Short Cases IM 2021 PDF

‫الفايل دا تجميع ألسئلة الدكاترة فى لجان الكلينكال ( االجابات هو اجتهاد شخصي لو في اجابة انت شاكك‬ ‫فيها اوي ارجع للكتاب وانا هعلملك على الى انا نفسي مش متأكد منه انا حاولت اجمعلك االسئلة بس‬ ‫ من الدكاتره بتبقى عايزه كالم سهل وبسيط متقلقش ) – بص على اخر صفحة‬%80‫و‬ DM 1- Uncontrolled DM:...

‫الفايل دا تجميع ألسئلة الدكاترة فى لجان الكلينكال ( االجابات هو اجتهاد شخصي لو في اجابة انت شاكك‬ ‫فيها اوي ارجع للكتاب وانا هعلملك على الى انا نفسي مش متأكد منه انا حاولت اجمعلك االسئلة بس‬ ‫ من الدكاتره بتبقى عايزه كالم سهل وبسيط متقلقش ) – بص على اخر صفحة‬%80‫و‬ DM 1- Uncontrolled DM: - Is this patient controlled? - Values of controlled DM? = FBG 80-130, PPBG 50F, Cholesterol ‫ حابه تسمع‬caplan syndrome ( nodules + pneumococcus ) = ILF = pleurisy 1_RA ‫دكتوره منى حلمى‬ ‫ ايه ال‬other systems scelromalcia = bilateral thinning of sclera and blue color of the underlying choroid ‫ هديلها ايه قبل ما تبقى‬perforant methotrexate ‫مش هستخدمه فى ايه فى ال‬lung ‫ قولتلها‬IPF ‫ايه انواع ال‬biological ‫ وامته استخدم ال‬il-6 inhibitor ‫ليه بدى‬steroids = end stage of any chronic inflammatory disease = bridge therapy = contraindication to MTX as pregnancy = intra articular to relieve ‫مثال‬kidney‫وبعدين قالتلى فى ال‬ OMAR MOHAMED 22 kidney affection in RA common or not and mechanism = NSAIDs = Vasculitis = amyloidosis strategy of ttt other investigations signs of activity = Sc nodules = palmer erythema = increase ESR,CRP = thrombocytosis = morning stiffness = boggy synovium of wrist Radiological signs = Joint erosions in x-ray and bony calcifications = us: joint swelling and effusion OSCE : examine RA hand / inspection = tenderness test name : squeezing test = do Tinel test = causes of carpal tunnel s : = Causes of muscle wasting in RA : nonfunctioning – deformity – drugs (CST) – vasculitis associated myositis = palmer erythema ( describe & its causes ) OCPs – SLE – pregnancy – liver cirrhosis OMAR MOHAMED 23 Ankylosing 4.inspect back causes of scapular winging? = long thoracic nerve injury = wasting of serratus muscle = dorsal thoracic nerve injury = wasting of trapezes muscle Q: what is meaning of AS? Define y3ny = inflammation of axospinal bones and cause lower back pain and - What is the most affected part in Joint? = Enthesis ( part when tendon attach to bone ) ‫والمرض ده اى نوع‬ = Seronegative arthritis ‫واى أمراض زيه‬ = psoriatic arthritis = enteropathic arthritis = reactive arthritis ‫العالج‬ = joint protection = physiotherapy = NSAIDs = DMARDs = TNF-alpha - Gene defect? = HLA-B27 - Extra articular manifestations? = anterior uveitis = Aortitis = IBD OMAR MOHAMED 24 Inspect back of AS (Dx, how to confirm radiologically and serologically) = X-ray Sacroiliac joint = MRI or CT (better) = Serology : RF -ve , HLA-B27 = lab : CBC anemia – ESR – CRP ‫االسبوت الجاية دي تبع الجيراتريك او الريماتويد مش هتفرق كتير‬ primary and secondary OA ‫اشهر سؤال ممكن يتسأل فيها ايه الفرق بين الـ‬ OSCE: Knee examination = Inspection - Skin: 1- color 2- nodules 3- scars - Joint: 1- swollen 2- deformity - Muscle” quadriceps”: Wasting or not = palpation - temperature ( by back of hand ) - tenderness ( flexion of 30 degree and pressure of joint line ) - crepitus ( put your hand on knee and passive movement of leg ) - movement ( active – passive ) = special test for effusion - patellar tapping ( ‫) هنجمع بايدينا الشمال المياة فى السوبرا باتيلير باوش ونضغط بصباعين ادينا اليمين على الباتيال‬ - bulge test ( ‫هنجمع المياة برده بايدي الشمال وهعمل اب ستروك بايدي اليمين لغاية اما اجمع المياة برا فى الالترل باوش‬ ‫)وبعدين هزق بايدي اليمين وايديا الشمال ثابته من برا لجوا لو اتحركت او بقى فى بلج يبقى تما‬ patellar for massive – bulge for mild or moderate if patellar is positive don’t do bulge ‫عشان مش هيهظهر اصال‬ OMAR MOHAMED 25 Diff bet gout and pseudogout? = Gout is caused by sodium urate crystals and pseudogout is caused by calcium pyrophosphate crystals. ‫مش عارف في فرق كلينكال وال ال هتعبك معلش ودور عليها‬ Causes of unilateral knee swelling? = trauma = Ankylosing = gout = cyst Acromegaly ‫ونصيحة شوف فيديو دكتور مها بندق وركز فيه عشان تفهم‬ 2- Acromegaly ‫ وطلبت‬edema ‫ قلتلها أل ممكن‬acromegaly ‫الهيستوري مكتوب فيه ان الخاتم بقا ضيق على صباعها قالتلي هل الزم السبب يكون‬ test for edema Test for neuropathy (sensations and reflexes and don't forget planter reflex) Peripheral pulsations Causes of headache in acromegaly? = Increase intra cranial pressure = HTN as a complication What's the cause of sudden acute severe headache? = Apoplexy Management (investigations, imaging and Tx) = Lab: IGG-1, glucose suppression test, basal GH, prolactin, FSH, LH and TSH = radiological: MRI Sella Tricia Dynamic Scan = TT: Surgery: transsphenoidal pituitary resection, trans frontal pituitary resection : medical: Octreide : somatostatin analogue , pegvisoment : GH receptor antagonist ‫ طلبت أعمل‬confrontation test = ‫بقف على مسافة متر من العيان وبعدين بخليه يغمي عينه وانا كمان اغمي عيني واحرك اوبجيكت من بعيد لقريب وهو يقولي بدأ‬ ‫يشوفه امتى‬ OMAR MOHAMED 26 2- Acromegaly: missing history ‫= المرض جالك وحضرتك كام سنة‬ ‫= متزوج ؟ عندك كام طفل واخر طفل عنده كام سنة‬ ‫= حضرتك بيجيلك صداع وشكله عامل ازاي وبيجي امتى وبيستجيب للعالج وال ال‬ ‫= فى مشكله فى النظر عينيك بتزغلل او حاجة‬ ‫= بتسوق‬ ‫= وزن حضرتك قل او زاد الفترة الى فاتت‬ ‫= فى تغيير فى عادتك فى الحمام يعني بتميل لالمساك وال لالسهال وبتدخل كام مره‬ cranial symptoms of acromegaly = Headache = diplopia = narrow visual field (bi temporal hemianopia) best treatment = surgery approaches for surgery = transsphenoidal and trans frontal when we use trans frontal not transsphenoidal = in case of macro adenoma (1-2cm) 1)acromegaly take history ‫مش مكتوب جنب المريض قالتلي‬ ‫بعدين سألتني في الموضوع من اول االسباب للعالج‬ ‫وقالتلي‬ = cases: pituitary adenoma = MEN I syndrome ( pituitary – parathyroid – pancreatic ) = paraneoplastic syndrome inspect face = coarse facial features = face elongation = prominent supra orbital ridge = prominent maxilla and zygoma = increase angle of mandible = ‫اقول للعيان يحط سنانه فوق بعض‬ protrusion of lower jaw : prognathism = ‫ افتح بوقك‬deviation between teeth = : ‫ طلع لسانك‬slight macroglossia = enlarged nose and ears = no acanthosis = goiter ‫ابلع كدا لو سمحت‬ OMAR MOHAMED 27 palpate liver and spleen = splenomegaly because increase of soft tissue and also hepatomegaly relation bet acromegaly and goiter? = Long lasting stimulation of the follicular epithelium by growth hormone and insulin like growth factor 1 by3ml goiter after surgical removal, single best test to follow up? = IGF-1 Long term complications = HTN = ischemic heart disease = LVF = DM = myopathy = carpal tunnel syndrome = blindness 1- Acromegaly Missing point in history? Headache analysis = Site “frontal “ = time "more at morning" = associated eye manifestation: diplopia, squint He wanted me to ask about other signs of increased intracranial pressure = " vomiting WITHOUT NAUSEA " = diplopia = bitemporal hemianopia He asked about face features = elongated face = coarse facial features = prominent supra orbital ridge, maxilla, zygomatic = increase angle of mandible = lower jaw protrusion after put two jaws on each other (prognathism) = macroglossia = enlarged lips = enlarged nose and ears He asked how to examine prognathism? ‫بخلي العيان يحط اسنانه علي بعضها و اشوف من الجنب مش مجرد نبص عالدقن و اكدلي عالحتة دي‬ OMAR MOHAMED 28 He asked about hand features = enlargement of width and length (spade like) = enlargement of fingers = greasy doughy hand “Shake hand “ = carpal tunnel syndrome “reversed prayers sign “ ‫ و سألني يعني ايه‬doughy ‫قلت له زي العجينة قالي ال عجينة ايه الجيل دا معدش بيدخل مطبخ وال يعمل عجينة يعني انتي تعرفي‬ ‫احساس العجينة ؟ كان عايزني اقول حاجة تانية بس طبعا انا فهمته اني مش بطلع من المطبخ و مظبطاهم بالعجينة و عارفة احساسها و‬ ‫كدا فاضطر يعديها‬ He asked how to proceed with diagnosis: Investigation lab w imaging ‫قالي لو هتعملي للعيان اشاعة واحدة بس تختاري ايه‬ MRI CELLA TURCICA WITH gadolinium Dynamic scan How to manage your patient? I said surgery is the first choice ‫و مسابنيش اكمل و قالي تمام‬ 3_Acromegaly Missing items w Comment on features w investigations w complication w Rx ‫والدكتور سألنى ال‬height w breadth ‫ بيبقوا ايه لبعض المفروض هيبقي‬proportionate ‫ عشان ده‬after puberty w not affecting long bone 1. Acromegaly: complete hx, examine acral parts, tx, investigations, ‫بعدين سألني عن جرعات االدوية‬ ‫إيه اإلشاعات اللي بطلبها للكعب‬ = CT – x-ray OSCE Acromegaly face hand ‫واهم حاجه تفتح بوقها‬ Causes and treatment = pituitary adenoma = paraneoplastic = MEN 1 Acromegaly - identify - signs in picture (face) - signs in the hands you would expect - 2 lab tests 4-inspect face of acromegaly investigation OMAR MOHAMED 29 ttt GH secreted from each cell and under effect of what = somatolactotrophe = GHRH from hypothalamus Acromegaly, what are radiological signs = increase heel bad soft tissue = spade like hand = kyphosis acromegalic face &acral parts, how to dx & examine carpal tunnel $ = revised prayers test =Tinel test ٤- ex of face hand feet acromegaly ‫العالج ؟‬ ‫االدوية ؟‬ Pegvisoment mechanism of action? GH receptor antagonist Octreotide 3. Acromegaly identify, 3 clinical from picture and 3clinical in his hand 2 confirmatory test for the case : GH supperion test OMAR MOHAMED 30 Thyroid Graves’ disease Missing points in history = wt. loss = ‫نهجان وانتي قاعده وال وانتي بتشتغلي وبترتاحي ازاي‬ = ‫الحمام زياده وال اقل ؟‬ = ‫حد من العيلة جاله نفس المرض دا او جاله اورام عموما ؟‬ = ‫حضرتك بتدخن‬ = ‫الحالة بدأت من امتى وبقالها قد ايه‬ Investigations: = thyroid profile: TSH low T3T4 high = nonspecific ( AST/ Ck/ LDH) = specific antibodies ( thyroid stimulating immunoglobin ‫)اسمها مهم لبعض الدكاتره‬ = US = diffuse iodine uptake scan Treatment and contraindications of RIA therapy = Antithyroid drugs, B-blockers, RAI, surgery = Antithyroid: carbamizole, propylthuracil = Surgery: total thyroidectomy = MNG, retrosternal goiter, recurrent thyrotoxicosis = RAI: indicated in (elderly – patient refused to surgery – contraindicated to surgery) = Contraindications: ( young age – pregnancy – lactation ) Other cause of weight loss in this patient: Type 1 DM Inspection and palpation = inspection: 6 items ( ‫ابلع‬- site – size – shape – per penton sign – skin overlaying) = palpation: Gland = 8 items (4 s + 1 c + 3 t) (site – size – shape – surface – consistency – temperature – tender – thrill) Carotid “in place or not “(if shifted that’s mean infiltration of the underlying structure) LN (supra clavicular – retro auricular – submental) Hyperthyroidism (symptoms, diagnosis graves, investigation, other causes of wt. loss with increase appetite, treatment, if pregnant which type of drug = PTU (proprothiouracil) OMAR MOHAMED 31 --why thyroid is movable with deglutition: because It’s attached to peritracheal facia Thyroid in elderly dr Marwa ‫ و دخلت في تفاصيل نظري‬video osce ‫زي ما قالت في‬comment ‫هي بتسأل من دماغها و بتقلب الورقة المتعلقة و عايزة ال‬ ‫بس‬geriatrics ‫ و اسباب خاصة بال‬ttt ‫ و‬features ‫و كانت عايزة‬ ‫ بس‬RAI ‫ و بدي‬oral ‫سألت ليه مش بدي‬ = because oral takes time to effect on gland and I’m not sure about patient’s compliance ‫ ايه ال‬investigations (‫ مش‬T3 or T4 or TSH) = US = thyroglobulin levels = nonspecific ( AST/ Ck/ LDH) most common features of hypothyroidism in elderly confusion, anorexia, weight loss, falling, incontinence Most features of hyperthyroidism in older = tachycardia>90, wt. loss, fatigue extra questions of Dr. Marwa videos: - Main causes of hyperthyroidism in elderly: = Graves, MNG - main causes of hypothyroidism in elderly: Hashimoto’s disease/ idiopathic. Previous irradiation Surgical removal of the thyroid gland After 131I therapy for hyperthyroidism - Complications of hyperthyroidism: = AF = HF -TT of choice in elderly: = RAI - TT of choice in MNG = Surgery - TT of AF in patient: = B-blockers (dual effect: decrease t3 w t4 activity + protect heart by decrease contractility) ‫ شوفوا‬video ‫ النظري و‬osce ‫بتاعها عشان عايزة كالمها‬. ‫المعيدين قالوا اسألتها مش سهلة بس درجاتها كويسة‬ OMAR MOHAMED 32 2. Thyroid ‫ هي الست كانت نفس الي بفيديو‬thyroid in elderly ‫ فالمفروض انها‬hyper ‫ بس حاطين ال‬case scenario ‫ انها‬hypo Examination of thyroid Investigation other than TSH T4 ‫النها عامالهم‬ Rx 2. Hypothyroidism Cause acc to hx autoimmune b/c her cousin has celiac ‫هخه‬ Thyroid examination Other signs = wt. gain, constipation, cold intolerance, memory change, bradycardia Other inv. = US and ECG 2- hypothyroidism ‫جايبيين الست الللي في فيديو الجيرياتركس بس الكيس مكتوبه على انها هيبو مش هيبر‬ ‫ الدكتوره سالت في الهيستوري وكانت عايزه تسمع مني‬family history of malignancy ‫ واني اعمل‬US ‫ عشان استبعد ان دا‬malignant swelling ‫ ولما وصلتلهاوقفتني وقالت اعمل‬examination ‫نفس الفيدديو بتاع الجيريارتكس‬ Hyperthyroidism. Smoking w family hx significance Typ l smoking by2sr 3la a fl thyroid? Oltlo cancer ali la2 l cancer thyroid is tha only cancer not related to smoking 2li nodules w eye manifestation of graves w graves nfso S2lni 3n asbab el tender thyroid ? Ana otl w howa a3d zwd overall kan bytklm y3ni w discussion OMAR MOHAMED 33 ‫)‪Subacute Hypothyroidism (a case of high tsh and normal t3 w t4‬‬ ‫تسأل المريض عن ايه تاني؟‬ ‫هسأله عن ال ‪constipation‬مثال وباقي الحاجات اللي ممكن تحصل مع ال ‪hypothyroidism‬انا طبعا مفتكرتش اسأله عن ايه‬ ‫فعملت نفسي بقري الورقه تاني ورجعت قولتله اتفضل يادكتور فقالي هو انا مسألتكش قولتله ايه السؤال فراح سألني السؤال اللي‬ ‫بعده‬ ‫اعملي ‪ inspection of thyroid‬وايه اكتر حاجه تفيدك في ال‪inspection‬؟‬ ‫هتعمل زي االوسكي عادي‬ ‫اكتر حاجه هتفيدني غالبا اني اقوله ابلع واشوفها‪movable with deglutition.‬‬ ‫‪if she has hyperthyroidism manifestation but she is hypothyroidism what do think the‬‬ ‫?‪cause‬‬ ‫‪= She takes overdose of levothyroxine.‬‬ ‫‪= May in early thyroiditis.‬‬ ‫المريضه قالت حاجه غريبه بس افترضت انها تقصد انه بيحصلها اختناق قدا او صعوبه نفس احيانا لما تيجي تنام فسألني دا‬ ‫يقولك انه فيه ايه؟‬ ‫قولتله عندها‪retrosternal goiter‬‬ ‫قالي طيب دا بيعنيلك ايه؟‬ ‫قولتله انه الحاله دي عالجها ال‪surgery‬‬ ‫وانه الحاله دي هيبقي عندها‪positive per penton sign‬‬ ‫وانه هيبقي فيه‪dullness on percussion on sternum‬‬ ‫كمان مش هقدر اعمل‪insinuation of my hand‬‬ ‫سألني بديها عالج ايه وبديلها العالج ازاي؟‬ ‫قولتله ‪ levothyroxine‬وبديلها قبل الفطار بساعه علي االقل ويتاخد علي معدة فاضيه ومفروض كمان تقريبا بعد اخر وجبة بالليل‬ ‫ب ‪٤‬ساعات‬ ‫سألني تعمل للحالة دي ‪ investigation‬ايه؟‬ ‫قولتله ‪ us‬و ‪tsh‬و ‪t3‬و‪t4‬‬ ‫قالي ليه هتعمل ‪ us‬هتفيدك بايه؟‬ ‫قولتله هشوف بيها لو فيه أي ‪ nodules‬او حجم ال ‪gland‬وكدا ولو احيانا ممكن تساعدني لو كان فيه ‪ malignancy‬فقالي تمام‬ ‫قالي لو أنا عايزك تعمل ‪ one investigation‬كافي لحاله ‪ hypothyroidism‬هتعمل ايه‬ ‫قولتله هعمل ال ‪ TSH‬بس هو في االغلب يادكتور لو هي حاله ‪ primary‬بعمل ‪ TSH‬لكن لو الحاله ‪ secondary‬بعمل‪t4‬‬ ‫قالي ‪ secondary‬زي ايه؟‬ ‫قولتله حاجه في ال ‪pituitary‬مثال‬ ‫‪OMAR MOHAMED‬‬ ‫‪34‬‬ Case thyroid examination of thyroid ‫امتى تموت العيان وانت بتعمل‬ When you felt both carotid at the same time full examination‫كان عايز‬ ‫ وزمان كان بيتشخص ازاى‬gravis ‫ اتسمى‬gravis ‫وسأل عن ليه‬ ‫ هبدت وقولتله العالم اللى اكتشفه كدا وزمان ما كانش فيه‬antibodies w lab investigation ‫ فكان بيتشخص ب‬goiter w acropathy w peritabial myxedema w exophthalmos ‫كان عايز االجابه دى بالظبط‬ fertility‫وسألنى ازاى اللى عندها يأثر على‬ estrogen level will be increased so this will inhibit LH surge so cause anovulation ‫ وسأل على‬ttt in details Skin manifestation in thyroid patient = hotness = redness = sweaty hand = palmer erythema and spider nevi (estrogen high) = pretibial myxedema = thyroid acropathy = alopecia OMAR MOHAMED 35 OSCE: - Thyroid Inspection Arm elevation What else? Kocher test ( move one lobe to anther if stridor happens this mean +ve) - Thyroid (BRUIT by bell or dipharagm of stethoscope and why) bell of stethoscope as it is low pitched sound - Thyroid examination -Full inspection and palpation -Why do we percuss the sternum? Retrosternal extension -Best test for thyroid: TSH Written osce 3/ three pictures ( face with exomphalos , diffuse goiter_ pretibial myxedema _ thyroid acropathy(clubbing grade 4) ) Diagnosis, four signs in pic , two investigation ‫ عين و رقبة و رجل‬graves ‫صور‬- Dx? Specific clinical finding? 2 invx? OMAR MOHAMED 36 CKD ‫عفانا هللا وعفاكم‬ 1-AV fistula: ‫دكتورة سهير من قسم النيفرولوجي‬ Examination Pathogenesis of bone disease in CKD = hyperphosphatemia + vit d deficiency = causes 2ry and 3ry hyperparathyroidism that causes increase in osteoclast activity so increase osteoporosis Grades of CKD = G1 = >90 = G2 = 60 – 89 = G3a = 45 – 59 = G3b = 30 – 44 = G4 = 15 – 29 = G5 = < 15 = A1 < 30 = A2 30-300 = A3 > 300 Treatment of CKD ‫اقراءه كويس من الكتاب ونظمه مع نفسك كده يمكن تجمعه احسن‬ = protein restriction, salt and water = treatment of HTN by ACI and diuretics = treatment of acidosis by NaHco3 = treatment of hyperkalemia by ( inlsuin,glucose,calcium gluconate and maybe dialysis) = treatment of anemia = treatment of bleeding Treatment of Anemia in CKD = erythropoietin 75-150 mg/week = Iron therapy = transfusion Examination of neck veins Causes of congested neck veins = CHF = constrictive pericarditis = tricuspid stenosis Auscultation of heart‫كان كويس كانت عايزه تشوف هعرف احدد االيبكس صح وال ال‬ Inspection of back ‫كان في ليبوما وتقول انها موجوده وخالص‬ OMAR MOHAMED 37 Chronic renal failure patient with dyspnea 1) grades of dyspnea ‫دي تقسيمه متألفه كدا معرفش ياقوت كاتب حاجة منظمه وال ال‬ 4 grades = dyspnea with after effort = dyspnea with during effort = dyspnea with minimal effort = dyspnea at rest 2) causes of dyspnea in renal patient = Volume overload, =pulmonary edema = CHF 3) signs of intravascular hypervolemia = Congested neck vein bradycardia.......‫ يبقي ايه سبب ال‬bradycardia ‫لو جالك االستقبال ومعاه‬4) management‫ وال‬sign ‫ وهيسألك ايه ال‬hyperkalemia ‫هتبقي‬ = insulin , glucose and calcium gluconate , dialysis and diuretics 5) type of breathing.... Kusmmel beathing ‫ وقولي ارقام ال‬acidosis 6) examine AVF ‫ ايه اللي تخاف منها‬danger sign ‫ وقولي ايه ال‬brachibisalic ‫عنده‬ infection – aneurysm – steel phenomenon ‫لو فاكر اكتر زود المهم تقول اول حاجة االنفيكشن‬ CKD Symptoms, signs, grades, investigation, treatment, exam AV fistula ‫ كل حرف كان ف الكتاب كان عايزه وسؤال الفزلكه حقنه‬erythropoietin ‫ كام‬unite 75 – 150 OMAR MOHAMED 38 1. CKD Definition = progressive irreversible decrease in renal function 2 most important causes = DM – HTN Missed history Rx Investigation = CBC, electrolytes, urine analysis, renal function test = US, biopsy Size of kidney in us = small in size when can be enlarged kidney with ckd = DM – polycystic kidney – hydronephrosis - amyloidosis Causes of dyspnea = CHF = volume overload = pulmonary edema Rx of DM with ckd = tight glycemic control = tight BP control TIPS - balloon tamponade may be bridge therapy in rebleeding until definitive treatment SLE hematology: Thrombocytopenia/ hemolytic anemia / leukopenia All types of anemia Increase D dimer Early radiology for RA changes? US for joint swelling and effusion Lung in RA => Caplan syndrome ( pneumoconiosis and nodules) ‫ تقول للعيانة افتحي بؤك‬acromegaly ‫مهم ف ال‬ ‫ وتشوف لسانها‬diastema ‫عشان تشوف‬.‫وكده‬ ‫ سبب الهيبو ايه؟‬celiac.. ‫ اخوه عنده‬hypothyroidism ‫كيس‬ Autoimmune Investigation? Lab specific (tsh/ t3/t4/ antibodies) nonspecific ( AST/ Ck/ LDH) Radio (US/ thyroid scan) ‫متنساش التقسيمة دي‬ LL inspection of DM … most common complication/ deformity? CHARCOT JOINT Cause of atrophied skin? macroangiopathy ‫ايه بيحصل بسببها؟‬ Macrovascular complications Chron’s ‫ اللي هو صوبعين على بعض عكس عكاس تشوف الزاوية اللي‬shamroth test ‫عن طريق‬Examine hand for (clubbing / muscle wasting)‫بينهم‬ Examine face for (Jaundice / red eye / aphthous ulcer) DVT: dx US Swelling in calf ms/ tender/ hot Abdominal Causes of clubbing ١ ‫من فايل الصور اللي بتاع باطنة‬ Bilharziasis with gastric polyps/ Hepatopulmonary syndrome / liver cirrhosis/IBD/ Primary biliary cirrhosis OMAR MOHAMED 42  Chron’s ‫ تساله ايه ليه عالقة باالعراض اللي هي‬abdominal pain w diarrhea w weight loss ‫ تعمل‬analysis ‫ يعني‬onset course duration ‫ تساله عن ايه ملوش عالقة باالعراض دي؟‬extracolonic manifestations ‫ متنساش تحليل‬calorotectin Normal 150 ‫ اليه ؟‬palpation ‫تعمل‬ Liver w gallbladder primary biliary cholangitis and cholesterol stones‫عشان‬ Splenomegaly with leukopenia? Hypersplenism and ITP Splenomegaly with leukocytosis? CML Splenomegaly with erythrocytosis? PRV SLE ‫ من الهستوري؟‬anti-phospholipid syndrome ‫تعرف ازاي انها‬ Repeated Abortions / DVT How to dd between sensory and cerebellar ataxia? ‫حليه يقف وهو فاتح عنيه‬ ‫ لو وقع يبقا‬cerebellar ‫ ثانية‬٢٠ ‫خليه يغمض عنيه بقا لمدة‬ ‫ لو وقع يبقا‬sensory (Romberg test) DM, test for coordination in upper limb? Finger to finger Finger to nose ‫مرة وهو فاتح عينه ومرة وهو قافل‬ confrontation test ‫ ده ف حاالت ال‬acromegaly ‫عشان تشوف العين‬ ‫تقعذ قدام العيان وتخليه يقفل عين وتقفل العين العكسية‬ ‫وتحرك صوباعك ف جيمع االتجاهات‬ Rx Raynaud’s, warming and CCB, nitroglycerin, Phosphodiesterase inhibitor but if severe => Alprost (Prostacyclin analogue) Written Case of hypoglycemia => Dx? Invx? Hx? ‫ موجود ف محمد حسين كسبوت‬.. ‫ الهستوري ده سهل لو مش عارفه‬history of hypoglycemia Spleen enlarged downward and medially. ‫حلو؟‬ ‫ بعد كده يكبر لتحت‬.. ‫ أضعاف حجمه‬٣ ‫بس السبلين ف البداية بيكبر لفوق االول لحد ما يبقا‬ ‫طيب امتا يكبر لتحت بس؟‬ phrenicocolic ligament or tumor infiltration of ligament or severe huge ‫لو فيه مشكلة قي ال‬ splenomegaly OMAR MOHAMED 43  Thromboembolic complications of SLE: 1- TTP (microangiopathic hemolysis/ Renal thrombosis/ thrombocytopenia) Invx: LDH / ADAMS13 Rx: plasma exchange 2- antiphospholipid syndrome (Repeated abortion/ thrombosis) Invx: anti phospholipid Ab (anti cardiolipin)/ lupus anticoagulant) Rx: Heparin, warfarin, hydroxychloloquine Rx diabetic nephropathy? - Glycemic control ‫وتقولي التارجت بتاع التحاليل‬ - BP control < 140/90 - Lipid profile to healthy range - Stop smoking - Reduce protein (0.6-0.8 g/kg/day) - Any diabetic nephropathy patient with any range of proteinuria even normotensive => ACEIS as renoprotection don’t forget to ask the patient about (Malar rash? Itchy or not ‫بيطلع قشر يعني‬ ? ‫ بيزيد مع الشمس؟‬photosensitive) Oral ulcers ‫وباقي الكريتيرتا‬ Causes of mouth ulcers? Bechet SLE Chron’s disease MTX Drug causing mouth ulcer? Methotrexate so we give folic acid with it emaciation: (>20%) body weight loss. Cachexia is the termed used to describe the end stage of emaciation. (extreme weight loss and muscle wasting) Chron’s: ‫ دور ع‬fistula ‫في الناحية الشمال كده‬ ‫ ايه انواع ال‬fistula ‫؟‬ Entero- vesical => Open to UB=> pneumaturia (gas in urine)/UTI Entero-cutaneous at site of surgical scar Entero-vaginal Entero-mesenteric Entero-Enteric Invs for hepatic encephalopathy? blood ammonia and not exclusive signs of HE? disorientation for place, time‫ وتتكلم عن ال‬tremors/ fetor hepaticus/ ‫متنساش‬ disoriented for time)‫ حوالي الساعة كام ( لو تالتة غلط يبقا‬،‫ يوم ايه‬،‫شهر كام‬،‫اللي هو احنا ف سنة كام‬ ‫ فين دلوقتي‬،‫ ف محافظة ايه‬،‫احنا ف بلد ايه‬ disoriented for place‫لو التالتة غلط يبقا‬ OMAR MOHAMED 44  Rx? Treat precipitating factor effective in 90% + + diet (high fiber intake/ protein restriction is controversial) ++ ‫االدوية‬ lactulose=> LOLA=> remove excess ammonia by Krebs cycle Neomycin: inhibit gut flora Rifaximin: selective inhibitor gut flora, (aerobic and anaerobic) + increase acidity/ minimal ‫ بس‬gut ‫عشان كده شغال ع ال‬systemic absorption Flumazenil: benzodiazepine receptor antagonist. Metronidazole Rifaximin? ‫ده ايه‬ ‫ وتقول الكالم اللي فوق عنه‬rifamycin derivative ‫ده‬ Danger sign in AVF? complications ‫ بعدها قول باقي ال‬infection ‫اهم حاجة ال‬ Thrombosis/ outflow obstruction ‫وهكذا‬ Mechanism of octreotide: VC of splanchnic vessels Paracentesis ‫صورة سهلة‬ Three Rx of refractory ascites? - Serial Large volume paracentesis - TIPS - Le Veen shunt - Alfa pump - Aquarerics - CART - Liver transplantation What cause generalized areflexia? Gallian Barre syndrome (bilateral ascending course) ‫ دعواتكم بئا وان شاء هللا امتحانكم يبقى كويس وسهل‬.. ‫بس كدا‬ OMAR MOHAMED 45