MRCP PART 1 NOTES

Muhammad Hassan Younas

MRCP Stereotypes

Africans : Malaria , AIDS

Pakistani , Indians : Tuberculosis

Turkish, Armenian, Arabic : Familial Mediterranean Fever

Europeans : Homosexuals

Businessmen : STDs

______________________________________________

1.Pulsus paradoxus is the decrease in pulse pressure with inspiration and not in pulse rate. As in pericardial
effusion, asthma, COPD etc. Decrease in systolic BP (>10 mmHg) and pulse wave amplitude also occurs in pulsus
paradoxus.

2.During orthostatic hypotension, on standing :

Systolic volume, CVP , venous compliance decrease, mostly due to the venous blood pooling & Systemic vascular
resistance increases due to increased SV tone to counter the venous pooling in lower limbs. And Heart Rate rises to
counter decrease SV and to maintain MAP.

3.Bile’s largest part is contributed by bile salts. Bile acids are conjugated into the bile salts. Most common bile acid
is cholic acid.

4.Structure overlying Left renal hilum is pancreas tail.

5.Alcohol in type 2 DM causes hypoglycemia because increased insulin first phase response.

6.Most common morbidity associated transfusion disorder in UK is TACO followed by TRALI. Monitor with fluid
balance during transfusion.

Also hypertension is characteristically associated with TACO while hypotension is related to TRALI.

7. Bacterial contamination mostly occurs during platelet transfusion especially by Staph. Epidermidis.

8. Strep. sanguinis is a part of oral flora. In case of Infective Endocarditis,, for dental abscess Orthopantogram
needs to be done.
9. Cortisol level is the highest in morning (0900h) and lowest at night . Adrenal insufficiency is ruled out if
incremental rise of cortisol is >200 and 30 minute value exceeds 600.

10. ACA occlusion (proximal vs distal ) :

In proximal ACA occlusion , neurological sequelae are less because of the collaterals .

While distal ACA occlusion causes stroke of the frontal lobe and other changes like incontinence and contralateral
grasp reflex.

11. Juvenile Mycolonic Epilepsy :

Mx in males : Valproic Acid

Mx in females ( child bearing age) : Levetiracetam

12. Right parietal stroke causes Left neglect :

As right parietal lobe is related to spatial and visual awareness esp. in temporoparietal junction and primary
parietal cortex. Left parietal lobe is related to language, mathematics, reading, writing and symbol processing.

13. Response to hypoxia by carotid body : Type 1 glomus cells detect partial pressure of O2 , if <8 , they increase
output via IX nerve.

14. Increase phosphate in chronic renal failure is mainly because of decreased functional renal tissue that causes
decrease in filtered phosphate .

15. Lateral Medullary Syndrome(Wallenberg) : Occurs due to vertebral artery occlusion. And rarely due to PICA
which originates from Vertebral Artery. If both options are given prefer vertebral over PICA.

Features: Ipsilateral cerebellar signs + ipsilateral horner's+ contralateral pain and temperature loss on limb/torso

Vestibular system disturbance, horner , nystagmus, decreased corneal reflex, palatal paralysis, contralateral
sensory loss , dysphagia (profound) __“PICA-CHEW ”

Vs

Medial Medullary Syndrome(Dejerine): Occurs due to occlusion of the para-median branches of anterior spinal
artery or vertebral artery.

Features: Ipsilateral hypoglossal paralysis , contralateral hemiparesis , contralateral loss of proprioceptive and
vibration sensation. (pain and temperature sensations preserved)

16. S1 just after QRS, S2 after T wave , S3 after S2 before P wave, S4 after P wave.

17. Correctly identify those with disease is Sensitivity. While specificity is to correctly identify those without
disease.

18. Reticulocytes and RBCs both have no nuclei. The unique feature of reticulocytes is rRNA which is not present in
the mature RBCs.

19. Rheumatoid factor is IgM against Fc portion of IgG.

20. Avoiding smoking can prevent >90 % lung CA. X-ray can miss 10-15 % lung CA cases. (Fun facts to
remember! )

Best way to slow the progression of lung fibrosis is to avoid smoking. (Steroids don’t affect the progression)
21. Whipple Disease(Chronic cough , weight loss and arthralgia triad)

Mx: IV Ceftriaxone or IV penicillin for 2 weeks.

22. Distal Right coronary artery occlusion causes ST elevation in II, III, aVF while proximal RCA occlusion causes ST
elevation in II, III, aVF and V1-V3.

23. Calf pain with no plantar flexion indicates damaged gastrocnemius muscle. Plus muscle that contracts in ankle
clonus is gastrocnemius muscle.

24. Blood volume depends on muscle mass, fat mass and body surface area. So it increases in patients with heart
fail due to salt and water retention and decreases in case of GIT losses.

“ 25 y males would have 75 ml/kg blood volume and females would have 65 ml/kg blood volume.”

25. Acromegaly investigation : Initial IGF -1 levels(screening test) and then OGTT with Growth Hormone measure
(Definite test) . Normally glucose administration should suppress GH levels. If 0.1 ug/l then it indicates
acromegaly.

26. Cushing syndrome investigation: 24 urinary cortisol levels and then the next most important test is
dexamethasone suppression test ( preferred over ACTH level).

27. Autoimmune Hemolytic Anemia secondary to CLL (patient on fludarabine for few weeks , now develops
anemia, SOB at rest , splenomegaly, coombs +ve )

Mx:

Initial: Prednisolone , If fails give Rituximab.

28. Lithium induces hypothyroidism because it inhibits thyroid hormone release and proteolytic degradation of
thyroglobulin as well.

Mx: “First start thyroxine “

DO NOT STOP Li WITHOUT PSYCHIATRIC CONSULT!

29. Rheumatoid Arthritis : DR4 (DRB1 04:01)

Takayasu Arteritis : DR B52

Behcet Syndrome : B51

Abacavir hypersensitivity: B5701

30. Bartter Syndrome : Loop Diuretic Effect

Gitelman's Syndrome: Thiazide Diuretic Effect

Liddle Syndrome : Opposite of K-Sparing Diuretic Effect

31. Cardiac patient on metformin with uncontrolled diabetes with heart failure risk. To manage his diabetes add
add SGLT-2 inhibitor in place of DPP4 inhibitor with metformin .(-Gliflozins > -Tins)
32. In Hypertensive Afro-Caribbean patients, as per new guidelines , if Ca channel blockers fail then prefer ARBs
over ACEls in addition to CCBs.

33. SVT (vitally stable patient) – narrow QRS complexes.

Mx : Most appropriate initial management is posture modified Valsalva maneuver (head down Valsalva reverts
40% vs 20% in case of standard maneuver)

Second line : Adenosine (Contra-indication : Asthma)

34. Suspected SAH, CT is negative. Next step is to perform LP after 12 hours.

35. Chronic Pancreatitis :

Initial Mx: “ Creon Capsules “ plus pancreatic enzymes.

While cholestyramine is useful in case of Bile Acid Diarrhea.

36. Acanthosis nigricans is famously associated with gastric adenocarcinoma.

And Erythema Gyratum Repens ( woody granular appearance) is related to Bronchial carcinoma and other solid
organ malignancies (erythematous rash can appear on abdomen even months before carcinoma diagnosis.

Tylosis is linked to SCC of esophagus.

37. TCA overdose (QRS > 100 ms) , increased seizure risk and VT.

Mx : Initially Sodium Bicarbonate ( reverses Na-channel blockade)

Second line : Mg

38. HOCM patient with 2 collapses in last 6 months , double apex beat , systolic murmur @ Left sternal edge, echo
done, 24h tape shows PVCs.

Most appropriate step in Mx: ICD > Amiodarone( although amiodarone suppresses VT , it is less effective in
preventing sudden death than ICD)

39. Tourette Syndrome : Motor / Vocal tics , may involve arm movements.

Mx: Low dose risperidone

High dose risperidone is used in case of tardive dyskinesia.

40. MDMA excessive dose case. Patient has high temperature 40°, Increased CK and dehydration (Neuroleptic
Malignant Syndrome Suspected)

Mx:

First step is to take mechanical cooling measures i.e., ice bath etc.

Second line: Dantrolene ( on top of anticholinergics like glycopyrronium etc) – not alone.

41. Birch Fruit Syndrome : Corresponding seasonal asthma and allergic rhinitis . Allergic to uncooked proteins for
instance in apple, kiwi , cherry , plum , pear , strawberry, carrot , apricot…….

Mx : Oral Anti-histamines

42. Eczema management includes emollients and steroids . Most useful advice to give to eczema patient?
“Avoid smoking while using emollients as they contain paraffin which may cause burns/fire”.

43. Acute alcohol withdrawal, most appropriate Mx:

Chlordiazepoxide ( if not available then use other BZDs)

Thiamine (B1) is useful in case of chronic alcoholism in order to avoid Wernicke&Korsakoff syndrome.

44. Transcutaneous Liver Biopsy Contraindications:

1) Ascites

2) Platelets < 60 (cut off)

3) INR > 1.6

If liver biopsy is required in case of increased INR , it should be done under FFP cover.

45. RNA splicing occurs in nucleus either immediately before or after transcription. In this process , introns are
removed and exons are joined & pre- mRNA is edited into mRNA.

46. Holmes Adie pupil ( dilated ) occurs due to damage to parasympathetic ciliary ganglion.

Parasympathetic supply to iris and ciliary body occurs via III and synapses at ciliary ganglion. After damage to ciliary
ganglion, re-innervation and up regulation of post-synaptic receptors cause aberrant pupillary reaction to light.

Holmes Adie Syndrome : Dilated pupil + Absent knee / ankle reflexes

47. Scombroid toxin is present in tuna , mackerel , sardine , blue, marlin , herring types of fish ( Poisoning occurs
due to eating fish high in histamine because of improper processing).

Symptoms : Flushed skin , irregular heart beat , difficulty in breathing

Mx : IM adrenaline

Tetrodotoxin in present in puffer fish. (too much fishy )

48.

1) Venous ulcers occur over medial malleoli.

2) In arterial ulcers, there are absent pulses, blue/white discoloration hair loss and delayed venous return. Occur
on lower legs and feet.

3)Neurotrophic ulcers commonly occur on soles.

4) Necrobiosis lipodica diabeticorum: red brown with yellow atrophic center. Typically on shins. Mx : Topical CCS.

49. Out of hospital cardiac arrest , most appropriate next step : CALL FOR HELP !!!!

50. Macroprolactinoma management :

Cabergoline > Bromocriptine ( due to its better tolerance and less adverse effects as compared to bromocriptine )

These ergot derived dopamine agonists are

contraindicated in the retroperitoneal fibrosis and other fibrotic conditions)

Initially managed with Dopamine D2 receptor agonists as dopamine would decrease prolactin levels.
If refractory , surgical resection is done .

&

1) Prolactin levels < 1000 : Drug induced hyperprolactinemia i.e., anti-psychotics, anti-emetics etc.
2) Prolactin levels 1000-3000 : Microprolactinoma
3) Prolactin levels > 3000 : Macroprolactinoma

In hyperprolactinemia , first test should be to exclude pregnancy as it is the most common cause for high prolactin
levels.

51. Neuromyelitis Optica vs Vitamin B12 deficiency :

NMO does not cause any sensory changes like vibration or touch losses.

While B12 deficiency does cause vibration and touch sensation abnormalities and optic atrophy etc.

NMO (Devic's disease) is an autoimmune disorder caused by immunoglobulin G against aquaporin 4 channels.
Affects eyes and spinal cord.

Nephrogenic diabetes insipidus is caused by mutation in aquaporin 2 channels in collecting ducts of kidneys.

52. SAH case , 14 days later patient presents with headache, nerve palsy , bilateral papilledema , neurologically
intact . Suggestive of hydrocephalus.

As in case of vasospasm , neuronal degeneration would occur and there would be no rise in ICP.

53. Muscular dystrophies like Duchenne and Becker's occur because muscle cells lose their ability to regenerate
(Telomere shortening).

54. Sarcoidosis vs TB

Sarcoidosis never causes false +ve IGRA while latent TB gives false +ve IGRA results. Because Interferon- y is
specific for Mycobacterium.

55. Occupational Asthma :

Most appropriate investigation : Twice peak flow measurement ( both in week and at weekend)

56. Freiberg Disease vs Navicular Fracture

Stress or trauma as in high jumpers causes avascular necrosis of 2nd metatarsal head that leads to pain in forefoot.
(X-ray : sclerotic and flattened head)

Navicular fracture causes pain in the middle of foot.

57. Tetanus (trismus , spasms)

Mx:

1. IVIG tetanus ( to delay neurological deterioration)

2. Wound debridement
3. IV Metronidazole

58. Acne roasacea [Dry skin (not greasy) , flushed face, telangectasias etc. ]

Mx:
 1. Topical Metronidazole 0.75% initially (Acetic acid is an alternate)
2. If fails , give brimonidine topically .

59. Sudden Cardiac Death :

HOCM and Long QT syndrome typically manifest during exercise . While Brugada Syndrome leads to sudden death
usually at night in sleep.

If Brugada syndrome is suspected, administring Ajmaline would unmask ECG changes.

60. Olfactory groove meningioma : Loss of smell and taste , blurry vision and headaches.

61. Persistent microscopic hematuria w/o symptoms : (Suspect Transitional Cell Carcinoma)

Dx: Perform cystoscopy first and then go for contrast enhanced CT.

62. ABPA vs Aspergilloma

ABPA occurs due to asthma exacerbations mostly with increased eosinophils and +ve aspergillus precipitate.

Mx : Oral CCS and Itraconazole , if no effect then start Omalizumab .

While Aspergilloma occurs in cavitatory lung diseases like TB. Usually asymptomatic but may cause life threatening
hemoptysis if pulmonary vessels are eroded.

Mx: Itraconazole (long course) & Surgery is required in case of massive hemoptysis.

63. Malingering vs Factitious Disorder (Muchausen's Syndrome) :

Malingering is the intentional production of deception to gain some external incentive i.e., leave, bail etc.

In comparison, factitious disorder involves a person ‘s intentional deceptive action without any external incentive
in sight. It is usually for sympathy and not for any gain.

64. Painter( Left handed) presents with BP discrepancy between two arms and repeated syncope episodes at work
.

Subclavian Steal Syndrome : Due to retrograde blood flow through vertebral artery to supply blood to left arm.
Syncope episodes while on work most likely due to overhead arm movements .

65. In case of organ transplant, HLA match has the biggest impact on rejection chances.

66. Ascending loop of Henle is impermeable for water. And descending loop of Henle is impermeable for ion
reabsorption.

67. Lichen planus : Intensely itchy rash usually on B/L wrists flexor aspects, red white papules , shiny on top and
white streaks are present in oral cavity (inside cheeks)

Mx : For itch : Topical Corticosteroids and for oral lesions corticosteroid mouthwash

68. Right heart border X-ray is obscured , it indicates Right middle lobe consolidation.

69. COPD management :

Aim 88- 92 % Oxygen saturation via 28 % O2 venturi mask. Not more than 92, in order to avoid respiratory failure
type 2.
70. GBS : Albuminocytologic Dissociation ( Increase in CSF protein levels without any rise in white cell count . High
CSF protein level is thought to be caused by widespread inflammation of nerve roots.)

Mx: IVIG >>> Plasma exchange ( because IVIG is easier to administer and increased chances of treatment
completion) IVIG should be given within 2 weeks of symptom onset.

71. Patient with Marfan syndrome has elevated BP .

Mx : Beta Blockers ( Decrease MAP and aneurysm risk),

ARBS

72. Micro RNAs perform the functions of silencing of mRNA and preventing ribosomal binding to mRNA and thus
prevent protein translation.

While protein transcription is regulated by the repressors (which slow down RNA polymerase by occupying the
operator region on DNA) and the activators ( which increase attachment of RNA polymerase to DNA promoter
region).

73. Aortic stenosis patient presents with anemia ( low Hb, low MCV) with normal upper and lower GI endoscopies .

Dx : Small Intestine Angiodysplasia (AS + SI Angiodysplasia constitute Heyde Syndrome.

Anemia is due to tearing of RBCs because of the sheer stress as they pass across the stenotic valve. Coagulation is
also seen due to the degradation of VW multimers because of the same stress . (acquired VWD 2A)

Investigation : Capsule Endoscopy

74. Hepatitis is the necrosis of hepatocytes and not apoptosis.

75. Anal fissure refractory to high fiber diet and fluid intake should be treated by applying Glyceryl Trinitrate .
(GTN)

GTN may cause headaches as a side effect.

76. Patient with dyspepsia , night sweats , weight loss , suspected area gastric antrum , on biopsy there is extensive
lymphocytic infiltration. (atypical)

Dx : H pylori infection that leads to MALTOMA

Mx: 1°- H pylori eradication for MALTOMA and biopsy every three months for response.

MALTOMA H pylori eradication ( 1° - H pylori eradication triple therapy, if fails then give Rituximab + Imatinib)

77. Androgen Insensitivity Syndrome : “ Males in Female Bodies"

XY karyotype with female external genitalia, normal height and little or no pubic hair at all. Bilateral inguinal hernia
is also present during first few life weeks due to the undescended testes. Testosterone levels are often high as
well.

AIS occurs due to congenital abnormality of androgen receptor that leads to insensitivity to androgen .

78. Aortic Stenosis patient is to undergo colonoscopy , no pre-procedure antibiotics are required.

Because in case of valve lesions , no antibiotic prophylaxis is required for dental procedures or procedures
involving gastrointestinal and genitourinary tracts.

79. Vitamin D :
1. Increases Ca and phosphorus gut absorption

2. Enhances enterocytes differentiation

3. Positively affects muscles strength

4. Supports PTH in Ca regulation

5. Regulates osteoblasts function and PTH induced osteoclasts activity and bone resorption

80. Most common primary immunodeficiency is IgA deficiency. AND most common IgG variant is IgG-1.

81. Loops decrease preload while BB decrease afterload.

82. Hyperparathyroidism ( old male with Ca 2.95 , constipation, increased Cr, pains, nocturia)

Mx: Para-thyroidectomy

Indications :

Ca > 2.85

Symptomatic hypercalcemia (bones, moans , groans etc.)

Organ involvement like kidney stones etc.

83. Cluster headache prophylaxis is done by Verapamil unless heart failure or Left ventricle dysfunction is present.

84. Most important parameter to determine the severity of ulcerative colitis is the Stool Frequency .

TrueLove -Witts Criteria :

=<4 → Mild

4-6 + systemic symptoms → Moderate

> 6 + systemic upset → Severe

85. Most reliable diagnostic predictor of Obesity Hypoventilation Syndrome is elevated serum bicarbonate level
(>27) , even more sensitive and specific than high BMI (>37).

86. Complex partial epilepsy management in Han Chinese patient : Levetiracetam

Usually partial epilepsy is treated with carbamazepine but in Han Chinese population drugs like carbamazepine and
oxycarbamazepine cause Steven Johnson Syndrome most of the times.

87. Graves disease management involves combination of Carbimazole & Thyroxine ( Block & Replace).

As carbimazole may lead to hypothyroidism if used alone and propylthiouracil may worsen eye symptoms.

88. In pneumonia , SpO2 decreases due to the intra-pulmonary shunts.

89. Stroke:

No ICH within < 4.5 h , Mx = Alteplase

No ICH and 4.5 to 6h , Mx = Alteplase

No ICH and >6h , Mx = Aspirin

90. Salmeterol is a partial B2 agonist and more lipophillic as compared to salbutamol.

91. COPD management , refractory to inhaled salbutamol, no asthmatic features present. Next step would be to
add LABA + LAMA ( these would decrease exacerbations frequency and hospital admissions)

92. Cystic fibrosis treatment drugs like Lumacaftor and Ivacaftor work by opening CFTR channels and increasing
their conductance activity.

93. Afro- Caribbean diabetic patient has high prick glucose but low/normal HBA1C.

The reason for this discrepancy is sickle trait that is prevalent in that population.

Sickle trait leads to hemolysis ( in some) , recurrent hematuria and renal impairment. Chronic hemolysis leads to
decrease RBC lifespan that limits glycosylation time and thus decrease HbA1C.

94. Returned from Himalayas , changes in CBC?

Increase in Hct ( as chronic hypoxia due to high altitude leads to compensatory changes to increase Oxygen
delivery to tissues. This is achieved by increased HIF-1 Alpha levels that increase RBC production.

95.Most reliable indicator for future suicide attempt risk :

Suicide Note >>> Self-harm wounds

96. Hypercalcemia ( Nausea , vomiting , drowsiness , anorexia , etc.)

Mx : IVF (Normal saline) -1° ( Dehydration and osmotic diuresis increase Ca levels , therefore, IVF would decrease
it.)

IV bisphosphonate/calcitonin – 2° ( if hypercalcemia is due to carcinoma then Iv pamidronate)

97. Hypoparathyroidism vs Pseudohypoparathyroidism vs Pseudopseudohypoparathyroidism

Hypoparathyroidism has low PTH , low Ca , low phosphate and high Alkaline phosphate levels. In comparison,
pseudohypoparathyroidism has high PTH levels due to resistance ( caused by G- protein coupled receptor
mutation) , low Ca , high Phosphate , short stature , round face and short 4th and 5th metacarpals and metatarsals)

Dx : Differentiation between these two is done by cAMP and phosphate levels following PTH infusion:

1) In Hypoparathyroidism both cAMP and phosphate levels rise.

2) Pseudohypoparathyroidism type I (complete receptor decfect) does not show any rise in these two.
3) In pseudohypoparathyroidism type II (intact receptor) , cAMP rises but phosphate does not.

Pseudopseudohypoparathyroidism would have same features but normal lab profile !!!

Moreover , pseudohypoparathyroidism is inherited from mother while psudopseudohypoparathyroidism is

inherited from father.

98. Patient has stable blood glucose control on metformin , monitoring protocol :

As blood glucose level is stable , HbA1C should be done 6 monthly for monitoring purpose. In case of any changes
in treatment, HbA1C needs to be done after 3 months till blood glucose reaches stable level.

99. Stress incontinence , pelvic floor exercises gave no benefit, next step would be duloxetine (as it increase
urethral sphincter activity)
Urge incontinence in 96y old frail lady with bilateral knee replacements , orthostatic hypotension , bladder
retaining attempts failed, next step of importance :

Commode should be preferred over oxybutynin. No urinary catheterization as it would increase the infection risk.

100. Constructional Apraxia occurs due to lesion in frontal lobe.

101. Pupils size difference of 1mm or less with normal light and accommodation reflexes is a normal variant.

102. Single painless ulcer with concurrent lymphadenopathy (inguinal) → Lymphogranuloma venerum

And

Single ulcer with lynphadenopathy ( later up to 6 weeks) → Syphilis

103. Correcting serum Na too fast :

“ From high to low , your brain will blow.(Cerebral edema) From low to high , your pons will die . ( Osmotic
demyelination)”

Correcting hypernatremia too fast would cause relative hypertonic ICF to accumulate water and thus brain cells
would swell leading to cerebral edema.

Correcting hyponatremia rapidly would cause brain cells to shrink as water moves outside the cells and organic
osmotic molecules like glutamate which normally protect against water injury would not be replaced in time. This
would cause central pontine myelinolysis which would cause paralysis.

104. SIADH ( hyponatremia , BP and renal function is normal).

Mx :

1) Restrict fluid intake ( 500 ml approximately)

2) Demeclocycline

105. Functional Residual Capacity : Volume of air left in lungs at the end of passive expiration.

Forced Vital Capacity : Total air exhaled in active / forced expiration.

Peak expiratory Flow : Maximum expiration speed during forceful exhalation.

106. K-sparing diuretics like spironolactone and eplerenone act on Distal Convoluted Tubule.

Spironolactone causes erectile dysfunction and gynecomastia while Eplerenone doesn't cause any.

107. Pregnant patient with chicken pox exposure , VZV antibodies are positive : Just reassurance !

If VZV antibodies are negative then give VZIG .

Give oral acyclovir only when pregnant patient exposed to chickenpox virus presents within 24 h of the onset of
rash.

108. Recurrent vaginal candidiasis Mx: Fluconazole (150 mg – single dose)

Itraconzole is used in esophageal candidiasis and Voriconazole is used for invasive aspergillosis mostly.

109. The most specific ECG change for pericarditis is PR depression. Even more specific than widespread concave
shaped ST elevation. ( PR depression > ST elevation)
Pericarditis gives concave ST elevation across I, III ,aVF, aVL, V2-V6 and ST depression in V1 & aVR. While MI gives
convex shaped ST elevation.

110. Patient taking immunosuppressants should not be given live attenuated vaccines like Varicella , Yellow Fever ,
MMR , live influenza vaccine.

111. In haemotological malignancies like CLL , transfused products should be irradiated ( to deplete donor white
blood cells) . This would decrease risk of Transfusion Associated Graft vs Host Disease.

112. In pituitary hemorrhage , Always replace cortisol before thyroxine as the latter may cause adrenal crisis.

“First cortisol then thyroxine"

113. Wolf – Parkinson Syndrome (Short PR interval , Delta wave )

Mx:

1) Radiofrequency Ablation- long term ( especially in young as long term anti-arrythmics would be required).
Risks involve failure (<5%) and heart block.
2) BB (Not if pre-excital Atrial Fibrillation is present)

114. Brugada Syndrome : Sudden cardiac death especially at night or rest vs other SCD causes like congenital long
QT syndrome .

Autosomal Dominant. Na-channel mutation (>60 mutations). Successful interventions like electrophysiological
mapping & ablation have decreased VT risk.

O/E no significant CVS finding usually SCD occurs in a young person with positive Family Hx who had 1 or 2 syncope
episodes per year .

ECG: Cove ST-T ( ST elevation > 2mm in V1-V3 followed by negative T waves)

Mx : Implantable Cardioverter Defibrillator

(ICD > Amiodarone in high risk of SCD as amiodarone does decrease VT risk but doesn't abolish Brugada.)

DD:

1)Congenital LQTS : SCD due to ventricular arrythmia without any cardiac anatomy changes or QRS morphology on
ECG.

Mx: BB ( by decreasing sympathetic outflow) & if collapse history present then ICD.

2)HOCM : Septal and Left Ventricular Hypertrophy

Mx: BB to reduce angina . ICD in high risk.

115. If Brugada patient on ICD develops frequent ventricular arrythmias then anti-arrythmic of choice would be
Quinidine > Amiodarone due to less toxicity.

Quinidine prevents polymorphic VT by blocking Na inward current and decreasing Vmax of phase 0 .

116. Fibrofatty Right ventricular infiltration : Arrythmogenic Right Ventricle Cardiomyopathy . Over the time
cardiac myocytes are apoptosed and replaced by fibrofatty tissue. Progressive infiltration of RV ensues and
increases ventricle arrythmias.
Leads to SCD. Often Family Hx is positive for SCD.

Mx: ICD in high risk cases.

Otherwise, medical Mx with heart failure medications ( ACEIs, Diuretics) although heart transplant is favourable in
many patients.

117. VT more likely than SVT in :

1) +ve or -ve concordance across chest leads ( with no RS complexes)

2) QRS > 160ms

3) Extreme axis deviation (Northwest) where QRS is +ve in aVR and -ve in I and aVF.

4) Absence of a typical RBBB / LBBB

5) AV dissociation

6) Fusion / Capture beats

7) Hx of IHD

8) -ve response to carotid massage / adenosine

9) Left R wave taller ( RSR complexes with a taller 2nd R wave indicates normal RBBB)

118. In cardiac resynchronization therapy , during pacemaker implantation LV lead is placed via coronary sinus
ostium ( partially covered by thebesian valve ) in Right Atrium.

119. ACS ( ST depression ) resolved with aspirin, clopidogrel and fondaparinaux. Patient develops Atrial fibrillation
during ACS :

Mx: Atrial fibrillation during ACS may be temporary and should be managed with ACS ischemia medications which
are mentioned.

Oral Xa inhibitors and Warfarin are less effective and difficult to reverse in emergency situations.

If Atrial fibrillation persists then Oral Xa inhibitors should be given ( CHADs>1)

120. Biventricular Heart Failure already taking ACEI+ BB + Spironolactone + Statins , heart failure is progressing ,
HR > 88 , EF= 30% , next to add?

Ivabradine ( I (f) channel inhibitor) :

Indication: NYHA II -IV stable chronic heart fail with

1) Sinus HR 75 or more
2) LVEF 35 or less
3) In combination with ACEIs + BB + Aldosterone Antagonist or when BB contra/ in tolerated

121. Atrial fibrillation w/o structural defect : Fleicanide

Atrial fibrillation with structural defect : Amiodarone

122. Right coronary stent passed 4 weeks back, now presented with pain due to Inferior MI with ST elevation in II,
III , atrial fibrillation as patient stopped using clopidogrel.

Dx : Stent Thrombosis
“ Thrombosis occurs earlier than Restenosis”

Although restenosis is more common but it uses takes time to occur (few months) and it isn't related to use of 1 or
2 anti-platelets. While thrombosis usually occurs within first 30 days , So antiplatelets should be continued till 12
months to avoid it.

123. Pulseless VT cardiac arrest , fifth CPR cycle completed , amiodarone 300 mg was given after 3 rd cycle .

Now amiodarone 150 mg should be given. Use lignocaine if amiodarone is not available.

124. Primary Pulmonary Hypertension in pregnant patient stable on bosentan and amlodipine , walks up to ½ a
mile without stopping , minor B/L pitting edema on ankles.

Mx : Switch Bosentan to Sildenafil (PDE5-Inhibitor) as in pregnancy Bosentan may cause malformation of head ,
mouth , face and blood vessels. It should be discontinued as pregnancy is confirmed .

On the other hand, Sildenafil is not teratogenic.

Pulmonary HTN in pregnancy : CCBs , PDE5I , Inhaled Prostaglandins

125. Myocardial Infarction ( against chronic cocaine abuse which causes stimulation of alpha receptors in coronary
vasculature ) , though normal troponin but ST depression due to coronary spasm.

Chest Pain Mx : GTN infusion or CCB > BB (due to risk of unopposed alpha stimulation which would worsen the
spasm)

126. Mitral Stenosis in Pregnancy (20 weeks) , Increased SOB , palpitations on exertion , Basal crackles , Atrial
fibrillation, Diastolic murmur , refractory to loop 40 mg .

Next Mx : Percutaneous Mitral Valvotomy

Contra indication : Significant valve calcification or Left atrial thrombus . “Echo should be done before it.”

127. Strongest pointer in Mitral Stenosis for worsened valve stenosis : Hemoptysis due to pulmonary venous
dilation and alveolar hemorrhages due to pulmonary HTN and mitral stenosis.

128. Mobitz – 2 with 2 syncopal episodes management : Dual chamber pacemaker insertion .

129. Atropine 3mg failed , patient in shock. Heart rate 38 , complete heart block , next step in Mx: Transcutaneous
Pacing

130. Rheumatic Fever Surgery Indications :

1) Complete heart block episodes due to paravalvular extension of infection.

2) Moderate to severe symptomatic heart failure

3) Medical Mx given for 1 or more weeks

131. ST depression in V1-V3 : Proximal Descending Artery Occlusion

PDA (Branch of RCA) supplies posterior ventricle walls in 80 to 85% cases.

Widespread anterior ST elevation : Left Anterior Descending Occlusion

132. Hypokalemia : U wave especially in V2,V3 same as T wave directly after it. U wave occurs because of electrical
changes seen due to purkinje fiber repolarisation .
U wave occurs in hypokalemia , hypocalcemia , hypomagnesimia , hypothyroidism , HOCM ,Increased ICP , LVH etc.

Hypercalcemia : J wave ( +ve defect in aVR and V1 , -ve usually)

J wave also occurs in hypothyroidism and in idiopathic cases.

133. Ebstein Anomaly : RBBB ( complete or incomplete, JVP often not elevated though a wave is high)

LBBB: MI , HOCM, AS , Dilated Cardiomyopathy

134. Symptomatic aortic stenosis in 75 years old .

Mx: Bioprosthetic valve replacement . ( If anticoagulants are contra-indicated like in gastric ulcer etc.)

Bioprosthetic > Mechanical

135. Poor night vision , glare , dark adaptation difficult , “Drusen” present – Age Related Macular Degenration (Dry)

“D for Drusen , D for Dry “

136. Thyrotoxicosis : Long acting thyroid stimulating antibodies – Anti TSH receptor antibodies ( stimulate TSH
receptor and act as its agonist)

137. Subacute Thyroiditis ( Dequervain Thyroiditis) : Post-viral infection , painful , hyperthroid features maybe
present initially .

Investigation : Isotope Scan

“DequerPAIN Thyroiditis"

Toxic Adenoma Mx : Radioiodine ( contraindicated in pregnancy) . If refractory go for partial thyroidectomy.

138. Sudden B/L headache , blurry vision , dizziness and bitemporal hemianopia in pregnant patient .

Dx: Pituitary Apoplexy ( Sudden hemorrhage in pituitary gland in pregnancy especially in 3rd trimester)

IOC : MRI

Mx: Delivery week later under hydrocortisone cover followed by Pituitary function tests.

139. Red papular rash plus louse dirt in pubic region : Pubic Lice

Mx : Malathion/ Permethrin

140. Bells Palsy : Facial nerve LMN lesion w/o brow sparing (involves entire face on the same side) , post-auricular
pain is present . NO RASH .

Mx: Prednisolone

141. Argyll – Robertson Pupil : Small irregular pupil with normal accommodation reflex but absent light reflex .

Also called “Whore‘s Eye “ .

As it is associated with tertiary Syphilis and also because in it pupil accommodates but does not react.

142. Pemphigus Vulgaris Vs Bullous Pemphigoid :

PV : Blisters are flaccid and easily ruptured , painful but NOT itchy and mucosa is also involved.
Auto-immune disorder due to antibodies against Desmoglein – 3 (epithelial cell adhesion molecule )

BP : Blisters are tense , itchy , usually around flexures , no mucosal involvement , blisters are usually sub epidermal
and heal without scarring. Mouth is not involved. More common in elderly.

Autoimmune disorder due to antibodies against hemidesmosomal proteins BP180 , BP230.

Mx: Oral CCS , Immunosuppressants

PV : If refractory to oral Prednisolone and Azathioprine then start IV rituximab as it is more effective in inducing
remission as compared to IVIG and Methotrexate.

143 : Systemic mastocytosis : neoplastic mast cells proliferation

Features : Flushing , abdominal pain , urticaria pigmentosa ( wheal is produced on rubbing - Darier's sign ) ,
monocytosis on blood film.

Dx: Increased Serum tryptase level and urinary histamine level.

144. Conus Medullaris vs Cauda Equina Syndrome vs ASAO:

Conus medullaris syndrome is sudden and bilateral distal lower limb weakness with hypertonia and hyperreflexia (
knee reflex preserved and ankle reflex exaggerated), fasciculations. Sensory loss is symmetrical, bilateral and
numbness is localized to peri-anal region.

Cauda Equina Syndrome : Gradual and may be unilateral leg signs initially. Flaccid paralysis. May be areflexic
paraplegic, may be asymmetric , atrophy more common than fasciculations. Both knee and ankle reflexes are
absent. Radicular pain is more severe. Numbness localized to saddle area, may be asymmetrical.

Anterior Spinal Artery Occlusion : Complete lower limbs paralysis with pain & temperature loss. Usually sudden
onset pain and loss of power and sensations beginning in thoracic region.

145. Horner Syndrome :

Anhydrosis determines the site of location:

Face , Arm , Trunk = Central lesion : Stroke , Syringomyelia, Multiple Sclerosis

Face only = Pre- ganglionic lesion : Pancoast , Cervical Rib, Thyroidectomy , Trauma.

Absent = Post-ganglionic lesion : Carotid artery aneurysm or dissection , Cavernous Sinus Thrombosis , Cluster
headache

146. DKA patient recovered , glucose levels return to normal , able to eat , urine ketone level still positive even
when patient is normal . Reason:

Acetoacetate persists much longer than B-hydroxybutyrate which is rapidly metabolized. It is because of this
acetoacetate that urinary ketones sometimes persist despite patient's stability.

147. Latex allergy Investigation : Skin Patch Test ( +ve : histamine and -ve saline)

RAST is an alternate to Skin Prick test.

148. Basal cell carcinoma ( rolled edges , telangiectasias , slow growth , located at temple ) : Excision with 4 mm
margins.

149. Dermatomes :
T1 : Wasting of intrinsic hand muscles and sensory loss of upper medial arm

C6 : Thumb and index finger

C7 : Middle Finger

C8 : Medial hand and forearm

150. Frontotemporal Dementia Mx : SSRI i.e., paroxetine for behavioral alterations

Avoid donepezil as it would enhance disinhibition . And BZDs would increase agitation.

151. ACEIs are contraindicated in pregnancy due to renal damage. Should be stopped if BP is normal , otherwise
anti-hypertensives like labetalol and methyldopa should be used.

Anti -TNF infliximab : safe in early pregnancy, should be discontinued at 16 weeks or at 2nd trimester end.

152. IgA nephropathy Mx:

If no hypertension or proteinuria: Observe

If proteinuria present : Prednisolone

If HTN +/- proteinuria: ACEIs

153 : DVT patient develops stroke .

IOC: Transesophageal Echocardiography

( to look for Patent Foramen Ovale that has given passage to embolus from venous side to arterial circulation i.e.,
paradoxical embolus)

154. Trigeminal nerve branches foramina: “SRO"

Ophthalmic Nerve : Superior Orbital Fissure

Maxillary Nerve : Rotundum Foramen

Mandibular Nerve : Ovale Foramen

155. HLA matching between siblings : 25% and HLA matching between identical twins is 100%

156. Takotsubo Cardiomyopathy / Broken Heart Syndrome :

Acute and reversible form of heart failure that involves apical ballooning of myocardium , usually transient in
nature and occurs due to emotional or physical stress .

Features involve sudden chest pain , SOB or fainting.

Mx is same as of heart failure.

157. The most important factor in :

Psychiatry & Alzheimer's : Family History

Infective Endocarditis : Previous IE episode

Melioidosis : Diabetes Mellitus

MRSA Prevention : Hand Hygiene

Toxic Shock Syndrome Toxin : Tampon

158. Nephrogenic Diabetes Insipidus :

1) Li causes desensitization of ADH receptors in collecting duct and thus inhibits their ability to respond to ADH
causing NDI.

Mx :

A) Fluid restriction then add

B) Thiazides & then add
C) Amiloride

2)Increased Ca and K levels cause autophagy of aquaporin channels that leads to NDI.

159. Eczema herpeticum : Eczema patient with sudden worsening of blisters especially on hands and feet .

Mx : IV Acyclovir

160. VWD : Autosomal Dominant, Normal PT , APTT may be normal or increased.

161. Alpha 1 Antitrypsin Deficiency ( MZ vs SZ )

MZ : More prone to CLD especially against alcohol consumption . Lung disease only apparent in SMOKERS .

SZ : Lung and Liver both are involved. Lung (emphysema) more likely even in non-smokers.

162.

T-test : Difference between means of 2 data sets in Normal Distribution.

ANOVA: : 3 or more independent groups involved

Kaplan Meier Estimator : Difference in survival curves.

163. Turkey's range test : Means across different populations/ ethnic groups are statistically different .

Vs

Student t-test : Difference in means between 2 sample populations like treat vs control.

164. Parametric tests : follow Normal Distribution ( Mean=Median=Mode) like Student ‘s t-test paired or unpaired
and Pearson's co-efficient.

Non-parametric tests : Don't follow Normal Distribution :

Mann Whitney : unpaired data

Wilcoxon matched pairs : compares 2 sets of observations on single sample.

Chi-squared : compares proportions or percentages.

Spearman’ s co-efficient : Correlation

Mc-Nemar : Determines whether row and column frequencies are equal in nominal data.

165. Student' t-test (Paired vs Unpaired):

Paired : Data obtained from single group of patients like before and after intervention in normal distribution.

Unpaired : Data belongs to 2 different patient groups i.e., control and treatment.

166. Carrier frequency in an area is 1/25 , female cystic fibrosis carrier has partner from that local area , chance of
child with CF?

½ x 1/25 × ½ = 1/100

As

chance of passing defective gene in each = ½

Carrier frequency in that area = 1/25

So,

Chance of child with CF comes to be 1/100.

167. X- Linked Recessive disorders occur in males. Except in condition like (Turner Syndrome : XO) when females
are affected because they have only one X chromosome.

168. Noonan Syndrome is male turner (feature wise) but the karyotype is normal.

169. Mitochondrial Disease inherit via female line ( from mothers) because sperm contributes no cytoplasm to
zygote. No children would inherit if male is affected.

170. Neutropenia without any symptoms or any other abnormality is normal in Afro-Caribbeans and needs no
intervention.

INFECTIOUS DISEASES:

171.Hepatitis B serological markers :

HBsAg -ve and Anti-HBs +ve only : Vaccinated

HBSAg -ve , Anti-HBs +ve and Anti-HBc +ve : Previous infection (resolved and immunized)

172.Infected human bite , gram +ve cocci detected : Strep. anginosus (mouth commensal)

173.Early measles diagnosis needs “Oral Fluid for Measles RNA" (till three days after rash).

Because IgG levels are -ve till 7 days after rash and peak at 14 days after rash resolution. And IgM can be detected
after 3 days of rash onset.
174.Associations :

Bacillus Cereus : Re-heated Rice

Staph. Aureus: Dairy Products

Listeria : Cheese

Legionella : Air-conditioners (Air cooling System)

175.Managements:

A) Chlamydia :

Doxycycline – 1°

Macrolides in pregnancy (Azithromycin 1 g single dose) and test 3 weeks after antibiotics.

Amoxicillin if azithromycin is contraindicated.

B) Gonorrhea :

Ceftriaxone

Macrolides (Azithromycin 2g single dose in penicillin allergics) - not Ciprofloxacin due to resistance .

C) Lyme disease if rash appeared : Doxycycline

D) Legionella : Macrolides (If not in options then Levofloxacin > Doxycycline)

E) Clostridium diphtheria : Azithromycin (Macrolide) or Penicillin

F) Campylobacter: Azithromycin

G) Salmonella : Ciprofloxacin

H) Schistosoma haematobium (Bladder Infection) : Praziquantel (Increases Ca permeability of cell membranes

causing paralysis)

Schistosoma mansoni ( Hepatic Fibrosis)

I)Cyclospora : Cotrimoxazole or Nitazoxanide (if sulphur allergic)

J) Giardiasis : 7 days Metronidazole course or single Tinidazole dose

K) Syphilis: Penicillin , if allergic then Azithromycin 2 gram stat

L) Yersinia (Often B-Lactamase) : Ciprofloxacin, tetracycline or macrolide

176. Projectile vomiting and diarrhea to several people at a time as in nursing homes : Norovirus ( Incubation
Period 24-48h) .

177. Bacillus Cereus Infection : Vomiting (<6h) or Diarrhea ( >6h) , especially after eating reheated rice.

Vs
Staph Aureus Infection : Explosive Vomiting (1-6h) , especially after dairy products.

178. Dog bite , erythema and axillary lymphadenopathy.

Causative Organism : Pasteurella multocida

Mx : IV- Coamoxiclav

Oral Coamoxiclav for prophylaxis and for less severe infection.

Prophylaxis in penicillin allergics : Oral Doxycycline + Metronidazole

If fever and lymphadenopathy : IV Coamoxiclav

179. HIV , umbilicated fleshy papules : Molluscum Contagiosum Virus

Mx : Observe (Supportive if needed)

180. Bullous Impetgio vs Non- bullous impetigo

Bullous impetigo has flaccid bullae with straw fluid leaking out that heal with erythematous base.

Caused by Staph aureus.

Mx: Topical muciprocin / Fusidic Acid

While non-bullous impetigo is caused by Strep. pyogenes and does not involve bullae formation.

181. Chancroid : 1 or 2 large painful ulcers on abrasional areas followed a few days later by “Fluctuating Inguinal
Lymphadenopathy “ .

Caused by Haemophillus ducreyi .

Mx: Azithromycin (single dose ) or IM ceftriaxone

While in HSV there are small vesicles crops intensely itchy with no lymphadenopathy.

And In case of Granuloma inguale, there is a single painless highly vascular lesion.

182. Post-splenectomy , increase in infections by encapsulated bacteria (NHS) like Neisseria meningitidis
Haemophillus influenzae, Strep. pneumoniae as well as malaria occurs.

183. For the earliest detection of HIV, HIV RNA should be given priority over p24 antigen test in a patient
presenting with non-specific symptoms like fever, rash , sore throat for few weeks.

Because p24 has low senstivity as HIV RNA can be detected 5 to 7 days earlier in acute cases.

184. Asymptimatic bacteriuria in pregnancy :

Mx : Nitrofurantoin (except in 3rd trimester) , if eGFR>45 -1°

Fosfomycin or Pevmicillinam -2°

185. Hospital acquired pneumonia S/P hip replacement , due to Pseudomonas:

Mx : Piperacillin+Tazobactam

In mild cases : Oral doxy + metronidazole

If penicillin allergic : IV ciprofloxacin + metronidazole

186. Lady fit and healthy needs malarial prophylaxis before visit to Africa :

Atovaquone/ Proguanil should be given 1 to 2 days before and 7 days after return.

Mefloquine is not first line due to pdychotic side effects.

187. Diabetic foot ulcer with pus and erythema, swab shows aerobes , anerobes and tinea :

Mx: Co-amoxiclav

PHARMACOLOGY:

188.Drugs and associated side effects :

A)Tramadol : Serotonin Syndrome (tramadol has serotonin effects , if used excessively as in depressive patients , it
may lead to high temperature, clonus, hyper-reflexia,hyper-tonia)

B) Mefloquine : Psychosis ( hallucinations, delusions , suicidal thoughts , schizophrenia)

Do not recommend Mefloquine if there is family history of psychiatric illness.

C)Ofloxacin : Nephrogenic Diabetes Insipidus ( due to free fluoride accumulation via ofloxacin metabolism which
activates Gq/11 activation that mediates vasopressin receptor activity.

Other NDI drug causes include Li , Demeclocycline & Orlistat

D)Carbamazepine : SJS (HLA B1502)

E) Valproic Acid : Pancreatitis

F) BB : Worsen Psoriasis , Erectile Dysfunction

G) Ethambutol : Optic Neuritis – Central Scotoma and Red-green color blindness.

H) Sildenafil : Cyanopsia (Blue discoloration of vision due to Phosphodiesterase-6 activation.)

I) Digoxin: Xanthopsia (Yellow discoloration)

J) Verapamil : Constipation

Verapamil is metabolized by CYP3A4 , if given simultaneously with Fluconazole (CYP3A4 Inhibitor ) , this would
enhance verapamil effect and thus constipation.

K) Infliximab : Drug Induced Lupus

L) Spironolactone: Erectile Dysfunction, Gynecomastia While Eplerenone doesn't cause any.

M) Cisplatin : Peripheral Neuropathy

N) Nitrofurantoin: Pulmonary Fibrosis, Pneumonitis, Hepatitis

189. P450 enzyme inducers :

CRAPGPs

Carabamazepine , Rifampicin , Alcohol chronic , Phenytoin , Griseofulvin , Phenobarbital, Sulfonylureas

190.P450 enzyme inhibitors :

SICKFACES.COM

Sulfonamides , Isoniazid , Chloramphenicol, Ketoconazole, Fluconazole , Acute alcohol, Cimetidine ,

Erythromycin, Sodium Valproate , Ciprofloxacin, Omeprazole, Metronidazole

191.P450 subtypes :

CYP-1A2 : Acetaminophen

CYP-2E1 : Ethanol

CYP-2C9 : Warfarin / Coumadin

CYP-2D6 : Cardiac Drugs

CYP-3A4 : Most common

Metabolizes 60% of all drugs , most

among the rest

192. Drug Interactions:

i) Tacrolimus is metabolized by P450 enzyme CYP3A4. If given along with CYP3A4 inhibitors like Clarithromycin or
Fluconazole , they would inhibit its metabolism, , increase Tacrolimus levels which would lead to nausea, vomiting ,
QT prolongation.

Tough Azithromycin is a less potent CYP3A4 inhibitor and can be used simultaneously in extreme cases.

ii) Same goes for verapamil which if given concurrently with CYP3A4 inhibitors like fluconazole , it would increase
verapamil levels and its side effects like constipatio.

iii) Statins if given with macrolides like clarithromycin, it would lead to muscle myalgia and may cause muscle
breakdown in severe cases.

iv) Similarly , grapefruit juice leads to increased statin levels by inhibiting its metabolism.

193.Vincristine inhibits metaphase while colchicine blocks pro-metaphase.

194. PPI along with diuretics increase hypomagnesemia risk.

195. Morphine around 60% is excreted in urine after 24h , if Cr increases or renal clearance decreases then
morphine and morphine-6 sulphate accumulate in body resulting into toxicity.

196. Combination of chemotherapeutic agents is required to decrease resistance chance and to increase the
number of killed tumor cells because of different mechanisms of action.

197. Spironolactone acts as an aldosterone receptor antagonist at distal collecting tubule.

198. Li levels increase in lean patients as in lean body mass distribution volume tends to decrease.

199. Agitation , paranoid and non-compliant young patient with Hx of ecstasy and MDMA intake recently :

Mx: IM haloperidol (If contraindicated: IM Lorazepam )

&

Delirium Mx : Low dose Haloperidol (if pre-existing movement disorder like Parkinson’s disease then give BZD like
lorazepam)

200. Benzodiazepines increase the frequency of gaba channels opening while Barbiturates increase the duration
for which these channels remain open.

PSYCHIATRY :

201. De Clerambault's Syndrome / Erotomania :

Firm but false belief of a person that another individual (often a famous celebrity) is in love with him/her.

More common in females!

Othello : Belief that partner is cheating

Cotard : Belief that he is dead / part is mutilated

Capgras: Belief that other person is replaced/imposter/alien

Fregoli Delusion : Belief that stranger is actually a friend in disguise

202.Schizophrenia features include auditory hallucinations , thought insertion, withdrawal or interruption,

thoughts broadcasting , primary delusional perception , feeling of being controlled (passivity) - Schneider's First
Rank Symptoms.

Patients often use cannabis as a form of self-medication.

Mx : Atypical Anti-psychotics

203.Body Dysmorphic Disorder :

Mx : Cognitive behavioral therapy

204.Mania (Grandiose, Pressured Speech )

Mx : Atypical Anti-psychotics like Risperidone.

205.Managements:
PTSD : Trauma focused CBT or EMDR

Venlafaxine/ SSRI (Sertraline) – 2°

In severe cases, Risperidone

Generalized Anxiety Disorder : Sertraline – 1°

Agoraphobia : Sertraline

Bulimia Nervosa : Trial of High Dose Fluoxetine

Sleep Paralysis : Clonazepam

206. Mental Capacity Act :

Section 5 (2): Allows doctor/psychiatric to detain patient up to 72hours, not in emergency department , if he/she
lacks mental capacity and is not already admitted.

Section 5(4): Gives Psychiatric Nurse power to detain patient for up to 6 hours if he may pose some risk to
themselves or others and seeking for Section 5(2) in the meantime.

207.

Mania : Delusions of grandeur and hallucinations.

Psychotic depression: Delusions related to illness, loss of self-worth.

208. Acute stress disorder : Symptoms onset < 1 month after traumatic event.

PTSD : Symptoms onset > 1 month after traumatic event and last few months.

Post-concussion syndrome: Symptoms start soon (within a few days) + obvious concussion history.

209. SSRI if given with NSAID/Aspirin increase GI bleed risk, therefore, PPI cover should be given.

210. Poor interaction with baby refers to puerperal psychosis as it is very unusual in postnatal depression. And
unlike psotnatal depression, it involves hallucinations as well. Onset within 1-3 weeks after birth and hospital
admission is usually required.

Talking in an incoherent fashion about future and stating that baby has been brought into a very bad world
indicate puerperal psychosis.

RHEUMATOLOGY:

Managements:

211.Ankylosing Spondylitis :

A)“Lower back pain worse in morning , improved by exercise and not by rest especially in young males.”

B)“Limited forward and lateral lumbar spine expansion occurs earlier while reduced chest expansion occurs late.”
Dx: MRI > X-ray (as it may miss earlier changes)

Mx:

A)First line: NSAID and Intensive Physiotherapy

B) Second line Alternate NSAID

C)Then Anti-TNFs if 2 NSAIDs fail(NICE recommends Etanarcept, adalimumab, golimumab etc but not infliximab in
this instance). Pre-check for TB as they may exacerbate dormant TB.

D) Azathioprine (if anti-TNFs fail or not tolerated)

222.Rheumatoid Arthritis:

Most important initial investigation for hand changes in Rheumatoid Arthritis : Color Doppler > MRI

Mx:

Initial management: DMARD monotherapy +/- steroid

After 2 DMARDs , give biological agents ( Anti-CD20, Anti-IL6 inhibitors,Anti-TNF etc)

2 DMARDs --> Anti- TNF --> Tocilizumab(anti-IL-6) --> CTLA4 inhibitor ( Abatacept etc)

223. Palindromic Rheumatoid Arthritis:

“Complete" recovery between attacks & No joint damage .

Mx : Hydroxychloroquine

224. Psoriatic Arthritis:

A) Two DMARDs initially

B) If resistant, Anti TNF ( golimumab etc) for 12 weeks

C) If fail try alternate Anti-TNF (adalimumab etc)

225. Osteoarthritis:

First line : Paracetamol (Add topical NSAID ONLY IF knee or hand is involved. Otherwise no need for it.)

Second line: Oral NSAID / COX-2 inhibitor . Give PPI for the side-effects. Avoid these agents if patient is on apirin.
Opioids/ intra-articular steroids are other alternates

226. Reactive Arthritis :

“Whether post dysentery or post genitourinary infection, no organism can be detected on the joint aspirate in case
of reactive arthritis. “

Mx:

First line: Oral NSAIDs (Not antibiotics)

Second line : Steroids

If still refractory , start DMARD therapy.

227. Pregnancy and anti- rheumatic agents:

Contraindicated: Methotrexate , Cyclophosphamide, Mycophenolate Mofetil

Azathioprine is safe in pregnancy for both SLE and IBD cases. Though less effective in lupus nephritis but carries
less risk as well.

If it fails, try cyclosporin (anti-IL2) in pregnant patients. Although it may cause premature birth and decrease birth
weight but it is not TERATOGENIC.

228.Anti – GBM : Pulmonary hemorrhages plus kidney impairment with NORMAL ESR ( as compared to increased
ESR in vasculitides).

Mx: Plasma Exchange

229. Inflammatory arthritis like Rheumatoid Arthritis involves the lateral or non-weight bearing portion of joint
while OA involves the medial or weight bearing portion of joints mostly.

230. Systemic Sclerosis :

A)Most common antibody : ANA

B)Most specific antibody for

i)Diffuse systemic sclerosis: Anti-scl 70

ii)Limited Systemic Sclerosis: Anti-centromere.

231. Systemic Sclerosis causes Small Intestine Bacterial Overgrowth (SIBO) syndrome indicated by disordered GIT
motility .

Dx: Hydrogen Breath Test

Mx: Rifaximin , Metronidazole or Tetracyclines.

232. Lateral Epicondylitis vs Radial Tunnel Syndrome :

Lateral epicondylitis pain is localized to the lateral epicondyle and is worsened by Supination of forearm with
elbow extended.

While Radial Tunnel Syndrome pain is 4 to 5 cm distal to the lateral epicondyle and it gets worse by Pronation of
forearm and extending the elbow.

LESS : Lateral Epicondylitis, Supination, Straightening of elbow

233. Proximal median nerve injury V/S Distal median nerve injury (at wrist)

Distal median nerve injury causes thenar wasting plus sensory loss at finger tips (lateral 3.5) with NO sensory loss
over thenar eminence. While proximal median nerve injury also causes sensory loss over thenar eminence in
addition to other changes.

234. Pain at the snuff box indicates scaphoid fracture.

Pain and swelling at thumb base that is worse on pinching and worse on ulnar deviation indicates Dquervain
Tenosynovitis.

235. Gout patient on allopurinol 300 mg/day has recurrent attacks despite naproxen. Most appropriate would be
to start Benzbromarone ( uric acid transporter 1 inhibitor and non-competitive inhibitor of Xanthine Oxidase).
Febuxostat is alternative to allopurinol in case of intolerance. And colchicine is used in acute Mx when NSAIDs or
CCS are ineffective. Raspburicase is important in hametological malignancies to avoid to tumor lysis syndrome and
thus increased urate levels due to chemotherapy.

236. Allopurinol and Febuxostat both are XOI and thus increase 6- Mercaptopurine levels, therefore may cause
bone marrow suppression and neutropenia. Therefore, must be avoided if patient is taking azathioprine. While
benzbromarone is relatively safe with concomitant azathioprine use.

237. Polymyalgia Rheumatica ( shoulder/hip pain , morning stiffness > 45 minutes , high ESR)

Mx: Prednisolone 15 mg daily for 3 weeks. If refractory, increase dose to 25 mg.

Temporal arteritis Mx involves higher prednisolone dosage (60 mg).

238. Young lady presents with Oligoarthritis , intermittent fever episodes , Hepatosplenomegaly , Trunk rash , -ve
ANA , -ve RF :

Dx : Adult Onset Still Disease

Mx : NSAIDs, CCS , if fail Methotrexate can be used as a steroid sparing agent. Anakinra (Anti- IL-1) , Tocilizumab
(Anti-IL6) can also be used as alternatives to methotrexate in case of systemic disease.

239. Denosumab : RANK ligand inhibitor that inhibits osteoclasts activity and pre-osteoclasts maturation into
osteoclasts thus down regulate bone resorption in this way.

Used in the osteoporosis treatment when 2 bisphosphonate are already used and failed. It is administered via S/C
injection every six months. T-score criteria is the strictest for it . (T= -3.5)

240. Single ,red, hot and tender joint : most useful investigation : Joint Aspiration ( because of suspected septic /
gout / pseudo gout arthropathy .

241. Unilateral joint pain , decreased movements and isolated high Alkaline phosphate:

Dx : Paget's Disease.

Next investigation: Joint X-ray

242. SLE Antigens :

With dry eyes , mucus membranes : Anti - Ro

SLE in mother and neonate develops complete heart block : Anti- Ro

SLE in pregnant patient with venous thrombosis : Anti-phospholipid Antibody

SLE active disease assessing parameter : C3

243. Sjogren's syndrome investigation of choice : Labial gland (Lip) Biopsy

244. Disorders and Causes:

Marfan Syndrome : Fibrillin I

Beals Hecht Syndrome : Fibrillin II

Epidermolysis Bullosa : Laminin V

Alport Syndrome : Collage IV

Ehler-Danlos Syndrome: Collagen V

245.Agents of specific choice:

• SLE
1) If skin and joint predominant : Hydroxychloroquine first line
2) If life threatening/drug induced/ cerebral : Cyclophosphamide
• Discoid SLE: Topical corticosteroids then Hydroxychloroquine

HCQ should be avoided in psoriasis due to exfoliative dermatitis risk.

• Lupus nephritis : Mycophenolate Mofetil > Cyclophosphamide (T cell modulator)

Especially in young females (Because MMF reduces Ovarian Carcinoma risk and it is safe to use as well.)

• Behcet (B51) : Prednisolone then add azathioprine if uncontrolled

If can't take prednisolone and patient has extensive genital ulceration then give Colchicine.

• Ulcerative colitis fails on oral mesalazine + oral steroids then add azathioprine.

But in case of refractory colitis : Give cyclosporin or infliximab if cyclosporin is unsuitable.

• Thyroid eye disease: Corticosteroids (Prednisolone)

Second line: If resistant prefer Tocilizumab over Rituximab

• Rheumatoid Arthritis & Psoriatic Arthritis : Methotrexate is the DMARD of choice

• Good Pasteur syndrome: Methylprednisolone plus Cyclophosphamide (IV in case of vomiting)

• Minimal change disease : Prednisolone then cyclophosphamide

• Membranous Glomerulonephritis:
1) Prednisolone + cyclophosphamide( in severe cases)
2) ACEI/ ARBs (decrease proteinuria and increase prognosis)
3) Anticoagulants

• Dermatomyositis:
Prednisolone and then add azathioprine in severe cases

• Myasthenia Gravis:
1)Initially Pyridostigmine ( short acting agent)
2)Then immunomodulators if symptoms continue: First prednisolone then azathioprine in refractory
cases.

Rivastigmine is a long acting acetylcholinesterase inhibitor used in Alzheimer.