Internal Medicine - Rapid Revision Notes.pdf

Manoj Aryal
Manoj AryalConsultant physician at Lumbini Medical College (Kathmandu University)
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FMGE-RAPID REVISION Dr.Rajesh Gubba MD GENERAL MEDICINE DNB CARDIOLOGY
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r u v r f
• Most common cause of Right heart failure ! • Most common cause of acute corpulmonale ! • Most common cause of chronic corpulmonale ! L HF Massive PE COPD
Classification of Heart failure 1 55 70 4 AfpEF Afp EF DUMP 40 Diastolic CAD t HEMP systolic RCMP
Earliest manifestation of left heart failure PND I
8 NILA O Exertional Less than ordinary
Earliest manifestation of right heart failure I A JVP
Pattern of breathing in congestive heart failure R Apnea
Name of the criteria for congestive heart failure I Framingham's
Which CXR is suggestive of increased Pulmonary venous pressure ? • A • B • C • D I CJ OO o
Cardiac biomarker for congestive heart failure MyProBMP
Drug of choice for Acute left ventricular failure I furosemide
Treatment of Acute Heart Failure Oxygen & Ventilatory support Morphine Vasodilators Diuretics Ionotropic agents t t It NE MTG preload Dob re HE gommHg
Drugs for chronic heart failure F B ACE ES's ARBS Ald
Preferred drug for HFrEF I AR NI Valsautans secubitril
• 24/M patient presented with h/o ataxia of gait with rhombergs sign positive & dysmetria. He also c/o dyspnea on exeretion. Echo showed EF of 30% with dilated chambers. What would be the etiology? A. Cerebellar ataxia B. Freiderich ataxia C. SACD D. Selenium deficiency SEA
• B
Most common toxin causing Dilated cardiomyopathy I Alcohol
What are the inflammatory causes of DCMP? SLE S S DM
What are the nutritional causes of DCMP? I B t se t
What are the endocrine causes of DCMP? DM Thyroid
What are the hematological causes of DCMP? F sickle cell dis
What are the toxins that causes of DCMP? Cocaine
What are the infiltrative causes of DCMP? t Hemochromatosis
27
What is the criteria for cardiomegaly ? I CE I C T 705
1st line 2DEcho 7 5
Which of the following drugs is not given in dilated cardiomyopathy? a. Beta blocker b. Calcium channel blocker c. Spironolactone d. ACE inhibitors
Ans. (b) Calcium channel blockers
Indication of this device in DCMP with LBBB patients? A. QRS duration > 110msec B. QRS duration > 100msec C. QRS duration > 150msec D. QRS duration > 120msec Or O PIMP Wide Qrs It no LBBB MEC CI
• C CRT O O 3 leads O
Peripartum Cardiomyopathy 34 I Damp Last month I I in 6 months of delivery No pre existing cardiac dis
Peripartum Cardiomyopathy • Defined as: • Features of dilated cardiomyopathy during the last month of pregnancy or within 6 months of delivery • Absence of a demonstrable cause for the cardiac failure 35
• Treatment • Beta-blockers Sotalol
• Treatment • Beta-blockers have been administered judiciously to these patients, with at least anecdotal success. • Sotalol is acceptable for ventricular or atrial arrhythmias if other beta-blockers are ineffective. • Diuretics, hydralazine, and nitrates help treat the heart failure with minimal risk to the fetus.
38
39 Stress cardiomyopathy, also called :- apical ballooning syndrome, broken heart syndrome, tako-tsubo cardiomyopathy. É t
• Modified Mayo criteria for Takotsubo Cardiomyopathy (T.C.M)/ Broken heart syndrome • 1. Transient hypokinesia/ akinesia of Left ventricle • 2. Absence of any coronary artery occlusion by a thrombus • 3. ST segment elevation/T wave inversion or modest cardiac troponin elevation • 4. Absence of pheochromocytoma or myocarditis • *Needs all four for diagnosis 40 O E I
Treatment Aspirin
Treatment • Immediate therapy is similar to any acute MI. • Most patients receive aspirin, beta-blockers, and ACE inhibitors until the LV fully recovers. • Despite the presumed association with high catecholamines, the use of ACE inhibitors or ARBs, but not beta-blockers has been associated with improved long-term survival.
If cardiogenic shock 43 TTC IABP
If cardiogenic shock • Rx:If cardiogenic shock! IABP • Because causative agent is catecholamine excess ! so NE, Dopamine & Dobutamine should not be given. • SCD can happen 44 O
HYPERTROPHIC CARDIOMYOPATHY
All are true regarding the specimen shown except: a. Asymmetrical septal hypertrophy b. Left ventricular outflow tract obstruction c. Diamond-shaped cavity of left ventricle d. Diastolic dysfunction O I Banana
Ans. (c) Diamond-shaped cavity of left ventricle
Definition
Definition • The definition has evolved over time; while it traditionally has been defined by LV outflow obstruction due to septal hypertrophy, now it is considered present any time that any LV wall is measured at more than 1.5 cm thick on an echocardiogram.
50 f 71.5 In
51 Hold a
Internal Medicine - Rapid Revision Notes.pdf
Ace of Spades Apical hypertrophy
•Mutations:- B myosin Ch 14 AD
•Mutations:- • Greater than l00 mutations have been identified in at least 12 sarcomeric genes with the beta-myosin heavy chain being most frequently affected, followed by myosin-binding protein C and troponin T. It is autosomal dominant with defect of beta myosin gene with defect on chromosome 14. These three genes account for 70% to 80% of all cases of HCM. e
56
• Precordial auscultation: 57 I S 52 54 ESM
• Precordial auscultation: • normal or paradoxically split S2, S4, • harsh systolic diamond-shaped murmur at LLSB or apex, • enhanced by squat to standing or Valsalva (murmur secondary to LVOT obstruction as compared to aortic stenosis); • often with pan-systolic murmur due to mitral regurgitation. 58
2D echo 59 1st line confirm cardiac MRI
2D echo • Also know, • Best investigation in case of HOCM is 2-D Echocardiography which demonstrates the characteristics systolic anterior motion of the mitral valve. 60
61 ECG LIAM SOKOLOW LYON I criteria SU RVs RUG 35mm
62 verapamI
Treatment 63
Treatment • Medical agents: DOC is Propranolol as it will decrease heart rate and reduce oxygen consumption. • The comparative increase in duration of diastole will enhance the filling of the heart with corresponding increase in cardiac output. • Verapamil may also be used 64
65 I
RESTRICTIVE CARDIOMYOPATHY
• Restrictive cardiomyopathy - Definition 67 Diastolic dysfunction HfpEE O
• Restrictive cardiomyopathy includes a group of heart disorders in which the walls of the ventricles become stiff, but not necessarily thickened and resist normal filling during diastole. • The heart cannot relax normally during diastole so it is unable to fill properly. • Usually with intact systolic function • Rarest cardiomyopathy. 68
• What is the most common etiology causing RCMP ? 69 AA At AB
• The AL (light-chain) type is the most common, with cardiac involvement in 50%.
• How does Fabrys disease causes RCMP ? 71 I Lysosomal storage dis X Galactosidase A 4 GI
• How does Fabrys disease causes RCMP ? • Fabrys disease - Fabry disease is a rare genetic disease a deficiency of the enzyme alpha-galactosidase A (a-Gal A) that causes a buildup of a type of fat called globotriaosylceramide . • It is a type of lysosomal storage disorder. • Neoplasm 72
What is the antibody in this condition causing Restrictive cardiomyopathy ? A. Anti Smith B. Anti centromere C. Anti topoisomerase D. Anti ds DNA Localised Diffuse scleroderma
• C
What is the adverse effect of the drug used for treatment in the following condition causing RCMP? A.Peptic ulcers B. Weight loss C. Distal muscle weakness D.Dementia TO sarcoidosis t steroid
• A • The following are causes of Bilateral hilar Lymphadenopathy :- • Sarcoidosis • Infection • Tuberculosis • Fungal infection • Mycoplasma • Intestinal Lipodystrophy (Whipple's disease) • Malignancy • Lymphoma • Carcinoma • Mediastinal tumors • Inorganic dust disease • Silicosis • Berylliosis
Thromboembolic complications 77 I 1 Common Af
Thromboembolic complications • As many as one-third of patients with idiopathic RCM may present with thromboembolic complications, especially pulmonary emboli secondary to blood clots in the legs. • If atrial fibrillation is present, a high risk of left atrial clots and systemic emboli is present. 78
• On Examination – JVP:- 79 A JVP K S tent n ca y descent Exagerrated
• On Examination – JVP:- • The increased venous pressure is reflected in increased jugular venous pulse. • The degree of elevation of the jugular venous pressure indicates the severity of impaired filling of the right ventricle. • Rapid x and y descents are seen with rapid ‘Y’ descent being the most prominent finding. • Kussmaul's sign. 80
ECG:- Low voltage O Llomm O 5m
ECG:- • low voltage, conduction disturbances, Q waves.
• Echocardiogram :- I 1st line Amyloidosis Dotted appearance I
• The echocardiogram reveals a small, thickened LV with bright myocardium (speckled), • rapid early diastolic filling revealed by the mitral inflow Doppler, and biatrial enlargement. • The LV chamber size is usually normal with a reduced LVEF. • Atrial septal thickening may be evident.
Treatment • Diuretics
Treatment • In acute cases, diuretics can help, but excessive diuresis can produce worsening kidney dysfunction. • As with most patients with severe right heart failure, loop diuretics, thiazides, and aldosterone antagonists are all useful.
Anticoagulation Lmult warfarin
Anticoagulation • Atrial thrombi are not uncommon, although the role of anticoagulation in amyloidosis remains ill defined.
• Can we use Digoxin in RCMP ? I
• Digoxin in RCMP may precipitate arrhythmias and should not be used. O
• Q) Which is the location of Erb's point during auscultation? 91 a. A = 2nd intercostal space right parasternal line b. B = 2nd intercostal space left parasternal line c. C = 3rd intercostal space left parasternal line d. D = 5th intercostal space left parasternal line and 1 2 O
92 I
• Aortic area —* Second intercostal space to the right ofthe sternum (along right upper sternal border). • Pulmonic area — Second intercostal space to the left of the sternum (along left upper sternal border) • Erb'spoint — Third intercostal to the left of the sternum (along left sternal border). • Tricuspid area —p Fourth or Fifth intercostal space to the left of the sternum (along left lower sternal border). • Mitral area (Apex) — Fifth intercostal space on the left midclavicular line. 93
S1 S2 S3 S4 t t t t IVC IVR 1st rapid and rapid filling proto diastole filling
Comparison of all Heart Sounds Feature 1st Heart Sound 2nd Heart Sound 3rd Heart Sound 4th Heart Sound Character Duration Frequency Cause Timings Better heard with High High Low Low 0.14sec 0.11 010 0.10 25 45 5043 220 220 Mr El TV AVG PV Rapid V f and v f IVC IVR 1st 2nd D Dr Bell Bell
96
97
Wide Physiological Splitting of S2 Early A2 Delayed P2 MR ASD USD P Embolism P HTM RBBB w ectopic beats LV paced
Causes of Fixed (wide) split s2 are all except? A. ASD B. VSD C. Pulmonic Stenosis D. Acute Right Heart Failure 99 wide variable split
• B
101
• Ans. is 'a' i.e., 3rd left intercostal space • Best areas to auscultate for both components of the second heart sound (A2 and P2) are either the left sternal border at the level of second intercostal space (Pulmonic area) or the left sternal border at the level of third intercostal space (Erb 'spoint).
3rd Heart sound are best heard with ? • A • B • C • D
• A
3rd Heart sound is best heard at ? i. A ii. P iii. E iv. T v. M APE
• V
Physiological S3 is heard in all except ? A. Age upto 40yrs B. Children C. Pregnancy D. Sumo fighters 39
• D
Pathologic S3: I RUF LVF IHR MR AE
Pathologic S3: 1) Ventricular dysfunction - poor systolic function, increased end- diastolic and end-systolic volume, decreased ejection fraction, and high filling pressures. • Idiopathic dilated cardiomyopathy • Ischemic heart disease • Valvular heart disease • Congenital heart disease • Systemic and pulmonary hypertension
Fourth heart sound 111 Alway pathological APE
Fourth heart sound • S4 is low pitched', presystolic sound, produced in ventricle during 2nd rapid filling phase caused due to atrial contraction. • S4 is never present in normal individuals. • Presence of S4 is always pathological. • Loudest (Best heard) at the Left ventricular Apex when the patient is in left Lateral position. • It is accentuated by mild isotonic or isometric exercise in the supine position 112
Causes of Fourth Heart Sound (S4 gallop) • Mnemonic: HOCM • 1. HOCM/HTN • 2. Obstruction other than HOCM • • Aortic stenosis • • Pulmonary stenosis • 3. Cardiac tamponade • 4. Myocardial infarction 113 I
114 t t t t AS MS Ts CP Atrial Myxoma Ps High High High LOL systoli Diastolic
115
• The Jugular venous pulse (JVP) reflects phasic pressure changes in the right atrium and it consists of three positive waves and two negative troughs. 116 5
Wave Form Phase of Cardiac cycle Mechanical event A wave C wave X wave V wave Y wave 0 End diastole AC Early systol TV bulging Mid n A R Late Ven fillin Early Diastole A emptying
118
Abnormalities of A wave a absent Giant a cannon t t t j CAB RA Myxoma AE TS P HTM
Abnormalities of X wave 120 X A x Reversed I t TR RCMP
• ABNORMALITIES OF THE V WAVE • V wave is increased in - 121 TI
Abnormalities of Y wave 122 ent Early Exag slow Y t t t t C T TR TS CP
123
Kussumal Sign Kussumal respiration O t t A JV Vol DEA on insp RAF RCMP CP
Arterial Pulse • Pulsus paradoxus:- • Pulsus alternans:- • Pulsus parvus ET tardus:- • Pulsus bigeminus:- I Electrical Alte CP ECG Massive PE severe LVF IS Digoxin
Arterial Pulse • Waterhammer pulse • Dicrotic Pulse:- • Pulsus bisferiens:- AI MI Damp I HOLE
Which condition following murmur is seen? • A. Aortic regurgitation • B. ASD • C. Transposition of great arteries • D. Branch pulmonary artery stenosis I Continuous u r
Continuous murmur Mammary S PDA RsoV B V P S AV fistula venous hum
129
CONDITIONS? A. ASD B. VSD C. PDA D. RSOV Psy VSD MR TI
• B
CONDITIONS? A. MVPS B. Venous hum C. Coarctation Aorta D. Aorto pulmonary window LSM MVPS TUPS I
• A
A. AS B. PS C. HOCM D. TS CONDITIONS all except ? O MSM ESM MIM
• D
Q) Early diastolic murmur is seen in: a. VSD b. ASD c. Mitral stenosis d. AR 136 1 AR MS PR TS
• D
• Carey Coombs murmur - • Austin Flint murmur - • Graham-Steel murmur - • Rytands murmur - • Docks murmur - • Mill wheel murmur - • Gibsons murmur - 138 ARF VSD PDA AI P HTM PR CAB LAD stenosis Diastolic murmur Tir emboli PDI
• Carey Coombs murmur -Rheumatic fever • Austin Flint murmur -Aortic regurgitation • Graham-Steel murmur -Pulmonary regurgitation • Rytands murmur -Complete heart block • Docks murmur -Left Anterior Descending (LAD) artery stenosis • Mill wheel murmur -Due to air emboli (air in PV cavity) 139
Mitral Stenosis
Q) Area of mitral orifice in adults is: A. 6-8 cm2 B. 0.5-2 cm2 C. 4-6 cm2 D. 1-4 cm2 141
D D
Etiology of Mitral stenosis 143
• S1______________________S2__________________________S1 O snap p Pst a mus o d d I Loud soft s cage MDM t p AIN
Complications of MS
Complications of MS • Atrial fibrillation • Dysphagia • Wheeze • Ortners syndrome i g RLM Hoariness
• A O t p nitrate LEH
148
RA É
150 2D echo J t ECG Digoxin
In symptomatic patients • In symptomatic patients, some improvement usually occurs with restriction of sodium intake and small doses of oral diuretics.
Which procedure is being done in the image shown? a. Percutaneous mitral balloon valvotomy b. Percutaneous mitral valvuloplasty c. Percutaneous mitral valve repair d. Percutanous coronary intervention yea calcified LA thrombus severe V MR MS MUI symptoms
Ans. (a) Percutaneous mitral balloon valvotomy
Mitral Regurgitation 154
by 2mm y
156 g PSM Apex Axilla
Dynamic Auscultation in MVP 157
2D-Echo 158 0 Diuretics
Indications for MVR I EF 2607 MR LV ESD 7452m
160
g N 3 4am As L IMI S AT ESM syncope EV SBP t IFI Instagram
162 t y ME ME
• Aortic regurgitation results from two major mechanism:- • By causing valvular deformities • By deforming the Aortic root 163
164
204 1430 FA BA y c sommHg spy cnn.cn O Q
Treatment-AR • Vasodilators such as an ACE, ARB, or Aldosterone antagonists are the standard of care. • Perform surgery when the • ejection fraction is <55% or • left ventricular systolic diameter is >55 mm. 166 v r B blockers NO Oo
PERICARDIAL DISEASES
• Acute Pericarditis • Etiology of Pericarditis/Pericardial Effusion 168 to Mcc Viral 1 COX A I Echl
• Acute Pericarditis • Etiology of Pericarditis/Pericardial Effusion • 1 . Idiopathic is most common: Usually presumed to be viral. • 2. Infectious • • Viral: Coxsackie virus A, B (most common), echovirus 169
Signs and Symptoms • Diagnostic triad: 170 chest pain pointed Insp P rub ECG
Signs and Symptoms • Diagnostic triad: Chest pain, friction rub, and ECG changes • Pleuritic chest pain: Alleviated by sitting up and leaning forward • Pericardial friction rub - may be uni-, bi- or triphasic • ± Fever, malaise. 171
PERICARDITIS ECG 172 Global 554 except our concave Global PRI except gut
• Treatment • Treat the underlying disease • Anti-inflammatory agents 173 t a Aspirin steroids
• Treatment • Treat the underlying disease • Anti-inflammatory agents (high dose NSAIDs/ ASA, steroids if severe or recurrent); analgesics 174
CONSTRICTIVE PERICARDITIS
• Definition:- 176
• Definition:- • Constrive pericarditis is a condition in which the pericardium becomes thickened scarred and often calcified. • This leads to increase in pericardial pressure which limits diastolic filling of the ventricles. • Though this condition is quite similar to cardiac tamponade, there are certain, characteristic differences. 177
D D
Most common cause of Constrictive pericarditis 179 TB PYOpericardium I
Most common cause of Constrictive pericarditis • C.P is the sequelae of Pyopericardium • TB pericarditis 180
181 d) Takotsubo cardiomyopathy
182 Cardio caths pressure changes V filling i in I t Rel
Broad Bent's sign 183
Broad Bent's sign • The apical pulse is reduced and retracts in systole (tapping apex). (Broad Bent's sign). 184 O
185 Ans. is 'c' i.e., Ejection click [Ref: Harrison 18th/e p. 1826,1827& 17/e p. 1385, 1386] y
Low voltage complexes
00
188 I septal bounce
• Cardiac CT and MRI :- Q confirmatory O
• Cardiac CT and MRI—These imaging tests are only occasionally helpful. • Pericardial thickening of more than 4 mm must be present to establish the diagnosis, but no pericardial thickening is demonstrable in 20–25% of patients with constrictive pericarditis. • Some MRI techniques demonstrate the septal bounce and can provide further evidence for ventricular interaction.
• Treatment • Medical: • Surgical: 191 Diuretics pericardiectomy
• Treatment • Medical: Diuretics, salt restriction • Surgical: Pericardiectomy (only if refractory to medical therapy) 192 o
HYPERTENSION
Types of Hypertension
195 851
Most common cause of Secondary hypertension is? • a. Renovascular disease • b. Pheochromocytoma • c. Renal parenchymal disease • d. Hyperthyroidism I 157
• C
• Common causes of isolated systolic hypertension are: 198 I AR PDA Tz Tg A
• Common causes of isolated systolic hypertension are: • Atherosclerosis • Aortic regurgitation • Patent ductus arteriosus • Thyrotoxicosis • Coarctation of aorta 199
Unequal BP between Left & Right arm:- • T • C • S • A • O O u r okay ou 0 Aorta upravalvular As Dissection bstructive AE
201
202 8 10180
E e
Choice of antihypertensive agent based on demographic considerations
205 A 3 Full dose
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Infective Endocarditis
Definition 209 friable veg
Definition • It is the colonisation of the heart valves with microbiologic organisms, leading to the formation of friable, infected vegetations and frequently valve injury. 210
Q) Which of the following have most friable vegetation: • A. Infective endocarditis • B. Libman Sack's endocarditis • C. Rheumatic heart disease • D. SLE 211 O
Friability of Vegetations 212
Friability of Vegetations 213 I t Most Least
214 D
• C
Prosthetic valve endocarditis: 216
4. Prosthetic valve endocarditis: • This may be early (symptoms appearing within 60 days of valve insertion), due to intraoperative infection of the valve or insertion of an infected valve or late (symptoms appearing after 60 days of valve insertion), due to late bacteraemia or earlier infection with microorganisms having a long incubation period. 217
< 2months 2-12 months >12months t S viridans coagulase ve staph
219
Austrian syndrome or Osler's triad represents an association of 220 pneuma Menin IE
Austrian syndrome or Osler's triad represents an association of 1. pneumonia, 2. meningitis and 3. infective endocarditis(Pneumococcal). 221
222 E
223 I pros t I AR MS MVP IMR AS TS MR Ps AID TOF MVP MI Co A PDA
224 USD
Splinter hemorrhages appearing as red lineal streaks under the nail plate and within the nail bed, in endocarditis, psoriasis, and trauma.
Osler node causing pain within the pulp of the big toe and multiple painless flat Janeway lesions over the sole of the foot. O O painless
227
228 O
229 Roth spots
Internal Medicine - Rapid Revision Notes.pdf
• DUKE CRITERIA for IE • DUKE STAGE for Ca. Rectum • DUKE SCORE for Chronic stable angina 231 O
Treatment 232 ceftriaxone Vanco Break 15 mins
Treatment • Empiric regimens for endocarditis while culture results are pending should include agents active against staphylococci, streptococci, and enterococci. • Vancomycin 1 g every 12 hours intravenously plus ceftriaxone 2 g every 24 hours provides appropriate coverage pending definitive diagnosis; consultation with an infectious disease expert is strongly recommended when initiating treatment. 233
Acromegaly
235 O
236 somatotroph Macro 710mm 8
237 Gl I Death
• Cause of death UE
• Diagnosis :- • The best initial test is:- • Confirmatory test :- 239 Igf 1 a GH Suppression test
• Radiographs may also show tufting of the terminal phalanges of the fingers and toes. • (Isolated spade Phalanx). 00
A lateral view of the foot shows increased thickness of the heel pad. (Normal persons these ranged from 13 to 21 mm.) 0 I
• Management:- • Transsphenoidal surgery provides a rapid response. • Hypopituitarism can result in 10–20%. • Primary treatment is surgery. • Medical management:- 242 pituitary and lines PEGUISOMAN O A DOC octreotide Bromocriptine
• A patient was prescribed bromocriptine for prolactinoma, and responded to her symptoms. What is it's mechanism of action? a. D2 receptor partial agonist b. Increases prolactin levels c. Normalizes serum prolactin levels d. D2 receptor antagonist DaCr Agonist
Ans. (c) Normalizes serum prolactin levels
PITUITARY
• Which of the following is the most common type of pituitary adenoma? • a) Thyrotropinoma • b) Gonadotropinoma • c) Prolactinoma • d) Corticotropinoma 246 I Me tumor Mc secretory 1 I prolactinoma Non secretory
• Ramkali Bai, a 35 year old female presented with one year history of menstrual irregularity and galactorrhoea. She also had off and on headache her examination revealed bitemporal superior quadrantopia. Her fundus examination showed primary optic atrophy. Which of the following is most likely diagnosis in this case • a) Craniopharyngioma • b) Pituitary macroadenoma • c) Ophthalamic IcA Aneurysm • d) Chiasmal Glioma 247 o
Microadenoma Macroadenoma I I 710mm Lomm I only Endocrine Mass effect
Internal Medicine - Rapid Revision Notes.pdf
250
• Investigation of choice of hypeprolactinemia- • a) TRH estimation • b) LH estimation • c) Prolactin estimation • d) Estradiol estimation 251 or 5 Longline
252 o
253 Doc Cabergoline O preg Bromo
Hypopituitarism 254 Earliest GH FSH LH
• Definition :- Hypopituitarism is partial or complete loss of anterior function that may result from any lesion that destroys the pituitary or hypothalamus or that interferes with the delivery of releasing and inhibiting factors to the anterior hypothalamus. • GH and gonadotropins (FSH, LH) are typically lost early.
• Etiology:- 256 Mcc pit Adenomas
• Etiology:- • Pituitary adenomas are the most common cause of panhypopituitarism. 257
• Management. Management of hypopituitarism involves treating the underlying causes. 258 cortisol 1st I
• Management. Management of hypopituitarism involves treating the underlying causes. • Multiple hormones must be replaced, but the most important is cortisol replacement. 259
DIABETES INSIPIDUS ADA 1 polyuria 3L 24hr5 40 50mAkg in 24h1
Diabetes insipidus • Diabetes insipidus (DI) is a syndrome characterized by the excretion of abnormally large volumes of dilute urine. • The 24-h urine volume exceeds 40-50 mL/kg body weight, and the • 24-h urine osmolarity is <280 mosm/L. 261
• Choose the best Lab value for a patient with central diabetes insipidus - • Urinary Osmolality & Serum Osmolality • a) 50 - 300 • b) 500 - 260 • c) 50 - 260 • d) 500 – 100 262 I Sr Osma Uv Osm to
• A
Wolfram syndrome I Nephrogenic DI MFS 1 gene II AR Drugs Nephrogenic Li AG cisplatin methoxyfl Amphotericin B
Wolfram syndrome • Mutations of the WFS1 gene responsible for Wolfram’s syndrome. • Wolfram syndrome, also called DIDMOAD (diabetes insipidus, diabetes mellitus, optic atrophy, and deafness), is a rare autosomal-recessive genetic disorder that causes childhood-onset diabetes mellitus, optic atrophy, and deafness as well as various other possible disorders.
Investigation of Choice Sr Osma d un Osm I water deprivation Sr Not a test
A 33 year old lady presents with polydipsia and polyuria. Her symptoms started soon after a road traffic accident 6 months ago. The blood pressure is 120/80 mm Hg with no postural drop. The daily urinary output is 6-8 liters. Investigation showed, Na 130 mEq/L, K.3.5 mEq/L, urea 15mg/dL, sugar- 65 mg/dL. The plasma osmolality is 268 mosmol/L and urine osmolatity 45 mosmol/L. The most likely diagnosis is – • a) Central diabetes insipidus • b) Nephrogenic diabetes insipidus • c) Resolving acute tubular necrosis • d) Psychogenic polydipsia 267 Plosm t Orion
Q) Which of the following agents is the drug of choice for CentralDiabetes Insipidus - a) Desmopressin b) Demeclocycline c) Thiazide Diuretics d) Lithium 268 O
DOC of Nephrogenic DI I Hydrochlor T Doc Li t Dl Amiloride
SIADH is associated with - a) Small cell carcinoma lung b) Adeno cercinoma lung c) Squamous cell carcinoma lung d) Mixed cell tumor lung 270 loot cell t
• A • Small cell Ca of lung causes SIADH due to ectopic secretion of ADH. • SIADH ! Small cell lung Ca Head & Neck cancer
• All are true regarding SIADH, except - • a) Increased level of ADH • b) Urine hypo osmolar • c) Hyponatremia • d) Adequate hydration status 272 Hyperosmalar Ur not a
Clinical features of SIADH I I Nat
Investigations Sr Osm Ioc water loading ur Osm A Sr Matt Ur NOT A BUM El Sr Cr t
• SIADH true is all except - • a) Serum Na can be less than 135 meq/1 • b) Urine sodium is normal or slightly low • c) Vaptans are new FDA approved drugs for its Rx • d) Water loading test can be used 275 red DOE Tolvaptan conivaptan I 4 oral IV
• Lady with central obesity & abd. Skin showing purple striae a) Conn’s syndrome b) Cushing’s syndrome c) Addison’s disease d) Hypothyroidism 276
Q) The most common cause of Cushing’s syndrome is- a) Pituitary adenoma b) Adrenal adenoma c) Ectopic ACTH d) Adrenal carcinoma 277
• Most common cause of Cushing syndrome – • Most common cause of non Iatrogenic cushing’s – • Most common cause of Acth dependent type of cushing‘s – • Most common cause of ectopic Acth – Cushings – • Most common cause of Acth independent type of cushing‘s - Iatrogenic P Adenoma P Adenoma Small cell Ca Adrenal
• Earliest manifestation of cushing‘s - de MI I met Gain
Internal Medicine - Rapid Revision Notes.pdf
• Features not seen in Cushing’s Syndrome is- • a) Hypoglycemia • b) Hypertension • c) Frank psychosis • d) Hypokalemia 281 Hyperglycemia
• What is the first line investigation in cushing‘s ? 0 I 24hr Urinary Cortisol A
Earliest biochemical change in Cushing syndrome O t Loss of diurnal variation
• Lalloo, 50 years old, a chronic smoker, presents with history of hemoptysis. He was having truncal obesity and hypertension. He had an elevated ACTH level which was not suppressible with high dose dexamethasone. What would be the most probable diagnosis- a) Bilateral adrenal hyperplasia b) Adrenal adenoma c) Pituitary tumour d) Ectopic ACTH producing lung cancer 284 u r e
Q) Patient having Cushing syndrome due to adrenal tumor. Drug to be given - a) Cortisol b) Betamethasone c) Ketoconazole d) Fludrocortisones 285 Toc Surgical resection
286
287 Medical adrenelectomy – Ketaconazole,(oral and it is preferred) & other MM r r
NELSON SYNDROME BIL Adrenalectomy steroids te te Ici man a
NELSON SYNDROME • In B/L Adrenal adenoma with mass effect ! B/L adrenelectomy is done! IV hydrocortisone drip and Post op Hydrocortisone tablets • Follow up ACTH incr. (due to static incr. in steroids) & there is hyperpigmentation of palmar and creases of sole • This is called as NELSON SYNDROME
CONNS SYNDROME 290
Testing for primary aldosteronism should be done for all hypertensive patients except ? • (A) sustained hypertension above 150/100 mm Hg on 3 different days; • (B) hypertension resistant to three conventional antihypertensive drugs, including a diuretic; • (C) controlled blood pressure requiring four or more antihypertensive drugs; • (D) Hyperkalemia, whether spontaneous or diuretic induced; 5 Kt
• D
• Most common cause of Conn's syndrome is - • a) Adrenal hyperplasia • b) Adrenal carcinoma • c) Adrenal adenoma • d) Pituitary ACTH hypersecretion 293 o I
Etiology of primary hyperaldosteronism 294 • Most common cause of Conns syndrome :- • Most common cause of primary hyperaldosteronism :- A Adenoma BIL Adrenal hyperplasia
PRIMARY HYPERALDOSTERONISM NO EDEMA 295 000 I I I D HIM severe M Alf muscle weakness polyuria Arrhythmias No edemy
Difference between primary and secondary Hyperaldosteronism I CAF Cirrhosis Gland A Renin I
• Laboratory anomalies :- 297 screening Aldosterone Renin ration
Confirmatory tests for PA: 298 I oral salt solution test Iv saline suppression test
What is the treatment of choice in Primary hyperaldosteronism ? I surgical resection
What is the drug of choice in Primary hyperaldosteronism ? D Digoxin t y in't s Spiro BIL Adrenal c cimetidine K keto d o oestrogen spironolactone Gynaedmastiostilbestro Eplevenone
Prior to testing for Hyperaldosteronism patient ideally hold all medications except ? A. Diuretics B. ACE inhibitors C.NSAIDs D.Verapamil I r
• D
ADDISONS DISEASE
What is the difference between primary and secondary adrenal cortical insufficiency ? I A Gland PGland Steroidst i steroid t i sex H I
• Most common cause of adrenal insufficiency in India is- • a) Autoimmune • b) Surgery • c) Steroid withdrawal • d) Tuberculosis 305
• Most common cause of primary adrenocortical insufficiency in India:- • Most common cause of primary adrenocortical insufficiency in west :- O te Autoimmune Adrenal its
What are the fungal infections which causes Addison's disease ? Histoplasmosis
What are the Viral infections which causes Addison's disease ? I Cnt
What is Adrenomyeloleucodystrophy ? X Linked fats a q Adrenal t neurological
What are the infiltrative disorders causing Addison's disease ? Q Hemochromatosis Sarcoidosis
What are the malignancies causing Addison's disease ? Metastasis Lymphomg
What are the causes of secondary adrenal cortical insufficiency ? pit trauma
313 I I t Glc Mat Loss SE I Hypotly AK pigment Nkt ze t ze Hyper HYPE
Hyperpigmentation occurs in : 314 I Palm a sole creases ISD Areola Axilla Groin oral Mucosa
Hyperpigmentation occurs in : • Palm/sole creases(first) • Areola/Axilla/Cubital fossa • Groin • Oral mucosa • Nails 315
316 J FI Hypo JADD 150 2CAl
Waterhouse Friderichsen syndrome: I Adrenal crisis N meningitidis Doc Hydrocortisone ceftriaxone
• In addison's disease, most diagnostic test is – a) Serum Na+, K+, renin b) S. Na+, K+, saline suppression c) Serum creatinine /urea ratio d) ACTH stimulation test 318 I co syntopin test
ACTH stimulation test
• CT abdomen – Moth eaten Adrenal glan 320 o
Drug of choice for Primary adrenal cortical insufficiency ? 321 I oralHydrocortisone
Drug of choice for Secondary & Tertiary adrenal cortical insufficiency ? 322 Dexamethasone
PHEOCHROMOCYTOMA
Q) Pheochromocytomas arise from- a) Non endocrine cells of the adrenal cortex b) Non endocrine cells of the adrenal medulla c) Neuroendocrine cells of the adrenal cortex d) Neuroendocrine cells of the adrenal medulla 324 I ME
• What is the MOST common extra-adrenal site of a pheochromocytoma? • a) Renal hilum • b) Mediastinum • c) Urinary bladder • d) Organ of zuckerkandl 325 paragangliomal Chemodectoma I MET
• All are clinical features of pheochromocytoma, except- • a) Increased hematocrit • b) Orthostatic hypotension • c) Low cortisol level • d) Impaired glucose tolerance 326 AGI Mc symptom H Ache Mc sign HII
• IOC for screening is 24hr U.fractionated metanephrins • Normal VMA levels : Adults≤6.0 mg/24 h
Confirmatory test I pl metanephrine levels t times
For Localisation of Tumor I 6,68 DOTATATE SEI
VMA is elevated in which of the following conditions? a. Primary micronodular adrenal hyperplasia b. Conn's Syndrome c. Neuroblastoma d. Tuberous Sclerosis
Ans. (c) Neuroblastoma
Vanillyl mandelic acid is a metabolic by-product of norepinephrine and epinephrine. It is used for detection of tumors of neural crest origin.
• 1. Neuroblastoma • 2. Pheochromocytoma • 3. Ganglioblastoma • 4. Ganglioneuroma • 5. Severe anxiety • For diagnosis of pheochromocytoma, fractionated metanephrine level in urine and stool are preferred. I Vanan
TOC for Pheochromocytoma I surgical resection t BP 2160180mmHg phenoxybenzamine
Hyperparathyroidism
• The commonest cause of primary hyperparathyroidism is - • a) Carcinoma parathyroid • b) Solitary adenoma of parathyroid • c) Chronic renal failure • d) Hyperplasia of the parathyroid 336
337 Its
2) Osteitis fibrosa cystica: O O
2) Osteitis fibrosa cystica: • Healing in case of hyperparathyroidism occurs by fibrous tissue replacement or sometimes the centre may liquefy and a bone cyst remains. • The cysts expand the cortex and the cortex becomes grossly thinned. • Together with fibroid tissues in the bone marrow it gives the appearance of osteitis fibrosa cystica.
• Deformities 340 CoD fish spine
• The Rugger Jersey spine refers to band like osteosclerosis of the superior and inferior margin of the vertical body. • Rugger Jersey Spine is characteristically seen in chronic renal failure due to secondary hyperparathyroidism or Renal osteodystrophy. 341
342 1 37
• Deformities: • Long bones bend under the stress of weight bearing. • Intervertebral disk becomes ballooned as they indent soft vertebral bodies forming the ‘Cod Fish spine. • Pathological fractures: • These fractures occur frequently. • Marrow fibrosis: • Replacement of marrow element causes anemia. 343
• Pinhead stippling: 344 O
345
• Absence of lamina dura: 346
347 y
• Pinhead stippling: • The skull displays a diffuse osteoporosis described as pinhead stippling. • Absence of lamina dura: • Dental films reveal demineralisation of the mandible, disappearance of the lamina dura and epulis tumours. 348
349
• What is the name of this scan and what is its application ? 350 I Te99m sestamiki
• 99mTc-sestamibi scan of a patient with primary hyperparathyroidism secondary to a parathyroid adenoma. • A. After 1 hour, there is uptake in the thyroid gland (thick arrow) and the enlarged left inferior parathyroid gland (thin arrow). • B. After 3 hours, uptake is evident only in the parathyroid 351
• Rx: Surgery (Treatment of choice) 352 MM A cat 1st ME Furosemide Loss of cat DOC IBANDRONATE calcitonin
• Rx: Surgery (Treatment of choice) • 1st MM stabilisation done by NS ! Dilution effect • Furosemide ! Ca+ loss in urine • IV Ibandronate(DOC) • Calcitonin nasal spray – Antagonist of PTH 353
HYPOPARATHYROIDISM I Thyroid Sx
HYPOPARATHYROIDISM • Causes : • Autoimmunity • Thyroid Sx – PTH resection • Digeorge syndrome – Ch- 22 defect • ( Thymus gland and PTH gland hypoplasia ! CMI is reduced resulting pneumonia & Rickets like illness) 355
r I D
ASBP 140 1 2mins
Chovstek's sign
o
f la pancreas
O 0
Treatment at
PSEUDO HYPOPTH 363 I P Adequate Gene GNI DTH R Resistant It Hypo cats R cat
PSEUDO HYPOPTH • PTH – adequate Qt. • PTH receptors are resistant ! Due to defect in GNAS gene • So there is HypoCa+2 ! Incr. in PTH • C/F: • Similar to Hypo PTH ! AHO(Rickets like illness) • Inv.: = Hypo PTH but PTH levels are incr. • Rx – Ca+2 supplementation 364
g K D K K K K p K k k p p
Thyroid disorders • Most common cause of hypothyroidism in India :- • Most common cause of hypothyroidism Globally :- Hashimoto's Is I
Hashimoto's thyroiditis • Type of cells which infiltrates the thyroid gland ? • What are hurthle cells ? Autoimmune Lymphocyte surviving follicular cells pink colloid
What are the antibodies in hashimoto's thyroiditis ? I IgG Anti TG Ab Colloid Anti Microsomal Ab TSH R
• Pathogenesis - • Hashimoto’s thyroiditis is an autoimmune disorder characterized by the presence of following IgG antibodies- 1) Antithyroglobulin antibody. 2) Antimicrosomal antibody. 3) Antibody directed against a component of colloid. 4) Antibody against TSH receptors. • These antibodies do not correlate with severity of disease. • They have a diagnostic value. 369
What are the drugs causing hypothyroidism ? Q Amiodarone Li PAS Sunitinib
371
What is the most common cause of hyperthyroidism ? 0 I Grave's dls Ab's Thyroid t Ig's
What are the drugs causing hyperthyroidism ? I Amiodarge
374
What is Dequervains thyroiditis ? I RA viral inf Biopsy pain thyroid fever Giant Cell Granulomatous Giant cell T Early Hyper Later Hypo
376
Q) The occurrence of hyperthyroidism following administration of supplemental iodine to subjects with endemic iodine deficiency goiter is known as - • a) Jod-Basedow effect • b) Wolff-Chaikoff effect • c) Thyrotoxicosis factitia • d) De Quervain’s thyroiditis 377
A patient with endemic iodine deficiency goitre ? t Hypo Hyper I JOD Basedow Wolf ChaiKoff I organification
• What is this sign and in which endocrine disorder do you observe this ? 379 4 Grave's ophthalmopathy T
• Ophthalmopathy in Graves' disease • Lid retraction, • Periorbital edema, • Conjunctival injection, and proptosis are marked. 380
• What is the dermatological abnormality you're observing over the legs and in which endocrine disorder do you see this ? 381 I Infiltrate dermopathy pretibial Myxoedemy
• Thyroid dermopathy over the lateral aspects of the shins. • An infiltrative dermopathy, resulting as a rare complication of Graves' disease. • Presents itself as a waxy, discolored induration of the skin. • Precedes ocular sign. 382
Beta carotenemia Yellowish Skin Eyes N Hypo I
• In which endocrine disorder do you observe clubbing of the fingers ? 384 1 Thyroid Acropachy Hyper t
• Thyroid acropachy • Characterized by soft-tissue swelling of the hands and clubbing of the fingers. • Radiographic imaging of affected extremities typically demonstrates periostitis, most commonly the metacarpal bones. 385
000
• Lid retraction and proptosis in a patient with thyrotoxic Graves' disease. 387
Large Multinodular Goitre 388
Myxoedema 389
What are the cardiac manifestations in thyroid disorders ? Hyper Hypo t I Means hermann D ATM S HTM P Effusion Af CCF Ie AV blog
What are the neurological manifestations in thyroid disorders ? 0
Hung up reflex Delayed relaxation of DI Hypos
• In retrosternal goiter - Pemberton sign • That is on rising the arms there is facial congestion. • Evaluated by CT/MRI 393 O
• Which can cause profound hyperlipidemia ? • a) Hypoparathyroidism • b) Hypothyroidism • c) Hyperparathyroidism • d) Hyperthyroidism 394 Accelerated Atherosclerosis 7 CAD
Thyroid storm I Iv p blockers NG PTU Lugol's Is
Myxedema coma 0 I IV 73 Ta Hydrocortisone
397 Radioactive uptake studies :- I13t B I 131 T O
• A pregnancy woman is diagnosed to suffering from graves’ disease. The most appropriate therapy for her would be • a) Radioiodine therapy • b) Total thyroidectomy • c) Carbimazole parenteral • d) Propylthiouracil oral 398 I
Treatment of Hyperthyroidism Doc Methimazole I pregnancy in 1st 2nd 3rd I MethimaZOE PTU
• A 40 yrs old female who is known case of ischemic heart disease (IHD) is diagnosed having hypothyroidism. Which of the following would be most appropriate line of management for her – • a) Start levothyroxine at low dose • b) Do not start levothyroxine • c) Use levothyroxine • d) Thyroid extract is a better option 400 I
A Patient with Hypothyroidism Leveothyroxine Ty orally Early Mng fasting Dose I bugkg India NO tent I t full
DIABETES 402 O
Classification of DM
Which of the following endocrine disorders does not lead to DM ? A. Pheochromocytoma B. Somatostatinoma C. Hypothyroidism D. Acromegaly I DM Glucaganoma Hyperthyroidism
• C
What is the use of this instrument ? Monofilaments (Diabetes) 406 Monofilament pneuropathy
407 e
What is this sign and in which clinical condition do you see this ? 408 D Chievo pathy iii mobility
409 Tweeted
Diabetic Chieropathy • Diabetic cheiroarthropathy, also known as Diabetic stiff hand syndrome or limited joint mobility syndrome, is a cutaneous condition characterized by waxy, thickened skin and limited joint mobility of the hands and fingers, leading to flexion contractures.
What is this sign? 411
In which endocrine disorder do you see this? 412 g DM
XANTHELASMA 413
• A xanthoma is a deposition of yellowish cholesterol-rich material that can appear anywhere in the body in various disease states. • Types:- • Xanthelasma • Xanthoma tuberosum • Xanthoma tendinosum • Eruptive xanthoma • Xanthoma planum • Palmar xanthoma • Tuberoeruptive xanthoma 414
• In which endocrine disorder do you observe this complication ? 415 Neuropathic ulcer DI
Neuropathic foot ulcer • Diabetic foot ulcer is a major complication of diabetes mellitus. • Treatment :- • Blood sugar control, removing dead tissue from the wound, dressings, and removing pressure from the wound through techniques such as total contact casting.Surgery in some cases may improve outcomes. • Hyperbaric oxygen therapy may also help but is expensive 416
417
What is the name of this dermatological sign and in which endocrine disorder do you observe this ? 418 T MI DI
Necrobiosis lipoidica diabeticorum • Rash that occurs on the lower legs. • It is more common in women, and there are usually several spots. • They are slightly raised shiny red-brown patches. • The centers are often yellowish and may develop open sores that are slow to heal. 419
Necrobiosis lipoidica diabeticorum • Rash that occurs on the lower legs. • It is more common in women, and there are usually several spots. • They are slightly raised shiny red-brown patches. • The centers are often yellowish and may develop open sores that are slow to heal. 420
A nigricans
• T2DM correlate with which fat reserve - • a) Intraabdominal fat • b) Lower body fat • c) Subcutaneous fat • d) Upper body fat 422 t central obesity
Risk factors for Type 2 diabetes mellitus I central obesity Vit D I Smoking Inadequate physical activity
• A 29-years-old male taking oral hypoglycemic drug never had ketonuria in his life. His BMI is 20.5. His grandfather had diabetes and his father who is only son of his grandfather too had the disease. Which type of DM this person will be most likely- • a) Pancreatic • b) MODY • c) Type I • d) Type II 424 y Maturity onset Diabetes young B cell dysf very strong flH10 2 Gen BMI N NO D KA
• B Gene mutation ANF II MODY 3 DOC Low dose so
• Type 1.5 DM (LADA) : 426 I Adults Autoimmune Anti GAD B cells DOC Insulin
• Type 1.5 DM (LADA) : • Variant if T1DM • Auto Ab’s ! Present ! Anti GAD Ab’s • Anti islet cell Ab. • Anti GAD Ab’s !Also seen in paraneoplastic manifestations of oat cell cancer = as stiff person syndrome • Causes damage to Beta cells • Rx – Insulin ! Mfg by DNA recombibnant tech. • Pork/beef insulin causes ! Lipodystrophy,Resistance develops(due to Ab production) 427
Investigations:- Normal Impaired DM Fasting blood sugar PPBS HbA1C 1100 101 125 7126 140 141 199 7 200 5 6 5 7 16 4 76.5 N Micro vase comp 7 Target Hba C X 25 Avg Bld Glc
• HbA1C – Retrospective test • Doesn’t get effected by Exercise/Food • HbA1C * 25 = Avg. blood glucose • Target HbA1C < 7(good sugar control) • >7% poor sugar control 429 Gold OGI
• Microvascular compl directly proportional to HbA1C • So to reduce Microvascular compl reduce HbA1C values. 430
• Early morning hyperglycemia with increased blood glucose of 3.00 AM suggests – • a) Insufficient insulin • b) Dawn phenomenon • c) Somogyi effect • d) None of the above 431 GAMA D I 3AM 3AM M GAM A L
432 Bld Gk Inadequate insulin 13AM AGAM AGI 3AM N GAM A a nightdose 3AM insulin 6AM A
433
• Early morning hyperglycemia with increased blood glucose at 3.00 AM typically suggests inadequate night time insulin dose (insufficient insulin). • - Dawn phenomenon also presents with early morning hyperglycemia but blood glucose is typically stable (normal) at 3.00 AM. 434
• An obese NIDDM patient present with FBS=180 mg% and PPBS=260 mg% Management include- • a) Glibenclamide • b) Diet therapy+exercise • c) Diet therapy+exercise+metformin • d) Insulin • e) Chlorpropamide 435 TIM DM get line LSM I proc metformin
• Ans. is C i.e., Diet therapy +Exercise + Metformin • The level of hyperglycemia decides the initial choice of therapy.
What is the first line management in Type 2 diabetes Mellitus ?
What is the drug of choice for type 2 diabetes mellitus?
• Most useful investigation in diagnosis of diabetic ketoacidosis - • a) Ketonemia • b) pH of blood • c) Urinary sugar • d) Urine ketone 439 D BAE
Complications in Diabetes mellitus Acute chronic I i
Chronic complications Macro Micro Avatar I 4 CAD D Neuro D Amyofrophy CVA D Nephro Glaucoma PAD D Retina cataract
Diabetic ketoacidosis • Triad :- • Anion gap :- • Respiration:- • First line treatment:- T DM TDM 7250 pH Acidic KB ve High AG Kussumas resp ME Regular insulin IN
Hyperosmolar nonketotic coma:- • Most common acute complication in :- • ketone bodies :- • First line treatment :- TDM TDM TDM Absent Bl Glc 7600 1200mg d Ivf Yan Saline Insulin
Diabetic neuropathy • Sensation lost 1st is ? • Most common type of neuropathy :- • Most common cranial nerve affected :- • Drug of choice for Autonomic neuropathy :- sensory vibration Distal S S 3rd 7th Midodrize
• A patient presents with symptoms of hypoglycemia. Investigations reveal decreased blood glucose and increased insulin levels. C-peptide assay is done which shows normal levels of C-peptide. The most likely diagnosis is – • a) Insulinoma • b) Accidental sulfonylurea ingestion • c) Accidental exogenous insulin administration • d) Accidental metformin ingestion 445 Insulin a c pepa a Insulin C I never
446
447 n II P 3rd P 1St PTA X P 2nd pheo Pheo MCT MCT foregut Hirsprung's neuroma carcinoid amyloidosis Martanoid 11 10
448
MEN - 4 Reproductive organ tumors cervical tumors q Testicular 87 I CDKNIB
• Werners syndrome is asscociated with? 1) MEN 1 2) MEN 2a 3) MEN2b 4) NONE 450 WERIERS
• Werners syndrome is asscociated with? 1) MEN 1 2) MEN 2a 3) MEN2b 4) NONE 4 451 progerid
Carcinoid Tumors
• A carcinoid (also carcinoid tumor) is a slow-growing type of neuroendocrine tumor originating in the cells of the neuroendocrine system. • In some cases, metastasis may occur. • Carcinoid tumors of the midgut (jejunum, ileum, appendix, and cecum) are associated with carcinoid syndrome.
454 u r u O é
• Carcinoid tumors are associated with elevated levels of metabolites of Tryptophan/ serotonin which include 5HIAA, 5HT and 5HTP. • 5-hydroxytryptophan (5-HTP). • (5-HT) 5-hydroxytryptamine 455
• Carcinoid heart disease: I Rt sided valves TI TIE T insult TR p stenosis
• Carcinoid heart disease: About 19% to 60% of the those affected by carcinoid syndrome develop carcinoid heart disease. • Serotonin induces fibrosis in valves of the right heart especially tricuspid valve
Gastrointestinal Manifestation Diarrhea
Respiratory manifestations:- I wheeze
460 r é O
Imaging:- • Octreoscan:- • Gallium-68 labelled somatostatin analogues such as 68Ga-DOTA-Octreotate (DOTATATE), performed on a PET/CT scanner is superior to conventional Octreoscan. Improved
Imaging:- • For localization of both primary lesions and metastasis, the initial imaging method is Octreoscan, where indium-111 labelled somatostatin analogues (octreotide) are used in scintigraphy for detecting tumors expressing somatostatin receptors. • Gallium-68 labelled somatostatin analogues such as 68Ga-DOTA-Octreotate (DOTATATE), performed on a PET/CT scanner is superior to conventional Octreoscan.
Treatment • For symptomatic relief of carcinoid syndrome: DOC Octreotide
Treatment • For symptomatic relief of carcinoid syndrome: • Octreotide (a somatostatin analogue which decreases the secretion of serotonin by the tumor and, secondarily, decreases the breakdown product of serotonin (5-HIAA). • Telotristat ethyl (Xermelo) along with a somatostatin analogue in patients not responding to somatostatin analogue monotherapy. • It is a tryptophan hydroxylase inhibitor and reduces the production of serotonin. • Peptide receptor radionuclide therapy (PRRT) with lutetium-177, yttrium-90 or indium-111 labeled to octreotate is highly effective.
Glucagonoma X cells DM wet Loss Necro lytic migratory E MEN 1
Glucagonoma • Glucagonoma is a very rare tumor of the pancreatic alpha cells that results in the overproduction of the hormone, glucagon. • Typically associated with a rash called necrolytic migratory erythema, weight loss, and mild diabetes mellitus, most people with glucagonoma contract it spontaneously. • However, about 10% of cases are associated with multiple endocrine neoplasia type 1 (MEN-1) syndrome
• Blood glucagon concentration greater than 500 mg/mL along with the glucagonoma syndrome. O
Treatment I octreotige C Glucagos
Treatment • Heightened glucagon secretion can be treated with the administration of octreotide, a somatostatin analog, which inhibits the release of glucagon. • Doxorubicin and streptozotocin have also been used successfully to selectively damage alpha cells of the pancreatic islets.
Guillian Barre Syndrome Instagram Rajesh gabba
• Guillian Barre Syndrome is ? • a) Demylinating disorder of CNS • b) Demylinating disorder of PNS • c) Both • d) Axonal neuropathy 471 AI
• B
• Guillian Barre Syndrome is an Auto immune disorder with Type of HSR ? 473 O Type E
• Guillian Barre Syndrome is an Auto immune disorder with Type 4 HSR 474
• Which of following is the most common antecedent infection associated with Guillain-Barre syndrome- • a) Mycoplasma • b) Epstein-Barr virus • c) Chlamydia infection • d) Campylobacter jejuni 475
• Which of following is the most common antecedent infection associated with Guillain-Barre syndrome- • a) Mycoplasma • b) Epstein-Barr virus • c) Chlamydia infection • d) Campylobacter jejuni • D 476
Earliest manifestation in GBS is A. Distal areflexia B. Facial nerve involvement C. Acute flaccid paralysis D. Urinary incontinence Ankle Jerk Ascending paralysis
• A
Type of Respiratory failure in GBS ? A. Type 1 RF B. Type 2 RF C. Type 3 RF D. Type 4 RF Die
• B
• Cranial nerve involvement can occur :- • Disturbance of autonomic function:- 481 I 7th N BK postural hypoIn
• Cranial nerve involvement can occur :- • The most common cranial nerve to be involved is facial nerve. Sometimes B/L facial nerve involvement(facial diplegia) can also occur. • Sarcoidosis & Melkerson Rosenthal syndrome also have facial diplegia • Other cranial nerves can be involved later on. • Disturbance of autonomic function:- • (Sinus tachycardia and less often bradycardia, facial flushing, fluctuating hypertens ion and hypotension(Neurogenic shock), loss of sweating or episodic profuse diaphoresis). 482
Q) Which is the most common form of GBS? A. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) B. Miller Fisher syndrome (MFS). C. Acute motor axonal neuropathy (AMAN) D. Acute sensorimotor axonal neuropathy (AMSAN). D Rave
MC affected cranial nerve in MFS ? A. 7th Nerve B. 3rd Nerve C. 6th Nerve D. 10th Nerve O
• B
Miller Fischer Syndrome 486 Anti Go 1 t cranial N 1st 3rd Oph O A A EE Aretlexia Ataxia
Miller Fischer Syndrome • Rare variety • Cranial nerves are affected first • MC affected nerve is 3rd cranial nerve • O,A,A(Triad) ! Ophthalmoplegia ,areflexia, ataxia • Anti GQ1 ab. Seen in MFS 487
• Prognosis of the patient with Guillain Barre syndrome:- 488 I Good
• Prognosis of the patient with Guillain Barre syndrome:- • The clinical course is usually benign and spontaneous recovery begins within 2-3 weeks . • Most patients regain full muscular strength although some are left with residual weakness. • The tendon reflexes are the last to recover. • Improvement usually follows a direction, inverse to the direction of involvement with recovery of bulbar functions first and lower extremity weakness resolving last. • Mortality rate is only 5%. • Bulbar and respiratory involvement may lead to death if the syndrome is not recognized and treated 489
• C.S.F. findings in Guillain Barre syndrome:- 490 Albumino cytological dissociation Ioc anti GM I
• NCS ! Demylenation • Latency period of F-Reflex is increased • MRI spine shows demylenation (also seen in vit B12 deficiency) • IOC is anti GM1 ab. 491
Disease modifying treatment:- 492 I s Iv lg plasma pharesis
Disease modifying treatment:- • The main modalities of therapy for Guillain-Barre syndrome (GBS) include : 1. - Plasma exchange (also called plasmapheresis) 2. - Administration of intravenous immune globulin (IVIG) ! DOC 493
MYASTHENIA GRAVIS 494
All of the following are NM disorders except ? A. Eaton lambert syndrome B. Botulism C. Congenital Mysthenia D. Tetanus
• D
• Myasthenia gravis is caused by dysfunction of - • a) Pineal gland • b) Thymus gland • c) Pituitary gland • d) Parathyroid gland 497
• Myasthenia gravis is caused by dysfunction of - • a) Pineal gland • b) Thymus gland • c) Pituitary gland • d) Parathyroid gland • B 498
Thymic abnomalities 499
Thymic abnomalities • Thymic hyperplasia – 65% • Thymoma – 10% 500
Q) Myasthenia gravis is associated with- a) Decreased acetylcholine at nerve endings b) Decreased myosin c) Absent troponin C d) Decreased myoneural junction transmission 501 O
• HLA association :- • Other Autoimmune disorders:- HLA Bq HLA DR V3 Grave's RA SLE
• HLA B8 / HLA DR W3 • Antibodies associated with thyroiditis/Grave's disease/ rheumatoid arthritis/ SLE.
• All are clinical features of myasthenia gravis, except - • a) Spontaneous remission • b) Absent deep tendon reflexes • c) Proximal muscle involvement • d) Worsen by exertion 504 Der M
• The muscles which are mainly affected are those innervated by motor nuclei of brainstem. 505
• The muscles which are mainly affected are those innervated by motor nuclei of brainstem. • - Occular • - Masticatory, • - Facial, • - Deglutition and • - Lingual muscles. 506
507 Q Earliest
508
509
• A 50-year-old male presented with complaints of ptosis, difficulty in chewing and occasional difficulty in swallowing. There is no h/o diplopia or visual loss. On examination, there is asymmetric ptosis and mild restriction of exraocular muscle movement with finger abduction test 600. Nerve conduction study shows decremental response in orbicularis only. ERG revealed a myopathic pattern. Anti AChR radioimmunoassay was negative. The most probable diagnosis would be - • a) Ocular myasthenia gravis • b) Generalized myasthenia gravis • c) As the Anti-AChR radioimmunoassay is negative, you will consider an alternative diagnosis • d) Chronic external Ophthalmoplegia 510 only ocular involvement
Occular myasthenia gravis is characterized by a triad of:- ptosis Anti Musk Diplopia steroids orbicularis oculi Weakness
Occular myasthenia gravis is characterized by a triad of:- • - Ptosis • - Diplopia • - Orbicularis occuli weakness
• In ocular MG Ab’s are anti MUSK ab’s • Rx of choice is Prednisolone. 513
• The most sensitive test for the diagnosis of myasthenia gravis is - • a) Elevated serum ACH-receptor binding antibodies • b) Repetitive nerve stimulation test • c) Positive edrophonium test • d) Measurement of jitter by single fibre electromyography 514 I
515
516 O
517 HER Edrophonium
• Ice pack test is due for - • a) Myesthenia gravis • b) Multiple system atrophy • c) Hyperparathyroidism • d) Hypokalemic periodic paralysis 518
• Drug of choice for myasthenia gravis – • a) Gallamine • b) Succinylocholine • c) D. tubocurare • d) Pyridostigmine. 519 Mod severe t steroids mild
• The treatment of this disease involves the careful use of two groups of drugs:- • A) Anticholinesterases 520
• B) Immunosuppressants :- • Corticosteroids:- 521
• Myasthenic crisis :- 522 Ing plasm apheresis
• Myasthenic crisis is best managed with IVIG/ Plasmapheresis. • Treatment of choice for ocular M. gravis is steroids 523
Role of thymectomy in patients with myasthenia gravis:- 524 15 55
Role of thymectomy in patients with myasthenia gravis:- • “Thymectomy is an appropriate procedure in practically all patients with uncomplicated myasthenia gravis between puberty and 55 years of age”. 525
• Which one of the following is correct regarding Eaton-Lambert syndrome- • a) It commonly affects the ocular muscle • b) Neostigmine is the drug of choice for this syndrome • c) Repeated electrical stimulation enhances muscle power in it • d) It is commonly associated with adenocarcinoma of lung 526 3,4 DAP X proximal moles ocular RNS small cell E
Lambert Eaton Myaesthenic syndrome 527
Lambert Eaton Myaesthenic syndrome • It is a paraneoplastic syndrome associated with cancer particularly small cell Ca of lung. • It is a disorder of neuromuscular junction transmission (Presynaptic). 528
529 Associated with Thymoma Oat cell Cancer of lung
• Which one of the following is correct regarding Eaton-Lambert syndrome- • a) It commonly affects the ocular muscle • b) Neostigmine is the drug of choice for this syndrome • c) Repeated electrical stimulation enhances muscle power in it • d) It is commonly associated with adenocarcinoma of lung •C 530
• Treatment:- 531
• Treatment:- • The drug most effective in these patient is ! 3- 4 diaminopyrimidine. • It blocks potassium channels in distal motor terminal thus prolonging depolarization and enhancing the release of Acetylcholine containing vesicles. • 3, 4-DAP can be given alone or in combination with pyridostigmine. 532
BRAINSTEM SYNDROMES O
• Q) All of the following are true about Weber’s syndrome. • A. Ipsilateral occulomotor nerve palsy • B. Diplopia • c. Contralateral hemiplagia • D. Ipsilateral facial nerve palsy except Midbrain pontine
• Q) All of the following are true about Weber’s syndrome. • A. Ipsilateral occulomotor nerve palsy • B. Diplopia • c. Contralateral hemiplagia • D. Ipsilateral facial nerve palsy • D
Internal Medicine - Rapid Revision Notes.pdf
o
• Q) Benedikt's syndrome, all are true except : • A. Contralateral tremor • B. 3rd nerve palsy • C. Involvement of the penetrating branch of the basilar artery • D. Lesion at the level of the pons
• Q) Benedikt's syndrome, all are true except : • A. Contralateral tremor • B. 3rd nerve palsy • C. Involvement of the penetrating branch of the basilar artery • D. Lesion at the level of the pons • D
• Q) Millard Gubler syndrome includes the following except A. 5th nerve palsy B. 6th nerve palsy C. 7th nerve palsy D. Contralateral hemiparesis
• Q) Millard Gubler syndrome includes the following except A. 5th nerve palsy B. 6th nerve palsy C. 7th nerve palsy D. Contralateral hemiparesis A
I
Do
A 65 year old diabetic woman develops weakness in the left side of face, right arm and right leg. She also has diplopia on left lateral gaze. What is the site of lesion? a. Right pons b. Left pons c. Right midbrain d. Left midbrain
A 65 year old diabetic woman develops weakness in the left side of face, right arm and right leg. She also has diplopia on left lateral gaze. What is the site of lesion? a. Right pons b. Left pons c. Right midbrain d. Left midbrain é
A 65 year old diabetic woman develops weakness in the left side of face, right arm and right leg. She also has diplopia on left lateral gaze. What is the site of lesion? a. Right pons b. Left pons c. Right midbrain d. Left midbrain
1 39. Ans. (b) Left pons
• Lateral medullary syndrome is caused by thrombosis of- • a) Anterior inferior cerebral artery • b) Posterior inferior cerebellar artery • c) Vertebral artery • d) Basilar artery 548 PIL Waldenburg
• C
Q) Lateral medullary syndrome (Wallenberg syndrome) is characterized by all, Except – • a) Giddiness • b) Dysphagia • c) Crossed hemianaesthesia • d) Horner’s syndrome is rare 550
Q) Lateral medullary syndrome (Wallenberg syndrome) is characterized by all, Except – • a) Giddiness • b) Dysphagia • c) Crossed hemianaesthesia • d) Horner’s syndrome is rare • D 551
• All are features of Wallenberg’s syndrome, except- • a) Ipsilateral loss of pain and temperature • b) Ipsilateral loss of taste sensation • c) Ipsilateral loss of posterior column sensations • d) Ipsilateral involvement of lower cranial nerves. 552
• All are features of Wallenberg’s syndrome, except- • a) Ipsilateral loss of pain and temperature • b) Ipsilateral loss of taste sensation • c) Ipsilateral loss of posterior column sensations • d) Ipsilateral involvement of lower cranial nerves. • A 553 Dejerine roussy Thalamic
Ant spinal in
A middle aged patient presents with the worst headache of his life. What is the investigation of choice? a. NCCT b. CECT c. MRI d. Lumbar puncture I SAH
Ans. (a) NCCT
Subarachnoid haemorrhage • Most common cause of SAH :- • Second most common cause of SAH :- • CSF findings:- Head trauma BAneurysm Rapture xanthochromia
NCC T Mimo dipize Sylvian
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
A middle aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? a. Aspirin/Clopidogrel b. Mechanical Thrombectomy c. Mannitol d. Decompressive surgery I
A middle aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? a. Aspirin/Clopidogrel b. Mechanical Thrombectomy c. Mannitol d. Decompressive surgery
A middle aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? a. Aspirin/Clopidogrel b. Mechanical Thrombectomy c. Mannitol d. Decompressive surgery
A middle aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? a. Aspirin/Clopidogrel b. Mechanical Thrombectomy c. Mannitol d. Decompressive surgery O
A middle aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? a. Aspirin/Clopidogrel b. Mechanical Thrombectomy c. Mannitol d. Decompressive surgery
• Endovascular Mechanical Thrombectomy is done for: 1. Contraindications to lschemic Stroke 2. Failure to achieve vascular recanalization with iv thrombolysis
What is the window period of thrombolysis in a stroke patient? a. 1.5 hours b. 2.5 hours c. 3.5 hours d. 4.5 hours 160 9ommHg EPI Ischemia hemorrhage 43 Age 184ns No hagge edema of y3mc
Ans. (d) 4.5 hours
Internal Medicine - Rapid Revision Notes.pdf
Which of the following complications of stroke need not be treated? a. Fever b. Spasticity c. Neglect d. Dysphagia I
Which of the following complications of stroke need not be treated? a. Fever b. Spasticity c. Neglect d. Dysphagia MCA
Which of the following complications of stroke need not be treated? a. Fever b. Spasticity c. Neglect d. Dysphagia
Ans. (c) Neglect Rt
• Hemi-neglect or spatial agnosia implies blockage of inferior division of MCA and is seen more common in nondominant parietal lobe lesion. • Most patients will not be able to copy left side of the image. See the pie
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Aphasia
• Which of the following is not a feature of right middle cerebral artery territory infarct - • a) Aphasia • b) Hemiparesis • c) Facial weakeness • d) Dysarthria 579 I
• Broca’s aphasia is - • a) Fluent aphasia • b) Non fluent aphasia • c) Sensory aphasia • d) Conduction aphasia 580
• Brocas area :- Wernickes area:- I t Inf frontal sup Temporal 44145 22
• Wernicke’s aphasia ! • Broca’s aphasia! 582 Sensory Neologisms Normal fluency fluent Non fluent Motor No neologisms
• Wernicke’s aphasia ! Empty meaningless and full of nonsensical paraphasic errors. • Normal fluency • Broca’s aphasia! Decreased Fluency and spared comprehension, Naming difficulties. • Impaired repetition 583
• Conduction Aphasia:- 584
• Conduction Aphasia:- • Arcuate fibers are bundle of nerve fibres that connect Brocas area to the Wernicke’s area. • Damage to the arcuate fasciculus causes a disorder called conduction aphasia. • Conduction Aphasia is a ‘Fluent’ Aphasia with preserved comprehension and impaired repetition. 585
• Aphasia which affects the arcuate fibres is called- • a) Global aphasia • b) Anomic aphasia • c) Conduction aphasia • d) Broca’s aphasia 586
• Aphasia which affects the arcuate fibres is called- • a) Global aphasia • b) Anomic aphasia • c) Conduction aphasia • d) Broca’s aphasia • C 587
• Fluent Aphasia with preserved comprehension and impaired repetition is – • a) Broca’s • b) Wernicke’s • c) Anomic • d) Conduction 588 I
• Fluent Aphasia with preserved comprehension and impaired repetition is – • a) Broca’s • b) Wernicke’s • c) Anomic • d) Conduction • D 589
• Fluent Aphasia with preserved comprehension and impaired repetition is – • a) Broca’s • b) Wernicke’s • c) Anomic • d) Conduction 590
• Fluent Aphasia with preserved comprehension and impaired repetition is – • a) Broca’s • b) Wernicke’s • c) Anomic • d) Conduction • D 591
Brown Sequard syndrome
• The following are components of Brown sequard syndrome except - • a) Ipsilateral extensor plantar response • b) Ipsilateral pyramidal tract involvement • c) Contralateral spinothalamic tract involvement • d) Contralateral posterior column involvement 593 Sensory Ill post C CIL 5577 t At Lesion LMM Below UMM
• The following are components of Brown sequard syndrome except - • a) Ipsilateral extensor plantar response • b) Ipsilateral pyramidal tract involvement • c) Contralateral spinothalamic tract involvement • d) Contralateral posterior column involvement • D 594
Brown sequard syndrome
• Type of sensation lost on same side, in Brown sequard syndrome is - • a) Pain • b) Touch • c) Proprioception • d) Temperature 596 O I
597
598
599
• Type of sensation lost on same side, in Brown sequard syndrome is - • a) Pain • b) Touch • c) Proprioception • d) Temperature • C 600
• A ventrolateral cordotomy is performed to produce relief of pain from the right leg. It is effective because it interrupts the - • a) Left Dorsal Column • b) Left Lateral Spinothalamic Tract • c) Right Lateral Spinothalamic Tract • d) Right corticospinal Tract 601
• A ventrolateral cordotomy is performed to produce relief of pain from the right leg. It is effective because it interrupts the - • a) Left Dorsal Column • b) Left Lateral Spinothalamic Tract • c) Right Lateral Spinothalamic Tract • d) Right corticospinal Tract • B 602
Conus medullaris & Cauda equina
604
Internal Medicine - Rapid Revision Notes.pdf
606
DISORDERS OF CRANIAL NERVES 607
• A patient presents with recurrent episodes of sharp pain over his right cheek that is precipitated on chewing. Between attacks patients is otherwise normal. The most probable diagnosis is- • a) Preherpetic neuralgia • b) Trigeminal neuralgia • c) Mumps • d) Thalamic syndrome 608 V2 V3 UIL Max Rt Lt
Clinical features
• Clinical features:- • TN defined clinically by paroxysmal, stereotyped attacks of usually intense, sharp, superficial, or stabbing pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve. • The pain of TN tends to occur in paroxysms and is maximal at or near onset. • Facial muscle spasms can be seen with severe pain. 610
• This finding gave rise to the older term for this disorder, “tic douloureux”. • The pain is often described as electric, shock-like or stabbing. • It usually lasts from one to several seconds, but may occur repetitively. 611
• TN is typically unilateral. • Occasionally the pain is bilateral, though rarely on both sides simultaneously. • The distribution of pain most often involves the V2 and/or V3 subdivisions of the trigeminal nerve. 612
• Autonomic symptoms 613 u
• Autonomic symptoms, usually mild or moderate, can occur in association with attacks of TN in the V 1 trigeminal distribution, including lacrimation, conjunctival injection, and rhinorrhea. • The most common division of the trigeminal nerve involved in trigeminal neuralgia is the maxillary division (V2) followed by the mandibular division (V3). 614
• Drug of choice for Trigeminal Neuralgia is - • a) Chlorpromazine • b) Carbamezapine • c) Gabapentin • d) Fluoxetine 615
FACIAL NERVE
• Causes of facial palsy are - • a) Bell’s palsy • b) Herpes infection • c) Ramsay Hunt syndrome • d) Acoustic neuroma 617 Geniculate Ganglia I H Zoster
• B • R • A • S • H
• Causes of Facial narve palsy:- • Bell’s palsy (idiopathic) • Herpes infection • Ramsay Hunt Syndrome (Herpes zoster of geniculate ganglia) • Rosenthal Melkerson syndrome . • Sarcoidosis • Acoustic neuroma causes VIIth Nerve palsy and involve facial Nerve by local compression. 619
• TRUE regarding upper motor neuron Vllth nerve paralysis is - • a) Ipsilateral upper face paresis • b) Ipisilateral lower face paresis • c) Contralateral upper face paresis • d) Contralateral lower face paresis 620 I upper 42 face spared I
621
622 UMMI LMM X Rt LMN paralysis YL 112 Of face X paralysed O
Q ) LMN type Facial palsies - • a) Cornea should be protected • b) Bilateral paralysis is seen in Melkerson syndrome • c) Unilateral paralysis is seen in Mobius syndrome • d) Prognosis affected before repeated electric stimulation 623 T y 6th a 7th It
• Moebius syndrome is a rare neurological condition that primarily affects the muscles that control facial expression and eye movement. • The signs and symptoms of this condition are present from birth • Weakness or paralysis of the facial muscles is one of the most common features of Moebius syndrome. • Moebius syndrome is caused by the absence or underdevelopment of the 6th and 7th cranial nerves, which control eye movement and facial expression.
• A
626 Triad Fissured tongue
Differential diagnosis of Headache 0
• Most common cause of headache • a) Tension headache • b) Migraine • c) Cluster headache • d) Trigeminal neuralgia 628
629 I 0
• Most common type of headache is ! • Most common type of 2° headache ! • MCC of head ache in Females ! • MCC of head ache in Males ! • MCC of frontal HA ! 630
• Most common type of headache is tension headache. • Most common type of 2° headache is due to infection. • MCC of head ache in Females ! Tension HA >Migraine • MCC of head ache in Males ! Tension HA >Migraine> Cluster HA • MCC of frontal HA ! Tension HA 631
• For diagnosis of migraine POUND Mnemonic is used: • P – • 0- • U - • N - • D - 632 Pulsating one day 4 72hrs Uk Nausea Disabling
• For diagnosis of migraine POUND Mnemonic is used: • P - Pulsating headache • 0- One day duration (4-72 hours) • U - Unilateral • N - Nausea • D - Disabling in character, throbbing type • If 4 out of 5 criteria are present & 5 attacks per year diagnosed to have migraine. 633
Status migraniosus ① 72h 1
Status migraniosus • If duration is >72hrs ! Status migraniosus
• Migraine is predominantly of two types 636
• Migraine is predominantly of two types • Migraine with aura (classical migraine) • Migraine without aura (common migraine) • Migraine without aura is more common • The ratio of classic to common migraine is 1: 5 637
638
639 O
• For Status Migraniosus :- 640 O Prochlorperazine
• For Status Migraniosus :- DOC is prochlorperazine 641
642 x
• A 45-year old man presents with a daily headache. He describes two attacks per day over the past 3 weeks. Each attack lasts about an hour and awakens the patient from sleep. The patient has noted associated tearing and reddening of his right eye as well as nasal stuffiness. The pain is deep, excruciating, and limited to the right side of the head. The neurologic examination is nonfocal. The most likely diagnosis of this patient’s headache is- • a) Migraine headache • b) Cluster headache • c) Tension headache • d) Brain tumour 643
• Characteristics of pain :- • Attack duration: • One more characteristic feature of cluster headache is: - 644
• Characterized by characteristics unilateral periorbital localization i.e., the pain is felt in and around the eyes. • As a rule the pain is very intense and nonthrobbing & explosive in quality. • Attack duration: < 3 hours • One more characteristic feature of cluster headache is: - • Nightly recurrence between and 2hr after the onset of sleep, or several times during the night. 645
• Treatment • Acute cluster headache:- 646 1st line If 124min Sumatriptan prophylaxis Verapamil
• Treatment • Acute cluster headache:- • High flow oxygen at 12 L/min (First Line Treatment) • Sumatriptan injection • Gabapentin/pregabalin • Prophylaxis • Verapamil • Greater occipital nerve block. 647
• A woman has bilateral headache that worsens with emotional stress: she has two children, both doing badly in school diagnosis is • a) Migraine • b) Cluster headache • c) Tension headache • d) Trigeminal neuralgia 648
• Tension headache 649
Primary parkinsonism I Gene mutation PARK Ch I
Primary parkinsonism • Paralysis agitans or Parkinson's disease or idiopathic parkinsonism
Secondary (symptomatic) • Post-encephalitic • Toxins • Drugs • Ischaemic • Tumours • Punch-drunk syndrome • lnfections MPTP Matt CO vascular BG Boxer HIV INE
Secondary (symptomatic) • Post-encephalitic (post-encephalitis lethargica) • Toxins-e.g. MPTP (methyl-phenyl-tetrahydropyridine), manganese, carbon monoxide • Drugs-e.g. reserpine, phenothiazines, butyrophenones (including haloperidol), a-methyldopa, metoclopramide • Ischaemic (vascular parkinsonism) • Tumours in basal ganglion • Punch-drunk syndrome in boxers • lnfections-e.g. HIV, influenza
• Earliest feature of parkinsonism ? • a) Resting tremors • b) Brady or hypokinesia • c) Rigidity • d) Loss of postural reflexes 654
• A • RAT
656 (Anosmia & constipation precedes development of motor symptoms by 4 years Resting tremors are earliest motor symptoms. E
657
first line drug O
659
MENINGITIS O
• DEFINITION • Bacterial meningitis is an acute purulent infection within the ? A. Subarachnoid space B. Subdural space C. Extradural space D. All the above 661
• A
• Q) The organisms most often responsible for community acquired bacterial meningitis are? A. Streptococcus pneumoniae B. Neisseria meningitidis C. Group B streptococci D. Listeria monocytogenes 663 Neonate India Klebsiella E coli
• A
Which organism causes post meningitis deafness? A. Listeria Monocytogenes B. Pneumococcus C. Hemophilus Influenzae D. Staphylococci D
• C
c/f • Triad: 667
c/f • Triad: • Fever, H.ache, Nuchal rigidity • Decr. Consciousness, N.V, Photophobia • Papilledema, Dilated pupil(Compression of 3rd N.) • Sixth N palsy(false localizing sign) – Due to long course • Decorticate posturing as the severity progress 668
Internal Medicine - Rapid Revision Notes.pdf
670 O
What is the correct sequence to be followed in suspected bacterial meningitis? a. Draw blood culture sample, empirical antibiotics, neuroimaging followed by LP b. Empirical antibiotics, neuroimaging, blood culture sample followed by LP c. LP, Empirical antibiotics and CSF culture d. Empirical antibiotics, mannitol, LP followed by neuroimaging I E x
Ans. (a) Draw blood culture sample, empirical antibiotics, neuroimaging followed by LP
What is the site for Lumbar puncture? A. L1 – L2 B. L2 – L3 C. L3 – L4 D. L4 – L5 O
• C
Work up • Needle - Quincke needle & Sprottes needle 675
CSF NORMAL ACUTE BM TBM VIRAL MENINGITIS GBS FUNGAL MENINGITIS PRESSURE COLOUR CELLS GLUCOSE PROTEINS 50 180 A A A N A clear Turbid straw clear n clear 71000 0 4 m LA LA N LA 43rd I t N N H 15 45 A A A N A Froin DID A C
Internal Medicine - Rapid Revision Notes.pdf
CSF collected in a Test tube. Diagnosis? 678 COB web TBI
Hypoglycorachia – Low glc. In CSF Zero in Ac.Bacterial meningitis Cob web coagulum(proteins) seen in TBM 679
MOTOR NEURON DISEASE
• Which is pathognomic for motor neuron disease - • a) Fasciculation • b) Bladder, bowel involvement • c) Pseudohypertrophy • d) Sensory loss in patchy manner 681 x x x
Introduction
Introduction • Motor neuron disease in adults generally commences between 30 and 60 years of age. • There is degeneration of the anterior horn cells in the spinal cord, the motor nuclei of the lower cranial nerves, and the corticospinal and corticobulbar pathways.
Risk factor:- ①
Risk factor:- • Cigarette smoking may be one risk factor.
686 Amyotrophic lateral sclerosis is most common type of motor neuron disease. o
• MCC of death in MND is respiratory failure. 687
Riluzole a Glutamate
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
Internal Medicine - Rapid Revision Notes.pdf
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