oral morphine not tolerated + stable pain = fentanyl patches and oral

morphine not tolerated + unstable pain = s/c morphine

Patient well controlled on oral morphine but can't tolerate oral route - shift to
transdermal patch (fentanyl)
Patient not well controlled on oral morphine and not tolerating oral route - shift
to s/c or IV morphine with dose adjustment (half dose)
Patient not able to tolerate the side effects of morphine - change to oxycodone
Post Coital Bleeding for the first time: Cervical smear first and depending on
result colposcopy. ( sometimes with punch biposy or core biopsy)
If PCB is persistent i.e 3 months duration etc, direct colposcopy.
Also, postmenopausal bleed most common cause is ca endometrium and
most common cause for post coital postmenopausal is also ca endometrium is
this ok till now?
ectropion we have to perform smear first if the female is on COCP. If the
qestions mentions young sexually active female then go SWAB firs
Ca endometrium first is TVUSG then biopsy or endometrial sampling,

pneumonia+headache+confusion=legionella
H influenza and pseudomanas staphylococcus are most common
superimposed infections in CF
SOB + such high fever+ Localized pleural rub - seems Lobar pneumonia
Pleural rub present in pneumonia, PE and pleurisy.

endomysial antibodies for celiac disease. Weight loss. Abdominal bloating.

Bulky stools etc.
Sweat test if for cystic fibrosis. There will be associated recurrent chest
infections along with abdominal symptoms.
Tft. Hypothyroidism in children. They will have prolonged jaundice not
increasing jaundice.

This woman has lower abdominal pain and a positive pregnancy test
with signs of haemodynamic instability: an ectopic pregnancy (C) should

therefore be excluded urgently. Ovarian torsion (E) and ruptured ovarian

cysts (A) classically present with a sudden onset abdominal pain, and
are not commonly associated with a significant tachycardic hypotension.
Differentiating between them can be difficult. However, the natural
history of the pain is often helpful. Both may present with sudden onset
pain, but usually the pain of ovarian torsion will be out of keeping with
the clinical findings and will not improve with simple analgesia. Indeed
it does not normally decrease significantly at all. By contrast, the pain
of cyst rupture, while being of sudden onset, is often reduced by simple
analgesia and may decrease gradually as the peritoneal lining (having
been irritated by leaking fluid or blood from the cyst, causing pain)
absorbs intraperitoneal free fluid. A woman with a perforated appendicitis
(D) would often show signs of sepsis, including fever and peritonitis,
and pain is normally localized initially to the central abdomen or right
iliac fossa. At this level of beta hCG, an intrauterine pregnancy would
normally be visible on transvaginal ultrasonography. Of the two ectopic
pregnancy options available, cervical ectopics (B) would normally be
demonstrable on transvaginal ultrasound. Ruptured ectopic pregnancy
is a surgical emergency requiring prompt assessment, resuscitation and
urgent surgery. The urgency of the situation is even more pronounced if
there are signs of haemodynamic instability, such as in this case where
there is evidence of hypovolaemic shock
For osteoporosis, raloxifen
Clonidine is also used in the treatment of dysmenorrhea (severely painful
cramps during menstrual period), hypertensive crisis (a condition in which
your blood pressure is very high), Tourette's syndrome (a condition
characterized by the need to perform repeated motions or to repeat sounds or
words), attention deficit hyperactivity disorder (ADHD), menopausal hot
flashes, and alcohol and opiate (narcotic) withdrawal. Clonidine is also used
and as an aid in smoking cessation therapy and to diagnose
pheochromocytoma (a tumor that develops on a gland near the kidneys and
may cause high blood pressure and fast heart rate).. Incubation prd:

Polio 6-20 days

TB 2-12 wks
HIV 2wks or 6 months. Syphilis 3wks -3months

Important point
Increased thirst
Increased urination
High fever Weakness Drowsiness Altered mental state
Headache Restlessness Inability to speak Visual problems
Hallucinations Paralysis Warm skin that doest not prespire
(signs of hyperglycaemic shock....)

CI OF THROMBOLYSIS (alteplase or streptokinase). ARE

Systolic BP of >200mmhg and diastolic BP >120mmhg
Recent strokes and previous TIA
Prolonged CPR a-internal bleeding b-vaginal bleeing cesophageal varices d-recent haemorrhagic shock in 3 months.
Prolong or traumatic cpr, recent trauma and surgery lee than 2
wks, recent head trauma, severe htn, severe liver disease, and
allergy to streptokinase. Pregnancy or less than 18 wks post
deliver(Alteplae has 2 types accelerated with in 6 hrs , young pts
with anterior MI. standard with in 6- 12 hrs.)
(Should be given to all patients except
Haemorrhagic stroke has been excluded.
The patient presents within four and a half hours of having the
event.)(
(Indications:
1-st elevation, posterior infarction,
HAEMOCHROMATOSIS
.joints, (arthralgia, osteoporosis, pancrease(bronze dm heart,
(dilated cardiomyopathies pituitary,(hypogonadisim and
hypoaldosteronisism liver(cirrhosis).
Is autosomal recessive

 Is associated with more ferritin and decrease iron binding

capacity. >50% patients are diabetic Predispose to hepatoma
Is caused by absorption of iron Perls stain on liver biopsy for iron
loading.
The rooting reflex is present at birth and disappears around four months of
age, as it gradually comes under voluntary control.A newborn infant will turn
his head toward anything that strokes their cheek or mouth, searching for the
object by moving their head in steadily decreasing arcs until the object is
found.

The palmar grasp reflex appears at birth and persists until five or
six months of age. When an object is placed in the infant's hand
and strokes their palm, the fingers will close and they will grasp it
with a palmar grasp.
Pregnant female exposed to child with chicken pox:Next step is measure her IgG antibodies- if she is immune- reassure
If she is non-immune- give varicella Igs
And if she unfortunately develops chicken pox, then give her acyclovir within a
day of appearance of rash (no immunoglobulins will help her once she
develops the disease so avoid)
If fetus develops chicken pox (soon after birth) give both immunoglobulin and
acyclovir A-- pale optic disc becoz artery is occluded

C - dof blot heamorrhages

swelling and edema is always vein
and pale retina with cherry macula is artery block

WILSONS DISEASE The onset of symptoms is usually between 10 - 25

years. Children usually present with liver disease whereas the first sign of
disease in young adults is often neurological disease

Features result from excessive copper deposition in the tissues, especially the
brain, liver and cornea:
liver: hepatitis, cirrhosis
neurological: basal ganglia degeneration, speech and behavioural problems
are often the first manifestations. Also: asterixis, chorea, dementia
Kayser-Fleischer rings
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails
Diagnosis
reduced serum caeruloplasmin
increased 24hr urinary copper excretion
Management
Penicillamine (chelates copper) has been the traditional first-line treatment

MUST READ THIS:

Primary prevention of cardiovascular disease (CVD):
Previously, aspirin was recommended for those without apparent
CVD in whom the total CVD risk over 10 years is >20%, and for
almost all diabetic patients over the age of 50 years. The evidence
to support this unlicensed indication is not robust and thus current
guidance is that aspirin should not be used in primary prevention
(including in those with diabetes mellitus or hypertension) But note:
aspirin is increasingly being used in the primary prevention of
some cancers - particularly bowel cancer.
Clopidogrel and dipyridamole are neither indicated nor licensed
for primary prevention of cardiovascular (CV) events.
Secondary prevention of CVD:
In those with established atherosclerotic disease, low-dose
aspirin (75 mg daily) is recommended indefinitely for long-term
secondary prevention.
Modified-release dipyridamole 200 mg bd plus low-dose aspirin
(50 mg or 75 mg daily) is recommended for secondary prevention
following an ischaemic stroke or a transient ischaemic attack (TIA)

for a period of two years from the most recent event,[ Where
aspirin is contra-indicated or genuinely not tolerated (ie proven
hypersensitivity or history of severe low-dose aspirin-induced
dyspepsia), clopidogrel 75 mg daily is a suitable alternative to
aspirin (or aspirin plus dipyridamole post-stroke)

Myocardial ischaemia
A single dose of aspirin 300 mg and clopidogrel 300 mg (600 mg
- unlicensed in some centres prior to urgent percutaneous
coronary intervention (PCI)) should be given as soon as possible
after an ischaemic event (both non-ST segment elevation
myocardial infarction (NSTEMI) and STEMI), preferably dispersed
in water or chewed
Clopidogrel 75 mg daily is licensed for the treatment of acute
coronary syndrome (ACS) ST elevation, in combination with
aspirin (usually following loading doses)
Post-PCI clopidogrel 75 mg should continue for one month if a
bare metal stent is inserted and 12 months if a drug-eluting stent is
inserted. Thereafter, treatment should revert to low-dose aspirin
alone.
Eptifibatide and tirofiban are licensed for use with heparin and
aspirin to prevent early MI in patients with unstable angina or
NSTEMI where early percutaneous transluminal coronary
angioplasty (PTCA) is desirable but delay is likely.
Cerebral ischaemia
Acute ischaemic stroke - thrombolyse if appropriate and follow
with aspirin 300 mg once daily for 14 days. If not able to be
thrombolysed then aspirin alone should be given. Aspirin caused
an excess of about two intracranial and four extracranial
haemorrhages per 1,000 people treated, but these small risks were
more than offset by the reductions in death and disability from
other causes
Long-term management of both TIA or ischaemic stroke dipyridamole 200 mg bd with aspirin 75 mg once daily.

 Atrial fibrillation (AF) carries a high risk of stroke and other

thromboembolic events. Warfarin is more efficacious than aspirin
at preventing stroke (particularly in those at highest risk) but
carries a greater risk of major haemorrhage:
. The CHA2DS2-VASc score is one method of assessing stroke
risk (it has superseded the CHADS2 score)
CHA2DS2-VASc[26]
Condition Points
C Congestive heart failure (or left ventricular (LV) dysfunction). 1
H Hypertension. 1
A2 Age 75 years. 2
D Diabetes mellitus. 1
S2 Prior stroke, TIA or thromboembolic disease. 2
V Vascular disease - eg presence of peripheral vascular disease,
myocardial infarction, aortic atherosclerosis. 1
A Age 65-74 years. 1
Sc Sex category (ie female). 1
Score 0 = low risk; no treatment or treat with aspirin.
Score 1 = moderate risk; aspirin daily or warfarin based on the
patient's preference. Warfarin is probably preferred if there are no
contra-indications.
Score 2 or more = high risk; treat with warfarin maintaining an
INR 2-3.
New oral anticoagulant drugs, eg dabigatran, are likely to become
an option
Fibrinolytic drugs
For patients who cannot be offered PCI within 90 minutes of diagnosis, a
thrombolytic drug should be administered along with either unfractionated
heparin (for maximum two days), a low molecular weight heparin (eg,
enoxaparin) or fondaparinux. Thrombolytic drugs break down the thrombus so
that the blood flow to the heart muscle can be restored to prevent further
damage and assist healing.
Reperfusion by thrombolysis is often gradual and incomplete and may be
inadequate. There is a risk of early or late reocclusion and a 1-2% risk of

intracranial haemorrhage.
Fibrinolytic drugs act as thrombolytics by activating plasminogen to form
plasmin, which degrades fibrin and so breaks up the thrombi.
Streptokinase and alteplase have been shown to reduce mortality. Reteplase
and tenecteplase are also licensed for AMI.
Streptokinase and alteplase are given by intravenous infusion. Reteplase and
tenecteplase can be given by rapid bolus injection.
The benefit is greatest in those with ECG changes that include ST-segment
elevation (especially in those with anterior infarction) and in patients with
bundle branch block.
The earlier the treatment is given, the greater the absolute benefit. Alteplase,
reteplase and streptokinase need to be given within 12 hours of symptom
onset, ideally within one hour. Tenecteplase should be given as early as
possible and usually within six hours of symptom onset.
In patients presenting within 12 hours after the onset of symptoms but
reperfusion therapy is not given, or in patients presenting after 12 hours,
aspirin, clopidogrel and an antithrombin agent (heparin, enoxaparin or
fondaparinux) should be given as soon as possible
1:2:1
1:4 25% unaffected
2:4 or 1:2 50% carrier
1:4 25% affected

Hemochromatosis is deposition of iron in hepatocytes, with

resulting damage to the liver cells.
Hemosiderosis is the deposition of iron in Kupffer cells, with no
damage to the liver cells
SIGN suggested the following criteria for referral to hospital (children)
poor feeding (< 50% normal)
lethargy
apnoea
respiratory rate > 70/min
nasal flaring or grunting

severe chest wall recession

cyanosis
oxygen saturation < 94%
uncertainty regarding diagnosis
Oral lichen planus is an ongoing (chronic) inflammatory condition that affects
mucous membran nes inside your mouth. Oral lichen planus may appear as
white, lacy patches; red, swollen tissues; or open sores
Post-coital bleeding in middle aged females is CERVICAL cancer until proven
otherwise.
Post-coital bleeding in post-menopausal females is ENDOMETRIAL cancer
until proven otherwise.
Since they're asking for the most appropriate (not the initial most)
investigation, I'll go for endometrial sampling.
Remember transvaginal ultrasound > endometrial sampling > biopsy.

bilateral parotid and lacrimal gland enlargement was characterized

by the term Mikulicz's disease if the enlargement appeared apart
from other diseases. If it was secondary to another disease, such
as tuberculosis, sarcoidosis, lymphoma, and Sjgren's syndrome,
the term used was Mikulicz's syndrome.
the best choice for lowering potassium is 10ml calcium gluconate 10% . the
next option is insulin plus dextrose infusion (the insulin helps potassium go
into cells and the dextrose protects against hypoglycemia).
calcium resonium takes time to act
Sudden severe -- PID
Gradual ( chronic ) with other features eg scoliosis etc -- AS
Morning -- they can because while getting up if posture is nt straight ..
AS -- involvement of sacroiliac joints is classic

And also morning stiffness

Myasthenia is autoantibodies to post ganglionic acetylcholine receptors, LES
is autoantibodies against presynaptic receptors.
Clinically, LEMS has weakness predominantly in lower limbs and less of
ocular weakness etc.
Also LEMS the weakness improves (means patient gets better) with repeated
use unlike myasthenia where patient gets fatigue due to repeated use
antibodies differ....MG...anti ACH abs while in LEMS...abs against Ca
channels plus usually associated with SCLC!
Painless syphlis
Painful single ulcer -- hem ducreyi
Hsv -- multiple
Beneficence - promote the well being of your patient
Non-maleficence - principle of NOT harming your patient in any way is more
important than doing them good.

CT scanning is recommended for most patients in the acute phase of stroke.

CT is widely available, practical, quick and easy to use in ill patients.
CT is very sensitive in diagnosing haemorrhage in patients in the acute stage.
In patients with ischaemic stroke, especially those with mild neurological
deficits, CT imaging is often normal in the first few hours but the accuracy for
ischaemic stroke delineation improves after six hours.
However, CT remains less accurate than MRI for determining the site and
extent of ischaemic damage, particularly for small lesions and posterior fossa
lesions.
The accuracy of CT is reduced after one week following the stroke event,
especially distinguishing between haemorrhagic and ischaemic stroke origin.
Also have a look here please:MRI may be contra-indicated in up to a fifth of patients because they are too
ill, confused, dysphasic, have an intraocular or intracerebral metallic foreign
body or have a pacemaker.

MRI should be the imaging investigation of choice in individuals with epilepsy.

It is particularly important in patients

who develop epilepsy before the age of 2 years or in adulthood
who have any suggestion of a focal onset on history, examination or EEG
(unless clear evidence of benign focal epilepsy)
in whom seizures continue in spite of first-line medication.
CT is used when MRI is not available or contraindicated to identify underlying
gross pathology or for children and young people in whom a general
anaesthetic or sedation would be required for MRI but not CT - gpnotebook.

CT of the sinuses as well as the orbit brain:

CT is usually indicated only for children (unless the child is very well and the
episode is mild) or if orbital cellulitis is suspected in an adult.
if an intracranial abscess is suspected, CT is the gold standard imaging
modality, carried out to identify any subperiosteal abscesses, paranasal
sinusitis or cavernous sinus thrombosis (all needing multi-speciality input).
It is also valuable in assessing trauma where there may be concerns about a
retained orbital or intraocular foreign body.

Pancoast tumour is a type of lung cancer defined primarily by its location

situated at the top end of either the right or left lung
Pancoast tumour can include a complete Horner's syndrome in severe cases:
miosis (constriction of the pupils), anhidrosis (lack of sweating), ptosis
(drooping of the eyelid) and enophthalmos (sunken eyeball). In progressive
cases, the brachial plexus is also affected, causing pain and weakness in the
muscles of the arm and hand (thoracic outlet syndrome). The tumour can also
compress the recurrent laryngeal nerve and from this a hoarse voice and
bovine cough may occur.
Current screening protocols in the United Kingdom
Newborns
Well baby protocol:
For babies who had no requirement for special care (or <48 hours in special
care).
Uses the AOAE test. Babies not passing this test are given the AABR test.

Neonatal intensive care/special care baby unit protocol:

Uses both AOAE and AABR tests. The latter can detect auditory neuropathy,
which is more common in special care babies.
Automated otoacoustic emissions (AOAE) test
Automated auditory brainstem responses (AABR) test
It was brain stem evoked response till 6 months.
6months till 2 years it's distraction tests
>2 years audiometry.
5years..pure tone audiogram

grey membrane on tonsils diphtheria

yellow membrane on tonsils - infective mononucleosis!!

Muscle pain due to inflammation in the body's soft tissues. Myofascial pain is
a chronic condition that affects the fascia (connective tissue that covers the
muscles). Myofascial pain syndrome may involve either a single muscle or a
muscle group. In some cases, the area where a person experiences the pain
may not be where the myofascial pain generator is located. Experts believe
that the actual site of the injury or the strain prompts the development of a
trigger point that, in turn, causes pain in other areas. This situation is known
as referred pain.
Myofascial pain symptoms usually involve muscle pain with specific "trigger"
or "tender" points. The pain can be made worse with activity or stress. In
addition to the local or regional pain associated with myofascial pain
syndrome, people with the disorder also can suffer from depression, fatigue
and behavioral disturbances.
Diagnosis
Trigger points can be identified by pain that results when pressure is applied

to an area of a person's body. In the diagnosis of myofascial pain syndrome,

four types of trigger points can be distinguished:

Adjustment disorder usually lasts < 6 months

Anticipation of next episodes and persistent concern of additional attack is
there in Panic disorder and not in adjustment

Parvovirus B19 is a common infection, usually presenting as erythema

infectiosum in children. There is a wide range of potential consequences of
parvovirus B19 infection. These extend from minor febrile illness to erythema
infectiosum (fifth disease, slapped cheek syndrome), a generalised rash
illness clinically indistinguishable from rubella, aplastic crises in patients with
increased red cell turnover, arthropathy, and persistent infection in the
immunocompromised.
If hyperkalemia is interfering either cardiac function then give calcium
glucionate.. but calcium chloride can be used alternativly in central line n than
start insulin n glucose
both calcium chloride or cal gluconate can be given.
Considering both,10% calcium chloride is 10 mL and contains 6.8 mmol of
calcium. Also a standard ampule of 10% calcium gluconate is also 10 mL but
has only 2.26 mmol of calcium.
So cal chloride is better, however it is more concentrated & it is caustic to the
veins and should only be given through a central line.Good thing is onset of
action is less than 5 minutes and lasts about 30-60 min.
median nerve compression actually a complication of tight
cast...decompression surgery is done
The National Institute for Health and Clinical Excellence (NICE) advises that
women should be offered screening for anaemia at booking and at 28 weeks
of gestation.[2] Anaemia is defined as an Hb level <11.0 g/dL at booking;
haemodilution will result in further drops during pregnancy and subsequent
reduction in oxygen-carrying capacity. In the second and third trimesters the
diagnostic level for anaemia is an Hb level of <10.5 g/dL. Postpartum the
diagnostic level is 10.0 g/dL.
Parkinson type effects plus urinary symptoms are shy drager syndrome

shy dagger syndrom..wet wobbly wacky..

Pancoast's Syndrome

Classically
caused by an apical (superior pulmonary sulcus) malignant
neoplasm of the lung. The neoplasm is usually bronchogenic in
origin (most commonly squamous cell carcinoma, sometimes
adenocarcinoma and large-cell carcinoma).

Presentation

This syndrome results from the invasion of a number of structures

and tissues around the thoracic inlet and may be characterised by:
An ipsilateral invasion of the cervical sympathetic plexus leading to
Horner's syndrome (miosis, enophthalmos, ptosis; in 14-50% of
patients).[1]
Ipsilateral reflex sympathetic dystrophy may occur.
Shoulder and arm pain (brachial plexus invasion C8-T2) leading to
wasting of the intrinsic hand muscles and paraesthesiae in the
medial side of the arm.
Less commonly, unilateral recurrent laryngeal nerve palsy
producing unilateral vocal cord paralysis (hoarse voice bovine
cough), and/or phrenic nerve involvement.
There may be arm oedema secondary to the compression of blood
vessels.
Superior vena cava syndrome may also occur.
A conversion disorder causes patients to suffer from neurological
symptoms, such as numbness, blindness, paralysis, or fits without
a definable organic cause. It is thought that symptoms arise in
response to stressful situations affecting a patient's mental health.
Stockholm syndrome can be seen as a form of traumatic bonding,
which does not necessarily require a hostage scenario, but which
describes "strong emotional ties that develop between two persons
where one person intermittently harasses, beats, threatens,

abuses, or intimidates the other.

Echopraxia (also known as echokinesis[1]) is the involuntary
repetition or imitation of another person's actions. [1] Similar to
echolalia, the involuntary repetition of sounds and language, it is
one of the echophenomena ("automatic imitative actions without
explicit awareness").[1] It has long been recognized as a core
feature of Tourette syndrome,
Echolalia (also known as echologia or echophrasia[1]) is the
automatic repetition of vocalizations made by another person
Anosognosia (/nsnozi/, /nsno/; from Ancient
Greek - a-, "without", nosos, "disease" and
gnsis, "knowledge") is viewed as a deficit of self-awareness, a
condition in which a person who suffers certain disability seems
unaware of the existence of his or her disability.
Couvade syndrome, also called sympathetic pregnancy, is a
proposed condition in which a partner experiences some of the
same symptoms and behavior of an expectant mother.[1] These
most often include minor weight gain, altered hormone levels,
morning nausea, and disturbed sleep patterns.
Apraxia (from Greek praxis, an act, work, or deed[1]) is the inability
to execute learned purposeful movements,[2] despite having the
desire and the physical capacity to perform the movements
Ganser syndrome is a rare dissociative disorder previously
classified as a factitious disorder. It is characterized by nonsensical
or wrong answers to questions or doing things incorrectly, other
dissociative symptoms such as fugue, amnesia or conversion
disorder, often with visual pseudohallucinations and a decreased
state of consciousness. It is also sometimes called nonsense

syndrome, balderdash syndrome, syndrome of approximate

answers, pseudodementia, hysterical pseudodementia or
prison psychosis. This last name, prison psychosis, is sometimes
used because the syndrome occurs most frequently in prison
inmates, where it may represent an attempt to gain leniency from
prison or court officials.
Folie deux (/fli du/; French pronunciation: [fli a d]; French
for "a madness shared by two"), or shared psychosis, is a
psychiatric syndrome in which symptoms of a delusional belief are
transmitted from one individual to another
The Capgras delusion (or Capgras syndrome) (/kpr/,
US dict: kpgr)[1] is a disorder in which a person holds a delusion
that a friend, spouse, parent, or other close family member (or pet)
has been replaced by an identical-looking impostor.
The Cotard delusion (also Cotard's Syndrome and Walking
Corpse Syndrome) is a rare mental illness, in which the afflicted
person holds the delusion that he or she is dead
The delusion of negation is the central symptom in Cotard's
syndrome. The patient afflicted with this mental illness usually
denies their existence, or the existence of a certain body part, or
the existence of a portion of their body.
Asperger's syndrome (AS) lies within the autistic spectrum.
Previously it was called high-functioning autism. The main
difference from classic autism is a lack of delayed or retarded
cognition and language. Those with AS are also more likely to seek
social interaction and share activities and friendships.

Rett's syndrome is an X-linked neurodevelopmental condition

characterised by loss of spoken language and hand use with the
development of distinctive hand stereotypies. It is a pervasive
developmental disorder (PDD).

Synonym: Ekbom's syndrome

The term restless legs syndrome (RLS) was to describe a disorder
characterised by sensory symptoms and motor disturbances of the
limbs, mainly occurring during rest.

Tourette's syndrome is a disorder that starts in childhood. The

prime symptom is to have repeated tics. A tic is a sudden
movement or sound that is repeated over and over. A tic has no
purpose and, in general, you cannot help doing it. For example,
repeated blinking, repeated throat clearing, repeated head
nodding, etc. Tics are very common in children and usually last
less than one year.
The main symptom is multiple (many) tics. These are classified as
either motor (movement) or vocal tics.
Motor tics include things such as blinking, head turning, head
nodding, kicking, mouth pouting, mouth opening, mouth twitches,
etc.
Vocal tics include things such as throat clearing, coughing, sniffing,
yelling, or making animal sounds.
The most common conditions seen with Tourette's syndrome are
listed below with how often they occur in children with Tourette's
syndrome.
Obsessive-compulsive disorder (OCD), or obsessive-compulsive
behaviour (OCB). This occurs in about 5 in 10 children with
Tourette's syndrome.
Attention deficit hyperactivity disorder (ADHD, or ADD). This
occurs in about 6 in 10 children with Tourette's syndrome.
Self-harming behaviours such as head banging occur in about 3 in
10 children with Tourette's syndrome.

A patient with Serum Na of 122 mmol\L, the following are likely

causes:
DKA.
Hypoadrenalism.
Prolonged Infusion of 5% Dextrose.
Syndrome of Inappropriate ADH secretion.
In young lady psychologically disturbed and drinks water
excessively
Like

According to patient.co, sleep alarms is the best option in uncomplicated mildmod enuresis. Desmopressin for severe symptoms or when immediate effect
is needed. Behavioral therapy for daytime symptoms only. Please correct me
if I'm wrong.

Osler weber rendu syndrome ( hereditary hemorrhagic telangectasia).

Family history is suggesting it in the scenario as it is Autosomal dominant
As all other tests are normal , Upper gastrointenstinal endoscopy ( UGIE )
should be done to check for melena

Laurence-Moon-Biedl syndrome and Laurence-Moon-Biedl-Bardet

syndrome are no longer considered valid terms, because the
patients of Laurence and Moon had paraplegia, but no polydactyly
and obesity, which are the main characteristics of the Bardet-Biedl
syndrome.[1]

Features

These are:[2]
Short stature.
Retinitis pigmentosa, nystagmus, choroidal atrophy, cataract and
squint.
Micropenis with hypoplastic scrotum.
Type 2 diabetes mellitus.

General learning disability.

Speech delay and deficit.
Ataxia with spastic paraplegia.
Renal anomalies, eg clubbing, diverticula or calyceal cysts.
Goodpasture syndrome (GPS; also known as Goodpastures
disease, anti-glomerular basement antibody disease, or antiGBM disease) is a rare autoimmune disease in which antibodies
attack the lungs and kidneys, leading to bleeding from the lungs
and to kidney failure

The American College of Rheumatology has identified six criteria

for the diagnosis of Churg-Strauss syndrome:[2]
Asthma (wheezing, expiratory rhonchi).
Eosinophilia of more than 10% in peripheral blood.
Paranasal sinusitis.
Pulmonary infiltrates (may be transient).
Histological confirmation of vasculitis with extravascular
eosinophils.
Mononeuritis multiplex or polyneuropathy.

Syringomyelia is a rare condition in which there is fluid-filled

tubular cyst (syrinx) within the central, usually cervical, spinal cord.
The syrinx can elongate, enlarge and expand into the grey and
white matter and, as it does so, it compresses the nervous tissue
of the corticospinal and spinothalamic tracts and the anterior horn
cells. This leads to various neurological symptoms and signs,
including pain, paralysis, stiffness and weakness in the back,
shoulders and extremities. Syringomyelia may also cause loss of
extreme temperature sensation, particularly in the hands, and a
cape-like loss of pain and temperature sensation along the back
and arms. Symptoms typically vary depending on the extent and
location of the syrinx. 50% of patients (when all types of syrinxes
are considered) experience no or only mild disability.

If the syrinx extends into the brainstem, syringobulbia results. This

may affect one or more cranial nerves, resulting in facial palsies.
Sensory and motor nerve pathways may be affected by
interruption and/or compression of nerves.

Hypnagogic or hypnopompic hallucinations are visual, tactile,

auditory, or other sensory events, usually brief but occasionally
prolonged, that occur at the transition from wakefulness to sleep
(hypnagogic) or from sleep to wakefulness (hypnopompic).
The person may hear sounds that are not there and see visual
hallucinations. These visual and auditory images are very vivid and
may be bizarre or disturbing.

Usually it is part of the tetrad of narcolepsy that includes:

Excessive daytime sleepiness
Cataplexy
Hypnagogic hallucinations
Sleep paralysis.
This tetrad is rarely seen in children.

Ulcer on posterior stomach wall - always bleed (gastroduodenal artery) - blood

in lesser sac or beneath diaphragm
Ulcer on anterior wall - always perforate - gas under diaphragm

Clonidine drug of choice for hot flushestibolone also given

Reloxifine given for osteoporosis prevention in menopause

pitting nails is psoriasis

0-14yrs- ALL
15-59yrs- AML
40-60yrs- CML

60+ CLL
Status epilepticus
Administer intravenous lorazepam as first-line treatment. Administer
intravenous diazepam if intravenous lorazepam is unavailable, or buccal
midazolam if unable to secure immediate intravenous access. Administer a
maximum of two doses of the first-line treatment (including pre-hospital
treatment)
Phenytoin is 2nd line.

to correct Hyperkalemia
1st n qickest is calcium gluconate
Then insulin n dextrose
Then calcium resonium

Laparoscopy is the criterion standard for the diagnosis of PID. It is significantly

more specific and sensitive than are clinical criteria alone. The minimum
criteria for diagnosing PID laparoscopically include tubal wall edema, visible
hyperemia of the tubal surface, and the presence of exudate on the tubal
surfaces and fimbriae.
For severe PID--- broad spectrum (ceftriaxone) plus doxycycline
Moderate PID-----moderate doxy plus metro

when AIDS (Active disease) do not give any vaccination

when HIV, only BCG is contraindicated

Afib is the most common arrythmia in alcoholics. Also known as holiday heart
syndrome
in holiday heart syndrome AF occurs due to binge drinking and theres no
underlying heart patho
swelling in ankles in an elderly female indicates heart failure. alcoholic so AF
hence reathlessness and palpitations

CRAO, cherry red sopt is clincher. applying pressure might increase the blood
flow

A 40 year old man after an operation had a heavy bleeding. What

abnormality will you find? Low calcium

TIA. Doppler usg. Majority of TIA develop due to emboli which are picked up
on carotid doppler.
Carbimazole (used in hyperthyroidism), clozapine (atypical antipsychotics),
INH .s/eagranulocytosis (neutropenia)

statins cause muscle ache

neuroleptic malignant syndrome.typical antipsychotics suchas haloperidol

osteosarcoma is relatively painless whereas ewings presents with pain and

redness around the tumor area.
Remember
Knee or shoulder..painless..osteosarcoma
Thigh or pelvis..painful..ewings

for dehydration and dka its NS and for burns its hartmans solution
if on the electrolyte picture it shows hypernatremia only then go for 0.45% NS.
otherwise give 0.9% NS if normonatremia or hyponatremia.
and potassium is always added to the fluid regimen after confirming the lab
values and a good urine output
before surgery for diabetics iv insulin n glucose n k

Anti-smooth muscle antibodies are antibodies (immunoglobulins) formed

against smooth muscle. These antibodies are typically associated with
autoimmune hepatitis.[

Chicken has blisters of different ages .. Some healing ( crusted in this case ) ,
others ( the new ones ) still erupting ( weeping in this case )
In Shingles , all come at same time and with preceding pain in dermatomal
area and heal by crusting at the same time
for shingles , there should be some history , a minor clincher towards
immunocompromised state . It doesnt usually erupt just like that in healthy
young individuals whereas chicken pox can !!
Also though chicken pox starts from trunk , it surely is there on face and
around eyes.

Aspirin should b given from the 1st day of +ve pregnancy test n heparin
should b given as soon as fetal heart is seen on us.Anti phospholipids
syndrome
in children UTI always present due to some underlying disease...it could be
VUR or something. So even on single episode of UTI we need to further
investigate by doing an USG

Cerebral abscess presents as ring enhancing lesion

Toxoplasmosis being one of the causes of cerebral abscess

dexa scan for osteoporosis and nuclear bone scan to see metastasis
Normal is a T-score of -1.0 or higher
Osteopenia is defined as between -1.0 and -2.5
Osteoporosis is defined as -2.5 or lower, meaning a bone density that is two
and a half standard deviations below the mean of a thirty-year-old
man/woman.
Calcium stones : Envelop or dumbell shaped
Struvite ( ammonium Mg PO4 stones ) : Coffin lid shaped
Uric acid : Rhomboid or Rossette shaped
Cystine : Hexagonal

All are Radio opaque except Uric acid stones

Also ammonium Mg stones and cystine stones can form " staghorn calculi "
which if large enough require surgical removal
Beningn essential tremors ease off and become less noticeable on use of
affected limb or movement
Whereas in cerebellar disease there are tremors specifically on desired
movement ( intention tremors )
lung cancer 2 complication hyponatremea or hypercalcamia
Lung carcer particularly small cell CA lung releases ADH one of its
paraneoplastic features leading to dilutional hyponatremia

The Valgus stress test is a test for ligament damage. It involves placing the leg
into extension, with one hand placed as a pivot on the knee. With the other
hand placed upon the foot applying an abducting force, an attempt is then
made to force the leg at the knee into valgus. If the knee is seen to open up
on the medial side, this is indicative of medial collateral ligament damage and
may also indicate capsular or cruciate ligament laxity.
similarly varus stress test for lateral collateral

Patient allergy to contrast media or renal failure do V/Q scan. If they give
chest Xray is normal or if no significant cardiopulmonary history in the patient
then again V/Q scan preferred.
CTPA in all other cases

Otitis media with effusion aka secretory otitis media aka glue ear. Common in
young children, 40db hearing loss, increase volume of tv. Dull greyish blue
tympanic membrane with air fluid levels are all the clinchers
BCC usually presents as a pearly nodule with telangiectatic edge
Any lesion above the neck is BCC until proved otherwise
Actinic keratosis presents as yellowish scaly crusts not as a nodule
Acute management of SVT is vagal maneouvers, if not then iv adenosine. If
patient is asthmatic (breathless as in this case) then verapamil is the option

B blockers and radiofrequency ablation are for prevention of SVT episodes

SIADH is a common complication of small cell lung ca, paancreas, prostate

ca. 1st line is fluid restriction
Hoarsness persisting > 3 weeks requires investigation

Right dominant circulation= 85%= Post desc artery arises from Right coronary
artery
Left dominant circulation= 8%= PD arises from Left coronary artery
so basically dominancy depends on this Post desc artery.. from where it arises

Isonatremic and hyponatremic volume depletion states may be treated with

normal saline or other isotonic solutions. The goal for correction rates for
either hyponatremic or hypernatremic patients should be no more than 1
mEq/L/h to prevent the devastating CNS complications of overrapid correction
(central pontine myelinolysis and cerebral edema, respectively). Full correction
of severe sodium abnormalities usually should be staged over 24 hours or
longer.
Although a potassium deficit is present in all cases of volume depletion, it is
not usually clinically significant; few patients with moderate dehydration
require supplemental potassium. However, failure to correct for hypokalemia
during volume repletion may result in clinically significant hypokalemia.
Add potassium to fluids when the patient has documented hypokalemia. For
all other patients, avoid adding
potassium to fluids until the patient has received several hours of resuscitation
and the patient has demonstrated adequate urine output.

Painful ulcers on vulvaAnti-HSV antibodies check for herpes

Forking HAY" + upper zone consdolidation .farmers lung treatment is

prednisolone

Rathke cleft cysts (RCCs) are benign lesions that typically arise within the
sella between the anterior and posterior lobes of the pituitary.Most often they
are asymptomatic. These lesions, however, can cause mass effect on
surrounding structures such as the pituitary gland and optic chiasm, leading to
headache, pituitary dysfunction, or visual disturbance.Rathke cleft cysts are
remnants of the Rathke pouch, a structure of ectodermal origin formed during
the fourth week of gestation

discharge swelling n redness of ear with normal tympanic membrane..thats

otitis externa
treatment: topical gentamicin or steriod drops

No gas bubble means oesophageal atresia. Double bubble sign for duodenal
atresia

Synonyms: HAE, hereditary angioneurotic oedema, C1-inhibitor

deficiency, C1-esterase inhibitor deficiency, familial angioneurotic
oedema, hereditary bradykinin-induced angioedema, hereditary
non histamine-induced angioedema
Hereditary angio-oedema (HAE) is a rare genetic condition
causing episodes of angio-oedema - including life-threatening
laryngeal oedema. Episodes can be unpredictable, or triggered by
factors such as trauma, drugs or dental treatment.

In Symptomatic patient (test once only) : fasting glucose >=7 or Random

blood glucose>=11.0 confirms diabetes
In asymptomatic patient (do test on 2 occasions): fasting glucose > 7 or
random blood glucose> 11 confirms diabetes

Propranolol is used AF with hyperthyroidism due to the additional benefit of

inhibition of peripheral conversion of T4 to T3.

Acamprosate works by reducing the desire or craving to drink alcohol. It is

only given to people who have successfully stopped drinking. Acamprosate
calcium helps to reduce the chances of you drinking again. People who are
taking Acamprosate calcium will usually have a programme of counselling as
part of their treatment. Treatment with Acamprosate calcium usually lasts one
year.

Clang associations are ideas that are related only by similar or rhyming
sounds rather than actual meaning.[8] Example: "He ate the skate, inflated
yesterdays gate toward the cheese grater
in flight of ideas thy jump from topic to topic

Smoking is the most important risk factor for bladder cancer. Smokers are at
least 3 times as likely to get bladder cancer as nonsmokers. Smoking causes
about half of the bladder cancers in both men and women.

atypical depression..characterized by temporary mood lifting by good

news,weight gain n increased sleep usually mote than 10 hrs
Typical - decreased sleep ( esp. early morning awakening in maj dep) ,
appetite. Atypical increased
HTN+ hypoK = conn's

Ovarian torsion
'sudden onset vomiting and pain abdomen' + mobile swelling in RIF is the
clincher.

Drug of choice for a hypertensive who is above 55 years of age

with no cough or renal problems (no contraindications i mean)
CCB

PRADER WILLI: After birth there is hypotonia, failure to thrive and sleepiness.
The child usually has blue eyes and blond hair. They tend to lag behind other
children in the transition to solid food.
The second stage becomes apparent at the age of 12-18 months, when an
exceptional interest in food becomes apparent.[7] Hyperphagia, obesity,
hypogonadism, short stature and sleep apnoea and cor pulmonale occur.[12]
They have markedly elevated levels of ghrelin, a hormone associated with
hunger.

Lawrence moon biedel syndrome/LM SYNDROME: Short stature.

Retinitis pigmentosa, nystagmus, choroidal atrophy, cataract and squint.
Micropenis with hypoplastic scrotum.
Type 2 diabetes mellitus.
General learning disability.
Speech delay and deficit.
Ataxia with spastic paraplegia.
Renal anomalies, eg clubbing, diverticula or calyceal cysts.

Nappy rash is a skin inflammation. Most cases are due to a reaction of the
skin to urine and poo (faeces, stools, or motions). In addition, a germ called
candida commonly thrives on the inflamed skin. (This is the germ that causes
thrush.) Candida can cause a more inflamed rash which may include darker
red spots spreading around the nappy area ('nappy thrush')

Erotomania or Clerambaults Syndrome, is a psychological

condition in which the affected person has delusions that the object

of his or her affection feels the same toward him or her. This
condition is otherwise known as love obsession
Usually the object of their affection is inaccessible like a superstar,
an actress, a rock star

Pyromania is an impulse control disorder[1] in which individuals

repeatedly fail to resist impulses to deliberately start fires, [1] in order
to relieve tension or for instant gratification.
Kleptomania is the inability to refrain from the urge to steal items
and is done for reasons other than personal use or financial gain
Trichotillomania is a condition where a person feels compelled to
pull their hair out.

Grandiosity refers to an unrealistic sense of superioritya

sustained view of oneself as better than others that causes the
narcissist to view others with disdain or as inferioras well as to a
sense of uniqueness: the belief that few others have anything in
common with oneself and that one can only be understood by a
few or very special people.[1]
Grandiosity is chiefly associated with narcissistic personality
disorder, but also commonly features in manic or hypomanic
episodes of bipolar disorder

De Quervain syndrome (French pronunciation: [d kv]; also

known as BlackBerry thumb, gamer's thumb, washerwoman's
sprain, radial styloid tenosynovitis, de Quervain disease, de
Quervain's tenosynovitis, de Quervain's stenosing
tenosynovitis, mother's wrist, or mommy thumb), is a
tenosynovitis of the sheath or tunnel that surrounds two tendons
that control movement of the thumb.
Symptoms are pain, tenderness, and swelling over the thumb side
of the wrist, and difficulty gripping

Mnire's disease is a condition of the inner ear.

Symptoms that come and go

Mnire's disease typically comes in attacks (episodes) of the

following symptoms:
Dulled hearing in the affected ear(s). The degree of hearing loss
varies.
Vertigo. This is dizziness with a spinning sensation. It can be quite
severe and make you feel sick or vomit. Vertigo can develop with
little or no warning. You may feel very dizzy and ill. You may need
to go to bed until it passes.
Tinnitus. This is a noise such as a ringing, roaring, or buzzing
noise which you can hear from inside the affected ear.
Ear pressure. You may get a sense of fullness or pressure inside
the ear.
Loud noises may seem unpleasant and distorted.

An acoustic neuroma is a rare type of brain tumour (growth). It is

not cancerous and so is called a benign tumour. The tumour grows
along a nerve in the brain (a cranial nerve) that is called the
acoustic or vestibulocochlear nerve. This nerve controls your
sense of hearing and balance.
The most common symptoms of an acoustic neuroma are:
Hearing loss. Some degree of deafness occurs in most
people with an acoustic neuroma. Usually hearing loss is
gradual and affects one ear. The type of deafness caused is
called sensorineural deafness and means the nerve for
hearing (the acoustic nerve) is damaged.
Tinnitus. This is the medical name for ringing in the ears.
Vertigo
Loss of feeling (facial numbness), tingling or pain. These
symptoms are due to pressure from the acoustic neuroma on
other nerves. The commonly affected nerve is called the
trigeminal nerve which controls feeling in the face. About 1 in

4 people with acoustic neuroma have some facial numbness

- this is a more common symptom than weakness of the
facial muscles. However, it is often an unnoticed symptom.
Similar symptoms can occur with other problems, such as
trigeminal neuralgia or a tumour growing on the facial nerve
(a facial neuroma).
The best test to diagnose an acoustic neuroma is a magnetic
resonance imaging (MRI) scan of the brain.
The main treatments for acoustic neuroma are surgery or
stereotactic radiosurgery
Distinguisher is in labrynthitis hearing loss will be present but not in vestibular
neuritisboth occur after URTI