Friday, May 18, 2012


In constrictive pericarditis and tamponade, catheterisation shows the same diastolic pressure in all 4 chambers!

Reye syndrome

Encephalopathy following an acute viral illness  in a child due to aspirin use

high level of ammonia

liver biopsy shows fatty changes

No treatment. supportive care: correct hypoglycemia, anti emetics, electrolytes etc

Rash involving hands and feet

Most rashes don't involve hands and feet. If an acute illness with rash involves hands and feet, think of
  • Syphilis (secondary)
  • Rocky mountain spotted fever (centrifugal rash)
  • Coxsackie virus (hand, foot and mouth disease)


Pronator drift is a sign of upper motor neurone lesion

Patient is asked to hold out both arms at shoulder level, fully extended with forearms supine, and hold the position.

If the patient is unable to hold the position and the forearm pronates, then pronator drift is positive and the patient most likely has a contralateral pyramidal tract (UMN) lesion.

Closing the eyes accentuates it.

School phobia

School phobia is a seperation anxiety disorder.

It must be present for at least 4 weeks

Order of changes at Puberty

At puberty, it's time to TAG along!
Thelarche - breast development (usually the first sign of Gonardache -onset of true central puberty)
Adrenarche: axillary hair and Pubarche- pubic hair (Adrenarche:can preceed true puberty)
Growth acceleration
Then Menarche

Testicular growth (due to gonardache)
Adrenarche : axillary and pubic hair
Growth acceleration
Then Spermache


If u see migratory thrombophlebitis, look for visceral malignancies.


FeNa> 2% = intrinsic renal disease i.e acute tubular necrosis or acute interstititial nephritis

In prerenal azotemia e.g due to dehydration, FeNa is <1%, urine sodium is <20mEq/L, urine osmolality> 500mEq/L
Kidney reabsorbs Na and water to compensate for the hypovolaemia or hypotension.

Pneumococcal vaccine indications for adults

age >65yrs

Chronic diseases (hrt disease, lung disease, DM, cochlear implants, CSF leak, SCD, alcoholism)

Immunosuppressive diseases (HIV/AIDS, MM, Lymphomas,Leukemias, Chronic renal failure, organ transplant, nephrotic syndrome etc)

Immunosuppressive therapy (long term steroids, chemotherapy, radiotherapy)



Nursing home residents

Splenectomized individuals


Tetralogy of Fallot
Pulmonary stenosis+ VSD+overriding aorta+RVH

Cyanotic congenital heart disease (The 5 Ts. others are TGA, Truncus arteriosus, Total anomalous pulm venous return, Tricuspid atresia)

Right to left shunt leads to mixing

May not be cyanotic at birth

Difficulty feeding, polycythaemia, finger clubbing, dyspnoea, FTT, murmur

Tet spells
sudden, marked increase in cyanosis followed by syncope ,often precipitated by crying, feeding or exercise , may also occur on waking up.
It is due to an increase in rt to left shunting of unoxygenated blood following a decrease in systemic vascular resistance or increased pulmonary vascular resistance, favouring the "right to left to aorta shunt"
It can be relieved by squatting or placing child in knee chest position (This increases afterload thus allowing more blood to go thru pulmonary circulation rather than systemic)

Chest x ray shows boot shaped heart and decreased pulmonary vascular markings.

Tangier disease

Tangerines in the throat!

Aut recessive, rare

Deficiency of ABCA1 transporter needed to transport cholesterol out of cells

Low serum cholesterol, No cholesterol to pick up leading to low HDL

cholesterol accumulation in cells and tissues

Enlarged, yellow or orange tonsils, premature artherosclerosis, hepatosplenomegaly, corneal clouding

Thursday, May 17, 2012


Both are microangiopathic hemolytic anemias
Both present with
  1. Thrombocytopenia
  2. hemolytic anemia (low hct, schistocytes, unconjugated hyperbilirubinemia, high LDH etc)
  3. Acute renal insufficiency (high BUN)
  4. Fever
  5. Altered mental status
To differentiate however,

Altered mental status is more prominent in TTP
Acute anuric renal failure is more prominent in HUS

less specific is that HUS more in children while TTP more in adults

Wednesday, May 16, 2012

Colles fracture

Fall on outstretched hand,

Fracture of distal radius and ulna, dorsal angulation= dinnerfork deformity

Tmt: closed reduction and long arm cast involving wrist and elbow works well

de Quervain tenosynovitis

Tendons involved can be remembered by ALEB (ALL Exclusively Breastfeeding mothers!)

Abductor pollicis Longus and Extensor policis Brevis

Remember, it occurs commonly in new mothers due to the awkward way they support the baby's head with their hand e.g during breastfeeding. It can also be occupational (washer woman, carpenters, musicians, office workers)

The Finkelstein test is positive

© Cork Emergency Medicine 2013.

Bell's palsy

a post infectious demyelinating facial neuritis.

Associated infections include:

Herpes simplex
Varicella zoster
Lyme dx (Borrelia)

Selective Estrogen Receptor Modulators

Clomifene: @ hypothalamus: antagonist

Raloxifene:                              @breast :antagonist   @bone: agonist   @uterus: antagonist

Tamoxifene:                            @breast :antagonist   @bone: agonist   @uterus: agonist

Others include: femarelle, toremifene etc.

All reduce risk of breast cancer
All reduce risk of postmenopausal osteoporosis
Tamoxifene increases risk of endometrial cancer
SERMs increase risk of DVT

Clomifene used for treatment of infertility(anovulation)
Raloxifene used for treatment of Osteoporosis and breast cancer
Tamoxifene used for treatment of breast cancer

Tuesday, May 15, 2012

Dieulafoy lesion

Upper GI bleeding with no risk factors and normal endoscopy findings: suspect Dieulafoy lesion- a submucosal vessel that fails to divide into capillaries but bleeds intermittently and retracts under the mucosa during non bleeding periods.

Fanconi anemia

Autosomal recessive

Aplastic anemia



Short stature



upper limb anomalies
File:Fanconi's anemia 101.jpg
Cure is BM transplant

Glaucoma screening

 > 40yrs with risk factors: every year

>40 but <60yrs, no risk factors: every 3-5 yrs

 >60yrs , no risk factors: every 1-2 yrs

Risk factors for glaucoma include:
Black race
High IOP
Family history
Severe eye injury
Chronic corticosteroids

Treatment of Primary pulmonary hypertension

IV vasodilator  challenge (prostacyclin, NO, adenosine) in order to decide definitive treatment

Definitive treatment:
If responsive to vasodilator challenge, start Calcium channel blockers. Try for at least 3-6months, if no response use prostacyclin

If no response to vasodilator challenge, other modalities including Transplant depending on the NYHA classification

Anticoagulation for all patients (Warfarin)

Monday, May 14, 2012


Neonate turns blue when feeding, turns pink when crying = choanal atresia

may be part of the CHARGE Syndrome

Heart defects
Atresia of the choanae
Retardation (mental)
Genitourinary anomalies
Ear anomalies

suspect if you can't pass an intranasal catheter, confirm with  contrast CT.


Psychogenic non epileptic seizure
Triggered by emotional stress
Normal EEG
Normal prolactin level following episode unlike in neurogenic seizure in which prolactin is elevated within 20 minutes of seizure.
There may be side to side head movement, pelvic thrusting, eyes may be closed, no post ictal confusion or incontinence
Very easy to be taken as malingearing.
Tmt is psychotherapy +/- antidepressants. Do not use anticonvulsants.


Immune Thrombocytopenic Purpura:
Isolated thrombocytopenia, no hemolysis, normal red cell morphology
Tmt: first line is steroids

Thrombotic Thrombocytopenic purpura:
Microangiopathy due to narrowing of small vessels by thrombus
Thrombocytopenia, fragmented rbcs, schistocytes, neurological symptoms.
Tmt: plasmapheresis


Physiologic steatorrhoea can occur in neonates especially preterm neonates due to low amounts of bile acids.
Treatment is to replace long chain triglycerides in formular with medium chain trig (which do not require bile acids for digestion).

Do not confuse with CF which will show other features like meconium ileus, family history etc.


Patient with sudden onset cardiac decompensation with acute pulmonary edema should have an ECG done first before any medications, to rule out arrhythmia e.g atrial fibrillation which may require immediate synchronised cardioversion.

If no arrhythmia, then reduce preload with diuretics, nitrates and morphine.


For all left heart stenotic murmurs, reducing preload (e.g diuretics) prolongs devt of pulmonary congestion

For all left heart regurgitant murmurs, drug treatment is aimed at reducing afterload (vasodilators)

For mitral valve prolapse, drug treatment (if symptomatic), is aimed at increasing preload (propanolol)

For hypertrophic cardiomyopathy, increasing preload reduces the murmur( squatting increases VR, beta blockers and calcium channel blockers allow more ventricular filling)

note: Valsava manoeuvre increases afterload, reduces preload. It therefore increases intensity of murmur in aortic stenosis but reduces the intensity in HCM.


Elderly woman with new onset ascites, no Liver involvement: investigate for ovarian CA


14 days to go!

Still pushing through Kaplan qbank. Results not what I expected, I guess Kaplan's style of questions is quite different and I see I still haven't mastered a few details.

2nd round MTB going well, quite fast actually.

Need to work on paediatrics, still.

Let's do this!

Sunday, May 13, 2012


Bloody diarrhoea + leucocytosis post abdominal aortic aneurysm repair, think of ischemic colitis (desc and sigmoid)

Confirm with colonoscopy or flexible sigmoidoscopy

Do colonic resection + colostomy

Renal tubular acidosis

 common USMLE topic

Non anion gap metabolic acidosis

Type 1:
Distal RTA
Failure of H+ secretion by the α intercalated cells of distal tubes
There's hypokalaemia
Met. acidosis is severe, more alkaline urine >5.3
May be associated with urolithiasis , rickets

Type 2:
Proximal RTA.
e.g Fanconi syndrome (prox tubular cell dysfunction)
Failure of  HCO3 reabsorption from the urine by the proximal tubular cells
There's hypokalaemia. Also associated with rickets
Met acidosis is less severe because distal tubular function is normal. urine PH<5.3

Type 4:
No aldosterone (Addisson's disease,ACEIs,ARBs,DM nephropathy,Sickle cell nephropathy)
Na/K pump not responding to aldosterone (NSAID nephropathy,CKD,)
There's hyperkalaemia, hyponatremia, hyperchloraemia
urine PH<5.3. . Met. acidosis is mild


Fixed splitting of S2 = ASD