1MEDICINE

PulseRadial against radial head, brachia against humerus just above antecubital fossa, carotid against transverse process of cervical vertebra, femoral against underlying femur, popliteal against popliteal fossa with leg flexed, posterior tibial 1 cm behind medial malleolus, dorsalis pedis against tarsal bone. Pulse deficit- difference in heart beat and pulse rate, e.g. atrial fibrillation. Slow rising pulse- Aortic stenosis, pulsus et tarsus, used to be known as anacrotic pulse. Collapsing( Water-hammer) pulse- Aortic regurgitation. Also found in PDA and ruptured sinus of Valsalva. Pulsus bisferiens -aortic incompetence with aortic stenosis. Pulsus paradoxus - alternate weak and strong pulse due to severe LV disease. Radio- femoral delay- Coarctation of aorta. Koratkoff sounds- 5( five). Fourth phase when sound muffled and fifth phase when sound disappears. Silent gap in hypertensive patient, but significance is unknown. Venous pulse a wave- atrial contraction c wave- coincides with ventricular systole and results from bulging of tricuspid valve in atrium. v wave - passive rise in pressure in atrium due to venous return. y descent due to decreased right atrial pressure when blood flows rapidly to right ventricle. Giant a wave - Tricuspid stenosis, pulmonary stenosis, pulmonary hypertension.

Cannon a wave- Tricuspid regurgitation, complete heart block( Levs and Lenegres disease). No a wave in atrial fibrillation. Apex of heart- 9 cm lateral to mid line, 1 cm inside the mid clavicular line at fifth intercostal space. Heaving apex beat in AS. Tapping apex beat- MS. First heart sound due to AV valve closure( mitral/ tricuspid). Second heart sound - Semilunar valve closure (Aortic/ Pulmonary). Third heart sound- rapid ventricular filling- healthy young adult, pregnancy, LVF, MR. Fourth heart sound- caused due to atrial contraction when the ventricles are stiff or non- compliant. Pericardial knock in constrictive pericarditis. Bipolar leads- Lead I- right arm left arm Lead II- right arm left leg Lead III- left arm right leg Unipolar Leads- aVR - right arm - aVL - left arm - aVF - left foot. Chest leads- V1- 4th intercostal space on right side of sternal margin - V2 - 4th intercostal space on left side of sternal margin. - V3 - between V2 and V4. - V4 - Mid clavicular line in 5th intercostal space. - V5 - Anterior axillary line 5th ICS. - V6 - Mid axillary line horinzontal to V4. Auscultatory area are - Mitral area- correspond to apex beat. - Tricuspid area- just left to lower sternum

- Aortic area- right to sternum in second intercostal artery - Pulmonary area- left to sternum in second intercostal space. Addison disease- Primary adrenocortical deficiency, hyponatremia, hyperkalaemia, hypotension, weight loss, hyperpigmentation( excess ACTH). SLE like syndrome- Hydralazine, Isoniazid, Phenytoin, Procainamide, Penicillamine( HIPP) Auto-splenectomy - Sickle cell anaemia. Eaten Lambert syndrome- associated with Oat cell carcinoma. Widows artery- Left anterior descending artery. Kartageners syndrome- bronchiectasis+sinusitis+ situs inversus+ impotency. Normal fat excretion 10 gm / day. Primary hemochromatosis- do weekly venesection. Phenformin- Lactic acidosis. Dissociated sensory loss- SYRINGOMYELIA. Flapping tremor- Hepatic failure, CO2 narcosis, uremia. Fine tremor - Thyrotoxicosis Antidote for cyanide- Amylnitrate Bloody mucoid diarrhoea- campylobacter, shigella, salmonella Rice water stool- Vibrio cholera. Salicylate poisoning- Metabolic acidosis with respiratory alkalosis

Mono-neuritis multiplex - Polyarteritis nodosa, leprosy, hypertension. Most subtle symptom of decreased cardiac output is fatigue. Niacin deficiency leads to pallegra- diarrhoea, demetia, dermatitis. Isoniazid causes pallegra like dermatitis. Transverse myelitis affects thoracic and lumbar segment. Chloramphenicol causes- Aplastic anaemia, Grey baby sydrome. Phototherapy- Bronze baby syndrome, dehydration, eyes should be covered. Mees line in nail is caused by Arsenic. Myocardial infarction - rupture of ventricle occurs in 4 to 7 days of MI. FIGLU in urine to demonstrate the folic acid deficiency. Tetralogy of Fallot- Ventricular septal defect, Pulmonary stenosis, Right ventricular hypertrophy, and Over riding of aorta. Feltys syndrome- Rheumatoid arthritis+Splenomegaly+ Neutropenia. Huntingtons chorea - degenerative changes in Caudate nucleus. Webere syndrome- Ipsilateral 3rd nerve palsy with contralateral hemiplagia. Staphylococcus aureus - commensal in nose. Coagulase positive. Roths spot seen in infective endocarditis is in eye. Wireloop nephropathy- Infective endocarditis Libmann Sach Endocarditis - Infective endocarditis. Magnesium sulphate orally causes diarrhoea. In sarcoidosis the most common cause of death is Cor Pulmonale.

In cerebral stroke and myocardial infarction quick reduction of blood pressure is not desired, however, in hypertensive encephalopathy blood pressure should be quickly reduced. Bence Jones protein in urine in multiple myeloma. CLL in seventh decade of life is self limiting. In renal failure- Rifampcin and minocycline are safe. Graham Steel murmur- Pulmonary regurgitation Austin Flint murmur- Aortic regurgitation, sometimes mistaken for mitral stenosis. Carey Coombs murmur in acute rheumatic fever. Morbilli- Measles. Opportunistic infection in lungs of AIDS patient is Pneumoncystis carnii. Anocrotic pulse - Aortic stenosis. Todds paralysis- Epilepsy. Hyperpathia- Thalamic syndrome. Tubular breathing sound- Consolidation. Cavernous breathing- Cavity lungs Amphoric breathing- Pneumothorax. Ascotis test- Plague. Kevims test- Sarcoidosis. Paul Bunnel test- Infectious mononucleosis. Schultz Charlton test- Scarlet fever.

Leonine facies- Leprosy. Riboflavin deficiency- Angular fissure/ stomatitis HypothalamusAnterior hypothalamus- cools body when it is too hot. (A/C). Posterior hypothalamus- makes the body warm when it is too cold. Lateral (ventrolateral) hypothalamus- hunger( Lateral- Le) Medial( ventromedial) - satiety (Medial- Majja) Caplans syndrome = Rheumatoid arthritis+Pneumoconeosis Pre excitation syndrome- ECG shows delta wave. (WPW Syndrome) Infant fed on goat milk for a long while suffers megaloblastic anaemia. Penicillamine - used for lead/copper/ mercury poisoning. Intrapleural pressure - minus 3 to minus 4 mm Hg. Differential cyanosis- PDA. Patent ductus arteriosus. Phrynoderma- Vit A deficiency, Free fatty acid deficiency. Bilateral hilar lymphadenopathy with non caseating granulomaSarcoidosis. Thymoma- Associated with Hypogammaglobinaemia. Kaussmaul breathing- due to presence of H+ ions. Acidosis. In endemic goitre radioactive iodine uptake is increased. Apart from allergic skin reaction nickel also causes nasopharyngeal cancer. Acidosis with increased anion gap- starvation, salicylate poisoning, diabetic ketoacidosis, lacti acidosis.

Acidosis with normal anion gap- renal tubular acidosis. Zinc deficiency leads to acrodermatitis enteropathica. Mothers age more than 35 yrs- Downs syndrome. Old father- Marfans syndrome in child. Digoxin C/I in hypertrophic cardiomyopathy. Digoxin toxicity predisposed by- hypokalaemia, hypomagnesemia, hypothyroidism. Prinzemetal angina treated by Diltiazem. Most common ASD is osteum secondum type. Alcoholic cirrhosis = Laennecs cirrhosis. Ebstein anomaly- tricuspid atresia and RV hypertrophy. Atrialization of right ventricle. Restrictive lung disease is associated with low PO2. Confabulation - story to hide the fact of amnesia in alcoholic patient, Karsakoff syndrome. Sustained heaving cardiac impulse in Aortic stenosis. Commonest rheumatic valvular disease- MR. T1/2 of chloroquine- 7 days. Stop aspirin before 7 days of elective surgery. Hypertrophic cardiomypathy- treat with beta blockers. Meralgia parasthetica - due to involvement of lateral cutaneous nerve of thigh. Sulfadiazine- Oligospermia. Porphyria - Test done are- Hoesch test and schumms test.

Frenkels skin test- Toxoplasmosis. Tapioca- Endomycardial fibro-elastosis. FEV markedly decreased in pleural effusion, bronchial asthma, fibrosing alveolitis. Narcolepsy HLA- DR2. In hemoptysis blood comes from bronchial artery. Carey Coombs murmur in acute rheumatic fever. Charcots joint- most commonly involve the knee joint, occurs in diabetem mellitus. Clutton joint- Syphilis. DIC- PT,aPTT, BT, CT, fibrin degradation product all are increased, while platelet and fibrinogen are decreased. X - linked recessive- Glucose-6- phosphate dehydrogenase - hemophilia - Colour blindness - Duchenne muscular dystrophy Chronic bronchitis does not cause amyloidosis. Prolonged parenteral feeding causes hypomagnesemia. Rheumatoid factor - IgG Wilsons disease - decreased Ceruloplasmin. Cognition - thought disorder. Lithium cause Ebstein anomaly in new born if taken by mother during pregnancy. Other ADR of lithium are- tremor, hypothyroidism, cardiac arrhythmia, diabetes insipidus, acne form of eruption, exacerbation of psoriasis. High carbohydrate diet causes hypokalaemic periodic paralysis.

High blood glucose causes pseudohyponatremia. Hyperkalemia-increased T wave amplitude( tall tented T wave), prolonged PR interval and QRS duration, atrioventricular conduction delay, and absent P wave. Terminal event is ventricular fibrillation and asystole. Hypokalemia- Flattening or inversion of T wave, a prominent U wave, ST depression and prolonged QU interval. Prolonged PR interval and widening of QRS complex. Ventricular arrhythmia. Hypercalcemia- Shortened QT interval. Polyurea, nephrolithiasis, anorexia, nausea, vomiting, and marked dehydration. Hypocalcemia- Prolonged QT segment. Trousseaus sign and Chovsteks sign. Hypermagnesemia- Prolonged PR and QT interval,complete heart block and asystole. Hypomagnesemia-Prolonged PR and QT interval. Abdomen distension- Hypokalemia, hypomagnesemia, Hirschsprungs disease. Primary biliary cirrhosis- Itching. Edrophonium test- Tensilons test for Myesthenia Gravis. Commonest opportunistic infection is herpes simplex. C- Peptide increased in Insulinoma, but not in factitious disorder. Cutting pitutary stalk prolactin secretion is not affected at all , however, ACTH, GH, FSH secretions are decreased. Reverse splitting of the second heart sound occurs in LBBB, systolic hypertesion, aortic stenosis.

Slow rising pulse, parvis et tardus and anacrotic pulse are features of Aortic stenosis. Mycoplasma pnuemoniae- myalgia, dry cough, pleuritc chest pain. Tumor lysis syndrome- uric acid, potassium, phosphate and temperature increase, but there in no increase in calcium level. Most infective type of diphtheria is anterior nasal variety. Schicks test positive means-child is susceptible to diphtheria. Kallamans syndrome- primary amenorrhea with anosmia. HCOM murmur is reduced in supine position. Sterptokinase overdose treatment is epsilon amino-caproic acid. Warfarin antidote - Vitamin K Heparin antidote - Protamine. Hang up ankle reflex in hypothyroidism Levimasole and azathioprine are immune modulators. HSV II causes temporal lobe encephalitis. SURGERY Rectal incontinence is due to puborectalis. Budd Chiari syndrome- hepatic vein thrombosis. Ca Stomach associated with blood group A. Duodenal ulcer associated with blood group O. Self breast examination by lying down. Commonest site for amoebiasis- sigmoid colon. Dentigerous cyst- from un-erupted teeth.

Commonest form of actinomycosis is fascio- cervical. Treatment is penicillin. GFR stops when systolic is below 70 mm Hg. Highest K+ level in Darrows solution. Parotid duct- Stensons duct. Duct of Wirsung- Main duct of pancreas. Duct of Santorini- Accessory duct of pancreas. Commonest form of hypospadias- Glandular. Parathyroid gland develops from 3rd (Inferior) and 4th ( superior) branchial pouches. Pancreatic pseudocyst in adult is due to pancreatitis, and children is due to trauma. Bladder rupture is diagnosed by retrograde cysto-urethrogram. Thumb printing sign in AXR - Ischemic colitis. Gas gangrene- Liver foaming also occurs. Erysipelas- Streptococcus pyogens. Commonest form of anthrax is- Cutaneous form- Malignant pustules. Globi seen in lepromatous leprosy. Moth eaten alopecia- syphilis. Lipoma- Universal tumor. Hydrocele- exudation cyst. Pitting oedema seen after at least 4 liters of fluid exudation. Sclerotherapy done by- Ethanolamine oleate. Dupytrens contracture starts from ring finger. Commonest site for ectopic salivary gland is palate. Commonest site for colonic diverticulum is sigmoid colon. Sistrunks operation- for thyroglossal cyst. Mixed parotid tumor- treatment is superficial parotidectomy.

Commonest site for carcinoma tongue is anterior 2/3 lateral aspect of dorsum. Commonest site for carcinoma oesophagus is middle 1/3. Squamous cell carcinoma. Adenoid cystic carcinoma of salivary gland spreads perineurally. Most active anti- tubercular drug against intra- cellular mycobacterium is Pyrazinamide. Pyrazinamide causes hyperuricemia. Tinels sign indicates regeneration of nerve. Carcinoid syndrome- 5 HIAA Pheochromocytoma- Metanephrines, VMA in urine. Gas-less AXR- intussusception. Pudendal nerve block is S1/2/3. Spontaneous regression Strawberry angioma, Salmon patch, Small cavernous hemangioma. Portwine stain - does not regress spontaneously. Strawberry GB- Cholesterolosis. Strawberry tongue- Scarlet fever. Strawberry vagina- Trochomonas vaginalis. Articular cartilage- type II collagen Pathological joking(Witzelsuscht syndrome) - frontal lobe tumors. Raspberry tumor- Umbilical adenoma. Hernia with hydrocele- Gibbsons hydrocele. Obliterated umbilical vein- ligamentum teres. Hernia to pouch of Douglas- Bergers hernia.

Direct hernia through Hesselbachs triangle. Indirect hernia comes through deep inguinal ring outside the Hesselbachs triangle. Littres hernia- Hernia containing Meckels diverticulum. Early exploratory laparotomy needed for perforation due to typhoid and biliary peritonitis. Femoral hernia- common in females, Richters hernia. Spigelian hernia- hernia through linea semilunaris at lateral boarder of rectus sheath. Congenital pyloric stenosis -first born male child, mass palpable in epigastric region, failure to thrive, rarely bile stained vomit, eager for food after vomiting, weight loss and dehydration, hypochloremic metabolic alkalosis. Treatment is Ramstedts operation = Pyloromyotomy. Squamous cell carcinoma- everted margin. Rolled up margin- Basal cell carcinoma. Arrow headed finger in X-ray is acromegaly. Lid lag- Von Graefes sign. Moebius sign - difficulty to converge the eyes. Most important factor in assessing fertility is sperm motility. Corpora amylaciae- in prostate. Bilharzia- associated with bladder cancer. Gas gangrene- most important part of treatment is wound debridement. Pre-operative antibiotic one hour before the operation. Squamous cell carcinoma-of lungs is associated with hypercalcemia. Carcinoma colon right side - fungating mass. Skip transmural lesion- tuberculoid granuloma- Crohns disease. Treatment with cryo-therapy complication is -persistent watery

discharge. Hurthle cells- Hashimotos thyroiditis. Clue cell- Vaginal epithelial cell containing bacteria in bacterial vaginosis. Clara cells- Terminal bronchioles Kuppfer cells- Liver macrophages. Hofbaeur cell in placenta. Peg cell in fallopian tube. Rat tailed appearance in barium swallow - achalasia Cork screw appearance - Diffuse oesophageal spasm. C harcots triad = Cholecystitis- Pain/Jaundice/ Fever Charcots triad = Multiple sclerosis-Nystagmus/ intention tremor/ scanning speech. Murphys triad = Acute appendicitis- Pain/ vomiting/ Fever. Saints triad- Hiatus hernia, gall bladder stone and ? Porto- systemic shunts1. Left gastric artery with azygous- oesophageal varices 2. Superior rectal artery with middle/ inferior rectal artery- hemorrhoids. 3. Periumbilical artery with inferior epigastric artery- caput medusae. 4. Retroperitoneal - renal. 5. Retroperitoneal with paravertebral. Venous ulcer- Bisgard treatment. Hiltons method for axillary abscess to prevent the damage to the vital sructures. Cruciate incision in carbuncle. Troseirs sign- Left supra-clavicular lymph node in carcinoma stomach.

Lisch nodule in neurofibromatosis is hamartomas in iris. Zollinger Ellisons syndrome - most provocative test is calcium infusion test. Bleeding in obstructive jaundice is by fresh frozen plasma. Marfans aortic aneurysm occurs in ascending part of aorta. Kochers incision- for cholecystectomy. Right paramedian incision for laparotomy. Gridiron for appendicectomy. Pfannenstiel incision for pelvic surgery. Loin incision for renal surgery. Left lower paramedian incision for sigmoid colectomy. Non- absorbable sutures- silk, linen,wire, nylon, polypropyline or proline. Absorbable sutures- catgut, chromic catgut, dexon, vicryl(polyglactin). Suture removal- Face and neck 3-4days. - Scalp 5-7 days - Limbs 5-7 days - Hands and feet 10- 14 days. - Abdomen 8-10 days Colostomy- LIF, flush with skin, Ileostomy - RIF, not flush with skin, spout for about 2.5 cm. Ulcer edge - Sloping- healing ulcer, venous ulcer. - Punched out edge- syphilitic gumma, ischemic ulcer. - Undermined edge- tuberculous ulcer. - Rolled edge- Rodent ulcer. - Everted edge- Squamous cell carcinoma. Transducer in USG is piezo-electric crystals. Glasgow coma scale-(EVM) Eye opening response------

Spontaneous--------- 4 To voice ------------- 3 To pain -------------- 2 None -------------- 1 Verbal response -----Oriented -------------- 5 Confused ------------- 4 Inappropriate -------- 3 Incomprehensive ---- 2 None -------- 1 Motor response -------Obeys command ---- 6 Localizes pain ------- 5 Withdraws from pain-4 Flexion to pain ------- 3/ decorticate. Extension to pain ---- 2/ decerebrate. None ---------------- 1 Cryoprecipitate- used in hemophilia. Fresh frozen plasma in liver diseases and DIC. Adjuvant therapy to treat the undetectable metastasis. Pilonadal sinus occurs due to hair penetrating to the skin and subcutaneous tissue- common sites are-posteriorly in midline over sacrococcygeal area, between fingers in hair dressers, umbilicus and axilla. Vincents angina- acute ulcerative gingivitis. Aneurysm- True- Fusiform/ sacular - False- dissecting Superior mediastinum- Thymoma / retrosternal goitre. Anterior mediastinum- Dermoid cyst / teratoma / pericardial cyst, bronchogenic cyst/ diaphragmatic hernia.

Posterior mediastinum- Neurogenic tumors, para-vertebral mass, achalasia, hiatus hernia.