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

SIGN suggested the following criteria for referral to hospital (children)

poor feeding (< 50% normal)
lethargy
apnoea
respiratory rate > 70/min
nasal flaring or grunting
severe chest wall recession
cyanosis
oxygen saturation < 94%
uncertainty regarding diagnosis

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.

the best choice for lowering potassium is 10ml calcium gluconate 10% . the next
option is insulin plus dextrose infusion (the insulin helps potassium go into cells and
the dextrose protects against hypoglycemia).
calcium resonium takes time to act

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.

Also have a look here please:-

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
Like

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
in flight of ideas thy jump from topic to topic
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

Pyromania is an impulse control disorder[1] in which individuals repeatedly fail to

resist impulses to deliberately start fires,[1] in order to relieve tension or for instant
gratification.
Kleptomania is the inability to refrain from the urge to steal items and is done for
reasons other than personal use or financial gain
Trichotillomania is a condition where a person feels compelled to pull their hair
out.
Grandiosity refers to an unrealistic sense of superiority—a sustained view of oneself
as better than others that causes the narcissist to view others with disdain or as
inferior—as well as to a sense of uniqueness: the belief that few others have anything
in common with oneself and that one can only be understood by a few or very special
people.[1]
Grandiosity is chiefly associated with narcissistic personality disorder, but also
commonly features in manic or hypomanic episodes of bipolar disorder

De Quervain syndrome (French pronunciation: [də kɛʁvɛ]̃ ; 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