ADA Criteria for DM Dx.

1. HbA1c 6.5%. 2. FBS 126 mg/dL (7.0 mmol/L). 3. 2-h OGTT 200 mg/dL. 4. Random BS >200 mg/dL in the presence of symptoms (3P's). Sx. of hypoglycemic attack: 1. Confusion/ LOC. 2. Headache. 3. Tachycardia. 4. Sweatiness/shakiness. --> pt should carry a hard candy or glucose gel to take immediately. Our Targets for Optimal DM(2) Control: 1. FBS 70-130 mg/dL // 2hrs postprandial <=180 2. HbA1c <7% 3. BP<= 130/80 4. Lipids (LDL<100, TG<150, HDL>40) mg/dL. Red Flags of chest pain: 1.SOB. 2. Sx. of hypoperfusion. 3. Abnormal vitals. 4. Asymmetric heart sounds or pulses. 5. New murmurs. 6. Pulsus paradoxus. Life-threatening causes of chest pain: "[PAPPA]"

P: Pericarditis. A: Acute MI. P: Pneumothorax. P: PE A: Aortic Dissection. Management of acute MI: "[MONALISA]" M: Morphine or Pethidine + anti-emetic. O: O2, if hypoxic. N: Nitroglycerin. A: Aspirin. L: Lazix, if CHF. I: Inotropes, if cardiogenic shock (digoxin, dobutamin, epinephrine, ...). S: Streptokinase. A: Anti-coagulation. C/I of thrombolysis: 1. Bleeding (internal, heavy vaginal). 2. Esophageal varies. 3. Recent hemorrhagic stroke. 4. Suspected aortic dissection. 5. Severe HTN. 6. Pregnancy. 7. cerebral neoplasm. 8. Prolonged or traumatic CPR, recent head trauma, recent trauma or surgery.

9. Acute pacreatitis, severe liver dis., active lung dis. with cavitation. 10. Previous allergic rxn. Sx. of Hyper-dynamic circulation: 1. Tachycardia. 2. Cardiac enlargement. 3. Ejection systolic murmur. Blood film findings in varois types of anemia: * IDA: 1- Hypochromic Microcytic. 2- Target cells. 3- Poikilocytosis. 4- Anisocytosis. * Thalassemia: 1- Target cells. 2- Anisocytosis. * Megaloblastic (Vit.B12 def.or folate def.): 1- Macroovalocytes. 2- Hypersegmented neutrophiles. 3- Poikilocytosis. 4- Anisocytosis. * G6PD def. anemia: (Normo- OR Macro-)cytic 1- Bite cells. 2- Heinz Bodies. & decreased levels of G6PD.

Red Flags of epigastric pain: 1. Age>55. 2. Projectile vomiting. 3. Hematemesis or melena. 4. wt. loss. Alerting Sx. of dyspepsia: +add to them: 5. severe pain in RUQ or sudden severe abdo.pain. 6. anemia, jaundice. 7. Possible MI (jaw, chest, back - pain & sweating & anxiety). 8. Family or personal Hx. of CA. 9. progressive dysphagia or odynophagia. 10. fever, palpable abdo.mass or lymphadenopathy. Red Flags in GERD: 1. Dysphagia & odynophagia. 2. wt.loss. 3. Jaundice. 4. Vomiting. 5. Palpable mass. 6. occult bleeding. 7. Family Hx. of GI CA. According to AGA, the most common organic causes of dyspepsis are: 1. GERD. 2. PUD. 3. Gastric CA. Every gastric ulcer should be biopsied to R/O CA

Sx. of gastric CA: "[weapon]" W: Wt.loss. E: Emesis. A: Anorexia. P: Pain or discomfort (epigastric). O: Obstruction. N: Nausea. ROME II criteria to Dx. Functional Dyspepsia: - at least 12 wks (not necessarily consecutive) in the last 1 yr: 1. persistent or recurrent dyspepsia. 2. no evidence of organic cause. 3. Not IBS. ROME III criteria to Dx. IBS: 1. relieved by defecation. 2. change in stool form or frequency. 3. abdo. distension. 4. passage of mucus. 5. sense of incomplete evacuation. BiRad score of mamogram: 0= need further assessment. 1= negative. 2= benign. 3= probably benign. 4= suspicious abnormality.

5= highly suspicious malignancy. 6= proven malignancy. Most common cause of bloody nipple discharge >> Intra-ductal Papilloma. Red Flags of Red Eye: 1. Foreign body sensation. 2. Blurred vision. 3. Photophobia. 4. Eye pain with/without eye movement. 5. If pt can't move the eye Notes about Periodic Health Evaluation (Screening): 1. DM2: start at 45 YO ,,, every 3 yrs ,,, by FBS. 2. HTN: start at 18 YO ,,, every 2 yrs ,,, by measuring BP (every year if preHTN). 3. Hypercholestrolemia: start at 45 YO if female/35 YO if male ,,, every 5 yrs ,,, by fasting lipid profile. 4. Osteoporosis: start at 65 YO if female/70 YO if male ,,, every 5 yrs ,,, by DEXA scan. 5. Colon CA: start at 50 YO ,,, every 5 yrs (by sigmoidoscopy) OR every 10 yrs (by colonoscopy). 6. Breast CA: start at 40 YO ,,, every 1-2 yrs ,,, by mamography & every 2 yrs after age of 50.

7. Prostate CA: start at 50 YO (or at 45 YO if high risk) ,,, every 1 year ,,, by PSA+ digital exam. 8. Cervical CA: start at 21 YO (for sexually active) ,,, every 3 yrs until 30 YO then every year ,,, by Pap smear. 9. do CBC for screening, for adults, once! * Always start before, if there're risk factors. * Stop Prostate CA screeing at age of 70. * Stop Cervical CA screening at age of 65 (if the last 3 are normal). Red Flags of Headache (H/A): 1. Onset >50 YO. 2. Hx. of significant trauma. 3. Sudden severe. 4. Progressively worsen. 5. Systemic Sx. (wt.loss, fever, rash, ...). 6. Neuro. Sx. (seizures, diplopia, mental state change, ... ). 7. Triggered by cough, exertion, valsalva. 8. Pregnancy or postpartum. 9. New H/A in CA or HIV pt. 10. Severe, Unresponsive to tt. 11. BP>200/130 12. Sx. of temporal arteritis (visual disturbance, temporal art. tenderness, fever, wt.loss, jaw claudication, proximal myalgias Gastric pseudo-lymphoma is a side-effect of >> Phenytoin. Causes of fatigue .. remember the word FATIGUED *Failure (CHF)

*Anemia *Tumors (like leukemia) *Infections( hepatitis , TB , infectious mono) *GI causes (like malnutrition) *Uremia *Endocrine (DM, Hypothyroid, hyperparathyroid..) *Depression (also anxiety as a psychological cause) S/E of Nsaid Nausea/Vomiting Dyspepsia Gastric ulceration/bleeding. Diarrhea erectile dysfunction increase the risk of myocardial infarction and stroke Salt and fluid retention Hypertension (high blood pressure) Photosensitivity raised liver enzymes, headache, dizziness investigations for newly diagnosed hypertensive pt: CBC as a baseline. Fasting bloog sugar. KFT, U/A. Lipid profile. TSH. investigations for newly diagnosed DM: CBC, HA1c, lipid profile, KFT.

U/A, FUNDOSCOPY. Red Flags of back pain: "[BACK PAIN]" B: Bowel or bladder dysfunction. A: Anesthesia (Saddle). C: Constitutional Sx./malignancy. K: Chronic disease (7sab el no6o8 :P). P: Parasthesias. A: Age >50 & minor trauma. I: IV drug use. N: Neuromotor deficit. Indications for lumbar spine X-ray: no improvement after 1 month fever >38C unexplained wt loss prolonged corticosteroid use significant trauma progressive neuromotor deficit suspicion of ankylosing spondylitis history of cancer (R/O mets) alcohol/ drug abuse (increased risk of osteomyelitis, trauma, fracture). The most effective drug in lowering LDL is statin. The most effective drug in lowering TG is fibric acid or niacin. The most effective drug in increasing HDL is niacin.

DM only elevates TG , lowers HDL --- no effect on LDL nephrotic syndrome elevates tolat cholesterol and LDL , no effect on HDL , TG The most specific symptom of UTI >> Urgency Cough with pink frothy sputum >> distinctive Sx. for pulmonary edema. The 1st & most reliable symptom of PE >> Tachycardia. the most specific symptom for GERD heartburn anf for IBS flatulence Metformen in DM tt: * Good effects: 1. don't cause hypoglycemia. 2. dec. wt. 3. dec. all causes of mortality & morbidity in DM pt. 4. has +ve effect on heart. * S/E: 1. GI upset. 2. Lactic acidosis (rare, but fatal!). * C/I: 1. renal insufficiency. 2. CHF. Causes of treatable dementia: 1. Hypothyroidism. 2. Vit.B12 def. 3. Sub-dural hematoma carpopedal spasm caused by HYPOcalcemia - Trousseau sign

IHD and DM ---> tertiary prevention HTN --- > secondary prevention ACE C/I: 1. Bilateral RAS (renal art. stenosis). 2. Female in reproductive age group >> Teratogenic (so stop it if she wants to be pregnant). the most common causes of fatigue : 1- depression (40%) 2-DM 3-acute infection : Hepatitis , flu 4-adjustment reactions Ketone Bodies: 3 types: 1. Acetone. 2. Acetoacetic acid. 3. Beta-hydroxybuteric acid ((NOT detected by dipstick)). in GE : we give antibiotics in : shigella , clorea , C.defficile , enteoinvasive e.coli in salmonella only if : immunocompromised , < 3 months , bacteremia , suppurative complications DDx. of BILATERL milky discharge: 1. physiological. 2. HypOthyroidism. 3. HypeRprolactinemia 4. Drugs: (cimitidine, antiemetics, antipsychotics, ...).

Immunization >> primary prevention. Screening >> secondary prevention. Median age of breast CA detection in Jordan = 51 yrs CCB S/E: 1. Constipation. 2. Flushing. 3. Peripheral Edema. Cardio-protective Drugs (Y3ni post-MI & HF): 1. Aspirin (increases survival in HF). 2. selective BB. 3. ACEI. 4. Statins. Sub-Clinical HypOthyroidism: - elevated TSH + Normal T3 &T4. - if TSH >10 ... give tt (thyroxine). - if TSH <10 ... test for anti-thyroid peroxidase Ab.s ,,, if +ve ... give tt. * Normal TSH = roughly (0.4 - 4). In tt of HTN: - start with CCB >> if pt is black OR >55 YO. - start with ACEI >> if pt <55 YO. Diseases with hypOkalemia:

- Conn's synd. - Cushing's synd. - DKA. Strep. Score (McIsaac Criteria): - fever>38C. - absecnce of cough. - lymphadenopathy. - exudates. - age <15 >> hadool kol w7deh feehom bta5od (+1) but if age (15-45) ... bta5od zero // age > or = 45 ... bta5ood (-1) if the result is: 0-1: symptomatic tt. 2-3: do Ag. test: (if +ve >>treat strep.) (if -ve >> do culture). >> if CULTURE is (+ve >> treat strep.) (if CULTURE is -ve symptomatic tt.). 4-5: treat strep. strep throat score: One point is given for each of the criteria: Absence of a cough Swollen and tender cervical lymph nodes Temperature >38.0 C Tonsillar exudate or swelling Age less than 15 (a point is subtracted if age >44) if strep score(0-1) symptomatic tt. if >4 Empiric AB.

(2-3) do rapid antigen test > If +ve treat strep ,-ve >>do throat culture >>If +ve give antibiotics ,,,if -ve>>> symptomatic tt Drugs with mortality benefit in heart failure: 1) ACEI/ARBs -decrease ventricular remodelling (both cause hyperkalemia, ACEI cause dry cough and angioedema) 2) B Blockers 3) Spironolactone 4) Hydralazine/Nitrates 5) Implantable Defibrillator Diuretics and Digoxin control symptoms but do not improve mortality Diabetic Nephropathy- screen for microalbuminuria annually. Microalbuminuria (30-300mg) does not show up on routine dipstick. In the presence of microalbuminuria begin ACEI/ARBs, because they decrease the rate of progression. Without signs of renal failure (azotemia), the best measure to prevent diabetic nephropathy is blood sugar control With azotemia, Blood Pressure control is most important. Treatment of Diabetic Ketoacidosis: 1) Normal Saline (fluid replacement) 2) Normal Insulin 3) Replace potassium when levels normalize Most accurate measure of severity of DKA is serum bicarbonate levels. DKA has hyperkalemia due to extracellular fluid shift, but total body stores are decreased.