‫بسم اهلل الرحمن الرحيم‬

Prometric High-Yield
NOTES

By : Dr.Eyas .N

References:

- Toronto Notes
- FIRST AID USMLE STEP 2 CK
- Kaplan lectures
- UP TO DATE
Internal Medicine
 Cardio :
 INFX :
 GASTRO :
 NEURO :
 ENDO :
 Nephro :
 Hemat :
 RHEUMATO :
 PULMO :
 MISC :

OBSTETRICS AND GYN:

Pediatrics :
SURGERY :
Orthopedics :
Psychiatry :
Dermatology :
ENT :
Ophthalmology
Cardio :
An S4 gallop signifies a stiff,
noncompliant ventricle and
↑ “atrial kick” and may be
associated with hypertrophic
cardiomyopathy
Major risk factors for CAD
include age, male gender,
hyperlipidemia , DM,
hypertension, obesity, a family
history, and smoking
Only ASA and β-blockers
have been shown to have
a mortality benefit in the
treatment of angina
Aortic aneurysm is most
often associated with
atherosclerosis, while aortic
dissection is commonly linked
to hypertension
Ascending aortic dissections
are surgical emergencies, but
descending dissections can
often be treated medical
3
Coartation of aorta : Systemic
hypertension, accelerated
coronary heart disease, stroke,
aortic dissection, and heart
failure are common
complications in adults The
most common
complication in adult is HTN and
CAD.
Which of these anti HTN
medications decrease afterload
and preload ? ACEI
right coronary artery
dominance" is explained as right
coronary artery giving branch
to: Posterior Descending
We recommend that patients
with acute rheumatic fever be
initiated on antibiotic therapy as
delineated for eradication of
streptococcal pharyngitis,
whether or not pharyngitis is
present at the time of diagnosis
‫ال فرق بٌن االسبرٌن و الستٌروئٌد فً عالج‬
‫االعراض‬
Phytosterols (plant sterol ):
Because phytosterols are
structurally similar to the body‘s
cholesterol, when they are
consumed they compete with
cholesterol for absorption
in the digestive system. As a
result, cholesterol absorption is
blocked, and blood cholesterol
levels reduced
‫متالزمة درسلر تعالج باالسبرٌن و ال‬
NSAIDS
woman underwent lung lavage
hemosiderin laden
macrophages‖ seen indicates ?
Heart failure
heart failure lead to diffuse
alveolar hemorrhage syndromes
Dyslipidemia is the most
powerful modifiable risk factor
for the development of
cardiovascular disease
A medication that will decrease
cardiac output and decrease
peripheral resistance ? CCB
4
Patients with asymptomatic
carotid artery stenosis should be
treated with aspirin
Cardiogenic shock (~7%) = MAP
<60 mmHg, CI <2 L/min/m2,
PCWP >18
Amyloidosis Normal voltage &
normal septal thickness has NPV
~90%
Digoxin ↑ arrhythmias in
amyloid.
avoid venodilators (nitrates) &
NEG inotropes (bB/CCB) if severe
AS
Pulmonary stenosis is the most
common pathological ejection
systolic murmur heard in
children
Athletic come for check-up all
thing normal except xanthelasma
on achllis tendonand
cholesterol? Ldlreceptor
Familial hypercholesterolemia
Liddle syndrome is a rare
autosomal dominant disorder
characterized by severe
hypertension and hypokalemia
symptomatic TGA neonates:
prostaglandin E1 infusion to
keep ductus open until balloon
atrial septostomy
Aortic dissection: first with IV bB
to blunt reflex ↑ HR & inotropy
that would occur in response to
vasodilators; verap/dilt if bB
contraindic. then ↓ SBP with IV
vasodilators (eg, nitroprusside)

aortic aneurysm, initial

Aspirin poisoning
investigation US, confirmed by
Interference with cellular CT.
metabolism (eg, Krebs cycle,
oxidative phosphorylation ) leads
to metabolic acidosis. Drug that will delay need of
surgery in AR: Nifedipine-
(beta-blockers) may be indicated
BP : to slow the rate of aortic
dilatation and delay the need for
• Emergency: ↓ MAP by ~25% in
surgery in patients with AR
mins to 2 h w/ IV agents ; goal
associated with aortic root
DBP <110 w/in 2–6 h, as
disease
tolerated

• Urgency: ↓ BP in hours using

PO agents; goal normal BP in ~1– Diuretics and particularly
2d effective in African-Americans

Screening AAA: ONCE U/S >60 y

w/ FHx of AAA & 65–75 y w/
Not bleeding: withhold warfarin,
prior tobacco
give vit K 1–2.5 mg PO only if INR
AAA: infrarenal ≥5.5 cm but 5–10, ✓ serialINRs
consider ≥5.0 cm in femlas ; sx;
• Bleeding or INR >10: FFP ± low-
↑ >0.5 cm/y; inflam/infxn
dose (1 mg) vit K IV
Screen : AAA: q3y if 3–3.9 cm;
q6–12 mo if 4.0–5.4 cm

5
anaerobic exercise (endurance) : associated with increased
isotonic like running >>> rise HR mortality.
more than BP to improve cardiac

function
Weight bearing exercise
(isometric): isometric like weight
lifting, may build muscle
strength, bone density >>> cause
spike rise in BP and is bad for
CAD pts
warfarin : barbiturates decrease
the anticoagulant effect of
warfarin - it crosses placenta as
well as blood brain barrier
The prophylactic administration
of class 1C antiarrhythmic agents
(eg, encainide, flecainide ) in the
post-MI period is associated with
increased mortality
effectiveness of ventilation
during CPR measured by : Chest
rise
Digoxin toxicity : In addition to
gastrointestinal symptoms, visual
changes may occur, including
alterations in color vision, the
development of scotomas, or
blindness.
What will increase heart blood
flow when increase load on
heart? Dilation of coronary
hypercholesterolemia, he should
avoid: Organ meat

We recommend not using

amiodarone Class III as
native valve ABE: vanco (± gent;
prophylaxis against ventricular
no longer routinely
arrhythmias post-MI . Instead,
recommended)
we reserve its use in the post-MI
period for patients with native valve SBE: ceftriaxone (or
symptomatic VPBs that require amp if ? enterococcus; eg, older
antiarrhythmic drug therapy. We or ob/gyn) ± gent
prefer amiodarone to other
antiarrhythmic agents in this
setting because it has not been
6
Patient treated from
endocarditis. Recurrence: 12%
Initial regulation of BP in vascular
system occur at : Arterioles
Troponin appears 1-6 h after
injury, peaks at 24 h, and may
remain elevated for 7-10 d in
STEMI
About half of the children who
have had rheumatic fever
develop it again after another
streptococcal throat infection if
it is not treated
complain of buttock pain ,In
angiogram which artery most
likelyoccluded? Internal iliac
Hypertension in child? More
than 95th
Familial hypercholesterolemia
(fh) is an autosomal dominant
disorder that causes severe
elevations in total cholesterol
7
and low-density lipoprotein
cholesterol (ldlc).
Xanthomas are noted commonly
on the achilles tendons and
metacarpal phalangeal extensor
tendons of the hands of patients
with untreated fh. caused by
defects in the gene that encodes
for the apo B/E (LDL) receptor
early monomorphic VT (<48 h
post-MI) does not carry bad
prognosis
Immunosuppression : for giant
cell myocarditis (prednisone +
AZA), collagen vascular disease,
peripartum (? IVIg), &
eosinophilic ; no proven benefit
for viral myocarditis
AVR: indicated in sx severe AS
asx severe AS + EF < 50%. May
consider if asx but either sx or ↓
BP w/ exercise
AI: AVR, replacement : sx severe
AI - asx severe AI and EF ≤ 50%
or LV dilation (end syst. diam.
>50–55 mm or end diast. diam.
>70–75 mm, esp. if progression)
or undergoing cardiac surgery
Surgery MR (repair [preferred if
feasible] vs. replacement w/
preservation of mitral apparatus (
sx severe MR, asx severe MR
and EF 30–60% or LV sys. diam.
>40 mm consider MV repair for
asx severe MR w/ preserved EF,
esp. if new AF or PHT
MS : sx w/ MVA ≤1.5, or sx w/
MVA >1.5 but ↑ PASP, PCWP, or
MV ∇ w/ exercise, or asx Pts w/
MVA ≤1.5 and PHT (PASP >50 or
>60 mmHg w/ exercise) or new
onset AF
Contrast CT: quick, noninvasive,
high Se & Sp for all aortic
aneurysms
Orthostatic syncope: volume
replete (eg, 500 mL PO q a.m.); if
chronic → rise from supine to
standing slowly, compressive
stockings, midodrine,
fludrocortisone, high Na diet
8
CT(contrast) is used as the initial
screening study in patients with
suspected aortic dissection,
particularly those presenting to
the emergency department
setting when TEE and MR may be
unavailable
diagnosing AAA
For asymptomatic patients, we
recommend abdominal
ultrasound as the initial
diagnostic modality - For
symptomatic patients who are
hemodynamically stable, we
recommend computed
tomography of the abdomen as
the initial diagnostic modality
AAA :recommend surveillance
every 6 to 12 months using
ultrasound or computed
tomography (CT) for medium-
sized aneurysms (4.0 to 5.4 cm in
diameter)
PULMO :
The most common cause of
croup is: Parainfluenza
‫ بعد هجمة‬COPD
Pneumococcal vaccine &
influenza vaccine 4 weeks after
discharge
Best early sign to detect tension
pneumothorax : Tracheal shift
CXR, PPD, AFB “Ziehl Neelsen
stain”, These are the basic
investigations for TB patient.
Symptoms of nicotine
withdrawal generally start within
2 - 3 hours after the last tobacco
use, and will peak about 2 - 3
days later
Air bronchogram is characteristic
feature of: Lobar Pneumonia
COPD coughing greenish sputum,
what's the organism :
Haemophilus influen
The most common cause of
nodule calcification is granuloma
formation, usually in the
response to healed infection
9
Best drug to decrease bronchial
secretion in COPD? Ipratropium
patient with ―pertussis best
swap : Nasopharyngeal
lung cancers is associated with
anti epithelial cell receptor
therapy? Adenocarcinoma
in some cases, patients are
diagnosed with TB disease on
the basis of their signs and
symptoms, even if their
specimen does not contain M.
tuberculosis
Hypersensitivity pneumonitides
(organic dusts): loose,
noncaseating granulomas
SOLITARY PULMONARY
Ø Ca → ↑ likelihood malignant;
laminated → granuloma;
“popcorn” → hamartoma
Ground-glass nodules: longer f/u
b/c even if malignant can be
slow-growing
upper→ coal, silicon, hypersens,
sarcoid, TB, RA;
lower → IPF, asbestos,
scleroderma
Sarcoidosis Rx: steroids (eg,
prednisone 20–40 mg/d) if sx or
extrathoracic organ dysfxn
Lymphangioleiomyomatosis
(LAM): cystic, ↑Females , Rx w/
sirolimus
PLEURAL EFFUSION
complicated = + Gram stain or
culture or pH <7.2 or glucose <60
>1/2 hemithorax or complicated
or empyema → tube
thoracostomy
Thrombophilia : APC resistance,
protein C or S deficiency, APS,
prothrombin gene mutation,↑
factor VIII,
hyperhomocysteinemia, HIT,
OCP, HRT, tamoxifen , raloxifene
Thrombolysis in PE
10
Use if PE a/w hemodynamic
compromise (“massive PE(“
Consider if PE w/o hemodynamic
compromise, but high-risk
(“submassive PE,” eg,marked
dyspnea, severe hypoxemia, RV
dysfxn on echo, RV enlargement
on CTA(and low bleed risk.
After early resuscitation, if
ALI/ARDS, target CVP 4–6 mmHg
as additional fluids may be
harmful
Supplemental oxygen titrated to
> 90% SaO 2 for > 15 hours a day
and smoking cessation are the
only interventions proven to
improve survival in patients with
COPD.
Squamous and Small cell cancers
are Central lesions.
pharyngitis then cough &fever,
what is the most likely organism
: Streptococcus pneumonia
For patients with clinical SVC
syndrome who present with
stridor, respiratory compromise,
or depressed central nervous
system function, we recommend
emergent treatment with
endovascular stenting followed
by radiation therapy (RT
In general, beta-lactam agents
(eg, amoxicillin or a second- or
third-generation cephalosporin)
are the preferred antimicrobial
for haemophilus influenza
In children, both ICS therapy and
untreated asthma itself have
been associated with
deceleration of growth velocity
Streptococcus pneumonia 60%
‫ٌحدث فٍها انصثاب‬
causes of shift to right can be
remembered using the
mnemonic, "CADET, face Right!"
for CO2, Acid, 2,3-DPG , Hypoxia
chromosome of cystic fibrosis:
Long arm of chromosome 7
11
The Screening Questionnaire to
recognize primary snoring from
OSAS is : Horchover
Questionnaire
FEV1 Values of between 80% and
120% of the average value are
considered normal
The first step in the evaluation of
a pulmonary nodule is to look
for a prior x-ray-In low-risk
patients follow the patient with
chest x-rays or chest CT every 3
months for 2 years -High-risk
patients open lung biopsy and
removal of the nodule
The most common cause of
nodule calcification is granuloma
formation, usually in the
response to healed infection.
Mediastinal and central
diaphragmatic pleural pain
referred to root of neck and over
shoulder
lactose non-fermenting, gram
negative motile bacilli producing
greenish colony and oxidase
positive what is the organism:
Pseudomonas
If there is objective evidence of a
substantial degree of
improvement in airflow
limitation (FEV1 increase >15%),
prednisolone should be
discontinued and replaced by
inhaled corticosteroids
Hemat :
COLD AIHA: avoid cold; steroids
ineffective; rituximab
ITP ; Anti-plt Ab tests not useful.
HIT (need clinical + pathologic) :
Clinical: plt <100k or ↓ 50% from
baseline; or venous (DVT/PE) or
arterial (limb ischemia, CVA, MI)
thrombosis (4:1 ratio); skin
necrosis
Heparin use if h/o HIT: if PF4 Ab
neg (typically >100 d after dx) →
re exposure to UFH reasonable
HUS: Shiga toxin
12
Poor prognostic factors CML : ↑
age, ↑ platelet count, ↑ spleen
size, ↑ percentage of blasts
sickle cell anemia Patients should
be admitted for management of
acute chest crises or for painful
episodes that do not respond to
outpatient care.
Mixing study: useful if ↑ PT or
PTT; mix Pt’s plasma 1:1 w/
normal plasma and retest PT/PTT
normalizes → factor deficiency;
PT/PTT remains elevated →
factor inhibitor
(PT) to measure the functioning
of factors I, II, V, VII, and X partial
prothrombin time (PTT) to
measure the functioning of
factors VIII, IX, XI, XII, and von
Willebrand factors
splenomegaly and teardrop RBC
on bloodfilm: Myelofibrosis
Long term complication of
Hodgkin lymphoma is solid
tumor (breast cancer, which can
metastasize to bone) due to
radiotherapy
Beta Thalassemia The genetic
defect usually is a missense or
nonsense mutation in the beta-
globin gene
HODGKIN LYMPHOMA: ABVD -
NHL: CHOP-R
Sequestration is recurrent in 50
percent of survivors; as a result,
splenectomy is usually
recommended after the first
acute event
For anemic crisis with splenic
sequestration, give early red cell
transfusions because the process
can rapidly progress to shock. Do
not allow hemoglobin (Hb) levels
to rise to more than 10 g/dL,
since the spleen may disgorge
trapped cells, which can create a
relative polycythemia and
increased blood viscosity.
Beta thalassemia is more
common in Mediterranean Sea
13
Area; whereas Alpha
Thalassemia is more common in
South East Asia & Africa.
post-transfusion fever : Cytokine
accumulation during storage
may play a primary role in this
setting, since it has been
demonstrated that the risk of a
transfusion reaction increases
with the age of the unit
transfused, and that removal of
plasma is more effective than
post-storage leukoreduction in
preventing reactions, especially
severe reactions to platelets.
HIT :Avoid plt transfusions if not
actively bleeding
spectrin-ankyrin binding
deficiency : (spherocytosis)
response to iron treatment
reticulocyte count will begin to
increase after one wk
vitamin K deficiency → ↓ factors
II, VII, IX, X (and protein C, S)
liver disease → ↓ all factors
except VIII
HYPERCOAGULABLE STATES Asx
w/ inherited risk factor: consider
prophylactic anticoag. if
develops acquired risk factor
Patients with SCD classically get
osteomyelitis with Salmonella.
They are also at ↑ risk of
avascular necrosis of the hip.
The telltale sign of porphyria
is pink urine.

The classic case of porphyria

Hypopigmentation, hypetrophy
involves a college student who
of radial nerve : Leprosy
consumes alcohol and
barbiturates at a party, and then
has an acute episode of
Ever smoker = 100 sig per life
abdominal pain and brown urine
the next day.

Most common cause of primary

health care visits : coryza
A characteristic sign for AML
type M3 (APL) is the Auer rod.

ITP : Anti-D (Rh) immunoglobulin

and IVIG act as “decoys” so that
The combination of anemia and
WBCs will recognize them
bone pain must always raise
instead of IgG on platelets
suspicion of multiple myeloma.

Patients with Fanconi’s anemia

CML : The Sokal prognostic
may be identified on physical
score, for example, identified
exam by café au lait spots, short
four clinical variables: spleen
stature, and radial/thumb
size, percent blasts, age, and
hypoplasia /aplasia
platelet count >700,000/microL

14
Sickle cell anemia false positive
test because: HIGH PROTEIN
LEVEL
INFX :
Syphilis Treatment
• for 1º, 2º, early latent:
benzathine penicillin G 2.4
million units IM x 1
• for 3º, late latent: benzathine
penicillin G 2.4 million units IM
weekly x 3
• if allergic to penicillin:
doxycycline 100 mg PO bid x 14 d
The pneumococcal conjugate
vaccine is currently
recommended for all children
under 5 years of age.
Polysaccharide pneumococcal
vaccine that is currently
recommended for use in
1) All adults who are older than
65 years of age
2) Persons who are 2 years and
older and at high risk for disease
(e.g., sickle cell disease, HIV
infection, or other
immunocompromising
conditions)
15
Which of the following NOT
transmitted by mosquitoes :
Relapsing fever
Malaria :
P. vivax, P. ovale: chloroquine
(and primaquine to eradicate
liver forms
P. falciparum: most areas of the
world show chloroquine
resistance : artemisinin
combination therapy (e.g.
artesunate + doxycycline or
clindamycin or
atovaquone/proguanil)
Endotoxins are bacterial wall
lipopolysaccharides that are
responsible for many of the
cellular and hemodynamic
effects of septic shock .
Cat bite predispose to skin
infection by witch organism‫؟‬
Pasteurella multocida
high morbidity associated with
clenched fist injuries, “fight
bites” .Relaxation of the fist may
carry organisms into the deep
compartments and the deep
tendon spaces of the hand.
Tetanus Prone Wounds :
wounds >6 h old, >1 cm deep,
puncture wounds, avulsions,
wounds resulting from missiles,
crush wounds, burns, frostbite,
wounds contaminated with dirt,
feces ,soil, or saliva.
intravascular catheter infections
: The skin flora is probably the
most important source of
intravascular catheter infection.
Thus, coagulase-negative
staphylococci and
Staphylococcus aureus are the
most common isolates from
nosocomial bloodstream
infections. Gram-negative
predominate in patients with
hematologic and non-
hematologic malignancies.
We suggest streptomycin or
gentamicin for treatment of
plague
we do not routinely recommend
chemoprophylaxis against
traveler‘s diarrhea
16
low hg low platelet with normal
reticulocyte which Antibiotic
cause this? Cloroampincoal
CMV chorioretinitis is the most
common manifestation of CMV
disease in HIV-infected patients
The type of Hepatitis B vaccine is
; Recombinant
mastoiditis :IV VANCO
nodule by ct found calcium and
fat : hamartoma
droplet/contact precautions
(private room, gown, gloves, eye
protection, fluid-resistant mask)
(e.g. used for influenza,
meningitis due to Neisseria
meningitidis)
airborne precautions (negative-
pressure private room with door
closed, ft-tested N95 respirator)
(e.g. used for TB, measles, VZV)
Giardia no hematochezia (no
invasion into intestinal wall)
human bites (pathogens: the percentage of complete
Eikenella corrodens, S. aureus, S. recovery from HCV? 80%
viridans, oral anaerobes)

atypical chest radiograph is a

We recommend acyclovir for the
reflection of immunosuppression
treatment of varicella in the
, rather than primary TB , HIV
following children who are at
status is associated with
increased risk of complicated
lymphadenopathy, effusion,
disease: those who are 12 years
lower lung zone involvement,
of age or older, those with
and miliary pattern; cavitary
chronic cutaneous or pulmonary
lesions are less often seen.
disorders, or in those individuals
Patients with advanced HIV may
taking steroid or salicylate
have a normal CXR.
therapy

Primary syphilis usually begins

At least three gram-positive
with a single, painless, well-
sporeforming rods are known to
demarcated ulcer (chancre) with
cause bacterial food poisoning:
a clean base and indurated
Clostridium perfringens (welchii),
border.
C. botulinum, and Bacillus cereus

polished rice is deficient in

Catheter-associated UTI: yeast
thiamine (B1)
(30%), E. coli (25%), other GNR,
enterococci

Certain medical conditions (eg,

chronic disorders,
honeymoon cystitis. Sexual
immunocompromising
activity increases the risk of s.
conditions, CSF leaks, cochlear
Saprophyticus uti because
implants) increase the risk of
bacteria are displaced from the
pneumococcal disease
normal flora of the vagina and
perineum into the urethra.

17
Cytomegalovirus (CMV) retinitis
is the most common serious
ocular complication of AIDS
Amphotericin.B the only azole
metabolized in the kidney
cervical infection can enter to
superior-mediastinum through:
Retro-pharyngeal space
Patients with 2º or 3º syphilis
treated with penicillin may
experience a Jarisch Herxheimer
reaction. Lysis of organisms
release pyrogens thought to
cause fever, chills , myalgia , flu-
like symptoms may last to 24 h
the most common etiology for
aseptic meningitis with periphral
facial nerve palsy was Borrelia
burgdorferi
development of sporotrichosis
include landscaping, rose
gardening, and other activities
that involve inoculation of soil
through the skin.
18
deficiency of C3 is associated
with increased susceptibility to
meningococcal disease
Transmitted of parasite by
ingestion of undercooked beef?
Taenia saginata ‫شرٌطٌة عزالء‬
Struvite stones are invariably
associated with urinary tract
infections. Specifically, the
presence of urease-producing
bacteria, including Ureaplasma
urealyticum and Proteus species
(most common),
fever with spot in molar tooth?
Measles
The majority of infections in
patients with Chronic
granulomatous disease are due
to five organisms:
Staphylococcus aureus,
Burkholderia (Pseudomonas)
cepacia complex, Serratia
marcescens, Nocardia, and
Aspergillus
Increase of which of the
following prevalence cause
reactivation of TB in developed
countries? HIV
Immunocompromised hosts and
patients in intensive care units
are at the highest risk of
candidemia , the most common
antifungal agents used currently
for the treatment of candidemia
are fluconazole and the
echinocandins.
Cutaneous is the most common
form of leishmaniasis affecting
humans caused by (e.g., L. major
and L.tropica) - Visceral
leishmaniasis also known as kala-
azar caused by (e.g., L. infantum
and L. donovani)
Botulism : Pattern of paresis
often starts with gi symptoms
(constipation, early satiety), then
paresis of extraocular muscles,
then dysphagia, then
limbs/respiratory involvement;
all associated with dry mouth.
Acute Bloody Diarrhea: CHESS
19
Campylobacter
Hemorrhagic E. coli (e.g.
O157:H7)
Entamoeba histolytica
Salmonella , Shigella
avoid abx if suspect E. coli
O157:H7(Enterohemorrhagic) as
may ↑ risk of HUS
best treatment for traveler's
diarrhea? ciprofloxacin
The best way to prevent
brucellosis infection is to be sure
you do not consume:
undercooked meat
,unpasteurized dairy products
Chlamydia & gonorrhea are the
most common causative
organisms causing PID.
Ceftriaxone is used for
gonorrhea Tx
Recurrent UTI
Behavioral risk factors:
Spermicide use during the past
year
Having a new sex partner during Fluorescent treponemal
the past year antibody absorption (FTA-ABS)

Having a first UTI at or before 15

years of age
Having a mother with a history
of UTIs
Pelvic anatomy: Pelvic anatomy
may predispose to recurrent UTI
in some women,
There are two major classes of
antivirals available for the
treatment and prevention of
influenza, the M2 inhibitors and
the neuraminidase inhibitors
(NAIs).

Postmenopausal women
latent herpes virus stay?
Urinary incontinence
Sensory neuron
Presence of a cystocele

Post Voiding residual urine

No associations were found
between a history of recurrent
UTI and pre- and postcoital
voiding patterns, frequency of
urination, delayed voiding habits,
wiping patterns, douching, use
of hot tubs, frequent use of
pantyhose or tights, or body
mass index.
Agents with activity against
visceral leishmaniasis (VL)
include amphotericin B(‫ )خط أول‬,
paromomycin (a parenteral
aminoglycoside) and miltefosine
Fluoroquinones work through
inhibition of DNA
Oral penicillin V is the agent of
choice for treatment of GAS
pharyngitis - The preferred
antibiotic approach for
secondary prevention of
recurrent rheumatic fever is
administration of long acting
benzathine penicillin G (Bicillin
L-A) intramuscularly every four
week - Sulfadiazine or
sulfisoxazole is appropriate for
patients allergic to penicillin

The most specific/ best

diagnostic test for syphilis?.
20
Rubella STAR complex (sore
throat, arthritis, rash) and
Positive serology for rubella IgM
Empiric antibiotic therapy for
CRBSI in health care settings
should include activity against
methicillin resistant S. aureus;
vancomycin is a reasonable
agent. Patients with neutropenia
or sepsis should also receive
empiric antibiotic therapy for
gram negative organisms
CLOSTRIDIUM DIFFICILE- Stool
EIA: detects toxin B and/or A (1–
2% strains make A); fast (2–6 h);
most often used -We favor use
of PCR for diagnosis of C. difficile
on a single stool sample
Oxidase + : pseudomonas –
V.Cholerae –n.neisseria –
Campylobacter
Urease + : proteus – ureaplasma
Coxsackie virus A: affects skin
and mucous membranes. •
Causes herpangina and HFMD.
21
Coxsackie virus B:• Usually
affects the heart, lungs, pancreas
and liver. • Causes Bornholm
disease, hepatitis, myocarditis
and pericarditi
An artificial fever may be
suspected if the pulse rate is
much less than expected for the
degree of fever noted
Toxoplasma gondii : no
treatment if: immunocompetent,
not pregnant, no severe organ
damage
• pregnancy: spiramycin
• HIV: pyrimethamine +
sulfadiazine
Acute infection may be inferred
through serologic testing, which
is the most common diagnostic
method that is used. A positive
IgM serologic test in the
appropriate clinical context
Painless genital ulcer
Syphilis(primary)
Lymphogranuloma venereum
Granuloma inguinal
 Pyelonephritis is the most
common serious medical
The Centor criteria for
complication of pregnancy
identifying streptococcal
pharyngitis are fever, tonsillar
exudate, tender anterior cervical
About one-third of patients with
lymphadenopathy, and lack of
infectious mononucleosis have
cough (three of four are
coexisting streptococcal
required.
pharyngitis that requires
treatment.

Always consider occult sinusitis

in febrile ICU patients.
Rocky Mountain spotted fever
starts on the wrists and ankles
and then spreads centrally
Although other medications may
be used, rifampin is the
frequently tested prophylaxis of
CSF Gram Stain Findings
choice for close contacts of
patients with meningococcal • S. pneumoniae – GP
meningitis diplococcic

• N. meningitidis – GN diplococci

The presence of RBCs in CSF • H. influenzae – Pleiomorphic

without a history of trauma GN coccobacilli
indicates HSV encephalitis.
• L. monocytogenes – GP rod

MMR is the only live vaccine that

Rabies : 3 general principles:
should be given to HIV patients.
wound care: clean wound
Suspect P. jiroveci pneumonia in
promptly and thoroughly with
any HIV patient who presents
soap and running water
with nonproductive cough and
dyspnea passive immunization: HRIg
infltrated into wound site, with

22
any remaining volume
administered IM in anatomical
site distant from vaccine
administration
active immunization: inactivated
rabies virus vaccine (series of
shots post-exposure)
Fever in a traveler from a malaria
zone is malaria until proven
otherwise; consider
hospitalization and empiric Rx
In general, symptomatic primary
HSV infections (ie, initial HSV
infection in a seronegative host)
are associated with an increased
risk of constitutional symptoms,
a longer duration of lesions, and
prolonged viral shedding
compared with recurrent disease
50 : ‫الكلٌنداماٌسٌن – ماكرولٌد‬s‫بروتٌن‬
30 ‫ بروتٌن‬: ‫تتراسٌكلٌن‬+ ‫امٌنوغلٌكوزٌد‬s‫ا‬
‫ اصطناع ال‬: ‫الكٌنولونات‬DNA
: ‫ الرٌفا‬mRNA
‫ الغشاء الخلوي‬: ‫البولً مٌكسٌن‬
‫ الجدار الخلوي‬: ‫سٌفالوسبورٌن‬+‫بنسلٌن‬
A previously vaccinated person
who has had a potential rabies
23
exposure should receive two
intramuscular doses of vaccine;
the first dose should be given on
day 0, as soon after exposure as
possible, and the other three
days later-It is not necessary to
also give RIG
Nephro :
Adult polycystic kidney disease is
inherited as: Autosomal
dominant - chromosome 16
Prevention of UTIs
• Maintain good hydration
(especially with cranberry juice)
• Wipe from front to back to
avoid contamination of the
urethra with feces from the
rectum
• Avoid feminine hygiene sprays
and scented douches
• Empty bladder immediately
before and after intercourse
Recurrent/Chronic Cystitis
lifestyle changes (limit caffeine
intake, increase fluid/H2O
intake)
• ABx: continuous vs. post-coital
• post-menopausal women:
consider topical or systemic
estrogen therapy
• no treatment for asymptomatic
bacteriuria except in pregnant
women or patients undergoing
urinary tract instrumentation
Estimating Urine Osmolality
Last 2 digits of the specifc gravity
x 30= urine osmolality
approximately
The most common cause of
chronic renal failure: DM
effects of adenosine are
antagonized by methylxanthines
such as caffeine and
theophylline. In the presence of
these methylxanthines, larger
doses of adenosine may be
required or adenosine may not
be effective
Prostatitis
chronic: similar to cystitis except
symptoms of obstruction
(hesitancy, weak stream)
24
acute: perineal pain, fever,
tenderness on prostate exam
‫ أٌام فقط‬3 ‫عالج االنتان البولً المختلط‬
‫ اٌام‬5 ‫النترو ٌحتاج‬
Legionella species are aerobic,
gram-negative bacilli that do not
grow on routine bacteriologic
media
acute rejection: graf site
tenderness, rise in Cr, oliguria, ±
fever, although symptoms are
uncommon
bladder cancer. What’s the likely
causative agent?
Schistosoma haematobium
BPH Surgery Absolute Indication
• Renal failure with obstructive
uropathy
• Refractory urinary retention
Epididymitis is the most
common cause of scrotal pain in
adults in the outpatient setting.
More advanced cases often
present with testicular swelling
and pain (epididymo-orchitis).

Radiolucent IVP: uric acid, blood
clots, sloughed papillae
UTI >14 day, most probably
cause pyelonephritis: 50%
The most likely cause of gross
hematuria :The causes vary with
age with the most common
being inflammation or infection
of the prostate or bladder stones
, and, in older patients, a kidney
or urinary tract malignancy or
benign prostatic hyperplasia
Urinary calculi are often
idiopathic, 90% are radiopaque
and 75% are calcium oxalate
stones
It is generally felt that the testis
suffers irreversible damage after
12 hours of ischemia due to
testicular torsion
Cl : 96 – 106 mEQ
IgA nephropathy : This is the
most common cause of
glomerular hematuria
ATN
Heme pigment -Rhabdomyolysis,
intravascular hemolysis
Crystals - Tumor lysis syndrome,
seizures, ethylene glycol
poisoning, megadose vitamin C,
acyclovir, indinavir,methotrexate
Drugs - Aminoglycosides, lithium,
amphotericin B, pentamidine,
cisplatin, ifosfamide,
radiocontrast agents

History, physical examination,

and laboratory tests can provide
Increased levels of
reasonable certainty of the
mineralocorticoid secretion lead
diagnosis. Urinalysis should be
to increased tubular
done and serum creatinine and
reabsorption of Na+ and HCO3−,
PSA should be measured in all
and an excessive loss of Cl− in
patients with lower urinary tract
the urine
symptoms (BPH)

Epididymitis Pain may ↓ with

scrotal elevation (+Prehn’s sign).
25
Testicular torsion : scrotal pain
that remains the same or ↑ with
Uric acid in body how the body
scrotal elevation (- Prehn’s sign)
removed by:: increase execration
of uric acid in urine

group A strept pharyngitis : Early Interstitial Cystitis Treatment

treatment decrease incidence of
• first-line: patient
post strept GN
empowerment (diet, lifestyle,
stress management), pain
management
screening for prostatic cancer

• initial screening should include

both serum PSA and DRE with severe hypokalemia: P-R
prolongation, wide QRS,
• all men should be offered
arrhythmias; increases risk of
screening at age 50 if >10 yr life-
digitalis toxicity
expectanc

Several electrolyte
Urinary calculi are often
abnormalities, including
idiopathic, 90% are radiopaque
hypokalemia, hypomagnesemia,
and 75% are calcium oxalate
and hypercalcemia, increase
stones - stones <5 mm especially
patient susceptibility to the toxic
likely to pass spontaneously
effects of digoxin

Once proteinuria is detected,

Pt on diuretic develop palpation,
renal function gradually
which electrolyte lead to this: K
deteriorates over 10-15 years

There is no specific therapy to

Premature ejaculation (PE) is the
treat PSGN. Management is
most common sexual
supportive
dysfunction in men younger than
40 years

26
Biochemical properties are
normally important in making
bacterial survival difficult in
urine: acid pH, high urea
content, and high osmolality
(sensorineural hearingloss)
-alport syndrome
Renal tubular acidoses (RTAs)
• Proximal (Type II): ↓ proximal
reabsorption of HCO3
1° (Fanconi’s syndrome = ↓
proximal reabsorption of HCO3,
PO4, glc, amino acids)
Treatment : proximal
RTA(including Fanconi's
syndrome)1st line : sodium
alkaliand/or potassium
containing alkali solution
-adjunct potassium
supplementation
-Adjunct hydrochlorothiazide
IgA nephropathy;
Asymptomatic recurrent
hematuria/mild proteinuria is
common. This is the most
common cause of glomerular
hematuria. Gross hematuria
27
after an upper respiratory
infection (or exercise) is
common.
‫فرط المغنٌزٌوم ٌسبب شلل و ضعف‬
‫منعكسات و حصار قلب‬
‫نقص المغنٌزٌوم ٌسبب ال نظمٌات و هبوط‬
‫ضغط و هٌاج و اختالج‬
The glomerular capillary wall,
consists of the following three
layers:
●Fenestrated capillary
endothelium
●Glomerular basement
membrane (GBM)
●Podocytes (or epithelial cells)
The long-term morbidity in
patients with HSP (IgAV) is a
result of renal disease.
The string-of-beads appearance
is considered pathognomonic for
medial fibromuscular dysplasia
on diagnostic angiography
Intravenous hydration, mesna,
and Amifostine have
demonstrated efficacy in treating
hemorrhagic cystitis in patients
receiving chemotherapy
hyperaldosteronism (either 1° or
2°) → distal Na reabsorption in
exchange for K+ and H+
excretion (and consequent HCO3
retention)
Saline-resistant metabolic
alkalosis (urine chloride >20
mEq/L) characterized by ECF
expansion and hypertension
(due to increased
mineralocorticoids)
What dreaded complication can
arise from treating hyponatremia
too rapidly ? Central pontine
myelinolysis
Alcoholics are the most common
patient population with
hypomagnesemia
28
Aspirin (salicylate) overdose can
cause both a metabolic acidosis
and a respiratory alkalosis.
A VCUG should be obtained in all
boys presenting with their first
UTI , girls < 3 years of age with
their first UTI or < 5 years of age
with febrile UTI, and older girls
with pyelonephritis or recurrent
UTIs.
Bringing the testes into the
scrotum does not ↓ the risk of
testicular cancer.
An annual DRE after age 50 is the
recommended screening method
for prostate cancer
‫نقص المغنزٌوم == اسهال مزمن‬
Gross, painless hematuria in
adults is bladder cancer until
proven otherwise
Evaluate the ureters and kidneys
(ie, upper tract) after lower tract
injury is excluded .Suspect upper
tract injury and obtain an IV
contrast enhanced CT scan (or
Positive family history is the
IVP )in patients with gross
largest independent risk factor
hematuria, microscopic
for CD and UC
hematuria (≥3 to 5 RBCs/HPF)
associated with shock, or injuries
sustained from rapid
Celiac Disease HLA DQ2/DQ8
deceleration.
hereditary chronic pancreatitis :
autosomal dominant
GASTRO : oncogene for pancreaticca ? Ki-
Ras
Drain cleanser is a sulphuric acid
and its ingestion cause GI Antacid causes constipation?
perforation and ARDS so no use Aluminum hydroxide
of gastric lavage

Rota confirmatory diagnosis?

Sacroiliitis and ankylosing
spondylitis are associated with
inflammatory bowel disease
independent of disease activity
PARENTERAL IRON THERAPY
Indications :
Excessive continuing blood loss -
IBD-CKD-Use in cancer patients
Stool antigen
Because of the tendency of
Whipple disease to relapse on
short courses of antibiotics (2 wk
to several mo), most authorities
suggest a prolonged course (as
long as 1 y)

What is maximum normal 2 h

postprandial blood glucose 140=
Primary biliary cirrhosis
7.8 mmol/L
pathophysiology: intrahepatic - T
lymphocyte mediated attack on
small intralobular duct

29
Preventable cause of invasion of the intestinal
gastroenteritis by vaccine? mucosa, regional lymph node
Rotavirus and bacteremia: Salmonella

Initial investigation in small Benign tumors of stomach

bowel obstruction :Erect & represent almost : 7 %
supine abdominal X- ray :
stepladder pattern
endoscopy shows loss of rugal
folds, biopsy shows infiltration of
indication of surgery in Crohn’s B lymphocytes, treated with
disease: antibiotic, what is the cause?
H.pylor
Failure of medical therapy
Obstruction , fistula, abscess or
Hemorrhage  Growth
Criglernajjar syndrome 1: this
Retardation (in the pediatric
can't survive adult life. Only type
population)  Perforation ,
II survive
Carcinoma & extraintestinal
manifestations

most common cause of chronic

diarrhea : Irritable bowel
Organophosphate poisoning
syndrome
 cause the inhibition of
acetylcholinesterase leading to
the accumulation of ‫التهاب الرتوج == امساك‬
acetylcholine in the body which
cause Salivation, Lacrimation,
Urination, Defecation, malignant potential: villous >
Gastrointestinal motility, Emesis, tubulovillous > tubular
miosis

Celiac disease : most severe in

the duodenum and proximal

30
jejunum and less severe, or
absent, in the ileum.
Ulcer-related pain generally
occurs 2-3 hours after meals and
often awakens the patient at
PUD : relieved with food (DU) or
night
worsened by food (GU)

PPSV23 is recommended for

recommendations for patients
adults and children ≥2 years who
with severe liver disease include:
do not have a functional spleen
 Large amounts of carbohydrate
foods. Moderate intake of fat
HBV is the commonest type in
 About 1 gram of protein per
KSA
kilogram of body weight..
Vitamin supplements, especially
B-complex vitamins. Reduce
What gene is related to Celiac
salt you intake
Disease? HLA-DQ2 - HLA-DQ8
(chromosome 6)

Test for H. pylori Stool antigen or

EGD + rapid urease test now dx
Liver biopsy taken at level of
tests of choice
intercostal space: Seventh

•Esophageal SCC:
First sign of portal HTN? Ascites
underlying esophageal disease
such as strictures, diverticula,
achalasia more common in Urea breath testing performed at
patients from Asia least four weeks after treatment
has been promoted as the test of
• adenocarcinoma: Barrett’s
choice to confirm eradication of
esophagus (most important),
infection
smoking, obesity (increased
reflux), GERD

31
Zone 3 is located around central
veins, where oxygenation is
poor. >>most susceptible to
hypoxic in-jury
Misoprostol can help patients
with PUD who require NSAID
therapy (e.g., for arthritis).
The leading cause of SBO in
children is hernias. The leading
cause of SBO in adult is
adhesions
Diverticulosis is the most
common cause of acute lower GI
bleeding in patients > 40 years of
age
association between colon
cancer and Streptococcus bovis
bacteremia.
Iron deficiency anemia in an
elderly male is colorectal cancer
until proven otherwise
to sacrifice of the inferior
mesenteric artery
Pigmented gallstones result from
hemolysis (black) or infection
(brown)
Most gallstones are
precipitations of cholesterol and
are not radiopaque
nonvisualization of the
gallbladder on HIDA scan
suggests acute cholecystitis.
Noncirrhotic causes of portal
hypertension include right heart
failure, splenic vein thrombosis,
and schistosomiasis
80% of patients with HCV
infection will develop chronic
hepatitis
all clotting factors except factor
VIII are produced by the liver

Ischemic colitis is a known

complication of AAA repair due

32
Identify key organisms causing NEURO :
diarrhea:
Seizure CAUSES
■ Most common organism :
Campylobacter Alcohol & drug withdrawal

■ Recent antibiotic use: Drug intoxication

Clostridium difficile
Hyponatremia, Hypernatremia
■ Camping : Giardia
Hypomagnesium
■ Traveler’s diarrhea :ETEC
Hypocalcemia
■ Church picnics/mayonnaise :S.
Hypoglycemia
aureus
Nonketotic hyperglycemia
■ Uncooked hamburgers :E. coli
O157:H7 Uremia

■ Fried rice :Bacillus cereus Hypoxia

■ Poultry/eggs :Salmonella Hyperthyroidism

■ Raw seafood : Vibrio, HAV Dialysis disequilibrium syndrome

■ Pseudoappendicitis :Yersinia Porphyria

Hernia with highest risk of Treatment of opioid toxicity :

incarceration—Femoral hernia Naloxone

Most common presentation of The commonest initial

acutegastritis: Melena manifestation of increased ICP in
patient after head trauma is
Change in level of consciousness

The two most common types of

biofeedback for migraines are

33
thermal biofeedback and MRI findings in AD include both
electromyographic biofeedback generalized and focal atrophy, as
well as white matter lesions

Parkinsonism what is the most

common presenting symptom of reduce the risk of post herpetic
this disease : Tremors neuralgia: valacyclovir only

CT brain for dementia : including Restless leg syndrome Treatment

factors such as young age (<60), : Dopamine agonists “Ropinirole,
focal signs, short duration of Pramipexole or gabapentin
symptoms (less than two years), enacarbil” as first line drugs
After head trauma

penis numbness after sitting for

Side effects of Levodopa long time: pudendal nerve
involuntary movements known entrapment
as dyskinesia, abnormal cramps
and postures of the extremities
and trunk known as dystonia ‫الم مثلث التوائم‬

first line: carbamazepine or

oxcarbazepine• second line:
Bell's palsy Spontaneous
baclofen or lamotrigine
remission should begin within 3
wk of onset

Most women (60 to 70 percent)

with a history of migraine report
Brain cell death in Alzheimer
improvement over the course of
disease : Temporal lobe
pregnancy,

First sign of increase intracranial

Tarsal tunnel syndrome refers to
pressure: HTN
posterior tibial nerve

34
compression in the region of the clinical presentation of common
ankles peroneal neuropathy at the
fibular neck is acute foot drop

The initial criteria for CT scan

some antiepileptic drugs are
diagnosis of Alzheimer disease
glutamate receptor antagonists‖
includes diffuse cerebral atrophy
works specifically on glutamate
with enlargement of the cortical
receptors
sulci and increased size of the
ventricles.

Least one cause tardive

dyskinesia(‫)من مضادات الذهان‬:
The treatment for mild to
clonazpine
moderate alzheimer‘s disease is
central cholinesterase inhibition.
We chose rivastagmine because
What is the most accurate test
it crosses the blood-brain barrier
for carpal tunnel syndrome:
while neostigmine doesn‘t
Durkan's carpal test

before you say he has dementia,

Neurofibromatosis gene 1
you should exclude:
located in: Chromosome 17
Hypothyroidism and vitB12
q22:11
deficiency

parkinson location (damage) in

LP :
the brain Substantia nigra
● Skin

● Fascia and SC fat

Risperidone is the best studied
of the atypical antipsychotics for ● Supraspinous ligament
psychosis and behavioral
● Interspinous ligament
disturbances associated with
dementia ● Ligamentum flavum

35
● Epidural space and fat foot plantar flexion (Tibial.n) :L5-
(epidural anesthesia needle S1
stopshere)

● Dura
drop foot, loss of sensation in 1st
brain death certification includes & 2nd metatarsal joints= Deep
Absent corneal, oculocephalic Peroneal ( ‫السطحً مسؤول عن حس‬
(doll's eye), cough and gag ‫)بقٌة االصابع‬
reflexes

the most common brain tumors

which of this drug cause seizure? are Glioma ( Astrocytomas,
Isoniazid Ependymomas, Glioblast
,Medulloblastoma - ‫ػند االطفام هى‬
‫االشٍغ‬-)
meninges after swimming in a
Meningiomas are the most
river; causative organism
common benign intracranial
amobeic meningitis
tumors
(naegleriafowleri) ‫لر َّيٌ ُةة ال َّيدجا ِرجٌَّية‬ ‫ال ِّنن ْغ‬
‫ٌغ ِر‬

Sensation of parotid by
auriculotemporal

Autonomic innervation
(salivation) by glossopharyngeal

Damage caused to wernicke's

area results in receptive, fluent
aphasia

foot dorsal flexion (PERONEAL.N

‫ )شظىي‬:L4-L5

36

ENDO :
Investigations thyroid mass
• thyroid ultrasound to
determine size and
characteristics (cystic vs. solid vs.
mixed)
• thyroid function tests (TSH)
• thyroid scan only if TSH is low
to determine if nodule is hot (i.e.
signifcant 131I uptake into
nodule) which signifes very low
malignant potential
• FNA for all nodules >1-1.5 cm,
if not a hot nodule
The amount of estrogen in
hormonal contraceptives
generally does not cause
hyperprolactinemia.
Serum prolactin values between
20 and 200 ng/mL (20 to 200
mcg/L SI units) can be found in
patients with any cause of
hyperprolactinemia. On the
other hand, serum prolactin
values above 200 ng/mL usually
indicate the presence of a
lactotroph adenoma
37
For most patients with papillary
or follicular cancer, we suggest
total thyroidectomy if the
primary tumor is 1.0 cm in
diameter or greater, there is
extrathyroidal extension of
tumor, metastases, or if there is
a history of exposure to ionizing
radiation of the head and neck
We recommend therapeutic
regional neck dissection in
patients with papillary cancer
only if there is clinical evidence
(on exam or preoperative
ultrasound) of nodal
involvement
Healthy patient with family
history of DM type 2, the most
factors that increase chance of
DM are: HTN and Obesity
diabetic retinopathy, most
related factors: HTN and obesity
In patients with risk factors for
thyroid cancer guidelines
suggest that the nodule
threshold size for FNA biopsy is
smaller. The ATA guidelines
recommend ultrasound-guided
FNA biopsy for all nodules >5
mm in high-risk patients
The optimal therapy of patients
with autonomous nodules is
controversial. Those in whom
the nodule causes
hyperthyroidism should be
treated with radioiodine or
surgery, possibly after a period
of antithyroid drug therapy
The thyroid gland primarily
secretes T4, whereas the
majority of T3 production, the
bioactive form of thyroid
hormone, occurs extrathyroidally
if HbA1c >9.0%, initiate
pharmacologic therapy
immediately and consider
combination oral therapy or
insulin immediately
We suggest using PTU rather
than methimazole in the first
and switching to methimazole at
the start of the second trimester
38
Features associated w/ ↑ risk of
malignancy: age <20 or >70 y,‫ئكر‬
, h/o neck XRT, hard and
immobile mass, cold nodule on
RAIU, large size, worrisome U/S
findings (hypoechoic, solid,
irregular borders,
microcalcifications , central
blood flow),cervical LAN
Features associated w/ benign
dx: FHx of autoimmune thyroid
disease or goiter, presence of
hypothyroidism or
hyperthyroidism, nodule
tenderness , multiple nodules
20-40% of persons with Type 1
DM (after 5-10 yr) and 4-20%
with Type 2 DM have progressive
nephropathy
The dawn phenomenon: Early
morning hyperglycemia due to
increase secretion of GH.
Increasing the dose of the night
insulin treats it
The Somogyi effect: rebound
hyperglycemia from late night or
early morning hypoglycemia.
Decreasing the dose of the night
insulin treats it
dipstick detect acetoacetate but
not beta-hydroxybutyrate
LFT should be carried out before
and within 4-6 weeks of starting
statin therapy , treatment should
be discontinued if serum
transaminase concentrations rise
to, and persist at, 3x normal
range
(GLP)-1 analogue: Exenatide or
Liraglutide causes muscle
weakness
DKA : The most common
precipitating factor is infection,
followed by noncompliance with
insulin
hormone increases body cells
sensitivity and response to
insulin? Leptin
In adults, 80% of Cushing
Syndrome is due to ACTH-
dependent causes and 20% due
to adrenal causes
39
Hürthle cell carcinoma is a
variant of papillary cell
carcinoma.
Fragile X syndrome, also termed
Martin-Bell syndrome, is the
most common cause of inherited
mental retardation
Incretin promotes insulin
secretion, suppresses glucagon,
and slows gastric emptying
adults of any age who are
overweight or obese, and who
have one or more diabetes risk
factor
• Testing should begin at age45
• If test is normal? Repeat it at
least every 3y
Approximately 1/3 of individuals
with Turner syndrome have a
thyroid disorder, usually
hypothyroidism.
Paget’s : inc serum ALP (unless
burnt out), Ca2+ normal or inc ,
PO43- normal - urinary
hydroxyproline inc (indicates
resorption)
treat medically if ALP >3x normal
: bisphosphonates
Prolactinoma Most common
type of pituitary adenoma (up to
40%)
patients with
pheochromocytoma need to
undergo preoperative alpha-
adrenergic blockade; we suggest
phenoxybenzamine as the first
line drug other alpha blocker
medication : ( prazosin ,
terazosin , doxazosin ) after
alpha blocker is given we give
beta blocker but never start beta
blocker before the alpha blocker
Cushing case which skin
manifestation is associated with
it : Telangiectasia
The 2 most common
precipitating DKA are inadequate
insulin therapy and infection
40
Hürthle cell carcinoma is a
variant of papillary cell
carcinoma.
adults of any age who are
overweight or obese, and who
have one or more diabetes risk
factor
• Testing should begin at age45
• If test is normal? Repeat it at
least every 3years
- at least annual monitoring for
the development of diabetes in
those with prediabetes is
suggested
somatomedin C test, also called
an insulin-like growth factor-1
(or IGF-1) test
Magnesium deficiency
contributes to osteoporosis
directly and indirectly by
impacting on the secretion and
the activity of parathyroid
melanocyte-stimulating
hormone (MSH) peptides are
secreted specifically by the
intermediate lobe of the
pituitary gland
Familial hyperkalemic
hypertension (FHHt) syndrome
also known as Gordon syndrome
or pseudohypoaldosteronism
type 2 , is a rare inherited form
of low-renin hypertension
associated with hyperkalemia
and hyperchloremic metabolic
acidosis in patients with a
normal GFR
MISC :
Lymphangitis Most common
cause is S. pyogenes
The early signs and symptoms of
aspirin overdose include
impaired hearing and ringing in
the ears - toxic dose of aspirin is
generally considered greater
than 150 mg per kg
Organophosphorus poisoning
antidote: Atropine
(dystonia) treatment :
Antihistamine and
anticholinergic
41
Silver Sulfadiazine, the toxicity of
this drug can cause ( ‫) للحروق‬
Neutropenia
MUMPS
In children the most common
complication is Meningitis
In ADULT the most common
complication is Orchitis
Normal daily caloric requirement
is 20-40 kCal/kg
Aluminum hydroxide &
magnesium hydroxide inhibits
the intestinal absorption of
Tetracycline
The two main criteria for
diagnosing exertional heat stroke
(EHS) are a core temperature
above 104°F (40°C), measured
immediately following collapse,
and CNS dysfunction
Heparin is an indirect thrombin
inhibitor which complexes with
antithrombin (AT, formerly
known as AT III), converting this
circulating cofactor from a slow
to a rapid inactivator of
thrombin
Labetalol and Carvedilol (block
beta and alpha)
Most serious symptom of CO
poisoning is: Arrhythmia
The most common side effects of
bupropion are insomnia,
agitation, dry mouth, and
headache. A more serious side
effect is seizure
acute acetaminophen
intoxication :
0.5 to 24 hours :Nausea,
vomiting , diaphoresis, pallor,
lethargy, and malaise -
Laboratory are typically normal /
24 to 72 hours Hepatotoxicity
and nephrotoxicity become
evident /72 to 96 hours Liver
enzyme and function
abnormalities peak (enzymes
may be >10,000 IU/L)
42
The minimal toxic dose for an
acute ingestion is 150 mg/kg for
a child or 7.5 to 10 g for an
adult- single ingestions greater
than 250 mg/kg or ingestions of
greater than 12 g in a 24-hour
period
Patients with acute
acetaminophen overdose should
undergo measurement of serum
acetaminophen levels between 4
and 24 hours of ingestion
screen children with a family
history of hypercholesterolemia
or chylomicronemia
men over age 40, women over
age 50 or post-menopausal
• if following risk factors present,
screen at any age:
Sex partners of patients with
chancroid should be examined
and treated if they have had
sexual contact with the patient
within ten days of symptom
presentation [ 30 ]. This
recommendation is not
dependent on the presence of
symptoms or signs of the the treatment of acute visual
disease. loss where intravenous steroids
appear to be better

sharp pain in the index finger

RHEUMATO : increase with using scissors :
mallet finger
SLE : Keratoconjunctivitis sicca,
episcleritis , scleritis, cytoid
bodies (cotton wool exudates on
best way for bone and muscle to
fundoscopy = infarction of nerve
prevent aging process.: Low
cell layer of retina)
resistence excercises with
conditioning

Juvenile Idiopathic Arthritis

NSAIDs and strengthening
Mallet finger injuries are the
exercises. Corticosteroids and
result of a partial or complete
immunosuppressive medications
rupture of the extensor tendon's
second-line agents.
terminal insertion distal to the
distal interphalangeal (DIP) joint.
They are caused by a forced
Psudogout : Deposition of
flexion injury
Calcium Pyrophosphates
Dehydrate crystal, +ve
birefringent, rhomboid shape,
Standard treatment for acute
(CACO3)
hamstring injuries includes
protection, rest, ice,
compression, and elevation
Diet supplement for
(PRICE)
osteoarthritis Ginger

‫االصابات القاطعة فً الساعد األمامً تؤدي‬

Giant-cell arteritis Oral steroids
‫الصابة العصب الناصف و عدم القدرة على‬
are at least as effective as
‫تشكٌل حرف‬o‫بٌن االبهام و السبابة‬
intravenous steroids, except in
43
‫ال اصابة حسية‬
Osteoarthritis :
non-pharmacological therapy
weight loss (minimum 5-10 lb
loss) if overweight
physiotherapy: heat/cold, low
impact exercise programs
occupational therapy: aids,
splints, cane, walker, bracin
Behcet disease is more
commonin? equal in men &
women
anti-topoisomerase anti-Scl-70:
specific but not sensitive ( for
diffuse systemic sclerosis ) anti-
centromere: favours diagnosis of
CREST ( for limited systemic
sclerosis)
gout in patient with comorbid
condition cannot use nsaid or
colchicine use intra articular
steroid injection!
colchicine is effective for the
arthritis of Behçet‘s syndrome
44
Patients at risk for developing
osteoporosis are candidates for
screening. These include (1)
postmenopausal women below
65 years of age with one or more
risk factors besides menopause;
(2) all postmenopausal women
over age 65; (3) postmenopausal
women with a history of
fractures; (4) those who are on
long-term corticosteroid
treatment; and more recently (5)
men over age 70.
most types of EDS are autosomal
dominant
NSAIDs are the primary
medicines used to manage long-
term symptoms of lumbar spinal
stenosis, 2ed line is epidural
steroid injection
Non-nitrogen containing
bisphosphonates (such as
etidronate) are metabolized into
non-functioning ATP analogues
which cause eventual osteoclast
apoptosis
In gout what substance would be
high? elevated 5'-
phosphoribosyl-1'-
pyrophosphate synthetase (PRPP
synthetase) activity.
Gout : Deposition of
Monosodium Urate
Monohydrate, –ve of
birefringent, needle shape
subcromial bursitis : The patient
actively abducts the arm and a
painful arc occurs between 80°
and 120°.
Adhesive capsulitis is associated
with a history of shoulder injury
and restricted active and passive
glenohumeral motion.
Rotator cuff tear :weakness
often present with resisted
abduction and/or external
rotation
The first initial treatment of
osteoarthritis in middle aged
patient is : Muscle strengthening
45
It is recommended that calcium
intake should be 1000 mg/day
for premenopausal women and
1500 mg/day for
postmenopausal women
DEXA SCREEN
All women and men age ≥65 yr
Menopausal women, and men
aged 50-64 yr with clinical risk
factors for fracture
Osteoporosis TREATMENT
In addition to nonpharmacologic
therapy, we recommend that
postmenopausal women with
established osteoporosis (T-
score ≤-2.5) or fragility fracture
(hip or vertebral) be treated with
a pharmacologic agent
For the treatment of high risk
postmenopausal women with T-
scores between -1.0 and -2.5, we
also suggest pharmacologic
therapy
For the treatment of
osteoporosis in postmenopausal
women, we suggest
bisphosphonates as first-line
therapy
Physical therapy is the mainstay
of conservative management of
Lumbar spinal stenosis

Plantar fasciitis :Tenderness

along medial aspect of the base
of the heel - Pain on bottom of
the heel when walking

SERONEGATIVE
SPONDYLOARTHRITIS :Peripheral
arthritis: typically asymmetric,
oligoarticular, large joints, lower
>upper limb

‫بهجت التهاب مفاصل غٌر متناظر غٌر‬

‫مخرب‬

46
OBSTETRICS AND GYN:
Pregnant lady with cardiac
disease : Aim for vaginal
delivery - elective forceps to
shorten the second stage of
labor - Watch closely for
postpartum intravascular
overload
PLACENTA PREVIA . Indications
for delivery include labor, life-
threatening bleeding, fetal
distress, documented fetal lung
maturity, and 36 weeks’ GA.
Deliver by C-section
commonest symptom in the
presentation of abruption
placenta is:Vaginal Bleeding 80%
Ultrasound: Can identify the
gestational sac 5–6 weeks from
the LMP, a fetal pole at six
weeks, and fetal cardiac activity
at 6–7 weeks
Recurrenta Abortion
47
If early in pregnancy, often due
to chromosomal abnormalities. If
later in pregnancy, often due to
hypercoagulable states
Incompetent cervix should be
suspected with a history of
painless dilation of the cervix
and delivery of a normal fetus
between 18 and 32 weeks.
Preeclampsia Risk : factors
nulliparity, African-American
ethnicity, extremes of age (< 20
or > 35), multiple gestation,
molar pregnancy, renal disease
(due to SLE or type 1 DM), a
family history of preeclampsia,
and chronic hypertension
Preeclampsia Conservative
management. Before 37 weeks’
gestation as long as mother and
fetus are stable, mild
preeclampsia is managed in the
hospital or as outpatient No
antihypertensive agents or
MgSO4 are used - Delivery. At
≥37 weeks’ gestation
Impedance plethysmography
‫ٌستخدم كبدٌل عن الفٌنو غراف و هو‬
‫غٌر غاز لكشف الخثرات الورٌدٌة‬
must do endometrial biopsy in
all women presenting with
postmenopausal bleeding to
exclude endometrial cancer
35< yr: after 1 yr of regular
unprotected intercourse
40-35 •yr: after >6 mo
40> •yr: immediately
OCP decrease the risk of ovarian
cancer, endometrial cancer and
colorectal cancer
• safe: tetanus toxoid,
diphtheria, influenza, hepatitis B
• avoid live vaccines (risk of
placental and fetal infection):
polio, measles/mumps/rubella,
varicella
• contraindicated: rubella, oral
typhoid
Postpartum rubella vaccine for
all non-immune mothers
48
Antepartum haemorrhage
bloody show –most common
etiology in T3
abruptio placentae –most
common pathological etiology in
T3
dating ultrasound best done
between 8-12 wk GA (most
accurate form of pregnancy
dating)
fibroid : Tumors are estrogen
and progesterone sensitive, so
they ↑ in size during pregnancy
and ↓ after menopause.
PID : Cervical motion tenderness
(chandelier sign) and adnexal
tenderness
Administer maternal IM
betamethasone to stimulate
fetal type II pneumocyte
surfactant production if
gestational age is <34 weeks
Depo-Provera (injectable depot during their first year of
medroxyprogesterone acetate) diagnosis and then yearly if

• side effect: decreased bone

density (may be reversible)
What is the most complication
• disadvantage: restoration of after hysterectomy ?
fertility may take up to 1-2 yr. Hemorrhage

BREECH : Up to 75% Most common site of

spontaneously change to vertex gonococcus infection in females :
by week 38 The vulva and vagina are usually
spared

initial evaluation couples for

infertility: Semen analysis Before you start instrumental
delivery

• Clinically adequate pelvic

First step: One-hour 50-g glucose
dimensions • Experienced
challenge test;one hour later
operator • Full cervical dilation •
Values ≥ 140 mg/dL are
Engaged fetal head• Orientation
considered abnormal.
of fetal head is certain.
■ Next step: Confirm with an oral
three-hour (100-g) glucose
tolerance test showing any two Pregnant lady delivered
of the following: fasting > 95 Anencephaly still birth
mg/dL; one hour > 180 mg/ dL; occurrence of neural tube defect
two hours > 155 mg/dL; three in next pregnancy 2%
hours > 140 mg/Dl

postpartum psychosis: onset of

PAP : HIV+ patients should be psychotic symptoms over 24-72
screened every six months h within first month postpartum

49
Weight gain during pregnancy:
Weight gain: 1 – 1.5 kg / month,
11 – 16 kg gain during pregnancy
Prolactin levels in excess of 200
ng/mL are not observed except
in the case of prolactin secreting
pituitary adenoma
(prolactinoma). In 50 % of those
having high prolactin levels there
is radiological changes in the
sella turcica
When the fetal head is engaged,
2/5 or less of the head is
palpable above the pelvic
About 2 percent of pregnant
women develop an intraoral
Pyogenic granuloma in the first
five months of pregnancy
usually regress after childbirth
what is most common cause of
death in the first trimester:
Ectopic pregnancy
Osteoporosis is the single most
important health hazard
associated with menopause
Cardiovascular disease is the
leading cause of death post-
menopause

Regarding postpartum Psychosis:

Which of the following oral
Recurrences are common in
contraceptive drugs cause
subsequent pregnancies
hyperkalemia : Ethinyl estradiol

The first step in the diagnosis of

hyperemesis gravidarum is to
rule out molar pregnancy with
ultrasound +/– β-hCG.
Pregnancy test positive after :
Positive 1 week before the
expected menstruation
transmission of HIV to the baby
1/3 in utero,
1/3 at delivery, 1/3
breastfeeding
Trimethoprim is a folic acid
antagonist associated with NTD.

50
HIV+ mothers should be
counseled not to breastfeed
their infants
Rate (normal = 110–160 bpm) -
Variability (normal beat-to-beat
variability = 6–25 bpm
Undetectable variability:
Indicates severe fetal distress.
The first step in the management
of hyperemesis gravidarum is
vitamin B6 and doxylamine if not
severe or antiemetics and IV
fluids if severe.
Greater than eight, investigate! If
HbA1c is > 8%, look for
congenital abnormalities.
Hyperglycemia in the first
trimester suggests preexistin
diabetes and should be managed
as pregestational diabetes.
Consider early delivery in the
setting of poor maternal glucose
control, preeclampsia,
macrosomia, or evidence of
fetal lung maturity. ■ Cesarean
51
delivery should be considered for
an estimated fetal weight (EFW)
> 4500 g
Anti-D is routinely given to un-
sensitized mothers at 28 and 34
wks of gestation
women with PMS typically
consume more dairy products,
refined sugar, and high-sodium
foods than women without PMS
avoidance of salt, caffeine,
alcohol, chocolate, and/or simple
carbohydrates may improve
symptom
Cord prolapse
increased incidence with
prematurity/PROM, fetal
malpresentation (~50% of cases),
low-lying placenta,
polyhydramnios, multiple
gestation, CPD
Breech presentation %4_3 ‫ٌشكل‬
‫من المجٌئات تمام الحمل‬
Infertility Female causes 58% -
Male causes 25%
Unexplained17%
Risk factors of puerperal
infection Predisposing factors,
such as prolonged and
premature rupture of the
membranes, prolonged (more
than 24 hours) or traumatic
labor, cesarean section, frequent
or unsanitary vaginal
examinations or unsanitary
delivery, retained products of
conception, hemorrhage, and
maternal conditions, such as
anemia or dehilitation from
malnutrition
transdermal estrogen worn for 3
consecutive weeks (changed
every wk) with 1 wk off to allow
for menstruation
as efective as OCP in preventing
pregnancy (>99% with perfect
use)
differentiate between abruption
placenta and spontaneous
abortion? Gush of blood
Surveillance of patient on
hormone replacement therapy
Breast examination. Glucose
tolerance test. Pelvic
examination. Endometrial
52
sampling in the presence of
abnormal bleeding
Age of menopause : Genetics
HRT may actually prevent the
development of heart disease
and reduce the incidence of
heart attack in women between
50 and 59
Ectopic pregnancy
intrauterine sac should be
visible when serum β-hC >1,500
mIU/mL (transvaginal)
>6,000 mIU/mL or 6 wk GA
(transabdominal)
specific finding on transvaginal
U/S is a tubal ring
if a woman with preeclampsia is
not treated prophylactically to
prevent eclampsia; her risk of
seizure is approximately: 1/200
Those with previous normal
pregnancy have about 80% after
their ectopic pregnancy to
achieve intrauterine pregnancy
progesterone level less than 5
ng/mL (15.9 nmol/L) was highly
unlikely to be associated with a
viable pregnancy
Compared with the traditional
drugs used to terminate seizures
(e.g., diazepam, phenytoin )
magnesium sulfate has a lower
risk of recurrent seizures with
non-significant lowering of
perinatal morbidity and mortality
FPG in 1st trimester ↓
FPG in
2nd 3ed trimester ↑
Sex partners of patients with
chancroid should be examined
and treated if they have had
sexual contact with the patient
within ten days of symptom
presentation
We suggest that patients with
proven or suspected chancroid
be treated with one dose of
either azithromycin
53
Pregnancy is the most common
cause of abnormal uterine
bleeding and amenorrhea.
Always check a pregnancy test!
Cone biopsy. If the Pap smear is
worse than the histology
(suggesting the site of abnormal
Pap smear cells was not
biopsied), then a cone biopsy is
performed
Propylthiouracil drug
contraindicated with : Maternal
HTN

Most benign cause of
postmenopausal bleeding:
Atrophic vaginitis
Fibroma/thecoma :
Nonfunctioning
Granulosa-theca cell tumours :
Estrogen-producing
Sertoli-Leydig cell tumour :
Androgen-producing
Suspensor ligament of ovary
contains the ovarian artery,
ovarian vein, ovarian plexus and
lymphatic vessels
Women are prone to vaginal
thrush between puberty and the
menopause because, under the
influence of the hormone
estrogen, the cells lining the
vagina produce a sugar and
yeasts which Candida albicans
are attracted to
‫مانعات الحمل الفموٌة تؤهب لالنتانت‬
‫الفطرٌة بالمبٌضات‬
‫ثلث اول زغابات مشٌمٌة‬
ً‫ ثلث ثان‬amniocentesis ( ‫الجراء‬
‫) صٌغة صبغٌة‬
‫ ثلث اول‬combined test
‫ثلث ثانً فحص رباعً الثالثً مع‬
inhibin A
medical Ectopic Pregnancy
<3.5 cm unruptured ectopic AND
no fetal heart rate AND β-hCG
<5000 AND no hepatic/renal/
hematological disease AND
54
compliance assured AND able
and willing to follow-up
Planned cesarean delivery may
be considered for an EFW > 5000
g in women without diabetes
and for an EFW > 4500 g in
women with diabetes.
To minimize the risk of infection,
do not perform digital vaginal
exams on women with PROM
Trial of breech vaginal delivery:
Attempt only if delivery is
imminent; otherwise
contraindicated
Routine use of episiotomy is not
recommended
For persistent postpartum fever
that is not responsive to broad-
spectrum antibiotics, think septic
pelvic thrombophlebitis
High IgA levels in colostrum
provide passive immunity for the
infant and protect against
enteric bacteria
Contraindications to
breastfeeding include HIV
infection, active HBV and HCV
infection, and use of certain
medications (e.g., tetracycline,
chloramphenicol , warfarin)
Abruptio placentae is the most
common cause of DIC in
pregnancy
post-dates pregnancy (generally
>41 wk) = most common reason
for induction of labor
The L/S ratio is a measure of
fetal lung maturity – less than
2:1 indicates pulmonary
immaturity
CPD diagnosed if adequate
contractions measured by
intrauterine pressure catheter
(IUPC) with no descent/dilatation
for >2 h
55
POSTPARTUM BLUES 85% of
new mothers - onset day 3-10 -
self-limited, should resolve by 2
wk
POSTPARTUM DEPRESSION
defnition: major depression
occurring in a woman within 6
mo of childbirth
POSTPARTUM PSYCHOSIS onset
of psychotic symptoms over 24-
72 h within first month
postpartum
Safe During Breastfeeding
Antidepressants (e.g. sertraline,
fluoxetine, TCAs) Antiepileptics
(e.g. phenytoin, carbamazepine,
valproic acid) Antihistamines
M ENOPAUSE 51y - Premature
menopause” is defined as
ovarian failure and menstrual
cessation before age 40
Absolute Contraindications to
HRT - ABCD
Acute liver disease -
Undiagnosed vaginal Bleeding-
Cancer (breast/uterine)-
Cardiovascular disease - DVT
(thromboembolic disease)
Copper T IUD—used within 7 Fibrocystic Change
days of unprotected sex (99%
The most common of all benign
effective)
breast conditions.

Fibroadenoma
If onset of 2° sexual
The most common breast lesion
characteristics is seen by age
in women < 30 years of age
eight , work up for precocious
puberty by determining bone
age and conducting a GnRH
↑ exposure to estrogen (early
stimulation test to distinguish
menarche, late menopause,
central from peripheral
nulliparity) ↑ the risk of breast
precocious puberty.
cancer

Premenstrual Dysphoric Disorder

treatment with SSRIs (first line)
Normal secretions are as follows:
■ Midcycle estrogen surge:
Clear, elastic, mucoid secretions.
The first step in the workup of a
suspicious mass in
postmenopausal women and in
those > 30 years of age is a
mammogram. For
premenopausal women < 30
years of age, get an ultrasound.

■ Luteal phase/pregnancy: Thick

and white secretions; adhere to
Fibroids : conservative approach
the vaginal wall.
(watch and wait) if: symptoms
absent or minimal

HPV DNA is found in 99.7% of all fbroids <6-8 cm or stable in size

cervical carcinomas. HPV 16 is
the most prevalent type in
squamous cell carcinoma; HPV
18 is most prevalent in
adenocarcinoma.
not submucosal (submucosal
fbroids are more likely to be
symptomatic)
currently pregnant due to
increased risk of bleeding

56
 HIV :the major route of vertical
transmission is contact with
Actinomyces israelii PID cases
infected genital secretions at the
associated with IUD
time of vaginal delivery

breastfeeding is not a
A positive nitrite test indicates
contraindication to MMR vaccine
that the cause of the UTI is a
gram negative organism, most
commonly Escherichia coli
Betamethasone is given if < 34
weeks who are at increased risk
of preterm delivery within the
diagnosis of cervical insufficiency
next seven days.
: one or two prior second
trimester pregnancy losses or
preterm births and cervical
As zidovudine (ZDV) is the only
length <25 mm
agent specifically shown to
reduce perinatal transmission
(HIV )
advise that women with epilepsy
Dizygotic TWINS Identifiable risk taking AEDs can breastfeed they
factors include IVF, newly should exercise caution and
discontinued OCP, race (e.g. closely monitor
certain African regions),
increased maternal age,
geography, family history, or FSH is the diagnostic marker for
ovulation induction. ovarian failure

Vaginal Birth After Cesarean Gram's stain of vaginal discharge

recommended after previous is the gold standard for diagnosis
low transverse incision – of BACTERIAL VAGINITIS
contraindications previous
classical

57
Cigarette smoking during
pregnancy is the most important
modifiable risk factor associated
with adverse pregnancy
outcomes
Aggressive prompt delivery is
indicated for preeclampsia with
severe features at any
gestational age with evidence of
maternal jeopardy or fetal
jeopardy
HSV : Suppressive antiviral
therapy is suggested at 36 weeks
of gestation through delivery for
women with a history of
recurrent genital herpes to
reduce the risk of lesions at the
time of deliver
Hepatocellular adenomas occur
mostly in women of childbearing
age and are strongly associated
with the use of oral
contraceptive pills (OCPs)
magnesium sulphate toxicity >
respiratory depression so
Calcium gluconate Is the
antidote for magnesium sulphate
58
A trial of labor may be offered if
one or two previous LTCDs were
performed, the uterine incision
did not extend into the cervix or
uterine upper segment, and
there is no history of prior
uterine rupture
having HCV-infection is not a
contraindication to breastfeed
For average-risk women aged 30
to 65 years, we suggest either
Pap smear screening every three
years or a combination of Pap
smear and HPV testing every five
years, if both initial tests are
negative
We recommend that women
under age 30 not be screened
with HPV testing ( Grade 1B ).
The combination of HPV and Pap
testing is an option for screening
women age 30 and older
We recommend that women
who have undergone total
hysterectomy (including removal
of the cervix) for indications
unrelated to cervical cancer or
cervical cancer precursors not
undergo screening for cervical
cancer
Women who are infected with DM : Consider early delivery in
HIV (or otherwise the setting of poor maternal
immunocompromised ) should glucose control
undergo cervical cancer
screening twice in the first year
after diagnosis of HIV infection can wait for spontaneous labour
and then annually, if blood glucose well-controlled
and BPP normal - induce by 40
In premenopausal women with
wk
low grade squamous
intraepithelial lesions (LSIL) on
cervical cytology, immediate
Fetal Scalp Blood Sampling :pH
colposcopy is the preferred
≤7.20: indicates fetal acidosis,
method of evaluation
delivery is indicated
In postmenopausal women with
LSIL, options for further
evaluation include: immediate Pregnant females —
colposcopy, repeat cytologic Immunoprophylaxis (ie, VariZIG)
evaluation at 6 and 12 months, is recommended for susceptible
and HPV testing. pregnant females who have
been exposed to varicella
The preferred approach for
infection
evaluation of women age 21 or
older with ASC-US is reflex HPV
testing with triage of women
Drainage of a tubo-
positive for high risk HPV types
ovarian/pelvic abscess is
to colposcopy
appropriate if the mass persists
after antibiotic treatment; the
abscess is > 4–6 cm; or the mass
pudendal nerve blocks are useful
is in the cul-de-sac in the midline
for alleviating pain arising from
and drainable through the vagina
vaginal and perineal distention
during the second stage of labor

lumbosacral plexus afferent Women experiencing first-

during the FIRST stage of labor episode postpartum psychosis

59
appear to have a high risk of
recurrence
Vaginal delivery Placenta
previa—This may be attempted
if the lower placental edge is >2
cm from the internal cervical os
increase during pregnancy?
Tidal Volume + MV
Sheehan's syndrome Eventual
development of a small pituitary
within a sella of normal size,
sometimes read as an "empty
sella" on MRI
Treat PID with FOXY DOXY
(cefoxitin + doxycycline)
Pyelonephritis in pregnancy
Parenteral beta-lactams are the
preferred antibiotics
GTN : contraception required to
avoid pregnancy during entire
follow-up period
60
• serial β-hCGs every week until
negative x 3 (usually takes
several wk), then monthly for 6-
12 mo prior to trying to conceive
again
The most common presenting
symptom of ectopic pregnancy
is: Abdominal pain
HSV : If membranes have been
ruptured >8–12 h, the virus may
already have infected the fetus
and cesarean delivery would be
of no value.
Rh mother delivers an Rh+ infant
at term and does not receive Rh
immune globulin. The probability
of detection of anti-D antibody
during her next pregnancy is
about. 16%
FPG in 1st trimester ↓
FPG in
2nd 3ed trimester ↑
PMS : Proven treatments
include the following:
• Selective serotonin reuptake
inhibitors (SSRIs).
• Yaz (drospirenone/ethinyl
estradiol),
Unproven treatments include
the following
Progesterone therapy
• Diuretics
• Pyridoxine. Vitamin B6
Pregnancy in the final month and
labor may be associated with
increased WBC levels.
Follicular cyst 4-8 cm mass -
Lutein cyst Larger (10-15 cm) and
firmer than follicular cysts
The signs and symptoms of all
histological types of vulvar
malignancy are similar. Most
patients present with a unifocal
vulvar plaque, ulcer, or mass
(fleshy, nodular, or warty) on the
labia majora
positive urine pregnancy test at
home what next to do: Serum
beta HCG
61
Dystocia : during active phase:
>4 h of <0.5 cm/h
• during 2nd phase: >1 h with no
descent during active pushing
The fertilized egg, if it doesn't
reach the uterus in time, will
hatch from the nonadhesive
zona pellucida and implant itself
inside the fallopian tube, thus
causing the pregnancy.
If fetal assessment after 26
weeks of gestation suggests
impending death rather than
demise of one twin of a
monochorionic pair, we suggest
prompt delivery of both twins
rather than expectant
management
As zidovudine (ZDV) is the only
agent specifically shown to
reduce perinatal transmission, it
should be used whenever
possible as part of the highly
active antiretroviral therapy
(HAART) regimen.
All HIV-exposed infants should
receive zidovudine.
Dizygotic twins are the most
common. Identifiable risk factors
include IVF, newly discontinued
OCP, race (e.g. certain African
regions), increased maternal age,
geography, family history, or
ovulation induction.
the steps in staging
cervicalcancer? Colposcopy,
cystoscopy,hysteroscopy
The ureter is the organ most at
risk during hysterectomy
procedures because it lies only
one centimeter lateral to the
cervix
women with epilepsy taking
AEDs can breastfeed
HBV infection not be considered
a contraindication to
breastfeeding of infants who
receive the HBIG and HBV
vaccine as advised
62
Metronidazole(Flagyl):cessation
of breastfeeding for 12 to 24
hours is recommended.
Face presentations Mento
anterior < the
mostcommon(60%)
For vertex-vertex twins, we
suggest vaginal delivery - When
the first twin is not in vertex
presentation, we suggest
cesarean delivery- For vertex-
nonvertex twins, we suggest
breech extraction
if fetal assessment after 26
weeks of gestation suggests
impending death of one twin, we
suggest prompt delivery of MC
twins rather than expectant
management
Levonorgestrel ( ‫بروجسترون‬
)emergency contraception
regimens are more effective and
cause fewer side effects than the
Yuzpe regimen
Sertraline, paroxetine &
nortriptyline are the safest &
most effective in PPD.
Psychological treatments for PPD
are often the treatment of
choice for women, as they are
effective for73 the treatment of
depressive symptoms and do not
involve the risks of exposure to
medications.
conservative ttt fibroid we
perform annual pelvic exams
and, in patients with anemia or
menorrhagia
Endometriosis Gold standard is
laparoscopy
A trial of labor may be offered if
one or two previous LTCDs were
performed, the uterine incision
did not extend into the cervix or
uterine upper segment, and
there is no history of prior
uterine rupture. Adequate
ECV contraindication: fetus with
a hyper extended head
63
It has been determined that
amniotic fluid volume increases
steadily throughout pregnancy
to a maximum of 400–1200 ml at
34–38 weeks
Best way to diagnose
Adenomyosis? Histology section
ofhysterectomy
Meigs syndrome is defined as
the triad of benign ovarian
tumor its benign sex cord-
stromal tumour
(HPV) is the major etiologic
agent of cervical precancer and
cancer.The association between
HPV and cervical neoplasia is so
strong that most other
behavioral, sexual, and
socioeconomic covariables have
been found to be dependent
upon HPV infection and do not
hold up as independent risk
factors.
AUB in women >40 yr requires
an endometrial biopsy to r/o
cancer even if known to have
fibroids.
Women post intercourse
bleeding ?Uterine cervix

Tamoxifen may increase the risk

of Cancer of the uterus

increase risk of dysmenorrhea?

copper IUD

cervical length of 25–30 mm

before 32 weeks gestation seems
to increase the risk of preterm
delivery >>cerclage

64
Pediatrics :
Pyloric Stenosis More common
in first born males
It’s recommended to give
Vitamin K shortly at birth &
Vitamin D at 2 months.
Breast milk jaundice : glucuronyl
transferase inhibitor found in
breast milk onset 7 d of life,
peak at 2-3 wk of life, usually
resolved by 6 wk
Apgar Score
Appearance (colour)
Pulse (heart rate)
Grimace (irritability)
Activity (tone)
Respiration (respiratory effort)
‫تعوٌض الحاجة الٌومٌة من السوائل حسب‬
: ‫الوزن‬
‫كغ‬/‫ مل‬100== 10 ‫ ل‬3.5 ‫من وزن‬
‫ مل لكل‬50 + ‫ مل‬1000== 20-11 ‫من‬
10 ‫كٌلو فوق ال‬
65
‫ مل لكل‬20 +‫ مل‬1500 ‫ نعوض‬20 ‫فوق ال‬
20 ‫كٌلو فوق ال‬
2400 ‫الحد االقصى‬
Intussusception The most
common cause of bowel
obstruction in the first two years
of life (males > females )
An air-contrast barium enema is
both diagnostic and therapeutic
in most cases of intussusception.
Most common chromosomal
abnormality: Down's syndrome
(trisomy 21)
Female spinal length completed
after menarche 24 m
Meckel’s Diverticulum The most
common congenital abnormality
of the small intestine - painless
rectal bleeding.
Meckel’s rule of
‘2s— Most common in children
under 2 y
2times as common in males
Contains 2 types of tissue •Herpes: skin vesicles,
(pancreatic and keratoconjunctivitis, acute
meningoencephalitis
gastric(
•Syphilis: osteochondritis and
2inches long
periostitis; skin rash involving
Found within 2 feet of palms and soles and is
desquamating; snuffles
the ileocecal valve Occurs in 2%
(mucopurulent rhinitis)
of the Population

HSP long term prognosis

Malrotation with Volvulus If the
dependent on severity of
patient is stable, an upper GI is
nephritis
the study of choice and shows an
abnormal location of the
ligament of Treitz
Cellulitis in neonate mostly
caused by ) Group B
streptococcus
Many of the findings of the
TORCH infections are very
similar, so note the most likely
Henosch-Scholein purpura
presentations:
affect: Arteriole, capillary and
•Toxoplasmosis: hydrocephalus venule
with generalized calcifications
and chorioretinitis
most worried side effect of
•Rubella: the classic findings of
steroid inhaler use in child :
cataracts, deafness, and heart
Growth retardation
defects

•CMV: microcephaly with

periventricular calcifications; The first sign of puberty in boys
petechiae with testicular enlargement
thrombocytopenia

66
The vast majority of cases of  If steeple sign: croup
erysipelas are caused by beta-
hemolytic streptococci
Infants absorb 100% of the iron
The most common cellulitis
in breast milk (less than 1 mg/L),
pathogens are beta-hemolytic
but cannot absorb all of the iron
streptococci (groups A, B, C, G,
in infant formulas.
and F) and S. aureus, including
methicillin-resistant strains
(MRSA)
Formula versus cow milk—Fe-
deficiency anemia with early
introduction (<1 yr) of cow’s milk
Marasmus occurrence increases
Do not give cow milk to infants
prior to age 1 , whereas
age <1.
kwashiorkor occurrence
increases after 18 months.

Treatment for primary nocturnal

enuresis should not be
Kawasaki disease
considered until 7 yr of age due
CRASH and BURN to high rate of spontaneous cure

Conjunctivitis

Rash Infantile Colic medications have

no proven benefit, some
Adenopathy
evidence for probiotics - all
Strawberry tongue resolve, most in the first 2-3 mo
of life
Hands and feet (red,

swollen, flaky skin)

Most clavicles fracture in
BURN (fever > 40°C
newborn no need to treatment
for ≥ 5 days) apart from careful handling

If thumbprint sign: Epiglottis

67
Neuroblastoma : most common
cancer occurring in first year of
life - blueberry mufin” skin
nodules
urine smell like burned sugar =
Maple syrup urine syndrome
IgA Nephropathy (Berger
disease) : Most commonly
presents with gross hematuria in
association with upper
respiratory
Acute Poststreptococcal
Glomerulonephritis : 1–2 weeks
after strep pharyngitis or 3–6
weeks after skin infection
(impetigo) infection or
gastrointestinal infection
Contraindications: DTP or DTaP
Absolute:
 Severe reaction following prior
DTP or DTaP
 Immediate Anaphylaxis
 Encephalopathy within 7 days
of Vaccine
68
The most common cause of
failure to thrive in paediatric is
Malnutrition
Full Septic Workup (SWU) –
blood C&S, CBC and differential,
urine R&M, C&S, LP, CXR if
respiratory symptoms, stool C&S
if GI symptoms
varicella vaccine: Two doses
should be administered instead
of a single dose to decrease the
risk of breakthrough varicella.
Adolescents and adults who had
previously received only one
dose of varicella vaccine should
receive a "catch-up" dose.
recommends administration of
VariZIG to newborns : Neonates
whose mothers have signs and
symptoms of varicella around
the time of delivery (five days
before or two days after).
VariZIG should be administered
within 96 hours
In URTI there’s a McIsaac
criterion (weather or not to start
antibiotics): no cough, tender
anterior cervical L.N.,
erythmatous tonsils with
Hypothyroid in young baby
exudates, fever> 38, age 3-14. if
usually due to: Agenesis
0-1 no culture no antibiotics,

2-3 culture if positive antibiotics,

4 start antibiotics. And in this
cause 4 are present..
 Treatment is by penicillin V if
allergic erythrmomycin
Cystic Fibrosis (CF) chromosome
7 - Sweat chloride test > 60
mEq/L for those < 20 years of
age and > 80 mEq/L in adults;
DNA probe test

The amount of Na+ in standard

MMR given at age of 12m and 4-
ORS “oral rehydration solution”
6y
in (WHO) is: 90 meQ

Tonsillitis and enlarged adenoids

Risk factor of sudden death
may occlude the nasopharyngeal
syndrome :
airway especially during sleep,
 smoking, drinking, or drug use this results in obstructive sleep
during pregnancy apnea

 poor prenatal care

 Prematurity or low birth- KERNICTERUS Complications

weight
sensorineural deafness,
 Mothers younger than 20 choreoathetoid cerebral palsy
(CP), gaze palsy, mental
 Smoke exposure following
retardation
birth

 Overheating from excessive

sleepwear and bedding Fibrinogen deplete faster than
platelets
 Stomach sleeping

Crowded living room

69
Vasoconstrictive nasal drops
complication : Rebound
phenomenon
Epididymitis Typically affects
those > 30 years
ALL : most common childhood
tumor
Rabdomyosarcoma : most
common soft tissue tumor
Wilm's tumor: most common
intra- abdominal childhood
tumor
most common parotid gland
tumour in children is: Mixed
tumor (pleomorphic adenoma)
the most common malignant
parotid tumour in children:
Mucoepiptheloild carcinoma
Hirschsprung’s Disease Neonates
present with failure to pass
meconium within 48 hours of
birth, accompanied by bilious
vomiting - explosive discharge of
stool following rectal exam.
70
Pneumatosis intestinalis on plain
films is pathognomonic for
necrotizing enterocolitis in
neonates.
If severe coarctation presents in
infancy, the ductus arteriosus
should be kept open with
prostaglandin E1 (PGE1)
Transposition of the great
vessels is the most common
cyanotic heart disease of
newborns. Tetralogy of Fallot is
the most common cyanotic heart
disease of childhood
Both transposition of the great
vessels and tetralogy of Fallot
are initially treated with PGE1
and are definitively treated with
surgical correction
Diphtheria Management
treat based on clinical suspicion;
awaiting culture results will
postpone treatment and worsen
prognosis- diphtheria antitoxin -
penicillin G or erythomycin
(halts furthers toxin production
and prevents carrier state)
Infectious Mononucleosis:
generalized non-tender
lymphadenopathy - if airway
obstruction admit for steroid
therapy
GAS pharyngitis peak incidence
at 5-12 yr of age
suspected diagnosis of GAS
pharyngitis should be confirmed
with a rapid streptococcal
antigen test and a follow-up
throat culture if the rapid test is
negative
Scarlet Fever : 4 Ss and 4 Ps
Sore throat - Swollen tonsils -
Strawberry tongue - Sandpaper
rash - Perioral Sparing - Non-
Pruritic - Non-Painful – Peeling
ORS : Rehydration – During the
rehydration phase, the fluid
deficit is replaced quickly over
three to four hours - total of 50
mL/kg in mild dehydration and
100 mL/kg in moderate
dehydration
71
Legg-Calve-Perthes disease
(LCPD) is avascular necrosis of
the proximal femoral head
resulting from compromise of
the tenuous blood supply to this
area. LCPD usually occurs in
children aged 4-10 years. The
disease has an insidious onset
and may occur after an injury to
the hip. In the vast majority of
instances, the disorder is
unilateral. Both hips are involved
in less than 10% of cases, and
the joints are involved
successively, not simultaneously
Apgar Scoring Scores of 0–3:
Indicate the need for immediate
resuscitation
Child with garlic smell:
Organophosphate toxicity
Encephalitis ( Acute cerebellar
ataxia) and, mostly in the past,
Reye syndrome, are the most
serious complications of VZV
infection
Dew drops on rose petal? 4) Significant number of pills on
Chicken pox X-ray

Routine vaccination for all Regarding pneumococcal vaccine

healthy persons aged >13 years for SCD patients:
is recommended for those
 7-valent (heptavalent)
without evidence of immunity .
“conjugate” pneumococcal
Two doses of single-antigen
vaccine < 2 years old.
varicella vaccine should be given
four to eight weeks apart  23-valent “polysaccharide”
pneumococcal vaccine > 2 years
old.
Dry beriberi = neurological
symptoms.
Most common cause of
Wet beriberi = cardiac
epiglottitis is haemophilus
symptoms.
influenza type b

Patients with iron toxicity should

In OCP overdose there is no need
be treated with IV deferoxime in
for intervention if the patient is
the following circumstances:
clinically stable
1) Severe symptoms: altered
mental status, hemodynamic
instability, persistent vomiting, Spiral fractures in children raise
diarrhea. the suspicion of abuse. They
difficult in casting and may
2) High anion gap metabolic
require surgery.
acidosis.

3) Serum iron concentration >

500 mcg/dL. Waddling gait at start is normal
up to approximately 3 years

72
spinal cord length will stop after
In children up to L2-L3, In adults
up to L1
Most common cause of vaginal
discharge in pediatric patients is
FB
GERMAN MEASELS : Primary
infection among teenagers and
adults tends to be of longer
duration than that among young
children. Patients are more
frequently symptomatic, and
symptoms are more frequently
accompanied by a prodrome of
fever and systemic complaints
Hepatitis A Postexposure ppx:
age 1–40 y → vaccine; age <1 or
>40 y or immunosupp → Ig.
The most characteristic feature
of RokyMSF is a rash that
develops on days 2 to 4 of illness
after the onset of fever, and it is
often quite subtle - rash begins
as small, flat, pink, non-itchy
spots (macules) on the wrists,
forearms, and ankles
73
Child with painless hematuria
what initial investigation :
Repeat urine analysis
imperforated anus the most
useful diagnostic procedure is:
Plain abdomen X-ray of with
child inverted position
The preventable nutritional
disease in child is: Kawshoirkor
Mumps Complications -
common: aseptic meningitis,
orchitis/oophoritis
A child with hemangioma on the
eyelid, in order to prevent
amblyopia, operation must be
done within:1 week
eczema corticosteroids, topical
calcineurin (Tacrolimus )
Mumps : droplet precautions
recommended until 5 d after
onset of parotid swelling

Jaundice in the first 24 h and
conjugated hyperbilirubinemia
are always pathological.
if recurrent episodes of croup-
like symptoms, consider
bronchoscopy to rule out
underlying subglottic stenosis
X-linked agammaglobulinemia :
male children - B cells and
lymphoid tissues are diminished
- T cells are normal
karyotypes is associated with
turner syndrome? 45, XO
Congenital rubella syndrome
(CRS) is characterized by the
triad of cataracts, PDA, and
sensorineural hearing loss.
Duchenne Muscular Dystrophy
(only affects males) - death in
75% by the age of 20—dilated
cardiomyopathy
74
hallmark physical findings in
intussusception are a right
hypochondrium sausage-shaped
mass and emptiness in the right
lower quadrant (Dance sign)
familial intrahepatic cholestasis?
Autosomal-recessive
Marfan syndrome = autosomal
dominant disorder
Measles (rubeola) : (Koplik
spots) on the oral mucosa, and a
maculopapular rash that spreads
cephalocaudally
osteolytic lesion with “onion-skin
= Ewing's sarcoma
Constitutional growth delay is
the most common cause of short
stature and pubertal delay in
adolescents.
Nursemaid's elbow, also called
as subluxed radial head -
manifests as refusal to move the
elbow - radiographs are often
normal

Osteosarcoma : The most
common malignant bone tumor
in youth - X-ray shows
“Codman’s triangle” and “sun-
burst” appearance.
Osteogenesis imperfecta :
autosomal dominant mutation of
COL1A1- Treatment includes
growth hormone for some types
and bisphosphonates
Gingivostomatitis is the most
common manifestation of
primary herpes simplex virus
(HSV) infection during childhood
the most common cardiac lesion
associated with Down syndrome
Endocardial cushion
avulsion of the secondary
ossification center (apophysis) of
the tibial tubercle
In contrast to irritant diaper
dermatitis, candidal infections
commonly involve the skin folds
Rotavirus is the most common
cause of gastroenteritis in infants
and young children worldwide,
Typical presentation is Vomiting
followed by Diarrhea
Cryptorchidism is the most
common congenital anomaly of
the genitourinary tract due to
failure of testicular descent from
the abdomen into the scrotum

Fragile X syndrome It is the most

Klinefelter's syndrome is the common inherited cause of
most common congenital intellectual disability ‫– ضخامة‬
abnormality causing primary ‫نهاٌات‬
hypogonadism The most
common genotype is 47,XXY
Measles : Otitis media is the
most common Complications
Osgood-Schlatter disease is an
overuse injury caused by
repetitive strain and chronic

75
Erythema toxicum neonatorum
(ETN) is a benign self limited
eruption occurring primarily in
healthy newborns in the early
neonatal period
Migraine headaches are the
most common form of
headaches in the pediatric
population.
Wiskott–Aldrich Syndrome :
Thrombocytopenia - Eczema
(seen before 6 months of age) -
Recurrent infection
Fanconi anemia autosomal
recessive
Kallmann's syndrome consists of
a congenital absence of GnRH
secretion associated with
anosmia and a normal karyotype
(46 XX)
Fibromyalgia either amitriptyline
or cyclobenzaprine are the initial
drugs of choice
76
The most common forms of
Hereditary angioedema (types I
and II) are caused by deficiency
or dysfunction in C1 inhibitor
(C1INH)
Duodenal atresia is strongly
associated with Down syndrome
Ultrasonography is the method
of choice to detect
intussusception.
The most common cause of
acquired isolated angioedema is
due to angiotensin-converting-
enzyme inhibitor use
Botulism immune globulin
should be administered as soon
as possible, even before
diagnostic confirmation of stool
spores or toxin.
Henoch-Schonlein purpura
thrombocytosis in 67% of cases
Cellulitis in neonate mostly
caused by : Group B
streptococcus
‫اهتهاب اهقصٍثاخ اهشؼرٌح قد ٌؤهة هورتى‬
Isoniazid (INH) is the regimen of
choice for treatment of latent
tuberculosis infection (LTBI)
among children known to have
INH-susceptible infection or for
whom the source case is
unknown
We suggest NOT treating
patients with simple febrile
seizures with antiepileptic drug
(AED) therapy.
Heiner syndrome — Heiner
syndrome (food-induced
pulmonary hemosiderosis) is a
pulmonary disease that is caused
by food hypersensitivity,
primarily to cow's milk.
pulmonary infiltrates-cough,
recurrent fever, wheezing, nasal
congestion, hemoptysis-This
disorder mainly affects infants
77
decrease head growth, decrease
social interaction, decrease in
language = Rett's syndrome
Urinalysis should be performed
in all children with
monosymptomatic enuresis -
Urologic imaging (renal
sonogram and voiding
cystourethrogram) is reserved
for children who have significant
daytime complaints, a history of
urinary tract infection(s) not
previously evaluated, and/or
signs and symptoms of structural
urologic abnormalities
ORS Maintenance Alternatively,
10 mL/kg of body weight of ORS
is administered for each watery
or loose stool, and 2 mL/kg of
body weight for each episode of
emesis.
Indications for Medical
Evaluation of Acute Diarrhea
• Age <6 mo
• Fever
• Visible blood in stool
• Frequent, substantial volume following: a family history of
of diarrhea renal or urologic disease; poor
growth; or hypertension.
• Signs of dehydration

• Change in mental status

Individuals with recent exposure
to HAV who have not previously
Most common cause of acute
received HAV vaccine should be
bilateral cervical LAD is viral
administered a single dose of
illness.
single-antigen HAV vaccine or
immune globulin (IG

Clindamycin not effective against

gram –ve organisms
Varicella : Tzanck smear of the
base of a vesicle may
demonstrate multinucleated
Infants and children who require
giant cells.
chest compressions should
receive two breaths per 30 chest
compressions for a lone rescuer
Duchenne’s muscular dystrophy
and two breaths per 15 chest
Muscle biopsy is diagnostic (DNA
compressions for two rescuers
testing has now replaced muscle
biopsy for diagnosis.)

varicella vaccine in adult , which

is true : 2 vaccine apart of 1
Vitamin D deficiency rickets :
month
Metaphyseal cupping & fraying

we now suggest voiding

the most likely causative
cystourethrogram (VCUG) to
organism of a child with dental
evaluate possible vesicoureteral
caries? Streptococcus mutans
reflux (VUR) for children of any
age with ≥2 febrile UTIs or a first
febrile UTI and any of the

78
For premature infants with
hemodynamically significant
PDA, give a COX inhibitor
Trendelenburg sign is caused by
weakness or paralysis of
the gluteus medius and minimus
muscles
The most common types of brain
tumors in children are
astrocytoma(benign), The three
most common primary CNS
tumors in children are
astrocytoma (benign),
medulloblastoma (malignant),
and ependymoma.

Rubella : Forschheimer spots;

rose colored spot on soft palate
Pityriasis rosea: most commonly
occurs between ages 10 and 35-
women more often-condition
Pubertal gynecomastia resolves
classically begins with a single,
spontaneously within several
primary, 2- to 10-cm herald
weeks to 3 years in most
patch that appears on the trunk
patients; breasts larger than 4
or proximal limbs
cm in diameter may not regress
completely

Kallmann's syndrome consists of

a congenital absence of GnRH
Duodenal atresia presents within
secretion (i.e. low FSH and LH)
the first 24 hours of life and is
associated with anosmia and a
seen generally in newborn
normal karyotype (46 XX).
nurseries

down syndrome : Single

regarding moro reflex
transverse palmar crease -
Disappears by 3 to 6 months of
Duodenal atresia - Hirschsprung
age
disease - Hypothyroidism -Type 1
diabetes mellitus- Complete
atrioventricular canal -
6-year old child Can draw a
diamond shape

79
Cow's milk allergy: extensively
hydrolyzed or amino acid-based
infant formulae -Extensively
hydrolyzed casein protein:
Similac Alimentum -Nutramigen-
Nutramigen with Enflora LGG -
Pregestimil

Amino acid-based : Elecare

Infant -Neocate Infant DHA and
ARA - Puramino (previously
known as Nutramigen AA)

80
SURGERY :
The first step in the workup of a
breast mass is bilateral : Lobular
suspicious mass in
carcinoma
postmenopausal women and in
those > 30 years of age is a
mammogram. For
Fibrocystic Change: (FNA) of a
premenopausal women < 30
discrete mass that is suggestive
years of age, get an ultrasound
of a cyst is indicated to alleviate
pain as well as to confirm the
cystic nature of the mass
Breast conserving surgery can be
offered to most women with
stage I/II disease.
Fibroadenoma The most
common breast lesion in women
< 30 years of age- consider
ACS/NCI recommend annual
excision if size 2-3 cm and
mammo + Clinical breast exam
growing on serial ultrasound if
beginning at age 40 -Self breast
symptomatic or patient
exam (SBE): no proven mortality
preference
benefit

Breast cancer stages:

Gender followed by age are the
■ Stage I: Tumor size < 2 cm. two greatest risk factors for
breast cancer
■ Stage II: Tumor size 2–5

cm.
An intraductal papilloma is the
■ Stage III: Axillary node
cause of pathologic discharge in
involvement. over half the cases, while
underlying malignancy is the
■ Stage IV: Distant
cause of nipple discharge in 5 to
Metastasis 10 percent of cases

81
breast self-examination :
monthly - after 3-5 days of cycle
start
mastitis: dicloxacillin or
cephalexin/ Cephalosporin (First
Generation)
Always rule out more serious
causes (e.g. colon CA) in a person
with hemorrhoids and rectal
bleeding
Visible rectal or occult bleeding
should not be attributed to
hemorrhoids until other
potential bleeding sites have
been excluded by endoscopic
testing. Flexible sigmoidoscopy
or anoscopy in low-risk younger
patients or colonoscopy in most
other patients establishes the
diagnosis of hemorrhoids, and
excludes other causes
rupture is usually the first hint of
AAA.
82
‫تصنٌف القرحات االضطجاعٌة‬
Stage I: nonblanchable erythema
present >1 h after pressure
relief, skin intact
Stage II: partial-thickness skin
loss
Stage III: full-thickness skin loss
into subcutaneous tissue, but
not through fascia
Stage IV: through fascia into
muscle, bone, tendon, or joint
ƒ if an eschar is present, must
fully debride before staging
possible
Folic acid and vitamin C both are
prevent colon cancer, but folat
reduce risk in people who
genetic predisposing
ASA assoc. w/ ↓ CRC incidence
COLORECTAL CANCER (CRC)
screen Average risk:
colonoscopy starting at age 50 &
repeat q10y - FHx: age 40 or 10 y
before index dx then q5y. IBD:
8–10 y after dx, then q1–2y-
Known or suspected familial
syndrome: very early screening
(eg, age 20–25 y), then q1–2y.
we recommend that
colonoscopy be repeated one
year after primary resection of
colon or rectal cancer to exclude
new lesions,
Colon cancer stage 1 prognosis:
More than 90% (94-97%)
Most hyperplastic polyps are
small and are found on the left
side of the colon and are not
associated with an increased risk
of colon cancer
Thyroid cancer associated with:
Euthyroid
Facial nerve is the most lateral
structure within parotid gland
We recommend that patients
with skin abscesses, furuncles,
and carbuncles undergo incision
and drainage - we suggest
incision and drainage and no
antimicrobial therapy
83
femoral hernias most commonly
present inferior to the inguinal
ligament and medial to the
femoral artery.
We suggest that most
asymptomatic and minimally
symptomatic patients with
inguinal hernia undergo elective
surgical repair . Patients who
wish to avoid surgery can
reasonably be treated with
watchful waiting
Indirect Inguinal : Most common
hernia in men and women Males
> females - Lateral to inferior
epigastric artery Often descends
into scrotal sac
Direct Inguina Medial to inferior
epigastric artery
true about appendicitis in
elderly: Rupture is common
Complication of appendicitis ƒ
perforation (especially if >24 h
duration) abscess, phlegmon
Acute appendicitis — In patients
with acute non-perforated
appendicitis , a single pregnancy, obesity, portal
preoperative antibiotic dose for hypertension, heavy lifting
surgical wound prophylaxis is
adequate - single dose of
cefoxitin ampicillin /sulbactam Hemorrhoidal bleeding is almost
the combination of cefazolin (1 always painless. Thus, bleeding
to 2 g IV) PLUS metronidazole associated with painful
defecation should prompt
In patients with perforated
investigation for other causes
appendicitis, the antibiotic
such as anorectal fissures.
regimen should consist of
empiric broad-spectrum therapy
with activity against gram-
We recommend dietary
negative rods and anaerobic
management consisting of
adequate fluid and fiber intake
as the primary medical
peak incidence of acute
treatment of symptomatic
appendicitis is between 12 and
hemorrhoids
18 years (school ).
medically refractory grades I and
II hemorrhoids We recommend
mortality rate from acute rubber band ligation as the initial
appendicitis in the general office-based procedure
population is: 4 per 1000
For patients with grade IV
hemorrhoids or who have
combined internal and external
Acalculous cholecystitis 20%
hemorrhoids with significant
cases of cholecystitis
prolapsed , we recommend
Hemorrhoid : associated with surgical excision
advancing age, diarrhea,
pregnancy, pelvic tumors,
prolonged sitting, straining, and 1 liter fluid deficit equals 1 kg
chronic constipation.

-increased intra-abdominal
pressure: chronic constipation,
84
CCY in asx Pts w/: GB irregularity + ablation of
calcification (~7% risk of ca) dysplasia (radiofrequency or
photodynamic).
GB polyps >10 mm, Native
American, stones >3 cm or
bariatric surgery or cardiac
wound will heal when:
transplant candidates
Formation of epithelium

Facial suture should be removed

Indicators of positive DPL:
between 4-7 days
1) 10ml of blood or enteric
contents (stool, food, etc.)
UC : Surveillance: colonoscopy
2) More than 100,000
w/ random bx 8 y after dx to eval
RBCs/mm3
for dysplasia, q1–3y thereafter
based on risk factors. If high- 3) More than 500 WBCs/mm3
grade dysplasia or dysplasia
4) Amylase more than 175 IU
assoc.lesion/mass → colectomy.
5) Detection of bile, bacteria or
food fibers.
Surgery is required in cases of
Gross inspection of DPL effluent
complete SBO, necrotic bowel,
is neither adequate nor reliable
or symptoms lasting > 3 days
without resolution

Evisceration of bowel or
mesentery is an indication for
Barrett’s w/o dysplasia:
immediate laparotomy at most
surveillance EGD q3–5 y; low-
trauma centers
grade dysplasia: q 6– 12 mo. 4
quadrant bx q 2 cm.
Chemopreventive benefit of ASA
Most commonly affected organ
under study. High-grade
in blunt abdominal trauma is:
dysplasia: U/S to r/o invasive
Spleen
cancer; endoscopic mucosal
resection of any visible mucosal
85
Excess alcohol consumption also
contributes to cancers of the
mouth, esophagus, pharynx,
larynx, and breast
Parenteral nutrition is associated
with metabolic complications,
including hyperglycemia, serum
electrolyte alterations, macro-
or micro-nutrient excess or
deficiency, refeeding syndrome ,
Wernicke's encephalopathy , and
hepatic dysfunction
GL is contraindicated :
Unprotected airway
Caustic ingestion (due to risk of
exacerbating any esophageal or
gastric injury)
Hydrocarbon ingestion (due to
high aspiration risk)
Patients at risk of GI hemorrhage
or perforation (recent surgery,
underlying anatomic abnormality
or pathology, coagulopathy)
Indications for emergent
laparotomy : hemodynamic
instability, unequivocal
peritoneal signs on physical
86
examination, signs of
gastrointestinal hemorrhage,
and implement in situ, gunshot
wounds
Bartholin’s duct cyst: The most
common large cyst of vulva
Sebaceous cyst: The most
common small cyst of vulva
C. botulinum is a gram-positive,
rod-shaped, spore-forming
Antibiotics are recommended for
wound botulism after antitoxin
has been administered. Penicillin
G is frequently used.
Metronidazole is a possible
alternative for penicillin-allergic
patients.
Deltoid paralysis : Axillary nerve
by Anterior shoulder dislocation
initial treatment of Carpal tunnel
syndrome involves neutral wrist
position splinting - Local steroid
injection is indicated in cases
where wrist splinting is
insufficient - Surgical
decompression is reserved for
cases when conservative
management fails.
If one finds blood at the meatus
of the urethra, a scrotal
hematoma, a pelvic fracture, or a
high riding prostate then a high
suspicion of urethral tear is
present
Antibiotics are not typically
helpful in the treatment of
perianal abscesses.
Anorectal abscess begins in the
anal crypts and glands

Ischemic leg urgent management

Serious complications of
required: treat within 6 h or
laparoscopic cholecystectomy,
irreversible ischemia and
including bile duct injury, bile
myonecrosis may result
leaks, bleeding and bowel injury

The best method for temporary

Pilonidal Disease acute abscess:
control of bleeding is: Direct
I&D (often performed by primary
finger pressure
care doctors) wound packed
open surgery: indication: failure
of healing after I&D, recurrent
Perianal streptococcal dermatitis
disease, complex disease
is a bright red, sharply
demarcated rash that is caused
by group A beta-hemolytic
origin of pancreatic carcinoma:
streptococci - primarily occurs in
Ductal epithelium 80%
children between six months and
10 years

Compression U/S >95% Se & Sp

for sx DVT (lower for asx DVT);
Percentage of re-infarction for
survey whole leg rather than just
patient undergoing non-cardiac
proximal if ≥mod prob ;
surgery: 15%, 3 months after
venography rarely used
the infarct

B12 == terminal ileum

inguinal canal is : shorter in
B9== jujenum infants than adults
87
the integrity of the abdominal
wall requires which of the
following structures to be intact:
Transversals fascia
Patients with peritonitis of any
cause tend to "look sick" and lie
still to minimize their discomfort
- Initial diagnostic testing :
laboratory measurements
Wound infection is the common
complication of laparoscopic
cholecystectomy
SBO : Plain abdominal
radiography is used to confirm
the diagnosis; in most patients,
no further radiologic tests are
needed
indications for surgicay Crohn’s
disease :
failure of medical management
- SBO (due to stricture
/inflammation): indication in
50% of surgical cases
- abscess, fistula (enterocolic,
vesicular, vaginal, cutaneous
abscess), quality of life,
88
-perforation, hemorrhage,
chronic disability, failure to
thrive (children), perianal disease
Measles is a risk factor to
develop parotid gland swelling
and infection, due to stone in the
Stensen duct
predisposing to gastric cancer
• H. pylori, causing chronic
atrophic gastritis
• hereditary nonpolyposis
colorectal cancer (HNPCC) ,
hereditary diffuse gastric
carcinoma (HDGC)
• smoking, alcohol, smoked
food, nitrosamines
• pernicious anemia associated
with achlorhydria and chronic
atrophic gastritis
• gastric adenomatous polyps
• previous partial gastrectomy
(>10 yr post-gastrectomy)
• hypertrophic gastropathy
• blood type A
Thyroid Carcinoma:
Ps – Papillary cancer
Popular (most common)
Carcinoma of the colon is:
Predominantly found in the
rectum and the left side of the
colon

Palpable lymph nodes

Positive I131 uptake liver tumors is often associated

with oral contraceptive agents :
Positive prognosis
Liver cell adenomas
Post-op I131 scan to guide
treatments
The diagnosis of lymphedema
Fs – Follicular cancer
can be made by history, physical
Far away mets exam, and clinical measurements
of the affected versus unaffected
Female (3:1)
limb. While imaging of the
NOT FNA (can’t be diagnosed by lymphatic system is usually not
FNA) necessary to confirm the
diagnosis of lymphedema
Favourable prognosis

The most common cause of

20 French catheter is: 20 mm in
hypercalcaemia in a hospitalized
circumference
patient is: Cancer

The clinical manifestations of

The most common complication
postoperative
of Meckel's diverticulum among
hypoparathyroidism are usually
adults is: Intestinal obstruction
evident within 24 hours

Parkland formula “fluid

adhesion formation : careful
requirement = TBSA(%) x Weight
operative technique may
(Kg) x 4ml”
minimize its occurrence.

89
 Give half of total requirement Silver Sulfadiazine, the toxicity :
in the 1st 8 hours, then give 2nd Neutropenia
half over next 16 hours

One half (1/2) of pediatric burns

LGIB: first r/o UGIB before are scalds.
attempting to localize presumed
For 15-24 year old males, the
LGIB (10–15% actually UGIB, 3–
most common etiology for
5% small bowel), then
thermal injury involves :
colonoscopy
automobiles

Indications for Transfer to Burn

Centre
total 2° and 3° burns >10% TBSA
burns involving the face, hands,
feet, genitalia, perineum, or
major joints
3° burns in any age group
electrical burns, including
lightning (internal injury
underestimated by TBSA)
chemical burns
inhalation injury (may lead to
respiratory distress)
End-tidal carbon dioxide
detection is the most accurate
technology to evaluate
endotracheal tube position
the most common complication
following hemorrhoidectomy is :
urinary retention
The main complications
following a standard closed
hemorrhoidectomy include
urinary retention, urinary tract
infection, fecal impaction, and
delayed hemorrhage.

the first step in mild burn : Wash Best view to see the rib fracture :
by water with room temperature oblique x-ray

inhalation injury remains a

leading cause of death in adult
burn victims
90
Diabetic foot spread of infection into the
mediastinum, which can lead to
Grade 0 – No ulcer in a high-risk
acute necrotizing mediastinitis.
foot

Grade 1 – Superficial ulcer

involving the full skin thickness
but not underlying tissues
Grade 2 – Deep ulcer,
penetrating down to ligaments
and muscle, but no bone
involvement or abscess
formation
causes of postoperative fever
are: Atelectasis (Day 1)-
Pneumonia (Day 2-3) - Urinary
tract infection (Day 3 -5)- Deep
venous thrombophlebitis (Day 4-
5 ) - Wound infection (Day 5-7) -
Drug fever ( Day 7-15)

Grade 3 – Deep ulcer with

cellulitis or abscess formation,
often with osteomyelitis
Grade 4 – Localized gangrene
Grade 5 – Extensive gangrene
involving the whole foot
A winged scapula can result from
injury to the long thoracic nerve
. Damage to the nerve may also
occur during surgical procedures
including thoracoplasty, axillary
nodal clearance, mastectomy
and resection of the first rib

spleen injury : hemodynamically

unstable and unresponsive to
The elderly often have a normal
fluid administration= emergent
white blood cell count with
exploratory laparotomy is
appendicitis
required.

If the responds to fluids and

does not require The most common cause of
blood=abdominal CT scan is the epidural hematoma is damage to
best next step the middle meningeal artery
from blunt trauma

The most feared complication of

a retropharyngeal abscess is

91
the most common etiologic
agent that causes gas gangrene :
Clostridium perfringensis
Sudden asphyxiation is the most
common cause of death in
patients with Ludwig's angina
Dumping syndrome is a common
post-gastrectomy Complication.
Patients complain of post-
prandial abdominal cramps, light
headedness , weakness and
diaphoresis
common causes of foot drop
are:1. Peripheral neuropathy
2. Radiculopathy to any part of
the spinal roots that contribute
to the common peroneal nerve
(L4 – S2).
3. Traumatic damage to the
common peroneal
Cervical spondylosis : . The C5
and C6 nerve roots are most
commonly affected, resulting in
weakness of the deltoids,
supraspinatus , infraspinatus,
biceps, and brachioradialis
92
nerve injuries is associated with
fracture of midshaft humerus?
Radial nerve
Prostate cancer : Older men may
not be treated because tumors
are frequently slow growing.
Black pigment stones form in
conditions of stasis or excess
unconjugated bilirubin
Brown pigment are usually
found in conditions where there
is infected bile
Median nerve injury at the elbow
or forearm can cause inability to
flex the index finger and distal
phalanx of the thumb
Sigmoid Volvulus occurs in cases
of long-standing chronic
constipation-X-ray shows an
inverted U-shaped appearance
of the distended sigmoid loop
"coffee bean sign"-
decompression and untwisting of
the sigmoid loop may be
achieved by passing a
sigmoidoscope gently into the
rectum as far as possible and
passing a flatus tube alongside
the sigmoidoscope
Whenever an open wound fails
to heal after a prolonged period,
biopsies have to be obtained to
ensure that the ulcer has not
degenerated into a squamous
cell carcinoma.
Hemothorax : Urgent
thoracotomy if Initial bleeding is
> 1500 mL
the most common cause of lung
abscess? Aspiration
long thoracic nerve originate
from : C5, C6 and C7
Trauma is by far the most
common cause of subarachnoid
hemorrhage
Cigarette smoking appears to be
the most important preventable
risk factor for SAH.
If the diagnosis of acute
appendicitis is clear from the
history and physical
93
examination, prompt surgical
referral is warranted -In atypical
presentations, ultrasonography
and computed tomography (CT)
may help lower the rate of false
negative appendicitis diagnoses
The most characteristic sign of
pancreatic carcinoma of the
head of the pancreas is painless
obstructive jaundice. Smoking is
the most significant reversible
risk factor for pancreatic cancer
Doppler ultrasound can
differentiate between torsion of
appendix and testis-Testicular
appendage torsion appears as a
lesion of low echogenicity with a
central hypoechogenic area-
Usually resolve spontaneously
Risk factors of AAA
1.Tobacco use (Smoking
cessation is the intervention with
the greatest likelihood of slowing
AAA progression )
2. Atherosclerosis
3. Age > 55 years
4. Family history
5. Hypertension the pulse oximeter as a normal
saturated hemoglobin molecule.

abdominal Ultrasound The

study of choice for diagnosis and Complete claw hand results from
follow up of abdominal aortic combined lesions of the median
aneurysms and ulnar

Epidural hematomas :Bleed is Squamous cell carcinoma in

from the medial meningeal most of the esophagus cancer
artery - cannot cross suture lines

Subdural hematomas: result

The lymphatic drainage of both
from shearing of the dural
the upper and lower lips is
bridging veins-coupled with
primarily to the submandibular
retinal hemorrhages constitutes
group of lymph nodes
child abuse until proven
otherwise.
layers is involved in Chagas and
Hirsch sprung disease affecting
Aortic disruption is often
the myenteric (Auerbach's)
associated with first and second
plexus located between the
rib, scapular, and sternal
layers of the muscularis externa
fractures

Suspect spleen or liver injury

when lower rib fractures are
present
In carbon monoxide poisoning,
the patient’s oxygen saturation is
usually normal. This is because
carboxyhemoglobin is read by
The posterior lobe of prostate is
the medial part of the lateral
lobes and can be palpated
through the rectum during
digital rectal exam (DRE)
Pheochromocytoma should
always be suspected to avoid the

94
risk of lethal hypertensive crises,
especially during biopsy or
surgery
nerve pass through jugular
foramen ? cranial nerve 9th ,
10th , 11th
a single intravesical instillation of
mitomycinC (40 mg in 20 mL of
saline) has been shown to
reduce the frequency of tumor
recurrence.
Most common malignant tumor
in adult is Gliomas (principally
astrocytoma) 30% -Most
common primary tumor in the
brain is meningioma
Tarsal tunnel syndrome
(posterior tibial nerve)
Richter’s hernia: only part of
bowel circumference (usually
anti-mesenteric border) is
incarcerated or strangulated so
may not be obstructed
Hodgkin's lymphoma is
charactrized by enlargement of
95
single group of lymph nodes
(generalised lymphadenopathy is
rare)-Lymphocytic lymphoma is a
NHL charactrized by generalised
lymphadenopathy
The mortality rate for acute
mesenteric ischemia is > 50%.
Squamous cell carcinoma
associated with sun exposure
and usually present on the hand
Keratoacanthoma with typical
volcano appearance
Patients with a history of
Hashimoto thyroiditis are at
increased risk for papillary
thyroid cancer.
Thoracentesis : between the 7th
and 9th rib spaces and between
the posterior axillary line and the
midline
Microsatellite instability is
detected in about 15% of all
colorectal cancers
posterior urethra: common site
of injury is junction of
membranous and prostatic
urethra due to blunt trauma,
MVCs, pelvic fracture
PDA which nerve affected during
surgery? Lt Vagus N
Vague abdominal pain with
weight loss ± jaundice in a
patient over 50 yr old is
pancreatic cancer until proven
otherwise
Pancreatic CA : most important
prognostic indicators are lymph
node status, size >3 cm,
perineural invasion
Mammography often detects a
lesion before it is palpable by
clinical breast examination and,
on average, 2 years before noted
by breast self-examination.
carpal tunnel compression test
(Durkan's test): is the most
sensitive test to diagnose carpal
tunnels syndrome
96
open cholecystectomy, name of
incision: Kochar ( subcostal)
short gastric artery arise from
splenic artery at the hilum of
spleen .. supply the fundus
The most significant prognostic
indicator for patients with early-
stage breast cancer is the
presence or absence of axillary
lymph node involvement. The
more lymph nodes with cancer
at the time of the mastectomy,
the higher recurrence rate
Thrombophlebitis migrans can
be a sign of malignancies such as
pancreatic carcinoma (Trousseau
sign of malignancy) and lung
cancer or early sign in gastric or
pancreatic cancer
Acute paronychia : caused by S.
aureus - Therapy of acute
paronychia without abscess
formation includes local care
Oral antibiotic therapy may be
helpful - with abscess formation
is treated with incision and
drainage in addition to the above
management after appropriate
local anesthesia
perforated gallbladder post
cholecystectomy >>Subphrenic
abscess
‫سرطان القولون ال عقد مصابة اال بالمرحلة‬
‫ – الجراحة‬4 ‫ و ال نقائل اال المرحلة‬3
‫ مع الكٌماوي‬3 ‫شافٌة حتى المرحلة‬
partial urethral disruption : very
gentle attempt at catheterization
by urologis - with resistance to
catheterization  suprapubic
cystostomy -complete disruption
, delayed repair if unstable
(suprapubic tube)
athletic ,with history of foot pain
planter surface, diagnosis is :
Planter fasciitis
peak incidence of acute
appendicitis is between: 12 and
18 years( ً‫)العقد الثان‬.
%45 ‫ الحصاة باالنثقاب‬-‫اشٌع عند الذكور‬
‫ بدون‬%19 ‫مقابل‬
97
LGIB : Diverticular hemorrhage
(33%)-Anorectal (4%):
hemorrhoids, anal fissure, rectal
ulcer
carbuncle and furuncle : I&D -
For patients with abscess >5 cm,
multiple lesions, extensive
surrounding cellulitis,
immunocompromise, or
systemic signs of infection, we
recommend both incision and
drainage and antimicrobial
therapy
Metabolic toxicities from red cell
transfusion include the following
: Hypocalcemia and/or
hypoglycemia in newborns due
to the infused citrate in the
preservative solution.
- Hyperkalemia in patients who
receive large volumes of blood
Alvarado scale assigns a score to
each of the following diagnostic
criteria:
Migratory right iliac fossa pain
(1 point)
Anorexia (1 point)
 Nausea/vomiting (1 point) disease should be considered in
patients who have refractory to
Tenderness in the right iliac
medical
fossa (2 points)

Rebound tenderness in the right

iliac fossa (1 point) Laparoscopic Surgery : Append.

Fever >37.5°C (1 point) • Wound infection less likely

Leukocytosis (2 points)
• Intra-abdominal abscesses 2
times more likely

CLOSTRIDIAL MYONECROSIS • Reduced pain on POD #1

(GAS GANGRENE) : Surgical
• Reduced hospital stay by 1.1 d
exploration with débridement -
Antibiotics: high-dose penicillin G
+ clinda

Papillary thyroid cancer

Contents of Spermatic Cord : vas
-Patients diagnosed between the
deferens, testicular artery/veins,
ages of 20 and 45 years have the
genital branch of genitofemoral
best long-term prognosis
nerve, lymphatics, cremaster
muscle, ± hernia sac - The tall-cell variant form of
papillary cancer is a more
aggressive tumor than common-
The treatment of fistulas in CD : type papillary cance- prognosis
In patients with mild to was still worse compared with
moderate Crohn's disease, we classic papillary cancer
suggest treatment with
-At diagnosis, clinically
metronidazole (500 mg twice
detectable regional lymph node
daily) as initial therapy-In
metastases are more common in
patients with severe or
children (approximately 50
refractory perianal Crohn's
percent) than adults.
disease, we suggest treatment of
fistulas with an anti-TNF alpha
agent - Surgery for anal fistula
98
femoral artery laceration : If
small can be done by primary
repair if bigger it’s better to go
for venous graft
Long thoracic nerve arises from
roots C5, C6, C7
gastrectomy which one will be
defecient : Pepsin
The axillary nerve is a branch of
the posterior cord of the brachial
plexus
SVC = superior mediastinum
Anterior part of the face and
forhead => Submandibular LN
- Lateral part of the face
=>ParotidLN
- Central part of the lower lip and
chin => SubmentalLN
rigler's sign {visualization of air in
both sides of the bowel wall}
99
Kid with bilateral abscess of
inguinal nodes=Chronic
granulmoatous disease
management of splenic injury by
conservative includes : patients
with stable hemodynamic signs,
stable hemoglobin levels over
12-48 hours, minimal transfusion
requirements (2 U or less), CT
scan in-jury scale grade of 1 or 2
without a blush, and patients
younger than 55 years
most accurate test for acute
cholysctitis : HIDA
For initial treatment of pelvic
abscess <7 cm, we suggest
empiric antibiotic therapy only
and do not perform drainage as
initial treatment. If fever,
leukocytosis, pain and lack of
abscess resolution on imaging
persist despite 48 to 72 hours of
antibiotic therapy, we proceed
with drainage
Prostatic acid phosphatase
(PAP), also called prostatic
specific acid phosphatase (PSAP),
is an enzyme produced by the
prostate. It may be found in
increased amounts in men who
have prostate cancer or other
diseases

Chondrosarcoma occurs most

often in the pelvis

femoral tumors contain tumors

and calcification ? osteosarcoma

earliest sign of local anesthesia

toxicity? perioral numbness

Left-sided enlargement of a
supraclavicular node (Virchow’s
node) may indicate an
abdominal malignancy

• Right-sided enlargement may

indicate malignancy of the

mediastinum, lungs, or
esophagus

100
Orthopedics :
Shoulder dislocations : Anterior
(90%) brachial plexus injuries,
rotator cuff tears, fracture of the
greater tuberosity, and axillary
nerve injury.
Posterior dislocations classically
caused by seizures, electric
shock, or electroconvulsive
therapy arm is held adducted
and internally rotated AP
shoulder x-ray If it shows no
obvious fracture or dislocation,
posterior shoulder dislocation
should be considered- light bulb
or ice cream cone sign –
humeral head appear circular
Slipped capital femoral
epiphysis : painful limp - obese
adolescent (> 12 years) - X-ray
shows widening of joint space -
Loss of abduction and internal
rotation -Treatment: Internal
fixation
Frozen shoulder (adhesive
capsulitis) : painful and stiff
glenohumeral joint -The hallmark
of diagnosis is a marked
reduction in both active and
passive range of motion, with
101
pain especially at the deltoid
insertion- The condition is self-
limited in the great majority
Colles’ Fracture: extra-articular
transverse distal radius fracture
with dorsal displacement ± ulnar
styloid fracture.
2. Most common wrist fracture-
associated with a fall on an
outstretched hand-“dinner fork”
deformity
A common cause of rotator cuff
tear is fall on outstretched
hands- MRI is sensitive and
specific for rotator cuff injuries
Subacromial bursitis :
characterized by shoulder pain,
which is absent at rest but
present on overhead activity -
pain with active range-
Ultrasound or MRI
Lachman's test is the most
sensitive physical test for
diagnosis of anterior cruciate
ligament injury(forceful
hyperextension injury to knee.).
De Quervain's tenosynovitis
(Tenderness is noted over the
radial side of wrist and first
dorsal compartment) =
Finkelstein's test
Lateral epicondylitis (Tennis
elbow) : excessive wrist
extension - exacerbation of pain
by extension of wrist against
resistance
Meniscal injuries may be the
most common knee injury - A
sudden twist or repeated
squatting- Medial meniscus is
more commonly -Tenderness is
generally felt along the medial
side of the knee in case of medial
meniscus injury- Initial treatment
in acute injury is conservative
with immobilization and bracing
hematogenous osteomyelitis
most commonly affects which of
the following ? Metaphysis of
long bones
Anterior talofibular ligament is
the most commonly affected
ligament in ankle sprains.
102
Legg-Calve-Perthes disease :
Self-limiting disease. - presents
with limp and the pain is absent-
The patient may have abnormal
limb length- AP show widening
of the joint space and collapse of
the femoral head
The scaphoid is the most
commonly injured carpal bone -
Scaphoid fractures usually result
from wrist hyperextension,
typically during a fall on an
outstretched hand-Tenderness in
anatomical snuffbox is a very
sensitive marker of scaphoid
fracture- Treatment: thumb spica
cast immobilization
Patellofemoral syndrome is a
very common cause of anterior
knee pain - retropatellar and
most often manifests during
activities that require knee
flexion and forceful contraction
of the quadriceps- affects
women- Treatment involves
stretching and strengthening the
thigh muscles
Scoliosis based on Cobb angle
ƒ <20°: observe for changes
ƒ >20° or progressive: -ƒ >40°,
cosmetically unacceptable or
respiratory problems: surgical
correction

Supracondylar fracture over 60%

of all paediatric elbow injuries

Posterior fat pad sign indicates

effusion/injury: In children, it
implies supracondylar fracture.
Anterior fat pad can found in
normal xrays

103
Psychiatry : duration is the best indicator of
the extent of the overdose
Thiamine deficiency (vitamin B1)
Raloxifene is the first-line agent
can cause dry beriberi
for the prevention of
(peripheral neuropathy), wet
osteoporosis.
beriberi (dilated cardiomyopathy
) , and Wernicke-Korsakoff
syndrome.
Dysthymia: depressed mood for
most days for at least two years
Additional features is two or
Antidepressants: 2-6 weeks at a
more
therapeutic-dose level are
needed to observe a clinical
response.
Panic disorder Along with SSRis,
patients may benefit from
benzodiazepines . Begin with
Borderline personality disorder :
both and then taper the
instability and hypersensitivity in
benzodiazepine
interpersonal relationships-
demonstrate suicidal or self-
mutilating behavior
side effect of SSRI Sexual
dysfunction - ‫األرق‬
Compulsions : Response to
obsessive with repeated
Trichotillomania Characterized
behaviors
by the presence of hair shafts of
different lengths in the area of
alopecia-Cognitive behavioral
Tricyclic antidepressant
therapy is superior to medication
overdose : hyperthermia-
treatment.
hypotension - anticholinergic
effects; dilated pupils - leading
to QRS prolongation and risk of
Adjustment disorder Behavioral
developing ventricular
and emotional symptoms in
arrhythmia.QRS complex
response to a specific stressful
104
event or occurring within 3
months of the event – the
symptoms resolving within 6
months of the removal of the
stressor-Psychotherapy is the
treatment of choice
Brief psychotic disorder :
delusions, hallucinations, or
other psychotic symptoms for at
least 1 day but < 1 mo , return to
normal premorbid functioning-
caused by severe stress in
susceptible people
Acute Dystonia commonly
responsible include: 1. Typical
antipsychotics (e.g Haloperidol)
2. Metoclopromide
3. Prochlorperazine
Posttraumatic stress disorder
(PTSD) is recurring, intrusive
recollections of an overwhelming
traumatic event; recollections
last > 1 mo and begin within 6
mo of the event-avoidance of
stimuli associated with the
traumatic event, nightmares,
and flashbacks.
105
classic interaction of tyramine-
containing foods (e.g., cheese,
beer, wine) with monoamine
oxidase inhibitors (MAOIs as
Phenelzine )>> lethal
sympathetic crisis
Unlike patients with anorexia
nervosa, patients with bulimia
nervosa maintain a normal body
weight and are not amenorrheic.
NMS: clinical features, mental
status change, rigidity, fever, or
dysautonomia- in the setting of
neuroleptic use or dopamine
withdrawal.
Illness anxiety disorder (
hypochondriasis ), fear of
having serious disorder. despite
reassurance after a thorough
medical evaluation
Conversion disorder is
characterized by the
development of unexplained
serious neurological symptoms
preceded by an obvious
emotional trigger
Bipolar disorder is a mood
disorder that is characterized by
episodes of mania, hypomania ,
and major depression, as well as
mixed - return to normal
between episodes.
antidepressants can precipitate
mania
Generalized anxiety disorder :
Excessive, anxiety that occurs
daily for more than 6 months -
No single event or focus is
related to the anxiety.
Phencyclidine causes vertical
nystagmus
Cannabis
(marijuana)intoxication :
euphoria, paranoia, anxiety,
increased appetite , conjunctival
injection
features that distinguish delirium
from dementia include all of the
following: abrupt onset, brief
duration, reduced consciousness,
incoherent or disorganized
106
speech, and a fluctuating course
Impaired attention
food allergies: IgE
pellagra (Niacin (Vit B3)) is the 4
D’s: diarrhea, dementia,
dermatitis, and if severe, death
Narcolepsy : modafinil-
methylphenidate-amphetamines
Huntington disease : autosomal
dominant chorea,
neuropsychiatric symptoms, and
progressive cognitive
deterioration - ‘anticipation’ over
generations.
The most common side effects of
olanzapine are sedation and
weight gain
Methadone treatment of opioid
addiction
A history of seizure disorder ( ‫أو‬
‫)افة مؤهبة‬, history of anorexia
nervosa/bulimia,, is an absolute
contraindication to the use of
bupropion.
Conversion disorder : educating
the patient may lead to
spontaneous resolution of
symptoms in 40% to 50% of
cases; second-line treatments
include cognitive behavioral
therapy and physical therapy
Clozapine is the least likely
atypical antipsychotic to cause
Extrapyramidal symptoms - it can
cause agranulocytosis.
Major depressive episode
5 of 9 of the following
symptoms: (Sleep disturbances,
appetite change, low energy,
psychomotor changes, low
mood, anhedonia, guilt, focus/
concentration difficulty, suicidal
ideation)
Nephrogenic (NDI):
Damage to the kidney
2. Chronic pyelonephritis
107
3. Sickle cell disease
4. Hypercalcemia
5. Hypokalemia
6. Lithium
First-line treatment for specific
phobia is cognitive behavior
therapy (CBT) that includes
exposure treatment.
Pharmacotherapy, including
benzodiazepines and SSRIs has a
limited role in treatment .
Body dysmorphic disorder refers
to the patient who is
preoccupied with the belief that
some part of the body is marred
in looks.
Delusional disorder is presence
of one or more delusions for a
month or longer - other
psychotic or marked mood
symptoms are absent.
Vitamin B2 (riboflavin)
deficiency : Angular cheilitis-
Glossitis -Stomatitis -Normocytic-
normochromic anemia -
Seborrheic dermatitis
Obsessive neurosis patients will bulimia: Elevated liver enzymes
have: Major depression

Suicide risk may ↑ after

initial management of insomnia:
Good sleep hygiene
Agoraphobia is defined as fear of
being alone in public places.
antidepressant therapy is
initiated because a patient’s
energy to act on suicidal
thoughts can return before the
depressed mood lifts.

Effect of Fluoxetine start after 1-

Treatment of dementia is 2 weeks
cholinesterase inhibitor (
Half life of fluoxetine 1–3 days
galantamine , donepezil ,
(acute), 4–6 days (chronic)
rivastigmine )
the effective half life of
stertaline : 2 days
Patient with mushroom toxicity
will present with : Hallucination
Electroconvulsive therapy
indications
Social phobias: CBT, SSRIs, low-
Sever depression.
dose benzodiazepines, or β-
blockers Sevre mania

Initial ttt in catatonic

schizophrenia until drugs start to
bereavement after the loss of a
work.
loved one. No severe
impairment- usually resolves in
one year -Illusions/hallucinations
Delusion False belief not in
of the deceased can be normal
accordance of a persons culture
as long as the person recognizes
them as such.

108
A personal history of depression enlargement - On brain
is the major risk factor for Severe microscopy amyloid plaques and
postpartum depression neurofibrially tangle

Hopelessness most predictor : Alprazolam is recommended for

Suicide the short-term of severe acute
anxiety

Risk factors for

Somatoform pain disorder:
suicide—
intensity pain is main symptoms
SAD PERSONS

Sex (male)
Antipsychotic drug side effect for
Age (older) onset : 4 hours: Acute dystonia ,
4 days: Akinesia , 4 weeks:
Depression
Akathisia , 4 months: Tardive
Previous attempt dyskinesia (often permanent)

Ethanol/substance

abuse To measure the cognition in old

patient: Clock test
Rational thought

Sickness (chronic
The most common side effect of
illness)
antipsychotics: Weight gain
Organized plan/access

to weapons
Buspirone is another drug, in
No spouse addition to SSRIs, that should not
be used with MAOIs.
Social support lacking

Flumazenil Antidote to
Alzheimer disease MRI & CT may
benzodiazepine intoxication
show atrophy, venticule

109
Post-traumatic Stress Disorder
SSRIs are first line
TCA toxicity—Tri-C’s:
Convulsions
Coma
Cardiac arrhythmias
Discontinue SSRIs at least two
weeks before starting an MAOI.
Wait five weeks if the patient
was on fluoxetine
MAOIs : orthostatic hypotension,
weight gain.
TCAs :cardiac conduction
arrhythmias (e.g., long QRS)-
Anticholinergic effects (dry
mouth, constipation urinary
retention, sedation).
SSRIs :Sexual side effects,
Serotonin syndrome (fever,
myoclonus, mental status
changes, cardiovascular collapse)
can occur if SSRIs are used with
MAOIs.
Antidepressant use may trigger
manic episodes
110
Neuroleptic malignant
syndrome Stop medication ;
provide supportive care in the
ICU; administer dantrolene or
bromocriptine
Giving anticholinergics or
decreasing neuroleptics may
initially worsen tardive
dyskinesia
Fetal alcohol syndrome is the
number one avoidable cause of
mental retardation
administer thiamine before
glucose (which depletes
thiamine) to prevent Wernicke’s
encephalopathy
A 13-year-old boy has a history
of theft, vandalism, and violence
toward family pets = Conduct
disorder.
A violent patient has vertical and
horizontal nystagmus =
Phencyclidine hydrochloride
(PCP) intoxication

A man unexpectedly flies across
the country, takes a new name,
and has no memory of his prior
life = Dissociative fugue.
Good Prognostic Factors
Schizophrenia
• Acute onset
• Later age at onset
• Shorter duration of prodrome
• Female gender
• Good cognitive functioning
• Good premorbid functioning
• No family history
• Presence of affective
symptoms
• Absence of structural brain
abnormalities
• Good response to drugs
• Good support system
Bereaved patients who have
symptoms of depression for at
least two weeks, six to eight
weeks after a major loss, should
111
be considered candidates for a
therapeutic trial of
antidepressants and
psychotherapy.
Antidepressant, Tricyclic :
Orthostatic hypotension: May
cause orthostatic hypotension
(risk is very high relative to other
antidepressants)
: ‫قلق االداء‬
‫ بنزودٌازٌبٌنات او‬: ‫القلٌل التوارد‬
ً‫حاصرات بٌتا كخط ثان‬
ً‫ عالج سلوك‬: ‫الكثٌر التوارد‬
A personal history of depression
(prior to pregnancy, antepartum
or postpartum) is the major risk
factor for PPD
Hypochondriasis appears to
occur equally in men and
women -More common in
medical students ,More common
in ً‫ التعلٌم المتدن‬,
Tricyclic antidepressant
intoxication : Sedation, coma,
seizures , conduction
abnormalities prolonged QT ,
Anticholinergic ; Dilated pupils,
dry mouth, absent bowel
sounds, urinary retention
Postpartum psychosis is
relatively rare - Suicidal and
homicidal ideation are common
features of postpartum psychosis
.Women with postpartum
psychosis are more likely to
commit suicide or infanticide
than the general population
Generalized Anxiety Disorder :
six or more months -
anxiety disorders often require
treatment at higher doses for a
longer period of time (i.e. up to
8-12 wk than used for
depression)
Social Phobia (Social Anxiety
Disorder) : behavioural therapy
is more efcacious than
medication -ƒb-blockers or
benzodiazepines in acute
situations (e.g. public speaking)
112
Post-traumatic Stress Disorder
SSRIs are first line
Bipolar depression: Mood
stabilizers +/– antidepressants.
Start mood stabilizers first to
avoid inducing mania
mania are psychiatric
emergencies 2° to impaired
judgment and great risk of harm
to self and others.
Somatization disorder :All the
following historical criteria are
required for a diagnosis:
1. Four different pain sites or
painful functions (eg,
menstruation, sexual
intercourse, urination)
2. Two gastrointestinal
symptoms other than pain
3. One sexual or reproductive
symptom other than pain
4.One pseudoneurological
symptom (eg, impaired balance,
paralysis, aphonia, urinary
retention)
Alcohol Withdrawal symptoms
typically begin within 4 to 12
hours after alcohol cessation, but
can appear as late as a few days
later. Their intensity typically
peaks on the second day and
improves by the fourth or fifth
day.

113
Dermatology :
Erythema toxicum neonatorum
is a very common rash seen in up
to 50% of newborns ( first 2
days) sparing the palms and
soles-No therapy is required
Seborrheic dermatitis : may
present inflammatory response
to Pityrosporum Ovale -In
infants =cradle cap - topical
antifungals and/or topical
corticosteroids zinc pyrithione
shampoos for the scalp
Suspect HIV in a young person
with severe seborrheic
dermatitis
Lichen planus small, discrete,
polygonal, flattopped, violaceous
papules - autoimmune disorder
associated with disorders such as
hepatitis C - Treatment topical or
intralesional corticosteroids
Psoriasis provoked by local
irritation or by trauma
(Koebner’s phenomenon) - Treat
with topical steroids - Systemic
114
corticosteroids should be
avoided, as tapering can induce
psoriatic flares
Actinic keratosis ( ً‫)تقران سعف‬is a
precursor of squamous cell
carcinoma in situ - caused by
exposure to sunlight
BCC is the most common type of
skin cancer. 65-80% of all skin
cancers (10–25% SCC )
erythrasma (‫ ) اهىذح‬Caused by
Corynebacterium minutissimum
(‫ – )اهىتدٌح اهمستدقح‬erythromycin
Tinea corporis (O-shaped)
patches expand peripherally and
tend to clear centrally -pruritic -
Diagnosis KOH wet mount –
Treatment :Topical or oral
antifungal : imidazole
Acanthosis Nigricans : DM,
Cushing’s disease, HAIR-AN
syndrome, and obesity. May also
be a paraneoplastic sign of
underlying adenocarcinoma
(usually GI).PCO
Characteristic of a suspicious skin
lesion including:
1- Asymmetric and irregular
borders
2- Bleeding or ulceration;
persistent itching or tenderness
3- Color change or variegation of
color
4- Diameter > 6 mm
Erythema multiforme : type IV
hypersensitivity reaction -
sudden onset of erythematous
"target-like" lesions and usually
follows herpes simplex infection-
especially occur on the palms
and soles-caused by Sulfa drugs
(most common)
Tinea versicolor is a common,
benign, superficial cutaneous
fungal infection.- Caused by
Malassezia furfu -
hypopigmented or
hyperpigmented macules and
patches on the chest and the
back - confirmed by KOH
preparation of scale that reveals
a “spaghetti and meatballs”
pattern of hyphae
115
and spores - topical
ketoconazole or selenium
sulfide
Kaposi sarcoma in HIV patients is
caused by human herpesvirus 8.
Dermatomyositis associated with
malignancy often remits once
the tumor is removed - Anti Jo-1
antibodies are positive in
polymyositis and
dermatomyositis
We recommend acyclovir for the
treatment of varicella in the
following children who are at
increased risk of complicated
disease: those who are 12 years
of age or older, those with
chronic cutaneous or pulmonary
disorders, or in those individuals
taking steroid or salicylate
therapy
Scabies (Sarcoptes scabiei ) = 5%
permethrin topically - head and
neck are usually spared -
Contacts should be treated as
well
folliculitis : Staphylococcus - - Psychological distress
Topical antibiotics for mild cases
- Systemic antibiotics for severe
cases rosacea = Oral doxycycline 1line

Genital warts (condyloma Hutchinson‘s sign: involvement

acuminata) is caused by (HPV) -
teardrop appearance - chief
complaint usually is one of
painless bumps, pruritus, or
discharge - treated with
trichloroacetic acid or
podophyllin.
of tip of nose suggests eye
involvement ( 75 %)
MILD ACNE: Topical Therapies :
Benzoyl peroxide -Erythromycin -
Adapalene (e.g. Differin )

MODERATE ACNE: After topical

treatments have failed, add oral
Granuloma annulare :annular
antibiotics, such as tetracycline,
plaque on the distal extremity-
or. Antibiotics require 3-6 mo of
thickened indurated ring like-
use before assessing effcacy
self-limited
SEVERE ACNE: Consider systemic
retinoids Isotretinoin
Recent streptococcal infection is
the most common cause of
ERYTHEMA NODOSUM First line of defense in the skin is
= Keratinocytes.

PSORIASIS Systemic Treatments

should be considered if: side effects of local steroids Skin
thinning (atrophy) - Easy
- Unsuccessful topical therapies
bruising - telangiectasia
- Lesions >10% of total body
surface area
The best test for hypersensitivity
- Involvement of face, hands, or
type = Subdermal skintest
genitalia
116
leishmania with cutaneous thyroid dysfunction
disease, L. mexicana and L. ,physical/mental stress
tropica

Visceral leishmaniasis (VL) is

primarily caused by L. donovani
ANAGEN EFFLUVIUM ( ‫ْر‬ ِ ‫تَساقُطُ اه َّشؼ‬
‫ ) اه َّدوائِ ًُّ اه َم ْنشأ‬hair loss due to
and L. infantum (synonym L.
insult to hair follicle precipated
chagasi)
by chemotherapeutic agents
(most common)

The epidermal separation of SJS

involves < 10% of body surface
Lichen planus : 6 P : pruritic ,
area (BSA), whereas toxic
purple, polygonal, papules and
Epidermal Necrolysis involves
plaques
> 30% of BSA.

pink patch under wood‘s lamp it

trichotillomania : irregular
fluorescent a coral red color =
patches of hair loss, and with
Erythrasma
remaining hairs broken at
varying lengths

ALOPECIA AREATA “exclamation

mark” pattern (hairs fractured
Alopecia Areata ( ‫)ثَ ْؼوَثَحٌ تُقَ ِؼٍَّح‬
and have tapered shafts, i.e.
Subtypes
looks like “!”)
Alopecia totalis: loss of all scalp
hair and eyebrows
rash over elbows, knees, and
Alopecia universalis: loss of all
cheeks =Eczema
body hair

Commonest site for Lichen

TELOGEN EFFLUVIUM ( ‫ْر‬ ِ ‫تَساقُطُ اه َّشؼ‬ planus is Mouth - mucous
ًّ ِ‫ ) اهلَرْ ت‬decrease in hair density
membranes in 60% (mouth,
secondary to precipitated by:
vulva, glans) – Koebner phenomenon
malnutrition, Fe defciency,
117
mild rosacea: topical
metronidazole or azelaic acid
creams and gels.
For severe rosacea: doxycycline
(first line therapy), tetracycline
and erythromycin.
Exanthematous Eruptions
(Maculopapular
Eruptions/Morbilliform) :the
“classic” and most common
adverse drug reaction -starts on
trunk –
White patches after sun
exposure =pityriasis versicolor
=treatment selenium sulfide
Papules and pustules represent
inflammatory acne lesions.
Accumulation of sebum and
keratinous material converts a
microcomedo into a closed
comedo (a whitehead)
The follicular orifice is opened
with continued distension,
forming an open comedo (a
blackhead)
118
Follicular rupture contributes to
the development of
inflammatory lesions - leading to
inflammatory papule or nodule
formation
Necrotizing fasciitis = ‫كابابٌنٌم او‬
‫تازو فقط‬
‫ فالجٌل‬+ ‫للتحسس عالبنسلٌن = سٌفٌٌم‬
lichen sclerosus :The classic
appearance is thin, white,
wrinkled skin localized to the
labia minora and/or labia majora
-There is a small increased risk of
squamous cell cancer of the
vulva in patients with lichen
sclerosus. For this reason, the
skin of patients with vulvar
lichen sclerosus should be
examined at least yearly, with
biopsy of suspicious lesions,
Fixed Drug Eruptions sharply
demarcated erythematous oval
patches on the skin or mucous
membranes-reoccurs in same
location upon subsequent
exposure to the drug (fixed
location)-most common causes:
antimicrobials (tetracycline,
sulfonamides)
Tinea Cruris Scaly patch/plaque may be used in patients with > 6
with a well-defned, curved outbreaks per year (HSV).
border and central clearing
Pruritic, erythematous,
dry/macerated Site: medial
thigh-Topicals: 1% clotrimazole,
If you see giant molluscum
2% ketoconazole
contagiosum, think HIV

Tinea pedis can usually be

Aplasia cutis congenita :
treated with a topical antifungal
newborn child is missing skin
cream for four weeks -
from certain areas.- The defects
Terbinafine -treatment with
are non-inflammatory and are
allylamines (terbinafine or
well demarcated.
naftifine) produces a slightly
higher cure rate than treatment
with an azole
List of rashes involved Palm &
soles : Hand, Foot, and Mouth
Disease - Bacterial endocarditis-
Pityriasis rosea it begins (Viral
Rocky Mountain Spotted Fever -
)with a single "herald patch"
Graft Versus Host Disease rash. -
lesion, followed in 1 or 2 weeks
Kawasaki, Measles, or Toxic
by a generalized body rash
Shock Syndrome - Steven
lasting up to 12 weeks.
Johnson syndrome - Secondary
Treatment : none required;
and Congenital Syphilis
clears spontaneously in 6-12 wk,
reassurance - topical steroids
post-inflammatory pigmentation
Cold induced Urticaria
is a concern or if patient is
treatment: Antihistamine
uncomfortable.(severe =
acyclovir ‫)فموي‬

Rash all over the body except the

face after week of unprotected
Daily acyclovir, valacyclovir, or
sexual intercourse: 2ry syphilis
famciclovir suppressive therapy

119
Patients with mild to moderately
severe axillary, palmar, or
plantar hyperhidrosis should
initially be treated with topical
agents such as aluminum
chloride hexahydrate in alcohol

120
ENT :
Pulling on the pinna is extremely
painful in otitis externa, but is
usually well tolerated in otitis
media.
Otitis Externa : combination of
antibiotic and steroid- do not
use aminoglycoside if the
tympanic membrane (TM) is
perforated because of the risk of
ototoxicity
chronic otitis externa (pruritus
without obvious infection)
corticosteroid alone
do not cauterize both sides of
the septum at one time due to
risk of septal perforation from
loss of septal blood supply
Control the Bleeding : first line
topical vasoconstrictors
if unable to visualize bleeding
source, then usually posterior
source:
121
indication for tonsillectomy
Absolute Indications
• most common indication:
sleep-disordered breathing
• 2nd most common indication:
recurrent throat infections
• tonsillar hypertrophy causing
upper airway obstruction,
obstructive sleep apnea, severe
dysphagia, or cardiopulmonary
complications such as cor
pulmonale
• suspicion of malignancy (e.g.
lymphoma, squamous cell
carcinoma)
• orofacial/dental deformity
• hemorrhagic tonsillitis
In the elderly, unilateral tinnitus
or SNHL is acoustic neuroma
until proven otherwise.
presbycusis the most
sensorineural hearing loss in
adult and otosclerosis
commonest cause of conductive
hearing loss -Most common
cause of hearing loss in children:
Chronic serous otitis media
most common site of malignancy
in paranasal sinuses : 90%
Maxillary and ethmoid sinus
Myringotomy (is used for bulging
acute otitis media)
 Grommet tube insertion (is
used for recurrent acute otitis
media)
MOST Prominent symptom of
Acute otitis media : Pain
Hoarseness that lasts for more
than two weeks, in the absence
of symptoms of an acute upper
respiratory infection, requires a
complete otolaryngologic
examination, particularly in
patients with a history of
tobacco or alcohol use.
Lung malignancy is the most
common cause of extralaryngeal
vocal cord paralysis
Tinnitus often becomes less
bothersome over time, especially
in the setting of hearing loss.
122
What is the commonest cause of
otorrhea? Otitis externa
Quinsy Triad
• Trismus
• Uvular deviation
• Dysphonia ("hot potato voice)
Do not diagnose AOM if no
middle ear effusion
perforated tympanic membrane
with foul whitish discharge dX? 
Cholesteatoma
Noise induced deafness:
bilateral SNHL initially dificulty
with speech discrimination,
especially in situations with
competing noise
Child is having a croup early
morning, the most common
cause is: Post nasal drip
Mumps complication orchitis in
adult males, oophoritis in adult
females and meningitis in
children
Complication of measles
children, the most common one
is otitis media; for adult, it is
Pneumonia
Complications of tonsillar
abscess : Retropharyngeal
abscess, airway compromise(
Ludwig's angina), Septicaemia,
necrosis of surrounding deep
tissues , rare mediastin
Given the prolonged course of
resolution of MEE after an
episode of AOM, follow-up
typically is recommended 8 to 12
weeks after AOM (when 80 to 90
% of MEE should have resolved).
Otosclerosis is the 2nd most
common cause of conductive
hearing loss in 15 to 50 year olds
(after cerumen impaction)
A case of chronic sinusitis;
systemic antibiotics may be tried
along with steroid,
123
decongestants, and
vasoconstrictors
Postsurgical acute suppurative
parotitis is a bacterial gland
infection that occurs from a few
days up to some weeks after
abdominal surgical procedures-
S.aureus is the org .
How to examine child ear - Pull
pinna?
Inferior backwards = child
Superior backward = adult
Benign paroxysmal positional
vertigo is the most common
cause of vertigo
Unilateral foreign bodies affect
the right side about twice as
often as the left
Allergic rhinitis: First-line
treatment is with a nasal
corticosteroid (with or without
an oral or a nasal antihistamine)
In children : Most common cause
of epistaxis in children: Voluntary
nose picking.
In adolescent male :
Angiofibroma
In elderly : Hypertension
Streptococcus pyogenes is the
most commonly associated
organism with peritonsillar
abscess
Presbycusis : difficulty of hearing
in crowded or noisy
environments and trouble
hearing high-pitched voice or
noises.
Noise-induced hearing loss is the
most common cause of tinnitus (
other : Quinine - Aspirin -
Diuretics - Antibiotics including
polymyxin , vancomycin - High
blood pressure....)
Cerumen impaction is the most
common cause of conductive
hearing loss for those aged 15-50
yr.
124
Tympanostomy tubes can be
offered for recurrent AOM (3
episodes in 6 mo, 4 episodes in 1
yr) with 1 episode in preceding 6
mo
Chronic Rhinosinusitis: surgery if
medical therapy fails or fungal
sinusitis
90% of nose bleeds occur in
Little’s area (anteriorinferior
portion of the cartilaginous
septum)
Parotid Gland Neoplasms 80%
benign (pleomorphic adenoma –
most common), 20% malignant (
mucoepidermoid – most
common)
Strawberry tongue(scarlet fever)
palatal petechiae (infectious
mononucleosis)
rheumatic fever risk emerges
approximately 9 Days after the
onset of symptom
no evidence for the role of
antibiotics in the avoidance of
post-streptococcal
glomerulonephritis
do NOT prescribe prophylactic
antibiotics to reduce frequency
of AOM
The utricle is largely horizontal in
the head, and largely registers
accelerations acting in the
horizontal plane of the head
(called the axial plane by
radiologists). The saccule is
largely vertical, actually
parasagittal, in the head, and
registers accelerations in the
vertical plane (called parasagittal
or coronal plane).
the saccule and utricle >> for
linear acceleration
High resolution noncontrast CT
scanning is currently the imaging
modality of choice for the
evaluation of salivary stones
aphthous ulceration in the
mouth : he most common
treatment for aphthous ulcers
includes symptomatic relief with
agents such as triamcinolone
125
acetonide in Orabase- The
pathogenesis of aphthous ulcers
is not well-defined. Alterations in
local cell mediated immunity
may be important in the
pathogenesis of RAS
URTI with streptococcus type A,
treatment is Penicilline for 10
day- Erythromycin or another
macrolide can be used in
patients who are allergic to
penicillin
post rhinoplasty, presented with
brown discharge with foully odor
from the wound, what could be
the management? Debridement
and antibiotic
For patients with seborrheic
dermatitis of the scalp
(desquamation with
inflammation) we suggest
treatment with an antifungal
shampoo with or without a
topical high-potency
corticosteroid.
ulcer on the nose with averted
edge : Basal cell carcinoma
meniere disease advised to take:
Low salt no caffeine
tympanogram
‫ اوال‬A ‫ضغط طثٍؼً تاالذن اهىسطى‬
‫ ثانٍا‬B ‫ال حركٍح او حركٍح خفٍفح ( اما‬
‫انثقاب ) او تجمغ سائن‬
‫ ثاهثا‬C ‫) ضغط سوثً ( انسحاب غشاء اهطثن‬
‫ راتؼا‬As ‫ هنا نجد‬very stiff middle
ear system ‫سثثها تصوة اهغشاء او‬
‫ تصوة االذن‬otosclerosis ‫او‬
myringosclerosis
‫ خامسا‬Ad ‫غشاء مطاوع تشدج تراه فً ػدى‬
‫اتصام او ثثاخ اهسوسح اهؼظمٍح‬
external laryngeal nerve ==Loss
of sensation superior to vocal
cords
Tinnitus is most commonly
associated with SNHL.
126
Hearing loss most often occurs at
higher frequencies. Noise-
induced (occupational) HL is seen
at 4000 Hz. HL associated with
otosclerosis is seen at 2000 Hz
(Carhart’s notch).
Auditory Brainstem Response
does not require co-operation of
patient (therefore of value in
children and in malingerers)
Otoacoustic Emissions = often
used in newborn screening
BPPV :drugs to suppress the
vestibular system delay eventual
recovery and are therefore not
used
Noise-Induced : 85 to 90 dB over
months - single sound impulses
>135 dB
: ً‫التهاب االنف التحسس‬
2 ‫خفٌف متقطع = انتً هٌستامٌن جٌل‬
‫فموي ا و انفً عند اللزوم‬
= ‫اعراض دائمة او مؤثرة على الحٌاة‬
ً‫ستٌروئٌد انف‬
ً‫شدٌد دائم = ستٌروئٌد انفً مع انت‬ decreased hearing but his own
‫هٌستامٌن انفً او فموي او كرومولٌن‬ sound feels louder than before
‫أنفً او أنتً لٌكوترٌن‬ to him = ً‫نقص سمع نقل‬

: ‫التهاب االنف المحرك الوعائي‬ The nasopharynx is innervated

ً‫انسداد انف = ستٌروئٌد انف‬ by the maxillary nerve (CNV2).

‫سٌالن فقط = ابراتروبٌوم‬ • The oropharynx by the

glossopharyngeal nerve (CNIX).
ً‫سٌالن مع عطس او سٌالن خلفً = انت‬
ً‫هٌستامٌن انف‬ • The laryngopharynx by the
vagus nerve
‫التهاب الطبلة الفقاعً نفس العوامل‬
‫المرضٌة اللتهاب االذن الوسطى – االولى‬
‫الرئويات‬
External otitis : polymyxin B -
neomycin - hydrocortisone
ofloxacin and ciprofloxacin
How to assess hearing in adult:
sound of watch

burkitt lymphoma : ki67 +ve /

BCl2 over expression
external laryngeal nerve=tension
of vocal cords

‫تعصٌب الغدد اللعابٌة = العصب السابع‬

superior laryngeal nerve =
external laryngeal nerve +
the lingual nerve is a branch of
Internal laryngeal nerve ( ‫الحس فوق‬
the mandibular division of the
‫)مستوى الحبلٌن الصوتٌٌن‬
trigeminal nerve (cn v ), which
supplies sensory innervation to
the tongue
OSA : CPAP is the best initial
management. If failed, bilevel
positive airway pressure (BiPAP)
device then an oral appliance
(OA) therapy
127
Ophthalmology:
Neonatal conjunctivitis
Chemical :First 24 hours
Gonococcal :2-5 Days - IV or IM
ceftriaxone
ChlamydiaI :5-14 Days –Oral
erythromycin
Viral conjunctivitis : The most
common form of conjunctivitis -
recent history of upper
respiratory tract infection-
antihistamine/decongestant
drops.
Open-angle glaucoma generally
occurs bilaterally, but angle-
closure glaucoma occurs
unilaterally
Central retinal artery occlusion
Ophthalmoscopy Pallor of the
optic disc and cherry red fovea -
Treat with an ocular massage
and high-flow oxygen
BC Most commonly caused by S.
aureus in adults,
128
Age-related macular
degeneration (AMD) is the most
common cause of irreversible
central vision loss in elderly -
dietary supplements, intravitreal
injection of antivascular
endothelial growth factor drugs,
laser photocoagulation
The most common
ophthalmologic finding in HIV is
cotton-wool spots caused by
retinal ischemia secondary to
microvascular disease
Vitreous hemorrhage : The most
common cause is diabetic
retinopathy -Immediate
ophthalmoscopic consultation is
required
Graves ophthalmopathy is the
most common cause of
exophthalmos in adults
Prevention of gonococcal
conjunctivitis in newborn by
erythromycin ointment on eyes
Elevated intraocular pressure is a
risk factor for open angle
glaucoma, but it is not diagnostic
Indications for ophthalmology
referral in corneal abrasions
include ulceration, pus, drop in
visual acuity, or lack of healing
within 3-4d
What is the most common cause
of corneal abrasions ? Contact
lens trauma
Infant born with hemangioma on
the right eyelid what is
appropriate time to operate to
prevent amylopia:1 week
Acute dacryocystitis can be
complicated by preseptal or
orbital cellulitis, sepsis, or
meningitis and should be treated
promptly with systemic
antibiotics - oral clindamycin , or,
if more severe, intravenous
vancomycin is often a first-line
antibiotic in combination with a
third-generation cephalosporin
to cover a broader spectrum
129
sneezes see flashes asking the
possible causes: Mechanical
stimuli to retina, irritation of
optic disc
The standard approach to herpes
zoster ophthalmicus is to initiate
antiviral therapy ( acyclovir ,
valacyclovir , or famciclovir ) to
limit VZV replication and to use
adjunctive topical steroid drops
to reduce the inflammatory
response and control immune
keratitis and iritis
blow out fracture: restricted
EOM, diplopia, enophthalmos
(sunken eye)
corneal ulcer Treatment
• urgent referral to
ophthalmology
• culture prior to treatment
• topical antibiotics every hour
• must treat vigorously to avoid
complications
moisturizing eye drops 4 times
daily : 1 drop in the lower fornix
Herpes Simplex Keratitis :
topical antiviral such as
trifluridine, consider systemic
antiviral such as acyclovir
• dendritic debridement-NO
STEROIDS initially – may
exacerbate condition
Subconjunctival hemorrhage :
give reassurance if no other
ocular findings, resolves
spontaneously in 2-3 wk
if recurrent, consider
medical/hematologic work-up
Long use of topical corticosteroid
lead to: Cataract
This patient see letters at 20 feet
, where normal person see it: At
70 feet
Average IOP = 15 ± 3 mmHg
In children, bacterial
conjunctivitis is more common
than viral and is mainly caused
by H. influenzae, S. pneumoniae
and M. catarrhalis
130
leukocoria: white reflex (absent
red reflex, must rule out
retinoblastoma)
Orbital Cellulitis :IV antibiotics
(cefriaxone + vancomycin) for 1
wk
Hordeolum vs. Chalazion
Hordeolums are due to an
infectious etiology, whereas
chalazions are granulomatous
inflammation
Follicles are usually seen in viral
and chlamydial conjunctivitis
Papillae are usually seen in
allergic and bacterial
conjunctivitis
CHLAMYDIAL CONJUNCTIVITIS :
leading infectious cause of
blindness in the world-
treatment: topical and systemic
tetracycline
To differentiate between
episcleritis and scleritis, place a
drop of phenylephrine in the
affected eye. Re-examine the Timolol is A Nonselective B
vascular pattern . Episcleral blocker Should be avoided in
vessels should blanch. Scleral asthma/COPD
vessels should not .

Cavernous sinus syndrome CN VI

Scleritis : systemic NSAID or
steroid (topical steroids are not
effective)
NEVER patch abrasion if patient
wears contact lenses (prone to
Pseudomonas infection).
corneal hypoesthesia (in viral
keratitis)
an abrasion appears clear while
an ulcer is more opaque
(6) is most susceptible to injury
squint some time corrected by
glasses and some time need
surgery) Nonsurgical treatments
include patching, correction of
full hyperopic refractive error
(glasses) then if not improved
surgery.
function of superior rectus
muscle elevates , intorsion , and
rotate medially the eye
(Adduction)

Steroid treatment for ocular

disorders should only be
Bacterial keratitis occurs with
prescribed and supervised by an
contact lenses mc organism
ophthalmologist, as they can
pseudomonas aeruginosa
impair corneal healing and
exacerbate herpetic keratitis.

Severe purulent discharge is

suggestive of gonococcal
the risk of both cataracts
infection.
(posterior subcapsular) and
glaucoma is increased in patients Mucopurulent discharge
on glucocorticoids and is dose- typically occurs in chlamydia
related
131
Ophthalmologist referral is
indicated for any pt with
conjunctivitis presented with
one of the follow- ing Sx:
Patients with pain, photophobia
or blurred vision , Severe
headache with nausea , Recent
trauma to the eye , Use of
contact lenses
Complications of cataract
surgery : Endophthalmitis
mainstay therapy of orbital
pseudotumor is Systemic Steroid
Scleromalacia Perforans :
Strongly associated with
rheumatoid arthritis
treatment for high myopia:
Phakic Intraocular lens
Retinoblastoma is the most
common intraocular tumor of
childhood- Leukocoria is the
most common presenting
finding-Other presentations may
include strabismus, decreased
vision, ocular inflammation, and
132
family history. Spontaneous
necrosis of the tumor can lead to
a severe intraocular
inflammatory response,
presenting as pseudo-
endophthalmitis.
A patient who has been
discovered to have a bruit over
the eye : Cavernous sinus
fistulas
In patients with acquired
esotropia, surgery is indicated
when the deviation is greater
than 15 PD and stable
A punctal plug (tear duct plug) is
a small medical device that is
inserted into the tear duct
(puncta) of an eye to block the
duct
Neuroblastoma is the most
common occult malignancy to be
associated with pediatric Horner
syndrome
Nummular ( ً‫ )درهم‬keratitis
[cloudy dots on the cornea] It is a
common feature of adenoviral
keratoconjunctivitis , as well as
approximately 1/3rd of cases of
Herpes Zoster Ophthalmicus
infections. It represents the
presence of anterior stromal
infiltrates.
Hallmark of Central Retinal
Artery Occlusion "Cherry-red
spot" located at centre of macula
(visualisation of unaffected
highly vascular choroid through
the thin fovea)
Foreign Body in cornea :treat as
per corneal abrasion
Snellen Acuity = testing distance
(usually 20 feet or 6 metres )
Acute dacryocystitis can be
complicated by preseptal or
orbital cellulitis, sepsis, or
meningitis and should be treated
promptly with systemic
antibiotics
133
Bacterial conjunctivitis Systemic
antibiotics are indicated for N
gonorrhea infant (penicillin G),
mother and high risk contacts
(ceftriaxone) and chlamydial
infections: infant (erythromycin)
mother and at-risk contacts
(doxycycline)
Photokeratitis (ultraviolet
keratitis) is an acute syndrome
causing severe eye pain that
begins 6 to 12 hours after
exposure to ultraviolet light .
fluorescein staining may show
punctate corneal staining.
The “blood and thunder”
appearance on fundoscopy is
very characteristic of a CRVO.
Macular Degeneration :
progressive central visual loss-
metamorphopsia due to macular
edema
CN III palsy will respond to drugs
(e.g. pilocarpine), unlike a pupil
dilated from medication
(mydriatics)
Argyll-Robertson
Pupil=neurosyphilis
Diabetes Mellitus = sudden
change in refractive error :
changes in blood glucose levels
(poor control) can suddenly
cause refractive changes by 3-4
diopters
Macular edema is the most
common cause of visual loss in
patients with background
Diabetic Ritinopathy.
Epiphora in children – r/o
congenital glaucoma
In children, bacterial
conjunctivitis is more common
than viral and is mainly caused
by H. influenzae, S.pneumoniae
and M. catarrhalis
Ring lesion in eye (keratitis ) =
Acanthamoeba infection
post op complications of laser is
dryness of the eye , to prevent
134
this dryness =blockage of
punctua
Which layer remove excessive
water from cornea=endothelium
Follicular Keratosis = Vitamin A
deficiency
works on the computer for long
hours per day came with tearing
of eyes =because of Lack of
blinking
bacterial conjunctivitis =
erythromycin ophthalmic
ointment
Diabetes Mellitus : most
common cause of blindness in
young people
changes in blood glucose levels
(poor control) can suddenly
cause refractive changes by 3-4
diopters
Chemical Burns alkali burns have
a worse prognosis than acid
burns because acids coagulate
tissue and inhibit further corneal
penetration

135