 (HbA1C) can predict progression of diabetic complications, & goal is

recommended to stay <7%.

 Metformin is first-line therapy for DM 2, but it is not appropriate for

patients with kidney dysfunction. While glipizide is safe in stage 4 renal
failure, it is not the best choice for this patient.

 The sodium-glucose cotransporter 2 inhibitors are now recommended as

alternative first-line treatment for type 2 diabetes mellitus. Their
advantage is kidney and heart protection as well as help for patients
who want to lose weight.

 Diffuse thyroid tenderness is common with subacute thyroiditis.

Malignancy tends to present as a hard, possibly fixed, but painless mass.
Multiple palpable thyroid nodules are most likely benign, commonly due
to multinodular goiter or Plummer disease.

 The Jod Basedow effect is hyperthyroidism following administration of

iodine either in diet or in contrast medium. The phenomenon is iodine-
induced hyperthyroidism. It can occur when a patient with an endemic
goiter is relocated to an abundant iodine region.

 This should not be confused with the Wolff-Chaikoff effect, which

exhibits a reduction in thyroid hormone secondary to large iodine
ingestion, an autoregulatory phenomenon.
 The Jod Basedow effect can be seen with small increases of iodine in a
diet previously starved of iodine.
 Jod-Basedow is sometimes seen with iodine administration in the diet or
iodinated intravenous contrast. It can also be seen after amiodarone or
prolonged use of iodinated antiseptic solutions. A history of chronic
kidney disease is a predisposing factor. However, it is not the direct
cause of the patient's symptoms.

 Eosinophilic esophagitis is a disorder in individuals who have allergies,

reflux and dysphagia. Proton pump inhibitors may provide symptomatic
relief. Clinicians should arrive at the diagnosis of eosinophilic esophagitis
only after positive findings on clinical, endoscopic, and histopathologic
examinations. Patients who present with food impaction, dysphagia, and
history of atopy should undergo an upper endoscopy evaluation with
esophageal biopsy to diagnose eosinophilic esophagitis. Biopsies during
 endoscopy typically show a high number of eosinophils, which is the
diagnostic indicator for this disease. Treatment includes dietary changes,
Elemental diet, evaluation for allergies, and proton pump inhibitors.
Budesonide, Corticosteroids can be used for severe or refractory
disease.

 Screening guidelines for colon cancer vary according to the family

history of cancer and the number, size, and histology of the colonic
polyps. With no family history, if no polyps are found on colonoscopy,
repeat the test after ten years.

 If there are 1 or 2 polyps < 1 cm that are tubular adenomas, repeat the
test after 7 years.

 If there are 3 to 10 polyps on colonoscopy, any adenoma greater than 1

cm, or adenoma with high-grade dysplasia, repeat colonoscopy after 3
years.
More than 10 polyps on colonoscopy should prompt the repetition of
colonoscopy in less than 3 years and assessment of an underlying
familial syndrome.

 According to the approved surveillance plan by the American Society of

Colorectal Surgeons for individuals with a history of adenomas, the
following interval colonoscopy is recommended:
 1). 5 years for equal or < 2 of smaller than 1 cm tubular adenomas.
 2). 3 years for equal or more than three adenomas.
 3). 3 years for advanced adenoma (greater than 1 cm in size, high-grade
dysplasia, or villous component). However, multiple adenomas or large
sessile adenomas should be removed based on clinical judgment.

 Sulfonamides, penicillin, barbiturates, and certain anti-seizure drugs,

including lamotrigine, phenytoin, and carbamazepine, are the most
common drugs associated with SJS. This patient was likely treated with
lamotrigine for his focal seizures.

 Lamotrigine is a mood stabilizer and antiepileptic and is associated with

an increased risk for SJS. SJS is predominately a T–cell–mediated disease
during which CD8+ cells induce keratinocyte apoptosis.
 Panic disorder is an anxiety disorder described by recurrent unexpected
panic attacks. These include an intense fear that peaks within minutes
with simultaneous anxiety and physiological symptoms.

 A minimum of 4 anxiety symptoms are required to meet dx criteria for

panic disorder -- Possible symptoms include palpitations, sweating,
trembling, shortness of breath, sensation of choking, chest pain, nausea,
dizziness, chills, paresthesia, derealization, fear of dying, and fear of
losing control.
 Individuals with panic disorder also present with a persistent concern or
worry about future panic attacks and/or have maladaptive behavior
changes in attempts to avoid panic attacks.

 set of clinical criteria for dx of major depressive disorder (MDD) to be

met for at least 2 weeks. Some of these clinical symptoms include sad
mood, lack of interest, weight change, sleep disturbance, fatigue, and
psychomotor agitation or retardation. It can lead to significant declines
in social and school functioning.

 Adjustment disorder usually resolves within six months, depression lasts

much longer and usually requires professional management.
Management of depression includes counseling, antidepressant
medications, psychotherapy (cognitive behavioral therapy and
interpersonal therapy), and electroconvulsive therapy. The treatment
should involve shared decision-making with the patient and family.

 Risk factors for childhood depression are multiple. They include a +ve
family hx of depression, previous hx of depression or suicide,
concomitant mental health disorder(s), chronic medical illnesses, obesity
or body image disorders, female gender, child abuse or neglect, adverse
childhood experiences, poor school performance, loss of a family
member or loved one, low socioeconomic status, uncertainty about
sexual orientation, break up of a romantic relationship, and family
problems.

 In grief reaction, painful feelings come in waves. The sadness is

intermixed with positive memories of the deceased. Whereas in
depression, mood is always negative. In grief, self-esteem is preserved.
In contrast, feelings of worthlessness and self-loathing are seen in
depression. Bipolar disorder is diagnosed when a patient has had at least
one manic episode.
  lamotrigine is linked to a greater risk of suicide. This drug is an
anticonvulsant that can lead to incidences of self-injury or even violent
suicide.

 There is a high rate of co-occurring mental disorders among adolescents

(12 to 18 years of age) who use substances or have a substance use
disorder, including conduct disorder, attention deficit hyperactivity
disorder, major depressive disorder, bipolar disorder, anxiety disorder,
schizophrenia, and post-traumatic stress disorder.
 45% of individuals diagnosed with a substance use disorder have a
comorbid psychiatric disorder. Substance use and/or substance use
disorders (SUDs) are associated with many negative consequences
among youth, including accidents, death, adverse health effects, crime,
unplanned pregnancy, and low achievement.

 Vascular dementia often presents with acute changes in cognition

spread out over time. After the MMSE, a complete assessment is
needed. A complete medical history, including medications, should be
done. Laboratory evaluation, including CBC, TSH, and vitamin B12 levels
would be essential. CT of the brain or MRI will most likely be needed.

 While cognitive changes such as memory loss or personality changes can

indicate the development of dementia, other symptoms such as falls or
depression can also be indicative of this disease.

In a patient with various disparate acute problems, such as worsening mobility or mood,
it is crucial to attempt to correlate them.

 Management of Malaria.
 Tx of Uncomplicated falciform malaria
 ★case not resistant to chloroquine >>1st line Chloroquine
 ★Case resistance to chloroquine (in Asia, Africa) >> Artemisinin based
combination
 ★Any confusion whether any resistance to chloroquine or not >>Treat
with Artemisinin based combination.

 Tx of severe falciform malaria (cerebral malaria):

 ★Severe >>IV artesunate is tx of choice
  ★Parasite count more than >2 % = Need IV treatment
 ★Parasite count > 10% then exchange transfusion is the tx of choice.

*Mx of Multifocal atrial tachycardia:

If NO COPD --- give Bisoprolol
If pt with pre-existing COPD--- give Verapamil.

★A couple both have achondroplasia came to know the chance of having a

normal height child + Chance is >> 25%.@MOT >> Autosomal Dominant.

★Rheumatoid Arthritis patient taking NSAIDS for long time, now with raised
Creatinine & proteinuria + NSAIDS contributes renal impairment by >> Cyclo-
oxygenase inhibition.

★43 y female with persistent headache + unable to open Rt eye, pupil is

deviated to Rt & out + likely cause >> Post: communicating artery aneurysm.

★Parkinson patient came with delirium due to UTI + agitated & refused
medication + MAT for patient’s mental state >> IM lorazepam.

*A-Symmetrical resting tremor + bradykinesia + rigidity-- Idiopathic Parkinson

disease
*Symmetrical resting tremor+ rigidity + no/mild bradykinesia --Drug induced
Parkinson dis
*Symmetrical parkins + vertical gaze problem --Progressive supranuclear palsy.
*Parkinso + Visual hallucination +fluctuating cognition --Lewy body dementia.
*Parkins + autonomic Disturbance (hypotension) + gait abnormality --Multiple
system atrophy.
*Parkinsonism + liver cirrhosis --Wilson disease

★Pt with syncope and VT following 8 wks. of STEMI + ECG shows persistent ST
elevation in V1 to V3 with anterior T wave inversion + most likely cause of
patient’s ventricular Tachycardia >> Ventricular aneurysm.
Investigation of choice >> ECHO & MRI.
Treatment of choice >> Excision of aneurysm.