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29-year-old man presents with a cough and some mild aches in the hands, wrists and ankles. The
symptoms have been present for 2 months and have increased slightly over that time. Six weeks
before he had some soreness of his eyes, which resolved in 1 week.
The cough has been non-productive. He had noticed some skin lesions on the edge of the hairline
and around his nostrils. Previously he had been well apart from an appendicectomy at the age of 17
years.
Examination..............
There is no deformity of the joints and no evidence of any acute inflammation. In the respiratory and
cardiovascular system there are no abnormal findings. In the skin there are some slightly raised
areas on the edge of the hairline posteriorly and at the ala nasae. They are a little lighter than the
rest of the skin.
Questions
1. What is the likely diagnosis????
2. How might this be confirmed????

A 33-year-old woman is brought to the emergency department accompanied by her husband. Her
husband reports that she has periodic episodes of confusion that quickly resolve. He also reports
that she has been extremely weak and fatigued over the last 4 or 5 days. Her temperature is 39.0 C
(102.2 F), blood pressure is 140/70 mm Hg, pulse is 103/min, and respirations are 18/min. Physical
examination shows jaundiced skin and mild scleral icterus. She has a III/VI systolic ejectionmurmur
that does not radiate and 1+ edema in her lower extremities. Laboratory studies show anemia,
thrombocytopenia, elevated BUN and creatinine. A peripheral smear shows hemolysis with few
platelets.
The most appropriate next step is.........
A. conservative management with supportive care as needed
B. begin high-dose prednisone therapy
C. begin large-volume plasmapheresis

D. give platelet and red cell transfusion

E. obtain a surgical consult for urgent splenectomy

This patient has thrombotic thrombocytopenic purpura (TTP). She has the classic pentad of anemia,
thrombocytopenia, neurological abnormalities (which are often waxing and waning), fevers, and renal
abnormalities. The treatment is large-volume plasmapheresis daily until the patient is in complete remission. This
condition needs to be differentiated from ITP, which typically has isolated thrombocytopenia and hemolytic uremic
syndrome (HUS), which is similar to TTP except that renal abnormalities predominate over neurological findings.
Conservation management with supportive care (choice A) is a reasonable option in HUS in children. In the pediatric
population, this is typically self limited and only supportive care for acute renal failure is required.
High-dose prednisone therapy (choice B) is a treatment option in ITP. It is thought to work by both decreasing
antibody production and by reducing binding of antibodies to platelets. In TTP it is often an adjuvant therapy based on
theoretical principles, but it's true role has not been studied.
Platelet and red cell transfusions (choice D) are typically reserved for life-threatening bleeds since it is likely that
exogenous platelets and red cells will quickly be destroyed.
Splenectomy (choice E) in combination with steroids is reserved for patients who do not respond to plasmapheresis
and would not be the appropriate step at this time

Upper Abdominal Pain:

The first question you always ask yourself with abdo pain: IS THEIR PERITONISM OR NOT. If their
is, you need to automatically request a surgical consult.With peritoneal pain there will be percussion
tenderness, cough tenderness and rebound tenderness. This is a surgical abdomen until proven
otherwise. Localized peritonism occurs in area over organ that is inflamed. LIF think diverticulitis, RIF
think appendicitis & RUQ think cholecystitis. Generalized peritonism is caused by leakage of blood,
bile, bowel contents. Pancreatitis does not typically cause peritonism but can cause ascites.
If it is not peritonitis pain you then have to ask yourself whether it is the embryological upper, mid or
hind gut that is affected.
Upper Abdominal PainGastric - pain can be caused by either: acid - in order to feel better you therefore need to acid.
Hence this pain will be relieved with anything which dilutes the acid: Vomiting, Drinking milk, Eating
food, Bleeding into the stomach, Antacids.H2 R antagonists or PPIs .
Gastroporesis - suspect this if pt reports fullness extending beyond 2 hr postprandial. Succussion
splash confirms this - you hear noises when you put your steth on pt stomach and shake their belly.
Suction will relieve all gastric pain.
Liver: Pain is likely due to liver if there is palpable liver with deranged LFT & jaundice.Tenderness
indicates acute hepatitis - pain due to capsule stretching in acute inflammation.If non tender this
indicates chronic hepatitis - capsule has had a chance to compensate to slow expansion of liver.
Gallbladder: To be considered when liver indicators are absent i.e. no hepatomegaly, normal LFTs,
no jaundice. Gallstones will have right hypochondrium tenderness but have a negative Murphys
sign.Cholecystitis (gallstones + inflammation) will have right hypochondrium tenderness and a
positive Murphys sign.
Common bile duct: If inflamed you may get symptoms of cholecystitis i.e. RUQ tenderness +
Murphys sign + jaundice + deranged ALP and GGT.
Pancreas: Pancreatitis often causes inflammation of the duodenum and being adjacent to the
vertebral column pain in the mid thoracic region and pain worsens on vomiting. As the pancreas is
retroperitoneal and adjacent to vertebrae, pain is relieved when leaning forward. 1 in 10 patients will
have normal pancreatic enzymes so you need to do imaging to confirm dx. Air-filled bowel overlies
the pancreas so ultrasound is a terrible way to image it.Do CT or MRI.
NB: with pain due to cholecystitis, CBD and pancreas it will be worse on eating as their is increased
organ activity in an effort to digest the food and this will irritate.
Transverse colon: Pain can be either better or worse on bowel movements.Pt may have diarrhoea or
constipation. Tenderness runs in a straight line across the upper abdomen.
Abdominal wall:Nerves supplying the wall can be irritated causing pain. Alternatively the pain may be
referred from the spine or the chest.Do cardio and resp hx/exam if indicated.Get pt to move spine,
percuss along vertebral column

Peritonitis Ecoli
*Pyogenic peritonitis bacteriodes
*Peritonitis 2 to gyne infec bacteriodes
*Scar tissue strength collagen1
*Granulation tissue strength collagen3
*Opportunistic kleibsella
*Sensitive myoglobin
*Specific troponin
*First 6hrs CK
*within 1 hr CK MB cpsp key
*reversible cell swelling nd myelin figures both if one to choose then cell swelling
*Cell shrinkage irreversible
*Hep D dosenot cause malignant leison
*DVT Popliteal vein
*Pulmonary emboli femoral vein
*barr body diagnostic/ diagnosis word in senario then turner
*Scantty bar body kline filter
*X linked recessive more common in males..
*Pleural effusion drainage from lower part of space nd upper border of rib..
*Glutathione and vit E both antioxidant....
If in vitamins asked then select vit E..
Nd if asked b/w vitamin E nd glutathione then glutathione always..
*milk Is deficient in panthothenic acid cpsp key
*Hep A common wether pregnant non pregnant
*HEP D LETHAL
*HEP E in pregnant lethal
*typhoid inves(BASU)
1 week blood culture
2 week blood culture nd widal
3 week stool culture
4 week urine culture
*oesophageal opening in left curs
*in dysplasia select plemorphism
*in Premalignant leison high N to C ratio
*in ileostomy increase loss of water
* If ulcer in burn tissue asked then marjolin ulcer nd if gastric ulcer in burn tissue asked then curling
ulcer
*smoking dangerous in 3rd trimester
*left coronary artery supplies right bundle branch
*right coronary artery does NOT supply right bundle branch
*preganglionic fibers are B Fibers myelienated

*postganglionic fibers are C fibers unmyelienated

* histological finding in TB then its caseous necrosis not AFB
* cogulative necrosis in TB occurs
*diabetes dry gangrene
* glucagon increases insulin nd insulin decreases glucagon
* best for GFR inulin clearance but if asked clinical then creatinine clearance
Dialysis fluid contain glucose nd bicarb more than plasma rest of all other is decreased
*right border of heart formed by R atrium nd
Right border of heart on xray its R atrium nd SVC
nd if one to choose on xray then SVC
*pregnant lady bile obstruction ggt other wise bile obstruction alp
*atrophy of breast asked then estrogen nd pogesterone def..
If adult female breast atrophy then estrogen deficiency
*Plasma osmolarity regulated by ADH
Urine osmolarity regulated by ADH
Most potent stimulus for ADH seccretion its nausea
*indirect bilirubin raised hemolytic anemia
* urea other than liver synthesized by brain