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The Most Important Points For PLAB

Discussion in 'PLAB' started by Egyptian Doctor, Jun 10, 2019.

  1. Egyptian Doctor

    Egyptian Doctor Moderator Verified Doctor

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    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 c-esophageal 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 Perl’s 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

    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 Sjögren's syndrome, the term used was Mikulicz's syndrome.

    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.

    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
     

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  2. Egyptian Doctor

    Egyptian Doctor Moderator Verified Doctor

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    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 SyndromeClassically 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 (/æˌnɒsɒɡˈnoʊziə/, /æˌnɒsɒɡˈnoʊʒə/; from Ancient Greek ἀ- a-, "without", νόσος nosos, "disease" and γνῶσις gnōsis, "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 à deux (/fɒˈli ə ˈduː/; French pronunciation: [fɔli a dø]; 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) (/kæpˈɡrɑː/, US dict: kăpgrâ′)[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

    According to patient.co, sleep alarms is the best option in uncomplicated mild-mod 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 Goodpasture’s disease, anti-glomerular basement antibody disease, or anti-GBM 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 flushes…tibolone 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
     

  3. Egyptian Doctor

    Egyptian Doctor Moderator Verified Doctor

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    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/e…agranulocytosis (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 vulva………Anti-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

    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 Clerambault’s 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

    Trichotillomania is a condition where a person feels compelled to pull their hair out.

    De Quervain syndrome (French pronunciation: [də kɛʁvɛ̃]; 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

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

    Symptoms that come and go

    Ménière'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 neuritis…both occur after URTI
     

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