ESSENTIAL POINTS FOR FCPS IMM THEORY, MRCP1,2 (MEDICINE)doctkhalil
- 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
- 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.
Worsening pain at night
( Periostel new bone formation at diphysis )
10 to 20 years males
Giant cell tumor
Soap bubble appearance
20 to 40 years females
Ouch my bad hands
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
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
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
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
SILICOSIS centrilobular emphysema
Rusty sputum Pneumococal
Pink Frothy Pulmonary Edema
Cystic Fibrosis has obstructive pattern on spirometery
Lower lobe fibrosis
CRYPTOGENIC FIBROSING ALVEOLITIS
BLEOMYCIN and other drugs
SLE / SCLERODERMA
PULMONARY FIBROSIS WITHOUT VOLUME LOSS
NEURO TUBERO LYMPHO X
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
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
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
1. Stool osmolality is equal to serum osmolality
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
hemochromatosis == idiopathic == transferin saturation , secondary == liver biopsy
gastrinomas == neck of pancreas insulinoma confirmation == supervised fasting
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)
* radio femoral delay
*mid systolic Murmur over the back
* 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
left dominant circulation
Dilated cardiomyopathy == mitral regurgitation
Left dominant circulation
posterior descending artery arises from circumflex instead of right coronary artery
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)
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.
- 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
- 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
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
oxygen binds less well to hemoglobin
better O2 elimination
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
- 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
- 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
Gynecomastia increased risk of breast cancer
Short fourth metacarpal associated with Turner syndrome and pseudo hypoparathyroidism
- Chloride shift bicarbonate replaced
- 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
Polycythemia rubra Vera
Octreotide is used in cluster headaches as abortive treatment
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.