Important One liners

Coccidiodis immitis has more possibility of dissemination in Blood Group B individual.

Amphotericin B doesnt cross blood brain barrier so one needs to administer Fluconazole.

Meningitis is most serious problem associated with Disseminated coccioides.

Important One liners :Dermat

• Porphyria Cutanea Tarda:

4th-5th Decade
Precipitating factors:-
Alcohol,Iron, Estrogen hence birth control pills,exposure to sun
Blisters not healing or healing by scarring on sunexposed areas
Treatment;Chloroquine and phlebotomy

• Pemphigus Vulgaris:

seen in fourth-fifth decade
Skin shows autoantobodies against intercellular antigens hence shows acantholysis.

• Bullous Pemphigoid:

70-80 yrs age and Blisters at dermo-epidermal junction

Important One liners :CNS

• Myaesthenia Gravis:-
• Most accurate test of Myaesthenia gravis:- Electromyography
• Best initial and specific test:Antibody Receptor Test
• Treatment:Anticholinesterase(Pyridostigmine ) , or for non-responsive shud be given immunotherapy first being steroids in combination with azathioprine
• Acute Myasthenic Crisis:- Plasmapharesis and IV immunoglobulin
• Post-pubertal patients withage above 55 yrs are treated with thymectomy before trial of immunosuppression

Important One liners

• Fulminant hepatitis -- More common with HBV and HDV coinfection
• Chronicity - 80% with HCV maximum n all hepatovirueses
• Association with transfusion of HBV- 5-10%
• association of HCV with Blood transfusion----50%
• No post exposure prophylaxis is effective for HCV
• Association with Cirrhosis , HCC :- HBV,HCV,HDV.
• HbcAb IgG along HbEAb indicates resultion of infection. in HBV.
• Single dose for Gonorrhea: Ceftriaxone IM (or Cipro or Cefixime) PLUS Doxy for 7 days /or Azithromycin single dose
• Type1 RTA cant have urine pH<5.4 bicarbonate="10
• Type 2 RTA initially have basic pH because of inability to absorb bicarbonate and later on with decrease in bicarbonate load which is within limits for distal tubule to reabsorb it becomes acidic ; Serum bicarbonate=18-20 ; hypokalemia

Rheumatoid Arthritis

Important Points:-

RA doesnt get manifested in AIDS patients because of reduction in number of T Cells which play significant role in synovial inflammation .

Articular Diagnostic criteria:-

1 RF positive

2 Swellings seens in wrist , metacarpoplangeal joint, proxinal interphalangeal joints

3 Morning stiffness usually more than 1 hour

4 Symmetric joint involvement (for 1.5 months)

5 >3 joints involvement (for 1.5 months minimum)

6 Rheaumatoid involvement

Minimum 4 needs to be qualified out of above criteria

Diagnosis:-

RF is neither sensitive nor specific .

So Diagnosis is based on clinical criteria

Rx;-

NSAIDS
Cox-2 Inhibitors(less toxic than NSAIDs
Disease Modifying Agents of Rheumatoid Factor
Methotrexate
Hydroxychloroquine
Gold
Penicillamine
Sulfasalazine
TNF inhibitors like Infliximab, Etanercept

ARTHROPATHIES

.
Actue Arthropathies: Septic,Gout, Pseudogout (Symptoms less than a week, could be 1-2 days)

Symmetric, Polyarticular: RA , SLE

Asymmetric Oligoarticular:Ankylosing spondylitis

Migratory Arthropathies:Rheumaic fever, Lyme disease, Gonococcal Arthritis

Gilbert Disease

Gilbert Disease:-

Autosomal recessive /dominant

Mild deficiency of Glucuronosyl Transferase

Unconjugated hyperbilirubunaemia

Jaundice waxes and wanes

Never more than> 5mg/dl

Precipitated by:-

Fever

stress

infection

surgery

Fasting

Alcohol

Rx:-

No Treatment is reqd.

Spontaneous Bacterial Pertonitis

SBP:-

diagnosed by Absolute neutrophil Count >250

Remember:-

Culture , Gram Stain may be negative

Diverticulosis

Diverticulosis:-

Most commmon in sigmoid colon

Outpouchinngs of colonic mucosa at entrance of nutrient artery

low fibre diet as etiology

Symptoms:-
#aymptomatic

#Painful Diverticular Syndrome

#Left Lower abdominal colicky pain which gets relieved by defecation

Complications:-
(Most common cause of lower Gi bleeding in older patients.)

Painless Rectal Bleeding( most common cause of diverticular disease)

Heamatochezia

Diverticulitis:-

Inflammation caused from mechanical obstruction by fecolith.

Dx:-
Barium enema

Colonoscopy

For bleeding:-

Bleeding Scan

Angiography

Treatment:-

Increase fiber content

Surgery :-
If there is massive and recurrent bleeding

Malabsorption syndrome Tropical sprue, whipples' disease

Tropical sprue:

Infectous agent/Toxin

Region:- Tropics

Histopath:- same as Celiac Sprue

Dx:- No improvement with withdrawl of gluten in symptoms or histopath of intestines

treatment:-Trimethoprim+Sulphamethoxazole or Doxycycline for 6 months.

Whipples' disease:-

Tropheryma whippleii

Extraintestinal manifestations:-

Arthralgia

Dementia ,

opthalmoplegia

Diagnosis:-

Hp:-Small bowel biopsy with foamy macrophages ( PAS positive ).

Treatment:-

Antibiotics

Bactrim/Tetracycline for 6 months-1 year.

Malabsorption syndrome

Celiac Sprue:-

#Antiendomysial antibodies
#antigliadin antibodies

Whites , of european descent

#Characteristic papulovesicular rash - Dermatitis herpetiformis

#Dx:-
Abnormal small bowel biposy- Flat villi and response of symptoms and histologic improvement

Rx:-
Remove gluten from diet

Complication:
Intestinal lymphoma

Malabsorption syndrome

Diagnosis:-

Steatorrhoea:-
Sudan Stain
48-72 hours of stool collection of fat

>14 g/dl -- steatorrhoea; >40 g/dl comes from pancreatic origin

#D-Xylose Test:-
Normal test:-Pancreatic Insufficiency
Abnormal Test:- Gi insufficiency

#Small Bowel Biopsy:-

Or
Trypsin Test and secretin test.

Sexual Abuse

Diagnostic Studies done to post abuse on postmenopausal women:-
1) Acid phosphatase
2)Gonorrohea
3)Chlamydia
4)Syphillis
5)HBV
6)HIV

7)Use wood lamp to examine emen if it happened within 72 hours.
8)Fingernail scraping
9)Pubic Hair scraping

PS:-trichomonas and condyloma acuminatum after age of 3 indicates sexual abuse

Treatment:
Councelling
Antipregnancy medication within 72 hours of intercourse.
Antibiotics to cover venereal disease risk.

Follow up:-
May turn towrads promiscuity, prostitution.
Drug addiction
Depression
Suicidal Gestures
Interrelationship problems

Child Abuse

Intentional injury

Dx:-
If Bruises:- PT ,BT,APTT
If physical abuse :- Xrays of bones in <2 yrs , at times may help even till 6 yrs of age.
Abdominal trauma:-Urine , Stool examination

DD:-
ITP
Coining
Impetigo
Insect bites

Fractures:Osteogenesis imperfecta
Scurvy
Syphillis

Sturge Weber Syndrome

Charactersitic features:-

• Port wine stain in trigeminal distribution area.(upperface, eyelids)
• Periventricular calcification
• Hemiparesis contralateral to facial lesion side
• Mental retardation
• Seizures( may develop in first year)
• Developmmental delays
• Glaucoma (Later on)

Dx:-

Skulll Radipgraphs
Ct Head

Rx:-

Portwine stain:
it doesnt resolve on its own , so either need
cosmetic coverage or
Flashlamp pulsed laser therapy.
Seizures: Need apt medication; uncontrolled seizures may be cured by hemispherectomy and hemilobectomy and may play a role in preserving mental functions .
Treatment is conservative in absence of mental retardation.

Important:- Uncontrolled seizures appearing in infancy may be associated with hemiparesis.

Paediatric NHL

St Jude system of Staging:-
Stage 1 : Disease is confined to single tumour (Extra nodal)
or single anatomic area
excluding abdominal /mediastinal tumour.

Stage 11 :Single tumour extra-nodal or regional involvement.
2 or more nodal areas same side of diaphragm
2 single extranodal areas same side of diaphragm

Staege 111:
Prmary Abdominal extensive disease.
Primary Midiastinal , thymic, pleural
Two or more nodal areas above or below the diaphragm
Two single tumours extra nodal on opposite side of diaphragm.

Stage 1v: Any CNS or bone marrow ivolvement.

Periorbital cellulitis

Highlights:-

As an extension of paranasal cellulitis

organisms:H influnenzae(non-typable), Group A beta-streptococcus, Staph aureus,

Pneumococcus,anaerobes

Dx
Clinical

CT:primarly to know the extent of involvement of paranasal sinuses

Rx
Systemic antibiotics.

Drainage of abscess if present.

Complications:

Loss of vision if involves optic nerve

meningitis,

cavernous thrombosis

brain abscess

Opthalmology

Amblyopia:-

Decrease in visual acuity
becuz of inappropriate clarity in images falling on retina
Causes:-
*Strabismus
*Visual Deprivation

Tretament:-
Remove any possible opacity present in visual axis.
Patching /Covering of normal eye.
Early diagnosis prompts good response and better prognosis.

Post partum Issues

Post partum Psychosis:

Loss of reality

Hallucination

needs

1) Hospitalization

2)Anti psychotic medication

3)Psychotherapy

Granuloma inguinale

Calymmatobacterium donovani

:-it shows up with
*painless ulcer
*Lymphatic obstruction
-hence vaginal swelling

Overflow Incontinence

Hypotonic ,Overflow Incontinence



Related to diabetic neuropathy, MS, systemic medications

Stress Incontinence

Genuine stress incontinence

Only at day , not at night

with increase in abdominal pressure by coughing sneezing etc.

Q tip positive ( it rotates more than 30 degree with increase in abd.pressure)

Urinary Incontinence

Irritative incontinence:

infection tumour stress foreign body

Ix
urinalysis
urine culture
cystometric study

Management
Antibiotics
Cystoscopy

Respiratory System

BRONCHIECTASIS

destruction of small sized and medium sized bronchi
destruction of elastic and muscular elements

SIGNS AND SYMPTOMS

Chronic cough
Heamoptysis
Foul smelling sputum
Recurrent pulmonary infectoins( Psuedomonas)
sinusitis
immune deficiencies

wheezes /crackles
Secondary Polycythemia

Radiograph

Early:-Normal

Late stage:- 1-2 cm cysts, crowding of bronchi, tram tracking of bronchi

Best non-invasive way to diagnose :-HRCT

Treatment:-

• Control of Broncial secretions:-

* Bronchodilators
*Chest physical therapy
*Postural Drainage

• When sputum secretion increases or they have mild symptoms then(as Rotating Antibiotics ie diferent antibiotic each time to diminish resistance)

*Antibiotics
Amoxicillin, trimethoprim+sulphamethoxazole
Augmentin(Mox+clavulanic acid)

• In severe sypmtoms or Pneumonia

Give gram negative coverage
Ceftazidime, Quinolones, Aminoglycosides

Surgical Therapy
:considered with localized bronchiectasis with adequate pulmonary functions
:with massive hemoptysis

Vaccination
influenza annualy
Pneumococcus every 5 years

Complications
Massive heamoptysis
amyloidosis
cor pulmonale
visceral abscesses

Respiratory System

COPD

Emphysema
irreversible dilatation and destruction of cartilage beyond terminal bronchioles

P/E
distant breath sounds even audible in periphery

X ray
Hypreinflated periphery
small heart
increased retro sternal area
flattening of diaphragm

Chronic Bronchitis

P/E
wheezes and rhonchi

X Ray

Enhanced pumonary markings

Diagnostic of COPD
Pulmonary function tests are diagnostic and differentiate it from asthma where in being the reversible obstruction improves FEV1/FEC ratio with Bronchodilators in conrtast to COPD

Respiratory System

Pleural Effusion:-

Causes:-
Transudative:-(Bilateral and Equal)
CHF
Nephrotic
Cirrhosis
PE ( An unexplained transudative effusion cud be PE)

Exudative:-(Unilateral)
Infections(Pneumonia, TB)
Carcinoma
PE

Investigation of choice:-
Thoracocentesis

In transudative
LDH<200>200
LDHE/S>0.6
Protein E/s>o.5

Parapneumonic effusion
are caused by bacterial pneumonias
mandatory to perform thoracocenetsis
to rule out empyema(complicated parapneumonic effusion)
Needs chest-tube drainage.

Respiratory System

Radiographs

COPD
Asthma
Emphysema
Cor Pulmonale
Lung Cancer
Punemonia
Diffuse Infiltrate
ARDS
Pleural effusion
Atelectasis

Pleural effusion

Pulmonary Function Test



Pulmonary Nodule
Solitary Nodule
<35>
while in canada in first yr it is 3-6 month in first yr and every 6 month n 2nd year.
>50yrs, smoker is high risk for carcinoma.
Open Lung biopsy is best choice for diagnosis in USA as bronchoscopy wud not yield anything other than inflammatory cells in peripheral lesions.
While in canada CT , transthoracic aspiration cyto /Bronchoscopy precedes open lung biposy as per protocol.
Difference between Benign and Malignant Nodule Check kaplans for that.

Atelectasis

Acute atelectasis

most common reason
Post-op 1st day owing to poor inspiration and inadequate coughing
Other causes:
Tumour
Mucus plug
Foreign body

Signs and Symptoms:-

Acute atelectasis:-
Tacypnea, mild fever , cough , dypspnea ,hypoxemia.

Chronic :asymptomatic clinically , seen on x ray only.

X RAYS:

Upper lobe atelectasis:
Trachea deviation on same side

Lower Lobe atelectasis:
Elevation of diaphragm on same side.

Massive atelectasis:
Mediastinal shift

Treatment

Post op:
induce deep breathing
stimulate coughing
Incebtive spirmetery and pulmonary toilet are effective.

Treatment of choice in spontaneous atelectasis
Bronchospy with removal of mucus plug

Canada Examination portion:-

Chest wall abnormalities

Anterior chest wall

pectus carinatum , excavatun , sternal fissures

surgery for

Cosmetic purposes

resp./ cardiovascular insufficiency

Psychosocial factors

Thoracic outlet synd.

impingement of subclvian vessels and brachial plexus

etio: Congenital rib, Trauma, degenrative( osteoporosis , arthritis)

Sx/syx:

Neurogenic: distribution areas of ulnar and motor+sensory fn of median nerve

Arterial: Cold, fatigue,weakness, ischemic pain, paresthesia.

Venous:edema , collateral formation, cyanosis , venous distension

Treatment:

Conservative50-90%

Physiotherapy

Surgery if conservative fails , removal of cervical or first rib indicated.

Preventive Medicine

Preventive Medicine

Review points

Hepatitis A vaccine
needed in

*Travelers in endemic areas
*Homosexuals
*Chronic liver Disease (HBV,HBC)
*Day care Centre employees

Varicella
Live attenuated
Not to be given in immunocompromised/AIDS/pregnant patient

MMR
Live attenuated
Indications:
Healthy adults born after 1956 shud be vaccinated with one dose.
C/I
pregnant patient
immunocompromised(BUT Asymptomatic HIV may receive the vaccine)

Smoking Cessation

Ask about smoking
Advice quitting
Attempt to identify willing to quit
Assist: set a quit-date (usually 2 weeks)
Nicotine Patch or Gum OR oral antidepressant Bupropion ; both are equally effective.
Arrange Follow up

Cholesterol Screening Age

Men 35and plus
Women 45and plus

managemenet shudnt be based on single reading as cholestero may nomally vary upto 14% within two consecutive readings.

Diabetes Mellitus

Routine screening :- Only when patients is at high risk eg

*Obesity
*High Risk ethnicity
*Impaired fasting glucose
*Positive family History

Diagnosis
>126 fasting on two separate occassions
>200 Random on any occassion

Blood Pressure

screening recommended at every visit ; and atleast every two years

Alcohol Abuse

CAGE questionnaire
one 'yes' to cage= possibility of alcohol abuse

Prevention of Violence and Injury

Advice them about saftey practices.
In cases of violence simply asking them if they were hit or physically abused can increase identification by 10%

27 July 2008

Om namah Bhnagwate Vasudevaya!Om shri Gurve namah!