PLAP - 1

Revision
Notes
 Traumatology

( I ) ORTHO

- Fracture Clavicle = - Stepping deformity

-injury of subclavian artery, brachial plexus or pneumothorax.
- Rx = broad arm sling

- Shoulder dislocation= * Anterior more common than posterior.

*Anterior is mainly due to direct trauma(95%) and fall on
outstretched hands.
* Posterior dis. = due to epilepsy and electric shock
* injury of axillary nerve = loss of sens over badge area
( skin over deltoid ) and loss of shoulder contour.

Rx = Simple reduction or kocher’s method. Surgical repair only if : athlete

or recurrent shoulder dislocation.

Humerous Fracture of shaft = radial nerve injury ( wrist drop)

Supracondylar humeral fracture is the MC fracture of childhood
injury of = radial/ulnar nerve and arteries are possible

pain around elbow + lost radial pulse = supracondylar fracture

Radius & Ulna :

- Monteggia’s = fracture of the proximal Ulna + dislocation of radius
- Galeazzi’s = Fracture of distal radius + dislocation distal radioulnar
joint

Mnemonic = GRIMUS = Galeazzi: #radius and dislocation is inferior

Monteggia: #ulna and dislocation is superior
Nightstick’s fracture: Isolated mid-shaft ulnar fracture. Mainly due to direct
blow.
Colle’s fracture post-menopausal women falling on outstretched hands
Dinner fork deformity - might affect median n. > Carpal tunnel’s s.
Posterior displacement.
RX = Displacement < 10 degrees = plaster of paris
> 10 degrees = closed reduction needed.

Smith’s fracture garden spade deformity // Anterior displacement // called

reverse colle’s // rx = fixation and reduction needed more than colle’s

Barton’s Fracture =Fracture distal radius + RADIOCARPAL DISLOCATION

Green stick # = child falling on outstretched hands have tenderness at elbow but
otherwise well = greenstick = might cause compression of median n.

Hands:

Scaphoid fracture= Tender Snuff box = avascular necrosis

De quervian’s tenosynovitis inflammation include tendons of ABDUCTOR pollises

longus and extensor pollisis brevis // pain with forceful abduction of thumb and
also on pulling the thumb to the ulnar side ( Finkelstein’s sign )

Bennet’s fracture carpometacarpal subluxation / hyperextension of thumb

Mallet’s finger : drooping of the distal phalanyx ( avulsion of extensors’ tendon)

Gamekeeper’s thumb = Skier’s thumb = rupture of ulnar collateral lig. With

forceful abduction of the thumb

Supraspinatus tendonitis =painful arc ( on abduction 40 to 160 degrees)

Lower Limbs:

Malgaigne fracture: 20 % of all pelvic fractures and 60 % of unstable pelvic

fractures / disruption of pelvis at two points; anteriorly and posteriorly, plus
displacement of a fragment including hip dislocation.

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Knee:
common associations = Collateral lig. = injury in athletes.
*ACL = twisting injury= usually the typical triad of ACL/ Mdial mens/ Medial Coll
lig.
* PCL = injury as in posterior hip disloc = Front Passenger’s injury
* LAT collateral lig + fx fibular head
Patellar fx = Avulsion = Rx either cylindrical cast or ORIF
Prepatellar bursa is commonly injured in falling traumas

Legs and Feet

Condylar tibial fx = Genu Valgus /

Genu Varus = Rickets and osteomalacia.
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Miscellaneous Ortho :

Myofascial pain = strain = rx RICE ( rest, Ice , compression , elevation )

Complex Regional Pain Syndrome ( CRPS) :

following trauma. If no nerve injury happened in that trauma, it’s CRPS-type1 = reflex
sympathetic dystrophy. If there was a nerve injury, it’s CRPS-type 2 (causalgia ).
C/p = Pain in the region weeks to months after trauma + Hyper algesia/reflexia/aemia +
Vasomotor instability + Allodynia ( non-painful stimuli are painful)

Rx= Psychtherapy + Amitriptyline has a role

Limbing child :
1) SUFE : commoner in obese adolescents / the MCC / slipped upper fem epi,
2) Perth’s disease : aseptic necrosis of femoral head
3) Septic Arthritis : Acute monoarthropathy = ix aspirate for CS .

Whiplash injury = rx physio no need for Neck Collar

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( II ) Neuro

* Nerve injuries:
1) Axillary nerve : ( fx head and neck humerous) lost abduction and sens over
badge area

2) MC nerve : weak flexion and supination of elbow

3) Ulnar nerve : partial claw ( the higher the injury the lesser the weakness
Ulnar paradox ) and lost sens in medial one and half fingers and hand

4) Median nerve : ape hand, lost sens over the lat 3and half palm and palmar
fingers + tips of these fingers dorsally

5) Radial : wrist drop

6) Long thoracic nerve : winged scapula

7) Suprascapular nerve: pain and difficulty of initiating movement

8) Common peroneal : foot drop ( lost dorsiflexion) and lost eversion

injury of common peroneal is commoner in Football players

9) Femoral nerve : weak quadriceps ( weak knee extension ) and lost sens in ant
thigh.

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( III) BURNS
Criteria of admission : 1) partial thickness of : > 10% or 5% in children and elderly
2) Full thickness > 5% of any age group 3) face, hands, feet, perineum, chest
4) Special injuries = all electric, chemical and inhalational injuries
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( IV) Others

* Simple pneumothorax = chest drain 5th ICS

* Open pneumothorax = Sterile occlusive dressing > then > drain in 5th ICS
* Tension pneumothorax = urgent Needle decompression in 2nd ICS then drain
* Fx Ribs = just one or two points > simple analgesia
more than two ribs at diff levels > FLAIL CHEST
( a segment of the chest has paradoxical resp. movement) >
surgery.

* Abdominal injuries : CT is the best dx. US is done initially

* Blunt trauma > Spleen ( 50%) then liver ( 40%) then small bowel
* Stab wounds : LIVER ( 40%) then small bowel then diaphragm then colon
* FAST scan : search for any effusion in 4 spaces: pericardial/ perisplenic/
perihepatic/ pelvic

DPL FAST scan CT

Sensitivity High Medium High

Specificity LOW High ( which High

space has fluids
indicate which
organ injured )

* transpyloric plane = T1= duodenal injury = seat belt injury

Ix = DPL ( surgery if blood, RBC> 100,000 / wbc > 500 / alk ph 1,75 IU)
>> Pseudopancreatic cyst ( fluid in lesser sac )

* indication of laparotomy: 1) shock 2) peritonism 3) positive DPL or FAST

4) penetrating tx 5) Gunshot 6) Bl PR/
* Rupture diaph = CXR first then CT
* Rupture oesophagus :
retrosternal pain + vomiting + haematemesis + shock
Signs = Gurgling sensation in mediastinum ( Gas)
IX = First CXR ( Gas or air-fluid in mediastinum )
THEN CT
Boerhaave’s syndrome = non-spontaneous oesoph rupture ( SHOCK)
Mallory-weiss = vomiting+ haematemesis but not transmural injury
( the oesophagus has not ruptured yet ) NO SHOCK

* suspecting URETHRAL injury :

- retrograde urethrocystogram
- Suprapubic not urethral cathetrisation

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 Surgery

Thyroid cx :
1) Papillary Solitary 2) Follicular : Slow + mets
3)Anaplastic rapid + compression 4) Medullary :mainly as part of MEN II
medullary carcinoma
parathy hyperplasia
pheochromocytoma
** Severe epigastric pain + vomiting ( Bl +- ) + shoulder tip pain >>
Perforated peptic ulcer >> CXR >> Air under diaph.

** Paralytic ileus >> C/p less colic no intest sound / hx of Tricyclic

antidepressants / opioids / antiparkinsonian/ immobility.

Inx = CXR first ….. Best is CT

ttt = NGT + IV fluids + correct hypokalaemia

** Ascitis = transudate > PHTN // Exudate > malignant & inflammatory

** Varicocele is more common on lt side ( LT testicular vein doesn’t drain in

IVC directly like the rt one )

** Faecal impaction >> Rx : phosph Enema

** Acute Gastric dilatation >> Ground BL in NGT + Shock

** Upper GI bleeding = ABC + NGT and lavage > then > endoscopy
** Colon cancer = rt sided ( non-specific symptoms+ anemia+ melena )
Lt sided ( constipation and BPR )

** Curling’s ulcer in Oesophagus after burn injury

** Fever + lt iliac fossa colic relieved by defecation >> DIVERTICULITIS
** PILES >> 1st and 2nd degree >> Band ligation or sclero
3rd >> haemorrhoidectomy

** Anal fissure > key treatment is relaxing sphincter > 1st line GTN ointment
2nd line Diltiazem oint
3rd line Botulinium toxin
* Ureteric colic :
IV urogram ----- < 5mm = pass spontaneously ( Give antispasmodics )
----- > 5mm and < 1 cm >> ESWL or medical expulsive
( Nifedipine or alpha-blockers)
----- > 1cm >> PCNL
Breast lump >> Triple assessment >> Examination
>> less than 35 YO > US
more than 35 > mammo then US
>> Cytology

Nipple discharge >> Clear or Bloody >> intraductal papilloma

greenish / brown >> Duct ectasia
Purulent >> Abscess
Ix = Ductogram

Ankle-brachial index = <0.5 critical limb ischaemia

< 0.7 moderate
< 0.9 mild

Burger’s disease >

Claudication / OE >> neuropathy ( tingling numbness anaesthesia )
Multiple ulcers and gangrenes
Ix angio Rx Amputation if gangrenous / stop smoking

Pyoderma Gangreniosum = LEG ulcer plus hx of IBD

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IN THE ER if Hg is
1) < 8 ==== transfuse and stabilise then proceed
2) < 10 ==== Ix firstly
3) > 10 proceed

POSTPONE SURGERY IF :
1) HB < 10
2) PLT < 50,000
3) SBP < 90
4) MI or Stroke < 3 ms
5) Uncontrolled : HTN/ DM / Asthma or chest disease / epilepsy ( recent fit)
Bowel pre-op preparation 1 day before with :
Na picosulphate or mg citrate
needed in all of these:
Colonoscopy Rectoplexy lt Hemicolectomy pancolectomy sigmoidectomy
Anterior resection heartmann’s reversal

Anastomosis Leakage = Ix = CT // Rx Cefruxime and metronidazole

laparotomy

D-dimer > 200 = PE ( CTPA and modified well score to diagnose )

DVT ( US and well score )
thrombophlebitis

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 SKIN

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* Any genital ulcer is considered syphilitic until proven otherwise

Genital Lesions :
1) Multiple painful shallow ulcer after flu-like illness >> HSV
Ix = PCR Rx; acyclovir for 5 days

2) Painless ulcer with rolled up edges and central slough >> primary syphilis
( chancre / 2ry is maculopapular lesions + Condyloma lata + Hepatitis , LN,
systemic toxaemia //// tertiary Neurosyphlisis : aseptic meningitis / focal
lesions / tabes dorsalis .. Cardiac > aortic regurgitation and aneurysm
Gummatous destructive granulomata in skin/mucous membranes and bone)

Ix = PCR / serology TPPA and TPHA ( these are specific but not used in
screening as they take time to elevate and not much sensitive )

Rx = Benzylpenicillin

3) Painless papule/ulcer + LN + Fever + Arthritis = Lymphogranuloma venereum

Ix : PCR for Chlamydia Rx= Doxycyclin

4) Ulcer + LN + Fever + Pseudobubo ( soft tissue spread ) =

Chancroid ( Haemophilus ducreyi ) & Donovanosis ( Klebsiella granulomatis)
Ix : PCR/ Donovan bodies in tissue rx : Azithromycin / ceftriaxone
_____ _ __ _____ ___ _ ___ ____ __ ____ ___ __ __ __ ____ ___ _
For Rapid diagnosis ( only suspicion-based method ) in
Dermatology:

White ? Rings ? BROWN ! Coin-shaped Very Itchy

+ + Early BCC + sun exposed = + Discoid Eczema +Derma causes:
Pityriasis moles , + Psoriasis ( on ext Scabies (more at night/
versicolor + Tinea ( melanomas surface, scalp,
burrows)
( active scaly natal cleft)
Urticarial reaction
Malassezia edge and + others: Lentigo
(hx of allergen/ wheals)
yeast) central healing , chloasma ( preg + P.rosea ( Trunk)
or pills) , café au Herald patch Atopic Eczema(
+ Vitiligo + Errythema lait ( thickening)
Multiforms ( neurofibromatosis + Impetigo :Honey Lichen planus( Violet
drugs? ) like crust
+ Chronic cut. lupus ( see systemic causes)
Systemic diseases associated with dermatological conditions
( suspect who gets what )

Endocrine Diabetes = Flexural candida / cellulitis / erysipelas / impetigo

/ Necrobiosis Lipoidica
Addison’s = Brown hyperpigmentation / vitiligo
Rheumatology Rheumatic Fever = SC nodule, erythema marginatum
RA = rheumatoid nodules / vasculititc rash
SLE = 1) non-specific lesions = reynaud’s / butterfly rash
2) chronic discoid LE =inflamed plaques and scarring
3) Sub-acute LE = psoriasis-like with +ve ANA or Ro/la
Sarcoidosis’s = Hypopigmentation / Erythema nodosum
Scleroderma = CREST syndrome ( R for reynaud’s )

GIT Inflammatory Bowel disease = Erythema nodosum ( chin of tibia)

Coeliac disease = Extremely itchy blisters on shoulders and back)
Autoimmune hepatitis = Pyoderma gangriniosum

Cardiology Mitral stenosis = Malar flush RF = Erythema marginatum/SCN

IE = Osler’s nodules on fingers / cutaneous vasculitic rash

Haematology Purpuras : ITP / TTP …………….. Vasculitic rash : Henoch-schonlein

Wagner’s

Psychiatry Dermatitis Artefacta : multiple self-inflicted lesions of various

pathology BUT THE PTN DENIES AND HAS NO SUICIDAL IDEAS
( commoner if there’s chronic skin condition ‘’ I hate my skin ‘’ like
alopecias, acnes and ulcers + commoner among borderline
personalities/ chronic fatigue syndrome/ MDD / eating disorder)
Rx: CBT – antipsychotic + antidepressants

Trichotillomania : Hair loss and abnormalities

commoner with OCD spectrum in general // Clomipramine & CBT
are effective
HIV All skin infections ( particularly molliscum contagiosum / tineas / thrush )
Syphilitic lesions = multiple ulcers + leonine features

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Erythemas !

Psoriasis = for mild cases = topical vit-d analougues +or- steroids

2nd line = Phototherapy // 3rd line = biological ( anti-
TNF-alpha and others) are better than methotrexate.
Eczema = mild > Rx emollient on the lesion / sedating antihistamines on the
sufferer’s brain
moderate > topical steroids
Resistant > local Tacrolimus

Impetigo = Rx flucloxacillin
Erysipelas = Benzyl penicillin + flucloxacillin
Acne vulgaris = mild > topical benzoyl peroxide +or- clindamycin
moderate > topical retinoids + doxycycline
Severe > systemic retinoids
P.rosea = rx oral erythromycin
P.versicolor = selenium sulphide shampoo or clotrimazole cream

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 PSYCHIATRY

In those <18 Y.O e depression = non-pharmacological ttt

if Antidepressants to be used : only mirtazapine and fluoxetine
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GAD and phobias in general :
First line = Non-pharmacological measures = CBT, meditation, hypnosis
relaxation therapy , regular exercising
Second line = SSRI ( paroxetine in social phobias) Buspirone as well
( pregabalin and venlafaxine are off-label alternatives)
Third line = Diazepam ( addictive, used for no more than 4 weeks , as last
resort or during a severe panic attack, though alprazolam is better for panic )
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Post-traumatic stress disorder :

Social support / group therapy
Amitriptylline / Mirtazepine / paroxetine +or- atypical antipsychotics
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SLEEP DISORDER:

Insomnias = try to avoid stimulant / increase daytime activities/ relaxation

therapy. AVOID drugs as soon as possible. The safest sleep aid =
Trazodone (sedating antidepressant ) or Cloral betaine ( for children
2nd line Non-benzodiazepine GABA-agonist ( Zaleplon, eszopiclone )
( dependence is still an issue )

Parasomnias= The only approved anti-parasomniacs = Clonazepam/

carbamazepine / amitriptyline

Narcolepsy = Methylphenidate ( amphetamine-like action, dependence)

Modafinil ( unknown action/ SE= allergy ( it increase histamine
level in the CNS and perhaps peripherally ) aggression / euphoria

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Acute delirium = Haloperidol 1-10mg IV/IM ---- Risperidone 0.5 to 4mg PO

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Schizophrenia

For positive symptoms-predominated type or Aggression = Start typical

Chlorpromazine/ Haloperidole: Excellent outcome regarding
hallucination/thoughts/perception abnormality but doesn’t improve negative symptoms
-- leads to Extrapyramidal side effects ( Can be serious)
Rx of EPSE = Parkinsonism = decrease dose / shift to atypical
if severe +ve symptoms then = add procyclidine
2.5 mg/ 8 hrs PO
Acute dystonia and Occulogyric crisis = procyclidine 10-30mg IM
Akathisia = Propranolol / cyproheptadine
Tardive dyskinesia = Tetrabenazine ( deplete monoamine=
depression and suicidal ideas )

For negative-predominated symptoms or well-controlled +ve symptoms:

All atypical antipsychotics are similarly efficacious in controlling symptoms ( no
one is superior to the other ) ; however , the choice is made on bases of SE :

** The safest for EPSE = quetiapine/ clozapine

** The safest for prolactin ( doesn’t cause hyperprolactinaemia) = quetiapine/
clozapine and aripiprazole
** All of them cause weight gain and increase risk of CVS/CNS stroke/ DM
The lowest incidence of that is with aripiprazole
** CLOZAPINE CAN CAUSE FATAL AGRANULOCYTOSIS, SO IT’s reserved for
resistant cases or who do not tolerate other ones

** Sometimes, combined atypical is tried with resistant cases = risperidone+

quetiapine or olanzapine ( NEVER COMBINE ARIPIPRAZOLE with other atypical) .

Ptn on atypical anti psychotics require = FBC / BP / Blood glucose and HBA1C /
prolactin level Monitoring
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Substance Abuse disorder =

Opiates = Methadone ( long-acting opiate. Dose/24 hours then reduce gradually
/ drawbacks : overdose is no less than morphine)
Buprenorphin ( mixed agonist/antagonist so less overdose risk)
 Lofexidine alpha-2 agonist= increase noradrenaline reuptake= ease
withdrawal symptoms

Naltrexone = Blocks the euphoria even if opiates are taken. Useful in

former addicts to prevent relapses. Risk is elevated liver function
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Alcohol = Disulfiram + Naltrexone or

Acamprosate
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Psychotherapy :

Flooding/exposure and systematic desensitisation = in phobias

Relaxation exercises = GAD
Response prevention, exposure-response therapy and thought stopping =
in OCD

Token economy = in children with Learning disabilities / addictive disorder

Aversion therapy = Sexual deviation and alcoholism
Behavioural Therapy = Sex/shopping / gambling and impulse disorder

CBT = nearly all psychiatric disorders

Group therapy = especially in PTSD, after certain kind of abuse

Addiction ( Alcohol and drug anonymous groups) personality
disorder
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Autism spectrum= Behavioral therapy/ speech therapy / special schools +
Parents training
Medication ( NO real role) but Fish oil may help.
Atomoxetine for hyperactivity and risperidone for social
withdrawal or aggression
Dyslexias = Unsaturated fatty acids ( Omega-3 ) Efalex
ADHD = first line is atomoxetine… second line = methylphenidate
( amphetamine is usually kept the last option for limited time)
 + or – atypical antipsychotics ( risperidone) for behavioural
symptoms
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Weird psych syndromes

Asperger's syndrome (AS) lies within the autistic spectrum. Previously it was
called high-functioning autism. The main difference from classic autism is a
lack of delayed or retarded cognition and language.

The Cotard delusion (also Cotard's Syndrome and Walking Corpse Syndrome) is
a rare mental illness, in which the afflicted person holds the delusion that he
or she is dead

The Capgras delusion (or Capgras syndrome) (/kæpˈɡrɑː/, US dict: kăpgrâ′)[1]

is a disorder in which a person holds a delusion that a friend, spouse, parent,
or other close family member (or pet) has been replaced by an identical-
looking impostor.

Couvade syndrome= a male partner experiencing hormonal change/ wt gain/

disturbed sleep/ morning nausea as his partner becomes pregnant (
sympathetic pregnancy ‫ﯾؤازرھﺎ اﻻﺣزان‬

Folie à deux (Shared psychosis) a certain delusion is contagious !!

Personality disorder =
Cluster A ( weirdos ) Paranoid = suspicious / Schizoid= social withdrawal /
schizotypal = introspective ( self-consumed)  risky to have psychosis

Cluster B ( emotionally liable) antisocial = bullying and psychopaths

Borderline = impulsive// Histrionic = Attention seeker / Narcissist= everyone
loves him  risky to develop mood disorder/ substance abuse/ suicide

Cluster C ( avoidant/ dependent)

Obsessive = strict, obstinate, very tough if become a parent.
 Avoidant/ Dependent  risky for OCD, somatization, GAD, phobias and
substance or other dependences
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Qs=

- suicidal attempts no psychotic symptoms = problem focused therapy

- a man believes his leg is rotten and wants to remove it = Nihilistic
-3 wks after childbirth mother is severely depressed + thoughts to harm the baby= Rx ECT

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Ophthalmology and E.N.T____________
-- Curtain falling ? amaurosis fugax or retinal detachment

-- A patient with hx of IHD, STEMI, developed acute loss of vision =

C.R.A.O

-- Tunnel vision, seeing holes = glaucoma

Acute Glaucoma= Rx= topical pilocarpine and steroids, controlling BP and IV

mannitol

Doubled vision when climbing downstairs = paralytic squint of 3rd nerve palsy.

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-Diabetics with ear furuncle = staph

-Any ear perforation = immediate refer

-Mass in fron of ear drum = wax/ ???

-Mass behind of ear drum = cholestema

-Family history of hearing loss = otosclerosis

-Hearing loss with facial numbness + tinnitus = acoustic neuroma

-Old age degenerative hearing defect = presbycusis

-Unilateral sensory hearing loss = acoustic neroma (will have facial pain)
Bilateral sensory hearing loss = noise induced ( heals spontaneously) Bilateral
progressive sensory hearing loss = presbycusis

-Bilateral conductive hearing loss = otosclerosis, wax

-Mx of otitis externa = Genta (topical), Cipro (oral)

-vertigo following URTI = vestibular neuritis (labyrinthitis)

-Deafness + vertigo + tinnitus = Menier’s

-Basal skull fracture (temporal) = ear discharge (petrus)

-Basal skull fracture (ethmoidal) = nasal discharge

-Pink ear drum = viral OM

Red ear drum = bacterial OM

Best ABx for OM = amoxicillin + anti-b-lactamase or anti-staph penicillin

A nasal septal defect = suspected cocaine abuse

Hoarsness / loss of voice following physiological or prolonged intubation =

functional dysphonia

Causes of tinnitus =
CVS= high BP ,Anaemia( hyperdynamic)
ENT causes = Menier’s disease, post-stapedectomy
otosclerosis, acoustic neuroma
Drugs = Salicylates, loop diuretics, aminoglycosides
Psychological
Subjective Idiopathic Tinnitus( SID) diagnosis by exclusion
of all the above + Functional MRI ( due to abnormal signalling between
nucleus accumbens and auditory cortex( Rx = Melatonin at night)

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 OBSGYN_______________________

Osteoporesis

_ Management of osteoporosis= DEXA(diagnostic investigation ),

BISPHOSPHONATES, CALCIUM AND VITD SUPPLEMENTS

_ OSTEOPOROSIS>>> treatment- Alendronate> Etidronate, Risedronate>

Strontium

_ Post menopausal symptoms=HRT

_ OSTEOPOROSIS secondary to steroid intake in IBD(CROHNS)-first add

calcium and vitamin D supplements, Then check bone density after 1 year, if
<-1.5 ,start bisphosphonates

_ Patient doesn't tolerate BISPHOSPHONATES- give RALOXIFENE

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Menstrual Problems
_ Primary amenorrhoea+ cyclical lower abdominal pain= imperforate
hymen=anatomical cause

_ Hyperthyroidism=ologmoenorrhoea+tremors+ palpitation= do TFts

_ Lactational amenorrhoea=amenorrhoea following breast feeding

_ Reassure for perimenopausal symptoms

_ primary dysmenorrhoea (without any cause) =mefenemic acid

_ Menorrhagia with contraception = IUS>COCP

_ Acute treatment for heavy menstrual bleed=tranexemic acid

Pelvic Mass
_ Old woman+abdominal bloating+ frequency micturition+ difficulty
defaecation+ usg-cystic and solid areas raising from left ovary+ free fluid in
pouch of douglas=OVARIAN CARCINOMA
_ Right ovary with complex solid cystic mass=DERMOID CYST

_ Young lady+dysmenorrhoea+dypaeurnia+infertility+tenderness on abdominal

pelvic exam, usg=right sided cystic lesion with numerous echogenic
areas=ENDOMETRIOSIS

_ Acute PID= abdominal pain+dysuria+vaginal discharge +tender in lower

abdomen+vague mass in left Iliac fossa+inflamed cervix+purulent discharge
+unprotected intercourse

_ TUBOOVARIAN ABSCESS=high temperature +lower abdominal pain + past

history of PID + usg-cystic ads with mixed echo patterns

_ TORSION OF OVARIAN CYST=acute sharp shooting pain in right lower

abdomen+ vomiting+ periods 3 weeks ago+usg=cystic mass in right adnexal
region +absent flow on Doppler

Miscarriage
_ Obese and Hirsutism >>> PCOS ( Luteal phase defect)

_ Miscarriage in second trimester is unlikely to be caused by congenital

abnormality

_ Recurrent miscarriages early in the first trimester=APLA

_ CERVICAL INCOMPETENCE= recurrent pregnancy loss in second

trimester+h/o PROM+ early dilatation of cervix

_ Give prophylactic antibiotics in PROM to prevent choriamnionItis

DOC=METRONIDAZOLE.

Contraception
_ young lady non smoker + regular partner+ contraception= COCP

_young lady, smoker+ family history of DVT+ PE +regular partner+ heavy

periods=IUS

_ HIV patient+ contraception = Barrier method=male +female condoms

_young woman with learning disability +heavy bleed=INJ. DEPOT PROVERA

_ 14year girl + sexually active>>>contraception =COCP+ condoms

_ >35 year old smoker+contraception + doesnot wish to gain

weight=IUCD(inserted within 48 hours of delivery / after 4 weeks)

_ young lady+heavy periods+ dysmenorrhoea+ contraception=COCP

_ rifampicin+COCP=use additional Barrier method

_ learning disability+ contraception = IMPLANON

_ Breast feeding woman+contraception =POP

_ Lady presenting within 96hours of unprotected intercourse, on the 12TH

day of the cycle >>>emergency contraception >>>>not interested in long term
contraception =ELLA ONE (ULIPRISTOL ACETATE)

_ Lady presenting within 36hours of unprotected intercourse >>> emergency

contraception =LEVONORGESTEROL

_TUBAL STERILISATION FAILURE RATE = 1:200

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- Any post-coital bleeding = 1st > speculum examination and Cx smear

- Smear showing inflammatory changes > treat infection and repeat in 6
months
- showing any degree of dyskariosis> colposcopic biopsy
- EndoMetrial carcinoma mets > MRI scanning
- Cervical carcinoma mets > CT scanning

- A patient after Hysterectomy wetting herself > Iatrogenic Ureterovaginal

Fistula.

- Post-menoupausal endometrial thickness > 8 mml best step > Hysteroscopy

_ Post-miscarriage haemorrhage > D I C

 MEDICINE .

C.V.S

NICE GUIDELINES FOR HTN AND MI

Angina : ( proved to be ischaemic )

Rx= Aspirin 75 + Statins + GTN spray or subling ( to relieve attacks) +
An anti-anginal; one of these
1st line ( BB or rate-limiting CCB)
2nd line Long-acting nitrates
3rd line newer agents = Ivabradine, ranolazine or nicorandil
- CHF = not improving on loop diuretics > Add thiazide
- HOCM = B-blockers
- DCM = diuretics

- Ix of choice in murmurs > Echo

- Symptoms=
Rapid pounding = VT
Slow pounding = Heart block
Missed beat = V. ectopic
Thumbing heart= atrial myxoma

- RF =
Sure diagnosis = Rx = 1) Benzylpenicillin then phenoxymethylpenicillin ( For allergic
Erythromycin or azithromycin)
2) High dose aspirin +or- steroids for carditis
3) Haloperidol for chorea

Then  2ry prophylaxis  if no carditis at all  for 5 years

Carditis but no valvular damage  for 10 years
Valve involved  at least until the age of 40 or for life
 the Antibiotic used  Penicillin V or sulfadiazine or Erythromycin.

- Contraindications ! =
ACEIS and ARBS = Renal artery stenosis, Hypertensive nephropathy, angioneurotic
oedema
B-blockers = Asthma, heart block
Calcium channel Blocker = heart block, oedema, heart failure
 Non-DHP CCB ( Diltiazem and verapamil) are CI with BB ( both rate-limiting and
slowing conduction  fatal heart block )

B-blockers = in Prinzmental’s angina ( worsen coronaries spasm)

- WPW resistant to ttt  accessory pathway ablation

- Pregnancy-induced HTN  A-methyl dopa

__________________________________________________________________
Neuro

_________________________________________________________________
- Anti-platelet after stroke= Aspirin 300mg for 2 wks then clopidogrel or Aspirin 75 +
dipyridamole
- Post-TIA  aspirin 75 + statins ( if applicable )
- Weakness everywhere ( UMNL and LMNL that you can’t detect where’s the lesion)
but intact sensory, sphincteric and eye movement functions  MOTOR neuron disease

- Severe headache, vomiting, seizures, decreased VC = Sagittal sinus thrombosis

- Acute personality change/ frontal release sings ( Snout reflex, rooting reflex ,palmo-
mental reflex, wetting themselves without being ashamed – in spinal cord lesion patients
wet themselves but feel embarrassed – offensive speech)  FRONTAL LESION

- all the frontal CP + fever  Encephalitis

- Meningitis  no cortical symptoms ( just meningism; stiffness, Kernig’s sign, fever)

- Alzheimer’s disease =
Donepezil, galantamine Rivastagmine are NICE-recommended lines of ttt
Memantine ( and anti-glutamenergic are reserved for severe symptoms or late
presentation only)
vitamins = The only evidence of efficacy exist for vitamin E.

- 
Temporal lobe= Déjà vu, emotional disturbance, dysphasia, oral stereotyped
movements( lip smacking, chewing) Bizarre behaviour like severe unreasonable crying

Frontal = Jacksonian march( fits that spread; starting from face or thumb and then
generalise; consciousness is not impaired), motor arrest, dysphasia, post-ictal palsy

Parietal = sensory aura or any sensory changes

Occipital = visuals
--------------
RX=
Focal = 1st line carbamazepine/ lamotrigine
GTC = 1st Sodium Valproate or Phenytoin
Tonic or Atonic = 1st line Sodium Valproate
Myoclonic = 1st Sodium valproate or levetiracetam
Absence = 1st line = Ethosuximide or sodium valproate
 In pregnancy= LAMOTRIGINE is safe ! the others no ( worst of them; Absolute CI,
Sodium valproate, phenytoins)
The only anti-epileptic that do not go to breast milk Carbamazepine and sodium
valproate ( Lamotrigine is present in brest milk but does no harm to infants)

- Patient in fits now  ABCD  Lorazepam

- Status  Fosphenytoin  then barbiturates  then propofol
----------------

Parkinsonism= Rx ( consider PD like type 2 DM; the best ttt is insulin but we try to delay it
using Orals until risk-benefit ratio impose using insulin )

Levo-dopa combined with peripheral dopa-decarboxylase inhibitor is the most effective

( but the earlier you rx it the earlier the wear off  will double the dose  wear off 
and so on until not more increase is possible . So many try to control symptoms early with
other lines and postpone L-dopa as long as possible)

Anticholinergics effective but doesn’t improve hypokinesia + cause urinary retention and
dementia in old ptns ( reserved for the young)

Apomorphine ( EMERGENCY PEN ‘’ SC injectable pen ‘’ FOR FREEZING CRISIS )

Dopamine agonist pramipexol and ropinirole : used early to delay starting L-dopa and with
it to minimise the dose. Also = MAO-B inhibitors and COMT inhibitors.
____________________________________________

- Ipsilateral: deafness, decreased coreal reflex, nystagmus, ataxia, VI palsy and

papilledema  Cerebellopontine angle lesion ( Acoustic neuroma, schwannomas)

- Myasthenia gravis Rx

long-term  Pyridostigmine + propantheline ( to decrease cholinergic S/E)
Steroids or azathioprine
Myasthenic crisis  Admit + Ventilatory support
Plasmapheresis or IVIG

- Benign increased intracranial tension An adult with signs and symptoms of raised ICT+
Free Ct and MRI  Rx  Acetazolamide
__________________________________________________________________
- Fever + Behavioural changes + seizures + ear discharge  Cerebral abscess.
- Loss of skilled movements to a further extent than gross and primitive movement
 UMNL

- Loss of everything as if the limb is dead  LMNL

___________________________________________________________________
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___________________________________________________________________
TYPES 
Type 1 DM  Autoimmune destruction of beta cells ( HLA DR3 +or- HLA DR4)
LADA  The same but with adult onset.

Type 2 DM  multifactorial disease

Drug induced DM  after
Pregnancy-induced DM  might resolve or progress to type 2
Impaired glucose tolerance ( postprandial ) – Impaired Fasting glucose
Associated with other conditions ( curable)  Cushing’s/ Acromegaly/ pancreatic diseases
Hyperthyroidism. MODY  DMII in young

Syndrome X  central obesity + at least two of

1) Blood pressure > 135/85
2) Fasting glucose > 5.6 mmol
3) Type 2 diabetes
4) Triglycerides > 1.7 mmol
5) HDL < 1.03 males or 1.29 females
__________________________________________________

Rx  Type 1  Insulin
Type 2  1st line Diet and lifestyle +or- Metformin
2nd line If HBA1c > 58 mmol  Metformin + any of ( SU or glitazones or
DPP4 inhibitors or glifazon )
rd
3 line if HBA1C > 58 mmol after dual  Metformin + SU + one of:
Glitazones or DPP4 inhibitors or glifazon )
 INSULIN if 
Tripple therapy not tolerated.
HBA1C still > 58 mmol
Pregnancy induced  Insulin. Drug induced Stop drug causing and metformin
+ Excess Cortisol HTN. Low BP –
 HTN + Lemon-on-stick Hypokalaemic Metabolic Hypoglyvameia- Episodic attacks like
obesity + moon face+ alkalosis Abd pain, nausea n Panic attacks
Hyperglycaemia+ Abd Hypernatraemia vomiting + pigments! ( headache + tachycardia
striae. ( or everything low + tremors + sweating
+ Terror and feeling of
: Picture of
impending death )
hypothyroid+ Addison
it’s like hyperthyroidism
+ hypogondadism
but episodic is the key
Hypopituitarism )
st
1 line test 
overnight dexa. 1) Plasma electrolytes: 1) Plasma electrolytes
Suppression test  - High Na  everything low 1) 24 hrs urinary
> 50 nmol abnormal - low K except K+
METANEPHRINS &
nd
2 line test  METADRENALINE
2) Hormones  2) ACTH stimulation
if 1st is positive do test ( synacthin test)
48 hr dexa suppression in 1ry hyperaldosteronism 2) CT-MRI adrenal
test. Because 1st has  LOW renin + high if cortisol rises
many false +ve)  if aldosterone  NO Addison
Abnormal it means just but it’s pituitary hypo TESTS to exclude
cushing’s syndrome in 2ry hyperaldosteronism MEN syndromes
confirmed  High renin + high if no rise
aldosterone ( Renal artery 
To localise lesion  stenosis and any it’s Addison’s disease
^^ Plasma ACTH  renovascular disease --
undetectable  Adrenal faulty use of ACEI )
tumor ( do MRI/Ct
adrenal) 3) Image the suprarenal

^^ Plasma ACTH Hyperplasia
detected  malignancy or what?
High dose suppression
test or CRH test  if
cortisol level respond to
manipulation
Pituitary tumor. If not
chest ,abdomen ,pelvis)
Rx 
- Addisonian crisis  Steroids
- Conn’s  Spironolactone
- Pheochromocytoma  phenoxybenzamine and b-blockers  BB alone will increase the crisis
_________________________________________________________________________

ACROMEGALY  Spade-like hands + Bitemporal hemianopia

Ix OGGT + IGF-1 and GH levels during the OGGT
MRI pituitary
Mx Surgery
if it fails  Sandostatin.

_________________________________________________________________________

THYROID

GRAVE’S  Bruit sign + Eye signs + Antibodies.

Toxic multinodular Goitre  none of the above + high ESR + History of SMNG
Toxic adenoma  solitary nodule.
Ectopic thyroid tissue  T3 is very high in proportion to mildly elevated T4
2ry hyperthyroid  TSH is also high

TSH T3T4 dx
High High 2ry hyper
Low High 1ry Hyper
High Low 1ry Hypo
Low Low 2ry Hypo
High N Subclinc hypo
Low N Subclinc Hyper

Isotope Scan 
Hot nodule  Toxic adenoma / Localised form of toxic MNG
Diffusely hot  Graves / Toxic MNG
Cold nodule  Cancer  next step  FNAC
__________________________________________________________________________
Diapetes Insipidus 
Water Deprivation Test 
Urine osm b4 < after  CRANIAL DI
Urine osm b4 and after alike  The Urine doesn’t respond to the test and the kidneys do not
respond to ADH  Nephrogenic DI

- Tall, infertile, bilat gynecomastia and small testis  Klinefelter’s

- Ambiguous genitalis  Cong adrenal hyperplasia
- 1ry hyperpara  Surgery
2ry hyperpara  Vit D and Ca+
2ry hypopara  Ca gluconate and Ca supplements

__________________________________________________________________________

RESPIRATORY

Asthma Stepped approach 

-  Occasional inhaled short acting B-agonist ( to relieve attacks)

-  Add inhaled steroid at standard dose

-  Add inhaled long acting B-agonist  increase dose of inhaled steroids ( 2000 mcg is
maximum dose/day)

-  Omit inhaled long acting b-agonist and use:

occasional inhaled short-acting b agonist + inhaled steroids high dose + one of :
- Modified release theophylline oral
- Modified release B-agonist oral
- Leukotriene antagonist and mast cell stabilizers

-  Add to them oral prednisolone.

__________________________________________________________________________
 Stop smoking / Vaccine
- Mucolytics + ttt of any infection
- Consider stepped approach 
Short acting B agonist ( SABA ) + short acting anti-muscarinic ( SAMA )
Then  add LABA + or – LAMA
Then  add Inhaled corticosteroids
_______________________________________________________________________

- Bilateral HL + infiltrates + Extra-pulmonary ‘’ Erythema nodosum, keratoconjunctivitis, arthralgia

‘’  SARCOIDOSIS

-
Lung carcinoma/ mesothelioma / lung fibrosis /
chronic pus ( abscess/ empyema/bronchiectasis)
Cyanotic heart disease/ Atrial myxoma / IE
Inflammatory bowel disease / cirrhosis
Idiopathic ( no disease).

_________________________________________________________________________

A triad of  Paroxysmal dry cough and dyspnea + CXR  small infiltrates + Restrictive pattern PFT


Autoimmune  Sarcoidosis, RA ( Caplan’s syndrome) , SLE and others

Exposures 
Coal worker ( small round opacities in upper zone )
Silicosis ( Diffuse nodular pattern )
Asbestoses ( will develop mesothelioma)
Drugs

Idiopathic pulmonary Fibrosis  Consider offering clinical trials participation

Pirfenidone / Nintedanib slow progression
__________________________________________________________________________
a patient with RF ( malignancy, surgery, immobility or , perhaps, without RF and young ! ) +
Acute chest pain and dyspnea +
ECG  ST abnormality or normal ST / Rt Vent Strain or normal / might be just tachy
CXR  No thing obvious
ABG  Type one RF

Rx H. unstable  Altepase

H. stable  LMWH then either warfarin or DOAC
IVC filter if CI anticoagulation
________________________________________________________________________

Pneumonia and  1) Rash and target lesion  Mycoplasma  Rx doxycycline or clarithromycin

2) Hotel air-conditioner traveler’s pneumonia + extrapulm ( hepatitis, diarrhoea)

+ LYMPHOPENIA
 Legionella  Rx Ciprofloxacin or Clarithromycin
3) Biphasic Illness ( otitis, pharyngitis or hepatitis  then pneumonia )
rash, arthralgia  Chlamydia  Rx Clarithromycin or doxycycline

4) in Stroke, bulbar palsy or GORD  Aspiration  Anaerobes 

Rx cephalosporin + metronidazole
5) typical pneumonia with lobar CXR  Pneumococci  Rx co-amoxiclav or
cephalosporins
6) Bronchiectasis or cystic fibrosis  Pseudomonas  Aminoglycosides +
Ceftazidime or meropenem or cipro
7) HIV  Pneumocystis jirovecii  Co-trimozazol
8) Hospital-acquired  Pseudomonas, staph, Bacteroides or Gm-ve enterobact.
__________________________________________________________________________
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___________________________________________________________________
Infections

___________________________________________________________________

Dx  Consider in any patient with fever who has been in an endemic area within 14d: 3
months duration !
Symptoms  Fever ( no specific pattern uless RBS rupture)
- Every other day ( tertian fever): P.falciparum, ovale, and vivax
- Every three days ( quartan). P.malariae.
Signs  only with haemolysis  Jaundice + Hepatosplenomegaly
Ix  Thick and thin blood smears . Rapid antigen detecting test
Rx  Artimether-lumefantrine 4 tablets at 0-4-8-24-
36-48-60 hours or Dihydroartemisinin-piperaquin 4 tabs OD for 3 days
Chloroquine
 Non-specific Flu-like symptoms in a patient with RF (injections, sexually active, blood
transfusion, surgery )
Fever of Unknown origin / persistent lymphadenopathy
Unusual infections ( Fungal pneumonia, candidiasis, atypicals) or repeated
infections or
 Opportunistic infections + Lymphomas / kaposi’s sarcoma
+ CD4 count <200 .

1) Rapid immunoassay kit  if +ve needs serological confirmation

2) ELISA ag-ab test  confirms
3) PCR and other Viral load 4) CD4 count

- Diarrhoea  Cryptosporidium - Oral ulcer/ Dysphagia  Candidiasis

- Neuro symptoms or personality change  Toxoplasmosis Gondii
- Pneumonia  Pneumocystis jirovecii

Consider prophylaxis of opportunistic infection if CD count < 350

- Anti-retroviral therapy  NRT inhibitors ( abacavir, tenofovir, lamivudine) + one of
- Protease inhibitors - non-NRT inhibitors - integrase inhibiotrs
_________________________________________________________________________

Sexually Transmitted diseases  Ix

Chlamydia trichomonas and N. Gonorrhoea  Nucleic Acid Amplification Test ( NAAT) on :
Vulvo-vaginal swabs for females/ first-pass urine for males / pharyngeal and anal swabs
( if oral and anal sex were practised )

Syphilis  Screening : RPR and VDRL serology ‘’ non-specific ‘’

Confirming: PCR or Specific serology ‘’ TPHA & TPPA ‘’

Lymphogranuloma venereum  PCR .

Donovanosis and chancroid  PCR and donovian bodies in tissues.
- After Exposure prophylaxis of Rabies  Vaccine + anti-rabies IG

- Seizures + Odd behaviour + Focal signs in pork-eating individual  neurocysticercosis (T.solium)

- MRSA in ward  Test all staff

-MRSA +ve in staff  Mupurocin Nasal Spray.

- Glandular fever or rash after amoxicillin  EPV

- Has been in India  Membranes on tonsils that bleed + low grade fever + Bradycardia
 Diphteria
__________________________________________________________________________

Gastroenterology

Abd crampy pain + diarrhoea with mucous

and blood in relapsing-remitting pattern + extra-GIT Erythemas, rash, arthralgias

1) Pathology: Proctitis (30%)

Left-hemicolitis (40%) pancolitis 1) Pathology: any part of GIT but
(30%) . Ulcers+ pseudopolyps mainly terminal Ileum. Skipped
Never spread proximal lesions
to Ileocaecal valve. Never skip . Masses. Transmural
mucosa. Never Transmural.

2) Ix: -scopy +or - Biopsy or xray 2) Ix :

- decreased goblet cells
- No skip lesions - increased goblet cells
- Pseudopolyps and ulcers - skipped lesion
- Fistulae and masses
3) Rx=
Mesalazine. In severe attack: 3) Rx=
Induce remission with prednison Steroids mainly
then maintain of mesalazine

__________________________________________________________________________
IBS like symptoms + steatorrhea or ( stinking stool ) + Stomatitis + Anaemia ( IDA and low vit b 12
as well )  Coeliac disease

Pellagra  disease:
iarrhoea + ementia + ermatitis + ( any neuro symptom is possible : ataxias, fits,
neuropathies, depression . In an individual on soniazid or with arcinoid tumor
Rx  Nicotinamide

Scurvy   regnant, oor and irates ( actually sailors and anyone on strict diet)
Bleeding gum and gingivitis + Musculoskeletal and joint abnormaities
Rx ascorbic acid.

Beriberi  Dry beriberi is just a fancy way of describing Wernicke’s encephalopathy

Wet beriberi  congestive heart failure and edema in an alcoholic or strict vegetarian.

_______________________________________________________________________

- Chronic HBV B and C infection - Chronic alcoholism

- Congenital  ( cirrhosis + jaundice + Lung ‘’obstructive’’ patho)
any young man with MOVEMENT disorder ( Pk or chorea) + cirrhosis
 high Iron + skin pigmentation + diabetes.
- Autoimmune  Primary Biliary cirrhosis ( AMA +VE) and Primary sclerosing cholangitis
AIHA  Type I ANA and ASMA +Ve
Type II ANA and ASMA -ve but LKM +VE
- Non-alcoholic steatohepatitis  starting as fatty liver
-Budd-Chiari syndrome  rapid deterioration in LFT but the liver is large and tender
- Drugs  Paracetamol overdose/ methotrexate/ amiodarone /methyldopa.

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___________________________________________________________________
Nephrology

After strenuous exercise, running for long distances  Rhabdomyolysis

- After Certain drugs  Antiplatelets/ Rifampicin
If porphyria after  OCP – Barbiturates – Oral Hypoglycaemic
- Stone and Lower UTIS  UA  no casts
- Glomerular causes  Renal carcinoma + Glomerulonephritis  UA : CASTS

____________________________________________________________________
- In CKD  Small kidneys/ lost corticomedullary differentiation
- After a week of URTI in a child  GN  IGA nephropathy
- Mx of anaemia in CKD  Erythropoietin

- Stone + thiazide use  Gout

Mx of lupus nephritis 
Class I and II  ACEI + control of SLE elsewhere
Class III immunosuppression : Mycophenolate / cyclophosphamide / rituximab / prednisolone
Class IV  The same + consider Kidney transplantation

- Acute tubule-interstitial nephritis  consider in any AKI when no recognizable pre or post
renal cause and when there’s no either nephritic or nephrotic syndromes 
Causes  Drugs: NSAIDS / Lithium / PPIs / Antibiotics ( esp aminoglycosides ) Contrast
Infections: Strept, Enterobact, mycoplasma, EPV, HSV
Autoimmune !

- Autosomal Dominant PKD  Manifest later ( 30 year old ) Young man+ resistable HTN
- ARPKD  manifest severely during the perinatal stage.

-Alport syndrome  X-linked  defect in collagen IV  GN + sensorineural hearning loss

- Fabry disease  X-linked  defect in alpha-galactosidase  proteinuria and ZEBRA BODIES in

Urine ( deposited lipids)
__________________________________________________________________________
__________________________________________________________________________

Haematology

- Anaemia + repeated infection ( FEVER and Sore throat) + Bruises  Leukaemias and
aplastic anaemia  Bone marrow biopsy

- Bleeding tendency + …..

1) All tests normal + family history  AHereditary Haemorrhagic Telangiectasia
2) Prolonged clotting time + family history  Von Willebrand disease
3) low platelets. Young Girl  ITP
4) Low platelets + KFT abnormal  TTP
- A young girl presented with ITP. Initial management  Steroids
Platelets are given only if Plat count is less than 20x10 ( they will be destructed)

- Post-splenectomy 
1) Vaccines against Pneumococci and HI
2) Life-long phenoxybenzamine
3) Prophylaxis against Malaria if travelling to endemic area

-Supportive treatment in Acute Leukaemia ( more life-saving than chemo) :

1) Platelet and blood transfusion
2) Neutropenic Antibiotic regimen  piperacillin-tazobactam + or- Vancomycin
Co-trimoxazol if pneumocystis suspected

- Hodgkin lymphoma regimen  ABVD

- Non-Hodgkin  R( for rituximab ) CHOP regimen.

- Most common cause of iron deficiency anaemia  Gastrointestinal Bleeding

_________________________________________________________________________

Paediatrics

Female with coarctation of aorta = turner’s (45XO)

Small chin, low ears, rocker bottom feet = Edward’s synd 47XY (Chr.no.18)

Tall boy with female features = kleinfilters synd (47Xxy)

Dysmorpphic, floppy body = Down’s 47XY (21)

Large head with large testes = fragile X-syndrome

Cyanosed body = boot shaped heart = tetrology of fallot

Failure to thrive, pansystolic murmur t lower sternal edge, prasternal thrill= VSD Cool extremities,
no femoral pulse = transosition of great vessels????? Machinary murmur = PDA
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
1) Eosinophilia, Bell's palsy, multiple shadows on CXR plus asthma ?
Churge strauss syndrome
( +ve ANCA vasculitis characterized by small vs vasculitis + eosinophilia and asthma , may be e
polyneuropathy, pulmonary infiltrates and paranasal sinusitis )
________________________

2) plummer vinson : dysphagia ( esophageal web ) + iron def anaemia ( glossitis and cheilitis )
__________________

35 yo female on PPIs for 9 months with poor response developed an attack of haematemesis.
Upper Gi biopsy of a duodenal ulcer reveals it is non-malignant peptic ulcer . There were 3
ulcers? Dx

Well : any resistant peptic ulcer should raise the suspicion of 2 things : Malignant ulcer / gastrin-
secreting tumour.
Dx : zollinger ellison. ( a pancreatic tumor secrete gastrin leading in multiple resistant peptic
ulcers )
________________

Crohn's disease= cobble stone appearance

___________________
Milk alkali syndrome : abusing calcium suppl  stone, psychic moan, abdominal groan (
recurrent renal colic _ dyspepsia _ deprezsion ) with any hypercalcaemia in general.
___________________

Syndromes in yellow

Jaundice ptn ?
Is it unconjugated ? Or conjugated?
Uncong but everything normal ( LFT ane FBC no liver affection no haemolysis )  Gilberts
syndrome
" familial impaired bilirubin conjugation intermittent insignificant hyperbilirubinaema "

Crigler Najjar : the same ( indirect hyperbilirinaemia without haemolysis ) but present since 1st
day of life with serious consequences ( it's two types of mutation in a gene responsible for
conjugation . Type 1 is Absence mutatiom so severer, Type 2 is impairment mutation so milder )
Is it conjugated ?
Well if conjugated with normal AST and ALT and serious affection , presenting in teens
intermittently and resolving spontaneously  Dubin johnson  genetic impairment of
hepatocytes excretion of bilirubin ( no liver ds and no biliary obstruction )

Rotor : rarer and severer.

Conjugated hyperbilirubinaemia , normal liver enzymes normal FBC , but in cholecystography
 absent liver ( no biliary flow at all )
________________

Budd-chiari syndrome  transudate ascitis

_____________________
Ramsay Hunt Syndrome :

Due to herpes zooster - Facial nerve invasiom  severely painful vesicles on face and ear
( key is the ptn is considerable unwell fever , high ESR, BP and pulse affected by sympathetic
panicking )
__________________

Sjogren syndrome : autoimmune distruction of dear body lubricants

Primary ( in middle age female on its own ) or 2ry to CT diseases ( SLE, RA, SS) or can occur
with ( AHepatitis, thyroid diseases)

Dyspareunia + red eye and gritty sens + dry mouth and saliv problems + or- arthralgia

Dx : shimer test and rose bengal( ophthalmology stuff ) +ve Ro La and positivr ANA and RF

Rx : symptomatic ( lubricants and artificial tears) + hydroxychloroquin or stronger immun-supp

drugs

There's a risk of non-hodgken lymphoma

_________________________

Loffler's syndrome : bilateral hilar LN + arthralgia + erythema nodosum

________________
Kounis syndrome : a young man developing coronary syndrome ( ECG changes are positive
sometimes ) after a certain allergen. Penicillin injection/ unusual food . It is an allergic
inflammatory response of coronaries to that allergen .Rx is steroids
_____________________
Good-pasture syndrome : cough and urinate blood
Haematuria-proteinuria ( anti-glomerular basement membrane ab) + haemoptysis ( anti- alveolar
basement membrane abs )
___________________________

Steven Johnson syndrome

( Aka acute skin failure, or, sarcastically, the only dermatological emergency )

Starts as fever and erythema multiforms ( target lesiom ) rapidly progressing to shedding of skin
,shock , sepsis and death if not treated after :
Infections : pneumonia HAV or HIV
Drugs : anti-convulsants ( particularly barbiturates, carbamazepin and phenytoins )
Penicillin and sulfa
Acetaminophin / ibuprofen
Modafinil ( CNS stimulant for narcolepsy )
With Cancers

Rx : infection controlling measures. In severe cases steroids , IV IG and plasmapheresis are

proven good
_______________

Neuroleptic malignant syndrome:

A young newly diagnosed schizophrenic patient presented with pyrexia, tachycardia, and acute
dystonia ( torticollis " head pulled backwards" trismus and occulogyric crises " eyes fixed
upwards " ) it is not meningitis despite fever and not tetanus

It occurs after chlorpromazine Halodol and some atypicals , also anti-emetics like
metoclopramide and cyclizine

Rx : 10 to 30 mg of procyclidine IM or if not available chlorpheniramine Im relieve the crisis (

unlike tetanus and meningitis )
_____________________

Post-concussion syndrome :
Any neuropsychiatric symptom after a concussion ( when is not known ) the key is :
+ it started after concussion not
Preexisting
+ No CT or MRI or EEG abnormality

_______________________
Korsakoff's syndrome :
Chronic alcoholic with memory loss, confabulation ( invent nonsense imaginary stories about
themselves to fill the gap of massive amnesia both retro&ante grade ones ) it is like wernickh
caused by thiamine deficiency
_________________
Horner syndrome :
Ipsilaterall ( to the lesion which might be vascular or neoplastic ) ptosis, myosis, enophthalmus
and anhydrosis
________

Lateral medullary syndrome :

Post-infarctiom( PICA or vertebral ar occlusion)

cerebellar ataxia and horner's syndrome , dysphagia dizziness and crossed sens loss (ipsilat on
face contra on body )

___________________
Try this wonderfully quick neuro game :
Dizzy and.... To know which artery( dizziness indicates posterior circulation involvement
generally)

Dizzy : SCA
Dizzy and deaf : AICA
Dizzy , dysphagic and dysphonic: PICA
______________

Subclavian steal phenomenon :

Usually TIA following effort done by one hand.
There's stenosis in subclavian artery before it gives the vertebral and axillary. The blood going to
vertebral is withdrawn by backflow to axillary after using that arm

Suspect if BP measures are 20 or more diff between two arms.

______________________
Antiphospholipids syndrome :
Repeated first trimesteric miscarriages + any of these +vein serology:
Anti-cardiolipin, Lupus anti-coagulant or anti-phospholipids

rx aspirin high dose for conception and once preg start heparin
______________________
Sheehan's syndrome :
A young lady cannot breastfeed her baby because no milk and no power  might become
shocked later  electrolytes are not ok
( post-partum hmg  pituitary ischaemia  insufficiency)
_________________
HELLP:
Hx is identical to a preeclamptic women but with severe epigastric pain, severely anaemic and
have purpuric eruption or becomes yellow
( Haemolysis, elevated liver, low platelet)
_________________________
Reiter's syndrome :
Urethritis, conjunctovitis and arthritis after GIT or GUT infection ( esp chlamydia )
It is an example of the broader condition reactive arthritis ( associated with +ve HLA-B27
individuals)
______________________
Meigs syndrome :
Benign ovarian tumor
Pleural effusion
Ascitis
_____________________

Alport syndrome :
sensorineural hearing loss and glomerrulonephritis
_____________________

________
HUS :
haemolytic anaemia
Thrombocytopenia
RF

Minimal change disease :

Loss of podocyte foot processes
Vaculation
Appearance of microvilli
Nephrotic syndrome :
Oedema
Proteinuria ( more than 3.5)
Hypoalbuminaemia

Nephrotic is complicated by 3 :
Increased lipoproteins ( hyperlipidaemia )
Hyperviscosity ( water lost in edema ) and so thrombi
Lost immunoglobulin.( infection)

GN nephritis :
Haematuria
Proteinuria is less than 3.5
HTN
____________________
Wernick encephalopathy : a chronic alcholic ( might be a ptn with anorexia nervousa ،
hyperemesis or strict diet ) developing :
- Acute confusion
- Cerebellar ataxia
- ophthalmoplegia

Minier's ds :
- Dizziness
- Vertigo
- sensorineural Deafness.
_______________________

Subacute combined degeneration of the SC. ( affecting 3 things: motor, sensory and
coordination)
So a triad of :
- Bilateral parasthesia
- Sensory ataxia ( +ve romberg sign )
- UMNL signs on Both LL ( knee jerk and brisk ankle reflexes )

___________________
Optic neuritis ( in neuro when the onset is gradual and the course is weeks to months it's either
inflammation or tumor, seconds to hours is vascular ) so gradually prog of :
- decreased VA
- Painful eye
- decreased color vision
____________________________
Mooren ulcer :
- prog poor prognosis
- ulcerative keratitis ( not degen)
- painful
___________________
Acute ascending cholangitis:
Charcot's traid
-RUQ pain
- jaundice
- fever
____________________

Beck triad " cardiac tamponade "

- Engorged neck veins
- muffled heart sounds
- hypotension
________________________

Rheumatic MS triad:
- cardiac : exertional dyspnia/af
- Malar flush
- radio: straight lt cardiac border
Silhouete on CXR

_________________________

MEN I : 3 ps
Pancreatic tumor
Parathyroid adenoma
Pituitary adenoma
( to translate this into ptn language : hypoglycemic psychologically suffering sexually
incompetent man )
MEN II A
Medullary thyroid carcinoma
Hyperparathyroidism
Pheochromocytoma

MEN IIB
Like IIA but take hyperpara out and replace it with marfanoid features or mucousal neuromas

Polyendocrine Autoimmune syndrromes:

Common association of. ( addison, vitiligo, alopecia, pernicious anaemia, primary and premature
hypogonadism)

In APE type 1: hypopara

In APE type 2 : type 1 DM, thyroid disease.
___________________________

Hiccough and :
Yawning and vomiting: lower brain stem lesion

Itching, earthy look and edema :

Uremia

And on chemotherapy: good hydration needd.

Hiccough metabolic cause: correct and might use haloperidole

________________

Lymphopenia 
SLE / Steroids / HIV / Hodgkin’s Lymphomas / Radio and chemo