hemorrhage (ruptured aneurysm)
2- Worst headache of their life + meningismus (neck stiffness) without fever + risk factors (hypertension, smoking, cocaine, pregnancy, use of
OCP), CT brain normal OR enhanced ventricles, LP shows yellow CSF + RBC (xanthochromia) subarachnoid hemorrhage
3- Severe headache + proptosis (III nerve palsy) + risk factor (female, history of OCP use, DVT, PE, thrombophilia) cavernous sinus
thrombosis
Secondary
o Diagnosis: CT brain with arterial and venous contrast (CTV + CTA) + MRI (MRA/MRV)
headache
o Treatment: anticoagulation like PE/DVT
4- Severe headache, young, female, obese, OCP, tetracycline, Roaccutane, diplopia with lateral gaze (6th nerve/abducent palsy), papilledema
idiopathic intracranial hypertension (pseudotumor cerebri)
o Diagnosis: CTA/CTV to exclude venous thrombosis then LP: elevated opening pressure (>250mm or 25 cmH2O)
o Treatment: therapeutic LP + acetazolamide
- Stroke and blood
- Acute (within 3
pressure:
4.5 hours)
o <180
- Anterior cerebral artery thrombolytics
thrombolytics
contralateral hemiplegia in leg + (alteplase)
o 180-210
urinary incontinence o If contraindicated
antihypertensive
- Middle cerebral artery - Came within 3 4.5 hours CT brain to thrombolytic
or wait
contralateral hemiplegia in arm + no contraindication start arterial
o >220 treat
aphasia + homonymous hemianopia treatment + stroke work up: thrombectomy
hypertension (by
Ischemic - Posterior cerebral artery macular o Lipid profile - Chronic:
ACE inhibitor) until
stroke sparing homonymous hemianopia o Carotid ultrasound o Embolic cause:
become 180
- Basilar artery paraplegia + palsies o ECHO High risk (A.
- Lacunar stroke
(CN) + pinpoint pupils o Holter monitor fib)
stroke in basal
- Cerebellar artery ipsilateral, o Fasting blood sugar and HbA1C anticoagulant
ganglia resulting in
intension tremor, nystagmus, ataxia, + aspirin
pure weakness OR
diplopia, truncal ataxia (vermes Low risk
numbness OR
affected) aspirin
aphasia
o Atherosclerotic
o Treatment: aspirin
cause aspirin

67
 - UPRTI (viral), LRTI (mycoplasma),
- Acute:
surgery, bloody diarrhea
- Nerve conduction study o Plasma exchange if going to ICU
(campylobacter Jejuni) >2 weeks
Gillian-Barre - Biochemical Anti-GM1 OR anti-GD1 o IVIG if going to ward
- Back pain + bilateral distal (lower
syndrome - LP increase in protein only - No chronic treatment except in chronic
limb) weakness (symmetrical) +
(albuminocytologic dissociation) inflammatory demyelination polyneuropathy
ascending + numbness
(>8 weeks) give IVIG
- Hyporeflexia or areflexia
- Bilateral proximal (upper limb) - Clinical:
weakness + descending o Edrophonium test improved
- Acute (myasthenic crisis = weakness +
- Symptoms worse with repetition symptoms
respiratory distress) IVIG or plasmapheresis
- Associated with other autoimmune o Simson test develop fatigue and
- Prevention of relapse:
disease ptosis
Myasthenia o Thymoma Thymectomy
- Normal tendon reflex - Biochemical Anti Ach receptor
gravis o No thymoma cholinergic drug
- Thymoma antibody
(pyridostigmine)
Lambert Eaton syndrome: - Electromyogram decrease response
If no improvement steroid if no
weakness in arms and shoulders of neuromuscle with repetition
improvement azathioprine
improves with repetition + small - Imaging (CT chest) to rule out
cell lung cancer thymoma
- Acute IV methyl - Intraocular
- Young + female
prednisone ophthalmoplegia
- Sudden right arm numbness + left - Gold standard MRI brain and spine
- Chronic, options: (lesion in MLF)
leg weakness for 1 week (periventricular plaques)
o Interferon B o
Multiple - Right painful eyesight or diplopia - LP high protein CSF (pathognomic:
o Natalizumab IV adduct
sclerosis - Sudden urinary retention IgG oligobands)
o Fonglomoid PO o Contralateral eye
- Post URTI - If presenting with flare urine
(do baseline ECG, nystagmus
- Optic neuritis, UMN (hyperreflexia, analysis to rule out UTI
can cause o Occurs in MS and
clonus, Babinski), spastic
arrythmia) stroke
Amyotrophic - Progressive skeletal muscle
lateral - Clinical
weakness starts from hands and legs - Rilozole (increase survival)
sclerosis - LP
(fasciculations) + normal sensory
(ALS)

68
 - Start treatment:
- Tongue biting, up rolling of eye o 2 or more seizure
- First line options: unprovoked
o Without post ictal (simple partial)
Partial o Carbamazepine or topiramate obese o Seizure + structural
o With post ictal (partial complex)
seizure o Levetiracetam or lamotrigine safe in pregnancy brain disease (CNS
- Second line: phenytoin tumor)
happened
- Stop treatment
when seizure free
- Limb movement: for 2 years
- First line options: - Steven Johnson
o Tonic clonic (opens and closes
o Valproic acid (S/E: weight gain, increase LFT) syndrome:
Generalized hand)
o Topiramate (kidney stone) o Extensive
seizure o Myoclonic (random movement)
o Levetiracetam (safe in pregnancy) erythema + red eye
- Absence (only staring)
- Second line: phenytoin from lamotrigine
- All have post ictal
use
- Benzodiazepine twice (lorazepam better or diazepam) no improvement phenytoin or
- Continued seizure for 5 minutes
Status phenobarbital as bolus then effusion (monitor by ECG) no improvement anesthesia
- >2 seizure without returning to
epilepticus (midazolam or propofol)
baseline (without resolution)
- If elderly and has seizure give thiamine and dextrose
- Bradykinesia, Shuffling gait
- Resting tremor - Treatment only if functional impairment Levodopa + carbidopa
disease
- Cog wheel rigidity
1- Difficulty remembering + disorientation + behavioral changes (mood changes) + gradual onset Alzheimer disease:
o Best investigation: MRI brain.
o Treatment: Mild or moderate cholinesterase inhibitors (donepezil or rivastigmine), Severe add memantine
2- Elderly + rigidity + tremor + hallucination + early dementia + behavioral problems Lewy body dementia
Dementia 3- Rigidity + tremor + dementia + low BP multisystem atrophy (shy dragger syndrome)
4- Young + aggressive behavior + dementia + loss of empathy frontotemporal dementia
5- Elderly + dementia + urinary incontinence + abnormal gait normal pressure hydrocephalus
o First step is CT or MRI brain (dilated ventricles) therapeutic LP no improvement ventriculoperitoneal shunt
6- Dementia + stepladder wise vascular dementia (MRI brain for diagnosis)
69
 Toxicology Scenario Medication Antidote
Young, vomiting, suicidal attempt, labs: high anion Acetaminophen toxicity take acetaminophen - N-acetylcysteine (side effect: anaphylaxis)
gap metabolic acidosis + normal osmolar gap + high level (king college criteria for transplant, focus on - Hemodialysis (severe cases like AKI or no
AST, ALT, creatinine low pH) antidote)
History of depression + low BP + seizures + ECG Tricyclic antidepressant (amitriptyline) - Urine alkalization by NaHCO3 + IV fluid
prolonged QT interval contraindicated in BPH (causes urinary retention) resuscitation (for low BP)
Farmer, increase salivation, SOB, diarrhea, vomiting, - Respiratory failure intubation
Organophosphate toxicity (pesticides)
tearing, miosis - No respiratory failure atropine
IHD, stroke, abdominal pain, vomiting, high RR,
- Alkalinization by NaHCO3
ringing in ears (tinnitus), ABG: (high anion gap
Salicylate (Aspirin) toxicity - Maintain respiratory alkalosis
metabolic acidosis with normal osmolar gap and
- Consider hemodialysis if no improvement
respiratory alkalosis)
Change mental status, low RR (depression),
Morphine (opiate) toxicity IV naloxone
miosis
Change mental status, low RR (depression),
Benzodiazepine toxicity Flumazenil
ataxia
Change mental status, high anion gap metabolic
Alcohol or ethylene glycol or isopropanol Ethanol or fomepizole or hemodialysis (severe)
acidosis, high osmolar gap
Change mental status, high anion gap metabolic Methanol (formic acid causes blindness by Same as up
acidosis, high osmolar gap + blindness affecting the optic nerve) Blindness is irreversible (permanent damage)
Change mental status, seizure, pink spots on
skin, almond odor, ABG normal, pulse oximeter Cyanide (hydroxocobalamin) toxicity Sodium thiosulfate
normal
ER Change mental status, headache, vomiting,
cherry red skin, ABG normal, pulse oximeter Carbon monoxide toxicity Hyperbaric oxygen (100% oxygen)
low
Change mental status, chocolate brown blood,
Methemoglobinemia Methylene blue
ABG normal, pulse oximeter low
Bradycardia, hyperkalemia, delirium,
xanthopsia (yellow vision), AV block, nausea, Digoxin Digibind
and vomiting
Bradycardia, low BP, heart failure,
CCB toxicity Calcium gluconate + pacing
hyperglycemia, AV block
Bradycardia, low BP, heart failure,
BB toxicity Glucagon + pacing
hypoglycemia, AV block
70