FMED ICINE

INA

OSCE Review

2022-2023
1st Edition
 PREFACE

While preparing for our family medicine program's OSCE, we

encountered some challenges to find an updated and
organized resource.

Therefore, under the guidance of our program committee,

We cooperated together to cover the majority of topics that
related to the family medicine curriculum to pass the exam.

To our supervisors and colleagues, Thank you all

We appreciated your time, effort and commitment.

Special mention to Dr. Samir Samman, Dr. Riyadh Aljohani

And Dr. Yazeed Alsenani
For their outstanding support

Best Wishes..
Dr. Ghaida Adel Turkistani
Dr. Budur Abdullah Almohammadi
Senior Family Medicine Resident,
Family Medicine Academy, Medina

X T I
"‫ﻤﺎ ﻋﻠﻤﺘﻨﺎ وزدﻧﺎ ﻋﻠﻤﺎ‬S ‫"اﻟﻠﻬﻢ ﻋﻠﻤﻨﺎ ﻣﺎ ﻳﻨﻔﻌﻨﺎ واﻧﻔﻌﻨﺎ‬

1
 APPRECIATION
‫ علم اإلنسان ما لم يعلم‬،‫احلمدلله الذي علم بالقلم‬
It is a pleasure and something we are proud of at the Family Medicine
Academy to see this distinguished group of residents , trainees of
post graduate family medicine, some graduates and trainers working
together to produce this good reference for the practical exams for
the specialty of family medicine.

I extend my thanks and appreciation to Dr. Ghaida Turkistani,

Dr. Budur Al-Mohammadi and all colleagues involved in writing,
reviewing or supervising this important medical reference.
I ask God to benefit it and make what they wrote in the balance of
their good deeds.
Administration of Family Medicine Academy in Medina

I would like to acknowledge the talented team for their determined

effort in completing this comprehensive OSCE guide book.
This distinguish work could not be accomplished without the
assistance of senior trainee and through review by excellency of
trainers at Family Medicine Academy.

Also, we are eternally grateful to Dr. Ghaida and Dr. Budur

for coming up with the idea of creating this guide, which is go to be
essential and helpful to all future family medicine residents in their
exam and clinical practice.
I appreciate your effort more than you’ll ever know.
Dr. Bader Saad Aljohani

2
DONE BY:
Dr. Abeer Abdulsalam Albushi Dr. Sahar Hussain Alalawi
Dr. Arwa Abdulrahman Alhejaili Dr. Seham Luwayfi Albalawi
Dr. Budur Abdullah Almohammadi Dr. Shouq Abdulmohsen Aloufi
Dr. Ghaida Adel Turkistani Dr. Abdulaziz Saad Alahmadi
Dr. Laman Akeel Bajri Dr. Abdulrahman Mohaimeed Aloufi
Dr. Norah Mubarak Almutairi Dr. Ahmed Mansour Al Ahmadi
Dr. Ola Anwar Dhaher Dr. Albaraa Saleh Alhemaidi
Dr. Omaymah Yahya Aljardi Dr. Baraa Ali Felemban
Dr. Raghad Osama Alhelali Dr. Hosam Mohammed Abduljabar
Dr. Rahaf Eid Alhazmi Dr. Jebreel Mohammed Fallatah
Dr. Rahaf Hassan Alsharif Dr. Osama Abdullah Alsaadan
Dr. Rehab Nasser Alrashidi Dr. Riyadh Mesfer Aljohani
Dr. Raneem Omar Alqaidi Dr. Yazid Mohammed Alrahili
Senior Family Medicine Resident,
MBBS, Family Medicine Academy, Medina.

Dr. Abdullah Salem Babaker

Dr. Aseel Sameer Tammar
Senior Family Medicine Resident,
MBBS, Joint program of family medicine, Jeddah.

REVIEWED BY:
Dr. Yazeed Saeed Alsenani Dr. Meshari Saud Al Harbi
Family Medicine Consultant, Family Medicine Family Medicine Consultant
Academy MBBS, SBFM.
MBBS, SBFM, ABHSFM.

Dr. Riyadh Mohammed Aljohani Dr. Marwan Abdulaziz Alluhaybi

Family Medicine Consultant, Family Medicine Academy Family Medicine Senior Registrar, Family
MBBS, SBFM, ABHSFM, JMCFM Medicine Academy
CPHQ, CHQM. MBBS, SBFM.

Dr. Osama Hamad Alsaedi

Family Medicine Consultant, Family Medicine Academy
MBBS, SBFM.

3
 Table of contents
Internal medicine
Neurology • Planning to pregnancy
Headache • Insulin use
Dizziness • Glucometer use
TIA, Stroke Examination
Dementia • Diabetic foot Ex
• MMSE Thyroid disorders
Bells palsy • Hyperthyroidism
Epilepsy + counselling • Hypothyroidism
Tremors • TFT interpretation
Osteoporosis
Respiratory • DEXA
Bronchial asthma Metabolic syndrome
• Newly diagnosed Obesity + post-bariatric
• Initiation of treatment Cushing syndrome
• Adjustment and maintenance of treatment
Vit D deficiency
COPD
Hirsutism
Obstructive sleep apnea
Acromegaly
URTI
• Sore throat (pharyngitis) Addison’s disease
• Rhinosinusitis Gynecomastia
LRTI
• Cough
Gastroenterology
• Acute Bronchitis Abdominal pain
• COVID 19 Dyspepsia
• Pneumonia • PUD, DU
Smoking cessation • H-pylori
Peak flow mete use • Gastritis
Metered dose inhaler use Bowel Disorders
PFT interpretation • Irritable Bowel Syndrome
• Inflammatory Bowel Diseases
Cardiology • Celiac diseases
HTN • Traveler’s Diarrhea
• Newly diagnosed Gastrointestinal Reflux Disease (GERD)
• Follow up Jaundice
Palpitation
Heart failure Urology
Chest pain (MI) + counselling Urinary tract infection UTI
Dyslipidemia • Recurrent UTI
• UTI during pregnancy
Endocrinology Renal colic
• Renal stone
DM
Urinary incontinence + counselling
• Newly diagnosed
Prostatitis
• Breaking bad news
• Follow up Benign prostatic hypertrophy BPH
• In Ramadan

4
 Table of contents
Testicular mass
• Hydrocele
Pediatric
Testicular torsion Well baby clinic
Sexual history Febrile convulsion
• Premature ejaculation Infantile colic
• Erectile disfunction Short stature
Failure to thrive
Breathing hold spells
Rheumatology Nocturnal enuresis
Rheumatoid arthritis
Limping
Gout/Pseudogout Down syndrome
Systemic lupus erythematosus SLE
Fibromyalgia
Surgery
Hematology and vascular Acute abdomen
Anemia • Cholecystitis
• Iron deficiency anemia • Pancreatitis
• Sickle cell anemia • Appendicitis
Breaking ban news of leukemia
Breast mass
Venous thromboembolism • Fibroadenoma
• Pulmonary embolism PE • Fibrocystic changes
• Deep vein thrombosis • Mastitis, breast abscess
Abnormal mammogram
Infectious diseases
Fever of unknown origin
CNS infections Obstetric and
• Meningitis
• Encephalitis gynecology
Pericarditis Vaginal Discharge
Travel ID Polycystic Ovarian Syndrome
• Malaria Menstrual Disorders
• Typhoid • Dysmenorrhea
• Dengue fever • Abnormal Uterine Bleeding
• Yellow fever Family Planning
Leishmaniasis Antenatal care
Monkeypox Postpartum care
Pinworm Breast feeding
Herpes zoster Post menopausal bleeding
Brucellosis Infertility
Tuberculosis HRT initiation

Geriatric
Geriatric assessment

5
 Table of contents

Emergency Dermatology
Hypertension HTN Acne
• Emergency Pruritis
• Urgency • Urticaria
Diabetes millets DM • Scabies
• Hypoglycemia • Dermatitis
• Hyperosmolar hyperglycemic state HHS
• Diabetic ketoacidosis DKA
Bite ENT
Status epilepticus Hearing loss
• Cerumen impaction
Psychiatry • Otitis media with effusion
Depression Tinnitus
Post partum depression Audiogram
General anxiety disorder GAD Tympanogram
Obsessive compulsive disorder OCD
Eating disorder Ophthalmology
Insomnia Red eye
Attention deficit/hyperactivity disorder ADHD
Autism
Screening &
Orthopedic Immunization
Neck pain Periodic health examination
• Degenerative cervical spine disease Immunization
Shoulder pain Screening (Cancer)
• Adhesive capsulitis • Breast cancer
• Rotator cuff tear • Cervical cancer
• Shoulder dislocation • Colorectal cancer
• Shoulder impingement
Hand pain
• Carpal tunnel syndrome
• De Quervain tenosynovitis
Back pain
• Lumbar muscle strains/sprains
• Brucellosis
• Ankylosing spondylitis
Knee pain
• Osteoarthritis
Foot pain
• Plantar fasciitis
• Achilles tendinopathy
Ankle pain

6
 Simulated Clinic
Introduce yourself and establish good rapport
Starting ( Name, age and job)
‫أخدمك؟‬/‫ كيف ممكن اساعدك‬،‫سالمات ما تشوف شر‬
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness
Clarify what you understood
Course, onset and duration, SOCRATES for pain
Associated symptoms (DDx)
Analysis of
Risk Factors and Red Flags including Constitutional
chief complain
Symptoms (NWAFF: Night sweating, Weight changes,
Appetite changes, Fever and/or Fatigue)
Medical, Surgical, Allergy, Medication, Vaccination,
Past Hx
Hospitalization and Blood transfusion
Family Hx same condition, chronic diseases
Marital status , Smoking: type and frequency
Psychosocial
History Screening: depression and anxiety
Female Child Old age
Menses
Pregnancies Vaccination
Deliveries Development Geriatric assessment
Lactation School performance
OCP
Ideas: ‫ايش ممكن يكون السبب؟‬/‫ايش فكرتك عن األعراض اللي عندك؟‬
Concerns: ‫هل عندك أي مخاوف أوفي شي مقلقك؟‬
ICEE
Expectation: ‫نساعدك فيه؟‬/‫هل في شي معني حابب اننا نعمله لك‬
Effect: ‫هل اثرت األعراض على حياتك؟ عملك؟ كيف؟‬
Systemic Review
..... ‫ حابب تضيف حاجة؟ طيب ممكن استأذنك تقوم على السرير عشان أفحص‬، ..... ‫فهمت منك إنك تشتكي من‬
General Vital signs Local/ special test
Temperature
Look (ill/well) Blood pressure
Pallor Herat rate
Examination As needed
Jaundice Respiratory rate
cyanosed SPO2
BMI
‫ عشان نتطمن عليك اكثر‬..... ‫ أشعة‬/‫ نحتاج نطلب لك حتليل‬،.... ‫لقينا في الفحص‬
Labs/Imaging or other ( Culture/Biopsy )
Investigations
..... ‫اتبني معانا في التحاليل‬
C Name the diagnosis, Explain the cause R Dietitian, Educator or specialist
Management As appropriate:
R I Done
Common/Curable/Controllable
Shared
understanding &
A Non-Pharma: Diet/Exercise/ Avoidance O F/U: When? Why?
plan P Pharma: name the Drug + Dose, P Immunizations + Screening
Frequency and duration
Safety Netting
‫في شي مهم في بالك ما أتكلمنا عنه؟‬
Closing ‫في أي أسئلة حتب جناوبك عليها؟ في شي ما هو واضح؟‬
.‫ تشرفنا بزيارتك‬،‫الف سالمة عليك‬

7
Neurology

8
Neurology
Headache
Dizziness
TIA, Stroke
Dementia
• MMSE
Bells palsy
Epilepsy + counselling
Tremors

9
 Headache Hx
Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Site: Cluster headache:
- Unilateral (migraine) - Pain around one eye
- Scalp or temporal (temporal arteritis) - Lacrimation/eye watering
- Face/in front of ear (trigeminal neuralgia) - Excruciatingly severe
Onset (how it started): - Attacks lasting 30–60 minutes persist for a few
- Sudden (subarachnoid hemorrhage) weeks to 1–2 months and then stop for 6–12
- Gradual months
Character: Tension headache:
- Throbbing (migraine) - ‘Tight’ headache
- Dull - Diffuse, not localized
Radiation: - Related to stress
- To neck (subarachnoid hemorrhage) Chronic analgesic-dependent headaches:
- Long-term extensive use of high-dose
Associated symptoms: analgesics
Raised intracranial pressure: - Daily occurrence
- Nausea, vomiting (increased intracranial Time:
Analysis of chief complain (SOCRATES)

pressure) - Duration of headaches

- Worse on straining/bending - Duration of pain-free periods
down/coughing - Intermittent/continuous/progressive (raised
Meningitis: intracranial pressure)
- Fever Alleviating factors:
- Photophobia - Darkness
- Neck stiffness Exacerbating factors:
- Hemorrhagic rash - Touching scalp (temporal arteritis)
Subarachnoid hemorrhage: - Worse in early morning (raised intracranial
- Sudden onset (like being hit on the head pressure)
with a cricket bat) - Light (migraine, meningism)
- Occipital Severity:
- ‘Worst’ pain the patient has ever had - Severity scale from 1-10
Temporal arteritis: - Affecting daily activity
- Scalp tenderness - Awaking him from sleep
- Ipsilateral visual disturbance
- Shoulder/hip muscle aches (polymyalgia Red flags for 2ry headache
rheumatica)
Migraine:
- Nausea, vomiting
- Photophobia
- Periodic (e.g. every month), correlation
with menstrual periods
- Visual disturbance (zigzag lines, flashing
lights)
- Aura
Trigeminal neuralgia:
- Like ‘electric shock’
- Short duration (seconds to a few minutes)
- Face/in front of ear
- Chewing makes it worse

10
 Headache Hx
Trauma
RFs

Medical: Medication
Past Hx

- Malignancy - Analgesics
- Hypertension - Oral contraceptive pill (contraindicated in
Surgical certain types of migraine)
Allergy - Over-the-counter medication
Migraines Subarachnoid hemorrhage
Psychosocial FHx

Berry aneurysms Malignancy

Marital status Diet
Smoking: type and frequency Occupation
Alcohol Stressors – financial, occupational, relationship
Illicit drug use Screening: depression and anxiety
Caffeine intake
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE

Expectation: is there anything you want me to do for you?

Effect: does this affect your life? How?
Differential Diagnosis
• Migraine • Temporal arteritis
• Cluster headache • TIA: Transient visual loss (amaurosis fugax)
• Tension headache • Trigeminal neuralgia
• Depression: PHQ-2: low mood or loss of interest in the • Acute angle closure glaucoma: Very painful
past 2 weeks red eye, haloes around the lights, blurred
• Sinusitis: Fever, nasal congestion or discharge, facial vision, nausea and vomiting, similar episodes
fullness or pain that were aborted in few minutes
• Meningitis: Fever, neck pain or stiffness, photophobia, • Cervicogenic headache: Neck pain or spasm,
rash and recent travel shoulder pain, numbness in upper extremity
• Subarachnoid hemorrhage • Acoustic neuroma: Unilateral hearing loss,
• Increased intracranial pressure tinnitus and facial palsy
Systemic Review
Conclusion

Examination
Vital signs:
Obtain blood pressure, pulse, and temperature (to R/O infection or urgent HTN).
General Appearance:
Intermittent headache with generalized sweating, tachycardia, paroxysmal hypertension is
suggestive of pheochromocytoma
Meningeal signs
Sinus tenderness
Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous malformation
Palpate the head, neck, and shoulder regions for any trauma
Check temporal and neck arteries (R/O temporal arteritis)
Special Examine the spine and neck muscles
The neurologic examination should cover mental status testing, cranial nerve examination,
fundoscopy and otoscopy, HENT, and symmetry on motor, reflex, cerebellar
(coordination), and sensory tests. Gait examination should include getting up from a sat
position without support and walking on tiptoes and heels, tandem gait, and Romberg
test.

11
 Headache
Migraine
Migraines are a kind of headache that can also involve other symptoms. The pain of a migraine
Clarification ranges from moderate to severe and throbbing. The pain may be limited to one side of the head.
There is usually nausea and sometimes vomiting.
Reassurance Don’t warry, Migraines are a common type of headache, affecting up to 12 % of adults.
Encourage patients to maintain a lifestyle that may help avoid migraines: regular meals, good sleep
hygiene, avoid volume depletion, regular exercise, and identify and avoid specific migraine triggers.
Some people find that their migraines are triggered by certain things. If you can avoid some of these
things, you can lower your chances of getting migraines
Common migraine triggers include:
- Stress
- Skipping meals or not eating enough
- Changes in the weather
- Sleeping too much or too little
- Bright or flashing lights
Advice
- Drinking alcohol
- Eating certain foods, such as aged cheese and hot dogs
- Smoking or being around smoke
You can also keep a "headache diary." In the diary, write down every time you have a migraine and
what you ate and did before it started. That way you can find out if there is anything you should
avoid eating or doing. You can also write down what medicine you took and whether or not it
helped.
If your migraines are frequent or severe, we can suggest other ways to help prevent them. For
example, it might help to learn relaxation techniques and ways to manage stress. There are also
medicines that can help.
Acute treatment:
- Mild to moderate symptoms à NSAIDs
Ex: ibuprofen: 800 mg as a single dose at onset, then 400-800 mg orally every 4-6 hours
when required
- Severe symptoms à Triptan
Prescribing
Ex: sumatriptan: 25-100 mg orally as a single dose, may repeat in 2 hours
+\- metoclopramide: 5-10 mg orally/intramuscularly/intravenously every 8 hours when required
Note:
Triptans, ibuprofen, naproxen, aspirin, and high-dose acetaminophen are effective treatments for
acute migraine. Intravenous magnesium and greater occipital nerve blocks are also effective.
Referral Cognitive behavioral therapy for relaxation techniques and manage stress
Diagnosis is based on history and physical exam. Testing is not used to 'rule in' a diagnosis of
Investigations migraine, but rather to 'rule out' plausible alternative diagnoses that are suggested by the patient's
presentation
Observation Follow up after 2 weeks
- Propranolol: 80-240 mg/day orally (immediate-release) given in 2-4 divided doses
or
Plan/ - Amitriptyline: 10-150 mg/day orally
Prevention
Note:
Effective migraine preventive medications include candesartan, telmisartan, lisinopril, oral
magnesium, topiramate, propranolol, erenumab, fremanezumab, and galcanezumab.
See your doctor immediately or go to the emergency room if you have any of the following signs and
symptoms, which could indicate a more serious medical problem:
- An abrupt, severe headache like a thunderclap
- Headache with fever, stiff neck, confusion, seizures, double vision, numbness or weakness in any
Conclusion
part of the body, which could be a sign of a stroke
- Headache after a head injury
- A chronic headache that is worse after coughing, exertion, straining or a sudden movement
- New headache pain after age 50
- if the pattern changes or your headaches suddenly feel different

12
 Headache
Trigeminal autonomic cephalgia (Cluster)
Very severe headaches that happen in clusters, sometimes more than once a
day, over several weeks.
An episode of cluster headache can last between 15 minutes and three hours.
There seems to be a genetic link to cluster headaches.
Several other things have been suggested as causes of cluster headaches,
Clarification
including:
- Heavy smoking
- Heavy drinking
- Sleep apnea, and a history of head injuries.
But there isn’t much evidence to support these ideas.
Treatments can make cluster headache attacks shorter and less severe. In
Reassurance
addition, medications can reduce the number of cluster headaches you have.
Behavior and Lifestyle Interventions
Advice relaxation, smoking cessation, and alcohol intake reduction should be
considered
Acute attack:
High-dose and high-flow-rate oxygen
sumatriptan: 6 mg subcutaneously as a single dose
Prescribing
Note:
Galcanezumab reduces cluster headache frequency, whereas triptans and
oxygen may improve acute cluster headaches.
Neurology (All patients with suspected cluster headache should be seen by a
Referral
neurologist *BMJ*)
Cognitive behavioral therapy
For R\O
MRI brainà R\O secondary causes
Investigations
ESR à R\O giant cell arteritis
Blood tests, including TSH, LH, FSH, insulin-like growth factor 1, cortisol,
prolactin, testosterone, estradiol, progesterone, glucose, and growth hormone,
should be considered at the discretion of specialist à pituitary adenoma
Observation Follow up after 2 weeks
Verapamil: 80 mg orally (immediate-release) three times daily initially, increase
Plan/prevention
gradually according to response, maximum 480 mg/day
See your doctor immediately or go to the emergency room if you have any of
the following signs and symptoms, which could indicate a more serious medical
problem:
- An abrupt, severe headache like a thunderclap
- Headache with fever, stiff neck, confusion, seizures, double vision, numbness
Conclusion or weakness in any part of the body, which could be a sign of a stroke
- Headache after a head injury
- A chronic headache that is worse after coughing, exertion, straining or a
sudden movement
- New headache pain after age 50
- If the pattern changes or your headaches suddenly feel different

13
 Headache

Tension

Tension-type headaches often happen when you're feeling stressed, tired, or

Clarification angry.
A tension-type headache usually feels like an ordinary headache. Some people
say it's as if a band is pressing on both sides of their head. The pain isn't
usually throbbing.
Most people get headaches from time to time, and tension-type headaches
Reassurance
are among the most common
Recommendations for regular exercise, sleep hygiene, and planned relaxation
Relaxation training, cognitive behavioral therapy, and myofascial trigger point-
Advice focused massage all have been shown to reduce tension-type headaches.
Music therapy is of dubious value in the treatment of tension-type headache.
Brief mindfulness therapy may be of value in chronic tension-type headache.
Physical measures, including physiotherapy, acupuncture, and spinal
manipulation, may also provide benefit
Paracetamol: 500-1000 mg orally/rectally every 4-6 hours when required
Ibuprofen: 400-800 mg orally every 4-6 hours when required,
Prescribing chronic symptoms (>7-9 headache days/month)
Amitriptyline: 10 mg orally once daily at bedtime initially, increase by 10
mg/day increments every week, maximum 100 mg/day
Referral Cognitive behavioral therapy for stress control
Imaging and laboratory studies do not aid in the diagnosis of tension-type
Investigations
headaches and should only be considered in refractory or progressive cases.
Follow-up is considered every few months for patients with tension-type
Observation
headache to determine progress and for medicine adjustments. The patient
can be encouraged to record the number of attacks, dates, and doses of acute
agents taken, which may be taken into consideration when tailoring medicine.
Stress reduction and regular exercise might reduce the incidence of tension-
Plan/prevention
type headaches.
See your doctor immediately or go to the emergency room if you have any of
the following signs and symptoms, which could indicate a more serious
medical problem:
- An abrupt, severe headache like a thunderclap
- Headache with fever, stiff neck, confusion, seizures, double vision, numbness
Conclusion or weakness in any part of the body, which could be a sign of a stroke
- Headache after a head injury
- A chronic headache that is worse after coughing, exertion, straining or a
sudden movement
- New headache pain after age 50
- If the pattern changes or your headaches suddenly feel different

14
 Headache
Temporal arteritis

Giant cell arteritis (or GCA for short) is thought to happen when
the body’s immune system, which usually protects us from
infection, attacks some of our arteries.
When the immune system acts in this way, it causes swelling in the
Clarification
lining of these arteries, which interferes with blood flow. The
arteries most often affected are those in the temples, so that the
symptoms of GCA mainly affect the head.
Giant cell arteritis needs urgent treatment.
There are good treatments for giant cell arteritis. But treatment
Reassurance can take time, and symptoms can return from time to time in
some people.
Advice General advice lifestyle modification
Prescribing
Prednisolone: 40-60 mg orally once daily initially, adjust dose
according to response
Giant cell arteritis needs urgent referral for rheumatology.
Referral Ophthalmologist should also see the patient to perform a full eye
exam to rule out other serious causes of vision loss
CRP
Investigations ESR
Temporal artery biopsy
Observation Follow up for tapering prednisolone every 2 weeks
Appropriate immunizations, including influenza and
pneumococcal vaccines, should be administered.
Plan/prevention Long-term glucocorticoids should be accompanied with agents to
prevent glucocorticoid-induced bone loss: calcium, vitamin D, and
bisphosphonates
See your doctor immediately or go to the emergency room if you
have any of the following signs and symptoms, which could
indicate a more serious medical problem:
- An abrupt, severe headache like a thunderclap
- Headache with fever, stiff neck, confusion, seizures, double
Conclusion
vision, numbness or weakness in any part of the body, which could
be a sign of a stroke
- Headache after a head injury
- A chronic headache that is worse after coughing, exertion,
straining or a sudden movement
- New headache pain after age 50
- If the pattern changes or your headaches suddenly feel different

15
 Headache

Subarachnoid hemorrhage

Subarachnoid hemorrhage is a rare type of stroke. It happens when there is bleeding in

the subarachnoid space - the area in between the inside of your skull and the surface of your
brain.
Clarification The hemorrhage (bleeding) often happens when an aneurysm bursts. An aneurysm is a bulge
in a blood vessel. It happens when a weak place in the blood-vessel wall stretches and fills
with blood.
Reassurance Seek urgent medical attention
Smoking and alcohol cessation
Control Bp by healthy diet (DASH diet) and exercise
Advise patients to rest for 2 to 4 weeks after discharge (in particular, no lifting) and slowly
return to normal life pace.
Advice
If untreated aneurysms are still present, advise the patient to:
Abstain from sexual activity, lifting, and straining, in order to avoid blood pressure swings,
until the aneurysm(s) is treated
Seek urgent medical attention if they experience sudden, severe headache or weakness;
numbness on one side of the body; slurred speech; double vision; vision loss; or difficulty
swallowing.
This ER case start ABC then complete CRAPRIOP
Use an ABC approach
Protect the airway with simple airway manoeuvres and adjuncts
Aim for a target oxygen saturation of 94% to 96% in acutely ill patients who are not at risk of
hypercapnia use of supplemental oxygen (target SpO2 >96%)
Use isotonic/normal saline Start with 3 L/day (isotonic/normal saline 0.9%)
Prescribing
As soon as the diagnosis is confirmed, referral for neurosurgeon
Use the Glasgow Coma Scale
Monitor ECG continuously for arrhythmias
Monitor BP continuously Maintain systolic blood pressure (SBP) <180 mmHg until occlusion
Monitor temperature continuously. Give routine antipyretic medication (e.g., paracetamol)
and apply cooling blankets to aim for normothermia
Referral Urgent for neurosurgery
CT brain
Coagulation profile
CBC
Investigations
Electrolyte à Hyponatraemia is the most common electrolyte abnormality in SAH.
Lumbar puncture à xanthochromia
ECG
Observation After discharge from hospital.
Treat hypertension and offer advice on smoking cessation according to national guidelines as
Plan/prevention these are the most important modifiable risk factors
See your doctor immediately or go to the emergency room if you have any of the following
signs and symptoms, which could indicate a more serious medical problem:
An abrupt, severe headache like a thunderclap
Headache with fever, stiff neck, confusion, seizures, double vision, numbness or weakness in
Conclusion any part of the body, which could be a sign of a stroke
Headache after a head injury
A chronic headache that is worse after coughing, exertion, straining or a sudden movement
New headache pain after age 50
if the pattern changes or your headaches suddenly feel different

16
 Headache
Benign intracranial hypertension
In idiopathic intracranial hypertension (IIH) there is unknown raised pressure within
the skull (increased intracranial pressure). Essentially, for some reason, there is too
Clarification much cerebrospinal fluid. The subarachnoid space that contains the CSF cannot
expand and, because of this, the pressure around the brain rises.
This raised pressure leads to the symptoms of idiopathic intracranial hypertension.
The cause is unknown but treatment available, treatment will reduce symptoms
Reassurance such as headaches.
Early treatment will prevent complication
Patients should be encouraged to maintain weight loss and a low-sodium diet. They
Advice
should notify their physician of any vision loss or unmanageable symptoms.
1st line
Acetazolamide: 500 mg orally twice daily, increase by 250 mg/day increments every
4 days according to response, maximum 4000 mg/day
2nd line
Furosemide: 20-40 mg orally two to three times daily
Prescribing
For persistent headache
Amitriptyline: 10-50 mg orally once daily at bedtime
**but will increase weight
Naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day
(maximum 2 days per week)
Referral for neurosurgery ( for cerebrospinal shunt) and ophthalmology (for
Referral
papilledema and loss of vision)
Visual field test
Dilated fundoscopy
Investigations Visual acuity
MRI brain
Lumber puncture à elevated: opening pressure
Patients with mild optic disc oedema and mild loss of vision followed every 6 months
loss of vision that is mild to moderate at the onset can be followed every 2 to 6
weeks
Observation severe loss of vision They should be followed daily to weekly until their condition
improves.
When the patient's condition becomes stable or improves, the examination intervals
are gradually extended
Plan/prevention
See your doctor immediately or go to the emergency room if you have any of the
following signs and symptoms, which could indicate a more serious medical problem:
- An abrupt, severe headache like a thunderclap
- Headache with fever, stiff neck, confusion, seizures, double vision, numbness or
weakness in any part of the body, which could be a sign of a stroke
Conclusion - Headache after a head injury
- A chronic headache that is worse after coughing, exertion, straining or a sudden
movement
- New headache pain after age 50
- If the pattern changes or your headaches suddenly feel different

17
 Dizziness Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of Allow pt to explain the chief complain
Clarify what you understood:
present • clarify what pt means exactly by dizziness
illness • Is it true vertigo (spinning) / light headaches(vague floating
sensation) / disequilibrium(unbalance) / presyncope(will faint)
Onset: (acute or chronic)
Course: constant or attacks (duration or frequency)
Timing and severity
Trigger factors (aggravating):
• Head movement
• Postural change (standing)
• Coughing or sneezing
• Decrease diet or sleep
• Stress or fatigue
• Auricle manipulation
• Valsalva maneuver
• Hyperventilation
• Explosion
Relieving factors
History of previous attacks
Head or neck trauma
Analysis of Recent hx of URTI or otitis media
chief Associated symptoms:
complain • Vertigo with fluctuating deafness, tinnitus, ear fullness, nausea
and vomiting = suggestive of meniere's disease.
• Ear pressure, hearing loss, increased with Valsalva maneuver =
suggestive of prelymphatic fistula of middle ear.
• Vertigo (severe or persistent for days followed by gradual
improvement over weeks) with history of upper respiratory
tract infection, gait instability, nausea, vomiting, lateralized falls
= suggestive of acute labrynthitis (vestibular neuritis).
• Progressive facial numbness, weakness = suggestive of acoustic
neuroma.
• Vertigo (positional and lasts for up seconds) with nausea,
vomiting and wakes the patient from sleep when turning over
in bed = suggestive of benign positional vertigo.
• Lightheadedness with hyperventilation = suggestive of
Psychosomatic.
• Pallor, fatigue, palpation, dizziness = suggestive of anemia

18
 Dizziness Hx
Red Flags:
• Vertigo e diplopia, dysarthria, weakness, numbness, confusion,
LOC, swallowing problem, seizures = suggestive of central causes
• Presyncope e nausea , vomiting, headache, sweating, tremor =
suggestive of hypoglycemia
• Presyncope e palpitation or chest pain = suggestive of valvular
heart disease or ACS
• post traumatic dizziness ( recent head trauma, injury, concussion)
• Early morning awake from sleep with vomiting, weight loss,
Analysis fatigue, poor appetite, diplopia = Brain tumors
of chief Risk Factors:
• Age: 50 and 70 years
complain • Female
• Menopause
• HTN
• Dyslipidemia
• Cardiovascular disease
• Obstructive sleep apnea or pulmonary disease
• Migraine
• Allergies
• Surgical procedure as cochlear implant or ear infection
Differentiate dizziness, vertigo, lightheadedness and presyncope.
1-Peripheral causes of vertigo
Ø Benign paroxysmal vertigo (Sudden vertigo positional change,
recurrent lasting minutes to hours, released if the pt motionless,
associated e nystagmus/nausea/ vomiting/loss balance) caused
by dislodged canaliths in the semicircular canals
Ø Meniere’s (Spontaneous episodes of vertigo associated with
Differential unilateral hearing loss, tinnitus, minutes to hours) caused by
Diagnosis excess endolymphatic fluid pressure in the inner ear.
Ø Vestibular neuritis( followed viral infection of inner ear) caused
For every
by inflammation of the vestibular nerve or labyrinthine organs,
Dx have at usually from a viral infection
least 1 Ø Labyrinthitis (spinning sensation, hearing loss )
questions 2-Central causes of vertigo:
Ø Vestibular migraine (visual flashes , vomiting, nausea ,
photophobia)
Ø Acoustic neuroma(headache, aural fullness, hearing loss,
tinnitus)
Ø Cerebrovascular disease as TIA or stroke (transient paralysis
,numbness, weakness, visual/speech change, LOC)
Ø Multiple sclerosis ( weakness or eye manifestation)

19
 Dizziness Hx

3-others:
Differential Ø Anemia (pallor, fatigue, palpation, dizziness)
Diagnosis Ø Metabolic: hypoglycemia, hyponatremia, hypoxia )
Ø Psychogenic : anxiety, hysterical, panic, somatization,
For every Dx hyperventilation
have at least 1 Ø Drugs: antihypertensive (diuretics), nitrates, insulin, oral
questions hypoglycemic, anticonvulsant, antidepressant,
antipsychotic, sedatives or alcohol
Medical: any chronic diseases
Surgical: any previous surgery (head or ear surgery)
Allergy
Past Hx Medication:
Use of any regular medications such as: antihypertensive,
sedatives, antihistamine, antibiotics, aminoglycosides,
quinine, anticonvulsants and antidepressant.
Same condition, autoimmune disease, malignancies, cardiac
Family Hx or psychiatric diseases or any chronic illness
• Marital status , relation with family members and
colleagues.
• Traveling , occupation
• If female patient : menstrual, obstetric and contraceptive
history
Psychosocial • If female or geriatric patient add abuse (physical, verbal
or sexual abuse )
• lifestyle (diet especially caffeine- exercise, stresses,
smoking or alcohol )
• Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

20
Dizziness Ex
Ø Vital signs: BP, Pulse, HR and rhythm
including blood pressure in sitting and standing (a drop in
Systolic Blood Pressure of as much as 20 mmHg or Diastolic blood
General pressure of up to 10 mmHg, or a rise of heart rate of up to 20 beats
per minute is indicative of orthostatic hypotension)
Ø Appearance: pallor
HINTS (head-impulse, nystagmus, test of skew) examination can
help distinguish a possible stroke (central cause) from acute
vestibular syndrome (peripheral cause)
Video: [Link]
Ø Eye: for nystagmus and papilledema.
Ø Ear:
• Otoscopic examination: to visualized the tympanic
membrane, cholesteatoma.
Special • Hearing assessment:
1. Weber test :finding normal
2. Rinne test: air conduction better than bone conduction.
Ø CVS: carotids for bruits, heart sounds or murmurs.
Ø CNS:
• cranial nerves, motor and sensory.
• Balance: gait, Romberg’s test and heal-toe test
• cerebellar signs
Ø Special test: Dix-Hallpike maneuver.

1
2

Positive if the manuver provokes paroxysmal vertigo and nystagmus

21
 ‫‪Dizziness‬‬

‫)‪CRAPRIOP for Management (BPPV‬‬

‫دوار الوضعة االنتيابي احلميد هو أحد األسباب األكثر شيوًعا للدوار‪ ،‬وهو اإلحساس املفاجئ بأنك‬ ‫•‬
‫تدور أو أن اجلزء الداخلي من رأسك يدور‪.‬‬
‫ويسبب دوار الوضعة االنتيابي احلميد نوبات قصيرة من الدوار تتراوح حدته من اخلفيف إلى‬ ‫•‬
‫الشديد‪ .‬وعادًة ما يكون تغيير وضع رأسك بطريقة معينة السبب وراء حتفيز هذه النوبات‪ .‬ومن‬
‫املمكن أن يحدث ذلك عندما متيل رأسك ألعلى أو ألسفل‪ ،‬أو عندما تستلقي‪ ،‬أو عندما تتقلب في‬
‫سا من وضع االستلقاء‪.‬‬‫الفراش أو تنهض جال ً‬
‫‪Clarification‬‬ ‫غالبًا ما ال يوجد سبب معروف لإلصابة مبتالزمة متلمل الساقني ‪.‬وهو ما يُعَرف بتململ الساقني‬ ‫•‬
‫مجهول السبب‬
‫عند وجود سبب معروف‪ ،‬غالبًا ما يرتبط دوار الوضعة االنتيابي احلميد بضربة طفيفة إلى شديدة‬ ‫•‬
‫في رأسك‪ .‬ومن األسباب األقل شيوًعا لدوار الوضعة االنتيابي احلميد ‪ ،‬االضطرابات التي تلحق‬
‫الضرر بأذنك الداخلية‪ ،‬أو نادًرا‪ ،‬الضرر الذي يحدث أثناء جراحة األذن أو لفترات طويلة على‬
‫ضا‬
‫ظهرك‪ ،‬مثل اجللوس على كرسي طبيب األسنان‪ .‬ارتبط دوار الوضعة االنتيابي احلميد أي ً‬
‫بالصداع النصفي‪.‬‬
‫ضا مزعجة‪ ،‬فإنه نادًرا ما يكون خطيًرا‪.‬‬ ‫على الرغم من أن دوار الوضعة االنتيابي احلميد قد يسبب أعرا ً‬
‫‪Reassurance‬‬ ‫و نادًرا ما يسبب مضاعفات‪ .‬من املمكن أن جتعلك الدوخة الناجتة عن داء دوار الوضعة االنتيابي‬
‫احلميد غير متزن‪ ،‬مما يجعلك أكثر عرضة للسقوط‪.‬‬
‫•‬ ‫‪Advise the patient to avoid provocative movement.‬‬
‫•‬ ‫‪Ask the patient to lie still in a darkened room and avoid head‬‬
‫‪movement if acutely vertiginous.‬‬
‫‪• Healthy diet and practice exercise.‬‬
‫‪• Educate about safety especially (falls, occupation, driving,‬‬
‫‪dealing with heavy machinery).‬‬
‫‪Advice‬‬ ‫‪Ø BPPV:‬‬
‫‪• bed rest‬‬
‫‪• Repositioning maneuver as modified Epley maneuver OR‬‬
‫‪modified semont maneuver.‬‬
‫‪Contraindication to Epley procedure (recent neck fracture or‬‬
‫‪instability, history of unstable carotid disease, recent retinal‬‬
‫) ‪detachment‬‬
‫‪Symptomatic relief medications:‬‬
‫‪Antihistamines as meclizine:‬‬
‫‪Betahistidene tablet 8 mg BID for 1 week‬‬
‫‪Inhibit vestibular organ receptors and prevent activation of vagal‬‬
‫‪Prescribing‬‬ ‫‪response.‬‬
‫‪To be taken for few weeks followed by gradual discontinuation.‬‬
‫‪Discuss Side Effects: dry mouth and sedation.‬‬
‫‪Antiemetic e.g. Prochlorperazine‬‬
‫‪Discuss Side Effects: Sedation‬‬

‫‪22‬‬
 Dizziness

Arrange for follow up or referral if indicated:

• neurologist if central cause,
Referral • cardiologist if cardiac cause,
• ENT if medical treatment fails,
• ER with red flags
Laboratory testing and imaging are not required and are
usually not helpful

Order required investigations as indicated:

Ø Patients with chronic medical conditions (e.g., diabetes
mellitus, hypertension) may require blood glucose and
electrolyte measurements.
Ø Patients with symptoms suggestive of cardiac disease
should undergo electrocardiography, Holter monitoring,
Investigations and possibly carotid Doppler testing
Ø Routine imaging is not indicated. However, any abnormal
neurologic finding, including asymmetric or unilateral
hearing loss, requires computed tomography or
magnetic resonance imaging to evaluate for cerebro-
vascular disease
Ø CBC
Ø Urine drug scan
Ø Audiogram
Observation/
Follow up appointment as needed
follow up
Plan/
prevention
Includes:
Ø Safety netting and when to return immediately (if SE of
medication or complication of vertigo)
Conclusion Ø Give reading educational materials (How to perform
Epley's exercise)
Ø Discuss health maintenance and age-appropriate
screening.

23
 Dizziness
Epley’s Manuver

Right

Left

This maneuver should be carried out three times a day. Repeat

this daily until you are free from positional vertigo for 24 hours.

24
Dizziness

25
 Stroke/TIA Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness Allow pt to explain the chief complain and Clarify what you understood
Course, onset and duration
SOCRATES for pain or weakness
Associated symptoms as (limb weakness, numbness or pain - facial weakness - speech
difficulties - syncope - dizziness - vision loss or blurring vision)
Previous attacks – action taken
TIA risk factors :
(HTN- DM – AS – AF – CHF - valvular heart diseases – cigarette smoking-alcohol abuse-
advanced age – hyperlipidemia – obesity - hypercoagulability – Inactivity - family history -
OCPS)
Differential diagnosis and exclude red flags :
-TIA (transient paralysis ,numbness, weakness one side of body - difficult talking-blindness-
dizziness – loss of consciousness)
-Stroke (paralysis ,numbness, weakness one side of body -difficult talking-blindness – loss
of consciousness for longer duration)
-Intracerebral hemorrhage (headache-weakness-confusion-paralysis)
Analysis -Migraine (throbbing pulsating headache- visual flashes ,vomiting, nausea, diplopia,
of chief dizziness , photophobia, phonophobia) episodes with triggers + respond to analgesics
-Hemiplegic migraine (migraine headache with tingling ,numbness and weakness one side
complain
of body) previous episodes + rare
-Seizures , epilepsy or post ictal (loss of consciousness –cyanosis –eye symptoms –
uncontrolled jerky movement of arms or legs – urinary or fecal incontinence - tongue or lip
pitting – drooling saliva)
-Post traumatic ( recent head trauma- injury- concussion)
-Brain tumors (early morning awake from sleep with vomiting- weight loss-fatigue- poor
appetite – diplopia)
- Meningitis or infection (fever–neck rigidity–vomiting-rash- impaired consciousness)
- Hypertensive encephalopathy (headache –vomiting-confusion-high blood pressure)
- Hypo or hyper glycaemia ( abnormal blood glucose level –impaired consciousness or
confusion )
-Others (vertigo –syncope –bell’s palsy –trigeminal neuralgia )
-Psychiatric causes (conversion – somatization ) in young + no Risk factors
- Risk assessment TIA : A age B blood pressure C clinical D duration D DM
- IF AF CHAD 2 score
Medical : any chronic diseases as risk factor or contraindication for fibrinolysis medication,
Sickle cell anemia.
Past Hx Surgical : any previous surgery-head surgery
Medication: Drug history and allergies, herbal drugs or blood transfusion or OCP
Vaccination
Family Hx Same condition, malignancies, psychiatric diseases or any chronic illness
Marital status, travelling and Lifestyle (diet - exercise – stresses – smoking or alcohol )
If female patient : (menstrual, obstetric and contraceptive history )
Psychosocial
If female or geriatric patient add abuse (physical, verbal or sexual abuse )
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

26
 Stroke/TIA Ex
General Vital signs + BMI
Look and Appearance
Ex is mostly normal in TIA
Focal exam: neurological examination for power, tone,
sensation, reflexes ,cranial nerves and meningeal signs if
Special suspected
- Fundoscopy examination and visual acuity
- lymph node, and ENT, CVS , and MSK examination
-Cardiac for heart sound and rhythm, carotid bruit

CRAPRIOP for Management (TIA)

‫النوبة العابرة عبارة انسداد قصير في الشرايني املغذية للدماغ غالبا بسبب تصلب الشرايني‬
‫نتيجة لتراكم الدهون فيها تنتج عنه جلطات صغيرة تدوم اعراضها لعدة دقائق بدون ترك‬
Clarification ‫ صعوبة في‬، ‫ او الساق او الذراع‬، ‫ أعراضها قد تكون ضعف أو تنميل في الوجه‬.‫أي تلف‬
.‫ دوار أو فقدان التوازن‬، ‫ صداع شديد بدون سبب واضح‬، ‫ فقدان مؤقت للبصر‬، ‫الكالم‬
Reassurance ‫ مع أهمية العالج والوقاية ملنع حدوث مضاعفات في الفترة القادمة‬،‫ال تسبب تلف دائم‬
Lifestyle modification:
Advice Decrease weight – healthy diet with salt restriction - practice
exercise – stop smoking and alcohol
First line : anti platelet therapy
- Aspirin: 75-300 mg orally once daily for two weeks Or
colpidogrel (Plavix): 75 mg orally once daily
Prescribing
- Statin: atorvastatin 40 – 80 mg orally once daily Or
Rosuvastatin 20- 40 mg orally once daily
- Start antihypertensive drugs if blood pressure >= 130/80
ACEI or ARABS or diuretics
Referral Referral to neurologist or ER with red flags And consider
referral to physiotherapy if needed.
Investigations Order appropriate laboratory tests, (CBC, FBS, coagulation PT
PTT INR , lipid, renal ,cardiac enzymes )
Order EKG, echo, carotid Doppler , CT or MRI brain
Observation/ After 1 week to check the results of ordered investigations
follow up
Plan/prevention Control chronic diseases, wt loss and smoking cessation
Check understanding of patient.
Next appointment follow up ,safety netting and when to
return back immediately (if SE of medication or complication
Conclusion
of TIA)
Opportunistic chance for health education (vaccination and
screening)
27
 Stroke
Stroke is defined as an acute neurological deficit lasting more than 24 hours and caused by cerebrovascular etiology.
Ischemic stroke 87% Hemorrhagic stroke 13% Signs & Symptoms:
- Unilateral weakness or numbness
Causes: Causes:
(face, arm or leg)
- Thrombosis - High blood pressure
- Slurred speech, confusion or
- Embolism - Aneurysm
difficulty understanding speech
Heart: AF, valvular heart disease - Anticoagulant medication
- Double vision, loss of vision in one
or DVT - Cerebral amyloid angiopathy
eye or in one half of the visual field
Carotid stenosis - Trauma
- Imbalance, dizziness or a loss of
- Systemic hyperperfusion
coordination (ataxia)
Investigations: - Sudden decrease LOC
• non-contrast CT head (best initial) but MRI most accurate - Severe headache , nausea ,
• serum glucose vomiting (hemorrhagic stroke)
• serum electrolytes
• serum urea and creatinine
• Liver function tests
• cardiac enzymes
• FBC
• ECG F A S T
• Coagulation profile
• Serum toxicology screen (may consider)

28
 Management
Initial:
1st line: stabilization and referral to hyperacute or acute stroke unit within 4 hours of presentation to hospital
-ABC
• Consider endotracheal intubation for patients who are unable to protect their airway or those presenting with a depressed
level of consciousness (Glasgow Coma Scale score ≤8)
• Give supplemental oxygen only if oxygen saturation drops below 93%. If oxygen is started, maintain a target range of 94% to
96%.
Acute: confirmed intracerebral hemorrhage/ ischemic :
•1st line: supportive care plus monitoring Administration of r-tPA
-Level of consciousness: using the Glasgow Coma Scale. Inclusion Criteria Exclusion Criteria
In patients with decreased level of consciousness or coma, • Age 18 years or • intracranial hemorrhage
urgently exclude hemorrhage and stroke mimics such as seizures. older • Subarachnoid hemorrhage
-Blood glucose: Maintain between 4 and 11 mmol/L • Diagnosis of an • Active internal bleeding
-Blood pressure ischemic stroke • Recent intracranial or intraspinal surgery
-Hydration with neurologic • Serious head trauma
deficit • Intracranial neoplasms, or aneurysms)
-Temperature (Give an antipyretic)
• Treatment within • Acute bleeding diathesis
-Cardiac rate and monitoring
4.5 hours • Uncontrolled hypertension (systolic >180
-Intracranial pressure & diastolic >110 mm HG
-Seizures
Do not start statin treatment in patients with spontaneous ICH unless required for other indications
Ischemic stroke Hemorrhagic stroke
1-presentation within 4.5 hours, thrombolysis not •1st line: supportive care plus monitoring
contraindicated, AND intracranial hemorrhage has been
excluded by imaging: •Plus: immediate referral for neurosurgery assessment
• 1st line: supportive care plus monitoring
•Adjunct: rapid blood pressure control
• Plus: alteplase (0.9mg/kg IV. Give 10% as IV bolus over 1 min -Aim for a systolic BP target of 130 to 140 mmHg within 1 hour
then remaining as a continus infusion over 60 mins) of starting treatment and maintain this BP for at least 7 days.
- Don’t delay unless you suspect CI
- Exclude hypoglycaemia, hyperglycaemia before giving •Adjunct: urgent reversal of anticoagulation
thrombolysis; hypoglycaemia is a stroke mimic
and hyperglycaemia is associated with intracerebral
Anticoagulant Reversal
bleeding and worse clinical outcomes.
- Consider in: Warfarin (and have prothrombin complex
• Pt <80 elevated [INR]) / vitamin concentrate (4-factor)
• NIHSS < 25 K antagonist + IV vitamin K (
• Nondiabetic with a previous stroke phytomenadione)
• Adjunct: mechanical thrombectomy
• Plus: antiplatelet agent (Aspirin 300mg or clopidogrel 75mg Dabigatran Idarucizumab
if allergic po od)
- Delayed 24hrs after alteplase Factor Xa inhibitor Prothrombin complex
- Delayed if there is active bleeding concentrate (4-factor)
- Continue daily until 2 weeks
• Adjunct: venous thromboembolism prophylaxis plus early •Adjunct: venous thromboembolism prophylaxis plus early
mobilisation mobilization
• Plus: high-intensity statin ( atorvastatin 20-80mg po od ) -Give intermittent pneumatic compression within 3 days of
-start after 48hrs admission for the prevention of deep venous thrombosis and
Continue in pt who are already receiving statin pulmonary embolism in immobile patients. Give continuous
2-presentation after 4.5 hours OR thrombolysis treatment for 30 days or until the patient is mobile or
contraindicated: discharged, whichever is sooner.
•1st line: supportive care plus monitoring
•Adjunct: mechanical thrombectomy helpful up to 6- -Help the patient to sit out of bed, stand, or walk as soon as
12 hrs after stroke their clinical condition permits as part of an active
•Plus: antiplatelet agent management programm in a specialist stroke unit.
•Adjunct: venous thromboembolism prophylaxis plus
early mobilization
•Plus: high-intensity statin

29
 TIA
sudden-onset, focal neurological deficit that has completely resolved within 24 hours of onset and cannot
be explained by another condition such as hypoglycemia.

Treat all patients with suspected TIA as a medical emergency.

The risk of recurrent stroke is up to 10% in the first 7 days following a TIA.

Admit any patient with suspected stroke directly to a hyperacute (or acute, depending on availability) stroke
unit within 4 hours of presentation.

Investigations:
• serum glucose
• serum electrolytes
• FBC
• Coagulation profile
• ECG
• Consider CT scan : may show hemorrhage
Do it only when suspect an alternative DDx
Management
Initial:
1- Give a loading dose of aspirin immediately (if not contraindicated) to any patient with suspected TIA
2- Refer them immediately to a TIA clinic (or suitable alternative) for specialist assessment and
investigation to be seen within 24 hours of onset of symptoms.
Give clopidogrel as an alternative to aspirin in patients who are allergic or intolerant to aspirin.
Do not use scoring systems, such as ABCD2, to inform the urgency of referral. Consider all people with
suspected TIA to be at high risk of having a stroke.

Acute: after the diagnosis of TIA is confirmed

1- Start (clopidogrel 75mg po od) immediately (Clopidogrel replaces aspirin for long-term secondary
prevention).
-Continue aspirin 75mg po od (maintenance dose) for long-term secondary prevention in people who are
allergic to or cannot tolerate clopidogrel.
-Give a proton-pump inhibitor to anyone with dyspepsia associated with aspirin use.

2- Start high-intensity statin therapy (atorva 20-80mg po od) immediately, unless contraindicated, in all
patients (independent of baseline LDL ) for long-term secondary prevention.
Use an alternative statin at the maximum tolerated dose if high-intensity statin therapy is unsuitable or not
tolerated.

3- Give an anticoagulant with a rapid onset of action:

- LMEH
OR
- direct thrombin inhibitor of factor Xa inhibitor in pt with non valvular Afib
If not contraindicated, to patients with atrial fibrillation as soon as intracranial bleeding has been
excluded.

30
 Dementia Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of present
Chief complain (open question)
illness
Onset – course –duration – severity – recent or remote memory-
intermittent or constant, aggravating and relieving factors,

Associated symptoms as (agitation - concentration–language-

hallucination – delusions-impaired daily activity-judgment-personality
changes )

Previous attacks – Action taken

Ask for specific symptoms:

Progressive- gradual memory loss, forgetting keys, misplacing objects,
difficulty in learning and retaining new information, performing complex
tasks, solving simple problems and expressing self, getting lost in familiar
places and wandering, irritability, and apathy: (Alzheimer's' disease).
Acute onset- fluctuating level of consciousness –loss of orientation –
recent surgery or infection as UTI or pneumonia -fever – recent
hospitalization (Delirium).
Analysis of Chorea, behavioral disturbance, and executive impairment: (Huntington's
chief disease).
Ataxia, urinary incontinence, dementia: (Normal pressure
complain hydrocephalus).
Visual hallucinations, parkinsonism, fluctuating alertness, and falls: (Lewy
body dementia).
Sudden or gradual deterioration in memory, motor and sensory functions,
history of cerebrovascular event TIA or stroke –HTN (vascular dementia).
Depressed mode and social isolation (Depression).
Risk factors
Old age, family history of dementia; personal history of cardiovascular
disease, cerebrovascular disease, diabetes, or midlife obesity; use of
anticholinergic medications; nutritional deficiencies, and lower education
level.
Red flags
Brain tumor ( weight loss-fatigue- poor appetite – headache awake from
sleep with early morning vomiting – diplopia )
Brain infection as meningitis ( fever – projectile vomiting – headache –
neck rigidity – rash )
Head trauma

31
 Dementia Hx
Medical, any chronic diseases (Dm, HTN, cerebrovascular – CVS-
neurological diseases, Vitamin B12 deficiency)
Surgical( Any previous surgeries, head surgery, gastric surgery)
Past Hx Allergy
Medication sedatives, antihistamines, antidepressants, narcotic
analgesics, anticonvulsants or sleeping pills.
substance abuse (IV drug or alcohol abuse) and herbal drugs
( Same condition, Alzheimer - malignancies, psychiatric or any chronic
Family Hx illness)
Marital status, traveling, occupation, relation with family members and
colleagues
Smoking: alcohol: type and frequency
Screening: depression and anxiety
Explore possibilities of caregiver and/or family abuse: untreated
Psychosocial physical conditions, over or under-medication, changes in behavior in
the elder, frequent arguments between the elder and the caregiver,
caregiver not allowing interviewing or assessing the elder alone, history
or signs of unexplained injuries, unsuitable clothing, sudden significant
changes in the financial status of the elder
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
Examination
Ask patient permission to start examination, explain what to examine
and ensure privacy.
*Hand wash
General *Vital signs (temp –blood pressure –pulse ) and BMI
* General examination look and appearance (hygiene – nutritional status
)
-Complete neurological examination
-Fundoscopy examination and visual acuity
- Lymph node, and ENT hearing, CVS, and MSK examination (to R/o other
Special diseases eg Parkinsonism .
- auscultation heart and lung
* perform special test (mini mental test – clock draw test, and cognitive
tests[MMSE, Mini Cog. Montereal Cognitive Assessment])
Order appropriate laboratory tests, (CBC, FBS, coagulation profile, TSH,
Investigations vitamin d, vitamin b12, VDRL, lipid profile, renal, and liver enzymes)
*Order CT or MRI brain

32
 Dementia

CRAPRIOP (Alzheimer’s disease)

Alzheimer’s disease is a brain disorder that slowly destroys
memory and thinking skills and, eventually, the ability to carry
out the simplest tasks. People with Alzheimer’s also experience
Clarification changes in behavior and personality.
‫مرض الزهامير هو مرض انحاللي عصبي يسبب‬. ‫مرض الزهامير ليس جزء طبيعي من الشيخوخة‬
.‫فقدان خلاليا الدماغ مما يؤدي الى مشاكل في الذاكرة والتفكير والسلوك‬
medical management can improve the quality of life for
individuals living with Alzheimer’s disease.
There is currently no known cure for Alzheimer’s disease.
Treatment addresses several areas:
Reassurance Helping people maintain brain health.
Managing behavioral symptoms.
Slowing or delaying symptoms of the disease.
‫ ولكن العالج املتاح يعطى للمحافظة على استقرار‬،‫ال يوجد عالج شافي يعيد للمريض ذاكرته‬
. ‫ أي لإلبطاء من تفاقم املرض‬،‫وضع املريض ألكبر مدة ممكنة‬
occupational therapy – mind stimulating activities such as puzzles, word
games, indoor gardening, and baking – cognitive stimulation therapy
-safety environment (locks or rings on the door - driving- - wear
Advice Bracelet/necklace/card to inform personal and caregiver contact data)
- healthy lifestyle (adequate sleep - healthy diet - practice exercise) -
patient support group and family support.

Management of any underline and coexisting diseases

1-cholinesterase inhibitors:
-Rivastigmine: 1.5mg orally twice per day for 2 weeks then increase dose
1.5 mg every 2 weeks – maximum dose 12 mg per day
–Donepezil (Aricept): 5 mg orally at bedtime then 10 mg after 4-6 weeks

2- N-methyl – D-aspartate (NAMDA): for moderate to severe

Prescribing Memantine 5 mg daily –titrate up each week by 5 mg twice daily-
maximum dose 20 mg twice daily

3- symptomatic treatment is needed to manage such as:

Behavioral/psychiatric treatment: e.g., agitation by atypical
antipsychotic, anticonvulsant, or benzodiazepines
Treatment of depression: SSRIs, SNRIs, or other (bupropion or
mirtazapine)
Treatment of insomnia: alprazolam or trazodone

33
 Dementia

Referral to neurologist or ER with red flags

Referral And consider referral to physiotherapy or psychiatry if needed.
Investigations Mentioned above
Observation/ Next appointment follow-up, safety netting and when to return
immediately (if SE of medication or complication of dementia)
follow up
Opportunistic chance for health education (vaccination and
Plan/prevention
screening
Conclusion

Non-reversible dementia:
o Alzheimer disease (AD)
o Vascular dementia
o Parkinson disease dementia (PDD)
o Dementia with Lewy bodies (DLB)
o Frontotemporal dementia
o Huntington’s disease
o Cortical-Basal Ganglionic Degeneration (CBGD)
Differential o Primary AIDS encephalopathy
o Post traumatic dementia
Diagnosis
Reversible dementia:
Neurosurgical: (Normal Pressure Hydrocephalus (NPH)
Nutritional: (Vitamin B12 deficiency o Folate deficiency)
Alcoholism
Endocrine and Metabolic disorders: (Hypothyroidism &
Hyponatremia)
Psychiatric: (Severe depression (pseudodementia))
Sleep disorders: (Obstructive sleep apnea o Narcolepsy)
Others: (Vasculitis, infections)

34
Mini-Cog Test

35
 MMSE

Mini-Mental State Examination (MMSE)

Patient’s Name: Date:

Instructions: Ask the questions in the order listed.

Score one point for each correct response within each question or activity.

Maximum Patient’s
Score Score Questions

5 “What is the year? Season? Date? Day of the week? Month?”

5 “Where are we now: State? County? Town/city? Hospital? Floor?”

The examiner names three unrelated objects clearly and slowly,then asks the
3 patient to name all three of them. The patient’s response is used for scoring. The
examiner repeats them until patient learns all of them, if [Link] of trials:
“I would like you to count backward from 100 by sevens.”(93,86,79,72,65,…)
5 Stop after five answers.
Alternative:“Spell WORLDbackwards.”(D-L-R-O-W)
3 “Earlier I told you the names of three [Link] you tell me what those were?”

Show the patient two simple objects,such as a wristwatch and a pencil,and ask
2
the patient to name them.
1 “Repeat the phrase:‘No ifs, ands, or buts.’”

“Take the paper in your right hand,fold it in half,and put it on the

3
floor.” (The examiner gives the patient a piece of blank paper.)
1 “Please read this and do what it says.”(Written instruction is“Close your eyes.”)

“Make up and write a sentence about anything.”(This sentence must contain a

1
noun and a verb.)
“Please copy this picture.”(The examiner gives the patient a blank piece of paper
and asks him/her to draw the symbol [Link] 10 angles must be present and two
must intersect.)
1

30 TOTAL

36
 MMSE

Instructions for Administration and Scoring of the MMSE

Orientation (10 points):
• Ask for the [Link] specifically ask for parts omitted (e.g.,“Can you also tell me what season it is?”).One
point for each correct answer.
• Ask in turn,“Can you tell me the name of this hospital (town, county, etc.)?”One point for each correct
answer.

Registration (3 points):
• Say the names of three unrelated objects clearly and slowly, allowing approximately one second for each.
After you have said all three,ask the patient to repeat [Link] number of objects the patient names
correctly upon the first repetition determines the score (0-3). If the patient does not repeat all three
objects the first time, continue saying the names until the patient is able to repeat all three items,up to six
[Link] the number of trials it takes for the patient to learn the [Link] the patient does not
eventually learn all three,recall cannot be meaningfully tested.
• After completing this task,tell the patient,“Try to remember the words,asI will ask for them in a little while.”

Attention and Calculation (5 points):

• Ask the patient to begin with 100 and count backward by [Link] after five subtractions (93,86,
79,72,65). Score the total number of correct answers.
• If the patient cannot or will not perform the subtraction task,ask the patient to spell the word“world”
backwards. The score is the number of letters in correct order (e.g.,dlrow=5, dlorw=3).

Recall (3 points):
• Ask the patient if he or she can recall the three words you previously asked him or her to [Link]
the total number of correct answers (0-3).

Language and Praxis (9 points):

• Naming:Show the patient a wrist watch and ask the patient what it [Link] with a pencil. Score one
point for each correct naming (0-2).
• Repetition: Ask the patient to repeat the sentence after you (“No ifs,ands,or buts.”).Allow only one trial.
Score 0 or 1.
• 3-Stage Command:Give the patient a piece of blank paper and say,“Take this paper in your right hand,fold
it in half, and put it on the floor.”Score one point for each part of the command correctly executed.
• Reading:On a blank piece of paper print the sentence,“Close your eyes,”in letters large enough for the
patient to see clearly. Ask the patient to read the sentence and do what it says. Score one point only if the
patient actually closes his or her [Link] is not a test of memory,so you may prompt the patient to “do
what it says”after the patient reads the sentence.
• Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not
dictate a sentence; it should be written spontaneously. The sentence must contain a subject and a
verb and make sense. Correct grammar and punctuation are not necessary.
• Copying: Show the patient the picture of two intersecting pentagons and ask the patient to copy the
figure exactly as it is. All ten angles must be present and two must intersect to score one point. Ignore
tremor and rotation.

37
 MMSE

Interpretation of the MMSE

Method Score Interpretation

Single Cutoff <24 Abnormal
<21 Increased odds of dementia
Range
>25 Decreased odds of dementia
21 Abnormal for 8th grade education
Education <23 Abnormal for high school education
<24 Abnormal for college education
24-30 No cognitive impairment
Severity 18-23 Mild cognitive impairment
0-17 Severe cognitive impairment

Sources:
• Crum RM,Anthony JC,Bassett SS,Folstein [Link]-based norms for the mini-mental state examination by age and educational level.
JAMA.1993;269(18):2386-2391.
• Folstein MF,Folstein SE,McHugh PR.“Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J
Psychiatr Res. 1975;12:189-198.
• Rovner BW,Folstein [Link]-mental state exam in clinical practice. Hosp Pract. 1987;22(1A):99,103, 106, 110.
• Tombaugh TN,McIntyre [Link] mini-mental state examination: a comprehensive review. JAm Geriatr Soc. 1992;40(9):922-935.

38
Facial Palsy VII Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Unilateral facial weakness.
Allow patient to explain the chief complain
illness
Clarify what you understood
Course, onset and duration
SOCRATES
• Unilateral facial weakness:
LM neurone type :weakness of whole side of upper facial muscles.
UM neurone lesions: less drop of the mouth while
• Pain around the ear, altered taste and lacrimation.
• Feeling of facial numbness that precedes the onset of facial weakness.
Upper facial muscles are not included.
• Fever, recent infection or trauma.
Associated symptoms (DDx)
Difficulty speaking, dribbling or drooling, food collecting between the
cheeks and gums, dry eye, excessive tears on the affected side, hyperacusis

Differential diagnosis:
• Acute unilateral facial weakness started suddenly after local anaesthesia
during dental procedure (complication of an inferior alveolar nerve block
anaesthesia).

Analysis of • Acute painful unilateral facial weakness, history of vesicles involving the
chief hard palate, or anterior two thirds of the tongue, severe otalgia and/or
complain vertigo at the onset of facial weakness is suggestive of Ramsay-hunt
syndrome.

• A prolonged, steadily progressive weakness is suggestive of a tumour

(such as a parotid tumour) compressing the facial nerve.

• Loss of facial sensation (trigeminal dermatomes) or gradual ipsilateral

hearing loss (eighth cranial nerve) should raise suspicion of an underlying
cerebellopontine angle tumour.

• Facial nerve dysfunction due to diabetes mellitus, ear infection or URTI.

• Weakness that occurs over days to weeks is suggestive of

cholesteatoma.

• Trauma to the temporal bone or stylomastoid foramen may cause

• Damage to the facial nerve (facial trauma).

39
Facial Palsy VII Hx

• History of tick bite in an endemic region or other clinical features of

Lyme disease (rash, arthritis, vertigo, or hearing loss).

• People with HIV infection may develop other conditions that can cause
facial nerve palsy, such as herpes zoster infection and meningeal
lymphomatosis.

• Combination of facial nerve palsy, anterior uveitis which can cause eye
pain, mild blurring of vision, photosensitivity and enlargement of the
parotid gland is suggestive of Heerfordt's syndrome.
Analysis of
chief • Swelling of the face, oral mucosa, gums, and lips, which is associated with
complain recurrent facial nerve palsy is suggestive of Melkerson-Rosenthal
syndrome
Red Flags:
• Gradual onset over >2 weeks → mass lesion

• Forehead not involved→ Central Nervous System cause (supranuclear

lesion)

• Bilateral involvement autoimmune Polyneuropathy, Lyme Disease 4.

Hearing Loss and Vestibular Symptoms or Ataxia → Acoustic Neuroma
Medical & Surgical:
Previous bells palsy, diabetes mellitus, hypertension, Sjogren's syndrome,
Past Hx systemic lupus erythematosus or vasculitis.
Allergy
Medication
Bells palsy (In some patients Bell's palsy may run in the family with reports
Family Hx of autosomal dominant inheritance)
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
ICEE Concerns: is there anything you are worried about?
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

40
Facial Palsy VII Ex

Vital signs and Appearance.

Head and neck:

• The external ear, TM, ear canal → rule out infection, cholesteatoma,
rash (Ramsay hunt syndrome)
• Oropharynx → rule out herpes simplex
• Parotid Gland for any masses →→ rule out tumor

Complete neurological exam

• Cranial nerves

• Cranial nerve VII:

o Facial creases and nasolabial folds disappear

o The forehead unfurrows
o The corner of the mouth droops
o The eyelids will not close, and the lower lid sags; on attempted
General closure, the eye rolls upward (Bell's phenomenon)
o Gait will be normal.
o Extremity motor and sensory examination → will be normal

Skin

• Vesicular rash⇒ rule out Herpes Zoster

• Ramsay Hunt Syndrome
• Erythema Migrans rule out Lyme Disease

• Lab testing is not regularly indicated – look for DM if suspected

• MRI for head only indicated in patients with gradual onset (within
Investigations 2weeks), forehead sparing, bilateral palsies, if no improvement
within the first two or three weeks after onset of symptoms.

41
 Facial Palsy VII

CRAPRIOP for Management

Bell's palsy is defined as an acute peripheral facial nerve palsy of
unknown cause. It is typically presents with sudden onset (usually over
hours) of unilateral peripheral nerve palsy (Lower Motor Neurone)
Clarification involving isolated facial nerve (7th/VII carinal nerve). Recently, research
attention has focused on infection with herpes simplex virus type 1
(HSV-1) as a possible cause.
Diagnosis is usually clinical.
There is no preference for either side of the face, and the peak
Reassurance incidence was noted in the 40s. It is expected in diabetes and pregnant
women or post-partum three times risk. If left untreated, 85% of
patients will show partial recovery within three weeks of onset.
Eye care: Use ophthalmic lubricants. Preservative-free teardrops during
the daytime while a viscous ointment is preferred overnight. Appose
their eyelid overnight with microporous tape.
Advice Physical and Occupational Therapy: Facial massage and exercise can
maintain facial muscle tone and bulk, and may help prevent permanent
contractures, especially if symptoms persist more than 4-6 weeks.
Bell's palsy with the typical presentation, → start steroid orally to
improve facial nerve inflammation within three days of the
presentation. Table 2 details grades of Bell's palsy.

In severe presentation of palsy → antiviral initiation according to the

House Brackmann (H-B) grade 4 or higherin (table 2)

All patient needs eye care to prevent complications as corneal injury

Prescribing
Management plan includes:

• Prednisone 60 mg tab one time per day for one week (no need for
tapering). (Grade 1A).

• Either acyclovir 400 mg 5 times per day for seven days or

valacyclovir 1 g 3 times per day for one week (Grade2C).

In cases of atypical presentation of the facial nerve, palsy → treat the

underlying cause.

42
 Facial Palsy VII

Arrange Referral to subspecialty clinic as needed.

a. Refer urgently to neurology or ENT if there is:

• Recurrent Bell's palsy.
• Bilateral Bell's palsy.

If the paralysis shows no sign of improvement after one month, or

there is suspicion of a serious underlying diagnosis refer urgently to
Referral ENT (cholesteatoma, parotid tumour, malignant otitis externa).

If there is residual paralysis after six to nine months, particularly if this

paralysis is complete, consider referral to a plastic surgeon with special
interest in facial reconstructive surgery

Urgent referral to ophthalmologist if the cornea remains exposed after

attempting to close the eyelid of affected side.

neurology referral (MRI) if indicated

• Lab testing is not regularly indicated – look for DM if suspected

Investigations • MRI for head only indicated in patients with gradual onset (within
2weeks), forehead sparing, bilateral palsies, if no improvement
within the first two or three weeks after onset of symptoms.
• 2-3 weeks from the presentation to assess the improvement,
monitor for ocular complications

• If incomplete recovery within 3 to 4 months, consider botulinum

Observation/ toxin injection for cosmetic appearance and referral to
follow up multidisciplinary facial nerve clinic

• Approximately 80 to 85 percent experience complete recovery of

facial nerve function by six months. The main risk factor for
incomplete recovery is the severity of weakness at the time of
presentation.
Plan/prevention
Conclusion Includes Safety netting

43
 Facial Palsy VII

House Brackmann (H-B) grades

Good references:
[Link]

[Link]

44
 Epilepsy Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness
Analysis of chief Before the spell ?
complain • Did he experience lack of sleep or unusual stress or trauma?
3 PARTS • Were he sick recently?
• Did he take any kind of medication, including over-the-counter
Before medicines, alcohol, or illegal drugs?
• What was he doing immediately before the event (for instance, lying
down, sitting, standing, getting up from a lying position, heavy
exercise)?
During the spell?
• What time of day was it?
• Was he just waking up or falling asleep?
• How did it begin?
During • Was there a warning?
• Did he eye, mouth, face, head, arms, or legs move abnormally?
• Was you able to talk and respond appropriately?
• Dose he lose control of his bladder or bowels?
• Dose he bite his tongue or the inside of cheeks?
After the spell?
• Were he confused or tired?
After • Could he speak normally?
• Dose he have a headache?
• Dose he have muscles ache?
stress – noise – missed meals – fatigue- noise –lack of sleep –excess use
Risk Factors
of electronics and relieving factors
Brain tumor ( weight loss-fatigue- poor appetite – headache awake
Red Flags from sleep with early morning vomiting – diplopia )
Brain infection as meningitis ( fever – projectile vomiting – headache –
neck rigidity – rash )
Medical
Surgical
Past Hx
Allergy
Medication (OCPs + Drug-Drug Interaction) and vaccination
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

45
Epilepsy Counselling
Introduce yourself and establish good rapport.

-ldeas, concerns, and expectations (ICE)

• Newly diagnosed epileptic

• Epileptic non-compliant due to medication side effects
• Pre-employment counselling,
Ask • Epileptic who wants to drive
• Pre-marital counselling).

Other medical problems.

Medications and compliance.
Social history: age, marital status, smoking, alcohol, driving, occupation.
Knowledge about epilepsy "It is a common disorder (1 in every 100 people),
that runs in families, in which a person is prone to have recurring seizures. A
minor fault, in the complex electrical circuits in the CNS for an unknown
reason, results in brief brain dysfunction. The various symptoms depend on
Advise what part of the brain is affected. Seizures can range from generalized
seizures to partial ones“

"As your doctor, I think it's very important for you to know that most patients
with epilepsy can achieve complete seizure control and lead a normal life
(marry, have normal sexual life, and have children)".
-Compliance: "Take your medication regularly. If you suddenly stop them this could
precipitate a severe fit".
-Side effects: "If you get fever, rash, mouth ulcers, bruising or bleeding please contact
Medications
your physician". –
Avoid precipitating factors (fatigue, physical exhaustion, stress, sleep deprivation,
hunger, flashing devices as television and cinema screens
Inform the driving licensing Authority: "You will not be able to drive till you are fit free for
Driving
a period of 1 to 2 years."
And
"People with epilepsy can hold down most jobs except that they should not operate
occupation
heavy machinery because the medications commonly cause drowsiness".
"Avoid potentially dangerous sites or activities when alone (kitchen, bathtub)".
Home
"Please do not lock bathroom doors".
"Avoid swimming, cycling, or rock climbing when alone".
Sport "Avoid boxing". "You can enjoy playing football".
"Wear an epileptic card or bracelet.
Some antiepileptics may reduce the efficacy of oral contraceptive pills.
You will need dual contraceptive methods (Mirena intra-uterine device (IUD) or
injectable are more suitable)
Female f you wish to get pregnant, discuss this with your doctor first.
You will need prenatal folic acid supplements to prevent back bone(and spinal cord)
anomalies (neural tube defects) and prophylactic vitamin K to prevent neonatal
bleeding".

46
Epilepsy Counselling
Re-explore ideas, concerns and expectations.
Assess Level of understanding.
Knowledge about red flags and precautions to take.
Grand mal.
• Don’t restrain convulsion movements
• Don’t place anything in mouth
• Don’t cover with blankets, don’t move to another place
• Position on side during clinic phase, wipe away froth
During • From mouth to help airway. Take, away items that could cause
attack injury
• Allow patient to rest post seizure.

Myoclonic: remove objects which may cause injury

Absence : don’t try to alert patient (useless)

• Major attack does not stop as anticipated
• Duration >5 minutes
Status
epileptics
• Recurrent attacks with no consciousness in between
• Call ambulance
• Keep rectal valium at home
Let share a plan which is suitable for helping you
Ensure compliance and regular follow up
Assist Ensure safe environment during attack.
Inform a responsible person at work or school
Medication name and dose in case of ER
-Follow up and monitor drug levels.
-Invite the patient to bring close relatives, friends or colleagues to
be educated about dealing with him or her in case he or she
develops a fit.
-When it lasts more than 5 minutes with no consciousness between
attacks this is called status epileptics. You will need a suppository to
Arrange stop it and then you have to be taken immediately to the
emergency"
Review of ongoing treatment by a specialist at least annually BMJ
-Anticipate complications, safety netting, red flags.
-Brief assessment of underlying conditions, age-appropriate
screening.
-Give away reading material if available.

47
 Tremor Hx

Introduce yourself and establish good rapport.

Chief Complain (Open Question)

Hx Of Present Identify The Complaint (What Do You Mean By Tremor?)
Illness Allow Patient To Explain The Chief Complain
Clarify What You Understood
• Onset (Gradual Or Sudden),
• Character (Visible Or Only Sensation Of Tremor, Resting Or With
Movement)
• Duration and Onset Of Worsening Of The Tremor
• Part Of Body Involved (Neck, Hand, Head)
• Symmetry (Symmetrical Or Asymmetrical),
• Relieving Or Aggravating Factors
• Clarifies If Tremor Occurs During Rest Or Activity (Rest)
• Difficulty Performing Specific Tasks Due To Tremor (Writing)
• Change In Gait – Slowing, Fewer Steps, Less Arm Swing
• Need For Assistive Devices For Ambulation
• Difficulty With Fine Motor Skills
• Posture Changes
• Difficulty Initiating Movement
• Difficulty With Short Term Memory
Analysis Of Chief
Complain Differential Diagnosis
• Sweating, palpitations, weight loss (Hyperthyroidism).

• Excessive worries, poor concentration, fatigue, disturbed sleep,

irritability (Generalized Anxiety Disease).

• Coarse resting tremors, pill-rolling movements suggestive of

Parkinson diseases.

• Wing-beating, resting tremor suggestive of Wilson's disease.

• Coarse, slow tremor that appears both in rest and with movements
suggestive of Rubral tremor.

• Tremors that decrease by distraction suggestive of Psychogenic

causes.

• Tremor that decrease with alcohol intake suggestive of Familial

causes.

• Immediate limb jerk after standing suggestive of Orthostatic tremor.

48
 Tremor Hx & Ex

Medical & Surgical:

Cerebellar disease, Parkinson, Diabetes Mellitus, Hypertension, thyroid
Head trauma, Multiple Sclerosis, brain tumour.
Past Hx
Medication
Lithium, Tricyclic antidepressant toxicity, Thyroxine, Ventolin, OTC.
Allergy
Similar problem in the family → Familial tremor
Family Hx
Any neurological disease.
Marital Status
Smoking: Type And Frequency
Psychosocial
Alcohol and drug abuse.
Screening: Depression And Anxiety
Ideas: What Do You Think You Might Have?
Concerns: Is There Anything You Are Worried About?
ICEE
Expectation: Is There Anything You Want Me To Do For You?
Effect: Does This Affect Your Life? How?
Systemic Review
Conclusion

Examination
Measures orthostatic changes – comments on hypotension
Vital Signs Inspects for masked face (none)
Comments on stooped posture
Inspection Comments on presence of resting tremor
Comments on altered speech
Motor Examination
tone in UE– comments on presence of cogwheeling
Tests for essential tremor, likely not present
Tests for intent tremor, likely not present

Sensory Examination
Tests reflexes (normal)
Neurological States that a sensory examination should be performed

Gait Examination
Evaluates patient getting up from chair, comments on bradykinesia
Comments on shuffling gait
Comments on stability of gait
Comments on festinating gait and lack of arm swing
CBC, TSH, Blood glucose , LFT and basic metabolic panel.
Investigations + See next pages

49
 Tremor

CRAPRIOP for Management

Tremor is a involuntary movement of a body part.

The most common tremors are physiologic tremor, essential tremor,

and parkinsonian tremor, which all are more common in older age.

Essential tremor is the most common pathologic tremor, which affects

0.4% to 6% of the population.

Tremor is the presenting feature in more than 70% of patients with

Clarification Parkinson's disease.

Other less commonly encountered tremors include cerebellar, dystonic,

and drug- or metabolic-induced. Categorizing the tremor is the first step
in evaluating a patient with tremor.

Resting tremors affect a body part that is completely supported against

gravity and is relaxed. This tremor is usually unilateral, appears at rest,
and fades away with voluntary movement.

It is the most common movement disorder seen in PHC. There is no

specific test to differentiate between common forms of tremor, As a
Reassurance result, tremor diagnosis is based on careful clinical observation and,
where indicated imaging.
Avoid caffeine; it can aggravate symptoms.
Advice Mange of stress → CBT
To reduce tremors when using hands, hold elbows close to body
Prescribing See next pages
For neurological assessment →for suspected parkinsonian tremor,
Referral other asymmetric tremor, or tremor associated with stiffness, slowness,
balance problems or gait disorders before treatment.
Investigations Mentioned above
Observation/
follow up
Plan/prevention
Conclusion Includes Safety netting

50
 Tremor

Types of tremors

51
Tremor

Patient with tremor

Yes No

Yes No

Yes No

Tremor with
organic cause

Yes No

+ve -ve

Yes Yes No
No
Yes No

52
Respiratory

53
Respiratory
Bronchial asthma
• Newly diagnosed
• Acute asthma exacerbation management
• Initiation of treatment
• Adjustment and maintenance of treatment
COPD
Obstructive sleep apnea
URTI
• Sore throat (pharyngitis)
• Rhinosinusitis
LRTI
• Cough
• Acute Bronchitis
• COVID 19
• Pneumonia
Smoking cessation
Peak flow mete use
Metered dose inhaler use
PFT interpretation

54
 Asthma Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow pt to explain the chief complain and Clarify what you understood
illness
Onset:
Sudden ( important to R/O life threatening conditions ) or gradual
Course:
Constant, intermittent, progressive, diurnal variation (night or in the early
morning?).
Duration:
-Acute (<3 weeks) ex URTI, LRTI, exacerbation of BA or COPD and life
threatening conditions
-Subacute (3 - 8 weeks) ex Postinfectious cough, pertussis, pneumonia.
-Chronic (> 8 weeks) ex Upper airway cough syndrome (postnasal drip), Asthma,
COPD, GERD, Non-asthmatic eosinophilic bronchitis, psychogenic cough or
medication side effect.
Character:
-Dry (croup, asthma, ILD)
-Productive ( bronchitis, pneumonia, bronchiectasis)
-Barking (croup)
-Frothy (pulmonary edema)
-Bloody (TB, pulmonary embolism, lung tumor)
Analysis -Painful ( tracheitis, left ventricular failure)
of chief Exacerbating/relieving factors:
Worse by:
complain
-Lying down (post nasal drip, esophageal reflux, bronchiectasis, bronchitis and
heart failure)
-Exercise and exposure to allergens (asthma)
Relieved by:
-Use bronchodilator, rest (BA)
-Use pillows or rise bed up (Heart failure)
Associated symptoms (DDx):
-Wheezing = BA, Bronchiolitis, foreign body aspiration, hypersensitivity reaction include
anaphylaxis
-Fever= URTI, LRTI, COVID, TB
-Night sweating= TB, Tumor
-Sputum if present ask about color, consistency, volume and blood ex Clear white
(uninfected bronchitis), Thin, clear mucoid (viral infection) Yellow or green or purulent
(infection), Rusty ( S. pneumoniae) due to blood
Thick and sticky (asthma), Thick plugs (cast-like) (bronchial carcinoma), Pink frothy
sputum (pulmonary oedema)
Bloody (TB, pulmonary embolism, lung tumor, Foreign body )
-Dyspnea= BA, COPD, Pulmonary edema, ILD
-Orthopnea, PND, Edema = Heart failure
-Chest pain= IHD, PE
-Heart burn = GERD
-Rhinorrhea = Common cold, sinusitis, postnasal drip
-Weight loss = TB, lung tumor

55
 Asthma Hx
Red Flags:
sudden, dyspnea, hemoptysis, night sweating, weight loss or chest pain
Most likely asthma:
Then ask about: Duration, how diagnosed, medication type, how to use and
how frequent,
adherence and any recent change in medication?
Asthma control assessment:
In the past 4 weeks:
-Day time symptoms more than twice/week
-Any night walking due to asthma
Analysis -Any limitation activity due to asthma
of chief -Reliever use for symptoms more than twice/week.
complain Ask about ER visit, hospital admission or ICU.
C-ACT or TRACK for younger than 5 years
Risk Factors:
Infections, nasal polyps, ,atopy , allergic rhinitis, food allergy, family history of
asthma or past personal history of airway hyperresponsiveness or early life
respiratory infection, preterm , Maternal - (higher risk): smoking, use of
antibiotics, and delivery by cesarean section. (Lower risk): higher intake of fish
or fish oil during pregnancy, and higher prenatal vitamin E and zinc levels,
active or Secondhand smoke , dust, perfumes, Animal, carpet, pollen, air
pollution, exercise, stress, obesity, occupational exposer, travel or changing in
weather, Early menarche, medications (NSAIDs (aspirin), B blocker )
Medical: Asthma, atopy, drug allergies, currently taking or recently run out of
any
Medications, exposure to TB or other infectious diseases, vaccination.
Past Hx Surgical
Allergy
Medication : over the counter medications aspirin, NSAIDs, B blocker and
herbals

Family Hx Asthma, Atopy, TB

Psycho Travel or immigration, occupation, hobbies (i.e., glue or chemical exposures),

alcohol or tobacco use, new pets or rugs, etc.
social Screening: depression and anxiety.
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How? Affecting work or sleep, Causing
syncope or incontinence, effect on family members
Systemic Review
Conclusion

56
 Asthma Ex
General Ø Vital signs
Ø Appearance
Special Respiratory Ex

CRAPRIOP for management

The management plan should cover the following aspects:
1. Inform patient /parents about the diagnosis.
2. Education about asthma possible triggers.
3. Available options of medications.
4. Proper technique of using inhaler devise.
5. How can the patient/parent minimize exacerbations?
6. How do patient/parent deal with worsening symptoms (action plan)?
7. How would the patient/parent communicate with the treating physician?
8. How frequent is the patient going to be seen in the clinic?
The last part in the management plan is to give the patient/ parent a chance to ask further
questions.

Clarification ‫الربو هو التهاب حتسسي مزمن في الشعب الهوائية يؤدي الى ضيق في التنفس و هناك عدة اعراض حتدث‬
‫ صفير اثناء التنفس و سعال‬,‫ صعوبة التنفس‬,‫بشكل متكرر وهي الشعور بضيق الصدر‬
Asthma affects 300 million individuals worldwide; Asthma is one of the
Reassurance most common chronic diseases in Saudi Arabia. There are many types of
drug help to control asthma and improve quality of life.
Reduce exposure to risk factors: Indoor allergens and air pollutants,
Advice Outdoor allergens and dust. Occupational exposures, Food and drugs.
Encourage vaccination(influenza, Pneumococcal) and adherence to
medications
3 SCENARIOS:
- ACUTE ASTHMA EXACERBATION MANAGEMENT
- INTIATION OF ASTHMA TREATMENT
Prescribing
- ADJUSTMETN AND MAINTENANCE OF TREATMENT
REVIEW IT BELOW THIS TABLE BUT FIRST REVIEW (BOX1,2 and 3) TO KNOW
THE AVAILABLE MEDICATIONS USED TO TREAT ASTHMA
Referral criteria to an asthma specialist:
1. Exercise induced symptoms that are atypical or not responding to
pretreatment with bronchodilators.
2. Persistent uncontrolled asthma (Asthma severity step 5)
3. Any risk factors for asthma related death (e.g.: ICU admission or
Referral mechanical ventilation for asthma).
4. Suspected asthma is not confirmed especially with normal pulmonary
function tests.
5. Evaluation of inhalant (e.g. pollens or animal dander) sensitization to
confirm the triggers and provide education regarding avoidance measures
or possible immunotherapy.
6. Patient with major co-morbidity that need management by specialist.

57
 Asthma
-The diagnosis of asthma is based on clinical assessment by a detailed
history ( See Box 1) and physical examination supported by spirometry
with reversibility testing.
-The degree of significant reversibility is defined as an Improvement in FEV1
≥12% and ≥ 200 ml from the pre-bronchodilator value. However, normal
spirometry or failure to show reversibility does not rule out the diagnosis of
asthma, as it can be normal with the patient still being symptomatic.
-Serial peak expiratory flow rate (PEF) measurements may be
helpful in the diagnosis of asthma by showing the characteristic increased
variability and for follow-up after starting treatment.
Investigations -Bronchoprovocation testing is another tool to rule out asthma with
atypical presentation and normal spirometry but it is not routinely
required.
-Chest X-ray is not routinely recommended unless the diagnosis is in doubt,
when symptoms are not typical , or suggest alternative diagnoses.
-Peripheral eosinophilia and elevated IgE level are supportive of the
diagnosis but are not routinely recommended unless dealing with
moderate to severe asthma
A. The follow up frequency depends on the degree of asthma
control. After starting treatment we need to see patient earlier
(1-3 months) and once the patient is controlled then clinic visit
every 3-6 months, pregnant women should be followed every 4-
6 weeks.
B. After acute exacerbation the patient needs to be seen within
one week.
C. At each follow up visit conduct the following:
1. Review ACT score and assess degree of Asthma control.
Observation/ 2. Peak flow meter to monitor and assess the control
follow up 3. Adjust asthma medications if necessary.
4. Check the proper technique of how the patient is using his
medication device (inhaler).
5. Assess adherence: Check the frequency of asthma therapy
use in the past 2 weeks and check inhaler’s counter if
available.
6. Review the avoidance of exposure to triggers (Environmental
control measure).
7. Check for co-morbid conditions e.g: chronic rhinosinusitis,
obesity,
8. Refer whenever indicated.
Plan/prevention Screening and vaccination
Conclusion Includes Safety netting

58
Asthma
Box 1: Relevant Questions in the Diagnosis of Asthma
• Does the patient or his/her family have a history of asthma or other atopic conditions,
such as eczema or allergic rhinitis?
• Does the patient have recurrent attacks of wheezing?
• Does the patient have a troublesome cough at night?
• Does the patient wheeze or cough after exercise?
• Does the patient experience wheezing, chest tightness, or cough after exposure to
pollens, dust, feathered or furry animals, exercise, viral infection, or environmental
smoke (cigarettes, burning incense “Bukhoor,” or wood)?
• Does the patient experience worsening of symptoms after taking aspirin/nonsteroidal
anti- inflammatory medication or use of B-blockers?
• Does the patient’s colds “go to the chest” or take more than 10 days to clear up?
• Are symptoms improved by appropriate asthma treatment?
• Are there any features suggestive of occupational asthma?

59
 Asthma
Box 1: List of inhaled corticosteroids for adults and adolescent and daily
recommended doses *
Drug (Doses in mcg)** Low dose Medium dose High dose
Beclomethasone dipropionate (Standard particles, HFA) 200–500 >500–1000 >1000
Beclomethasone dipropionate (Extra fine particles, HFA) 100-200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (Extra fine particles, HFA) 80–160 >160–320 >320
Fluticasone propionate (DPI & HFA) 100–250 >250–500 >500
Mometasone furoate (DPI) 100 100 200
DPI: Dry powder inhaler; HFA: chlorofluoroalkane propellant
*Adapted from reference (1)
**Based on availability in the Saudi market for children

Box 2: List of inhaled corticosteroids inhalers and daily recommended doses*

Less than 5 years Children above 5 years
Drug (Doses in mcg)** Low dose Low dose Medium dose High dose
Beclomethasone 100 200-500 >500–1000 >1000
dipropionate (Standard
particles, HFA)
Beclomethasone 50 100-200 >200–400 >400
dipropionate (Extra fine
particles, HFA)
Budesonide 200 200-400 >400–800 >800
Budesonide (Nebules) 500 250–500 >500–1000 >1000
Ciclesonide Not applicable 80-160 >160–320 >320
Fluticasone propionate (DPI) Not applicable 100–250 >250–500 >500
Fluticasone propionate (HFA) 50 100–250 >250–500 >500
Mometasone furoate 100 200-400 200-400 >400
DPI: Dry powder inhaler; HFA: chlorofluoroalkane propellant
* Adapted from reference (1)
**Based on availability in the Saudi market for children

Box 3: List of fixed combinations of inhaled steroid and long acting β2 agonists
Inhaled Steroid Long Acting β2 agonist Brand name Device Type Device Name
(Doses in mcg)
(Doses in mcg)
Beclomethasone (100) Formoterol (6) Foster® MDI
Budesonide (80,160, 320) Formoterol (4.5, 9) Symbicort ® DPI TurbuhalerTM
Budesonide (200, 400) Formoterol (6, 12) Pulmoton® DPI ElpenhalerTM
Fluticasone propionate (50, 125, 250) Salmeterol (25) Seretide® MDI EvohalerTM
Fluticasone propionate (100, 250, 500) Salmeterol (50) Seretide® DPI DiskusTM
Fluticasone furoate (100, 200) Vilanterol (25) Relvar® DPI** ElliptaM
Fluticasone propionate (50,125,250) Formoterol (5,10) Flutiform® MDI
Fluticasone propionate (250, 500) Salmeterol (50) Rolenium® DPI ElpenhalerTM
Mometasone furoate (100) Formoterol (5) Dulera® MDI
MDI: Metered dose inhaler, DPI: Dry powder inhaler
*Based on availability in the Saudi market for children
**Once a day combination

60
Asthma Management

SCENARIO 1 :
ACUTE ASTHMA EXACERBATION MANAGEMENT

3 steps for the management of acute asthma:

1. Assess severity of the attack.
2. Initiate treatment to rapidly control the attack.
3. Evaluate continuously the response to treatment.

61
Asthma

62
Asthma

63
 Asthma

SCENARIO 2 :
INTIATION OF ASTHMA TREATMENT

Prior to commencing a patient on treatment, the SINA panel recommends

ensuring the following:
• Assessment of asthma control.
• Assessment of risk factors for poor asthma control and fixed airway
obstruction.
• Performance of pulmonary function testing with spirometry and/or PEF to
assess for airflow Limitations and postbronchodilator reversibility.
• Documentation of current treatment and any issues related to adherence,
inhaler technique, or side effects.
• Utilization of a written asthma action plan.
• Assessment of comorbidities such as rhinosinusitis, gastroesophageal reflux
disease (GERD), obesity, obstructive sleep apnea, anxiety, and exercise-
induced laryngeal obstruction.
• Close monitoring for patients with severe asthma and history of asthma
attacks.

Assessment of asthma symptoms control

Box 4.1: GINA Assessment of Asthma Control in Adults and Adolescents

64
 Asthma

Asthma Control Test items Score

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at
work,
at school, or at home?
All of the time Most of the time Some of the time A little of the time None of the time
□1 □2 □3 □4 □5
2. During the past 4 weeks, how often have you had shortness of breath?
More than once Once a day 3–6 times a week Once or twice Not at all
a day a week
□1 □2 □3 □4 □5
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of
breath,
chest tightness, or pain) wake you up at night, or earlier than usual in the morning?
4 or more nights 2 to 3 nights Once a week Once or twice Not at all
a week a week
□1 □2 □3 □4 □5
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication
such as
salbutamol?
3 or more times 1 or 2 times 2 or 3 time Once a week or less Not at all
per day per day per
week
□1 □2 □3 □4 □5
5. How would you rate your asthma control during the past 4 weeks?
Not controlled at all Poorly controlled Somewhat Well controlled Completely controlled
con-
trolled
□1 □2 □3 □4 □5
TOTAL SCORE

The level of asthma control is categorized into:

• Controlled: An ACT score of ≥20
• Partly controlled: An ACT score of 16-19
• Uncontrolled: An ACT score of <16

65
Asthma

Initiation of asthma treatment for adults and

adolescents

The SINA * Approach for Asthma Treatment Initiation

*S a u d i In itia tiv e f o r A s t h m a

Obtain history and perform physical examination

Assess symptoms and obtain PEF measurement (spirometry if needed)
Assess aggravating factors and treat commodities
Ensure optimizing patient education and proper assessment of aggravating factors

Initiate asthma treatment at appropriate step based on asthma system

Step 1 Step 2 Step 3

ACT ≥20 ACT 16-19 ACT <16
Controlled Partially controlled Uncontrolled
Status Status Status

Form oterol/ICS as n e e d e d Low dose ICS (use Low-medium dose ICS +

L o w d o s e I C S in s p e c ia l
SABA as a reliver) LABA
s itu a tio n s
Formoterol/ICS For patients presenting
combination as with severe asthma
needed symptoms, consider starting
LTRA at step 4
Patient with an acute
attack may require short
course oral corticosteroids

ICS: Inhaled corticosteroids; LABA: Long-acting beta-agonists; SABA: Short acting beta-agonists

66
 Asthma
SCENARIO 3 :
ADJUSTMETN AND MAINTENANCE OF TREATMENT
Asthma severity can be retrospectively assessed based on the step of treatment
required to control symptoms:
• Mild asthma: controlled asthma at step 1 or 2
• Moderate asthma: controlled asthma at step 3
• Severe asthma: requires asthma management at step 4 or 5
Assessment when control is not achieved:
If asthma control is not achieved at any step during therapy,
the SINA panel recommends assessing the following:
• Appropriateness of prescribed medications and doses.
• Patient’s adherence and correct technique in using devices

Outpatient asthma treatment for adults and adolescents

The SINA Approach for asthma treatment

Severe
Adjustment and maintenance Step 4-5
Moderate Step 4
Mild Step 3 Recommended
Step 1-2 • Medium-high dose ICS +
LABA
Add on therapy
Step 1 Step 3
• LAMA
• LTRA
• Formoterol/ICS as
needed
• SABA and ICS as needed
Recommended Step 5
• Low dose ICS + LABA Based on phenotype,

Step 2 Alternative
consider:
• Anti IgE therapy
• Low maintenance dose • Anti IL5 or IL5R therapy
• Low dose ICS + LTRA
ICS (SABA as reliever) or • Medium dose ICS • Anti IL$Ra therapy
• Low-medium dose ICS + Less preferred controllers
• Low dose oral
• Formoterol/ICS as Theophylline
corticosteroids
needed

• Referral to a physician
• Alternatively, LTRA
specialized in asthma is
(SABA as reliever)
recommended

Relivers: SABA as needed for non formoterol/ICS combination – Formoterol/ICS

combination as needed when used as maintenance

Patient education, environmental control, and management of comorbidities

67
Asthma
The SINA approach for
Outpatient asthma treatment for children aged 5-12 years

The SINA Approach for asthma treatment

Severe
Adjustment and maintenance Step 4-5
Moderate
Mild Step 3 Step 4
Step 1-2 Recommended
• Medium-high dose ICS +
LABA
+/-
Step 1 Step 3 • Leukotriene modifier

• ICS as needed when Recommended

SABA is used • Low dose ICS + LABA Step 5
Step 2 Alternative Step 4 regimen
+
• Medium-high dose ICS
• Low dose ICS or • Biologic therapy If not a
• Low dose ICS + candidate, consider:
Leukotriene modifier • Systemic steroids
• Alternatively, ICS as
needed when SABA is
used • Referral to a physician
specialized in asthma is
• Leukotriene
recommended

Relivers: SABA as needed Salbutamol (as needed)

Patient education, environmental control, and management of comorbidities

68
Asthma
The SINA approach for
Outpatient asthma treatment for children aged <5 year

Severe
Step 4-5
Moderate
Mild Step 3
Step 1-2 Step 4
• Double dose ICS

Step 1 Step 3 +
• Leukotriene modifier
• Salbutamol (as needed) Recommended
• Double dose ICS
Step 5
Step 2 Alternative Step 4 regimen
• Low dose ICS + +
• Low dose ICS Leukotriene modifier • Systemic steroids

Alternatively • Referral to a physician

• Leukotriene modifier specialized in asthma is
recommended

Relivers: SABA as needed Salbutamol (as needed)

Patient education, environmental control, and management of comorbidities

69
‫‪Asthma‬‬
‫اخلطة العالجية للربو‬

‫اإلجراد الواجب اتخاذه‪:‬‬ ‫احلالة املستقرة‪:‬‬

‫اإلجراد الواجب اتخاذه‪:‬‬

‫التأزم اخلفيف‪:‬‬

‫التأزم الشديد‪:‬‬
‫اإلجراد الواجب اتخاذه‪:‬‬

‫‪70‬‬
 COPD Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow pt to explain the chief complain and Clarify what you understood
illness
Analysis of complaint (dyspnea): onset – course –duration – severity -
intermittent or constant, aggravating factors (dust, cold, walk,
exercise...) and relieving factors ( rest, drug, position...), progression
and time.

MRC Dyspnea Scale

Analysis
of chief
complain
Associated symptoms as:
Cough (characteristics of cough)
• Sputum (color, amount, frothy, rusty, bloody?)
• Wheezing, Dyspnea, Chest pain, Night sweating, fever, Recurrent
LRTIs, Heartburn, Leg swelling, Running nose, Weight loss
• Previous attacks –action taken

Risk factors:
age older than 35 years with significant smoking history, α1-antitrypsin
deficiency, and a history of significant exposure to indoor or outdoor
air pollution, occupational dust, or chemicals.

Red flags:
Night sweating
Hemoptysis
Unexplained wight loss
Cyanosis
Lower limb edema

71
 COPD Hx

Differential
Diagnosis

Previous exacerbations or hospitalizations

Medical comorbidities, including lung disease (such as asthma)
Psychiatric comorbidities, including depression and anxiety
Past Hx Previous operations
substance abuse (IV drug or alcohol abuse) and herbal drugs, Regular
medications (and any recent changes) *ACE-inhibitors can cause a dry cough
Over-the-counter medications
Family Hx Same condition, lung disease
Liver disease (may suggest alpha-1 antitrypsin deficiency)
Marital status, traveling.
Screening: depression and anxiety
Psycho Alcohol and Smoking history: quantify in pack-years (1 pack-year = smoking 20
social cigarettes a day for a year)
Recreational drug use
Occupation: may be exposed to indoor air pollution
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How? Affecting work or sleep, Causing
syncope or incontinence, effect on family members
Systemic Review
Conclusion

72
 COPD Ex
Ask patient permission to start the examination, explain what to
examine, and ensure privacy.
• Hand wash
• Vital signs (temp –blood pressure –pulse) and BMI
General • General look: Pursed lips breathing (COPD) cachectic (T.B, cancer)
dyspnea (BA, CHF, COPD, ILD),
Cyanosis, Clubbing, Obese or Thin, Lower Limp for edema.
• Head and neck: Sinus, LN, ENT.
• Respiratory examination (Wheeze, decrease air entry, Stridor,
Crepitation, decreased chest expansion, Resonance, Percussion)
• CVS examination: (Muffled heart sounds)
Special • Spirometry
Typical finding in COPD: FEV1/FVC < 70%
FEV1 is also used to classify the severity of COPD

CRAPRIOP for management

Chronic obstructive pulmonary disease (COPD) is a chronic
inflammatory lung disease that causes obstructed airflow from
the lungs. Symptoms include breathing difficulty, cough, mucus
(sputum) production and wheezing.
Clarification

‫( هو مرض رئوي التهابي مزمن يتسبب في إعاقة تدفق الهواء‬COPD) ‫داء االنسداد الرئوي املزمن‬.
.‫ تشمل األعراض صعوبة التنفس والسعال وتكوُّن املخاط )البلغم( واألزيز‬.‫خارجًا من الرئتني‬

Although COPD is a progressive disease that gets worse over time,

COPD is treatable. With proper management, most people with
COPD can achieve good symptom control and quality of life, as well
as reduced risk of other associated conditions.
Reassurance
‫ فإنه مرض قابل‬،‫على الرغم من أن داء االنسداد الرئوي املزمن مرض تقدمي يتفاقم مبرور الوقت‬
‫ مع اإلدارة السليمة‬- ‫ ويستطيع معظم األشخاص املصابني بداء االنسداد الرئوي املزمن‬.‫للعالج‬
.‫ أن يسيطروا جيًدا على األعراض ويتحكموا في جودة حياتهم‬- ‫للمرض‬

Smoking cessation,
Regular physical activity
Advice Regular review/ correction of inhaler technique
Influenza vaccine, pneumococcal vaccine, covid vaccine

73
 COPD

Several kinds of medications are used to treat the symptoms and

complications of COPD
Short-acting beta agonists (SABAs): e.g., salbutamol, fenoterol
Long-acting beta agonists (LABAs): e.g., salmeterol, formoterol
Prescribing Short-acting muscarinic antagonists (SAMAs): e.g., ipratropium
bromide
Long-acting muscarinic antagonists(LAMAs): e.g., tiotropium
bromide
Inhaled corticosteroids (ICS): e.g., budesonide, fluticasone,
beclomethasone

referral to pulmonologist (a respiratory medicine specialist)

Referral
And consider referral to pulmonary rehabilitation

No laboratory test is diagnostic for COPD,

CBC (to identify anemia/polycythaemia)
plasma brain natriuretic peptide (BNP)for evaluation of
Investigations suspected heart failure
Alpha 1 Antitrypsin: if young, minimal smoking or family history
ABG in acutely ill patient
*consider Chest Xraybrain, CT chest.

Next appointment follow-up, safety netting and when to return

Observation/ back immediately. (Chest pain, Rapid breathing or heart rate
follow up
Cyanosis, fever, confusion)

Plan/prevention screening and vaccination

Conclusion Includes Safety netting

74
 Obstructive Sleep Apnea Hx

Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow pt to explain the chief complain and Clarify what you understood
illness
Analysis of complaint (Daytime sleepiness/sleep apnea): onset – course
–duration
Sleep history
Sleep Timings:
A. How many hours do sleep?
B. Do you take daytime naps &for how long?
Normal sleeping habits:
[Link] time do you go to bed.
[Link] time do get out of bed?
[Link] is the time required for you to fall asleep?
[Link] you get up in middle of the night ?if yes ,how many times
5.&what wakes you up ?
[Link] quickly do you go back to sleep?
Sleep Quality:
[Link] you feel refreshed in the morning?
[Link] long does it take you to feel refreshed ?
Analysis [Link] the day ,are you chronically Fatigued , Sleepy or Tired?
of chief
Associated symptoms as:
complain Snoring :
A. Do you think you snore at night?
B. Are your snores heard outside the bedroom?
C. Does it awaken the bad partner?
D. What makes it worse e.g stuffed nose.
Apneic Events:
Has your partner noticed you stop the breathing transiently while asleep?
Have you experienced episodes of choking or waking up at night short of
breath ?
Any Abnormal behavior or movements at night ?

Daytime functioning:
Do you wake up with headache?
Have you felt mostly tired during the day?
Have you ever dozed of in meeting or while driving?

75
 Obstructive Sleep Apnea Hx

Risk factors:
• Age (40 to 70 years)
• Commercial motor vehicle driver
• Family history of obstructive sleep apnea
• Male sex
Differential • Obesity (body mass index > 35 kg per m2)
Diagnosis • Postmenopausal woman not taking hormone therapy
• Preoperative for bariatric surgery
• Retrognathia
• Hypothyroidism
• Polycythemia
Red flags:
Rapidly progressive OSA
Medical history:
• Obesity
• GERD
• Heart diseases (Atrial Fibrillation ,Congestive Heart failure, Coronary heart
disease ,Hypertension.
Past Hx • CNS (Headache, Epilepsy, CVA, Mood disorders, Cognitive impairment,
insomnia)
• Respiratory( [Link], COPD, Sinusitis ,Enlarged tonsils, blocked nose,
Deviated Nasal septum)
• Endocrine(Thyroid diseases, DM)
Drug history:
• All need to be noted. Allergy ,O.T.C. Or Herbals.
Family Hx Obstructive sleep apnea, HTN, obesity and Hypothyroidism
Marital status
Occupational history:
Any stress ,Out of hours ,any flight travel.
Psycho Personal habits:
Any history of tobacco consumption ?if yes how many per day &for how many
social years ?
History of consumption of tea or coffee?
how many times &what time of the day?
any consumption of hyper caffeinated drinks?
Any history of Alcohol consumption?
Screening: Depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

76
 Obstructive Sleep Apnea Ex
Initial evaluation:
General BP, Pulse oximetry and other vitals + weight and BMI
Waist circumference.
Focused head and neck Ex:
Oropharynx
- Elongated soft palate
- Enlarged tonsils, large tongue
- Retrognathia or Micrognathia
Special - Enlarged uvula ,DNS , turbinate's hypertrophy.
Nasopharynx
- Deviated nasal septum
Neck
- Short neck with large circumference > 17 In
Respiratory Ex
CVS Ex
Initial Tests when clinically indicated :
CBC to evaluate anemia and polycythemia, which can indicate
nocturnal Hypoxemia
Investigations - Anemia: Hb <12 g/dL in women and <13 g/dL in men
- Polycythemia: Hb >16.5 g/dL in women and >18.5 g/dL in men
TSH to evaluate hypothyroidism
- TSH >5.5 mIU

CRAPRIOP for management

‫انقطاع النفس االنسدادي النومي هو الشكل األكثر شيوًعا من اضطرابات النفس‬
.‫ ويسبب توقف النفس وبدئه مرارًا أثناء النوم‬.‫املرتبطة بالنوم‬
Clarification ‫يحدث هذا النوع من انقطاع النفس عندما تسترخي عضالت احللق بشكل متقطِّع‬
‫ ومن العالمات امللحوظة على انقطاع النفس‬.‫وتغلق مجرى الهواء أثناء النوم‬
.‫االنسدادي النومي؛ الشخير‬
‫ إال أن أكثرها شيوًعا هو‬،‫هناك عدة أنواع من انقطاع النفس االنسدادي النومي‬
Reassurance ‫انقطاع النفس االنسدادي النومي‬
‫وميكن عالجه بتغيير منط احلياة وبطرق غير جراحيه وجراحيه‬
Lifestyle modification :
Weight loss, exercise, avoidance of smoking and sedatives,
Advice especially before bedtime.
Sleeping in lateral position

77
 Obstructive Sleep Apnea

Oral appliances
Alternative to CPAP therapy for mild to moderate OSA. Not as
effective as CPAP in reducing AHI.

Prescribing

Referral to pulmonologist (a respiratory medicine specialist) for

sleep study (polysomnography) to quantify the apnea-hypopnea
Referral index., CPAP
Referral to surgery ( nasal, oral ,hypopharyngeal or global airway
procedures) and bariatric surgery (if needed)
Investigations Mentioned above
Observation/ Next appointment follow-up, safety netting and when to return
follow up back immediately.
Patient education:
Significantly sleepy patients:
Plan/prevention
• Should be advised to stop driving or referred him to driving
policy
• Avoid using dangerous equipment.
Screening and vaccination
Conclusion

78
 Obstructive Sleep Apnea

STOP BANG Score

APNEA-HYPOPNEA INDEX (AHI)

is calculated by dividing the number of events by the number of hours of sleep.

79
 Sore throat Hx
Introduce yourself and establish good rapport ( Name, age and job).
Greeting the pt
Introduce yourself
Introduction
Establish relationship with pt: ask name, age and job.
Hx of present Chief complain (open question)
Allow pt to explain the chief complain
illness
Clarify what you understood
Course, onset and duration
SOCRATES for pain
Associated symptoms (DDx): (fever, malaise, runny nose, cough, SOB, neck mass,
rash, joint pain/swelling acid regurge, ear pain , toothache.
Risk Factors
Contact with sick patient
Travel hx
Vaccination hx
Analysis of Red Flags
chief - Ashen color and drooling child indicating Epiglottis
- Unstable vital signs indicating streptococcal sepsis,
complain
- Murmur, heart failure indicating rheumatic fever
- Unilateral swelling, marked tenderness, trismus indicating peritonsillar
abscess
- Neck stiffness, high fever, sensitivity to light indicating meningitis.
- Fever, weight/appetite loss, night sweating
HTN, Dm, IHD, Asthma , Thyroid diseases, immunocompromised
Surgical
Past Hx
Allergy (drug , food, smells)
Medication
Family Hx HTN,DM,IHD, Asthma, Thyroid diseases
Hx of same complain
Psychosocial Marital status
Smoking: type and frequency
Screening: depression and anxiety
ICEE Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
General Vital signs
Appearance
ENT Ex
Cervical LNs (anterior – posterior)
Special Chest Ex
Skin for rash
Abdomen for splenomegaly (indicate infectious mononucleosis )

80
 Sore throat
CRAPRIOP for Management
Explain to the patient or parents the nature of the
disease: Infections of the upper respiratory tract can
be viral or bacterial (viral most common 80%).
bacterial infection can be controlled by antibiotics.
However, the viral infections do not.
Explain to the patient or parents the role of Centor
criteria:
"There are a set of clinical features that we can use to
determine whether this is a viral or bacterial
infection.
Clarification These are (mention the centor criteria). Fortunately,
you or your child does not fit the criteria and thereby
does not need an antibiotic

Centor criteria [0 – 1 ]no further testing

or antibiotic
q Age 3-14yr (1) , - ≥ 45yr (-1)
q Temperature ≥ 38◦C (1)
[2-3]test (rapid Ag test or
q Absence of cough (1)
throat culture) treat if +ve
q swollen tender anterior cervical
LNs (1)
[≥ 4]consider empiric
q Tonsillar swelling or exudate (1)
treatment with antibiotics

Reassurance It’s self-limiting disease, most pt improve without medication

Rest – fluids – warm beverages (chicken soup – honey or
Advice lemon tea) –nasal spray– stop smoking
Advice against use of antitussives
Ø Paracetamol 10mg-15/kg q6-4h /prn
Treatment of pharyngitis due to group A Streptococcus in
children and adolescents as prevention of acute rheumatic
fever.
Prescribing Ø Penicillin V (preferred)
if <27kg 250mg BID or TID × 10d
If >27kg 500mg BID or TIDx10d

81
Sore throat

Or
Ø Amoxicillin
50 mg/kg per day orally(maximum 1000 mg per day)for 10 days
May be administered once daily or in 2 equally divided doses

Prescribing Ø Cephalexin (if potential alternatives for mild reactions to penicillin)

40 mg/kg/day divided twice daily for 10 days (maximum500 mo/
dose)

Ø Macrolides as Azithromycin (alternatives for patients with

anaphylaxis or other IgE mediated reactions or severe delayed
reactions to penicillin
12 mg/kg/day (maximum500 mg/dose) for 5 days Update

Referral if indicated (to ENT for epiglottitis or tonsillectomy)

Indication for tonsillectomy (Toronto Notes, Otolaryngology pg. 43,

2011)

A. Tonsillitis: Chronic or recurrent ([Link] 7 episodes in 1 year or more

than 5 episodes per year over 2 consecutive years or more than 3
episodes per year over 3 consecutive years)
B. Obstruction: compromise to airway, swallowing or voice quality
Referral C. Malignant tumor of the tonsil or suspicion of malignancy
D. Uncontrollable hemorrhage from tonsillar blood vessels.
E. Peritonsillar abscess: more than 1 eisode or 1 episode with history
recurrent tonsillitis
F. Chronic pharyngeal carriage of Group A Beta-Hemolytic
Streptococci
G. Halitosis, refractory to other measures.
H. Syndrome of periodic fever, aphthous stomatitis, pharyngitis, and
cervical adenitis, PAPA syndrome (Periodic Fevers with Aphthous
I. Stomatitis Pharyngitis and Adenitis Syndrome] unresponsive to
conservative treatment.
Rapid strep Ag test (if Centor criteria 2-3)
CBC
Investigations Monospot test if suspecting infectious mononucleosis
Throat culture if recurrent pharyngitis

Observation/ Arrange for follow up

follow up
Plan/prevention Influenza and COVID-19 vaccine
Conclusion Includes Safety netting

82
 Rhinosinusitis Hx

Introduce yourself and establish good rapport ( Name, age and job).

Greeting the pt
Introduction Introduce yourself
Establish relationship with pt: ask name, age and job.
Hx of Chief complain (open question)
present Allow pt to explain the chief complain
illness Clarify what you understood
Onset , duration , Course
Associated symptoms : nasal obstruction,
purulent nasal discharge, facial pain/pressure,
Hyposmia/anosmia, Ear pain/pressure/fullness, fever
headache, dental pain, cough, myalgia, sore throat ,
Halitosis.
Symptoms supports the diagnosis of acute bacterial
rhinosinusitis (ABRS):
1. Symptoms that last longer >10 days
2. Biphasic pattern illness ("double worsening"),
Analysis of
characterized by worsening symptoms after an
chief initial period of improvement.
complain 3. The onset of severe symptoms or signs of severe
illness (ex, high fever [>39°C or 102°F], purulent
nasal discharge, facial pain) for at least 3 to 4
consecutive days at the beginning of illness.
Risk Factors :
URTI
Contact with sick patient
Atopy (allergic rhinitis/conjunctivitis , BA, Eczema)
GERD
Tobacco smoke

83
Rhinosinusitis Hx
Red Flags :
q Symptoms concerning for complicated ABRS :
high, persistent fevers >39 C; periorbital edema,
inflammation, or erythema; cranial nerve palsies;
Analysis of
abnormal extraocular movements; proptosis;
chief vision changes (double vision or impaired vision);
complain severe headache; altered mental status; or
meningeal signs.
q If child and have unilateral nasal congestion/
offensive odor think of foreign body .
q Fever, weight/appetite loss, night sweating
Medical : HTN, Dm, IHD, Asthma , Thyroid diseases,
immunocompromised
Surgical
Allergy (drug , food, smells)
Medication
Past Hx § Topical vasoconstrictors or cocaine (cause
rhinitis medicamentosa) .
§ Oral antihypertensive drugs, antiosteoporosis
agents, hormone replacement sprays (cause
mucosal edema)
HTN,DM,IHD, Asthma, Thyroid diseases
Family Hx Hx of same complain
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

84
 Rhinosinusitis Ex
Vital signs
General Appearance
Full ENT Ex
Special Cervical LNs (anterior – posterior)

CRAPRIOP for Management

Acute sinusitis / rhinosinusitis is inflammation of
the mucosal lining of the nasal cavity and paranasal
sinuses, presenting with purulent nasal drainage
accompanied by nasal obstruction, facial
Clarification
pain/pressure/fullness, caused by either a viral or a
bacterial infection. Viral most common cause .

It’s self-limiting disease, most pt improve without

Reassurance investigation or Antibiotic.
Adequate rest and hydration
Saline irrigation , Warm facial packs
Advice Use of vitaminC
Stop smoking
Acute Viral Rhinosinusitis (AVRS)
v Adult and Pediatric
(symptomatic management )
o Paracetamol 10mg-15/kg q6-4h /prn
o Intranasal saline spray
o Intranasal glucocorticoids as mometasone nasal
Prescribing • children 2-11 years of age: 50 micrograms (1
spray) in each nostril once daily;
• children ≥12 years of age and adults: 100
micrograms (2 sprays) in each nostril once
daily

85
Rhinosinusitis

o ipratropium nasal
• child ≥6 years of age: (0.03%) 42 micrograms
(2 sprays) in each nostril two or three times
daily;
• adults: (0.06%) 84 micrograms (2 sprays) in
each nostril three times daily

o Oral decongestants as (Pseudoephedrine) for

short course (three to five days) useful when
Eustachian tube dysfunction is a factor for
patients with AVRS.
• Children 4 to <6 years: Immediate release:
Fixed dose: 15 mg every 4 to 6 hours;
maximum daily dose: 60 mg/24 hours
Prescribing • Children 6 to <12 years: Immediate release:
30 mg every 4 to 6 hours; maximum daily
dose: 120 mg/24 hours
• Children ≥12 years and Adolescents:
Immediate release: 60 mg every 4 to 6 hours;
maximum daily dose: 240 mg/day
• Extended release: 120 mg every 12
hours or 240 mg once daily; maximum daily
dose: 240 mg/24 hours

o Intranasal decongestants as Oxymetazoline

o May cause rebound congestion or mucosal
damage when used for long-periods
o Should not be used for >3 days
o Not recommended for children <6 years

86
Rhinosinusitis

Acute Bacterial Rhinosinusitis (ABRS)

v Adult (uncomplicated mild/moderate ABRS)

q Observation and symptomatic management: Watchful
waiting for a seven-day period after clinician diagnosis
with symptomatic management for immunocompetent
patients with ABRS who have good follow-up (assurance
that antibiotic therapy can be started if the patient does
not improve or worsens).
q Amoxicillin-clavulanate (500 mg/125 mg orally three times
daily or 875 mg/125 mg orally twice/5-7 days
q Patient with a penicillin allergy:
Doxycycline (100 mg orally twice daily or 200 mg orally
daily)/ 5-7days.

v Pediatric (uncomplicated mild/moderate ABRS)

q Preferred: standard-dose Amoxicillin-clavulanate 45
Prescribing mg/kgΔ per day orally divided in 2 doses (maximum 1.75
g/day)/10 days
q Penicillin allergy: Mild delayed reaction Cefpodoxime 10
mg/kg per day orally divided in 2 doses/ 10 days
(maximum 400 mg/day)
q Penicillin allergy: Immediate (eg, anaphylaxis) or serious
delayed reaction: Levofloxacin¥ 10 to 20 mg/kg per day
orally divided in 1 or 2 doses / 10 days (maximum 500
mg/day)

(If pt not improve on standard-dose after 72h or

worsen at any time after initiation of Abx, reassess
the pt and find the cause of ttt failure consider high
dose of Augmentin or switch to another Abx )

Up to date

87
Rhinosinusitis

• Urgent early referral for patients with symptoms

that are concerning for complicated ABRS or have
Referral evidence of complications on imaging.
• Diagnosed or suspected immunodeficiency
• Recurrent ABRS, particularly if it exacerbates
underlying pulmonary conditions (eg, asthma)
• Diagnosis clinically
Investigations • For refractory case or subsect complication
• Nasal Endoscopy, sinus culture ,sinus CT, MRI,
Xray
Observation/ • AVRS F/U after 7 days
follow up • ABRS F/U after 3 days check for Abx response.
Plan/ • Influenza, COVID-19 vaccine
prevention • According to patient age, sex , risk factor
Conclusion Includes Safety netting

88
 Cough Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question)

Allow t to explain the chief complain
illness Clarify what you understood
Cough (onset , duration) > 8 weeks consider chronic (course,
intermittent-continuous)

Character: dry (BA,CROUP,ILD)

Productive green ,yellowish (bronchitis, bronchiectasis),
Barking (croup) ,frothy (Pulmonary Edema) ,
Rusty (Pneumonia) bloody (T.B. lung tumor, pulmonary infarction,
chest infection)

Severity: timing: (at night ,work or exercise related :BA, with meals or
sleeping GERD)
Progression: aggravating factor (dust, cold, walk: BA) Reliving
factor:(rest, drugs: BA,position: BA,CHF)
Analysis of Associated symptoms:
chief complain -SOB(BA, pulmonary edema, interstitial lung disease ) Audible
wheezing ,orthopnea(heart failure)
hemoptysis(T.B, lung tumor, chest infection)
chest pain(PE, chest infection)
leg swelling (PE,CHF),Fever (chest infection)
night sweating or weight loss (T.B, Tumor)
throat tickling (postnasal drip)
heartburn or sour taste(GERD)
runny nose or facial pain (sinusitis, common cold and postnasal drip)
Red flags
(fever, weight or appetite loss, night sweating )
-Contact with sick people
Differential -Travel history
diagnosis -Covid-19 vaccination
-Occupational history
Medical
(chronic bronchitis 3month in last 2year)
URTI,[Link], Allergic rhinitis , eczema.
Surgical
Past Hx Allergy (drugs, dust, food, smells, atopy)
Medication
ACEI(dry cough),Nitrofurantoin(lung fibrosis) inhalers(BA)cough
remedies, diuretics(CHF)
B-blocker CI in BA

89
 Cough Hx

Family Hx Sick patient or contact with family member ,T.B, BA, Atopy.
Marital status
Social: home ventilation ,no living ,animals/ alcohol(GERD) /Smoking
Psychosocial type and frequency
(BA, chronic bronchitis, tumor) / work/ diet ,exercise
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
Appearance
General HEENT
Nasal passage, sinus, throut, adenopathy
Special Respiratory Examination

CRAPRIOP for Management

Cough is a widespread symptom for patients to be present within
Primary Care. The distinction between acute cough (lasting less than
three weeks) and chronic cough (greater than three weeks).
Clarification The treatment of the two conditions is different. Therefore, underlying
the severe pathology needs to be excluded from a careful history and
specific tests and clues in the history. The majority of chronic cough is
due to GERD, Bronchoconstriction, or Post-Nasal drip
It is common problem in PHC and most of patients improve without
Reassurance need any investigations or antibiotic.
Self-care treatments for acute cough include honey, natural remedies,
Advice and over-the counter cough medicines.
Take full vaccination's , avoid contact with sick people

90
Cough
Acute Cough Usually, Self-limiting, improving in 3 to 4 weeks without
antibiotics, and can be managed

just by self-care Acute cough associated with an upper respiratory tract

infection and Acute bronchitis.

In Patients who are not systemically very ill or at increased risk of

complications, do not prescribe an antibiotic; supportive care and
symptom management is the mainstay of treatment for an acute cough
with acute bronchitis and an upper respiratory tract infection.
Reasons to Prescribing Antibiotics for Acute Cough

People with an acute cough who are identified with clinical examinations
as systemically very unwell or have suggestive signs/symptoms of serious
illness or complications,

They are at high risk of serious complications because of pre-existing

comorbidities, such as significant heart, lung, renal, liver, or
neuromuscular disease, immunosuppression, or cystic fibrosis.
People who are older than 65 years with two or more of the following
Prescribing criteria, or older than 80 years with one or more of the following criteria:

§ Hospitalization in the previous year

§ Type 1 or type 2 diabetes

§ History of congestive heart failure

§ Current use of oral corticosteroids

91
Cough
Chronic Cough
The first step in treating a patient with chronic cough is to find out what's
causing it so that medication can be aimed at the source

Prescribing

Red flags

To the pulmonologist to consider

bronchoscopy or further studies
if Red flags are present or symptoms
Referral continue after empiric treatment
for common problems
for their full treatment duration.

92
 Cough

Usually, no investigation is needed for acute cough.

However, if the cough continues > 3 weeks; consider the
below:
Plain chest X-rays (should be applied to rule out most
infectious, inflammatory and malignant thoracic conditions).
Pulmonary function tests /spirometry (asthma, COPD)
Investigations Sputum cytology and culture (elevated with bacterial
overgrowth, bronchiectasis, TB, lung abscess, and bronchial
carcinoma)
CT scan (more sensitive than X-ray)
chest X-ray is required for any cough that lasts longer than 3
W.
Observation/ Arrange appropriate follow up visit in 2-3 week
follow up
Plan/prevention Offer immunization for flu, Covid-19 vaccination
and smoking quitting advice
Conclusion Includes Safety netting

93
 Acute Bronchitis

CRAPRIOP for Management

Acute bronchitis is typically associated with a cough that is worse
at night or with exercise; lasts >2 weeks in 50% of patients and 4
weeks in a 25% of patients; may be associated with bronchospasm
and/or excessive mucus production.

Diagnosis is primarily clinical. Other causes for acute cough such

as pneumonia, asthma, or postnasal drip should be ruled out if
suspected.

Treatment is aimed at symptom reduction until infection is

Clarification resolved and bronchial damage repaired. Antibiotics are not
recommended in the majority of patients.
Complications are rare; the primary complication is a post
bronchitis syndrome, which can produce a cough lasting several
months.

.‫التهاب الشعب الهوائية التهاب في بطانة شعبتا القصبة الهوائية‬

‫ قد‬.‫ والذي ميكن أن يتغّير لونه‬،‫عادة ما يسعل املصابون بالتهاب الشعب الهوائية مخاًطا سميًكا‬
Reassurance .‫يكون التهاب الشعب الهوائية حاًدا أو مزمًنا‬
‫ينشأ التهاب الشعب الهوائية احلاد غالًبا من نزالت البرد أو أي عدوى أخرى في اجلهاز التنفسي؛‬
‫ فعبارة عن‬،‫ وهو حالة مرضية أكثر خطورة‬،‫ أما التهاب الشعب الهوائية املزمن‬.‫فهو شائع احلدوث‬
.‫تهيج مستمر أو التهاب في بطانة أنابيب الشعب الهوائية ينتج غالًبا عن التدخني‬
‫ضا بالبرد الصدري في غضون أسبوع‬ ً ‫عادة ما يتحسن التهاب الشعب الهوائية احلاد املعروف أي‬
.‫ بينما قد يستمر السعال ألسابيع‬،‫ أيام دون آثار طويلة املدى‬10 ‫إلى‬
.‫ وهي عادة الفيروسات نفسها التي تسبب نزالت البرد واإلنفلونزا‬،‫غالبًا بسبب الفيروسات‬
‫املضادات احليوية ال تقتل الفيروسات؛ لذلك ال يفيد هذا النوع من األدوية في معظم حاالت‬
.‫التهاب الشعب الهوائية وال نحتاج إلى أشعة صدر للتشخيص ّيكتفى بالتاريخ املرضي‬
Patient education about acute bronchitis being a self-limited illness
that usually resolves in up to 4 weeks
without treatment can help with patient satisfaction.
Advice Counselling patients who smoke that they should discontinue
cigarette use is the most effective approach to
preventing acute bronchitis. In addition, there is some evidence
that the use of vitamin A and vitamin D could
reduce the risk of acute bronchitis and other respiratory infections.
Honey and Pelargonium sidoides.

94
 Acute Bronchitis

Supportive care and symptom management are the

mainstay of treatment for acute bronchitis.
• Over-the-counter as 1st treatment for acute cough.
• Ibuprofen and acetaminophen
Prescribing • Antihistamines used with decongestants
• Antitussives
• Expectorants: Guaifenesin
• Beta 2 agonist
• Antibiotic
For chest X-ray if :

Referral

Lab: Needed to exclude other diagnoses such as asthma or

Investigations pneumonia.
Imaging:
No need .
Long term monitoring is rarely necessary.
Observation Symptoms resolve in most patients within a few weeks.
For patients with post-bronchitis syndrome, further evaluation
follow up to rule out other causes of chronic cough such as asthma,
postnasal drip, oesophageal reflux, ACE-inhibitor use, or
infections (e.g., tuberculosis) may be necessary.
Plan • smoking cessation
Prevention • Influenzas vaccine
Conclusion Includes Safety netting

95
Acute Bronchitis

96
Acute Bronchitis

97
Acute Bronchitis

98
 COVID-19
CRAPRIOP for Management
Coronavirus disease 2019 (COVID-19) is an infectious acute respiratory
disease caused by a novel coronavirus. (WHO) was informed of cases of
pneumonia of unknown microbial aetiology associated with Wuhan City,
Hubei Province, China on 31 December 2019.
Clarification COVID-19 is a notifiable disease.
‫ضا مثل الزكام‬ً ‫فيروسات كورونا هي عائلة من الفيروسات التي ميكنها أن تسبب أمرا‬
‫ وأعراضه‬2019 ‫وااللتهاب التنُّفسي احلاد قد تظهر مؤشرات مرض فيروس كورونا املستجد‬
.‫ يوًما من التعُّرض له‬14 ‫بعد يومني إلى‬
Reassurance .‫وتسمى هذه الفترة التي تلي التعُّرض للفيروس وتسبق ظهور األعراض بفترة احلضانة‬
.‫ قبل أن تظهر عليك األعراض‬19 ‫بإمكانك نشر عدوى فيروس‬
‫ مثل ضيق النفس‬،‫ وقد تتفاقم األعراض‬.‫بعض األشخاص ال ُيصابون سوى بأعراض قليلة‬
.‫والتهاب الرئة لدى بعض األشخاص بعد بداية ظهور األعراض بأسبوع تقريًبا‬
• Provide supportive care, Hand hygiene
• Isolate all suspected or confirmed cases immediately
Advice • Get vaccine
‫ باللغة العربية‬:‫الرعاية املنزلية للمصابني ومخالطيهم‬
[Link]
[Link]
Management predominantly depends on disease severity and
focuses on the following principles: isolation at a suitable
location; infection prevention and control measures; symptom
management; prevention of disease progression; optimized
supportive care.

Generally, patients with asymptomatic or mild to moderate

disease can be managed at home.

Start supportive care according to the clinical presentation.

Prescribing This might include symptom relief, oxygen therapy, intravenous
fluids, venous thromboembolism prophylaxis, high-flow nasal
oxygen (HFNO), non-invasive or invasive mechanical ventilation,
or extracorporeal membrane oxygenation.
• empirical antibiotics if there is clinical suspicion of a
secondary bacterial infection.
• systemic corticosteroid therapy in patients with severe or
critical disease.
• the antiviral remdesivir in patients with severe disease.
• an interleukin-6 inhibitor (tocilizumab or sarilumab) in
patients with severe or critical disease.

99
 COVID-19

Referral See next pages

Widespread screening of asymptomatic people is no longer
recommended in most countries.
The WHO recommends testing all people who meet the
suspected case definition, regardless of vaccination status or
disease history
Investigations 1st investigations to order
real-time reverse transcription polymerase chain reaction (RT-
PCR)
rapid antigen test
pulse oximetry
ABG
Observation See next page
follow up
Primary prevention by Vaccines
(WHO) has authorized the use of the following monovalent
vaccines for global use:
• mRNA vaccines: (Pfizer/BioNTech), (Moderna)
Plan • Adenovirus vector vaccines
Prevention • Protein subunit vaccines
• Inactivated virus vaccines.
One-, two-, or three-dose schedules may be recommended
depending on the vaccine used and the patient’s age.
Lifestyle modifications (e.g., smoking cessation, weight loss) may
help to reduce the risk of infection.
Conclusion Includes Safety netting

[Link]
s/Documents/[Link]

100
 Standard precautions

Droplet and contact precautions

available
• Cohort, if not
Airborne precautions

• Single room, if
Isolate or cohort
For aresol-generationg procedures
COVID-19

101
 Pneumonia CAP
Community Acquired Pneumonia
Pneumonia is inflammation of the lungs. It categorised according to the causative organism.
Typical symptoms might include fever, cough, dyspnoea, and chest pain. Because each specific
type of pneumonia may result from a different aetiology and pathogenic mechanism, each
subtype also has its characteristic risk factors, signs, and symptoms.
• Community-acquired pneumonia (CAP) is defined as pneumonia acquired outside hospital
or healthcare facilities. Patients with CAP typically present with signs and symptoms of
lower respiratory tract infection.
Bacterial and viral pathogens are the leading cause of CAP; most infections are caused
by Streptococcus pneumoniae
However, other studies have found that influenza virus is the most common cause of CAP in
adults
Clinical judgement along with a validated prediction rule for prognosis are used to determine
the need for hospital admission in adults with CAP.
Confirm diagnosis in all patients presenting to hospital with evidence of consolidation on chest
x-ray.
A chest x-ray should not be requested routinely for CAP
Use the CURB-65 mortality risk score (hospital setting) or CRB-65 severity score (community
setting), together with your clinical judgement, to decide whether to manage the patient in
hospital or at home and to determine appropriate therapy.
Risk factors
• age >65 years
• residence in a healthcare setting
• COPD
• exposure to cigarette smoke
• Overuse of PPI

CRAPRIOP for Management

.‫االلتهاب الرئوي هو التهاب احلويصالت الهوائية في إحدى الرئتني أو كلتيهما‬
‫ بسبب مجموعة متنوعة من الكائنات‬.‫قد متأل احلويصالت الهوائية بالسوائل أو بالصديد‬
‫ والفيروسات والفطريات‬،‫ مبا في ذلك البكتيريا‬،‫احلية‬
.‫ وصعوبة في التنفس‬،‫ وحمى‬،‫يظهر االلتهاب سعال مصحوب بالبلغم أو صديد‬
Clarification
‫ميكن أن يتراوح مدى خطورة االلتهاب الرئوي من درجة خفيفة إلى درجة شديدة اخلطورة وتهدد‬
،‫ سنة‬70 ‫ واألشخاص األكبر من‬،‫ ويكون أكثر خطورة على الرضع واألطفال الصغار‬.‫احلياة‬
.‫واألشخاص الذين يعانون من مشاكل صحية أو ضعف في جهاز املناعة‬
Reassurance In 2019, lower respiratory tract infections affected 489 million
people worldwide. Children <5 years old and adults >70 years
old were the populations most affected by pneumonia.
Patients treated in the community generally have a good
prognosis.

102
 Pneumonia CAP
• Get vaccinated.
Advice • Make sure children get vaccinated.
• Practice good hygiene.
• Don't smoke.

Prescribing

Severe CAP, use of corticosteroids within 36 h improves

outcomes(A).
Referral See next page
1st investigations to order
• chest x-ray
Investigations • pulse oximetry
• arterial blood gas (ABG)
• urea and electrolytes
Advise patients to seek medical advice if their symptoms
worsen rapidly or significantly; symptoms do not start to
improve within 3 days; or they become systemically very unwell.

Observation Do not request a repeat chest radiograph before discharge from

follow up hospital in patients who have recovered satisfactorily from CAP.

Arrange a follow-up visit at around 6 weeks either with the

patient’s general practitioner or in a hospital clinic

Consider bronchoscopy in patients with persisting signs,

symptoms, and radiological abnormalities at around 6 weeks
after completing treatment.
The main means of prevention are pneumococcal and influenza
Plan/ vaccination of at-risk people and smoking cessation.
prevention Insufficient evidence to determine the effect of vitamin C or D
supplementation in the prevention (or treatment) of
pneumonia.
Conclusion Includes Safety netting

103
Pneumonia CAP
Note: Pneumonia Severity Index (PSI) is important to decide if the patient
need to hospital admission or can be treated in Out-Patient.

CURB-65 and CRB-65 Mortality prediction

tools for patients with CAP
0-1
Low-severity
(risk or death<3%)

Yes

Influenza vaccination

0
Low-severity

Likely suitable for

home treatment*

PNEUMOCOCCAL VACCINE FOR ADUTS

Pneumococcal vaccination

104
 Smoking Cessation Counselling
Smoking History
Explore the patient’s current ICEE regards to smoking:
Establishing ICE creates common ground between you and the
patient, this will help you to tailor your advice and make sure the
ICEE patient feels listened to
• How do you feel about smoking?”
• Is there anything that worries you about smoking or giving up?”
• What are you hoping to get from the visit today?”
• Does affect your life? How?
It’s important to take a comprehensive smoking history before counselling
a patient about smoking cessation.
In an OSCE, you may be provided with these details in the brief
Asked to move straight on to counselling.

1. What type of tobacco/nicotine does the patient use?

2. How long has the patient been smoking?
(pack-years = [number of years smoked] x [average number of packs
smoked per day]; one pack is equal to 20 cigarettes)
3. How much does the patient smoke?
4. In what situations does the patient smoke?
5. How does smoking make the patient feel?
6. How does the patient finance their smoking habit?
Smoking 7. Has the patient previously tried to quit? If so, what resulted in the
Hx patient relapsing?
8. Does the patient experience any withdrawal symptoms?
(Craving, irritability, dizziness, low mood, fatigue, insomnia)
9. Assess Alcohol intake by using CAGE questionnaire.

Medication Currently or was previously prescribed any nicotine replacement

(if so, ask the patient about its effectiveness).
Family Hx Explore the patient’s family history for evidence of malignancy (this may
suggest an increased baseline risk for the patient)
1. Ask about recreational drug use.
2. Explore psychosocial aspects of the patient’s health including stressors
Social hX at home and work – do these factors affect their smoking habit?
3. Ask about the patient’s employment: does this have a relationship with
their smoking

105
 Smoking Cessation Counselling

5 A’s for counselling

Ask Ask about and record the patient’s smoking status.

• Commend the patient for coming in to speak to you about smoking
cessation and advise the patient on the risks of smoking and long-
term effects on their own health (e.g. risk factor for cardiovascular
disease, lung cancer, stroke, peripheral vascular disease).
• Reassure the patient that the healthcare team will
Advise provide support throughout the process.
• Even if the patient is not ready to quit, it is still important to advise
them to quit (reducing frequency/quantity can be used as an
alternative but complete cessation is still advised)
1. Assess the patient’s understanding of the consequences of
smoking in relation to their own health condition(s).

2. Explore the patient’s views on smoking cessation and ask if they

currently feel motivated to quit.
Assess 3. Attempt to quantify the patient’s level of motivation by asking
them to describe their level of motivation on a scale from 1 to 10;
with 1 being the least motivated and 10 being the most
motivated.

106
 Smoking Cessation Counselling
Use the Stages of Change model to guide the assessment of behaviour
modification. The stages of this model include:
§ Pre-contemplation: no interest in changing behaviour
Assess § Contemplation: an awareness of the negative aspects of smoking
§ Preparation: an understanding of why they should quit smoking
§ Action maintenance: an attempt to stop smoking
§ Relapse: the attempt to quit was unsuccessful
Use the STAR approach:
1. Set a quit date based on the patient’s willingness, motivation and
agreement. This should usually be within 2-4 weeks (abrupt
quitting is usually more effective than gradual quitting).
2. Tell family and friends. Advise the patient to make family and
Assist friends aware that they are quitting to provide further
accountability and support.
3. Anticipate challenges that a patient will face and make plans on
how to overcome them.
4. Remove all tobacco products as well
as recommending counselling programs and pharmacological
therapies as indicated
I. Nicotine replacement therapy:
o Used as first-line therapy and available in a variety of forms (e.g.
patches [7mg, 14mg or 21mg], spray)

Pharmacological
therapies

o Increases successful cessation by 1.5 times

o Caution in patients with cardiovascular disease or acute coronary
syndrome

107
 Smoking Cessation Counselling
I. Bupropion:
o Increases successful cessation by 2 times
o Advise the patient to commence the medication for 1-2 weeks before
the quit date and complete a 12-week course
o Contraindications: hypersensitivity reactions, seizure disorders and
eating disorders
Pharmacological
therapies
I. Varenicline:
• Works as a nicotine receptor partial agonist
• It is the most effective pharmacological therapy, increasing successful
cessation by greater than 2 times
• Advise the patient to commence the medication 1 week before their
quit date and complete a total course of 12 weeks
• Contraindications: hypersensitivity reactions
Brief intervention:
A brief form of face-to-face behavioural therapy
These short discussions have been shown to increase overall abstinence
rates
Non Individual counselling:
pharmacological
sessions consisting of multiple visits by a trained therapist
therapies
Group counselling:
a group setting can provide mutual support
Telephone counselling:
A proactive approach involving a counsellor calling the patient at a pre-
arranged time
Follow-up appointment within 1-2 weeks
The highest rates of relapses in the first 3 months of cessation.

In the event of a relapse, reassure the patient that this is not a setback but
merely a natural part of the behavioural modification process.
Patients will often need multiple attempts to achieve permanent cessation.
During each follow-up visit:
1. Assess the level of motivation
Arrange 2. Congratulate and encourage the patient to remain abstinent
3. Monitor progress and response to therapies
4. Identify current and upcoming challenges
5. Remain supportive and help to develop plans to overcome challenges
Recommendations for the frequency of follow-up visits:
• Within 1-2 weeks after the patient’s quit date and then at 4 weeks
• At 3 months and 1 year to follow-up on new side effects, smoking status
and relapse
• Ask the patient if they have any questions or concerns that have not
been addressed.
Closing • Check the patient’s understanding at regular intervals using “teach-
Session back” by asking phrases like “Can you repeat back to me just to make
sure I have mentioned the important points regarding…..?”
• Direct to further information using websites and leaflets

108
 Peak Flow Meter Use counselling

Introduce yourself and establish good rapport ( Name, age and job).

Explain the device's:

- Name: Peak Flow Meter (PFM).
- Purpose: "Tells you how well your Iungs are working with the current medications
and serves as an early warning sign of deterioration".
- Show the patient the instrument and explain its parts (clear plastic body,
logarithmic scale, internal flow indicator with color zones, mouth piece).

Explaining and demonstrating to the patient how to use the device:

§ Ensure the pointer is at zero.
§ Proper posture: standing (sitting will restrain the diaphragm movement by stomach
contents giving a false reading), avoid bending your neck down, no
§ food or gum in the mouth.
§ Hold the peak flow meter so that your fingers are clear of the scale.
§ Breath in as deeply as possible and hold your breath.
§ Place the mouthpiece well into your mouth (bite mouth piece lightly and seal your lips
firmly around it).
§ Ensure that you are not blocking the mouthpiece with your tongue or teeth. Blow as
hard and as fast as you can.
§ Write down the level (aside) and put the marker back to zero.
§ Repeat the measurement 3 times and record the highest reading on the chart as your
peak expiratory flow (PEF) L\min.
§ Allow the patient to use the PFM by his or her own and tell you what the actual
reading is, determine if he or she does that correctly.

Determining the personal best peak flow number:

§ When you get out of this attack, measure your PFM daily, between 12-2 pm, between 7-
9 am and 6-8 pm for 2-3 weeks so that you know your best Peak Expiratory Flow Rate
(PEFR) number.
§ Record any event that has happened and might have exacerbated your cough (e.g.
common cold).
§ You will notice that your readings will not form a flat line but more of a zigzag pattern.
which is normal.

Explain the peak flow zones and action plan:

§ Based on the best PEFR number that you will get, we will develop an accurate action
plan.
§ Meanwhile, we will use a specific calculation formula that uses your age and height to
estimate your expected PEFR.
§ Using the readings, we develop an action plan to help you control your asthma and
modify your treatment as needed. Possible readings are divided into different zones that
are colored as the traffic light.
§ Any drop below the zone means that you need to step up your medications

109
 Peak Flow Meter Use counselling
Green zone Yellow zone Red zone
50-79% of predicted PEFR.
Means: Caution: asthma is Less than 50% of
getting worse. predicted PEFR.
More than or equal Means: medical alert.
80% of predicted Mild symptoms (wheezing,
coughing, waking at night). Severe symptoms: Shortness
PEFR. Of Breath (SOB), decreased
Means: Good control Take a dose of the
activity tolerance. Take a
rescue medication
Asymptomatic. rescue medication as well as
Use daily long-term and repeat the oral steroid I available. Then
medications if any + reading in an hour. If call your doctor. If you
you go back to the remain in the red zone after
rescue medications as
green zone then well 15 minutes, repeat the rescue
needed before and call the ambulance.
exercise. and good.
Otherwise repeat a rescue Continue repeating the
dose. Then arrange an rescue every 15 minutes until
the paramedics
appointment with me so arrive or you improve.
that we adjust your therapy.

Advise:
After determining your best
PEFR, use the PEF meter every
morning, and whenever you
have any symptoms.

The instrument needs to be

cleaned, according to the
manufacturer's instructions,
every now and then. Store
away from dirt and dust.

110
 Metered dose inhaler Use counselling

Introduce yourself and establish good rapport ( Name, age and job).

Explain the device's:

Name: Metered Dose Inhaler (MDI).
Purpose: either used as a symptom reliever "quick acting medication that opens the airways and resolves
your symptoms during an attack" or as a preventer
"slow acting medication that prevents the symptoms from occurring in the first place".
-If both types of inhalers are prescribed, advise the patient to use the symptom reliever first.
-Show the patient the inhaler and explain its parts (cap, mouth-piece, plastic holder, canister, with or
without spacer). Emphasize on the need to revise the expiry date, and double-check that the inhaler is
not empty prior to use.

Explain the steps of use

§ "It is very important to use your inhaler correctly so that the medication in the spray reaches deep into
your lungs to treat your asthma":
§ Sit upright or stand up for better medication delivery.
§ Remove the cap and check correct positioning (canister up/L-shape).
§ Shake the inhaler for 1-2 seconds.
§ Breath out slowly and gently through your mouth.
§ Put the mouth piece into your mouth, and seal tightly with your lips.
§ Tilt your head back slightly with your chin up.
§ Start to breathe in slowly through your mouth while pressing the puffer firmly as you do so.
§ Continue breathing in from your mouth as far as you can for 3-5 seconds.
§ When you cannot breath in any more take the inhaler out of your mouth and hold breath for 10
seconds, then breathe out gently.
§ In case your dose is more than 1 puff; repeat steps c to h as above after 1 minute.
§ Re-cap the inhaler, wash your mouth if steroid inhaler used.
§ Let him or her do it and observe to correct.

Advise the patient about taking care of the MDI:

§ Wash the cap twice a week.
§ Ensure that you always have the reliever around in case you need it.
§ Introduce the patient to spacers and their benefits -"Many people who have trouble using inhalers do
better when using a special device called a spacer. It is very efficient and cause less irritation of the
mouth and throat":

Indications:
§ Children less than 5 years, elderly, or patients who have difficulty coordinating.
§ Show the patient the instrument and explain its parts: (inhaler entry port, body, valve, mouthpiece
mask and cap).

Method of use:
§ Repeat the instructions above (steps mentions above) then advise the patient to: -Press on the
canister once to deliver one puff into the spacer.
§ Take 4 normal breaths in and out from the mouthpiece.
§ Repeat the above for the number of puffs needed.

111
 Metered dose inhaler Use counselling

Advise the patient about taking care of the spacer:

§ Prime the spacer by pushing one puff in before first use. Clean by rinsing it
with water only once a week.
§ Do not use soap and do not attempt rubbing the spacer from inside, allow the device to dry
overnight.
§ Replace the spacer every 6 months. Encourage any
questions.

Ensure:
§ Positive reinforcement "Many others use it, you can definitely use it correctly".
"We are always available to support you".
§ Patient understands the doses (reliever: 1-2 puffs every 3-4 hours).
§ Patient understands side effects of short acting beta agonist: palpitations, tremors.
§ Arranging a follow up.
§ Give away reading materials if available.

Step 1: Shake the inhaler and remove the cap

Step 2: Hold the inhaler upright and
insert it into the spacer

Step 3: Place the mask spacer Step 4: Press down on the inhaler

Step 5: Have your child breathe in the medicine

112
PFT interpretation

113
Cardiology

114
Cardiology
HTN
• Newly diagnosed
• Follow up
Palpitation
Heart failure
Chest pain (MI) + counselling
Dyslipidemia

115
 Hypertension Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present illness - Hypertension is typically asymptomatic
Chief complain (open - If already diagnosed ask about 3Cs: complain, compliance to
question) medications, complications
Analysis of chief complain SOCRATES for pain & headache if present
Associated symptoms or secondary HTN
Symptoms of secondary HTN
• Symptoms suggestive of obstructive sleep apnea: (snoring ”notes by others”, day somnolence,
decrease concentration & fatigue)
• Symptoms suggestive of coarctation of the aorta: (headache, epistaxis, intermittent claudication,
lower limb weakness, cold legs and feet)
• Symptoms suggestive of kidney disease: (hematuria, ‘frothy’ urine suggestive of proteinuria,
dyspnea (pulmonary edema), lower limb swelling (peripheral edema), flank tenderness and pain,
weight loss is suggestive of renal cell carcinoma)
• Symptoms suggestive of endocrine disease:
• muscle weakness, muscle spasms and paresthesia (hyperaldosteronism).
• Severe headache, palpitations and sweating (pheochromocytoma).
• weight gain particularly abdominal, facial and on the back of the neck and shoulders (Cushing’s
syndrome)
• tall statures, swelling of the hands and feet and deepening of the voice (acromegaly).
• weight gain, cold intolerance and low mood (hypothyroidism).
• weight loss, heat intolerance and palpitations (hyperthyroidism).
Presence of CV-Risk factors (DM, dyslipidemia, obesity and smoking)
Red Flags “end organ damage”:
• Stroke or increase intracranial pressure & hypertensive retinopathy
Analysis of chief (headache, visual disturbances or, weakness, seizures, nausea and
complain vomiting)
• CHD or MI or arrhythmia (Chest pain, dyspnea, palpitation & claudication)
Medical (chronic disease)
Surgical Hx & Allergy
Medications (glucocorticoids, oral contraception pill, NSAID, TCA, nasal
Past Hx decongestant, cocaine & stimulants, amphetamine, cyclosporine, tacrolimus,
antihistamine, erythropoietin and OCPs)
Herbal (licorice, ephedra &bitter orange)
Family Hx FHx of HTN and associated diseases (DM, dyslipidemia, CAD, stroke, or renal
disease).
Lifestyle: physical inactivity, alcohol intake, sodium intake, and psychosocial
stress
Psychosocial Marital status
Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

116
Hypertension Ex

General Vital signs (BP both arms) & Weight, height, BMI, and waist & neck
circumference
Examination • Cardiac and vascular examination: carotid bruit, abdominal bruit
&presence of peripheral pulses
• Coarctation of the aorta findings: systolic murmur in the left
infraclavicular region under the left scapula and radio-
femoral delay.
• Abdominal examination: renal masses and bruit, aortic aneurysm
and abdominal obesity
• Autosomal dominant polycystic kidney disease
findings: enlarged palpable kidneys when balloting the
kidneys.
• Renal artery stenosis findings: renal bruits heard when
auscultating over the area of the renal arteries.
• Neurological examination to look for evidence of stroke
• Signs of endocrine disorders
• Cushing’s syndrome: moon facies, abdominal purple striae
Special Ex and bruising.
• Hyperthyroidism: fine tremor, palmar erythema and a neck
goiter.
• Pheocromocytoma: skin stigmata of neurophypromatosis
Café au lait spots
• Retina examination for hypertensive changes (papilledema &
hemorrhage). Dilated fundoscopic examination by an ophthalmologist
is recommended afterwards.
Assessing cardiovascular disease risk (QRISK3-online tool) contain
patient gender, age, ethnicity, smoking status and presence of
comorbidities to generate an overall percentage that estimates the
risk of a patient having a heart attack or stroke in the next 10 years
Basic workup:
1. Urinalysis (protein, glucose, blood, casts)
2. Blood chemistry: potassium, sodium, creatinine with e-GFR, fasting
blood glucose, and serum uric acid
Investigations 3. Complete fasting lipid profile
4. Hemoglobin and hematocrit
5. Electrocardiography (ECG)
Additional Optional Investigations, if needed:
1. TSH, Free T4
2. Chest X-ray
3. Abdominal sonography
4. Echocardiography

117
 Hypertension
CRAPRIOP for Management
High blood pressure or (hypertension) is a chronic and
common condition that affects the body's arteries. If you
have high blood pressure, the force of the blood pushing
against the artery walls is consistently too high. The heart
Clarification has to work harder to pump blood.
‫ارتفاع ضغط الدم هو مرض مزمن و شائع يحدث عند حصول ضغط مستمر على‬
.‫ وعادة ال يكون له أعراض‬،‫جدران الشرايني وعلى مدى طويل‬
.‫سبب اإلصابة به هو زيادة عبء العمل على القلب واألوعية الدموية‬
It is common problem worldwide, 1 in 4 men and 1 in 5
women had hypertension
Reassurance With proper healthy lifestyle & medication can be
controlled.
• DASH diet (low fats and rich in potassium, calcium,
magnesium, fiber, and proteins, vegetables and fruits)
effect on BP:-11.4/-5.5mmHg
• Sodium reduction (<1500mg/day) effect on BP:-5.8/-
2.5mmHg
• Weight loss (loss 4.5kg) effect
Advice on BP:-7.2/-5.9mmHg
• Exercise (3 times/week or 30minutes on most days of
the week, aerobic or dynamic resistance exercise)
effect on BP:-10.3/-7.5mmHg
• Smoking cessation
• ‫ شراب الكركديه‬Hibiscus
Prescribing Mentioned below
• Resistant HTN & Malignant HTN
• Suspicion of secondary HTN
• Sudden onset of HTN
Referral • HTN diagnosed at young age 30 Y
• Worsening of HTN
• Ophthalmology , dietitian, smoking clinic
Investigations Mentioned above
Observation/ follow up after 2 weeks-4 weeks until BP goal archived.
•
After BP is at goal and stable, follow up visits can
•
follow up
usually be at 3 to 6 monthly.
Plan/prevention Health promotion & screen according to the age
Conclusion Includes Safety netting (mention the red flags)
118
 JNC 8 HTN Guideline
Adult aged ≥ 18 years with HTN
Implement lifestyle modifications
Set BP goal, initiate BP-lowering medication based on algorithm

General Population
(no diabetes or CKD) Diabetes or CKD present

Age ≥ 60 years Age < 60 years All Ages All Ages and Races
Diabetes present CKD present with or
No CKD without diabetes
BP Goal BP Goal
< 150/90 < 140/90
BP Goal BP Goal
< 140/90 < 140/90

Nonblack Black Initiate ACEI or ARB,

alone or combo
w/another class
Initiate thiazide, ACEI, ARB, Initiate thiazide or CCB,
or CCB, alone or in combo alone or combo**

Yes
At blood pressure goal?
No
Reinforce lifestyle and adherence
Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide)

Yes
At blood pressure goal?
No
Reinforce lifestyle and adherence
Add a medication class not already selected (i.e. beta blocker, aldosterone antagonist, others) and titrate
above medications to max (see back of card)

Yes
At blood pressure goal? Continue tx and monitoring
No
Reinforce lifestyle and adherence
Titrate meds to maximum doses, add another med and/or refer to hypertension specialist

**Thiazide diuretics more effective than ACEI for improving heart failure and cardiovascular outcomes in African Americans.
•CCBs more effective than ACEI for reducing strokes in African Americans.
•ACEI/ARB still recommended in CKD, heart failure

Strategy Description Lifestyle changes:

Start one drug, titrate to maximum dose, and then add a • Smoking Cessation
A • Control blood glucose and lipids
second drug.
• Diet
B Start one drug, then add a second drug before achieving
ü Eat healthy (i.e., DASH diet)
max dose of first ü Moderate alcohol consumption
Begin 2 drugs at same time, as separate pills or ü Reduce sodium intake to no more than 2,400 mg/day
combination pill. Initial combination therapy is • Physical activity
C recommended if BP is greater than 20/10mm Hg ü Moderate-to-vigorous activity 3-4 days a week averaging 40
above goal min per session.

119
 HTN follow up Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question)

Allow pt. to explain the chief complain
illness
Course, onset and duration
SOCRATES & Associated symptoms (DDx)
• Check the patient level of understanding of HTN & explore his false
beliefs .
• Hx of HTN : duration ,severity, compliance to drug.
Analysis of Drug use : type, dose, side effect, compliance and using herbs.
• CVS Risk assessment: ( family hx of MI, smoking, exercise) Co-
chief morbidities (DM, DLP, obesity).
complain Red Flags “end organ damage”:
• Stroke or increase intracranial pressure & hypertensive retinopathy
(headache, visual disturbances or, weakness, seizures, nausea and
vomiting).
• CHD or MI or arrhythmia (Chest pain, dyspnea, palpitation, LL
edema & claudication).
Medical (chronic disease)
Surgical Hx & Allergy
Past Hx Medications (glucocorticoids, oral contraception pill, NSAID, TCA, nasal
decongestant, cocaine & stimulants, amphetamine, cyclosporine,
tacrolimus) Herbal (licorice, ephedra &bitter orange)
Family Hx HTN, stroke, renal disease, DM, IHD and sudden death.
Lifestyle: physical inactivity, alcohol intake, sodium intake, and
psychosocial stress
Psychosocial Marital status
Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

120
HTN follow up Ex
Vital signs (confirm BP by appropriate technique
General ,sitting and standing , for both arms), weight, height,
BMI, and waist circumference.
• Cardiac and vascular examinanon: carond bruit,
abdominal bruit &presence of peripheral pulse
• Coarctanon of the aorta findings: systolic murmur
in the leq infraclavicular region under the leq
scapula and radio-femoral delay.
• Abdominal examinanon: renal masses and bruit,
aornc aneurysm and abdominal obesity
• Autosomal dominant polycysnc kidney disease
findings: enlarged palpable kidneys when
ballonng the kidneys.
• Renal artery stenosis findings: renal bruits
heard when auscultanng over the area of the
renal arteries.
• Neurological examinanon to look for evidence of
stroke.
Special • Signs of endocrine disorders
• Cushing’s syndrome: moon facies, abdominal
purple striae and bruising.
• Hyperthyroidism: fine tremor, palmar
erythema and a neck goiter.
• Pheochromocytoma: skin sngmata of
neurofibromatosis café au lait spots
• Renna examinanon for hypertensive changes
(papilledema & hemorrhage). Dilated fundoscopic
examinanon by an ophthalmologist is
recommended aqerwards.
• Extremines for arterial pulse (radio femoral delay
and LL edema).
• Peripheral pulses (dorsalis pedis, popliteal &
femoral).

121
 HTN follow up
Assessing cardiovascular disease risk (QRISK3-
online tool) contain patient gender, age, ethnicity,
smoking status and presence of comorbidities to
generate an overall percentage that estimates the
risk of a patient having a heart attack or stroke in
the next 10 years
Basic workup:
1. Urinalysis (protein, glucose, blood, casts) 2.
Blood chemistry: potassium, sodium,
Investigations creatinine with e-GFR, fasting blood glucose, and
serum uric acid
3. Complete fasting lipid profile
4. Hemoglobin and hematocrit
5. Electrocardiography (ECG)
Additional Optional Investigations, if needed:
1. TSH, Free T4
2. Chest X-ray
3. Abdominal sonography
4. Echocardiography

CRAPRIOP for Management

‫يجب متابعة الضغط بشكل مستمر واحلرص على القراءات باملعدل الطبيعي‬
‫للعمر وذلك ألن الضغط الزائد على جدران شرايينك بسبب ارتفاع ضغط‬
‫ وكلما‬.‫الدم قد يؤدي إلى تلف أوعيتك الدموية باإلضافة إلى أعضائك‬
.‫ زاد التلف‬،‫ارتفع ضغط الدم وطالت مدة عدم السيطرة عليه‬

Clarificawon :‫قد يؤدي ارتفاع ضغط الدم غير املسيطَر عليه إلى مضاعفات منها‬
،‫ فشل القلب‬،‫ متدد األوعية الدموية‬،‫النوبة القلبية أو السكتة الدماغية‬
،‫ضعف األوعية الدموية أو ضيقها في الكلى‬
‫ مشكلة في‬،‫زيادة سمك األوعية الدموية في العني أو ضيقها أو متزقها‬
‫ اخلرف )قد تقلل الشرايني الضيقة أو املسدودة من‬،‫الذاكرة أو االستيعاب‬
.(‫ ما يؤدي إلى نوع معني من اخلرف )اخلرف الوعائي‬،‫تدفق الدم إلى املخ‬
With proper healthy lifestyle & medication can be
Reassurance controlled.

122
 HTN follow up

• Stress on importance compliance on TTT to

avoid complication, target (BP): <140/90 or <
150 in elder patients.
• Correct false beliefs of HTN and anti
hypertension medications.
• DASH diet.
Advice • Sodium reduction.
• Weight loss.
• Exercise (3 times/week or 30minutes on most
days of the week, aerobic or dynamic resistance
exercise).
• Smoking cessation
• Hibiscus ‫ﺷراب اﻟﻛرﻛدﯾﮫ‬
Prescribing Detailed management mentioned above
• Resistant HTN & Malignant HTN
• Suspicion of secondary HTN
• Sudden onset of HTN
Referral
• HTN diagnosed at young age 30 Y
• Worsening of HTN
• Ophthalmology , dietitian, smoking clinic
Investigations Mentioned above
• follow up after 2 weeks-4 weeks until BP goal
Observation/ archived.
follow up • After BP is at goal and stable, follow up visits
can usually be at 3 to 6 monthly.
Plan/prevention Health promotion & screen according to the age
Conclusion Includes Safety netting (mention the red flags)

123
 Initial Drugs of Choice for Hypertension
thiazide, ACEI, ARB, or CCB, alone or in combo
Agents of Choice Comments

-Increase excretion of
-Na
-K (Monitor for hypokalemia)
-Mg (Complicates correction of hypo-K)
-Reduce excretion of
-Ca (reduce recurrence of kidney stones; slows bone
demineralization/osteoporosis)
-Uric acid (increases likelihood of gout)
Diuretics
Thiazide

Thiazide SE mnemonic

-Lithium (increases risk of lithium toxicity)

Hyper GLUC -Average increase in glucose attributed to thiazide
HyperGlycemia use: 3-5 mg/dL (Presence of diabetes is not a
contraindication to use of thiazides)
HyperLipidemia -Can increase triglycerides
HyperUrecemia Typically considered ineffective when GFR <30-40
mL/min, Exception is Metolazone
HyperCalcemia -Most effective when combined w/ ACEI
-Stronger clinical evidence w/chlorthalidone
-In the population >18 years with CKD,
treatment should include an ACEI or ARB to
improve kidney outcomes (regardless of race
or diabetes status).
-Slows the progression of microalbuminuria in
diabetic patients
-Do not use an ACEI and an ARB together in
the same patient.
-SE: Cough in 10-20% of patients, due to
bradykinin accumulation (ACEI only),
ACEI/ARB

angioedema is 2-4 times more common in African-

American patients (more with ACEI),
hyperkalemia.
Losartan lowers uric acid levels; candesartan
may prevent migraine headaches
Treatment-Induced Decline in Renal Function
•A 20-30% increase in creatinine, which then stabilizes, represents a hemodynamic change, and not a
structural change (if more than 30%, look for other causes and change to another class of meds).
•This is an indirect indicator that intraglomerular (IG) pressure has been reduced.
•Independent of agent used
•ACEI/ARB also dilate efferent arteriole, exaggerating decline in IG pressure

Cause edema;
Calcium channel

Dihydropyridines: amlodipine 5-10mg, Dihydropyridines vasodilators with little or no

negative effect upon cardiac contractility or AV nodal
blockers

nifedipine ER 30-90mg,
conduction may be safely combined w/ B-blocker
Non-dihydropyridines: diltiazem ER 180-
360 mg, verapamil 80-120mg 3 times Non-dihydropyridines less-effective vasodilators that
daily or ER 240-480mg slow AV nodal conduction
(verapamil > diltiazem) and have negative inotropic
effect reduce heart rate and proteinuria

124
 Resistant hypertension
Persistent HTN despite >3 drugs
-Most common cause: poor adherence
-Exogenous drugs
-Caffeine (energy drinks, supplements), alcohol, nicotine, cocaine, NSAIDs, OCPs,
steroids, erythropoietin, herbal agents
-Secondary HTN
-Suboptimal therapy
-Typically inadequate diuresis
•Consider a longer-acting diuretic such as chlorthalidone
•Add spironolactone
-No benefit to switching ACEI to ARB.
-Consider vasodilating β-blocker (carvedilol, labetalol, nebivolol)
-Consider clonidine, hydralazine, α-blocker
Agents of Choice Comments

-Good for resistant HTN even when hyperaldosteronism

Aldosterone Antagonists

is not present
-Provided GFR >30 mL/min and K+ <5 mEq/dl

-Resistant hypertension is associated with higher

levels of aldosterone, leading to secondary pharyngeal
edema, increasing upper airway obstruction, so good
choice for patients with OSA.

-Spironolactone - gynecomastia and hyperkalemia

Not first line agents – reserve for post-MI/CHF

Cause fatigue and decreased heart rate
Adversely affect glucose; mask hypoglycemic awareness
Beta-Blockers

Beta-1 Selective Beta-blockers

possibly safer in patients with COPD, asthma, diabetes, and
-Metoprolol succinate: Tartrate 50-100mg twice peripheral vascular disease:
daily. •Metoprolol
-Labetalol: 100-300mg twice daily. •Bisoprolol
-Nebivolol: 5-10mg, propranolol 40-120mg twice •Betaxolol
daily. •Acebutolol
•Nebivolol ( best safer in COPD+Asthma)
Vasodilators

-Hydralazine 25-100mg twice daily, minoxidil 5-10mg Hydralazine and minoxidil may cause reflex tachycardia and
fluid retention – usually require diuretic + B-blocker

-Terazosin 1-5mg, doxazosin 1-4mg given at bedtime Alpha-blockers may cause orthostatic hypotension

-Clonidine 0.1-0.2mg twice daily, methyldopa 250- Clonidine available in weekly patch formulation for
Central

Agents

500mg twice daily resistant hypertension

acting
ly-

-Guanfacine 1-3mg

125
 Palpitation Hx
Introduce yourself and establish good rapport ( Name, age and job).
Introduction Age:younger patient tends to have congenital heart or psychiatric cause
of palpitation more
Hx of present Chief complain (open question)
illness
§ Onset, frequency
§ Duration: lasting less than 5 minutes make a cardiac ethology less
likely.
§ Character: regular, rapid, pounding sensation in the neck (Cardiac)
§ Activity during palpitation:
Analysis of chief 1. At rest: even cardiac cause can occur at rest (e.g. VPCs)
complain 2. With exertion (more worrying some, e.g. mitral valve prolapses)
3. During sleep (more worrying some, could be cardiac / metabolic)
§ Position: if triggered by standing up after bending over or when lying
in bed (suggestive cardiac: SVT)
§ Snoopy or pre-soupy; (suggests of cardiac cause: Ventricular
tachycardia, or structural heart disease)
Risk Factors Evaluate for: an ischemic cardiac cause, ASCVD risk estimation / for
structural cardiac causes (valvular disease/congenital heart disease)
§ Organic causes: anemia / thyroid disorder / pheochromocytoma.
§ Psychiatric causes: GAD / specific anxiety / panic attack / panic
Screening disorder somatization
Non-cardiac causes § Medications: Substance / dietary supplement Use: e.g.: B agonists /
decongestants / antihistamines / anabolic steroids / caffeine /
nicotine
Medical
Surgical
Past Hx
Allergy
Medication
Focused on early cardiac death HCM/ inherited cardiac conditions.
Family Hx Cardiac disease
HTN,DM, psychiatric, thyroid diseases, anaemia.
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Should cover symptoms of causative disorders, including heat
intolerance, weight loss, and tremor (hyperthyroidism); chest pain and
Systemic Review
dyspnea on exertion (myocardial ischemia); and fatigue, weakness,
heavy vaginal bleeding, and/or dark tar-like stools (anemia).
Conclusion

126
 Palpitation Ex

Vital signs and appearance:

Asse the pulse (rate, rhythm, regularity)
• An irregular pulse may indicate atrial fibrillation or atrial flutter.
• A regular pulse may indicate sinus tachycardia or paroxysmal
supraventricular tachycardia.
• Bradycardia with regular pulse or irregularly irregular pulse – very
General rarely seen
• Pulse discrepancy / Radio femoral delay - Coarctation of aorta
• Tachypnea – Hyperventilation seen in panic disorder
• Bradypnea – Respiratory depression secondary to substance
abuse
• Possible signs of orthostatic hypotension –
Dehydration or electrolyte imbalance.
Special Cardiac Examination
Blood works:
• CBC
• TSH / Free T4
• Renal function
ECG; for all cases:
• Normal resting ECG findings do not eliminate a cardiac etiology.
Investigations Ambulatory ECG monitoring (Holter): If the index of suspicion for a
cardiac cause remains high even with normal resting ECG
Echo: for suspected structural or ischemic cardiac disease / known
cardiac disease / more complex signs and symptoms
Standard exercise stress testing: for patients with exertional
symptoms

CRAPRIOP for Management

Palpitations are one of the most common presentations to
general practice. While they are usually benign, they may be
associated with an adverse prognosis.
Clarification It is the second most common presentation to cardiologists
after chest pain. Although the vast majority are benign, there
are some clinical and electrocardiographic signs that
determine when further investigations may be necessary.
Treat underlying metabolic or psychiatric disease.
If resolved ok / if not, re-evaluate for
Reassurance structural or ischemic cardiac cause.
If structural or ischemic cardiac causes, and found normal for ECG,
Echo or Holter: reassurance.

127
 Palpitation

CRAPRIOP for Management

• avoiding or drinking less caffeinated drinks
• avoiding or drinking less alcohol
Advice • avoiding foods and activities that trigger palpitations and
managing stress levels.
• smoking cessation or using tobacco products
If diagnosis: AF will follow ABC strategies (arrythmia file)
Do not use rhythm control therapy in asymptomatic AF patients
Prescribing or permeant AF.
To more details: Review theory part.
Referral to a specialist — Elective referral to a cardiologist indicated
Any patient with an arrhythmia when the primary care physician is
uncomfortable with either diagnosis or management.
• Candidates for permanent pacing.
• Those with an uncertain diagnosis, prognosis, or management
Those who might benefit from implantation of a pacemaker.
Or catheter ablation procedure or antiarrhythmic drug therapy.
• Those who have a confusing picture or difficult to interpret ECG.
Urgent transfer— to a facility with emergency care capabilities:
• Syncope or near syncope in patients with high degree AV block
or bradycardia.
Referral • Wide complex sustained rhythms, including ventricular
tachycardia especially if not well tolerated or associated with
hypotension.
• Patients with a history of heart disease (including coronary artery
disease, cardiomyopathy, or HF) who present with syncope, near
syncope, and/or documented ventricular arrhythmia
• Sustained supraventricular tachycardia (SVT)
• Atrial fibrillation or flutter with rapid or slow rates
• Arrhythmias associated with chest pain, dyspnea or congestive
HF
• Family history of sudden cardiac death
Investigations Mentioned above
Observation/
follow up Follow the link > Theoretical part
Plan/prevention
Conclusion Includes Safety netting

128
 Heart failure Hx

Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question) Shortness of breath
illness
Time (duration)
Alleviating factors
Exacerbating factors:
Exertion/exercise
Pollen/chemicals (asthma)
Orthopnoea (worse when lies flat)
Severity:
Exercise tolerance on a flat surface
Exercise tolerance when walking upstairs/up an incline Shortness of
breath (SOB) at rest
Analysis of chief Variability:
complain Is the SOB continuous throughout the day, intermittent or progressively
worse? If intermittent, when is it worse/better?
Asks if patient is suffering from any other symptoms
Asks about any recent illnesses
Previous episodes of SOB
Red flags:
Haemoptysis
Weight loss
Night sweats
Hoarseness
Acute MI: central chest pain radiating to shoulders and neck
CHF/LV failure: orthopnoea, paroxysmal nocturnal dyspnoea, exertional
dyspnoea, chest pain, ankle swelling
Arrhythmias: sudden-onset weakness, light-headedness, syncope,
palpitations;
COPD: progressive dyspnoea, chronic productive cough , fever increased
sputum production, change in sputum character
Associated Asthma: wheezing, cough, chest tightness
Symptoms Pneumonia: fever, chills, cough, pleuritic chest pain, and dyspnoea;
(Differential Pulmonary embolism: sudden-onset dyspnoea and chest pain;
diagnosis) haemoptysis, palpitations
Pleural effusion: pleuritic chest pain
Anemia: severe dyspnoea at rest; associated symptoms related to
impaired oxygen delivery to tissues (confusion, lethargy, syncope, coma)
and compensatory mechanisms (palpitations)
Anxiety and panic attacks: possible prior history of anxiety, phobias,
and panic; dyspnoea may be accompanied by a choking sensation,
discomfort in various locations, dizziness, and a sense of fear

129
Heart failure Hx

Risk factors
(heart failure)

Medical HTN? DM? Dyslipidemia? Coronary artery disease? Myocardial

infarction? Valvular heart disease?
Past Hx Surgical
Allergy
Medication: Methotrexate, Amiodarone, NSAIDs, OTCs
Lung cancer
Family Hx Atopy: Asthma, Eczema, Hay fever
Ischemic heart disease/myocardial infarction
Pulmonary fibrosis
Marital status
Smoking
Alcohol
Psychosocial Illicit drug use
Occupation
Exposure to asbestos
Activities of daily living/functional assessment and impairment due to SOB
Screening: depression and anxiety
Ideas: what do you think you might have?
ICEE Concerns: is there anything you are worried about?
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

130
 ‫‪Heart failure Ex‬‬

‫‪General‬‬ ‫‪Vital signs‬‬

‫‪Appearance: cyanosis, pallor‬‬
‫‪cardiac Examination‬‬
‫‪Volume assessment: (Peripheral edema, Elevated‬‬
‫‪Special‬‬ ‫‪jugular venous pressure, Pulmonary congestion (Fine‬‬
‫))‪Crackles or Rales‬‬
‫‪Abdominal examination: Hepatojugular Reflux,‬‬
‫‪Hepatomegaly, Ascites‬‬

‫‪CRAPRIOP for Management‬‬

‫ف‪ ،‬وعادة‬‫حتدث اإلصابة بالفشل القلبي عندما يكون الفعل االنقباضي أو االنبساطي غير كا ٍ‬
‫ما يكون ذلك بسبب ضعف عضلة القلب‪ ،‬أو تصلبها‪ ،‬أو كليهما‪.‬‬
‫ميكن للعديد من االضطرابات التي تؤثر في القلب أن ُتسبب الفشل القلبي‪.‬‬
‫في بداية احلالة ال تظهر أية أعراض على املريض‪ ،‬ولكن في غضون أيام أو أشهر يبدأ املريض‬
‫بالشعور بإرهاق وضيق في التنفس‪.‬‬
‫وقد تتجَّمع السوائل في الرئتني‪ ،‬أو البطن‪ ،‬أو الساقني‪.‬‬
‫تنطوي بعض اَألعَراض الشائعة على‪:‬‬
‫ضيق في التنُّفس‬
‫ِ‬
‫اإلرهاق‬
‫جتُّمع السوائل)الوذمة( في الساقني‬
‫‪Clarification‬‬ ‫عدم القدرة على ممارسة الرياضة أو القيام بأنشطة أخرى تتطلب اجلهد‬
‫تتضمن اإلجراءات الوقائية من الفشل القلبي ُمعاَجلة االضطرابات التي ميكن أن تسببه في‬
‫ت التي ميكن عالجها على‬ ‫مرحلة مبكرة قبل أن ُتفضي إلى اإلصابة به‪ .‬تنطوي االضطرابا ُ‬
‫اآلتي‪:‬‬
‫إدمان الكحول‬ ‫انسداد الشريان التاجي‬ ‫ارتفاع ضغط الدم‬
‫فقر الدم‬ ‫اضطرابات صمام القلب‬ ‫السُمنة‬
‫اضطرابات الغدة الدرقية‬ ‫عدم انتظام بعض ضربات‬ ‫انقطاع التنفس االنسدادي في‬
‫القلب‬ ‫أثناء النوم‬

‫‪Reassurance‬‬ ‫يركز العالج على ُمعاَجلة أسباب فشل القلب‪ ،‬وإجراء تغييرات في منط احلياة‪ ،‬وعالج الفشل‬
‫القلبي باستخدام األدوية أو التداخالت األخرى‬

‫‪131‬‬
 Heart Failure

Smoking cessation
Salt restriction: ( <1.5g – 1g)
Fluid restriction (1.5 to 2 L/d) is reasonable in stage D
Advice Encourage physical activity especially when symptoms absent or mild
Daily home weight monitoring
Vaccination: annual influenza, 5-yearly pneumococcus

To more details: Review theory part below

Prescribing
Referral Refer to cardiology

Investigations

132
 Heart Failure
Primary prevention
Coronary artery disease: manage with aspirin, beta-blockers,
statins, and ACE inhibitors, as needed
Optimizing treatment of hypertension, smoking cessation,
and lipid control provides substantial benefit in patients with
coronary artery disease. Optimal control of hypertension may
require more than one antihypertensive medication.
Different antihypertensive drugs (diuretics, ACE inhibitors,
Observation angiotensin receptor blockers, beta-blockers, calcium channel
/ blockers) have been shown to be effective, especially in older
people, both with and without a history of myocardial
follow up infarction.
Diabetes mellitus: in addition to metabolic control, ensure
aggressive control of lipids and blood pressure.
Alcohol consumption and excessive salt and fluid intake:
discourage in patients with known left ventricular
dysfunction
Secondary prevention
All patients with heart failure are recommended to have
pneumococcal vaccination and annual influenza vaccine.
After discharge from hospital, a follow-up clinical assessment
Plan/prevention should be undertaken by a member of the specialist heart
failure team within 2 weeks.
See your doctor if you think you might be experiencing signs
or symptoms of heart failure.
Chest pain
Fainting or severe weakness
Rapid or irregular heartbeat associated with shortness of
breath, chest pain or fainting
Conclusion Sudden, severe shortness of breath and coughing up white or
pink, foamy mucus
If you have a diagnosis of heart failure and if any of the
symptoms suddenly become worse or you develop a new sign
or symptom, it may mean that existing heart failure is getting
worse or not responding to treatment. This may also be the
case if you gain 5 pounds (2.3 kilograms) or more within a
few days. Contact your doctor promptly.

133
 Heart Failure

Dyspnoea Classification NYHA OR AHA

Class NYHA Stage AHA
No limitation of physical activity. Ordinary physical At high risk for HF but without structural heart
I A
activity does not cause symptoms of HF. disease or symptoms of HF
Slight limitation of physical activity. Comfortable at
Structural heart disease but without signs or
II rest, but ordinary physical activity results in B
symptoms of HF
symptoms of HF.
Marked limitation of physical activity. Comfortable
Structural heart disease with prior or current
III at rest, but less than ordinary activity causes C
symptoms of HF
symptoms of HF.
Unable to carry on any physical activity without Refractory HF requiring specialized
IV D
symptoms or symptoms at rest interventions

134
 Heart Failure

Management of chronic HF

Does patient have vascular disease or DM

135
Heart Failure

136
 Heart Failure

Management of HFrEF
Management of HFrEF
AHA\ACC B C D
NYHA I II to III IV
Dyspnea at
Symptomatic
rest
Asymptomatic Hx of
Never hospitalized hospitalizati
on
ACE inhibitor
YES YES YES YES
and ARB
First line drugs

Beta blocker YES YES YES YES

Aldosterone
YES YES YES
antagonist

Diuretic As needed As needed As needed

Selected Selected
Ivabradine
Patients Patients

Hydralazine Selected Selected

Selected Patients
Second line drugs

plus nitrate Patients Patients

Digoxin As needed As needed As needed

Angiotensin
receptor-
YES YES YES
neprilysin
inhibitor

137
 Heart Failure

Management of HFrEF
ACE I is beneficial for patients with prior or current symptoms of chronic HFrEF to
I
reduce morbidity and mortality
ARBs is reduce morbidity and mortality and recommended in patients with who are
I
intolerant to ACE inhibitors because of cough or angioedema
In patients with chronic symptomatic HFrEF, NYHA class II or III who tolerate an ACE
inhibitor or ARB, replacement by an ARNI is recommended to further reduce I
morbidity and mortality.
ARNI should not be administered concomitantly with ACE inhibitors or within 36 III:
hours of the last dose of an ACE inhibitor Harm
III:
ARNI should not be administered to patients with a history of angioedema.
Harm
Use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all
I
stable patients
Aldosterone receptor antagonists are recommended in patients with:
1. NYHA class II–IV who have LVEF 35% I
2. Following acute MI who have LVEF 40% with symptoms of HF or DM
Inappropriate use of aldosterone receptor antagonists may be harmful
Careful monitoring of potassium and renal function to avoid risk of hyperkalemia III:
and renal insufficient Harm
The risk of hyperkalemia is increased with use of higher doses of ACE inhibitors
The combination of hydralazine and isosorbide dinitrate is recommended for
I
African Americans with NYHA class III–IV HFrEF
A combination of hydralazine and isosorbide dinitrate can be useful in patients with
HFrEF who cannot be given ACE inhibitors or ARBs because of drug intolerance, IIa
hyponatremia and renal insufficiency.
Ivabradine can be beneficial to reduce HF hospitalization for:
1. Patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%)
IIa
2. Who are receiving beta blocker at maximum tolerated dose, and
3. Who are in sinus rhythm with a heart rate of 70 bpm or greater at rest
Diuretics should be used for relief of symptoms due to volume overload. I
Digoxin can be beneficial in patients with HFrEF to decrease hospitalization IIa

138
 Heart Failure

Management of HFpEF
Recommendations for Stage C HFpEF
COR Recommendations
Diuretics should be used for relief of symptoms due to volume overload
I
in patients with HFpEF
Systolic and diastolic blood pressure should be controlled in patients
I with HFpEF in accordance with published clinical practice guidelines to
prevent morbidity.
The use of beta-blocking agents, ACE inhibitors, and ARBs in patients
IIa with hypertension is reasonable to control blood pressure in patients
with HFpEF.
In appropriately selected patients with HFpEF (with EF ≥45%, elevated
BNP levels or HF admission within 1 year, estimated glomerular filtration
IIb rate >30 mL/min, creatinine <2.5 mg/dL, potassium <5.0 mEq/L),
aldosterone receptor antagonists might be considered to decrease
hospitalizations.

139
 Heart Failure

Management of AHF

140
 Chest Pain (MI) Hx

Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow pt to explain the chief complain
illness Clarify what you understood
Site: chest, epigastric, retrosternal.
Onset: constant or intermittent, gradual or sudden
Character: •Crushing •Heaviness •Pressure (MI) •Burning(GERD)
•Stepping. • Localized and sharp •Tearing (aortic dissection).
Radiation: jaw, left arm and back (myocardial infarction), back (dissection)
SOCRATES

Timing: changes in the pain between onset and now

Exacerbating factors: •Exercise(unstable angina) •Deep inspiration (muscular
source of pain)
•Respiration •Movement and lying supine (pericarditis)
•Heavy meals or fatty foods (gall bladder disease)
Alleviating factors: • Rest and nitrate (stable angina) • Antacids (PUD)
•Leaning forward and sitting(pericarditis),
Severity: •1 to 10 •Affecting daily activity • awaken patient at night
• Pericarditis: Increased pain with respirations, movement, or lying supine,
radiation to the shoulder and relieved with leaning forward and sitting indicate.
• Ischemia: Palpitations, sweating, nausea, vomiting, dizziness, typical radiation to
the jaw or shoulder, pain that increases with exertion and decreases with rest,
sharp squeezing pain or heaviness in chest.
Analysis of • Pulmonary Embolus: Shortness of Breath, hemoptysis, calf pain, recent travel,
chief pregnancy, postpartum, use of oral contraception, Hx of DVT\PE, immobilization,
Associated symptoms

complain surgery, cancer

• Pneumonia or Pleurisy: Cough, fever and sputum.
• Aortic Dissection: Cough, fever and sputum indicate Pneumonia or Pleurisy. Pain
radiating to the back and history of smoking.
• Peptic Ulcer Disease: Heart burn, retrosternal pain, dysphagia, dyspepsia, and
NSAIDs use
muscular source of pain: Localized sharp pain, increased with movement or deep
inspiration, history of trauma or fall, heavy exertion
• Metastasis: History of skeletal pain or tumor.
• Costochondritis: Pain and swelling at costo-chondral junctions.
• Psychiatric: anxiety, malingering, depression therefore ask about mood, excessive
worries, stresses .etc.
• Herpes Zoster: Skin rash with pain (Fire band).
Cardiac risk factors:
• Family history of myocardial infarction in first-degree • Relative <55
Risk Factors

years of age
• Smoking • Hypertension • Diabetes mellitus • Hyperlipidaemia
Pulmonary embolism/deep venous thrombosis:
• Calf pain/swelling • Recent travel • Recent surgery • Pregnancy
• Family history of clotting disorders • Malignancy • OCPs

141
 Chest Pain (MI) Hx

Known coronary artery disease

Clammy, unwell patient
Exertional chest pain
Analysis of
Red Flags

Heavy, tight, pressure type chest pain

chief
Pain radiating to left arm, right shoulder or both arms
complain
Association with nausea or vomiting
Known history of coronary artery disease
Family history of premature coronary artery disease
Male sex
Medical
• Previous Myocardial Infarction • Hx of DVT or PE • current pregnancy
•Hx of malignancy
• Diabetes Mellitus • Hypertension. •Hyperlipidemia
Surgical
Past Hx
• Recent surgery • Hx CABG (Coronary artery bypass graft surgery)
• Angioplasty
Allergy
Medication
• oral contraceptive pills • Aspirin • NSAIDS
cardiac events and at what age
Family Hx
Contact with sick patient
Stressful events
Marital conflicts
Job instability
Sedentary lifestyle
Psychosocial
Alcohol
Smoking: type and frequency
alcohol
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

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 Acute Coronary Syndrome
CRAPRIOP for Management
‫متالزمة الشريان التاجي احلادة مصطلحٌ ُيستخدم لوصف مجموعة من احلاالت املصاحبة النخفاض تدفق الدم املفاجئ إلى‬
.‫القلب‬
‫ وهي حالة ُيؤَِّدي فيها موت اخللية إلى َتلَف أنسجة القلب أو‬- (‫إحدى هذه احلاالت هي النوبة القلبية )احتشاء عضلة القلب‬
Clarification ‫ فإن انخفاض تدُّفق الدم ُيغيِّر من آلية‬،‫ حتى عندما ال تتسبَّب متالزمة الشريان التاجي احلادة في أي موت للخاليا‬.‫تهتُّكها‬
.‫ وُيعَدُّ عالمةً على خطر اإلصابة بنوبة قلبية‬،‫عمل القلب‬
.‫وغالبًا ما ُتسبِّب متالزمة الشريان التاجي احلادة أًملا حاًدا أو شعورًا بعدم الراحة في الصدر‬
‫ وتتضمن أهداف العالج حتسني تدفق الدم‬.‫وعالج فهي حالة مرضية طارئة تتطلب التعجيل في التشخيص والرعاية‬
Reassurance
‫املضاعفات والوقاية من املشكالت املستقبلية‬
Primary prevention of coronary artery disease
Stop smoking cessation
• Eat a healthy diet (more fruit, vegetables, and nuts)
• eat whole meal bread and pasta instead of white bread and pasta
• eat less sugar, red meat, and processed foods
• cook with olive oil rather than other types of fat.
Advice • eat between 2 and 4 portions of oily fish a week. Oily fish include salmon, trout,
mackerel, tuna and sardines
Regular exercise: Stop if you have any pain
Maintenance of ideal body weight
Statin and aspirin therapy
Control Risk factors: blood pressure and diabetes management must be tightly
controlled as appropriate.
1. Airway, breathing, and circulation assessed
2. Preliminary history and examination obtained
3. 12-lead electrocardiogram (ECG) interpreted
4. Resuscitation equipment brought to the bedside
5. Cardiac monitor attached to patient
6. Oxygen given as necessary
Prescribing 7. IV access and blood work (including high-sensitivity troponin, if available) obtained
8. Aspirin 162 to 325 mg given + clopidogrel 600 mg or tigrelol
9. Nitrates given 0.4 mg every five minutes for a total of three doses,
(contraindications to nitrates include severe aortic stenosis, hypertrophic
cardiomyopathy, suspected right ventricular infarct, hypotension, marked
bradycardia or tachycardia, and recent use of phosphodiesterase 5 inhibitor [eg,
Viagra])
Referral ER Referral
- ECG within 10 minutes, cardiac enzymes if cardiac cause suspected
- chest x ray
- fasting or random blood sugar
Investigations
- liver and renal function test
- electrolyte
- lipid profile
Observation/
Follow up after discharge from hospital to control risk factors ( DM, HTN,..)
follow up
Plan/prevention Offer immunization for flu, COVID 19, Smoking cessation

If you have Exertional chest pain, Heavy, tight, pressure type chest pain, Pain
Conclusion radiating to left arm, right shoulder or both arms, Association with nausea or
vomiting URGENT visit ER

143
 Chest Pain

Differential Diagnosis
• MI • Stable myocardial ischemia (angina) •Myocarditis
Cardiac •Pericarditis • Aortic valve disease • Tamponade

• PE • Pneumothorax/hemothorax •Tension pneumothorax

• Pneumonia • Empyema • Pulmonary neoplasm
Pulmonary • Bronchiectasis • Pleuritis • Asthma
• COPD • Pleuritis • Sarcoidosis
• Pulmonary hypertension • TB

• GERD • Achalasia • Neoplasm • PUD • Mallory-Weiss syndrome

Gastrointestinal • Esophageal rupture, spasm, esophagitis, ulceration
• Gastritis • Pancreatitis • Biliary colic

Mediastinal • Lymphoma • Thymoma

Drug use • Methamphetamine • Cocaine intoxication

Vascular • Dissecting aortic aneurysm • Aortic rupture

• Surface structures • Costochondritis • Trauma

Other • Rib fracture • Skin (bruising, herpes zoster)
• Breast • Anxiety/psychosomatic • Referred pain

Acute coronary syndrome

Stable
Unstable Angina STEMI non-STEMI
Angina
Pain Exercise @ rest @ rest @ rest
Rest +
Relief Ø Ø Ø
Nitrates
Biomarkers Ø Ø ↑ ↑
ECG (ST
Ø Ø Ø ↑
elevation)

144
Acute Coronary Syndrome

145
Acute Coronary Syndrome

146
 Dyslipidaemia Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Dyslipidemia itself usually causes no symptoms but can lead to

illness symptomatic vascular disease, including coronary artery
disease (CAD) and peripheral arterial disease.
Coronary artery disease (major risk factors):
• Advancing age
• High total serum cholesterol level
• High non–HDL-C
• High LDL-C and Low HDL-C
• DM or HTN
Analysis of • Cigarette smoking
Risk factors • Family history of CAD
Additional risk factors:
• Obesity, central obesity
• Family history of hyperlipidemia
• Moderately high LDL-C
• Apo B
• LDL particle number
• Fasting/postprandial hypertriglyceridemia
• Poly cystic ovary syndrome
Past medical history:
Diabetes mellitus
Chronic kidney disease
Hypothyroidism
Primary biliary cirrhosis
Other cholestatic liver diseases (these diseases causes
Past Hx secondary dyslipidemia)
Past surgical history:
Allergy
Medication
High dose thiazides, β-blockers, retinoids, highly active
antiretroviral agents, oral contraceptive pills, glucocorticoid,
atypical antipsychotic: olanzapine ,cloazpine (these drugs
causes secondary dyslipidemia)

147
 Dyslipidaemia Hx
1. Familial hypercholesterolemia
Family Hx 2. CAD
3. DM
4. HTN
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
General Vital signs
Appearance
Ophthalmologic Signs:
Corneal Arcus (sensitive sign of familial hypercholesterolemia)
Corneal Opacification (In classical familial LCAT deficiency)
Lipemia retinalis or a "milky-white" appearance of the retina
(In diabetic patient with severe hypertriglyceridemia)

Special

Dermatologic signs:
The most common dermatologic manifestation is xanthomas.
They are classified as: Tendinous,Tuberous, Tuberoeruptive
,Panar and Eruptive

148
 Dyslipidaemia

CRAPRIOP for Management

Dyslipidemias is Abnormalities of lipoprotein
metabolism and include elevations of total cholesterol,
LDL cholesterol, or triglycerides; or deficiencies of HDL
cholesterol.

Causes of abnormalities of cholesterol

Alcoholism, AIDS (protease inhibitors) , Acute hepatitis,
anorexia nervosa.
Biliary disease.
Cholestasis, Chronic renal failure.
Diet, diabetes (poorly controlled), Drugs (steroids, B-
block blockers and oral contraceptives, acutane).
Hypothyroidism, Hepatocellular disease
Nephrotic syndrome
Clarification Obesity, obstructive jaundice
Pregnancy, Pancreatic and prostatic malignant neoplasm
Systemic lupus erythematosus

Benefits of lowering LDL cholesterol

Reducing of cholesterol plaques on the artery walls
Decreasing the risk of heart attacks
Decreasing the risk of strokes

Expected complications
CAD, PAD and stroke
12.6% of population over 15 years old have
hypercholesterolemia
20% of population over 60 years old have
Reassurance hypercholesterolemia
1% drop in LDL = 1-2% decrease in CVD events
1% drop in cholesterol = 2-3% reduction in CVD events
Reassure the patient that you’ll give him/her the best
available care

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Dyslipidaemia

Reach the optimal BMI: < 25 kg/m2

Smoking cessation, if the patient is a smoker.
Diet:
↓ saturated and trans fats
Advice ↓ simple sugars and refined carbohydrates
↑ fruits and vegetables
↑ whole-grain cereals
↑ proportion of mono- and polyunsaturated oils,
including omega-3 fatty acids
Exercise: 30 min. daily moderate physical activity
The reason I prescribed this treatment is that we care
about your health and in order for us to keep you away
from complications, we need to start these medications
The importance of this medicine is it can prevent
Prescribing further complications/prophylaxis
Importance of complying with the treatments.
Explain what are the side effects.
(Down in Management guideline)
To whom e.g. cardiologist, endocrinologist
For what? Diagnosis, treatment or shared care.
When? Urgent/emergent
How? Patient’s opinion, explanation?

Referral

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Dyslipidaemia

Investigations
Lipid profile test – Reference values

Unit Optimal Intermediate High

Total mg/dl <200 200-239 >239

cholesterol
(calculated) mmol/L <5.2 5.3-6.2 >6.2

LDL mg/dl <130 130-159 >159

cholesterol
(calculated) mmol/L <3.36 3.36-4.11 >4.11

HDL mg/dl >60 40-60 <40

cholesterol
mmol/L >1.55 1.03-1.55 <1.03

Triglycerides mg/dl <150 150-199 >199

mmol/L <1.69 1.69-2.25 >2.25

Non-HDL mg/dl <130 130-159 >159

cholesterol
(calculated) mmol/L <3.3 3.4-4.1 >4.1

TG to HDL mg/dl <3 3.1-3.8 >3.8

ratio
(calculated) mmol/L <1.33 1.34-1.68 >1.68

In 2/3 weeks
Observation/ Why is it needed? Follow up/result of
follow up investigations/drugs effectiveness
How often is it needed? Every month/3 months
Agree with the patient on a plan.
(Diet and exercise vs. medications or both)
Plan/prevention Anticipatory care according to the patient’s age, sex
Opportunistic health promotion
Modification of help seeking behavior
Conclusion Includes Safety netting

151
 Dyslipidaemia
Managing Dyslipidemia : Clinical Practice Guidelines
Patients Without Diabetes Miletus
( for diabeticTable1)
Comprehensive life style modifications

+
LDL 70-190 mg/dl (LDL> 190mg/dl Box3)
+
age 40-75 years (other agegroups Box4)

ASCVDrisk≤ 5% Calculate the10-yASCVDrisk Box 7 ASCVDrisk>20%

ASCVDrisk5-20% Highintensitystatin
Doesthe patient ASCVDRisk-enhancingfactors? Box6 treatment Box5
DoNot offer statins

ASCVD5%- 7.5% ASCVD7.5%-20%

Consider Moderate-intensitytreatment Moderate intensitystatin treatment Box5

Table1:ADArecommendationfor statin therapy in diabetics

Age ASCVD or 10-year Statin Therapy Box5: statin dose&treatment targets Boxes8,9 ,10
ASCVD risk >20%
Moderate-intensity therapy
<40 years No No treatment • Atorvastatin 10-20mg
• Rosuvastatin 5-10mg
Yes High intensity • Simvastatin 20-40mg
≥40 years No Moderate intensity
Target: 30-50%LDL-Creduction.
Yes High intensity
High-intensity therapy
• Atorvastatin 40-80mg
Box1: Cardiovascular diseaseprevention • Rosuvastatin 20mg
• Thisguidelineconcernsprimary CVDprevention.
• Patients with establishedASCVDshouldbeon high intensity statin treatment . Target: >50%LDL-Creduction

Box2: measuringbloodcholesterol Box6: ASCVDRisk-enhancingfactors:

• Familyhistoryof prematureASCVD
• Fastingor non-fasting plasmalipid levelsis effectivein estimatingASCVDrisk • PersistentlyelevatedLDL-C >160mg/ dl
• If initial non-fasting lipid profile reveals a triglyceride ≥ 400mg/dl a repeat fasting • Metabolicsyndrome
lipidprofileshouldbeobtained • Chronickidneydisease
• Fasting lipid measurement should be repeated 4to 12weeks after starting or • History of preeclampsiaor premature menopause(younger
changing statin therapy to assess:adherence, response to medications and than40years)
lifestyle changes. • Chronicinflammatory disorders(e.g., rheumatoid arthritis,
• Afterwards; lipid measurement should be repeated every 3to 12months as psoriasis, chronicHIV infection)
needed • High-risk ethnicgroups(e.g., southAsiandescent)
• Persistent triglyceride levelsof >175/dl
Box3: LDL>190mg/dl
• Highintensity statinif LDL>190mg/dl regardlessof age
Reference:
2019ACC/AHAGuidelineonthe Primary Prevention of Cardiovascular
Box4: other agegroups Disease AReport of theAmericanCollegeof Cardiology/American
• Age<20y: start statin if Familial Hypercholesterolemia HeartAssociation TaskForceonClinical Practice Guidelines.
• Age20-39y: consider statin if family history, prematureASCVD&LDL>160mg/dl
• >75yrs: consider lower intensitystatin basedonrisk assessment&discussion

152
 Dyslipidaemia
Box7: Atherosclerotic cardiovascular Disease (ASCVD) Risk Estimator

• Intended for patients with LDL-C < 190 mg/dl, NoASCVD, not on LDL-C lowering therapy
• Componentsinclude : sex, age, race, Totalcholesterol , HDL-C,systolic bloodpressure, diabetes,
smoking, treatment for hypertension.
• [Link]

Box 8 : Statins
Commonagents: Simvastatin 10-80 mg, Atorvastatin 10-80 mg,
Rosuvastatin 5-20 mg.
Dose titration : increase dose gradually at intervals of at least 4 weeks.
Cautions: history of liver disease , at risk of muscle toxicity ( muscle disease , high alcohol intake),
untreated hypothyroidism
Interaction: Clopidogril (reduce dose of Rosuvastatin), Clarithromycin (stop Simvastatin ,Atorvastatin
for the duration of treatment), Amlodipine (reduce dose of Simvastatin).
Side effects: Common: lack of energy , constipation, diarrhea, nausea, dizziness, headache , myalgia
thrombocytopenia, sleep disorders. Uncommon: alopecia, memory loss, pancreatitis, paresthesia, sexual
dysfunction, hepatic disorder.
Rarely: myopathy, peripheral neuropathy, tendinopathy,.
Frequency unknown : depression , diabetes mellitus , interstitial lung
disease
Simvastatin: rarely acute kidney injury , frequency unknown: cognitive
impairment
Atorvastatin: epistaxis, hyperglycemia, hypersensitivity, laryngeal pain,
nasopharyngitis Rosuvastatin: rarely gynecomastia, hematuria
Muscle effect: The risk of myositis, myopathy and rhabdomyolysis is rare although myalgia is common
among statin users.
If statin is suspected to cause myopathy and Creatine kinase is markedly elevated stop statins and monitor
symptoms, once CKconcentration return to normal re introduce statin at lower dose and monitor patient.
Monitoring:
Prior to starting treatment: all patients should have their TSH, Liver function, and
Renal panel checked. NICE guidelines suggest checking liver function before
treatment and at 3 and 12 months.
If ALT/AST are elevated but less than 3 times upper limit of reference statin therapy should not
be stopped routinely. Creatine kinase should be measured in patients with persistent
generalized unexplained muscle pain prior to treatment. Statin can be started if the level is
elevated less than 5 times upper limit on 2 repeated sample 1 week apart.
Diabetes: patients at risk should have HbA1cbefore starting andrepeated 3monthsafter
starting statin treatment .
Renalimpairment:eGFR<30(avoid Rosuvastatin, reduce simvastatin to 10mg, atorvastatin
reduce to 20mg).
Pregnancy: discontinue 3 months before attempting to conceive
Breast feeding: Avoid
Hepatic Impairment: avoid

153
 Dyslipidaemia

Box 9 : other lipid lowering agents

Ezetimibe (Ezetrole)
Indications: Adjunct to dietary measures and statins treatment in primary
hypercholesterolemia, familial hypercholesterolemia and in adults whom in initial statin
therapy is contraindicated or can not be tolerated
Caution: increases the risk of rhabdomyolysis when given with Atorvastatin.
Side effects: fatigue, diarrhea; gastrointestinal discomfort; arthralgia , chest pain,
hypertension, hot flushes.
Hepatic impairment: avoid in moderate to severe impairment.
Pregnancy: no information available .
Fenofibrate
Indications: severe Hypertriglyceridemia (TG >500 mg/dl), if statin is contraindicated or
not tolerated, adjunct to statin if triglycerides inadequately controlled in patients at
high cardiovascular risk.
Dose: 145 mg daily
Contraindications: Gall bladder disease; pancreatitis (unless due to severe
hypertriglyceridemia); photosensitivity.
Caution: Correct hypothyroidism before initiating treatment, may increase risk of
hypoglycemia if the patient is on insulin sulfonylurea. Increase the anticoagulant effect
of warfarin. May cause myopathy/rhabdomyolysis when used with statins.
Side effects: Abdominal pain; diarrhea; flatulence; nausea; vomiting, sexual dysfunction,
skin reaction, embolism and thrombosis, headache, cholelithiasis, pancreatitis.
Pregnancy, Breast feeding & Hepatic impairment : avoid
Renal Impairment: avoid if eGFR <30 (max. dose 67 mg daily if eGFR 30–59).

Box 11: Hypertriglyceridemia

Box 10: Whento refer to secondary
• Rule out Secondary causes: Alcohol, hypothyroidism, obesity, Diabetes,
care :
Drug Induced.
• Suspected Familial • Aim of Treatment is to prevent Pancreatitis and lower the risk
Hypercholesterolemia Cardiovascular risk.
• Family history of Premature Heart • Refer Triglycerideshigher than > 885mg/dl.
Disease • In Isolated Hypertriglyceridemia treat with Omega3 or fibrates to a
target less then 500mg/dl.
• Cholesterol > 290 mg/dl in the
• If the patient is already on Statin and triglyceride is persistently
absence of Family history above 500mg/dl then add omega 3 or refer to secondary care.
• Triglycerides level > 885 Box11. • If the patient has an indication to start statin and triglyceride is above
• Intolerance to Statins 500mg/dl then the first line will be statin andthey do reduce
triglyceride.

154
Endocrinology

155
Endocrinology
DM Obesity + post-
• Newly diagnosed bariatric
• Breaking bad news Cushing syndrome
• Follow up Vit D deficiency
• In Ramadan Hirsutism
• Planning to Acromegaly
pregnancy Addison’s disease
• Insulin use Gynecomastia
• Glucometer use
Examination
• Diabetic foot Ex
Thyroid disorders
• Hyperthyroidism
• Hypothyroidism
• Thyroid storm
• TFT interpretation
Osteoporosis
• DEXA
Metabolic syndrome

156
 Diabetes mellitus Hx
Newly diagnosed DM

Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Allow t to explain the chief complain
Hx of present
illness
Clarify what you understood
According to the presentation: could be present with
hypo/hyperglycemic symptoms
Analyse the presented symptoms: Onset, course and duration
Associated symptoms:
Hyperglycemic Hypoglycemic DKA HHS

- Sweating
- Palpation - Nausea
- Pallor - Vomiting
- Polyuria - Tremor. - Abdominal
- Polydipsia - Decrease level of pain
- Confusion
- Polyphagia consciousness - Fast
- Nocturnal - Syncope breathing
- Wight - Headache - Dizziness or
loss/catabolism - Hunger LOC
Ask about: frequency and
cause

See ER Section

Analysis of Macrovascular:
chief • CAD (Chest pain, HF symptoms [dyspnea, orthopnea, PND, LL
complain edema]).
• CVA (neurological weakness/paralysis).
• PAD (intermittent claudication, decreased lower limb hair,
skin changes/discoloration, ulcers).
Microvascular:
• Nephropathy: urinary smell or changes (usually laboratory
diagnosis), ↓ urine output & other CKD sx.
• Retinopathy: blurred vision, vision loss (see page for vision
loss DDx).
• Neuropathy: Sensory → bilateral symmetrical
numbness/burning, ↓ sensation in the feet, foot
trauma/ulcer, falls or unsteady gait Autonomic:
hypoglycemia or chest pain unawareness, Achalasia (solids &
liquids dysphagia), Gastroparesis (early satiety, fullness),
constipation, Erectile dysfunction.

157
 Diabetes mellitus Hx

Medical: HTN? Dyslipidemia? Coronary artery disease?

Myocardial infarction? Valvular heart disease? Other
autoimmune conditions: hypo/hyperthyroidism, celiac.
Malignancies: thyroid CA [MEN], Pancreatic CA
Other conditions: pancreatitis, gallbladder stones
(cholelithiasis), OSA, hemoglobinopathies, anemias.
Last Dental visit
Last dilated eye Exam
Surgical: bariatric surgery, cardiac PCI or CABG, pancreatic
Past Hx surgery, Amputation
Previous ER visits of Hospitalization (for DKA,HHS or
hypoglycemia)
Allergy
Medication: Storied topical or systemic, antipsychotics,
antiepileptic, antiviral(HIV) immunosuppressants, diuretics, B
blockers, OCP, growth hormone, OTC, herbal medicine.
Vaccinations: influenza vaccine (annually), Pneumococcal (19-64
y & ≥65 y if not previously received), Zoster (≥50 y). And other
age-appropriate vaccinations
HTN, CVD
DM (father or mother side or both, how many generations
Family Hx affected, age of diagnosis, DM complications) mother GDM,
other autoimmune diseases (thyroid), Thyroid CA, HTN, Obesity,
Cardiac, sudden death & malignancies
lifestyle: physical inactivity, diet, psychosocial stress & Smoking,
Alcohol, Substance use (type and frequency).
Psychosocial
Marital status
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
conclusion

158
Diabetes mellitus Ex
Vital signs + BMI + waist circumference, waist to hip ratio
(Obesity).
Appearance, GCS, signs of dehydration, tremors or
General sweating, cachectic or obese, cyanosis or jaundice,
Walking or on wheel chair (amputation), respiratory
distress (DKA Kussmaul breathing, acetone smell), any
obvious trauma
Hand: onychomycosis
Mouth: oral hygiene & teeth health, ulcers, candidiasis &
leukoplakia
Neck: Acanthosis nigricans, thyroid exam & LN
Shoulder: ROM (frozen shoulder)
Eye: Visual Acuity, Retina: Proliferative vs non-Proliferative
retinopathy, macular edema, retinal detachment
CNS: CN, power, tone, reflexes, sensory
CVS: (CABG scar), HF signs
Special Respiratory, Abdomen
Foot & skin: (mentioned below in details)
Neuro → monofilament, vibration, proprioception &
reflexes
Vascular → Dorsalis pedis & posterior tibial pulse (if
abnormal → ABI, then Doppler)
Deformity (Charcot’s foot), DM dermopathy, loss of
hair, skin changes, edema, ulcers, tinea pedis or tinea
unguium (onychomycosis), ingrowing toenail,
amputation, signs of inflammation.
Glucose random, Fasting glucose & HbA1C ± OGTT
CBC for anemia (so we can’t depend on HbA1C). In acute
setting look for leukocytosis
U&E for Cr & Na,K levels & eGFR calculating
LFTs for MAFLD/NAFLD vs NASH & for medication safety
(statin)
Urine Albumin/Creatinine ratio > Urine
Investigations microalbuminuria
Fasting Lipid profile for ASCVD risk & monitoring statin
therapy
TSH (Screening)
T1DM is suspected → GAD-Ab, C-peptide
Female with suspected PCOS: serum testosterone ±
US ovarian
ECG
159
 DM Breaking bad news
Introduce yourself and establish good rapport ( How are you today? ).
• Close the door, ensure no interruptions (call the nurse and ask
her not to allow any interruptions and put your phone on silent)
Setting and ensure proper setting (tissue around with some water).
• Ask if any family members are with the patient: "Are you here
alone?"
• Check using open-ended questions: "Mr. X, how can we help you
today?" "Do you know why you are here?" "Do you know what
tests you had last time and why were they done?" "Do you have
Perception any idea what the results might be?" "Some people like to have
someone (family or friend) with them when they receive their
results.
• "Before we review the results, tell me, Mr. X, are you the sort of
person who like to know details or not?"
• "Mr. X, I am afraid I have a bad news."
• "Mr. X, your blood glucose levels are high. I am sorry to tell you
that this means that you are diabetic"… Pause… Hand in the
patient some tissue papers.
Invite • Encourage expression of feelings: "I am sorry I had to give you
Patient to such a bad news. I wish things were different. It must be difficult
share in the to hear, how do you feel about it?" "I understand that it can be
difficult to take the news."
discussion
• "It is okay. Take your time. I am here for you."
• "Would you like to have some rest in the treatment room before
we proceed?"
• Remember to facilitate verbal and non-verbal cues.
• Remember to Listen attentively and ask several times about
extent of understanding.
• How much patient already knows? "Can you tell me what you
know about diabetes?” "It is not easy to hear that you are
diabetic, but we will work with you to improve your health,
wellbeing, and prevent diabetes complications".
• "As you know diabetes is common worldwide. Many are
diagnosed with it and are doing well, and so would you".
• "Simply, there are two main types of diabetes, yours is type Il,
Knowledge where your body is not responding to the insulin that is produced
check and by the pancreas".
sharing • "Insulin is needed to make use of the glucose, the basic fuel that
we get from food, for energy)".
• "When glucose is in excess and is not been utilized by the body,
it accumulates and harms the eyes, heart, kidneys, nerves and
vessels".
• "To decrease the glucose to normal, patients need to adjust their
diet, start to exercise, take oral tablet, and/or take insulin
injections".

160
 DM Breaking bad news
"Tell me Mr. X, how do you feel now?"
• Acknowledge your limitations in breaking bad news.
Empathy • Reinforce support provision, give clinic phone number.
expression • Ask about feelings and emotional acceptance.

Brief what has been discussed and upcoming plan: "What you can
do is ".
• Start eating healthy food. I will refer you to a dietitian to help
you with that.
§ ↑ non-starchy vegetables (green vegetables) to almost ½ of
your plate
§ Avoid high glycemic index food (rice, potatoes, pasta, bread,
corn, soft drinks, candies,…etc.)
§ Carbs calculating (as you and your Dietitian will discuss)
• Exercise using the right shoes for 30 minutes 5 times a week,
Resistance exercise 2-3 sessions/wk
• Take your medications regularly.
Summarize • Ensure self-monitoring of blood glucose (SMBG) and to write the
readings
• Come back for your appointments: every 3 months with annual
check up.
From our side we will help you with:
• Regular labs [HbA1C, lipids, kidney functions and Electro Cardio
Gram (ECG)]. Foot exam, education about foot care, and referral
to ophthalmologist for retinal screening annually.
• Referral to dentist for screening and follow up every 6months.
• Vaccinations (influenza, Hepatitis B, Pneumococcal virus).
• Direct to associations and support groups.
• Answer any queries and address concerns clearly.
• Give hope but not false one: "I know it's difficult to handle this,
we are always available to support you and answer your
questions"
• Safety netting; "diabetics are at risk of decreased blood glucose
level. You need to be aware of the symptoms to be able to help
yourself by half a cup of juice. These are: sweating, shivering,
Arrange dizziness, palpitation, syncope"
• Give follow up appointment soon and arrange the referrals as
mentioned above.
• Give away reading material, support groups contact if available
• Ensure patient's safety: "Do you think you can drive back home,
or would you like me to arrange for you an appropriate
transportation?"
Ensure organized approach, mixed questioning style
Communication
skills (open and close ended questions), active listening, clear language
and reflection on patient's ideas, concerns and expectations.

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 Diabetes mellitus Hx
Follow up visit of DM patient

Introduce yourself and establish good rapport ( Name, age and job).
Age of DM onset, how diagnosed?
Last A1C?
Assess In F/U pt with K/C of DM we should ask about 6Cs:
Controlled or not, New Complain, Complications, Compliance to
medications, Diet and physical activity, ICEE and ASCVD Calculation.
Is it controlled or not?
New complain If present
(open question) + analyze ( Onset, course and duration .. )
Symptoms of DM:
complain Hypoglycemia: Polyuria, Polydipsia, Polyphagia, Nocturnal
•
and Wight loss/catabolism.
• Hypoglycemia: Awareness/Frequency/Causes/Timing of
episodes.
Macrovascular:
• CAD (Chest pain, HF symptoms [dyspnea, orthopnea, PND,
LL edema]).
• CVA (neurological weakness/paralysis).
• PAD (intermittent claudication, decreased lower limb hair,
skin changes/discoloration, ulcers).
Microvascular:
• Nephropathy: urinary smell or changes (usually laboratory
Complications
diagnosis), ↓ urine output & other CKD Sx.
• Retinopathy: blurred vision, vision loss.
• Neuropathy: Sensory → bilateral symmetrical
numbness/burning, ↓ sensation in the feet, foot
trauma/ulcer, falls or unsteady gait Autonomic:
hypoglycemia or chest pain unawareness, Achalasia (solids
& liquids dysphagia), Gastroparesis (early satiety, fullness),
constipation, Erectile dysfunction.
Current DM medications: Metformin, other oral hypoglycemic
med, Insulin.
Assess medications
Compliance to
Taking behavior: compliance/dosing/timing/adjustment
medications
Intolerance or SEs
Complementary/ Alternative medicine use.
Home blood sugar monitoring : if Pt on Insulin

162
 Diabetes mellitus Hx
Medical: HTN? Dyslipidemia?
Surgical: bariatric surgery, cardiac PCI or CABG, pancreatic
surgery, Amputation
Previous ER visits of Hospitalization (for DKA,HHS or
hypoglycemia) in details
Check follow up with (Optha / Diet clinic / Educator / Podiatry /
Dentist (annually)..
Past Hx
Allergy: sulpha allergy?
Other Medication: Storied topical or systemic, antipsychotics,
antiepileptic, antiviral(HIV) immunosuppressants, diuretics, B
blockers, OCP, growth hormone, OTC, herbal medicine.
Vaccinations: influenza vaccine (annually), Pneumococcal (19-64
y & ≥65 y if not previously received), [Link] (≥50 y). And other
age-appropriate vaccinations
Family Hx Changes in previous Family Hx
lifestyle:
• Diet : type of diet / compliance / reason of poor compliance
(underestimate disease/ underestimate role of diet / does
not know how / fear of hypoglycemia / no support at home /
social issues )
• Exercise: type / timing / regularity / complications / reason
for poor exercise ( joint pain / hypoglycemia / underestimate
disease/ underestimate role of exercise . social issues)
Psychosocial • Sleep behaviors
• Smoking, Alcohol, Substance use (type and frequency).
Marital status and social support esp for elderly pt:
• Care giving support at home/ who give Rx esp Insulin/
financial barriers (aged ≥65 years) assess for cognitive
impairment
For women at childbearing age:
• Contraceptive needs / preconception planning
Screening: depression and anxiety
Ideas:
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does DM affect your life? How?
Systemic review
conclusion

163
 Diabetes mellitus Ex

Vital signs (esp; BP+RBS)

General BMI + waist circumference (Obesity)
Appearance
• Skin examination : acanthosis nigricans / injection site /
Skin tag/ lipodystrophy
• Foot exam: visual inspection every visit
• Thyroid palpation (as indicated)
Special • Neurological examination: for polyneuropathy check temperature or
pinprick sensation (small-fiber function) and vibration sensation using
a 128-Hz tuning fork (for large-fiber function).
• Annually: fundoscopic, neurologic, complete foot ex,
presence/absence of patellar and achilles reflexes
A1C goals

< 7% <8 %
Many non-pregnant • Limited life expectancy
< 6.5 % • History of level 3
adult
• Short duration DM without significant hypoglycemia
• Long life expectancy hypoglycemia is • Advanced micro or
• No significant CVD macro vascular
appropriate
complication
↓ • Cognitive impermeant

• A1C: Every 3 months if abnormal / every 6 – 12 months if normal

• Albumin/Creatinine Ratio (ACR): every 3 months if abnormal /
annually if normal
Investigations • Creatinine & GFR: every 3 months if abnormal / annually if normal
• Serum potassium: annually routinely/ more frequent if needed
Lipid control

LDL Triglyceride HDL

<100 mg/dl <150 mg/dl >40 mg/dl

• Lipids profile: at initiation of statins or other lipid-lowering therapy, 4–

12 weeks after initiation or a change in dose, and annually thereafter.
• Vit B12: annually if patient of Metformin / if abnormal, every 3
months until corrected
• Liver function test: baseline before starting lipid lowering agents,
and then every 6-12 months if normal
• Ankle-brachial index: for patients with symptoms of
claudication or decreased or absent pedal pulses

164
 Diabetes mellitus Hx
Non pharmacotherapy
Provide patients with self-management support
Home blood sugar monitoring(HBSM) if patient taking Insulin
Medications: timing/dosing /how to deal with SE
Education Foot care
For hypertensive patients with diabetes, advice to monitor
their blood pressure at home
Directed to deal with reasons for poor diet
May advice for nonnutritive sweeteners
Diet Limit protein to 0.8 g/kg body weight per day if pt has CKD
Low salt intake if pt has HTN
Should engage in 150 min or more of moderate-to-vigorous
intensity aerobic activity per week, spread over at least 3
days/week, with no more than 2 consecutive days without
activity
Should engage in 2–3 sessions/week of resistance
Exercise exercise on nonconsecutive days
Prolonged sitting should be interrupted every 30 min
Should be directed to deal with reasons for poor exercise
Avoid vigorous exercise if patient have retinopathy since it
may triggers triggering vitreous
hemorrhage or retinal detachment
Pharmacotherapy
• If A1c target achieved after 3 months with monotherapy
(Metformin): continue same
• If A1c target not achieved after 3 months with monotherapy
despite good compliance: add another agent
• In choosing Rx , Considerations include efficacy,
hypoglycemia risk, history of ASCVD, impact on weight,
potential side effects, renal effects, delivery method (oral
versus subcutaneous), cost, and patient preferences
Glycemic assessment
Assess glycemic status at least two times a year in patients who are
meeting treatment goals (and who have stable glycemic control).

Assess glycemic status at least quarterly and as needed in patients whose

therapy has recently changed and/or who are not meeting glycemic goals.

165
 DM treatment approach

Glycemic targets (A1C goals)

<8 %
< 6.5 % < 7% • Limited life expectancy
• Short duration DM Many non-pregnant adult • History of level 3 hypoglycemia
• Long life expectancy without significant • Advanced micro or macro
• No significant CVD hypoglycemia is appropriate vascular complication
• Cognitive impermeant

When to start ?
Patients with A1C near target (<7.5 %) A1C at or above target level (>7.5 to 8 %)
A three- to six-month trial of lifestyle A1C Pharmacologic therapy should be initiated at
modification before initiating pharmacologic the time of type 2 diabetes diagnosis
therapy is reasonable 7.5 (with lifestyle modification)

First line: Metformin (with lifestyle modification)

Patient should be evaluated for difficulty adhering to the medication, side effects, poor understanding
of the nutrition plan, assessed for age-related barriers, such as cognitive and/or functional decline,
depression, and other social and financial issues that might be interfering with self-care. If glycemic
control is still above the individualized target, an additional agent is needed.

1. If monotherapy at maximal tolerated dose not achieve target over 3-6 months
Or
2. Newly diagnosed with HbA1C ≥ 1.5 above the target

Add second agent

When selecting the next step in type 2 diabetes management after metformin
for a given patient, clinicians should consider the following questions:
1. Does the individual have preexisting ASCVD or indicators of high risk for ASCVD?

o Established ASCVD includes an ischemic stroke, previous MI, unstable angina with
ECG changes, or revascularization of the coronary, carotid, or peripheral arteries.

o Indicators of high risk for ASCVD: include ≥55 years of age with coronary, carotid,
or lower-extremity artery stenosis >50% or left ventricular hypertrophy.
2
2. Does the individual have HF (particularly HFrEF) or CKD (eGFR of 30–60 mL/min/1.73 m )?
3. Is there a compelling need to avoid weight gain or promote weight loss in this individual?
4. Is there a compelling reason to avoid hypoglycemia in this individual?
5. Is medication cost the major issue for this individual?

166
DM treatment approach

167
DM treatment approach

168
DM treatment approach

169
Micro/Macrovascular Complications
Cardiovascular risk assessment and management:
• Explore & calculate the risk of ASCVD at least annually
Blood pressure

<130/80 mmHg for pt at higher CV risk <140/90 mmHg for pt at lower CV risk
• Life- style intervention consists of weight loss when indicated, a Dietary
Approaches to Stop Hypertension (DASH)-style eating pattern including reducing
sodium and increasing potassium intake, moderation of alcohol intake, and
increased physical activity.
BP • Should be kept <130/<80o First line drug may be either ACE inhibitors,
management angiotensin receptor blockers [ARBs], thiazide like diuretics, or
dihydropyridine calcium channel blockers
• Use ACE inhibitor or ARB for HTN treatment if pt has albuminurea
• serum creatinine and potassium should be monitored at least annually during
treatment with an ACE inhibitor, ARB, or diuretic, particularly among patients
with reduced eGFR, who are at increased risk of hyperkalemia and AKI.
• Patients with BP ≥160/100 mmHg should, in addition to lifestyle therapy, have
prompt initiation and timely titration of two drugs.
• If pt at any age has ASCVD, high-intensity statin therapy should be added to
lifestyle therapy
Lipid • For patients with diabetes aged <40 years with additional ASCVD risk factors,
management consider using moderate-intensity statin in addition to lifestyle therapy.
• For patients with diabetes aged 40–75 years and >75 years without ASCVD,
use moderate intensity statin in addition to lifestyle therapy.
• Use Aspirin for pt with ASCVD & DM (use Clopidegrel if allergic to ASA) as 2nd
prevention
• Give ASA for pt with DM and at least one additional risk factor for ASCVD if no
Antiplatelet risk of bleeding (family history of premature ASCVD, hypertension, dyslipidemia,
therapy smoking, or albuminurea)
• No combined Antiplatelets except after acute coronary syndrome and only
one year
• Smoking cessation counseling if applicable.
• Assess each patient’s readiness to achieve weight loss and jointly
determine weight loss goals and intervention strategies
• Lifestyle intervention (diet, physical activity, and behavioral therapy)
Obesity
programs should be intensive and have frequent follow-up
management
• Offer bariatric surgery for pt with BMI > 30, if hyperglycemia is inadequately
controlled despite optimal medical control by either oral or injectable
medications (including insulin).
• Diagnosed by the persistent presence of elevated urinary albumin excretion
(albuminurea), low eGFR, or other manifestations of kidney damage
Chronic • For non pregnant women, ACE inhibitor or an ARB is recommended for pt with
kidney high ACR
disease • The combined use of ACE inhibitors and ARBs should be avoided.
• Ref to specialist if GFR < 30 , rapidly progressing kidney disease or
uncertainty about the etiology of kidney disease.
Diabetic • Pregabalin or duloxetine are recommended as initial pharmacologic treatments
neuropathy for neuropathic pain in diabetes.
General
• Immunizations: Influenza annually, Pneumococcal vaccine, Hep B vaccine
preventive
• Routine age- and sex-appropriate cancer screenings
measures

170
 Recommended Referral

Recommended Referral in Diabetic Pt

Dilated and comprehensive eye examination by an
ophthalmologist or optometrist should be repeated annually.
(B)

Podiatry: Patients who smoke patients with foot ulcer or high

risk feet (h/o prior ulcer or amputation)

Refer patients with significant claudication or a positive ABI

for further vascular assessment and consider exercise,
medications, and surgical options. (C)

Consider referral to Nephrologist:

• When there is uncertainty about the etiology of CKD
• Alb/Cr ratio >300 mg/g (nephrotic range),
• Difficult management issues (anemia, secondary
• Hyperparathyroidism, metabolic bone disease, resistant
• Hypertension, or electrolyte disturbances),
• Stage 4 CKD (eGFR <30 mL/min/1.73 m2) requiring
discussion of renal replacement therapy for end stage renal
disease.

Consultation with a nephrologist when stage 4 CKD develops

(eGFR <30 mL/min/1.73 m2) has been found to reduce cost,
improve quality of care, and delay dialysis.

Medical Nutritional therapy.

Referral to a Mental Health Specialist :

• Positive screening for overall stress related to work-life
balance, DD, diabetes management difficulties,
• Depression, anxiety, disordered eating, and cognitive
dysfunction.

171
DM in Ramadan

172
DM in Ramadan

Risk Calculation for diabetic Pt that seek to fast during Ramadan

Low Risk Moderate Risk High Risk

Score 0 to 3 Score 3.5 to 6 Score >6
Be able to fast Advised not to fast Should not fast

173
DM in Ramadan

Self-Monitoring of Blood Glucose (SMBG) – 7 point guide for Ramadan

ALL INDIVIDUALS SHOULD BREAK THEIR FAST IF:

Hypoglycemia Hyperglycemia Dehydration

174
DM in Ramadan

Medication Dosing Adjustment During Ramadan

Metformin

Sulfonylurea

175
DM in Ramadan

Medication Dosing Adjustment During Ramadan

Long and Short Acting Insulin

Premixed Insulin

Insulin Titration

176
 Preconception counseling

Female with DM planning for pregnancy

Glycemic target during pregnancy
1-hour 2-hour
A1C Fasting
postprandial postprandial
<95 mg/dL (5.3
<6.5% (48 <140 mg/dL (7.8 <120 mg/dL (6.7
mmol/L) and
mmol/mol) mmol/L) mmol/L)
either
Management:
Pre-Conception counseling:
a) Counseling about diabetes & pregnancy related risks of malformations associated
with poor glycemic control as (spontaneous abortion, fetal anomalies, preeclampsia,
fetal demise, macrosomia, neonatal hypoglycemia, and neonatal
hyperbilirubinemia, In addition, it may increase the risk of obesity and type 2
diabetes in offspring later in life)
b) Women with preexisting type 1 or type 2 diabetes should be counseled on the risk of
development and/or progression of diabetic retinopathy.
Dilated eye examinations should be done before pregnancy or in the first
trimester, and then every trimester and 1-year postpartum.
c) Women with preexisting DM should ideally be managed in a
multidisciplinary clinic including an endocrinologist, maternal-fetal medicine
specialists, dietitian, and diabetes educator.
d) Effective contraception use is mandatory until glycemic control is achieved (offer to
continue OCP) discuss HbA1c level: (recommendation to optimize glycemic control prior to
conception, with A1C <6.5% (48 mmol/mol)
associated with the lowest risk of congenital anomalies
Non-pharmacological:
• Nutrition and Exercise education to support glycemic control
• Consider dietitian and health educator referral for details advices & how to adjust
insulin dosage
Pharmacological:
[Link] oral hypoglycemic agents and start insulin therapy to achieve target HbA1c (pt
weight 90 kg, the total daily dose 45units, should be given as (50%) basal insulin eg. Lantus 22
units HS, and (50%) as prandial insulin eg. Aspart, 7 units with the 3 main meals)
[Link] about the importance of blood glucose monitoring and prescribe a glucometer to
measure fasting, preprandial and postprandial glucose to achieve target control:
*fasting capillary blood glucose concentration 80 to 110 mg/dL (4.4 to 6.1
mmol/L)
* two-hour postprandial glucose concentration <155 mg/dL (8.6 mmol/L). from up to
date
3. Start folic acid supplement 5mg OD
• Referral for ophthalmology for retinal examination
• Check patient understanding & agreement on her management plan
• Appropriate follow up
• Appropriate health promotion advice for risk factors ([Link] smoking)

177
 Insulin use

Explain what the medication is

Name: Insulin injection or pen,

Purpose: "Provides the body with the insulin that it lacks, in order to regulate its
utilization of sugar".
Show the patient the insulin injection or pen and explain its parts.

Explain the steps of use

"The proper technique is very important to ensure that your body benefits from the
medication used":
"Wash your hands for 15 seconds, dry them, and get your insulin ready (cleaning the
skin with an alcohol swab is not necessary)".

For insulin in syringe

• Gently mix by turning the bottle on its side and rolling or rubbing it between the
palms of your hands.
• Do not shake the bottle because shaking can make the insulin clump together.
• Prepare the insulin bottle: If the insulin bottle is new, remove the cap.
• Clean the top of the insulin bottle with an alcohol pad before you put a needle into
it.
• Pull air into the syringe and inject it into the vial (to increase its pressure).
• Pull the plunger to fill the syringe with just a little more than the insulin dose you
need.
• Release any air bubbles form the syringe: tap the syringe with your finger to make
them rise to the top. Slowly push in the plunger just enough to push out the air and
the extra insulin.
• Prepare for injecting the insulin:
• Change the needle before injecting yourself (as it gets blunter when it is pushed
into the vial.
• Use areas with good layer of fat under the skin (2.5 centimeter can be pinched
between two fingers), as this is the place that you want the insulin to stay and
slowly go to the blood.
• Use the abdomen below the navel, outer part of the thighs, arms, or buttocks.
• Lift up or pinch the skin and insert the needle perpendicularly using your dominant
hand (hold the syringe between your thumb and middle finger).
• Push the plunger using your index finger all the way down.
• Keep the needle in for 10 seconds (to avoid insulin leakage after withdrawal of the
needle).
• Quickly withdraw the needle.
Press down firmly (do not rub or massage) over the injection site for up to 60
seconds".

178
 Insulin use
For insulin pen
• Get your supplies: insulin pen (double-check that it is the right kind of insulin and that the fluid is
clear, colorless, with no clumps, and not expired), insulin cartridge (follow the pen manufacturer's
instructions for inserting an insulin cartridge into a reusable pen), disposable needles, their cap and
alcohol pads.
• Attach the disposable needle to the pen:
• Remove the pen cap. Clean the rubber seal on the insulin cartridge with a sterile alcohol swab.
• Attach the disposable needle to the pen. Remove the outer needle cap and save it to use after your
injection. Remove the inner needle cap and throw it away.
• Prepare the insulin:
• Gently mix it by turning the pen upside down for 10 times.
• Prime the pen before each injection. "This releases a small amount of insulin into the needle in
order to get rid of any air bubbles and ensure the use of correct dose.
• Point the needle up.
• Tap the insulin cartridge to force any air bubbles to the top. Dial 2 units of insulin on the dose
selector (for most insulin pens, you will hear a click for each unit of insulin that you have dialed).
• Firmly press the plunger until a drop of insulin appears at the needle tip.
• Repeat this step if a droplet does not appear, or change the needle if you had to repeat it several
times".
• Return your dose selector to "zero" and dial the correct dose (make sure there is enough insulin in
the pen for your full dose).
• Lightly pinch a fold of skin and insert the injection perpendicularly.
• Push the plunger all the way in and keep pressing it for a count of 5-10 before you remove the
needle from the skin. Gently apply pressure on the injection site, but do not rub it.
• Demonstrate to the patient all the steps.
• Let him or her do it and observe to correct.

Advise the patient:

• To decrease the pain:" keep your insulin out of the refrigerator for 30 minutes prior to use, allow
alcohol to dry before pricking ourself, relax the muscle at the injection site, and avoid changing the
direction of the needle during insertion and removal".
• Rotating the injection site is very important to avoid complications (lipohypotrophy or
lipohypertrophy).
• Always keep a distance of 3 centimeters (1.5 inches) from the last injection site.
Use a new needle every time you inject insulin and dispose it in your sharp trash after use.
• Do not store the insulin with the needle attached.
Store all your unused medications in the refrigerator (not the fridge). Keep the currently used pen
(not insulin vial) at room temperature. At all times keep away from reach of children".
• When traveling, your insulin should be kept in your handbag not your luggage (you will need a
prescription for the airlines to allow that).
• If you are traveling in the car for long time, use ice-bags to avoid damaging the insulin".
• If you forget your insulin in a hot place or were direct sun light is present, discard it.
• Encourage any questions.
Ensure:
• Positive reinforcement: Many others use it, you can definitely use it
correctly.
• We are always available to support you.
• Patient understands the doses.
• Patient understands side effects including hypoglycemia and ways to manage it.
Arrange follow up.
Give away reading materials if available.
Communication skills: ensure organized approach, mixed questioning style
(open and close ended questions), active listening, clear language and
reflection on patient's ideas, concerns and expectations.

179
Insulin use

180
 Glucometer Use

Introduce yourself and establish good rapport ( Name, age and job).

Explain the device:

Name: "Glucometer is a medical device for determining the approximate concentration of
glucose in the blood".
Purpose:
"This helps you determine how well controlled your diabetes is” Show the patient the
glucometer and explain its parts (Meter, test strips, lancet, and lancet's pen). Explain: "Always
check the expiry date of the lancets, and double-check that the meter is working prior to use".
Explain the steps of usage:
"It is very important to use your glucometer correctly as it will provide you with instant
feedback and let you know immediately what your blood sugar level is (too low, too high or in
a good range). Keeping a record of your results gives your doctor an accurate picture of how
your treatment is working. It is small and easy to take with you. You can test anywhere, and
anytime:". "Wash your hands for 15 seconds, dry them, and get your equipment". "Open the
lancet pen and put a lancet in. Adjust the lancet to the shallowest depth that allows the blood
drop to flow out freely (avoid squeezing the finger as this will denature the blood and give
false readings). Take the cap off the lancet without touching it, and cover the pen” "Pull out a
test strip and put it in the meter to turn it on.
Double check that the code that appears on the meter’s screen matches that on the test strips'
bottle". "Wait until a test strip symbol flashes on the screen before you draw the drop of
blood".
Checking Blood Sugar:
"Prick yourself using the lancet pen against the outer or inner borders of one of your fingers
(avoid finger tips that are rich with nerves, thus painful). Do not use the same finger or side
every time". "Allow the blood drop to form freely, and then approximate the test strip to
absorb it. Be sure that the test area on the strip fills completely with blood".
” Place the test strip in the meter and wait for the reading to appear on the screen. Record it
in your logbook or diary” Demonstrate to the patient all the steps. Let him or her do it and
observe to correct.
Advise the patient about cleaning up the supplies:
"With every use: throw the test strip in the trash, and the needle in a puncture proof
container with a lid (such as an old bleach or detergent bottle)". "Store your equipments or
medications away from children and pets". Encourage any questions.
Ensure:
Positive reinforcement:" Many others use it, you can definitely use it correctly" "We are
always available to support you".
Patient understands side effects:
Risk of infection (decreased by
hand-washing), pin-prick pain on needle use.
Arranging a follow up (in 2 weeks) to check the results and adjust medications.
Give away reading material if available.
Communication skills:
Ensure organized approach, mixed questioning style
(open and close ended questions), active listening, clear language and
reflection on patient's ideas, concerns and expectations.

181
Glucometer Use

182
 Diabetic foot care
Introduce yourself and establish good rapport ( Name, age and job).
"How long have you been Diabetic?, treatment used?, level of control?"
Any previous foot injury, infections, nail problems, accidental
foreign bodies (indicates loss of sensation).
Any end organ damage: kidney (deranged glomerular filtration rate
Ask (eGFR) or microalbuminurea), eye, or cardiac disease (angina or MI).
Ideas, concerns, and expectations (ICE): medication, vaccination, care related to
underlying condition.
Brief past medical, family and social histories along with the vaccination status.
"Feet problems among diabetes patients are common, treating them
early is very important to prevent serious complications. This is because;
Advice healing is slow in diabetics due to the decreased blood supply and less sensitive
nerves".
Current care routine, ability of patient to take care of the foot
Assess (limited by obesity), availability of family support.

"Clip your toe-nails regularly

(square shaped). Ask for help
if you cannot reach".

Assist

If any wound: simply wash it

with tap water, cover it with
clean gauze, see your doctor
within 2 days maximum".

"Keep the blood flowing to your feet. Put your feet up when sitting.
Wiggle your toes and move your ankles up and down for 5 minutes, two or three times per day.
Don't cross your legs for long periods of time. Do not smoke".
"Keep your Diabetes Mellitus under very good control with regular visits to your doctor"
Follow up: Every 3 to 6 months for labs to check control level and screen for
cardiovascular risk factors (hypertension or hyperlipidemia).
Annual foot exam and retinal screening.
Brief assessment of underlying conditions and age appropriate screening.
Arrange Give away reading materials if available.
Communication skills: ensure organized approach, mixed questioning style (open and close
ended questions), active listening, clear language and reflection on patient's ideas,
concerns and expectations.

183
 Diabetic foot Ex

Diabetic foot Examination

Introduction
•Wash hands
•Introduce self
•Ask Patient’s name, DOB and what they like to be called
•Explain examination and obtain consent
•Expose feet

Inspection
•General: gait, shoes (flat heel, pattern of wear), amputations
•Skin: vascular insufficiency (hairlessness, pallor), rubor/corns/callus at pressure
points, texture, fissures, skin breaks/lesions/ulcers, diabetic dermopathy,
infection (swelling, erythema, gangrene, cellulitis), oedema, venous
eczema/lipodermatosclerosis
•Nails: dystrophy, ingrown nails
•Webspaces: cracking, ulcers, maceration, infections
•Deformity: clawed toes, bony prominences, Charcot joints (joint swelling with
collapse of medial longitudinal arch – due to loss of protective pain sensation)

Arteriopathy assessment
•Temperature: use dorsum of each hand to feel up legs
•Pulses: femoral, popliteal, posterior tibial, dorsalis pedis
•Capillary refill (should be <2 seconds)

Neuropathy assessment
•Sensory: show patient how each feels on sternum before and ask them to close
their eyes
•10g monofilament: fully extend the monofilament and press with enough
force to make it bend. First let patient feel the sensation on their sternum, then
ask them to close their eyes and tell you when they feel you touch their feet.
Test sensation in multiple places, e.g. hallux and metatarsal heads.

184
 Diabetic foot Ex
•128Hz Tuning fork: use your fingers to twang prongs and hold circular base on the patient’s
joint. First let patient feel the sensation on their sternum, then ask them to close their eyes
and tell you when they feel a vibration on their feet and when they feel it stop (stop the
vibration yourself by gripping the prongs). Start over first MTP joint and move to proximal
joints if the patient cannot feel it.
•Proprioception: hold the distal phalanx of the big toe with a finger on each side (while
stabilizing the proximal phalanx with your other hand). Flex and extend the joint with the
patient watching these movements and then ask them to close their eyes. Wiggle the distal
phalanx up and down a few times, then stop and ask the patient if their toe is up or down. If
they cannot tell, test more proximal joints in succession until they can.
•Motor: muscle wasting, pes planus, pes cavus, Charcot joints
•Reflexes: ankle jerk
•Autonomic: sweaty, dry, cracked skin

To complete
•Thank patient and restore clothing
•‘To complete my examination, I would perform a full neurovascular examination.’
•Summarize and suggest further investigations you would consider after a full history, for
example:
• ABPI
• Doppler arterial pulses
• Blood glucose
• HbA1C

185
Diabetic foot Ex

186
 HYPERthyroidism Hx
•Role out Hyperthyroidism in Pt with Palpitations, Panic attack,
Common
Anxiety or chronic Diarrhea
/Expected
• Goiter (or nodule) with thyroid examination
Scenarios
• Thyrotoxic Crisis (Rare)
Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question)

Allow pt to explain the chief complain
illness Clarify what you understood
Identify patient complaint, duration, site and radiation, onset, character,
relieving or aggravating factors, associated symptoms.
• Tremor
• Heart rate up
• Yawning (fatigue due to insomnia)
• Restlessness
Associated
• Oligomenorrhea/amenorrhea
symptoms
• Intolerance to heat
• Diarrhea
Analysis of • Irritability
chief complain • Sweating
• Muscle wasting/weight loss
Red Flags Thyrotoxic Crisis: Fever, Acute abdomen, Confusion
• Family history of autoimmune disorders
• Radiation therapy to head and neck
• Radioiodine therapy
Risk Factors
• High iodine supplementation
• Smoking
• Lithium use
• Exogenous Thyroxin (common in athletes)
• Medical: Autoimmune disorders
• Surgical: thyroidectomy, radiation to the neck, use of radioactive iodine.
Past Hx • Allergy
• Medication: Lithium
Family Hx Hypo or hyperthyroidism in the family or any auto immune disease.
• Marital status
Psychosocial • Smoking: type and frequency
• Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

187
 HYPERthyroidism Ex
General Vital signs (tachycardia or hypertension)
General look
• Thyroid Examination
• CVS: Tachycardia, atrial fibrillation, palpitations Elderly patients may
have only cardiovascular symptoms, commonly new onset atrial
fibrillation
• GI: Weight loss with increased appetite, thirst, increased frequency of
bowel movements (hyperdefecation)
• Neurology: Proximal muscle weakness, hypokalemic periodic
paralysis (more common in Asian individuals)
• GU: Oligomenorrhea, amenorrhea, decreased fertility
Special • Dermatology: Fine hair, moist and warm skin, vitiligo, soft nails with
onycholysis (Plummer’s nails), palmar erythema, pruritus
• Graves’ disease: clubbing (acropachy), pretibial myxedema (rare)
• MSK: Decreased bone mass
• Hematology: Graves’ disease: leukopenia, lymphocytosis,
splenomegaly, lymphadenopathy (occasionally)
• Eye: Graves’ disease: lid lag, retraction, proptosis, diplopia, decreased
acuity, puffiness, conjuctival injection
• NOTE: Lid lag is a reflection of a hyperadrenergic state and can be
present in any form of thyrotoxicosis
• TSH, T3-T4, TSH receptor antibodies (TRAb) (Specific to Graves)
• Ultrasound
• Thyroid isotope scan
Investigations • Thyroid peroxidase antibodies (TPOAb) (in Hashimoto’s)
• CT or MRI scan of orbit
• Skin biopsy to confirm thyroid dermopathy

CRAPRIOP for Management

‫يحدث َفرْط نشاط الغدة الدرقية عندما تنتج الغدة الدرقية كمية كبيرة من هرمون‬
‫ وينتج عنه فقدان‬،‫ قد يسبب َفرْط نشاط الغدة الدرقية زيادة سرعة األيض‬.‫الثايروكسني‬
‫ باإلضافة الى‬.‫الوزن غير املقصود وسرعة وعدم انتظام ضربات القلب‬
‫اإلسهال‬ ‫احلساسية املتزايدة جتاه احلرارة‬ ‫العصبية والتهيج والقلق‬

Clarification ‫ش ع ر خ ف ي ف وه ش‬ ‫نقصان الوزن غير املقصود‬ ‫ترقق اجللد‬

‫تضخم الغدة الدرقية‬ ‫التعرق‬ ،‫تسارع معدل ضربات القلب‬
‫خفقان‬
‫تعب وضعف العضالت‬ ‫صعوبة النوم‬ ‫تغييرات في أمناط احليض‬

‫ يستخدم األطباء األدوية املضادة للدرقية واليود‬.‫يوجد العديد من طرق عالج َفْرط نشاط الغدة الدرقية‬
Reassurance ‫ يتضمن العالج إجراء جراحة إلزالة غدتك الدرقية‬،‫ في بعض األحيان‬.‫املشع إلبطاء إنتاج الهرمون الدرقي‬
‫ ويوجد ادوية للسيطرة على االعراض‬.‫بأكملها أو جزء منها‬

188
HYPERthyroidism

• General advice for healthy lifestyle

• Smoking Cessation
Advice • Patients who take radioactive iodine should wash their
hands frequently, double flush the toilet, and avoid close
contacts, especially with women and children, afterwards.
BB: propranolol: adults: 80-160mg divided 3-4 times
Antithyroidals (thionamides):
• Methimazole (MMI) 15-30 mg OD
• Propylthiouracil (PTU)100-200 mg TID (in 1st trimester)
• Carbimazole: 20-40 mg/day orally initially, adjust
according to T4 level and response
Prescribing Radioactive iodine thyroid ablation for Graves’ disease and
toxic nodules/adenoma
Surgery in the form of hemi, subtotal, or complete
thyroidectomy for toxic nodules
Thyroid Storm: ABC, IV Fluid, IV paracetamol, IV BB, PO PTU,
IV hydrocortisone, inorganic iodine, admit to ICU
Arrange Referral for endocrinology
Referral If orbitopathy referred to an ophthalmologist
Investigations Mentioned above

Follow-up if thyroidectomy for thyroxin replacement

Observation/ Follow-up while on antithyroid medications with CBC as
follow up baseline then when fever devolved for agranulocytosis AND
TFT for 6-12m every 4 to 8w
Hyperthyroidism causes bone mineral loss screen for
Plan/prevention
osteoporosis
Patients who take antithyroid drugs should immediately
report fever, rash, sore throat, or any symptoms of infection,
Conclusion and patients experiencing these symptoms should stop taking
antithyroid drugs until their neutrophil count is confirmed to
be normal.

189
 HYPOthyroidism Hx
Common • ANC + Hypothyroidism (adjustment of dose)
• CTS or Frozen Shoulder Exam + Hypothyroidism
/Expected • Role out Hypothyroidism in Pt with Fatigue, Depression, Infertility,
Scenarios Dementia
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness
Clarify what you understood
Identify patient complaint, duration, site and radiation, onset, character,
relieving or aggravating factors, associated symptoms.
• Fatigue.
• Skin or hair changes.
• Cold intolerance.
• Decrease memory or concentration.
• Carpal tunnel syndrome.
Associated • Slow speech.
symptoms • Heavy periods.
• Constipation.
Analysis of chief • None refreshing sleep.
complain • Hx of Treated hyperthyroidism, head or neck radiation
• Depression.
• Weight gain.
• Hx of URTI with neck pain (Subacute/De Quervain)
Red Flags Changes in mental status (myxedema coma)
• Family history
• Autoimmune disorders (DM1, vitiligo or Sjogren's syndrome)
Risk Factors • Post-partum thyroiditis
• Radiation therapy to head and neck
• Iodine deficiency
• Amiodarone or lithium use
• Medical: Autoimmune disorders (Diabetes Mellitus, celiac, anemia,
vitiligo, rheumatoid arthritis, hypercholesterolemia, depression, Down
syndrome, Addison disease, cardiac disease
Past Hx
• Surgical: thyroidectomy, radiation to the neck, use of radioactive iodine.
• Allergy
• Medication: Lithium, amiodarone
Family Hx Hypo or hyperthyroidism in the family or any auto immune disease.
• Marital status
Psychosocial • Smoking: type and frequency
• Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
190
 HYPOthyroidism Ex

Vital signs (bradycardia, hypotension or diastolic HTN,

General hypothermia, BMI)
General: Obese, hoarseness, macroglossia
• Thyroid Examination
• CVS: Pericardial effusion, worsening CHF + angina, myxedema
heart
• Respiratory: Hypoventilation secondary to weak muscles
• Neurology: Paresthesia, slow speech, muscle cramps, delayed
Special
deep tendon reflex relaxation (“hung reflexes”), carpal tunnel
syndrome
• Dermatology: Facial puffiness, periorbital edema, cool and
pale, dry and rough skin, dry and coarse hair, hair loss
(eyebrows thinned (lateral 1/3), discoloration (carotenemia)
TSH, free T4, Anti- TPO antibodies, Lipid panel, CBC,
CRP(Thyroiditis), Prolactin
Investigations
ECG, Ultrasound of the thyroid (if nodule is present)
Note: T3 levels are often normal, even in severe cases

CRAPRIOP for Management

‫قصور الدرقية )الغدة الدرقية اخلاملة( هي حالة ال تنتج فيها الغدة الدرقية لديك ما يكفي‬
‫ وذلك‬،‫ تختلف عالمات مرض قصور الغدة الدرقية وأعراضه‬.‫من بعض الهرمونات املهمة‬
‫ غالًبا ما تصل إلى عدة‬،‫ متيل األعراض إلى الظهور ببطء‬.‫على حسب شدة نقصان الهرمون‬
.‫سنوات‬
‫ أو‬.‫ مثل اإلرهاق واكتساب الوزن‬،‫بالكاد قد تالحظ في البداية أعراض قصور الغدة الدرقية‬
‫ فقد تصاب‬،‫ ولكن مع استمرار تباطؤ عملية األيض‬.‫رمبا يعزو ذلك إلى التقدم في السن‬
:‫ قد تتضمن العالمات وأعراض قصور الغدة الدرقية ما يلي‬.‫بأمراض أكثر وضوًحا‬
Clarification
‫اإلمساك‬ ‫احلساسية املتزايدة جتاه البرد‬ ‫التعب‬

‫تساقط الشعر‬ ‫زيادة الوزن‬ ‫جفاف البشرة‬

‫تضخم الغدة الدرقية‬ ‫االكتئاب‬ ‫بطء معدل ضربات القلب‬
‫ضعف العضالت‬ ‫ارتفاع نسبة الكوليسترول‬ ‫غزارة احليض آو عدم انتظامه‬

‫ عادًة ما يكون العالج‬.‫اختبارات وظائف الغدة الدرقية الدقيقة متاحة لتشخيص قصور الدرقية‬
Reassurance ‫بالهرمون الدرقي بسيًطا وآمًنا وفعاال‬

191
 HYPOthyroidism
Advice General advice for healthy lifestyle
Levothyroxine 25 mcg OD
BMJ:
L-thyroxine (up to 1.6 μg/kg/d)
Elderly patients and those with CAD: start at 25 mcg
daily and increase gradually every 6 wk (start low, go
slow)
Replacement with levothyroxine for life
Prescribing Intake instruction: take it early in the morning on an
empty stomach. Delay breakfast until 30-60 minutes,
after taking it.
Visit your doctor once pregnant (usually needs
monitoring of TSH in each trimester with a probable
dose increase by 25-50mcg).
Side effects: palpitations, sweating, disturbed sleep,
loose motions.
Arrange Referral to endocrinology :
Referral
central hypothyroidism ↓TSH↓T4
hypothyroidism unresponsive to treatment.
Pregnant or Goiter
Investigations Mentioned above
First TSH should be monitored 6-8 weeks then 6m then
Yearly.
Observation/ For Pregnant Woman:
follow up every 4-6w until 20 weeks
Once at 24-28w and once at 32-34w, then 4-6w after
delivery
In the developing world, prevention of iodine deficiency
Plan/prevention (mainly through iodization of salt) prevents primary
hypothyroidism.
Complications of hypothyroidism (if untreated):
Conclusion increased risk of coronary artery disease , secondary
hyperlipidemia, depression, memory decline.

192
 Thyroid disorders
Summary of Diagnostic Testing in Hyperthyroidism & Hypothyroidism

Hyperthyroidism Hypothyroidism
TSH
TSH T3, T4 TSH T3, T4
Free T4 1° HypeR ↓ ↑ 1° HypO ↑ ↓
Subclinical HypR ↓ Normal Subclinical HypO ↑ Normal
2° HypeR ↑ ↑ 2° HypO ↓ ↓
Antibodies Graves’: TRAb Hashimoto’s: TPOAb, TgAb
RAIU Increased uptake Decreased uptake
- Graves’ - Subacute thyroiditis
- Toxic multinodular goitre - Recent iodine load
- Toxic adenoma - Exogenous thyroid hormone
Radioisotop Graves’: homogenous diffuse uptake
e Thyroid Multinodular goitre: heterogeneous uptake
Scan Toxic adenoma: single intense area of
uptake with suppression elsewhere
•Thyroid peroxidase antibodies (TPOAb), can be positive in healthy person
•Thyroid-stimulating hormone receptor antibodies (TRAb)
•Thyroglobulin antibodies (TgAb)

TFT interpretation

TSH

•TSH (0.4 – 4)mU/L

•Free T4 (9 – 25)nmol/L
•Free T3 (3.5 – 7.8) nmol/L

193
 Hyperthyroidism
Thyroid
Disorder TSH T4/T3 RAIU Other
Antibodies

Graves’ Disease ↓ ↑ TRAb ↑ Homogenous uptake on scan

Toxic Nodular Goiter ↓ ↑ ↑ Heterogeneous uptake on scan

Intense uptake in hot nodule on

Toxic Nodule ↓ ↑ ↑ scan with suppressed uptake in
the rest of the gland

50% of case
THYROIDITIS (Subacute, In classical subacute painful thyroiditis, ESR
↓ ↑ (TPO antibo ↓
Silent, Postpartum ) increased
dies)
Exogenous (drugs) ↓ ↑ ↓
Endogenous (ovarian Low thyroglobulin since endogenous thyroid
↓ ↑ ↓
teratoma, …) hormone production suppressed

194
Hypothyroidism

195
 Thyroid Storm ER

Clinical Features
• Hyperthyroidism extreme
• hyperthermia°40(≥ C ,(tachycardia ,vomiting ,diarrhea ,hepatic
failure with jaundice ,atrial fibrillation ,congestive heart failure
• CNS manifestations including agitation ,delirium ,psychosis ,
lethargy ,seizures ,coma
Laboratory Investigations
• increased free T 4and T ,3undetectable TSH
• ± Anemia ,leukocytosis ,hyperglycemia ,hypercalcemia ,
elevated LFTs
Management
ABCD
• Support airway and respiration as necessary.
• Take control of the body temperature. Start cool IV fluids and
cooling blanket and acetaminophen can be used to treat the
pyrexia

Medication Dose
Inhibit peripheral effects of thyroid hormone
Propranolol 60-80 mg orally (immediate-release) every 4-6 hours
Stop new hormone production
Propylthiouracil 500-1000 mg orally initially as a loading dose, followed by 250 mg orally
(PTU) every 4 hours
Methimazole 20-25 mg PO
Glucocorticoids
300 mg intravenously initially as a loading dose, followed by 100 mg
Hydrocortisone every 8 hours
Inhibit hormone release
(Do Not Start Until at Least 1 hour After PTU or Methimazole)
iodine/potassi 5 drops (250 mg) orally every 6 hours;
um iodide

196
 Osteoporosis Hx
Common/Expected • Care of elderly with Hx of fall
Scenarios • Prevention of osteoporosis in high risk
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present Usually asymptomatic until fracture occurs
illness Fracture maybe found during imaging for other clinical indications
or during screening in high-risk person.
Associated symptoms:
• Back pain and postural change (kyphosis)
• loss of height
• Impaired gait, imbalance, and lower-extremity weakness
• Impaired vision, it may increase risk of falling and cause fracture.
• Constipation, abdominal pain, distention, reduced appetite
• Age of menopause, secondary amenorrhea
Analysis of • Risk of falls ( history of falls, LOC /muscle weakness)
chief Risk factors:
Modifiable Nonmodifiable
complain • Smoking and Alcoholism • Advanced age
• Poor nutrition • Family history
• Inadequate physical activity • Race/ethnicity
• Use of certain drugs (eg, • Female sex
anticonvulsants, systemic steroids, • Estrogen deficiency
thyroid supplements, heparin, • Primary/ secondary hypogonadism in
chemotherapeutic agents, insulin) men
• Frequent falls
Medical & Surgical:
Prior fracture, COPD, Cushing’s syndrome, Hyperparathyroidism,
hyperthyroidism, hysterectomy/ oophorectomy.
Past Hx Allergy
Medication
PPI, Corticosteroid, Loop diuretics, Heparin, anticonvulsant, HRT, lithium
Family Hx Bone fracture, osteoporosis, Cystic fibrosis, hemochromatosis.
Marital status
Smoking and alcohol: type and frequency
Psychosocial Physical activates
Nutritional history: dairy products daily or daily calcium & vitamin D
Screening: depression and anxiety
Elderly Polypharma, fall, dementia, visual/auditory and UTI/urinary incontinence
assessment For more details see Geriatric section
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

197
 Osteoporosis
BMI: low body mass index Risk of fall and fracture may be assessed
Height loss by testing vision and assessing patient's
General Spinal kyphosis balance, gait, and lower-extremity
Ex signs of hyperthyroidism (such as tachycardia, strength
weight loss, hypertension, goiter)
Laboratory evaluation for all newly diagnosed patients to determine if there
are contraindications for certain osteoporosis medications and to identify the
more common secondary causes.
Alkaline phosphatase: Normal
Calcium: normal
Phosphate: normal
PTH: normal.
investigations

25-hydroxy vitamin D: To rule out vitamin deficiency

Thyroid function test: normal
Serum Creatinine: to evaluate renal function with concern for chronic
kidney disease (CKD)-bone and mineral disorder.
Testosterone (men): should be considered in all young males with
osteoporosis (hypogonadism).
Imaging:
DXA (Dual-energy x-ray absorptiometry ) X-ray
may reveal osteopenia and/or fractures
Quantitative CT
Alternative modality if dual-energy x-ray absorptiometry not available

CRAPRIOP for Management

Osteoporosis is a systemic skeletal disease characterized by low bone mass ,
Clarification microarchitectural deterioration of bone tissue, consequent increase in
bone fragility.
It is common problem, 34% of Saudi women, 30% of Saudi men have
Reassurance osteoporosis
• Decreased caffeine intake (≤ 2.5 cups of coffee per day)
• Multicomponent exercise with strength and balance training
• Multifactorial falls risk assessment
• Smoking cessation
• Sunlight/ultraviolet exposure and Vitamin D supplementation
(800 IU per day)
• To reduce risk of fall in home
Advice ‫عدم وجود أرض مبللة‬ ‫تعديل أو تثبيت أطراف السجاد‬ ‫وجود حواجز بأطراف السرير‬
‫الفحص الدوري للسمع والنظر‬ ‫وجود إنارة كافية في الغرفة‬ ‫ارتفاع السرير قصير ومناسب‬
‫وجود دعامات ومقابض في دورة‬ ‫وجود جهاز مناداة قريب وقائمة‬
‫التأكد من عدم وجود أدوية غير‬ ‫املياه‬ ‫كبيرة باألرقام لالتصال‬
‫مناسبة لكبار السن أو منتهية‬
‫الصالحية‬ ‫وجود سجادات مانعة لالنزالق‬ ‫احلرص على عدم وجود أدوية‬
‫أمام األحواض‬ ‫مبعثرة قريبة‬

198
 Osteoporosis
Who to treat?
• a personal history of hip or vertebral fracture
• a T-score of –2.5 or less.
• a combination of low bone mass (T-score between –1 and –2.5) and a 10-
year probability of hip fracture of at least 3% or any major fracture of at
least 20% as calculated by the FRAX
Non-Pharmacological: 1200 mg of pure ca (total of diet and supplement)
and 800 IU of vitamin D daily
Pharmacological ttt:
❖ Bisphosphonate: (preferred and 1st line)
1- alendronate: oral 10 mg/ day or 70 mg/ week, for 5 years (check DEXA
after 2 years if good response
continue), after 5 years if low risk >>stop, if high risk>> continue for another
5 years. SIDE EFFECT: esophagitis, esophageal perforation.
Prescribing Advice: Take on empty stomach with full glass of water and remain upright
for 30 to 60m. Delay drinking, eating or Ca for 30-120m.
2- Risedronate: oral lower GI side effect 35 mg/ week
3- Zoledronic acid: 5 mg per year, IV route, indication: who cant tolerate
oral. (For 3 year, can continue to 6 years as explained above in alendronate)
SIDE EFFECT : hypocalcemia, acute renal impairment
❖ Denosumab: 60 mg every 6 months, subcutaneous, indication: who cant
tolerate oral, renal impairment
❖ Selective estrogen receptor modulator (raloxifene) Advantage: Prevent
breast cancer
❖ Calcitonin
❖ Parathyroid hormone : (Teriparatide)
- In sever non responding cases
- 20 mcg per day for up to 2 years, subcutaneous because: risk of
osteosarcoma
Guidelines for Osteoporosis in Saudi Arabia (SOS):
Screening for osteoporosis in postmenopausal women and men start at a
younger age because the panel recognized that osteoporosis and
osteoporotic fractures occur at a younger age in Saudi Arabia.
Referral Routine Screening indicated by age:
All Saudi women above the age of 60 years must undergo a BMD
assessment using DXA.
All Saudi men above the age of 65 years must undergo a BMD
assessment using DXA.
Investigations Mentioned above
Observation/ Follow up 1/12 to check compliance on Rx with plan to repeat DXA scan
follow up after l -2 Years.
Plan/preventio See above J
n
Conclusion Includes Safety netting

199
 Osteoporosis
Screening:

• Central Dual Energy X-ray Absorptiometry (DEXA) scan of the hip and lumbar spine.
• Postmenopausal women younger than 65 years who have at least 1 risk factor, should be screened
with a clinical risk assessment tool, Example: FRAX score. [Link]

•What is FRAX score? It is a risk assessment tool used to assess the need of DEXA scan, and the
need of treatment in non osteoporotic patient.
•(FRAX) model allows estimation of 10-year probability of hip fracture and major osteoporotic
fractures using clinical risk factors alone or in combination with femoral neck BMD.
If FRAX score ≥ 9.3% 10-year risk for any osteoporotic fracture, go for BMD (DEXA).
• Consider high risk patient if risk of hip fracture >3%, or risk of breaking any bone >20%.
(Start treatment in high-risk patient even if not osteoporotic in DEXA)
Factors affecting FRAX score:

DEXA Considered to be the standard measurement of bone density by The World

Health Organization (WHO) criteria, it is used to screen and diagnose osteoporosis.
Skeletal site selection: (WHO) recommends to
measure T-score at femoral neck. however, the
NOF recommends the lumbar spine (L1-L4), total
proximal femur or femoral neck.

200
 Metabolic Syndrome Hx
Common/Expected
• Obese came for check-up/investigations or to prescribe new GLP-1 inj.
Scenarios

Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

Allow pt. to explain the chief complain.
present
May present as: complication of HTN, DM, heart disease, PCOs
illness and non-alcoholic fatty liver disease.
Analysis of Course, onset and duration
chief SOCRATES for pain
complain Associated symptoms (DDx), Risk Factors & Red Flags
HTN
If already diagnosed ask about 3Cs: complain, compliance to medications,
complications.

Could be newly diagnosed & ask about secondary HTN:

Symptoms suggestive of obstructive sleep apnea: (snoring & day somnolence
…etc.)
Symptoms suggestive of coarctation of the aorta: (headache, epistaxis,
intermittent claudication, lower limb weakness, cold legs and feet)
Symptoms suggestive of kidney disease: hematuria, ‘frothy’ urine, dyspnea,
lower limb swelling, flank tenderness and pain)
Symptoms suggestive of endocrine disease:
• muscle weakness, muscle spasms and paresthesia
(hyperaldosteronism).
• Severe headache, palpitations and sweating (pheochromocytoma).
• weight gain particularly abdominal, facial and on the back of the neck
and shoulders (Cushing’s syndrome).
• tall statures, swelling of the hands and feet and deepening of the voice
(acromegaly).
• weight gain, cold intolerance and low mood (hypothyroidism). weight
loss, heat intolerance and palpitations (hyperthyroidism).
Drug induced: OCPs, steroids, decongestant …etc. & herbal (ephedra).

Red flags:
• Stroke or increase intracranial pressure & hypertensive retinopathy
(headache, visual disturbances or, weakness, seizures, nausea and vomiting)
• CHD or MI or arrhythmia (Chest pain, dyspnea, palpitation & claudication)

201
 Metabolic Syndrome Hx
DM
If already diagnosed ask about 3Cs: complain, compliance to medications, complications.
Symptoms of hyperglycemia (polyuria, polydipsia, unintended weight
loss and its duration).
Symptoms of hypoglycemia (Dizziness, headache, tremors, sweating and headache )
symptoms of any complications :
• Macrovascular: CVD (chest pain, dyspnea, …etc.), stroke (headache, visual loss, unilateral
weakness …etc.) , peripheral vascular disease (claudication, sexual impotency, …etc.) &
diabetic foot .
• Microvascular: neuropathy (numbness, painful limps) ,nephropathy & retinopathy (blurred
vision).
Polycystic ovary syndrome
Ask if already diagnosed, if not ask about symptoms of PCOS:
Hirsutism, menstrual irregularities, acne, weight gain & darkness of neck fold (acanthosis
nigricans).
Sexual dysfunction in men.
Non alcholic fatty liver diseas
Mostly asymptomatic, when it does they may include:
Fatigue & abdominal pain
Ask about liver cirrhosis as complication:
• Abdominal swelling (ascites)
• Yellowish skin (jaundice)
• Confusion (encephalopathy)
• Nail changes (clubbing, leukonychia & terry nail)
• Hand changes (dupuytren contraction and palmar erythema)
• Skin changes (spider naevi)
Medical: heart disease, dyslipidemia , cancer hx.
Past Hx Surgical hx.
Allergy & medication: for HTN,DM, PCOS & dyslipidemia
Family Hx HTN,DM, PCOS, dyslipidemia & similar condition.
lifestyle: physical inactivity, diet, psychosocial stress &
Smoking:(type and frequency).
Psychosocial
Marital status
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
conclusion

202
 Metabolic Syndrome Ex
Vital signs (BP, waist circumference & calculate BMI)
General Appearance (apple &bear body shape)
Cardiac Ex
Abdominal Ex
• Signs of PCOs & insulin resistance:
Acne, hirsutism, acanthosis nigricans & obesity
• Signs of dyslipidemia:
Special Xanthelasma, tendon xanthomas & central arcus
• Signs of endocrine disease:
• Cushing’s syndrome: moon facies, abdominal purple striae and bruising.
• Hypothyroidism: goiter, delayed tendon reflex, bradycardia, dry skin,
brittle hair, loss of outer third of eyebrow &myxedema
Diabetic foot examination
• 10-Year-CV RISK ASSESSMENT
• CBC, urinalysis, blood chemistry & (ECG)
• lipid profile (LDL, HDL, triglyceride …etc.)
Investigations • Metabolic panel (liver function test, …etc.) & HA1c , fasting glucose.
• TFT
• FSH,LH, testosterone level & US of ovaries
• OSA: polysomnography

CRAPRIOP for Management

Metabolic syndrome is a cluster of conditions that occur together, increasing
your risk of heart disease, stroke and type 2 diabetes. These conditions
include increased blood pressure, high blood sugar, excess body fat around
Clarification the waist, and abnormal cholesterol or triglyceride levels.
‫متالزمة األيض هي مجموعة من املشاكل التي حتدث معًا وتزيد من خطر اإلصابة بأمراض القلب والسكتة‬
‫ تشمل تلك املشاكل ارتفاع ضغط الدم وارتفاع السكر في الدم وزيادة‬.‫الدماغية ومرض السكري من النوع الثاني‬
.‫دهون اجلسم حول الوسط ومستويات غير طبيعية من الكوليسترول أو الدهون الثالثية‬
Reassurance With proper healthy lifestyle (1ST line) & medication can be controlled.
• Atherogenic diet (better to describe it in simple phrase)
• Reduce intake of total, saturated, and trans fats, cholesterol, simple
sugars, and foods with high glycemic index
• Provide adequate intake of fiber, unsaturated fats, fruits, vegetables,
Advice whole grains, and fish
• Weight loss: reduce body weight by 7%-10% in 1st year with goal of
<25 BMI
• Exercise : for 30 minutes, preferably 45–60 minutes, ≥ 5 days/week
• Smoking cessation
Prescribing Treat the HTN, DM, PCOs, Obesity and dyslioidemia accordingly
Dietitian, health educator, gynecologist if need it, Bariatric Surgery
Referral (indications)
Investigations Mentioned above
Observation/follow up follow up after 4 weeks.
Plan/prevention Health promotion & screen according to the age
Conclusion Includes Safety netting

203
Metabolic Syndrome

204
Metabolic Syndrome

205
 Obesity Hx
Common/Expected
• Obese came for check-up/investigations or to prescribe new GLP-1 inj.
Scenarios

Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness
Allow pt to explain the chief complain and Clarify what you
understood
Wight gain:
• When weight gain started ? (since childhood , adulthood or
recently or sudden)
• How long he is complaining of obesity?
• Does she measure herself regularly and keep the records?
• Current weight , height , BMI ?
• Does she see herself as obese and why?
• Past trial to reduce weight (when, how, and the result).
• Childhood complains: short stature, obesity, dysmorphic,
stunted growth.
Associated symptoms (DDx):
Cardiac and respiratory symptoms:
-OSA: Excessive daytime sleepiness, morning headache, Snoring.
-CAS: dyspnea, PND, Orthopnea, chest pain.
Endocrine symptoms:
Analysis of -Diabetes: Polyuria, polydipsia.
chief -Hypothyroidism: Constipation, cold intolerance, fatigue, hair
complain loss.
-Cushing’s syndrome: moon-face, buffalo hump , visual
disturbance.
-PCOS: Infertility, hirsutism, acne, irregular period.
-Pituitary adenoma: Visual disturbance.
Musculoskeletal symptoms:
-Limitations in exercise, tolerance.
-Osteoarthritis: Joint pain, Difficulty in moving, Back or knee
pain.
-disc herniation: lower limb pain , neurological deficit.
GIT symptoms:
-Food intolerance: Sweating, palpitations, rapid breathing, rash
and burning sensation of the skin, face and chest tightness, and
diarrhea.
-Gallbladder disease: Nausea, vomiting, abdominal pain at the
RUQ, radiate to the back, abdominal tenderness, jaundice.

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 Obesity Hx
Post bariatric surgery care:
-Nausea & vomiting / Food intolerances
-Dumping: refers to the post-prandial occurrence of symptoms elicited by
the rapid transit of calorie-dense food to the small (headache / fatigue /
sweating / nausea / weakness / sleepiness / Dyspnea /desire to sit down /
Analysis of palpation / restlessness / syncope or fainting)
chief -Diarrhea and Steatorrhea (malabsorptive pathology)
-Weight change
complain -Cold intolerance, hair loss, and fatigue
-Local pain at surgical site.
Red Flags:
-visual disturbance to exclude pituitary adenoma
-Binge eating disorder
Medical:
DM / HTN / Dyslipidemia (metabolic syndrome), Asthma, COPD, OSA,
Coronary heart disease or any CVD, Thyroid, GERD, Knee OA, Epilepsy,
Cancers.
Surgical:
Past Hx Any past operations for obesity.
Allergy
Medication:
steroid, OCP, antidepressant, Anti-psychotics , antiepileptic, and Oral
hypoglycemic drugs.
Family Hx Obesity, Metabolic syndrome or Polycystic ovaries.
Marital status
Smoking: type and frequency
Screening: depression and anxiety
Sexual or physical abuse.
Situational issues (recent divorce, death, job change).
Diet: Types of food, how many meals, contents of meals, fast food.
Psychosocial Eating disorders: unusual eating behaviors, Self-imaging.
Exercise: Type, frequency, duration, impact on Wight.
Status of physical activity: EXCERISE (type ,frequency ,duration ,impact on
weight )
Sexual dysfunction.
Alcohol, Drug abuse.
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

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 Obesity Hx
Vital signs
Pulse
BP
Anthropometric for assessing obesity include:
BMI (most common)
General Waist circumference
Waist-to-hip ratio (truncal obesity)
General
Appearance (ill/well).
Body built (normal/overweight/obese).
Distress (using accessory muscles).
(To find secondary causes or complication of obesity such as Cushing ,
thyroid , PCO)
Skin Ex: Dry/sweaty skin, Striae, Acanthosis nigricans, Rash and itching at
skin folds.
Thyroid Ex
Special CVS Ex: Bradycardia, tachycardia, heart sounds, LL edema.
Respiratory Ex: Dyspnea, Chest tightness, Wheeze/stridor
Abdominal Ex: Organomegaly, Abd. Tenderness, striae or rashes.
Limbs Ex: Edema, Varicose veins, DVT.
Others: Buffalo hump, Gynecomastia.
Labs:
-CBC: For anemia.
-Blood glucose and HbA1c : For diabetes.
-Lipid profile: For dyslipidemia.
-LFT: For fatty liver disease
-Electrolytes and urea
Hormones
-Thyroid stimulating hormone (TSH): For hypothyroidism.
-FSH:LH For PCOS.
-Total testosterone and dehydroepiandrosterone sulfate (DHEAS) tests: For
Investigations PCOS.
-Cortisol and adrenocorticotropic hormone (ACTH) tests: For Cushing’s
syndrome.
-insulin-like growth factor
Imaging
-Pelvic ultrasound For PCOS
-Liver US: screen for fatty liver, steatohepatitis.
ECG
Polysomnography (sleep study): screen for OSA

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 Obesity

CRAPRIOP for Management

‫ وهذا التراكم ناجت عن عدم التوازن‬،‫السمنة هي زيادة وزن اجلسم عن حده الطبيعي نتيجة لتراكم الدهون فيه‬
. ‫بني الطاقة املتناولة من الطعام و الطاقة املستهلكة في اجلسم‬
.‫ قد تكون نفسية و عضوية‬:‫أسبابها‬
Clarification .‫ نتيجة ضغوطات احلياة والتوتر فيؤدي الى االكل بشكل مفرط‬:‫نفسية‬
.‫ خمول في افراز الغدة الدرقية‬:‫عضوية‬
-Treatments available: Diet therapy, exercise, medications, or surgery.
-Expected complications (CVD, HTN, DM, asthma, joint pain, back pain,….)
-Reassure the pt that you’ll give him/her the best available care.
Reassurance -Reassure the pt that you’ll be available when needed.
-Physical activity: More details in counseling “Assist”
-Healthy diet: More details in counseling “Assist”
Advice -Healthy sleep (7.5-8.5 hours per night)
-Smoking cessation, if the patient is a smoker.
Medications:
• Orlistat: around 2.6 kg weight loss per month.
SE: flatulence, oily stool and severe liver disease (rare
therefore, monitor the liver functions).
• Liraglutide (Saxenda): starting with 0.6 mg once daily and followed by
weekly increases of 0.6 mg [0.6, 1.2, 1.8, 2.4, 3] until maintenance
dosage of 3 mg once daily)
Prescribing SE: Nausea, vomiting, diarrhea
• Phentermine plus extended-release topiramate
• Naltrexone/bupropion
Surgeries: (If body mass index more than or equal to 40, or index
more than or equal to 35 with obesity related comorbidities)
• Gastric Band.
• Sleeve gastrostomy.
• Roux-en-Y gastric bypass.
-Dietician
-Bariatric medicine or surgery clinic:
Referral • If the behavioral and drug therapy fail to reduce weight within 6m
• If obesity was morbid or associated with CVD risk factors.
-Stress management sessions.
Investigations Mentioned above
Observation/ -Follow up in 2 weeks
follow up -Please come any time in between that you feel you are out of track".
Plan/prevention
Conclusion -Includes Safety netting -Written health education material

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 Obesity
5 A’s for counselling
-Current weight, height, and body mass index?
-How long he is complaining of obesity?
-Childhood complains short stature, obesity, dysmorphic feature stunted growth.
-Previous trials to reduce weight (medical or surgical, reasons for
failure).
-Medical history: Diabetes Mellitus, hypertension, coronary artery
disease, Hyperlipidemia, smoking, obstructive sleep apnea, knee
osteoarthritis, GERD, cancers.
Ask -Regular use of any medications including steroids, oral contraceptive pills,
antidepressants, antipsychotics, antiepileptics.
-Rule out organic causes: Hypothyroidism (constipation, fatigue, cold intolerance),
or polycystic ovarian syndrome (irregular menses , hirsutism, acne).
-Social History: self image or feeling and impact of obesity in social life.
-Explore ideas, concerns, and expectations (ICE).
" Being your doctor, I think it is very important for you to start
losing weight".
"Obesity is a behavioral, socio-cultural problem and occurs when
you have an unbalance between your intake and energy use".
5Rs:
Relevance:
‫ ينتظم السكر و كمان حتصل علي جسم متناسق‬، ‫لو خسرت وزن بإذن الله حتتحسن أشياء كثير مثل الم الركب‬-
-List the personal and health advantages of losing weight. Link the obesity to the
current medical condition if present: "Losing weight will help improving your
sugar control, knee pain…etc. Moreover, weight loss losing will give you a nice
body shape, and this will boost your self-esteem".
Risks:
. ‫ الضغط و امراض القلب والعقم‬، ‫ كما تقلل من مخاطر السمنة كحدوث مرض السكري‬-
-"Do you know how obesity can affect your life?" If no, explain: "It has been
Advice proven by studies to be an independent risk factor for diabetes mellitus,
hypertension, ischemic heart disease, infertility, and cancers. It also has a
negative effects on mood and social interactions"
Rewards:
. ‫انا متأكدة انك بنزول الوزن حتكسب كثير واهمها صحتك بشكل عام‬-
-I am sure that you will gain many rewards from losing weight and reaching your
target weight. Losing weight will have significant impact on your general well
being"
Roadblocks:
.‫من االن اختار تاريخ و حدده وبلغ فيه اهلك و اصدقائك‬-
‫هل في احد ممكن يعقيك عن حتقيق هدفك؟ او هل تنزعج من ردة فعل اصحابك او اهلك ؟‬-
-Set a date and share it with family and friends. Do you think of anyone who can
stand between you and this achievement? Are you worried about the reaction of
a friend or family to your decision?.
Repetition: Remember its all about your health, you can do it.

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Obesity

Ask the patient:

-On a scale of 0 to 10, how confident are you that you can loose
weight?(‫) قد ايش انت متحمس النقاص الوزن ؟‬
-On the same scale, how motivated you are to lose weight?
Assess (‫)قد ايش تتوقع انك تقدر تنزل وزنك؟‬
Stage on behavioral change cycle according to motivation and
willingness to lose weight (precontemplation, contemplation,
preparation, action, maintenance).
Tell the patient: "Ask family members to help you and list down
roadblocks that you might face and ways to avoid them".
Lifestyle modification:
Diet: (make it simple and referral to dietitian for full information)
Be sensible with your plan. Do not crash diet but set a goal over 6-12
months.
• Reduce intake of total, saturated, and trans fats, cholesterol,
simple sugars, and foods with high glycemic index
• Provide adequate intake of fiber, unsaturated fats, fruits,
vegetables, whole grains, and fish
• Do not eat too fast. Chew food adequately.
• Do not eat in front of the television, or while driving.
• Eat in small plates and do not eat leftovers.
• Eat 5 to 6 times a day, 3 meals with small healthy snacks.
Assist Explain to the patient the idea of the healthy plate (1/2 of the plate
should consist of vegetables or fruits, 1/4 of it whole grains & ¼
protein)
Exercise: (For 30 minutes, preferably 45–60 minutes, ≥ 5 days/week)
• Choose a sport that you like (tennis, swimming, golf, or cycling)
and do it regularly.
• Take the stairs instead of lifts.
Hints to help:
• Keep a diary to record type of food you eat and your total
Calories.
• Avoid shopping when feeling hungry.
Always shop with a previously prepared list or let someone else
shop for you.
• Weight yourself weekly.

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Obesity
Medications:
• Orlistat: around 2.6 kg weight loss per month.
SE: flatulence, oily stool and severe liver disease (rare
therefore, monitor the liver functions).
• Liraglutide (Saxenda): starting with 0.6 mg once daily and followed by weekly
increases of 0.6 mg [0.6, 1.2, 1.8, 2.4, 3] until maintenance dosage of 3 mg
once daily)
SE: Nausea, vomiting, diarrhea
• Phentermine plus extended-release topiramate
• Naltrexone/bupropion
Surgeries: (If body mass index more than or equal to 40, or index
more than or equal to 35 with obesity related comorbidities)
Assist

Positive reinforcement:
-Many others did it before you, you can do it, we are always available to support
you.
-We will work together even after loosing weight to help you in maintaining your
weight for the first 2 years. This will help in stabilizing your weight onwards.
Examination: Short stature, moon-face, body mass index, hirsutism,
striae, waist- hip ratio (truncal obesity).
Labs:
-LH/FSH (PCOs),
-TSH
-insulin-like growth factor and cortisol
Arrange -cardiovascular risk factors: glucose, lipids.
Follow up in 2 weeks
-Please come any time in between that you feel you are out of track".
Referral:
-to dietician.
-bariatric medicine or surgery clinic.
-stress management sessions.
-Teach coping strategies (how to cope with life stressors).
-Brief assessment of underlying conditions, perform age appropriate
screening.
-Give away reading material if available.

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 Obesity
CRAPRIOP for Management
(Bariatric surgery /post bariatric surgery care)
: ‫بالنسبة للجراحة‬
‫ مع وجود مشاكل صحية فإننا نلجأ‬۳٥ ‫ فما فوق او‬٤۰ ‫تعتمد على كتلة اجلسم فاذا كانت كتلة اجلسم‬
.‫للجراحة‬
‫ عمليات تهدف الي انقاص الوزن إما‬: ‫هناك عدة أنواع‬
:‫ بالتأثير علي عملية االمتصاص‬-۱
. ‫ تقلل من امتصاص املواد الغذائية نتيجة إزالة جزء وإعادة ترتيب اجلهاز الهضمي‬:‫عملية حتويل املسار‬-
‫ يشعر فيها املريض بالشبع بسرعة‬، ‫ هي عادة تكون باملنظار‬:‫ تصغير حجم املعدة‬-۲
.‫ تكون بإزالة جزء من املعدة وإبقاء خمس حجم املعدة‬:‫ تكميم املعدة‬-
Clarification ‫ ربط املعدة‬-
‫ بالون داخل املعدة‬-
:‫املضاعفات‬
.‫ جلطات وريدية او رئوية و نسبة حدوثها ضعيف‬، ‫ التهاب‬، ‫ نزيف‬:‫عامة‬
.‫ حصوات في املرارة و ترهالت‬،‫ اسهال‬،‫ غثيان‬،‫ فقر دم‬، ‫ نقص الفيتامينات‬:‫خاصة بعمليات السمنة‬
- Weight regain after bariatric surgery is a result of hormonal and metabolic
alterations, surgical failure, nutritional non-adherence, mental health issues
and physical inactivity.
-Reassure the pt that you’ll give him/her the best available care.
Reassurance -Reassure the pt that you’ll be available when needed.
Physical activity:
-moderate aerobic physical activity to include a minimum of 150
min/week.
-goal of 300 min/week, including strength training 2-3 times per
week
Healthy diet:
-Gradually and progressively change the food consistency,
moving from clear liquids to soft or creamy foods and then to
solid
-Eat three structured meals and one or two high-protein snacks
Advice per day.
-Each meal should begin with protein to ensure adequate intake
of 80 to 90 g per day to minimize the loss of lean body mass.
-Gradual change of food consistency in the first post-operative
weeks is preferred in order to avoid or
minimize regurgitation and vomiting,
-A minimal protein intake of 60 g/day and up to 1.5 g/kg ideal
body weight per day should be targeted.
The use of liquid protein supplements (30 g/day) can facilitate
adequate protein intake

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 Obesity
-To avoid dumping syndrome: eating small but frequent meals,
avoiding ingestion of liquids within 30
min of a solid-food meal, avoiding simple sugars, increasing
intake of fiber and complex carbohydrates and increasing protein
intake
-Late symptoms and reactive hypoglycemia may be also
prevented by drinking half a glass of orange juice (or taking the
Advice equivalent small sugar supplement) about 1 h after eating
Smoking cessation: if the patient is a smoker. (Avoid smoking)
Pregnancy :is not recommended in the first 12-18 months
following bariatric surgery.
General advice & education:
-Enforcing and sustaining healthy lifestyle prevent weight regain.
Medications:
-Multivitamin (including fat-soluble vitamin (A, E, K, D) / zinc,
copper, selenium, magnesium, potassium) and vitamin (B6) one
tab BID - lifelong
-Prophylactic empiric iron supplementation: 60 mg elemental
iron/day
-B12 : 350-500ug/day (alternatively: 1 mg/month
intramuscularly, 3 mg every 6 months tramuscularly or 500 ug
every week intranasally)
-Calcium : 1,200-2,000 mg/day of elemental calcium
-Vita D : 400-800 / day
-oral or parenteral thiamine supplementation (50-100 mg/day)
:in every bariatric patient suffering from persistent vomiting
Prescribing
severe enough to interfere with regular nutrition.
-PPI : in a regular basis or prn according to the case
Use of other medications:
-If possible, liquid oral dosage forms should be used instead of
solid dosage forms for at least two months after surgery.
-NSAIDs, salicylates, corticosteroids should be avoided.
-Oral contraceptives should be replaced by non-oral
contraceptives due to reduced efficacy after gastric bypass and
bilio-pancreatic diversion.
-Replace extended-release formulations with immediate release
formulations
-Avoid bisphosphonates.
-Use diuretics with caution due to the increased risk of
hypokalemia.

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Obesity

Periodic counselling by a registered dietician about

Referral long-term dietary modifications in order to
maximize the results of the bariatric procedure.
Every 3/12 for
the first year
CBC , FBG, Creatinine
LFT (Albumin and total Proteins)
Every 6/12 Iron profile
years for the Vit b12
Investigations first year
Folic acid
Every year
after the first Calcium , P.T.H
year
All the above test
At 2 years
DEXA ( BMD)
every 3-6 months in the first year and then every 12
Observation/ months thereafter: CBC, , electrolytes, iron, ferritin,
follow up vitamin B12, folate, vitamin D, PTH, LFT, zinc ,
copper.
Plan/prevention
Safety netting:
-Symptoms of continuous vomiting, dysphagia,
intestinal obstruction (gastric bypass) or severe
abdominal pain require emergency admission
under the local surgical team.
Conclusion -persistent vomiting or regurgitation (>6 months)
and/or frequent vomiting, a physical cause should
be suspected and a surgical diagnostic work-up
considered.
-Written health education material

215
 Obesity
Definition
Overweight and obesity are defined according to calculated body mass index (BMI) BMI = kg/m2

Risk Factors: Adult

STRONG
BMI Classification
-Hypothyroidism -Hypercortisolism -Steroid
therapy < 18.5 Under weight
WEAK 18.5 - 24.9 Normal weight
-Age ≥40 years
-Peri and postmenopausal -Prior pregnancy 25 - 29.9 Overweight
-Married
30.0 - 34.9 Class I obesity
-Sleep deprivation
-Smoking 35.0 - 39.9 Class II obesity
-Less formal education
-Low socioeconomic status ≥40 Class III obesity
-Sedentary lifestyle
-Television watching and video games >2 to 3 Waist circumference
hours daily • Men: WC >102 cm
-Diet high in sugar, cholesterol, fat, and fast food • Women: WC >88 cm.
-Binge-eating disorder -Night eating syndrome Children
-Antidepressant therapy •Overweight children: >85th% for age
-Antipsychotic therapy and gender
-Beta-blocker therapy •Obesity children: >95th% for age and
Screening gender.

Population Recommendation Grade

The USPSTF recommends that clinicians offer or refer adults with a
Adults BMI of 30 or higher to intensive, multicomponent behavioral B
interventions
Children and The USPSTF recommends that clinicians screen for obesity in
adolescents 6 years and children and adolescents 6 years and older and offer or refer them B
older to comprehensive, intensive behavioral interventions to promote
improvements in weight status.

The post bariatric surgery

Complications & Management:
1. Rapid weight loss leads to cholethiasis and prophylactic cholecystectomy
during the surgery or bile salt therapy given complication.
2. Dumping syndrome: is influx of undigested CHO in tojejenum from poor
dietary compliance-it is self-limited and usually subsides 1-2 hours after
consuming sweet food.
3. Panniculitis: is severe infection of the excess abdominal walls skin and
treated with antibiotics and skin hygiene. recurrent panniculitis is effectively
treated by surgical excision of the excess skin.
216
 Cushing syndrome Hx
Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain and Clarify what you
illness understood
Associated symptoms:
• Weight gain • Psychiatric symptoms
• Facial Puffiness Depression is the most
• Irregular menses or common.
amonherea • decreased libido
• Short stature in children • Skin bruising
• Acne • Muscle weakness
• Polyurea, polydipsia • Hirsutism
Analysis of • Renal stones • Fractures
chief complain • Headache • Blood clot
• Blurring of vision
Risk factors:
• Exogenous corticosteroid use
intra-articular, inhaled, topical therapy
• Pituitary Adenoma
Patient came with headache, double vision
• Adrenal adenoma
• Adrenal Carcinoma
only 1% of Cushing syndrome caused by adrenal carcinoma.
DDx Obesity and metabolic syndrome
Medical :arthritis
Surgical(renal transplant) and allergy
Past hx
Medication: steroid (prednisolone , injectable, cream)
Allergy, vaccination
Family hx family hx of hex gland malignancy
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
conclusion

217
 Cushing syndrome Ex
Vital signs :
exclude high B/P ,obesity (central obesity)
General Appearance :
moon face, buffalo hump , supraclavicular fat pad , haituism
Skin:
Special ACNE, abdominal stria, proximal muscle wasting, skin bruising
Assess: Galactorrhea , visual field defects
1- 24-hour urinary free cortisol
Generally >50 micrograms/24 hour. Need 2 sample at least .
Positive results should be confirmed with late-night salivary
cortisol or 1 mg overnight
2-late-night salivary cortisol
between 11 p.m. and [Link] least 2 sample.
Value greater than the upper limit of normal is considered
Investigations positive.
3-1 mg overnight dexamethasone suppression test
A positive test is defined as morning cortisol >50 nanomole/L
(>1.8 micrograms/dL).
1mg of dexamethasone is administered at 11pm and then
serum cortisol is measured at 8am the following morning.
If a patient has only mild Cushing’s syndrome, it may not be
detected using this test alone.

CRAPRIOP for Management

Clarification ‫ وقد يكون‬.‫حتدث اإلصابة مبتالزمة كوشينغ عندما تتراكم كميات كبيرة من هرمون الكورتيزول في اجلسم‬
.‫ أو رمبا بسبب فرط إنتاج اجلسم للكورتيزول‬.‫ذلك نتيجة تناول أدوية الكورتيزون عن طريق الفم‬
‫ جلد رقيق او شعر سميك في اجلسم‬,‫ حب الشباب‬,‫االعراض قد تكون زيادة في الوزن‬

Reassurance ‫عالج متالزمة كوشينغ يحسن االعراض ويؤدي إلى إعادة مستويات الكورتيزول في اجلسم إلى معدالتها‬
.‫الطبيعية وحتسني األعراض‬
.‫ كانت فرصك في الشفاء أفضل‬،‫وكلما بدأ تلقي العالج مبكًرا‬
Advice Exercise ,lose weight and Healthy diet
Referral Refer to endocrinology
Observation • Standard cardiovascular screening and treatment should
follow up be applied to patients with Cushing syndrome.
• Reduce corticosteroid to minimum required dose.
Plan • Depression screening
prevention • management for associated conditions of hypertension,
diabetes, and osteoporosis

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 Cushing syndrome

Causes of Cushing
ACTH dependent ACTH independent Physiological
Therapeutic
Pituitary adenoma Pregnancy
corticosteroid
Ectopic ACTH producing
tumor (bronchial Adrenal tumor Stress , Alcohol
carcinoma)
Identifying the underlying cause:
Plasma ACTH
• Levels of ACTH have a diurnal variation, with the plasma concentration
being highest at 8am and lowest at midnight. An elevated ACTH level
alongside a raised serum cortisol level suggests a diagnosis of ACTH-
dependent Cushing’s syndrome (see causes above). An undetectable ACTH
level alongside a raised serum cortisol level suggests a diagnosis of ACTH-
independent Cushing’s syndrome (see causes above)
High-dose dexamethasone suppression test
• This test is indicated if ACTH levels are detectable. The test is useful for
differentiating between pituitary and ectopic ACTH production. A reduction
of basal urinary free cortisol of greater than 90% supports a diagnosis of a
pituitary adenoma (ectopic ACTH causes less suppression).
Management:
• Exogenous Cushing’s syndrome:
reviewing the patient’s current glucocorticoid treatments and reducing
doses where possible (often with steroid-sparing immunosuppressive
agents)
• Endogenous Cushing’s syndrome
Definitive treatment of endogenous Cushing’s syndrome typically involves
resection of the causative tumor,medical therapies used in the interim
period to stabilize the patient prior to definitive therapy.

• Medical management:
Ketoconazole, metyrapone and mitotane all directly inhibit glucocorticoid
synthesis and secretion in the adrenal gland.
• Surgical management

219
 Vitamin D deficiency Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness Allow pt to explain the chief complain and Clarify what you understood
Course, onset and duration of symptom
SOCRATES for pain
Symptoms
• Bone discomfort or pain (often throbbing) in low back, pelvis, lower
extremities
• Increased risk of falls and impaired physical function
• Muscle aches
• Proximal muscle weakness
• Symmetric low back pain in women
• Dark skin color
• Obesity (BMI greater than 30 kg per m2)
• Live in cold climates
• insufficient sunlight exposure
Analysis of • Neonates breastfed exclusively
Risk Factors

chief • Primary hyperparathyroidism

complain • Hyperthyroidism
• Malabsorption syndromes (coeliac disease, cystic fibrosis, Crohn's
disease, Whipple's disease, short bowel syndrome, or a history of
gastric bypass surgery)
• Hx of liver failure or chronic kidney disease, or tumors
• Medications: glucocorticoids, anti-epileptic medications, highly active
antiretroviral therapy, rifampicin, or St John's wort
Signs of Vitamin D Toxicity
Headache
Red Flags

Metallic taste
Nephrocalcinosis or vascular calcinosis
Pancreatitis
Nausea and vomiting
Medical: Primary hyperparathyroidism, Hyperthyroidism, Chronic kidney disease,
Malabsorption syndromes (coeliac disease, cystic fibrosis, Crohn's disease, Whipple's
disease, short bowel syndrome,), liver failure or chronic kidney disease, or tumors
Past Hx Surgical: gastric bypass surgery
Allergy
Medication: glucocorticoids, anti-epileptic medications, highly active antiretroviral
therapy, rifampicin, or St John's wort
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

220
 Vitamin D deficiency Ex
Vital signs
General BMI
Appearance
In children with a severe vitamin D deficiency, the examination may reveal
bowing in the legs. swelling of the wrists and ankles, rachitic rosary
Special In adults with a severe vitamin D deficiency, the examination can reveal
periosteal bone pain.
This is best detected using firm pressure on the sternal bone or tibia.
• Serum 25-hydroxyvitamin D, Ca, Ph, ALP, BUN, Creat
Investigations • PTH to assess for 2ry hyperparathyroidism

CRAPRIOP for Management

‫ في أن‬،‫ضا للغاية‬ ً ‫في جسمك منخف‬D ‫حني يكون مستوى فيتامني‬D، ‫من املمكن أن يتسبب نقص فيتامني‬
.‫تصبح عظامك ضعيفة أو هشة أو مشوهة‬
‫ إال‬،‫من الطعام أقل من املوصى به‬D ‫وعلى الرغم من أن البالغني عادًة ما يحصلون على مقدار من فيتامني‬
Clarification ‫ لكن‬.‫مشكلة‬D ‫ ال ميثل نقص فيتامني‬،‫ وبالنسبة ملعظم البالغني‬.‫أن التعرض للشمس ميكنه تعويض الفارق‬
‫ وخاصًة األشخاص الذين يعانون من السمنة وذوي البشرة الداكنة والذين‬،‫قد يكون لدى بعض املجموعات‬
‫ أو تعرضهم القليل‬،‫بسبب نظامهم الغذائي‬D ‫ مستويات أقل من فيتامني‬،‫ عاًما‬65 ‫تزيد أعمارهم عن‬
.‫ أو أي عوامل أخرى‬،‫للشمس‬
Reassurance ‫ال تقلق نسبة اإلصابة بنقص فيتامني د مرتفعة بالسعودية والعالج جدا بسيط وسهل‬
Sun Exposure
Exposure of the arms and legs (with sun protection on the face) for about 5
to 30 minutes (depends on degree of skin pigmentation, time of day,
season, latitude, and age of patient) between 10 a.m. and 3 p.m. twice a
week is sufficient.
UV-B radiation
Advice If limited sunlight is available, UV-B radiation exposure using a tanning bed
for 30% to 50% of the time recommended for tanning (sunscreen should
be applied to the face) is an alternative.
Diet
ingest adequate amounts of foods that contain vitamin D. However, most
dietary sources of vitamin D do not contain sufficient amounts.
Example: salmon, Mackerel, sardines, Codfish. Swiss cheese, Fortified milk
Cholecalciferol:
Children: 2000 IU orally once daily, 50,000 IU orally once weekly for 6-8
weeks followed by 400-1000 IU/day (<1 Y) or 600-1000 IU/day (≥1 Y) as
maintenance

Prescribing Adults: 6000 IU orally once daily or 50,000 IU orally once weekly for 8
weeks, followed by 1500-2000 IU/day as maintenance

+\- calcium: Calcium carbonate

Children: 45-65 mg/kg/day orally given in 4 divided doses;
Adolescents/adults: 1-2 g/day orally given in 3-4 divided doses
Referral If suspected other etiology (hyperparathyroidism..)
Investigations Mentioned above

221
 Vitamin D deficiency

A repeat level of serum 25-hydroxyvitamin D is recommended 2

Observation/
to 3 months after initiating therapy, to ensure that vitamin D
follow up deficiency has been treated
Primary prevention
From birth and throughout childhood the American Academy of
Pediatrics recommends
- Infants 0-12 months receive 400 IU/day of vitamin D
- Children ≥1 year and adults receive 600 IU/ day
Secondary prevention
Plan/prevention
• Daily oral vitamin D maintenance doses are initiated and
should be continued for life to prevent a recurrence.
• Lactating women 4000-6000 IU daily to satisfy their infant's
vitamin D requirements.
• Outdoor sensible sun exposure 2 to 3 times a week should be
recommended.
Includes Safety netting
Signs of Vitamin D Toxicity
Conclusion Headache, Nausea and vomiting, Metallic taste
Nephrocalcinosis or vascular calcinosis
Pancreatitis

Criteria:
Vitamin D deficiency
• Serum 25-hydroxyvitamin D level of <50 nanomoles/L (<20 nanograms/mL).
Vitamin D insufficiency
• Serum 25-hydroxyvitamin D level between 52-72 nanomoles/L (21-29
nanograms/mL).

Screening:
Population Recommendation Grade
Asymptomatic, The USPSTF concludes that the current evidence is insufficient
community-dwelling, to assess the balance of benefits and harms of screening for I
nonpregnant adults vitamin D deficiency in asymptomatic adults.

222
 Vitamin D deficiency

Differential Diagnosis
Differentiating signs and
Disease Diagnostic findings
symptoms
•Nonspecific musculoskeletal pain
•Low serum 25(OH)D
Vitamin D •Muscle weakness
level
deficiency •Symmetric low back pain
•High PTH level
•Throbbing bone pain
Symptoms have been present at a
similar level for at least 3 months.
•Chronic musculoskeletal pain with
•All lab tests are
Fibromyalgia multiple tender points
normal
•Stiffness, numbness, and fatigue
•Headaches
•Sleep disorder
Fatigue plus 4 of the following
symptoms:
•Short-term memory loss
•Sore throat •Diagnosis of
•Tender lymph nodes in the neck or exclusions
Chronic fatigue
armpit •Symptoms must
syndrome
•Muscle pain present for more
•Joint pain without swelling or redness than 6 months
•Headaches
•Insomnia
•Malaise
•An elevated ESR and
Polymyalgia •Older at onset CRP
rheumatica •Generalized stiffness •Response
to corticosteroids
•Localized joint pain •X-ray of the involved
Osteoarthritis •Restricted to affect joints joints demonstrate
•Older at onset degenerative change

223
 Hirsutism Hx
Important note: should be differentiated true hirsutism from hypertrichosis,
Hypertrichosis is a condition of excessive hair growth in non-male pattern distribution, which is of
hereditary origin or occurs following use of certain medications (glucocorticoids, phenytoin,
minoxidil, cyclosporine)
Virilization is a more severe form of hirsutism and masculinization (development of male
secondary sexual characteristics)

Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow patient to explain the chief complain
illness Clarify what you understood
Age: development of excessive coarse hair after the fourth decade of life
suggests ovarian hyperthecosis and malignancies
Course, onset and duration
• Onset: rapid progression of hair growth may be due to androgen-
secreting neoplasm, particularly when associated with virilisation (e.g.,
male-pattern alopecia, deepening voice, clitoromegaly, increased muscle
bulk).
Analysis of • Presence of virilisation: indicates high levels of androgens and raises
chief suspicion of androgen-secreting neoplasia.
complain Associated symptoms (DDx)
• temporal balding, clitoromegaly, breast atrophy, deepening of the voice
and obesity.
• rate of progression of hirsutism,
• modality and frequency of epilation practiced (waxing, threading, laser).
• History of acne, amenorrhea or oligomenorrhea (polycystic ovaries).
• Moon face (Cushing).
• Galactorrhea, headache and visual disturbances (prolactinoma).
Medical
• Menstrual cycles: irregularity (particularly oligomenorrhoea) may be due
to anovulatory cycles in polycystic ovarian syndrome, non-classic
congenital adrenal hyperplasia, or hyperprolactinaemia.
Past Hx
• Reproductive history: infertility may be associated with polycystic ovarian
syndrome, non-classic congenital adrenal hyperplasia, or
hyperprolactinaemia
• Ovarian, breast and endometrial cancer.
Surgical
Allergy
Medication
Use of medications: use of androgenic medications (anabolic or androgenic
steroids, danazol (treatment of endometriosis) oral contraceptives with
androgenic progestins) may be associated with excessive hair growth.
Family Hx Ovarian cancer or presence of hirsutism in other family members suggests a
genetic component as well as idiopathic hirsutism.

224
 Hirsutism Hx
Psychosocial Marital status
Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
• Acanthosis nigricans or polycystic ovary syndrome,
particularly when associated with a family history of
type 2 diabetes mellitus, suggests insulin resistance.
• The presence of galactorrhoea may be associated with
Focus hyperprolactinaemia, particularly in nulliparous
• Hirsutism pattern women.
• Signs of virilisation indicate moderately to severely
• clitoromegaly increased androgen levels.
• Acanthosis nigricans • Obesity is associated with increased androgen
production and clearance rates,
• signs of Cushing • A pattern of fat distribution of truncal obesity
associated with a dorsocervical fat pad and other
cushingoid features (purple striae, thin skin, bruising,
facial plethora) indicates that Cushing's syndrome
should be considered.
• Palpation of an abdominal or pelvic mass in a hirsute
woman is suggestive of androgen-secreting neoplasm.

The Ferriman-Gallwey scale

for hirsutism.
A score of 1 to 4 is given for nine
areas of the body.
A total score less than 8 is
considered normal,
• a score of 8 to 15 indicates mild
hirsutism
• a score greater than 15 indicates
moderate or severe hirsutism.
• A score of 0 indicates absence
of terminal hair.

225
 Hirsutism
There is no consensus on laboratory and imaging diagnosis
in patients with hirsutism.
Lab:
Hormonal evaluation is recommended in patients with
hirsutism.
• Early morning serum total and free testosterone
• Cortisol by 24 -hour urinary free or salivary cortisol to
exclude Cushing syndrome.
Investigations • 21-hydroxylase and 17-hydroxyprogesterone
to excluded non-classical congenital adrenal hyperplasia
• Prolactin
Images:
• CT or MRI of the adrenals: may be helpful in
distinguishing adenomas from carcinomas
• MRI: elevated serum prolactin should prompt imaging of
hypothalamic/pituitary area after ruling out primary
hypothyroidism.
• Transvaginal ultrasound (TVUS): when there is suspicion
for ovarian hyperthecosis.

CRAPRIOP for Management

Based on the a etiology, hirsutism can be divided into 2
broad categories, with approximately 50% of cases falling
under each.
1) Increased local sensitivity to androgens or increased local
conversion of testosterone to dihydrotestosterone

• Idiopathic hirsutism: these women have no identifiable

aetiology for the excessive hair growth. They have normal
Clarification androgen levels and regular menstrual cycles.
• Increased androgen levels
• Polycystic ovary syndrome (Most common cause)
Reassurance • Hyperprolactinaemia
• Non-classic congenital adrenal hyperplasia
• Cushing's syndrome (benign or malignant)
• Use of androgenic medication
• Androgen-secreting ovarian tumours
2) Ovarian hyperthecosis (a condition with features similar
to polycystic ovary syndrome, but with more severe
androgenisation). May occur post-menopausally; the cause is
luteinised theca cells, which become hormonally active.
226
 Hirsutism

• Lose weight because obesity increases serum androgen

levels and reduces the effectiveness of medical
treatment
• Hair Removal Methods
Advice
Shaving is fast, safe
Epilation methods, such as waxing or plucking
Laser therapy
• Pregnant women: no pharmacologic approved
Pharmacologic therapy aimed at the underlying causes.
Divided into those that decrease ovarian or adrenal
androgen production and those that inhibit androgen
action in the skin.
Prescribing • Oral contraceptives
• Glucocorticoids: Prednisone
• Aldosterone Antagonists: Spironolactone (Aldactone)
• 5 alpha-reductase inhibitors: Finasteride
Endocrinologist if hormonal evaluation abnormal.
Referral Gynecologist if suspected ovarian tumor
Investigations Mentioned above
Observation/
follow up
Plan/prevention
Conclusion Includes Safety netting

227
Hirsutism

228
 Acromegaly Hx

Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow patient to explain the chief complain
illness
Clarify what you understood
Course, onset and duration
Associated symptoms (DDx):
• Coarse facial features such as prognathism
• Enlarged hands, feet, and tongue
• Headaches
Analysis of • Thickened skin of the face and hands
chief complain • Hyperhidrosis (excessive sweating)
• Visual field defects: bitemporal hemianopia
• Arthropathy
• Nerve compression symptoms: CTS
• Snoring
• Alterations in sexual functioning
Medical
HTN, diabetes mellitus, cardiomyopathy, and OSA
Past Hx Surgical
Allergy
Medication
Family Hx Acromegaly or Multiple endocrine neoplasia type
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

229
 Acromegaly Ex
General Vital signs BP for HTN
Appearance
• Facial features: coarse features, such as prominent
supraorbital ridges and prognathism, may be indicative of
acromegaly.
• Hands and feet: may be enlarged.
• Skin: may display thickening in the hands and face and
excess sweating or oiliness in acromegaly.
• Skin tags: acromegaly can cause an increase in the number
Special of skin tags.
• Hair growth: hirsutism in women and hypertrichosis may
occur.
• Gait: acromegaly can cause a rolling gait or varus deformity.
• Posture: patients with acromegaly can present with signs of
osteoarthritis, especially in the weight-bearing joints
(knees and hips).
• Clothes: clothes or jewellery may appear tight if significant
weight gain has occurred.
• Carpal tunnel syndrome tests
• Serum insulin-like growth factor 1 (IGF-1)
Investigations • oral glucose tolerance test (OGTT)
• random serum growth hormone (GH)

230
 Acromegaly
CRAPRIOP for Management
‫اضطراب تضخم األطراف هو اضطراب هرموني ينشأ عندما تفرز الغدة النخامية كمية‬
.‫كبيرة للغاية من هرمون النمو أثناء مرحلة البلوغ‬
،‫يزداد حجم عظامك عن احلجم الطبيعي باإلضافة إلى عظام اليدين والقدمني والوجه‬
Clarification .‫وتُعرف هذه احلالة باسم تضخم األطراف‬
‫نظرًا إلى أن تضخم األطراف هو حالة مرضية غير شائعة وأن حدوث التغيُّرات اجلسدية‬
‫ ولكن‬.‫شف إال بعد وقت طويل في بعض األحيان‬ َ ‫ فإن هذه احلالة ال تُكت‬،‫يكون تدريجيًا‬
Reassurance ‫ فقد تؤثر املستويات املرتفعة لهرمون النمو على األجزاء األخرى‬،‫إذا تُركت دون عالج‬
.‫ال عن العظام‬
ً ‫ فض‬،‫للجسم‬
‫ مبا في ذلك‬،‫مع العالج ميكن تقليل خطر حدوث املضاعفات وحتسني األعراض بشكل كبير‬
.‫تضخم السمات اجلسدية‬
95% Of cases are caused by pituitary macroadenoma
The goals of treatment of acromegaly are to:
• Restore life expectancy to normal
• Relieve symptoms of the condition
Advice • Completely remove the causative tumour, if possible; if
not possible, control its growth and related mass effects
• Preserve normal pituitary functioning
• Improve quality of life.

Prescribing

Referral Endocrinologist and depended to complications

Investigations Mentioned above
Observation/ lifelong monitoring of growth hormone and insulin-like
follow up growth factor 1 (IGF-1) levels.
Once the initial treatment interventions (surgical, medical,
and radiotherapy, as required) have remediated or
Plan/prevention significantly improved the disease state, regular monitoring
of disease-related parameters is recommended. Medical
complications of acromegaly also require ongoing monitoring
and treatment.
Conclusion Includes Safety netting

231
 Addison's disease Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question)

Allow pt to explain the chief complain and Clarify what you
illness understood
Course, onset and duration
Typically, insidious course over years *making dx difficult*
Associated symptoms
• Constitutional symptoms: anorexia , weight loss,
weakness, fatigue
• GI: N/V, diarrhea , abdominal pain
• Miscellaneous: salt craving, delirium, pastoral dizziness,
Analysis of myalgia
chief Risk Factors
complain • Effected with other autoimmune diseases
• Infections as N. Meningitis , HIV , histoplasmosis and TB
(TB Most Common cause of AI worldwide)
• Having Risk factors for adrenal haemorrhage or
haemorrhagic infarction include thromboembolic and/or
hypercoagulable states, such as antiphospholipid
syndrome, sepsis, and heparin-induced
thrombocytopenia.
Medical : HTN, Dm, IHD, Asthma , Thyroid diseases,
autoimmune diseases
Surgical
Allergy (drug , food, smells)
Past Hx Medication :
• Corticosteroids use cessation of long-term glucocorticoid
ttt) lead to secondly adrenal insufficiency
• Anticoagulants are at increased risk of adrenal
haemorrhage
Family Hx HTN,DM,IHD, Asthma, Thyroid diseases
autoimmune diseases
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
232
 Addison's disease Ex
Vital signs :
Pt have (hypotension , hypoglycemia )
General Appearance :
ill patient,
Skin hyperpigmentation (due to high ACTH)
• CBC (anaemia, eosinophilia, relative
lymphocytosis, and neutropenia
• Serum electrolytes (▼Na, hypoglycemia, ▲k , ▲
Ca)
• Urea and creatinine (may elevated)
Diagnostic test
• Early Morning serum cortisol (at 6- 8am)
<3 mcg/dl (80 nmol/l) is strongly suggestive of
Investigations adrenal insufficiency.
• ACTH stimulation test by Standard high-dose test
(250 mcg)
o A normal response is a rise in serum cortisol
concentration after either 30 or 60 minutes to
a peak of ≥18 mcg/dL (500 nmol/L).
o A normal response to the high-dose (250 mcg)
ACTH stimulation test excludes primary
adrenal insufficiency

CRAPRIOP for Management

‫ هو اضطراب غير شائع يحدث‬،‫ضا بالقصور الكظري‬ ً ‫ ويدعى أي‬،‫داء أديسون‬
‫ في داء أديسون‬.‫عندما ينتج جسدك كميات غير كافية من هرمونات معينة‬
‫تنتج الغدد الكظرية املوجودة أعلى الُكليتني كمية ضئيلةً من الكورتيزول‬
Clarification .‫ضا‬
ً ‫واأللدوستيرون أي‬
‫ وميكن أن‬،‫يحدث داء أديسون في جميع الفئات العمرية ولكال اجلنسني‬
‫ وينطوي العالج على تناول هرمونات الستبدال‬.‫يشِّكل تهديدًا للحياة‬
.‫الهرمونات الناقصة‬
‫لكن احلمدلله انه هناك دواء ملثل حالتك‬
Reassurance ‫والدواء متوفر لدينا ونحن هنا ملساعدتك متى ما احتجت ستجدنا ان شاء‬
‫الله‬

233
Addison's disease

‫املتابعة بشكل مستمر مع طبيب الغدد الصماء‬

‫اتباع نصائحه وااللتزام بأخذ االدوية‬
Advice ‫االبتعاد عن الضغوط النفسية واجلسدية لتجنب مضاعفات املرض مثل نوبة‬
‫اديسون‬
(For lifelong Glucocorticoid and mineralocorticoid
replacement)
• Corticosteroid (prednisolone 5 mg or
hydrocortisone 15 mg OD
• Fludrocortisone (mineralocorticosteroid) 0.1 mg
Prescribing OD
In Adrenal crisis:
For Primary • Provide IV steroids (hydro or dexamethasone)
adrenal • Fludrocortisone
insufficiency
• Correct electrolyte abnormalities as needed
Or Addison’s.
• Provide 50% dextrose to correct hypoglycemia;
and initiate aggressive volume resuscitation
If pt suspected adrenal crisis (not diagnosed) Give
dexamethasone iv because it will not interfere with
ACTH stimulate test as soon test is done, then switch
to hydrocortisone
To Endocrinologist
Referral If suspect Addison crises refer to ER
Investigations Mentioned above
Observation/
Arrange for follow up
follow up
Plan/prevention According to patient age sex and risk factors
‫ خاصة إذا كان مصاحب الم باملعدة و‬،‫في حال شعرت اعياء شديد‬
Conclusion .‫ فاذهب إلى الطوارئ‬،‫تقيؤ ولم تستطع تناول الدواء‬

234
Addison's disease

235
 Gynecomastia Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Asymptomatic in majority but occasionally there can be

present some irritation and some chafing of the breast and less
illness commonly, patients may complain of tenderness
Course, onset and duration
Associated symptoms (DDx)
• Unilateral or bilateral
• Nipple discharge, tenderness
• Palpable masses or skin changes
• History of sexual dysfunction
• Presence of breast pain or tenderness
Analysis • Detailed drug history (Medication Part)
of chief • Changes in virilization
complain Differential Diagnosis:
• weight loss, symptoms of liver and kidney disease, as
well as overt hyperthyroidism or hypothyroidism.
• hypogonadism (genital system symptom eg
hypospadis, micropenis and cryptorchidism,
decreased libido and sexual function and decreased
muscle strength)
• Testicular masses or Testicular injury from illness e.g.
mumps, TB, hemochromatosis or trauma .
• Genetic condition . e.g. Klinefelter syndrome
Medical
• Medications, indirect or environmental exposure to
oestrogenic compounds, supplements, hormones,
drugs of abuse including alcohol and marijuana, over
the counter medication (including herbal products)
Past Hx etc
• Antipsychotics, spironolactone, antiretroviral and
exogenous testosterone
Surgical
Allergy
Medication
236
 Gynecomastia Hx

Family Hx Gynecomastia, Cancer

Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
Examination
Vital signs, BMI
General Appearance: syndromic features
It is important to differentiate between gynecomastia and
pseudo gynecomastia - the thumb and forefinger should be
placed over the outer and inner breast margins and brought
together in a pinching movement which will create a distinct
disc of breast tissue under the nipple and areola tissue and if
the diameter is under 2cm it is considered normal while a
diameter of more than 2cm is consistent with the
Special gynaecomastia

signs of hyperthyroidism, chronic liver disease and

hypogonadism

Testicular examination - to look for signs suggesting

hypogonadism (small testicles) or testicular cancer (masses or
abnormal consistency)
Blood works:
Liver enzymes /serum creatinine and B-hcG
Investigations serum dehydroepiandrosterone sulfate, or urinary 1/-
ketosteroid
total and tree testosterone, estradiol, LH and FSH

237
 Gynecomastia

CRAPRIOP for Management

Gynecomastia : Benign proliferation of glandular breast
tissue in men.
‫ وينتج عن‬،‫التثدي الَّذَكري هو زيادة في كمية نسيج الغدة الثدية لدى الصبية أو الرجال‬
Clarification ‫ وقد ُيؤثر التثدي‬.‫وجود خلل في التوازن بني هرموني األستروجني والتستوستيرون‬
.ٍ‫ وأحيانًا بشكل غير متساو‬،‫الذكري على أحد الثديني أو كليهما‬
‫أما التثدي الذكري الكاذب فيشير إلى زيادة في الدهون وليس في النسيج الغدي في‬
.‫منطقة الصدر لدى الرجال بسبب السمنة‬
Common in newborns, adolescents, and older men. It is self-
Reassurance limited but can be treated to minimize emotional distress
and physical discomfort.
If symptoms persist after two years or past 17 years of age,
Advice further evaluation is indicated.
Medical management (not routinely recommended)
Indicated in symptomatic or distressing Gynecomastia
Tamoxifen 10 mg daily for 3 months
Raloxifene 60 mg daily for 3-9 months
Dihydrotestosterone
Prescribing Danazol
Clomiphene (Clomid)
Surgical management
Indicated in prolonged, severe, refractory to
medication cases
Refer to endocrine: If no other ethology can be found and if
the patient desires treatment, supplementation with
Referral testosterone, or use estrogen receptor- modifying agents
may be considered or is warranted .
Refer to GS: to improve cosmesis upon patient request
Investigations Mentioned above
Routine follow-up on an every 6 month basis
Observation/ Red flags suggestive of non-physiologic Gynecomastia
• Persistent Gynecomastia for >2 years
follow up • Nipple Discharge, Breast Skin Changes
• Rapid Breast enlargement, Testicular Mass, Weight loss
Plan/prevention
Conclusion Includes Safety netting

238
Gastroenterology

239
Gastroenterology
Abdominal pain
Dyspepsia
• PUD, DU
• H-pylori
• Gastritis
Bowel Disorders
• Irritable Bowel Syndrome
• Inflammatory Bowel Diseases
• Celiac diseases
• Traveler’s Diarrhea
Gastrointestinal Reflux Disease (GERD)
Jaundice

240
 Abdominal Pain Hx

Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow pt to explain the chief complain
illness Clarify what you understood
Site
Onset (how it started): • Sudden • Gradual
Character:
• Colicky (renal stones) • Sharp/sudden (rupture of viscus)
• Burning (peptic ulcer disease) • Dull
Radiation:
• To back (abdominal aortic aneurysm, ruptured duodenal ulcer)
• To testicles/groin (hernia) • To shoulders (gallbladder) • Loin to groin
SOCRATES

(renal stone)
Time: • Duration. • Intermittent, continuous, progressive
Alleviating factors: • Dietary factors • Opening bowels
Exacerbating factors: • Dietary factors • Swallowing (esophagus/stomach).
• Fatty foods (gallstones) • Acidic/spicy foods, hot drinks (peptic ulcer disease)
Severity: •1 to 10 •Affecting daily activity • awaken patient at night
Asks if patient is suffering from any other symptoms
Asks about any recent illnesses
Previous episodes of abdominal pain
Family members/contacts with similar symptoms
Analysis of Gastrointestinal/colorectal symptoms:
chief • Nausea/vomiting • Diarrhea/constipation • Dysphagia • Dyspepsia.
complain • Fevers
• Bloating/abdominal swelling (generalized/localized) • Flatulence
• IBD symptoms: arthralgia, eye symptoms, skin features, oral ulcers, bloody
diarrhea
Liver/hepatic symptoms:
• Right upper quadrant pain • Jaundice • Ankle swelling
Associated symptoms

Gallstone symptoms:
• Jaundice • Right upper quadrant pain radiating to shoulders • Dark stools •
Pale urine
Renal symptoms: Location and character:
• Loin to groin + flank + colicky: renal stones • Flank + burning dysuria:
pyelonephritis
• Generalized lethargy • Pruritus • Ankle swelling
Females: gynecological symptoms:
• Correlation with menstrual periods • Menorrhagia • Irregular periods • Vaginal
discharge
Females: obstetric symptoms: Possibility of patient being pregnant
• Last menstrual period • Unprotected sexual intercourse • Contraception
• Vaginal bleeding (with severe abdominal pain = ectopic pregnancy until proven
otherwise)

241
 Abdominal Pain Hx
Bleeding:
• Rectal: fresh red, melaena

Red flags
• Vaginal: intermenstrual, postcoital
• Hematemesis
• Hematuria
Weight loss
Loss of appetite
• Pain that awaken patient at night, fever, nausea, vomiting, weight loss, change in
bowel habits, anemia and blood in stool that indicate malignancy.
Abdominal distention, nausea, vomiting, absent bowel motion that indicate bowel
obstruction.
Differential
• Vomiting and hyperglycemia that indicate diabetic ketoacidosis.
diagnosis • Rectal bleeding, perianal lesions, joint pain, red eye that indicate inflammatory bowel
disease.
• Dysuria, fever, pain radiating to flanks that indicate pyelonephritis.
• Amenorrhea, vaginal bleeding, dizziness that indicate ectopic pregnancy.
• Epigastric pain with hematemesis that indicate acute gastrointestinal bleeding.
Medical
• Any bowel disorders
• Diabetes (for autonomic neuropathy)
• Radiotherapy (for radiation colitis)
• Previous abdominal/intestinal surgery
Past Hx Surgical
• Recent abdominal surgery
Allergy
Medication
• NSAIDs
• Over-the-counter medication
• GI cancer
• IBD (Crohn’s disease, ulcerative colitis)
Family Hx
• Celiac disease
• Rheumatologic disorder.
Marital status
Alcohol (peptic ulcer, gastritis)
Smoking
Illicit drug use
Diet:
Psychosocial
• Spicy foods (peptic ulcer disease)
• High-fibre foods (low intake may correlate with diverticulitis)
Occupation
Activities of daily living
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

242
 Abdominal Pain

Differential Diagnosis of Abdominal Pain

Pain location Possible diagnoses
• Biliary: cholecystitis, cholelithiasis, cholangitis
• Colonic: colitis, diverticulitis
Right upper
• Hepatic: abscess, hepatitis, mass
quadrant
• Pulmonary: pneumonia, embolus
• Renal: nephrolithiasis, pyelonephritis
• Biliary: cholecystitis, cholelithiasis, cholangitis
• Cardiac: myocardial infarction, pericarditis
Epigastric • Gastric: esophagitis, gastritis, peptic ulcer
• Pancreatic: mass, pancreatitis
• Vascular: aortic dissection, mesenteric ischemia
• Cardiac: angina, myocardial infarction, pericarditis
• Gastric: esophagitis, gastritis, peptic ulcer
Left upper
• Pancreatic: mass, pancreatitis
quadrant
• Renal: nephrolithiasis, pyelonephritis
• Vascular: aortic dissection, mesenteric ischemia
• Colonic: early appendicitis
• Gastric: esophagitis, gastritis, peptic ulcer, small bowel mass or
Periumbilical
obstruction
• Vascular: aortic dissection, mesenteric ischemia
• Colonic: appendicitis, colitis, diverticulitis, IBD, IBS
Right lower • Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
quadrant • Renal: nephrolithiasis, pyelonephritis

• Colonic: appendicitis, colitis, diverticulitis, IBD, IBS

Suprapubic • Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
• Renal: cystitis, nephrolithiasis, pyelonephritis

• Colonic: colitis, diverticulitis, IBD, IBS

Left lower • Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
quadrant • Renal: nephrolithiasis, pyelonephritis

• Abdominal wall: herpes zoster, muscle strain, hernia

Any location • Other: bowel obstruction, mesenteric ischemia, peritonitis, narcotic
withdrawal, sickle cell crisis, porphyria, IBD, heavy metal poisoning

243
Abdominal Pain

244
 Abdominal Pain

Investigation
• Complete blood count in case of acute appendicitis, inflammatory bowel disease
(leukocytosis, anemia).
• Pregnancy test to exclude ectopic pregnancy.
• Urinalysis to exclude urinary tract infections.
• Computed tomography scan to exclude masses suggestive of malignancy.
• Ultrasound to exclude ectopic pregnancy or bowel obstruction.
• Tissue transglutaminase level to exclude celiac disease.
• Upper or lower GI endoscopy to exclude gastric ulcers, inflammatory bowel
disease.
• Fecal occult blood to exclude lower GI bleed.

245
 Dyspepsia Hx

Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow pt to explain the chief complain
illness Clarify what you understood
Site
Onset (how it started): • Sudden • Gradual
Character: • Colicky • Sharp/sudden • Burning • Dull
Radiation:
Time: • Duration. • Intermittent, continuous, progressive
Alleviating factors: • Heavy and fatty meals • Supine or bending, • Eating or
SOCRATES

being hungry.
Exacerbating factors: • Rest • Analgesia • Antacid • Eating
Severity: •1 to 10 •Affecting daily activity • awaken patient at night
Asks if patient is suffering from any other symptoms
Asks about any recent illnesses
Previous episodes of abdominal pain
Family members/contacts with similar symptoms

Bloating
Associated symptoms

Irregular bowel habits

Vomiting and nausea
Analysis of Acid regurgitation
chief Throat discomfort
complain Change in voice
Stressful life events
Shortness of breath, or chest pain.
Age: 50 years of age
Gastrointestinal (GI) bleeding, hematemesis, Melena
Unexplained iron deficiency anemia
Persistent vomiting
Red Flags

Weight loss
Dysphagia
Odynophagia
Nocturnal pain that wakes the patient from sleep.
Palpable mass or lymphadenopathy
Family history of upper gastrointestinal cancer
Chronic cough
Complications

Dental erosions
Chest pain
Change in voice
Anxiety or depression.

246
 Dyspepsia Hx

Medical
• Any bowel disorders
• Diabetes (for autonomic neuropathy)
• Radiotherapy (for radiation colitis)
• Diabetes mellitus, arthritis, pernicious anemia, depression.
Past Hx Surgical
• Hx abdominal surgery (vagal nerve injury)
Allergy
Medication
• NSAIDS, steroids, aspirin, theophylline, calcium channel blockers,
anti-cholinergic, or bisphosphonate
• GI cancer
• IBD (Crohn’s disease, ulcerative colitis)
Family Hx
• Celiac disease
• Rheumatologic disorder.
Marital status
Alcohol (peptic ulcer, gastritis)
Smoking
Psychosocial
Illicit drug use
Diet: Spicy foods (peptic ulcer disease)
Occupation
Activities of daily living
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
General Vital signs
Appearance
Special Abdominal Ex

247
 Dyspepsia
CRAPRIOP for Management
Clarification See Functional dyspepsia, Peptic ulcer disease
Reassurance See Functional dyspepsia, Peptic ulcer disease
Lifestyle: stop smoking and alcohol, avoid tight fitting
clothes, regular exercise, reduce stress, maintain your ideal
weight.
Food: eat healthy food, avoid spicy, fatty and heavy meals,
Advice take small frequent meals, moderate coffee amount, avoid
eating late at night (ideally no food 3 hours before
bedtime), elevate the head of the bed.
Aggravating drugs: "avoid drugs that irritate your stomach.
Example: steroid, ibuprofen".
Prescribing See Functional dyspepsia, Peptic ulcer disease
Arrange Referral to gastroenterology clinic if red flags
Referral found, for Esophagogastroduodenoscopy (EGD)
Helicobacter pylori stool antigen, urea breath test ** Leave
a 2-week washout period after PPI use and a 4-week
washout after antibiotic use before testing for H pylori
Complete blood count
Investigations Endoscopy (to r\o peptic ulcer)
Abdominal ultrasound (to r\o cholelithiasis).
Lactose breath test ( to r\o lactose intolerance)
CT of abdomen ( to r\o pancreatitis )
Observation/
Arrange for follow up in 2 to 4 weeks.
follow up
Plan/prevention Discuss health maintenance and screening for age.
Includes Safety netting
Age: 50 years of age
Gastrointestinal (GI) bleeding, hematemesis, Melena
Unexplained iron deficiency anemia
Persistent vomiting
Conclusion Weight loss
Dysphagia
Odynophagia
Nocturnal pain that wakes the patient from sleep.
Palpable mass or lymphadenopathy
Family history of upper gastrointestinal cancer

248
 Dyspepsia
Functional Dyspepsia

Diagnostic criteria
1. One or more of the following:
a. Bothersome postprandial fullness
b. Bothersome early satiation
Overview c. Bothersome epigastric pain
d. Bothersome epigastric burning
AND
2. No evidence of structural disease (including at upper
endoscopy) that is likely to explain the symptoms
‫ أو‬،‫ أو انزعاًجا‬،‫ أو أًملا‬،‫عسر الهضم الوظيفي هو املصطلح الطبي للحالة التي تسبب اضطراًبا‬
‫ ومع ذلك‬،‫ عادة ما يكون غير واضح‬.‫عدم شعور بالراحة في املعدة أو اجلزء العلوي من البطن‬
‫ أو العوامل النفسية االجتماعية‬،‫ والعدوى‬،‫قد يكون السبب مشاكل في العضالت واألعصاب‬
:‫يختلف العالج حسب احلالة؛ ولكن توجد نصائح لتخفيف وجتنب عسر الهضم‬
.‫ والشاي‬،‫ القهوة‬:‫• التقليل من الكافيني مثل‬
Clarification .‫• التقليل من الوزن إذا كنت تعاني السمنة‬
Reassurance .‫ ساعات‬4- 3 ‫• جتنب األكل قبل النوم بـ‬
Advice .‫• التقليل من التوابل احلارة واألكل الذي يحتوي على دهون‬
.‫• اإلقالع عن التدخني‬
.‫• جتنب الرياضة بعد األكل مباشرة‬
.‫• تناول وجبات صغيرة ومضغ الطعام جيًدا‬
.‫ وتقنيات تقليل التوتر‬،‫ من خالل االسترخاء‬،‫• التقليل من التوتر‬
‫• شرب السوائل بعد الوجب‬
Test for H pylori if –ve :
1st line: Proton pump inhibitors 20mg OD or BID
- If no improvement 4-8 weeks before stopping.
- If respond to PPI therapy discontinue PPIs every 6 to 12
months to minimize long-term risk of therapy.

2nd line: H2-receptor antagonists

Prescribing
3rd line: Antidepressants (eg, amitriptyline 10 mg
or desipramine 25 mg at night ) The dose may be increased at
two-week intervals. A dose of 20 to 30 mg is adequate in many
patients, and we do not exceed a dose of 75 mg
- 8 to 12 weeks before stopping, if it is ineffective.
- usually continue the drug for appropriately six months and then
consider slowly tapering the medication off.

249
 Dyspepsia
Peptic ulcer disease

‫القرحة الهضمية هي حدوث تآكل أو جرح في الغشاء املخاطي املبطن جلدار املعدة أو في اجلزء األول من األمعاء‬
. ‫ وفي معظم احلاالت يكون األلم هو أكثر األعراض ظهوراً وشكوى‬، ‫الدقيقة أو أسفل املريء‬
‫إلى وقت قريب كان يعتقد أن لنمط سلوكيات احلياة دوراً هامًا )كاألكل املشبع بالبهارات احلارة أو ضغوط‬
Clarification ‫ لكن أصبحت اآلن العدوى البكتيرية وكذلك استخدام بعض األدوية )وليس الضغوط النفسية أو‬، (‫العمل‬
Reassurance ‫النظام الغذائي( هما السبب الرئيسي في اإلصابة مبعظم حاالت القرحة املعدة واإلثني عشر مع العلم أن القرحة‬
.‫أسفل املريء يرتبط وجودها بوجود ارجتاع حلمض املعدة إلى املريء‬
‫إن القرحة الهضمية هي من أكثر األمراض املنتشرة حول العالم ولكن من األخبار السارة أن عالجها أصبح ممكنًا‬
. ‫اآلن‬
Treat the underlying etiology
H. pylori induced peptic ulcer or gastritis
Triple therapy recommended for 14 d: (PPI + two antibiotics)
• Omeprazole: 20-40 mg orally BID
• Amoxicillin: 1000 mg orally BID**
• Clarithromycin: 500 mg orally (immediate-release) BID or
metronidazole: 400 mg orally BID
If resistance
Quadrable therapy for 14 d: (Bismuth + PPI + two antibiotics)
• Bismuth subsalicylate: 525 mg orally QID
• Omeprazole: 20-40 mg orally BID
• Tetracycline: 500 mg orally QID
• Amoxicillin: 1000 mg orally BID **

Prescribing **Penicillin allergy change amoxicillin to metronidazole: 400 mg orally BID

NSAIDs induced peptic ulcer or gastritis

• Discontinue any NSAID the patient is taking, if possible. In not, consider
a COX-2 (Celecoxib (Celebrex)) inhibitor instead of a standard NSAID and
prescribe a PPI
• Omeprazole: 20 mg orally once daily for 8 weeks

Stress induced peptic ulcer or gastritis

Prophylaxis with
PPI omeprazole: 20 mg orally once daily
Or
H2 blockers
- famotidine: 40 mg orally once daily at night
- nizatidine: 300 mg orally once daily at night
Re-test patients with peptic ulcer (gastric or duodenal) and who were
initially H pylori positive, 6 to 8 weeks after beginning treatment, depending
on the size of the lesion.
Follow-up Leave a 2-week washout period after PPI use and a 4-week washout after
antibiotic use before re-testing for H pylori with a breath test, as these drugs
suppress bacteria and can lead to false negatives. ( for diagnose or follow-up)

250
 Dyspepsia

Rome IV classification:
• Post-prandial distress syndrome (PDS), which is characterised by meal-induced
dyspeptic symptoms, such as discomfort, pain, nausea, and fullness
• Epigastric pain syndrome (EPS), which refers to epigastric pain, or epigastric
burning, that does not occur exclusively post-prandially, can occur during
fasting, and can even be improved by meal ingestion
• Overlapping PDS and EPS, which is characterized by meal-induced dyspeptic
symptoms and epigastric pain or burning.

251
 Dyspepsia
Coronary artery disease: This should be excluded as the first step in the assessment of dyspepsia

DDx HX EX Investigations
Symptoms of dyspepsia;
Functional Hemoglobin: normal
Psychosocial factors may Normal
dyspepsia Urea breath test: negative
present
Helicobacter Hx of peptic ulcer, Urea breath test: +
Normal
pylori infection FHx of peptic ulcer, Stool antigen test for H pylori: +
PPI trial: symptoms improve
Fhx of GORD bloating, laryngitis,
GERD and EGD: esophagitis (erosion,
Hiatal hernia, heartburn, enamel erosion,
esophagitis ulcerations, strictures) or
acid regurgitation, dysphagia halitosis
Barrett's esophaguss
NSAIDs use or past ulcers; Mid-epigastric Upper GI endoscopy: peptic
Peptic ulcer Smoking; tenderness to ulcer; H pylori breath test or
disease Ingestion of food transiently palpation (pointing stool antigen test: + if H
improves abdominal pain sign) pylori present
Diabetes mellitus
Hx abdominal surgery (vagal
nerve injury) Succussion splash
Gastroparesis
Post-prandial nausea, sign CBC: lymphocytosis
vomiting, early satiety,
epigastric pain, fullness,
bloating, weight loss
Normal or mild Endoscopy: reveals gastritis
Gastritis and NSAIDs use or Helicobacter
epigastric urea breath test or stool
duodenitis pylori infection
tenderness antigen test: +
Bloating, abdominal distress,
Lactose
and loose stool after Normal Lactose breath test: +
intolerance ingestion of lactose
• NSAIDs • Metformin Diagnosis is clinical
• Codeine • Acarbose a link between starting a
Drug-
• Alendronate • Iron medication and onset of
induced Normal
• Theophylline • Orlistat dyspepsia symptoms is
dyspepsia • Antibiotics (macrolides) critical to making the
• Corticosteroids diagnosis
Epigastric or RUQ pain Abdominal US: gallstones
Biliary pain + Murphy's sign
Jaundice or fever and/or dilation of bile ducts
Tachycardia, Grey-
Turner's sign,
Cullen's sign, Fox's CT of abdomen: enlarged
Acute or Abdominal pain, hx of
sign, Chvostek's pancreas with areas
chronic gallstone disease, alcohol
sign, Trousseau's suggesting necrosis, fluid
pancreatitis intake, hypertriglyceridemia
sign, hypotension, collections
abdominal
distension

252
Dyspepsia

Management of Bleeding Peptic Ulcers (ER case)

253
 Bowel disorders Hx
Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Present Allow pt to explain the chief complain
illness Clarify what you understood
Constipation & Diarrhoea
v Constipation

• Onset (acute, chronic) more than 3 M.

• Frequency per days and week.
• Stools thin like a pencil → colon cancer or stricture
• Pass mucus or blood→ IBS ,IBD, Cancer.
• Anorectal disease → fissure ,stricture.
• Pass gas→complete intestinal obstruction.
• pain made better by a bowel movement→ IBS
• Diarrhoea Alternating with constipation → IBS
• Any recent weight loss→ colon cancer

v Diarrhoea
Analysis of
chief
complain Onset, Character:
• Consistency: Watery, Loose , Greasy and difficult to
flush away, Well formed, Mucus
• Colour: Black (melaena),Red (blood), Green
• Smell: offensive, Pellets
• Time, Duration: Intermittent, continuous,
progressive
• Frequency, Volume (more or less than usual)
• Alleviating factors, Exacerbating factors:
Dietary factors
Gluten-containing foods (coeliac disease)
• Severity
Psychosocial stressors
Flatulence

254
Bowel disorders Hx
Risk Factors
• Any recent illnesses
• Previous episodes of diarrhoea
• Family members/contacts with similar symptoms
Associated symptoms:
• Gastrointestinal/colorectal symptoms:
Nausea/vomiting or Bloating
Abdominal pain: is it reduced with defecation? Abdominal swelling
Anal pain or Tenesmus
Constipation
Fecal incontinence
Fevers
• Symptoms of IBS:
Constipation
Psychosocial stressors
Analysis of Flatulence
chief • Symptoms of anemia:
Lethargy, SOB, Dizziness and Postural hypotension.
complain • Symptoms of Celiac disease:
Generalized weakness/lethargy and anemia symptoms.
• Symptoms of IBD:
Blood
Arthralgia
Back pain (sacroiliitis)
Oral ulcers
Skin problems:
Pyoderma gangrenosum, Erythema nodosum
Eyes pain
• Risk factors for Clostridium difficile:
Recent hospital admissions or Recent antibiotic courses
Red Flags:
Rectal bleeding.
Black stools (melaena)
Weight loss or Loss of appetite
Medical:
• Any bowel disorders
• Diabetes (for autonomic neuropathy)
• Radiotherapy (for radiation colitis)
Past Hx Surgical
• Previous abdominal/intestinal surgery
Allergy
Medication
• Laxatives, Metformin, Iron tablets, Antibiotics (e.g. erythromycin),
Thyroxine, Over-the-counter medication

255
 Bowel disorders Hx

Marital status
Water consumed or Diet.
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Gynaecological symptoms: related to ovarian cancer
Review Urological symptoms: dysuria or haematuria
Conclusion

Examination
• Vital signs
Orthostatic hypotension
• Appearance
General Peripheral edema, Ecchymosis, Hyperkeratosis or
dermatitis herpetiform, glossitis, Evidence of peripheral
neuropathy
• BMI
• Abdominal Examination: tenderness, distention,
mass, hepatomegaly, and bowel
• Musculoskeletal: arthritis, arthralgia
• Skin: pallor, jaundice, aphthous ulcer, erythema
Special nodosum, pyoderma gangrenosum
• Ophthalmic: episcritits, uveitis
• Growth: decrease in growth velocity, pubertal
delayed
• PR: fistula, fissure and tag

256
 Bowel disorders
CRAPRIOP for Management
Irritable Bowel Syndrome

IBS symptoms include recurrent abdominal pain or discomfort

that is associated with a change in stool frequency or form.
The pain or discomfort may be relieved by defecation for at least
3 days per month in the previous 3 months, with the absence of
other cause .
Clarification There is association between IBS and psychological disorders
(anxiety, depression, posttraumatic stress disorder)

Treatment should be individualised and is dependent on the

patient's predominant symptoms. And the main goal of it
decrease the severity of the symptoms and improve life.
Diagnosis is based on the patient's history; there are no specific
diagnostic tests. If the patient has worrying symptoms or
findings such as anaemia, weight loss, or fever, then these
require thorough investigation.
Reassurance
There are no structural abnormalities to explain the pain.
IBS occurs in about 15% of the adult population.
The aetiology is probably multi-factorial and evidence suggests
motility, inflammatory, genetic, immune, psychological, and
dietary components.
Lifestyle and dietary modifications
Initial treatments should be conservative, including discussion of
lifestyle changes that may lessen stress.
Possible precipitating substances, such as caffeine, lactose, or
fructose, may need to be eliminated from the diet.

Pharmacological therapy is frequently used, but there is limited

Advice evidence from large study.
Symptom monitoring with a diary can be helpful to identify
precipitating substances and factors.
• Low FODMAP diet
low fermentable oligosaccharides, disaccharides,
monosaccharides, and polyols (FODMAPs) diet is recommended
for patients with IBS.
• Probiotic

257
 Bowel disorders

Constipation-predominant IBS
• Soluble fibre (found in ispaghula, oat bran, barley, and
beans) is often recommended.
• Laxative such as lactulose 10-20 g (15-30 mL) orally once
daily initially, can increase to twice or three times daily if no
response, maximum 40 g/day (60 mL/day)
• Polyethylene glycol/electrolytes 17 g in 225 mL water orally
once daily
Advice
Diarrhea-predominant IBS
• Loperamide are recommended as first-line treatment.
Prescribing 2-4 mg orally initially, followed by 2 mg after each loose stool
when required, maximum 16 mg/day

Pain or bloating
• Antispasmodics ccombination of mebeverine and
simethicone
• Peppermint oil is effective
• Antidepressants, TCA and SSRI, amitriptyline 25mg OD
• Other treatment: (used with all types) Psychological
therapies, CPT, relaxation, tech. self-management.
For GIT clinic:
Referral If Age >50 years
Red flags present
1st investigations to order: FBC
Investigations to consider:
• Serologic tests for celiac disease
• Fecal calprotectin& fecal lactoferrin
• Fecal occult blood test
Investigations • (CRP) & (ESR)
• Hydrogen/methane breath test
• Stool tests for Giardia lamblia
• Pla in abdominal x-ray
• Colonoscopy or flexible sigmoidoscopy
Observation No long-term monitoring is necessary.
follow up Patients with IBS should follow recommendations for screening
for colorectal, gynaecological, and genitourinary malignancies.
prevention
Conclusion Includes Safety netting

258
Bowel disorders
Inflammatory Bowel Diseases (Crohn’s disease, Ulcerative colitis)
Crohn's disease (CD) is a disorder of unknown aetiology characterised by
transmural inflammation of the gastrointestinal tract.
Common presenting symptoms is chronic diarrhoea, weight loss, and right lower
quadrant abdominal pain mimicking acute appendicitis.
Diagnosis confirmed by colonoscopy with ileoscopy and tissue biopsy.
The overall treatment goals are to induce and maintain remission, and to prevent
relapse or recurrence.
Complications include extra-intestinal involvement, intestinal obstruction, abscess
Clarification formation, sinuses, and fistulae.
Ulcerative colitis (UC) is a type of inflammatory bowel disease characterised by
diffuse inflammation of the colonic mucosa and a relapsing, remitting course.
Common presenting symptoms is bloody diarrhoea, chronic diarrhoea (or both),
Reassurance lower abdominal pain, faecal urgency, and extraintestinal manifestations,
particularly those related to activity of the colitis.
Diagnosis requires endoscopy with biopsy and negative stool culture.
Treatment aims to induce and maintain remission. Drug choice and formulation
depends on the severity and extent of disease.
Complications include Toxic megacolon can occur with associated risk of
perforation. Bowel adenocarcinoma is a complication in 3% to 5% of patients.
Patient involvement and education are necessary components of effective
management.
Advice Mild disease requires only symptomatic relief and dietary manipulation.
Lactose malabsorption is present in 35% of patients with Crohn's disease and 20
%of patients with ulcerative colitis.
B12 Supplementation
Crohn Disease:
• Corticosteroid for acute treatment.
• Immunomodulator as Azathioprine or methotrexate for corticosteroid-
Prescribing induced remission.
• anti–tumor necrosis factor agents (e.g., infliximab, adalimumab)
Ulcerative Colitis:
• 5-Aminosalicylic acid
• + same previous drugs for CD.
Referral For GIT clinic
For Surgery clinic
FBC
Iron studies (serum iron, serum ferritin, total iron binding capacity [TIBC], transferrin
saturation)
Serum vitamin B12
Serum folate
Investigations comprehensive metabolic panel (CMP)
CRP) and (ESR)
stool testing
plain abdominal x-ray
MRI abdomen/pelvis
CT abdomen
Observation Colonoscopy should be initiated 8 to 10 years after ulcerative colitis is diagnosed,
follow up
prevention with regular-interval biopsies every one to two years.
Conclusion Includes Safety netting

259
 Bowel disorders
Celiac Disease
Coeliac disease is common, affecting up to 1% of the general population, and
may present at any age.
Presentation is varied and ranges from diarrhoea and failure to thrive, to iron-
deficiency anaemia or osteoporosis.
Diagnosis is suggested by positive immunoglobulin A tissue transglutaminase
serology, but in most cases is confirmed by duodenal biopsy and histology.
Clarification
Celiac disease has a strong hereditary component

The rapidity of the response to a gluten-free diet is variable. Approximately 70

percent of patients have noticeable clinical improvement within two weeks.
Reassurance
Complications of untreated coeliac disease include gastrointestinal symptoms,
malabsorption, increased risk of malignancy, and higher overall mortality than
in the general population.

Identification and treatment of nutritional deficiencies

Foods containing wheat, rye, and barley should be avoided as Soybean, rice,
corn, buckwheat, and potatoes are safe.

Advice Dairy products may not be well tolerated initially, since many patients with
celiac disease can have secondary lactose intolerance.

Oats should be introduced into the diet with caution. Patients with severe
disease should avoid oats.

Dietary education should focus on identifying hidden sources of gluten,

planning balanced meals, reading labels.
Prescribing lifelong gluten-free diet.
• For GIT clinic for upper endoscopy with biopsy should be performed in
patients with established celiac disease who fail to respond to a gluten-
Referral free diet or with relapse of symptoms despite a gluten-free diet
• For skilled dietitian
• CBC, Anemia due to deficiency in iron, folate.
• vitamin B-12
• Electrolyte: hypokalemia, hypocalcemia, hypomagnesemia,
Investigations • Metabolic acidosis
• LFT
• Lipid profile
• Serology: tissue transglutaminase IgA, endomysia IgA
• Genetic testing: human leukocyte antigen DQ2, DQ8, or both
Observation IgA-tTG titres are typically checked at least three times in the first year
following the diagnosis (3 months, 6 months, and 12 months), and then yearly
follow up as an indication of diet adherence.
prevention Bone mineral density may be assessed in adults at the time of diagnosis, or
after they have been on a gluten-free diet for 1 year.
Conclusion Includes Safety netting

260
Bowel disorders
Traveler’s Diarrhea
Traveller's diarrhoea is a common problem among travellers, typically
caused by the consumption of contaminated food or water.
Predominantly caused by bacteria.

E. coli may be responsible for up to 71% of cases of TD

It Defined as ≥3 unformed stools in 24 hours accompanied by at least 1 of

the following: fever, nausea, vomiting, cramps, tenesmus, or bloody
Clarification stools (dysentery) during a trip abroad, typically to a low- or middle-
income country.

Prevention strategies include careful selection of food and beverages,

Reassurance though these are not fail-safe.

Prophylactic antibiotics are not recommended for most TD

Management is self-diagnosis while still travelling, followed by hydration,

medicine for symptom relief, and possibly, antibiotics. Antibiotic therapy
is generally reserved for moderate to severe infections.

In healthy patients, resolution is typically within 3 to 5 days even without

antibiotic treatment
• Hand washing
• Rehydration
• Avoiding high-risk foods and adventure some eating behaviours may
reduce the inoculum of ingested pathogens or prevent the
Advice development of other enteric diseases such as typhoid and hepatitis
A and E.
• Boiling is the best way to purify water.
• Iodination or chlorination is acceptable

Prescribing

261
 Bowel disorders

Prescribing

Referral • For refractory symptoms or red Flags

For persistent diarrhoea (usually >14 days)
Investigations • Stool culture and sensitivity
• Stool occult blood
• Stool ova and parasite examination
Observation
follow up See advise section
prevention
Conclusion Includes Safety netting

262
 GERD Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

Allow pt to explain the chief complain
present
Clarify what you understood
illness
Differentiate between chest pain and regurgitation. (acid
reflux )
Onset , course , duration and recurrence .
Aggravating and reliving factors : Aggravating (post prandial
fullness, lying down ) RELEAVING (Antacid) Diet , life style and
Analysis of habits : eating late before bed time , consuming coffee ,
citrus , spicy food , chocolate , soft drinks , carbonated food .
chief
complain Associated symptoms and red flags : chronic cough , halitosis
, dysphagia , odynophagia , hoarseness of voice , weight loss ,
neck and throat mass or tenderness , chest pain radiated to
the left shoulder or neck , SOB , diaphoresis , coughing or
vomiting blood , dark stool , pallor.
DM , HTN , MI , Hiatal hernia , Dyspepsia , Obesity Asthma .
Medication : NSAID , Statin .
Past Hx Smoking , Alcohol consumption
Surgical history Allergy
Family Hx Family history of GERD or GI cancers
Marital status
Psychosocial Smoking: type and frequency
Screening: Stress , depression and anxiety
Ideas: what do you think you might have?
ICEE Concerns: is there anything you are worried about?
Expectation: is there anything you want me to do for
Systemic Review
Conclusion

Examination
Vital signs , weight , height and BMI
General Appearance , Pale , Pallor , cachexia , neck mass , hoarseness
of voice .
Special Neck and throat examination
Cardiac examination

263
 GERD
CRAPRIOP for Management
‫ارجتاع املرئ عرض شائع وهو ليس مرض بحد ذاته عبارة عن ارجتاع وصعود حمض املعدة‬
‫ االكل بالسرعة‬: ‫الى املرئ مما يسبب االحساس بحرارة صاعدة ومن األسباب الشائعة‬
Clarification ‫ الكحول والقهوة والفواكة احلمضية‬: ‫األكل أكثر من احلاجه بعض األطعمة واملشروبات‬
‫والبهارات والفلفل احلار التوتر والقلق السمنه‬
Reassurance ‫غالبا األسباب تكون شائعة وغير خطيرة لكن نحتاج نعمل بعض الفحوصات والتحاليل‬
‫لإلطمئنان‬
: ‫ننصح ب‬
‫ التقليل من األطعمة واملشروبات املسببه لإلرجتاع التأني في األكل وعدم اإلكثار‬-
‫ تناول الوجبه على دفعات صغيرة‬-
Advice ‫ تناول وجبة العشاء قبل ساعة على االقل من موعد النوم‬-
‫عدم االنحناء أو االستلقاء مباشرة بعد الوجبات االقالع عن التدخني والكحول‬-
‫ ممارسة الرياضة و تخفيف الوزن‬-
‫ االسترخاء وتنجنب التوتر والضغوطات‬-
Start treatment with the lowest effective dose of PPI
Omeprazole 20 mg orally once daily 30-60 min before meals
for 8 weeks
Or
Prescribing esomeprazole 20-40 mg orally once daily 30-60 min before
meals for 8 weeks
adjunct: H2 antagonist Famotidine 20 Mg PO BID 8 - 12
Weeks
Referral If Pt is older than 55 Years
If there is any red flag
Ambulatory pH monitoring
Result pH <4 more than 4% of the time is abnormal oesophageal
manometry Result may suggest achalasia, oesophageal spasm, or
other motor disorders
barium swallow
Result may exclude other causes of dysphagia
Investigations Oesophago-gastro-duodenoscopy (OGD) Result normal or may show
oesophagitis (erosion, ulcerations, strictures) or Barrett's oesophagus
Indicated for alarm symptoms or symptoms suggesting complicated
disease (atypical, persistent, or relapsing symptoms)
[Link] test
ECG and Cardiac enzymes to exclude MI
Observation/
follow up
Plan/prevention

Conclusion Safety netting: advice to come to the ER if he experience any red flag.

264
GERD

265
 Jaundice Hx

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present Patient could complain of yellowish in skin/sclera or other symptoms of
illness liver disease like RUQ abd pain.
Allow pt to explain the chief complain and Clarify what you understood
Clarify following points in history to reach the most likely diagnosis:
- Jaundice: duration, onset, reliving and aggravating factors, timing, profile
(same, improving, worsening)
Associated symptoms (fever, nausea, vomiting, loss of appetite,
abdominal pain, diarrhea)
- Recent travel to India or east Asia
- Hemolytic anemia: street, food, drug
- Gilbert’s disease.: onset associated with URTI, fasting
Analysis of - Chronic hepatitis, alcohol abuse, liver crisis: dyspepsia, weight loss,
pruritus, urine and stool color changes, mood swings.
chief complain
- Autoimmune disease SLE or primary biliary crisis: skin rash, vitiligo,
arthralgia renal disease, miscarriage
- Gallstone, biliary duct obstruction: pale stool, itching, steatorrhoea, dark
urine
- Liver failure and impaired synthetic function: abdominal swelling, ankle
swelling, bleeding, bruising
-Hepatitis: history of new tattoo or IV drug abuse ,ear/body pricing , heath
care professional, mother or spouse diagnosed with HBV or HCV
- Medical: previous jaundice, heart failure, IBD, hemolytic anemia,
autoimmune Disease
- Surgical: any previous surgeries
- Medication: hepatoxic medication (statins, antibiotics, antiepileptic,
Past Hx paracetamol, tuberculosis medications, cytotoxic medication, herbal
medication)
- Vaccination: hepatitis A and B
- Allergy
Family Hx Hemolytic anemia, viral, hepatitis, heatobilliry cancer, autoimmune
disease
- Psychological: Anxiety, anhedonia, low mood, stress, mood and interest
- Social: smoking , alcohol, IV drug abuse
Psychosocial - Sexual: homosexuality, multiple sexual partner, new sexual partners, type of
intercourse (anal, oral, vaginal), use of barrier contraception.
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

266
 Jaundice Ex

Vital signs
General appearance: pallor, icterus, thalassemic
facies, cachexia, tattoos,
injection sites
General Hands: cubbing, flaps, palmar erythema, dipyrrin’s
contracture
Special Abdomen: gynecomastia, spider nevi
,hepatosplenomegaly, murphy’s sign,
ascites, ecchymosis

CRAPRIOP for Management

-share differential diagnosis and prognosis
(hepatitis, hemolysis, travel to endemic areas, drug
Clarification users, STD’S, history of
transfusion, alcohol consumptions, autoimmune
conditions like primary biliary
crisis
Reassurance According to differential
Advice According to differential

Prescribing According to differential

-arrange referral as needed for hemolysis or hepatic

Referral failure
Investigations CBC, LFT, LDH, hepatitis and human
immunodeficiency virus screen, US or CT
Observation/
follow up
Plan/prevention
Conclusion Includes Safety netting

267
Jaundice

Hepatitis A

Hepatitis A virus (HAV) is an RNA virus.

Mode of transmission is faecal-
Clarification oral. Foods associated with outbreaks
are typically eaten raw, and include fruits,
vegetables, and shellfish.
• Unlike hepatitis B and C, hepatitis A
infection is not associated with chronic liver
Reassurance disease.
• 85 % recover fully in a 3-month period ,
while the rest recover withing 6 months.
Rest , careful food handling.
Advice
Avoid excess paracetamol and alcohol
Prescribing Supportive care. No specific antiviral therapy
-arrange referral as needed for co-infection
Referral with hepatitis B/C , or liver cirrhosis .
CBC, LFT, LDH, hepatitis and human
Investigations immunodeficiency virus screen, US or CT
Anti-hepatitis A IGM is the test of choice
Follow-up patient weekly by clinical
assessment & liver enzymes
Observation/ until normalisation.
follow up • Children should not return to school or day
care until at least 1 week after onset of the
illness.
Primary prevention :
Plan/prevention 1-washing hands
2-careful food-handling practices
3- 2-dose hepatitis A vaccine series .
Conclusion Includes Safety netting

268
 Jaundice
Hepatitis B
HBV is a DNA virus transmitted by percutaneous and permucosal routes. HBV
infection is also a sexually transmitted infection. HBV infection may result in a
self-limiting disease requiring no treatment, particularly in adult-acquired
Clarification infection. but it may also result in a chronically infected state, particularly if it
is acquired perinatally or in early childhood.
Mainly supportive treatment, 95 % of immunocompetent adults will
recover completely and form anti-HBs.
Reassurance
If it is chronic however, complete eradication is rare , but treatment is
available to keep disease under control .
• Advise patients who are hepatitis B surface antigen-positive to:
• Have household and sexual contacts vaccinated if they test negative for
HBV serological markers
• Use barrier protection during sex if their partner is not vaccinated or is not
naturally immune
Advice • Not share toothbrushes, razors, injection equipment, or
glucose testing equipment
• Not donate blood, organs.
• Cover open cuts and scratches, and clean blood spills with bleach
• Vaccinate against hepatitis A if necessary
• Abstain from, or limit, alcohol use.
• There are several agents used for the treatment of chronic HBV, including
Prescribing interferon alfa 2b, peginterferon alfa 2a, nucleoside analogues (e.g.,
entecavir, lamivudine), and nucleotide analogues (e.g., tenofovir disoproxil
or tenofovir alafenamide, adefovir).
Referral Arrange referral for gastroenterology department for further
management
Investigations CBC, LFT, LDH, hepatitis and human immunodeficiency virus screen, US
or CT, detailed hep B serology added in later slide.
Observation/follow up
Primary prevention:
can be via passive immunization with hepatitis B immunoglobulin (HBIG) or via
active immunization with hepatitis B vaccine (recombinant inactive hepatitis B
surface antigen [HBsAg]).
Infants, children, and adolescents ≤18 years
Saudi immunization schedule : at birth (within 24 hours) > 2 months > 4
months > 6 months.
Children and adolescents who have not previously received the hepatitis B
Plan/prevention vaccine should receive the standard schedule of three vaccinations at 0, 1-2,
and 6 months.
Babies born to HBsAg-positive mothers should receive both hepatitis B vaccine
and HBIG (in separate limbs) within 12 hours of birth, regardless of birth
weight.
Adults.
Saudi immunization schedule : 0, 1, 6 months if no previous vaccination or
evidence of immunity .
High-risk groups : (chronic liver disease, HIV infection, sexual exposure risk,
healthcare workers, household contacts, incarcerated , pregnant, traveling to
endemic country)
Conclusion Includes Safety netting
269
 Jaundice

Hepatitis C

Hepatitis C transmission is through percutaneous exposure to

infected blood, most commonly through injection of illicit
Clarification drugs or transfusion of contaminated blood products in
developed countries, or via contaminated medical or dental
equipment in resource-poor countries.
Reassurance Infection will most likely become chronic, but treatment is
available to achieve a complete cure.
You can reduce the risk of passing hepatitis C on to other
people by:
• Keeping personal items, such as toothbrushes or razors, for
your own use
Advice • Cleaning and covering any cuts or grazes with a waterproof
dressing
• Cleaning any blood from surfaces with household bleach
• Not sharing needles or syringes with others
• Not donating blood
• The risk of spreading hepatitis C through sex is low.
Oral direct-acting antiviral therapies are standard treatment.
Prescribing Examples include : glecaprevir/pibrentasvir (300/120) mg
orally OD for 8 weeks .
Referral Arrange referral for gastroenterology department for further
management
CBC, LFT, LDH, hepatitis and human immunodeficiency virus
screen, US or CT
Investigations • An HCV antibody test followed by reflex HCV RNA
polymerase chain reaction (PCR) testing is recommended
for initial diagnosis.
• Monitor cbc, hepatic and renal function 4 weeks after
starting treatment.
Observation/
follow up • Hepatitis C virus (HCV) RNA (HCV viral load): recommended
12 or more weeks following completion of therapy to
document sustained virological response
Plan/prevention

Conclusion Includes Safety netting

270
 Jaundice
Hepatitis C

Hepatitis C transmission is through percutaneous exposure to

infected blood, most commonly through injection of illicit
Clarification drugs or transfusion of contaminated blood products in
developed countries, or via contaminated medical or dental
equipment in resource-poor countries.
Infection will most likely become chronic, but treatment is
Reassurance available to achieve a complete cure.
You can reduce the risk of passing hepatitis C on to other
people by:
• Keeping personal items, such as toothbrushes or razors, for
your own use
• Cleaning and covering any cuts or grazes with a waterproof
Advice dressing
• Cleaning any blood from surfaces with household bleach
• Not sharing needles or syringes with others
• Not donating blood
• The risk of spreading hepatitis C through sex is low.
Oral direct-acting antiviral therapies are standard treatment.
Prescribing Examples include : glecaprevir/pibrentasvir (300/120) mg
orally OD for 8 weeks .
Arrange referral for gastroenterology department for further
Referral management
CBC, LFT, LDH, hepatitis and human immunodeficiency virus
screen, US or CT
Investigations • An HCV antibody test followed by reflex HCV RNA
polymerase chain reaction (PCR) testing is recommended
for initial diagnosis.
• Monitor CBC, hepatic and renal function 4 weeks after
starting treatment.
Observation/ • Hepatitis C virus (HCV) RNA (HCV viral load): recommended
12 or more weeks following completion of therapy to
follow up document sustained virological response
• Care about co-morbid conditions (DM, obesity...)
• Avoid smoking & alcohol intake in addition to weight loss
No available vaccine
Plan/prevention Advice patient to complete other vaccinations (hep A,B and
pneumococcal polysaccahride vaccine)
Conclusion Includes Safety netting
271
Jaundice

272
Hepatitis Serology

273
Urology

274
Urology
Urinary tract infection UTI
• Recurrent UTI
• UTI during pregnancy
Renal colic
• Renal stone
Urinary incontinence + counselling
Prostatitis
Benign prostatic hypertrophy BPH
Testicular mass
• Varicocele
• Hydrocele
Testicular torsion
Sexual Hx
• Premature ejaculation
• Erectile disfunction

275
 UTI Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question)

Allow pt to explain the chief complain and Clarify what you understood
illness
Course, onset and duration
SOCRATES for pain
Timing (relation to sex )
Associated symptoms (For female à Frequency, hematuria, back , Flank or
Analysis of suprapubic pain , fever , vaginal discharge, dyspareunia, depression ) (For male
chief à Urgency , hesitancy , fever , hematuria , abdomen or pelvic pain , nocturia and
terminal drippling , poor steam , incontinence , weight loss or anorexia , urethral
complain discharge , testicular mass or testicular pain )
Risk Factors ( Pregnancy , catheter use , elderly , anatomical urogynecological or
urological abnormalities , sexual dysfunction , sexual contacts : presence of
symptoms in partner )
Red Flags ( To exclude Pyelonephritis: high grade fever , vomiting , sever pain )
Cystitis: presents as dysuria, frequency, urgency, suprapubic pain ± hematuria.
-Pyelonephritis: presents as fever, chills, nausea/vomiting, flank pain,
costovertebral angle tenderness, ± symptoms of cystitis.
-Complicated UTI: ( Male, DM, pregnancy, immunocompromise, renal failure or
transplantation, functional/anatomic urinary tract abnormality or obstruction):
Differential symptoms > 7d before seeking care - hospital acquired - recent instrumentation
Diagnosis of urinary tract or presence of catheter/stent/tube - resistant organism - H/o
acute pyelonephritis past year or UTI in childhood.
For every -Acute prostatitis: symptoms of cystitis + fever/malaise/
Dx have at perineal pain + obstructive symptoms (dribbling - hesitancy)
least 1 -Urethritis: must be considered in sexually active men ± C/P Penile ulceration ±
urethral discharge - no hematuria
question -PID: must be considered in sexually active women C/P vaginal discharge ±
cervical motion tenderness on P/V
-Asymptomatic bacteriuria: + culture in asymptotic pregnant women
-Kidney stone: unilateral flank pain which may radiate to the groin , red urine ,
possible visible stones after urination
Medical ( diabetes mellitus , ureteric stone, recurrent UTI ) renal disorder (
Congenital , polycystic kidney , vesicoureteral reflex ) incontinence , neurological
disease.
Past Hx Surgical (pelvic procedure )
Allergy
Medication (regular medications , immunosuppressant medication )
Family Hx
Psychosocial Marital status , Domestic violence
Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
conclusion

276
 ‫‪UTI Ex‬‬

‫‪General‬‬ ‫‪-Vital signs for fever and any sign of dehydration.‬‬

‫‪-Appearance if look well , pale or dehydrated.‬‬
‫‪-Abdominal examination : to exclude suprapubic or‬‬
‫‪costovertebral angle tenderness.‬‬
‫‪Special‬‬ ‫‪-Pelvis : to exclude signs of vaginitis , cervical motion‬‬
‫‪tenderness (PID) .‬‬
‫‪-Genital examination : penile ulcer or discharge ,‬‬
‫‪scrotal swelling or tenderness (epididymitis), tender‬‬
‫‪per rectal exam (prostatitis ).‬‬

‫‪CRAPRIOP for Management‬‬

‫تشمل املسالك البولية‪ :‬الكلى )التي ترشح الدم إلنتاج البول( ‪ ،‬واحلالبني )األنابيب التي‬
‫تنقل البول من الكلى إلى املثانة( ‪ ،‬واملثانة )التي تخزن البول( ‪ ،‬واإلحليل )األنبوب الذي‬
‫ينقل البول منه(‪.‬‬
‫حتدث التهابات املسالك البولية عندما تدخل البكتيريا إلى مجرى البول وتنتقل إلى‬
‫املثانة‪ .‬إذا بقيت العدوى في املثانة فقط ‪ ،‬فإنها تسمى عدوى املثانة ‪ ،‬أو "التهاب املثانة‬
‫البسيط"‪ .‬إذا انتقلت العدوى عبر املثانة إلى الكلى ‪ ،‬فإنها تسمى عدوى الكلى ‪ ،‬أو‬
‫"التهاب احلويضة والكلية"‪ .‬التهابات املثانة والكلى كال النوعني من عدوى املسالك‬
‫البولية‪.‬‬
‫وتشمل العوامل التي تزيد من خطر اإلصابة بعدوى املسالك البولية ما يلي‪:‬‬
‫‪Clarification‬‬ ‫●ميكن أن تنتشر البكتيريا من حول فتحة الشرج إلى مجرى البول‬
‫●ممارسة اجلنس بشكل متكرر‬
‫●اإلصابة مبرض السكري‬
‫●اإلصابة بعدوى في املثانة أو الكلى خالل الـ ‪ 12‬شهرًا املاضية‬
‫●استخدام مبيد النطاف ملنع احلمل‬
‫●بالنسبة للذكور ‪ ،‬عدم اخلتان أو ممارسة اجلنس الشرجي التدخلي‪.‬‬
‫●وجود انبوب القسطرة البولية‬
‫●احلمل والوصول الى سن اليأس‬
‫مبني من األعراض أن عندك التهابات في البول وهذا الشيء مو خطير بس الزم نعاجله‬
‫‪Reassurance‬‬ ‫عشان ما تزيد االمور سوء ويوصل اللتهاب للكلى ال قدر الله‪.‬‬
‫االكثار من شرب املاء ) اكثر من ‪ 2‬لتر باليوم ( وعصير التوت البري ‪ ,‬الذهاب للحمام‬
‫‪Advice‬‬ ‫بعد اجلماع مباشرة ‪ ,‬غسل املنطقة يكون من قدام للخلف وليس العكس ‪ ,‬جتنب غسول‬
‫املهبل بالصابون‪.‬‬

‫‪277‬‬
 UTI

1- Nitrofurantoin 100mg PO BID*5days (in pregnant, penicillin

allergy).
2- TMP-SMx (160/800 mg) BID*3days.
3- Ciprofloxacin 250mg BID*3days (if sulfa allergy, Not
pregnant).
Prescribing 4-Painkillers : paracetamol 500 mg PRN ,phenazopyridine can
help reduce the burning pain of some UTIs. A similar
medication is available over the counter without a
prescription (eg, Uristat).
In pyelonephritis:
1)Outpatient: Ciprofloxacin 500mg BID*7days.
2)Inpatient: aminoglycoside/ fluoroquinolones ± ampicillin.
No need for referral unless if the patient develops a signs of
Referral sepsis or acute complicated UTI/ pyelonephritis.
Investigations urine dipstick culture -Vaginal swab – Renal function- KUB x-
ray)
Observation Follow-up urine testing is not routinely needed following a
UTI if symptoms resolve.
/
follow up
The mainstay of UTI prevention is avoidance of known risk
factors. Women who are prone to UTIs should avoid
spermicidal products. Vaginal estrogen therapy in post-
Plan/prevention menopausal women with symptomatic UTIs should be
considered as a preventative measure.

Safety netting : you should see a doctor straight away if you

Conclusion have signs of a kidney infection. These include:
Fever , pain in your side , nausea, and vomiting.

278
UTI

279
UTI

280
UTI

281
 Recurrent UTI Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt to explain the chief complain
illness Clarify what you understood
Analysis of complaint: onset, course,
duration, aggravating/relieving factors,
recurrence -
Associated symptoms:
change color/clarity of urine, dysuria, frequency,
urgency, hesitancy, Supra- pubic pain ,nausea and
vomiting,
hematuria ,urgency , Incontinence ,nocturia,
signs or symptoms of pyelonephritis( fever , rigors
and flank pain)
vaginal discharge, itching , dyspareunia,,menopausal
status ,pregnancy .
Analysis of
Relation to sexual activity .
chief
Elaboration on recurrence: frequency, previous
complain treatment duration, previous investigation, pelvic
infections.
Predictors of recurrent UTIs include symptoms
following intercourse, and prompt resolution of
symptoms with antibiotics.
Hx of urinary catheterization .
Hx of STD , presence of cystocele.
Risk Factors: new sexual partner, frequent sexual
activity, use of spermicide ,age at first UTI ,maternal
hx of UTI, pregnant women .
Red flags: decrease LOC , convulsions, persistent
hematuria ,weight loss ,fatigue, loss of appetite.

282
 Recurrent UTI Hx
PMH & PSH : Previous history of UTI , diabetes, renal
disorder (congenital, polycystic kidney, vesico-uretric
reflux, stones), incontinence, neurological disorder,
Past Hx pelvic procedures or urological surgery.
Gynecological hx : LMP ,regularity and duration, IPD .
Medication & allergy hx : immunosuppressant
medications use, antihistamine ,recent antibiotics
Family Hx Family hx of UTI or congenital kidney disease.
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic review
Conclusion

Examination
Assess vital signs for fever, BP and any signs of
General dehydration.
General examination
Abdomen: to exclude suprapubic or costovertebral
angle tenderness.
Special
Pelvis: to exclude signs of vaginitis, cervical motion
tenderness (which suggests pelvic inflammatory
disease).
Order investigation as indicated, pregnancy test,
Urinalysis, urine culture, X-ray kidney, ureter and
Investigations bladder (KUB) to role out anatomical or structural
abnormality, renal function test, and glucose level to
exclude diabetes.

283
 Recurrent UTI

CRAPRIOP for Management

UTI is an infection in any part of urinary tract includes kidney
Clarification ureters bladder and urethra.
Most infections involve the lower urinary tract .
Every one prone to get UTI ,including men and children but
Reassurance women are more likely .but don’t worry it is treatable and
preventable infection.
Discuss preventive factors such as:
Increased fluid intake, postcoital voiding, avoid delayed avoiding, wiping
Advice pattern (from the front to the back passage) and Cranberry products
seem to notably reduce the recurrence of symptomatic cystitis,
although there is no clear evidence about dosage or duration of use.
Uncomplicated UTI 1st line:
TMP-SMX (Bactrim) 160/800 po bid x 3days or Nitrofurantoin 100mg po
bid x 5days or
Fosfomycin 3g po single dose
2nd line: ciprofloxacin 250 po bid 3days
Pregnancy:Nitrofurantoin 100mg po bid x7days OR cephalexin (keflex)
Prescribing 500mg po bid x7days
Augmentine 500 mg Tid for 5-7 days
-Postcoitall UTI:single dose TMP-SMX or cephalexin
-complicated UTI : extend course ciprofloxacin 250-500 mg twice for 7-
14 days (avoid nitrofurantoin)
- Prophylaxis (recurrent UTI):Daily low dose of TMP-SMX 40/20mg OR
Nitrofurantoin 50-100mg x 6-12 months
Consider referral to urology: men ,children with anomalies or < 1 year
Referral for further investigation.
Order investigation as indicated:pregnancy test , Urinalysis, urine
culture, X-ray kidney, ureter and bladder (KUB) to role out anatomical or
Investigations structural abnormality, renal function test, and glucose level to exclude
diabetes.
Routine F/U is not required for pt with uncomplicated UTI with
Observation/follow experience resolution of symptoms after treatment
up Follow up after 3 days if symptoms not improved or develop signs and
symptoms of Upper infection.
Prevention Opportunity or vaccine and screening.
Conclusion Includes Safety netting

284
Recurrent UTI
Acute pyelonephritis:
Nausea, fever, flank pain, costovertebral angle
tenderness, pyuria with casts
Atrophic vaginitis: Postmenopausal women, no
infectious etiology
Bladder cancer: Frequency, urgency, hematuria
Cystitis: Frequency, urgency, pyuria, bacteriuria,
urinary dipstick positive for nitrates.
Genital herpes: Dysuria, fever, vulvar pain, grouped
vesicles, tender inguinal adenopathy
Interstitial cystitis: Frequency, urgency, long-standing
symptoms, pain in bladder or urethra relieved by
urination; negative urine cultures; ulcers or
glomerulations (bladder hemorrhages) identified on
cystoscopy
Irritant cystitis:
Symptoms related to dietary intake, chemical irritant,
DDX or other exposures
Overactive bladder:
Urgency, frequency, and possibly incontinence,
without dysuria
Sexually transmitted
Infection: Vaginal discharge, history of unprotected
sexual
intercourse
Urethritis:
Delayed symptoms or asymptomatic, history of
unprotected sexual intercourse, positive test for
Neisseria gonorrhoeae or Chlamydia trachomatis
Vaginitis:
External irritation, dyspareunia, vaginal discharge,
positive potassium hydroxide or wet-mount
preparation

285
 UTI during pregnancy

Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt to explain the chief complain
illness Clarify what you understood
Course, onset and duration
SOCRATES for pain
Associated symptoms (DDx)
Acute cystitis : dysuria, urgency and frequency in
afebrile patients with no evidence of systemic illness.
Pyelonephritis: fever, chills, lower abdominal pains,
nausea, vomiting or flank pain.
A symptomatic bacteriuria : positive culture with No
symptoms.
vaginal discharge, menopausal status ,pregnancy, .
Relation to sexual activity .
Elaboration on recurrence: frequency, previous
treatment duration, previous investigation, pelvic
Analysis of
infections.
chief
Predictors of recurrent UTIs include symptoms
complain following intercourse, and prompt resolution of
symptoms with antibiotics.
Hx of STD , presence of cystocele .
Hx of urinary catheterization .
Risk Factors: smoking , pregnant women ,mulitparity ,
maternal hx of UTI ,advanced maternal age .
new sexual partner, frequent sexual activity, use of
spermicide.
DM , kidney stone , spinal cord injuries.
Red flags: decrease LOC , convulsions, persistent high
grade fever ,vomiting sever pain , vaginal bleeding
,hematuria ,weight loss ,fatigue, loss of appetite.

286
 UTI during pregnancy

Menstrual LMP , regularity , duration.

Hx
Gravidity and parity included ( abortions , ectopic
pregnancies, complications )
Contraceptive Hx : types and duration.
Obstetric Hx
GA , EDD .
Baby movement , abdominal pain ,vaginal bleeding or
discharge.
Medical : DM , kidney diseases( ureteric stones
recurrent UTI or cystitis , , hx of IPD , anatomical
urogynecological abnormalities ) .
Past Hx
Surgical : CS or any pelvic surgeries.
Allergy
Medication : any regular use of medication.
Family Hx History of same condition or kidney diseases.
Marital status
Socioeconomic status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

287
UTI during pregnancy

Vital signs ( Temperature , hydration status or any

General signs of sepsis)
BMI ,Appearance
Abdominal and pelvic examination .
Pelvic examination is recommended for all
Special symptomatic patients ( with the exception of third
trimester patient with bleeding) to rule out
vaginitis or cervicitis .
SCREENING:
§ ACOG recommends that a urine culture be
obtained at the first prenatal visit.
A repeat urine culture should be obtained during
the third trimester.
§ The recommendation of the U.S. Preventative
Services Task Force is to screen all pregnant
women by urine culture at least once between
12 and 16 weeks of gestation (an “A”
recommendation).
§ The diagnosis of ASB : when ≥ 105 colony-
forming units (CFU)/mL of a single bacterial strain
Investigations
isolated from 2 consecutive voided urine
specimens.
§ For cystitis: presence of symptoms plus
isolation of ≥ 1,000 CFU/mL from midstream clean-
catch urine culture
§ For pyelonephritis: presence of signs and
symptoms of upper tract infection plus isolation of
≥ 1,000 CFU/mL from midstream clean-catch urine
culture
§ Consider ultrasound or (MRI) to rule out urinary
obstruction or stones .
§ Consider blood cultures for women in whom
bacteremia or sepsis is suspected.

288
 ‫‪UTI during pregnancy‬‬

‫‪CRAPRIOP for Management‬‬

‫التهابات املسالك البولية‪:‬هي عدوى بكتيرية شائعة تصيب اجلهاز البولي السفلي‪ ،‬وقد‬
‫تصيب اجلهاز البولي كامال وتوصل إلى الكلى‪ ،‬ممكن تصيب جميع الفئات العمرية‪،‬‬
‫ولكن النساء أكثر عرضة لها من الرجال وذلك لقصر مجرى البول‪ ،‬وقد تصاب نصف‬
‫‪Clarification‬‬ ‫النساء بالتهابات البول على األقل مرة واحدة خالل فترة حياتهم‪.‬الفئات األكثر عرضة‬
‫لإلصابة‪:‬احلوامل‪.‬املصابون بداء السكري‪.‬املصابون بضعف في اجلهاز املناعي‪.‬من لديهم‬
‫مشاكل خلقية في مجرى البول‪.‬مرضى زراعة الكلى‬
‫ما تقلقي هي عدوى شائعة و فيه لها عالج دوائي وطرق وقائية و نادرًا ما يسبب‬
‫‪Reassurance‬‬ ‫مضاعفات إذا عاجلنا االلتهاب بالشكل املناسب‪ ،‬وإذا لم ُيعالج فقد يسبب بعض‬
‫املضاعفات عند احلوامل قد تزيد احتمالية الوالدة املبكرة‪.‬‬
‫نقدر نتفادى اإلصابة عن طريق ‪:‬‬
‫‪ ü‬اإلكثار من شرب السوائل‪.‬‬
‫‪ ü‬احلفاظ على نظافة املنطقة وتعقيمها واالبتعاد عن املعقمات العطرية‪.‬‬
‫‪ ü‬الذهاب لدورة املياه مباشرة عند اإلحساس بالرغبة في التبول‪.‬‬
‫‪Advice‬‬ ‫‪ ü‬بالنسبة للنساء‪ ،‬االبتعاد عن أجهزة منع احلمل واستبدالها بوسائل كيميائية‬
‫كاألدوية‪.‬‬
‫‪ ü‬أن تكون عملية التنظيف من األمام إلى اخللف بعد التبول أو التبرز‪.‬‬
‫‪ ü‬إفراغ املثانة بعد العالقة احلميمة‪.‬‬
‫‪Ø Common options for asymptomatic bacteriuria and‬‬
‫‪acute cystitis in pregnancy include:‬‬
‫‪Ø Amoxicillin 500 mg every 8 hours for 3-7 days‬‬
‫‪Ø Amoxicillin-clavulanate 500 mg every 12 hours for 3-7‬‬
‫‪days‬‬
‫‪Ø Cephalexin 500 mg every 8 hours for 3-7 days‬‬
‫‪Ø Fosfomycin 3 g as single dose‬‬
‫‪Ø Common options for treating pyelonephritis in‬‬
‫‪Prescribing‬‬ ‫‪pregnancy include:‬‬
‫‪q Ceftriaxone 1-2 g IV or intramuscularly once daily‬‬
‫‪q Aztreonam 1 g IV every 8-12 hours‬‬
‫‪q Piperacillin-tazobactam 3.375-4.5 g IV every 6 hours‬‬
‫‪q Cefepime 1 g IV every 12 hours‬‬
‫‪q Imipenem-cilastatin 500 mg IV every 6 hours‬‬
‫‪q Ampicillin 2 g every 6 hours plus gentamicin 3-5‬‬
‫‪mg/kg/day IV in 3 divided doses‬‬

‫‪289‬‬
 UTI during pregnancy

If acute pyelonephritis or sepsis is suspected

Referral pregnancy complications
Investigations Mentioned above
Ø Follow-up culture should be obtained as a test
of cure. We typically perform this a week after
Observation/ completion of therapy.
follow up Ø Repeat urine cultures monthly until
completion of the pregnancy because of the
risk of persistent or recurrent bacteriuria.
A single, postcoital dose or daily suppression with
Plan/prevention cephalexin or nitrofurantoin in patients with
recurrent UTIs is effective preventive therapy.
Safety netting :
If you have a fever, chills, lower abdominal pains,
nausea, vomiting or flank pain, you should return
Conclusion back . Also if you have any contractions, or if, after
taking medicine for three days, you still have a
burning feeling when you urinate.

290
 Renal colic (Stone) Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain ex( Unilateral acute sever colicky pain , acute flank pain..)
Usually asymptotic until stone cause obstruction and present as acute pain
Hx of Allow pt to explain the chief complain and Clarify what you understood
present Note
( some pt asymptomatic but if it’s get obstructive , pt usually come with sever
illness colicky unilateral pain, some other pt presented as gross hematuria Or as sepsis
with hypotension and tachycardia )
Course, onset and duration
Dose the pain started suddenly or over time (Usually sudden)
Nature of the pain (Colicky)
Nature (Sever)
Duration( variables)
Where to radiate (ipsilateral area, groin)
Aggravating , relief by (usually unrelieved by position)
SOCRATES for pain
Associated symptoms ddx:
Analysis of Nausea, vomiting , fever, testicular pain , groin pain
chief Urinary symptoms:
complain Hematuria, dysuria , polyuria
Obstruction symptoms:
( intermittently, weak stream,
Incomplete emptying, staring,
hesitancy, post void dripping )
Risk Factors
Previous episode, Family hx ,Obesity, Dehydration, Higher salt intake,
male sex,
Red Flags:
Sign of sepsis
Medical
Surgical
Past Hx Allergy
Medication
Family Hx Renal stone
Excessive physical activity
Social Hx Diet and fluid intake ( low fluid ,ca , k) ( hight na, oxalate, fructose) >>
this risk of the calcium stone common type.
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
291
 Renal colic (Stone) Ex
Vital signs
Fever ( infection sepsis)
General General appearance in distress or pain or not , sign
of dehydration)
( tachycardia , hypotension ( sepsis)
Abdomen Ex
Tense or rigid
Special Lion tenderness
Kidney enlargement

CRAPRIOP for Management

Renal stone is typically stone that obstruct the urinary tract system and causing
your symptoms usually the stone variates in size and according to the size and
Clarification the type of the stone and place it will cause your symptom’s , it different from pt
to other
Don’t worry renal stone can be treated and according to there size and types
Stone <or = 5 mm and stone >5 mm to <= 10 mm and stone > 10 mm to<= 20
Reassurance mm or > 20 mm
And each type treatable and usually pass with urine according to size and
medication use
Drink a lot of fluid , try not to swallow a lot ,don’t do unhealthy diet to promotes
Advice fast wt loss
Don’t eat salt a lot
If pt come as acute renal colic pain at time we will stabilize him first ( pain
management) NSAID if GFR >30
But if or stable will treat renal stone according to the size and severity
Prescribing Watchful waiting of less than 5 mm ( usually pass spontaneously) asymptomatic
More than 5 mm and less than 10 mm less likely to pass spontaneously ( medical
expulsive therapy tamsulosin 0.4. Mg do for. 4 weeks.
Sign of sepsis infection or obstruction
, more than 10 mm to opd
Referral Anuria
Failure of stone pass after conservative medical therapy ,
Sever Uncontrolled pain
CBC , urine culture, urine analysis
Investigations U/s if child or pregnant
Ct for adult

Observation/ F/u is recommended to see response to medical therapy usually 4-6 weeks ( no
follow up obvious source to exact time)

Plan/prevention Dehydration, drink water , vaccination and screening

Conclusion Includes Safety netting

292
 Urinary incontinence Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt to explain the chief complain
Clarify what you understood
illness
Onset, course, duration of incontinence
[19-63-stress, >65---mixed, from childhood---congenital causes]
Amount, frequency and timing
Aggravated factors ( sneeze, lifting , bending) and relieved factors.
Associated symptoms :
Hx of supra-pubic pain and dysuria indicates UTI
Hx of fever flank pain, chills , rigors and sweating indicates pyelonephritis.
Hx of urinary urgency , nocturia .
Any vaginal discharge ,itching or dyspareunia
Analysis of History of fecal leakage or fecal urgency.
chief caffeine and fluids intake
complain Risk factors : DDx:
- Old age • Stress incontinence : small spurts with
- Obesity coughing or straining and dry at
- Pregnancy • Night
- Chronic cough: smoking, • Urge incontinence: sudden, large
amount, frequency and nocturia.
COPD, GERD, BA
• Overflow incontinence: large without
- Chronic constipation
urge to void and urinary retention,
Red flags: Total: continuous leakage due to
Fever , weight loss , congenital Anomaly.
night sweating.
Medical : CVA, Parkinson, MS, DM, spinal cord
Obstetric: weakness of the pelvic floor is more likely in multiparous
women , forceps use obstetrical laceration , pelvic organ prolapse.
Surgical : pelvic surgery, including gynecologic and bowel surgery
Past Hx Medication Hx and allergies: alpha-blocker (terazosin, prazosin, Doxazosin,
tamsulosin, alfuzosin, sildosin), antidepressant, antipsychotic,
anticholinergics, opioids.
Radiation history to pelvic and vaginal area.
Family Hx Same condition, pelvic diseases
Psychosocial Marital status , Smoking ,traveling hx , occupation, quality of life .
Hx Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

293
 Urinary incontinence Ex

Vital signs
General BMI , General examination .
Neurological examination :
Motor: gait, generalized or focal weakness , rigidity,
tremor.
Sensory: impairment of perineal-sacral area sensation
Abdominal exmination :
masses , scar ,Supra-pubic tenderness , palpable
distended bladder .
Special Pelvic examination : perineum and external genitalia,
vaginal for prolapse, bimanual pelvic exam for masses,
fecal impaction and pelvic floor function.
looking for skin excoriation, cystocele, rectocele .
Rectal examination : fullness of the rectum ,external
hemorrhoids or anal fissure
Cough Stress test : ask the patient to cough or strain.
Cotton swab test for identifying urethral hyper mobility.
Urinalysis , culture , Renal function
Bladder scan to evaluate +ve residual in case of overflow
(<50-100ml expected)
Investigations
Upper tract imaging: scan or US
3 days voiding diary to evaluate fluid intake, caffeine,
timing of leakage, and patient habits- urodynamic studies

CRAPRIOP for Management

.‫ مما يؤدي إلى تسرب البول‬،‫سلس البول هي حالة يتم فيها فقدان السيطرة على املثانة‬
.‫التغيرات اجلسدية من احلمل والوالدة غالًبا ما تسبب سلس البول‬
‫ يحدث عند السعال أو‬:‫ سلس البول اإلجهادي‬:‫وهناك أنواع لسلس البول عند النساء‬
Clarification .‫العطس أو النشاط البدني‬
.‫ أو امللحة إلى التبول‬،‫ يحدث عند الرغبة القوية والعاجلة‬:‫سلس البول اإلحلاحي‬
.‫ يحدث عند اإلصابة بسلس البول اإلجهادي واإلحلاحي معًا‬:‫سلس البول املختلط‬
‫ال تقلقي سلس البول شائع لدى النساء وميكن عالجه بوسائل غير جراحية كخيار أول ثم‬
Reassurance .‫ وميكن تقليل خطر اإلصابة به عن طريق اتخاذ بعض اخلطوات‬.‫الوسائل اجلراحية‬

294
 Urinary incontinence
Non pharmacological : life style changes for all types
Weight reduction , Fluid management, caffeine
reduction
Advice Pelvic floor exercise: kegel exercise( 8 contraction
TID for 3 months)
Smoking cessation
Resolution of chronic constipation
Pharmacological:
Stress incontinence :
pseudoephedrine 15-50 mg Tid daily.
Duloxetine 40 mg twice daily.
Vaginal Estrogen
Urgency incontinence:
Prescribing Antispasmodic drug: oxybutynin 5-30 mg / day
Anti cholinergic agent : Tolterdine; 2-4 mg / day ,
Solifenacin 5-10 mg /day
Or
Surgery procedure(midurethral sling ,pubovaginal
sling ,urethral injection therapy “bulking agents”).
women with urinary incontinence should receive
urgent referral within 2 weeks If have any of the
following :
Visible hematuria
Referral recurrent UTI infection associated with hematuria in
women >40 years old .
Suspected malignant mass .
Abnormality suggesting neurological disease
Investigations Mentioned above
Observation/ Offer Follow up after 4 weeks or earlier if
follow up intolerable adverse event
Opportunity for health education
Plan/prevention
(vaccination and screening)
conclusion Includes Safety netting

295
 Prostatitis Hx

Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present Allow pt to explain the chief complain
illness Clarify what you understood
- Onset, course and duration (acute vs chronic: for 3 month of
the last 6 months)
- Fever, chills, malaise
- Lower back pain
Analysis of - Frequency, urgency, dysuria, polyuria, nocturia, hematuria,
hesitancy, poor stream - Pelvic pain, perineal pain, testicular
chief pain or penile pain
complain - cloudy urine
- Sexual dysfunction, painful ejaculation, haematospermia
- Sexual hx
- Hx of UTI, HIV, BPH, obstructive renal disease,
- Hx of trauma or previous catheterization
Medical
Surgical
Past Hx Allergy
Medication
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do
for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

296
 Prostatitis Ex
Vital signs
General Appearance
Back & Abdomen (suprapubic + flank) Examination
Prostate: Acute: very tender prostate, warm, firm,
Special edematous Chronic: tender, enlarged, nodular, edematous
Urinalysis, urine culture, CBC , blood culture (if fever and
Investigations septic), if testicular pain do scrotal US

CRAPRIOP for Management

- Explain The diagnosis (or provisional diagnosis) to the patient in a
simple language.
Clarification - Check for patient understanding of the diagnosis by asking him/her
to say what he/she understood.
- Always address any uncertainty by saying “well, now the diagnosis
Reassurance is unclear for me, but it could be apparent on later stage of the
disease during next visits
Limit night-time water consumption ,wt loos(if over wt), reducing
Advice consumption of mild diuretics such as caffeine to empty the bladder
completely.
*Acute prostatitis:
➢ Ciprofloxacin 500mg po bid or Levofloxacin 500 po OD x 2-4
weeks or
➢ TMP-SMX 1 double strength tab po bid x 2-4 weeks
In case of sexually transmitted:
Prescribing ➢ Ceftriaxon 250mg IM one dose + (Doxycyclin 100mg po bid x 1
week or Azithromycin 1g po single dose)
*Chronic prostaitis:
➢ Levofloxacin 500mg po OD x 4 weeks or
➢ Ciprofloxacin 500mg bid x 4-12 weeks
Consider referral to urology if: treatment fail, persistent symptoms,
Referral suspect abscess, immunocompromised
Investigations Mentioned above
Observation/ Regular F/U
follow up
smoking cessation if the patient smoking, vaccination and screening
Plan/prevention according age, sexual education

Conclusion Includes Safety netting

297
 Benign Prostatic Hyperplasia Hx
Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
- Obstructive symptoms: (weak stream, intermittent stream,
drippling and retention)
- Irritative symptoms: (increased frequency of urination,
Analysis of nocturia, hesitancy, urgency)
- Hematuria
chief - Associated symptoms: nausea, vomiting, diarrhea and
complain constipation)
- Constitutional symptoms: (weight loss, appetite changes,
night sweat)
- History of STDs
Medical
Surgical
Past Hx Allergy
Medication
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
Appearance
General Abdominal exam: palpation, percussion, auscultation, check for
renal angle tenderness to R/O other causes
Digital rectal exam should be done to assess prostate: (size, contour,
Special consistency, border) Findings are: Enlarged prostate, smooth
contour, firm in consistency, NO nodule or irregularity)

298
 Benign Prostatic Hyperplasia

Urine analysis and PSA, Diagnostic study : Trans abdominal

US to assess post-void residual volume ( normal < 100ml),
Investigations Other study to consider : transrectal US to evaluate prostate
size and IV pyelogram to assess urinary obstruction

CRAPRIOP for Management

- Explain The diagnosis (or provisional diagnosis) to the patient in a
simple language.
Clarification - Check for patient understanding of the diagnosis by asking him/her
to say what he/she understood.
- Always address any uncertainty by saying “well, now the diagnosis is
Reassurance unclear for me, but it could be apparent on later stage of the disease
during next visits
Limit night-time water consumption , wt loos(if over wt), reducing
Advice consumption of mild diuretics such as caffeine to empty the bladder
completely.
Asses the severity of symptom with BPH symptom index : If 7 or less :
conservative ttt If 8-19 : consider pharmacological drugs
- Pharmacological treatment:
1. Alpha-1-adrenergic antagonists: Terazosin 1mg po QHS, gradual
increase to 10mg/day Or Uroselective : Tamsulosin initial and
maintain 0.4mg po QHS after meal
*Explain possible drug side effects: Orthostatic hypotension, dizziness
and ejaculation failure “retrograde”
Prescribing 2. 5-alpha-reductase inhibitor: Finasteride (Proscar) 5mg po QHS,
require long-term treatment for efficacy.
3. Anticholinergic agents : May be used as adjunct in combination to
other e.g. oxybutynin, solifenacin or tolterodine.
- If failed medical therapy or recurrent UTI or refractory urinary
retention or BPH symptom index 20 or higher = refer to surgery
- Check understanding of patient and acceptance of management
plan
Referral Urology if need

Investigations Mentioned above

Regular F/U
Observation
smoking cessation if the patient smoking, vaccination and screening
Plan/prevention according age, sexual education
Conclusion Includes Safety netting

299
 Testicular mass Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness Allow pt to explain the chief complain and Clarify what you understood
Onset (sudden- torsion, orchitis, gradual- epididymitis, testicular cancer), course
and duration
Site: mass lying posterior to and above the testis(varicocele), bilateral or unilateral
(commonly on left side varicocele ), is it painful (torsion, epididymitis , orchitis) or
painless (hydrocele, Spermatocele, varicocele, testicular cancer ), aggravating and
reliving factors:
small in size and soft before the patient arises in the morning and increase in size
become denes during the day and increases in size with activities such as coughing,
straining, crying, or raising the arm (hydrocele)
Dilation of veins is commonly decreased when the patient is supine, and dilation
and tortuosity are increased when the patient is upright(varicocele)
After trauma or vigorous exercise (torsion)
Associated symptoms (DDx):
Testicular torsion: severe scrotal pain that is often associated with nausea and
vomiting, lower abdominal pain
Analysis of Epididymitis: scrotal pain, with fever, urethral discharge and urinary symptoms
Orchitis: scrotal pain, high fever ,Nausea and vomiting
chief strangulated hernia: Hx of previous intermittent inguinoscrotal swelling, with or
complain without pain. Sudden onset of pain and inability to reduce the hernia, associated
nausea and vomiting.
Testicular cancer: a sense of scrotal heaviness, hx of undescended testis
Risk Factors:
Prematurity and low birth weight (hydrocele)
Hx of trauma (A new hydrocele or one that hemorrhages after minor trauma may
signal testicular cancer)
previous history of minor similar scrotal pain that resolved spontaneously (torsion)
Hx of tuberculosis, UTI, BPH (Epididymitis)
Hx of mumps parotitis (3-4 days before onset of scrotal pain ), syphilis, TB (orchitis)
Hx of infertility(varicocele)
Red Flags:
an increase in the firmness of a testicle
a difference in appearance between one testicle and the other
Intermittent a dull ache or sharp pain in testicles or scrotum
a feeling of heaviness scrotum
Past Hx Medical: recurrent UTI, BPH Surgical, Allergy , Medication

Family Hx Testicular cancer

Marital status : multiple sexual relationships
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

300
Testicular mass Ex
Vital signs
General Appearance
Penis: inspected for ulcers and palpated for plaques or induration.
Cultures for gonorrhea and Chlamydia should be performed to evaluate
any urethral discharge.
Testes: should be palpated for masses, equal volume, tenderness or
cryptorchidism
A testicle less than 3.5 cm long = small
All masses and swellings should be transilluminated
If a testicle cannot be palpated in the scrotum, the inguinal canals and
lower abdomen should be examined
A nonpalpable testicle may be physiologically retracted transiently, or it
may be truly cryptorchi
Hydrocele: painless, in light transilluminate: will glow a soft red color
testicular torsion: Scrotal edema and erythema present ,tender, firm
affected testis that may appear retracted upward as a result of twisting
of the spermatic cord. It is usually found higher in the scrotum than its
mate. The cremasteric reflex is usually absent.
Elevation of the scrotum without relief of pain (Prehn's sign). can cause
unilateral or bilateral testicular atrophy.
Orchitis: The testis is enlarged, indurated and tender on palpation. can
cause unilateral or bilateral testicular atrophy.
testicular cancer: solid, firm masses that are not transilluminated,
evaluation for gynecomastia should also be performed
Special epididymis: is posterior to the testicle. In epididymitis may be enlarged
and indurated. The cremasteric reflex is usually present, and elevation
of the scrotum may provide relief of pain
The presence of edema may cause difficulty in distinguishing the
epididymis from the testicle. The scrotum may also be erythematous
The inguinal canals should be explored for hernias or cord tenderness
Varicocele: should perform the Valsalva maneuver while standing to
accentuate dilation. The classic description is that of a “bag of worms”
superior to the testicle.
Spermatic Cord:
palpation should be performed to evaluate for induration and to
localize pain to the testicle or adjacent structures .
Spermatocele: painless cystic mass separate from the testis. It is located
superior and posterior to the testis, is freely movable and
transilluminates easily
Vas Deferens: palpation should be performed to evaluate for induration
and to localize pain to the testicle or adjacent structures
Special test:
The cremasteric reflex on both sides must be checked. This can be done
by lightly stroking the medial thigh, with a normal reflex of transient
cephalad retraction of the ipsilateral testicle.
How to do it: Cremasteric reflex – YouTube

301
Testicular mass Ex

Urinalysis: normal in 90 % of patients with

testicular torsion, pyuria in epididymitis the
absence of pyuria makes the dx of epididymitis
unlikely. Proteinuria or hematuria (orchitis).
urethral Gram's stain and culture in case of
urethral discharge (to direct
treatment)(epididymitis)
Scrotal ultrasonography (Color duplex US)to
differentiating between intratesticular and extra
testicular lesions
Confirm dx of epididymitis, testicular cancer
Investigations Testicular torsion (absent or decreased blood flow
in the affected testicle; decreased flow velocity in
the intra-testicular arteries).
Other diagnostic procedures include tumor
marker screening:
AFP and HCG (indicate tumor activity), LDH.
An abdominal CT scan should be performed for
staging, chest Xray and a CT scan of the lungs for
evaluation of metastatic disease
HIV and syphilis test (in case of multiple sexual
relationship)

302
 Testicular mass

CRAPRIOP for Management (Hydrocele)

‫من خالل التاريخ املرضي والفحص السريري عندك القيلة هي نوعٌ من التورم في كيس‬
‫ كثيرًا ما تصيب‬.‫الصفن سببه جتمع السوائل في النسيج الرقيق املحيط باخلصيتني‬
Clarification ‫ قد‬.‫ عاٍم من عمرهم‬1 ‫القيلة حديثي الوالدة وتختفي دون عالٍج في املعتاد بانتهاء‬
.‫تصيب القيلة األوالد أو الرجال‬
‫احب اطمنك ان املوضوع ماهو خطير وال تسبب القيلة أًملا أو أذى وقد ال حتتاج إلى‬
Reassurance ‫عالج‬
≤2 years old= observation
2-11 y/o= elective surgical repair
Adolescent=In most cases, observation is
appropriate. If the hydrocele gets very large and
uncomfortable, surgical repair is the definitive
Advice management.
Adults= conservatively with reassurance and scrotal
support once underlying pathology has been
excluded,
If there is discomfort or infection= surgery or
aspiration (referral)
Prescribing
testicular torsion, epididymitis, acute orchitis,
strangulated hernia and testicular cancer. Referral to
Referral a urologist should be made immediately if one of
these diagnoses is suspected
Investigations Mentioned above, clinical dx
Observation/
follow up
Plan/prevention
Includes Safety netting: if you noticed any
Conclusion scrotal pain or changes , urinary symptoms or
urethral discharge come to clinic

303
 Testicular Torsion Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
ilness Allow pt to explain the chief complain and Clarify what you understood
• Testicular pain
Patient came with sudden onset scrotal pain.
May came also with intermittent pain.
There is usually no relief of pain upon elevation of the scrotum (negative
Prehn’s sign).
• Scrotal edema
Analysis of
With time, the scrotum becomes more oedematous.
Chief
• Scrotal erythema
Complain
• Nausea and vomiting
Common in pediatric
• Abdominal pain
Any male child presenting with abdominal pain should always have their
testes inspected as part of a complete examination.
• Fever
• Age under 25 • Trauma
Risk Factors • bell clapper deformity • Cold weather
• Undescended testis • Intermittent scrotal pain
• Testicular appendix torsion • Varicocele
Pain located superiorly on Painless scrotal swelling (a bag of worms)
testicle; onset is more gradual, o/e: Valsalva maneuver
no nausea or vomiting • Inguinal hernia
• Epididymitis Hx of heavy lifting or previous surgery.
Pain is more gradual , located o/e: non reducible hernia , normal
DDX inferiorly and posteriorly cremasteric reflex
Painful micturition. • Renal colic
Diffuse enlargement of testicle. Flank pain
• Hyrocele o/e: normal testicular exam
pain worse at end of the day • Orchitis
o/e transillumination Signs of inflammation such as erythema,
fever, and pain may be present.

Examination
Vital signs
General Appearance : patient may appear ill or in severe pain.
Testicular: 5- high testicle.
1- Tenderness 6-horizontal lie of the affected
2- no relief of pain upon elevation of testicle.
Special the scrotum (negative Prehn’s sign). Special test
3- edema or erythema 7-absent cremasteric reflex
4-reactive hydrocele

304
 Testicular Torsion

Management
This is an emergency case , any young male with sudden
onset scrotal pain you should r/o testicular torsion by
ultrasound .
• Ultrasound:
presence of fluid and the whirlpool sign (the swirling
appearance of the spermatic cord from torsion as the
Investigation ultrasound probe scans downwards perpendicular to the
spermatic cord). You have to do doppler ultrasound to
confirm diagnosis .
• Color Doppler ultrasound :
absent or decreased blood flow in the affected testicle.
• Power doppler ultrasound:
Is more sensitive than color doppler ultrasound.
Immediate urological consultation for scrotal exploration :
Immediate detorsion should be done .
Management orchiectomy versus orchidopexy is based on the extent of
damage to testicular tissue
Analgesic to relive pain:
morphine sulfate: children: 0.1mg/kg
subcutaneously/intravenously every 4 hours when required,
maximum 10 mg/dose; adults: 10 mg
Prescribing intramuscularly/intravenously every 4 hours when required.
Ondansetron: children 1 month to 12 years of age and ≤40
kg: 0.1 mg/kg intravenously as a single dose; children >12
years of age or >40 kg: 4 mg intravenously as a single dose;
adults: 4 mg intramuscularly/intravenously as a single dose
You should rush in any case suspected to
Conclusion
be testicular torsion

305
 Sexual Hx

Introduce yourself and establish good rapport ( Name, age and job).
"I understand that talking about sexual problems can
be uncomfortable for you. However, I need to ask you few questions to be able to help you". "I
assure you that I will maintain your confidentiality all through"
Identify the Clarify the complaint (example. "What do you mean by weakness?") And
repeat it in clear, scientific terms (example. "I see, so you have difficulty
complain developing penile erection long enough to complete penetration").
- Onset, duration, and timing:
• "Have you always had this problem or is it recent?". A recent onset
suggests psychogenic etiology while a lifelong problem might be organic.
•- "Does the problem happen all the time or only sometimes?"
Generalized or situational (related to the partner or the place).
- Any relieving or aggravating factors
Describe the sexual activity:
a. Source of their sexual background, literacy: "Patients come from
different backgrounds with different sexual believes. Where did you get
yours from?"
b. Frequency: "How often do you have sexual intercourse per week?“
Hx present c. Initiation: "Who usually initiates the process, your partner or
yourself?“
illness d. Earlier experience (masturbation or previous partners).
e. "Can you please describe your sexual activity to me": explore the
patient's and partners sexual cycle:
• Desire: "Do you or your partner feel like you want to have sex?"
• Arousal: female "Do you have vaginal lubrication?" male
"Do you have penile erection that is long enough to
complete penetration?"
• Orgasm: (female "Do you reach a point of maximum
happiness or develop vaginal contractions?" male "Do you
ejaculate?"). If it does not occur with current activity ask if it occurs with
masturbation.
• Resolution.
a. Diabetes mellitus, hypertension, coronary artery disease, asthma,
arthritis, menopause.
Past Hx b. Operations, obstetric and gynecological problems.
c. Depression, sleep, mood and appetite.
d. Medications: viagra, testosterone, oral contraceptive pills.

306
 Sexual Hx
a. "How long have you been married?" "Have you been living
together'?
b. "How do you describe you intimate relation with your partner?"
c. "Do you have any children? How many?"
Psychosocial d. Occupation and job satisfaction.
e. Alcohol, smoking, extra-marital affairs, relationships before
marriage.
f. Family, financial problems.
a. Fears, peer or family pressure.
b. Explore partner's opinion about the same problem too.
c. "Do you think there is a solution?"
ICEE d. "How motivated are you to solve this problem?"
e. "Any specific treatment you have in mind?"
f. "Is your partner motivated to solve this problem with you?"
Systemic Review
Conclusion

Female sexual dysfunction:

• Desire disorders: either hypoactive sexual desire dysfunction(non-
responsive), or aversion disorder(avoidance): treatment: partners add
intimacy, perform foreplay, eliminate routine, and communicate about sex.
• Pain disorders:
-Superficial dyspareunia (with attempted penetration): cause is either
anatomical or irritation (screen for infections and do anatomical
studies)treatment: relaxation, Cognitive behavioral therapy (CBT) and
sensate focus.
-Deep dyspareunia (with thrusting, fast penile movement in the vagina):
cause is either Irritable bowel syndrome or adhesions.
• Arousal disorder: (absence of vaginal lubrication, intermediate
DDx dyspareunia) treatment: vaginal lubricants, CBT and sensate focus.
• Orgasmic disorders treatment: Fantasizing, Kegel exercises,
CBT and sensate focus.
Male's sexual dysfunction:
• Desire disorder treatment: CBT and sensate focus.
• Arousal and orgasmic disorders:
-Organic (no anatomical problems if normal morning erection).
-Premature ejaculation treatment: squeeze technique, CBT and sensate
focus.
Non-gender related:
Treat psychological ( depression, anxiety,,,) and systemic diseases( prostate
disorder, thyroid , UTI and STD, neurology, hepatic,,,) .

307
 Erectile dysfunction + Premature ejaculation
Introduce yourself and establish good rapport ( Name, age and job).
Onset (gradual or sudden) and course (static or progressing) of the
impotence.
Degree of dysfunction (chronic, occasional or situational).
Early morning and nocturnal erection (present or absent).
Degree and part of sexual cycle affected: desire, arousal, orgasm.
Is there another sexual partner or wife? and is the problem the same
with her?
Hx of present
Precipitating factors:
illness • Is the marriage stable and happy?
• Does the wife contribute to the problem?
Associated symptoms:
• Gynecomastia, loss of secondary sexual characteristics.
• Presence of visual or neurological symptoms.
• Psychosocial history: depressive symptoms.
Previous treatment for this problem.
• History of diabetes, hypertension, dyslipidemia, renal failure, hepatic
cirrhosis, neurologic disease (like multiple sclerosis), thyroid
dysfunction, hypogonadism, hyperprolactinemia.
• History of pelvic trauma, pelvic surgery, or spinal cord surgery.
Past Hx • History of psychiatric illnesses.
• History of Alcohol, smoking and intravenous drug abuse.
• Diuretics, anti hypertensive, H2 blockers and antidepressant. Ensure
compliance to diabetic medications if any to estimate adherence to
treatment and level of control.
Any new stressful event.
Home environment.
Psychosocial Emotional or financial problem.
Loss of job or loss of a relative.
Drug and alcohol history use if any.
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
Conclusion

Examination
Vital + BMI
General General (signs of hypogonadism, breast).
Thyroid
Abdomen: hepatomegaly
CNS: (motor; power-tone-reflex), sensation.
Special Genital; penile, testicular.
Rectal exam: to check prostate.
Cremasteric + bulbocavernosus reflex

308
 Erectile dysfunction + Premature ejaculation

CRAPRIOP for Management

Screen questionnaire of premature ejaculation
Clarification Questionnaire to assess impotence survey
‫هي مشكلة شائعة عند كثير من الرجال قد يكون سببها جنسي أو سبب هرموني أو سبب نفسي‬
Reassurance .‫ وأن شاء الله له عالج‬.‫وتختلف الشدة على حسب كل حالة‬
-The relation between control of diabetes mellitus and
erectile
dysfunction.
Advice
-Life-style modification: weight loss, exercise, smoking
Cessation
-vacuum pump device.
-phosphodiesterase type 5 inhibitor (like sildenafil).
- Alprostadil (intracavernous or intraurethral injection).
- Testosterone therapy for hypogonadism [side effects:
Prescribing fatigue, muscle weakness, mood changes, erythrocytosis
(follow up hematocrit) increase prostate size and elevated
Prostate Specific Antigen (PSA), may worsen heart disease,
migraine and Obstructive Sleep Apnea OSA)].
-SSRI and TCA
Surgical prosthesis.(urology )
Referral Psychiatry if needed
Rule out diabetes mellitus, check morning
testosterone level (level less than 12 nmol/L directs to
hypogonadism)
CBC,U/E, RFT, LFT, TFT, lipid profile, AbA1c, FBG, iron,
Investigations ferritin,
Urinalysis & c\s, FSH, LH, GH, DHEH, 17- hydroxylase, B-
HCG,
- US for testis.
Observation/
Arrange for follow up
follow up
Plan/prevention Discuss health maintenance and age appropriate screening
Conclusion Includes Safety netting

309
Rheumatology

310
Rheumatology
Rheumatoid arthritis
Gout/Pseudogout
Systemic lupus erythematosus SLE
Fibromyalgia

311
 Rheumatoid Arthritis Hx

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present Joint pain
illness Allow patient to explain the chief complain
Clarify what you understood

Has there been recent trauma?

Articular or non articular ?
Articular: is localized to specific joint, and both passive and active ROM
are restricted in all planes.
Non articular: originate from periarticular structures (tendon or bursa)
and only active ROM is restricted in plane of involved structure.
Inflammatory or non inflammatory ?
Characteristics of inflammation:
ü Pain.
Analysis of ü Erythema.
ü Warmth.
chief complain ü Swelling.
ü Morning Stiffness.
ü Malalignment/deformity.
Extra-Articular Manifestations
Pattern of joint involvement ?
Number of joint involvements:
• Monoarthritis is the involvement of one joint.
• Oligoarthritis is the involvement of 2-4 joints.
• Polyarthritis is the involvement of ≥5 joints.
Sequence of joint involvement
• Migratory: inflammation persists for only a few days in each joint.
• Additive: inflammation persists in involved joints as new ones
become affected.
• Intermittent: repetitive acute attacks with complete remission.
Distribution of joint involvement:
• Symmetrical or asymmetrical
• Axial or peripheral
• Large or small joints

312
Rheumatoid Arthritis Hx

• Extra-articular manifestation in RA?

Analysis of
chief
complain Associated symptoms
ü Fever, sweats or chills.
ü Dry eye / dry mouth.
ü Fatigue and weight loss.
ü Inflammatory eye disease.
ü GI symptoms
ü Urinary and URT symptoms.
ü Raw milk ingestion.
ü Genital pain/lesions.
ü Skin rash.
ü Travel and tick exposure.
ü Mucocutaneous ulcer.
Differential diagnosis:

Red Flags:
Gradual onset over >2 weeks → mass lesion
Forehead not involved→ Central Nervous System cause (supranuclear lesion)
Bilateral involvement autoimmune Polyneuropathy, Lyme Disease 4.
Hearing Loss and Vestibular Symptoms or Ataxia → Acoustic Neuroma

313
Rheumatoid Arthritis Hx

Medical:
• History of any similar episodes.
• Rheumatological disease.
• Diabetes Mellitus.
• Psoriasis.
• IBD
• Hematological disease.
Surgical:
• Previous surgery in a specific joint.
Past Hx Drug :
• Thiazide and loop diuretics.
• Drug-induced lupus:
• Phenytoin
• Carbamazepine
• Hydralazine
• Methyldopa
• Chlorpromazine
• Isoniazid
• ACE inhibitors
• Hormone replacement therapy or OCP.
Similar problem in the family.
Family Hx Rheumatological disease in the family.
Sexual history
Travel history
Psychosocial Tick bites
Alcohol/Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

314
Rheumatoid Arthritis Ex

Vital signs
General Appearance
Look

Special Feel Move

FBE, ESR
• U&Es
• LFTs
• Anti-CCP, ANA, CRP
Investigations • XR affected joints
• Urinalysis
• screening for latent tuberculosis (TB), hepatitis B virus,
and hepatitis C

315
 Rheumatoid Arthritis

CRAPRIOP for Management

Rheumatoid arthritis is the most commonly diagnosed systemic
inflammatory arthritis, Women, smokers, and those with a family history
of the disease are most often affected. Rheumatoid arthritis may impact
organs other than the joints, including lungs, skin, and eyes. Rapid
Clarification diagnosis of rheumatoid arthritis allows for earlier treatment with
disease-modifying antirheumatic drugs, which is associated with better
outcomes. The goal of therapy is to initiate early medical treatment to
achieve disease remission or the lowest disease activity possible.
Rapid diagnosis of rheumatoid arthritis allows for earlier treatment with
disease-modifying antirheumatic drugs, which is associated with better
Reassurance outcomes. The goal of therapy is to initiate early medical treatment to
achieve disease remission or the lowest disease activity possible.
Exercise includes:
• Stretching
• Low-impact aerobic exercise.
Advice • Strengthening.
Healthy diet
Quit Smoking
Physical and Occupational Therapy
Methotrexate as the first-line treatment
Up to 25 mg orally or subcutaneously every week

Disease-modifying antirheumatic drugs (DMARDs) can be considered

for first-line treatment,
Prescribing including leflunomide (Arava),
hydroxychloroquine (Plaquenil),
and sulfasalazine (Azulfidine).
If disease activity is high, glucocorticoids may also be added
Typically, 5 to 10 mg of prednisone daily for four to six weeks
Arrange Referral to subspecialty clinic as needed.
a. Fevers that are not diagnosed
b. Patients with normal laboratory studies, but local or generalized joint
pain and/or swelling
Referral c. Abnormal laboratory findings such as elevated sedimentation rates,
anti-nuclear antibodies, rheumatoid factor)
d. Unexplained musculoskeletal pain
e. Unexplained constellation of symptoms
Investigations Mentioned above

Observation
/prevention
Conclusion Includes Safety netting

316
Rheumatoid Arthritis

Differential diagnosis

317
 Gout & pseudogout Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness Allow pt to explain the chief complain and Clarify what you understood
Course, onset and duration
SOCRATES
S: metatarsal-phalangeal joint of the great toe in 90% of cases.
Others: instep, ankle, wrist, finger joints, and knee. Monoarticular In early
gout. The most common sites of pseudogout arthritis are large joints, such as
the knee, wrist, elbow, or ankle. polyarticular acute flares are not rare.
O: Gout, abruptly, reach maximum intensity within 8-12 hours. pseudogout
onset can resemble acute gout or be more insidious and may occur over
several days.
C: the first attacks resolve spontaneously in less than 2 weeks. A history of
intermittent inflammatory arthritis, in which the joints return to normal
between attacks, is typical of crystalline disorders and is characteristic of
gouty arthritis early in its course.
The pattern of symptoms in untreated gout changes over time. The attacks
can become more polyarticular. More proximal and upper-extremity joints
become involved. Attacks tend to occur more frequently and last longer.
Indeed, chronic polyarticular arthritis that began as an intermittent arthritis
should prompt consideration of a crystalline disorder in the differential
diagnosis.
R: usually no radiation
Analysis of Exacerbating factors: any movement or touch even a bed sheet on the
chief swollen joint is uncomfortable.
complain T: gout pain tends to act up most often in the middle of the night.
S: excruciating
Associated symptoms:
swelling, redness, hotness , and tenderness
Differential Diagnosis:
Bacterial cellulitis: Erythema over the surface of a joint can be confused for a
gout flare-up; however, the joint is typically nontender without the presence
of effusion.
Basic calcium phosphate deposition disease: Milwaukee shoulder syndrome
intra- (rapidly progressing crystal arthropathy involving the shoulder and
articular deposition of hydroxyapatite crystals)
Calcium pyrophosphate dihydrate deposition disease (pseudogout)
Osteoarthritis: Gradual typical onset, commonly in the hand, knee, hip, or
first metatarsophalangeal joint.
Psoriatic arthritis: pruritus, rash , dystrophic nails, Conjunctivitis or
blepharitis.
Reactive arthritis: Urethritis, conjunctivitis, diarrhea, and rash.
Rheumatoid arthritis: Slow onset with symmetric joint involvement,
commonly in hands. Ask about malaise, weakness, stiffness that improve
with movement, eye redness and pain ( Keratoconjunctivitis ), subcutaneous
nodules, dyspepsia (interstitial fibrosis).

318
Gout & pseudogout Hx
Sarcoidosis: fever, anorexia, dyspnea on exertion, cough, chest pain,
and hemoptysis. erythema nodosum, lower extremity panniculitis.
Eye pain and redness (Anterior or posterior granulomatous uveitis)
Septic arthritis: Ask about associated fever.
Risk Factors of Gout
Cardiovascular disease
Diabetes mellitus
Diuretic use (loop: furosemide, bumetanide, and torsemide) and
thiazide
Elevated triglyceride and cholesterol levels
Hyperuricemia
Menopause
Analysis of Obesity
Renal disease
chief Male sex (incidence 2 to 6 times higher than in females)
complain Alcohol consumption
Diet rich in meat
Diet rich in seafood
Fructose-rich food and drink consumption
Pseudo-gout risk factors:
Hyperparathyroidism
Hemochromatosis
Rheumatoid arthritis
Hypomagnesemia
Osteoporosis
Thiazide diuretics
Loop diuretics
Proton pump inhibitors
Medical: Renal disease, Diabetes mellitus, DLP, Hyperparathyroidism,
Hemochromatosis, RA, OA
Past Hx Surgical history
Allergy
Medication: Diuretics, PPIs
Family Hx Family of chronic diseases
Marital status
Smoking: type and frequency
Psychosocial Alcohol consumption
Screening: depression and anxiety
Ideas: What do you think you might have?
Concern: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life ? How?
Systemic review
conclusion

319
Gout & pseudogout Ex
Vital signs:
Temperature: if febrile consider septic arthritis
General Appearance
BMI: obesity is a risk factor for gout
Joint examination:
Involved joints have all the signs of inflammation: swelling, warmth, erythema,
and tenderness. loss of range of motion
All joints must be examined to determine whether the patient’s arthritis is
monoarticular or polyarticular.
Posterior interosseous nerve syndrome is a rare compression neuropathy that
Special manifests as inability to extend the fingers actively. The syndrome has been
reported in a patient with elbow swelling from an attack of pseudogout.
Skin examination:
Tophi: classically located along the helix of the ear, but they can be found in
multiple locations, including the fingers, the toes, the prepatellar bursa, and
along the olecranon, where they can resemble rheumatoid nodules.
Points to consider:
-Diagnosis of gout is made clinically unless a septic joint is suspected based on
acute onset of a hot, painful, red, tender, swollen joint with systemic
symptoms such as fever or elevated white blood cell count.
-Synovial fluid or tophus analysis is recommended only when the diagnosis is
uncertain (i.e., intermediate risk on acute gout diagnosis tool) or a septic joint
is suspected.
-Serum uric acid levels are usually elevated in people with gout; however, they
may be lower during an acute episode and therefore should not be measured
in this circumstance
CBC: high WBC
KFT: to decide about type of medication
Investigation

High ESR and CRP

Lipid profile
Blood glucose
Synovial Fluid Analysis: Finding negatively birefringent urate crystals, needle-shaped
Pseudogout positively birefringent crystals (CPP) , rod-shaped with blunt ends and
are positively birefringent.
In both: synovial fluid is inflammatory, with white blood cell counts in joint fluid that
usually range between 10,000 to
100,000 with neutrophil predominance
Tests specific for pseudo gout:
Serum magnesium
Serum Calcium
Iron levels
Thyroid function tests.
Radiography:
Plain radiographs may show findings consistent with gout, but these findings are not
diagnostic.
Findings: Erosions with overhanging edges and sclerotic borders( punched-out
borders)

320
 Gout & pseudogout
CRAPRIOP for Management
‫ سبب زيادتها‬. ‫النقرس هو التهاب في املفصل بسبب تراكم جزيئات اليورات الناجتة من حمض اليوريك‬
‫في اجلسم يعود ألسباب منها ارتفاع الضغط و الكوليسترول و السكري و السمنة و امراض الكلى و‬
Clarification ‫نظام حياة غير صحي مثل شرب الكحوليات و االكثار من اكل اللحوم ومأكوالت البحر و العصائر و‬
‫ هو التهاب مؤقت ال يؤثر على املفصل في املرات االولى و مع اتباع نظام حياة صحي و‬.‫قلة احلركة‬
.‫االمتناع عن املسببات في النسبة االكبر من الناس ال يتكرر االلتهاب‬
‫ بإذن الله االعراض ستتحسن مع استخدام الدواء في اول‬.‫االلتهاب قابل للعالج و ال داعي للخوف‬
Reassurance .‫يومني و خالل اسبوع إلى اسبوعني سينتهي االلتهاب‬
Low-fat, low-purine diet (high purine foods include Alcoholic beverages (all
types) , Some fish, seafood and shellfish, including anchovies, sardines,
herring, mussels, codfish, scallops, trout and haddock. Some meats, such as
bacon, turkey, veal, venison and organ meats like liver), weight loss if
Advice overweight; increased exercise; and avoidance of soft drinks and foods
containing fructose. Consumption of skim milk and low-fat yogurt,
vegetables, soybeans, vegetable sources of protein, and cherries is
recommended.
Acute gout
1- NSAID is first-line unless use is contraindicated (gastric ulcer, GI bleeding,
abnormal LFT, renal impairment):
naproxen (500 mg BID) or ibuprofen (400-800 mg TID) or diclofenac
potassium (50 mg TID) indomethacin (25-50 mg three times daily) for 10-14
days. PPIs should be considered for all pts who are taking NSAIDs
COX-2 (celecoxib 100-200 mg BID) maybe safer in pt with GI bleeding or
comorbidities
2- Oral prednisolone 30 mg once daily for 5 days.
Prescribing 3- colchicine , 1.2 mg orally followed by 0.6 mg one hour later.
Continue 0.6 mg daily or BID as tolerated for two to three days after
complete resolution of the gout flare.
The most common adverse effects of colchicine, diarrhea and abdominal
cramping.
Acute Pseudo-gout
One or two joints:
Intra-articular glucocorticoid injection
More than two joints:
Systemic anti-inflammatory drugs: similar options of gout
• Acute gout attack that does not respond to NSAIDs within 2 days or to
colchicine within 1 day
Referral • Refractory hyperuricemia.
• Septic arthritis or for any patient in whom a septic arthritis cannot be
ruled out.
Investigations Mentioned above
Follow-up visit in 2-4 weeks to evaluate or therapy to lower serum uric acid
levels.
If uric acid–lowering therapy is begun, patients should be seen within 2
Observation/ weeks to ensure that no untoward toxicity has developed and then every 1-2
follow up months while medication dosages are adjusted to achieve the target uric acid
level of 5-6 mg/dL. Once this level is achieved and maintained, patients can
be seen every 6-12 months and their serum uric acid monitored to help
assess efficacy and adherence.
321
 Gout & pseudogout
For gout, Indications for urate lowering therapy:
1- At least 2 flare ups per year
2- Chronic gouty arthritis
3- Chronic kidney disease
4- Joint damage
5- Tophus
6- Urolithiasis
• Allopurinol: is the drug of choice for patients choosing
urate-lowering therapy. The dosage of allopurinol will vary
with the severity of disease, with a typical initial dosage of
100 mg orally once per day. The daily dosage should be
titrated gradually (100-mg increments each week) to
avoid precipitating a flare-up. Dosages of more than 300
mg per day are given in divided doses after meals, with a
maximum of 800 mg per day.
• Febuxostat: 40-80 mg
Plan/ • Uricosuric drugs: For Patients with relative renal
underexcretion of uric acid
Prevention § Probenecid is started at a dose of 250 mg twice daily
§ Benzbromarone, 100 mg/day.
§ Sulfinpyrazone, started at a dose of 50 mg twice daily,
with increments over several weeks to 100 to 200 mg
three or four times daily as needed.
§ Lesinurad, is taken in a single dose of 200 mg once daily
always combined with an XOI, either allopurinol or
febuxostat.
Duration of therapy: usually indefinite.
Prophylaxis during initiation of urate-lowering therapy:
Colchicine, or a nonsteroidal anti-inflammatory drug
The 2020 American College of Rheumatology (ACR) guidelines
support the use of colchicine prophylaxis for at least three to
six months.
Prophylaxis for pseudogout:
Indications: three or more attacks annually.
Use colchicine (0.6 mg twice daily)
Safety netting:
Instruct patient to go ER if:
Conclusion • No improvement within 2 days from start of treatment
• Persistent or developed fever
• If Symptoms worsen
322
Gout & pseudogout

323
 Systemic lupus erythematosus Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness
Clarify what you understood
Course, onset and duration
SOCRATES for pain
Associated symptoms (DDx):
Skin manifestation:
• Malar- butterfly rash (sparing nasolabial fold)
• Photosensitive rash
• Discoid lupus (keep scaring )
• Oral ulcers, non-scaring alopecia
Constitutional sx : Fatigue, weight loss, fever, arthralgia
Musculoskeletal : arthralgia, myalgia, arthritis (symmetrical or asymmetrical )
Analysis of CNS manifestation : Seizers , psychosis
chief Renal : Oedema , proteinuria and haematuria
complain Cardiopulmonary : chest pain and SOB
Other as Raynaud's phenomenon
Strong Risk Factors:
• Female ( child-bearing age)
• African descent in Europe and US
• Drugs as (procainamide, hydralazine, minocycline, penicillamine,
terbinafine, sulfasalazine, isoniazid, phenytoin, and carbamazepine)
Weak Risk Factors:
• Sun exposure
• Family history
• Tobacco smoking
Medical :
• Autoimmune diseases as (Dm, hypothyroidism , alopecia ,vitiligo ).
• Antiphospholipid syndrome ( recurrent miscarriage , Arterial and
microvascular thrombosis and venous thromboembolism )
• Fibromyalgia
Past Hx • HTN
• Dyslipidemia
Surgical
Allergy
Medication: specially drugs induced lupus that mentioned above
Family Hx
Psychosocial Marital status, Smoking: type and frequency
Hx Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
conclusion
324
 Systemic lupus erythematosus Ex

Vital signs
General Appearance
• Mucocutaneous EX: ( looking for skin rash, as
malar and discoid), Oral and nasal ulcers
• Neurologic EX
• Cardiac and Respiratory Ex
Special • Musculoskeletal EX
• Rheumatology EX
• Ophthalmology EX (keratoconjunctivitis,
episcleritis) Fundoscopy for retina ( cotton wool
exudate)
• CBC with differential (anaemia, leukopenia,
thrombocytopenia; pancytopenia)
• Activated partial thromboplastin time(
prolonged in patients with antiphospholipid
antibodies)
• Urea and electrolytes(elevated urea and
creatinine)
• ESR and C-reactive protein (elevated)
• Antinuclear antibodies(ANA) (positive)
Investigations
• Anti-dsDNA (double-stranded) (positive)
• Anti-Smith (positive)
• Antiphospholipid antibodies: Anti-cardiolipin
antibody, Anti-beta2 glycoprotein 1, Lupus
Anticoagulant (positive)
• Urinalysis (haematuria, casts (red cell, granular,
tubular, or mixed) or proteinuria)
• Chest x-ray (pleural effusion, infiltrates,
cardiomegaly)
• ECG (exclude other causes of chest pain)

325
 Systemic lupus erythematosus SLE
CRAPRIOP for Management
،‫ اجللد‬:‫مرض الذئبة احلمراء هو مرض مناعي ذاتي مزمن ميكن أن يؤثر على اي جزء من اجلسم )مثل‬
Clarification .‫ كما أنها غير معدية‬.(‫ واألعضاء‬،‫املفاصل‬
‫احلمدلله ان التدخالت الطبية وتغييرات منط احلياة ميكن أن تساعد في السيطرة على املرض‬
Reassurance ‫ونحن هنا ملساعدتك متى ماحتجت ستجدنا ان شالله‬
.‫احلرص على تناول غذاء صحي ومتوازن‬ •
.‫أخذ قسط كاف من الراحة‬ •
.‫ممارسة النشاط البدني بانتظام‬ •
Advice .‫احلد من اإلجهاد ومحاولة استخدام تقنيات االسترخاء‬ •
.‫ وارتداء قبعة للحماية من الشمس‬،‫استخدم واق من شمس‬ •
.‫جتنب اجللوس في ضوء الشمس املباشر‬ •
.‫التوقف عن التدخني‬ •
For all patients with SLE with any degree and type of disease activity,
recommend treatment Hydroxychloroquine is available as a 200 mg
Prescribing tablet (up to date), consider NSAIDS, if still inadequate (severe) give
prednisolone 5-60 mg OD.
for Rheumatologist , Dermatologist, Nephrologist, Cardiologist
Referral ,Neurologist
Psychologist Or ER depend on HPI
Investigations Mentioned above
Observation/ • Patients with mild SLE that does not involve major organ
systems can be monitored by primary care physicians.
follow up • Every 3-6 months
• screening for Osteoporosis, dyslipidemia and DM for patient
receive steroids
Plan/prevention • Annual eye examinations for patients receiving
hydroxychloroquine
• According to patient age sex and risk factors
Includes Safety netting :
Conclusion ‫ ارتفاع‬، ‫ فقدان الوزن‬,‫ ألم دائم أو إرهاق‬، ‫جتب مراجعة الطبيب في حال ظهرطفح جلدي غير مبرر له‬
(‫ ضعف الدورة الدموية في أصابع اليدين والقدمني )رينود‬،‫تورم الغدد‬, ‫في درجة احلرارة‬
Diagnosis of SLE After excluding alternative diagnoses, we diagnose SLE in the patient who fulfills
the 1997 ACR criteria, the 2012 SLICC criteria or the 2019 EULAR/ACR criteria. (Up to date )
Clinical manifestations and diagnosis of systemic lupus erythematosus in adults - UpToDate

326
 Fibromyalgia Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question): Widespread body pain for longer than 3 months +
fatigue and sleep disturbance
present Allow pt to explain the chief complain: Pain may be myalgia, arthralgia, or both and
illness Clarify what you understood
Course, onset (chronic) and duration (>3 months)
SOCRATES for pain
Site: at least six sites include the head, each arm, the chest, the abdomen, each leg,
the upper back and spine, and the lower back and spine (including the buttocks
Aggravating factors: minor activities aggravate the pain and fatigue, although
prolonged inactivity also heightens symptoms)
Associated symptoms (DDx): Fatigue(90%) , sleep problems, memory problems, and
stiffness, numbness/tingling sensations, headache( migraine and muscular (tension)
types) , anxiety
Chronic fatigue syndrome: fatigue > 6 months, Not alleviated by sleep, rest, or activity
restriction, flu-like symptoms , Attention or concentration difficulties, Sleep disruption,
Widespread muscular and joint pain
Polymyalgia rheumatic: >55 yo, hip and shoulder girdle pain with significant weakness
Analysis of and stiffness. Sleeping disorders: difficulty initiating sleep or maintained sleep ,
unrefreshing sleep, sleep hygiene
chief rheumatoid arthritis: symmetrical small joint pain ,joint swelling , stiffness > 1 h, eye
complain pain or redness , SOB
SLE: butterfly rash, photosensitive rash, joint pain , SOB, chest pain, edema , alopecia
Osteoarthritis: old age, joint pain and swelling increase with activity , decrease with
rest , stiffness < 30 min
Myositis: Weakness and muscle fatigue Hypothyroidism: cold intolerance, constipation,
poor concentration, menstrual irregularities
Depression: loss of interest, bad mood
Risk Factors: female, all are triggers
Hx of significant infection (e.g., [EBV] infection, Lyme disease)
Hx of Injury, physical trauma such as motor vehicle collision
Hx of Emotional trauma or war deployment
Hx Major surgical procedures
Hx of Peripheral pain syndrome such as osteoarthritis, rheumatoid arthritis
Red Flags: fever , night sweating and weight loss
Medical: co-exist ( RA, OA,IBS ,depression, anxiety, interstitial cystitis )
Surgical, Allergy
Past Hx Medication: sedative-hypnotics, antidepressants, muscle relaxants, opioids,
antihypertensive and antihistamines
Family Hx 1st relative degree of fibromyalgia
Marital status, New stress in life(work , financial)
Diet(poor diet or vegetarian (anemia)and exercise
Psychosocial
Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

327
 Fibromyalgia Ex
Vital signs + BMI
General Appearance : pallor (anemia )
Musculoskeletal Ex: diffuse tenderness to palpation
(Fig 1), no evidence for a systemic disease (e.g.,
joint inflammation or muscle weakness) causing
the widespread pain (R/o RA or OA)
Special patients are not as tender over joints, and FM
does not cause swelling or erythema of soft tissue
or joints.
Thyroid Ex
Routine laboratory testing is normal. But we need
to R/o other DDX
CBC and Iron study, vit-b12 (R/O anemia as a cause
for fatigue or iron deficiency as a cause for muscle
pain and fatigue)
TFT (hypothyroidism)
Investigations ESR and CRP(↑in inflammatory cause of muscular
pain or fatigue e.g.: polymyalgia rheumatica, SLE )
Vit- D levels (vit.D deficncey)
Creatine kinase (↑ myositis )
Rheumatoid factor , anti-CCP antibody (RA)
Antinuclear antibody (SLE) may be obtained if
patients have symptoms of SLE

CRAPRIOP for Management

‫األلم الليفي العضلي هو اضطراب مزمن يسبب أًملا واسع املدى في البنية‬
‫العضلية الهيكلية ويصحبه الشعور باإلرهاق واضطرابات النوم والذاكرة‬
Clarification ‫ تبدأ األعراض غالًبا بعد وقوع حادث كاإلصابة اجلسدية‬.‫واحلالة املزاجية‬
‫أو اجلراحة أو العدوى أو اإلجهاد النفسي الشديد واحيانا يكون ماله محفز‬
‫وهو مرض شائع في النساء‬
‫احب اطمنك ان هذا االضطراب مو شي خطير ولكن ماله عالج نهائي‬
Reassurance ‫وبالرغم من عدم وجود عالج له اال انو توجد مجموعة متنوعة من األدوية‬
..‫تساعد في السيطرة على أعراضه‬

328
 Fibromyalgia

: ‫ومن األمور املفيدة‬

• Diet (eg, promote good nutrition, vitamin
supplementation, bone health, weight loss)
• Stress management
• Aerobic exercise (eg, low-impact aerobics,
Advice walking, water aerobics, stationary bicycle)
• Sleep therapy (eg, education/instruction on
sleep hygiene)
• Psychologic/behavioral therapy (eg, cognitive-
behavioral, operant-behavioral)
1- TCAs (e.g., amitriptyline, cyclobenzaprine)
Benefits do not seem to persist beyond 8 weeks, If
no benefit is seen after a trial of 6 weeks, the
medication can be stopped. If the medication was
initially effective but then loses efficacy, it can be
temporarily discontinued and then restarted.(BMJ)
2- SNRIs (e.g., duloxetine, milnacipran)
Prescribing Good first choice for patients with comorbid
depression or fatigue)
3- Gabapentinoids (e.g., pregabalin, gabapentin)
Better first choice for a patient with significant
comorbid sleep issues.(BMJ)

NSAIDs(naproxen) and opioids are highly effective

for acute pain(BMJ)
Referral to psychologist for CBT
Investigations Mentioned above
Observation/
follow up after 6-8 weeks
follow up
Plan/prevention
Includes Safety netting if you feel no improvement
Conclusion or the pain increase, comeback to the clinic

329
 Fibromyalgia

Diagnostic evaluation
• Symptoms of widespread pain, occurring both
1990 ACR above and below the waist and affecting both
classification the right and left sides of the body
criteria • Physical findings of at least 11 of 18 defined
tender points (Fig 1)
• Widespread pain index (WPI) >7 and symptom
2010 ACR severity (SS) scale >5 or WPI 3 to 6 and SS scale
>9
preliminary
• Symptoms have been present for at least three
diagnostic months
criteria • There is no other disorder that would explain
the patient's symptoms
• MSP defined as 6 or more pain sites from a
total of 9 possible sites (see Fig 2)
• Moderate to severe sleep problems OR fatigue
APTT criteria • MSP plus fatigue or sleep problems must have
FM Core been present for at least 3 Months
Diagnostic Note: The presence of another pain disorder or
Criteria related symptoms does not rule out a diagnosis of
FM. However, a clinical assessment is
recommended to evaluate for any condition that
could fully account for the patient's symptoms or
contribute to the severity of the symptoms.

330
Fibromyalgia

Fig. 1

Fig. 2

331
Hematology &
vascular

332
Hematology & Vascular
Anemia
• Iron deficiency anemia
• Sickle cell anemia
Breaking bad news for leukemia
Venous thromboembolism
• Pulmonary Embolism
• Deep Venous Thrombosis

333
 Anemia Hx

Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
-May be presented as easy fatigue, headache, bleeding, exertional
dyspnea, pica - Or maybe noticed as pallor in examination - or
discovered in routine investigation.
Analysis of -Course, onset and duration
-Risk Factors &Red Flags :
chief Nutrition: Is patient vegetarian? On diet? Eating disorders or food
complain allergy? Had bariatric surgery? full nutritional history or food diary for 3
days .
Blood loss: per orifices e.g. Vaginal/rectal/ epistaxis/hematuria... ±
black stool ± NSAIDs use ± prolonged dyspepsia -
Medical:
- Malabsorption.
- Liver disease, since it may cause coagulation abnormalities.
- Systemic disease (i.e., anemia of chronic illness), e.g., rheumatoid
arthritis, renal failure.
Surgical:
- Gastric surgery: may cause anemia due to malabsorption.
Past Hx - Venesection in polycythemia patients.
Allergy
Medication: (Iron supplement , vit B12 supplement)
Blood transfusion
Menstrual history:
§ Heavy menstrual loss. § Duration.
§ Occurrence of clots.
§ Number of sanitary towel (to assess the severity).
Family Hx Family Hx of hemoglobinopathies, cancer colon or IBD
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

334
 Anemia Ex
-Vital signs
-Appearance : look well or unwell ,Pallor ± jaundice? ± angular
General stomatitis/glossitis ±
spooning of nails
Cardiac Ex , Abdominal Ex , Rectal Ex , LNs.
Special Special test
CBC: anemia is diagnosed when HBG < 13gm/dl in men,
<12 in women, in pregnant <11.0 g/dl in the 1st and 3rd trimesters
and <10.5 g/dl in the 2nd trimester , < 10.5 in children
MCV < 78 microcytic, > 95 macrocytic, otherwise normocytic
Reticulocyte count : will be low in IDA and high in hemolytic anemia
Serum iron : Decreased in IDA
Total iron-binding capacity : increased in IDA
serum ferritin: low (<12 nanograms/mL is generally diagnostic of
Investigations IDA, but thresholds vary between guidelines).
coeliac serology: if positive, coeliac disease is likely
Urinalysis: blood in the urine may indicate blood loss is from the
renal tract
Helicobacter pylori testing: blood in the urine may indicate blood
loss is from the renal tract
Hemoglobin electrophoresis : in cases of haemoglobinopathy

CRAPRIOP for Management

Iron deficiency anemia
‫فقر الدم هي حالة ال يحتوي فيها الدم على ما يكفي من كرات الدم احلمراء السليمة‬
‫املعروف‬- ‫ قد يجعلك فقر الدم‬.‫حلمل كمية األكسجني الكافية إلى أنسجة اجلسم‬
Clarification .‫ حتس باإلرهاق والوهن‬-‫أيضًا بانخفاض مستوى الهيموغلوبني‬
‫ فقد يكون فقر الدم مؤقتًا أو‬.‫ ولكل منها سببه اخلاص‬،‫هناك عدة أنواع من فقر الدم‬
.‫ وقد يتدّرج من البسيط إلى احلاد‬،‫طويل األجل‬
‫ال تقلق وتشيل هم كثير من الناس لديهم فقر دم ومع االلتزام بالعالج والتقليل من‬
Reassurance ‫عوامل اخلطورة راح تتحسن وتشفى بإذن الله‬
Food rich in iron as meat, beans, lentils, dark green leafy
Advice vegetables, dried fruits and iron-fortified cereals
Adult: 120 mg elemental iron/day .
Child: 3mg/kg (up to 60mg/d)
• 3-4 months after correction of HGB to replenish
Prescribing stores. Reserve parental iron to resistant patients, who do
not tolerate oral, or have malabsorption, renal failure or IBD
• Absorption is enhanced by ascorbic acid (vitamin C) and meat,
and inhibited by calcium, fiber, tea, coffee, and wine

335
Anemia IDA
• Intravenous iron should be considered as a first-line treatment
for selected patients with inflammatory bowel disease, including
those with active disease or previous intolerance of oral iron.
• Intravenous iron may be considered in pregnancy during the
second or third trimesters if benefits outweigh the risks to
mother and fetus, but it should be avoided in the first trimester.
Prescribing • Iron dextran is only available as a low-molecular-weight
preparation.
• Adverse effects include anaphylaxis, arthralgias, and myalgias.
• Iron sucrose has a similar safety profile to low-molecular-weight
iron dextran. It appears to be safe during pregnancy, and has
been shown to be more efficacious than oral iron.
Resistant ± HGB<7 gm/dl ± suspect hemolysis or malignancy
Referral ± man or postmenopausal female with no obvious cause
Investigations Mentioned above
Repeat CBC after 1 month should have at least 1 gm
increase in HGB to confirm iron deficiency anemia, if not:
Observation/ 1. Check adherence
follow up 2. Re-evaluate: - Family history of hemoglobinopathies e.g.
thalassemia, sickle cell, elliptocytosis, ...
- Iron studies and blood film.
-The American Academy of Pediatrics recommends iron
supplementation between 1 and 12 completed months of age for
infants who are born <37 weeks gestation and who are breastfed.
Plan/prevention -Term infants who are exclusively breastfed should receive iron
supplementation from 4 months of age until appropriate iron-
containing foods have been introduced.
Conclusion Includes Safety netting

336
Anemia IDA

337
Anemia IDA
Treatment of Iron Deficiency Anemia

338
Anemia SCA
Sickle cell anemia
‫فقر الدم املنجلي هو اضطراب ينتمي إلى مجموعة من االضطرابات تُعرف باسم‬
‫ وتؤثر هذه احلالة في شكل خاليا الدم احلمراء التي حتمل‬.‫مرض اخلاليا املنجلية‬
‫ عادًة ما تكون خاليا الدم احلمراء مستديرة‬.‫األكسجني إلى كل أجزاء اجلسم‬
‫ ولكن في حال اإلصابة‬.‫ األمر الذي يسهل حركتها في األوعية الدموية‬،‫ومرنة‬
Clarification ‫ وتصبح‬.‫بفقر خاليا الدم املنجلية تتخذ خاليا الدم احلمراء شكل منجل أو هالل‬
‫ لكي‬.‫ ما قد يبطئ تدفق الدم أو مينعه‬،‫هذه اخلاليا املنجلية صلبة ولزجة أيضًا‬
‫ يجب أن حتمل األم واألب معًا نسخة واحدة من جني اخلاليا‬،‫يتأثر الطفل‬
‫ وميررا نسختي الشكل املعَّدل‬،‫ الذي ُيعرف أيضًا بسمة اخلاليا املنجلية‬،‫املنجلية‬
‫إلى الطفل‬
‫فقر الدم املنجلي هو مرض وراثي مزمن والى االن لم يتم اكتشاف عالج شفائي‬
Reassurance ‫كامل لكن هدفنا بالعالج واملتابعة هو تقليل املضاعفات واالالم والتحسني من‬
‫جودة احلياة‬
-Avoid precipitating factors for vaso-occlusive crisis
Advice such as cold temp , infection , hypoxia
-Take immunization and antibiotic prophylaxis.
Prescribing -in the next page
Every patient with SCA should be referred for
Referral hematology
Investigations Mentioned above
-Patients require continuous monitoring for
complications of sickle cell disease. The frequency at
which the physician will see the patient is dependent
on the frequency and severity of the patient's
complications.
Observation/ -Patients treated with hydroxycarbamide require full
follow up blood count with differential and reticulocyte count
monitored on a monthly basis.
-Patients require annual retinal examinations to
screen for proliferative retinopathy, and annual
screenings for the presence of increased urinary
albumin excretion
-The American College of Obstetricians and
Gynecologists recommends universal
Plan/prevention haemoglobinopathy testing for those planning
pregnancy
Conclusion Includes Safety netting

339
 Anemia SCA
Management SCA
• Hydration and keeping a good room temperature is important. Pain control with
the appropriate analgesia like NSAIDs, paracetamol, or opioids when needed.
Treating sickle cell pain with long-acting opioids decreases hospital admissions
and emergency room use; oral opioids are preferred to IV opioids.
• For pain crises, strong opioids should be offered within 30 minutes of presentation
for patients with a severe acute painful sickle cell episode. If pain continues with
the same severity after 30 minutes, another bolus of strong opioid can be given.
Consider patient-controlled analgesia if repeated doses of a strong opioid are
needed over two hours (NICE guideline). Laxatives, antiemetics, and antipruritic
can be used as needed. Oral controlled-release morphine provides a safe and
effective alternative to continuous IV morphine. Very close monitoring for side
effects is very important. Patients will need hourly monitoring initially for the first
6 hours.
• Hydroxyurea appears to be safe and effective for patients with severe Hb-SS
disease. It is indicated for patients who have 3 or more painful episodes per year
and who have sickle cell complications. Long-term folic acid supplement is
indicated. Patients with sickle disease need psychological support and may benefit
from cognitive behavioral therapy.
• Blood transfusions are used to treat and prevent complications of SCD, including
preparation for surgery; treatment of symptomatic anemia, acute stroke,
multiorgan failure, and acute chest syndrome; and prevention of stroke, acute
chest syndrome, and recurrent priapism.
• Sequestration crisis is managed as an emergency with blood transfusion. Splenectomy
at an appropriate point in time may be performed to reduce the risk of recurrence and
mortality.
• Aplastic crisis can happen due to Parvovirus B19, or other infection. There is a
severe drop in hemoglobin and reticulocyte count. Blood transfusion is needed
until spontaneous recovery of bone marrow which occurs in 2-14 days
(reappearance of reticulocyte in the peripheral smear).
• Acute chest syndrome (ACS) is the second cause of hospitalization after a pain
crisis in SCD patients. ACS is managed as an emergency, by giving the appropriate
analgesia for a pain crisis. Keeping O2 saturation above 92% using the appropriate
oxygenation method and incentive spirometry. Use of a bronchodilator and a short
course of corticosteroid for those who wheeze or have asthma. Broad spectrum
antibiotic coverage is recommended (third generation cephalosporin and a
macrolide for atypical organisms). Blood transfusion is recommended in severe
cases of ACS and in patients who continue to have a drop in their hemoglobin
despite adequate treatment.
• immunizations recommended: Strep. Pneumoniae, Neisseria meningitidis, H
influenza B, Hepatitis B, and viral influenza.
• Prophylaxis: Children between 3 months to 3 years require Penicillin V 125 mg
BID and children between ages 3–5 years require 250 mg bid as a prophylaxis.
After the age of 5 prophylaxis is controversial.

340
Anemia SCA
Acute Pain Management in Sickle Cell Disease

341
Anemia SCA

342
 Breaking bad news
Child with leukemia

Introduce yourself and establish good rapport ( Name, age and job).
a. close the door, ensure no interruptions (call the nurse and
ask her not to allow any interruptions and put your phone on
silent mode) and proper setting (tissue box around with
Setting some water)
[Link] if any family member are with the attending parent:
"Are you here alone"
Check perception using open-ended questions:
"Mr./Mrs. X, how can I help you today"
"Do you know why you are here today"
"Do you know what tests were done last time for your child
and why they were done"
Perception "Do you have any idea what the result might be"
"Some people would like to have someone (family or friend)
with them when they take the result. Is there someone
attending the clinic with you or you would rather to be alone"

Invite the patient to share in the discussion:

a."Before we review the result, are you the sort of person
who likes to know about all results related details or just in
brief"
b."Mr./Mrs. X, I am afraid I have bad news"…Pause… Hand
the patient some tissue papers
c."Mr./Mrs. X, I am sorry to tell you that your child has a
blood picture that suggests blood cancer (Leukemia)"
[Link] feelings expression: "I am sorry I had to give
you such a bad news. I wish things were different. It must be
Invitation difficult to hear; how do you feel about it"
"I understand that it can be difficult to take the news. Would
you like to express yourself" (Rotte & Lopez, 2012)
e. "It is okay, take your time. I am here for you"
f." would you like to have some rest in the treatment room
before we proceed"
g. Remember to facilitate verbal and non-verbal cues
[Link] to listen attentively and ask several times
about extent of understanding"

343
Breaking bad news
Check the knowledge and sharing
[Link] how much parent already knows. " Just so that
we are on the same page, can you tell me what you know
about Leukemia"
b."Acute Lymphoblastic Leukemia is the most common
cancer in children, occurring equally among males and
females"
c. "It usually occurs between 2 to 8 years of age"
d."It occurs when normal cells in the bone marrow grows
abnormally, leading to the following:
▪ Bone marrow infiltration, leading to bone pain
Knowledge ▪ Bone marrow failure,
- Low RBCs leading to weakness and exercise
intolerance
- Low platelets leading to bleeding and bruising
- Low WBCs leading to infections
▪ Secondary hemiparesis, leading to enlargement of
lymph nodes, liver and spleen
e. "Poor prognostic factors include: increased primitive cells
(blast) count, T (9:20) translocation, no remission with 1st line
treatment or recurrence"
Expression Empathy:
" Tell me Mr./Mrs. X, how do you feel now"
Empathy a. Acknowledage your limitations in breaking bad news
b. Reinforce support provision, give clinic phone number
c. Ask about feelings and emotional acceptance
a. Brief what has been discussed
b. Reassure and discuss the upcoming plan:
▪ " With advances in medicine, patients with acute
lymphocytic leukemia(ALL) have highest chances of being
curable of all leukemia. Almost all children are cured and
80% has no recurrence in 5 years' time"
▪ Explain nature of investigation and expected outcomes:
"The hematologist taking care of your child will be ordering
Summarize more investigations including:
- CBC: expect Pancytopenia
- Blood film: expect blast cells
- Bone marrow aspiration to confirm the diagnoses:
expect (reduction in erythropoiesis as will be evident
by more than 20% of cells in blast form), for analysis
of tumor linage (myeloid or lymphoid), to test for
genetic mutation (Philadelphia chromosome or JAK-
2 Mutation)
- Chest x-ray: expect mediastinal lymphadenopathy

344
Breaking bad news

▪ Discuss treatment options:

- Supportive treatment: " the hematologist taking care
of your child will arrange for treating of anemia,
preventing bleeding and infections"
- Curative measures:
▪"Treatment aims at destroying the abnormal clonal
cells without destroying normal cells, so that can
repopulate after cure, this is achieved by
Summarize chemotherapy. It is given continuously while your
child is admitted until tumor cells are destroyed. It is
then continued as outpatient therapy for 3 years to
prevent recurrence"
▪"Patients need close follow up after that for early
detection of any recurrence"
c- Answer any queries and address concerns clearly
a. Give hope but not false ones: "I know it is difficult to
handle this, we are always available to support you and
answer your questions"
[Link] a referral to pediatric hematology/oncology clinic
for further workup and treatment plan
[Link] netting: "If your child develops any fever, extreme
Arrange fatigue, or stops taking orally bring him to the emergency
department immediately"
d. Follow up soon
e. Give away reading material, support groups contact
[Link] parents safety: " Do you think you can drive back
home, or would you like me to arrange for you appropriate
transportation"

345
 Venous thromboembolism VTE
Pulmonary Embolism

Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question) Shortness of breath
present Allow patient to explain the chief complain (Dyspnea)
illness Clarify what you understood
Course, onset and duration
SOCRATES for SOB and Chest pain
Onset:
• Sudden: PE, pneumothorax or an acute cardiac
• Sub-acute progression: pneumonia, exacerbations of asthma or COPD, fluid
overload or arrhythmia.
• A more insidious onset may indicate underlying malignancy, pleural effusion,
neuromuscular disease or undiagnosed lung disease
Associated symptoms (DDx):
• chest pain: pleuritic in nature or associated with sweating, nausea or vomiting
• Syncope
• Palpitations: tachyarrhythmia.
• Cough: Productive, colour or volume of sputum. Blood: PE or underlying
malignancy or TB
• Fevers
• Diurnal variation or wheezing → asthma
• travel abroad recently or flying
• accidents or falls or trauma
• orthopnoea or PND → CHF
• peripheral oedema or leg swelling → DVT
Analysis • Weight loss
of chief
complain

Risk Factors:
• PE, DVT, Resent surgery, lung or cardiac disease or infection or malignancy.
• Family history as PE or hematological disease.
• Antiphospholipid syndrome (APS), recurrent abortions.
346
 Venous thromboembolism VTE
Medical: CHF, hypercoagulability or malignancy
Surgical: recent surgery, trauma or recent fracture

Past Hx

Allergy
Medication:
Oral contraceptive pill , chemotherapy agents, long term
steroids, methotrexate
Family Hx similar cases, PE, DVT, hematological disease.
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
ICEE Concerns: is there anything you are worried about?
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
General Appearance:
Skin→ Cyanosis massive PE.
Neck→ Jugular venous distension massive PE.
Cardiac:
Inspection Parasternal heave →massive PE.
Auscultation →murmur
Chest:
• Reduced breath sounds may be present.
• Rales or Crackles.
• Pleural friction rub
Extremities:
Special Signs of deep vein thrombosis
• Unilateral calf or thigh tenderness, pitting edema
• Or swelling
• Difference in calf diameters > 3 cm (the calf circumference is measured
10 cm below the tibial tuberosity)
• Difference in thigh diameters (the thigh circumference is measured 10-15
cm above the patella)
347
 Venous thromboembolism VTE

1st investigations to order

-CBC -UREA and ELECTROLYTES
Anemia Check renal function –
Thrombocytopenia – bleeding risk with medications/CTPA
anticoagulant -Coagulation studies
Thrombocythemia or polycythemia – risk of -LFT
VTE -D-dimer
-UREA and ELECTROLYTES Negative test excludes a clot
Check renal function – medications/CTPA -Cardiac biomarker
Best initial
Investigations

-ABG
Hypoxia
Respiratory alkalosis ( high pH, low pCO2 )
-ECG
Usually shows Sinus tachycardia
Most common abnormality is nonspecific ST-T
wave changes -Chest XR
S1Q3T3 pattern Usually normal
Most common abnormality is
atelectasis

•D-dimer: This test is very sensitive (better

than 97% negative predictive value), but the
specificity is poor since any cause of clot or Use the Wells PE scores for all patients.
increased bleeding can elevate the d-dimer
level. A negative test excludes a clot, but a
positive test doesn’t mean anything.

•If the D-dimer is negative, no further testing is

needed.
•If the D-dimer is positive or the Wells score
indicates that a PE is likely (Wells PE score >4),
obtain an imaging study.
•Duplex ultrasonography and CTA are the
diagnostic tests of choice for PE, respectively.
•CT pulmonary angiography is the most
accurate
Adverse effects:
-Allergy
-Renal toxicity
-Death 0.05%
•PEs are categorized as “low risk” if cardiac
enzyme levels and echocardiography are
normal.

348
 Venous thromboembolism VTE
Deep vein thrombosis

Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question) Leg pain

Allow patient to explain the chief complain
illness Clarify what you understood
Swelling or oedema , Pain
Warmth cramps and heaviness, especially in calf
Increased visible skin veins
blue-red or cyanotic discoloration
Course, onset and duration
SOCRATES for pain
Site:
Unilateral: deep vein thrombosis - ruptured Baker’s cyst -
compartment syndrome
Bilateral: Medication induced, Systematic disease : Heart
failure-OSA-Thyroid disease –Renal disease – cirrhosis.
Onset:
Acute: within 72 hours :DVT-rapture baker cyst –cellulitis
Chronic: venous insufficiency –systematic disease
Reliving factors: Improve with leg elevation → venous
Analysis of insufficiency
chief complain Associated symptoms (DDx)
PE→ Sudden onset of dyspnea -Chest pain-Presyncope or
syncope Cough with or without hemoptysis
Dry skin→ Hypothyroidism, Lymphedema.
Showed below in details
Risk Factors & Red flags: Trauma, Covid -19 vaccine

349
 Venous thromboembolism VTE

Medical
Cancer, Hematological or rheumatological disease (APS)
Surgical
Past Hx
Recent, C\S.
Allergy
Medication
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
General Vital signs and Appearance
Inspection: temperature-colour-skin changes –hair loss –
pigmentation.
Palpation: pitting-tenderness –girth (Start by locating the
tibial tuberosity and measuring 10 cm inferior to the tibial
tuberosity.
Special
(lower limbs)

Venous US
Investigations CBC, Renal function, BNP, D DIMER

350
Venous thromboembolism VTE

351
DDx of Localized Edema

352
 Venous thromboembolism VTE
Treatment of PE and DVT
Therapy can be initiated with a NOAC or LMWH for 5 days with transition to
warfarin.

For PE with hypotension, systemic thrombolytic therapy is appropriate.

A NOAC or low-molecular-weight (LMW) heparin (enoxaparin) followed by warfarin is an

acceptable therapy. Hemodynamically stable patients can be treated with a NOAC without
using enoxaparin first.
Rivaroxaban, apixaban, edoxaban, and dabigatran (NOACs) are oral agents that do
not require INR monitoring and can be used for the treatment of pulmonary emboli.
•NOACs cause less intracranial bleeding than warfarin.
•NOACs do not need enoxaparin first.
•NOACs treat PE with efficacy at least as well as enoxaparin and warfarin.
•They reach a therapeutic effect in several hours, instead of several days like warfarin.
Warfarin requires initial therapy with low-molecular-weight
What agents reverse anticoagulation?
•Andexanet alfa reverses rivaroxaban, apixaban, and edoxaban. DON’T BE TRICKED
•Parenteral anticoagulant
•Idarucizumab reverses dabigatran. administration must over
•Prothrombin complex concentrate (PCC) reverses warfarin. lap with warfarin for at
least 5 days and until the
•When is an inferior vena cava (IVC) filter the right answer? INR is >2 for 24 hours.
•Contraindication to the use of anticoagulants (e.g., melena, CNS bleeding) •Do not use a NOAC
(Dabigatran, Edoxaban,
•Recurrent emboli while on a NOAC or fully therapeutic warfarin (INR of 2–3) Rivaroxaban, Apixaban) if
•Right ventricular (RV) dysfunction with an enlarged RV on echo. In this case, BMI >40 or GFR
disease is so severe that an IVC filter is placed because the next embolus, <30mL/min/1.73m . 2

even if seemingly small, could be potentially fatal.

When are thrombolytics the right answer?
•Hemodynamically unstable patients (e.g., hypotension [systolic BP <90 mm Hg] and
tachycardia)
•Acute RV dysfunction

353
 DOAC dosing
Drug Dosing in VTE treatment Dosing in AF
5mg BID
Apixaban 10mg BID for 7 days then 5mg BID

Rivaroxaban 15mg BID for 21 days then 20mg OD 20mg OD

Wt >60kg: 60mg OD
Edoxaban 60mg OD
Wt <60kg: 30mg OD

Dabigatran 150mg BID 150mg BID

DOAC Renal dose adjustment

Renal dose adjustment in
Drug Renal dose adjustment in AF
VTE
Serum creatinine < 1.5 mg/dl: No dosage adjustment
necessary (5mg BID).
Serum creatinine ≥ 1.5 mg/dl And either :
- Age ≥80 years
SCr >2.5 mg/dL or CrCl - Weight ≤60 kg
Apixaban <25 mL/min: excluded 2.5 mg twice daily
from clinical trials. ESRD on Hemodialysis: No dose adjustment provided
in the label manufactures.
Unless either :
- Age ≥80 years
- Weight ≤60 kg
2.5 mg twice daily.
CrCl >50 mL/min: No dosage adjustment necessary
CrCl <30mL/min: avoid
Rivaroxaban (20mg OD).
use.
CrCl 15 to 50 mL/min: 15 mg once daily.
CrCl 15-50 mL/min: 30 mg CrCl> 95 ml/min: Use is not recommended.
once daily CrCl CrCl 51 to 95 ml/min: No dosage adjustment necessary
Edoxaban
<15mL/min is not (60mg OD).
recommended. CrCl 15 to 50 mL/min: 30 mg once daily.
CrCl >50 mL/min: No dosage adjustment necessary
(150mg BID).
CrCl 30 to 50 mL/min: No dosage adjustment
CrCl ≤30 mL/minute: has
Dabigatran necessary unless patient receiving concomitant
not been studied.
dronedarone or oral ketoconazole reduce dose to 75
mg BID.
CrCl 15 to 30 : 75 mg BID.

Done by: Dr. Abdulrahman Alshammari

Clinical pharmacist
@Ph_Abdulr2hman

354
Infectious Diseases

355
Infectious Diseases
Fever of unknown origin
CNS infections
• Meningitis
• Encephalitis
Pericarditis
Travel ID
• Malaria
• Typhoid
• Dengue fever
• Yellow fever
Leishmaniasis
Monkeypox
Pinworm
Herpes zoster
Brucellosis
Tuberculosis

356
 Fever of Unknown Origin
Introduce yourself and establish good rapport ( Name, age and job).
Hx of
Chief complain (open question)
present
illness Allow pt to explain the chief complain and Clarify what you understood

o How do the patient know they had pyrexia?

o What was the temperature (if measured)?
o Onset (how it started)
o Pattern: Day/night/intermittent/continuous/progressive
• Fever with rigors or chills is most suggestive of infection
• Fever that occurs every other day (tertian) or every 3rd day (quartan)
may suggest malaria in patients with risk factors
• Evening fevers and sweats which resolve by morning: brucellosis
• Week-long fevers with week-long remissions: tick-borne fever in
borreliosis
• Week-long high fevers with week-long remissions: Pel-Ebstein in Hodgkin
disease
Analysis of • Periodic fevers in cyclic neutropenia
chief • Double quotidian fever (two fever spikes a day) in adult Still’s disease;
complain also seen in malaria, typhoid, and other infections
• Morning fevers in polyarteritis nodosa, tuberculosis, and typhoid
o Frequency
o Exacerbating factors
o Alleviating factors (paracetamol)
o Rigors/shivers
o Lethargy
o Night sweats, Weight loss
o Reduced urine output (septic shock)
o Recent recurrent boils/other infections
o Asks if the patient is suffering from any other symptoms
o Asks about recent illnesses
o Previous episodes of pyrexia of unknown origin (PUO)
Respiratory: Liver/gallbladder:
• Cough, sputum (pneumonia) • Right upper quadrant pain
• Haemoptysis (cancer, tuberculosis) • Jaundice
• Shortness of breath Neurological:
Gastrointestinal: • Headache (abscess, meningism)
• Diarrhoea (gastroenteritis) • Neck stiffness, rash (meningism)
• Bloody stools (inflammatory bowel
• Focal neurological symptoms
disease)
By system (abscess, encephalitis)
• What/when did the patient last eat?
Cardiovascular:
Rheumatological, musculoskeletal:
• chest pain, shortness of breath, • Severely painful single joint (septic
haematuria (infective endocarditis) arthritis)
Urological: • Pain in small joints (rheumatoid
• Haematuria arthritis, systemic lupus
• Dysuria (urinary tract infection) erythematosus)
• Loin pain (pyelonephritis) • Muscle pain (myositis)
357
Fever of Unknown Origin
Vascular:
ENT:
• Calf pain/swelling (deep vein
• Throat pain (upper respiratory tract
thrombosis)
infection, tonsillitis)
Lumps (lymphadenopathy)
By system Dental:
Gynaecological symptoms:
• tooth pain (tooth abscess)
• Vaginal bleeding/discharge (pelvic
Skin:
inflammatory disease)
•rash, inflammation, redness (cellulitis)
• Use of tampons
Risk factors for HIV:
• Multiple/new sexual partners, contact with sex workers (must signpost)
• Contraception
• Intravenous drug abuse
Recent travel history:
Risk factors • Where/when/what country?
• Accommodation
• Food, water, restaurants
• Did others on holiday have same symptoms?
• Swimming in rivers, at coasts or in possible contaminated waters
• Fever on holiday
• Insect/tick bites
Medical
• HIV • Tuberculosis • Cancer • Organ transplants. • Rheumatic fever
• Valvular heart disease/replacement (infective endocarditis) • Diabetes •
Immunizations
Surgical
• Blood transfusions • Recent hospital admissions • Recent surgery: any healing
Past Hx wounds?
Allergy
Medication
• Anti-microbials (sulfonamides, penicillins, nitrofurantoin, antimalarials)
• Anti-thyroid • Anti-hypertensives (hydralazine, methyldopa) • Anti-histamines
• Anti-epileptics (barbiturate, phenytoin) • Anti-arrhythmics (quinine, procainamide)
• Anti-inflammatories (NSAIDs) • Anti-thrombotics (ASA)
Family Hx • TB • Cancer • Immunosuppressive illnesses • Familial Mediterranean fever
Marital status
Smoking
Alcohol (peptic ulcer, gastritis), Illicit drug use
Diet: Unpasteurized dairy products, Barbecues, Drinking water abroad
Occupation
Psychosocial Recent contact with farm animals
Recent contact with persons with similar symptoms
Foreign contacts
Sexual history
Activities of daily living
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

358
Fever of Unknown Origin Ex

Vital signs:
General Unequal pulse in upper extremities: Takayasu arteritis
Appearance
Skin, eyes, lymph nodes, throat, teeth
• Eyes (Roth spots, retinal artery occlusion): SLE, vasculitis,
bacterial endocarditis
• Oral ulcers: SLE, Bechet disease, histoplasmosis
• Tender tooth on percussion, caries/gingivitis: dental abscess
Abdominal assessment
• Liver and spleen masses or organomegaly
• Hepatomegaly without splenomegaly: granulomatous hepatitis,
primary liver cancer, renal cell carcinoma, or liver metastases
• Splenomegaly without hepatomegaly: bacterial endocarditis,
EBV/CMV infection, typhoid, tuberculosis, histoplasmosis,
brucellosis, malaria, Q fever, borreliosis (relapsing fevers),
cirrhosis
• PR exam: prostatitis, perirectal abscesses
Cardiovascular assessment
• Cardiac murmur: SLE (Libman-Sacks endocarditis), bacterial
Special endocarditis
• Tenderness to palpation of sternum: hematologic malignancy
• cutaneous findings of endocarditis, including painful
erythematous subcutaneous nodules on the tips of digits (Osler
nodes), petechiae, and splinter hemorrhages
Pelvic exam
Mental state changes
mental status change related to meningitis and encephalitis
Nails, joints, temporal arteries

Inspection should include the perineum and feet, particularly in

diabetics, who are prone to infections in these areas

The entire body : particularly over the spine, bones, joints, abdomen,
and thyroid) palpated for areas of tenderness, swelling, or organomegaly

Thyroid: thyroiditis enlarged tender

359
 Fever of Unknown Origin
Classification of Fever of Unknown Origin (FUO)
Category of
Definition Causes
FUO
• Temperature >38.3°C (100.9°F)
• Duration of >3 weeks • Infection
Classic • Diagnosis uncertain after 3 outpatient • Malignancy
visits or 3 days in hospital or 1 wk of • collagen vascular disease
intensive ambulatory investigation
• Temperature >38.3°C • Pulmonary embolism
• Patient hospitalized ≥24 hours but no • Clostridium difficile enterocolitis
fever or incubating on admission • Drug-induced fever
Nosocomial
• Diagnosis uncertain after 3 days of • Patients with nasogastric or
investigation, including at least 2 days nasotracheal tubes
incubation of cultures • Sinusitis

• opportunistic bacterial
• Temperature >38.3°C
infections
Immune • Neutrophil count ≤ 500 per mm3
• Occult infections caused by
deficient • Diagnosis uncertain after 3 days of
fungi (hepatosplenic candidiasis
(neutropenic) investigation, including at least 2 days
and aspergillosis)
incubation of cultures
• Herpes simplex virus

• Mycobacterium avium,
• Temperature >38.3°C
• Intracellular complex,
• Duration of >4 weeks for outpatients,
HIV-associated • Pneumocystis
>3 days for hospitalized patient with
carinii pneumonia,
HIV infection.
• Cytomegalovirus.

Differential Diagnosis
• Tuberculosis (especially in extrapulmonary sites) and abdominal or pelvic
abscesses are the most common.
Infections • Intra abdominal abscesses are associated with perforated hollow viscera
(appendicitis), diverticulitis, malignancy, and trauma.
• Subacute bacterial endocarditis, sinusitis, osteomyelitis, and dental abscess.
• Chronic leukemias
• Lymphomas
Malignancy
• Renal cell carcinomas
• Metastatic cancers
• Rheumatoid arthritis
• Rheumatic fever
Autoimmune • Adult still’s disease
• Temporal arteritis
• Polymyalgia rheumatica
Drug-induced fever : diuretics, pain medications, antiarrhythmic agents, antiseizure
Miscellaneous drugs, sedatives, certain antibiotics, antihistamines, barbiturates, cephalosporins,
salicylates, and sulfonamides.

360
Fever of Unknown Origin

Assessment of fever of unknown origin in adults

361
 Fever of Unknown Origin
Children
Fever history Potential significance
Is the fever associated with ill-
Absence of malaise or other generalized symptoms with high fever may
appearance or symptoms (eg,
suggest factitious fever
malaise)?
Lack of response to anti-inflammatory antipyretics may suggest
Does the fever respond to
rheumatologic disease (eg, familial dysautonomia, ectodermal
antipyretic agents?
dysplasia)
Persistence of constitutional
Persistence is worrisome for systemic disease
symptoms after fever abates?
Is there associated sweating Yes: Hyperthyroidism
with fever? No: Ectodermal dysplasia
Is there associated sweating
No: Factitious fever
with defervescence?
Associated complaints Possible cause(s)
Kawasaki disease Leptospirosis
Red eyes
Tuberculosis Infectious mononucleosis
Nasal discharge Rhinosinusitis
Recurrent pharyngitis with
PFAPA syndrome
ulcerations
Salmonellosis Intra-abdominal abscess
Gastrointestinal complaints Hepatic cat scratch disease Inflammatory bowel disease
Leptospirosis
Brucellosis Leukemia Lymphoma
Limb or bone pain
Osteomyelitis Infantile cortical hyperostosis
Exposures Possible cause(s)/potential significance
Medications Drug fever
Abdominal surgery: Intra-abdominal abscess
Surgery
Tracheotomy or gastric tube, cochlear implant or other
Ill-contacts unusual presentations of common illnesses
Endemic pathogens, for example:
Travel history, extending back
Histoplasmosis Coccidioidomycosis Blastomycosis
to birth (including tick and
Leishmaniasis Malaria Tuberculosis
insect exposure)
Typhoid fever
Animals Zoonotic disease
Rocky Mountain spotted fever Tularemia
Ticks Human ehrlichiosis or anaplasmosis Lyme disease
Tick-borne relapsing fever
Mosquitos Arboviruses (eg, West Nile virus)
Sand flies Leishmaniasis

362
 Fever of Unknown Origin
Exposures Possible cause(s)/potential significance
Game meat: Toxoplasmosis, tularemia
Diet Raw/undercooked meat: Tularemia, brucellosis
Raw shellfish: Hepatitis
Visceral larva migrans
Pica (specifically eating dirt)
Toxoplasmosis
Ethnic or genetic background Possible cause
Ulster Scot descent Nephrogenic diabetes insipidus
Turkish, Armenian, North
Familial Mediterranean fever
African Jewish, Arab descent
Ashkenazi Jewish descent Familial dysautonomia

Assessment of fever of unknown origin in children

363
 CNS infections Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question)

illness Allow pt. to explain the chief complain.
Course, onset and duration
SOCRATES for pain/headache

CNS infection presented as flue-like symptoms such as:

headache, fever, aches in muscles or joint, fatigue and
weakness.
Associated symptoms:
Neck stiffness, rash, seizure, alter mental status
personality changes, sensory disturbances, movement
Analysis of disorder, ataxia, difficulty swallowing (dysphagia), nausea &
vomiting
chief Risk Factors :
complain • Contiguous infection (e.g., sinusites)(meningitis)
• Contact with infection transmitted animal (mosquitos, tick
bites) (encephalitis)
• Exposure to human blood or body fluids with meningitis
with or without prophylaxis (meningitis)
• Swimming, diving or boating in fresh water (meningitis)
• Intravenous (IV) drug abuse (both)
• Dural defect (e.g., traumatic, surgical, or congenital) hx of
cochlear implants (meningitis).
• Sexual history (HIV) (both)
• Travel history to endemic area/ crowding such as hajj or
omrah (both)
• Seasons : Mumps, measles, and varicella-zoster virus
(VZV) are more common during winter and spring.
Analysis of Arthropod-borne viruses (e.g., West Nile virus, St Louis
chief encephalitis, and California encephalitis virus) are more
complain common during the warmer months (meningitis).
• A history of recurrent bouts of benign aseptic meningitis
suggests Mollaret syndrome, which is caused by HSV
(meningitis).
• Immunodeficiency

364
 CNS infections Hx
Medical: Diabetes mellitus, and sickle cell disease,
thalassemia major, chronic kidney failure, adrenal
insufficiency, hypoparathyroidism, cystic fibrosis, bacterial
endocarditis, liver cirrhosis and malignancy.
Past Hx
Surgical: hx. of splenectomy
Allergy
Medication: drug users & alcoholism
Family Hx contact with ill persons
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
General Appearance
Cardiac Ex
CNS Ex
Abdominal Ex: splenomegaly & liver cirrhosis
HEENT:
• Signs of infection indicating sinusitis and otitis media help identify the
source of infection.
Ophthalmology Ex
• The icteric sclera is seen in cases of hepatic encephalopathy.
Special • Nystagmus: cranial nerve dysfunction.
• Papilledema, hemorrhages, exudates were seen in hypertensive
encephalopathy
Skin Ex:
• Skin rash could indicate Neisseria meningitidis infection also may
be present in encephalopathy due to viral infection
• Cyanosis, severe hypoxia, and poisoning.
• Jaundice liver failure and in neonatal encephalopathy.
• Special test: kernig & Brudzinski signs

365
 CNS infections

CRAPRIOP for Management

Meningitis is a clinical syndrome characterized by
inflammation of the meninges: the three layers of
membranes that enclose the brain and spinal cord
Encephalitis is inflammation of the brain parenchyma
‫التهاب السحايا هو التهاب السائل واألغشية )السحايا( املحيطة بالدماغ واحلبل‬
Clarification ‫ يحفز التوُّرم الناجت عن التهاب السحايا غالًبا مؤشرات املرض وأعراضه مثل‬.‫النخاعي‬
.‫الصداع واُحلمّى وتيبس الرقبة‬

‫ ويحدث لعدة أسباب؛ منها العدوى‬.‫التهاب الدماغ هو التهاب في أنسجة املخ‬

.‫الفيروسية والتهاب املناعة الذاتية والعدوى البكتيرية ولدغات احلشرات وغيرها‬
.‫ويحدث في بعض األحيان دون سبب معروف‬
Reassurance Can be controlled by medication
Meningitis prevention:
• Regular hand washing before eating & in crowded places
• Hemophilus influenza type b (Hib) vaccine
• Pneumococcal conjugate vaccine (PCV13),
• Pneumococcal polysaccharide vaccine (PPSV23),
• Meningococcal conjugate vaccine
• Vaccination before hajj and Umrah :
Vaccination must be issued not less than ten days before
arrival and not more than three years (polysaccharide
vaccine) or five years (conjugate vaccine) before arrival.
Chemoprophylaxis for household contacts, childcare
Advice contacts, and people who have had direct exposure to the
Patient's oral secretions as sharing utensils
Encephalitis prevention:
• Prevent mosquito bites by wear full-sleeved clothing,
sleep under mosquito nets, use mosquito repellent
cream, use pesticides around water bodies that breed
mosquitoes/larva.
• Children protection by getting MMR and Chickenpox
vaccinations.
• Check for ticks in and around the hairline, groin area,
armpits.

366
 CNS infections
Management of meningitis:
• Stabilization of the Patient's cardiopulmonary status takes priority.
• Intravenous fluids may be beneficial within the first 48 hours.
• Intravenous insertion should be assessed.
• Proper isolation during transmission to hospital and patients should be
placed on droplet precautions
• initiating empiric antibiotics as soon as possible after blood cultures are
drawn, and the LP is performed, Acyclovir should be added if there is a
concern for HSV.
• Corticosteroids are used as adjunctive treatment in Meningitis to
reduce the inflammatory response.
• Dexamethasone should be given before or at the time of initial
antibiotics while awaiting the final culture results in all patients older
than six weeks with suspected bacterial Meningitis.
• Dexamethasone can be discontinued after four days or earlier if the
pathogen is not H. influenzae or S. pneumoniae or if CSF findings are
more consistent with aseptic Meningitis.
Prescribing • If viral infection: supportive care
Management of encephalitis:
Prehospital setting :
• Evaluation and treatment for shock or hypotension.
• Airway protection
• Seizure precautions.
• Oxygen and IV access secured before hospital referral.
In the ER:
• Administration of the first dose of acyclovir, with or without antibiotics
or steroids, as quickly as possible.
• Consideration in the ED triage protocol to identify patients at risk for
HSV encephalitis.
• Collection of laboratory samples and blood cultures before the start of
IV therapy.
• Neuroimaging (e.g., MRI or, if that is unavailable, contrast-enhanced
head CT) before LP
• Ttt: in table below
Refer the Patient as soon as clinical suspicion of Meningitis/ encephalitis is
Referral diagnosed
• CBC,Serum electrolyte levels, Serum glucose level, BUN and creatinine
levels , Urine electrolyte levels , Urine or serum toxicology screening.
• Lumber puncture
• Cultures and Bacterial Antigen Testing (Blood, nasopharynx, respiratory
Investigations secretions, urine, skin lesions)
• The PCR assay for enteroviruses
• Serum Procalcitonin Testing elevated serum PCT levels (predict
bacterial Meningitis).
• neuroimaging
Plan & prevention Health promotion & screen according to the age
Includes Safety netting (mention the red flags)
conclusion

367
CNS infections

368
 CNS infections

Encephalitis treatment
Antivirals Corticosteroids Diuretics
• Used for the treatment
The goal of antivirals for the treatment These agents are
of postinfectious
of herpes simplex encephalitis (HSE) used in patients with
encephalitis and acute
and varicella zoster encephalitis is to: hydrocephalus and
disseminated
• Shorten the clinical course. increased intracranial
encephalitis.
• Prevent complications. pressure (ICP).
• Dexamethasone is used
• Prevent recurrences. to treat various allergic
• Decrease transmission. and inflammatory
Furosemide (Lasix) :
diseases.
• The onset of action
Acyclovir (Zovirax) : • 0.75-9 mg/day
is within 1 hour.
• Acyclovir has demonstrated inhibitory IV/IM/PO divided q6-
• The dose must be
activity directed against HSV-1 HSV-2. 12hr (11).
individualized to the
• Patients who have a poor clinical
Lorazepam Patient. Depending
response or experience persistent viral
on the response,
excretion during therapy, especially HIV- (Ativan) administer 20-40 mg,
positive patients, may be resistant to
• Lorazepam is a after 6-8 hours of the
acyclovir.
sedative-hypnotic with a previous dose, until
• 10-15 mg/kg IV q8hr for 10 days
short onset of effects the desired diuresis
Foscarnet (Foscavir) : and a relatively long occurs.
• It inhibits replication of known herpes half-life. When treating
viruses, including, CMV, HSV-1, and • It is important to infants, titrate with 1-
HSV-2. monitor the Patient's mg/kg/dose
• 120 mg/kg/d early in treatment. blood pressure after increments until a
Dosing should be individualized in administering a dose, satisfactory effect is
consideration of the Patient's renal adjust the dose as reached.
function. necessary.

369
 CSF Analysis

Normal CSF
WBC RBC Protein Glucose Opening
pressure
0-5 cells/µL 0 – 10/mm³ 0.15 – 0.45 g/L (or 2.8 – 4.2 mmol/L (or 10 – 20 cm
<1% of the serum ≥ 60% plasma H2 O
NO NEUTROPHIL
protein glucose
concentration) concentration)

Subarachnoid Gulian barre Multiple sclerosis

hemorrhage syndrome
blood-stained initially, then clear or clear
Appearance xanthochromia (yellowish) >12 xanthochromia
hours later
Opening pressure elevated normal or normal
elevated
WBC elevated (WBC to RBC ratio of normal 0 – 20 cells/µL (primarily
approx 1:1000) lymphocytes)
RBC elevated - -
Protein elevated elevated (>5.5 mildly elevated (0.45 – 0.75
g/L) g/L)
Glucose normal normal normal

370
 Acute pericarditis Hx

Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (open question)
present Allow pt to explain the chief complain
illness Clarify what you understood
Site: chest, epigastric, retrosternal.
Onset: constant or intermittent, gradual or sudden
Character: •Crushing •Heaviness •Pressure (MI) •Burning(GERD)
•Stepping. • Localized and sharp •Tearing (aortic dissection).
Radiation: jaw, left arm and back (myocardial infarction), back (dissection)
SOCRATES

Timing: changes in the pain between onset and now

Exacerbating factors: •Exercise(unstable angina) •Deep inspiration (muscular
source of pain)
•Respiration •Movement and lying supine (pericarditis)
•Heavy meals or fatty foods (gall bladder disease)
Alleviating factors: • Rest and nitrate (stable angina) • Antacids (PUD)
•Leaning forward and sitting(pericarditis),
Severity: •1 to 10 •Affecting daily activity • awaken patient at night
• Pericarditis: Increased pain with respirations, movement, or lying supine,
radiation to the shoulder and relieved with leaning forward and sitting indicate.
• Ischemia: Palpitations, sweating, nausea, vomiting, dizziness, typical radiation to
the jaw or shoulder, pain that increases with exertion and decreases with rest,
sharp squeezing pain or heaviness in chest.
• Pulmonary Embolus: Shortness of Breath, hemoptysis, calf pain, recent travel,
Analysis of
pregnancy, postpartum, use of oral contraception, Hx of DVT\PE, immobilization,
Associated symptoms

chief
surgery, cancer
complain
• Pneumonia or Pleurisy: Cough, fever and sputum.
• Aortic Dissection: Cough, fever and sputum indicate Pneumonia or Pleurisy. Pain
radiating to the back and history of smoking.
• Peptic Ulcer Disease: Heart burn, retrosternal pain, dysphagia, dyspepsia, and
NSAIDs use
muscular source of pain: Localized sharp pain, increased with movement or deep
inspiration, history of trauma or fall, heavy exertion
• Metastasis: History of skeletal pain or tumor.
• Costochondritis: Pain and swelling at costo-chondral junctions.
• Psychiatric: anxiety, malingering, depression therefore ask about mood, excessive
worries, stresses .etc.
• Herpes Zoster: Skin rash with pain (Fire band).
Cardiac risk factors:
• Family history of myocardial infarction in first-degree • Relative <55
years of age
Risk Factors

• Smoking • Hypertension • Diabetes mellitus • Hyperlipidaemia

pericarditis:
• male sex • age 20 to 50 years • hx of an upper respiratory tract infection
or diarrheal illness • Fever • Trapezius ridge pain is more specific for
pericardial pain

371
 Acute pericarditis Hx
Known coronary artery disease
Clammy, unwell patient
Analysis of Heavy, tight, pressure type chest pain

Red Flags
chief Pain radiating to left arm, right shoulder or both arms
complain Association with nausea or vomiting
Bilateral lower limbs swelling ( acute heart failure due to cardiac
tamponade )
Male sex
Medical
• Previous Myocardial Infarction •Hx of malignancy
• Systemic autoimmune disorders • Hypertension. •Dialysis treatment
Surgical
Past Hx
• Recent surgery • cardiac surgery
Allergy
Medication
• Hydralazine • Isoniazid • Phenytoin
cardiac events and at what age
Family Hx
Contact with sick patient
Stressful events
Sedentary lifestyle
Psychosocial Alcohol
Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Typical presentation: An otherwise healthy young adult male presents with a several-
day history of progressive, severe, retrosternal chest pain that is sharp and pleuritic in
Conclusion nature, The pain is constant and unrelated to exertion, radiate to the neck improved
by leaning forward

Examination
Vital signs
General Appearance
Cardiac Ex and Respiratory Ex
Pericardial Friction Rub
Must role out Cardiac tamponade (Beck’s triad)
• Distended neck veins
Special • Muffled heart sounds
• Hypotension
Early sign: pulsus paradoxus (fall in a patient's blood pressure during
inspiration by greater than 10 mm Hg)

372
Acute pericarditis

ECG changes occur in up to 60% of patients.

Global upwardly concave ST-segment elevations with PR-segment
depressions in most leads

373
Acute pericarditis

374
 Acute pericarditis
CRAPRIOP for Management
،‫التهاب غشاء القلب هي حالة تؤدي الى الم شديد بالصدر بسبب الضغط على عضلة القلب‬
Clarification ‫ لكن االعتقاد السائد يقول إنه يرجع في أغلب‬،‫غالًبا ما يظل سبب االلتهاب غير معروف‬
.‫احلاالت إلى عدوى فيروسية‬
‫تتحسن األعراض عادة في غضون أيام قليلة إلى أسابيع و يكون العالج في معظم احلاالت‬
Reassurance ‫مبضادات االلتهاب‬
Ø Primary prevention of pericarditis:
Colchicine may be of benefit for primary prevention of
Advice pericarditis and pericardial effusions in patients undergoing
cardiac surgery
Ø Advise the patient to restrict strenuous physical activities
1. Ibuprofen: 600 mg orally every 8 hours for 1-2 weeks, then
decrease by 200-400 mg/dose every 1-2 weeks
2. Omeprazole: 20 mg orally once daily
3. Colchicine 0.5 mg orally once daily for 3 months, then may
taper to 0.5 mg once daily on alternate days in the last weeks
Prescribing
4. Consider prednisolone if failure of treatment or
contraindication of NSAIDS or colchicine, prednisolone: 0.2 to
0.5 mg/kg/day orally until resolution of symptoms, then
gradually taper
5. Pericardectomy
ER Referral if PT has symptoms or signs of cardiac tamponade for
Referral
pericardiocentesis
- ECG within 10 minutes, cardiac enzymes if cardiac cause
suspected
- ESR & CRP
Investigations - CBC
- liver and renal function test
- electrolyte
- Echocardiography
Observation/ evaluate in the clinic after 1 week to assess the response to
follow up treatment
Plan/preventi
offer immunization for flu, COVID 19, Smoking cessation
on
if you have Exertional chest pain, Heavy, tight, pressure type
chest pain, Pain radiating to left arm, right shoulder or both
Safety Netting
arms, Association with nausea or vomiting
URGENT visit ER

375
 Travel ID Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt to explain the chief complain
illness Clarify what you understood
Course, onset and duration
Fever:
• Patterns to the fever
• Have they measured it?
Organ-specific symptoms:
• Respiratory: SOB, cough, chest pain, hemoptysis
• Abdominal: diarrhea, vomiting, abdominal pain,
constipation
• GU: dysuria, frequency, hematuria
• Neurological: neck stiffness, headaches, seizures
Skin: localized rash, erythema, swelling
red flags:
Weight loss, Night sweats , confusion and hemoptysis
Analysis of Travel history:
• Which countries?
chief
• Urban/rural environment
complain • Types of accommodation
• Dates of entering each country/returning home
Risk factors:
• Sexual intercourse
• Procedures e.g.: hospitalization ,blood products
received ,vascular access lines , Piercings.
• Animal contact: Any bites received (animals or
insects), Close household contact with animals.
• Contacts with sick patients.
• Eating & drinking ; high-risk foods e.g. street meat,
unpasteurized milk, unsterilized water
• Swimming: Any swimming in natural lakes
Prevention:
Vaccinations up to date , Malarial prophylaxis
376
 Travel ID Hx
Medical:
HIV
Any previously treated infectious diseases
chronic conditions
Past Hx Surgical
Medication and allergy:
Immunosuppressants, Antiretroviral therapy, Antimalarials,
Recent chemotherapy
HIV, TB, Malaria
Family Hx
Marital status
Smoking: type and frequency
Psychosocial Intravenous drug use
Living situation :Shared bathroom/kitchen?
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
Examination
Vital signs:
Relative bradycardia in case of Typhoid fever and Yellow
fever
Appearance:
Color: Jaundiced, Pale
General Skin (Rash):
• Dengue fever: Maculopapular rash involving the whole
body
• Typhoid fever: Rose spots ( Blanching erythematous
maculopapular lesions usually 2 to 4 mm diameter)
GI exam: Abdominal distention, Splenomegaly,
Hepatomegaly
Special Special test:
Dengue hemorrhagic fever: Positive tourniquet test showing
presence of umbelliform rash and petechiae.

377
 Malaria
CRAPRIOP for Management
‫ ينتقل‬,‫املالريا هو مرض معدي يتسبب في حدوثه كائن طفيلي يسمى البالزموديوم‬
Clarification ‫ ويتسلل هذا الطفيلي داخل كريات الدم احلمراء في جسم‬,‫عن طريق البعوض‬
.‫االنسان فيدمرها‬
‫ تستخدم حسب نوع الطفيل‬,‫هناك مجموعة من األدوية املستخدمة لعالج املالريا‬
Reassurance .‫املكتشف ومكان اإلصابة‬
People should be advised to protect themselves
from infection by avoiding outdoor activity after
sunset, using insect repellents, wearing long-
sleeved shirts and trousers, and using
Advice insecticide-treated bed nets.
Covering potential house entry points with
netting or mesh (screening) may reduce malaria
transmission and infection in people living in
the house

Prescribing

378
 Malaria
To ER for Admission Falciparum Malaria or undifferentiated
Referral cases where species of Malaria cannot be discerned
• blood glucose
• CBC: Thrombocytopenia, anemia, variable WBCs
• Coagulation panel: PT may be prolonged
• LFT: elevated bilirubin or elevated aminotransferases
• serum electrolytes, urea and creatinine (renal failure may
be present in severe infection)
Investigations • Urine analysis (In severe Plasmodium falciparum infections,
massive hemolysis combined with acute tubular necrosis
produce acute renal failure with hemoglobinuria and
proteinuria)
• ABG: (metabolic acidosis or lactic acidosis in severe disease)
Confirmation: Giemsa-stained thick and thin blood smear
• Once treatment has started, patients with Plasmodium
falciparum infection usually improve rapidly over a few days
Observation/ • Daily blood films should be performed until parasites are
undetectable by microscopy.
follow up • Hemoglobin should be checked 2 to 4 weeks after starting
treatment in patients treated with intravenous artesunate
to check for late-onset hemolysis
People travelling to P falciparum chloroquine-sensitive areas
can be given chloroquine or hydroxychloroquine, to be taken
1 week prior to travel, weekly (same day each week) during
travel, and for 4 weeks after leaving the endemic area.
People travelling to P falciparum chloroquine-resistant areas
should be prescribed one of the following chemoprophylactic
regimens:
• Atovaquone/proguanil: to be taken 1 to 2 days prior to
Plan/prevention travel, daily during travel, and for 7 days after leaving the
endemic area
• Doxycycline: to be taken 1 to 2 days prior to travel, daily
during travel, and for 4 weeks after leaving the endemic
area
• mefloquine: to be taken 2 to 3 weeks prior to travel,
weekly during travel, and for 4 weeks after leaving the
endemic area.
Malaria Vaccine
Conclusion Includes Safety netting

379
 Dengue Fever

CRAPRIOP for management

,‫حمى الضنك هي عدوى فيروسية تنتقل بواسطة لدغة أنثى بعوضة الزاعجة املصرية‬
Clarification .‫أعراضها تشبه األنفلونزا ولكنها شديدة‬
‫ لكن احلصول على الرعاية الطبية املناسبة يقلل نسبة‬،‫ال يوجد عالج حلمى الضنك‬
Reassurance .‫الوفيات‬
• Patients should be encouraged to rest and take oral fluids
(e.g., approximately 2.5 L/day for an adult, or age-
appropriate maintenance fluid requirement for children).
• Oral rehydration products, fruit juices, and clear soups
Advice are better than water.
• Red- or brown-coloured fluids should be avoided, as
these may lead to confusion about the presence of
hematemesis if the patient vomits.
There is no specific treatment or antiviral agents for dengue
fever, management can be classify into 3 groups according to
the symptoms and severity:

Prescribing

• if Developing warning signs:

(abdominal pain or tenderness, persistent vomiting, clinical
fluid accumulation such as ascites or pleural effusion,
mucosal bleeding, lethargy/restlessness, liver enlargement
>2 cm, increase in hematocrit concurrent with rapid decrease
Referral in platelet count)

• If Co-existing risk factors for serious infection

(e.g., pregnancy, extremes of age, obesity, diabetes, renal
impairment, hemolytic disease

380
 Dengue Fever
•FBC: leukopenia; thrombocytopenia; elevated hematocrit
•LFT: elevated
•Serology:
Investigations •Positive IgM and IgG in a single serum sample (highly
suggestive of infection);
• IgM:IgG ratio <1.2 (suggests secondary infection);
• reverse transcription-polymerase chain reaction (RT-PCR)
• There are no long-term sequelae associated with dengue
infection once the patient has recovered.
Observation/ • Some patients may experience post-viral fatigue
follow up syndrome after recovery.
• Complete normalization of LFT may take up to 3 or 4
weeks
Preventative measures include:
• Regularly removing all sources of stagnant water.
• Preventing mosquito bites by wearing appropriate
Plan/prevention clothing to cover exposed areas of the skin.
• Use of mosquito nets and coils around people who are
sick with dengue fever.
Includes Safety netting
Go to the hospital if you develop any of the following:
Conclusion (abdominal pain or tenderness, persistent vomiting, mucosal
bleeding, lethargy/restlessness)

381
 Typhoid Fever
CRAPRIOP for management
‫ وتنتشر عادةً عن طريق األغذية أو‬.‫ تسببها بكتيريا الساملونيال التيفية‬،‫حمى التيفويد عدوى تهدد احلياة‬
‫تشمل األعراض اإلصابة باحلمى لفترة طويلة والتعب والصداع والغثيان وآالم البطن واإلمساك‬. ‫املياه امللوثه‬
Clarification ‫ وقد تؤدي حاالت حمى التيفود الوخيمة إلى‬.‫ وقد ُيصاب بعض املرضى أيضًا بالطفح اجللدي‬.‫أو اإلسهال‬
.‫حدوث مضاعفات خطيرة‬
‫ رغم أن تزايد مقاومتها ألمناط مختلفة من املضادات احليوية‬،‫ميكن عالج حمى التيفود باملضادات احليوية‬
Reassurance .‫يزيد من تعقيد عالجها في الوقت الراهن‬
Rest , drink fluids, hygiene control
Advice

Prescribing

Referral to a hospital is necessary if the patient is vomiting and unable to

Referral take oral medication, is clinically unstable has developed complications, or
if the diagnosis is uncertain
• FBC: leukopenia, mild anemia, low platelets,
• LFT
Investigations • blood culture, urine culture, stool culture
• bm culture
Stool cultures of convalescent cases are followed and positive culture
Observation/ •
reported to the local health office.
follow up • With antibiotic treatment, prognosis is generally good
• Among traveler: strict observance of hygiene rules (i.e., avoiding
contaminated food and water)
• Patients should be careful to avoid spread of infection by adhering to
Plan/prevention rigorous personal hygiene, mainly proper handwashing.
• There is no need for isolation of the patient.
• Typhoid vaccine.
Includes Safety netting
Conclusion
382
 Yellow Fever
CRAPRIOP for management
‫احلمى الصفراء هى حمى فيروسية نزيفية حادة تنتقل عن طريق نوع معني من البعوض‬
Clarification ‫ وتشير كلمة )الصفراء( إلى اليرقان الذي يصيب بعض املرضى‬.‫املصاب‬
‫ لكن ميكن عالج‬،‫ال يوجد حالًيا أي نوع محدد من األدوية لعالج احلمى الصفراء‬
Reassurance .‫ وأدوية لتقليل احلمى‬،‫ تناول مسكنات األلم‬،‫ شرب السوائل‬،‫األعراض وذلك بالراحة‬
Patients should be isolated/protected from further
Advice mosquito exposure (e.g., staying indoors) for up to 5 days
following onset of fever to break the transmission cycle
• Specific antivirals for yellow fever are not available,
supportive care is the mainstay treatment.
• Patients should be hospitalized for supportive care and
observation when possible.
• Analgesics/antipyretics are recommended for pain and
Prescribing fever
• Avoid: NSAIDs, including aspirin due to the increased
risk of bleeding in these patients
• Ribavirin may be given if a viral hemorrhagic fever is
suspected until yellow fever is confirmed.
Yellow fever patient should be referred to hospital for
Referral supportive care.
• CBC: Leukopenia, neutropenia, thrombocytopenia
• LFT
Investigations • Coagulation profile: elevated PT
• RT-PCR
• Serology: positive for yellow fever virus antibodies
Most patients remain asymptomatic or experience only
Observation/ mild symptoms.
Some patient after period of remission patient my
follow up developed: Hemorrhage, multiorgan failure,
Abdominal pain, severe jaundice
Travelers should be instructed:
• To use an insect repellent on exposed skin to repel
mosquitoes in areas of risk.
Plan/prevention • Should wear tucked-in long-sleeved shirts, long
trousers, and hats to cover exposed skin. Permethrin-
containing (e.g., permanone).
Yellow fever vaccine
Conclusion

383
 Leishmaniasis Hx
Prominent risk factors for infection include exposure to sand fly bites, poor disease
awareness, malnutrition, immunosuppression, and in some cases proximity to infected
patients.
History taking and physical examination are crucial to determine the degree of clinical
suspicion for both cutaneous leishmaniasis (CL)
and visceral leishmaniasis (VL).
Laboratory confirmation is mandatory

Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow patient to explain the chief complain
illness
Clarify what you understood
Course, onset and duration
Skin lesions at the bite site?
Ulcerative, nodular, plaque-like, or verrucous
SOCRATES if pain
Associated symptoms (DDx):
Prolonged fever
Fatigue
Analysis of Anorexia
chief Weight loss
complain Abdominal distention
Cough
Diarrhoea
Rigors
Bleeding, including epistaxis
Risk Factors:
A previous stay in an endemic area
Red Flags
Medical , Surgical
Past Hx Allergy , Medication
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
conclusion
384
Leishmaniasis Ex

Vital signs
General
Appearance
Presenting signs in CL include:
Ulcerative, nodular, plaque-like, or verrucous skin
lesions at the bite site (localized CL). Lesions
typically affect readily exposed skin, including the
face, arms and lower limbs.
• A single ulcerative lesion involving the ear
pinna is known as ‘chiclero’s’ ulcer in southeast
Mexico and Latin America, when caused
by Leishmania Mexican
• Lesions at sites distant from the sand fly bite,
Special such as areas of minor trauma
• Multiple non-ulcerative skin nodules (diffuse
cutaneous leishmaniasis)

In VL, the following can be detected:

• Wasting
• Lymphadenopathy (common in Sudan,
uncommon elsewhere)
• Splenomegaly
• Hepatomegaly
• Hyperpigmentation (in South Asia).

385
 ‫‪Leishmaniasis‬‬
‫‪CRAPRIOP for Management‬‬
‫الليشمانيا عدوى طفيلية تنتقل بوساطة لدغات ذباب الرمل املصاب بالطفيلي‪.‬‬
‫وينشط هذا الذباب في ساعات املساء‪ ،‬والشفق‪ ،‬والليل‪ ،‬أي من غروب الشمس‬
‫حتى الفجر‪ ،‬كما أنه يكون أكثر انتشارًا في املناطق الريفية‪.‬‬
‫هناك أنواع مختلفة لليشمانيا‪ ،‬لكن األكثر شيوًعا هما‪:‬‬
‫النوع اجللدي‪ :‬يسبب تقرحات اجللد‪.‬‬
‫النوع احلشوي‪ :‬يؤثر في األعضاء الداخلية‪ ،‬مثل‪ :‬الطحال‪ ،‬والكبد‪ ،‬ونخاع‬
‫العظام‬
‫يتم عالج داء الليشمانيا بحسب توجيهات الطبيب املناسبة للحالة‪.‬‬
‫ال توجد لقاحات ملنع العدوى‪ ،‬ولكن هناك إرشادات‪ ،‬وطرق؛ ملنع اإلصابة به‪Clarification .‬‬
‫األعراض‪:‬‬
‫الليشمانيا اجللدية‪ :‬قد ال تظهر أعراض‪ ،‬أو عالمات عند بعض املصابني بها‪،‬‬
‫‪Reassurance‬‬ ‫ولكن قد يعاني بعضهم قرحة واحدة‪ ،‬أو أكثر على البشرة‪ .‬وقد تتغير شكل‬
‫القرحة‪ ،‬أو حجمها مع مرور الوقت حتى تتكون قرحة لها حواف مرتفعة على‬
‫شكل فوهة البركان‪ .‬وعادة ما تكون هذه القرحة غير مؤملة‪ ،‬ولكنها قد تصبح‬
‫مؤملة‪ .‬وقد تتورم الغدد الليمفاوية لدى بعضهم‪ ،‬وذلك بحسب املنطقة التي بها‬
‫القرحة‪.‬‬
‫الليشمانيا احلشوية‪ :‬قد يعاني بعض املصابني عدوى صامتة‪ ،‬أي دون أعراض‪،‬‬
‫ولكن إذا ظهرت األعراض فإنها تكون في صورة‪:‬‬
‫ارتفاع درجة حرارة اجلسم ‪,‬فقدان الوزن‪ .‬تضخم الطحال‪ ،‬والكبد‬
‫نقص في عدد خاليا الدم احلمراء أو خاليا الدم البيضاء أو الصفائح الدموية‪.‬‬
‫ال توجد لقاحات‪ ،‬أو أدوية ملنع عدوى الليشمانيا‪ .‬وأفضل طريقة للمسافرين‬
‫ملنع اإلصابة بالداء هي حماية أنفسهم من لدغات ذبابة الرمل؛ لتقليل خطر‬
‫التعرض للدغات‪ ،‬مع احلرص على اتباع التدابير الوقائية التالية‪:‬‬
‫• جتنب األنشطة اخلارجية خصوصًا من الغسق حتى الفجر‬
‫• جتنب النوم في العراء بالقرب من املزارع‪ ،‬وحظائر احليوانات‪ ،‬وجحور‬
‫الفئران‬
‫‪Advice‬‬ ‫• عندما تكون في الهواء الطلق‪ ،‬أو في أماكن غير محمية‪ ،‬يجب تغطية‬
‫اجلسم‬
‫• استخدام الناموسية عند النوم‪.‬‬
‫• ارتداء جوارب‪ ،‬ومالبس بأكمام طويلة‪.‬‬
‫• استخدام طارد احلشرات على اجللد املكشوف‪.‬‬
‫• اتباع اإلرشادات املوجودة على ملصق املادة الطاردة‪.‬‬

‫‪386‬‬
 Leishmaniasis
Leishmaniasis

Prescribing

Referral

A full blood count is recommended in VL to identify and

monitor anemia, leukopenia, and thrombocytopenia.

Certain medications used in the treatment of leishmaniasis

may cause hepatic or renal dysfunction, necessitating
measurement of liver function tests and urea at baseline.

A human chorionic gonadotrophin (hCG) pregnancy test is

essential prior to choosing treatment options as various
Investigations medicines are toxic to the fetus.

An ECG prior to using pentavalent antimonial drugs or

pentamidine to assess the baseline QT interval is prudent.

Diagnosis is confirmed by microscopic examination of

relevant specimens (histopathology), parasite isolation by
blood or tissue culture, and molecular detection of parasite
DNA by polymerase chain reaction (PCR)
Observation
follow up
Plan See above
prevention
Conclusion
387
 Monkeypox Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of Usually patient complains of symptoms of febrile illness with a typical rash after 1-3
present days .
Allow pt to explain the chief complain
illness Clarify what you understood
Course, onset and duration
Associated symptoms (DDx)
Common symptoms include:
• Rash • Pharyngitis
• Fever • Cough
• Chills • Asthenia
• Lymphadenopathy • Malaise
• Headache • Nausea/vomiting.
• Backache • Anorectal symptoms : pain/bleeding
• Myalgia per rectum
Less common symptoms include:
• Diarrhea
Analysis of • Delirium/confusion
chief • Seizures.
Risk Factors
complain • Recent travel to an endemic country • Contact with African-endemic species
(or country with a current outbreak) of wild animals or exotic pets (dead or
• Contact with a suspected, probable, alive) or products derived from these
possible, or confirmed case (or animals.
contaminated materials)
• Intimate physical contact (including
sexual contact) with people in a
social network currently
experiencing monkeypox activity
(e.g., men who have sex with men
[MSM]), or multiple and/or casual
sexual partners
Medical
Determine the HIV status of all sexually active adults and adolescents, as patients
Past Hx with HIV-associated immunocompromise are at a higher risk for severe
manifestations
Surgical , Allergy and Medication
• Contact with a suspected, probable, possible, or confirmed case (or
Family Hx contaminated materials)
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

388
 Monkeypox Ex
Vital signs
General Appearance
Physical examination usually reveals a rash and possibly
lymphadenopathy. Perform a thorough skin and mucosal examination
(e.g., anal, vaginal, oral, nasal, ophthalmic) for the characteristic
vesiculo-pustular rash.
Examination may reveal lesions that the patient may not be aware of.
Shortly after the prodromal period, a characteristic rash develops. The
rash usually presents 1 to 3 days after the onset of the acute febrile
illness, and typically spreads to all parts of the body within 24 hours.
The rash often affects the palms and soles.
.2022 outbreak:
Nearly all patients present with a rash. However, rash lesions in this
outbreak may be atypical.
Special • Lesions tend to be localized to the genital, perineal/perianal, or
perioral areas and often do not spread further. This suggests
transmission occurs as a result of contact during sexual
intercourse, with lesions possibly starting at the site of
inoculation.
•Lymphadenopathy
•Lymphadenopathy may be generalized or localized to several areas. It
typically occurs with onset of fever and preceding the rash or, rarely,
with the onset of the rash. May be submandibular, cervical, axillary, or
inguinal, and may occur on both sides of the body or just one side.
•Enlarged lymph nodes are approximately 1 to 4 cm in diameter, firm,
tender, and sometimes painful.

CRAPRIOP for management

‫ حتدث عدوى جدري القرود عادًة في‬.‫جدري القرود مرض نادر يسببه فيروس جدري القرود‬
:‫ وغالًبا ما تكون احلاالت التي تظهر خارج أفريقيا ناجتة عما يلي‬.‫غرب ووسط أفريقيا‬
‫ املخالطة اللصيقة حليوان أو إنسان مصاب‬،‫ احليوانات املستوردة‬،‫السفر إلى اخلارج‬
‫بجدري القرود‬
Clarification ‫ يوًما من التعرض‬21‫ و‬5 ‫قد تبدأ أعراض جدري القرود في الظهور خالل مدة تتراوح بني‬
‫ وقد‬،‫ تستمر أعراض جدري القرود ملدة تتراوح بني أسبوعني وأربعة أسابيع‬.‫للفيروس‬
:‫تشمل ما يلي‬
‫ تورم‬،‫ الشعور بالتعب‬،‫ القشعريرة‬،‫ آالم العضالت والظهر‬،‫ الصداع‬،‫ الطفح اجللدي‬،‫احلمى‬
.‫العقد اللمفية‬
Inform patients that once the skin rash has healed they will
Reassurance be fully recovered and no longer infectious, and that they
will also have immunity.

389
 Monkeypox

1- Isolate
Advice 2-wear a mask
3-no sharing equipment
symptomatic treatment and supportive care (simple
Prescribing analgesia for fever/pain, anti-emetic for N/V...)
.immediately isolate patient in isolation room and notify
public health.
.Isolation at home is possible in uncomplicated cases.

.Patients may require hospital admission for the

Referral management of pain, difficulty swallowing (odynophagia),
or bacterial superinfection. Nearly all patients with
perianal or rectal lesions report pain, and hospital
admission has been required for patients with severe
rectal pain and proctitis.

Investigations CBC, U/E, LFT , PCR for monkeypox

Monitor patients for deterioration of their clinical

condition. Advise patients about signs and symptoms of
Observation/ complications that should prompt urgent care (e.g.,
lesions get worse or increase in quantity, worsening pain,
follow up persistent fever, decreased oral intake, visual symptoms,
difficult breathing, dizziness, confusion).

Vaccination with the smallpox vaccine can prevent

infection.
• Routine vaccination against smallpox ceased in the
1970s. However, smallpox vaccines are stockpiled in
Plan/preventi case of an emergency.
on The World Health Organization recommends pre-
exposure vaccination with an appropriate approved (or
off-label) second- or third-generation vaccine (e.g., MVA-
BN, ACAM2000®, LC16) for high-risk groups

Conclusion Includes Safety netting

390
 Anal itching Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

Allow pt to explain the chief complain
present Clarify what you understood
illness
Site: where the itch occur at anus only or other parts of the
body like finger whips and abdomen (scabies)
Onset: at day or at night the itch ,
Course: getting better or getting worse or the same
Durations: for how long have you been suffering from this
itch
Reliving factor
Aggravating factors: more at night,
Severity: how much you rate the itch from 1-10
Associated symptoms (DDx):
-Constipation, diarrhea, nausea , abdominal pain
(complication from pin worms that has infested
Analysis of extraintestinal areas)
chief -insomnia , irritability , restlessness (child abuse)
-dysuria, urinary frequency (UTI)
complain
-vaginal discharge (vaginitis)
-other itchy areas in the body (scabies)
-heavy lifting, chronic cough, rectal bleeding , anal lump
(piles)
-pain on bowel opening (fissure)
Risk Factors:
-crowded humid and worm areas
-no hand hygiene
DDx:
-pin worms
-child abuse. - eczema – psoriasis - atopy
-UTI - vaginitis -perianal abscess - piles - fissure
Medical:
-previous episodes of pinworms infection
-if yes did the pt use any medication? What type? How many
Past Hx doses?
-Hx of anemia , eczema, atopy , psoriasis , DM.
-developmental history and vaccination
Surgical, Allergy and Medication

391
 Anal itching Hx

Family Hx Any family members with the same complain

- Did you notice any change on your child sleep\
appetite
- Who takes him to school
Psychosocial
- Other adults living in the house
All previous above questions about child abuse
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
Expectation: is there anything you want me to do for
ICEE
you?
Effect: does this affect your child school or
attendance
Systemic Review
Conclusion
Examination
Vital signs
General Appearance
Abdominal and anal examination
Special Paddle test with adhesive tape

CRAPRIOP for Management

Pinworm

Pin worms are tiny white worms about 1 cm long,

they commonly infect children 5-10 years of age from
all socioeconomical statues.
Clarification Human to human spread is by contact with infected
person, animate objects in crowded places , pin
worms survive on bedlinen , toys , and others for
about 1 month.

392
Anal itching
- Pinworms are easy to treat and curable but
because its highly contagious the infection can
Reassurance recure again so if the Symptoms appear again seek
doctor help.
- Hand hygiene for all family members
- Wash all clothes, bedlinens , and toilets daily for 2
weeks
- Avoid sharing the personal belongings like towels
Advice - Trim nails regularly
- All family members should be treated
simultaneously regardless if they have symptoms
or not
- Showering preferred over bathing
all family members should be treated with 2 doses 2
weeks apart
For nonpregnant adults and children:
-albendazole:400 mg once po repeat after 2 weeks.
-mebendazole:100 mg once po repeat after 2 weeks
Prescribing For pregnant:
Usually they are not treated unless they have severe
symptoms.
Preferred pyrantel pamoate 11 mg\kg once po repeat
in 2 weeks.
If complications occurred from the pinworms like
Referral (gastritis, vulvovaginitis, oophoritis, salpingitis)
Confirm the diagnosis either by on of the following:
-direct inspection of the female adult larvae at the
anal area
-paddle test with adhesive tape placed in the anal area
Investigations at night or early morning before showering for 3 days
repeated to increase the sensitivity then direct
inspection under microscope
-taking sample from the finger nails
Observation/
No follow up needed
follow up
Plan/prevention All previously mentioned in advice section
Conclusion If the symptoms persist then seek medical advice.

393
 Herpes Zoster Hx
Introduce yourself and establish good rapport ( Name, age and job).
Main symptoms: Rash
Hx of present dermatomal distribution, typically affecting 1–3 dermatomes
illness on one side of the body (most commonly affects the
cervical, trigeminal, thoracic, and lumbar dermatomes.
Course, onset and duration
SOCRATES for pain
The most frequent symptom and may precede the rash
Usually described as “burning”, “throbbing”, or “stabbing
Associated symptoms (DDx)
Fever, headache, fatigue
Paraesthesia
Itching
Analysis of Motor deficits (rare)
chief complain Eye pain (Corneal ulceration)
Risk Factors
Age more than 50 Years, Female, HIV, Cancer, Chronic use of
steroid, chemotherapy
Red Flags
Eye symptoms : pain or reduced of vision.
Other presentations: See theory part
• Herpes zoster ophthalmicus (HZ)
• Herpes zoster oticus
Medical
Surgical
Past Hx Allergy
Medication
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

394
 Herpes Zoster Ex
General Vital signs & Appearance
Dermatology:
Erythematous: maculopapular rash
that quickly evolves into vesicular lesions
Vesicles are initially clear.
Pustulation and rupture typically occur after 3 or 4 days.
Crusting and involution typically occurs between day 7 and 10
Special Lesions may become necrotic generalized.
• Herpes zoster ophthalmicus (HZ)
bridge and tip of the nose Involvement
+ve Hutchinson sign of the nose: a vesicular rash on the nasal
alae
• Herpes zoster oticus
Rash and facial nerve palsy.
Diagnosis is usually clinical, not requiring tests or culture
Investigations
But could be consider PCR, immunohistochemistry, HIV test

CRAPRIOP for Management

Clarification ‫ ميكن أن يصيب الهربس‬.‫الهربس النطاقي هو عدوى فيروسية تسبب طفًحا جلدًيا مؤًملا‬
‫ وهو يظهر عادًة على شكل خط واحد من البثور يغطي اجلانب‬.‫النطاقي أي مكان من اجلسم‬
Reassurance
.‫األيسر أو األمين من اجلذع‬
‫ وهو الفيروس نفسه الذي يسبب جدري‬،‫ينتج الهربس النطاقي عن الفيروس النطاقي احلماقي‬
‫ قد ينشط الفيروس مجدًدا ويسبب الهربس‬،‫ بعد سنوات‬،‫ ففي حال اإلصابة بجدري املاء‬.‫املاء‬
.‫النطاقي‬
Advice .‫ ولكنه قد يسبب آالًمأ شديدة‬.‫ضا يهدد احلياة‬ً ‫الهربس النطاقي ليس مر‬
.‫وميكن أن تساعد اللقاحات على تقليل خطر اإلصابة بالهربس النطاقي‬
.‫العالج املبكر يقلل احتمال حدوث مضاعفات‬
.‫ومن أكثر املضاعفات شيوًعا األلم العصبي التالي للهربس‬
Antivirals shorten the duration of viral shedding, stop the
formation of new lesions, and reduce pain severity.

Treatment is usually with orally administered antiviral

medications such as acyclovir, famciclovir, and valacyclovir.
Prescribing
They should be started within 48 to 72 hours of rash onset and
administered for 7 days (up to 10 days in patients with eye
manifestations).
See theoretical part

395
 Herpes Zoster

Prompt referral to an ophthalmologist is required for all patients

Referral who have eye manifestations (Urgent)
Observation After treatment with a 7-day course of antiviral drugs should be
follow up closely monitored to assess the need for treatment extension.
Vaccine:

Plan
prevention

Conclusion Includes Safety netting

396
 Herpes Zoster

Quick Review

Special syndromes:
• Special syndromes:
Herpes ophthalmicus (cranial nerve V [V1 branch] affected)
• • Ramsay
Ramsayhunt
huntsyndrome (cranial
syndrome nerve
(cranial VIII
nerve affected)
VIII affected)

TEST & TREAT

397
 Brucellosis Hx
Introduce yourself and establish good rapport ( Name, age and job).
Brucellosis could present as Fever of unknown origin,
Hx of lymphadenopathy, arthritis or back pain.
present Please refer to another checklist accordingly
Chief complain (open question) Allow pt to explain the chief complain
illness and Clarify what you understood
Duration (acute or chronic), onset (sudden or gradual, post-
surgery or trauma, travel, contact with animal, ingestion of
raw milk insect bite, contact with patient with upper
respiratory tract infection, exposure to heat or transfusion),
Character(low or high grade), relieving and aggravating factor
(response to antipyretics), timing (continuous, intermittent or
Analysis of diurnal variation), progression (deteriorating or improving),
chief Associated symptoms (rigors, rash, lumps, coryza, diarrhea,
complain vomiting, arthralgia, myalgia and dizziness),
Red flags:
(neck stiffness, weight loss, headache, confusion and
(fever of hemoptysis).
Unknown (DDx) Infection (abscess, TB, granulomata, parasites,
origin/ bacteria, rheumatic fever, fungi and viruses), Autoimmune(
SLE, PAN, PMR, IBD), tumors (lymphoma, solid tumors).
brucellosis) Medication fever.
Risk Factors:
Contact with animal, ingestion of raw milk
DDx) Infection (abscess, TB, granulomata, parasites, bacteria,
rheumatic fever, fungi and viruses), Autoimmune( SLE, PAN,
PMR, IBD), tumors (lymphoma,
Medical H/O brucellosis
Past Hx Surgical, Allergy and Medication
Family Hx Same condition
Occupation ‫راﻋﻲ اﻏﻧﺎم‬
Marital status
Psychosocial Smoking: type and frequency
Illicit drugs IV drug abuse
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

398
 Brucellosis Ex
Vital signs
General Appearance
Cardiac Ex
Focused examination like meningeal signs, rash and lymphadenopathy
Special Abdomen; Hepatosplenomegaly
GU: orchitis
MSK: joints swelling, bursitis

CRAPRIOP for management

‫هو مرض بكتيري تسببه أنواع البروسيال املختلفة التي تصيب بشكل رئيس املاشية واخلنازير واملاعز‬
.‫واألغنام والكالب‬
.‫ينتقل عن طريق االتصال املباشر مع احليوانات املصابة بشكل مباشر أو غير مباشر‬
Clarification .‫تعود معظم احلاالت إلى تناول احلليب غير املبستر أو اجلنب من املاعز أو األغنام املصابة‬
.‫ مبا في ذلك احلمى واخلمول‬،‫أعراضه تشبه أعراض األنفلونزا‬
.‫ لكن من املهم اتخاذ االحتياطات الالزمة ملنع العدوى‬،‫ال يوجد لقاح بشري للوقاية منه‬
Symptoms can resolve 3 to 11 days after starting treatment in
Reassurance uncomplicated disease. Relapse can occur in approximately 10% of
patients.
‫ أو تناول حلوم غير مطهوة بشكل جيد من حيوانات مصابة‬،‫عدم شرب احلليب غير املبستر أو منتجاته‬
.‫باملرض‬
Advice ،‫ إفرزات مهبلية‬،‫ بول‬،‫ دم‬،‫عدم االحتكاك املباشر مع احليوانات املصابة أو إفرازات هذه احليوانات )نسيج‬
(‫أجنة مجهضة وباألخص املشيمات‬
Doxycycline 100 mg PO BID + Rifampin 600-900mg PO OD for 6weeks
OR
Doxycycline 100 mg PO BID for 6weeks + Streptomycin 1 Gram IM daily
for 14-21 days
Tetracyclines are generally contraindicated in children aged <8 years due
to the risk of tooth discoloration and inhibition of bone growth.
Prescribing Therefore, tetracyclines can be replaced by
trimethoprim/sulfamethoxazole in children aged <8 years.
The World Health Organization (WHO) recommends
trimethoprim/sulfamethoxazole 8-9 mg/kg/day PO in divided dose for 6
weeks, plus either an aminoglycoside (streptomycin 30 mg/kg IM OD for
3 weeks or gentamicin 5 mg/kg IM/IV OD for 7-10 days) or rifampicin
15-20 mg/kg/day PO 1-2 divided dose for 6 weeks.
Complicated disease(orchitis, sacroiliitis, spondylitis, endocarditis,
Referral meningoencephalitis, focal brain or cranial nerve lesions
CBC(anemia, thrombocytopenia) SEROLOGY;(serum agglutination test
Investigations >1:160, >1:320 endemic areas,) ELISA, B Culture BM Culture, CSF Culture
Observation/follow 3-6 weeks to monitor for relapse and Abx adherence
up
Plan/prevention
Conclusion Includes Safety netting

399
 Tuberculosis Hx
Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain
illness
Clarify what you understood
-Shortness of breath (onset , course , duration , timing
,productive or not )
-Cough (onset , course , duration , productive and bloody or
not )
-SOCRATES for Chest pain
-Associated symptoms: ( Fever, malaise , night sweeting ,
anorexia , weight loss , headache, sore throat , runny nose ,
swelling in any area )
-Risk Factors ( exposure to infection , high endemic area ,
-Red Flags ( ask about extrapulmonary TB):
Analysis of 1-Meningitis TB : Headache for 2-3 weeks, subtle mental
status changes ,Low-grade or absent fever
chief 2-Skeletal TB : back pain , joint pain
complain 3-Genitourinary tuberculosis and renal tuberculosis : flank
pain , dysuria , frequent urination , hematuria.
4-Gastrointestinal TB (according to the site):
-Non-healing ulcers of the mouth or anus
-Difficulty swallowing (with esophageal disease)
-Abdominal pain mimicking peptic ulcer disease (with gastric
or duodenal infection)
-Malabsorption (with infection of the small intestine)
-Pain, diarrhea, or hematochezia (with infection of the colon)
5-Tuberculous pericarditis : subacute onset of fever, night
sweats, dyspnea and pedal edema
Medical ( Hx of of active or latent TB , HIV , malignancy ,
Diabetic , asthma immunocompromised)
Surgical
Allergy
Past Hx Hx of blood transfusion
Hx of vaccination
Hx of travelling to endemic area
Medication (Especially systemic corticosteroids and tumor
necrosis factor-alpha antagonists) IV drug user.

400
 Tuberculosis Hx

Family Hx Hx of active or latent TB in family members .

Marital status
Smoking: type and frequency
Alcohol drink
Psychosocial Occupational hx ( industrial lung disease)
Socioeconomic status
Screening: depression and anxiety
-TB: mostly in endemic area ,presents with productive cough ,
night sweating , fever and weight loss .
-Bacterial pneumonia: presents as sudden onset of
symptoms, such as high fever, cough, purulent sputum, chest
pain, leukocytosis, chest X-ray shows consolidation.
-Brucellosis: Fever, anorexia, night sweats, malaise, back pain
Differential , headache, and depression. History of exposure to infected
Diagnosis animal.
For every - Mycoplasma pneumonia: Gradual onset of dry cough,
headache, malaise, sore throat. Diffuse bilateral infiltrates on
Dx have at chest X-ray.
least 1 -Sarcoidosis : usually in young African American women
question presents with S.O.B on exertion and occasional fine rales on
examination without wheezing of asthma , erythema
nodousum and lymphadenopathy.
-Bronchogenic carcinoma: may be asymptomatic, usually at
older ages (> 50 years old), cough, hemoptysis, weight loss.
-Hodgkin lymphoma: Fever, night sweats, pruritus, painless
adenopathy, mediastinal mass.
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
Conclusion

401
 Tuberculosis Ex
-Vital signs for fever and any sign of dehydration.
General -Appearance if look well , pale.
Typical clinical findings on respiratory examination may
include:
-Sputum pots with purulent or blood-stained sputum
Enlarged, tender lymph nodes.
-Crackles or bronchial breathing over consolidation
Special Dullness to percussion and decreased fremitus over pleural
effusions.
-As extra-pulmonary TB has the potential to affect almost any
organ, consider performing neurological, abdominal,
cardiology, musculoskeletal and skin examinations depending
on features in the history.

CRAPRIOP for Management

‫اﺗﺿﺢ أن اﺣﺗﻣﺎﻟﯾﺔ أﺻﺎﺑﺗك ﺑﺎﻟدرن‬
‫اﻟدرن ھﻲ ﻋﺑﺎرة ﻋن ﺑﻛﺗﯾرﯾﺎ ﺗﺻﯾب اﻟﺟﮭﺎز اﻟﺗﻧﻔﺳﻲ وﻣﻣﻛن ﺗﻧﺗﺷر وﺗﺻﯾب أي ﺟﮭﺎز ﻓﻲ‬
Clarification .‫اﻟﺟﺳم )ﯾﻧﺗﻘل ﻋن طرﯾق اﻟرذاذ ﺑﺎﻟﮭواء( ﻋﻧد اﻻﺣﺗﻛﺎك ﺑﺎﻟﺷﺧص اﻟﻣﺻﺎب‬
.‫ ﻓﻘدان ﺷﮭﯾﺔ ووزن‬-‫ﺗﻌرق ﻟﯾﻠﻲ‬- ‫ ﻛﺣﺔ ﺑﺎﻟدم‬-‫ ﻛﺗﻣﺔ ﺑﺎﻟﻧﻔس‬-‫ ﺣرارة‬:‫أﻋراﺿﮫ ﻣﺛل اﻟﻠﻲ ﻋﻧدك‬
Reassurance ‫ﻻ ﺗﺷﯾل ھم ان ﺷﺎء ﷲ ﻣﻊ اﻟﻌﻼج راح ﺗﺧف اﻷﻏراض وﯾﺗم اﻟﻘﺿﺎء ﻋﻠﻰ اﻟﺑﻛﺗرﯾﺎ‬
‫اﺗﺑﺎع ﻧﻣط ﺣﯾﺎة ﺻﺣﻲ )ﺣﻣﯾﺔ وﺗﻣﺎرﯾن ( واﺧذ ﻟﻘﺎح اﻟﺳل ﻟﻠﻧﺎس اﻟﻠﻲ ﯾﻛون ﻋﻧدھم ﻓﺣص اﻟﺟﻠد‬
Advice ‫ﺳﻠﺑﻲ وھم ﻋﻠﻰ ﻣﺳﺗوى ﺧطورة ﻋﺎﻟﯾﺔ ﻣن اﻟﻌدوى‬
-(INH) is the treatment of choice for latent TB
-For adult, duration is at least 6 month and preferably 9months.
-children younger than 18 years and HIV patient should be treated for 9
Prescribing months
-education about worrisome symptoms and instructed to stop taking
INH and seek medical attention promptly if such symptoms occur.
Referral In case of active TB
The target tuberculin test (TST),also called Mantoux test , ml(5tuberculin
units) intradermal injection
of purified protein derivatives is placed in the forearm, most commonly
Investigations the volar surface. This raises an initial wheal of6-10mm in diameter.
-reaction size is determined after 48-72 hrs
-Interpretation in next page.
-CXR , sputum AFB , CBC , LFT , RFT
Follow up appointment should be after 1 month after initiation of INH
Observation/
for signs and symptoms of
follow up anemia , hepatitis and neurotoxicity.
Plan/prevention Possible need to screen contact
Conclusion Includes Safety netting

402
Tuberculosis

403
Tuberculosis

404
Geriatric

405
 Geriatric Assessment Hx
Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
5 Ms ( matters most, Mind, Mobility, Medication,
Multi-complex )
1- Matters most : reason for visit as in any other case
2- Mind: depression (PHQ2) Anxiety (GAD7),
dementia (Mini-cog test) for more details review
Dementia at neurological section.
Analysis of 3- Mobility: Falls risk ( hx of fall, gait imbalance, home
chief safety check), Activity of daily living (eating, dressing,
complain bathing), change of Vision & Hearing
4- Medication: polypharmacy (≥ 5
meds+Herbal+OTC), Adherence & side effects
(orthostatic hypotension?)
5- Multi-complex: Abuse, urinary & fecal
incontinence, nutritional assessment (↓ appetite, ↓
wt, balanced diet, chronic constipation)
Medical: DM, HTN, Dyslipidemia, osteoarthritis, IHD
Surgical: Glaucoma & cataract surgery
Past Hx Allergy
Medication
Family Hx Hx of malignancy (to focus on during screening)
Marital status
Smoking: type and frequency
Psychosocial Alcohol
Live alone or with family ? Any care giver ?
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
406
 Geriatric Assessment Ex

Vital signs, BMI,

General Appearance (well or ill, hygiene, any tremor)
According to the scenario
Special Special test: Timed up and go test
Functional reach test

CRAPRIOP for Management

Clarification
Reassurance
1-Regular exercise (at least 150 min/week
moderate intensity I; brisk walking, 2 days
muscle strengthen exercise)
Advice
2- Home safety check list ( grab bars for toilet,
remove rugs, improve lighting)
3- Smoking cessation
Prescribing
Referral If impaired hearing for Audiometry
Investigations
Observation/
follow up
1-screening: osteoporosis (DEXA,FRAX),
colon(Colonoscopy) breast(mammogram)
cervical(PAP smear, HPV) lung (LDCT) cancers,
AAA(US)
Plan/prevention 2- vaccine: Annual influenza - PCV at 65 years of
age and PPSV23 one year later - Herpes zoster
vaccine (Shingrix) 50 years or older - Tdap
vaccine (older than 65 years) , and (Td) booster
vaccine every 10 years thereafter
Conclusion Includes Safety netting

407
Pediatric

408
Pediatric
Well baby clinic
Febrile convulsion
Infantile colic
Short stature
Failure to thrive
Breathing hold spells
Nocturnal enuresis
Limping
Down syndrome

409
 Well baby clinic Hx

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Analyze the symptoms if any
Onset , course , duration , site , frequency , severity , relieving factor
and exacerbating factor ,school missing , associated symptom
Pregnancy and neonatal history
Pregnancy Labor Baby
Pre-term/term/post-
Type of delivery
Overall health term Weight , height
Problems in labor
Follow up Mother , Head
(breech, premature
illness Medication circumference
rupture of
use Neonatal disease or
membranes)
NICO admission
Nutritional history
- Breast-fed or bottle-fed ( for how long, which formula, amount,
frequency, total daily intake, No. of wet diaper ) - Weaning - time of
introduction of solids and cereals - Supplements
Immunization history
Analysis of Check immunization card status; up to date or delayed and why? Any
chief previous reaction
Developmental history
complain Gross and fine motor , visual , speech ,social and play , schooling,
Screen for ADHD & autism (mentioned below in details)
Red flags (Developmental):

Medical, Surgical,
Medication: vit D, Iron
Past Hx Hospitalization, Blood transfusion
Allergies
Result of previous tests

410
 Well baby clinic Hx
Family Hx Consanguinity , congenital dis
‫عایش مع مین ؟‬, ‫مین املعیل؟‬, ‫مین الداعم ؟‬
Psychosocial Occupation , parent smoking , housing , education of parent , contact
with animal Psychological à depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
General: Feeding and appetite , Wight loss and irritability
CVS: Breathlessness , sweaty on feeding , Cyanosis
Respiratory: SOB , cough , Runny nose , Noisy breathing
GIT: Abdominal pain , N/V , Diarrhea ( frequency , appearance of stool )
, constipation ,jaundice
Systemic Genitourinary: Frequency , dysuria , Nocturia , enuresis , hematuria ,
incontinence , age of menarche
Review CNS: irritability ,drowsiness , fits or abnormal movement , headaches ,
numbness , weakness
Hematological &oncological: pallor , jaundice ,bone pain , bruises ,
bleeding
Infections: Skin rash , contact with sick people , recent travel
Musculoskeletal &skin: joint swelling or pain , skin rash
Conclusion Hidden agenda :Do you want to discuss anything else ?

Examination
Vital signs and Measure and Plot on Growth Chart : Weight , Crown-
heel length , Head circumference Top to toe
Appearance
Cry: feeble, pitch
Color: cyanosis, pallor, jaundice (hemolysis),rashes/petechiae
Birth trauma: caput succedaneum, subconjunctival hemorrhages
(pressure), cephalohematoma (ventouse),forceps marks
Dysmorphic features: dysmorphia, cleft lip (Downs),small jaw/tongue
(Pierre-Robin syndrome)
Posture, tone and movements: hemiparesis, opisthotonos,
hypertonicity, myoclonus
General Cranium: look for cephalohematoma, cranium deformities, feel
fontanelles and sutures(check fused)
Face: dysmorphic features, cleftlip, ears(low set, pre-auricular skin tags,
deformity (Downs)),feel with little finger inside mouth roof of mouth
(cleft palate; high arched palate =Marfans) and determine presence of
suck reflex
Eyes: check red reflex using ophthalmoscope (absent = congenital
cataracts; white = retinoblastoma)
Shoulders: check aligned, feel clavicles
Arm: extend, palmar creases(Downs), look for extra digits(polydactyly)
or fused digits(syndactyly)

411
 Well baby clinic Ex
Chest: Respiratory rate o Capillary refill o Look for signs of respiratory
distress(in-drawing of intercostals muscles) o Auscultate chest and heart
sounds
Abdomen: Inspect for distension (bowel obstruction),scaphoid abdomen
(diaphragmatic hernia) and comment on umbilical stump (any tracking, bleeding,
discharge) o Palpate for masses, hepatosplenomegaly and ballot kidneys
Femoral pulses
Genitalia:
Boy: feel testes, check testes are descended, check for hypo/epispadias,
foreskin;
Girls: check vulvar lesion, cysts/tags; check anus is patent
Hips:

Legs: extend, check same length, femoral creases (Down’s), check feet for
Special talipes (‘clubfoot’) and calcaneovalgus (abducted forefoot and dorsiflexed
ankle) and do ROM at ankles, look for extra digits (polydactyly) or fused digits
(syndactyly)
Back: turn baby prone Inspect for lipomas, tufts of hair (spina bifida), port
wine stains and Mongolian blue spot o Palpate for spinal abnormalities(spina
bifida) and natal cleft.
Reflexes:

Investigations 9-12 month do CBC

412
 ‫‪Well baby clinic‬‬

‫‪CRAPRIOP for Management‬‬

‫تقي التطعيمات‪ ،‬األطفال من اإلصابة ببعض األمراض املعدية ومضاعفاتها اخلطيرة‬
‫‪Clarification‬‬
‫هنالك بعض االثار اجلانبية البسيطة كالتفاعالت املوضعية مثل األلم او حدوث احمرار‬
‫‪Reassurance‬‬ ‫او تورم في موضع احلقن او حمى تو االنزعاج والتوتر لبعض الوقت ومن النادر ان‬
‫حتدث اثار جانبية خطيرة‬
‫ینصح بعمل كمادات بارد على موضع احلقن‬
‫‪Sleeping‬‬
‫• من عمر ‪ 6‬شهور ينام لوحده على ظهره او على اجلنب‪ -‬بدون إكثار املالبس‪-‬‬
‫دون اكثار العاب بجانبه‪.‬‬
‫• من عمر ‪ 12‬شهر ينتظم النوم‪ ,‬ينام طول الليل و يأخذ قيلولة بالنهار‪.‬‬
‫‪Feeding‬‬
‫• الرضاعة الطبيعية إلى ‪ 6‬شهور‪ - .‬بدأ الفطام فطوم على سنة و‪ 6‬شهور‪.‬‬
‫• نبدأ بنوع واحد من الطعام كل ‪ 3‬أيام‪.‬‬
‫نبدأ باخلضار قبل الفواكه ثم الدجاج‪ - .‬السمك \وصفار البيض على ‪8‬‬ ‫•‬
‫شهور‪.‬‬
‫• زبادي\ جنب من عمر ‪ 9‬شهور‪.‬‬
‫• تكون وجبتني باليوم إلى ‪ 3‬وجبات‪.‬‬
‫• ال يعطى عسل\ مكسرات\ حليب بقر ‪ :‬قبل عمر السنة‪.‬‬
‫‪Oral health‬‬
‫‪Advice‬‬ ‫• تنظيف األسنان عن طريق قماش أو شاش‪ - .‬بعد عمر السنة الزم يزور طبيب‬
‫األسنان‪ - .‬ويأخذ فلورايد من عمر ‪ 6‬شهور وكل ‪ 6‬أشهر‪.‬‬
‫• ال يشرب رضاعة وقت النوم أوبعد عمر السنة أو يشرب عصير في الرضاعة‪.‬‬
‫• ال ميص إصبعه باإلبهام‪.‬‬
‫‪Toilet training‬‬
‫• يبدأ من عمر سنتني و‪ 5‬شهور إلى عمر ‪ 4‬سنوات‪.‬‬
‫• تعليم التبول في الليل من عمر ‪ 8‬سنوات‪.‬‬
‫• عشان نعرف أن الطفل مستعد الزم يفك مالبسه بنفسه\ ويجلس وقت طويل‬
‫ناشف‪.‬‬
‫• تنظيم وقت دخول احلمام بحيث يكون كل ساعة إلى ساعتني‪.‬‬
‫‪Safety‬‬
‫• طبعا ممنوع التدخني في املنزل‪ ,‬ال تترك األدوات اخلطيرة في متناول يد الطفل‪,‬‬
‫تغطية أفياش الكهرباء‪ ,‬قفل الشبابيك والدرج ‪,‬تعريض املنزل للشمس كل يوم مدة‬
‫‪ 30‬ساعة‪.‬‬

‫‪413‬‬
 Well baby clinic

Reading
.‫ شهور‬6 ‫ إلى‬4 ‫• القراءة للطفل مهمه تزود معدل الذكاء من عمر‬
‫العقاب‬
.(‫• كرسي العقاب من عمر سنة )حسب العمر أعطي دقيقة‬
Advice ‫كرسي السيارة‬
rear-facing in back seat ‫• من الوالدة إلى عمر السنتني‬
forward-facing in back seat‫ سنوات‬5 ‫• من سنتني إلى عمر‬
Booster seat‫ سنوات‬5 ‫• بعد‬
VITAMIN D
400 IU daily for children of all ages
Paracetamol
10-15mg/kg
IRON
• Preterm: 1 to 12 months
- if exclusively breastfed ➔ 2 mg / kg per day
Prescribing - if using iron-fortified formula ➔ 1mg/kg per day
• Term infant:
4 to 6 months to 12 months.
- if exclusively breastfed ➔ 1 mg / kg per day
- if using iron-fortified formula ➔ Supplements not needed
• Toddlers 1 to 3 years: 7 mg per day
• Children 4 to 8 years: 10 mg per day
Referral Failure to thrive or obesity of case in Diet
Investigations Mentioned above
Observation/ Follow up soon and encourage child's presence. Give
follow up away reading material if available.
Plan/prevention Screening: mentioned below in details
Is everything clear? Or do you need me to repeat
Conclusion anything else? If there is anything you are concerned
about you can book an appointment. Thank you

414
Well baby clinic

415
‫‪Well baby clinic‬‬

‫الفحوصات الهامة للطفل‬

‫‪416‬‬
 Febrile convulsion Hx

Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
-Attack of seizure onset, course ,frequency , duration
part of body or generalized.
-Site and action taken.
-Associated with (loss of consciousness –cyanosis – eye symptoms –
uncontrolled jerky movement of arms or legs – urinary or fecal
incontinence - tongue or lip pitting – drooling saliva )
-precede with aura ( headache –nausea – vomiting )
-Followed with post ictal ( duration – coarse breathing – weakness or
paralysis )
Analysis of -Aggravating factors (risk factors ) : stress – noise – missed meals –
chief fatigue- noise –lack of sleep –excess use of electronics and relieving
factors
complain red flags :
Brain tumor ( weight loss-fatigue- poor appetite – headache awake
from sleep with early morning vomiting – diplopia )
Brain infection as meningitis ( fever – projectile vomiting – headache –
neck rigidity – rash )
Post trauma (recent head trauma- injury- concussion )

Prenatal- Neonatal and Postnatal HX:

Vaccination history, Growth ,developmental and nutritional.
Medical Previous Similar conditions, hospital admission,
surgical
Past Hx Medication
Allergy
Family Hx Same condition, malignancies, psychiatric diseases or any chronic illness
Family structure
Living environment
Psychosocial Family stressors , Smoking and substance abuse - Education level of
parents
Parent-child relationship
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

417
 ‫‪Febrile convulsion Ex‬‬

‫‪Vitals‬‬
‫‪General‬‬ ‫‪General Inspection, appearance, signs of trauma‬‬
‫‪Full neurological examination and cranial nerves Ex.‬‬
‫‪Special‬‬ ‫‪Meningeal signs if suspect meningitis‬‬
‫‪CBC‬‬
‫‪blood glucose level‬‬
‫‪Electrolytes‬‬
‫‪Investigations Liver enzymes‬‬
‫‪Renal function test‬‬
‫‪EEG‬‬
‫‪Ct or MRI brain‬‬

‫‪CRAPRIOP for Management‬‬

‫التشنجات احلرارية عبارة عن نوبات تشنجيه حتدث في األطفال في الفترة‬
‫العمرية ما بني ‪ 6‬أشهر إلى ‪ 5‬سنوات‪ .‬حتدث هذه التشنجات نتيجة لعدم‬
‫قدرة الدماغ على حتمل درجة احلرارة العالية في ظل استعداد وراثي‪.‬‬
‫وهي نوعان‪ :‬النوع البسيط ‪ :‬وهو التشنج الذي يكون عامًا أي تشنج في‬
‫‪Clarification‬‬ ‫جميع أجزاء اجلسم وليس بجانب واحد فقط‪ ،‬ومدته اقل من ‪15‬دقيقه‬
‫النوع املركب ‪ :‬هو التشنج الذي يحدث جلزء واحد من اجلسم ومدته أكثر من‬
‫‪ 15‬دقيقة‪ ، ،‬وملرتني أو أكثر خالل ‪ 24‬ساعة‪ ،‬وقد يعقبه شلل أو خلل في‬
‫األعصاب‬
‫اطمئني التشنجات احلرارية شائعة بني األطفال تبلغ نسبة حدوثها‬
‫‪ % 4-2‬وتعد أكثر أنواع التشنجات انتشارا في األطفال‪.‬‬
‫في حالة التشنجات احلرارية البسيطة ‪ ،‬يكون خطر اإلصابة بالصرع حوالي‬
‫‪٪ ، 2-1‬وهو أعلى بقليل من خطر اإلصابة مقارنة بعامة األطفال‪.‬‬
‫‪Reassurance‬‬ ‫بالنسبة لألطفال الذين يعانون تشنجات حرارية معقدة ‪ ،‬أو منو غير طبيعي ‪،‬‬
‫أو تاريخ عائلي للصرع ‪ ،‬فإن اخلطر يكون بني ‪ 5‬و ‪ ٪10‬اآلثار العصبية ‪،‬‬
‫واإلعاقة الفكرية ‪ ،‬واالضطراب السلوكي ‪ ،‬نادرة بعد نوبات التشنجات‬
‫احلرارية‪ .‬يتحسن على عمر ال ‪ 5‬سنوات‬

‫‪418‬‬
 Febrile convulsion

, ‫ الكمادات‬, ‫ عن طريق االستحمام‬:‫أحرص على عدم ارتفاع درجة حرارة طفلك‬-

‫تخفيف املالبس و إعطاء أدويه خافضه للحرارة‬
.‫اعطائه خافض حرارة قبل وبعد التطعيم‬-
:‫ما يجب عليك فعله وقت التشنج‬
‫كن هادًئا‬-
Advice ‫قم بإزالة أي شيء في فم املريض بأصبعك و ال تضع أي شيء في فمه لتجنب‬-
.‫االختناق‬
.‫ وابعد اي مصدر للخطر‬،‫أرخي قطع املالبس املشدودة‬-
‫ضع طفلك على جانبه أو على بطنه ملنع اختناقه بلعابه مع جتنب محاولة تثبيت املريض‬-
.‫و منع حركته‬
‫حسب الوقت\ إذا استمرت التشنجات أكثر من خمس دقائق اتصل باإلسعاف‬-
Adequate dose of antipyretics(syrup or rectal Paracetamol
15 mg/kg 6 hourly)
Prescribing or Ibuprofen 10 mg/kg 6-8 hourly
Treat the cause of fever
Need referral in complex febrile seizure or if there is
Referral abnormal findings on examination.
Investigations Mentioned above

Observation/
F/U in 2 days or earlier if any red flag occurs.
follow up
Vaccination
Nutrition advice
Plan/prevention
Car seat
Teeth cleaning
If the attack was more than 5 minutes , involved one part of
Conclusion the body, more than once in the same day:
Call ambulance or go to ED.

419
Febrile convulsion

420
 Infantile colic Hx
Introduce yourself, consent, establish good rapport ( Name, age and job, etc.)

• Chief complain (open question)

Hx of present
• Allow pt to explain the chief complain
illness
• Clarify what you understood
• Onset: (age when the problem first started, time of the day that
usually the episodes happen)
• Duration: (how long has the problem been there, length of the crying
episodes)
• Infant’s behavior:(active or lethargic)
• Aggravating and reliving factors
• Associated symptoms: (urine or stool abnormalities, blood in urine or
stool fever, irritability, skin rash ,SOB ,cyanosis, apnea, vomiting,
change in appetite, poor weight gain, or weight loss)
Analysis of • Dose the baby fit the Wessel criteria (rule of 3):
[Link] is less than 3 months of age.
chief
[Link] episodes last more than 3hours per day.
complain [Link] more than 3 days per week.
[Link] more than 3 weeks.
• Rule out organic reasons: hair tourniquet around finger or toe,
constipation, or anal fissure, or
sign of otitis media
• Red flags:
[Link] crying, projectile vomiting, absence of bowel motion, rectal
bleeding, red currant jelly stool (Intussception, or intestinal
malrotation)
[Link] of testicular torsion
[Link] of intracranial bleeds (shaken baby syndrome)
• Medical, Surgical, Allergy, Medication
As a children need to add:
• Prenatal, natal and postnatal
(mode of delivery, issues during pregnancy, term?, NICU admission)
• Previous medical illnesses or hospital admission
Past Hx • Developmental milestones
• Nutrition
(breast fed or bottle, amount, weaning, wet dippers per day, supplements,
weight gain)
• Immunization
Family Hx
Psychosocial
Ideas: what do you think it might be?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
421
 Infantile colic Ex
• Vital signs
• Appearance
• General appearance, level of distress
• Weight, height, and plot them in growth chart.
General • Look for sign of organic causes: fever, ear infection,
pulse for tachycardia, hair tourniquet)
• abdomen for hernia, distention or tenderness and
for torsion
• CHEST, CVS, ABDOMINAL Ex

CRAPRIOP for Management

No clear cause was found for infantile colic, self-limiting episodes
Clarification of inconsolable crying of a healthy infant. It peaks around six
weeks of age and resolves by 3 months of age.
Self-limiting course, peaks around six weeks of age and resolves by
Reassurance 3-6 months of age
Breastfed infant:
• advice mother of low allergen diet
• 5 drops of Lactobacillus reuteri
Formula-fed infant:
• Change to hydrolyzed formula (2weeks trial)
Advice • Breastfeeding should be continued
• suggest changes to feeding technique and/or experimenting
with a number of techniques to soothe the infant (e.g.,
rubbing the infant's abdomen, providing "white noise," etc.)
as first line interventions
Prescribing No need, (check advices)

Referral No need

Investigations Diagnosis of exclusion by history and physical examination

Observation/
follow up
• immunization
• Vit D supplement
Plan/prevention • Car seat
• House hazards
Includes:
• Summarization
Conclusion • Do you have any further questions
• Safety netting

422
 Infantile colic

• self-limiting episodes of inconsolable crying of a healthy infant.

• It peaks around six weeks of age and resolves by 3-6 months of age.
• It usually happens in the evening and without triggers.
• It leads to parental distress and multiple medical visits.
Infantile colic • Some differentials that need to be excluded include Hirschsprung
disease, incarcerated hernia, testicular torsion, child abuse,
gastroesophageal reflux disease, pyloric stenosis, anal fissure,
corneal abrasion, cow's milk allergy, hair tourniquet syndrome, and
inadequate feeding.
• diagnosis of exclusion by history and physical examination
• rule out red flags (like Distended abdomen, Fever, Lethargy )
Diagnosis • "Rule of three“ (crying more than 3 hours per day, more than three
days per week, for longer than three weeks in a healthy infant of less
than three years of age.
• Most significant step in the management is parental reassurance:
(Learning about the temporal pattern of colic can be reassuring:
the mean crying duration begins to decrease at 6 weeks of age and
decreases by half by 12 weeks of age. Colic does not always resolve
by 3 months of age. Approximately 15% of infants with colic
continue to have excessive crying after 3 months of age,
reassurance that colic passes by age of 5-6 months)
• Self-limiting course
• Breastfeeding should be continued
Management • In bottle-fed infants, changing the formula to hydrolyzed type
reduces colic symptoms.
• Additionally probiotic Lactobacillus reuteri
• Suggest changes to feeding technique and/or experimenting with a
number of techniques to soothe the infant (e.g., rubbing the infant's
abdomen, providing "white noise," etc.) as first line interventions.
Simethicone and proton pump inhibitors are no better than
placebo
• Dicyclomine in infants less than six months of age

423
 Short stature Hx
Introduce yourself and establish good rapport ( Name, age and job).
• Chief complain (open question): being short
Hx of present
• Allow pt to explain the chief complain
illness • Clarify what you understood
Course, onset and duration
Associated symptoms:
Constitutional: Fever , loss of Wt &appetite , night sweat
- GIT : appetite ,chocking , dysphagia, vomiting , abdominal pain , abdominal
distention , diarrhea or constipation, stool character :appearance , color
associated blood mucus or fat , volume , frequency ,perianal irritation .
- Resp :Breathing abnormalities , snoring , apnea , recurrent respiratory infection ,
ear discharge.
- Neurological sympt ;night blindness, ataxia, convulsion
-Endocrine: polyuria , polydipsia , wt changes , appetite changes , cold or heat
intolerance .
- Skin; infection , rash , pallor , bruising
Analysis of -Pubertal symptoms : enlarged breast , testis , underarm and pubic hair , voice
change .
chief - Any pregnancy complication : infection , bleeding , IUGR
complain - Maternal malnutrition , smoking,alcohol
• Neonatal hx :
- GA , birth WT ,SVD or SC , NICU admission .
- Apgar score and ventilation
- Growth parameters : length , WT , HC
- Congenital anomalies or feeding problems , jaundice , sepsis
• Postnatal hx :
Vaccination hx, Developmental hx, Nutritional hx .
Risk Factors: Father and mother HT
-age at menarche , age at pubertal growth spurt .
- Hx of similar condition in family (constitutional delay or familial short stature in
parents or siblings)
- Hx of GH def in parent or sibling
Medical : bone or cartilage disease , cystic fibrosis ,thalassemia , hypothyroidism ,
GH def , renal Disease, malignancy.
Past Hx Surgical ;
Medication ; steroids ,ADHD meds , anticonvulsants, chemotherapy , l-thyroxine
and Allergy
familial growth pattern : short stature , GH def
Family Hx hx of : celiac disease , IBD , CF , TB , HIV , chronic diarrhea , endocrine problems.
Social history: exclude neglect, poor care, stress related to peer pressure or
Psychosocial bullying at school, alcohol, smoking.
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
Conclusion

424
 Short stature Ex
Vital signs
Appearance; dysmorphic feature ? webbed neck ,cubitus valgus and
absent puberty in girls (turner syndrome or down )or disproportionate
General short stature (ie, short limbs compared with trunk)as chondrodystrophy
• General systemic exam.

Weight and height plotted on the chart, upper to lower body segment
ration, arm span.
• Mid-parental height in cm:
Special Boys: (Fathers Height(cm) + Mother's Height(cm)+13)/2
Girls:(Father's Height(cm) + Mother's Height(cm)-13)/2.
• Tanner Pubertal staging.
(CBC), (ESR), CRP , tissue transglutaminase (tTG) (IgA), creatinine,
electrolytes, (TSH), (T4), insulin-like growth factor-I (IGF-I), and insulin-
Investigations like growth factor binding protein-3 (IGFBP-3). FSH , karyotype ,Celiac AB
,Urinalysis

CRAPRIOP for Management;

.‫هو حالة تتميز بقصر الطول بشكل غير عادي قد ال يكون ملحوًظا حتى وقت الحق في مرحلة الطفولة أو البلوغ‬
.‫قد يعاني بعض املصابني مشاكل جسدية أخرى‬
Clarification Short stature is a height more than two standard deviations below the mean for
age (less than the 3rd percentile)
Reassurance ‫ ويكونون قادرين على عيش حياة طبيعية نسبيًّا‬،‫معظم املصابني ال يعانون أي مشاكل خطيرة‬
Dietary advice ( Undernutrition, Celiac disease)
Advice Limb lengthening procedures( skeletal dysplasias )
Treat the underline cause
Levothyroxine ( In Hypothyroidism).
Recombinant growth hormone, It is administered through
daily injections over several years. For children with idiopathic short stature,
Prescribing four years of treatment results in an increased height of 3.7 cm .
Oxandrolone (Oxandrin) is an oral anabolic steroid that has been shown to
increase height velocity but has little effect on final height.
Insulin like growth factor has been used in children with insulin like growth
factor deficiency.
if chromosomal, endocrine or chronic illness defined.
Referral Growth velocity < 5 cm (2 in) per year
Investigations Mentioned above

Observation/
For monitoring we will schedule f/u q 6-12 months to assess for GV.
follow up
Plan/prevention
Conclusion Includes Safety netting

425
 Failure to thrive Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness Allow pt to explain the chief complain and Clarify what you understood
Onset, course, duration, Current WT , previous WT
Prenatal hx :
Age of mother , gravida para - Any pregnancy
complication : infection , bleeding - Maternal malnutrition , smoking , depression
Neonatal hx :
GA , birth WT ,SVD or SC , NICU admission .
Apgar score and ventilation
- Growth parameters : length, WT , HC
- Congenital anomalies or feeding problems , jaundice , sepsis.
Analysis of Postnatal hx
Vaccination hx
chief Developmental hx
complain Nutritional:
-Detailed feeding hx from infancy through this period --milk : breast feeding or
formula feeding
-when he was started on formula, how the mother prepare it .
- Formula type, amount, number of feeding q how many hours solids :
- Age of weaning - use of baby food and table food - beverage consumption :
juice , soda - composition of food , healthy or not - how many meals per day ,
snack - family routine mealtime, daycare routine - any special restriction in food
- any difficulty in feeding, sucking , chewing , swallowing
- Constitutional : Fever , loss of Wt &appetite , night sweat.
Previous hospital admission, recurrent respiratory, bacterial or viral infection, ,
exposure to TB, GERD , UTI , congenital heart disease .
Past Hx Past surgical hx: bowel resection
Medication hx
Allergy hx: allergy to milk or certain food , atopy or asthma
Familial growth pattern : FTT in siblings
Hx of : celiac disease , IBD , CF , TB , HIV , chronic diarrhea , endocrine problems.
Family Hx Parental malnourishment
Hx of psychiatric disorder
Family structure, no of siblings
Financial status
Psychosocial living environment
Family stressors , Smoking and substance abuse - Education level of parents
Parent-child relationship
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
GIT : appetite ,chocking , dysphagia, vomiting , abdominal pain , gases , abdominal
distention , diarrhea or constipation, stool character :appearance color associated
Systemic blood mucus or fat , volume , frequency , perianal irritation .
Review Resp :Breathing abnormalities , snoring , apnea , recurrent respiratory infection , ear
discharge. - Neurological abnormalities , night blindness , ataxia , convulsion ,
Skin infection , skin rash , pallor , bruising
Conclusion
426
 Failure to thrive Ex
-Vitals
-growth parameters : HT , WT , HC Wt for age and sex below 5th percentile = FTT
Head to toe:
Mental status, Distress, pain, Dysmorphism
Mouth : palate deformities , dental caries , thrush
Ear : ear infection
General Neck :thyroid exam
CVS : murmur Chest : infection
Abdomen : distention , hepatomegaly , mases -Genitalia
CNS : fontanelle , wasting , power and reflex , gait --Extremities: edema
Skin and hair : rash skin changes , bruising , hair color and texture
Assessment for signs of possible child abuse
CBC
urea and electrolytes
LFTs
Investigations

Thyroid function
Test for celiac antibodies (anti tissue transglutaminase and IGA )
Urinalysis
Bone age study of wrists if constitutionally short stature
HIV, TB
Zinc level
Food allergy tests
ESR , CRP
Sweat test for cystic fibrosis

CRAPRIOP for Management

‫ التي حتدث غالبًا عند بعض األطفال وهم دون السنتني من‬،‫ هو تأخر في منو الطفل‬:‫اخفاق في النمو‬
Clarification ‫ وهي ال تشكل مرض معني‬،‫ وتتسم بعدم الزيادة في الوزن كما ينبغي وفشل في النُمُوّ الطبيعي‬،‫العمر‬
‫ بل مجموعة من األعراض التي قد تنجم عن أسباب عديدة ومتنوعه‬،‫بحد ذاته‬
Reassurance Avoid premature assurance if not sure about the diagnosis.
-Advice about healthy food 3 meals with 2 snacks
-Offer solids before liquids in mealtime to avoid early satiety , limit fruit
Advice juices and carbonated drink
-Avoid junky food , use high calorie rich nutrient food -Increase protein
intake
Multi vitamins and mineral supplements .
Prescribing Anti-acid if needed
Health educator , dietitian , General pediatrics , dentist , social worker
Referral if needed
Investigations Mentioned above
Observation/ FU Schedule a follow up to monitor the pt and monitor growth velocity
Admit pt in case if:
- Severely malnourished
Plan/prevention - Suspected child abuse ,
- Failed outpatient management
- There is serious underlying condition
Conclusion Includes Safety netting
427
Failure to thrive

428
 Breath Holding Spells Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Details of the spells:
Nature (how it happens).
Frequency, provoking factors (crying & frustration, fever, flash
of lights), its occurrence at sleep time (seizure can happen at
Analysis of sleep time whilst BHS does not).
Associated symptoms: (jerky movement, brief cyanosis or
chief pallor, loss of consciousness, tongue biting, post-ictal signs),
complain parent’s reaction during the spells, duration.
DDx:
congenital heart disease/ Epilepsy: last longer, no provoking
factor/may happen at sleep, jerky body movement, loss of
sphincter control, remaining confused for longer time
Medical & Surgical:
Allergy
Past Hx Medication
vaccination
Family Hx Similar condition in siblings & parents, seizure disorders
caregiver, parents’ job & educational level, recent family
Psychosocial changes, parent’s status (conflict, divorce).
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Growth & development: prenatal condition, birth trauma &
Systemic
asphyxia, developmental delay, known neurological disease,
Review congenital heart problems (cyanotic).
Conclusion
Examination
General Vital signs.
Growth parameters & blot on growth charts.
Special CVS & chest examination (murmurs, breath sounds,
cyanosis).
Investigations CBC, iron, ferritin. - Cardiac echo

429
 Breath Holding Spells

CRAPRIOP for Management

Explain what breath-holding spells is: a phenomenon happens as
breath stop with brief jerky movement of stiffness, may lead to
LOC.
Skin may be pale, sweaty or cyanotic.
This condition occurs as a reflex, involuntary in case of anger,
frustration, pain, IDA. May happen for more than one child in
family.
• Nature: stop of breathing for less than one min. with brief jerky
Clarification movement of stiffness, may lead to LOC. Skin may be pale,
sweaty or cyanotic
• Age: at age 6m-6y, more 1-3 y.
• Types: cyanotic with anger and palled with slow heart rate,
• Cause: Reflex/ involuntary
• Precipitating factors: Anger / frustration / pain / IDA
• Prognosis: benign condition / no complication / go as child
grows up
• Frequency; very variable, may occur daily of rarely
It’s a benign condition & has no complications nor leads to
Reassurance developmental problems.
- Try to keep videotaping of the condition if possible
Advice on how to deal with it at home: be calm / do not shake
him/ lay child down on floor to keep him safe/ call 937 if not wake
up quickly or breath again / take him to ER
Advice • After the spell: do not blame child (involuntary) or feel angry on
him / reassure him, helps him to manage his frustration after its
resolution
Prescribing Iron if IDA suspected

Referral Health educator, child neurologist (if seizure is suspected).

Investigations Mentioned above

When to see again: open / if has more frequent or new
Observation/ symptoms
follow up Follow up after 2 weeks for: (lap results, chart record of the
events, opportunistic care, Nutrition advice, Advice for safety).
Plan/prevention if not wake up quickly or breath again take him to ER.
Includes:
• Summarization
Conclusion • Do you have any further questions
• Safety netting

430
 Nocturnal enuresis Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Clarify the presenting complain.
Age of the child (not diagnosed <5years), and duration.
Onset: primary (did not achieved dry bed) or secondary (incontinence
after 6 month of successful dry bed).
Day time incontinence, encopresis (stool incontinence).
Signs of UTI (urgency, dysuria, lower abdominal pain, frequency),
change
of urine.
Urine diary (frequency at morning & night, amount, fluid intake).
Analysis of Constipation, bowel habit, pinworm (anal itching) .
chief complain neurological problems: abnormal movement, limping, difficult
swallowing
Associated conditions :
OSA: Snoring during sleep, period of cessation of breath, enlarged
tonsils
& adenoid.
ADHD: attention / hyperactivity
Autism: avoid eye contact /social interaction
Red flags:- Dysuria - Genital / rectal pain or discharge- Straining to
urinate- Combine diurnal and nocturnal
Developmental School performance
Medical: DM , DI , CKD, seizure, birth complications, congenital
anomaly.
Past Hx Surgical allergy
Medication: diuretics
Family Hx Family Hx:Family hx of enuresis / DM
Social Hx: Home / school: stress (divorce / new baby) Parents
Psychosocial occupation/ issues / drug use.
Screening: depression and anxiety
What family priority? Short/long term
depression: + ABUSE:
- Have you ever been worried that someone was going to hurt your
child?
ICEE - Who takes care of child?
- Who Takes him to school?
- Any new adult or baby at home?
(Also consider abuse if the parents report that the child is deliberately
wetting the bed.)
Systemic Review
Conclusion

431
 Nocturnal enuresis Ex

Vitals + BMI or Growth charts

- Fever
General - Bp
- ( poor growth / HTN >> renal disease)
- ENT: tonsillar hypertrophy, mouth breathing, blocked nose.
- Abdomen: (suprapubic, renal angel)
- Neuro + BACK:
- Neurological exam (power, tone, reflexes, gait and plantar
responses).
- Back for lumbosacral spine (hair tuft / gluteal folds) (neural
Special tube defect).
(Local) - Signs of abuse (physical or sexual)
- Pelvic:
- ✓ Perineal excoriation / vulvovaginitis ( pinworm / sexual
abuse)
- ✓ Boys: hypospadias, epispadias /meatal stenosis
- ✓ Undergarment if wet >> daytime
- ✓ Rectal sphincter tone
Routinely For exclusion:
Urinalysis ( 1st morning void) >> UTI/ kidney disease / DM / DI
Imaging if indicated:-
Investigations - Constipation (fecal impaction)>> Abd. Xra
- Daytime / recurrent UTIs/ suspected structural >> Urology
imaging
- Abnormal Neuro ex / abnormal lumbosacral spine >> MRI

CRAPRIOP for Management

‫سلس البول الليلي )لتبول في الفراش( — هو التبول الالإرادي في أثناء‬
Clarification .‫النوم بعد بلوغ عمر يتوقع فيه البقاء جافًا في الليل‬
‫التبول الالإرادي أمر شائع مافي شي يدعي للقلق احلمدلله مافي أي‬
‫ فغالبا ما يكون مجرد جزء‬....‫عالمات تدل انه في امراض مسؤوله عنه‬
Reassurance ‫طبيعي من تطور منو الطفل‬
‫فتعامل مع املشكلة بالصبر والتفهم‬
‫وكوني داميا بقرب طفلك وال تعاقبيه اذا بلل فراشه‬

432
 Nocturnal enuresis
Education :
‫ سنوات عندهم نفس املشكلة وأغلب احلاالت تتعافى‬5 ‫من اللي عمرهم‬%15
- Voiding diary (effect of interventions)
- Limit fluid intake at night / avoid caffeine
- Scheduled voiding time( total of 4-7 times/ day, including just
before going to bed; if the child wakes at night >> take the child to
Advice the toilet)
- Impact of bedwetting:-
- Bed protection and washable/disposable products
- Room deodorizers
- Washing the child before dressing
- Using emollients
Non-pharmacological:
- Scheduled voiding time
- limit fluid intake at night, reinforcement system (star chart and
rewarding) and responsibility training, no punishment or conflicts.
- Bladder training (awaking schedule).
- Bed wetting alarm.
Prescribing Pharmacological:
- Oral Desmopressin (for ›7 years).
Desmopressin was effective in reducing bedwetting in a variety of
doses and forms. Each dose of desmopressin reduced bedwetting by at
least *one night per week during treatment compared with placebo.
- Imipramine (25mg in 6-8 years & 50mg in 8-12 years old children)
INDICATIONS FOR REFERRAL:
( developmental-behavioral pediatrician, behavioral psychologist, child
psychiatrist, pediatric urologist)
- Suspicion of structural or anatomic abnormalities>> pediatric
urologist.
- Non-monosymptomatic enuresis.
- Developmental, attentional, or learning difficulties.
- Behavioral or emotional problems
- Known or suspected physical or neurologic problems.
Referral - Parents who ✓ difficulty coping with bedwetting or express anger,
negativity, or blame toward the child >> needs additional support
- If no response ( alarm / desmopressin / or combination)
- If suspect child abuse:
- • Always notify Child Protective Services.• Interview child and
parent/caregiver separately if possible.• Keep verbatim record.•
Admit to hospital for medical stabilization if required • Document
in detail the characteristics (location, size, shape, color, nature) of
the lesion(s).• Perform an ophthalmologic exam and skeletal
survey if appropriate.
Observation\FU After 3 months
Plan/prevention
Conclusion
433
 Limping Hx
Introduce yourself, consent, establish good rapport ( Name, age and job, etc.)

Hx of present chef complain (open question)

illness Allow pt to explain the chief complain and Clarify what you understood
Course, onset and duration
SOCRATES for pain
Note: (Hip pain may be described mistakenly by child or parents as groin, knee, or
thigh pain)
Gait:
Limp, inability to weight bear (walking, running)
Trauma:
Any known mechanism of injury Previous injuries, including any patterns
suggestive of non-accidental injury
Aggravating/ Alleviating Factors:
Aggravating factors: weight-bearing, activity types and intensity (running vs.
Analysis of walking), positional, footwear.
chief Alleviating factors: rest, analgesics
Associated Symptoms:
complain 1. Skin changes (erythema, swelling, lacerations/abrasions/bites, rash)
2. Mechanical symptoms (clicking, catching, snapping)
3. Neurological symptoms (weakness, altered sensation)
4. Inflammatory symptoms (morning stiffness)
5. Recent illnesses (especially respiratory, gastrointestinal)
6. Any recent medication use
Physical Activity :
Types of sports/activities (frequency and intensity) Any new
activities
Risk Factors
Red Flags
Medical: (Neurological, inflammatory, endocrine, or rheumatological disease)
Surgical
Allergy
Medication: (Analgesics, anti-inflammatory medications, physiotherapy)
As a children need to add:
Prenatal, natal and postnatal
(mode of delivery, issues during pregnancy, term?, NICU admission)
Past Hx Previous medical illnesses or hospital admission
Growth and developmental milestones
Nutrition
(breast fed or bottle, amount, weaning, wet dipers per day, supplements, weight
gain)
Immunization
Travel Hx: Recent travel (e.g., to areas endemic for Lyme disease, TB)
Family Hx Rheumatic disease or other inflammatory conditions
Ideas: what do you think it might be?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
434
 Limping Ex
Vital signs
• General appearance, level of distress
• Weight, height, and plot them in growth chart.
• Skin changes (rashes, insect bites, pallor, bruising)
• Gait (antalgic, non-antalgic)
General Important notes:
-Start with a general regional exam to help relax the child.
-Limb evaluation should begin with the non-painful limb.
-Examine adjacent joints – both for comparison and because
referred pain (groin, thigh, knee) is common in hip conditions.
Look:
skin changes over the joint; joint swelling;
signs of chronicity (e.g., leg length discrepancy, fixed flexion
deformity, muscle wasting/hypertrophy, deformity);
asymmetrical skin creases; foreign bodies or evidence of trauma;
spinal alignment
Feel:
tenderness; warmth; swelling
Move:
Musculoskeletal Focus on spine and all lower limb joints; active and passive range of
movement (check for symmetry with other side and evidence of
discomfort);
specialized tests:
Trendelenburg test, Galeazzi, Thomas, Faber, Ober- as needed.
Function:
Weight-bearing status and, if able to walk, observe gait pattern
(bearing in mind the child’s age and stage of development).
Measure:
Leg length; muscle strength (as appropriate)
• Abdominal examination
• Testicular examination in boys
Other Systems • Lower limb neurological examination
• System specific exam as indicated (e.g., HEENT esp if a history of
URTI symptoms)
Laboratory:
testing will depend on the findings on history and physical exam:
• CBC, ESR, and C-reactive protein are indicated in the assessment for
possible septic arthritis, osteomyelitis, inflammatory arthritis, or
malignancy.
• Blood cultures should also be ordered in cases of suspected infection.
Investigations Imaging:
required when patients have an acute injury, persistent symptoms, or
signs of infection:
• Plain radiographs are the initial modality of choice: anteroposterior
(AP) pelvis and bilateral frog-leg views.
• Ultrasound is highly accurate in detecting effusions.
• MRI may be used where SCFE is suspected but XR results are
equivocal or if osteomyelitis and neoplasm are suspected.

435
 Management
Condition

Management

• Transient synovitis of the hip is an acute aseptic inflammation of the hip's synovial membrane. It is
a benign, self-limiting condition that typically resolves within 1 to 2 weeks.
Transient Synovitis

• Its etiology is not established, although there appears to be an association with a preceding viral
infection within 1 to 2 weeks in approximately half of cases.
Treatment:
• rest, OTC analgesics, and reassurance for parents.
• Close follow-up is essential, and parents should be instructed to seek medical attention if a child
does not improve within two weeks, becomes febrile, is unwell, has worsening symptoms, or has a
recurrence of symptoms after initial resolution.
• Septic arthritis is caused by a bacterial infection of the synovium and joint space and is a surgical
emergency. Delay in diagnosis can lead to rapid joint destruction and permanent deformity.
• The most common community-acquired microbe implicated in septic arthritis is methicillin-
sensitive Staphylococcus aureus (MSSA)
Kocher Criteria: Differentiating Transient
Synovitis from Septic: Arthritis
Temperature > 38.5C 2.
Septic Arthritis

1. White blood cell count > 12 x 109/L 3

2. ESR > 40 mm/h
3. Inability to ambulate.
• If CRP >2.0nmol/L and all 4 of the Kocher criteria were positive, the PPV for septic arthritis was 98%
Treatment:
• Patients with suspected septic arthritis are typically diagnosed and treated based on clinical
exams, labs. plain radiography and ultrasound (to detect hip effusion and determine the need for
joint aspiration.
Depending on the level of suspicion for septic arthritis, early referral for surgical management and
joint washout to prevent bony damage is recommended.
• LCPD is idiopathic avascular necrosis of the capital femoral epiphysis in a growing child.
• Children with LCPD have delayed skeletal or bone age, disproportionate growth, and mildly short
stature.
Presentation:
Legg-Calve-Perthes Disease (LCPD)

• The symptomatic onset of LCPD typically occurs between 2 and 12 years of age, at a mean age of 7
years.
• Most of these children present to care with either a painless limp or with mild or intermittent pain
in the anterior thigh or knee.
• Pertinent early physical findings include antalgic gait; muscle spasm with mild restriction of hip
motion, especially abduction and internal rotation; proximal thigh atrophy; and mild short stature.
Treatment:
• LCPD is a self-limited process that can take several years from the start of necrosis to complete
healing.
• Treatment is largely related to symptom control, particularly in the early phase of the disease. As
the disease progresses, fragmentation and destruction of the femoral head occur.
• Early referral to a pediatric orthopedist is recommended and operative management is sometimes
required to prevent femoral head deformity.
• In later life, total hip replacement may be necessary to treat secondary degenerative osteoarthritis
of the hip.

436
 Management
Condition

Management

• SCFE is the most common adolescent hip disorder in which the proximal femoral head
(femoral epiphysis) slips posteriorly and inferiorly on the femoral neck (metaphysis) at
the level of the growth plate.
• It is more common in boys than girls
Obesity is a significant risk factor. It can occur as a complication of an underlying
endocrine disorder such as hypothyroidism and pituitary disorders.
• It generally occurs in obese adolescents with delayed skeletal maturation or in tall thin
Slipped Capital Femoral Epiphysis (SCFE)

adolescents who have had a recent growth spurt.

Presentation:
• SCFE usually presents with chronic pain, usually in the knee, groin, or thigh, which can
delay diagnosis.
• The adolescent has an antalgic, out-toed gait. The hip range of motion demonstrates an
increase in external rotation and a lack of internal rotation.
• SCFE is clinically classified as:
- Stable: patient can weight bear on the affected extremity with or without crutches
- Unstable: the patient is unable to weight bear due to pain and instability. (Unstable SCFE can
compromise vascular flow to the femoral head resulting in avascular necrosis)
Treatment:
• When diagnosed, they should be immediately advised to remain non-weight bearing and
sent for hospital admission and expedited surgery (epiphyseal fixation and possible
osteotomy) to avoid possible worsening of the slip or conversion to unstable SCFE.
• Unstable SCFE is an orthopedic emergency, and the patient should be seen and undergo
surgery as soon as possible.

• Patients are less than 16 years old and have arthritis of one or more joints of > 6 weeks
duration with the exclusion of other causes of joint inflammation.
Legg-Calve-Perthes Disease (LCPD)

• Symptoms of JIA are typical: morning stiffness; gelling (stiffness after periods of
inactivity); improvement in symptoms with activity; involvement of more than one joint;
and exclusion of other conditions.
• Associated symptoms may vary depending on the subtype and include fever, rash (e.g.,
present on the trunk and proximal extremities in systemic JIA), weight loss, anorexia, and
mood changes
Treatment:
• Initial monotherapy with Disease-modifying antirheumatic drugs (DMARDs)
(methotrexate) over NSAIDs
• Initial use of non-biologic over biologic DMARDs except in cases of patients with risk
factors such as involvement of high-risk joints (e.g., cervical spine, hip, or wrist)
• Use of NSAIDs and steroid injections as adjunct therapies

437
 Limping

Etiology of Limp in Children

(Common Hip Pathologies According to Age)

0-3years 3-10 years 11-18years

• Trauma: stress fracture, soft

• Trauma: physical
tissue injury
fracture
• Occult Trauma: fracture • Transient synovitis (peaks at
• Slipped capital femoral
• Septic arthritis (peaks at age 6)
epiphysis
age 3) • Septic arthritis
• Legg-Calve-Perthes
• Osteomyelitis • Osteomyelitis
Disease (LCPD)
• Transient synovitis • Legg-Calve Perthes disease
• Neoplastic
• Neoplastic (LCPD)
• Juvenile idiopathic
• Neoplastic
arthritis
Juvenile idiopathic arthritis

• Trauma (sprains, strains, contusions, non-accidental injury, toddler's fracture) is the most
common cause of limp in children.
• Transient synovitis of the hip is the most common cause of atraumatic limp in children.
• Hip pathology is the most common articular cause for a painful limp

438
 Down syndrome

Introduce yourself and establish good rapport ( Name, age and job).
• History: patient's age, gestational age, prenatal follow up, any down
syndrome's screening test performed during this pregnancy, past, obstetric
history (any previous child with down syndrome).
• Ideas, Concerns and Expectations (ICE), example: pregnant lady who found
Ask out one of her cousins had a baby with Down syndrome and she is worried
that she might have a similar baby.
• Patient's knowledge: "What do you know about Down syndrome?"
"Has she heard about screening or diagnostic test for down
syndrome?" "Does she expect specific test?"
• "Being your doctor, I think you should understand that if your cousin had a
child with Down syndrome that does not mean that you will have a Down
syndrome baby too".
• "Just so that we become in the same page, can you tell me what do you know
about Down syndrome?
", Explain:
§ Down syndrome is a genetically determined (caused by an extra copy of
chromosome 21 resulting from a new mutation or acquired from a
carrier), lifelong condition that presents from birth in the form of
learning or behavioral problems (varying from mild to severe, the child
can take longer to learn
how to sit, walk, and talk) as well as other medical problems
Advise § (Obstructive sleep apnea (OSA)), stomach, blood, and heart problems ).
§ Features of down syndrome: flat face, depressed nasal bridge, extra
skin at the back of the neck, eyes that slant up, floppy muscles, single
palmar crease.
§ Causes are unknown, and there is no known risk factors increases a
pregnancy risk. Even healthy young women can have a baby with Down
syndrome. It occurs in 1:700 births,
and its chances gets higher as women gets older.
§ Early detection and the latest advancement in medicine increased their
life expectancy from 25 year in 1980s to 49 years in 1997. By allowing
early treatment of any complications (like heart conditions), many
people with Down Syndrome live happy and full lives. But they usually
need help with some day-to-day tasks.
Understanding and exclude red flags: thoughts of aborting herself.
4 ‫إذا ﻛﺎن اﻟﺟﻧﯾن ﻣﺻﺎﺑًﺎ ﺑﺎﻟﻣرض (اﻟﺣﯾﺎة ﻏﯾر ﻣﺳﺗﻘرة ﻣن ﺷدة اﻟﺗﺷوھﺎت)؛ ﻓﻼ ﺣرج ﻓﻲ إﺟﮭﺎﺿﮫ ﻗﺑل ﺗﻣﺎم‬
.‫أﺷﮭر ﻣن اﻟﺣﻣل‬
:‫ ﻧذﻛر ﻣﻧﮭﺎ‬،‫ﻗد ﯾﻛون اﻻﺟﮭﺎض ﻣﺷروﻋﺎ ً وﺟﺎﺋزا ً ﻓﻲ ﻣﺟﻣوﻋﺔ ﻣن اﻟﺣﺎﻻت اﻟﺗﻲ ﺣد ّدﺗﮭﺎ اﻟﺷرﯾﻌﺔ اﻹﺳﻼﻣﯾﺔ‬
‫ﺿﺢ أّن اﻟﺣﻣل ﯾﺿر‬ ّ ‫ وﺑﻌد ذﻟك ﺗو‬،‫ وﺗّم ﻧﻔﺦ اﻟروح ﻓﯾﮫ‬،)‫ ﺷﮭور‬4 ( ً ‫ ﯾوم ا‬120 ‫• إذا ﺗﺟﺎوز ﻋﻣر اﻟﺟﻧﯾن‬
Asses ‫ وﯾ ُﺷّﻛل‬،‫ﺑﺎﻷم‬
‫ﺧطرا ً ﻋﻠﻰ ﺣﯾﺎﺗﮭﺎ ﻓﺈن اﻟﻘﺎﻋدة اﻟﺷرﻋﯾﺔ ﺗﻘﺗﺿﻲ اﻹﺟﮭﺎض ﻟﻠﻣﺣﺎﻓظﺔ ﻋﻠﻰ اﻷﺻل وھو اﻷم‬
‫ وﺗﺑﯾّن أﻧﮫ ﺳﯾوَﻟد ﻣﺷّوھﺎ ً ﺑﺻورة ﻛﺑﯾرة ﻻ ﯾُﻣﻛن‬،ً ‫ ﯾوم ا‬120 ‫ ﯾوﻣﺎ ً وﻟم ﯾﺗﺟﺎوز‬40 ‫• إذا ﺗﺟﺎوز ﻋﻣر اﻟﺟﻧﯾن‬
‫ﺷﻔﺎؤھﺎ أو ﻻ‬
.‫ﯾﻣﻛن اﺳﺗﻣرار ﺣﯾﺎﺗﮫ ﯾﺟوز إﺟﮭﺎﺿﮫ ﺷرﯾطﺔ أن ﯾواﻓق اﻟزوﺟﺎن ﻋﻠﻰ ذﻟك‬
‫• ﯾﺟوز اﻻﺟﮭﺎض ﻣﺎ دام اﻟﺟﻧﯾن ﻧطﻔﺔ ﺳواء أﻛﺎن ذﻟك ﻟﻌذر أم ﻟﻐﯾر ﻋذر‬

439
 Down syndrome
"Lets share a plan which is suitable for helping you…
• Explore: "Some mothers like to know everything about her expected child
before he or she is born in order to be relieved from anv anxiety/prepared for
a special child, others choose to wait until the child is born. Which type
describes you best?
• It is important that you understand that there are multiple ways to know if
your current fetus has Down syndrome:
§ Screening can be done in women who are less than 20 weeks pregnant
by: triple screen blood tests (alfa-fetoprotein, hCG, Estriol) and, or
ultrasound. These can tell if you have a low or high risk. If tests where
positive confirmatory test is
needed.
§ Two confirmatory tests available, used depending on the gestational
age:
v Chorionic villus sampling (CVS) if 11-14 weeks:
during which a needle is put into the mother's
uterus and removes a tiny piece from the placenta, (the organ
that delivers oxygen, nutrients and carries waste away from the
fetus). Risk of miscarriage with the procedure is about 1/200.
v Amniocentesis if 15-20 weeks: a needle is put into the mother's
uterus and removes some of the fluid that is around the baby.
Assist Risk of miscarriage with the procedure is about 1/300 to 1/600.
§ If you choose to have no testing in pregnancy and the baby turns out to
have features of Down syndrome, a genetic testing after birth
will be done to confirm the diagnosis.
§ If the child turns to have Down syndrome, then regular follow up with
screening for common problems:
v Growth delay: at first visit, at 2, 4, 6, 12, 18, 24 months and
annually thereafter.
v Obstructive Sleep Apnea: start screening at first year of age and
Sleep study by 4 years of age.
v Ophthalmology review: At 6 months and annually until the age of
5 years. Every 2-year from 5-13 year. Every 3 years
from 13-21 years.
v Hearing abnormalities: At birth, 6months, then annually.
v Thyroid hormone: At birth, 6 months, 12 months, then
annually.
v Heart defects: Ultrasound before and after baby born.
v Blood disease: Blood test Complete Blood Count (CBC) every year
from age 1-21 years.
v Muscle and nerve problem, joint problem (atlantoaxial
instability): Careful neurological exam annually.
Positive reinforcement, arrange follow up, give her the time to
decide, give away reading material if available, and safety netting: if she did
Arrange decide not to have a screening test and then she become anxious and want
to
do a screening test to relieve her anxiety she shall come back.
ensure organized approach, mixed questioning style
Communication
(open and close ended questions), active listening, clear language and
Skills
reflection on patient's ideas, concerns and expectations.

440
Surgery

441
Surgery
Acute abdomen
• Cholecystitis
• Pancreatitis
• Appendicitis
Breast mass
• Fibroadenoma
• Fibrocystic changes
• Mastitis, breast abscess
Abnormal mammogram

442
 Acute Abdomen Hx
Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Site: RUQ, RLQ, LUQ,LLQ, Epigastric, central. {figure1}
Onset: constant or intermittent, acute or chronic
Character: •Colicky •stabbing •Burning(GERD)
• Localized and sharp
Radiation: back (pancreatitis), LT shoulder (cholecystitis), genitalia (ureteric
SOCRATES

stone)
Timing: worsening, stable, or improving
Exacerbating factors: •↑ with tensing abd wall (hernia) •eating(PUD,
Mesenteric Ischemia)
•Heavy meals or fatty foods (gall bladder disease)
Alleviating factors: • defecation (IBS) • Antacids (PUD)
•pain medication
Severity: •1 to 10 •Affecting daily activity • awaken patient at night

• gastroenteritis: N/V, watery diarrhea, diffuse abd pain

• appendicitis: N/V, migratory pain RLQ, anorexia, fever
• PUD: epigastric pain, NSAIDS Hx, pain ↑ w/eating
Analysis of • Bowel obstruction: absolute constipation, distention, hx abd surgeries
Associated symptoms

chief complain • Pancreatitis: severe epigastric pain radiate to back, N/V, diarrhea, hx of gallbladder
stone,alcohol use
• pyelonephritis: flank or RUQ or LUQ pain, fever, N/V, hematuria
• Diverticulitis: LLQ pain, fever, distention, rectal bleeding
• Testicular torsion: lower abd pain, testicular pain, hx of trauma
• Ectopic pregnancy: young female, missed periods, IUD use.
• Ovarian torsion: severe lower pain, N/V, hx of ovarian cyst
• DKA: diffuse abd pain, polyuria polydipsia, ketone breath
• Inferior MI: epigastric pain with excretion SOB palpitation
• Herpes Zoster: Skin rash with pain (Fire band).
Risk Factors

Risk factors: Depends On The Cause.

Fever (esp in immunosuppressed),unwell patient

Red Flags

protracted vomiting or intolerance to oral intake

severe pain; e/o peritonitis (rigid abdomen, pain w/ minimal movement)
Pain radiating to left arm, right shoulder or both arms
Jaundice
Medical
• Cancer hx (tumor, hypercalcemia) •immunosuppression
• CAD/PAD • adrenal disease. •DM
Surgical
Past Hx • Abdominal surgery • Bariatric surgery
Gyn: LMP, IUD , IVF
Allergy
Medication
• NSAID • recent antibiotic use
443
 Acute Abdomen Hx
Contact with sick patient
Family Hx
Hx of DM type 1
Sedentary lifestyle
Smoking: type and frequency
Psychosocial alcohol
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
General Appearance
Abdominal Ex and Pelvic Ex
Rectal EX is essential
Appendicitis signs:
Special • psoas sign
• obturator sign
• Rebound tenderness at McBurney's point
• Rovsing sign

Differential Diagnosis
• Perforated bowel • Bowel obstruction •Strangulated hernia
Gastrointestinal
• Appendicitis • Pancreatitis • Gall bladder • PUD
&
• GI malignancy • Gastritis • Mallory-Weiss syndrome • IBS
surgical • Crohn's & UC • Gastroenteritis
Renal
• renal colic • UTI •Pyelonephritis
& • Testicular torsion
urological
• Ectopic pregnancy • Ovarian torsion • PID • Ovarian cyst rapture
Gynecological
• Endometriosis • Dysmenorrhea

Other intra abd • AAA • Mesenteric ischemia • Mesenteric adenitis • SCA crisis

Metabolic •DKA • Addison's disease

• MI • Pneumonia • Trauma
Other
• muscular pain • herpes zoster

444
 Acute Abdomen

Cholecystitis
acute gallbladder inflammation caused by complete cystic duct
Pathogenesis
obstruction usually due to an impacted gallstone
RUQ pain + fever + vomiting + RT shoulder pain + pain increase
Clinical Picture with fatty meals
Positive murphy’s sign
High ALP
Diagnostic First line imaging: US look for distended gall bladder neck or wall
+ 3 mm
Management Early Laparoscopic cholecystectomy

445
Acute Abdomen

Pancreatitis
-Autodigestion of exocrine pancreas: a process whereby
pancreatic enzymes destroy its own tissue leading to
Pathogenesis inflammation.
-The most common causes are gallstones and excessive alcohol
consumption.
-severe sudden-onset mid-epigastric or LUQ abdominal pain
radiates to the back.
Clinical Picture
-Nausea and vomiting
-Grey turner sign ( rare + not specific)
-Lipase/amylase: >3 times the upper limit of the normal range (in
setting of Acute abdomen, this is diagnostic)
-CBC: leukocytosis
Diagnostic
-CRP: >200 mg/L, is associated with pancreatic necrosis
Imaging: US look for: gallstones, pancreatic inflammation, peri-
pancreatic stranding, or fluid collections
-fluid resuscitation: RL 10 ml/kg/hour then proceed with goal-
directed: Urinary output >0.5 to 1 mL/kg/hour
- Morphine 10 mg iv/sc q4h
Management
- Ondansetron 4 mg PO
- Calcium & magnesium monitor
- Antibiotics if infection is suspected

Appendicitis
Acute inflammation of the vermiform appendix, due to
Pathogenesis obstruction of the lumen of the appendix (by normal stool,
infective agents, or lymphoid hyperplasia)
Clinical Picture Peri umbilical or RLQ pain + Fever+ Anorexia + vomiting

-CBC: leukocytosis
Diagnostic -First line imaging: US: +6 mm appendix wall
-Gold standard imaging: CT Abdomen w/contrast IV
Management Laparoscopic appendicectomy

446
 Breast mass Hx

Introduce yourself and establish good rapport ( Name, age and job).

Chief complain (open question)

Hx of present
Allow pt to explain the chief complain
illness
Clarify what you understood
Breast mass(Socrates) v Mastitis, breast abscess
How it was discovered Hx of breast feeding
§ Accidentally Erythema
§ Breast exam , mammogram Tender breast
Site Fever
Size ( increase with v Malignancy
menstruation ?) • Bloody nipple discharge
Duration • Nipple inversion
Associated symptoms • Skin changes( ulceration,
v Fibrocystic changes : peau d’orange, dimpling,
§ Pain before menstruation erythema ).
§ Decrease after menstrual • Old age
period begin • Chest pain, bone pain
v Fat necrosis • Loss of appetite
Analysis of § Hx of trauma v Fibroadenoma
chief v Intraductal papilloma • Usually painless
complain Hx of bloody nipple discharge v Gynecomastia
Ask about nipple • In puberty , last from 6
discharge(bilateral, timing, color, month to 2 years
frequency, of the discharge
v Risk factors: v Protective factors:
• Old age • Breast feeding
• Family hx of breast cancer • High Number of parity
• Early menarche , late • Aspirin
menopause • Oophorectomy before
• Use of OCP or HRT age 35
• Brca1,2 gene mutation • exercise
• Alcohol
• Hx of breast cancer or
hyperplasia on biopsy
• obesity

447
 Breast mass Hx

• Breast cancer
• Fibroadenoma or benign breast diseases
• Ovarian cancer
Past Hx • Colon cancer
• Chronic diseases
• Past surgical(breast augmentation, abscess drainage)
Family Hx breast, ovarian, colon cancer
• Pain ( SSRI, Methyldopa, digoxin, cemitidine, ketonazole)
• Nipple discharge(metoclopramide, codeine, SSRIs, reserpine,
Medication verapamil)
• Gynacomastia (cemitidine, ketonazole, spironolactone, alcohol,
digitalis, phenytoin, estrogen, minoxidil).
Marital status ,number of children
Smoking: type and frequency and alcohol use
Psychosocial Occupation
Exposure to radiation
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs, appearance
Chest examination (plural effusion , crackles)
General Abdomen (distention, tenderness)
Back ( tenderness in the vertebrae)
LN (Axillary , infraclavicular , supraclavicular, cervical)
Inspection :
Asymmetry – Observe the breast Palpation
outline and contour for any using concentric circles, a radial
bulging areas. approach, or vertical strips.
●Skin changes – Check for Palpation should be done with the
Special dimpling or retraction, edema, finger pads rather than the
(Breast) ulceration, erythema, or fingertips. Circular motions with
eczematous appearance light, medium, and deep pressure
●Nipples – Assess for symmetry, ensure palpation of all levels of
inversion or retraction, nipple breast tissue
discharge, or crusting.

448
 Fibroadenoma

CRAPRIOP for Management

• A fibroadenoma is a solid breast lump. This breast
lump is not cancer. A fibroadenoma happens most often
Clarification between ages 15 and 35. But it can be found at any age
in anyone who has periods.
• Don’t worry , most fibroadenomas are benign
Reassurance • We will follow up with you just for reassurance.
Advice
Prescribing
Referral Referral for general surgery for biopsy
• Mammogram
• Breast ultrasound
oval or round,
it is typically well-
circumscribed, may have
circumscribed, round to
Investigations ovoid, or macrolobulated.
coarse calcifications
• Biopsy
It has uniform
epithelial and stromal
hypoechogenicity.
elements.
Most fibroadenomas in Follow up every 6 months
adolescents decrease in with general surgery.
size, and some completely
disappear with time.
Fibroadenomas less than 5
Observation/Plan cm without concerning
features can be observed
at one to two month
intervals for growth or
regression up to 2 years

Prevention • Screening for breast cancer

449
 Fibrocystic changes

CRAPRIOP for Management

• Fibrocystic breast changes is a condition of
the breasts where there may be pain, breast cysts,
Clarification and breast masses.
• Symptoms may worsen during certain parts of
the menstrual cycle due to hormonal stimulation.
• Don’t worry, we will give you medication to relive
Reassurance your pain
Elimination of caffeine
Advice Supporting bras
• Mild analgesia (eg, nonsteroidal anti-inflammatory
agents [NSAIDS])
Prescribing • Tamoxifen if pain not relived(10mg od) for 3
months.
• Oral contraceptives
Referral
• breast ultrasound:
• simple cysts: well-circumscribed with sharp borders,
no internal echoes; complex cysts: cystic and solid
components
Investigations • mammography:
• cannot distinguish between cystic and solid masses
• breast aspiration:
• resolution of cysts after aspiration suggests a benign
cyst
F/U to ask pain relive
Observation/
If there is concerning symptoms(increase in cyst size,
follow up skin changes) refer for biopsy.

450
 Mastitis, breast abscess

CRAPRIOP for Management

• Mastitis is an inflammation of breast tissue that
sometimes involves an infection. The inflammation
results in breast pain, swelling, warmth and redness.
You might also have fever and chills.
Clarification • Mastitis most commonly affects women who are
breast-feeding (lactation mastitis). But mastitis can
occur in women who aren't breast-feeding and in
men.
• Don’t worry,if you follow our advices your symptoms
Reassurance will disappear .
• Optimize feeding technique
• Continue breastfeeding
Advice • warm compresses or showers
• manual massage
• Analgesics such
as ibuprofen and acetaminophen may decrease the
discomfort
Prescribing • persistent symptoms beyond 12 to 24 hours, with
fever give antibiotic dicloxacillin (500 mg orally four
times daily) or cephalexin (500 mg orally four times
daily)
if there is abscess referral for general surgery for
Referral drainage
• Ultrasound if there is fluctuating mass by
Investigations examination
Abscess demonstrating a fluid collection

Observation/ symptoms should be relived after 24-48 hours after

starting antibiotic.
follow up
• Continue to evacuate breast by pumping or
Plan/prevention breastfeeding.

451
 Abnormal mammogram

Introduce yourself and establish good rapport ( Name, age and job).
• Close the door; ensure no interruptions (call the
nurse and ask her not to allow any interruptions
and put your phone on silent) and ensure proper
Setting setting (tissue around with some water). Ask if any
family members are with the patient (Are you here
alone?)
• how can we help you today ?"Do you know why
are you here? “
• Do you know what tests you had last time and why
were they done? “
Perception • Do you have any idea what the results might be?"
"Some people like to have someone (family or
friend) with them if they take their results. Are you
that type or you are happy to be alone?
"Before we review the results, tell me, Ms. X, are you
the sort of person who like to know the details or in
brief?“
- I am afraid I have bad news, your results from the
mammogram showed an abnormal area. “Pause...
Hand the patient some tissue papers. - Encourage
feelings expression: "lam sorry I had to give you such
bad news. I have double checked with the radiologist
(imaging doctor) to make sure that they read it right
for the right patient. I wish things were different. It
Invite must be difficult to hear; how do you feel about it?"
- Clarify: We are not yet sure what can this
abnormal looking area be and for that reason you
need to have biopsy (which is taking a sample by
needle) from your breast to see this area under
the microscope and see if they have cancer"
- - Would you like to have some rest in the
treatment room before we proceed?“
- - Remember to facilitate verbal and non-verbal
cues. - Remember to Listen attentively & ask
several times about understanding.

452
Abnormal mammogram
How much patient already knows: "Just so that we are on
the same page, can you tell me what you know about
abnormal mammogram and what it could be?
If patient asks about breast cancer, explain:
• "Breast cancer occurs when normal cells in the breast
change & grow out of control“
• "It is common in females, but may also occur in males".
"It can runs in families".
• "Breast cancer treatment depends on the stage at which
it is diagnosed, and the patient preferences. When surgery
Knowledge is considered, women with breast cancer can choose
between mastectomy (removal of the whole breast) or
breast conservative therapy/lumpectomy (removal of the
cancer and a section of the healthy tissue around it)".
• "Other therapies that can be considered are ones that
help the body to kill any leftover cancer cells. These include
chemotherapy, radiotherapy or hormonal therapy".
• "After treatment, most patients do well. You will only
need to be checked with a mammogram annually to see if
the cancer comes back".
expression: Reinforce support provision, give clinic phone
Empathy number & ask about feelings and emotional acceptance.

Brief what has been discussed and upcoming plan: "I have
arranged for a biopsy to be done with our radiologist and
we will take it from there. The biopsy is usually taken under
local anesthesia and ultrasound guidance. During the
Summarize procedure, we take one or more small samples of the
abnormally looking tissue from the breast. In that way we
can look at the cells under the microscope to see if they
have cancer". - Answer any queries & address concerns
clearly.
Give hope but not false ones: "I know it's difficult to
handle this, we are always available to support you and
Arrange answer your questions". - Safety netting: "If you develop
any fever, pain, bleeding from the nipples please come back
immediately". - Follow up soon. - Give away reading
material, support groups contact if available.

453
Obstetric & Gynaecology

454
Obstetric & Gynecology
Vaginal Discharge
Polycystic Ovarian Syndrome
Menstrual Disorders
• Dysmenorrhea
• Abnormal Uterine Bleeding
Family Planning
Antenatal care
Postpartum care
Breast feeding
Post menopausal bleeding
Infertility
HRT initiation

455
 Vaginal discharge Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Onset: when did the symptoms started to appear
Course: getting better getting worse or the same
Duration: for how long that you have been having those symptoms.
Characters: amount, odor, appearance, color, consistence.
-Candida: white ,thick, lumpy, cottage cheese like.
-Bacterial vaginosis: milky off white in color, thin, homogenous with
fishy odor, may worsen after intercourse.
-Trichomoniasis: copious , frothy , greenish yellow in color, offensive
odor.
-Atrophic vaginitis: thin, clear discharge.
-Chlamydia or gonorrhea: often asymptomatic or purulent vaginal
discharge, post coital bleeding or intermenstrual, dyspareunia, dysuria,
lower abdominal pain.
-Physiological leukorrhea: odorless, thin or thick, white or transparent.
Pain severity: from 1 to 10
Associated symptoms (DDx)
-Physiological leukorrhea: none
-Candida: pruritis, dyspareunia, burning, dysuria.
-Trichomoniasis: burning, postcoital bleeding , dyspareunia, dysuria
-UTI: dysuria , frequency , urgency
Analysis of -PID: lower abdominal and pelvic pain.
chief complain -Toxic shock syndrome: dyspareunia, fever, skin rash because of
tampon use
-Side effect of hormonal contraceptive: altered level of bleeding.
Risk Factors:
Use of new soaps, vaginal douches, bubble bath, detergent, spermicidal
foam jelly or cream, tampons condoms.
-Bacterial vaginosis: vaginal douching, smoking, STI, obesity, Copper
IUD.
-Trichomoniasis: STI and sexual activity, douching.
-Candida vaginalis: DM, immunosuppression state as HIV and steroid
therapy, oral contraceptives, IUDs, high estrogen levels as in pregnancy
and HRT, antibiotics use, wearing non breathable clothing, local
hypersensitivity and allergic reaction.
Detailed Menstrual history
Pregnancy history:
Is the discharge related to pregnancy
Relation to the intercourse
Red flags:
Appearance of systemic symptoms like fever, nausea or vomiting.
Pelvic pain.
Failure to initiate treatment.

456
 Vaginal discharge Hx
Medical:
STI, previous discharge, PID, DM,HIV,HPV, chlamydia or gonorrhea
infections, DM, immunosuppression, severe medical illness.
Surgical
Past Hx Allergy
Medication: previous medications for vaginal symptoms, antifungal,
antibiotics, steroids, OCP or IUD.
Travel
Family Hx Same complain or other diseases like DM ,HTN.
Marital status
Sexual history:
Any new sexual partner, Symptoms in partner, Hx of multiple sexual
Psychosocial partners.
Smoking: type and frequency, Alcohol.
Screening: depression and anxiety.
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
General Appearance: skin, oral mucosa, abdomen, joints, rectum.
Genital and vaginal examination ((discharge characteristic, adnexal
Special tenderness).
-Vaginal pH
Elevated pH is seen in bacterial infections, including trichomoniasis, and in
atrophic vaginitis.
-High vaginal swab for whiff test and wet mount:
• Amine 'whiff' test of vaginal secretions
The presence of a fishy odour following addition of 10% potassium
hydroxide to the vaginal sample is suggestive of bacterial vaginosis when
accompanied by at least two other Amsel criteria.
• Wet mount microscopy of vaginal secretions
Investigations Bacterial vaginosis: clue cells are present and are seen as vaginal epithelial
cells covered with many rods and cocci, with a granular appearance. The
numbers of lactobacilli are decreased and WBCs are absent.
Trichomonas: show motile flagellates
-Chlamydia and gonorrhea: PCR, NAAT test of choice (also Highly sensitive
for trichomoniasis)
-To exclude other diagnosis: uranalysis for UTI, blood sugar for DM, FSH
and Estradiol for estrogen deficiency (peri-menopausal, inadequate HRT)
Test all pt with chlamydia for HIV, gonorrhea and syphilis.

457
 Vaginal discharge

CRAPRIOP for Management

‫ هي افرازات تخرج عن طريق فتحة املهبل لها عدة أسباب من أهمها‬:‫االفرازات املهبلية‬
Clarification ‫البكتيريا املهبلية او الفطريات والطفيليات ويتم تشخيصها من قبل الطبيب املعالج‬
. ‫وعالجها بناء على املسبب‬
Most of the causes are benign and treatable with
Reassurance appropriate medications and follow up
-If the patient is DM then try to control the blood glucose
level
-Try to wear cotton underwear.
-Frequent pad changing
-Avoid using of vaginal douching, soaps or bubble baths
Advice -In case of trichomanias infection avoid sexual intercourse
until clear of symptoms usually one weak and treat the
sexual partner
-Screen for other sexually transmitted infections in case of
trichomanias.
Prescribing Mentioned below
Usually no need for referral unless there is complications
Referral like PID, recurrent infections, persistent infection.
Investigations Mentioned above
All of them no need for follow up except the trichomanias
Observation/
need to follow to repeat the NAAT within 3-12 months after
follow up treatment.
Plan/preventi Use of condoms , avoid smoking .
Limiting number of sexual partners.
on
Conclusion Includes Safety netting

458
Vaginal discharge

459
Vaginal discharge

460
 Polycystic Ovarian Syndrome Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of present Chief complain (open question)
illness Allow pt to explain the chief complain and Clarify what you understood
Menstrual irregularities: Insulin resistance and Skin conditions: Virilization:
• Primary or secondary associated conditions: • Hirsutism • Hirsutism
amenorrhea • Metabolic syndrome) • Androgenic alopecia • Male-pattern hair loss
• Oligomenorrhea especially obesity) → • Acne vulgaris • Acne
• Menorrhagia ↑ risk of sleep apnea • Oily skin • Increased muscle mass
• Infertility or • Nonalcoholic fatty liver • Acanthosis • Voice deepening
difficulties conceiving disease nigricans • Clitoromegaly
Onset, course and duration.
Analyze according to complain.
Associated symptoms (DDx):
• PCOS: acne, amenorrhea • Hypothalamic amenorrhea: low body
or oligomenorrhea, weight, eating disorder or excessive exercise
obesity, insulin resistance • Primary ovarian insufficiency: hot flashes,
signs like acanthosis urogenital symptoms
Analysis nigricans • Androgen-secreting tumor: severe
of chief • Pregnancy virilization
complain • Thyroid dysfunction • Cushing syndrome: buffalo hump, purple
• Hyperprolactinemia striae, HTN
• Nonclassical congenital • Acromegaly: change in hat of glove size,
adrenal hyperplasia protruding jaw, impaired vision
Risk factors:
• Family Hx of PCOS
• Premature adrenarche
• Obesity
Medical:
DM , HTN, dyslipidemia, metabolic syndrome, NAFLD, obstructive sleep apnea,
CVD, ovarian tumors, Mood disorders (Depression, Anexity)
Surgical:
Past Hx Previous surgeries
Allergy
Menstrual history and if married pregnancy history and infertility.
Medication
Family Hx PCOS , same complain and ovarian tumors.
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

461
Polycystic Ovarian Syndrome Ex
Vital signs: HTN, RBS, BMI
General Appearance
Hirsutism pattern , Acne, Alopecia, skin tags, evidence of
clitoromegaly, acanthosis nigricans, and signs of Cushing
Special disease, Abd Ex (assessment of liver size to evaluate
possible hepatomegaly due to NAFLD)
Investigations

462
 Polycystic Ovarian Syndrome

CRAPRIOP for Management

‫ قد تواجه فيه املرأة‬،‫متالزمة املبيض متعدد الكيسات هو اضطراب هرموني شائع بني النساء مجهول السبب‬
.(‫ او زيادة مستويات هرمونات الذكورة )االندروجني‬،‫املصابة مبشكالت في انتظام دورة احليض او طول مدتها‬
Clarification ‫قد ينتج املبيضان او أحدهما مجموعات عديدة ممن أكياس السوائل الصغيرة ويفشالن في إنتاج البويضات‬
.‫بانتظام‬
Reassurance Most of the women had it and it can be controlled with some tips and tricks
No treatment until now for this syndrome only we can reduce its symptoms
and complications by practicing those none pharmacological behaviors like:
-Weight loss of 10% by diet and exercise decrease insulin resistant and
Advice increase conception rate
-In addition to none pharmacological we add the pharmacological treatment
to maximize the benefits.

Prescribing

Referral If the women not improving or history suggestive of other diagnosis

Investigations Mentioned Above
Observation/ Follow up for any new complain , improving of the symptoms
Follow up
Plan/prevention Screening for breast and endometrial cancer (PCOS increase the risk)
Conclusion Includes Safety netting

463
Polycystic Ovarian Syndrome

464
 Dysmenorrhea Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (dysmenorrhea )
Hx of present
Allow patient to explain the chief complain
illness Clarify what you understood
Duration: for how long chronic vs acute
Site: where this pain is located more
Lower abdomen and back pain (period pain )
Generalized abdominal pain ( IBS , IBD)
Onset: does this pain occur few hours before mensuration and
continues 2-3 days after (primary dysmenorrhea )
-Is this pain not in periods since menarche then started later in life
during mensuration (2nd dysmenorrhea)
-started 6-12 months after menarche (primary dysmenorrhea)
Characters: recurrent , crampy and ln the lower abdomen with back
(primary dysmenorrhea )
Radiation: does the pain go to any other areas other than pelvic.
Alleviation: does this pain gets relived with use of any medications like
NSAIDS, paracetamol, OCP, heat pads, exercise.
Aggravating: does this pain gets more sever with emotion, special kind
of foods spicy , fatty (IBS)
Severity: there is special grading system for it you will find it in page
472
Associated symptoms (DDx):
Analysis of -adenomyosis: bulky uterus , heavy bleeding.
chief -endometriosis: cyclical or noncyclical pain , dyspareunia, dyschezia.
-PID: vaginal discharge, fever, lower abdominal pain, fever, dyspareunia.
complain -imperforated hymen: sever cyclical pain with bulge in examination.
-fibroids: dyspareunia, bulky uterus, noncyclical pelvic pain
-hematometra and adhesions: history of endometrial ablation or
uterine surgery with amenorrhea and cyclical crampy pain.
-chronic pelvic pain syndrome: pain persistent throughout the
menstrual cycle.
-UTI: dysuria, frequency, urgency, suprapubic pain, fever , chills .
-IBS: constipation , diarrhea, generalized abdominal pain, nausea,
vomiting, loss of appetite, fever.
-CNS: headache, fatigue, weakness, sleepless, depression, irritability,
nervousness, dizziness, light headedness.
-skin: acne, flushing
-primary dysmenorrhea: pain that occurs during menses and continues
for 1-2 days and gets relived by 24-72 hours without any pelvic
pathology more in younger ages.
-IBD: constipation, diarrhea, loss of weight, anorectal disease , skin
disorders, fever, loss of appetite, fatigue.
-psychological: any disorder after exclusion of other diseases.
-Ectopic pregnancy: bleeding, abdominal pain.

465
Dysmenorrhea Hx
-Ovarian cyst: sudden onset of pain and resolution.
-Uterine polyps: irregular vaginal bleeding.
-Cervical stenosis: amenorrhea, infertility
-Pelvic mass: bloating, frequent urination, nausea.
Risk Factors:
Family history of the same condition
Stress, anxiety and depression
Analysis of Young age less than 20 years
Nulliparity
chief Heavy menses
complain Loss of weight
Smoking and disruption of social support
Red Flags:
Abnormal uterine bleeding , menorrhagia
Noncyclical pain , dyspareunia, changes in intensity and duration of the
pain
Post coital bleeding , infertility and abnormal pelvic examination
findings
Medical:
Psychological disease , any uterine abnormalities
PID, STI, diagnosed gynecological problems like polyps , fibroids and
abnormal pap smear.
Surgical:
Uterine ablation , uterine surgery.
Allergy
Medication:
Past Hx Previous medications that has been used for how long, frequency , and
what was the effect
NSAIDS, OCP.
Menstrual history:
Age at menarche, duration of bleeding, intervals between menstrual
periods, flow, regular or not , pregnancies and miscarriages
Sexual history:
Current sexual activity and type of contraception used
History of PID, STI.
Of primary dysmenorrhea, secondary causes of dysmenorrhea.
Family Hx Family history of endometrial or ovarian cancer
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How? Effect on work, sport.
Systemic Ask about other signs and symptoms which can be associated with
primary dysmenorrhea like:
Review Nausea, vomiting, headache, myalgia, fatigue, dizziness , diarrhea.
466
 Dysmenorrhea Ex

Vital signs
General Appearance
Abdominal examination to rule out any palpable
Special pathology.
Special test : pelvic examination.
Trans vaginal US if history suggestive of other diagnosis
other than primary dysmenorrhea
Or trans abdominal if the patient is young and unmarried
Investigations with history suggestive of other diagnosis also pregnancy
test, CBC, ESR.
-MRI 2nd line, CT, cervical cytology, hysteroscopy.

CRAPRIOP for Management

،‫ ويكون في أسفل البطن‬، ‫عسر احليض هو ألم او تشنج ذو صلة باحليض‬
.‫وهو من أكثر مشكالت املرأة شيوعا‬
‫وتعاني معظم النساء خالل فترة املراهقة وقد يستمر فترة أربع او خمسة‬
.‫سنوات من الدورة الشهرية األولى‬
‫وقد يؤثر عسر احليض اذا كان شديدا في أنشطة بعضهن اليومية لبضعة‬
.‫أيام من كل شهر‬
: ‫وهناك نوعان‬
Clarification ‫هي تقلصات متكررة حتدث خالل الدورة الشهرية‬: ‫عسر احليض األولي‬
‫وليس بسبب حالة مرضية ويبدأ األلم عادة قبل يوم او يومني من الدورة أو‬
.‫أو الفخذين‬، ‫أو الظهر‬، ‫ ويكون األلم في أسفل البطن‬،‫عندما يبدأ احليض‬
‫ ساعة وقد يصاحبه‬۷۲-۱۲ ‫ويستمر بني‬، ‫ويتراوح األلم بني املعتدل واحلاد‬
.‫أو اسهال‬، ‫ إرهاق‬،‫ قيء‬،‫غثيان‬
‫ وهو األلم الناجم عن اضطراب في األعضاء‬:‫عسر احليض الثانوي‬
‫التناسلية للمرأة‬
Primary dysmenorrhea tends to improve with advancing
Reassurance age and often improves after childbirths.
Usually we start with non pharmacological methods like
Heat pads, Exercise for 3-4 months before starting any
Advice treatments
-low fat vegetarian diet and green tea consumption,
ginger.

467
Dysmenorrhea

1st line is:

-NSAIDS: like ibuprofen and naproxen, those taken with
onset of mensuration and continued for 1-3 days unless
there is no cramps and if the patient has sever
dysmenorrhea we can start 1-2 days before menses for
patient who is not improving on one class of NSAID we
can switch to another like mefenamic acid or increase the
dose
If the patient can not tolerate the NSAID due to GIT side
effect we can start with paracetamol.
Prescribing -2nd line OCP either alone or in combination with NSAID.
We but in our minds if the patient desiring contraception
or not and if there is any contraindication to it.
-Others with no or little evidence:
Vitamins like vit D,E, B1, fish oil, zinc sulphate.
Diet low in fat and high in vegetables
Acupuncture
Transcutaneous electrical nerve stimulation
Yoga
-last resort: laparoscopy and hysterectomy
If uncontrolled dysmenorrhea
History suggestive of other diagnosis
Referral
Not responding to treatment
Red flags
Investigations Mentioned above
Patients should be followed closely for the first few
months after treatment is initiated to evaluate the
response and adherence to therapy. If first- or second-line
treatments are not effective, if the pain recurs, or if
Observation/
symptoms worsen, the patient should be reevaluated for
follow up the causes of secondary dysmenorrhea and possibly
referred to an adolescent gynecologist or adolescent
medicine specialist to further assess for underlying pelvic
pathology
Plan/prevention No preventive methods
Conclusion Includes Safety netting

468
Dysmenorrhea

469
Dysmenorrhea

470
 Abnormal Uterine Bleeding Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (menorrhagia)

Allow patient to explain the chief complain and Clarify what you
illness understood
Course: Getting better getting worse or the same,
Onset: When did it start, related to menses or not.
Duration
Site: From where does the bleeding occur vagina , premium, rectum, anus,
urethra.
Alleviating: Did the patient use anything to decrease the bleeding like
previous surgical procedures , IUD, OCP or other herbal medicines.
Menstrual history:
-LMP when it was
-how many days bleeding continue, how many days light bleeding and how
many heavy bleeding
-is the bleeding associated with dysmenorrhea or dyspareunia.
-frequency of the period: <24day cycle(frequent)or>38 day
cycle(infrequent)
-regular or not each month
-if there is any intermenstrual bleeding between the cycles or not
-unscheduled bleeding because of IUD and COP, rings, patches, injections.
-heavy or not and this according to the patient any volume of blood that
Analysis of interferes with patient physical, social , emotional and marital life or we
chief can use the table in slide number(6) to determine if its heavy or not.
Associated symptoms (DDx):
complain We use the PALM COEIN for cause of AUB
-Polyps: menorrhagia or asymptomatic, intermenstrual bleeding
-Adenomyosis: Bleeding, Bulky Uterus, Dyspareunia, Painful, Heavy Or
prolonged Bleeding
-Fibroid: Bulky Uterus , Dysmenorrhea
-Malignancy: Bleeding , Loss Of Weight, Appetite, Fatigue, Fever.
-Coagulopathy: By Asking The Patient Like In Slide Number (7)
-Ovulatory dysfunction
-Endometrial
-Iatrogenic: Asherman syndrome, hormonal contraception, anticoagulant,
TCA or tamoxifen.
-Not Yet Classified
-Trauma, Foreign Body, Sexual Abuse, Straddle Injury, Cesarean Scar Defect.
-PID, STI, Endometritis.
-Atrophic vaginitis: dryness, bleeding , itching ,
Risk Factors and Red Flags: RFs of endometrial cancer mentioned below
Systemic signs and symptoms like fever, symptoms of Anemia,
hyper/hypothyroidism, hyperprolactinemia and menopause.

471
 Abnormal Uterine Bleeding Hx
Medical:
DM, any type of cancers, PCOS, IBD,AV malformation,
Bleeding disorders like von will brand disease,
thrombocytopenia and platelets dysfunction, advanced liver
disease, renal disease, hemorrhoids, UTI, thyroid disease,
Cushing disease
Gynecological and obstetrical history:
-recent or current pregnancy
-abortions.
Sexual history:
Active or not
Surgical:
Past Hx -previous D&C, pelvic surgery, uterine surgery
-previous cesarean sections.
Allergy
Medication:
-OCP , IUD
-antipsychotic and antidepressants
-chemo or radiotherapy
-steroids, HRT, tamoxifen
-anticoagulant , antiplatelet
- antibiotics, phenytoin
Contraceptive history:
-what type, for how long , any complain
Same complain, ovarian , endometrial , breast or colon
Family Hx cancer.
Bleeding disorders
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic By asking questions about other systems not related to the
genital system
Review
Summarize to the patient you finding and understanding of
Conclusion the history

472
 Abnormal Uterine Bleeding Ex
Vital signs
Appearance: ecchymosis, enlarged thyroid gland , acne , hirsutism,
General acanthosis nigricans, clitoromegaly, male pattern balding and
galactorrhea.
Abdominal and pelvic examination with a particular focus on:
Special Potential sites of bleeding, current uterine bleeding, size and
contour of the uterus, presence of adnexal mass or tenderness
-Pregnancy test for all females of reproductive age regardless of the
complain either by urine or serum HCG
-US part of secondary evaluation which depends on the information
obtained from history and physical examination.
Investigations -CBC for all to asses anemia with ferritin level
-If needed TSH , prolactin, LH , FSH
-if coagulation disorder suspected do INR, PT , PTT
-Endometrial sampling for selected patient (Mentioned below)
-Pap smear

CRAPRIOP for Management

‫نزف الرحم الغير طبيعي هو خلل وظيفي يؤدي إلى حدوث نزيف مهبلي خارج او داخل‬
Clarification . ‫الدورة الشهرية‬
Reassurance .‫يجب معرفة السبب املؤدي إلى هذا اخللل وعندها ميكن معرفة العالج‬
Keep menstrual diary
Take iron supplements
Advice Eat will balance diet
Avid medications that cause bleeding of possible like
aspirin
Prescribing Mentioned below
-if the patient has heavy uncontrolled bleeding, sever
anemia
-persistent bleeding despite treatment
Referral -suspicious of malignancy or surgery is required
-if the primary care clinician uncomfortable performing
endometrial sampling
Investigations Mentioned above
To see correction of anemia and bleeding pattern
Observation/
improved or not
follow up Of the patient needs referral
Plan/prevention Screening and vaccination according to age
conclusion Includes Safety netting

473
Abnormal Uterine Bleeding

474
Abnormal Uterine Bleeding

475
Abnormal Uterine Bleeding

Other progestin therapies (eg, DMPA, LNG 52) are not appropriate
for treating patients with AUB who may wish to conceive in the
next one to two years. NSAIDs may be used as an alternative, but
should be discontinued upon conception.
LNG 52: 52 mg levonorgestrel-releasing IUD (Mirena or Liletta).
Alternatives for selected patients include high-dose progestin-only
oral or injectable medications, nonhormonal therapies, minimally
invasive surgery, or definitive treatment with hysterectomy;
however, surgical options are limited in patients who desire future
childbearing.

476
Abnormal Uterine Bleeding

477
 Family planning & contraception

Introduce yourself and establish good rapport ( Name, age and job).

Ideas, concerns, and expectations (ICE)

•
Age, job, smoking Hx. & years of marriage
•
Menstrual Hx: LMP, regularity, heaviness, duration
•
& symptoms of premenstrual syndrome( breast
tenderness, irritability, tiredness, mood swing
…etc.)
• Parity, hx. of abortion, any complication during &
after pregnancy, current lactation.
• Any contraindication to contraception: personal or
Ask family history of deep vein thrombosis, ischemic
heart disease, liver disease, cancers (ovarian,
breast & endometria), migraine with or without
aura, epilepsy, tuberculosis, uncontrol diabetes,
uncontrol HTN and multiple sexual partner (risk of
sexual transmitted disease).
• Allergies to latex and copper
• Previous experience: any problem? compliance?
• Personal preference, acceptability of
contraception, cost and dose the partner agree?
Examination: BP, BMI, abdominal & pelvic examination
Investigation: pregnancy test as needed
explain to the patient choices, types of contraception
methods, effectiveness of each, advantages,
Advice disadvantages and instructions for use
“total risks of birth control are much less than the
total risks of pregnancy”.

478
 Family planning & contraception
Types of contraception
Hormonal methods
Combined contraception:
Is a combination of tow female sex hormone that prevents pregnancy by
changing the hormone balance in your body to stop ovulation.
There are different types:
• 21-days packet: start the pill on 1st to 5th day of period and take it every day
at the same time for 21 day and 7 days free for getting the period.
• 28-day packet: the 7 extra pills are inactive, sugar pill, start the pill on 1st to
5th day of period and take it every day at the same time for 28 day and no
free days.
Effectiveness: 99% starting 7 days after the first pill
Advantages: reduce period pain & flow, reduce risk of endometrial, ovarian &
colorectal cancer and maintain bone density, cycle regulation, decrease
dysmenorrhea and decrease acne and hirsutism.
Side effect: nausea, mild headache, tender breast, dizziness, slight weight gain.
Interaction: OCPs effectiveness decrease when used along with antibiotic, anti-
epileptic and anti-TB medications (when taking any, use another method of
contraception during the course and up to 7 days after the last dose). OCPs
decrease effectiveness of hypoglycemic agents.
Missed pills:

Progesterone only pill (28 days packet):

start the pill on 1st to 5th day of period and take it every day at the same time
for 28 day and no free days.
indications: lactating ladies, history of estrogen secreting hormone.
Missed pills: taking it within 3 hours of usual time would not affect the
effectiveness. If these three hours passed the chance of get pregnant is higher.
Non contraceptive benefits: reduce pain associated with endometriosis,
decrease amenorrhea, and decrease pain in women with pelvic congestion
syndrome.
479
 Family planning & contraception
Depo-Provera injections (Depo-medroxy progesterone acetate (DMPA) 150mg IM or 104mg SC).
Effectiveness: 99.7%
Intramuscular (IM) injection in the deltoid, thigh, gluteus, in the first 5 days of bleeding or less
than or equal 21 days of giving birth. This gives immediate effectiveness that continues for 3
months.
Advantages: Good for ladies with compliance issue, less expensive than pills, no Pelvic
Inflammatory Disease (PID) risk, decrease dysmenorrhea.
Side effects: irregular menses, amenorrhea, headaches, depression, weight gain (2-3 Kg per
year), decrease High Density Lipoprotein (HDL), loss of bone mineral density (if used > 2 years)
then giving vitamin D & calcium supplements, acne, hirsutism, alopecia.
Does not increase risk of VTE and MI or stroke.
Contraindications: as with OCPs , drug addiction & seizure.
Missed injection:
• If started the first 7 days of menstrual period, no additional contraceptive protection is
needed.
• If started >7 days of menstrual period bleeding started, needs to use additional
contraceptive protection for the next 7 days.
• The repeat DMPA injection can be given up to 2 weeks late. , If late>2 weeks needs
additional protection for next 7 days.
Correct any myths: "You could become pregnant as soon as 3-4months after the last shot. But
some women take up 1 to 2 years to conceive after stopping this method.
Implants
Etonogestral implant (implanon) 68 mg
Instructions : placed under the skin of the inner aspect of the nondominant upper arm under
local anesthesia, which last for 3 years.
Effectiveness: 99.95%.
Ovulation restarts 6 weeks after removal of the implant.
Side effects: bad scars, neurovascular injury, angioedema, implants migration and need to be
located by Magnetic Resonance Imaging (MRI), high frequency Ultrasound(US)).
Same mechanism of action, efficacy, and contraindications as Depo injections.
Vaginal Nauva ring:
A flexible, transparent plastic ring that is self-inserted deep into the vagina after menses and
left for 3 weeks. Removed at the 4th week to allow menstruation to occur.
Mechanism of action: as oral contraceptive pills.
Effectiveness: 95% at 7 days from starting use of the ring.
Side effects: as with OCPs, vaginitis, irregular bleeding, maybe expelled from the vagina.
Contraindications: as in OCPs & repeated fall after insertion and prolapse.
fertility returns within 1 month.
Delayed insertion or reinsertion of vaginal ring:

480
Family planning & contraception

481
 Family planning & contraception

Patch
Instructions : 1 patch attached in the 1st day of cycle and changed every week
(day 8,15) followed by 7-days patch free.
Special consideration: Wight , site of application and skin hypersensitivity.
Advantage: less breakthrouge bleeding and spotting but more breast discomfort
or pain, nausea and vomiting.
Side effect: Detachment, contact dermatitis, erythema and skin irritation. Risk of
VTE higher than in the pills.
Delayed Application Or Detachment Of Patches

Intrauterine device (IUD):

"Small T-shaped device that is inserted and kept in the uterus to prevent
implantation of any embryo. The hormonal types also prevent
ovulation. A small connected thread is left in the cervix for easy removal when
desired".
Two types: Copper coils (works for 10 years), and hormonal intrauterine systems
(Mirena: works for 5 years).
Effectiveness: 99.2 to 99.9%.
Suitable candidates: women who have contraindication or in tolerant to OCPs,
smokers and more than 35 years of age.

Advantages: easy office based insertion, good for ladies with compliance issue,
reversible, decreased heavy bleeding (only Mirena).
Side effects: pelvic inflammatory disease, ectopic pregnancy, breast tenderness,
spotting (for copper + first three months in Mirena), nausea, or headache.
Contraindications: pelvic inflammatory disease, multiple sexual partners, ectopic
pregnancy copper allergy or Wilson's disease (for copper IUD only).
Correct any myths: "Does not interfere with sex or daily activities.” "Uterine
perforation is uncommon (0.1 - 0.3% risk)".

482
Family planning & contraception

483
 Family planning & contraception

Barrier Methods
Male Condoms Female Condoms
Thin sheath of rubber, latex, that should be A thin plastic pouch that lines the vagina. It is
worn over an erected penis. held in place by close inner ring at the cervix
Effectiveness: 79-97%. and an outer ring at the vagina.
Advantages: Cheap, readily available, Effectiveness: 79-97%.
provides the best protection against STD’s It should be placed prior to and kept in for 6-
especially the latex and polyurethane type. 8 hours after the intercourse.
Side effects: Risk of condoms breaking down Side effects: Expensive, no protection against
with oil-based lubricant, latex allergy, loss of STD’s, slippage/breakage, loss of sensation,
sensation, inconvenience/ interruption of inconvenience/ interruption of sexual
sexual intercourse intercourse
Diaphragm Cervical cap
A small dome shape device of latex or Small plastic dome placed over the cervix
silicone that fits inside the vagina and covers and used with spermicide.
the cervix. Effectiveness: in nulliparous 80-90%, in
Should be kept in for 6-8 hours postcoital. multiparous 60-70%.
Effectiveness: 84 - 94%. Advantages: Can be fitted 6 hours before
Advantages: Can be fitted 2-4 hours before intercourse.
intercourse with the ability to increase the Side effects: Risk of UTI and toxic shock
period syndrome, should be kept in for 6-8 hours
by reapplying spermicide. postcoital.
Side effects: Allergy, Urinary Tract Infection
(UTI), toxic shock syndrome if left more than
24hrs.
Sponge Spermicides
Doughnut-shaped device made of soft- Types: Foam, creme, jelly or suppository.
coated foam with spermicide. Method of use: Inserted into vagina near the
Effectiveness: 84%. cervix no more than 30mins before having
Advantages: each sponge allows repeated sex.
acts for 24 hours period. Effectiveness: 71 - 85%.
Side effects: risk of toxic shock syndrome, Advantages: Cheap and readily available.
allergy, and vaginal irritation. Side effects: allergy, vaginitis, may increase
risk of HIV.

Natural methods
Absenteeism during peri-ovulation period, or using basal body temp.
cervical mucus method, periodic abstinence, lactation amenorrhea, coitus
interruptus (effectiveness: 80-99%).

484
 Family planning & contraception

Permanent sterilization
Vasectomy for males Tubal ligation for
Done through a small incision at the base of the females
scrotum. There are different techniques to do it, Advantages: decrease
the one with the lowest failure rate is cauterization of risk of PID and
the vasa with or without fascial interposition. ovarian cancer.
Effectiveness: 99.85%. Disadvantage:
Advantages: Safer and quicker than tubal ligation. expensive, surgical
Disadvantage: expensive, surgical risks, takes time to risks, risk of ectopic
be effective (confirmed by post vasectomy semen pregnancy.
sample at 12 weeks showing rare, nonmotile sperms if Effectiveness: 99.5%.
any). Reversal: not
Reversal: expensive and success rate is highly variable. evidence based,
Correct any myths: does not increase the risk of rarely successful.
prostate, testicular cancer.

compliance of the patient, level of understanding, any

Assess questions or extra clarification needed.
Positive reinforcement a "Many others did it before
you, you can definitely do it, we are always available
Assist to support you".
Reached to shared understanding and management
Negotiate appropriate contraception.
Explain red flags (unexplained fever, abnormal vaginal
discharge
with foul smelling, dyspareunia, or pelvic pain).
Follow up as required.
Arrange Brief assessment of underlying conditions and age
appropriate
screening: vaccination, Pap smear, and mammogram.
Give away reading material if available.
Thank the patient.

485
 Family planning & contraception

More detail of natural family planning.

Emergency contraception

Emergency contraception, Plan B

Effectiveness: 88% if within 72 hours of unprotected
intercourse, and 95% if within 24 hours. Based on
levonorgestrel (2 tablets of 0.75 mg, to be taken 12 hours
apart).
Side effects: mild nausea, spotting, or bleeding.
Correct any myths: prevents ovulation. Does not cause
abortion. Not for regular use.

486
 Family planning & contraception

Emergency contraception cont.

487
Family planning & contraception

488
Family planning & contraception

489
 Antenatal care Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of present Chief complain (open question)

Allow pt to explain the chief complain
illness Clarify what you understood
Obstetric and gynecological Hx :
Analysis of • Gravida
chief • Para
• Abortion(< 20 wks)
complain • Ectopic pregnancy
• Number of Living children
• Preterm(< 37 wks)
• Still birth (>20weeks)
• Neonatal death(<28 days)
• Twins
• Type of delivery? Any complication.
Menstrual cycle:
• Regularity
• Frequency
• LMP:
• EDD: +7 days -3 months+ 1year Or +14 days in hijri
• GA:
Contraception use and type
Current pregnancy :
Planned or not ?
Regular follow-up or not ?
Any complain ?
• Nausea, vomiting ,Heartburn
• Abdominal/Pelvic/Back pain
• Vaginal discharge/bleeding/leaking
• Urinary symptoms (dysuria, frequency)
• Constipation. Headache, visual change
Fetal movement in >18 weeks GA
Medical
• DM, HTN, Bronchial asthma, Thyroid disease
• Cardiac disease
• Hematological disease(iron deficiency anemia, SCA)
• Epilepsy
• Autoimmune diseases
• DVT, PE
• Psychiatric disease
• Recurrent UTI
Surgical
• C/S
• D and C
• Cervical sutures
• Laparotomy
• Myomectomy
Allergy
Medication

490
 Antenatal care Hx
Family Hx Inheritance disease, Congenital disease
Multiple pregnancy
As mentioned above in past medical
Psychosocial Marital status, (consanguinity)
Smoking: type and frequency
Screening: depression and anxiety
ICEE Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
Examination
Vital signs (BP - weight) each visit
Appearance
General Initial or first visit:
Oral and dental EX, Thyroid Ex, Chest and Cardiac Ex, Lower
limp for edema
Obstetric EX in subsequent visit :
• Fetal heart sound >10 weeks
• Fundal height >20 weeks
Special • Symphysis-Fundal Height in (cm) >20 weeks and blot it in
uterine hight chart
• Fetal lie & presentation >36 weeks
Initial lab investigation
Hematology Infectious
• Blood group + RH • Rubella IgG
• indirect coomb’s test (if • Syphilis –VDRL /RPR
RH –ve) • Hepatitis B (HBsAg)
• CBC • Hepatitis C antibodies
• Ferritin level • HIV

Investigations Endocrinology Urine

• FBS/HbA1C • Rapid urine Dipstick
• TSH • Urine culture
US examination :
First trimester (Dating Scan )<12 weeks
Second trimester (anatomy scan) 18-22 week
Third trimester scan 30-34 weeks
OGTT: 24-28 week (screening for GDM)
Vaginal swab: 36-37 weeks (screening for GBS) according to ACOG
2020

491
 ‫‪Antenatal care‬‬
‫‪CRAPRIOP for Management‬‬
‫متابعة احلمل بشكل منتظم متكن من التشخيص املبكر ملشاكل صحية من‬
‫‪Clarification‬‬ ‫شأنها أن تنشأ خالل فترة احلمل وعالجها‪ ،‬وبهذا تزيد من احتمال احلمل‬
‫السليم وإجناب مولود معافى‪.‬‬
‫‪Reassurance‬‬ ‫نحن هنا ملساعدتك متى ماحتجت ستجدنا ان شالله‬
‫لتجنب االغثيان والقيء ‪:‬‬
‫جتنب الروائح املسببة للغثيان‪.‬‬
‫تناول وجبة خفيفة كل ‪ 2‬إلى ‪ 3‬ساعات‪.‬‬
‫جتنب األطعمة كثيرة الدهون‪.‬‬
‫شرب الزجنبيل لتقليل الشعور بالغثيان‪.‬‬
‫وضع سناكس مملحة بجوار السرير وتناول بعضها عند االستيقاظ وقبل النهوض من الفراش‪.‬‬
‫حلرقة املرئ‬
‫قسيم الوجبات الرئيسة إلى وجبات صغيرة خالل اليوم‪.‬‬
‫جتنب األطعمة املقلية وكثيرة التوابل‪.‬‬
‫جتنب االستلقاء مباشرة بعد تناول الطعام‪.‬‬
‫شرب كمية كافية من املاء بعد ‪ 30‬دقيقة من تناول الوجبة‪.‬‬
‫جتنب العصائر احلمضية )مثل‪ :‬الليمون وغيره(‪.‬‬
‫للتبول املتكرر ‪:‬‬
‫تقليل شرب السوائل خالل الليل‪.‬‬
‫التبول كل ‪ 2‬إلى ‪ 3‬ساعات لتقليل خطر اإلصابة بالتهابات املسالك البولية‬
‫ممارسة متارين تقوية عضالت احلوض )متارين كيجل( ‪ 10‬مرات يوميًّا‪.‬‬
‫جتمع السوائل في القدم‪:‬‬
‫جتنب اجللوس أو الوقوف لفترات طويلة‪.‬‬
‫‪Advice‬‬ ‫ارتداء اجلوارب الضاغطة‪.‬‬
‫جتنب ارتداء املالبس الضيقة حول الركبة والساق‪.‬‬
‫جتنب اجللوس مع وضع رجل على رجل‪.‬‬
‫عمل متارين دورية لتعزيز الدورة الدموية في القدم‪.‬‬
‫رفع الساق واألقدام عند االستطاعة‪.‬‬
‫اإلمساك والبواسير ‪:‬‬
‫شرب كمية كافية من املاء يوميًّا‪.‬‬
‫تناول الطعام الغني باأللياف كالفاكهة واخلضراوات‪.‬‬
‫تناول امللينات الطبيعية مثل اخلوخ‪.‬‬
‫أخذ الوقت الكافي لقضاء احلاجة‪.‬‬
‫أللم الظهر‪:‬‬
‫عمل التمارين الداعمة لعضالت الظهر‪.‬‬
‫االعتماد على عضالت الساق بدًال من الظهر عند حمل األجسام‪.‬‬
‫جتنب حمل األجسام الثقيلة‪.‬‬
‫تضخم الثدي ‪:‬ارتداء حمالة صدر مريحة‬
‫‪Avoid unpasteurized milk, soft cheese, row or undercooked meet,‬‬
‫‪poultry and shellfish , avoid undercooked ready prepared meals(to‬‬
‫)‪avoid Listeriosis‬‬
‫)‪Avoid partially cooked eggs or meat (to avoid Salmonella‬‬

‫‪492‬‬
Antenatal care

Breastfeeding: throughout antenatal care, healthcare providers

should provide information about the benefits of breastfeeding and
breastfeeding support should be provided.

Working: most women with an uncomplicated pregnancy can

typically continue working until the onset of labor. However, if
women have medical complications or other pregnancy
complications, or the occupation involves physical work, prolonged
standing, or significant stress, some adjustments may need to be
made.

Air travel: women with uncomplicated pregnancies can fly safely

until 36 weeks' gestation. Pregnant women who are planning to fly
should be informed about the increased risks of venous
thromboembolism from the combination of pregnancy and venous
stasis, and instructed to take appropriate precautions (support
stockings, movement of lower extremities, hydration).

Exercise: women should be encouraged to continue or begin a

Advice moderate aerobic exercise program during pregnancy. NICE:
weight management before, during and after pregnancy Although
the limited available randomized controlled trial data do not clearly
support a benefit of exercise during pregnancy for the prevention of
glucose intolerance or gestational diabetes mellitus, there may be
other physical and psychological benefits derived from aerobic
exercise in pregnancy. Structured physical exercise has been
demonstrated to significantly reduce the risk of delivering a
macrocosmic or large-for-gestational-age newborn without
influencing the risk of having a small newborn. When not
otherwise contraindicated, physical exercise during pregnancy may
reduce risk of caesarean delivery. Potential risks from contact
sports, high-impact sports, activities with risk of abdominal
trauma, and scuba diving should also be discussed.

Childbirth education: attendance in childbirth education classes

may be considered. Classes teach expectant mothers about labor
and delivery, pain relief options, potential obstetric complications
and procedures, normal newborn care, and postnatal adjustment.

493
‫‪Antenatal care‬‬

‫)‪Folate 400 mcg daily ( 1mg‬‬

‫‪if diabetic, epileptic or if H/o neural tube‬‬
‫)‪defect 5 mg‬‬
‫‪Iron 30-60 mg elemental iron daily, start 2nd‬‬
‫‪Prescribing‬‬ ‫‪trimester‬‬
‫‪anti-D if Rh -ve (at 28 wks, 1st 72 hrs‬‬
‫)‪postpartum‬‬
‫& ‪Tdap vaccination 27-36 week, influenza‬‬
‫‪COVID 19‬‬
‫‪Referral (to hospital for 38th and 40weeks‬‬
‫‪Referral‬‬ ‫‪visits‬‬
‫‪Or in case of high-risk pregnancy‬‬
‫‪Investigations‬‬ ‫‪Mentioned above‬‬
‫عدد الزيارات للحمل السليم هو ‪ 8‬زيارات ‪ 6‬منها باملراكز الصحية‬
‫االولية و ‪ 2‬تتم في املستشفى‬
‫الزيارة االولى ‪ :‬قبل امتام ‪ 12‬اسبوع‬ ‫•‬
‫‪Observation/‬‬ ‫الزيارة الثانية ‪ :‬عند االسبوع ‪18‬‬ ‫•‬
‫الزيارة الثالثة‪ :‬عند االسبوع ‪24‬‬ ‫•‬
‫‪follow up‬‬ ‫الزيارة الرابعة‪ :‬عند االسبوع ‪28‬‬ ‫•‬
‫الزيارة اخلامسة ‪ :‬عند االسبوع ‪32‬‬ ‫•‬
‫الزيارة السادسة‪ :‬عند االسبوع ‪36‬‬ ‫•‬
‫الزيارة السابعة عند ‪ 38‬والثامنة عند ‪ 40‬اسبوع في املستشفى‬ ‫•‬
‫‪Plan/prevention‬‬ ‫‪According to patient age sex and risk‬‬
‫‪Includes Safety netting :‬‬
‫يجب رؤية الطبيب في احلاالت التالية‪:‬‬
‫نزول دم أو أي سائل من املهبل‪.‬‬ ‫•‬
‫تورم شديد أو فجائي في الوجه أو األصابع‪.‬‬ ‫•‬
‫صداع شديد ومستمر‪.‬‬ ‫•‬
‫‪Conclusion‬‬ ‫غثيان وقيء شديد مستمر‪.‬‬ ‫•‬
‫دوار وضعف في الرؤية‪.‬‬ ‫•‬
‫مغص أو ألم شديد في املنطقة السفلية من البطن‪.‬‬ ‫•‬
‫ارتفاع في درجة احلرارة أو رعشة‪.‬‬ ‫•‬
‫نقص في معدل حركة اجلنني‪.‬‬ ‫•‬
‫حرقان عند التبول أو نقص كمية البول‪.‬‬ ‫•‬

‫‪494‬‬
 Postpartum care
Introduce yourself and establish good rapport ( Name, age and job).

Any complain ?
Current obstetrical Hx:
• Current Delivery: type, episiotomy
• Any Prenatal, natal or postnatal complications
Neonate history
• Gender, weight, health (NICU admission ), feeding (type,
frequency, duration, complication such as pain )
vaccination.
ICEE
• asking about her ability to coping with the new changing(
taking care of her newborn )
Screening for depression
• low mood, low interest (if positive continue with PHQ 9);
guilt( feeling inadequate in taking care of the baby), sleep
disturbance, low energy, difficult concentration, change in
appetite, crying and irritable, suicidal or homicidal
thought( hurting your baby) and psychosis.
Past Medical ,Surgical ,Drug, allergy history, and family Hx
Ask Social Hx
• Current family and husband support
• Family planning (contraceptive use )
• Lifestyle (diet ,exercise, weight control)
• Smoking
Red flags
• 2ndry post-partum hemorrhage (significant vaginal
bleeding that occurs beyond 24 hours postpartum)
should refer to hospital or ER .
• Vaginal lochia: color, amount, frequency, foul smelling
( if sign of endometritis Vaginal discharge with fever ,
tachycardia , and uterine tenderness, ) late can occurs
more than 7days after delivery. Risk factors include
chorioamnionitis and prolonged rupture of membranes.
• SOB, cough , chest pain , leg pain &swelling , HX of
thromboembolic events PE , DVT) higher during the 6
weeks postpartum than during pregnancy.
• Episiotomy or C/S scar (bleeding, discharge, pain, smell)

495
Postpartum care
• Vital signs, BMI (w.t assessment )
• General appearance, mental state ,signs of anemia
• Breast examination: nipple cracks , inflammatory sings
• Chest and cardio & LL edema
• Abdomen: tenderness &uterus size
• Vaginal examination: episiotomy site
Assess • Investigation according to her past obstetric history :
• CBC (anemia or leukocytosis), iron profile
• 75-g, 2-hour fasting oral glucose tolerance test 4 to
12 weeks postpartum to detect type 2 diabetes
mellitus, then screening every 1 to 3 years –
• TSH and free T4
• Consider pap smear
• Advice for proper diet and postnatal exercise (wt and
DM prevention ), for Hemorrhoid : Increased dietary
fiber and water intake
• Post partum depression : psychotherapy, adjunct asking
for support ( Family or friend) , exercise, Pt education .
(Explain about postpartum period and mood swings after
childbirth, that starts 2-3 days after delivery and lasts for
Advice 7- 10 days)
• Encourage continuing breast feeding alone and explain
the benefit (improve immunity, reduce GI symptoms,
better bonding with baby, help reduce the weight,
reduce risk of breast and ovarian cancers) breasts care
from cracks and engorgement Manage breast conditions
if she had any.
• Discuss contraceptive methods
• Taking care of C/S or episiotomy scar
• Encourage the patient to return to clinic if felt any
symptoms f depression, breast problems….or any
We are here for you, and we will help you to pass this period
Refer: Breastfeeding education, Dietitian , Psychologist,
Assist Psychiatrist or ER according to Pt hx

Follow up at 4-6 weeks of postpartum

Arrange We have two postnatal ; visits first one at first week and the
second from 4-6 weeks

496
 Breast Feeding
Introduce yourself and establish good rapport ( Name, age and job).
§ Mother's inquiries: Ideas, concerns and expectations (ICE)
§ Mother's diet, calcium and vitamin d supplements, fluids intake and maternal
medications.
§ Feeding history: type of feeding, onset, frequency, duration, method (Shifting breasts),
Ask ask if the child sleeps after feeds, passes stool and urine.
§ Current situation: Breast-feeding attempts or difficulties, working mother, anyone who
helps her taking care of the child, social support, husband's attitude toward breast
feeding and thoughts from others regarding breast feeding.
§ Ask about contraception measurements.
"As your doctor, I encourage you to breast feed your baby as
breastfeeding has multiple benefits for you and your baby". a. Benefits of breast feeding
for the mother and the baby:
§ Psychological bonding. Increases your baby's immunity.
§ Decreases risk of developing dermatitis, , asthma, Acute
Otitis Media and gastroenteritis.
§ Maternal weight loss, lowers risk of developing diabetes mellitus, hypertension,
cardiovascular disease and breast and ovarian cancer.
§ Cheaper and easier (no need to prepare).
Techniques of breast feeding: (starting breastfeeding best after delivery).
Maintain right position: sit comfortably with back support.
Baby position: directly facing the nipple without turning
his neck.
Ensure good latching by having large part of the areola in his mouth.
Start feeding by compressing the nipple and areola
Advise between your thumb and index finger.
Allow your baby to feed for 10 minutes on each breast.
Nursing frequency based on baby's demand.
Its normal to feel period-like cramps while you feed your baby, it's a normal reflex
following breast feeds and it indicates that your uterus is going back to its normal pre-
pregnancy size.
Other Advices:
§ Milk supply improves with adequate sleep, fluids, relaxed
environment and less Stress.
§ Clean your breasts with water, keep the nipple dry with loose clothing. Avoid using
antiseptics or soaps on the nipple. You may need to pump your breast to relieve pain or
to store milk. Engorgement may be helped with: hot shower, massage, milk expression,
supportive bra.
Counsel about appropriate contraception methods such as progesterone pills.
Breast-feeding alone is not a contraceptive method.
Understanding of the importance of breast feeding and exclude red flags (Fever, sore
Assess breast, bleeding or discharge from nipples indicating mastitis).
How the mother knows if the baby is getting enough milk
The baby has 6-8 wet diapers per day.
Assist Baby has 3-4 bowel movements per day.
The baby is back up to birth weight by 2 weeks of age.
Positive reinforcement: e.g.: Working mothers: You can use working break hours to feed
the baby or pump your breast.
§ Schedule her a follow up.
Arrange § Provide appropriate contraceptive method and consider other options when beast
feeding is stopped.
§ Vitamin D drops for the baby and vitamin D with calcium tablets for mother.
§ Safety net: come back if any fever or sore breast

497
 Breast Feeding
For more information

[Link]

•During early weeks of breastfeeding 8-12 feedings recommended at breast

every 24 hours
•avoid pacifier use during early weeks of breastfeeding

•long-term effects of not breastfeeding may include increased risk of3

• diabetes mellitus type 1
• celiac disease
• asthma
• being overweight or obesity

Management of problems
•Low milk volume:
• Maternal perception of low milk supply is the most common reason
for cessation of breastfeeding. Methods to increase milk supply
include:
• ensuring proper attachment of infant to breast to increase
likelihood of breast drainage
• offering both breasts at each feed or switching sides frequently
• expressing milk after breastfeeding infant
• No medication or supplement has clearly established efficacy for
increasing breast milk production.
•Additional problems during breastfeeding include:
• mastitis - management may include:
• increasing milk expression from affected breast
• application of cold packs
• supportive treatments, such as analgesia, increased fluid intake,
and rest
• poor infant attachment - management may include education on
proper positioning and attachment
• dermatitis - treatment depends on cause
• breast engorgement - management may include:
• manual expressing or pumping for softening and compressibility
of nipple-areolar complex or for milk extraction
• encouraging more frequently nursing before recurrence of
engorgement

498
 Breast Feeding

Breast milk storage

•Academy of Breastfeeding Medicine protocol on human milk storage for home
use for full-term infants
• preparation for milk storage
• wash hands with soap and water or alcohol-based hand sanitizer before
milk expression
• use hand or pump to express milk
• consider the following when choosing a milk storage container
• glass and polypropylene contains appear similar in their
effects on adherence of lipid-soluble nutrient to container
surface
• polyethylene containers may decrease immunoglobulin A
levels
• steel containers associated with decrease in cell count
and cell viability compared to polyethylene and glass
• store plastic bags used for milk storage in an area where
damage to the bag is minimized
• avoid storage containers containing bisphenol A
• wash containers for milk storage in hot soapy water and rinse or wash in a
dishwasher, sterilization is not needed
• breasts/nipples do not need to be washed prior to expression
• storage of milk
• freshly expressed milk can be stored safely at room
temperature
• 3-4 hours for room temperatures ranging from 27 degrees
C (80.6 degrees F) to 32 degrees C (89.6 degrees F)
• 6-8 hours at lower room temperatures for very clean
expressed milk
• minimal bacteria growth reported in samples stored at 15 degrees C (59.0
degrees F) (equivalent to blue ice pack in small cooler) for 24 hours
• refrigerator storage for 5-8 days
• freezer storage 6-12 months
• consider storage in 60- to 120-mL increments, which is typical amount for
infants in daycare to consume in 1 feeding
• cool down newly expressed milk before adding to previously cooled or
frozen milk

499
 Breast Feeding

Contraindications
breastfeeding and/or feeding expressed milk from birthing parent
contraindicated in individuals who have
• HIV infection in United States (but not necessarily individuals
living in areas with endemic HIV infection)
• human T-cell lymphotropic virus (HTLV) type I- or II infection
• Untreated brucellosis
• Suspected or confirmed Ebola virus infection
• Herpes simplex lesions on a breast (infant may feed from other
breast if clear of lesions)
• hepatitis C virus infection in the presence of cracked or
bleeding nipples
• individuals using illicit opioids, cocaine, and phencyclidin
infants with classic galactosemia.

breastfeeding not contraindicated in

• infants born in areas with endemic HIV infection
• Individuals with prenatal opioid use
• Individuals with hepatitis C virus infection who do not have cracked
or bleeding nipples
• Individuals who drink alcohol in moderation (up to 1 standard drink
per day) particularly if parent waits ≥ 2 hours after having single drink
before breastfeeding or expressing milk intended to be fed to the
infant
• individuals who smoke tobacco or vape
• infants born to individuals who have history of breast surgery (breast
augmentation or breast reduction)

500
 Post menopausal bleeding Hx

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (bleeding after menopause)
Hx of present
Allow patient to explain the chief complain
illness Clarify what you understood
Onset: When did start, after menopause or before, how many months
after menopause.
Duration: How long this bleeding has been.
Site: Make sure it is from vagina not from any other opening.
Character: Heavy or light, on an off or continues associated to the use
of HTR especially during first 6 months of usage or not.
Menstrual history:
-age of menopause, menarche, LMP, regularity
Associated symptoms (DDx):
-cancer: loss of weight , appetite , fever fatigue and night sweats.
-fibroid: heavy bleeding , bulky uterus
-adenomyosis: menorrhagia, dyspareunia and dysmenorrhea.
-bowel or urinary problems
-abdominal pain
-post coital bleeding
-bleeding disorder: epistaxis , ecchymosis, bruising.
-trauma.
Analysis of Risk Factors:
chief
complain

Red Flags:
-loss of weight , appetite fever , fatigue , night sweats.
-pallor , fatigue indicated sever anemia.

501
 Post menopausal bleeding Hx

Medical:
Fibroid, adenomyosis, PCOS, DM, bleeding disorders,
Polyps, abnormal PAP smear before
STI
Gynecological and obstetrical history:
-number of parity, miscarriages, breast feeding and sexual activity
-last PAP smear and results.
Past Hx Surgical:
-Pelvic or uterine surgery, hysterectomy, cesarean section.
-chemo or radiotherapy.
Allergy
Medication:
HRT duration, type, and indications , herbal medicines , anticoagulant,
antiplatelet, steroids, antipsychotics, SSRI, antibiotics, alcohol, vitamin
E, garlic, gingko biloba.
bleeding disorders, ovarian , breast, endometrial or colon cancer.
Family Hx PCOS, post menopausal bleeding
Marital status
Intimate partner violence
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
General Appearance
Special Pelvic examination and abdominal.
-CBC: for anemia
-coagulation profile: if suspected bleeding disorder
Investigations -US for endometrial thickness and endometrial
biopsy

502
 Post menopausal bleeding

CRAPRIOP for Management

‫نزيف بعد انقطاع الطمث هو شي غير طبيعي ويجب ان يقيمه‬
‫الطبيب ملعرفة السبب وعالجه ميكن ان ينجم عن عدة أسباب‬
: ‫من أهمها‬
‫ سرطان عنق الرحم واملهبل‬،‫سرطان الرحم‬-
‫ترقق االنسجة التي تبطن الرحم او املهبل‬-
Clarification ‫األورام الليفية الرحمية‬-
‫الزوائد اللحمية‬-
‫التهابات في بطانة الرحم‬-
‫بسبب األدوية‬-
‫نزيف من املسالك البولية او املستقيم‬-
‫يجب مراجعة الطبيب ألخذ عينه من بطانة الرحم ومعرفة‬
Reassurance .‫السبب‬
To know the cause and exclude
Advice malignancy which is the most common
cause
Prescribing According to the underlying cause
All post menopausal bleeding should be
Referral referred for endometrial sampling which is
not available in the PHC.
Investigations Mentioned above
After patient has been referred to
Observation/ appropriate specialty you should follow
follow up with her to see if there is any new
complain.
Plan/prevention
Conclusion Includes Safety netting

503
 Infertility Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of Chief complain (inability to conceive)
present Allow pt to explain the chief complain
Clarify what you understood
illness
Onset: when the couple has been unable to conceive since getting married or
did they have previously successful pregnancy then they could not get conceive
again.( to differentiate between primary and secondary infertility)
Duration: for 12months or less or more. As Infertility is inability to get pregnant
after 12 months of regular and unprotected sexual intercourse for female <35
years. And after 6 months if >35 years.
Associated symptoms (DDx): •Uterine:
Gynecology: •- History of PID, or STDs
Menstrual: •- septic abortion
•- Menarche, (LMP), •- Previous (D&C) [Asherman's] or
frequency, •surgeries (abdominal or pelvic).
•duration, flow (heavy or •- Endometriosis
light) •Obstetric:
•- History of amenorrhea •- Previous pregnancies
•- secondary dysmenorrhea •- ectopic pregnancy
•(endometriosis) •- abortions or complications
•- dyspareunia •(Sheehan's)
Analysis •Ovarian: •Hypothalamic:
of chief •- Hot flushes, libido •- stress, diet, weight loss, excessive
complain changes, •exercise (eating disorder)
•nervousness, palpitations •- depression.
•(premature ovarian failure) •Endocrine:
•- Facial hair, acne, obesity, Hypothyroidism: obesity, cold
deepening intolerance, and constipation.
•of voice (PCOS) Hyperthyroidism: diarrhea, hot
•- Feeling bloating, increase intolerance, tremor, sweating.
abdominal Cushing disease.
•size (symptoms of ovarian
tumor).
Risk Factors:
Life style like smoking, alcohol , excessive workouts, diet, environmental and
occupational exposure.
Red Flags:
Delayed puberty, visual disturbance or virilization.
Information about the husband:
Age, occupation (exposure to toxin, radiation)
Hx of previous marriage, children and age of youngest child
Past medical history of mumps, varicocele or undescended testis

504
 Infertility Hx
Medical:
DM, HTN, depression , anxiety , SLE, IBD, malignancies, cystic fibrosis,
TB, sarcoidosis.
Menstrual history:
Time, frequency <28 days or more , regular or not, age of menarche,
LMP, flow, history of amenorrhea or 2nd dysmenorrhea, IUD use and
other COP.
Obstetrical history:
Past Hx Previous pregnancies, abortions, IVF, ectopic pregnancies.
Surgical:
Previous pelvic or abdominal surgeries , or tube surgeries, adhesions,
previous D&C.
Allergy
Medication:
Antipsychotics, antidepressants, steroids, OCP, chemo or radiotherapy,
previous infertility therapies that has been used.
Mother and sisters’ age of menarche and menupause, menstrual
Family Hx dysfunction, infertility, DM, autoimmune diseases or chromosomal
abnormalities.
Marital status:
Infertility in other partner , marital conflicts, duration of marriage ,
Psychosocial sexual activity (frequency), stressful events, domestic violence
Alcohol, Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Endocrine causes:
Systemic -hypo or hyperthyroidism: obesity, hot\cold intolerance,
constipation\diarrhea .
Review -Cushing disease.
-history of varicocele, undescended testicles, mumps.
conclusion
Examination
Vital signs
General Appearance any syndromic features , BMI, secondary sexual characters.
Breast Ex (formation, galactorrhea) Thyroid, abdominal examination ,
Special Genitourinary Ex (uterine masses, vaginal discharge).
Endocrine (hirsutism, acne vulgaris, clitoromegaly suggest hyperandrogenism)

505
Infertility Ex
Investigations

506
 Infertility
CRAPRIOP for Management
‫ على الرغم من ممارسة اجلماع بشكل متكرر ومنتظم ودون ارتداء‬، ‫ هو عدم القدرة على احلمل‬:‫العقم‬
Clarification .‫واق ملدة عام على األقل‬
‫ حلسن احلظ‬.‫ أو مجموعة من العوامل التي متنع احلمل‬، ‫قد ينتج العقم عن مشكلة بك او بشريكك‬
Reassurance . ‫توجد العديد من العالجات اآلمنة والفعالة التي تزيد بشكل كبير من فرصتك في احلمل‬

Advice
&
Prescribing

Referral To infertility clinic

Investigations Mentioned above

Observation/follow up Follow the patient after referral to see the results
Plan/prevention Pap smear and mammogram screening
Conclusion Includes Safety netting

507
HRT initiation

Understand that you are visiting me today because you are disturbed
by "hot flushes".
Can you tell me more about It?
• Ask about decreased concentration and activity, disturbed
sleep, night sweats, mood swings, sexual impairment,
dyspareunia, dysuria or incontinence.
"To be able to help you, I need to ask you further questions"
ICEE :
• Idea, concern and expectations, effect of live

Screening for depression and GAD

Past medical Hx:

• DM , HTN, cardiovascular diseases, stroke, deep vein
thrombosis, Liver disease, Cancers (malignant melanoma,
Ask endometrial, breast, ovarian, colorectal) gall bladder disease ,
and migraine.
Menstrual Hx:
• Regularity , frequency, duration , dysmenorrhea
Obstetric and Gynecological Hx:
• Vaginal bleeding, fibroids, hysterectomy
Surgical ,Drug, allergy history Hx:
Social Hx:
• Current family and husband support
• Lifestyle (diet ,exercise, weight control)
• Smoking
Family Hx:
• Osteoporosis, breast or endometrial cancer
Screening:
• last mammogram, pap-smear , colorectal cancer , lipids
profile, HA1c , BP
• Vital signs, BMI (weight assessment),CVR assessment
• General appearance
• Local focused:
• Pelvic: look for signs of vaginal atrophy, such as
Assess bleeding and fissures due to thinning of vaginal
epithelial tissues, loss of subcutaneous fat in labia
majora, narrowing of introitus, fusion of labia
minora, vaginal secretions.

508
HRT initiation

Assess

Precautions (not clearly contraindications)

• Personal history or known high risk of thromboembolic
disease
• Breast cancer
• Uncontrolled hypertension
• Unexplained abnormal vaginal bleeding
• Abnormal liver function
• History of endometrial or ovarian cancer
• High-risk gallbladder disease
"I understand how frustrated you are, all the feelings that you are
describing point towards menopause. These symptoms can be
Improved with HRT.
HRT are safe when indicated appropriately. In your case, HRT Is
considered safe because you have no health risks to prevent us from
starting HRT and you will benefit from." (indicate the appropriate type)
Advice and explain clearly the advantages and disadvantages of HRTs.
Advantages:
•Decrease hot flushes, Improve sleep, muscle aches, mood, sexual
activity and vaginal dryness, Increase bone mineral density and
decreases fractures risk in forearm, vertebrae and hip. Decrease the
risk of colorectal cancer, treatment of urogenital symptoms, decrease
risk of diabetes, osteoarthritis and cataract.

509
HRT initiation
Disadvantages:
•Gl upset, decreased appetite, Nervousness, Breast enlargement and
tenderness, spotting or vaginal bleeding, acne, Increase risk of uterine
and ovarian cancer, Increase risk of breast cancer especially if obese
Advice lady or when used for more than or equal to 3 to 5 years, Increase risk
of cardiovascular diseases, stroke and deep vein thrombosis if used in
women 60 years or older, increase risk of gall bladder stone and GB
diseases, worsen urinary incontinence,
Determine your patient willingness and level of
understanding RT initiation, advantages and disadvantages."
So, what do you think about starting you in HRTS? " Do you
think you can cope with those side effects?"
Choice of the appropriate medication
Assist Assurance: "To decrease the side effects, we will start you
with the smallest dose and use them for the least time
possible and at that time we will be stop it gradually*

Answer questions and clarify concerns "Do you have any

questions for me?
Positive reinforcement and reassurance "Many others did it
before, you can do it and we are always available to support
Arrange you"
Follow up soon and ensure safety netting
Give away reading material if available

510
Emergency

511
Emergency
HTN
• Emergency & urgency
Diabetes mellites
• Hypoglycaemia
• DKA
• HHS
Bite
Status epilepticus

512
HTN emergency & urgency

1- Headache
2- Epistaxis
3- Faintness and psychomotor agitation
Suggested 4- Chest pain/dyspnea
presentations 5- Neurological deficit
6- Uncontrolled KCO HTN
7- OSA with Sever HTN
Acute target organ injury symptoms (Hypertensive Emergency):
neurologic (headache, vision changes, seizure, neurologic deficits),
cardiovascular (chest pain, shortness of breath, myocardial infarction,
syncope, history of palpitations or arrhythmias), renal (oliguria, anuria),
peripheral arteries (claudication, cold extremities, weak distal pulses),
pulmonary (sleep apnea, chronic lung disease)

Other symptoms due to high BP but not related to target organ injury
(Severe asymptomatic hypertension or Hypertensive urgency):
headache, lightheadedness, nausea, shortness of breath, palpitations,
epistaxis, or anxiety, depending on the acuity and severity of blood
pressure elevation.

Treatment: compliance, side effects

Concurrent medication/drug use: nonsteroidal anti-inflammatory drugs,

antidepressants, oral contraceptives, cold medications,
sympathomimetics (amphetamines, cocaine, phencyclidine),
corticosteroids, herbal remedies

Previous hypertension (duration and levels)

Any similar episodes before
Focused Past Medical Hx: Personal history: coronary artery disease, congestive
history heart failure, cerebrovascular disease, chronic kidney disease,
peripheral vascular disease, diabetes mellitus, sleep apnea
Family history of kidney disease, personal history of renal disease,
medications and illicit drug use,
Any acute psychosocial event
Red flags
• Stroke or increase intracranial pressure & hypertensive
retinopathy (headache, visual disturbances or, weakness, seizures,
nausea and vomiting)
• CHD or MI or arrhythmia (Chest pain, dyspnea, palpitation &
claudication)
ABC We can use algorithm (updated)

513
HTN emergency & urgency

A 30-minute rest period is recommended when the initial blood pressure

reading is severely elevated. (in > 30% of cases, BP will lower to an acceptable
level without intervention) With correct way (Table 2)
Look for signs of target organ injury:
Focused • Neurologic(motor or sensory deficits),
Physical Ophthalmologic (arteriolar narrowing, hemorrhage, papilledema),
examination Cardiovascular (arrhythmia, displaced point of maximal impulse, murmur,
third heart sound
• gallop), Pulmonary (rales, hypoxia, tachypnea)
Vascular (diminished or absent peripheral pulses, abdominal bruits, unequal
pulses or blood pressure, jugular venous distension)
• No recommend laboratory testing for patients with severe asymptomatic
Focused hypertension
• Patients with symptoms or clinical findings suggesting acute target organ
investigation injury require appropriate diagnostic testing and evaluation for possible
hypertensive emergency like: KFT, electrolytes and TFT CXY / ECG / CT brain
Aggressive lowering of blood pressure can be harmful and should be avoided in
patients with severe asymptomatic hypertension.
• Gradual reduction over several days to weeks is recommended
• In the absence of acute target organ injury, blood pressure should be
lowered gradually to less than 160/100 mm Hg, but not acutely by more
than 20% to 25% of the mean arterial blood pressure over several days to
weeks.
• Every two to four weeks, antihypertensive intensification is recommended
to achieve target blood pressure goals.
• Patients who have not been compliant often can safely resume their
outpatient medications and appropriate dosing adjustments
Management • Hospitalization is rarely required for patients with severe asymptomatic
Observation hypertension.

Pharmacologic:
• Short acting Anti HTN medications: Prazosin / Labetalol / Clonidine /
Captopril
• When blood pressure improves, long-acting antihypertensive therapy
should be initiated, restarted, or adjusted
• Parenteral medication is not indicated and should be reserved for the
management of hypertensive emergencies.
• Inpatient treatment of acute hypertension is often aggressive, and
intravenous antihypertensives are commonly used
• FU in 1-3 days
Conclusion • Recheck compliance, do basic lab and CV risk assessment

514
 HTN emergency & urgency

BP 140/90 – 159/99
New patient Known HTN
• Assess adherance to medications
• Arrange for 3-5 BP readings over
• Enforce follow up in chronic
2 weeks.
disease clinic
• Follow up in morning clinic
• (optional) add one of: ACEi/ARB,
Thiazide/indapmide, Amlodipine

BP 160/100 - 179/109
New patient Known HTN
• Roll out pregnancy in female
• Initiate one or two of:
• ACEi/ARB, Thiazide/indapmide, • Same as above
Amlodipine
• Follow up in 1-2 weeks

Asymptomatic BP>180/110
• Aim to reduce BP over hours to days. MAP should not be reduced over
30%
• Rest 30 min in quite room
• Initiate either:
• Short acting: oral Captopril 12.5-25mg stat and assess after 45-60 min
• Or long acting CCB (Amlodipine 5mg) with ACEi/ARB or Thiazide and
follow up in clinic
• Follow up in 1-3 days

Symptomatic BP>180/110 (HTN Emergency)

Immediate refferal to hospital ER

515
HTN emergency & urgency

516
HTN emergency & urgency

517
HTN emergency & urgency

518
 Hypoglycaemia

Hypoglycemia is defined as all episodes of an

abnormally low plasma glucose concentration (with
Definition or without symptoms) that expose the individual to
harm. ≤70 mg/dL (3.9 mmol/L).
Drugs (exogenous insulin, sulfonylureas,
Causes quinolones, beta blockers, ACEIs, alcohol),
omitting food after having insulin, critical illness.
Level 1
Glucose <70 mg\dL(3.9mmol\L) and Glucose ≥ 54
mg\dL (3.00 mmol\L)

Level 2
Classification Glucose < 54 mg\dL (3.00 mmol\L)

Level 3
A severe event characterized by altered mental
and/or physical status requiring assistance.
• Age>60
• African American race
Risk factors • insulin use
for Level 3 • poor or moderate glycaemic control
• albuminuria
• poor cognitive function
Neurogenic: tremor, palpitations, anxiety, sweating,
hunger, & paresthesia.
Suggested
presentations Neuroglycopenic: cognitive & behavioral changes,
psychomotor abnormalities, seizure & coma.
Last meal.
Focused
Use insulin, medications.
History Fever, vomiting

519
Hypoglycaemia

Pure glucose is the preferred treatment, but any

form of carbohydrate that contains glucose will
raise blood glucose.

Treatment

15-15 Rule

Patients with impaired consciousness and

established IV access:
A 25-50 ml of 50% dextrose is administered slow IV
while the patient’s airway, breathing, and
circulation are assessed and maintained.
In children < 8 years, providers should use D25W or
ER
D10W.
Sitting For patients with impaired consciousness and no
established IV access:
0.5-1 mg glucagon SQ or IM.
Recheck BS after 5-10 min if BS still less than
70mg\dl repeat treatment till BS level exceed
70mg\dl
Not improve
Referral to
Persistent or caused by oral drugs
ER hospital Suspected other causes as infection or malnutrition
Once the glucose returns to normal, the individual
Prevention should be counseled to eat a meal or snack

520
 Hyperglycemic Hyperosmolar state HSS
Polyuria, Polydipsia, Weight loss, Weakness, extreme dehydration, Mental
Suggested status change
presentations
*Higher risk in older patients with multiple comorbidities
May be the initial presentation of type 2 diabetes mellitus .
Gather the following information:
1- Preexisting diabetes diagnosis, usual medications and adherence
2- Triggers:
Focused history
• Recent symptoms of infection (pneumonia, UTI)
• Stroke, myocardial infarction, and trauma
• Medications that may precipitate HHS, such as corticosteroids, thiazides,
first- and second-generation antipsychotic drugs

Vital signs, degree of dehydration (tachycardia, dry mucous membrane, poor

Focused
skin turgor), mental status changes, examine for possible signs of infection (e.g.
Physical
pneumonia, UTI, GE), fever is not always presents due to peripheral
examination
vasodilation.
• Serum glucose, electrolytes, blood urea nitrogen (BUN), creatinine, beta-
hydroxybutyrate (ketones), osmolality, and CBC with differential
• Arterial (or venous) blood gas
Focused • Urine dipstick and urinalysis for ketones if beta-hydroxybutyrate is not
Investigations measured
• Urine, blood, and/or sputum gram stain and culture if infection is
suspected
• Electrocardiogram
Diagnostic criteria:
Glucose > 600 mg/dl (33.3 mmol/L)
Serum osmolality > 320 mosm/kg
Diagnosis Arterial pH > 7.3
Serum bicarbonate > 15-18 meq/L (15-18 mmol/L)
Little or no ketonemia and ketonuria, and stupor or coma.
• Stabilize the patient's airway, breathing, and circulation.
• Obtain large bore IV (≥16 gauge) access
• monitor using a cardiac monitor, capnography, and pulse oximetry.
ABC • Monitor serum glucose hourly, and basic electrolytes and venous pH or
bicarbonate every two to four hours until the patient is stable.
• Determine and treat any underlying cause (e.g. pneumonia or urinary
infection, myocardial ischemia)
Admit to ICU
Fluid:
• Patients with HHS are estimated to require about 7-12 L of fluid
replacement.
• Begin with 0.9% saline IV at 1-1.5 L/hour (15-20 mL/kg/hour) for the first
hour.
Management • After intravascular volume is restored, give one-half isotonic (0.45%)
saline at 4 to 14 mL/kg per hour (250-500ml /hour) if the corrected
serum Na+ is normal or elevated; isotonic saline is continued if the
corrected serum Na+ is reduced.
• Add dextrose to the saline solution when the serum glucose reaches ~300
mg/dL (11.1 mmol/L).(5% dextrose with 0.45 Nacl at 150- 250ml/hour)

521
Hyperglycemic Hyperosmolar state HSS
Electrolytes:
• Calculate the corrected serum sodium. Avoid rapid correction of sodium,
and do not exceed serum sodium reduction > 10 mmol/L (10 mEq/L) per
24 hours.
• If sodium remains persistently high in patients who are no longer
hypovolemic, consider changing to 0.45% saline.
• Provide potassium supplementation 20-30 mEq/hour IV (and withhold
insulin) until potassium level is ≥ 3.3 mEq/L, and then as needed to
maintain serum potassium level of 4-5 mEq/L.
• Do not give potassium if serum potassium level is ≥ 5.2 mEq/L.
• Limit phosphate replacement to persistent severe hypophosphatemia
after initial 24 hours, and magnesium replacement to symptomatic
hypomagnesemia.
Insulin:
• Continuous IV infusion of regular insulin is treatment of choice with either
of:
• Insulin 0.1 units/kg IV bolus followed by continuous infusion at 0.1
units/kg/hour
• Insulin 0.14 units/kg/hour IV by continuous infusion (no bolus)
• If serum glucose does not fall by at least 10% in first hour, give 0.14
units/kg as IV bolus
• Once serum glucose falls to 300 mg/dL (16.7 mmol/L), reduce infusion
rate to 0.02-0.05 units/kg/hour and maintain serum glucose 200-300
Management mg/dL (11.1-16.7 mmol/L) until patient is mentally alert
• When hyperglycemic hyperosmolar state (HHS) resolves (osmolality and
mental status normal), and when patient able to eat, transition to
subcutaneous insulin therapy
• Continue IV insulin for 1-2 hours after initiation of subcutaneous insulin to
prevent recurrence of hyperglycemia
In pediatric
• Give 0.9% saline 20 mL/kg IV bolus and repeat until peripheral perfusion is
restored.
• Once perfusion is restored, change to 0.45% saline IV at a rate sufficient to
provide maintenance fluids plus replacement of fluid deficit over 24-48
hours. (Assume a fluid deficit of 12%-15% of body weight.)
• Target a 75-100 mg/dL/hour (4.1-5.5 mmol/L/hour) decrease in serum
glucose and a 0.5 mEq/L/hour decrease in serum sodium.
• Provide potassium replacement if potassium is < 5 mEq/L (establish
adequate renal function first), and consider magnesium replacement in
children with low magnesium and hypocalcemia.
• Give insulin by continuous IV infusion.
• Start insulin at 0.025-0.05 units/kg/hour and titrate to achieve a 50-75
mg/dL/hour (2.7-4.1 mmol/L/hour) decrease in serum glucose.

Resolution of hyperglycemic hyperosmolar state:

• Effective serum osmolality < 310 mmol/kg
• Plasma glucose level ≤ 13.8 mmol/L (250 mg/dl)
• Recovered mental status
• After resolution follow up should include review of current home insulin
Follow up plans and reinforcement of diabetes management while sick to prevent
recurrences.

522
Hyperglycemic Hyperosmolar state HSS

523
 Diabetic ketoacidosis DKA
The earliest symptoms of marked hyperglycemia are polyuria, polydipsia, &
Suggested weight loss. Hyperventilation, abdominal pain, N&V, lethargy & coma in
presentations later stages.
Treatment compliance , Side effects, Concurrent medication/drug use:
glucocorticoids, thiazide, cocaine)
Risk factors for developing DKA:
Focused history Acute illnesses (MI, CVA, pancreatitis), infection (pneumonia, UTI, sepsis),
new onset type 1, psychological problems particularly in young patients
with type 1 diabetes.

Vital sign (tachypnea, tachycardia, orthostatic hypotension), o2 saturation.

Assess mental status.
Focused Assess volume status: vital signs, skin turgor, mucosa, urine output.
Physical Examine for possible signs of infection (e.g. pneumonia, UTI, GE).
Signs that may indicate cerebral edema (extremely rare in adults:
examination hypertension, bradycardia, pupillary changes, papilledema).
• Serum glucose
• Serum electrolytes (with calculation of the anion gap), blood urea
nitrogen (BUN), and plasma creatinine
• Complete blood count (CBC) with differential
Focused • Urinalysis and urine ketones by dipstick
Investigations • Plasma osmolality
• Serum beta-hydroxybutyrate (if urine ketones are present)
• Arterial or venous blood gas
• Electrocardiogram
• Blood glucose >250 mg/dL (13.9 mmol/L)
Diagnosis • Ketosis(in urine or serum)
• Metabolic acidosis (<7.3, co3 < 18)
• Stabilize the patient's airway, breathing, and circulation.
• Obtain large bore IV (≥16 gauge) access; monitor using a cardiac
monitor, capnography, and pulse oximetry.
ABC • Monitor serum glucose hourly, and basic electrolytes and venous pH
or bicarbonate every two to four hours until the patient is stable.
• Determine and treat any underlying cause of DKA (e.g., pneumonia or
urinary infection, myocardial ischemia).
The goals of management of DKA are:
To restore intravascular volume
To prevent and/or correct electrolyte abnormalities
To correct acidosis
To correct hyperglycemia
IV Fluid
• Give IV isotonic (0.9%) saline at 15 to 20 mL/kg per hour (i.e., 1 to 1.5
Management L per hour)
• After intravascular volume is restored, give one-half isotonic (0.45%)
saline at 4 to 14 mL/kg per hour (250-500ml /hour) if the corrected
serum Na+ is normal or elevated; isotonic saline is continued if the
corrected serum Na+ is reduced.
• Add dextrose to the saline solution when the serum glucose reaches
~200 mg/dL (11.1 mmol/L).(5% dextrose with 0.45 Nacl at 150-
250ml/hour)

524
Diabetic ketoacidosis DKA
Potassium
• If initial serum K+ is below 3.3 mEq/L, hold insulin and
give potassium chloride 20 to 40 mEq/hour IV until K+
concentration is above 3.3 mEq/L;
• If initial serum K+ is between 3.3 and 5.3 mEq/L, give
potassium chloride 20 to 30 mEq per liter IV fluid;
maintain serum K+ between 4 to 5 mEq/L
• If initial serum K+ is above 5.3 mEq/L, do not give
potassium; check serum K+ every 2 hours; delay
administration of potassium chloride until serum K+
has fallen to 5 to 5.2 mEq/L.
Insulin
• Give all patients without a serum K+ below 3.3 mEq/L
regular insulin.
• Either of two regimens can be used: 0.1 units/kg IV
bolus, then start a continuous IV infusion 0.1 units/kg
per hour; OR do not give bolus and start a continuous
IV infusion at a rate of 0.14 units/kg per hour.
• If serum glucose does not fall by at least 50 to 70
mg/dL (2.8 to 3.9 mmol/L) in the first hour, double the
Management rate of insulin infusion.
• When the serum glucose reaches 200 mg/dL (11.1
mmol/L), it may be possible to decrease the infusion
rate to 0.02 to 0.05 units/kg per hour.
• Continue insulin infusion until ketoacidosis is resolved
Sodium bicarbonate
If the arterial pH is below 6.90, give 100 mEq of sodium
bicarbonate plus 20 mEq of potassium chloride in 400 mL
sterile water over two hours.
Phosphate replacement
For patients with severe hypophosphatemia (<1 mg/dL
[0.32 mmol/L]), respiratory or cardiac failure, or hemolytic
anemia.
According to American Diabetes Association criteria for
resolution of ketoacidosis includes:
• Blood glucose < 200 mg/dl and 2 of the following
criteria:
• Serum bicarbonate level ≥ 15 meq/L.
• Venous ph > 7.3
• Calculated anion gap ≤ 12 mEq/L

525
Diabetic ketoacidosis DKA

Patient with mild DKA who is alert and able to tolerate oral
fluids, management may occur in emergency department

treat patients in intensive care unit settings with IV insulin

Disposition if have any of following:
• Severe DKA
• Hypotension
• Anasarca
• Other comorbid critical illness

526
Diabetic ketoacidosis DKA

527
 DKA in Pediatric
Diagnosis and management of DKA In pediatric
DKA Is the first presentation of diabetes in approximately one-third or
children, presenting symptoms:
Presentation Initial - Polyuria, polydipsia, weight loss, nocturia, enuresis , fatigue
Subsequent - Nausea/vomiting. abdominal pain. Fruit breath odor,
Kussmaul breathing, sometimes altered conscious.
DKA IS defined by the presence of all of the following in a patient with diabetes:
• Hyperglycemia- blood glucose =>200 mo/ol (11 mmol/L)
• Metabolic acidosis: venous pH <7.30 and/or serum bicarbonate <18 mEg/L
• Ketosis - Elevated levels of ketones in urine or blood
Diagnosis Severity of DKA:
• Mild: PH 7.2 - 7.3 Bicarbonate 10-18 mEq/L
• Moderate: PH 7.1 - 7.2 Bicarbonate 5-10 mEq/L
• Severe: PH <7.1. bicarbonate <5 mEq/L
Degree of dehydration:
Patients with DKA are usually more dehydrated than suggested by the
clinical examination.
Initial fluid management should be Based on:
• If pH <7.1 (suggesting severe DKA), BUN >20 mg/dL, or new onset of
diabetes - Assume approximately 8% dehydration
• All others - Assume approximately 6% dehydration.
Fluids
Give 10 to 20 mL/kg of IV 0.9% NaC (normal saline), or other isotonic
solution over 20 to 30 minutes:
• Mild DKA: 10 ml/kg
• Moderate: 20 ml/kg
• Give additional boluses if necessary based on cardiovascular status.
• Replace the estimated fluid deficit over 24 to 48 hours using 0.45 and
0.9% NaCI in addition to maintenance fluids.
Potassium
Management • Low potassium (3.5 mEq/I)- Add 40 mEq/L of potassium to the fluids as soon
as possible and delay insulin until serum potassium is normal
• Normal potassium (3.5 to 4.5 mEq/L) - Add 40 mEa/L of potassium to IV
fluids when insulin therapy is started.
• High potassium (>4.5 mEq/L) - Monitor every hour and begin potassium
replacement when serum potassium decreases to the normal range and
when urine production or adequate renal function is documented.
• Provide potassium as a 1:1 mixture of potassium phosphate plus either
potassium chloride or potassium acetate.
Insulin
After the initial fluid bolus is complete, begin a continuous insulin infusion
at 0.1 units/kg per hour. Mix 50 units of regular insulin in 50 ml of saline
(0.45 or 0.9% NaCl), such that 1 mL of the infusion provides 1 unit of
insulin.
Glucose
Add dextrose to the IV fluids when the blood glucose below approximately
300 mg/dl (17 mmol/L) to prevent hypoglycemia.

528
DKA in Pediatric

Bicarbonate therapy generally should not be used in

children with DKA.

Phosphate should be replaced during DKA treatment

(typically by including potassium phosphate in IV fluids),
guided by intermittent monitoring of serum phosphate
concentrations.

Monitoring:
Management Monitor vital signs., neurologic status, fluid intake (IV and
oral) and losses and blood glucose hourly.
Electrolytes, venous pH and pCO2 every 2 to 4 hours.

Resolution of DKA:
When all of the following conditions are met:
• Serum anion gap reduced to normal (12±2 mEq/L)
• Venous pH >7.3 or serum bicarbonate >18 mEq/L
• Blood glucose <200 mg/dL (11.1 mmol/L)
• Patient is tolerating oral intake
A pediatric intensive care unit (PICU) or specialized
inpatient diabetes care unit is appropriate for patients with
severe DKA or signs of or risk factors for cerebral injury,
which include:
• Altered consciousness
• Age younger than five years
• Severe acidosis (venous pH <7.1)
Disposition
• Low pCO2 (≤20 mmHg)
• High BUN
• Significant hyper- or hypokalemia, or other severe
electrolyte disturbances.

The regular inpatient care area is appropriate for patients

with mild to moderate uncomplicated DKA

529
DKA in Pediatric

530
 Bite
Snake bite
Presentation differ according to venom type which can be cytotoxic
envenoming, neurotoxic envenoming, myotoxic envenoming,
hemorrhagic envenoming.
local swelling, nausea, vomiting, diarrhea
severe headache, drowsiness
Spontaneous bleeding
Dark brown or black urine.
Suggested Systemic envenomation is suggested by:
Presentations • neurotoxic symptoms (paresthesia of tongue and lips, progressive
descending paralysis, drooping eyelids (ptosis), double vision due to
external and internal ophthalmoplegia, difficulty swallowing or
breathing weakness and paralysis, convulsion)
• Bleeding and clotting disorders
• AKI (oliguria/anuria, and rising blood creatinine/urea)
• cardiovascular signs such as hypotension, shock, cardiac arrhythmia,
• Part of body bitten, Time since snakebite
• snake identified as clinically important (snakes that are known in
the region with potential for envenomation)
• Occupations: farming, herding, hunting, fishing, snake handling.
• local swelling
• tender lymph node enlargement (indicates spread of venom) within
Focused history 30-60 minutes
• early systemic symptoms (hypotension, shock, nausea, vomiting,
diarrhea, severe headache, pathologic drowsiness, ptosis)
• spontaneous bleeding
• dark brown or black urine (myoglobinuria) or no passage of urine
since bite occurred
-Immobilize the affected limb with a splint or sling and limit movement
-Rapid clinical assessment and resuscitation:
Check airway, breathing, circulation, level of consciousness
-Use cardiopulmonary resuscitation, oxygen, and IV access as needed
-Assess severity of envenomation
-Try to identify snake species
-Clean and cover wounds with sterile dressing
Harmful treatments that should be avoided include:
× cauterization, incision or excision, or immediate prophylactic
ABC amputation of the bitten digit.
× Suction of venom by mouth or vacuum pumps
× Application of ice pack
× Tourniquet use is not recommended.
Treatment:
• Oral acetaminophen for intense local pain
• Reserve anti-venom for patients with signs or symptoms suggestive
of systemic or severe local envenomation.

531
Bite
• Consider a prophylactic tetanus toxoid booster as needed
• Antibiotics are usually not needed unless necrosis is present
• Prophylactic epinephrine is recommended to reduce the frequency
and severity of early antivenom reactions:
-Adult prophylactic dose: 0.25 mL of 0.1% solution (0.25 mg) by
ABC subcutaneous injection.
-Pediatric prophylactic dose: 0.005 mL/kg of 0.1% solution by
subcutaneous injection.
• In patients with asthma, prophylactic use of an inhaled adrenergic
B2 agonist, such as salbutamol, may help prevent bronchospasm.
Vital signs: hypotension, tachycardia
Fang marks may or may not be visible
Assess for: signs of shock, such as cold, cyanotic, and sweaty skin, local
bruising, lymphangitis,
signs of necrosis, evidence of bleeding disorder such as petechiae,
purpura, ecchymoses.
HEENT
Examine for nasal bleeding
Assess for signs of neurotoxicity, including:
bilateral ptosis, pupillary abnormalities, internal and external
Focused Ophthalmoplegia
Size and reaction of pupils (to check for paralysis or intracranial
Physical hemorrhage [asymmetrical pupils])
examination Trismus or paralysis of pterygoid (ask patient to open his/her mouth
and protrude tongue)
Neck: stiffness (subarachnoid hemorrhage)
Chest: respiratory muscle paralysis
Cardiac : arrhythmias
Abdomen: tenderness may indicate gastrointestinal or retroperitoneal
bleeding.
Neuro: generalized flaccid paralysis
Extremities: inflammatory signs (swelling, redness, heat)
Enlarged and tender lymph nodes
Blistering, abscess formation, or necrosis
• ABG
• Coagulation profile
• CBC
• Serum biochemical testing
Focused • Peripheral smear to look for evidence of hemolysis
Investigations • urine studies , for signs of rhabdomyolysis
• ECG: abnormalities detected on ECG may include sinus bradycardia,
ST-T waves, atrioventricular block, hyperkalemia (tall peaked T
waves, prolonged P-R interval, absent P waves, wide QRS
complexes), myocardial infarction, or infarction
• All cases of suspected or confirmed snakebite should be observed
Follow up with serial blood testing for at least 12 hours to exclude severe
envenoming.

532
Bite

Mammalian bite
The majority of the bites are from dogs, followed by cats, and then
humans.
Signs of infection may arise 24-72 hours after bite including:
Suggested
• Tenderness
Presentations • Redness
• Swelling
• Clear or purulent discharge
• Regional lymphadenopathy
• Reduced range of motion
• Site (risky sites: hands [prone to infection] or near joints)
• Time of injury.
• Pain (pain out of proportion to severity of injury and near a joint
or bone may indicate periosteal penetration)
• Swelling
• Immunocompromising conditions, such as, asplenia or hepatic
dysfunction in patient.
• Immunization status including tetanus and hepatitis B virus.
Factors in the biter, either animal or human, that may alter
Focused history management, including:
For animal bites:
-Type of animal involved
-Health of the animal and immunization status, particularly rabies
For human bites:
-Whether the bite was an occlusive or a clenched fist injury
Any health conditions of the biter, particularly Hepatitis B ,C and HIV
(note transmission via saliva is rare and generally postexposure
prophylaxis not generally recommended).
1- Vital signs suggestive of infection
2- Examine the wound
-Assess location and size of wound and type of injury (laceration,
Focused puncture, or crushing injury)
-Assess for penetration of any joint, nerve, or tendon damage
Physical (consider evaluation by hand surgeon if bite in hand)
examination -Foreign matter, such as, embedded teeth
-Signs of infection including, redness, swelling, purulent drainage,
fluctuance (abscess)
-Regional lymphadenopathy
CBC
Coagulation profile
Focused CRP & ESR
Investigations For systemically ill: blood culture and gram stain
X-ray may be needed to assess for foreign body such as teeth fracture
abscess osteomyelitis

533
Bite

Wound care:
High-pressure irrigation with sterile normal saline
Debridement of any devitalized tissue
Timing of closure: overall controversial. Infected wounds
should not be closed (apart from those on the face, which
may need closure by plastic surgeon)
Prophylactic antimicrobial therapy recommended for
patients with:
Immunocompromise
Asplenia
Advanced liver disease
Edema at bite site, whether preexisting or arising after bite
Moderate-to-severe degree of injury, especially to hands or
face
Injuries penetrating the joint capsule or periosteum
Antibiotic prophylaxis for other high-risk bite wounds
including:
Cat bites
Puncture wounds
Management
Crush injuries
Wounds to hands or face
Bites to extremities with underlying venous or lymphatic
compromise
Bite in close proximity to bone or joint, especially
prosthetic joint
Primary closure performed at bite site
Delayed presentation
Treatment of infection:
Amoxicillin-clavulanate 875 mg/125 mg orally every 12
hours
Duration: 7-14 day for infections limited to soft tissue
≥ 21 days for infections involving bones or joints
Alternative: second- or third-generation cephalosporin plus
anaerobic coverage: e.g. cefuroxime 500 mg orally twice
daily plus clindamycin 300 mg orally 3-4 times daily
Vaccination and postexposure prophylaxis for:
-Tetanus and rabies with animal bites
-Hepatitis B virus and HIV with human bites
Follow up In 24-48 hours to assess for development of infection.

534
 Status Epilepticus

• Prolonged seizure (any seizure lasting ≥ 5 minutes)

or ≥ 2 sequential seizures without recovery of full consciousness
Suggested between seizures
• Incontinence and tongue biting
presentations • Altered mental status (lethargy, confusion, coma)
• Persistent postictal depression of neurologic function between
seizures
• Details about attack (onset, duration, generalized or partial, level
of consciousness .. etc.) from witness if possible
• Is it provoked? Any precipitating factor(Infection (fever), Trauma,
sleep deprivation, electrolytes imbalance)
• Past medical or surgical (Known case of epilepsy ?)
• Drug Hx: antiepileptic drug use including (compliance, withdrawal,
Focused discontinuation, recent changes), use of other drugs
history • Any medication is giving during this attack
Red flags:
• Poor adherence to anticonvulsant therapy
• Alcohol-use disorder, alcohol withdrawal, illicit drugs
• processes leading to cortical structural damage such as hypoxic-
ischemic brain injury, head trauma, stroke subarachnoid
hemorrhage, tumors, or brain infections
• Check for airway, breathing, and circulation
• Maintain Airway: by position in lateral decubitus or head up with
ongoing suction, use a nasopharyngeal airway
• Offer Oxygen if needed, Establish IV access
• Continuous monitoring of heart rate and rhythm, breathing, pulse
oximetry, and periodic measurement of blood pressure and
temperature
Correct hypoglycemia and metabolic derangements:
• Hypoglycemia should be treated with 100 mg of thiamine and 50
ABC mL of 50 percent dextrose solution. If IV access is not available,
IM glucagon or IO 50 percent dextrose can be given.
Start 1st Line Medication:
- Lorazepam 4mg (0.1 mg/kg) IV
- Diazepam 10mg (0.15-0.2mg/kg) IV
- Diazepam (0.2-0.5mg/kg) Rectal
- Midazolam 5-10mg IM

Repeat the dose once after 5-10 min

535
 Status Epilepticus

Start 2nd Line Medication:

• levetiracetam is given at a loading dose of 60 mg/kg
(maximum 4500 mg) infused over 15 minutes
• Valproate is given with a loading dose of 40 mg/kg and
infused at a rate of 10 mg/kg per minute in adults
(maximum dose 3000 mg)
• phenytoin/fosphenytoin: fosphenytoin is started with a
ABC loading dose of 20 mg phenytoin equivalents (PE)/kg
infused at 100 to 150 mg PE/min; phenytoin is started
with a loading dose of 20 mg/kg and infused at 25 to 50
mg/minute.

Repeat 2nd line or Offer Intubation, Consult Neurology, Shift

to ICU
Treat Secondary causes if present (hypoglycemia, infection)
Focused General Ex,
Physical GCS
examination Neuro Ex
Send for VBG, glucose, CBC, electrolytes, LFT, tox screen, CK,
Focused Cr, urea, lactate, Calcium, phosphorus, and magnesium,
Investigations anticonvulsant drug levels.
CT, MRI, EEG (AS NEEDED)
Observation Neurological observations, GCS, vitals, ECG, Biochemistry,
Follow up blood gases, clotting, blood count.
Educate the family about how to deal when status epileptics
occur:
• Don’t restrain convulsion movements
• Don’t place anything in mouth
• Don’t cover with blanket
Conclusion • Put the Patient in recovery position, wipe frothy
secretion
• Take away items that could cause injury
• Use rectal diazepam if = or > 5 min
• Call ambulance if prolonged

536
 Status Epilepticus

Status Epilepticus:

Definition: Prolonged seizure (any seizure

lasting ≥ 5 minutes) or ≥ 2 sequential
seizures without recovery of full
consciousness between seizures
Epidemiology: 7 per 100,00
Classification:
1. Generalized (tonic-clonic, myoclonic,
absence, atonic, akinetic)
2. Partial (simple or complex)
Etiology:
• Acute brain injury (stroke, SAH, head
trauma, cerebral anoxia or hypoxia)
• Brain tumor
• Noncomplince with anti-epileptic drugs
• Alcohol withdrawal syndromes
• Metabolic distrurbance (eg,
Hypoglycemia, hyperglycemia,
hyponatermia, uremia,
hypomagnesemia, hypocalcemia,
hepatic encephalopathy) or sepsis
Diagnosis:
is a clinical diagnosis, confirmed of sustained
and rhythmic generalized tonic and clonic
motor activity lasting for longer than 5
minutes or repetitive convulsive seizures
without a return to baseline consciousness
between seizures. Although the diagnosis of
GCSE is usually obvious, a detailed
neurologic examination is important in
making the diagnosis of more subtle or focal
forms of status epilepticus. The
electroencephalography (EEG) is often
obscured by muscle and movement artifacts,
but it may show continuous spike and wave
activity indicative of generalized seizure
activity.

537
Status Epilepticus

538
Status Epilepticus

539
Psychiatry

540
Psychiatry
Depression
Post partum depression
General anxiety disorder GAD
Obsessive compulsive disorder OCD
Eating disorder
Insomnia
Attention deficit/hyperactivity disorder ADHD
Autism

541
 Depression Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt. to explain the chief complain
Clarify what you understood
illness
• Specific incident (death of loved one, stressor, home environment,
emotional problem, financial problem, loss of job …etc.)
• Somatic complain (headache, back pain & fatigue)
Depression symptoms
• Depressed mood (most of the day?, nearly every day?) “onset &
duration of low mood”
• Loss of interest or pleasure in all, or almost all, activities
• Significant weight loss or decrease or increase in appetite
• Engaging in purposeless movements, such as pacing the room
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Diminished ability to think or concentrate, or indecisiveness
• Recurrent thoughts of death, recurrent suicidal ideation without a
specific plan, or a suicide attempt
• Diurnal variation
• Loss of libido
Manic symptoms to exclude (bipolar type II):
Analysis of • High self-esteem or grandiosity
• Decreased need for sleep
chief • Increased talkativeness
complain • Racing thoughts
• distracted easily
• Increase in goal-directed activity or psychomotor agitation
• Engaging in activities that hold the potential for painful
consequences, e.g., unrestrained buying sprees
Anxiety:
• Excessive worry about a variety of topics, events, or activities.
• The worry is experienced as very challenging to control.
• The anxiety and worry are accompanied by following physical or
cognitive symptoms:
• Edginess or restlessness
• Tiring easily; more fatigued than usual
• Impaired concentration or feeling as though the mind goes
blank
• Irritability
• Increased muscle aches or soreness
• Difficulty sleeping (due to trouble falling asleep or staying
asleep, restlessness at night, or unsatisfying sleep)

542
Depression Hx

Psychotic features:
Cont. • Delusions (grandiosity , persecutory delusions
analysis of “believe an individual or organization is making
plans to hurt or kill them”)
chief
• Hallucination (sights, sounds, touch, taste & smell)
complain • confused and disturbed thoughts
Any phobia or personality disorders (OCD, borderline
…etc.)
previous depression dx (medications, psychotherapy,
response, admission & any other psychiatric dx)
Medical (hypothyroidism, anemia, multiple sclerosis,
vitamins deficiency & hx. of cancers)
Past Hx Surgical history & obstetric history (post-partum
depression)& relation to menstruation (pre-menstrual
syndrome).
Allergy & Medication (beta blockers, OCP, chemo,
corticosteroids, digoxin, methyldopa & H2 blockers).
Family Hx family history of psychiatric illness & suicide attempt.
Marital status (domestic violence, marital conflict)
Psychosocial Smoking: type and frequency
Alcohol abuse & IV drug use
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

543
 Depression Ex
Vital signs
General Appearance
mental status exam
Special Thyroid examination
Investigations CBC, thyroid function test, serum chemistry panels (U&E, LFTS),
human chorionic gonadotropin (pregnancy), urinalysis & urine
toxicology screen for drugs of abuse.

CRAPRIOP for Management

‫االكتئاب هو اضطراب مزاجي يسبب شعوًرا دائمًا باحلزن وفقدان االهتمام ويؤثر على شعورك‬
‫ قد‬.‫وتفكيرك وسلوكك وميكن أن يؤدي إلى مجموعة متنوعة من املشاكل العاطفية واجلسدية‬
‫ وأحيانًا قد تشعر كما لو أن احلياة ال تستحق‬،‫تواجهك صعوبة في القيام باألنشطة اليومية العادية‬
Clarification .‫العيش‬
‫ فهو ليس نقطة ضعف وال ميكنك‬،‫يعتبر االكتئاب أكثر من مجرد نوبة من احلالة املزاجية السيئة‬
.‫ قد يتطلب االكتئاب العالج على املدى الطويل‬.‫"اخلروج" منه ببساطة‬
‫سن معظم األشخاص املصابني باالكتئاب باألدوية والعالج النفسي أو‬ َّ ‫ يتح‬،‫يجب أال تثبط عزميتك‬
Reassurance .‫كالهما‬
1. ِExercise
Aerobic exercise or resistance training (3-5 sessions/ week,
session duration 45 to 60 min/session)
Exercise intensity:(Aerobic exercise: 50 to 85 percent
maximum heart rate, resistance training: three sets of eight
repetitions at 80 percent of maximum weight that can be lifted
in a single repetition for a given exercise)
Advice Intervention duration: At least 10 weeks
2. Encouraging pts to pursue social support
3. Use relaxation techniques
4. Plan short term activity that gives you joy (e.g. Friends , travel )
5. Thinking: don’t be hard on yourself resist self critic , don’t
concentrate on guilt thoughts & don’t act on pessimistic ideas
6. Adherence to medication
Prescription SSRI, SNRI, TCA, MAOs & others(bupropion, mirtazapine, Trazodone)
• Psychotherapy & CBT
Referral • Suicide attempt/ idea, psychotic feature & not response to ttt.
Investigations Mention above
Follow up pt. 1-2 week after initiating ttt. then monthly for next 12
Observation/ weeks *BMJ
follow up If response <25%: add dose of the medication
If no response: change the medication
Plan/prevention Health promotion & screen according to the age
Safety netting: If you have suicide ideas , intent or plan to come to
Conclusion ER

544
 Depression

Differential diagnosis
• Major depression disorder
• Adjustment disorder with depress mood: A reaction of specific
incident or stressor leading to depression , begin within 3 months
of stressors and lessen within 6months (after removal of stressors
& behavioral change & adaptation)
• Dysthymia: depress mood occurring on most days & lasting at least
2 years.
• Grief
• Substance/medication induced depression
• Post partum depression
• Premenstrual dysphoric disorder & premenstrual syndrome
• Bipolar disorder
• Schizoaffective
• Anxiety
• personality disorders (OCD & borderline)
• Mood disorder due to medical condition

545
Depression

546
Depression

547
 Perinatal mood and anxiety disorders Hx

As known as Post partum depression, should be screened during pregnancy not only at postpartum

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt. to explain the chief complain
illness Clarify what you understood
Depression symptoms
• Depressed mood “onset & duration of low mood”
• Loss of interest or pleasure
• weight loss or decrease or increase in appetite
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Diminished ability to think or concentrate
Analysis of • Recurrent thoughts of death, recurrent suicidal ideation without a
chief specific plan, or a suicide attempt
• Obsessive thoughts focusing on aggression toward the infant.
complain Anxiety:
Excessive worry & uncontrollable.
Psychotic features:
• Delusions
• Hallucination (sights, sounds, touch, taste & smell)
• confused and disturbed thoughts
Any phobia or personality disorders (OCD, borderline …etc.)
Medical history
• previous depression dx (medications, psychotherapy, response,
admission & any other psychiatric dx)
• Medical (hypothyroidism, anemia, multiple sclerosis, vitamins
Past Hx deficiency & hx. of cancers)
Surgical history
obstetric history
relation to menstruation (pre-menstrual syndrome).
Allergy & Medication (beta blockers, OCP, chemo, corticosteroids,
digoxin, methyldopa & H2 blockers).
Family Hx Family history of psychiatric illness & suicide attempt.

Psychosocial Marital status (domestic violence, marital conflict)

Smoking: type and frequency
Hx Alcohol abuse & IV drug use
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
Conclusion

548
 Perinatal mood and anxiety disorders Ex

Vital signs
General Appearance
mental status exam
Special Thyroid examination
CBC, thyroid function test, serum chemistry panels
(U&E, LFTS), human chorionic gonadotropin
Investigations (pregnancy), urinalysis & urine toxicology screen
for drugs of abuse.

CRAPRIOP for Management

‫تعاني معظم األمهات احلديثات من » الكآبة النفاسية‬
‫« للطفل والذي يشتمل في العادة على تقُّلبات في املزاج ونوبات من البكاء والقلق‬
‫ وقد‬،‫ تبدأ حاالت الكآبة النفاسية خالل يومني أو ثالثة بعد الوالدة‬.‫وصعوبة في النوم‬
baby blue.‫تستمر ملدة أسبوعني‬
Clarification
‫لكن بعض األمهات اجلديدات قد يعانني من أشكال من االكتئاب أكثر حدًة وأطول‬
‫ قد يظهر اضطراب في املزاج بعد‬،‫ بشكل نادر‬.‫ وتعرف باكتئاب ما بعد الوالدة‬،‫زمًنا‬
.‫والدة الطفل يسمى ذِهان ما بعد الوالدة‬
‫تتحسن معظم األمهات املصابني باالكتئاب ما بعد الوالدة باألدوية والعالج النفسي أو‬
Reassurance .‫كالهما‬
1. Exercise
Advice 2. Adherence to medication
3. Use relaxing technique
SSRI, SNRI, TCA, MAOs & others(bupropion, mirtazapine,
Prescription Trazodone)
• Psychotherapy & CBT
Referral • Suicide attempt/ idea, psychotic feature & not
response to ttt.
Investigations Mention above
Follow up pt. 1-2 week after initiating ttt. ttt continue for
Observation/ 6-9 months
follow up The Edinburgh Postnatal Depression Scale can be used to
monitor progress over time.
Plan/prevention Health promotion & screen according to the age
Safety netting: If you have suicide ideas , intent or plan to
Conclusion come to ER

549
Perinatal mood and anxiety disorders

Screening can be performed at the four- to six-week postpartum visit

or the two-month well-child visit. The Edinburgh Postnatal Depression
Scale is completed by the patient.
([Link]
df).

550
Perinatal mood and anxiety disorders

551
 Generalized anxiety disorder Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt. to explain the chief complain
illness Clarify what you understood
• Excessive worry about a variety of topics, events,
or activities (at least 6 months)
• The worry is experienced as very challenging to
control.
• The anxiety and worry are accompanied by
following physical or cognitive symptoms:
• Edginess or restlessness or (feeling on edge)
• Tiring easily; more fatigued than usual
• Poor concentration
• Irritability
• Increased muscle aches or soreness
• Difficulty sleeping (due to trouble falling
asleep or staying asleep, restlessness at night,
Analysis of or unsatisfying sleep)
chief Any phobia or personality disorders (panic disorder,
complain social phobia, specific phobia, OCD, borderline …etc.)
Depression symptoms
• Depressed mood (most of the day?, nearly every
day?) “onset & duration of low mood”
• Loss of interest or pleasure in all, or almost all,
activities
• Significant weight loss or decrease or increase in
appetite
• Engaging in purposeless movements, such as
pacing the room
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Diminished ability to think or concentrate, or
indecisiveness

552
 Generalized anxiety disorder Hx

•Recurrent thoughts of death, recurrent suicidal

ideation without a specific plan, or a suicide
attempt
Cont.
• Diurnal variation
analysis of • Loss of libido
chief Somatic symptoms that may anxiety present with:
complain Headache, sweating, dizziness, gastrointestinal
symptoms, muscle aches, increase heart rate,
shortness of breath, trembling, chest pain.
• previous anxiety dx (medications, psychotherapy,
response, admission & any other psychiatric dx)
• Medical (hypothyroidism, anemia, cardiovascular
disease, respiratory disease, DM, PCOS & hx. of
cancers)
Past Hx • Surgical history & obstetric history (post-partum
depression)& relation to menstruation (pre-
menstrual syndrome).
• Allergy & Medication
family history of anxiety and psychiatric illness
Family HX (depression, phobias …etc.)
• Marital status (domestic violence, marital conflict)
• Sexual assault or abuse
• Unexpected loss of a loved one
Psychosocial • Bullying, peer victimization
• Smoking: type and frequency
• Alcohol abuse & IV drug use
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICE Expectation: is there anything you want me to do for
you? Effect: does this affect your life? How?
Systemic Review
Conclusion

553
 Generalized anxiety disorder Ex

Vital signs
General Appearance
mental status exam
Special Thyroid examination, cardiac & respiratory,
neurological examination
Clinical diagnosis , investigation to be consider to
exclude other DDx.
Investigations CBC, thyroid function test, PFT, ECG, 24-hour urine
for vanillylmandelic and metanephrines, urine
toxicology screen for drugs of abuse.

CRAPRIOP for Management

‫ ميكن أن يكون‬، ‫ مثل التوتر أو اخلوف‬، ‫القلق هو شعور بعدم االرتياح‬
.‫ وقد يعترض أي شخص‬.‫خفيفًا أو شديدًا‬
Clarification ‫أما اضطراب القلق العام هي حالة طويلة األمد جتعلك تشعر بالقلق حيال‬
‫ و ميكن‬.‫ بدالً من حدث واحد محدد‬، ‫مجموعة واسعة من املواقف والقضايا‬
.‫أن يسبب أعراض نفسية )عقلية( وجسدية‬
‫ ميكن للعديد من األشخاص التحكم في‬،‫مع العالج واجللسات النفسية‬
Reassurance .‫مستويات القلق لديهم‬
1. Cognitive behavioral therapy
2. ِExercise
3. Applied relaxation training
Advice 4. Improve sleep hygiene
5. Mindfulness therapy, self help ttt(such as
books), inter-personal therapy, problem solving
therapy
SSRI, SNRI, TCA, & others(benzodiazepine,
Prescription pregabalin, quetiapine)
Referral Psychotherapy & CBT
Investigations Mention above

554
Generalized anxiety disorder

Observation/ Follow up pt. after 12 weeks. Treatment should

follow up continue for 12 months
Health promotion & screen according to the
Plan/prevention age
Safety netting: If you have suicide ideas , intent
Conclusion or plan to come to ER

555
Generalized anxiety disorder

556
Generalized anxiety disorder

557
 Obsessive compulsive disorder Hx

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question): how OCD is presented (direct
Hx of presentation of OCD, hand eczema, body itching, ordering or frequent
present checkups, family complain
Allow pt to explain the chief complain
illness Clarify what you understood
Course, onset and duration:
Initial screening for OCD:
1. Do you wash or clean a lot?
2. Do you check things a lot?
3. You would like to get rid of it but cannot? Cannot control it.
4. Do you daily activities take a long time to finish it?
5. Are you putting things in a special order? Upset if disordered?
6. Do these problems trouble you?
OCD manifestations:
Obsessions: Recurrent thoughts, impulses or images (Germs,
impurity, safety, religious thoughts, sexual or criminal
images). Attempts to ignore or suppress these thoughts.
Patient is aware obsessions are products of his mind (intact
insight).
Compulsions: repetitive purposeful intentional action in
stereotyped manner (washing hands, safety checkup,
Analysis of repeating prayer or ablution). The behavior is done to
chief neutralize obsessions or prevent discomfort. The patient
complain recognizes his behavior is unreasonable.
Q. what do you do to relieve yourself? How frequent? How
long you do it? Does it relieve your anxiety?
Associated symptoms (DDx):
Major depression: loss of interest , low mood, social isolation, feeling
guilty ,Suicidal thoughts, attempts.
GAD: excessive worriers, Irritability ,Trouble falling or staying asleep,
Trembling, Twitching, Tense muscles, Headaches
Psychosis: Feeling things that are not present (visual, auditory or other
hallucinations), delusions (fixed false believes).
Body dysmorphic disorder: worry a lot about a specific area of your
body (particularly your face),
spend a lot of time comparing your looks with other people's, look at
yourself in mirrors a lot or avoid mirrors altogether, go to a lot of effort
to conceal flaws – for example, by spending a long time combing your
hair, applying make-up or choosing clothes
pick at your skin to make it "smooth".(onset at the beginning of
puberty)

558
 Obsessive compulsive disorder Hx
Excoriation(Skin picking d) : impulse or urge is difficult to resist picking
at the skin, Picking usually involves fingernails and fingertips, biting with
your teeth (especially when the skin surface affected is on your lips),
they often feel relief or other positive emotions after picking at their
skin, obsessions don’t happen with skin picking d.(onset at the
beginning of puberty)
Trichotillomania: recurrent pulling of hair from any part of the body
Analysis of resulting in hair loss. After pulling their hair out, they feel a sense of
chief relief.(onset at the beginning of puberty)
Bipolar: Mood swings, being elated, euphoric or unexplained
complain hyperactivity.
eating disorders: intense fear of gaining weight(anorexia, Skipping
meals or making excuses for not eating, Excessive exercise, Persistent
worry or complaining about being fat and talk of losing weight
Frequent checking in the mirror for perceived flaws.
Risk Factors
Red Flags: Suicidal thoughts, attempts.
Medical: depression, anxiety, chronic illnesses, previous hospital
admission, antecedent infections (streptococcal & herpetic).
Past Hx Surgical
Allergy
Medication: Antidepressants or Antipsychotics drugs
Family Hx Family history of similar or other psychiatric problems
Marital status: home environment, loss of job due to OCD, conflicts and
bullying
Psychosocial Smoking: type and frequency , substance abuse
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
Examination
Vital signs
General Appearance
Patient behavior, speech, eye contact, abnormal movements.
Patient affect, insight & judgment, thought content.
Special Cognition, attention.
Hands (eczema), hair (trichotillomania), excoriations
Special test
Investigations Indicated if secondary organic cause is suspected.

559
 Obsessive compulsive disorder

CRAPRIOP for Management

‫اضطراب الوسواس القهري هو مرض مزمن يتسم بنمط من األفكار‬
‫واملخاوف غير املرغوب فيها )وساوس( تدفعك إلى القيام بسلوكيات‬
Clarification ‫ تُعيق هذه الوساوس والسلوكيات القهرية‬.(‫تكرارية )سلوكيات قهرية‬
.‫األنشطة اليومية وتتسبب في ضيق شديد‬
Reassurance ‫ال تشيل هم كل مشكله ولها عالج وهذا االمر شائع‬
Advice CBT (1st line)
SSRI (Citalopram 20 mg or Paroxetine 20 mg
and/ or Fluoxetine 20 mg), TCA.
• Explain the need of high dose of SSRI and
possible SE & importance of compliance on
treatment to sustain improvement.
Prescribing • Explain that expected time to see the effect
of medication is from 4–6 weeks/ for 1–2
years to sustain improvement.
• Management of physical problem (eczema,
hair loss, excoriation).
to psychotherapist, psychiatrist.
Patients with severe symptoms or lack of
Referral response to first-line therapies should be
referred to a psychiatrist
Investigations Mentioned above
Follow up 1-2 weeks to monitor response to
medications, side effects.
Observation/
Patients with OCD should be closely monitored
follow up for psychiatric comorbidities and suicidal
ideation.
Plan/prevention
Conclusion Includes Safety netting

560
 Eating disorder Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt. to explain the chief complain
Clarify what you understood
illness
Weight loss:
• Last year weight and recent weight
• How much weight loss over how much time
• Clothing or belt size changes
• Impressions of friends and family on weight change
Psychiatric hx:
• Did you see yourself fat?
• How afraid are you of gaining 3 pounds/ 1 kilogram?
• In the past 3 months, how many times have you done any of
the following as a means to control your weight and shape:
• Made yourself throw-up?
• Used diuretics or laxatives?
• Exercised excessively? Fasted?
• Do you struggle with a lack of interest in eating or food?
Dietary Hx:
• 24hr recall
• Are meals skipped?
Analysis of • Does the patient need help preparing meals?
chief • Are meals well balanced (Food Pyramid)?
• Are any nutritional Supplements used?
complain • Is patient following any dietary restrictions
GIT: painful oral lesions, poor dentition (e.g., dental caries). dysphagia,
abdominal pain, post-prandial pain, heartburn, diarrhea, bloody stools,
black/tarry stools, oily/floating stool, constipation & rectal bleeding
Respiratory: fever & cough (complication of eating disorder is aspiration
pneumonia)
CNS: headache, seizures, neuropathy (decrease of calcium, magnesium
& phosphate)
Endocrine: symptoms of hypothyroidism (cold intolerance, loss of
concentration, fatigue, weight gain …etc.). Symptoms of
hyperthyroidism (anxiousness, heat intolerance, palpitation …etc.)
Constitutional: loss of appetite, fever, chills & night sweats (exclude
malignancy)
MSK: muscle wasting & generalized weakness
Skin: dry skin, lanugo hair, hair loss or thinning & brittle nails
(complication of eating disorder)
Menstrual Hx: amenorrhea

561
 Eating disorder Hx
Previous eating disorder dx (medications, response, admission & any
other psychiatric dx)
Past Hx Medical (hypothyroidism, anemia, vitamins deficiency & hx. of cancers)
Surgical history.
Allergy & Medication
Family Hx Similar condition & psychiatric illness
Psychosocial Smoking: type and frequency
Hx Alcohol abuse & IV drug use
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
conclusion

Examination
General Vital signs (BMI) & Appearance
mental status exam / thyroid examination
Signs found in bulimia nervosa:
• Russell sign(callosities, scaring and abrasions on knuckles
secondary to repeated self-induced)
Special • Hyporeflexia
• Salivary gland enlargement (sialadenosis)
• Dental enamel erosion
• ECG: U wave, T wave flattening, ST depression & QT
prolongation.
Investigations CBC, electrolytes, LFT, thyroid function test and ECG (arrhythmia)

CRAPRIOP for Management

،‫سم بفقدان الوزن غير الطبيعي‬ ِ َّ‫فقدان الشهية العصبي هو اضطراب األكل الذي َيت‬
‫ ُيوِلي األشخاص الذين‬.‫ واإلدراك املشوَّه لوزن اجلسم‬،‫واخلوف الزائد من اكتساب الوزن‬
‫ وذلك ببذل اجلهود‬،‫لديهم فقدان الشهية اهتماًما كبيرًا للتحُّكم في وزنهم وشكلهم‬
‫الشديدة التي تتعارض بشكٍل كبير مع حياتهم‬
Clarification ‫بوليميا نرفوزا )الشره املرضي العصبي( هو اضطراب خطير في األكل ميِكنه أن ُيهِّدد‬
‫ األشخاص الذين يعانون من البوليميا قد ُيفرِطون في الطعام سرًّا أو يتناولون‬.‫احلياة‬
‫كميات كبيرة من الطعام مع فقدان التحُّكم في األكل ثم يقومون بالتقيُّؤ كمحاولة‬
‫للتخُّلص من السعرات احلرارية الزائدة بطريقة غير صحية‬

562
 Eating disorder

‫اتباعك للعالج الفعَّال قد ُيساعدُك في الشعور بتقُّبل نفسك واتباعك‬

Reassurance .‫ألمناط غذائية صحية قد يخلصك من املضاعفات اخلطيرة‬
‫ بغض النظر عن‬،‫• تعزيز وتوطيد صورة اجلسم الصحي لدى الشخص‬
‫ املساعدة على بناء الثقة بأنفسهم بطرق أخرى غير‬.‫حجمهم أو شكلهم‬
.‫مظهرهم‬
.‫ وممتعة برفقة العائلة‬،‫• تناَول وجبات منتظمة‬
Advice ‫ يَجب أن يَنصب تركيز الشخص‬.‫• جتنب احلديث عن الوزن في املنزل‬
.‫على اتباع أسلوب حياة صحي وسليم‬
‫ خاصة إذا تضمنت‬،‫• التخلص من الرغبة في اتباع أنظمة إنقاص الوزن‬
‫ أو تناُول‬،‫ مثل الصيام‬،‫سلوكيات غير صحية للحفاظ على الوزن‬
.‫ أو إجبار نفسك على القيء‬،‫مكمالت إلنقاص الوزن أو ملينات‬
• Antidepressant (SSRI- Fluoxetine), TCA &
lithium carbonate.
• Enteral or parenteral feeding in patient with
Prescription sever malnutrition.
• Hospitalization in cases of severe malnutrition
or complication of eating disorder (heart
failure, arrythmias, suicide attempt …etc.)
Behavioral therapy (psychotherapy & family
Referral therapy)
Investigations Mention above
Follow up pt. 1-2 week after initiating ttt. then
Observation/ monthly for next 12 weeks *BMJ
follow up If response <25%: add dose of the medication
If no response: change the medication
Plan/prevention Health promotion & screen according to the age
Safety netting: If you have seizure, suicide attempt,
Conclusion arrythmia …etc. come to ER

563
 Eating disorder

Physiologic complications of eating disorders

Bulimia Nervosa Anorexia Nervosa

Bulimia Nervosa

564
 Insomnia Hx

Introduce yourself and establish good rapport ( Name, age and job: night shift ).
Chief complain (open question): the problem with falling asleep (taking
30 minutes or more to fall asleep) or trouble staying asleep (spending
Hx of 30 minutes or more awake during the night), Early morning awakening
present (termination of sleep at least 30 minutes prior to the desired wake-up
time)
illness Allow pt to explain the chief complain
Clarify what you understood
Course, onset ( acute: < 4 weeks , chronic: > 4 weeks ) and duration
Detailed description of the sleep problem:
(ie, number of awakenings, duration of awakenings) and sleep times
(ie, bedtime, duration until sleep onset, final awakening time, nap
times, and nap lengths) over both a 24-hour period and week
Sleep hygiene: excess caffeine intake, temperature, light, noise levels,
dinnertime, exercise time, bedroom activities, place ”change in place
recently.
Any medication used for sleep ?
Effect of problem:
Social life dysfunction
Work: Increased errors or accidents
Fatigue, tiredness, difficulty with memory, concentration, and attention;
worry about sleep; mood disturbances; or irritability.
Associated symptoms (DDx):
Analysis of Anxiety: Nervous mood, excessive worries
Panic attack: palpitations, hyperventilation and chest pain
chief Depression: Low mood, loss of interest, low energy, feeling guilty, social
complain isolation
Psychotic symptoms: Hallucination, abnormal thought, manic
attack(hyperactivity, impulsivity or aggression), suicidal ideation, night
sweeting.
OSA: Fatigue, Poor attention or concentration, Daytime sleepiness,
Observed episodes of stopped breathing during sleep and snoring.
Thyroid disease: Hot intolerance, palpitation, weight loss despite good
appetite
Narcolepsy: Excessive daytime sleepiness, Cataplexy is a sudden, brief
loss of muscle tone or strength triggered by stress or a strong emotion,
such as laughter (common cause in children), sleep paralysis (inability to
move or speak just before falling asleep or just after waking up),
Hallucinations.
Restless leg syndrome : unpleasant sensations in the legs or feet , Relief
with movement, Worsening of symptoms in the evening, RF: renal
failure , IDA, Parkinson d.

565
 Insomnia Hx
Medical: Cardiovascular diseases, COPD , GERED, thyroid problem ,
asthma, obstructive sleep apnea or chronic pain, psychiatric illness
Past Hx Surgical
Allergy
Medication: Stimulant, coffee, Benzo, ahistantimine, alcohol
Family Hx
Marital status: Stressful events, marriage conflict and family problems,
grief , job instability or new job.
( exercising, smoking, or drinking alcohol or caffeine) shortly before
Psychosocial bedtime
Smoking: type and frequency
Substance misuse / dependence / withdrawal (important)
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs : BP ( HTN in pt with insomnia) BMI ( obesity; OSA)
General .
Appearance: dressing & hygiene
neck circumference > 40 cm , oropharyngeal abnormalities
(excessive oropharyngeal tissue in obstructive sleep apnea).
Signs of thyroid disease (Goiter) / Signs of anemia
Chest and Cardiac Ex: wheezing , murmur
lower extremity: swelling in heart failure.
Mental examination:
• Motor & behavior: agitation, retardation, abnormal
movement, eye contact & facial expression.
Special • Speech: rate, rhythm, amount & articulation. Thinking:
stream, form & content.
• Affect & mood: stability, range & mood. Perception:
illusions, derealization or depersonalization.
• Cognition & intellect: orientation, registration, recall,
concentration & or attention.
• Insight and judgment: awareness of illness
Special test

566
 Insomnia Ex

Insomnia is clinical diagnosis unless the history suggests

concurrent sleep disorders or initial treatment is ineffective=
Sleep Study (Polysomnography), Sleep Diary
Polysomnography: RESULTS in:
o PLMS: index (number of PLMS per hour of sleep) >15 for
the whole night.
o OSA: An apnea-hypopnea index of 15 or more events per
hour, or 5 or more events per hour in the presence of
symptoms or cardiovascular comorbidities.
Investigations o Laboratories — No routine LAB are necessary in the
evaluation of chronic insomnia. On clinical suspicion of
comorbidity:
echocardiography, TSH , blood glucose and A1C - RFT blood
urea nitrogen and creatinine,
iron studies may be performed if restless legs syndrome is
suspected, respectively. - Polysomnography if ( OSA) –
Actigraphy (when a circadian sleep-wake rhythm disorder is
suspected)

CRAPRIOP for Management

‫األرق هو اضطراب شائع في النوم ميكن أن يؤدي إلى صعوبة النوم أو صعوبة االستمرار فيه‬
‫ قد ال تزال تشعر‬.‫أو يجعلك تستيقظ مبكًرا مع عدم القدرة على العودة إلى النوم مرة أخرى‬
Clarification ‫ضا من‬
ً ‫ ميكن أن يوهن األرق من مستوى طاقتك ومزاجك وأي‬.‫باإلرهاق عند االستيقاظ‬
.‫صحتك وأدائك في العمل وجودة احلياة‬
‫املوضوع بسيط ان شاءالله عادة ما ميكن لتغييرات بسيطة في عاداتك اليومية أن تكون‬
Reassurance .‫مفيدة وحتسن من جودة النوم‬
CBT: (Identify and reframe dysfunctional beliefs about sleep), 1st line in
chronic insomnia.
Sleep hygiene:
• Avoid alcohol for 4-6 hours before bed
• Avoid caffeine, and nicotine after 4 p.m.
• Exercise regularly, but not within 3–4 hours before bedtime.
Advice • Keep bedroom cool and conductive to sleep
• Avoid daytime naps.
• no clock watching.
• Avoid bright lights (including electronic screen use) before
bedtime.
• Go to bed and wake up at the same time every day.

567
 Insomnia
Stimulus control:
• Use the bed/bedroom only for sleep or sex
• Go to another room if unable to fall asleep within 15-20
min.
• Go to bed only when sleepy.
• engage in other quiet activity and return to bed only
when sleepy.
Advice Sleep restriction: (reduction of sleep latency) decrees the
time spent in bed to the time of sleep only (after that
increase gradually )
NOTE: Avoid sleep restriction in patients with seizure
disorders or bipolar disorders, as it can lower the threshold
for seizures or precipitate manic episodes. Patients using
sleep restriction to manage insomnia should avoid driving
and operating heavy machinery
Sleep-onset and maintenance:
Benzodiazepines (preferably short acting benzodiazepines
like triazolam)
Z-drugs: zolpidem CR
Orexien receptor agonist: lemborexant , suvorexant
Prescribing Sleep-maintenance insomnia:
Z-drugs: eszopiclone
TCA: Doxipen
Sleep-onset insomnia:
Z-drugs: zaleplon, zolpidem
Melatonin: ramelteon
• Patients with insomnia who do not respond to
medications and CBT should be referred to a sleep
center for further testing and treatment.
• Patients with insomnia report profound daytime
Referral sleepiness or symptoms of other sleep disorders,
including sleep apnea, periodic limb movements,
narcolepsy, parasomnias, or circadian rhythm sleep-
wake disorders.
Investigations Mentioned above
Observation/ Acute insomnia after 2-4 weeks to establish whether
insomnia is persistent.
follow up
Plan/prevention
Conclusion Includes Safety netting

568
 ADHD Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

Allow pt. to explain the chief complain
present
Clarify what you understood
illness
CC: Onset, duration, severity, impact of daily activity, settings,
and compare to his level of age.
Hyperactive/impulsive ADHD:
squirmy/fidgety, can’t remain seated, runs about, difficulty
playing, on the go, talks excessively, blurts out, difficulty
awaiting turn, intrudes on others.
Inattentive ADHD:
No attention to details, can’t sustain attention, seems not to
listen when spoken to directly, does not follow through, can’t
organize tasks, avoid tasks with mental efforts, easily
Analysis of distracted, forgetful
Conditions mimicking or co-existing:
chief • Developmental variation (Intellectual disability,
complain giftedness, normal variation).
• Neurologic or developmental disorders
(Neurodevelopmental syndromes ( e.g. fragile X
syndrome, fetal alcohol syndrome), Seizure disorder,
motor coordination disorder)
• Emotional/Behavioral disorders (OCD, PTSD,
adjustment disorder)
• Selected medical conditions (hearing or vision
impairment, sleep disorder, endocrine (thyroid, DM),
cardiac ( e.g. HF), IDA, Lead poisoning,
undernutrition).
• CNS infection, head trauma, recurrent otitis media, and
medications.
• Ask about foods or drinks that appear to influence
hyperactive behavior
Past Hx • Sleep disturbance, and history of sleep patterns before
initiation of pharmacotherapy to avoid attributing
preexisting problems to medications obtain a thorough
child and family cardiac history before initiating
medications

569
 ADHD Hx

prenatal exposures (e.g., tobacco, drugs, alcohol).

Prenatal/ perinatal complications or infections, central nervous
perinatal system infection, head trauma, recurrent otitis media,
Hx and medications.
Mode of delivery or complication
• Developmental milestones, particularly language
milestones.
Developmen • Psychosocial stressors; Emotional, medical, and
developmental events
tal
• presence of coexisting mental health and
Behavioral neurodevelopmental conditions
• Testing using any of the ADHD rating scales (i.e.
ADHD rating scale, Conner’s rating scale).
• Classroom behavior and interventions, learning
Educational patterns, and functional impairment
performance • Review school reports: School absences, forgets
his books & fails to do his homework
Family history of same abnormality (1st degree or 2nd
Family Hx degree); ADHD has a strong genetic component
Assessment Social, familial and educational or occupational
of the circumstances
person need
Social Hx Child abuse, neglect & occupation of parents
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you? Effect: does this affect your life? How?
Systemic Review & Conclusion

570
 ADHD Ex
Examination
General Vital signs & growth chart
• Observation of the child's behavior and
communication skills ( impaired in autism)
• Observation of parent-child interactions
• dysmorphism.
Special • Neurological Ex including coordination and verbal or
motor tics
• Assessment of vision and hearing levels.
• Cardiovascular Ex
• Testing of formal cognitive achievement.
ADHD cannot be reliably diagnosed in children younger
than four years. Although it is difficult to determine
whether symptoms are beyond the expected behavior of
four- and five- year-olds.
If indicated:
• Speech and language evaluation
• Occupational therapy evaluation > motor coordination
disorder
• Mental health evaluation >suspected psychiatric
disorders.
• Blood lead level > lead poisoning
• Thyroid hormone levels > (thyroid disorder)
Investigations
• Genetic testing and/or consultation > (fragile X
syndrome)
• Overnight polysomnography > symptoms suggestive of
and/or risk factors for sleep disorder.
• Neurology consultation or EEG > (neurologic or seizure
disorder)
• Psychometric testing (intellectual and academic
testing)
1. to exclude other disorders (e.g., learning disability)
2. identify specific problem areas for children with
ADHD, including abstract reasoning, mental flexibility,
planning, and working memory, a collection of skills
broadly categorized as "executive functions.

571
 ADHD
CRAPRIOP for Management
‫ وغالبًا ما‬،‫ حالة مزمنة تصيب ماليني األطفال‬ADHD ‫اضطراب نقص االنتباه مع فرط النشاط‬
‫ يتضمَّن اضطراب نقص االنتباه مع فرط النشاط مجموعة من املشكالت‬.‫تستمُّر في مرحلة البلوغ‬
Clarification .‫ والسلوك االندفاعي‬،‫ وفرط النشاط‬،‫ مثل صعوبة احلفاظ على االنتباه‬،‫املستمرة‬
‫ لكن ميكنهم تعلُّم‬.‫ال يتخطَّى بعض األشخاص أعراض اضطراب نقص االنتباه مع فرط النشاط متاًما‬
.‫االستراتيجيات لتكون ناجحة‬
‫ فإنه ميكن أن يُساعد بشكل‬،‫في حني أن العالج لن يعالج اضطراب نقص االنتباه مع فرط النشاط‬
Reassurance ‫ قد يُحِدث التشخيص‬.‫ يشمل العالج عادًة األدوية والتدخُّالت السلوكية‬.‫كبير في عالج األعراض‬
.‫والعالج املبكران فرًقا كبيًرا في النتائج‬
Behavioral Strategies, Motivation:
Short clear verbal instructions, positive motivation, written short
tasks, multiple breaks (10/3), fixed routine, achievable goals.
Educational evaluation & strategies: discuss the treatment plan and
identified special educational needs, including advice for reasonable
adjustments and environmental modifications within the
Advice educational placement
Safety evaluation: Discuss safety and injury prevention because
children with ADHD are at increased risk of intentional and
unintentional injury
Support & resources: family, parents, group based parents training
programmed.
4-5 years: behavioral therapy (consider medications if symptoms are
not responsive to behavioral therapy)
≥6 years: medications (choice of therapy based on patient and his or
her parents ).
suggest a stimulant as the first line agent (Grade 2B).
behavioral therapy (no additional benefit for core symptoms, but
Prescription may lower the dose of stimulant therapy + affect symptoms of
coexisting conditions (e.g., oppositional/aggressive behavior)
Stimulants: Methylphenidate, Amphetamine:
the first-line agent for children >6years, rapid onset & safe
Non stimulant: Selective norepinephrine reuptake inhibitor
(Atomoxetine) OR Alpha-2 adrenergic agonists (Guanfacine &
Clonidine)
• Refer to child psychiatrist, pediatrician, psychologist, learning
consultants,
obtain audiology and vision evaluation
• Urgent evaluation is necessary for children with suicidal
Referral ideation or the potential to harm themselves or others (e.g.,
children with severe outbursts of anger)
• ADHD in children 4 to 18 years of age without comorbid
conditions can usually be managed by the primary care
provider

572
ADHD

Indications for referral:

• Coexisting psychiatric conditions (e.g., oppositional
defiant disorder, conduct disorder, substance abuse,
emotional problems)
Coexisting neurologic or medical conditions (e.g.,
Referral seizures, tics, autism spectrum disorder, sleep
disorder)
• Lack of response to a controlled trial of stimulant
therapy or atomoxetine
• Refer to parent support group.
Refer to obtain audiology and vision evaluation.
Investigations Mention above
Nor receiving medication >> at least twice per year,
particularly during critical transitions (e.g., into middle
school or high school).
Receiving medication >> depends upon the stage of
pharmacotherapy range from:
- weekly during the titration stage
- every 3-6 months during maintenance phase
Observe:
Observation/ • response to treatment
• depression and suicidal ideation are rare
follow up National guidelines recommend that physicians consider
electrocardiography
and/or cardiology referral before initiating
psychostimulants in patients with a
history of heart disease, palpitations, syncope, or seizures,
or with a family
history of sudden cardiac death, Wolff-Parkinson-White
syndrome,
hypertrophic cardiomyopathy, or long QT syndrome
Plan/prevention Health promotion & screen according to the age
Safety netting: If you have seizure, suicide attempt,
Conclusion arrythmia …etc. come to ER

573
 ADHD

Differential diagnosis
• Autism spectrum disorders (ASD)
• Mood disorders (Depression & Anxiety)
• Seizure disorders
• Learning disabilities, Language disorders, hearing & vision
disorders
• Developmental coordination disorder: problems with motor
coordination that interfere with academic performance and social
integration in otherwise healthy
• children Tics
• Sleep disorder
• Substance use (adolescent)
• Conduct disorders (a persistent pattern of aggression toward
people or animals, destruction of property, deceitfulness, or theft)
• Oppositional defiant disorder (persistent pattern of angry or
irritable mood, argumentative or defiant behavior)

574
ADHD

575
ADHD

576
ADHD

577
ADHD

578
ADHD

579
 Autism Hx

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt. to explain the chief complain
illness Clarify what you understood
Symptoms of Autism spectrum disorder
• Persistent deficits in social communication and social
interaction (failure to initiate or respond to social
interactions).
• Deficits in nonverbal communicative behaviors used for
social interaction (abnormalities in eye contact and body
language or deficits in understanding and use of gestures,
lack of facial expressions and nonverbal communication)
• Deficits in developing, maintaining, and understanding
relationships (from difficulties adjusting behavior,
difficulties in sharing imaginative play or in making
friends, absence of interest in peers)
• Restricted, repetitive patterns of behavior, interests, or
activities
Analysis of • Stereotyped or repetitive motor movements, use of
chief objects, or speech (e.g., simple motor stereotypies, lining
up toys or flipping objects, echolalia, idiosyncratic
complain phrases).
• Insistence on sameness, inflexible adherence to routines,
or ritualized patterns of verbal or nonverbal behavior
(e.g., extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need
to take same route or eat same food every day).
• Highly restricted, fixated interests that are abnormal in
intensity or focus (e.g., strong attachment to or
preoccupation with unusual objects, excessively
circumscribed or perseverative interests).
• Hyper- or hyperreactivity to sensory input or unusual interest in
sensory aspects of the environment (e.g., apparent indifference to
pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, visual fascination with
lights or movement).

580
 Autism Hx
Conditions mimicking or co-existing:
• Developmental variation (Intellectual disability).
• Neurologic disorders (Seizure disorder, motor
Analysis of disorder)
• Psychiatric disorders (anxiety, depression,
chief
ADHD)
complaint • Medical conditions (hearing or vision
impairment, sleep disorder).
• GI problem: chronic constipation, diarrhea and
abdominal pain
• CNS infection, head trauma, recurrent otitis media
and medications.
Past Hx • Ask about nutritional history
• history of sleep patterns.
prenatal exposures (e.g., tobacco, drugs, alcohol).
Prenatal/ perinatal complications or infections, central nervous
perinatal system infection, head trauma, recurrent otitis media,
Hx and medications.
Mode of delivery or complication
• Developmental milestones (language milestones)
Developmenta
• Testing using any of the ADHD rating scales (i.e.
l/Behavioral
ADHD rating scale, Conner’s rating scale).
• Classroom behavior and interventions, learning
Educational patterns, and functional impairment
performance • Review school reports: School absences, school
achievement
Family history of same abnormality, family history of
Family Hx mental health.
Social Hx Child abuse, neglect & occupation of parents
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic review
Conclusion

581
 Autism Ex

General Vital signs & growth chart

• Observation of the child's behavior and
communication skills ( impaired in autism)
• Observation of parent-child interactions
• dysmorphism.
Special • Neurological Ex including coordination and
verbal or motor tics
• Assessment of vision and hearing levels.
• Cardiovascular Ex
• Testing of formal cognitive achievement.
The evaluation should include a complete history
and direct assessment of social communication
skills and restricted, repetitive behaviors with
Investigations standardized testing of language and cognitive
skills. The diagnosis must be confirmed using the
DSM-5 criteria for ASD.

CRAPRIOP for Management

‫اضطراب طيف التوحد هو مجموعة من االضطرابات التي تؤثر على النمو‬
.‫ مؤدية الى فشل الطفل في التواصل بشكل طبيعي مع االخرين‬، ‫العقلي‬
Clarification ‫ مع وجود أطفال يتواصلون‬، ‫هنالك طيف واسع في مستويات حدة احلالة‬
‫ واخرين تنعدم عندهم القدرة‬، ‫بشكل قريب جدا من االطفال الطبيعيني‬
.‫على التواصل‬
‫ال يوجد عالج شافي للتوحد لكن التعليم اخلاص يهدف الى حتقيق اقصى‬
Reassurance ‫قدر من قدرات كل طفل حتى‬
‫كانت النتائج افضل‬، ‫ كلما كان التدخل مبكرا‬.‫يكون بالغا‬

582
Autism

‫• معظم االطفال املصابني بالتوحد يتم عالجهم سلوكيا بهدف تقليل‬

.‫السلوكيات الغير مفيدة وحتفيز مهارات التواصل اجليدة‬
‫• التعليم اخلاص يساعد في تكوين مهارات اللغة و التواصل‬
‫• دعم وتعليم العائلة مهم للغاية‬
‫• هنالك دور لعالج النطق و اللغة‬
Advice ‫• العالج الوظيفي قد يساعد االطفال و العائلة للتأقلم مع‬
.‫الصعوبات التي يواجهونها‬
‫ ولكن احيانا تكون هنالك حاجة‬، ‫• االدوية نادرا ما تستخدم‬
‫لألدوية للتحكم في االنفعاالت حني يكون لدى الطفل فورة من‬
.‫االثارة او العنف‬
Medical management may target comorbid
diagnoses, such as anxiety disorders, attention-
deficit/hyperactivity disorder (ADHD), and sleep
disorders.
Aripiprazole (Abilify) and risperidone
Prescription (Risperdal) are the only medications approved
by the U.S. Food and Drug Administration for
the treatment of ASD have proven beneficial for
treating aggression, explosive outbursts, and
self-injury.
Aripiprazole (6-17y), Risperidone (5-16y)
Refer to child psychiatrist, child neurologist
,pediatrician, psychologist, audiologist, speech
Referral & language pathologist, occupational therapist,
social worker and genetic counselor
Investigation Mention above
Follow up Follow up 4 weeks
Plan/prevention Health promotion &screen according to the age
Safety netting: If the child has seizure,
Conclusion aggression …etc. come to ER

583
Autism

584
Autism

585
Orthopedic

586
Orthopedic
Neck pain
• Degenerative cervical spine disease
Shoulder pain
• Adhesive capsulitis
• Rotator cuff tear
• Shoulder dislocation
• Shoulder impingement
Hand pain
• Carpal tunnel syndrome
• De quervain tenosynovitis
Back pain
• Lumbar muscle strains/sprains
• Brucellosis
• Ankylosing spondylitis
Knee pain
• Osteoarthritis
Foot pain
• Plantar fasciitis
• Achilles tendinopathy
Ankle pain

587
 Neck pain Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Course: constant, progressive, intermittent
Duration: acute (<6 weeks), subacute (≤3 months), chronic (>3 month)
SOCRATES for pain:
Site
Onset: acute, gradual
Character: shooting, stabbing, burning, electrical-like, and low-level
throbbing or aching pain.
Radiation: to one or both the upper extremity
Associated symptoms: numbness, weakness, weight loss, fever,
anorexia.
Timing
Exacerbating factors: Movement, lifting heavy object
Reliving factors: with rest, analgesic
Severity: does it effect his/her usual activity? Severity range out of 10.
Hx of Trauma? (detailed Hx of the mechanism of injury)
Hx of previous similar condition.
Associated symptoms (DDx):
Infection: Fever, photophobia, night sweats, meningism (combination of
headache, neck stiffness, and photophobia)
Analysis of Malignancy: anorexia, weight loss, Fever, intractable night pain, pain not
relieved with rest, Hx of malignancy
chief CVS:
complain • Myocardial ischemia/infarction: chest pain, SOB, diaphoresis,
nausea, extension of pain into left upper arm (typically medial
aspect).
• Patients with cervical arterial dissection: history of sudden forceful
neck extension, neck pain (ripping or tearing in nature), diplopia,
headache, syncope, vertigo
Cervical Myelopathy: upper extremity numbness, weakness in the lower
extremities, bowel or bladder dysfunction, decreased fine motor control
in the hands.
Ankylosing Spondylitis: back pain and morning stiffness
Polymyalgia Rheumatica (PMR): fatigue, malaise, anorexia
Risk Factors:
• Age: > 50 years (polymyalgia Rheumatica), <45 years (ankylosing
spondylitis)
• Trauma, High impact sports, Strenuous occupations
• Activities with repetitive neck movements
Red Flags:
Weight loss, unexplained fever, anorexia, photophobia, incontinence,
sexual dysfunction, Chest pain, SOB, gait abnormalities, sensory deficits,
headache, limited neck mobility

588
 Neck pain Hx
Medical: previous neck injury, OA, RA, ankylosing spondylitis,
Down syndrome
Past Hx Surgical: prior cervical spine surgery
Allergy
Medication
Family Hx Hx of similar condition
Marital status
Smoking: type and frequency
Screening: depression and anxiety
Sedentary lifestyle
Psychosocial Stress
Occupation: higher in (manual laborers, office workers,
health care workers)
Alcohol and substance abuse
IV drug using
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Neurological : Headache, weakness, numbness, back pain,
Systemic Review incontinence
CVS: chest pain, SOB, diaphoresis
Conclusion
Examination
Vital signs
General Appearance
Neruo Ex
Musculoskeletal Ex: (look, feel, move)
Spurling test
Special Upper limb tension test
Elevated arm stress test (EAST)/Roos test (+ve in thoracic
outlet syndrome)
X-ray: Hx of severe neck pain, chronic neck pain, or pain with
a history of trauma or neck surgery (recent or previous)
Investigations MRI: if neck pain persists for 4 to 6 weeks, radicular pain
does not subside with treatments, or more severe deficit
suggestive of myelopathy is present.

589
 Neck pain
CRAPRIOP for Management
Degenerative cervical spine disease is osteoarthritis
of the spine, which includes the spontaneous
degeneration of either disc or facet joints. It is
related to age and to wear and tear. This
spontaneous degeneration is commonly
asymptomatic. It can lead to either arthritis-specific
symptoms referable to the neck (i.e., loss of joint
motion, pain on motion, joint incompetency) or
neurological complications of the joint degeneration,
Clarification including pressure on the spinal cord and/or cervical
nerve roots.

‫مرض العمود الفقري العنقي التنكسي )داء الفقار الرقبية( هو التهاب‬

‫ والذي يشمل التأكل واالهتراء ملفاصل القرص في‬، ‫مفاصل العمود الفقري‬
‫ ال يظهر على‬.‫ هذا املرض له عالقة بالعمر‬.‫العمود الفقري في منطقة الرقبة‬
‫ فعادةً ما تشمل أًملا‬،‫ وإذا بدت عليهم األعراض‬.‫أغلب األشخاص أي أعراض‬
‫ يسبب داء الفقار الرقبية تضيّق القناة‬،‫ في بعض األحيان‬.‫وتيبسًا في الرقبة‬
‫النخاعية داخل عظام العمود الفقري )الفقرات( وجذور األعصاب لالنضغاط‬
Most patients with cervical radiculopathy will
improve with nonsurgical care: 80% to 90% have
significantly improved pain and resolution of
Reassurance weakness or reflex deficits within four weeks

‫ من‬٪۹۰-۸۰ ،‫معظم املرضى تتحسن حالتهم مع العالج الغير جراحي‬

‫ أسابيع‬٤ ‫املرضى تتحسن أعراضهم بشكل كبير خالل‬
Advice on posture, sleeping position, daily activities,
work and hobbies, stretching exercises, mobility
exercises, and head, neck, and shoulder exercises
Advice may benefit individual patients. Massage and
immobilization with semihard cervical collar.
Pt can return to do physical activities and exercises
after being asymptomatic

590
Neck pain

NSAIDs:
• ibuprofen: 300-400 mg PO Q6-8 hours PRN,
maximum 2400 mg/day
• naproxen: 250-500 mg PO BID PRN,
maximum 1250 mg/day
• diclofenac potassium: 50 mg PO (immediate-
release) BID or TID PRN
Muscle relaxant:
• tizanidine: 4 mg PO Q6-8 hours PRN initially,
increase by 2-4 mg/dose increments
according to response, maximum 18 mg/day
• methocarbamol: 1500 mg PO QID for 2-3
Prescribing days initially, then decrease dose according
to response, usual dose 4000-4500 mg/day
given in 3-6 divided doses
• diazepam: 5-10 mg PO Q 8 hours PRN
Oral corticosteroids
• prednisolone: up to 60 mg PO OD for 2-3
days, then taper dose gradually over 10-14
days
Trigger-point and/or facet joint injections
• dexamethasone: 4 mg intraarticularly/
intrasynovially/ into tendon sheath as a
single dose
Physical therapy
Referral Urgent referral if red flags present
Investigations Mentioned above
Observation/
Follow-up after 4-6 weeks
follow up
Seasonal vaccination
Plan/prevention Screening according to age
Conclusion Educate pt about red flags - Safety netting

591
 Shoulder Pain Hx
Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

present Allow pt to explain the chief complain
illness Clarify what you understood
(Joint pain) Course, onset and duration
Timing: at night (Rotator Cuff Tear or Shoulder
Impingement, Adhesive Capsulitis)
SOCRATES for pain
Pain with overhead activity (Rotator Cuff Tear,
adhesive capsulitis, or Shoulder Impingement)
Associated symptoms (DDx)
• Arm weakness (rotator cuff tear, shoulder
Impingement, glenohumeral osteoarthritis, or
peripheral Neuropathy)
• Stiffness ( adhesive capsulitis )
• Decreased Shoulder Range of Motion (Adhesive
Capsulitis, Glenohumeral Osteoarthritis)
Analysis of • Distal arm Paresthesia beyond the elbow(Cervical
disc disorder or thoracic outlet syndrome)
chief
• Instability Sensation (Shoulder
complain dislocation, Shoulder Subluxation)
• Catching or locking Sensation (Glenohumeral
labrum tear or Glenohumeral Arthritis)
• Fever, swelling, red skin (joint infection)
• Hx of heavy lifting or repetitive movements
(rotator cuff tendinopathy)
• Exclude other causes of referred shoulder pain:
cardiovascular, pulmonary, GI, and neuropathic
causes
Risk Factors: History of trauma, old age, obesity,
diabetes, heavy lifting, overhead activities, smoking.
Red Flags: weight loss, unexplained fatigue, fever,
significant trauma, acute disabling pain

592
 Shoulder Pain Hx
Medical
degenerative joint disease
seizures (associated with posterior glenohumeral
dislocation)
diabetes and hypothyroidism (associated with
adhesive capsulitis)
Past Hx autoimmune diseases
infectious diseases
Surgical: on shoulder, breast, or cervical spine,
prolonged immobilization of the shoulder
Allergy
Medication history of local injection
Family Hx
Marital status
Occupational history: repetitive overhead movement
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs, BMI
General Appearance
Shoulder Ex
Inspection: (Anterior, lateral, and posterior aspects)
Special to inspect the Posture, symmetry, skin (swelling,
scars, erythema, bruising), deformity and muscle
wasting.

593
Shoulder Pain
Palpation:
▪ Temperature
▪ Tenderness over (sterno-clavicular joint, clavicle,
acromioclavicular joint, coracoid process, gleno-humeral
joint, Head of humerus, Greater tuberosity of humerus, Spine
of scapula)
ROM (Active and passive) and Power (resisted movements):
Flexion, extension, abduction, adduction, internal and
external rotation, and circumduction.

Special

Special test
Impingement tests:
• Hawkin's test: 90° forward flexion of the shoulder with the elbow
flexed to 90° then internal and external rotation movements of the
shoulder [Link]
• Neer's test: extreme forward flexion with the forearm pronated
[Link]
• Crossover test: extreme horizontal adduction
[Link]
Biceps tests:
• Speed's test: Palms up with elbows bent to 15° flexion and resisted
upward motion [Link]
• Yergason's test: Simultaneous resisted supination and elbow flexion
[Link]
Rotator cuff tests:
• drop arm test: inability to lift or hold the arm in the 90° abducted
position (full thickness tear)
[Link]
• empty can test / Job's test: Abduction with thumbs down and 30°
horizontal adduction (supraspinatus)
[Link]

594
Shoulder Pain

• lift-off test: resist int. rotation; by placing the patient's

arm behind the back with the dorsum of the hand resting
against the mid-lumbar spine (Subscapularis)
[Link]
• Lag sign – inability to hold the arm in 90° abduction and
maximum external rotation (infraspinatus, teres minor)
[Link]
Instability tests:
• Anterior apprehension test: feeling of apprehension or
discomfort while you abduct the shoulder and trying to
externally rotate it
[Link]
• Posterior apprehension test: feeling of apprehension or
discomfort while you push the humerus backward with
90° shoulder flexion
[Link]
• Sulcus sign: with arms hanging at side. Downward pull on
arm causes “sulcus” between acromion and humeral
Special head, this indicates inferior instability
[Link]
Labrum tests:
• Obrien's test: with the shoulders flexed at 90° and 10°
horizontally adducted, and elbows extended. Apply a
downward force to both arms, first with the thumbs up
and again with the thumbs down. Increased pain in the
thumbs-down position (compared to the thumbs-up) is
suggestive of superior, anterior, or posterior (SLAP) injury
to the labrum.
[Link]
• Labrum grind (Crank) test: with the shoulder at 160°
abduction and elbow at 90° flexion, The humeral head is
compressed into glenoid while internally and externally
rotating the humerus.
[Link]
Neurovascular examination, Cervical and
Elbow examination

595
 Shoulder Pain

CRAPRIOP for Management

Adhesive capsulitis
‫ يتطور‬،‫الكتف املتجمد هو حالة عادة ما تتسبب بألم وتيبس في الكتف‬
‫تدريجيًا ويزداد سوًءا مبرور الوقت وقد يستغرق ذلك من سنة إلى ثالث سنوات‬
Clarification ‫ مرض السكري والغدة وعدم حتريك الكتف‬،‫جتمد الكتف قد يصيب أي شخص‬
‫ملدة طويلة تعتبر من األسباب املحتملة‬
‫ممكن ان تتحسن األعراض بدون عالج خالل فترة تتراوح بني سنة واحدة وثالث‬
Reassurance ‫سنوات‬
‫ ويوصى‬،‫يجب عليك خالل هذه الفترة استخدام الكتف والذراع قدر اإلمكان‬
.‫بالعالج الطبيعي ومتارين جتمد الكتف‬
Advice Pt can return to do physical activities and exercises
after being asymptomatic
• Analgesics: NSAID
• Intra-articular corticosteroid injections
• The injection may be repeated up to 3 times over
Prescribing 4 months
• consider prednisone in patients with severe pain
(40-60 mg/day for 2-3 weeks tapering by 10 mg
every 4-7 days)
• Referral to physical therapy for close follow-up to
reinforce exercise
Referral • Refer to orthopedic for surgery or manipulation
under anesthesia in severe cases
Plain X-ray
Investigations FBS, TSH: if suspect DM , thyroid disorders
Observation/ Arrange follow up within 4-6 weeks
follow up
Opportunistic chance for health education
Plan/prevention (vaccinations and screening)
Conclusion Includes Safety netting

596
‫‪Shoulder Pain‬‬

‫‪Rotator cuff tear‬‬

‫إصابة الكفة املدورة‪ ،‬الُكفة املدّورة هي مجموعة من العضالت‬
‫واألوتار املحيطة مبفصل الكتف‪ ،‬وتسبب إصابات الُكفة املدّورة أًملا‬
‫بسيطًا في الكتف‪ ،‬ويزداد سوءًا خالل ساعات الليل‪.‬‬
‫‪Clarification‬‬ ‫إصابات الُكفة املدّورة شائعة وتزداد مع تقدم العمر‪ .‬وقد حتدث في‬
‫مرحلة مبكرة بني األشخاص الذين تتطلب وظائفهم إجراء حركات فوق‬
‫مستوى الرأس بشكل متكرر‪.‬‬
‫ممكن ان تكون العالجات التحفظية ‪ -‬مثل الراحة والثلج والعالج‬
‫الطبيعي ‪ -‬كافية للتعافي من إصابة الُكفة املدّورة اذا كانت اإلصابة‬
‫‪Reassurance‬‬ ‫خفيفة‪.‬‬
‫وإذا كانت اإلصابة شديدة‪ ،‬فقد حتتاج إلى إجراء عملية جراحية‪.‬‬
‫ابتعد عن مسببات األلم‪ ،‬وحاول جتنب احلركات املؤملة‪ .‬قِّلل من رفع‬
‫األحمال الثقيلة أو ممارسة األنشطة على مستوى أعلى من الرأس حتى‬
‫‪Advice‬‬ ‫يزول ألم كتفك‪.‬‬
‫‪Pt can return to do physical activities and‬‬
‫‪exercises after being asymptomatic‬‬
‫‪Prescribing‬‬ ‫‪NSAIDs and/or corticosteroid injections‬‬
‫‪• Referral to physical therapy‬‬
‫‪Referral‬‬
‫‪• Refer to orthopedic for surgical repair‬‬
‫‪plain x-ray to exclude other causes‬‬
‫‪Investigations‬‬
‫‪MRI to diagnose rotator cuff tear‬‬
‫‪Observation/‬‬
‫‪follow up‬‬ ‫‪Arrange follow up within 4-6 weeks‬‬
‫‪Opportunistic chance for health education‬‬
‫‪Plan/prevention‬‬
‫)‪(vaccinations and screening‬‬
‫‪Conclusion‬‬ ‫‪Includes Safety netting‬‬

‫‪597‬‬
Shoulder Pain

Shoulder dislocation

‫خلع الكتف هو إصابة تخرج فيها عظام الذراع العلوية من‬

‫ وهي معرضة للخلع بدرجة كبيرة ألنها‬.‫جتويف مفصل الكتف‬
Clarification .‫املفصل األكثر مرونة في اجلسم‬
‫قد تشمل اعراضه تغير في شكل الكتف والم وعدم القدرة‬
.‫على حتريك املفصل‬
‫غالبًا تتحسن حاالت خلع مفصل الكتف بعد بضعة أسابيع‬
Reassurance ‫إذا كان اخللع بسيًطا ولم يؤدِ إلى اإلضرار بعصب رئيسي أو‬
.‫تلف األنسجة‬
.‫ وحاول جتنب أداء حركات مؤملة‬،‫إراحة الكتف‬
‫قلل من رفع األحمال الثقيلة أو ممارسة األنشطة على مستوى‬
Advice .‫أعلى من الرأس حتى تتحسن حالة كتفك‬
Pt can return to do physical activities and
exercises after being asymptomatic
Analgesics: NSAID
Prescribing
Refer to orthopedic for closed reduction
Referral Refer to orthopedic for surgical repair
Referral to physical therapy
X-rays (AP), axillary, and lateral scapular
Investigations views to verify diagnosis and rule out
humeral and glenoid fractures
Observation/
Follow up after 2-4 weeks
follow up
Opportunistic chance for health education
Plan/prevention
(vaccinations and screening)
Conclusion Includes Safety netting

598
Shoulder Pain

Shoulder impingement syndrome

‫ هي حالة مرضية حتدث بسبب تضّيق‬:‫متالزمة انحشار الكتف‬

‫مفصل الكتف هذا التضّيق يحدث غالبًا بسبب اإلصابات‬
Clarification ،‫ مما يسبب الشعور بألم‬،‫والتآكل املرتبط باإلجهاد وقلة احلركة‬
.‫ال سيما عند رفع الكتف‬
‫غالبًا تتحسن االعراض مبرور الوقت مع االلتزام باخلطة‬
Reassurance .‫العالجية املحددة‬
‫ التوقف التام عن‬,‫يتم عالج العديد من احلاالت بالتزام الراحة‬
‫النشاطات التي قد تتسبب باأللم وااللتزام بجلسات العالج‬
.‫الطبيعي‬
Advice ‫ دقيقة كل‬20 ‫وميكن وضع كمادات باردة على الكتف ملدة‬
.‫ساعتني‬
Pt can return to do physical activities and
exercises after being asymptomatic
Acetaminophen
Prescribing NSAIDs
Corticosteroid injection
Refer to orthopedic if symptoms do not
Referral improve after 3 months of conservative
management.
Xray
Investigations
MRI
Observation/ Arrange follow up within 4-6 weeks
follow up
Opportunistic chance for health education
Plan/prevention
(vaccinations and screening)
Conclusion Includes Safety netting

599
 Hand pain Hx
Introduce yourself and establish good rapport ( Name, age and job).
Hx of Ask about Chief complain and Allow pt to explain it (open question) ( pain,
present numbness,
illness
or tingling in your wrist and hand) and Clarify what you understood
Onset, duration and Course
The clinical course of CTS may follow an alternating pattern with periods of
remission and exacerbation. In some cases, there is progression from intermittent
to persistent sensory complaints in the hand as CTS worsens, and later to the
development of motor symptoms in the hand.
SOCRATES for pain
Site: wrist and hand, mostly in the palmar aspect of the thumb, index and middle
fingers, and radial half of the ring finger
Onset:
Character:
Radiates: radiate to the forearm or rarely the shoulder
Associated symptoms: -weakness : over time your grip gets weaker and you tend to
drop heavy objects.
Time/duration: The symptoms are usually worse at night and when use wrists and
hands a lot.
Exacerbating/relieving factors: Patients often awaken with symptoms and shake
out their hand to provide relief. This is known as the flick sign.. or by placing them
Analysis under warm running water.
of chief Provoking factors include tasks that require repetitive wrist flexion or hand
complain elevation, such as driving or holding a telephone for extended periods, sleep and
sustained hand or arm positions.
Severity: In more severe cases, motor fibers are affected, leading to weakness of
thumb abduction and opposition, so ask about difficulty holding objects, opening
jars, or buttoning a shirt.
Disappearance of pain is a late finding that implies permanent sensory loss.
Associated symptoms (DDx)
-Neck pain, The exacerbation of symptoms with neck movement, radiation of pain
from the neck into the shoulder and arm, numbness of the thumb and index finger
only = Cervical radiculopathy (C6)
-Tenderness at the distal radial styloid = de Quervain tendinopathy
-Swelling, redness, reduce range of motion= Arthritis
-Pain with thumb motion = Carpometacarpal arthritis of the thumb
-Bilateral, lower extremity involvement with DM = Peripheral neuropathy
-Forearm pain; sensory loss over the thenar eminence; weakness with thumb
flexion,wrist extension= Pronator syndrome (median nerve compression at the
elbow)
-Bilateral sensory loss and motor dysfunction in the hands= Cervical spondylotic
myelopathy and cervical polyradiculopathy
-Chronic widespread musculoskeletal pain and fatigue = Fibromyalgia
-Cold exposure and color change= Raynaud syndrome
-Trauma =Fracture
-Paresthesias of the ring and little fingers =Ulnar compressive neuropathy
600
 Hand pain Hx

Risk Factors:
-Pregnancy and women ( 3 times more than men)
-Family and personal history of DM, obesity ,
hypothyroidism , rheumatoid arthritis, and Connective
tissue disease
-Occupation with repeated forceful hand movements
-Trauma
-Genetics
-Mass lesion
Analysis of
-Preexisting median mononeuropathy
chief
complain -Aromatase inhibitor use
-There is limited and conflicting data with regard to the
potential association of age, estrogen-progestin oral
contraceptive use , and smoking with CTS. (UP TO DATE)
Red Flags:
severe CTS ex weakness of thumb abduction and
opposition, and permanent sensory loss. A history of
bilateral symptoms or multiple carpal tunnel release
surgeries is common in patients with amyloidosis and
should be considered a red-flag symptom.
Medical: Amyloidosis , sarcoidosis , multiple myeloma, and leukemia
Past Hx
Surgical
Allergy
Medication : Aromatase inhibitor use
Family Hx
DM, obesity , hypothyroidism , rheumatoid arthritis and
Connective tissue disease
Marital status
Psychosoci
al
Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic
Review
Summery Summarize and ask the patient if he/she want to add any thing

601
 Hand pain Ex
Vital signs + BMI
General Ø
Ø Appearance
Hand Ex
Special tests:
a. Carpal tunnel Syndrome (to check for median nerve):
• Phalen's test: ask the patient to flex his or her wrist maximally for 1 min, positive If
numbness develop over the lateral 3.5 fingers.
• Tinel's test: tap on the volar side of the wrist over the median nerve, positive if
numbness develop over the lateral 3.5 fingers.

Special

• Flick test: command: "shake your hand", positive if the test relieves the numbness
(has highest sensitivity and specificity).
b. Ulnar tunnel Syndrome (to check for Ulnar nerve):
• Indian salaam test: ask the patient to extend the wrist at 90 degree for 1 min,
positive if numbness develop over the (medial 1.5 fingers).
• Froment's sign test: ask the patient to hold a paper between his thumb & index
finger against your resistance (test for adductor pollicis muscle, positive if not able to
maintain pinch or flexes the thumb to compensate).
c. De Quervain's tenosynovitis :
• Finkelstein's test: command the patient to "adduct the thumb, make a fist, and
deviate the wrist ulnarly, positive test results in pain along the sheath of abductor
pollicis longus.
Neurological Ex (Upper Limbs)
Median nerve Wasting of the thenar muscles, loss of sensation over the
entrapment lateral 3.5 fingers , weak thumb abductors and wrist flexors,
as well as positive Phalen's, Tinel's and Flick tests.
Ulnar nerve injury Claw hand, hypothenar wasting, loss of sensation over the
medial 1.5 fingers, weak small finger’s abductors and
Summary

interossii, as well as positive Formant's and Indian Salaam

tests
Radial Nerve injury Drop wrist because of loss of wrist extensors and thumb
abductors.
De Quervain's Tenderness over the abductor polices longus and extensor
tenosynovitis pollicis brevis tendons, as well as a positive Finkelstein test.

602
 Hand pain
CRAPRIOP for Management
Carpal tunnel syndrome
Clarification .‫ بسبب الضغط على العصب املتوسط مما يؤدي إلى تنميل والم في اليد‬: ‫تعاني من متالزمة النفق الرسغي‬
Reassurance ‫واحد من اكثر اعتالالت االعصاب شيوعا له طرق عالج متعددة حسب شدة االعراض و نسبة التحسن مع العالج خالل‬
%90 ‫سنة تصل الى‬
‫ يعتبر االختيار‬.‫استخدام جبيرة او دعامة للمعصم حيث متنع احلركة التي تودي الى زيادة الضغط على العصب‬-
‫ استخدامها اثناء النوم يحسن من االعراض و أيضا من قدرة‬. ‫العالجي األول في احلاالت اخلفيفة الى املتوسطة‬
‫العصب على التوصيل اما بالنسبة الى استخدامها طوال اليوم لوحظ انه يحسن قدرة العصب على التوصيل لكن ال‬
Advice .‫ أسابيع‬4 ‫ ميكن استخدامها ملدة‬.‫يؤثر على االعراض‬
-Physical therapy like carpal bone mobilization, therapeutic ultrasound, and
nerve glide exercise: there is limited evidence
-Pt can return to do physical activities and exercises after being asymptomatic
-Wrist splint every night for 1 month
-Oral prednisone ,20 mg daily for 10 to 14 days improves symptoms and
function; the improvement lasts up to 8 weeks. Oral
Prescribing corticosteroids are less effective than corticosteroid injection.
-Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin
B6 are not effective therapies.
-Local corticosteroid injection (40-80-mg methylprednisolone) : improvement
lasting 10 weeks to more than one year and its delay need for surgery.
Surgery is the treatment of choice for patients with severe median nerve damage
as characterized by permanent sensory or motor loss, or ongoing axonal loss or
denervation on electrodiagnostic studies. Endoscopic and open techniques are
equally effective; however, patients return to work on average 8 days earlier with
Referral endoscopic repair than with open repair. The most common complications are a
painful scar and pillar pain. Most patients note significant improvement in one
week and are able to return to normal activities in two weeks.
-Clinical diagnosis.
-Electrodiagnostic studies confirming CTS in atypical cases, can exclude other
conditions, such as polyneuropathy and
radiculopathy, and gauge the severity of CTS. Obtained before surgery to
confirm the diagnosis and estimate prognosis.
-Advantages of U/S include lower cost; noninvasiveness; patient comfort; and
evaluation of etiologies such as tenosynovitis, mass lesions, and
Investigations tendinopathies. However, U/S relies on local expertise and cannot rule out
etiologies such as polyneuropathies or
gauge severity of CTS.
-Laboratory testing for comorbidities, such as diabetes or hypothyroidism, may
be considered if there are other signs suggesting disease.
Patients who comply with nocturnal splinting but remain symptomatic at one
month, we suggest continuation of splinting for another one to two months
Observation/FU while adding a different nonsurgical modality for CTS rather than stopping
splinting. We suggest adding a single injection of methylprednisolone (40 mg)
as the next therapeutic option; for patients who decline injection therapy, we
suggest adding oral glucocorticoids (eg, prednisone 20 mg daily for 10 to 14
days). Oral glucocorticoid treatment should not extend beyond four weeks .
Plan/prevention Screening and vaccination
Conclusion Includes:
Safety netting

603
 Carpal Tunnel Syndrome

Predicting the Outcome of Conservative

Treatment for Carpal Tunnel Syndrome

604
Hand pain
De quervain tenosynovitis
‫ وهو‬.‫التهاب غمد الوتر دي كورفان هو حالة تسبب األلم في اإلبهام والرسغ‬
Clarification ‫يحدث عندما يستخدم املعصم و االبهام كثيرًا بطرق ناجت عن مشكلة في الوتر‬
.‫ أو مضرب التنس مرارًا وتكرارًا‬، ‫ مثل امساك مضرب اجلولف‬.‫معينة‬
Reassurance ‫ال تقلق هي حالة شائعة و لها طرق عالج متعددة‬
-Resting your thumb – To avoid moving your
thumb, you can wear a splint made for keeping
the thumb still (thumb spica splint).
-Avoiding repetitive thumb movements as much
as possible and avoiding pinching with the thumb
when moving the wrist from side to side
Advice -Ice – You can put a cold gel pack, bag of ice, or
bag of frozen vegetables on the painful or swollen
area every 4 to 6 hours, for 15 minutes each time.
-Exercises – Finger stretches : After symptoms
improve, some exercises to help wrist and thumb
move more easily.
-NSAIDs includes ibuprofen and naproxen
-Steroid Methylprednisolone 20-40 mg around
Prescribing the inflamed tendon in wrist – Steroids help
with inflammation.
-physical therapist or an occupational therapist
Referral -In refractory cases surgery is needed to cut or
loosen the covering around the tendon
Clinical diagnosis
-Physical exam: Finkelstein test is positive (ulnar
deviation of the hand with the thumb flexed
Investigations
elicits pain).
- Imaging: x-ray only needed to rule out bony
conditions
Observation/ Follow up after 4 weeks to check improvement
if you develop any new complain before that
follow up
inform me
Plan/prevention Age related screening and vaccination
Conclusion Includes Safety netting

605
 Back pain Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
SOCRATES for pain :
ü Site
ü Onset: sudden/gradual
ü Course
ü Duration: Acute (<4 wks), Subacute (4-12 wks), Chronic (>12 wks)
ü Timing: diurnal variation
ü Frequency
ü Character of pain: Dull/ache/sharp
ü Radiation (If radiated to lower limb or not)
ü Exaggerating factor: Sitting/walking/bending
ü Relieving factor: rest
• relieved by activity: ankylosing spondylitis or other
inflammatory conditions.
• Worsening by standing or walking and relief by bending: Spinal
stenosis.
ü severity (1-10)
Associated symptoms (DDx)
ü Lumbosacral muscle strains/sprains: diffuse back pain with or without
buttock pain, pain worse with movement, relieved by rest. isolated
Analysis of traumatic incidents or repetitive overuse.
ü Osteoporosis: age >70yr, chronic steroid use , menstrual hx.
chief ü Symptoms of fever: onset, duration, time, documentation, pattern,
complain aggravating & relieving factors, associated symptoms as rigors and chills,
night sweat, joints pain, URTI symptoms.
ü Brucellosis: fever peaks in evening , fatigue, arthralgia, headache,
diaphoresis, weight loss and or anorexia, History of animal contact or
ingestion of raw milk or its products.
ü TB: cough, night sweat and fever , unexplained weight loss, hx of travel
and contact with sick people.
ü Infection: Spinal procedure in the past 12 months, spine surgery,
Intravenous drug use, immunosuppression, History of travelling abroad
or to an endemic areas of malaria.
ü Inflammatory (ankylosing spondylitis ,IBD): back pain relieved by
activity,
ü Spinal sclerosis: low back pain and stiffness worse with extension
(standing and walking down hill) improves with flexion (leaning forward,
pushing a cart, walking uphill),, sensory loss or weakness in the legs, calf
pain with ambulation that is relieved with rest/sitting
“pseudoclaudication”. (Leg pain >back pain)
ü Spondylolisthesis: back pain radiates posteriorly to knees. Bending,
lifting or twisting worsens the pain.
ü Cauda equina syndrome: bilateral lower extremity numbness or
weakness, new urinary retention or overflow incontinence, new fecal
incontinence, saddle anesthesia.

606
Back pain Hx
ü Disk herniation: abrupt onset of pain that is sever and exaggerated by
sitting , walking, standing or coughing, radiates into the buttock or legs,
paresthesia, sensory change. (Leg pain >back pain)
ü Vertebral compression fracture: Abrupt onset of localized back pain ,
worse with flexion, position changes” pulling up from a supine to sitting
and from sitting to standing” , coughing, sneezing or lifting. Pain at rest
and at night. risk factors include age >70yr, history of trauma, chronic
steroid use, and osteoporosis.
ü Malignancy: History of metastatic cancer or Unexplained weight loss,
pain at rest or at night.
ü Multiple myeloma: hypercalcemia, Renal insufficiency, Anemia, bone
pain, fatigue, generalized weakness, weight loss and infections. (CRAB)
ü Referred pain (genitourinary, gastrointestinal): dysuria, abdominal pain,
diarrhea/constipation.
ü Psychological (depression)
Risk Factors
• History of TB
• Raw milk ingestion (For brucellosis infection)
• Long steroid use
Analysis of • I.V drug use
chief • Trauma
• Repeated lifting heavy object.
complain • Smoking
Red Flags
• Age >50 yr
• Neurological Symptom:
1. lower limb numbness or paresthesia
2. saddle anesthesia
3. progressive motor or sensory deficit
4. urinary and or stool incontinence
5. Sexual dysfunction
• Constitutional Symptom: unexplained weight loss, fever, chills or
night sweat, Fatigue, LN enlargement.
• recent urinary or skin infection
• pain at night or at rest
• prolonged use of steroids Rx
• immunosuppression
• functional limitations
• failure to improve after 6 weeks of conservative therapy
• H/O malignancy, significant trauma ,osteoporosis
Medical: similar symptoms before, prior cancer diagnosis, osteoporosis,
DM, brucellosis, TB, or HIV.
Past Hx Surgical: Back surgeries or any surgeries
Allergy
Medication: prolonged corticosteroid, pain killers, IV drug abuse
Family Hx Similar problem, Rheumatologic problem

607
 Back pain Hx
Marital status
Occupational history: physically strenuous, lifting heavy object,
prolonged sitting, operating vibrating machine, frequent
bending & twisting.
Exercise: type and frequency
Diet (sedentary lifestyle)
Psychosocial Smoking: type and frequency
Alcohol use
Psychosocial "yellow flags”:
disability in patient with chronic low back pain leading to
(anxiety/depression, impaired sleep because of pain, lack of
social support/financial problem and job dissatisfaction).
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How? (Consequences in
term of daily functioning)
Systemic Full systems (headache, dizziness, visual changes, Runny nose,
sorethroat, cough, SOB, chest pain, N/V, abd pain, Diarrhea,
Review constipation, Rash, joint pain, back pain)
Summarize the main points
If there is anything you are concerned about you can book an
Conclusion appointment.
Thank the patient

Examination
Vital signs and BMI
General Appearance
Neuromuscular examination Ex
Inspection: gait, posture (scoliosis, Kyphosis, or lordosis), symmetry,
skin (swelling, scars, fat pads, erythema) and muscle wasting.
Palpation: Temperature, Tenderness over (spinous process,
paraspinal muscles, paravertebral area, sacroiliac joint, coccygeal tip,
Special anterior and posterior iliac spine), spasm, Masses.
Movement: Flexion, extension, lateral bending, and twisting.
Power:
✓ Heel walking / resisted Foot dorsiflexion (L4)
✓ Resisted Big toe dorsiflexion (L5)
✓ Toe walking / resisted planter flexion (S1)

608
Back pain Ex
reflexes:
✓ knee reflex (L4)
✓ Hamstrings reflex (L5) ✓ ankle reflex (S1)
Sensation:(to determine involved dermatome)
✓ medial side of foot L4
✓ dorsum of the foot L5
✓ Lateral side of the foot S1
Vascular examination: pulses, Capillary refill
Special test
• Straight leg raising test: performed by lifting the leg, with the
knee extended, in the sitting (or supine) position. Pain radiating
past the knee suggests sciatica. Dorsiflexion of the ankle during
the straight-leg raise test increases sciatic tension and pain,
while plantar flexion relieves sciatic tension and pain.
• Braggard test: A straight leg raising is done; if positive the leg is
lowered just below the point of pain and then the ankle is
dorsiflexed, increase pain is further indicative of nerve
compression.
[Link]
• Crossed straight leg raising test: performed by doing a straight-
leg raise test on the opposite (uninvolved leg). If this maneuver
aggravates the sciatica pain in the opposite leg, it is highly
Special suggestive of sciatica.
[Link]
• FABER test: performed by placing the hip and leg into (flexion,
abduction and external rotation), this will aggravate sacroiliac
joint pain.
[Link]
• Modified Schober's test: with the patient in upright position,
using a pin marker to determine the level of sacral dimples (5th
lumbar spinus process), then draw two more marks 10 cm
above and 5 cm below the 1st one. Ask the patient to bend
forward maximally and measure the distance between these
marks..(normally will increase from 15cm to at least 20cm with
lumbar flexion). Difference of < 5cm will raise suspicion of
Ankylosing spondylitis.
[Link]
Others (Brucellosis)
ü Cervical or inguinal lymphadenopathy
ü Abdominal Ex: Hepatosplenomegaly
ü Orchitis or epididymitis
ü purpura.
ü CNS

609
 Back pain
As indicated
Lab:
• ESR and CRP (suspecting inflammation, infection or malignancy)
• CBC (Anemia, leukopenia, lymphocytosis, thrombocytopenia or
pancytopenia),
• LFT+ alk
• Serology (Brucella titer), Brucella PCR
• Blood Culture (the mainstay of dx brucella)
• Ca + phosphate
• Vit D
• cerebrospinal fluid (CSF) analysis (Brucellosis with neurological
signs)
• HLA-B27
Imaging
• DEXA
• Back X-ray
• MRI
• CXR: if Respiratory sx or source of infection not apparent
• US: if hepatosplenomegaly suggested
• Echo: if possible endocarditis (Brucellosis complications)
• Head CT: if altered mental status or focal neurologic deficits
• Biopsy: may be required to establish a diagnosis in certain patients
Investigations (Brucellosis )
The American College of Radiology Appropriateness Criteria for
low back pain recommends imaging only if there is:
ü No improvement after six weeks of conservative medical and physical
therapies, or
ü There is high suspicion for cauda equina syndrome, malignancy,
fracture, or infection.

610
 ‫‪Back pain‬‬

‫‪CRAPRIOP for Management‬‬

‫‪Lumbosacral muscle strains/sprains‬‬
‫غالبا ما حتدث ألم الظهر من دون سبب معني ‪ ،‬ولكن من احلاالت الشائعة املرتبطة‬
‫بألم الظهر ما يلي‪:‬‬
‫إجهاد العضالت أو األربطة‪ .‬ميكن أن يؤدي رفع األثقال املتكرر أو احلركة املفاجئة‬
‫إلى إجهاد عضالت الظهر واألربطة في العمود الفقري‪ .‬وبالنسبة ملن لديهم حالة‬
‫بدنية ضعيفة‪ ،‬فقد يؤدي الضغط املستمر على الظهر إلى حدوث تقلصات عضلية‬
‫مؤملة‪.‬‬
‫انتفاخ األقراص أو متُّزقها‪ .‬تعمل األقراص كوسائد بني العظام في العمود الفقري‪.‬‬
‫ومن املمكن أن تنتفخ املادة اللينة داخل القرص أو تتمّزق وتضغط على أحد‬
‫‪Clarification‬‬ ‫األعصاب‪ .‬ومع ذلك‪ ،‬فقد ال يسبب القرص املنتفخ أو املمّزق أًملا في الظهر‪ .‬حيث‬
‫يظهر مرض القرص غالًبا عند فحص العمود الفقري باألشعة السينية أو التصوير‬
‫املقطعي املحوسب أو التصوير بالرنني املغناطيسي لسبب آخر‪.‬‬
‫التهاب املفاصل‪ .‬من املمكن أن يؤثر االلتهاب املفصلي العظمي على أسفل الظهر‪.‬‬
‫وفي بعض احلاالت‪ ،‬ميكن أن يؤدي التهاب املفاصل في العمود الفقري إلى تضّيق‬
‫املساحة املحيطة باحلبل النخاعي‪ ،‬وهذا مرض يسمى تضيق العمود الفقري‪.‬‬
‫هشاشة العظام‪ .‬قد ُتصاب فقرات العمود الفقري بكسور مؤملة إذا أصبحت العظام‬
‫مسامية وهشة‪.‬‬
‫‪Reassure the patient that the prognosis is often good, with‬‬
‫‪Reassurance‬‬ ‫‪most cases resolving with little intervention‬‬
‫‪ü patient education + return to normal activity. (Advise the‬‬
‫‪patient to stay active, avoid bed rest, and return to normal‬‬
‫)‪activities as soon as possible‬‬
‫‪ü heat-wrap therapy for short-term reductions in pain and‬‬
‫‪stiffness. while ice is often used to alleviate lower back‬‬
‫‪pain, but the evidence for its benefit is limited to poor-‬‬
‫‪quality studies.‬‬
‫‪ü massage improves short-term pain, but not function, in‬‬
‫‪some patients with subacute and chronic lower back pain‬‬
‫‪Advice‬‬ ‫‪ü acupuncture may improve symptoms of acute lower back‬‬
‫‪pain , but not function.‬‬
‫‪ü physiotherapy‬‬
‫‪Smoking cessation.‬‬
‫‪Weight loss.‬‬
‫‪Manage stress e.g. relaxation, meditation‬‬
‫‪Follow a healthy diet‬‬
‫‪Pt can return to do physical activities and exercises after being‬‬
‫‪asymptomatic‬‬

‫‪611‬‬
Back pain

1st line
ü Analgesia
Primary options
» ibuprofen: 300-400 mg orally every 6-8 hours when required,
maximum 2400 mg/day OR
» naproxen: 250-500 mg orally twice daily when required,
maximum 1250 mg/day OR
» celecoxib: 100-200 mg orally twice daily when required
Secondary options
» paracetamol: 500-1000 mg orally every 4-6 hours when
required, maximum 4000 mg/day
Tertiary options
» paracetamol/codeine: 500-1000 mg orally every 4-6 hours
when required, maximum 4000 mg/day
Prescribing Dose refers to paracetamol component. Maximum 240 mg/day
of codeine.
ü Muscle relaxant
» cyclobenzaprine: 5-10 mg orally three times daily when
required OR
» tizanidine: 4-8 mg orally three times daily when required,
maximum 24 mg/day OR
» metaxalone: 800 mg orally every 6-8 hours when required,
maximum 3200 mg/day

There is some evidence suggesting that the combination of

muscle relaxants and either paracetamol or NSAID leads to
improved outcomes compared with either alone.

• Physiotherapy: for the McKenzie method

• nutritionist if obese
Referral • Rheumatologist
• orthopedic
Investigations Mentioned above
• I need to see you again in a month
Observation/ • Why is it needed? Results of the investigations, drugs S.E.,
follow up compliance, any new complains
• How often is it needed: every 3 months
Plan/prevention Opportunistic health promotion
Conclusion Includes Safety netting

612
 Back pain
Brucellosis
‫احلمى املالطية او داء البروسيال هي عدوى بكتيرية تصيب احليوانات في األصل ثم تنتقل منها الى االنسان عن‬ •
‫ قد تنتقل‬،‫ وفي بعض األحيان‬.‫طريق تناول مشتقات احلليب اخلام أو غير اُملبسَترة او عن طريق تناول حلومها‬
.‫البكتيريا املتسببة عن طريق الهواء أو التعامل املباشر مع احليوانات املصابة‬
،‫ الصداع‬،‫ التعرق الليلي‬،‫ فقدان في الشهية ونقص الوزن‬،‫وقد تتسبب بظهور اعراض مثل )ارتفاع في درجة احلرارة‬ •
Clarification .(‫ وقد يحصل تضخم في العقد اللمفاوية والكبد والطحال‬،‫ ألم في الظهر واملفاصل‬،‫اإلرهاق الشديد‬
‫ والتهاب الشغاف الطبقة الداخلية‬Meningitis ‫وفي حاالت نادرة قد حتصل مضاعفات خطرة كالتهاب السحايا‬ •
.‫ وغيرها‬Osteomyelitis ‫ والتهاب العظم‬Endocarditis ‫من القلب‬
.‫ال يوجد لقاح بشري للوقاية منه لكن املهم اخذ االحتياطات للوقاية‬ •
‫ال تقلق يوجد عالج وتوجد مناذج ناجحة استجابت للعالج‬
Reassurance
:‫بعض النصائح من اجل الوقاية من خطر اإلصابة باحلمى املالطية‬
.‫جتنب األطعمة التي حتتوي على منتجات األلبان الطازجة غير املبسترة‬ •
.‫طبخ اللحوم جيدًا قبل تناولها واالمتناع عن اللحم الني‬ •
‫ارتِد قفازات مطاطية عند التعامل مع احليوانات املريضة أو امليتة أو األنسجة احليوانية أو عند مساعدة احليوان‬ •
Advice .‫أثناء الوالدة‬
.‫غسل اليدين جيدًا والتطهير عند التعامل مع املواشي‬ •
.‫لِّقح احليوانات املحلية‬ •
• Pt can return to do physical activities and exercises after being asymptomatic
Non-pregnant adults and children aged ≥8 years
1st line (WHO)
Doxycycline 100 mg BID for 6 weeks OR tetracycline 500 mg Q6h daily for 6
weeks
+ Streptomycin 1 g IM daily for 2-3 weeks OR Gentamicin 5 mg/kg/day IV or IM
for 7-10 days
2nd line (WHO)
Doxycycline 100 mg BID for 6 weeks OR tetracycline 500 mg Q6h daily for 6
weeks
+ Rifampicin 600-900 mg/day given in 1-2 divided doses for 6 weeks
OR (CDC)
trimethoprim/sulfamethoxazole: 160/800 mg orally BID for 6 weeks
+ rifampicin 600-900 mg/day orally given in 1-2 divided doses for 6 weeks
pregnant or breastfeeding adults
1st line
rifampicin 600-900 mg/day orally given in 1-2 divided doses for 6 weeks
Prescribing 2nd line
trimethoprim/sulfamethoxazole 160/800 mg orally BID for 4 weeks (not
recommended in 1st trimester of pregnancy)
+ rifampicin 600-900 mg/day orally given in 1-2 divided doses for 4 weeks
children aged <8 years
1st line (CDC)
trimethoprim/sulfamethoxazole 8-10 mg/kg/ day orally given in 2 divided doses
for 4-6 weeks
+ rifampicin 15-20 mg/kg/day orally given in 1-2 divided doses, maximum 900
mg/day for 4-6 weeks
OR (WHO)
trimethoprim/sulfamethoxazole 8-10 mg/kg/ day orally given in 2 divided doses
for 6 weeks
+ streptomycin 30 mg/kg IM once daily for 3 weeks OR Gentamicin 5 mg/kg IV
or IM once daily for 7-10 days
Supportive treatment for pain and fever
Observation/ FU In 3 wks & 6 wks to encourage patient adherence to Rx
613
Back pain
Ankylosing spondylitis
‫ التحام بعض عظام‬،‫ مبرور الوقت‬،‫سط هو مرض التهابي قد يسبب‬ ِّ ‫ التهاب الفقار اُملق‬-
‫ وقد‬،‫ ويؤدي هذا االلتحام إلى جعل العمود الفقري أقل مرونة‬.‫)فقرات( العمود الفقري‬
.‫يؤدي إلى تقوّس وضعية اجلسم‬
‫ خاصًة‬،‫ األلم والتيبُّس في أسفل الظهر والوركني‬:‫ األعراض املبكرة اللتهاب الفقار املقسط‬-
Clarification .‫ وآالم الرقبة واإلرهاق‬.‫في الصباح وبعد فترات من عدم النشاط واحلركة‬
‫ مع أنه يبدو أن العوامل الوراثية قد‬،‫سط‬ ِّ ‫ ال يوجد سبب ُمحَّدد معروف اللتهاب الَفَقر اُملَق‬-
HLA- ‫ األشخاص الذين لديهم جني ُيسمى‬،‫ وعلى وجه اخلصوص‬.‫يكون لها دور في حدوثه‬
.‫سط‬ ِّ ‫أكثر ُعرضًة لإلصابة بالتهاب الَفقار اُملَق‬B27
‫ لكن العالجات املتاحة ميكنها‬،‫سط‬ ِّ ‫ف اللتهاب الفقار اُملق‬ ِ ‫لألسف ال يوجد عالج شا‬
Reassurance .‫ ورمبا تبطئ تفاقم املرض‬،‫أن تقلل من حدة األعراض‬
Pt can return to do physical activities and exercises after being
Advice asymptomatic
1st NSAID + non-pharmacological therapy
Primary options
» naproxen: adults: 500 mg orally twice daily, maximum 1250
mg/day
OR
» ibuprofen: adults: 400-800 mg orally three times daily,
maximum 2400 mg/day
adjunct
» paracetamol: adults: 500-1000 mg orally every 4-6 hours,
maximum 4000 mg/day
If there is local intra-articular inflammation or enthesitis
Prescribing plus
» intra-articular hydrocortisone injection: consult specialist for
guidance on dose (localized inflammation)
If there is peripheral joint involvement :
» sulfasalazine: adults: 500 mg orally once daily for 1 week,
then 500 mg twice daily for 1 week, then 1000 mg in the
morning and 500 mg at night for 1 week, then 1000 mg twice
daily
OR
» methotrexate: adults: 7.5 mg orally once weekly on the same
day of each week initially, increase gradually according to
response, maximum 25 mg/week
• Physiotherapy
Referral • Nutritionist if obese
• Rheumatologist
Investigations Mentioned above

Observation/FU
Plan/prevention
Conclusion Includes Safety netting
614
 Knee pain Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Allow pt to explain the chief complain
Clarify what you understood

Hx of
present
illness

Course, onset and duration

SOCRATES for pain
Site: unilateral or bilateral

Associated symptoms (DDx):

• Osteoarthritis: Symmetrical Joint pain (large and small), early Morning
stiffness < 15 minutes, relieved by rest, aggravated by movement
Analysis of Functional difficulties.
There should be no systemic manifestations with OA
chief • Rheumatoid arthritis: Symmetrical, involved hand’s joints (PIPs, MCPs)
complain wrist and ankle, early morning stiffness > 1 hour, relieved by
movement, aggravated by rest.
Other differentials mentioned below.
Risk factors (osteoarthritis):
-Age: older than >50 years
-Female > male
-Overweight or obesity (Obesity has a strong association with knee OA
-Genetic factors.
-Knee malalignment (Varus (bow-legged) or valgus (knock-kneed)
malalignment (detected on full-length lower limb x-ray) and associated
with tibiofemoral OA)
-Physically demanding occupation/sport including running, weight-
lifting, and wrestling.
Red Flags: swelling, redness, hotness, limited range of motion, systemic
manifestation (fever)

615
 Knee pain Hx
Medical: previous similar attack, trauma, chronic diseases.
Surgical: knee replacement, other knee surgeries
Past Hx Allergy
Medication: analgesics
Family Hx Same or chronic.
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs + BMI
General Appearance
Knee Ex:
Signs of inflammation (mild), Bony malalignment, Bony deformities,
Special Crepitus Restricted movements.
Special test
1st test to order
X-ray of affected joints: The Radiographic Hallmarks of OA: Joint space
narrowing, Subchondral sclerosis, Subchondral cysts and Osteophytes
Serum CRP and ESR.
Other tests to consider
Investigations Rheumatoid factor.
Anti-CCP antibody.
Synovial fluid Analysis (Clear, Pale yellow, High Viscosity, PMN< 25%,
negative culture and gram Stain, WBCs <2000)
MRI of affected joints.

CRAPRIOP for Management

Osteoarthritis
‫ ويحدث عند تآكل النسيج‬،‫يعد االلتهاب املفصلي العظمي أكثر أنواع التهاب املفاصل شيوًعا‬
.‫الغضروفي الواقي املوجود في املفاصل مع مرور الوقت‬
Clarification ‫ إال أنه ال ميكن إصالح التلف الذي يصيب‬،‫وميكن معاجلة أعراض االلتهاب املفصلي العظمي في العادة‬
.‫املفاصل‬
‫ والوزن الصحي واخلضوع لطرق العالج األخرى على إبطاء تقُّدم‬،‫وقد يساعد احلفاظ على النشاط البدني‬
Reassurance .‫ وحتسني أداء املفصل لوظيفته‬،‫ وتخفيف األلم‬،‫املرض‬

616
 Knee pain
-Weight loss and moderate exercise (hydrotherapy [swimming], tai
chi,Yoga).
-Use of assistive/adaptive devices (walking aids), and appropriate
Advice footwear
-Pt can return to do physical activities and exercises after being
asymptomatic
- 1st line: Topical analgesia: capsaicin cream/Diclofenac (3-4 times daily
PRN)
- 2nd line: paracetamol + topical analgesia
- 3rd line: NSAIDs + paracetamol + topical analgesia
- Consider gastroprotection with long term NSAIDs use (ex:
Prescribing omeprazole 20mg OD)
- Consider intra-articular corticosteroids injections (ex:
methylprednisolone acetate 4-80mg as a single dose
- Joint replacement if function is compromised
- Duloxetine 30mg OD effectively treats knee pain, may be continued
while awaiting joint replacement.
To physiotherapy
Referral To rheumatologist and/or orthopedic specialist if he has significant pain
or limitation in his activity.
Investigations Mentioned above
Observation/ If Pt on NSAIDs or COX-2, tests for renal function and full blood count
follow up are obtained every 3-6 months)

Plan/prevention
Conclusion Includes Safety netting

617
Knee pain

618
Knee pain

619
 Foot pain Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

Allow pt to explain the chief complain
present Clarify what you understood
illness
Foot pain: Onset, Course, Duration, at early morning waking
up or after period of rest
Site: one foot or both, planter or posterior or mid foot
(medial, lateral)
severity, aggravating and reliving factors
Analysis of Hx of trauma, fall down and mechanism of injury
chief Hx of pop or click or snaps
complain Associated symptoms: swelling immediately or afterward,
skin discoloration, numbness or tingling or paresthesia or
coldness, ability to weight bearing or limping, pain in other
joints
Red flags: foot drop or deformity, bleeding or ecchymosis,
loss of sensation
Past medical hx: DM, arthritis, neuropathy, DVT, connective
tissue disease
Past surgical hx: any surgery or previous fractures
Past Hx Allergy hx
Medication hx (use of Fluoroquinolones
antibiotic)
Family Hx Family hx of any diseases
Marital status
Social: Job or athletes (long standing or runner)/ alcohol
Psychosocial /Smoking/ drug abuse/ level of intensity of sport or
activity
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

620
Foot pain Ex

Vital signs
BMI
General Appearance
Pain scoring
For both feet and ankles
Inspection:
Gait, swelling, skin (scar, erythema, corns or calluses),
muscles wasting, deformity (Charcot joint, hallux valgus).
Foot shao and arch when standing (asymmetry or flat foot),
examine the footwear
Palpation:
Temperature, effusion and tenderness over the following:
1- lower leg: fibula, anterior compartment, anterior ankle
joint line
2- medial ankle: medial malleolus, deltoid ligament, tibialis
posterior tendon
3- lateral ankle: lateral malleolus, anterior talofibular
ligament(ATFL), calcaneofibular ligament (CFL), posterior
Special talofibular ligament (PTFL)
4- posterior ankle: Achilles tendon, calcaneus
5- foot: proximal 5th metatarsal, navicular
Movments (active and passive) power:
Dorsiflexion, planter flexion, eversion and inversion.
Special Tess:
1- squeeze test: indicate tibiofibular ligament injury
(syndesmosis sprain)
2- anterior drawer test: indicate ATFL injury
3- Talar tilt test: indicate CFL ligament injury
4- Thompson test: indicate Achilles tendon rupture
Neurovascular examination: pulses. Capillary refill,
sensations and reflexes
Examine joint above and below
X-ray (Ottawa Ankle Rules)
If bone tenderness at tip of medial malleolus, lateral
Investigations malleolus, or at the base of 5th metatarsal or navicular bone,
inability to bear weight both immediately or after injury at
the clinic.

621
Foot pain

622
Foot pain

623
 Foot pain

CRAPRIOP for Management

Achilles tendinopathy

It is mild condition due to excessive mechanical loading

Clarification of the muscle, such as with increased running, can
cause tendinopathy that leads to posterior heel pain
Self-limiting condition with conservative proper treatments
Reassurance most patients will improve within 6 months
Activity modification
Eccentric exercises
Functional rehabilitation (physiotherapy)
Reduction of pressure to the area
Advice Deep friction massage and tendon mobilization
Heel lifts or other orthotic devices
Pt can return to do physical activities and exercises
after being asymptomatic
Analgesia oral or topical (NSAID)
Injections with corticosteroids should be avoided
Prescribing because of the risk of tendon rupture
severe cases may require surgery
Most of the cases do not need referral
Referral May need to referral to Physiotherapy
For sever cases may need to refer to surgery
X-ray (Ottawa Ankle Rules)
If bone tenderness at tip of medial malleolus , lateral
Investigations malleolus, or at the base of 5th metatarsal or navicular
bone, inability to bear weight both immediately or
after injury at the clinic.
Observation/
Arrange for follow up in 4-6 weeks
follow up
Consider to return to sport once the current routine activities
Plan/prevention can be performed without pain
Includes Safety netting
Conclusion Educate the patient about Red flags as foot drop or deformity,
bleeding or ecchymosis, loss of sensation or loss of function

624
 Foot pain

CRAPRIOP for Management

Plantar faciitis
It is a common problem that one in 10 people will experience in
their lifetime. Plantar fasciopathy is an appropriate descriptor
Clarification because the condition is not inflammatory it is degenerative.
Risk factors include limited ankle dorsiflexion movements,
increased BMI, and standing for prolonged periods of time
Self-limiting condition with conservative proper treatments
Reassurance most patients will improve within 6 months
Relative rest and activity modification
Stretching and strengthen exercise
Functional rehabilitation (physiotherapy)
Advice Ice massage and Arch support
Pt can return to do physical activities and exercises after being
asymptomatic
Analgesia oral or topical (NSAID)
Corticosteroid and platelet-rich plasma injections can provide
short-term pain relief and are often used when conservative
Prescribing measures are ineffective (Corticosteroid injections increase the
risk of plantar fascia rupture or fat pad atrophy)
Extracorporeal shock wave therapy and plantar fasciotomy can
be used to treat recalcitrant cases.
Most of the cases do not need referral
May need to referral to Physiotherapy
Referral For sever cases may need to refer to surgery or corticosteroid
injection
X-ray (Ottawa Ankle Rules)
If bone tenderness at tip of medial malleolus , lateral
Investigations malleolus, or at the base of 5th metatarsal or navicular
bone, inability to bear weight both immediately or after
injury at the clinic.
Observation/
Arrange for follow up in 4-6 weeks
follow up
Consider to return to sport once the current routine activities
Plan/prevention can be performed without pain
Includes Safety netting
Conclusion Educate the patient about Red flags as foot drop or deformity,
bleeding or ecchymosis, loss of sensation or loss of function

625
Foot pain

626
 Ankle pain Hx

Introduce yourself and establish good rapport ( Name, age and job).

Hx of Chief complain (open question)

Ankle pain/twist/sprain or strain
present Allow pt to explain the chief complain
illness Clarify what you understood
Mechanism of foot injury:
▪ site, position of foot, direction and duration of
trauma and progression of
the pain severity
Analysis of ▪ history of "pops or chicks or "snaps"
▪ Immediate swelling after injury, bleeding or
chief
deformity
complain ▪ loss of consciousness
▪ other injury in the body
Associated symptoms: pain, swelling, skin
discoloration (ecchymosis), numbness,
paresthesia or coldness, weight bearing
Diabetes, arthritis, connective tissue disease,
Past Hx neuropathy, DVT
Past ankle injuries/surgeries
Family Hx
Psychosocial level and intensity of sport and activity
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for
you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

627
Ankle pain Ex

Vital signs
General Appearance
Proper exposure: up to knees (if appropriate)
Body Position: Standing/sitting

Inspection: gait, skin (swelling, scars, erythema, corns or calluses) and muscle
wasting
,deformity (hallux valgus, Charcot joint), foot shape (asymmetry) and arch
when standing,
any flat feet, and don't forget to examine the foot wear.
Palpation: Temperature, Tenderness over:
1. Lower leg: fibula, interosseous membrane, anterior compartment, anterior
ankle
joint line.
2. Medial ankle: medial malleolus, deltoid ligament, tibialis posterior tendon.
3. Lateral ankle: lateral malleolus, anterior talofibular ligament (ATFL),
calcaneofibular
ligament (CFL), posterior talofibular ligament (PTFL), peroneal tendon
4. Posterior ankle: achilles tendon, calcaneus.
5. Foot: proximal 5th metatarsal, navicular.
Movement (Active, passive and power): Dorsiflexion, plantar flexion, eversion
and
inversion
Special test:
Special • Squeeze test :performed by compressing the tibia and fibula in the midway
of the
leg, pain may indicate fracture or tibiofibular syndesmosis. (Figure 7).

Anterior Drawer test: ankle at 20° planter flexion, fixate the lower
tibia by one hand and using the other to grasp the heel trying to
move the ankle anteriorly and posteriorly.. laxity will indicate rupture
of anterior talofibular ligament. (Figure 8)
• Talar tilt test :ankle at anatomical position, fixate the lower tibia by one
hand, and
invert the foot by the other one.. pain or laxity will indicate calcaneofibular
ligament injury.
• Thompson test: patient in prone position, squeeze the calf muscles to
observe the
normal planter flexion of the foot.. Absence of this response will indicate
Achilles
tendon rupture
[Link] (Ankle Examination Video)
• Neurovascular examination: pulses, Capillary refill , sensation and reflexes
• Examine joint above (knee) and joint below (foot)
• Quick back exam (ROM, straight leg raise test) if related

628
 ‫‪Ankle sprain‬‬
‫‪CRAPRIOP for Management‬‬
‫ميثل التواء الكاحل إصابة حتدث عندما تقوم بلف‪ ،‬أو ثني أو إدارة كاحلك‬
‫بطريقة غير مناسبة‪ .‬قد يؤدي هذا األمر إلى حدوث شد أو متزق في األشرطة‬
‫القوية للنسيج )األربطة( التي تساعد على ربط عظام الكاحل مع بعضها‪.‬‬
‫تساعد األربطة على تثبيت املفاصل‪ ،‬ومنع احلركة املفرطة‪ .‬يحدث التواء الكاحل‬
‫عندما يتم إجبار األربطة على اخلروج عن نطاقها الطبيعي للحركة‪ .‬تتضمن‬
‫‪Clarification‬‬ ‫معظم حاالت التواء الكاحل إصابات باألربطة باجلانب اخلارجي من الكاحل‪.‬‬
‫يعتمد عالج التواء الكاحل على مستوى شدة اإلصابة‪ .‬على الرغم من أن تدابير‬
‫الرعاية الذاتية وأدوية األلم التي تُصرف دون وصفة طبية قد تكون كل ما‬
‫حتتاجه‪ ،‬فقد يكون التقييم الطبي ضرورًيا للكشف عن مدى تأذي كاحلك‪،‬‬
‫ولتحديد العالج املناسب‪.‬‬
‫يعتمد عالج التواء الكاحل على درجة خطورة اإلصابة‪ .‬ويستهدف العالج تقليل‬
‫األلم والتورم وتعزيز شفاء األربطة واستعادة وظيفة الكاحل‪ .‬في حاالت اإلصابة‬
‫‪Reassurance‬‬ ‫احلادة‪ ،‬قد ُيحال اُملصاب إلى اختصاصي اإلصابات العضلية الهيكلية مثل جراح‬
‫تقومي العظام أو الطبيب املتخصص في الطب الطبيعي وإعادة التأهيل‪.‬‬
‫‪-PRICE: Protection(functional support e.g. ankle brace for 4-6‬‬
‫‪weeks), rest, ice,‬‬
‫‪Advice‬‬ ‫‪compression, elevation‬‬
‫‪Pt can return to do physical activities and exercises after being‬‬
‫‪asymptomatic‬‬
‫‪Prescribing‬‬ ‫)‪-Analgesia: oral or topical (NSAID‬‬
‫‪-Operative management for particular injuries according to‬‬
‫‪Referral‬‬ ‫‪degree and presence of fractures .‬‬
‫‪-X ray : if bone tenderness at tip of medial malleolus , lateral‬‬
‫‪malleolus, or at base of fifth‬‬
‫‪Investigations‬‬ ‫‪metatarsal or navicular bone , inability to bear weight both‬‬
‫‪immediately after injury and in‬‬
‫)‪the clinic (Ottawa Ankle rules‬‬
‫‪Observation/‬‬ ‫) ‪-Functional rehabilitation (physiotherapy‬‬
‫‪-Consider return to sport/activity phase once current activities‬‬
‫‪follow up‬‬ ‫‪are performed without pain‬‬
‫ميكن أن تساعدك النصائح التالية في الوقاية من التواء الكاحل أو تكرار االلتواء‬
‫قم باإلحماء قبل ممارسة التمارين أو ممارسة الرياضة‪.‬‬ ‫•‬
‫وكن حذًرا عند املشي‪ ،‬أو اجلري أو العمل على سطح غير مستوٍ‪.‬‬ ‫•‬
‫استخدم دعامة أو شريط دعم الكاحل على الكاحل الضعيف أو الذي سبق له اإلصابة‪.‬‬ ‫•‬
‫وقم بارتداء األحذية التي تناسب مقاس قدميك واملصنوعة لتناسب نشاطك‪.‬‬ ‫•‬
‫‪Plan/prevention‬‬ ‫وقلل من ارتداء األحزية عالية الكعب‪.‬‬ ‫•‬
‫وال تقم مبمارسة الرياضة أو املشاركة في األنشطة التي تكون غير مضطر إلي‬ ‫•‬
‫ممارستها‪.‬‬
‫قم باحلفاظ على قوة عضالتك ومرونتها‪.‬‬ ‫•‬
‫قم مبمارسة تدريبات الثبات‪ ،‬مبا في ذلك متارين حتقيق التوازن‪.‬‬ ‫•‬
‫‪Conclusion‬‬ ‫‪Includes Safety netting‬‬

‫‪629‬‬
Dermatology

630
Dermatology
Acne
Pruritus
• Urticaria
• Scabies
• Dermatitis

631
 Acne Hx

Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Identify the complaint: duration, site, onset,
why now? (preparation of social event)
relieving or aggravating factors (exam, stress, menstrual period),
other areas involved, previous attempts for treatment in detail (type,
duration of use, and outcome)
Associated symptoms (DDx)
Analysis of • Hirsutism, weight gain, irregular periods, and infertility (PCOS).
chief • Use of heavy oil-based hair products and cosmetics (Acne
cosmetica)
complain • Spreads with scratching or shaving (folliculitis)
• Obesity, moon face, hirsutism, stria (Cushing syndrome)
Pregnancy and last menstrual period.
Risk Factors PCOS, use of androgens, stress, tobacco smoke
Red Flags: Severe psychological distress, Uncontrolled acne developing
scarring, Nodulo-cystic acne
Medical: irregular periods, PCOS, Cushing syndrome, congenital adrenal
hyperplasia, diabetes mellitus, asthma.
Surgical
Past Hx Allergy
Medication: Use of oral contraceptive pills glucocorticoids, lithium,
phenytoin, isoniazid, or androgens (Drug-induced acne)
Ask about family history of all the following:
• Acne
Family Hx • endocrine abnormalities
• polycystic ovary syndrome
• hirsutism
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

632
 Acne Ex

Vital signs , BMI

Appearance hair distribution, acanthosis nigricans,
General sweating or oily skin, moon face, dorsocervical fat
pad.
Inspection of the face, shoulders, back, upper
arms, and chest looking for:
• Comedonic lesions, including blackheads and/or
whiteheads (mild non-inflammatory acne) or
Special • Papules, pustules, nodules, and/or cysts
(inflammatory acne).
• Post-inflammatory Scarring, Pigmented
macules, Keloid scarring
luteinizing hormone, follicle-stimulating hormone,
Investigations testosterone, HbA1c, and pelvic ultrasound.

CRAPRIOP for Management

hair ‫حب الشباب هو مشكلة جلدية حتدث بسبب انسداد بصيالت الشعر‬
.‫( في اجللد بفعل تراكم الزيوت واخلاليا اجللدية امليتة‬follicles)
Clarification ‫ ليس لها عالقة بالنظافة اواكل‬،‫هي مشكلة شائعة وخاصة بني املراهقني‬
‫ ولكن االكل الغني بالسكر قد‬،‫الشكوالتة او املكسرات او األطعمة الدهنية‬
.‫يزيد املشكلة‬
‫غالبا يخف حب الشباب بشكل تلقائي بعد سن املراهقة وقد يستمر مع‬
Reassurance ‫ يجب التحلي بالصبر وااللتزام باألدوية للحصول علي‬.‫بعض األشخاص‬
‫النتيجة املطلوبة‬
‫ميكن تفادي اإلصابة بحب الشباب او السيطرة عليه باتباع هذه النصائح‬
‫مع االدوية املناسبة‬
‫• استخدام غسول الوجه مرتني يوميا‬
Advice ‫• جتنب املهيجات مثل املكياج واملقشرات‬
‫• استخدام واقي الشمس‬
‫• جتنب حك املنطقة املصابة او الضغط عليها‬
Prescribing Mentioned below

633
Acne
Refer immediately to dermatologist if
• Severe psychological distress
• Uncontrolled acne developing scarring
• Nodulo-cystic acne
Referral • Diagnostic uncertainty
• Patients failing to respond to multiple
therapeutic interventions or to two
adequate courses of antibiotics (12 weeks
each)
Investigations Mentioned above
Observation/
Follow up after 8 weeks
follow up
Opportunistic chance for health education
Plan/prevention (vaccination and screening)
Conclusion Includes Safety netting

634
 Pruritus Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Identify the complaint (what do you mean by pruritus? which part of the body is
involved?)
onset, duration, timing (day or night), site, character, relieving or aggravating
factors (known allergies, any new exposure to soap, perfumes, or food), radiation,
severity (interfering with sleep and daily activity), associated symptoms (skin
changes: describe the rash if any),
Relationship of itching to occupation or exposures to plants, animals, or chemicals.
History of similar attacks before (atopic dermatitis)
Associated symptoms (DDx)
• Respiratory symptoms, diaphoresis, nausea, vomiting, flushing, Hx of
anaphylaxis (anaphylaxis)
• Irritability, sweating, weight loss, and palpitations (hyperthyroidism)
• Depression, dry skin, and weight gain (hypothyroidism)
Analysis of • Headache, pica, hair thinning, and exercise intolerance (iron deficiency
anemia)
chief • Constitutional symptoms of weight loss, fatigue, and night sweats (cancer)
complain • Intermittent weakness, numbness, tingling, and visual disturbances or loss
(multiple sclerosis)
• Steatorrhea, jaundice, and right upper quadrant pain (cholestasis)
• Urinary frequency, excessive thirst, and weight loss (diabetes)
Risk Factors: asthma, eczema, exposure to triggers, dry skin, high BMI, high
anxiety score, and liver disease.
Red Flags
• Weight loss, fatigue, and night sweats: think of (HIV), malignancy (multiple
myeloma, polycythemia, Hodgkin's lymphoma).
• Extremity weakness, numbness, or tingling
• Abdominal pain and jaundice
• Urinary frequency, excessive thirst, and weight loss
Pregnancy
Oral contraceptive pills
Medical: renal disease, cholestatic disorder, cancer being treated with
chemotherapy.
Past Hx Surgical, Allergy
Medication: aspirin, vitamin B, opiates, amphetamine and quinidine.
Family Hx Family members with similar itching and skin symptoms (eg, scabies, pediculosis)
Marital status, History of recent travel.
Psychosocial Smoking: type and frequency, Alcohol
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

635
 Pruritus Ex

Vital signs, BMI

General Appearance (weight loss, jaundiced, alcohol smell)
• Skin Ex (any rash or lesions)
Scabies: Small erythematous or dark papules at one
end of a fine, wavy, slightly scaly line up to 1 cm long
(burrow); possibly on web spaces, belt line, flexor
surfaces, and areolas of women and genitals of men
Urticaria: Evanescent, circumscribed, raised,
erythematous lesions with central pallor
Special Atopic Dermatitis: diffuse erythematous patches and
plaques, papules, vesicles, oozing, crusting.
• Lymph nodes
• Central nervous system Ex
• Thyroid Ex
• Cardiovascular system Ex
• Chest and abdomen Ex

• Complete Blood count to exclude polycythemia

rubra vera.
• Electrolytes and eGFR to exclude renal disease.
• IgE level to exclude allergic conditions.
• Liver function test to exclude chronic liver
disease.
Investigations • HIV screen.
• H pylori infection
• Chest X-ray to exclude malignancy
• Stool analysis to exclude parasitic infestations
• Fecal immunochemical test to exclude
gastrointestinal malignancy.
• Urine examination if there are urinary symptoms

636
 Pruritus
CRAPRIOP for Management
Urticaria
‫ تظهر‬،‫سسي في اجللد‬ ُّ ‫ يحدث بسبب تفاعل حت‬-‫ بالشرى‬- ‫االرتيكاريا هو طفح جلدي يعرف‬ •
Clarification .‫ وقد تكون هذه احلَِّكة شديدًة‬.‫توُّرمات حمراء مرتفعة بعض الشيء ُتسبِّبُ احلَِّكة‬
50% of chronic urticaria are idiopathic •
Reassurance .‫تختفي االعراض من تلقاء نفسها غالبا بعد يوم او يومني‬ •
:‫ميكن تخفيف االعراض باتباع النصائح التالية‬
Advice .‫ ارتداء املالبس الفضفاضة من القطن الناعم‬،‫جتَنَّب املحفزات‬
Acute urticaria with airway involvement
• if anaphylaxis is suspected, airway protection + treat with
epinephrine 0.3-0.5 mg (0.01 mg/kg in children up to 0.3 mg)
intramuscularly in anterolateral thigh every 5-10 minutes as
needed to control symptoms and maintain blood pressure
• diphenhydramine: 10-50 mg intravenously every 4-6 hours when
required, maximum 400 mg/day
• methylprednisolone sodium succinate: 10-40 mg by intravenous
Prescribing infusion initially, followed by 40-120 mg once daily thereafter
Acute urticaria without airway involvement
• Second generation antihistamine
• Such as loratadine: 10 mg orally once daily
• Secondary options
• diphenhydramine: 25-50 mg orally every 4-6 hours when
required
• In severe cases, prednisolone: 0.5 to 1 mg/kg/day orally given in
1-2 divided doses for 5-7 days
consider referral to allergist or dermatologist for patients with any of
the following:
• urticaria associated with anaphylaxis
• suspected immunoglobulin E (IgE)-mediated cause of acute
urticaria if symptoms persist after elimination diet
Referral • acute urticaria with unidentified cause and continued symptoms
after 1-2 weeks of treatment
• acute urticaria not well controlled on antihistamine medication
or symptoms or medication adverse effects that are interfering
with participation in routine activities and impairing quality of life
Investigations Mentioned above
follow-up patients in 2-6 weeks to assess symptoms and treatment
Observation/
response
follow up
Plan/prevention Opportunistic chance for health education (vaccination and screening)
Conclusion Includes Safety netting

637
 ‫‪Pruritus‬‬
‫‪CRAPRIOP for Management‬‬
‫‪Scabies‬‬
‫اجلرب هو مرض جلدي معٍد‪ ،‬يصيب جميع الفئات العمرية‪ ،‬ليس له عالقة بالنظافة‪ ،‬ينتقل‬
‫بسهولة عن طريق االتصال املباشر بجلد الشخص املصاب لفترة طويلة‪ ،‬أو بشكل غير مباشر‬
‫‪Clarification‬‬ ‫عن طريق مشاركة املالبس‪ ،‬املناشف‪ ،‬أو الفراش وغيرها‬
‫يتسبب في حكة شديدة خاصة في الليل وطفح جلدي‬
‫ميكن عالج اجلرب بسهولة عن طريق االدوية التي السوس الذي يسبب اجلرب وبيضه‪ .‬ولكن‬
‫‪Reassurance‬‬ ‫قد تزيد احلكة اول يومني من العالج وقد ال تتوقف احلكة متاًما لعدة أسابيع بعد العالج‪.‬‬
‫ملنع انتقال املرض‪ ،‬يجب عالج جميع األشخاص املخالطني للمصاب حتى وان لم تظهر‬ ‫•‬
‫عليهم االعراض‬
‫• غسل أغطية السرير واملالبس التي مت استخدامها خالل ‪ 3‬أيام قبل العالج‪ ،‬وذلك في‬
‫جهاز غسيل املالبس‪ ،‬وشطفها باملاء الساخن وجتفيفها في درجات حرارة عالية‪.‬‬
‫‪Advice‬‬ ‫• جتنب مشاركة املالبس أو املناشف وغيرها‪.‬‬
‫• املحافظة على تنظيف الغرف جيًدا وتهويتها‪.‬‬
‫• احلرص على وضع املواد غير القابلة للغسل في كيس بالستيكي وتخزينها بعيًدا ملدة‬
‫أسبوع‪.‬‬
‫• االبتعاد عن األماكن املزدحمة‪.‬‬
‫‪Treatment for non-crusted scabies‬‬
‫‪• Topical permethrin 5% apply a thin layer to ALL skin‬‬
‫( ‪surfaces from neck to toes for 8-14 hours then wash off‬‬
‫)‪repeat after 1week if evidence of live mites‬‬
‫‪Secondary option‬‬
‫‪• Ivermectin 200 mcg/kg orally, two doses 14 days apart‬‬
‫‪Prescribing‬‬ ‫‪Treatment for crusted scabies‬‬
‫‪combination of‬‬
‫‪• Ivermectin 200 mcg/kg orally on days 1, 2, 8, 9, and 15,‬‬
‫‪with additional doses on day 22 and 29 for severe cases‬‬
‫‪• either topical permethrin 5% or benzyl benzoate 5% full‬‬
‫‪body application daily for 7 days, then twice weekly until‬‬
‫‪cured‬‬
‫‪Referral‬‬
‫‪Investigations‬‬ ‫‪Mentioned above‬‬
‫‪Observation/‬‬
‫‪follow up after 4 weeks‬‬
‫‪follow up‬‬
‫‪Plan/‬‬ ‫‪Opportunistic chance for health education (vaccination and‬‬
‫‪prevention‬‬ ‫)‪screening‬‬
‫‪Conclusion‬‬ ‫‪Includes Safety netting‬‬

‫‪638‬‬
Pruritus
CRAPRIOP for Management
Dermatitis
.‫التهاب اجللد )اإلكزميا( هي حالة مزمنة من جفاف اجللد تسبب حكة واحمراًرا للبشرة‬
Clarification ‫ لها عدة‬.‫ ولكن ميكن أن يحدث في أي مرحلة عمرية‬،‫غالبا يصيب األطفال الصغار‬
.‫أنواع وميكن أن يصاب الشخص بأكثر من نوع في الوقت نفسه‬
.‫ تخف االعراض عندما يكبر األطفال او تختفي متاما‬،‫في بعض االحيان‬
Reassurance .‫وقد يعاني آخرون من االكزميا مدى احلياة‬
: ‫ناك بعض النصائح التي قد تقي من نوبات التهيج‬
:‫جتنب مسببات االكزميا التالية‬
.(‫ الكرميات‬،‫ بعض األقمشة‬،‫ بعض أنواع الصابون‬:‫• بعض مهيجات اجللد )مثل‬
.‫• الضغوط النفسية‬
Advice ‫ حبوب‬،‫ احليوانات‬،‫ بعض األطعمة‬:‫• املواد التي يتحسس منها املصاب )مثل‬
.(‫اللقاح‬
.‫• جتنب شدة احلرارة وشدة البرودة‬
.‫• احلرص على الترطيب املستمر بكرميات مناسبة وخالية من العطور‬
.‫• جتنب احلكة قدر املستطاع ومعرفة مسبباتها‬
Moisturizer
Antihistamine for pruritis

Allergic contact dermatitis

First line therapy
• hydrocortisone topical: (2.5%) apply sparingly to the
affected area twice daily
Second line therapy
• Tacrolimus topical: (0.03% or 0.1%) apply to the
affected area twice daily (They are not indicated for use
in children <2 years of age)
Prescribing Third line therapy
• Phototherapy

Atopic dermatitis
topical corticosteroids
• use low potency, such as desonide 0.05% gel, cream or
ointment, or foam; or fluocinolone0.01% cream twice
daily for mild atopic dermatitis
• use medium potency, such as betamethasone valerate
0.1% cream or lotion; or fluticasone propionate 0.05%
cream twice daily for moderate atopic dermatitis

639
Pruritus

Secondary options
• tacrolimus ointment (0.03% and 0.1%
Prescribing
strengths) or pimecrolimus cream (1%)
twice daily on flaring areas
Refer to a dermatologist when:
• The diagnosis is unclear to you.
• There is a severe or refractory disease
• The eczema is causing a lot of
psychosocial stress
Referral
• There is eczema on the face that hasn’t
responded to treatment.
• The patient has frequent flare-ups.
• There is widespread bacterial
superinfection or eczema herpeticum.
Investigations Mentioned above
Observation/
follow up
Opportunistic chance for health education
Plan/prevention
(vaccination and screening)
Conclusion Includes Safety netting

640
ENT

641
ENT
Hearing loss
• Cerumen impaction
• Otitis media with effusion
Tinnitus
Audiogram
Tympanogram

642
 Hearing loss Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Allow pt to explain the chief complain
Hx of present Clarify what you understood
illness Patients may or may not be aware that their hearing is decreased. They
may state that their ear feels muffled, blocked, or plugged, or complain
of pressure or the sensation of water in the ear
Course, onset and duration, unilateral or bilateral
SOCRATES for pain
Associated symptoms (DDx)
Fever, ear pain, drainage of fluid from the ear, tinnitus or pulsatile
tinnitus , dizziness, vertigo, facial weakness, or headache.
Risk Factors
External ear:
cleaning their ears with cotton swabs (cerumen impaction)
In children, putting something in the ear
Analysis of local trauma
chief complain Recurrent ear infections
regular immersion in cold water
Middle ear:
(URTI) or aeroplane
strong odour and a history of chronic ear infections
a blow to the head or barotrauma from scuba diving
Inner ear:
exposure to sustained high levels of noise or sudden loud noises
through occupational use of power tools or hobbies
Age
Medical
For example, DM , stroke , SLE and several other conditions
Surgical
Allergy
Medication
Past Hx Aminoglycoside antibiotics, such as gentamicin, azithromycin,
nonsteroidal anti-inflammatory drugs, chemotherapeutic drugs,
antimalarial drugs, and loop diuretics in high dose, can all be ototoxic
Prenatal history in children , especially neonatal jaundice (toxic effects
of high levels of unconjugated bilirubin)
Family Hx FH of hearing loss
Psychosocial Occupation (Loud noises)
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion
643
Hearing loss Ex

Vital signs
General Appearance
To determine whether the cause of hearing loss is
conductive (outer or middle ear) or sensorineural
(inner ear) requires a visual inspection of the outer-
ear canal and tympanic membrane using an
otoscope and performance of tuning fork tests.
Removal of cerumen may be required to
Special adequately examine the ear canal. Any obstructing
hairs or foreign bodies should also be removed to
get a clear view of the tympanic membrane.
Neurological exam :
Focusing on cranial nerves especially V and VII.
Dix-Hallpike maneuver if needed
Head & neck for masses
Following otoscopy and tuning-fork testing, further
investigation will be guided by probable cause.
If a cause has been identified in the outer-ear
canal, such as cerumen or a foreign body, then no
Investigations further investigations may be necessary.
Audiometric testing can be useful to confirm the
degree of hearing loss and whether the hearing
loss is conductive, sensorineural, or mixed.
Further imaging by CT or MRI as indicated

644
 Hearing loss

CRAPRIOP for Management

Cerumen impaction
Depends on dx, for example if due to cerumen impaction :
‫يحدث انسداد األذن الشمعي عند تراكم شمع األذن )الصماخ( داخل األذن أو يصبح صلبًا جًدا لدرجة‬
Clarification .‫جتعل تنظيفه صعبًا‬
،‫ فهو ينظف قناة األذن ويغطيها ويحميها‬.‫شمع األذن مفيد وهو جزء طبيعي من دفاعات اجلسم‬
.‫فتعَلق به األتربة ويُبطِّئ منو البكتيريا‬
‫ ميكن أن يتخذ الطبيب خطوات بسيطة إلزالة الشمع بطريقة‬،‫إذا أصبح انسداد األذن الشمعي مشكلة‬
Reassurance .‫آمنة‬
Never attempt to dig out excessive or hardened earwax with
available items, such as a paper clip, a cotton swab or a hairpin. You
Advice may push the wax farther into your ear and cause serious damage to
the lining of your ear canal or eardrum.
Treatment is by ear irrigation mainly with ear-wax removal agent
(eg. Docusate sodium otic , 1 drop in affected ear)
Performed mainly in primary care. The choice of treatment depends
on the skill, experience, and comfort level of the clinician, as well as
on the patient's history.
Should be avoided in patients with a history of tympanic-membrane
perforation; ear-canal stenosis; prior ear surgery, including canal-
Prescribing wall-down mastoidectomy; an un-cooperative child; external otitis;
or when previous treatment methods are unsuccessful.
This method appears to be safe if low pressures are used and the
stream of water is directed towards the ear canal rather than
towards the tympanic membrane.
Alternatively: prescribe ear-wax removal agent to be used once a day
for a few days if irrigation cannot be done.
Referral If initial irrigation or treatment failed to ENT
Investigations Mentioned above
After treatment, the clinician should re-examine the patient's ear
and document the resolution of the cerumen impaction, and also
inspect the previously non-visualised tympanic membrane.
Patients who have a predilection for cerumen impactions should
Observation/ consider regular follow-up visits to their physician for diagnosis and
follow up treatment of the impaction. The typical time frame is 6 months, but
some patients prefer to wait until they are symptomatic with hearing
loss.

The primary prevention strategy is to encourage patients to avoid

Plan/prevention using cotton-tipped applicators in their ears.
Conclusion Includes Safety netting

645
 Hearing loss

CRAPRIOP for Management

Otitis media with effusion
Depends on dx, for example if due otitis media with effusion :
‫التهاب األذن )يطلق عليه أحيانًا اسم التهاب األذن الوسطى( عدوى ُتصيب األذن الوسطى‬
‫وهي املساحة اململوءة بالهواء التي تقع خلف طبلة األذن وحتتوي على عظام األذن االهتزازية‬
.‫ يكون األطفال أكثر عرضًة لإلصابة بعدوى األذن من البالغني‬.‫الصغيرة‬
‫ فقد يبدأ العالج بالسيطرة على األلم ومراقبة‬،‫نظًرا لزوال التهابات األذن غالبًا دون عالج‬
Clarification ‫ بعض األشخاص‬.‫ ُتستخَدم املضادات احليوية لعالج العدوى‬،‫ وفي بعض األحيان‬.‫املشكلة‬
‫ من املمكن أن يُسبِّب ذلك مشكالت في‬.‫أكثر عرضًة لإلصابة بعدوات متعِّددة في األذن‬
.‫السمع وغيرها من املضاعفات اخلطيرة‬
‫ من احلاالت الشائعة التي حتدث‬،‫ إن فقدان السمع اخلفيف الذي يظهر ويزول‬.‫ضعف السمع‬
‫ قد تؤدي التهابات األذن‬.‫ ولكنه عادًة ما يتحسن بعد شفاء االلتهاب‬،‫مع التهابات األذن‬
. ‫املتكررة أو وجود سائل في األذن الوسطى إلى فقدان سمع أكثر شدة‬
‫ فقد يوصي الطبيب باخلضوع إلجراء طبي‬،‫إذا كان طفلك مصاًبا بحاالت مرضية معينة‬
‫ إذا تكرر إصابة طفلك بأنواع عدوى األذن )التهاب‬.‫لتصريف السائل من األذن الوسطى‬
‫األذن الوسطى املزمن( أو تراكم السوائل املستمر داخل األذن بعد الشفاء من العدوى )التهاب‬
Reassurance .‫ فقد يُوصي طبيب طفلك بهذا اإلجراء‬،(‫األذن الوسطى املصحوب باالنصباب‬
‫يُحِدث اجلّراح ثقبًا صغيًرا في طبلة األذن أثناء إجراء جراحي في العيادة اخلارجية يُسمى بضع‬
.‫ ما يتيح له شفط السائل خارج األذن الوسطى‬،‫الطبلة‬
To prevent recurrent acute otitis media:
1-Advice for prevention of URTI or allergic rhinitis symptoms
Advice 2-prevent exposure to smoking
3-routine immunization
Tympanostomy tubes are appropriate for children six months to
12 years of age who have had bilateral OME for three months
or longer with documented hearing difficulties, or for children
with recurrent AOM who have evidence of middle ear effusion
Prescribing at the time of assessment for tube candidacy. Tubes are not
indicated in children with a single episode of OME of less than
three months' duration, or in children with recurrent AOM who
do not have middle ear effusion in either ear at the time of
assessment for tube candidacy.
Referral ENT referral is indicated
Investigations Mentioned above
Evaluate tympanic membranes at every well-baby clinic visit . If
Observation/ transient effusion is likely, follow-up after 3 months including
follow up screening for language delay.
If complications are suspected, refer to ENT.
Plan/prevention Discussed above
Conclusion Includes Safety netting

646
Hearing loss

HEARING LOSS

647
 Tinnitus Hx
Introduce yourself and establish good rapport ( Name, age and job).
Chief complain (open question)
Hx of present
Allow pt to explain the chief complain
illness Clarify what you understood
Course, onset and duration, unilateral or bilateral
Progressive hearing loss with tinnitus and advancing age suggests
presbycusis.
Worse with chewing
SOCRATES for pain
Associated symptoms (DDx)
Hearing loss
Analysis of Vertigo
Episodic ringing tinnitus, aural fullness, fluctuating hearing loss, and
chief episodic vertigo suggests Meniere's disease.
complain Pulsatile , clicking sounds
History of visual changes, especially when these are accompanied by
headaches, can lead to a diagnosis of arteriovenous fistula (AVF).
Polydipsia/polyuria (DM)
Risk Factors
older age, hearing loss, loud noise exposure, vestibular schwannoma.
Red Flags

Medical
Cranial nerve palsies, cerumen impaction, cholestatoma and many
other illnesses can all cause tinnitis
History of stroke, multiple sclerosis , head trauma
Surgical
Past Hx Allergy
Medication
Aspirin, non-steroidal anti-inflammatory drugs, aminoglycosides,
furosemide, ethacrynic acid, chloroquine, quinine, and cisplatin are
associated with tinnitus.
Family Hx
Marital status
Psychosocial Smoking: type and frequency
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

648
 Tinnitus Ex

Vital signs
General Appearance
Otoscopy
Erythema, perforation, an obstructing mass,
cholesteatoma, or effusion may be seen.
Weber's with the Rinne's test will differentiate
sensorineural from conductive hearing loss.
When the Weber's test lateralises to the affected ear and
Special the Rinne's test demonstrates bone conduction greater
than air conduction, one can usually assume a conductive
hearing loss in that ear.
If significant asymmetrical sensorineural hearing loss is
present, the Weber's test often lateralises to the
unaffected ear and the Rinne's test demonstrates air
conduction greater than bone conduction.
Audiometry
Investigations Hearing loss is the most common cause of tinnitus.

CRAPRIOP for Management

.‫طنني األذن هو أن تشعر برنني أو أي ضوضاء أخرى في إحدى أذنيك أو كلتيهما‬
‫والضوضاء التي تسمعها عندما تكون مصاًبا بطنني األذن ليست ناجتة عن مصدر‬
Clarification ‫ وطنني األذن مشكلة شائعة؛‬.‫خارجي وال يستطيع األشخاص اآلخرون سماعها غالًبا‬
‫ ويكون أكثر شيوعًا بني البالغني‬،‫ من األشخاص‬%20 ‫ إلى‬15 ‫فهو يصيب نحو‬
.‫األكبر سًنا‬
‫ مثل فقدان السمع املرتبط بتقدم العمر أو‬،‫ينتج طنني األذن عادًة بسبب حالة كامنة‬
‫ ويتحسن طنني األذن لدى كثير‬.‫إصابة في األذن أو مشكلة في جهاز الدورة الدموية‬
Reassurance ‫من املصابني عند استخدام عالج السبب الكامن أو استخدام عالجات أخرى تقلل‬
.‫ وبالتالي تقلل الشعور بأعراض طنني األذن‬،‫الضوضاء أو تخفيها‬
Avoidance of excessively noisy environments or use of
adequate ear protection may help to prevent noise-
induced tinnitus.
Patients with tinnitus should avoid medication such as
Advice quinine, furosemide, valproic acid, and non-steroidal anti-
inflammatory drugs unless the benefit that the medication
provides outweighs the tinnitus that the medication may
be causing or worsening

649
 Tinnitus
Known etiology :
Appropriate treatment for the underlying aetiology should be
given as this may resolve tinnitus without further need for any
treatment.
Troublesome tinnitus:
Education about relaxation techniques to decrease anxiety
associated with tinnitus can be provided. Hypnosis or
biofeedback techniques are also sometimes used to reduce
Prescribing anxiety.
In counselling sessions the physician should show an
understanding attitude towards the patient and provide them
with information about the pathophysiology and prognosis of
tinnitus.
Hearing loss on audiogram:
Hearing aids
Associated depression/anxiety :
Antidepressant/anxiolytics
Depends on dx diagnosis
Referral Tinnitus-masking devices, CBT are other treatment modalities
Investigations Mentioned above

Observation/ Audiometry should be performed once a year to evaluate for

asymmetry or progression in hearing loss. If asymmetrical
follow up hearing loss develops, further tests may be required.
Plan/prevention Mentioned in advice section

Conclusion Includes Safety netting

650
Audiogram

651
Tympanogram

By Dr. Ghufran Hariri

652
Ophthalmology

653
Ophthalmology
Red eye
Vision loss

654
 Red eye Hx
Introduce yourself and establish good rapport ( Name, age and job).
Greeting the Patient
Introduction Introduce yourself
Establish relationship with pt: ask name, age and job.
Chief complain (open question)
Hx of present Allow t to explain the chief complain
illness Clarify what you understood
Red Eye :Onset, Course, Duration
Site: one eye, both
Frequency, severity, pt activity at the time, quality of sx
aggravating and reliving factors

Associated symptoms: tearing, Eye discharge and character (watery,

mucoserous, mucopurulent), crusting in the morning, itchiness, eyelid
swelling, burning, sensation of foreign body.
Analysis of
chief complain Red flags: moderate to severe eye pain, proptosis, photophobia,
reduced or impaired vision.

ROS; Respiratory symptoms, constitutional sx

hx of trauma, contact lenses
hx of contact with sick pt
hx of previous episodes
Past ocular hx: previous eye problems , refractive errors, trauma
Past medical hx: DM, HTN, BA, eczema, systemic disease
Past surgical hx (ocular surgery)
Past Hx Allergy hx
Medication hx or grug abuse as marijuana, heroin, ocaine, methamphetamine
Family Hx Family hx of eye disease or autoimmune disease
Marital status and sexual hx
Social: Job/ alcohol /Smoking/ drug abuse/ Family member contact
Psychosocial
or work contact
Screening: depression and anxiety
Ideas: what do you think you might have?
Concerns: is there anything you are worried about?
ICEE
Expectation: is there anything you want me to do for you?
Effect: does this affect your life? How?
Systemic Review
Conclusion

Examination
Vital signs
BMI
General Appearance
HEENT
655
Red eye Ex
Vitals: fever with orbital cellulitis
Visual Acuity: any abnormalities consider referral
IOP: for acute angel glaucoma
Fluorescein stain blue filter to visualize cornea (abrasion, ulcer, injury)
Inspection:
Proptosis : orbital cellulitis
Eyelid margin: crusting, ulceration, masses (stye or chlazion)
Conjunctiva: pattern and distribution of redness, ciliary flush, foreign
bodies, discharge.
Local Sclera redness
Pupil: size, symmetry, reactivity
Iris and cornea: look for white spots, opacity, haziness, Is there hypopyon
or hyphema .
Pupil light reflex: look for Relative Afferent Pupillary Defect (RAPD) due to
retina or optic nerve diseas
EOM: look for ophthalmoplegia with orbital cellulitis
Slit lamp exam
Fundoscopy
Preauricular LN in case of viral etiology
For exclusion:
Investigation conjunctival smear
CBC , blood culture

656
Red eye

657
 Red eye
CRAPRIOP for Management
Clarify the most properly diagnosis and share other
Clarification differential diagnoses with the patient
Conservative approach to self-limiting conditions (like
Reassurance subconjunctival hemorrhage, hordeolum or stye)
counsel infected individuals during period of
contagion to:
- Wash hands frequently with soap and water (not
onlysanitizer)
- Use separate towels
- Avoid close contact with others
- Food handlers, child care workers, and healthcare
Advice workers shouldnot work until eye discharge ceases
Patients with viral conjunctivitis may be contagious for 7- 14 days,
and should avoid sharing personal items exclusion from school for
conjunctivitis is controversial
Exclusion from school recommended in children with
conjunctivitisuntil they are asymptomatic
Return to school or work depends on age of patient,
occupation, andtype and severity of conjunctivitis

Prescribing

658
Red eye

Prescribing

Referral

For exclusion: conjunctival smear CBC , blood

Investigations culture

659
Red eye

Viral conjunctivitis
- Refer if symptoms not resolved after 7-10 days
or if corneal involvement
- Inform patients with adenoviral conjunctivitis that
condition is highly contagious and explain measures to
Observation/ reduce risk of spreading infection to other eye or other
people
follow up
Bacterial conjunctivitis
- Ask patients to return for visit in 3-4 days if no
improvement of symptoms
- Refer if symptoms not improved within 1 week of
treatment
- Prophylactic topical antimicrobials (such as erythromycin ophthalmic
ointment) recommended for all newborns to prevent
ophthalmia neonatorum
Plan/prevention - Prenatal screening and treatment of expectant mother, and
prophylactic treatment at birth, can prevent infectious
conjunctivitis in neonates
Includes Safety netting
Educate the patient about Red flags as moderate to
Conclusion severe eye pain, proptosis, photophobia, reduced or
impaired vision
In case of any to come back or to go to ER

660
Red eye

661
 Vision loss

Causes of acute persistent visual loss by

presentation

Presentation Differential diagnosis

Unilateral Lens dislocation

painless
Vitreous hemorrhage
Acute maculopathy
Retinal detachment
Retinal artery occlusion
Retinal vein occlusion
Ischemic optic neuropathy
Unilateral Corneal abrasion
painful
Keratitis
Acute glaucoma
Hyphema
Endophthalmitis
Anterior uveitis
Optic neuritis
Bilateral Pseudotumor cerebri (variable symptoms)
painless
Metabolic or toxic (hyperglycemia, methanol toxicity)
Homonymous field loss (chiasmal or retrochiasmal
etiology)
Bilateral Keratitis from bilateral exposure (eg, contact lens, UV light,
painful chemical, etc)

662
 Screening &
Immunization

663
Screening & immunization
Periodic health examination
Immunization
Screening (Cancer)
• Breast cancer
• Cervical cancer
• Colorectal cancer

664
Periodic health Ex
Under 6 years

665
Periodic health Ex

6-17 years

666
Periodic health Ex
18-59 years

667
Periodic health Ex
60 years and above

668
 Pediatric immunization

Types of immunity

Active Passive

It happen when exposure to a disease organism It is provided when a person is given

triggers the immune system to produce antibodies to a disease rather than producing
antibodies to that disease. them through his or her own immune system.
Natural immunity Newborn baby
vaccine-induced immunity Antibody-containing blood products
Active immunity is long-lasting, and sometimes life- passive immunity lasts only for a few weeks or
long. months.
Types of vaccination

Live Attenuated vaccines Inactive vaccines

BCG, MMR, Varicella, rotavirus, OPV Whole cell (polio, hepatitis A)

Polysaccharide Vaccines (pneumococcal,
meningococcal) Recombinant Vaccines ( Hep B,
HPV)
toxoids (diphtheria, tetanus)

Administration of vaccination

669
Pediatric immunization

670
Pediatric immunization

671
 Pediatric immunization
Catch up vaccinations
General rules:
- Healthy individuals can receive inactivated vaccines at any time before or after, or at the same time.
- People can receive multiple live vaccines either at the same time or at least 4 weeks apart.
- For some vaccines, catch-up vaccination is not recommended. For example, rotavirus.
- Don’t give other vaccine at site of BCG vaccine for at least 3 months.
- If >1 injection is to be given in the same limb, they must be at least 2.5cm apart
- Avoid Rubbing the site of vaccination because it will lead to more local inflammation.

Vaccine Minimum age for dose 1

Hepatitis B Birth

Rotavirus

DTaP
Hib 6 weeks

Pneumococcal
IPV
Meningococcal 9 months
Varicella
Hepatitis A 12 months
MMR

Influenza vaccine

- CDC recommends everyone 6 months

of age and older get vaccinated every
flu season.
- Children 6 months through 8 years
of age may need 2 doses during a
single flu season.
- Everyone else needs only 1 dose
each flu season.
- 2 doses, separated by at least 4
weeks, for children age 6 months–8
years who have received fewer than
2 influenza vaccine doses .
- 1 dose for children age 6 months–8
years who have received at least 2
influenza vaccine doses before
- 1 dose for all person's age 9 years and
older

672
 Pediatric immunization
Rota vaccine DTaP Hepatitis A
- 5-dose series at 2, 4, 6,
-Maximum age for first dose is
15–18 - 2 dose series (minimum interval: 6
14 weeks, 6 days.
months, 4–6 years months) beginning at age
-Between the 1st to 2nd dose 12 months
4 weeks. - Dose 5 is not necessary
if dose 4 was
-Between the 2nd to 3rd dose
administered at age 4 - Unvaccinated persons through 18
4 weeks.
years or older and at years should complete a 2-dose series
-Maximum age for final
least 6 months after (minimum interval: 6 months).
dose 8 months, 0 days.
dose 3.
Hib PCV13 Varicella
-Minimum Age for first
dose is 6 weeks.
-4 dose series at 2, 4,
-Minimum age for the first dose 6, 12–15 months.
6 weeks
-1 dose for healthy
- Routine dose 2,4,6,15 months children age 24 months or - Minimum age is 12 months
older with any - 2 dose series
-Dose 1 at 7–11 months:
incomplete* PCV13 series.
Administer dose 2 at least 4 -Minimum interval between them is 3
weeks later and dose 3 (final - 1-2 dose interval: months
dose) at 12– 15 months or 8 -4 weeks if the first one -Ensure persons age 7–18 years
weeks after dose 2 given before the age of 12 without evidence of immunity have
-Dose 1 at 12–14 months: months 2-dose series:
Administer dose 2 (final dose) -8 weeks If first dose was
at least 8 weeks after dose 1. given at 12 months or after. -Age 7–12 years: routine interval: 3
months
-Unvaccinated at 15–59 months: - 2-3 dose interval:
1 dose -Age 13 years and older: routine
-4 weeks if current age is interval: 4–8
-Previously unvaccinated younger than 12 months
and previous dose given -The maximum age for use of
children age 60 months or MMRV is 12 years.
older who are not considered at <7 months old.
high risk do not require catch- -8 weeks (as final dose for
up vaccination. healthy children)
if previous dose given
between 7-11
months
Inactivated poliovirus vaccine (IPV) MMR Human papillomavirus vaccination
- 4 dose series at ages 2, 4, 6–18
-2 dose series at 12–15 -HPV vaccination routinely
months, 4–6 years
months, 4–6 years recommended at age 11–12 years
-Minimum interval between -Dose 2 may be
-catch-up HPV vaccination
doses 4 weeks, 4 weeks, 6 administered as early
recommended for all persons
months (minimum age 4 years as 4 weeks after dose
through age 18 years if not
for final dose). 1.
adequately vaccinated.
MCV4
- Minimum age is 9 months -Age 9 through 14 years at initial
-Unvaccinated children
vaccination: 2-dose series with
- (age 9–23 months): and adolescents: 2-dose
minimum interval: 5 months
series at least 4 weeks
- 2-dose series (dose 2 at least
apart -Age 15 years or older at initial
12 weeks after dose 1; dose
2) -The maximum age vaccination: 3- doses minimum
for use of MMR is 12 intervals: 1-2 : 4 weeks / 2-3 : 12
-Children age 2 years or older:
years. weeks / 1-3 : 5 months.
1 dose.

673
 Pediatric immunization

Special vaccinations
Mother with Hep B
- Give both HBIG and hepB vaccine at birth within 12 hours.
- For infants ≤2,000 grams, administer 3 additional doses of vaccine (total of 4 doses)
-If the mother’s HBsAg status is unknown, providers should first attempt to determine the
mother’s status within 7 days.

Prematurity and LBW

-In the majority of cases, preterm infants, regardless of birth weight,

should be vaccinated at the same chronological age.
-The full recommended dose of each vaccine should be used. Divided or
reduced doses are not recommended.

Immunodeficiency

-Have active leukemia or lymphoma, or other generalized malignancy or have

aplastic anemia
- Have received recent chemotherapy or radiotherapy
- Had a solid organ transplant or hematopoietic stem cell transplant less than 2
years ago
-Are taking highly immunosuppressive therapy, including bDMARDs or
tsDMARDs or high-dose corticosteroids
- Have congenital immunodeficiency

Don’t forget the ethical issues

674
Adult immunization

675
 Adult immunization
Influenza
Routine vaccination:
- Persons age 19 years or older: 1 dose Influenza inactivated (IIV)
or Influenza recombinant (RIV) annually .
Special situations:
-Egg allergy, hives only :- you can give any influenza vaccine .
-Egg allergy more severe than hives (e.g., angioedema, respiratory distress):- you can give but
under supervision of health care provider.
LAIV should not be used in following condition :-
1History of severe allergic reaction to any vaccine component (excluding egg) or to a
previous dose of any influenza vaccine.
2 Immunocompromised (including medications and HIV infection).
3 Anatomic or functional asplenia.
4Cochlear
implant. 5-
Pregnancy.
6-Received influenza antiviral medications within the previous 48 hours .
History of Guillain-Barré syndrome within 6 weeks of previous dose of influenza vaccine:
Generally should not be vaccinated unless vaccination benefits outweigh risks for those
at higher risk for severe complications from influenza .
Te t a n u s , d i p h t h e r i a , a n d p e r t u s s i s
Routine vaccination:
- Previously did not receive Tdap at or after age 11 years: 1 dose Tdap, then Td or Tdap every
10 years.
Special situations:
-Pregnancy: 1 dose Tdap during each pregnancy, preferably in gestational weeks 27–36.
-Use of Td or Tdap as tetanus prophylaxis in wound management.

M e a s l e s , mumps, and r u b e l l a
Routine vaccination:
No evidence of immunity to measles, mumps, or rubella: 1 dose
Special situations:
-Pregnancy with no evidence of immunity to rubella: MMR contraindicated during
pregnancy after pregnancy (before discharge from health care facility) 1 dose.
-Nonpregnant women of childbearing age with no evidence of immunity to rubella: 1 dose.
- HIV infection with CD4 count ≥200 cells/μL for at least 6 months and no evidence
of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart;
MMR contraindicated in HIV infection with CD4 count <200 cells/μL.
-Severe immunocompromising conditions: MMR contraindicated
-Health care personnel :
1Born in 1957 or later with no evidence of immunity to measles, mumps, or rubella: 2-
dose series at least 4 weeks apart for measles or mumps or at least 1 dose MMR for rubella.
2Born before 1957 with no evidence of immunity to measles, mumps, or rubella: Consider
2- dose series at least 4 weeks apart for measles or mumps or 1 dose for rubella.

676
 Adult immunization
varicella
Routine vaccination:
No evidence of immunity to varicella:
2-dose series 4–8 weeks apart if previously did not receive varicella-containing vaccine (VAR or MMRV
[measles-mumps-rubella-varicella vaccine] for children); if previously received 1 dose varicella-containing
vaccine, 1 dose at least 4 weeks after first dose .
Special situations:
-Pregnancy with no evidence of immunity to varicella:
VAR contraindicated during pregnancy
After pregnancy (before discharge from health care facility), 1 dose if previously received 1 dose
varicella- containing.
-Health care personnel with no evidence of immunity to varicella:
1 dose if previously received 1 dose varicella-containing vaccine; 2-dose series 4–8 weeks apart if
previously did not receive any varicella-containing vaccine.
-HIV infection with CD4 count ≥200 cells/μL with no evidence of immunity: Vaccination may be
considered (2 doses, administered 3 months apart); VAR contraindicated in HIV infection with CD4
count <200 cells/μL.
Severe immunocompromising conditions:
VAR contraindicated.
Zoster
Routine vaccination:
VAR ZVL RZV
CDC Abbreviation Varicella vaccine Zoster vaccine live Zoster vaccine
recombinant
TYPE LIVE LIVE RECOMBINANT
RECOMMENDED AGE ≥ 12 months ≥ 60 Y ≥ 50 Y
NUMBER OF DOSES 2 1 2
(4-8 weeks apart) (2-6 month apart)
ROUT SubQ SubQ INTRAMASCULAR
Special situations:
-Pregnancy:
ZVL contraindicated
Severe immunocompromising conditions (including HIV infection with CD4 count <200 cells/μL): ZVL
contraindicated
Human papillomavirus
Routine vaccination:
-HPV vaccination recommended for all adults through age 26 years: Special situations:
2- or 3-dose series depending on age at initial vaccination. -Pregnancy through age 26
-Age 27 through 45 years based on shared clinical decision- making: years:
2- or 3-dose series as below . HPV vaccination not
AGE AT INITIAL DOSES NOTE recommended until after
VACCINATION
pregnancy; no intervention
15 years or older 3 8 weeks between 1st and 2nd dose
12 weeks between 2nd and 3rd dose
needed if vaccinated while
Age 9 through 14 years 1 If received 1 dose or 2 doses <5
pregnant; pregnancy testing
month apart not needed before vaccination
Age 9 through 14 years HPV vaccination If received 2 doses at least 5 month
complete apart

677
 Adult immunization

NOTE:
Shared clinical decision-making
Age 65 years and older (immunocompetent): 1 dose PCV13 based on shared clinical decision-
making
If both PCV13 and PPSV23 are to be administered, PCV13 should be
administered first PCV13 and PPSV23 should be administered at least 1
year apart.
PCV13 and PPSV23 should not be administered during the same visit

678
Adult immunization

Hepatitis A Hepatitis B
Routine vaccination: Routine vaccination:
Not at risk but want protection from hepatitis A Not at risk but want protection
(identification of risk factor not required): from hepatitis B
2dose series HepA (Havrix 6–12 months apart or Vaqta 2- or 3-dose series :-
6–18 months apart [minimum interval: 6 months]) - 2 dose series Heplisav-B at least
Or 4 weeks apart.
3dose series HepA-HepB (Twinrix at 0, 1, 6 months - 3 dose series Engerix-B or
[minimum intervals: 4 weeks between doses 1 and 2, 5 Recombivax HB at 0, 1, 6
months between months OR
doses 2 and 3] - 3 dose series HepA-HepB
Special situations: Special situations:
At risk for hepatitis A virus infection: At risk for hepatitis B virus
2-dose series HepA or 3-dose series HepA-HepB: infection :
-Chronic liver disease (e.g., persons with hepatitis B, as before.
hepatitis C, cirrhosis, fatty liver disease, alcoholic liver
disease, autoimmune hepatitis, alanine aminotransferase -Sexual exposure risk
[ALT] or aspartate aminotransferase [AST] level greater than (e.g., sex partners of hepatitis
twice the upper limit of normal). B surface antigen [HBsAg]-
-HIV infection. positive persons; persons
-Men who have sex with men. seeking evaluation or
-Injection drug use. treatment for a sexually
-Travel in countries with high or intermediate endemic transmitted infection; men
hepatitis A. who have sex with men).
-Pregnancy if at risk for infection. -Incarcerated persons .
Haemophilus influenza type b
Recommended vaccination for adults with an additional risk factor or another indication .
-Anatomical or functional asplenia : 1 DOSE if previously did not receive Hib; if elective
splenectomy, 1 dose, preferably at least 14 days before splenectomy
-Hematopoietic stem cell transplant : 3 DOSES 4 weeks apart starting 6–12 months after successful
transplant, regardless of Hib vaccination history .
Meningococcal
MenACWY vaccine:
Adults should receive a MenACWY vaccine if they :-
-Anatomical or functional asplenia (including sickle cell disease), HIV infection, persistent
complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab)use :
2-dose at least 8 weeks apart and revaccinate every 5 years if risk remains .
-Travel in countries with hyperendemic or epidemic meningococcal disease: 1 dose MenACWY
(Menactra, Menveo) and revaccinate every 5 years if risk remains .
- military recruits : 1 dose

679
 Adult immunization
Meningococcal
MenB vaccine:
Based on shared clinical decision-making MenB
-Adults age 16 through 23 years not at risk:
-2 dose series MenB-4C at least 1 month apart Or
-2 dose series MenB-FHbp ar 0, 6 months (oif dose 2 was administered less than 6 months after dose 1

-(if dose 2 was administered less than 6 months after dose 1, administer dose 3 at least 4
months after dose 2) . MenB-4C and MenB-FHbp are not interchangeable (use same product
for all doses in series)
-Adults should receive a MenB vaccine if they:
- Anatomical or functional asplenia (including sickle cell disease), persistent complement
component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use :-
2-dose primary series MenB-4C month apart, or 3-dose primary series MenB-FHbp at 0, 1–2, 6 months 1
dose MenB booster 1 year after primary series and revaccinate every 2–3 years if risk remains.-
Pregnancy: Delay MenB until after pregnancy unless at increased risk and vaccination benefits outweighs
potential risks.
Covid-19
Vaccines to prevent SARS-CoV-2 infection are considered the most promising approach for
curbing the COVID-19 pandemic.
Types of covid 19 vaccine: (used in Saudi Arabia)
Platform Description Covid 19 Another Comment
example example
• Consist of mRNA
• BNT162b2 § mRNA remains in cell
encoding target
(Pfizer- cytoplasm, does not
gene BioNTech enter nucleus, and does
• Once vaccine) not interact with or
mRNA
administered, None integrate into recipient
vaccines • mRNA-1273
mRNA is translated (Moderna DNA.
into target protein, vaccine) § May require low
which elicits temperature storage.
immune response.
§ Ad26.COV2.S
(Janssen/Johnson
& Johnson)
Replication- § ChAdOx1 nCoV- Failure of the vector to
incompetent 19/AZD1222 [Link]/ reproduce could
Viral vector has been (AstraZeneca)
vector MVA-BN-Filo theoretically reduce
engineered not to
vaccines § Gam-COVID-Vac (an Ebola virus potential adverse events
replicate.
Sputnik V vaccine) that could occur with
(Gamaleya replicating vectors
Institute)
§ Ad5-nCoV
(CanSino)

Indication: We recommend COVID-19 vaccination for all individuals aged six months and
older. (UpToDate)
For individuals who are eligible for any COVID-19 vaccine, we suggest an mRNA vaccine
Extensive data supporting the use of mRNA vaccines have accumulated since their availability.

680
 Adult immunization

Pfizer

Moderna

Special situation
Immunocompromised individuals: should undergo COVID-19
vaccination with Additional vaccine dose in the primary series
Pregnant & breast-feeding mothers: recommended
Contraindications and precautions (including allergies):
1. A severe allergic reaction (eg, anaphylaxis) to a previous COVID-19 vaccine
dose
2. A history of thrombosis with thrombocytopenia following an adenoviral
vector COVID-19 vaccine (AstraZeneca) or a history of thrombosis or
thrombocytopenia that is thought to be immune mediated (including
heparin-induced thrombocytopenia)

681
 Hajj counselling
Maintaining personal hygiene, bathing regularly, and washing hands well
by using water and soap, or other disinfectants used for handwashing,
especially after coughing and sneezing. • Using handkerchiefs when
coughing or sneezing by covering the nose and mouth, and then
eliminating them in the trash. In case there are no handkerchiefs at hand,
use the upper arms rather than hands. • Using a face-mask, especially in
crowded places, and changing it every now and then. • In case there are
General no handkerchiefs at hand, use the upper arms, rather than hands, for
advises covering the nose and mouth when coughing or sneezing. • Wash your
hands well, using water and soap, or the hand-sterilizing gel, especially
after bathing, after coughing and sneezing, before eating, and when
coming back to your residence. • Paying close attention to the oral and
dental cleanliness. • Eliminating wastes in the trash. • Changing cloths
with new ones every now and then. • Paying close attention to the
cleanliness of your residence, on a daily basis. • Avoiding spitting on the
floor, since it is a hazardous source of infection.,
When shaving or haircutting, be sure to follow certain health tips and
Shaving instructions to protect yourself against such infectious diseases as
hepatitis (B) and (C) and AIDS
• Wash fruits and vegetables well before eating. • Verify of the expiry
date when buying canned foods and drinks. • Keep away from the
uncovered food, since it is exposed to insects and pollution. • Wash your
Food hands well before and after preparing food. • Wash your hands well
poisoning before and after eating. • Cooked food should be eaten immediately
after cooking, and, when need be, it could be kept in the fridge. • Avoid
storing cooked food in buses for long when moving from on Hajj site to
another. This is one of the major triggers of food poisoning during Hajj.
• Consult your doctor before setting out for Hajj, to assess your health
situation. • Take with you sufficient medications, and keep them
properly. • Take medicines on time. • Adhere to the doctor's instructions,
such as following a certain diet. • Put on the wrist strap (or the
information card), which shows your name, age, disease, the kind of
Chronic treatment, address and contact information. • You'd better tell your
disease fellow pilgrims about your disease and proper medications, so that they
can help you when necessity be. • Avoid making too much effort, and use
patient the Hajj legal concessions (like assigning someone to do the stoning ritual
on your behalf), when the conditions of such concessions are true. •
Head for the nearest health center when necessity be. • For more
information on chronic diseases, check out the chronic diseases section
in the Main Menu.
Coronavirus (COVID-19)
Required Meningococcal meningitis
vaccinations Poliomyelitis
Yellow fever
Recommended
Seasonal Influenza
vaccinations

682
 Hajj counselling

Meningococcal vaccine
Vaccination with ONE of the following vaccines is acceptable:
Quadrivalent (ACYW) polysaccharide vaccine within the last 3 years.
Quadrivalent (ACYW) conjugate vaccine within the last 5 years.

683
 Breast cancer screening

Breast cancer screening

Average-risk women have less than a 15 percent lifetime risk

of developing breast cancer.
• Women aged 40-49 (shared decision)
• 50-74 routine mammography every 2 year Grade B
recommendation.
• For women age 75 and older, we suggest screening only if their life
expectancy is at least 10 years (Grade 2C).
• We suggest not using clinical breast examination (CBE) (Grade 2C)
Moderate-risk women (approximately 15 to 20 percent
lifetime breast cancer risk)
• Include most women with breast cancer in a first-degree
relative but without a known genetic syndrome
• Same recommendation as average risk women.
High-risk women (greater than 20 percent lifetime breast
cancer risk)
• Include those who have a personal history of ovarian, peritoneal,
tubal, or breast cancer; a family history of ovarian, peritoneal, or
tubal cancer or a strong family history of breast cancer.
• BRCA1 or 2 mutations
• refer to a high-risk screening clinic
• Annual MRI with Mammography.

684
 Breast Cancer

Question Ideal Answer

The total number of new cases of breast cancer diagnosed
annually exceeds one million, and expected to reach 1.5
million in 2010 worldwide (WHO)
How It is cancer number 1 among women in SA
important is - The National Cancer Registry Report in 2015 revealed that
the topic breast cancer represented 16.7% of all cancers among
(breast Saudi population, with age specific incidence rate of
cancer)? 11.8/100,000 among adult females
- Frequently diagnosed in younger women in Saudi Arabia.
In fact, breast cancer is the single leading cause of cancer
death for women 20 to 59 years of age.
The survival benefit of early detection with mammography
screening has been demonstrated
- Early detection is widely endorsed by organizations that
issue clinical recommendations for breast cancer care.
How
important is - Early detection and management are cost effective.
the screening - The presentation of breast cancer in SA usually is late and
programs? with advanced disease.

-
Most patients are in the age group of 40 to 50 years and
were predominantly premenopausal. More than 50%
were stage II and III
The USPSTF recommends biennial screening mammography
What is the for women aged 50 to 74 years. Earlier screening and shorted
recommendat duration should be considered for high-risk women.
ion regarding
screening? - Debate and inconclusive evidence to recommend for or
against self-breast exam or clinical breast exam
The mobile - Younger women
units are best - Single women
utilized by - Women with no access to cancer centers
- Remote areas - Underserved populations
whom?

685
Breast Cancer
Question Ideal Answer
• Many women have no access to mammography due to
racial, environmental, financial/ insurance barriers; lack of
education; and, most importantly, lack of encouragement
by a physician.
• A mobile mammography van can increase the breast
Why mobile cancer screening participation.
screening is • A mobile mammography van can erase social and
important? geographic inequalities in screening.
• In a local survey (2015), among 1,135 Saudi women aged
50 years or older, 92% never had mammogram.
• In another local study (2013), among 200 Saudi women,
50% know tow warning signs of breast cancer and less
than 60% know risk factors of breast cancer.
• A positive family history: the presence of a diagnosis of
breast cancer in one or more of the patient’s direct blood
relatives (mother, sister and daughter)
• Oestrogen use (hormone replacement, contraceptive
pills)
• Early menarche: women who started their period before
12 years of age
What are the • Menopausal status: women who had menopause at the
risk factors time of screening, defined as “those who reported an age
for breast at which menopause started”
cancer? • Late parity: women who had their first child after the age
of 30 years (women with nulliparity were defined as
women who did not have any children or who did not
report any pregnancies [term or non-term] at the time of
the study)
• Previous breast surgeries included mastectomy, fine-
needle aspiration, breast reconstruction (implants) and
other surgeries
BI-RADS system:
• Category 1 (negative finding) or
How to • category 2 (benign) - Resume routine screening.
• Category 3 (probably benign) - Diagnostic mammograms
interpret at 6 months, then every 6 to 12 months for 1 to 2 years as
results? appropriate.
• Categories 4 and 5 (suspicious or highly suggestive of
malignancy
686
Breast Cancer

687
 Cervical Cancer
Question Ideal Answer
• In Saudi Arabia, cervical cancer ranks the 9th most common form of
cancer among females aged 15 to 44 years.
• Current estimates indicate that every year 358 women are di-
What is the agnosed with cervical cancer and 179 die from the disease.
incidence of • In 2020, the crude cervical cancer incidence per 100,000 women in
cervical Saudi Arabia was 2.4 and the cervical cancer mortality to incidence
ratio was 0.5 .
cancer in • Human papillomavirus (HPV) is a sexually transmitted virus that has
KSA? been identified as the main cause associated with the occurrence of
cervical cancer.

•Women aged 21 to 65 years:

The USPSTF recommends screening for cervical cancer :
Women younger than 21 years:
The USPSTF recommends against screening for cervical cancer in women
younger than 21 years.
21 to 29 years :
• every 3 years with cervical cytology alone
30 to 65 years :
• every 3 years with cervical cytology alone,
When to • every 5 years with high-risk human papillomavirus (hrHPV) testing
screen for alone,
cervical • Or every 5 years with hrHPV testing in combination with cytology
(cotesting).
cancer ?
• 2020 ACS:
• Age 21‒24: No screening
• Age 25‒65 :
Ø HPV test every 5 years (preferred)
Ø HPV/Pap cotest every 5 years (acceptable)
Ø Pap test every 3 years (acceptable)
Ø Age 65 and older: No screening if a series of prior tests were
normal
Screening Options: There are now three recommended options for
cervical cancer:
ü primary hrHPV testing every 5 years,
What are the ü cervical cytology alone every 3 years, or
recommende ü co-testing with a combination of cytology and hrHPV testing every 5
d screening years
v HPV test and a Pap test are done the same way—by collecting a
tests? sample of cervical cells with a scraper or brush.
*If you are getting a Pap test, the cells will be checked to see if they look
normal.*If you are getting an HPV test, the cells will be tested for HPV.

688
 Cervical Cancer

Question Ideal Answer

• Human papillomavirus (HPV) infection
• Becoming sexually active at a young age (especially younger than
18 years old)
• Having many sexual partners
What are the • Smoking
• human immunodeficiency virus (HIV)
risk factors
• past or current chlamydia infection
for cervical • Long-term use of oral contraceptives
cancer? • Having multiple full-term pregnancies
• Young age at first full-term pregnancy
• Having a family history of cervical cancer
• Exposure to diethylstilbestrol (DES).
• Being overweight
• Cervical cancer is highly preventable and highly curable if caught
early. Nearly all cervical cancers could be prevented by
HPV vaccination, routine cervical cancer screening, and appropriate
follow-up treatment when needed.
What are the
• HPV vaccination is a safe and effective way to help prevent cervical
protective cancer.
factors for • Children ages 11–12 years should get two doses of HPV vaccine,
given 6 to 12 months apart. HPV vaccines can be given starting at
cervical age 9 years.
cancer? • Everyone through age 26 years should get HPV vaccine if they were
not fully vaccinated already.
• HPV vaccination is not recommended for everyone older than age
26 years.
The USPSTF concludes with moderate certainty that the benefits of
screening in women older than 65 years who have had adequate prior
What is the screening and are not otherwise at high risk for cervical cancer do not
risk of outweigh the potential harms.
screening The main risks of cervical screening come from removing abnormal cells
during a colposcopy and not from the screening test itself. Removing
above age 65? abnormal cells can sometimes cause bleeding or an infection, and it can
also affect future pregnancies.
What to
consider if
Patient life expectancy
wish to Medical and surgical conditions
screen above
65?

689
 Colorectal Cancer

Question Ideal Answer

2010 studies:
What is the • The age-standardized rate (ASR) incidence was 9.6/100 000
incidence of • Median age :60 years for men and 55 years for women
colorectal • The overall 5-year survival was 44.6%
cancer in • Distant metastasis was diagnosed in 28.4% of patients at
KSA? the time of presentation
• Rectal cancer represented 41% of all colorectal cancers
When to • Average risk: start at age 45 and stops at age 75
screen for • High risk: start at age 40 years or 10 years before age of
CRC? youngest relative at time of diagnosis
UpToDate
A. Preferred tests: (in the following sequence)
1. Colonoscopy every 10 years:
We advise colonoscopy every 10 years for most patients on
average risk.
(Colonoscopy is recommended as a screening option by many
expert groups, including the USPSTF, ACS, American College of
Physicians (ACP), National Comprehensive Cancer Network (NCCN), and
American Academy of Family Physicians (AAFP), and is in the most highly
recommended tier of tests according to the US Multi society Task Force on
Colorectal Cancer (MSTF))

What are the If Colonoscopy is unavailable or patient is unwilling to do

recommended colonoscopy? (Patients prefer it)
screening tests? 2. Fecal immunochemical testing (FIT) every 1 year
3. FIT-DNA every 3 years
4. CT Colonography (CTC) every 5 year:
CTC is more sensitive than any test other than colonoscopy to
detect adenoma polyps
B. Other tests used
5. Sigmoidoscopy combined -every 10 year with FIT (or
sensitive gFOBT) every 1 year
6. Sigmoidoscopy alone: every 5 to 10 years
7. The sensitive gFOBT: every 1 year
8. Capsule Colonoscopy: every 5 years
NOTE: Decision on which test to choose should be shared
with the patient

690
 Colorectal Cancer
Question Ideal Answer
High risk factors
1. A personal history of colorectal cancer or a diagnosis of
ovarian cancer or uterine cancer
2. A family history of colorectal cancer and /or documented
advanced polyp (first degree relative (FDR) (parent, sibling, or
child) with CRC increases the risk approximately two fold over
that of the general population)
3. A personal history of inflammatory bowel disease
(ulcerative colitis or Crohn’s disease)
4. A confirmed or suspected hereditary colorectal cancer
What are the syndrome, such as familial adenomatous polyposis (FAP) or
Lynch syndrome (hereditary nonpolyposis colon cancer or
risk factors for HNPCC)
Colorectal 5. Adenomatous polyps (adenomas)
cancer? 6. A personal history of getting radiation to the abdomen
(belly) or pelvic area to treat a prior cancer
Other Risk factors
Age: >45
Gender: M>F
Race: Afro-American > white
Obesity
physical inactivity
Diabetes mellitus and insulin resistance
Red and processed meat
Tobacco or Alcohol
Cystic Fibrosis
• Long-term ASA use (>15 years)
• Physical activity
What are the • Diet: high in fiber, fruits & vegetables
• Vitamin B6 (pyridoxine)
protective • Magnesium
factors for Not supported by evidence
colorectal • Calcium and dairy products
cancer? • Folic acid and folate
• Garlic
• Statin

691
 Colorectal Cancer

Question Ideal Answer

What is the Higher adverse event risks, including:
• Perforation during colonoscopy,
risk of
• False-positive results,
screening • Electrolyte disturbances and dehydration during bowel
above age 75? preparation.
What to
consider if Patient life expectancy
wish to Adverse outcome risk.
Medical and surgical conditions
screen above
75?
• Aspirin does not reduce CRC risk in the first 10 years after
Is there any initiating
role for ASA in therapy, but it may reduce incidence with longer use.
prevention? • The use of aspirin is not a substitute for recommended
screening.

Reference:
(SOE) Prof. Mazen Ferwana
(SOE)Dr. Mohammed AlAteeq

692
Appendix-Skills

Folly Catheters
CBC
[Link] blood gases
2. Audiogram
3. Barium studies
4. Bone x-ray
5. Cardiac enzymes
6. Cerebrospinal fluid analysis
7. Chest x-ray
8. Complete blood count
9. Dermatology
10. DEXA scan
11. Electrocardiogram
12. ENT slides
13. Eye slides
14. Family pedigree
Master Data interpretation 15. Growth charts
Dr. Mona Yehia 16. Hepatitis B markers
17. Hormonal profile
18. Lipid profile
19. Liver tests
20. Mammography
21. Pulmonary function tests
22. Renal function tests
23. Semen analysis
24. Serous fluid analysis
25. Stool analysis
26. Synovial fluid analysis
27. Thyroid function tests
28. Tympanogram
29. Urine analysis
30. Vaginal discharge

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 References

• American Academy of Family Physicians AAFP

• American Diabetes Association ADA 2023
• BMJ Best Practice
• Center of Disease Control and Prevention CDC
• DynaMed
• E-Guide Family Medicine (The Essentials 1st Edition)
• Family Medicine For Oral and Clinical By Dr. Rasmah
• Family Medicine OSCE First Aid (Emirate’s book)
• Family Medicine OSCE - Med10
• Family Medicine Residency Resources By Dr. Abdulaziz Bagasi
• Family practice notebook (Application)
• First Aid for FM 3rd Edition
• Master OSCE Exam and Data Interpretation By Dr. Mona Yehia
• National Guideline for Periodic Health Examination
• OSCE Aid
• OSCE Checklist Collection
• OSCE for Medical Final
• Structured Objective Examination (SOE) and Family Medicine OSCE Checklist
By Dr. Mohammed Al Ateeq
• The Eighth joint National Committee JNC8 guidelines
• The Saudi Initiative for Asthma SINA 2021
• U.S. Preventive Service Task Force USPSTF
• UpToDate

‫ﺤﻤﺪك أﺷﻬﺪ أن ﻻ إﻟﻪ إﻻ أﻧﺖ‬Ž‫ ﺳˆﺤﺎﻧﻚ اﻟﻠﻬﻢ و‬،‫ و{ن أﺧﻄﺄﻧﺎ ﻓﻤﻦ اﻧﻔﺴﻨﺎ واﻟﺸ…ﻄﺎن‬y ‫ﻨﺎ ﻓﻤﻦ‬s‫”إن أﺻ‬
"‫اﺳﺘﻐﻔﺮك وأﺗﻮب إﻟ…ﻚ‬

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