Dr.

Rami Abazid

MAGDY ABBAS

BRAIN MAP

FOR

PACES
PREPARED BY:
DR. RAMI ABAZID

1
Dr. Rami Abazid

TO: THE SOUL OF MY PARENTS

TO: Jailan, Diaa,

Mariam and Reham

2
Dr. Rami Abazid

PREFACE

This edition of the brain map for

PACES is basically designed for the
busy dynamic young doctors who
intended to go through the exam.

I hope this will help candidates to

pass with case.

3
Dr. Rami Abazid

ACKNOWLEDGEMENTS

I would like to express my sincere feelings and

thanks to the following people.

Dr. Abdulfatah Arafaa-Medical Consultant in the

Farouk Charity Hospital-Cairo

Dr. Abdulla Hamed Abo Jabal-Consultant in Tropical

Medicine, Embaba Fever Hospital-Cairo

Dr. Mohamed Samer-Senior Cardiologist in Mubarak

Hospital-Kuwait

Dr. Samy Zaki-Professor of Gastroenterology-Al

Azhar University-Cairo
4
Dr. Rami Abazid

ABOUT THE AUTHOR

DR. MAGDY ABBAS

Graduate from Cairo University worked as a

Registrar in Kasr El Aini Hospital (Cairo)
Senior Registrar In Adan University (Kuwait)
Consultant in Embaba Fever Hospital (Cairo)

Participated in many Teaching programmed in

Egypt

5
Dr. Rami Abazid

THE PACES EXAMINATION:

Brief Clinical
Consultation
Communication
10 mins.
Skill
Brief Clinical
20 mins.
Consultation Cardiology
10 mins. 10 mins.

(5) (4)
(3)
(1) (2)
Neurology
Chest History taking 10 mins.
10 mins. 20 mins.
Abdomen
10 mins.

6
Dr. Rami Abazid

STATION I

MAP FOR

ABDOMEN

&

CHEST

7
Dr. Rami Abazid

ABDOMEN CASES

With stigmata of without stigmata of

CLD CLD

Cirrhosis

Hepatomegally hepatosplenomegally Splenomegaly Ascites

Abdominal masses

 I would like to complete my examination

1- Per rectal examination

2- External genitalia
3- Hernia orifices
4- Lymph nodes
5- Urine dipstick
6- BP – T˚ (temperature)

8
Dr. Rami Abazid

CLD

Signs Decompensated D-D Investigation

Signs General
* CBC
Spider Clubbing Ascites * electrolyte complications
Naevi Arms leuconychia
Fistula Hands Palmer erythma Assess
Dupuytrens Jaundice Liver & FP
Contracture Function
Hepatic Encephalopathy -S. Bil. U/S
Flap -S. Alb
. -PT
-ALT Search
-AST for the
Parotid cause
Swelling
Jaundice
Wasting Face
Pallor Spider
Anthelasma Naevi
Chest reduced axillary hair hepatitis H.chr. Wilson
Gynaecomastia C. B.
Alcohol PBC Virdogy
Shrunken Drugs Study
Liver
Hepatomegaly AIH Alpha 1,AT Auto Immune Iron
Splenomegaly Abdomen Study Study
Ascites
venous
Hum ---L.L. oedema Metabolic Wilson
Alpha1 AT

Caput Medusa -Testicular Atrophy

9
Dr. Rami Abazid

COMPLICATION
OF
CIRRHOSIS

Portal hypertension Hepato Cellular Dysfunction

Varices Ascites hepato Encephalopathy Hepato

Renal cellular
Syndrome carcinoma

Coagulopathy
Bleeding Spontaneous
Bacterial
Peritonitis

10
Dr. Rami Abazid

POOR PROGNOSTIC FACTORS

IN
LIVER CIRRHOSIS

Encephalopathy Na Albumin PT ↑
< 120 ↓ 25g/L

FACTORS PRECIPITATE HEPATIC ENCEPHALOPATHY

Infection Diuretics Electrolyte Sedative Surgery

Diarrhea Imbalance

Vomiting Paracentesis

GI Bleeding

11
Dr. Rami Abazid

TREATMENT OF ASCITES
IN

CLD

Salt restriction Furosemide Serial

to <29/day up to Paracentesis
Rest (Dietician) 120mg/day
Fluid
Spirino Lactone Restriction
Na excretion >78 If Na is < 125mmol/L
mmol/day
up to 400mg/day

TIPS
Transjugular
Intra hepatic
Portal systemic
Shunt

(Aim: one KG weight loss/day)

12
Dr. Rami Abazid

PRIMARY PREVENTION OF VARICEAL BLEEDING

DIAGNOSIS OF CIRRHOSIS

OGD

No varices Grade I Varices Grade 2 or 3 varices

Repeat OGD repeat OGD one year Propranolol

3-4 years 80-160mg/day

HR60
Band ligation if
Propranolol intolerant
or Verapamil
Diltiazem
MANAGEMENT OF VARICEAL BLEEDING
IN CIRRHOSIS

TIPS
Blood transfusion Octreotide Endoscopic Endoscopic Balloon
Sclerotherapy ligation Tamponade

13
Dr. Rami Abazid

HEPATOMEGALY

3 “C” 3 “I”

1-Cirrhosis 1-Infection

2-Cardiac CCF -HBU

3-Cancer -HCU

-T.B.

-Brucella

2-Infiltrative

-Amyloid

-Sarcoid

-Myeloproliferative

3-Immune

-AIH

-PBC

14
Dr. Rami Abazid

SPLENOMEGALLY

Mild Moderate Massive

<4 cm (4-8 cm)

INFECTIONS -Infections

EBU -Myeloproliferative Kala Azar

Infective Endocarditis -Lymph proliferative Malaria

Hepatitis -Hemolytic anaemia Bulhorzia

AUTO IMMUNE - Infiltration -Myeloproliferative

Rh. Arthritis Gaucher’s CML

Infiltration Amyloidosis Myelofibrosis

Sarcoid

15
Dr. Rami Abazid

MOST COMMON CAUSES OF ASCITES

Pancreatitis

Cirrhosis Malignancy Heart Failure Tuberculosis

TRANSUDATIVE OR EXUDATIVE

S-A ALBUMIN GRADIENT

↑ 11 g/L ↓ 11 g/L

Transudative Exudative

MYXAEDEMA MAG’s SYNDROME

CLD CHC CRF MALIGNANCY T.B. INFECTION

16
Dr. Rami Abazid

RENAL ANGLE MASS

Polycystic Renal Cell Hydronephrosis

Carcinoma Adrenal mass

Retroperitoneal
Mass

WHY RENAL MASS

Can get Minimal Resonant to

Above it Ballottable No movement with Percussion
Notch inspiration

17
Dr. Rami Abazid

SURGICAL INTERVENTION IN
POLYCYSTIC KIDNEY

Massive Recurrent Transplant Recurrent Possible

Cysts Pain work up Infected Malignancy
Cysts

ASSOCIATED INHERITED CONDITION

WITH RENAL CYSTIC DISEASE

Autosomal
Tuberous Von-Hippel Autosomal recessive
Sclerosis Lindou disease dominant polycystic Polycystic
Kidney Kidney

18
Dr. Rami Abazid

CHEST CASES

19
Dr. Rami Abazid

INTERSTITIAL LUNG DISEASE

Dry S.O.B. Fine Endispiratory

Cough Crackles

CAUSES

TIP
Rheumatological
- Rh. Arthritis Vasculitis
- S.L.E. - PAN
- Systemic Sclerosis -Wegner’s Pneumocomosis
- Polymyositis -Churg-Strauss -Asbestosis Drugs
- Dermatomyositis -Good Pastures Silicosis Amiodarone
- Ankylosing Spondilitis -Beryliosis Nitrofurnatone
- MCTD Busulphan
- Sjogren’s Syndrome Bleomycine
Allergic Gold
Radiation Methotraxte
OTHERS
Extrinsic Gaucher’s
Allergic Lymphangiomyelomatosis
Alveolitis Niemann Pick
NF
Tuberous Sclerosis

20
Dr. Rami Abazid

IDIOPATHIC INTERSTITIAL PNEUMONIA

TIP

N D A R U C Linda

Usual lymphoid
Interstitial Interstitial
Pneumonia Pneumonia
(UIP) (LIP)
Non Specific
Interstitial Desefuamative Respiratory Cryptogenic
Pneumonia Interstitial Bronchiolitis organizing
(HSIP) Pneumonia Interstitial Pneumonia
(DIP) Lung disease (COP)
(RB-ILD)

Acute Interstitial
Pneumonia
(AIP)

21
Dr. Rami Abazid

INVESTIGATIONS OF ILD

Lab. Radiology Respiratory

-FBC better for
-Inflammatory markers upper lobe
-immunoglobulin
-autoimmune profile CXR HRCT MRI
ANA Pul. Function lung
ENA Test biopsy
ANCA restrictive
Anti G-BM pattern
Reticular Coarse Ground
Shadowing reticular glass BAL
-Precipitins
-Serum ACE
-ABG Honey combing neutrophils lymphocytes

Not responded
To cortisone
Good response
To corticosteroid
Bad prognosis Good prognosis

Respond to
Corticosteroid

22
Dr. Rami Abazid

MANAGEMENT OF ILD

Non Pharmacological Lung Transportation

Smoke Avoid exposure long term corticosteroids Young Patent

Cessation to toxic oxygen + rapidly
Substance Azathoprine progressive
Disease

If not tolerate
Corticosteroids if not tolerate
Azathoprine alone Azathoprine
Cyclophosphamide
Discontinuation
Of toxic medication

23
Dr. Rami Abazid

UNILATERAL LUNG FIBROSIS

EXAMINATION

Flattening of
The affected side
Heterogenous Breath sounds trachea is
percussion of reduced shifted to
the affected + the affected
side coarse crackles side
not changed with
cough
+
VR
on the affected side
Reduced movement
Of the affected side

24
Dr. Rami Abazid

CAUSES OF APICAL FIBROSIS

Histoplasmosis
Old T.B. Radiation Ankylosing
Spondolitis Sarcoidosis

Extrinsic allergic
Alveolitis

CAUSES OF BASAL FIBROSIS

ILD

Aspiration Asbestosis Drugs Connective

Tissue disease

25
Dr. Rami Abazid

PLEURAL EFFUSION

Chest expansion breath sounds

On the affected side ± bronchial breathing
Above the effusion

Stony dullness on
Percussion

PLEURAL EFFUSION

Exudates Pl. Protein between Transudates

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

Lights criteria
For exudates

26
Dr. Rami Abazid

PLEURAL EFFUSION
Exudates Transudates

Protein >35g/L between Protein <25g/L

25g/L – 25g/L
Light’s criteria for
Exudates
Meg’s
Syndrome
Cardiac
Failure CLD
Infiltration
(neoplasm) CRD

infections Inflammation
Rh. arthritis
SLE

Infarction P.E. Pl. Fluid LDH 2/3 of

serum LDH
Protein/Serum Protein >0.5

Pl. Fluid LDH

DRUGS
Serum LDH >0.6

Amiodorone Phenytoin

Methotrexate

27
Dr. Rami Abazid

PNEUMONECTOMY

Chest wall

Chest expansion Trachea

Scar Flattering of the
Affected side
Absent on Grossly deviated
The affected side to the affected side

Breath sounds
absent on
the affected side

LOBECTOMY
Scar

Chest wall Chest expansion Trachea Breath sounds

localized reduced on the deviated to the reduced on the

Deformity affected lobe affected lobe affected lobe
On upp.lobectomy

28
Dr. Rami Abazid

LUNG CONSOLIDATION

Chest wall Chest expansion Trachea Percussion

normal
Reduced not shifted dullness
Except if associated
Collapse

Breath
Sounds

CAUSES
Bronchial
breathing
±

crepitations

Infection Vasculitis malignancy Cysts

Vocal
Infarction resonance

Granuloma

29
Dr. Rami Abazid

BRONCHIECTASIS
Irreversible dilatation, destruction and Inflammation
of the Bronchial wall
Examination

Excessive ±
Productive finger clubbing Coarse Inspiratory
Cough Crepitations which
Alter with coughing

CAUSES

T.B. Malignancy
CONGENITAL CHILDHOOD INFECTION
- Immotile -measles
- Cilliary syndrome -Pertussis Foreign
- Kartagner’s syndrome Body
- Young syndrome
C.F. -Post Pneumonia Immune deficiency
(Staph., Klibsella) - hypogan maglobulnoia
-Allergic Aspergillosis

30
Dr. Rami Abazid

BRONCHIECTASIS
Investigations

Lab Radiology Special

-Sputum CLS
-Sputum AFB
-Sputum gram stain CXR HRCT Bronchoscopy
-Immunoglobulins for malignancy
-Rheumatology profile
-Na Sweat Test
-Genetic Screening for C.F. Tranlines shadows Signet ring sign
Ring shadows Thickened dilated
Bronchi Larger than
Vascular bundle

31
Dr. Rami Abazid

BRONCHIECTASIS MANAGEMENT

Non Pharmacological Medical

-Stop smoking
-Pulmonary Rehabilitation Vaccination Surgery
-Multi-disciplinary -annual Influenza for localized
Management -H. influenza -Antibiotic disease
-Pneumococcal for exacerbation
-long term antibiotic
-bronchodilators
-Inhaled corticosteroid

32
Dr. Rami Abazid

OBSTRUCTIVE AIRWAY DISEASES

Chronic Asthma Chronic

Obstructive
airway disease
COAD

Reversible Cause Chronic Emphysema

Bronchitis

Diurnal
Variation Smoking

Irreversible No Cause
Diunal
variation Pollution

33
Dr. Rami Abazid

INVESTIGATIONS OF OBSTRUCTIVE
LUNG DISEASE

Lab.
Others

-FBC Radiology E.C.G.

-urea Electrolytes
-LFT -CXR -Rt. ventricles
Hypertrophy
-Inflammatory marker’s -HRCT -P. Pulmonale
-S. & antitypsis for emphysemia
-ABG -Echo

-Sputum -RFT
CLS (Spirometry)
gram
Stain

34
Dr. Rami Abazid

MANAGEMENT OF OBSTRUCTIVE
AIR WAY DISEASE

Non pharmacological Vaccination Pharmacological

-Stop smoking
-Pul. Rehabilitation
Annual H. Influenza Pneumococcal
Influenza Pneumonia
Vaccine

Bronchial Asthma

COAD

B2 against or LABA LABA

Anticholinegic + +
SABA inhaled inhaled
Or SAMA corticostriods +
Theophylline
35
Dr. Rami Abazid

BRITISH THORACIC SOCIETY GUIDELINES

STEP 1 STEP 2 STEP 5 =step 4

Add beclomethasone +
100-400 ug/12h -oral Prednisolone

Occasional
Short acting
Inhaled B2 against STEP STEP 4
+ 3
-LABA -Beclomethasone to 1000 ug/12h
- dose of ± oral Theophylline
Beclomethasone ± oral leukotrene antagonist
To 400ug/12h
If > than once daily ± oral B2 against
Or night –Time symptoms ± oral leukotrene receptor
± oral Theophylline

STEP 2

36
Dr. Rami Abazid

STATION 3

MAP FOR

CARDIOLOGY

NEUROLOGY

37
Dr. Rami Abazid

CARDIOLOGY EXAMINATION

Non Auscultatory Auscultatory

Rt. A.S.

Carotid
Thrill
Pulse

Lf. P.S.
Both
Radial

AF JVP
or not
-small pulse
Or
-Big pulse volume
-Average

Collapsing
Water V Wave w/
Hammer Carotid TR
Or not

38
Dr. Rami Abazid

AUSCULTATORY
APEX
Axilla 2nd Rt. Intercostal 3rd left intercostals space
Soft Pansystolic space while patient leans forward
Murmur -1st H.S. after expiration early
MR ejection systolic diastolic murmur
Murmur A.S.
H.S. Murmurs
Lower left A.R.
nd
Sternal edge 2 left
TR (↑ Insp.) intercostal

4th H.S. Left sternal Carotid

Near the 1st H.S. edge R A.S.
V.S.D. L P.S.
2nd H.S. opening A.S.D. 2nd H.S.
snap near it fixed splitting
2nd H.S.
HOCM
valsalvis
1st H.S.
P. HTN

normal M.R. A.S.

P.S.

M.S.

39
Dr. Rami Abazid

AORTIC STENOSIS
A.S.

Symptoms Non Auscultatory Auscultatory

Findings

Ejection systolic
Murmur ↑ with
Expiration radiate to
neck
Dyspnoea Syncope -small pulse
Volume Apex
heaving
-Slow Rising
Chest pain Pulse
-Narrow Pulse
Pressure Systolic thrill in
Aortic area

SIGNS OF SEVERITY
Pul. HTN

Pul.
congestion

Slow-rising pulse
Small Pulse volume
Narrow Pulse Pressure Heaving Systolic Soft 2nd 4th H.S. Long
Apex Thrill heart sound murmurs
A2

40
Dr. Rami Abazid

Bicuspid Congenital Rheumatic Degenerative

Indications for Aortic

Valve replacement

41
Dr. Rami Abazid

AORTIC REGURGITATION A.R.

SYMPTOMS NON AUSCULTATORY AUSCULTATORY

FINDINGS FINDINGS

SIGNS OF SEVERITY

Long duration of
The murmur Austin Flint murmur P.HTN

Wide Pulse 3rd H.S.

Pressure

42
Dr. Rami Abazid

A.R.

CAUSES INDICATION FOR SURGERY

43
Dr. Rami Abazid

MITRAL STENOSIS

SYMPTOMS NON AUSCULTATORY AUSCULTATORY

↑↑

44
Dr. Rami Abazid

M.S.

COMPLICATION DD SIGNS OF SEVERITY

Left Atrial myxoma Clinical Echo

Austin-flint murmur

INDICATION OF SURGERY

Pul. Pul. Recurrent

Congestion HTN thromboembolic
Events despite
Anticoagulation

Haemoptysis

45
Dr. Rami Abazid

MITRAL REGURGITATION

Symptoms Non Auscultatory Auscultatory

1st H.S. ± S3

Pan-systolic murmur
soft and radiating
to axilla

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

CAUSES INDICATIONS FOR SURGERY

Acute Chronic Symptomatic Asymptomatic

Despite optimum
Prolapse Medical therapy LVEF LVES D
Rupture MI NYAH III-IV ↓ 60% ↑ 45mm
Rheumatic Functional EF~35-50%

3 act. Endocarditis

Connective tissue
Disease

46
Dr. Rami Abazid

SOME CONGENITAL ANOMALY

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

On Pulmonary at the lower

area sternal edge
Coarctation Thrill left
of Aorta Inter-space
Thrill fixed splitting
2nd H.S. thrill at machinery
Lower sterna murmurs
Ejection systolic Edge loudest below
Murmur left clavicle
Ejection systolic
Murmur ↑ valsalvi
Systolic Pansystolic
thrill murmur

no radiation

Fallots
continuous
V.S.D. Rt. vent. Pul. Stenosis radiofemoral murmur radiating
Hypertrophy delay to back

47
Dr. Rami Abazid

48
Dr. Rami Abazid

49