INDEX

SUBJECT TOPIC TOTAL TOPICS PAGE NO

INTERTUBERCULAR SULCUS/ BICIPITAL GROOVE&
ANATOMY 1
1 1 ROTATOR CUFF

2 2 SKULL FORAMEN 1

3 3 NEUROANATOMY 2

4 4 CIRCLE OF WILLIS 2

5 5 BRAIN AREAS & APHASIA 3

6 6 IMPORTANT ROOT VALUES 3

7 7 BRACHIAL PLEXUS INJURY 3

8 8 IMPORTANT REFLEXES 4

9 9 TYPES OF JOINTS 4

10 10 POPLITEAL FOSSA 4

11 11 DIAPHRAGMATIC OPENINGS & EMBRYOLOGY 5

12 12 TONGUE 5

13 13 GERM LAYER DERIVATIVES 6

14 14 DERMATOMES & VERTEBRAL LEVELS 6

15 15 PHARYNGEAL ARCH DERIVATIVES 7

16 16 PHARYNGEAL POUCH DERIVATIVES 7

17 17 AORTIC ARCH DERIVATIVES 7

18 18 GENITAL DERIVATIVES 8

19 19 IMP IMAGES 8

PHYSIOLOGY 1 20 ACTION POTENTIAL 9

2 21 SARCOMERE 9

3 22 BODY FLUID COMPARTMENTS 9

4 23 HEART SOUNDS 10

5 24 JVP 10

6 25 GFR -STARLING FORCES & FACTORS 11

7 26 GFR REGULATION 11

9 27 POISEUILLE LAW 11

10 28 SPIROMETRY 12

11 29 O2 HB DISSOCIATION CURVE 12

12 30 O2 CONTENT OF BLOOD 13

13 31 HYPOXIA AND HYPOXEMIA 13

14 32 COAGULATION PATHWAY 14
 INDEX
15 33 BASAL GANGLIA CIRCUIT 15

16 34 SITE OF LESION OF MOVEMENT DISORDERS 15

17 35 THALAMIC AND HYPOTHALAMIC NUCLEI 16

18 36 CEREBELLUM 16

19 37 BROWN SEQUARD SYNDROME 16

20 38 HORMONES SECOND MESSENGER 17

21 39 TESTOSTERONE 17

BIOCHEMISTRY 1 40 PATHWAY –SITE & RATE LIMITING ENZYMES 18

2 41 ETC INHIBITORS 19

3 42 HSL VS LPL 19

4 43 FED & FASTING STATE 20

5 44 ENZYME INHIBITION 21

6 45 ENZYME COFACTORS 22

7 46 ENZYME DEFICIENCIES- CARBOHYDRATE DISORDERS 23

8 47 LYSOSOMAL STORAGE DISORDERS 24

9 48 AMINO ACID DERIVATIVES 25

10 49 AMINO ACID DISORDERS 26

12 50 HOMOCYSTINURIA 26

13 51 FOLATE VIT B12 DEFICIENCY 26

14 52 PELLAGRA 27

15 53 VITAMINS 27

17 54 MINERALS 29

18 55 LIPOPROTEINS 29

19 56 MOLECULAR BIOLOGY 30

PATHOLOGY 1 57 INHERITANCE PATTERNS 31

4 58 PEDIGREE CHART 33

6 59 GENETIC DISORDERS- TRISOMY 37

GENETIC DISORDERS BY CHROMOSOME ( IMP GENES
39
7 60 & CHROM NO)

8 61 TRINUCLEOTIDE REPEAT DISORDERS 41

10 62 CD MARKERS 43

11 63 TUMOR MARKERS 44

14 64 HYPERSENSITIVITY REACTIONS 46
 INDEX
15 65 AMYLOIDOSIS 49

16 66 ANEMIA 49

18 67 LYMPHOMA 50

23 68 MEN SYNDROMES 52

24 69 VASCULITIS 53

25 70 INFECTIVE ENDOCARDITIS 53

26 71 LUNG CANCER 54

27 72 AUTOANTIBODIES 54

28 73 FLASHCARDS 55

MICROBIOLOGY 1 74 MOTILITY 56

2 75 CULTURE MEDIA 56

3 76 GRAM POSITIVE BACTERIA 57

4 77 GRAM NEGATIVE BACTERIA 59

5 78 BACTERIOLOGY IMAGES 61

6 79 DIARRHEA & FOOD POISONING 61

7 80 BACTERIAL TOXIN MOA 62

8 81 VECTORS & RICKETTSIA 62

9 82 PARVOVIRUS 63

10 83 VIROLOGY-DNA VIRUS 63

11 84 VIROLOGY – RNA VIRUS 63

12 85 HEPATITIS 63

13 86 HEPATITIS B SEROLOGY 64

14 87 HIV 64

15 88 AIDS AND OPPORTUNISTIC INFECTION 64

16 89 MYCOLOGY 65

17 90 DERMATOPHYTES 66

18 91 PARASITOLOGY 66

19 92 PARASITOLOGY EGGS 67

20 93 MALARIA 68

21 94 STERILISATION & DISINFECTION 68

GENERAL PHARMACOLOGY- DOSE RESPONSE

PHARMACOLOGY 69
2 95 CURVE

3 96 INTRINSIC ACTIVITY 69
 INDEX
4 97 THERAPEUTIC INDEX 69

5 98 FIRST VS ZERO KINETICS 69

6 99 CLINICAL TRIALS 70

7 100 DRUG SCHEDULE 70

10 101 BIOAVAILABILITY/AUC 70

11 102 CYTOCHROME P450 INDUCERS & INHIBITORS 71

DRUGS IN PREGNANCY – SAFE & TERATOGENIC
71
12 103 DRUGS

13 104 IMP ADR IMAGES 71

14 105 POISONING & ANTIDOTES 72

15 106 ANS 72

16 107 GLAUCOMA DRUGS 72

18 108 ASTHMA DRUGS 73

19 109 DIURETICS 74

20 110 CVS PHARMACOLOGY- ANGINA DRUGS 75

21 111 HEART FAILURE DRUGS 76

22 112 ANTI HYPERTENSION DRUGS 76

23 113 ANTIARRHYTHMICS 77

25 114 RAAS DRUGS 77

26 115 ANTICOAGULANTS ANTIPLATELETS FIBRINOLYTICS 78

27 116 GOUT 78

28 117 DIABETES MELLITUS DRUGS 79

29 118 ANTI MICROBIALS 80

30 119 ANTI TB DRUGS 81

31 120 HIV DRUGS 81

35 121 ANTI CANCER DRUGS 82

FMT 1 122 PLANT POISONS 84

7 123 SNAKE 85

10 124 METALLIC POISON- ARSENIC 86

11 125 LEAD POISONING 86

12 126 MERCURY POISONING 87

15 127 DRUG ABUSE METHODS 87

16 128 ANTIDOTES 87

17 129 IPC 88
 INDEX
18 130 HANGING VS STRANGULATION 88

20 131 SEXUAL PERVERSIONS 89

25 132 AUTOPSY TYPES 89

26 133 TESTS FOR SEMINAL AND BLOOD STAINS 90

28 134 TYPES OF WOUNDS 90

29 135 BALLISTICS & WOUND OF ENTRY RANGE 91

32 136 IMPORTANT ONE LINERS 91

PSM 1 137 HDI VS PQLI 92

2 138 LEVELS OF PREVENTION 92

3 139 EPIDEMIOLOGY- DISEASE TRANSMISSION 93

4 140 EPIDEMIOLOGICAL STUDIES 93

6 141 ODDS RATIO, RELATIVE RISK, ATTRIBUTABLE RISK 95

7 142 VACCINES 96

8 143 VACCINE VIAL MONITOR 97

9 144 NATIONAL IMMUNISATION SCHEDULE 98

10 145 RABIES & TETANUS PROPHYLAXIS 98

17 146 NVBDCP 99

18 147 LEPROSY 100

19 148 NTEP 100

20 149 DEMOGRAPHY CYCLE 101

21 150 FERTILITY INDICATORS 101

22 151 FOOD ADULTERATION 101

23 152 RDA 102

24 153 WATER 102

25 154 AIR 103

26 155 BIOMEDICAL WASTE MANAGEMENT 103

28 156 DISASTER MANAGEMENT 104

29 157 TRIAGE 104

31 158 PNEUMOCONIOSIS 105

33 159 MEASURES OF CENTRAL TENDENCY 105

34 160 GRAPHS/ BIOSTATISTICS 106

36 161 CORRELATION COEFFICIENT / SCATTER DIAGRAM 107

37 162 TESTS OF SIGNIFICANCE 108

 INDEX
ENT 1 163 HEARING TESTS 109

2 164 AUDIOGRAM 109

3 165 TYMPANOGRAM 110

4 166 BERA 110

5 167 NASAL BONE FRACTURE 110

6 168 MEATUS STRUCTURES OPENING 110

7 169 RHINO_____ & RHINITIS 111

8 170 PARANASAL SINUSES 111

9 171 LARYNX ANATOMY 112

10 172 LARYNX PATHOLOGIES 113

11 173 VOCAL CORD PALSY 113

12 174 CA LARYNX 113

13 175 TONSILS 113

14 176 IMP IMAGES 114

15 177 MANEUVER/TESTS 114

16 178 ENT TRIAD 114

OPHTHALMOLOGY 1 179 CATARACT CORNEAL ULCER 116

2 180 IMP CLINICAL VIGNETTES 116

4 181 FUNDUS IMAGES DIABETIC RETINOPATHY 117

7 182 CLINICAL VIGNETTES 118

8 183 ONE LINERS 118

9 184 INSTRUMENTS / INVESTIGATION 119

10 185 ONE LINERS – MX SURGERIES 119

11 186 ANATOMY 120

12 187 NERVE PALSY 120

15 188 DIRECT VS INDIRECT OPHTHALMOSCOPY 121

16 189 KERATOCONUS 121

MEDICINE 1 190 NORMAL ECG 122

2 191 ECG IN ELECTROLYTE ABNORMALITIES 123

3 192 ECG - SUPRAVENTRICULAR ARRHYTHMIAS 124-125

4 193 VENTRICULAR ARRHYTHMIAS 125-126

 INDEX
5 194 ECG - AV BLOCK 126-127

6 195 ECG IN MI & PERICARDITIS 127-128

8 196 JVP 128

9 197 ACID BASE DISORDERS 129-130

15 198 AUTOANTIBODIES 130-131

16 199 CSF MENINGITIS 131

21 200 FLASHCARDS 131-132

SURGERY 1 201 TRAUMA 133

11 202 GCS 133

12 203 GCS- P 134

13 204 TRAUMA SCORING 134

14 205 SHOCK 134

16 206 BURNS 134-136

22 207 LIVER SCORES & CLASSIFICATION 137

24 208 STRASBERG CLASSIFICATION 137

29 209 CEAP CLASSIFICATION & OTHER SCORES 138

33 210 IV CANNULA COLOR CODING AND GAUGE SIZE 138-139

34 211 FOLEY’S CATHETER 139

35 212 VACUTAINER COLOR CODING 139

36 213 CENTRAL LINE 140

40 214 BREAST CANCER 141-143

43 215 BREAST ABSCESS 143

44 216 FIBROADENOMA 143

52 217 INGUINAL HERNIA 144

57 218 ACUTE PANCREATITIS 144

64 219 URINE CRYSTALS 145

65 220 SCROTAL SWELLING 145

66 221 FOURNIER’S GANGRENE 146

67 222 UNDESCENDED TESTES 146

74 223 ULCERS 146

OBGY 1 224 MATERNAL PELVIS & FETAL SKULL 147

3 225 ECTOPIC PREGNANCY 149

 INDEX
5 226 TWINS 149

6 227 BISHOP SCORE & APGAR SCORE 150

7 228 AMNIOTIC FLUID 150

9 229 DUAL/TRIPLE/ QUADRUPLE MARKER TEST 150

11 230 BIOPHYSICAL PROFILE 151

12 231 MOLAR PREGNANCY 152

16 232 ANTEPARTUM HEMORRHAGE 152

17 233 OBSTETRIC MANEUVERS 152

18 234 LEOPALD MANEUVER 153

19 235 VAGINAL INFECTIONS 153

OVARIAN TUMORS CLASSIFICATION & TUMOR
154
20 236 BODIES

23 237 CONTRACEPTION 155

26 238 IMP IMAGES 155

PAEDIATRICS 1 239 IMPORTANT ONE LINERS –PYQ BASED 157

2 240 CLINICAL VIGNETTES 157

5 241 VITAMIN A 158

6 242 DEHYDRATION 158

7 243 NEONATAL RESUSCITATION PROTOCOL (NRP) 159

12 244 TORCH INFECTIONS 160

13 245 SHORT STATURE 160

246 DENTITION 161

14 247 DEVELOPMENTAL MILESTONES- GROSS MOTOR 161

15 248 DEVELOPMENTAL MILESTONES- FINE MOTOR 161

DEVELOPMENTAL MILESTONES- SOCIAL &
162
16 249 LANGUAGE

17 250 IMPORTANT GENETIC DISORDERS 162

18 251 ACUTE EPIGLOTTITIS VS CROUP 162

19 252 NEURAL TUBE DEFECTS 163

20 253 MALNUTRITION- MARASMUS, KWASHIORKAR 163

DERMATOLOGY 1 254 STI 165

2 255 WOOD’S LAMP 166

3 256 ACNE VULGARIS 166

 INDEX
4 257 PSORIASIS 166

5 258 LICHEN PLANUS 167

6 259 KOEBNER PHENOMENON 167

PEMPHIGUS VULGARIS VS BULLOUS PEMPHIGOID VS
167
7 260 DH

8 261 STREPTOCOCCAL & STAPHYLOCOCCAL INFECTIONS 168

9 262 OTHER INFECTIONS – TINEA 168

10 263 LEPROSY 169

11 264 IMPORTANT IMAGES 170

12 265 NEUROCUTANEOUS SYNDROMES 170

ANESTHESIA 1 266 PREOPERATIVE ASSESSMENT- MALLAMPATI SCORE 172

3 267 BISPECTRAL INDEX & NM MONITORING 172

4 268 MAPLESON CIRCUITS 172

5 269 CYLINDER – COLOR CODING & PIN INDEX 173

6 270 O2 DELIVERY DEVICES 174

7 271 REGIONAL ANESTHESIA - LOCAL ANESTHETICS 174

8 272 SPINAL VS EPIDURAL NEEDLE 174

9 273 INHALATIONAL AGENTS 175

10 274 MALIGNANT HYPERTHERMIA 175

11 275 IV DRUGS – GENERAL ANESTHESIA 176

12 276 MUSCLE RELAXANTS 176

13 277 OPIOIDS 176

14 278 IMPORTANT POSITIONS MANEUVERS 177

15 279 CPR - BASIC LIFE SUPPORT (BLS) 177

PSYCHIATRY 1 280 DISORDERS OF THOUGHT 179

2 281 DELUSION 179

3 282 TIMELINE 180

4 283 PERSONALITY DISORDERS 180

5 284 DRUGS OF ABUSE 181

6 285 DRUG ABUSE – WITHDRAWAL 181

7 286 BEHAVIOUR 181

8 287 SLEEP PHYSIOLOGY & DISORDERS 182

9 288 EATING DISORDERS 182

 INDEX
10 289 PSYCHOPHARMACOLOGY- ANTIPSYCHOTICS 182

11 290 ANTI DEPRESSANTS 183

12 291 LITHIUM 183

13 292 ALZHEIMER DRUGS 183

14 293 ONE LINERS 184

15 294 IMP POINTS 184

RADIOLOGY 1 295 GIT RADIOLOGY 185

2 296 HBP 186

3 297 EMERGENCY RADIOLOGY 186

4 298 CNS HEMORRHAGE 186

5 299 RESPIRATORY -PLEURAL 187

6 300 IOC 187

7 301 IDENTIFY INVESTIGATIONS 187

8 302 NUCLEAR SCANS 188

9 303 RADIOSENSITIVITY 188

ORTHO 1 304 NERVE INJURIES 189

3 305 FRACTURES- FAQ 189

4 306 FRACTURE NECK FEMUR 189

5 307 HIP FAQ 190

6 308 METABOLIC BONE DISORDERS 190

7 309 ARTHRITIS 190

8 310 BONE TUMORS POTTS SPINE FD 191

9 311 BONE TUMORS 191

10 312 CTEV 191

11 313 NAMED FRACTURES 192

SURE SHOT 5.0

Medsynapse by Dr. Nikita

1
ANATOMY

2
 INTERTUBERCULAR SULCUS/ BICIPITAL GROOVE& ROTATOR CUFF
Sup. glenoid tubercle = Biceps Long head

Inf. glenoid tubercle = * Lat lip:

Long head Triceps • Lady between 2 majors Pectoralis
Lesser tubercle Medial lip:
Floor Teres SITS - Teres Minor
LD Greater Teres major X
tubercle* *Coracoid
Process SS
*Lesser Greater tuberosity
tubercle
T. minor
IS

INTERTUBERCULAR SULCUS ROTATOR CUFF MUSCLES

Mnemonic – Lady between 2 majors Mnemonic – Supraspinatus m/c : Injured —> Supraspinatus
Infraspinatus
minor
Teres _______
Subscapularis
Floor : LD - Latissimus Dorsi —> Thoracodorsal N. (C6,C7,C8)

Lateral lip : Pectoralis major Vs. Pectoralis minor : Coracoid Process insertion

Medial lip : Teres major Not inserted on

= Subscapularis
Content : Long head of biceps greater tuberosity
Nerve supply of teres = Axillary Nerve —> Deltoid
SITS Muscle
SITS Muscle Nerve
Nerve Supply
supply : minor + Regimental badge
• Supraspinatus - Suprascapular
• Infraspinatus - Supraspinatus + 15 - 90° abduction
• Teres minor - Posterior end of Axillary
• Subscapularis - Upper Subscapular
• Teres major - Lower subscapular

ABDUCTION :
Start 0 - 15° —> Supraspinatus
15 - 90% —> Deltoid
Overhead —> Trapezius and Seratus anterior

SKULL FORAMEN

* Olfactory —> Anosmia (COVID 19)

— Optic N : Lesser wing

Lesser wing*
* Rotundum
* Ovale
* Spinosum

* IAM

Hypoglossal canal * * Jugular Foramen

Greater wing —> Ant to post.

• Inferior Auditory meatus Vs Jugular Foramen
FROST
IAM —> Int in the Petrous
• Fissure (SOF)
Jugular Foramen —> Junction of petrous and
• Rotundum
Occipital
• Ovale —> Oval shape, Large

• Spinosum
3
 CRANIAL NERVE FORAMEN
1 Cribriform —> COVID - 19

2 Optic Canal —> Ophthalmic Artery (Branch of Int Carotid A)

3 Superior Orbital Fissure

4 Superior Orbital Fissure (Outside Central ring)

5 Parasympathetic CN
• Ophthalmic —> Sup Orbital fissure
• Maxillary —> F. Rotundum (Maxi - Rotating) — 3 7 9 10
• Mandibular —> Mandibular - MALE structures —> Ovale
Sup Orbital Fissure 3 Edinger
6
Westphal
Inf Auditory Meatus
7 7 Sup. Salivatory
8 Inf Auditory Meatus
9 h(IN)e Inf salivatory nucleus Parotid
9 Jugular Foramen
Otic
10 Jugular Foramen 10 Dorsal motor
ganglion
11 Jugular Foramen Thickest 5th
Hypoglossal Canal Thinnest 4th
12
• Foramen spinosum - Spine —> Middle meningeal Art Dorsal origin 4th alphabet
• Superior orbital fissure : 3, 4, 6 +5i (Ophthalmic N) ICT 6th nerve False localising sign
Not through Central tendinous Ring - 4th L e f t Out
Lacrimal br. of V1
Frontal
Trochlear

NEUROANATOMY

Caudate
insula Caudal
FH CC CC
C IC
IC P Ant. Commisure
G Cent
TH
Lentiform MRI Putamen Corpus Callosum
3rd V * Lentiform • Commisural fibers
cc GP
IC

Bone - Black Thalamus

(MRI) White
Bone
(CT)

Fat
MRI

CC Substantia Nigra *
Fornix

MB * Red Nucleus
Cerebellum * Aqueduct
Pituitary
Pons 4th V * Cavity of Midbrain
Sphenoid —> Aqueduct of Sylvius
Medulla CSF White
• T2 MRi
MRi MIDBRAIN
WW2
• Water white T2

4
 —> Nucleus - 6th
—> Nerve - 7th Pontomedullary Jn.
• Med - 6th
• Lat - 7, 8th

P
• Midbrain —> 3,4
M • Pons —> 5,6,7,8 (Medial 6)
• Medulla —> 9,10,11,12 (Medial 12)
• Motor —> Medial CN - 3, 4, 6, 12
(Rule of 12) EOM Tongue - Motor

Colliculi dorsal
Optic
SC
IC
Dorsal 4th CN
4th 4th - thinnest
(6th Nucleus)
P 5th 5th - Thickest
6

7
8
M
P 12
Crosses CST - Lower medulla
Y • Wallenberg Syndrome
R • Lat Medullary Syndrome
A
• Spared - 12th CN
M

CIRCLE OF WILLIS

• BA - In front of pons

(Basilar)
• Not a part of 1 - MCA
• 3rd CN - Between PCA and SCA
- Pcom Aneurysm

• Ant —> iCA —> 1) ACA • Post —> 2VA join to Basilar
2) MCA — Terminal by - PCA
3) Opthalmic — 2nd Last - SCA
4) AC - iC • Inf Cerebellar Art
Ant. Choroidal —AiCA - Br of Basilar
5)P.com A —PiCA - Br of Vertebral
Wallenberg Sx

5
 BRAIN AREAS & APHASIA
Motor
Middle Frontal <— PreMotor
Gyrus
• Broca —> IF - 44,45 BRODMANN
• 1° Motor —> 4 (Limbs)
• 1° Sensory —> 1, 2, 3
• Wernicke —> ST - 22
• 41, 42 —> Hearing (1° Auditory)
—>Visual • 43 —> Taste / Gustatory
• 44, 45 —> Speak, Speech
MOTOR - Broca’s Area
• 1° Visual —> See —> Seventeen
Aphasia • Heschl’s gyrus -Hearing and Auditory
• BROCA (Motor) —> Frontal 44, 45
Repetition Global • BiF = Inf Frontal
All affected • Wernicke’s Sensory 22 —> W E S T
N Gone Fluency
Sup Temporal
Comprehension gone
Transcortical Repetition

B W Conduction
Fluency gone Compensation Only
gone repetition
Fluency N gone

IMPORTANT ROOT VALUES

Nerves Root value 5 Rats

Musculocutaneous nerve C567 Radial - C5 - T1

Axillary nerve C56 Assassinated

2 Unicorns
• Ulnar C8 T1
• Axillary N C5, C6
Radial n C5 - T1 Three Long Musketeers
• C5, C6, C7

Median n C5 - T1 •
•
Long Thoracic N
Musculocutaneous N 5 Mice
• C5 - T1 Median

Ulnar n C8T1
Brachial Plexus —> C5 -T1
Thoracodorsal nerve —> Lat dorsi —> C678
Pudendal n (Ischial Spine) S234
Phrenic n (Diaphragm) C345 - Keeps us alive
Nucleus tractus solitarius N9, T10, S7 (7,9,10) —> Taste
Nucleus ambiguous 9, 10, 11 Baroreceptor

6
 BRACHIAL PLEXUS INJURY
• Urbs - Upper trunk
WINGING OF SCAPULA
• Long Thoracic N (C567) - N to serratus anterior
-Medial winging
• LSD
Long Thoracic nerve
Spinal accessory nerve
kLump Dorsal scap - Levator scapulae,
Rhomboids
lower

• Klumpke’s - Klaw hand • Erb’s Palsy

+ Horner’s Policeman/ Porter’s Tip

IMPORTANT REFLEXES
REFLEX ROOT VALUE RESPONSE NERVE
Ankle S1S2 Plantar flexion Tibial nerve TIP
Knee L3L4 Knee extension Femoral nerve Knee extensors - Quadriceps
Biceps C5C6 Elbow flexion Musculocutaneous
Triceps C7C8 Elbow Extension Radial (Extensor)
Cremasteric (Groin) L1L2 Ilioinguinal & genitofemoral —> Efferent
Plantar L5S1S2 Plantar Flexion Tibial
(Lat aspect of foot)

PED TIP Knee flexion

• Peroneal • Tibial N • Hamstring muscles
• Eversion • Inversion • By sciatic N
• Dorsiflexion • Plantar flexion

7
 Types of Joints
Syndesmosis
Sutures Gomphosis

Fibrous / Synarthrosis —> S, S, G Schindylesis

Cartilaginous •• 1° - Synchondrosis —> Growth plate (epis/diaph)
2° - Midline - Symphysis
Synovial
• Ball and socket Pivot

• T — TCN
• H Hip Radioulnar • Superior & inferior—> Pivot - Rotation
• I joint • Middle —> Syndesmosis / Fibrous MRUJ
Incudostapedial Syndesmosis
• S Shoulder Tibiofibuar • Superior – Plane fibrosis

• Saddle jt • Inferior - Fibrous

• SC — Sternoclavicular • Vomer—>Sphenoid—>Occipital—>Atlas—>Axis
• CC — Calcaneocuboid Fibrous Cartilage-
schindylosis Synchondrosis Ellipsoid Pivot
• 1st CMC —> Osteoarthritis
Atlanto- • ____ ________Movement
Yes
• Elbow – H occipita
• Wrist – E l joint • ES
___________joint
= Ellipsoid

• MCP- E * Fibrocartilage
-Same movement

• IP(interphalangeal joint) -H Atlanto • _______________

No / Axial (X = No) movement
-2° Cartilage/ Symphysis

• Ossicles axial
joint • ________________
Pivot (Rotation) joint
• Malleus & incus – Saddle
• Incus & stapes- IS —> thIS
(Ball & Socket)

Popliteal fossa
Mideal

-Tibial N
-Popliteal vein Semi
Biceps
f —-> Lateral (CPN)
-Popliteal Art (Deepest)
-Common Peroneal N
(Lateral)

• CPN —> Fibula Neck

(Lateral)

Baker’s cyst
(Medial)
Medial Lateral
GN GN

• Most superficial – Tibial Nerve

• Deepest – Popliteal Artery
• Lateral – Common Peroneal Nerve

8
 Diaphragmatic openings & embryology
Foramen of Morgagni (Rt) Level Primary structure Other structures
-Rt. Ant —> Rt. cardiophrenic
Inf epigastric
passing
-IE—>EI = Ext Iliac Art
T8 IVC —> Rt. Side Rt. phrenic
(RA)
-Vagus
-Gastric A
VENA CAVA HIATUS
• Central tendon

T10 Esophagus -Vagus R, L —> CN 10 —> T10

ARCUATE
• Medial
-Lt. Gastric A.
-Sympathetic trunk
• Lateral
-Subcostal

T12 Aorta Azygos veins - veins

Thoracic duct - lymph
• Pipes

• Opening in central tendon – Caval —> IVC at T8 Diaphragm embryology

• Osseo-aponeurotic opening – Aorta (Vertebra) • Central tendon develops from – Septum transversum
-Post to crus
• Nerve supply of diaphragm – Phrenic Nerve
V

• Root value – C345 —> Keeps us Palsy

Y
• _________________
Pleuroperitoneal membrane contributes
alive CXR - Elevated Diaphragm • ___________
Dorsal mesentery of esophagus

-Rt. Ant

• T8 - i IVC
• T10 - Eggs Eso
• T12 - At Aorta
BOCHDALEK HERNIA
• m/c - CDH
• m/c site - LPL
LPL
• Left
• Pleuropericardial memb
• BochdaLek

-Dorsal mesentry

i8 CDH - BMV C/I

E10 * CDH • Pulm hypoplasia
-Worst prognosis
A12
Esoph

Aortic

IVC

9
 TONGUE
Taste —> NTS (9, 10, 7)
Part of tongue Develops Nerve carrying Nerve carrying
from arch general taste sensation
sensation
Ant 2/3 rd 1 5 (Lingual) 7 (Chorda Tympani)

Post 1/3 rd 3 9 9

Posteriormost 4 10 10

Important points about tongue

• Tongue develops from arch – 1, 3, 4 x2
• CN 1, 3, 4 X2
Basal • Dorsal alar Sensory
1st arch 5 —> Post
ventral plate
• 12 CN is pure motor – develops from ________ - Basal Ventral (Motor)
7 —> Pre
3rd 9 • Rule of 12 —> 3, 4, 6, 12 (GSE)
4th 10 • 12 CN palsy occurs in brainstem syndrome – Medial Medullary Syndrome
(Dejerine)
• Tongue deviates to Rt. Side, Same side
Tongue licks the wound

PG SH
-Geniohyoid SG
SG -Genioglossus HG
-Hyoglossus GG
SH
-Styloglossus GH

• All muscles of tongue are supplied by

12
_______ Palatoglossus
nerve except ________
• Muscles of tongue develop from
Occipital / Cervical somites
__________
• Safety muscle of tongue – Genioglossus
-Tongue protrusion

10
 GERM LAYER DERIVATIVES

Thyroid

Dorsal
-All
Parasympathetic, Sympathetic
Vs Enamel Ectoderm

-crest • Adrenal Cortex - Mesoderm

• PA MD - Para axial Mesoderm

LAP MD CAP

DERMATOMES & VERTEBRAL LEVELS

O Inferior angle of scapula T7

> T4 - Arch of aorta

(Umb)
L1 Umbilicus - L4
L3
L5
Thumb C6

Little finger C8

Knee Cap L4 • Bifurcation —> 4

1) Carotid C4 - Sup. thyroid Cart.
2) Trachea T4
3) Aorta L4
• Nipple —> pore - T4
• Umb —> Belly button T10
• Groin / Ing. Ligament - L1
• 1st dorsal Webspace —> L5 / Deep
Peroneal Nerve
⑨
&
Knee cap L4
*
Thumb C6

11
 PHARYNGEAL ARCH DERIVATIVES
• 5th Arch - Regresses
Ar Nerve Muscles Skeletal
ch
1 5 M2AT2
(Mandibular) • Mylohyoid • Malleus
• Mastication muscles -m.ptery • Incus
-L.ptery • Meckel’s
• Ant digastric -masseter
• Tensor tympani -temporalis Cartilage
• Tensor veli palatini
(Opens jaw —> Lowers jaw —> L.pterygoids)
Not
2 7 Stylohyoid (Styloglossus - Tongue
(Facial) Stapedius Occ. somites)
2nd
Post digastric —> 7th N • Stapes
3rd
Facial muscles —> Buccinator • Suprastructure
Foot plate Otic capsule Hyoid -2,3rd arch
3 9 Stylopharyngeus —> Only pharyngeal mscls not supp by pharynx plexus SSS
• Small Cornu
4 10 (SLN) Cricothyroid —> SLN - ELN —> Thyroid cartilage • Sup. Body
• Second
6 10 (RLN) Rest larynx muscles
• Nerves
Nervesof
ofpharyngeal
pharyngeal arch
app belong
belongstotocolumn
column- • Larynx Cartilage not from ph. Apparatus
• C A P -Not epiglottis —> Elastic cartilage —> Doesn’t calcify
SVE • Treacher Collin —> Mand hypoplasia —> 1st arch
Cleft Arch pouch
Ectod Mesod Endod
+NCC

PHARYNGEAL POUCH DERIVATIVES

• Endoderm
1st —> Ear —> Middle ear
(Ear)
Eust. Tube
2nd —> 2 tonsils
3rd —> Thymus, Inf PTH
4th —> Sup PTH
• Di George Synd/ —> Def in 3rd pouch
CATCH 22 Thymus —> Aplasia (T Cell)
Inf PTH —> Ca reduced

Tetany

12
 AORTIC ARCH DERIVATIVES
Aortic arch Derivatives
1 M —> Maxillary A.
2 S —> Stapedial A.
3 —> C Carotid
4 On left - ARCH (4) - Left aorta
On right - 4 Limbs - Subclavian Rt.
6 Pulmonary Art.
On left - Ductus arteriosus
(Aorta)
Carotid

R.S.A
—> Longer - Increased risk of injury

DA

GENITAL DERIVATIVES
• Gartner duct - Mesonephric duct
• Appendix of testis - Paramesonephric • MRKH Synd.
• Epididymus - Mesonpehric duct
(SEED)
• Scrotum - Swelling Mullerian agenesis absent
/ genital ridge
• Clitoris - Tubercle
(uterus absent)

1° amenorrhea with
(XX - Ovaries) Secondary sexual
* Female / mullerian character present
(Mesonephros) / (Ovary Normal)
Wolffian - Male —> SEED

FOLDS

*Genital *Outermost

13
 IMP IMAGES
Lt.
Drops <— —> Rt. Stand

Rt. Abn - Sup. Gluteal N palsy Winging of scapula Post tibiala —> Between Cleft Lip
med malleolus and tendoachilles

i. Abnormal
Stands on ________ Nerve – Long thoracic Nerve i. Failure of fusion of
Medial nasal and
side maxillary process

-Drops – Opposite side Muscle – Serratus anterior

-Muscles affected – Root value – C567

• Abductors of hip
• Glut. Med. and minimus
• Glut max. - Extension Arises from ________
Roots of
Nerve - Superior Gluteal N brachial plexus

Inf Glut A.

* Sup Glut A.
B
B
* Inf Glut A. S
V AA PA
* Post C

Musculocut *
* Median N —> Both Lat
Axillary *
(C5 - T1) and med cords

* Radial Nerve
Piriformis - Insert on Greater Trochanter
- Lateral rotator of hip
R L
Piriformis Synd —> Sciatic N.
AA
SVC PA

RB LB
CT White aorta =
Contrast scan

• Rt. Lt.
S AA P
SVC Asc Aorta Pulm A

14
PHYSIOLOGY

15
 Action Potential
1/3 repolarisation > Na conductance zero, K conductance maximum

NPG 23
Na -55
+65
1) AP vs Graded potential no threshold
Depolarisation 2) all or none in AP
3) cannot be summated - AP
4) Refractory period +. - AP
Repolarisation

+
Na in Depolarisation — +ve — Na in
Repolarisation
Hyperpolarisation
} K+out
K out

-70
RMP neuron

Hyperpolarisation
K+ slow closely

-85
K

SARCOMERE
Sarcomere MHA Zi
A 2 I Z arcomere
Z-Z I — only thin (1=I)
m
M 2 A — all - thin + thick
I • light — I band
~H
• dark — A
• Thin — acthin - actin
2 band
A 1
troponin
MHA|Zi tropomyosin

• Thick — Mota - myosin

1/2 I 1/2 I
1A PYQ

* During contraction — shortening sarcomere

• HI — Bye
H & I — size
.

• A — (same) (aise hi)

• M — more prominent

Z line to D — Desmin — sarcolemma (sarcomere membrane)

DATZ it A — actinin - actin to Z
T — Titin - M line to Z line (I)
(A)
two interconnecting
largest proteins - Titin

16
 BODY FLUID COMPARTMENTS
70 kg — 42 L ICF = 2x ECF • Cannot be measured directly :
60% Total body weight indirectly — i - iCF — TBW - ECF
i - interstitial fluid (ECF - plasma)
28 L 14 L • Plasma volume measurement :
1) Evans blue — Blue plasma
2) albumin — 1125 labelled
increased • ECF:
1/4

}
1) mannitol 4) Na thiosulfate
2) inulin
3/4 ECF plasma
3) sucrose
H2O — • D2O • antipyrine
• TBW: • T2O • aminopyrine

Dye Dilution
ICF ECF

{ }
cation K+ Na
salt
Plasma volume = 1/4 x 1/3 x TBW anion phosphate Cl
= 1/12 TBW ATP

• Major contributor to serum osmolality : Na sodium

PYQ 275-295 mosm
Increased — ICF > ECF (ICF = 2x ECF)
interstitial> plasma
Total blood volume = plasma volume

60 40 20 (
1 - Hematocrit
0.45 )
3 2 1
TBW ICF ECF

HEART SOUNDS
HEART SOUNDS
Closure of AV valve S1 T MV closure

Closure of semilunar valve second - AV/PV closure

First Rapid filling S3 ventricular filling — diastole early — Normal in pregnancy hyperdynamic S3 S4

Last rapid filling S4 atrial contraction — late diastole — pathological — stiff ventricle early late

....
AV diastole diastole

CARDIAC CYCLE RELATION

Marks the onset of systole S1
S1 S2 S1

Marks the onset of diastole S2

ECG CORRELATION systole

Follows P wave = atrial depolarisation — atrial contraction — S4

Follows R wave = ventricular depolarisation — ventricular contraction — systole — S1
Later half of T wave = ventricular repolarisation = relaxation — depolarisation - diastole — S2
Between T & P wave S3 as it is split NIKMONIC

• Wide fixed split of S2 : s/o ASD **

• Normal in pregnancy : S3
• Hyperdynamic circulation : S3

17
 JVP
JVP DUE TO SEEN IN
S1 WAVE /
S2
descent
Late
A Atrial contraction — Late diastole
systole diastole
diastole early C — cusp — Tricuspid valve bulge — ivc systole

X — Relaxation of atrium — Systole

V Venous return — Before onset of diastole

Emptying of atrium into —
y ventricle
Diastole early

a S4
S1 Systole
S2

}
S1 S2
ivc early
mid-
C CxV systole

V
T
P

X
y

constrictive CP
pericarditis combined present
x+, y+
DYAstole
I y 7 early diastole
cardiac y absent
tamponade x prominent Late diastole
a >

18
 GFR -Starling forces & factors
afferent
-
efferent
-

GFR
GFR
- narrow incoming
afferent
dilation
constriction GFR
efferent
1. v biphasic
GFR
2. PGs — afferent dilation — GFR
NSAIDS — - PG > GFR (nephropathy)

Tubular

iNN
more water holding
} less water holding

Pg dilate Afferent
Plasma proteins — osmotic / concotic plasma water holding Angiotensin constricts efferent

PP — GFR
PP PP

GFR REGULATION
GFR increased by

( ventricles — bypass)
• Renal plasma flow _______

• Afferent arteriole ________________

dilatation

• Efferent arteriole _________________

constriction (biphasic - latex GFR)

Numerical + - -
• Plasma protein concentration ________
decrease

STARLING FORCES
• Ureteric stone - GFR
Glomerulus :
Hydrostatic pressure — push effect — fluid out (+)
how much plasma is cleared out of substance per unit time

Oncotic pressure — water holding — pull effect (-) unit — mL/min

numerical
• CLEARANCE
UV •• U,P
• GFR :
= concentration mg/mL
V = mL/min (flow rate) of urine
Bowman space : P
insulin clearance - best
also for creatinine > insulin clearance

Hydrostatic pressure - ECF • Renal plasma flow :

PAH
Oncotic pressure o — no proteins filtered
-

Normally
i Zero

19
 Poiseuille LAW

4
X (radius)

* Doubling radius | diameter — 16 times flow — Resistance 1/16

doubling length — 1/2 flow (inversely related to length)
Flow
1
* Resistance — X
flow

Length

viscosity

SPIROMETRY

↑
iC = TV + iRV
iC

N tide E
ERV
E
• Everything except residual volume : = vital capacity
• Cannot be measured by spirometry: live - exchange TLC = TV + iRV + ERV + RV
VC = TLC - RV
dead space, RV, FRC TLC
residual
• Remains at the end of
• Normal expiration: F residual capacity = RV + ERV
• Forceful expiration Residual volume — does not come out

20
O2 HB DISSOCIATION CURVE
unloading / affinity ( O demand)
H+
alkalosis
Rt — releases O2
aciDosis pH
Lt — loves O2

-
friends with O2( affinity) loves = left shift Dextro (right)
affinity
unloading
aLkalosis pH
Left — lower values Raised - Right
Left shift H+
Right — raised values H+

21
 Rectangular hyperbola : no post coop

anemia 1 O2 molecule
loves O2
Right down 1 myo
(4 O2 )

ARDs
anemia
Right
down

O2 CONTENT OF BLOOD

22
HYPOXIA AND HYPOXEMIA

23
COAGULATION PATHWAY

24
 BASAL GANGLIA CIRCUIT

Nigrostriatal dopamine

II
D1 D2 Main input L
direct
stimulatory

Main input <

Site of Lesion VA/VL nucleus

• Athetosis :Globus pallidus
• Chorea : Caudate
• Hemiballismus : Subthalamic nucleus
• Parkinsonism Substantia Nigra

(SubTAlamus)

(Talamus)

25
 Site of lesion of movement disorders

(Earth)

(C-C)
(Ball-thal)
(PC)

THALAMIC AND HYPOTHALAMIC NUCLEI

THALAMIC NUCLEI HYPOTHALAMIC NUCLEI
VISION VISION

HEARING HEARING

FACE SENSATION , TASTE FACE SENSATION , TASTE

SENSATION FROM REST OF BODY SENSATION FROM REST OF BODY

PAPEZ CIRCUIT PAPEZ CIRCUIT

INPUT FROM BASAL GANGLIA & CEREBELLUM – INPUT FROM BASAL GANGLIA & CEREBELLUM –
MOTOR FUNCTION MOTOR FUNCTION

26
 CEREBELLUM

BROWN SEQUARD SYNDROME

= Hemisection of cord

1) vit B12. deficiency

2) Tabes dorsalis

O
3 syphilis

OPT = opposite pain & temperature — STT

crosses at
spinal level

Rest — same side

• vibration / position — dorsal column — medulla crossing

27
 HORMONES SECOND MESSENGER
Second messenger Hormones Second messenger Hormones

{
cAMP FSH
— basophils of
Prolactin
LH Tyrosine kinase
FLAT anterior pituitary
dir TY PIG
Insulin MAP Kinase
Base ACTH IGF
TSH Growth hormone JAKSTAT

{
Calcitonin
cAMP
ADH – V2 receptor — in kidney (2)
MSH intracellular Steroid hormones
receptors
PTH STD
Thyroid

{
Beta 1 , 2
Beta HCG Vit D
HCG CRH
{
cGMP ANP
Glucagon > cAMP GANE NO cGMP
EDRF

Gq GnRH except CRH

GHRH cAMP
IP3 / DAG TRH
2nd messenger — Calcium
Calcium Oxytocin
ADH- V1 I - IP3

S
P3 Estrogen — steroid - intracellular
H|
Hipoth Post pit Angiotensin II I - IP3
Alpha 1 receptor Cholesterol
RH I

Vasoconstriction

TESTOSTERONE

28
BIOCHEMISTRY

29
 PATHWAY –SITE & RATE LIMITING ENZYMES
Glycolysis PFK Site RL enzyme
Gluconeogenesis Fructose 1,6 bisphosphatase

TCA /Kreb cycle Isocitrate dehydrogenase

Glycogenesis Glycogen synthase

Glycogenolysis Glycogen phosphorylase

Fatty acid synthesis Acetyl coa carboxylate

Fatty acid oxidation ( beta ) CAT/ CPT

Cholesterol synthesis Hmg coa reductase

Ketone body synthesis Hmg coa synthase

Urea cycle CPS 1

De novo pyrimidine synthesis CPS 2

Purine synthesis Glutamine prpp amidotransferase

HMP pathway G6PD

ETC inner mi to
membrane
O2 oxidation Link reaction

Genesis in mito Kreb

RBC

Steroids (NADPH) cynthesis

HUG

Nik-monic
Both HUG H - Heme (XXHMP) - cytoplasm
synthesis U - Urea cycle
G - Gluconeogenesis (glucose synth.)

RBCs Glucose only Glycosis

Q. All synthesis Cytoplasm except ketogenesis

LYSIS in cytoplsm glycosis (RBC)

30
 Both C & M
Fru 6 Phosphate (HUG)

Fruc 1,6 biphos

Nik-monic
UMN
• Urea
(reverse) • Mitochondria
• NH3 + CO2
Kreb Nik-monic
( i saw carb in city)
iso kreb citrate

(Lysis) G6PD —> def —> XLR

oxidative stress —> heterolysis
Hum Paanch —> gunder
guons
fova beans / antimalarials
di-2 CPS II

PRine
uredaaaaa
A —> Arginine
Carboxylation backbone A —> Aspartate
CAT / CPT - I

- statins (chol)

ETC INHIBITORS
Nik-monic
Oligomycin V, V, V

—> BROWN ADIPOSE

BAL T3 T4 heat

ETC
xxx ATP
ETC -
- electron transport
- ATP

31
Complex Inhibitor Thermogenin –
I Nik-monic Phenobarbitone present in Brown
_____ adipose
Physiological
One Rotenone

UNCOUPLERS
Thyroxine heat
II Malonate MSD (second) respiration
O2 consumption
TTFA two ETC
III BAL 3 Chemical 2,4 Dinitrophenol
IV Cyanide no ATP
4
Hydrogen sulphide
ATP transporter ADP/ATP (ATRA)CTYLOSIDE
transporter
Abolishes proton
Oligomycin / Venturicidin
gradient
going of protons
Blocks proton flow
through the complex

Nik-monic
M S D —> competitive
Malonate Succinate —> iron
Dehydrogenase
Second
bi
(Dimercaprol)
3 ide
One Two -anthremycin 4
NADH
C-3&4 Cyto C oxidase

final
acceptor
Complex- V
/ phenobarbitone
ATP synthase
(F0 - F1)

* No fes —> in
complex IV

.
1 NADH —> 2.5 ATP
1 FADH2 —> 1.5 ATP

Protons 4 0 4 2
ATP 1 0 1 0.5

32
 HSL vs LPL

• LPL = Anabolic —> Insulin

• HSL = Catabolic —> Glucagon
• INSULIN Increase = Loves LPL (Increases - Anabolic)
= Hates HSL (Decreases - Catabolic)

FED & FASTING STATE

• HUG —> Both Cyto and Mito

-H = Heme
-U = Urea
-G = Gluconeogenesis

33
 • High Insulin: glucagon ratio = Fed State (Anabolic)
—Glycogenesis
• Low insulin :glucagon ratio = Fasting State (Catabolic)
—Gluconeogenesis

• 1st - Glycogen —> Gluconeogenesis —> Fats

—> Proteins (Muscle)
• Anabolic fed Inc. Synthesis :
- Cytoplasm except Ketone body synthesis
- Ketone bodies synthesis in Mitochondria (Catabolic)
• Oxidation = Mitochondria
• RBCs —> Cytoplasm only, No Organelle
- Dependent only on Glucose (Glycolysis)
-HMP —> Cytoplasm

• DM —> Type 1
DKA precipitated by Insulin Decrease
—> Diabetic Ketoacidosis (DKA)
-Rx —> Regular Insulin
- Breath - Fruity odour

34
 Enzyme inhibition
Competitive

Enzyme inhibition

Km Vmax Line Weaver plot

COMPETITIVE Inc. Same Crossing

NONCOMPETITIVE Same Dec. V Shape

UNCOMPETITIVE Dec. Dec. Parallel

INHIBITOR INHIBITS ENZYME

Fluoride E F G
Enolase Fluoride Glycolysis

Malonate M S D • Km is directly proportional to substrate

—> Competitive concentration ( Recent Q)

35
Vmax

= Same level
as Normal

= Below Vmax

-Crossing -Parallel -V shaped

• Km Inc. = Dec. Affinity
Inversely proportional
to affinity
• Km = Substrate conc. at which
Vmax = Vmax / 2

Enzyme cofactors

36
 VITAMIN
TPP / B1 —> Def —> Transketolase (HMP Shunt)
- Oxidative Decarboxylation

—> 1) 6 —> Cystathionine Synthase

PYRIDOXINE 2) ALA Synthase —> RLE - Heme synth
B6 / PLP B6 def = Sideroblastic Anemia
ENZYME 3) Transamination —> Pyruvate —> ALT
SGOT —> AST
4) Rx = Neonatal Seizures —> B6 forms GABA
Xanthine oxidase = MOLYBDENUM —> Dec. Brain Activity
RIBOFLAVIN
Carbonic anhydrase = ZINC FAD
Oxidation Reduction
Glutathione NIACIN
= SELENIUM
peroxidase NAD
Lysyl oxidase = COPPER B5 —> Pantothenic acid —> CoA
Tyrosinase = COPPER
Succinate B7 (BIOTIN) —> Carboxylation
= IRON
dehydrogenase
Post Translational Modificaton = Protein synthesis
Alcohol = ZINC K —> Clotting Factors 2, 7, 9, 10
Gamma - Karboxylation
dehydrogenase —> Lactate Dehydrogenase Glutamic Acid

• Universal methyl donor is : SAM C —> Collagen = Wound Healing

(S-Adenosyl • Vits B1 + B2 + B3 + B5 + Lipoic acid
Methionine) 1) PDH = Pyr
2) alphaKGDH = alpha Keto
3) BCKD = Branched chain

37
 ENZYME DEFICIENCIES- CARBOHYDRATE DISORDERS
C/F Disorder Enzyme deficient

Severe fasting hypoglycemia, lactic Von Gierke Glucose 6 Phosphatase

acidosis , inc ketones , hyperuricemia - Common for
Glycogenesis +
Gluconeogenesis

Heart failure Pompe - Pump Acid Maltase / Alpha Glucosidase

Cori = Debranching

Liver cirrhosis Anderson = Branching

Muscle cramps Mc Ardle Muscle Gycogen Phosphatase

Her Hepatic Glycogen Phosphatase

Hemolytic anemia (Torn RBCs) Tarui PFK (Glycolysis)

OTHER CARBOHYDRATE DISORDERS

Oil drop cataract Galactosemia GALIPUT (Gal 1 PO4)

Inc fructose in urine without Essential (Asymptom)

Fructokinase
Significant symptoms fructosuria
Symptoms when fruit juice given , Hered Fructose Aldolase B
Failure to thrive, liver kidney intolerance All Symptoms +
affected , Symptoms +

• Glu 6 Phosphatase absent in muscles, Present only in Liver

38
• Pyruvate dehydrogenase
deficiency :
• C/f :
• Diet –

Lysosomal storage disorders

Bone pain, pancytopenia,

Beta - glucosidase crumpled tissue paper
appearance

GM2 gangliosidosis
Hexosaminidase Exaggerated startle reflex/ hyperacusis

Foam cells or zebra

Sphingomyelinase bodies

Multisystem - stroke, nephrotic syndrome. Angiokeratoma

Galactosidase

Beta galactosidase Optic nerve - optic atrophy

Thalamic hyperdensity

Tigroid on MRI Brain

Arylsulfatase

39
 MUCOPOLYSACCHARID
OSIS
SPHINGOLIPIDOSIS
GAUCHER HURLER

L - idueonidase deficiency
• accumulation of
TAY SACHS dermatan sulfate
• Clinical features -
abnormal facies, HSM,
J shaped sella,
skeletal
NIEMANN- PICK

FABRY
HUNTER

Iduronate sulfatase
KRABBE Good vision
No corneal clouding

METACHROMATIC
LEUKODYSTROPHY

40
 AMINO ACID DERIVATIVES
PRODUCT DERIVED FOM IMP POINTS
• Treatment of pulmonary HTN
Arginine
Nitric oxide Arginine • cGMP
Melanin Tyrosine Albinism - defect of tyrosine

Melatonin Tryptophan

Serotonin Tryptophan

Amino acid derivatives

Tryptophan
Vitamin B3/ Niacin TRIptophan
60 mg Tryptophan - 1 mg B3

Thyroxine (T3,T4) Tyrosine

Catecholamines Tyrosine Dopamine,

Parkinson’s

Urea Arginine, Aspartate

Creatine Methionine, arginine, glycine

Glutathione Tripeptide - glutamic acid, cysteine,

glycine

41
 Urea cycle disorder (in liver)
Ammonia increased
Causes encephalopathy + flapping
tremors/ asterixis
Rx - lactulose

ENZYME DEFICIENCIES- AMINO ACID DISORDERS

AMINO ACID DISORDERS
C/F URINE Disorder Enzyme deficient
Blonde hair , microcephaly , PAH
Musty/ mousy PKU.
low IQ Phenylalanine hydroxylase

Ochronosis Black urine on Alkaptonuria HGO

standing (Kala) urine Homogentisate (tyrosine)
oxidase

Burnt sugar odour MSUD BCKD

branched chain keto acid
dehydration

Tyrosinemia I - FAAH
Cabbage odour Black (melanin), fumarate
enters TCA

Albinism -tyrosinase deficiency- copper, AR, chromosome

number 15
NUCLEOTIDE DISORDERS
Nail biting, self mutilation, aggressive , hyperuricemia Lesch nyhan syndrome -
HGPRTase complete absence

FTT , oral thrush in an infant , multiple infections SCID - ADA deficiency

• gene therapy

42
 HOMOCYSTINURIA Homocysteine inccreases

Deficiency of vitamin B6, B9, B12

Treatment -
• supplement cysteine
• Restrict methionine (forms homocystinuria)

• Presentation similar to – Marfan syndrome

• Lens subluxation – Marfan - up and out

Homocystinuria - down and in

• Pro thrombotic – Early MI and stroke

• Low IQ

Folate Vit B12 deficiency

Foliate - leafy veggies

BOTH stored in liver
Involved in
1. DNA synthesis - megaloblastic anemia causing with hyperpigmented neutrophils
2. Increased homocysteine - B6, 9 and 12 must be taken
3. Functional folate deficiency in B12 deficiency
4. MMA increased only in B12 deficiency and not folate deficiency
folate absorbed in jejunum
Vitamin B12 absorbed in ileum
IF, pernicious anemia, gastrectomy - cases where deficient seen
5. Neurological cases - b12 deficiency
SACD - subacute combined degeneration
6. If B12 deficiency- folate supplement - anemia improves but neurological problems worsen

Tests
Folate deficiency - FiGLU - histidine load test
B12 - increased MMA - increase methylmalonic acid

43
 Pellagra

B3
Maize
Diarrhea, dermatitis, dementia, death
Tryptophan

Flushing, liver toxicity and

Pruritus

Maize - b3 deficiency
Hypolipidemic
Niacin - increases HDL
Carcinoid - B3 deficiency
Hartnup’s disease
Vitamin b6 deficiency - required for b3 deficiency

VITAMINS
WATER SOLUBLE VITAMINS
VITAMIN DEFICIENCY FEATURES TEST/ASSAY IMP POINTS
Beri Beri - wet and dry
B1(Thiamine) Wernicke’s in alcoholics
RBC 3 enzymes
+ transketolase - thiamine • PDH
• global confusion
• Ataxia • ALPHA KGDN
• Nyastgmus • BCKD

B2(Riboflavin) FAD
FMD Glutathione reductase
Sebo -seborrheic dermatitis
Rubro - red - cornea and red tongue
Corneal neovascualris, cheilosis, glossitis
B3 (Niacin)

Casal’s necklace - b3
Maize

B5 (Pantothenic acid) COA

Pants - feet - burning feet

B6(Pyridoxine) PLP
• Decarboxylase of aa - amine
• Histidine - histamine

B7(Biotin) Raw egg white - avidin - no biotin absorption

Carboxylation - ACC -Fas
Rx - multiple carboxylation deficiency

44
VITAMIN DEFICIENCY FEATURES TEST/ASSAY IMP POINTS
B9 (Folic acid )
Megaloblastic anemia

B12 Megaloblastic anemia

Increased MMA, vegan diet, SACD

Scurvy - toxicity
C (Ascorbic acid ) Absorb iron increased
- hydroxylation of proline lysine- collagen - wound healing affected, perifollicular hx, bleeding gums

FAT SOLUBLE VITAMINS deficiency - steatorrhea, cystic fibrosis, malabsorption, celiac disease
A Eye (II cis retinal) - night blindness, bitot’s spots, dry skin, toad
like skin
Toxicity - pseudo tumor cerebri
Deficiency causes rickets, osteomalacia
D Sunlight required for Bones - increased Ca, Phosphate
conversion of Active form - 1, 25 (OH)2
Erythrocytes - hemolytic anemia, acanthocytosis
E Antioxidant
Enterocolitis in infants
Neurologic - SACD
K Karboxylic
Koegrelin
Epoxied reductase (- )
warfarin - vitamin K antagonist
Breast feeding - DK supplement

Phyroderma Bleeding gums Casal’s necklace

Perifolicular hx Pellagra/ b3
Vitamin A deficiency Scurvy Vitamin c deficiency
Vitamin C

Dorsal column
Vitamin B12 deficiency
Dementia

45
Vitamin assays

46
 MINERALS
Acrodermatitis enteropathica
KF ring - cornea and descement membrane
Zinc deficiency- diarrhea
Wilson’s disease
AR - chromosome 13
MRi
Face of giant panda

Insulin resistance - chromium

deficiency

Menke’s - cu deficiency
TRIAD OF Kinked hair
DAD: Dermatitis , alopecia, diarrhea Cork screw hair

• Keshan disease Heart - selenium deficiency

• Kashin Beck disease Bones - selenium and
iodine deficiency

Calcium
• vitamin D
• PTH - DECREASED GIP
• Calcitonin - decreased Ca
•

47
 LIPOPROTEINS
CHEMISTRY
Maximum exogenous TG
Maximum endogenous TG
Maximum cholesterol
FUNCTIONS
Delivers dietary TGs to peripheral tissues
Delivers hepatic TG s to peripheral tissues
Delivers hepatic cholesterol to peripheral tissues
Mediates reverse cholesterol transport from peripheral
tissues to liver

APOLIPOPROTEINS

Intestine – CM -

Liver – VLDL, IDL, LDL

REMNANTS

Binds LDL receptor

Lipoprotein lipase cofactor

Found only in HDL , activates LCAT

48
 FAMILIAL DYSLIPIDEMIA
TYPE II/ HYPER Inheritance :
CHOLESTEROLEMIA Defect :
Xanthoma :
Corneal arcus
Atherosclerosis

TYPE I / Defect :
HYPER Inc :
CHYLOMICRONEMIA C/f :
No inc atherosclerosis ABETALIPOPROTEINEMIA
• Infant with
steatorrhea, FTT ,
retinitis pigmentosa,
acanthocytosis
• Intestinal biopsy :

• Deficiency of :

• Defect in :

MOLECULAR BIOLOGY
BLOTTING TECHNIQUES
SOUTHERN
NORTHERN
WESTERN
SOUTH-WESTERN
POLYMERASE CHAIN REACTION
STEPS :
ENZYME:
RT- PCR :
MUTATION
POINT MUTATION :
SILENT MUTATION

MIS SENSE MUTATION

NON-SENSE MUTATION
FRAMESHIFT MUTATION

49
PATHOLOGY
SURE SHOT
COMBINED

so
 - Hereditary / familial - metabolic IEM /
Noon enzyme deficiency
Wilson vs Menke’s - XLR
Tall Sickle cell
Hemochromatosis
Round
Hemophilia C vs Hemophilia A & B - XLR
- Turban Congenital adrenal hyperplasia - ambiguous genitalia
- Dwarf Friedrich ataxia
- Fractures Ataxia telangiectasia - taxi
- Muscles Spinal muscular atrophy - SMA
Thalassemia - Thalaiva vs G6PD deficiency - XLR
Non Lysosomal storage disorders - AR
Inborn errors of metabolism Tyrosine

Amino acid disorders - Albinism, alkaptonuri,

PKU
Glycogen storage disorders
Lysosomal storage disorders / sphingolipidosis
except - Fabry (Fabrix)
MPS except - Hunters (XLR)
Alpha 1 antitrypsin deficiency (emphysema)
Huntington chorea AD
MEN syndrome 2 men
Huntington’s - hunting
Von Hipple Lindau disease
Hereditary (AD) hemorrhagic telangiectasia vs Ataxia,
telangiectasia (AR)

- Female
|
CAR
(Mnemonic)

- Whiskey

Retts - females MECP gene

Ornithine transcarbamilase deficiency - OTC

MNEMONIC

Granny

Lesch
Nyhan
Bruton 6 goons

Color blind
Mnemonic : KLMNOP
 No skip Skip (+)
Dominant Recessive
rr- heterozygous 25% chance
parents

Affected : M > F = XLR

Dominant - present in all generations Recessive - unaffected parents (carrier) have affected children
Recessive - skip (+) Mitochondrial inheritance - maternal transmission
Autosomal - M = F Affected mother to all
X linked : No male to male transmission Father to none
Recessive - M > F Affected parents - unaffected child in dominant : S/o parents =
Dominant - XX, fathers to all daughters herterozygous
Pp Pp

-Pp -Pp Pp pp

Affected 2/4

Unaffected
Lethal 1/4
1/4
 M-M not present

Mothers (N) & Fathers affected

In XLD : all daughters
affected
XLR : all daughters carriers

Most Likely Inheritance

A) AD
B) AR
C) Mitochondrial
D) XLD
E) XLR
Mother to all - mitochondrial

A) AD
B) AR
C) Mitochondrial
D) XLD
E) XLR
 A) AD
B) AR
C) Mitochondrial
D) XLD
E) XLR

A) AD
B) AR
C) Mitochondrial
D) XLD
E) XLR

Father to all daughters

Unaffected parents - affected

children = recessive
Males > Females
 Mnemonic
13 - Puberty - Patau
18 - Edwards
21 - Drink - Downs

Downs (21 Trisomy)

Dx - Patau

Turners
% - deletion
Criduchat - cry cat

Double bubble appearance

Seen in normal / Downs /

other

Simian
Incurved 5th finger gap - clinodactaly
Gap between 1st 2 toes - sandal gap
Congenital heart disease - Endocardial cushion defect (ECD - MC)
Downs - ECO - Cushion - goose neck : LV elongated
Trisomy - increased amyloid precursor protein
Robertsonian translocation - Acrocentric chromosomes (14 & 21)
M/C non-viable chromosome disorder - trisomy 16
Increased nuchal translucency >3 mm
Hypoplastic nasal bone - NBNT around 11-13 wks
Triple test - inhibin xx (UE3)
Quad : A - allowed, B - banned
NT + dual marker - combined 1st trimester screening
Beta HCG increased
PAPPA decreased

Edward

Patau

Prominent occiput - strawberry skull

Ed - everything decreases in Edwards
Patau - Cleft palate, prosencephaly, aplasia
Holoprosencephaly - alobar variant = cyclops feature
 Turner - bicuspid AV, normal IQ
vs Noonan - M/F - PS, decreased IQ
Webbing of neck might be seen in both

Hypergonadotrophic (high FSH) hypogonadism (low estrogen)

Edema - Feet & hands, pedal edema - Lymphatic obstruction (Turners)
No. of bar bodies = X-1

KLINEFILTERS :

Barr = 1
Increased FSH, LH & decreased testosterone - hypogonadism
No secondary sexual characters - gynecomastia
 VHL (3) - RCC (clear cell)
- 4 CAG, achoncroplasia - 4 limbs
5p | 5q - AD |

Williams - deletion in long arm of chr. 7

Beta - 11, alpha - 16
- 11
- 13 yr - Brca - 2 eyes - Wilson (Mnemonic)
Mnemonic : Father - Prader, Mother - angel,
Tall son - Marfan (AD)
Fair daughter - Albinism
(AR)
Catch 22 - defect of 3rd and 4th pharyngeal pouch
- B/L vestibular schwannoma

Brutons

HEMOCHROMATOSIS :

Bronze (skin) diabetes (pancreas affected) + cirrhosis Prussian Blue Stain

MRI - T2* sequence
CPPD - Hook like metacarpals

Williams : Elastin gene affected , Elfin facies

 CFTR - cystic fibrosis,
(Fehylalanine) chloride channel
coding gene
Lung - bronchiectasis
GI - meconium ileus

Pilocarpine - cholinergic
Alkalosis + Hypokalemia

CFTR : Lungs & GIT - Secretion (thick mucus), Sweat glands - absorption (increased chloride in sweat)
Cystic fibrosis - microcolon
ABPA predisposing conditions (allergic) - asthama & cystic fibrosis (increased IgE)
Ivacaftor - potentiator

FBN1 - fibrillin 1 (glycoprotein)

Lens subluxation - superotemporal vs Homocystinuria (inferomedial)
 Silencing - muting - methylation

Paternal del Maternal del

PS : Paternal deletion - maternal imprinting / maternal uniparental disomy (UPD)

Angelman : Maternal deletion - Paternal imprinting / paternal disomy UPD

Deleted gene - functional / active gene

ARKD - recessive (severe & early)
PKHD - hepatic fibrosis
ADPKD - dominant
Renal failure : cysts - non communicating with excretory system
appearance - Swiss cheese
MRA brain - to look for berry aneurysm

Christmas tree
Fragile X Huntington
Myotonic Chr. 4
chorea
AD

Myotonic
CTG
dystrophy
Chr. 19
AD

Friedrich Box car Fragile X XLD

Huntington’s chorea Chr. X

Friedrichs AR
Chr. 9
 Diagnosis - Myotonic dystrophy
CTG repeat C __G - Can’t Terminate Grip (Mnemonic)
Coding : CAG
Non-coding:
CTG - myotonic dystrophy
CGG - fragile X
C - Cataract (christmas tree)
T - Takla - frontal baldness
G - gonadal atrophy

FRAGILE X SYNDROME :

XL size - ears, jaws, testis

Fragile - self mutation
Hypermethylation - mutes the gene (decreased
expression)

HUNTINGTON’S CHOREA

Caudate affected
MNEMONIC :
Box car - ventricles on MRI, dilated frontal horn of
lateral ventricles
Cage - CAG repeat
4 walls - Chr. 4
Dominant - AD [vs Hunter’s - XLR]
CAG = caudate - decreased ACh & GABA
Mnemonic 3M : Memory - dementia , Mood - aggression,
Movement (abnormal) - chorea
FRIEDRICH’S ATAXIA

Recessive Increased severity or earlier onset of disease in

Mnemonic : Friend Sweet (DM) Teda succeeding generations - anticipation
Singer Big heart skeletal
GAA HOCM

31 -PECAM CD 13, 33, MPO+

- reproductive CD 34 34 - Repro Stem CD 5+, CD 23-
CD 45 38 - plasma state Combined - CD5, 23+
45-RO
40 - Switching isotype Ig CD 103, 11C, 25, annexin A1
CD 10 CD 10+
19 41, 42 - megakaryocyte
CD 15, 30+
CD 3 (also 61)
CD 20, 45+
CD 4 43 - Whikott Aldrich
CD 8 CD 40 (B) - CD 40L (ligand T)
CD 25 / suppressor cells
CD 13 & 33
CD 16 & 56 CD 43
CD 38 (best) & 138
LAD adhesion CD 188, CD 11
CD 41, 41, 61
CD 14 LPS - CD14 Integrin beta 2 - CD 18
CD 95
CD 25 - Daclizumab (multiple sclerosis)
CD 99/mic 2 t (11, 22) CD 21 / CR2

CD 99 CD 1a, 207

CD 117/c-kit Def of CD 55 & 59 (-) compliment

Signaling component of T cell receptor (TCR)

complex : CD 3+ (pan T) Daclizumab withdrawn from market due to S/E -
Costimulatory on T cell : CD 28 autoimmune encephalitis
Annexin 5 - apoptosis CD 55 - decay accelerating factor, CD 59 - MAC if
HL classical : CD 15 & 30 - Reed sternberg cell
 Owl’s eye of Reed sternberg cells
CD 15, 30+
Hodgkin’s lymphoma

Tennis racket of Birbeck

granules
LCH - CD 1a, 207

CD 152 present on T cell

CD 80 /86 on ATC
CTLA4 agonist
(-) immune -> transplant
CD 28 (costimulatory on T) Abatacept rejection
Belatacept

CD 4 - MHC 2
CD 8 - MFC 1

CTLA4 antagonist Increase immunity (cancer)

CD 3 Ipilimumab - Immune point inhibition
- Rx melanoma

Tremelimumab
- Rx HCC, NSCL
- Along with Durralumab

CTLA4 - immune check point

 Prostrate

HCC, yolk sac tumor

Choriocarcinoma Neuroendocrine

Breast Ca. Carcinoma

Pan colon Muscle tumor

Epithelial Ovarian Ca. Glial

MTC Neuronal

Non specific Prostrate

Neuronal - endothelium Vascular - angio

DPL Schwannoma, Melanoma, LCH

HCL
Mesenchymal, meningioma &
endometrial

CA- carbohydrate
Dysgerminoma counter part - seminoma
Alpha-feto protein - elevated in HCC, body defect in fetus (Abd / NTD)

Epithelial

(Semen)

+ PLAP, Dysgerminoa - PLAP & LDH

- Albinism - melanoma

B/plasma cells
(prognostic)

(choriocarcinoma)
- syncytiotrophoblast
Parafollicular cells - med - MEN 2
- Adrenal medulla
(yolk sac tumor)
 - IHC

(mesenchymal) , meningioma, endometrial tumor

, GBM

(Neural crust
cells)

Leukocyte

Neural crust cells

1. Melanoma
2. Schwannoma

- HCC, yolk sac tumor

- Prostrate
- Non specific : breast, stomach, pancreas
- Pancreas & Colon
- Breast cancer
CK 7+ | CK 20- : above the diaphragm - Breast, lung, thyroid
CK 7- |CK 20+ : Merkel cell, colon
Both (+) : All evident in Ovarian & Urothelial cancer
Both (-) : Liver & Kidney

CDX2 - (+) in intestinal tumors

Mast cells
Eosinophils

NK cells ADCC

Neutrophils

T cells (+)
macrophages
Mnemonic
I : A - Anaphylaxis III : C - Complex / complement
II : B - antiBody IV : D - Delayed

Not Ab mediated - type IV Mnemonic : A PACT

Type I - IgE Allergy - PK (Prausnite Kusmer reaction)
Mast cells release histamines Anaphylaxis - A
Eosinophils - contain basic protein Asthma - Casoni test (Hydatid test)
IgE - Omalizumab - mast cells Atrophy - Theobald smith (TS)

Mnemonic
ABCD ACID - Antibody / cytotoxic

CD 16

ADCC

(Type 2 - preformed Ab)

: Ach receptor - post synaptic

: TSH receptor - pre synaptic

Type V - Ab against receptor

Mnemonic : I Push 2 GEAR

I : IDDM, Immune hemolytic anemia / E : Erythroblastosis, fetalis / blood transfusion rxn
Thrombocytopenia A : Autoimmune HA / ITP
Push : Pernicious, Pemphigus R : Rheumatic fever / RHD, Rh incompatibility
2 : HSN
G : Graves, M. Gravis, GPS
Complex / complement mediated
Arthus reaction - localized

- vasculitis

- complement decrease

Mnemonic : SHARP
S : SLE, Serum sickness
H : HSP, Hypersensitivity pneumonia
A : Arthus
R : Reactive & Rheumatic arthritis
P : PAN, PSGN

Mnemonic :
Delayed
Skin - skin tests
Cell mediated, T cells
Contact - contact dermatitis
Activated macrophage - IF N gamma
Graft - chronic GVHD
Delayed type hypersensitivity - granuloma
Granuloma
Type V - receptor mediated
Subtype of type 2
Ab against the receptor
Graves & M. Gravis

Combined :
1. SLE - 2 & 3
2. Rheumatoid arthritis - 3 & 4
3. H.S pneumonitis - 3 & 4
4. Transplant rejection : Hyperacute (preformed Ab) - 2, Acute & chronic - 2, 4

Lepra reaction - rule of 5

Type 1 Lepra reaction - type 4 H.S
Type 2 Lepra rxn - type 3 H.S
AMVLOIDOSIS

73
 - Hereditary spherocytosis
<80 >100
- Rx : Splenectomy
80-100
- Also seen in AiHA
(Coombs +ve)

- initially normocytic

Macrocytic anemia involves megaloblastic (hypersegmented neutrophils)

Folate - foliate vegetables, junk
B12 - Non veg + neurologic features, increase MMA
Increased homocystiene is seen in both
Methotrexate (-) DHFR

IDA - M. sensitive - ferritin (stored) reduced

TiBC increases
S. Ferritin level - most sensitive test
RBS distribution - Thalassemia : genetic cause
Electrophoresis for Dx of thalassemia
Hepcidin - +ve acute phase reactive
Iron absorbed in stomach & duodenum (ferrous form)
Vit C (ascorbic acid) - increases Fe absorption
Fe transporter : DMT-1, Ferroportin (into circulation)
Hepcidin from hepatocytes - inhibits ferroportin
Increase in Fe - Increases Hepcidin (inflammation)
 Owls eye (also in CMV)
Starry sky appearance Hairy cell leukemia Reed sternberg cells
Macrophages (stars) Memory B cell Hodgkins lymphoma
Lympho - blue
CD 103, 110, 25
C/o LN, wt loss, fever
Jaw sewlling child Africa Hairy - red pulp of spleen
CD 15, 30+
t (8, 11) Annexin Ai +
Except non-classical
a/w EBV infection Elderly patient with
L.P - C 20, 45+
B cell CD20+ massive splenomegaly &
a/w EBV infection
C-myc on Chr. 8 pancytopenia
Lymphocyte dep. - bad
DOC - Cladribine /
prognosis
Pentostatin
Nodular - lacunar
BRAF mutation present
Predom - popcorn cell

Follicular lymphoma Cerebriform

Flower - clover leaf
nucleus
M/c indolent NHL ATLL - HTLV-1 (also a/w Smudge / Parachute cell
M/c overall - DLBCL tropical sp poresis) Seizures CLL
(aggressive) Sezary
Elderly patient
c/f : waxing, waning, c/f : cutaneous lesions, syndrome -
LN +ve
LN Ca inc., China, Japan, mycosis
CD flow cytometry -
t (14, 18) Clover leaf fungoids
CD5+, 20+
CD 10+ CTCL - CD4+
(combined +ve)
MF - Pautrieis
vs Mantle : CD5+,
Psoriasis -
CD23-
Munro
DOC : Fludarabine
Rx : Electron
Beam
 8 - c-myc, t (8, 11)
Starry sky, jaw swelling
CD 5+, CD23-, t (11, 14), cyclin D, SOX11 +

t (14, 1), B cell, Waxing waning

Memory B, red pulp, CE103+, annexin A1+, Cladribin, no LN
Tartarate Resistant Acid Phosphatase +
CD15, 30+
CD 20, 45+ LP
Elderly Fludarabine parachute smudge
Combined +ve : CD5, 23+
CTCC, Helper T, CD4+, Pautrier, Sezary, EB Rx

CML (Philadelphia Chr. t 9, 22),

DOC - Imatinib

Lymphoblast > Myeloblast

Acute leukemia

AML, Faggots M3

M3

CML

CLL
 3P + 0M - XX pheochromo
2P + 1M
Pheochrom
1P + 2M
(Calcitonin)
MEN 2 - Pheochromo

Pheo - adrenal medulla

MTC - Parafollicular C cells
NCC: MEN2 - RET - gain of function

Insulinoma (hypoglycemia) LOF RET - Hirschprung (aganglionic

(NONCC) megacolon)

Elevated peptic ulcers - gastrinoma

[(+) acid] = Zollinger-Ellison (ZES)

NME - Glucagonoma (NMC)

Diarrhoea :
Carcinoid - Flushing + Tricuspid regurgitation (inc. urine 5 HiAA)
ViPOMA - WDHA - watery Dx, hypoK, achlorhydria
 Squamous cell Ca.
Adeno Ca.
Small cell Ca.
Mesothelioma

Associated with Asbestosis

Keratin Pearls
SCC
MC radiological finding: Calcified pleural plaques p40, p63 (+)

- Ach receptors post synaptic

- ANA
- anti smith (dsDNA - activity)
- anti Ro (neonate)
- anti Ro / La SSA/SSB - dry eyes, mouth
- anti Histone (SHIP)
- Rheumatic factor Specific - anti CCP
- Diffuse - Topoisomerase (SC - 70) - Raynaud’s (+) + esophageal dysmotility
- Centromere (Hd scleroderma)
- C ANCA - URT (sinusitis)+ LRT (OM/septum) + Kidney
- TSH receptors (CATS+)
- TPO (+) - lymphoma / Hurthle cell (+)
- anti endomysial / TTG (tissue trans glutamine) - gluten sensitive + Dermatitis
Herpetiforms
- anti GBM (glom. basement membrane)

Dapsone
 12/10/23

MICROBIOLOGY
SURE SHOT
COMBINED

MOTILITY
DOC - Azithromycin xx Penicillin STAINS SPORE FORMING

walking Gram stain : +ve — purple Autoclave Bacillus Clostridium

atypical (Mycoplasma do not gram stain since no cell wall )
pneumonia Also Rickettsia , Chlamydia – intracellular
PAS stain : PAS + macrophages — Whipple’s

Acid fast : ZN stain – Mycobacteria , Nocardia , cryptosporidium

acid
Dx in HiV +
India ink stain :
Cryptococcus — mucicarmine

MOTILITY

• Swarming — Proteus (swimming)

PIGMENT • Tumbling — Listeria
Golden yellow (Au)reus. s
• Darting — Cholera
Blue green Pseudomonas
• Gliding — Mycoplasma
Yellow sulfur granules Actinomyces • Stately — Clostridium
Madurra foot
Red Serratia Treponemma
• Corkscrew — re s e t t

(Red) — pseudohemoptysis • Falling leaf — Giardia

[Lung — Paragonimus] String Test

⑧

(duodenum)

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Recurrent infection in
Chronic granulomatous disease

CULTURE MEDIA
BYCE — legionella BC YE LE
Lulu — Ludlam Casanova
Castenada
Staphy cat — milk salt Black (PLET)
plate
Catalase +

milk
added salt Anthrax
Bruce Lee Eschar

Diphtheria sparrow camp IRUVAR

~-
Ash
pseudo malki
pyogenes crystal

Tinder
McLeod
Butchard
Tellu
CVA

84
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Corynebacterium diphtheriae

Streptococcus pyogenes

Brucella

B. pseudomallei

B. cereus

Campylobacter

Legionella

Bordetella

Anthrax

Staphylococcus aureus

Salmonella

Pseudomonas
cholera — yellow
MonsuisGTTA — Vibrio
parahemo — green

— H. influenzae
phil philus SATELLISTISM
Neisser Ne er

— TB mycobacterium

— list listeria — Tumbling motility

— anaerobic clostridium

— differential — lactose vs KFT

punic E. coli

Kliebsella
Shigella
salmonella
shigella

• Barbour - Stoenner - Kelly Broth media — Borrelia recurrentis

• EMJH medium — Leptospirosis (3R)

• BSK media — Bas Karo — B. burgoderfem

Lyme disease

85
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GRAM POSITIVE BACTERIA

chain
clusters
Streptococcus pneumoniae streptococcus
diplococcus pyogenes

all + - cat +
coag +

GBS neonatal
meningitis

2 Optochem Ca colon
+
GBS — gm + coccus
Neonatal
meningitis

Listeria — gm + bacilli

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Actinomycetes
Gram +ve
(A B C)
Branching
anaerobic
filaments
Nocardia

SNAP Penicillin

sulfon NOC Actino Heart acid

fast
• dental caries ZN stain
• cervical sinus Kinyosis

GRAM NEGATIVE BACTERIA

• Have LPS in
outer
membrane : not
present in gram
positive

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88
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89
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Actinomycetes

BACTERIOLOGY IMAGES
Anaerobes Bacteroides
Metronidazole Clostridium
Drugs
Clindamycin

⑧ anaerobe

cutaneous anthrax
lecthinase
MC Fadyean reaction Black eschar X- toxin

Medusa head Anthrax Gram +ve Chinese letter

capsule
colonies polypeptide metachromatic granules

Corynebacterium diphtheriae
+
TCBS Vibrant
Vibrio
Cholera
X
Yellow
positive — purple

⑧ Neisseria
Gram negative — piNk
Löwenstein-Jensen Media mycoplasma — fried egg appearance
Meningitis + shock + petechinae
egg Mycobacterium
Waterhouse Friedrichson

adrenal hemorrhage

Hand
Tick

Cholera

H. influenzae
Spirochetes Staphylococcus aureus
Corkscrew Secondary syphilis

motility
Treponema 00 ⑧

00 wwr

leptospira
- 1. Hutchinson teeth (incisors) (Bolo)
R R R
2. Intestinal keratitis (dekho)
Rats Rains Rice 3. SNHL (suno)
Weils — icterohemmorhagic Dark field
microscopy Cong
fever

Treponema — syphilis
painless
ulcer

90
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DIARRHEA & FOOD POISONING

Serious/aureus
• 1-6 hrs incubation period
• Staph aureus — milk/pastry (NP421)
• Bacillus cereus — Chinese rice fried

• Fried rice : — B. cereus

• Poultry : — Campylobacteria (GBS)
• Dairy products, pastry : — S. aureus
• Antibiotic use : Clostridium difficile Diarrhoea
• Canned food : Bottle Botulism — flaccid
• Dysentery – Shigella , Vibrio parahemolyticus
• Rice water stools — cholera
• Diarrhea in infants : Rotavirus

E. Coli
• ETEC:
• EHES:
• EIEC:
• EPEC :

BACTERIAL TOXIN MOA

Increase fluid secretion Superantigens
Increase cAMP causing shock:

Toxic shock
Increase cGMP syndrome :
Inhibit protein synthesis
Inhibit EF-2 by ADP ribosylation

Inhibit 60s ribosome

Inhibit neurotransmitter release (cleave SNARE )

Spastic paralysis, risus sardonicus, trismus
(lockjaw), opisthotonos

Infant botulism, canned food

• Burns
• Malignant otitis
Lyse cell membrane
externa
• Cystic fibrosis lungs

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VECTORS & RICKETTSIA

Anopheles Louse

Aedes
Hard tick

RICKETTSIA
Culex
Soft tick R.Prowazeki

R. Typhi
Sandfly Mite

R. Rickettsia

Rat flea Cyclops

R. Tsusugamushi

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PARVOVIRUS

VIROLOGY-DNA VIRUS

93
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VIROLOGY – RNA VIRUS

HEPATITIS
IMP POINTS ABOUT HEPATITIS VIRUS HEPATITIS B serology

Feco oral transmission : Sequence :

Non enveloped : Always present in infection irresp of stage :

Enveloped, DNA virus : Window period :

Post vaccine :
Enveloped , RNA virus :
High infectivity / Replication :
Fulminant hepatitis in pregnancy :
Acute infection :
Superinfection with Hep B :
Chronic infection:
Chronic , carcinoma , carrier :
HAV :Enterovirus Recovered :

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HEPATITIS B SEROLOGY

95
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HIV
OPPORTUNISTIC INFECTIONS

Ground glass opacities on chest imaging PCP Pneumocytis (cotrimoxazole CD4 < 200)

Meningitis : India ink stain – encapsulated yeast Cryptococcus

Brain abscess, multiple ring enhancing lesions Toxoplasma

Solitary ring enhancing lesion in brain CNS lymphoma — EBV

• Screening test detects : p24 Progressive multifocal leukoencephalopathy JC virus (S/E — MS drug Natalizumab)

• HIV binds to T Helper — CD4 + Retinitis , Cotton wool spots CMV retinitis DOC — Ganciclovir

• Reverse transcriptase : Cutaneous lesions, perivascular spindle cells Kaposi sarcoma HHV8
Telomerase RNA DNA
Biochemistry dependent polymerase
Oral scrapable white plaques Candida

Oral non scrapable white plaques Hairy leukoplakia

Fever , cough , Oval yeast cells withing macrophages Histoplasmosis (hides in macrophages)

AIDS AND OPPORTUNISTIC INFECTION

96
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MYCOLOGY

97
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MYCOLOGY

Blastomycosis Tuberculate
Broad shaped budding NTB — Histoplasma
OHIO disease
Bat/caves

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Copper penny /
aseptate hyphae, -
H/0 thorn medlar Germ tube formatn/
obtuse/900
prick Verrucous sclerotic bodies Reynauld braude phenom
branching

Pneumatocele HIV t
Spaghetti & meat ball app

DERMATOPHYTES
Trichophyton
→
-affects
-Tricolour pencil

Epidermophyton
↓
. affects
,
MICROSPORUM

-
-spindle
affects -S
↳
-S

99
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PARASITOLOGY
PROTOZOAN

• Only trophozoite, no cyst form , STI:

• Foul smelling , fatty diarrhea

• Dysentery , liver abscess, anchovy sauce

• Oocysts in cat feces

• Swimming in warm water , raidly fatal meningoencephalitis

• Dilated cardiomyopathy, megacolon , megaesophagus , Romana sign

• Liver , skin, pancytopenia , macrophage containing amastigote

TREMATODES NEMATODES

• Urinary bladder SCC , penetrate skin , Cercaria • Entering through skin

• Cholangiocarcinoma • Anal pruritis , worse at night , tape test

• Myositis

• Whipworm

• River blindness

• CESTODES • Cutaneous larva migrans , microcytic anemia

• Vit B12 deficiency

• NCC

• Dog / sheep , liver cysts

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PARASITOLOGY EGGS
Barrel shape with
Clear space, Linear striations
bipolar mucus plugs FEATHer Light – So float
segmented
• Fertilised Ascaris
• Enterobius
• Ancylostoma
• Trichuris
• H .nana

Terminal spine
A scary egg with irregular Planoconvex Terminal knob
surface
lateral spine

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MALARIA
MALARIA IMP POINTS

Over & over again

Falciparum
Relapse in

Crescent / banana gametocyte Falciparum

No schizont Falciparum
Definitive host Female anopheles
Malignant Tertian Falciparum-fatal
Quartian
Malariae
Nephrotic syndrome

Cerebral malaria Falciparum

DOTS

Maurer’s Falciparum
James Ovale=male
Ziemann Malaraie
Schuffner SUV = vivax

STERILISATION & DISINFECTION

Autoclaving 1) culture media except LJ/Loeff. Serum slope QUALITY CONTROL AGENTS
egg
Inspissation
2) suture material 3) surgical metallic • Hot oven: Bacillus atropheus subspecies niger (nigro hot)
• Autoclave : Geobacillus stearothermophilus
Hot air oven • Radiation: Bacillus pumilus (PURA)
Glassware • Filtration: Serratia marcescans Brevundimonas dimunita
• Ethylene oxide (Eto) : B. atropheus subspecies globigii
Inspissation Serum slope / egg - LJ

Blood spill Sodium hypochlorite

Bronchoscope Glutaraldehyde

Ionizing radiation Catgut HIGH LEVEL DISINFECTANTS :

Ethylene oxide Heat sensitive sporicidal
• Chlorine

}
Heart lung machine
• Glutaraldehyde Scopes
• Formaldehyde
• H2O2

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PHARMACOLOGY

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PHARMACOLOGY

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GENERAL PHARMACOLOGY- Dose response curve

• Most potent – X (Left)

• Most efficacious – X = Z

• Adrenaline and histamine

on bronchi -=
• Adr. = Bronchodil. (B2)
• Histamine = Bronchoconst.
• Physiological Antagonism
- Diff receptor = Opp. Action

Nik-monic
• H - Ht
• E - Efficacy
• L - Left
• P - Potent

Intrinsic activity
Intrinsic activity for

• Agonist —> +1
• Antagonist —> 0 (Baseline)
• Inverse agonist—> -1
• Partial agonist
—> 0 to +1

• Antagonist —> High affinity = Binding, No IA

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Therapeutic index
• Nik-Monic : TILE
LD50 —> Toxic Dose
• TI = ———
ED50

• Therapeutic
drug monitoring
for drugs with
Narrow TI = Upsafe
E.g. Lithium, Phenytoin,
digoxin

TI = 100/1 = 100

First vs Zero kinetics

• First order kinetics

Constant fraction is eliminated in _______

• amOunt is eliminated in zero order kinetics Irresp of

Constant __________
plasma conc.
• T1/2 constant in first order (fraction, t1/2)
___________

—> Dependent
—> const. on pl conc.
amt. (majority)

• Zero - Const amount

100 mg —> 90 min —> 60 mg
After 3 hrs —>
100 —> 60 —> 20
90m 90m
-40 -40

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CLINICAL TRIALS

Investigational
New Drug

In healthy Small pts R.C.T New Drug

humans -Companying with Approval
• Pk, Safety, previous FDA / DACI
Tolerability

3
• Drug marketed after phase ______

• Post marketing surveillance – 4

• Randomised controlled trial to compare new

drug with existing drug - 3 - RCT
• Bioavailability 100% —> IV
= Systemic circ. unchanged
• First pass metabolism = In Liver
= Oral route

Drug schedule

Drug schedule
Drug given on prescription H = Health practitioner prescription
Clinical trial
Drug given under supervision —> Guidance (G)
Psychotropic drugs / Abuse
Vs Category X —> Pregnancy unsafe (Thalidomide)
• Loading Dose = Vd x Plasma conc.
L V P
• Maintenance Dose = Clearance x plasma conc.
M C P
• Time taken to reach steady state pl. conc = (4 - 5 t1/2)

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Bioavailability/AUC

Metabolism Failure of other drugs Toxicity

a A A

CYTOCHROME P450 INDUCERS & INHIBITORS

Enzyme inducers = New Bar Enzyme inhibitors
• Carbamazepine (Failure) Y • INH —> Inhibitor
Chronic alc.
• Barbiturates (Phenobarbitone ) • Cimetidine —> C/I —> Cyto P
I
• Griseofulvin Car • Ciprofloxacin
• Phenytoin I
• Omeprazole -

• Rifampicin G • Erythromycin
• Smoking P • Chloramphenicol -
OM/ON
• St John's wort R • Ketoconazole
• Chronic alcohol S • Amiodarone
• Metronidazole
• Sulfonamides -

• Ritonavir
Substrates - • Acute alcohol
○ OCPs • Grape fruit juice
○ Warfarin • Valproate = Anti - epileptic cyp inhibitor
○ Theophylline
○ Anti epileptics
• TB + OCP Failure —> Rifampicin
• Asthma + Antifungal therapy toxicity
—> Ketoconazole (inhib)

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DRUGS IN PREGNANCY – SAFE & TERATOGENIC DRUGS

TERATOGENIC EFFECTS
• Antimicrobials safe in pregnancy • Lithium
• Warfarin
• Tetracyclines and aminoglycosides C/I • Phocomelia

• Diethylstilbesterol
• HTN drugs safe in pregnancy
• Premature closure of
ductus arteriosus
• Tetracyclines
• Aminoglycosides
• Phenytoin

IMP ADR IMAGES

SIDE EFFECT DRUG

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POISONING & ANTIDOTES

C/F Diagnosis Antidote
Farmer , increased salivation ,lacrimation, diarrhea OPC Atropine +
, sweating (AchEi’s) Pralidoxime

Child playing eats fruit , 9Ds – dry , delirium DHATURA Physostigmine

Old house , wall paint Lead EDTA
Heart failure pt , xanthopsia , nausea Vomiting Digoxin Digibind
Antidepressant , arrhythmia , broad QRS TCA Na Bicarbonate iv
3C – coma, constipation, constriction of pupil Opioid Naloxone
Anti freeze, oxalate crystals in urine Ethylene glycol Fomepizole
Fire victims , gas heaters CO 100% O2 oxygen
Desferioxamine /
Iron poisoning
Deferiprone
Beta blocker ———->Glucagon (Inc. cAMP)
Scorpion sting Prazosin

Blurry yellow vision , AV block Digoxin ——> Autonomic symptoms

-Xanthopsia Paracetamol N-acetyl cysteine (Glutathione)

ANS
= Blood vessels M1 ——-> Stomach
Alpha1 - Vasoconstriction PUD = M1 inhibiter
Alpha
Sympathetic

Alpha 2 = Presynaptic —> Sympatholytic M2 ——-> Heart Muscarinic

Parasympathetic

Beta1 = Heart, Renin —> By JG Cells M3 = Rest —> Bronchi - Ipratropium

of Kidney —> Acetylcholine
= Lungs —> Asthma
Beta Beta2 = Vasodilation NM —> NMJ
Nicotinic
Beta3 = Lipolysis NN —> Ganglia

• Atropine —> M Blocker

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• Noradrenaline - No B2 action —> No vasodil. = No dec. in dBP

• Adr / Epi —> Every Receptor action
• Labetalol —> Alpha + Beta Blocker
• Cardioselective Beta Blockers —> A to M
—> Nebivolol except Atenolol, Metoprolol
• Shortest acting beta blocker - Esmolol

• Noradrenaline – DIAGNOSIS -
C/o bee sting – breathing difficulty, hypotension
• Adrenaline / Epinephrine –
DOC- Adrenaline 1:1000 IM (Not SC) = Anaphylaxis —> Type 1 / IgE
• Labetalol • Myasthenia Gravis = Auto Antibodies against NMJ
Post synaptic Ach Receptors
• Cardioselective beta blockers
Ptosis , • Diagnosis —-> Myasthenia Gravis
• Shortest acting beta blocker - fatigue
more in • Drug used
evening
/ with • For diagnosis —> eDRophonium / Tensilon test
exertion -MG —> Improves
• For treatment —> pyRIDostigmine - Long acting AchEi = Inc. Ach
—> Inc. Muscle contraction

Nik-monic : DoBAmine
• Dopamine actions

D B1 A1
• Urinary retention —> Caused by Anticholinergic • D1 —> Renal vasodil. —> Inc. Urine output
• Cholinergic —> Constriction of pupil -DOC in shock with oliguria
—> Contraction of secretions • B1 —> Inc. heart contraction
• Post-Op Bowel / Bladder retention = Bethenachol • A1 —> Vasoconstriction
Fenoldopam : D1 used in HTN Emergency
DoButamine : Only B1 stimulation (Heart)

GLAUCOMA DRUGS
MECHANISM OF ACTION
DECREASE AQUEOUS C —> Acetzolamide (Inhibit CA)
PRODUCTION A —> Alpha agonist (Alpha2 - Clonidine)
B —> Beta Blockers - Timolol, Betaxolol
INCREASE TRABECULAR = IOT = mIOTics (Pilocarpine) = Cholinergic Constriction
OUTFLOW
INCREASE UVEOSCLERAL
= PGF2alpha = Flow increases
OUTFLOW

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SIDE EFFECTS
• BRAIN DEPRESSION , So C/I in —> BRimonidine
infants (Apnea) Brain inhibition
• Lid retraction —> ApracLonIDine (LID)
• Black conjunctival pigmentation —> Dipivefrine
• Pigmentation of iris
• Growth of eyelashes ( Hypertrichosis —> PGF2alpha
)
• Fluid – cystoid macular edema
• Corneal hypoaesthesia
• Precipitation of asthma attack : Beta Blockers —> Local anesthetic - Propranolol

• Topical CA inhibitors
—> Dorzolamide
-Not Acetazolamide

• Non selective beta blockers

C/I in —> Asthma
-A to M —> Cardioselective

• Timolol : Non-selective

• Betaxolol: Cardioselective

POAG DOC: PGF2alpha —> Latanoprost

Sx: Trabeculoplasty
ACG First drug: Mannitol / Acetazolam
Definitive drug: Miotic —> Pilocarpine
Definitive Sx: Iridotomy
in both eyes /
Trabeculectomy

• ACG = Precipitated in dim light —> Mydriasis - Closes angle

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ASTHMA DRUGS
Bronchoconstriction

Ach Ipratropium —> Anticholinergic

Zileuton —> Leukot synthesis

inhibitors
Leukotriene
Montelukast —> Receptor
antagonist
Bronchodilatation

Theophylline—> PDE inhibitor

cAMP
Salbutamol —> Beta2

Asthma - Drugs
• Beta agonists
• Asthma —> Anti-Cholinergic (Beta2) = Bronchodilation
• Theophylline
• Anticholinergics
• Leukotriene antagonists
• Theophylline

• Mast cell degranulation

——————> MDI
• Anti IgE = Omalizumab

• Cromoglycate
——————-Dec. deposition
in pharynx
-Dec. Candida
Side effects of salbutamol —> Beta2 agonist = Vasodilation - Tachycardia
1) Tachycardia
2) Tremors • Inc. Toxicity / Narrow TI
3) Hyperglycemia —-> Theophylline
4) Hypokalemia (Used in treatment of hyperkalemia)

Drug used in asthma but does

not cause bronchodilation
STEROIDS

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—> Inhibits Mast cell

degranulation

• Adalimumab —> TNFalpha inhibitor

- Italy —> Adalat —> Gold Certificate
• Infliximab —> Unsafe
• Cetuximab —> EGFR2

—> Anti-inflammatory
- No Bronchodilation
- But potentiate Beta2
agonism

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DIURETICS

• Acetazolamide - Reabsorbs Bicarb ion

• Loop Diuretics - Loop of henle
• Thiazides - Early DCT
• K+ Sparing - Collecting Duct

MECHANISM OF ACTION
ACETAZOLAMIDE—> CA inhibitor = Bicarb Reabsorption
LOOP DIURETICS —> TAL = NaK2Cl
THIAZIDES —> NaCl = Early DCT
SPIRONOLACTONE—> K+ Sparing Diuretic (Ald R blocker)
AMILORIDE —> ENaC blocker Epithelial Na Channels

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DIURETICS CAUSING DIURETICS CAUSING

METABOLIC METAB ACIDOSIS
ALKALOSIS
a/w —> Decreases K+ 1) Inc. K+ = Acidosis
• Loop K+ Sparing
• Thiazides 2) Acetazol = Causes Acidosis

USES OF DIURETICS
Acetazolamide —> Mountain sickness, Angle cl. Glaucoma,
Rx of toxicity of acidic drugs
Thiazides (Makes Urine Alkaline)
1) HTN
2) Nephrogenic DI
3) Rx of nephrolithiasis —> Dec. Ca2+ in Urine
Mannitol —> Inc. ICT without haemorrhage
Amiloride —> Liddle, Lithium induced DI
SIDE EFFECTS
HYPERCALCIURIA : Inc. ca2+ in Urine —> Loop loses Ca2+
INCREASE LITHIUM TOXICITY:Thiazides —> By Inc. Li reabsorption
GYNECOMASTIA : Spironolactone
Others : - Digoxin
- Ketoconazole

CVS PHARMACOLOGY- Angina drugs

ANGINA DRUGS
MOA
• Dec preload : Venodilator —> Nitrates
• Dec contractility : Heart - Beta1 R antagonism —> Metaprolol
• Block L type Ca channels :
• More action on heart : Non - DHPs
Verapamil, Diltiazem
• More action on peripheral vessels : DHPs
Nifedipine
• Late Na channel blocker: Ranolazine = Na Late inhibitor
• Inhibits funny current in SA node : Eva Funny
Ivabradine

• Nitrates Not used with Sildenafil

( Erectile Dysfn, )

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HEART FAILURE DRUGS

HEART FAILURE
Digoxin toxicity is ppted by HYPO Kalemia —> Furosemide
Drugs which reduce mortality in heart failure = Beta Blockers, ACEi’s,
(Digoxin does not Dec. Mortality) Spironolactone
C/I in bilateral renal artery stenosis —> ACEi

• Digoxin comp. with K —> Dec. precipitation

- Thereby Toxicity Acute Heart
Failure

Anti hypertension drugs

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HTN DRUGS

MOA

Dec fluid volume - Diuretics —> Thiazides

Vasodilatation -—> Nitrates, ACEi, CCB (Dipines), K+ Channel Openers

Dec cardiac contractility - Beta Blockers / CCB’s

-
Decrease sympathetic tone - A B C D
Apha Beta Const. Dilat.
T
Inhibit RAAS-

Nik-monic : K+ Channel Openers

• M = Minoxidil
• D = Diazoxide
• H = Hydralazine
Alpha Blockers = Prazosin/ Tamsulosin
• In HTN + BPH
• Orthostatic Hypotension

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ANTIARRHYTHMICS
CLASSIFICATION

I —> One —> Na+ Channel Blocker—> Lignocaine —> Used only in Vent. Arrhythmia
- Post MI V. Tach
II = Beta2 —> Beta Blockers (Sotalol) —> Not in Atrial - Atrial fibrillation

Nik-monic : AIDS
III = K+ Channel Blockers —> • A = Amiodarone
• I = Ibutilide
• D = Dofetilide
• S = Sotalol

IV = Ca2+ —> CCB —> Non dipines —> Heart

SIDE EFFECTS

QT prolongation : Three (3) + One a (1a)

Amiodarone s/e : Thyroid Dysfn., Pulm, Photosensitivity,

fibrosis, Corneal deposits
Significant AV block A B C D
AV by BB + CCB Digoxin
and bradycardia if combined: Block

• AV Block —> DOC = Atropine

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Anti arrhythmic drugs

RAAS drugs

ACE (Lungs)
Ang - 1 ——————> Angiotensin 2
• ADR’s of ACEi : Due to Inc. Bradykinin
A = ACEi
C = Cough
E = AngioEdema
—-> Chance to ARBs
• ADR’s of ARBs : HYPERKalemia —> Spironolactone

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ANTICOAGULANTS ANTIPLATELETS FIBRINOLYTICS

HEPARIN WARFARIN

ROUTE Parenteral Oral

ONSET Fast Slow
SITE OF Indirect Thrombin inhibitor VIT - K inhibitor
ACTION Antihrombin —> Blood In Liver = Dec. Synthesis of CF

MONITOR aPTT PT
CROSSES In 1st Trim Teratogenic -
PLACENTA Heparin

REVERSAL Protamine VIT - K

AGENT Sulphate

FACTOR XA INHIB DIRECT THROMBIN

INHIB
Xaban TROBAN —> Arga TROBAN
Rivaroxaban TRAN —> DabigaTRAN
Oral D in —> BivaliruDIN
(Direct LepiruDIN
Inhibitor)
Oral DTI —> Dabigatran
REVERSAL REVERSAL
AndeXanet iDAricizumab —> Dabi reversal

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Gout = Great Toe GOUT

• Risk factors - Alcohol, Aspirin • Allopurinol MOA – Xanthine Oxidase
inhibitors

• Drug acting on microtubules –

-Colchicine

• Probenecid - Uricosuric

GOUT:
Negative Biref
-Needle shaped

Pseudo GOUT:
Positive biref
-Parallelogram/rhomboid

Nik-monic = Drugs in Acute Attack

• N = NSAIDs except Aspirin
• C = Colchicine —> Microtubules
• C = Corticosteroids
Allopurinol —> Not used in Acute Attack
Rate visible on - DECT (Dual Energy CT) 121
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DIABETES MELLITUS DRUGS

Increase insulin release —> Sufonylureas SIDE EFFECTS
( hypoglycemia causing) - Surge of insulin • Lactic acidosis —> Metformin
- KCB (K+ Channel)
(Met Acid)
• Vitamin B12 def = Methyl Cobal
Decrease glucose absorption —> Acarbose
MECHANISM OF ACTION

from GIT x No Carb Absorb • UTI —> SGLT2 inhibitor = Flozins

• Flatulance, abd cramps, Dx

Increase glucose excretion —> Inc. Flow of Glucose in -Inc. Glucose in gut
from kidney Urine -Dec. Acarbose in GIT
• Long Acting —> Large act
- Glargine
- Detemir
Increase glucose utilization by —> Inc. Sensitivity
• Short —> No LAG
tissue
-Lispro
-Aspart
-Glu / Lysine
Decrease hepatic —> Metformin
gluconeogenesis - 1st Drug in DM with Obesity

Incretins :
1) GLP-1 Analogues = Inc. Insulin Release = Tide = Exenatide, Liraglutide
2) Inhibit GLP Degrad. = DPP4 Inhibit. = Gliptins
- Safe in Renal Failure = Linagliptins

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 ANTI MICROBIALS
CELL WALL SYNTHESIS INHIBITORS

• Beta
• Cycle
• Van
• Ford
• Bus

PROTEIN SYNTH INHIBITORS

• 30s –

• 50s –

• Initiation inhibitor -

• Inhibit DNA gyrase –

• Inhibit folic acid synthesis –

 ANTI TB DRUGS
SIDE EFFECTS
• Peripheral neuropathy –
• Drug induced SLE –
• Vit B6 deficiency -
• Red orange urine –
• Gout –
• Eye – colour blindness
/ optic neuropathy
• Tendinopathy , cartilage –
MECHANISM
• - OF ACTION
• INHIBITS MYCOLIC ACID SYNTHESIS – • Neurosychiatric , seizures -
• INHIBITS RNA POLYMERASE –
• INHIBITS PROTEIN SYNTHESIS - IMP POINTS
• INH cross resistance –
• Rifampicin does not require dose reduction • Metabolised by acetylation –
in renal failure • Bactericidal -
 HIV drugs

HIV DRUGS

SIDE EFFECTS

NEPHROLITHIASIS :

LIPODYSTROPHY:

HLA TESTING FOR :

Nucleotide RTI :

Boosting drug :
ANTI CANCER DRUGS
 • Methotrexate –

• Antimetabolites –

• M phase -

SIDE EFFECT
• Pulmonary fibrosis
• Rituximab -
• Flagellate dermatitis
• Cardiotoxicity
• Radian recall effect
• Hemorrhagic cystitis
• Methotrexate
• Cisplatin

• Drug for chemotherapy induced

• Nausea and vomiting –

• Neutropenia -

• Thrombocytopenia –

• Anemia -
 12/10/23

SIDE EFFECT
• Pulmonary fibrosis
• Rituximab -
• Flagellate dermatitis
• Cardiotoxicity
• Radian recall effect
• Hemorrhagic cystitis
• Methotrexate
• Cisplatin

• Drug for chemotherapy induced

• Nausea and vomiting –

• Neutropenia -

• Thrombocytopenia –

• Anemia -

FMT

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PLANT POISONS

Nux vomica
Arbus Precatorius Strychnine
Crab’s eye Spinal poison
Sui = Cattle poison Similar tetanus Ophistotonus
Viper (vasculotoxic) Risus sordonicas

Pen/Pencil

(Artificial bruise) Marking nut

Semicorpus
Active Bhila wanol

Horse radish

Aconite
Males
Wolffian

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Ricinus communis

Cockroach Castor
( - protein synthesis)

Digitalis Purpurea

Cardio toxic
Fox glove

Datura Anti cholinergic

Child
Playing Dry Secretions
Eats Delirium Rx Physostigmine MOA AChE
Crosses BBB
ACh levels

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SNAKE

Xx

Binocellate mark

Krait Straight

Viper Diamond

Cobra Hood Spectacle Common cobra

C Xx King cobra

Convulsion

Cobra
Elapids CNS (Neurotoxic)
Krait

Viper Vasculotoxic Clotting time

Sea snake Myotoxic

(Hydrophidae - Elapids)

POISONOUS VS NON POISONOUS SNAKES Nikmonic

Belly ,fangs
RIGHT
Wash
Reassurance

Immobilisation
3rd
Incision
& Suction

4th Torniquet
Arterial
Constriction band
C/I in Viper

GH Get to hospital

T Tell doctors
Torniquet

(Night bite) Polyvalent

Without test
dose
10 vials
4 big

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Spanish fly Scorpion

Priapism, vesicles Similar snake - Cobra, krait, viper

Cantharidin Autonomic crisis Adrenergic

Cholinergic

Krait Min. local reaction

Min. fatal dose (6 mg)

Rx Prazosin

METALLIC POISON- ARSENIC

Yellow/fatty liver (acute)

Bones - Chronic

Delays putrefaction

Tests
Hyperkeratosis Raindrop
Black foot

Hyperkeratosis

Aldrich Mees Lines

Raindrop pigment

Garlic odor

Red velvet stomach

Cholera

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LEAD POISONING

Bands 1 2

Pb 3b

1. Bands Dense metaphyseal

Nikmonic
2. Basophilic stippling (RBCs) Heme ALA dehydratase
A(LAD)
Ferrochelatase lead
3. Blue/Burtonian line on gums - not specific

Nikmonic
A Anemia

B 3B

C Colic, constipation (cf)

D Drop (wrist/foot)

E Encephalopathy (children)

F Facial pallor

G Gout Saturnine gout

MERCURY POISONING
MEATS
Mercuria lentis
Erethism
Pink colour disease:
Acrodynia/pink disease Hg (Mercury) Acrodynia - Seen with Mercury poisoning
Tremors – Danburry tremors / Glass
blower’s / Hatter’s shake
Salivation
PCT necrosis (Nephrotoxic)
Minamata disease

Nikmonic
MERCURY
Minamata disease
Erethism
tREMors
PCT

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DRUG ABUSE METHODS

Handkerchief

Huffing

Body packer

Bagging

• Sniffing: Inhaling fumes from the liquid in an open container

• Bagging: Placing the chemical in a bag and then putting it over the face.
• Huffing: Applying the chemical to a cloth/rag and then inhaling it by covering
nose and mouth with the cloth/rag.

ANTIDOTES
Poisoning Antidote

Arsenic BAL Ferric oxide

EDTA
Lead
Physostigmine
Datura

CO O2

Cyanide Hydroxy cobalamin / Lily’s kit (Nitrite)

Morphine Naloxane

Iron Desferioxamine

Methanol Fomepizole/Ethanol

Protamine sulphate
Heparin

BAL except Iron

Cadmium

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Toxic agent Specific antidote

1. Acetaminophen N-acetyl cysteine
2. Anticholinergics (e.g. dhatura, atropine) Physostigmine
3. Anticholinesterases (e.g. OPCs) Atropine and pralidoxime (2-PAM)
4. Benzodiazepines Flumazenil
5. CO Oxygen, hyperbaric oxygen
6. Cyanide Sodium nitrite, sodium thiosulfate
7. Heavy metals (lead, mercury, iron) and arsenic Specific chelating agents
8. Methanol, ethylene glycol Ethanol or fomepizole
9. Opioids Naloxone
10. Snake venom Specific antivenin

1
IPC
1 9
Nikmonic • Perjury definition I know none (191)

• Perjury punishment 193 (Fee-three)

• Issuing false certification 197 (Sertificate)

• Involuntary intoxication Not liable / FORCED8 5

• Voluntary intoxication Responsible Self 86

• Mc Naughten rule 84 Four Foul mind (Insane)

• Null / void consent / Invalid 90 O value consent

<12 yrs / Insane 9 2
• No consent in emergency 92 (Nahi do)

• Rape definition 375

• Rape punishment 376 (Sticks)

• Victim suffers death or PVS due to rape Affected for lifetime

376 A
• Sex with wife during separation (Biwi) B
• Sex by a person in authority / Custody C
• Gang rape Don D

• Punishment for repeated offenders Expert E

• Non consensual Unnatural sexual offences 377

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• Dying declaration IEA 32

• Expert witness IEA 45

Embalming before autopsy
• Causing disappearance of evidence of offence, 201
or giving false information to save offender. Naugh 0 evidence
• Punishment for acid throwing (vitriolage) Acix 326

• Definition of Hurt 319

• Definition of Grievous Hurt 320

• Punishment for Criminal abortion with consent 312 with consent

(3-1=2)
• Punishment for Criminal abortion without consent 313 Without consent
• Punishment for Criminal abortion leading to death
• of mother NPG 314 Foul play

• Murder definition 300

• Murder punishment IPC 302

• Police inquest CrPC 174

• Magistrate inquest CrPC 176 (xxIPC) (magix)

• Punishment for revealing identity of rape victim 228

naugh to 8 ppl
Medical negligence 304 A Apron
Q Homicide
Dowry death 304 B Biwi

Magistrate inquest

• Medical negligence 304 A

• Dowry death 304 B

• Examination of accused by doctor

• Abandonment of infant/ newborn

• implied consent - Sec. 92 IPC

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HANGING VS STRANGULATION
Transverse Typical
Hanging - Knot - Occiput
Complete Off ground
Incomplete Touching ground

Incomplete

Hanging Strangulation
Ligature mark Oblique Incomplete Transverse Complete

Base
Pale Congestion
Ecchymosis ,
contusion
Hyoid fracture
Thyroid cartilage

STRANGULATION
Garotting
________________ involves
attacking the victim from behind
using a ligature.

Squeezing to death using sticks is

called Bansdola

Smothering
Mugging = Hug ____ involves closing the external
respiratory orifices either by hand
or by other means
Internal Gagging
Bansdola
Bamboo
Stick
Smothering . Strangulation of the neck from
smooth behind between the arm and the
Mugging (Hug)
forearm is called ___

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SEXUAL PERVERSIONS
• Sexual satisfaction by contact with articles of opposite sex.
• Contact with other persons to obtain sexual gratification. Frotteurism
• Sexual intercourse with dead body. Necrophilia
• Eonism Transvestism
• Voyeurism (Scoptophilia) Peeping tom
• Scatologia Obscene language
• Bestiality Animals

AUTOPSY TYPES

AUTOPSY TYPES
One by one Organ Von Virchow 1st - Cranial

Block dissection Focus Ghon’s

In situ Rokitansky Infection spillage HIV +

En masse Letulle
(fastest)

Routine Incision

Last to be opened in asphyxia Neck Modified Y insulin

Preserved in strychnine poisoning Spinal cord

Preserved in heavy metal poisoning Bones

Arsenic Bones

138
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TESTS FOR SEMINAL AND BLOOD STAINS

>
NP423
Nikmonic
Semen Blue
SUV

X Alkaline

Best

SEMEN TESTS
FLORENCE

• Seminal fluid identification by detecting BLOOD

the presence of choline through the • KASTLE MEYER
addition of an iodine based reagent, which • HAEMIN CRYSTAL
produces characteristic brown choline
periodide crystals.
Fl Cl Iodine Bromine
Choline Reagent Brown
Rhombic

BARBERIO’s Prick Picric acid

Needle

• When the questioned stain is allowed to

react with picric acid it leads to the
formation of yellow needle shaped
spermine picrate crystals, including the
presence of seminal stain.

139
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TYPES OF WOUNDS

• Tissue bridging + in :
Tissue Laceration
bridging
• Tailing in : Incision

Abrasion
Laceration Bruise/contusion
(skin intact)
Lathi

Patterned/ Incision Tail +

Imprint abrasion Stab wound
Chop wound
Heavy weapon
Muscles/bones

BALLISTICS

Stellate Contact

Nikmonic Near shot Tattoo +

Nikita
Cannot be removed
XB XS Near
Tattoo Distance Dispersion Size of 1 wound
Collar +B +S Close

140
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WOUND OF ENTRY RANGE

Contact / Close / Near

Collar in all out of BBT

Close BBT
Near BT
Intermediate T only
Distant XX
>60 cm

Shot gun

Contact Close Near Intermediate Distant

<1 1-2m 2-4m >4m

Stellate BBT + Rat hole Dispersion Each pellet

starts
Individual
Satellite

IMPORTANT ONE LINERS

[FGH]
Hasse rule Fetus GA
F GA Hasse
Mortis Nysten
MN Nysten rule Sequence of rigor mortis

Puppe rule Skull fracture age

Sex
Ashley rule Sternum
Cephalic index is to determine raCE

Best bone for determining sex of individual pelvis

Best for identification Finger print

M/c fingerprint Loop

Gastric lavage not contraindicated in Carbolic acid

Leading questions are allowed in Cross Examination

Consent to be given by guardian if child less

than < 12 yrs
Filigree burns
Death in fresh water drowning is due to Fibrillation Lightning

141
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PSM

HDI vs PQLI
↳
Dr 7 KiL Padhaai [ PQLI > Li = L I L infant
Literacy
L -

Li
W

L imR

I 7 Li —7 PQLi

K 7 Schooling

* > not now

Dr

Std. of HDI : KiL Standard of living Quality of life : PQLI

HDI

KiL > Knowledge

income longevity

1.3 at birth

142
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LEVELS OF PREVENTION

1 : Specific protein 2 : Screening, Early diagnosis, Rx 3 : Rehabilitation

Vaccines, DOTS, MDT for leprosy, ACT for Crutches for polio, giving
chemoprophylaxis, malaria, ART for HIV, LASIK, prosthesis, amputations, artificial
pre exposure PAP smear, Health check ups, limbs, transplant
prophylaxis, re School health check ups
exposure rabies
prophylaxis, hand
washing, iron folic
Eg: Blood donation —7 HIV
acid
supplementation,
chlorination
7
Healthy

NPG : • Prospective Layer prospect Layer prospect 7

1o
• Prescriptive i Case prescription " Discuss 7 2
o
Early diagnosis

Before Primordial EPIDEMIOLOGY-

• Life style
>
DISEASE TRANSMISSION
Risk factors • Environment
• First case in community:
decrease • CAD Primary case
—> childhood
• Healthwhich
Subsequent cases promotion
arise —7 hand
from wash case: secondary
primary

E
Specific protection —— vaccine
Case Primary chemoprophylaxis
• Iron and
First observed case noticed by investigator: Follicle Acid deficiency
Index
Disease
• Time between primary and secondary case: serial interval
• Time between entry of organism and appearance of first signs
Secondary
and symptoms: Incubation Period
• Time between
Screening : Papentry
smearof organism and maximum communicability
of the causative agent: generation time
• Early diagnosis
After • Done for diseased
• Treatment people
- ART, ATT for maximum communicable period :
Isolation(secondary
Tertiary level)
Rehabilitation
• Done for healthy people for maximum incubation period:
• Crutches
Quarantine(primary level of prevention )
• Prosthesis

143
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LEVELS OF PREVENTION

Vaccines, DOTS, MDT for leprosy, ACT for Crutches for polio, giving
chemoprophylaxis, malaria, ART for HIV, LASIK, prosthesis, amputations, artificial
pre exposure PAP smear, Health check ups, limbs, transplant
prophylaxis, re School health check ups
exposure rabies
prophylaxis, hand
washing, iron folic
acid
supplementation,
chlorination

EPIDEMIOLOGY- DISEASE TRANSMISSION

• First case in community: Primary case
• Subsequent cases which arise from primary case: secondary
Case
• First observed case noticed by investigator: Index In = In
• Time between primary and secondary case: serial interval S-S-S
• Time between entry of organism and appearance of first signs
and symptoms: Incubation Period
• Time between entry of organism and maximum communicability
C=G C=G
of the causative agent: generation time
• Done for diseased people for maximum communicable period :
Isolation(secondary level) = diseased +
• Done for healthy people for maximum incubation period:
Quarantine(primary level of prevention )

> Before Disease

143
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S 0 S

G-I

EPIDEMIOLOGICAL STUDIES
(Single point of time)
Case Control
X

Exp Case Odds ratio

I Case starts

> Risk factor : Start Cohort

R P F
P P
>

Forward
Direct 3

7 • Attributable
• Incidence (new cases)
• RR>1 or OR>1→risk factor Protective Risk factors
• RR=1 or OR=1→ No association [ >

.
-

• RR<1 or OR<1→ Protective factor none association

S 1 case : multiple risk factors
• Best study design for Multiple exposure: Case Control
• Strength of association in case control study: Odds
Lung Ca
Ratio 7

• Best study design for Multiple outcomes:cohort >

Smoking
>
COPD

~
Gastric cancer

144
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Epidimiological Studies

⑲
L Non-experimental /
Experimental / Observational
interventional

1. Trial —> Randomised C.T (R.C.T)

Analytical
Descriptive

• Formulate Hypothesis Tests hypothesis

• Case reports/ series
: Comparison group present

Population Individual
PYQ Ecological study 1. Cross
sectional
2. Case control
3. Cohort

Smokers Lung cancer

Exposure Lung cancer
Case Smokers
Disease
Risk factors

>=π-
Retrospective Prospective

.
>

-
Case control Single point of time ~ 1 level
EPIDEMIOLOGICAL STUDIES COHORT

·
Cross sectional

.....
Starts with case
(At level) Can be retrospective
— prevalence ambispective
(Old + new cases)

Vs incidence new cases only

Cohort Cohort
PID : prevalence = incidence x duration ·
Prospective C
A Retrospective B
Past Present Future

5 year
Lung 7 1
•Smokers RR>1 or OR>1→risk factorI
Cancer
• RR=1 or OR=1→ No association
• RR<1 or OR<1→ Protective factor
• Best study design for Multiple exposure:
Ecological 7 Case Control
• Data resource
• Strength of association in case control
• study: Odds
Data matching population
Ratio
• Best study design for Multiple outcomes:cohort

144
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Case series E

> Cross sectional

3 Cohort

EPIDEMIOLOGY – STUDIES TYPES

Longitudinal Horizontal > Observational / analytical/ /
non experimental

7 Population
-
Individual

• Rare / expensive Investigation

Nested case control

• Cohort > Attrition

Attrition bias
L
Lost to follow up

• Case control - > Recall bias

Nested case control study 7 Misnomer : it is cohort

W 100 new borns
Present
within 1 nest only 2 NB +
W
>
2 NB -
W

Case Control
For rare / expensive investigations
Cohort ↓ C C
↓ C C
v
↓
Future 145
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ODDS RATIO, RELATIVE RISK, ATTRIBUTABLE RISK

--
Case control Cohort

D+ D-

E+
E- -

D+ D- Diagonally opposite

Odds ratio

⑩
a b
E+ Opp ratio
D+ E+
ad ++ x - -
bc + -) - +)
(88
E- c L - d
D+E- -
CROSS OVER RATIO

Attributable Risk
Relative risk = IE a

INE a+b % attributed to risk factor

80% smoking : Stop smoking reduces

lung cancer by 80%
c

c+d

A.R IE INE
=
Attributable risk

IE

Population A.R = I total population I not exposed

I total population

146
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ODDS RATIO, RELATIVE RISK, ATTRIBUTABLE

10
RISK
E
Smokers 8

100 Lung cancer

g
5 non smokers
100

10

3
Relative risk :
100 5 - 2
100
10 Y 100
100 5

2
Covid vaccine = Covid +
100
D

No vaccine = 8
D
Covid +
100

⑧
⑤ RR > Protective > 2
<1 = 0.25 (Protective)
8
⑤ Relative risk reduction -
1 - RR 1-0.25 = 0.75

B
Odds ratio
.
8 R.R = I.E
N.E
PAR = IP INE I
RRR= (1-RR)
A.R = IE INE
-
⑤
⑧

IE IP

146
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VACCINES
Delayed Immunization age limits:
• Till 1 year→ BCG, Rota Virus, Pentavalent,IPV , Hepatitis B within 24 hours
• Till 5 year→ Measles/MR., OPV, PCV, Vitamin A
• Till 7 year→ DPT Nikmonic
• Till 15 year→ JE • at Birth
Happy Birthday O
W W V

HepB BCG OPV

Adverse events of vaccines
a.Measles/MR/MMR: Thrombocytopena,toxic shock Syndome. HOB • BCG: 1yr (BiRP)
b.Rota virus:intussception -

c.Influenza(killed):GBS
W 7 1yr BCG iPV Rota Penta
24hr
d. inconsolable cry 2 DPI give next dose. Take precaution
C/I - Anaphylaxis W

15d
• Most heat sensitive vaccine:reconstituted BCG OPV 7 Keep bottom (coolest)
•Alum L Most freeze sensitive vaccine: Hepatitis B DPT I Q. C/I in progressive
• Loss of potency of vaccine to heat :vaccine vial monitor : heat neurological (seizures)
• Loss of potency of vaccine to cold: Shake test : cold
• Cold chain temperature of vaccines: +2- +8°C. V

Pertusis
• Most important equipment of cold chain: ILR

1yr 5yr 7yr 15yr

Ne
5MO DPT Jawaan
BiRP J.E
5 measles / Vit A
• Reuse of partially used multi dose vials in subsequent sessions upto. : 28 days
OPV
• Vaccines which follow Open Vial Policy: DPT,Td,hepatitis B, pentavalent except rotavirus vaccine
(old)+ PIO-PCV,IPV,OPV
• • Which do not follow open vial policy :BCG,measles/MR,JE,YF,rotavirus,COVID. (JE & rota-
Strains - MTCin open vial policy)
updated

1. 17D > Yellow fever dirty (D) >8 (Live)

⑧
C/I in egg allergy (egg yolk -yellow)

2. Jeryll lynn Jumps (mumps)

⑧
BCG 7 Danish 1331
J.E 7 Code language
Malaria RTS (Sporozoites)
- Moraton
①

⑧
Nagajama
Measles
· Schwartz
D

⑤
SA 14-14-4-2 > Live
Edmonton Zagreb
Varicella /
3 Oka (aka various
E

RA 27/3 > Rubella (RA)

Chicken pox
D

names)
Rubella Rota Rabies
-
Live
W
Live vaccine
mine
Killed
100% CFR 1. Yellow
Live 7
Sabin 2. Rubella
OPV 3. Varicella
B
Polio >

Killed 3 Salk - killed

iPV

147
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VACCINES
Delayed Immunization age limits:
• Till 1 year→ BCG, Rota Virus, Pentavalent,IPV
• Till 5 year→ Measles/MR., OPV, PCV, Vitamin A
• Till 7 year→ DPT Open Vial Policy
• Till 15 year→ JE

Adverse events of vaccines

a.Measles/MR/MMR: Thrombocytopena,toxic shock Syndome. -
L
b.Rota virus:intussception
iT-PiO Donot follow
c.Influenza(killed):GBS Followed by
e

W Reconstituted/ Power

9
J.E (killed)
•
Updates : New
Most heat sensitive vaccine:reconstituted
Rota BCG W

3
• Most freeze sensitive vaccine: Hepatitis B MR water

.
B

• Loss of potency of vaccine to heat :vaccine vial monitor

Containing BCG
B normal saline
• Loss of potency
• of vaccineBto cold: Shake test
Hepatitis DJE phosphate buffer
• • TT
Cold chain temperature of vaccines: +2- +8°C. I
-Old Rota 7 VVM on cap
• • equipment
Most important DPT of cold chain: ILR
• Penta C New Rota > follows)

TPiO > iPV, OPV W

VVM on label

• COVID

• Reuse of partially used multi dose vials in subsequent sessions upto. : 28 days
• Vaccines which follow Open Vial Policy: DPT,Td,hepatitis B, pentavalent except rotavirus vaccine
(old)+ PIO-PCV,IPV,OPV
• • Which do not follow open vial policy :BCG,measles/MR,JE,YF,rotavirus,COVID. (JE & rota-
updated in open vial policy)

147
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VACCINE VIAL MONITOR XXX Expiry

7 Outer circle
S Heat damage Inner square
7

Nikmonics

Till square light

V

You take it light Freeze 7 Shake test

NATIONAL IMMUNISATION SCHEDULE

• Diluents
• Penta 7 DPT + HepB + HiB

• Intradermal Subcutaneous

R L
HBO
1yr
BiRP
S Right
Arm
- ->
Left
Arm I
...................
B > 0.1 ID

M J O.5 SC

• TT Boosters only if last pregnancy within 3 years

and complete 2 dose received in last pregnancy
• Till 5 yrs of age 7 Child visits > 7 visits

Total 17 L
• Mission Indradhanush 7 12 disease
1 Lakh S
+ 16 Lakh JE — Endemic
8 doses • Measles early (6m) 7 Outbreak
2 Lakh IU
Then continue routine

148
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RABIES & TETANUS PROPHYLAXIS

No protection
Exposure L
No

Some

3 Not gluteal
II Some W

No RiG

L Severe
III Severe
Essen

⑧
Re exposure within 3 months > no ARV
③
RiG S
within 7 days
given only once in lifetime
0> 21/28
0 3 7 14 28 Human / Equine
1 I
-

Better
e
-

20U 40U

Wound Remaining IM away

I
Site of from vaccine site
infiltration
Never IV

149
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PEP

Exposure Protection

I No ↳
Intact No >
No vaccine

II Some >
Scratch Some Y Vaccine only

III Severe >

Transdermal Severe 7 V + RiG

1 Dermal >
0.1 ml IM 7 Complete vial
Thai Essen

4 vials/ 8 doses 5 visits/ doses

D
4 > 4th forgotten
0 3 7 14 28
0 3 7 14 28

RABIES & TETANUS PROPHYLAXIS

149
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TETANUS -PEP

7 >10 years
>
Ig
I
Never
5

5-10

>10

Never

⑤
Complete dose required only if never immunised/ unknown
⑨
If anytime received 7 Only single dose

S I 5 [ > 10 E S

STI kits
V
1 dose 1 dose
No vaccine - only care

1g 7 Only in unclean wound

Immunised Never immunised

1g > 10 years 1g in all

150
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NVBDCP
Hypnozoites Primaquine
> > Mosquito
• Treatment of malaria: Chloroquine
Sandfly 3 Kala Azar
Falciparum F A antesunate
• North eastern states: ACT + LM NE
• Other states: ACT + SP Relapse +

• Pregnancy: (1st trimester) : Quinine (ACT in CI )

• Other trimesters: north eastern states- ↳
ACT Side effect : Hypoglycemia
Other states-
• Vivax:
• Short term chemoprophylaxis (upto 6 weeks) : Doxycycline D 7 M
<6wk >6wk
• >/=6 weeks: Mefloquine
• Kala azar treatment: LAMB injectables
Ivermectin
• Filariasis : fiDA mDA ( mass dry administration) DEC
-

Albendazole

LEPROSY

151
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152
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NTEP

DEMOGRAPHY CYCLE

IMP POINTS
DG maximum: late stage 2

DG contraction starts in: early stage 3

DG negative: stage 5

• India is currently in stage :

153
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FERTILITY INDICATORS
• Indicator of complete family size:

• Mortality dependent fertility indiactor:

• Most sensitive indicator of family planning achievement services:

• For population to stabilize: TFR- , NRR-

FOOD ADULTERATION

Argemone

FOOD TOXIN DISEASE C/F

Khesari Dal BOAA (Bal) Lathyrism

Mustard oil >

Mexicana Sanguinarine Epidemic dropsy
Millet Payrolizidine Endemic ascites
Groundnut Aflatoxin : Aspergillus Hepatotoxic > HCC
Jowar/ bajra >
Ergotism >
Claviceps 7 Gangrene
7 Vasoconstriction
2

Treatment in migraine

154
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Flow AR
-

Argemone

Nikmonics
Tal — Dal —- Bal
7 >

> Stay alert epidemic is arriving

I
V

Lower limb
: Edema,
Cardiac
>
Stay alert
- Mustard oil
failure
⑮
Glaucoma Crotolaria

> Pascites
-> Hepatotoxic

RDA
male Female
Sedentary 2100 S 1700 (1660) Seventeen
> Sedentary (F)
Moderate 2700 - 2100
2100 1700
Heavy 3400 k 1 2700

+6 2700 I

+7 3400
o Additional calories I

o Pregnancy:+350
o Lactation:+520
o 1st trimester :no additional calories
o 2nd trimester:+350
o 3rd trimester:+450 Fetal growth

REFERANCE MAN & WOMAN

• Age 19-39
• BMI 18-22
e

• WT F-55 M-65

155
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WATER
Water purification:
• Disinfecting property of chlorine is due to : hypochlorous acid+hypochlorite ions
• Major disinfecting property of chlorine due to: hypochlorous acid (90%)
Starch iodide
Chemical quality- Drink 0.5 1.0 swim 2.0 guinea
• Level of residual chlorine in drinking water:>0.5 mg/L.
• Level of residual chlorine in outbreaks/post disaster has:>0.7 mg/l Disaster
• Level of residual chlorine in swimming pool:>1 mg /l Seven
• Level of residual chlorine to kill cyclops/ guinea worm:>2mg/L
• Contact period:1 hour

Instruments:
• Measure chlorine demand of water: horrock apparatus
• Measure residual chlorine: chloroscope
• Test which measures both free and combined residual chlorine separately: OTA Test OTA All seperately

........
• Yellow color produced is due to: Free Chlorine within first 10-15 sec

Bacteriological surveillance of Drinking Water

• Most reliable and efficient indicator for fecal contamination of water: E.coli E.C
• Recent contamination of water: fecal streptococci
• Remote contamination of water: clostridum perfringens

Water Chlorine Bleeching

AIR
Air pollution indicators M/C Hypochlorous acid
• Most important air pollution indicator: sulphur dioxide
• Soiling index: smoke
d s guine Chloroscope
• Grit index: dust
• Most important
1 biological indication:lichens
2
0.5 • fecal contamination- E.Coli
0.7
• resent contamination- Streptococci
AQI: Air quality Index: CPCB
Disaster • remote contamination- perfringens
• 0-50: Good
• 51-100: Satisfactory
• Horrock Measure the chlorine demand of water
• • 101-200: Moderate
Free Chlorine and combined chlorine seperately OTA
• 201-300: Poor
• 301-400: Very poor
• 401-500: Severe

Instruments
• cooling power of air & low air velocity: kata thermometer
• Radiant heat temperature or corrective effective
temperature:globe thermometer
• Air humidity :Hygrometer, Psychrometer, Assman
Psychrometu,dry & Wet Bulb hygrometer

156
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WATER
Grit air soiling
-
Katathermpmeter
Water purification: GAS
• Disinfecting property of chlorine is due to : hypochlorous acid+hypochlorite ions
• Major disinfecting property of chlorine due to: hypochlorous acid (90%) 3 Red blood

Sling
Chemical quality- psychrometer
• Level of residual chlorine in drinking water:>0.5 mg/L.
• Level of residual chlorine in outbreaks/post disaster has:>0.7 mg/l Radiant heat
• Level of residual chlorine in swimming pool:>1 mg /l
• Level of residual chlorine to kill cyclops/ guinea worm:>2mg/L
• Contact period:1 hour Globe
↓
Earth
Instruments:
↓
• Measure chlorine demand of water: horrock apparatus GOL
> Cooling air
• Measure residual chlorine: chloroscope Low air
• Test which measures both free and combined residual chlorine separately: OTA Test
• Yellow color produced is due to: Free Chlorine Humidity
Sling
Bacteriological surveillance of Drinking Water
W

Hygrometer Globe thermometer

• Most reliable and efficient indicator for fecal contamination of water: E.coli
• Recent contamination of water: fecal streptococci
• Remote contamination of water: clostridum perfringens

AIR
Air pollution indicators
• Most important air pollution indicator: sulphur dioxide
• Soiling index: smoke
• Grit index: dust
• Most important biological indication:lichens

AQI: Air quality Index: CPCB

• 0-50: Good
• 51-100: Satisfactory
• 101-200: Moderate
• 201-300: Poor
• 301-400: Very poor
• 401-500: Severe

Instruments
• cooling power of air & low air velocity: kata thermometer
• Radiant heat temperature or corrective effective
temperature:globe thermometer
• Air humidity :Hygrometer, Psychrometer, Assman
Psychrometu,dry & Wet Bulb hygrometer

156
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BIOMEDICAL WASTE MANAGEMENT

Yellow Red White Blue Blood — Red
↓
Fetus, organ, tissue, Recyclable, Sharps Orthopaedic implants, Yellow bag
soiled cotton, gauze plastics, tubes Needles glassware, artificial Urology —- Yellow
, dressings, vacutainers pacemaker
bandage, casts, without blood, Glass, metals
↓
Red bag
plasters, IUD , syringes without
expired/discarded needles,
medicines , cytotoxic urobags,catether,
waste, body ryles tubes, IV
secretions-sputum, drip sets, face
pus, faeces , X ray shields, goggle
developer fluids, I
disinfectants, linens, Extra red
beddings, mattress,
gowns, culture plates
, blood bags, BT
sets, live vaccine
vial, blood products,
Routine
masks, shoe cover,
head cover I Yellow

> Yellow

> Red
- Rubber > Red

(LIC) Yellow bag

(Plastics) —- Red

— Sharp —— white

—- yellow

—- Blue

—— Blue

(Ribbon) —- Red
Prophylaxis vaccine
1. Hepatitis B
—- sharp white
2. Tetanus

157
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DISASTER MANAGEMENT Ministry

Home affairs Building earthquake
• Planning and legal measures to make communities safe and decrease impact of disaster: Mitigation

• Gather resources(manpower, money, material, technical skills) which maybe required during disaster:
GI Preparedness
• Most common disease and vitamin deficiency during post disaster phase:
> Vitamin A
• MC long term sequel of disaster: Malnutrition

• MC zoonotic disease after floods: (Rain) > Leptospirosis

• All vaccines contraindicated in post disaster phase except: Measles > in 3 days

• Vaccine for health workers and disaster response team working in disaster endemic zones:

Mitigation > Disaster > Response

Prepared Rehabilitation

To Health Care
Typhoid HepB Cholera

TRIAGE 7 Primitive Treatment

0-6 hrs Highest

6-24 hrs/ yellow / blue

Ambulatory

Moribund/ dead

158
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Triage

PNEUMOCONIOSIS > Dust particles

• Most dangerous size: 0.5 - 3 MM

• Most common cause of mortality and permanent disability: Inorganic Organic

• Associated with TB: Silicosis ~ V

• Silicosis • Byssinosis
• Asbestosis • Bagossosis
• Cement, glass, fireproof textiles: Asbestosis

• Coal miners: anthraCOsis

0

• Textile mills: Byssinosis (Busi - Textile) I

Ferruginous
• Sugarcane waste, also in cardboard/paper industry: baGAssosis Asbestosis

• Not notifiable under factories act: bagassosis W

Cardboard
LL - Base asBASEtossis

159
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HEALTH COMMUNICATION TECHNIQUES

• 6-12 participants discussion among themselves: FGD Focus group discussion

• Discussion among experts in front of audience: Panel PANE Live

People and experts live
• Series of lectures by experts in front of an audience, no discussion among experts: Symposium

• Best method to educate community about ORS use, application of scabies ointment: Demonstrate

• Development of skill : Workshop

MEASURES OF CENTRAL TENDENCY

A6
• 1SD=18%observations,
• 2SD=95% of
observations
• 3SD=99% of
observations

Mean=median= mode: coincide→ normal distribution

• Mean>median>mode: right sided skewnees / positive
• Mean<median<mode: left sided skewness / negative

• Statistically best measure of central tendency, average: Mean.

• Best measure of central tendency for skewed data, middle value when
data arranged in ascending or descending order-Median
• Most frequent value occurring in any data set -mode

160
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MMM - middle

MMM

si
SE= SD Central
Deviation
SE, variance n

L
7

Mean +/- 1SD = 68%

+/- 2SD = 95%
+/- 3SD = 99%

Neglected 7

Tail
Tail
-

161
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GRAPHS
• Graph to represent frequency of continuous variables: Histogram
• Graph to represent frequency of discrete variables: Bar graph.
• Joining of midpoints of histogram using straight lines: Frequency polygon
• Trends of disease with time: line chart.
• Correlation between two variables: scatter diagram
• Always in circles with percentage, proportion representations :Pie chart.
• Layman person: pictogram
• Local distribution of cases: spot maps

BIOSTATISTICS

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CORRELATION COEFFICIENT / SCATTER DIAGRAM

↳ Relation between two variables
> Perfect
Always -1 to +1
W

Perfectness
-> Close to 1 : Strong

GT

Social media usage

-
-

8
Positive 7 V 2

Same direction GT
Medsynapse
1
W

Socialised GT

⑧ The more scattered > Lesser relationship

Study r = +2
r=0 no relationship
3 invalid

TESTS OF SIGNIFICANCE
• Non parametric test to compare qualitative data between 2 or more than 2 groups: ~
↑
-

Coefficient
testof
to determination
-

I
• Parametric compare quantitative data(means & SDs in a single group):
↑
↑
↑

• Parametric test to compare quantitative data(means & SDs in two group):

S
- ·

W
~ /

2 :
• = rto compare quantitative data(means & SDs in three
Parametric test -
or more group): -

IMR & socioeconomic family OPP Negative

a. - 1
b. -0.4
c. 0
d. +0.4
e. +1

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CORRELATION COEFFICIENT / SCATTER DIAGRAM

Chi square

Paired t test

Unpaired t test

ANOVA

7
units/measured
• Quantitative——. t test
• Qualitative——. Chi square/ Fischer
I
Categorical/
nominal/
Qualitative

• Quantitative data ——- t test ——- average/mean

...
• chi square Test ——- association / proportion Smoking Lung Cancer

• Paired t test 1 group 1 intervention before & after

DM —-> sugar ——- sugar

Dry

• unpaired t test ———7 2 group ——— Two interventions

A > Drug 1
TESTS OF SIGNIFICANCE
> Drug 2
B parametric
• Non test to compare qualitative data between 2 or more than 2 groups:

• > 2 •groups ——-

Parametric
7 ANOVA test to compare quantitative data(means & SDs in a single group):

• Parametric test to compare quantitative data(means & SDs in two group):

• Parametric test to compare quantitative data(means & SDs in three or more group):

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ENT

HEARING TESTS
NORMAL CHL SNHL

RINNE SNRP CORN SNRP

Positive Rinne Rinne positive
AC>BC negative AC>BC
AC>BC

WEBER Equal C-S SNHL -

No lateralisation CHL - ContraLateral/
same/ better ear
worse side CORN - Conductive Rinne negative
Weber lateralised to same

Air bone + SNRP - SNHL, negative, Rinne, positive

Unilateral severe SNHL - false negative Rinne
gap Weber lateralised to contralateral side

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Frequency - 512 Hz
If less then vibration less
If more then decays fast

Rinne - 15-20dB
Weber - 5dB

256 Hz. - 15dB

512 Hz - 30 dB
1024 Hz - 45

Gelle’s test - negative in otosclerosis

Bing test
Bone conduction -> ABC/ absolute bone conduction
Schwabach test - SNHL, shortened and bone conduction

AUDIOGRAM
Bone conduction not shown -> S/O N BC Carhart’s notch - Autosclerosis

AC decreased, AB positive -> CHL bilateral Otosclerosis

CORN - Rinne negative Upsloping = low frequency affected more

Hearing loss - >25dB

CHL
Men - upslope
SNHL Old age/ presbycusis - downslope

Child - congenital SNHL - middle frequency

MIXED

Higher
frequency
affected
more
Old age/ NIHL/ Ototoxicity

Downsloping

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Otosclerosis

:
Carhartz

2K - BC
R+ - mixed HL

Upslope -> Ménière’s disease

- ->
Downslope -> old age/ presbycusis

j -> Congenital SNHL

Dip at uK -> NiHL Boiler’s

Dip at 2K BC -> Otosclerosis -> Carhart’s

TYMPANOGRAM
Flat
TMperforation
Flat/dome
↓

- E ractead
Basal Fluid in ME

negative

Sclerosis
os/o
- -> Discount graph
- /shortened -
Discount ossicles
↳ n/o trauma

Impedance audiometry
• resistance in middle ear - Tympanic membrane

Tympanometry
• TF - 226 Hz
• N -> A

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BERA
• Subjective / Objective
• Invasive / non invasive BERA
• Can be used in infants ? Yes
Not for screening in all neonates
• Wave V – ICU -> high risk

• Uses –
i. Confirm hearing loss in infants
ii. Differentiate cochlear vs retrocochlear hearing loss
iii. Diagnose acoustic neuroma
iv. Diagnose non organic hearing loss

• Auditory pathway
E C O L I M A
8th
Cochlear
SO
Lateral lemniscus
Inferior colliculus
Medial geniculate body
Auditory cortex

Auditory Visual

Midbrain rectum - colliculus. Inferior colliculi Superior colliculi

(Thalamus) general body. Medial - music Lateral - light

NASAL BONE FRACTURE

• Bony septal perforation in – Syphilis

• Drug abuse causing septal perforation

- Cocaine - coca (nose)
Black teeth tongue - gold coca

NASAL BONE FRACTURE

• c/o trauma, nasal deformity ,

crepitus , edema
• Ix- X-Ray -> lateral view
• Rx –
• If no edema – : Closed reduction immediately
• If edema + : Subside edema - closed reduction -> open reduction
• Forceps : Walsham

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MEATUS STRUCTURES OPENING

Inferior meatus INDia -> IND inferior nasolacrimal duct
• M/c site of obstruction by nasal polyp
from maxillary sinus - Infundibulum
Middle meatus Nikmonic: my frame - maxi, frontal, anterior middle, ethmoid

• DCR opening is done in __________

Middle meatus

Superior meatus Posterior ethmoid

Sphenoethmoidal recess Sphenoid

• Inferior meat is: Nasolacrimal duct, guarded by valve of Hassner

• Middle meatus, Fiontal sius, mailar sinus anteror ehmoidal sinus.
All these together form the oste-eatal complex or Picadle's drde
• Superior meatus: Posterior ethmoidal sinus.
• Sphenoethmoidal recess: Sphenoid sinus.

RHINO_____ & RHINITIS

Sebaceous glands

Potato

RhinoSPORidiosis Rhinoscleroma Rhinophyma

i. Sporangium with i. Mickuliz cells i. a/w acne Rosacea

endospores ii. Russell bodies ii. Potato tumor

• C/o blocked nose , anosmia , crusty

nasal discharge, roomy nasal cavity , • Vidian neurectomy is done for -
atrophic turbinates = Anosmia, roomy, discharge

• Sx – Young operation

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PARANASAL SINUSES
Well
• superior - SOF
• front - frontal
• Caldwell - occipitofrontal

Town - Down
• towne - inferior orbital fissure

Maxillary - water’s
• closed
• Open - + sphenoid sinus - Pierre’s

Foramen/ canal - Rhese

STRUCTURE BEST VIEWED ON • PNS present at birth - Maxillary, Ethmoid

1. Frontal sinus Well - Caldwell

• Gold std for FESS : HRCT PNS

2. Maxillary sinus Water

Caldwell
3. Superior orbital fissure
Towne
4. Inferior orbital fissure

5. Optic foramen Rhese

LARYNX ANATOMY
• Only abductor of vocal cords – Posterior cricoarytenoid

Recurrent laryngeal nerve except CT - external laryngeal nerve

• Safety muscle of larynx – PCA
branch of superior laryngeal nerve

• Muscle not supplied by recurrent laryngeal nerve – CT (External

laryngeal nerve - Superior laryngeal nerve
Superior laryngeal • motor external laryngeal nerve - Cord tensor
• Action of cricothyroid – CT - Cord tensor nerve) • Sensory above vocal cord - Inferior laryngeal nerve

• Laryngeal crepitus –
• Present in – N

• Absent in - Posterior cricoid mass - malignancy

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LARYNX PATHOLOGIES

Epiglottis
Vocal nodules - Bilateral Polyp - unilateral Omega - laryngomalacia Mouse nibbled vocal cords
Due to vocal abuse Excision - MCS Tuberculosis

Recurrent respiratory or laryngeal papillomatosis

History of vaginal delivery - 3-5 years
Microdebridement
No RT - increased malignancy

Reinke edema - smokers

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VOCAL CORD PALSY

C/F PALSY • Bilateral incomplete palsy is
Dyspnea with good voice Bilateral recurrent laryngeal nerve more dangerous than the
complete variety
No dyspnea, aphonia , Aspiration Bilateral complete (CC)

No dyspnea, Hoarse Paramedian Abductor - unilateral Recurrent laryngeal nerve

voice with cord Cadaveric/ Unilateral complete LSCN + RCR

position - intermediate

Unilateral complete (cadaveric)

• THYROPLASTY
• Type I – Medialisation – done in Adductor palsy
Unilateral recurrent laryngeal nerve
• Type II – Lateralisation
• Type III – Shortening Relaxation - decreased pitch in male
• Type IV –Lengthening Increased pitch in female
Bilateral complete palsy aphonia
For respiration - vocal cord abducted (open)
For speech - vocal cord adducted
Dyspnea/ stridor - bilateral recurrent laryngeal
nerve palsy
Bilatera; Recurrent laryngeal nerve Bilateral
• Respiration gone - bilateral Recurrent laryngeal
nerve (most dangerous)
• Aphonia - bilateral complete

Superior laryngeal nerve - superior thyroid - ELN

Recurrent laryngeal nerve - inferior thyroid

Ca LARYNX Males> females

Smoker

• Mc site = Glottis - hoarseness of voice

• Subtype – SCC

Mx of Ca Larynx

Radiotherapy if Surgery if

VC mobile Cartilage invasion

Superficial exophytic
Fixed cords
lesions

Subglottic extension

Nodal mets

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TONSILS
MUST KNOW
• Major blood supply Facial artery - tonsillar

• Pain referred to ear by Glossopharyngeal nerve

• Lymphatic drainage Jugulodigastric LN (II)

Pharyngeal pouch - 2 - 2nd pouch

Epithelial - strap. Squamous non keratinised
History of - paratonsillar vein
Capsule - pharyngobasilar fascia

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IMP IMAGES

Nasal obstruction + hearing difficulty in child - adenoid

hypertrophy
Psuedo-membrane
• ET block - fluid in middle ear
Diphtheria - bullneck
• X ray sign - Dodd sign negative
Myocarditis
• Rx- medical management then surgery
• Surgery - adenoidectomy, myringotomy and grommet insertion
Zenker’s diverticulum
• = Retention cyst of • posterior upper esophagus -
Killian’s dehiscence
_______
Sublingual gland • Inferior constrictor - TP and CP
• elderly - pulsing divert, false divert
• Mucocele m/c site in • H/O - dysphasia, halitosis,
regurgitation
oral cavity = Lower up • BOYCe sign - esophagus - Zenker’s
• Rx - Dohlman surgery (old man)
• It is retention cyst of • Best treatment - Barium swallow

minor salivary glands

of lip
• Rx : Marsupialis

MANEUVER/TESTS

Hemlich maneuver — if responsive Cottle test - cheek pulled - nasal

Trotter’s/ hippocratic method for epistaxis Epley’s maneuver - treatment of
adult choking valve patency (DNS)
Trotting - pinching nose BPPV - dislodging
If non responsive - BLS

Vs Dix Hallpike - diagnosis of BPPV

Most common - posterior SCC

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ENT

Asymptomatic
Hollman Miller Sign - JNA
Button battery - immediately removed
• anterior blowing of posterior wall of maxillary
sinus
• C/O of adolescent, recurrent epitaxis
• Fossa of Rossenmuller vs NPC/ elderly
• Treatment - Surgery

Trumpet blower

Decreased pressure
Tear drop sign in orbital
Laryngocele (diverticulum air) - black floor/ blow out fracture

Lyre’s sign = splaying of ICA, Nikmonic

ECA
DSA (black vessel) BRYCe - Respiratory - laryngocele

BOYCe sign - oesophagus - Zenker’s

Vascular

Mucormycosis - black turbinate sign -

necrosis
Aspergillus fumigatus Diabetes mellitus/ COVID steroids
Unilateral DOC - Liposomal AMB
Serpingeous/ double density - CT
major
Bent’s and Kurt’s criteria
Fungal culture - minor

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TRIAD
Nasal polyp , asthma , aspirin sensitivity
Samter’s triad

Neuralgia ( trigeminal ) , I/L palatal palsy, I/L CHL Trotter’s triad

Ear discharge, Abducens palsy (diplopia) , retroorbital pain (V Gardenigo

nerve )
Recurrent sinusitis , situs inversus , bronchiectasis Kartagener

Recurrent sinusitis , bronchiectasis , azoospermia ( infertility ) Young (Atrophic)

Postcricoid dysphagia , esophageal webs , iron deficiency anemia Plummer Vinson syndrome

Otosclerosis , blue sclera , Osteogenesis imperfecta Van der hoeven vs Barett’s

Auditory canal vesicles , otalgia, I/L facial n palsy Ramsay Hunt syndrome

OPHTHALMOLOGY
SURE SHOT
COMBINED

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TRIAD
Nasal polyp , asthma , aspirin sensitivity

Neuralgia ( trigeminal ) , I/L palatal palsy, I/L CHL

Ear discharge, Abducens palsy (diplopia) , retroorbital pain (V

nerve )
Recurrent sinusitis , situs inversus , bronchiectasis

Recurrent sinusitis , bronchiectasis , azoospermia ( infertility )

Postcricoid dysphagia , esophageal webs , iron deficiency anemia

Otosclerosis , blue sclera , Osteogenesis imperfecta

Auditory canal vesicles , otalgia, I/L facial n palsy

OPHTHALMOLOGY
SURE SHOT
COMBINED

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CATARACT CORNEAL
ULCER
Image Diagnosis Contact lens , swimming
In tap water Ring
Sunflower cataract -> Wilson’s
Copper deposits -> Descement membrane -> KF ring • Acanthamoeba
• Liver , psychiatric • Lot of pain
• Ring abscess
• ATP7Beta
• Chromosome 13 AR

h/o blunt trauma

Results in
Nikmomic
TV - Trauma ->
Vegetative material
• Rosette Cataract
• Vossius ring
Vossius ring injury ( leaves , thorn )
Vesler Wesley ring -> immunological -> type 3 HSN
Fungal
Christmas tree -> CTG -> myotonic dystrophy • finger projections (Satellite)
• Fixed hypopyon
• Trinucleotide repeat – CTG Symptoms < signs
Tx - Natamycin, no steroids
• c/f-
Dendritic ulcer - herpes zester keratitis
• Myotonic , C - Cataract, Christmas cataract Decreased corneal sensation - DM, leprosy
• takla, T - Frontal baldness + hechet facies
• gonadal atrophy G Pseudomonas Pus - bacteria
Contact lens , purulent
Snowflake -> Sugar snow -> Diabetes mellitus
discharge , hypopyon+ ,
• Due to accumulation of Sorbitol serpiginous ulcer
Bacterial Ulcer - serpingeous -
pneumococcus

• Steroids use - Posterior Subscapular cataract • Contact lens user with foreign body sensation , watering ,
redness , papillae+= GPC - Giant papillitis conjunctivitis

IMP CLINICAL VIGNETTES

Xeropthalmia
• First symptom – Nyctalopia • Diagnosis –
• Leukocoria , calcification ,
• First sign – Conjunctival follicles
Flexner Wintersteiner
• Pathognomonic - Bitot spots
rosettes
• Gene-
• Recurrent bilateral
• Ropy discharge ,intense
itching
• Hot weather
• Follicles • Cobblestone app
• Herbert’s pits • Tranta spots
• Arlt’s line • Ig ____
• Rx –
• Type ______
4 HSN reaction
• SAFE strategy –
• Surgery ,Antibiotics,Facial
cleanliness

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IMP CLINICAL VIGNETTES

Image C/f Image C/f
Acute , painful red eye Penetrating injury f/b 2m
later redness, photophobia ,
dec vision , pain and yellow
white nodules on fundus
Bilateral granular panuveitis

Pain in eye, h/o chicken pox

Herpes zoster opthalmicus
photophobia , Joint pain Hutchinson rule sign

Child - Mucopurulent
discharge with h/o increased
watering

Neonate with watering and

photophobia.
Haab’s striae+
Congenital glaucoma

FUNDUS IMAGES DIABETIC

RETINOPATHY
Pale fundus due to
ischemia
Congested vein
•

•
Cherry red in Tay
Sachs, Niemann pick
Pseudo-cherry in
Microaneurysms
CRAO - cherry red spot Gaucher’s disease
Cattle trucking Earliest

• CRVO - Congestion
• Increased blood - splashed
tomato/ blood and thunder
• 100 day glaucoma

Star app - Stargardt’s disease

Pisciform flecks
+ dark/ silent choroid
(Stars in dark night)

• FFA - iv. Antecubital vein Rx - spontaneous

• White vessels (contrast) resolution
• Smoke stack/ ink blot/ umbrella Steroids C/I
• Contrast extravasation
• CSR = central serous retinopathy seen in serious
individuals (type A) steroids
Neovascular
Flower petal on FFA S/O PDR
Fluid = custodial macular edema
PGF2 - latanoprost

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FUNDUS IMAGES
• congenital CMV Toxoplasmosis Pale disc + anterior attenuated + bony spicules
• Cottage cheese and Chorioretinitis/ vitreitis - Black pigment - retinitis pigmentosa
pizza pie foggy Rods - night blindness, tubular vision
• Infarct pale Looks like headlight in fog Abetalipoproteinemia

Sea fan retinopathy-

sickle cell anemia CME flower petal
Smoke stack CSR

Egg yolk appearance - EOG absent

Cherry red spot - CRAO
Splashed tomato - CRVO

Diabetic Retinopathy
Type 1 -> after 5 years
Type 2 -> screen Immediately

Moderate NPDR

Contrast leak -> S/O neovascularisation -> PDR

Posterior PRP
Panretinal photocoagulation - argon laser

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CLINICAL VIGNETTES
C/F Diagnosis
Miosis , anhidrosis , ptosis , small pupil Horner
Pituitary tumor , visual field defect
Lid swelling without chemosis or proptosis ,
Ocular movement – normal
Fever, severe pain and swelling , proptosis + ,
eye movement restricted
COVID-19 positive ,
Visual acuity improving after pin hole is s/o
Improvement in near vision of presbyopic
patient (second sight )

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ONE LINERS
Pathognomonic sign of acute anterior uveitis

M/c symptom in Anterior uveitis - Photophobia

Posterior uveitis –
Floaters
Snowbanking is seen in
Elastic degeneration and hyalinizaton of
conjunctival connective tissue =

Elastic degeneration of collagen with fibrovascular

proliferation =

Clearest image formed at point -

ONE LINERS
Laser most suitable for cataract surgery at
present
M/c ocular finding in Marfan
Glycosaminoglycan for corneal transparency

M/c orbital wall fractured with blunt trauma

Laser in LASIK

Laser in posterior capsulotomy ( AFTER

CATARACT)

Laser in retinal photocoagulation

M/c cause of blindness (overall )
M/c cause of preventable blindness in
childhood
IOC for metallic foreign body in eye

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INSTRUMENTS / INVESTIGATION
Instrument /Ix Imp points Instrument /Ix Imp points
• Segmental view • Direct Ophthalmoscopy
• One eye at a time
• Mirror image is seen
• Indentation possible • Indirect ophthalmoscopy -
• Viscous required

• Chalazion vs stye

• Normal – 15 mm
• Rx of dry eye -

• C/o floaters, flashes of

light, curtain drawing over
eye

ONE LINERS – Mx Surgeries

Surgery Done for
Tarsorrhaphy
Drugs used in acute uveitis Atropine , steroids
PERFECT surgery
Chronic dacryocystitis
Rx for recurrent pterygium
Drug used in Rx of recurrent pterygium
Collagen cross linking treatment
Leucomatous corneal opacity
V-Y procedure
Amblyopia in right eye Occlude __________ eye
Biconcave lens is used in management of Myopia

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ANATOMY
Embryology • Lens Surface ectoderm -> LEGS (lens, epithelial cornea Yoke muscle
conjunction, glands lacrimal, surface ectoderm
• Right lateral rectus –
• Cornea epithelium Left medial rectus

• Cornea endothelium CREST - Cornea endo stroma

• Iris muscles Sphincter/ dilator papillae -> MINE (muscle iris neuroectoderm)
• Left superior oblique-
Right Inferior Rectus
• EOM Mesoderm - > paraxial
• Ciliary muscles Crest (NCC)

Extraocular • All extraocular muscles are supplied by

muscles ________
3rd nerve except SO4, LR6
Primary - Torsion
• Primary • Rectus -> straight • Oblique SiN - sup -> intorsion
recti - adduction
action of • MR- Medial (adduction) • SO Primary - intorsion
• LR- Lateral (adduction) • IO Primary - Extorsion
• SR- Elevation
• IR Depression
• Superior • Primary Torsion - SiN intorsion
oblique
actions • Secondary Oblique -
• op -> depression (secondary)
• Ab -> Abduction (tertiary)
• Tertiary-

NERVE PALSY
• Palsy? Lateral rectus
Medial deviation
Convergent squint/ esotropia

• Worse on looking
towards : Paralysed
action
muscle

Same side - R + LR
-> Right side
• Head turned to :
• Squint – Right side (same side)
Esotropia (convergent)
Uncrossed diplopia

• Palsy ? : 3rd cranial nerve

• Ptosis + LPS palsy

Dilated
• Pupil- 3rd cranial nerve -> parasympathetic (GVE)
Colinergic -> constriction

• Eyeball - SO4 - Depression

LR6 - Out

• Palsy? 4th SO
PCOM aneurysm/ PLA/ SCA
• ________
Hyper tropia Pupil involved - angio CT
• Better on ________
Opp tilt Pupil - peripheral (aneurysm
compresses)
• Worse on _________
Opp Pupil sparing 3rd nerve palsy
DM - ischemic in center
gaze

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EXTRA OCULAR MUSCLES & PALSY

Sin - intorsion RAD 3

Extorsion RAD 3

Adduction 3

Abduction LR6

Ob - op Ob - Ab
Intorsion Abduction SO4

Extorsion Elevation 3

6th nerve palsy

7th nerve palsy - orbital oculoplasty (not able to close eye)

Ptosis - 3rd Cranial nerve

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Direct vs Indirect Ophthalmoscopy

KERATOCONUS Cornea cone like

Keratoconus - C3RA -> cornea collagen cross linking

Riboflavin and UVA radiation
Corneal topography

Haab’s - horizontal congenital glaucoma
Tear in cornea - permanent
Oil droplet - rice oil (Rizzuti’s sign)
Vogt’s striae - stress lines, temporary, vertical
lines
Scissoring reflex
Fleischer ring - Fe deposition
Funnel
Munson - coming down gaze

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MEDICINE

NORMAL ECG
• Ground: Right foot

I
RA >
LA

II

↑ ->

LL
L
III

• lead II: assessment of rhythm

• P wave: Atrial depolarisation S4

• QRS complex: Ventricular depolarisation S1( systole starts)
• T wave: Ventricular repolarisation S2

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• PR interval: from beginning of P wave to beginning of QRS (Normal: 3-5 small squares of 0.12-0.20s
• QR interval: from beginning of QRS complex to end of T wave ( Normal: 0.44s)

1 big square = 5 small squares= 0.2s

#
1 small square = 0.04s

0.2s
MEDICINE

#
0.04s

• PR segment: end of P wave to beginning of QRS

Isoelectric segment

F
- NORMAL ECG

PR segment

• QTc (corrected QT interval): QT (Bazett formula)

R-R

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• Normal Axis: -30 to +90 degrees (Lead I, aVF : both positive deflection)
• Left axis deviation: 0 to -90 degrees ( Lead I: positive, aVF: negative
deflection, Lead II: negative deflection)
• Right axis deviation: +90 to 180 degrees (Lead I: negative, aVF: positive
deflection)
• Northwest axis or Extreme axis: -90 to 180 degrees ( Lead I: negative,
aVF: negative deflection)

Left axis deviation: LVH, Left anterior hemifascicular block

(VILLA)

Right axis deviation: RVH, Left pneumothorax, Left posterior hemifascicular

block
+ 1868
-
aXiS

NORMAL
08

(RALPH)
+900

ECG in electrolyte abnormalities

• Hypercalcemia: QT shortening
• Hypocalcemia: QT prolongation
• Digoxin: - Na/K ATPase—> increased intracellular
calcium—> QT shortening

NIKMONIC
• UK: U wave seen in Under-Kalemia

TORSADES DE POINTES
• Polymorphic ventricular tachycardia
• Causes: Hypokalemia (most common),
Hypomagnesemia, Hypocalcemia
• Prolonged QT interval increases risk of TDP
• Treatment: Magnesium sulphate

K+: leads to ventricular repolarisation=> T wave

1. HYPOKALEMIA: Slightly peaked P wave( pseudo P pulmonale), prolonged PR interval, shallow T wave, U wave
2. HYPERKALEMIA: Tall peaked T wave, wide flat P wave, prolonged PR interval, depressed ST segment, widened QRS, Sine
wave pattern

u SINE WAVE PATTERN(K+ >9mEq/l)

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TREATMENT OF HYPERKALEMIA
1. If ECG changes present: Stabilise heart with i.v Calcium
gluconate
2. To decrease K+ levels: - Insulin with dextrose
- Salbutamol (Beta2 agonist)
- Kayexalate
- Diuretics

MEDICINE

NORMAL ECG

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ECG - Supraventricular arrhythmias

1.PSVT
• HR: 300bpm (300/ 1 large square)
• Regular R-R interval
• Regular rhythm (not Atrial fibrillation)
• P wave is absent
Management:
• unstable patient(SBP<90mmHg): DC Cardioversion
• Stable patient (SBP>90mmHg)
1. Vagal stimulation: stimulates parasympathetic system,
stops AV transmission: Carotid massage, ice
pack(unilateral) (never bilateral)
2. i.v Adenosine: DOC (Class V anti-arrhythmic)
S/E: bronchospasm, flushing
3. If not responding to Adenosine: CCB/ Beta blocker

2. ATRIAL FIBRILLATION
• Irregular R-R interval
• P wave absent
• Usually seen in alcoholics (Holiday Heart syndrome)
MANAGEMENT
1. Rhythm control: Ibutilide, Propafenone(Ic),
Amiodarone
2. Rate control: AV block: Beta blockers, CCB, Digoxin
(never give CCB and Beta blockers together)
3. Anticoagulation: CHADVASC score is used to
determine need of anticoagulation
To visualise clot in left atrium: Transesophageal
echocardiography => can embolize leading to stroke

DOC for anticoagulation: NOAC

• SAW TOOTH WAVES
• Management is similar to Atrial Fibrillation
Direct thrombin inhibitor Xa inhibitors
• Dabigatran • Rivaroxaban
• Apixaban
• Warfarin is DOC in case of:
1. Mitral stenosis (RHD)
2. Prosthetic valves

3. Multifocal atrial tachycardia

• history of COPD
• multimorphic P waves (>3)
• No cardioversion
• Management: CCB

SUPRAVENTRICULAR. VS. VENTRICULAR

NARROW QRS BROAD QRS (abnormal pathway)

• also seen in bundle branch blocks

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(Ia)

WOLFF PARKINSON WHITE SYNDROME

• accessory pathway: Bundle of Kent
• QRS=> Broad
• Short PR interval (faster conducting)
• Delta waves (slurred upstroke of QRS complex)
TREATMENT
• Definitive treatment: Ablation of Bundle of Kent
• Avoid AV blocking drugs: Beta blockers, CCB, Digoxin
• Digoxin is contraindicated in WPW syndrome

(Short)

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Ventricular arrhythmias
• QRS broad
• Ventricular tachycardia
1. Monomorphic
2. Polymorphic (Torsades de pointes)

Management of Ventricular tachycardia

• DOC: Amiodarone
• Treatment of choice: Cardioversion

• Amiodarone is a broad spectrum anti-arrhythmic expect in the

following conditions
1. Torsades de pointes( causes QT prolongation) ( max risk with Ia
antiarrhythmics)
2. Digoxin induced arrhythmia: increases digoxin toxicity

• small amplitude
• Treatment : Defibrillation

• no activity
• Flat

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• DOC: MgSO4
• Associated with QT prolongation

• Fusion beats
• Capture beats
• AV dissociation

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ECG - AV block

(>5 small squares) 1. First degree heart block

• increased PR interval
• No dropped beats
• No treatment required

2. Second degree heart block

• Dropped beat present

MOBITZ

I II
Progressive PR Constant PR interval
interval
prolongation

3. Third degree heart block

• Atria and ventricles beat independently of each
other
• Idioventricular rhythm under bundle of his, purkinje
system
• Atrial rate> Ventricular rate
• broad QRS • P walking through the QRS
• Regular P-P interval, Regular R-R interval
• RBBB MARROW • Seen in Lyme’s disease
V1 V6
• LBBB
WILLIAM

V1 V6

• No dropped QRS

• progressive PR prolongation followed by

drop QRS
• No treatment

• PR interval constant

• 2 P waves, 1 QRS complex

• R-R interval constant

• P-P interval constant

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ECG in MI & Pericarditis

ST ELEVATION

PERICARDITIS MI

LCx • Concave upwards • convex upwards

• Diffuse ST elevation
RCA ( Reverse in aVR)
• PR depression
LAD

(Right)

• Posterior wall MI: Reciprocal ST

depression in V1-V3

V1 V2 V3 V4 V5 V6

Septal Anterior Lateral

(SEPTAL)
(Anterior)
(Lateral)

(Foot)

Lateral

Inferior
(Foot)

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• ST depression in V1,V2: Posterior wall MI

• ST elevation in lead II, III, aVF (STE in lead III>II) : Inferior wall MI
• Involvement of RCA
• Bradycardia, decreased BP
• Treatment: i.v Fluids, Atropine

• ST depression in V2, Dominant R wave in V2:

Reciprocal changes of Posterior wall MI • Pericarditis: Diffuse ST elevation, PR segment depression

MI CHANGES

1st change: Tall T waves

ST elevation: Convex upwards, Pardee/Tombstone pattern

Old MI: Pathological Q waves

T wave inversion

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JVP

• Canon a waves : complete heart block

• Absent a wave : Atrial Fibrillation

• Large a wave : increased atrial contraction: Tricuspid stenosis, Pulmonary

stenosis
Constrictive pericarditis: calcification
• Pericardial knock (Occurs in Diastole ~S3)
• Kussmaul sign (JVP not decreased with
• Steep x and steep y descent : Constrictive pericarditis inspiration)

• Steep x and absent y descent : Cardiac Tamponade (Pay Tax: absent Y descent and
Steep X descent)

• CARDIAC TAMPONADE ON ECG : Cardiac tamponade

Electric alternans
Increased JVP
(Pulsus alternans: LVF)

Beck’s
TRICUSPID REGURGITATION triad
• C goes with V: CV waves
• Increased amplitude of V waves due to increased VR Decreased BP Muffled heart
• Absent X descent sounds

Waves in JVP in diastole: DyAstole • S2 = V wave (onset of diastole)

• early diastole: Y descent • Onset of diastole: C wave
• Late diastole: A wave

ACID BASE DISORDERS

DISORDERS pH pCO2 HCO3 pH vs CO2/HCO3
Metabolic acidosis Dec Dec Dec (Same)
NIKMONIC
Metabolic alkalosis Inc Inc Inc (Same)
ROME
Respiratory acidosis Dec Inc Inc (Opposite)
Metabolic equal/ same
Respiratory opposite
Inc Dec Dec (Opposite)

• Hyperventilation leads to : Respiratory alkalosis

Increased CO2 washout: decreased pCO2=
Increased pH
Respiratory opposite
• Hyperventilation is a compensatory mechanism
in Metabolic acidosis ( Kussmaul breathing: DKA)

195
• Diabetic patient
pH: 7.7 ALKALOSIS
HCO3: 30
pCO2: 48 METABOLIC ( moving in same direction)

Cause: Vomiting => acid gets vomited: Metabolic alkalosis

• Diarrhoea=> Acidosis( Normal anion gap metabolic acidosis)

• whenever pH=> Normal, Values of Na,Cl,HCO3 given=> calculate anion gap as it is a mixed
acid base disorder like HAGMA with alkalosis

• Anion gap is due to unmeasured anions

• Normal anion gap: 8-12 Methanol DKA
• Measured anions: Cl, HcO3
• Unmeasured anions: organic acids like lactic acid, Formic acid, keto acid
• Measured cations: Na
• AG: measured cations - measured anions= Na- (Cl+HCO3)
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WINTER’S FORMULA: compensation in metabolic acidosis

Compensated CO2: 1.5XHCO3 +8 +/- 2

Occurs in respiratory
Occurs in metabolic
disorders
disorders

Decreased Decreased pCO2 Hyperventilation

HCO3

Increased Increased pCO2 Hypoventilation

HCO3
CO2 retention
Increased HCO3
Increased CO2 reabsorption
Increased HCO3
Increased H+ secretion

Decreased HCO3
Decreased CO2 Decreased HCO3 reabsorption
Decreased H+ secretion

ACUTE CHRONIC
Example 1: Normal Increase in
pH: 7.2 pH: 7.4 pCO2 1 4
HCO3: 24 RESPIRATORY ACIDOSIS
HCO3: 18 by
pCO2: 30 pCO2: 40 10mmHg
Metabolic acidosis
Decrease in 2
RESPIRATORY ALKALOSIS pCO2 by 5
Compensated CO2: 1.5X18+8= 35 (33-37)
10mmHg
Disproportionate correction: Mixed disorder: Additional Respiratory alkalosis

<7.4 >7.4

CO2. pH
:Hypokalemia + alkalosis

Salicylates: metabolic acidosis +

• any cause of respiratory depression respiratory alkalosis Aldosterone=> Alkalosis =
associated with Hypokalemia
(Except: RTA type 1,2 where there
is Hypokalemia associated with
acidosis)

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Urinary anion gap

GIT NeGUTive: negative

Diarrhoea

Present
RENAL

: S/E: acidosis, RTA type 2

aldosterone antagonist : causes RTA type 4

• Fistula, ureterosigmoidostomy
NIKMONIC

ISONIAZID causes ACIDosis!

Autoimmune diseases with Antibodies

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CSF MENINGITIS
Bacterial Viral

• Normal glucose: Viral

• Bacteria: increased PMNs
• Increased Lymphocytes

TB Fungal

• lipid peak
• Basal exudates

• DOC for cryptococcal meningitis: Amphotericin B +

Fluconazole
• Maintenance: Fluconazole
• Albumino-cytological dissociation: GBS
• associated with Campylobacter
• Ascending neuropathy

• Oligoclonal bands: Multiple sclerosis

MRI: Dawson fingers

LISTERIA
• Newborn HSV
• History of PROM • hemorrhagic: CSF blood +
• Treatment: Ampicillin • Temporal lobe involvement
• Selective media: PALCAM • Treatment: Acyclovir( check
• Tumbling motility creatinine before)
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FLASHCARDS
Only serological marker present during window period in Hep.B infection is Anti –HBc.
Roth’s spots – Infective endocarditis
Cannon ‘a’ waves in JVP represents Complete heart block
Hyperkalemia is a prominent feature of Type 4 Renal tubular acidosis.
Cancer-causing Polycythemia: Renal cell carcinoma
Nodular glomerulosclerosis is pathognomonic for Diabetic Nephropathy.
Pure red cell aplasia is associated with – Thymoma
Initial investigation of choice in DVT: Duplex USG.
Bilateral upper limb pulsesless disease is : Takayasu arteritis.
Anion gap is NOT increased in Renal tubular acidosis
Hypokalemia is seen with Metabolic Alkalosis
Hypochloremia, hypokalemia and alkalosis are features of Congenital hypertrophic pyloric stenosis.
Granulomatous condition with Hypercalcemia – Sarcoidosis
Disease-causing orchitis: Mumps

Conn’s syndrome – Hyperaldosteronism with Hypokalemia

The commonest cause of Paroxysmal hypertension: Pheochromocytoma.
Henoch – Schonlein in purpura is due to IgA deposition.
Spontaneous bleeding is seen in Hemophilia
Most virulent form of medullary Carcinoma Thyroid in associated with: MEN 2B
Drug of choice of Chronic myeloid leukaemia: Imatinib.
Respiratory acidosis is seen in Emphysema.
Pneumatocele is commonest in Staphylococcal Pneumonia
Antiendomysial antibodies are seen in coeliac disease.
Alpha – I antitrypsin deficiency is associated with Chronic liver disease.
Wilson’s disease is diagnosed with increased urinary copper.
Drug of choice for trigeminal neuralgia: Carbamazepine
Episodic flushing, diarrhea, wheezing, right-sided valvular heart disease (eg, tricuspid
regurgitation, pulmonic stenosis), niacin deficiency (pellagra), urinary 5-HIAA.-
carcinoid
cirrhosis, diabetes mellitus, skin pigmentation (“bronze diabetes”)- Hemochromatosis
Onion peel bile duct fibrosis - PSC
High levels of IGF 1 – Acromegaly
Water deprivation test – Diabetes insipidus

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SURGERY

TRAUMA SIGNS
CT cisternogram

Battle sign: behind ear Raccoon eye

Middle cranial fossa fracture • anterior cranial
fossa fracture Halo sign

CSF RHINORRHEA

Focussed abdominal assessment in trauma (FAST) No

No

PNEUMOTHORAX
• on M mode:
Barcode sign or
stratosphere sign
( Normal:
Seashore sign)

Positive FAST
(Free fluid)
Seashore sign Barcode sign

Most specific sign: Lung point

200
FOCUSSED ASSESSMENT SONOGRAPHY TRAUMA (FAST)
• 1st investigation to be done in case of blunt abdominal
trauma (stable/unstable)
• If FAST positive (free fluid present):

Stable: CECT

Unstable: Exploratory laparatomy

eFAST: Right and left thoracic cavity is also included

LIMITATIONS OF FAST
• minimum fluid required: 100ml
• Cannot assess retroperitoneum
• Not sensitive for Hollow viscus perforation
 12/10/23

GCS
GCS

Score: 3-15
Severe head injury: less than or equal to 8
Written as: E4V5M6

GCS- P
PUPIL RESPONSE (GPS - P)
Score: 1-15

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TRAUMA SCORING
TRAUMA SCORES

RR+ GCS+ Systolic BP ( DBP and HR is not R T S

(Revised trauma score)
included) (RR) (Trauma: GCS) (SBP)

(Trauma and injury severity ACTRISS

Age + mechanism+ RTS +ISS
score) Age+ mechanism +RTS+ ISS

( Mangled extremity severity E LI S A (Does not include

Energy of injury+ Limb ischemia+ shock+ age
score) neurological injury)
Abbreviated injury scale (AIS): multiple injuries are
scored by adding together the squares of the three
highest AIS scores

SHOCK

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SHOCK

SIGNS + SYMPTOMS OF HEMORRHAGE - CLASS

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SHOCK

SHOCK
• All shock have – Inadequate perfusion

• Neurogenic shock – Bradycardia + Hypotension

• JVP is raised in – CARDIOGENIC SHOCK

• Warm extremities in - Septic shock or Distributive shock

• Best measure to determine fluid requirement – Pulmonary capillary wedge pressure

• Best measure for adequacy of fluid resuscitation - Urine output

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BURNS ASSESSMENT
Wallace Rule of 9

CHILDREN
• Head: 18%
11 areas each contributing 9% + 1% perineum • Each leg: 14% (13.5%)
• Genital: 0% (1%)
Better: Lund and Browder chart
• Head : 9%
• age specific
• Chest: 9%. TORSO
• Abdomen: 9%
• Back: 18% • Patient’s hand: 1% TBSA
• Each arm: 9%
• Each leg: 18%
• Perineum: 1%

DEPTH OF BURNS

• epidermis • beyond dermis

involved • Not red
• Painless

(Nerves destroyed)

NIKMONIC
Bi-Di: blisters= Dermis
involvement

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1st, 2nd degree burns: Partial thickness

3rd, 4th degree burns: Full thickness
Epidermis Dermis Beyond dermis

(Papillary)
(Reticular)

3rd, 4th degree: requires skin grafting

Superficial: epidermis only, red, painful
Partial thickness Full thickness: beyond dermis: painless, white, no capillary
refill, no blisters
Superficial: papillary dermis: Blisters +, painful, brisk capillary refill
Deep: Reticular dermis: less painful, no capillary refill

BURNS- FLUID RESUSCITATION

• most common fluid used: RL

• Colloids are not given in 1st 12 hours

Parkland formula:
4 X TBSA % X weight in kg= volume in ml
• 1st half is given in 8 hours
• Second half is given over 16 hours

As myoglobinuria is present
Can cause cardiac arrest

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LIVER SCORES
CHILD-TURCOTTE-PUGH CLASSIFICATION : used for CHIRRHOSIS => severity and mortality
• score: 5-15

Compensated

Multiples of 3
Decompensated

NIKMONIC
• Every child has EKBAAP:
E: Encephalopathy • ASCITES: included in CHILD score
K: • Albumin: All: included in all liver scores
B: Bilirubin • CTP: ALT,AST, Creatinine is not included
A: Ascites • Creatinine is included in MELD score
A: Albumin
P: Prothrombin time

LIVER SCORES
SCORES

EK BAAP

• prioritise liver transplant

CBI
• Creatinine, Bilirubin, INR

Added Na+ 3.0: Female/albumin

NIKMONIC
NIKMONIC
PELD
MELD( Model for end stage liver disease) • 2 twins: NABIA and GABIA
• components: C B I • N: Nutrition
• C: Creatinine • A: Age
• B: Bilirubin • B: Bilirubin
• I: INR • I: INR
• MELD: FAst updating: female sex and albumin • A: Albumin
• G: growth failure

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STRASBERG CLASSIFICATION

• Type A: Aise hi
• Type B: Band ho Jana
• Type C: Cut
• Type D: lateral half is cut of CBD D
• Type E:Stricture: similar to
Bismuth

CEAP classification

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CEAP classification

2a: asymptomatic

Aczema: Ak

Bi/Di: Atrophia Blanche and

Lipodermatosclerosis

NIKMONIC
C1: T: Telangectasia
C2: V: Varicose veins
C3: E: Edema
C4: S: Skin and subcutaneous tissue
C5: H: Healed venous ulcer
C6: A: Active venous ulcer

IV CANNULA COLOR CODING

26G:
Violet 24G 24G

22G 22G

20G

17G: white 18G 26G:

Violet
16G

14G: Orange 14G 17G: white

• increased in Gauge: decreased in flow rate and

vice versa
• According to ATLS: minimum 2 green 18G JVP
cannulas secured with 90-100ml/min fluid

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IV CANNULA COLOR CODING AND GAUGE SIZE

FOLEY’S CATHETER
Measured in French French Outer diameter

G O R Y • 1 French: 1/3 mm
• 18 French: outer diameter of 6mm
• 3 way foley’s catheter: irrigation,
bleeding
Green Orange Red Yellow
14G 16G 18G 20G

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Vacutainer color coding

Blue uniform: PT=> Prothrombin time

ABG
Black: Eschar

ESR
E (enolase) F(Fluoride) G(Glucose)

• CBC: Lavender: Contains EDTA

(Everyone loves doing CBC)

• Pink vacutainer also contains K EDTA: used for

cross matching
• Gray: Glucose: Contains Fluoride and K oxalate
• Red: STOP: Plain

Vacutainer color coding

Plain

Heparin

Fluoride and Oxalate

EDTA CBC
/Lavender/Pink

Citrate ESR

Citrate PT/INR

Serum separation tube

(Contains Gel)

Order of Draw: Culture->Blue->Red->Yellow->Green->Lavender->Pink->Grey

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CENTRAL LINE

BREAST CANCER

(Andar)
(Bahar = skin)
(Combined)
(D: dangerous)

History of redness, warmth, rapid growing

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BREAST CANCER

• Peau de orange: Skin involvement due to infiltration of

subdermal lymphatics
• Dimpling: Not skin involvement, Involvement of Coopers
ligament
• Chest wall: SIR: serratus anterior, intercostal muscles, ribs
(Pectoralis: not included)

• any C/L lymph node: M1

• N1: mobile ipsilateral axillary LN ( Sentinel LN biopsy: methylene blue)
• N2 a: fixed axillary LN, B: internal mammary LN
without axillary
• N3a: infraclavicular ipsilateral B: internal
mammary+ axillary LN c: supraclavicular LN)

BREAST CANCER
Peau de orange

• most common quadrant: Upper outer

• Bilateral, multicentric: Lobular CIS

1. Her2 neu: membrane is stained brown: Treatment=> Trastuzumab(S/E: Cardiotoxicity),

Lapatinib
2. ER/PR: intranuclear: good prognosis

ER, PR +

Hormonal therapy response +

IHC Postmenopausal
Premenopausal

Tamoxifen
(SERM) Aromatase inhibitors
• monitor for Endometrial
Cancer with TVS, USG

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BREAST CANCER
• Inflammatory breast ca- Worst Chest wall includes - SIR
prognosis • Serratus anterior
• Atleast 1/3rd breast erythema • Intercostal muscles
• Stage IIIB (T4D) • Ribs

Prefix NOT INCLUDED – pectoralis

• c- clinical
• p-pathological • Due to - PDO

• y- received neoadjuvant • Stage - T4b

chemotherapy
Paget’s disease
• nipple eczema
Skin involvement does not • Vacuolation +

include –
• Nipple retraction • Contralateral LN – M1
• Skin dimpling
• LCIS is benign and not included under Tis

BREAST CANCER
• Due to -
• Stage -

• Axillary nodal status is the most

important single prognostic factor

NIKMONIC
Van Nughs prognostic index

S: Size
C: Class (grade and necrosis)
A: Age
M: Margin
Does not include ER/PR status

( decreased estrogen)

Smoking
Mondor’s disease

Duct ectasia
(Not for fibroadenoma)

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BREAST CANCER
Mutated gene

HER2
Luminal A/B- enriched – Triple negative
BRCA2 – BRCA1
p53

BRCA2 p53 BRCA1

• Most common & best prognosis Luminal A(ER/PR +, Ki67: low)

• Claudin low – TNBC with low E- cadherin , poor prognosis

EARLY BREAST CANCER

Early breast cancer
• T1/T2
• N0/N1
• M0
<40 years: USG
>40 years: Mammography

With 1 mm margin Simple: no LN removal

To prevent recurrence

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LOCALLY ADVANCED BREAST CANCER

Includes In LABC (Not in early breast cancer)

• Tumour >5 cm Treatment: Neoadjuvant chemotherapy
• Skin/muscles involvement (T4)
• Multiple LN (N2/3, T3N1, T4N0) MRM
• Inflammatory breast carcinoma

RT/ Chemotherapy

Neoadjuvant chemotherpay

M1: Advanced breast cancer

Follow up after treatment of breast cancer: physical examination

once in 3-6 months for first 3 years + annual mammogram

Tamoxifen: annual pelvic examination

BREAST ABSCESS

BREAST ABSCESS
C/f Lactating , point tenderness,
fluctuation + , throbbing pain
M/c
Staphylococcus aureus
organism

Rx Initial –

If fail –

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FIBROADENOMA

FIBROADENOMA

Breast mouse, mobile painless , lump

USG -

Mammography - Popcorn calcification

Next step BCS

INGUINAL HERNIA
Indirect Inguinal hernia Direct inguinal hernia
Traverses inguinal canal
_____ to inferior epigastric
vessels
Can pass into scrotum
Bulge through weak
abdominal fascia
Age group
Controlled after pressure over
deep inguinal ring

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PANCREATITIS
IOC: CECT: after 72 hours: better assessment of necrosis
To distinguish between Necrotizing ( nonenhancing) or interstitial
Colon cutoff sign

Centre: Cullen sign

Flank: Gray Turner sign
Splenic artery pseudo Pseudocyst Inguinal: Fox sign
aneurysm

Enzymes elevated – Lipase(more specific) Non specific

• also present in retroperitneal
C/f – hemorrhages like Ectopic pregnancy,
AAA
H/o –
Lab features –
CT scoring-
X ray signs-

SCORES – ACUTE PANCREATITIS

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URINE CRYSTALS

SCROTAL SWELLING
Torsion
Testis Testicular Tumor
Hydrocele Fluctuation ? Brightly transilluminant

Epididymitis
Swelling Epididymis Spermatocele Barley fluid
of
Epididymal cyst Clear fluid – Transilluminant : Chinese lantern
Varicocele Bag of worms
Spermatic
Indirect inguinal hernia Cough impulse +
cord
Infantile hydrocele

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Mx:

FOURNIER’S GANGRENE
Causative organism
Testis , urethra
Possible to put Foley’s?
SPC needed?
Managed by antibiotics alone ?
Surgical emergency

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UNDESCENDED TESTES
M/c site Inguinal _______
Palpable swelling in inguinal canal : Ix =
IOC Non palpable = intra abdominal : Ioc =
Mx Age =
Risk of

Testis in perineum s/o :

Testis in inguinal canal s/o

ECTOPIC TESTIS

M/c site :

Mx :

ULCERS
(Trophic: DM, leprosy)

Sloping edge

• great saphenous
vein
• Oozing +

• venous ulcer according to CEAP: C3: skin changes, C4: healed venous ulcer,
C5: active venous ulcer
• Ischemic ulcer: decreased blood supply: cold, dry
• Neuropathic: sensations absent, painless 221
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ULCERS
Arterial

(On walking)
(Stasis)

(Decreased nerve compression)

Increased venous return

• distal to block

• sloping edge: venous ulcer

• TB ulcer: undermined edges
• Rolled out, pearly white edge: BCC (occurs at face, locally invasive)
• Cauliflower like: SCC
• Arterial, trophic, DM: Punched out
• Bisgaard regimen: venous ulcer
E: elevation
E: education
E: elastic compression

OBGY

222
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ULCERS

OBGY

222
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MATERNAL PELVIS & FETAL SKULL

B

V
F
SMB

F
O

3 SMV SO
M
SM
1 Minimum diameter , flexed
M/C

Three presentations are

VERTEX ->Suboccipito/Occipito
FACE -> Submento
BROW (max diameter) -> Mentovertical diameter (remember as BMV/BMW)

facE presentation= complete Extension

Completely flexed vertex : SOB —-> SOF ——-> OF

9.5 10 11.5

Most favourable pelvis = Gynecoid

Least favourable = Android/ male pelvis
(Deep Transverse Arrest is common)

T= Transverse circle
Rounded

Heart shaped AP>Transverse diameter = Vertical Oval

Face to pubis

Tricks to remember:

Pelvic cavity= circle-> all equal diameter (AP/O/T) -> 12 cm

Oblique = oval -> 12 cm
Outlet = diamond (AP>Trans = 13> 11)
Inlet = opposite (Trans > AP = 13 > 11): Engagement takes place at transverse diameter, outlet is AP>Trans)
. Hence 90 degree rotation takes place
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1) Naegele (1 sacral ala absent) 2) Robert (both sacral ala absent)

T
O Minimum: Obstretic conjugate
D

True : 11
Obst : 10
Diagonal : 12

IBQ: Diagonal conjugate/ clinical conjugate measurement

OC = DC - 1.5 cm

ECTOPIC PREGNANCY
Relative Contraindications for Mtx Single. 50mg/m2. D7 2nd dose
Multiple. D 1357. 1mg/m2
• Sac size > ____cm Leucovorin
• FCA _______
• Beta hCG levels _______ iu/l
Absolute contraindication

• Intrauterine
Intrauterinepregnancy
pregnancy
USG sign - PseudoGSac Ring of fire sign

Most common 1. Site

SiteAmpulla
-
- 2. Rupturesite.
Rupture site -Isthmus
3. Risk
Riskfactor
factor -PID
Management Conservative
Conservative Surgical
Surgical
Ruptured
MTX >4cm
KCl >5000
Actinomycin Live
Anti-D

224
 Ectopic Pregnancy. Outside Uterus
Tube MC. Ampulla
LC Interstitium

Max risk. Previous tubal surgery

MC risk PID (very common)

MC Easiest. Isthmus (narrowest)

Rupture

Late Interstitium. Supp by myometrium

Susp ectopic

Unstable
Stable

USG. TVS Stabilise Laparotomy

empty uterus
Pseudogestational sac. Fluid, Central,
Adnexal sac(Tubal ring Doppler sign)

Yolk sac= Intra uterine pregnancy

If USG -ve: serum BHCG. >2000. Ectopic
C1500
Doubling
Present Absent Failed
IUP not doubled
Ectopic
In ectopic
- BHCG low
- doubling time high

Mx
FCA absent Expectant: If BHCG falls, pt understands, BHCG<1500,
Unruptured

In sac KCl
Medical: MTX Actinomysin
Ruptured. Blood. POD. fluid USG
BHCG < 3000/5000 Systemic
Sac < 3-4 cm
Shoulder pain
Single Multi
Hx. Shock. High shock
50mg/m Day 1,3,4,7 BP <90. Unstable
BHCG <15% Synapse

Stabilise fast. Laparotomy

Ruptured Sx Anti D
Definitive salpingectomy
<12 wk >12 wk If fertility preserved Salpingectomy
50 mug 300 mug
Follow up after
BHCG falls

Heterotrophic pregnancy. Intrauterine + Extrauterine

XX MTX

Mx SURGICAL
 12/10/23

Ectopic pregnancy criteria

Cannula. Cervix. (Cervical)

Sperm. Ova. Ovarian
Abdominal

TWINS

LA-DDU (Lambda in DCDA pregnancy) Mo-Di (Monochorionic Diamniotic)

Separn early
Twin peak sign
<3d >13 d
Lambda
Thick > 2mm DCDA MCDA MCMA Conjoint

Max complication. Monochorionic

Monoamniotic

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BISHOP SCORE & APGAR SCORE

Favourable for induction.

C= Consistency
P= Position
Cervix Nothing related to maternal pelvis
E= Effacement
D= Dilatation
S= Station Fetal head

Mod: cervical length instead of effacement

AMNIOTIC FLUID
Condition Causes Initial. Maternal tranusudate
Duodenal atresia Espoph atresia Polyhydroamnios
Fetal skin
Renal agenesis Clubbed feet
20wks. Fetal urine Oligohydroamnios. Renal urine
(Potter sequence) outflow obst
Maternal DM Polyhydroamnios Fetal hyperglycaemia
No nutrition. Predom water
Isoimmunization
Anencephaly CSF seeping. Polyhydroamnios

Uteroplacental Eg: Preeclampsia. Oligohydroamnios

Swallowing problem. AFI
Polyhydroamnios
insufficiency Cleft palate
• Maximum amniotic fluid is at _________
34 weeks
McConium stain. Green
Rh Incompatibility. Hemolysis. Bilirubin. Golden yellow Oligo Poly Amnioreduction mx
SDP<2cm SDP > 8cm
AFI < 5 AFI > 25

>2L

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Dual/Triple/ Quadruple Marker Test

Dual. First trimester

Beta PapA

Triple

UE3 Triol (predominant)

Not in triple
A= Allowed
B = Banned

Downs: HCG, Inhibin A are increased (HI are high)

Rest are decreased

Edward. Everything Decreased

BIOPHYSICAL PROFILE

Early deceleration HE
6 Terminate
Late deceleration LP

Variable deceleration VC
CTG

VC deceleration. HELP
Sine wave pattern: Fetal anemia
Variable Head Late Mx Terminate pregnancy
Cord comp Early Placental

Gradual Steep

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C110. Brady
1) Antepartum period. NST. FHR Beat to beat variability

FHR acceleration
2) Intrapartum. CTG. Cardiotocography
FHR , contraction

Steep

Acute stress. FHR 3) Biophysical profile

4) Modified BPP Breathing
Amniotic Fluid
Tone
Chronic stress. AFI Movement of fetus
NST/Fine

MOLAR PREGNANCY
GTD

Molar Non molar

-villi present -villi absent
Choriocarcinoma(MC)
PSTT
Benign Epitheloid
Malig
Partial.
Invasive
Triploid
Fetal parts
Complete
Non metastatic Malignant:
no Fetal part
HCG Ovaries BHCG even after S/E
Theca Lutein cyst Monitor BHCG after evacuation till -ve
(In twins) 48 hrs Boeline Weekly till -ve. Monthly
Non GTN
Vesicles USG. snowstorm appearance
6m 12m
(Molar) Malig. Chemotherapy
CF : BHCG. 1) Hyperemesis gravidara
2) Inc ut size
S/O malignant. Persistent/ Inc BHCG
UPT False -ve 3) PV bleed 1st trim. grape like vesicles
4) Thyrotoxicosis (HCG mimics TSH) Persist TLC inc size
5) Preeclampsia. Antiangiogenic factors Metastasis
Stages
1 Uterus
Mgmt: Suction evacuation irresp of uterine size
2 genital adnexa/vagina(suburethral nodules)
Theco LC HCG gore. Spontaneous resolution in 2 months
3 lungs
If not. S/o. GTN
4 others
Symptomatic Aspiration
Twisting. Untwisting/oopherectomy (ext necrosis/haemorrhage)
Contraception. No IUD. Bleed/Perforation
WHO Risk score
Trmt: >6 EMACO 228
Single drug Methotrexate < 6 Mtx (low risk)
Multi EMACO
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ANTEPARTUM HEMORRHAGE
>24 weeks of pregnancy (RCOG)
> 28 weeks (India)

USG first: Whether placenta is low lying

TVS next as it gives better images of
margin of placenta

Placenta Previa: MC for transverse lie of fetus

I. Low lying (< 2cm)
II. Marginal (touching)
III. Partial/ Incomplete. PP:
LSCS if in labour/ >37 weeks
IV. Complete/ Central
Conservative McCafee regimen
C/F Sudden painless bleeding. Night during sleep In hospital <34 weeks
Uterus. POG. US abruptis, hence concealed size is more) Abruptio:
DIC/Shock/Fetal distress Delivery
No tocolytics
Abruptio If stable. Conservative in hosp mgmt
painful Page classfn (torn placenta)
Uterus > POG H/o trauma
PP Vasa previa Preeclampsia high risk factor
(Concealed) Uterine rupture
painless Fetal bleed
APT test H/O LSCS
DIC. Thromboplastin
Couvelaire/uterine apoplexy Velamentous Contraction stop
(Concealed) Not an indication for Foetal distress Well felt
hysterectomy

Obstetric Maneuvers
Best for aftercoming head:
Pipers Forceps

Sharva

Shoulder dystonia Popliteal pinard Wigord margin Burns Marshall

Breach

Breech. Arm MSV

Lovsets

Prague: Chin offset

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Shoulder dystosia

Impacted

Rubins
Unimpacted

Mc Roberts Wood corkscrew

Zavanelli

Meralgia paresthetica Craskin

LEOPALD MANEUVER
Foot end

Pawlik. 3rd

Ritgen Controlled delivery of head

Perineal tear

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Vaginal infections

Thin yellow Green Curdy thick

Not
<4.5

(Fishy)

Metro/Clinda meTRo Flucanazole

1) Bacterial. A. B. C
Altered flora
No inflammation Amsels Back Cells
No WBCs
No itch criteria vag
Metro/clinda

No itch, fishy smell

2) Trichomonas: sTRawberry
meTRonidazole
TRophozoite only, no cyst
TReat partner also, STI

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Ovarian tumors classification

I. Common epithelial tumors III. Germ cell tumors:
• Serous tumors Oysgerminoma
• Mucinous tumors Endodermal sinus tumor (Yolk sac tumor)
• Endometnoid tumors Embryonal carcinoma
• Clear cell Polyembryoma
• Brenner tumors (transitional cell tumors) Non-gestational chonocarctnoma
• Seromucinous Undifferentiated carcinoma
Teratoma (Mature/immature)
II. Sex cord-stromal tumors:
• Pure stromal cell tumors- Fibroma. Thecoma. Leydig cell Mixed forms
tumor. Steroid cell tumor IV. Gonadoblastoma
• Pure sex cord tumors- Granulosa cell tumor (Adult/Juvenile). • Pure
Sena cell tumor • Mixed with dysgerminoma or other germ cell
• mixed sex cord-stromal tumors- Sertoli-Leydig cell tumors tumors

V. Soft tissue tumors not specific to ovary

VI. Miscellaneous tumors
VII. Secondary (metastatic) tumors
VIII. Tumor-like conditions

Yolk sac tumour: They are also called endodermal

sinus tumour. The bodies seen are Schellar Duval
Bodies, as it looks like a Glomerulus (YES -> G)

Germ cell -> Alfa feto protein

Dysgerminome -> DPL-> PLAP, LDH
Granulosa cell Tumour -> CD99/mic 2
(Call-Exner Bodies, Coffee bean nodules,
pseudorossette, inhibin B)
Chorio carcinoma -> HCG 232
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CONTRACEPTION

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IMP IMAGES

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PAEDIATRICS

IMPORTANT ONE LINERS –PYQ BASED

1. Reflex appearing after birth and never Parachute
disappears
2. Breast feeding should be started within ASAP WITHIN 1 hr

3. Vitamin deficient in breast milk Vit D, K ( In vegtarians - B12)

4. Collagen defect – Vitamin deficiency C (Delayed wound healing)

5. ABCDE D- disability , E- exposure
6. Hep- B positive mother ( antenatal ), neonate Hep-B vaccine and Ig
should be given
7. Recent update - Additional dose of Fipv3 is 9 months (Fractional
IPV) along with measles
given at
8. Vaccines given at birth Hep B BCG OPV (HBO)
9. Yellow fever vaccine gives protection for Lifelong
10. Vaccines not following open vial policy BCG, Measles, Rota, JE (OTP)

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11. Most common cause of inspiratory Laryngomalacia

stridor in a child
12. Single umbilical artery is associated Renal anomalies
with
13. M/c seizure in <5yr age group Febrile
Hypo
14. Infant of diabetic mother is at risk of -------- glycemia
development of
15. Vitamin K is given at birth to prevent Hemorrhagic Disease of Newborn
16. Drug used to close PDA Indometh/Ibuprofen.

17. Post term neonate is neonate born 42 weeks

_____
beyond

CLINICAL VIGNETTES
1. Short stature , primary
amenorrhea, widely spaced Turner Syndrome

nipples
2. Abdominal pain, Diagnosis - Henoch Schonlein purpura
hematuria, palpable Deposits Ig - IgA
purpura
3. Duodenal villous atrophy Anti endomysial antibodies / TTG

4. Cola coloured urine, HTN Post streptococcal glomerulonephritis

following boil over leg
5. Effacement of podocytes,
edema, massive Minimal change disease

proteinuria in a child
EEG - 3Hz spike and wave pattern
6. Stare with absent blinking Absence seizure In Doc - Ethosuximide
B

&

Whipple PAS + macrophages

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VITAMIN A
i. Treatment of Vit A deficiency
2L
1L
>12m
50k
6-12 months

<6 months

● XN – Night blindness
● Pearly white lesions with foamy appearance
● X1A Conjunctival xerosis
● X1B Bitot spots
● X2 Corneal xerosis
● X3A-
Corneal ulceration
● X3B-
● XS Corneal scar

DEHYDRATION
CLASSIFICATION OF DEHYDRATION IN DIARRHEA
Classification FEATURES Mx

No dehydration/Minimal
Well alert, moist mucosa , drinks normally Plan A 5- 10ml/kg/ loose stool
ORS
Restless, irritable , dry mucosa , thirsty & drinks eagerly Plan B 75 ml/kg over 4 hrs
Some/moderate
ORS + Zinc

100 ml/ kg over

Severe Lethargic, not able to drink, capillary refill time > 2 sec Plan C IV.
Age Age > 1yr
RL- <1
• Supplement in acute diarrhea – Zinc Ideal yr
• Normal diet – Continued > NS.
• WHO ORS – Reduced Osmolarity ORS
• Glucose – 75 Given in 6 hrs 3 hrs
• Na- 75 1st 30ml/ kg
given in 1 hr 0.5 hr
• Cl- 65
• Citrate- 10
• K- 20 Next 70
ml/kg given 5 hr 2.5 hr
in

ment of severe dehydration

yr Age > 1 yr

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NEONATAL RESUSCITATION PROTOCOL (NRP)

TTC Suction mouth

Nose

Bag mask
ventilation C/I in CDH

Neonatal resuscitation

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TORCH infections
Congenital syphilis

Varicella
Limb scarring
Rubella - PDA, SNHL cataract

• CONGENITAL TOXOPLASMOSIS
• CLINICAL TRIAD- CHORIORETINITIS , HYDROCEPHALUS, CEREBRAL
CALCIFICATIONS
• TOXOPLASMOSIS – MACROCEPHALY (Hydrocephalus)
• HEADLIGHT IN FOG APPEARENCE
• CONGENITAL RUBELLA
• C- CATARACT
• H-HEART DISEASE (MC –PDA )
• D-DEAFNESS
• SALT AND PEPPER RETINOPATHY
• BLUE BERRY MUFFIN LESIONS – CHARACTERISTIC OF CONGENITAL RUBELLA
• CMV
• 90% are Asymptomatic
• Developing countries – reactivation of CMV infection of mother
• PeriVentricular calcifications, microcephaly ,chorioretinitis
• S – SNHL(non syndromic)
• Most children symptomatic at birth develops hearing loss
• Incidence of CMV infection in fetus with mainly primary infection

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• Herpes zoster
• Limb hypoplasia
• Zika virus
• Aydes aegyptie mosquito
• Hoffbauer cell in placental tissue
• Feature –
• Microcephaly (HC <-3SD) AND Micrencephaly
• Macular scarring
• Hypertonia and limb deformities (CTEV)
• Subcortical calcifications
• Congenital Syphilis
• Late (>2yrs)
• Hutchison triad
• Teeth (notching / peg shaped incisors )
• Interstitial keratitis
• Deafness
• Mulberry molars
• Fissure – Rhagades

SHORT STATURE
● Constitutional Height < 3rd percentile
or
○ -Weight N
< -2SD
○ -Parents height N

○ less than chronological age

- Bone age is _______
puberty delayed

Achondroplasia

Familial parent - Height short Short limb dwarfism

BA = CA

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DENTITION
PRIMARY DENTITION 2102 SECONDARY DENTITION 2123
Begins at 6-7 m 6 yrs
Completes by 2 1/2 - 3 yrs 12 yrs complete except 3rd molar
1st tooth Lower central incisor 1st molar
Last tooth 2nd molar 3rd molar
Number 20 28-32

DEVELOPMENTAL MILESTONES- Gross motor

Neck holding 3m Stairs
Rolls over 5m 2 feet up/ down 2 yrs
Sits with support (tripod ) 6m 1 feet up 3 yrs
Stands with support 9m 1 feet down 4 yrs
Walks with support / Hops 4 yrs
12 m
creeps well Skips
Sits without support 6m 5 yrs
Stands without support 12 m
Walks without support 15 m
Rides a tricycle 3 yrs

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DEVELOPMENTAL MILESTONES- Fine motor

2 yrs

Bidextrous grasp 4m 3 yr

Unidextrous grasp 6m
4 yr /
Transfers objects 7 months
cross

Immature princer 9m 5 yr

Mature pincer 12 m

Haadedness establishes 3 yrs

Tower 6 blocks 2 yr (X3)

9 blocks 3 yr (X3)

DEVELOPMENTAL MILESTONES- Social & language

Social milestones Language milestones
Social smile 2m Alerts to sound 1m
Recognises mother 3m Coos 2m-3m
Stranger anxiety 6m Laugh aloud 4m
Waves bye bye , plays Monosyllables 6m
9m
peek a boo Bisyllables 9m
Jargon 15m 1-2 words with meaning 12m
Knows full name and 3 yrs 8-10 words vocabulary 18m
gender
2-3 word sentences 2 yrs
Plays co-operatively in
4 yrs Tells stories 4 yrs
group , goes to toilet alone
Asks meaning of words 5 yrs

Dresses, undresses 5 yrs

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IMPORTANT GENETIC DISORDERS

TURNER SYNDROME DOWN SYNDROME
45 X 0
(X-1) = 0
MR
Barr bodies
A/W
Vs Klinefilter 47 XXY = B.B = 1
Duod atresia
Short stature Hirschprung’s
Webbing neck
Endocardial cushion
Shield chest defect
1 amenorrhea with secondary sexual characters ABSENT ALL
A/W Bicuspid AV/ COA Hypergonadotropic Streak gonads AML M7
A/W Horse shoe kidney hypogonadism FSH Single 21 Trisomy
in ovarian failure Palmar
N menopause Crease
SIMIAN
< 40 yrs -
Puberty PATAU EDWARD
Premature
13 ovarian failure
Trisomy 18
Trisomy 13
Palate cleft/lip Over riding of fingers
Cutis aplasia Rocker bottom feet

Klinefilter — Tall pt. with gynecomastia

ACUTE EPIGLOTTITIS vs CROUP

CROUP EPIGLOT
Causative agent Parainfluenza Streptcoccus
Viral Bacterial Thumb LTB
epiglottitis Steeple
C/F Low grade fever, High grade fever , Croup
cough, coryza,
Drooling of saliva
stridor

Barking cough

Rx Steroids Iv antibiotics

( dexamethasone )
,Adrenaline
nebulisation
Dilation of airways

CXR

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NEURAL TUBE DEFECTS

Lemon
Inheritance - Multifactorial Sign

Vitamin
supplement Folic acid (Imp)
to prevent –
Dose – Normally 400 ug 0.4 mg
Banana
High risk- 4000 ug 4 mg sign
-Cerebellum
Failure of Anterior / rostral neuropore Anencephaly
closure of
Posterior / caudal neuropore Spina bifida
Folic acid
started at
1m
least ______
before
planning
pregnancy
Frog eye
Anencephaly

Mx MTP
A/w polyhydram. CSF out
AF

MALNUTRITION Serious condition - multisystem

Acute Chronic
Weight for height Height for age
Kwashiorkor vs Marasmus
Edema
Wasting Stunting Calories
Fatty liver Protein

hepatomegaly
Severe wasting Severe stunting
<3SD <3SD Appetite
Severe acute malnutrition
Skin and hair
Definition of SAM( 6m-5yr)-
changes (Flag
Any one of
sign)
CNS apathy
involvement
Weight for
MAC < Pedal edema
height < 11.5 cm unexplained
3SD

● SAM with shock – Fluid of choice : RL + Dextrose

● Only shock ( cold clammy extremities ) NS

Age independent - MAC

Kwashiorkar Marasmus
Recent Baggy pant

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Marasmus vs Kwashiorkar

Grade 4 - Loss of buccal fat Grade 4 - Ascites +

1 Pedal

Triad
Infections
Hypoglycaemia
Hypothermia
Oral 10% dextrose
IV only
Shock + 50% dextrose

Yellow

Initial stabilisation
XXX (Iron)
F75 Catch up No in acute
XX Refeeding F100 Free radical
Hypophosphatemia
>5KCal 100 kCal
1 gm proteins in 100 ml 3 gm protein
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DERMATOLOGY

STI
With painless Ln Syphilis

Painless With painful LN LGV

Genital ulcer

No LN Donovanosis

Without vesicles ,
Chancroid
multiple , soft, bled
Painful
With vesicles Herpes

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249
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Wood’s lamp
WOOD’S LAMP

Erythrasma

Ivory white

P. veriscolor

Pseudomonas

• Wavelength of light :

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ACNE VULGARIS
STAGE 1 Topical retinoids
Keratin plug(comedone) in follicles 2 (Adaplene>Tretioin)
types of lessions
i. BLACK/OPEN COMEDONE Sytemic retinoids not used here since
(black head) has many S/E
ii. WHITE/CLOSED COMEDONE
(white head)
STAGE 2 Topical retinoids & Topical Antibiotics
Propionibacterium acnes(commensal)
grows and sebum gland burst in (clindamycin,dapsone)
dermis
Benzoyl peroxide can also be given.
PAPULES(<0.5cm) + Stage 1 lessions
STAGE 3 Oral antibiotics started along with
PUSTULES + Stage 2 lessions topical retinoids and topical antibiotics

Stage 4 Sytemic Retinoids (ISOTRETINOIN)

NODULES/CYSTIC lessions + Stage3 • Chelitis(m.c)
lessions • Strongly teratogenic
• Hepatitis(LFT required)
• Hypertriglyceridemia

PSORIASIS

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LICHEN PLANUS

Koebner phenomenon
True False

Lichen Mollucum
Psoriasis Vitiligo Warts
plasnus contagiosum

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Pemphigus vulgaris vs Bullous pemphigoid vs DH

• Dermatitis Herpetiformis :
Bulla

Antibody

Location

Immunofluorescence

Mouth involved

Nikolsky sign

Symptoms Painful Pruritic

STREPTOCOCCAL & STAPHYLOCOCCAL INFECTIONS

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OTHER INFECTIONS – TINEA

• DOC :
Terbinafine for
_____

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LEPROSY

• SATELLITE LESIONS
IN :

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IMPORTANT IMAGES

256
 12/10/23

NEUROCUTANEOUS SYNDROMES

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ANESTHESIA

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PREOPERATIVE ASSESSMENT- Mallampati Score

PRE OP & Post op DRUGS
Anxiolytic — > Midazolam
Dec secretions —> Anticholinergic = Glycopyrrolate
Antibiotics —> Given 30 min-1 hr before surgery —> Cefazolin-Zero infection
PONV —> Ondansetron = 5HT3 Antagonist
(1st gener. Cephalosporins)

NPO / NBM = Nil per oral —> Hours before surgery the following
foods are taken
Class I: soft palate, fauces, entire uvula, pillars; Clear fluid —> 2 hrs
Class II: soft palate, fauces, the portion of uvula; Breast milk —> 4 hrs
Class III: soft palate, the base of uvula;
Semi solid —> 6 hrs
Class IV: hard palate onIy.
Solid Meal —> 8 hrs

Nik-Monic : P U S H Rule of 5 :
• Pillars Class 1 = 4 structures seen
• Uvula Class 2 = 3 structures seen
• Soft palate Class 3 = 2 structures seen
• Hard palate Class 4 = 1 structures seen

BISPECTRAL INDEX & NM MONITORING

Adductor
——>Frontal electrodes policis <———

• Neuromuscular monitoring = for TOF

• m/c = Ulnar Nerve
• TOF = Train of four

Fading response = 4/1 ratio

R

> Has 2 phases

-Fade

BIS
W
Coma = 0 g I

In all 4 stimuli Lesser TOF Same amplitude,

Normal stimulus = Adequate but decreased
Adequate = 40 - 60 for general anesthesia block when compared to
normal

Fully awake = 100

Sedation = 80
• BIS —> To assess depth of anesthesia

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MAPLESON CIRCUITS
APL MODIFIED
Adj. Both near Out = Exp.
pt Magill —> A circuit In = Insp

Lack —> AC = Mapleson A Coaxial circuit

Corrugation
absent Bain —> D Circuit (Dominant use in adults)
Ayre T piece —> E Circuit
Distal APL Jackson Rees —> F Circuit (Paediatric
Bag(-)
spontaneous Circ)
APL Absent

• Not used : B, C
A = Spontaneous
MAPLESON CIRCUIT
• Used in adults: D = Dominance of assisted
A —> APL adj. to patient —> Fresh gas inlet away from pt circulation
B —> Both APL, FG near pt • Used in infants : E, F = Most common

C —> Combined, Corrugated tube absent

D —> Distal APL
E —> Everything absent - APL, Reservoir bag absent Valveless Decreased
F —> Free flow - No APL Valve, Reservoir bag present -I
resistance
• Semisolid circuit ↳

m/c in paediatric = “F”

• Reservoir bag present
• Rebreathing not present
• Rebreathing seen in closed circuit, So more scavenging present
- Has soda lime, CO2 absorber (Not present in semi closed circuit)

(Distal flow)

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CYLINDER – COLOR CODING & PIN INDEX

White shoulder • White shoulder seen in,
M
-Oxygen
-Air
*
Cyclopropane *
Helium -
-Entonox

O2
Cylinder
-

I
Black body

CYLINDER BODY SHOULDER PIN INDEX

AIR Grey White 1, 5
OXYGEN Black White 2, 5
NITROUS OXIDE Blue Blue 3, 5
1, 6 if CO2 > 7.1
CO2 Grey Grey 2, 6 if CO2 < 7.1

CYCLOPROPANE Orange Orange 3, 6

——>Single
HELIUM Brown 7 Entonox
• DISS = Diameter index safety system • WOW = O2 White
- For pipelines • AB = Air black
- Colour coding for this ↳• VY = Vaccuum suction yellow
• NN = Nitrous oxide Blue
ENTONOX pin index:

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O2 DELIVERY DEVICES
Routine / Hudson Venturimask Rate Max Fio2
Nasal Cannula mask = Inc. Flow rate
(Or) Prongs Nasal cannula 5 40
Hudson mask 10 60
Venturi 15 60
Non rebreathing 15 85
HFNC 60 100
NIV Unlimited 100

• Venturi
• Principle : Bernoulli principle
• Fixed performance device
• Prefd in COPD pts = as no over oxygenation needed

Non - Rebreathing HFNC Niv • Fixed performance High flow

mask = Has bag Humidifier = High flow - Venturi
• Variable performance Low flow
- Prongs/ Cannula
- Masks with (or) without bag

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REGIONAL ANESTHESIA - LOCAL ANESTHETICS

LOCAL ANESTHETICS
Bind to channels : Inactivated Na+ Channel
Most cardiotoxic : Bupivacaine
Rx : Intra lipid 20%
Causes methHB : Prilocaine (Treat. Methylene blue)
Causes vasoconstriction : Cocaine
Max dose of lignocaine : 4.5 mg/kg
Max dose of lignocaine + adrenaline : 7 mg/kg
Most suitable for IVRA ( Bier’s block Lignocaine
ÈMLA : Prilocaine + Lignocaine
(2.5%) (2.5%)
• Esters = 1i —> Procaine
• Amides = 2i —> Lignocaine (Xylocaine)
• Bupivacaine = Cardiotoxic —> Not used in Bier block
• If arrhythmia = Amiodarone given
• Cardiac arrest = Epinephrine
• Cocaine = Inc. NE by inhibiting reuptake —> Vasoconstriction
• Adrenaline = Vasoconstriction —> Delays absorption - Inc. Duration
of action when used with Local Anesthetic
• Conc. Of Adrenaline :
- Anaphylaxis = 1:1000
- Cardiac arrest = 1:10,000
- When used with Local anesthetic = 1:2,00,000
-Most Potent and Most toxic —> Dubivacaine

SPINAL VS EPIDURAL NEEDLE

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INHALATIONAL AGENTS
INHALATIONAL
Children, Induction choice , Neuro ,
Asthma , liver : Sevoflurane

Nephrotoxic ( Compound A) —> Not used in renal patient

Cardiostable Isoflurane (In IV = Etomidate)

Renal , elderly, obese Desflurane

Most hepatotoxic , arrhythmogenic , Halothane
sensitises heart to catecholamines , (C/I in pheochromocytoma,
bronchodilator used in asthma)

Most epileptogenic Enflurane

Most potent : Methoxyflurane (Not used), So Halothane
Least potent : N2O
Sequence : HIS D (Nik-Monic)
Most potent- least potent Halothane - Isoflurane - Sevoflurane - Desflurane
(MAC)
Slowest –fastest
(Blood gas solubility)
• Sevoflurane = Sweet, in children • Potency = Related to minimum alveolar conc.
= Used everywhere - Low MAC = Inc. Potency
= Not used in renal patients - MAC also decreases in elderly, Pregnancy
• N2O = Second gas effect - Onset = Blood gas partition Coefficient
= Diffusion hypoxia (Give O2 during recovery) - Blood solubility dec. = Slow onset
= Cause megaloblastic anemia
Inc. Air present in cavity = C/I in pneumothorax
VAPORISER COLOR CODE
• Halothane-red
• isoflurane-purple
• enflurane - orange
• sevoflurane- yellow
• desflurane- blue

Nik-monic :
• Sevo = Sun
• Halo = Red
• Desflurane = Desi cricket (blue)
• Enflurane = ENO (Orange)
• Isoflurane = PISO (Purple)

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MALIGNANT HYPERTHERMIA
MALIGNANT HYPERTHERMIA
Drugs causing : Halothane, Succinylcholine
Defect : RyR Receptor overactivation
C/F:
Earliest / most sensitive indicator : Inc. ET CO2
Rx : IV Dantrolene (Dec. Ca release)
• Inc. Temperature
• Drugs causing = Halothane
= Succinylcholine
• Defect : RyR Receptor Overactivation —> Inc. Ca2+ Release from SR
—> In Heart - Arrhythmia / Tachycardia
—> Inc. Muscle contraction/ Rigidity = Myoglobinuria, Renal Failure
—> Inc. ATP Use —> Inc. Metabolic Rate = Fever

IV DRUGS – GENERAL ANESTHESIA

IV DRUGS
• Daycare DOC —> Propofol (Dec. Vomiting)
• Antiemetic = Propofol
• C/I in egg allergy (Egg Protein)
• Painful iv injection
• Infusion syndrome
• Emergence delirium , dissociative anesthesia —> Ketamine
• DOC in asthma —> Sympathomimetic
• DOC in shock
• Cardiostable , DOC in cardiac
• Adrenal suppression
-
Etamidate

• C/I in porphyria
• Neuroprotective
• Prefd in seizures —> Barbiturates
• Truth serum = Brain Silent

• Ketamine
- Sympathomimetic
—> Bronchodilation = Used in Asthma
—> Vasoconstriction = Shock
• Barbiturates
- Phenobarbitone = CYP Inducer —> Induce attack of porphyria

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MUSCLE RELAXANTS
= 2 phases
MUSCLE RELAXANTS
Fade
Most sensitive muscle : Eyelid
Depolarising : Succinylcholine (Shows 2 phases)
Sch causes K : Hyperkalemia (Malignant Hyperthermia)
Used for ECT / RSI : Succinylcholine
Malignant hyperthermia causing : Sch
Cardiostable : Vecuronium
Hoffman elimination : Plasma Degradation = Atracurium
Prefd in renal or hepatic failure : = Cistacurium (Better)
Reversal : —> Inc. Ach = AchE Inhibitor = Neostigmine
—> Sugammadex = Rocuronium, Vecuronium
Best for monitoring : TOF, Ulnar Nerve used
• TOF less, Adequate Relaxation

OPIOIDS
OPIOIDS
• Morphine C/I in biliary colic = Causes Sphincter of Oddi Contraction
• Post thoracotomy pain managed by: IV fentanyl = Can be used as a patch
• Drug of choice for controlling severe pain in cancer
patients: Morphine
• Drug of choice for OPD analgesia: Alfentanyl
• Most potent: sufentanyl
• Shortest acting opioid-remifentanyl
• Sufentanyl = Most potent
• Remifentanyl = Shortest
• Alfentanyl = Can be used in OPD as well
(Alfavourable)
• Morphine also contraindicated in Head Trauma

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IMPORTANT POSITIONS MANEUVERS

CPR - BASIC LIFE SUPPORT (BLS)

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HIGH QUALTITY CPR FOR ADULTS

Adult tachycardia with pulse algorithm

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PSYCHIATRY

DISORDERS OF THOUGHT
/ Flow of thought Stream/ flow

Form

Content
(Rhyming words)
Possession
(Persistence of the same
response beyond the point of
relevance)

(Sudden block in train of thought and

begin with entirely new thought)

Tangentiality: going off track and never

reaching the answer

Loss of logical sequence of events

Coining new words

(Incoherence)

Q - Ans Circumstantiality: beating around the bush

followed by return to the topic, end goal is
Su achieved

Q ----- Ans Tangentiality: going off track and never

reaching the answer
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(Recurrent intrusive irresistible own thoughts)

(Act)
Insertion Broadcast

(Possession of thought)

Withdrawal

(PYQ: thought content disorder)

DELUSION False, firm,unshakeable belief

C/F DELUSION
• M/C TYPE : Persecution

• False belief of being harassed or persecuted Delusion of persecution

• One’s lover is unfaithful / Morbid jealousy Othello syndrome( associated with alcohol)

• Another person is in love with them ~ Higher status EROTOMANIA Declerambault syndrome
• Familiar person has been replaced by a stranger Capgras: common person (wife) replaced by a nurse

• Different people are in fact a single person who changes his or her appearance Fregoli syndrome
(Disguise)
Different role: 1 person

Delusion of misidentification

• Ekbom syndrome: Delusion of infestation Delusion Schizophrenia

• Cotard syndrome: Delusion of Nihilism , intestines are rotten
• delusion+
• only delusion hallucinations
• No hallucinations • Duration: 6 months

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TIMELINE
Disorder Duration
Schizophrenia Schizo: six 6 months
Schizophreniform disorder 1-6 months

Brief psychotic disorder <1 month

Delusional disorder (No hallucinations) > 1 month

Hypomania : 4 days Mania: 1 week

PTSD History of flashbacks and avoidance: > 1 month

Acute stress disorder <1 month

Panic disorder:
Generalised anxiety disorder All the time worried: >6 months acute, palpitations
Major depressive disorder Dipressiwe 2 weeks

Dysthymia Dy-y 2 years

PERSONALITY DISORDERS
Cluster A Paranoid Suspicious
Weird
Schizotypal Magical thinking
PASS

Schizoid Happy loner

Cluster B Borderline Self harm, labile, impulsive

Wild Histrionic Rakhi Sawant

BHAN
Antisocial Violent, illegal: associated with drug abuse

Narcissistic Hitler: supreme power

Cluster C Obssesive Perfectionist/Rigid/anakistic

Worried

Avoidant Fear of criticism

COAD

Dependent People pleaser

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Schziod: society avoid

PASS

Suicide/wrist cuts

Management of Boderlibe personality

disorder: Dialectical behavioural therapy

BHAN

COAD
People pleaser

DRUGS OF ABUSE
FEATURES INTOXICATION
Magnan symptom
Cocaine
Black pigmentation of teeth and tongue • Erythroxylum
coca
• Red coloured
Sympathethic symptoms

Amotivational syndrome , Run amok Cannabis

Bas karo Carnivorous
Carnivorous Bas karo
Bad trips, Flashback
LSD (Bangkok)

Paranoid hallucinatory syndrome, Schizophrenia like Amphetamines

McEwan sign, Morbid jealousy, Mellanby effect Alcohol: all M

(not Magnan)

Dissociative anesthesia, Angel Dust Phencyclidine

Fairy Fairy
Fairy world

Increases NE: Sympathomimetic

Cocaine

• increased HR, BP
Coca cola Coca in nose • MI
Cockroach • Mydriasis

Tactile hallucinations Septal perforation

Black tongue

Magnan symptoms
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DRUG ABUSE – WITHDRAWAL

ALCOHOL WITHDRAWAL SYNDROME
Earliest feature Tremors

Hallucinations with intact orientation Alcoholic hallucinosis

Delirium tremens: occur after 48-72 hours
Hallucinations with impaired orientation and autonomic hyperactivity Treatment: BZD
In alcohol withdrawal with seizure, treatment is IV diazepam and thiamine.
Disulfiram : aversive therapy - inhibits AlDihyde dehydrogenase inhibitor: increased Aldehyde : accumulation of
aldehyde: Symptoms
Motivated patient

NIKMONIC
• Varenicline :
Nicli: Nicotine like
Nicotine receptor partial agonist
Use: Smoking cessation
Bupropion: pio nahi NIKMONIC
Mydriasis OPIOD toxicity:
Lacrimation , Rhinorrhea OPIOD withdrawal
~ exam hall C: coma : respiratory depression:
Yawning Respiratory acidosis
Piloerection C: constipation
Diarrhea
C: constriction of pupil(Pinpoint pupil)

BEHAVIOUR
Conduct disorder Violent
<18 years

Anti social personality >18 years

Oppositional defiant disorder <10 years

Opposing parents

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SLEEP PHYSIOLOGY & DISORDERS

NIKMONIC

BAT drinks blood

Beta waves: awake, eyes open

Alpha waves: awake, eyes closed

Theta waves: light sleep: NREM1

Delta waves: deep sleep: NREM3,4

Beta: saw tooth pattern: REM sleep

NREM REM

• dreams are
• Night terrors
remembered
• Bruxism
• Nightmares
• Somnambulism

EATING DISORDERS
BMI less Lean Amenorrhea Nervous about weight gain=> purging and vomiting

Obese

Purging
Bulimia Present

Binge eating

Binge eating disorder Absent

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PSYCHOPHARMACOLOGY- ANTIPSYCHOTICS
ANTIPSYCHOTICS SIDE EFFECTS – EPS
Diagnosis C/F Rx
Acute dystonia Torticollis , eyes Promethazine
rolling upwards
Akathisia Restlessness Propranolol
Drug induced Anticholinergic –
Parkinsonism Trihexyphenidyl

Tardive dyskinesia Lip smacking Valbenazine/

Tetrabenazine
Neuroleptic high temperature, Dantrolene (DOC),
malignant increase CPK, Amantadine,
syndrome muscle rigidity, Bromocriptine
Sweating

CLOZAPINE SIDE EFFECTS

METABOLIC SYNDROME
D2 partial agonist
Atypical causing max hyperprolactinemia

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ANTI DEPRESSANTS
ANTIDEPRESSANTS: DOC- SSRI ( onset : 3- 4 weeks )
SSRI Fluoxetine
Citalopram
Mirtazapine

SNRI Duloxetine
Venlafaxine

SARI Trazodone

NDRI Bupropion

S/e :
Least sexual S/e :
Smoking cessation:
Priapism :
C/I in anorexia, bulimia
TCA toxicity

LITHIUM
LITHIUM
Therapeutic range
Toxicity >
Ideal time to monitor blood levels :
S/E
Tremors
Hypothyroidism
Diabetes insipidus
Teratogenic :
Has antisuicide property
Features of lithium toxicity
SEVERE TOXICITY RX ( > 4 meq/L )

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ALZHEIMER DRUGS
ALZHEIMER DRUGS
• Increase Ach – AchEsterase inhibitors
Donepezil
Rivastigmine
Galantamine
• NMDA antagonist
Memantine
• Mab
Aducanumab

ONE LINERS
La Belle indifference is seen in
Recent memory loss and confabulation
Psychotherapy of choice in OCD Exposure and response prevention
Repetition of last heard words of others Echolalia
Imitation of observed behaviour Echopraxia
Palpitations, sweating , feeling of choking and dying (
suicide attempt not seen )
Only delusions , no hallucinations
Delusions with hallucinations
Earliest symptom of alcohol withdrawal
Vitamin deficiency – cognitive impairment in old age

Aggression towards people / animal

Property destruction
Violation of rules
Theft

Delirium vs dementia

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IMP POINTS
MANIA HYPOMANIA
Duration 1 week 4 days

Social or occupational Absent Present

functioning

IMPULSE CONTROL DISORDER:

• Stealing
• Compulsive alcohol drinking
• Mutilating animals
• Set fire

• Eonism - The wearing of female clothing by a male

• Frotteurism-. male rubbing of genitals against fully clothed woman to achieve orgasm
• Exhibitionism - recurrent desire to expose genitals to stranger
• Necrophilia - Sexual pleasure with dead bodies

RADIOLOGY

278
RADIOLOGY

GIT
 GIT

GIT- INTUSUSCEPTION
 HBP

EMERGENCY RADIOLOGY

ü Note –
ü Screening-
ü IOC- ü M mode USG –
ü H/O –
ü Criteria- ü Mx –
 CNS HEMORRHAGE

ü C/F-

ü First Ix-

ü Cause -

RESPIRATORY -PLEURAL
 IOC
Fluid
Air
Calcification
Soft tissues

Bone cortex

Bone marrow

Acute Hemorrrhage
Chronic hemorrhage
Acute cholecystitis

IDENTIFY INVESTIGATIONS

i. Water white – i. Hybrid / fusion

imaging

ii. White matter

white -

iii. All black -

 INVESTIGATIONS

i. Radiation exposure i. Sequence – i. Black vessel –

i. Therapeutic
ii. Contrast route -
ii. IOC for bile duct
ii. Invasive

NUCLEAR SCANS
Parathyroid adenoma
Meckels diverticulum
Pheochromocytoma
Ejection fraction = LV function
Used for diagnostic scan RAIU
Used for thyroid ablation
Used as brachytherapy implant
I131 therapeutic effect due to
 RADIOSENSITIVITY

Most radiosensitive
Tissue
Pelvic organ
Tumors
Cell cycle phase
 12/13/23

ORTHOPEDICS

NERVE INJURIES
ABCDEF ULNAR.n Ra dial
nerve
Ulna r 1. Book tes t → Adductor pollicis
nerve 2. Ca rd tes t Pa lma r interos s ei Wrist Cock up
3. (Dors a l) - Dors a l drop splint
Ega wa DR-Drop,radial.n
4. Froment Adductor pollicis
Media n 1. Nevin (Kiloh Claw
nerve Nevin) s ign ha nd

2. Os chners
cla s p tes t APE
MNOP 3. Pen tes t Median Ulnar
4. Pointing claw
index
claw
5. Ape thumb
6. Pope’s
benediction Mus cle tes ted - Pointing
ha nd Abductor Index
pollicis
(Claw)
Knuckle bender
PAD,DAB interossi-Unterossi= all by ulnar =Ulnar palsy
Lumbricals = ulnar(3,4)+ median(1,2)
Action-Flexion at MCP,extension at IP 285
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FRACTURES- FAQ

Patella fracture

Severely Scaphoid#
Undisplaced Displaced
comminuted
Glass holding
Tenderness in anatomical
Cylinder cast TBW Patellectomy snuff box

8
-TBW
Olecranon
fracture
Colles-Hand shake
Cast in ulnar deviation
Oblique view- and palmar flexion
Risk of AVN + Dorsal displacement
with radial deviation
Fracture neck femur C-D= Dinner fork
Short ER + = SER ious deformity
• Elderly pt , fall in bathroom
Age<65yrs Age> 65 yrs
Replacement• Now LL shortened and ER+
• Shenton’s line broken
No
within 3wks After 3 weeks OA+
osteoarthritis

CRIF with MRI to assess

cancellous femur head Hemiarthroplasty THR
screws vascular supply

If + If-

Osteotomy –
Bipolar prosthesis
McMurray or
(Hemiarthroplasty)
•Elderly pt, fall in
Pauwel
bathroom
Reconstruction
•Now LL shortened
op- Meyer’s and ER +
•Shenton’s line
broken

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HIP FAQ

Femur head Anterior

collapsed dislocation
AVN= perthes FABER
Abducted

More common
Posterior dislocation
FAD(iR)
-Limb shortening
SCFE= Klein line = + Trethowan sign Dashboard injury
Posteromedial Adducted

METABOLIC BONE DISORDERS

x:Bisphosph Cod fish vertebrae-
onates, osteoporosis
Teriparitide Dx-Dexa scan
+bone Bone mineral
formation, density
enosumab. Multiple myeloma-elderly,CRAB Salt and pepper
T score <-2.5SD
features (hypercalcemia,renal skull- PTH
Ca,p,ALP-all
failure,anemia,bone lesions Primary-ca ,p
normal
Alp normal,no new bone formation. Secondary-
Cold spots on bone scan. ca ,p

Picture frame vertebrae-pagets Rachitic rosary-Rickets,vitamin D

disease=Elderly with sensorineural deficiency-ca ,p
hearing loss with heart failure.
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Gout-great toe,1st MTP involvement
Rat bite bite erosions,martel sign.
Precipitated by alcohol/aspirin.

ARTHRITIS
Morning Charcot’s joint-
stiffness Diabetes +
+,anterior Dense
uveitis- debris,dislocation
inflammatory Relatively
Ankylosing asymptomatic.
spondylitis-
HLA B27
Bamboo spine
Dagger sign
Sacroiliac
fusion

Osteoarthritis-Degenerative,osteophytes+,asymmetric
RA factor/anti ccp involvement
Swan neck-DIP flexion,PIP extension Knee-medial affected first
Boutonnière-DIP extension,PIP flexion. 1st carpometacarpal joint,DIP
Text
Bouchards nodes-PIP
Heberdens nodes-DIP
BONE TUMORS POTTS SPINE FD

Fibrous dysplasia-
Gaint cell tumour-in gaint Aneurysmal 2 vertebrae
shepherd crook
(30-40 yrs),joint surface bone cyst- involvement-
femur=ground glass
=Epiphysis,soap bubble Metaphysis, potts spine
matrix.
appearance. unfused Most common-
Mccune albright
Unfused,young paradiscal,interv
syndrome-precocious
Fused,gaint ertebral disc.
puberty +cafe au
lait+polyostic fibrous
dysplasia.

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BONE TUMORS

Osteochondrom Osteoid
Simple bone cyst/ osteoma- Enchondroma-5 fingers
unicameral=fallen leaf sign a-exostosis
Night 1.Ollier’s-All enchondromas
Most common-proximal continue with
bone pain( prostagl 2.Mafucci syndrome-mix of
humerus. andins) enchondroma+Hemangiom
Cartilage cap+
Relieved by a
Ix-MRI
Malignant aspirin
change-T Rx-radio
cartilage frequency
cap>1.5/2cm. ablation.

CTEV
Plantar flexion,inversion,angle-Cite(kite)
Mx-<1 yr:cast,ponsetti POP
Order of correction-CAVE(Adduction,varus,eqinus)
>10 yrs-Triple arthrodesis.
Over correction-rocker bottom feet

Dennis brown splint-CTEV

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NAMED FRACTURES

Monteggia #-
Galeazzi #-distal proximal radioulnar
Isolated ulna# without Boxer’s #-5th
radioulnar joint joint dislocation.
displacement-nightstick # metacarpal
dislocation

Thumb Rolando #-
Smith #- base#- comminuted #
Colles #-extraarticular extraarticular,volar Intra articular #-Bennetts #
with dorsal Garden spade Bartons #
displacement. deformity.

Bohlers #
Talus#-Aviator #,risk of Calcaneal #- Behind
AVN(Hawkin sign) Lover # •Below
Jump from height causes this #

Jefferson #-C1 (atlas#)

#Lower cervical
Text
spine(C7-11)
Clay shovellers # Straddle #-
Hangman’s #-#C2 pedicel Spinous process Bilateral,superior,inferior
of lower cervical pubic rami #
Text
vertebrae One side
anterior+posterio- 290
malgaigne#
 INDEX
S.NO TOPIC SUBJECT PAGE NO

1 APOCRINE GLANDS VS ECCRINE GLANDS ANATOMY 193

2 EYES AND EARS ANATOMY 193

3 HYOID DEVELOPMENT ANATOMY 193

4 ROTATOT CUFF MSCLES ANATOMY 194

5 SUPERIOR ORBITAL FISSURE ANATOMY 194

6 THE BRAINSTEM ANATOMY 195

7 ULNAR NERVE ANATOMY 195

8 BRANCHES OF AXILLARY ARTERY ANATOMY 196

9 4 TYPES OF PELVIS ANATOMY 196

10 DNA REPLICATION BIOCHEMISTRY 197

11 GLYCOGEN STORAGE DISEASES BIOCHEMISTRY 198

12 INSULIN BIOCHEMISTRY 198

13 LYMPHOMA PATHOLOGY 199

14 STOP CODONS BIOCHEMISTRY 199

15 ANTI ARRHYTHMICS PHARMACOLOGY 200

16 POTENCY VS EFFICACY PHARMACOLOGY 200

17 AUTOPSY FMT 201

18 BLOOD STAIN TESTS FMT 202

19 IPC 376 FMT 202

20 SLEEP FMT 203

21 LEAD POISONING FMT 204

22 ARSENIC POISONING FMT 204

23 PQLI VS HDI PSM 205

24 TYPE 1 VS TYPE 2 (REPEATED) PSM 206

25 AUDITORY PATHWAY ENT 207

26 COIN IN THE THROAT ENT 207

27 NASAL CAVITY ENT 208

28 PARANASAL SINUS VIEWS ENT 208

29 FUNDUS FLUORESCEIN ANGIOGRAPHY OPHTHALMOLOGY 209

30 FUNDUS IMAGE OPHTHALMOLOGY 210

31 SIGNS OF KERATOCONUS OPHTHALMOLOGY 210

32 ACID BASE DISORDER MEDICINE 211

33 CARDIAC AUSCULTATION & MURMURS MEDICINE 212

34 DEEP TENDON REFLEXES MEDICINE 212

35 UMN VS LMN LESIONS MEDICINE 213

36 CEAP SURGERY 214

37 URINE CRYSTALS SURGERY 215

38 BISHOP SCORE OBGY 216

39 TWINS SIGN OBGY 216

40 CYANOTIC CHD PEDS 217

41 TETRALOGY OF FALLOT PEDS 218

42 TRISOMY PEDS 218

43 MICRO ABSCESSES SKIN 219

44 MAPLESON CIRCUIT ANESTHESIA 219

45 ALCOHOL INTOXICATION PSYCHIATRY 220

46 COCAIN ABUSE PSYCHIATRY 221

47 LIVE & PANCREAS RADIOLOGY 221

48 GUSTILO ANDERSON ORTHOPEDICS 221

49 LOVER'S FRACTURE ORTHOPEDICS 222

50 SALTER HARRIS ORTHOPEDICS 223

51 TENNIS ELBOW ORTHOPEDICS 224

52 UNHAPPY TRIAD ORTHOPEDICS 224

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