oral morphine not tolerated + stable pain = fentanyl patches and oral

morphine not tolerated + unstable pain = s/c morphine

Patient well controlled on oral morphine but can't tolerate oral route -
shift to transdermal patch (fentanyl)
Patient not well controlled on oral morphine and not tolerating oral
route - shift to s/c or IV morphine with dose adjustment (half dose)
Patient not able to tolerate the side effects of morphine - change to
oxycodone

Post Coital Bleeding for the first time: Cervical smear first and
depending on result colposcopy. ( sometimes with punch biposy or
core biopsy)
If PCB is persistent i.e 3 months duration etc, direct colposcopy.

Also, postmenopausal bleed most common cause is ca endometrium

and most common cause for post coital postmenopausal is also ca
endometrium is this ok till now?
ectropion we have to perform smear first if the female is on COCP. If
the qestions mentions young sexually active female then go SWAB
firs
Ca endometrium first is TVUSG then biopsy or endometrial sampling,

pneumonia+headache+confusion=legionella

H influenza and pseudomanas staphylococcus are most common

superimposed infections in CF

SOB + such high fever+ Localized pleural rub - seems Lobar

pneumonia
Pleural rub present in pneumonia, PE and pleurisy.

endomysial antibodies for celiac disease. Weight loss. Abdominal

bloating. Bulky stools etc.
Sweat test if for cystic fibrosis. There will be associated recurrent
chest infections along with abdominal symptoms.
Tft. Hypothyroidism in children. They will have prolonged jaundice
not increasing jaundice.

This woman has lower abdominal pain and a positive pregnancy test
with signs of haemodynamic instability: an ectopic pregnancy (C)
should
therefore be excluded urgently. Ovarian torsion (E) and ruptured
ovarian
cysts (A) classically present with a sudden onset abdominal pain, and
are not commonly associated with a significant tachycardic
hypotension.
Differentiating between them can be difficult. However, the natural
history of the pain is often helpful. Both may present with sudden
onset
pain, but usually the pain of ovarian torsion will be out of keeping
with
the clinical findings and will not improve with simple analgesia.
Indeed
it does not normally decrease significantly at all. By contrast, the pain
of cyst rupture, while being of sudden onset, is often reduced by
simple
analgesia and may decrease gradually as the peritoneal lining (having
been irritated by leaking fluid or blood from the cyst, causing pain)
absorbs intraperitoneal free fluid. A woman with a perforated
appendicitis
(D) would often show signs of sepsis, including fever and peritonitis,
and pain is normally localized initially to the central abdomen or right
iliac fossa. At this level of beta hCG, an intrauterine pregnancy would
normally be visible on transvaginal ultrasonography. Of the two
ectopic
pregnancy options available, cervical ectopics (B) would normally be
demonstrable on transvaginal ultrasound. Ruptured ectopic pregnancy
is a surgical emergency requiring prompt assessment, resuscitation
and
urgent surgery. The urgency of the situation is even more pronounced
if
there are signs of haemodynamic instability, such as in this case where
there is evidence of hypovolaemic shock

For osteoporosis, raloxifen

Clonidine is also used in the treatment of dysmenorrhea (severely
painful cramps during menstrual period), hypertensive crisis (a
condition in which your blood pressure is very high), Tourette's
syndrome (a condition characterized by the need to perform repeated
motions or to repeat sounds or words), attention deficit hyperactivity
disorder (ADHD), menopausal hot flashes, and alcohol and opiate
(narcotic) withdrawal. Clonidine is also used and as an aid in smoking
cessation therapy and to diagnose pheochromocytoma (a tumor that
develops on a gland near the kidneys and may cause high blood
pressure and fast heart rate)..Incubation prd:

Polio 6-20 days

TB 2-12 wks
HIV 2wks or 6 months.
• Syphilis 3wks -3months

Important point
Increased thirst
Increased urination
High fever
• Weakness
• Drowsiness
• Altered mental state
•
Headache
• Restlessness
• Inability to speak
• Visual
problems
• Hallucinations
• Paralysis
• Warm skin that doest
not prespire
(signs of hyperglycaemic shock....)

CI OF THROMBOLYSIS (alteplase or streptokinase). ARE

Systolic BP of >200mmhg and diastolic BP >120mmhg
Recent strokes and previous TIA
Prolonged CPR 
a-internal bleeding b-vaginal bleeing c-
esophageal varices d-recent haemorrhagic shock in 3 months.
Prolong or traumatic cpr, recent trauma and surgery lee than 2
wks, recent head trauma, severe htn, severe liver disease, and
allergy to streptokinase. Pregnancy or less than 18 wks post
deliver
(Alteplae has 2 types accelerated with in 6 hrs , young
pts with anterior MI. standard with in 6- 12 hrs.)
(Should be given to all patients except
Haemorrhagic stroke has been excluded.
The patient presents within four and a half hours of having the
event.)(
(Indications:
1-st elevation, posterior infarction,

HAEMOCHROMATOSIS
…….joints, (arthralgia, osteoporosis, pancrease(bronze dm
heart,(dilated cardiomyopathies pituitary,(hypogonadisim and
hypoaldosteronisism liver(cirrhosis).
Is autosomal recessive
Is associated with more ferritin and decrease iron binding
 capacity.
• >50% patients are diabetic 
• Predispose to
hepatoma 
• Is caused by absorption of iron 
Perl’s stain on
liver biopsy for iron loading.

The rooting reflex is present at birth and disappears around four

months of age, as it gradually comes under voluntary control.A
newborn infant will turn his head toward anything that strokes their
cheek or mouth, searching for the object by moving their head in
steadily decreasing arcs until the object is found.

The palmar grasp reflex appears at birth and persists until five or six
months of age. When an object is placed in the infant's hand and
strokes their palm, the fingers will close and they will grasp it with a
palmar grasp.

Pregnant female exposed to child with chicken pox:-

Next step is measure her IgG antibodies- if she is immune- reassure
If she is non-immune- give varicella Igs

And if she unfortunately develops chicken pox, then give her

acyclovir within a day of appearance of rash (no immunoglobulins
will help her once she develops the disease so avoid)

If fetus develops chicken pox (soon after birth) give both

immunoglobulin and acyclovir A-- pale optic disc becoz artery is
occluded

C - dof blot heamorrhages

swelling and edema is always vein
and pale retina with cherry macula is artery block

WILSONS DISEASE The onset of symptoms is usually between 10

- 25 years. Children usually present with liver disease whereas the first
sign of disease in young adults is often neurological disease

Features result from excessive copper deposition in the tissues,

especially the brain, liver and cornea:

liver: hepatitis, cirrhosis

neurological: basal ganglia degeneration, speech and behavioural
problems are often the first manifestations. Also: asterixis, chorea,
dementia
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails
Diagnosis

reduced serum caeruloplasmin

increased 24hr urinary copper excretion
Management
Penicillamine (chelates copper) has been the traditional first-line
treatment

MUST READ THIS:

Primary prevention of cardiovascular disease (CVD):
Previously, aspirin was recommended for those without
apparent CVD in whom the total CVD risk over 10 years is
>20%, and for almost all diabetic patients over the age of 50
years. The evidence to support this unlicensed indication is not
robust and thus current guidance is that aspirin should not be
used in primary prevention (including in those with diabetes
mellitus or hypertension) But note: aspirin is increasingly being
used in the primary prevention of some cancers - particularly
bowel cancer.
Clopidogrel and dipyridamole are neither indicated nor licensed
for primary prevention of cardiovascular (CV) events.
Secondary prevention of CVD:
In those with established atherosclerotic disease, low-dose
aspirin (75 mg daily) is recommended indefinitely for long-term
secondary prevention.
Modified-release dipyridamole 200 mg bd plus low-dose aspirin
(50 mg or 75 mg daily) is recommended for secondary
prevention following an ischaemic stroke or a transient
ischaemic attack (TIA) for a period of two years from the most
recent event,[ Where aspirin is contra-indicated or genuinely
not tolerated (ie proven hypersensitivity or history of severe
low-dose aspirin-induced dyspepsia), clopidogrel 75 mg daily is
a suitable alternative to aspirin (or aspirin plus dipyridamole
post-stroke)
•
Myocardial ischaemia
 A single dose of aspirin 300 mg and clopidogrel 300 mg (600
mg - unlicensed in some centres prior to urgent percutaneous
coronary intervention (PCI)) should be given as soon as
possible after an ischaemic event (both non-ST segment
elevation myocardial infarction (NSTEMI) and STEMI),
preferably dispersed in water or chewed
Clopidogrel 75 mg daily is licensed for the treatment of acute
coronary syndrome (ACS) ± ST elevation, in combination with
aspirin (usually following loading doses)
Post-PCI clopidogrel 75 mg should continue for one month if a
bare metal stent is inserted and 12 months if a drug-eluting stent
is inserted. Thereafter, treatment should revert to low-dose
aspirin alone.
Eptifibatide and tirofiban are licensed for use with heparin and
aspirin to prevent early MI in patients with unstable angina or
NSTEMI where early percutaneous transluminal coronary
angioplasty (PTCA) is desirable but delay is likely.
Cerebral ischaemia
Acute ischaemic stroke - thrombolyse if appropriate and follow
with aspirin 300 mg once daily for 14 days. If not able to be
thrombolysed then aspirin alone should be given. Aspirin
caused an excess of about two intracranial and four extracranial
haemorrhages per 1,000 people treated, but these small risks
were more than offset by the reductions in death and disability
from other causes
Long-term management of both TIA or ischaemic stroke -
dipyridamole 200 mg bd with aspirin 75 mg once daily.
Atrial fibrillation (AF) carries a high risk of stroke and other
thromboembolic events. Warfarin is more efficacious than
aspirin at preventing stroke (particularly in those at highest risk)
but carries a greater risk of major haemorrhage:
. The CHA2DS2-VASc score is one method of assessing stroke risk (it
has superseded the CHADS2 score)
CHA2DS2-VASc[26]
Condition Points
C Congestive heart failure (or left ventricular (LV) dysfunction). 1
H Hypertension. 1
A2 Age ≥75 years. 2
D Diabetes mellitus. 1
S2 Prior stroke, TIA or thromboembolic disease. 2
V Vascular disease - eg presence of peripheral vascular disease,
myocardial infarction, aortic atherosclerosis. 1
A Age 65-74 years. 1
Sc Sex category (ie female). 1
Score 0 = low risk; no treatment or treat with aspirin.
Score 1 = moderate risk; aspirin daily or warfarin based on the
patient's preference. Warfarin is probably preferred if there are
no contra-indications.
Score 2 or more = high risk; treat with warfarin maintaining an
INR 2-3.
New oral anticoagulant drugs, eg dabigatran, are likely to become an
option

Fibrinolytic drugs
For patients who cannot be offered PCI within 90 minutes of
diagnosis, a thrombolytic drug should be administered along with
either unfractionated heparin (for maximum two days), a low
molecular weight heparin (eg, enoxaparin) or fondaparinux.
Thrombolytic drugs break down the thrombus so that the blood flow
to the heart muscle can be restored to prevent further damage and
assist healing.

Reperfusion by thrombolysis is often gradual and incomplete and may

be inadequate. There is a risk of early or late reocclusion and a 1-2%
risk of intracranial haemorrhage.

Fibrinolytic drugs act as thrombolytics by activating plasminogen to

form plasmin, which degrades fibrin and so breaks up the thrombi.
Streptokinase and alteplase have been shown to reduce mortality.
Reteplase and tenecteplase are also licensed for AMI.
Streptokinase and alteplase are given by intravenous infusion.
Reteplase and tenecteplase can be given by rapid bolus injection.
The benefit is greatest in those with ECG changes that include ST-
segment elevation (especially in those with anterior infarction) and in
patients with bundle branch block.
The earlier the treatment is given, the greater the absolute benefit.
Alteplase, reteplase and streptokinase need to be given within 12
hours of symptom onset, ideally within one hour. Tenecteplase should
be given as early as possible and usually within six hours of symptom
onset.

In patients presenting within 12 hours after the onset of symptoms but

reperfusion therapy is not given, or in patients presenting after 12
hours, aspirin, clopidogrel and an antithrombin agent (heparin,
enoxaparin or fondaparinux) should be given as soon as possible
1:2:1
1:4 25% unaffected
2:4 or 1:2 50% carrier
1:4 25% affected

Hemochromatosis is deposition of iron in hepatocytes, with resulting

damage to the liver cells.
Hemosiderosis is the deposition of iron in Kupffer cells, with no
damage to the liver cells

Oral lichen planus is an ongoing (chronic) inflammatory condition that

affects mucous membran nes inside your mouth. Oral lichen planus
may appear as white, lacy patches; red, swollen tissues; or open sores

Post-coital bleeding in middle aged females is CERVICAL cancer

until proven otherwise.

Post-coital bleeding in post-menopausal females is ENDOMETRIAL

cancer until proven otherwise.

Since they're asking for the most appropriate (not the initial most)
investigation, I'll go for endometrial sampling.

Remember transvaginal ultrasound > endometrial sampling > biopsy.

bilateral parotid and lacrimal gland enlargement was characterized by

the term Mikulicz's disease if the enlargement appeared apart from
other diseases. If it was secondary to another disease, such as
tuberculosis, sarcoidosis, lymphoma, and Sjögren's syndrome, the
term used was Mikulicz's syndrome.

Sudden severe -- PID

Gradual ( chronic ) with other features eg scoliosis etc -- AS

Morning -- they can because while getting up if posture is nt straight ..

AS -- involvement of sacroiliac joints is classic

And also morning stiffness

Myasthenia is autoantibodies to post ganglionic acetylcholine

receptors, LES is autoantibodies against presynaptic receptors.
Clinically, LEMS has weakness predominantly in lower limbs and less
of ocular weakness etc.
Also LEMS the weakness improves (means patient gets better) with
repeated use unlike myasthenia where patient gets fatigue due to
repeated use
antibodies differ....MG...anti ACH abs while in LEMS...abs against Ca
channels plus usually associated with SCLC!

Painless syphlis
Painful single ulcer -- hem ducreyi
Hsv -- multiple

Beneficence - promote the well being of your patient

Non-maleficence - principle of NOT harming your patient in any way
is more important than doing them good.

CT scanning is recommended for most patients in the acute phase of

stroke. CT is widely available, practical, quick and easy to use in ill
patients.
CT is very sensitive in diagnosing haemorrhage in patients in the acute
stage.
In patients with ischaemic stroke, especially those with mild
neurological deficits, CT imaging is often normal in the first few
hours but the accuracy for ischaemic stroke delineation improves after
six hours.
However, CT remains less accurate than MRI for determining the site
and extent of ischaemic damage, particularly for small lesions and
posterior fossa lesions.
The accuracy of CT is reduced after one week following the stroke
event, especially distinguishing between haemorrhagic and ischaemic
stroke origin.

MRI may be contra-indicated in up to a fifth of patients because they

are too ill, confused, dysphasic, have an intraocular or intracerebral
metallic foreign body or have a pacemaker.

MRI should be the imaging investigation of choice in individuals with

epilepsy. It is particularly important in patients
who develop epilepsy before the age of 2 years or in adulthood
who have any suggestion of a focal onset on history, examination or
EEG (unless clear evidence of benign focal epilepsy)
in whom seizures continue in spite of first-line medication.
CT is used when MRI is not available or contraindicated to identify
underlying gross pathology or for children and young people in whom
a general anaesthetic or sedation would be required for MRI but not
CT - gpnotebook.

CT of the sinuses as well as the orbit ± brain:

CT is usually indicated only for children (unless the child is very well
and the episode is mild) or if orbital cellulitis is suspected in an adult.
if an intracranial abscess is suspected, CT is the gold standard imaging
modality, carried out to identify any subperiosteal abscesses, paranasal
sinusitis or cavernous sinus thrombosis (all needing multi-speciality
input).
It is also valuable in assessing trauma where there may be concerns
about a retained orbital or intraocular foreign body.

Pancoast tumour is a type of lung cancer defined primarily by its

location situated at the top end of either the right or left lung

Pancoast tumour can include a complete Horner's syndrome in severe

cases: miosis (constriction of the pupils), anhidrosis (lack of
sweating), ptosis (drooping of the eyelid) and enophthalmos (sunken
eyeball). In progressive cases, the brachial plexus is also affected,
causing pain and weakness in the muscles of the arm and hand
(thoracic outlet syndrome). The tumour can also compress the
recurrent laryngeal nerve and from this a hoarse voice and bovine
cough may occur.

Current screening protocols in the United Kingdom

Newborns

Well baby protocol:

For babies who had no requirement for special care (or <48 hours in
special care).
Uses the AOAE test. Babies not passing this test are given the AABR
test.

Neonatal intensive care/special care baby unit protocol:

Uses both AOAE and AABR tests. The latter can detect auditory
neuropathy, which is more common in special care babies.
Automated otoacoustic emissions (AOAE) test
Automated auditory brainstem responses (AABR) test

It was brain stem evoked response till 6 months.

6months till 2 years it's distraction tests
>2 years audiometry.
5years..pure tone audiogram

grey membrane on tonsils – diphtheria

yellow membrane on tonsils - infective mononucleosis!!

Muscle pain due to inflammation in the body's soft tissues. Myofascial

pain is a chronic condition that affects the fascia (connective tissue
that covers the muscles). Myofascial pain syndrome may involve
either a single muscle or a muscle group. In some cases, the area
where a person experiences the pain may not be where the myofascial
pain generator is located. Experts believe that the actual site of the
injury or the strain prompts the development of a trigger point that, in
turn, causes pain in other areas. This situation is known as referred
pain.
Myofascial pain symptoms usually involve muscle pain with specific
"trigger" or "tender" points. The pain can be made worse with activity
or stress. In addition to the local or regional pain associated with
myofascial pain syndrome, people with the disorder also can suffer
from depression, fatigue and behavioral disturbances.
Diagnosis
Trigger points can be identified by pain that results when pressure is
applied to an area of a person's body. In the diagnosis of myofascial
pain syndrome, four types of trigger points can be distinguished:

Adjustment disorder usually lasts < 6 months

Anticipation of next episodes and persistent concern of additional
attack is there in Panic disorder and not in adjustment

Parvovirus B19 is a common infection, usually presenting as erythema

infectiosum in children. There is a wide range of potential
consequences of parvovirus B19 infection. These extend from minor
febrile illness to erythema infectiosum (fifth disease, slapped cheek
syndrome), a generalised rash illness clinically indistinguishable from
rubella, aplastic crises in patients with increased red cell turnover,
arthropathy, and persistent infection in the immunocompromised.

If hyperkalemia is interfering either cardiac function then give calcium

glucionate.. but calcium chloride can be used alternativly in central
line n than start insulin n glucose
both calcium chloride or cal gluconate can be given.
Considering both,10% calcium chloride is 10 mL and contains 6.8
mmol of calcium. Also a standard ampule of 10% calcium gluconate
is also 10 mL but has only 2.26 mmol of calcium.
So cal chloride is better, however it is more concentrated & it is
caustic to the veins and should only be given through a central
line.Good thing is onset of action is less than 5 minutes and lasts about
30-60 min.

median nerve compression actually a complication of tight

cast...decompression surgery is done

The National Institute for Health and Clinical Excellence (NICE)

advises that women should be offered screening for anaemia at
booking and at 28 weeks of gestation.[2] Anaemia is defined as an Hb
level <11.0 g/dL at booking; haemodilution will result in further drops
during pregnancy and subsequent reduction in oxygen-carrying
capacity. In the second and third trimesters the diagnostic level for
anaemia is an Hb level of <10.5 g/dL. Postpartum the diagnostic level
is 10.0 g/dL.

Parkinson type effects plus urinary symptoms are shy drager

syndrome
shy dagger syndrom..wet wobbly wacky..

Pancoast's SyndromeClassically caused by an apical (superior

pulmonary sulcus) malignant neoplasm of the lung. The neoplasm is
usually bronchogenic in origin (most commonly squamous cell
carcinoma, sometimes adenocarcinoma and large-cell carcinoma).
Presentation
This syndrome results from the invasion of a number of structures and
tissues around the thoracic inlet and may be characterised by:
An ipsilateral invasion of the cervical sympathetic plexus leading to
Horner's syndrome (miosis, enophthalmos, ptosis; in 14-50% of
patients).[1]
Ipsilateral reflex sympathetic dystrophy may occur.
Shoulder and arm pain (brachial plexus invasion C8-T2) leading to
wasting of the intrinsic hand muscles and paraesthesiae in the medial
side of the arm.
Less commonly, unilateral recurrent laryngeal nerve palsy producing
unilateral vocal cord paralysis (hoarse voice ± bovine cough), and/or
phrenic nerve involvement.
There may be arm oedema secondary to the compression of blood
vessels.
Superior vena cava syndrome may also occur.

A conversion disorder causes patients to suffer from neurological

symptoms, such as numbness, blindness, paralysis, or fits without a
definable organic cause. It is thought that symptoms arise in response
to stressful situations affecting a patient's mental health.

Stockholm syndrome can be seen as a form of traumatic bonding,

which does not necessarily require a hostage scenario, but which
describes "strong emotional ties that develop between two persons
where one person intermittently harasses, beats, threatens, abuses, or
intimidates the other.

Echopraxia (also known as echokinesis[1]) is the involuntary

repetition or imitation of another person's actions.[1] Similar to
echolalia, the involuntary repetition of sounds and language, it is one
of the echophenomena ("automatic imitative actions without explicit
awareness").[1] It has long been recognized as a core feature of
Tourette syndrome,

Echolalia (also known as echologia or echophrasia[1]) is the

automatic repetition of vocalizations made by another person

Anosognosia (/æˌnɒsɒɡˈnoʊziə/, /æˌnɒsɒɡˈnoʊʒə/; from Ancient

Greek ἀ- a-, "without", νόσος nosos, "disease" and γνῶσις gnōsis,
"knowledge") is viewed as a deficit of self-awareness, a condition in
which a person who suffers certain disability seems unaware of the
existence of his or her disability.

Couvade syndrome, also called sympathetic pregnancy, is a

proposed condition in which a partner experiences some of the same
symptoms and behavior of an expectant mother.[1] These most often
include minor weight gain, altered hormone levels, morning nausea,
and disturbed sleep patterns.
Apraxia (from Greek praxis, an act, work, or deed[1]) is the inability
to execute learned purposeful movements,[2] despite having the desire
and the physical capacity to perform the movements

Ganser syndrome is a rare dissociative disorder previously classified

as a factitious disorder. It is characterized by nonsensical or wrong
answers to questions or doing things incorrectly, other dissociative
symptoms such as fugue, amnesia or conversion disorder, often with
visual pseudohallucinations and a decreased state of consciousness. It
is also sometimes called nonsense syndrome, balderdash syndrome,
syndrome of approximate answers, pseudodementia, hysterical
pseudodementia or prison psychosis. This last name, prison
psychosis, is sometimes used because the syndrome occurs most
frequently in prison inmates, where it may represent an attempt to gain
leniency from prison or court officials.

Folie à deux (/fɒˈli ə ˈduː/; French pronunciation: [fɔli a dø]; French

for "a madness shared by two"), or shared psychosis, is a psychiatric
syndrome in which symptoms of a delusional belief are transmitted
from one individual to another

The Capgras delusion (or Capgras syndrome) (/kæpˈɡrɑː/,

US dict: kăpgrâ′)[1] is a disorder in which a person holds a delusion
that a friend, spouse, parent, or other close family member (or pet) has
been replaced by an identical-looking impostor.

The Cotard delusion (also Cotard's Syndrome and Walking

Corpse Syndrome) is a rare mental illness, in which the afflicted
person holds the delusion that he or she is dead
The delusion of negation is the central symptom in Cotard's
syndrome. The patient afflicted with this mental illness usually denies
their existence, or the existence of a certain body part, or the existence
of a portion of their body.

Asperger's syndrome (AS) lies within the autistic spectrum.

Previously it was called high-functioning autism. The main difference
from classic autism is a lack of delayed or retarded cognition and
language. Those with AS are also more likely to seek social
interaction and share activities and friendships.
Rett's syndrome is an X-linked neurodevelopmental condition
characterised by loss of spoken language and hand use with the
development of distinctive hand stereotypies. It is a pervasive
developmental disorder (PDD).

Synonym: Ekbom's syndrome

The term restless legs syndrome (RLS) was to describe a disorder

characterised by sensory symptoms and motor disturbances of the
limbs, mainly occurring during rest.

Tourette's syndrome is a disorder that starts in childhood. The prime

symptom is to have repeated tics. A tic is a sudden movement or
sound that is repeated over and over. A tic has no purpose and, in
general, you cannot help doing it. For example, repeated blinking,
repeated throat clearing, repeated head nodding, etc. Tics are very
common in children and usually last less than one year.
The main symptom is multiple (many) tics. These are classified as
either motor (movement) or vocal tics.
Motor tics include things such as blinking, head turning, head
nodding, kicking, mouth pouting, mouth opening, mouth twitches, etc.
Vocal tics include things such as throat clearing, coughing, sniffing,
yelling, or making animal sounds.
The most common conditions seen with Tourette's syndrome are listed
below with how often they occur in children with Tourette's
syndrome.
Obsessive-compulsive disorder (OCD), or obsessive-compulsive
behaviour (OCB). This occurs in about 5 in 10 children with
Tourette's syndrome.
Attention deficit hyperactivity disorder (ADHD, or ADD). This occurs
in about 6 in 10 children with Tourette's syndrome.
Self-harming behaviours such as head banging occur in about 3 in 10
children with Tourette's syndrome.

A patient with Serum Na of 122 mmol\L, the following are likely

causes:
DKA. 

Hypoadrenalism. 

Prolonged Infusion of 5% Dextrose.
Syndrome of Inappropriate ADH secretion.

 In young lady psychologically disturbed and drinks water
excessively

According to patient.co, sleep alarms is the best option in

uncomplicated mild-mod enuresis. Desmopressin for severe symptoms
or when immediate effect is needed. Behavioral therapy for daytime
symptoms only. Please correct me if I'm wrong.

Osler weber rendu syndrome ( hereditary hemorrhagic telangectasia).

Family history is suggesting it in the scenario as it is Autosomal
dominant
As all other tests are normal , Upper gastrointenstinal endoscopy (
UGIE ) should be done to check for melena

Laurence-Moon-Biedl syndrome and Laurence-Moon-Biedl-Bardet

syndrome are no longer considered valid terms, because the patients of
Laurence and Moon had paraplegia, but no polydactyly and obesity,
which are the main characteristics of the Bardet-Biedl syndrome.[1]
Features
These are:[2]
Short stature.
Retinitis pigmentosa, nystagmus, choroidal atrophy, cataract and
squint.
Micropenis with hypoplastic scrotum.
Type 2 diabetes mellitus.
General learning disability.
Speech delay and deficit.
Ataxia with spastic paraplegia.

Renal anomalies, eg clubbing, diverticula or calyceal cysts.

Goodpasture syndrome (GPS; also known as Goodpasture’s
disease, anti-glomerular basement antibody disease, or anti-GBM
disease) is a rare autoimmune disease in which antibodies attack the
lungs and kidneys, leading to bleeding from the lungs and to kidney
failure

The American College of Rheumatology has identified six criteria for

the diagnosis of Churg-Strauss syndrome:[2]
Asthma (wheezing, expiratory rhonchi).
Eosinophilia of more than 10% in peripheral blood.
Paranasal sinusitis.
Pulmonary infiltrates (may be transient).
Histological confirmation of vasculitis with extravascular eosinophils.
Mononeuritis multiplex or polyneuropathy.

Syringomyelia is a rare condition in which there is fluid-filled tubular

cyst (syrinx) within the central, usually cervical, spinal cord. The
syrinx can elongate, enlarge and expand into the grey and white matter
and, as it does so, it compresses the nervous tissue of the corticospinal
and spinothalamic tracts and the anterior horn cells. This leads to
various neurological symptoms and signs, including pain, paralysis,
stiffness and weakness in the back, shoulders and extremities.
Syringomyelia may also cause loss of extreme temperature sensation,
particularly in the hands, and a cape-like loss of pain and temperature
sensation along the back and arms. Symptoms typically vary
depending on the extent and location of the syrinx. 50% of patients
(when all types of syrinxes are considered) experience no or only mild
disability.

If the syrinx extends into the brainstem, syringobulbia results. This

may affect one or more cranial nerves, resulting in facial palsies.
Sensory and motor nerve pathways may be affected by interruption
and/or compression of nerves.

Hypnagogic or hypnopompic hallucinations are visual, tactile,

auditory, or other sensory events, usually brief but occasionally
prolonged, that occur at the transition from wakefulness to sleep
(hypnagogic) or from sleep to wakefulness (hypnopompic).
The person may hear sounds that are not there and see visual
hallucinations. These visual and auditory images are very vivid and
may be bizarre or disturbing.

Usually it is part of the tetrad of narcolepsy that includes:

Excessive daytime sleepiness
Cataplexy
Hypnagogic hallucinations
Sleep paralysis.
This tetrad is rarely seen in children.

Ulcer on posterior stomach wall - always bleed (gastroduodenal

artery) - blood in lesser sac or beneath diaphragm
Ulcer on anterior wall - always perforate - gas under diaphragm
Clonidine drug of choice for hot flushes…tibolone also given
Reloxifine given for osteoporosis prevention in menopause

pitting nails is psoriasis

0-14yrs- ALL
15-59yrs- AML
40-60yrs- CML
60+ CLL

Status epilepticus
Administer intravenous lorazepam as first-line treatment. Administer
intravenous diazepam if intravenous lorazepam is unavailable, or
buccal midazolam if unable to secure immediate intravenous access.
Administer a maximum of two doses of the first-line treatment
(including pre-hospital treatment)
Phenytoin is 2nd line.

to correct Hyperkalemia
1st n qickest is calcium gluconate
Then insulin n dextrose
Then calcium resonium

Laparoscopy is the criterion standard for the diagnosis of PID. It is

significantly more specific and sensitive than are clinical criteria
alone. The minimum criteria for diagnosing PID laparoscopically
include tubal wall edema, visible hyperemia of the tubal surface, and
the presence of exudate on the tubal surfaces and fimbriae.

For severe PID--- broad spectrum (ceftriaxone) plus doxycycline

Moderate PID-----moderate doxy plus metro

when AIDS (Active disease) do not give any vaccination

when HIV, only BCG is contraindicated

Afib is the most common arrythmia in alcoholics. Also known as

holiday heart syndrome
in holiday heart syndrome AF occurs due to binge drinking and theres
no underlying heart patho
swelling in ankles in an elderly female indicates heart failure.
alcoholic so AF hence reathlessness and palpitations
CRAO, cherry red sopt is clincher. applying pressure might increase
the blood flow

A 40 year old man after an operation had a heavy bleeding. What

abnormality will you find? Low calcium

TIA. Doppler usg. Majority of TIA develop due to emboli which are
picked up on carotid doppler.

Carbimazole (used in hyperthyroidism), clozapine (atypical

antipsychotics), INH ….s/e…agranulocytosis (neutropenia)

statins cause muscle ache

neuroleptic malignant syndrome….typical antipsychotics suchas
haloperidol

osteosarcoma is relatively painless whereas ewings presents with pain

and redness around the tumor area.
Remember
Knee or shoulder..painless..osteosarcoma
Thigh or pelvis..painful..ewings

for dehydration and dka its NS and for burns its hartmans solution
if on the electrolyte picture it shows hypernatremia only then go for
0.45% NS. otherwise give 0.9% NS if normonatremia or
hyponatremia.
and potassium is always added to the fluid regimen after confirming
the lab values and a good urine output
before surgery for diabetics iv insulin n glucose n k

Anti-smooth muscle antibodies are antibodies (immunoglobulins)

formed against smooth muscle. These antibodies are typically
associated with autoimmune hepatitis.[

Chicken has blisters of different ages .. Some healing ( crusted in this

case ) , others ( the new ones ) still erupting ( weeping in this case )
In Shingles , all come at same time and with preceding pain in
dermatomal area and heal by crusting at the same time
for shingles , there should be some history , a minor clincher towards
immunocompromised state . It doesnt usually erupt just like that in
healthy young individuals whereas chicken pox can !!
Also though chicken pox starts from trunk , it surely is there on face
and around eyes.

Aspirin should b given from the 1st day of +ve pregnancy test n
heparin should b given as soon as fetal heart is seen on us….Anti
phospholipids syndrome

in children UTI always present due to some underlying disease...it

could be VUR or something. So even on single episode of UTI we
need to further investigate by doing an USG

Cerebral abscess presents as ring enhancing lesion

Toxoplasmosis being one of the causes of cerebral abscess

dexa scan for osteoporosis and nuclear bone scan to see metastasis
Normal is a T-score of -1.0 or higher
Osteopenia is defined as between -1.0 and -2.5
Osteoporosis is defined as -2.5 or lower, meaning a bone density that
is two and a half standard deviations below the mean of a thirty-year-
old man/woman.

Calcium stones : Envelop or dumbell shaped

Struvite ( ammonium Mg PO4 stones ) : Coffin lid shaped
Uric acid : Rhomboid or Rossette shaped
Cystine : Hexagonal
All are Radio opaque except Uric acid stones
Also ammonium Mg stones and cystine stones can form " staghorn
calculi " which if large enough require surgical removal

Beningn essential tremors ease off and become less noticeable on use
of affected limb or movement
Whereas in cerebellar disease there are tremors specifically on desired
movement ( intention tremors )

lung cancer 2 complication hyponatremea or hypercalcamia

Lung carcer particularly small cell CA lung releases ADH one of its
paraneoplastic features leading to dilutional hyponatremia

The Valgus stress test is a test for ligament damage. It involves

placing the leg into extension, with one hand placed as a pivot on the
knee. With the other hand placed upon the foot applying an abducting
force, an attempt is then made to force the leg at the knee into valgus.
If the knee is seen to open up on the medial side, this is indicative of
medial collateral ligament damage and may also indicate capsular or
cruciate ligament laxity.
similarly varus stress test for lateral collateral

Patient allergy to contrast media or renal failure do V/Q scan. If they

give chest Xray is normal or if no significant cardiopulmonary history
in the patient then again V/Q scan preferred.
CTPA in all other cases

Otitis media with effusion aka secretory otitis media aka glue ear.
Common in young children, 40db hearing loss, increase volume of tv.
Dull greyish blue tympanic membrane with air fluid levels are all the
clinchers

BCC usually presents as a pearly nodule with telangiectatic edge

Any lesion above the neck is BCC until proved otherwise
Actinic keratosis presents as yellowish scaly crusts not as a nodule

Acute management of SVT is vagal maneouvers, if not then iv

adenosine. If patient is asthmatic (breathless as in this case) then
verapamil is the option
B blockers and radiofrequency ablation are for prevention of SVT
episodes

SIADH is a common complication of small cell lung ca, paancreas,

prostate ca. 1st line is fluid restriction
Hoarsness persisting > 3 weeks requires investigation

Right dominant circulation= 85%= Post desc artery arises from Right
coronary artery
Left dominant circulation= 8%= PD arises from Left coronary artery
so basically dominancy depends on this Post desc artery.. from where
it arises

Isonatremic and hyponatremic volume depletion states may be treated

with normal saline or other isotonic solutions. The goal for correction
rates for either hyponatremic or hypernatremic patients should be no
more than 1 mEq/L/h to prevent the devastating CNS complications of
overrapid correction (central pontine myelinolysis and cerebral edema,
respectively). Full correction of severe sodium abnormalities usually
should be staged over 24 hours or longer.
Although a potassium deficit is present in all cases of volume
depletion, it is not usually clinically significant; few patients with
moderate dehydration require supplemental potassium. However,
failure to correct for hypokalemia during volume repletion may result
in clinically significant hypokalemia.
Add potassium to fluids when the patient has documented
hypokalemia. For all other patients, avoid adding
potassium to fluids until the patient has received several hours of
resuscitation and the patient has demonstrated adequate urine output.
Painful ulcers on vulva………Anti-HSV antibodies check for herpes
Forking HAY" + upper zone consdolidation ….farmers lung treatment
is prednisolone
Rathke cleft cysts (RCCs) are benign lesions that typically arise within
the sella between the anterior and posterior lobes of the pituitary.Most
often they are asymptomatic. These lesions, however, can cause mass
effect on surrounding structures such as the pituitary gland and optic
chiasm, leading to headache, pituitary dysfunction, or visual
disturbance.Rathke cleft cysts are remnants of the Rathke pouch, a
structure of ectodermal origin formed during the fourth week of
gestation
discharge swelling n redness of ear with normal tympanic
membrane..thats otitis externa treatment: topical gentamicin or
steriod drops
No gas bubble means oesophageal atresia. Double bubble sign for
duodenal atresia
Synonyms: HAE, hereditary angioneurotic oedema, C1-inhibitor
deficiency, C1-esterase inhibitor deficiency, familial angioneurotic
oedema, hereditary bradykinin-induced angioedema, hereditary non
histamine-induced angioedema
Hereditary angio-oedema (HAE) is a rare genetic condition causing
episodes of angio-oedema - including life-threatening laryngeal
oedema. Episodes can be unpredictable, or triggered by factors such as
trauma, drugs or dental treatment.
In Symptomatic patient (test once only) : fasting glucose >=7 or
Random blood glucose>=11.0 confirms diabetes
In asymptomatic patient (do test on 2 occasions): fasting glucose > 7
or random blood glucose> 11 confirms diabetes
Propranolol is used AF with hyperthyroidism due to the additional
benefit of inhibition of peripheral conversion of T4 to T3.
Acamprosate works by reducing the desire or craving to drink alcohol.
It is only given to people who have successfully stopped drinking.
Acamprosate calcium helps to reduce the chances of you drinking
again. People who are taking Acamprosate calcium will usually have a
programme of counselling as part of their treatment. Treatment with
Acamprosate calcium usually lasts one year.
Clang associations are ideas that are related only by similar or
rhyming sounds rather than actual meaning.[8] Example: "He ate the
skate, inflated yesterdays gate toward the cheese grater
Smoking is the most important risk factor for bladder cancer. Smokers
are at least 3 times as likely to get bladder cancer as nonsmokers.
Smoking causes about half of the bladder cancers in both men and
women.
atypical depression..characterized by temporary mood lifting by good
news,weight gain n increased sleep usually mote than 10 hrs
Typical - decreased sleep ( esp. early morning awakening in maj dep) ,
appetite. Atypical – increased
HTN+ hypoK = conn's
Ovarian torsion
'sudden onset vomiting and pain abdomen' + mobile swelling in RIF is
the clincher.
Drug of choice for a hypertensive who is above 55 years of age with
no cough or renal problems (no contraindications i mean) CCB
PRADER WILLI: After birth there is hypotonia, failure to thrive and
sleepiness. The child usually has blue eyes and blond hair. They tend
to lag behind other children in the transition to solid food.
The second stage becomes apparent at the age of 12-18 months, when
an exceptional interest in food becomes apparent.[7] Hyperphagia,
obesity, hypogonadism, short stature and sleep apnoea and cor
pulmonale occur.[12] They have markedly elevated levels of ghrelin, a
hormone associated with hunger.
Lawrence moon biedel syndrome/LM SYNDROME: Short stature.
Retinitis pigmentosa, nystagmus, choroidal atrophy, cataract and
squint.
Micropenis with hypoplastic scrotum.
Type 2 diabetes mellitus.
General learning disability.
Speech delay and deficit.
Ataxia with spastic paraplegia.
Renal anomalies, eg clubbing, diverticula or calyceal cysts.
Nappy rash is a skin inflammation. Most cases are due to a reaction of
the skin to urine and poo (faeces, stools, or motions). In addition, a
germ called candida commonly thrives on the inflamed skin. (This is
the germ that causes thrush.) Candida can cause a more inflamed rash
which may include darker red spots spreading around the nappy area
('nappy thrush')
Erotomania or Clerambault’s Syndrome, is a psychological condition
in which the affected person has delusions that the object of his or her
affection feels the same toward him or her. This condition is otherwise
known as love obsession
Usually the object of their affection is inaccessible like a superstar, an
actress, a rock star
Trichotillomania is a condition where a person feels compelled to
pull their hair out.
De Quervain syndrome (French pronunciation: [də kɛʁvɛ̃]; also
known as BlackBerry thumb, gamer's thumb, washerwoman's
sprain, radial styloid tenosynovitis, de Quervain disease, de
Quervain's tenosynovitis, de Quervain's stenosing tenosynovitis,
mother's wrist, or mommy thumb), is a tenosynovitis of the sheath
or tunnel that surrounds two tendons that control movement of the
thumb.
Symptoms are pain, tenderness, and swelling over the thumb side of
the wrist, and difficulty gripping
Ménière's disease is a condition of the inner ear.
Symptoms that come and go
Ménière's disease typically comes in attacks (episodes) of the
following symptoms:
Dulled hearing in the affected ear(s). The degree of hearing loss
varies.
Vertigo. This is dizziness with a spinning sensation. It can be quite
severe and make you feel sick or vomit. Vertigo can develop with
little or no warning. You may feel very dizzy and ill. You may need to
go to bed until it passes.
Tinnitus. This is a noise such as a ringing, roaring, or buzzing noise
which you can hear from inside the affected ear.
Ear pressure. You may get a sense of fullness or pressure inside the
ear.
Loud noises may seem unpleasant and distorted.
An acoustic neuroma is a rare type of brain tumour (growth). It is not
cancerous and so is called a benign tumour. The tumour grows along a
nerve in the brain (a cranial nerve) that is called the acoustic or
vestibulocochlear nerve. This nerve controls your sense of hearing and
balance.

The most common symptoms of an acoustic neuroma are:

Hearing loss. Some degree of deafness occurs in most people with an
acoustic neuroma. Usually hearing loss is gradual and affects one ear.
The type of deafness caused is called sensorineural deafness and
means the nerve for hearing (the acoustic nerve) is damaged.
Tinnitus. This is the medical name for ringing in the ears.
Vertigo
Loss of feeling (facial numbness), tingling or pain. These symptoms
are due to pressure from the acoustic neuroma on other nerves. The
commonly affected nerve is called the trigeminal nerve which controls
feeling in the face. About 1 in 4 people with acoustic neuroma have
some facial numbness - this is a more common symptom than
weakness of the facial muscles. However, it is often an unnoticed
symptom. Similar symptoms can occur with other problems, such as
trigeminal neuralgia or a tumour growing on the facial nerve (a facial
neuroma).
The best test to diagnose an acoustic neuroma is a magnetic
resonance imaging (MRI) scan of the brain.
The main treatments for acoustic neuroma are surgery or stereotactic
radiosurgery
Distinguisher is in labrynthitis hearing loss will be present but not in
vestibular neuritis…both occur after URTI