magdy abbas (1)

8/14/2019 Magdy Abbas (1)

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Dr. Rami Abazid

1

MAGDY ABBAS

BRAIN MAP

FOR

PACES

PREPARED BY:

DR. RAMI ABAZID


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Dr. Rami Abazid

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TO:THE SOUL OF MY PARENTS

TO: Jailan, Diaa,

Mariam and Reham


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Dr. Rami Abazid

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PREFACE

This edition of the brain map for

PACES is basically designed for the

busy dynamic young doctors who

intended to go through the exam.

I hope this will help candidates to

pass with case.


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Dr. Rami Abazid

4

ACKNOWLEDGEMENTS

I would like to express my sincere feelings and

thanks to the following people.

Dr. Abdulfatah Arafaa-Medical Consultant in the

Farouk Charity Hospital-Cairo

Dr. Abdulla Hamed Abo Jabal-Consultant in Tropical

Medicine, Embaba Fever Hospital-Cairo

Dr. Mohamed Samer-Senior Cardiologist in Mubarak

Hospital-Kuwait

Dr. Samy Zaki-Professor of Gastroenterology-Al

Azhar University-Cairo


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Dr. Rami Abazid

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ABOUT THE AUTHOR

DR. MAGDY ABBAS

Graduate from Cairo University worked as a

Registrar in Kasr El Aini Hospital (Cairo)

Senior Registrar In Adan University (Kuwait)

Consultant in Embaba Fever Hospital (Cairo)

Participated in many Teaching programmed in

Egypt


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Dr. Rami Abazid

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THE PACES EXAMINATION:

Cardiology

10 mins.

Communication

Skill

20 mins.

Brief Clinical

Consultation

10 mins.

Brief Clinical

Consultation

10 mins.

(5) (4)(3)

(1) (2)

Neurology

10 mins.

History taking

20 mins.

Chest

10 mins.

Abdomen

10 mins.


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Dr. Rami Abazid

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ST TION I

MAP FOR

ABDOMEN

&

CHEST


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Dr. Rami Abazid

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ABDOMEN CASES

With stigmata of without stigmata of

CLD CLD

Cirrhosis

Hepatomegally hepatosplenomegally Splenomegaly Ascites

Abdominal masses

I would like to complete my examination

1-Per rectal examination2-External genitalia3-Hernia orifices4-Lymph nodes5-Urine dipstick6-BP T (temperature)


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Dr. Rami Abazid

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C L D

Signs Decompensated D-D Investigation

Signs General* CBC

Spider Clubbing Ascites * electrolyte complicationsNaevi Arms leuconychia

Fistula Hands Palmer erythma Assess

Dupuytrens Jaundice Liver & FP

Contracture Function

Hepatic Encephalopathy -S. Bil. U/SFlap -S. Alb

. -PT

-ALT Search

-AST for the

Parotid cause

Swelling

Jaundice

Wasting Face

Pallor Spider

Anthelasma Naevi

Chest reduced axillary hair hepatitis H.chr. Wilson

Gynaecomastia C. B.Alcohol PBC Virdogy

Shrunken Drugs Study

Liver

Hepatomegaly AIH Alpha 1,AT Auto Immune Iron

Splenomegaly Abdomen Study Study

Ascites

venous

Hum ---L.L. oedema Metabolic Wilson

Alpha1 AT

Caput Medusa -Testicular Atrophy


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Dr. Rami Abazid

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COMPLICATION

OF

CIRRHOSIS

Portal hypertension Hepato Cellular Dysfunction

Varices Ascites hepato Encephalopathy Hepato

Renal cellular

Syndrome carcinoma

Coagulopathy

Bleeding Spontaneous

Bacterial

Peritonitis


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Dr. Rami Abazid

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POOR PROGNOSTIC FACTORS

IN

LIVER CIRRHOSIS

Encephalopathy Na Albumin PT < 120 25g/L

FACTORS PRECIPITATE HEPATIC ENCEPHALOPATHY

Infection Diuretics Electrolyte Sedative Surgery

Diarrhea Imbalance

Vomiting Paracentesis

GI Bleeding


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Dr. Rami Abazid

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TREATMENT OF ASCITES

IN

C L D

Salt restriction Furosemide Serial

to 78 If Na is < 125mmol/L

mmol/dayup to 400mg/day

TIPS

Transjugular

Intra hepatic

Portal systemicShunt

(Aim: one KG weight loss/day)


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Dr. Rami Abazid

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PRIMARY PREVENTION OF VARICEAL BLEEDING

DIAGNOSIS OF CIRRHOSIS

O G D

No varices Grade I Varices Grade 2 or 3 varices

Repeat OGD repeat OGD one year Propranolol

3-4 years 80-160mg/day

HR60

Band ligation if

Propranolol intolerant

or Verapamil

Diltiazem

MANAGEMENT OF VARICEAL BLEEDING

IN CIRRHOSIS

TIPS

Blood transfusion Octreotide Endoscopic Endoscopic Balloon

Sclerotherapy ligation Tamponade


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Dr. Rami Abazid

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HEPATOMEGALY

3 C 3 I

1-Cirrhosis 1-Infection

2-Cardiac CCF -HBU

3-Cancer -HCU

-T.B.

-Brucella

2-Infiltrative

-Amyloid

-Sarcoid

-Myeloproliferative

3-Immune

-AIH

-PBC


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Dr. Rami Abazid

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SPLENOMEGALLY

Mild Moderate Massive


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Dr. Rami Abazid

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MOST COMMON CAUSES OF ASCITES

Pancreatitis

Cirrhosis Malignancy Heart Failure Tuberculosis

TRANSUDATIVE OR EXUDATIVE

S-A ALBUMIN GRADIENT

11 g/L 11 g/L

Transudative Exudative

MYXAEDEMA MAGs SYNDROME

CLD CHC CRF MALIGNANCY T.B. INFECTION


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Dr. Rami Abazid

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RENAL ANGLE MASS

Polycystic Renal Cell Hydronephrosis

Carcinoma Adrenal mass

Retroperitoneal

Mass

WHY RENAL MASS

Can get Minimal Resonant to

Above it Ballottable No movement with Percussion

Notch inspiration


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Dr. Rami Abazid

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SURGICAL INTERVENTION IN

POLYCYSTIC KIDNEY

Massive Recurrent Transplant Recurrent Possible

Cysts Pain work up Infected Malignancy

Cysts

ASSOCIATED INHERITED CONDITION

WITH RENAL CYSTIC DISEASE

Autosomal

Tuberous Von-Hippel Autosomal recessive

Sclerosis Lindou disease dominant polycystic Polycystic

Kidney Kidney


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Dr. Rami Abazid

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CHEST C SES


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Dr. Rami Abazid

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INTERSTITIAL LUNG DISEASE

Dry S.O.B. Fine Endispiratory

Cough Crackles

C A U S E S

TIP

Rheumatological

- Rh. Arthritis Vasculitis

- S.L.E. - PAN

- Systemic Sclerosis -Wegners Pneumocomosis- Polymyositis -Churg-Strauss -Asbestosis Drugs

- Dermatomyositis -Good Pastures Silicosis Amiodarone

- Ankylosing Spondilitis -Beryliosis Nitrofurnatone

- MCTD Busulphan

- Sjogrens Syndrome Bleomycine

Allergic Gold

Radiation Methotraxte

OTHERS

Extrinsic Gauchers

Allergic Lymphangiomyelomatosis

Alveolitis Niemann Pick

NF

Tuberous Sclerosis


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Dr. Rami Abazid

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IDIOPATHIC INTERSTITIAL PNEUMONIATIP

N D A R U C Linda

Usual lymphoid

Interstitial Interstitial

Pneumonia Pneumonia

(UIP) (LIP)

Non Specific

Interstitial Desefuamative Respiratory Cryptogenic

Pneumonia Interstitial Bronchiolitis organizing

(HSIP) Pneumonia Interstitial Pneumonia

(DIP) Lung disease (COP)

(RB-ILD)

Acute Interstitial

Pneumonia

(AIP)


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Dr. Rami Abazid

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INVESTIGATIONS OF ILD

Lab. Radiology Respiratory

-FBC better for

-Inflammatory markers upper lobe

-immunoglobulin

-autoimmune profile CXR HRCT MRI

ANA Pul. Function lung

ENA Test biopsy

ANCA restrictive

Anti G-BM pattern

Reticular Coarse Ground

Shadowing reticular glass B A L

-Precipitins

-Serum ACE

-ABG Honey combing neutrophils lymphocytes

Not responded

To cortisone

Good response

To corticosteroid

Bad prognosis Good prognosis

Respond to

Corticosteroid


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MANAGEMENT OF ILD

Non Pharmacological Lung Transportation

Smoke Avoid exposure long term corticosteroids Young Patent

Cessation to toxic oxygen + rapidly

Substance Azathoprine progressive

Disease

If not tolerate

Corticosteroids if not tolerate

Azathoprine alone Azathoprine

Cyclophosphamide

Discontinuation

Of toxic medication


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Dr. Rami Abazid

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UNILATERAL LUNG FIBROSISEXAMINATION

Flattening of

The affected side

Heterogenous Breath sounds trachea is

percussion of reduced shifted to

the affected + the affected

side coarse crackles side

not changed with

cough

+VR

on the affected side

Reduced movement

Of the affected side


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Dr. Rami Abazid

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CAUSES OF APICAL FIBROSIS

Histoplasmosis

Old T.B. Radiation Ankylosing

Spondolitis Sarcoidosis

Extrinsic allergic

Alveolitis

CAUSES OF BASAL FIBROSIS

ILD

Aspiration Asbestosis Drugs Connective

Tissue disease


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Dr. Rami Abazid

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PLEURAL EFFUSION

Chest expansion breath sounds

On the affected side bronchial breathing

Above the effusion

Stony dullness on

Percussion

PLEURAL EFFUSION

Exudates Pl. Protein between Transudates

PL. protein>35g/L (25-35) g/L Pl. protein


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Dr. Rami Abazid

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PLEURAL EFFUSION

Exudates Transudates

Protein >35g/L between Protein 0.5

Pl. Fluid LDH

DRUGSSerum LDH >0.6

Amiodorone Phenytoin

Methotrexate


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Dr. Rami Abazid

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PNEUMONECTOMY

Chest wall

Chest expansion Trachea

Scar Flattering of the

Affected side

Absent on Grossly deviatedThe affected side to the affected side

Breath sounds

absent on

the affected side

LOBECTOMY

Scar

Chest wall Chest expansion Trachea Breath sounds

localized reduced on the deviated to the reduced on the

Deformity affected lobe affected lobe affected lobe

On upp.lobectomy


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Dr. Rami Abazid

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LUNG CONSOLIDATION

Chest wall Chest expansion Trachea Percussion

normal

Reduced not shifted dullness

Except if associatedCollapse

Breath

Sounds

C A U S E SBronchial

breathing

crepitations

Infection Vasculitis malignancy Cysts

Vocal

Infarction resonance

Granuloma


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Dr. Rami Abazid

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BRONCHIECTASIS

Investigations

Lab Radiology Special

-Sputum CLS

-Sputum AFB

-Sputum gram stain CXR HRCT Bronchoscopy-Immunoglobulins for malignancy

-Rheumatology profile

-Na Sweat Test

-Genetic Screening for C.F. Tranlines shadows Signet ring sign

Ring shadows Thickened dilated

Bronchi Larger than

Vascular bundle


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BRONCHIECTASIS MANAGEMENT

Non Pharmacological Medical

-Stop smoking

-Pulmonary Rehabilitation Vaccination Surgery-Multi-disciplinary -annual Influenza for localized

Management -H. influenza -Antibiotic disease

-Pneumococcal for exacerbation

-long term antibiotic

-bronchodilators

-Inhaled corticosteroid


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OBSTRUCTIVE AIRWAY DISEASES

Chronic Asthma Chronic

Obstructiveairway disease

COAD

Reversible Cause Chronic Emphysema

Bronchitis

Diurnal

Variation Smoking

Irreversible No Cause

Diunalvariation Pollution


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INVESTIGATIONS OF OBSTRUCTIVE

LUNG DISEASE

Lab.

Others

-FBC Radiology E.C.G.

-urea Electrolytes

-LFT -CXR -Rt. ventricles

Hypertrophy

-Inflammatory markers -HRCT -P. Pulmonale

-S. & antitypsis for emphysemia

-ABG -Echo

-Sputum -RFTCLS (Spirometry)

gram

Stain


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Dr. Rami Abazid

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MANAGEMENT OF OBSTRUCTIVE

AIR WAY DISEASE

Non pharmacological Vaccination Pharmacological

-Stop smoking

-Pul. Rehabilitation

Annual H. Influenza Pneumococcal

Influenza PneumoniaVaccine

Bronchial Asthma

C O A D

B2 against or LABA LABA

Anticholinegic + +

SABA inhaled inhaled

Or SAMA corticostriods +

Theophylline


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Dr. Rami Abazid

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BRITISH THORACIC SOCIETY GUIDELINES

STEP STEP STEP =step 4Add beclomethasone +

100-400 ug/12h -oral Prednisolone

Occasional

Short acting

Inhaled B2 against STEP STEP

+-LABA -Beclomethasone to 1000 ug/12h

- dose of oral TheophyllineBeclomethasone oral leukotrene antagonistTo 400ug/12h

If > than once daily oral B2 againstOr nightTime symptoms oral leukotrene receptor

oral Theophylline

STEP

12

3

4

5

2


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STATION 3

MAP FOR

CARDIOLOGY

NEUROLOGY


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Dr. Rami Abazid

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CARDIOLOGY EXAMINATION

Non Auscultatory Auscultatory Rt. A.S.

Carotid

Thrill

Pulse

Lf. P.S.

Both

Radial

AF JVPor not

-small pulse

Or

-Big pulse volume

-Average

Collapsing

Water V Wave w/

Hammer Carotid TR

Or not


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AUSCULTATORY

APEXAxilla 2

ndRt. Intercostal 3

rdleft intercostals space

Soft Pansystolic space while patient leans forward

Murmur -1st

H.S. after expiration early

MR ejection systolic diastolic murmur

Murmur A.S.

H.S. MurmursLower left A.R.

Sternal edge 2nd

left

TR (Insp.) intercostal

4th

H.S. Left sternal Carotid

Near the 1st

H.S. edge R A.S.

V.S.D. L P.S.

2ndH.S. opening A.S.D. 2nd H.S.

snap near it

fixed splitting

2nd

H.S.

HOCM

valsalvis

1st

H.S.

P. HTN

normal M.R. A.S.

P.S.

M.S.


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Dr. Rami Abazid

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AORTIC STENOSIS

A.S.

Symptoms Non Auscultatory Auscultatory

Findings

Ejection systolic

Murmur with

Expiration radiate to

neck

Dyspnoea Syncope -small pulse

Volume Apex

heaving

-Slow Rising

Chest pain Pulse

-Narrow PulsePressure Systolic thrill in

Aortic area

SIGNS OF SEVERITYPul. HTN

Pul.

congestion

Slow-rising pulse

Small Pulse volume

Narrow Pulse Pressure Heaving Systolic Soft 2nd

4th

H.S. Long

Apex Thrill heart sound murmurs

A2


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Bicuspid Congenital Rheumatic Degenerative

Indications for Aortic

Valve replacement


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AORTIC REGURGITATION A.R.

SYMPTOMS NON AUSCULTATORY AUSCULTATORY

FINDINGS FINDINGS

SIGNS OF SEVERITY

Long duration of

The murmur Austin Flint murmur P.HTN

Wide Pulse 3rd

H.S.

Pressure


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Dr. Rami Abazid

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A.R.

CAUSES INDICATION FOR SURGERY


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MITRAL STENOSIS

SYMPTOMS NON AUSCULTATORY AUSCULTATORY


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Dr. Rami Abazid

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M.S.

COMPLICATION DD SIGNS OF SEVERITY

Left Atrial myxoma Clinical Echo

Austin-flint murmur

INDICATION OF SURGERY

Pul. Pul. Recurrent

Congestion HTN thromboembolic

Events despite

Anticoagulation

Haemoptysis


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MITRAL REGURGITATION

Symptoms Non Auscultatory Auscultatory

1st

H.S. S3

Pan-systolic murmur

soft and radiating

to axilla

===========================================================================

CAUSES INDICATIONS FOR SURGERY

Acute Chronic Symptomatic Asymptomatic

Despite optimum

Prolapse Medical therapy LVEF LVES D

Rupture MI NYAH III-IV 60% 45mm

Rheumatic Functional EF~35-50%

3 act. Endocarditis

Connective tissue

Disease


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Dr. Rami Abazid

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SOME CONGENITAL ANOMALY

A.S.D. V.S.D. HOCM PDA

On Pulmonary at the lowerarea sternal edge

Coarctation Thrill left

of Aorta Inter-space

Thrill fixed splitting

2nd

H.S. thrill at machinery

Lower sterna murmurs

Ejection systolic Edge loudest below

Murmur left clavicleEjection systolic

Murmur valsalvi

Systolic Pansystolic

thrill murmur

no radiation

Fallotscontinuous

V.S.D. Rt. vent. Pul. Stenosis radiofemoral murmur radiating

Hypertrophy delay to back


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Dr. Rami Abazid

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