Académique Documents
Professionnel Documents
Culture Documents
Chest pain
M.I.
Heart failure
AF
HTN
ARF
Q. Name some common cardiac emergencies you have seen in our ward.
Ans.
MI
Acute left ventricular failure
Acute coronary syndrome
1
Q. How will you differentiate between cardiac chest pain from non cardiac chest pain?
Ans:
Trait Cardiac chest pain Non cardiac chest pain
1) Site Central Peripheral
2) Character Choking, tighting, squeezing Sharp, stabbing
3) Aggravating factor Exertion, heavy meal, cold Not so
exposure
4) Relieving factor Rest , Nitrate Not so
5) Radiate to Left shoulder blade, arm, jaw Not so
Q. A 40 years old male came to you with severe chest pain with sweating, cold calmy skin,
vomiting and BP 90/62 mm of Hg. What is your diagnosis?
Ans. Acute myocardial infarction.
2
Q. Assume, you are in CCU. What will you do to manage the patient?
Ans. First I shall give high flow o2. Then I shall do ECG.
Q. What other investigation you will do?/ Do we measure any enzyme level?
Ans. Toponin I.
Q. What are the follow up you will give after administration of streptokinase?
ans. I shall regularly measure the B.P. to see hypotension.
3
Q. What are the contraindications of thrombolytic therapy or streptokinase?
Ans.
Active internal bleeding
Previous sub-arachnoid haemorrhage/ Intracerebral haemorrhage.
Uncontrolled hypertension
Recent surgery
Active peptic ulcer disease
Pregnancy
Q. A patient was administered streptokinase 2 years back. Now he developed M I. Can he take
streptokinase again?
Ans. No. Because, as he took streptokinase before, there is developed antibody against
streptokinase.
Q. If this patient of MI goes to higher center, what could be done?/ What are the interventions in
MI?
Ans. In higher center, we can do:
PCI [primary percutaneus coronary intervention]
CABG [ coronary artery bypass grafting]
Q. What will you give if a patient comes 12 hours later of MI or have no ST elevation or non Q
wave MI?
Ans. Here we give low molecular weight heparin. Name Enoxaparin (1unit/kg), [trade name
claxene].
Q. How it is given?
Ans. It is given subcutaneously, 12 hourly for 5-7 days.
4
Q. Mention the complications of MI.
Ans.
1) Arrhythmia (tell the names of every arrhythmia)
VF
Ventricular tachycardia
Ventricular ectopic
AF
Atrial flutter
SVT
A-V block
Complete heart block
2) Cardiogenic shock
3) Heart failure
4) Pericarditis
5) Late complications:
Rupture of papillary muscles
Rupture of interventricular septum
Ventricular aneurysm
Heart failure
Q. A patient came to you with sudden, sever respiratiory distress. What are the differential
diagnosis?
Ans. First say,
Acute LVF with pulmonary edema
Tension pneumothorax
Next you may say,
Acute severe asthma
Acute exaggerations of COPD
5
Q. What are the causes of left ventricular failure?
Ans.
1st cause- Systemic hypertension
MI -2nd cause
AS (aortic stenosis )
Q. What are the cardinals sings of LVF?
Ans.
Pulsus alternus/ Tachycardia
Gallop rhythm
Bilateral basal creps
Q. What will be the management?
Ans. Frist say the following three:
Propped up position
High flow O2 inhalation
Diuretic: Inj. Frusemide ,I.V. up to 160mg (1 amp Lasix= 20mg, Tab. Lasix=40mg)
If sir wants to know more, then say the followings
Glycerinetrinitrate
ACE inhibitor
In some cases, opiate or morphin.
Q. What are the causes of right heart failure/ CCF?
Ans.
PHTN
Cor pulmonale
VSD/ASD
Anaemia
MS
Q. What are the cardinal features of CCF/ right heart failure?
Ans.
Raised JVP
Tender hapatomegaly
Dependent edema
Q. What is the management of right heart failure?
Ans.
Propped up position
Low flow O2
Injectable diuretic
Q. What are the complications of heart failure?
Ans. To remember (RATE )
R-Renal failure
A-Arrhythmia
T-Thromboembolism
E--Electrolyte imbalance: hyponatramia, hypokalaemia, hyperkalaemia.
Impaired liver function
6
Q. What is systolic heart failure and what is diastolic heart failure?
Ans.
systolic heart failure diastolic heart failure
When heart fails in systole, that means reduced When heart fails to dilate
contractility Or poor diastolic filling
e.g.- M I, cardiomyopathy e.g. constrictive pericarditis,
restrictive cardiomyopahty.
To remember the causes of heart failure, you may see the chart, but do not write in the exam
paper.
Pressure overload Volume Muscle,
Type of heart failure overload Usually biventricular
Visible Invisible
pressure pressure due to
Due to valve HTN
stenosis
LV AS Sys. HTN MR, AR Cardiomyopathy
MI /IHD
RV PS P. HTN PR, TR Cardiomyopathy
(uncommon) MI /IHD
VSD, ASD,
anaemia,
pregnancy,
thyrotoxicosis
Volume overload occurs to that chamber of the heart which is weaker. LH is stronger than RH
due to more pressure. So in case of VSD, ASD, anaemia, pregnancy- there is right heart failure.
Q. In systemic hypertension, which type of heart failure occurs?
Ans. LHF
Q. Define dyspnea.
Ans. Dyspnoea can be defined as an unpleasant subjective awareness of sensation of breathing.
7
Q. Define orthopnea.
Ans. Dyspnea in lying position
Q. Define PND.
Ans. It is a sudden severe breathlessness which wakes the patient form sleep.
Atrial fibrillation
Q. What are the causes of atrial fibrillation?
Ans. Mnemonic: MITHA
M- mitral stenosis
I- IHD
T- thyrotoxicosis
H- hypertension
A- alone (lone atrial fibrillation)
Q. What are the causes of irregularly irregular pulse?
Ans.
AF
Atrial flutter with variable block
Multiple ventricular ectopics
Then sir may ask question from AF
Q. What are the treatment of AF?
Ans.
Rate control
Rhythm control
Restoration sinus rhythm
Q. What are the drugs used in AF?
ans. Mnemonic: ABCD
A- amidarone
B- -blocker
C- calcium channel blocker: verapamil, diltiazem.
D- digoxin
Q. which drug commonly used?
Ans. -blocker
Q. which drug used in a patient with MS?
Ans. Digoxin
8
Q. What are the complications of AF?
Ans. 1.Thromboembolism
2.Heart failure/ acute pulmonary edema
Q. A patient with AF came to you with unconsciousness or right sided hemiparesis. What is your
diagnosis?
Ans. AF with stroke due to thromboembolism.
Hypertension
Q. In your chamber, you found a patient with BP 190/95 mm of Hg. What will be the approach
to this patient?
Ans. Sir, I shall take some history, do some clinical examination and suggest some investigations
to find out etiology, co-morbid conditions and to see complications (target organ damage).
9
Q. A patient of 15 years age came to you and you found his BP 150/100 mm of Hg. What will be
the cause?
Ans. Here answers will be the secondary causes: AGN and other causes.
Q. A newly married female patient came to you and you found her BP 160/90 mm of Hg. What
may be the causes?
Ans. May be due to OCP.
Q. Classify HTN.
Ans.
1) Primary or essential: 95%
2) Secondary: 5%
10
Q. What do you mean by White coat hypertension?
Ans. When a patients BP becomes elevated when he goes to the doctor, but otherwise, his BP is
normal, this incident is called White coat hypertension.
11
Renal USG: to diagnose PKD
RBS and lipid profile
Antihypertensive drug
A- ACE inhibitor-
Ramipril
Captopril
A-Angiotensive receptor blocker
losartan
valsartan
B-Beta blocker
Cardioselective
Metoprolol
Atenolol
Combined - and -adrenoceptor antagonists .
Carvedilol
Nonselective
propranolol used in anxiety, palpitatinon and portal HTN
D- Diuretic
Thiazide -Indepamide
D- Vasodilator
-blocker Prazosin
12
Commonly asked questions
BETA BLOCKER
Indications Contraindications
Myocardial infarction Bronchial asthma/ COPD
Angina Heart block /if pulse less than 60
Heart failure stable--only carvedilol DM
Atrial fibrillation Psoriasis
PVD
Heart failure (can be used in Carvedilol
compensated heart failure)
Why beta blocker is not used In DM:
it will mask the sign +symptoms hypoglycaemia (tremor I tachycardia I sweating )
13
Before giving beta blocker see following:
H/O DM, COPD. asthma, heart failure, Auscultate lung for spasm and pulse for bradycardia
Ca channel blocker
Indications Contraindications
Amlodipin- Heart block
Any patient/Elderly patient without Heart failure
heart failure
Isolated systolic HTN Complications
CRF Amlodipin
COPD/ Bronchial asthma Flushing of face, headache
Verapamil (240 mg daily) Palpitation
Can be useful when hypertension Fluid retention
coexists with angina Verapamil
Verapamil used in SVT Constipation
Diltiazem
Bradycardia
Hypertensive crisis
Hypertensive emergency
Hypertensive urgency
Hypertensive emergency
Severe elevation of BP > 180 /120 mm of Hg complicated by evidence impending or
progressive target organ damage.
They require immediate reduction of BP ( not necessarily to normal )
14
Renal ischemia
Coronary ischemia
Then reduction of BP to normal in next 24-48 hours.
Hypertensive urgency
Severe elevation of BP with target organ damage
Upper level of stage ii with
Severe headache
Epistaxis
Dyspnea
Severe anxiety
Minor criteria:
Fever
Arthralgia
Elevated acute phase reactants (e.g. high ESR,CRP)
Prolonged P-R interval
15
Q: Which organism is responsible for RF?
A: Group A haemolyticus streptococcus (S.pyogens)
Q: Causes of HF in ARF?
A:
o Myocarditis
o Vulvular causes (MR, AR)
16
Q: Rx of ARF?
A:
Bed-rest (Next Q: How many days? > The duration should be guided by symptoms
along with temperature, leucocyte count & ESR. It should be continued until these have
settled)
Aspirin 60-100mg/kg BW/day in 6 divided dose. Continue until ESR falls and then taper
gradually.
Steroid (If severe arthritis or carditis): Tab. Prednisolone 1-2mg/kg BW/day
Antibiotic (to eliminate residual streptococcal infection)
Inj. Benzathine pencillin 1.2million unit 1ampule I/M stat. or,
Tab. Phenoxymethyle penicillin 250mg, 6hourly for 10days
Q: Complications of Aspirin.
A: Nausea, vomiting, tinnitus, deafness and metabolic acidosis*.
NB: if pain is not subsided within 24hours, then it suggests that it is not due to RF.
17
Q: What is the mechanism of development of MS?
A: Repeated RF cause progressive fibrosis & thereby cause MS.
Q. scenario : 15 yr old male comes to u with fever and increased ASO titer will u start anti-
rheumatic fever treatment or prophylaxis ?
Ans. No I will not started anti-Rheumatic drug . I look for major criteria and minor criteria if it
fulfilled then only start drug .
Q: What is the pathognomic feature of RF?
A: Aschoff nodules (multinucleated Giant cell surrounded by macrophage & T-lymphocytes)
Important
18
Infective endocarditis
Q: Scenario: A pt. comes to you with fever for 2weeks. On examination there is clubbing, rash,
splinter haemorrhage, there is also changing murmur & splenomegaly. What is your diagnosis?
A: Infective endocarditis.
Rx: according to culture report.
Q: Clinical feature:
A: Symptom: Blackout, Syncope and Dizziness
Pulse: Regular but bradycardia
JVP: Cannon wave
Complications: Stoke Adams attack
Q: Scenario:A pt. comes to you with sudden loss of consciousness & fall. On examination
pulse is 30-35beats/minutes. What is your Diagnosis?
A: Complete heart block with Stoke Adams attack.
19
Q: What is the Rx of 1 & 2 heart block?
A:
1 HB & 2 HB Type-1 No need of Rx
2 HB Type-2
o If due to Inferior MI:
-Asymptomatic: No Rx
-Symptomatic: Inj. Atropine
Q: Sequele of 2 HB.
A: mnemonic--HSC
a. C-Complete HB
b. S-Stoke Adams attack
c. H-Heart failure
20
Q: What are the causes of acute pericarditis?
A: In our country: TB
Foreign: Viral
Then: MI, Uraemia, Malignancy, Connective tissue
If there is effusion:
o Apex beat non palpable
o Area of cardiac dullness
o Heart sound-muffle
o JVP
21
o Ascites
o Pulsus paradoxus ( excessive fall of BP during inspiration)
o Oedema
Q: Scenario: A pt. comes to you & on examination you get early diastolic murmur in left lower
sterna area with high volume pulse, what is your diagnosis?
A: AR
Q: Scenario: A pt. comes to you & on examination you get ejection systolic / a systolic murmur
murmur in aortic area with radiation to neck and low volume pulse, what is your diagnosis?
A: As
Q: Scenario: A pt. comes to you & on examination you get diastolic murmur in mitral area with
loud first heart sound , what is your diagnosis?
A: MS
Q: Scenario: A pt. comes to you & on examination you get systolic murmur in mitral area with
radiation to axilla , what is your diagnosis?
A: MR
22
GIT and Pancreatic Disease
Q: 30 years old man come to you with haematomesis and malaena. How will you approach?
A:
A:
Q: what is the most important one investigation for Upper GIT Bleeding?
A:
hemorrhoids
Anal fissure
Diverticulitis
Cancinoma rectum
Polyps
23
Q: a patient with CLD comes with haematomesis and melaena. What wiil you do?
A:
-I.V. fluid
. sclerosis therapy
.band and ligation
.balloon tamponade
Medical Rx
Q. 30 years old female comes to you with epigestric pain . what will be the diffential;
diagnosis?\
Acute cholecyctitis
Acute pancreatitis
PUD- epigestric pain, recurrent episodic pain; if relief by food-in duodenum, if increase by food-
in Gastric
Acute cholecystitis- in epigastric and right hypochondrium region, Murphys sign present
Acute pancreatitis- severe pain, pain radiate to back, patient in knee-elbow position.
24
Q What Investigation for patients:
Q. If normal then,
A: By CRP
-NG Feeding
-Inj. PPI
-I/O chart
A G-. gall-stone
I-idiopathic
A-alcohol
ERCP--post ERCP
(to remember:GIA-ERCP)
25
Q. Complication of acute pancreatitis?
2. Hypoxia
3. hypo-albominia
4. hypo-calcaemia
5. hyperglycemia
GIT complication-
V--Variceal bleeding
E-Erosion of colon
D--Duodenal obstruction
O-Obstructive jaundice
A. MI
A.Pencreatitis
DKA
Rx- Drainage in stomach , duodenum, after 6 weeks(because pseudo capsule takes 6 week to be
matured)
26
Q. when ERCP is needed?
A. 2 weeks later
q. A patient comes to you with recurrent upper bdominal pain with diarrhea specially after falts
good. And the patien is cachectic. What will be you diagnosis?
A. chronic pancreatitis
A.
C-Hypercalcemia
C-CRF
A-Alcoholism
A.
27
Q. what are the investigations for the diagnosis of chronic pancreatitis?
A.
USG
CT
Plain X-ray of abdomen to see stone
MRCP
Q. a patient comes to you with different lump in region. What are the causes?
A. if epigastric region-
Carcinoma stomach
Ca- left lobe of liver
Pancreatic pseudocyst
Ca transverse colon
If hypochondrium region-
Appebdicullar lump
Ileo-caecal TB
Caecal carcinoma
Ca sigmoid colon
Viverticular mass
Stool/ impaoted stool
A.
duodenal ulcer
gastric ulcer
28
Q. what is the difference between ulcer and erosion?
Q.Causes of PUD?
A.
H.Pylori
NSAID
Smoking
Q. causes of erosion?
A. NSAID
A.
A. Gastric ulcer
Q.what is h. pylori?
29
Q. what are the complication of PUD?
A.
Haemorrhage(Haematomesis , malaena)
Gastric ulcer(Carcinoma)
Perforation
Gastric outlet obstruction
A. Eradication of H. pylori
Triple therapy one strip on the morning and one strip at night
One strip contains the following (Tab. Amoxicillin 1 gm, Cap. Clarithrimycin 500mg,
Cap. PPI 20 mg)
For 7 days
A.
D-Diarrhoea
R-Rash
C-Clostrideum difficle associate colitis
A-Abdominal pain/cramp
N-Nausea, vomiting
A.
PUD
H.pylori paritive dyspepsia
MALToma
30
Q. What are the investigations for diagnosis?
A. non-invensive
Invasive
A. it is a disorder characterized by severe peptic ulcer, gastric acid hyper secretion ann non-beta
cell eslet tumour of the pancrease(gastrioma)
A.
IBS
Pshychogenia dysphagia
Volumia nervosa
Anorexia nervosa
A.
IBD
IBS
Chronic pancreatitis
Celiac disease
Malsbsorption
Colonic neoplasm
A 20 years female comes to you with history of frequent loose stool proceed by abdominal pain
without nocturnal symptom? What is your diagnosis?
A. IBS
31
Q. what are the clinical features of IBS?
A.
Abdominal pain/cramp/colic
Pain relief by Defecation
Alternation of bowel habit
More on day and nocturnal symptom free.
Age>50 years
Weight loss
Fever
Anaemia
Rectal bleeding
ESR---normal
Colonoscopynormal
A. treatment
Q. name of IBD?
32
A. Difference between ulaerative colitis and chronns disease
A. Erythama nodusum
Q. how will you differentiate the colonic carcinoma left side to right side?
A.
in case of right sided colon: anaemia due to malaena , alternation of bowel habit
In case of left sided colon: obstruction and fresh blood
Q. how will you approach to a patient with dysphagia? How will you differentiate these?
A.
A.
Bulbar pulsy
Pseudobalbar pulsy
Myasthenia graves
33
Q. Name some causes of mechanical dysphagia?
A.
Inside lumen
Ca. aesophagus
Stricture aesophagus
Q. what is GERD?
Diagnosis by-
Othe investigation
2. 24 hour intraluminal pH monitoring of the esophagus.
3. Esophageal manometry.
Esophagitis
Barretts esophagus
34
Treatment of GERD:
Cessation of smoking,
loss of weight
Avoid alcohol, fatty meals & drugs e.g. nitrates.
Avoid heavy meals especially before sleep.
Raising the head of the bed at night.
should not go to bed within 2 hours of taking foods
Avoid any other precipitating factor.
Drugs-PPI 20 mg (1+0+1)
Domperidone 10 mg(2+2+2)
Hematemesis Hemoptysis
Def Hematemesis is the vomiting of blood Hemoptysis means coughing out of
blood
Source GIT tract stomach and duodenum From respiratory tract
Color dark red or brown or coffee ground Bright red
due to action of gastric acid
pH Acidic pH Alkaline pH
Mixed Mixed with food Mixed with mucous
Associated Abdominal pain , nausea Cough , chest pain , resp. distress
Investigation Upper GIT endoscopy Bronchoscopy
35
Hepato billiary
Define jaundice?
Jaundice refers to the yellow appearance of the skin, sclerae and mucous membranes
resulting from an increased bilirubin concentration in the body fluids.
Classify jaundice?
Haemolysis.
Gilbert's disease.
Dubin-Johnson syndrome.
Rotor syndrome.
Extrahepatic
Choledocholithiasis
Carcinoma
Ampullary
Pancreatic
Bile duct (cholangiocarcinoma)
Secondary
Parasitic infection
36
Intrahepatic
Viral hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Alcohol
Drugs
Autoimmune hepatitis
Pregnancy
Common causes:
Hepatitis A
Hepatitis B hepatitis D
Hepatitis C
Hepatitis E
Uncommon causes:
Cytomegalovirus
Epstein-Barr virus
Herpes simplex
Yellow fever
37
Route of transfusion?
Hepatitis B
which virus have chronic form ?
SGPT (ALT)
Alkaline phosphatase
S. Blirubin
Prothrobin time
Viral marker
HBs Ag
Anti HAV
Anti HEV
Anti HCV
USG of hepato billiary system
38
What are the complications of viral hepatitis?
Which one has more chance of turn in to chronic viral hepatitis between B @C?
parental
39
A patient comes to you with deep jaundice for 1 month what may be the cause?
Non-A-E hepatitis is the term used to describe hepatitis thought to be due to a virus that is not
HAV, HBV, HCV or HEV.
No treatment is needed
Do the following
40
Sexual partner should be vaccinated
Breast feeding allowed
When will u tell chronic active hepatitis?
Anti-HBC Ig G
What will u do A patient comes to u with HBs Ag positive and wants to go foreign?
41
what advise u will give to wife of HBsAg positive husband
Do HBs Ag of wife
Immunized her if negative
Until developing immunization ( 36 mon) pl. use barrier contraceptic method
If she become positive do not immunized her.
What is cirrhosis?
CAUSES OF CIRRHOSIS
TO remember ---ABCDEFGHI
A--- Alcohol
B---
o Biliary
o Primary biliary cirrhosis
C--- Chronic viral hepatitis (B or C)
D---Drug
E--- Endocrine - Wilson's disease
F--- Non-alcoholic fatty liver disease
Ggenetic- 1-antitrypsin deficiency
H--- Haemochromatosis
I---
o Autoimmune liver disease/hepatitis
o Primary sclerosing cholangitis
42
Mention the Complication of CLD?
1. Hepatic encephalopathy.
2. Ascites
3. Spontaneous bacterial peritonitis.
4. Hepatorenal syndrome.
5. Hepatopulmonary syndrome
6. Hepatocellular carcinoma
7. Portal hypertension.
o Variceal haemorrhages.
o Portal gastropathy
8. Coagulopathy and feature of hypersplenism
43
What investigation u want to done in case of CLD ?
SGPT------N /
S.Bilirubin --- N /
Prothrombin time N /
s.ablumin----
AG ratio---- alter
Viral marker
HBs Ag
Anti-HBc Ig G
Anti-HCV
Imaging
Diet
o Salt restriction
o No fluid restriction until Na< 120 m mol / l
Diuretic
o spirolactone
o or Combination spirolactone and frusemide
Paracentesis
o Aspiration of 2-5 L/ d ascitic fluid is safe
o If more than 5 L is done in one day then need 6-8 gm albumin for each litre
Syp. Lactulose is given for bowel movement
Treatment of complication such as
SBP
Hepato-renal syndrome
Specific Rx -- liver transplantation
what is the definite treatment of CLD ?
liver transplantation
44
what is refractory ascites ?
failure to decrease wt loss 0.5 kg/d after 1 wk of max dose of combin diuretic (frusemide 160
,spirolactone-400 )
Clinical
Short HO < 1 month Jaundice present Usually absent if present duration is > 3
month
Bio-chemical
Albumin and A:G ratio normal hypoAlbuminia and A:G ratio alter
Viral marker HBs Ag + < 6 months Viral marker HBs Ag + > 6 months
Imaging ( USG )
Normal
45
What the clinical signs are of decompensate CLD?
To remember JEA
Jjaundice
EEncephalopathy
A---Ascites
What is management hepatic encephalopathy? Or A patient with CLD suddenly become
unconscious
What is ur diagnosis?
Hepatic encephalopathy
A, B, C
NGfeeding
Based on carbohydrate diet and protein restricted
IV fluid
o glucose containing fluid
injectable antibiotic
o ceftriaxone
H 2 blocker
syp . lactulose What is 1st neurological sign in encephalopathy?
enema simplex
inj. Vitamin K Constructional apraxia (ask to draw star )
If the patient of CLD develop fever and abdominal pain? what is your diagnosis ?
How many organism is responsible for SBP and what is the organism?
46
Clinical feature is to remember -- BAFAR
A- ascites,
Ffever,
A abdominal pain,
Rrebound tenderness
A patient with CLD suddenly comes to u recently appearing lump in the right upper
abdomen .what is ur diagnosis ?
Hepatocellular carcinoma
What are sign of hepatic insufficiency? What are the signs of portal hypertension?
Hepatic faces (sunken eye, Malar To remember it keep mind SEA
prominent) SSlepnomegaly
Jaundice EEngorged vein
Flapping tremor o Abdomen
Gynaecomastia o Esophageal varices
In case of female breast atrophy AAscites
Spider nevi Other
Loss of body and pubic hair o Fetor hepaticus ,
In hand o Hepatic encephalopathy
leukonychia.
Dupuytren's contracture
Palmar erythema
Testicular atrophy
47
How the portal vein is formed
Half of the oxygen supply is met by the portal vein and rest half by the hepatic artery
H- Hypersplenism
A- Ascites
V--Variceal bleeding (Oesophageal)
H-- Hepatic encephalopathy
C--Congestive gastropathy
R--Renal failure
48
CAUSE of HEPATOMEGALY:
Ma-Malaria Ka-Kala-azar
MYMylofibrosis
ThaThalassaemia
o Lymphoma
o leukaemia
What are causes of just palpable spleen? o Dessiminated TB
ThaThalassaemia
Enteric fever
Malaria
Subacute bacterial endocarditis
SLE
Other cause of spelnomegaly
o Lymphoma
o Leukemia
o CLD with Portal HTN
o Disseminated TB
49
A patient with hepatomegaly with ascitis A patient with splenomegaly with ascites
CCF o CLD
Hepatoma with secondary in the peritoneum o Lymphoma
Lymphoma o leukaemia
Dessiminated TB o Dessiminated TB
Chirrohsis of liver with portal HTN
mention the causes of Fever with ascites ? mention the causes of Fever with
splenomegaly ?
o Abdominal TB o Kala-azar
o Lymphoma o Malaria
o leukaemia o Enteric fever
o SBE
o Lymphoma
o leukaemia
o Dessiminated TB
Primary case sing of hepatic insufficiency present such as ascites, splenmegaly , spider ,
jaundice
Palmer erythema , leuconychia , gynaecomastia testicular atrophy
50
What may the primary site?
To remember PUBLIC-T
C-Colon, I-intestine-- gastric, P--prostate and pancreas, B--breast and T--thyroid , L--Lung , U
uterus
51
Connective Tissue Disease
Q.What do you mean by arthritis & arthralgia?
Arthralgia: only pain in the joint Arthritis: Pain & swelling of joint.
Causes monoarthritis:
Septic arthritis
Tubercular arthritis
Trauma
Gout
Pseudogout
Haemophila
A: Ankylosing spondylitis
P: Psoriatic arthritis
E: Enteropathic arthritis
Ulcerative colitis
Chronns diseases
52
Causes polyarthritis:
Viral arthritis
Rheumatoid arthritis
SLE
Osteoarthritis
JIA
Osteoarthritis
Haemochomalasis
Acromegaly
Q.How will you differentiate from mechanical low back pain from inflammatory back pain?
Seronegative arthritis
R: Reactive arthritis
A: Ankylosing spondylitis
P: Psoriatic arthritis
E: Enteropathic arthritis
G: Gout
SLE
RA
53
Causes of seronegative arthritis:
R: Reactive arthritis
A: Ankylosing spondylitis
P: Psoriatic arthritis
E: Enteropathic arthritis
Q: A pt of 5-15 yrs old with fever,joint pain & swelling.what is your diagnosis?
Q: A 30 yrs old pt comes to you with H/O lose motion 3-4 wks ago.Now, he develops pain
& swell at rt knee.Left ankle & rt wrist joint?
Q: A female pt comes to you with pain & swell of hand joint with morning stiffness.What is
your diagnosis?
RA D/D SLE
Gout
Q: A male Pt comes to you H/O recurrent joint swell due fall during playing. What is your
diagnosis?
Haemophilic arthritis
Q: A female old pt(60) yrs complained of knee joint pain during sitting from standing
position. What is your diagnosis?
Osteoarthritis
Q: A 40 yrs old lady comes to you with pain & swell of both hand joint & also Rt knee
joint.She gave H/O morning stiffness. What is your diagnosis?
RA arthritis
Q: A Pt comes to you with H/O hand joint arthritis with rt sided pleural effusion. What is
your diagnosis?
SLE, RA
54
Q: Mention the diagnostic criteria for RA?
Symmetrical arthritis
Rheumatoid nodule
RA factor positive
Radiological change
Female
Q . Zzwg GKUv ARcvov Mvq AvQ,hLvb Kvb investigationGi myweav bvB|mLvb Zzwg wK RA Dx KiZ
cvie?
By seeing the ARA diagnostic criteria .If I find 4 or more, without investigation doing.
Because this is Deforming arthritis.It causes deforming the joint and pt will be disable if
55
Q.Name common DMARD we use in RA?
Methotrexate ( MTX)
Sulphasalazin
4-12 mvn
GIT upset
Hepatic fibrosis
Q. Dose of Sulphasalazin:
Sulphasalazin(500mg)
2+0+2 continue
56
Q. Complication of Salazin:
Common:
Agranulocytosis
Others:
GIT upset
Reversible sterility
Haemolytic anaemia
Agranulocytosis
Sterility
Q. Is it reversible or irreversible?
Q.Name some biological agent use in RA? Mention the remission criteria in RA
Lymphoma
57
Q.If sir directly ask Rx?
* Suppertive Rx
Rest
* Specific Rx
DMARD
we do CBC - ESR
CRP
RA factor
P - Pain
G Grip strength
T Joint tenderness
58
*Laboratory:
ESR
CRP
Plasma viscosity
Sudden death due sublaxation Atlanto-axial joint, which compress on vital centre of brain
stem
EYE
Piscleritis
Scleritis
RESPIRATION
Pleurosy
Pleural effusion
Fibrosing Alveolitis
CVS
Pericarditis
Pericardial effusion
Neurological
Peripheral neuropathy
Entrapment neuropathy
Menneuritis multiplex
59
Vasculitis
Raynaud Phenomennon
Ulcer
Degital arthritis
Recurrent ( relapsing & remitting) episode of joint pain and stiffness and swelling which
last only for few hours or days..
Swan neck
Boutinniere
Z sorm deformity
Triggering of fingers
60
Q. what do you mean by Rheumatoid factor?
RA - 70%
SLE
30% of RA with typical clinical feature . if RA factor negative this called seronegative
RA
Q.30 yrs old female comes to you with complaints of fever,arthralgia/arthritis with H/O
Alopecia or photosensitivity [ mvi GLvb ejZ cvi iv` Mj cyo hvq/rash nq/Burning
sensation]
Dx - SLE
Oral ulcer
Q. 30 yrs old women comes to you with complaints of fever & joint pain with rash.She also
give H/O recurrent abortion for 6 years. what Dx?
61
Q.Name some connective tissue disease?
SLE
Systemic sclerosis
Jorgen syndrome
D- Discoid rash
P- Photosensitivity
A- ANA
62
Q.what investigation you want to do?
CBC - ESR
CRP normal
SLE
Systemic sclerosis
Jorgen syndrome
63
Q.what is Rx of SLE?
avoid survey
NSAID
o I.V. cyclophosphamide
Renal failure
Lupus cerebrilitis
Q.SLE pt comes to you with renal failure/ s.creatinin /oligourea. what is your Dx?
Lupus nephritis
Q. GB Zzwg wK Rx w`e?
plus
64
Q. KZ w`b w`e? 3-5 days. Repeat: 3 wks interval on 6-8 occasion
Haemorrhagic cystitis
SLE is non-erosive arthritis but deforming arthritis & erosive arthritis in RA.
Anti-Ro-Antibody
Anti-histone-antibody
Q.Classification of SLE?
65
Q.Describe rash of SLE------
Butterfly rash this erythematous raised up painful,itchy over cheeks with spare the
naso-labial fold.
Q.20 yrs old boy H/O low back pain & morning stiffness with pain & swell of rt knee,left
ankle, rt elbow joint.What is your Dx?
Ankylosing Spondylitis
Q. GKUv jvK bvgvh covi mgq iKzZ Mj mgmv nq.wK Dx? / Qj`i ewk nq Ggb wKQy arthritis
R: Reactive arthritis
A: Ankylosing spondylitis
P: Psoriatic arthritis
E: Enteropathic arthritis
[ to rememberSALFER-27]
A- asymmetrical oligoarthritis
F- familiar
E- inflammation enthesitis
R- Ra factor negative
Qj`i 3:1
66
Q. Kvb eqm ewk nq? - 2nd & 3rd decade
stiffness
examination
C---- conjunctivitis
P---- prostatitis
enthesitis.
67
Q.X-ray of lumber spine/ s-g joint?
irregularity, marginal sclerosis, later on fusion at S.I joint from below to upward
L-S spine:
- squaring of vertebra
- bridging syndesmophyte
- bamboo spine
General measure:
Swimming, cycling
68
Q.Newer drugs/ biological agent/ Anti TNF Therapy?
Infleximab
Etanercept
Q. A 30 yrs old man comes to you H/O pain & swelling rt knee joint,left ankle, rt wrist joint.
Pt have diarrhoea 3 wks/1 month ago.what is your Dx?
Reactive arthritis
Q. A 30 yrs old man comes to you with the complaints of conjunctivitis, urethritis , arthritis.
Reiters disease
As because infection nIqvi ci antibody Zix nZ 3 mvn mgq jvM|GB antibody cross react
with joint/eye cause arthritis & conjunctivitis.
Urethritis: C--Chlamyda
male>female, asymmetrical
69
Q. what is triad Reiter disease?
- conjunctivitis
- reactive artyhritis
- CBC--- ESR
- RA--- negative
Q. Rx:
- Rest
- NSAID
- Antibiotic
- recurrent arthritis
- keratoderma blennorrhagia
Sulpha- salazin
70
Q.A pt with AKS. Avi wK examination Kie?
PHTN
Type 11 failure
HEART--- AIR/MR
syndesmophyte osteophyte
Inflammatory Degenerative
Q.A 30 yrs old man comes to you with complaint of red,hot,tender & painful rt
metatersophalangeal joint.What is Dx?
Acute gout
Q. who are suffer for primary gout? ----- common in male> 40 yrs
Q. Avi wK investigation :
S. uric acid
S. creatinine
Urine RME
RBS
CBC
NSAID
o red meat,kidney,liver,brain
o cabbage,cauliflower
precipiating drugs.
R--recurrent attack
T--presence of tophi
72
Q.X-ray finding of gout?
Para-articular punchout lesion with well delineated border & normal bone density
Q.Causes of pseudogout?
Deposotion CPPD
Osteoarthritis
Haemochromatosis
Hyperparthyroidism
MSUM CCPD
Q.Causes of Hyperuricaemia?
Renal failure
Drugs: Diuretic----
Thiazide
Aspirine
Pyrazimamid
Increased production:
Idiopathic( primary)
Myeloproliferative disease
Psoriasis
73
Q.What are the disease responsible for enteropathic arthritis?
Ulcerative colitis
Chronns disease
Psoriatic arthritis
RA Psoriatic arthritis
Q. Rx of Psoriatic arthritis:
NSAID
DMARD--- MTx
Salazin
yes, Infleximab
entararcept
Retenoid
PUV-A
Q. A 65 yrs old female complaint of pain in rt knee joint from sitting to standing position on
exam.The joint not warm/tender/swell.Passive movement produce crepitus.what is your Dx?
Osteoarthritis
74
Q. GUv wK aibi arthritis?-------- Degenerative arthritis
Old age
Insidion onset
Sign:
restricted movement
[to rememberJOS]
S---Subchondral sclerosis
O----Marginal osteophyte
Cyst
Q. Rx of OA?
explanation reassurance
Drugs----
Paracetamol
75
NSAID
Capsalcin
Surgery----
Hip replacement
Knee replacement
Postmenopausal women
Q.Why?
After the menopause oestrogen deficiency causes uncoupling of bone resorption & bone
formation that means the amount of bone removed by osteoclast exceeds the rate of new bone
formation by osteoblast.
76
Q.What can you do in diagnosis of osteoporosis?/Name a single test to diagnose the
osteoporosis?
Q.Treatment of osteoporosis?
Stop smoking on
Exercise
HRT with oestrogen & progestagens prevents post- menopausal bone loss
Calcitonin
77
Bisphosphonates inhibit bone resorption by binding to hydroxyapatite crystal on the bone
surfacewhen osteoclasts resorb bone that contains bisphosphonate, the drug is released
within the cell,where it inhibits signaling pathways that are essential for osteoclast function.
In morning
History
78
Low back pain classified in 4 category
Prolapsed
intervertebral
dise
spondylysis
79
Neurological disease and Stroke
Q: What neurological disease you have seen in your ward?
A: CVD, epilepsy , GBS , paraparesis
A:
80
Q: classify the epilepsy?
A:
According to seizure type: (mnemonic: TATA MP3)
i. P--Partial seizure ( simple & complex)
ii. P--Partial seizure secondarily generalized
iii. P-Primary generalized seizure
iv. T-Tonic-clonic seizure
v. A-Absence seizure
vi. T--Tonic seizure
vii. A--Atonic seizure
viii. M--Myoclonic seizure
*first tell the above ,if the examiner ask more..then tell following:
(remember:
Major seizure: fall occur
Minor seizure: no fall
Simple seizure : pt conscious
Complex seizure: pt become unconscious
A: mnemonic: CAF
81
E--EEG shows focal seizure.
C--Difficult to control seizure.
A:
Explain the disease & also say that it is a natural ,it is not related with curse/stigma.
Avoid exposure to :
Height
Dangerous machinery
Open fire and
Water
Only take shallow bath ( dont take bath or dive in the pond)
Bathroom door should be unlocked
Avoid driving
Keeping card regarding information about the pt &the disease.
82
Anti-convulsant therapy:
Partial /secondary GTCS carbamazepine
Primary GTCS /myoclonic seizure Na-valproate
Absence seizure ethosuximide
Q: what advice will you give a pt. taking anti-epileptic drug about contraception?
A:
[all anti epileptic drugs are enzyme inducer so, cause enhanced metabolism of estrogen as
result there will be:
o Contraceptive failure
o Breakthrough bleeding]
Q: what do you mean by Dejavu, Jamais Vu, Todds palsy, Jacksonian seizure?
A:
Deja vu : undue familiarity temporal lobe lesion,,
Jamis Vu: undue reality. complex partial seizure
Todds palsy: in case of some partial motor seizure ,pt may develop paresis of involved limb
lasting for several hours after the seizure ceases.
Jacksonian seizure: in case of partial motor seizure, some attacks begin in one part of the body
(e.g. mouth ,thumb,great toe) and spread (march) gradually to other parts of the body, this is
known as Jacksonian seizure.
83
Q: what do you mean by Absence seizure (petit mal)?
A:
Q: Scenario- a 20years old lady comes with fever for 3days followed by unconsciousness. What
is your diagnosis?
A: Encephalitis, Cerebral malaria, Meningoencephalitis
(then sir will ask you about the treatment of cerebral malaria or meningitis..here we discuss
the treatment of meningitis onlyl)
What are the CSF findings of meningitis due to bacteria, virus, TB?
A:
Traits Bacterial meningitis Tubercular Viral meningitis
meningitis
1.cell count neutrophil (1000- lymphocyte(50- lymphocyte(10-
(WBC) 5000) 5000) 2000)
2.glucose
3.protein
85
Q: Name the organism causing meningitis according to age?
A:
NEONATE: E.coli, proteus, group-B streptococci (mnemonic- EPS)
PRE-SCHOOL: Haemophilus influenza, Neisseria meningitides, Streptococcus pneumonia
(mnemonic- HNS)
OLDER CHILDREN: NS (above)
Q: scenario: a pt comes to you with H/O splenectomy 3years back. Now he develops fever, rash,
neck rigidity & hypotension, what is your diagnosis?
A: meningococcal septicaemia.
Q: what preventive measures should be taken in case of close contact with meningococcal pt?
A:
In case of adult: Tab.ciprofloxacin (500mg) single dose
In case of child: Tab. Rifampicin( <1yr 5mg/kg, >1yr 100mg/kg)
86
Q: scenario: A pt came to you with a fever for 15days.The Fever is intermittent for few months,
on examination :pt is drowy, neck rigidity (+ve), kernigs sign (+ve), 6th nerve palsy with
fundoscopy reveals papilloedema
Q: What is meningism?
A: It consist of headache, photophobia & stiffness of neck often accompanied kernigs sign.
Cause: meningitis, subarachoid haemorrage.
Cause:
Malignancies: breast cancer, leukaemia, bronchogenic carcinoma
Connective tissue: SLE, Bechet disease.
87
Q: mortality rate of Rabies?
A: 100%
Guillain-barre syndrome
Q: Scenario-A pt comes to you with progressive lower motor neuron type or faccid type
paraparesis, on examination there is no sensory or bowel-bladder involvement. He has a H/O of
fever or diarrhoea 3weeks back. What is your diagnosis?
A: GBS
Q: C/F of GBS?
A:
It is immune reaction where antibody is formed against gangliosides in the Schwann cell
88
Q: What type of lesion?
A: Autoimmune
Finding: albumino-cytologic dissociation that means protein increase but cell count doesnt
increase. If lymphocyte >50x106 suggest alternative diagnosis.
89
Q: What is the mechanism of GBS?
A:
Infection by Campylobacter jejuni
Antibody formation against it
Due to molecular mimicry it crosses reacts with ganglioside in Schwann cell
Destruction of myelin sheath
Blockade of nerve conduction
Myasthenia gravis
Q: Scenario: a 40years lady comes to you with complaints of easy fatigability with dropping of
both upper eyelids which is more marked on the evening. She had recurrent type of attack of this
type of disesase. What is your diagnosis?
A: myasthenia gravis
90
Q: what investigation will you do?
A:
Tensilon test ( by I/V inj. Of endrophonium bromide.
Electromyogram
Detection of antibody against acetylcholine receptor.
Q: A pt comes with the complaints of inability to move Rt side of the body & deviation of the
mouth to the Lt side. What is your diagnosis?
A: stroke with Rt sided hemiparesis
Q: If your pt. has hemiparesis or hemiplegia, what will be the site of lesion?
A: Anterior 2/3rd of posterior limb of internal capsule.
91
Stroke
Q: Define stroke,TIA & completed stoke
A:
Acute stroke: acute stroke is characterized by the rapid appearance (usually over minutes) of a
focal deficit of brain function, most commonly a hemiplegia with/without signs of focal higher
cerebral dysfunction (such as aphasia) ,hemi-sensory loss & visual field defect or brainstem
deficit.
Classification of stroke:
TIA: when symptoms resolve within 24hours of onset.
Stroke: when neurological symptoms lasts >24hours
Progressive stroke/stroke in evaluation: the stroke in which the focal neurological deficit
worsen after the pt. first present. Such worsening may be due to increasing volume of infarction,
haemorrhage or related oedema.
Completed stroke: The stroke in which the focal deficit persists & is not progressing.
92
Dysphagia
Dysphonia(tone)
Diplopia
Where it is found?
A: In brainstem lesion.
S- Smoking
H- Hyperlipidaemia
O- OCP
P- Polycythaemia
93
Cranial nerve palsy- 3rd, 6th, 7th nerve
Pulse- irregular- AF
Bradycardia- haemorrhage or ICSOL
BP- high BP- haemorrhagic stroke
Carotid bruit- if + , indicating atherosclerosis , source of embolus
Fundus- papilloedema- ICSOL, haemorrhage
Heart rhythm- (atrial fibrillation)
Murmurs- (source of embolism)
Apex beat- shifted or not
Peripheral pulses (generalized arteriopathy) & bruits(carotid)
A: Sub-arachnoid hemorrhage
94
Q: Write down the causes of UMNL?
A:
Stroke
ICSOL
Cerebral abscess
Multiple sclerosis
Spinal cord compression:
3T: trauma, TB, tumor (2ndary & multiple myeloma)
Q:
95
Q: What investigation will you do in a pt with stroke?
A:
For Diagnosis: Imaging- CT Scan of brain
To detect cause & risk factor:
I. ECG
II. RBS
III. S. Creatinine
IV. Echocardiography
V. Fasting lipid profile
96
Q: What are the causes of episodic loss of consciousness?
A:
TIA
Seizure
Syncope
Q: A young pt comes with lt sided hemiparesis & examination reveals irregular pulse & diastolic
murmur. What is your diagnosis?
A: Mitral stenosis with AF & infarctive stroke (due to thromboembolism that arise from the
left atrium & goes to cerebral vessel.)
Q: A pt comes with absent rt knee jerk & exaggerated rt ankle jerk. What is the cause?
A:
It happens if lesion is in L3 & L4 level of spinal cord
Knee jerk absent as there is LMNL at the level of L3 & L4 & ankle jerk is exaggerated as
there is UMNL below it.
Q: 26 yrs old woman came to you with the complaints of unilateral headache with nausea,
vomiting & photophobia? What is the Diagnosis?
A: Migraine headache
97
next you try to differentiate tension type headache and migraine headache:
points Tension type headache migraine headache
Site Bilateral, occipital, vertex Usually unilateral
character Dull ,diffuse, band like Throbbing pain
pressure
Duration & frequency Many hours to days, even Last for 24 hour to 72 hour
months
Severity Mild to moderate severe
Prodrome/aura Absent Visual aura ,tingling
sensation, numbness over
affected area , nausea
vomiting
Photophobia& Absent Present
phonophobia
Aggravating factor Workload, depression, anxiety Cheese, chocolate, red wine,
OCP, bright light, loud noise,
menstruation, changing
weather, citrus food, travel
Frequency Infrequently daily, episodic, Sub acute, acute, weekly,
chronic monthly, before menstruation
Q: A pt comes with chronic mild headache with hypertension and bradycardia with
papilloedema. What is the Dx?
A: ICSOL
98
Q: Give the treatment of migraine and tension type headache.
A:
Rx of migraine Rx of tension headache
Life style modification Drugs:
Regular exercise During acute attack:
Regular sleep patterns Tab. Paracetamol
Avoidance of excess caffeine and Anxiolytic
alcohol
Avoidance of acute changes in stress Prophylaxis:
level Low dose Amitriptyline 10 mg
Drugs: 0+0+1
A. During acute attack: NSAID,
Paracetamol
B. Prophylaxis:
Tab. Pizotifen 1.5-3.0 mg/day
0+0+1..continue
99
Q: What are the causes of unilateral & bilateral facial nerve palsy?
A:
Unilateral Bilateral
Bells palsy (idiopathic) GBS
Herpes zoster Sarcoidosis
Cerebellopontine angle tumours Lyme
Parotid tumour
Skull fracture
Herpes zoster
Q: A pt comes to you with unilateral vesicular rash in any part of the body, which does not cross
the midline. What is the Diagnosis?
A: SHINGLES (HERPES ZOSTER)
100
Q: When/why it becomes reactivated?
A:
Spontaneous reactivation or
Due to immunosuppression (as in DM, malignant disease or AIDS)
Q: If this pt comes to you 1yr later with severe pain of affected areas, what is your diagnosis?
A: Post herpetic neuralgia.
Parkinsonism
Q: A pt comes to you with resting tremor & difficulty in walking mainly starting, stoping &
turning with expressionless face. What is the Dx?
A: Parkinsonism (PD)
101
Q: Why is the lesion?
A: Due to dopamine secretion.
102
Q: Why Carbidopa is used?
A: it is a peripherally acting (does not cross BBB) dopa-decarboxylase inhibitor which prevent
peripheral (in GIT, blood vessel) conversion of levodopa.
103
Resting tremor:
PD/ extrapyramidal
Action tremor:
Flapping tremor
Respiratory failure
Renal failure
Hepatic failure
Intention tremor: cerebellar lesion
Q: A pt comes to you with bending of neck following after taking drug. What is the Dx?
A: Extrapyramidal syndrome (due to drug probably stemetil / anti-psychotic drug).
104
Q: What is the treatable cause of dementia?
A:
Chronic sub dural haematoma
Cerebral tumour
Hydrocephalus
Deficiency
Q: A pt comes to you with the complaints that he forgets telephone no. address, can not
recognize known people. He goes out for market but eventually reaches the school. What is your
Dx?
A: Dementia
What may be the cause?
A: Alzheimers disease
105
Q: What are the differences between Wernick-korsakoff syndrome & Wernick encephalopathy?
A:
Wernick encephalopathy Wernick-korsakoff syndrome
Acute Chronic
Reversible Irreversible
Remission if treated No Rx available
106
Q: What is the Rx in case of acute transverse myelitis?
A: Inj. Methyl prednisolone.
Q: A pt comes with inability to see with rt eye, lt sided hemiparesis & cerebral sign. He has H/O
similar type of attack 2 years back. . What is the Dx?
A: Multiple sclerosis
Q: A pt. when splashes his face with water, he fall down. Why?
A: Due to sensory ataxia.
Q define Ataxias
A. It is an Incoordination of voluntary movement in absence of motor weakness
107
Environmental and Nutritional Factor Diseases
NAME SOME ENVIRONMENTAL DISEASES
Cold injury
Frostbite
Non-freezing cold injury (trench or immersion foot
Heat syncope
Heat exhaustion
Heat stroke
Heat cramp
108
Headache, nausea, vomiting and weakness,
Neurological: confusion, coma and death.
The skin feels very hot to the touch.
Sweating is often absent
Treatment
Resuscitated the patient with rapid cooling by
spraying with water,
fanning and
ice packs in the axillae and groins.
IV fluid
o Cold crystalloid intravenous fluids are given(but potassium fluid containing should
be avoided)
Manage in intensive care
Q a patient becomes unconscious during working at field in very hot humid day. What is
your diagnosis and what how you manage it?
The patient is suffering from heat stroke :
Management : like heat stroke
What is the causes of heat cramp
It is Painful muscle cramps, usually in the legs, often occur when people exercise
excessively in hot weather
Cramps are probably due to low extracellular sodium caused by excess intake of water
without salt .
109
give Prophylactic antibiotics if it occur in contaminated contaminated water
correction of electrolyte imbalance and metabolic acidosis
What happened in drowning ?
Hypoxaemia
Metabolic acidosis
electrolyte imbalance
Acute lung injury
complication
o dehydration,
o hypotension,
o haemoptysis,
o rhabdomyolysis,
o renal failure and cardiac dysrhythmias.
What metabolic and electrolyte imbalance occur in sea water and fresh water
drowning
Fresh water hypotonic haemolysis of RBC Sea water as hypertonic
Metabolic acidosis Metabolic acidosis
Hyponatraemia Hypernatraemia and hypercalcaemia
Alveolar collapse Alveolar edema
110
Write down the consequence of drowning or near-drowning :
inhalation of water inhalation of water
which leads to alveolar collapse and impairs So fluid comes into alveoli from vessel
surfactant function
hypoxaemia
To remember: MRCP
When we go under water partial pressure of gass is increase so more gass (nitrogen) is dissolved
.when driver descend more nitrogen is dissolved in blood . the amount dissolved depends on the
depth/pressure and on the duration of the dive.
On ascent, the tissues become supersaturated with nitrogen and other gass as partial pressure is
decrease.These extra nitrogen that was desolved released as gas bubbles in tissues if the ascent
is too fast.produce following symptoms in different part of the body .
111
Pain: often large joints, e.g. shoulder ('the bends')
Neurological: any deficit is possible
Ear : vertigo, tinnitus, nystagmus; may mimic inner ear barotrauma
Pulmonary: chest pain, cough, haemoptysis, dyspnoea; may be due to arterial gas
embolism
Cutaneous: itching, erythematous rash
Lymphatic: tender lymph nodes, oedema
Arsinocosis
112
What are the complications of obesity
Hypothyroidism
Cushing's syndrome
Insulinoma
Drug
Name some causes of drug that causes weight gain
Drug treatments
Tricyclic antidepressants
Estrogen-containing contraceptive pill
Corticosteroids
Sodium valproate
113
Vitamin
Name some fat soluble and water soluble?
Fat soluble : ADEK
Water soluble : BC
Acute overdose leads to nausea and headache, increased intracranial pressure and skin
desquamation.
Chronic overdose :liver damage, hyperostosis and teratogenicity
114
What are human source of Vit-K?
Vegetables source : leafy vegetables and liver
In human :synthesised by bacteria in the colon
Name Vit- k depend coagulating factor ?
II, VII, IX and X
Mention 3 clinical uses of vitamin K?
To prevent haemorrhagic disease of the newborn.
In obstructive jaundice
Warfarin induced bleeding
115
Geneitic
Human have 23 pair of chromosome of then 22 are autosome and 1 is sex chromosome .
Genes are functional units of the chromosome. It produce messenger mRNA from DNA. this
mRNA is responsible for protein synthesis .
What do you mean by haploid and diploid chromosome? Which cell contain haploid and
diploid chromosome?
When chromosome number is 23 is called haploid present germ cell like sperm and ovum karyo
typing 23X or 23Y
When chromosome number is 46 is called diploid present somatic cell 46, XY
In human chromosome have each has two copies one come from mother and one from father
Homozygote state : when both the copy of the gene is defected
Heterozygote state when one of copy of the gene is defected / abnormal and other is normal
Autosomal dominance: disease express in Heterozygote state
Autosomal recessive: disease express in Homozygote state
When will trait / carrier : it found in autosomal recessive when one chromosome have defected
gene and other chrosome is normal . it will not manifest disease .
116
o 50% of his offspring have chance to have / transmit the disease
be normal o 25% of his offspring wil be normal
One of his parent is have affected o 50% of his offspring have chance to
chromosome be carrier or trait
Both of the parent carry the affect
chromosome
117
What do you mean by lionization theory Random inactivation of one of the two X
chromosome is called lionization theory
Mitochondrial DNA comes from mother So both male and female are affect but
affect female transmit the disease . But
affected male does not transmit diseases
Frequent question will be ask about the syndrome must read karyotype and some
important
Phenotype
118
Klinefelter's syndrome Turner's syndrome
Phenotype Male Female
Karyotype 47,XXY 45,X
Stature Tall stature Short stature
Clinical feature Phenotypic male, Phenotypic female,
Tall stature short stature,
infertility, webbed neck,
Gynaecomastia, coarctation of the aorta,
small testes primary amenorrhoea
fish mouth appearance
FALL
DEMENTIA
CATARACT
BEP
HYPERTENSION
STROKE
HEARING LOSS
OSTEOARHTRITIS
OSTEOPOROSIS
Postural hypotension
Visual disturbance
Accidental
Osteoarthritis
Drug
Perkinson disease
Muscle weakness
Gait or balance abnormality
Use of a walking aid
119
Define postural hypotension
If postural hypotension defined as a drop in blood pressure of > 20 mmHg systolic or > 10
mmHg diastolic pressure on standing from supine
Cause
Autonomic neuropathy DM
Addison disease
Drugs vasodilator
Management of postural hypotension
Correction of dehydration
Head-up tilt of the bed
Support stockings
NSAIDs
Fludrocortisone (causes salt and water retention)
120
PaCO2 < 4.3 kPa (< 32 mmHg) or ventilated
Sepsis Systemic inflammatory response caused by documented infection
Patients requiring support for a single failing organ system, excluding invasive ventilatory
support:
Patients no longer requiring intensive care but who cannot be safely managed on a general
ward
121
A very cachetic or emaciated patient admitted in your ward? You give NG feeding and
patient died after NG feeding what may the cause ?
Due to refeeding syndrome
Because patient was feed carbohydrate rich food and which causes hypokalaemia
and pt died due to arrhythmia
What may another causes
Patient was in B1 deficiency . giving only glucose causes wernicks encephalopathy
122
Respiratory Disease
Q.Name some respiratory emergency?
Tension pneuumothorax
Acute severe asthma
Acute exacerbation COPD
Q.Name disease of respiration you have seen in ward?
COPD
Bronchial asthma
Pneumothorax
Pleural effusion
Pulmonary TB
Bronchogenic carcinoma
Q.GKUv Pt. Zvgvi KvQ Avmj sudden severe respiratory distress with chest pain.What is
your DX?
Tension pneuumothorax
Acute LVF
123
Q KLb Thoracotomy KiZ ne?
If bubbling continue after 5-7 days of IT tube insertion
QCauses of pneuumothorax?
According to etiology [ to remember SIT]
S spontaneous
primary 1) rupture apical subplural bleb
2) emphysematous bullae
secondary 1) COPD
2) TB
3) Lung abscess
4) Bronchial asthma
Q RX of pneuumothorax?
Primary pneuumothorax
Closed type mild< 20% , moderate 20-50 %,large > 50%
Mild < 20% of lung volume or lung edge is less than 2 cm from the
chest wall are normally absorb
Moderate to large percutaneous aspiration with wide bore needle
Open type & Tension pneuumothorax IT(intercostal) insertion
Secondary pneuumothorax
COPD IT tube
Q. percutaneous aspiration KLb e Kie?
Aspiration> 2.5
Pt cough excessive
Felt resistance during aspiration
Q Kvb space nZ aspiration Kiv nq?
2nd intercostal space at mid-clavicular line
124
Q.Name some causes of recurrent pneumothorax?
{To remember- CASE]
S- Subpleural bullae
E- Emphysematous bullae
C- Cystic febrosis
A-alpha anti trypsin deficiency
Q.Indication of thoracotomy?
persistent air leak or unexpanded lung after 5-7 days of giving IT tube
3rd recurrence
Q. 45 yrs old man comes to you with haemoptysis.what will you do?
At first I will do resuscitation of this Pt
See pulse, BP & urine output
Give immediate open a I.V. channel (Inj. Hartsol 1000 I.V 20dl/min)
Do blood grouping & cross matching
Give one unit of blood
After resuscitation try to find out the cause
For this I take H/O,do clinical exam and some investigation when the Pt is salt led
Q. Common cause
TB
Bronchongeinc Ca
Bronchiectasis
Acute/chronic bronchictis
Acute pulmonary edema due to acute LVF
Examination
Clubbing,lymphadenopathy or SVO & horners :Gas fever Br. carcinoma
Cyanosis,clubbing,coarse geps: Bronchiectasis
Vesicular breath soundwith prolong expiration with cough: Bronchitis
Cyanosis,tachycardia,bilateral basel gep,murmur,gallop rhythm: Acute LVF
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Next I do investigation:
TC,DC,ESR ESR- in TB,BR. ca
Sputum for AFB: TB
Sputum for malignant cell: Bronchogenic carcinoma
MT: positive TB
CxR PA: TB, Br. Ca, Bronchiectasis,Bronchitis,LVF
Bronchiectasis: honey comb, ring like,tram line
Bronchitis: COPD feature
LVF: Perihilor hoziness,Bat wings, Kerlys B.line,Cardiomegaly, upper lobe
diversion
If lymph node palpable: FNAC, Biopsy
if suspect Br.carcinoma:
PeripheralCT biopsy
Central lession: Bronchoscopy & Biopsy,Bronchial cleavage
ECG- to LVF
Pneumonia
Q.A 30 yrs old man comes to you with fever,chest pain,cough for 5 day.On xm, you
find increase breath sound,Bronchial or increase & percussion is not dull.What is
your diagnosis?
Pneumonia/ pheumonic consolidation/CAP
Q.What is Pneumonia?
Pneumonia define as acute respiratory illness with recently developed
radiological pulmonary shadows which be lober,segmental or multilober.
Common: 1,2,3,4
QGKUv Pt Zvgvi KvQ Avmj Breath sound increase & vocal resonance increase. 2 w`b
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ci `Lj Breath sound deminesh & percussion note dull/ stony dull.what is Dx?
Q.A pt with pneumonic consolidation & but get crep+ on auscultation .what Dx?
Pt is in resolution phase
Q.Pneumonia pt Gi wK Rx?
Specefic:
Uncomplicated: Cap: Amoxycillin(500 mg) 1+1+1----------7-10 days
Severe:
Inj. co-amoxyclav 1.2 1ampI.V.8hrs
Inj. clarithromycin 500 mg 1 amp I.V. B.d
Surpportive:
O2 inhalation of need
Pain killer----NSAID( but if not control/severe nj opiate `B)
Fluid balance
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K-- Klebsiella
Ppseudomonas
Q.Gi Rx wK?
Injectable 3rd generation cephalosporin [ cefotaxin/ceftriaxin with
aminoglycosides- gentamycen]
Q.what do you mean by CURB-65?
C- confusion
U- urea> 7 mmol
R- respiratory rate> 30/min
B- Blood pressure[ systolic<90,Diastolic<60]
65- Age>65
each pointscore-1
0/1- home Rx, 2- hospital supervised 3 or more- ICU treatment
Q.A pt comes to you with foulsmelling & clubbing & fever.what is your Dx?
or
Zzwg IqvW ivMx `LQ|Ggb mgq GKUv jvK Gm Kvwk w`q Kd ei nj `~M mviv IqvW fi Mj|
Dx wK?
Bronchiectasis
Lung abscess
Q.GKUv ivMx Zvgvi KvQ clubbing & bilateral coarse Gep(+) wbq Avmj|what is your Dx?
Bronchiectasis
Fibrosing Alveolitis(ILD)
Q.Causes of Bronchiectasis?
Congenital causes----[to rememberCKD]
C- cystic fibrosis
K- Karteyener syndrome
D- primary celliary dyskenesea
Acquired causes-----[to remember---PTB]
P- pneumonia
T-T.B.
B- Bronchogenic carcinoma {in case of children----foreign bodies}
Q.Complication of Bronchiectasis?
recurrent infection
abscess formation
empyema
pulmonary HTN
corpulmonale
Res. failuretype 11
amylodosis
Q.Rx of Bronchiectasis?
[to remember PAST]
Ppostural drainage chest physiotherapy
A- antibiotic ( during acute infection)
S- Surgery( if young pt & confined, unilateral & localized single lobe)
T- Heart-Lung transplantation( Done in bilateral extensive Bronchiectasis)
Q.Clinical presentation?
Coughchronic productive foul smelling spudum,that increase in change posture
& more marked in murmer.
Clubbing
Haemoptysis
Coarse Gep that changed after coughing
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Bronchogenic carcinoma
Q.Which is peripheral bronchogenic carcinoma?
Squamous cell carcinoma
Periphery carcinoma grow largely without producing symptoms. Central lesion
small but produce early symptom
endocrine
-ACTH---cushing
-carcinoid tumour
Q.Indication of Radiotherapy?
squamous cell ca.
SVO
reecurrent haemoptysis
chest pain/skeletal metastasis
bronchial obstruction
132
Q.Why Horner syndrome occur?
due to involvement of cervical sympathetic ganglia
COPD
Q.Write down the management of acute exaggerated of COPD?
1. low flow O2 inhalation (2-4 l/min)
2. Nebulization stat and sos or 4/6 hrly (sulbutamol .sol 1ml+1ml ipratropium
.sol +2 ml normal sal.)
3. Inj. Hydrocortisone ( 2amp I.V sat and 1 amp I.V 6 hrly)
4. Antibiotics
5. Salbutamol inhaler ( 2 puff qds)
6. Ipratropium inhaler (2 puff tds)
7. Beclomethason inhaler (2 puff tds)
8. Tab. Theophyline
133
Q. How will you differentiate bronchial asthma & COPD?
134
Q. What test you will do to establish diagnosis of bronchial asthma?
What investigation you want to do?
Pulmonary function test with spirometry
The diagnosis is certain if:
*20% diurnal PEF variation on> 3 days per week, in a week of peak flow diary
measures.
*FEV1 > 15% decrease after 6 minutes exercise
*FEV1 >15% (and 200ml) increase after 2 week trial of oral steroid
(30 mg prednisolone od)
*bronchodilator reversibility testing FEV1> 15% ( or 200ml) increase after
short- acting beta agonist therapy
135
Q. Write down the feature of severe asthma?
[to rememberHIP Replacement]
HHR> 110/min
Iinability to complete sentence in one breath
PPEFR 3350% predicted or best (<200 l/ min)
ReplacementRR>25/min
136
Q. Types of Emphysema?
Panacinar Emphysemaall the alveoli and alveolar ducts in acinus are
involved
Centriacinarinvolve proximal part of acini
Periacinar or paraseptal Emphysema along the septa, blood vessels and pleura
Scar and irregular Emphysema
restrictive obstructive
FEV1 & FVC decreased Markedly decrease
FEV1 / VC normal decreased
Q. Complications of COPD?
Pulmonary hypertension
Corpulmonale
137
Type 11 respiratory failure
Pneumothorax
Polycythaemia
Secondary infection
Q.How will you differentiate between pink puffer & blue puffer?
138
Q.What will you get if pt have pulmonary hypertension and corpulmonalae?
In GE:
Eyecongested
Tonguecyanosis
Oedema(+)
Sign of rt heart failure
Raised JVP
Tender hepatomegally
Sign of pulmonary hypertension:
Palpable P2 and loud P2
Left para sterna heave
Epigastric pulsation
TB
139
Q. what do u mean by 'Ghon focus?
A. Ghon focus is the aggregation of numerous granuloma at site of lesion it is the
primary lesion in the lung. Usually situated in periphery of lung.
140
Pleural effusion
Some definition :
New case who have never received anti- TB drugs or received less than one
months
Relapse ----- A patient who previously received treatment and was cured or treatment
completed .And again developed Smear positive pulmonary TB.
Treatment A patient who while treatment ,remain smear positive or became
failure smear Positive again at 5 month or more after the start of treatment
Or
Patient was initially sputum negative but again become sputum at the
end of 2 months
Q. What do u mean by cryptic TB?
A . In some specially in old patient TB present with only wt loss and low grade fever
without radiological change in , MT and sputum negative . Diagnosis only done by
biopsy of the bone marrow . This called cryptic TB.
141
Q . How will u make difference from active TB to inactive TB?
ActiveTB Inactive TB
Clinical Fever , wt loss, night Absent
feature sweat usually present
142
Q Mention the categoryI treatment
Intensive phase Continuation phase
4FDC drugs for ---- 2 month 2FDC drugs -------------4 month
RIEZ -- RI
Rifampicin Rifampicin
Isoniazid Isoniazid
Ethambutol
Pyrazinamide
RIEZ -- 3 months RI
Rifampicin Rifampicin
Isoniazid Isoniazid
Ethambutol Ethambutol
Pyrazinamide
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Do the following
Stop the drugs immediately
Do liver function test ( SGPT and s.bilirubin )
When test become normal or near to normal
Strar anti TB drug in challenging dose
Start with low dose single less hepato toxic drug
Goes its optimum dose gradually and
Start one by one drug and
Finally give combination drug
Due to unknown mechanism jaundice does not develop
Q Now read the pleural effusion effusion from long case sheet
Q. finding consolidation , pneumothorax , collapse and fibrosis , other question from
shortcase sheet
144
Define dyspnea ?
Breathlessness or dyspnoea can be defined as the feeling of an uncomfortable need to
breathe.
145
Blood
Q. Define Anaemia.
Ans. Anaemia is a clinical condition characterized by both qualitative and quantitative decrease
in Hb below the normal level irrespective to age and sex of a person.
Q. Classify anaemia.
Ans.
Etiological
a) Central cause Marrow failure aplastic anaemia, anemia of chronic disease.
b) Peripheral cause blood loss, heamolysis
Morphological classification
a) Microcytic hypochromic anaemia
b) Macrocytic anaemia
c) Normocytic normochromic anaemia
146
Q. What are the causes of macrocytic anaemia?
Ans. Vitamin B and folic acid deficiency.
Q. What are the investigations you will do to diagnose Iron deficiency anaemia?
Ans.
TC, DC, Hb%, ESR
PBF- Microcytic hypochromic anaemia
Iron profile: Serum ferritin
Total iron binding capacity
To find etiology:
Upper GI endoscopy
Colonoscopy
Stool for ova of helminthes
Q. How will you differentiate PBF of iron deficiency anaemia and Thalassaemia.
Ans.
147
Q. Mention the treatment of iron deficiency anaemia.
Ans. Tab. Ferus Sulphate (200mg), tds, for 3-6 months.
Follow up: Hb will increase 1gm/dl in every 7-10 days. Reticulocyte count will increase after
1 week.
Angina
Heart failure
Evidence of cerebral hypoxia.
Q. Vitamin B and Folic acid deficiency- which one is more common? Why?
Ans. Folic acid deficiency is more common than vitamin B12 deficiency.
For following reasons:
Point Vitamin B Folic acid
Store 3years 3 months
Sources Animal plant
Effect of cooking Not destroyed Destroyed during cooking
148
Q. Name causes of Vitamin B and Folic acid deficiency.
Ans. causes of Vitamin B and Folic acid deficiency:
Vitamin B Folic acid
Diet: vegan Increased demand, poor intake of
Stomach: pernicious anaemia, partial/ vegetables
total gastrectomy Intestine: malabsorption, coeliac
Intestinal: tropical sprue, coeliac disease
disease, crohns disease Drug: phenytoin, MTX
Other: haemolysis,
Q. What are the PBF findings of Vitamin B and Folic acid deficiency?
Ans. Pancytopenia with Macrocytosis with hypersegmented neutrophil. Megaloblast & Howel-
jolly body may present.
149
Q. What is pernicious anaemia?
Ans. It is an autoimmune disease in which antibody is formed against parietal cell (which secrete
intrinsic factor).
Q. To prevent neural tube defect in fetus, when folic acid supplementation should be started?
Ans. Folic acid supplementation should be started before conception, because, neural tube
development occur within 1-3 weeks of conception.
Q. If a patient with Vitamin B deficiency is given folic acid without giving Vitamin B,
what will happen?
Ans. It will cause subacute combined degeneration of spinal cord.
Q. . What are the neurological feature of subacute combined degeneration of spinal cord?
Aplastic anaemia
Q. A patient comes to you with gum bleeding, petechiae, purpuric spot. What will be the
differential diagnosis?
Ans.
Acute leukaemia
Aplastic anaemia
I.T.P
(*If fever present, Dengue will be added to the D/D)
151
Q. what is the treatment of aplastic anaemia?
Ans. Supportive treatment
For anaemia Blood transfusion
For infection Antibiotic
Granulocyte stimulating factor/ colony stimulating factor.
Specific treatment
Allogenic bone marrow transplantation
Anabolic steroid
Cytotoxic drug- cyclosporine
Purpura
Q. What are the causes of purpuric spot?
Ans.
I.T.P.
Aplastic anaemia
Leukaemia
DIC
Henoch- schonlein purpura
Dengue
152
Q. What are the differences between purpura and spider neavi?
Ans.
purpura spider neavi
Due to extravasation of blood Due to arteriolar dialation
No blanch on pressure blanch on pressure
Due to platelet Due to estrogen
153
Q. What is the cause of I.T.P. in splenectomized patient?
Ans. Probably patient has ectopic spleen.
Q. A patient comes to you with bloody diarrhoea, abdominal pain, purpuric spot in the buttock,
leg. What is your diagnosis?
Ans. Henoch-Scheonlein purpura.
Multiple myeloma
Q. What are the diagnostic criteria of multiple myeloma?
Ans. 2 of the following 3:
Skeletal lesion (lytic lesion)
Bone marrow plasma cell >30%
Serum and urinary paraprotein
Q. A 60 years old man comes to you with generalized bony ache. What are the differential
diagnoses?
Ans.
multiple myeloma
chronic renal failure
osteoporosis
malignancy with bony metastasis
155
Q. Mention the treatment of multiple myeloma?
Ans.
Specific treatment: Melphalan and prednisolone
Supportive treatment:
For hypercalcemia- fluid intake, I.V. fluid, Bisphosphonate
For pain- analgesic
Correction of anaemia
Antibiotic- if infection
Q. the patient of multiple myeloma comes to with paraparesis . what is your diagnosis ?
Leukaemia
Q. What are the difference between acute lymphoblastic leukaemia and acute myeloblastic
leukaemia? Some ques will ask from this such as common luekaemia in child , which leukaemia
is better ?
Ans.
Topic Acute lymphoblastic Acute myeloblastic leukaemia
leukaemia (AML)
(ALL)
Common age group Children (1-5) years Adult
Lymph node enlargement Present absent
PBF and bone marrow Lymphoblast Myeloblast
Prognosis Good/ better Not so
156
Q. What are the investigations you will suggest?
Ans. TC-, DC, Hb%, ESR
PBF- Blast cell- only test for diagnosis of leukaemia
Bone marrow- done for typing of leukaemia
Ultrasonography and chest-X ray- for staging
Q. Which leukaemia may involve CNS, what measures taken for it?
Ans. In ALL, there is chance of CNS involvement. For this reason, intrathecal MTX is
administered.
Q. What is the definite treatment?
Ans. Allogenic bone marrow transplantation.
157
Q. What are the complications of bone marrow transplantation?
Ans.
A) Mucositis, B) Acute graft versus host C) Chronic graft versus
Infection disease with 100 days host disease.
Bleeding after transplantation
Pneumonitis Skin rash
Liver- jaundice
GUT- diarrhoea
CML
Q. A 65 years old patient comes to you with the complaints of fatigue and weakness. On
examination, you find that, the patient is anaemic and there is huge splenomegaly. What is your
diagnosis?
Ans. CML
158
Q. Minimum which investigation can diagnose CML?
Ans. Only CBC by seeing precursor of granulocyte series.
Q. Which follow up is done during treatment with Hydroxyurea? For how long Hydroxyurea is
given?
Ans. Regular CBC is done. Target WBC count <20,000.
Stop drug if WBC <10,000
Duration- upto when the WBC count becomes 20,000.
159
Lymphoma
Q. What are the causes of generalized lymphadenopathy?
Ans.
Lymphoma
Leukaemia
Disseminated TB
160
Red- Reed sternburg cell
All these features are present in Hodgkin lymphoma and absent in Non-Hodgkin lymphoma.
Other therapy
COPP MOPP ABCD
C- Cyclophosphamide M- Mustin A- Adriamycen
O- vincrestin O- Onchovesin B- Bleomycen
P- Procarbazin P- Procarbazin V- Vencrestin
P- Prednisolone P- Prednisolone D- Decurbazin
161
Q. Name cause of lymphadenopathy , (infective , non-infective )
Haemophilia A
Q. A patient came to you with recurrent swelling of right knee joint after fall, during playing.
What is your diagnosis?
Ans. Haemophilia.
162
Ans. BT- normal, CT- prolonged. [ In ITP, BT- normal, CT- normal]
Ideally PT, APTT should be done. PT- normal, APTT- increased.
163
Q. A patient continued to bleed, even after 24 hours of circumcision. What is the diagnosis?
Ans. Haemophilia.
Q. Name the coagulation factors that are produced in the liver with the help of
vitamin k ?
Ans. These are- factor II, VII, IX, X.
164
Q. A patient of 65 years age came to you and you found anaemia on examination. Investigations
showed no cause of blood loss, PBF was normal, no history of chronic disease. 6 months later
the patient developed blast cell 20% in PBF. Now what is your diagnosis?
Ans. Myelodysplastic syndrome.
Neoplastic:
165
Primary: lymphoma, leukaemia(ALL (child),CLL (old))
Secondary: lung, breast, thyroid, stomach
166
Endocrine Disease
Q.Name some endocrine disease you have seen in ward?
DM
Thyroid--- hypo & hyper
Cushing
Acromegaly
1st tell------- DM-Hypoglycemic coma
-DKA
-HONKC
Then thyroid---thyrotoxicosis crisis
Myxedema coma
Addisonian crisis
Q.Name some endocrine condition where wt gain occur?
Hypothyroidis
Cushing
Thyrotoxicosis
Adrenal insufficiency ( Addison)
DM
Thyroid
Q.Name thyroid hormone?
167
Q.Name the investigation you will do in pt with thyroid disease?
Hyperthyroid Hypothyroid
Temp Heat intolerance Cold intolerance
Hand Warm but sweaty hand
Fine tremor
Palmer erythma
Wt & appetite Loss of Wt Weight gain
But increased appetite
Face Irritability, staring look Moon/puffy face, baggy eye,
q. what is face finding of pt Agitated, eye sign periorbitaledema, loss of
with hypo & hyper thyroid Lid log, lied retraction lateral eye brow
exophthalmus
GIT Loss motion Constipation
ascitis
CVS Sinus tachycardia Bradycardia
What is the CVS finding of AF HTN
Hypothyroid or hyperthyroid Systolic BP/HTN IHD
Palpitation Pericardial effusion
Heart failure astherosclerosis
Angina
Menstruation Amenorrhea menorrhea
What is the mens finding ind
Hypothyroid pt ?
Neurological Hyper refiexia Delay relaxation ankle jerk
Periodic paralysis Hoarsness of voice
Proximal myopathy Depression
Carpal tunel syndrome
deafness
Q.30 yrs old cachexic lady comes to you polyphagia & diarrhea with increased appetite.What
is your Dx?
Hyperthyroidism
DM
Q.30 yrs obes female comes to you H/O constipation, depression & hoarsness of voice &
easily fatigue. What is your Dx?-----------Hypothyroidis
168
Q.Clinically/ bed side wK exam Ki hypothyroid cgvY Kiv hve ?
[to remember---GAMSa]
G- graves disease
Name three sign u look in a pt with hypothyroid ?
A- Toxic adenoma Speech husky voice
Pulse brady cardia
M- Toxic multinodular goiter Jerk delayed relaxation of ankle jerk
Sa- Sub-acute thyroiditis
D- drug
R- radio-iodine
T- thyroidectomy
I- Iodine deficiency
Hashimotos thyroiditis
Spontaneous atrophic thyroiditis
Iodine deficiency
169
Q.Name some cause of goiter?
Simple goiter
Multinodular goiter
Graves
Toxic ademona
Hashimotos thyroiditis
Spontaneous atrophic thyroiditis
Graves
Hashimotos thyroiditis
Spontaneous atrophic thyroiditis
Q.Rx of hyperthyroidis?
-------Radio-iodine
-------Surgery
< 40 yrs
Q.Complication of Carbimazol?
Rash
Agronulocytosis
Q.A pt with hyperthyroidism on Carbimazole comes to you with sore throat?What Dx?
Pt develop agronulocytosis
Stop drug,give antibiotics
170
Q.mv_ Avi wK `Iqv nq?----Tachycardia Gi Rb -blocker w`Z nq
Q.Contraindication of radio-iodine?
Q.Indication of surgery?
[to remember---MRCP]
C- Cosmetic purpose
P- pressure affect
Q.Complication of surgery?
Hypothyroidism
Hypo parathyroidism
Transient hypocalcaemia
Recurrent laryngeal nerve palsy
Radio-iodine thrrapy
Same as thyrotoxicosis
Exophthalmus
Goiter
Dermopathy pre-tibial myxoedema
Eye ------lid lay eye lid log behind the eye ball
------ Exophthalmus
172
A patient come to you with pain in the throat and have HO of fever 7 days ago? On
examination pt have tenderness over thyroid gland ? What is your diagnonsis ?
My diagnosis is subacute thryroiditis or Dequervain s syndrome
What will be the treatment?
NSAID
blocker if symptomatic
may need oral steroid prednisolone
careful monitoring of thyroid function
if patient become hypothyroid may need temporary thyroxin therapy
What is feature of subacute thryroidistis ?
HO FEVER
Pain in thyroid
Pain worse on chewing or swallowing and movement of neck
On exam ---diffuse tender thyromegaly
Age : female , 20 -40 yr
Thyroid scan
Low uptake
ESR---increased
What is the nature history of subacute thryroiditis ?
Hyperthyroid (4-6wks) ----then hypothyroid(4-6 month)----then euthyroid
What is biochemical feature sub acute What is biochemical feature sub acute
hyperthuroidism ? hyperthuroidism
TSH---is undetectable TSH---is increased
T4 and T3 --upper limit of normal T4 and T3 --lower limit of normal
Is treatment need in this condition? Is treatment is needed ?
.
Yes Usually not needed
why Mention the indication of treatment in
subclinical hypoth?
Because chance of Treatment is needed only in following
AF condition ?
Osteoporosis THS>10
TPO is more
Pregnancy
Infertility
Goiter
173
Suppose a patient of graves disease if you give treat become hypo / if not then become
hyper what will you dc?
We will give both carbimazole and thyroxin.
What are the clinical features of hypothyroid?
174
Name two thryroid emergency
Mortality 10 % 50 %
175
Name thyroid malignancy
Papillary carcinoma
Follicular carcinoma
Medullary cell carcinoma
Anaplastic carcinoma
Lymphoma
Acromegaly
Scenario : A patient comes to you with history head ache and when he go out through the door
he stuck with the door right or left side of body
Or Scenario :pt complain of head ach and he also notice that he has to change hat and shoe size
day to day
176
What are feature of acromegaly ?
Large hand and feet
Large face with with prominent supraorbital ridge
Teeth show malocclusion and widely apart
prognathisin (protrusion of lower jaw forward,)
Large tongue (macroglossia).
Eyes: bitemporal hemianopia
Skin: thick, greasy and sweaty
Why it occur ?
Acromegaly is due to excess growth hormone secretion from pituitar, macroadenoma (>10mm)
after union of epiphysis. As long bone fused pt does not in height rather peripheral part grow
177
ADDISON :
Cachetic and emaciated Patient comes to with with nausea vomiting and diarrhea , dizziness on
examination you find postural hypotension . and (marked pigmentation )
178
What are the other causes of small heart ?
COPD
Addison
Constrictive pericarditis
If you do plain X-ray of abdomen what you expect?
Calcification of adrenal gland
What will b the electrolyte finding of Addison and cushing ?
Addison Hyper kalaemia and hyponatraemia
Cushing Hypo kalaemia
Short synacthen Basic principal if you give ACTH then it normally increase cortisol level
test and if it dose not occur then it is adrenal insufficiency . may be primary
(addison)or secondary
250 mg ACTH (synacthen) IM or IV is givevn
Serum cortisol at 0 and 30 minutes is measured.
If cortisol raises> 460nmoVL, rule out Addison's disease.
Failure to raise may indicate partial adrenal insufficiency or secondary
adrenocorrical insufficiency
179
long synacthen Basic principle if u give ACTH injection for 3 three day
test If secondary insufficiency ---cortisol increased
In case primary / addison not increased
I mg- ACTH IM daily for 3 days.
Measure serum cortisol at 0, 4, 8 and 24 hours (each day).
Progressive raise of cortisol indicates secondary adrenocortical
insufficiency.( >700ninol/1- at 8 hours after last injection.)
fallure to raise indicates Addison'sdisease cortisol remains < 700ninol/1- at 8
hours after last injection
Why pigmentation
Due to increase ACTH secretion.
Primary Secondary
Pigmentation No , pallor
Increased ACTH level Undetectable
180
Name some autoimmune endocrine disease?
Graves
Hashimotos thyroiditis
Addison
Name some endocrine emergency?
Scenarios a patient come to you with complaint of nausea , vomiting , diarrhea ,weakness with
history of long time oral steroid which he suddenly stop 7 days ago ?
Dx :
Secondary adreno-cortical insufficiency
Rx continue stroid
Cushing syndrome
You will give answer two frequent question from this picture?
181
What are the feature of cushing syndrome?
What are the feature of steroid over doses?
Neck
Buffalo hump
Supraclavicular fat deposition
HTN
DM
Central obesity
Striae
Osteoporosis
Fracture of vertraeba / bone
Skin thin
Bruising
Proximal myopathy
Cant stand up from sitting position
What is the common cause of cushing syndrome? have you seen any patient of cushing in ward
what was the causes ?
Iatrogenic chronic glucocorticoid therapy which given in
bronchial asthma ,
nephrotic syndrome ,
Rheumatoid arthritis
SLE
What are cause of cushing diseases ?
Classification of Cushing's syndrome
ACTH-dependent
Pituitary adenoma secreting ACTH (Cushing's disease)
Ectopic ACTH syndrome (bronchial carcinoid, small-cell lung carcinoma, other neuro-
endocrine tumour)
Non-ACTH-dependent
Iatrogenic (chronic glucocorticoid therapy)
182
Adrenal adenoma
Adrenal carcinoma
MRI of brain
CT or MRI of adrenal gland
What is the electrolyte in cushing ?
Hypokalaemia
How will differentiate cushing from pseudocushing ?
Cortisol excess due to other illness is called pseudoCushing's syndrome. May occur in chronic
alcoholics, severe depression and in simple obesity
Biochemical parameter :
183
There is increased urinary excretion of steroid,
absent diurnal variation of cortisol and
Failure of suppression by dexamethasone.
All revert to normal after removal of the cause
How will differentiate from cushing :
By insulin stimulation test
In Cushing's syndrome almost no response,
but in pseudo-Cushing's syndrome, insulin-induced hypoglycaemia due to s excess
cortisol secretion.
Treatment of cushing ?
ACTH dependent pituitary Cushing :
Surgery :
Transphenoidal removal of microadenoma
Radiotherapy :
Pituitary irradiation
Is there any drug use in
Ketoconazole
Adrenal causes :
Surgery
Adrenalectomy
Radiotherapy
Patient of cushing comes to with back pain ?
Osteioporosis
184
Causes of tall stature
Marfan Constitutional
Klinefelter Turnners
Kallman Achondroplasia
Gigantism Cretinism
Constitutional Hypopituitarism
Chronic systemic disease in child hood
Heart failure
Asthma
Renal failure
Scenario :
A patient come to you hypertension , oedma and proximal muscle weakness (ubable to getting
up from sitting position )
My diagnosis is conn diseas
What are the feature
Hypertension due Na retention
muscle weaknessdue to hypokalaemia
polyuria---due to DI
tetany ----metabolic alkalosis
oedema
Biochemical
Hypo K
Metabolic alkalosis
Hypernatraemia
CT--/ MRI adrenal adenoma
A patient comes to you with paroxysmal head ache, sweating, palpitation and hypertension what
is your diagnosis .
My diagnosis is phaeochromocytoma
185
Clinical features of phaeochromocytoma
Hypertension (usually paroxysmal; often postural drop of blood
pressure)
Paroxysms of:
o Pallor (occasionally flushing)
o Palpitations
o Sweating
o Headache
o Anxiety (fear of death-)
Abdominal pain, vomiting
186
Diabetis Mellitus
Define Diabetes mellitus?
Write down the difference between types I and Type II diabetes mellitus?
Type 1 Type 2
age of onset young less than 4o yrs more than 50 yrs
Body weight low / underweight Obese
Diabetic complications at absent usually present in 25 %
diagnosis
ketonuria present absent
Autoantibodies & usually present absent
autoimmune disease
family history absent present
Immune-mediated
Idiopathic
Genetic defects
Pancreatic disease
Excess endogenous production of hormonal antagonists to insulin
Drug-induced
Associated with genetic syndromes
Name some pancreatic causes of DM?
187
Name some diabetogenic hormone or hormonal antagonists to insulin? or
Drug-induced diabetes
Corticosteroids,
Thiazide diuretics,
Phenytoin
Down's syndrome;
Klinefelter's syndrome;
Turner's syndrome;
Diabetes insipidus, Diabetes mellitus,optic atrophy, nerve deafness; Friedreich's ataxia; myotonic
dystrophy
188
When u told that the patient is suffering from diabetes?
Some teacher want hear 2HABF or 2 hr after 75 gm glucose 11.1 mmol/l ( in case of
chandan sir )
Or what will u do if you want to get accurate result of 2 hrs after breakfast result?
I will tell the patient to do blood glucose 2 hrs after 75gm glucose
What examination will you do if u want to know the glycaemic status of previous 2/ 3
months?
Indication of OGTT
189
What do you mean by micro vascular and macro vascular complication ?
Ans :
Microvascular
Retinopathy,
Nephropathy
Neuropathic
Peripheral neuropathy or somatic
Autonomic neuropathy
Foot disease
o Ulceration
o Arthropathy
Macrovascular
Coronary circulation
Myocardial ischaemia/infarction
Cerebral circulation
Transient ischaemic attack
Stroke
Peripheral vascular disease
Claudication
Ischaemia
o Hypolgycaemia
o DKA
o Hyper osmolar nonketotic coma, (HONK)
From here sir will ask what will be the management of any one of these three ?
190
How will u differentiated from hypoglycemic coma from hyperglycemic coma?
If u fail to differentiate the between hypoglycemic coma from hyperglycemic coma then what
will do ?
Why ?
191
Oral carbohydrate as form of
IV fluid:
Inj. 25 % glucose 100 ml (in text book ---50 ml of 50 % glucose if any one ask to know the
text book )
-----------------------------------------------------------
IV @ 20 D / min
(if u do not get 25 % then 1st give 5%DA and ask the pt bring immediately )
Followed by
Inj. 10 % DA 1000 ml
--------------------------------
IV @ 20 D/ min
What will u do if a patient with hypoglycemia come to u with unconsciousness but 25% or 5%
DA is not available?
Give him NG tube and give glucose / orange juice/ sugar via it
What may the causes of hypoglycaemia in this pt ? or what history u will ask the pt ?
192
SPONTANEOUS HYPOGLYCAEMIA When hypoglycaemia develops in non-diabetic
people,(if < 3 mmol/L) it is called 'spontaneous' hypoglycemia
Basic principal of DKA Mx (all have to memorized these four line if u want to pass )
Correction of dehydration
193
What antibiotic we use?
How will u correct the hypokalaemia? (Not for all to memorized it)
In following way
To remember it D--CAT
194
Usually not asked but some time sir wants to know the following information about HONK
Thats means
Treatment of DM is combination of 3D
1. Discipline
2. Diet
3. Drug
In discipline
195
Here sir may ask u what exercise and how long u do Tell the Contraindication of exercise?
it? a. Coronary heart disease,
Methods of exercise: b. Proliferative retinopathy,
Stretching Exercise c. Severe neuropathy,
Free hand exercise Duration 10 minutes d. Osteoarthritis,
Aerobic Exercise e. Neprhopathy,
(Minutes i.e., brisk walking, swimming, cycling, f. Ketonuria.
jogging.
Treadmill, static
cycling)
Duration at least 30 min at least 3 times a week.
Diet
Carbohydrate 45-60%
Drugs
If patient is obese
196
Now sir will ask about metformin
A 40 years obese leady newly diagnosed DM Diet ---Diabetic diet (low calorie diet )
.BMI 30 Exercise : 30 min each day
or wt -60 kg FBS13 mmol/l and 2HABF Drug ----OHA----Metformin 500 mg
18 mmol/ l
A 40 years non-obese leady newly diagnosed Diet ---Diabetic diet (weight maintaining
DM diet)
.BMI 22 or wt -50 kg FBS13 mmol/l and Exercise : 30 min each day
2HABF 18 mmol/ l Drug ----OHA----Sulphonylurea
A 20 years obese leady newly diagnosed Diet ---Diabetic diet (weight maintaining
DM .BMI 22 diet)
or wt -30 kg FBS13 mmol/l and 2HABF Exercise : 30 min each day
18 mmol/ l Drug ----insulin
I will take some history, do some clinical examination to find out the etiology , and
complication of DM and
1st history
examination
general examination
198
What is the target BP in DM ?
Somatic neuropathy
Sensory --- Motor jerk , muscle power
loss joint sense position and vibration Diabetic amyotrophy
loss of Touch and pain sensation
Buring and Parasthesia ,
Numbness
Autonomic neuropathy
Cardiac Resting tachycardia
Fixed heart rate
Postural hypotension
Gastro-intestinal Gastro-paresis
Dyphagia
Diarrhea (nocturnal )
Constipation
Gentio-urinary Urinary incontinence
Erectile disfucntion
Retrograde ejaculation
SUDOMOTOR Gustatory sweating
Anhidrosis;
Vasomotor Cold Feet
Dependent oedema
Cranial nerve Pupillary reflex
Opthalmoplagia
Name of oral hypoglycemic agent
1. Insulin Secretagogues:
A. SULPHONYLUREA
Glibenclamide ,
Glimepride ,
Gliclazide
B GLINIDES
Rapaglinide.
199
Nateglinide
2. INSULIN SENSITIZERS
A. BIGUANIDES
Metformin 500 mg /850 mg
B. THIAZOLIDINEDIONES
Rosiglitazone 4 mg / 8 mg
Pioglitazone 15 mg / 30 mg
3. OTHERS : The -glucosidase inhibitors
Acarbose 50 mg
1. Type 1 DM patients
2. Type 2 DM patients
* Myocardial infarction
* Stroke
200
* Kidney disease: nephropathy Serum Creatinine >2.5 mg/dl.
4. Prior to surgery;
5. pregnancy
Classify insulin:
Hypoglycaemia
Weight gain
Peripheral oedema (insulin treatment causes salt and water retention in the short term)
Local allergy (rare)
o Lipodystrophy at injection site
201
How will u differentiated between HTN & Diabetic retinopathy?
Treatment of retinopathy
vitrectomy
referral after diagnosis of type 2 DM; in type 1, only after 5 years of DM)
Treatment of nephropathy
202
Kidney and Urinary Tract Disease
Q: Mention 3 important functions of kidneys?
A:
Excretory function: it excretes many metabolic breakdown of products ( including
ammonia, urea & creatinine from protein & uric acid from nucleic acids) ,drugs &
toxins.
Metabolic function: in vitamin-D metabolism, the kidneys hydroxylate 25-
hydroxycholecalciferol to the active form 1,25,-dihydroxycholecalciferol(failure of this
process contributes to the hypocalcemia & bone disease of chronic kidney disease)
Endocrine function: the kidneys secrete
Erythropoietin- from interstitial peritubular cells in response to hypoxia
Renin- from the juxtaglomerular apparatus in response to reduced afferent
arteriolar pressure, stimulation of sympathetic nerves & changes in sodium
content of fluid in the distal convoluted tubule at the macula densa.
Q: Define haematuria. Causes of painless & painful haematuria.
A:
Heamaturia: passes of blood in the urine.
Causes of painful haematuria: stone ,UTI, loin pain haematuria syndrome
Causes of painless haematuria: glomerulonephritis ,tumour, TB, polycystic kidney
disease, vascular malformation
203
Q: What are the causes of nephrogenic DI?
A: Due to tubular dysfunction ( By- drugs:lithium ,diuretics, interstitial renal disease,
hypokalemia, hypercalcemia, genetic)
204
Q: What is the triad of pyelonephritis?
A:
Fever with chills & rigor.
Abdominal pain or loin pain
Renal angle tenderness
Q: Treatment of UTI?
A:
Uncomplicated UTI Tab. Ciprofloxacin (500mg)-1+0+1 3days
Complicated UTI Same 10days
In pyelonephritis Inj. Cefuroxime (750mg)-1+1+1+1 14days
In acute prostatitis Tab. Ciprofloxacin (500mg)-1+0+1 28days
Q: What advice will you give in a pt. coming with recurrent UTI?
A:
Fluid intake at least 2litres/day
Regular complete emptying of bladder
Maintenance of good personal hygiene
Emptying of bladder before & after sexual intercourse
205
Possible explanation includes:
Infection with organisms not readily cultured by ordinary methods (Chlamydia, certain
anaerobes)
Intermittent or low-count bacteriuria
Reaction to toiletries or disinfectants
Post-menopausal atrophic vaginitis
Symptoms related to sexual intercourse
Q: Causes of ARF.
A:
Pre-renal Volume loss:
-blood loss (hemorrhage)
-fluid loss (diarrhea, vomiting, pancreatitis)
-3rd space loss (peritonitis, intestinal obstruction)
cardiac output ( heart failure, CCF)
Renal arterial stenosis/occlusion/diseases affecting
arterioles
renal Mnemonic- TIA
Acute tubular necrosis/toxins-85%
[toxins: endogenous-drug(gentamycin), exogenous-
bacteria(malaria)]
Interstitial disease -10%
AGN -5%
Post-renal Prostatic enlargement, stone ,tumour
Q: Treatment of ARF.
A:
Diet: -protein restriction
-fluid restriction (fluid =previous day output +500ml)
Diuretics: Inj. Frusemide
Treatment of complications: e.g. if hyperkalaemia then treat it.
For acidosis: Inj. Sodium-bicarbonate
If infection: antibiotic
Other : -avoid nephrotoxic medication, maintain intake-output chart
If urinary output not increase then go for dialysis
206
Q: Name the causes of CRF (now it is called chronic kidney disease).
A: mnemonic-DGHS
DM
Glomerulonephritis
Hypertension
SLE & connective tissue diseases
Others polycystic kidney disease
To remember it-
A=anaemia
B=bony change
C=HTN, uraemic pericarditis, pulmonary edema (c for cvs features)
D=dermopathy, pruritus
E= endocrine: hyperparathyroidism, hyperprolactenemia
F=fluid overload: edema
G=GIT: anorexia, nausea, vomiting, hiccough
H=haematological: bleeding manifestation
207
I=evidence of Infection
K=kidney: polyuria & nocturia
M= myopathy
N=neurological : sensory-polyneuropathy ; motor-foot drop
Q: What are the bony changes in Renal failure? Or, a pt. with CRF complaint of bone pain, what
is your diagnosis??
A: Renal osteodytrophy which contain- osteomalacia, osteoporosis, osteosclerosis,
hyperparathyroid bone disease (osteitis fibrosa)
Q: Treatment of CRF.
A:
Diet & fluid: plenty of fluid intake 3L/day
Correction of anaemia: -blood transfusion
-erythropoietin supplementation
- iron
Control of HTN
For hypocalcemia: Tab. vitamin-D/Dicaltrol (2.5microgram) - 0+0+1
For binding of dietary phosphate: Tab.Calcium (300mg) after meal - 1+1+1
Diuretics
Pantoprazole
Treatment of infection
208
Q: Name some anti-hypertensive drug in CRF.
A:
ACEi / Angiotensin Receptor blocker
Diuretics
Calcium channel blocker
vasodilator
209
Q: Staging of CKD (chronic kidney disease).
A:
Stage-1 Kidney damage with normal GFR ( >90 ml/min)
Stage-2 Kidney damage with mild decrease of GFR 60-89
Stage-3 Kidney damage with moderate decrease of GFR 30-59
Stage-4 Kidney damage with severe decrease of GFR 15-29
Stage-5 Kidney damage with GFR <15
SOME DEFINITIONS:
210
Nephrotic syndrome2
Massive proteinuria-usually > 3.5 g/24 hrs (urine may be frothy)
Hypoalbuminaemia (< 30 g/l)
Oedema and generalised fluid retention
Hyper lipideamia
AGN NS
211
Mention the causes of nepphrotic and nephritic syndrome
Cause of nephrotic syndrome Cause of nephritic syndrome
212
Electrolyte and Acid base Balance
Q. Name some electrolyte imbalance/ what type of electrolyte imbalance you have seen in
ward?
Ans. Hyponatraemia
Hypernatraemia
Hypokalaemia
Hyperkalaemia
Intracellular Extracellular
K Na
PO3- Cl-
Mg+ HCO-
Q. What is the normal level of Na and K in extracellular fluid?
Ans. Na 135-145 mmol/L
K 3.5-5.5 mmol/L
213
Q. what is the target of daily correction of Hyponatraemia?
Ans. 10 mmol/day.
Q. How will you correct Hyponatraemia in the following cases where serum Na level is 128
mmol/L, 120 mmol/L and 102 mmol/L?
Ans.
Na level Method of correction
128 mmol/L ORS / Oral table salt
120 mmol/L Inj. 0.9% NaCl
102 mmol/L Inj. 3% NaCl
Q. What is Myelinolysis?
Ans.
Rapid correction of Hyponatraemia
Abrupt increase in extracellular osmolarity
Water shift out of the cerebral neuron
Abrupt reduction of cell volume of cerebral neuron and detachment from their myelin
sheath (Myelinolysis)
Permanent structural and functional damage of midbrain structures.
214
Q. What are the causes of Hyponatraemia? (not for all )
Ans. Causes of Hyponatraemia
Hypovolumic Hyponatraemia Euvolumic Hyponatraemia Hypovolumic
Hyponatraemia
Na loss > water loss Only water re-absorption, To remember- causes of
To remember- all loss Dilutional hyponatraemia edema
Q. An unconscious patient is brought to you with a history of vomiting 2/3 times. What is the
probable diagnosis?
Ans. Hyponatraemia.
215
Potassium
Q: What is the normal level of k+?
A: 3.5-5.5 mmol/L
Hypokalaemia: Hyperkalaemia:
Flat T
Inverted T
Appearance of U wave Wide QRS complex
Sine wave
216
Q: Name the causes of hypokalaemia?
A: Common causes mnemonics DVD
D= Diarrhoea
V=Vomiting
D=Diuretic
If K+ <2.5 mmol/L
Oral correction +
Parenteral correction( in drip)
Inj. NS 1000ml+ inj. K+ 2 amp iv. @ 30 drops/ min
Q: A hospital admitted pt complains about inability to stand from squatting position. What is the
diagnosis?
A: Hypokalaemia (cause- probably pt gets I/V glucose containing saline)
Q: A pt comes with the complaints of inability to move the 4 limbs after awakening from sleep
in morning. There may also be history of heavy exercise or heavy CHO meal in the previous
night. What is the diagnosis?
A: Hypokalaemic periodic paralysis.
217
Q: What are the predisposing factors?
A:
heavy exercise
heavy CHO meal or glucose intake
218
THEN: (to remove K+ from body)
I/V Frusemide & NS
Ion exchange resin (eg Ca-resonium)
Dialysis
219
Q: tell about electrolyte imbalance after vomiting.
A:
Hyponatraemia
Hypokalaemia
Metabolic alkalosis
Paradoxic aciduria
Hypocalcaemia
Q: name some cause of hypocalcaemia.
A:
CRF
Hypoalbuminaemia
Alkalosis
Acute pancreatitis
Hypoparathyroidism
Hypo-Mg
220
Q: A pt comes to you with hyperventilation followed by spasm of hand. What is the diagnosis?
A: Tetany
Then albumin binds with positive ion Ca2+
in ionized serum calcium
Tetany
221
Q: What is the characteristic position of hand in carpopedal syndrome?
A:
Flexion of Metacarpophalangeal (MP) joint
Extension of Interphalangeal (IP) joint
Opponens of thumb
Like PV Hand (Position of hand during pervaginal examination )
Chvosteks sign: tapering over the branch of facial nerve as they emerge from parotid gland
causes ipsilateral contraction of facial muscle in hypocalcaemic pt. It is less specific.
Metabolic Acidosis
Q: Define Acidosis.
A: Accumulation of acid rather than H2SO4
Q: A 13 years old school girl comes to you with respiratory distress. But examination reveals
lung is clear. What is your diagnosis?
A:
Metabolic Acidosis
Psychogenic hyperventilation
222
Others: mnemonics KUSsMaL
K- DKA
U- Uraemia
Ss- Salicylic acid
Ma- Methanol
L- lactic acid
223
OTHERS
Complication:
o Type-2 respiratory failure.
Complication:
o Tetany.
Q: scenario: A 30years old man comes to you with H/O diarrhoea for 3days, now he complains
of respiratory distress. What is your diagnosis?
A: metabolic acidosis due to ARF followed by diarrhoea.
224
Infectious Disease
Malaria
Q.A 40 yrs old man comes to you with H/O fever for 3 days followed by
Unconsciousness. Write the provisional Dx?
Encephalitis
Cerebral malaria
Meningo-encephalitis
Q.what investigation?
CSF study
MP
ICT for malaria
CBCNeutrophilic leukocytosis--- Bacterial meningitis
Q.I.V. quinine KZY w`e?---- until the pt is able to take food orally
225
Plasmodium malariae
Plasmodium falciparum
Q.Describe the life cycle of malaria?
Vector--- the female anophelis mosquito
h form G gvbyli kixi XyK------------ sporozite
gvbyl nZ gkvq h form G XyK-------- Gametocytes
In mosquito--- sexual cycle ; In man--- Asexual cycle
Q. Investigation:
Blood film
thick film
thin film
ICT for malaria
226
Q.Rx of malaria:
In case vivax
Tab. chloroquine 150mg (4,4,2)
1st day4 Tab 2nd day4 Tab 3rd day2 Tab
Plus
Tab. primaquine 15mg (0+0+1-----------for 14 days)
In case of falciparum
complicated---Rx of cerebral malaria
uncomplicated--- Tab. coartem
1st day4 Tab Zvi 8 NUv ci 4 Tab
2nd day4+o+4
3rd day4+o+4
nd
2 line: Quinine sulphate 300 mg (2+2+2------------7 days)
Q. Chemoprophylaxis?
Choroquine 150mg 2Tab wkly
proguanil 100mg daily
stinted 1 wk before 4 wk after travel
If Choroquine resist---
Doxycyclin 100mg daily
stinted 1 wk before 4 wk after travel
227
Enteric Fever
Q.A pt comes to you fever for for 10 days.what are the D/D?
Enteric fever
Malaria
Q.Route of transmission?----------oro-faecal route
Q.Ri KgZ KZw`b mgq jvM?--- Antibiotic i Kivi ci 5 w`b mgq jvM Ri KgZ
Type of fever
Continued
Remittent
Intermittent -
o a.Quotidian
o b.Tetrtian
o C.Quartan
1. Continued fever : When fever does not fluctuate more than about 1` C
(1.5' F) during 24 hours but never touches the base line is called
continued fever.
Causes :-
I. I .Typhoid fever
II. 2- Millar,y tuberculosis
III. Lobar pneumonia
2.Remmittent fever
When daily fluctuations exceed 2 0 C called remittent fever.
229
Causes
I. I Amoebic liver abscess
II. Luna abscess
III. Collection of pus in the tissues
3.Intermittent fever
When the fever is present only, for several hours during the day it is called
intermittent-fever.
a) Quotidian: When a paroxysm of intermittent fever occurs daily. the
type is quotidian.
Cause - Kala-azar (double quotidian)
b) Tertian
When fever comes on alternate days, it is tertian. Causes: P. Vivax and P
.Ovale Malaria.
C) Quartan
W h e n t h e r e i s T w o d a y s i n t e r v a l b e t w e e n t w o consecutive
attacks. Then it is call quartan.
Cause- P. Malariae infection.
230
Q.Who is the definitive host? -----Dog
Q.Life cycle:
worm with in dog gut----- ova comes with defecation it usually enter into
sheep or other animal
Q.How it comes to man?
By handling dog or drinking contaminated water
it enter (egg) in human intestine ( small intestine)
Enter into liver
Form hydatid cyst
Q. Rx:
Medical Rx-------- Tab. Albendazol (400mg) 1+0+1-------------3 months
Others---------
Surgery excision
PAIR ( percutaneous puncture,aspiration , injection of scolicidalayent &
respiration)
Q.Rx:
A single dose of albendazol 400mg or
Tab. mebendazol 100mg-------1+0+1--------3 days
Q.Rx:
Mebendazol 100mg ----- 1+0+1----------- 3 days
231
Q. Name some causes of acute watery diarrhoea?
232
Q. What are causes of urethral discharge?
Gonorrhea
Chlamydia trachomatis
Trichomonus vaginitis
Q.Name some cause of genital ulcer?
Chancre Chancroid
single single/multiple
painless painful
Organism: Traponema pallidium Organism: Haemophilus ducreyi
Q.Classify syphilis?
*early--------
primary
secondary
*Late---------
Benign tertiary
Cardiovascular
Neuro syphilis
233
Q.Tertiary syphilis?
3-10 yrs after primary syphilis
muscle, skin,bone,viscera
Q. Change in CVS?
Aortitis
Aortic aneurysm
Aortic incompetence
Q.Neuro syphilis?
Meningovascular disease
Tabes dorsalis
General paralysis of insane constitute
Argyl Roberson pupil
Q.what investigation you will do?
*Non-treponemal/non specific
VDRL ( venereal disease research laboratory test)
RPR (Rapid plasma reugin)
*Treponal Antibody test (specific)
TPHA ( Treponema pallideum haemo agglutination assay)
TPPA ( Treponema pallideum particle agglutination assay)
234
Q. Organism of gonorrhea?--------- Nisseria gonorrhoeae
Q. Investigation?
Gm stain Kij gm(-) ve deplococci cvIqv hvq
Q.Rx:
Cap: cefixime (400mg) 1 tab stat
Tab.Ceprofloxacin (500mg) stat
or
Inj. Ceftreaxon (250mg) 1 amp IM stat
Q. Complication of gonorrhea?
*In male:
Acute prostatitis
Epididymo-orchitis
Stricture urethra
*In female:
Salphingo-ophoritis
PID
Barthrolin abscess
Ectopic pregnancy
Sterility
*In children:
opthalmia neonalum
Q. Chlamydial infection?
Q.Rx?
Tab. azethromycin 1 gm orally single dose or
Tab. Doxycyclin (100mg) 1+0+1------------7 days
235
Q.Name condition where fever with rash?
Dengue
Rikettsia
Typhoid
Measless
Meningo coccal seplis
viral hemorrhagic fever
Q.name the causes of fever with chill and rigor and anemia
Fever with chill rigor Fever with jaundice Fever with anaemia
Malaria viral hepatitis aplastic anaemia
UTI(pylonephritis) leptospirosis leukomia
Cholangitis lymphomea kala-azar
Pneumonia leukaemia lymphoma
Abscess dessiminalei TB Malaria`
236
Q. Define PUO?(332)
PUO is defined as a temperature persistently above 38.00C for more then 3 wks
without diagnosis despite initial investigation during 3 days of inpatient care or after
more then 2 out patient visit.
Causes:
Malignancy---- lymphoma, leukamia, myeloma renal,liver,colon
Infection-------Abscess, infective endocarditis
Connective tissue disease
Q. Pt comes to you hypo pigment patch with loss of sensation over that area. What is
your Dx?
Leprosy
Q.Classify leprosy?
Mainly 2 types:
Tuberculoid leprosy / paucibacillary
Lepromatous leprosy/multibacillary
Q. Treatment of leprosy?
237
Leperomatous leprosy skin will less and late and tuberculoid all marked nd early
Lepromatous Tuberculoid
Bacilli (bacterial index) Multibacillary Paucibacillary
many ( 5 or 6+) Absent (0)
Distribution Widely disseminated One or a few sites,
asymmetrical
Natural outcome Progression Healing
Reactions Immune complexes Cell-mediated
Nerve enlargement & Late Early and marked
damage
Reactions on leprosy
Lepra reaction Lepra reaction type 11 (erythema nodosum
type 1 (reversal) leprosum)
Mechanism Cell- mediated Immune complexes
hypersensitivity
Clinical Painful tender Tender papules and nodules;may ulcerate
feature nerves Painful tender nerves
Loss of function Loss of function
Swollen skin Iritis,orchitis,myositis,lymphadenitis,fever,oedema
lesions
New skin lesion
Management Prednisolone Moderate: Prednisolone 40mg daily
40mg Severe:Thalidomide2 or Prednisolone 40-80mg
Reducing over 3- Reducing over 1-6 month;local if eye involved3
6 months1
238
Q.How will differentiate it leprosy?
By seeing sensation with pink
Dengue
Q . a 30 yr old boy comes to you with the complaint of multiple purpuric rash whole
over the body mostly on the trunk . He give history fever with headache 7 days ago.
The pt live in Dhaka .
Write down the diagnostic criteria of Dengue Fever, Dengue Hemorrhagic Fever,
Dengue Shock Syndrome? (No all student need to memorized it )
239
Dengue Hemorrhagic Fever (if u want more mark )
Dengue Hemorrhagic Fever is a probable manifestation of dengue syndrome with
hemorrhagic manifestations having the following features:
240
Q Name the vector of dengue fever?
A. Female aedes aegypti mosquito
Q. When it bites?
A It bites in the day times?
DF and DHF are not distinguishable in febrile phase and treatment is essentially same.
Treatment is symptomatic and supportive. These are:
Rest
Antipyretic therapy for fever above 39 C.
Sponging: With tepid water at room temperature.
Paracetamol (not more than 4 times in 24 hours)
Do not give Aspirin or any other NSAID
Do not give antibiotics
Oral Rehydration Salt (ORS) is recommended for patients with moderate dehydration
If patient is in shock then give management of sock
If platelet transfusion is given when platelet count is 10000 or less
241
Write down the Severity Grading of Dengue Syndrome?
Signs of Recovery
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetite
Good urinary output
Stable hematocrit
Convalescent stable petechial rash
Absence of fever for at least 24 hours without the use of anti-fever therapy
Return of appetite
Visible clinical improvement
Good urine output
Minimum three days after recovery from shock
No respiratory distress from pleural effusion and no ascitis
Platelet count of more than 50,000/mm3
242
What follow up you will give in patient with dengue?
Daily vital sign of circulation
Pulse
BP
Urine out put
Evidence of external or internal bleeding
Hematocrit
platelet count
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Skin
Q . Define itch or pruritus ?
A.
Q. sites of scabes
A. finger , interdigital area , anticubital fossa , axilla ,around the umbilicus , genitalia , buttock ,
dorsum of the foot
A . Scabetic furrow
A .These are short, wavy, dirty appearing line found in the edge of fingers , toes or side of hand
or foot . burrow contain . female mites and egg .
244
Q. what are complication of scabies ?
A.
secondary infection / impetigo
Eczema
Lichenification
AGN
Urticaria
Exfoliative dermatitis
Following scabies scratching due to itching --- Breach the continuity of skin and secondary
infection with streptococcus infection --- immunity develop against strep--- that cross react with
glomerular basement membrane ( antibody +antigen + complement C 3 )
245
Why kidney affect in after strep. Infection
1. AGN develop only when skin or sore throat infection by nephritogenic strain of
streptococci
2. kidney is involved due antigenic mimicry between the bacteria and GBM of kidney
Q. This question is frequently asked by dr. CN sarker ----4 boys with scabies were playing in
field but suddenly Develop head ache followed by convulsion and unconsciousness what is ur
diagnosis?
A. diagnosis is hypertensive encephalopathy
Acne
Q.Female patient is frequently usually the teen ager are suffer from a skin disease usually
affect the face ?
A. this is acne
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Q Mention the treatment of acne ?
A non pharmacological
Maintain personal hygiene
Was face with soap or antiseptic cream
pharmacological
First-line therapy
topical agent
keratolytics
o benzoyl peroxide
o azelaic acid
topical retinoids
o tretinoin
o isotretinoin
retinoid-like agents
adapalene
Topical antibiotics,
erythromycin or
clindamycin
Tenia
Name some superficial fungal infection? Name of tenia or Dermatophyte infection according to
site of body
Site
scalp Tinea capitis
Body surface or trunk Tinea corporis
Groin Tinea cruis
Between two figner cleft Tinea pedis
In nail Tinea ungium
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Q. What do you mean by ring worm or dermatophytosis ?
A. These are the superficial fungal infection causes by dermatophyte known as ring worm or
dermatophytosis
A. the Central of the lesion is smooth and peripheral border or margin is elevated. Itchy and
sensation intact
Microsporum
Trichophyton
Epidermophyton
Q. Treatment of Tinea
Topical
clotrimazole,
miconazole,
terbinafne
systemic
Fluconazole
itraconazole
terbinafine
Q A patient comes to u with area of hypo pigmentation or alter pigmentation area over trunk what is ur
diagnosis ?
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Q. name the organism responsible form Pityriasis versicolor ?
A. Malassezia furfur
Q. Treatment of it?
Topical
Selenium sulphide or
2% ketoconazole hampoo
Apply to body and remove after 3060 minutes and repeat daily for 1 week
Systemic
itraconazole
terbinafine
Psoriasis
Q. A patient comes to you with multiple erythematous plaques with silvery scales ? what is your
diagnosis ?
A. psoriasis
Q. Describe the lesion of psoriasis ?
A.these are well circumscribed erythematous plaque with silvery scales .
Q. site of psoriasis ?
Extensor surface of elbow , knee wrist
Extensor surface of limb
Nail , scalp , hair line , cleft and flexures
249
Q. what is the basic pathology of this disease ,
Hyper proliferation of keratinocyte with a grossly increased mitotic index leading to retention of
nuclei in the statum corneum which not normally present
In single word ----It is the diseases of rapid turn over . cellproliferation is more than turn over so
nucleus deposit in the epidermis .
Q. Complication of psoriasis?
A.
Psoriasis
Exfoliative dermatitis
Secondary infection
Hyper uricaemia and gout
Q. if the patient develop joint pain then what is ur diagnosis ?
Psoriatic arthropathy or seronegative arthritis
Q. Name two important sign of psoriasis?
A.
Auspitz sign
koebners phenomeno
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Q. What are the causes of Erythema multiform ?
Infection Herpes simplex , streptococcus
Drugs Sulfonamide , carbamazepin
Idiopathic
Maligjnancy
Q. treatment of SJS ?
Stop offending drugs
IV fluid
Antibiotic
Steroid
Mouth and eye care
252
Q Cause of erythema nodosum ?
Bacteria M Mycobacterium tuberculosis , leprosy , mycoplasma
R rickettsia,
c Chlamydia
s Streptococci
Urticaria
Q. A patient give history of localized swelling of skin which is itchy and disappear after 15
hr what is your diagnosis?
A. Acute urticaria
Define urticaria ?
253
How long does the individual lesion last'
Acute urticaria: if the condition is persist < 6 weeks then called acute urticaria
Chronic urticaria : if the condition is persist > 6 weeks then called chronic urticaria
Autoinimunc
Allergens (in foods, inhalants and injections)
Drugs
Treatment of urticaria?
Antihistamin
H
2 Mocker
in some case mastcell stabilizer or leukotriene inhibitors
254
Q. which disease u may find Dermatitis herpetiformis as skin manifestation?
In celiac diseases.
Disease Pemphigus vulgaris Bullous pemphigoid
Age
40-60 yrs 60s and over
Site of blisters Torso, h e a d Trunk a n d l i m b s
Nature blisters Flaccid and fragile Tense
Mucous membrane involvement 1 0 0 % Occasionally
level of blister intra-epidermal(superficial) subepidermal
Q. defines eczema?
The terms 'eczema' and 'dermatitis' are synonymous. Here The skin can become so acutely
inflamedthat fluid weeps out or vesicles appear.
Classify eczema?
Classification of eczema
Endogenous Exogenous
255
Define Atopy?
Atopy is a genetic predisposition to form excessive IgE which leads to a generalised and
prolonged hypersensitivity to common environmental antigens
Management of eczema
General management
Education Explanation, reassurance and encouragement
Avoidance of irritants/allergens
Regular use of greasy Emollients
Bath oils/soap substitutes
Topical therapies:
Appropriate use of topical corticosteroids
Adjunct therapies:
oral antibiotics
sedating antihistamines
Remember following as question may ask where u will use what type of steroid
The face should be treated only with mild steroids.
In adults the body should be treated with either mild, moderately potent or diluted potent
steroids.
In young children the body should be treated with mild and moderately potent steroids.
Potent steroids are used for short courses (710 days).
Treatment of the palms and soles (but not the dorsal surfaces) may require potent or very
potent steroids as the skin is much thicker.
Regular use of emollients may lessen the need forsteroid use.
Name the treatment of following eczema:
General management is common in all types
256
Seborrhoeic eczema ketoconazole shampoo and
ketoconazole creams
Irritant eczema avoidance of irritants
protective clothing, e.g. gloves, and
regular use of emollients
Appropriate use of topical corticosteroids
Contact allergic eczema Avoidance of the culprit allergen
lifestyle changes such as
a new job or
giving up hobbies.
Appropriate use of topical corticosteroids
IgE and specific IgE to support the diagnosis of atopic eczema and
to determine specific environmental allergens, e.g. pet dander, horse
hair, house dust mite, pollens and foods.
257
Read the following definition which is frequently asked ?
Macule : A flat, colored lesion, <2 cm in diameter, not raised above the surface of the
surrounding skin.
Patch : A large (>2 cm) flat lesion with a color different from the surrounding skin. This
differs from a macule only in size.
Papule : A small, solid lesion, <0.5 cm in diameter, raised above the surface of the surrounding
skin and hence palpable
Nodule : A larger (0.55.0 cm), firm lesion raised above the surface of the surrounding skin.
This differs from a papule only in size
Tumor : A solid, raised growth >5 cm in diameter.
Plaque : A large (>1 cm), flat-topped, raised lesion; edges may either be distinct (e.g., in
psoriasis) or gradually blend with surrounding skin (e.g., in eczematous dermatitis).
Vesicle : A small, fluid-filled lesion raised above the surface, <0.5 cm in diameter,
Pustule : A vesicle filled with pus .
Bulla : A fluid-filled lesion raised above the surface >0.5 cm in diameter.
Erosion : Loss of epidermis without an associated loss of dermis.
Ulcer: Loss of epidermis and at least a portion of the underlying dermis.
Petechiae, Petechiae are pinhead-sized macules of extravascular blood in the dermis.
purpura These are larger than petechiea (>2mm )
ecchymosis Large confluent area of purpura (bruise)
Telangiectasia The visible dilatation of small cutaneous blood vessels
258
Psychiatric disorder
259
Bulimia nervosa
Somatoform disorders to remember To remember ADH , FCPS
A----Somatoform autonomic dysfunction
D--Body dysmorphic disorder
H--Hypochondriasis
T--- Tremor
D--- Diarrhoea
S--- Sweating
In
I---Initial insomnia
C--- Chest pain
U--- Frequent desire to pass urine
260
What are the features of depression?
Psychological Somatic
Depressed mood Reduced appetite
Reduced self-esteem Weight change
Suicidal thinking Disturbed sleep
Pessimism Fatigue
Guilt Loss of libido
Loss of interest Bowel disturbance
Loss of enjoyment (anhedonia) Motor retardation (slowing of activity)
Story I
261
story 2
262
Anti depressant therapy how long given?
Treatment should be continue 6-12 months after recovery
263
Name some anti depressant drug with their complication.
Anti- depressant drug:
Group Drug Usual dose side effect
Tricyclics 75-150 mg daily Anticholinergic effects,
Amitriptyline
Postural hypotension,
Cardiotoxicity.
Imipramine 75-150 mg daily Deteriorate Glaucoma and
prostatism.
SSRIs 10-20 mg daily Headache,
Escitalopram
Nausea, anorexia and
20 mg daily Sexual dysfunction
Fluoxetine
50-100 mg daily
Sertraline
8-12 mg daily
Reboxetine
15-45 mg daily
Mirtazapine
265
Define schizophrenia?
Schizophrenia is a psychosis characterized by delusions, hallucinations and lack of insight
Mention the sign of Define schizophrenia?
Schizophrenia is a psychosis characterized by delusions, hallucinations and lack of insight
First-rank symptoms of acute schizophrenia Symptoms of chronic schizophrenia
(negative symptoms)
To remember A,B,C,D To remember it ASP BP
266
What will be the Rx?
Dugs
Antidepressant drugs such as clomipramine
CBT (cognitive behavior therapy) which
Name some eating disorder?
Anorexia nervosa
Bulimia nervosa
Diagnostic criteria:
Anorexia nervosa Bulimia nervosa
A Amenorrhoea for at least 3 months 1. Recurrent bouts of binge eating
B--- Body mass index 17.5 / Bwt loss at least 15 2. Lack of self-control over eating during binges
% of total body wt 3. Self-induced vomiting, or dieting after binges
C-- Avoidance of high-calorie foods 4. Weight maintained within normal limits
D--- Distortion of body image so that patients
regard themselves as fat even when grossly
underweight
The clinical feature of these disorders is somatic symptoms which are not explained by a medical
condition and not better diagnosed as part of a depressive or anxiety disorder.
G--Gait disturbance
B--Blindness
S---Sensory loss
A--Aphonia
L---Loss of function in limbs
S---Non-epileptic seizures
268
Not for all who want get more marks:
269
SOMATIC SYNDROMES of deferent system:
270
management of anxiety :
Psychological treatment
Explanation and reassurance
Graded exposure (desensitisation) to feared situations for phobic disorders, and
CBT for panic.
Drug treatment
Antidepressants are the drugs of choice
Benzodiazepines are useful in the short term
A -blocker ( propranolol) can help when peripheral somatic symptoms are prominent
271
Name some anxiolytic drugs ?
Benzodiazepines
Action Main groups Clinical use
Antipsychotic Phenothiazines
Butyrophenones
Schizophrenia
Mania
atypical Acute confusion
272
Insomnia
Alcohol withdrawal
-adrenoceptor antagonists Anxiety (somatic symptoms)
273
Poisoning
What type poisoning case you have seen in the word?
OPC
Sedative
Kerosene
Herpic and savlone
Corrosive poisoning
Dhutura poisoning
Snake bite
OPC
POISONING
MUSCARINIC
Smell of OPC
Salivation
Constricted pupil
Bradycardia
NICOTINIC
weakness of muscle
274
CNS
Coma, confusion ,
Then
Inj. Atropin , 5- 15 amp 5 to 15 min interval untill sign of atropinisaion appear
Inj. PAM / Pralidoxime
2 amp iv over 10 min stat and
Pralidoxime
Pupil dilated
Tachycardia
Increased temperature / dry axilla
Clear lungs or no creps
Increased blood pressure
276
Benzo-diazepam poisoning
Do not be worried
Lethal dose is more then 40 / 50 tab.
Dangerous complication is
o Respiratory distress or respiratory arrest , -- main complication
What treatment you will give in patient with diazepam poisoning?
277
What treatment you will give?
Tachycardia. ,
ST depression ,
QT prolongation ,
Arrhythmia
Do s.creatinin
Or patient may comes to u with his attendance with HO that he ate something in bus and
followed he cannot remember anything and lost all his money.
278
What is your diagnosis?
Rx of Dutra poisoning?
Inj. Antibiotics
Inj. Ranison 50 mg
Continuous catheterization
Maintain input output chart
Pulse
BP
Respiration
Heart
GCS
Neurological exam
Fundoscopy
Evidence of external injury
Acid , alkali ,
Bleaching powder ,
kerosin
279
Harpic , savelon , Shampoo and
TREATMENT OF CORROSIVE
Inj.ceftriaxone 1 gm
1 vial IV BD
Inj. Pantonix 40 mg
1 vial IV stat and daily
Usually child
Write down the treatment of kerosin poisoning
280
Do not try to do induce vomiting ( because of aspiration pneumonia )
Keep the patient NPO for 6 hrs
Inj. DNS 1000 or 2000 ml
Iv @ 20 D / min
Inj.ceftriaxone 1 gm
1 vial IV BD
inj. Dexamethason
I amp iv 6 hrly
Inj. Pantonix 40 mg
1 vial IV stat and daily
A patient with HO kerosin poisoning comes to 3 days later with complaint of fever and
respiratory distress what is your diagnosis ?
Chemical pneumonitis
Yes sir
What type of snake bite it was?
281
Bed rest
Inj. Normal saline 1000 ml
IV @ 10 D / min
Cap . Omeprazole 20 mg
1+ 0 + 1
Inj. Oradexon
Inj Avil
And NSAID
Observe the patient at least for 24 hours
Cobra @ krait
Cobra Krait
282
What are the sign of poisonous snake bit ?
Nasal voice
Ptosis
Opthalmoplegia
Dysphagia
Broken neck sign
Dyspnea
Difficult in opening mouth and
protruding tongue
Unconscious
Hematological (not in our country )
What the nature toxin release by out poisonous snake in our country?
Neurotoxin
How Will u diffrentites the poisonous snake bit from non poisonous ?
Informed the patient may has 50% chance to die due to reaction of antivenom and
283
100 % chance to die with out antivenom .
Total vial = 10 vial , each vial dilute with 10 ml distilled water (if vials are not in dilute
form ) Mix this 10 vial(100 ml) with 100 ml NS saline and give in 1 hour via micro
burette set
Inj. Normal saline 100
+
Inj . Antivenom 10 vial
IV @ 60 D/ min
Some want to Give following before starting anti-venom to prevent anaphylactic reaction
Inj. Neostigmine
50-100 gm / kg body weight SC stat and repeat every 4 hrly until neuro .sign
improved
Give call to ICU as patient may need assisted ventilation for respiratory paralysis
Inj. Cotson
1 vial iv stat @ 8 hrly
284
Paracetamol poisoning
Intravenous N-acetylcysteine
Q Management?
ALT
Prothrombin time
S.creatinine
Blood paracetamol level
Wasp bite
Some time a patient may comes to you with history wasp bite or
Swelling of different part of the body after eating Chinese soap / thi soap
characterized by
Bp ---hypotension
Stridor laryngeal spasm
Lung wheeze
Kidney oligouria
285
What follow-up you will give the patient
Exam .
Pulse
BP
Auscultation of lung
I/O chart
Do
ECG
S.Creatinine
In severe case:
Inj. Ranisone
1 amp IV stat
Inj. Avil
1 amp IM / IV stat
In mild to moderate
286