These are the ESSENTIAL POINTS FOR FCPS IMM THEORY , MRCP 1 and 2 (MEDICINE). They are compiled from multiple sources and should ideally be given one or two reads one week prior to the exam. The points which are new to you should be marked or highlighted and the points which you already know should be left as it is. Write down the new points , separately. For CPSP exams in particular, there are many points and association in this collection which you just need to know in order to get through some questions and there isn’t much logic involved there.
- Pseudo Bulbar ===> Spastic tongue
- Bulbar ==> Flaccid and wasted tongue
- Raised Calcium + inappropriately raised or normal PTH ==> Primary Hyperparathyroidism
- Vitamin D increases both Ca and PO4 plasma levels.
- PTH is Phosphate Trasher so decreases its levels.
- Calcium levels are unaffected by hypophosphatemia.
- Carbimazole can be given in 3rd trimester.
- Pregnant women with gonorrhea ==> Rx Erythromycin
- Mitochondrial Inheritence = Maternal ==LEBER, MERFMELAS, KERNS, Hearing Loss (Sensory).
- DPP4 inhibitors e.g Sitagliptin are weight neutral i.e dont cause weight gain or loss.
- Oral glucose causes an increased insulin release than an IV dose. This is mediated by GLP 1 and is known as the INCRETIN effect. GLP 1 is low in T 2 Diabetes.
- There are only 2 cases where you would find a low ESR
a) Polycythemia
b) Hypofibrinogenemia
- SOB, Weight loss history of greater than 3 weeks + HYPONATREMIA ==> Screen for Lung Ca.
- METHIMAZOLE ==> AGRANULOCYTOSIS
- You start a patient on antithyroid like methimazole and patient develops sore throat, always look for and rule out Agranulocytosis.
- BENEDICT SYNDROME Obstruction of paramedian branch of basillar artery.
- Celiac disease associated with AV Cushion defects.
- BRUCELLOSIS affects reticuloendothelial system.
- Granuloma inguinale ==» klebsiella granulomatosis.
- Tabes dorsalis ==» charcot joints
- AML (15 : 17) good prognosis
- CML (9:22) Philadelphia good prognosis
- 9:22 in AML/ ALL poor prognosi
- Auer Rods ==> AML (15:17)
- AML M3 Rx ATRA
- HRT adding a progesterone increases risk of breast cancer.
OSTEOSARCOMA
Metaphysis
Worsening pain at night
Codman triangle
( Periostel new bone formation at diphysis )
Sunburst pattern
#OSTEOMETACODMANSUNBURST
EWING SARCOMA
onion skinning
diaphysis
10 to 20 years males
#EWINGONIONDI
Giant cell tumor
Soap bubble appearance
Epiphysial
20 to 40 years females
#GiantSoapEpi
Osteoarthritis mnemonic
Ouch my bad hands
Bouchard PIP
Hebberden DIP
Important Associations and points continued
- HLA DR 4 ==» rheumatoid arthritis
- HLA B27 ==»ankylosing Spondylitis
- Avoid and stop aspirin in gout even in flares as it decreases uric acid excretion.
- Give supplemental oxygen in COPD if anyone of the following are present
Post Strep Glomerulonephritis
Low C 3
2 to 6 weeks after infection
IgA Nephropathy
Normal C 3
Few days after initial infection
Membranous GN SPIKE AND DOME
Membranoproliferative Tram Track
Good Pasture Linear Anti GBM deposits IgG
Congenital Adrenal Hyperplasia ==> 21 hydroxylase deficiency ==> high 17 hydroxy progesterone
Cold Water Ear Test
COWS (COLD OPPOSITE WARM SAME)
Fast phase of nystagmus is towards opposite side Normally.
If fast phase is towards same side then its Pathological.
Severe hypoglycemia with no elevation of C peptide is Factitious Disorder.
Difference between schizophreniform and schizophrenia is duration. Form 3 months , Phrenia 6 months.
Haloperidol used for one year, now weird tongue movements ==> Tardive Dyskinesia
Acute dystonia, occulogyric crisis, acute squint ==> Rx Haloperidol
Asthma investigation of choice for Dx Spirometery with Reversibility
For asthma severity and response ==> PEFR
ADH ACTS ON COLLECTING DUCTS.
RV (RESIDUAL VOLUME) is increased in obstructive lung diseases.
Lung Cancer + cavitations ==> Squamous cell Ca
Bronchogenic Ca most common cause of ADENOcarcinoma
ASSOCIATIONS
SMALL CELL CA ==> SIADH, LAMBERT, CUSHING
LARGE CELL CA ==> GYNECOMASTIA
ADENOCARCINOMA ==> THROMBOPHLEBITIS, ENDOCARDITIS, HYPERCOAGABILITY
SQUAMOUS CA ==> HYPONATREMIA, HIGH CALCIUM, HIGH PTH
NON SMALL ==> HPO ( HYPERTROPHIC PULMONARY OSTEOARTHROPATHY)
PAP is not increased in ARDS
Pulmonary Embolus
SOB but stable ==> Heparin
Shock plus PE ==> Thrombolytics
O2 inhalation worsens CO2 narcosis so taper 1.2 L per minute.
Differential Bronchospirometery is done to determine volume and diffusion capacity of each lung.
Succusion splash ==> Hydropneumothorax
Pleural effusion doesnt cause lung collapse
Empyema thoracis Rx INTUBATE
Tidal volume remains same in both obstructive and restrictive lung disease.
RA + Obstructive PFTs ==> Bronchiolitis Obliterans
ILD bilaterally fine crepts all over the lungs, Dx HRCT
Post operative Fever Cough Crepts
Day 1,2 Atelectasis
Day 3 Pneumonia
Farmer Lung associations Gram Market and Mouldy hay
BAGGASOSIS SUGARCANE
SILICOSIS centrilobular emphysema
Rusty sputum Pneumococal
Pink Frothy Pulmonary Edema
Cystic Fibrosis has obstructive pattern on spirometery
Lower lobe fibrosis
CRABS
CRYPTOGENIC FIBROSING ALVEOLITIS
R.A
ASBESTOSIS/ ASPIRATION
BLEOMYCIN and other drugs
SLE / SCLERODERMA
PULMONARY FIBROSIS WITHOUT VOLUME LOSS
NEURO TUBERO LYMPHO X
NEUROFIBROMATOSIS
TUBEROUS SCLEROSIS
LYMPHANGIOMATOSIS
HYSTIOCYTOSIS X
Tuberous Sclorosus
Young girl
seizures
mental retardation
adenoma sebaceum
TIA investigation of choice CT BRAIN
Most common brain tumor GLIOMA
MLF lesion Impaired Ipsi Adduction and nystagmus in contralateral eye
B12 replacement can lead to hypokalemia and low iron.
Absent knee jerk plus upgoing plantars
MIXED SIGNALS FROM THE SPINAL CORD (Mnemonic)
MND (ALS TYPE)
SCD OF SPINAL CORD
FREDRIECH ATAXIA
TABES DORSALIS
STROKE + DIABETIC NEUROPATHY
CONUS MEDULLARIS COMPRESSION
ARNOLD CHIARI MALFORMATION ==> DOWNBEAT NYSTAGMUS
SUPRANUCLEAR PALSY ==> MARKED POSTURAL INSTABILITY
LEWY BODY DEMENTIA ==> VISUAL HALLUCINATIONS
Patient with increased ICP has shallow breathing
Neurology (focal) + CP Angle hypodense area ==> Schwanoma
Thalamus ==> Planning motor movement
Pregnant epileptic patient on valproate ==> what to do next ==> Dont change drug. Just Add Folate.
Subdural Bleed is VENOUS.
CST (Cavernous Sinus Thrombosis) ==> Complete Ophthalmoplegia
Elderly + Spastic Paraplegia + Dysphagia + UMN signs in Upper limbs ==> PseudoBulbar Palsy
MLF (Medial Longitudinal Fasiculus) Lesion ==> Ipsilateral Impaired Adduction + Contralateral Nystagmus
Carbon monoxide poisoning ==> Secondary Parkinsonism
Red cell casts ==> Glomerulonephritis
Granular casts ==> ATN
Papillary Necrosis ==> Diabetes in adults, Sickle cell in children
Peritoneal Dialysis Contraindicated in Ascites.
Peritoneal Dialysis preferred over hemodialysis in LVF + Hypotension.
Cystinosis is not a risk factor for urinary tract stones.
Quack Medications ==> Oliguria ==> Acute Tubular Necrosis
Antibiotics ==> Oliguria ==> Acute Interstitial Nephritis
Menetrier’s disease == protein loosing enteropathy
Partial lipoDystrophy == mesangiocapillary Dystrophy
Acute tubular necrosis== hyperkalemic metabolic acidosis
Genitourinary tuberculosis == sterile pyuria
Glomerulonephritis with normal complement levels
a) IgA nephropathy
b) Goodpasture syndrome
Uremia == normochromic microcytic anaemia
Hexagonal crystal == cystinuria
Renal failure + coagulopathy== RX desmopressin
Heavy chain proteinuria == glomerular disease
Diagnosis of reflux uropathy == CT pelvis or retrograde pyelography
IgA nephropathy Rx == cod liver oil
Membranous Glomerulonephritis == hepatitis B
Lutembacher syndrome == ASD + acquired mitral stenosis( rheumatic)
Aortic regurgitation == End diastolic Austin Flint durozier
Subacute endocarditis == strep viridans
Pulmonary capillary wedge pressure approximates left Atrium pressure
Swan ganzz catheter does not measure cardiac output directly
Dyspneoa == mitral stenosis
syncope == aortic stenosis ; palpitation == atrial fibrillation
Aniline dye == bladder cancer
Alpha-fetoprotein == teratoma
s100 == Melanoma shwanoma
Bombesin == neuroblastoma , small cell cancer, gastric cancer
CA 19-9== pancreas
CA 15-3 == breast
Pure red cell aplasia == normochromic normocytic anaemia
Best test polycythemia rubra Vera == red cell mass
X-linked factor VIII haemophilia A
X linked factor IX haemophilia b
Auto recessive factor 11 haemophilia c
Agranulocytosis == sore throat
MyeloFibrosis == lethargy
For hemolysis confirmation == LDH
For bone marrow response == retic count
ITP + autoimmune hemolytic anaemia == evAn syndrome
heparin resistant == antithrombin 3 deficiency
AML M 3 ==PML(Promyelocytic Leukemia) == all Trans retinoic acid == DIC (15-17)
CML (9 -22) Philadelphia good prognosis in CML poor in others
Erythropoietin administration is a risk factor for thrombosis
Anemia of chronic disease versus iron deficiency anaemia == TIBC… total iron binding capacity low in anaemia of chronic disease high in iron deficiency
Maximum reticulocytosis after 7 days of iron replacement
Polycythemia rubra Vera distended abdomen hepatic vein thrombosis buDD Chiari syndrome
Achalasia
1) Bronchitis common complication
2) squamous cell carcinoma serious complication
Barrett’s esophagus == adenocarcinoma
gastric ulcer greater with food
dUOdenal ulcer decreases with food, strong Association with H pylori
claw sign == barium enema
reverse Claw sign == Barium follow through
celiac disease associated with CA oesophagus
Vincent angina == gums == smokers
celiac disease == dx == endoscopy with jejunal biopsy
crohn’s disease == oxalate stones
VIpoma
1. Stool osmolality is equal to serum osmolality
2. achlorhydria
3. its excluded if stool volume is less than 700 ml
villous adenoma == hypokalemia
Puddle sign == minimal Ascites
shifting dullness == moderate Ascites
fluid thrill == massive Ascites
#PuddleDullThrill
hemochromatosis == idiopathic == transferin saturation , secondary == liver biopsy
gastrinomas == neck of pancreas insulinoma confirmation == supervised fasting
Sheehan syndrome diagnosis == pituitary function tests
Hyperthyroidism pregnancy == PTU propylthiouracil
Pagets disease == hydroxyproline in urine
Don’t give yellow fever vaccine in HIV
Faget sign seen in yellow fever
Rabies vaccine schedule 0,3,7,14,28
PUVA associated with squamous cell cancer
HypERkalemia with hypertension == liddle syndrome
Severity of DIC low fibrinogen levels
Thrombophlebitis carcinoma of pancreas
Nonpulsatile JVP == SVC obstruction
Kussmaul sign == constrictive pericarditis
(paradoxical rise in JVP upon inspiration)
Sudden onset flash pulmonary edema look for renal artery stenosis FM dysplasia fibromuscular dysplasia string of beads appearance on angiography
Turner syndrome
a. bicuspid aorta
b. coarctation of aorta
Post myocardial infarction( inferior wall) complete heart block is common and managed conservatively if blood pressure is normal
Pregnancy induced hypertension or preeclampsia does not occur before 20 weeks of pregnancy
Cardiac tamponade absent Y descent
pulsus paradoxus is present
Don’t give verapamil in ventricular tachycardia can lead to ventricular fibrillation
Angina persists increase Atenolol dose to 100 milligrams per day
Bisfiriens pulse mixed aortic valve disease
Collapsing pulse == aortic regurgitation, PDA patent ductus arteriosus
Hyperkinetic pulse (eg fever anemia pregnancy hyperthyroidism)
Primary pulmonary hypertension prominent a waves with raised JVP
Primary pulmonary hypertension Pulmonary artery pressure greater than 25 mmhg at rest and greater than 30 on exercise
Digoxin least effective at controlling heart rate during exercise. Its preferred choice in atrial fibrillation with left ventricular failure
SVC syndrome == non pulsatile JVP
HOCM diagnosis via Trans thoracic echocardiogram
Paradoxical emboli patent foramen ovale PFO more common than atrial septal defect
Stent thrombosis first month
Restenosis in 3 to 6 months (that is later)
Coarctation
* radio femoral delay
*mid systolic Murmur over the back
*apical click
* blood pressure upper Limbs greater than lower Limbs
Congestive heart failure introduce ACE inhibitors prior to beta blockers
BNP == good negative predictive value in CHF
In hypertrophic obstructive cardiomyopathy avoid Ace inhibitors nitrates and Inotropes
QT interval 430 milliseconds in males and 450 milliseconds in females
Implantable cardiac defibrillator ICD if QTc is greater than 500 millisecond or previous cardiac arrest episode
In low risk long QT treatment is propranolol
Digoxin decreases QT interval
Complication related with vsd ventricular septal defect is AoRtic REGURGITATION complication associated with atrial septal defect is atrial fibrillation
Drug eluting stent
decreases restenosis == angina 3 to 6 months
increases thrombosis == MI one month
Hypothermia J wave on ECG
BNP secreted by left ventricular myocardium
BNP lower than hundred excludes heart failure
Mitral valve replacement == 2.5 to 3.5 INR
Bioprosthetic valve == Aspirin
Mechanical valve == Aspirin + warfarin
Warfarin given only for first three months in bioprosthetic valve
Bicuspid aortic valve increase risk of aortic dissection by 6 folds
Bicuspid aortic valve associations
coarctation
Turner
dissection
left dominant circulation
Dilated cardiomyopathy == mitral regurgitation
Left dominant circulation
posterior descending artery arises from circumflex instead of right coronary artery
MURMURS
Ejection Systolic : A.S P.S ASD FALLOT (TOF) HOCM
DIASTOLIC : EARLY ==> A.R , P.R (Graham Steele)
MID TO LATE ==> A.R (Austin Flint), M.S
SYSTOLIC HOLO ==> VSD, M.R, T.R
LATE ==> MVP , COARCTATION
Lateral wall MI == Left circumflex artery
MVP == Apical click + late systolic murmur
Whilst, MVP is seen in Marfan quite a bit but still, Dilatation of aortic sinuses is much more commonly associated with Marfan syndrome.
Cardiac CT (Calcium score + Contrast CT ) == Very high Negative Predictive Value for Ischemic Heart Disease
SK contraindicated in severe hypertension, pregnancy and previous stroke less than 3 months back
DC shock contraindicated in Digoxin Toxicity , Catecholamines and MFAT
ASD associated with RBBB
Aortic Stenosis associated with LBBB
Coarctation associated with Berry Neuro (Berry aneurysm, Neurofibromatosis)
Brugada Syndrome
Convex ST elevation in V 1 — V 3, Partial RBBB, Changes more evident if Flecainide is administered
Tenson tuberous Xanthelesma == Familial, Remnant
Eruptive == High TG, LPL deficiency, Extensor surfaces
Palmar == Remnant
Most common acute complication of dialysis is HYPOTENSION.
Most common cause of hypotension in dialysis is ACETATE.
Nephronophthis is the most common cause of ESRD in adolescence.
Thyroid carcinoma
Follicular hematological spread
Papillary lymphatic spread
Third heart sound ==> Lvf and constrictive pericarditis
Eisenmenger occurs in Vsd ASD PDA
Mitral stenosis
Normally mitral valve 4 to 6 square cm
Tight valve if less than 1 cm square cm
loud S1 opening snap mid diastolic Murmur (best in expiration)
severe mitral stenosis
Murmur length increases opening snap becomes closer to S2
- Aspirin best outcome unstable angina
- ACE inhibitor and Beta blocker best in post MI and angina
- CPVT, Ryanodine receptor , symptoms before 20 years treatment beta blockers plus ICD
- Wolff-parkinson-white Associates associations HOCM MVP thyrotoxicosis Ebstein Secundum ASD
- Wpw ejection systolic Murmur increases with valsalva decreases with squatting
- QRS Complex corresponds to tricuspid closer on ekg
- Cholesterol embolism eosinophilia livedo reticularis
- Hypertensive patient using Lithium drug of choice amlodipine
- Patient with Central crushing chest pain St elevation in 2 3 avf give Aspirin clopidogrel heparin, immediate PCI
JVP waveform
- a atrial contraction
- c closure of tricuspid valve
- v passive filling of Atrium against a closed tricuspid valve
- X atrial relaxation
- y opening of tricuspid valve
- Recurrent pulmonary embolism is associated with secondary pulmonary hypertension it is not associated with primary pulmonary hypertension
- Atrial flutter radiofrequency ablation of tricuspid valve is is curative
- Atrial Flutter 150 ventricular rate 300 atrial rate
- Displacement of Apex beat shows severe aortic stenosis
- Canon waves regular vtach and avnrtCanon waves irregular (complete heart block )SVT A further dose of adenosine should be given if first injection doesn’t work 6 milligram IV stat than 12 milligram iv statebstein anomaly (tricuspid regurgitation / high V waves ) ==> exposed to Lithium in uteroLithiumfine tremor chronic treatment
course tremor acute toxicitymetformin should be stopped post MI ==> risk of lactic acidosistooth extraction of patient using 75 milligram Aspirin, continue to do so do not sto
- Gingival hyperplasia phenytoin cyclosporine
nifedipine AML
C-peptide increased in insulinoma and Sulfonylurea abuse
low in insulin abuse
Adhesive capsulitis frozen shoulder associated with Type 1 Diabetes
type 2 diabetes 100% Concordence in identical twins
Cushings vs pseudo Cushings ==> insulin stress test
Acromegaly ogtt with growth hormone test
Gynecomastia associated with hyperthyroidism not hypothyroidism
Leptin decreases appetite
Ghrelin increase appetite
Wilson disease does not lead to hepatocellular carcinoma
Physiological dead volume is equal to Anatomical Dead Space + alveolar Dead Space
Cbeat ( mnemonic ) carbon dioxide bpg exercise acid / altitude
all increases lead to HBO ( hemoglobin oxygen
dissociation curve) shift to right except pH
Bohr affect
oxygen binds less well to hemoglobin
better O2 elimination
Haldane effect
carbon dioxide bind less well to hemoglobin
better CO2 elimination
Lower lobe Fibrosis crabs (mnemonic)
Cryptogenic fibrosing alveolitis rheumatoid arthritis aspiration asbestosis Bleomycin plus
drugs SLE ,scleroderma
bullous pemphigoid hemidesmosomes no mucosal involvement
- Cyclosporine points Calcinurine inhibitor , hyperkalemia and non Myelotoxic
- Bupropion contraindicated in epilepsy
- drugs that can be cleared with hemodialysis blast
barbiturates Lithium alcohol salicylates theophyllineno
- No statins with macrolides ,no statins with fibrates (Significant drug interaction/ contraindicated)
- Tricyclic antidepressant poisoning
most common ECG finding wide QRS
greater than 100ms QRS higher risk of seizure attack
greater than 160 millisecond QRS risk of ventricular arrhythmia
- Avoid amiodarone in tricyclic antidepressants as it prolongs qt interval
- Alcohol poisoning disulfiram is contraindicated in psychosis and ischemic heart disease
- acamprosate reduces alcohol cravings
- Varencicline and bupropion are contraindicated in pregnancy
- NRT , mixed reports for pregnancy
Varencicline Suicidal
- Ecstasy hypernatremia
- hyperthermiahypercalcemia hypernatremia acidosis precipitate digoxin toxicity
- nicorandil antianginal potassium channel activator
- tamoxifen serm increased endometrial carcinoma risk
Roloxifen PERM pure oestrogen receptor modulator instead of selective oestrogen receptor modulator
- raloxifene lower risk of endometrial carcinomaAuto recessive are metabolic except inherited ataxias
Complement Deficiencies
- C3 leads to recurrent bacterial infections
C5 liner disease diarrhea dermatitis
C5 to C 9 MAC, Nesseria meningitis
C 1,2,4 SLE, HSP
J waves hypothermia
Delta waves wpw
U waves hypokalemia
hypokalemia also presents with long PR long QT and St depression
vitamin D increases both plasma calcium and phosphate levels
negative acute phase reactants albumin , transthyretin (prealbumin) transferrin , retinal binding protein ,cortisol binding proteinlow ESR
polycythemia and Low fibrinogenCRP is normal in SLE !!!
Normal anion gap (hyperchloremic metabolic acidosis )
Renal tubular acidosis
diarrhea
addison’s
fistula
ureterosigmoidostomy
thiazides, nh4cl
Gynecomastia increased risk of breast cancer
Short fourth metacarpal associated with Turner syndrome and pseudo hypoparathyroidism
- Chloride shift bicarbonate replaced
by chloride
- Bohr effect increased acidity low binding of oxygen to hemoglobin
- Haldane effect increased PO2 so low CO2 binding to hemoglobin
- Funnel plot Publication bias in meta analysis
- Low calcium low phosphate raised ALP generalized bone pain ==> osteomalacia
- Erect posture leads to increased Renin
- Beta blocker and NSAIDs lowers Renin
- Klinefelter LH to fsh ratio is raised
- LH to fsh ratio is low or normal in KALLMAN
- Cisplatin lowers magnesium , lowers calcium , without correcting magnesium calcium can’t be corrected same for Potassium with magnesium
- Diagnostics test for cystinuria and homocystinuria is the same which is Sodium nitroprusside test cystinuria treatment d-penicillamine urine alkalinisation
- Homocystinuria features Mental retardation and lens dislocation
- Cystinuria Features Stones, COLA defect AAs
- Carbimazole ===> aplasia cutis of neonates so avoid in pregnancy
Cushing ===> overnight dexamethasone suppression test diagnosis
high dose dexamethasone suppression suppression test localisation / cause of Cushing
insulin stress test to differ between cushing and pseudo cushing
Failure to thrive ===> BARTER syndrome
Congenital adrenal hyperplasia ===> precocious puberty
strongest Association of h pylori is with duodenal ulceration
High chylomicrons most associated with recurrent acute pancreatitis
PCR is more accurate than a brain biopsy in herpes encephalitis
GLUTEN, test when taken gluten for at least 6 weeks
h pylori breath test stop PPI two weeks prior
no antibiotics four weeks prior
NO pregnancy within 6 months of stopping ribavirin as its teratogenic
no anti HCV drugs in pregnancy all contraindicated
Pancreatitis ===> masalazine
Oligospermia ===> sulfasalazine
Purtscher retinopathy associated with pancreatitis
Celiac disease associated with hyposplenism
Achalasia ===> retrocardiac air fluid level
Moxifloxacin covers anaerobes so no need of adding Flagyl with it (unlike Cipro and Levofloxacin)
In hepatitis B as long as surface antigen is there a risk for infection / transmission exists once its negative then the risk is gone
Foscarnet for acyclovir resistant Herpes but it’s even more nephrotoxic then acyclovir so if creatinine Rises than lower acyclovir dose and increase hydration don’t switch to foScarnet
Clostridium septicum has an even greater Association with colon cancer then strip Bovis
Hereditary angioedema no response to steroids
diagnosis C2 and C4
C1 esterase inhibitor
treatment Airway , ffps , ecallantide , androgens
Avoid dipyridamole and adenosine in asthmatics
Heparin prevents clot formation in coronary arteries it doesn’t dissolve a clot
In ACS with no St elevation SK is of no use so St elevation MI SK plus heparin afterwards
NSTEMI ===> heparin GP 2B 3A PCI
Septal rupture Step Up in oxygen right Atrium to right ventricle
CHF spironolactone develops gynecomastia switch to eplerenone
Valvular heart disease
right side (tricuspid Pulmonic)
left side (Aortic and mitral)
right sided murmurs increase in intensity with inhalation/ increased venous return
left sided murmurs increase intensity with Exhalation / squeezes blood out of lungs into left heart
regurgitant lesions medical treatment vasodilators
Ace inhibitors , ARBs Nifedipine, hydralazine
diastolic === AR, MS
systolic ==== AS MR
Valsalva standing decreases venous return
squatting leg raising increases venous return
all left sided murmurs increase with expiration except MVP and HOCM
Diuretics contraindicated in HOCM , Ace inhibitors also don’t work
treatment Beta blocker / Verapamil
Ace inhibitors / Diuretics can be used in hypertrophic cardiomyopathy they cannot be used in hypertrophic obstructive cardiomyopathy
Hyperparathyroidism decreased phosphate increased chloride
Irreversibility c o p d (no) ASTHMA (YES) the only difference
FEV 1 greater than 20% decrease is on methacholine or histamine tell challenge Diagnostic for asthma
Carcinoid syndrome patients also develop niacin deficiency so it can lead to pellagra
Asthma plus respiratory acidosis ===> intubate
Mpgn / bronchiectasis Tramtrack appearance
Allergic bronchopulmonary aspergillosis
Give oral steroids as inhaled steroids don’t work
Esophageal carcinoma metastasis is only because it doesn’t have a serosa
Cystic fibrosis
inhaled aminoglycoside
IVACAFTor
rh DNaSe
Chlamydia == hoarseness
Mycoplasma == young healthy
PCP requires bronchoscopy b a l for diagnosis
Imipenem renal failure seizures
aspiration pneumonia upper lobes
No Daptomycin for lungs as its inactivated by surfactant
IGRA equal in significance to ppd to exclude TB exposure blood test
Yearly PPD for all health care workers
In prostate CA give flutamide before leuprolide
Finasteride is for BPH + male pattern hair loss
Lung nodule high probability resect
intermediate probability bronchoscopy
cotton == byssinosis
sugarcane === bagassossis
electronics === berylliosis
berylliosis respond well to steroids
Fondaparinux is alternative for heparin if heparin induced thrombocytopenia is present
IVC filter if RV dysfunction
Stop Thiazides, Aspirin Niacin in Gout
Best BP drug in Govt is losartan
Compression T4 loss of sensation below nipples
compression at T 10 loss of sensation below umbilicus
Rheumatoid arthritis in pregnancy hcq and sulfasalazine safe in pregnancy
Hcq retinal toxicity (Do fundoscopy )
APL increased aptt + clotting
Abortion == anticardiolipin antibodies
DermatopolyMYOSITIS
Shawl sign
Helitrope rash
gottren papules
predispose to cancer
CPK Aldolase
Anti JO antibodies
treatment immunosuppression plus hcq for skin lesion
Sjogren
Lymphoma 10% risk
Schirmer test
Rose Bengal test abnormal corneal epithelium
Polyarteritis nodosa
hepatitis B C
lungs not involved
foot drop most common any peripheral nerve can be invloved
mononeuritis Multiplex
Stroke in young person
mesenteric vasculitis / abdominal pain
beading biopsy most accurate test
CPK and aldolase normal in polymyalgia rheumatica
cryoglobulins Hepatitis C joint pains Glomerulonephritis
cold agglutinin epstein barr virus lymphoma mycoplasma leading to hemolysis
Hsp leukocytoclastic vasculitis on biopsy
Steroids not useful for seronegative spondyloarthropathy
Osteopenia t score 1 to 2.5 standard deviation below normal
Bisphosphonates when this score is more than 2.5 standard deviation below normal
Hormone replacement therapy in postmenopausal women
Abpa
inhaled steroids don’t work use oral steroids in severe cases
Itraconazole if recurrent episodes occur
Occurs in asthmatics and atopics
Nasal calcitonin lowers vertebral fracture risk
Teriparatide == assoc with osteosarcoma in rats and hypercalcemia
In recurrent Gonorrhea test for terminal complement deficiency
Macrocytic anaemia give low rate count
Sidroblastic maybe either microcytic or microcytic
Cryoprecipitate contains factor VIII and Von willebrand factor
One print red blood cells raises hemoglobin by 1 and hematocrit by 3
Microcytosis below 80 fl rbc size
Iron absorption
1 to 2 mg men
two to three mg women
four to five milligrams pregnant women
Sidroblastic alcohol lead INH HB 6 deficiency
Iron studies
high iron in Sidroblastic
normal in Thalassemia
prussian blue stain for ringed Sidro blasts
in Sidroblastic anaemia
basophilic stippling in Sidroblastic anaemia
Sidro is only anemia with high circulating iron
Thalassemia
diagnosis HB electrophoresis
normal red cell distribution width
Alpha Thalassemia diagnosed by DNA analysis
3 gene deletion hemoglobin H disease
Beta 4 tetrads
Four gene deletion
Gamma 4 tetrads
Barts hemoglobin
death in utero
Beta thalassemia high fetal hemoglobin ,High HBA2
intermedia normal fetal hemoglobin no transfusion independence
complication of B12 folate replacement is hypokalemia
Morulae seen in Polys in ehrlichia infections
Sickle Cell trait ===> isosthenuria
(A.S) Hetero ====> hematuria
no treatment required for either
autoimmune hemolytic anaemia
WARM IgG
coombs most accurate
COLD IgM
cold agglutinin most accurate
direct comb only for complement
G6PD deficiency
x-linked so exclusively in men very rarely in females
HEINZ ( methylene blue stain)
BITE CELLS
G6PD level 1 to 2 months after hemolysis episode
HUS/TTP
platelet transfusion contraindicated
treatment plasmapheresis if not available then give FFPS
APLASTIC anemia
young bone marrow transplant
old ATG, tacrolimus cyclosporine alemtuzumab
Polycythemia rubra Vera
high hematocrit
low erythropoietin
high B12 low iron
Renal cell carcinoma
High hematocrit high erythropoietin
Essential thrombocytosis
Platelets greater than 1 million
thrombosis and bleeding
best initial treatment hydroxyurea
jak2 mutation in 50% cases
Ruxolitinib inhibits jak2 ,used in both essential thrombocytosis and MyeloFibrosis
hydroxy urea can lead to increased red cell suppression if so then anagrelide is used
aspirin is used for erythromelalgia
Myelodysplastic syndromes
Pancytopenia despite hypercellular bone marrow
pelger huet cells
ringed sideroblasts
treatment
1) 5q deletion type has excellent response to Lenalidomide
2) erythropoietin
3) Citidine, citabine
4) radiation leads to premature coronary artery disease
5) chemo leads to solid tumors (lung breast thyroid)
Nuclear bone scan detect Blastic activity so it won’t show anything in multiple myeloma as its lytic.
Multiple myeloma ==> low anion gap
multiple myeloma diagnosis ==> Bone marrow biopsy greater than 10% plasma cells
Elevated total protein but normal albumin
Bence Jones is found on urine immunoelectrophoresis dipstick only detects albumin , it does not detect bence Jones
Factor 11 deficiency ==> increased bleeding with trauma and surgery
anticardiolipin ==> abortions
APL antiphospholipid syndrome ==> thrombophilia High APTT
Fondaparinux safe alternative in HIT
3 conditions where no platelets are transfused despite low platelet count
1. HIT
2. TTP
3. ITP
Pills causing esophagitis
potassium chloride
alendronate
doxycycline
Shatzkii ring plummer vinson ==> dysphagia
shatzki ==> hiatal hernia
plummer ==> squamous cell carcinoma
ZAnkar ==> bad smell ,halitosis , don’t scope or pass NG
Alcohol and tobacco don’t cause ulcers they delay healing of ulcers
4% gastric ulcer cases related to cancer
No case with duodenal ulcer related to cancer
After h pylori eradication retest with breath test or student Antigen at 30 to 60 days interval
Rice and wine are safe in celiac celiac disease avoid wheat oats rye barley
D xylose old text to differ between pancreatitis and bowel wall disorders
d-xylose normal in pancreatitis
lubiprostone chloride channel activator and LINaclotide both treatment for irritable bowel syndrome constipation predominant IBS-C
Ulcerative colitis anca positive
Crohns asca positive
Acute diverticulitis ==> Keep Nil per oral
Worse prognosis in pancrEatitis ==> low calcium
Serum Ascites to albumin gradient greater than 1.1
portal hypertension
congestive heart failure
constrictive pericarditis
hepatic vein thrombosis
Serum Ascites to albumin gradient less than 1.1
infections except SBP
spontaneous bacterial peritonitis
cancers
nephrosis
hepatopulmonary syndrome ===> lung disease + hypoxia based on liver failure
orthodeoxia , hypoxia upon sitting upright
Liver biopsy most accurate for all causes of cirrhosis except sclerosing cholangitis
80% of primary sclerosing cholangitis associated with ulcerative colitis
primary sclerosing cholangitis MRCP or ercp is the most accurate test
Primary biliary cirrhosis
normal bilirubin raised Alkaline phosphatase
xanthoma xanthelasma
osteoporosis
Hemochromatosis increased incidence of the following as they feed on Iron
Vibrio Vulnificus, Yersinia, Listeria
Wilson disease
Start with kayser fleischer ring KF ring
Most accurate is penicillamine challenge followed by looking for increased copper in urine
Stroke
MCA most common
90% middle cerebral artery
Anterior cerebral artery (ALU)
anterior cerebral artery
lower Limb weakness greater than upper Limbs
urinary incontinence
Posterior cerebral artery
ipsilateral sensory involvement of face
9th and 10th cranial nerve
contralateral sensory involvement of limbs
If ischemic stroke occurs while using Aspirin then add dipyridamole or switch to clopidogrel
Carotid stenosis greater than 70% ====> ENDARTEREctomy
If greater 100% then no treatment
If less than 50% then also no treatment
Carotid Stenosis is equal to coronary artery disease so same protocol that is statins diabetes control hypertension control stop smoking etc
Octreotide is used in cluster headaches as abortive treatment
Cluster headaches: Men affected 10 times more than women
Pseudomotor Cerebri
associated with Vitamin toxicity and Venous Sinus thrombosis
Papilledema
Diplopia(6th cranial nerve Palsy)
Brown Sequard
Ipsilateral loss of position / vibration
Contralateral loss of pain/temperature
Huntington ==> Caudate nucleus involved
Natalizumab , An M.S drug associated with PML (Progressive Multifocal Leucoencephalopathy)
Charcot Marie Tooth ==> Pes Cavus, Inverted Champaigne bottle appearance
Prognosis IN PULMO
Peak expiratory flow ==> ASTHMA/ COPD
Peak Inspiratory flow / FVC ==> GBS
Hemoglobin and Myoglobin give false positive hematuria test on dipstick but microscopic exam shows no RBCs in Hemoglobinuria or myoglobinuria
Casts
Red == Glomerulonephritis
White == Pyelonephritis
Granular == ATN
Broad waxy == CKD
Hyaline == Dehydration
NSAIDS constrict Afferent arteriole
ACE inhibitors constrict Efferent arteriole
Prerenal, Postrenal == BUN / creat range > 20:1
Intrinsic Renal failure == BUN / creat range > 10:1
Methanol == Retinal Inflammation
Ethylene Glycol == AKI
IgA Nephropathy == 1 to 2 days after upper respiratory tract infection
Post strep GN == 1 to 2 weeks after Pharyngitis
Diabetes Insipidus
Insufficient (CDI)
Low ADH
Inadequate (NDI)
High ADH , its just not working
Hypernatremia (Euvolemic)
Psuedo,Psycho, Hypo, SIADH (mnemonic)
Pseudohyponatremia
Psychogenic Polydypsia
Hypothyroidism
SIADH
SIADH is associated with Bipolar Disorder
Low magnesium leads to increase urinary loss of potassium
RTA and Diarrhea are differentiated by Urine anion gap
RTA Positive UAG and Diarrhea negative UAG
Kidney stones in Crohns because of increased oxalate reabsorption
Uric acid stones visible on CT scan but not on X rays
No Gastric lavage in
Caustics(Acid or Base)
Paracetamol poisoning
Altered mental state
Bicarbonate in aspirin overdose increases urinary excretion
Bicarbonate in TCA overdose protects heart
Carbon monoxide == RED
MEthemoglobinemia == BROWN
In Carbon monoxide poisoning, oxygen is not released.
In Methemoglobinemia , oxygen is not picked up.
Cyanosis + normal oxygen saturation === Methemoglobinemia
Rx == Methylene Blue
Organophosphorus Poisoning
SLUD, SOB, MIOSIS
Salivation, Lacrimation, Urination , Defecation
Rx== Atropine (1st line) , 2-PAM
Low K == Digoxin Toxicity
Digoxin Toxicity == Hyperkalemia
Chronic atrial fibrillation == anticoagulate before cardioversion
acute unstable atrial fibrillation == no need to anticoagulate
Don’t give verapamil or Digoxin in wolff-parkinson-white syndrome
As they block conduction via AV node and force conduction through the abnormal Pathways
Melanoma == brain metastasis
Squamous cell carcinoma == wide margin is needed
Basal cell carcinoma == wide margin is not needed , shave biopsy sufficient
Hepatitis C associated with porphyria cutanea tarda
Steven Johnson Syndrome toxic epidermal necrolysis
Intravenous immunoglobulin for both of them
Steroids for Steven Johnsons not clearly beneficial
Steroids in toxic epidermal necrolysis have no use
Pulmonary function tests obstructive lung disease Low FeV1, high TLC and raised residual volume
Residual volume increases in obstructive lung disease
Pursing of lips in chronic obstructive pulmonary disease prevents atelectasis
Chest X Ray in lobar pneumonia == air bronchogram with nonhomogeneous consolidation
Chronic obstructive pulmonary disease patient presents with fever cough === multiple nodular shadows on chest x ray == Likely organisms staphylococcus
Churg Strauss syndrome === bilateral fluffy shadows on chest x ray asthma eosinophilia vasculitis
Squamous cell carcinoma == cavitatory Lesions
Dry cough shortness of breath erythematous Rash with target lesions == mycoplasma
Penicillamine can be treatment option for pulmonary Fibrosis
No lung collapse in plural effusion
Tidal volume does not change in obstructive or restrictive lung disease it remains the same for both
Rheumatoid arthritis + obstructive pattern on pulmonary function tests == bronchiolitis obliterans deduction
Nitrates diuretics Ace inhibitors contraindicated in hypertrophic obstructive cardiomyopathy
Malt worker == Barley
Moildy hey == Farmer Lung
Suberosis == cork
Sequsosis == Redwood
arc welding == Siderosis
Neurofibromatosis axillary freckling
Myasthenia gravis patient , No eye involvement best treatment == acetylcholine inhibitors thymectomy
No seizures in Wernicke encephelopathy
Cavernous sinus thrombosis complete ophthalmoplegia
Rapidly given intravenous potassium causes cardiac arrest in diastole because Potassium is involved in repolarization
Pulmonary capillary wedge pressure is approximation of pressure in left Atrium
Post myocardial infarction run of pvcs just observe as its normal up to 48 hours
Ventricular tachycardia shock only ones then reassess Rhythm to see if re shock required or not.
Elderly patient petechiae on thigh look for vitamin C deficiency
Pure red cell aplasia == normocytic normochromic anemia
Most common mediastinal tumor is thymoma
Thymoma associated with pure pure red cell aplasia
Systemic lupus erythematosus has coombss positive hemolytic anaemia
Paroxysmal nocturnal hemoglobinuria == coombs negative hemolytic anemia
Antithrombin 3 deficiency resistant to heparin
Factor 10 a levels should be monitored in all such situations to ensure adequate anticoagulation
Crohn’s disease == Non caseating granuloma , Rose thorn ulcers, cobblestone pattern
Most common duodenal ulcer location first part anterior wall
Cholangitis is most common cause of pyogenic liver abscess
Vipoma is excluded if stool volume is less than 700 ml per day
Stage 1 diabetic nephropathy === hyper filtration
Growth hormone deficiency == do insulin tolerance test
In addison’s impaired water diuresis
Scleroderma == hypertensive renal crisis
Systemic lupus erythematosus dsDna == monitor disease activity
DIP plus hyperkeratosis == psoriatic Arthritis
bone pain + hydroxyproline in urine + hearing loss Pagets disease
Adhesive capsulitis pain increases on Active movement no pain on passive movement
Rheumatoid arthritis monitor with serial CRP
Leprosy spread by nasal droplets
Malaria attacking stage upon plasmodium == Merozoites
Hepatitis C vertical transmission 3%
actinomycosis treatment == penicillin
Yellow fever vaccine cannot be given in HIV
Mechanical ventilation increase in right atrial pressure
Klinefelter == buccal smear
lactic acidosis lactate levels greater than 5 mmol
Best test for DVT is venography
Cocaine inhibits adrenaline uptake
Posterior mediastinal mass == neurogenic tumor
In chronic kidney disease adjust doxycycline dose
Anorexia nervosa== enlarge Salivary glands
Renal cortex spared in malignant hypertension
Pheochromocytoma == MRI with MIBI scan
Rifampicin associated with nephrotic syndrome
Colon cancer most common area sigmoid
Bile duct carcinoma == ascaris lumbricoides
Hyponatremia post laparotomy == water intoxication
Common valvular involvement in Rheumatoid arthritis == Aortic regurgitation AR
Platypnea is dyspnea in upright position
Ankle brachial index less than 0.9 ==abnormal
Ankle brachial index less than 0.3 ==critical ischemia
Alternation of right and left bundle branch block is a sign of trifascicular block
Hypothermia == Osborne waves J point elevation
Avoid bile sequestrants cholestyramine and colestipol in metabolic syndrome as they increased triglycerides
Thyroid acropachy == hyperthyroidism
For cyanosis to occur and be appreciated hemoglobin should be greater than 4 grams / dl
Steroid resistant asthma is defined as resistance despite using prednisolone 40 milligram once daily for 2 weeks
Silicosis egg shell pattern calcification
Lung abscess most common == posterior segment lower lobes
HeRedFort waldenstrom == anterior uveitis
In mycobacterium avium complex == nodular bronchiectasis
Yellow nail syndrome === lymphedema plural effusion bronchiectasis
Hamman Rich syndrome == acute interstitial pneumonia
Batwing distribution opacity == pulmonary alveolar proteinosis (PAP)
Lupus pernio == chronic sarcoidosis , cheek and nose
Sarcoidosis == increased ALP Alkaline phosphatase low TLC / lymphopenia
Mechanism of hypercalcemia in Sarcoidosis is high levels of 1, 25 hydroxyvitamin D production
Dangerous bleed associated with warfarin Rx== factor 7A concentrates
Most common non bleeding side effect of warfarin is alopecia
Pulmonary embolism may respond to Fibrinolysis ,14 days after it has occurred
500 ml fluid required to detect via physical examination
Type 3 respiratory failure == atelectasis
Type 4 respiratory failure == ischemic respiratory muscles
Type 1 respiratory failure == ARDS , multiple blood transfusions
Type 2 respiratory failure == COPD + cor pulmonale + hypothyroidism
Adult hypopituitarism == most common presentation=== hypogonadism
Pheochromocytoma sensitive test metanephrines plasma
Pheochromocytoma specific test VMA
Appendicectomy protective against ulcerative colitis but increases risk of crohn’s disease
Turner syndrome predisposes to inflammatory bowel disease
Fecal lactoferrin sensitive and specific for intestinal inflammation
Suspected crohn’s disease first-line == CT enterography
Marker for worsening of liver Fibrosis == thrombocytopenia
Hepatitis with only insidious onset is Hepatitis C others may have a cute or insidious onset
Portal hypertension is hepatic venous pressure gradient greater than 5. There is a greater chance of variceal bleed if the HVPG hepatic venous pressure gradient is greater than 12 so goal with propranolol is to keep it below 12
Minoxidil Side Effects hypertrichosis + pericardial effusion
Hand foot mouth syndrome related to Sickle Cell disease
HypOsegmented polys == chronic myelogenous leukaemia
Henoch scholein purpura == small vessel vasculitis
Upper motor neuron distal muscles affected more than proximal muscles
Hypertensive intraparenchymal bleed Putamen is the most common site
Most common cause of subarachnoid hemorrhage == saccular aneurysm rupture
Schistosoma haematobium associated with transverse myelitis typical
Absence seizure === valproic acid
Atypical absence seizure === Ethosuximide
Recurrence of fits after stopping antiepileptic drugs is expected/predicted within the next 3 months of stopping the drug.
- Chest pain with widespread ST elevation in a CKD patient, think of uremic pericarditis. Treatment is hemodialysis.
- In TTP (Thrombotic Thrombocytopenic Purpura) and HUS (Hemolytic Uremic Syndrome), fever, hemolytic anemia and thrombocytopenia, all three are present in both conditions. Kidney insult is typically more severe and more common in HUS. Neurological symptoms are more severe and more common in TTP.
- Erythropoietin therapy in CKD patients can lead to hypertension as a side effect in these patients requiring antihypertensive medication
- Rhabdomyolysis is associated with hypocalcemia and hyperkalemia.
- Severe hypophosphatemia can lead to rhabdomyolysis.
- Gentamicin related acute renal failure is usually evident after 5 days of initiation of therapy.
- Urine microscopy in Gentamicin related acute renal failure is usually normal. If casts are present then they are either granular or epithelial.
- The goal of treatment in Gentamicin related acute renal failure is tubular regeneration.
- Gentamicin related acute renal failure patients will not have oliguria.
- Gentamicin related acute renal failure is not irreversible i.e the patient usually regenerates the tubules after the insult related to the medication is stopped.
- Gadolinium based contrast studies should be avoided in patients with CKD stage 3 or greater due to the risk of Nephrogenic systemic fibrosis.
- Hydration with I.V fluids and N acetylcysteine have no role in preventing the damage associated with Gadolinium based contrast studies.
- Hydration and N acetylcysteine use is more pertinent in case of prevention of radio contrast induced nephropathy.
- The physiological concentration of saline is taken as 0.9 %. Hypertonic saline include 3 and 5 % solutions, respectively.
- Reduced creatinine levels subsequent to an amputation can be misleading. It does not indicate improved GFR but shows that the creatinine normally produced is lowered due to the loss of muscle mass.The creatinine levels are mainly determined by the muscle mass and total dietary intake e.g meat.
- Antidiuretic hormonesynthesistakes place inhypothalamus.
- Antidiuretic hormone storage takes place in posterior pituitary and it is also released from the posterior pituitary.
- ADH action is on the collecting ducts of the kidneys, facilitating water absorption through insertion of aquaporin channels in the collecting ducts.
- Diagnosis of Peritoneal Dialysis related peritonitis requires PD fluid white cell count of greater than 100 mm3 or a PD fluid polys percentage of greater than 50 percent. By polys we mean neutrophils.
- In SIADH (Syndrome of Inappropriate Anti Diuretic Hormone) there is increased urine osmolality despite a low serum osmolality. The urine is inappropriately concentrated despite a hypotonic serum.
- Demeclocycline is the treatment for SIADH by blocking the effect of ADH on the distal tubules which are retaining the excess water.
- In CKD, a high PTH level due to a secondary hyperparathyroidism is responsible for the bone reabsorption and subsequent fractures.
- The stimulants responsible for the high PTH are low calcium and high phosphate levels. Both of these need to be corrected to keep the PTH in check in CKD.
- Phosphate binding agents like calcium acetate lower the phosphate levels and hence lower PTH levels preventing bone fractures, ultimately.
- In a dehydrated and hypovolemic patient, ACE inhibitors should not be continued. They should be withdrawn immediately.
- In a patient with typical age group and classical minimal change disease picture, renal biopsy is deferred till 3 or 4 episodes of edematous flares have occurred.
- Low erythropoietin, low vitamin levels including folic acid and B 12, low ferritin levels , chronic blood loss in tubing during dialysis are the factors responsible for an anemia in a CKD patient especially if he/she is dialysis dependent.
- With regards to the anemia in CKD, iron, folic acid and B 12 should be corrected. If the patient is anemic despite correction of these factors then erythropoietin can be started.
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