FARAZ’S PEARLS FOR MRCP [1, 1 ed.]

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FARAZ’S PEARLS FOR MRCP

➡ Chapter wise POINTS for part-i & part-ii ➡ points taken from past papers ,onexam,passmedicine ,passtest ➡includes scenarios ,investigations, treatments ➡single source to pass both parts of MRCP ➡ALL 14 chapters points are added ➡Past papers pointes are added in separate section ➡main points are highlighted ➡Valid for all exams of MEDICINE ( IMM,FCPS PART-II) ➡SINGLE read takes less than A week

EDITION 1st VOLUME - I BY:DR FARAZ AHMED MRCP (UK) PART-I & PART-II 1

Faraz’s

Pearls for MRCP VOLUME-I First edition

By: Dr Faraz Ahmed MBBS SMBBMU larkana (Pakistan) MRCP(part-I,II) United kingdom 2

Faraz’s

Pearls for MRCP MRCP (UK) Copyright ©2019 All rights reserved No part of this application may be reproduced, printed or transmitted in any for or by any means, Electronics of mechanical, including photocopying ,recording or any information storage or retrieval System without permission in writing from the publisher.

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SUCCESS IS NO ACCIDENT. It is hard work, perseverance ,learning ,studying ,sacrifice and most of all ,Love of what you are doing.

DEDICATION This book is dedicated to my father who always taught me to love giving & helping others. Had it not been him I would have not been what I am today. And to my dear colleagues ,wishing that this book could help and ease their approach in exam both part-I and part-II. Special Thanks to Dr SADAM H. BHUTTO (MRCS UK) 4 Dr ABDUL FATAH TUNIO

Contents 1. Information regarding MRCP examination. i.

How to prepare for MRCP part-I …………………………………………………8

ii.

How to prepare for MRCP part-II………………………………………………….12

2. NEUROLOGY…………………………………………………………...17 3.PULMONARY ……………………………………………………………30 4.GIT+HEPATOLOGY…………………………………………………..44 5.CARDIOLOGY ……………………………………………………………56 6.NEPHROLOGY …………………………………………………………………….65 5

Contents 7.HAEMATOLOGY ………………………………………………………74 8.ENDOCRINOLOGY……………………………………………………84 9.RHEUMATOLOGY…………………………………………………….96 10.INFECTIOUS DISEASE ……………………………………………108 11.DERMATOLOGY………………………………………………………118 12.PHARMACOLOGY &TOXICOLOGY………………………..130 13.PSYCHITARY …………………………………………………………….146 6

Contents 14.ONCOLOGY……………………………………………………………..157 15.OPTHALMOLOGY…………………………………………………..169 16.CLINICAL SCIENCE…………………………………………………181 17.PAST PAPERS……………………………………………………………209 18.QUESTIONS DISTURBATION PART-I…………………….219 19.QUESTIONS DISTURBATION PART-II……………………221 20 .HOW TO ATTEMPT PAPER …………………………………..223 7

HOw TO prEpArE fOr pArT-I Duration required = if you are non traniee-4.5 month minimum  Hours of daily study if you are non trainee is - 8 hours for 1st 3 months,  9 hours for last 1.5 month.  If you are trainee - 6 Months minimum 

4 hours daily for 1st 3 months, 5 hours daily for next 2 Months and in last Month 6 hours daily.

Sources: theory books :  Notes & Notes  Step up to Mrcp by Khaled El Magraby  Faraz’s pearls for MRCP

Chapters to be read from notes ¬es rest from Khaled     

1.Clinical science 2.pharmacology 3.Nephrology 4.Cardiology 5.GIT+HEPATOLOGY

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Q banks:  Pass medicine (most important q bank)  Pass test  On examination

Cover following chapters from on examination     

1.nephrology 2.blood oncology 3.clincal science 4.infectious disease Rest from pass test

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 Past papers: read recent papers at least of 8 years ,read them after your 1st read of q banks.

 Faraz’s pearls for MRCP: Read Faraz's pearls in last 25 days of your preparation at least twice ,one read will take minimum of 12 days.

Sample papers : solve sample paper before 10 days of your exam and solve your weakness in last days specially the topics in which you perform poor in sample paper... 10

What you should not do?  1.skiping past papers  2.leaving sample paper for last 5 days  3.reading lengthy books  4.not reading said theory books  5.making day off from studies  6.overuse of face book  7.not taking participation in whatsapp discussion 11

How to prepare for MrCp part-II Duration required : if your score is very high in part-I then 5 month is enough, if your score is low in part -I then 6-8 month... Sources: Theory books: what ever theory books you read in part I . Faraz’s pearls for Mrcp (very much important during last of your exam ).

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Q banks : Pass medicine :read at least 1.5 times Pass test :read it once On examination :read only those chapters in which you are weak Faraz’s pearls read it twice ,it will cover all your q banks and past papers

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 Past papers :  Solve at least previous eight years past papers  Images :  Radiology =Your Q banks and Google is enough search every picture from Google.  Dermatology =DermNEt NZ website, Google Q banks.  Rheumatology : use Google and q banks  Echo :Google, data interpretation by Philip hughes and sanjay Sharma (read sanjay Sharma first to understand about Echo )  Respiratory volume loops questions :sanjay Sharma and data interpretation by Philip hughes . 14

ECG : do Hampton 150 cases and LITFL ECG library website Data interpretation by Philip Hughes: Solve each chapter data questions from this book. Faraz’s Mrcp visuals : This book has all images collected ,u can skip above image books if u read only this.

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Sample paper : Solve 10 days before your exam,this will tell you whether u pass or not.  Cover topics which feel you are weak in last 10 days .  Remember success comes to those who work hard for it,sit it in chair stop your breadth ,life after your success is beautiful and loving.  good luck 

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Neurology pearls

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NEUROLOGY PEARLS

 1.Best parameter to monitor in GBS is =Forced vital capacity  2. Young patient +Cerebellar hemgioblastomas+polychethemia+kidney cyst + renal cell carcinoma is =von hippel landau syndrome  3. Middle aged lady+ personality changes + sexual habits + inappropriate in social situations + repeatedly asking same questions+=picks disease  4. 1st line treatment to prevent vision loss in idiopathic intracranial hypertension is=urgent LP shunt

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NEUROLOGY PEARLS

 5. Sensor neural deafness + absent corneal reflex absent + facial nerve palsy =Acoustic neuroma  6.Young patient + ipsilateral headache + ipsilateral Horner syndrome + contralateral hemiparesis +neck pain =Carotid artery dissection  7. 1st line drug in status epileptics is =Benzodiazepines IV Lorazapam  8. Patient on neuroleptic treatment +visual hallucinations +features of Parkinson +dementia less than 1 year is = lewy body dementia

NEUROLOGY PEARLS

 9. History of migraine with Aura +stroke +positive family history of migraine and early dementia is=CADASIL (cerebral autosomal dominant arteriopathy with subcortical infract and encephalopathy)  10. Visual hallucinations in clear conscious + visual field defect + MME score for dementia is normal + history of glaucoma or cataract is =Charles Bonnet syndrome  11. Deafness + pulsatile tinnitus + cranial nerve IX,X1+ pulsatile reddish blue mass in tympanic membrane =Glomus jugulare tumour.  12. 1st line drug treatment in neuroleptic malignant syndrome is = Bromocriptine  13. Young patient +pain after excessive exercise +Dark urine /tea coloured urine is = McArdle disease Do muscle biopsy

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NEUROLOGY PEARLS

14. Young patient +lancinating pain in extremities after vigorous exercise +stroke + angiokartomas periumblicaly is = Fabry's disease  15. Young patient + opthalmoplegia+ ptosis +Retinitis pigmentosa (RP) +cerebral syndrome +cardiac conduction defect + hearing loss is=Kearns Sayre syndrome  16. Iv drug use + descending progressive weakness +Cranial nerve involvement affecting ocular movement + swallowing facial musculature +autonomic features +loss of reflexes is= Botulism  17. Optic neuritis + myelitis + vomiting + Aquaporin 4 antibody+ MRI spinal cord lesson extend over 3 vertebral segment = Neuromyelitis optical/ Devic's disease

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NEUROLOGY PEARLS

 18. . 30 to 50 years + chorea(piano playing)+ personality changes + unsteady gait + dementia + saccadic eye movement + lack of coordination + caudate nucleus atrophy putamen atrophy =Huntington disease  treatment with tetrabenazine  19. History of viral infection + recurrent vertigo + nausea , vomiting + horizontal nystagmus + no hearing or tinnitus is= Vestibular neuronitis  20. Investigation of choice to diagnose Carotid dissection is =Ct Carotid angiogram  21. Distal weakness + common peroneal palsy +ulnar nerve palsy + pescavus + clawed toes+ areflexia+ kyphosis is= Charcot Marie tooth disease

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NEUROLOGY PEARLS

 22. Yoga exercise +neck pain + occipital headache + numbness of face + loss of pain and temperature ipsilateral + nausea ,vomiting vertigo +nystagmus is =Vertebral artery dissection  diagnostic test is =MRA brain  23. Peripheral neuropathy + sensorneural deafness +anosmia +cerebral ataxia + pes cavus+ night blindness+ cardiomyopathy + retinitis pigmentosa + short 4th and 5th toe +high phytic acid is = Refsum's disease  24. Multiple nerves involvement + conduction blocks + fasciculation + sensory exam normal + reflexes normal +anti GM1 antibodies high =Multifocal motor neuropathy treat with immunoglobulin's  25. Headache ,vomiting +local infection sinusitis + perioribital oedema + opthalmoplegia 6th CN+ 3rd and 4th nerve + 5 CN hyperaesthesia if upper face and eye pain is=Cavernous sinus thrombosis

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NEUROLOGY PEARLS

 26. Lower limb is more involve than upper limb contralateral hemiparesis =Anterior cerebral stroke  27. Upper limb \face more involve than lower limbs contralateral hemiparesis =middle cerebral artery stroke  28.Agitation+hallucinations+delusion+seizures+dyskinesia +ovarian tumours + MRI normal or showing deep subcortical limbic structures =Ct scan of abdomen pelvis confirms ovarian carcinoma + antiNMDA antibodies is=Anti NMDA rec encephalitis give iv steroids and immunosuppression  29. After Ct scan confirm nontruamatic SAH next step is to confirm It by Urgent angiography thru Ct scan or MRI before endovascular clipping or coiling  30. Seizures + behaviour changes like patient accuses her wife of having affair with pm + headache + oral facial dyskinesia + insomnia is= Autoimmune limbic encephalitis

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NEUROLOGY PEARLS

 31. Cancer patient /chronic immunodefient state/ immunosuppressive drugs +personality changes +intellectual impairment + focal neurological signs + cortical blindness + seizures + coma + csf normal + MRI non enhancing white matter lesions + jc virus is=Progressive multi focal leucoencephlopathy  32 . Most accurate test for myasthenia gravis is=Single fibre electromyography  33. Moderate sized haematoma in basal ganglia with minimal mass effects next step is=Admission to stroke unit or observation  34. L4 =i) anteromedial part of shine ii) knee reflex hip adduction ,knee extension, ankle dorsiflexion and foot inversion  L5=hip extension, knee flexion, ankle dorsiflexion, big toe extension  S1=sole of foot, ankle reflex ,hip extension, ankle plantar flexion and foot eversion  35. Radiotherapy more than chemotherapy in neurooncology  36. Smacking his lips and spontaneous recover +remain unaware of episode +as child had history of febrile convulsion ,is=complex partial seizure

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NEUROLOGY PEARLS

 37. déjà vu + epigastric sensation fallowed by loss of consciousness + lip smacking + history of febrile convulsion is =temporal lobe epilepsy do MRI  38. Short stereotyped events + abrupt onset termination + bizarre voculations + nocturnal nature of events is = Frontal lobe seizures  39. Opthalmoplegia +disturbance of consciousness + ataxia + hyperreflexia + antiGqIb + history upper tract infection is=Bicker's staff brain stem encephalitis  40. Young women + dilated pupil one is larger than other + absent ankle/knee reflex + mostly unilateral + slow reactive to near accommodation reflex is =Holmes Adie pupil  41. Dix Hall pike manoeuvre help in diagnose of benign positional vertigo ,Epley manoeuvre treat benign positional vertigo.  42. Sudden loss of vision + optic nerve swollen + retinal haemorrhages in all quadrants + affarent pupillary defect is=CRVO treat with steroids or antiplatelet  43. Investigation of choice for CRVO is =Fluorescein angiography

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NEUROLOGY PEARLS

 44. HIV patient + neck stiffness + photophobia + mild raise csf protein ,decreased csf glucose ,lymphocytic pleocytosis+MRI ventricular enlargement with ependymal enhancement +gradual memory loss is= Cmv meningoencephalitis  45. Chinese /Japanese + stenous exercise + meal rich in carbohydrates + heaviness in limbs + palpitations + tendon reflexes hypoactive, plantar mute =thyrotoxicosis hypokalemic periodic paralysis  46. Patient already on antiepileptic sodium valproate then continue at low dose and give folic acid and do scan at 12 week  47. Loss of fingers touch, vibration,proproception on ipsilateral side + hyperreflexia, extensor plantar on ipsilateral side + segmental anaesthesia at level of lesson loss of pain and temperature on contralateral side is =Brown sequard syndrome  48. Alien limb i.e. limb arm moves on it's own + sensory loss + supranuclear gaze palsy + non fluent aphasia + adult onset Parkinson disease is= corticobasal degeneration  49. Investigation for CADSIL is =Notch 3 genetic testing

NEUROLOGY PEARLS

50.Nystagmus+ophthalmoplegia+ataxia+alchlocs+ confusion + peripheral sensory neuropathy decrease red cell transketolase is = Wernicke's encephalopathy Treatment = give thiamine 51. Unilateral complete Ptosis + Normal/ Mydriasis --3rd nerve Palsy Unilateral partial Ptosis + MIOSIS--- Horner Bilateral Ptosis + NO Opthalmoplegia--- Myotonic dystrophy Bilateral Ptosis + Opthalmoplegia--- Myasthenia Gravis 52.vesticular schwanoma has unilateral symptoms unlike Minners disease which is bilateral

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NEUROLOGY PEARLS

 53.Buttock and thigh claudication + normal straight leg raise + pain relieved by rest is = lumbar Spinal stenosis  Investigations are : MRI shows loss of epidural fat on T1 weighted images loss if csf signal around Dural sac and degerntivr disc disease  Treatment : DE compressive lumbar laminectomy first line surgical intervention.  54.Normal straight leg raise in spinal stenosis differentiate it from other causes of lower limb nerve pain.  55.In prolapsed lumbar disc there is pain on straight leg raise 28

NEUROLOGY PEARLS

 56.HTN + localized cerebellar signs = Cerebellar haemorrhages  57.In MS if significant residual volume = self Catherization . If no significant {anticholinergic oxybutynin imipramine  58.Botuslism in urge incontinence  Pelvic floor exercise for stress incontinence.  59.L2 = hip flexion  L3=knee extension  L4=ankle dorsi flexion  L5=great toe extension  S1=ankle plantar flexion  S2=knee flexion  60.Lesion in ventral pons leads to locked in syndrome include tetra paresis with loss of lower cranial nerve resulting in bilateral facial nerve palsy and dysphagia. 29

RESPIRATORY PEARLSPEARLS

respIratory pearls  1.Gold standard diagnostic test for Obstructive sleep apnoea = Polysomnography  2 .Yellow discoloration of nails + lymphedema +pleural effusion + bronchiectasis is = yellow nail syndrome  3.Obese man + tired all time day time somnolence + apnoea at night reduced REM sleep + snoring + Hypertension + retained C02 is=obstructive sleep apnoea syndrome (sleep apnoea/hypopnoea  4. HRCT is investigation of choice in idiopathic pulmonary fibrosis showing honey combing  5. Pulmonary function in obesity  Restrictive  No effect on KCO 30

RESPIRATORY PEARLSPEARLS

 6. Findings of obstructive pattern:  FEV1 significantly reduced less 70%FVC reduced or normal FEV1/FVC =reduced less than 80% or 0.7Raised total lung capacity Raised residual Volume  7. Findings of restrictive pattern:FEV1 reduced less than 80%FVC =significantly reduced FEV1/FVC =normal or increased more than 80%Lung compliance , TLC RV are decreased  8. Causes of obstructive pattern :  COPD  Asthma  Bronchiectasis  Bronchiolitis obliterans  9.Causes of restrictive pattern  Idiopathic pulmonary fibrosis  Pulmonary haemorrhages  Asbestosis  Sarcodosis  ARDS  Extrinsic allergic alevolitis  Histocytosis Coal worker's pneumococcal  Polio  Myasthenia Obesity 31  Scoliosis

RESPIRATORY PEARLSPEARLS

 10. Causes of increased TLCO :  Most obstructive has low TLCO except Asthma  Pulmonary haemorrhages ( Wagner's, good pasture) Left to right shunt Polchythemia Exercise  Male Hyperkinetic state  11. Causes of Low TLCO:  All restrictive gives low TLCO except pulmonary haemorrhages)  Pulmonary fibrosis Pulmonary emboli  Emphysema Pulmonary oedema  Anaemia Low CO  Pneumonia  Sarcodosis  12. Pulmonary function in obesity  Restrictive  No effect on KCO  13.Causes of high KCO with normal or low TLCO  Lobectomy / pneumoectomy  Neuromuscular weakness Scoliosis/kyphosis  Ankylosing spondylitis 32

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14. KCO reduced in interstitial lung disease Restrictive disease Pulmonary embolism Vasculitis 15,KCO increased in: Haemorrhage Polchythemia 16. Young patient with DM + recurrent chest infections + Diarrhoea + abnormal LFTs + gallstones + steatorrhoea + constipation is = Cystic fibrosis 17. Features of cystic fibrosis Delayed puberty Short stature Pancreatic polyps Diabetes Miletus Rectal prolapse Male infertility (due to Mal development of vas deferens Female subinferlity Meconium ileus 18.Oragnisms in Cystic fibrosis patients Infants and young children = Staphylococcus aureus, Haemophilus Teenagers = Pseudomonas aeruginosa treated by inhaled tobramycin Aspergilus Burkholderia cepacia Mycobacterium tuberculosis

RESPIRATORY PEARLSPEARLS

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RESPIRATORY PEARLSPEARLS

 19.Teenger with Cystic fibrosis presents with chest infection treated with ceftazidime + tobramycin  20.Rapidly progressive fever + high volume of purulent sputum uncontrolled bronchopneumonia weight loss septicaemia by Burkholderia cepacia treated by Ceftazidime+aminoglycosides  21.Lab of cystic fibrosis :  Sweat test :sweat chloride more than 60mmol/L  Decreased chloride secretion  increased sodium absorption  CFTR gene Genetic test is confirmatory F508(DF508)mutation on chromosome 7  22.Treatment of cystic fibrosis :  Chest physiotherapy postural drainage  High calorie + high fat Vitamin D  Pancreatic enzymes  Supplement N- Acetylcystein  Heart lung transplant  Gene therapy Human Recombinant DNASE 34

RESPIRATORY PEARLSPEARLS

 23.CT scan of Chest is diagnostic for pancoast tumour.  24.Diagnostic investigation of choice for sarcodosis is = Trans bronchial lung biopsy  25.Mangement of obstructive sleep apnoea is :  Weight loss  CPAP is first line for moderate and severe OSA  Intraoral devices ( Mandibular advancement )  If CPAP is not tolerated Uvulopalatophrngraphy  Tracheostomy is last resort.  26.Epworth sleepiness in obstructive sleep apnoea is:  Mild = 4-14  Moderate=15-30  Severe = more than 30  Mild is treated by weight loss  Moderate and severe is treated by = CPAP 35

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27.Survival benefits in stable COPD patients are : Smoking cessation LTOT Lung volume reduction surgery Steriods reduced exacerbation frequency but not the mortality 28.peripheral edema + raised JVP +SYSTOLIC Parasternal heave + loud p2 + COPD is =. Cor pulmonale Treatment is = loop diuretics for oedema LTOT ACEI ,CCBs ,Alpha blockers are not recommended. 29. Indications of LTOT are : pO2 of < 7.3 kPa (55 mmhg) or to those with a pO2 of 7.3 - 8 kPa( 60mmhg ) and one of the following: secondary polycythaemia nocturnal hypoxemia peripheral oedema (cor pulmonale ) pulmonary hypertension At least 15 hours a day. 30. Patients who are critically ill (anaphylaxis is ,shock) oxygen should be at 15 /min. 36

RESPIRATORY PEARLSPEARLS

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RESPIRATORY PEARLSPEARLS

 31.carbon monoxide transfer factor shows prognosis in = idiopathic pulmonary fibrosis .  32. 50-70 years + exceptional dyspnoea + bilateral fine basal crackles + clubbing + dry cough + restrictive spirometry is = Idiopathic pulmonary fibrosis .  33.indications of lung volume reduction surgery :  1. CO2 retention 7.3 cut of  2.severe limitation of exercise  3. upper lobe emphysema  34. Treatment of idiopathic pulmonary fibrosis :  Prednisolone 0.5 mg  LTOT  Lung transplantation .  Pulmonary rehabilitation  Pirfenidone ( antifibrotic agent )  Interforne gamma 1 beta and bosentan  Nintendanb.

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35. if PH is less than 7.25 = give invasive ventilation. 36. NIV complication = pneumothorax 37.Treatment of exacerbation of COPD : Increase frequency of bronchodilator give via nebulizer Prednisolone 30mg for 7-14 days. 38.History of tuberculosis / cystic fibrosis + haemoptysis + cough + chest round opacity surrounded by rim of air + serum increase titre Aspergilus precipitants ( IgG antibodies ) is = Aspergiloma . 39. Treatment of Aspergiloma . Surgical resection Long term itraconazole if not fit for surgery. Life threatening haemoptysis=after transfusion and resuscitation angiography and arterial embolization after that lobar resection as intervention of last resort 38

RESPIRATORY PEARLSPEARLS

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RESPIRATORY PEARLSPEARLS

 40.Asbestosis occur in Plumber , boiler , shipyard , pipe occur after 15-30 years causes lower lobe fibrosis Plural plaques are benign calcification in hemidiaphrgm.  41.Bilteral infiltrates (hazy showading) in Chest X-ray + P02/Fi02 less than 200 + Low PCWP less than 18 + burn history is =ARDS  42.Causes of ARDs Infections :  Sepsis.  pneumonia,  Tuberculosis ,  uraemia  anaphylaxis  Burns  Pancreatitis  Trauma  43.Massive blood transfusion Smoke inhalation injury Cardiopulmonary bypass.  44.Pcwp in ARDs is less than 18mmhg while in Cardiogenic pulmonary edema it's more than 18.  45.Treatment of ARDS  Mechanical ventilation with maximal ventilatory therapy Fi02 100% PEEP 15cmH20 peak pressure 40cmH20  If still unresponsive(on maximum ventilatory therapy and still hypoxia) Extracorporeal oxygenation (ECMO)

RESPIRATORY PEARLSPEARLS

 46. Progressive breathlessness + large amount of sputum (bronchorrhoea)+ alveolar walls filled with mucin is = bronchoalveolar cell carcinoma  47.Dyspnoea + fatigue, weakness, syncope + left parasternal heave + loud P2 + pansysytolic from TR + early diastolic murmur is = Pulmonary arterial hypertension  48.Drugs associated with pulmonary arterial hypertension is appetite suppressants, amphetamine.  49.. With GCS less than 8 and patient suffering from unprotected airway = intubation fast bleep ETT and give high flow oxygen if he is not chronic co2 retainer.  50. Acute exacerbation  pneumonia  Lung fibrosis,  pulmonary embolism  Causes of type2 respiratory failure are :  COPD,  acute severe asthma,  Ankylosing spondylitis,  Kyphoscoliosis  Treatment of type1 :High conc Oxygen(>35% usually 60%high flow 6-8L  Treatment of type2:Low conc(24-28%)Low flow (1-2L/min) 40

RESPIRATORY PEARLSPEARLS

51.Type1 respiratory failure = Pao2=less than 8 PaC02 =less than 6.6 Type2 respiratory failure = Pa026.6 (hypercapnia) 52.Causes of type 1 respiratory failure are : acute Asthma, emphysema,  COPD + respiratory type 2 is treated by NIV if there is no contraindication to it if there is contraindications then use intubation ventilation. 41

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RESPIRATORY PEARLSPEARLS

 53.Punemonia + high WBC + high inflammatory markers + unilateral consolidation + pigeons is = Chlamydia psittaci pneumonia  Treatment: tetracycline or macrolides  54.Shortness of breath + dry cough + fever + bilateral basal inspiratory crackles + upper lobe fibrosis + IgG precipitins is= Extrinsic allergic alevolitis  55.Lab in extrinsic allergic alevolitis (hypersensitivity pneumonitis) :  Chest X –RAY : upper lobe fibrosis  BAL : lymphocytosis  Blood : NO Eosinophilia IgG precipitants  Saccharopolyspora in farmers lung No high IgE  No positive skin test  No antibiotic  Remember in hypersensitivity pneumonitis there is bilateral findings on x-ray  56.Treatment of extrinsic allergic alevolitis Antigen avoidance Oral steroids

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57. Pigeons bird fanciers :avian proteins Farmers lung : Saccharopolyspora rectivirguls Malt workers lung: Aspergilus clavatus Mushroom workers lung: thermophilic actinomyces Bysinosis :textile industrial cotton hemp dust Baggassosis: sugarcane 58.Spirometry in extrinsic allergic alevolitis is mixed. 59.Techypnae+techycardia+Low grade fever + sudden onset chest pain + haemoptysis + normal chest x-ray is = Pulmonary embolism. 60.Lab in pulmonary embolism: PE likely >4 points = Do CTPA if there is delay give LMWHPE unlikely≤4 or less consider D dimer if positive then do CTPA CTPA is contraindicated in renal impairment and contrast allergy use v/Q scan ECG:S1Q3T3,RBBB,right axis deviation ,sinus tachycardia V/Q mismatch: pulmonary embolism , AV malformation, Vasculitis ,COPD gives matched defect Pulmonary angiography gold standard but complication 43

RESPIRATORY PEARLSPEARLS

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• 1.Truma / violet vomiting / endoscopic procedure/ malignancy + shock + pain + left side pleural effusion + pleural Fluid Exudative and high amylase + ratio of pleural fluid amylase to serum amylase >1 is = Oesophageal rupture • Diagnosis : radio logically with water soluble contrast Treatment : Surgical • 2.Gastroenteritis : Empirical antibiotic only indicated if systemically unwell , immunosuppresion,or elderly even if patient has bloody Diarrhoea so give oral rehydration solution otherwise 44

GASTROENTEROLOGY PEARLS

gastroeNterology & Hepatology pearls

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GASTROENTEROLOGY PEARLS

 3.Patient taken metronidazole for 7 days for Clostridium diffcle he improved no symptoms but yet stool shows c.diffcle next step = Nothing needed  4.Investigation of choice for barret oesophagus is = Endoscopic biopsy.  5.Management of barret oesophagus is :  No dysplasia + 3cm =endoscopy every 2 to 3 years + start PPI and repeat endoscopy and biopsy every 2 .  grade dysplasia = High dose PPI +every six monthly biopsy.  High grade dysplasia = oesophagectomy + photodynamic therapy and ablative therapy.  6.Isolated unconjugated hyperbilirubmina + normal LFTS is = Gilbert syndrome  7.Jaundice in Gilbert is exacerbated by : fasting,alchol,acute illness even like sore throat also by ostrogen improved by low dose barbiturates

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8.Risk factors for barret oesophagus are : Gerd Male Stricture or ulcer Has increased risk of adenocarcinoma Metaplasia of lower oesophagus when normal squamous epithelium replaced by columnar epithelium 9.Investigations in Gilbert syndrome are: Rise in bilirubin provoked by prolonged fasting or IV nicotinic acid. 10.Management of Gilbert syndrome is : No treatment required If severe jaundice = Phenobarbitone 11.Non bloody Diarrhoea + young patient + weight loss + abdominal mass palpable on right iliac fossa is = Crohn's disease. 12.Complications of Crohn's diseases are : Gallstones oxalate renal stones Fistula Anal tags Mouth ulcers Perianal disease Episelritis

GASTROENTEROLOGY PEARLS

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GASTROENTEROLOGY PEARLS

 13.Lab in Crohn's disease are:  Histology : all layers trans mural ,High goblet cells ,Granulomas Endoscopy : deep ulcer, skip lesion , cobblestone  Radiology : stricture : Kantor's string sign ,rose thorn ulcers, fistula, proximal bowel dilation  ASCA +P-ANCA –  14.Smoking worsen Crohn's but improves ulcerative colitis .  15.Management of Crohn's diseases:  Inducing remission : steroids (oral, rectal ,IV) Azathioprine or 6 meracaptopurine add on Methotrexate alternative to azathioprine (Contraindicated in anaemia )  2nd line is steroids but not as affective as azathioprine is 5ASA( mesalazine ) Refractory Crohn's = infliximab IV Fistulating Crohn's = Infliximab  Perianal disease = Metronidazole  Diet in Crohn's : short term TPN,enteral feeding elementary diet low fat medium chain TGA in diet Lactose intolerance dairy free diet.  16.Crohn's disease in pregnancy is = steroids 47

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17.Maintaining remission in Crohn's disease : No steroids Stop smoking Azathioprine or meracaptopurine is 1st line Methotrexate 2nd line 5-ASA drugs(Mesalazine) if surgery has done. 18.Complications of surgery in Crohn's disease: 1.bile salt Malabsorptive =bile acid diarrhoea with abnormal 14C glucolate test treatment : Cholestrayamine 2.Cholesterol gall bladder stones 3.urinary Cal oxalate stones and renal calculus treatment : good hydration, dietary oxalate restriction (cocoa, peanut tea coffee wheat germ rhubarb spinach ,Cholestrayamine 4.pyoderma gangreosum. 19.Crohn's disease + surgery ileostomy +deep ulcer begin to form skin round stoma = pyoderma gangreosum treatment oral steroids. 20.Depression+ sertraline use + Lymphocytes infiltration is = Lymphocytic colitis treatment is withdrawal of drug Loperamide,Cholestryamine,Azthioprine. 48

GASTROENTEROLOGY PEARLS

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 21.Young patient +bloody Diarrhoea + abdominal pain on left lower quadrant is = ulcerative colitis  22 Investigation in ulcerative colitis :  Crypt abscess  Depletion of goblet cells  No Granulomas  Endoscopy : pseudo polyps  Radiology: loss of haustrations Colon narrow and short drainpipe colon  P-ANCA + ASCA –  23.Most common site of ulcerative colitis = rectum  Most common site of Crohn's diseases=terminal ileum.  24.Management of ulcerative colitis : Inducing remission: rectal topical 5ASA,oral ASA  2nd line = oral steroids  Servere colitis = IV steroids  Maintaining remission in ulcerative colitis  Oral 5ASA :  Mesalazine  Azathioprine or meracaptopurine  No Methotrexate here  25.Colorectal cancer UC > Crohn's 49

26.Mild to moderate Ulcerative colitis = sulphasalzine Severe UC =IV steroids. 27.Side effects of sulphasalzine are : Skin rashes Oligospermia Headache Heinz bodies Agranulocytosis Pancytopenia Stomatitis Parotitis 28.Side effects of Mesalazine are : GI upset Headache Agranulocytosis Pancreatitis Intestinal nephritis 29.Oligospermia by sulphasalzine Pancreatitis with Mesalazine >sulphasalzine 30.Investigation in IBD are : Endoscopy is investigation of choice = ileocolonscopy C -reactive shows disease activity High faecal Cal protectin high in IBD (50)Normal faecal calprotecin make it less likely

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 31.With use of infliximab and azathioprine care of non melanoma skin cancer should be kept in mind.  32.Crohn's like enterocolitis = Mycophenolate mofetil.  33.Air bubbles on passing urine = Crohn's with colovesical and fistula.  34.Ulcerative colitis : Mild :6 stool per day , visible blood,37.8 C temperature pulse>90 anaemia 30 CRP>30  35.Most reliable sign in toxic megacolon = pulse rate.  36.Helpful investigation in toxic megacolon = X- ray  37.Treatment of choice in toxic megacolon = Colectomy  38.Best investigation in toxic megacolon is = Flexible sigmidoscopy

39.Investigation contraindicated in toxic megacolon are : Barium enema Colonoscopy 40.Criteria for toxic megacolon : >6 stools bloody per day >37.8 C HR>90 TLC neutrophils >10Hb 30 CRP >30 Dilated colon 6m X-ray loss of haustrations and mucosal oedema thumb printing 42.Management of toxic megacolon : HDU + high dose IV steroids + rectal steroids + IV fluid + LMWH + cyclosporine (+infliximab + surgery + no antibiotic  43.Treatment in Toxic megacolon :  1st IV steroids then Colectomy + cyclosporine if contraindicated then Infliximab  44.Toxic megacolon seen in : Ulcerative colitis mainly Pseudomembranous colitis, Ischemic colitis

GASTROENTEROLOGY PEARLS

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45.Precipating factors for toxic megacolon are : Low K Low Mg Under treatment Nsaids Opioids Bowel perforation Antidiarrheal 46.Total Colectomy in UC+ high stool + urgency + incontinence + nocturnal sleepage is = pouchitis following ileal anal anastomosis treatment : antibiotics metronidazole ciprofloxacin. 47.UC ≤ colorectal cancer : Low risk : 7 + hirutism + virilisation + deep voice + ciltromegaly is =Adrenal or ovarian tumour. 84

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eNDoCrINology pearls

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 7.Tall + lack of secondary sexual characteristics + Gynaecomastia + low testosterone + high LH FSH + firm small tests is = Klinefilters syndrome  8.Investigation in Klinefilters syndrome:  Low testosterone  High LH FSH  Karyotype 47,XXY,47XX  Low HDL cholesterol  high TGA  Most appropriate test is FSH LH level.  9.Treatment of Klinefilters syndrome =Testosterone to improve bone minerization  10.Anosmia + delayed puberty + low Testosterone, low FSH,LH + normal height + Cryptorchidism + hearing defects/cleft lip plate visual defect + primary amenorrhea + no mental retardation is =Kallman's syndrome  11.Investigation in Kallman's syndrome :  Diagnostic test is FISH MRI =absent olfactory bulbs  Low testosterone and low FSH LH

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12.Treatment of Kallman's Syndrome is : Pulses not continuous GnRH Once family is completed then testosterone. 13. Klinefilters syndrome = Low testosterone + raised LH and FSH Kallman’s Syndrome = Low testosterone + Low FSH and LH. 14.Primary hypogondasim ( Klinefilters syndrome ) = High LH + Low testosterone. Hypogondotrophic hypogondasim (Kallman’s Syndrome ) =Low LH and FSH + Low testosterone . Androgen insensitivity syndrome =High LH + Normal / High testosterone. Testosterone secreting tumour = Low LH + High testosterone. 15.thyrotoxicosis + goitre + Autoantibodies + thyroid eye disease is =Graves disease . 16. 5 hypo’s in Addison’s disease: Hypotension (postural ) Hypoglycaemia Hyponatremia Hypo aldosterone HypoPH 17. 2 HYPER in Addison’s disease : Hyperkalaemia Hyperreninemia .

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 18.Patient of Addison’s disease who undertaken strenuous activity should double their dose of glucocorticoid and mineralocorticoids .  19.lethargy , weakness + anorexia + nausea , vomiting + weight loss + hyperpigmentation at palmer or buccal mucosa + loss of pubic hairs + hypotension + high K + Low sodium is = Addison’s disease  20.treatment of Addison’s disease is :  Hydrocortisone 100 mg IV TDS.  Fludrocortisone for postural drop  21. In Addison’s disease there is low T4 and high TSH so never treat thyroid problems treat Addison’s thyroid will become normal .  22.treatment of thyroid overdose is :  Propranolol  Plasmaphresis in severe cases.  Cholestrayamine.

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23. Investigation in Addison disease: ACTH stimulation test(short synacthen test) After giving synacthen of 250ug normally there increase cortisol of greater than 550 if below this confirm diagnose of adrenal insufficiency to dx localize it we do long synacthen test where if cortisol raise then it's secondary adrenal insufficiency if not then it's Primary. 24.Other tests in Addison’s diseases : Adrenal autoantibodies anti21 hydroxylase Ab 9am cortisol and ACTH test low Cortisol and high ACTH Metabolic acidosis Macrocytic anaemia pernious Blood: high Eosinophila,lymphocytosis , neutropenia mild hypercalcemia. 25.Causes of Addison’s diseases: Autoimmune (most common)Infections TB = do CT abdomen showing shrinkage of adrenals Hiv Cmv Antiphospholipid syndrome (Hughes syndrome) Waterhouse fried ache syndrome Metastasis (bronchial breast kidney) 26. Female patient with history of recurrent DVT and confirmed hypoaldostrone low sodium high K positive short synacthen test is = Antiphospholipid syndrome ( Hughes syndrome)

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 27.Sepsis / surgery/ steroid withdrawal/infection + hypotension + hypothermia + syncope + convulsions + hyponatremia + hyperkalaemia + hypoglycaemia is = Addisonian crisis  28.Treatment=IV fluids IL normal saline and steroids IV hydrocortisone 100mg of IV Dexamethasone  29.Tiredness Lethargy + postural Hypotension + high ESR + DIC + purpura + hyponatremia high K is =Waterhouse fridirch syndrome Treatment=IV fluids and IV hydrocortisone  30.Low ACTH + no skin pigmentation + no hyperkalaemia + BP normal + low Cortisol + normal aldosterone is = secondary hypoadrenalsim  Treatment : only glucocorticoid.  31.Cortisol curve can be used to asses how appropriate dosing of glucocorticoid steroids in Addison patient.

ENDOCRINOLOGY PEARLS

 32.Expothalmus + diplopia + conjunctival oedema + optic disc swelling + opthalmoplegia + inability to close eye lids lid lag lid retraction + eu,hypo,hyperthyroid is =Thyroid eye disease.  33.Management of Thyroid eye disease :  Stop smoking  Stop Radioiodine  Use topical lubricant  High dose steroids  Orbital decompression  In replased or active disease = Radiotherapy  Malignant exophthalmos,,= steroids  34.Referral to Ophthalmologist in Thyroid eye diseases:  Unexplained sudden deterioration in vision  Change in intensity or quality of colour  eye pooping out globe subluxation  Corneal opacity  Optic disc swelling  35. Thyrotoxicosis + goitre + autoantibodies + Thyroid eye disease is = Graves disease 90

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36.Specific features in graves but not in other causes of thyrotoxicosis Eye signs (30%) exophthalmos, opthalmoplegia Pretibial myxoedema (most specific) Thyroid bruit Thyroid acropacy. 37.Investigation in graves disease AntiTSH receptor stimulating antibodies (thyroid stimulating immunoglobins)(specific) Anti thyroid peroxidase TPO antibodies Increased level of SHBG Globally increased uptake on thyroid scanT4,T3 high but T3 more specific. 38.Treatment of graves disease: Propranolol block adrengenic initials Carbimazole 40mg for 12-18 Mon block thyroid peroxidase SE: agranulocytosis ( sore throat) Treatment : stop drug start PTU once neutrophils recover Carbimazole should be stopped when neutrophils less than 1.5Infection : antibiotic (cephalosporin)G-CSF Erythromycin increase it's activity Definitive treatment of thyrotoxicosis is Radioiodine only indication is toxic multinodular goitre and single toxic adenoma Surgery. 39.Contraindications to Radioiodine therapy : Pregnancy avoid at least 4-6 Mon and breast feeding Age less than 16yearsThyroid eye diseases 91

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40.Indications for Surgery total Thyroidectomy: Large goitre compression Symptoms Intolerant to drugs. 41. Side effects of thyroid surgery: Transient hypoparathyroidism hypocalcaemia Tetany Infections Bleeding Superior laryngeal nerve palsy Permanent recurrent laryngeal nerve plasy 42.Gold standard test for diagnosis of growth hormone defiency is = Insulin tolerance test insulin induced hypoglycaemia = GH response of less than 9mU/L when it is contraindicated (Epilepsy) use Alginate or glucagon test Treatment: replacement therapy with biosynthetic human GH[ 43.Weight gain + intermittent sweating + hypoglycaemia (feel hungry sweaty tremors diplopia weakness ),+ early in morning or just before meal + high insulin + high c peptide + high proinsulin :insulin ratio is = Insulinoma treatment: surgery If not fit for surgery : Diazoxide and somatostatin 44.Radioiodine therapy should be avoided 8 weeks following CT contrast. 92

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45.Investigation in Insulinoma: Supervised , prolonged fasting (up to 72 hours) CT pancreases 90%are less than 2cm in size. 46.High insulin + high C peptide + high proinsulin + normal SU level = Insulinoma High insulin + high C peptide + high SU level is= sulphonylurea overdose High insulin + low C peptide = Exogenous insulin or insulin misuse Low insulin + low C peptide is = non beta cell tumour 47.Causes of hypoglycaemia less than 60mg/dl: Insulinoma Self administration insulin/ sulphonylurea Liver failure Alcohol Addison disease 48.sweating + confusion + headache + hunger + tremors + diplopia = Hypoglycaemia 49.Treatment of hypoglycaemia : Patient is conscious = oral glucose Patient is unconscious = 50ml of 50%Dextrose water , IV Glucagon 50. Type 2 DM + bilateral Quadriceps wasting weakness + diminished knee reflex (LMNL)+pain in hip buttock and thigh burning pain at night + ankle reflexes preserved and planters could be extensor or flexor + EMG Multifocal denervation in paraspinous and leg muscles is = Diabetic amyotrophy Treatment :resolves with improved glycaemic control and drugs

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51.Hyponatermia + urine sodium more than 20 + low plasma osmolality less than 270 + high urine osmolality more than 1000 or more than 300 is = SIADH

53.Treatment of SIADH : 1st line : Fluid restriction (750-1000) ADH V2 receptors antagonist = tolvaptan Demeclocycline :reduces responsiveness to In refractory cases Hypertonic saline in severe case like fits Slowly correct sodium other CPM

ADH used

54.T scores > -1 =Normal T score b/w -1 to -2.5 =osteopenia T score less than -2.5=osteoporosis

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52.Causes of SIADH are : Cancer : small cell lung cancer, pancreatic and prostate CNS : stroke, subarachnoid haemorrhage, subdural haemorrhages, meningitis/encephalitis/abscess ,head injury/neurosurgery operation, Infections : Tuberculosis pneumonia Drugs: Sulphonylurea, SSRI , TCA,. Antipsychotics (Haloperidol,quetapine , clozapine Carbamazepine Thiazide , Vincristine, Cyclophosamide, Omeprazole Other: positive end expiratory pressure (PEEP) Porphyria

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 55.Lady with hysterectomy has risk for osteoporosis give unopposed oestrogen  56.Family history+ high plasma Calcium + low Urine calcium is = Familial hypocalcuric hypercalcemia  Treatment : no treatment  57.Best initial treatment for carcinoid Syndrome is = somatostatin analogues (octreotide) Then Hepatic artery embolization  58.Viral infection + tender Goitre + high ESR + globally reduced uptake on radioactive iodine(,or no uptake) + initially hyperthyroidism then hypothyroidism is = Sub acute (De Quervain's ) thyroiditis  59.Treatment of DeQuervain thyroiditis :  Usually self limiting no treatment Thyroid pain= aspirin or other Nsaids Steriods if hypothyroidism  Beta blockers to control tremor No role of antithyroid drugs  60.Radioactive iodine uptake (RAI 131 scan)In graves = high homogeneous diffuse uptake  Toxic nodular goitre = patchy uptake or solitary area of high uptake  DeQuervain thyroiditis=no uptake or reduced uptake

RHEUMATOLOGY PEARLS

rHeuMatology pearls  1. Poorly controlled Rheumatoid arthritis + Proteinuria+ hypoalbuminemia is=Systematic Amyloidosis, Do rectal biopsy  2. Elderly man +pain and stiffness in shoulder pelvic girdle proximal not weakness is=polymyalgia rheumatica ,check ESR level  3.Turkey patient + oral ulcers + genetic ulcers + anterior uveitis + thrombosis + aseptic meningitis + abdominal pain + diarrhoea colitis + erythema nodsum is = Behcets syndrome  4. Urethritis + conjunctivitis + Arthritis + history of GI infection + brown papules on palms and soles + circinate balnatis is = Reactive Arthritis 96

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 5. Bone fractures + bone pain + low calcium + low phosphate + high Alp + high PTH + losser's zone on x-ray is= Osteomalacia  6. Foot drop + abdominal pain + livedo reticularis + renal failure + HTN + purpura + testicular pain + Hep B serology +No lung involvement is= Polyarteritis nodusa  7. Arabs,itians ,Turks Jews azarbijans+fever+abdominal pain +signs of peritonitis + pluritis+leg joint involvement+ inflammation of tunica vaginals + increase WBC c Reactive is=Familial mediaterian fever give colchicine  8. Dull shoulder pain + global restriction of shoulder movement in all direction +external rotation more effected +pain at rest +movement effected in active and passive +diagnosis is clinical no investigation is required is=Adhesive capsulitis  9. Raynaud disease + tight skin in face +below elbow and below knee+ anti centromere antibodies + scerlodactly + oesophageal dysmotity +calcinosis is=Crest syndrome  10.Antibody showing renal crisis in systematic sclerosis is= anti RNA polymerase III antibody

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 11. +Tightening of skin in upper limb above elbow lower limb above knee trunk +Hypertension + lung fibrosis + renal involvement + anti scl 70 is =Diffuse cutaneous systematic sclerosis  12. Foot drop ,ulnar nerve palsy + purpuric rash +arthralgia + low C4 level is = Cryoglobulimia  13. Old patient +pain on base of thumb + tenderness and swelling on 1st carpometacarpal joint + crepitus +pain on abduction of thumb + atrophy of thenar muscles is=Osteoarthritis  14. Old man +weakness in finger flexors + weakness of shoulders + difficulty in swallowing + Ck level normal + muscle biopsy shows internuclear or cytoplasmic tubofilaments is =Inclusion body myositis

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 15. Women patient + anticardiolipin antibody + lupus anticoagulant +high Aptt (does not improve after human plasma )+venous ,arterial thrombosis + low platelets is= Antiphospholipid antibody syndrome  16. Don't give anticoagulation in Behcets even with thrombosis give steroids  17. Cyclophosphamide causes premature ovarian failure and infertility  18. Raynaud phenomenon + myositis + fibrosing alevolitis + mechanic hands i.e. thickened ,cracking and peeling skin +Ck level high +proximal myopathy+anti jo1 antibody is =anti synthase syndrome /polymyositis • 19.Spastic paraplegia +upper motor signs in lower limbs +urinary retention +HTLV1 positive is = Tropical spastic Para paresis • 20. Massive hepatosplenomegaly + pancytopenia + bone fractures + yellow papules (pingueculae )+no brain pathology +Erlenmeyer flask shaped cyst is = Gaucher disease • 21. Long term management in patient with idiopathic intracranial Hypertension is =weight loss

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 22. Pauci articular still disease has ANA positive but systematic still disease has negative ANA + RF  23. Pain and swelling over lateral dorsal aspect of wrist +Finklestein test positive is=De Quervain's tenosynovitis  24.Hip replacement gram positive bacillus think of = propionibacterium acnes  25. Organism associated with development of RA is =Proteus mirablis  26. Gout +warfarin use give = Rasburicase  27. African Caribbean lady +Well demarcated macular rash with erythema ,scales, plaques atrophy + photosensivity +scaring alopecia + negative ANA and anti dsdna is=Discoid lupus  28. Swollen tender mass in calf + Doppler u/s shows compressible lumen + osteoarthtris is = Baker's cyst

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 29. 30 year old + absent limb pulses + unequal blood pressure in upper limbs + Carotid bruit + claudication + TIA + angina + aortic regurgitation + glomerulonephritis + high ESR Crp is = Takayasu's disease  treatment with steroids  30.Best way to differentiate primary Raynaud Disease and Raynaud secondary to connectivity tissue disease is =Nail fold capillarsocopy i.e. distorted missed nail fold capillary loops  31. Confirmation test for carpal tunnel syndrome is=EMG /nerve conduction studies  32 . Smoker + pain on walking + digital ulcerations + cyanosis and gangrene of fingers and toes + absence of pulses in radial, dorsal pedis tibial artery +burning sensation in fingers is = Burger's disease

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 33.⛹♂Sitting down..... relieve the pain of spinal stenosis.⛹♂Sitting down..... aggravate the disc prolapse pain .  both cause low back pain which extended to the LEG.  34. Back pain + leg raise pain aggravated +sitting relives pain or leaning forward while walking +pain with extension of lumbar spine + loss of lumbar lardosis is=spinal stenosis  35. 4 to 8 years of age +hip joint hip pain + limp + decrease hip movement +x-ray widening of joint space + decrease femoral head size is= perthes disease  36. Drug for long term renal involvement in SLE is =Mycophenolate mofetil  37. Stains has interaction with grape fruit juice  38. cute gout + colchine contraindicated + small joints involvement + renal failure = give oral steroids not intraarticular that is used for large joint involvement  39. SLE: normal CRP unless an infection

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 40. The recommended treatment for myelosuppression secondary to her methotrexate therapy is with folinic acid rescue therapy  41. Bilateral proximal myopathy + neuropathic pain in thighs +absence of lumbosacral structural lesson is =Diabetic amyotrophy  42. Loin pain + haematuria in Antiphospholipid syndrome -> renal vein thrombus  43. Osteoporosis treatment  1st line oral bisphosphonates  1st aldereonate if contraindicated then risedronate or etidronate  2nd line raloxifene and strontium Donosumb  Raloxifene contraindicated in thromboembolism  Strontium contraindicated in thromboembolism  Teriparatide contraindicated in previous hyperparathyroidism  Donosumb has side effects of diarrhoea ,dyspnoea ,hypocalcaemia and upper respiratory tract infection.  44. Bisphosphonates and Donosumb used to prevent pathological fractures in bone metastasis .  if eGFR less than 30 , Donosumb is preferred Donosumb is not used for preventing skeletal related events with bone Mets from prostate carcinoma

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• 45. Painting/playing tennis +pain and tenderness in lateral epicondyle + pain worse on wrist extension against resistance with elbow extended or supination of forearm with elbow extended +pain on wrist dorsiflexion and middle finger extension is= Lateral epicondylitis /tennis elbow • 46. Painful abduction between 60 to 120 degree + tenderness over anterior acromion + calcification on x-ray is=supraspinatus tendonitis/ Sub acromial impingement painful arc • 47. Pain through out body with tender points + lethargy + sleep disturbance , headache + normal blood lab normal ESR is = Fibromyalgia treatment is explanation, aerobics exercise, CBT • drugs :pregablin ,duloxetine, amitriptyline • 48 . Methotrexate used as a steroids sparing agent in difficult to control , frequently relapsing giant cell arteritis • 49. Elastic fragile skin + recurrent joint dislocation easy bruising + aortic regurgitation + MVP + subarachnoid haemorrhage + angiod retinal streaks + type 3 Collagen is =Ehler danlos syndrome

RHEUMATOLOGY PEARLS

 50. 10 to 15 years of age + obese child +knee or distal thigh pain + loss of internal rotation of leg in flexion +displacement of femoral head epiphysis posterior inferiorly is =Slipped upper femoral epiphysis  51.SLE + Systematic sclerosis + Polymyositis +Raynaud phenomenon + puffy hands + arthralgia + myalgia AntiRNP positive is =Mixed connective tissue disorder  52. Fever more than 5 days + cervical lymphadenopathy + erythema and oedema of palms and soles with desquamation of skin + nonpurlent bilateral conjunctivitis + strawberry tongue + coronary artery aneurysm On Echo =Kawasaki disease / Lymphomucocutaneous disease  Treatment give aspirin and IVIG 105

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RHEUMATOLOGY PEARLS

53. NICE They now recommend diseasemodifying anti rheumatic drug (DMARD) monotherapy with a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step. 54.Multiple small joints + gout = oral steroids for large joint use intraarticular steroids 55.Methotrxate can be used as steroid sparing agent in giant cell arteritis 56. 3 weeks of osteomyelitis = x-ray foot not MRI

RHEUMATOLOGY PEARLS

57.Systmatic sclerosis + lung involvement restrictive pattern treated by = high dose oral steroids and cyclophosamide 58.RCP guidance states that individuals should be given prophylaxis against osteoporosis if they : Are under 65 years Require steroids for longer than 3 month a have T score of less than -1.5 59.Best way to monitor disease activity in Paget disease is = 6 monthly alkaline phosphatase level 60.In Paget disease skeletal survey >bone scan 107

 1.. Patient presents with dysuria +urethral discharge + gram staining shows neutrophils but no bacteria is= Chlamydia trochmatis  2.Azithromycin is treatment of choice for Lymph granuloma venrum.  3.Meningitis + brainstem involvement + immunocompromised patient is = Listeria meningitis  4.Ataxia + seizures + headache + menigism + pneumonia + diarrhoea + not responding to cephalosporin + trumblibg motility is = Listeria monocytogenes  Diagnosed by blood Culture  5.Treatment of Listeria meningitis : IV amoxicillin/ampicillin and gentamicin (cephalosporin usually inadequate)  6.Lymphocytic CSF predominates in TB and fungal meningitis

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INfECTIOUS DISEASE pEArLS

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INFECTIOUS DISEASE PEARLS

 7.Urethral discharge + dysuria + gram negative dipplococci = Gonorrhoea  8.Tenosynovitis+migratory polyarthritis + dermatitis = disseminated gonococcoal infection  9.Patient with Gonorrhoea received ceftriaxone but unfortunately his symptoms have not resolved is = coexistent infection chlamydia  10. Treatment of Gonorrhoea  Cephalosporin (cefixime or ceftriaxone) Is treatment of choice  Ciprofloxacin was used  11.Investigation for Gonorrhoea Standard Culture fail to grow selective media is needed like Thayer Martin medium  12.Dysuria + penile discharge thin colourless + had sexual intercourse + urethral swab 10PMN/HPF no bactermia is = nongonococal urethritis  13.Treatment: doxycycline 7 days or azithromycin Erythromycin is 2nd line  14..Complications of Gonorrhoea  Local: urethral stricture Epidymitis Salpingits (infertility)  DG Imononarthritis + pustular rash synovial fluid is suggestive of joint sepsis in young woman is gonococcal arthritis

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 16. HIV patient + Cottage cheese and tomato ketchup or (pizza) appearance is = CMV Retinitis  Treatment: Ganiclovir (Side effects : myelosuppression do CBC) Foscarnet If both contraindicated give = Cidovir  17.Dyspanae + CD count less 200 + dry cough + fever + exercise induced desaturation +  Lymphadenopathy + choroid lesion + HSM + very few chest signs is = pneumocystis jiroveci pneumonia  18.Lab in pneumocystis jiroveci pneumonia  CXR : bilateral interstial pulmonary infiltrates lobar consolidation or normal  Exercise induced desaturation  BAL silver stain showing cysts  19.Treatment of pneumocystis jiroveci pneumonia :  Co -Trimoxazole  IV Clindamycin(not used as prophylaxis)  IV pentamidine  severe cases Steriods when Hypoxic PO2 less than 9.3kpa or less than 70mmhgDapsone  20.Treatment of lung abscess = Cefuroxime + metronidazole

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 21. History of sinusitis + fever+ headache CNS signs + seizure + meningeal irritation + ring enhancing lesion on CT scan is = pyogenic brain abscess.  22. DD of Ring enhancing lesions :  Pyogenic brain abscess  Toxoplasmosis  Cerebral metastases  Histoplasmosis  Primary brain tumours giloblastoma multiforme  23. Walking barefoot + abdominal pain + Diarrhoea + pneumonitis + papulovesicular rash on soles of feet buttocks linear rash over groin(larva current) + eosinophilia = Strongyloides stercoralis  24. Treatment Strongyloides stercoralis :  Ivermectin  Albendazole  Thiabendazole  25.if patient has Strongyloides and HIV diarrhoea then treat 1st Strongyloides then HIV  26.Children + perianal itching at night + sticky plastic tape at perianal area and see eggs is = Enterobius vermicularis(pinworm)  Treatment : bendazoles i.e. menbendazole

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INFECTIOUS DISEASE PEARLS

 27.Nemtodes which causes anaemia is = ancylostoma duodenale N nector Americans  Treatment: bendazoles.  28.Rainforest region + transmitted by chrysops deerfly + Itchy red swelling below skin Calabar swelling + urticaria + pruritis + eye work is= Loiasis loa loa  Treatment : diethylcarbamazine  Ivermectin (DOC) Both drugs contraindicated if microfilals exceeds 2500  29.Eating raw pork + fever + perioribital oedema +myositis is = trichinella spiralis  Treatment: bendazoles  30.Black files + blindness + hyper pigmented skin + allergic reaction to microfilaria is = onchocerca volvus  Treatment: ivermectin River blindness  31.Lyphmodema elephantiasis = wanchere bancrofti Tropical eosinophilia =mylasia fatigue w8 loss cough dyspnoea lymphadenopathy high level of eosinophilia + bilateral reticulocytosis shadowing  Treatment : Diethylcarbamzine

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 32 Dog faces eggs + visceral larva migrans + eye granulomas, liver lung involvement is = toxocara canis  Treatment : diethylcarbamazine  33. Pneumonitis + intestinal obstruction + Loffler's syndrome + biliary pancreatic duct obstruction = Ascaris  Treatment: piperazine for bowel obstruction  Menbendazole for other infections.  34.Painful liver mass + flushing urticaria + anaphylactic reaction + liver cyst obstructive jaundice + Ct abdomen best test is = hydatid disease  Treatment: Albendazole and aspiration.  35.Seizures + Ct brain periventricular cystic lesion in partial love Swiss cheese appearance ,= Neurocysticerosis Taniae solium (uncooked pork) Taniae saginata (beef)  Treatment : niclosamide  36.Swimmer's itch + haematuria + bladder calcification (Squamous cell  carcinoma) + frequency = Schistoma haematobium  Schistoma japonicum causes spinal cord compression 37.Treatment of schistosomiasis:  S.haematobium and S.mansoni = Praziquantel 40mg for 3days  S.japonicum = Praziquantel 60 mg for 6days+Prednisone 1mg

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 38. Cholangiocarcinoma = clonirchis sinensis  Treatment: Praziquantel  39.Same as tuberculosis + brown red sputum + fever night sweats rashes urticaria + eosinophilia + symptoms not as severe as tuberculosis is = Paragonimiasis  Treatment: Praziquantel  40.Cutaneous larva migrans = Ancylostoma brazillience  Visceral larva migrans = toxocara canis  Treatment of Ancylostoma brazillience = Ivermectin  41. High fever + stridor + drooling saliva (specific sign) + rapid onset + cheery red epiglottis is = Acute epiglottitis  Organism : Haemophilus influenza type B  42.Lab of acute epiglottis  Preferred method : Direct visualization of epiglottis cheery red epiglottis Lateral neck radiographs=swollen epiglottis (thumb sign)Blood Culture]  43.Cough =croup Drooling of saliva=Acute epiglottitis is Laryngomalcia improve in prone position

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INFECTIOUS DISEASE PEARLS

 44. Treatment of acute epiglottitis  Unstable=early intubation  Stable,=ICU monitoring 3rd generation cephalosporin ceftriaxone Hib vaccine rifampicin prophylaxis  45. Widespread pruritis + linear burrows on side of fingers ,interdital webs + flexor aspects of wrist + skin scrapings sarcoptes scabei =scabies  46.Treatment of scabies:  1st line : permethrin 5%  2nd line : Malathion 5%  47.Suppressed immunity +HIV patient + crusted skin scabies Is = Crusted(Norwegian) scabies  Treatment : Ivermectin  48.Cattle sheep /unpasteurized milk infected cow in abattoirs +fever chills sweats + confusion +abdominal pain diarrhoea + hepatosplenomegaly ,+ low platelets + Vasculitis rash is = Q fever coxiella burneti  49.Q fever Endocarditis:  Aortic valve involvement Murmur not always present.  low grade fever(or no fever)  Signs of heart failure  Clubbing  Hepatosplenomegaly  Vasculitic rash

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50. Lab of Q fever: Confirmation Q fever antibody coxiella burneti IgG or igA greater than 1:2000 Anaemia Low PLT High ESR High immunoglobulin's Abnormal LFTS Haematuria 51.Doxycycline is treatment of choice , Macrolides 52.Decreased consciousness , dysphagia + epilepsy history or Alcohol history + fever+ features of pneumonia is = Aspiration pneumonia Treatment: amoxicillin + metronidazole 53. Risk factors of Aspiration pneumonia: Epilepsy High alcohol intake Use of recreational drugs with history of drug overdose. 54.Altered mental status + fever headache + neck stiffness + seizures + erratic behaviour + Ct or MRI mass in temporal love for lap high protein, high lymphocytes, normal csf glucose +PCR for HSV is=Herpes encephalitis Treatment : HSV encephalitis = IV/acyclovir Acyclovir resistant =Foscarnet 55.HSV encephalitis is confirmed by =CSF PCR HSV

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 56. Business man + fever + pharyngitis + generalized lymphadenopathy + maculopapular rash + mouth ulcers + low WBCS Lymphocytes low platelets ,atypical Lymphocytes is = Acute HIV disease ,(seroconversion illness).  57. Hiv (RNA )PCR and p24antigen confirm diagnosis of acute HIV disease seroconversion illness  58.Infectious mononucleosis in teenage years and rash after ampicillin unlike HIV illness.  59.Flow cytometry used measure CD4 count in HIV patients : CD4 less than 350 = opportunistic infections  CD4 less than 200 = 80%risk of developing OI in 3years  CD4 100-200=PCP and Oesophageal candidiasis  CD4 less than 50= disseminated mycobacterium avium complex and CMV Retinitis  blood Culture next step to confirm to diagnose  60.Start antiretroviral therapy in every HIV positive individual regardless of CD4 count

DerMatology pearls DERMATOLOGY PEARLS

1.Symetrical + brown + velvet plaques on neck, axilla and groin is acanthosis nigricans 2.Causes of Acanthosis nigricans: Adenocarcinoma of stomach DM Obesity PCOS Acromegaly Cushing syndrome Hypothyroidism Familial Prader Willi syndrome Drugs: OCP nicotinic acid 3.Shiny painless areas if yellow red skin on shin of DM patient thickened blood vessel is = Nacrobiasis lipodica Treatment : topical steroids Injectable steroids Camouflage creams 4.Tender erythema nodular lesion on shins is = Erythema nodsum Treatment: usually resolve with in 6weeksNsaids ,light compression. 5.Causes of Erythema nodsum: Streptococcus infection most common, Brucellosis , tuberculosis , sarcodosis , IBD. Behcets SLE malignancy 118

DERMATOLOGY PEARLS

6. Drugs causing Erythema nodsum : OCP Sulphonamides Penicillin Antipyretics Montoleukast Hepatitis B vaccination Omeprazole Pregnancy HLA B 27 27 7.Pinkish pearly white papules with central umbilical on occur any where except palms and soles + children + HIV less than 200 count is = Molluscum contagiosum by pox virus Treatment: usually resolved watchful waiting Troublesome : simple trauma cryotherapy topical imiquoid cathardin Itchy : topical steroids fusidic acid. 8.Skin disease associated with HIV : Molluscum contagiosum Corweign scabies Saborhic dermatitis 9.Sysmmetrical erythematous lesion and raised pinkish indurated lesion and shiny orange peel skin is = Pretibial myxoedema seen in graves disease 10.Skin disorders with Tuberculosis is : Lupus Vulgaris Erythema nodsum Scarring alopecia Scrofuloderma Verrucosa cutis Gumma 119

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 11.Erythmatous flat plaque elevated ulcerated with apply jelly colour and centre scar is = lupus vulagris  Treatment : antiTuberculosis Drugs  12.Papular lesion hyper pigmented depressed centrally associated with DM,HIV lymphoma is = Granulomas annulare  Treatment: resolved spontaneous Steriods  13.Mainstay treatment of granuloma annulare is = Observation.  14.Infrated radiation sitting to fire heater + reticulated erythematous patches hyperpigemented telangiectasia + hypothyroidism is = Erythema Ab igne If not treated with develop squamous cell cancer  15.Well circumscribed raised erythematous lesion on finger tender which bleeds when touched =pyogenic granuloma.  16.Solitary lesion with central areas of ulceration volcano or crater is = Keratoacanthoma  Treatment : sponatoulsy regress with in 3minSuch lesion should be excited

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 17.Red indurated papules later narcotic black easchar at centre + middle East with cattle/sheep/goat is = Cutaneous anthrax  Treatment: resolve on 80-90% Penicillin for treating infection.  18.IgA deposit within blood vessel = HSP Granular IgA deposit in Basement membrane is = dermatitis herpertiformris  Intracellular igA deposit in pemphigus.  19.Streptococal sore throat 2-4 weeks + tear drop scaly papules on trunk and limbs is = Guttate psoriasis  Treatment: if lesion not widespread (10%body surface area =Refer urgent dermatologist phototherapy UVB phototherapy = recurrent episodes referral ENT should be considered = Tonsillectomy.  20.Erythmatous sharply demarcated papules and rounded plaques covered by silvery scales +HLA-B13,B17 cw6 + nail pitting oncycholysis koebnar phenomenon + anterior uveitis = psoriasis

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21.Complications of Psoriasis are : Psoriatic arthropathy Metabolic syndrome Increased CVS disease Venous thromboembolism Psychologically distress 22. Drugs causing psoriasis are : Beta blockers Lithium Antimalarial (chloroquine, hydroxychloroquine) Gold Nsaids ACEi infliximab BB >ACEI Withdrawal systematic steroid Trauma Alchols 23.Treatment of Psoriasis : Topical steroids 1st line : potent steroids once daily + vitamin D 2nd line: vitamin D twice daily Third line : potent steroids twice daily diathronl Side effects are :steroids skin atrophy striae rebound symptoms. Secondary management : UV B light : phototherapy psoralen + UV A light (PUVA) it's Side affects are : skin ageing Squamous cell carcinoma Systematic :oral methotrexate cyclosporine TNF inhibitor like Brodalumab = IL-17 Rituximab=CD20 Toculzumab =IL-6 Ustekinumab =IL12 and IL-23 Side effects are : dental ulceration. 24 Never use Oral steroids in Psoriasis.

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25.Treatment of pyogenic granuloma Lesion in pregnancy and post partum resolve sponatoulsy If persist then removal curettage and catherization cryotherapy excision. 26.Herpes simplex virus is commonest cause of Erythema multiforme. 27.Target lesion like bulls eye and symmetrical distribution on dorsal surfaces of extensor extremities is =Erythema multiforme Treatment: supportive. 28.Causes of Erythema multiforme are : Virus herpes simplex virus Mycoplasma streptococcus Drugs: Penicillin, sulphonylurea, barbiturates, carbamazepine, Allopurinol, NSAIDS,OCP nevirapine SLE IBD Sarcodosis Malignancy. 29.Severe macular atypical target lesion mucosal involvement on face and trunk + less than 10% body involvement+ fever arthralgia is =Steven Johnson syndrome Causes are same as EM. 30.Pyrexia + tachycardia + niklosky sign positive + severe mucocutaneous exfolitive disease is =Toxic epidermal nacrolysis Treatment : stop precipating Iv immunoglobins Immunosuppressive cyclosporine cyclophosphamide plasmaphresis

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31.Causes of Toxic epidermal nacrolysis are : Viral Leukaemia Lymphoma Drugs. 32.Drugs causing Toxic epidermal nacrolysis are : Phenytoin Sulphonamides Allopurinol Penicillin Carbamazepine Nsaids 33.50-60 years + Diabetic + swollen red warm foot and ankle + high arched foot + neuropathic + Normal C reactive white cells unlike osteomyelitis is = Charcot foot Diagnosed by :X-ray Indium labelled white cell scan best way to differentiate Infective causes. 34.Treatment of Charcot foot Immobilisation in case for 3-6 month Total contact plaster Bisphosphonates Surgery Good blood glucose control. 35.Female 40-60 years +diabetes/DVT + ulcer on medial/lateral malleous which pink yellow green hair thick hardened +ABPI 0.9+ venous ulcer Treatment: multilayer banding For banding u need ABI of 0.8

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36.Male >60years +HTN/DM/ hyperlipidaemia/smoking + severe pain on heel metatarsal regular deep green absent swelling +ABI Crohn's  RA,SLE  Myeloperlifertive disorders Lymphoma leukaemia  Monoclonal gammopathy  PBC.  55 Treatment of Pyoderma gangreosum is :  1st line : Oral steroids  1st confirm pain relief Culture biopsy then oral Prednisolone  2nd line ciclosporin,infliximab.  56 10-35 years +Herald patch on trunk + erythematous oval scaly patches fir tree appearance is = Pityriasis rosea caused by Herpes hominis virus 7  Treatment: usually disappears after 4-12 weeks.

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DERMATOLOGY PEARLS

 57.Patches hypo pigmented pink brown scale on truck in immunocomprismed /malnutrition is = Pityriasis versicolor (Tinae versicolor) caused by Melassezia furfur  Treatment: topical antifungal ketoconazole topical selenium sulphide Extensive=Oral itraconazole.  58.Tender erythematous indurated plaque with sharply demarcated border is = Erysipelas caused by streptococcus pyogens (group A)  Treatment: Benzylpenicilin if allergic then erythromycin  Complications are :sepsis, cerebral abscess ,venous sinus thrombosis  59.Treatment of Eczema :  Topical steroids :Mild : hydrocortisone  Moderate : Clobetasone butyrate 0.05%,betamethasone valerate 0.025% (Betnovate BD) Potent: betamethasone valerate 0.1%(Betnovate), Fluticasone propionate  Very potent : Clobetasone propionate 0.05%.  60.Inflamed itch crackle rough blisters on neck and face of children +fever = Eczema Herpticum  Treatment: acyclovir

• 1. Overdose of benzodiazepines + reduced conscious level +respiratory depression =intubate and ventilate rather than flumazenil • 2.Clozapine not only cause agranulocytosis but also myocarditis so never forget to do ECG prior to it's use • 3.. Some clues about poisons : • ecstasy all hyper except sodium. • Methotrexate : cerebellar signs • Cocaine : chest pain , ECG wide QRS . • Ghb : patient usually in coma and may show some lucid interval Nexus: nasal pain, tactile sensation increased

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pHarMaCology & toXICology pearls

PHARMACOLOGY& TOXICOLOGY PEARLS

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4. Drugs causing peripheral neuropathy :VITNAM Vincristine INH TCA Nitrofurantoin Amiodarone Metronidazole 5.Drugs causing retroperitoneal fibrosis are: Bromocriptine Beta blockers Methlyseriglycide 6.Drugs causing lymphocytic colitis are : PPI NSAIDS SERTALINE 7.Osteonecrosis of jaw is well recognised complication of bisphosphonates therapy 131

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PHARMACOLOGY& TOXICOLOGY PEARLS

• 8.Nsaids:COX-2 selective inhibitor (Celecoxib,rofecoxib) associated with increased risk of thrombotic risk (MI and stroke) but associated with lower risk of upper GI side effects good in ulceration or bleeding • Non selective Nsaid=also associated with Elevated risk of thrombotic risk(,diclofenac and ibuprofen) Naproxen has lower risk of thrombosis hence best choice • 9.Drugs causing acute dystonia : • Neuroleptics (Haloperidol,levomepromazine) • Antiemetic's(metoclopramide) • Antidepressants (amitriptyline,trazodone) • Management :stop drug fallowed by either benztropine or diphenhydaramine , benzodiazepines may be helpful.

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PHARMACOLOGY& TOXICOLOGY PEARLS

10.Drug causing Hypertension are : Steroids monoamine oxidase inhibitors the combined oral contraceptive pill NSAIDs leflunomide 11.Contraindications of beta blockers : Heart block uncontrolled heart failure Asthma sick sinus syndrome concurrent verapamil use: may precipitate severe bradycardia 12.Indication of statin : Primary prevention:10 years CV risk is 10%or more OR most type 1diabetes Or CKD if GFR less than 60 give =Atorvastatin 20mg (if non HDL is not fallen by 40% then titrate up to 80mg Atorvastatin Secondary prevention : known ischemic disease of stroke or peripheral atrial disease give = Atorvastatin 80mg 13.Treatment of carbon monoxide : Apply tight fitting non rebreather mask and give 100%oxygen If patient is comatose then intubation and ventilation with 100% oxygen

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PHARMACOLOGY& TOXICOLOGY PEARLS

14.Side effects of statins : myopathy myalgia, myositis, Rhabdomylosis asymptomatic raised creatinine kinase Myopathy is more common in (simvastatin, atorvastatin) than (rosuvastatin, pravastatin, fluvastatin). liver impairment: the 2014 NICE guidelines recommend checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range statins may increase the risk of intracerebral haemorrhage in patients who've previously had a stroke avoid in patient with intracerebral haemorrhage 15.Cyclophosphamide Adverse effects : haemorrhagic cystitis : incidence reduced by the use of hydration and mesna Myelosuppression transitional cell carcinoma 16.Treatment of cyclophosphamide induced side effects =Mesna2mercaptoethane sulfonate and metabolite of cyclophosphamide called acrolein is toxic to urothelium mesna binds to and inactivates acrolein helping to prevent haemorrhagic cystitis

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17.Phases of drugs Phase I =studies study safety = phramcokinetics,phramcodymanics first usage in human subjects. Phase II=studies are designed to elucidate any therapeutic response in specific settings combined with phase I . Phase III =Performed once initial safety and efficacy evaluation is completed , compare the drug with alternative. 18.Side effects of Ketamine are : Raised intracranial pressure i.e. headache, papilloedema,vomiting Hypertension Hallucinations Bladder and liver dysfunction 19. Side effects of Exogenous androgens are : Acne Gynaecomastia Hypertension Hypercholesterolemia Hepatic tumours Paranoid delusions 20.Opiates safe in renal impairment are : Fentanyl Buprenorphine Methadone

21.Drugs altering absorption or clearance of Thyroid : Cholestrayamine Ferrous sulphate Lovastatin Aluminium hydroxide Rifampicin Amiodarone Carbamazepine Phenytoin 22.Drugs causing thrombocytopenia Quinine Diuretics Sulphonamides Aspirin Thiazides Pseudo thrombocytopenia occurs with use of EDTA Thrombocypenia occurs on 7day of transplant unlike graft VS host diseases which occur after 2 weeks  23 Carboxyheamoglobin cohb is best for prognosis in carbon monoxide poisoning 136

PHARMACOLOGY& TOXICOLOGY PEARLS

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PHARMACOLOGY& TOXICOLOGY PEARLS

24.Contraindictions to metformin : Renal failure hepatic failure heart failure lactic acidosis CKD review when Cr>130 Stop when >150 or GFR less than 30 Recent MI within 6 weeks Alcohol use,IV contrast angiography. 25. side affects of sulphonylurea are : Hypoglycaemia Weight gain SIADH Liver damage Photosensitive Haemolytic anaemia G6PD 26 Side effects of GLP 1 Extentide is : Severe pancreatitis Renal impairment 27.Side effects of DPP-,4 inhibitor Gliptin : Git disturbance nausea diarrhoea constipation Little Pancreatitis 28.Side effects of SGLT2 inhibitor : canagliflozin depagliflozin empagliflozin Genital infection Flucytosine,DKA Hypoglycaemia UTI 137

PHARMACOLOGY& TOXICOLOGY PEARLS

 29.SGLT-2 batter in HTN and cardiovascular disease in diabetes mellitus  30. Drugs causing photoxiocity are :  Antibiotics:tetracyclines,fluroquinolones,sulphonamides Nsaids  Diuretics :furosemide,bumetanide Sulphonylurea  Neuroleptics : chlorpromazine Antifungals:terbinafine ,itraconazole  Other drugs : Amiodarone diltizem  31.In cases of severe theophylline toxicity ,charcoal haemoperfusion can be used.  32.Acidosis + hypokelmia + vomiting + tachycardia arrhythmias + seizures is = Theophylline toxicity  Treatment : gastric lavage if 100=seizures  QRS >160= Ventricular arrhythmias  34.Treatment of TCA poisoning :  Mainstay :I/V bicarbonate reduce acidosis Don't use Quindine,flecainde Amiodarone  Gastric lavage =1 hour of ingestion Charcoal 2hr ingestion if GCS is not reduced IV lipid emulsion Dialysis is not effective in TCA.  35.Most appropriate intervention in lead poisoning is DMSA  36.Mixed sensorimotor polyneuropathy + pesticides in farmer + nausea, vomiting gastroenteritis garlic breath coma seizures+ mees lines + abdominal pain + peripheral neuropathy is = Arsenic poisoning  Treatment : DMSA (sucimer) penicillamine.

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 37.Agitiation + confusion + sleepiness lasting up to 24 hours or more + pupils dilated and unreactive to light + visual and auditory hallucinations is = Procylidine poisoning used to treat parkinsonian side effects of neuroleptics.  38.Hypokelmic alkalosis + high urine potassium + athletes is = Diuretics abuse.  39.Farmer + pesticides + DUMBLESS : Diarrhoea,urination,miosis, bradycardia/ bronchospasm,lacrimation,emesis,salivation,sweating , hypotension, twitching fasciculation's, muscle weakness tremor hyperreflexia is = Oragnophosphorous poisoning (Malathion, parathion)  Treatment:Atropine,pralidoxime  40.Alcohol abuser + nausea vomiting headache confusion early + high anion gap Metabolic acidosis + retinal injury visual problems with blindness optic neuropathy macular edema is = Methanol toxicity.  41.Treatment of methanol poisoning :  1st line : Femipizole inhibit alcohol dehydrogenase  2nd line : if Femipizole not available ethanol (it competes with alcohol dehydrogenase  Na bicarbonate if PH 20.  43.Antifreeze used for suicide + stage 1 confusion ,slurred speech ,dizziness 2nd stage metabolic acidosis with high anion gap, tachycardia Hypertension stage 3 renal failure, respiratory, cardiac failure , oxalate stone symptoms like alcohol is = Ethylene poisoning  Treatment: 1st: Femipizole  2nd line : ethanol  In severe acidosis : Give fluids with bicarbonate  Haemodialysis refractory cases.  44.Oxalte stones = Ethylene poisoning  Eye problems = Methanol poisoning

PHARMACOLOGY& TOXICOLOGY PEARLS

45.Protamine sulphate is antidote for heparin. 46.Warfarin has narrow therapeutic index affected by drugs like SSRI Sertraline and citalopram are safest antidepressants with warfarin. 47.Inhibitor of 450 = decease serum level and causes toxicity SICKFACES.COMS: sodium valproate / SSRII: Isoniazid C: Ciprofloxacin K:Ketoconazole F: Fluconazole A:alchol(acute)/amiodarone C: Cimetidine E:Erythromycin S: sulphonamides C: chloramphenicol O: Omeprazole M: Metronidazole Others: Grape juice ,navir, Disulfiram, quinpristin. 48.Inducer of p450 CRAP GPSC: Carbamazepine R: Rifampicin A:alchol(chronic) P: phenytoin G:Grieflvin P: Phenobarbitone S:St John's wart Smokers 142

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PHARMACOLOGY& TOXICOLOGY PEARLS

 49.3-7 days after cessation of alcohol ingestion + visual hallucinations + autonomic instability (tachycardia, Hypertension and fever) + obtundation confusion + sweating , tremor's agitation is = Delirium tremens  Treatment: benzodiazepines  50.Diaphoresis,shaking, cramping,agiation , Diarrhoea  but no autonomic instability and hallucinations is = Opiate withdrawal.  51.Elevation transaminases more than 100 times upper limit of normal is seen in :  ischemic Hepatitis  paracetamol overdose.  52.Co-adminstration of aminophylline and ciprofloxacin can cause toxicity and macrolides hence avoided

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53.Dance (club ) active guy + agitation anxiety confusion ataxia + tachycardia + Hypertension + hyponatremia + hyperventilation + hyperthermia + Rhabdomylosis + blurred vision + acute renal failure+ DIC + ARDs + hyperkalaemia is = Ecstasy (MDM 3,4 methlynediomethamphetamine ) poisoning Associated with Serotonin syndrome. 54.Treatment of Ecstasy poisoning : I/V fluid if temperature >39 Dantrolene if simple measure fail Paralysis ventilation. 55.Poor prognostic factors in Ecstasy poisoning : Fever >42 Rhabdomylosis Renal failure, liver failure HTN DIC 56.Drugs treatment for acute dystonia dyskinesia reactions : I/V benztropine Procylidine Antihistamine diphenhydaramine. 57.Lathergy ,anorexia + nausea vomiting diarrhoea confusion + yellow green vision + arrthymais AV block is = Digoxin toxicity

PHARMACOLOGY& TOXICOLOGY PEARLS

58.Precipating factors for digoxin toxicity : Low k Low mg Low PH Low temperature. Low albumin Hypothyroidism Increasing age Renal failure High sodium Myocardial ischemia. 59.Drugs causing digoxin toxicity: Quinidine Verapamil and diltizem but not amlodipine Spironolactone Thiazides Furosemide Amiodarone Cyclosporine Cholestrayamine colpestol decrease level 60.Treatment of digoxin toxicity KLAM Slowly normalize K Lidocaine ,phenytoin Digoxin antibody Mg(avoid in bradycardia)

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PSYCHITARY PEARLS

• 1..Flight of ideas + pressure speech + grandiose delusions + elevated mood is = Mania • Treatment is lithium, sodium valproate ,carbamazepine • 2.Mania and hypomania is differentiate by presence of delusion of grandeur and auditory hallucination in mania not hypomania • 3.Major disaster, childhood sexual abuse + re-experiencing flashbacks, nightmares, repetitive distressing images, avoiding people or circumstances resembling event is =post traumatic stress disorder • 4.Winter season + hyperphagia + hyper insomnia + weight gain is =seasonal affective disorder • Treatment expose patient to light for few hours of day • 5 .Insomnia + tremor + loss of appetite + perspiration + tinnitus+ seizures anxiety is= benzodiazepine withdrawal syndrome

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 6.Depression +high mood is =cyclothymia  7.Chronic depression +sleep badly, and feel inadequate is=dysthymia  8.Techycardia+HTN + pyrexia + visual hallucinations + agitation is = delirium tremens  9 .Treatment of alcohol withdrawal is = benzodiazepines Lorazapam  For abstinence = Disulfiram  To reduces craving= Acamprosate  To reduces pleasure that alcohol brings and craving= Naltrexone  10.. 12 to 24 Hours after alcohol withdrawal + visual auditory, tactile hallucinations is = Alcoholic hallucinosis  11.. Impairment in consciousness + nocturnal worsening + intact memory for recent + visual hallucinations is = delirium  12.Fixed ,false, firmly held belief out of keeping with persons social and cultural background is= delusion Belief of exaggerated importance and often occur in mania = grandiose delusions  13.Misperception of stimuli is =illusion  14.Fear of open spaces , crowds + patient can go outside for years is = Agoraphobia  15 .Specific phobia or fear of heights is = acrophobia

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16.Lab in Anorexia Nervosa Most things Low except: 3Gs and 3Cs which are high Growth hormone Glucose Salivary Glands Cortisol Cholesterol Carotinemia High amylase 17.Features of anorexia Nervosa : BMI 5 cm in diameter usually require surgical intervention to achieve adequate drainage  54.Hypertension + localized cerebellar signs = Cerebellar haemorrhages.  55.1st line in human bite is = Co amoxiclav  2nd line metronidazole doxycycline 217

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PAST PAPERS PEARLS

 56.Best evidence with respect to virus clearance in hepatitis B is= Entecavir  57.Licorice = low Aldosterone and low renin  58.HIV patient + mononuclear Leucocytosis + raised csf + Ventricular enlargement is = CMV encephalitis  59.To localize phaeochromocytoma and not to know that adenoma is realising catecholamine = MIBG scan  60.Student house + headache + nausea vomiting + confusion vertigo + pink skin mucosa + weakness + arrthymais + coma + red lip + lactic acidosis is = Carbon monoxide poisoning  Investigation :pulse oximeter to measure level CO

Questions distribution for part -1

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Questions distribution for part-2 • Part -2 has images questions including : • Ecgs ,chest x- ray ,MRI,CT scan ,bone scan, pathology slides , ophthalmology pictures ,ECHO, Pulmonary volume loops • 40 questions approx. are from pictures questions ,where long scenario with image is given and investigation diagnosis or treatment is asked . 221

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How to attempt exam paper. 1.Read question well with full concentration (if you don't read question well no matter how good u are ,u won't make it correct ) 2.Exclude options which are pretty wrong 1st 3.when You are confused b/w two options click the one which hit 1st in your mind and move and don't rethink again 4.never Change your 1st marked question until u are 100% sure that u marked completely incorrect option 5.when u have no idea about question click the one which has longer statement (mostly they are right) 6.if you have short time like in Mrcp part-2 written try to read options 1st then come to question ,it will give you an idea ,what question will ask for and it will save your time too. 7.If u are not sure about correct answer and want to spend bit more on question then just give little dot on answer which u feel may be right and come back in the end if time remains . 223