Differentiating tests:

Central Vs nephrogenic DI Desmopressin acetate replacement test: inject ADH? à if urine osmolality doesn’t
increase è patient unresponsive to ADH à DI
Familial hypocalciuric Look at urine Ca: in FHH there will be no calcium in the urine (parathyroid and
hypercalcemia Vs kidney always think Ca is low, so PTH is high and kidneys reabsorb Ca2+
Hyperparathyroidism
Cushing’s disease or High dose dexamethasone test: if cortisol remains high = ectopic ACTH secretion
ectopic ACTH secreting
tumor:
Grave’s disease from Autoantibody testing: Anti -TSH receptor antibodies positive in graves’ disease
other causes of
hyperthyroidism
COPD & Asthma Asthma has higher peak volume
difference Bronchodilator test à ratio will improve in asthma?
For COPD the ratio remains the same despite the bronchodilator
Primary sclerosing
cholangitis Vs Primary
Biliary Cirrhosis?
ANGINA vs. NSTEMI + troponins in NSTEMI & STEMI only
Tb Vs Lung abscess Assess sputum to rule out TB (Exclude: dental carries)

Gold standard in diagnosis:

Diabetes Insipidus 1. Water deprivation test: used to confirm diagnosisà patients with DI
will have high urine volume and the urine will be dilute despite fluid
deprivation
2. Give an injection of desmopressin (a synthetic analogue of ADH) after
water deprivation to distinguish between central and nephrogenic DI
Hypercalcemia Measure PTH:

Addison’s disease Short synachten test: 250 mcg IV or IM of an ACTH analogue à cortisol
levels don’t rise in adrenal insufficiency
Cushing disease 1. 24h urinary cortisol
2. Low dose dexamethasone suppression test (0.5 mg every 6 h for 2 d)
 Acromegaly • Obtain IGF-1 levels (initial screening tool)
• Oral glucose tolerance test (confirmatory) à normally GH levels are
suppressed by glucose thus a small glucose load is given and serial
measures of GH are obtained à in px w/ acromegaly glucose loads
fail to suppress the excessive GH

Neuroendocrine tumors • Free plasma metanephrines

• Other: 24-h urinary catecholamines, Chromogranin A • Tumour localisation
by – CT or MRI scan – MIBG scan – PET/CT
Insulinoma 72h fast à Insulin levels should fall as the patient becomes
hypoglycaemic, but in insulinomas the level stays the same
or is increased compared to baseline
Pyelonephritis Ultrasound 1st line

CT to confirm (striated parenchymal enhancement)

Hydronephrosis & US
pyelonephritis
Renal stone 1. Non contrast CT-KU B(kidneys, ureters, bladder)
2. Blood test, urine dipstick, screening

IgA nephropathy Renal biopsy showing mesangial deposition of IgA

AKI Any of the following criteria:

- A rise in serum creatinine of ≥26.5 micromol/L within 48 hours

- A ≥50% rise in serum creatinine known or presumed to have occurred
within the past 7 days/an increase of 1.5-fold from baseline
- A fall in urine output to <0.5ml/kg/hour for >6 hours in adults and >8
hours in children and young people
- A ≥25% fall in eGFR in children and young people within the past 7
days

Ectopic pregnancy Initial investigation: urine hCG

Diagnosis: transvaginal ultrasound

Cholelithiasis US of the abdomen
(Gallstones -
gallbladder)
CKD Assess GFR & ACR

AIN Renal biopsy = definitive diagnosis

Barrets esophagus GI endoscopy w/ biopsy

Hiatal hernias Barium Swallow

Coeliac disease 1st line investigation: Total IgA + anti tissue Transglutaminases

IgA anti-endomysial and IgG anti-gliadin may be used as alternatives.

Diverticulosis Contrast CT best modality of choice to look for abscess formation or
active inflammation

Angiodysplasias Confirmed by angiography

Perforated esophagus – Chest Xray – air in mediastinum

Boerhave
Appendicitis CT: distended appendix , peritorneal free fluid, appendiceal abscess

Cholelithiasis US

Cholecystitis US or cholescintigraphy (HIDA) scan

Pancreatitis diagnosis 2of3:

Acute epigastric pain radiating to back, increased serum amylase /lipase or

characteristic imaging findings
Cholangiocarcinoma Diagnosis is made on imaging – CT or MRCP

Splenic rupture ultrasound or draw a sample of fluid from your abdomen with a needle à
check for bleeding in the abdomen
Asthma Spirometry: 1st line test à reversibility with bronchodilators increases the
likelihood of asthma diagnosis

Challenge testing: confirm the diagnosis (histamine or methacholine )

COPD Spirometry is the best initial test for COPD

Bronchiectasis Chest x-ray

High resolution CT (Gold standard investigation to diagnose the disease

and assess severity)
ARDS Utilising pulmonary capillary wedge pressures as a diagnostic tool is
extremely helpful. An elevated PCWP suggests cardiogenic pulmonary
oedema, while a lower PCWP may help indicate ARDS.
MI à In first 6 h: ECG = gold standard

Aortic Dissection Transthoracic Echocardiogram (TTE) or CT

Boerhave CT is the confirmatory diagnosis

Idiopathic pulmonary Perform high-resolution CT of the thoraxè gold standard investigation

fibrosis may demonstrate a ‘ground-glass appearance’

Chronic cough Sinus imaging

investigations
 Nasopharyngoscopy

Allergy evaluation
Foreign body inhalation Bronchoscopy (Diagnostis and therapeutic)

Chest Xray is normal usually

Lung Cancer Chest X-Ray (diagnosis) à coin lesion, hilar enlargement or pleural
effusion)

Gold standards in treatment:

Acromegaly 1st line: transsphenoidal resection

If unfit for surgery à somatostatin analogues (mimic GHIH)
GH receptor antagonists
Radiotherapy (last resort)
Addisonian crisis hydrocortisone
Hypocalcemia Emergency: Administer IV calcium gluconate
mainstay of treatment outside the emergency setting is calcium and
vitamin D replacement
Primary Surgical removal of PTH is 1st line
hyperparathyroidism
DKA (p.185 med in a 1. Fluid replacement
minute) 2. Insulin administration

Insulinoma Surgery
Hypoglycemia 1. If patient is alert, offer an oral or liquid source of glucose
2. If the patient is drowsy but has an intact swallow, buccal Glucogel
may be offered
3. If the patient is unconscious, or has impaired swallow, obtain
prompt IV access and treat with 125ml of 20% dextrose or 250ml of
10% dextrose
Alternatively, 1mg of glucagon may be used as an intramuscular
injection

* Glucagon has poor efficacy in patients with hypoglycaemia who also

have a background of liver disease or alcohol excess.

Phaeochromocytoma Surgical resection (open or laparoscopic)

à treatment with an α-adrenoceptor blocker (phenoxybenzamine)
before surgery èminimizes the likelihood of severe intraoperative HTN
A β-adrenoceptor blocker (propranolol) can be added to control the
pulse rate. However, it should never be used alone as β-adrenoceptor
blockade without concurrent α-adrenoceptor blocker may lead to
severe hypertension
Usually advised to "salt load" patients prior to surgery in order to avoid
severe hypotension once the tumour has been resected
 2nd degree heartblock – When symptomatic IV atropine , permanent pacemaker
Mobitz type 1 aka
Wenckebach block
Renal stone 1. 1st line treatment: NSAIDS & IV fluids
2. Intervention depends on size of stone (>1cm=lithotripsy)
Minimal change disease Corticosteroids
Upper GI bleed 1. High Flow O2
Simple pneumothorax Aspiration 2nd IC space midclavicular line à then chest tube insertion
TP Needle decompression
- Aim: release air from pleural spaceà equilibrate pressure between
pleural space and atmosphere
- Insert a large-bore (14-16G) needle with a syringe into 2nd intercostal
space, midclavicular line OR 4th -

5th interspace anterior axillary line, on side of suspected pneumothorax

2. in affected side, once patient is stable.

- Restore negative pressure and allow lung to re-expand and re-seal.

Eosinophilic asthma Highly responsive to inhaled corticosteroids (+ trigger avoidance)

Pneumonia C: confusion

U: urea> 7

R: RR>30

B: BP < 90/60

65: Age > 65

0-1: Outpatient – antibiotics

2: Inpatient

3: ITU
TB 1. ISOLATE
2. XRAY
3. SPUTUM SAMPLE (AT. LEAST 3) à ZIEL NEELSEN acid fast
bacilli

Medication or other associations w/– certain conditions:

Lithium Diabetes Insipidus (low sodium, high calcium)

Hypothyroidism
Demeclocycline used to treat Diabetes insipidus (demeclocycline reduces the efficacy of ADH
SIADH at the collecting duct as a SE)
Thiazide diuretics Hypercalcemia
Struma ovari Ectopic thyroid hormone secretion
Small cell lung cancer Ectopic ADH [SIADH] & ACTH Secretion [Cushing’s]
Renal cell carcinoma Ectopic ACTH
Squamous cell lung cancer Ectopic PTH secretion
 Inferior MI Inferior MI might cause à 1st, 2nd (Mobitz I) or 3rd degree AV
block
Anterior MI 2nd (Mobitz II) or 3rd degree
LBBB
Lyme disease 3rd degree Heart Block
B lactams, NSAIDS Acute Interstitial Nephritis
Primary sclerosing Ulcer>>???
cholangitis
NSAIDS, Penicillin Membranous Nephropathy
Renal cell transplant SCC of skin
ACE inhibitors Renal artery sclerosis
Autoimmune gastritis Associated with autoimmune thyroid disease, Addison’s, T1DM
Postnasal drip Chronic rhinosinusitis, allergic rhinitis, GOERD
Dry cough > 8 weeks with sensation smth stuck in throat
ACEIs Dry cough (may persist 1-2 w after cessation) à Replace with
ARB

Emergency situations & Common presentations

:
Hyperthermia + arrythmia + altered mental
status
Hypothermia + seizures + altered mental status Myxedema coma
Hyperglycemia + ketonemia + acidemia
Dehydration + hyperglycemia +
hyperosmolarity + hypovolemia in the absence Muscle cramps and confusion, weakness,
of significant ketoacidosis
Thyrotoxicosis
Treatment:
- Fluids + cool down patient
- B blockers & Antithyroid agents
(propylthiouracil)
- Iodine (inhibits further hormone production)
-
Treatment:
- IV levothyroxine & steroids
- Ensure px is warm
Diabetic ketoacidosis (more common in young
& undiagnosed)
Rapid onset: abdominal pain + vomiting, fruity
breath, Kussmaul respiration, reduced
consciousness
Hyperosmolar Hyperglycemic state (HHS):
weight loss, p[polydipsia, polyuria

Hypercalcemia bone pain, nephrolithiasis, abdom- inal pain,

pancreatitis and depression (bones, stones,
moans and abdominal groans)

Hypocalcemia muscle twitching, lethargy, muscle spasms,

psychosocial changes and a prolonged QT
interval

Trousseau & Chvostek’s

Cushing’s disease Suprascapular fat pads, abdominal striae,
depression, truncal obesity and easy bruising

Pheochromocytomas Headache Excessive sweating Palpitations

Treatment resistant hypertension Anxiety Pallor
Chest pain Glucose intolerance with elevation of
 blood glucose Increased metabolic rate with
weight loss

Right axis deviation RBBB, RV hypertrophy, Conditions that strain

right heart (PE, lateral MI)

Left axis deviation LBBB, LV hypertrophy, Conditions that strain LH

e.g. HTN, Inferior MI

RCA occlusion II, III, aVF

LAD V1-V4
LCA I, aVL, V5, V6
Tall QRS complex LVH
QRS complex alternates in height Cardiac tamponade
Sokolow Lyon criteria for LVH S wave in V1 + R wave in V5 or V6 > 35 mm =
LVH
Hypotension + JVD + muffled heart sounds Becks triad à Cardiac tamponade
P wave tall RAE

P wave is bifid LAE

Tall T waves & short QT &small P waves + wide Hyperkalemia
QRS
ST elevation/ depression + T wave inversion in STEMI/NSTEMI
>2 contiguous leads

ST elevation (saddle shape) & PR depression PeRicarditis

T wave inversion (V1,V3) + Right axis deviation Pulmonary Embolism
Constantly prolonged PR interval 1st degree heart block
Constantly prolonged PR until a beat drops 2nd degree- Mobitz type I AKA Wenckebach
Dropped beat without prolongation in PR 2nd degree HB Mobitz Type II
interval
QRS>120 ms + M shaped QRS + Wide slurred S RBBB
wave in lateral leads MaRRoW= M in V1, W in V6
QRS >120 ms + Dominant S wave V1 + broad R LBBB
wave in lateral leads + absence of Q waves in
lateral leads + prolonged R wave peak time WiLLiaM= W in V1, M in V6
dysuria, frequency, suprapubic pain, cloudy strong- Cystitis
smelling urine
Fever/rigors + loin pain + malaise Pyelonephritis

+ costovertebral angle tenderness and or

nausea/vomiting
Urine dipstick: UTI suspicion:
Positive for leukocyte esterase àintermediate chance of UTI
Positive for nitrates àUTI very likely irrespective of leukocyte
esterase level
• Sudden loin to groin pain (renal colic) Renal stone
• Pain radiating to the labia or scrotum
• Haematuria, dysuria or urinary retention

Proteinuria > 3.5 g /day or urine protein:creatinine Nephrotic syndrome

ratio >300mg/mol
+ hyperlipidemia +hypoalbuminemia + oedema
Normal light microscopy + effacement of foot MCD
processes
IgM,C3,C1 deposition FSGS
IgG deposits + spike and dome pattern & diffuse Membranous nephropathy
capillary and GBM thickening
Hematuria + HTN + Proteinuria with oedema Nephritic syndrome
(periorbital/pulmonary)
Visible hematuria a few days after URTI IgA nephropathy / Berger disease

1-2 weeks after URTI à Post Streptococcal

Glomerulonephritis
Increased anti-streptolysin O titer and decreased PSGN
C3 levels
IgG, IgM and C3 deposition à lumpy bumpy
appearance
Glomeruli enlarged and hypercellular
Hematuria + hemoptysis + linear IgG deposits on Goodpasture syndrome (anti-GBM antibodies)
biopsy to type IV collagen
c-ANCA = PR3 ANCA Granulomatosis with Polyangiitis aka Wegener
Granulomatosis
p-ANCA = MPO ANCA Microscopic polyangiitis, Churg Strauss
syndrome
Proliferation of mesangial cells + BM thickening Membranoproliferative glomerulonephritis
*Associated with SLE
haematuria and progressive pro- teinuria, Alport syndrome (Type IV collagen defect – X
sensorineural deafness and lens abnormalities linked recessive)
(e.g., cataracts and lenticonus – a spherical
projection of the lens anteriorly or posteriorly)
Fever + eosinophilia+ rash Acute Interstitial nephritis
• Uraemia – general malaise, lethargy, pruritus, AKI
paresthesia, altered mental state, pericardial
rub, pale skin
• Hyperkalemia – palpitations, chest pain
• Acidosis – Kussmaul breathing, confusion
• Fluid overload – peripheral oedema,
breathlessness, raised JVP
Arrythmia 72 h after MI VT
Pericarditis 2-3 weeksafter MI Dressler syndrome
S3 and gallop rhytm CHF

Wheezes/Crackles + low pitched wheezing + bronchiectasis

clubbing + airway thickening
Hoarse voice + miosis+ amhydrosis + ptosis Pancoast tumor
Telangiectasia + central ulceration Basal Cell carcinoma
+ raised pearly edges
Anti-dsDNA SLE
Anti-d
BORROWS MORPHOLOGY Scabies
Marked central clearing Lyme disease
Jaundice + pain + fever Ascending cholangitis (­GGT & ­ALP)
*ALP elevated when bile duct is involved
Jaundice + pain Choledocholithiasis (­GGT & ALP)
Jaundice + palpable gallbladder Pancreatic cancer (­GGT & ALP)à Courvoiser
sign
Granular casts Acute Tubular Necrosis
pruritus, polyuria, oedema, fatigue and muscle CKD symptoms
weakness)
Fever + rash+ pyuria (eosinophils) + hematuria + Acute Interstitial nephritis (5P’s hypersensitivity-
CVA tenderness haptens)
- Uraemia – general malaise, lethargy, pruritus, AKI
paraesthesia, altered mental state, pericardial
rub, pale skin
- Hyperkalaemia – palpitations, chest pain
- Acidosis – Kussmaul breathing, confusion
- Fluid overload – peripheral oedema,
breathlessness, raised JVP

- Prolonged PR interval

Flank pain + hematuria + palpable mass RCC (Renal Cell Carcinoma)

NO FEVER!
Coffee gorunf hematemesis Post stomach
Frank hematemesis Pre stomach
High UREA normal creatinine SEVERE UGB
Acanthosis nigricans & Leser Trelat sign Gastric cancer

Rectal sparring Crohn’s (usually terminal ileum + colon)

Left Iliac Fossa pain + Fever Diverticulitis
Atrial Fibrillation Can lead to Acute Mesenteric Ischemia

Embolic occlusion of SMA Acute Mesenteric Ischemia

Red currant jelly stools
Coffee bean sign on X-Ray Volvulus (Midgut = Minoirs, Sigmoid =
Seniors)
Apple core on barium enema X-Ray Colon cancer

• Steatorrhoea or diarrhoea Chronic pancreatitis

• Decreased appetite
• Weight loss

V/Q > 0.8 PE

V/Q < 0.8 Asthma

FEV1/FVC < 0.7 Obstructive (asthma, chronic bronchitis,

emphysema and bronchiectasis are
obstructive respiratory )

Both FEV1 & FVC are low

FEV1/FVC >0.7 RESTRICTIVE (pulmonary fibrosis,
sarcoidosis, neuromuscular disorders)

FVC reduction is greater than FEV1

low DLCO fibrosis

Wheeze, breathlessness and cough, particularly Bronchiectasis

with copious amounts of purulent sputum
produced

Coarse inspiratory crepitations and finger

clubbing may be present in some cases

Batwing appearance + Upper Lobe Diversion Chest X-ray in HEART FAILURE

Hampton Hump & Fleishner sign Pulmonary Embolus on CT

Diastolic decrescendo murmur= aortic insufficiency Aortic Dissection

AKA regurgitation

Inter-arm SBP discrepancy >20 mmHg

Muscle weakness Metabolic alkalosis (LAVA UP)

• Myalgia
• Cardiac arrhythmias • Hypoventilation
Patients generally present at an older age Idiopathic Pulmonary Fibrosis
• Persistent, progressive dyspnoea that is worse on

• exertion

• Cough

•Finger clubbing may be present

• Bilateral inspiratory crackles on auscultations
• PFTs demonstrate a restrictive type pattern in IPF
RHF

LHF

Cardia Tamponade

Pericarditis

MI

RBBB

LBBB

Atrial Flutter

Atrial Fibrillation

Ventricular Tachycardia

Ventricular fibrillation

Eosinophilic asthma FeNO: exhaled nitric oxide test, in patients

with allergic or eosinophilic asthma, is a way
to determine how much lung inflammation is
present
Pancoast tumor Horner’s syndrome(due to compression of
superior cervical ganglion): ptosis, miosis,
anhidrosis
Extra manifestations of TB arthritis, meningitis, Pott spine(, back pain,
tenderness, paraplegia or paraparesis, and
kyphotic or scoliotic deformitie), erythema
nodosum and finger clubbing

Finger clubbing Bronchiectasis

Bronchial cx (weight loss)

IPF
 TB??

Lung abscess
Cor pulmonale RHF due to Lung problem (e.g.
bronchiectasis)

­JVP, Loud P2 = RVH & R ventricular heave

Bronchiectasis à Pulmonary HTN à RHF

Signs:
Chvostek’s
Trousseau
Murphy’s sign Respiratory arrest on RUQ palpation à cholecystitis w
Boa’s sign
Mc burneys point
Mackler triad Retching/vomiting + chest pain + subcutaneous emphysema è
Boeerhave syndrome (esophagus perforation)

SC emphysema with crunching sound

(Hamman’s sign)

Charcot’s triad Ascending cholangitis:

RUQ pain + jaundice + fever
Courvoisier sign Painless jaundice with palpable non-tender gallbladder
nikolsky's sign top layers of the skin slip away from the lower layers when rubbed
Prehn sign Elevation of testis eases pain
+ Prehn: epididymitis
- Prehn: testicular torsion
Cullen sign peri-umbilical discoloration

Turner sign flank discoloration – grey

- Rovsing's sign: Acute Appendicitis
- Psoas sign:
- positive obturator sign.
Tracheal deviation away from Tension pneumothorax
affected side Increased
percussion note
Reduced air entry/ breath
sounds on affected side

Tb xray findings Nodular shadowing – upper lobe consolidation + hilar/mediastinal

lymphadenopathy + exudative pleural effusion