DR Medhat MRCP

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General pharmacology Pharmacokinetics : i.e What the body does to the drug (drug journey in the body & its handling) Pharmacodynamics : i.e what the drug does to the body (potency, drug-receptor interaction) Pharmacokinetics • Def : The ways in which drugs move into, around & out of the body& how they are handled by the tissues and organs i.e what the body does to the drug Pharmacon = drug Kineen = to move • Include : 1) Administration , absorption & availability 2) Distribution 3) Metabolism 4) Elimination 2
- When a drug is administrated to the body , a relationship between plasma drug concentration & the time is created & the following is detected : Cmax : i.e maximum drug concentration in plasma. Tmax : i.e the time at which the drug reaches its maximum concentration in plasma. T-1/2 (half life) : i.e time at which the drug reaches ½ of its maximum plasma conc. → → 3
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A-PDF Merger DEMO : Purchase from w
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It contains : - 46 (23 pairs) of ch
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6. Glycolipids - signal molecules.
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Eukaryotic cell cycle : - Human bod
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• Regulation of the cell cycle :
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• Morphology of apoptosis (EM) :
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Ion transport - Trans-membrane ion
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Disease Signal transduction Ligands
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Example of GP-CR → Adrenergic rec
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- There are around 30,000 gene , on
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- The language used by DNA is calle
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Autosomal dominant Autosomal recess
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Modes of disease inheritance Autos
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Autosomal dominant conditions Very
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X-linked dominant inheritance - The
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Fragile X syndrome : - Trinucleotid
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Some common genetic syndromes Triso
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Edwards Syndrome - Also known as Tr
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• Prognosis of Marfan syndrome -
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Noonan Syndrome - Often thought of
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Immune system - Immunity is the lin
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Classification of immunity Innate i
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Immune response to pathogen : A) In
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Expression Structure MHC I - In all
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C) Adaptive immune response : - The
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Cytokines produced by different kin
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ANCA o There are two main types of
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Tolerance & autoimmunity : o The im
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Complement system o It`s a group of
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Inflammation o Inflammation is a no
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o Immunosuppressive therapy is used
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C. Antimetabolites Cytotoxic Mechan
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o The mode of action of sirolimus i
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Primary immunodeficiency o Primary
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o Recently, a further category has
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- Reabsorption of HCO3 - (85% in PC
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Pathogenesis: Causes : Features : T
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A) Respiratory centers depression A
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o Treatment of chronic respiratory
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Saline - Responsive metabolic alkal
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Hypertonic Isotonic Hypotonic Plasm
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Hypernatremia (Na + > 145 mmol/L) :
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Hyperkalemia (K + > 5.2 mmo/L) : -
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Hypokalemia - Potassium and hydroge
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Medical statistics • Def : • St
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MEDIAN (=mid-point) Def : It is the
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Q : A study is performed to find th
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- Whilst correlation coefficients g
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Statistics which test differences P
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B. Statistics which test confidence
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P- VALUES • Def : - The P (propab
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Q 1: Q2 : If a drug reduces the inc
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Q4 : - CER (Aspirin) = 3% - EER (ne
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SPECIFICITY = →This is the rate a
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Q : 123
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Randomised controlled trial Experim
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Case-control study • Def : - It`s
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Study Design: Evidence and Recommen
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Intention to treat analysis Q - It
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CORONARY ARTERY DISEASES Definitio
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Risk factors of CAD: High risk fac
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Stable (chronic) angina (= angina o
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A) Medical ttt of stable angina(CKS
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DVLA rules: cardiovascular disorder
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STMI NSTMI/UA ACS < 12 hrs of symto
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• Treatment : A. Medical TTT : I
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Cardiac arrhythmias I. Tachyarrhyth
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Atrial fibrillation (AF) Def : - o
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2. Echocardiography: - Significant
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Acute newly detected AF Hemodynamic
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Rate vs rhythm control : Factors fa
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Digoxin and digoxin toxicity - Digo
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Long QT syndrome Def: - Long QT syn
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Conducting system of the heart : He
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Ventricular tachycardia Ventricular
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• Treatment of shockable rhythms
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Peri-arrest rhythms A. Peri-arrest
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B. Peri-arrest tachycardia Hemodyna
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QRS Deflection Inferior leads (II,I
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B-type natriuretic peptide (BNP) :
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Hypertension Clinic BP measurement
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Stepwise approach of treatment of H
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Pulmonary arterial hypertension(PAH
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Normal pulse in young (25y) person
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Jugular venous pulse(JVP) 52
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Valvular heart disease Aortic steno
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• Features Aortic regurgitation
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• Echocardiography : A 'tight' m
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Murmur Causes Character Point of ma
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Pericarditis Pericarditis is one of
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Myocarditis • Causes Viral: Coxs
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- Most of cardiologists proceeds to
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Causes of sudden cardiac death : In
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2) Atrial Septal Defects (ASDs) - T
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Eisenmenger's syndrome - In acyanot
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- When properly positioned, the dis
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Down syndrome - Down syndrome is th
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Marfan's syndrome - Marfan's syndro
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Causes: - Streptococcus viridans (m
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Treatment of IE : A) Medical ttt :
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CVS medications Antiarrhythmic drug
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Amiodarone Class : III antiarrhyth
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‣ Β- blockers cardiotoxicity : -
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Aspirin : Mechanism of action : -
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Diuretics : Thiazides Diuretics Act
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lesions Macule Patch Papule Nodule
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Acne vulgaris - Acne vulgaris is a
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Isotretinoin - Is an oral retinoid
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Pityriasis Versicolor (= tinea vers
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Plaque psoriasis Flexural psoriasis
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- Finger tip rule 1 finger tip uni
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D. Contact dermatitis - Contact der
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Pemphigus vulgaris - Is an autoimmu
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Erythematous skin rash Erythema mul
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Erythema nodosum - Idiopathic condi
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Lichen-like diseases - Lichens are
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Scabies • Overview : - It is a pr
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Diseases of hairs Hirsuitism & Hype
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Diseases of the nails Onycholysis -
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Skin infections Impetigo - Is a hig
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Pyoderma Gangrenosum - Is a conditi
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Granuloma annulare - Papular lesion
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Molluscum contagiosum - Flesh-white
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Skin disorders associated with mali
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*Langer lines were historically use
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Pituitary gland Anatomy : - Small
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Diseases of pituitary gland Anterio
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Anterior pituitary hpofunction in a
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Anterior pituitary hyperfunction I.
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o Hands & feet : - Spade-like hands
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Prolactin is unique amongst the pit
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Very rare drug causes of gynaecomas
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Investigations : 1) High plasma osm
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Treatment of DI : Cranial DI (ie wi
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Non-functioning adenoma (chromophob
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Thyroid gland Anatomy : - Butterfl
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Control of thyroid hormones (hypoth
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o Thyrotoxic crisis (thyroid storm)
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- Graves' disease is the most commo
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Subclinical Hyperthyroidism - It is
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Myxoedema Causes : Primary hypothy
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Subclinical Hypothyroidism Basics
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Thyroiditis - i.e Inflammation of t
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- It`s the commonest endocrine mali
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Amiodarone-induced thyroid disease
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Actions of parathyroid hormone ( pl
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Latent tetany +ve Provocative tests
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■ Clinical picture : Bones, Stone
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Hyperparathyroidism - i.e over prod
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Hypoparathyroidism - i.e decrease p
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- Histologically : bone is formed o
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• Management : (NICE 2011 ,2ndry
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8) Hip protectors : - Evidence to s
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Osteomalacia Def : - Defective min
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Osteogenesis Imperfecta (= brittle
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• Functions of adrenal hormones :
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Primary hyperaldosteronism Causes
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Investigations : A. Diagnosis of Cu
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Adrenal insufficiency Causes : o P
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Differences between 1ry & 2ndry adr
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Def : Diabetes Mellitus (DM) - Met
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سؤال اليخلو منه امت
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3)Other risk factor modification C
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I. Insulin sensitizers 1) Biguanide
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■ Management of type I DM [Insuli
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5) Insulin resistance (i.e requirem
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Complications of DM : Complication
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Diabetic foot ulcers : • Classifi
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Investigations : سؤال amylase.
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Treatment of HONK : as in DKA with
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D. Post delivery : DC TTT(in GDM) ,
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Insulinoma is a neuroendocrine tumo
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Def : body mass index ( BMI) > 30 O
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■ Sibutramine - Withdrawn January
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- Dietary fat (TG) is digested by b
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Classification of hyperlipidemia :
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• Management Referral to a speci
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• Physiology of reproductive syst
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• Def : Delayed growth & puberty
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Hypogonadism ■ Def: - A diminishe
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MRI →Absence of olfactory bulb.
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• Initial investigations Exclude
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■ Diagnostic approach of 2ndry am
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تبدو وتتصرف ك بنت و
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■ Diagnosis : ■ Treatment : Kar
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3) Infertility : (under specialist
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Carcinoid tumours - Group of slowly
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1
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• Hormones of GIT : Hormone Gastr
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• Treatment : A. Acute treatment
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• DD (causes of heart burn sensat
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Dysphagia - The table below gives c
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Disease Achalasia Scleroderma Manom
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Oesophageal cancer - The most commo
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سؤال مهم : dyspepsia Drug-in
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Management of endoscopy proven gast
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Management of endoscopy proven non-
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• Investigations of H.Pylori : س
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• Clinical features of ZES : Zoll
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• Diagnosis: • Staging : Endosc
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Coeliac disease • Def : - An auto
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B. Jejunal biopsy (see pathology).
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• Investigations : 1) Jejuna biop
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Short bowel syndrome - Malabsorptio
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Inherited (familial) colorectal can
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Pelvi-abdominal CT/MRI/PET scan wit
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Acute Intestinal ischemia • Def :
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سؤال امتحان Melanosis col
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Inflammatory bowel diseases (IBD)
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Histology Involve whole bowel wall
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B. Management of ulcerative colitis
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هام : UC) Colo-rectal cancer on
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Acute infective diarrhea (infective
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• Management : 1) Rest ,rehydrati
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Liver diseases Hepatitis • Def :
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• Complications: Hepatitis C : 80
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Viral hepatitis B - HBV is a double
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• Immunisation (vaccination) agai
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• Risk factors of ALD : - Men : w
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Fatty liver (steatosis) - It`s live
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• Types according to the types of
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liver: hepatitis, cirrhosis lentif
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• Features Homozygous PiZZ →(A
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• Complications Malabsorption: o
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Chronic liver disease (cirrhosis)
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سؤال امتحان classificatio
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Meigs' Syndrome : = Ovarian fibroma
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Type I HRS Rapidly progressive. D
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Hepatic Encephalopathy: • Def: A
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Haemochromatosis: - Is an autosomal
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Hepatomegaly : • Common causes of
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B. Causes of conjugated (direct) hy
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Crigler-Najjar Syndrome (CNS): - (C
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Diseases of pancreas Acute pancreat
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Chronic Pancreatitis - Is an inflam
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• Diagnosis: Contrast CT is used
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Liver biopsy • Contraindications
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Diseases of RBCs Include 3 main gro
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Microcytic hypochromic anemias I. I
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II.Thalassemia - It`s an inherited
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• Pathogenesis of thalassemia : -
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Hb electrophoresis : - The major Hb
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• Management : 1) Phlebotomy (ven
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Chronic Hemolytic Anemia with acute
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Autoimmune hemolytic anemia (AIHA)
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- Hemolysis which ↑↑ during sle
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• Causes: 1. Post-infection e.g.
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Glucose-6-phosphate dehydrogenase (
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- These other forms of sickle-cell
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• Investigations : CBC : normocy
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• WHO 2008 classification of MDS
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Macrocytic megaloblastic anemias Ca
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• Incidence - Peaks in the sixth
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Hemoglobinopathies Quantitative (Im
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• Typical carboxyhemoglobin level
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Leukemoid reaction - Describes the
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Hyper Eesinophilic syndrome: - Rare
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B. Lympho-proliferative disorders (
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- Further classification of each ty
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• Management of AML : Chemothera
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Chronic Myeloid Leukemia (CML) - Th
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Chronic Lymphocytic Leukemia (CLL)
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Incdence Commonest acute leukemia
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• Ann-Arbor staging of Hodgkin's
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- Chemotherapy includes : 1. Doxoru
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Burkitt's Lymphoma : - Is a high-gr
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Multiple myeloma - It`s a neoplasm
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Diseases of platelets 1. Thrombocyt
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• Causes of severe thrombocytopen
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• Normal response to vessel injur
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Von Willebrand's disease - Von Will
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- There are two main types of hepar
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2. Warfarin - Warfarin is an oral a
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74
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Acquired Factor VIII Deficiency - I
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Thrombophilia ( = thrombotic tenden
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Hyposplenism e.g. post-splenectomy
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Graft versus host disease (GVHD) :
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Tumour markers • Tumour markers m
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C. Antimetabolites Cytotoxic Mechan
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Therapeutic antibodies : Monoclonal
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• Conversion between opioids From
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Thymoma - Thymomas are the most com
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Prostate cancer - Prostate cancer i
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Oncogenes • Def : - They are endo
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Classification of pathogens الح
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Anaerobes Aerobes G-ve bacteria G-v
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B. Whole killed organism (= inactiv
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Necrotizing fasciitis : - Is a medi
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A. Actinomycosis - Actynomyces is f
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Clostridium difficile: - Is a Gram
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1. Septic arthritis ( the most comm
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Atypical bacteria I. Mycobacterium
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Extra-pulmonary TB ( in immunocompr
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هام جدا : TB Management of Ac
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III. Spirockaetes A. Leptospirosis
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IV. Ricketsiae A. African Tick Typh
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• Management : A. Uncomplicated f
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- It is again advisable to avoid tr
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• Diagnosis : Splenic or bone ma
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• Investigation Antibody test S
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Cryptosporidium : سؤال - It`s t
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Antiretroviral group NRTI Examples
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B. Focal neurological lesions : 1)
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• Complications : A. Common compl
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• Complications : 1) Encephalitis
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6) Infectious mononucleosis (glandu
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8) Novel Coronavirus - Human corona
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B. Trematodes (flat worms) Schistos
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• Management (SIGN 2009) : Azyth
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Genital ulcers : Common causes of g
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Lymphogranuloma venereum سؤال t
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Mechanism of action of common antib
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Leprosy liptospirosis Lyme disease
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(Human papilloma virus) UTI in woma
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Osteomyelitis : - Osteomyelitis des
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مرض األغنام Orf - Orf is
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1
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3
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Diseases of thick ascending limb of
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III. According to clinical presenta
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9
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Minimal Change disease (MCD) - Near
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Management Minimal change glomerulo
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Focal Segmental Glomerulosclerosis
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B. I.F : no immune deposits (C3 & I
Page 671 and 672:
3 rd line ttt Plasma exchange: - Th
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Causes : 1ry ( idiopathic) MCGN .
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New classification (according to th
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2) Type II MCGN : 25
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Membranous nephropathy (MN) - It`s
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Approaching MN : - Careful history
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Prognosis : (rule of thirds) 1/3 o
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IgA nephropathy Basics: Also calle
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Management of IgA nephropathy Low r
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Renal parenchymatous diseases accor
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NB : The antigens against which th
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Management of nephritic syndrome :
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Management: ACE-I ARBs Approximat
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Acute renal failure (now termed acu
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Causes of CKD : Common causes of CK
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Anemia in CRF: All types of anemia
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There is transformation among the p
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III. Pauci-immune (ANCA+ve) nephrop
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Hereditary renal disease I. Alport
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NEUROLOGY DR. MEDHAT M.SLEAT 2013
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Brain anatomy - It`s a gelatinous o
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C. Cerebellum : o It lies behind th
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Frontal lobe Area Site Function Les
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Parietal lobe Cortical sensory area
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Occipital lobe Visual sensory area
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Upper & lower motor neurons - For a
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U.M.N. Lesion L.M.N. Lesion Paralys
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اللهم السهل اال ماج
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II. Optic nerve • Pathway of visi
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III. Oculomotor nerve - The nucleus
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IV. Trochlear nerve : - The nucleus
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V. Trigeminal nerve : - It`s a mixe
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• Trigeminal nerve palsy: o Cause
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سؤال هام فى اال متح
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VII.Facial nerve : - it`s a mixed n
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U.M.N.L Affects ∆ tract above fac
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VI. Vestibule-cochlear nerve : - Th
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VII. Glossopharyngeal nerve : - It`
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Petrous apex syndrome : • Causes
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Control of eye movement during head
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Conjugate gaze palsy Supranuclear N
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Carotid (anterior) system : Anterio
Page 755 and 756:
47
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Basilar artery • Origin : - Forme
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B. Total occlusion : is fatal 1. De
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Middle cerebral artery Anterior cer
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Posterior inferior cerebellar arter
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IV. Carotid artery endarterectomy
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Subarachnoid hge (rupture aneurysm)
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• Clinical presentation : - Typic
Page 771 and 772:
Traumatic brain injury: Extradural
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Medial pontine syndrome - e.g occlu
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• Prognosis : - Variable prognosi
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Incomplete lesions of spinal cord B
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Investigations 1. Decreased red cel
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• Management In primary care; a
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Lewy body dementia - Is the second
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Transient global amnesia (TGA) •
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• Management : Riluzole 1. Anti-
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Gower`s sign of Duchenne`s muscle d
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• Management : - 1 st line invest
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Pricipitating factors of myasthenia
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- *In reality this is seen in only
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- The basal ganglia and cerebellum
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• Extra pyramidal tracts : Tract
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• Main clinical features : Dyskin
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2) Levodopa: Usually combined with
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III. Hemiballism (subthalamus) - Oc
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• Investigation of choice : MRI (
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Cerebellar syndromes : Archicerebe
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Herido-familaial ataxia : A. Friedr
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سؤال امتحان Meniere's dis
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Nystagmus - Oscillatory eye movemen
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Diseases of the nerves • Def : -
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2. Predominantly sensory : o Friedr
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Common peroneal nerve (L4,5 & S1,2)
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Femoral nerve o Origin : lumbar ple
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L3 nerve root compression L4 nerve
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Nerve supply of the upper limb Medi
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121
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Carpal tunnel syndrome • Def : Mo
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Sensory to : 1. Dorsal aspect of la
Page 835 and 836: Elbow Pain: - The table below detai
Page 837 and 838: Reflex Biceps reflex Triceps reflex
Page 839 and 840: 131
Page 841 and 842: Gastroparesis Symptoms include err
Page 843 and 844: Nerve Conduction Studies (NCS) - Ar
Page 845 and 846: - Complex partial seizures can take
Page 847 and 848: 8. It is advised that pregnant wome
Page 849 and 850: سؤال امتحان : Cataplexy
Page 851 and 852: • Management : o Aim: reducing th
Page 853 and 854: Tuberous sclerosis (TS) - Autosomal
Page 855 and 856: • General C/P : ( it`s not a must
Page 857 and 858: Headache - Headache is the term use
Page 859 and 860: Neuropathic pain - Neuropathic pain
Page 861 and 862: • Management Stop antipsychotic
Page 863 and 864: Lamotrogine (lamictal) • Uses : A
Page 865 and 866: 1
Page 867 and 868: - Layers of the eyeball : Sclera :
Page 869 and 870: N.B New classification of non-proli
Page 871 and 872: Dry (geographic atrophy) macular de
Page 873 and 874: B. Congenital causes 1. Friedreich'
Page 875 and 876: Acute angle closure glaucoma - In a
Page 877 and 878: سؤال هام فى االمتحا
Page 879 and 880: Relative afferent pupillary defect
Page 881 and 882: Homocystinuria - Homocystinuria is
Page 883 and 884: Causes of bilateral ptosis 5. Myoto
Page 885: 1
Page 889 and 890: 2) Binding to plasma & tissue prote
Page 891 and 892: - Metabolism of the drugs ccurs in
Page 893 and 894: Metabolism of paracetamol in overdo
Page 895 and 896: Management of paracetamol toxicity
Page 897 and 898: NB : the most helpful test in deter
Page 899 and 900: King's College Hospital criteria fo
Page 901 and 902: • Time course of drug metabolism
Page 903 and 904: Measurement of plasma drug level :
Page 905 and 906: Digoxin and digoxin toxicity - Digo
Page 907 and 908: Ectasy (= MDMA = Methylene-dioxy-me
Page 909 and 910: Mood disorders Depression • Def :
Page 911 and 912: Psychotic depression : - Major depr
Page 913 and 914: More sedative Amitriptyline Clomi
Page 915 and 916: • Discontinuation symptoms 1) Inc
Page 917 and 918: • Examples of typical antipsychot
Page 919 and 920: • Treatment of bipolar disorder :
Page 921 and 922: Lithium - Lithium is a mood stabili
Page 923 and 924: Post partum mental health problems
Page 925 and 926: Functional deterioration : 1) Impai
Page 927 and 928: B. Compulsions : - Stereotyped acti
Page 929 and 930: Generalized anxiety disorder (GAD)
Page 931 and 932: Somatoform disorders (unexplained s
Page 933 and 934: Eating disorders 1. Anorexia nervos
Page 935 and 936: Sleep disorders 1. Sleep paralysis
Page 937 and 938:
• Mechanism : • Features : Subs
Page 939:
• Diagnosis : Chronic fatigue syn
Page 942 and 943:
- Causes of defective lung perfusio
Page 944 and 945:
1) Central regulatory centres : A)
Page 946 and 947:
Lung capacities :
Page 948 and 949:
Functional Residual Capacity (FRC)
Page 950 and 951:
FEV1 Meaning (units) Description Fo
Page 952 and 953:
هام جداPFT Algorithm of inter
Page 954 and 955:
Interpretation of flow volume loope
Page 956 and 957:
Bronchial asthma - BA is a reversib
Page 958 and 959:
Diagnosis of BA in adults(British T
Page 960:
Step 4 Step 5 Consider trials of:
Page 963 and 964:
Causes : 1. Smoking (tobacco smooki
Page 965 and 966:
The severity of COPD is categorised
Page 967 and 968:
2. Bronchodilator therapy A short-
Page 969 and 970:
Bronchiolitis oblitrans(BO) - Progr
Page 971 and 972:
Extrinsic allergic alveolitis (=hyp
Page 973 and 974:
Subtypes a) Cylindrical (bronchi ha
Page 975 and 976:
Cystic fibrosis(CF) - Autosomal rec
Page 977 and 978:
Pulmonary embolism (PE) - PE is pre
Page 979 and 980:
CTPA or V/Q scan? The British Thor
Page 981 and 982:
Management of PE (The NICE guidelin
Page 983 and 984:
1- General constitutional symptoms
Page 985 and 986:
Mycoplasma pneumonia - Is a cause o
Page 987 and 988:
Investigation األهم diagnosis.
Page 989 and 990:
Aspergilloma : - A fungus ball that
Page 991 and 992:
Asbestos-related lung diseases Pleu
Page 993 and 994:
• Clinical features : Dyspnoea
Page 995 and 996:
• Investigations (NICE 2015) : Sy
Page 997 and 998:
Stage IIIb Stage IV T1 N0 - No L.N
Page 999 and 1000:
Non-small cell carcinoma : Squamous
Page 1001 and 1002:
Lung carcinoid - Neuro-endocrine tu
Page 1003 and 1004:
Pulmonary eosinophelia - Group of d
Page 1005 and 1006:
• Investigations : - There is no
Page 1007 and 1008:
Pleural diseases Pleural effusion -
Page 1009 and 1010:
3) Pleural(Abram`s) biopsy : - Indi
Page 1011 and 1012:
• Investigations : 1) Chest X-ray
Page 1013 and 1014:
- Tension pneumothorax ► Tension
Page 1015 and 1016:
Respiratory questions reveiw for MR
Page 1017 and 1018:
Q6 : A 63-year-old woman presents a
Page 1020 and 1021:
Evaluation & diagnosis of a case of
Page 1022 and 1023:
- It`s a common degenerative joint
Page 1024 and 1025:
Cervical spondylosis - It`s an age-
Page 1026 and 1027:
Rheumatoid arthritis (RA) • Def :
Page 1028 and 1029:
c) Boutonniere deformity (i.e exten
Page 1030 and 1031:
هام جدا : arthritis • Diagn
Page 1032 and 1033:
Methotrexate: - Methotrexate is an
Page 1034 and 1035:
Ankylosing spondilitis - One of HLA
Page 1036 and 1037:
• Management of AS: - Early diagn
Page 1038 and 1039:
The table below shows the organisms
Page 1040 and 1041:
Behcet's syndrome Behcet's syndrome
Page 1042 and 1043:
Crystal-induced arthritis GOUT - Go
Page 1044 and 1045:
IV. Gouty nephropathy : Acute gout
Page 1046 and 1047:
C. Lifestyle modifications: 1. Redu
Page 1048 and 1049:
Dermatomyositis • Def : - Inflamm
Page 1050 and 1051:
Inclusion body myositis (IBM) : - T
Page 1052 and 1053:
34
Page 1054 and 1055:
firm surface or flexed for extended
Page 1056 and 1057:
Ottawa rules: Def : - Are a set of
Page 1058 and 1059:
Autoimmune rheumatic diseases Syste
Page 1060 and 1061:
J. Neurological : 1. Lupus cerebrit
Page 1062 and 1063:
سؤال امتحان Discoid lupu
Page 1064 and 1065:
• Investigations : 1. Thrombocyto
Page 1066 and 1067:
• Antibodies: ANA positive in 90
Page 1068 and 1069:
Sjogren's syndrome - It is an autoi
Page 1070 and 1071:
Large vessel vasculitis Giant cell
Page 1072 and 1073:
• Investigations : ( there is no
Page 1074 and 1075:
Small vessel vasculitis ANCA +VE (
Page 1076 and 1077:
ANCA -VE vasculitis : Henoch-Schonl
Page 1078 and 1079:
Disorder Wegener`s granulomatosis G
Page 1080 and 1081:
Referral to specialist CFS : - With
Page 1082:
Leflunomide : • Mechanism of acti
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DR Medhat MRCP

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