09/24/2017

High Yield Points for MCI Screening Test (FMGE)- INTERNAL MEDICINE

By Live Dr - Wed Feb 18, 7:01 am

The following seems to be the high yield areas from where most of the Qns usually come for MCI Screening test in Internal Medicne. It may be useful for the final preparation. Also when u study the subject, u may give more importance to these areas.

This may or not be right. Any correction or other high yeild topics that u find are, most welcome

01. Viral Hepatitis
02. Acid base balance – Disorders, SIADH
03. CA lung
04. Migraine/Temp Arteritis/Cluster Head Ache
05. Intracranial
06. Hyperparathyroidism
07. Cardiac Tamponade
08. CSF in meningitis
09. HOCM
10. Antiphosholipid antibody syndrome
11. Multiple myeloma
12. Coarctation of aorta
13. HSP
14. Psoriatic/Osteo/Rheumatoid Arthritis
15. Thymoma leading to Hypogammaglobulinaemia
16. MEN
17. Phaeochromocytoma
18. No infective endocarditis in ASD
19. Polycythaemia
20. Vit B12 deficiency
21) Leukemia
22) Malaria
23) BM transplantation
24) STDs
25) Rickettsial infections
26) Leptospirosis
27) Leukemia
28) Malabsorption syndrome
29) Buddchiari – 7
30) H pylori – 7
31) Osteoporosis – 7
32) ALP – 7
33) PAN – 6
34) SIADH – 6
35) Hem/Hep/Obstructive jaundice – 5
36) IgA nephropathy- 5
37) Bronchiectasis – 5
38) Rt Ventricular Infarction – 4
39) Sarcoidosis – 4
40) ECG in STEMI – 4
41) ARDS – 4
42) GBS – 4
43) Cushings syndrome – 4
44) Craniopharyngioma – 4
45) Pulm Embolism – 4
46) HSV Encephalitis – 4
47) InfEndocarditis involve Tricuspid – 4
48) Leucocyte Alkaline Phosphatase – 4
49) JVP – 4
50) Conns syndrome – 4

 

51) MVP – 4
52) Sickle cell Anaemia – 4
53) PSGN- 4
54) Scleoderma – 4
55) Legionnaires disease – 4
56) Hepatocellular CA- 6
57) Digitalis ==> Cardiac toxicity – 6
58) HUS – 6
59) ECG – QT interval – affected- 6
60) Wernickes encephalopathy/Delerium tremens – 5
61) Wilsons disease – 5
62) Zollinger Ellinson syndrome – 5
63) Hypercalcaemia – 5
64) Haematology section in Harrison
65) Entire pharmac topics in Harrison- On the back page of both volumes of Harrison u can see “Topical Contents” heading. In it the pharmacological topics are given.
66) Infectious diseases section- It will help with Microbio and PSM as well

 

01) Viral Hepatitis
Refer 16th edition Harrison Vol 2 page no 1845-1851

Clinical & Laboratory features of Chronic Hepatitis

Chronic Hepatitis B
*Diagnostic Test – HbsAg, IgG anti-HBc, HBeAg, HBV DNA
*Auto antibodies – Uncommon
*Therapy – IFN alpha, Lamivudine

Chronic Hepatitis C
*Diagnostic test – Anti HCV, HCV RNA
*Auto antibodies – Anti – LKM1
*Therapy – PEG IFN-alpha plus Ribavirine

Chronic Hepatitis D
*Diagnostic test – Anti HDV, HDV RNA, HBsAg, IgG anti-HBc
*Auto antibodies – Anti – LKM3
*Therapy – IFN alpha

Auto immune Hepatitis
*Diagnostic test – ANA (homogenous), antiLKM, hyperglobulinaemia
*Auto antibodies – ANA, Anti – LKM1, Anti – SLA
*Therapy – Prednisolone, Azathioprine

02) Acid base balance
Refer 16th edition Harrison Vol 1 page no 263-270

AG = Na – (Cl + HCO3) –Normal = 10-12 mmol/L

Causes of high Anion Gap Metabolic acidosis (Table 42.3)
• Lactic Acidosis
• Keto Acidosis – DM /starvation/alcoholic
• Toxins –Ethylene Glycol, Methanol, Salicylates
• Renal Failure(A/C & C/C)

Causes of Non anion Gap Acidosis (Table 42.4)
• Gastrointestinal bicarbonate loss – Diarrhea, External Pancreatic or small bowel drainage, Uretrosigmoidostomy ,Drugs – Calcium chloride, Magnesium sulphate,Colestyramine.
• Renal Acidosis – *Hypokalemia – a . Proximal(Type2)RTA b. Distal(Type1)RTA *Hyperkalemia – generalized distal nephron dysfunction(type4RTA)
• Drug induced Hyperkalemia – Potassium sparing diuretics, Trimethoprim, Pentamidine, ACE inhibitors, NSAIDs, Cyclosporine.
• Other – Acid loads, Loss of potential bicarbonate, Expansion acidosis, Hippurate, Cation exchange resins.

Treatment of severe Acidosis (Metabolic)
Severe acidosis (pH<7.20) warrants iv administration of 50-100meq of NaHCO3

Treatment of Lactic Acidosis
Then underlying condition that disrupts lactate metabolism must first be corrected: tissue perfusion must be restored when it is adequate.

AG in DKA
>17mmol/L accompanied with Hyperglycemia

 

03) CA lung
(Ref: 16th edition Harrison vol 1 page no 506-514)

Frequency of CA lung (Table 75-1)
• Adeno CA – 32%
• Squamous cell CA – 29%
• Small cell CA – 18%
• Unspecified – 11%
• Large cell CA – 9%
• Bronchoalveolar – 3%
• Carcinoid – 1%
• Muco epidermoid CA – 0.1%
• Sarcoma & other soft tissue tumors – 0.1%
• Adenoid Cystic CA – <0.1%

04) Head Ache- Migraine/Temp Arteritis/Cluster Head Ache
(Ref: 16th edition Harrison vol 1 page no 87-93)

Temporal arteritis
• Common disorder of the elderly i.e. 50yrs or older.
• Average age of onset 70yr
• 65% occurs in women.
• 50% untreated patients cam develop blindness
• Symptoms – Headache (50%pts site- temoporal) with malaise & muscle aches, Polymyalgia Rheumatica, Jaw claudication, Fever & Weight loss
• Pain usually appears gradually over a few hours before peak intensity is reached – Usually Dull & Boring with superimposed ice pick like lancinating pains.
• Scalp tenderness – present
• Head ache – worse at night & is often aggravated by exposure to cold
• ESR – is often, though not always: elevated

Tension Head Ache
• Chronic head pain syndrome characterized by a bilateral tight, band like discomfort.
• Pain typically builds up slowly, fluctuates in severity & may persist more or less continuously for many days.
• Exertion does not worsen the head ache.
• Episodic/Chronic headache
• Common in women
• Occurs in all age groups
• In some patients – anxiety or depression may co-exist with tension head ache.

Migarine
• Occurs in 15% women & 6% men
• Nausea, Photophobia, Light headedness, Scalp tenderness, Vomiting, Visual disturbances, Paraesthesias, Vertigo, Alteration of consciousness, Diarrhoea
• Activators – Red wine, Menses, Hunger, Lack of sleep, glare, Estrogen, Worry, Perfumes, Let-down periods)
• De-Activators – Sleep , pregnancy, Exhilaration, triptans.

 

Cluster Head ache
( Raeders syndrome, Histamine cephalagia , sphenopalatine neuralgia)
• Usually episodic
• Men affected 7-8 times often than women
• 1-3 short lived attacks of Periorbital pain per day over a 4 to 8 week period, followed by a pain free interval that averages 1 year
• Peri-orbital or less commonly,temporal pain begins without warning & reaches a crescendo within 5 min.
• Pain is usually excruciating in intensity and is deep non fluctuating and explosive in quality
• Pain is strictly unilateral & usually affects the same sides in subsequent months
• Attacks last from 30min to 2 hours
• Associated symptoms – Homolateral Lacrimation, Reddening of the eye, Nasal stuffiness, Lid ptosis & nausea
• Alcohol provokes attack in 70% patients
• Periodicity occurs in 85% patients
• Onset is nocturnal in 50% cases which awkens the patients within 2 hours of falling asleep.

05) Intracranial Haemorrhage
(Ref: 16th edition Harrison vol 2 page no 2387)

• MCC of SAH = Head trauma
• 2nd MCC of SAH = Saccular aneurysym
• Saccular Aneurysm rupture is preceded by a brief moment of excruciating head ache
• 45% cases severe head ache is associated with exertion.
• Most common type of intracranial hemorrhage = Intra parenchymal hemorrhage
• Hypertensive intra parenchymal hemorrhage usually results from spontaneous rupture of a small penetrating artery deep in the brain.
• Most common sites are Basal Ganglia, Deep cerebellum & Pons

06) Hyperparathyroidism
(Ref: 16th edition Harrison vol 2 page no 2252)

• Hypercalcaemia causes – Fatigue, depression, Mental confusion, Anorexia, Nausea, Vomiting, Constipation, Short QT interval
• Familial Hypocalciuric hypercalcaemia – occurs due to mutation affecting calcium sensing receptor.

 

07) Cardiac Tamponade
(Ref: 16th edition Harrison vol 2 page no 1415)

• Narrow pulse pressure
• Hypotension
• Elevation of JVP
• Prominent X descent & diminutive or absent Y descent
• Pulsus paradoxus
• Electrical Alternans

08) CSF in meningitis
(Ref: 16th edition Harrison vol 2 page no 2476-Table 360-1)

A/C Bacterial Meningitis
• Pressure >180mmH2O
• Cells – Neutophils
• Glucose <40mg/dL(<2.2mmol/L)
• CSF/serum glucose <0.4
• Protein >45mg/dL(>0.45g/L)

09) HOCM
(Ref: 16th edition Harrison vol 2 page no 1410)

• Asymmetric left ventricular hypertrophy often with preferential hypertrophy of the inter ventricular septum
• Dynamic left ventricular outflow tract pressure gradient
• SAM(Systolic Anterior Movement) of the Mitral valve

• Conditions aggravating murmur of HOCM ==>A)Which increase myocardial contractility- Exercise, Sympathomimetic amines, Digitalis Glycosides
==> B)Which reduce ventricular volume – Valsalva maneuver, Sudden standing, Nitroglycerin, Amyl nitrite, Tachycardia

? Conditions ameliorating the murmur ==> Phenylephrine, Squatting, Sustained hand
grip, passive leg raising
• Digitalis, Diuretics, Nitrates, vasodilators & Beta Adrenergic agonists are best Avoided if possible

11) Multiple myeloma
(Ref: 16th edition Harrison vol 1 page no 656)

• Classical triad of Myeloma – Plasmacytosis (>10%), Lytic bone lesions & Serum/Urine M component.
• MGUS – <10% Bone marrow plasma cells; <30g/L of M components, No urinary Bence jones proteins & No anemia, renal failure, lytic bone lesions or hyper calcaemia.

 

12) Coarctation of aorta
(Ref: 16th edition Harrison vol 2 page no 1387)

• Most common site is distal to the origin of left subclavian artery near the insertion of ligamentum arteriosum.
• It is twice as common in males
• More frequent in patients with gonadal dysgenesis
• C/F – Hypertension in upper extremities & absence, marked diminution or delayed pulsations in femoral arteries.
• A mid systolic murmur over the anterior part of the chest, back and spinous process may be heard which may become continuous if the lumen is narrowed sufficiently.
• Additional systolic & continuous murmurs over the lateral thoracic wall may reflect increased flow through dilated & tortuous collateral vessels.
• Roentgenograms show the “3” sign and Notching of ribs.
• Chief hazard – Severe hypertension.

13) HSP
(Ref: 16th edition Harrison vol 2 page no 2010)

• Also known as Anaphylactoid purpura
• Pathogenesis by immune complex deposition
• IgA is the antibody class most often seen in the immune complexes
• Diagnosis – skin biopsy specimen – IgA & C3 deposition in immunoflourescence

 

14) Psoriatic/Osteo/Rheumatoid Arthritis
(Ref: 16th edition Harrison vol 2 page no 1998/2036/1968)

PSORIATIC ARTHRITIS
• HLA-Cw6 is highly associated with psoriasis, particularly familial juvenile onset
(Type1) psoriasis
• HLA-B27 is highly associated with psoriatic spondylitis
• HLA-DR7, HLA-DQ3, HLA-B57 are also associated with psoriatic arthritis
• Frequency in Men & Women almost equal
• Disease can begin in childhood, but typically begins in fourth or fifth decade, at an average of 37years
• It can present as a) arthritis of the DIP joints b)asymmetric oligo arthritis c)symmetric polyarthritis similar to RA d)axial involvement(spine & sacro iliac joints) e)Arthritis mutilans

OSTEOARTHRITIS
* Interphalangeal joints – Heberden’s nodes(bony enlargement of the DIP joint) are most common form of Idiopathic osteoarthritis. Bouchards nodes – at the PIP joint.
* 2nd most frequent area is the thumb base

15) Thymoma leading to Hypogammaglobulinaemia
(Ref: 16th edition Harrison vol 2 page no 1946)

• The association of thymoma and hypogammaglobulinaemia usually occurs in late adult life.
• Bacterial infections and sever diarrhea reflect the antibody deficiency
• Fungal and viral infections are infrequent complications
• T cell numbers and CMI is usually intact
• Patients are deficient in circulating B lymphocytes and pre B cells in the bone marrow.

16) MEN
(Ref: 16th edition Harrison vol 2 page no 2231)

MEN1
• Parathyroid hyperplasia or adenoma
• Islet cell hyperplasia, adenoma or carcinoma
• Pituitary hyperplasia or adenoma
• Other less common manifestations – Foregut carcinoid, pheochromocytoma, s/c or visceral lipoma

MEN2 A
• Medullary Carcinoma thyroid
• Phaeochromocytoma
• Parathyroid hyperplasia or adenoma

MEN2 B
• Medullary Carcinoma thyroid
• Phaeochromocytoma
• Mucosal & GI neuroma
• Marfanoid features

 

17) Phaeochromocytoma
(Ref: 16th edition Harrison vol 2 page no 2148)

• In adults 80% are unilateral or solitary
• 10% bilateral
• 10% extra adrenal
• Out of the 10% extra adrenal tumors, icon_idea.gif 10% are in the thorax
• <10cm in diameter
• <100g in weight
• <10% are malignant
• Most common manifestation – Hypertension
• Associated with MEN2A&B

thank you

Rejaneesh

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