PLAB Notes

 Be careful because a Mercedes Benz (Benzodiazepine side effects) may CRASH

Cognitive Impairment
Respiratory depression
Anterograde Amnesia
Sedation
Hypotension

 pCO2 high + Acidosis = Respiratory Acidosis

 pCO2 low + Acidosis = Metabolic Acidosis
 Bicarbonate low + Acidosis = Metabolic Acidosis
 Bicarbonate high + Acidosis = Respiratory Acidosis
 Upper airway FB inhalation – stridor, gagging, drooling of saliva – Laryngoscopy for Dx
 Lower airway FB inhalation – SOB, wheezy chest – Bronchoscopy for Dx
Type TSH T4
Hyperthyroidism Low High
Hypothyroidism High Low
Subclinical Hyperthyroidism Low Normal
Subclinical Hypothyroidism High Norm
Secondary Hypothyroidism Low Low

 Multi nodular goitor

Toxic Non-Toxic
Produces high amount of thyroid hormone Produces normal amount of thyroid hormone
HOT COLD
Definitive treatment – Radioiodine Surgery

 Cushing Syndrome – Medication to inhibit Cortisol Synthesis

Metyrapone
Ketoconazole
Mitotane

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  Sodium and Potassium Pattern
Type Sodium Potassium
Primary Adrenal Hyponatremia Hyperkalemia
Insufficiency
Secondary Adrenal Normal Normal
Insufficiency
Conn’s Hypernatremia Hypokalemia
Cushings Syndrome Hypernatremia Hypokalemia
Congenital Adrenal Hyponatremia
Hyperplasia

 Bloods
Type Osteporosis Paget’s Disease Osteomalacia
Serum Calcium Normal Normal Low
Serum Normal Normal Low
Phosphate
ALP Normal High High

Paget Disease (usually present unilaterally) = Chronic change of the nipple with:
Itching, Erythema, Scale formation, Erosions, Nipple discharge including bleeding, Inverted
nipple.

Type ALP Calcium

Bone metastasis High High
Hyperparathyroidism High High
Ostemalacia High Low

 Addison disease – ACTH stimulation test (Synacthen test)

 High dose Dexamethasone suppression test – Cushing syndrome
 Water deprivation test – Diabetes Insipidus
 Iron profile – Haemochromatosis
 Addison Disease
UK cause is – Autoimmune

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 Worldwide cause is – TB
 Hypothyroidism
UK cause is – Autoimmune
Worldwide cause is – Iodine deficiency
 DKA
Systolic BP < 90 mmHG – 1L of 0.9% sodium chloride in 10 to 15 minutes
Systolic BP > 90 mmHG – 1L of 0.9% sodium chloride over 1 hour
Administering 0.9% sodium chloride over 6 hours in the acute management is never the
answer
 One of the established complications of DM is autonomic neuropathy. Also, remember one
of the common side effect of Metformin is
 Polymyositis elevates creatine kinase with weakness.
 Polymyalgia rhuematica elevated ESR with normal CK but more stiffness of proximal
muscles and joints.
 Osteomalacia elevated ALP with low calcium and phosphate
 Paget disease elevated ALP only, normal calcium and phosphate
 Osteoporosis usually normal ALP, calcium, and phosphate
 Multiple myeloma elevated calcium and normal ALP
 Thyroid crisis medication – 3Ps - PTU, Propanolol, Prednisolone
 Diabetis Insipidus – Types (central & Nephrogenic), Initial test : 24 hours urinary collection
> urine osmolality > fluid deprivation test & IM Desmopressin.
 Drug induced hepatitis – Elevated Bilirubin, Massive elevated ALP and AST
 The target HbA1c of one drug is < 48. If HbA1c > 58, start 2 drugs. The aim of 2 drugs is
HbA1c < 53, with no hypoglycaemic attacks. If there were attacks, stop the second drug.
 Treatment for suspected Adrenal crisis:
1. Hydrocortisone IV
2. Normal saline infusion
3. Cardiac and electrolyte monitoring
4. Broad spectrum antibiotics if an infection is suspected as the precipitant cause
5. Hydrocortisone in 5% via IV infusion
6. Weaning off of IV steroids and commencing oral steroids
 Stay away from 0.45% normal saline as a junior doctor this is out of your clinical judgement.
Generally, a senior advice will be required. 0.45% normal saline is usually given in
hypernatremia along with dextrose and potassium.
 Subclinical Hypothyroidism

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 TSH is high but T4 is normal
Repeat TSH blood test in 3 months. If the test shows subclinical hypothyroidism again,
take action
TST is raised but below 10 miU/L (2nd test, 3 months apart)
1. Asymptomatic patient – No treatment
2. 65 years and above - No treatment
3. Symptomatic patient + below 65 years of age – Consider Levothyroxine
TST is raised but above 10 miU/L (2nd test, 3 months apart)
1. Consider Levothyroxine
 Hyperparathyroidism
Types PTH Calcium Phosphate
Primary Elevated Elevated Low
Secondary Elevated Low/Normal
Tertiary Elevated Elevated Elevated

 Primary Hyperaldosteronism = Hypokalemia + Hypertension

In exam, if rennin levels are not mentioned in the stem, then you should choose primary
hyperaldosteronism unless there is something in the stem to suggest secondary
hyperaldosteronism e.g. hepatic disease, diuretic, neprotic syndrome or abdominal bruit.
Think of Conn’s Syndrome:
HTN associated with Hypokalemia
Refractory HTN e.g. despite 3 anti-HTN drugs
HTN occurring before age 40

 Diabetes Insipidus = Urine osmolality low, Plasma osmolality high

After fluid depreviation, if plasma osmolality > 305, the patient has Diabetes Insipidus
Urine Osmolality Central Diabetes Insipidus Nephrogenic Diabetes
Insipidus
After fluid depreviation Less than 300 Less than 300
After desmopressin Greater than 800 Less than 300

 Diabetic patient
If medication should be started, Metformin is the initial one to think about.

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SGLT-2 inhibitor (Empagliflozin, Dapagliflozin) should be prescribed in addition to Metformin in the
presence of heart failure.
Pioglitazone is contraindicated in heart failure.
If the patient has a smoking history nad is frequently exposed to occupational chemotherapeutic
agents like hair dyes, do not pick Pioglitazone as an option because of high risk of bladder cancer.
 ACEI mnemonic
A - Angioedema
C - Cough
E – Electrolyte (K+)
I - Increased

 Spironolactone is a potassium sparing diuretic and Ramipril is ACEi. Both can cause
hyperkalemia.
 Phaeochromocytomas – 24 hour urine metanephrines is the initial investigation of choice. If
urine metanephrinesis not seen as part of the options, the next best would be urinary
catecholamines or urinary vanillylmandelic acid.

 Impaired glucose tolerance:

1. Fasting plasma glucose concentration of less than 7.0 mmol/L, And
2. 2-hour oral glucose tolerance test of 7.8 or more but less than 11.1 mmol/L

Plasma glucose test Normal Pre-diabetic Diabetes

Random Below 11.1 - 11.1 or more
Fasting Below 5.5 6.1 to 6.9 7.0 or more
2-hour post-prandial Below 7.8 7.8 to 11.0 11.1 or more

HbA1c Normal Pre-diabetic Diabetes

HbA1c Below 42 (6.0 %) 42 to 47 (6.0% to 6.4%) 48 (6.5% or more)

 Management of hypercalcaemia includes IV fluids, followed by bisphosphonates like

Pamidronate or Zoledronate IV.
 Hearing Test (Children)
Below 6 months Otoacoustic Emissions (OAE)
Audiological brainstem responses (ABR)

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6 months to 18 months Distraction test
18 months to 24 months Visually reinforced audiometry (VRA)
2 years to 4 years Conditioned response audiometry (CRA)
Speech discrimation
5+ years Pure tone audiometry (PTA)

 Tonsillectomy (715233)
>7 episodes/year for 1 years
>5 episodes/year for 2 years
>3 episodes/year for 3 years

 Centor criteria
Score 3+ then give antibiotics.
1 score for each point.

 Meniere’s Disease
Acute attack medication – Prochlorperazine (other anti-histamine can alse be used – Cinnarizine,
Cyclizine, Promethazine)
Prophylaxis – Betahistine
 Causes of Vertigo
Type URTI history Vertigo Hearing Loss Tinnitus
BPPV - Yes - -
Meniere Disease - Yes Yes Yes
Vestibular Neuritis Yes Yes - -
Labyrinthitis Yes Yes Yes +/-
Meniere Disease = Prevention of attack = Betahistine

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Meniere Disease = Termination of attack = Prochlorperazine
BPPV vertigo less than <30 seconds.
Meniere’s disease vertigo last 2-3 hours.
Vestibular Neuritis & Labyrinthitis vertigo last several days.
 Acoustic Neuroma
Investigation Management
- MRI of the cerebellopontine angle (gold - Microsurgery (most common)
standard)
- Stereotactic radiosurgery
- Audiometry

 Cranial Nerve VIII : Hearing loss (Sensorineural deafness), vertigo, tinnitus

 Cranial Nerve V : Absent corneal reflex
 Cranial Nerve VII : Facial Palsy
 Acoustic Neuroma = Hearing loss, tinnitus, vertigo points towards an affected
vestibulocochlear nerve. Acoustic neuroma could have these set of symptoms in which
case MRI of the internal auditory meatus would reveal a benign tumor at the
cerebellopontine angles causing their effect by exerting pressure on the surrounding
structures.
 Otitis Media – OM can look retracted or with a bulging tympanic membrane. It can look dull
grey or yellow (bluish grey) with the presence of an air-fluid level.
Flamingo pink (Schwartz sign) is Otosclerosis ; Wheel cart sign of tympanic membrane is Acute
suppuratives OM.
 Otitis Externa is caused by Stap. Aureus – Treatment = Flucloxacillin, topical gentamicin,
topical gentamicine with hydrocortisone.
 Perichondritis is caused by Pseudomonas Aeruginosa – Treatment = Fluoroquinolone
 Vestibular neuritis is the inflammation of the vestibular nerve whereas Labyrinthitis involves
vestibular nerve and the labyrinth.
Both produce vertigo and nystagmus however labyrinthitis has hearin loss and tinnitus which is not
a feature of vestibular neuritis.
 Acoustic Neuroma & Presbycusis = Sensorinueral Hearing loss
 Otosclerosis = Conductive hearing loss
Most common cause of progressive deafness in young adults
Usually presents between 15 and 35 years of age
50% have positive family history
Bilateral in 80% of the cases
Other symptoms include tinnitus and vertigo

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It is progressive
Management involves surgery (stapedectomy or stapedotomy) or bilateral hearing aids for those
not fir for surgery.
 Peritonsillar Abscess (Qunisy)
Sore throat Hot potato voice Trismus Uvula deviation Fever
Peritonsillar bulge Dysphagia Fetor Drooling Pain localized to
one side of the
throat

Management = IV antibiotics (benzylpenicillin), needle aspiration, incision and drainage.

 Tonsilitis
Bacterial Infection Viral Infection
Red swollen tonsils Red swollen tonsils
Throat redness Throat redness
Swollen uvula
Whitis spots
Grey furry tongue

 Acoustic Neuroma

Any symptoms tend to develop gradually and often include:

hearing loss that usually only affects 1 ear
hearing sounds that come from inside the body (tinnitus)
the sensation that you're moving or spinning (vertigo)

A large acoustic neuroma can also sometimes cause:

persistent headaches
temporary blurred or double vision
numbness, pain or weakness on 1 side of the face
problems with limb co-ordination (ataxia) on 1 side of the body
voice changes or difficulty swallowing (dysphagia)
 Malignant Otitis Externa
Life threatening infection of the external ear canal causing osteomyelitis of the temporal bone.

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Severe pain Purulent discharge Vertigo

Unilateral Conductive Ipsilateral Facial palsy High Fever

hearing loss

Granulation tissue is seen on floor of the ear canal (In Cholesteoma granulation tissue is seen on
the upper part of the tympanic membrane)
Management = Urgent referral to ENT
 Samter Triad = Nasal Polyp + Asthma + Aspirin sensitivity
Presentation (RAN) = Rhinorrhoea + Anosmia + Nasal obstruction
 Nasal steroids can be used to shrink nasal polyps. The fact that the polyps are bilateral is
reassuring, as unilateral polyps should always raise the concern of malignancy.
Other treatments for polyps if nasal steroids fail include oral steroids or nasal polypectomy.
 Mastoiditis is an infection of mastoid hair cells which leads to severe otalgiaand post-
auricular swelling.
Feature Management
Post-auricle swelling and erythema Ear swab if discharge is present
Loss of post-auricle sulcus IV antibiotics
Fever CT scan of the pertous bone and brain if
abscess suspected or if fails to improve after 24
hours of IV antibiotics
Otalgia
Discharge from ear
Headache
Hearing loss

 Tonsilitis
For viral – just give paracetamol
For bacterial – Phenoxymethylpenicillin (Clarithromycin if penicillin allergy)
 The p value is a number, calculated from a statistical test, that describes how likely you are
to have found a particular set of observations if the null hypothesis were true.
P values are used in hypothesis testing to help decide whether to reject the null hypothesis. The
smaller the p value, the more likely you are to reject the null hypothesis.
P < 0.05 would be considered statistically significant.
P < 0.01 indicates very strong evidence
A value of more than 0.1 would mean that it is statically insignificant.

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 Absolute Risk (AR) = the number of events (good or bad) in a treated (exposed) or control
(non-exposed) group, divided by the number of people in that group
 Absolute Risk Reduction (ARR) = the AR of events in the control group (ARc) - the AR of
events in the treatment group (ARt)
 Relative Risk (RR) = ARt / ARc = (a/(a+b)) / (c/(c+d))

RR = risk of disease in exposed / risk of disease in unexposed

 Relative Risk Reduction (RRR) = (ARc – ARt) / ARc; or RRR = 1 – RR

 Number Needed to Treat (NNT) = 1 / ARR
 Number Needed to Harm (NNH) = 1 / (ARt – ARc)
 Odds Ratio (OR) = (odds of the event in the exposed group) / (odds of the event in the
non-exposed group) = (a/b)/(c/d) = ad/bc (from 2x2 table, see below)
 Hazard Ratio (HR) = (risk of outcome in exposed group)/(risk of outcome in non-exposed
group), occurring at a given interval of time
 Chronic Pancreatitis investigation – Faecal elastase
 Peptic Ulcer in Acute setting:
Steps Epigastric pain with Hematemesis No upper GI bleed
1 Hematemesis + shock Still considering a perforated
peptic ulcer
2 Resus first (IV fluids & red cell transfusion if Erect chest X-ray
necessary)
3 Remember to treat like an upper GI bleeding
4 Urgent Endoscopy

 Site of Absorption
Duodenum Iron
Jejunum Most nutrients
Ileum Bile salts + B12

 Diseases (Crohn’s, Coeliac) or surgery which affects these areas can give rise to the
following:
Duodenum Microcytic anemia
Ileum Megaloblastic anemia or gallstones

 Achalasia Investigation:
Most initial : Endoscopy
Gold Standard: Manometry. If manometry unavailable, Barium swallow

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Treatment of choice: Heller myotomy. If patient is unfit for surgery then Pneumatic dilation.
 Which 2 medication can worsen esophagitis and GERD? NSAIDs & Bisphosphonates.
Also, one of the major side effects of Bisphosphonates is Osteonecrosis of Jaw.
 Medication
GERD PPI
(Omeprazole + Amoxicillin + Clarithromycin)
Diffuse esophageal spasm Nitrates
CCB (Nifedipine)
Botulinum toxin injection
Autoimmunie Hepatitis Prednisolone + Azathioprine
Primary Biliary Cirrhosis Ursodeoxycholic acid, Cholestyramine
Primary Sclerosing Cholangitis Supportive, Liver transplant for end-stage
Giardia Metronidazole
Cryptosporidiosis HAART, Nitazoxanide
Pseudomembranous Colitis Oral Vancomycin (First Line)
Pernicious Anemia Hydroxocobalamin (IM)

 Plummer Vinson Syndrome

Triad = Iron deficiency anaemia + Oesophageal webs + Atrophic glossitis
 Crohn’s Vs Ulcerative colitis
CD UC
Affects Ileum Affects rectum
Induce remission: Induce remission:
Glucocorticoid (if contraindicated, then use Budesonide *Topical aminosalicylates e.g. rectal
or Aminosalicylate (e.g. Mesalazine) if mild to moderate masalazine
disease.
*If not responding, then add 5-ASA (e.g.
Maintain remission: oral mesalazine)
Azathioprine or Mercaptopurine or Mercaptopurine *If still not responding then add oral
prednisolone
Maintain remission:
*Oral aminosalicylates e.g. mesalazine
*If remission is not well maintained,
consider oral azathiprine or

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 mercaptopurine
*If severe colitis, treat in hospital with IV
steroids

 Faecal Calprotectin – Differentiates inflammatory bowel disease from Irritable bowel

syndrome
 Primary Biliary Cirrhosis = 3Ms
Anti-Mitochondrial antibodies, Middle-aged female, IgM
 Serological testing for Coeliac disease
Suspected Coeliac disease
Total IgA and IgA tTG tested as first choice
Weakly positive/ Equivocal IgA deficient

Request IgA endomysial antibiodies Request IgA tTG

 Esophageal Rupture
Mackler’s Triad = Chest pain + Vomiting + Subcutaneous emphysema
 Dysphagia + Initial investigation = Endoscopy
 Dysphagia + Diffuse oesophageal spasm/achalasia stem + Most appropriate investigation =
Barium swallow or Manometry
 Upper Abdominal Pain
Acute Pancreatitis Peptic Ulcer Biliary Colic
Tender epigastrium Reflux symptoms RUQ pain with radiation to the
Pain radiates to the back May have scapula
Fever melaena Secondary to gallstones
Vomiting No fever
Risk factors include gallstones and
alcohol
Bending forward provides temporary
relief
Acute Cholecystitis
Murphy’s sign (RUQ pain)
Fever
Vomiting
Raised white cell count
Think its biliary colic but with fever

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  Other abdominal pain
Appendicitis Renal Colic Acute Pyelonephritis
Generalised pain prior to Severe loin to groin pain Urinary symptoms such as
localising to RLQ Haematuria dysuria, increased frequency,
Rebound tenderness May have a history of previous or urgency
Unilateral loin pain
Fever renal stones
Fever
Rigours
Ectopic Pregnancy Ovarian Torsion Pelvic Inflammatory disease
RIF or LIF pain which radiates Severe pain at RIF or LIF Adnexal tenderness
to shoulders Usually with history of an Cervical excitation
Women who had their LMP ovarian cyst seen on US Fever
previously Young female
more than 6 weeks ago
History of sexually transmitted
Beta-hCG positive infection
Bowel Obstruction Abdominal Aortic Aneurysm Mesenteric Ischaemia
Rupture
Constipation Sudden onset of abdominal
Vomiting Severe pain in abdomen or pain
Abdominal distension back Systemically unwell
Not passing flatus Elderly Vomiting
Hypotensive History of atrial fibrillation or
history of hypotension
secondary to myocardial
ischaemia
Diverticulitis
Age usually 50 to 70 years old
LIF pain
Nausea and vomiting
Fever
Diarrhoea or constipation
Blood mixed with your stools
Raised WBC

 Motility problems
Intermittent motility dysphagia – Diffuse oesophageal spasm
Progressive motility dysphagia – Achalasia or Scleroderma
 Mechanical obstruction
Intermittent mechanical dysphagia – Oesophageal ring
Progressive mechanical dysphagia – Peptic stricture or oesophageal cancer
 Acute Fatty Liver of pregnancy (AFLP)
HELLP + Increased serum Ammonia + Low serum Glucose
 Halitosis in Pharyngeal pouch
 Mega oesophagus in Achalasia

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  Primary Biliary Cirrhosis Vs Primary Sclerosing Cholangitis
Primary Biliary Cirrhosis Primary Sclerosing Cholangitis
Autoimmune, Idiopathic Autoimmune, Idiopathic
FEMALE predominance MALE predominance
Association: Sjogren, Coeliac disease, thyroid Association: IBD (especially UC)
disease, Scleroderma (Autoimmune)
Pruritus, ALP Pruritus, ALP
Anti-mitochondrial Antibody (AMA) positive ERCP is most specific test
Management invloces ursodeoxycholic acid, Management involves liver transplant (mainstay
cholestyramine for end-stage disease), cholestyramine reduces
the itch

 Vitamin B12 and Folate deficiency

Causes Vitamin B12 deficiency Folate deficiency
Malabsorption Pernicious anaemia Poor bioavailability
Medical conditions Inflammation of small intestine Inflammation of small intestine
(celiac disease, tropical sprue, (celiac disease, tropical sprue,
Crohn disease) Crohn disease)
Gastric resection (for reasons of
obesity or cancer)
Inadequate dietary intake Low intake of cobalamin-rich Low intake of folate-rich foods
foods (usually vegetables)

 Haematogenous spread to the liver from lung is the most common route of metastasis.
TTF-1 is a protein seen by immune-staining which is used as a clinical marker of lung
adenocarcinoma.
 Proctoscopy investigation – rectal bleeding from internal haemorrhoids
 Hepatitis A
Shellfish are known reservoirs of hepatitis A.
In the UK, hepatitis A infection is a notifiable disease. This means that your doctor will need
to inform (notify) the health protection unit (HPU) in your area.
Highest risk areas of the world for HAV infection include the Indian subcontinent (in particular
India, Pakistan, Bangladesh and Nepal), Africa, parts of the Far East (except Japan), South
and Central America and the Middle East.
Risk factors Clinical features

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 Most people acquiring HAV infection do not The incubation period is 2-6 weeks with a
have risk factors but these include: mean of four weeks.
-Personal contact. There is a prodrome of mild flu-like symptoms
-Certain occupations (for example, staff of (anorexia, nausea, fatigue, malaise and joint
large residential institutions, sewage workers). pain) preceding the jaundice. Smokers often
-Travel to high-risk areas. lose their taste for tobacco. Diarrhoea can
-Male homosexuality with multiple partners. occur, particularly in children.Fever is not
-Intravenous drug abuse. usually common.
-People with clotting factor disorders who are
receiving factor VIII and factor IX This can progress to the icteric phase with:
concentrates.
-Dark urine (appears first).
-Pale stools (not always).
-Jaundice occurring in 70-85% of adults with
acute HAV infection.
-Abdominal pain occurring in 40% of patients.
-Itch or pruritus (usually with jaundice but can
occur without).
-Arthralgias and skin rash. These occur less
often (lower limbs and with a vasculitic
appearance).

Tender hepatomegaly, splenomegaly, and

lymphadenopathy may occur.

Specific antibody tests Liver enzymes

IgM antibody to HAV is positive with onset of Alanine aminotransferase (ALT) rises more
symptoms (usually about 3-4 weeks after than aspartate aminotransferase (AST) again
exposure but up to six weeks). The test is with onset of symptoms, about four weeks
sensitive and specific. It remains positive for after exposure. Levels usually return to
between 3-6 months (up to 12 months). It reference ranges over several weeks but can
remains positive in relapsing hepatitis. remain elevated for months.

IgG antibody to HAV appears soon after IgM Alkaline phosphatase rises with ALT and AST.
and persists for many years. In the absence of
IgM it indicates past infection or vaccination
rather than acute infection. IgG remains
detectable for life.

 Coeliac Disease
Autoimmune condition caused by sensitivity to gluten protein
Features: Chronic or intermittent diarrhoea
Steatorrhoea
Bloating, nausea, vomiting
Fatigue
Unexpected weight loss

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Iron, folate or B12 deficiency
In children, tapering growth may be seen
Complications:
Osteoporosis
T-cell lymphoma of the small intestine (rare)
Specific Auto-Antibodies:
Tissue transglutaminase (TTG) antibodies (IgA) are first-choice
Endomysial antibody (IgA)
Jejunal/Duodenal biopsy:
Villous atrophy
Crypt hyperplasia
Increase in intraepithelial lymphocytes

 Clostridium Difficile
Caused by use of Amoxicillin, Ampicillin, Co-amoxiclav, Cephalosporins, Clindamycin, Quinolones
Treatment = Vancomycin
 PEG (percutaneous endoscopic gastrostomy, is usually done in stroke patients who are at
risk of aspiration pneumonia or to decompress the stomach in cases of gastric volvulus.
 Pancreatitis
Faecal Elastase Chronic Pancreatitis
Faecal Chymotrypsin Chronic Pancreatitis
Serum Amylase Acute Pancreatitis
Faecal Calprotectin Inflammatory Bowel Disease

 Plummer Vinson Syndrome = Dysphagia + Glossitis + Postcricoid oesophageal web + Iron

deficiency anemia

 Which organisms can cause gastroenteritis?

Rotavirus Noroviruses

most common cause of viral gastroenteritis increased prevalence during colder months
in children
Symptoms begin 24–48 hours after infection and last
Most cases in the UK occur in winter and for 12–60 hours.
spring.
Sudden-onset nausea is followed by projectile
vomiting and watery diarrhoea.
Symptoms include watery diarrhoea and
vomiting with or without fever and There may be associated fever, headache,

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abdominal pain. Vomiting usually settles abdominal pain, and myalgia.
within 1–3 days, and diarrhoea within 5–7
days, but can persist for 2 weeks. spread by the faecal-oral route
It can also be transmitted by consumption of
spread by the faecal-oral route contaminated food (such as oysters) or water, or
contact with contaminated surfaces (such as toilets,
soft furnishings, or floors), and outbreaks are
common in semi-closed environments such as
schools, hospitals, care homes, and cruise ships.

Campylobacter Escherichia coli

jejuni and Campylobacter coli
highest in children under 5 years of age, with the
commonest causes of travellers' diarrhoea peak incidence in children aged 1–4 years.
in the UK.
fever, abdominal cramps, and vomiting.
asymptomatic in 25–50% of people or
transmitted through contaminated food, particularly
cause diarrhoea (which may be bloody),
meat, salad products, water, and unpasteurised
nausea, vomiting, abdominal cramps, and
milk. It can also be transmitted person-to-person by
fever.
direct contact (faecal-oral route), particularly in
usually associated with the consumption of households, schools and childcare settings, and
contaminated food and drink, such as care homes; by contact with infected animals
undercooked meat (especially poultry), (especially cattle, sheep, goats, and other
unpasteurised milk, or untreated water ruminants); or environmental exposure to
contaminated water.

Salmonellosis Shigella dysenteriae, Shigella flexneri, Shigella boydii,

and Shigella sonnei
Ingestion of contaminated food is the most
common source, such as red and white transmitted person-to-person by the faecal-oral
meats, raw eggs, milk, and dairy products. route, particularly in households, nurseries, and
schools
Typical features are watery and sometimes
bloody diarrhoea, abdominal pain, More rarely, it can be transmitted through
headache, nausea, vomiting, and fever. contaminated food, or sexually transmitted
(particularly in men who have sex with men).
occurs most commonly in children less than 5 years
of age, but infection can occur in all ages. Infections
peak in late summer in the UK.
Giardia intestinalis or Giardia lamblia

Giardiasis can be transmitted by person-to-

person spread by the faecal-oral
route; by contact with the faeces of infected
animals; by consumption of contaminated
food or drink; waterborne including
swimming in contaminated water; or by
sexual transmission, particularly among
men who have sex with men.
Many cases are associated with recent
foreign travel, particularly from South Asia,

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and it is the most commonly identified
pathogen in returning travellers with
prolonged diarrhoea.
ymptoms include diarrhoea,
malaise, abdominal pain, loss of appetite,
flatulence, bloating, and rarely nausea.
Malabsorption, weight loss, and faltering
growth may occur in children.

 Diverticulitis – complication of acute diverticulitis is a massive per rectal bleed which

warrants hospital admission.
 Common prophylactic antibiotics for an anterior resection of the colon = Cephalosporin &
Metronidazole
 Iron deficiency anaemia in a patient above 60 who is otherwise asymptomatic = Right-sided
colon cancer (Caecum)
 Anyone with shortness of breath and stridor after a very recent thyroidectomy needs their
sutures cut. A rare complication of thyroidectomy is upper airway obstruction secondary to
haematoma.
 Due to high risk of secondary bacterial infection, all patients with asplenia or hyposplenia
are recommended to receive the annual influenza vaccine.
 Pre-surgery give Total Parental Nutrition.
Post-surgery give Jejunostomy feeding tube or J-tube
 Hernia
Inguinal hernia = above the inguinal ligament and medial to the pubic tubercle/pubic symphysis
Femoral hernia = below the inguinal ligament and lateral to the pubic tubercle/pubic symphysis
 Diverticulitis disease complications:
Intra-abdominal abscess
Perforation and Peritonitis
Stricture and fistula formation
Intestinal obstruction
Sepsis
 Common Tumor markers
Ovarian cancer CA 125
Pancreatic cancer CA 19-9
Breast cancer CA 15-3
Prostatic cancer PSA

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Colorectal cancer CEA
Hepatocellular cancer, Teratoma AFP
Testicular Seminoma LDH

 Paralytic Ileus
Causes Clinical features
Prolonged surgery, exposure and handling of Nausea, Vomiting
the bowel
Abdominal distension
Peritonitis and abdominal trauma
Absent bowel souns
Electrolyte disturbances – Hypokalemia,
Hypercalcaemia
Anticholinergics or opiates
Immobilization
Imaging Treatment
Abdominal X-ray shows air-/filled loops of small NG tube to empty the stomach of fluid and gas
and/or large bowel if the patient is nauseated or vomiting
Adequate hydration by IV infusion
Maintain electrolyte balance
Reduce opiate analgesia
Encourge the patient to mobilize
Lactulose or erythromycin may help stimulate
bowel movement

 Internal Hemmorrhoids

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 No matter how terrible the haemorrhoids look, they do not need to be treated unless
symptomatic.
 Postoperative urinary retention occurs due to the effect of the spidural during a C-section.
If postvoid residual volumes on BLADDER SCAN (PVRVs) are 300-500 ml and patient
unable to void or uncomfortable, or if PVRV > 500 ml the usual management would be to
reinsert catheter.
 CT vs US
Painless jaundice, weight loss, (or perhaps vague epigastric pain, back pain) (red flag signs
where pancreatic cancer is suspected) – Pick CT scan
Jaundice with epigastric pain or right upper quadrant pain (basically, where gallstones) –
Pick US
This applies to both initial and appropriate diagnosis
 Laryngeal Nerve injury
Unilateral recurrent laryngeal nerve injury – Hoarsness
Bilateral recurrent laryngeal nerve injury – Aphonia and Airway obstruction
Supieror recurrent laryngeal nerve injury – Dysphonia (inability to create high-pitched sound
 Congenital Adrenal Hyperplasia = 21 Hydroxylase deficiency, Hyponatraemia,
Hyperkalaemia
Female – Ambiguous genitalia
Male – Penile enlargement, Hyperpigmentation
 Huntington’s Disease
Son’s risk = 50% Affected 1st generation offspring = 50%
Grandson’s risk = 25% Affected 2nd generation offspring where 1st

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 generation not tested yet = 25%
Carrier Status = 0% Unaffected 2nd generation offspring where 1st
generation not tested yet = 75%

 Neurofibromatosis (NF) – It is an autosomal dominant disease.

If 1 parent affected = 50% chance of child affected
Affected Mother
X x
Unaffected Father x Xx xx
y Xy xy

NF Type – 1 NF Type – 2
Present more with skin lesions Present more with CNS tumour
Café-au-lait spots Bilateral acoustic neuroma
Axillary/groin freckles Multiple intracranial schwannomas
Iris hamartomas Meningiomas
Scoliosis

 Alport Syndrome
Most commonly X-linked disease
Father passes on Y-chromosome, Mother passes on X-chromosome
If father is affected but the mother is not, chance of male child affected is nearly 0%
Features:
Kidney disease: Hearing loss: Eyes abnormalities
Haematuria + Proteinuria Sensorineural hearing loss
End stage renal disease

Affected Father + Healthy Mother = 0% chance of Male child disease

 A pregnant woman who is blood type O+ suffered with haemolytic disease of a newborn
when she was born. The likelihood of her 1st born having haemolytic disease of newborn is
0%. Remember haemolytic disease of a newborn is not a genetic condition.

 Genes & Associated Diseases

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BCL2 B cell lymphoma
Apolopoprotein E (APOE) Alzheimer’s
FBN1 Marfan Syndrome
NOTCH1 t-cell leukaemia
HOXB13 Prostate cancer

 X-Linked recessive disorder

X- Linked recessive
Duchenne muscular dystrophy
Becker muscular dystrophy
Haemophilia A and B
Lesch-Nyhan syndrome
Red-green color blindness
Hereditary Haemochromatosis (HHC)

 Chorionic Villus sampling = 11 to 14 weeks

 Amniocentesis = 15 to 18 weeks

 Autosomal Recessive
Child has 25% chance of inheriting the genetic condition if BOTH parents are carriers of the faulty
gene.
Cystic fibrosis
Sickle cell anaemia
Thalassaemia
Haemochromatosis
 Autosomal Dominant
Child has 50% chance of inheriting the genetic condition if ONE parent has the mutation
Huntington
Autosomal dominant polycystic kidney disease
Neurofibromatosis
Von Willebrand disease
Hereditary spherocytosis
 X-Linked Dominant

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Child has a 50% chance of inheriting the genetic condition if MOTHER has the mutation
(MOTHER would also be affected by the disorder). Female child has 100% chance of inheriting
the genetic condition and male child has 0% chance of inheriting the genetic condition if FATHER
has the mutation (FATHER would be affected by the disorder).
Fragile X-syndrome
 X-Linked Recessive
Male child has a 50% chance of inheriting the genetic condition if MOTHER is a carrier. Female
child has a 50% chance of becoming a carrier if MOTHER is a carrier. X-linked recessive
conditions do not affect females to a significant degree as the other X-chromosome would most
likely be normal can compensate for the mutated chromosome.
Haemophilia
Duchenne muscular dystrophy
G6PD deficiency

 Cervicitis
Chlamydia N. Gonorrhoeae
Doxycycline 100 mg BD for 7 days (1st line) Ceftriaxone 1g IM injection single dose or
Azithromycin 1g single dose + 500mg OD for 2 Ciprofloxacin 500mg oral single dose
days (In pregnancy + 2nd line)

 Pelvic Inflammatory Disease (PID)

Outpatient

Metronidazole 400mg BD for 14 days + Ceftriaxone 1g IM single dose + Doxycycline 100mg BD

for 14 days
Inpatient
IV ceftriaxone + IV doxycycline + Oral Metronidazole

 Vaginal Infections
Trichomoniasis Bacterial Vaginosis Vulvovaginal Candidiasis
Yellow-Green discharge Grey-White discharge Thick White discharge
Frothy, offensive smell Fishy smell Cheese-like
Vaginal itch Clue cells Odourless
Strawberry cervix Whiff test + (potassium Vagianl itching
hydroxide)
Vaginal pH > 4.5 Vaginal pH 4-4.5
Vaginal pH > 4.5
Treatment – Oral Treatment – Topical

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Metronidazole Treatment – Oral Clotrimazole or oral
Metronidazole or oral Fluconazole
All sexual partners need to be
Clindamycin
treated and followed up as
well.

 Syphilis
Primary Secondary Tertiary
Chancre – Painless ulcer at the Often appears 6 weeks after the Gummas
site of sexual contact beginning of the primary lesions or (granulomatous
not appear for several months lesions can occur in
Local non-tender lymphadenopathy
any organ but most
Systemic symptoms: fever,
In women, they are found on the commonly affect
lymphadenopathy, headaches,
vulva, labia and can also be found bone and skin)
malaise
on the cervix or within the anal
Cardiovascular
canal Generalized polymorphic rash often
syphilis – Ascending
affects the palms, soles and face
Aortic Aneurysms,
Papules enlarge into condylomata Aortic regurgitation
lata in moist warm areas
Neurological Syphilis
– Tabes dorsalis,
dementia

Summary for EXAM:

Penile ulcer present – Pick darkfield microscopy or PCR of penile ulcer
Penile ulcer healed but mouth ulcer present – Pick PCR of mouth ulcer (if not present, pick
serology). Remember: Dark field microscopy is not suitable for oral ulcers
Penile ulcer and mouth ulcer healed – Pick serology
 Catheter Infection
If there is a significant infection and source is likely the urinary catheter:
Send a catheter specimen urine to the lab for culture
Remove the catheter if possible
If not possible to remove the catheter, then change the catheter
Start a narrow-spectrum antibiotic such as Trimethoprim or Nitrofurantoin
Advice patient on adequatehydration
 Female Infertility Investigation
Mid-luteal progesterone level (assess ovulation) = measured 7 days prior to the next period (21 st
day in a 28 day cycle)

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FSH & LH
Hysterosalpingogram (tubal patency)
Type FSH LH Estrogen Prolactin
PCOS Normal Normal to mild Normal to mild
Premature Normal
Ovarian failure
Prolactinoma
Sheehan’s
Turner Normal

 Folic acid in pregnancy = 400 mcg daily for first 12 weeks for all women
5 mg daily for first 12 weeks: 5 mg daily for entire pregnancy
BMI > 30 Sickle cell disease
DM Thalassemia or thalassemia trait
Taking anti-epileptics
Previous pregnancy with neural tube defect
Family history of neural tube defect
Personal history of neural tube defect

 Chorioamnionitis = IV antibiotics = Ampicillin & Gentamicin

 Postpartum Haemorrhage Management = Uterine Atony (most common cause)

1. Bimaual compression of uterus
2. Oxytocin IV infusion
3. Ergometrine IV or IM
4. Carboprost IM
5. Ballon tamponade
6. B-lynch sutures
7. Bilateral ligation of uterine arteries
8. Hysterectomy
 Hyperemesis Gravidarum
First line = Prochlorperazine, promethazine or cyclizine
Second line = Metoclopramide or ondansetron

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Third line = Corticosteroids
 In exam Pre-eclampsia is diagnosis if :

Hypertension + over 20 weeks gestation + one of this protein values:

-24 hour urine protein >= 0.3g/24 hours or

-Protein creatinine ratio (PCR) >= 30 mg/mmol or
-Albumin creatinine ratio (ACR) (>= 8 mg/mmol)

 Postpartum Endometritis = IV Clindamycin and Gentamicin (First line)

 Ruptured Ectopic Pregnancy = The presence of moderate to large amounts of free fluid in
the Pouch of Douglas (cul de sac) is indicative of ruptured ectopic pregnancy
If haemodynamically stable – Laparoscopic salpingectomy or salpingostomy
If haemodynamically unstable – Laparotomy (open salpingectomy or salpingostomy)

 Molar pregnancy – After the diagnosis of molar pregnancy, when is a women advised to try
to conceive again?
6 months after hCg levels have been normal or
If on chemo, 12 months after completing treatment
Women should be placed on contraception (oral or barrier) until the end of this surveillance period.

 Placental abruption = Cocaine use in pregnancy is one of the risk factors.

 UTI in pregnancy – Cefalexin is safe
Trimethoprim Nitrofurantoin
It should be avoided in 1st trimester It should not be used near term
Risk of neural tube defects Risk of neonatal haemolysis
If used, supplementary 5mg folic acid should be Nitrofurantoin, Neonatal haemolysis, Not for
prescribed) term
Trimethoprim, Teratogenic, Term OK

Do not use Amoxicillin if there is a culture resistant to Ampicillin

Exam tips:
Pick Nitrofurantoin (unless at term)
If no Nitrofurantoin – pick Cefalexin
If no Nitrofurantoin or Cefalexin – Pick Amoxicillin

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  Obstetrics Cholestasis
Pruritus is common in palm Investigation: Management
and soles and worse in night
LFTs Monitor LFTs weekly
No rash is seen
Bile acid Topical emollients
Prothrombin time may be Calamine lotion and
increased due to the presence Chlorpheniramine maleate
of vitamin K deficiency (Piriton) are commonly used to
reduce the itch
Ursodeoxycholic acid (UDCA)
Induction of labour at 37 weeks
is common
Vitamin K daily particularly if
there is prolonged PT

 HRT Types to be given

Estrogen only Sequential combined HRT Continuous combined HRT
Had a hysterectomy Peri-menopausal women (i.e. Menopausal women
women who are within 12 of
Have an IUS Women who have been using
their LMP)
sequential combined HRT for 1
year.

 Vaccines offered to pregnant women in UK

Influenza
Pertussis – between 16 & 32 weeks
 Anti-D immunoglobulin
Recommended time to administer to a previously non-sensitised negative mother after delivery =
As soon as possible and always within 72 hours
 Endometrial Cancer
First-line investigation is trans-vaginal US – a normal endometrial thickness (<4 mm) has a
negative predictive value
Hysteroscopy with endometrial biopsy gives the definitive diagnosis
 Contraception Clinchers
Young woman, not sexually active (don’t require contraception) = Menorrhagia only – IUS 1st
line
Tranexamic acid = more useful for menorrhagia

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Mefenamic acid = more useful for dysmenorrhoea

Sexualy active woman (require contraception)

Menorrhagia/dysmenorrhoea or those suffering from fibroids (which do not distort the uterine
cavity) – IUS Mirena (1st line). These Q’s will also mention possible contraindications for COCP
like obesity/smoking/history of thromboembolism
Note: If woman are younger than 20 years old, IUS Mirena is not the 1st line as it is considered to
be UKMEC 2, thus if no contraindications, COCP, POP or implant may be more suitable as they
would be UKMEC 1
Woman with Sickle Cell Disease and menorrhagia = Depo-provera IM
Safest time to prescribe COCP postpartum is after 6 weeks for non breastfeeding mothers and
after 6 months for breastfeeding mothers.
Emergency contraception:
Within 72 hours of unprotected sex = Levonelle pill
Within 120 hours of unprotected sex – IUCD or EllaOne pill
SUMMARY:
Dysmenorrhoea in a young girl = Mefenamic acid
Dysmenorrhoea, menorrhagia, and irregular menstrual cycle in a young girl = COCP
Dysmenorrhoea, menorrhagia, and irregular menstrual cycles in sexually active women =
Levonorgestrel intra-uterine system
 Enzyme Inducers can lower the effect of contraception
CRAP GPS
Carbamazepine Griseofulvin
Rifampicin Phenobarbitone
Alcohol – chronic consumption Sulfonylureas
Phenytoin

 Colposcopy indication:
Abnormal cervical cytology on cervical screening
Women with symptoms of cervical cancer (e.g. post-coital bleeding or persistent vaginal discharge
that infection has been ruled out)
Cervical polyps that cause bleeding
Ectropion that causes postcoital bleeding

 Anemia in Pregnancy

RS Page 28
<110 or 11 g/L in the 1st trimester
<105 or 10.5 g/L in the 2nd & 3rd trimester
<100 or 10 g/L in the postpartum period
 Fitz-Hugh-Curtis syndrome = is a complication of PID. Usually present with an acute onset
of RUQ abdominal pain aggravated by breathing, or coughing. This pain may be referred to
the right shoulder.
 Asherman syndrome – are adhesions of the endometrium often associated with D&C of the
intrauterine cavity. It results in infertility. Often, they experience menstrual irregularities.
 Meigs Syndrome = Benign ovarian tumour + Ascites + Pleural effusion
 FSH levels
FSH test should be undertaken in women aged under 40 years in whom menopause is suspected
(FSH is also appropriate if women between 40 and 45 with menopausal symptoms = this is termed
as early menopause rather than premature ovarian failure
Two raised levels (more than 24 IU/L) taken at least 4 weeks apart are diagnostic

 Missed Pill Rules:

If 1 pill is missed (at any time in the cycle)
-Take the last pill asap even if it means taking two pills in one day
-Continue with the rest of the pack as usual
-No additional contraception protection needed
If 2 or more pills missed
-Take the last pill asap even if it means taking two pills in one day and continue the rest of the
pack as usual
The woman should abstain from UPSI (unprotected sexual intercourse) until she has taken pills for
7 days in a row
-If pills are missed in week1 + UPSI in the pill-free interval or in week1 = Emergency contraception
-If pills are missed in week2 = Emergency contraception not needed
-If pills are missed in week3 = Emergency contraception not needed but she should omit the pill-
free interval and start the new pack of pills the day after finishing the current pack
 Antiphospholipid syndrome = pregnant women can be treated with Aspirin 75 mg +
Heparin.
These women are usually cared for by haematologist and obstetricians throughout pregnancy.
 Pre-eclampsia in pregnancy = Women who are at high or moderate risk of developing pre-
eclampsia in pregnancy are prescribed = Aspirin 75 – 150 mg daily from 12 weeks
gestation until delivery.
Following women should take Aspirin:
-Hypertensive disease during a previous pregnancy
RS Page 29
-Chronic kidney disease
-Autoimmune disease such as SLE or antiphospholipid syndrome
-DM type 1 or 2
-Chronic HTN
 Constipation in Pregnancy
NICE puts Isphahula husk as the first-line for constipation in pregnancy, if this is not given in the
options, pick Lactulose
 COCP unlikely to be appropriate choice in the following:
MBBS is Very Hard
Migraine with aura VTE history or family history of VTE
BMI more than 30 kg/m2 Hypertension (even if adequately controlled)
Breast cancer history
Smoker or ex-smoker

 Management of Urge incontinence in elderly

Tolterodine – 1st line
Mirabegron is also used but it’s not 1st line
 Anaemia Types
Microcytic Anaemia MCV <80 (TAILS) Macrocytic Anaemia MCV>100 (FAT RBC)
Thalassemia Fetus/Folate (pregnancy)
Anaemia of chronic disease Alcohol
Iron deficiency anaemia Thyroid disease (Hypothyroidism)
Lead poisoning Reticulocytosis
Sideroblastic anaemia B12 and Folate deficiency
Cirrhosis and Chronic liver disease

 Iron Deficiency Anaemia Labs

Low = Ferritin, MCV and Haemoglobin
High = TIBC and Transferin
Iron deficiency Anaemia of Chronic Thalassaemia Trait
Anaemia disease
Serum Iron
Ferritin
TIBC Or

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Transferrin Saturation

 Folic acid deficiency medication = Methotrexate, Anticonvulsants, Trimethoprim

 Haemolytic anaemia = Low haemoglobin, Raised bilirubin, Raised/normal MCV
Diagnostic test = Direct antiglobulin test
 G6PD deficiency = Haemolytic crisis caused by:
Broad beans – favism
Primaquine
Nirtofurantoin
Sulfonamides

 Multiple Myeloma (CRAB)

HyperCalcemia Labs:
Renal failure Urine protein electrophoresis = Bence Jones
Protein
Anaemia
Serum protein electrophoresis = Increased
Bone pain
monoclonal immunoglobulin spike
X-ray – punched out lytic lesion
Blood films = Rouleaux formation
Bone marrow biopsy = Abundant plasma cells


Haemophilia A treatment Haemophilia B treatment Tumor Lysis Syndrome
Factor VIII infusion, Recombinant factor IX IV fluids and diuretics
Demopressin (it increase
Rasburicase
factor VIII)
Hemodialysis if kidney failure
Allopurinol (prevention)
Von Willebrand’s disease Sickle Cell Anaemia
Tranexamic acid, Folic acid
Demopressin
Blood transfusion
Oral penicillin prophylaxis
Avoiding situation causing
crisis such as cold,
dehydration and exhaustion

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  Acute Leukaemia
Acute Lymphoblastic Leukaemia (ALL) Acute Myeloid Leukaemia (AML)
Seen in Children Seen in adults
Presentation: Presentation:
Anaemia Fatigue
Recurrent infections (low WBCs) Fever not responding to antibiotics
Bleeding (thrombocytopenia) Gingivitis
Bone marrow biopsy – numerous lymphoblast Bleeding (thrombocytopenia)
Hepatosplenomegaly
Peripheral smear – Auer rods
Bone marrow biopsy – numerous myeloblasts

Chronic Lymphocytic Leukaemia (CLL) Chronic Myelocytic Leukaemia (CML)

Mostly age > 60 Average age onset = 50
Smudge cells (smear cells) Philadelphia chromosome t(9;22)
Presentation: Presentation:
Symmetrically enlarged lymph nodes Crazy Massive splenomegaly
Bleeding due to thrombocytopenia Leukocytosis
Anaemia Hyperviscosity syndrome
FBC shows B cell lymphocytosis Blood smear – Granulocyte without blast cells
Blood film = Mature lymphocytes Treatment : Imatinib

 Question: The stem has a patient who presents with pancytopenia. What clinical symptoms
will allow you to choose acute leukaemia over aplastic anaemia?
Proliferative signs – lymphadenopathy or hepatosplenomegaly
 Anaemia in Pregnancy
1st Trimester = Hb < 110 g/L
2nd/3rd Trimester = Hb < 105 g/L
Postpartum = Hb < 100 g/L

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  How do you distinguish primary from secondary polycythaemia?
Primary = EPO is low to normal
Secondary = EPO is high

 Lymphoma
Hodgkin’s Non-Hodgkin’s
Bimodal distribution (age <25 and > 55) Follicular and diffuse large B cell lymphoma are
most common
Associated with Epstein-Barr virus infection
Absence of Reed-sternberg cells
Histology: Reed-sternberg cells (multilobulated
gaint cells, large bi-nucleated cells with Extranodal presentation is more common
prominent nucleoli)
Bone marrow infiltration causing cytopenia
Risk factors: Immuno-suppression and smoking
Treatment is by chemotherapy and is based on
histological type and staging

 Question: A patient with HIV presents with painless peripheral lymphadenopathy, fever,
night sweats, weight loss and splenomegaly. What is the diagnosis?
Non-Hodgkin lymphoma. HIV is most commonly associated with Burkitt lymphoma which is a form
of NHL
 Bleeding disorders
Von Willebrand disease Haemophilia DIC
Platelet-type bleeding Factor type bleeding (deep Bleeding everywhere:
(mucosal bleeding) bleeding into muscles and
Venepuncture sites
joints)
GI tract
Ear, Nose, throat
Skin: Purpura
aPTT prolonged aPTT prolonged aPTT prolonged
BT prolonged BT prolonged
PT prolonged

 Polycythaemia Rubra Vera (PRV)

Mutation in JAK2 is present in >90%
Management:

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-Venesection
-Chemo
Less than 40 years of age: Interferon 1st line
Older tha 40 years of age: Hydroxycarbamide (hydroxyurea) 1st line
-Low dose Aspirin 75 mg OD – to reduce thrombotic events

 COOMBS Test
DIRECT INDIRECT
Test a patient’s RBCs Tests a patients Serum
RBCs are incubated with anti-human globulin Serum is incubated with RBCs of known
(Coombs reagent) antigenicity
If this produces agglutination of RBCs, the Anti-human globulin is then added
direct coombs test is positive
If agglutination occurs, the indirect coombs test
A positive coombs test indicates that an is positive.
immune mechanism is attacking the patient’s
own RBCs

 DIC (Disseminated Intravascular Coagulation)

3 most frequent causes: Presentation:
-Infection Ecchymoses or spontaneous bleeding at
venepuncture sites, and the site of trauma
-Malignancy
Bleeding from ears, nose, and throat, GI tract
-Obstetric complications
Petechiae, purpura
Labs: Treatment:
Fibrin degradation product is elevated Treat the underlying condition
PT is elevated Transfusion of platelets or plasma for patients
with severe bleeds
aPTT is elevated
In bleeding patients with DIC and prolonged PT
Fibrinogen level is low
and aPTT, administer fresh frozen plasma

Henoch-Schonlein Purpura Haemolytic Uraemic Thrombotic

Syndrome Thrombocytopenic Purpura
Seen in children Seen in children
Purpura Triad Pentad (Triad of HUS) +
Abdo pain 1.Acute renal failure 4.Neurological manifestation

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Glomerulonephritis 2.Microangiopathic haemolytic 5.Fever
anaemia (MAHA)
Periarticular edema
3.Thrombocytopenia
Features of IgA nephropathy Inhibition of ADAMTS 13
May occur, for example: ADAMTS 13 is responsible for
haematuria, renal failure the breakdown of vWF.
Without ADAMTS13,
coagulation occurs.
Usually follows an Upper
respiratory tract infection

 Hereditary Spherocytosis

Presence of spherocytes + positive family history + negative direct Coombs test

Hereditary spherocytosis = Direct Coombs test negative
Autoimmunie haemolytic anaemia = Direct Coombs test positive

 Tuberculosis Vs Lymphoma
Tuberculosis Lymphoma
-Fatigue, malaise, fever, weight loss, anorexia -Drenching night sweats, fever, weight loss
-Hilar, paratracheal or superficial node -Enlarged but otherwise asymptomatic lymph
involvement. Palpable nodes may be initially node, typically in the lower neck or
tender, firm and discrete supraclavicular region
-Chronic, productive cough with purulent +- -Patients might complain of chest discomfort
bloodstained sputum with a cough or dyspnoea
-May result in lobar collapse, bronchiectasis, -Mediastinal masses are frequent and are
pleural effusion and pneumonia sometimes discovered on a routine CXR
-Erythema nodosum -Findings on examination include
lymphadenopathy, hepatomegaly,
splenomegaly, and superior vena cava
syndromes

 Hepatitis B Serology
HBsAG + First marker to become abnormal in both acute
and chronic infection
HBeAG + Indicates highly infectivity
Anti-HBs + Indicates recent vaccination
Anti-HBc + Indicates past infection and remain positive
after recovery

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IgM Anti-HBC + Indicates recent acute infection
HBV DNA + Shows infectivity (Acute viral replication)

 Prophylaxis Antibiotic for HIV+ patients

If CD4 < 200 If CD4 < 50
Co-trimoxazole Azithromycin
Against pneumocystis jirovecii Agaisnt mycobacterium avium

 Notes on breatfeeding
HIV Avoid breastfeeding
Breast abscess Continue breastfeeding
Nipple abscess Continue breastfeeding
Hepatitis B Continue breastfeeding (if baby has received
Hep B vaccine)
Hepatitis C Continue breastfeeding (unless nipples is
cracked or bleeding)
Tuberculosis Continue breastfeeding (baby needs BCG
vaccinated ASAP)
Depression Continue breastfeeding (if mother is on
Sertraline)

 HIV post-exposure prophylaxis

Truvada and Raltegravir for 28 days
Follow-up HIV testing is recommended 8-12 weeks after exposure
 Important points
Malaria Dengue fever Typhoid Diphtheria
Africa Far East Asia South America India
Fever, chills, rigour Generalised rash, Severe headache, Presents with flu-like
biphasic fever, retro- patient adopt a symptoms initially,
orbital pain crouching position enlarged anterior
cervical lymph nodes

 Human bites + Dog bite = 7 day course of oral Co-amoxiclav. If the patient has a penicillin
allergy, Metronidazole + doxycycline, erythromycin or clarithromycin.
 Campylobacter jejuni with travel history in Southeast Asia:

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Erythromycin 1st Line
Ciprofloxacin 2nd Line
 Salmonella = Ciprofloxacin 1st Line
 Pneumocystic Carinii pneumonia prophylactic = Co-trimoxazole
 Mycobacterium Avium complex prophylaxis = Azithromycin
 Whipple’s disease = PAS+, jejuna biopsy shows deposition of macrophages in the lamina
propria-containg granules
 Lyme disease = Doxycycline (Contra in pregnancy)
If pregnant = Amoxicillin
 Goodpasture syndrome & differential diagnosis
Goodpasture Alport syndrome Churg Strauss Wegener’s
syndrome (Eosinophilic granulomatosis
granulomatosis with (Granulomatosis with
polyangiitis) polyangiitis)
Autoimmune disease Haemaproteinnuria Asthma Haematuria
Rapidly progressive Abnormal U&E Eosinophilia Nasal septum
glomerulonephritis perforation
Loss of sight p-ANCA
Pulmonary alveolar Epistaxis
Loss of hearing Allergic Rhinitis
haemorrhage
c-ANCA
Nasal Polyps
Haematuria,
Hemoptysis, Impaired Skin nodules
renal function test

 Normal pressure hydrocephalus

Management – CSF shunt (definitive)
Acetazolamide (decrease CSF pressure)
Serial lumbar puncture (if unfit for surgery)
 Intervertebral disc prolapsed
Management – usually resolves spontaneously in 6 weeks but can last for months
NSAIDs
Amitriptyline
 Parkinson’s Disease:
Levodopa + Carbidopa (1st line)
MAO-B Inhibitors – Selegiline
Dopamine agonist – Pramipexole and Ropinirole

RS Page 37
Amantadine

 Shy-Drager Syndrome
Features: Memory Tool:
Parkinsonism Shy-Drager is SHY because of erectile
dysfunction & Wets his pants
Cerebellar ataxia
Shy-Drager often DRAGS his feet (cerebellar
Urinary incontinence
ataxia)
Postural hypotension
Shy-Drager Drops his BP when he stands
Erectile dysfunction

 Progressive Supranuclear Palsy

Eye movement restriction (downward gaze restriction)
Frequent falls early in the disease course (often falling backwards) due to axial rigidity
Change in behaviour – Apathy and Impulsivity
 Guillain Barre Syndrome
Nerve conduction studies are the best test to perform for GBS.
Lumbar puncture is non-specific for GBS

 Myasthenia Gravis
Investigation – Serum anti-acetylcholine receptor antibody
Management – Pyridostigmine (1st line)
Corticosteroids
Azathioprine
Thymectomy
 Lambert-Eaton Myasthenic syndrome
Autoantibodies towards presynaptic Calcium channels
Presentation: Management:
Weakness (usually proximal muscles of lower Diaminopyridine
limb)
Treating the underlying neoplasm
Waddling gait
Associated with Small cell cancer of the lung

 Epilepsy vs NEAD (Non-Epileptic Attack Disorder)

RS Page 38
Genetic factor History of childhood physical or sexual abuse
Trigger : sleep depreviation, alcohol, flashing Stress, panic
lights, sudden noises
Sudden onset Gradual onset
Duration: 0.5 to 2 min Often > 2 mins
Pelvic thrusting rare Pelvic thrusting occasional
Breathing is Apnoeic Breathing is continuous

Suspension to licence after seizure:

Car driver – 1 year
Lorry driver – 5 years
 Cranial Nerve Nuclei
Cortex – 1,2
Midbrain – 3,4
Pons – 5,6,7,8
Medulla – 9,10,11,12

 Horner Syndrome = MAP

Miosis, Anhidrosis, Ptosis

 Amyotrophic Lateral Sclerosis (ALS)

Treatment = Riluzole, Non-invasive positive pressure ventilation

 Multiple Sclerosis – MRI - Methylprednisolone

Investigation: Management:
MRI – periventricular lesions and white matter Acute: Oral/IV Methylprednisolone
abnormalities
Long Term therapy for relapses:
CSF = High protein, High immunoglobulins
-Interferon beta
(oligoclonal bands)
-Glatiramer acetate
-Natalizumab (2nd line)

 Stroke
Rule out haemorrhagic stroke by CT scan

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If < 4.5 hours from symptom onset, thrombolysis with Alteplase. After 24 hours, commence Aspirin
300 mg for 2 weeks
If > 4.5 hours, give Aspirin 300 mg for 2 weeks
Long term treatment for Ischaemic stroke
-Clopidogrel 75 mg lifelong (1st line)
-Statins
If the patient has atrial fibrillation – Warfarin or NOAC + Statin, should be given instead of
Clopidogrel
Suspect TIA Suspect Stroke
Aspirin 300 mg Scan within 1 hour
Patient to be referred to be seen by specialist Do not give aspirin until haemorrhagic stroke
within 24 hours ruled out by CT scan

Remember:
Ischaemic stroke + AF = Warfarin/DOAC + Statin
DOAC’s = Dabigatran, Rivaroxaban, Apixaban, Edoxaban
Ischaemic stroke + No AF = Clopidogrel + Statin

Ischaemic stroke, TIA, PAD Angina MI

Atorvastatin Atorvastatin Atorvastatin
Clopidogrel Aspirin (if already taking Dual antiplatelet theray: Aspirin
clopidogrel for stroke, TIA, + Clopidogrel to be given for
PAD then continue Clopidogrel the first 12 months only, and
instead of Aspirin) Aspirin to continue lifelong

 Migraine Prophylaxis
Beta blockers – Propranolol (1st line)
Amitriptyline
Topiramate (contra in pregnancy)

 Cluster Headache
Acute attack = Sumatriptan (subcutaneous injection or nasal, NOT ORAL), Oxygen
Prophylaxis = Verapamil (1st line)

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  Intracranial Bleeding
Epidural Haematoma Subdural Haematoma Subarachnoid Haemorrhage
Middle meningeal artery Bridging veins rupture Middle cerebral artery

 Aphasia
Broca’s Aphasia Werbicke’s Aphasia
-Inferior frontal lobe of dominant hemisphere -Fluent but unmeaningful speech
Broken speech -Patient does not understand
Patient can understand

 Restless Leg Syndrome

Investigation – Serum ferritin (since RLS is associated with iron deficiency)
Treatment = Pramipexole, Ropinirole,Dopamine, agonist, Gabapentin, Pregabalin, Iron
supplement if serum ferritin is low

 Neurocysticercosis
Treatment = Niclosamide, Praziquantel

 Cerebral toxoplasmosis
Treatment = Pyrimethamine + Sulfadiazine

 Cryptococcal meningitis
Treatment = Amphotericin + Flucytosine

 Diencephalon = consist of thalamus, hypothalamus including posterior pituitary,

epithalamus and subthalamus.
A lesion near or at the posterior pituitary would give rise to symptoms of diabetes Insipidus.

 Midbrain Infarct will cause

Contralateral hemiparesis
Ipsilateral oculomotor nerve palsy
Case: 78 year old smoker collapses. He is unable to lift his right hand and leg. He complains of
double vision. His left eye is mydriatic and his left eyelid droops downwards. His left eye deviates
downward and outward.

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  Golden points for dizziness
Dizzy when rolling over bed = BPPV
Light sensitivity during dizzy spells = Migraine
First attack severe vertigo lasting hours with vomiting = Vestibular neuritis
Light headed when getting up from bed = Orthostatic hypotension

 Syringomyelia vs Syringobulbia
Syringomyelia Syringobulbia

 Muscle weakness and wasting (atrophy)  Facial sensory loss can occur as the trigeminal
nerve becomes involved.
 Loss of reflexes
 Vestibulocochlear nerve involvement causes vertigo
 Loss of sensitivity to pain and temperature
and nystagmus.
 Headaches
 Facial, palatal and laryngeal nerve palsy can occur
 Stiffness in your back, shoulders, arms and legs
 Weakness and atrophy of the tongue is caused by
 Pain in your neck, arms and back XIIth nerve involvement.

 Spinal curvature (scoliosis)

 Wernicke’s Encephalopathy
Triad = Confusion + Ataxia + Opthalmoplegia
Usually seen in alcoholic. Can also be seen in pregnancy where there is severe persistent
hyperemesis gravidarum.
Wernicke-Korsakoff syndrome = Atrophy of Mammillary bodies is seen in brain.

 Alzheimer’s
Treatment = Galantamine, Rivastigmine, Donepezil. These medication also decrease heart rate,
and therefore are not suitable for patients with bradycardia, heart block or taking concomitant
cardiac rate-limiting medication such as beta blockers and amiodarone.

In the above case, Memantine (2nd line) should be prescribed.

 Obstructive sleep apnoea = Polysomnography (gold standard)

 Narcolepsy = Multiple sleep latency test

RS Page 42
  Cerebellum lesions signs = Ataxia, dysdiadochokinesia, nystagmus, intention tremor,
slurred speech, hypotonia, past pointing.

 Lateral medullary syndrome (Wallenburg syndrome)

Vertigo
Diplopia
Nystagmus
Ipsilateral sensory loss in the face
Contralateral sensory loss in the trunk and limbs
Dysphagia

 Meningitis
Bacterial Viral Tuberculous
Glucose Low Normal Low
Protein High Normal to high High
WBCs Neutophils Increased lymphocytes Neutrophils in early
disease, lymphocytes
later

Sreptococcus pneumonia is a common organism that causes meningitis. It is a gram positive

diplococcic.

 Multiple Sclerosis = definitive diagnostic test is MRI of brain and spinal cord.

 Shy-Drager Syndrome = Shows characteristics of parkinsonism (rigidity, pill-rolling tremor of

the hands) + autonomic dysfunction (urinary incontinence, erectile dysfunction) consider
Shy-drager syndrome.
 When a patient needs rapid tranquillisation via the IM route, 2 options:
-IM lorazepam
-IM haloperidol + promethazine

 Brain tumor = headache that is worse in the morning and papilloedema.

MRI scan of the brain is preferred. If MRI contraindicated then CT

 Alzheimer’s Vs Normal pressure hydrocephalus MRI scans

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Alzheimer’s disease = MRI shows enlarged ventricles + Cortical atrophy
Normal pressure hydrocephalus = MRI shows enlarged ventricles + NO Cortical atrophy
 Parkinson’s disease patient has vomiting:
Medication to AVOID (May Cause Medication of CHOICE (DOCtor)
Parkinsonism)
Metoclopramide Domperidone
Cinnarizine Ondansetron (causes constipation, not good for
elderly)
Prochlorperazine
Cyclizine

 HIV patient with acute cryptococcal meningitis = Amphotericin & Flucytosine

 Guillain-Barre Syndrome = Nerve conduction studies (gold standard)
Main treatments are:
intravenous immunoglobulin (IVIG) – a treatment made from donated blood that helps bring your
immune system under control
plasma exchange (plasmapheresis) – an alternative to IVIG where a machine is used to filter your
blood to remove the harmful substances that are attacking your nerves
treatments to reduce symptoms such as painkillers

 Idiopathic Intracranial HTN

Obese Female in 30s
Associations: Investigation: Management:
Cushings, MRI with contrast & MR Weight reduction
Hypoparathyroidism, Iron venogram (gold standard), if
Stop causative drug
deficiency anaemia, thyroid MRI not available then CT.
disorder Acetazolamide or other
Once structural lesion
diuretics
excluded, next step Lumbar
puncture (high opening Serial lumbar puncture
pressure indicates ICH
Prednisolone

Culprit drug = Isotretinoin

 Drop attacks can be defined as sudden falls with or without loss of consciousness, due
either to collapse of postural muscle tone or to abnormal muscle contractions in the legs.
 Oral corticosteroids can cause steroid induced Cataracts.

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Cataract causes:
Someone from Australia who never wears sunglasses, high UV exposure
Long term use of steroids
High myopia
Trauma the eye

 Timolol can be used to treat acute angle closure glaucoma

 Periorbital cellulitis (Preseptal cellulitis) = Oral Co-amoxiclav. If it worsens, it may progress
to Orbital cellulitis = IV Co-amoxiclav
 Diabetic Retinopathy
Non-proliferative Preproliferative retinopathy Proliferative retinopathy
Retinopathy
Microaneurysms (dots) Addition of cotton wool spots Addition of new vessel
formation (neovascularisation)
Haemorrhage (blots)
More serious. Progresses
Hard exudates
rapidly to blindness.
Neovascularization. May lead
to vitreous haemorrhage
Floaters in vision
Laser photocoagulation is
needed

 Retinal detachment = Scleral buckling

 Anterior Uveitis = Unilaterla red eye + irregular shaped pupil (not oval) in the absence of
trauma
 Central retinal vein occlusion = painless ;oss of vision alongside the fundoscopy finding of
retinal haemorrhage
 Simple (primary) open-angle glaucoma
Present in around 2% of people older than 40 years. Risk factors:
Family history
Black patient
Myopia
 Rotator Cuff muscles
Supraspinatus – Initiates abduction
Infraspinatus – Involved in external rotation
Subscapularis – Invloved in internal rotation
RS Page 45
Teres minor

 Shoulder Impingement Syndrome = Supraspinatus tendinitis

 Supraspinatus Tendinitis vs Adhesive Capsulitis
Supraspinatus Tendinitis Adhesive Capsulitis
Difficulty lifting arm above shoulder Reduced active and passive glenohumeral joint
movement (like a stiff shoulder)
Painful arch test positive
More important of external rotation (jacket
Associated with injury or heavy lifting
would be difficult due to external rotation)
History of diabetes

 Colles Fracture
Dinner fork deformity – (distal radial fragment deviates backward and laterally)
Treatment = Closed reduction and immobilisation with Colles cast
 Smith’s Fracture
Anterior displacement of the distal fragment
Garden spade deformity
 Galeazzi fracture vs Monteggia fracture
Galeazzi Fracture Monteggia Fracture
Dislocation Distal radioulnar joint Dislocation of the head of the
dislocation radius
Bone fractured Fracture of distal 1/3 of the Fracture of distal 1/3 of the
radius shaft (GaleaZzi, Z is ulna (MonteggiA, A is
distal) proximal)
Mnemonic GRUesome MURder
G – Galeazzi M – Monteggia
R- Radius fracture U – Ulnar fracture
U – radioUlnar dislocation R – Radius dislocation

Note – Radial nerve is damaged in Monteggia fracture

 Scaphoid Fracture
X-ray = One immediately and one 10-14 days later in the first one does not show the fracture line
Treatment: if visible on X-ray = Scaphoid cast for 6 weeks

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If not visible on X-ray = Cast immobilisation of the wrist and review after 2 weeks with X-ray

 Test for knee ligament injuries

Valgus stress test Medial collateral ligament
Varus stress test Lateral collateral ligament
Anterior drawer test, Lachman test Anterior cruciate ligament
Posterior drawer test Posterior cruciate ligament

 Osteoid Osteoma
Benign bone tumor that develops in the long bones of the body such as the femur and tibia
Pain is unrelated to activity and is relieved quickly by NSAIDS
Pain is usually worse at night
Frequently affects children and young adults
Usually less than 1 cm in diameter

 Osteoporosis, Paget’s disease, Osteomalacia

Osteoporosis Paget’s disease Osteomalacia
Serum Calcium Normal Normal Low
Serum phosphate Normal Normal Low
Alkaline phosphatase Normal High High

RS Page 47
RS Page 48
  Nerves Injuries
Wrist drop = Radial nerve
Foot drop = Either common peoneal nerve or sciatic nerve
Claw hand = Ulnar nerve
Paraesthesia of thumb, index and middle finger = Median nerve
Numbness on superior aspect of upper arm just below shoulder joint = Axillary nerve
Fibular neck fracture = Common peroneal nerve
Femur neck fracture or Acetabular fracture = Sciatic nerve
Fracture of humeral shaft = Likely Radial nerve
Fracture of humeral neck = Likely Axillary nerve
Monteggia fracture = Radial nerve
Paraesthesia and impaired sensation in both hands (glove distribution) = Peripheral neuropathy

 Site of compression
L2 Anterior thigh pain. Positive femoral stretch test
(uncommon)
L3 Sensory loss over anterior thigh. Absent or decreased knee jerk. Positive femoral
stretch test
L4 Sensory loss of anterior aspect of knee. Absent or decreased knee jerk.
Weakness in ankle dorsiflexion. Positive femoral stretch test.

RS Page 49
 L5 Sensory loss dorsum of foot. Weakness in toe dorsiflexion. Reflexes intact.
S1 Sensory loss posterolateral aspect of leg and lateral aspect of foot. Weakness in
plantar flexion of foot. Absent or decreased ankle reflex.

Anal reflex (anal wink) S2-S4

Ankle reflex S1 & S2 Sciatic Nerve
Knee (patella) reflex L3 & L4 Femoral Nerve
Biceps reflex C5 & C6 Musculocutaneous nerve
Brachioradialis (supinators) reflex C6 Radial nervemainly Radial nerve
Triceps C7 & C8 Radial nerve

Flex Elbow C5
Extend Wrist C6
Extend Elbow C7
Flex Fingers C8
Adduct & Abduct Fingers T1

 Meckel’s Diverticulum
Investigation: Radioisotope scan (initial), laparptomy
 Management of Hernia in Children
Umbilical Hernia Inguinal Hernia Secondary Care
Asymptomatic umbilical hernia All infants with asymptomatic Asymptomatic inguinal hernias
– Reassure (closes inguinal hernia – Refer to in neonates – operated before
spontaneously by 4th year) secondary care due to high risk discharge from maternity unit
of incarceration
Asymptomatic umbilical hernia Asymptomatic inguinal hernia
in > 4 year old – Refer to Older children with in < 6 months old – operated
paediatric surgeon asymptomatic inguinal hernia – on next available list
Routine referral to secondary
Incarcerated/strangulated Asymptomatic inguinal hernia >
care
hernia – Urgent referral to 6 months old – Elective repair
paediatric/general surgery Incarcerated or strangulated
hernia – Emergency referral to
secondary care

 Necrotising Enterocolitis
Air in the bowel wall
Bloody stools
RS Page 50
Cannot tolerate feeds
Distended abdomen
Investigation: Abdominal x-ray (initial)
Treatment: Stop feeds, NG tube drainage & aspiration, Penicillin + Gentamicin + Metronidazole
If pneumoperitoneum present - Surgery
 Acute Epiglottitis
Unvaccinated individuals – H. Influenzae (Hib)
Vaccinated individuals- Streptococcus
Gold standard = Laryngoscopy

 Croup – most commonly caused by Parainfluenza virus

Treatment – Dexamethasone
 Bronchiolitis Vs Croup
Expiratory wheeze Inspiratory stridor
Age group less than 1 year old Age group between 6 months and 3 years
HER SPA
H- Humidified oxygen S- Stridor, Starts after Six months, Single dose
of Steroids
E- Expiratory wheeze
P- Parainfluenza
R- Respiratory syncytial virus
A- Adrenaline (nebulised)

 Pertussis
Investigation – Pernasal or nasopharyngeal swabs
Treatment – Macrolides
 Osteogenesis Imperfecta – Autosomal dominant, defect in type 1 collagen
Bone- Increased chance of fracture
I (eye)- Blue sclera
T- Teeth imperfections
Ear- Hearing loss

 CAH – Congenital Adrenal Hyperplasia = Autosomal recessive, 21-hydroxylase deficiency

Males = Hyperpigmentation and penile enlargement
Females = Ambiguous genitalia with an enlarged clitoris
Vomiting, hyponatremia, hyperkalemia, shock

RS Page 51
Treatment = Glucocorticoids (hydrocortisone & prednisolone), Mineralocorticoid (fludrocortisones)
Biochemical test = 17-hydroxyprogesterone

 Kawasaki Disease = CRASH & Burn

Conjunctivitis (non-exudative)
Rash (polymorphous, non vesicular)
Adenopathy (cervical)
Strawberry tongue
Hands (palmar erythema and swelling)
Burn (fever lasting >= 5 days)
Complications = coronary aneurysym
Treatment – IVIg (mainstay), hhigh dose aspirin

 Causative agents for common illnesses

Condition Causative agent
Scarlet fever Streptococcus pyogenes
Impetigo Staphylococcus aureus
Osteomyelitis Staphylococcus aureus
Rubella Rubella virus
Roseola HHV-6 (Human herpes virus)
Chickenpox Varicella-zoster virus (VZV)
Measles Morbillivirus (paramyxovirus)
Mumps Paramyxovirus
Erythema infectiosum Parvovirus B19
Hand, foot and mouth disease Coxsackie virus A16 and Enterovirus 71

 Rashes and School

Condition Recommendation
Scarlet fever Keep away from school and nursery until 24
hours from starting antibiotics treatment
Impetigo Keep away from school and nursery until
lesions are crusted and healed, or 48 hours
after starting antibiotic treatment

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Chickenpox -Keep away from school and nursery until
vesicles have crusted over & at least 5 days
have passed from onset of rash
-keep away from pregnant women
Measles Keep away from school and nursery for 4 days
from onset of rash
Rubella Keep away from school and nursery for 4 days
from onset of rash

Do NOT withdraw from school or nursery in:

-Hand, foot and mouth disease
-Cold sores (herpes simplex)
-Molluscum contagiosum
-Roseala
-Parvovirus B19 (once the rash has developed)

 Lateral Neck Masses

Branchial cyst = Fluctuant + non-translucent + does not move on swallowing
Lymphangioma (cystic hygroma) = Translucent + Fluctuant

 OSA in Children
Investigation = overnight in-lab Polysomnography
Most appropriate action = Refer to ENT surgeon

 IV Fluids – Maintenance fluid over 24 hours (child > 28 days age)

100 mL/kg for the first = 0 – 10 kg
50 mL/kg for the next = 10 kg to 20 kg
20 mL/kg for remaining = 20+ kg
Replace over 24 hours unless in Hypernatraemia, replace over 48 hours
Use Sodium Chloride 0.9% + Glucose 5%
Reduce by 1/3 if there is a risk of inappropriate ADH secretion

 First 2 – 15 days of birth = Opthalmia neonatarium = Red eye + lid swelling mucopurulent
discharge think of Chlamydia = Refer to ophthalmologist

RS Page 53
Most common reason for thick discharge from eye below 12 months = Blocked nasolacrimal duct
= No red eye + No swelling = Just reassure and simple cleaning

 ALL = Acute leukaemia but less acute and only with gum hypertrophy
 AML = Acute leukaemia in a very acute setting with bleeding from gums

 Serous otitis media = Conductive hearing loss

Congenital cytomegalovirus = Sensorineural hearing loss

Gentamicin (aminoglycosides) = Sensorineural hearing loss
Sensorineural hearing loss is caused by lesions in the cochlea or auditory nerve

 Hand, foot and mouth disease

Caused by Coxsackievirus (CA16) and Enterovirus (EV71)
Low-grade fever
Malaise
Loss of appetite
Sore throat
Oral ulcer – may be on buccal mucosa, tongue or hard palate
Following later by vesicles on the palms and soles of the feet
Small erythematous macules on palms and soles of the feet which progress to grey vesicles and
may last for up to 6 days.

 Down syndrome patient cardiac defect = Atrioventricle Septal defect

 If a patient develops side effects from oral morphine e.g. nausea, vomiting or drowsiness =
Switch to oral oxycodone
Oxycodone has double potency of morphine
 Treatment for excessive respiratory secretions in palliative care =
Glycopyrronium bromide subcutaneously or
Hyoscine butylbromide subcutaneously

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  Medication for Nausea and Vomiting (L-CHOP)
When to use
Levomepromazine N & V associated with Parkinson’s disease
Cyclizine Increased ICP
Htperemesis gravidum (1st line)
Haloperidol Renal failure
Hypercalcaemia
Drug or toxin induced
Onansetron Chemotherapy
Radiotherapy
Post-operative N & V
Buccal Prochlorperazine Vertigo
Meniere’s
BPPV
Vestibular Neuritis

 Nausea and Vomiting in palliative patient give

Delayed gastric emptying = Metoclopramide, Domperidone
Bowel obstruction = Cyclizine, Ondansetron, Levomepromazine

 Hypercalcaemia (> 2.6) in Palliative care

Treatment = IV bisphosphonate e.g. Pamidronate or Zoledronate
 Bleeding in Palliative care (haematemesis)
Administer subcutaneous Midazolam or Morphine

 Anticipatory Medication that are allowed to be given to a patient during the last days of life
Morphine Pain and breathlessness
Haloperidol Nausea and Vomiting
Midazolam Anxiety, delirium, agitation
Hyoscine Butylbromide Noisy respiratory secreation

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  Medication to remember in Exam
Morphine Sulphate Pain
Breathlessness
Cyclizine Antiemetic
Useful for ICP causes of nausea and vomiting
Octreotide Nausea and vomiting with bowel obstruction
Metoclopramide Nausea and vomiting with delayed gastric
emptying
Midazolam Agitation and restlessness
Glycopyrronium Excessive respiratory secretions at end of life
Hyoscine butylbromide Excessive respiratory secretions at end of life
Bowel obstruction
Dexamethasone Vomiting or headaches with raised ICP
Appetite stimulant

 Persistent Hiccups
Diaphragmatic Irritation = Metoclopramide, if not given in option consider Domperidone or
Nifedipine
Central Cause = Chlorpromazine, if not given in option consider Haloperidol, Midazolam or
Phenytoin

 Oral tramadol 600 mg = Oral Morphine 60 mg

Oral morphine 60 mg = Subcutaneous morphine 30 mg
Oral morphine has ½ the potency of Oral Oxycodone = when converting from oral morphine to
Oxycodone, use ½ the dose
Oral morphine has ½ the potency of injectable morphine = when converting from oral morphine to
injectable morphine, use ½ the dose
Oral morphine has 1/3 the potency of injectable di-morphine = when converting from oral morphine
to injectable di-morphine, divide the dose by 3

 Anti-depressants
Sertraline Best drug to pick for the exam for history of MI,
preferred for breastfeeding

RS Page 56
Citalopram Risk of Qtc prolongation
Fluoxetine Best medication to pick if below 18 years of age
Paroxetine Least preferred as higher risk of drug interaction
Duloxetine Benefical side effect of weight loss (ideal fro
those with weight issues, eg from side effect of
Clozapine)
Mirtazapine Preferred choice if patient is on monoamine-
oxidase B inhibitors (eg. Selegiline) or on
Warfarin/Heparin

 Ramsay Hunt Syndrome

Treatment = Aciclovir with addition of Corticosteriods (If Prednisolone, can be started within 2
weeks from the onset of the rash)
If >2 weeks has passed then Amitriptyline

 Liver impairment or pancreatitis should be suspected in those on Sodium Valproate

treatment with signs of abdominal pain, vomiting, drowsiness, anorexia or jaundice.
 Methotrexate for Rheumatoid Arthritis should be monitored for symptoms such as
dyspnoea, cough or fever at each visit and the drug must be discontinued if pneumonitis is
suspected.
 Metoclopramide is an anti-emetic that blocks dopamine receptors, making symptoms of
Parkinson’s worse.
TO reverse the parkinsonism symptoms caused by Metoclopramide, Procyclidine should be given.
Procyclidine is an anticholinergic that reduces the effects of the Cholinergic excess resulting from
dopamine deficiency.
 Statin amd Macrolides should not be used together as it can increase the serum levels of
statin. It would be appropriate to stop the Simvastatin while patient in on any macrolides
(Clarithromycin or Erythromycin).
 Calculating Alcohol Units
Strength (ABV) x Volume (ml) Divide 1,000 = Units
1 litre of Vodka (40% ABV) contains 40 units of alcohol
A pint is 568 ml approx.
A pint of standard beer (3.5% ABV) would equate to 2 units of alcohol
Men and Women are advised not to drink more than 14 units a week and 3 units per day
 Community acquired pneumonia
1st choice is Amoxicillin

RS Page 57
If penicillin allergic Clarithromycin. But Methadone and Clarithromycin cannot be used together as
both prolong QT interval.
DOXYCYCLINE can be given for CAP who are penicillin allergic and cannot be given
Clarithromycin.
 SNRI (DULOXETINE) increase the risk of falling. Elderly patients who take SNRI have
impared psychomotor function and orthostatic hypotension which increases the risk of falls.
SSRI would also have similar risk of falls. HYPONATRAEMIA is an important side-effect of
Duloxetine.
Clozapine side-effect is postural hypotension which could account for falls but Hyponatraemia is
not a feature of Clozapine.
 ACE-inhibitors can cause HYPERKALEMIA (Ramipril, Enalapril, Captopril, Peridopril,
Lisinopril.
If no option for ACE-inhibitors, then ARBs next best option that too can cause HYPERKALEMIA
(Losartan, Candesartan, and Valsartan)
Concomitant treatment with NSAIDs increases the risk of renal damage and potassium-sparing
diuretics increase the risk of hyperkalemia.

 Asthma
Long-acting beta agonist (Salmeterol) and Inhaled corticosteroid (Beclomethasone)
Short-acting agobist (Sambutamol). The side effects are Arrhythmias; headache; palpitations;
tremor, Hyperglycaemia
40 mg x 2 = 80mg
50 mg/5ml

 Lithium toxicity
Increasing diarrhoea, vomiting, anorexia, muscle weakness, lethargy, dizziness, ataxia, lack of
coordination, tinnitus, blurred vision, coarse tremor of the extremities and lower jaw, muscle hyper-
irritability, choreoathetoid movements, dysarthria, and drowsiness.
Toxicity signs STOP treatment, urgent level and supportive
care
Level > 1.5 mmol/L and no toxicity signs STOP treatment and supportive care
Level > 1 mmol/L and no toxicity signs If level is within range per specialist, Continue
dose, If not, reduce dose per specialist advice
Cjeck and correct for causes of higher level
(dehydration, timing of level (12 hours post-
dose), brand change, medication interaction),
then recheck the level

RS Page 58
  Naltrexone is an opiod antagonist and is licensed to treat opiod-dependent people who
have remained opiod free for at least 7 to 10 days. Revent relapse
Naloxone = used in overdose
Methadone or Buprenorphine (oral) = (opposite to Naltrexone) used in detoxification in opiod
dependence.
 Opioid Calculation
Patient pain is controlled by Morphine immediate release 20 mg x 4 times daily, what is her main
and breakthrough dose?
Main dose = (20 mg x 4)/2 = 40 mg twice daily
Breakthrough dose
= (40x2)/6 = 13 mg every 4 hours or
= (40/2) x 10% = 8 mg every 4 hours

 ADHD treatment
Children = Methylphenidate (1st line), focused group parent-training programme
Adults = Lisdexamfetamine or Methylphenidate (1st line), CBT

 Dysthymia = Chronic mild depression for > 2 years

 Atypical depression = Example: A woman presents with low mood, increased appetite,
weigh gain, somnolence and hypersomnia.
 Cyclothymia = Milder form of bipolar disorder fluctuating between mild depressive and
hypomanic symptoms for >= 2 years
 Bipolar Disorder = Mania or Hypomania + Depression
Remember, you cannot have bipolar unless you have mania or hypomania and episodes of
depression.
 Lithium Toxicity = Coarse tremor, Nausea/Vomiting, drowsiness, hyperreflexia,
seizure/coma
Diuretics and NSAIDs can cause lithium toxicity by increasing renal reabsoption
Management
Mild to moderate Severe toxicity
IV fluids and stop drug immediately Haemodialysis

Lithium should not be used in pregnancy as it can cause Ebstein’s anomaly.

 Delusions

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Erotomania Delusional belief that a person of higher social
status falls in love with him/her
Folie a deux (shared psychosis) Delusional belief and even hallucinations are
shared between two individuals who are in a
relationship
Capgras Syndrome Fixed belief that someone they know or
recognize has been replaced by an imposter
Cotard Syndrome Combination of severely depressed mood with
Nihilistic delusions. Patient may state that he is
already dead and should be buried. He may
state that his insides have stopped working and
are rotting away, or that he has stopped existing
altogether.
Fregoli (delusion of doubles) Delusional belief that different people (more
than one) are in fact a single person who
changes appearance
Nihilistic delusion Delusion that the person is already dead, or
does not exist, or the world has ended or is not
real. As such, nothing really matters or has any
meaning.
Todd’s syndrome Also known as ‘Alice in Wonderland syndrome’.
It involves perceptual distortion of the size or
shape of objects and altered body images.
Patients may feel as though their body is
expanding or getting smaller.
Delusion of reference Is the false belief that insignificant remarks,
events, or objects in one’s environment have
personal meaning or significance. Example,
someone constantly gives him or her a special
messages through the newspaper.
Persecutory delusion Is a delusion belief that one’s life is being
interfered with in a harmful way. It refers to false
belief or perceptions in which a person believes
that they are being treated with malicious intent,
hostility, or harassment despite significant
evidence to suggest otherwise. This may occur
in the context of being tormented, followed or
spied on.
Ganser syndrome Factitious disorder, a mental illness in which a
person deliberately and consciously acts as if
he or she has a physical or mental illness.
-Mostly seen in prison inmates. They produce
‘approximate answers’. They may give repeated
wrong answers to questions which are

RS Page 60
 nonetheless ‘in the right ballpark’.
-Example what is the capital of Scotland? Paris
Othello Syndrome Delusional jealousy, marked by suspecting a
faithful partner of infidelity like cheating, adultery
or having an affair. The patient may attempt
monitoring his spouse or partner.
Hypnagogic Hallucination Transient false perception experienced while on
the verge of falling asleep (hearing a voice
calling one’s name which then startles you back
to wakefulness to find no-one there.
Hypnopompic Hallucination Same phenomenon experienced by health
people while waking up

 Schizophrenia management
Atypical anti-psychotics = Risperidone, Olanzapine
Depot injections if there is non-compliance
ECT (treatment resistance)

 Schizoaffective disorder = Schizophrenia + Mood disorder such as depression or bipolar

disorder
 Schizophreeniform disorder = Symptoms of schizophrenia lasting 1-6 months

 Acute Psychosis
Question = When a person known to have a history of Parkinson’s disease or dementia with Lewy
bodies has acute psychosis and is elderly what is the most appropriate medication to administer?
Answer = IM Lorazepam (Haloperidol is usually preferred in the elderly but is contraindicated
where there is a history of Parkinson’s disease or dementia with Lewy bodies.
Question = A schizophrenic man is seen laughing and smiling about his father’s death whom he
liked, loved and respected. What term describes his body language?
Answer = Incongruent affect
Question = A schizophrenic says the following. “Life is unfair, I eat air, lawn chair, I kike fairs, fairs
have food, it must be good, in adulthood, I misunderstand”. What term describes this speech?
Answer = Clang association

 Rapid Tranquillisation
IM Lorazepam – safe in cardiac disease
IM Haloperidol + Promethazine – Should not be used in patients with cardiac disease

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  PTSD management
Trauma-focused CBT (first line)
Eye Movement Desenitisation & Reprocessing (EMDR)
Paroxetine & Mirtazapine (second line)

 Tardive Dyskinesia = Involuntary, repetitive body movements like lip smacking, repetitive
chewing or tongue thrusting
 Neuroleptic Malignant Syndrome = Confusion, neck stiffness, muscle rigidity, high
temperature
 Akanthisia = Pacing around the room, feeling restless and needs to move legs

 Alcohol withdrawal treatment = Oral Chlordiazepoxide

 Delirium Tremens = Oral Lorazepam

 Mania vs Hypomania
Mania Hypomania
Abnormally elevated mood A lesser degree of mania with persistent mild
elevation of mood and increased activity and
energy
Hallucinations or delusions No hallucinations or delusions
Significant impairment of the patient’s day-to- No significant impairment of the patient’s day-
day functioning to-day functioning

The presence of psychotic symptoms differentiates Mania from Hypomania

-Delusion of grandeur
-Auditory hallucinations
Remember for Exam:
-If you see a patient with high mood = Likely Hypomania
-If you see a patient with high mood and other times depressive moods = Likely Bipolar
-If you see a patient with high mood and psychotic symptoms = Likely Mania
-If you see a patient with high mood that are significantly impairing patient’s day-to-day functioning
= Likely Mania

 Postpartum Blues, Postnatal Depression, Postpartum Psychosis

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 Postpartum Blues Postnatal Depression Postpartum
Psychosis
Onset Starts at 2 or 3 days Peaks at 3 to 4 weeks Peaks at 2 weeks
after birth and can postpartum postpartum
lasts anywhere from 1-
2 days to a week
Mother cares for baby Yes Yes. Thoughts of harming
baby
Occasional thoughts of
harming baby
Symptoms -Mostly crying -Symptoms of -Psychotic symptoms
depression e.g. hears voices
-Irrational
saying baby is evil
-Feels not capable of
-Anxious
looking after her child -Insomnia
-Low moods
-Feels as if she will not -Disorientation
be a good mother
-Thoughts of suicide
-Tearful, Anxiety
-Worries about baby’s
health
Management Reassurance & Anti-depressants or -Admit to specialist
explanation CBT mother & baby unit if
available
-Antidepressant, mood
stabilizers
(Carbamazepine) and
ECT

 Anorexia Nervosa – diagnostic criteria for Anorexia nervosa is BMI of 17.5 kg/m2 or less
 Paracetamol poisoning = 24 tablet is the benchmark. If a patient has consumed less than
24 tablets, it’s not life threatening.
 Patient depressed + Warfarin + Anti-depressants warranted = Pick Mirtazapine
If not on Warfarin then Sertraline (SSRI) 1st choice. SSRI can increase of GI bleeding. Avoid
combination of SSRI & Warfarin.

 Pleural Effusion or Empyema from Pneumonia

A patient has features of an unresolving pneumonia and a chest x-ray is given.
In general, a patient with an empyema is more ill (higher swinging fevers, higher WBC + CRP,
more night sweats, weight loss, more chest pain).
Convex (lenticular shape) = Empyema
Concave (crescentic shape) = Pleural effusion
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  Superior Vena Cava Syndrome
Investigations Management
-Chest x-ray = may reveal a tumor -Stenting/Angioplasty
-Contrast enhanced CT – Investigation of -Treatment of specific cancer
choice

 Pancoast Syndrome (Horny PAMELa)

Horner’s Syndrome
Ptosis
Anhidrosis
Myosis
Enophthalmos
Loss of ciliospinal reflex

 Pulmonary Embolism
Chest x-ray must always be done before a CTPA to rule out other causes of SOB
Ventilation-Perfusion scans to be offered in the following situations:
Allergy to contrast medium
Renal impairment
High risk from irradiation (pregnancy)

 Fetal Ultrasounds
No visualisation of fetal stomach bubble = Oesophageal atresia
Double bubble sign = Duodenal atresia

 Ovarian Endometrioma = chocolate cyst or ground glass appearance

 Auto-antibodies
Disease Autoantibody

RS Page 64
SLE -Anti-ds DNA (specific)
-Antinuclear antibody (sensitive)
Drug induced lupus Anti-histone antibody
Diffuse Scleroderma Anti-scl70
Limited Scleroderma (CREST syndrome) Anti-centromere
Polymyositis Anti-Jo1
Sjoren’s syndrome Anti-Ro
Anti-La
Primary biliary cirrhosis Anti-mitochondrial
Autoimmune Hepatitis Anti-smooth muscle
Churg Strauss syndrome p-ANCA
Wegener’s granulomatosis c-ANCA (remember as WBC)
Coeliac disease Anti-tissue transglutaminase
Anti-gliadin
Anti-endomysial
Graves disease TSH-receptor antibody
Rheumatoid arthritis Rheumatoid factor (initial)
Anti-CCP (most specific)

 SLE management:
ANA (high sensitivity)
Anti-dsDNA antibody (high specificity)
Hydroxychloroquine – skin lesions, arthralgia and myalgia, oral ulcers
NSAIDs – arthralgia and myalgia
Prednisolone – severe cases
Cyclophosphamode – life threatening lupus nephritis and vasculitis

Drug induced Lupus caused by = Hydralazine, Chlorpromazine, Isoniazid

In exam choose answer as per below
ANA Anti-dsDNA
Most sensitive test Most specific test
Initial test Most discriminative test

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Best screening test

 Dermatomyositis
Muscle weakness
Heliotrope rash – Blue-purple discoloration on the upper eyelids with periorbital oedema
Gottron’s papules – Raised purple-red scaly patches over the extensor surfaces of joints and
fingers
Shawl sign: rash around the neck

 Myositis = Weakness > pain + increased CK

 Polymyalgia = Pain > weakness + normal CK

 Behcet’s Disease
Recurrent oral ulcers
Recurrent genital ulcers
Anterior or posterior uveitis
Exaggerated skin injury after minor trauma

 Reiter’s Syndrome (Reactive arthritis) – Presents 2-4 weeks after a genitourinary or GI

infection
C. Trachomatis & C. Pneumonia are most common cause
Triad:
Can’t see Can’t pee Can’t climb a tree
Conjunctivitis Urethritis Arthritis

 Gout & Thiazides – Thiazides precipitate gout.

Culprits – Bendroflumethiazide, Chlorthalidone, Indapamide, Metolazone

 De Quervain’s Disease
Tenosynovitis of extensor pollicis brevis and abductor pollicis longus involved in the movement of
the thumb.
RS Page 66
Risk factors = Pregnancy, repetitive movements, rheumatic disease
Note: De Quervain’s thyroiditis or subacute thyroiditis caused by viral infection causing
hyperthyroidism and tenderness of thyroid gland.
 Churg-Strauss syndrome (EGPA (eosinophilic granulomatosis with polyangiitis)
Vasculitis affects small- and medium-sized arteries and veins and is associated with asthma.
PAVE
P-ANCA
Asthma
Vasculitis
Eosinophilia
 Granulomatosis with Polyangiitis (Wegener’s Granulomatosis)
World Cup = Wegner C-ANCA
Upper Lower Renal Investigations Some Key
respiratory tract respiratory tract words
Nasal perforation Haemoptysis Haematuria C-ANCA Saddle-shaped
(glomerulonephritis) nose
Chronic sinusitis Dyspnoea RBC casts in
urine Crusting around
Epistaxis
nose
Biopsy of
affected site Subcutaneous
nodules on the
elbow

 Sarcoidosis – chronic inflammatory condition characterised by formation of non-caseating

granuloma
Presentation Investigation Treatment
Erythema Nodosum Hypercalcaemia Oral corticosteroids
Polyarthralgia ESR
Fever & night sweats Chest x-ray – bilateral hilar
lymphadenopathy
Lupus pernio
Uveitis

 Raynaud’s Phenomenon treatment = Nifedipine

 Rheumatic Fever treatment = Penicillin
Most appropriate investigation ASO
Specific Lab test ASO

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Most likely lab value to be abnormal ESR

 Peripheral Arterial Disease (PAD) (older adult with/without smoking history

Investigation Management
ABPI (1st line) Quit smoking
Duplex US after ABPI if considering intervention Atorvastatin (irrespective of lifestyle)
MRA/CTA – if further imaging required after Clopidogrel
duplex US
Naftidrofuryl Oxalate (only if patient doesn’t
want revascularisation and exercise has
failed to improve symptoms)
Angioplasty & stenting, bypass surgery

 Claudication pain in PAD

Aorto-iliac occlusion = pain in buttocks +- erectile dysfunction
Common iliac artery = pain extending just above the inguinal ligament
Femoral artery = pain is below the inguinal ligament
Femoro-popliteal occlusion = pain is below the knee

 Thromboangiitis Obliterans (Buerger’s disease) (Young adult with smoking history)

Presentation Management
Claudication pain in the legs or hands Iloprost (prostacyclin analogue)
Discoloration of the affected limbs Smoking cessation
Numbness and tingling in the the affected limb
Skin ulceration and digital gangrene
Associated with smoking

Berger’s disease is IgA nephropathy.

URTI followed by episodic haematuria within 2 days
 Leg Ulcers
Venous Ulcers Arterial Ulcers Neuropathic Ulcers

RS Page 68
 (diabetic ulcers)
Causes Include Varicose veins PAD (smoking, high Diabetes
BP, diabetes)
DVT Pressure points on
bottom of feet
Pregnancy
Location Medial malleolus Toes, feet Plantar surface of foot
(inguinal lymph nodes)
Lateral malleolus Toes
Tibial area
Clinical features Haemosiderin deposits Deep Deep and punched out
Granulation tissue Necrotic Ulcer is surrounded by
callous
Shallow Irregular shaped
Reduced sensation
Sloughy Absent or weak pulses
Normal capillary refill Prolonged capillary
time refill time
Typically very painful

 Aortic Aneurysm – most common cause is an Atheroma

<5.5cm = US surveillance
>=5.5 cm or >4 cm with more than 1 cm growth in 1 year = Endovascular repair
Treatment:
Initial management = IV fluid 0.9% NS (if SBP <90 mmHg)
AAA screening don by US, Men only, One time only, Age 65

 Bilateral Renal Artery Stenosis

Presentation Investigation Management
High BP resistant to treatment Renal angiography (gold Angioplasty + Stenting
standard)
Worsening renal function after
starting ACEi/ARB USG: equally reduced size of
kidneys with smooth borders
Causes: Fibromuscular
dysplasia, Atherosclerosis

 Carotid Artery Stenosis

Investigation Management
Duplex US (initial test) Carotid endarterectomy

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CT/MR angiography (gold standard)

 Superior Vena Cava Syndrome

Dilated superficial veins of neck, arms and Difficulty breathing
anterior chest wall
Coughing
Oedema of the face, neck and upper limb
Common cause: cancer
Contrast enhanced CT – Investigation of choice

 Superficial femoral artery – A man has a road traffic accident. He has a right mid femoral
shaft fracture. He does not have a dorsalis pedis or posterior tibial pulses on his right foot.
 Coarctation of Aorta
Neonatal presentation Late presentation Mnemonic
Usually seen within the first 3 Usually asymptomatic Hypertension – Nosebleeds
weeks of life
Radiofemoral delay Headache
Poor feeding
Higher BP in arms and low in
Lethargy the legs
Tachypnoea Heart murmur – Systolic or
continuous murmur
Congestive heart failure
Systolic murmur in left
infraclavicular area

 Ureteric Stones – Non-contrast CT scan (investigation of choice)

In pregnancy – US of whole abdomen is preferred over Non-contrast CT scan
Asymptomatic stones < 5 mm Watchful waiting
Asymptomatic stones > 5 mm Explain the risk & benefits
Wait & watch if the patient agrees
Symptomatic stones < 10 mm ESWL
Ureteroscopy
Symptomatic stones 10-20 mm Ureteroscopy (1st line), JJ stent
ESWL (2nd line)
Symptomatic stones > 20 mm PCNL

ESWL – Estracorporeal shock wave lithotripsy

PCNL – Percutaneous nephrolithotomy
RS Page 70
Patient with only one kidney + hydronephrosis = Percutaneous nephrostomy or ureteric stent
(decompression)
Patient with 2 kidneys + AKI + hydronephrosis = Percutaneous nephrostomy or ureteric stent
Note: Patient has stones + fever/AKI = try not to pick percutaneous nephrostomy or JJ stent
(ureteric stent)
Obstructive Uropathy
With 1 functioning kidney With 2 kidneys
A stone (any size) with dilation of pelvic calyceal AKI
system (PCS)
Fever
+- Anuria
Hydronephrosis
+- Fever
Treat with decompressing PCS by Treat with decompressing renal collecting
percutaneous nephrostomy system by percutaneous nephrostomy

Summary:
Loin pain + stone + hydronephrosis = Manage according to stone size
Loin pain + stone + hydronephrosis + AKI + Fever = Percutaneous nephrostomy

 Urinary Incontinence – Detrusor overactivity

Treatment:
First = Bladder training
Second = Anti-cholinergic drugs eg. Oxybutynin, Tolterodine or Darifenacin (only after trying
bladder training.
Mirabegron – Used only if anti-muscarinic drugs contraindicated

 Benign Prostatic Hyperplasia Treatment

Selective α-1 Blocker 5- α reductase inhibitor TURP
Tamsulosin Finasteride If medical management fails
Mild to moderate LUTS Urinary tract symptoms + TURP syndrome can cause
significant prostatomegaly or hyponatremia due to irrigation
PSA >1.4 ng/ml of bladder used during the
procedure
Severe LUTS + prostatomegaly/PSA > 1.4 ng/ml = combination
of α-1 Blocker and 5- α reductase inhibitor

In exam pick Tamsulosin first. (Retrograde ejaculation side effect of tamsulosin)

RS Page 71
Finasteride can take 3 to 6 months to see improvements of symptoms
NICE guidelines state that if PSA level in men aged 50-69 years is 3.0 nanogram/mL or higher,
they should be referred urgently for an appointment within 2 weeks to urology.

 Acute Prostatitis treatment = Quinolone such as Ciprofloxacin or Ofloxacin

 Bladder Cancer – transitional cell carcinoma is common
Investigation = CT urogram but it has radiations so if patient is young <40 years, US may be
appropriate)
Note: First differential for an elderly male with haematuria should be bladder cancer, and for an
elderly female with vaginal bleeding should be endometrial cancer.
CT KUB = Excellent for demonstrating STONES
CTU = Excellent for demonstrating MALIGNANCY

 Haematuria
Symptoms or signs of UTI
Yes No
Treat as UTI, send culture Refer to urology
Do urinalysis in 7 to 14 days after antibiotics If age >= 45 = 2 week wait referral (thinking of
caner)
NICE CKS uses the age cut-off as 45 years old

 Urology Scans
CT-KUB Renal stones, hydronephrosis
CT Urogram Renal & ureteric cancers
Cystoscopy Bladder cancers
Cystogram Vesicoureteral reflux (VUR)
Intravenour Urogram (IVU) Largely superseded by CT urography (unlikely
going to be the answer)
DMSA scan Renal scarring
MAG3 scan PUJ obstruction

 Testicular Cancer
Seminoma (always asked in exam) = Raised LDH, hCG
Teratomas = mixed tissues (cartilages, squamous epithelium)

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  Epididymo-Orchitis
<35 years old sexually transmitted organisms >35 years old sexually transmitted organisms
Chlamydia & Gonorrhoea E.Coli & Pseudomonas. Spp

Treatment
Sexually transmitted pathogen Enteric organisms
Ceftriaxone 1 gm IM stat PLUS Ofloxacin 200 mg BD for 14 days OR
Doxycycline 100 mg BD for 10-14 days Levofloxacin 500 mg OD for 10 days

 AD – Polycystic kidney disease

Abdominal USG (initial test)
MRI/CT (most sensitive)
Management: Hypertension with ACEi or ARB, Regular screening for intracranial aneurysm

 Haematuria Differential Diagnosis

Goodpasture syndrome Haematuria
Hemoptysis
Anti-GBM antibodies
Wegener’s Granulomatosis (granulomatosis Haematuria
with polyangiitis)
Haemoptysis
Arthritis
Haemolytic Uremic Syndrome Haematuria
Bloddy diarrhoea
Haemolytic anaemia
Thrombocytopenia
Infection with E. Coli
Bladder Cancer Haematuria
Occupational exposure – Aniline dye/smoking
Old age
Post-streptococcal glomerulonephritis Haematuria

RS Page 73
 H/o Imetigo or pharyngitis
Odema
Hypertension
Children

 Vesicoureteric Reflux
Micturating cystourethrogram – Gold standard
 Interstitial Cystitis
Presentation Investigation Management
Increased urinary frequency Urine routine and C & S to R/O First line:
UTI
Urgency Bladder training
Cystoscopy to R/O bladder
Suprapubic pain increased with Pelvic floor relaxation
cancer
bladder filling and decreased technique
with voiding Hunner’s ulcer
Analgesics
Common in women
Second line:
Amitriptyline

 Acute Urinary Retension

In men – If enlarged prostate + normal PSA = Prescribe Tamsulosin + trail without catheter

 Management of Recurrent Urinary Tract Infection in Women

Important to remember that vaginal oestrogen is tried first before long term antibiotics in a
postmenopausal woman.

 Renal Cell Cancer

The most common secondary cause of left sided varicocele is renal cell cancer. Newly diagnosed
varicocele over the age of 40 years are very much suggestive of renal cell cancer.

 Epididymal cyst vs Hydrocele

Epididymal cyst Hydrocele
Painless “Transilluminates with a pen torch”
Lie behind and above testis Anterior to and below the testis
Testis is palbale separately from the cyst (or Testis is palpable within the fluid-filled swelling
swelling)

RS Page 74
Diagnosis – Ultrasound
Management – usually supportive but surgical
removal

 Urge Incontinence – Pick bladder training in exam before considering anticholinergics like
oxybutynin for cases of urge incontinence.
Oxybutynin should not be used in frail older women who have increased risk of sudden physical or
mental deterioration.
 Macroscopic haematuria
Cystoscopy – to look for bladder cancers
CT urogram – to look for renal and ureteric cancers
Urine cytology – in case we pick up cancerous cells

 TURP is the treatment for BPH

TURP syndrome is a rare side effect which causes Hyponatremia (confusion, bradycardia, nausea
and vomiting)
Management = Fluid restriction to correct hyponatremia

 Diagnosis of Mesothelioma = Pleural biopsy

Deaths of mesothelioma should be reported to a coroner as compensation is often available.

 Pneumonia
Pneumococcal Streptococcal Strep. Pneumonia is the most common cause of
bacterial pneumonia.
Herpes Labialis
Mycoplasma Erythema Multiforme
Atypical features: Young adult, dry cough,
bilateral patchy consolidation
Pneumocystis Jirovecii HIV with CD4 < 200
+- desaturation on exercise
Stap. Aureus Pneumonia developed after influenza (flu)
Multilobe involvement & cavitation
Legionella Pneumophila Pneumonia developed after exposure to water,
staying in hotel
Low sodium

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 Low lymphocytes
Macrolides/tetracyclines are the usual choice of
treatment (Clarithroymycin)

Treatment
Community acquired pneumonia (mild) Amoxicillin
Community acquired pneumonia (moderate) Amoxicillin + Clarithromycin
Community acquired pneumonia (severe) Co-Amoxiclav (Amoxicillin + Clavulanic acid) +
Clarithromycin
Pneumocystis jirovecii ‘P.Carinii’ Co-Trimoxazole (Trimethoprim +
Sulfamethoxazole)

 Pneumonia Antibiotics Cases

Severe penicillin allergies DO NOT USE
Amoxicillin or Co-amoxiclav
Cephalosporins
Patient on Statin DO NOT USE
Clarithromycin due to risk of rhabdomyolysis
USE
Doxycycline
Patient on Methadone DO NOT USE
Clarithromycin due to risk of prolonged QT
syndrome
USE
Doxycycline

 Brain Trainers
A man with pneumonia has a history of a 3 day Clarithromycin
stay in a hotel, hyponatremia and
lymphocytopenia. What is the most appropriate
antibiotic for this patient?
Community acquired pneumonia needing Doxycycline or Clarithromycin
antibiotics + Penicillin allergy + taking Warfarin
Community acquired pneumonia needing Doxycycline
antibiotics + Penicillin allergy + taking Warfarin
+ taking Statins

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Note: Doxycycline & Clarithromycin can increase the anticoagulation effect of Warfarin so
manufacturer advices monitor INR

 Hospital Acquired Pneumonia

Causative organism <5 days = Strep. Pneumoniae
>5 days = H. influenza, Pseudomonas
aeruginosa and MRSA
Non-Severe – requires Oral drugs Co-amoxiclav (1st choice)
Alternative (penicillin allergy) – Doxycycline
Severe – requires IV drugs Piperacillin + Tazobactam (1st choice)
Alternatives = Ceftriaxone or Meropenem
MRSA confirmed Vancomycin

 Pneumonia and HIV

HIV + dry cough + exertional dyspnoea = Pneumocystic jirovecii
HIV + productive cough = Mycobacterium tuberclulosis
Initial investigation = Chest x-ray
Definitive investigation for TB = Sputum sample for culture and microscopy

HIV patient may need prophylactic antibiotics

CD4 < 200 CD4 < 50
Co-trimoxazole against Pneumocystis jirovecii Azithromycin against Mycobacterium Avium

 Common Chest X-ray finding

Features Causative Organism
Lobar consolidation Strep. Pneumonia
Bilateral cavitation + pneumatoceles Stap. Aureus
Hotel stay + bi-basal consolidation Legionella
Bilateral patchy consolidation + perihilar Mycoplasma
shadowing + young adult (usually)
Perihilar shadowing + HIV Pneumocystic jirovecii
Patchy consolidation + Working in a Pet shop Chlamydophila psittaci

RS Page 77
  A man with lung cancer presents with a number of non-metastatic systemic symptoms.
What is the most likely explanation for this? Paraneoplastic Syndrome
 Pulmonary Embolism
Initial investigation = Chest x-ray
Appropriate investigation = CTPA
A woman has shortness of breath and is feeling unwell for the past 12 hours. She has a history of
panic attacks. Arterial blood gases show hypoxia, hypocapnia and alkalosis. What is the most
likely diagnosis? Pulmonary Embolism
Pulmonary Embolism in Pregnancy
CTPA = Better for baby, worse for mother
V/Q = Better for mother, worse for baby

First investigation to perform = Chest x-ray

PE suspect + Pregnant + abnormal chest x-ray = Perform a CTPA over V/Q scan
PE suspect + Pregnant + Normal chest x-ray = Perform V/Q scan first

Start treatment with LMWH in all pregnant patients who are suspected to have PE and continue till
it has been excluded.

 Pulmonary Fibrosis
A person presents with SOB. Lung function test show:
FEV1 60% of predicted
FVC 40% of predicted
FEV1/FVC ration 0.8

 Obstructive Vs Restrictive
Obstructive Restrictive
FVC > 80% FVC < 80%
FEV1/FVC < 0.7 FEV1/FVC > 0.7

 End of Life medication (only Subcutaneously)

Pain & breathlessness = SC Morphine
Nausea & Vomiting = SC Haloperidol
Anxiety, delirium, agitation = SC Midazolam

RS Page 78
Noisy respiratory secretion (rattling throat) = SC Hyoscine Butylbromide

 Extrinsic Allergic Alveolitis

Bird fancier = Avian protein
Malt workers = Asergillus Clavatus
Farmer = Spore of Saccharopolyspora Rectivirgula
Mushroom Workers = Thermophilic Actinomycetes
 Types of Sputum
Clear, Watery, frothy or pink (serous) Acute pulmonary edema
Clear, greyish-white, viscous (mucoid) Chronic Bronchitis
Asthma
Yellow-green (purulent) Pneumonia
Bronchiectasis
Cystic fibrosis
Lung abscess
Rusty red Pneumococcal pneumonia
Black currant jelly sputum Klebsiella

 CURB-65
Score Medication
0 Amoxicillin
If penicillin allergy, prescribe Doxycycline or
Clarithromycin
1 or 2 Dual theray with Amoxicillin and clarithromycin
or monotherapy with Doxycycline
Hospital admission can also be considered for
patients who score 2 on their CURB-65 score
3 Arrange hospital admission usually for IV
antibiotics

 Asthma life threatening features:

PEF < 33 % best or predicted SpO2 < 92%
PaO2 < 8 kPa Normal PaCO2 (4.6 – 6.0 kPa)

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Silent chest Cyanosis
Poor respiratory effort Arrhythmia
Exhaustion Altered conscious level, Hypotension

SHO for immediate management = Salbutamol, Hydrocortisone, O2

SIM for life threatening asthma = Salbutamol, Ipratopium, MgSO4

 Pancoast Tumors
Most appropriate next step = Chest X-ray
Most appropriate diagnostic step = MRI

 Aspirin poisoning = Tinnitus (ringing in the ears), Nausea, Vomiting

 Common Peroneal Nerve = Foot drop or Unable to dorsiflex
 Retinal detachment = Treatment = Scleral Buckling
 Mesothelioma best investigation that lead to diagnosis = Pleural biopsy

 Brain Trainer
What is the long term management of Dermatitis Life-long gluten-free diet
Herpetiform?
Which condition is associated with dermatitis Coeliac disease
herpetiformis?
Which is the pattern of lesion found on buccal Lacy pattern
mucosa in lichen planus?
What is the treatment of Lichen planus? Skin lesions = Topical corticosteroids eg.
Clobetasol propionate
Oral lesions = Benzydamine mouthwash
How is psoriasis treated? Silvery scales = topical corticosteroids,
vitamin D analogues

 Notifiable diseases
Measles Scarlet Fever
Meningitis Pertussis
Hepatitis A Malaria

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Tuberculosis COVID-19

 Haematological Markers
AML Auer Rods
CML Granulocytes without blasts
CLL Smudge Cells
Hodgkin’s Lymphoma Reed Sternberg cells
G6PD deficiency Heinz bodies, Bite cells
Iron deficiency anaemi Target cells
Multiple myeloma Plasma cells
Schistocytes Helmet Cells

 Impetigo treatment = 1st Line (Hydrogen Peroxide – antiseptic cream)

2nd Line Topical antibiotics = Fusidic acid or Mupirocin

 Irritable bowel syndrome = Abdominal bloating + pain + worse during eating + relieved by
defecation + passage of mucus
 Hyperthyroidism in Pregnancy
1St Trimester = PTU (Propylthiouracil)
2nd/3rd Trimester = Switch to Carbimazole
Fatal side effect of Carbimazole = Neutropenia and Agranulocytosis

 Diabetes
 MODY = <25 yrs old + low BMI + family history of DM
Refer for genetic counselling before genetic testing
LADA = Consider in patents 30 to 50 yrs old

 Chemotherapy drugs that cause peripheral neuropathy:

Vincristine
Cisplatin
Carboplatin
Taxanes

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  Features of significant Haemolysis:
Low haemoglobin
High MCV and MCHC
Elevated Bilirubin & LDH suggest red cell destruction
Polychromasia signifies an increase in the turnover of immature red cells and is an established
finding of haemolytic anaemia.

 A maculopapular, pruritic rash develops in around 99% of patients who take Ampicillin or
Amoxicillin whilst they have INFECTIOUS MONONUCLEAOSIS
 Standard Deviation = The measure of dispersion of a set of values

 Postpartum thyroiditis
Phase 1 - Hyperthyroid phase Phase 2 - Hypothyroid phase
usually within 4 months of delivery followed by phase 2 occurs 4 to 6 months after delivery.
Management is symptomatic with Beta-Blocker (Proponolol) Management - Levothyroxine

Thyroid dysfunction usually resolves spontaneously within a year from delivery.

 Homonymous Hemianopsia = Optic Tract lesion

 GBS infection causedby bacterium Streptococcus agalactiae

 UTI in Pregnancy
Pick Nitrofurantoin = 1st line (Early pregnancy)
If Nitrofurantoin is not an option = Pick Cefalexin
If Nitrofurantoin/Cefalexin are not options = Pick Amoxicillin

 Ulcers on leg
Ulcers at Medical Malleolus + Haemosiderin deposits = Venous Ulcers
Reduced sensation on toes or sole of foot = Neuropathic ulcers
Ulcer on Lateral Malleolus + NO haemosiderin deposit = Arterial ulcers

 Seizures drug in Pregnancy = Lamotrigine and Carbamazepine

 Non-Hodgkin’s Lymphoma = Small irregular B lymphocytes + No REED-sternberg cells

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  Tricuspid Atresia = 6 week old baby, progressive cyanosis, poor feeding, tachypnoea,
HOLOSYSTOLIC murmur

 Vascular Dementia = >50 + Hx of smoking + HTN + Subcortical lacunae + Past stroke +

TIA
Cardiovascular risk factor would Always be present in the stem.

 Superior Vena Cava occlusion = CT chest with Contrast (Treatment = DEXAMETHASONE)

 Prepatellar Bursa = 12 year old with painful swollen knee after a sudden fall on his right
knee. Pain is at the knee cap. Localized swelling over the patella.
 Crohn’s disease = Fistula formation with RECTUM/Ileum (fecal matter is seen within
vagina). Women with Crohn’s disease can also develop a fistula between the rectum and
vagina.

 Viral Meningitis = Less severe than Bacterial

Normal or high CSF pressure
Increased Lymphocytes
Elevated protein
Glucose normal
Regardless of type of meningitis – give antibiotics before performing CT brain and/or lumbar
puncture

 Syringomyelia – If you see burn marks on fingertips, think of loss of sensation of

temperature and pain in the hands.

 Which artery descends into the anterior interventricular groove = Left anterior descending
artery

 Extensor Pollicis Brevis extends the THUMB at Metacarpophalangeal joint (BTM)

 Extensor Pollicis Longus extends the THUMB at Interphalangeal joint (LTI)
 Flexor digitorum superficialis causes Flexion at Metacarpophalangeal & Interphalangeal
joint

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  Tuberculosis treatment such as Isoniazid can cause drug-induced lupus in which ANTI-
HISTONE antibodies are found in 95% of cases.
 Ventrricular Septal Defect = 7 week old baby + poor feeding + poor weigh gain +
PANsystolic murmur + acyanotic
Pansystolic murmur = MR, TR and VSD
Usually, MR and TR will not be given in the options if the answer is VSD
 Episodes of fainting + Ejection SYSTOLIC murmur = Aortic Stenosis
 Painful muscle spasms = Muscle relaxant like Baclofen & Diazepam
 Patient has MI + moderate depression = Sertraline or Citalopram
 Acute delirium + Parkinson’s disease = Lorazepam or Clonazepam
Medication to avoid in Parkinson = Haloperidol, Olanzapine, Chlorpromazine, Risperidone

 Goodpasture Syndrome = 30 yr old female + history of haemoptysis & haematuria +

shortness of breath + oliguria + chest X-ray showing patchy interstitial infiltrates bilaterally +
anaemia + raised creatinine
 Angiosarcoma = History of angiosarcoma + purple discolouration surrounding a nodule
 Meniere’s disease = Attacks of vertigo lasting for 30 minutes to 1 hour + hearing loss +
nausea
Can give Cyclizine, Cinnarizine, Prochlorperazine or Promethazine
Prevention of attacks = Betahistine
Termination of attacks = Prochlorperazine

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  LMWH mechanism = Inhibits the conversion of prothrombin to thrombin
 Cystic Fibrosis in neonates/infants include:
Poor weight gain
Failure to thrive
Meconium ileus
Bilious Vomiting
Echogenic bowel on prenatal ultrasound

 Diastolic murmur at the Apex = Mitral Valve Stenosis

 Continuous Machinery Murmur = PDA
 Corkscrew patter = Esophageal spasm

 Nerves involving the eye

 SGLT-2 inhibitors (Dapagliflozin) common side effect BALANOPOSTHITIS (rash & itch of
the penis)
 Raynaud’s phenomenon treatment = Nifedipine
 Villous adenoma causes HYPOkalaemia
 Beta2 agonist (Salbutamol or Terbutaline) can cause HYPOkalaemia
 Vaginal discharge
Both Gardnerella vaginalis and Trichomonas vaginalis can cause foul smelling discharge, itching,
pH > 4.5. But the differentiating feature is vulvovaginisits which is one of the signs of Trichomonas.

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  Foot Nerves
Saphenous Nerve Loss of sensation in Medial Foot
Sural Nerve Loss of sensation in Lateral Loot
Common Peroneal Nerve Foot Drop

 Achalasia
Regurgitation of undigested food
Difficulty swallowing both food and liquids
Chest X-ray show MegaEsophagus

 U wave is present in Hypokalemia

 Amniocentesis done at 15 to 18 weeks
 CVS done at 11 to 14 weeks

 Orbital Blowout Fracture

Infraorbital Nerve injury = Woman with orbital blowout fracture + loss of sensation at cheek and
upper lip

 Alcoholic with severe memory impairment = Mammillary body affected

 Lambert-Eaton Syndrome

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  Progressive Supranuclear Palsy
Axial rigidity
Restricted downgaze
Falling backwards due to axial rigidity
Inappropriate behaviour

 SSRIs are avoided in patients receiving triptan drugs for migraine. MIRTAZAPINE is a safe
alternative in such patients.

 Sciatica management = CODEINE. Do not pick Pregabalin

 Acne Rosacea = Patient blushes easily, especially when consuming hot liquids, a;cohol, or
spicy foods. Recurrent papules and pustules in symmetrical pattern on cheeks.
 Optic neuritis = loss of vision, eye pain, Dyschromatopsia – specially Red vision.
 Methemoglobinemia caused by CHLOROQUINE

 Ethambutol (Tuberculosis medication) is associated with optic neuritis (Visual deterioration)

and color blindness.

 Whipple’s Disease = PAS stained macrophages with weight loss, abdominal pain and
polyarthritis

 T(9:22) translocation encoding for the BCR-ABL gene is Philadelphia chromosome and is
found in CML (Chronic Myeloid Leukaemia)
 Anterior Interosseous Nerve compromise can result in inability to pinch the thumb and
forefinger together.
 Acute Asthma
ABG reveals respiratory acidosis with hypoxaemia.
IV Aminophylline is used when there is no response to nebulizers and corticosteroids
Aminophylline is a brochodialator

 Ehlers-Danlos Syndrome
Hyperelasticity of skin
Joint Hypermobility
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  Limited Systemic Sclerosis = Diagnosis of CREST with anti-centromere antibodies to be
positive

 Morphine
3mg oral morphine = 1.5mg SC morphine = 1mg SC diamorphine
 Symptoms of Overactive bladder = Oxybutynin (Anticholinergics (Ach)
 Not associated with HYPERKALAEMIA = Deepening of Q-waves

 Asbestos causes mesothelioma and cancers of the lung, larynx, and ovary
 ECGs

 Infective Endocarditis
Most common cause Stap. Aureus

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Common after Prosthetic Valve surgery Staph. Epidermidis
Common in people with poor dental hygiene or following dental procedure Strep. Viridans

 SVT (Supra Ventricular Tachycardia) management = Adenosine

But if patient has Asthma, then give Verapamil (CCB)

Ventricular Tachycardia

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  Atrial Myxoma = Patient with Hx of syncope, SOB, Pulmonary Embolism, EARLY-MID
DIASTOLIC Murmur
 Concept of uncertainty = Answer = Standard error of mean.
Standard error of the mean is the standard deviation of the sampling distribution of the mean.

 Haemosiderosis causes = deposit of iron in Kupffer cells

 Haemochromatosis causes = deposit of iron in Hepatocytes/Liver cells

 Holmes-Adie pupil is a cause of anisocoria. Affects young adults and accommodation is

also impaired and sluggish. The clue is it is associated with the loss of tendon reflexes.

 Peyronie’s disease is a form of erectile dysfunction that causes a bend in the penis that can
make an erection quite painful.

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  Long standing diabetes can cause gastroparesis = Metoclopramide is the management.
Example: Patient has 15 year history of type 2 diabetes. Her symptoms are worse after eating,
and on occasion she vomits food that appears to be undigested. Her weight is stable.

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  Pyrazinamide (TB drug) can cause hyperuricaemia causing gout arthralgia, myalgia and
hepatitis.
 Rifampicin is a P450 enzyme inducer and will therefore increase the metabolism of
Warfarin, therefore decreasing the INR.
 Ethambutol needs dose adjusting in patients with renal impairment since its nephrotoxic.

 For a chlamydia infection, a woman's vaginal discharge might have a strong odor and
yellowish tint. Men might have a cloudy or clear discharge. With gonorrhea, both women
and men may experience green, yellow, or white discharge.

 Patau’s Syndrome (Trisomy 13) –

New born, delivery at term, under weight, Punched-out skin lesion on the scalp, cleft lip, and a
small chin, convex shaped deformity of the plantar surface of the feet, Holosystolic murmur,
INTESTINE protrude through the umbilicum, Polydactyly.

 Vitamin B12 deficiency results in elevated Methylmalonic acid (MMA) levels.

 APGAR Score

 GCS Score

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  Painless chancre of primary syphilis treatment = Benzathine Benzylpenicillin
 Cystic Fibrosis (CF) presents with Meconium ileus, characterised by bilious vomiting,
distended loops of bowel and failure to pass meconium.
 Infectious mononucleosis = Heterophile antibody tests
 LTOT (Long Term Oxygen Therapy) - Evidence for use of long-term oxygen therapy in
patients with chronic obstructive pulmonary disease
Patients with stable chronic obstructive pulmonary disease (COPD) and a resting
PaO2 ≤7.3 kPa should be assessed for long-term oxygen therapy (LTOT) which offers
survival benefit and improves pulmonary haemodynamics. (Grade A)
LTOT should be ordered for patients with stable COPD with a resting PaO2 ≤8 kPa with
evidence of peripheral oedema, polycythaemia (haematocrit ≥55%) or pulmonary
hypertension. (Grade A)
LTOT should be ordered for patients with resting hypercapnia if they fulfil all other criteria
for LTOT. (Grade B)
 Cytomegalovirus is the most common and important viral infection in solid organ transplant
recipients.
 Myasthenia gravis vs Multiple Sclerosis
Symptoms of myasthenia gravis can vary from person to
person and may include: More common symptoms of MS include:

 blurry or double vision  bladder dysfunction

 drooping eyelids  bowel problems
 eye muscle weakness  cognitive disturbances
 facial paralysis  chronic pain sensations
 shortness of breath

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  speech impairment  depression
 trouble swallowing or chewing  dizziness or vertigo
 weakness in the limbs or neck  emotional disturbances
 fatigue
 itching
 muscle spasticity or weakness
 numbness or tingling
 sexual dysfunction
 trouble walking
 vision disturbances

Other uncommon symptoms of MS may also

include:

 speech problems
 loss of taste
 swallowing problems
 tremors
 seizures
 breathing problems
 hearing loss

 Chlamydia is the most common sexually transmitted infection in the UK.

Gonorrhoea is the second most common bacterial STI in the UK after Chlamydia
 Atropine and Pralidoxime is a combination medicine used as an antidote to treat poisoning
by a pesticide (insect spray).
 Polycythaemia Rubra Vera diagnosis screen for JAK2 mutation
 Missed Miscarriage (Delayed miscarriage) = Dead fetus before 20 weeks without the
symptomsof explusion. May or may not have vaginal bleeding. Cervical os is closed.

 Abortion is allowed in UK till gestational age 24 weeks.

After 24 weeks gestation it is illegal.

 Nitrofurantoin (used in UTI) can cause haemolysis in G6PD deficiency. This is often self-
limiting.

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Osteosarcoma
You can get osteosarcoma at any age. But it's the most common type of primary bone cancer in
adolescents (10 to 19 years). Osteosarcomas can grow anywhere in the skeleton. The most
common sites for osteosarcoma include the:

 thigh bone (femur)

 upper shin bone (tibia)
 upper arm bone (humerus)

Chondrosarcoma
Chondrosarcoma is most common in adults aged 30 to 60 years old. It is a cancer of cartilage
cells within the bone.

Cartilage is the shiny, smooth substance that normally covers the ends of bones in the joints. But it
can also be found within the bone.

Chondrosarcoma can grow inside a bone or on the bone surface. The most common sites for
chondrosarcoma are the:

 hips (pelvis)

 shoulder bones (girdle)

 upper thigh bone (femur)

 ribs

Ewing sarcoma
Ewing sarcoma is most common in children (0 to 14 years) as well as adolescents. It usually starts
in the:

 pelvis (hips)

 thigh bone (femur)

 shoulder bones (girdle)

 ribs

You can also get a Ewing tumour in the soft tissues of the body. Soft connective tissue tumours
are called soft tissue sarcomas. These are treated the same way as Ewing bone tumours.

Spindle cell sarcoma

Spindle cell sarcomas are mostly found in adults aged 30 to 60 years old. The most common sites
are the bones of the legs.

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Spindle cell sarcoma of the bones is rare. They are very similar to osteosarcomas but don't
produce the bony substance called osteoid, which osteosarcomas do. They behave like
osteosarcomas, and doctors treat them in a similar way.

There are several types of spindle cell sarcoma:

 fibrosarcomas

 leiomyosarcomas

 angiosarcomas

 undifferentiated pleomorphic sarcomas

Chordoma
Chordoma is a very rare, slow growing type of bone cancer.

Chordomas grow from the notochord, which forms the early spinal tissue in a baby developing in
the womb. During development, the notochord gets replaced by bone. But sometimes small areas
of notochord may remain in adults.

About 50 out of 100 chordomas (50%) grow in the bone at the bottom of the spine (sacrum). The
rest develop in the bones of the skull and spine.

 Shellfish reservoir of Hepatitis A. If a patient presents with features of hepatitis after having
seafood meal, think Hepatitis A.
Request = IgM antibodies to Hepatitis A virus

 90 year old female with Urge incontinence = treatment = Tolterodine

 Alzheimer’s Disease treatment = Donepezil, Rivastigmine and Galantamine
NOTE: Use Memantine if patient has heart block shown on ECG

 Parkinson disease related severe tremor and dustonia treatment = BENZHEXOL

 Coeliac Disease
If TTG IgA/EMA is negative +IgA deficiency ---> perform IgG
If TTG is positive ---> Perform EMA (IgA endomysial antibody)
 Fetal US Atresia

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No gastric bubble Esophageal Atresia

Single Bubble Gastric/Pyloric Atresia

Double Bubble Duodenal Atresia

Triple Bubble Jejunal Atresia

 Direct Vs Indirect Inguinal Hernia

Direct pass through the Posterior Indirect passes through the deep
wall of the inguinal canal and superficial inguinal ring

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Lies MEDIAL to the inferior Lies LATERAL to the inferior
epigastric artery epigastric artery

 Patient undergoing colectomy, prophylactic antibiotic = Cefuroxime + Metronidazol

 Paralytic Ileus caused by Hypokalemia & Hypercalcemia

 Malaria = Schuffner’s dot are exclusively found in Plasmodium ovale and Plasma vivax.
PRIMAQUINE treatment

 ABO incompatibility or Rhesus haemolytic disease in new born at day 2 jaundice

DAT positive (Direct Antiglobulin Test) is seen in both ABO incompatibility & Rhesus haemolytic.
In general, DAT is weakly positive for ABO but stringly positive in Rhesus haemolytic.
The decrease haemoglobin level and raised reticulocyte count point to ABO incompatibility.

 HLA gene
HLA-DQ2 Type 1 DM and Coeliac disease
HLA-DQ3 Type 1 DM
HLA-B27 Ankylosing spondylitis, Psoriatic arthritis,
Inflammatory bowel diasese, Reactive arthritis

 Patent Foramen Ovale = TOE (Transoesophageal Echocardiagraphy) with bubble contrast

is the gold standard
 Mandibular fracture = Inferior Alveolar nerve damage
 STI
Painless multiple ulcers HPV (6 & 11)

Painful multiple ulcers HSV (Genital Herpes) (give analgesics &

Aciclovir)
Painless single (Chancre) Syphilis (Treponema Pallidum)

Painful single (Chancroid) H. Ducreyi (can be multiple, painful)

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  INR = Normal value should be between 2 – 3
However, with a mechanical heart valve replacement, target INR = 2.5 – 3.5 (3 to 4 in PlabKeys)

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  Actinic Keratosis treatment = Fluorouracil

 Common ECGs
Anterior Myocardial Infarction = ST elevation in V2, V3, V4

MI involves ST segment elevation in the inferior leads II, III and aVF

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  GoodPastures Syndrome Vs Rhabdomyolysis
GPS is the coexistence of acute glomerulonephritis and pulmonary alveolar haemorrhage.
Best initial test for diagnosis for GPS = anti-GBM antibodies.
Single most accurate test is lung or kidney biopsy
Treatment of GPS = Plasmapheresis and Immunosuppressant medications.

Rhabdomyolysis will never have lung involvement (haemoptysis) and CK will be high.
Don’t be tricked by “Marathon Runner” patient, read carefully.

 Haemophilia-A feature:
Prolonged aPTT
Reduced factor VIII level
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Normal PFA-100
Normal Ristocetin-induced platelet aggregation

 Anterior Uveitis is also referred to as iritis and iridocyclitis

Commonly associated with Ankylosing spondylitis, Reactive arthritis, Crohn’s, Ulcerative colitis
Treatment = Prednisolone eye drops to reduce inflammation; Cyclopentolate to prevent adhesions
b/w lens and iris by keeping pupil dilated

 Cyclical combined or Continuous combined HRT

Permenopausal patient = Cyclical combined HRT
Menopausal patient (12 months or more of no periods) = Continuous combined HRT

 Leukemia

 Bleeding disorder

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  Upper GI bleeding management for VARICES
Step 1: IV fluids
Step 2: Endoscopy for unstable patients, so that bleeding point is visualized.
Step 3: Band Ligation is the first choice treatment for all patients with upper GI bleeding from
oesophageal varices.
Step 4: Administer Terlipressin. Stop after definitive haemostasis achieved or after 5 days
Step 5: Avoid Omeprazole acutely unless the patient has known peptic ulcer disease.
If Q specifies that “initial management” has been performed, assume that IV fluids and Terlipressin
have been given and thus answer then would be “Emergency Endoscopic Band Ligation”.

 Massive transfusion causes HYPOCalcaemia which results from citrate toxicity.

Hypomagnesaemia, Hyperkalemia can also occur

 Antibiotics

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  Acute Prostatitis treatment = Ciprofloxacin or Ofloxacin
 Benign Paroxysmal Positional Vertigo (BPPV) is cause by dislodgement of tiny calcium
carbonate crystal (otoconia) which affects Posterior semi-circular canal.
 Womena ta hight risk of Pre-eclampsia (who has pre-eclampsia in the previous pregnancy)
Should take ASPIRIN 75-150 mg daily from 12 weeks gestation until delivery.
 Important Epidemiology
Malaria Africa Fever, Chills, rigours
Dengue Fever Far East Asia Generalised rash, biphasic
fever, retro-orbital pain, bone
pain

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Typhoid South America Severe headache, patients
adopt a crouching position
Diphtheria India Presents with flu-like
symptoms initially, enlarged
anterior cervical lymph nodes

 HIV Post-Exposure Prophylaxis (PEP)

PEP to be given after non-safe sex with a high risk individual, needle stick injury when the source
is high risk, bite froma high-risk biter such as drug addict.
PEP to be given asap up to 72 hours post-exposure
PEP = Truvada and Raltegravir for 28 days
Follow-up HIV test done at 8-12 weeks after exposure
When can we reassure the contact person? If the source is on Anti-retrovirals for >= 6 months and
his HIV viral load < 200

 HIV Prophylaxis

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  LEUKEMIA (brief table)
Blast cells = Rule out Chronic Leukaemia
Mature cells = Rule out Acute Leukaemia
0-20 = ALL = Blood blast cells, bone-marrow lymphoblasts
20-40 = AML = Blood blast cells and Auer rods, bone-marrow myeloblasts
40-60 = CML = Blood no blast + Mature granulocyte, Ph- chromosome, Massive spleen
60+ = CLL = Blood no blast + Mature lymphocyte (smudge)
Multiple Myeloma= MM = Plasma cells

 Standard rule before elective surgery:

6 hour fasting minimum (No food) before procedure.
Taking small anounts of clear fluid is safe up to 2 hours before the procedure.

 Wolff-Parkinson-White syndrome
Key = DELTA waves, Pre-excitation, Prolonged QRS
 Anaphylaxis Adrenalise dose
0 to 6 years = 0.15ml 1 in 1000
6 to 12 years = 0.3ml 1 in 1000
12+ and adult = 0.5 ml 1 in 1000

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  CLOZAPINE
If a SMOKER patient is on Clozapine and he quits smoking, CLOZAPINE dose needs to be
lowered.
In smoker a higher dose of CLOZAPINE is required since it broken down more quickly.

 Rhinophyma seen in ACNE ROSACAE

The first signs of rosacea include: Common triggers for rosacea include:
 redness (blushing) across your nose,  alcohol
cheeks, forehead and chin that comes  spicy foods
and goes  cheese
 a burning or stinging feeling when using  caffeine
water or skincare products  hot drinks
 aerobic exercise like running

 Superior Vena Cava occlusion = CT chest with Contrast (Treatment = DEXAMETHASONE)

 Haemorrhagic Shock

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  Metformin is Nephron-harmful and thus needs to be ceased “stopped” before any contrast
study

 Blood Gas abnormality

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  Drug Conversion
Percentage conversion is based on g/100 ml so;
0.5% solution would be 0.5g/100 ml or 500 mg/100ml
This gives 5 mg/ml
If a patient had already been given 30 ml of a 0.5% solution so he’s been given 30 ml at 5mg/ml
= 30 ml x 5 mg/ml = 150 mg). He is been given 150 mg of the drug.
If max dose for patient is 3 mg/kg and patient is 100 kg.
SO max dose will be 100 kg x 3 mg/kg = 300 mg
This mean he can only be given remaining 150 mg (300 mg – 150 mg = 150mg)

Oral Tramadol 600 mg = Oral Morphine 60 mg

Oral morphine 60 mg = Subcutaneous morphine 30 mg

 Epidural Vs Subdural

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  Multiple Sclerosis
Treatment = initial and in acute phase (replase) = Oral or IV Methylprednisolone
Long Term = Interferon-beta or Glatiramer acetate

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  RO-ME mnemonic for Acidosis or Alkalosis
Respiratory Opposite
When pH is up, PaCO2 is down = Alkalosis
When pH is down, PaCo2 is up = Acidosis

Metabolic Equal
When pH is up, HCO3- is up = Alkalosis
When pH is down, HCO3- is down = Acidosis

 Calculating Alcohol units

Strength (ABV) x Volume (ml) / 1000 = Units

A pint of beer is approx. 568 ml. A pint of standard beer (3.5 % ABV) would equate to 2 units of
alcohol.

 Vaccination for Pregnant in UK = Influenza and Pertussis

 Pertussis vaccine best time between 16 weeks and 32 weeks gestation.
 Barrett’s Oesophagus causes Columnar Metaplasia, columnar epithelium replaces the
normal stratified squamous epithelium.
 Scarlet Fever = Strawberry tongue = caused by Streptococcus Pyogenes
 Listeria Monocytogenes in CSF treatment = IV Ampicillin + Gentamicin
 Streptococcus Pneumoniae is the common bacterial pneumonia

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Gram positive-diplococci
Herpes Labialis is one of its feature
 ARB blocker like CANDESARTAN may drop BP during anaesthesia. Discontinue it 24
hours before the surgery.

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  Age related Macular degeneration = Straight line appear wavy (Metamorphosia)

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Central retinal artery occlusion (CRAO)

Branch Retinal Artery Occlusion (BRAO)

Wedge shape

Central Retinal Vein Occlusion (CRVO)

Dot-blot, flame haemorrhages (stormy sunset)

Branch Retinal Vein Occlusion (BRVO)

Wedge shape

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Diabetic Retinopathy

Hypertensive Retinopathy

CMV Retinitis
Pizza appearance of retina

Anterior Uveitis (iritis)

Irregular in shape

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Acute angle closure glaucoma
Oval in shape

Orbital Cellulitis

Periorbital Cellulitis

Chalazion (Meibomium gland obstruction)

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Stye

IRIDODIALYSIS
Traumatic detachment of iris from ciliary body at
its root.
‘D’ shaped pupil.

 Keratoconjunctivitis Sicca treatment = Hypromellose drops, NaCl, Sodium Hyaluronate

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  Bacterial Conjunctivitis rule
If less than 3 days = Self care, Clean discharge using cotton wool soaked in water
If more than 7 days = Topical antibiotics

 DDH (Developmental Dysplasia of the Hip)

Less than 4.5 months age do UltraSound
More than 4.5 months age do X-ray

 Fracture of Femur and Hip Dislocation

Fracture neck of FEMUR Shortened leg + Externally rotated
Anterior HIP dislocation Shortened leg + Externally rotated + Abducted

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Posterior HIP dislocation Shortened leg + Internally rotated + Adducted

 Colle’s fracture = Dinner fork deformity = MEDIAN Nerve Injury

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  Biliary Atresia
Definitive diagnosis = Percutaneous Biopsy
Treatment = Kasai Procedure (Hepatoportoenterostomy)
 Fluid Deficit = % Dehydration x Weight x 10
Total fluid needed = Maintenance fluid + Fluid deficit

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  IV Fluid Resus :
For term Neonate (first 28 days in life) = 10ml per kg
For children & young people = 10ml per kg

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  CYSTIC Fibrosis
1 day old infant developed abdominal distension, bilious vomiting and meconium ileus. Prenatal
US shows echogenic bowel.

In the above case don’t get confused with Hirschsprung’s disease. Hirschsprung’s disease
(increased frequency in foetuses with Down syndrome) could produce hyperechogenic bowel due
to hypoperistalsis.

Indications to consider screening for cystic fibrosis

 Family history
 Congenital intestinal atresia (50% Duodenal)
 Meconium ileus
 Rectal prolapse
 Acute or chronic pancreatitis

 Majority of HUS (Haemolytic Uraemic Syndrome) is caused by E.coli and it causes Acute
Kidney injury.
Creatinine is always raise. Don’t pick :Addison’s if the it showing hyponatremia and
Hyperkalemia

 Kawasaki Disease long term complication is Coronary Artery Aneurysm.

Treatment = IV immunoglobulin and high dose aspirin in acute phase
Perform Echocardiogram at 6 weeks to exclude an Aneurysm

 Coeliac disease has Alpha-Gliadin antibodies

 Congenital Hypothyroidism
Investigation = Heel prick test of newborn at Day 5
If Heel Prick test is positive, proceed to:
-Radioisotope Scan

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-Ultrasound of the neck

 Cow Milk Allergy

IgE Mediated Non-IgE Mediated
Occurs within 2 hours of milk being Occurs 2 to 72 hours of milk being
consumed consumed
Skin symptoms - Acute pruritus, Symptoms: Reflux, Loose stool or
Urticaria, Angioedema constipation, perianal redness,
Abdominal pain, food aversion
Symptoms: Nausea, Vomiting,
Colicky abdominal pain Skin symptoms: Pruritus, Erythema,
Atopic eczema

 Acute Prostatitis treatment = Quinolone such as Ciprofloxacin or Ofloxacin

Symptoms:
Suprapubic tenderness, lower back or perineal pain
Tender prostate
Low grade fever
Urinary symptoms such as dysuria, frequency and urgency

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  Aortic Dissection diagnosis
Haemodynamically Stable patient = CT Angiography
Haemodynamically Unstable patient = Trans-Oesphageal Echocardiogram

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  Lithium Interactions
Increase Lithium concentration QT Prolongation when used with
ACEi, ARBs Amiodarone, Amisulpride
NSAIDs Citalopram
Diuretics Clarithromycin

 NALTREXONE prevents relapse in opioid dependents who have remained opioid-free for at
least 7 to 10 days and motivated to stay abstinent.
Naloxone (injectable) = For Overdose
Naltrexone (oral) = For Abstinence
Methadone = For Detoxification

 Genes
Genes Disease
BCL2 B cell lymphoma

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Apolipoprotein E (APOE) Alzheimer’s
FBN1 Marfan Syndrome
NOTCH1 T-cell leukaemia
HOXB13 Prostate cancer
HLA-DQ2 Type 1 DM & Coeliac disease

 Types of Hypersensitivity reactions

Type I Type II Type III Type IV
IgE IgG or IgM IgG or IgM Delayed
hypersensitivity
Immediate reaction Hours to days Hours, days or weeks 24 to 72 hours
Mast cells & Basophils
-Allergy -Haemolytic disease of -Serum sickness, -Contact dermatitis
the newborn
-Anaphylaxis -Rheumatoid arthritis -Tuberculin skin test
-Autoimmune (RA) (Mantoux).
-Atopic disease
haemolytic anaemia
-SLE
-Goodpasture’s
-Post-streptococcal
syndrome
glomerulonephritis.

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