PLAB1 KeyPoints#

Acute stroke/ Aspirin 300mg for 2wks

Post stroke/ clopidogrel alone OR Aspirin 75mg and dipyrimadole
PostTIA / Clopidogrel +/- statin for life
Post Mi Aspirin+Clopidogrel

Painless hematuria in an elderly man- bladder cancer- cystocopy

Painless hematuria in a young person- poly cystic kidney- ultrasound

Palpitations/pounding heart with high pulse (in the old)- VT- treated with beta blockers
Pounding heart/palpitations with high pulse (in the young)- SVT- treated with Carotid massage, Adenosine
Missed beats - VE
Palpitations with ankle swelling in a known alcoholic- AFib
Elderly lady, collapsed, ventricular rate of 220- VT

In full thickness burns, there is no pain. A child with full thickness burns doesn't need analgesia, but give IV
fluids (first step) and referral to burns unit (definitive).

Sudden episode of visual loss. Happened before 1yr ago, resolved completely. Upper limb weakness and
hyperreflexia. - Multiple Sclerosis- give Corticosteroids.
The episodic loss of vision is remission and relapse of optic neuritis.

Sudden loss of vision, normal fundoscopy- Retrobulbar neuritis

Obese woman with dry cough,not responding to inhaler,worse at night- Esophageal reflux
Small kidneys with proteinuria - CGN,
Small kidneys only- Renal artery stenosis
Hemophilia- deranged APTT alone
Heparin- elevated APTT and Thrombin Time

Short term contraception

-COCP
-POP (u give ppl with contraindications to COCP)
-injectables

Long term contraception

-Mirena
-Ligation/Vasectomy

For STEMI and NSTEMI, give Aspirin and analgesia.

For STEMI, give Percutanous Intervention first line, or Alteplase, or Streptokinase
For NSTEMI, add aspirin.

For new cases of dyspepsia, less than 55 years, do H.Pylori

For cases >55years, with ALARM symptoms, do endoscopy
For those who have taken PPI and are better, do Urea breath test
For those who are not better despite PPI, do endoscopy

For those with stress incontinence, do pelvic floor exercise

For urge incontinence, do bladder neck surgery
For prolapse, give ring pessaries

Increased urea + indigestion= Peptic ulcer

A boy with partial thickness burns- refer to burn unit

Early morning stiffness in small joints+ red eye- scleritis
Early morning low back pain/stiffness + red eye- iritis in ankylosing spondylitis
Red eye and pain 12hrs post check of visual acuity with optician- Anterior chamber
Asthma patient with postnasal discharge + bilateral painless nasal blockage- Nasal polyp

MS patient with loss of sensation in all 4 limbs- Cervical spinal cord lesion.

If on breast examination, lump is suggestive of cancer, but USS and FNAC is normal, do a core biopsy. If
breast examination is suggestive of cancer, and FNAC is inconclusive or shows borderline changes and
patient has positive family hx, do genetic testing.

Chronic diarrhea, mouth ulcers, low back pain, morning stiffness- seronegative arthritis
Child with seizure and CT showing hemispheric lesion- Cerebral Tumor/S.O.L
Mother with conductive deafness, worried for child - Do BrainStem Evoked Response

Loss of color vision. Impaired vision. "When pupil is stimulated with light, it dilates" - Retrobulbar neuritis.

Emergency contraception pills do NOT prevent implantation. They inhibit/delay ovulation (so that the released
sperm/semen in the woman's genitourinary tract will not see an ovum to fertilize). So they actually prevent
conception from starting at all.
But emergency contraception IUCD inhibit implantation.

Both excessive diarrhea and vomiting- hypokalemia

Exess vomiting- metabolic alkalosis
Excess diarrhea- metabolic acidosis
Antipsychotic that causes erectile dysfunction -Haloperidol

Diuretic side effects- hyponatremia, hypokalemia, hypotension, hyperglycemia, hyperuricemia, erectile

dysfunction
Patient postcholycystectomy has abdominal complaints/discomfort- do ERCP
Fever, jaundice, RUQ pain 24hrs after gallstone removal by ERCP- acute pancreatitis

Fever, drooling, barking cough in a child- Epiglottitis- Intubate immediately

3days post obstructed labor, with blue mottled cold painful swollen leg- Embolus
Floppy as a baby, difficult to feed, "Always eating even as parents try to hide food"- PraderWilli syndrome

Cobblestone mucosa- Crohn's disease- transmural

Goblet cell depletion- Ulcerative colitis
Diarrhea, bleeding, weight loss, fistula - Crohn's disease
Commonest site of fistula in Crohn's - ileosigmoid- especially ileum
Anemic man wit constipation.Barium enema shows stricture on RIF close to appendix- CD

Hypertension, proteinuria, small kidneys with smooth renal pelvis- GN

Hematuria, proteinuria, edema in middle aged man- renal biopsy
Unexplained hematuria, unexplained proteinuria - renal biopsy

LSD -seeing colors with eyes closed

Ecstasy- seeing colors with eyes open

Dilated pupil irresponsive to light- extradural hemorrhage

Pain postAppendectomy- tramadol
Pain post anterior resection of rectum- iv morphine

Hypercalcemia in elderly- Multiple myeloma- increased plasma cells

Large amount of iron within hepatocytes- hemochromatosis
Widespread hemosiderin deposition in lungs, liver, brain, skin- hemosiderosis

Acute angle closure glaucoma

-Pilocarpine drops + iv acetazolamide stat
-Analgesics and antiemetics may be used
-admit to monitor intra ocular pressure and give mannitol if necessary

Trochar btw umbilicus and anterior ischial spine- external and internal oblique
Trochar btw umbilicus and ASIS- ext & internal oblique and transverse abdominis

Normal mcv 80-100 fL

Microcytic anemia (low mcv) - IDA, chronic disease, malabsorption, malnutrition
Macrocytic anemia (high mcv)- alcohol, b1, b12 and folate deficiency, pernicious anemia

Macrocytic anemia with paraesthesia, loss of proprioception and joint vibration- B12deficiency
Macrocytic anemia with cognitive impairment- B1 deficiency

Blue sclera, short stature and murmur in a child- Osteogenesis imperfecta

Once GCS<8, please intubate or secure airway.
Child presents with history of seizures. Previously well. Normal examination. No neurological deficits.
Afebrile. No LOC during seizures- check serum electrolytes.

OSAS- polysomnography (best investigation)

Multiple sclerosis patient, drooping of left side of lips with loss of sensation over the face, hearing
impairments and uncoordinated movements- Brain stem affectation

ASD irregularly irregular pulse, loud P2

PDA bounding pulse, continuous machinery murmur
COA radiofemoral delay
TOF cyanosis, holosystolic murmur, clubbing
VSD pan systolic murmur, no cyanosis

Management of hyperkalemia
-IV Calcium Gluconate
-IV Calcium Chloride
-IV Insulin with Glucose

For azoospermia, check FSH

For blacks and those >55yrs, start with C or D, then add A.

For whites <55yrs, start with A then add C or D.

In bilateral renal artery stenosis, there is very high hypertension and no proteinuria
In chronic glomerulonephritis, there is proteinuria with hypertension
That's a simple way to differentiate.

Paul Bunnel positive - Glandular fever

PAS positive- Whipples disease
Raynaud's phenomenon, breathlessness, food sticking to the throat- Systemic sclerosis

Child born at 34 was with murmur, kept in cot for 4wks, no murmur at discharge- PDA

Frontotemporal dementia (Pick's dementia)- change in personality with visuospatial sparing, with sexual
inappropriate behavior and disinhibition

To confirm anterior mesenteric artery thrombosis, do antiphospholipid antibodies

Protein c, protein s, fibrin, factor V is for venous thrombosis

For Hypercalcemia,
-IV fluids
-biphosphonates
-calcitonin

Anti phospholipid syndrome (APL antibodies)

Prevention- Aspirin
During pregnancy- Aspirin and heparin

Anaphylaxis doses
In adults 0.5ml 1:1000 adrenaline IM
In children 0.25ml 1:1000 adrenaline IM
Osteoarthritis- bone pain/stiffness gets better as day progresses- Paracetamol
RA and Gout- NSAIDs
Punched out lesions on X-ray is Gout

Migraines - Aspirin and NSAIDs first line

The girl with old cuts and boyfriend issues

Superficial cuts only - borderline personality

Excessive daytime enuresis in a child >5yrs- Desmopressin

For acute PID

-Ceftriazone 500mg stat + Metronidazole and Doxycycline (CMD first line) OR
-Ofloxacin + Metronidazole

Slurred speech, hemiparesis, drooling- internal capsule

Hemiparesis + visual loss of the opposite side- carotid artery stenosis

10days post partum, passing clots- secondary PPH

A patient on sodium valproate can use COCP

Give Rifampicin/Ciprofloxacin prophylaxis to all contacts of a child with meningococcal meningitis. Once
there is meningococcal meningitis (evidenced by rash)- iv benzylpenicillin
If just meningitis symptoms, give IV cefotaxime or ceftriazone

Tidal volume 500ml is not physiological in pregnancy

Nosebleeds- press soft parts of nose
Kidney stones in sarcoidosis- hypercalcemia

Post menopausal woman

If full menopausal symptoms are complaints- give HRT
If only genitourinary complaints- topical/gel oestrogen
Brown discharge/bleeding in them - endometrial CA (TVS first line, Endometrial sampling for biopsy is
diagnostic).

Febrile neutropenia (in malignancy cases)

Give iv broad spectrum antibiotics- usually Piperacillin+Tazobactam
If not improving, add Vancomycin
If not improving, add antifungal

For COPD management (stepwise management)

-put on drugs
-assess for long term oxygen
-24% oxygen
-28% oxygen
-Nasal IPPV
-Intubation under G.A

After using antibiotics

Sorethroat + Rash + cervical lymphadenopathy- Infectious mononucleosis (usually after using
Amoxycillin/Ampicillin
A close differential is Erythema Multiforme (Drug Eruption) caused by Penicillin use, but there is no
lymphadenopathy.

Elevated APTT alone, in a young boy with bruises- Hemophilia

Elevated APTT and deranged Thrombin time in a boy with bruises- Heparin

Jaundice brought on by ongoing infections- G6PD deficiency

Pregnant woman, hemolysis, elevated liver enzymes, low platelets - HELLP
Pregnant woman, no hemolysis, normal liver enzymes, low platelets, deranged PT and APTT, fibrin
degradation factors- DIC

Nephritis (proteinuria and hematuria) 2-5days post Viral illness - IgA nephropathy (also called Berger's
disease).
Nephritis (proteinuria and hematuria) 2-12weeks post viral illness- Post Strep nephropathy. Viral illness
usually sore throat and URTI

Massive proteinuria and hematuria in a child- minimal change disease

Massive proteinuria and hematuria in an adult- membranous glomerulonephropathy
Proteinuria, pedal edema, hypoalbuminemia, hyperlipidemia- nephrotic syndrome

Nephritis, Arthritis, Abdominal pain with Rash on extensor surfaces and buttocks, may follow a viral illness,
usually with normal platelet count but deranged APTT- HSP
Similar presentation as HSP but with low platelets- ITP

Uterine bleeding after sex in pregnant woman- Placenta Previa- Admit and observe
BluishPurple discoloration of catheter bag- Bacteria colonization (by E.Coli)

Calf pain for months. Not diabetic or hypertensive but smokes. Loss of posterior tibial & dorsalis pedis pulses.
Non healing ulcer at base of 1st MTP joint. -Thrombangitis Obliterans/Buerger's disease.
A good way to distinguish this from Chronic Limb Ischemia is to look at the age.
Buerger's usually occurs in young people <40yrs, while CLI is in older people.

Woman stopped using COC, has amenorrhea, normal FSH LH Estradiol and prolactin levels- Post pill
amenorrhea
Woman stopped using COC, with amenorrhea, high FSH LH, low estradiol levels- Premature Ovarian failure
Woman athletic, with amenorrhea, low FSH LH Estradiol levels- hypothalamic dysfx
Woman with normal FSH LH Prolactin Estradiol yet amenorrhic, no history of pill use or athletic activities-
Absent uterus

Obesity, amenorrhea, high LH Prolactin levels, Acne, Facial hair- PCOS

Anytime u see Prolactin >5,000- Prolactinoma
Mobile hard breast lump. USS, mammo, FNAC normal - Core biopsy

For a missing IUCD

-do a vagina exam (preferably a speculum examination, look at the posterior fornix and see if u find it)
-use a hook or a forceps (under generous analgesia with Mefanamic acid) to see if u find it
-do a serum betaHCG
-give emergency contraception
-do USS
-do an X-ray if USS is unhelpful

MI 2months ago- Reasons to reschedule surgery

A patient can only do surgery 6months postMI
Systolic <90 is no reason to postpone surgery. Remember cases of abruptio placentae and ruptured ectopic
pregnancy, u do an urgent exploratory laparotomy even if BP is low.

Poorly controlled DM, earpain, foulsmelling discharge, deafness- Malignant Otitis Externa
Rash on skin, doesn't respond to antibacterial - give antifungal
Child with epistaxis, normal FBC, deranged APTT- hemophilia
Pregnant woman, on IV MgSO4 drip has another fit- MgSO4 bolus

Pansystolic murmur, heart failure, pulm edema DAYS after MI- Ruptured papillary muscle
Widespread ST elevation 2-5Days post MI- Acute pericarditis
ST elevation in v1-v4 about 6wks post MI- Left ventricular aneurysm
Fever, anemia, SOB, raised ESR, pleural effusion, pericardial rub 4WEEKS postMI- Dressler syndrome

Once u see dyskaryosis, do a colposcopy

Once u see cervical ectropion or inflammatory cells, take a swab
Once u see normal smear under 18months ago, do another smear
Once u see friable cervix, bleeds on touch, do swab, give antibiotics

CXR shows round fibrotic tissue- progressive massive fibrosis

Irregular lesion on face, has dimple, teleganctasia,on pinna, doesn't bleed- Basal cell ca
Skin lesion, bleeds on touch, usually on neck/arm- Squamous cell carcinoma
Moreen's ulcer- not a degenerative corneal dx

Sudden severe pain in left skull, jaw pain- Giant Cell Arteritis- do ESR, give aspirin
Middle aged man with bone pain and highALP- Pagets dx
For hyperemesis gravidarum- Oral antiemetics, then IV antiemetics, then IV steroids

Previous TIA- clopidogrel for life

Double vision, facial numbness- Brain stem
Early diastolic murmur postCyanotic heart dx in childhood- Pulmonary Regurgitation
Ear pain, no discharge, uncomfortable chewing, grinds teeth during sleep- TMJ pain

Pallor of the optic disc- optic nerve lesion

Papilloedema- optic disc lesion

<4mm ureteric stone- conservative and fluids

4mm to 2cm- ESWL Extracorporeal Shock Wave Lithotripsy
>2cm- surgery
Once u see "impending ARF"/anuria in a patient with ureteric stone- Percutaneous Nephrostomy regardless of
size.

Itchy annular rash- Lyme disease, give PO Doxycycline (taken after meals)
Trigeminal neuralgia- Carbamazepine (1st), gabapentine (2nd), amitryptilline (3rd)
Otherwise in neuropathic pain, Gabapentin (1st), Amytrptylline then Carbamazepine

Left eye pain, papilloedema, previous MS- monoocular field loss

Asthma, heart failure, rash, eosinophilia, Bell's palsy- pANCA
A similar scenario but with epistaxis- cANCA

Headache with seeing haloes at night- tunnel vision

Headache worse on bending forward- chronic sinusitis

Hypertensive with sudden visual loss, pale retina and fovea appears as cherry red spot- CRAO- treat with
pressure over eyeballs.
Cherry red retina- CRAO

Flame shaped hemorrhage- CRVO, hypertensive retinopathy

But if visual loss is sudden, suspect CRVO ahead of hypertensive retinopathy

Punched out ulcer, inbetween toes, yellow base- arterial ulcer

Irregular borders, red base, on medial leg above ankle- venous ulcer

Child with HIV due for immunization- give everything except BCG
Child with AIDS due for immunization (MMR)- don't give
Don't give immunization in face of febrile illness or immunosuppression
Child with family history of egg allergy due for MMR. Also has acute otitis media- defer for 2weeks.

Menopausal symtoms in a postMI woman- give COCP

Perforated posterior gastric ulcer- fluid accumulates in lesser sac, but if it involves the gastroduodenal artery,
it accumulates under diaphragm
CXRay shows bowel loops- Diaphragmatic rupture/hernia
Young child, raising TV volume, not hearing teacher, with air fluid levels on otoscopy- OME
Protrusion of tongue, tip deviation- hypoglossal nerve
Nerve supply tip of tongue- Lingual nerve
Patient with panic disorder, now having tingling/numbness- Acute respiratory alkalosis

Muscle weakness, inability to stand or climb stairs unsupported, raised CPK- Duchenne's muscular dystrophy
(in children), Polymyositis (in adults. Or dermatomyositis, if there are palm fissures involvement).

Anti Jo antibodies- DMD, Polymyositis, Dermatomyositis

Anti Ro- Sjogren
Anti Centromere- Raynauds+Teleganctasia- Systemic sclerosis
Anti dsDNA and AntiSmith- SLE
AntiHistone- patient undergoing treatment (drug induced LE)

PostOp, increasing calf size, swollen, tender- DVT - LMWHeparin

Diabetic, fever with tender lump near anal opening- Anal abscess- I &D with antibiotics
Constipation, purple painful lump around anus- Perianal hematoma- I&D with antibiotics

Anytime u see K+ >5.5, always give Calcium gluconate

Trauma to knee, Valgus test +ve, points to torn Medial Collateral Ligament

Fever, tachycardia 2hrs PostOp Appendectomy, with pain radiating to shoulder tip and abdominal pain- intra
abdominal bleeding
Anastomotic leak is a close differential but it always occurs 2-5 days postOp.
Not as early as a few hours post op.

Recurrent UTI, occasional hematuria, unusual cells on urinalysis- do USS

Sudden onset breathlessness in tall persons/athletes/basketball players- Spontaneous Pneumothorax-do

CXRay, Give oxygen.
Sudden onset breathlessness, trachea deviated/central, reduced breath sounds, raised JVP, engorged neck
veins- Tension Pneumothorax- do Needle thoracentesis at 2nd ICS MCL.
CXRay for both.

Beck's triad- in cardiac tamponade- muffled heart sounds, raised JVP, hypotension
Sudden onset breathlessness, trachea central, clear chest, raised JVP, muffled heart sounds, hypotension
(usually 50/0 to 80/0), globular heart on chest Xray- cardiac tamponade.

Ptosis with diplopia on upright gaze- Oculomotor palsy- do CT

Constricted pupil, ptosis, weight loss, cough, chest pain, SOB- Pancoast Tumor
Horner's syndrome with malignancy symptoms- usually Pancoast

Comcerning Travels to Africa/SouthEast Asia:

Once u see "coming from Thailand", think of EBV first.
Once there is fever, joint pain, malaise, vomiting- Malaria
Malaria symptoms with neurological signs (neck stiffness, seizures)- Cerebral Malaria
Malaria symptoms with petechia/pain behind the eyes- Dengue
Malaria-like symptoms with hematuria- Schistomiasis or Severe Malaria
But general tips are once u see "visit to/coming from Asia/Africa", look out for Malaria, TB, HIV, AIDS.

Weight loss, night sweats, fever +/- splenomegaly and lymphadenopathy is TB (if patient is coming from
Africa or Asia especially India).
But if patient is coming from Europe or US with same symptoms, it is Lymphoma

Criteria for tonsillectomy,

- >7 tonsillitis episodes last year,
->5 per year in last 2 yrs,
- >3 per year in 3 straight years.
Otherwise, give paracetamol/ibuprofen for pain relief.
Antibiotics have not been shown to be helpful in tonsillitis.

PSA >5.5 do radical prostatectomy

Fall in a child, forearm pain, no swelling no deformity- Greenstick fracture- even if symptoms are around the
elbow, it is still greenstick fracture.
Only consider a fracture if there is swelling and deformity along with tenderness.And consider Supracondylar
fracture if there is fall on an outstretched arm with pain, swelling, deformity. It is a spiral fracture if there is a
twisting force that caused the injury.

Tenderness with carrying baby- Mummy thumb/DeQuervain tenosynovitis/Scaphoid fx

Tenderness below radius, no swelling no deformity, X-ray says no fracture- ?Scaphoid fracture, immobilize
with cast for 6weeks, do repeat X-ray after.

Rapid growing mandibular mass- do FNAC- most likely malignant.

"DVT" Symptoms of deafness,(vertigo +/-vomiting), tinnitus (without any extra issues)- Menierres disease-
give Cyclizine (1st line) or Buccal Prochlorperazine (if vomiting)
The same "DVT" symptoms plus headache, loss of corneal reflex, ear discharge, mass in the eardrum etc-
Acoustic Neuroma
When u start seeing yellow ear discharge, perforation of the ear drum- think Cholesteatoma
For all of them, do MRI.
MRI internal auditory meatus>>MRI brain

Exercise induced Asthma, now still breathless- Sodium cromoglycate

But if child has history of exercise induced asthma, but is now having symptoms at rest/during sleep, then
follow the normal asthma management ladder.
Sodium cromoglycate is useless at that point.

Obesity , diabetes, no renal compromise- give biguqnide (metformin)

Obesity, diabetes with renal compromise (proteinuria, microalbuminuria) - give insulin

Foot drop- common peroneal nerve

Wrist drop- radial nerve
Fracture humeral neck- axillary nerve
Fracture femoral neck- sciatic nerve

Tablespoonful mucopurulent sputum with no response to bronchodilator- Bronchiectasis

Copious sputum, Previous measles, Finger clubbing- Bronchiectasis
COPD patient becoming breathless despite drugs with FEV <30% - assess for long term oxygen therapy.
COPD patient not improving despite drugs and 24% o2, give nasal IPPV

Tragal tenderness, recent travel, intact eardrum- Otitis Externa- Drop antibiotic+steroid
Fever, previous URTI, earache, bulging eardrum +/- ear discharge and relief- AOM- Amoxycillin.

Elderly patient on Alendronate. Sudden collapse with inability to move/lift leg- Fracture neck of femur (?
Osteoporosis).
Elderly patient, anemic, enema shows ascending colon mass- Cecal carcinoma

Chickenpox mode of spread- Airborne- spreads from trunk to limbs and face
Measles- spreads from face and neck to trunk
Coxsackie- feco oral.
Schizophrenia patient laughs talking about father's death- Incongruent affect
Intractable nausea and vomiting in malignancy- IM ondasentron

Patient with hypotension & abdominal pain, post abdominal trauma and splenectomy, on insertion of Ryles
tube drained 2litres of coffeground fluid- Acute gastric dilatation.

Pinpoint pupils with bradypnea- Opiod Toxicity- give Naloxone

Running nose, Nasal bleed, Nasal septum tear, drug use- Cocaine
To stop craving hard drugs- Methadone
To stop craving alcohol- Acamprosate
To act as deterrent to alcohol- Disulfiram (but has terrible side effects)
Once you see "deterrent" from alcohol, the answer is Disulfiram, except the patient says they want a drug
without terrible side effects.
A former alcoholic "hears voices"- Olanzapine

Agression, confusion, restlessness- Delirum Tremens (due to alcohol withdrawal)

Ataxia, Opthalmoplegia, confusion- Wenicke encephalopathy (alcohol intoxication)
Delusions, Comfabulations, Hallucinations- Korsakoff psychosis (chronic alcoholism)
Delusions, Hallucinations (with acute alcohol intake)- Alcohol hallucinosis
Patient has hallucination symptoms improved since stopping alcohol- Alcohol hallucinosis

The presence of any 2 of

1. Dietary deficiency,
2. Oculomotor abnormalities(diplopia, ophthalmoplegia),
3. Cerebellar signs(ataxia, nystagmus),
4. Altered mental state(memory impairment, confusion)
is the diagnostic criteria for Wernicke's encephalopathy.

Delirium Tremens- give Chlordiazepoxide

For Wernicke's encephalopathy, Korsakoff psychosis- give Thiamine VitaminB1

Young boy with leg pain, settled with aspirin- Osteod ostoma
Young man, sudden severe lower back pain on getting up from bed- Disc Prolapse
Elderly man, deaf, fractured hip, bilateral pedal edema- Paget's disease
Child on 70% oxygen- TOF

Painless testicular enlargement over months. No redness.- testicular tumor

Painful scrotum/testis over days- epididymorchitis (adults), orchitis (child)- antibiotics
Acute sudden painful red elevated testis- testicular torsion- Analgesics, Urgent surgery
Fourniers gangrene- requires surgery

Beta blockers eg Atenolol - wheezing

Calcium channel blockers- ankle swelling, gingival hyperplasia
ACE inhibitors- dry cough, hyperkalemia
Fluoxetine- inability to ejaculate, erectile dysfunction
Lithium- coarse tremors (do TFT and E/U before prescribing it)

Hypertensive whites <55yrs ACEi first. Then add C/D if ACEi fails.
Hypertensive blacks- CCB OR diuretics, then add ACEi if C/D fails.
Hypertensive whites >55yrs, treat like hypertensive blacks.

Constipation, blood on side of stool, painful defecation, impossible PR- Anal fissure
Sharp rectal pain, no painful Per Rectum examination- Proctalgia
Homosexual male with urethral discharge, if untreated- Epididymorchitis
Homosexual with weight loss and retinal hemorrhage- CMV

"Some weeping, some crusted" lesion.

If it is an 18yrs old, pick Shingles.
If it is a child, and it is localized (eg peri oral), pick Impetigo.
If it is a child, and it is generalized, pick Varicella/Chickenpox.

Chronic sinusitis, nasal obstruction, bloodstained nasal discharge, no ear affectation- Sinus squamous cell
cancer
Frank epistaxis, nasal obstruction, no sinusitis, otalgia, deafness, smoking & alcohol use- Nasopharyngeal
cancer.
Progressive hoarseness, hemoptysis, regular cannabis user- Squamous Cell Laryngeal Ca

Sudden temporal loss of vision in DM+HTN patient- Amarousis fugax

Elderly man on permanent catheter. Wants to attend wedding. Catheter Specimen Urine shows lots of EColi-
Change the catheter.
Fecal impaction in an elderly woman in nursing home- phosphate enema

Change in shoe size, preference for hot weather, painful wrist- Pseudogout
Carpal tunnel syndrome- median nerve- inability to move thumb, index and middle fingers- release of flexor
retinaculum/transverse carpal ligament

2days Fever, dry cough, hoarse voice with edematous vocal cords- do no investigation
Weak hands, burn marks on fingertips, weak spastic legs, "dissociated sensory loss" -Syringomyelia

Fever, cough, crepitations, negative urine on dipstick- CXR

Fever, seizures, negative urine on dipstick- CSF analysis
Fever, lethargy, rash from urticaria, negative urine on dipstick - Blood culture
Fever, irritability, lethargy, leukocyte on urine dipstick- urine mcs

Erectile dysfunction, reduced facial hair and galactorrhea- Hyperprolactinemia

To prevent Cot Death, baby to lie on back with feet towards feet end of cot.
To prevent renal damage against contrast, give plenty fluids

New York to UK returnee, cervical lymhadenopathy, fever- Lymphoma

Returnee from Thailand, cervical lymphadenopathy, fever- Epstein Barr Virus

Parkinsonism, ataxia, genitourinary features (ED, incontinence)- ShyDrager Syndrome

Patient taking Warfarin. Cutoff INR limit is 2-3
Patient with blood loss, pulse 130, has lost 30-40% of blood volume
Anytime u see a DKA scenario, intervention is do ABG and IV fluids +/-insulin.

Elderly patient, painful swallowing- Candida

Testis, Ovary- Paraoartic lymph nodes
Vulva, Labia Majora, Scrotum, Anus- Inguinal lymph nodes

Hypertension, hypokalemia- Conn's syndrome- Check aldosterone

Hyperkalemia, hyponatremia, skin tanning - Addison's - check cortisol
Acute diarrhea- low ph, low HCO3,normal/low pCO2- metabolic acidosis

Severe colicky RIF pain, no bleeding, no amenorrhea, no fever, mass felt - Ovarian cyst
Severe RIF pain, no bleeding, no amenorrhea wit fever & mass felt- TuboOvarian abscess
Severe RIF pain, amenorrhea, +/-bleeding, previous PID, - Ectopic Pregnancy
Lower abdominal pain, fever, vagina discharge- Acute PID
If very foulsmelling or ph <4.5- BV (Gardnerella).

BPPV following upper RTI- Vestibular neuronitis/Labyrinthitis

Cancer of esophagus middle third- Stenting
Patient on Warfarin, most important side effect- Headache (possible Subdural bleed)

IV drug user in prison, visual hallucinations, odd behavior, incorrect but approximate answers to questions
(Clinton is PM of England)- Ganser Syndrome
"Aliens" have replaced a relation- Capgras syndrome
Jealous and untrusting wife, Pathological jealousy- Othello syndrome
Pregnancy symptoms in a man- Couvade syndrome
Essentially nihilistic delusions- Cotard syndrome
Belief that a popular figure is in love with her - Erotomania
Tics, Shouting expletives, Odd behavior, Barking like a dog- Tourette syndrome

An asthmatic patient, on salbutamol only, still having symptoms- beclamethasone

If on salbutamol and beclamethasone, still having symptoms- add LABA

Itching, worse at night, following bathing, linear wrist marks- Scabies

Itching after a hot bath, burning fingers/toes, face flushed red, very high PCV- Polycythemia RubraVera
Itching after a bath, low PCV, high urea and creatinine- Chronic renal failure

Patient falls. Lucid interval of consciousness is hours. - Extradural hematoma

Patient falls. Lucid interval of consciousness is in days/weeks -Subdural hematoma

Subdural hematoma- cerebral veins

Extradural hematoma- middle meningeal artery

Selfdiagnosis of disease despite investigations disproving it- Hypochondriasis

Complaining of symptoms despite normal investigation results- Somatization
Creating symptoms, going as far as bringing samples(urine, blood) from home and undergoing needless
surgeries and laparoscopies- Maunchausen syndrome

4yr old with enuresis, do behavioral therapy

6yr old with daytime enuresis, give Desmopressin

Weight gain, cold sensitivity, bradycardia, cardiomegaly, murmur- Hypothyroidism

Prolonged neonatal jaundice- congenital hypothyroidism
Anxiety, weight loss, tachycardia, tremors, proptosis-Due to increased metabolic rate
4day history of LIF pain and fever. Sudden severe pain. - Perforated diverticulum
Diarrhea, weight loss, flatulence- give flagyl
Increasing jaundice and pale stools- obstructive jaundice- do USS (to know cause)

Elderly man falls, loses consciousness, pale, recovers fully within minutes- do ECG- most likely a StokeAdam
attack. They usually have Complete heart block and tachybrady syndrome on ECG.
If it were blood sugar issues, he can never recover on his own within minutes.

Patient with cough, purulent sputum, herpes labialis- GramPositive Diplococci GPD
Patient with bilateral cavitating consolidation BCC- Coagulase+VE Cocci CPC- Staph
Bilateral patchy consolidation- Mycoplasma
Fever and cough after influenza- Staph
Lobar Consolidation- Strept
"Hostel"- Legionella
"Boarding school" - Mycoplasma
Dry cough, Patchy consolidation- Mycoplasma- Cold agglutinins

5yrs treatment for RA, now dizzy&tired, MCV 106. Cause of anemia - Methotrexate
Methotrexate is an anti folate. Causes folic acid deficiency which explains the macrocytic anemia, tiredness
and dizziness.
Offensive greenish-brown breast discharge- Duct Ectasia
Offensive yellow discharge. Previous breast abscess -Duct fistula
Breast abscess causative organism -Staph Aureus
GBBC Green Brown Black Creamy- Duct ectasia

Patient with bipolar disorder- mood stabilizers- and carbamazepine too

Rash and mouth ulcers. Previous healed penile ulcer. - do PCR for treponema antibodies
On jejunal biopsy, shortening of villi and lymphocytosis - Celiac disease
Celiac disease is a risk factor for Lymphoma.

Knee jerk L3L4

Failure rate tubal sterilization- 1:200
"EVERYONE says he is evil"- 3rd person auditory hallucinations

1st person hallucinations- like hearing one's own thoughts

2nd person hallucinations- hearing one person talk to you
3rd person hallucinations- hearing people talk about you

Severe chest pain. ECG shows progressive prolonged PR til QRS is dropped - Mobitz type1 second degree
heart block.

"Flare in anterior chamber"- Acute iritis

"Mucoid discharge expressed from lacrimal punctum"- Acite dacrocystitis

The man that hung his hand across operation table & had wrist drop- Radial nerve
The man that crosslegged for 30mins and could not dorsiflex foot - Peroneal nerve

Ovarian cancer CA125

Colonic cancer CEA
Breast cancer CA 153
Pancreas Cancer CA 199
Hepatocellular carcinoma AFP

Visual deterioration with large cotton wool spots on fundoscopy- CMV

Fall on an outstretched hand. Elbow pain -Greenstick fracture
Artery in anterior inter-ventricular groove - Left anterior descending

Regurgitation of stale food, wakes up at night with feeling of suffocation, wakes up in the morning with food
on the pillow- Pharyngeal pouch
Corkscrew oesophagus on X-ray, food suddenly getting stuck in throat but then cleared with water-
Esophageal spasm
Sudden pain in the medial calf as patient climbs a hill- Popliteal/baker's cyst

Seizure, inattention, hyperreflexia- Cerebral tumor

No wasting, No fasciculations, hyperreflexia, hypertonia, extensor plantar response- UMN lesions or Cerebral
lesions.
Upper Motor neuron lesions+ear discharge and fever- Cerebral abscess
Wasting, Fasciculations, hypotonia, hyporeflexia, flexor plantar response- LMNL

Best test to know if a woman is ovulating- Day21 progesterone (or day 25 progesterone if it is a 32 day cycle).
That is for a regular cycle.
If it is an irregular cycle, do day3 FSH.

Philadelphia chromosome - CML

Reed Steinberg cell- Hodgkin's Lymphoma
AuerRod cells- AML
>40yrs with anemia, thrombocytopenia, leukopenia, hepatosplenomegaly - CML
>40yrs with all CML features above plus lymphadenopathy -CLL
<40yrs with anemia, thrombocytopenia, leukopenia, hepatosplenomegaly -ALL/AML
A child (usually under 15yrs old) with Leukaemia features- ALL

Mature lymphocytes- CLL

Blast cells- ALL
Immature granulocytes without blasts- CML
Immature granulocytes with blasts- AML
Plasma cells- Multiple myeloma

Just above the midinguinal point- Deep inguinal ring

5th intercostal space anterior axillary line- chest drain insertion
What structures are encountered in chest drain insertion- intercostal vessels/muscles
Tip of 9th costal cartilage- fundus of gall bladder
Transpyloric plane- L1
Termination of spinal cord- between L1-L2
Midpoint between xiphisternum and pubic bone- transpyloric plane- L1

Structures affected in chest drain passage:

Intercostal nerve (most likely)
Intercostal artery
Intercostal vein (least likely)

Repeated UTI in the past. Now has hematuria and loin pain - Acute Pyelonephritis
Repeated UTI in the past. Now has hypertension in early cyesis - Chronic Pyelonephritis

Persistent crushing central chest pain radiating to neck in a DM patient- Aortic Dissection (or is it MI?)
To detect early menopause/premature ovarian failure- Serum FSH
Recurrent facial and tongue swelling. Father has same. - C1 esterase deficiency (Hereditary angioedema)
Recurrent parotid swelling. Gritty eyes on waking up. Speech difficulty -Sjogren's synd
Bone/back pain following rough car ride.- Myofacial pain.
Patient on Lithium, planning pregnancy. -Reduce lithium gradually till pregnancy confirmed
Patient with goiter, planning pregnancy- Use propylthiouracil for 18months
Acute back pain radiating to legs. Relieved by lying, worse on sitting. -do MRI
Prolonged heartburn. PreviousCAPancreas. Now with hypotension, tachycardia, rigid abdomen- do XRay
abdomen.
Prolapsed disc, bone metastatic lesions, spinal cord compression- do MRI

For Crohn's dx, ideal is colonoscopy followed by barium enema. Tx- Sulfasalazine
Prolonged Epistaxis with normal clotting profile- anatomical causes
History of chest pain radiating to Left arm. Normal ECG. -Do cardiac enzymes
Obesity, short height, previous renal transplant, bullied in class -Cushings syndrome
Management of tremor in Parkinson's dx- benzhexol.
Diabetic on antiHTN developed chest pain with cold sweating & dyspnea- MI
Collapsed in shoppingmall. Now conscious. Irregular rhythm on ECG - do echo

For Inflammatory bowel disease, the diagnostic investigations are :

-Endoscopy (Ileocolonoscopy) with histology
-Radiological studies (Barium enema)
-Stool studies (microscopy, culture, sensitivity)
This is in order of importance.

Hearing deficiency noticed in pregnancy. Normal eardrums. -Otosclerosis

Hearing deficiency noticed on telephone calls. Father has same - Otosclerosis
Fever, weight loss, diarrhea, lemon yellow skin, high MCV- seen in Pernicious anemia-Hypothyroidism

Rapid temporary loss of vision, previous episode a yr ago, upper limb weakness, hyperreflexia- Multiple
sclerosis- treat with corticosteroids
Difficulty moving right shoulder, post surgery of posterior neck triangle- Accessory nerve injury- Trapezius
weakness.
Weak hands, stiff legs, dysphagia, tongue fasciculations, impaired pain and temperature sensation-
syringobulbia
Farmer with fever, cough, wheeze, tachypnea and fluffy nodular shadowing on CXR- extrinsic allergic alveolitis
Diarrhea post treatment of UTI with antibiotics- Pseudomembranous colitis- Treat with metronidazole or
vancomycin

Frequent change of glasses in a young person, Cupping in optic disc, sickleshaped Scotoma- Glaucoma- Give
pilocarpine
Cervical lymphadenopathy and splenomegaly- NonHodgkins Lymphoma
Hematuria, proteinuria, renal failure 2days-2weeks after bloody diarrhea- HUS
Hypothyroidism, jaundice, altered sleep pattern- Autoimmune hepatitis
Grey membranes on tonsils and uvula- Diphtheria
Diplopia on downward gaze- trochlear nerve
Diplopia on upward gaze, fixed dilated pupil- occumulotor nerve.

Eye pain with semidilated pupil- Acute angle closure glaucoma

Rheumatoid arthritis with redness in lateral- Episcleritis
Eye pain, red eye, hazy cornea, fixed dilated pupil, headache, nausea, vomiting- Glaucoma- Measure the intra
ocular pressure

Headache, unilateral; jaw muscles pain- Temporal arteritis- do ESR- give aspirin, steroids, and prophylactic PPI
to prevent gastric ulcers.
Give biphosphonates too to treat osteoporosis from prolonged steroid use.

BCL Bladder, Cervical, Lung CA- smoking is major risk

POBC Prostate, Ovarian, Breast, Colorectal- family history is major risk

Asbestos is biggest risk- mesothelioma.

Once u see "shipyard worker", "plumber", "asbestos exposure" with shortness of breath, cough and weight
loss, it is mesothelioma.

Once an adult suffers >15% TBSA burns, or child >10%TBSA burns- give IV fluids
Preferred IV fluids for resuscitation in Burns is Crystalloids (especially Hartmann's soln)
IV fluid resuscitation in acute burns is 4mls x bodyweight kg x TBSA =Total mls in 24hrs
You give half of total mls in 8hrs, the other half in the other 16hrs (from the time of burn).

Crystalloids- Hartmann's solution, Normal Saline, Ringer's lactate

Colloids- Synthetic (eg pentastarch, dextran, etc); Natural (eg whole blood etc)

To calculate TBSA- Rule of 9s

Head & Neck, Right Upper Limb, Left Upper limb- 9% each= 27% for the three.
Left LL, Right LL, Ventral trunk, Dorsal trunk- 18% each= 72% for the four.
Perineum is 1%
Add it all together, it gives you 100%

Facial burns, soot in mouth/throat, tingeing of nose- Intubate immediately.

Patient has signs of heart failure. Echo shows "septal wall thinning"- DCardiomyopathy

Once a patient "wakes up with stroke" or presents in the hospital with stroke features, and CT shows an
infarct/ischemia, the stroke is already >4.5hrs - give Aspirin.
But if the presentation is within 4.5hrs of stroke occurrence or CT is plain, with no hemorrhage, then give
Alteplase

Breast cancer patient with nonproductive cough not relieved by codeine.- nebulize with 0.9% Normal Saline
Swollen leg. Increased calf diameter and tenderness. Small movement cause pain - DVT

Continous Projectile vomiting in a child. 6weeks old. Olive shaped mass in the abdomen.- Hypertrophic Pyloric
Stenosis- do USS and Check Serum Pottasium- prone to metabolic alkalosis.

PostOp complications
Day1- Atelectasis
Day3- UTI, Pneumonia
Day5- DVT
Day 7- Wound infection
Day 10- Abscess with swinging pyrexia

Patient on warfarin for A-fib. Confusion for days. Multiple bruises- Subdural hematoma
Ring-enhancing lesions on CT- Toxoplasmosis- Tx: Sulfadoxine+Pyrimethamine OR Trimethoprim (for AIDS
patients).
Once BMI <15, admit into Acute Medical Ward.

14yr old girl. Amenorrhea. No secondary sexual characteristics. Normal height and weight.- Constitutional
delay.
Premature menarche is <8yrs. Late menarche is >16yrs.
Average age of menarche is 13yrs.
14yrs old. Amenorrhea. No secondary sexual characteristics. Short height- Turner's Syn
Dinnerfork deformity- Colles fracture- posterior/backward angulation of distal radial fracture- seen in elderly
people with osteoporosis
Gardenspade deformity- Reverse Colles fracture/Smith fracture- anterior/forward angulation of distal radial
fracture- seen in young people
Gunstock deformity- Supracondylar fracture
Mallet finger- avulsion of the extensor tendon at fingertip
Gamekeeper thumb- rupture of ulnar collateral ligament of thumb- severe pain trying to "grasp" any object
Trigger finger- click sound heard on flexion or extension of middle finger
Valgus test positive on knee- Rupture of medial collateral ligament of knee

Chances of children born

Neurofibromatosis, -1/2
Cystic Fibrosis (already with one child): 1/4
Cystic Fibrosis (one child healthy, the other with disease): 1/2

Itching, excoriations, redness, ulceration of nipple plus bloody discharge- Paget's disease
Painless bloody discharge without any nipple changes- Duct Papilloma
Thirst, frequency, confusion, abdominal pain in a cancer patient- Hypercalcemia
Twitches, spasms, Chvostek sign, paraesthesia- hypocalcemia
Mechanism of scabies- Allergy
In SIADH, restrict fluids +/- demeclocyclin

For a localized brain tumor- Surgery

For a localized metastatic tumor- Radiotherapy

Failure rate condom 1:50

Philadelphia chromosome - CML
AuerRod cell- AML
Reed Steinberg cell- Hodgkin's lymphoma
11month old. Painful hands&feet swelling, with jaundice.- Sickle cell disease

Tinnitus and vertigo associated with "turning on bed"- BPPV- do DicksHallpike/HeadTilt test- Treat with
Betahistine (first line), Prochlorperazine (second line)
Code:BP for BPPV

Slow shallow breaths with fruity smell. Altered sensorium. ABG of ph7.20. Ketones in urine- DKA- Urgent
rehydration with IVFluids, monitor ABG.

C5,6 Biceps jerk

C7,8 Triceps jerk
L3,4 Knee jerk
S1,2 Ankle jerk

Celiac disease diagnosis

Endomysial antibodies- initial step
Duodenal biopsy- diagnostic
But if no duodenal biopsy in options, pick jejunal.

Bleeding and pain, 10days posttonsillectomy- Admit, give IV antibiotics

Berry aneurysm bleeds into subarachnoid space. One of the commonest causes of SAH.
Patient having heartburn. Taken PPIs without relief. HPylori -ve. Do Endoscopy.
Severe gastric tenderness wit cell infiltration of lamina propria- Adenocarcinoma stomach

Young person with Prolonged Diarrhea. Stool is mixed with blood and mucus. Abdominal pain. -Crohn's
Disease- Treatment of choice is Mesalazine (1st line) then Steroids.

Greenish vagina discharge. Vulval itching. Speculum reveals strawberry cervix. -Trichomonas infection- give
Metronidazole.
Fever with rash on face and neck of a child. Now spreading.- Chicken pox.

Clinically obese child. Difficult to feed as a baby. Has learning difficulties. Always eating despite measures by
parents to hide food- PraderWili Syndrome

Chlamydia- Doxycycline
Trichomonas and Gardnerella- Metronidazole
Nesseria Gonorrhea- Azithromycin+Ceftriazone

Preferred analgesic postAppendectomy- Tramadol

Most common PostOp complication of anterior resection of rectum- Infection

Pain Control Ladder:

Paracetamol
NSAIDs
Codeine, Tramadol
Morphine
Oxycodone
Fentanyl patches
PCA (Patient Controlled Analgesia)

Terminally ill patient with metastatic disease and bilateral hydronephrosis wants to attend daughter's
wedding- Do a Palliative Nephrostomy
Widespread ovarian cancer. Now has bowel obstruction and severe intermittent colic and pain- do a Palliative
colostomy.
Child with hypertrophic villi- Allergy.

Prolonged QRS, tall tented T waves- hyperkalemia- Give Calcium gluconate

Short QT- Hypercalcemia
Disorganized complexes- VFib
Absent P waves- AFib

Dry skin and severe itching in a young boy whose mother is asthmatic and brother has hay fever.- Eczema- To
use Emollient first then steroid.
Dry skin in a young boy with no family history of asthma,eczema or atopy- Emollient only

Dry skin on flexor areas- eczema

Dry skin on extensor areas- psoriasis

Poor feeding, facial swelling, oliguria, proteinuria in a child- Nephrotic Syndrome- give Prednisolone
Severe intermittent breast pain, no lump, not related to menses- NonCyclical Mastalgia
Severe intermittent breast pain, no lump, related to menses- Cyclical Mastalgia

Case of placenta abruption. After all measures, still bleeding.- Do clotting profile. (Most likely patient now has
DIC).
Prolonged Epistaxis with deranged APTT- Hemophilia
Prolonged Epistaxis with normal clotting profile - Anatomical causes
LFT for Breastmilk jaundice- unconjugated hyperbilirubinemia- low Total bilirubin, low conjugated bilirubin.

Child with metal spike puncture to foot. "Next Best" step- Clean the wound.
Now if child was vaccinated at birth and received any TT in the last 10yrs, give Ig only.
If child was never vaccinated at birth, give full DPT and Ig.

A patient post-evacuation for molar pregnancy- monitor HCG levels

A patient post-prostatectomy -monitor PSA levels
Trauma patient with dilated left people irresponsive to light- Extradural hemorrhage
Prostate cancer causes bilateral hydronephrosis. Not BPH. Pls note.

UTI in children, do Clean Catch Urine for MCS first, then USS next.

Oral candidiasis- Nystatin suspension (for mild oral disease)

Pharyngeal and Esophageal candidiasis- Fluconazole tabs
For severe oral candidiasis- give Fluconazole tabs too

Absence of gastric bubble on antenatal USS- esophageal atresia

Doublebubble sign- Duodenal atresia -seen in Down's syndrome
Absent thymic shadow- DiGeorge syndrome
Food regurgitation with "air fluid levels behind normal sized heart"- Achalasia
Immobility,Obesity,Diabetes,Recent longbone fracture/hip surgery- Pulmonary Embolism

A child ingested his grandparent's drugs

-If amytriptyline, it causes dilated pupils and cardiac arrythmias
-if digoxin, it causes "yellow" vision, nausea, vomitting and cardiac arrhythmia.

Single best test to evaluate HPylori eradication by PPI- Urea breath test
Heroin addict, after car crash, can't remember the accident- Organic brain injury
Child, tall for age, refractory error, crushing chest pain- Marfans syndrome
Young man/College student brought unconscious. No medical history.- check blood sugar

Stab in the upper chest. No rib fractures. Unequal chest movement- Phrenic nerve damage
Parents unsure if child will use prescribed bronchodilator- Peak flow rate diary
Midshaft femoral fracture- femoral artery amd femoral nerve injury
Severe chest pain, ECG shows ST elevation- Percutanous angiography
Decreasing vision in a patient on multiple asthma medication. Cause: Oral steroid use.
Hematuria, hypertension, proteinuria in a young person. - Renal biopsy diagnostic.
Once vagina ultrasound reveals endometrial thickness >5mm- suspect Endometrial CA

30yr old woman. Gradual decrease of vision over 3yrs. Now has "disability due to low vision"- Retinitis
Pigmentosa.
Woman with "widespread metastases" now has severe back pain. Primary tumor? Breast.
If it were a man, primary tumor would be in the lungs.

Child with nephrotic syndrome. Later presents with hematuria, loin pain, "fluctuating urea levels"- Renal vein
thrombosis.
Cause of renal vein thrombosis- Loss of antithrombin 111

In panic disorder, rebreathing bag is for acute presentation, beta blocker is prophylaxis for upcoming stressful
event like giving a public speech or writing exams.
Extremely severe panic attacks, give benzodiazepine.

Perioral paraesthesia, tingling, numbness in the hands, shortness of breath is peculiar to panic disorder, and
not seen in generalized anxiety disorder. In GAD, patient excessively worries for "many days for months" over
different issues, while a panic disorder patient only has episodes of anxiety and palpitations.
Best treatment for panic attacks, phobias and generalized anxiety disorder is CBT.

PostTURP- dilutional hyponatremia- restrict fluids

Paralytic ileus post op- do plain abdominal X-ray- pass NGTube and give IVFluids
Atelectasis PostOp - CXRay- chest physiotherapy
UTI PostOp - urine MCS- trimethoprim
Intra abdominal bleed/anastomotic leak PostOp - laparotomy

Branchial cyst- midline anterior neck swelling- USS, FNAC- surgical removal
Thyroglossal cyst- transilluminating midline neck lump- moves on tongue protrusion

Every breast lump must undergo "Triple Assessment"- Clinical examination, Imaging and Cytology. If <35yrs
old, do USS. If >35yrs, do mammo first, then USS.
If aspiration, gives clear fluid, no need for FNAC. If bloody aspirate, do FNAC.

Painful, paralyzed, pulseless, pale leg with paraesthesia- Acute Limb ischemia- urgent vascular surgery ASAP.

Severe pain. Purple-blue lump in anal region.- Perianal hematoma (thrombosed hemorrhoids)- do I and D with
antibiotics.
Severe pain.Purple-blue lump in anus.Diabetic patient -Perianal abscess- i&d +antibiotics
Congenital hypothyroidism- prolonged neonatal jaundice

Hydrocele is accumulation of fluid in tunica mucosa. Testes not palpable. No pain, but transilluminates.
Varicocele is dilatation of veins. Bluish color. Feels like worms. Disappears on lying flat.

Testicular tumor is painless progressive enlargement (teratoma if 20-30yrs old, seminoma if 30-40yrs old).
Orchidectomy and biopsy is definitive treatment.
Investigation for all the above 3 conditions is USS.

Painful vesicles in the ear with facial palsy- RamsayHunt syndrome/herpes zoster oticus
Complete anuria in patient with hypotension and shock from placenta abruption- acute cortical necrosis

Testicular torsion- severe sudden scrotal pain, for hours, one testis above the other, no fever, usually
associated with sports, but not trauma. Tx Urgent surgical exploration
Epididymorchitis- fever, dysuria, scrotal pain for days, swelling, redness. Tx :MSU for MCS plus antibiotics

MalloryWeiss tears usually occur in nonalcoholics who do binge drinking. They are hemodynamically stable
with little blood loss. Tx: Monitor vital signs closely.
Esophageal varices is common in alcoholics. There is massive hematemesis with hemodynamic
compromise. There is usually signs/stigmata of chronic liver disease (eg spider naevi). Tx: Urgent endoscopy
with band ligation.
All patients with upper GI bleeding need endoscopy except MalloryWeiss tears that has little blood loss.

Abd USS is the investigation of choice in Cholecystitis, Biliary colic, Gall stones.
In passing a chest drain, the structure most likely damaged is intercostal nerve.
In pancreatitis, initial confirmatory investigation is serum amylase, CT Abdomen is gold standard if diagnosis
not clear with amylase results.

Abdominal pain with per rectal bleed in a patient with IHD, AF or Valvular heart disease. No rigidity. - Acute
mesenteric ischemia

All atypical pneumonias cause dry cough.

That's Legionella, Mycoplasma, Chlamydia psitacci and Pneumocystis jirovecci
Legionella and Mycoplasma both appear as patchy consolidation on CXRay, but bilateral patchy consolidation
is mycoplasma.
Once u see foreign trip, or holiday, stay in hotel, with dry cough, think Legionella.
Once u see boarding house, dry cough, flu-like illness and CXRay features, think Mycoplasma. Cold agglutinins
is diagnostic of Mycoplasma.
Once u see "works in a pet/parrot shop" or has contacts with birds or cats and now has dry cough, think
Chlamydia Psittacci
Dry cough in an HIV patient, homosexual, iv drug abuser, or someone from Africa with low CD4 count, think
Pneumocystis jirovecci
Bilateral interstitial shadowing(BIS) on CXRay is Pneumocystis jirovecci
Upper lobe consolidation and cavitation is TB

HIV patient with dry cough- Pneumocystis jirovecci

HIV patient with productive cough- TB
Dry cough with flu-like illness -Mycoplasma
Productive cough with flu-like illness -Staph aureus
"Swinging pyrexia" always means abscess.

Rusty-brown sputum is Strep pneumonia

Purulent sputum is Staph pneumonia, Bronchiectasis and Lung abscess
Pink frothy sputum is pulmonary edema and left ventricular failure
Mucoid sputum is pneumonia

Once u see a shipyard worker, or exposure to asbestos, with pleural effusion -Mesothelioma - pleural biopsy is
diagnostic
Once u sea farmer with shortness of breath and wheezing- Extrinsic allergic alveolitis
Chronic SOB, erythema nodosum, pleural effusion on CT, bilateral perihilar lymphadenopathy on CXRay, raised
ACE and raised calcium- Sarcoidosis
Most likely damaged structure in chest drain passage- intercostal nerve.

Breath holding spells

In children when upset. Precipitated by trauma, or separation from parents. They just stop breathing, turn blue,
may even jerk the limbs, then suddenly start breathing again.
There's usually previous history.
Treatment: reassure parents

Abdominal migraine
Common in children. Abdominal pain with headache.
All clinical examination: normal.
All investigations: normal.
Tx- Reassure.

Hot concrete falls on a builder and causes erythema. Just reassure.

Erythema is not counted as an area of burn.
For burns, check airway (Intubate if anything suggests inhalational injury), give analgesia, give iv fluids and
transfer to burns unit- in that order.

Foreign body aspiration:

In a child, usually occurs with toys, do a laryngoscopy urgently -diagnostic and therapeutic
In an adult, usually occurs with food, do an urgent endoscopy- diagnostic and therapeutic

Small cell lung cancer causes SIADH

Squamous cell cancer causes Hypercalcemia
GCS <8 is Severe head injury. Calls for immediate intubation. (Mild:13-15, Mod:9-12)

Understanding the Arterial Blood Gas-

Normal ph -7.35-7.45
Normal pCO2- 4.5-6.0
Normal pO2- >10
Normal bicarbonate 22-28

CO2 is acid controlled by the lungs, signifying respiratory problems

HCO3 is base controlled by the kidneys, signifying metabolic problems
If base excess is -ve, it is acidosis (u don't expect much base in acidosis); if base excess is +ve, it is alkalosis

To interprete given arterial blood gas results:

1. Check ph. Low ph is acidosis. High ph is alkalosis.
Low ph is acidosis (caused by high acid CO2 and low base HCO3)
High ph is alkalosis (caused by low acid CO2 and high base HCO3)
2. After deciding by ph that it is either acidosis or alkalosis, check pCO2 levels. This is to know whether it is
respiratory or metabolic.
If the pCO2 is in keeping with the ph, it is respiratory problem, if not, it is metabolic.
3. Check the bicarbonate levels, to further confirm your diagnosis.

NonAccidental injury is the same as child abuse.

Patients usually present with bruises, fractures, and do not live with their parents.
Treatment: do FBC to rule out ITP for the bruises, do skeletal survey to rule out other causes of fractures,
admit under pediatrician care.
In that particular order.

Splenomegaly alone, lymphadenopathy, anemia, bruises in a child- AML

Hepatosplenomegaly, Lymphadenopathy, anemia, bruises in a child- ALL
Night sweats, weight loss, fever, splenomegaly, lymphadenopathy, hepatomegaly -TB like features in a
nonafrican nonHIV patient with no cough- Lymphoma
Splenomegaly alone is usually myeloid. CML or AML.

About Chicken pox,

Starts on the trunk and spreads peripherally
Child is infectious from 2days before rash onset till rash gets crusted.
That's why infected children are told to come to school after rash gets crusted.
For neonates and immunocompromised, give IV acyclovir
For >1month to 12yrs, no treatment
For >12yrs, oral acyclovir.

Fracture neck of femur- injury to circumflex artery and sciatic nerve

Fracture shaft of femur- injury to femoral artery, femoral nerve
Fracture neck of humerus- injury to axillary nerve, axillary artery

Measles:
3rd day disease
Presents with 1F3CK fever cough conjunctivitis coryza and koplik spots
Rash develops on 3rd day
Rash starts from head and neck and spreads to trunk
Symptomatic treatment

Roseola (4th day disease)- rash shows on fourth day.

Steps of Asthma management in a stable child

1. Inhaled SABA occasionally eg salbutamol
2. Inhaled steroid eg Beclomethasone
3. Add LABA eg Salmetrol
4. Increase inhaled steroid to maximum dose
5. Add oral Prednisolone

Footdrop can be caused by both sciatic nerve and common peroneal nerve. A trauma to the hip presenting
with foot drop is most likely sciatic nerve, a man who crossed his leg for a long period of time presenting with
foot drop is most likely common peroneal nerve.

Ovaries, testis, cervix- Paraaortic lymph nodes

Penis, vulva, perineum, buttocks, abdomen below umbilicus, scrotum- Superficial inguinal lymph nodes

For epidemiology:
Incidence- number of new cases divided by total population
Prevalence- number of all cases (old+new) divided by total population
Sensitivity- number of true positives (Code: SnP)
Specificity- number of true negatives (Code: SpN)

Once u see "old people in nursing homes" (or a child) with itchy lesions in between fingers, inbetween toes or
in groin, it is Scabies- Mechanism is Allergy (to toxins released by mites)- and treatment is 5% permethrin

Skin Lesions and Interpretation:

Erythema nodosum- TB, sarcoidosis, SLE, RA, IBD
Erythema multiforme- drug eruptions without "mucous membrane" involvement
SJS- drug eruption with mucous membranes involvement
Infectious mononucleosis- Generalised rash after treating patient with ampicillin/Amoxyl for sore throat. This
is very specific, unlike multiforme.

Eczema- suggests atopy and asthma.

To treat eczema, apply emollient first, after15mins then apply steroid.
Preferred steroid is 1% hydrocortisone, if not working, then use Bethametasone.

Single painless ulcer- Syphilis- check Treponema antibodies

Multiple painful ulcers- Herpes simples - check HSV
Painful ulcer+dysuria+lymphadenopathy - Chancroid (hemophilus ducreyi)

Chest XRay shows bilateral fibrosis and pleural effusion. - Do pleural biopsy.
Woman whose husband just died. Given antidepressants, got better, wants to stop medication but "still talks
about her husband"- Bereavement counseling
Woman whose husband just died. Given antidepressants, got better, but now thinks she "has cancer too like
her husband"- Neuropsychiatric analysis
Patient on metoclopramide and fentanyl developed neck stiffness and fever- metoclopramide side effects
Clinically obese child. BMI >95th centile. No other medical problems. Normal clinical examination- Primary
obesity.

Once Hb is <8g/dl, give blood transfusion. If between 8-10.5, give oral ferrous sulphate.
If Hb level is >10.5, just reassure patient that this is physiological anemia of pregnancy.

Delusions of any kind and abnormal thought processes (of insertion, withdrawal, and broadcasting) are
primarily schizophrenia. Except u see depression symptoms, then it may be psychotic depression.

Patient going for liver biopsy. Most important investigation- Coagulation profile
A woman who just had debulking surgery for ovarian ca, now presents with intestinal obstructions- do a pelvic
CT
Neonate with high fever- admit for infection screen, start iv antibiotics
7day old baby, birth weight 3.5kg, now 3kg- continue child care, reassure.
Discharge from left ear after fight- Coming from the CSF- do CT- possibly basal skull fracture.
Obesity, easy bruising and striae, with cortisol suppression only at high dose dexamethasone suppression
test - Pituitary adenoma.
Vagina discharge, unpleasant odor, ph >4.5 -Gardnerella- BV- give metronidazole

Middle aged man brought in unconscious. Has distended abdomen with caput medusae and spider naevi.
Has previous hx of esophageal varices. Skin is pale and clammy. Cause of loss of unconsciousness? -
alcoholic hypoglycemia.
Previous esophageal varices and stigmata of CLD confirms he's a chronic alcoholic. And chronic alcoholics
are prone to hypoglycemia which may lead to LOC.
Pathological jaundice- within 24hours, after 14 days
Physiological jaundice- between 24hrs of life to 14days of life.

Child with features of UTI

Initial investigation - clean catch urine for MCS
Most appropriate - Abdominal USS

For bee stings,

Local itching- oral antihistamines
Large local reaction- topical antihistamine
Systemic involvement (stridor, shock, cyanosis)- IM adrenaline

IM adrenaline doses in anaphylaxis

For children, 0.25ml of IM Adrenaline 1:1000
For adults, 0.5ml of IM Adrenaline 1:1000

Sudden severe back pain on getting up from bed- disc prolapse

Sudden severe back pain radiating to the leg on lifting heavy object- disc prolapse
Treatment:
Analgesics, Physiotherapy, Encourage mobilization/activity.
In prolapse intervertebral disc, bed rest is not a treatment modality.

Menorrhagia, fatigue, pallor- do pelvic USS

Machine operator with depression, prescribed Fluoxetine- take it at night (cos of sedation)

Pea in the ear- remove under GA

Flies/insect in the ear- remove with alcohol
Pencil end in the ear- remove with hook
Usually in children with FB in ear- remover under GA

Terminally ill patient with rattling breath sounds- Give scopolamine, hyoscine or antimuscarinic drug.
Pregnant woman. Hb 10.5 -do nothing. Only give oral FeSO4 at levels <10.5.
Patient with liver mets having severe pain and cholestasis, doesn't want opioids due to constipation- give
cholestyramine.
Chest pain and breathlessness after exercise- do exercise ECG
Abdominal pain and rigidity in patient with diverticula disease- do X-ray chest (erect) it may show
pneumoperitoneum.

Right sided facial swelling with pain, tenderness and swelling "around the eye". No proptosis or
ophthalmoplegia- Periorbital cellulitis- give IV morphine and antibiotics.
Orbital cellulitis however Requires urgent referral to the ophthalmologist cos it may cause cavernous sinus
thrombosis. If there is pain "in the eye" with phthalmoplegia and proptosis, it is Orbital cellulitis.

Right upper quadrant pain, postCS in patient with preeclampsia- HELLP syndrome- LFT
Baby cried a lot last time he was immunized- Go ahead with immunization anyway.
PID on treatment, still getting worse. Do pelvic USS.
Annual incidence of Down's syndrome- 700

Glandular fever- infectious mononucleosis- Paul Bunnel positive- rash after giving Amoxyl or ampicillin to child
with sorethroat/flu/coryza symptoms.
Rash after giving penicillin for sorethroat- Erythema multiforme

Elderly man with large gallstone that is an incidental finding- Medical management- wait and watch. But if it is
symptomatic, do a lap cholecystectomy.

For TIA
Carotid Doppler- initial
Carotid angiography -most definitive

Young Waitress, pelvic pain, dysmenorrhea, menorrhagia, dyspareunia, Generalised pelvic tenderness without
peritonism. -Pelvic congestion syndrome.
Also called pelvic vein incompetence. Due to varicose veins in the abdomen/pelvis. Worsened by prolonged
standing. Relieved by lying. Common in waitresses, bartenders.
Postmenopausal Patient on tamoxifen. Worst side effect to look out for? Brown vaginal bleed- usually
signifies endometrial CA
Child with bright red staining of her pants post horse-riding -examine under anesthesia
Child just completed chemo for ALL.Has large scrotum.-Do CT abdomen (for secondaries)
Bloody diarrhea, abdominal vomiting after holiday/vacation abroad- Stool MCS
Child not breathing. Failure of intubation- Incision at cricoid cartilage (cricothyroidotomy)
Baby weighs 1.8kg at birth. Has hepatosplenomegaly and RASH. High bilirubin and liver enzymes- congenital
viral infection.
6month baby, LOC, jerky movements of hands and feet- Infantile spasm

Scenarios of wound management:

1. Fully immunized, with booster doses up to date
If wound is clean, do nothing.
If wound is dirty, give Ig only.
2. If not immunized at all/incomplete immunization/unknown status
If wound is clean, give vaccine
If wound is dirty, give Ig and vaccine

Travelers diarrhea-
Causes are (for <1wk is EColi, >1week is Giardiasis)
This is for acute watery diarrhea.
For bloody diarrhea, after a recent travel, it is Campylobacter, Shigella, Salmonella.

MS patient with papilloedema -monoocular blindness

8wk boy, jaundice, feeding well, gained 300g since birth, yellow stools, pale urine- Galactosemia
History of corrective surgery for cyanotic congenital heart disease in the past, now has early diastolic murmur
later in life: Pulmonary regurgitation
Acute headache, seeing haloes at night- tunnel vision
Alcohol dependent woman wants to quit- call social services
Drug addict wants to quit- call Community Mental Health
For drug addiction prevention- substance abuse team

Intermenstrual spotting. Friable cervix that bleeds on gentle touch.- chlamydia cervicitis- take swab- give
antibiotics.
Previous flu. Now with fever, cough. Bullous appearance on CXRay- Staph pneumo
Heart failure, pulmonary edema and pansystolic murmur a few days after M.I- Ruptured papillary muscle.
Blurred vision. Intermittent clumsiness. Pale optic disc. Brisk arm reflexes.-multiple sclerosis- do MRI
Pituitary tumor>10mm- do surgery. Seems <10mm, give Octreotide.
Alcoholic man with yellow ascitic fluid- decompensated cirrhosis

Dyskaryosis only- do colposcopy.

Dyskaryosis with abnormal cells- do cone biopsy.

Recent upper RTI. Altered speech. Facial weakness- Bell's Palsy

Elevated bicarbonate with Hypercalcemia -Milk alkali syndrome
Haloperidol and diuretics cause erectile dysfunction
Incoherent speech. Difficulty finding the right words. Good comprehension.- Broca's area affectation.
For tardive dyskinesia, give IM risperidone.
Fever,refusal to eat,mouth ulcer, hands&foot blisters- Coxsackie- feco oral transmission.
Elderly woman with urinary incontinence. Sterile urine culture. Normal urodynamic study.- do pelvic floor
exercises.
3yr old boy, difficulty in walking and skin lesions- Parvovirus.
Double vision, facial numbness- brainstem affectation
Most appropriate initial action in flail chest- oxygen first, before analgesia.

Once u see "shipyard worker", "asbestos exposure for years", now has cough, weight loss, SOB, and pleural
effusion. - Mesothelioma
To improve symptoms- do thoracocentesis
Most appropriate management- chemotherapy

Treatment for Candidiasis in Adults

1. In immunocompetent adults
-mild oral disease, use nystatin suspension
-severe oral disease, oral fluconazole
2. In HIV and immunocompromised adults with oral disease, use oral fluconazole
3. In esophageal candidiasis, use oral fluconazole.

Clostridium difficile- treated with Metronidazole and Vancomycin.

12wks after renal transplant with fever, abdominal pain, deranged renal function, renal biopsy showed
immune cell infiltrate and tubular damage- Acute rejection.
If it were >6months of transplant, it will be chronic rejection.

B12 deficiency seen in hypothyroidism

Formula-fed baby, jaundice, poor weight gain, pale stools- Biliary Atresia
A new murmur posthemicolectomy or after a prosthetic valve placement, shows infection, most likely
infective endocarditis. Do a blood culture, then an echo.
Fever, Cough, chest pain, purulent sputum- Gram Positive Diplococci
Spontaneous pneumothorax- give oxygen first, if trachea central.
Tension pneumothorax- needle thoracocentesis first

"Pulmonary edema after MI"- mitral regurgitation

"Straight heart border post stroke and AFib"- mitral stenosis
"Prominent neck pulsation post mitral valve replacement"- tricuspid regurgitation
"Advised to have antibiotic prophylaxis before dental procedure"- rheumatic MS

Hodgkin lymphoma patient having fever and neutropenia- give Piperacillin+Tazobactam

Any patient with febrile neutropenia in cancer, give iv broad spectrum antibiotics. If it doesn't work, add
Vancomycin.
If that fails, add antifungals to it.

Acute migraine, OA, Asthmatic with pain- give paracetamol

Post rectal resection pain- morphine
RA, gout- NSAIDs

Bipolar disorder
Lithium -1st line
Carbamazepine -2nd line

15yr old with Knee swelling following a fall. Not subsiding despite rest and analgesia, with palpable mass in
the left inguinal region- Erwing's sarcoma
Inability to extend all fingers at metacarpophalangeal and interphalangeal joints- Extensor digitorum.
Chronic RA patient on methotrexate and naproxen. Has microcytic anemia. Most likely cause? GI hemorrhage
gives hypochromic microcytic anemia

Most likely cause of microcytic anemia in adult men and postmenopausal women is GI hemorrhage. In
premenopausal women, it is menorrhagia.

Double vision climbing downstairs- Trochlear nerve

Double vision looking up- oculomotor nerve

Missing IUCD thread- do a speculum vagina examination first

Patient with femoral shaft fracture- splint first, give iv fluids, do X-ray femur and send blood for investigations

Prolapsed intervertebral disc

-analgesia
-encourage to be active

For heavy blood loss questions:

-for young women <20yrs, give COCP
-for sickle cell, give depot
-for others, mirena

Transpyloric plane -L1

Termination of spinal cord- Between L1 and L2

Inability to extend interphalangeal joint of thumb- Extensor pollicis longis

Inability to extend metacarpophalangeal joint of thumb- Extensor pollicis brevis

30yrs old woman, chronic diarrhea, mouth ulcers, low back pain, morning stiffness -seronegative arthritis
(arthritis due to inflammatory bowel disease)
Eclampsia means convulsions happening on a background of preeclampsia
Preeclampsia is pregnancy induced hypertension with proteinuria +/- edema
Even then, a patient with no history of hypertension in pregnancy that developed fits 6hours post partum has
eclampsia.

Iron pigment accumulation in the liver cell (hepatocytes)- hemochromatosis

Drusen and yellow spots in centre of retina- macular degeneration
Diabetic patient with new vessels in retina- laser photocoagulation
For Listeria meningitis, add IV amoxicillin & IV gentamicin to current medication.

1st person hallucination- hearing your own thoughts

2nd person hallucination- hearing one person talk to you
3rd person hallucination- hearing people talk to you

Dysmenorrhea and menorrhagia, no contraception- Mefanamic acid

Menorrhagia only, no contraception- Tranexamic acid
Dysmenorrhea and menorrhagia, no contraception- Tranexamic acid.
Dysmenorrhea and menorrhagia, for contraception- COCP, Or IUS.
IUS has almost no medical contraindications ( tho they rarely give young women or those with distorted
uterus ?fibroids),
COC is contraindicated in smokers, breast/ovarian/endometrial cancer, DVT, migraine, cardiac disease,
obesity, liver disease.

Focused Assessment with Sonography for Trauma FAST- for abdominal injuries
ABCD2 score- assesses risk of stroke in T.I.A
National Early Warning Score NEWS- assess severity of acute illness
CHAD2 score- assess risk of stroke in Atrial fibrillation
ROCKALL score- assess severity of upper GI bleeding

ST elevation in leads 1,11,111- Percutanous angiography

Pallor. Bluish discoloration when she goes out in cold. Reddish spots on her body. Symmetrical peripheral
arthropathy - Diffuse systemic sclerosis
Sleep apnea, daytime headaches, somnolence, decreased tidal volume & vital capacity- Motor Neuron disease
Intense feet rubor. Absent foot pulse. Amputated toe- Buerger's disease
Intermenstrual bleed. Last smear was one year ago and negative -Do another smear.
When u see an ectropion, request a swab. An ectropion is an infection.

Pregnant woman with fever rigor frequency dysuria. Pain initially in the abdomen, later radiating to right loin
with occasional uterine tightening- Acute pyelonephritis
Intermittent tension, dizziness, anxiety- We need "collateral information" to diagnose.

Rash on forehead, lesions have affected the cornea- Trigeminal nerve

Young RA patient on treatment for 3yrs. Normal ocular pressure. Absent red reflex in both eyes- Cataract.
Patient with abdominal Symptoms relieved by defecation- irritable bowel syndrome.

Whenever u see dyskaryosis, do a colposcopy; and if you see "abnormal cells" with dyskaryosis, do a cone
biopsy.
Hypertension. Sudden loss of vision. Swollen retina- CRVO

If it is an ST elevation in 11,111,avf- give aspirin and heparin

If it is an ST elevation in anterior leads (V1-V4), avl- give PCI (1st choice), Alteplase (2nd choice), or
Streptokinase (3rd choice)

Panic disorder
Acute presentation- rebreathing bag
Impending stressful experience- propranolol
Long term treatment- CBT, then SSRI

Heavy periods treatment (without adressing pain/giving contraception)- Tranexamic acid

Heavy Painful periods treatment (without giving contraception)- Mefanamic acid
Heavy painful periods with contraception- COCP, IUS. Choose depending on age(COCP is preferred for young
ppl) and contraindications (COCP is c/i in migraine, smoking, obesity, DVT, heart disease, hypertension and
fam hx of ovarian, breast cancers)
Branch of dominant coronary artery that supplies inferior septum- Left main stem
Anemia, dysphagia, "feeling of something stuck in the throat", "esophagus can't be negotiated beyond
cricopharynx"- PlummerVinson syndrome
Patient on dexamethasone for cancer has normal K+,low Na+ values -Dilution hyponatremia
Acute marginal branch- Artery supplying anterior right ventricular wall
Circumflex artery- Artery that "runs along the left AV groove)
Pansystolic murmur post MI- mitral regurgitation

Right sided colon cancer- weight loss, occult blood, anemia

Left sided colon cancer- constipation alternating with diarrhea
Pregnant woman never had fits or high BP in pregnancy. Now has fits 6hours after delivery of term baby-
Eclampsia
Patient in labour. Liquor contains meconium. - take fetal scalp blood sample
Patient in labor. Has shoulder dystocia -give episiotomy
28wks Pregnant woman with constipation and hard stools- fibre diet

Young girl with heavy pv bleeding-

Initial: pelvic USS
Diagnostic: exam under anesthesia
Young girl with frequency, dysuria, urgency-
Initial: Clean Catch Urine for C&S
Diagnostic: USS KUB

Middle aged man with confusion and drowsiness- Cryptococcus

Middle aged man with persistent watery diarrhea- Cryptosporidium

Unconscious. Rescued from fire. No evidence of burns/external injury/soot- Intubate and ventilate. Altered
sensorium and loss of consciousness after being in a burnt building is an indication to Intubate and ventilate.

Repeated pancreatitis attacks. Dementia, loss of proprioception.- Cobalamin

For the preferred approach in myomectomy,

Look at the bigger sized fibroid and its location, that should guide your choice.
For Submucosal fibroids- vaginal hysterectomy,
For intramural/subserosal fibroids- abdominal hysterectomy

Visual hallucinations. Parkinsonian signs. Cognitive impairment- Lewybody dementia

Sudden loss of vision. Swollen retina- CRVO
Heavy bleeding. Uterine thickness >14mm - UAE
Dot&blots, Red swollen disc, Swollen retina, Flameshaped hemorrhage- CRVO
12hrs umbilical pain, anorexia, nausea, "not moved bowel in 24hrs"- Meckel's diverticulum

Stepwise Management of eczema:

Emollients
1% hydrocortisone
0.05% clobetasone
0.1 % Beclomethasone
Bethametasone

Fever with one joint pain- septic arthritis

Fever with multiple joint pains- osteomyelitis
For Colles' fracture- do a closed reduction
Generalised itching and tiredness with heavy menstrual periods- IDA

Hoarseness of voice post thyroidectomy.No phonation problems preop.-Do Laryngoscopy

Chronic cough with copious purulent sputum- Bronchiectasis
Fever, chest pain, cough, perioral vesicles, hx of splenectomy last year- Pneumococcal pneumonia.
Fever, cough, breathlessness that girlfriend also has. -chlamydia pneumonia

Returned to UK from UAE with dry cough, lymphopenia & bibasal consolidation BBC-
Legionella. (BBC is Legionella.)
Dry cough with upper lobe cavitations- Klebsiella
Productive cough with upper lobe cavitations -TB
Dry cough with patchy consolidation - Mycoplasma
Nystagmus, loss of corneal reflex with the "DVT" symptoms of Meniere's dx- Acoustic neuroma
Itchy scaly rash over wrists with white streaks, also over buccal mucosa- Lichen Planus
Hemiparesis with UMNL type of facial palsy with normal tone/reflexes- lacunae stroke

Fever, headache, petechia hemorrhage in temporal & inferior frontal lobe- Herpes simplex encephalitis
Dense hemiplegia, dysphasia, homonymous hemianopia- Middle cerebral artery
Pulsus bisferiens suggests HOCM hypertrophic obstructive cardiomyopathy
HPV associates with Verruca Vulgari
Staph aureus- Organism most likely to cause infection in aortoiliacfemoral reconstruction

"Non fluent effortful speech with dysarthria"- MRI frontal lobe

If u have decreased values of mcv, ferritin, serum iron and raised tibc- I.D.A
"Areas of yellow brown discoloration on nailbed"- psoriasis
Syphyllis typically causes- Orchitis

Nonsteroidal drug that inhibit mast cells from producing histamine- Sodium Nedocromil
Exercise induced asthma- sodium cromoglycate
If exerciseinduced before, but now having asthma at rest or in sleep- Treat as any regular asthma patient.
Follow the ladder of asthma treatment.
Ladder of asthma treatment:
-SABA
-Inhaled steroids.
-LABA
-Increase dose of inhaled steroids
-Oral steroids

Bronchial carcinoma with histology of "large polygonal or giant multinuclear cells"- Large Cell Carcinoma.

Epigastric pain postC.S- HELLP syndrome- do LFT

<10mm pituitary tumor- give octreotide
>10mm pituitary tumor- do surgery

COPD patient on many drug treatments but worsening- Assess for long term O2
COPD patient on drug +O2 treatment but worsening- Give nasal IPPV
Acute headache, seeing haloes at night- Glaucoma- Tunnel vision
Central Scotoma, optic nerve inflammation on MRI- Optic neuritis

Dilated pupils+/- extrasystole......it is amytriptyline

Extrasystole alone- digoxin
Yellow vision/haloes +/- extrasystole ....digoxin
Yellow tinge- beta blockers

Asthma, heart failure, eosinophilia- P Anca- Chaug Strauss

Epistaxis majorly- C Anca
Oculomotor palsy alone- Midbrain lesion
Facial numbness & double vision- Oculomotor and facial palsy together- Brainstem lesion

"Worries excessively wit sleep disturbances most days over months"- Generalised Anxiety Disorder
"Episodes of palpitations" "perioral tingling and paraesthesia"- Panic attacks
Patient with TIA- use Clopidogrel for life
Podocyte fusion- Minimal change disease
Rash on buttocks/extensor surfaces with hematuria- HSP
HSP is similar to ITP but ITP has low platelet counts.

Extradural hematoma- middle meningeal artery

Subdural hematoma- bridging cerebral veins
Pediatric CPR is 15:2, adult CPR is 30:2
Absence seizures- child went blank with upward rolling of eyes
Discharge from ear/nose after fight/trauma- CSF
yellow ascitic fluid- cirrhosis

Ileal resection- B12 deficiency

Duodenal resection- IDA
Jejunal resection- Folate
Code: (JIDe is FBI)

Progressive decrease in vision in a young person- Open angle glaucoma, Retinitis Pigmentosa.
Retinal detachment- scleral buckling
New vessel formation- laser photo coagulation

Short QT- Hypercalcemia

Tall tented T waves, wide QRS- hyperkalemia-give Ca Gluconate OR Ca Chloride OR Insulin with dextrose

"Bilateral shrunken kidney with smooth normal pelvic calyces" and hypertension- CGN or bilateral renal artery
stenosis-
A simple way to differentiate is:
Age- CGN happens in older people >40, RAS in younger people
Elevated BP- RAS causes an extremely elevated BP compared to CGN
Proteinuria- This is marked more in CGN.

Intra abdominal bleed PostOp - usually within 24hours (reactionary)

anastomotic leak PostOp - usually 1-3days

Man has stroke. CT shows no hemorrhage. ECG shows A-fib. Best prophylaxis- Warfarin
Weight loss. Loss of appetite. Supraclavicular mass.- Gastric carcinoma
Sudden loss of vision. Normal optic disc.- Retinal detachment.
Old woman, "changed glasses a number of time"- Cataract

Lung cancer patient, urinary retention, postural hypotension, hyporeflexia, sluggish pupils- Paraneoplastic
syndrome.

Child brought by mother with bruises on buttocks. Had URTI 2weeks ago. What inv will u do? Do a coagulation
profile.
This is most likely HenochSchonlein purpura. Rash/petechiae on buttocks following URTI suggests that. NAI
usually hav more details(fractures etc) and patient are brought by carer, not parents.

Prominent a waves- atrial myxoma

Fever, dry cough, breathlessness with a clear chest on examination- Pneumocystis Carinii
Obesity with daytime somnolence - OSAS

Best investigations to know if a woman is ovulating or not:

If it is a regular 28day cycle- day 21 progesterone
If it is a regular 28+x day cycle- day 21+x progesterone
If it is an irregular cycle- day3 FSH

Contraception in perimenopausal women:

<50yrs old: contraception for 24months after LMP
>50yrs old: contraception for 12months after LMP

Patient with Patent Foramen Ovale

Initial: Transthoracic Echo
Definitive: Transesophageal echo

Elderly woman with UTI. Treated with antibiotics and developed UTI. -Pseudomembranous Colitis. - Treat with
Vancomycin or Metronidazole.
Cervical lymphadenopathy with splenomegaly- NHL
Hematuria, proteinuria following bloody diarrhea caused by E.Coli- H.U.S

Ipsilateral UMNL/Cerebellar lesion with contralateral pain temperature impairment- Lateral medullary
syndrome.
Patient who smokes, develops DVT post-splenectomy, what's the biggest risk for having DVT- Splenectomy

Diarrhea, abdominal bloating, elbow rash, villi shortening and lymphocytosis on jejunal biopsy- Celiac disease.
Young woman, lemon-yellow skin, high MCV, diarrhea weight loss- Pernicious Anemia (from Graves' disease).
Toxoplasmosis -Sulfadiazine+Pyrimethamine OR Trimethoprim
Any solid organ tumor can give Hypercalcemia

Looking unkept agitated malnourished & nervous- heroin OD

Nasal signs (sneezing, epistaxis, perforated septum), sweating, shivering- cocaine OD
Pinpoint pupil, hypotension, bradypnea, needle marks- Opioid OD

AC>BC or AC normal, BC reduced- normal hearing or sensorineural deafness

CSSO code: Conductive deafness, same side; Sensorineural deafness, opposite side.

<50yrs -Buerger's disease

>50yrs -Chronic Limb Ischemia

Travelers diarrhea
-Watery: if <1week, it is EColi, if >1week, it is Giardiasis
-Bloody: Campylobacter, Shigella

For stress incontinence: (in order of importance)

-Pelvic floor exercise
-Drugs eg Duloxetin
-Surgical repair

Double vision, facial nerve lesion- Brain stem

Oculomotor nerve lesion only- Midbrain
Patient had M.I a day ago. Rapid pounding & fast breathing today- VT
Corneal ulcer with prolonged discharge- Pseudomonas

For mild dehydration in kids, ORS 60mEq/l

For severe dehydration in kids, IV 0.9% N/S bolus

For myomectomy options:

Look at the types of fibroids the patient has.
1. If the larger one is subserosal/intramural - do abdominal myomectomy
2. If the larger one is submucous- do vaginal myomectomy

Boy with plenty of transparent sticky liquid from eyes. Calm intact mucosa of lids and conjunctiva- Antibiotics
only
For malignant obstruction of urinary tract- Percutanous nephrostomy or ureteric stenting
Pregnant woman, smoker, whitish marks on tongue- Candidiasis
Part of intestine most commonly affected by Crohn's - Ileosigmoid (esp ileum)

best test to evaluate eradication of h.pylori- urea breath test

Best test to do if after months of PPI, no relief -OesophagoGastroDuodenoscopy

There are cases where the presentation of the patient -with multiple delusions and hallucinations- makes the
diagnosis of Psychotic depression or Schizophrenia very likely. Look out for any stressors or triggers(loss of
job, death of a loved one, etc) because that is the clincher, u will find it in depression, never in schizophrenia.

A fall on the outstretched arm can be Greenstick or Supracondylar fracture.

If the child feels mild tenderness on arm/elbow without any swelling, deformity, loss of pulsation, it is
Greenstick fracture (regardless of location).
If child feels swelling, deformity, loss of pulsation on the forearm (it is forearm fracture), if at elbow, it is a
Supracondylar fracture.

Severe blood loss causes hyponatremia majorly.

Patient comes from Europe/US to UK with night sweats, splenomegaly, cervical lymphadenopathy, fever-
Lymphoma. If patient comes from Africa or Asia (especially India or Thailand), with same symptoms, it is TB.

Treatment options for hot flushes-

-Hormone replacement
-Lowdose SSRI
-Clonidine
-Gabapentine

For bipolar disorder

-lithium
-anticonvulsant
-antipsychotics eg carbamazepine
For Trigeminal neuralgia
-Carbamazepine
-Gabapentine
-Amitryptilline

Unilateral tonsillar hypertrophy and tonsillar ulcer in elderly person- Tonsillar CA

Boy with red tender pinna following injury during rugby match.- give pain relief, not antibiotics. Otitis externa is
NOT trauma-induced.
Facial pain due to common cold is usually from Maxillary sinus.
Elderly man, weight loss, hoarseness of voice, upper mediastinum opacity- do LN biopsy
Elderly man, sudden collapse, recovered within minutes- do ECG (may be arrhythmia)
Sudden loss of vision. Hypertension. Swollen retina- CRVO

Early morning stiffness of small joints with eye pain- Scleritis (from RA)
Lower back pain and stiffness with eye pain- Iritis (anterior uveitis) from A.S
Flashes of light, Sudden loss of vision- Retinal detachment- Scleral buckling
New eye vessels formation- Photocoagulation
Acute headaches, seein haloes. Most likely eye defect- Tunnel vision
Sudden loss of vision, previous episode 1year ago that resolved on its own, Right upper limb paresis,
hyperreflexia- Multiple Sclerosis- give corticosteroids
In cardiac tamponade, give oxygen first before iv fluids.
In tension/spontaneous pneumothorax, do thoracocentesis/give oxygen first before analgesia.
RTA patient in ambulance, sudden deterioration of GCS- give oxygen.

Widespread diarrhea in town? E.Coli

For COPD, start with 24percent, then increase to 28percent if still hypoxia and hyper panic, then NIPV if no
improvement.

Commonest cause of IDA in adult men and postmenopausal women is GI bleeding. In premenopausal women
however, it is menorrhagia.
So a 40yr old woman with heavy blood loss, pruritus, pallor and tiredness has I.D.A
Alcoholics are at increased risk of heart failure due to thiamine deficiency that can cause wet beriberi and
lead to dilated cardiomyopathy

Mechanism of development and accumulation of ascites- Portal hypertension (DP)

Patient on chronic use of COCP going for surgery- do arteriography (cos OCPs cause arterial thrombosis)

You can't give fentanyl patch until u know the drug dose that controls patient's pain. Cos fentanyl patch is for
72hrs straight.
And u only move from one level to another on the pain ladder if a patient is not tolerating the current drug or
the pain is not controlled despite very high dose.

Most tumors have hyponatremia, Hypercalcemia.

patient got kicked in the groin/back, now has hematuria- do CT/IVU
Farmer with left arm pain with neuropathy affecting multiple areas in the arm, associated nodules and
purpura- Poly arteritis nodosa

Conn's- hypokalemia, hypertension- check aldosterone

Addison's -hyperkalemia, hyponatremia- check cortisol
Young man, weight loss, hypertension, anxiety, panic attacks- Pheochromocytoma
Middleaged woman checked visual acuity with local optician. 12hrs later developed severe pain/redness of
eyes- Anterior chamber affectation ?Glaucoma
Impaired vision, loss of color vision, light causes pupil to dilate- Retrobulbar Neuritis

study done in two hospitals for same number of cancer patients on treatment. Hospital A was noted to have
higher mortality than hospital B.- Observational Study
Patient "trapped under a rock/car" for hours, now has red urine. -Give IV fluids. If renal failure sets in, do
hemodialysis.

For type 2dm, give biguanides. If there is renal impairment, give insulin and ACEi/ARB (or CCB if none of those
is available). At serum Creatinine >200, don't give ACEi.

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Mofijur Rahman <rahman.orin89@gmail.com> Sun, 1 Nov 2015 at 3:20 am
To: md_hany@yahoo.com
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