Sanjay Sharma : Summary of difficult topics fro Sharma MRCP Part2

(By Dr Sujit Vasanth)

1. (8) RUQ pain, fever, jaundice --> ascending cholangitis. can occur even after
cholecsytectomy. Inv. blood cultures (E.coli), U/S to exclude abscess. liver biosy should
never be 1st test for jaundice and fever.
2. (10) Histiocytosis X: manifestations are due to histiocytomas 2-4 yrs, M>F. lung fibrosis
and COPD, bone infiltration (esp skull), proptosis, deafness, hepatosplenomegally,
lymphadenopathy, diabetes insipidus (pituitry infiltration). Dx by histology (small round
cells). Rx steroids, occasionally vincritine. occasional spontaneous regression.
3. (12) flow volume loop: URT obstruction decreased inspiratory flow.
4. (12, 39) leucoerrythroblastic blood film: immsture granulocytes, normoblasts Causes:
marrow infiltration (including msrble bone dx, myelosclerosis, storage diseases like Gucher's
- large white filled cells), severe infection (leaukaemoid dohle bodies, toxic granulations).
Differentiaite by presence of hepatosplenomegally or lymhadenopathy and absense of left
shift).
5. (14) inc Ca, inc BP, palpitations, goitre --> MEN2 = thyroid C cell Carcinoma, parathyroid
adenoma, phaeochromocytoma. Ret oncogene (chr 10). calcitonin elevated. Relatives need
regular screening.
6. (15) echoes of mitral valve prolapse (posterior motion of mitral valve in systole) and atrial
myxoma (obliteration of mitral valve orifice)
7. (16) sickle cell disease: hyposplenism means encapsulated bacterial infection, chronic low
grade haemolysis --> pigment gallstones
8. (17) antiphosholipid syndrome false positive VDRL, recurrent thrombosis/miscarriage, in
vitro prolonged clotting --> RAISED APTT +/- PT, does not correct with addition of normal
plasma due to lupus anticoagulant. Rx prophylactic anticoagulants. Assoc livedo reticularis
(conn tiss disorders), pulm hypertension, cerebral problems, valvular heart disease, low plt.
9. (18) alkapatonuria aut rec homogentesic oxidase deficiency. Urine darkens on standing,
ochronosis (pigmented cartilage, conn tissue e.g. Ears, joints). Premature arthritis. Xray -->
intervertabral disk calcification and aorta. Rx low protein diet, poorly affective.
10. (27) echordiography: mitral valve lesions
11. (28) porphyria cutanea tarda liver disease, skin rash (hands, head). Uroporphyrin
decarboxylase deficiency. XS uroporphyrin -> photosensitive blistering rash (PAS staining),
cirrhosis. Precipitants are enzyme inducers: alcohol, anticonvulsants, oestrogens. There is
often secondary haemaochromatosis, secondary polycythemia. Rx --> alcohol abstainence,
avoid sun exposure, venesect if Hb >12. Chloroquin binds uroporphyrin. End product blocked
is corporoporphyrin.
12. (30) purple = positive gram stain. (it went Positively Purple with pleasure). Pink =
negative. GPCocci=Strep/Staph. Gndiplococci=Neisseria, GNrods=Haemophilus. TB=ZN red.
13. (31) precipitants of HONK XS sugary drinks, infection, thiazides, steroids, MI. If
hypernatraemic use 0.45% N Saline, half strength sliding scale, DVT prophylaxis. Decrease
osmolality gradually. Treat underlying cause.
14. (32) genetic pedigrees. 1. look at transmission no male to male = X linked, 2. female to
male/female only then mitochondrial.

15. (32) alports syndrome: x linked dominant: renal failure in males (females haematuria),
senorineural deafness, ocular abnormailities (myopia, cataract, retinitis pigmentosa see
pic). Post renal transplantation anti-GBM disease because original defect was type 4 collagen
in GBM (goodpasture antigen).
16. (34) complications of nephrotic syndrome: portal vein thrombosis (abnormal lfts)
diagnose by US, venography Rx. Thrombolysis
17. (40, 123) Chronic Active hepatitis risk: old blood transfusion, high risk profession.
Usually asymptomatic, chronic progressive. Causes: Hep B (eAg present) and Hep C (antiHCAb's) also SLE, LKM, methyldopa, isoniazid, antytipsin, Wilsons, UC). AST, BR elevated
>>ALP. Piecemeal necrosis. Rx. Iv IFN, success 30%, often relapse. consider HIV screening.
18. (41) Cardiac catheter values 1. look for unusual pressures and saturations, 2. look for
gradients across pulmonary and aortic valves. mitral valve disease reflected in PCWP.
19. (44) Acute intermittent porphyria aut dom, Chr 11 PBG deaminase deficiency. 5F>M.
Increased dALA and PBG blood and urine--. gastro and neuro sequelae, (skin manifestations
rare cf PCT). Precipitants: drugs (barbiturates, anticonvulsants), alcohol, fasting, sepsis,
OCP. Presents as acute abdominal abdomen (can mimic surgical abdomen but AXR normal).
Neuropathy/ANS excitation/motor paralysis including CN's, epilepsy, hyponatraemia
(SIADH). Rx 1. withdraw precipitant, 2. high carbohydrate diet /iv dextrose (reduces haem
precursors in blood by reducing ALA sythetase activity), 3. haematin iv, 4. opiate analgesia.
Avoid metoclopramide (another precipitant), B blockers for tachy. Epilepsy: calories, fluid
restriction (inc Na), chlormethiazole or diazepam (most other anticonvulsants are
preciptants). Tests: erlichs dye --> red (also jaundice) PLUS chloroform --> purple sedimnt
(porhyria).clear (bilirubin). (Watson Scwarz test). Levels elevated in attack but may be
normal when well. Can assay red cell PBG deaminase (low), ALA dehydrogenase (high).
20. (51) Causes of erythema multiforme. Infection (mycoplasma, HSV, orf, TB), drugs
(penicillin, barbs, sulphonamides), other (conn tiss dx, vasculitis, internal malignancy)
21. (52) Hereditory angioedema (c1 esterase inhibitor deficiency) aut dom. Attacks
preceded by painful macular rash. precipitants: trauma. Laryngeal oedema, abdominal pain.
Normall rx supportive responds in 72 hours. Can give FFP if severe/protracted. Long-term
rx. Danazol (inhibits plasmin) Hydrocortisone/chlorpheniramine less effective cf.
anaphylaxis. Diagnosis C1 esterase inhibitor (low), c1 esterase (high), c2 & c4 both low.
22. (57) Aortic dissection: proximal --> urgent surgery. Seen clearly on 2D echo. Important
to exclude before thrombolysing any MI. assoc. hypertensive blacks, Marfans, Ehrler
Danlos, pregnancy, coarctation.
23. (58) Scurvy: elderly, normocytic anaemia, bruising (haematomas), prolonged bleeding
time --> always think of vitC deficiency. Easy bruising, bleeding gums, periosteal
haemmorhage, muscle haematomas. Classic: perifolicular haemorhage, corkscrew hairs.
APTT/PT normal, BT increased. Dx by plt or leucocyte ascorbate concentration. Rx. Vit C.
24. (71) livedo reticularis: assoc vasculitis and conn tiss disease e.g. PAN
25. (71) polyarteritis nodosa males 60-70 myalgia, night sweats, weight loss, livedo
reticularis, testicular pain, assoc HbsAg. Multisystem (neuro, gi, renal, cvs), aneuysm -->
thrombosis -->organ infarction. dx. ANCA suggestive, organ biopsy , microaneurysms on
angiography. Rx. Steroids.
26. (72) Heinz bodies: low Hb, high retic count -> bleed or haemolysis. Differentiate by
blood film --> Hz bodies (pptd Hb) seen in Hbopathies or metHbaemia (Fe3+) e.g.

Sulphasalasine Rx esp if G6PD deficiency. Cf Howell Jolly bodies, cf. Malaria blood films
(can be confused)
27. (74) Apical lung fubrosis: TB, EAA, ankylosing spondylitis, apergillosis, radiation,
sarcoidosis, histoicytosis X.
28. (76) Familial benign hypocalciuruc hypercalcaemia aut dom. Usually lifelong
asymptomatic hypercalcaemia occasional gall stones/pancreatitis/joint deposition. Difficult
to distinguish between 1ry PTHism so patients often have uneccesary parathyroidectomy
and FH parathyroidectmy. Can distgiuish because urinary calcium is LOW (it is high in all
other causes of hypercalcaemia). Conservative management.
29. (77) Eruptive xanthomas: think hypertriglyceridaemia (associated with pancreaitis).
There is pseudohyponatreamia due to lipids binding Na the free sodium only is normally
measured. Can differentiate by looking at serum osmolality.
30. (84) Wolf Parkinson White syndrome: accessory fast conducting atrioventricular
pathway (Bundle of Kent). Ventricles depolarise prematurely --> short PR, slurred (delta
wave) upstroke of QRS. 2 arrythmias possible: AV re-entrant tachycardia (P burried AFTER
QRS Rx. Vagal stim, adenosine) , AF (delta waves sometimes seen Rx adenosine, vagal stim
usually fails). 2nd line --> cardioversion. Definitive management radiofrequesncy ablation.
Prevention with class I/III
(sotalol, flecainide, amiodarone, disopyramide). Avoid digoxin and verapamil as they increase
accessory pathway conduction predisposing to malignant ventricular arrythmias.
31. (87) Polycythemia rubra vera Hb can be normal if coexisting Fe deficiency anaemia (low
MCV), look at PCV and rbc count to make the diagnosis. All marrow cells increased (wcc, plt)
and splenomegally.
Incidious onset assoc lethargy, depression, vertigo, tinnitus, amaurosis fugax. Plethora,
hypertension, spenomegally. Bledding (usually upper GI) due to throbocythaemia, stroke
(hyperviscocity), gout (increased cell tunover). Can progress to myelofibrosis or AML. Rx.
Venesection (can cause fe def anaemia). Busuphan and hydroxyurea to control
thrombocytosis.
32. (91) Hypokalaemic periodic paralysis aut dom, episodic paralysis classically while
patient asleep or with prolonged rest. Ppt by dextrose and insulin, alcohol, cho, anxiety,
tension. Rx can give K supplements or longeterm K sparing duiretics. Associated with
orientals with thyrotoxicosis. Hypokalaemic arrythmias. Rx of thyrotoxicosis prevents
paralysis too, propranolol also works. Only affects males. Need to exclude GBS or
myasthenia gravis.
33. (94) Schmidtz syndrome (polyendocrine deficiency type II) 10% of addisons pients
have other endocrine abnormailies too - autoimmune hypothyroidism and IDDM. Type I PED
= parathyroid, adrenal, candida, alopecia, pernicous anaemia. Vitiligo and hypogonadism occur
in both. Hypothyroidism can cuase a large heart.
34. (97) Leprospirosis (rat faeces) liver failure common, renal failure can also occur.
Brucellosis (unpasteurised cows milk) liver failure rare, assoc hepatosplenomegally, high
fever and leucopenia.
35. (98) Atrial enlargement on ECG. R atrium = tall P II, V1 >2.5 small squares tall. L atrium=
bifid P in II >3 small squares wide, V1 negative portion p wave >1 small square duration
AND amplitude.
36. (98) Sokolow's criteria for ventricular hypertrophy look at V1 ad V5/6: Right ventricle
>12.5mm. Left ventricle >40mm. LVH shows more toward V6, RVH in V1.

37. (101) HIV infections: oral hairy leucoplakia (H=EBC infection) - white plaques on the
lateral border of tongue Rx. Acyclovir cf candida rx. Nystatin, flucanazole.
Crypotosporidium diarrohea ZN stain of stool --> red cysts. Rx. Symptomtic +
spiramycin/paromomycin.
38. (103) SLE arthropathy, fever, polyserositis. 10F:1M, blacks, usully <40yrs. Multisystem
involvement: renal, resp, CVS, neuro, haematologic, cutaneous. DsDNA positive in 60%, ANA
in 90%. ESR usually high, CRP characteristically normal. C3 depressed. Lupus anticoagulant.
Rx. NSAIDs (joints), chloroquine (skin), corticsteroids, azathioprine, cyclophosphamide.
39. (103) coxsackie virus A/B - epidemic myalgia (Borholm's syndrome) usually
children/young adulys. Sudden abdo/thoracic pain. Myalgia, fever. Polyserositis. Virus in
faeces, retrospective diagnosis by serum antibody x4 rise.
40. (107) Guillain Barre syndrome onset often heralded by SEVERE lumbar or intrascapular
pain. Ans neuropathy e.g. Bladder atony. Csf albuminocytogenic dissociation. Rx. Iv Ig. Poor
prognstic markers: FVC<1litre, paO2 <8, paco2>6, LRTI, polm oedema, accelerated
hypertension, arrythmia, bulbar involvement, campylobacter infection.
41. (110) Homocytinuria cystathionine deficiency, aut recessive, chr 21---> homocysteine
accumulation--> oxidised to homocystine (elevated urine levels). Cystine NOT produced.
Defects in collagen crosslinking. Marfanoid features (tall, arachnodactyly, high arched
palate, lens dislocation), osteoperosis, epilepsy/mental hadicap, venous/arterial thrombosis
(OCP contraindicated), folate deficiency (inc MCV), premature coronary art disease. Rx.
Restrict methionine, add cystine. Give Pyridoxine as soon as diagnosis is made.
42. (112) hypotension, hyperkalaemia, metabolic acidosis --> Addisons, diuretics/salt loosing
nephritis.
43. (114) hypokalaemia --> gi or renal loss. RENAL if 1. HYPERTENSIVE with high renin
(malignant hypertension, RAS, diuretics), with low renin (conn's, cushing's, liddle's=tubular
defect mimics conn's biochemistry) 2. ACIDOTIC think RTA as most other causes give
alkalosis. 3. NORMOTENSIVE diuretics, carbenoxole, liquerish, aminoglycosides,
Barters=child JGA hyperplaia, weakness, nocturia, failure to thrive. liquorish and
carbenoxalone can also cause hypertension. THINK OF GASTRO CAUSES IF K IS AVIDLY
RETAINED FROM KIDNEY ie. <20 MMMOL/L URINARY K.
44. (115) Coeliac disease - whites esp. irish HLA A1,B8,DR7,DQW2, gluten sensitive
enteropathy. 20% do not have diarhhoea. anti gliadin antibodies. children:failure to thrive,
adults:abdo pain, fatgue, wt loss. Ankle oedema (albumin), mouth ulcers (Fe), osteomalacia
(vit D), hypocalcaemia. Anaemia may be Fe>>B12 but both occur. hyposplenism (Howell Jolly
bodies). endoscopic D2 or jejunal bx shows villous atrophy, anti gliadin/anti retiuculin
antibodies seen in most patients. antiendomyesial can be absent but are more specific.
Rx.gluten free diet. assoc with autoimmune thyroid dx, liver dx, fibrosing alveolitis, IDDM.
complications: lymphoma, adenocarcinoma, splenic atrophy.
45. (116) Cerebral manifestations of HIV - toxoplasmosis (IgM ,Sabin Feldman dye test,
CT...Rx pyrimethamine and sulphadiazine), TB meningitis (ZN stain...Rx Ansamycin and
clofazamine), crytococcal meningitis (India ink stain, CT..Rx amphotericin), lymphoma (dx
brain bx or csf cytology...rx radiotherapy). Uncertain dagnosis on CT --> Rx for
toxoplasmosis and repeat CT 2 weeks. biopsy if lesions persist. Other manifesations of HIV:
HIV dementa, PMLE, Herpes encephalitis, periph neuropathy).
46. (118) Charcot Marie Tooth disease - Hereditory Sensory Motor Nueropathy /Peroneal
Muscular Atrophy. HSMN1: familial diffuse demyelinating neuropathy, presents <20yrs.

wasted lower limbs --> inverted champagne bottle legs, foot deformity,scoliosis, sensory
ataxia. dx: FH, nerve conduction, chr 1q. HSMN2 milder. HSMN3 ( Dejerine Sottas dx) aut
rec. mixed neuropathy. presents <10yrs with palpable peripheral nerves (palpble nerves also
seen in acromegally, leprosy, nft, hiv)
47. (120) Methaemoglobinaemia (i.e. Haem Fe2+-->Fe3+) assoc with G6PD (low NADPH so Hb
more readily oxidatised). MetHb high afinity O2--> ox diss curve left shift--> dec tissue
oxygenation. variable degree of cyanosis. metHb level 20% (dyspnoea, headache, angina)
60%+ collapse, sudden death. Blood film intravascular haemolysis, Heinz bodies. Causes:
G6PD, drugs (sulphonamide, primaquin, phenacetin), toxins (ferric cyanide, chlorate, aniline
dyes)
48. (120) left shift of O2 dissociation curve: metHb, sulphHb, COHb, FetalHb, decreased
23BPG, alkalosis, hypocapnia, hypothermia.
49 (121) pain relief and renal failure --> think aute interstitial nephritis most likely.
50. (123) Hepatitis B serology. Onset of infection-->HBcAb IgM, Marker of previous
infection-->HBcAb IgG. HbeAb--> reduced infectivity (cf HBeAg--> increased risk). HBsAb-> immunity, last one to appear. CAH -> usually HBeAg amd HBsAg detected and history is for
several months.
51. (124) Rhematoid arthritis - episcleritis (painless), scleritis (painfull, bilateral, if
recurrent can cause perforation). anaemia, Felty's syndrome, renal, resp. Drugsfor rh pancytopenia (penicillamine or Felty's), nephrotic syndrome (pnicillamine membranous GN,
renal amyliod, NSAIDS/analgesics), anaemia (as above plus NSAIDS, chr dx, folate def,
atoimmune haemolysis, pernicious). eye dx (scleritis, sjorgens, steroid cateracts, chloroquine
retinopathy, eye movement - muscle synovitis, peniciillin inducedmyasthenia, mononeuritis).
Resp problems: effusions, fibrosis, bronchiolitis obliterans, pneumonitis, pulm nodules,
caplans (nodules plus PMD in coal workers, cricoarytinitis)
52. (125) vit D resistant rickets- no po4 resorption, high urinry po4 plus/minus paraplegia
53. (128) Kawasakais dx Hx, O/E, echo Rx. 1. aspirin PO, 2. iv Ig.
54. (129) atypical lymphocytes - HIV seroonversion (2-6weeks after exposure), CMV, EBV,
toxoplasma, secondary syphilis.
55. (129) syphilis serology: VDRL negative--> test FTA for previous infection. HIV IgG
(detctable at 6 weeks), p24 (72 hrs) or PCR for HIV RNA.
56. (130) renal tubular acidosis: serum K USUALLY FOLLOWS serum H but RTA is an
exception. hypokalaemic acidosis with hypocalcaemia and hypercholraemia. manifests
clinically as osteomalacia and muscle weakness. dx: abnormal acid load test, early morning
uirne pH>5.5. distal=RTA 1 (defective H excretion. failure to thrive, renal colic).
proximal=RTA 2 (absent H excretion, NaHCO3 loss. polyuria, polydypsia). Rx. 1. Na
bicarbonate (correct acidosis), 2. Potassium citrate (provides K and prevents Ca excretion).
Can be inherited, drug induced(acetazolaminde, tetracycline, Pb, Argon, vit D), assoc with
PBC, CAH, myeloma, hyperPTH, Fanconi, obstructive uropathy.
57. (131) Pulmonary embolisn - sudden onset, R heart failure, normal CXR, restictive lung
defect, low KCO, low pao2 low paco2. pulm bp.
58. (133) metabolic acidosis and resp alkalosis always think salicylate poisoning! Rx 1. fluids
if <500. 2. alkaine duiresis if <750. 3. haemodialysis if >750.
59. (135) paradoxical emobous with a soft (?stolic) murmur ---> ASD. ECG changes: RBBB,
RVH. LAxD-primum RAxD-secundum. for VSD to be soft takes v large defect.

60. (136) Amphetamines can induce coronary vasospasm, ventricular arrhythmia,

myocarditis, torsaeds (they prolong QT): e.g. cocaine i a young athlete --> MI, normal
angiogram. Betabloclers contraindicated because unopposed alpha stimulation in
amphetamine abusers causes severe hypertension. Amlodipine/verapamil should be used.
hocm is the commonest cause of death in young athletes.
61. (138) Congenital Adrenal Hyperplasia aut recessive. 21OH deficiency commonest. 3
pathways cholesterol can make: progesterone, aldosteron/cortisol (blocked), testosterone.
results in high testosterone (F:virulisation, hersuitism M: proc puberty) and progesterone
(amennorria), low adrenal hormones (hypotension, vomiting, failure to thrive). High ACTH, 17
OH prigesterone, high urinary ketosteroids (e.g pregnanetriol), low cortisol. Rx
hydrocortisone corrects deficiency and supresses androgen production 2. fludrocortisone as
necessary. Synacthen test is abnormal cf. PCOS.
62. (140) Toxicara infection, dog.cat reservoire, faecoral spread, 2 syndromes: visceral
migrans syndrom (local eosinophil eosinophil rich granulomas, flu like symptoms, recovery 2-3
weeks, Rx. thiabendazoleor diethylcarbazine), ocular tocicariasis (blindness, round swelling
near optic disk, IgM abs to oxocara in aqueous or vitreous humur Rx laser photocalgulation
+/- adjunctive stroids.
63. (144) Amoebic liver abscess. 50% have no dysentry. Enlargement of liver abscess is
UPWARADS hence raised Right hemidiaphragm, intecostal tenderness. Jaundica and
abnormal LFTs are rare. Dx US/CT, aspirate NOT sigmoidoscopy. Haemagglutination tests
have HIGH YIELD. Rx. metronidazole or tindazole. diolxanide to eliminate ongoing gu
infection.
64. (146, 158) Turners syndrome. phenotypical females, can exhibit X linked recessive traits
e.g. haemophilia that are normally only associated with men. the combination of short neck,
short metacarpals and short stature is seen in Turners and pseudhypoparathyroidism. short
fingers are also seen in Noonan's synfdrome. genotype XO, gonadal dysgenesis (primary
hypogonadism - > inc LH and FSH, low oestogen, primary amenorohea, infertitlity), buccal
smear Barr body.
65. (146) Haemophila A/B - NORMAL bleeding time (cf. Von Willibrands disease). both
conditions have prolonged APTT. Swollen knee (haemarthrosis, chondrocalcinosis).
66. (148) Pericardial constriction - right heart failure,normal heart size (radiotherapy, TB,
bacterial pericarditis). MRI/CXR reveals thickening/calicification. Cardiac catheter:
LVEDP=RVEDP and atrial pressures are equal. (restritive cardiomyopathy - which is patchy,
LVEDP>RVEDP, usually tricuspid r mitral regurg)
67. (149) HIV rx CD4<500, viral load >10,000. 2 nucleoside analogues (AZT, ddc/ddi, 3tc)
and protease inhibitor (sequinavir, indinavir)
68. (150) Amyloidosis: nephrotic syndrome and cardiac failure. cardiomyopathy (small QRS,
thick walls echo ground glass), macroglossia, peripheral neuropathy, F10 deficiency).
rectal/gingival bx --> apple green birefringence. Primary (AL) myeloma Ig light chain and
glycopotein deposition. Do serum Ig and eletrophersis, urine Bence Jones. Systemic amylois
(AA) chronic inflam (Rh, bronchiectasis, UC/Crohns, familial med fever) --> kidney more
affected (ARF, neohrituc syndrome), hepatosplenmegally.
69. (151) Freidrichs ataxia - aut dom, frataxin chr 9, trinucleotide repeat. spinocerebellar
degeneration, 20-40's assoc optic atrophy, HOCM, DM.
70. (151) Kyphoiscoliosis and high arched palate - Marfans, Freidrichs ataxia, homocystiuria.

71. (153) high wcc, myeoblasts, splenomegally --> diff diag CML, myelofibrosis. CML --> low
neutophil alk phosphatase, 90% philidelphia chr positive. blood film shows granulocytes if
varying maturity.
72. (156) Parkinsons plus syndromes: 1. multisystem atrophy=sporadic adult onset
parkinsonism, cerebellar signs, ANS failure. Parkinsone + ANS failure (e.g. impotence, resp
stridor, dysarthria) is called Shy Drager. shortened life expectancy (10 years). postural
hypotension --> compression stockings, fludrocortisone, ephidrine, poor respons to Ldopa. 2.
Steele Richardson syndrome = NFT's, 70's progressive supranuclear palsy (absence of
voluntary downgaze gaze), perseverence in speech(palililia, palilogia), falling backwards,
involuntary eye closure, frontalis hyperactivity (7 year survival). both are completely
different entities to PD.
73. (159) Hypogonadism - some causes: 1. PCOS - oestradiol slightly reduced, FSH low, 2.
coeliac dx - short stature, delayed puberty, 3. testicular feminization syndrme - no
receptors on end organs. phenotypic females, intrabdomial testicles, testosterone levels
very high. LH and FSH also very high (no testosterone Receptors on pituitry) --> high
oestrogens --> breasts. scanty or absent pubic hair. 4. Pituitry Cushings (basophil adenoma).
Usuallly cortisol supressed by high dose dexamethasone otherwise petrosal sinus sampling
for ACTH.
74. (162) Sarcoidosis: multisystem granulomas, f > m. assoc blacks, Lofgrens syndrome
(erythemna nodsum, arthralgia, hilar lymphadenopthy, ant uveitis). lacrymal or parotid gland
enlargement
(Mikulicz syndrome seen in sarcoid, TB, lymphoma/leukaemia. with uveitis, facial nerve palsy
known as Heerfort's syndrome). most patients resolve <2 years, a few chronic lung disease
--> apical fibrosis. full spectrum of eye , skin papules (nose=lupus pernio), arthralgia
xray=luscent phalenges, aseptic meingitis, psychosis, mononeuritismultiplex, hypercalcaemia
(1, 25oh vitD from granlomatous cells).
75. (162) erythema nodosum: common: strep, sarcoid, ocp, UC/Crohns, sulphonamides, rest:
behcets, TB, leprosy, histpolasma, yersinia, neiserria meningitis/gonnorrohea, pasteurella.
76. (162) diabetes insipidus: abnormal water depriviation test ..urine osmolality < 720.
cranial: (respond to desmopressin) familial, aut dom, DIDMOAD, cerebral tumor,
sarcoidosis, TB, hitiocytosis X, trauma, piruitry haemmohrage. nephrogenic (unresponsive to
desmopressin)x linked vasopressin R defect, aut rec aquaporin defect, hypokalaemia,
hypocalcaemia, Lithium, postobstructive uropathy, sicke cell, glibenclamide, aminoglycosides,
amphoteracin.

Pictures to know:
1.Heinz bodies (denatured Hb seen in haemolysis)
2.Livedo reticularis
3.Lymphoerythroblastic bone marrow
4.retinitis pigmentosa
5.eruptive xanthomas
6. dermatitis herpetiformis (rx dapsone --> metHb)
7. atypical lymphocyte
Approach
A&E dept, think overdose
CRF with normal Hb (APKD). due to epo ectopic secretion.
chornic GI and RESP infection in a child --> always think CF
smoker think malignancy
Calcium metabolism
1. raised ALP (bone): 1. function hyperparathyroidism 2. damaged cortex 3. low vit D
2. hypercalcaemia: 1. 1ry/3ry PTH, 2. malignacy, 3. myeloma 4. vit D intox, 5.some sarcoid
3. low calcium: rickets/osteomalacia, hypoparathyroidism, 2ry hyperpth
4. po4 metabolism: po4 follows calcium in vit D pathology, in parathyroid dysfunction it does
the opposite. in other pathologies usually normal.
Disease.....................

Ca.............

PO4..................ALP

1ry/3ry pth................

high...........

low.................. high

malignancy................

high...........

norm/high........

high

high............

norm............

norm (think marrow)

vit D intox................ .

high............

high..............

normal

sarcoid.................... .

high/norm.....

norm.............

norm

osteoperosis..............

norm...........

norm..............

norm

pagets dx and mobile..

norm...........

norm..............

high

2ry pth/crf/mg def.......

low/norm.....

high..............

high

rickets/osteomalacia...... .

low...........

low...............

high

hypoPTH/psudohypoPTH..

low...........

high..............

norm

myeloma no fracture.