Plabkeys Updates PDF Coe

4/20/2020
26 I Page [ M i s c e I I a n e o u s] ©Copyright www.plab1keys.com (Constantly updated for online subscribers)
Key20
v ffhyroglobulin (Tg)l levels are very helpful thyroid cancer markers. They may
indicate recurrent or metastasis of thyroid cancer after a successful removal of
the thyroid (during follow-up).
v They can be used after thyroidectomy for a thyroid cancer.
v (But they are not helpful in the Dx of thyroid cancer).
Key21
A patient with Hx of metastasized colorectal cancer presents with persistent
vomiting of fecal content, colicky abdominal pain. His abdomen is distended and
there are high-pitched sounds. What is the most appropriate management?
v Initial step -7 Insert INasogastric Tube (NGT)l "for decompression".
v Definitive/ most palliative step -7 ls tomal
Vomiting of f~.<;9.L~.9.n~~n.t?. -7 NGT.
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Key22
A 50 YO man has a Hx of productive cough and fever. He also as left chest pain
on breathing. On chest examination, there is dullness on percussion of the left
lower lobe along with absent breath sounds. What is the most likely chest X-ray
finding?
-7 IPleural effusion!.
He has likely suffered from pneumonia which has led to pleural effusion.
v Absent breath sounds+ Dullness on percussion -7 Pleural effusion.

v lnspiratory crackles+ Dullness on percussion -7 Consolidations.
Key23
ttJ A teratoma is a tumor made up of several different types of tissue, such as

hair, muscle, teeth, epithelium, cartilage or bone .
ttJ They typically form in the ovary, testicle, or tail bone and less commonly in
other areas.
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ttJ Symptoms may be minimal if the tumor is small.
ttJ A testicular teratoma may present as a painless lump.
ttJ Complications may include ovarian torsion, testicular torsion, or hydrops

fetal is.
ttJ In males, teratoma is always malignant, while in females, it is usually benign.
Testicular teratoma
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Key24
ttJ Capecitabine is a chemotherapy used in many types of cancer (e.g.

breast and colon).
ttJ Among its important side effects that it causes profuse diarrhea.
ttJ Patients who are on Capecitabine and develops diarrhea require fluid
replacements and anti-diarrheal medications e.g. loperamide to avoid
severe dehydration.
ttJ If still there is profuse diarrhea and dehydration, .C~p~~-i.t~.P.i.IJ.~.-~b.9.~Jd .. b.~
.~t9.P..P~.9..
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vague terms and modes of dying such as (Res'Ji dtory mst1 ess/
• , . .... ,1111
Ca idc d ·est/ Ca 0VdS dr event/ C est i tect1ons/ Cd ·d ovascc.la .eve t).
Key For the bed-ridden very elderly patients who still have mental
39 capacity, if they develop a disease (e.g. Pneumonia), we need to:
~ loiscuss their wishes on the management plan~ whether they prefer to be

treated at home or in hosQital.
Key An elderly woman with metastatic breast cancer being under the
40 palliative care team. She needs 60 mg oral morphine twice a day to
control her pain. However, she now has difficulty in swallowing and
thus will be shifted to subcutaneous morphine. What should be the
dose?
~ ~O mg subcutaneous morphine over 24 hoursl.
Ill From [Oral morphine to Subcutaneous morphine] ~ (~ 21)

Ill From [Oral morphine to Subcutaneous diamorphine] ~ (~ 3ll
111 From [Oral tramadol to IV morphine) ~ (r n)
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v Remember, palliative patients are preferred to receive Subcutaneous

medications rather than IV or IM.
v She takes 60 mg oral morphine twice a day (i.e. 120 mg over 24

hours).
v To shift to SC morphine, divide the 24-hour dose by 2 and give it over

24 hours.
v This means 120/2 = 60 mg over 24 hours.
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Also Remember:
oo Ramsay Hunt Syndrome {Herpes Zoster Oticus)
v Reactivation of Varicella Zoster Virus (VZV) in the geniculate ganglion of the

facial nerve (7th CN) -? Facial palsy (ipsilat eral facial palsy, loss of taste).
v Otalgia " ear pain" "First symptom", Tinnitus, Vertigo, Unilateral Hearing loss,
Painful rash/ vesicles around the ear or on the auditory canal.
v Rx -? Oral Aciclovir + Corticosteroids + Amitriptyline "for the pain".
Key Orbital cellulitis

48
• Orbital cellulitis is the result of an infection affecting the fat and muscles
posterior to the orbital septum, within the orbit but not involving the globe.
• It is usually caused by a spreading upper respiratory tract infection from the

sinuses (esp. ethmoid) and carries a high mortality rate.
• Orbital cellulitis is a medical emergency requiring hospital admission and
urgent senior review.
• Periorbital (preseptal) cellulitis is a less serious superficial infection anterior

to the orbital septum, resulting from a superficial tissue injury (chalazion,
insect bite etc ...). Periorbital cellulitis can progress to orbital cellulitis.
1111 Epidemiology
Mean age of hospitalisation 7-12 years.
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1111 Risk factors

v Childhood
v Recent Hx of URTI
v Previous sinus infection
v Lack of Haemophilus influenzae type b (Hibl vaccination
v Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis)
v Ear or facial infection
1111 Presentation
v Redness and swelling around the eye
v Severe ocular pain
v Visual disturbance (Not Always!).
v Proptosis
v Ophthalmoplegia (limited eye movements) /pain with eye movements
v Eyelid oedema and ptosis
v Drowsiness+/- Nausea/vomiting in meningeal involvement (Rare)
1111 Differentiating orbital from preseptal cellulitis

reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements
are NOT consistent with preseptal cellulitis
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1111 Investigations
• Full blood count - WBC elevated, raised inflammatory markers.
• Clinical examination involving complete ophthalmological assessment -
Decreased vi sion, afferent pupillary defect, proptosis, dysmotility, oedema,
erythema.
• CT with contrast of the sinus, orbit and brain - Inflammation of the orbital
tissues deep to the septum, sinusitis, excludes abscess formation.
• Blood culture and microbiological swab to determine the organism.
Most common bacterial causes - Streptococcus, Staphylococcus aureus,
Haemophilus influenzae B.
1111 Management
v Admission to hospital for broad spectrum IV antibiotics.
v CT scan of the sinus, orbit and brain.
v May require drainage of abscess and decompression.
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Scenario:
A 9 YO girl is brough to the ED by her mother complaining of left eye

pain of 3 days that has been worsening. She also has malaise. There is no
Hx of trauma. Her mother mentions that the girl had runny nose, fever
and cough 10 days ago. On examination, the left eye shows redness,
swell ing, protrusion, restricted and painfu l eye rnovernents. Her visual
acuity is 6/6. Her temperature is 39. What is the most appropriate initial
investigation?
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Key IPerthes' disease!

57
a Perthes' disease is a degenerative condition affecting the hip joints of

children, typically between the ages of 3-9 years.
a It is due to avascular necrosis of the femoral head, specifically the femoral

epiphysis. Impaired blood supply to the femoral head causes bone infarction.
a Perthes' disease is 5 times more common in boys. Around 10% of cases are
bilateral.
llill Features
v Hip pain : develops pr,qgr.~~.$.!v.g!Y. . 9.v.gr.w..~g~~.:.IJ'.\9.f.1~b~

v Limping.
v Stiffness and reduced range of hip movement.
v X-ray: early changes include widening of joint space, later changes include
decreased femoral head size/f!.~!!~f.!).Q_g, r.~9.!.9.!.Y.f.~.Q.~Y..9.f.!.t1.~..l?.f.Q~.lm.~.I.
m.gt~.t?.hY.$.!~.·
DDx according to age:

•I< 3 year~ -7 Developmental dysplasia of the hip (usually girl, breech
presentation) I toddler's fracture e.g. spiral injury, may not be seen on X-ray.
• ~-9 year~ -7 Perthes disease (Chronic, stiffness, flattening on x-ray).

• ~ 9 YOj -7 Slipped upper femoral epiphysis (boy, shorter leg, limping).
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Key Torus (Buckle) Fracture.

58
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Bone
Buckle
Fracture
Buckle, or torus, fractures are incomplete fractures of the shaft of a long bone
that is characterised by bulging of the cortex. They typically occur in children
aged 5-10 years.
As they are typically self-limiting, they do not usually require operative

intervention and can sometimes be managed with splinting and
immobilisation rather than a cast.
Scenario:
An 8 YO boy fell on his outstretched right hand and presents with marked
pain, swelling and bruising of his right hand and wrist . There is no
neurovascular deficit. What is the most likely fracture to be seen on X-ray?
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-7 Buckling of the distal radiu .
v As children have more elastic bones than adults, the buckling (not full
fracture, leaving a cortex portion intact) is common among children.
v The most common type of fracture in childhood is buckle (torus) fracture.
v The most common site is -7 distal radius.
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C. Performance anxiety
D. Depression
SSRl-induced sexual dysfunction can occur in both men and women.
SSRls examples -7 (Fluoxetine, Sertraline, Citalopram)
Key Pain ladder (Analgesia Ladder)

76
1) Simple analgesia -7 Paracetamol, NSAIDs, Aspirin.

2) Weak opiates -7 Codeine, Tramadol, Dihydrocodeine.
3) Strong opiates -7 Morphine, Fentanyl patches, Diamorphine, Oxycodone.
v Remember, we should not go back on the pain ladder, we either go

forwards, 1' dose, replace to a stronger option or add-on. (No Backward on
the ladder).
v Fentanyl patches have a slow onset of action; therefore, they should be

avoided in a patient who is still in pain.
Key A 44 YO woman had rib fracture and is now due for discharge. She still
77 needs pain relievers at home. Knowing that she has bipolar disorder and is
on lithium, what is the most appropriate pain killer for her among the
options?
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A. ~odeinel
B. Aspirin
C. Diclofenac
D. Naproxen
E. Ibuprofen
Ill lithium and (NSAIDs) e.g. ibuprofen interaction :
~1
1' renal reabsorption of lithium!i.e. I-!, renal clearance of lithium v.I
~ 11' Risk of lithium Toxicity!.
Note, Diuretics and NSAIDs (e.g. Ibuprofen) and Aspirin increase renal
reabsorption of lithium and hence, the serum lithium increases and may lead
to toxicity .
..../ Therefore , NSAIDs (e.g. Ibuprofen , Diclofenac, Naproxen) should not

be used in concurrence with lithium as they can increase the serum
concentration of lithium and thus lead to lithium toxicity .
..../ Codeine is safe to be used with lithium.
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..J Aspirin is not a typical pain killer for injuries.
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Desaturating (Despite High Flow 02), Silent Chest ~ Going into Resp. Failure
~Intubate
Key An asymptomatic child with Cytomegalovirus infection (CMV). His mother

128 wants to know the long-term complications?
A. Blindness
B. IDeafness (Hearing loss)I
C. Hydrocephalus
D. Microcephaly
v Congenital infections (e.g. Congenital Cytomegalovirus CMV)

~ ~ensorineural Hearing Loss (SNHLM.
The sequelae (Complications) following congenital CMV infection include

sensorineural hearing loss (SNHL), retinitis, mental retardation,
microcephaly, seizures, and cerebral palsy. The most common sequelae
following congenital CMV infection is SNHL.
Key A 10 months old boy presents with loose stools and persistent diarrhea. He
129 also has lost weight over the past few months since he was weaned. Celiac
disease is suspected and labs are as follows:
Tissue transglutaminase (TTG) antibodies (lgA): Negative.
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lgA deficiency present.
What is the most appropriate action?
7 IRequest lgG instead~
This child boy likely has celiac disease. As there is lgA deficiency, the negative
TIG here is false negative. Thus, order lgG instead.
Key A 5 YO boy presents with bilateral lower limb pitting edema, abdominal
130 pain, diarrhea, and puffy eyes in the morning. What is the best "NEXT"
investigation?
7 IUrinalysi~
v This is a likely case of Nephrotic syndrome.

v Urinalysis would show proteinuria, and it is usually the initial investigation.
v The definitive investigation is Renal Biopsy and it is not requested unless
there is no response to steroids.
v Remember, minimal change disease is the commonest cause of nephrotic
syndrome in children.
v Remember, boys: girls= 2:1 regarding nephrotic syndrome.
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Key An 8-week-old, exclusively breastfed infant is brough by his mother into the
131 GP with the following symptoms: vomiting small amounts of milk after most
feeds, refusing feeds and crying shortly after feeds. He is on the S01h centile
for height and weight (no faltering of growth). What is the likely diagnosis?
-7 ~astro-oesophageal reflux disease [GORD]~
• < 1 YO {begins before 8 weeks of age)
GORD • Non-projectile vomiting after feeds,

• Gags, Chocks after feeds,
in pediatrics
• Irritable, Crying, Difficult to feed,
• FTT (not always, unless if severe GORD).
• Rx -7 Assess breastfeeding {150 ml/kg/ day) for bottle-fed
. 1' frequency and -.!, amount.
PPI or H2 b lockers trial for 4 weeks.
• It usually resolves spontaneously with time mostly by age

of 1 year.
1111 Notes:
•!Pyloric stenosi~ -7 forceful (projectile) vomiting, Palpable olive mass.

• ltntestina( obstructior\J-7 Bile-stained vomiting.
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Another important differential is oesopho.geo.( o.tresio.;

• Early recognised before or soon after birth as any
attempt at feeding could cause aspiration pneumonia.
Oesophageal
• Associated with tracheo-oesophageal fistula and
atresia
polyhydramnios.
• May present with choking and Cyanotic spells following
aspiration.
• VACTERL associations (Vertebral, Ana l, Cardiac, Trachea-

Esophogeal, Renal/kidney, and Limb defects).
Key A 15 YO boy presents with a lump in his neck for a few months. He
132 is asymptomatic with no fever, night sweats or weight loss. On
examination, firm non-tender lymphadenopathy is noted in the left
cervical chain. What is the most appropriate investigation?
~ IExcisional Biops~.
+ Hodgkin's Lymphoma
•The most common presentation of Hodgkin's lymphoma is painless,
firm lymphadenopathy in one or two areas (supraclavicular/ cervical
LNs).
• Remember that constitutional symptoms such as fever, night sweats
and weight loss present in only 33% of the patients.
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• Excisional biopsy is essent ial fo r the diagnosis.
• Also remember t hat Ho dgkin's lymphoma has bimodal age

presentation: <25 YO or > 55 YO.
Key A 2 YO girl presents with blisters and vesicles on her hands and feet with a
133 temperature of 37.6. Th blisters are shown in the pictures below:
-7 ~he should not be kept from school is she is welll.
Hand, foot and mouth disease

v Hand, foot and mouth disease is a self-limiting condition affecting children.
v It is caused by the intestinal viruses of the Picornaviridae family (most
commonly coxsackie A16 and enterovirus 71).
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v It is very contagious and typically occurs in outbreaks at nursery
1111 Clinical features:
• mild systemic upset: sore throat, fever.

• oral ulcers.
• followed later by vesicles on the palms and soles of the feet.
1111 Management:
• Symptomatic treatment only. i.e. supportive: general advice about hydration

and analgesia.
• Reassurance no link to disease in cattle
• Children do not need to be excluded from school
the HPA (Health Protection Agency) recommends that children who are
unwell should be kept off school until they feel better
they also advise that you contact them if you suspect that there may be a
large outbreak.
Key Infantile spasms (March 2020)

134
• Infantile spasms, or West syndrome, is a type of childhood epilepsy which

typically presents in ~h.~.f.i.r.$.t.4..t.Q.~ ..r:l'.!9..r:llb.$.. 9.f..Uf~ and is more common in
male infants. They are often associated with a serious underlying condition
and carry a poor prognosis.
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1111 Features
v Characteristic 'salaam' attacks:
~ flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times
v Progressive mental handicap
1111 Investigation
v EEG ~ hypsarrhythmia in two-thirds of infants.
v CT~ diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)
1111 Management
v poor prognosis
v vigabatrin is now considered first-line therapy
v ACTH is also used
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),
Infantile Spasms Hypsarrhythmia
1---.A- )
•• Developmental problems
West Syndrome= Infantile Spasms
Key A 5 YO boy presents to the secondary care with persistent night-time

135 bedwetting +several incidences of day-time urinary leak. He has never been
able to keep dry before. His urine dipstick is normal. What is the most
appropriate management?
A) Enuresis alarm.
B) Intranasal desmopressin.
C) Reassurance.
D)loral Oxybutyninl.
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Since he has never been able to keep dry before, this is a Primary enuresis.
Management of Primary Enuresis (never achieved continence before)
•lit WITH Daytime enuresis (+) > 2 vOj

-7 Refer to 2ry care or enuresis clinic for further assessment.
This is the case here but he is already being seen in the 2ry care.
•lit WITHOUT Daytime symptoms! (only night bedwetting)
• < 5 YO -7 Reassure (they may achieve continence soon).
• ~ 5 YO:
o If infrequent (<2 times a week) -7 Reassure.

o If frequent (>2 times a week):
- If Long-term control is required -7 ~nuresis alarml (first-line) +reward systeml

- If short-term control of bedwetting is required (e.g. the child is going to sleep at
a camp for 2 days) or> 7 YO -7 pesmopressinl (temporary control)
If after 2 complete courses of treatment with alarm, reward system, desmopressin,

they are still bedwetting -? Refer to 2ry care.
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However, this patient also has Q.~~i.~.~..!:1.r.l.1'.'!.~.. !.~~.~~g~, which means he needs
to be referred to a specialist (2ry care) but it is not given in the options.
Therefore, as he has several urine leaks f!M.L!f.\K1b~.9..~Y. with normal urine
dipstick (excluding UTI}, he most likely has urge incontinence (overactive
detrusor muscle of the urinary bladder)
Remember, lurge incontinence! (IOVeractive bladde~) is treated by bladder

training and another line is by Oxybutynin, which is an antimuscarinic drug
(anticholinergic).
Another important type of incontinence is lstress incontinence! which presents

with urine leak on sneezing, coughing, laughing and it is treated with pelvic
floor exercise as a first line or with free -tension retropubic mid-urethral tape.
Other reasons for daytime incontinence:

Overactive bladder, UTls, Chronic constipation, Congenital malformations,
Neurological disorders.
Key A 5 YO boy presents with abdominal pain and mild fever. He also complains
136 of painful, swollen knees. 2 days ago, he developed non-blanching rash on
his buttocks and the back of the legs. He had cough and runny nose 10 days
ago. His vitals are stable. His labs are: normal platelets, elevated serum lgA.
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The likely Ox -7 IHenoch-Schonlein Purpura (HSP~.
• IHenoch-Schonlein Purpur~
HSP --+ PAAN : non-blanching Purpura ± Arthralgia, Abdominal pain,
Nephropathy (Hematuria, Proteinuria).
• Purpura is non-blanching and mainly on the buttocks and Lower Limbs.
• Precipitated by URTI - Sore Throat.
• All Blood Results are NORMAL "Normal Hb, WBCs and Platelets".
• However, there might be 1' ESR/ lgA/ Creatinine

• It is a self-limiting condition (needs supportive Rx) unless there is renal
involvement.
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If severe electrolyte imbalance, bradycardia, hypoglycemia

-7 Admit to acute medical ward regardless of the BMI.
4 ll 19 YO Sj2 , BMI 21, thinks that she is obese. She eats uncontrollably and then
feels guilty and thus performs self-inducing vomiting and heavy exercises.
The likely Dx ~ !Bulimia Nervosal. "Classic case"
5 ll 18 YO Sj2 , BMI is 17.8, has bilateral parotid swelling , and thickened calluses on
the dorsum of her hands.
The likely Dx ~!Bulimia Nervosal. "BMI > 17.5 + Parotid swelling"
6 ll 19 YO Sj2 , has obsessive thinking that she is overweight, Her BMI is 14.5, She
abuses laxatives and heavily exercises, her BP is 95/70 and HR is 70.
7 IRefer urgently to eating disorder unitl (nothing to treat in the medical ward as
no medical complications; the patient needs to eat as their BMI is very low).
Key Autism Spectrum Disorder

7
+Global impairment of language and communication
+ Impairment of social relationships
+ Compulsive behaviour
+ Collecting things (e.g. a boy has> 2000 toy cars}
+ Most children have a decreased IQ - the 'savant' is rare
+Autism patients usually present when there is a change in their lives e.g.
moving to a new school, death of someone they love.
ExaW\ple
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A 15 YO boy, performs poorly in school since he moved to a new school, has

very little social interactions and friends, prefers solitary activities, if disturbed,
becomes very upset and anxious, like collecting toys, has > 2000 toy cars.
7 ~utism spectrum disordea.
Attention Deficit Hyperactivity Disorder ADH D
Diagnostic Features
Attention Deficit (inattention) Hyperactivity/lmpulsivity
Does not follow through on instructions Unable to play quietly

Reluctant to engage in mentally-intense tasks Talks excessively
Easily distracted Does not wait their turn easily

Finds it difficult to sustain tasks Wi ll spontaneously leave their seat when
expected to sit
Finds it difficult to organise tasks or activities Is often 'on the go'
Often forgetful in daily activities Often interruptive or intrusive to others

Often loses things necessary for tasks or Wi ll answer prematurely, before a question
activities has been finished
Often does not seem to listen when spoken to Wi ll run and climb in situations where it is
directly not appropriate
IExaMple~
A 6 YO child is brought by his mother. She says that he is easily distracted,
interrupts other students when it is their turn to answer questions. He is also
careless, not able to do a task for a long time and is unable to play quietly.
7 ttention Deficit Hyperactivity Disorder (ADHD}
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Q) The child in the scenario above also has insomnia. What is the first line Rx?
-7 First line : !sleep Hygiene!.

-7 Second line: IMelatoninl.
Key Mania Hypomania

8 • Lasts ~ 7 days • A lesser version of mania
• Lasts for< 7 days, typically 3-4 days. Can
• Causes severe functional impairment in be high functioning and does not impair
social and work setting. functional capacity in social or work setting
• Unlikely to require hospitalization
• May require hospitalization due to risk of
• No psychotic symptoms
harm to self or others
• May present with psychotic symptoms

(Delusions/ Hallucination)
The following features can be seen in both IManial and IHypomanial
a Mood
v predominately elevated
v irritable
a Speech and thought
v pressured
v flight of ideas/ more talkative than usual
v poor attention
a Behaviour
v insomnia (Decreased need of sleep)
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D.ECT
E. Bereavement counselling
v Antidepressants are not addictive.

v For fear of relapse, it is advised that antidepressants are continued for at least
6 months in total even if there is improvement as in this case.
v So, the advice would be -7 lcontinue amitriptyline for another 3 months!.
Key A 32-year-old man presents with erectile dysfunction of 2 months. He had

83 depression 3 months ago and was started on Sertraline. He has no medical
history of note. What is the most likely cause of his symptoms?
A. ~ertraline side effect~

B. Autonomic neuropathy
C. Performance anxiety
D. Depression
SSRl-induced sexual dysfunction can occur in both men and women.
SSRls examples -7 (Fluoxetine, Sertraline, Citalopram)
Key Points on Treatment of Depression:

84
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a SSRls (e.g. fluoxetine, sertraline) are first line in moderate to severe

depression.
a If there is Myocardial Infarction 7 Sertraline "1st line" or Citalopram "2"d

line".
a If the patient is on Warfarin 7 Mirtazapine (because SSRls can cause GI

bleeding if taken with Warfarin).
a Also remember that if SSRls do not work with a patient, we can use another
family such as Mirtazapine (which is an atypical antipsychotic: presynaptic
alpha 2 adrenoreceptor antagonist).
a TCA (e.g. Amitriptyline) is the drug of choice in psychotic depression. It

should be continued for 6-9 months after resolution of symptoms.
(i.e. It cannot be discontinued if less than that even if there is improvement).
Key + Previous suicide attempts and previous self-harm are the biggest risk factors
85 for suicide.
+ Traumatic events during childhood are significant risk factor for depression.
For example, ~raumatic effect caused by parental divorce!.
Key Remember that in a patient with depression, once there is suicidal thoughts/
86 attempts or harm to self or others, it is -7 ISevere Depression!
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And th e pati ent needs to be -7 ~ompulsorily admitted to a psychiatric wardl.
Compulsory admission = (Sectioning) is used when the patient is a danger to

himself or to others.
Note, do not jump into Electroconvulsive therapy {ECT). It is usually the last
step.
Important:
What if the patient has improved and no longer holds suicidal thoughts or
harm to self or others and requests to be discharged and to stop ECT?
In this case, we respect the patient's wishes as long as he has mental capacity,
with no thoughts of harming himself or others, and with no psychotic symptoms.
However, we offer other treatment modalities and follow ups .
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Key Bone pain + 1' Alkaline Phosphatase (ALP) + Multifocal ~fJ~rQ!I~ patches on
59 X-Ray ±HF (e.g. shortness of breath on exertion).
-7 IPaget's disease!. (the other name is "Osteitis Deformans"}.
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Cil From [Oral morphine to Subcutaneous diamorphine] -7 (LI)

Cil From [Oral tramadol to IV morphine] -7 (m )
v Remember, palliative patients are preferred to receive Subcutaneous

medications rather than IV or IM.
v She takes 60 mg oral morphine twice a day (i.e. 120 mg over 24

hours).
v To shift to SC morphine, divide the 24-hour dose by 2 and give it over

24 hours.
v This means 120/2 = 60 mg over 24 hours.
Key [!]Anti-emetic in case of 1' ICP (e.g. intracerebral tumour) or vomiting due to bowel
41 obstruction
-7 Cyclizine.
[!]Anti-emetic in case of "delayed gastric emptying" e.g. peritoneal metastasis

causing P.£1.r.tl~J. bowel obstruction :
-7 Metoclopramide "a prokinetic". Also: domperidone.
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-..J Aspirin is not a typical pain killer for injuries.
Key Co-careldopa (Sinemet ®)

78
v Co-careldopa = Levodopa + Carbidopa combined together.

v Used in the treatment of Parkinson's disease.
v ~udden cessation of Co-carbidopa can result in Akinesial.
v Akinesia =inability to move muscles voluntarily.
Key Important Side Effects of TB Medications

79
Isoniazid (INH) Pevipheval Neuvopathy ((f ive Vit. 8 6)
Hepatitis
INH (3 lettevs) ~ SLE
Rifampicin Red-ora.n9e uviV\e O.V\d secvetioV\S

P4So iV\ductioV\
Hepatitis
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Pyrazinamide t Uvic Acid (HypevuviceW\ia) ~ Ciout
Ethambutol Visual (Eye) PvobleW\S:

e.9. Red-9veeVt discviW\iVtatioVt.
Retvobulbav Vteuvitis_, t Visual acuity.
Streptomycin Ototoxic ~ DeafVtess

(Contraindicated
in pregnancy) v
IExamplel:
A patient was diagnosed with TB and now presents with orange
urine and sweats and mildly elevated liver enzymes.
The likely cause 7 IRifampicinl
Key Patients with diarrhea are risk of dehydration (due to loss of

80 body fluid in the stool). Therefore, it is important to consider
stopping any diuretic drugs being used to avoid dehydration.
IExamplel:
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A patient with gastroenteritis presents with diarrhea of 3 days. He is on a

number of drugs : Citalopram, Warfarin, lndapamide, Allopurinol and
corticosteroids.
Which drug needs to be currently ceased?
7 llndapamidel
v lndapamide is a thiazide-like diuretic.

v Diuretics should be stopped if there is diarrhea because of the risk of
dehydration.
v Other examples of diuretics:

• Loop Diuretics (e.g. Furosemide}
• Thiazide-like diuretics (e.g. bendroflumethiazide, indapamide}
• Potassium-sparing diuretics (e.g. Spironolactone/ Eplerenone}
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Key According to BST/SIGN Asthma guidelines:

57
v The first step of stable asthma management is:
lsABA (Salbutamol) ~ l1ow dose corticosteroids (Beclomethasone)I.
Key How to clean the spacer used for inhalers?

58
v Wash it .IIlQD.tbJ.Y., NOT weekly.

v Soak in 9..~!~r.m~nt/..~Q9.P.Y..W.9.f..r:D..W..~!~r for 15 minutes.
v Then, allow it to .~J.r..9.f.Y. (No wiping with clothes or in the sun).
v When the plastic spacer is cloudy -7 does not matter.

v Replace the spacer every 12 month.
Key What test can differentiate Asthma from COPD?

59
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-7 IPost-bronchodilator FEVll
In Asthma and COPD, (FEVl/FVC) < 70% (<0. 7) "there is airflow obstruction"
In !Asthma~ FEVl significantly improves after giving bronchodilators (FEV1

>12% improvement after giving a bronchodilator). (reversible obstruction;
improve post-bronchodilation)
whereas in lcoPD~ it remains< 0.7 even post-bronchodilation.

{No significant improvement of post-bronchodilator FEVl).
Key In some occasions, spirometry fails to detect asthma. We use a "treat to

diagnose" method by giving .q..§::.w..~g.~..~Qh!f.~.~..9.f.LIJ.O.qJ.~.Q..~.Q.r.t.!~.9.?.t.~r.QL~t~. or a few
60
days of oral corticosteroids.
If the symptoms e.g. wheezes, SOB, cough improve -7 Likely !Asthma!.
Key Suspecting pulmonary embolism (e.g. long-time immobile, post-op, with

61
fever, SOB, tachycardia ... ):
v The Immediate Ix -7 IChest X-ra~ (to tule out other possible causes e.g.
pneumothorax, pneumonia).
v The Ix of choice -7 ~ (CT pulmonary angiography).

v Once pulmonary embolism is suspected -7 give or 1' the dose of LMWHI.
"a treatment dose, while awaiting CTPA"
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Key Bronchopleural Fistula

62
ttl A bronchopleural fistula is an abnormal passageway (a sinus tract) that

develops between the large airways in the lungs (the bronchi) and the space
between the membranes that line the lungs (the pleural cavity).
ttl It a serious complication often caused by J.~.o_g.~_9..IJ.~~.r..~.IJ.rn.~x.v., but may also

develop after chemotherapy, radiat ion, or an infection.
ttl It is usually asymptomatic, but when symptoms are present, they can be
easily dismissed as they are symptoms which may be expected following lung
infections and surgery, such as a persistent cough (with production of a clear to
pink, frothy fluid when a fistula occurs within 2 weeks of surgery and often
grossly pus-like later on), coughing up blood, or shortness of breath
ttl Lung cancer surgery: Pulmonary resection (removal of a lung or part of a

lung) for lung cancer is by far the most common cause of a bronchopleural
fistula. It is more likely to occur with 9...P..IJ.~.~.DJ.Q.IJ.~.c;;!Qf.D.Y. (complete removal of a
lung) than with procedures such as a lobectomy {removal of a lobe of the lung)
or a wedge resection (removal of a wedge-shaped section of a lobe of the lung).
ttl It is also more common in those who have r.Jgh.t.:.~.!Q~Q lung surgery.
ttl Diagnosis is usually made with a CT scan of the chest.
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Also, X-ray may show it.
The first post-pneumonectomy X-ray would show high air-fluid level (normal
after the lung resection, the space is filled with sterile fluid)
Then later when the fistula is persistent, there would be a drop in the air-fluid
level, and an increase in air level (i.e. more black).
ttl Treatment involves repairing the fistula, which may be done via endoscopy,
bronchoscopy, or open chest surgery.
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vaginal dryness, arthralgia, Raynaud's, myalgia, sensory polyneuropathy,
renal tubular acidosis (usually subclinical)
Investigation
v Schirmer's test: filter paper near conjunctiva! sac to measure tear formation
-7 decreased tear production .
v Rose Bengal stain -7 may show Corneal ulcerations "2ry to dry eyes".
v Rheumatoid factor (RF) positive in nearly 100% of patients.
v Anti-Ro (SSA) antibodies in 70%.
v anti-La (SSB) antibodies in 30%.
Management
+ No Cure.
+Give artificial saliva and tears {e.g. Hypromellose drops).
Key In Rheumatoid Arthritis, Glucocorticoids (e.g. IPrednisolonel) are very effective

23 to rapidly decrease the inflammation.
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Cystoscopy might then be done by a urologist.
2 weeks wait (urgent not routine). This is the usual in the UK.
v Above 40 YO+ Frank hematuria -7 Cystoscopy
v Below 40 YO+ Hematuria (malignancy less likely} -7 CT-KUB "for stones" .
Key • Hematuria < 40 YO -7 do US followed by CT scan (likely stone).

49
• Hematuria > 40 YO -7 do Cystoscopy (likely bladder cancer).
Key The I!'!!!.i.~! investigation for UTI -7 IDipstick urine analysis!.

50
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ctl Write --7 IPneumonia of the left lower lobel

Instead of "lung infection/ respiratory failure"
• fAfl•Jl•l vague terms and modes of dying such as (Res::>iratory distress/

Carc.1ac arres I Carc.1ovasc_lar even I Ches inrec ions/ Cardiovascular even ).
Key A known asthmatic child has been breathless for over 12hours. He has
10 Oxygen saturation of 86% on high Flow Oxygen. He has not taken his
nebulisers for a day. His chest is silent. What is the most appropriate initial
management?
A. IV aminophylline
B. IV magnesium su lphate
c. l1ntubate and ventilate!

D.CPAP
Desaturating (Despite High Flow 02), Silent Chest --7 Going into Resp. Failure
--7 Intubate
Key Regarding Acid-Base Imbalance (Import ant):

11
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v Excessive intake of Paracetamol, Aspirin, Alcohol, SSRI (e.g. Citalopram)

---+ !Metabolic Acidosi~.
v In Asthma and COPD

---+ !Respiratory Acidosis!.
.../In Pulmonary Contusion {e.g. after a fall on the chest --+ Pulmonary
contusion/ edema --+ hypoxemia and accumulation of C02)
---+ !Respiratory Acidosis!.
v Panic attacks AND Pulmonary embolism can cause

---+ !Respiratory Alkalosisl.
However, Pa02 is Normal in Panic attacks and Low in Pulmo nary
embolism.
The steps {approach) to determine the type of the blood gas

abnormality.
1. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)?

2. Respiratory component: What has happened to the PaC02?
• PaC02 > 6.0 kPa suggests a respiratory acidosis (or respiratory

compensation for a metabolic alkalosis)
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• PaC02 < 4.7 kPa suggests a respiratory alkalosis (or respiratory

compensation for a metabolic acidosis)
3. Metabolic component: What is the bicarbonate level/base excess?
• bicarbonate< 22 mmol/I (or a base excess< - 2mmol/I) suggests a

metabolic acidosis (or renal compensation for a respiratory alkalosis)
• bicarbonate> 26 mmol/I (or a base excess>+ 2mmol/I) suggests a
metabolic alkalosis (or renal compensation for a respiratory acidosis)
imply, know that C02 is an Acid, and Bicarbonate (HC03) is an Alkali.
Key Glasgow Coma Scale (GCS)

12
Important, you may encounter a question that asks you to calculate the
patient's GCS score.
Eyeopening Verbal response Motor response

4. Spontaneous S. Oriented 6. Obeys commands
4. Sentences S. Localises pain

3. To speech
4. Flexion/withdrawal to pain
3. Words
3. Abnormal flexlon to pain
2. To pain
2.Sounds 2. Extension to pain
1. No response 1. No response 1. No response
.Y Total score: 15
.Y Remember: below 8 ~ intubate.
13-15: mild I 9-12: moderate I 3-8: severe

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Example:
Calculate the GCS for the following patient:
v Unintelligible sounds.
v Opens his eyes on verbal request.
v Withdraw his hand on pain stimulation.
Answer:
v Unintelligible sounds = 2
v Opens his eyes on verbal request = 3
v Withdraw his hand on pain stimulation =4
Gcs ~ ~
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Glasgow Coma Scale

BEHAVIOR RESPONSE SCORE
Eye opening Spontan~usly 4
response To speech 3
Topa1n 2
No response 1
Best verbal Oriented to time. place, and person s

response Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Best motor Obeys commands 6

response Moves to localized pain s
Aexion withdrawal from pain 4
Abnormal flexion (decorticate) 3
Abnormal extension (decerebrate) 1
No response 1
Total score: lkst r~sponse 15

Comato~ cli~nt 8orless
Totaly unresponsive 3
Key Acute Chest Syndrome (A complication of Sickle Cell Disease)

13
v Acute chest syndrome in a patient with sickling disorder is defined by a new

pulmonary infiltration on chest x-ray +at least one of the following : ~b.~.?.tP..~J.o_,
.~Q~g!:J., ~.P..~J~.f.D, fgY.~.r_, .QY.P.9.~!9.i. (low oxygen level) and J.~.O.&.!n.f.U!r.~J~.?.· Acute
chest syndrome may be the result of sickling in the small blood vessels in the
lungs cau sing a pulmonary infarction/ embolus or viral or bacterial pneumonia .
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v It may develop as a single event, or during a painful vaso-occlusive crisis. The

clinical course is usually self-limited when small areas of the lung tissue are
involved, but without proper care, acute chest syndrome can rapidly progress
and result in death.
v Chest pain when breathing is the most common presenting complaint in

adults. Fever, cough, tachypnea (abnormally rapid breathing), hypoxemia (an
unusually low concentration of oxygen in the blood), or abdominal pain are
common presentations for infants and children.
vRx-7
• Adequate analgesia (the patient may need to be given !morphine sulphate!),
• 02,
• Empiric antibiotics,
• Blood transfusion (based on clinical picture and investigations),

• (IV fluid may worsen the pulmonary edema and thus is used with caution)
Key Asthma exacerbation that leads to low pH, high PaC02 (i.e.
14 Respiratory Acidosis) and fails to be managed needs to be ~l
a_ d_
m-it_t_
e~dl
~o ICUIas the patient may require intubation.
Key • Hypertension
15
•Severe chest pain radiating to the back
• A big difference in the blood pressure between right and eft arm
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~ Suspect [Aortic dissection!
Cil The investigation of choice ( important):
v If the patient is stable ~ ICT Angiograph~.

v If the patient is unstable ~ [rans-oesophageal echol in theatre.
Cil Important risk factors ~ Marfan' s syndrome I Ehlers-Danlos Syndrome.

[!]Chest X-ray ~ Wide mediastinum.
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'1 2 Potent topical steroids to remember:

IMometasone furoate 0.1%1
lsetamethasone Valerate 0.1%1
v When to be used?
(Potent topical steroids used for severe eczema that causes bleeding,
excoriations, severe itching that prevents sleeping and not responding to
emollients and over the counter hydrocortisone).
In cases of mild eczema, after using topical emollients, we add a mild topical
steroid such as IHydrocortisone ~f.~.~-~.t~I (either 0.5%, 1% or 2.5%).
Note that hydrocortisone .Q.l,.!1Y.f.9J~ is a POTENT steroid.
Here is the order of the topical steroids arranged from the least potent
to the most potent:
• Hydrocortisone A~~19J~ (either 0.5%, 1% or 2.5%) (Mild) -7
• Betamethasone Q...97.~.% I Clobetsone (Moderate) -7

• Betamethasone Q..J.% I Hydrocortisone .~.l,.!J.Y.~.~t~ I Mometasone (Potent} -7
• Clobetasol (Very Potent).
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The most important prognostic indicator for malignant melanoma is:

-7 &ertical growth! (~he depth of the tumour!}.
Severe itching, linear eruptions, between web-spaces, worse after

shower and at night, common in nursing home, may be found within
the family members
•Think -7 ~cabiesl
• The pathogen -7 lsarcoptes Scabieil
• ist line Rx -7 IPermethrin s%1

(should be applied to the entire body except the head. Rx is repeated after 7
days}.
• 2nd line Rx -7 Malathion 0.5%
•All family members and people with physical contact should be treated even if
asymptomatic.
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Example (3)
A patient recently diagnosed of asthma which has been well controlled, now
presents with increase respiratory rate, temp 36.7, auscultation reveals
absent breath sound.
Which of the following will indicate life threatening asthma?
A. ~bsent breath soundl
B. Increased respiratory rate

C. lntercoastal recession
Key Basal Skull Fracture

101
• Battle sign (mastoid ecchymosis).

• CSF rhinorrhea.
• Periorbital ecchymosis (racoon eyes).
• Hearing loss.
• Hemotympanum.
• 7th nerve palsy.
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Basal skull fracture mostly affects the following bones:

v J.~mP.9.I.~.1...~9..IJ.~. {the petrous part of the temporal bone).
v The eardrum.
v The external auditory canal.
Key Chest pain, Dyspnea, Obesity, Oral contraceptive pills, High 0-dimer.
102
Think 7 IPulmonary embolism!.
Key ttl The presence of the red flags of sepsis necessitates the start of Sepsis Six
103 within 1 hour and thus the patient .IJ.~.~-~-~.!9...~~-~~.mt~J~.~..W..l~hJr!::P.~!t~DJ
m~n~g~m.~DJ·
ttl Important Red Flags of Sepsis:

Systolic B.P:::; 90
Heart rate > 130
Respiratory rate ~ 25
Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr
ttl Sepsis Six:

1) High flow 02.
2) IV fluids.
3} IV antibiotics "broad-spectrum".
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4) Blood cultures.
5) Full blood count, U & E, Clotting factors, Lactate.
6) Monitor urine output hourly.
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Hypokalemia Hypokalemia HypeRkalemia
Gout (hyperuricemia) Gout (hyperuricemia) Gynecomastia
Postural Hypotension
Hyperglycemia
(impaired glucose tolerance)
ctl Remember that,
IACE inhibitors! (e.g. ramipril, enalapril) can cause:
IAngioedema~ lory coughl, IHyperkalemial (1' K+).
ctl Other important reasons for hY.P.~rk~J~.ml~. Ci K+) to remember:

v ACE inhibitors (e.g. ramipril, captopril, enalapril}.
v Potassium-sparing diuretics (e.g. spironolactone).
v Adrenal insufficiency (Addison's disease).
Key A 42 YO man presents with polyuria, polydipsia and raised red dots on his
146 glans penis.
The most imp. Ix to diagnose -7 IFasting blood glucose!.
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This patient has .f.µng~.!..R.~.l.~.IJ.iJi~. 2ry to DM.
Diabetic patients have reduced immunity --7 prone to fungal infections.
Key A 60 YO woman presents with the followings:

147
v Confusion.
vWeakness.
v Pains and aches.
v Polyuria and Polydipsia.
v Hx of renal calculi.
v High parathyroid hormone level.
v High serum calcium.
v Low serum phosphate.
v Normal eGFR.
Interpretation and most likely diagnosis:
.~..Qr...n9.r.m.~.!..e.T.H,..:t...~~±!.1..~...e.b..:7.Jb.!n.~.lir.Y...b.v.P..~.r.P.~.r.~JhY.r.Qt~J~.m~.
vThis woman likely has primary hyperparathyroidism.
vThe commonest cause of it is 7 IParathyroid Adenomal.
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v The features presented are due to Hypercalcemia (bone aches,

confusion, renal calculi, excessive thirsty and urination).
v Note that in 2ry hyperparathyroidism, the Ca++ would be low, and also
the eGFR would not be normal.
Hyperparathyroidism Parathyroid Hormone Calcium Phosphate
!Primary] Normal or High HIGH LOW

(Commonest cause is
parathyroid adenoma)
lsecondaryj HIGH LOW or High or

(1' PTH due to existing normal normal
hypocalcemia esp. 2ry to CKD)
~ertial'YJ End-Stage Renal Failure
Key A 60 YO woman presents with the Followings:

148
v Hypertension
v Weight gain
v Proximal muscle weakness (Cannot abduct shoulder, flex hip).
v Easy bruising
v Hypernatremia and hypokalemia
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ctl The .~.~.~JJ.oJti.~.Ll~~J to establish the Ox
-7 1 mg (low-dose)= !overnight Dexamethasone Suppression tes~.
ctl The likely Ox is 7 Cushing.
Key patient with hyperthyroidism and a swelling of the right lobe

A
149 of the thyroid gland.
Isotope scan shows ~ increased radioactive iodine uptake in a

solitary region of the right lobe of the thyroid gland while it is
low in the rest.
Both TPO antibody and TSH receptor antibody are negative.
v TPO antibody and TSH receptor antibody are negative

- NOT Graves.
v increased radioactive iodine uptake in an isolated region of the

right lobe
~ !Solitary nodular goitrel.
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ctl Perichondritis Treatment:

v Prompt oral antibiotic therapy, typically a lt1uoroquinolone~ sometimes with
an aminoglycoside plus a semisynthetic penicillin
v For an abscess, prompt incision and drainage.
The fluoroqulnolone antibiotics include ciprofloxacin {Cipro), emifloxacin (Factive),

levofloxacin (Levaqui n), moxifloxacin (Avelox), and ofloxacin (Floxi n)
Key ctl A patient with a suspected Obstructive Sleep Apnea presents to his GP.
95 What should be done?
1) Advise the patient not to drive cars or lorries!.

2) Urgent referral to a sleep cliniq "for Dx -polysomnography- and Rx".
ctl When should Driver and Vehicle Licensing Agency (DVLA) be informed?
v If already diagnosed with moderate to severe OSAS, or:

v If diagnosed with mild OSAS with excessive sleepiness not controlled within 3
months.
Key A mother is concerned about her 6 YO son as he has had 3 episodes of

96 tonsillitis within the past 6 months. What should be done?
7 IReassure and continue observation!.
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He does not meet the SIGN criteria for tonsillectomy.
Remember:
Tonsillectomy is indicated in any of the following:
• > 7 episodes of tonsillitis P..~!...Y.~.~r for 1 year.
• > 5 episodes P..~!...Y.~9.!. for 2 years.
• > 3 episodes P..~!...Y.~9.!. for 3 years.
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Secondary Attack Rate
2ry attack rate =

number of 2ry cases.;- (All people in the group - number of the lry cases)
Example:
A new virus has infected 10 people out of 40 bus riders during a long trip. These
infected 10 people had transmitted the virus to additional SO relatives. The
total number of the relatives including the 10 infected people is 110. What is
the 2ry attack rate?
number of 2ry cases= SO
All people in the group = 110
number of the lry cases = 10
2ry attack rate= SO.;- (110 - 10)
=so 7100
=O.S (X 100 -7 SO%)
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lry attack rate =
(Number of lry cases-;- total population at risk} X 100
So, in the example above:
Number of lry cases= 10
Total pop at risk (bus riders} = 40
(10 7 40} x 100

=25%
IKey 301
To measure the accuracy of a screening test:
Accuracy = a+d + (a+b+c+d)
+
A 13
+ True False
Positives Positives
c D
False T rue
Negatives Negatives
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Control Trial (lnterventional)
One group is taken a drug, the other is taken another drug. Then both groups are
followed over time to see the outcome.
The Key is the introduction of an .~n:t~r.Y.~n!!.Q.n (e.g. a ~.r..~.9).
Example
2 groups of smokers are followed over time. One group is taking drug (A), and the
other group is taking drug (B). They are then followed over time to see who would
develop lung cancer. What is the type of the study?
¢ ~ontrol trialJ. (lnterventional)
Remember, in case-control and cohort studies, no interventions (only

observational).
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[1 Radiculopath~
Affects Fingers Abduction and Adduction, Pain and Paraesthesia along the
affected nerve.
Also Remember:
The motor function of the nerve roots of an upper limb
CS, C6,C7,C8
Flex, extend, extend, flex
elbow, wrist, elbow, fingers
cs C6 C7 C8
Flex Extend Extend Flex
elbow wrist elbow Fingers
Adduct and Abduct Fingers ~Tl
Key A young man fell down on his right shoulder and arm and presents with the
73 following:
Weakness of right shoulder abduction and external rotation.
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Numbness over the lateral side of the right arm.
Numbness over the lateral side of the right forearm.
What is the likely affected structure?
Answer:
-7 IUpper brachia! plexusl
Numbness of latera l arm =axillary nerve= CS, C6.
Numbness of latera l forearm= musculocutaneous nerve= CS, C6, C7
Upper brachia! plexus= CS, C6, C7
Lower brachia! plexus= C8, Tl
Key ctl Pregnancy can predispose to Guyon's canal syndrome

74
(IUlnarl nerve compression at wrist
~ numbness over little finger+ half the ring finger).
ctl Pregnancy can predispose to Carpal tunnel syndrome

(fMedianl nerve compression
~ numbness over thumb, index and middle fingers).
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Key The arterial supply of the Lower Limbs:

75
artery
Profunda fem oris
artery
Gro in crease
Superficial fem oral

artery
Popliteal artery
Anterior t ibial
Peroneal artery artery
Posterior t ibial
artery
External iliac ~ Femoral ~ Popliteal ~ Anterior tibial ~ Dorsalis pedis
(The obstructed artery is always one level proximal "above" the

affected muscle g roup) .
Or, one level above the artery that cannot be felt.
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Example 1:
An elderly with Hx of smoking and uncontrolled OM presents with
pain on calf muscles after walking. He has to rest for a while to be
able to continue walking. Popliteal artery and dorsalis pedis cannot
be felt.
• The likely occluded artery is ~ ~emoropopliteal arterYI.
Example 2:
A patient whose femoral and popliteal pulses are not felt.
• The likely occluded artery ~ !External iliac arterYI.
Claudication pain in Peripheral Arterial Disease
The level of ischemia
+~orto-iliac artery occlusion!:

Pain in buttocks, thighs± Erectile Dysfunction (Leriche Syndrome)
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+~ommon iliac artery occlusion!:

-7 pain extends to just above inguinal ligament.
+!Femoral artery occlusion!:

-7 pain in leg (below inguinal ligament}. Femoral pulse is felt but the pulses
below it are not felt.
+I Femoro-politeall
-7 Pain is below knee.
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-7 IDual antiplatelets (Aspirin+ Clopidogrel)I

I+ Fondaparinuxl
I+ Blood transfusion!.
Notes:
v Triple vessel disease means that 3 big vessels (the left anterior descending,
right coronary and circumflex arteries) have blockages from atherosclerotic
plaques.
v This patient has ACS "acute coronary syndrome" secondary to anemia and
the pre-existing triple vessel disease.
v Aspirin (oral) and fondaparinux (SC LMWH) are given whenever there is
heart ischemia .
v Blood Transfusion is indicated if: I

~ Hb < 80 g/L + Symptoms of Anemia . Or:
~ HB < 70 g/L +With or Without Symptoms of Anemia .
Key Elderly+ Episodes of Fainting + SOB + Systolic murmur at the right second
127 intercostal space
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7 lt\ortic stenosisl.
Key A patient with a classic presentation of Ml {sudden onset central chest pain
128 radiating to neck and left shoulder, sweating, vomiting) but the -~~.G...i.~
n_g.r.m.~.l·
7 request troponin.
If troponin is elevated
7 IMvocardial infarction! {Non-ST Elevation Ml).
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7 (Bullous impetigo). It is caused by Staph. Aureus. These bullae eventually

rupture leaving yellow crusts.
Note that Non-bullous impetigo is more common.
Impetigo
Micro biology
• Staphylococcus aureus (most common)
• Beta-hemolytic streptococci
1 Non-bullous impeti go
• Papules, vesicles, and pustules

• Rapidly break down
• Form golden adherent crusts
• Often located on face or extremities
2 Bullous Impetigo
• Flaccid, fluid-filled bullae

• Rupture
• Leaves a thin brown crust
• Often located on trunk
3 Ecthyma
• "Punched-out• ulcers
• Overlying crust
• Raised violaceous borders
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Staphylococcal Scalded Skin Syndrome (SSSS)

= Ritter's disease
Plabtkeys.c:om
Version 2.2
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Online!
Ill What is staphylococcal scalded skin syndrome?

Staphylococcal scalded skin syndrome (SSSS) is an illness characterised by red
blistering skin that looks like a burn or scald, hence its name staphylococcal
scalded skin syndrome. SSSS is caused by the release of two exotoxins
(epidermolytic toxins A and B) from toxigenic strains of the bacteria
Staphylococcus aureus.
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5555 has also been called Ritter disease or Lyell disease when it appears in
newborns or young infants.
Ill Who is at risk of staphylococcal scalded skin syndrome?
SSSS occurs mostly in children younger than 5 years, particularly neonates

(newborn babies). Lifelong protective antibodies against staphylococcal exotoxins
are usually acquired during childhood which makes SSSS much less common in
older children and adults. Lack of specific immunity to the toxins and an immature
renal clearance system (toxins are primarily cleared from the body through the
kidneys) make neonates the most at risk.
lmmunocompromised individuals and individuals with renal failure, regardless of

age, may also be at risk of SSSS.
Ill What are the signs and symptoms of staphylococcal scalded skin syndrome?
SSSS usually starts with fever, irritability and widespread redness of the skin.
Within 24-48 hours fluid-filled blisters form. These rupture easily, leaving an area
that looks like a burn.
Ill Characteristics of the SSSS rash include:
Tissue paper-like wrinkling of the skin is followed by the appearance of large fluid -
filled blisters (bullae) in the armpits, groin and body orifices such as the nose and
ears.
Rash spreads to other parts of the body including the arms, legs and trunk. In
newborns, lesions are often found in the diaper area or around the umbilical cord.
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Top layer of skin begins peeling off in sheets, leaving exposed a moist, red and
tender area . Nikolsky sign is positive (i.e. gentle strokes result in exfoliation)
Other symptoms may include tender and painful areas around the infection site,
weakness, and dehydration.
Ill How is staphylococcal scalded skin syndrome fever diagnosed?
Diagnosis of 5555 depends on:

v History and physical examination
v Tzanck smear
v Skin biopsy, which shows intraepidermal cleavage at the granular layer
v Bacterial culture from skin, blood, urine or umblical cord sample (in a newborn
baby)
Ill What is the treatment of staphylococcal scalded skin syndrome?
Treatment of 5555 usually requires hospitalisation, as intravenous antibiotics are

generally necessary to eradicate the staphylococcal infection. A penicillinase-
resistant, anti-staphylococcal antibiotic such as flucloxacillin is used. Other
antibiotics include nafcillin, oxacillin, cephalosporin and clindamycin. Vancomycin
is used in infections suspected with methicillin resistance (MRSA). Depending on
response to treatment, oral antibiotics can be substituted within several days. The
patient may be discharged from hospital to continue treatment at home.
Corticosteroids slow down healing and hence are not given to patients with 5555.
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Ill Other supportive treatments for SSSS include:
Paracetamol when necessary for fever and pain.
Monitoring and maintaining fluid and electrolyte intake.

Skin care (the skin is often very fragile). Petroleum jelly should be applied to keep
the skin moisturised.
Newborn babies affected by 5555 are usually kept in incubators.
Although the outward signs of 5555 look bad, children generally recover well and
healing is usually complete within 5-7 days of starting treatment.
Staphylococcal Scalded Skin Syndrome (SSSS)

= Ritter's disease
• Signs and Symptoms:
SSSS usually starts with fever, irritability and widespread redness of the skin. Within 24-48
hours flu id-fil led blisters form. These rupture easily, leaving an area that looks like a burn.
Top layer of skin begins peeling off in sheets, leaving exposed a moist, red and tender area.
Nikolsky sign is positive (i.e. gentle strokes result in exfoliation).
• Management: Hospitalisation - Fluid and electrolyte balance - Nutrition - Analgesics - Antibiotics
(Flucloxacillin ), if MRSA ~ Vancomycin .
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Numbness over the lateral side of the right forearm.
Answer:
~ lupper brachia I plexus= superior trunk of the brachia I plexus.I
v Weakness of right shoulder abduction and external rotation =axillary nerve=

CS, C6.
v Numbness of lateral arm= axillary nerve= CS, C6.

v Numbness of lateral forearm= musculocutaneous nerve= CS, C6, C7
Upper brachia( plexus = CS, C6, C7
Key A young man fell on outstretched arm and was treated surgically. 6
76 months later, he presents with the following:
v Decreased sensation of little finger and medial half if the ring finger.
v Wasting of the interosseous muscles.
v Inability to cross the two fingers (little+ ring) or abduct his little finger.
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Answer:
~ !Lower brachia I plexus= Inferior trunk of the brachia I plexus.I

Another correct answer ~ !ulnar nervel.
v All given 3 features indicate damage to Ulnar nerve.

v Ulnar nerve= C8, Tl
v C8 and Tl= inferior (lower) trunk of brachia! plexus.
Upper brachia! plexus = CS, C6, C7
Remember:
ctJ Ulnar nerve injury (CB, Tl):
+Claw hand + Paraesthesia of little finger+ ring finger "ulnar border" .

+The ulnar nerve supplies dorsal and pal mar interossei that are involved in
fingers adduction and abduction ~ interosseous muscles wasting, no
abduction/ adduction of fingers.
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Remember:
Tonsillectomy is indicated in any of the following:
• > 7 episodes of tonsillitis pgr..yg.9.r. for 1 year .
• > 5 episodes P..~r...Y.~.9.f. for 2 years .
• > 3 episodes P.gr..yg.9.r. for 3 years .
Key • Dizziness/Vertigo on Moving head lasts for seconds to minutes

97
-+ IBPPV "Benign Paroxysmal Positional Vertigo, .
• If [!] Hx of Viral URTI QWithoutl tinnitus or hearing loss)
-+ l"estibular Neuritis!.
• If [!] Hx of Viral URTI l\Vithl Hearing loss/Tinnitus
-+ ILabyrinthitisl.
IJ To relieve vertigo, give ~ IProchlorperazinel

1' Short course of oral Prochlorperazine.
1' If rapid intervention is required -7 IV or JM Prochlorperazine or Cyclizine.
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so I Page [Medic a I Ethics) <fl Copyright www.plab1key s.com (Constantly updated for online subscribers)
It is inappropriate to start a relationship with your current or former patient,

especially if the professional relationship has ended recently like in this case.
Key A divorced mother who has 3 children under her care presents complaining of
81 depression. During history taking, she admits that she had used cocaine last
year for only a week to cope with her low moods. However, she has not used
it since then. She asks you not to write these notes about taking cocaine in
her medical records. What would you do?
7 llnform her that any clinically relevant notes have to be documented bu~
&Vmstay confidential!.
Key A 44 YO woman comes to the GP requesting sleeping pills because she cannot
82 sleep at night due to the loud music being played at nigh by her neighbours.
She asked them several times to keep it down but they did not response. She
cannot focus at work because of the lack of sleep. What is the most
appropriate action?
-? !Advise the patient to inform the local authorities!.
What if the local authorities have already been informed?
Then 7 Advise the patient to inform the police.
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• No point of advising on sleeping hygiene because the reason is physical (loud

music at night by the neighbours).
• Also, prescribing sleeping pills is incorrect as long as the cause is external and
can be stopped.
Key An FY2 doctor who is a friend of yours working at the same department has
83 been having suppurative tonsillitis. He asks you to write him antibiotics
prescription. What should you do?
-7 IAsk him to see his G ~.
v In the UK, it is a good practice not to prescribe for family, friends or

colleagues.
v Also, his GP is the best option as he knows his medical history and drug
history.
Key You were at a visit to a nursing home and saw one of the carers "a nurse"
84 yelling at a patient, using bad words, and threatening him to lock him up.
What should have you done?
-7 ~ontact social services/ the safeguarding authorit~.
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v Confronting the nurse is a lenient act in this scenario.

v Reporting the nurse to her principal/ supervisor is incorrect as the issue
involves threatening and we are not sure if the supervisor would take
appropriate actions in this case.
v In the UK, threatening is a crime, however, we leave it for the social services
to decide whether they need to inform the police or no after they investigate
the situation.
Key An old patient with terminal stage lung cancer presents to his GP and states
85 that her does not want to be resuscitated shall he undergo a cardiac arrest.
The GP believes that CPR would not help in his case and even if it goes
successfully, it would lead to a poor quality of life. The patient is also
following up with an oncologist and a palliative care team. What should this
GP do?
-7 IFill in and sign DNR forml.
DNR = Do Not Resuscitate.
v NHS states that: everyone has the right to refuse CPR "cardiopulmonary
resuscitation" if they wish.
v As this is the patient's wish, it is enough for his GP to fill in a DNR form.
v The GP is legible to fill in and sign a DNR form. In fact, most DNR forms are
signed by GPs given that they know their patients the best.
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v In the case of a junior doctor, the DNR form should be countersigned by a

more senior doctor.
Key An elderly lady with Alzheimer's disease presents to her GP asking him to
86 change her will as she believes that her family is looking for her money. What
should this GP do next?
7 IAssess her mental capacit~.
v Remember that the mere fact this lady has Alzheimer's does not mean she
lacks capacity. We need to assess first!
v Remember that having dementia does not necessarily indicate impaired

mental capacity.
v GMC says "mental capacity is decision and time specific".
+ Some may choose the option that says "refer for a psychiatrist to assess
her mental capacity". This is incorrect.
In the UK, any doctor can assess the mental capacity and thus no need to refer
to a specialist.
Key An elderly man with Alzheimer's disease living in the nursing home have been
87 deteriorating lately. He had signed his advance directive "living will" 2 years
ago that states that he does not want to be admitted to a hospital if he
deteriorated. He selected his son to be his lasting power of attorney 3 years
ago. The son now insists that his father should be admitted to a hospital. His
daughter is the next of kin insists to admit her father as well. The patient is
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assessed by the nurses and found to lack mental capacity. What should be
done?
A) !Follow the advance directive!.

B) Follow the son "The lasting power of attorney for health" .
C) Follow the daughter " The next of kin" .
v Let's firstly exclude the next of kin "the closest relative" as they legally cannot
take decisions.
v Now let's see the advance directive VS Lasting power of attorney:

• tfhe most recent one is the one to be followed!.
• Since the advance directive was signed 2 years ago while the lasting power of
attorney was appointed 3 years ago, the advance directive is to be followed as
it is more recent.
If the advance directive was signed 3 years ago, and the lasting power of
attorney was nominated 2 years ago, the wish of the lasting power of
attorney is to be followed as it is more recent.
Key You have successfully treated a patient and he handed you an envelope that
88 contains 60 GBP as a gift. What should you do?
A) !Politely refuse the gift!.

B) Accept it as it is less than 100 GBP.
C) Ask him to donate it to a charity or to the department.
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D) Refuse, but if he insists, accept it.
• Valuable gifts include Money of any amount + gifts that are of £100 or more.
You f~.f.l.!!Q~ accept these.
• You can accept small tokens, symbolic gifts.
If the patient insists ~ Recommend donating it to a charity or to the

department fund.
So, you should always decline Money of any amount!
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v Investigation -7 ,q..~~.~.I}..
Key llill A man presents with 2 episodes of passing blood per rectum after
103 defecation. There is no pain . There are splashes of blood around the toilet
bowl and streaks of blood on the toilet paper.
The likely Dx -7 Internal haemorrhoids "piles"I.

To diagnose? -7 Proctoscopy or rigid sigmoidoscopel.
llill A man presents with severe pain in anus especially on defecation,

blood streaks on the stools and Hx of constipation.
The likely Dx -7 ~nal Fissure!.
ltMPORTANT NOTE~:
+ Haemorrhoids -7 Blood+ Intermittent, bearable "tolerable" pain or
painless, splashes of blood.
(internal hemorrhoids are usually painless unless they have started to
prolapse out).
+ Perianal Abscess -7 Throbbing pain, swelling, Usually No blood.

+ Anal fissure -7 Intense pain (unbearable), acute pain, streaks of blood.
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Key Splenectomy Vaccines in the UK

104
111 IPre-splenectom~: Pneumococcal + Meningococcal vaccines.
111 IPost-splenectom~: influenza vaccines.
Additional notes:
1' Pneumococcal and Meningococcal vaccines are also given every 5 years
after splenectomy.
1' All patients with asplenia or hyposplenia should receive annual influenza
vaccine due to the high risk of 2ry bacterial infection. The best time is autumn
(October, November) before the onset of the "peak flu season".
Key An elderly patient + Tenesmus (feeling of incomplete defecation) +

105 Altered bowel habits (constipation alternating with diarrhea) +
Blood per rectum: Think - !Colon or Rectal cancerl.
In the case of diverticulitis, there is usually lower left abdominal

pain + Fever+ Tachycardia. Take a look at the following example:
A 60 YO ~ presents to the ED complaining of passing large amount of bright

red blood + Left lower abdominal pain for 2 days that is worse after eating+
Nausea but with no vomiting. The patient's main diet is canned meat. There is
localised left lower abdominal tenderness without rigidity or rebound
tenderness. On examining the rectum, blood is found on the examiner's
glove.
Vital signs: (BP: 85/55), (HR: 105), (Temperature: 38°C), (RR: 19).
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llill The likely diagnosis 7 Bleeding diverticulitis.
llill The most appropriate step 7 Urgent admission to the surgical ward.
llill The most appropriate "INITIAL" step 7 IV fluid {she is hypotensive).
Key A female patient has finished her surgery {cholecystectomy) 7 hours ago and
106 is now the surgical ward. She has nausea, blurred vision, confusion. Her
vitals are stable except for hypopnea {7 breaths per minute). What is the
likely cause?
7 IMorphine (opiates)!.
v Morphine overdose can cause all these side effects, including the
respiratory depression (low RR).
v Atelectasis, pulmonary embolism and hemorrhage do not present with

hypopnea (low respiratory rate).
Key + Intermittent, Burning or Stabbing Pain in one part of one breast that may
107 radiate to axilla, no palpable masses or lumps and no enlarged LNs
7 INon-cyclical Mastalgial
7 Gabapentin/ Amitriptyline can be useful.
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+If there is a mention of an association with menstruation (the pain increases

a few days before the menstrual cycle and subside after it), No lumps, but
there may be swelling and tenderness in both breasts.
~ ~yclical Mastalgial.
~ ~dvise her to wear a supportive bral. v
• If the pain is unilateral and there are lumps, nodularity, and is related to
menstruation, think of Fibroadenosis.
• If the pain is bilateral, no lumps, and is related to menstrual cycles, think of
cyclical M astalgia.
Breast pain (Mastalgia), 1' breast size, lumpiness (nodularity) of the breast, ~
in the reproductive age, !g.Qg~JQ..gP.P.g_g_r:.jl:\~tR.~.fg_rn..Qr...9.\.!.f.!D.&..mgn~.tt\.!.gJ..f.Yf.!g
and disappears after it~ IFibroadenosisl.
Key Which of the following is an absolute contraindication to elective

108 surgery?
A)IRecent M~. (within the last 6 months)

B) Previous Pulmonary Embolism (done 2 years ago).
C) Uncontrolled OM.
d) Uncontrolled HTN.
e) Anemia.
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41 I Page I Genetics) <fl Copyright www.plab1keys.com (Constantly updated for online subscribers)
If a ~athe~ carries the X-linked recessive gene (e.g. BMD):

+ 03 of MALE children will be DISEASED.
+ 1003 of Female children w ill be CARRIERS.
Key Fragile X-syndrome is an X::.U.nkg.d...P..9..mJo.~.o.t.~.9..0.d.i.tl9..o..

36
111 If the m.Q~n~r. is affected:
-7 50% of children "either male or fema le" will have the faulty gene.
111 If the f~Jn~r. is affected:
-7 0% of the male children will be affected (they take Y from their father, not X).
-7 100% of the f emale children will have the faulty gene.
Key Haemophilia A is an X-linked recessive condition. If the mother is a

37 carrier, there a lso%1
chance that her " male" baby to be affected.
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~ If there is Hx of recent endoscopy & the vitals are relatively stable

Think -7 IMediastinitisl "due to oesophageal perforation".
~ If No Hx of recent endoscopy & the vitals are worsening (esp . ..!,, BP)
Think -7 tJ'horacic artery dissection/ rupture!.
Key A 40 VO female known case of rheumatoid arthritis on celecoxib

131 (a NSAID) is brough to the A&E complaining of3 episodes of
vomiting blood. Her BP is 75/55. What is the NEXT step?
~ ~ ive IV fluids!.
-./ As the patient is haemodynamically unstable (the SBP <90), the

next step is to administer IV fluids for circulation stability. You
administer IV fluids while preparing for blood transfusion (cross-match
and blood group).
-./ If the patient deteriorated while on IV fluids and no time for cross
matching and blood grouping, 0 negative blood may be given.
-./ This hematemesis is likely due to gastric ulcer 2ry to the prolonged
use of NSAIDs for her rheumatoid arthritis.
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-./ After stabilisation, endoscopy would need to be done.

-./ IV proton pump inhibitors are useful in the case of gastric ulcer;
however, they can be given after the endoscopy.
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26 I Page [ M i s c e I I a n e o u s] ©Copyright www.plab1keys.com (Constantly updated for online subscribers)

v Initial step -7 Insert INasogastric Tube (NGT)l "for decompression".

v Definitive/ most palliative step -7 ls tomal

Vomiting of f~.<;9.L~.9.n~~n.t?. -7 NGT.

27 I Page [ M i s c e I I a n e o u s] ©Copyright www.plab1keys.com (Constantly updated for online subscribers)

v Absent breath sounds+ Dullness on percussion -7 Pleural effusion.

ttJ A teratoma is a tumor made up of several different types of tissue, such as

28 I Page [ M i s c e I I a n e o u s] ©Copyright www.plab1keys.com (Constantly updated for online subscribers)

ttJ Symptoms may be minimal if the tumor is small.

ttJ A testicular teratoma may present as a painless lump.

ttJ Complications may include ovarian torsion, testicular torsion, or hydrops

29 I Page [ M i s c e I I a n e o u s] ©Copyright www.plab1keys.com (Constantly updated for online subscribers)

ttJ Capecitabine is a chemotherapy used in many types of cancer (e.g.

Ca idc d ·est/ Ca 0VdS dr event/ C est i tect1ons/ Cd ·d ovascc.la .eve t).

~ loiscuss their wishes on the management plan~ whether they prefer to be

~ ~O mg subcutaneous morphine over 24 hoursl.

Ill From [Oral morphine to Subcutaneous morphine] ~ (~ 21)

33 J P age ( Pa 11 i at i v e care J © Copyright www.otab1keys.com (Constantly updated for online subscribers)

v Remember, palliative patients are preferred to receive Subcutaneous

v She takes 60 mg oral morphine twice a day (i.e. 120 mg over 24

v To shift to SC morphine, divide the 24-hour dose by 2 and give it over

v This means 120/2 = 60 mg over 24 hours.

64 I Pa g • [Op ht ha Imo Io g y J © Copyrighl www.plab1keys.com (Constantly updated for online subscribers)

oo Ramsay Hunt Syndrome {Herpes Zoster Oticus)

v Reactivation of Varicella Zoster Virus (VZV) in the geniculate ganglion of the

v Rx -? Oral Aciclovir + Corticosteroids + Amitriptyline "for the pain".

Key Orbital cellulitis

• It is usually caused by a spreading upper respiratory tract infection from the

• Periorbital (preseptal) cellulitis is a less serious superficial infection anterior

65 I Pa g • [Op ht ha Imo Io g y J © Copyrighl www.plab1keys.com (Constantly updated for online subscribers)

1111 Risk factors

1111 Differentiating orbital from preseptal cellulitis

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A 9 YO girl is brough to the ED by her mother complaining of left eye

68 I Pa g • [Op ht ha Imo Io g y J © Copyright www.ptab1keys.com (Constantly updated for online subscribers)

Key IPerthes' disease!

a Perthes' disease is a degenerative condition affecting the hip joints of

a It is due to avascular necrosis of the femoral head, specifically the femoral

v Hip pain : develops pr,qgr.~~.$.!v.g!Y. . 9.v.gr.w..~g~~.:.IJ'.\9.f.1~b~­

DDx according to age:

• ~-9 year~ -7 Perthes disease (Chronic, stiffness, flattening on x-ray).

Key Torus (Buckle) Fracture.

As they are typically self-limiting, they do not usually require operative

-7 Buckling of the distal radiu .

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SSRl-induced sexual dysfunction can occur in both men and women.

SSRls examples -7 (Fluoxetine, Sertraline, Citalopram)

Key Pain ladder (Analgesia Ladder)

1) Simple analgesia -7 Paracetamol, NSAIDs, Aspirin.

v Remember, we should not go back on the pain ladder, we either go

v Fentanyl patches have a slow onset of action; therefore, they should be

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Ill lithium and (NSAIDs) e.g. ibuprofen interaction :

~ 11' Risk of lithium Toxicity!.

..../ Therefore , NSAIDs (e.g. Ibuprofen , Diclofenac, Naproxen) should not

..../ Codeine is safe to be used with lithium.

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..J Aspirin is not a typical pain killer for injuries.

Key An asymptomatic child with Cytomegalovirus infection (CMV). His mother

v Congenital infections (e.g. Congenital Cytomegalovirus CMV)

v Hip pain : develops pr,qgr.~~.$.!v.g!Y. . 9.v.gr.w..~g~~.:.IJ'.\9.f.1~b~