Beruflich Dokumente
Kultur Dokumente
Rami Abazid
MAGDY ABBAS
BRAIN MAP
FOR
PACES
PREPARED BY:
DR. RAMI ABAZID
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.
ACKNOWLEDGEMENTS
Brief Clinical
Consultation
Communication
10 mins.
Skill
Brief Clinical
Consultation
20 mins.
Cardiology
10 mins.
10 mins.
(5)
(4)
(3)
(1)
(2)
Neurology
Chest
History taking
10 mins.
20 mins.
Abdomen
10 mins.
6
10 mins.
STATION I
MAP FOR
ABDOMEN
&
CHEST
ABDOMEN CASES
With stigmata of
CLD
without stigmata of
CLD
Cirrhosis
Hepatomegally
hepatosplenomegally
Splenomegaly
Ascites
Abdominal masses
CLD
Signs
Decompensated
Signs
Spider
Naevi Arms
Fistula
Hands
Parotid
Swelling
Jaundice
Wasting
Pallor
Anthelasma
Ascites
Jaundice
Investigation
General
* CBC
* electrolyte
Assess
Liver
Function
-S. Bil.
-S. Alb
-PT
-ALT
-AST
complications
& FP
U/S
Search
for the
cause
Face
Chest
Shrunken
Liver
Hepatomegaly
Splenomegaly
Ascites
Clubbing
leuconychia
Palmer erythma
Dupuytrens
Contracture
Hepatic
Encephalopathy
Flap
.
D-D
Spider
Naevi
reduced axillary hair
Gynaecomastia
hepatitis
H.chr. Wilson
C. B.
Alcohol PBC
Virdogy
Drugs
Study
AIH
Abdomen
venous
Hum ---L.L. oedema
Alpha 1,AT
Auto Immune
Iron
Study
Study
Metabolic
Wilson
Alpha1 AT
COMPLICATION
OF
CIRRHOSIS
Portal hypertension
Varices
Ascites
hepato
Renal
Syndrome
Encephalopathy
Coagulopathy
Bleeding
Spontaneous
Bacterial
Peritonitis
10
Hepato
cellular
carcinoma
Encephalopathy
Na
PT
Albumin
25g/L
< 120
Infection
Diuretics
Electrolyte
Diarrhea
Imbalance
Vomiting
Sedative
Surgery
Paracentesis
GI Bleeding
11
TREATMENT OF ASCITES
IN
CLD
Rest
Salt restriction
to <29/day
(Dietician)
Furosemide
up to
120mg/day
Serial
Paracentesis
Fluid
Restriction
If Na is < 125mmol/L
Spirino Lactone
Na excretion >78
mmol/day
up to 400mg/day
TIPS
Transjugular
Intra hepatic
Portal systemic
Shunt
OGD
No varices
Repeat OGD
Grade I Varices
3-4 years
Grade 2 or 3 varices
Propranolol
80-160mg/day
HR60
Band ligation if
Propranolol intolerant
or Verapamil
Diltiazem
Endoscopic
Sclerotherapy
13
Endoscopic
ligation
TIPS
Balloon
Tamponade
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
14
SPLENOMEGALLY
Mild
Moderate
<4 cm
(4-8 cm)
INFECTIONS
Massive
-Infections
EBU
-Myeloproliferative
Kala Azar
Infective Endocarditis
-Lymph proliferative
Malaria
Hepatitis
-Hemolytic anaemia
Bulhorzia
AUTO IMMUNE
- Infiltration
-Myeloproliferative
Rh. Arthritis
Gauchers
CML
Infiltration
Sarcoid
Amyloidosis
Myelofibrosis
15
Pancreatitis
Cirrhosis
Malignancy
TRANSUDATIVE OR EXUDATIVE
S-A ALBUMIN GRADIENT
11 g/L
11 g/L
Transudative
Exudative
MYXAEDEMA
CLD
CHC
MAGs SYNDROME
CRF
MALIGNANCY T.B.
16
INFECTION
Polycystic
Renal Cell
Carcinoma
Hydronephrosis
Adrenal mass
Retroperitoneal
Mass
Can get
Above it
Ballottable
Minimal
movement with
inspiration
No
Notch
17
Resonant to
Percussion
SURGICAL INTERVENTION IN
POLYCYSTIC KIDNEY
Massive
Cysts
Recurrent
Pain
Transplant
work up
Recurrent
Infected
Cysts
Possible
Malignancy
Tuberous
Sclerosis
Von-Hippel
Lindou disease
Autosomal
dominant polycystic
Kidney
18
Autosomal
recessive
Polycystic
Kidney
CHEST CASES
19
S.O.B.
Fine Endispiratory
Crackles
CAUSES
TIP
Rheumatological
- Rh. Arthritis
Vasculitis
- S.L.E.
- PAN
- Systemic Sclerosis
-Wegners
- Polymyositis
-Churg-Strauss
- Dermatomyositis
-Good Pastures
- Ankylosing Spondilitis
- MCTD
- Sjogrens Syndrome
Allergic
Pneumocomosis
-Asbestosis
Silicosis
-Beryliosis
Extrinsic
Allergic
Alveolitis
20
Drugs
Amiodarone
Nitrofurnatone
Busulphan
Bleomycine
Gold
Radiation
Methotraxte
OTHERS
Gauchers
Lymphangiomyelomatosis
Niemann Pick
NF
Tuberous Sclerosis
Linda
Usual
Interstitial
Pneumonia
(UIP)
Non Specific
Interstitial
Desefuamative
Pneumonia Interstitial
(HSIP)
Pneumonia
(DIP)
Respiratory
Bronchiolitis
Interstitial
Lung disease
(RB-ILD)
Acute Interstitial
Pneumonia
(AIP)
21
lymphoid
Interstitial
Pneumonia
(LIP)
Cryptogenic
organizing
Pneumonia
(COP)
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
BAL
-Precipitins
-Serum ACE
-ABG
Honey combing
neutrophils
lymphocytes
Not responded
To cortisone
Good response
To corticosteroid
Bad prognosis Good prognosis
Respond to
Corticosteroid
22
MANAGEMENT OF ILD
Non Pharmacological
Smoke
Cessation
Avoid exposure
to toxic
Substance
Lung Transportation
long term
oxygen
corticosteroids
+
Azathoprine
If not tolerate
Corticosteroids
Azathoprine alone
Discontinuation
Of toxic medication
23
Young Patent
rapidly
progressive
Disease
if not tolerate
Azathoprine
Cyclophosphamide
Flattening of
The affected side
Heterogenous
percussion of
the affected
side
Breath sounds
trachea is
reduced
shifted to
+
the affected
coarse crackles side
not changed with
cough
+
VR
on the affected side
Reduced movement
Of the affected side
24
Histoplasmosis
Old T.B.
Radiation
Ankylosing
Spondolitis
Sarcoidosis
Extrinsic allergic
Alveolitis
ILD
Aspiration
Asbestosis
Drugs
25
Connective
Tissue disease
PLEURAL EFFUSION
Chest expansion
On the affected side
breath sounds
bronchial breathing
Above the effusion
Stony dullness on
Percussion
PLEURAL EFFUSION
Exudates
PL. protein>35g/L
Lights criteria
For exudates
26
Transudates
Pl. protein
<25g/L
PLEURAL EFFUSION
Exudates
Transudates
Protein >35g/L
between
25g/L 25g/L
Lights criteria for
Exudates
Protein <25g/L
Megs
Syndrome
Cardiac
Failure
Infiltration
(neoplasm)
infections
CLD
CRD
Inflammation
Rh. arthritis
SLE
Infarction P.E.
DRUGS
Serum LDH >0.6
Amiodorone
Phenytoin
Methotrexate
27
PNEUMONECTOMY
Chest wall
Chest expansion
Scar
Trachea
Flattering of the
Affected side
Absent on
The affected side
Grossly deviated
to the affected side
Breath sounds
absent on
the affected side
LOBECTOMY
Scar
Chest wall
localized
Deformity
Chest expansion
Trachea
reduced on the
affected lobe
deviated to the
affected lobe
On upp.lobectomy
28
Breath sounds
reduced on the
affected lobe
LUNG CONSOLIDATION
Chest wall
Chest expansion
Trachea
Percussion
Reduced
not shifted
Except if associated
Collapse
normal
dullness
Breath
Sounds
CAUSES
Bronchial
breathing
crepitations
Infection
Vasculitis
malignancy
Cysts
Vocal
resonance
Infarction
Granuloma
29
BRONCHIECTASIS
Irreversible dilatation, destruction and Inflammation
of the Bronchial wall
Examination
Excessive
Productive
Cough
finger clubbing
Coarse Inspiratory
Crepitations which
Alter with coughing
CAUSES
T.B.
CONGENITAL
-
Immotile
Cilliary syndrome
Kartagners syndrome
Young syndrome
C.F.
Malignancy
CHILDHOOD INFECTION
-measles
-Pertussis
Foreign
Body
-Post Pneumonia
(Staph., Klibsella)
30
Immune deficiency
- hypogan maglobulnoia
-Allergic Aspergillosis
BRONCHIECTASIS
Investigations
Lab
-Sputum CLS
-Sputum AFB
-Sputum gram stain
-Immunoglobulins
-Rheumatology profile
-Na Sweat Test
-Genetic Screening for C.F.
Radiology
CXR
HRCT
Special
Bronchoscopy
for malignancy
Tranlines shadows
Ring shadows
31
BRONCHIECTASIS MANAGEMENT
Non Pharmacological
-Stop smoking
-Pulmonary Rehabilitation
-Multi-disciplinary
Management
Medical
Vaccination
Surgery
-annual Influenza
for localized
-H. influenza
-Antibiotic
disease
-Pneumococcal
for exacerbation
-long term antibiotic
-bronchodilators
-Inhaled corticosteroid
32
Chronic Asthma
Reversible
Chronic
Obstructive
airway disease
COAD
Cause
Chronic
Bronchitis
Diurnal
Variation
Emphysema
Smoking
Irreversible
33
No
Cause
Diunal
variation Pollution
INVESTIGATIONS OF OBSTRUCTIVE
LUNG DISEASE
Lab.
Others
-FBC
Radiology
E.C.G.
-urea Electrolytes
-LFT
-CXR
-Rt. ventricles
Hypertrophy
-P. Pulmonale
-Inflammatory markers
-S. & antitypsis
-ABG
-HRCT
for emphysemia
-Echo
-Sputum
-RFT
CLS
gram
Stain
(Spirometry)
34
MANAGEMENT OF OBSTRUCTIVE
AIR WAY DISEASE
Non pharmacological
Vaccination
Pharmacological
-Stop smoking
-Pul. Rehabilitation
Annual
Influenza
Vaccine
H. Influenza
Pneumococcal
Pneumonia
Bronchial Asthma
COAD
B2 against or
Anticholinegic
SABA
Or SAMA
35
LABA
+
inhaled
corticostriods
LABA
+
inhaled
+
Theophylline
STEP 1
STEP
STEP 5 =step 4
Add beclomethasone
100-400 ug/12h
Occasional
Short acting
Inhaled B2 against
+
-oral Prednisolone
STEP
+ 3
STEP 4
-LABA
-Beclomethasone to 1000 ug/12h
- dose of
oral Theophylline
Beclomethasone
oral leukotrene antagonist
To 400ug/12h
oral B2 against
oral leukotrene receptor
oral Theophylline
STEP 2
36
STATION 3
MAP FOR
CARDIOLOGY
NEUROLOGY
37
CARDIOLOGY EXAMINATION
Non Auscultatory
Auscultatory
Rt. A.S.
Carotid
Thrill
Pulse
Lf. P.S.
Both
Radial
JVP
AF
or not
-small pulse
Or
-Big pulse volume
-Average
Collapsing
Water
Hammer
Or not
V Wave w/
Carotid TR
38
AUSCULTATORY
APEX
Axilla
Soft Pansystolic
Murmur
MR
H.S.
Murmurs
Lower left
Sternal edge
TR ( Insp.)
4th H.S.
Near the 1st H.S.
2nd H.S. opening
snap near it
A.R.
nd
2 left
intercostal
Left sternal Carotid
edge
R A.S.
V.S.D.
L
P.S.
A.S.D.
fixed splitting
2nd H.S.
HOCM
valsalvis
2nd H.S.
1st H.S.
P. HTN
normal
M.R.
A.S.
P.S.
M.S.
39
AORTIC STENOSIS
A.S.
Symptoms
Non Auscultatory
Findings
Auscultatory
Ejection systolic
Murmur with
Expiration radiate to
neck
Dyspnoea
Syncope
Chest pain
-small pulse
Volume
Apex
heaving
-Slow Rising
Pulse
-Narrow Pulse
Pressure
Systolic thrill in
Aortic area
SIGNS OF SEVERITY
Pul. HTN
Pul.
congestion
Slow-rising pulse
Small Pulse volume
Narrow Pulse Pressure
Heaving
Apex
Systolic
Thrill
40
Soft 2nd
heart sound
A2
Bicuspid
Congenital
41
Rheumatic
Degenerative
SYMPTOMS
NON AUSCULTATORY
FINDINGS
AUSCULTATORY
FINDINGS
SIGNS OF SEVERITY
Long duration of
The murmur
Wide Pulse
Pressure
3rd H.S.
42
P.HTN
A.R.
CAUSES
43
MITRAL STENOSIS
SYMPTOMS
NON AUSCULTATORY
AUSCULTATORY
44
M.S.
COMPLICATION
DD
SIGNS OF SEVERITY
Clinical
Austin-flint murmur
INDICATION OF SURGERY
Pul.
Congestion
Pul.
HTN
Recurrent
thromboembolic
Events despite
Anticoagulation
Haemoptysis
45
Echo
MITRAL REGURGITATION
Symptoms
Non Auscultatory
Auscultatory
1st H.S.
S3
Pan-systolic murmur
soft and radiating
to axilla
===========================================================================
CAUSES
Acute
Chronic
Prolapse
Rupture MI
Rheumatic
Functional
Symptomatic
Despite optimum
Medical therapy
LVEF
NYAH III-IV
60%
EF~35-50%
3 act. Endocarditis
Connective tissue
Disease
46
Asymptomatic
LVES D
45mm
V.S.D.
On Pulmonary
area
HOCM
PDA
at the lower
sternal edge
Coarctation
of Aorta
Thrill
fixed splitting
2nd H.S.
thrill at
Lower sterna
Edge
Ejection systolic
Murmur
Thrill left
Inter-space
machinery
murmurs
loudest below
left clavicle
Ejection systolic
Murmur valsalvi
Systolic
thrill
Pansystolic
murmur
no radiation
Fallots
V.S.D.
radiofemoral
delay
47
continuous
murmur radiating
to back
48
49