SMLE – Internal Medicine Review

Dr. Amer’s Course

Twitter: @OmarALSowayigh

By: ‫عمر الصويغ‬.‫د‬

)‫ وال تنسونا من صالح دعائكم‬،‫(إن أحسنت فمن الله وإن أخطأت فمن نفسي والشيطان‬
Additional notes: Toronto Notes 2020, AMBOSS
)Pocket Medicine ‫عامر كمصدر للمعلومة (ومصدره‬.‫ هناك بعض المعلومات التي تختلف عليها جميع المصادر وفي هذا الملف تم اعتماد د‬:‫مالحظة‬
.Toronto Notes ‫وفي بعض المعلومات تم إعتماد‬
Contents:
1- Rheumatology: 2-17
2- Nephrology: 18-35
3- Cardiology: 36-58
4- Pulmonology: 59-80
5- Infectious Diseases: 81-90
6- Neurology: 91-102
7- Hematology: 103-114
8- Oncology: 114-117
9- Endocrine: 118-136
10- Gastroenterology: 136-153
11- Toxicology: 154-159
 Rheumatology
Autoimmune diseases are at high risk for developing Lymphoma.
Joint Disease
Rheumatoid arthritis:
Symptoms: Stiffness (Morning >1 Hour), Seven classic sites pain (PIP, MCP, Wrist,
Elbow, Knee, Ankle, Metatarsophalangeal, Cervical C1-C2), Symmetrical, Synovitis
(Swelling, Joint effusion), Subcutaneous nodules.
Hx: Female, Joint pain, Erythema, Fatigue, LG Fever.
Signs:
Intra-articular: Deformities (USB-C) Ulnar deviation, Swan neck, Boutonniere’s, C1-C2
subluxation >> Neck X-ray before surgery!
Extra-articular: Poor prognostic features
3S: Sicca/Scleritis, Subcutaneous nodules (20%), Splenomegaly (+Neutropenia=
Felty’s).
3P: Pulmonary Fibrosis, Pericarditis, Pleural effusion (Exudate).
3M: MI, Mononeuritis multiplex, Mesangial GN.
Special investigations:
CBC: Anemia of Chronic disease (Low Hgb, Normal MCC + MCH)
ESR, CRP: High
RF (+ve): Initial test
Anti-CCP: Confirmation
X-ray: Subchondral osteopenia, Joint destruction, Bone erosion.
US: only for Synovitis/Effusion >> Best imaging for such case.
Aspiration: RA + Swelling >> To rule out Septic Arthritis.

Treatment:
Remission (Maintenance):
DMARDs:
Biological:
A. Anti-TNF: Infliximab, Adalimumab, Etanercept.
 B. Non-TNF (Anti IL-1): Anakinra.
C. Anti-CD20 (B Cells): Rituximab
SEs (DMAR): Demyelination, Malignancy (Lymphoma), Acute reaction, Reactivation
of TB or Hepatitis. Order CBC + Hepatitis profile + PPD.
Non-Biological (HySLMA): Hydroxychloroquine, Sulfasalazine, Leflunomide,
Methotrexate, Azathioprine. DON’T CHOOSE Cyclosporine or Gold or
Cyclophosphamide or MMF.
HCQ SE: Retinopathy >> Eye Examination
SAS SE: Hemolysis in G6PD, Oligospermia.
MTX (Gold Standard): no Live vaccines, C.I: for HBV, HCV, Alcohol, CKD. SE: BMS
(Give Folate), High liver enzymes, Pulmonary fibrosis. Investigations prior to
prescription: CBC, LFT (AST, ALT), CXR + PFT, Hepatitis profile.
Anti-inflammatory: NSAIDs (Available as Joint injection) or Low dose Steroids (Acute
flares).

Technique:-
1) NSAID (Pain) <<< Mild or Steroid (only for Flares)? <<< Severe
+
2) Remission (J. Protection):
HCQ + Sulfasalazine >> Mild disease (Low ESR, no effusion,…)
MTX >> Moderate, Severe disease. If not improved 3 months add; SAS or, then HCQ,
then Biologicals (Anti-TNF). Alternative: Start Anti-TNF after MTX directly.

Refractory: Stop Anti-TNF, and start Anti IL-1 (Anakinra) or Rituximab.

Pregnancy (Hy.Aza,Sulfa): HCQ, Azathioprine, Sulfasalazine. Steroid is safe (Flares).
Avoid in pregnant: MTX, Leflunomide, Anti-TNF.

Serious considerations:
Caplan syndrome: Nodules in Lung, Heart,…
Poor prognostic factors: Hx (+ve FH of RA), PE (Increased joint count), Labs (High
ESR, High RF & Anti-CCP), Imaging (Early X-ray erosion), Extra-articular features.
Stop smoking immediately!
Prevalence: 1% of population (3:1 Female), 50-70 years old.
Steroids & NSAIDs combination is bad.
Nodules is severe disease and should be treated by Anti-TNF.

Osteoarthritis:
Symptoms: Stiffness (<30 mins), Site (DIP, Hip, Spine, PIP, Spine, Knee).
Signs:
- DIP (Heberden’s nodes) <<< DDx: Psoriatic DIP: Pitting nail, sausage digit.
- PIP (Bouchard’s nodes) <<< DDx: SLE, RA.

Special Investigations:
CBC: Normal, ESR: Normal, CRP: High or normal, RF: -ve.
Best imaging modality for early OA: MRI
X-ray: Confirmatory, Joint space narrowing, Osteophyte (late), Subchondral sclerosis.
Aspiration: OA + Swelling. Popliteal swelling >> NO Aspiration! Do US >> Baker’s cyst.

Treatment:
With CKD/HTN/PUD/CHF: No NSAIDs!
Paracetamol >> Tramadol >> I.A Steroid (Knees)
W/O CKD/HTN:
Paracetamol >> NSAID or Cox-2 inhibitor >> Tramadol >> I.A Steroid (Knee)

Weight loss is only for Knee/Hip!

Aqua exercises is best.

Serious considerations:
Don’t choose Glucosamine or Hyaluronic acid injections.
Squaring of 1st Caropometacarpals.
Primary: Obesity, Age,…
Secondary: Post-trauma, Metabolic syndrome, Hemochromatosis, Gout, Neuropathic
Joint of DM (Charcot’s).

Crystal Deposition Arthropathies:

Gout: Monosodium Urate
Acute: Sudden Monoarticular pain >> 1st MTP.
Chronic: Tophi >> Toes, Fingers, Wrist, Ears.
Tender, Warm, Swelling, Decreased ROM.
Association (RFs): DM, CKD, CHF, Diuretics.

Pseudogout: Calcium Pyrophosphate

Acute: Sudden Monoarticular pain >> Knee, Wrist, MCP
Pesudo-RA (RF -ve): Morning Stiffness,…
Tender, warm, swelling, Decreased ROM.
Association (RFs), 4H’s: Hyperparathyroidism, Hypomagnesemia, Hypothyroidism,
Hemochromatosis. Severely ill in ICU, Acute Knee swelling in an acutely ill pt.

Special investigations:
Gout:
CBC: High WBCs, ESR: High.
No uric acid measurement in acute phase!
X-ray: Early (Edema), Late (Erosion).
US showing Double Contour sign
Aspiration: Initial & Diagnostic test >> Needle shaped/Negative birefringent/Yellow.
Pseudogout:
Calcium, Magnesium, Ferritin, PTH, TSH.
X-ray: Chondrocalcinosis.
Aspiration: Rhomboid shaped/Positive birefringent/Blue.
Treatment:
Gout:
Not on Allopurinol:
NSAIDs (1: Indomethacin) >>
Colchicine: Not nephrotoxic, SE: BMS, Diarrhea >>
Prednisone: not used with PUD, better for CKD than Colchicine >>
IL-1 inhibitor (Anakinra).
On Allopurinol: Don’t stop it + Give >> NSAID or Colchicine or Prednisone or Anakinra.

Later (2 weeks), Urate lowering agents: Allopurinol [CKD low dose safe], Febuxostat
[CKD safe, No tolerance to Allopurinol], Pegloticase [Refractory Tophi, G6PD caution!].
Drop UA to less than 6 mg/dL or <5 mg/dL if tophi.
Indications:
Tophi (6 months ttt), 2 or more attacks/year, Nephropathy GFR <60, Joint erosions.

After 2 weeks, In addition to Urate lowering agents for prevention, we give Colchicine
or low dose steroids for at least 3 months.

Pseudogout: NSAIDs + treat underlying cause.

Seronegative Arthropathies: (ARIP)

Symptoms:
Arthritis: Non-symmetrical, Oligoarticular (1-3), Large joints, Lower > Upper (Except
Psoriatic arthritis)
Uveitis: Red eye/Pain, reduced visual acuity.
Sacroillitis (IPAIN): Insidious pain, Pain at night, Age <40, Improve with exercise, No
improvement with rest.
Dactylitis (Sausage shaped).
Enthesitis (Tendon pain).
Disease Key Consideration Treatment
Ankylosing Male > Female HLA-B27 Exercise + NSAIDs
Spondylitis <40 4 A’s: Apical lung fibrosis, Additional:
Ascending Spine Anterior uveitis, Aortic Peripheral (SIJ):
limitations regurgitation, IgA GN. Sulfasalazine
Tests: High ESR, X-ray of Axial (Spine): Anti-
Sacro-illiac joint TNF
Best modality: MRI
Reactive Male = Female Arthritis, Conjunctivitis, NSAIDs. No abx!
Arthritis 20-40 years Urethritis. Next if not
Post GI/GU infection GU (Chlamydia), Sexually improved: Steroids
(2-4 weeks) active. >> Severe: SAS or
GI (C.Diff, Salmonella, MTX
Shigella, C.Jejuni)
IBD Associated Male = Female Indicate active IBD: Peripheral: IBD
Arthritis 20% of IBD Arthritis, Erythema nodosum, drugs.
Crohn’s > UC Pyoderma gangrenosum Axial: Anti-TNF
Psoriatic Male = Female X-ray: Pencil in cup NSAIDs
Arthritis 45-54 years old Pitting nails, Sausage digit. Next if not
HIV (Scaly skin Silver Erythematous scaly improved:
patches) plaque. Mild: SAS
Severe: Anti-TNF

Septic Arthritis Vs Osteomyelitis

Septic Arthritis:
Symptoms: Swelling, Pain, Erythema, +- Fever, Monoarticular, Site: Knee, Shoulder,
Signs: Warmth, Deformity, Decreased ROM, Effusion.
Special Investigations:
High ESR, CRP, WBC
X-ray of joint: Edema
Aspiration
Joint fluid analysis:
OA, SLE Inflammatory, Gout, RA Septic
Color Yellow Yellow Pus
Count <3000 >3000 >30000
Culture -ve -ve +ve
Skin (S.aureus, S.Epidermid)
Condition - - Sexual (<40 y, Gonococcal)
Splenic Dysfunction (Strept.)

Treatment:
Antibiotics: 2 weeks minimum
Male: test urethra,
Gram -ve Diplococci pharyngeal; PCR For
2 weeks Ceftriaxone
Sexually active (Gono.) Chlamydia.
+
-ve Blood culture Female: test cervix,
1 dose Azithromycin
+ve Synovial Culture pharyngeal; PCR For
Chlamydia.
S. Aureus: Vancomycin
Gram stain +ve cocci
S. Epidermidis: Vancomycin
(Non-Gonococcal)
Streptococcus: Penicillin G, Ampicillin, Ceftriaxone
Gram stain -ve (E.coli,
Cefepime or Tazocin
Pseudomonas)

Sexually active (Gonococcal [Knee, Wrist, Ankle].

Osteomyelitis:
Symptoms: Swelling, Pain, Skin changes (Erythema), Fever.
Signs: Warmth, Tender, Sinuses, Probe to bone is +ve (If -ve >> exclude OM)
Special investigations:
Very High ESR. High CRP, WBC.
X-ray (Initial): edema surrounding bone, or no findings!
MRI (Diagnostic): e.g. going for OR, detects early onset <5 days.
Bone biopsy (Gold Stx, Confirmatory): Detects necrosis & pathogen >> Specific TTT.
Treatment:
Antibiotics: 4-6 weeks
MSSA: Oxacillin,
S. Aureus (IV abuse, Trauma) MRSA: Vancomycin
Cefazoline
Streptococcus Ceftriaxone, Penicillin G
Gram -ve Tazocin
Anaerobes Clindamycin

Extra:
TB: Chronic pain, Indian, Worker, Hx of Hip/Knee pain/Swelling, Reactivation of TB or
Primary, Aspiration; inflammatory (>3000, Mononuclear cells= Lymphocytes). Don’t do
PPD, IGRA, AFB smear! Instead do Synovial Culture.
Viral Arthritis: Acute, Young Female, School or nursery exposure (within 2 weeks) >>
Her hands have symmetrical lesions, Macular rash! Parvovirus B19. Conservative ttt
(NSAIDs). Test: IgM antibody for B19.
Q- 20 Years old male, fever for 2 weeks, arthritis, macular pink rash, Low Hgb, High
ESR, High Ferritin. Dx: Adult onset Still’s Disease. Tx: NSAIDs >> Steroid >Severe
or Refractory> Methotrexate.

PMR Vs Fibromyalgia:
Polymyalgia rheumatica:
Key features:
Female, 50s, Fever, Fatigue, Malaise, Pain or Stiffness of Joint (Shoulder, Hip, Neck).
Associated w/ Temporal arteritis in 50% of patients.
Investigations:
ESR: Very High, CRP: High, CK: Normal.
Treatment:
If only PMR: Low dose steroids (Oral).
If w/ Arteritis: High dose steroids + Biopsy

Fibromyalgia:
Key features:
>3 months complaint. Clinical diagnosis. Wide spread pain index.
Female w/ anxiety or depression, Hx of chronic fatigue, Stress, not enough sleep, Pain
in multiple sites, point tenderness on examination (8-11 points on body; Mid trapezius,
Costochondral junction). No Stiffness!
Investigations: ESR, CRP, CK: Normal
Treatment: Exercise, NSAIDs, Anti-depressants (SSRI, TCA)

Other:
Familial Mediterranean Fever:
Auto-inflammatory, Hx of travel to Lebanon, Turkey, Greece.
(MEFV Gene mutation) Pyrin protein: fires up IL-1, Episodic fever.
Pain in joints, Serositis (Peritonitis, Pleuritis, Pericarditis), Erythema.
During attack: ESR, CRP, WBC >> High
Treatment: Colchicine, No Abx!

Sjogren’s Disease (Between CTD & Joint):

Primary
Secondary: RA, SLE, Systemic sclerosis
Anti-Ro, Anti-La >> Specific
RF (75%), ANA (95%) >> Not specific
Complicated by B-Cell Lymphoma
Investigations:
Rose Bengal stain, Schrimer’s test: <5 mm
Biopsy (Diagnostic): Parotid or Salivary glands >> Lymphocytes infiltration (CD4 T
Cells)
Treatment:
Ocular drops: Tears, Cyclosporine
Oral: Pilocarpine tablets
If extra glandular manifestations: NSAIDs, if Severe: Steroids. If Refractory, Rituximab.
Q- Female w/ dry eye or mouth, RA or SLE symptoms, Parotid gland enlargement
(rare). Dx?

Connective Tissue Disease (ANA +ve)

SLE:
Severe Lupus (Cardiac, CNS,…), Musc/Cutaneous Lupus, Lupus Nephritis, Anti-
Phospholipid Syndrome

Criteria: At least 4 out of 11

SOAP BRAIN MD

Special investigations:
CBC: Low Hgb (Hemolytic Anemia, AIHA), Leukopenia, Thrombocytopenia.
ESR, CRP: High
Creatinine: High
Proteinuria, RBC casts.
ANA +ve >> Anti-dsDNA, Anti-Smith, Lupus Anti-coagulant, Anti-Ro, Anti-La,
Complement (Active disease: Low C3, C4).
Neonate of pregnant moms w/ +ve Anti-Ro is at high risk of Heart Block.
Treatment: General SLE
Avoid Sulfa drugs >> Increases flares
Flare-ups:
Non-Life threatening: IV Steroids
Life threatening (CNS, Renal, P.Hemorrhage): Cyclophosphamide ± Steroids
Maintenance:
HCQ >not improved> add Low dose steroids or MTX
Refractory: Biologicals >> Rituximab or Belimumab

SLE + RA: MTX + HCQ

Musc/Cutaneous SLE: MTX + HCQ

Lupus Nephritis:
Female, Alopecia, Oral ulcer, Arthritis, High Creatinine, Proteinuria…
Biopsy guides to which stage & therefore appropriate treatment.
Class 1: minimal mesangial. NO ± HCQ
Class 2: mesangio proliferative. NO ± HCQ
Class 3: Focal proliferative. Induction Cyclophosphamide + IV Steroid ± HCQ
Class 4: Diffuse proliferative (Nephritic L.C4).Induction Cyclophosphamide + IV Steroid
Maintenance: MMF ± HCQ
Class 5: Membranous (Nephrotic). Same as above + ACEI ± HCQ
Class 6: ESRD. Dialysis
Disease Active or not: Anti-dsDNA
SLE + High Creatinine + Proteinuria = Which class? Biopsy >> Treatment
Drug induced lupus:
“Yo am pro, am hy I smoke meth of Anti-TNF, living in Queens”
Procainamide, Hydralazin, Methyldopa, Infliximab, Quinidine. Nitrofurantoin.
Treatment: Stop the drug only

Antiphospholipid syndrome:
Female, Multiple miscarriage, DVT,…
Increases Venous thrombosis
Lupus anticoagulant / Anti-cardiolipin
Livedo reticularis
Libman-Sacks endocarditis
Low platelets
Long PTT
Treatment: LMWH + Low dose Aspirin

Skin:
Systemic Sclerosis: (key; Skin tight)
Scleroderma + Internal Organ Involvement
Fibrosis
30-50 years Female
Symptoms & Signs:
Diffuse SSc:
Tight skin (Trunk, Elbow to up) +
Heart (MI, Cardiac fibrosis), Lung (ILD, SOB), Renal (Sclerodermic renal crisis, High
Creatinine).
Bad prognosis
Anti-Scl 70 (Topio-isomerase 1)

Limited SSc (CREST): (More vascular)

Tight skin (Face, Hand to elbow) +
Cutaneous Telangiectasia
Pulmonary HTN
C Calcinosis
R Raynaud’s (White >> Blue >> Red)
E Esophageal dysmotility (Dysphagia)
S Sclerodactyly
T Telengiectasia
Anti-Centromere

Special Investigations:
No skin biopsy as long as there is +ve antibodies.
ESR, CRP: High
CK: Normal
ANA: +ve >> Scl-70 + Centromere

Treatment:
Raynaud’s: CCB (-pine) or Topical nitrates or Aspirin or SSRI.
No Steroids in Systemic Sclerosis (Renal crisis)!
Pulmonary fibrosis: Cyclophosphamide or MMF
Renal crisis: ACEI not ARB.

Skeletal Muscles:
Myositis:
Dermatomyositis (Rash):
Symptoms + Signs:
Painless, Proximal muscle, Weakness, Parallel, Progressive (Weeks, Months).
E.g. Can’t climb stairs, Can’t comb hair,…
+ Gottron’s papules in PIP/MCP purple color (Pathognomonic)
Heliotrope rash (Purple around eyes)
Sun exposed areas purple rash (Upper back: Shawl sign, Neck & Chest: V sign, Hip: Holster sign)
Organ involvement (Same as Scleroderma): Cardiac, GI, Arthritis, Raynaud’s,
Pulmonary.
Serious considerations:
U. GI Endoscopy, L. GI Endoscopy, Pelvic US.
Because 25% have hidden malignancies.

Polymyositis (w/o rash):

Painless, Proximal muscle, Weakness, Parallel, Progressive (Weeks, Months).
Organ involvement (Same as Scleroderma): Cardiac, GI, Arthritis, Raynaud’s,
Pulmonary.

Special Investigations:
ESR, CK: high
Aldolase, LDH: High .. Non specific
ANA +ve >> (Anti-mi, Anti-Jo) <<< Not commonly found
EMG: Decreased amplitude of muscle potential.
MRI (Diagnostic): Guide for muscle biopsy >> Muscle fiber necrosis

Treatment:
Mild: Oral Steroids <<< Drug of choice
Severe (Refractory, intolerant of Steroids): Aza/MTX or IV Ig or Plasmapheresis or
Rituximab.
Life threatening (Hypoxia, SOB): Cyclophosphamide

Vasculitis
Large Vessel: -ve ANCA
Takayasu’s Arteritis:
Young, Asian, Female,Fever, Malaise, Arthralgia, High ESR/CRP, No radial pulse.
Next imaging: CTA >> Stenosis. No Biopsy!
Treatment: Steroids
Giant cell arteritis (Temporal arteritis):
Old, Female or Male, Fever, Unilateral Headache, Fatigue, Decreased Eye vision,
Tender scalp, Palpable temporal artery, Very High ESR, High CRP.
Temporal biopsy (Diagnostic): Multiple, sometimes bilateral needed
Treatment: High dose Steroids >> PO for Headache only. IV for Headache + Vision.
Medium Vessel: -ve ANCA
Polyarteritis nodosa:
Male, >50, HBV, Fever, Malaise, Abdominal pain, L.E numbness & Rash
ESR/CRP: High. ANCA: -ve
Angiogram: numerous micro-aneurysms of vessels of involved organs (Mesenteric
arteries >> Abdominal pain)
Biopsy: Fibrinoid necrosis
Treatment: Steroids

Kawasaki: Pediatrics

Small Vessel: +ve ANCA

Wegner’s (Granulomatous Polyangitis):
Male=Female, Fever, Malaise, Hx of recurrent sinusitis, Hemoptysis, Hematuria or
RBC casts, High Creatinine.
ESR/CRP: High. C-ANCA: +ve
Biopsy: Granulomas!
Treatment:
Mild: MTX + steroids
Severe: Cyclophosphamide + Steroids
Microscopic polyangitis
…
Small & Medium: +ve ANCA (p)
Churg-Strauss (Eosinophilic Granulomatous Polyangitis):
Triad: Vasculitis, Asthma, Eosinophilia.
30-40 years, Purpuric rash, Asthma not improving on inhaler, High ESR/CRP,
Eosinophilia >10%.
Treatment: (Mostly Cardiac causes deaths)
Mild: Steroids
Severe (Cardiac): Cyclophosphamide

Behçet’s disease: -ve ANCA

Vasculitis of Arteries & Veins.
25-35 years, HLA-B51, Painful oral ulcer, Painful Genital ulcer, Uveitis.
High ESR/CRP
Pathergy test (Pathognomonic): +ve
Treatment: Steroids. If CNS, Cyclophosphamide.

Autoantibodies:
Key; Sensitive = Rule Out
RF (Joint disease): Joint limitation, stiffness
ANA (CTD): Alopecia, …
ANCA (Vessels): …
Key; Specific = Rule in
Anti Ro-La, Anti-dsDNA, Anti-smith, Anti-Jo,Anti-centromere, Anti-Scl70, Anti-RNP,
Anti-Phospholipid, Anti-Histone.
Immunomodulators
Immune-stimulants:
Vaccines
BCG
Interferon a/b
Immunosuppressives:
All are affected by smoking.
Cytotoxic:
Cyclophosphamide: Damages DNA directly. More severe SEs: Hemorrhagic cystitis.
Anti-metabolites: Methotrexate, MMF. Affect DNA but indirectly (Folate).
Cytokines inhibition: Calcineurin inhibitor (IL-2): Cyclosporines, Tacrolimus.
Cytokine Gene Expression: Glucocorticoids IL-1/IL-2, TNF-a,…
 Nephrology

Dialysis:
Indications of Urgent Hemodialysis:
A Acidosis (pH <7.1)
E Electrolytes (Refractory Hyperkalemia >6.5)
I Intoxication (Check next section)
O Overload (Fluid; refractory to diuretics)
U Uremia (Pericarditis, Encephalopathy)

Examples:
- K >6.5 + given Insulin & Dextrose & Albuterol > No improvement >> HD.
- CKD Stage 4 & Confusion & High Creatinine & High BUN >> Uremic Encephalopathy
>> HD
- CKD Stage 4 & Pleuritic Chest pain & High Creatinine & High BUN & Wide spread ST
Elevation >> Uremic Pericarditis > HD
- CKD & Hyperkalemia & Low Bicarbonate (Low pH) >> HD
- CHF or CKD or Both + P.Edema >> Given Furosemide but still symptomatic >> HD

Dialyzable drugs, toxins:

Salicylate, Methanol, Lithium, Ethylene Glycol, Barbiturates, Isopropyl Alcohol.
Q- CHF on Furosemide, not improving >> Hemodialysis.
Q- Pin-prick sensation, loss of knee & ankle reflexes, Hyperkalemia >> Toxin >> HD

Indications of Renal Biopsy:

H Hematuria (Unexplained)
H High Proteinuria
H Highly suspicious of GN
H High Creatinine (AKI that didn’t recover)
Contraindications of Renal Biopsy:
H HTN (Uncontrolled, >160)
H Hypotension
H High risk of bleeding (Bleeding disorder, Anticoagulants)
H Hydronephrosis (Solitary Kidney)
+ Pregnancy

Hyperkalemia:
Usually asymptomatic (unlike HypoK), Palpitations, Fatigue, Taking a drug (E.g. ACEI).
Management:
C Cardiac stabilization: IV Calcium Gluconate >> Doesn’t lower K level!
C Cell shifter: (Insulin & Dextrose) + Albuterol (Nebulized) or NaHCO3 (If Low HCO3)
C Clearance: Ca Resonium PO (Kayexalate) or Furosemide or HD
Any patient with risk of unstable heart or Rhythm, Ca gluconate should be given.

Q- If CKD, Hemodialysis is preferred.

UTI:
Never Nitrofurantoin or TMP for any ‘Complicated’ condition.
Urinalysis:
WBCs, Nitrite, Leukocyte esterase, Bacteria: Best.
Urine culture: KEEPS
K Klebsiella
E E.coli
E Enterobacter
P Proteus
P Pseudomonas
S Serratia
S Staphylococcus saprophyticus (Classical UTI in Female on Honeymoon)
Cystitis:
Dysuria, No fever.
Treatment: PO
Non-Complicated Cystitis:
Female non-pregnant
3-5 days ttt
3 days: TMP, Amoxicillin, Ciprofloxacin
5 days: Nitrofurantoin
Complicated Cystitis:
Male, DM, Renal transplant, Renal stones, Renal anomalies, Pregnancy.
7 days ttt. C.I: Nitrofurantoin or TMP
Ciprofloxacin, Amoxicillin, Levofloxacin

Pyelonephritis:
Dysuria, Fever, Chills, Rigor.
Treatment: IV
Non-Complicated:
Normal Kidney Function (No AKI)
7-10 days ttt
Ciprofloxacin, TMP, Ceftriaxone, Meropenem.
If not improved after 2-3 days>> US b/c he may have developed Perinephric abscess.
Complicated:
Hypotension, AKI, Perinephric abscess, Immunocompromised, U.Anomalies.
10-14 days ttt. C.I: TMP, Nitrofurantoin.
Ciprofloxacin + Ceftriaxone.

Asymptomatic Bacteriuria:
E.coli is most common. GBS could also cause it.
Treatment: TMP (G6PD caution), Amoxicillin (Best), Nitrofurantoin (Before 30 GA).
Renal drugs:
Diuretics:
Loop: E.T is FAB
Ethacrinic acid .. Torasemide .. Furosemide Azosemide Buthemide
Ethacrinic acid is used if allergic to Furosemide.
Uses:
HF, HTN, CKD 2nd line, Hyperkalemia, Hypercalcemia
Side effects:
Hyponatremia, Hypokalemia, Hyperchloremia.

Thiazides:
C.I: CKD, Chronic Liver Disease.
Hydrochlorothiazide (‫)زايد‬
Side effects: Hypercalcemia, Uricemia, Hyperglycemia, Hypertriglyceridemia,
Hyponatremia, Hypochloremia.
Hypocalcinuria (Less stone formation).
Q- Thiazide that’s ok to use in CKD or HTN? Indapamide

K-Sparing: “C.I in CKD >> Hyperkalemia”

Uses: CLD w/Ascites, 2ndry Hyperaldosteronism.

Hypokalemic Syndromes:
Hyperkalemia usually co-exists with acidosis.
Liddle’s Gittlemann’s Barter’s
High BP Normal BP Normal BP
Low K, Alkalosis Low K, Alkalosis Low K, Alkalosis
Autosomal Dominant Hypomagnesimia Stone (Hypercalciuria)
Aldosterone Thiazide like effect Loop like effect
Collecting Duct DCT Loop of Henle
Tri-amterene or Amilo-ride
Liddle’s, Conn’s, Cushing: Alkalosis, HTN, Hypokalemia.

Renal Tubular Acidosis:

NAGM: Non-Anion Gap Metabolic acidosis.
High Cl
Low K, Low pH <<< Unlike normal Potassium-Acidosis regulation.
Type I Type II Type IV
Distal Proximal Distal
DCT PCT DCT
Reduced +H secretion Bicarbonate wasting HypoAldosterone or Resi.
Urine pH: >5.5 <5.5 <5.5
Stones (Nephroclacinosis) Multiple Myeloma Principal cells
Autoimmune: SLE, Sjo, RA Fanconi syndrome: Low D.Nepro, CKD, Obstructive
Sickle Cell Nephropathy Na, K, HCO3,… Uropathy, Addison’s
Drugs: Lithium, NSAIDs, ACEI, ARB, TMP-SMX,
Acetazolamide
Amphotericin B Spironolactone
Hypercalcemia Hyperkalemia
Alkali therapy (NaHCO3) Alkali therapy PO K citrate Furosemide, Low K diet

Glomerular Disease:
Steroid resistant: not responding after 4 weeks.
Nephritic Nephrotic
Proteinuria <2gm Proteinuria >2gm
RBC Cast or Dysmorphic RBC, Hematuria Oval hyaline cast
HTN, Azotemia (BUN) Edema, Low albumin, High LDL
Low Complement: Kidney: Systemic:
Kidney: Normal Complement: Minimal Change Dise.: DM Nephropathy
PIGN (Low C3): Kidney: Pediatrics
URTI or Skin IgA nephropathy: People w/ AL protein
infection (Weeks), Leukemia/Lymphoma 1ry Amyloidosis: MM
 Hematuria,… Young, URTI (Days), Podocytes(Effacement)
Strep.Pyogenes Coca cola urine, Prednisone AA protein
TTT: Supportive HTN, High Cr,… Membranous: 2ndry Amyloidosis
(ACEI, Furosemide,…), TTT: Supportive, Malaria (Malarie) Autoimmune (RA):
No Abx! ACEI, Steroids (severe) Member w/ HBV Proteinuria,
MPGN Alport “Pilot”: Malignancy (Colon, Abdominal pain,
Systemic: Child, Deafness, Lung, Bowel, …) Facial rash.
SLE (lower C4) High Cr,… Mother SLE, RA
Endocarditis: Collagen Type 4 Medication (Gold, NSAID) Rectal or Kidney or
Fever, SOB, Murmur, TTT: None TTT: Prednisone + Abdominal fat biopsy
IV abuse, Rash. Systemic: ARB or ACEI (Dx) >> Congo-red
Cryoglobulinemia: HUS: Biopsy: Spikes/Dome stain >> Apple green
Purple rash, HCV Child, Raw beef, appearance appearance.
Fever, Low PLT, FSGS:
High Cr, Bloody Collapsing: Heroin,
Diarrhea, Low Hgb, HIV, SCD
E.coli. Non-Collapsing (Chronic):
TTT: Supportive Ureterovesical reflux
HSP: (Vasculitis) Pyelonephritis
Child, Abd pain, Biopsy: Scarring
Palpable purpuric TTT: ACEI + Steroids +
rash, buttock pain, Underlying cause
High Cr,…
Biopsy: IgA deposits.
TTT: Steroids
Goodpasture:
Linear deposits, BM
(Anti-BM), Hemoptysis,
Hematuria,…
Biopsy: IgG Deposits
RPGN:
Unclassified; could be Minimal or Membranous or other disease that changes.
GP vs GPA (Wegner’s):
Disease Goodpasture GPA (Wegner’s)
Sinusitis NO Recurrent sinusitis
Hemoptysis Hemoptysis Hemoptysis
RBC Cast RBC Cast RBC Cast
Renal biopsy IgG Linear Basement Membrane RPGN, Crescent, Pauci-immune
Cyclophosphamide + Steroids
Treatment Cyclophosphamide + Steroids
Or Plasmapheresis

Anti-GBM Disease: Goodpasture but w/o pulmonary hemorrhage (Only Hematuria).

Nephrotic syndrome:
Dipstick (Screening): ≥ 3+ Protein.
24-Hour urine collection or Spot urine (Confirmatory): >3.5 g/24h

HTN in Pregnancy:
Contraindicated HTN drugs:
A ACEI, ARB, Atenolol
B Beta blockers (non-selective)
D Diuretics

Chronic HTN: Before 20 weeks!

Gestational HTN: >20 weeks.
Treatment:
“Mama Loves Neonate”
Mild-Moderate: Methyldopa, Labetalol, Nifedipine.
Nifedipine: preferred in late gestation.

Severe HTN:
Preeclampsia (+MgSO4) or not:
Treatment: IV
“Husband Loves Neonate”
Hydralazine, Labetalol, Nifedipine.

Stages of Hypertensive Retinopathy:

1: Narrowing
2: Nicking
3: Dot-Blot Hemorrhages
4: Papilledema

Stages of Diabetic Nephropathy:

Features GFR Albumin
Stage 1 Hypernephrosis High Normal
Silent, Thickened BM,
Stage 2 Normal <30-300
glomerulosclerosis, KW nodules
Stage 3 Incipient Microalbuminuria, Low 30-300
Stage 4 Diabetic Nephropathy (Overt) Macroalbuminuria, Very Low >300
Stage 5 ESRD, Uremic <15 GFR

Acid Base Balance:

Go by the following order: pH >> PCO2 >> HCO3
Together pH/PCO2 = Metabolic
Opposite pH/PCO2 = Respiratory

LOW pH, HIGH PCO2, High HCO3:

Respiratory Acidosis, Compensated.

LOW pH, LOW PCO2, LOW HCO3:

Metabolic Acidosis, Uncompensated.
HIGH pH, LOW PCO2, LOW HCO3:
Respiratory Alkalosis, Compensated.

HIGH pH, HIGH PCO2, HIGH HCO3:

Metabolic Alkalosis, Compensated.

ABG vs VBG:
pH +- 0.04
PCO2 +- 8

Compensations:
Metabolic Acidosis: 1st floor
For 1 HCO3 decrease, there must be 1 PCO2 decrease. HCO3 1:1 PCO2 (+-2)
Anion gap: [Na+] – ([Cl-] + [HCO3-]). Normal: 8-12
Example:
pH 7.1, PCO2 30, HCO3 14?
HCO3 (24-14=10)
PCO2 40 – 10 = 30 <<< Compensated
Metabolic Alkalosis: 2nd floor
For 2 HCO3 increase, there must be 1 PCO2 increase. HCO3 1:2 PCO2 (+-2)
Example:
pH 7.55, PCO2 60, HCO3 30?
HCO3 (30-24=6), 6/2= 3
PCO2 40 + 3 = 43 >> Far from 60, so Non-compensated.
Respiratory Acidosis:
For 10 PCO2 increase, there must be 1 HCO3 increase. HCO3 1:10 PCO2 (+-2)
Example:
pH 7.15, PCO2 80, HCO3 26?
PCO2 (80-40=40), 40/10= 4
HCO3 24 + 4 = 28 >> When compared to 26, it’s acceptable, so compensated.
Respiratory Alkalosis:
For 5 PCO2 decrease, there must be 1 HCO3 decrease. HCO3 1:5 PCO2 (+-2)
Example:
pH 7.55, PCO2 20, HCO3 28?
PCO2 (40-20=20), 20/5= 4
HCO3 24 – 4 = 20 >> Far from 28, so Non-compensated.

Qs: 1: Racid; Comp. 2: Macid; Comp. 3: Rkalo; Comp. 4: Mkalo; Uncomp

Metabolic Acidosis:
NAGMA:
RTA: Type 1,2,4.
Addison’s:
Female, Abdominal pain, Low glucose, Hyperkalemia, Low pH, Hyponatremia,
Orthostatic hypotension.
Diarrhea

HAGMA: Acidosis = Abdominal pain

M Methanol >> Blindness (Permanent)
U Uremia
D DKA
P Paracetamol
I INH >> (TB patient on meds presents w/ Abdominal pain)
L Lactate >> Sepsis
E Ethanol
S Salicylate >> Resp. Alkalosis then Metabolic acidosis

Metabolic Alkalosis:
Normal BP: Vomiting
High BP: Cushing’s – Conn’s
Diuretics: Furosemide

Respiratory Acidosis:
Severe COPD, Severe Asthma, Neurogenic Respiratory Failure (Myasthenia gravis
with SOB), Narcotics, Sedatives.

Respiratory Alkalosis:
Pregnancy, Salicylate toxicity, Pulmonary embolism, …

Hypokalemia:
Sxs: Weakness, Paralysis, Fatigue, Hx of vomiting,…
Causes:
Metabolic Alkalosis (Vomiting; Pyloric stenosis), Diuretics, Conn’s, Cushing.
Refeeding syndrome (Associated w/ TPN): HypoK, HypoPO4, HypoMg, …
Refractory Hypokalemia or Hypocalcemia: Hypomagnesemia is the cause usually.
Potassium rich foods: Dates, Tomatoes, Banana.

Q- Asthmatic patient on Salbutamol, what’s the likely electrolyte disturbance?

Hypokalemia Or Hypomagnesemia

Hyponatremia:
High serum osmolality: Glucose, e.g. HONK
Normal serum osmolality: Lipid paraprotein (Hypertriglyceridemia).
Low serum osmolality (<280): True Hyponatremia
Volume Status: “Assessed Clinically”
Hypovolemic:
Renal loss (Na): Urine sodium test= >20 <— Diuretics
Extra renal: Urine sodium test= <10
Euvolemic:
Urine osmolarity: High
SIADH (SSRI, ACEI, Anti-psychotics, Trauma, Surgery, Severe Pneumonia, Paraneoplastic)
Addison’s
Hypothyroidism
Hypervolemic:
Renal loss: Urine sodium test= >20 <— CKD
Extra renal: Urine sodium test= <10 <— CHF, Chronic Liver disease

Q- Confusion or Seizure or Severe Headache? Acute emergency

Hypovolemic or Euvolemic or Hypervolemic? All= 3% Saline (Hypertonic)
Target:
A. Acute: 8 mg/dL/day
B. Chronic: 6 mg/dL/day
If the patient was mistakingly corrected rapidly: Stop 3% Saline, and give D5%.

Q- Dysarthria, Paraplegia, Dysphagia? Central Pontine Myelinolysis

Q- Euvolemic, Hyponatremia, Low osmolality, Asymptomatic? Fluid restriction
Q- Hypovolemic, stable, Asymptomatic? Normal saline 0.9%
Q- Hypervolemic, stable, Asymptomatic? Diuretics + Water restriction

CKD patient should not stop ACEI except if:

- Increase 30% Cr from baseline
- Hyperkalemia after stopping diuretics
- Cough
- Bilateral renal artery stenosis
- Pregnant

Acute Kidney Injury:

GFR is For CKD, Cr is for AKI.
Definition: “KDIGO Guidelines”
- Increase Creatinine 0.3 mg/dL within 48 hours.
 - Increase Creatinine >50% from baseline.
- Urine output <0.5 mL/Kg/hour for >6 hours.
Criteria: “KDIGO Guidelines”
Stage 1 Stage 2 Stage 3
↑ Creatinine ×1.5 baseline ↑ Creatinine ×2 baseline ↑ Creatinine ×3 baseline
Urine output <0.5 mL/hour Urine output <0.5 mL/hour ↑ Creatinine ≥ 4 mg/dL
for >6 Hours for >12 Hours Anuria

Causes:
Pre-Renal:
Hypotension, Hypovolemia (Vomiting, Diarrhea), Sepsis, Renal Artery Stenosis, Drugs:
ACEI, ARBs, NSAIDs.
Renal:
- Vessels: Toxins, Ischemia
- Tubules: ATN, AIN, Drugs
- Glomerulus: GN
Post-Renal: “Hydronephrosis”
Stones, Tumor, BPH. “Obstructive Uropathy”
Labs:
Pre-Renal Renal Post-Renal
BUN/Cr >20 <20 Variable
Urine Na <20 >40 Variable
Fractional excretion of Na <1% >2% Variable
Urine osmolality >500 <350 Renal US

Pre-Renal:
Urine Sediment: Hyaline cast (Normal)
Causes:
- ↓ Effective Arterial Volume: Hypovolemia, Sepsis, Cirrhosis (↓Oncotic Pressure).
- ↓ Local renal perfusion: Hepatorenal Syndrome, NSAIDs, ACEI/ARBs, Contrast.
 - Large vessel: Renal Artery Stenosis
Treatment: Isotonic IV Fluids
Renal:
ATN:
Urine sediment: Granular muddy brown cast
Severe ischemia, Sepsis, Contrast induced nephropathy.
Toxins: Vancomycin, Aminoglycosides.
Pigments: Myoglobin → Rhabdomyolysis (High Creatinine & CK)
Crystals: Uric Acid, Acyclovir, Methotrexate
Q- A patient w/ CKD/DM/CHF/Old undergoes CT w/ contrast, after 48 hours his
Creatinine is High → C.Induced Nephropathy, Treatment & Prevention is IV Fluids.
AIN:
Urine sediment: WBC cast, Urine Eosinophils.
Allergic: β-Lactams, Sulfa drugs, NSAIDs. → Stop offending drug
Autoimmune: SLE, Sjogren’s.
Infection: TB, Pyelonephritis, Legionella.
Infiltration: Leukemia, Lymphoma
Small Vessel:
Post-PCI or CABG → AKI two days later & Toe ischemia → Atheroembolic Kidney
Injury (Cholesterol emboli), there might be eosinophils in urine sediment.

GN: Urine sediment: RBC Casts

Post-Renal:
Foley’s catheter initially
Ultrasound:
- Bladder Neck: BPH, Prostate Cancer.
- Ureteral: Stone
US shows hydronephrosis.
Medications requiring dose adjustments or cessation in AKI:
Analgesics: Morphine, Pregabalin
Antiepileptics: Lamotrigine
Antiviral: Acyclovir
Antifungal: Fluconazole
Antimicrobial: All adjusted except Azithromycin, Ceftriaxone, Doxycycline, Rifampicin
← No need for adjustment. TMP/SMX is not used if GFR is <60.
Anti-diabetic: Metformin, Sulphonylurea. ← If GFR is <30
Others: Allupurinol, Colchicine, Warfarin, Digoxin, LMWH, NOACs (except Apixaban).
Chronic Kidney Disease:
Definition:
<60 GFR for ≥ 3 months and/or Kidney damage (Albuminuria, Structural Abnormality).
Causes:
Chronic HTN, Renal Artery Stenosis (27%)
GN (10%)
Diabetic Nephropathy (45%)
Criteria/Stages:
Stage 1: Normal >90
Stage 2: Mild 60
Stage 3: Moderate 30
Stage 4: Severe 15
Stage 5: ESRD <15
At stage 4, prepare patient for dialysis by making AV Fistula.

Complications:
Acute:
AKI on top of CKD e.g. Stage 3 patient developed septic shock & Creatinine increase
from 150 to 300 → Assess need for urgent dialysis or only TTT of underlying cause.
Chronic:
As stage progresses & the function decreases, the complications increase.
“Water”: Na retention → Edema, HTN
“Waste”: No H+ excretion (Metabolic Acidosis), No K excretion
No urea excretion “Uremia”:
- GI Bleeding (Coagulopathy)
- Pericarditis
- Encephalopathy
“Hormones”: ↓EPO → Anemia, ↓Vitamin D (1,25,OH) → Hypocalcemia → Secondary
Hyperparathyroidism (Low Ca, High PO4)
Progression of CKD complications is: “Water” → “Hormones” → “Waste”
Prognosis, All-cause Mortality, CKD Progression:
Albuminuria (Prognostic factor)
CKD is a strong Cardiovascular risk factor (e.g. Atherosclerosis, MI) and
Cardiovascular Disease is a major factor of mortality of CKD patients.
Mortality in Dialysis:
Acute: Arrhythmia (Electrolytes imbalance), Infection.
Chronically: Cardiovascular complications “Accelerated Atherosclerosis”

Considerations:
Cardiovascular: Statins
Diet: Low Na if HTN, K restriction if oliguric (U.O: 300-500 mL)
Diabetes: SGLT-2 (Slows CKD progression), stop if GFR <30.
BP: <130/80, Best drug is ACEI (Discontinue if Creatinine >30% or K >5.4)

Treatment of Complications:
Metabolic Acidosis: NaHCO3 → Dialysis
Hyperkalemia: All Should go through Anti-Hyperkalemia medication (Except if Anuric)
→ Dialysis
Anemia: Target HgB is 10, supplemental EPO injections.
Secondary Hyperparathyroidism: Phosphate Binder “Sevelamer”
Uremia “Pericarditis, Encephalopathy”: Dialysis
Uremic bleeding: Desmopressin
Volume overload: Furosemide → Dialysis

AKI Vs CKD:
AKI CKD
Size Normal Shrunken
PTH Normal >1000
Not by Creatinine or GFR!
 Cardiology

Any patient bleeding regardless of INR: Give Vit. K + (FFP or less favorably
Prothrombin complex) + Hold Warfarin.
If patient is not bleeding:
- INR 3-6: Stop Warfarin
- INR 6-10: Stop Warfarin, Give Vit. K Sc.
- INR >10: Stop Warfarin, Give Vit. K Sc.
Trans-esophageal Echo: IE, A.Fib
ECG:
Inferior MI:
Rule out Posterior MI: Suspicion if there is ST depression in V2, V3.
Bradycardia often resolves “AV block”

Anterior MI:
Bradycardia often needs Pacemaker.

Pericarditis:
PR depression, Diffuse ST elevation.
avL has high ST elevation in addition to other leads.

Multi-focal atrial Tachycardia:

Irregular rhythm, up & down P waves.
Common in COPDs.

Premature-Ventricular Contraction:
An abnormal R wave followed by compensatory pause.

Electrolytes disturbances:
Hypercalcemia: Narrow QRS
Hypocalcemia: Wide QRS
Hyperkalemia: At high levels; QRS complex is wide & P wave is lost.

VT:
Monomorphic:
- Stable: IV Amiodarone >> if failed: Cardioversion.
- Unstable w/ pulse: Cardioversion (Synchronized shock).
- Unstable w/o pulse: Defibrillation (Non-Synchronized).
Polymorphic:
- Stable w/ pulse: IV Magnesium. Usually caused by drugs.
- Unstable: Defibrillation (Non-Synchronized).

Arrhythmia:
“The name William Morrow can help identify LBBB and RBBB by looking at the
QRS morphology in V1 and V6. In LBBB the QRS looks like a W in V1 and an M in
V6 (WiLLiaM), in RBBB the QRS looks like an M in V1 and a W in V6 (MoRRoW).”
LBBB:
Left axis deviation: Lead I tented up & Lead aVF tented down, QRS complexes>> wide

WPW Syndrome:
Delta wave

Brugada Syndrome:
RBBB, Prolonged PR, Saddle shaped ST segment.
Trigger: Fever
Treatment: ICD

Cardiovascular Risk Reduction:

Risk Factors:
CKD, Cardiac FHx of early death <55 years Male or <65 Female, Cholesterol LDL 160-
190, Persistently High Triglycerides, Chronic inflammation (RA, SLE), Chronic Vascular
Insufficiency (ABI<0.9).
Diet:
DASH reduces Cardiovascular risk.
Low Salt, Low Fat, Lean protein, Very rich fruits & Vegetables, Variety of Fish.
Exercise:
Moderate intensity: >150 min/week
Vigorous intensity (Running, Jogging): >75 mins/week
Obesity: Caloric restriction, Counseling.
Diabetes: >6.5%
Lifestyle modification + Metformin + Exercise (As above)
Risk of MI:
A Albuminuria / ABI (<0.9)
B Bad Eye (Retinopathy)
C Complications (Nephropathy, Neuropathy)
D Duration (>15 year Type 2, >20 years Type 1)
Risk factors present:
No: Continue same treatment
Yes: GLP-1 (Semaglutide, Albiglutide) or SGLT-2 (Canagliflozin, Dapagliflozin)

When to give Statins:

- Age >75 = NO!
- LDL >190: High intensity statin
- DM (40-75 years old): Moderate intensity Statin
- 0-19: FHx of Hypercholesterolemia
- 20-39: FHx of MI or LDL >160
- 40-75: LDL 70-190 >> Framingham scoring:
A) <5%; Lifestyle modification.
B) 5% - <7.5% (Borderline); Moderate intensity Statin (Simvastatin) + Lifestyle.
C) 7.5% - 20%; Moderate intensity Statin.
D) >20%; High intensity (Rosuvastatin, Atorvastatin).

Drugs to stop smoking:

Bupropion; SE>> Seizure. C.I: Epilepsy
Varenciline; SE>> Nausea

Aspirin: Not enough evidence

Goal of LDL: High risk (DM, CAD): <100, preferred 70

Metabolic Syndrome:
Borderline Labs & BP:
DM: Fasting Glucose >100
BP: 130/80
TG: >150
HDL: <40
Cardiac Infections:
Infective Endocarditis:
Fever, SOB, Fatigue, Murmur, Splenomegaly, Jane way lesion, Osler’s nodes…
Rheumatic Fever: Could be complicated by infective endocarditis.
Duke’s Criteria: “2 Major, 1 Major & 3 Minor, 5 Minor”
Major:
+ve Blood culture in two separate sites.
+ve Blood culture 12 hours apart. “Persistent Bacteremia”
+ve Echo “Vegetation”.
+ve New Regurgitation.
Minor:
Predisposition: Drug abuse, Underlying heart disease.
Immunological phenomenon: Osler’s, Roth spot, GN, +ve RF.
Vascular: Janeway lesions, Conjunctival hemorrhages, Arterial emboli.
Fever >38
Positive blood cultures for atypical pathogens other than the ones typical in IE.
Treatment:
Antibiotics: 4 weeks for native valves & 6 weeks for prosthetics.
Modified from Dr.Amer’s + Toronto notes 2020
Non-IV abuse (Lt.)
IV Abuse (Rt. Sided) Native Valve: Damaged or w/:
Prosthetic Valve
VSD, ASD, Rheumatic H.Dis
Early: Late (>2 M):
Staph. Aureus (G+ve Tooth extraction e.g.: S. aureus S. viridans
cocci in clusters) S. viridans, S. aureus, Enterococci S. Epidermidis S. aureus
Strep. viridans S. Epidermidis

Vancomycin
Vancomycin + Gentamicin Ceft or Pen
MRSA: Vancomycin +
Or +
MSSA: Oxacillin Gentamicin
Ceftriaxone or Penicillin G Gentamicin
± Rifampin
Dr.Amer’s:

Complications: Stroke, Splenic infarction,…

Indications of Surgery:
C CHF
P Persistent Sepsis >72 hours
R Ruptured aneurysm
R Recurrent septic emboli
Fight! Fungal suspicion
P Peri-valve abscess

Prophylaxis: Amoxicillin 1g, 1 hour before surgery. Clindamycin if allergic.

C Cyanotic Heart Disease
P Prior Hx of Endocarditis
P Prosthetic Valve
R Repair of Congenital Heart Disease w/ prosthesis
Tough! Post-Cardiac Transplant
- No need for prophylaxis for GI or GU procedures,
No need: Bicuspid valve, Mitral valve prolapse, Valve repair w/o prosthesis, Previous
Rheumatic fever.
GI procedure + Prosthesis: NO Prophylaxis.
Lung Procedure (Above Diaphragm) + Prosthesis: YES Prophylaxis
Lung Procedure (Above Diaphragm) + Bicuspid valve: NO Prophylaxis

Aortic Aneurysms:
Types:
Root aneurysm: CTD, Congenital causes
Thoracic aneurysm: CTD, Congenital causes
Thoraco-abdominal: HTN
Abdominal Aortic Aneurysm: HTN + Smoking
Risk Factors:
Age, Atherosclerosis, High BP, CTD, Smoking, Congenital Bicuspid.
Screening:
TAA: CT scan
AAA: if symptomatic (Pulsatile,…) >> Abdominal US. If not symptomatic but 65-75 w/
Hx of smoking.
Diagnosis: Best is CTA
Treatment:
- Stop smoking
- Lower LDL to <70-100
- BP control:
To decrease aneurysmal growth >> Beta-Blocker
To decrease rupture risk >> ACEI

Aortic Dissection: “Acute Aortic Syndrome”

Type A: Thoracic
Type B: Abdominal
Risk factors: HTN (Most important RF) , Age, Atherosclerosis, CTD, Smoking,
Congenital Bicuspid. Pregnancy 3rd trimester + Early post-partum.
Screening: NO!
Diagnosis:
CXR shows widened Mediastinum.
CTA (Best): False lumen (Baseball appearance). If CKD >> ECHO or US.
D-Dimer can rise but less than <500.
Treatment:
Control BP <120, HR <60
First: BB (Labetalol) IV then reduce SBP w/ Vasodilators (Nitroprusside) >>
A) Proximal (Thoracic): Surgery
B) Distal (Abdominal): Conservative

Atrial Fibrillation:
Palpitations, SOB, Stroke,…
Causes:
Cardiac:
HTN, Hypertensive crisis, MI, New CHF.
Paroxysmal (<2 days), Persistent (>1 week), Long standing (>1 year)
Valvular, Non-valvular (No: RHD, Prosthesis, Replacement)
Non-cardiac:
Thyrotoxicosis, Pheochromocytoma
Alcohol, Cocaine, Amphetamine
Caffeine, Heavy smoking
PE, Severe Hypoxia (COPD)
Subarachnoid hemorrhage
Sepsis
Atrial Fibrillation Treatment:
Unstable: IV Heparin + Synchronized Cardioversion.
Duration of Symptoms:
>48 Hours:
1st Rate control (<110):
- BB (C.I: Decompensated CHF): Bisoprolol, Metoprolol.
- CCB (Asthma,…): Dilitiazim, Verapamil.
- 2nd line: Digoxin (Dilated CM). 3rd line: Amiodarone.
Rate controlled? Yes >>
2nd Rhythm needs correction?
- CHF, 1st time, Young >> Yes. (TEE: No thrombus) or (Warfarin >3 weeks) >>
Elective Cardioversion (Electrical or Pharmacological: Sotalol, Amiodarone,
Flecainide).
- No (e.g. Elderly)? Continue rate control.
3rd Risk factors for Stroke: CHA2DS2VASc
0: ASA, 1: consider Anticoagulation, 2 or more: Anticoagulation.
Prevent long term recurrence:
Rate control strategy: Elderly. C.I: AF due to Pre-excitation syndromes (E.g. WPW)
Rhythm control strategy: Young or Failed Rate-control. C.I: Long standing AF.
<48 Hours:
Stable: Heparin + Synchronized Cardioversion. Or Pharmacological cardioversion: IV
Heparin, Amiodarone (Strong, Broad-spectrum).

Q- HF w/ A.Fib treatment? Digoxin

Atrial Flutter TTT:

Rate control >> Radiofrequency ablation EPS (Electrophysiology Study).

Extra: Ventricular Arrhythmia >> Non-Synchronized shock (DC)

Stable Angina:
Stress ECHO indication: already diagnosed with ischemia and needs reassessment
again e.g. going for surgery.

Acute Coronary Syndrome:

UA:
Chest pain, ST Depression, Normal Cardiac enzymes.
Exercise stress test (Not done if in pain): Treadmill or Pharmacological (Dobutamine)
Next: CT Coronary Angiography >> Affected vessels
NSTEMI:
Chest pain, ST Depression, High Cardiac enzymes.
C.I: Thrombolytics
STEMI:
Chest Pain, STE, High Cardiac enzymes.
Myoglobin: 1st to rise
CK-mb: rises for 3 days
Troponin I/T: rises for 5 days
Q- MI had PCI, after 2 days he had chest pain. What labs to order? CK-mb (Specific
for Re-infarction)
Indication of Thrombolysis:
Chest pain <12 hours and can’t go for PCI within 120 minutes.
Alteplase better than streptokinase.
C.I of Thrombolysis:
Absolute: Active bleeding, Acute Ischemic Stroke within 6 months, Advanced
surgery/Head trauma within 3 weeks, Acute GI bleeding within 1 month, Brain cancer,
Prior hemorrhagic stroke (E.g Intracerebral Hemorrhage).
Relative: TIA within 6 months, Refractory HTN, Pregnancy or 1 week post-partum,
Advanced Liver disease, Oral Anticoagulant, Age >75, Active PU.
Q- Drug to reduce mortality in MI? BB
Management:
STEMI & NSTEMI: “Medical TTT” (Both the same except no Thrombolysis for NSTEMI)
Post MI: ACEI, BB.
During MI: “MONABSH”
Aspirin ASAP
BB During + post-MI
Heparin
High Statin: Anti-inflammatory, reduces lipid proliferation
Nitrates: reduces pain/BP
O2 if Hypoxic
+ (Within 90 mins)
Clopidogrel (or Ticagrelor [ADP receptor, P2Y12]) + Abiciximab.
+
STEMI:
PCI within 90 mins >> CTA: 3< vessels= PCI, ≥3 vessels or 2 Vessels + DM= CABG.
If patient can’t do PCI within 90 mins >> Alteplase >> ECG shows Ischemia (No: PCI
later, Yes: Repeat Alteplase) >> Repeat failed: PCI
NSTEMI: Timi score: “Done Post-Medical TTT”
Low risk: CTA 48-72 Hours
High risk: Urgent CTA. 3< vessels= PCI, ≥3 vessels or 2 Vessels + DM= CABG.

UA: As NSTEMI

Complications of Acute MI:

A Arrhythmia (V.Tach, V.Fib) or A.Fib
C CHF (anytime) post-MI
T Tamponade
R Rupture: Papillary muscle, Free wall ventricular rupture
A Aneurysm (Late & Persistent)
P Pericarditis (Post mi, Autoimmune dressler’s)
I Infarction again (CK-MB)
D Death, Dressler’s

0 Arrhythmia: V.Tach, V.Fib, A.Fib.

24 Hours Cardiogenic Shock: Low BP, High JVP
Tamponade (Free wall
Papillary M.R. (Most com. rupture): No murmur, No
Mechanical complic.): P.edema, Hypotension, 3
Murmur (Pansystolic; Mit. D’s: Distant muffled hearts
VSD (Pansystolic sounds, Distended Neck veins,
3 Days R) + Hypotension +
murmur) >> Surgery Decrease Pulse pressure (Low BP)
P.Edema ECG: Low voltage, Electrical
TTT: Diuretics + alternans, Sinus Tachycardia
Vasodilators >> Surgery TTT: Surgery, No
Pericardiocentesis!
Post-Mi Pericarditis: Chest pain, Improved by leaning forward,…
1 Week
TTT: High Dose Aspirin
2–4 Dressler’s: Chest pain, improved by leaning forward, Fever, High ESR.
Weeks TTT: High Dose Aspirin or NSAIDs

Special Considerations:
On Clopidogrel? Continue for 12 months
LDL <70
BP: <130/80
LV thrombus (as a complication): Anti-coagulant 3-6 months

Q- Acute Inferior wall MI with Hypotension? RV infarction >> IV Fluids, +- Dobutamine.

Avoid Nitrates.

Reduce mortality post-MI: βB

Q- If MI + (HF or HTN or DM)? Give ACEI
Post PCI Complications:
Stent:
Thrombosis: Tearing chest pain
Non-stent:
Bleeding
Contrast-induced AKI: Prevented by giving IV fluids.
Cholesterol Embolic Syndrome: High Creatinine + Abdominal pain + Toe necrosis
Valvular Heart Disease:
Diastolic:
ARMS
AR:
Early Diastolic, decrescendo murmur, increase by hand grip
or leg rise or sitting forward or expiration, Wide PP. LUSB
Austin flint murmur (Mid-diastolic rumble) → Severe regurge
Severity increases by duration of murmur:
- Valve: RHD, Bicuspid, IE
- Root: HTN
Treatment:
Severe & Symptomatic, Asymptomatic + EF <50: Aortic valve replacement.
Medical: ACEI, CCB, Hydralazine.
MS:
Low pitched, mid-diastolic murmur (Rumble) at apex, Opening Snap. Loud S1.
Decrease by hand grip, increase by leg raise/squat.
ECG: A.Fib, Left atrial enlargement.
CXR: Dilated Left atrium.
Echo: Best
Extra hints: Hoarseness of voice, Hemoptysis, Pregnant w/Hemoptysis (RHD most
common cause).
Treatment:
- Asymptomatic: BB, Diuretics, Abx prophylaxis (If known RHD), Anticoagulant.
Avoid excessive exercise.
- Symptomatic (HF, severe M. Valve area <1.5, RHD, Pregnant + HF): Balloon

Systolic:
MR: Apex radiation to axilla.
High pitched pansystolic murmur ± S3
Increase with Hand grip & Leg rise.
Causes:
- 1ry: RHD (late), Endocarditis, Post-MI (papillary M. Rupt.).
- 2ndry: Dilated Cardiomyopathy, HOCM.
ECG: LAE, LVH, A.Fib.
CXR: P.edema.
Echo
Treatment:
- Acute: is it IE or Ischemia? IE (Decrease Afterload by Nitroprusside, Reduce
Congestion by Diuretics, Low BP: Dobutamine, Surgery).
- Chronic: Symptomatic? Surgery [Repair]. Asymptomatic + EF declining? Surgery.
AS: RUSB Radiation to carotid.
Mid-systolic (Crescendo-Decrescendo), Slow rising pulse. Increase w/ leg rise & squat.
A Angina (Chest pain)
S Syncope
H HF (Orthopnea, edema, S4,…)
Causes: Calcified (>70; HTN, High Cholesterol), Congenital (Bicuspid; <70), Cardiac
(RHD).
Signs of severity:
1- Late peaking murmur
2- S2 (Paradoxical split)
3- Delayed carotid pulse (Pulsus parvus et tardus)
 4- S4 (HF)
ECG: usually nothing
CXR: AOV Calcification, Cardiomegaly, Pulmonary congestion.
Treatment:
- AVR: Symptomatic severe (HF), Asymptomatic severe + EF<50%, Asymptomatic
severe + Normal ECHO EF but sxs w/ exercise stress test.
- Medical TTT: If HF (Digoxin, Diuretics). Avoid: nitrates, BB, CCB.

Rheumatic Heart Disease:

GAS: 10 Days of penicillin to prevent Rheumatic fever. (Primary prevention)
If already Rheumatic → Secondary prevention:
- RF w/o Heart disease → 5 years or until 21 Antibiotics. (Whichever is longer)
- RF w/ Heart disease → (Check table)

Carditis:
- Mild: ASA 4-6 weeks. (Check pic)
- Severe: Steroids 2-4 weeks → (Surgery)
Chorea: Haloperidol
Polyarthritis: ASA 4-6 weeks
All: Anticoagulant for Stroke prevention.

Dx requires Labs Vs Clinical: Jone’s Criteria (2 Major or 1 Major + 2 Minor)

Labs:
- +ve Throat culture (GAS) or Rapid Antigen test
- High ASO Titer
+
Clinical:
JONES “Major”
Joint involvement (Pain)
Oh my heart (Carditis) CXR is performed in all “Carditis” suspected cases.
Nodule (Subcutaneous)
Erythema marginatum
Sydenham’s chorea
CAFÉ PL “Minor”
CRP High
Arthralgia
Fever
ESR High
Prolonged PR Interval
Leukocytosis “Not included in Criteria”

Pericardial Disease:
Pericardial effusion: Pericardiocentesis except MI tamponade.
Acute Pericarditis:
Post URTI (2 Weeks)
Etiology: Coxsackie, Uremia, TB, Idiopathic, Post radiation, CTD, Post-MI.
Investigations:
ECG: Concave diffuse STE, PR depression.
Troponin/Ck-mB: Normal
CXR: Pericardial effusion
ECHO: Fluid
MRI Cardiac, only done in Constrictive Pericarditis (Thickening)
Treatment:
Pregnant: Steroids
Post-MI: Aspirin
TB Pericarditis: Anti-TB + Steroids
CTD: Steroids
Viral or Idiopathic: NSAIDs (7-14 days) + Colchicine for 3 months (Reduce recurrence)
Recurrence: Colchicine for at least 6 months.
Constrictive Pericarditis:
Etiology: Infectious (TB,…)
Hx of travel, SOB, Orthopnea, Ascites, Hepatosplenomegaly, Kussmaul’s sign, Rt.
Side HF sxs & sign, no P.edema. Pericardial knock.
Investigations:
ECG: Normal
CXR (Initial): Calcifications & thickening
ECHO: Equalization of chambers
MRI Cardiac (Best): Thickened pericardium
Treatment:
Underlying cause (E.g. TB), Diuretics >> Not improved: Pericardiectomy

Pericardial Tamponade:
Low BP, Beck’s triad, Dyspnea, High JVP w/o P.edema, Pulsus paradoxus (Decrease
in SBP >10 w/ inspiration),…
Investigations:
ECG: Low voltage/ Electrical alternans
CXR: Increase cardiac shadow or silhouette
ECHO: Pericardial effusion
Treatment:
Pericardiocentesis

Constrictive Pericarditis Restrictive Cardio.

Both have Kussmaul’s, Low voltage
Physical Pericardial knock Murmurs (MR, TR)
Labs Normal BNP High BNP
Imaging +ve MRI Normal
Biopsy
Normal Fibrosis, Hypertrophy
(Endomyocardial)
Bradyarrhythmia:
Low HR + Symptoms,
ECG: Heart Block (1st, 2nd, 3rd)
Altered mental status or HF or Chest pain:
Atropine >> if not improved:
- Temporary (Transcutaneous) pacing
- Epinephrine
- Dopamine

Tachyarrhythmia:
Ventricular:
Wide QRS:
PVC:
- Symptomatic: βB
- Asymptomatic: Holter Monitor (48 h)
Ventricular Tachycardia:
Monomorphic:
- Stable: IV Amiodarone >> if failed: Cardioversion.
- Unstable w/ pulse: Cardioversion (Synchronized shock).
- Unstable w/o pulse: Defibrillation (Non-Synchronized).
Polymorphic: “Torsades De Point”
- Stable w/pulse: IV Magnesium. Usually caused by drugs.
- Unstable: Defibrillation (Non-Synchronized).
Stop offending drug, Correct electrolytes.
Causes: (Abx [Macrolides, Quinilones], Antipsychotics, Anti-depressants,
Methadone, Electrolytes disturbance [HypoCa, HypoMg], Class 1 anti-
arrhythmics).
Adenosine is avoided in VT!
Atrial:
Abnormal P wave +
- Normal QRS: A.Flutter, A.Fib, MAT.
- Narrow QRS: SVT
- Wide QRS + Short PR interval: WPW

SVT:
Regular rhythm, E.g. Female, stress, smoking, in hospital, Hx of Palpitations,…
Treatment: BP >>
- Low (Unstable): Synchronized shock.
- Normal: Carotid massage >> Not revert:
A) CHF: Adenosine (can repeat 3 times) >> Cardioversion/Amiodarone
B) Bronchial asthma: CCB (Diltiazem, Verapamil) >> Cardioversion/Amiodarone
C) None: Adenosine (can repeat 3 times) >> CCB or βB or Cardioversion
No βB or CCB in CHF. No Adenosine in Asthma.

WPW:
Young with Palpitations, Delta wave,…
Treatment:
Sotalol can be given as an acute initial therapy.
No Adenosine or Massage or CCB or Digoxin. Avoid CCB.
Drug of choice: Procainamide.
Definitive: Radio-frequency ablation
Cardiomyopathies:
Eventually: all will lead to CHF.
Type Etiology S&S Dx Treatment
Familial CXR (Edema),
ABSI, Treat
Myocarditis; ECG (A.Fib),
cause.
Parvovirus B19, ECHO (LV
Arrhythmia Peripartum:
HHV-6, Coxackie. dilation),
Dilated HF; S3, displaced Bromocriptine
Alcohol Coronary Angio
PMI Transplant,
Autoimmune (if ischemic
except post-
Peripartum (last CMP).
partum.
month - 6months) Endo.myo biopsy
CXR: P.edema,
Treat cause
Rt. Side sxs >Lt. no cardiomegaly.
Sarcoidosis Control HR
High JVP, ECG: Low
Amyloidosis Digoxin if
Restrictive Kussmaul’s, voltage.
Autoimmune Arrhythmia
Ascites, HSM. ECHO: Low EF
Hemochromatosis Best:
Murmur Endomyocardial
Transplant
biopsy
βB or CCB
“Young while
(Verapamil)
exertion, FHx
Refractory or
sudden cardiac CXR:
not tolerate
death” Cardiomegaly
Meds:
Dyspnea, Anginal ECG: LV
Hypertrophic Genetic AD Surgical
sxs, Arrhythmia, Hypertrophy,
myomectomy.
Syncope. Anterolateral T
Avoid:
Systolic murmur wave inversion
Digoxin,
increases with
nitrates,
valsalva/standing
Diuretics,…
Indication of ICD in HOCM Syncope, VT/VF, FHx of Sudden Cardiac death
Heart Failure:
Definition:
- Left Vs Right Failure
- Systolic Vs Diastolic Failure:
Reduced EF (<40%) Vs Preserved EF (≥50%)
Sequence:
High LVED Pressure:
- Normal LVED Volume: Diastolic Dysfunction >> HOCM, HTN, DM.
- High LVED Volume: Systolic Dysfunction >>
A) Low Contractility: Ischemia, MI, Dilated Cardiomyopathy.
B) High Afterload: AS, COA, Hypertensive Crisis.
Functional classification:
NYHA Class: SOB
1: Ordinary activities, no sxs
2: Ordinary activities, w/ sxs
3: Minimal activity w/ sxs
4: Symptomatic at rest (E.g. PND)
Major Symptoms:
Low output:
Fatigue, Exercise intolerance,
Congestive:
Left: P.edema, Dyspnea, Orthopnea, PND,…
Right: HSM, Ascites, L.L edema,…
Physical Examination:
Congestion:
High JVP, HSM, Ascites, L.L edema,…
Perfusion:
BP: Narrow PP, S4, Decreased Urine output,…
Labs:
Blood: RFT, LFT, BNP (Rules out Acute Decompensation, Sensitive not specific;
COPD, Renal, A.Fib, Age).
ECG: To rule out Ischemia or Arrhythmia.
CXR: Cephalization, Kerley B lines, P.edema,…
ECHO: EF, Wall motion, Valves.

Precipitating factors:
A Arrhythmia
D Dietary non-compliance
M Myocardial ischemia (MI)
R Renal failure
H HTN crisis
D Drugs: TZDs (oral Hypoglycemic agents), NSAIDs, CCBs,…
Toxin: Alcohol
Infection

Treatment:
Acute: “Not step-wise”
Congestion (Preload): LMNOP; IV Lasix (1st line), Morphine (Venodilator), Nitrates, O2
<92%, Pressure (CPAP). Still congested >> HD
Perfusion BP (Afterload):
- NL: nothing.
- High >> IV Nitrates (Decrease pre-after load).
- Low >> Inotropes (Dobutamine or Dopamine; Affect BP w/o HR).
NO Digoxin in Acute!
Chronic:
Furosemide as a reliever “Non-Post MI reliever”
A ACEI
B βB
S Spironolactone
I Isosorbide OR Ivabradine
Refractory (Stage D): Digoxin as a bridge to transplant.

Goal BP in HF: 130/80

Meds to avoid: High dose ASA, CCB, TZDs (Pigoglitazone), NSAIDs.
Decrease Mortality:
ACEI, BB, Spironolactone, Isosorbide.
Decrease Hospitalization:
Diuretics, Digoxin, Ivabradine.

Devices:
Cardiac Resynchronization Therapy:
EF <35% & Symptomatic Refractory. Decreases mortality.
ICD: “As Primary Prevention”
Chronic patient EF<30-35%

HF w/preserved EF:
HF w/ EF ≥50
Causes: DM, Age, HOCM, MI, Long standing HTN, Restrictive Cardiomyopathy.
ECHO: Decreased myocardial relaxation, Abnormal MV inflow.
Treatment:
Acute: Same as previous.
Chronic: No ACEI. Lasix >> BB
 Pulmonology

Airborne:
TB, Measles, Chicken pox.
Droplet:
Mumps, Neisseria meningitides. MRSA (If Respiratory infection)
Contact:
C.difficile, MRSA

Shock:
Preload, PCWP, JVP
Pump, CO
Afterload, Peripheral, SVR
Shock Type Preload Pump Afterload
Hypovolemic:
Low Low High
Loss (Fluid, Blood)
Cardiogenic:
High Low High
CHF, MI, Arrhythmia
Distributive:
Septic, Anaphylaxis, Low/NL High Low
Neurogenic shock

CASES:
Q- Trauma patient with massive intra-abdominal bleeding, LOW BP?
- Name of shock? Hypovolemic shock
- What’s the major physiological changes? ↓preload (LOW pulmonary capillary
wedge pressure + LOW JVP)
- Other cause? Fluids loss
- TTT? Blood in blood loss, Fluids in fluid loss.
Q- Post-MI patient sudden LOW BP, ECG found wide QRS complex tachycardia.
 - Dx? Cariogenic shock
- Physiological changes? ↓pump + high pre & afterload
- TTT? Dobutamine + Lasix
Q- Patient w/ fever + cough + LOW BP?
- Dx? Septic shock (distributive)
- TTT of septic? Empirical broad spectrum Abx.
- TTT of anaphylaxis? 0.3-0.5 in 1:1000 IM diluted epinephrin + secure airway.
ARDS:
Causes:
Direct: P Pneumonia, A Aspiration, N Near-drowning.
Indirect: Sepsis, Shock, Pancreatitis.
Definition:
Acute <1 Week of clinical insult, Bilateral infiltration w/o alternative explanation,
Hypoxemia (PaO2/FiO2) <100 “Intrapulmonary shunt”, Diffuse alveolar damage.
Treatment:
P Proning (Reduces mortality)
P Peeing (Fluid Balance) CVP 4-6 cm/H2O
P PEEP
P Paralysis “Rocuronium” >> No proven benefit
P Pulmonary vasodilation “Inhaled NO” >> No benefit in decreasing mortality
P Perfusion “ECMO” >> Refractory only
Prognosis: 40% death

Prevent Ventilation Associated Pneumonia:

Wash Hands, Frequent suction, HOB elevation, Non-nasal intubation, Enteral feeding.

Oxygen Delivery System:

Low Flow Nasal Cannula: FiO2 (24-40%) 1-4 Liters. Used initially in COPD
Simple Face Mask: FiO2 (35-50%) 5L/min up to 10 Liters.
Partial Non-Rebreather mask: FiO2 (40-70%)
Non-Rebreather mask: FiO2 (60-80%)
Special Mask (Venturi Mask): FiO2 (24-50%) Constant. Used in COPD
High Flow Nasal Cannula: FiO2 (21%-100%), O2 flow <40 Liters. Used in ARDS

Ventilation:
Invasive ventilation: Intubation
Non-invasive ventilation (No intubation):
C-PAP:
Hypoxemia (CHF), Pneumonia, OSAS.
Bi-PAP:
Hypoventilation (High PCO2, Low PO2), COPD.
LFNC doesn’t correct PCO2, and so Bi-PAP is used instead.

Indications of Non-invasive ventilation:

Clinical: Moderate-Severe dyspnea, RR >24-30, Breathing effort (Accessory muscles).
Gas Exchange: Poor gas exchange PCO2 >45 or Significant rise from baseline (w/
Dizziness), Hypoxemia.
Contraindications:
Altered mental status, Hemodynamic instability, Facial trauma, Active UGI Bleeding or
vomiting.

Respiratory Failure:
Lung Failure: (Gas Exchange Failure “Alveoli Vs Vessel”) Type 1 RF
Damaged: ARDS
Fluid: P.edema
Pus: Pneumonia
Fibrosis: Asthma
Vasculature: PE, P.HTN
Pump Failure: (Ventilation “Airway or what’s around”) Type 2 RF
Nervous System:
Central apnea (Hypoventilation)
Neuromuscular Failure:
Myasthenia Gravis
Muscle Failure:
Myopathies
Chest Wall:
Kyphoscoliosis
Airway problem:
Obstructive >> Acute COPD

Lung Cancer:
Lung Cancer develops after >20 years of exposure or smoking.

Types:
Small Cell Lung Cancer (Smoker): A neuroendocrine tumor
Central, SIADH (Hyponatremia), Cushing Puffy face/Plethora/Central obesity/High
ACTH, Weakness in arms & shoulders improves with repetition (Eaton-Lambert
Syndrome).
Oat cell “Lambert Eat Oat with Calcium” Pre-synaptic Ca channel Neurofunction,
Myasthenia-gravis like.

Non-small Lung Cancer:

Squamous (Smoker): Central, Cavitary lesion, Hemoptysis, High Ca (PTH hormone
related peptide), Clubbing.
Adenocarcinoma (Most common Lung Cancer): Peripheral, Woman + Non-smoker

Investigations:
CT guided Biopsy: Preferred in peripheral lesions. Best modality.
VATS: Preferred in Hilar (Central) lesions. Best modality.
Treatment:
SCLC:
Chemo + Radiation + Prophylactic cranial irradiation
NSLC:
Stage 1: Surgery then Radiation
Stage 2: Surgery then Adjuvant Chemo
Stage 3: Chemo + Radiation
Stage 4: Chemo then Targeted Therapy (immunotherapy)
Massive Hemoptysis:
First: Place on bleeding side dependent (Known by CXR), then Definitive Dx &
Treatment by Angiography Selective Embolization >> If not successful, Surgery.

Paraneoplastic Syndromes:
Smoker + Lung Nodule + Hyponatremia = Small cell (SIADH)
Smoker + Lung Nodule + Cushing features = Small cell (↑ACTH)
Smoker + Lung Nodule + Proximal weakness improves w/ repetition = Lambert Eaton
Smoker + Lung Nodule + Hypercalcemia = Squamous PTHrP

SVC Obstruction:
Oncological emergency.
Causes: Small Cell, Squamous cell.
Treatment:
Steroids + Radiation >> SVC Stent if no relieve.

Lung Nodule:
<3cm, Round, Single, Normal Lung Parenchyma, No Lymphadenopathy, No pleural
effusion.
Benign: 70%
Granulomas (Most comm lung nodule), Hamartoma, Aspergilloma, Rheumatoid
nodules.
Malignant: 30%
Primary Lung Cancer; Peripheral (Adenocarcinoma) [most comm in malignant], Less
common in Central.
Solitary Metastasis (Breast, Colon,…)

Investigations:
Nodule found on CT >> Compare with previous images (Check size or growth).
CT:
Check Features of Malignancy:
Malignant Features: Size >8 mm, (Any size w/ any of the following: Spiculated, Upper
lobe, Female, Age >60, Hx of Smoking) >> PET scan:
- Negative: Spiral CT every 6-12 months
- Positive: Biopsy
Benign Features: <8 mm, w/o other malignant features >> Spiral CT every 6-12 month
Pleural Effusion:
Analysis:
Exudate TB Transudate
Protein >3 g >3 g <3 g
Glucose <30 mg <30 mg >30 mg
pH <7.30 >7.30 >7.30
TB features: Lymphocytes 80%, Adenosine deaminase >40 (Most sensitive). Pleural
biopsy (Gold stx). AFB (specific?)
Exudate:
Causes:
P P.Infection/TB, P P.Malignancy, P PE, P Pancreatitis, P Post CABG (Lt. Side).
Meig’s Syndrome: Ovarian fibroma + Rt. Sided Pleural effusion + Ascites.
CTD: SLE, RA.
Yellow nail syndrome: Yellow nail + Lymphedema + Pleural effusion +- Bronchiectasis.
Transudate:
Causes:
C Cirrhosis, C CHF, C CKD (Nephrotic syndrome), C Constrictive Pericarditis, C
Chronic Fatigue (Hypothyroidism).

Light’s Criteria:
Exudate:
- Total protein effusion / Total Protein serum > 0.5
- LDH effusion / LDH serum >0.6
- Pleural LDH >2/3 of upper limit of normal serum LDH (Best Sensitive)
- Cholesterol effusion >55 (Best Specific)

Parapneumonic effusion:
IV abx, Pleural tap US guided “Thoracocentesis” (Pleural fluid analysis):
- Non-complicated para-pneumonic effusion: pH >7.2
Continue Abx only
- Complicated para-pneumonic effusion: pH <7.2, low glucose, ± +ve stain or culture
Abx + Tube thoracostomy (Chest Tube Drainage)
- Empyema: Pus
Abx + Tube thoracostomy (Chest Tube Drainage)

Upper Respiratory Tract Infections:

Most common is Rhinovirus; Runny nose, sore throat, post-nasal drip,…
If sore throat + Conjunctivitis or Diarrhea = Adenovirus

Bacterial:
Ear:
1:
Ear lobe pain & erythema & tender ± Fever = Otitis Externa >> Clinical diagnosis
Treatment:
Non-Diabetic: Ofloxacin drops for 7 days. Staph. Aureus most common.
Diabetic: Drops of Ciprofloxacin + Dexamethasone + PO Ciprofloxacin 7-10 days
Pseudomonas most common
2:
Ear pain, reduced hearing, Fever, Bulge tympanic membrane: Acute OM. Clinical Dx
Treatment:
Amoxicillin 5 days, not improved >> Augmentin
For smokers (G -ve; H.influenza, Moraxella): Cefuroxime

Q- patient had URTI viral infection, then 1 week later he developed dizziness &
reduced hearing >> Labrynthitis.

Throat:
Acute Streptococcal infection (GAS)
Fever, Sore throat, Cervical LAP, Exudative tonsils >> Throat culture + ASO Titer
Amoxicillin 10 days.

Sinuses:
Bacterial sinusitis: Fever, Tender maxilla (unilateral) ± nasal discharge >> X-ray PNS
(Air-Fluid level) >> CT (Air-fluid level, Bone destruction) >> Intrasinus culture >>
Anaerobes or Streptococcal: Augmentin or Clindamycin

Q- Patient w/ DM1 came to ER w/ DKA, he had fever, facial & orbital swelling, Black
Eschar from nose? Dx: Rhinocerebral mucormycosis. TTT: Surgical debridement,
Amphotericin.

Q- Patient with fever + sore throat + cervical LAP + splenomegaly, he received

amoxicillin then develops rash, Dx? EBV (infectious mononucleosis)

Lower Respiratory Tract Infections:

Bronchitis:
Fever, Cough, Colored Sputum, Normal CXR,…
Non-smoker, Non-COPD: Viral
Smoker: Bacterial (Hemophilus, Moraxella, Strep. Pneumoniae) >> Cefuroxime 5-7
days, stop smoking.
Pneumonia: A radiological diagnosis
Fever, Cough, Colored Sputum, Consolidation on CXR,…
Resolution of CXR findings takes 6 weeks.
Most common cause of all pneumonias: Influenza
S. Pneumoniae: most common cause of lobar pneumonia & Bacterial pneumonia
Prevention:
Any age (Immunocompromised, Asplenia, Cochlear transplant): PCV-13 >> After 8 weeks PPSV23
19-64: PPSV23 for: CHF, Lung disease (Asthma), DM, Cirrhosis, …
>65: PCV-13 >> After one year PPSV23

Types:
CAP:
Typical:
Productive cough, Consolidation,…
H.Influenza: Smoker, COPD
Klebsiella: Alcoholic, Currant jelly sputum, Cavitary lesions
S.Pneumoniae: No hints other than classical features. It also activates Herpes Labialis.
HIV: CD Count >>
- >200: As normal population (S.Pneumoniae)
- <200: Atypical organisms or fungi e.g. Pneumocystis Jirovici (PCP)
Atypical:
Atypical (Mycoplasma): Dry cough, Bilateral infiltration, … + Healthy/Military, Low Hgb,
Rash (Multiforme). TTT: Macrolide or Doxycycline. Levofloxacin can also be used.
Atypical (Legionella): Dry cough, Bilateral infiltration, … + Old, water source,
Abdominal pain or Diarrhea or Hyponatremia, High LFT. TTT: Same

Duration of TTT: 5 days.

Approach:
If a viral pneumonia is suspected, isolation is needed.
Severity Assessment CURB-65 Only for CAP
Confusion, Urea >6.5, RR>30, BP <90
0: Outpatient, PO
Healthy: Macrolides e.g. Azithromycin for 5 days
Co-morbidities (DM, SLE, CKD): (Levofloxacin or Cefuroxime) + Azithromycin
1-2: Ward, IV (Levofloxacin or Ceftriaxone) + Azithromycin << Cover Atypical
>2: ICU, Pseudomonas or MRSA, Levofloxacin + Vancomycin + (Cefepime or Tazocin
or Carbapenem)
Levofloxacin C.I: Pregnancy, Allergy, Asthma, Child.
Investigations:
Sputum culture & Gram stain (PMN≥25)
Specific testing:
S.Pneumoniae: Urinary antigen
Mycoplasma: PCR or IgM Cold agglutination test.
Legionella: Urinary antigen
Viral vs Bacterial (e.g. in Sepsis cases): Procalcitonin testing

HAP:
Patient hospitalized in ward for non-infectious cause, after 3 days develops fever,…
Organisms:
G -ve: Klebsiella, Pseudomonas
G +ve: MRSA
Subgroup of HAP: Ventilator associated pneumonia
Organisms: Acinetobacter baumannii, MRSA
Patient hospitalized in ICU (Mechanically intubated) after 5 days developed increased
secretions from tube & change in color of secretion & fever, CXR shows bilateral
consolidation.
TTT: Vancomycin + (Cefepime or Tazocin or Meropenem), 8 Days.
Health-care Associated Pneumonia: (Outside Hospital)
Patient in HD center or Old man in hospice for the <30 days, developed fever &
productive cough & CXR shows Consolidation.
TTT: Vancomycin + (Cefepime or Tazocin or Meropenem), 8 Days.

Aspiration pneumonia:
RFs: Epilepsy, Drunk (Alcohol), GERD, Stroke, TEF.
Gram -ve or Anaerobes
There must be typical CXR findings!
Augmentin or Levofloxacin or Tazocin

Lung Abscess:
Alcoholic found unconscious or Acute stroke or Post-seizure or Foreign body ingestion,
Fever + Foul (Purulent) smelling sputum ± Hemoptysis ± Clubbing. CXR shows Air-
Fluid level, Anaerobes (Oral flora).
Dx: Culture + CT Chest
Treatment:
Clindamycin or Augmentin, + if indicated for surgery.

Tuberculosis:
RFs: Travel, HIV, Chronic use of Steroids, Health care worker, Immunocompromised.
Fever, Night sweats, Tender LAP, Weight loss ± Hemoptysis, Cough (Dry or Productive),
± Pleuritic chest pain.
No PPD or IGRA in Active TB, They are for Latent TB.
PPD:
HIV/Immunocompromised/Chronic steroids/Close contact w/Active TB: 5 mm or more.
High risk (Health worker): 10 mm or more.
Others: 15 mm or more
False +ve: BCG Vaccine
False -ve: Active TB, Malignancy, Non-TB mycobacterium.
Treatment:
If TB is suspected, avoid Fluroquinolones (Levofloxacin,…). It affects AFB smear.
Suspected Active P. TB: Isolation in -ve pressure room & Start Anti-TB! >> CXR + 3
morning samples AFB sputum + Sputum TB Culture ± PCR.
Treat for at least 2 months w/ RIPE:

Rifampicin SE: Red/Orange discoloration, Cholestatic Jaundice,

“Continued for 4 extra months” Hypersensitivity Syndrome (High Cr, Hemolytic anemia, Low PLT).
Isoniazide SE: Vitamin B6 to avoid neuropathy, Hepatotoxicity, Seizure,
“Continued for 4 extra months” HAGMA, Drug induced Lupus, Thrombocytopenia.
Pyrazinamide SE: Hepatotoxic, Arthralgia, Hyperuricemia.
Excreted by kidney. SE: Optic neuritis, Color blindness. Not
Ethambutol
used for CNS TB.

Before Anti-TB TTT: Patients need Ophthalmological examination + LFT (Monthly if on

Isoniazide).
Q- When to discharge Active TB from isolation? Treated for 2 weeks (3 days minimum)
& AFB smear is -ve.
When to Stop Anti-TB Drugs:
- LFT increased 5 times Upper normal limit asymptomatic >> Stop all TB
medication then re-evaluate.
- Symptomatic: Stop.
- Other than that: Continue + Close follow up reevaluation (1-2 weeks).
Latent TB:
1st Line: Rifampicin for 4 Months
2nd Line: Isoniazid + B6 for 9 Months. Or Isoniazide + Rifampicin weekly for 12 weeks.

Extra-Pulmonary TB Treatment Duration:

LN TB: 6 Months
Pleural TB: 6 Months
Miliary TB: 6 Months
Genitourinary TB (Sterile Pyuria): 6 Months
Abdominal/Peritoneal TB: 6 Months
Pericarditis TB: 6 Months + Steroids
CNS TB: 9-12 months + Steroids
Bone TB: 9 Months

Bronchiectasis:
Hemoptysis, Productive cough, Foul smelling sputum, Smoker, Hx of TB, Clubbing,
Fever, Dyspnea, inspiratory crackles.
Associations RFs:
Cystic Fibrosis, Cilia (Primary ciliary dyskinesia), Central (TB, Malignancy, Repeated
pneumonia), High LFT (ɑ-1 antitrypsin Deficiency).
Investigations:
CXR: Tram-track appearance, Dilated bronchioles. (Permanent dilation of terminal bronchioles)
HRCT: Cystic ground glass appearance, Honeycomb.
PFT: Obstructive pattern, Reduced FEV1/FVC.
Treatment:
Acute
IV Abx: Levofloxacin
Inhaler: SABA / LAMA
Chronic
Inhaler: SABA / LAMA
Chest physiotherapy, Postural drainage
Prophylactic Abx: Azithromycin <<< Decreases Exacerbations for Bronchiectasis

Obstructive Sleep Apnea

Obese, Hypothyroidism, Acromegaly, Daytime somnolence, Snoring, Loss of
concentration, Headache,… If + BMI>30 + PCO2 >45 = Obesity Hypoventilation Syndrome
Investigations: Polysomonography (Sleep study): Assess Apnea/Hypopnea index
Treatment:
1: C-PAP: Reduces Mortality & Complications. 2: Weight reduction.
Severe Refractory: Tracheostomy.
In Central Sleep Apnea (CNS): If no HF, No C-PAP.
Obesity Hypoventilation Syndrome: Bi-PAP.
Mortality Causes: Stroke, P.HTN, HTN.

Pulmonary Function Test:

Pressure (Airway)
FEV1FVC <80% >> Obstructive pattern >> Bronchodilator:
- FEV1 >12%: Asthma, if equivocal Methacholine Challenge test.
- FEV1 <12%: COPD; Chronic Bronchitis or Emphysema >> DLCO Test:
A) Low: Emphysema
B) Normal: Chronic Bronchitis

Flow (Diffusion + Alveoli + Artery)

FEV1/FVC, TLC Normal >> DLCO Test:
- Low: PE
- High: Pulmonary Hemorrhage
Total Lung Capacity (Parenchyma)
<80: Restrictive >> Interstitial Lung Disease

Interstitial Lung Disease:

FVC: Reduced, FEV1: Normal, FEV1/FVC Ratio: Normal
SOB, Bilateral fine crackles, Finger clubbing,…
Investigations: PFT >> CXR >> HRCT

Q- Early sign of Restrictive disease? Low DLCO

Q- Major drug can cause lung fibrosis? Amiodarone >> Stop + Steroids. Also can
cause this: MTX, Nitrofurantoin, Bleomycin.
Q- Upper lobe fibrosis: Hypersensitivity pneumonitis, Silica, Smoking related ILD.
Q- Lower lobe fibrosis: Asbestosis, Idiopathic Pulmonary Fibrosis.

Autoimmune ILD: (Sarcoidosis, Scleroderma, CTD, RA “Fibrosing alveolitis”,…)

Sarcoidosis
Female (30-50), White or Black, Red eye, SOB, Dry cough, Clubbing, Facial rash,
Raised erythematous nodule on leg ± Hypercalcemia.
CXR (Best initial):
- Stage 1: Bilateral Hilar LAP
- Stage 2: Bilateral Hilar LAP + ILD
- Stage 3: ILD
- Stage 4: Diffuse Fibrosis
Then do >> HRCT >> Labs: Serum ACE level will be high (80% specific, Monitoring)
EBUS LN biopsy (Gold standard): Non-Caseating granuloma
Treatment:
Asymptomatic: None
If Neurosarcoidosis, HyperCa >> Steroids
NSAIDs for Symptomatic relief.

Q- Sarcoidosis, Fever + Erythema nodosum + Hilar LAP ± (Arthritis in ankle)?

Lofgren’s syndrome (Good prognosis)

Pneumoconiosis: “Occupational”
Non-organic dust:
Hypersensitivity pneumonitis: Farmer’s lung, Pigeon breeder’s lung, etc...
Organic dust:
Asbestosis (Synergistic w/ smoking for Lung Cancer)
Coal worker + Ships. Lower lobe fibrosis w/ calcified pleural plaques.
Silicosis (Can reactivate TB)
Miners or Sand blasters. Affects Upper lobe.
Berylliosis
Aerospace

Treatment for all: Stop offending agent >> O2 >> Lung transplant

Venous Thromboembolism:
Pulmonary Embolism:
Female, Hx of OCP, Travel, Pregnant, Cancer, Post surgery, Obese, Sudden SOB,
Pleuritic chest pain, Tachycardia, +- Hemoptysis, ECG: Sinus Tachycardia.
Specific ECG Finding: S1Q3T3
CXR: Increased broncho-vasc markers, P. effusion. Hampton sign, Westermark sign.
Approach:
IV Fluids, Oxygen, Analgesics.
Stable:
- Normal person: D-Dimer
A) <500: Probability test “Well’s Score”:
 ≥2: Probable >> CTA
 <2: Not PE
B) >500: CTA
- Pregnancy or CKD (C.I: D-Dimer, CTA):
A) CKD: V/Q scan
B) Pregnancy: Doppler US of L.L >>
 Positive: Treat
 Negative: V/Q scan >> if -ve No TTT
Gold standard: Pulmonary Angiography (Diagnostic & Therapeutic).

Massive PE: Low BP or Bradycardia. TTT: Alteplase. If Thrombolysis is C.I >> Surgical
thrombectomy.
Sub-massive PE: RV strain w/ normal BP. High Troponin, BNP.
DVT:
Calf pain, Swelling, Venous distension, Erythema, Usually Unilateral, Occasionally
affects Upper limb.
Investigations:
Probability test:
- High: Doppler US of L.L >> -ve: Not DVT.
- Low: D-Dimer:
A) >500: Doppler US of L.L
B) <500: Not DVT
Gold standard: Venography

Treatment DVT & PE:

Anticoagulation
- Provoked (Risk Factors):
A) LMWH (Until INR 2-3 then stopped) + Warfarin (3-6 months)
B) NOAC: Rivaroxaban - Dabegatran- Abixaban (CKD) 3-6 months. No bridging.
- Unprovoked: Same.1st PE: Treat for 3 months. 2nd PE: Treat for life +
Thrombophilia work-up.
If Pregnant: LMWH only until delivery.
CKD: PE or DVT >> (UFH IV Bridging + Warfarin) or Apixaban.
Cancer: anti-coagulation w/ LMWH for life or until cure.
Q- DVT with Hx of PUD (C.I: Anticoagulant): IVC filter.

Thrombo-prophylaxis:
Enoxaparin is contraindicated if there was recent eye surgery.
Low risk:
Medical: <40, Ambulated. TTT: Ambulation
Surgical: Minor surgery, Same day. TTT: Mechanical Prophylaxis “Compression device”
High risk:
Medical: Immobile, Hx of VTE or Cancer. TTT: CKD >> UFH SQ. No CKD >> LMWH.
Surgical: Major surgery, Trauma. TTT: Same as medical + Mechanical Prophylaxis.
Orthopedic (High Risk):
(LMWH or Fundoparinx or Warfarin INR 2-3 [For CKD]) + Mechanical Prophylaxis.

Risk Factors:
S Stasis: Bed rest, Inactivity, Air travel >6 hours.
I Injury to endothelium: Trauma, Surgery, Central catheter.
T Thrombophilia: Genetic disorders, OCP use, Tamoxifen
M Malignancy
O Others: Obesity, Post-partum
H Hx of Thrombosis << Greatest risk of recurrent VTE
Pulmonary HTN:
Definition: Pulmonary Artery pressure ≥25 mmHg at rest.
Q- Risk factors, Chronic dyspnea, Sxs of Rt. Side HF, RV heave, Tricuspid Regurgitation, Prominent P2.
Groups Classification:
1: Primary Pulmonary Artery HTN: Familial, Idiopathic, CTD, HIV.
2: Left Heart Disease (High PCWP) >> CHF
3: Lung Disease/Chronic Hypoxemia: COPD, ILD, Neuro-Muscular Disease.
4: Chronic Thromboembolism, PE.
5: Miscellaneous: Sarcoidosis, Schistosomiasis, SCD
Investigations:
Doppler Echocardiography (Best initial)
Right side Heart Catheterization (Gold Standard)
Poor prognostic Factors:
Clinical evidence of RV Failure, WHO class 4 symptoms, High BNP.
Treatment:
Supportive: Oxygen O2 sat >90%, Diuretics: Reduces RV stress, Digoxin (if: AF).
Vasodilation (Only for Group 1) >> Acute vaso-reactivity test:
- +ve: CCB
- -ve: PDE-5 Inhibitor (Sildenafil,…)
Pulmonary endarterectomy: Only for Group 4.
Refractory: Heart-Lung Transplantation

Obstructive Airway Disease:

Dis Asthma COPD
SXS Nocturnal Dry cough -White sputum Chronic Productive morning sputum
Smoking, Perfumes, BB, ASA,
Trigger Infections, Smoking, PE, BB
Cats, Pollen, Dander
Exac. URTI Infections (H.Influenza)
Spirometry Spirometry: High Residual Volume
CXR, IgE, Eosinophils ABG, ɑ-1 antitrypsin, PFT
Dx
PEFR: Monitor FU, Response to CXR (infiltration, Bulla, Emphysema type)
TTT ECHO (Cor Pulmonale), ECG (RVH/RAH)
Samter’s syndrome: ASA + Nasal
polyps + Wheeze/Cough (Asthma) A Appearance
C. Strauss: Eosinophilia, Vasculitis, A Age
P.ANCA B Bad
Extra
A.Rhinitis: Asthma, Atopy, High IgE. C Cor Pulmonale
Bronchopulmonary Aspergillosis:
Asthma w/ no improvement on Check table below
bronchodilators. TTT: Steroid ± Itraconazole

Bronchitis Emphysema
Appearance Blue Bloater Pink Puffer
Age 40 - 45 50 - 75
Bad (Oxygenation) Progressive Hypoxia, High HCT
Cor Pulmonale Common Not
DLCO Normal Low
Improve Quality of life, Reduce severity of progression in COPD: Smoking cessation!
Indications of Long Term O2 use in COPD: “To prevent cor pulmonale”
PaO2: ≤55 or SaO2: <89% (During: Rest, Exercise, Sleep)
Indication of Home Bi-PAP: PCO2 >53 mmHg. (Reduces mortality & admission)

Asthma Exacerbation:
Severity: Mild Moderate Severe
Mental Not agitated Agitated Agitated
Mouth Sentences Phrases Words
Muscle No Yes Yes
Monitor (HR, RR) <100, 18 100-120, 18-22 >120, >23
Peak Flow <80% <60% <40%
SaO2 Normal Normal <92%
PaO2 (ABG) Normal Normal <60
Pulsus paradoxus Normal 10-25 >25

Management:
Agonist (SABA) every 20 mins
Steroids (in ER: IV)
Theophylline causes Arrhythmia
Hydration / O2 SaO2 >90%. Nasal >> Face Mask >> High flow
Muscarinic antagonist = Ipratropium
Mg sulfate
An intubation (Mechanical)
C-PAP & Bi-PAP are avoided b/c they can cause barotrauma.
Life-threatening: Silent chest, Bradycardia, ABG starts to normalize. TTT: Intubation.
SABA 1 Hour before exercise!
Chronic Asthma Management:
F/U: Clinical not FEV1.
Tapering down is every 3 months.
Step-wise: SABA >> ICS >> LABA >> LTRA >> PO Steroids >> Omalizumab
Persistent
Stage Intermittent
Mild Moderate Severe
Daytime sxs <2 Week >2 Week <7 Days (3 in row) Throughout
Nocturnal sxs ≤2 Month >2 Month Weekly Continuous
SABA (Intermittent) >> ICS (Mild Pers.) >> LABA (Moderate Pers.) >> LTRA (Severe
Pers.) >> PO Steroids >> Omalizumab

COPD Exacerbations: “Chronic Bronchitis”

Acute on top of chronic: Increase sputum production, Change in sputum color, SOB, CRP>40.
Corticosteroids, O2, Pulmonary pressure (Bi-PAP), Dilators/Drugs (Abx).
1st line Bronchodilator for COPD Exacerbations: LAMA (Decreases Exacerbations,
Slows down progression of FEV1 in F/U, Decreases H.Admission, Decrease Secretion)
Approach:
1. LAMA (ipratropium) + SABA
2. IV Steroids
3. Antibiotics (Same efficacy: Amoxicillin vs Doxycycline vs Azithromycin vs Levofloxacin, for <5 days).
4. Oxygenation: Low flow Nasal cannula, Venturi mask. Increase FiO2 to achieve
PaO2 >55-60, SaO2 88-92%.
Non-Invasive PPV (Bi-PAP) Mechanical Intubation
Severe dyspnea RR>25, Low pH (<7.2), PaO2 <55-60, Increasing PCO2, Low pH,
Increasing PCO2 >45 Altered MS, Low BP, Resp Fatigue RR>30
If Non-Invasive is Contraindicated or deteriorated on it: Do Mechanical Intubation
Contraindications: Facial Trauma, Active UGIB, Low BP, Altered MS, Vomiting

Influenza vaccine (Annual): Reduces mortality & serious illness.

Steroids: Reduces Hospitalization, Increases FEV1. (No mortality benefit)
Antibiotics: Reduces treatment failure & Mortality.
High Flow 100% Oxygen cause Hypoxic Respiratory drive >> Confusion, Acidosis.
TTT: Reduce O2 Flow

COPD Chronic Management:

F/U: FEV1 << GOLD Stages:
1: ≥80% Mild
2: 50%-79% Moderate
3: ≥30%-49% Severe
4: <30% Very severe
F/U:
Already on SABA + ICS, presenting w/ the following in clinic:
FEV1 >50%: SABA + ICS + LABA or LAMA
FEV1 <50%: SABA + ICS + LABA + LAMA
ICS: Best in decreasing Hospitalization, No benefit in mortality.
 Infectious Diseases

Cellulitis
Disease Erysipelas
Purulent Non-Purulent
Poorly demarcated Well demarcated, L.L or Face
Features
Only Lymphadenitis Lymphangitis & Lymphadenitis
Organism S. aureus S. pyogenes S. pyogenes
Non-Septic: Clinda Clindamycin or Mild: Amoxicillin
Treatment
Septic: Vancomycin Dicloxacillin Septic: IV Ceftriaxone
Brucellosis:
RFs: Unpausterized milk, exposure to cows or goats or sheep, Butcher, Lab exposure.
Cause of death is usually IE.
Brucella is -ve coccobacilli.
Brucella melitensis: Goats, Sheep, Camel. Commonest in Saudi Arabia.
Clinical Features:
Fever, Sweats (Malodorous is Pathognomonic), Back pain, Arthritis, HSM, LAP, High ESR,
Low WBC.
Investigations:
Serum agglutination test (Initial)
Blood Culture: Gold standard, Specific.
Bone marrow culture: Gold standard & higher yield.
CT/MRI: for vertebral osteomyelitis (MRI is better).
Treatment:
Non-localized:
6 Weeks: PO Doxycycline + PO (Rifampicin or Streptomycin or Gentamicin 7 days IV)
Localized:
Pregnancy: Rifampicin + TMP/SMX “4 Weeks”
Joint (OM, Sacroilitis, Arthritis): 3 Mons (Doxycycline + Rifampicin) + “Gentamicin 7 Ds”
CNS: Ceftriaxone + Doxycycline + Rifampicin “6 Weeks – 2 Years” + CSF Normalized
Endocarditis: Surgery + Gentamicin 2 Weeks + (Doxycycline + Rifampicin + TMP/SMX
“6 Weeks – 6 Months”)
Dengue Fever:
Tropical (Jeddah, South, Jazan, Makkah), Periorbital rash, Petechial rash, Severe
headache, Myalgia. Sting at 2 Hours after sunshine. Low Platelets. Retroorbital pain.
Mosquitos: Aedes aegypti (Most important vector), Aedes Albopictus.
Single RNA (Flaviviridae)
Clinical phases:
Febrile illness:
Headache, Myalgia, Mouth/Nasal bleeding, Rash petechiae, Periorbital rash or pain.
Critical phase: “Acute Hemorrhagic Phase”
Low BP, Pleural effusion, GI bleeding.
Recovery phase:
Risk of: Seizure, Bradycardia.
Investigations:
Duration of Illness:
<3 days: Virus detection by Dengue PCR or ELISA >> If -ve, IgM detection.
>3 days: IgM detection >> If -ve, NS1 Test.
Treatment:
IV fluids + Paracetamol. No isolation.
No anti-viral, avoid Aspirin or NSAIDs, avoid anticoagulants.

Impetigo:
Organism: Staph. Aureus
Non-bullous impetigo:
Papules → small vesicles surrounded by erythema → pustules that rupture → oozing
secretion that dries → honey-colored crusts → heal without scarring.
Bullous impetigo:
Vesicles, Bullae, Ecthyma, Nikolsky sign.
Treatment:
Non-bullous impetigo with single lesions or small areas: topical antibiotics (mupirocin).
Bullous impetigo: ecthyma, or severe non-bullous impetigo: First generation
cephalosporins (e.g. Cephalexin) or Dicloxacillin.

Leishmania:
Leishmania donovani, Vector is Sandflies.
Investigations:
Biopsy (Gold standard):
- Skin or Tissue microscopy (Giemsa stain): Macrophages w/ amastigotes
- PCR
Cutaneous:
Reddish macules/papules that quickly increase in size w/ central ulceration.
Treatment:
Local: Cryotherapy, Thermotherapy, Topical Paromomycin
Systemic (Complicated): Sodium stibugluconate “Pentostam®”
Visceral:
Huge Splenomegaly, Weight loss, Spiking fevers, Ascites, Pancytopenia.
Treatment:
Systemic: Amphotericin B or Sodium stibugluconate “Pentostam®”

Rash:
Rubella
Post auricular LAP, rash. Face >> Trunk
Robeolla “Measles”
3 C: Cough, Coryza, Conjunctivitis. Koplik spots in buccal mucosa, rash. Face > Trunk
Roseolla infantum
HHV-6. Rash starts from trunk then to neck.

Herpes Zoster:
Herpes Zoster only: PO Acyclovir or Valacylovir
Ramsay Hunt Syndrome:
HZ + Decreased hearing & Vesicles in Auditory meatus.
TTT: IV Acyclovir + Good hydration
Acyclovir SE: could cause crystal induced AKI

Genital ulcers: STDs

Painless genital ulcer:
Inguinal LNs:
- Painful LN: Lymphogranuloma venerium (Chlamydia trachomatis). TTT:
Doxycycline
 - Painless LN: Syphilis (+ Maculopapular rash in palms & soles). TTT: Penicillin G
Painful genital ulcer:
Inguinal LNs:
Bilateral LN involvement: HSV-2
Unilateral LN involvement: Hemophilus ducry (Chancroid). TTT: Doxycycline

Syphilis:
RPR & VDRL tests are for screening & monitoring response to treatment.
Primary:
Painless genital ulcer (Chancre), Non tender inguinal LAP.
Investigations: Dark-field microscopy or PCR. RPR & VDRL will be -ve.
Secondary:
Ulcer (healed w/scar), Maculopapular rash, Inguinal or Generalized LAP, Warts.
Investigations:
FTA-ABS, +ve VDRL, +ve RPR, Dark-field microscopy.
Tertiary:
“Neurosyphilis”
Personality changes, Argyll Robertson’s pupils, Foot drop & Ataxia (Tabes dorsalis)
Investigations:
FTA-ABS
Treatment for all:
Treatment: Penicillin G, even if pregnant & has allergy “using desensitization”
Primary or Secondary: Intramuscular.
Neurosyphilis: IV for 2 weeks.
Treat sexual contacts also.
HIV:
Prophylaxis: PEP
Adult or Health care worker:
2 NRTI + Integrase inhibitor for 4 weeks.
Pregnant & Not on Meds:
Labour: Zidovudine (or Nivarapine) for mother & child.

Diagnosis:
RFs: Traveling, IV drug abuse, Sexual contact w/multiple partners, Mononucleosis-like
symptoms (Fever, Sore throat, LAP, Jaundice, Rash, Myalgia).
Acute retroviral infection:
Screening (ELISA) >> +ve >> Confirm (WB) >> +ve (HIV):
- Viral load: PCR
- CD4 Count (Prophylaxis)

AIDS Defining Conditions:

Pneumocystis Pneumonia:
Most common cause of death in AIDS patients. CD4 <200
Hypoxia, SOB, Dry cough, High LDH, Fever, Bilateral CXR infiltrates, High LDH.
Investigations:
BAL (Diagnostic)
Silver stain
CXR: Ground Glass appearance
Complications:
Pneumothorax
Treatment:
TMP/SMX +- Steroids (If still hypoxic PaO2: 60)
Kaposi Sarcoma:
HHV-8, Purple lesion in buccal mucosa, CD4 <200
Treatment: HAART
Candidiasis:
Oral thrush, CD4 <200
Treatment: Fluconazole
Toxoplasmsis:
Fever, Focal Neurologic deficits, Seizures, CD4 <100
Investigations:
CT: Multiple Ring enhancing lesions in Brain
Serology: IgG/IgM
Treatment: Pyrimethamine + sulfadiazine + folinic acid
Cryptococcus:
Headache, Altered MS, CD4 <100
Investigations: CSF, culture (india ink)
Treatment: Amphotericin B + Flucytosine/Fluconazole
Cryptosporidiosis:
Chronic Profuse watery diarrhea, CD4 <100
Investigations: Acid Fast cysts in stool
Treatment: Nitazoxanide
CMV Retinitis:
Visual changes, Cotton wool spots on fundoscopy, CD4 <50
Treatment: Gancyclovir
Primary Lymphoma:
Focal neurologic deficits, Seizures, CD4 <50
Investigations:
CT/MRI: Solitary Ring Enhancing lesion
PCR: EBV DNA
Vaginitis:
Disease Normal Trichomonas Candida BV
Symptoms X Itching Itching, dysuria Itching
Frothy, green, White, thick Fishy,
Discharge Clear
musty, grey cottage cheese Malodorous
Clinical Fx X Cervical petechiae Erythema X
Vaginal pH 3.8-4.2 >4.5 <4.5 >4.5
KOH “Whiff” -ve +ve -ve +ve
Motile flagellated
NaCl wet mount Lactobacilli X Clue cells >20%
protozoa
KOH “Wet
X X Pseudohyphae X
mount”
Topical
Metronidazole + clotrimazole,
Treatment X Metronidazole
Treat partner miconazole,
fluconazole

Malaria:
Diagnosis:
Subsahara Africa, Sudan, Jazan (South), Fever, Abdominal pain, Jaundice,
Splenomegaly, Increased Liver enzymes, Leukopenia, Thrombocytopenia.
Number 1 cause of FUO in returned travelers.
P.vivax (most common in SA)
Anopheles species: Night time or pre-dawn sting
Severe malaria features:
Cerebral malaria: Seizures, Confusion
Respiratory distress, Renal failure
Liver (Severe Hypoglycemia) + Lactic acidosis
Severe anemia, Parasitemia: >5%
Prophylaxis:
Chloroquine resistant “SA, Africa,…”:
Atovaquone-Proguanil “Malarone” (2 days before traveling & 5 days after leaving) or
Mefloquine (Pregnant, 2 weeks before travel & 4 weeks after leaving)
Or Doxycycline (2 days before & 28 days after leaving)
Chloroquine sensitive:
Chloroquine, 1 week before traveling.

Investigations:
Light microscopy: Giemsa stain
Thick film: detects Parasite
Thin film: determines species + % of parasitemia
Q- If negative? Repeat the whole thing every 8 hours for 2 days.
Rapid diagnostic tests: For screening purposes only
Treatment:
Non-Complicated:
A) P.Falciparum: Artesunate PO + Sulfadoxine-Pyrimethamine + Primaquine
(Gametocidal). Alternate: Artemether.
B) P.Vivax, Ovale, Malarie: Chloroquine + Primaquine (G6PD!)
Complicated (Severe): Regardless of Species >> IV Artesunate (G6PD!)
Pregnant: Clindamycin + Quinine
If severe in 2nd trimester: Artesunate + Clindamycin

Red man syndrome:

Vancomycin reaction (Flushing, Itching): reduce infusion rate + Antihistamines
Schistosomiasis:
Never causes liver cysts.
Non-hematobium:
Farmer, trips, lake, HSM or Diarrhea.
Peri-portal HTN: High AST/ALT/Bilirubin.
Dx: Stool microscopy. TTT: Praziquantel
Hematobium: “Genitourinary Schistosoma”
Trips, Hematuria, Dysuria, At risk of squamous cell carcinoma of bladder.
Investigations:
Stool or Urine microscopy (Best), Blood serology (antigen), Urinary bladder calcification
TTT: Praziquantel
 Neurology

CNS Infections:
Indications of therapeutic LP:
Normal pressure Hydrocephalus, Idiopathic Intracranial HTN, Intrathecal Chemotherap
Brain Abscess:
Fever, Progressive Headache (Night +- frontal), High ICP, Vomiting, Seizure, +- Focal
neurological deficit (Weakness, Hemiplegia). + RFs: Chronic sinusitis, Dental infection,
Chronic mastoiditis, Otitis media, IV drug abuse, Skull base fracture.
No isolation, No LP!
C.I for Lumbar puncture: High ICP, Coagulopathy, infection in spine, space occupying
lesion.
Investigations:
CT Brain w/contrast = MRI w/contrast >> Central hypodensity w/ ring enhancement.
Brain biopsy (Definitive): G -ve Anaerobes (Bacteroid Fragilis) << Common
Treatment:
Surgical Drainage & Biopsy
+
IV Metronidazole + Ceftriaxone “Empirical” 6-8 weeks.

Meningitis:
Fever, Headache, Neck Stiffness, Photophobia, ± Purpuric petechial rash
(N.Meningtides), ± Confusion, ± Seizure. Usually 2/4: Fever, Headache, Stiffness,
Confusion. Atypical sxs in elderly.
Physical exam: Nuchal rigidity (Sensitive), Knee flexion (Kernig’s sign), Passive neck
flexion (Brudzinski sign). Papilledema, Absent venous pulsation. Focal neurological
deficit. Petechial rash.
Waterhouse-Fredrichsen Syndrome: Nisseria Meningitis + Adrenal Hemorrhage.
Organisms:
18-50: N.Meningitides, S.Pneumoniae.
>50: S.Pneumoniae, N.Meningitides, Listeria monocytogenes (Elderly, Alcoholics,
Immunocompromised).

Management:
Blood culture
Empirical Antibiotics + Dexamethasone (Except: suspected Listeria, Given for 4 days)
Isolation: if there is rash only (Droplet: N.Meningitides)
CT (Can do LP or not): Done if >> Immunocompromised, >60 age, Seizure, Space
occupying tumor, Focal neurological deficit, Altered mental status.
LP (CSF Analysis):
Type Bacterial TB Viral
Protein High, 2 High, 1 Low, <1
Glucose Low, <45 Low, <45 High or Normal, >45
Count (Cell) PMN Lymphocytes PMN >> Lymphocytes
Bacterial (Rule of 2): WBC>2000, Total protein >200, Glucose <20.
TB: Chronic headache + Meningeal symptoms.
Viral: Protein could be Normal or High!
Empirical Abx:
18-50: Ceftriaxone, Vancomycin.
>50 (No dexa): Ceftriaxone, Vancomycin, Ampicillin.
Culture results:
G +ve Bacilli (Listeria): Ampicillin
G +ve cocci (S.pneumoniae): Vancomycin
G -ve Diplococci (N.Meningitides): Ceftriaxone

Viral Meningitis: Supportive treatment, unless HSV >> Acyclovir

Isolation:
Isolation (Droplet) Only for N.Meningitides: Discontinue after 24 hours of starting TTT.
Prophylaxis:
Rifampicin (2 days) or Ciprofloxacin (Once) or Ceftriaxone IM (Once).
Pregnant: IM Ceftriaxone, Rifampicin is contraindicated in 1st trimester.
Prophylaxis for N.Meningitides only, not S.Pneumoniae or Listeria.

Complications:
Hearing loss, Deafness, Seizures, Stroke (Acute or Late), Learning difficulties.
Immunization:
SCD, Asplenia, High risk (Hajj).
N.Meningitides vaccine types: (A, C, Y, W-135) and (B).

Encephalitis:
Fever, ± Headache, Photophobia, Seizure, Change in MS (e.g. Change in Sensorium),
Personality changes. Physical exam: Same as meningitis.

Work-up:
Same as meningitis
LP: Lymphocytes predominant
+ve PCR HSV-1 >> MRI w/contrast >> Temporal area involvement (HSV-1 all ages,
VZV in elderly w/ vesicular rash)

Treatment: IV Acyclovir (if Viral)

Treatment should be initiated while awaiting definitive diagnosis, as the progression of
HSE is very rapid!

Headache:
Secondary:
Severe Headache, in Occiput, Suddenly after lifting an object, Meningismus w/o fever
RFs: HTN, Smoking, Cocaine, Pregnancy, OCPs.
Investigations:
CT scan: Normal, Enhanced ventricles.
LP: Xanthochromia (SAH: Lysed RBCs)
Cavernous sinus thrombosis: Severe Headache + 3rd Nerve palsy, Female on OCPs or
Hx of DVT/PE. CT/MRI Brain w/venography + Arterial (CTV & CTA).
TTT: Anticoagulants (Like DVT/PE; Heparin…) & Stop OCPs.

Primary:
Tension Headache:
Bilateral, Pressure, Band-like pain, Mild-Moderate intensity, Stress, Increased w/
activity, Not throbbing, Can be associated w/ Photophobia & Phonophobia. No nausea
or vomiting. Sleep deprivation, dehydration.
TTT:
Episodic NSAIDs or Paracetamol (Risk of Medication overuse Headache).
Chronic Tension Headache: Tricyclic antidepressants

Cluster Headache:
Unilateral headache, Male, At night, Multiple attacks per day, Eye tearing, Rhinorrhea,
Miosis, Ptosis, Lid edema.
TTT:
Prophylaxis: CCB (Verapamil)
Acute episode: High flow oxygen (100%) or Hyperbaric Oxygen, or Sumatriptan.

Migraine Headache:
Unilateral, Pulsatile, Throbbing, Moderate-Severe, Aggravated by activity,
Photophobia, Phonophobia, Nausea, Vomiting. 4-72 Hours
Aura: Visual spots, Parasthesia, Speech disturbance, Numbness.
RFs: Female, Menestruating, Stress, Cheese, Chocolate, Caffeine, Emotion,
Excessive exercise.
Treatment:
Abortive: Sumatriptan (C.I: CAD, Prior Stroke) + NSAIDs
Prophylaxis: Propanolol (1st), CCB, TCA, Topiramate, Valproic acid.
Parkinson’s:
Bradykinesia, Rigidity, Tremors, Shuffling gait, Tremors, Cogwheel rigidity, Mask face.
Clinical diagnosis. Low dopamine (Substantia nigra)
Treatment:
Depends on function of patient: if mild, no need.
Levodopa-carbidopa (SE: Dyskinesia, Orthostatic Hypotension)

Dementia:
Not disoriented, unlike delirium!
Most common cause of dementia: Alzheimer’s.

Lewy’s body dementia: “Parkinson plus syndrome”

Rigidity + Tremor + Hallucination + Early dementia

Shy dragger syndrome: “Parkinson plus syndrome”

Multi-System Atrophy
Rigidity, Tremors, Dementia, Orthostatic hypotension, dizziness,…

Normal Pressure Hydrocephalus:

Urinary incontinence, Forgetfulness, Difficulty walking,…
Q- Dementia + U.Incontinence + Abnormal gait: Normal Pressure Hydrocephalus
CT/MRI: Shows dilated ventricles.
TTT: LP Periodically to reduce pressure. If not improved, V-P shunt.

Fronto-temporal dementia:
Dementia, Young, Aggressive behavior, Personality changes, Loss of empathy, No
Parkinson!

Reversible causes of Dementia:

B12 Deficiency, Thyroid
Investigations: B12 level, TSH.

Vascular dementia:
Hx of Stroke, Deterioration of Dementia, Step-wise ladder deterioration, Micro-strokes.

Alzheimer’s:
Chromosome 21 problem >> Deposition of B-Amyloid in the grey matter (Tau-proteins)
Aggressive, Disorientation (Unlike other dementias).
Diagnosis:
MRI (Diagnostic, Best)
CT Brain (Shape differs from other Dementias)
Other: PET scan.
Treatment:
Cholinesterase inhibitor: Donepezil or Rivastigmine not pyrostigmine!
Severe: Add Memantine.

Delirium tremens:
3rd day after stopping alcohol, Sympathetic hyperactivity; High HR & BP, Aggressive.
Unlike Alcoholic hallucinosis, there is impaired consciousness & abnormal vitals signs.
TTT: Benzodiazepine.

The Weakness Diseases:

Myasthenia gravis: “Opposite of Lambert-Eaton Syndrome”
Autoimmune, Neurotransmitter Ach antibodies.
Weakness bilateral (Proximal), Upper limbs (Descending weakness): Bilateral Ptosis or
Diplopia, nasal speech, Dysarthria, Dysphagia, Proximal weakness, Respiratory
failure. Worse with repetition.
Physical exam: Normal deep tendon reflex.
Associations: Thymoma, Any autoimmune disease: Hashimoto’s, DM1, Celiac,
Pernicious anemia, Vitiligo, Primary Billiary cholangitis.
Investigations:
Neostigmine test
CT Chest: Thymoma
NMJ Disease >> EMG: Decrease response w/ repetition.
Anti-Acetylcholine receptor antibody (Specific for Ocular MG)
Triggers: Pregnancy, URTI, Antibiotics (Aminoglycosides, Fluroquinolones, Macrolides)
Treatment:
Crisis (Weakness + Resp. Distress SOB): IV Ig or Plasmapheresis. if no response,
Prednisone or High dose Methylprednisolone (Needs close monitoring: Using FVC).
Chronic MG (Prevent relapse):
- Pyridostigmine (SE: Bradycardia, Diarrhea, Drooling, Increased lacrimation) +
immunosuppressant (Steroids [Close observation initially] + Azathioprine)
- Thymemectomy If Thymoma.

GBS:
Hx of URTI (Viral, 2 weeks after) or Surgery (2 weeks after) or Diarrhea (GE, Bloody,
C.Jejuni) >> Back pain & ascending bilateral L.L limb weakness, Numbness.
Physical exam: Hyporeflexia or Absent reflexes, Autonomic dysfunction: Arrhythmias
or Respiratory failure (Monitor by FVC).
Diagnosis:
LP: Albuminocytologic dissociation (High protein w/o WBCs). Others are normal.
NCS: Reduced
Serology: Detection of AntiGm1/AntiGD1

Subtypes:
Acute Motor Axonal Neuropathy “AMAN”: Bad prognosis.
Miller-Fisher syndrome: Ophthalmoplegia + Ataxia + Areflexia.

Treatment:
Plasmapheresis (Faster) or IV Ig (SE: Anaphylaxis, C.I: Kidney disease) << Equal Efficacy.
In children, use IV Ig. Plasmapheresis only if severe or rapidly progressing.
Multiple Sclerosis:
Relapsing-Remitting is most common.
Associations: Vitamin D deficiency. Smoking can worsen it.
Young Female, Arm numbness, Leg weakness >1 week, Painful eye sight, Diplopia,
Urinary retention,…
Physical exam: Optic neuritis (Earliest sign), Hyperreflexia, (UMN signs; Clonus,
Babinski), Lhermitte’s sign, Uhthoff’s phenomenon, Absent Abdominal reflex, CN Palsy
Investigations:
MRI w/ Brain & Spine (Best): Periventricular white plaque, Dawson’s fingers.
LP: High protein, Oligobands IgG. Indicated if MRI is inconclusive.

Treatment:
Acute Flare (e.g. New Lesion on MRI): High dose IV Methylprednisolone.
Chronic:
- 1st Line: SQ/IM Interferon B or PO Fingolimod (Used in RR-MS).
- 2nd Line: IV Natalizumab (Check: Jc virus PCR, Can cause PML, used in RR-MS)

Amyotrophic Lateral Sclerosis: “Motor Neuron Disease”

Progressive skeletal muscle weakness w/ normal Sensation. Combined UMNL/LMNL.
Anterior Horn affection (LMNL), Precentral gyrus (UMNL).
Asymmetric limb weakness, Fasciculations, muscles stiffness,…
Death: Usually by Acute Respiratory Failure or Pulmonary infections.
Investigations: EMG (Fasciculations), NCS will be normal.
Treatment: Riluzole slows progression & prolongs survival.

Epilepsy:
Diagnosis by EEG.
Partial:
Tongue biting, w/o limb involvement,…
Post-ictal: “Don’t Recall” << Partial Complex
Simple: Partial Simple

Generalized:
Post-ictal, Limb involvement (Except for Absence seizure).
Types:
Absence, Tonic-Clonic, Myoclonic, Atonic, Tonic, Clonic.
Treatment: “Chronically”
Not indicated for: 1 attack w/ normal brain structure.
Indicated for: 2 or more seizures unprovoked, CNS Tumor.
When to stop? Free of seizures for at least 2 years.
Drugs:
- Generalized: TC or Myoclonic: Valproate or Topiramate (Safe for liver) or
Levetiracetam (Pregnant, Safe for liver) or Lamotrigine. Not satisfactory: Add
Phenytoin.
- Typical Absence: Ethosuximide or Valproate
- Partial: Carbamazepine or Topiramate or Levetiracetam or Lamotrigine. Not
satisfactory: Add Phenytoin.
- Phenobarbital in children for Partial or Generalized TC.
SEs:
Phenytoin: Gum Hyperplasia, Ataxia
Valproate: Weight gain, High LFT
Topiramate: Weight loss, Kidney stones. C.I: Glaucoma
Carbamazepine: Aplastic anemia
Lamotrigine: (Rash + Desquamation + Red eye) “Stevens Johnson”

Status epilepticus:
Treatment:
Benz >> Phen >> GA
Lora or Diaz >> Phenytoin or Phenobarbital >> Propofol
Ischemic Stroke:
HTN is the Number 1 risk factor of stroke.
“AM People Best Celebrity”
Anterior Cerebral Artery: Hemiplegia Leg > Arms, U.Incontinence.
Middle Cerebral Artery: Hemiplegia Arms > Leg, Aphasia, Homonymous Hemianopia.
Posterior Cerebral Artery: No weakness, Macular sparing Homonymous Hemianopia.
Basilar Artery (3 P’s): Paraplegia, Palsies, (Pupil pin-point = Pons).
Cerebellar Artery (Ipsilateral): Intention tremor, Nystagmus, Ataxia, Diplopia.
Approach:
What’s the cut-off BP to start thrombolytics? 3-4.5 Hours & Depends on BP:
- <180: No Anti-HTN, Give thrombolytics.
- 180-210: Wait
- >220: Anti-HTN treatment.
C.I To Thrombolysis w/ large vessel: Mechanical thrombectomy.
Non-Contrast CT (Initial): Helps determine hemorrhagic vs ischemic in order to
administer tPA ASAP. It detects Ischemic changes ~6 hours post stroke onset.
DWI MRI: Detects ischemic changes ~3 minutes post stroke onset.

Work-up: “After Thrombolytics (Alteplase/Streptokinase)”

Lipid profile, Carotid US, ECHO, Holter monitor.
Types of Ischemic Strokes:
Work-up Helps Determine if it’s Embolic or Atherosclerotic.
Chronic Management:
- Atherosclerotic: MCA, ACA, Large artery, Small artery “or Lacunar”. TTT: Aspirin
+ … (Figure: stroke prevention by etiology), No Anti-coagulation.
- Embolic (Most common): AF, Carotid artery.
A) High risk: Anti-coagulation
B) Low risk: Aspirin

Secondary prevention:
Large vessel: Dual anti Platelets + Statin.
Small vessel: ASA + Statin.
When to give Clopidogrel alone? Aspirin allergy

Lacunar stroke:
Small arteriole stroke <3 mm. Usually in Basal ganglia & caused by HTN.
Can present with one feature only: Aphasia, Hemiparesis, Numbness,…
2ndry prevention: No anti-coagulation because it’s atherosclerotic.

TIA:
Approach:
Less than 1 hour, CT is normal.
ABCD2 Score:
High: Admission & work-up (Carotid US, Holter, Lipid, ECHO, MRI Brain,…)
Low: Discharge
 Hematology

Transfusion Indications:
Cryoprecipitate: “Contains: Fibrinogen, von Willebrand factor, factor VIII, factor XIII”
Bleeding in VwD, Factor 8 Deficiency, Low Fibrinogen.
Irradiated RBCs:
Stem cell transplant, Hematological malignancies.
FFP: “Contains: All of the clotting factors, Fibrinogen, Physiological anticoagulants”
INR>2 (Preoperative)
Active bleeding from anticoagulation
DIC
Liver disease (High INR)
IV Ig: Pregnant Post-exposure to Measles (<72 Hours), Autoimmune (GBS, MG, ITP).
Therapeutic Apheresis (Plasmapheresis): Goodpasture’s, TTP.
Platelets:
<50K with active bleeding.
<20K with infection.
<10K for asymptomatic << Lower Platelets count could cause intracranial hemorrhage.
Contraindications: HELLP, HUS, TTP, Heparin Induced Thrombocytopenia.

Transfusion Reactions:
Allergic:
Develops within minutes
Mild (Urticaria): Stop transfusion & Give Diphenhydramine.
Severe (Anaphylaxis): Stop transfusion & Give Epinephrine ± Steroids.
Acute Hemolytic:
Pain at site of infusion, Fever, Hypotension, AKI, Flank pain, SOB. No rash. Develops within hours.
Etiology: ABO Incompatibility.
Treatment: Stop transfusion, Start IV Fluids, ± Dopamine, ± Diuresis.
Febrile Non-Hemolytic:
0-6 Hours post transfusion
Fever, Rigors
Etiology: Reaction to donor WBCs or cytokines induced.
Treatment: Acetaminophen
Transfusion-Related Acute Lung Injury (Pulmonary Edema):
Within 6 hours
SOB, High RR, Non-Cardiogenic P.Edema “ARDS”

Peripheral Blood Smear:

Normal neutrophils have 3 segments, more than that it is Hypersegmented.
PBS Cell Shapes:
Sickle cells & Heinz bodies & bite cells &
SCD G6PD
polychromasia Blister cells (Precursors of Bite cells)
Thalassemia Target cells IDA Pencil cell
Cold AIHA Agglutination Warm AIHA Spherocyte
APL Auer Rod CLL Smudge cells
B12 Deficiency Hypersegmented Hyposegmented neutrophil,
MDS
Celiac Disease neutrophil Leukoerythroblast picture
Hemolysis Polychromasia Malaria Ring cells
Elliptocyte or Cigar cell Myelofibrosis
Elliptocytosis Tear drop cell
or Pencil cell Severe Anemia
MAHA Syndrome
Reed-Sternberg cell,
TTP, HELLP, Schistocytes (Helmet) Hodgkin’s
Popcorn cell (Variant of RSC)
Malignant HTN…
Lead Poisoning Multiple
Basophilic stippling Rouleaux formation
Sideroblastic An. Myeloma

Myelofibrosis:
Diagnosed by Bone marrow biopsy, result will be: Dry tap w/ tear drop cells.
Approach to Anemia:
Low Hgb, Low MCH, Low MCV: “Microcytic Hypochromic Anemia”
Investigations: Ferritin, TIBC, Transfusion Saturation.
IDA Thalassemia Sideroblastic AOCD
Iron Low Normal High Low
Ferritin Low Normal High High
TIBC High Normal Normal Low
Transferrin
Low Normal High High
Saturation

Low Hgb, High MCH, High MCV:

Megaloblastic:
Hypersegmented neutrophils, …
Types:
- B12 Deficiency: Neurological sxs, High Methyl-melanoic acid. Hx: Elderly on
Toast/Tea diet, Crohn’s, Pernicious Anemia (Anti-Parietal Antibodies).
- Folate Deficiency: No Neurological sxs, Normal Methyl-melanoic acid.
Non-Megaloblastic:
Normal neutrophil (2-3 Segments).
Causes: Alcohol, Parasite, CLD, Hypothyroidism, Pregnancy.

Low Hgb, Normal MCV, Normal MCH:

First test to order: Reticulocytes count
- Low: BM Failure, Aplastic Anemia (B19 virus), Fibrosis (Myelofibrosis).
- High: Hemolytic Anemia >> High LDH & Indirect Bilirubin, Low Haptoglobin.
 Autoimmune Hemolytic Anemia: +ve Direct Coomb’s Test.
A) Intravascular: Mycoplasma, MAHA, PNH.
B) Extravascular: SCD, Hereditary Membranopathies (Hereditary Spherocytosis:
P.Smear, Osmotic Fragility, TTT: Splenectomy).
Hemoglobinopathies:
Sickle Cell Disease:
Point mutation: Position 6 of Chromosome 11 (Glutamine >> Valine). Autosomal Rec.
Sickling triggers:
Unknown (60%), Acidosis, Infection, Weather or Exercise induced Hypoxia, Stress,
Dehydration.
Diagnosis: “Lab based”
Screening: Sickling test
Specific: Solubility test, HgB electrophoresis, DNA Mutation test, Isoelectric focus of β-
chain.
Course of Disease:
Mild: High HbF, Concomitant thalassemia
Severe: HbSS
Cause of Death:
Most common: Infections
Less common: Acute Chest Syndrome, Renal failure, PE
Crisis types:
- Vaso-occlusive crisis:
- Micro-infarctions: Pain in Bone, Joint (AVN), Abdomen (Mesentery), Chest (ACS)
Acute Chest Syndrome: Increased Interstitial markings on CXR, Hypoxia, Fever,…
- Macro-infarctions: Stroke, Seizure, Retinal infarction, Blindness, Acute Coronary
Syndrome, HF, Cardiomyopathy (Transfusion), Autosplenectomy, FSGS,
Membranous nephropathy, Papillary necrosis (Flank Pain & Hematuria), Sickle
Hepatopathy (High Total Bilirubin & AST & ALT, Normal BP), Pulmonary
Hemorrhage, PE, OM (Encapsulated organisms; SHiN S.Pneumoniae,
H.Influenza, Nisseria Meningitides, Salmonella).
- Splenic sequestration: Splenomegaly, Low BP,…
- Aplastic crisis: B19 virus, Low: WBCs & HgB & PLT. TTT: Resolves spontaneously, if
not then stem cell transplant.
- Liver sequestration: Hepatomegaly, Low BP, Jaundice,…
- Hemolytic crisis
Complications of SCD in Pregnancy:
Pyelonephritis, Pulmonary infarction, Problem w/ fetal growth IUGR.
SCD Patient has Jaundice & Pallor w/ no pain?
Hemolytic crisis: SCD, G6PD.
Parameters of Hemolysis:
High: Indirect bilirubin, LDH, Reticulocytes. Low: Haptoglobin.
SCD: Extravascular hemolysis usually
G6PD: Intravascular hemolysis
Criteria of Urgent Blood exchange:
Stroke, A. Chest Syndrome (Ineffective Simple transfusion), Splenic sequestration, Priapism.
Indication of Urgent Blood transfusion:
Hb <6 + Reticulocyte <4%, Major surgery HgB must be >10, Pregnant in CS.
Indications of Hydroxyurea:
Severe Acute Chest Syndrome, Frequent painful crisis (≥3 in one year). SE: BMS
Treatment of SCD:
Adequate Hydration, Adequate Analgesia, Crisis management.

Thalassemia:
Microcytic Hypochromic anemia, Normal iron studies.
Usual Presentation:
Baby Child/Adult
α-Intermedia or β-Major α trait (minor) or β-minor
Age: Hb Electrophoresis:
6 Months β-Minor:
Birth
β-Major: HbA 80-90%
α-Intermedia: α trait: Normal
HbF >90% HbA2 5-10%
HbH
HbA2 High HbF variable
Curative: Stem cell transplantation
Supplements of Iron & Folic acid
Symptomatic:
 Transfusion of erythrocyte concentrate
Indication: Hb <7–8 g/dL or marked
clinical symptoms. Target: Hb >10 g/dL
Chelating agents (e.g., deferoxamine) in
patients with:
Serum ferritin concentration > 1000 μg/L
Secondary iron overload

Alpha:
If ≥3 alleles: Hb Electrophoresis confirms diagnosis.
If less than 3 alleles: DNA Analysis detects & confirms diagnosis.
Beta:
Hb Electrophoresis: Confirms diagnosis, HbA2 >3.5%.

G6PD:
Diagnosis: Enzyme activity assay, Heinz bodies in PBS.
Triggers: Quinine, Sulfa. Drugs, Dapsone.

Bleeding Disorders:
Platelets Disorders: “Immediately after trauma”
Petechiae, Epistaxis, Gum bleeding, Ecchymosis, Menorrhagia.
Investigations:
PLT Count:
- Quantitative: Low (<150K). << Autoimmune destruction
- Qualitative: Normal count
Next after PLT >> Bleeding Time (=High)
ITP: “Quantity”
Q- Young + URTI + Petechiae or Purpura + Gum bleeding + Low PLT: ITP, High BT.
Treatment:
- >30K:
 A) Asymptomatic: Observe
B) Symptomatic: “IV Ig or Steroids” & Platelets
- Major Bleeding (e.g. GIT): IV Ig & Platelets
- <30K: Steroids ± Splenectomy or Rituximab

TTP: “Quantity”
Q- Pregnant + Confusion + Petechiae + Low PLT & Hgb + Cr 200: TTP.
Pentad: Confusion/Seizure, MAHA, -ve Coomb’s, AKI.
Next: PBS shows Schistocytes (Helmet Cells).
ADAMS-13 Deficiency
Treatment: Plasma exchange. If not available, FFP.

VwD: “Quality”
The most common bleeding disorder.
Petechiae, Bleeding after operation, Normal PLT count, High BT, High PTT (Factor 8
association).
TTT: Recombinant VWF Concentrate, Desmopressin (If not bleeding) or Cryoprecipitate
(If bleeding).
High BT + High PTT + Normal PLT count = VwD

Heparin Induced Thrombocytopenia:

Caused especially by UFH.
Heparin SEs: Low PLT, HIT, High aPTT, Osteoporosis, Hyperkalemia, Bleeding, High
ALT/AST, Alopecia, Eosinophilia.
Type 1 Type 2
Occurs within 5 days After 5 days up to 2 weeks (but can occur at any time)
Non-immune Antibody against platelets (Immune)
No complication “Asymptomatic” Thrombotic events
Stop Heparin & Observe, Switch to Stop Heparin & Start Argatroban or Bivalirudin or
other Anticoagulant e.g. Warfarin Lepirudin
Diagnosis: HIT Antibody ELISA
Coagulation Disordes: “Minutes to Hours after trauma”
Bleeding time is always normal.
Hematoma/Hemarthrosis, High PT & PTT,…
Warfarin: High PT
Heparin: High PTT
High PTT & Later High PT: Advanced Liver disease.
Hemophilia A:
Q- Male, Bleeding in Knee joint after minor trauma, What you’ll order? PTT/PT
If PTT is High & PT is normal >> Factor assay >> Factor 8 Deficiency (Hemophilia A)
TTT: Factor 8, if not available >> Cryoprecipitate. Desmopressin is used for mild cases.

Disseminated Intravascular Coagulation: “Variable onset”

High PTT/PT, Low PLT, High BT, High D-Dimer, Low Fibrinogen.
TTT:
Treat underlying cause (Mainly)
Blood products as required: Cryoprecipitate,…
Asymptomatic: Heparin

Myeloproliferative Disorders:
Polycythemia vera:
Headache, Dizziness, Blurring vision, Pruritus, Plethora, Splenomegaly, Tinnitus,
Thrombosis (Budd-Chiari Syndrome), Bleeding.
HgB>16.5, HCT>49%, High RBC mass.
Investigations:
Erythropoietin level: Low, unlike secondary polycythemia.
JAK2 Mutation
Treatment:
Phlebotomy (Target: <45% HCT) + ASA
High risk of thrombosis: Hydroxyurea
Leukemia:
Young Old
Anemia, Thrombocytopenia, Recurrent
infections, Gum bleeding, HSM, WBCs Fatigue, High WBCs
count is not reliable
Acute Chronic
ALL AML CLL CML
Fever, LAP, Bone High Lymphocytes,
APL “M3”: t(15:17) High Basophils,
pain, Night sweats. Smudged cells, LAP,
Death by DIC BCR-ABL t(9:22)
CALLA: B-ALL Splenomegaly
Asymptomatic: None Imatinib
Symptomatic: Very High WBCs
Aggressive
Transretinoic acid FCR Regimen <65 (>100K):
Chemotherapy
Chlorambucil + Leukopheresis or
Rituximab >65 years Hydroxyurea
PBS >> Blasts >20% >> BM Biopsy
(ALL or AML) >> Immunohistochemistry
(M3 or M4 or… Translocation)

Lymphoma:
Non-Tender LAP (e.g. Supraclavicular), B sxs, HSM,…
Diagnosis:
1. Labs: Lymphocytosis >> High LDH
2. Excisional LN Biopsy
3. PET-CT: Multiple LNs or Metastasis.
Ann Arbor Staging:

Hodgkin’s Lymphoma:
Age: Young & Very Old (Bi-modal)
RFs: EBV, HIV
Pathology:
Reed Sternberg cell
N Nodular sclerosis: Female
M Mixed Cellularity: Male
L Lymphocyte Predominant: Good prognosis
L Lymphocyte Depleted: Bad prognosis
Treatment:
ABVD + Radiotherapy: Adriamycin, Bleomycin, Vinblastine, Dacarbazine
SEs:
Adriamycin: Cardiomyopathy
Bleomycin: Lung fibrosis
Vincristine: Peripheral neuropathy
Vinblastine: Neutropenia
Non-Hodgkin’s Lymphoma:
Splenomegaly & Hepatomegaly more frequently than Hodgkin’s.
Who gets NHL:
Burkitt’s Lymphoma (African, Jaw mass)
Infections (EBV, H.Pylori: MALToma)
Autoimmune (Sjogren’s, Rheumatoid)
Immunocompromised: Post-transplant, HIV
Types:
Follicular NHL: Female t(18:14) << Most common
Mantle Cell NHL: Elderly
Burkitt’s Lymphoma
Marginal Zone Lymphoma: H.Pylori “MALToma” >> Gastric biopsy >> Abx
Treatment:
R-CHOP: Rituximab, Cyclophosphamide, Adriamycin, Oncovin “Vincristine”, Prednisone
Multiple Myeloma:
CRAB: Hypercalcemia, Renal Failure, Anemia, Bone lesions.
Elderly, Back pain, Repeated infections, Fractures, Hypercalcemia, High Creatinine,
Anemia.
Increased Plasma cells >> M proteins
Investigations:
ESR: Very High. Total protein: High
Serum protein electrophoresis (Best initial): M spike
Urine Protein electrophoresis: Bence Jones proteins “Light chain proteins”
Skeletal survey: osteolytic bone appearance. WBLD-CT is better.
Bone marrow biopsy (Definitive): Plasma cells >10%
β2-Microglobulin: For reassessment, F/U, Prognosis.
Variants:
Symptomatic MM Smoldering MM (Asymp.) MGUS
CRAB No CRAB No CRAB
BM Plasma Cells >10% BM Plasma Cells >10% BM Plasma Cells <10%
Treatment:
Transplant Eligible: Autologous Stem cell transplant
Non-Eligible: Bortezomib + Immunomodulator (Thalidomide or Lenalidomide) ± Steroid

Oncology

Tumor Markers:
CA 15-3: Breast
Alpha-Fetoprotein: HCC, Germ cell tumors
CA 19-9: Pancreas
CEA: Colon
CA-125: Ovary
PSA: Prostate
B-hCG: GTD (Choriocarcinoma)
Spinal Cord Compression:
Hx: Breast cancer patient presenting w/ back pain & numbness. Pain is most important
Thoracic spine is most common site.
Etiology: Prostate cancer (Most common), Breast cancer, Lung cancer, Renal Cell
Carcinoma, NHL, MM. “Back Pain is Large”
Management:
IV Dexamethasone >> MRI whole spine w/ contrast (Confirmatory) >>
- Only pain: Emergent Radiotherapy
- Neurological sxs: Surgical decompression

SVC Syndrome “Obstruction”:

Hx: Lung cancer patient presenting w/ SOB, Facial swelling & dilated chest veins.
Most common cause: Small cell lung cancer
Treatment:
Steroids + Radiation >> SVC Stent if no relieve.
Tumor Lysis Syndrome:
Hx: Leukemia patient who received chemo developed generalized weakness &
palpitations, Hyperkalemia, Hypocalcemia, ↑ Uric acid, ↑ phosphate, ↑ Creatinine.
Tumor + Electrolytes imbalance
More common in hematological malignancies.
Management:
Aggressive IV Hydration + Allopurinol or Rasburicase (G6PD C.I) + Treat
Hyperkalemia, Hyperphosphatemia, Hypocalcemia. Other: Diuretics
Severe Refractory: Hemodialysis

Febrile Neutropenia:
ANC <1000 + Fever = Febrile Neutropenia
Hx: Lymphoma patient presenting w/ Fever, WBCs 1.5K, ANC: 400.
Organisms:
G -ve (Commonest): E.Coli, Pseudomonas
If IV Line: G +ve >> MRSA

Management:
Isolation (+ve pressure room) + Sputum Culture + CXR + Blood culture + Urine culture
G -ve Abx: Cefepime or Tazocin or Imipenem or Ceftazidine. NO Ceftriaxone!
If pneumonia or IV Line: Add Vancomycin
Still febrile (No improvement 5-7 days): Add Anti-Fungal “-fungin” >> Caspofungin or
Micafungin.

Lung Cancer:
In Pulmonology section.
Focus on Paraneoplastic syndrome.

Prostate Cancer:
Metastasis loves bone. And in prostate cancer, lesions are osteoblastic unlike others.
Stage 1: Radiation
Stage 2: Radiation + Radical Prostatectomy
Stage 3: Radiation + Androgen deprivation drugs (GnRH) Leuprolide
Stage 4: Radiation + Androgen deprivation drugs (GnRH) Leuprolide + Chemotherapy

Colon Cancer:
Most common oncogene is KRAS.
Stage 1 “Subserosa”: Surgery
Stage 2 “Serosa”: Surgery + Adjuvant Chemotherapy
Stage 3 “LN”: Surgery + Chemo or Neo-adjuvant Chemo
Stage 4: Chemotherapy + Targeted Immunotherapy

Breast Cancer:
Stage 1: <2 cm. Mobile Axillary LNs.
Stage 2: >2 cm (IIA), >5 cm (IIB). Mobile Axillary LNs
Stage 3: Internal Mammary LNs
Stage 4: Metastasis

Management:
Stage 1: Surgery + Radiation
Stage 2: Surgery + Radiation + Adjuvant Chemo
Stage 3: Surgery + Radiation + Neo-Adjuvant Chemo
Stage 4: Receptor status:
- ER/PR +ve:
A) Premenopausal: Tamoxifen
B) Postmenopausal: Letrozole
- HER-2 +ve: Trastuzumab
- Negative all: Chemotherapy
Hepatocellular Carcinoma:
Causes: Hep B/C, Hemochromatosis, Wilson’s, NAFLD, Alcoholism, ɑ-1 antitrypsin
Deficiency, Autoimmune Hepatitis.
Screening for Cirrhosis: US every 6 months ± ɑ-Fetoprotein
If screening is +ve: Diagnose by Triphasic CT >> result: venous washout

Hx: Long standing cirrhosis patient found to have a solitary 2 cm liver mass on CT >>
Directly Surgery.
If multiple masses: Chemotherapy (TACE: Transarterial Chemoembolization).
Systemic therapy is Soratenib.
 Endocrine
Screening:
Colon Cancer “Colonoscopy” Screening F/U
General Population ≥50 Years old 10 Years
IBD 10 Years of Dx Annual
Polyps e.g. FAP Age: 10 Years old Annual, At 20: UGI Endoscopy
Non-Polyps e.g. HNPCC Age: 20 Years old Annual, At 40: UGI Endoscopy
1st degree relative w/ CC Age: 40 Years old 5 Year F/U w/ Colonoscopy

Lung Cancer Osteoporosis

Low-Dose CT: 55-80 Years w/ 30 Pack- DEXA Scan: >65 Years or <65 Years + 10-
Year or Ex-Smoker (quit within 15 Years) Year Fracture Risk 9% (e.g. Chronic Steroid Use)
HTN Lipid: (Fasting)
All adults >18 Years ≥35 Years if Male
HTN <40 Years: Do 2ndry HTN work-up ≥45 Years if Female

DM Breast Cancer
All Adults w/ BP >130/80
40-50 Years, Mammogram done every 1-2
Normal BP w/ Age >45 Years
years
PCOS
Screening for Dyslipidimia in high-risk CardioVD: ♂ > 20–25 years; ♀ > 30–35 years.

Bone Diseases:
Osteoporosis:
Calcium, Vit D, PO4: Normal
DEXA Scan:
- Osteoporosis: Less than -2.5 >> PO Bisphosphonates (Alendronate)
- Osteopenia: -1 to -2.4 >> FRAX Test 10 Year risk:
A) High: Bisphosphonates
B) Low: F/U?
Osteopenia + Fracture = Osteoporosis
Paget’s Disease:
Calcium, PO4, Vit D: Normal
High ALP
Leg pain, Reduced Hearing, increased Head size, Fracture, Osteosarcoma.
TTT: Bisphosphonates

Osteomalacia:
Low Calcium & Vit D.
TTT: Supplements

Hypercalcemia:
Polyuria, Dizziness, Constipation, Renal stones, Nausea/Vomiting, Pancreatitis,…
Approach:
Calcium level (Free ionized): >1 mmol/L
Parathyroid Hormone:
- High >> Urine Calcium Level:
A) High: Primary Hyperparathyroidism >> Neck US
B) Low: Familial Hypocalciuric Hypercalcemia >> Low FE Calcium <0.01
- Normal >> Parathyroid related Peptide:
A) High >> Malignancy (Lung Cancer; Squamous,..)
B) Normal >> Vitamin D Metabolism:
High 1,25 OH: Sarcoidosis or Lymphoma
High 25 OH: Vit D Toxicity
Normal: Multiple Myeloma
Treatment:
Aggressive Hydration IV NS 4-6 Liters/Day (Increases renal Ca excretion).
IV Zolendrinic acid “Bisphosphonates” (Malignancy). C.I: Renal Failure
Denosumab: Malignancy
Calcitonin
Steroids: Granulomas (Sarcoidosis)
Hemodialysis

Indications for surgery in asymptomatic Primary HyperPTH:

Age <50
Calcium >1 mg/dL Above lower normal limit
Creatinine clearance “eGFR” <60
DEXA Scan <-2.5
Evidence of Nephrolithiasis via imaging

Primary HyperPTH Secondary HyperPTH

PTH High High
Calcium High Low
PO4 Low High

Endocrinopathies:
Pituitary Gland:
Prolactinoma:
Galactorrhea, Amenorrhea, Decreased libido…
Investigations:
First >> Pregnancy test
Fasting Prolactin: High >> Pituitary MRI:
A) <10 mm Microadenoma: MRI F/U
B) >10 mm or Symptomatic: Cabergoline (Dopamine agonist)

Acromegaly:
Change of Voice, Change shoe size, Increased length, Carpal tunnel, Headache,
Sleep apnea, DM, Decreased Libido, Increased Sweating, Acanthosis.
At Risk of: HTN, DM, Cardiomyopathy, Colonic polyps,…
Investigations:
IGF-1 (Screening test) >> High: OGTT (Confirmatory) >> GH Level: Not suppressed
Pituitary MRI:
- Symptomatic (Eye sxs, Compression): Surgery “Transsephenoidal Adenomectomy”
- Other: Octreotide or Pegvisomant or Cabergoline

Diabetes Insipidus:
Case Scenarios:
- Surgery in brain, Trauma, Ischemic encephalopathy (Sheehan’s syndrome), +
Polyuria >3L /day ± Hypernatremia. “Central”
- Bipolar (Lithium), Fungal infection (Amphotericin), Severe Hypercalcemia, PKD,
Severe Hypokalemia, SCD, + Polyuria >3L /day ± Hypernatremia. “Nephrogenic”
Polyuria approach:
Urine osmolality:
- >1000 “Osmotic Diuresis” >> Glucose, Urea, Mannitol.
- <800 “Water Diuresis” >> Check Na Level:
A) <136: Water Deprivation test:
Urine osmolality increases: Primary Polydipsia
B) >145: Water Deprivation test:
Urine osmolality is the same: Diabetes Insipidus >> Vasopressin:
 Osmolality increases: Central DI. TTT: Desmopressin ± H.Thiazide
 Osmolality same: Nephrogenic DI. TTT: Amiloride + Stop Lithium
Adrenal Glands:
Hyperaldosteronism:
<40 Years, Weakness (HypoK), High BP, Metabolic Alkalosis.
Primary:
Screen w/ Aldosterone:Renin ratio: >20:1 >> Saline suppression test:
- Not Suppressed: Primary Hyperaldosteronism >> CT Adrenal:
 Unilateral: (>5 cm: Surgery), (<5 cm: Spironolactone + KCl)
 Bilateral Hyperplasia “Conn’s Syndrome”: Spironolactone + KCl
- Suppressed: Normal.
Secondary:
High renin >> High Aldosterone
Etiology: CHF, CLD (Ascites), Diuretics, Renin secreting tumors.

Pheochromocytoma:
Paroxysmal Palpitations, Episodic High BP, Diaphoresis.
Screen w/ Serum free metanephrines or VMA:
- High: Urine metanephrines (Confirmatory) >> High >> CT Adrenal
Treatment: IV Fluids, Alpha blocker (Phenoxybenzamine), BB then Surgery.

Cushing’s Syndrome:
Acne, Moon face, Truncal obesity, Purple striae, High BP, Hyperglycemia.
Labs: HypoK, Metabolic Alkalosis, …
Investigations:
Screen:
- 24 Hour Urine free cortisol
- Low dose overnight Dexa: C.I for Liver disease
- 11 pm salivary cortisol: Pregnancy
High Cortisol >> ACTH:
- High “ACTH Dependent”: Secondary Hypercortisolism >> High Dose Dexa:
A) Suppressed: Pituitary MRI >> Cushing’s Disease. TTT: Cabergoline >> Not
improved: Trans-sphenoidal surgery.
B) Not suppressed: Ectopic >> CT Chest & Abdomen & Pelvis >> Surgery.
- Low: Primary Hypercortisolism >> CT Adrenal >> Surgery >> Hydrocortisone +
Fludrocortisone.

Adrenal insufficiency:
Fatigue, Abdominal pain, Nausea, Vomiting, Dizziness, Hyperpigmentation in primary
only (e.g. in Buccal or Palmer crease), Orthostatic hypotension, HyperK, M. Acidosis,
Hypoglycemia, Hyponatremia, High Eosinophils, Lymphocytosis.
Etiology (Primary): Autoimmune, TB, Metastatic, Deposition (Sarcoidosis,
Hemochromatosis), Drugs: Rifampicin.
The most common site for TB dissemination is Adrenal Glands.
Screening: Serum cortisol a.m.
Low >> Cosyntropin or Synacthen, check cortisol level:
- High: Secondary adrenal insufficiency >> MRI Pituitary >> Hydrocortisone.
- Low: Primary adrenal insufficiency “Addison’s disease” >> CT Adrenal TTT:
A) Acute insult: IV Fluids + Hydrocortisone
B) Chronic insult: Hydrocortisone + Fludrocortisone

Adrenal Incidentaloma:
>1 cm
Most common cause is Non-Functioning Adenoma.
Approach: Is it functional or not?
- HTN: screen for Cushing, Hyperaldosteronism, Pheochromocytoma.
- Non-HTN: screen for Cushing, Pheochromocytoma.
Then, CT Adrenal (Venous contrast):
- Malignant Features >> Surgery
- Benign Features

In screening for Cushing, Low dose Dexa is preferred over other screening tests.
Before resection of Adrenal cancer or incidentaloma, Pheochromocytoma must be
ruled out by e.g. 24-Hour urine metanephrines.

Neuroendocrine Tumors:
Carcinoid tumor: “Serotonin”
Abdominal pain ± Diarrhea, Wheezes, Facial flush, Tricuspid Regurgitation, Rt. HF.
Investigations: Urine: High 5-HIAA. Serum: High serotonin. Somatostatin Scintigraphy.
Treatment:
Octreotide: relieves symptoms.
Surgical resection: Treatment of choice if resectable.

Glucagonoma:
Abdominal pain, New onset DM, Weight loss, L.L Rash (Necrolytic migratory erythema)
Treatment: Surgery.
Other option: Octreotide

Insulinoma:
Palpitations, Dizziness, Weight gain, Non-diabetic, Hypoglycemia (<35).
Whipple’s triad: 1) hypoglycemic symptoms (e.g., sweating, palpitations) that typically
follow exertion or fasting; 2) documented hypoglycemia during an episode, and 3) relief
of symptoms upon administration of glucose.
Approach:
Admission & 72 Hours fasting test >> (<35 Glucose) >> C-Peptide (High) + Insulin
level (High despite low glucose level) >> CT Abdomen.
Treatment: Surgery
Other option: Diazoxide or Octreotide

Multiple Endocrine Neoplasia:

Parathyroid Hyperplasia, Diarrhea, Abdominal pain, Infertility, Multiple Gastric
duodenal ulcer.
MEN 1 MEN 2A MEN 2B
Pituitary adenoma Parathyroid Hyperplasia Pheochromocytoma
Parathyroid Hyperplasia Pheochromocytoma Medullary Thyroid Cancer
Pancreatic (Gastrinoma) Medullary Thyroid Cancer Marfanoid Features
MEN 2A: Surgery at 5 years old. MEN 2B: Screen & Surgery at infancy.

Thyroid Mass: “Asymptomatic”

US Thyroid:
1) Benign Features: TSH >>
 - Normal / High: FNA
- Low: RAI uptake:
A) Cold (Low uptake): FNA
B) Hot (High uptake): Thyrotoxicosis
2) >20 mm, Hypoechoic, Solid, Microcalcification, LN, Taller than wider: FNA

Hyperthyroidism: “High Free T4”

Sweating, Tremor, Weight loss, Ophthalmoplegia, Warm skin, Increased reflexes,…
Primary:
High FT4/Low TSH, High Total T3.

RAIU Test:
Homogenous Diffuse: Grave’s Disease >> Thyroid Stimulating Antibodies (High) + Anti
TPO (Low).
Multiple nodular areas: Toxic MNG >> No antibodies!
A hot nodule: Toxic adenoma
No uptake: Exogenous Thyroid Hormone “Factitious”, Thyroiditis (Tender, Post-URTI,
High ESR).

Grave’s: Smoking, Pregnancy, RAI: increase the risk of developing Eye symptoms.
Subclinical Hyperthyroidism:
Q- Asymptomatic patient with Low TSH & Normal FT4? Subclinical Hyperthyroidism.
When to treat? TSH: <0.1

Thyroid Storm:
Q- Patient presented to ER w/ Delirium & High grade fever & Tachycardia & Systolic
HTN & Vomiting? Thyroid Storm.
Treatment: βB, Methimazole or PTU, IV iodide 1 hour later, ± IV Steroids.
Grave’s TTT:
Medical:
1st line: Methimazole, SE: Rash, Agranulocytosis F/U CBC. 2nd line: PTU, SE: Hepatotoxic
RAI: Not improved on medical or High risk (CAD) or elderly.
Surgery: Obstructive goiter or Severe Ophthalmopathy.

Toxic MNG TTT: RAI or Surgery.

Pregnant TTT: First trimester: PTU. Second & Third: Methimazole.

Surgery: Only if obstructive goiter.

Secondary:
High FT4/High TSH
MRI Pituitary

Hypothyroidism:
Weakness, Fatigue, Depression, Cold intolerance, Weight Gain, Constipation,
Menorrhagia, Hyperlipidemia, Diastolic HTN, Delayed Deep tendon reflexes.
Primary:
Low FT4/High TSH

Hashimoto’s Thyroiditis:
Anti-TPO: High Titer
Anti-Thyroglobulin
TTT: Levothyroxine, Check TSH every 6 weeks.
Pregnant: Add extra 30% of Levothyroxine dose (Increased TBC & demand in Pregnancy)

Subclinical Hypothyroidism:
High TSH, Normal FT4.
Treatment if: TSH >10, +ve Anti TPO, Pregnant.
Myxedema Coma:
Hypotensive, Hypothermia, Low RR, Altered MS, Hyponatremia, Hypoglycemia.
TTT: Warm blanket + Empirical Hydrocortisone (Low adrenal reserve), Load w/ IV T4 + T3
- T3 should not be given in Hypothermia or Bradycardia (It is arrhythmogenic)

Sick Euthyroid Syndrome:

Q- Patient in ICU, Low TSH & T4 & T3: Sick Euthyroid Syndrome. No TTT.
In recovery, TSH rises then T4 then T3. Confirmatory test: RT3.
Secondary:
Low FT4/Low TSH >> MRI Pituitary
Hypertension:
Complications: Stroke/TIA (Most comm.), Retinopathy, Cardiac, Vascular (Aortic
Aneurysm, Aortic Dissection), Renal.
Primary HTN:
“JNC 8”
Pre-HTN: 130-139 << Ambulatory BP monitor
Stage 1: 140-159 << Ambulatory BP monitor
Stage 2: ≥160 << Initiate Treatment immediately
“AHA”: All initiate ttt at BP ≥130/80 if w/ comorbidities e.g. DM, CHF, IHD,…

If you decrease BP by 10 mmHg: ↓ 13% mortality, ↓ 28% HF, ↓ 20% Stroke.

Stage 2 at diagnosis: Start with 2 combination ACEI + CCB.
Maintenance Treatment: “<180”
HTN w/o comorbidities:
ACEI >> Add CCB >> Add
<50 Years Stage 2 Black CCB + Thiazide
Thiazide
CCB >> Add ACEI >> Add Methyldopa or Labetalol or
>50 Years Pregnant
Thiazide Hydralazine or Nifedipine

CCB or Thiazide (Best: Chlorthalidone),

Black
Not improved: Add CCB if already on Thiazide or vice versa
HTN w/ comorbidities:
CKD ACEI GFR <30 Loop, no Thiazide!
CAD ACEI + BB Migraine BB or CCB
ACEI + BB +
Post MI ACEI >> Add CCB Heart Failure
Spironolactone,…
ACEI, Not
ACEI >> Add Secondary Stroke
DM improved: Add
Thiazide Prevention
Thiazide
Never choose BB alone unless Migraine.
Never choose alpha-Blocker unless Pheochromocytoma or BPH.

Target BP for:
Post-stroke <140/90 DM <130/80
Post MI <140/90 CKD <130/80
Heart Failure <140/90 Pregnant Diastolic 85-105
Age <60 <140/90 Age >60 <150/90

Hypertensive Crisis:
Target goal:
Reduce BP by 25% in 1st Hour, then to 160/100 over the next 2-6 hours, then return to
normal within 1-2 days.
Nitroprusside:
Renally excreted (Avoid in CKD), Hepatotoxic, High ICP.
What to monitor? Thiocyanate level (Thiocyanate toxicity). TTT: Sodium Thiosulfate
What’s the fastest drug to reduce BP? Nitroprusside

Crisis Treatment: “>180”

>180:
No End organ damage “Urgency”: Nitroprusside or Labetalol or Hydralazine or Captopril
End organ damage (Stroke, Papilledema, HF/MI, AKI, Aortic Dissection) “Emergency”:
 - Stroke: Labetalol or Nicardapine
- Papilledema: Labetalol or Nicardapine
- ACS: Labetalol or Nitroglycerin
- AKI: Labetalol or Nicardapine
- HF (P.edema): Nitroglycerin + Furosemide

>220:
- No End organ damage “Accelerated HTN”: Same as previous
- End Organ damage + MAHA “Malignant HTN”: Same as previous

Emergency BP goal:
1) Aortic Dissection <120 in 1 Hour.
2) Pheochromocytoma, Eclampsia, Severe Preeclampsia <140.
3) Emergency HTN w/o previously mentioned (1,2): Reduce BP by 25% in 1st Hour,
then to 160/100 over the next 2-6 hours, then return to normal within 1-2 days.
4) Acute Ischemic Stroke: Normal BP should be reached within 72 Hours. Don’t treat
HTN of <220/110 in Stroke.
Cases:
HTN Emergency + Acute P.edema: Nitroglycerin + Furosemide
HTN Emergency + ACS: Nitroglycerin + BB
HTN Emergency + Hypertensive encephalopathy: Labetalol
HTN Emergency + Intracranial Hemorrhage: Labetalol or Nicardapine

Secondary HTN:
<30 Years or Sudden onset or Refractory HTN (3 Anti-HTN + Diuretic)
Renal:
Renal parenchyma:
- DM
- Polycystic Kidney: Autosomal Dominant, Genes: PCKD1,2. Type 1 causes cysts
“Bilateral Full Flanks”. Features: Rupture of cysts causes Hypotension. Other
 sites: Liver, Pancreas, Brain (Aneurysm). Cause of death: Renal Failure,
Intracranial Hemorrhage. Screen: If FHx of Brain hemorrhage or sxs. Dx by US:
A) <30 years: Total of 2 cysts in one or both kidneys
B) 30-59 years: Total of 4 cysts
C) >60 years: Total of 4 cysts in each kidney
- GN
Reno-vascular:
- Renal Artery Stenosis (Usually atherosclerotic or after taking ACEI): Bilateral for
sxs to happen. Features: Renal bruit, High Cr, HypoK, Flash P.edema.
Dx: MRA or CTA. Initial test is Renal Doppler US.
TTT: Stop ACEI/ARB + (Percutaneous Angioplasty w/ stent Or Bypass Or Graft).
- Fibromuscular dysplasia: Female <40, High Cr, Flash P.edema. Dx: CTA >>
TTT: Percutaneous Angioplasty.
- Scleroderma

Endocrine:
Primary Hyperaldosteronism:
- Adenoma
- Hyperplasia
Cushing’s:
- Primary (Syndrome)
- Secondary (Disease)
Pheochromocytoma: Episodic, Palpitations, Headache, Chest pain, Diaphoresis,…
Myxedema: Dx by TSH/T3,4. TTT: Treat thyroid problem.
Hypercalcemia: HTN, Polyuria, Dehydration, Altered Mental Status,…
Liddle’s Syndrome

Others:
OSAS: TTT: C-PAP.
Drugs: OCPs, Steroids, NSAIDs, Erythropoietin.
COA: Lower extremity pulse, Radio-femoral delay, Systolic murmur.
Polycythemia Vera: High Hematocrit >> High BP

PCOS:
Rule out other causes: Pregnancy test,…
“Rotterdam Criteria”
- Androgen excess: Clinical/Biochemical
- Ovulatory dysfunction (Oligo-Anovulation)
- US
Treatment:
1st line: Lifestyle & weight reduction
DM2: Metformin
Acne: Topical
Infertility: Clomiphene citrate >> Not successful >> IVF (Childbearing)
Menstrual dysregulation: OCP (Non-Childbearing)
Hirsutism: OCP, Spironolactone

Diabetes Mellitus:
Diagnosis:
Diagnostic tests: “Usually 2 required”
HbA1C ≥ 6.5% Repeated once again
Fasting ≥ (7 x 18 = 126 mg/dL) Repeated once again
Random glucose + Symptomatic ≥ (11 x 18 = 200 mg/dL)
OGTT 2 hours ≥ (11 x 18 = 200 mg/dL) Repeated once again

Types:
DM1:
Insulin deficiency, Autoimmune, HLA Association (Anti-GAD, Anti Islet Cell, Anti-insulin).
TTT: Insulin for life
DM2:
Insulin resistance, Obesity, Family History, No HLA Association.
TTT: OHA. Curative: Gastric Bypass.
MODY:
Type 2 DM in Age <25 years, Autosomal dominant, Defect in insulin secretion.
TTT: Sulfonylurea or Oral Hypoglycemic Agent
LADA:
Type 1 DM in Age >50 years
Secondary:
Steroids, PCOS, Glucagonoma, Pancreatitis, CF, Cushing’s, Acromegaly, G.DM.

Treatment:
Goals:
DM1 & DM2: HbA1C <7%. Elderly: 8%. Low risk: 6.5%
BP <130/80
Lipid at 40-75 years: <100 LDL. DM + IHD: <70 LDL
No role for ASA

Scenarios: “OHA Choice” other than Metformin

DM2 + HF: SGLT-2
DM2 + IHD: GLP-1
DM2 + CKD: SGLT-2
DM2 + Obese: GLP-1 or SGLT-2
DM2 w/ initial HbA1C >9%: Insulin
DM2 only: DPP-4/GLP-1/SGLT-2/TZDs if risk of Hypoglycemia, Sulfonylurea if no risk.

Drugs:
Insulin secretogogus:
Sulfonylureas: C.I: Obese!
- Short acting: Gli-…. Can be given to elderly
- Long acting: Glibenclamide
Miglitinides:
- Repaglinide: Minimal effect (Short acting), Reduces HbA1C by 1%.

Insulin Sensitizers:
Biguanides:
- Metformin (1st line in DM2 + Lifestyle). SE: Lactic acidosis, B12 deficiency.
C.I: <30 GFR, Alcoholic, Liver disease. Reduces 1-1.5% HbA1C.
TZDs:
- Pioglitazone: No risk of Hypoglycemia, No weight gain.
SE: Hepatotoxic, Osteoporosis, Bladder Cancer. C.I: HF.

SGLT-2 Inhibitors:
Inhibit reabsorption of Glucose in Proximal tubule. Reduces 1% HbA1C.
Risk of UTI & Euglycemic DKA. Decreases weight.
Beneficial for HF/CVD/MI/CKD (Decrease progression of renal disease).
C.I: <30 GFR
- -glifozine
GLP-1 Analogs: “Decreases Glucagon to Increase Insulin”
Decreases Weight, Reduces 1-1.5% HbA1C
-glutide
Beneficial for CAD/MI/Stroke/Albuminuria
SE: Nausea & Vomiting

DPP-4 Inhibitors: “Decreases Glucagon to Increase Insulin”

Reduces 0.5-1% HbA1C.
-gliptin
Safe in Kidney disease. SE: Nasopharyngitis

Algorithm:
DM2 <9%: Metformin + Lifestyle >> Not controlled:
 - Established Atherosclerotic Coronary VD “IHD, CAD, Stroke”:
A) Yes: GLP-1 or SGLT-2
B) No: HF or CKD (>30 GFR)
 Yes: SGLT-2 or GLP-1
- No HF/CKD/IHD: Obese?
A) Yes: GLP-1 or SGLT-2
B) No:
 At risk of Hypoglycemia: DPP-4 or GLP-1 or TZDs or SGLT-2
 No risk of Hypoglycemia: Sulfonylurea
DM2 >9% HbA1C: still not controlled >> Basal insulin + Previous drugs.

DM1: Basal insulin (Glargine) + Bolus insulin

Complications:
“Acute”
Hypoglycemic
Hyperglycemic:
DKA:
Sxs: Hyperventilation, Fruity breath, Abdominal pain, Polyurea & Polydipsia.
Precipitating factors: UTI, Pneumonia,…
Normal serum osmolality.
ABG: Low pH, Low PCO2, Low HCO3, High Anion gap.
Serum ketones: Beta-OH-Butyrate
HypoNa: Correction >> Measured Na + [2.4x measured Glucose – 100/100]
HyperK: Total body (intracellular) K depleted.
PO4: Low, Amylase: High, WBCs: High.
Aim: Normalize pH/HCO3 “Anion gap”
Treatment:
Aggressive Hydration 10-15 mL/Kg/Hour, Rapid Acting insulin IV infusion 10 IU bolus,
then 0.1 IU/Kg/Hour continue until Anion gap is normal. Then, SQ insulin for 2 hours.
If High Anion gap + <250 mg/dL, Add D5 Normal Saline.
Electrolytes: KCl if K is <4.5. If K is 3: KCl + Stop insulin.
Low PO4 (<1): give phosphate
pH <7: Give HCO3

Mortality: CVD, Cerebral edema.

Q- DKA + Black eschar + Periorbital edema + Fever: Mucormycosis (Amphotericin B)

Hyperosmolar Hyperglycemic State:

Sxs: Altered MS, Low BP, Dehydration, Polyurea & Polydipsia.
Precipitating factors: Dehydration, Renal failure.
No ABG or Serum K! Serum osmolality >320.
Treatment:
IV NS Hydration, Insulin IV 10 IU bolus then 0.05-0.1 IU/Kg/Hour.
Aim: Replete/Hydrate 8-10 Liters
Mortality: CVD, Cerebral edema.

“Chronic”
Retinopathy:
- 1: Non-Proliferative (Dot/Blot)
- 2: Proliferative (Neovascularisation)
TTT: Photocoagulation, Intravitreal Anti-VEGF (Bevacizumab).

Screening: DM1: After 5 years of Dx. DM2: At Dx then Annual.

Cause of blindness: Macular edema

Nephropathy:
Screen: Albumin:Creatinine Ratio at time of Dx and yearly, Aim: ACR <30.
ACEI (1st line), SGLT-2 inhibitors
Neuropathy:
Peripheral: Symmetric, Distal, sensory loss. TTT: Amitriptyline or Gabapentin
Autonomic: Orthostasis, Gastroparesis (Early satiety), Neurogenic bladder.

Gastroenterology
Traveller’s Diarrhea:
Organism: Most common >> E.Coli (Within 9 – 72 Hours)
Investigations: Stool culture, Ova, Parasites.
Treatment:
Supportive: Loperamide (If No fever!)
Antibiotics only if fever.
Prophylaxis: Ciprofloxacin

Amebiasis:
>1 week Hx of travel, Bloody diarrhea, Tenesmus.
ELISA or PCR stool
Treatment: Metronidazole followed by Paromomycin
Abscess: US or CT guided drainage if indicated, otherwise it’s medical.
Giardiasis:
>1 week Hx of travel, Watery stool, bad smelling diarrhea, Malabsorption (B12, B9).
Stool analysis: microscopic confirmation of cysts or trophozites.
Treatment: Metronidazole
Infectious Diarrhea:
Salmonella: Diarrhea within 6-48 hours of raw chicken / eggs ingestion.
Nosocomial Diarrhea:
Clostridium Difficile Diarrhea
“Pseudomembranous Colitis” << Pathological diagnosis
Precipitating factors:
Drugs:
Ampicillin
C Cephalosporins (Ceftriaxone)
C Clindamycin
C Ciprofloxacin
Investigations:
Stool toxin assay (Highly specific)
Stool PCR (Highly sensitive)
Glutamate dehydrogenase (Highly Sensitive)
Organism: C.Difficile
Treatment:
Stop offending drug >> PO Metronidazole or PO Vancomycin >> Repeat if failed
If severe (Low BP, Leukocytosis 18K, Bloody stool): PO Vancomycin + IV Metronidazole
Toxic Megacolon >> Surgery

Shigellosis:
3 days, Bloody diarrhea, Raw eggs or chicken consumption

Organism: Shigella
Investigations: Stool culture: G -ve rods Lactose non-fermenter non-motile organisms
Treatment: Ciprofloxacin
Food Poisoning:
Salad or reheated rice >> Within 24 Hours Vomiting then diarrhea later
Organism:
Bacillus cereus (Reheated rice): Within 6 – 15 hours Diarrhea.
Staph. Aureus (Canned meats, Mayonnaise, Salad): Within few hours Diarrhea.
Treatment: Supportive, no antibiotics.

Emergency UGI Bleeding:

Low BP = Hypovolemic Shock ≠ Endoscopy <<< Stabilize first!
Approach:
Re-assess Vital signs: High HR (10% Loss), Orthostasis (20% Loss), Low BP (30% Loss)
2 Large bore Cannula + 2 Blood cross match
- If he’s stable, within 12-24 hours UGI Endoscopy.
- If he’s unstable, Embolization or Surgery.
Variceal UGI:
Hx of CLD
Management:
Pharmacological: Octreotide + IV Ceftriaxone. (Improves mortality in Cirrhosis)
Endoscopic: Esophageal Ligation >> Balloon >> TIPS (Complication: Hepatic Encephalopathy)

Non-Variceal:
Hx of PUD, Erosive Gastropathy (NSAIDs, Alcohol, ICU,…), Erosive Esophagitis
(Critical illness, Cirrhosis, Radiation, Anti-Coagulants)
Management:
Pharmacological: PPI bolus then infusion.
Endoscopic: Epinephrine injection + Cautery. If ulcer is present, Biopsy to rule out
H.Pylori.

Obscure GI Bleeding:
Bleeding w/ negative EGD.
Etiology: Dieulafoy Lesion, Small bowel angiodysplasia.
Approach:
Negative EGD & Colonoscopy >> Push enteroscopy (To rule out SB bleeding) >>
Capsule Endoscopy or Radionuclide scan

Non-Emergency UGI:
GERD:
RFs: Smoking (Aggravates GERD), Fatty foods, Coffee.
Sxs: Nocturnal cough, Dyspepsia, Heartburn, related to meals.
Complications: Reflux Esophagitis, Barret’s Esophagus (Irreversible), Stricture (TTT:
Balloon dilatation).
Approach:
<50: PPI Trial >> No improvement >> EGD >> Normal >> 24-Hour pH Manometry
(Diagnostic) >> High Dose PPI.
<50 (w/ Alarming features: Anemia, Dyspepsia, Weight loss, Vomiting): EGD
>50: EGD to rule out Malignancy + PPI

PUD:
GU: Worsens w/ food, starts within 30 minutes.
DU: Improves w/ food, then worsens after 2 hours.
Smoking decreases healing of ulcer.
Investigations:
Young healthy <50: Stool antigen for H.Pylori or Urea Breath Test.
Old >50 or any age w/ alarming feature: EGD w/ Biopsy + Rapid Urease test.
Biopsy w/ Histology & Staining (Gold Standard): G -ve Comma shaped Rods

Test of eradication (Urea Breath or Stool Antigen): One month after end of treatment.
(Stop Abx & PPI 4 weeks before testing for eradication)

Management:
Stop offending agent.
H. pylori Eradication: Clarithromycin + Amoxicillin + PPI for 10-14 days.
If Triple failed, Switch to Quadruple regimen or Levofloxacin based regimen.

EGD Findings in Esophagus: “Barret’s Esophagus”

w/o Dysplasia: Screen EGD 3-5 years
Low Dysplasia: Screen every 6-12 months
High Grade Dysplasia: Endoscopic ablation or Resection
Esophageal Cancer:
Dysphagia to solids then liquids, Weight loss, Chest pain, Hoarseness, Hematemesis.
Squamous cell carcinoma: Upper two thirds of Esophagus >>
Alcohol, Smoking, Hot drinks, Esophageal Webs/Rings.
Plummer-Vinson Syndrome (IDA, Post-cricoid dysphagia, Upper esophageal webs)
Adenocarcinoma: Barret’s Esophagus >> GERD >> Lower third of Esophagus.
Treatment:
Limited Disease: Surgery!
Locally Advanced:
- Squamous carcinoma: Definitive Chemo-Radiation
- Adenocarcinoma: Perioperative Chemotherapy

Gastric Cancer:
Weight loss, Early satiety, Epigastric Pain, Epigastric fullness, Hematemesis.
Treatment:
Limited: Endoscopic resection
Operable Locally Advanced: Chemotherapy >> Surgery >> Chemotherapy

Non-Emergency LGI:
Celiac:
Anxiety, Diarrhea, Fatty stool (Steatorrhea), Bloating, Anemia, Rash (Dermatitis
Herpitiformis). Vitamin D deficiency, Low evidence: B12 deficiency.
Associations: PBC, Addison’s, DM1, Hypothyroidism, Vitiligo, Myasthenia Gravis.
Gluten insensitivity (HLA-DQ2/DQ8): Bloating, Diarrhea, Mental fogginess. At risk of
developing Celiac disease. Treatment: Gluten free diet.
Investigations:
Serology can confirm diagnosis, but patient must be on Gluten diet.
IgA tTG +ve (Most Sensitive) >> IgA Anti-gliadin or IgA Anti-Endomysial.
Duodenum biopsy (Definitive): Blunted w/ Lymphocytes infiltration.
Complications:
T-Cell lymphoma, Osteoporosis, Hyposplenism, S.Bowel Adenocarcinoma, Subfertility.

Whipple’s Disease:
Similar sxs to Celiac + Fever, Steatorrhea, Joint pain, Weight loss, Skin
hyperpigmentation (Grey-Brown), CNS: Oculomasticatory myorhythmia “Pathognomonic”
Organism: Treponema whipplei
Investigations: Duodenal biopsy: Blunted villi & +ve PAS stain.
Treatment: IV Ceftriaxone 2 weeks + Long standing antibiotics for 1 year: TMP/SMX

Ulcerative Colitis:
Nocturnal diarrhea, Tenesmus, Bloody diarrhea w/ mucus, Fecal urgency, Fever.
Investigations:
pANCA, High ESR & CRP & WBCs.
Endoscopy w/ Histological examination (Definitive).
Extra-colonic features:
Pyoderma gangrenosum: Steroids + Immunosuppressive
Erythema nodosum
(Aphthous ulcer, Uveitis, Episcleritis, Arthritis) << Indicate Active disease.
Complications:
Colon cancer
Primary Sclerosing Cholangitis: Risk of Cholangiocarcinoma
Toxic megacolon
Treatment: (Adding in each stage)
Mild: 5-ASA (Sulfasalazine, Mesalanzine) SE: Pancreatitis, Diarrhea.
Moderate: Topical Oral Budesonide
Severe: PO Prednisone taper + Azathioprine (SE: BMS, Hepatitis)
Very Severe: IV Steroids taper then PO Steroids
Refractory: Anti-TNF (Infliximab, Adalimumab, Golimumab), Anti-Integrin (Vedolizumab).
Surgery (Ileal Pouch-Anal Anastomosis): Not tolerate Meds or Colon Cancer or Toxic megacolon.
Toxic Megacolon:
 - C.Difficile: Surgical
- UC: Steroids + Antibiotics (Ciprofloxacin + Metronidazole) >> Surgery
Criteria: Low BP, AXR ≥ 6 cm, Peritonitis.

Crohn’s Disease:
Mucus, Fever, Abdominal pain, Aphthous ulcer,…
Associated w/ smoking (Strongest RF)
Investigations:
ASCA, High ESR & CRP & WBCs.
Small Bowel assessment (MR-Enterography): Assess extent & pattern of inflammation.
Ileocolonoscopy + Biopsy: Cobblestone, transmural inflammation. Non-caseating granuloma (Histology)
Complications:
Malabsorption, Fistula, Abscess, Kidney stones (Oxalate), B12 Deficiency.
Treatment:
Mild: 5-ASA if colonic, if not then Steroids “Budesonide”. + Abx (Cipro+Metro) if Fistula
or Perianal disease + Drainage (for abscess).
Moderate: Topical Oral Budesonide
Severe: PO Prednisone + (Azathioprine or MTX)
Very Severe (Perianal/Fistula): Anti-TNF
Refractory: Vedolizumab
Surgery:
- Stricture: Stricture dilation
- Perianal Disease: Diverting ileostomy
- Refractory: Resection

Chronic Diarrheal Disease:

IBS:
Watery, Normal osmotic gap.
Malabsorption:
Fatty, High osmotic gap, High fecal fat
Etiology: Celiac, Whipple, Giardia.

Maldigestion:
Fatty, High osmotic gap, High fecal fat
Etiology: Pancreatic insufficiency

Inflammatory:
WBCs, +ve Fecal calprotectin
Infectious:
Viral: CMV
Bacterial: TB, C.Difficile, Shigella.
Parasite: Entamoeba
Non-Infectious:
IBD

Irritable Bowel Syndrome:

Abdominal pain (Generalized or Localized), Diarrhea, Improvement of pain after defecation
No nocturnal diarrhea, no fever, no bleeding or malabsorption.
IBS-D:
Rule out celiac by IgA Anti-tTG.
TTT: Loperamide, Cholestyramine, (SSRI or TCA: For Pain). ± Rifaximine Antibiotic
Not improved: CBT
IBS-C:
TTT: Laxatives, (SSRI or TCA: For Pain). Not improved: CBT

Pancreatitis:
Acute:
Etiology: Gallstones, Alcohol, Trauma,…
Lipase (99% Specific for Acute Pancreatitis), Amylase (Sensitive).
Approach:
Abdominal US (Initial): Rule out gallstones. If +ve, ERCP.
Aggressive hydration (Ringer lactate), IV opioid.
Aim: Reduce BUN & HCT within 12-24H.
Severe: After 48-72 Hours, do CT Abdomen.
Criteria: “2 out of 3”
Lipase or Amylase >3 Upper Limit of Normal / Upper Abdominal Pain / Imaging
Chronic:
At high risk of pancreatic cancer.
Causes: Alcohol, Recurrent pancreatitis.
There must be endocrine or exocrine insufficiency.
Sxs: Steatorrhea (Exocrine), Epigastric pain radiates to back relieved by leaning
forward & exacerbated after eating, Nausea/Vomiting, Pancreatic DM (Endocrine).
In late stages, pain may not be present!

Investigations:
Abdominal CT (Best initial): Dilated duct w/ strictures (Fibrosis), Atrophy.
EUS: indicated if on CT there was: pancreatic lesion, mass, suspicion of Autoimmune
Pancreatitis.

Treatment: Pancreatic enzymes replacement, Pain control.

Autoimmune:
Young, Female, Epigastric pain radiating to back,…
Associations: IgG4 Disease, Hypothyroidism, Hashimoto’s, Sjogren’s, UC.
Investigations:
Pathology: Lymphocytic infiltration
CT: Dense fibrosis
EUS
Treatment: Steroids
Pancreatic Complications:
Mortality Calculation: Ranson’s, BISAP, APACHE.
Systemic:
ARDS, AKI, DIC, Abdominal Compartment Syndrome.
Pancreatitis increases risk of Fungal infections!
Fluid Collection:
Acute fluid collection (Non-Capsulated): No treatment, <4 weeks.
Capsulated (>4 weeks): “Pseudocyst”
- Asymptomatic: Nothing
- Symptomatic: Endoscopic Drainage
Pancreatic necrosis:
Infected (High mortality): Imipenem or (Metro + Cipro) + Debridement.
Sterile necrosis:
- Asymptomatic: Nothing
- Symptomatic: Debridement only

Best intervention to speed early recovery: Early Enteral feeding (C.I: Nausea,Vomiting)

Bilirubin:
Isolated Hyperbilirubinemia, Normal AST/ALT/ALP:
Indirect:
Hx of Stress, Infection, Fasting >> then Jaundice
Gilbert syndrome “Pregnant in 1st trimester, High ALP” High ALP is normal in Pregnancy
No treatment
Direct: Dubin-Johnson Syndrome, Rotor Syndrome.

Direct Hyperbilirubinemia, High ALP/γGT: Cholestatic “biliary”

Indirect Hyperbilirubinemia, High ALT/AST: Hepatocellular
Hepatitis:
Autoimmune:
Female, Ascites, Jaundice, Abdominal pain, weight loss, signs of acute liver failure.
Associations: Hypothyroidism, Crohn’s, UC,…
Serology: ANA, ASMA
Diagnosis confirmation is by biopsy.
Treatment:
Steroids + Azathioprine

NAFLD:
Hx of HTN, Hyperlipidemia, DM, Rapid Weight loss, Drugs. Metabolic Syndrome, HSM.
High AST/ALT
Initial: Fibroscan (Elastography): Increased Stiffness of Liver. >> next is biopsy
Diagnosis is by biopsy.
Treatment: Vitamin E, Metformin, Weight reduction

Alcoholic Hepatitis:
Asymptomatic (Mild), Non-specific symptoms: Nausea, Loss of appetite, Weight loss.
Hepatomegaly, Jaundice, …
AST>ALT 2:1
Delirium tremens: treated by Benzodiazepines.
Treatment: Immediate cessation of Alcohol. Some cases; Steroids in Severe disease.
Ischemic Hepatitis:
Vein:
Female, OCP, Hx of DVT, Jaundice, Abdominal Pain.
Pathophysiology: Hepatic vein thrombosis
Budd-chiari syndrome
Artery:
ICU, Septic shock
Hypotension >> High AST/ALT.
Metabolic:
Hemochromatosis:
Male, Jaundice, Hyperpigmentation, Abd. pain, C.myopathy, Arthritis, DM, Pseudogout
Autosomal recessive, C282Y mutation of HFE gene.
Investigations:
High Transferrin saturation (>65%). All iron profile is high. High ALT/AST.
Biopsy: +ve Perl’s Prussian Blue stain
Treatment:
Phlebotomy (initial), Deferoxamine.

Wilson’s Disease:
Female, Jaundice, Abdominal pain, Abnormal movement, FHx of similar disease.
Kayser-Fleischer ring (Pathognomonic)
Investigations:
High AST/ALT
Serum Ceruloplasmin: Low
Urine copper: High
MRI: Panda sign (Pathognomonic)
Treatment:
Penicillamine + Zinc supplementation (Decrease intestinal Copper absorption)
Trientine if Penicillamine isn’t successful. Avoid Shellfish, Organs, Nuts, Chocolate.

Infectious Hepatitis:
ALT>AST
Hepatitis A: “RNA Virus”
Feco-oral, Anorexia, Fever, RUQ pain & Tenderness, Jaundice, Dark urine & Pale stool.
Etiology: Contaminated foods e.g. Raw shellfish,…
Investigations: IgM Hep A antibodies (Active Infection), Mixed Hyperbilirubinemia.
Treatment: Supportive
Hepatitis B: “DNA Virus”
Subclinical (70%). Symptomatic (30%): Fever, RUQ pain, Jaundice, Nausea.
Incubation period: 4-12 weeks, up to 6 months.
HCC more than Chronicity.
Etiology: Sexual contact, Needle stick injury, Perinatal, Blood products.
Treatment: “Indicated if HBV DNA > 20K IU/mL”
Tenofovir (Drug of choice), Entecavir, Lamivudine, Pegylated interferon-ɑ (Toxic).
Spontaneous Recovery Rate in Acute Hep B is high.

Hepatitis C: “RNA Virus”

Asymptomatic (80%), RUQ pain & Tenderness, Jaundice, Nausea, Diarrhea, Fever.
Incubation period: 2-12 weeks, up to 6 months.
Chronicity more than HCC
Etiology: IV drug abusers, Needle stick injury, Perinatal, Blood transfusion.
Investigation: ELISA: Anti-Hep C +ve >> PCR: HCV RNA (Viral Load), HCV Genotype (I-VI).
Treatment: Sofosbuvir (Can be used for all genotypes), Ribavirin, Pegylated interferon-ɑ.

Hepatitis E: “RNA Virus”

Feco-oral, Common in Asia & travelers to Asia. Similar sxs & Labs to Hepatitis A.
If Pregnant, Can cause Fulminant Hepatitis.
Investigations: IgM Hep E (Active Infection)
Treatment: Supportive
Hepatitis B Serology:
Infection:
HBsAg +ve >> Anti HBc:
- Acute: IgM +ve
- Chronic: IgG +ve
HBeAg:
- +ve: Highly infectious
- -ve: Non-infectious (Inactive)
Window Period:
HBsAg -ve
Anti-HBc +ve IgM/IgG
Non-Infection:
Anti-HBsAg +ve:
- Vaccinated: HBsAg -ve & Anti-HBc -ve
- Previously infected: HBsAg -ve & Anti HBc IgG +ve

Cholestatic Jaundice:
Primary Biliary Cholangitis: “Intra-Hepatic”
Female, 40s, ± Osteoporosis
Pruritus, Jaundice, Xanthelasma
Autoimmune, associated w/ Sjogren’s/SLE/Celiac.
Investigations:
AMA (Initial, Diagnostic) >> MRCP >> ERCP. Biopsy confirms Dx but is not required.
Treatment: Ursodeoxycholic acid: Increase survival, Decrease histological findings.
Cholestyramine: Decreases pruritus
Primary Sclerosing Cholangitis: “Extra & Intra Hepatic”
Male
Pruritus, Strictures, 70% associated w/ UC (Do colonoscopy).
Investigations (Mainly imaging): MRCP (Method of choice): Beading, Strictures >> ERCP
Treatment: Ursodeoxycholic acid. Treat flare ups of UC. Cholestyramine: For pruritus.

Biliary colic Vs Cholecystitis Vs Ascending Cholangitis:

Biliary colic Cholecystitis Ascending cholangitis
Pain (After meals) Fever, Pain Fever, Pain, Jaundice
Normal Normal High ALP or AST/ALT
NSAIDs, Elective Lap.Chole Antibiotics >> Cholecystectomy ERCP + Antibiotics

Q- Gallstone acute pancreatitis treated w/ ERCP, What will you do later? Cholecystectomy
Chronic Liver Disease:
Cirrhosis:
Etiology:
Viral Hepatitis (80% in SA) e.g. HCV, Alcohol, Autoimmune, NAFLD, Metabolic,
Vascular, Drugs (Amiodarone, Methotrexate, Isoniazide, Valproate), PSC, PBC.
Clinical Features:
Anorexia, Fatigue, Jaundice , Dry atrophied skin, Decreased body hair, or signs of
decompensation.
Initially, Liver is enlarged (Especially Left lobe). Later, it is shrunken & nodular.
Signs of Liver Failure: Palmer erythema, White nails, Duputryn’s contracture, Hepatic fetor,
Asterixis, Enlarged parotid gland, Gynecomastia, Spider angioma, Testicular atrophy, Clubbing.
Signs of Portal hypertension: Splenomegaly, Ascites, Caput medusa.
Decompensation: Occurs when there is increased Jaundice or Variceal Bleeding or
Hepatic Encephalopathy or Ascites (Worse Prognosis).
Investigations:
Labs: Anemia of Chronic D., Signs of Hypersplenism (Neutropenia, Thrombocytopenia, Anemia)
LFT (Bilirubin, ALT/AST, ALP/GGT, PT/PTT, Albumin): ↑ Bilirubin, ↑ PT (Poor prognosis).
Initially, PTT increases then PT. Low Albumin.
Bonacini index (Predictive of Cirrhosis): Platelet Score + ALT:AST Ratio Score + INR Score.
With time, ALT & AST will normalize.
Renal Panel: Low Na (High ADH).
Work-up:
After labs >> Abdominal US w/ Doppler (Rule out HCC & Ascites, Check Vessels)
Determine etiology: Hepatitis serology, Autoimmune serology.
Assess fibrosis: Labs (FibroSURE) or Imaging (Elastography)
Liver Biopsy (Gold stx for etiology):
- Percutaneous
- Transjugular: If has ascites or coagulopathy
Prognosis:
Child-Pugh Score:
- Ascites, Hepatic encephalopathy
- Bilirubin, Albumin, INR
Child A: score 5-6 “Well Compensated”
Child B: score 7-9 “Significant Functional Compromise”
Child C: score 10-15 “Decompensated” << Survival is <45% in one year
MELD Score: Predictive for liver transplant & mortality in 3 months.

Complications of Cirrhosis:
Ascites:
SAAG “Serum Albumin – Ascites Albumin”
- ≥ 1.1 ← P.HTN
A) Perisinusoidal: Schistosoma, Portal Vein Thrombosis
B) Sinusoidal: Cirrhosis, HCC
C) Post-Sinusoidal: CHF, Budd-chiari Syndrome
To differentiate between Cirrhosis Vs CHF: Ascites Fluid Total Protein (AFTP) → ≥2.5
Cirrhosis, <2.5 Cardiac.
- <1.1:
A) Malignant: Peritoneal Carcinomatosis
B) Infection: TB
C) Inflammatory: Pancreatitis
D) Hypoalbuminemia: Nephrotic syndrome
After SAAG → Cell Count: PMN is normal up to 250.
>250 suggests Spontaneous Bacterial Peritonitis. “20% incidence & 20% mortality”
Organisms: E.Coli, Klebsiella, S.Pneumoniae.
RFs: Current GI Bleeding, Hx of previous SBP.
Treatment for SBP: Cefotaxime or Ceftriaxone or Augmentin (5 Days) + IV Albumin 1.5
g/Kg at time of Dx then 1 g/Kg on day 3. Albumin increases survival in SBP.
Treatment for Ascites:
Decrease Na intake (1-2 g/day) + Fluid Free water restriction if Na is <125
Spironolactone then later Furosemide if not improved as 5:2 Ratio.
Refractory:
- Large volume paracentesis (>5L) + Albumin
- TIPS

Portal Hypertension: Hepatic venous gradient >5 mmHg.

GastroEsophageal Varices ± Bleeding:

Acute management: as mentioned in previous section.
UGI Bleeding Primary Prevention: Non-Bleeding Varices detected on Endoscopy →
Non-Selective BB (Propanolol); Reduces chance of Bleeding by 50% & reduces mortality.
UGI Bleeding Secondary Prevention: BB + Endoscopic variceal ligation.

Hepatorenal Syndrome:
CLD + AKI (w/o any cause; e.g. Diuretics, Sepsis, HTN)
Cause: Splanchnic vasodilation leading to Renal vasoconstriction & renal injury.
Criteria:
1) Cirrhosis w/ ascites
2) AKI
3) No improvement in Creatinine after stopping diuretics
4) No signs of shock
5) No nephrotoxic medication
6) No intrinsic kidney disease
Treatment:
- Critically ill: Vasopressors + Albumin
- Non-Critically ill: Octreotide + Midodrine + Albumin
Cure is Liver transplant.
Hepatic encephalopathy:
Failure of liver to detoxify Ammonia “NH3”
Clinical features: Disorientation, Insomnia, Asterixis.
Precipitating factors: UGI Bleeding, Constipation, Infection, SBP, Medication non-
adherence, Dehydration, Hyponatremia, Hypokalemia, Sedation, TIPS.
Treatment: Correct cause + Lactulose
 Toxicology

Amiodarone

Blue man syndrome: Reversible within 1 year.

- Amiodarone contains 6 mg of iodine in 200 mg Tablet.
8 P’s:
Prolonged QT interval
Photosensitivity
Pigmentation of Skin (Blue-Grey)
Peripheral neuropathy
Pulmonary fibrosis: Bad prognosis
Peripheral conversion of T4/T3 (Hypothyroidism – Hyperthyroidism)
Peripheral spots of cornea
Prolonged LFT
Amiodarone Induced Hypothyroidism: “10%”
Prior to initiating Amiodarone prescription, Base TSH should be identified then every 4-
6 months after starting treatment until after 1 year post end of treatment.
High TSH, Low T3/T4:
Wolff-Chaikoff effect (Opposite of normal iodine uptake phenomenon): iodine load
reduces Iodine uptake by thyroid >> Low T3/T4.
Immune mediated process
Treatment: Stop amiodarone & give Levothyroxine.

Amiodarone Induced Hyperthyroidism: “3%”

Low radioiodine uptake
Type 1 (Excessive Synthesis): Discontinue Amiodarone
Type 2 (Destructive Thyroiditis): Discontinue Amiodarone + Start Steroids

Digoxin
Toxicity: Level in blood increases to >2, causing side effects.
Causes of toxicity:
Hypokalemia (Increases digoxin binding)
Hypercalcemia
Hypomagnesimia
Side Effects:
Hyperkalemia, Nausea/Vomiting, Dizziness/Confusion, Gynecomastia.
Visual disturbance “Xanthopsia” (Yellow spots)
Arrhythmias: Paroxysmal Atrial Tachycardia “most common”, Bradycardia, AV block.
Benign Finding in ECG (Digoxin Effect): Sloping ST Depression
Management:
Digibind (Dig Fab), indicated when:
Acute ingestion level ≥10
Chronic ingestion level >6
Cytochrome P450 inhibitors & inducers:
Common scenario:
Patient on Warfarin has INR 5, Which drug is the cause? Inhibitor drugs
Patient on Warfarin has INR 1.5, Which drug is the cause? Inducer drugs
Inhibitors: “SICK FACES.COM”
Decrease dose of Warfarin.
Sodium valproate, Isoniazide, Cimetidine, Ketoconazole, Fluconazole,
Amiodarone/Alcohol (Acute drinking), Chloramphenicol, Erythromycin, Sulfonamide,
Ciprofloxacin, Omperazole, Metrondiazole. Grape fruit.
Inducers: “CRAP GPS”
Increase dose of Warfarin or change to NOACs.
Carbamazepine, Rifampicin, Alcohol (Chronic), Phenytoin, Griseofulvin, Phenobarbital,
Sulfonylurea.

Drug Toxicity Scenarios:

Q- Young, Vomiting, Suicidal attempt, HAGMA, Normal osmolar gap, High AST & ALT,
High Creatinine.
Acetaminophen toxicity
Antidote: N-Acetylcysteine. SE: Anaphylaxis if given IV.
Severe cases: Hemodialysis

Q- History of depression came w/ Hypotension, Seizure, ECG: Prolonged QT Interval.

TCA, Amitriptyline
Treatment: NaHCO3 Urine Alkalinization + IV Fluids resuscitation

Q- Ischemic Heart Disease, Stroke, Abdominal pain, Vomiting, High RR, Ringing in
ears “Tinnitus”.
Salicylate toxicity, ABGs: HAGMA + Normal osmolar gap + Respiratory Alkalosis
Treatment: NaHCO3 Urine Alkalinization + Maintain Respiratory Alkalosis. If severe,
consider Hemodialysis.
Q- Farmer, Salivation, SOB “Bronchospasm”, Diarrhea, Vomiting, Tearing, Miosis.
“Cholinergic manifestations”
Organophosphate toxicity
Treatment:
Respiratory Failure: Endotracheal intubation + Atropine or Pralidoxime
No Respiratory Failure: Atropine

Q- Altered MS, Low RR, miosis.

Opiate toxicity
Treatment: IV Naloxone

Q- Altered MS, Low RR, Ataxia.

Benzodiazepines toxicity
Treatment: Flumazenil

Q- Altered MS, HAGMA, High osmolar gap, Sweet smelling breath.

Ethylene glycol
Treatment: Ethanol or Fomepizole. If severe, Hemodialysis.

Q- Altered MS, HAGMA, High osmolar gap, Blindness.

Methanol toxicity. Methanol is present in perfumes. Blindness is irreversible.
Treatment: Ethanol or Fomepizole. If severe, Hemodialysis.

Q- Altered MS, High serum ketones, Sweet smelling breath.

Isopropanol “Isopropyl Alcohol”
Treatment: Supportive

Q- Bradycardia, Delirium, Xanthopsia, AV Block, Nausea/Vomiting, Hyperkalemia.

Digoxin toxicity
Treatment: Digibind + Treat Hyperkalemia . If Severe: Hemodialysis
Q- Bradycardia, Hypotension, HF sxs, Hyperglycemia, AV Block.
CCB toxicity
Treatment: Calcium gluconate + Pacing

Q- Bradycardia, Hypotension, HF sxs, Hypoglycemia, AV Block.

BB Toxicity
Treatment: Glucagon + Pacing

Q- Altered MS, Seizure, Pink spots skin, Almond odor, Normal PaO2, Co-oximeter:
Normal O2.
Cyanide toxicity
Treatment: Hydroxycobalamin (Vit. B12) + Decontamination

Q- Altered MS, Headache, Vomiting, Cherry red skin, Normal PaO2, Co-oximeter: ↓ O2
Carbon-monoxide toxicity
Treatment: Hyperbaric Oxygen

Q- Altered MS, Chocolate brown blood, Normal PaO2, Co-oximeter: Low O2.
Methemoglobinemia. Can be caused by Sulfonamides, Nitrates,…
Treatment: Methylene blue

Other Drug Antidotes:

Warfarin: Vitamin K “Phytonadione”, if active bleeding (FFP or Prothrombin complex)
+ Vit K.

Heparin: Protamine sulphate

Magnesium sulphate:
First check DT Reflex.
BURP: ↓ BP, ↓ Urine output, ↓ RR, Absent patellar reflex.
Antidote: Calcium Gluconate

Iron:
At risk of: Cardiomyopathy, Secondary hemochromatosis, Liver failure, Listeria
infection.
Antidote: Desferoxamine

Methotrexate: Lecovorin
Valproic acid: Levocarnitine

Lead Poisoning:
Hx: Living in old building, Abdominal pain, Anemia (↓MCV), Foot drop, Headache.
Antidote: Dimercapol “BAL”. Oral Succimer in children.

Snake bite: Polyvalent immune Fab.