Disease Clinical Features/Keyword Investigation Treatment

First Best

BREAST
Breast Lumps Smooth margins 1. PE. 1. FNAC. 1. Observation.
2. US (<35yo), 2. Core Biopsy 2. Excision
Mammography (>35yo)
Fibroadenoma Mobile, non-tender US 1. FNAC. 1. Reassure/Review in 3 months
2. Core Biopsy
Breast cysts Smooth, mobile, painful 1. PE. 1. FNAC. 1. Aspiration under US.
(sometimes) 2. US (<35yo), 2. Core Biopsy 2. Excisional biopsy if fluid has blood
Mammography (>35yo)
Fibrocystic disease 1 or > lumps <1cms, 1. PE. >1cm: FNAC/Biopsy 1. Primrose oil, Vitamin B1, B6, B12
watery/bloody discharge 2. US (<35yo), 2. NSAIDS
Mammography (>35yo) 3. Danazol/Tam
Fat Necrosis Previous trauma 1. PE. FNAC 1. Observation.
2. US (<35yo), 2. Excision
Mammography (>35yo)
Intraductal Papilloma Watery/Bloody discharge, 1 duct 1. PE. Breast Ductography, FNAC, 1. Surgery
2. US (<35yo), Core Biopsy
Mammography (>35yo)
Mammary Duct Sticky, toothpaste like green Mammography Ductal lavage (Cytology) Excisional biopsy
Ectasia discharge, multiple points
Phyllodes Tumour Mobile mass that grows rapidly 1. Mammography 1. Wide local excision (Benign)
2. US with core biopsy 2. Simple total mastectomy w/wo
axillary node dissection (Malignant)

DRCCF | ARIMGSAS
 Breast Cancer Dimpling, inversion of nipple, 1. Mammography e/ 2 1. Cytology with core biopsy See notes
ulcers, redness years from 50-74. 2. CT/MRI/Blood to stage
On demand e/ 2 years
from 40-49
Mammography From 40
or 10 years earlier than
youngest Ca member
for high-risk group

CARDIOLOGY
Pulmonary Embolism 1. Chest pain-ECG 1. ABCD/Oxygen/Morphine
1. SOB-CXR 2. LMWH. If renal dx Unfractionated.
1. Pregnancy (Doppler If shock-Thrombolysis
USD of legs)
2. Low Wells-D dimer.
High Wells-CTPA/V/Q

Pulmonary Oedema Wheeze (Kettle boiling) 1. CXR Arterial/Venous Blood 1. O2

Endocarditis Fever (Most common), new
murmur (AI-most common),
Osler's nodes (toes/fingers),
Petechiae
Gases to assess severity of
hypoxaemia
1. Blood culture 1. Transesophageal echo
- If HACEK-CT angio
- If arrythmias-ECG
- If spread CT/MRI
2. IV line
3. Furosemide/Morphine/NGT
- Empirical: Gentamicin
- Staph Aureus: Flucloxacillin 6w
- Strep: Adults uncomplicated
(Benzylpenicillin + Genta 2w).
Children, prosthetic (Benzylpenicillin
4w). If complicated add gentamicin.
- Enterococcal- Benzylpenicillin +
Genta

Prevention with Amoxy for dental,

DRCCF | ARIMGSAS

Pericarditis Acute (<6w), chronic (>6w).
Kussmaul sign (Inc JVP w/ insp,
dec JVP with exp) in constrictive
and cardiac tamponade
resp tract, inf skin, ligament
procedures
1. ECG, CXR, Echo, CT 1. Drainage and culture 1. AAS/Ibuprofen
1. Colchicine for recurrent sx
2. Prednisone
2. Atbs if infection

Myocarditis Viral, dyspnoea, chest pain, 1. Urgent transthoracic

fever, arrythmia echocardiogram
Mediastinitis In community:
- Empirical: Amoxi-Clav IV
- If septic shock: Cefazolin+Metro IV
In hospital:
- Piper+Tazo OR Cefepime+Metro

Stable Angina Neg ECG, Neg troponin, just - Prevention

discomfort 1. BB
2. CCB
- Relief
1. Nitrates

Unstable Angina ST Depression, Neg Troponin, 1. Admission to coronary unit

discomfort, or pain that has 2. Aspirin
changed, or >20 mins 3. Clopidogrel
4. Enoxaparin
5. Nitrate

Non-STEMI ST Depression, Pos Troponin, - Morphine

Pain - Oxygen
- Nitrates
- Aspirin
- Clopidogrel

DRCCF | ARIMGSAS
 STEMI ST Elevation, very high Troponin, - PCI (within 90 mins)
Pain. - Thrombolysis (within 12 hours)
- After: 12 months (Aspirin,
Clopidogrel), Forever (BB, ACE inh,
Statin)

Heart Failure 1. CXR 1. Echocardiogram - Class II (EF 40-50): Mild Symptoms

2. ECG on activity. Ace Inhs+BB, On/Off
Diuretics (Furosemide IV)
- Class III (EF<40): Severe symptoms
on activity but comfortable at rest +
Spironolactone
- Class IV (EF<35): Severe symptoms
on activity and at rest + Digoxin
HCOM Midsystolic murmur, increases 1. Admit to Cardiology 1. Echocardiogram 1. BB
with Valsalva, AD, young athlete 2. ECG 2. CCB
with syncope 3. CXR
Hypertension - >65yo with CHF: Thiazide
- >65yo with Ischaemia risk: BB
- Young with CHF and dx: ACE inhs
- Young with Ischaemia risk:
Amlodipine (Never
Verapamil/Diltiazem)
- Urgency (>180/110): Nifedipine,
captopril, clonidine orally, if no oral
IV hydralazine
- Emergency (>220/140): Hydralazine,
metoprolol, Nitroprusside, esmolol IV

DERMATOLOGY
Erysipelas Upper dermis and lymphatics,
non-purulent

DRCCF | ARIMGSAS
 Cellulitis Deeper dermis, SC fat, IV Flucloxacillin
purulent/non purulent
Hemangiomas - If in eyes, nose, ears, trachea->Laser
Qx or refer
- Other parts: Observe/Reassure
(self-resolve by 7yo.
- Propranolol can be used

Acne - Non-inflamm: Comedones - Mild: Benzoyl peroxide + Topical

- Inflamm: Pustules/Papules
- Severe: Scarring
retinoin
- Mod: Non inflamm (Benzoyl
peroxide + Retinoin. Inflamm
(Benzoyl peroxide+Doxicycline, if
pregnant Erythromycin)
- Severe: Isoretinoin (Oral). In
females add OCPs

Allergies Just local symptoms 1. Strop triggers

2. Emollients
3. Oral promethazine
4. Steroids

Anaphylaxis Respiratory problems 1. Adrenaline IM: (All 1:1000)

- <6m: 0.10 mg
- 6m-6y: 0.15mg
- 6-12y: 0.3mg
- >12y: 0.5mg

Androgenetic Alopecia 1. Topical steroids for 12w

2. Intradermal Steroid
(Triamcinolone)
3. Minoxidil

DRCCF | ARIMGSAS
 Hirsutism Cause: Valproate, phenytoin, 1. Shave
minoxidil, steroids, danazol 2. Laser
3. Spironolactone
Dermatitis Assoc w/ Celiac Dx in elbows, Skin biopsy 1. Dapsone.
Herpetiformes knees, lumbosacral area 2. Gluten free diet
Dermatitis Itchy, rash 1. Topical steroids & Moisturiser
Atopic Dermatitis Kids in face, cubital, popliteal 1. Topical Steroids & Moisturiser
2. Severe: Immunosuppressants
- Infected: Swab then
mupirocin/Dicloxacillin

Seborrheic Dermatitis Dandruff 1. Dandruff Shampoo

2. Ketoconazole
Tinea Ringworm 1. Oral Griseofulvin/Terbinafine
Psoriasis Cause: Autoimmune, lithium, 1. Tar
ACE inhs 2. Steroids
3. Calcipotriol
Naevi Surgery with 2mm margin
Basal Cell Carcinoma Biopsy Mohs Surgery with 3-4mm excision

Squamous Cell Surgery with 3-5mm margin

Carcinoma
Bowen Disease Shave or Punch Biopsy Fluorouracil, Imiquimod
Melanoma Surveillance: Excision margin:
- First 2 years: e/3m - In situ: 0.5cm
- Next 2 years: e/6m - <1mm: 1cm
- After: e/1y - 1-4mm: 1-2cm
- 1st Deg Rel: Skin check >4mm: 2cm
e/1y If eye: Refer to plastic surgery

DRCCF | ARIMGSAS
 Vitamin D deficiency Children: Rickets (Bowlegs,
rachitic rosary, soft skull).
Adults: HypoCa (Tetany, prox
myopathy, frontal bossing)

Vitamin A deficiency Night blindness, scaly skin, bitot

spots (foamy appearance on
conjunctiva), corneal
degeneration
Vitamin B3 deficiency 3 Ds (Dermatitis, Diarrhoea,
Dementia).
Molluscus No tx needed.
contagiosum Resolves in 3-6m
No school exclusion necessary
Avoid sharing towels/baths

Scabies Common in nursing homes 1. Permethrin.

If no improv, repeat in 1-2w
2. Benzyl Benzoate
3. Oral cephalexin, top mupirocin if
infection

Impetigo 1. Topical mupirocin 2% OR

1. cefalexin if widespread or large
areas.

EMERGENCY

DRCCF | ARIMGSAS
 Snakes Bleeding, headache, muscle 1. Pressure Immobilisation Bandage.
damage, nausea, vomiting, abd - Don’t clean the wound
pain - Don't apply PIB if more than 1 hour
has passed since bite,
2. IV line
3. Take blood
4. Give antivenom (Monovalent of
most common snakes in area
preferred)
- Admit all cases for at least 12 hours
- Remove PIB when pt is stable
Jellyfish - In Queensland: Vinegar +
Antivenom, Morphine for Irukandji
- In Victoria: Hot water (45C for 20
mins)

Human, cat, dogs 1. Wound care (Wash, elevate,

Bites immobilisation)
2. Tetanus prophylaxis
3. Post-Exposure prophylaxis: HIV,
HBV (Vaccine+Ig)
4. Atb Prophylaxis (Amoxi/Clav):
Indicated if >8hrs delay presentation,
bite in hands, feet, face, genitalia,
bones, joints, immunocompromised.
5. Review in 24-48 hours
Deadly Sidney Funnel Resp depression, salivation, Tx=snakebite
Web numbness, tingling around
mouth
Victorian Funnel Web Headache, nausea Wash area, apply cold pack and give
Spider simple analgesic.

DRCCF | ARIMGSAS
 Red black spider Slow progression - Wash area, apply cold pack and give
(Black widow) simple analgesic.
- No improvement, rest and reassure,
immobilise w/ splint, antihistamine
IM for 15 mins, give antivenom IM

Lyssavirus Bats. Incubation: 3-8w Wash wound and give rabies vaccine
(if immunised) and Igs (within 48hrs)
Cardiac Arrest (Vfib) 1. CPR (30:2)
2. Shock+CPR for 2 mins
3. 2nd Shock
4. Adrenaline IM

Bleeding - Class I (<15%): Normal

- Class II (15-30%): HR 100-120
- Class III (30-40%): Low BP
- Class IV (>40%): Very low BP,
>140HR
Gunshot Wound Stable pt: Unstable pt:
1. X-ray. 1. Exploratory Laparotomy
2. Triple Contrast CT

Ramsay Hunt Ipsilateral facial palsy, ear pain, 1. Control pain: Nortriptyline,
Syndrome vesicles in ear/mouth amitriptyline, gabapentin
2. Famciclovir, Valacyclovir, Acyclovir
(within 72 hrs)
3. Oral Steroids for 7 days (Esp>50yo)

Head Trauma 1. CT
Chest Trauma 1. CXR 1. CT
2. FAST US (Haem 2. MRI (For spinal cord,
unstable) ligamentous injuries,
epidural haematoma)

DRCCF | ARIMGSAS
 Abdomen Trauma - Haem stable: CT
- Haem unstable: FAST US,
dx peritoneal lavage

Spine Trauma Neurogenic shock (Dec BP, Dec 1. ABCDE

HR) 2. Ox if Sat<94%
3. Trendelemburg position
4. Atropine if HR<40
5. Adrenaline and Dopamine (If
resistant)

Flail chest Paradoxical resp 1. Oxygen

2. Pain management & Pulm toilet
3. Intubation & mechanical
ventilation (Positive Pressure)
4. Prophylactic bilateral chest tube

Haemothorax Dull resonance 1. Water-sealed chest tube

Pulmonary Contusion Symptoms hours after initial
injury (like lucid)
Urethral Injury Blood in urethra, inability to void
Foreign Body High Risk: button batteries,
Ingestion >6cms, two magnets, sharp, lead
object
1. Oxygen & Pulm toilet.
1. Retrograde 1. Suprapubic catheter
urethrogram
1. X-ray 1. High risk: Referral
2. Low risk: Observe

DRCCF | ARIMGSAS
 Burns Anterior (Posterior is the same)
- Genitals: 1%
- Face: 4.5%
- Upper limb: 4.5%
- Lower limb: 9%
- Thorax and abdomen: 18%
1st Degree: Erythema
2nd Degree: Erythema + Blister
3rd Degree: Pale, charred skin
Burns around
face/neck, hoarseness
CO poisoning
Dehydration - Mild: Normal
- Mod: Mild hypotension, in kids
(>2 refill time)
- Severe: Marked loss of skin
turgor, severe hypotension, in
kids (>3 refill time)
Alkali Ingestion
Organophosphate Diarrhoea, urination, miosis,
Poisoning bronchospasm, bradycardia,
sweating, lacrimation
DRCCF | ARIMGSAS
1. Analgesia
2. Hydration
3. Clean with water
4. Remove foreign material
5. Deroofing blister
1. Oxygen by face mask
2. Intubation
1. High flow (10-15L) Normobaric Ox
via Non-rebreathing mask
2. Hyperbaric oxygen to comatose,
pregnant, MI, seizures.
- Mild-Mod: Oral hydration (2-3Lt in
24 hours)
- Severe: 20mL/kg of IV hydration
(adults). 10-20mL/kg for children
- If dehydration + Hypochloremic
alkalosis: 0.9% NS+5% dextrose
- For colostomy is 3lt for men and 2lt
for women.
Oral fluids. No gastric emptying
Atropine + Pralidoxime
 Anticholinergic Constipation, urinary retention,
syndrome mydriasis, bronchodilation,
tachycardia, reduced sweat and
tears
ENDOCRINOLOGY
Hypothyroidism Bilateral, firm, rubbery goitre 1. TSH 1. Antithyroglobulin (TgAb) 1. Tx if TSH>7.
(Hashimoto 2. US If nodule 2. Antithyroid peroxidase Monitor tx at 3m, 6m, 1y. You start
Thyroiditis) 3. CT Scan if goitre is Ab (TPO) with low dose and you increase it
causing compression 3. Biopsy: Chronic progressively.
lymphocytic thyroiditis

Myxedema coma Hypotension, hypoventilation, IV Levothyroxine + IV hydrocortisone

hypoglycaemia, hyponatraemia
Congenital Macroglossia, harsh cry, dry skin, Neonatal Heel prick Start thyroxine before 2 weeks of age
hypothyroidism umbilical hernia TSH is (NEXT) if
hypotonic kid with large
open ant fontanelle

Subclinical High TSH and normal T3, T4 TSH - TSH 5-10: Review TSH in 3 months
hypothyroidism - TSH>10: Levothyroxine
Sick Euthyroid Decrease conversion from T4 to
Syndrome T3 so T3 will be low and T4, TSH,
and reverse T3 could be normal
or even high

DRCCF | ARIMGSAS
 Hyperthyroidism Fine tremor, proximal myopathy, 1. TSH 1. Carbimazole (Agranulocytosis)
frozen shoulder 2. Radioactive iodine 2. Propylthiouracil (Risk of liver dx)
uptake: 3. Surgery
- Low uptake: 4. Radioactive iodine (If CIs to
Thyroiditis surgery)
- High uptake:
Homogeneous (Graves),
heterogenous (multiple-
toxic multinodular
goitre, single area-toxic
adenoma)
Graves Disease TSH TSH receptor antibody, anti- Same than above + Tx of vision
TPO threatened:
1. IV Methylprednisolone
2. Oral high dose prednisolone

Hyperthyroidism in 1. Propylthiouracil in 1st trimester

pregnancy 2. Carbimazole in 2nd/3rd trimester
Subacute thyroiditis Pain/Tenderness, fever 1. TSH 1. ESR>50mm/Hr 1. Analgesia: NSAIDs
(De Quervains) 2. Severe: Oral prednisolone.
3. If constitutional symptoms: BB
NOT antithyroid medication

Thyroid Storm Anxiety, weight loss, Hospital admission: IV saline, IV

hyperpyrexia, tachycardia
Thyroid Nodule Moves with swallowing, can
cause compression.
steroids
1. TSH 1. FNAC
- TSH Normal or High:
Next: US. Next: FNA
- TSH Low: Next T3 &
T4. Next: Radioisotope
scan and US. If cold
nodule: FNA

DRCCF | ARIMGSAS
 Retrosternal Goitre Compression 1. X-ray CT of neck and upper chest Total thyroidectomy

Thyroid Cancer - Hoarseness 1. TFT 1. FNAB

- Psammoma bodies: Papillary
Thyroid Ca
- Follicular cells: always do
excisional biopsy bc it’s hard to
diff between non and carcinoma.
- Parafollicular C cells (secrete
calcitonin): Medullary thyroid
Ca. MEN2.
- Rapidly growing: Anaplastic

Hyperparathyroidism HyperCalcaemia (Stones, 1. Ca 1. PTH Qx for Ca<0.25, nephrolithiasis, bone

polyuria, hypoPh, constipation, erosions, reduction in bone mass,
psych disturbance) reduction of Cr clearance.
Diabetes Mellitus Urine Dipstick for sugar. FSB 1. Admission
Type 1 Other: Abs against 2. Insulin
Hashimoto 3. Follow up w/ HbA1c e/3m (<7%)
4. Vaccine for Pneumococcal,
Influenza, and dTPa

DRCCF | ARIMGSAS
 Diabetes Mellitus RBG≥11.1 FBG:
Type 2 - If ≥7: DM
- If 5.5-6.9->OGTT. If
OGTT≥11.1: DM, if 7.8-11
Retest in a year, if <7.8 with
FBG 6.1-6.9 retest in a year,
OGTT≤7.7 Retest in 3 years
- HbA1c: ≥6.5: DM, 6-6.4:
retest in 1y, ≤5.9 retest in 3
years
1. Lifestyle modifications for 3-6m
2. Metformin
3. Metformin+Sulfonilurias or
acarbose
4. Insulin (If HbA1c>9%)
5. Follow-up with HbA1c e/3m (<7)
except in risk of hypoglycaemia (7-8)
- Pioglitazone - bladder Ca
- Rosiglitazone-HF

Diabetic Nephropathy Annual screening for albuminuria

Diabetic Retinopathy Screening e/2y. Photocoagulation

- If nonproliferative dx:
e/1y
- If proliferative dx:
Urgent referral
- If vitreous
hemorrhage: Same day
referral
Diabetic Neuropathy 1. Check Vitamin B12 1. Amitriptyline
levels (Metformin can 2. Gabapentin/Pregabalin
decrease them)
Diabetic Ketoacidosis MCC: Infections, HypoK, Ketones in serum or ABG 1. Rehydration (NS IV 15-20mL/kg)
HypoNa, ketones urine 2. Short acting insulin IV

DRCCF | ARIMGSAS
 Hypoglycaemia Early dumping: 30 mins-1hr: Tx Conscious:
diet - <1yr: Milk, >1yr something sweet
Late dumping:1-3 hrs after meals Unconscious: If Glucose<3
- Children: 10% dextrose
- Adults: 50% Dextrose
Next: IM Glucagon
Hyperglycaemic Glucose >33 with normal 1. Rehydration (NS 0.45%)
hyperosmolar ketones 2. Insulin with caution
nonketotic Coma
Addison's dx Hypotension, weakness, fatigue, Cortisol level Short synacthen stimulation 1. IV line with fluids
HypoNa, HyperK test - Dx made: Hydrocortisone
- No Dx: Dexamethasone
Hyperaldosteronism Hypertension, HyperNa, HypoK. Plasma aldosterone and 1. Spironolactone/Amiloride
Renin low if primary. Renin high renin. 2. Surgery to remove adenoma
if secondary - Next: Adrenal CT if
primary

Cushing Syndrome Hyperglycaemia, Hypertension, 1. 24-hour cortisol 1. High dose Surgery. Give steroids if ACTH is
amenorrhoea, weakness, 2. Early morning cortisol dexamethasone supressed
obesity, HyperNa, HypoK levels following a low suppression test.
dose dexamethasone 2. Cranial CT/MRI
suppression test
3. ATCH

Pheochromocytoma Headache, palpitations, 1. 24-hour free 1. Plasma metanephrines + 1. Alpha Blockers

diaphoresis catecholamines MRI (Phenoxybenzamine)
(increased VMA) 2. BB
3. Qx
Adrenal Tumours - <4cm and benign: Follow up in 3-6m
- ≥4cm and suspicious:
Adrenalectomy

DRCCF | ARIMGSAS
 Pituitary Tumour 1. TFT 1. MRI - If <1cm: Review in 1y
2. CT - If ≥1cm: with visual field symptoms:
Transphenoidal resection
Hyperprolactinaemia Reduced libido, amenorrhoea, 1. Prolactin: 1. MRI 1. Dopamine agonist (Cabergoline,
erectile dysfunction - >5000: Prolactinoma bromocriptine)
- <5000: other causes 2. Surgery
Acromegaly Spade like hands, frontal 1. IGF-1. Pituitary MRI
bossing, greasy skin, thickened 2. Measurement of GH
palms, increased shoe size, following OGTT. If GH is
heteronymous hemianopia no supressed by
glucose, acromegaly

Diabetes Insipidus Low ADH, HyperNa, HypoK 1. Plasma Na and Water deprivation test: 1. Central: Desmopressin
osmolality - In primary polydipsia 2. Nephrogenic: Solute restriction
osmolarity will go back to and thiazides
normal.
Desmopressin
administration to see if its
central (Osm increases) or
nephrogenic

SIADH High ADH, HypoNa, 1. Plasma Na and 1. Water restriction

concentrated urine. osmolality 2. Hypertonic saline if pt is severely
Caused by SSRI, morphine, symptomatic.
surgery, etc 3. Demeclocycline
ENT
Rinne Test AC>BC: Normal, SNHL
BC>AC: Conductive

DRCCF | ARIMGSAS
 Weber Test Conductive: Louder in Deaf Ear
Sensorineural: Louder in Better
Ear
Deafness in Elderly Presbycusis: Loss of high
frequencies (F, S sound)
Deafness in Children Hearing loss: 1/1000 Screening at 8m-1y, and <4yo: Tympanometry
SNHL: 2/1000 school entry >4yo Audiometry
Otosclerosis AD, progressive, pregnancy, 1. Refer
conductive hearing loss with - Stapedectomy
normal TM, too many scars
Meniere’s dx Vertigo, hearing loss, tinnitus, 1. Prochlorperazine or urea crystal
2. Diazepam
3. Low salt diet (Main one for long
term)

Labyrinthitis Vertigo, hearing loss, tinnitus, 1. Prochlorperazine

previous viral inf. 2. Diazepam
Acoustic Neuroma Vertigo, hearing loss, tinnitus, 1. Observation (grows slowly)
diplopia, ataxia 2. Surgery
BPPV Vertigo, no hearing loss or Positive Hallpike Test 1. Reassurance
tinnitus 2. Epley Manoeuvre
Foreign Body in nose Unilateral nasal discharge Nasal examination under Removal
general anaesthesia

Epistaxis MCC: Local incidental trauma 1. FBE 1. Put pt leaning forward

2. INR/aPTT 2. Simple tamponade
3. Blood group 3. Anterior/Posterior Pack
Rhinitis IgE, pale nasal turbines, boggy IgE AB test, RAST Test Next: Antihistamines
membrane. <4d <4w- Best: Steroids (Daily life problems,
intermittent seasonal. >4d >4w hay fever allergy-fluticasone nasal
perennial spray)

DRCCF | ARIMGSAS
 Sinusitis Acute, Chronic (>8-12w).
Assoc w nasal polyps
Foreign Body in Ear Unilateral hearing loss, earache,
discharge
Acute Otitis Media <2 weeks. No itching. Pain.
School age-viral, <2yo or
aboriginal: Bacterial.
- Red flags (Immediate Atb):
<6m, immunocompromised,
aboriginal, only hearing ear,
cochlear implant.
Recurrent Otitis >3 episodes in 6m, >4-6 in 12
Media months
Chronic Otitis Media >2weeks. Discharge with no
pain.
- Organism: Pseudomona
(common in aboriginal)
Cholesteatoma Squamous, attic, perforation,
foul smelling, conductive HL.
- Complications: Facial Nerve
palsy, meningitis, brain abscess
DRCCF | ARIMGSAS
1. Fluoroquinolones OR Amoxi/Clav
2-3w
2. Cephalosporin 2-3w.
3. Refer if orbital/facial cellulitis
<1y: Give local anaesthesia
Live Insects: Next: Drops, Best:
Syringe ear
TM not perforated: Syringe
TM perforated: Suction
- No TM involved-Viral: PCM or
Lidocaine 2%
- If TM involved-Bacterial w/ red
flags: Amoxycillin for 5 days.
- No improvement after 48hr:
Amoxi/Clav for 5 days. Delayed
Penicilin hypersensitivity:
Cefuroxime. Immediate-Bactrim
Prophylaxis: Amoxi or Cefaclor for 4
months.
Pneumococcus vaccine in
children>18m + Atb
1. Atbs antipseudomona:
Ciprofloxacin, levofloxacin,
gentamicin, cephalosporin (children)
2. Ear drops and cipro (adults and
aboriginal children)
-<50% perforation: Ear toilet, drops,
Qx
->50% perforation: Qx
 Otitis Externa Itching, pain, hearing loss.
- Candida: Pale cream debris
- Aspergillus: Black spores
Eustachian tube Cracking, popping sound,
dysfunction fullness sensation, assoc w viral
URTIs.
Oral Candidiasis - RF: Immunodeficiency,
(Thrush) steroids, DM, HIV, chronic
xerostomia
Peritonsillar abscess Odynophagia, trismus
(Quinsy)
Strep Fever>38, sore throat, no cough,
Tonsillopharyngitis tender neck glands, white spots
GASTROENTEROLOGY
Globus Hystericus Sensation of something in
throat, symptoms of reflux.
Nothing on PE
Pharyngeal Pouch >70yo male, normal neck,
regurgitation of undigested food,
halitosis, dysphagia
Eosinophilic Hx of atopy, symptoms of GORD
Oesophagitis
Achalasia Dysphagia (intermittent to solids
and liquids), posture to aid
swallowing, food that sticks,
slow eaters.
DRCCF | ARIMGSAS
1. Aura toilet
2. Syringing+drying
3. Dressing impregnated w
steroid+Atb
4. Wick insertion
1. Systemic and intranasal
decongestants.
Avoid air travel or diving.
Topical: Nystatin
Oral: Fluconazole
1. Throat Swab 1. Incision and drainage
2. Intubation if symptoms of affected
airway (Epiglotitis, wheezing)
PCN oral for 10 days (Roxithromycin
if allergic)
1. Barium swallow Stent
1. PPI Endoscopy with biopsy 1. PPI for 4-8 weeks
2. Fluticasone swallowed for 8w
3. Oral prednisolone
1. Endoscopy. Oesophageal manometry - Young: Endoscopic Pneumatic
If not available->Barium (Increase pressure) Dilation (Less invasive) or
swallow-Bird's beak Laparoscopy Myotomy
-Old: Nifedipine, botulin inj.
 Presbyoesophagus Old pts with dysphagia and low
amplitude contractions on
manometry
Oesophageal In immunocompromised pts
Candidiasis
Viral Oesophagitis Cause: HSV, CMV
Barrets Oesophagus Metaplasia (From squamous to
simple columnar)
Most imp RF for Oesophageal
adenocarcinoma
Oesophageal Cancer - Adenocarcinoma (MC in Oz,
assoc w/ Barret).
- SCC (MC in world. Assoc w/
SAD).
- Progressive dysphagia first to
solids then liquids, hiccoughs,
hoarnesess, cough
Mallory Weiss Haem stable. Asoc w/ alcoholic
binge
Complete Chest pain, subcutaneous
Oesophageal rupture emphysema, crunching sound w/
heartbeat (Hamman's sign)
DRCCF | ARIMGSAS
-Asymptomatic and not
immunocompromised-Nystatin for 14
days
- Symptomatic or
Immunocompromised: Fluconazole
14-21d
Endoscopy w/ biopsy for Acyclovir IV followed by
pathology and PCR famciclovir/vala for 10 days
Endoscopy w/ biopsy 1. PPI
2. Surveillance
Metaplasia. Review in 3-5y if <3cm or
2-3y if ≥3cm.
- Dysplasia- Endoscopy e/6m
- High grade dysplasia: Refer.
* PPI
America recommends 3m in dysplasia
1. Endoscopy w/ biopsies. Surgery. CI in lesion>10cms, invasion
If unavailable->Barium to tracheobronchial tree and great
vessels
Endoscopy 80-90% stops spontaneously
 Boerhave's Sx Haem unstable. Complete
transmural tear
GORD Belching, odynophagia
Upper GI Bleeding -MCC: PUD.
- Tachy, hypotension, sweating
Hydatid Cyst Farmer, reservoir in dogs and
cattle, can happen in liver
(jaundice, RUQ pain, vomiting)
or lung (SOB, chest pain, cough)
DRCCF | ARIMGSAS
1. X-ray 1. Gastrograffin. Never 1. Atbs, fluids, Qx.
Barium
1. PPI >10y with GORD: Endoscopy 1. LSM weight loss
to r/o Barrett 2. Magnesium/Aluminum hydroxide.
3. H2 blocks
4. PPI (6-8w if severe). SEs: Interstitial
nephritis, malabsorption (Iron, Mg,
Ca).
5. Qx: Roux-en-Y: BMI>40, or BMI>35
w/ DM, HTN. Comp of Qx:
anastomotic leak (perforation)
1. Admission, IV fluids, PPI IV
2. Endoscopy to identify bleeding
point
3. Endoscopic haemostasis, Qx
US CT - Qx w/PAIR technique (Puncture,
Aspiration, Inj of hypertonic or
ethanol), Reaspiration.
- Albendazole for 4w after Qx.
- Praziquantel if cysts are spilled
during surgery or complicated cysts.
 Liver Abscess -MCC: Klebsiella (Risk of
Endopthalmitis). In children
Staph Aureus. In NA: Melioidosis
(Bulkdolheria). In travellers: E.
hystolytica
NASH Increased AST, ALT, GGT.
Haemochromatosis AR. Multiple symptoms.
Accumulate in pituitary (Libido,
impotence with low FSH and LH),
skin (dark skin), joint
(Polyarthritis), Pancreas (DM),
Liver (Chronic hepatitis).
- MC Heart manifestation: CHF
- MCC death: Cirrhosis
Wilson's Dx AR. Confusion, dysarthria, wide
based gate, acute change of
personality + cirrhosis
- Kayser Fleischer rings
DRCCF | ARIMGSAS
CT (Irregular multiple). - <5cm: Close needle drainage
2. US Blood cultures - >5cm: Rx guided catheter.
- Empiric Atbs:
Gentamicin+Amoxi+Metro for 4-6w.
If CI to genta: Ceftriazone or
Cefotazime.
- Confirmed Klebsiella: Ceftriazone or
cefotaxime.
- If high fever, tender
lymphadenopathy, effusion at base
of right chest->Amebiasis.
Percutaneous CT aspiration+Metro
1. LSM.
2. Statins. Metformin for DM risk
1. Ion studies- 1. HFE gene (C282Y gene- 1. Serial venesection until ferritin is
Transferrin 80-90% pts in Oz are <50ugs. Maintenance venesection
saturation>70% (Check homozygous for this 3x/year to keep ferritin<100
transferrin and ferritin mutation). If Hets pts will
e/2y) not develop symptoms.
1. Serum Ceruloplasmin 1. Biopsy 1. Lifelong penicillamine or zinc (dec
(low) and high 24 hour copper absorption)
urinary copper
excretion
2. Slip lamp
examination (Kayser
Fleisher rings)
 Autoimmune hepatitis - Cx by infliximab, nitrofurantoin,
minocycline
Primary Biliary - Pruritus, fatigue, cholestasis in
Cirrhosis biochemistry
Primary Sclerosing -Assoc w CU.
Cholangitis - stricturing in intra and
extrahepatic bile ducts
Alcoholic hepatitis - Marked neutrophilia, fever,
hepatic pain, tenderness,
encephalopathy
Hepatitis A - Not chronic, travel Hx, endemic
in Queensland and NT.
- Exclusion for 7 days after
appearance of jaundice OR until
resolution of symptoms
- NOTIFIABLE Dx
DRCCF | ARIMGSAS
Abs:
- ANA (cheaper)
- SMA (Smooth muscle ab)
- anti-LKM1 (anti liver
kidney microsomes)-assoc
w/poor response to tx
-AMA Abs Biopsy.
(Antimitochondrial) - Transient elastography to
stage severity of dx
1. US/P-ANCA MRCP
- Inc AST>ALT, GGT
Prednisolone + Azathioprine
Ursodeoxycholic acid for pruritus,
LFTs and survival.
Ursodeoxycholic acid also reduce risk
of CRC.
If encephalopathy->Prednisolone. If
CI (untreated inf)-> Oxpentifylline (CI
in allergy to caffeine or theophylline)
- Ig useful if immunocompromised
and <12months babies.
- Vaccine
 Hepatitis B -30% likely to pass it if needle
injury. Compared to 3% in HCV
and 0.03% in HIV.
- Sex is MCC of transmission.
- If HBsAg>6 months: Chronic
Hep B
Hepatitis C - #1 cx: needle sharing.
- No vaccine available.
- Chronic (>6m).
- 10-30% of pts develop Cirrhosis
in 20yrs. Compared to HepB that
goes to cirrhosis faster
Hepatitis D Uncommon in Oz. From migrants
If infectious is at the same time
with HBV: Fulminant hepatitis. If
superinifection-> Chronic
hepatitis
Hepatitis E Dangerous in prEgnancy, oldEr
pts, and preExisting liver dx->
acute liver failure
Simple liver cysts Asymptomatic, or dull right
upper pain, jaundice
DRCCF | ARIMGSAS
- HBsAg: aCute, Chronic, Chronic:
Carrier. - Interferon weekly injs for 48w. Not
- Anti-HbsAb: cleAred, in decompensated liver dx-Do Child
vAccination. Pugh Score)
-Anti-HBcIgM: Acute - Entacavir, tenofovir: Once daily
hep lifelong tx.
-Anti-HBcIgG: Chronic,
Carrier, Cleared
-HBeAg. Acute&Chronic
- Anti HCV Liver biopsy looking for - Sofospuvir/Ledipasvir
- HCV RNA cirrhosis - Peginterferon but causes BM
- Serial ALT (3x in 6m) to supression (Do FBC monthly),
see progression depression (give it with low dose
SSRI)
- Do SVR12 (means cure).
Undetectable HCV RNA by PCR 12
weeks after end of tx
Peginterferon for at least 48 weeks
Ribavirin
US CT
 Hepatic Adenoma Young pts with benign tumour Resection before pregnancy should
linked to OCPs or fertile women. be indicated.
- Pain, spontaneous rupture and
haemorrhage are complications
(esp in pregnancy).

HCC - Cx: Chronic alcoholism, Hep B C Surveillance: Biopsy Qx resection is not advised
D infection, obesity, DM, - Nodule<10mm: US - Sorafenib can prolong survival
smoking e/3m
- Nodule>10mm:
Contrast CT/MRI.
- Tumour marker: AFP

Cirrhosis - Low albumin is best indicator of 1. LFTs, FBE: Liver Biopsy

cirrhosis Thrombocytopaenia,
altered IRN, low
albumin
2. US.
3. CT/MRI

Ascites - Mild: low salt. If symptomatic use

spironolactone, if painful
gynaecomastia use amiloride.
- Moderate: Spironolactone, if
insufficient add furosemide, if tense
ascites paracentesis
Refractory: Repeated paracentesis,
shunt, liver transplantation

DRCCF | ARIMGSAS
 Gastro-oesophageal
varices
Hepatic - Changes in personality, sleep,
Encephalopathy disorientation, flapping tremor,
impaired ability to draw 5-point
star
Spontaneous Bacterial - MCC: E. coli, Klebsiella.
Peritonitis - Ascitic pt that deteriorates with
altered mental status, fever, abd
pain, inc WBC
- Mechanism: Bacterial
translocation from gut to
mesenteric lymph node
H pylori infection RF for gastric cancer.
Autoimmune Gastritis Abs against parietal cells and IF.
Atrophy of mucosa of stomach
DRCCF | ARIMGSAS
Dx endoscopy in all pts - Propranolol w or without
with cirrhosis looking endoscopic variceal band ligation.
for varices - Endoscopy e/ 6-12m
- Acutely Bleeding:
1. IV line + PPI
2. Blood transfusion.
3. Octreotide to reduce portal
pressure
4. Prophylactic Atb with Ceftriaxone
OR Cipro IV
1. Lactulose
2. Rifaximin
Ascitic fluid culture: - Empirical: Ceftriaxone OR
WBC>0.5 or neutrophil>0.25 Cefotaxime. If allergy to penicillin:
is dx cipro OR aztreonam.
- Secondary prophylaxis with Bactrim
1. Serology Test Biopsy urease testing - PPI+Amoxi+Clarythro. If penicillin
allergy: PPI+Metro+Clarythro.
- Post-tx you do Urea breath test 4
weeks after starting tx.
Endoscopy w/ biopsy IM Vitamin B12
 Peptic Ulcer Dx - Gastric has more vomiting and Urea Breath test: To Endoscopy. Compulsory for 1. PPI IV
weight loss monitor response to tx pts>55yo w/ chronic 2. Injection of adrenaline
- Duodenal no vomiting and no of H pylori dyspepsia to r/o Ca
weight loss.
- Strictures as comp: If in pylorus
(vomiting within 1 hour of meal),
duodenal (after 1hr of meal)

Gastric Outlet - Pt with vomiting>1hr after

Obstruction eating with undigested food with
hx of chronic PUD
Gastric Cancer - MCC: H Pylori infection Endoscopy+Biopsy
- Asymptomatic, later dysphagia,
epigastric mass, Virchow's node
(left supraclavicular node), hard
irregular hepatomegaly, anaemia

Crohn Dx - Pain is more common, affects - Stool sample faecal 1. Biopsy (Cobblestone sign) 1. Mild Crohn: Budesonide enteric-
all colon except for rectum, skip calprotectin (Neutrophil 2. MRI for perianal dx in coated.
lesions, transmural derived biomarker) Crohn. 2. Diffuse Crohn: Oral Prednisolone.
inflammation, causes fistulas, - CXR, AXR to see 3. Methotrexate
fissures, noncaseating complications of 4. Azathioprine
granulomas, perianal disease. peritonitis or toxic - Infliximab good for Crohn w/
megacolon. perianal fistula

DRCCF | ARIMGSAS
 Ulcerative Colitis - Bleeding is more common, only
affects the mucosa, but all the
colon with rectal involvement,
loss of haustra, crypt abscesses
and ulcers, can cause toxic
megacolon, perforation, Assoc w
Primary sclerosing cholangitis
IBS Abd pain assoc w/ change in
bowel habit.
Meckel Diverticulum - Lower GI bleeding, abd pain
Celiac Dx - Assoc w/ dermatitis
herpetiformis, thyroid dx, DM 1,
IgA deficiency, primary biliary
cirrhosis, lymphoma of small
bowel
- Lethargy, diarrhoea, abd pain,
bloating, indigestion, bleeding
(Vit K def), steatorrhea
- Skinny arms with flat bum and
big belly. Symptoms started by
4-5m when started Cerelac
DRCCF | ARIMGSAS
1. Biopsy 1. Mesalazine/Sulfasalazine
(Rectal+Oral preparation)
2. Add Steroids (Budesonide,
hydrocortisone, prednisolone
rectally.
3. Add Steroids orally (Prednisolone)
Methotrexate and sulfasalazine cause
oligospermia. But sulfasalazine is safe
to use in pregnancy and
methotrexate not
Stool examination w/ 1. LSM
fecal calprotectin 2. High fibre diet
3. Loperamide, TCAs, SSRIs
1. Endoscopy 1. CT
- IgA anti-tissue Duodenal biopsy with Avoid BROW (Barley, Rye, Oats,
transglutaminase and villous atrophy and intra Wheat)
anti-deamidated gliadin epithelial lymphocytosis
antibody.
- If pt is already on
gluten free diet, give
gluten for 4-6w and
repeat test
 Obscure GI Bleeding Blood persists besides upper and
lower endoscopy & Radiologic Ix
Carcinoid Tumour Facial flushing, diarrhoea,
wheezing, right valvular heart dx
CRC - Right: 1. Anaemia (Weakness,
fatigue). 2nd Palpable mass.
- Left: Pain, LB obstruction,
altered bowel habits
- Sigmoid Ca: Apple core
deformity, napkin ring
- Rectal Ca: Rectal bleeding,
mass in DRE, tenesmus
Adenomatous Polyps Familial Adenomatous Polyposis
Adenomas 100% risk of Cancer
HNPCC-Lynch AD. Most common hereditary
Syndrome form of Colon Ca. They can also
have ovarian, renal, etc.
DRCCF | ARIMGSAS
- Active:
Haem Stable: CT angio
Haem Unstable:
Interventional
Angiography
- Inactive (Occult)
Capsule Endoscopy
24hr 5-hydroxyl indole - Octreotide to block serotonin
acetic acid, plasma production
chromogranin A - Interferon alpha to reduce growth
- Artery embolization to cut blood
supply
For screening see Page 1. Colonoscopy Surgery (Terminal-terminal
9 of Bleeding. anastomoses). If lymphoid Pos ->
- Tumour marker CEA Chemo, If lymphoid Neg ->
Surveillance (Colonoscopies at 1, 3, 5
years +CEA).
- MC comp post-Qx->Faecal
incontinence
1. FOBT 1. Colonoscopy Screening w/ Colonoscopy:
- 1-2 polyps & nothing else: 5y
-3-4, high grade dysplasia, villous: 3y
-5-9: Every year
->10: 6 months
Genetic testing
 Peutz Jeghers sx Benign polyps (Hamartomas)
that can become malignant,
freckles on lips, inside mouth,
palms, soles.
- Assoc w/ ovarian Ca.
- MC site of Ca: Duodenal Ca.
- Common comp:
Intussusception at any age.

HAEMATOLOGY
Iron Deficiency - Cx: Breastfeeding after 6m FBC Ferritin - Oral Iron: ferrous sulphate.
Anaemia (Toddlers), Calcium
supplements, PPI, and antiacids
bc reduced absorption of iron,
toddlers with a diet in cow's milk
Anaemia of Chronic Hepcidin increased EPO. Transfusion of RBCs for severe
Diseases symptomatic anaemia.
Hereditary AD, MCHC inc (hyperchromic), Osmotic fragility test Eosin-5-maleimide test 1. Folic acid supplementation
Spherocytosis spherocytes, Coomb's test 2. Splenectomy->will decrease RBC
negative. lifespan. Give Pneumococcal and
- Dysfunction of spectrin. Haem Influenza vaccine and
prophylactic long-acting penicillin

G6PD Deficiency - X-linked recessive G6PD level - Avoid offending agents.

- Heinz bodies, bite cells. - Vit E
- Cx by fava beans, inf, - Severe: RBC transfusion
Antibiotics, Antimalarials, Aspirin

DRCCF | ARIMGSAS
 Sickle Cell Anaemia - Common in Africans Peripheral smear: Sickle Hb electrophoresis 1. Pain management with analgesics
- Replacement of Glu for Val cells and target cells 2. Hydration
producing HbS instead of HbA, 3. Oxygen tx
which gets stuck in several parts 4. HU reduce frequency of crisis
causing episodes of pain,
sequestration crisis, stroke,
blindness, acute chest sx (MCC
of hospitalization, immediate tx
with oxygen, admit bc can be
fatal), osteomyelitis with
salmonella
Thalassemia - Alpha (Asians), Beta (Greek, Hb Electrophoresis: HbF and - Trait: Observe
Turkish, Indian) HbA2 increased, HbA absent - Major: Folate supplementation,
- Hair on end appearance in skull regular (2-4 weekly) lifelong
Xray transfusions to keep Hb>90. Can
cause cirrhosis, CHF, and DM.
- If Hb<75: Packed RBCs

Sideroblastic anaemia Seen in lead excess, Blood film: Basophilic BM aspiration: Ringed 1. Remove the cause
myeloproliferative dx stippling, Pappenheimer sideroblasts 2. Pyridoxine
bodies
Lead Poisoning Home renovation, cognitive Basophilic stippling If >45 or >2.17, do chelation with
dysfunction, fatigue succimer
Notifiable dx
Vitamin B12 Hyper segmented Give B12. 1mg e/3m
Deficiency neutrophils, high
Methylmalonic, high
homocysteine.

Folic Acid Deficiency Goat's Milk, nomadic farmer Hyper segmented Folic acid better than folinic acid
parents, methotrexate, TMP, neutrophils, normal
OCP, sulfasalazine Methylmalonic, high
homocysteine.

DRCCF | ARIMGSAS
 Aplastic Anaemia Cx: Methotrexate, azathioprine,
chloroquine, NSAIDs, radiation
Autoimmune Warm: Worse when warm.
haemolytic anaemia Caused by CLL, lymphoma, SLE,
HIV.
Cold: Worse when cold. Caused
by mycoplasma, EBV.
ALL Little, Pancytopenia.
AML guM hypertrophy, Pancytopenia
CML CML: Chromosome Philadelphia,
Massive Load of wbcs, massive
splenomegaly
CLL Lymphadenopathy
(Symmetrical). They have
immunosuppression so
infections with herpes zoster,
haemophilus, pneumococcus.
Hodgkin Lymphoma Lymphadenopathy
(Asymmetrical), alcohol causes
pain of enlarged nodes, malaise,
night sweats, pruritus.
NHL Not a nun: Assoc w/ drugs, HIV,
EBV
Burkitt is here.
DRCCF | ARIMGSAS
FBC: Everything BM Biopsy (adipocytes high) Replacements
decreased
Microspherocytes. Agglutinin titration 1. Steroids.
Positive Coomb's Test 2. Immunosuppressants
3. Splenectomy
For Cold: Keep warm
Blast cells, PAS reagent Chemotherapy. Can cause tumour
positive lysis synd (Low Ca, High K, LDH, Uric
Acid). Tx with Allopurinol.
Def tx: Allogenic stem cell
transplantation
Auer rods, - Chemotherapy
myeloperoxidase - Prednisolone for maintenance
positive - Allogenic stem cell transplantation
Low LAP score Philadelphia chromosome - Chemo (Imatinib)
- Allogenic stem cell in young pts
Smudge cells - Chlorambucil for lymphadenopathy
Flow cytometry
1. CBC & Blood Film Biopsy (Reed Sternberg) -For stage IA and IIA: Radiotherapy
2. Flow cytometry cells - For stage iB until 4: Combined
Chemo (Doxo, Vincristine, Bleomycin,
Rituximab)
Excisional lymph node Follicular is incurable but Burkitt's is
biopsy curable
 Multiple Myeloma Anaemia, osteolytic lesions, - Serum electrophoresis BM biopsy (>10% plasma Stem Cell Transplantation if eligible
renal failure, blurring of vision, (high IgG, the rest low). cells) If not, chemotherapy alone.
hypercalcaemia - Bence Jones protein
on urine
electrophoresis
- Rouleaux formation of
Blood Smear
Waldenstrom Monoclonal IgM increase, Serum electrophoresis BM biopsy Rituximab
Macroglobulinemia peripheral neuropathy, Plasmapheresis
hyperviscosity syndrome
(Thrombosis, blurry vision,
headaches)
Polycythaemia Vera - Excess production of RBC, Pulse oximetry - normal JAK2 kinase mutation gene Venesection every week until Hb
granulocytes, platelets saturation, high uric normal
- Itchy after hot batch, acid Anti-HTN
splenomegaly Hydroxyurea
Essential Increase platelets-bleeding or JAK2 kinase mutation gene
Thrombocythemia thrombosis
Thrombophilia Caused by Protein C, S factor V BM shows hypercellularity Aspirin
deficiency, erytromegaly, TIA, with increased Hydroxyurea
headache megakaryocytes

Non-neoplastic proliferation of Teardrops RBCs Bone marrow biopsy

Myelofibrosis marrow stromal cells
Splenomegaly with high MCV
anaemia
Pancytopenia, fatigue, bleeding,
and infections

INFECTIOUS DISEASES

DRCCF | ARIMGSAS
 Meningitis Common causes:
- 0-2m: GBS, E. coli, Listeria
- 2m-6y: Strep Pneumo,
Neisseria
- 6-60y: Neisseria, Strep Pneumo
- >60y: Strep pneumo, Neisseria
Signs: Kernig sign (hip flexion
with extended knee causes pain)
Infants have non-specific
symptoms such as fever,
irritability, lethargy, poor
feeding, vomiting, diarrhoea
Meningococcaemia Meningitis+Rash
Encephalomyelitis Caused by demyelinating CNS dx
of Para infectious origin or after
vaccinations usually in young
people
Loss of consciousness, motor,
sensory impairment, optic
neuritis
Cat Scratch Dx Bartonella infection
Regional lymphadenitis with
TENDER lymph nodes and
swelling of arm/leg. They can
also have neurological
DRCCF | ARIMGSAS
1. LP first (Except in Blood cultures Acute:
immunocompromised, - Meningitis: Cefotaxime OR BZP OR
hx of CNS disease, Ceftriaxone + Dexamethasone to
papiledema, neurologic reduce deafness
deficit, new seizure in - Encephalitis: Acyclovir
which you do CT first) - Listeria: Ampicilin+Genta
- Bacterial: Low glucose
(<2.5), high protein (>1), Prophylaxis:
high PMNs 1. Cipro
- Fungal: Low glucose 2. Rifampin (CI in pregnancy, liver dx
(<2.5), high protein (>1), and alcoholism)
high monocytes and
high lymphocytes in Tb
- Viral: Normal glucose
and protein and high
lymphocytes
- Polyneuritis (GBS):
Only protein high with
normal cells
CSF for Gram stain Blood culture IV Ceftriaxone/cefotaxime
Notifiable disease
Lumbar puncture: Brain MRI: Multiple bilateral High dose IV steroids
elevated protein with lesions
lymphocytic pleocytosis
Serology or NAAT PCR Azythro for 5 days
 symptoms (encephalopathy is
most common )
Lyme Dx Hx of camping in NE USA.
Bull eye rash, facial nerve palsy,
encephalopathy
Malaria IP: 1-2w for Falciparum. Longer
for others.
- High fever with chills, sweating,
myalgia, thrombocytopaenia,
increased LDH, atypical
lymphocytes
Dengue Fever Recent travel to Thailand,
endemic in Queensland.
Headache (<39C), pain behind
eyes, backache, maculopapular
rash, myalgia
Yellow fever Fever, jaundice, bleeding,
bradycardia (Faget's sign),
albuminuria
Ross River Fever Mild fever, polyarthritis of small
joints (fingers and toes),
maculopapular rash
DRCCF | ARIMGSAS
Smears: Treatment:
- Thick smear to dx - P. Falciparum:
malaria Uncomplicated
- Thin smear to dx (Artemether+Lumefantrine),
species complicated (Artesunate IV)
- P vivax&ovale: Primaquine
- Pregnant and Malaria: 1st
trimester (Chloroquine), 2/3
trimester: Artemether +
Lumefantrine
FBC: Leukopaenia, IgM serology for dengue
thrombocytopaenia
Elisa (Serology)
Serology
Doxycycline. If severe ceftriaxone
Prophylaxis:
- Doxycycline: Daily. 1-2 days before
travel and 4 weeks after. Cheap. Not
for children <8yo.
- Malarone (Atovaquone+proguanil):
Daily. 1-2 days before travel and 1w
after. Expensive. For children too. CI
in pregnancy and infants <11kg
- Mefloooooquine: Weekly. 2-3
weeks before travel and 4 weeks
after. Can be used for long term. CI in
pregnancy (1st trimester),
children<5kg, hx of epilepsy,
depression, anxiety, cardiac
conduction, QT prolongation.
Symptomatic, analgesia, avoid atbs
and steroids.
Vaccine for ≥9 months who are
travelling to risk areas.
NSAIDS (No aspirin)
 Queensland Tick Localised tender Serology Doxycycline OR azythro
Typhus (Rickettsia) lymphadenopathy, fever, and
eschar at site of tick
Scrub Typhus More lymphadenopathy, black Serology Doxycycline
eschar, transmitted by mites
Trypanosomiasis Tsetse fly. Fever, headache, Trypamostigotes in Suramin
(Sleeping Sickness) lymphadenopathy, peripheral blood
hepatosplenomegaly,
hypersomnolence
Schistosomiasis Carrier is snail. From Egypt, Praziquantel
Somalia, Sudan.
Granuloma in bladder wall,
intestinal (fissures, fistules,
abscess, blood dripping after
toilet+pain w/ defecation)
Rocky Mountain Headache, fever, rash in palms
Spotted Fever and soles
Melioidosis Pneumonia, coming from Ceftazidime OR meropenem for 14
Northern Australia and returned days
travellers.
Leprosy Caused by M. Leprae, glove and Biopsy Dapsone and rifampin.
stocking loss of sensation,
hairless skin plaques, lion like
faces
Typhoid Fever Stepladder fever+abd Blood culture within 3-5 Azithro-Cipro
pain+bradycardia (Faget's sign), days
rose spots (clusters of pink
macules on skin)
Salmonella Non- Diarrhea less blood and with Adults: Cipro OR azythro
Typhoidal mucus. Notifiable dx Children: ceftriaxone OR azythro
Amebiasis Incubation: weeks to years. Pain 1. FBE 1. Elisa/PCR 1. Metro
in RUQ in liver abscess, severe 2. Tinidazole
diarrhoea

DRCCF | ARIMGSAS
 Giardiasis Bubble foul smelling, watery
explosive profuse diarrhoea,
weight loss. Hiking hx
Cholera Rice water diarrhoea, vomiting,
weakness, oliguria
E. coli diarrhoea Bloody diarrhoea., incubation for
3-5 days
Gonorrhoea IP: 2-7 days
In men produces a white
discharge from penis
Chlamydia IP: 5 days to 12 weeks/
Can be asymptomatic
HPV infection (genital
warts)
HSV (Genital herpes) Multiple painful ulcers
Syphilis - Primary: Single painless ulcer
- Secondary: Generalised
nontender lymphadenopathy,
rash in palms and soles, patchy
alopecia.
- Tertiary: Neurosyphilis or
cardiosyphilis
DRCCF | ARIMGSAS
Stool microscopy 1. Stool PCR 1. Metro
2. Tinidazole
Stool microscopy Doxycycline and resuscitation.
Vaccine available. Give 1 week prior
to exposure. Not for pregnancy,
breastfeeding and children <5yo
Fluids and rest. If needed, cipro
Ceftriazone+Azithro single dose. Test
of cure 2 weeks after.
Contact tracing: 2 months
NAAT-PCT with first pass Doxycycline. For pregnant or pts not
urine adherent give azythro single dose.
Endocervical swab Contact tracing for 6 months
Cytologic screen w/ pap - Small lesions: Observe
test - Large lesions: Cryotherapy or
Tzanck prep for keratolytics even in pregnancy. If
multinucleated giant persists, do cryotherapy again. If
cells persists again, Qx.
Acyclovir OR famciclovir. If too many
attacks: Valacyclovir for 6 months
Contact tracing not required
Dark field Microscopy Both tests must be positive: - BZP. Single dose in early syphilis, for
RPR and TPHA test late syphilis once weekly for 3 weeks,
for tertiary syphilis IV 4-hourly for 15
days
 HIV Advanced if CD4<50.
- Window period presents as a
flu like illness between 3w-3m
after infection with a rash as well
(including hands and feet), can
also cause aseptic meningitis,
which can present as
hydrocephalus
EBV (Infectious Teenagers (kissing dx), sore
mononucleosis) throat, splenomegaly (avoid
contact sports),
lymphadenopathy with atypical
lymphocytes and rash after atbs
(Blanching and non-pruritic). You
stop the antibiotic. Can cause
increase of GGT, AST, ALT,
choluria bc haemolytic anaemia
Influenza vaccine - Directed at >6 months babies
and >65 years old pts,
aboriginals,
immunocompromised.
- Can be given in pregnancy and
in egg allergy.
- Only CI is previous anaphylaxis
to components of vaccine
DRCCF | ARIMGSAS
ELISA WB
CD4 to see immune
function
Viral load (RNA) to see
tx response.
It takes 12 weeks for
HIV to be positive after
infection
1. FBS (>50%
Lymphocytes)
2. Monospot test (False
positive early in dx)
3. Serology (Only for pts
with symptoms and
negative monospot)
- PREP. Given if condomless anal sex,
or dx of rectal inf of gonorrhoea or
chlamydia or syphilis, or IV drug use.
All in past 3 months. You give
Tenofovir+Emtricitabine (Truvada)
- Post exposure prophylaxis: Low risk:
Zidovudine+Lamivudine for 4 weeks.
In high Risk: add Indinavir to previous
drugs within 8 hours for 6 weeks.
- Actual tx is started right after inf
regardless of CD4 count.
- Prophylaxis for infs: CD4<200
Pneumocystis jirovecci with Bactrim,
CD4<100 toxoplasmosis with
Bactrium, CD4<50 M. avium with
azythro
Supportive
 Measles vaccine - 2 doses: 12-18mo. If 2nd is - Ig useful for immunocompromised
missed give anytime before 4yo and children <12m
Mumps vaccine - Ig not used
Rubella vaccine - Advice termination - Ig not used
Tetanus vaccine - DTPa for clean wounds pts - Ig useful for immunocompromised
<10yo. dT or dTpa for pts ≥10yo. or dirty wounds with <3 doses or
uncertain
Whooping cough - Recommended in 30-32w - Ig not used
vaccine pregnant. - Prophylaxis (erythromycin- if CI
cotrimoxazole) only for people in
contact with <6 months age or
pregnant
HPV Vaccine - 1st dose before 14 years: 2 - Ig not used
doses (0 and 6 months)
- 1st dose after 14 years: 3 doses
(0, 2, 6 months)
- CI in pregnancy be it's live
attenuated virus and in yeast
allergies
Varicella vaccine - No need to do serology in - Ig useful in immunocompromised
children before giving vaccine. In and to pregnant pts within 96 hours
older adolescents and adults, we of exposure.
can do serology if no hx of
previous vaccination.
- Termination of pregnancy if
serial US show infection
Rotavirus vaccine - -Give vaccine to <6 months old
at 2 and 4 months

DRCCF | ARIMGSAS
 Contraindications to - Fever>38.5
vaccination - Previous anaphylaxis.
- Pregnancy (Only for live
vaccines: MMR, Varicella, yellow
fever)
- Encephalopathy (For DTPa)
- Egg allergy (For Rabies, Q
Fever, and Yellow Fever
Travel Vaccination - Always Tetanus toxoid and
diphtheria booster.
- If travelling to developing
countries, malaria prophylaxis,
Hep A, B, Tb, typhoid

NEPHROLOGY
Hyponatraemia Causes: 1. Serum Na Acute:
- Hypervolemic: CHF, ARF, 2. Serum Osmolarity - Symptomatic: 3% NaCl
cirrhosis and urine electrolytes - Asymptomatic: Water restriction
- Euvolemic: SIADH, psychogenic,
adrenal ins
- Hypovolemic: Diuretics
(Indapamide)
Symptoms:
- Nausea, vomiting, headache
Hypernatremia Causes:
- Diabetes Insipidus,
aldosteronism, dehydration
Symptoms:
- Doughy skin in infants

DRCCF | ARIMGSAS
 Hypokalaemia Causes: Risk of digoxin toxicity - K replacement
- Cushing syndrome, lung in hypokalaemia, so you - Check urine output
carcinoma, hyperaldosteronism stop digoxin in
Symptoms: hypokalaemia
- Distension, nausea, vomiting

Hyperkalaemia Causes: - 5.5-5.9: Stop K retaining drugs

- Acidosis, Spironolactone, - ≥6: No ECG changes: Short acting
rhabdomyolysis (Statin), Insulin+Glucose
ingestion, Addison's dx. - ECG changes: Calcium gluconate
Symptoms: - Refractory HyperK: Haemodialysis
- peaked T, wide QRS, muscle
weakness, flaccid paralysis.

Hypocalcaemia Causes: - Latent tetany (Chevostek, trosseau),

- Secondary asymptomatic, Ca low but >1.9: Oral
Hypoparathyroidism, OCPs Ca w or w/o Vit D
(increase of estrogen decreases - Symptomatic or asymp Ca <1.9: IV
Ca), chronic pancreatitis, Ca Gluconate.
hypoMg - If resistant to Ca: Check Mg levels
Symptoms:
- Perioral numbness, chvostek
trousseau sign, muscle cramps
Hypercalcaemia Causes: - Mild: Support
- Primary/Tertiary - Mod: IV fluids and bisphosphonates
hyperparathyroidism, benign - Sev: same than mod + calcitonin
familial hypercalcaemic
hypocalciuria, drugs (Thiazide,
diuretics, lithium, antacids,
thyroxine), myeloma, SCC of lung
Symptoms:
- Bones (Painful), Stones, Groans
(Constipation, PUD), Moans
(Depression, anorexia, impaired
memory)

DRCCF | ARIMGSAS
 Di-George Syndrome Hypoparathyroidism (HypoCa),
low T cells (Thymic dysplasia),
Congenital heart defects (TOF,
VSD, ASD)
Nephrolithiasis STRuvite->Staghorn calculi
UTI in babies - Most common cause
everywhere is E. coli
- Hospitalization to all infants
<2months
- In <2 years old: VUR
Asymptomatic ≥10,000 bacteria/mL of urine
Bacteriuria
Cystitis Just dysuria and urinary
frequency
Pyelonephritis Fever, marked flank tenderness
If chronic, rule out Tb
Perinephric abscess Pocket of pus, fever, seen in DM.
Genitourinary Tb Sterile pyuria, caseating
granulomas in medulla
DRCCF | ARIMGSAS
1. Non-contrast helical - Observe: ≤4mm in kidney and
CT ≤9mm in ureter.
2. US for pregnant - Lithotripsy: 0.5-2cm in kidney or
women, f/u of uric acid ≥10mm in ureter
stones, recurrent renal - Neprholithotomy: ≥2.1cm in kidney
colic bc risk of radiation - Indication for surgery: Fever
- <1yo: US KUB or
micturating
cystourethrogram
- >1yo: US is enough
Tx only in pregnancy, DM, infected
kidney stones, kidney transplant,
older age, VUR
Culture if doesn’t 1. Trimethoprim (Even if GFR<20)
improve with empiric 2. Cephalexin (1st in kids according to
atbs RCH)
3. Amoxi/Clavulanate
4. Nitrofurantoin
1. US Same than cystitis.
2. CT - Fluoroquinolones (Cipro,
Norfloxacin) used in antipseudomona
(PCKD, complicated UTIs)
Drain and IV antibiotics
 Renal Cell Carcinoma - Lots of paraneoplastic
symptoms, employment in
leather industry, cadmium
exposure.
- Gross haematuria, flank pain,
palpable mass.
Bladder Cancer - Assoc w/ working in painting,
leather dye industry,
pioglitazone.
- Haematuria, frequency,
urgency, nocturia, dysuria.
Epididymoorchitis - Fever, Prehn sign + (Relief of
pain when elevating scrotum)
- Cx: <35yo: Chlamydia. >35yo E.
coli, pseudomona, proteus
Testicular Torsion - No fever, neg prehn sign, short
and thick spermatic cord.
Varicocele - Bag of worms, caused by
mechanical problem in drainage
of left kidney vein (Renal
tumour)
- Neg Transillumination test
Hydrocele - Caused by tumour or infection,
no impulse on crying or straining
- Pos Transillumination Test
- Gets above the swelling
DRCCF | ARIMGSAS
1. US. If all cystic stop 1. Surveillance in 6-12 months for
there masses<1.5 cm, life expectancy<5y,
2. CT for solid masses or or comorbid condition that doesn’t
mixed solid liquid cyst let pt have Qx.
lesions. 2. Partial nephrectomy for
masses>1.5cm, life exp>5y, good
candidates for Qx.
3. Total nephrectomy for masses
>7cms, tumours of central location,
lymphs involved, extension to
adrenal gland
1. Cystoscopy and 1. CT IVU is the preferred - Stop smoking
biopsy is BEST initial ix study for all patients with - Immunotherapy
for dx and staging bladder cancer, regardless
bladder Ca. of stage
1. Urinalysis and urine - Old man: Tx like UTI Bactrim
culture - Young pt. Tx like STI:
Ceftriazone+Azythro+Doxy
1. Duplex US of scrotum 1. Surgical exploration with detorsion
(like opening a book)
1. US 1. Venous ligation
2. Tumour markers
(AFP, BHCG)
1. US Wait until 18m of age to see if it
2. Tumour markers resolves spontaneously. If persists
(AFP, BHCG) more than 2y: refer to Qx
 Undescended Testes - Fails to reach scrotum by 3m
- Comp: Inguinal Hernia,
testicular dysplasia, seminoma
Testicular Cancer - RF: Previous testicular Ca,
orchidopexy, cryptorchidism,
testicular atrophy
-Metastasis to retroperitoneal,
paraaortic, cervical (worst
prognosis)
- Assessment: 3-6m of life
- Orchidopexy: 6-12m
1. US After Dx: Orchidectomy plus:
2. Tumour markers - CT abdomen and CXR to - Radiotherapy for Seminoma
(AFP, BHCG- elevated in look for metastases - Chemotherapy for Non-seminoma
non-seminoma
testicular Ca)
- LDH for metastases

Male infertility - At least 2 specimens to dx it. 1. Sperm count x2

2. FSH if azoospermia
3. CFTR mutation if
Absence Vas deferens

Gynaecomastia Firm rubbery tender without skin

problems, uni or bilateral
Physiologic until 17yo
Caused by Spironolactone,
anabolic steroid, Leydig cell
tumour, cirrhosis, alcoholism,
CKD, hyperthyroidism,
Klinefelter

DRCCF | ARIMGSAS
 Acute Kidney Injury - Prerenal (US and urinalysis
normal cause kidney is fine):
haemorrhage, diarrhoea,
cirrhosis, CHF, NSAIDs
(vasoconstriction)
- Renal (US and urinalysis
abnormal cause kidney is
affected): ATN caused by
dehydration and toxins, GN, AIN,
renal artery stenosis
- PostRenal. obstructions by
stone, tumour, prostate,
lymphoma
Renal Artery Stenosis Hypoperfusion activates ATII,
which vasoconstric EEEEfferent
arteriole, blood stays in kidney
and maintain GFR
BPH - Hesitancy, micturition, urgency,
slow flow, terminal dribbling,
retention
Prostate Cancer - RF: Relative <60yo, age >75yo.
- Acute retention, bony pain,
weight loss, haematuria.
DRCCF | ARIMGSAS
- After Qx w/ - Prerenal: Fluid challenge
hypovolaemia: Oliguria - Renal: Remove toxins, ischaemic
(<500mL in 24hrs). AKI. - Post-Renal: relieve obstruction,
First is fluid challenge. bladder catheter, nephrostomy
Duplex US 1. Unilateral: ACE inhs, next CCB, next
Angioplasty (Best)
2. Bilateral (No ACE inhs)
- Urinalysis, culture 1. Alpha adrenergic blocking:
Doxazosin, tamsulosin, praxosin
2. Qx: TURP (Transurethral resection
of prostate). Short term
complication: UTI, long term comp:
retrograde ejaculation
1. PSA if pt wants it 1. Core biopsy 1. Radical postatectomy (MC comp.
(elevated in exercise, erectile dysfunction), radiotherapy
inf, instrumentation) for localised cancer with >10y life
expectancy. If <10y, consider active
surveillance w/ serial PSA.
2. Metastatic: Androgen deprivation:
Bilateral orchidectomy or
cyproterone
 Prostatitis - Urgency, frequency, dysuria, 1. Cipro
fevers, chills, leukocytosis, pain 2. Bactrim
w/ defecation, pos DRE
CKD - Comp: HypoCa bc secondary - Indications for haemodyalisis:
hyperPTH, hyperPh, Acidosis (<7.1), refractory HyperK,
encephalopathy, peripheral toxins like lithium, alcohol, refractory
neuropathy. fluid overload, pericarditis,
- MCC death: MI bc encephalopathy, asterixis.
hyperphosphataemia - MC Comp: Hypotension
- Peritoneal dialysis used in unstable
pts (ICU), most common comp:
peritonitis (1st Ix: peritoneal fluid
aspiration & Gram stain)

Simple renal cyst Benign, asymptomatic, most are

<2cm.
ADPCKD - Palpable kidneys. - Screening by US not Supportive tx
- ≥3 cysts is dx in 15-39yo recommended before
- ≥2 cysts is dx in 40-59yo 20yo
- Liver kidneys are common.
- Assoc w/ berry aneurysms.

Acute - Cx by amoxi, sulfonamides, 1. Tx underlying cause

tubuloinsterstitial rifampin, NSAIDS, diuretics, 2. Atbs if bacterial
Nephritis phenytoin, infections, SLE, 3. Steroids
Wegener
- Fever, rash, eosinophilia,
pigmented granular casts
NEUROLOGY

DRCCF | ARIMGSAS
 Epilepsy in general - Post-ictal paralysis (Todd): Lasts
hours or days after a seizure
- Trigger factors: Lack of sleep
Spinal Diseases
Alcoholic hallucinosis - Develops within 12-24 hours of
abstinence with normal
consciouness
Delirium tremens - Visual hallucinations, agitation,
fever, tachycardia, HTN 2-3 days
of abstinence
- Abnormal consciousness
Wernicke's - Nystagmus, Opthalmoplegia,
Encephalopathy Ataxis
Korsakov's psychosis - Confabulation, memory loss
(anterograde and retrograde
amnesia)
Creutzfeldt Jakob Caused by prions.
Disease - Dementia, clonus, chorea,
ataxia, farigue, somnolence
DRCCF | ARIMGSAS
1. CT to discard tumour - MRI - 1st episode of seizure: Reassure,
- EEG not antiepileptic
- Tx after 2 episodes in 6-12 months
- Prophylaxis: 1) Phenobarbitone 2)
Valproate 3) Phenytoin
Interactions with OCPs:
- OCPs decrease the concentration of
Lamotrigine so you need to increase
the dose of Lamotrigine
- Carbamazepine decrease the
concentration of OCPs so you need to
increase the dose of OCPs.
- If seizure free for 2 years, you
decrease gradually and then stop
drug
MRI
Most reliable ix to dx - Rapid correction of HypoNa can
alcoholism: Carbohidrate cause central pontine myelinolysis
deficient transferrin
Tx with Thiamine
Not reversed by thiamine
 Alzheimer's Disease - Assoc w/ Down syndrome
- Aggravated by thyroid,
depression, infs, neoplasms,
alcohol
Dementia Patients don’t give up
Pseudomentia MMSE >25 with mood disorders.
Pt gives up easily
Parkinson-Induced - Cx: Antipsychotics,
Disease metoclopramide, CCB
- Bilateral symmetrical
symptoms (Diff from Parkinson)
- Supranuclear Palsy: vertical
gaze palsy, postural instability,
axial rigidity, dysphagia
Parkinson's Disease - Bradykinesia, inaudible speech,
micrographia, constipation that
lead to SBO
Essential Tremor Only when doing stuff,
disappears at resting
Intention (Cerebellar) Intention or postural tremor,
Tremor abnormal finger to nose, and
heel to shin test
DRCCF | ARIMGSAS
1. MMSE EEG (Generalised 1. Cholinesterase inhibitors
2. FBC+ESR Background Slowing) (Donepezil, Galantamine,
Rivastigmine). SEs: Asthma,
hallucinations, diarrhoea,
bradycardia, HTN, headache) If risk of
any of these->Memantine
MRI shows Hummingbird
sign in Supranuclear Palsy
- If only tremor (at rest): Benztropine,
benzhexol
1. Levo+Carbidopa
- If uncontrolled movements,
decrease dose
2. Amantadine/Selegiline
3. Cabergoline/Bromocriptine
4. Entacapone
1. Propranolol
2. Primidone
3. Benzos
 Restless Legs 1. Levo/Carbidopa and ropinirole
Syndrome 2. Physostigmine
CI: Metoclopramide, Droperidol,
lithium, naloxone

TIA <24 hours, symptoms disappear 1. CT (Non-contrast) - Aspirin

completely, consciousness 2. Eco carotid doppler - Statins
preserved, recover - Warfarin
spontaneously - ACE inhibitors

Ischaemic Stroke Black on CT 1. A, B, C, D

2. Thrombolysis if <3hrs of onset and
no Cis (Active internal bleeding, HTN,
intracranial bleeding,
anticoagulation, low platelets, minor
stroke, Hypoglycaemia)
3. Aspirin & Clopidogrel

Haemorrhagic Strokes - Headache, LOC 1. CT (white) 1. Nimodipin

- Complications (Re-rupture 2. LP 2. Surgical clipping/baloon
30%), hydrocephalus, vasopasm, 3. MRI angioplasty
hypoNa)
Lacunar Strokes - SAME SIDE, NO CORTICAL
SIGNS (No neglect, afasia,
hemianopsia, LOC)
- Pure motor hemiparesis
(ipsilateral face and limb), or
pure sensory loss, or ataxic
hemiparesis or dysarthria-
Clumsy Hand syndrome
Internal Capsule Arm/Hand/leg/Foot Weakness,
Infarct clumsiness
Anterior Cerebral - Leg first then arm
Artery

DRCCF | ARIMGSAS
 Middle Cerebral - Arm first then leg, or arm and
Artery leg at same time
- Visual defects
- Aphasia or hemineglect

Posterior Inferior - Ipsilateral face sensory loss

Cerebellar Artery - Contralateral Body sensory loss
- Horner's syndrome (opposite
side)
Vertebro Artery - VAD (Vertigo Ataxia,
Dysphagia)
- Quadriplegia (Lock-in
syndrome)
Basilar Artery Dysarthria, dysphagia
Parietal Lobe Gerstmann syndrome (Can't
(Dominant Lesion) count left to right, aphasia,
acalculia, agraphia)
Parietal Lobe (Non- - Constructional apraxia (Can't
dominant Lesion) do pentagon)
- Astereognosis (Can't recognise
objects by touch)
Hemi-Neglect Sx: If patient
doesn’t shave left side and
patient is right handed the
problem is in right MCA
Micturition Syncope Reflex mediated, syncope when
or after urinating caused by
increased intra abdominal
pressure and vagal stimulation

Glasgow Scale ≤8: Intubate

>12 mild: no need to rush to ER
Cerebral Concussion Not severe, observe

DRCCF | ARIMGSAS
 Cerebral ConTTTusion Ta mal. Admit, residual 1. CT
neurological deficit
Increased ICP Cushing Triad (HTN, bradycardia, - Next: Mannitol
Cheyne stokes resp (Irregular), - Best: Bore hole
can cause brain herniation (Doll
eye reflex)
Motor Neuron Dx Only UMN or LMN symptoms
without sensory symptoms, or
cranial nerves involvement
Werdnig Hoffwan Dx Congenital hypotonia at born

Multiple Sclerosis - Motor symptoms, sensory
symptoms, optic neuritis,
bilateral trigeminal neuralgia
- Demyelination ocurring in
plaques in white matter
1. Lumbar puncture Visual Evoked Potentials - B interferon to prevent future
(Oligoclonal IgG bands) attacks
2. Brain MRI w w/o - IV steroid high dose: For optic
Gadolinium neuritis

Guillain Barre Sx - After GI or Resp Infection or
vaccination. MC org: Camp jejuni
- Ascending paralysis that can
involve resp muscles
- Complication: Resp failure (LVC
is best to monitor resp function.
If <20->ICU)
Myasthenia Gravis - Muscle weakness at end of day,
ptosis, dyplopia, dysphagia
1. CSF analysis: High - EMG best if problems with
protein with normal reflexes
cells - Nerve Conduction study
1. Edophonium Test
2. CT Scan chest to exclude
thymoma
3. EMG (Most sensitive)
- Next: IVIG
- Best: Plasmapheresis
1. Physostigmine and neostigmine
2. IVIG
3. Plasmapheresis
4. Steroids
- 1st step if O2 drop: Intubation

DRCCF | ARIMGSAS
 Lambert Eaton Lung Cancer (Small cell ca) + 1. Plasmapheresis
Syndrome proximal muscle weakness but
at the start of the day and
improve after activity.
- Atbs against calcium channel
Neurofibromatosis - Type I: Café au lair spots, lisch MRI w/ Gadolinium
nodules (pigmented iris
hamartomas), optic gliomas,
seizures. Chromosome 17
- Type II. Bilateral Swannomas

Erb's Paralysis - C5, C6, Waiter's tip (EW!).

- Trauma at birth, extended
elbow
Klumpke's Paralysis - C8, T1, Claw Hand (CK!)
- Breech delivery, pancoast's
tumour, flexed elbow
Common Peroneal Loss of PED (Peroneal eversion
Nerve Paralysis and dorsi flexion)
Tibial Nerve Paralysis Loss of TIP (Tibial, Inversion,
Plantar flexion)
Post-traumatic - Brachial plexus (C8-T1) affected
Paralysis in extended Trendelenburg
- Peroneal nerve and extensor
hallucis longus affected in
extended Lithotomy
CN Palsies caused by - Ptosis, Diplopia but doesn’t MRI best for all CNs palsies
Diabetes affect pupillary reflex.
Trigeminal Neuralgia - Severe stabbing pain, facial 1. Carbamazepine
numbness, difficulty opening 2. Gabapentin, Pregabalin
mouth.
- Trigger: cold weather, shaving

DRCCF | ARIMGSAS
 Bell's Palsy - Paralysis of mouth, eye, MRI only if doesn’t resolve 1. Cover eye
forehead (If doesn’t affect after 6-8w 2. Steroids (If severe)
forehead then it's serious 4. Antiviral (If severe)
because it's central stroke)
Pediatric Tumours - <1y, >10y: Supratentorial
- 1-10yo: Intratentorial
(Obstructive-headache,
vomiting, vertigo, CN palsies)

GYNAECOLOGY
Cyclical Mastalgia - 30-35yo. 1. Reassurance, low fat diet, no
- Pain with periods (3-5 days caffeine
before periods and stops with 2. NSAIDs
them). 3. Vitamin B1 and B6
- Assoc w/ fibrocystic dx 4. Evening prim rose oil
5. Norethisterone
6. Danazol and tamoxifen

Non cyclical mastalgia - >40yo 1. Reassurance, low fat diet, no

- Not related to periods caffeine
2. NSAIDs
3. Vitamin B1 and B6
4. Norethisterone

DRCCF | ARIMGSAS
 Dysfunctional Uterine - Most common cause of
Bleeding menorrhagia (>80mL or >8 days),
the most common organic cause
is fibroids though.
- Ovulatory: 35-45yo.
Anovulatory between 12-16 and
45-55
- Cx: Estrogen causes
endometrial growth and
outgrow blood supply: break
down of tissues
Fibroids - Estrogen dependent.
- Most common (Intramural),
most common to cause bleeding
(submucosal).
- Can cause menorrhagia,
dysmenorrhea, pressure
symptoms.
- Red degeneration: usually in
mid trimester, fever, severe
pain, local tenderness. US first
then strong analgesics
Imperforate hymen Blish discoloration , distended
vagina, suprapubic mass with or
without urinary symptoms
(Cyclical)
DRCCF | ARIMGSAS
1. FBE, coagulation 1. Mefenamic acid (4 days before
prolife, periods)
2. Hormonal profile 2. Tranexamic acid days 1-4 periods if
3. US heaving bleeding
4. Endometrial sampling 3. Mirena
4. High dose COC. (MPA only useful
for anovulatory)
5. Danazol
6. GnRh analogues
7. Endometrial ablation (if have
completed family, CI in pregnancy,
inf, postmenopausal).
8. Hysterectomy (if completed family)
1. US 1. COC
2. Progestogens
3. GnRh analogues
4. Danazol: Virilisation after 6 months
5. Qx if pressure symptoms, infertility
of failure of tx. WIth myomectomy or
uterine art embolization
- If pregnant: Observe
- Non pregnant: Uterine size <14w
observe. Uterine size >14w:
Myomectomy after GnRh to decrease
size
 Turner's syndrome - Bicuspid aortic valve, Co of Ao. - Hormonal therapy w/ GH and
- Ovaries have connective estrogen
fibrous tissue
Secondary - Absent periods for >3m if 1. BHCG
Amenorrhoea regular or >6m if irregular 2. Prolactiin
3. TSH
4. FSH & LH
5. Progestin challenge

Sheehan's sx Hypopituitarism due to post 1. Pituitary hormones 1. Steroids

partum hemorrhage 2. Pituitary stimulation 2. Replacement of hormones
test depending on pituitary estimulation
3. MRI/CT test

Ashennan's Sx - Adhesions after D&C for septic 1. Transvaginal US to 1. Histeroscopic removal of

abortion or surgeries see the adhesions adhesions under atb cover.
PCOS (Stein-Leventhal 1. Testosterone (High) 1. LSM for 6 months
Sx) 2. LH (High), FSH (Low) - For irregular periods: COC
3. OGTT, FBS, Lipid - For amenorrhoea: COC
profile - For Insulin resistance & BMI>30:
4. US (>10 follicules in Metformin.
each ovary is dx). Not - For hirsutism: Diane35,
reliable in young spironolactone
women - For infertility:
1) If <35yo and BMI>25: Weight loss
for 6 months
1) Clomiphene 2) Metformin (If
BMI<32). 3) Lap Ovarian Drilling

DRCCF | ARIMGSAS
 Premature Ovarian Loss of ovarian function <40yo. 1. FSH levels >25-40 2x 1. MHT
Inssuficiency Symptoms similar to menopause 4-6w apart 2. COC if contraception is requires
2. BHCG too
3. TSH
4. Pelvic US
5. DEXA

Mittelschmerz Pain during release of egg. 1. Reassurance

Relieved by leaning forward and 2. Analgesics
supporting lower abdomen 3. Hot packs
4. COC if severe

Ovarian Cysts - Dermoid (Teratoma. Mature all 1. Transvaginal US - ≤4.9: Observe

layers, immature only
neuroectoderm tissue)
- Sertoli-Leydig Tumour: Increase
androgen->virilisation
- Corpus luteum cyst: Cyst of
complex nature that appears
after menstruation and can
reach 10 cm.
Ruptured Cyst - Most are asymptomatic. If
symptomatic comes with sudden
pain in illiac fossa, nausea,
vomiting, settles in few hours
2. Colour Doppler US - 5-7, asympt: Repeat US in 3-4m
3. Ca125 tumour - >7, symp, complex: Refer to gyn,
marker tumour markers
- >10: Lap removal
1. Colour Doppler US 1. Bed rest + Analgesics
2. US guided aspiration if cyst is left
behind
3. Laparoscopy if severe bleeding

Torsion of Ovarian - ER!!! Looks like appendicits and
Cyst ruptured ectopic.
- Severe cramping, shock,
palpable round mass in midline
of abdomen
Cervical Ectropion - Mucosal discharge,
dyspareunia, post coital bleed.
- Red ring around cervical OS
1. Colour Doppler US - Ovary viable: Lap untwisting and
oophoropexy
- Ovary nonviable: Oopherectomy
1. HPV Screen - Asymptomatic: Observe
- Symptomatic: Cauterization by
diathermy or cryosurgery

DRCCF | ARIMGSAS
 Atrophic Vaginitis - After menopause, during
breastfeeding.
- Dyspareunia, spotting, yellow
brown discharge, itching,
dryness.
- PE: atrophic w/ diffuse
erythema
Endometrial - Thickness >5mm.
hyperplasia - RF: Obesity, >45yo, early
menarche, late menopause
Primary - Pain w/ menstrual cycles
dysmenorrhoea - Caused by PG secretion from
endometrium which cause
painful uterine contractions and
nausea and diarrhoea. Usually
starts at 2-3 years of menarche
and stops by 20 years. Starts 1-2
days before periods and stops
after
Endometriosis - Most common site (Ovaries),
least common site (Cervix).
Adenomyosis when invades
myometrium
- Dysmenorrhoea (MC sx),
menorrhagia, pelvic pain,
defecation pain, deep
dyspareunia.
- PE: Fixed, retroverted, tender
adnexa, tender DRE (If POD)
DRCCF | ARIMGSAS
1. Local estrogen in creams
2. Moisturisers
3. MHT only if other symptoms of
menopause
1. Transvaginal US Hysteroscopy and biopsy 1. Oral progesterons
2. Mirena
3. Hysterectomy
1. NSAIDS
2. COC (If sexually active)
3. Vit B1 & Magnesium
1. Transvaginal US 1. Laparoscopy (Dx and tx) 1. NSAIDS
2. MRI (More sensitive 2. COC
to see location before 3. Progestogens
Qx) 4. GnRh analogues
5. Danazol: Virilisation after 6 months
5. Laparoscopy if medicine failed or
infertility
6. Hysterectomy if no more kids
 PID - Cx. MC: STI (Chlamydia,
gonorrhoea. After abortion,
D&C, IUCD, recent pregnancy (E.
coli). After prolonged IUCD use:
Actinomyces
- Fever, abd pain, offensive
vaginal discharge,
dysmenorrhoea, menorrhagia,
CMT positive, adnexal
tenderness
PMS - Pain, behavioral changes 2-4
days before periods and stops
after periods start.
- If behavioral symptoms
(Depression, anxiety, sleep, etc)
is the mainproblem:
Premenstrual dysphoric disorder
(PMDD).
DRCCF | ARIMGSAS
1. FBE, STI 1. Laparoscopy EXOGENOUS
2. Endocervical swab for - Mild/Mod (Outpatient).
chlamydia, gonorrhoea Ceftriazone+Doxy+Metro for 14 days
3. Transvaginal US - Severe (inpatient):
Ceftriazone+Azythro+Metro
- Pregnant/Breastfeeding: Replace
doxy by azythro
ENDOGENOUS:
- Mild/Mod: Augmentin+Doxy
- Severe: Same than exofenous
1. LSM (Diet, exercise, caffeine, CVT,
Vit B6
2. COC or SSRI (If PMDD)
3. GnRh analogues (In very severe)
- PMS+Fluid retention:
Spironolactone
- PMS+Mastalgia: Danazol
- PMS+Dysmenorrhoea: Mefenamic
acid
 Menopause - Def: >12m without periods
(Can be spotting though). If
<45yo: Early menopause. If
<40yo: Premature menopause
DRCCF | ARIMGSAS
1. FSH & LH high, MHT:
estrogen very low - CI in active DVT, personal hx of
2. Mammogram and breast Ca, endometrial, ovarian,
cervical screen should undiagnosed vaginal bleeding, stroke
be uptodate. - Risk of DVT, stroke, breast Ca (If
used>5y, however can be used if hx
- Review in 6 months of family breast Ca), cholecystitis.
after MHT. - During 1st year of menopause:
- No need to stop Continuous estrogen + cyclic
mammogram after HRT progestogen.
(Do it e/2y) - After 1st year of menopause:
Continuous estrogen + Continuous
progestogen
- In women with hysterectomy:
Estrogen alone therapy
- Transdermal therapy in personal or
family hx of DVT, abnormal liver
functions, migraine.
- If only vasomotor symptoms: SSRI
(paroxretine, escitalopram,
venlafaxine), gapabentin
 Osteoporosis - RF: BMI<19, steroids, PPI, 1. 25 hydroxy vitamin D 1. DEXA Scan. Don’t take Ca T score normal or borderline:
phenothiazines, heparin, 24 hours before. - Calcium, exercise, sunlight, vitamin
menopause, RA. - T-score: >-1: Normal, -2.5-- D supplementation
1: Osteopenia, <-2.5 T score of osteoporosis or osteopenia
Osteoporosis w/ fracture:
- Z score: ≤-2: Ix - Biphosphonates:
* Measure Vit D and RFT before
starting tx. Decrease bone loss and
increase mineral density.
* Useful for vertebral & non-
vertebral fx
* CI in pregnancy bx it's teratogenic.
* SEs: GI discomfort, oesophagitis,
jaw necrosis
* In older people w/ pathological fx
can be started without bone scan
1. Alendronate and Risedronate
2. Zoledronic acid is parenteral
(Annual infusion) and used if pts have
oesophagitis sx.
3. Denosuman is given as 6-monthly
SC injections
4. Strontium ranelate: Reserved for
severe osteoporosis bc they cause MI
5. Raloxifene: 2nd line for women
with osteoporisis at risk of breast Ca,
good for vertebral fx
6. Tereparatide: Used if >1
symptomatic new fx after 12m of
biphosphonate or if T score is ≤-3.
Candidiasis Curdy, white, cheese-like, brick High vaginal swab 1. Clotrimazole
red vagina. 2. Oral fluconazole (If >4 episodes in
1 year) - Not in pregnancy

DRCCF | ARIMGSAS
 Trichomoniasis Yellow, green, malodorous fishy
discharge, vaginal and vulvar
oedema, strawberry cervix,
increase risk of cervical Ca
Bacterial Vaginosis Gardnerella, greyish white
watery profuse, bubbly smell,
clue cells.
Tampon Shock - Offensive vaginal discharge,
syndrome fever, muscle aches, rash in
hands, strawberry tongue
Labial adhesions in kids, caused by vulvovaginitis
Lichen sclerosis White shiny wrinkled plaques in
8 pattern. 4% risk of SCC
Cervical Cancer Screen - From 25-74 every 5 years
(recently changed).
- No sex: 2 years after 1st
intercourse
- Before 25 if woman have had
sex and no vaccine, could be
done between 20-24yo
Female infertility - Inability to conceive after 12
months of unprotected sex
DRCCF | ARIMGSAS
High vaginal swab 1. Metronidazole (Even in pregnancy)
2. Tinidazole
- Treat partner
- Notifiable in NT
High vaginal swab 1. Metronidazole
- Clindamycin for pregnant
1. Remove tampon
2. Take cultures
3. Povidine iodine
4. Atbs: Flucloxacilin/vanco
- Kids can void: resolve spontaneouly
- Kid can't void: Qx
separation+estrogen
Multiple punch biopsy from 1. Clobetasol
lesion 2. Retinoids/UV therapy
3. Calcineurin inhs
4. Cyclosporine, Methotrexate
Lifelong follow up with 6 months
checks then yearly
HSIL:
- Cone biopsy: Done when cervical
biopsy doesn’t explain severity of
cervical screen or if you can't see
upper margin of HSIL. Comp: Cervical
stenosis, incompetence
Ix should be done >12m - Mid luteal progesterone
if >35yo. >6m if <35yo assessment
1. TFT, Prolactin, FSH,
LH
 Stress incontinence - Caused by increased abdominal
pressure: coughing, sneezing,
exercising. UTI, constipation, big
babies, overweight
- Due to sphincter weakness
Urge incontinence - Urge to void, precipitated by
running water, putting key in
home door.UTI
- Due to detrusor instability.
Urine MCS Urodynamic studies: 1. Pelvic floor exercise (Kegel
- Cystourethroscopy exercise)
- Uroflowmetry 2. Bladder Neck Sling (Colpo
- Cystometry suspension), mid urethral sling
procedure, urethral bulking agents
Urine MCS Urodynamic studies: 1. Bladder retraining exercises
- Cystourethroscopy 2. Oxybutinin, solifenacin
- Uroflowmetry 3. Intravesical Botulinum toxin A
- Cystometry

Overreactive bladder - Caused by caffeine, alcohol,

fizzy drinks
Prolapse - Fullness or bulging in vagine, 1. LSM modifications
dragging low back pain, caused 2. Pelvic floor exercises
by weakness of uterosacral 3. Vaginal pessaries
ligament. 4. Qx: Colporrhaphy.
- Cx: Obesity, menopause,
constipation, chronic cough,
pelvic Qx
Ovarian Cancer RFs:
- Obesity
- Family hx of breast or ovarian
ca
- BRACA gene
- Early menarche and late
menopause
- Nulliparity
- Old pts

DRCCF | ARIMGSAS
 Endometrial Cancer RFs:
- Obesity
- Endometrial thickness >8mm
- Exposure to tamoxifen
- Lynch Sx
- Nulliparity
- Chronic anovulation
- PCOS

Cervical Cancer RFs:

- OCPs >5 years
- Smoking
- Immunosupression
- Early age of sex life
- Multiple sex partnerts
- Genital warts
- Persistance of HPV virus

OBSTETRICS
Visits - 0-12w: once - US: Normally at 18-20 weeks to check for Folic acid
- 12-28w: e/4w morphology, placenta, amniotic fluid. Heart sounds - 0.5: 1 month before and during first
- 28-36w: e/2w audible at 10 weeks 3 months of pregnancy
- 36w-Delivery: e/w - Fundal height +-2cm. Upt o umnilicus in 20w, - 5mg: Hx of antiepileptics, hx of
xiphisternium in 36w. Variation in fundal height: US neural tube defects in previous
- Diet: folic acid, iodine. For vegetarians: folic acid, babies, personal or family hx of
iodine, iron. neural tube defects, DM, BMI≥35,
coeliac dx, sickle cell dx, cong heart
defects

DRCCF | ARIMGSAS
 Alcohol - Miscarriage, premature birth.
- Fetal aochol sx: Microcephaly,
small teeth, faulty enamel,
micrognatia, short palpebral
fissures, long philtrym low set
ears
Smoking Complications: Ectopics, Nicotine dependence: General
miscarriage, placenta praevia, Smoking after waking 1. Behavioral counselling and support
abruptio, low birth weight, IUGR, up, when ill, difficulty 2. Nicotine replacement tx
premature, Sudden infant death stopping smoking, first 3. Varenicicline
Sx (Breastfeeding decreases its cigarrette of the day is 4. Bupropion (less impotence)
risk) hardest to give up, - No Bupropion & Varenicicline in
more in morning than pregnancy
afternoon

Miscarriages Chart is enough 1. BHCG, TORCH screen, - <9w: Vaginal misoprostol

STI screen, blood group, - >92: D&C
Rh coagulation
2. US If in shock. 1st stabilise with ABC,
fluids, oxygen, five antiD injection
- Atb in sepsis

DRCCF | ARIMGSAS
 Ectopic pregnancy - Only during 1st trimester
- MC site: Fallopian tube
(ampulla), least comon cervix,
most common for early rupture:
isthmus
- Sx: abd pain, amenorrhoea,
prune juice bleeding, lavatory
sign, shoulder pain (if
peritonitis), deep tenderness in
iliac fossa, hyperemic and
bulgiing cervix (Cervical ectopic)
- Ruptured ectopic: Shock,
rigidity, guardign, tenderness,
bleeding per vagina
Hydatidiform mole - Vaginal bleed w/
vesicles/grapes/bubbles,
hyperemesis, hyperthyroidism
(TSH), uterus large for dates
Unruptured: 1. Transvaginal US. Around 1. Methotrexate. CT in intrauterine
1. bHCG. Urine and 5-6 weeks. Before 5 you pregnancy, immunodeficiency,
blood can't see anything breastfeeding, liver/renal
2. Laparoscopy dysfunction. Only in haem stable
Ruptured: 2. Laparoscopy with salpingectomy.
1. Pelvic US
Ruptured:
1. Resuscitate
2. Laparotomy and salpingectomy
1. BHCG very high Pelvic US: Snow storm - Shock: Stabilise
2. All other tests appearance - Non shock: D&C, IV oxytocin
including inhibin and - Followup: Serial BHCG/w until
activin high. normal. If normal within less 2,=m,
do HCG e/m for 4m. If normal after
2m, do HCG e/m for 6m

Choriocarcinoma MCC site of mets: Lung. Methotrexate w/ folic acid

Age>40, complete,
BHCG>100,000
Hyperemesis 1. Urine dipstick for UTI US Dehydrates
Gravidarum and ketones 1. Admit and fluids+Metoclopramide
2. Urine MCS Nausea
1. Pyridoxine, doxylamine
2. Metoclopramide
3. Ondansetron

Round Ligament Strain Pt with recent cough/cold with

right illiac fossa pain while

DRCCF | ARIMGSAS
 getting up from chair w/ no
rebound ternderness

Symphisis pubis Pain on mons pubis aggravated

instability by walking
Asymptomatic - >100,000 if any bacteria, or in 1. Cephelexin
bacteriuria >10,000 if Strep. 2. Nitrofurantoin (Avoid in G6PD)
3. Trimethropim.
- After tx, wait 48 hrs, and repeat
midstream urine, then repeat
monthly
Acute cystitis 1. Cephelexin
2. Nitrofurantoin (Avoid in G6PD)
3. Trimethropim.
- After tx, wait 48 hrs, and repeat
midstream urine, then repeat
monthly
Pyelonephritis 1. IV Amoxy + Genta OR IV
Ceftriazone for 48hrs. Then switch to
oral atbs (Cephelezin, Bactrium,
Augmentin) for 10d.

Parvovirus Exposure - Minimal risk to baby, but can

produce hydrops fetalis
CMV Exposure. - Can produce chorioretinitis, Ganciclovir for baby
optic atrophy, hearing loss.
Toxoplasma - In baby: Chorioretinitis, Pyrimethamine + Sulfadoxine +/-
hydrocephalus, intracranial spiramycin
calcification, blueberry muffin
(cutaneous erythropoiesis)
Rubella Deafness, PDA, mental
retardation,
cataracts/retinopathy

DRCCF | ARIMGSAS
 Syphilis - In babies hydrops fetalis (Esp if Penicilin
in 1st trimester infection).
Hepatitis C - Ribavirin is teratogenic. If used, Infant should be
give contraception for 6 months screened at 18m for
to avoid pregnancy. anti-HCV titre and if
- No fetal scalp blood sampling. positive do HCV RNA
Breastfeeding allowed unless
cracked or bleeding nipples.

HSV (Genital Herpes) - Inf in 1st, 2nd trimester: Acyclovir

from 36w till delivery
- Inf in 3rd trimester: Acyclovir till
delivery
- Active lesions suring delivery or
primary inf within 6 weeks of delivery
date: C-section
- No active lesions or inf before 6
weeks to delivert: Vaginal delivery.

E. coli Can cause meningitis or sepsis Early onset sepsis: Benzyl+Genta

Late onset sepsis: flucloxacilin+Genta
Meningitis: Add cefotaxime
GSB - Early onset (<7d): Preterms, - Penicilin + Gentamicin
bacteraemia, pneumonia.
- Late onset (7d-3m). Term
babies, bacteraemia, meningitis

DRCCF | ARIMGSAS
 HIV - Foetal Infection rate with tx:
1%, without tx 15-25%
Gestational HTN Just HTN with no proteinuria
>20w pregnancy
Preeclampsia HTN+Proteinuria or organ
dysfunction (renal, liver,
neurological, haematological)
RF: Chronic HT, DM,
autoimmune dx, ≥40yo, BMI≥35,
1st pregnancy, multiple
pregnancy, >10y after last
pregnancy
Eclampsia HTN+convulsions
DRCCF | ARIMGSAS
- Give antiretrovirals to mother
- Viral load >50 at 36w: C-section
- Viral load >1000: IV Zidouvudine
during labour.
- Tx of baby: Oral Zidovudine in 1st
6hrs up to 4w. Test baby with PCR
until 3m. Exclusive formula feeding
- Forceps is better than ventouse if
instrumental delivery is needed
- Labetalol, methyldopa. Aim to BP
<150/100. If <140/90 can cause
placental hypoperfusion
- Mild: SBP: 140-149, +, - Mild: at home with
mild edema labetalol/methyldopa/nifedipine.
- Mod: SBP: 150-159, - Mod: Admit, bed rest but can go to
++, mod edema (until tolilet: Oral
calf) lebetalol/methyldopa/nifepidine
- Sev: SBP:≥160, +++, - Severe: Admit, magnesium sulfate,
edema until thigh IV labetalol or IV hydralazine
1. DRABC
2. Magnesium sulfate
3. IV hydralazine
4. Delivery after seizures are
controlled
 Gestational Diabetes - OGTT in 1st visit if BMI>30,
aboriginal, previous GDM, >40,
family hx of DM, previous
macrosomia, PCOS, steroids,
multiple pregnancy.
- Otherwise OGTT at 28w
Hypothyroidism
Cardiac Disorders High risk if MS, pulm HTN,
Eisenmenger's
Antiphospholipid Sx
Thrombocytopaenia
Acute Fatty liver of - Fulminant jaundice, vomiting,
pregnancy abd pain, multi organ failure
Cholestasis of Pruritus on hands and feet, mild
pregnancy haundice during last trimester of
pregnancy
Epilepsy in Pregnancy - Fit free for 6m to be pregnant
DRCCF | ARIMGSAS
OGTT: Diabetes before pregnancy: 1. LSM for 2 weeks
- FBS≥5.1 - Good control for at least 2. Insulin (1st line). Metformin is safe
- BLS 1hr: ≥10 3m before pregnancy as well. Stop insulin after delivery
- BSL 2hr ≥8.5 - HbA1c<7% Follow-up: OGTT at 6w post-delivery.
- Give high dose folic acid Then FBS/HbA1c e/3y if OGTT normal
(2.5) 3m before
Dose of thyroxine should be
increased by 30-50% in 1st trimester.
- Low dose aspirin
- Prophylactic dose of LMWH
- If plt gets to 50-70,000, give 2w of
oral prednisolone from 37-38w so
the count goes more than 100,000
Early delivery since condition
resolves after delivery
- Vit K
- Ursodeoxycholic acid for pruritus
- Avoid oral pills if hx of this condition
- Safest: Levetiracetam, Lamotrigine
- Avoid Valproic acid
- Nuchal translucency for
anencephaly and materal AFP at 16-
20w in case of use of antiepileptics
 Placenta Praevia - Painless vaginal bleeding - US at 20w - Minor bleed: Admit, bed rest, CTG,
around 28-30w - Repeat US at 32-34w steroid prophylaxis, plan C-section by
looking for migration 38w for grades 1, 2. 37w for grade 3,
4
- Major bleed: If mum is unstable or
baby in distress: C-section

Vasa Praevia Bleeding caused by fetal vessels

coursing over the internal os
Abruptio Placentae Painful bleeding, tenderness. "- Mild: admit, steroids if <34w, bed
rest. If >37w, deliver baby
- Mod: Mother hem unstable. 1st
stabilise mom, give steroids, delivery
baby by C-section whatever
gestational age
- Severe: Baby is usually dead. Induct
labour with amniotomy"

Uterine atony - Cx is everything that distend - Blood group and cross 1. Stabilise pt
uterus. match 2. Massage uterine fundus
- Symptoms: Heavy bleed, lax 3. IV oxytocin or Ergometrine
uterux ONGOING
4. Tranexamic acid
5. IM Carboprost
6. Continuous oxytocin
SURGERY:
7. Ligation of uterine art
8. Selective arterial embolization
9. Hysterectomy

DRCCF | ARIMGSAS
 Uterine Rupture - Cx: use of oxytocin, failure to
recognise obstructed labour,
high parity.
- Sx: Severe sudden abd pain,
shock out of proportion to
bleeding, cessation of uterine
contractions, fetal parts palpable
Inverted Uterus Severe abd pain, fundus not
palpable, vaginal mass, shock,
PPH
Endometritis Fever, abd pain, bleeding,
smelling vaginal discharge
RH isoimmunisation - Mum RH neg and dad RH Pos
- 1st baby protected, next baby
will be the problem, can cause
mild anaemia until hydrops
foetalis.
ABO incompatibility - Mother O, baby A or B.
- It will happen in 1st Pregnancy
because she already has Abs
DRCCF | ARIMGSAS
1. Resuscitation of mum
2. Urgent laparotomy/C-section
3. Hysterectomy
4. Next pregnancy: C-section at 37-
38w
1. Resuscitate mym
2. Manual resuscitation. Withhold
oxytocin.
3. O'Sullivan's hydrostatic technique
4. Qx repositioning
1. Blood culture if T>38 1. Resuscitate mother
2. Blood group, cross 2. Oral Augmentin for 7d if localised,
matching afebrile, no systemic symptoms
3. Coag profile 3. IV amoxi+genta+metro if severe
and then oral augmentin for 7d
Indirect Coomb's Test in Indicatins:
mum 1st Trimester: Miscarriage, ectopic,
chronic villi sampling
- Rosette Test 2-3 Trimester: APH, amniocentesis,
- Keihauer test external cephalic version, trauma.
After even, give antiD within 72hrs
but can be given up to 9-10d. AntiD
half life is 4w so every new event
needs new anti-D
Direct Coomb's Test in - Phototherapy
baby - IVIG infusion if severe
- Audiometry bc bilirubin causes
hearing loss
 DVT - RFs: Decrease Prot C, S,
increase factor V and VII,
multiple pregnancy,
thrombophilia, smoking
Breech - Types: Frank (legs extended-
better for vaginal birth), footing
(one foot down, C-section),
complete (legs flexed-you can
try vaginal birth)
Malposition Brow and Face presentation
always C-section.
DRCCF | ARIMGSAS
- Compression US - Proximal (Above knee): Therapeutic
LMWH for pregnancy and 6w
postpartum
- Distal (Below knee). Therapeutic
LMWH for 8w, then prophylactic for
rest of pregnancy until 6w
postpartum
- Warfarin NOT in pregnancy. In 1st
trimester causes fetal
chondrodysplasia punctata. In 2-3
causes fetal optic atrophy and mental
retardation
- Delivery: Discontinue therapeutic
LMWH 24 hours prior and give
prophylactic till 12 hours prior to
induction or C-section. THen you stop
everything and restart postpartum
- Future pregnancies: LMWH from
14w 4--6w post-partum
US - <37w: Spontaneous version can
occur
- >37w:
1. C-section
2. ECV done at 37w & IOL
3. Vaginal delivery if baby is <3.8Kg,
and frank/complete breech
 Preterm Labour Between 20-37w. - Fibronectin test: High 1. Admission to 3ry hospital with
Contractions at intervals NPV: if neg, pt wont NICU
deliver in next 7-10d. 2. Steroids (Betamethasone) if <34w.
- Transvaginal US with 3. Tocolytic (Nifedipine, Terbutaline)
measurement of to prevent uterine contractions. CI to
cervical length: Best tocolysis: Baby (Fetal distress-brady-
way to predict preterm tachy, fetal death, immaturity), Mom
delivery between 14- (Chorioamnionitis, PET, haem
24w instability, abruyptio, CHF, DM,
antepartum haemorrhage)

PROM ROM before labour start. If <37w 1. Sterile speculum to 1. Observe in hospital for 72hrs
preterm PROM see pooling of fluid in 2. Steroids
posterior fornix. 3. Swab
2. Tests for amniotic 4. Atbs (IV BZP) for 48hrs or until
fluid: Amnisure, delivery + Oral erythromycin for 10
nitrazine, Fern test. days.
5. Follow up: CTG, US 2x/w, A/N
weekly
- Infection <34w: No IOL unless
complications. >34w IOL

Cervical Incompetence RFs: Collagen disorders, cone - Transvaginal US with Cervical encerclage between 12-14w
biopsy, deep lacerations, cervical length<25mm Remove suture by 37w
instrumental deliveries.
- Miscarriage in 2nd trimester

DRCCF | ARIMGSAS
 Mecoinium Stained Cx: Post-date (>40w).
Liquor
Cord prolapse Variable deceleration
Polyhydramnios - Sx: Dyspnea, swelling of legs,
varices.
- Cx by multiple pregnancy, DM,
GI obstruction, Placental
tumours, infections.
Oligohydramnios Cx: PROM, Renal agenesis, IUGR,
CMV, toxoplasmosis, placental
infussificncy, NSAID, ACE
inhibitors
IUGR Fetus with weight <10th
percentile
- Dx: Adolescent mother,
comorbidities, smoking, SLE.
DRCCF | ARIMGSAS
1. Continuous CTG.
- If abnormal do fetal scalp blood
sampling, analise PH and if pH<7.21
and lactate >4.2 emergency delivery
by C-section or assisted vaginal
delivery
1. Knee to chest position or
exxageration Sims position
2. Manual elevation of presenting
part
3. Fill bladder with fluid
- Avoid overhandling of cord cause it
can lead to vasospasm
4. O2 to mum and continuous CTG
1. US - Mild: No tx
2. Amniotic Fluid Index - If SOB or abd pain: Give
(AFI) ≥24cm indomethacin (Not after 31w bc risk
of premature closure of PDA, or wih
AFI>40.
- If AFI>40: Amnioreduction,
amniocentesis
1. US 1. Drink fluids.
2. AFI≤5 2. Amnioinfusion if severe
1. US 1. Low dose aspirin to enhance fetal
2. Umbilical art Doppler growth
2. Delivery at 37w
 Trauma in pregnancy 1. DRABCDE
2. Position in left lateral position
3. CTG every 4 hours for 24 hours and
monitor for at least 24 hours

Down's Screening First Trimester: Second Trimester: (15- DIAGNOSTIC TEST:

- Combined test (87%): Blood (9-
11w) BHCG inc and PAPPA dec.
+ US nuchal translucency scan
11-14w.
- Harmony Test (99%) (Non
Invasive Prenatal Test) Check for
DNA.
17w) - 1st Trimester: CVS (10-
- Quadruple test (81%): 12w). Risk of miscarriage
BHCG inc, Inhibin Inc, 1%.
AFP dec, Estriol Dec. - 2nd Trimester:
- Triple test (67-71%): Amniocentesis (15-20w).
Everything above Risk miscarriage 0.5%
except inhibin A. - After 20w: Cordocentesis.
1% Risk

Mastitis Staph Aureus is most common
Painful lump in breast, fever,
tiredness.
US if doubtful of breast 1. Continue breast feeding
abscess 2. Atb:
Dicloxacilin/flucloxacillin/cephalexin
for 7d
- If candida: Fluconazole

Breast Abscess Tenderness, indurated area 1. Incision and drainage

2. Atbs
Puerperal Vaginal <3cms: Ice pack and analgesia
Haematoma >3cms: Surgical exploration
Contraception - Mini pills and implanon from 3w
postpartum
- Depo Provera and Mirena from 6w
Compression of IVC Veins from umbilicus towards
the head
Caput medusae Veins radiate out from umbilicus

DRCCF | ARIMGSAS
 CTG: Tachycardia >160. Caused by hypoxia, Early Deceleration - Start and end with uterine
chorioamnionitis, contraction. It's normal
hyperthyroidism, anaemia.
CTG: Bradycardia <120. Caused by cord prolapse, Variable Deceleration - Don't match uterine contraction.
prolonged cord comprssion, Seen in umbilical cord compression
epidural anasthesia, maternal
seizures
Reduced variability <5bpm for more than 40 Late Deceleration - Deceleration begins at peak of
minutes. Cx by fetal acidosis, uterine contraction and finishes
drugs, prematurity when the next finishes. Seen in fetal
hypoxia, acidosis. You do fetal blood
sampling

Sinusoidal pattern Looks like Vtach. Seen in severe Prolonged deceleration Deceleration for more than 2 mins. 2-
hypoxia, anaemia and 3 non-reassuring. >3: abnormal. Do
haemorrhage. Do Immediate C- fetal blood sampling/ER C-section
section ASAP!

CTG Non reassuring or abnormal: Non-reassuring Abnormal CTG:

1. Continuous CTG - HR: 100-109, 161-170 - HT <100 or >170
2. Stop oxytocin - Reduced variability 3- - Variablity absent or <3bpm
3. Put women in lateral position 5bpm for >40 mins - Decelerations: Late,
4. Give oxygen - Variable decelerations complicated variable, or
5. Fetal blood sampling prolonged >3mins
6. C-section

DRCCF | ARIMGSAS
 COC High dose COCs in:
- Break through bleeding
- Antiepileptics
- Fail of low dose
- Control of menorrhagia
POP Indicated in: Migraine, lactation,
well controlled HTN, DM, biliary
tract dx, superficial
thrombophlebitis, DVT, thyroid
dx, women>50yo, smoking
Debo Provera - Contraception for 12 weeks
- Injectable MPA
- 6 months to return fertility
Efficacy: 99.7%
Implanon - Contraception for 3 years
- Implanrable etonorgestrel
- 1 month to return fertility
- Efficacy >99%
- CI in enzyme enduing
medications (same with POP)
DRCCF | ARIMGSAS
CI in: DVT, CAD, ADVANTAGES: Obesity: Yasmin
migraine with aura, hx - Shorter lighter periods, Acne: Diane35 (EO+Cyproterone)
of breast Ca, age>35 decreased incidence of Epilepsy: High dose COC
and smoking >15 ovarian cysts, PID, acne,
cigarrettes per day, endometrium, ovary, and
polycythemia, active colon Ca, benign breast dx
liver dx, undiagnosed Ses: Break through
vaginal bleed, HTN bleeding, DVT, MI, Stroke,
>160/100, DM Thrombosis. Increase risk of
breast Ca after 10 years of
use.
CI in: Undiagnosed
vaginal bleeding, past
hx of Ca, ovarian cysts,
past hx of ectopic,
current DVT with
ongoing tx
 Mirena - Contraception for 5 years SIDE EFFECTS:
- IUCD with Levonogestrel - Ectopics, PID,
- rapid return to fertility intermenstrual
- Highest efficacy bleeding, translocation,
- DOC for women taking extrusion, perforation.
antiepileptics.
- Should be put in first 7 days of
cycle
Copper IUCD - Contraception for 10 years
Calendar Method Take the shortest and longest
cycle, substract 14 from each,
substract 6 from shortest and
add 2 from longest. Abstinence
is from those days
ORTHOPAEDICS
Harmstring Injuries - Occurs in football, cricket with RICE (Rest, Ice, Compression,
sudden acceleration Elevation, Referral) and NOHARM
deceleration movements, pain is (NO Heat, Alcohol, Re-injury,
immediately felt, audible pop, Massage) protocol
excruciating pain when walking.

Avascular necrosis of Common in elderly in long term With hip disease, limitations
femoral head steroid use, chronic alcohol eventually occur,
abuse, sickle cell dx, past hip fx particularly with internal
rotation and abduction

DRCCF | ARIMGSAS
 Pelvis Fracture Comp:
- Trapping of sciatic nerve
- PE
- Shock
- Urethra or bladder rupture
Hip-Femur Fracture
Hip Dislocation - Posterior: 90% of pts. Knee and
foot rotated toward middle of
body
- Anterior: Leg will rotate out
and away from middle of body
Wound management - Laceration: 1st wound
debridement.
- Pulselessness: 1st Reduction to
avoid cutoff of blood supply
Ankylosing Spondylitis - Limitation of lumbar spine
(Schober's test), improve with
exercise, affect sacroiliac joints
and spine, anterior uveitis, SOB
bc decrease expansion), back
stiffness, pain at rest, neck pain
and stiffness is rare and a late
symptom
DRCCF | ARIMGSAS
- Elderly:
Stable: low impact. Tx: Bed rest and
analgesics
- Young:
Unstable: high impact, after MVA. Tx
surgical fixation
- After discharge: Walk ASAP and give
pain killers to encourage being active
Intracapsular (Garden Fracture)
- Young: Open or closed reduction
- Old: Hip arthroplasty
Complications: Sciatic
nerve injury, avascular
necrosis, arthritis
1. X-ray lumnosacral 1. Physiotherapy
(Syndesmophyte 2. NSAIDs
formation, bamboo 3. Weak opioids/Paracetamol
spine by fusion of If no response to 2 NSAIDs:
spaces) 4. Axilar Involvement: Adalimumab,
2. HLAB27 Etanercept, Infliximab
3. ESR increased 4. Peripheral Involvement:
Methotrexate, Sulfasalazine
 Inferior Orbital Wall Vertical diplopia, anesthesia of
Fx (Blow-out/Tennis cheek (most common),
Racket) subjunctival haemorrhage,
enophtalmos, ptosis
Lateral Orbital Wall Fx Horizontal Diplopia

Zygomatic Fx Inability to open mouth,

horizontal or vertical diplopia,
ptosis, enophtalmos
Head Trauma Admit if >65yo, drug or alcohol
abuse, vomiting, focal
neurological deficit, skull fx
CT Scan Mild: Observe for 6 hours to see
neurological symptoms
Severe: Admit, CT scan, intubate if
GCS<8

Rip Fracture 1. Paracetamol

2. Paracetamol+codeine
3. NSAIDs
4. Morphine

Chest Trauma 1. PE: Crepitus, pain on

palpation
2. CXR
Acute Low Back Pain - Back pain with neurological
symptoms: If sciatica just
conservative tx, then MRI (for
the rest as well)
- Back pain only. If red flags
(Weight loss, previous Ca, AAA,
osteomyelitis, tb) do X-ray first,
then MRI
Cervical Spondylosis LMN signs and UMN signs below MRI - Non surgical: NSAID, massage,
lesion, sensory symptoms selective nerve root block
- Surgical: Cervical decompression

DRCCF | ARIMGSAS
 Osteomyelitis - Cx: Staph Aureus (Salmonella in
Sickle Cell Dx).
- RF: Infection, drugs, TB, deep
cellulitis)
- Back pain unrelieved by rest,
local tenderness, limping, fever,
increased ESR
Knee Injuries Indications to order X-ray:
- Isolated patellar tenderness
- Tenderness at head of fibula
- Inability to flex at 90 degrees
- Inability to bear weight after
trauma
Meniscal Tear - Seen in direct contact sport
- Pt hears a "pop", most people
can still walk or keep playing,
over 2-3 days knee become still
and swollen, stiffness and
swelling, catching or locking
knee, sensation of knee "giving
way"
Anterior Cruciate Rapid onset of hemarthrosis
Ligament
Posterior Cruciate
Ligament
Iliotibial Band - Lateral knee pain, palpable
Syndrome tenderness, pain increases when
running downhill
DRCCF | ARIMGSAS
1. Blood culture 1. MRI in DM pts and in pts 1. Strict bed rest
2. Xray/Bone Scan with osteomyelitis of 2. Ceftriaxone+Vanco
vertebral column
Absolute Cis to knee Acute Prepatellar Bursitis:
replacement: - Housemaid's knee: Bc knee
- Septic knee over hard surfaces
- Tx: Steroid injection into
prepatellar bursa
McMurray Test: LIME: Most sensitive and specific 1. RICEARS
Pain test: Thessaly test (Pt stands 2. Partial meniscectomy or meniscus
- Lateral meniscal tear. in one leg and move side to repair
pain on IIInternal side
Rotation
- Medial meniscal tear -
pain on External
rotation
Lachman test positive
Anterior Drawing test
Posterior Drawing Test
1. Plain radiographs 1. NSAIDS with steroid injections
2. MRI 2. Qx in refractory cases
 Achilles Tendon Injury - Hx of injury, high colesterol, 1. Rest
(rupture) obesity 2. Qx. For rupture refer to Qx for
- Tendibopathy (pain and repair within 3w
swelling)
- Rupture (thompson test
positive-calf squeeze, abscense
of plantar reflex, popping sound
during rupture)
Sprained Ankle - Pain, swelling, bruising, - Dislocation of ankle is considered
tenderness to touch. emergency bc of vascular structures.
- RF: sudden stop/start, If limb is cold and pale, reduce it in
hypermobility of joint field or ER. Don't wait for images
- If no vascular structures
compromised, use immobilisation,
pain killers, RICE, and NOHARM

Calcaneous Fx - Get an X-ray of spine

bc 23% of patients with
calcaneous fx also have
spinal fxs

Plantar Fasciitis Inflammation of plantar fascia, 1. Best: Physiotherapy to stretch

pain worse when pt gets out of plantar fascia and Achilles tendon
bed and better w/
walking/exercise, pain after but
not with exercise
- assoc/ w/ trauma, over
stretching, overweight
Morton Neuroma Severe burning pain between
3rd and 4th toe. Worse on
weight bearing on hard surgace
and relieved by taking shoes off
and squeezing foot. Localised

DRCCF | ARIMGSAS
 tenderness between metatarsal
heads.

Rotator Cuff US MRI

Syndrome
Compartment Sx Occurs when cast is too tight
- Earliest sign: increasing pain

PAEDIATRICS
Neonatal Pulmonary Baby at term w/ sibling that died - Bronchoalveolar lavage or lung
Alveolar Proteinosis of the same, and now have transplant
severe resp distress.
- AD

Neonatal Abstinence - Signs of withdrawal in kids: - Give morphine to assist gradual

Sx High pitched cry, hyperreflexia, withdrawal, then decrease slowly
tremors, seizures, hypertonia.
- Onset: Heroine (2-3 days),
methadone (up to 1-2w)

Neonatal Overdose Sx - Kid w/ pinpoint pupils, lethargic - Next: Bag and mask ventilation
- Use of opioids (meperidine - Best: Naloxone is tx. Should only be
(Demerol), heroine) given if mother has received
narcotics <2hrs of delivery.

Neonatal - Jitteriness, peripheral cyanosis,

Hypoglycaemia hypotonia, irritability.
- Assoc w/ hepatomegaly,
micropenis, macrosomia, cleft lip

DRCCF | ARIMGSAS
 Galarcosemia Cataracts, chronic liver failure, - Lactose free formula
FTT, delay - Screen family members
Neonatal Lupus 1st thing to think if there's
braducardia (AV block) in
newborn-> Do AntiRo atbs.
- Most commonly seen in mums
with primary Sjogren or
undifferentiated SLE
Cerebral Palsy It's persistent, non-progressive. Could be confused with
Muscle tone abnormalities, spinal muscular atrophy
delayed motor milestones. but SMA intellingence is
Usually the most common unaffected.
muscle abnormality is stiffness,
but also can be floppy,
unexplained irritability,
preference for one side of the
body.
Pain in Kids 1. Paracetamol
2. NSAIDs
3. Oxycodone
4. IN Fentanyl
CI: Codeine<18yo because can cause
respiratory depression

Foot Deformity NORMAL:

- 0-1y: Metatarsus varus
- 1-3y: Internal tibial torsion
- 5-6yr: Medial femoral torsion

DRCCF | ARIMGSAS
 Blocked Naso-Lacrimal - Mucopurulent discharge, Acute: Birth-neonates: Immediate
Duct watery eye, worse on waking, referral
conjunctiva not inflamed Chronic: 2-12m:
1. Massage the nasolacrimal sac
2. Wash wih salt water
3. Warm compress
4. Chloramphenicl drops until tears
clear

Opthalmia - Gonorrhoea (Most dangerous-

Neonatorum ER bc risk of corneal
(Neonatal perforation). 1-5d after birth. Tx:
conjunctivitis IV Cefotaxime for 7d
- Chlamydia (Most common). 10-
14d after birth. Tx: Erythromycin
for 21d+eye toilet
Umbilical Granuloma Umbilical mass in neonates. Silver Nitrate
Swelling, non mucopurulent
discharge cord is swollen and
pink
Circumcision - IndicationsL phimosis and Most effective method: Dorsal penile
balanitis nerve block
- Abs CI: Hypospadias
Balanitis Inf of foreskin, swelling, white 1. Local penile toilet
exudate, redness 2. Mupirocin
Penis shaft skin swollen to the pubis:
IV atbs

Phimosis Scarring of preputial opening Mild: Steroid topical cream

Severe: Circumsision
Botulism Dysarthria (MC symptom), Blood test for toxin Antitoxin.
descending paralysis, low Notifiable dx
reflexes, dry mouth, blurry
vision, urinary retention.

DRCCF | ARIMGSAS
 Nephroblastoma >2yo, does not cross midline, US CT/MRI to stage Nephrectomy+Chemo
(Wilms Tumour) asymptomatic
Neuroblastoma <2yo, cosses the midline, painful Bone Scan CT, MRI Qx+chemo and radio
abdominal mass, racoon eyes
(retroorbital mets)
Hepatoblastoma <5yo, intermittent abd pain, hx CT, MRI Chemo
of FAP
Hereditary AD, oedema in resp tract Low C3 & C4
angioedema (cough(), eye lids (swelling), Low C1 esterase
intestines (abd pain) inhibitor
Mongolian spots Bluish grey lesion in buttocks,
lower back, extensor surfaces of
extremitie, common in black,
asians, latin kids. Disappears by
1-2yo
Strawberry tongue Cx: Kawasaki Dx, scarlet fever, TSS1-toxin from S
allergies, toxic shock syndrome aureus for toxic shock
(assoc w tampons, diaphragms, sx
skin inf, pneumonia,
osteomyelitis)
BMI >95: Obese
85-95: Overweight
5-85: Normal
<5: Underweight

Height Calculation. Father+Mum/2

+6.5 in boys, -6.5 in girls
Growth chart Correct for prematurity but only
until 24m. So if an infant was
born at 36w, then you add 4w to
the normal milestone

DRCCF | ARIMGSAS
 Cystic fibrosis AR, defect in ion channel protein
CFTR, viscoid secrtetions in
lungs, pancreas, gut, meconium
ileus
Chronic lung dx, bronchiectasis,
fat globules on feces
examination (Diff from fatty
crystals in celiac and CMPA), vas
deferens atrophy, increase
sweat Cl: Hyponatremic
hypochloremic metabolic
alkalosis
Lactose Intolerance Watery, frothy stool, farty baby
with excoriation of buttocks.
Normal growth, hx of atbs
Cow's Milk allergy Diarrhoea, malabsoption, FTT
Toddler diarrhoea Diarrhoea with undigested food
(piece of carrot)
Caries in kids - Adult teeth replace baby teeth
between 6-12yo.E512
Infantile colic Crying for 3 hours, late
afternoon and ealy evening,
flexing legs, clenching fists,
appears in pain, everything else
normal
DRCCF | ARIMGSAS
1. Newborns: Heel Prick
test.
2. If (-) but parental
cocern: Do test for gene
mutations:
≥2 mutations: CF clinic
1 mut: Sweat chloride
test. If (+) CF clinic, if (-)
healthy carrier
1. Reducing substances
in stool
Complete elimination of
CMP challenge test
Fix nutritional deficiencies and
minimise chest infs
1. Endoscopy + biopsy - Continue breastfeeding unless
severe excoriation or inadequate
weight gain
- Formula fed infants should be
placed in soy formula
Doesn’t improve with soy milk
Reassure and explain
- Babies and toodlers: brush teeth
2x/day
- 18m-6y: brush with fluoride
toothpaste
1. Exclude organic causes
2. Reassure
 Male puberty Stage 1: kid
Stage 2: scrotal and testicular
growth
Stage 3: gynaecomastia and
voice break
Stage 4: Axillary hair and Acne
Stage 5: Adult
Females puberty 1. Boobs
2. Grow
3. Pubes
4. Flow
Short stature - Males <1.62, females <1.52.
- If constitutional delay BA<CA
(Bone Age less than
chronological age)
Enuresis - Daytime control: 4yo
- nightime control: ≥7yo
- Primary: never was dried
- Sec: dried for 6m and wet
again. MCC: Bladder inf.
Sexual abuse - C/F: guilt, anger, sex behaviour
w other kids, unexplained
physical symptoms, sleep
disturbance, poor school
performance
- Org dx: Chlamydis, syphilis,
gonorrhoea, HIV
Tourette Sx Blinking, eye twich, facial
frimacing, shoulder shrugging
DRCCF | ARIMGSAS
Delayed: 15yo. 1st Ix: Refer to endocrinologist
Bone age
Precoscious: <9.5. 1st
Ix: FSH and LH. 2nd MRI
of brain
Delayed: 13-14yo. 1st Ix Refer to endocrinologist
Bone age If only isolated growth public hair
Precoscious: <8. 1st Ix: <8yo: F/u in 6m
FSH and LH. 2nd MRI of
brain
1. Bone age x ray (left - GH Tx only if height<1st centile for
hand wrist) age, or Growth velicity <25th centile
2. TFT, LFT, IGF-1
1. Bedwetting Alarm (Start from 7yo).
Do for 6-8w, overlearn for 2w more.
2. Desmopressin. If kid is going to
school camp, preferred oral or
sublingual. IN rot recommended bc
high risk of HypoNa
- Prepubertal: Visual Refer to CPS
examination
- Postpubertal:
Speculum
1. Behavioural therapy
2. Risperidone
 with sniffing, coprolalia,
echolalia

Prodrome Difficulty concentrating, social

Schizophrenia withdrawal, decline in school
performance, becoming
superstitious
Breath Holding Spell 1-3yo, frustration->breath hold- Behavioural therapy
>cyanosis->LOC. (In seizures it's
LOC->Cyanosis
ADHD <7yo, sx in 2 situations, 1. Behavioral modification
impairment social, academic, 2. Mephylphenidate (MOA: Inhibition
occupational. Slurred speech of Dopamine and NE reuptake). If bas
compliance use the slow release

Autism Low inteligence, bad social If aggressive: Risperidone

interaction and communication,
repetitive stereotype
behaviours. Enjoys being alone

Asperger's syndrome Normal to superior intelligente, - Behavioral therapy

impaired social and
communication skills, seek
friendships
Oppositional Defiant - defiant, negative, disobidient, Best: Family therapy
Disorder hostile behaviour toward
authority figures that are
present >6m and interfere with
academic, social, occupational
functioning
But no violent or aggressive
behaviour

DRCCF | ARIMGSAS
 Conduct Disorder Violation of rules, theft,
destruction of property,
agression cruelty towards people
and animals, <18yo
Night terrors 5-7yo. Child wakes up, cannot be Family reassurance
consoled by parents, cannot
remember anything the day
after
OSA daytime sleepiness, disturbed Polysomnography 1. Adenotonsillectomy
sleep, HTN, narcolopsy 2. Weight loss
3. IN steroids for rhinitis
4. CPAP

ETHICS
Bioethical principles - Patient autonomy,
beneficence, justice (give
patients their due),
nonmalifecence
Physician assisted Illegal in Oz
suicide
Nonsexual violations Excessive self-disclosure, special
fee arrangements, extending
time beyond what was agreed,
allow telephone calls between
sessions, extra business
relationships, socialize with
patients, calling each other by
first name, treating the pt as a
friend

DRCCF | ARIMGSAS
 Sexual misconduct Mentioning pastients or doctors
sexual practices or orientation if
no relevant, ridiculling patient's
sexual preferences, commenting
in sex hx if no clinical issue,
requesting details of sex
preferences, conversations
about sexual problems or
fantasies
Vaccines in Oz Not compulsory but you can
contact court if it's for kids best
interest and parents don’t want
them
Communication with Ask family member to
indigenous people accompany them to visit, or
aboriginal healthcare worker, do
not touch pt, esp if opposite sex
Surrogacy You cant tx couple for which the
pt will be the surrogate,
compensation only for medical
expenses, provide the best care
regardless of pts keeping the
child or not, refer to mental
health counseling to the mum to
prefer her
Preventive Medicine -1ry: Prevent. Immunisation, quit PDR
smoking, promote sun
protection in 6-13yo, anti
alcohol and smoking 14-19yo
-2ry: Detect early. Screening
-3ry: Reduce Disability. Tx

DRCCF | ARIMGSAS
 CV Risk assessment E/2 years from ≥45 (35 in - Low risk (<10%): LSM + lipids e/5y
aboriginals). Assess risk for next - Mod risk (10-15%): LSM for 6m and
5 years if not change tx + lipids e/12m
- High risk (>15%): LSM+Tx + Lipids
e/12m

AUDRISK E/3 years from ≥40 (18 in

aboriginals). Assess risk for next
5 years
Hyperlipidaemia E/5 years from ≥45. Targets in pts w/ CAD Statins decrease cholesterol mainly
- Cholesterol <5.5 Fibrates decrease TG mainly
- LDL <4 - HyperTG
- TG <2 1. Diet w/ poli-unsaturated fats
- HDL >1 2. Fibrates & Omega 3 (fish oil)

Gastric banding:
- BMI>40 or BMI>35 with co-
morbidities (DM, OSA, HTN)

Obesity:
1. LSM for 6m
2. Refer to dietician
3. Medication

Case Control Studies Only retrospective. Case

(Disease) vs Control (Without
Disease) and looking for prior
exposure or RF.
- Best for outbreaks, rare
diseases

DRCCF | ARIMGSAS
 Cohort Studies Retrospective and prospective.
To diff from case control, you
have to ask what is the study
comparing. If it's people with dx
vs non disease it's case control, if
it's exposed vs non exposed then
it's cohort
- Best for incidence,
identification of RFs, causality
P value <0.05 is statistically significant
Standard Deviation Sigma is the value +/- of the SD.
1SD 68%, 2SD 95%, 3SD 99%
Confidence Interval If the CI crosses 1: Non
significant
If the CI doesn’t cross 1:
Significant
Power If you increase sample size, you
increase power
Reliability PR: Precision=Reliability.
Reproducibility, falling in same
spot
Validity Validity is accuracy. Falling close
to the middle
Sensitivity PID: Positive in disease.
Specificity NIH: Negative in Health
PPV Proportion of positive test that
are true positive
NPV Proportion of negative test that
are true negative

DRCCF | ARIMGSAS
 Laurence Moon Biedl Obesity, short stature,
hexadactily, intellectual
disability, hypogonadism
Noonan Syndrome AD, down slanting palpebral
(Male's Turner) fissure, widespread eyes, low set
ears, ptosis, short stature, Pulm
stenosis, webbed neck, FTT,
cardiac conduction and rhythm
abn
Marfan Syndrome Tall, long extremities, pectus
carinatum or excavatum,
hypermobile joints, subluxation
of lenses, aortic root aneurysms,
aortic dissection
Fragile X syndrome X-extra large testes, jaw, ears.
Pale blue irises, strabismus,
hypotonia, flexible flat feet
Duchenne Muscular Weakness in pelvic muscles and Increase CK and Genetic testing showing
Dystrophy progresses superiorly. Pt can't aldolase deletion of dystrophin
walk so uses hands to stand up
(Gowen's sign), which causes
hypertrophy of calf muscles
(Replacement of fiber for fat).
Dilated cardiomyopathy is MCC
death so you do an echo.

DRCCF | ARIMGSAS
 Klinefelter XXY so extra X makes them look
like women: Gynaecomastia,
female pubic hair, tall and long
extremities with testicular
atrophy
Dysgenesia of Comp: All effects of
seminiferous tubules hyperestrogenism
causes low inhibin B
and high FSH
Abnormal leydig cells
causes low
testosterone, and high
LH and estrogen

Huntington's Dx AD, person needs to be 18yo to

know their gene status.
Dementia, chorea, atethosis,
agression.
VATER Syndrome Vertebral anomalies, Anal
atresia, Absent radius,
Tracheoesophageal fistula, Renal
dysfunction
PSYCHIATRY

DRCCF | ARIMGSAS
 Major Depression >2w with 2 core symptoms (Low
mood, anhedonia, lethargy) and
5 of the others (change in
appetite and weight, poor
concentration, early morning
awakening, suicidal ideations,
tiredness, guilt)
- Highest Qxs with depression:
Heatt and prostate
Moderate Depression >2w with 2 core symptom + ≤3
other symptoms
Mild Depression >2w with 1 core symptom + ≤3
other symptoms
DRCCF | ARIMGSAS
SEs of antidepressants: - Mirtazapine: MOA: NA and - Without Tx episode can ladt 6-8m≥
- ALL: Erectile serotoninergic - F/u suicidal pts in 1 week.
dysfunction (sildenafil antidepressant. Causes - Pts respond best to medication +
before sex), weight gain and sedation, counseling (CBT)
anorgasmia, delayed used if hx of overdose w/ 1. SSRI (Sertraline)
ejaculation, low libido, other drugs 2. Change to another SSRI
GI distress, insomnia, - Venlafaxine: Diastolic HTN, 3. Augmentation therapy by adding
tremor. insomnia Lithium (1st) and atypical
- Fluoxetine: most likely antipsychotics (2nd).
to cause serotonin sx bc 4. Change to an SNRI
long half life, sleep - Monotherapy preferred 5. ECT (Very severe)
paralysis. But safe in - 1st ep: tx for 6-12m
pregnancy. Useful for - ≥episodes: Tx for 3-5y
post-stroke depression - Tx takes 2-4w to become
- Sertraline. Safe to use effective. If no
in pregnancy improvement by 6w you can
- Paroxetin: Pulm HTN change drug
in fetus. - Taper SSRI, then do wash
- CItalopram: Prolongs out period, then start the
Q-T other one
- Bupropion. decrease
seizure threshold. CI in
pts w seizures and
eating disorders.
Minimal sex SEs.
1. SSRI
2. CBT
1. CBT
 Dysthimia Depression before puberty or
less severe persisting symtoms
>2y
Cyclothimia Alternating episodes of
hypomania and moderate
depression for >2y
TCAs Nortriptiline, desipramine,
amitriptyline, imipramine.
SEs: Convulsions (drowsiness),
Cardiac arrythmias (prolong QT,
MCC of death), coma (Resp
depression, hypoxia) +
anticholingergic symptoms
(Hyperreflexia, dilated pupils,
urinary retention. Doesn’t cause
impotence though
Serotonin Syndrome Confusion, tremor, sweating,
tachycardia, hypertension,
CLONUS and HYPERREFLEXIA
Bipolar Depression Bipolar I: 1 manic episode
Bipolar II (True bipolar). 1
hypomania + 1 Depression
Risk: 1 parent: 15-30%. 2
parents: 50-70%. Fratenal twins:
15-25%
DRCCF | ARIMGSAS
1. CBT
2. SSRI
TCA Overdose:
- Within 1hr: Gastric lavage and ECG
for 48hrs
- After 1hr: Alkalinisation w/ IV
sodium bicarbonate
- Severe Hypotension: IV NS + IV
glucagon + Mg sulphate
- Seizures: IV Diazepam
Cx by SSRI, TCAs, MOA 1. DRABCDE
inhs, lithium, LSD, 2. Stop medications
Tramadol, St Johns 3. Cyproheptadine
wort, amphetamines,
methadone
Pregnancy 1. First line drugs: lamotrigine,
1. Lamotrigine, quetiapine, lithium, lurasidone, olanzapine and
olanzapine quetiapine
2. Lithium 2. If no response: use any of the
previous one + SSRI (any)
For PROPHYLAXIS: Use lithium
 Mania - Symptoms ≥7 days
- Functional impairment
- Delusions and hallucinations-
Psychosis
- Hospitalization
Hypomania - Symptoms ≥4 days
- NO Functional impairment
- NO Delusions and
hallucinations
- NO Hospitalization
Lithium Side effecs: Weight gain, fine
tremors, stomach pain,
hypothyroidism, hair loss,
hyperparathyroidism, DI
Toxicity Sx: Polyuria, polydipsia,
coarse tremors, hypertonia,
seizurea, arrythmias.
Precipitated by dehydration
(vomiting, gastro), diuretics
(Thiazides), NSAIDs, and exercise
DRCCF | ARIMGSAS
Grandiosity, decreased
sleep, talkative, flight of
ideas, distractibility,
psychomotor agitation,
excessive involvement
in pleasurable activityes
CI in chronic renal
failure, hypothyroidism.
In pregnancy you can
give in 1st trimester bc
risk of Epstein's
anomaly is very low
(0.05%) but you have to
do US at 16-20w to see
defects.
Pregnancy: 1. Antipsychotics: Risperidone, Olanzapine.
PLUS
1st trimester: Lithium, 2. Lithium, Sodium Valproate, Carbamazepine
olanzapine, risperidone, 3. Combine 2-3 of these drugs
4. ECT
quetiapine - Agitated pt:
2nd trimester: 1. Verbal de-escalation and psychological
Carbamazepine intervention
2. If agitation is caused by drug intoxication
then a benzodiazepine is preferred so
Midazolam
If agitation is caused by psychosis then typical
antipsychotic is preferred. Could be
zuclopenthixol (according to eTG) or
haloperidol (less preferred I think)
- Olanzapine or Risperidone
- If within 1 hour: Gastric lavage
- After 1hr: Check lithium levels:
Normal: 0.6-0.8
>2: Hospitalisation
>4 hemodialysis until zero. Monitor
for next 7d bc lithium can rebound
 ECT - 2Drs (1 a psychiatrist) should
agree ECT is best option before
doing it.
- Indications: Rapid deterioration
from depression, acute
suicidality, catatonia, poor
response to ddrugs.
Brief Psychotic Symptoms between 1 day and 1
Disorder month
1st Depression, then psychosis
(Brief) with a stressor present
Schizoaffective Schizophrenia+major affective
disorder disorder.
If psychotic symptoms are
present despite full tx of
depression, is schizoaffective
1st Psychosis, then depression
Schizophreniform Symptoms between 1 month
disorder and 6 months
DRCCF | ARIMGSAS
CI in: raised intracranial Side effects: If antidepressants are being taken,
tension or recent MI, - 10-30mins afterL Acute taper them, washout, and then ECT
retinal detachment, confusion
uncontrolled HTN, or - Resolves at 2w:
osteoporosis Anterograde amnesia
- Appears in weeks to
months: Retrograde
amnesia
Only antipsychotic for 1 mint. Don’t
tx the depressive part
Treat crazy first, bc if you tx
depression first you can cause more
mania
Similar tx than schizophrenia
 Schizophrenia - Symptoms >6m. 1 of Positive
Symptoms (DHD): Delusions,
Hallucinations, Disorganised
Speech + 2 of any symptoms
including disorganised
behaviour, flat affect,
amotivation, poverty of speech.
Pts usually have poor
insight.C578
- MCC of death: CV disease.
- Family Risk. 0 parents 1% risk, 1
parent 13% risk, 2 parents 45%
risk
DRCCF | ARIMGSAS
First episode of psychosis:
1. Tx of agitation.
- Admission and control
agitation with verbal de-
escalation.
- If pt tolerates oral:
Diazepam or Lorazepam. If
doesn’t: Haloperidol or
midazolam
2. Antipsychotics: All except
olanzapine bc metabolic
SEs. If sx last >6m keep for
2y, if sx last <6m, keep for
1y
1. Antipsychotics. Typical work better
for positive symptoms (DHD), and
atypical more for negative
symptoms.
2. If using typical and not responding
change to atypical.
3. Increase dose if no response in 3-
4w
4. Change to another antipsychotic if
no response in 4-6w doing cross-over
period.
5. Psychotherapy, family counseling
6. If 2 different antipsychotics were
tried and no change after 6-12w: ECT
 Antipsychotics MOA: Decrease dopamine
- Typical: Haloperidol,
droperidol, fluphenazine,
thioridazine, chlorpromazine,
prochlorperazine. Useful for tx of
positive symptoms. Ses:
Agitation, EPS.
- Atypical: Clozapine,
risperidone, quetiapine,
olanzapine, ziprasidone,
aripiprazole, lurasidone. Good
for negative seymptoms
DRCCF | ARIMGSAS
- Atypicals that don't - Thioridazine causes
cause EPS: ACQ reTTTinal pigmentation
Aripiprazole, Clozapine, - Risperidone: Used for
Quetiapine. tourette, ADHD. Causes
- Minimal weight gain: hyperprolactinemia (Switch
Aripiprazole, Lurasidone to aripiprazole).
- Olanzapine: Causes weight
gain & HbA1c>7.5->Change
to Aripiprazole. Can cause
hypertryglyceridemia (but
not cholesterol).
- Clozapine: Agranulocytosis
(Stop it when WBC goes
below 3000). Myocarditis
(Measure troponin),
tachycardia.
- Quetiapine: Causes
sleeping (DOC for psychosis
with insomnia). Doesnt
cause hyperprolactinemia
Side Effects:
- Acute Dystonia (2-3d): torticolis,
opisthotonos, oculogyric crisis. Tx: 1.
Reduce dose of antipsychotic. 2.
Change to another w/ less EPS For sx
relief: 3. Benztropine,
diphenhydramine, procyclidine
- Akathesia (weeks): Restlessness of
legs. Tx: 1. Reduce doses or change
drug. 2. Propranolol, diazepam,
benztropine
- Tardive Dyskinesia (3-6m): Lip
smacking, head nodding, tongue
protrussion. Tx: 1. Same than acute
dystonia but clozapine is preferred
- Neuroleptic Induced parkinsonism
(months): Classic parkin symptoms.
Tx: Same than acute dystonia
- Neuroleptic malignant Sx: = sx than
Serotonin sx but no hyperreflexia or
clonus. MOA: receptors of dopamin
are blocked and underactive. Tx:
Bromocriptine
 Common terms - Delusion: Fixed false belief
- Overvalued idea: Same than
delusion but holds stronger,
occupies person's mind
- Illusion: Misperception of a real
external stimulus
- Hallucination: Misperception
without a real stimulus
- Pareidolia: Misperception of a
real external stimulus and
association with meaning known
to the observer. Eg. Moon rabbit
- Capgras Sx: Disorder in
which a person believes
thant a relative or
friend has been
replaced by an identical
impostor.
- Paraphrenia.
Schizophrenia that
appears later in life

Delusional Disorder 1 month of JUST delusions with 1. Antipsychotics

no other psychotic symptoms. 2. Psychotherapy
The delusions are not bizarre
and can ocurre in real life like
being followed, having an
infection, etc
Folie a Deux Delusion in a person in a close 1. Separate the people
relationship who has already an
established delusion

DRCCF | ARIMGSAS
 Generalised Anxiety - Most common anxiety in
Disorder general practice. Most common
psychiatric disorder is
depression however.
- Anxiety for >6m (to fulfill
criteria, but you can have it for
2m and have anxiety)
- Restlessness, feeling on the
edge, fatigue, difficulty
concentrating, irritability, muscle
tension, sleep disturbance
Adjustment Disorder Within 3m of new stressor (new
with Anxiety job, migration, divorce).
Resolves within 6m
Acute Stress Disorder Appears within 1m and resolves
within 1m of stressor
Panic Attack Intense symptoms (palpitations,
tachycardia, sweating, shaking,
SOB, choking, fear of dying,
paresthesia) develop abruptly
and reaches a peak in 10m.
Trigger identified
Panic Disorder Recurrent panic attacks with no
triggers identified. At least 1
panic attack within 1 month
DRCCF | ARIMGSAS
1. Psychotherapy (CBT)
2. If CBT is ineffective after 3m, give
SSRI. Stop them with patient is
symptom free for more than 6m. You
can start at the same time Benzos
(diazepam, lorazepam) bc it can take
some time for SSRI to reach their
effect.
3. SNRI
1. Listen and empathy
2. CBT
3. Diazepam
4. SSRI
1. Debriefing and counselling
2. Stress bases psychotherapy
1. Perform PE to exclude medical
condition
2. Distraction methods (breathing in
and out in a paper bag)
3. To prevent future attacks: CBT,
stress management, exposure and
desensitization, SSRI (Paroxetine)
1. CBT
2. Behavioural therapy (Graded
exposure)
3. SSRI for 6-12m
 PTSD 3 symptoms for >1m after a Acute <3m 1. CBT
serious stressor (threatened Chronic >3m 2. Behavioural therapy (Graded
death or serious injury): Delayed onset: >6m exposure)
response with intense fear, after traumatic event 3. SSRI for 6-12m
horrow, helplessness, flashbacks,
difficulty falling asleep,
irritability
OCD Pt has an obsession (recurrent 1. CBT
thought from their own, not 2. BT (Exposure and response
inserted) and a compulsion (do it prevention)
w/ action, they know it's 3. SSRI: Fluoxetine, sertraline,
unreasonable and excessive), paroxetine
functioning impaired
Agoraphobia Anxiety of being in open places 1. CBT
where escape might be difficult 2. SSRI
(theatre, queue, public
transport), avoidance of
situations
Phobias Excessive fear to stimulus, 1. CBT
interfering with lifetyle 2. BT (Exposure and desensitation
therapy) 1. Teach relaxation
technique and breathing exercise. 2.
Hierarchy of unpleasant stimulus

Social phobia Persistent fear of social 1. CBT

performance, linked to panic 2. BT (exposure based)
attacks, avoidance of social 3. Training for social skills
events 4. SSRI/SNRI/MAOI

Opioids intoxication Pinpoint pupils, resp depression, Naloxone and naltrexone

euphoria, constipation, CNS
depression

DRCCF | ARIMGSAS
 Opioid withdrawal Flu-like reaction with rinorrhoea, Buprenorphine or methadone
dilated pupils, piloerection,
cramps, diarrhea, yawning, NO
FEVER according to bluebook

Amphetamine Agitation: tachycardia, fever, Haloperidol

intoxication diaphoresis, arrthmias, seizures,
midriasis, HTN
Amphetamine Crash with anxiety, lethargy, Antidepressants
withdrawal headache, cramps, fatigue,
nightmares
Cocaine intoxication = than amphetamine Benzos
intoxication + ECG changes +
fever
Cocaine withdrawal Same than amphetamines
PCP intoxication, Severe violence, psychomotor Benzos or haloperidol
angel dust agitation, HTN, nystagmus
Marihuana Euphoria, social withdrawal, CBT
intoxication can't drive, conjunctival
injection, hallucinations
Marihuana Insomnia, night sweats, nausea,
withdrawal depression, irritability, anger
Benzos intoxication Hypotension, bradycardia, resp 1. Monitor w/ IV fluids
failure, esp when used with 2. Flumazenil
alcohol
Benzos withdrawal Rebound anxiety, depression,
seizures, insomnia, HTN, tachy,
Noise sensitivity

DRCCF | ARIMGSAS
 Insomnia - In anxiety:Difficulty in initiation 1. Tx comorbidities causing insomnia
sleep 2. Implementing good sleep hygiene
- In depression: Early morning 3. Sleep restriction and stimulus
awakening control programs
4. Cognitive therapy (Best for chronic
>4w)
5. Drugs: Best for acute: Short acting
Benzos (Temazepam, zolpidem,
zopiclone, eszopiclone-do not give
with alcohol->resp depression).
Melatonin for >55 w/ chronic
insomnia

Grief Stages: 1 Denial, 2 Grief and Normal grief

despair (until 6m), 3 Acceptance 1. Short acting benzos
(6m-1y). If continues then tx. Abnormal grief: Stage 2 sx for >6m
Normal to have relapse of sx 1. Psychotherapy
during anniversary 2. SSRI-Antipsychotics
3. CBT
4. ECT

Suicide - More common season: Spring

- More common season in
schizoprhenics: Winter
- Highest risk: 1. After discharge
from hospital. 2. After
improvement of tx
Gender identity Transvesties: Just changing 1. Talk with patient
disorders clothes 2. Supportive psychotherapy
Transsexual: Considering or have
done Qx
Paraphilias Sexual fantasies for >6m with 1. Insight oriented psychotherapy
clinical impairment.

DRCCF | ARIMGSAS
 Premature ejaculation Most common sexual disorder in
Oz
Sexual impotence MCC: Vascular problem
Narcolepsy Excessive sleep
Bruxism Seen in stress, heavy alcohol
drinkers
Postpartum Blues Within 2w of delivery. Low
mood, sadness, mild depression,
doesn’t look after baby but no
thoughts of hurting baby
Postpartum Psychosis Appears within 2-w postdelivery.
Hallucinations, delusions,
thoughts of hurting baby
Postpartum Appears 1-3m postdelivery.
Depression Features of depression. Risk in
future pregnancies: 20-40%.
Thoughts about hurting baby
Postpartum obsession Appears 1-3m postdelivery.
Obsession of hurting the baby
DRCCF | ARIMGSAS
- Short term: Lignocaine before sex
- Long term: SSRI/TCA
Detailed Hx including 1. Optimise RFs and comorbidities
information about 2. Phosph 5 inhs: Sildenafil
libido and morning 3. PgE for Erection
erections
1. Day time Amphetamines/Modafinil
2. Nightime: Sodium oxybate
Place hot towel against side of face,
counselling, yoga, relaxation
exercises, meditation
1. Family support. Resolves in 1m
1. If hurting baby: CPS and organise
psych review
2. Antipsychotics: Olanzapine,
risperidone
3. ECT if resistant
If hx of previous postpartum
psychosis: start antipsychotics after
delivery
1. Antidepressants
2. ECT
If mum took SSRI or SNRI during
pregnancy, observe baby for 3 days
in hospital, then discharge
 Mature defense Mature adults wear a SASH:
mechanisms Sublimation, altruism,
supression, humour
Schizoid Happy loner, cold, not bothered
about criticism.
Schizotypal Social isolation, odd magical
thinking, body illusions, eccentric
behaviour
Paranoid Distrust and suspiciousness
about EVERYTHING (Diff from
paranoid delusion is only one
thing)
Antisocial Like conduct disorder but older Dialetical behavioral therapy
than 18yo
Narcissistic Sense of self importance,
preoccupied with power,
brilliance, beauty or love,
believes special or unique, needs
admiration, envious of others,
arrogant behaviour, lack of
empathy, his case is important
and urgent
Histrionic Attention seeking behaviour,
seductive, flirtatiouos, rapidly
shifting, exxagerating and
shallow expression, self
dramatic, pts use repression and
dissociation as defense
mechanisms

DRCCF | ARIMGSAS
 Borderline Hx of neglect during childhood, Dialectical behavioural therapy
or partner left them.
Characterised by insecurity,
impulsiveness, self harm,
difficulty coping with
abandonment, see everything as
black or white, good or bad
(extremes)
Avoidant Shy personality, alone, but they
want to socialise with people,
fear of rejection, scared of
criticism
Dependant Needs others to assume
responsibility, difficulty making
everyday decisions, clinging and
submissive behaviour
Obsessive-Compulsive Perfectionism, clearniliness,
excessive devotion to work
Dissociative Identity Different personalities at
Disorders different times
Dissociative fugue Amnesia to get away from
intolerable situation, sudden
travel away from home. They
don’t remember previous
episode
Dissociative amnesia Amnesia to escape from distress
but they don’t travel away

DRCCF | ARIMGSAS
 Depersonalisation Out of body experience. Changes
in body shape or size, cannot
recognise in mirror, feel like
watching character in boring
movie. Assoc w/ PTSH,
schizophrenia, borderline,
temporal lobe epilepsy
Derealisation External world seems unreal.
Feeling of being transported to
place you don’t know and don’t
understand
Internet Gaming Preocupation with gaming,
Disorder giving up other activities,
deceiving family members.
Pyromania Relief after setting fire
Hoarding disorder Attachment to possessions, 1. CBT
difficulties discarding, living
areas are unusable. Assoc with
emotional, sexual abuse and
neglect.
Anorexia Nervosa BMI<17.5, amenorrhoea, loss of Admission criteria: Refeeding Sx: HypoPh bc refeeding sx
body far, increased lanugo, - Postural
bradycardia (MC finding), drop>10mmHg, albumin
feelings of inferiority <20, BMI<15,
arrythmias, haem
unstable, severe
dehydration, HR<45
Bulimia BMI>18, dry skin, parotid gland
swelling, erosion of dental
enamel, hair loss, calluses on
dorm of hand, amenorrhoea

RESPIRATORY

DRCCF | ARIMGSAS
 Sarcoidosis - Noncaseating granulomas, 1. CXR Biopsy 1. No tx required in > of cases
bilateral hilar lymphadenopathy, 2. HRCT 2. Steroids
cough, arthralgia, malaise, 3. Elevated ACE 3. Methotrexate, azathioprine
erythema nodosum, anterior 4. Hypercalcemia,
uveitis, hepatosplenomegaly hypercalciuria

Idiopathic Pulmonary - Fine crackles, dypnea, clubbing 1. CXR: Ground glass 1. Bronchoscopy & Lavage 1. High dose steroids
Fibrosis appearance. 2. BEST: Lung transplant
2. PFTs: Restrictive
pattern

Asbestosis - Lower lung, inhalation of 1. Repeat CXR e/ 3-5y Pleural Biopsy (Dumbbells)
asbestos fibres, assoc/ w/
shipyard workers, insulation,
brake lining, calcification of
pleural plaques.
- Risk of:
1. Bronchogenic Ca
2. Mesothelioma
Silicosis - Upper lung, assoc w/ sand Check PPD every year Biopsy: Eggshell calcification
blasting, mining, glass and
pottery. Risk for Tb.
Coal's Worker's - Upper lung infiltrate, assoc w/ Coal macule
Pneumoconiosis coal dust. Risk of Caplan's
syndrome (rheumatoid nodules
in lungs)
Byssiniosis Cotton workers, carding rooms.
Berylliosis Work in electrical devices
companies and car industries
Common cold Malaise, tiredness, runny nose, - Drink fluids
sneezing, sore throat, low fever - Symptomatic tx

DRCCF | ARIMGSAS
 Influenza - High fever, muscle aches, less 1. Rest and fluids
sneezing and rhinorrhea. 2. Oseltamivit (within 36 hrs of onset
- IP: 1-3d and for 5d)
Hypersensitivity Intermittent cough, malaise,
Pneumonitis (Extrinsic fever, SOB
allergic alveolitis) - Related to Actinomyces or
aspergillus infection

Aspergillosis Central bronchiectasis, hx of Oral steroids.

recurrent asthma-like attacks, Antifungals
migratory pulmonary opacities,
eosinophilia, elevated IgE levels

Asthma - Hx of atopy, symptoms (worse 1. FEV1 (<60, if <40- 0-5y:

at night): cough, wheezing, SOB,
chest tightness
- Main trigger: Dust mites
severe) 1. Give salbutamol to see
2. PEF (Peak Exp Flow response to tx
Rate) (<60, if <40- >6y:
severe) 1. If child can do spirometry
3. Bronchial do FEV1, if not tx with
(Metacholine) challenge salbutamol to see response
test-give methacoline to to tx
cause asthma

DRCCF | ARIMGSAS
 COPD Cigarette smoking, alpha 1
antitrypsin deficiency
(emphysema). Hx of
exacernation (viral infection).
- Chronic bronchitis (>3m
productive cough for 2
consecutive years)
- Emphysema (Enlargement of
air spaces, skinny, pink)
Cor pulmonale Right HF (Increased JVP) + Loud
S2 or P2
DRCCF | ARIMGSAS
1. ABG (Initial for 1. Pulmonary Function test ( - At risk: Vaccines: Influenza,
exacerbation as well) to measure severity too) pneumonoccus, haemophilus, stop
2. CXR smoking
- Mild: SABA
- Moderate:
SABA+LAMA+LABA+Pulm rehab
- Severe: SABA+LAMA+LABA+Pulm
rehab+ICS
- Very severe:
SABA+LAMA+LABA+Pulm
rehab=+ICS+Long-term oxygen or
consider theophylline
Acute Exacerbation
1. Oxygen
2. SABA or LABA
3. Systemic steroids
4. ATBs despite normal CXR
5. Admit
 Pneumonia - MCC of Community: Strep
Pneumo
- MCC of hospital acquired:
Staph Aureus
Mycoplasma - Headache, X-ray looks worse
Pneumonia than pt, high fevers are rare.
- Outbreaks in military recruits,
prisons, classrooms.
Legionella Prodromal Influenza-like,
pneumonia, high fever (>40),
headache, diarrhoea. Hx of work
in cooling systems in large
buildings
Aspiration Pneumonia
Lung Abscess Fluid level, purulent sputum may
be blood straked, putrid odor
(anaerobes)
DRCCF | ARIMGSAS
CXR When to admit? CURB-65: Confusion,
urea>7, RR≥30, BP<90/60, age≥65. 0
outpatient, 1-2 inpatient, 3 inpatient
(consider ICU).
- Mild: Amoxi/Clav for 7d
- Moderate (Neonates, >65yo,
comorbidities, ≥1 lobe involvement,
≥38C): BZP+Azithro OR Ceftriaxone.
- Severe: Azythro IV + Ceftriaxone
CXR Doxycyclin
Azythromycin or doxycyclin
IV ampicilin/Sulbactam
1. CXR 1. Lung Biopsy (Best) Tx with clindamycin and review with
2. CT (More accurate) CXR:
- Responding->Continue tx
To define etiology: - Not responding->Bronchoscopy for
- Aerobic: MCS of drainage. Qx last resort.
sputum
- Anaerobic: BAL,
thoracocentesis
 Tuberculosis - Immigrant, nurse working in
rural area, caseating
granulomas, erythema nodosum,
hemoptysis, cough, night sweats,
fever
Bronchogenic - RF: Smoking, silicosis, asbestos,
Carcinoma working in gold mine and petrol
station.
- Important to exclude 1st in a
smoker pt w/ hemoptysis in the
morning
- Small cell carcinoma: SIADH,
Cushing (ectopic ACTH)
- Squamous cell carcinoma:
production of PTHrP
Pancoast Tumour Aplical malignant neoplasm of
the lung may lead to:
- Horners syndrome: miosis,
ptosis, anhydrosis
- Brachial plexus invasion:
Shoulder and arm pain, wasting
of intrinsic hand, paresthesia of
medial side of arm
Mesothelioma - Asbestosis hx.
- Takes 20-40 years for
mesothelioma to develop
DRCCF | ARIMGSAS
Prophylaxis: INH for 9
months. If resistant, use
rifapmin for 4 months
1. CXR 1. Lung Biopsy:
2. CT Scan - Bronchoscopy: Small cell
3. Sputum cytology Ca
- Transthoracic fine needle
aspiration: In periphery
(Adenocarcinoma, large cell
carcinoma)
1. CT 1. Biopsy
- No bronchoscopy or
sputum bc of location
1. CXR 1. Thoracoscopy-guided
2. CT scan pleural biopsy (98%Dx)
1. RIPE (Rifampin-orange
discoloration of urine/tears;
Isoniazid-B6 deficiency
agranulocytosis; Pyrazinamide-
arthralgia; Ethambutol-color
blindness optic neuritis) for 2 months
then RI for 4 months.
- Pyrazinamide used to reduce tx
from 9 to 6m, so if no pyrazinamide is
given like in pregnancy, tx will be
extended
Small Cell Carcinoma
1. Chemo
2. Radiotx
Qx not an option bc it metastases.
Non-small cell Carcinoma
1. Qx
2. Chemo/Radio
 Bronchiectasis Cough in the morning, purulent,
rancid odour, clubbing
RHEUMATOLOGY
Rheumatoid Arthritis - MCP, PIP, and DIP affected.
- Morning stiffness >1h, relieved
with activity.
- MCC death: CVS.
- Nodules (Tx: Intralesional
steroids), pericarditis,
myocarditis, bursitis,
mononeuritis multiplex.
Osteoarthritis - PIP, DIP affected, but NOT MCP
affected.
- Morning stiffness <30mins,
crepitus, pain, restricted
movements, joint deformity, if
affects hip (1st movement
restricted internal rotation, 2nd
movement restricted hip flexion)
Lupus - Cx: Drugs (hydralazine,
procainamide, quinidine,
phenytoin, isoniazid,
methyldopa, ACE inhibitors)
- Polyarthritis, fatigue, skin
lesions, mouth ulcers, chest
pleuritis, fever, photosensitivity,
malar rash, symmetrical arthritis,
DRCCF | ARIMGSAS
1. Sputum c/s 1. HRCT: Local honeycomb 1. Ticarcilin+Clavulanate,
2. CXR Piperacilin+Tazobactam
1. RF. 1. NSAIDs
2. anti-CCP (Specificty 2. Methotrexate (Cornerstone of Tx
96%) of RA, delays progression of disease):
3. X-ray: Loss of joint Don’t give it w/ trimetropim or
space, juxta articular cotrimoxazole bc risk of
osteoporosis, cysts. pancytopaenia. Give Cephalexin
instead for UTI; myelosupression (Do
FBC)
3. Hydroxycloroquine
1. X-ray: joint space 1. Paracetamol
narrowing with sclerosis 2. NSAIDs. If peptic ulcer: celecoxib
of subchondral bone, (increase CV risk).
osteophytes, cysts, 3. Weak opioids: codeine
periarticular 4. Intra articular steroids occasionally
osteoporosis for inflammatory episode.
5. Qx if medication doesn’t work
6. Stick: stick on good leg, 1st step
bad leg.
1. ANA Test (95% Sn) - Mild: NSAIDs
2. dsDNA. 90% Specific - Moderate: skin, joint serosa
3. ENA, especially Sm- involved: Hydroxychloroquine for
highly specific 3m. Used for long tx of lupus because
4. X-ray: Preserved joint decrease flare ups
space - Severe: Steroids mainstay of tx,
immunosupressants (Azathioprine,
methotrexate w/ folic acid)
 oral ulcers, thrombocytopaenia,
anaemia

Antiphospholipid - Recurrent thromboemnbolic 1. Anticardiolipin 1. Immunosupressants +

Antibody Syndrome events, spontaneous abortions, Anticoagulants
thrombocytopaenia
Scleroderma - CREST Syndrome: Calcinosis, Anticentromere 1. NSAIDs
Raynaud, Esophageal antibodies 2. Avoid vasospasm
dysmotility, Sclerodactily,
Teleangiectasia, sausage finger
- MCC death: Pulmonary HTN

Polymyositis and - Proximal muscle weakness 1. CK and aldolase high 1. Biopsy: Skin and muscle 1. Steroids
Dermatomyositis causing difficulty rising from low 2. Cytotoxic drugs
chair, climbing steps, lifting
objects, hanging clothes,
combing hair.
- Heliotrope rash, purple eye
lids, forehead, and cheeks;
Gottron's papules
- Assoc w/ lung and ovarian Ca
Sjogren Syndrome - Dry eyes, dry vagina, dry 1. Anti-Ro, anti-La 1. Biopsy of parotid 1. Symptomatic. Artificial tears, lube,
mouth, parotid glands 2. Schirmer's teat test. enlargement (lymphocytic saliva
enlargement, dyspareunia. infiltration of gland) 2. NSAIDs, hydroxychloroquine or
steroids

DRCCF | ARIMGSAS
 Polymyalgia - Fatigue, malaise, fever, weight 1. ESR very high 1. Oral steroids. If ocular involvement
rheumatica loss, morning stiffness >45 mins, then IV methylprednisolone
muscle weakness of shoulder
and pelvic girdle
- >50yo, weight loss.
- Assoc w/ Temporal arteritis
(unilateral throbbing headache),
jaw claudication, painless
sudden loss of vision, diplopia.
Reactive Arthritis - Can't see, can't pee, can't climb 1. NSAIDs/Physiotherapy
(Reiter's Sx) a tree: Iritis, painless ulcers of
glans penis and urethral meatus,
arthritis asymmetric. Achilles
tendonitis, oral ulcers, sausage
digits
- Usually after Chlamydia,
Salmonella, Shigella
Psoriatic arthritis Arthritis + Psoriasis 1. Steroid cream, tar
2. NSAIDs
3. Intra-articular steroids
4. DMARDs

Septic Arthritis - Haematogenous in adults,
osteomyelitis in children
- Previous Gonorrhea, staph
aureus, strep pneumo, haem
influenza
- Permanent joint destruction in
<2w
1. X-ray 1. Arthrocentesis 1. Obtain synovial fluid sample
2. Start IV Atbs empirically (don’t
wait until exams): Flucloxacillin.
- Delayed penicillin: cephazolin
- immediate hypersensitivity: Vanco
* Intra articular steroids CI in septic
art

DRCCF | ARIMGSAS
 Fibromyalgia - Hx of widespread pain, pain in
11 of 18 tender points,
dermatographia, fatigue,
anxiety, depression.
Rheumatic Fever - Common in indigenous people.
- May follow a sore throat
(Group A Strep inf), one joint
settles as the other is affected,
young person, acute fever, joint
pains, malaise
- Chorea, erythema marginatum,
fever ≥38, prolonged PR interval,
raised ESR
Gout - Pain in great toe, early hours of
morning, red shiny swollen hot
skin over joint, monoarthritis.
- Cx by alcohol, furosemide,
thiazide (indapamide), cancer,
low dose aspirin
DRCCF | ARIMGSAS
1. Reassurance and counselling
2. Rehab
3. Paracetamol for first line analgesia,
TCAs second line
1. Throat swab for ASOT 1. Paracetamol/Aspirin
and anti-DNAse B 2. BZP IM
2. Echocardiagram
*Most sensitive test for Prophylaxis
early detection) 1. Long-term penicillin (monthly). If
allergic, roxithromycin+NSAIDs.
Syndenham Chorea: Carbamazepine
or Valproate
1. Uric acid level (not 1. Synovial fluid analysis: Acute:
sensitive or specific) Monosodium urate crystals: 1. NSAIDs (Indomethacin).
2. X-ray. Joint space Negatively birefringent, Paracetamol and codeine are not
preserved, effusion, needle useful
punched out lesions. 2. Colchicine (> pain relief than
NSAIDs)
3. Steroids (If GFR<30, diarrhoea)
Chronic
1. Allopurinol (Start 8w after acute
attack)
2. Probenecid
 Pseudo-gout - Pain in knee (1st), MCP (2nd).
- Cx by dehydration, surgery,
hyperparathyroidism,
hemochromatosis, hypoMg,
hypothyroidism
1. X-ray: 1. Synovial fluid analysis: 1. NSAIDs (Ibuprofen)
Chondrocalcinosis Pyrophosphate, Positively 2. Intraarticular injections
refringent, romboid Prophylaxis:
- Colchicine, hydration

Polyarteritis Nodosa - Polyarthritis, fever, abdominal 1. ESR raised 1. Biopsy: necrotising 1. Steroids and immunosuppressants
pain, hematemesis, melena, vasculitis of small and
ischemic bowel, kidney medium arteries
impairment
Behcet Sx Oral and genital ulceration, 1. High dose steroids
arthritis (knees), ocular
symptoms, refer to
ophthalmology (sight saving)
Wegener - Lower resp tract, oral ulcers, 1. C-ANCA 1. Biopsy: Renal or lung 1. Cyclophosphamide
Granulomatosis rihonorrhea, epistaxis, biopsy
polyarthritis, GN
Takayasu Arteritis - Young female japanese with
absent peripheral pulses and
HTN
Churg Strauss Dx - Allergic rhinitis, asthma, 1. P-ANCA
systemic vasculatis,
hyperesoinophilia.
Microscopic - GN, weight loss, splinter 1. ESR, C-ANCA 1. Tissue biopsy: muscle, 1. Prednisone + Cyclophosphamide or
Polyangitis haemorrhages, wrist or foot lung, skin, nerve rituximab
drop, fever, arthralgia

DRCCF | ARIMGSAS
 Henoch Schonlein - Palpable symmetrical (non
Purpura blanching) purpura in lower
limbs/buttocks, arthalgia,
abdominal pain, hematuria, abd
pain
- Follows an upper respiratory
tract infection
- Deposition of IgA immune
complex in kidney

SURGERY
Cholelithiasis - Gallstones in the ballbladder
(cholesterol and bilirrubin).
- Majority are asymptomatic
(70%), 2% become symptomatic
every year
Cholecystitis - Fever, Jaundice, Murphy's sign
(localised tenderness over
gallbladder).
- Types: Calculous (90%) caused
by E. coli (in unstable pts) and
Kepsiella. Acalculous (10%)
emphysematous gallbladder
1. US 1. Qx if stones ≥3cm or porcelain
gallbladder
1. US (Most useful initial 1. HIDA Scan (If US is not INITIAL:
ix for detection of conclusive) 1. Bed rest, IV fluids, NPO, analgesia,
gallstones and dilation antibiotics
of common bile duct) Empiric of calculous
1. Gentamicin IV + Amoxi
- Genta CI: Clavulanate+Amoxi
Empiric of acalculous
1. Genta+Metro+Amoxi
Genta CI: Piper+Tazo

DRCCF | ARIMGSAS
 Cholangitis Charcot's Triad: Fever with chills
+ Upper abdominal pain +
Jaundice
Reynaud's pentad: + Sepsis +
Confusion
In the context of obstruction
(dark urine, acholia)
Post-cholecystectomy - Diarrhoea (MC Sx), abd pain,
sx nausea, jaundice, bloating,
dyspepsia
- Cx by previous Qx in biliary
tract
Appendicitis - Retrocecal: Loin tenderness,
psoas sign
- Pelvic: Diarrhoea, tenderness
on DRE, obturator sign. 1st Ix: US
of pelvis. Best Ix: Appendiceal CT
- Rovsign Sign: Pain in RIF when
palpation LIF
Appendiceal Cancer
DRCCF | ARIMGSAS
1. US 1. ERCP (Endoscopic 1. Fluids
decompression of bile 2. NPO
ducts. Dx and Tx 3. Analgesics
4. Antibiotics IV: Genta + Amoxi. If
chronic add metro
5. ERCP: Urgent decompression in
>70yo, DM, comorbid conditions.
6. Percutaneous cholecystostomy: If
pt is not fit for Qx and can't take pt
off medications. It's a temporary
drainage that relieves symptoms
1. US 1. ERCP w/ biliary
manometry
1. WBC 1. CT in adults 1. Atb: Genta+Metro+Amoxi
1. USG in pregnant and Genta CI: Ceftriaxone+Metro or
children Amoxi+clavulanate
Penicilin CI: Genta+Clinda
2. Laparoscopic > Open Qx
If they are only in the mucosa. Do
nothing. If they are a bit more bigger
then right hemicolectomy
 Perforated Peptic - Epigastric pain that doesn’t go 1. X-ray (Free gas under 1. CT Scan 1. Pain relief
Ulcer to back. diaphragm 2. NGT
2. Gastrograffin swallow 3. Atbs
or meal to identify 4. Immediate laparotomy
where perforation is

Peritonitis - Board like rigidity with 1. Genta+Metro+Amoxi

guarding, no abd distension Genta CI: Piper Tazo
(reduced bowel sounds) Hypersensitivity to penicilin:
- Normal first, then tachycardia, Genta+Clinda.
then shock 2. Swith to oral Amoxi+Clavulanate
for 5d

DRCCF | ARIMGSAS
 Acute Pancreatitis - Epigastric pain that goes to
back, pt feels better bending
forward, lack of guarding, rigidity
or rebound, reduced bowel
sounds, fever, tachycardia,
shock.
- Follows an alcohol binge.
- Cx: Gallstones, ethanol,
trauma, steroids, mumps,
autoimmune, scorpion, spider,
hyperlipidemia, ERCP, drugs
- Severe necrotising hemorrhagic
pancreatitis: Cullen sign (around
umbilicus), Grey turner (in loins),
polyarthritis. Earliest Comp:
Renal failure bc haemorrhage
and ARF
Pancreatic pseudocyst - Mass in epigastric area in
context of pancreatitis
Chronic Pancreatitis - Alcohol consumption,
epigastric pain, weight loss, loss
of pancreatic function,
diarrhoea, steatorrhoea. Serum
amylase and lipase and often
normal
DRCCF | ARIMGSAS
1. Lipase (Most 1. Admit to hospital
sensitive and specific) 2. NPO
and amylase 3. Bed rest
2. Abdominal X-ray: 4. NG suction
Colon cutoff sign and 5. IV fluids
sentinel loop (Dilation 6. Analgesics: Morphine IV
of ascending and 7. ERCP if obstructive LFTs (MCC of
transverse that abruptly acute bile duct obstruction in 3ry
finishes at splenic hospitals)
flexure) 8. Atbs: Only if infected, pancreatic
3. Abdominal US: necrosis, or pancreatic abscess.
peripancreatic fluid Empirical: Piper-Tazo IV for 7d. If
4. Abdominal CT: esp allergic to penicillin:
for complications Ceftriaxone+Metro
9. Surgery. Indications: Abscess,
infected pseudocyst, necrosis,
gallstone assoc pancreatitis,
uncertain in clinical dx, worsening
condition despite tx
1. US - ≤4: Observation.
2. CT - ≥5: Endoscopic cystogastrostomy.
- If pseudoaneurysm or complicated
pseudocyst: Laparotomy
1. CT Scan 1. Analgesia: PCM, codeine
2. US to detect 2. Pancreatic enzyme supplements
obstruction by stone or 3. Tx DM
stricture
3. MRCP (Most
sensitive)
 Pancreatic Cancer - Painless obstructive 1. US 1. CT Scan with contrast 1. Pancreaticoduodenectomy
progressive jaundice, dark urine, 2. ERCP if concurrent (Whipple)
steathorrhoea. cholangitis
- Trousseau Sx: Causes
superficial thromboflebitis and
increased thrombus
- Superficial thrombophlebitis.
Caused by IV infusion (NSAIDs),
spontaneous: LMWH for 4w
- Courvoisier sign: Enlarged
gallbladder bc obstruction
- RF: Smoking, DM, chronic
pancreatitis, obesity, inactivity

SBO - Cx: 1. Adhesions. 2. Tumours. 3. 1. X-ray erect abdomen 1. IV fluids

Hernias.
- High SBO: Mainly pain and
dehydration
- Low SBO: Mainly distension
- Noisy abdomen (sharp bowel
sounds)
(Step ladder air fluid 2. NGT
levels, coin sign 3. Gastrograffin follow through
2. Gastrograffin meal. 4. Laparotomy to remove obstruction
Dx and tx
- Ileotomy & extraction: Best for SBO
in long hx of cholecystitis

LBO - Cx: 1. Colon Ca. 2. Sigmoid 1. X-ray (Irregular 1. CT scan (Best) 1. IV fluids
volvulus (elderly). 3. Fecal haustral folds) 2. NGT
impaction (+ stools on DRE) 2. Gastrograffin enema 3. Gastrograffin enema
- Sx: Distension, mild pain, 4. Qx
increased bowel sounds

Paralytic ileus - PostQx, inf, hypoK, hypoCa, no

pain, no noise, absolute
constipation, distension. When
solved, accumulated fluid will be
reabsorbed and increase diuresis

DRCCF | ARIMGSAS
 Sigmoid Volvulus - Tympanic abdomen, colicky
abd pain, empty rectum.
- Common in elderly w/ use of
laxatives of hx of constipation, or
bedridden
- It's a LBO
Caecal Volvulus
Pseudo-obstruction - Oglivie's syndrome.
- Assoc w/ Anti-parkinsonian
drugs, parkinsonisms (Hx of
falls), opioids, CCB.
- Seen in elderly who are very
sick
Splenic Injury - Indications for splenectomy:
Trauma, spontaneous rupture
(Inf mononucleosis),
hypersplenism (ITP), neoplasia
- Comp: 1. Pneumonoccus inf. 2.
haemophilis. 3. Neisseria. 4.
Malaria
DRCCF | ARIMGSAS
1. X-ray (Coffee bean or 1. CT Scan (Best) 1. Sigmoidoscopy to relieve pressure
jelly bean sign) 2. Qx
1. X-ray (dead fetus 1. CT Scan
sign)
1. Neostigmine
2. Colonoscopic decompression
3. Laparotomy
1. FAST Scan is in 1. CT is preferred modality Prophylaxis:
hemodynamically for adults and children with Amoxi OR phenoxymethylpenicilin
unstable pt and not in abdominal blunt trauma for:
children - 3 years after splenectomy,
- Until 5 years old in children w/ SCD
or congenital haemoglobinopathy.
- Lifelong for pts that survived post-
splenectomy inf,
immunocompromised, had
haematological malignancy
Splenectomy and pt had sore throat
- <2 years since splenectomy: Amoxi
Oral
- >2 years: 1. Reassure and observe.
2. If fever->Amoxi
 Diverticulitis - Acute left iliac fossa pain, 1. WBC CT Scan (To detect fistula, 1. Hospital admission, NPO,
increases with change in abscess, or perforation) analgesics.
posture, tenderness, guarding, 2. Atbs:
rigidity in LIF, fever. Can - Mild: Amoxy+Clavulanate for 5d
perforate (high mortality), or - Severe: Amoxy + Genta + Metro IV
cause fistulas, abscess,
peritonitis, bleeding (MCC of
acute bleeding from large bowel)
Governerur Sx - Suprapubic pain, frequency, 1. Hospitalization
dysuria, tenesmus, pneumaturia, 2. Correct fluids
fecaluria 3. Diazepam
Pilonidal sinus - Nest of hairs in hirsute young 1. Qx
men, cyst or abscess 2. Atbs only if cellulitis is present
Recurrent: Shave area and keep it
clean

Haemorrhoids (Piles) - Cx: Constipation. Prevention:

- Bleeding, prolapse, mucoid 1. Fiber and fluids to avoid
discharge constipation
- (SI) Symptomatic, red when
prolapsed: Internal Stage I and II: Conservative tx
- (NE) Nosymptomatic: Externa Stage III and IV: Refer for rubber
band ligation
Stages: I above dentate line, II
only during straining, III requires
manual replacement, IV prolapse
cannot be reduced

DRCCF | ARIMGSAS
 Anal Fissure - Most fissures are at 6 o-clock. Acute
- Anal pain worse with 1. Glyceryl trinitrate
defecation and small bright red For kids (Anusol 1st, then laxatives)
blood from rectum
- MCC of bleeding per rectum in Chronic
2,5 yo child. 1. Local inj. Of botulinum toxin
- Severe excruciating pain after 2. Qx
30 mins of pooing + bleeding in
toilet paper
Proctalgia fugax - Brief self limited episodes of 1. Reassurance
sudden short attacks of intense
stabbing pain in anal sphincter
Anorectal abscess - Pain caused by inf of anal 1. Urgent surgical drainage
glands (above dentate line, 2. Atb: Mild (Amoxi/Clav), Severe
lubricate the poo) (Amoxy+Genta+Metro)
Perianal Abscess - Red area near anus 1. Incision under local anesthesia
2. Atbs
Anorectal Fistula - Hx of chrohn or schistosomiasis 1. Draining abscess, lay open fistula.
(Somalian w/ soiling) 2. Refer
Hiatal Hernia 1. X-ray 1. Barium X-ray
Incarcerated hernia No pain, no tenderness, no Emergency
cough impulse
Inguinal hernia - Indirect: Does not touch Birth-6w: Qx in 2d
midline, goes to testicle 6w-6m: Qx in 2w
(Examiner finger cannot get >6m: Qx in 2m.
above swelling bc the hernia is Irreducible: Urgent Qx
there), more change to
strangulate
- Direct: Touches the midline.
Less change to strangulate

DRCCF | ARIMGSAS
 Femoral hernia - Does not touch midline, lateral 1. Qx ASAP bc likely to strangulate
to pubic tubercle, most likely to
strangulate. VAN looking from
up to down

Epigastric hernia Pt lies supine and cough and - Qx if >6 months old
protrudes but doesn’t move
umbilicus
Diactesis of Recti Pt lies supine and cough and 1. Physio
protrudes and moves umbilicus. 2. Qx
Happy face
Post-Operative Fever - 24 hours: Atelectasis - Tx of Atelectasis: 1. Chest Physio. 2.
- 3-5d: Pneumonia, sepsis, Supplemental Oxygen. 3. Postural
wound inf, abscess, DVT drainage w/ bronchoscopy while pt is
- >5d: Specific comp of Qx: on CPAP
Bowel anastomosis, fistula,
wound inf Fever at 7d PostQx
- Superficial. Remove suture, no atbs
- Cellulitis but no fluctuance: Atbs
- Cellulitis, fluctuance: Abscess. 1.
Drain. 2. Atbs

Salivary Stone - Pain increase after eating 1. X-ray bc 80% of Excision or Sialendoscopy
submandibular calculi
are radio-opaque
Sialadenitis - MC germ: Staph Aureus
Suppurative - Painful swelling: Glands
enlarged, hot, tense, with pus.
- Does not affect facial nerve

DRCCF | ARIMGSAS
 Submandibular - Cx by Mycobacterium Avium. 1. Excision of abscess & lymph node
abscess - Painless cold abscess that starts
as lymph node enlargement for
4-6w at 1-2yo

Parotid Gland Tumour - Compression of VII->Facial 1. CT 1. FNA w/ biopsy

paralysis 2. MRI
Plemoporphic - Takes 5-10 years to grow, does 1. Needle biopsy Surgical excision
adenoma not cause facial nerve palsy
Adenoid cystic - Painless, causes facial nerve 1. Needle biopsy Surgical excision
carcinoma palsy
Neck Lumps 1. CT Scan if suspicion
of neoplasm (>2cm,
fixed, hard, non-tender)
1. US if suspicion of
inflammatory process
(<2cm, mobile, squishy,
tender)
Anterior Triangle BCC
- Branchial cyst: 20-40yo, can get
infected. Tx: excision
- Carotid body tumour: Pulsatile
mass that moves laterally. Tx:
Excision
- Carotid aneurysm
Posterior Triangle CCP
- Cystic Hygroma. Transluminal
mass. Tx Surgery
- Cervical Rib
- Pancoast Tumour

DRCCF | ARIMGSAS
 Midline Neck TTD
- Thyroid Nodule. Next: TSH
- Thyroglossal duct: Moves
upwards with protrussion of
tongue
- Dermoid cyst: Teratoma
Abdominal Aortic Suggested AAA surveillance (w/
Aneurysm US)
- 3.0-3.9 cm: e/ 24m
- 4.0-4.5 cm: e/ 12m
- 4.6-5.0 cm: e/ 6m
- ≥5.1 cm: e/3m
- If 1st degree rel has it, 20% risk
of getting it. Arrange regular
screening from 50yo.
- Ruptured: Sudden abd. Pain,
radiating to back, syncope,
shock, pulsatile tender abd mass
Aortic Dissection - Abrupt chest pain, sharpm
migratingm irradiating to the
back, unequal or absent pulses,
difference of BP in arms,
diastolic murmur if AR ocurred.
- Type A (ascending aorta), B
(descending)
DRCCF | ARIMGSAS
1. US. Best for 1. CT Scan (Best) When to refer?
screening. - Male w/ AAA >5.5cm
- Female w/ AAA >5.0cm
1. FAST US. Next - Male or female in thoracic aortic
bedside ix for ruptured. and aortic iliac aneurysms >3.5cm
not reliable in kids bc - Rapid growth >1cm/year
low volume. If it's - Symptomatic AAA (independently of
positive >800mL fluid the size)
loss.
Tx:
1. Referal to vascular Qx
2. Open repair or endovascular repair
Tx of ruptured:
1. IV line (Colloids), not crystalloid
(NS) bc will dilute coagulation factors,
more bleeding
1. Transesophageal 1. CT angiogram 1. BB (to reduce shear stress)
Echocardiogram 2. Immediate Qx for type A
(ascending aorta)
 Mesenteric Ischaemia - Cx by thrombosis or embolus
from Afib
- Central abd pain, vomiting with
bloody diarrhoea, tenderness,
rigidity, absent bowel sounds,
confusion
Pseudoaneurysm - Haematoma, painful pulsatile
groin mass
Carotid Artery
Stenosis
Carotid haematoma - Comp of carotid art
endarterectomy.
- Progressive and quick SOB
Retroperitoneal - Cx by warfarin tx
haematoma
Acute Lower limb - Cx: 1. Thrombosis. 2. Embolism
ischaemia - MC site of occlusion: Common
femoral art, esp superficial
femoral art: Pain in calf
- Thrombosis in common
iliac/external iliac: Pain in
buttock.
- Sx of arterial occlusion:
Paralysis: Most reliable sign
requiring Emergency Qx
intervention, pain, pulselessness,
pallor, paresthesia
DRCCF | ARIMGSAS
1. X-ray: Thumb printing 1. CT Scan 1. Resection of necrosed gut
1. Dupplex Doppler US 1. US-guided thrombin injection
1. Aspirin
2. Statin
3. Use of endarterectomy is >50 and
symptomatic or >70 and
asymptomatic
- Unstable: Intubation
1. Open wound layers in ER room
1. Vit K IV bc besides being the tx of
warfarin overdose, you can also give
heparin
2. Prothrombinex
3. FFP
1. US 1. Digital subtraction Golden time: 4hrs
2. CT angiogram arteriography or just 1. IV Unfractionated Heparin
arteriography 2. Embolectomy. Can cause
reperfusion injury (HyperK, metab
acid, myoglobinuria, increased CK).
Keep pt hydrated and perfused
3. After acute, give warfarin for 3-6m
 Chronic Lower Limb - Claudication (pain w/ exercise
Ischaemia and relieved by rest), if pain at
rest: RED FLAG, shiny hairless
legs, muscles atrophied
Raynaud - Bilateral vasopasms, fingers are
white or blue. Can be 1ry or 2ry
to a lot of dxs
Buerger Dx - Vaso-oclussive dx assoc w/
heavy tobacco use, auto
multilation, black fingers
Chilblains - Cx by cold weather and poor
circulation. Burning sensation,
finfers are red, blue or white
DVT - RFs: Age>60, smoking, flight or
qx, pregnancy, malignant
diseases, CHF, IBD (crohn
disease and UC)
- C/F: Tenderness in calf,
unilateral leg swelling
Upper Extremity DVT - Hx of young person trimming a
tree, wresting, using a chainsa
w/ edema (non pitting) of
shoulder, arm, and hand ->
Subclavian thrombosis
DRCCF | ARIMGSAS
1. Measure ABI 1. CT Angiography w/ ABI:
2. Duplex US contrast (Be aware in CKD) 1-1.4: Normal
0.9: Borderline. Nothing
<0.9: 1. Risk factor management
(Smoke cessation, statins, ace
inhibitors), for mixed ulcers (Do not
use compression bandage if ABI <0.8)
<0.4: Urgent referral
1. LSM: avoid cold, triggers, use
gloves
2. Nifedipine
1. Duplex US 1. Contrast Venography 1. LMWH
2. Warfarin (within 24-48 hrs)
3. Cava filters in pts that have CIs to
anticoagulation or have poor
compliance or failure of
anticoagulation
1. CXR
 SVC Syndrome Caused by malignancies 1. Dupplex US for Contrast Venography 1. LMWH
(Pancoast tumour, etc) or by catheter related
central catheter. 1. CXR for malignancies
Pt has facial plethora

Varicose Veins - RF: Female, pregnancy, age, 1. Venous duplex US (Ix of - ABI ≥0.9: Compression stocking safe
ocupation choice) - ABI≤0.8: Can't use compression
- C/F: 1st symptom: Ankle flare stocking.
edema (least likely indication for
referral), pain improves on - Varicose veins w/ Ulceration:
walking, varicose veins, skin Compression bandage
pigmentation, ulcers - Varicose veins w/OOO ulceration:
Compression stOOOcking

Venous Ulcers - Location: Medial distal leg (just 1. Venous duplex US (Ix of - Compression bandage
above internal malloeolus) choice) - Weight reduction
- edema, irregular borders - Increase exercise
- If eczema: Topical steroids
- Non healing ulcer: Wound swab
- Atbs only if clinical signs of infection
(But not topical bc delay wound
healing)

Arterial Ulcers - Location: Tops of feet or toes, 1. LSM

painful esp at night, punched out 2. Wound care
appearance, loss of leg hair, faint 3. Atbs in infection present
or absent ankle pulses, black
eschar, necrotic border

DRCCF | ARIMGSAS
 Diabetic Foot Ulcer - Location: First metatarsal area
- Non necrotic border
Marjolin Ulcers Cutaneous SCC, ulcer that
persists >3m at site of scar
DRCCF | ARIMGSAS
1. X-ray 1. MRI to r/o osteomyelitis
in an ulcer that doesn’t heal
1. Biopsy
MRI can be done to assess
degree of soft tissue and
bone involvement
- Uninfected: 1cm odorless ulcer.
Wet dressing
- Mild: Purulence, erythema BUT no
cellulitis/erythema and smaller than
2cm: 1 Wound debridement. 2. Swab
of wound for cultures. 3. Atbs
(Amoxi+Clavulanate OR
Cephalexine+Metro)
- Moderate: Infection + Cellulitis
>2cm. 1. Wound debridment. 2. Swab
of wound for cultures. 3. Atbs:
Dicloxacilin/flucloxacilin. Add metro if
discharge is odorous
- Severe: Infection + Systemic
symptoms (fever, tachy, hypotension,
confusion> Piper-tazo,
ticarcilin+clavulanate
1. Wide excision
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