FMGE-RAPID REVISION

Part - 1
2
•B
• Most common cause of Right heart failure 

• Most common cause of acute corpulmonale 

• Most common cause of chronic corpulmonale 

Classification of Heart failure
Earliest manifestation of left heart failure
8
Earliest manifestation of right heart failure
Pattern of breathing in congestive heart failure
Name of the criteria for congestive heart failure
Which CXR is
suggestive of increased
Pulmonary venous
pressure ?
• A
• B
• C
• D
Cardiac biomarker for congestive heart
failure
Drug of choice for Acute left ventricular failure
 Treatment of Acute Heart Failure
Oxygen & Ventilatory Morphine Vasodilators Diuretics Ionotropic agents
support
Drugs for chronic heart failure
Preferred drug for HFrEF
• 24/M patient presented with h/o ataxia of gait with rhombergs sign
positive & dysmetria. He also c/o dyspnea on exeretion. Echo
showed EF of 30% with dilated chambers. What would be the
etiology?
A. Cerebellar ataxia
B. Freiderich ataxia
C. SACD
D. Selenium deficiency
•B
Most common toxin causing Dilated cardiomyopathy
What are the inflammatory causes of
DCMP?
What are the nutritional causes of DCMP?
What are the endocrine causes of DCMP?
What are the hematological causes of
DCMP?
What are the toxins that causes of DCMP?
What are the infiltrative causes of DCMP?
27
What is the criteria for cardiomegaly ?
Which of the following drugs is not given in dilated cardiomyopathy?
a. Beta blocker
b. Calcium channel blocker
c. Spironolactone
d. ACE inhibitors
Ans. (b) Calcium channel blockers
Indication of this device in DCMP with LBBB patients?

A. QRS duration > 110msec

B. QRS duration > 100msec
C. QRS duration > 150msec
D. QRS duration > 120msec
•C
Peripartum Cardiomyopathy

34
 Peripartum Cardiomyopathy

• Defined as:
• Features of dilated cardiomyopathy during the last month of pregnancy or
within 6 months of delivery

• Absence of a demonstrable cause for the cardiac failure

35
• Treatment

• Beta-blockers
• Treatment

• Beta-blockers have been administered judiciously to these patients, with

at least anecdotal success.

• Sotalol is acceptable for ventricular or atrial arrhythmias if other beta-

blockers are ineffective.

• Diuretics, hydralazine, and nitrates help treat the heart failure with
minimal risk to the fetus.
38
Stress cardiomyopathy, also called :-

apical ballooning syndrome,

broken heart syndrome,

tako-tsubo cardiomyopathy.

39
• Modified Mayo criteria for Takotsubo Cardiomyopathy
(T.C.M)/ Broken heart syndrome

• 1. Transient hypokinesia/ akinesia of Left ventricle

• 2. Absence of any coronary artery occlusion by a thrombus

• 3. ST segment elevation/T wave inversion or modest cardiac troponin

elevation

• 4. Absence of pheochromocytoma or myocarditis

• *Needs all four for diagnosis

40
Treatment
Treatment
• Immediate therapy is similar to any acute MI.

• Most patients receive aspirin, beta-blockers, and ACE inhibitors until

the LV fully recovers.

• Despite the presumed association with high catecholamines, the use of

ACE inhibitors or ARBs, but not beta-blockers has been associated
with improved long-term survival.
If cardiogenic shock

43
If cardiogenic shock

• Rx:If cardiogenic shock IABP

• Because causative agent is catecholamine excess  so NE, Dopamine

& Dobutamine should not be given.

• SCD can happen

44
HYPERTROPHIC CARDIOMYOPATHY
All are true regarding the specimen shown except:

a. Asymmetrical septal hypertrophy

b. Left ventricular outflow tract obstruction

c. Diamond-shaped cavity of left ventricle

d. Diastolic dysfunction
Ans. (c) Diamond-shaped cavity of left ventricle
Definition
Definition

• The definition has evolved over time; while it traditionally has

been defined by LV outflow obstruction due to septal hypertrophy,
now it is considered present any time that any LV wall is
measured at more than 1.5 cm thick on an echocardiogram.
50
51
Ace of Spades
•Mutations:-
•Mutations:-
• Greater than l00 mutations have been identified in at least 12 sarcomeric genes
with the
beta-myosin heavy chain being most frequently affected,
followed by myosin-binding protein C and
troponin T.

It is autosomal dominant with defect of beta myosin gene with defect on

chromosome 14.

These three genes account for 70% to 80% of all cases of HCM.
56
• Precordial auscultation:

57
• Precordial auscultation:
• normal or paradoxically split S2, S4,

• harsh systolic diamond-shaped murmur at LLSB or apex,

• enhanced by squat to standing or Valsalva (murmur secondary

to LVOT obstruction as compared to aortic stenosis);

• often with pan-systolic murmur due to mitral regurgitation.

58
2D echo

59
2D echo
• Also know,
• Best investigation in case of HOCM is 2-D Echocardiography which
demonstrates the characteristics systolic anterior motion of the
mitral valve.

60
61
62
Treatment

63
Treatment
• Medical agents: DOC is Propranolol as it will decrease heart rate and reduce
oxygen consumption.

• The comparative increase in duration of diastole will enhance the filling of the
heart with corresponding increase in cardiac output.

• Verapamil may also be used

64
65
 RESTRICTIVE
CARDIOMYOPATHY
• Restrictive cardiomyopathy - Definition

67
• Restrictive cardiomyopathy includes a group of heart
disorders in which the walls of the ventricles become
stiff, but not necessarily thickened and resist normal
filling during diastole.

• The heart cannot relax normally during diastole so it is

unable to fill properly.

• Usually with intact systolic function

• Rarest cardiomyopathy.

68
• What is the most common etiology causing RCMP ?

69
• The AL (light-chain) type is the most common, with cardiac
involvement in 50%.
• How does Fabrys disease causes RCMP ?

71
• How does Fabrys disease causes RCMP ?
• Fabrys disease - Fabry disease is a rare genetic disease a
deficiency of the enzyme alpha-galactosidase A (a-Gal A) that
causes a buildup of a type of fat called globotriaosylceramide .

• It is a type of lysosomal storage disorder.

• Neoplasm

72
What is the antibody in this condition causing Restrictive
cardiomyopathy ?
A. Anti Smith
B. Anti centromere
C. Anti topoisomerase
D. Anti ds DNA
•C
What is the adverse effect of the drug used for treatment in
the following condition causing RCMP?

A. Peptic ulcers

B. Weight loss

C. Distal muscle weakness

D. Dementia
•A

• The following are causes of Bilateral hilar Lymphadenopathy :-

• Sarcoidosis
• Infection
• Tuberculosis
• Fungal infection
• Mycoplasma
• Intestinal Lipodystrophy (Whipple's disease)

• Malignancy
• Lymphoma
• Carcinoma
• Mediastinal tumors

• Inorganic dust disease

• Silicosis
• Berylliosis
Thromboembolic complications

77
Thromboembolic complications
• As many as one-third of patients with idiopathic RCM may present
with thromboembolic complications, especially pulmonary emboli
secondary to blood clots in the legs.

• If atrial fibrillation is present, a high risk of left atrial clots and

systemic emboli is present.

78
• On Examination – JVP:-

79
• On Examination – JVP:-
• The increased venous pressure is reflected in increased jugular venous
pulse.

• The degree of elevation of the jugular venous pressure indicates the

severity of impaired filling of the right ventricle.

• Rapid x and y descents are seen with rapid ‘Y’ descent being the most
prominent finding.

• Kussmaul's sign.

80
ECG:-
ECG:-
• low voltage, conduction disturbances, Q waves.
• Echocardiogram :-
• The echocardiogram reveals a small, thickened LV with bright
myocardium (speckled),

• rapid early diastolic filling revealed by the mitral inflow Doppler, and
biatrial enlargement.

• The LV chamber size is usually normal with a reduced LVEF.

• Atrial septal thickening may be evident.

Treatment
• Diuretics
Treatment
• In acute cases, diuretics can help, but excessive diuresis can produce worsening
kidney dysfunction.

• As with most patients with severe right heart failure, loop diuretics, thiazides, and
aldosterone antagonists are all useful.
Anticoagulation
Anticoagulation
• Atrial thrombi are not uncommon, although the role of anticoagulation
in amyloidosis remains ill defined.
• Can we use Digoxin in RCMP ?
• Digoxin in RCMP may precipitate arrhythmias and should not be used.
• Q) Which is the location of Erb's point during auscultation?

a. A = 2nd intercostal space right parasternal line

b. B = 2nd intercostal space left parasternal line

c. C = 3rd intercostal space left parasternal line

d. D = 5th intercostal space left parasternal line

91
92
• Aortic area —* Second intercostal
space to the right ofthe sternum
(along right upper sternal border).
• Pulmonic area — Second
intercostal space to the left of the
sternum (along left upper sternal
border)
• Erb'spoint — Third intercostal to
the left of the sternum (along left
sternal border).
• Tricuspid area —p Fourth or Fifth
intercostal space to the left of the
sternum (along left lower sternal
border).
• Mitral area (Apex) — Fifth
intercostal space on the left
midclavicular line.

93
S1 S2 S3
S4
Comparison of all Heart Sounds

Feature 1st Heart Sound 2nd Heart Sound 3rd Heart Sound 4th Heart Sound

Character

Duration

Frequency

Cause

Timings

Better heard
with
96
97
Wide Physiological Splitting of S2
Early A2 Delayed P2
Causes of Fixed (wide) split s2 are all
except?
A. ASD
B. VSD
C. Pulmonic Stenosis
D. Acute Right Heart Failure

99
•B
101
• Ans. is 'a' i.e., 3rd left intercostal space

• Best areas to auscultate for both components of the second heart

sound (A2 and P2) are either the left sternal border at the level of
second intercostal space (Pulmonic area) or the left sternal border
at the level of third intercostal space (Erb 'spoint).
3rd Heart sound are best heard with ?
•A
•B
•C
•D
•A
3rd Heart sound is best heard at ?
i. A
ii. P
iii. E
iv. T
v. M
•V
Physiological S3 is heard in all except ?
A. Age upto 40yrs
B. Children
C. Pregnancy
D. Sumo fighters
•D
Pathologic S3:
Pathologic S3:

1) Ventricular dysfunction - poor systolic function, increased end-

diastolic and end-systolic volume, decreased ejection fraction, and
high filling pressures.
• Idiopathic dilated cardiomyopathy
• Ischemic heart disease
• Valvular heart disease
• Congenital heart disease
• Systemic and pulmonary hypertension
Fourth heart sound

111
Fourth heart sound
• S4 is low pitched', presystolic sound, produced in ventricle
during 2nd rapid filling phase caused due to atrial
contraction.

• S4 is never present in normal individuals.

• Presence of S4 is always pathological.

• Loudest (Best heard) at the Left ventricular Apex when the

patient is in left Lateral position.

• It is accentuated by mild isotonic or isometric exercise in the

supine position 112
Causes of Fourth Heart Sound (S4 gallop)
• Mnemonic: HOCM

• 1. HOCM/HTN
• 2. Obstruction other than HOCM
• • Aortic stenosis
• • Pulmonary stenosis
• 3. Cardiac tamponade
• 4. Myocardial infarction

113
114
115
• The Jugular venous pulse (JVP) reflects phasic pressure changes in the
right atrium and it consists of three positive waves and two negative
troughs.

116
Wave Form Phase of Cardiac cycle Mechanical event

A wave

C wave

X wave

V wave

Y wave
118
Abnormalities of A wave
Abnormalities of X wave

120
• ABNORMALITIES OF THE V WAVE

• V wave is increased in -

121
Abnormalities of Y wave

122
123
Kussumal Sign Kussumal
respiration
Arterial Pulse
• Pulsus paradoxus:-

• Pulsus alternans:-

• Pulsus parvus ET tardus:-

• Pulsus bigeminus:-
Arterial Pulse
• Waterhammer pulse

• Dicrotic Pulse:-

• Pulsus bisferiens:-
 • A. Aortic regurgitation
Which condition following • B. ASD
murmur is seen? • C. Transposition of great arteries
• D. Branch pulmonary artery stenosis
Continuous murmur
129
 A. ASD
CONDITIONS? B. VSD
C. PDA
D. RSOV
•B
 A. MVPS
CONDITIONS? B. Venous hum
C. Coarctation Aorta
D. Aorto pulmonary window
•A
CONDITIONS all except ?
A. AS
B. PS
C. HOCM
D. TS
•D
Q) Early diastolic murmur is seen in:
a. VSD
b. ASD
c. Mitral stenosis
d. AR

136
•D
• Carey Coombs murmur -

• Austin Flint murmur -

• Graham-Steel murmur -

• Rytands murmur -

• Docks murmur -

• Mill wheel murmur -

• Gibsons murmur -
138
• Carey Coombs murmur -Rheumatic fever

• Austin Flint murmur -Aortic regurgitation

• Graham-Steel murmur -Pulmonary regurgitation

• Rytands murmur -Complete heart block

• Docks murmur -Left Anterior Descending (LAD) artery stenosis

• Mill wheel murmur -Due to air emboli (air in PV cavity)

139
Mitral Stenosis
Q) Area of mitral orifice in adults is:
A. 6-8 cm2
B. 0.5-2 cm2
C. 4-6 cm2
D. 1-4 cm2

141
Etiology of Mitral stenosis

143
• S1______________________S2__________________________S1
Complications of MS
Complications of MS
• Atrial fibrillation

• Dysphagia

• Wheeze

• Ortners syndrome
•A
148
2D echo

150
In symptomatic patients
• In symptomatic patients, some improvement usually occurs with
restriction of sodium intake and small doses of oral diuretics.
Which procedure is being done in the image shown?

a. Percutaneous mitral balloon valvotomy

b. Percutaneous mitral valvuloplasty
c. Percutaneous mitral valve repair
d. Percutanous coronary intervention
Ans. (a) Percutaneous mitral balloon valvotomy
Mitral Regurgitation

154
156
Dynamic Auscultation in MVP

157
2D-Echo

158
Indications for MVR
160
162
• Aortic regurgitation results from two major mechanism:-

• By causing valvular deformities

• By deforming the Aortic root

163
164
Treatment-AR
• Vasodilators such as an ACE, ARB, or Aldosterone antagonists are the
standard of care.

• Perform surgery when the

• ejection fraction is <55% or
• left ventricular systolic diameter is >55 mm.

166
PERICARDIAL DISEASES
• Acute Pericarditis
• Etiology of Pericarditis/Pericardial Effusion

168
• Acute Pericarditis
• Etiology of Pericarditis/Pericardial Effusion
• 1 . Idiopathic is most common: Usually presumed to be viral.

• 2. Infectious
• • Viral: Coxsackie virus A, B (most common), echovirus

169
Signs and Symptoms
• Diagnostic triad:

170
Signs and Symptoms

• Diagnostic triad: Chest pain, friction rub, and ECG changes

• Pleuritic chest pain: Alleviated by sitting up and leaning forward

• Pericardial friction rub - may be uni-, bi- or triphasic

• ± Fever, malaise.

171
PERICARDITIS ECG

172
• Treatment
• Treat the underlying disease

• Anti-inflammatory agents

173
• Treatment
• Treat the underlying disease

• Anti-inflammatory agents (high dose NSAIDs/ ASA, steroids if severe or

recurrent); analgesics

174
CONSTRICTIVE
PERICARDITIS
• Definition:-

176
• Definition:-
• Constrive pericarditis is a condition in which the pericardium
becomes thickened scarred and often calcified.

• This leads to increase in pericardial pressure which limits

diastolic filling of the ventricles.

• Though this condition is quite similar to cardiac tamponade,

there are certain, characteristic differences.

177
Most common cause of Constrictive pericarditis

179
Most common cause of Constrictive pericarditis

• C.P is the sequelae of Pyopericardium

• TB pericarditis

180
d) Takotsubo cardiomyopathy

181
182
Broad Bent's sign

183
Broad Bent's sign

• The apical pulse is reduced and retracts in systole (tapping apex).

(Broad Bent's sign).

184
Ans. is 'c' i.e., Ejection click [Ref: Harrison 18th/e p. 1826,1827&
17/e p. 1385, 1386]

185
188
• Cardiac CT and MRI :-
• Cardiac CT and MRI—These imaging
tests are only occasionally helpful.

• Pericardial thickening of more than 4

mm must be present to establish the
diagnosis, but no pericardial thickening
is demonstrable in 20–25% of patients
with constrictive pericarditis.

• Some MRI techniques demonstrate the

septal bounce and can provide further
evidence for ventricular interaction.
• Treatment
• Medical:

• Surgical:

191
• Treatment
• Medical: Diuretics, salt restriction

• Surgical: Pericardiectomy (only if refractory to medical therapy)

192
HYPERTENSION
Types of Hypertension
195
Most common cause of Secondary hypertension is?

• a. Renovascular disease
• b. Pheochromocytoma
• c. Renal parenchymal disease
• d. Hyperthyroidism
•C
• Common causes of isolated systolic hypertension are:

198
• Common causes of isolated systolic hypertension are:
• Atherosclerosis
• Aortic regurgitation
• Patent ductus arteriosus
• Thyrotoxicosis
• Coarctation of aorta

199
Unequal BP between Left & Right arm:-
•T

•C

•S

•A

•O
201
202
Choice of antihypertensive agent based on demographic considerations
205
Infective Endocarditis
Definition

209
 Definition

• It is the colonisation of the heart valves with

microbiologic organisms, leading to the formation of
friable, infected vegetations and frequently valve
injury.

210
Q) Which of the following have most friable vegetation:

• A. Infective endocarditis
• B. Libman Sack's endocarditis
• C. Rheumatic heart disease
• D. SLE

211
Friability of Vegetations

212
Friability of Vegetations

213
214
•C
Prosthetic valve endocarditis:

216
4. Prosthetic valve endocarditis:

• This may be early (symptoms appearing within 60 days of valve

insertion), due to intraoperative infection of the valve or insertion of
an infected valve or late (symptoms appearing after 60 days of valve
insertion), due to late bacteraemia or earlier infection with
microorganisms having a long incubation period.

217
< 2months 2-12 months >12months
219
Austrian syndrome or Osler's triad represents an association of

220
Austrian syndrome or Osler's triad represents an association of

1. pneumonia,
2. meningitis and
3. infective endocarditis(Pneumococcal).

221
222
223
224
Splinter hemorrhages appearing as red lineal streaks under the nail plate and within
the nail bed, in endocarditis, psoriasis, and trauma.
Osler node causing pain within the pulp of the big toe and multiple painless flat
Janeway lesions over the sole of the foot.
227
228
229
• DUKE CRITERIA for IE
• DUKE STAGE for Ca. Rectum
• DUKE SCORE for Chronic stable angina

231
Treatment

232
Treatment

• Empiric regimens for endocarditis while culture results are

pending should include agents active against staphylococci,
streptococci, and enterococci.

• Vancomycin 1 g every 12 hours intravenously plus

ceftriaxone 2 g every 24 hours provides appropriate
coverage pending definitive diagnosis; consultation with an
infectious disease expert is strongly recommended when
initiating treatment.

233
Acromegaly
235
236
237
• Cause of death
• Diagnosis :-

• The best initial test is:-

• Confirmatory test :-

239
• Radiographs may also show tufting of the terminal phalanges of the fingers and toes.
• (Isolated spade Phalanx).
A lateral view of the foot shows increased thickness of the heel pad.
 
(Normal persons these ranged from 13 to 21 mm.)
• Management:-

• Transsphenoidal surgery provides a rapid response.

• Hypopituitarism can result in 10–20%.

• Primary treatment is surgery.

• Medical management:-

242
• A patient was prescribed bromocriptine for prolactinoma, and
responded to her symptoms. What is it's mechanism of action?
a. D2 receptor partial agonist
b. Increases prolactin levels
c. Normalizes serum prolactin levels
d. D2 receptor antagonist
Ans. (c) Normalizes serum prolactin levels
PITUITARY
• Which of the following is the most common type of pituitary adenoma?
• a) Thyrotropinoma
• b) Gonadotropinoma
• c) Prolactinoma
• d) Corticotropinoma

246
• Ramkali Bai, a 35 year old female presented with one year history of
menstrual irregularity and galactorrhoea. She also had off and on
headache her examination revealed bitemporal superior quadrantopia.
Her fundus examination showed primary optic atrophy. Which of the
following is most likely diagnosis in this case
• a) Craniopharyngioma
• b) Pituitary macroadenoma
• c) Ophthalamic IcA Aneurysm
• d) Chiasmal Glioma

247
Microadenoma
Macroadenoma
250
• Investigation of choice of hypeprolactinemia-
• a) TRH estimation
• b) LH estimation
• c) Prolactin estimation
• d) Estradiol estimation

251
252
253
Hypopituitarism

254
• Definition :- Hypopituitarism is partial or complete loss of anterior
function that may result from any lesion that destroys the pituitary or
hypothalamus or that interferes with the delivery of releasing and
inhibiting factors to the anterior hypothalamus.

• GH and gonadotropins (FSH, LH) are typically lost early.

• Etiology:-

256
• Etiology:-
• Pituitary adenomas are the most common cause of
panhypopituitarism.

257
• Management. Management of hypopituitarism involves treating the underlying
causes.

258
• Management. Management of hypopituitarism involves treating the underlying
causes.

• Multiple hormones must be replaced, but the most important is cortisol

replacement.

259
DIABETES INSIPIDUS
 Diabetes insipidus

• Diabetes insipidus (DI) is a syndrome characterized by the

excretion of abnormally large volumes of dilute urine.

• The 24-h urine volume exceeds 40-50 mL/kg body

weight, and the

• 24-h urine osmolarity is <280 mosm/L.

261
• Choose the best Lab value for a patient with central diabetes insipidus -
• Urinary Osmolality & Serum Osmolality
• a) 50 - 300
• b) 500 - 260
• c) 50 - 260
• d) 500 – 100

262
•A
Wolfram syndrome
Wolfram syndrome
• Mutations of the WFS1 gene responsible for Wolfram’s syndrome.

• Wolfram syndrome, also called DIDMOAD (diabetes insipidus, diabetes

mellitus, optic atrophy, and deafness), is a rare autosomal-recessive
genetic disorder that causes childhood-onset diabetes mellitus, optic atrophy,
and deafness as well as various other possible disorders.
Investigation of Choice
 A 33 year old lady presents with polydipsia and polyuria. Her symptoms
started soon after a road traffic accident 6 months ago. The blood
pressure is 120/80 mm Hg with no postural drop. The daily urinary
output is 6-8 liters. Investigation showed, Na 130 mEq/L, K.3.5 mEq/L,
urea 15mg/dL, sugar- 65 mg/dL. The plasma osmolality is 268 mosmol/L
and urine osmolatity 45 mosmol/L. The most likely diagnosis is –

• a) Central diabetes insipidus

• b) Nephrogenic diabetes insipidus
• c) Resolving acute tubular necrosis
• d) Psychogenic polydipsia

267
Q) Which of the following agents is the drug of choice for CentralDiabetes Insipidus -
a) Desmopressin
b) Demeclocycline
c) Thiazide Diuretics
d) Lithium

268
DOC of Nephrogenic DI
SIADH is associated with -
a) Small cell carcinoma lung
b) Adeno cercinoma lung
c) Squamous cell carcinoma lung
d) Mixed cell tumor lung

270
•A
• Small cell Ca of lung causes SIADH due to ectopic secretion of ADH.

• SIADH  Small cell lung Ca

Head & Neck cancer
• All are true regarding SIADH, except -
• a) Increased level of ADH
• b) Urine hypo osmolar
• c) Hyponatremia
• d) Adequate hydration status

272
Clinical features of SIADH
Investigations
• SIADH true is all except -
• a) Serum Na can be less than 135 meq/1
• b) Urine sodium is normal or slightly low
• c) Vaptans are new FDA approved drugs for its Rx
• d) Water loading test can be used

275
• Lady with central obesity & abd. Skin showing purple striae
a) Conn’s syndrome
b) Cushing’s syndrome
c) Addison’s disease
d) Hypothyroidism

276
Q) The most common cause of Cushing’s syndrome is-
a) Pituitary adenoma
b) Adrenal adenoma
c) Ectopic ACTH
d) Adrenal carcinoma

277
• Most common cause of Cushing syndrome –

• Most common cause of non Iatrogenic cushing’s –

• Most common cause of Acth dependent type of cushing‘s –

• Most common cause of ectopic Acth – Cushings –

• Most common cause of Acth independent type of cushing‘s -

• Earliest manifestation of cushing‘s -
• Features not seen in Cushing’s Syndrome is-
• a) Hypoglycemia
• b) Hypertension
• c) Frank psychosis
• d) Hypokalemia

281
• What is the first line investigation in cushing‘s ?
Earliest biochemical change in Cushing syndrome
• Lalloo, 50 years old, a chronic smoker, presents with history of
hemoptysis. He was having truncal obesity and hypertension. He had
an elevated ACTH level which was not suppressible with high dose
dexamethasone. What would be the most probable diagnosis-

a) Bilateral adrenal hyperplasia

b) Adrenal adenoma
c) Pituitary tumour
d) Ectopic ACTH producing lung cancer

284
Q) Patient having Cushing syndrome due to adrenal tumor. Drug to be given -

a) Cortisol
b) Betamethasone
c) Ketoconazole
d) Fludrocortisones

285
286
Medical adrenelectomy – Ketaconazole,(oral and it is preferred) &
other MM

287
NELSON SYNDROME
NELSON SYNDROME
• In B/L Adrenal adenoma with mass effect  B/L adrenelectomy is done IV
hydrocortisone drip and Post op Hydrocortisone tablets
• Follow up ACTH incr. (due to static incr. in steroids) & there is
hyperpigmentation of palmar and creases of sole

• This is called as NELSON SYNDROME

CONNS SYNDROME

290
Testing for primary aldosteronism should be done for all
hypertensive patients except ?

• (A) sustained hypertension above 150/100 mm Hg on 3 different days;

• (B) hypertension resistant to three conventional antihypertensive drugs,

including a diuretic;

• (C) controlled blood pressure requiring four or more antihypertensive drugs;

• (D) Hyperkalemia, whether spontaneous or diuretic induced;

•D
• Most common cause of Conn's syndrome is -
• a) Adrenal hyperplasia
• b) Adrenal carcinoma
• c) Adrenal adenoma
• d) Pituitary ACTH hypersecretion

293
Etiology of primary hyperaldosteronism
• Most common cause of Conns syndrome :-

• Most common cause of primary hyperaldosteronism :-

294
PRIMARY HYPERALDOSTERONISM

295
NO EDEMA
Difference between primary and secondary
Hyperaldosteronism
• Laboratory anomalies :-

297
Confirmatory tests for PA:

298
What is the treatment of choice in Primary
hyperaldosteronism ?
What is the drug of choice in Primary hyperaldosteronism ?
Prior to testing for Hyperaldosteronism patient ideally
hold all medications except ?

A. Diuretics
B. ACE inhibitors
C. NSAIDs
D. Verapamil
•D
ADDISONS DISEASE
What is the difference between primary and secondary
adrenal cortical insufficiency ?
• Most common cause of adrenal insufficiency in India is-

• a) Autoimmune
• b) Surgery
• c) Steroid withdrawal
• d) Tuberculosis

305
• Most common cause of primary adrenocortical insufficiency in India:-

• Most common cause of primary adrenocortical insufficiency in west :-

What are the fungal infections which causes Addison's
disease ?
What are the Viral infections which causes Addison's
disease ?
What is Adrenomyeloleucodystrophy ?
What are the infiltrative disorders causing Addison's
disease ?
What are the malignancies causing Addison's disease ?
What are the causes of secondary adrenal cortical
insufficiency ?
313
Hyperpigmentation occurs in :

314
Hyperpigmentation occurs in :

• Palm/sole creases(first)
• Areola/Axilla/Cubital fossa
• Groin
• Oral mucosa
• Nails

315
316
Waterhouse Friderichsen syndrome:
• In addison's disease, most diagnostic test is –
a) Serum Na+, K+, renin
b) S. Na+, K+, saline suppression
c) Serum creatinine /urea ratio
d) ACTH stimulation test

318
ACTH stimulation test
• CT abdomen – Moth eaten Adrenal glan

320
Drug of choice for Primary adrenal cortical insufficiency ?

321
Drug of choice for Secondary & Tertiary adrenal cortical
insufficiency ?

322
PHEOCHROMOCYTOM
A
Q) Pheochromocytomas arise from-
a) Non endocrine cells of the adrenal cortex
b) Non endocrine cells of the adrenal medulla
c) Neuroendocrine cells of the adrenal cortex
d) Neuroendocrine cells of the adrenal medulla

324
• What is the MOST common extra-adrenal site of a pheochromocytoma?
• a) Renal hilum
• b) Mediastinum
• c) Urinary bladder
• d) Organ of zuckerkandl

325
• All are clinical features of pheochromocytoma, except-
• a) Increased hematocrit
• b) Orthostatic hypotension
• c) Low cortisol level
• d) Impaired glucose tolerance

326
• IOC for screening is 24hr U.fractionated metanephrins

• Normal VMA levels : Adults≤6.0 mg/24 h

Confirmatory test
For Localisation of Tumor
VMA is elevated in which of the following conditions?
a. Primary micronodular adrenal hyperplasia
b. Conn's Syndrome
c. Neuroblastoma
d. Tuberous Sclerosis
Ans. (c) Neuroblastoma
Vanillyl mandelic acid is a metabolic by-product of norepinephrine
and epinephrine.

It is used for detection of tumors of neural crest origin.

• 1. Neuroblastoma
• 2. Pheochromocytoma
• 3. Ganglioblastoma
• 4. Ganglioneuroma
• 5. Severe anxiety
• For diagnosis of pheochromocytoma, fractionated metanephrine level
in urine and stool are preferred.
TOC for Pheochromocytoma
Hyperparathyroidism
• The commonest cause of primary hyperparathyroidism is -
• a) Carcinoma parathyroid
• b) Solitary adenoma of parathyroid
• c) Chronic renal failure
• d) Hyperplasia of the parathyroid

336
337
2) Osteitis fibrosa cystica:
2) Osteitis fibrosa cystica:
• Healing in case of hyperparathyroidism occurs by fibrous tissue
replacement or sometimes the centre may liquefy and a bone cyst
remains.

• The cysts expand the cortex and the cortex becomes grossly thinned.

• Together with fibroid tissues in the bone marrow it gives the

appearance of osteitis fibrosa cystica.
• Deformities

340
• The Rugger Jersey spine refers to band like osteosclerosis of the
superior and inferior margin of the vertical body.

• Rugger Jersey Spine is characteristically seen in chronic renal failure

due to secondary hyperparathyroidism or Renal osteodystrophy.

341
342
• Deformities:
• Long bones bend under the stress of weight bearing.

• Intervertebral disk becomes ballooned as they indent soft

vertebral bodies forming the ‘Cod Fish spine.

• Pathological fractures:
• These fractures occur frequently.

• Marrow fibrosis:
• Replacement of marrow element causes anemia.

343
• Pinhead stippling:

344
345
• Absence of lamina dura:

346
347
• Pinhead stippling:
• The skull displays a diffuse osteoporosis described as pinhead stippling.

• Absence of lamina dura:

• Dental films reveal demineralisation of the mandible, disappearance of
the lamina dura and epulis tumours.

348
349
• What is the name of this scan and what is its
application ?

350
• 99mTc-sestamibi scan of a patient with primary
hyperparathyroidism secondary to a parathyroid
adenoma.
• A. After 1 hour, there is uptake in the thyroid gland (thick
arrow) and the enlarged left inferior parathyroid gland (thin
arrow).
• B. After 3 hours, uptake is evident only in the parathyroid 351
• Rx: Surgery (Treatment of choice)

352
• Rx: Surgery (Treatment of choice)

• 1st MM stabilisation done by NS  Dilution effect

• Furosemide  Ca+ loss in urine

• IV Ibandronate(DOC)

• Calcitonin nasal spray – Antagonist of PTH

353
HYPOPARATHYROIDISM
HYPOPARATHYROIDISM
• Causes :
• Autoimmunity
• Thyroid Sx – PTH resection
• Digeorge syndrome – Ch- 22 defect
• ( Thymus gland and PTH gland hypoplasia  CMI is reduced
resulting pneumonia & Rickets like illness)

355
Treatment
PSEUDO HYPOPTH

363
 PSEUDO HYPOPTH
• PTH – adequate Qt.
• PTH receptors are resistant  Due to defect in GNAS gene

• So there is HypoCa+2  Incr. in PTH

• C/F:
• Similar to Hypo PTH  AHO(Rickets like illness)
• Inv.: = Hypo PTH but PTH levels are incr.
• Rx – Ca+2 supplementation

364
Thyroid disorders
• Most common cause of hypothyroidism in India :-

• Most common cause of hypothyroidism Globally :-

Hashimoto's thyroiditis
• Type of cells which infiltrates the thyroid gland ?

• What are hurthle cells ?

What are the antibodies in hashimoto's thyroiditis ?
• Pathogenesis -
• Hashimoto’s thyroiditis is an autoimmune disorder
characterized by the presence of following IgG
antibodies-
1) Antithyroglobulin antibody.
2) Antimicrosomal antibody.
3) Antibody directed against a component of colloid.
4) Antibody against TSH receptors.
• These antibodies do not correlate with severity of
disease.
• They have a diagnostic value.
369
What are the drugs causing hypothyroidism ?
371
What is the most common cause of hyperthyroidism ?
What are the drugs causing hyperthyroidism ?
374
What is Dequervains thyroiditis ?
376
Q) The occurrence of hyperthyroidism following administration of
supplemental iodine to subjects with endemic iodine deficiency
goiter is known as -
• a) Jod-Basedow effect
• b) Wolff-Chaikoff effect
• c) Thyrotoxicosis factitia
• d) De Quervain’s thyroiditis

377
A patient with endemic iodine deficiency goitre ?
• What is this sign and in
which endocrine disorder
do you observe this ?

379
• Ophthalmopathy in Graves'
disease

• Lid retraction,
• Periorbital edema,
• Conjunctival injection, and proptosis
are marked.

380
• What is the dermatological abnormality
you're observing over the legs and in
which endocrine disorder do you see
this ?

381
• Thyroid dermopathy over
the lateral aspects
of the shins.

•  An infiltrative dermopathy,
resulting as a rare complication
of Graves' disease.

• Presents itself as a waxy,

discolored induration of the skin.

• Precedes ocular sign.

382
Beta carotenemia
• In which endocrine disorder
do you observe clubbing of
the fingers ?

384
• Thyroid acropachy
• Characterized by soft-tissue
swelling of the hands
and clubbing of the fingers. 

• Radiographic imaging of
affected extremities typically
demonstrates periostitis, most
commonly the metacarpal
bones.

385
• Lid retraction and
proptosis in a patient with
thyrotoxic Graves'
disease.

387
Large Multinodular Goitre

388
Myxoedema

389
What are the cardiac manifestations in thyroid disorders ?
What are the neurological manifestations in thyroid
disorders ?
Hung up reflex
• In retrosternal goiter - Pemberton sign
• That is on rising the arms there is facial congestion.
• Evaluated by CT/MRI

393
• Which can cause profound hyperlipidemia ?
• a) Hypoparathyroidism
• b) Hypothyroidism
• c) Hyperparathyroidism
• d) Hyperthyroidism

394
Thyroid storm
Myxedema coma
Radioactive uptake studies :-

397
• A pregnancy woman is diagnosed to suffering from graves’
disease. The most appropriate therapy for her would be

• a) Radioiodine therapy
• b) Total thyroidectomy
• c) Carbimazole parenteral
• d) Propylthiouracil oral

398
Treatment of Hyperthyroidism
• A 40 yrs old female who is known case of ischemic heart disease
(IHD) is diagnosed having hypothyroidism. Which of the
following would be most appropriate line of management for
her –
• a) Start levothyroxine at low dose
• b) Do not start levothyroxine
• c) Use levothyroxine
• d) Thyroid extract is a better option

400
A Patient with Hypothyroidism
DIABETES

402
Classification of DM
Which of the following endocrine disorders does not lead to DM ?

A. Pheochromocytoma
B. Somatostatinoma
C. Hypothyroidism
D. Acromegaly
•C
What is the use of this instrument ?

Monofilaments (Diabetes)
406
407
What is this sign and in which clinical
condition do you see this ?

408
409
Diabetic
Chieropathy
• Diabetic cheiroarthropathy,
also known as Diabetic stiff
hand syndrome or limited
joint mobility syndrome, is
a cutaneous condition
characterized by waxy,
thickened skin and limited
joint mobility of the hands
and fingers, leading to
flexion contractures.
What is this sign?

411
I n w hic h e ndo cr ine di s or der do yo u s ee th is ?

412
XANTHELASMA

413
• A xanthoma  is a deposition of yellowish cholesterol-rich material
that can appear anywhere in the body in various disease states.

• Types:-
• Xanthelasma
• Xanthoma tuberosum
• Xanthoma tendinosum
• Eruptive xanthoma
• Xanthoma planum
• Palmar xanthoma
• Tuberoeruptive xanthoma

414
• In which endocrine
disorder do you observe
this complication ?

415
Neuropathic foot ulcer
• Diabetic foot ulcer is a
major complication of diabetes
mellitus.

• Treatment :-
• Blood sugar control, removing dead
tissue from the wound, dressings, and
removing pressure from the wound
through techniques such as total
contact casting.Surgery in some cases
may improve outcomes.

• Hyperbaric oxygen therapy may also

help but is expensive 416
417
What is the name of this
dermatological sign and in which
endocrine disorder do you observe
this ?

418
Necrobiosis lipoidica diabeticorum

• Rash that occurs on the lower legs.

• It is more common in women, and

there are usually several spots.

• They are slightly raised shiny red-brown

patches.

• The centers are often yellowish and may

develop open sores that are slow to
heal.

419
Necrobiosis lipoidica diabeticorum

• Rash that occurs on the lower legs.

• It is more common in women, and

there are usually several spots.

• They are slightly raised shiny red-brown

patches.

• The centers are often yellowish and may

develop open sores that are slow to
heal.

420
• T2DM correlate with which fat reserve -
• a) Intraabdominal fat
• b) Lower body fat
• c) Subcutaneous fat
• d) Upper body fat

422
Risk factors for Type 2 diabetes mellitus
• A 29-years-old male taking oral hypoglycemic drug never had ketonuria
in his life. His BMI is 20.5. His grandfather had diabetes and his father
who is only son of his grandfather too had the disease. Which type of
DM this person will be most likely-

• a) Pancreatic
• b) MODY
• c) Type I
• d) Type II

424
•B
• Type 1.5 DM (LADA) :

426
• Type 1.5 DM (LADA) :
• Variant if T1DM
• Auto Ab’s  Present  Anti GAD Ab’s
• Anti islet cell Ab.
• Anti GAD Ab’s Also seen in paraneoplastic
manifestations of oat cell cancer = as stiff person
syndrome
• Causes damage to Beta cells
• Rx – Insulin  Mfg by DNA recombibnant tech.

• Pork/beef insulin causes  Lipodystrophy,Resistance

develops(due to Ab production)
427
Investigations:-
Normal Impaired DM

Fasting blood sugar

PPBS

HbA1C
• HbA1C – Retrospective test
• Doesn’t get effected by Exercise/Food

• HbA1C * 25 = Avg. blood glucose

• Target HbA1C < 7(good sugar control)

• >7% poor sugar control

429
• Microvascular compl directly proportional to HbA1C

• So to reduce Microvascular compl reduce HbA1C values.

430
• Early morning hyperglycemia with increased blood glucose of 3.00
AM suggests –
• a) Insufficient insulin
• b) Dawn phenomenon
• c) Somogyi effect
• d) None of the above

431
432
433
• Early morning hyperglycemia with increased blood
glucose at 3.00 AM typically suggests inadequate
night time insulin dose (insufficient insulin).

• - Dawn phenomenon also presents with early morning

hyperglycemia but blood glucose is typically stable
(normal) at 3.00 AM.

434
• An obese NIDDM patient present with FBS=180 mg% and PPBS=260 mg%
Management include-
• a) Glibenclamide
• b) Diet therapy+exercise
• c) Diet therapy+exercise+metformin
• d) Insulin
• e) Chlorpropamide

435
• Ans. is C i.e., Diet therapy +Exercise + Metformin

• The level of hyperglycemia decides the initial choice of therapy.

What is the first line management in Type 2 diabetes Mellitus ?
What is the drug of choice for type 2 diabetes mellitus?
• Most useful investigation in diagnosis of diabetic ketoacidosis -
• a) Ketonemia
• b) pH of blood
• c) Urinary sugar
• d) Urine ketone

439
Complications in Diabetes mellitus
Chronic complications
Diabetic ketoacidosis
• Triad :-

• Anion gap :-

• Respiration:-

• First line treatment:-

Hyperosmolar nonketotic coma:-
• Most common acute complication in :-

• ketone bodies :-

• First line treatment :-

Diabetic neuropathy
• Sensation lost 1st is ?

• Most common type of neuropathy :-

• Most common cranial nerve affected :-

• Drug of choice for Autonomic neuropathy :-

• A patient presents with symptoms of hypoglycemia.
Investigations reveal decreased blood glucose and increased
insulin levels. C-peptide assay is done which shows normal
levels of C-peptide. The most likely diagnosis is –

• a) Insulinoma
• b) Accidental sulfonylurea ingestion
• c) Accidental exogenous insulin administration
• d) Accidental metformin ingestion

445
446
447
448
MEN - 4
• Werners syndrome is asscociated with?
1) MEN 1
2) MEN 2a
3) MEN2b
4) NONE

450
• Werners syndrome is asscociated with?

1) MEN 1
2) MEN 2a
3) MEN2b
4) NONE

451
Carcinoid Tumors
• A carcinoid (also carcinoid tumor) is a slow-growing type of 
neuroendocrine tumor originating in the cells of the neuroendocrine system
.

• In some cases, metastasis may occur.

• Carcinoid tumors of the midgut (jejunum, ileum, appendix, and cecum) are

associated with carcinoid syndrome.
454
• Carcinoid tumors are associated with elevated levels of metabolites of
Tryptophan/ serotonin which include 5HIAA, 5HT and 5HTP.

• 5-hydroxytryptophan (5-HTP).
• (5-HT) 5-hydroxytryptamine 

455
• Carcinoid heart disease:
• Carcinoid heart disease: About 19% to 60% of the those
affected by carcinoid syndrome develop carcinoid heart
disease.

• Serotonin induces fibrosis in valves of the right heart especially 

tricuspid valve
Gastrointestinal Manifestation
Respiratory manifestations:-
460
 Imaging:-
• Octreoscan:-

• Gallium-68 labelled somatostatin analogues such as 68Ga-DOTA-Octreotate

(DOTATATE), performed on a PET/CT scanner is superior to conventional
Octreoscan.
 Imaging:-
• For localization of both primary lesions and metastasis, the initial imaging
method is Octreoscan, where indium-111 labelled somatostatin analogues (
octreotide) are used in scintigraphy for detecting tumors expressing 
somatostatin receptors.

• Gallium-68 labelled somatostatin analogues such as 68Ga-DOTA-Octreotate

(DOTATATE), performed on a PET/CT scanner is superior to conventional
Octreoscan.
Treatment
• For symptomatic relief of carcinoid syndrome:
Treatment
• For symptomatic relief of carcinoid syndrome:
• Octreotide (a somatostatin analogue which decreases the secretion of
serotonin by the tumor and, secondarily, decreases the breakdown product of
serotonin (5-HIAA).

• Telotristat ethyl (Xermelo) along with a somatostatin analogue in patients not

responding to somatostatin analogue monotherapy.

• It is a tryptophan hydroxylase inhibitor and reduces the production of

serotonin.

• Peptide receptor radionuclide therapy (PRRT) with lutetium-177, yttrium-90

 or indium-111 labeled to octreotate is highly effective.
Glucagonoma
Glucagonoma
• Glucagonoma is a very rare tumor of the pancreatic alpha cells that
results in the overproduction of the hormone, glucagon.

• Typically associated with a rash called necrolytic migratory erythema,

weight loss, and mild diabetes mellitus, most people with glucagonoma
contract it spontaneously.

• However, about 10% of cases are associated with 

multiple endocrine neoplasia type 1 (MEN-1) syndrome
• Blood glucagon concentration greater than 500 mg/mL along
with the glucagonoma syndrome.
Treatment
Treatment
• Heightened glucagon secretion can be treated with the
administration of octreotide, a somatostatin analog, which
inhibits the release of glucagon.

• Doxorubicin and streptozotocin have also been used

successfully to selectively damage alpha cells of the pancreatic
islets.