Internal Medicine - Rapid Revision Notes.pdf

Manoj Aryal
Manoj AryalConsultant physician um Lumbini Medical College (Kathmandu University)
FMGE-RAPID REVISION
Dr.Rajesh Gubba
MD GENERAL MEDICINE
DNB CARDIOLOGY
2
• B
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
Internal Medicine - Rapid Revision Notes.pdf