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3rd Term MBBS - General Medicine End Posting: High-Yield Topics

Cardiovascular System

• Rheumatic fever - Jones criteria (major/minor), pathogenesis, management
• Infective endocarditis - Duke criteria, organisms, complications, prophylaxis
• Hypertension - classification (JNC/WHO), complications, treatment stepladder
• Heart failure - types (systolic vs diastolic), NYHA classification, management (ACE-I, beta-blockers, diuretics)
• Ischemic heart disease / Angina - stable vs unstable, ECG changes, management
• Acute MI - STEMI vs NSTEMI, ECG changes, Killip classification, thrombolysis criteria
• Mitral stenosis - causes, clinical features, signs, complications

Respiratory System

• Pneumonia - community vs hospital acquired, organisms, CURB-65 score, treatment
• Pulmonary tuberculosis - primary vs post-primary, sputum findings, RNTCP regimens (Cat 1/2), DOTS
• Bronchial asthma - pathophysiology, severity classification, stepwise treatment, status asthmaticus
• COPD - GOLD classification, spirometry criteria (FEV1/FVC < 0.7), exacerbation management
• Pleural effusion - Light's criteria (exudate vs transudate), causes, approach
• Pneumothorax - types, management

Gastroenterology

• Peptic ulcer disease - H. pylori, NSAIDs, Helicobacter eradication regimen
• Cirrhosis of liver - Child-Pugh score, complications (ascites, SBP, HRS, HE, varices)
• Jaundice - pre-hepatic / hepatic / post-hepatic classification, workup
• Viral hepatitis - Hep A/B/C/E serology markers (HBsAg, anti-HBc IgM, etc.)
• Inflammatory bowel disease - Crohn's vs UC differences (classic comparison table)

Nephrology

• Acute kidney injury - RIFLE/KDIGO criteria, pre-renal vs intrinsic vs post-renal
• Chronic kidney disease - staging, complications, indications for dialysis
• Nephrotic vs Nephritic syndrome - differences, causes, management
• Glomerulonephritis - post-streptococcal, IgA nephropathy, RPGN
• Renal tubular acidosis - types 1, 2, 4

Endocrinology

• Diabetes mellitus - diagnostic criteria (ADA), types, complications (DKA vs HHS), oral hypoglycemics, insulin
• DKA management - fluid resuscitation, insulin protocol, K+ replacement
• Thyroid disorders - hypothyroidism (clinical features, TSH/T4), hyperthyroidism (Graves' disease, thyroid storm)
• Cushing's syndrome - causes, features, workup (overnight dexamethasone suppression test)
• Addison's disease - features, investigations, Addisonian crisis management

Hematology

• Anemias - classification by MCV, approach to anemia, iron deficiency vs B12/folate vs hemolytic
• Sickle cell disease - complications, crises types, management
• Bleeding disorders - hemophilia A vs B, ITP, DIC - coagulation profile patterns
• Leukemia - ALL vs AML vs CML vs CLL - key differentiating features
• Lymphoma - Hodgkin's (Reed-Sternberg cells, Ann Arbor staging) vs NHL

Neurology

• Stroke - ischemic vs hemorrhagic, NIHSS, thrombolysis criteria (tPA within 4.5 hrs), lacunar infarcts
• Meningitis - CSF analysis table (bacterial vs viral vs TB vs fungal)
• Epilepsy - classification, first-line drugs, status epilepticus management
• Parkinson's disease - features, dopaminergic pathways, treatment (Levodopa + carbidopa)
• Guillain-Barre syndrome - ascending paralysis, CSF (albuminocytological dissociation), management

Infectious Diseases

• Malaria - P. falciparum complications (cerebral malaria, blackwater fever), artemisinin-based therapy
• Typhoid - Widal test, Rose spots, complications, ciprofloxacin/azithromycin
• Dengue - NS1 antigen, warning signs, fluid management, thrombocytopenia
• Leptospirosis - Weil's disease, clinical features, doxycycline
• HIV/AIDS - WHO staging, CD4 thresholds, opportunistic infections, ART initiation

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Exam Format Tips (Typical Indian MBBS End Posting)

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Priority Order for Revision

1. Cardiology - RF, IE, HF, HTN, MI (always in clinicals)
2. Respiratory - TB, Asthma, COPD (bread and butter)
3. Endocrine - DM + DKA (very commonly asked)
4. Nephrology - Nephrotic/Nephritic distinction
5. Infectious diseases - Malaria, Typhoid, Dengue (India-specific, always asked)
6. Neurology - Stroke + Meningitis CSF table

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CARDIOVASCULAR SYSTEM

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• Carditis (pancarditis - endo, myo, pericardium)
• Polyarthritis (migratory, large joints)
• Sydenham's chorea (involuntary movements)
• Erythema marginatum (skin rash)
• Subcutaneous nodules

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• Fever
• Elevated ESR / CRP
• Prolonged PR interval on ECG
• Arthralgia (only if arthritis NOT used as major)
• Previous rheumatic fever

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• Group A beta-hemolytic Streptococcus (S. pyogenes) pharyngitis
• Molecular mimicry: antibodies against strep M-protein cross-react with cardiac tissue (myosin)
• Occurs 2-4 weeks after pharyngitis
• Aschoff bodies = pathognomonic granulomas in myocardium
• Anitschkow cells = caterpillar cells inside Aschoff bodies

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• Acute: Benzyl penicillin IM + NSAIDs (naproxen) for arthritis + steroids if severe carditis
• Primary prevention: Penicillin for strep throat within 9 days
• Secondary prevention: Monthly Benzathine penicillin IM for years
  • No carditis: 5 years or till age 21
  • Carditis without residual: 10 years or till age 21
  • Persistent valvular disease: lifelong

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1. Positive blood cultures (x2, typical organisms: Viridans strep, S. aureus, HACEK group)
2. Evidence of endocardial involvement (echo: vegetation, abscess, new valve regurgitation)

1. Predisposing heart condition or IV drug use
2. Fever >38°C
3. Vascular phenomena (septic emboli, Janeway lesions)
4. Immunologic phenomena (Osler nodes, Roth spots, RF positive, glomerulonephritis)
5. Microbiological evidence (culture not meeting major)

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• Osler nodes - painful nodules on finger/toe pads (immune complex)
• Janeway lesions - painless hemorrhagic macules on palms/soles (embolic)
• Roth spots - oval retinal hemorrhages with pale center
• Splinter hemorrhages - under nails
• Clubbing (subacute)
• Splenomegaly
• New regurgitant murmur

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• Native valve (most common): Streptococcus viridans
• IV drug users: Staphylococcus aureus (tricuspid valve)
• Prosthetic valve early (<60 days): S. epidermidis
• Prosthetic valve late: S. viridans
• Post-dental procedure: S. viridans
• Colon cancer / GI procedures: Streptococcus bovis (S. gallolyticus)
• Culture-negative: HACEK organisms (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella)

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• Grade 1 (mild): 140-159 / 90-99
• Grade 2 (moderate): 160-179 / 100-109
• Grade 3 (severe): ≥180 / ≥110

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• ACE inhibitors / ARBs - Diabetes, CKD, heart failure, post-MI
• Calcium channel blockers - Elderly, Afro-Caribbean, isolated systolic HTN
• Thiazide diuretics - Elderly, isolated systolic HTN, osteoporosis
• Beta-blockers - Post-MI, heart failure, angina, young patients
• Alpha-blockers - BPH + HTN

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• Class I: No symptoms with ordinary activity
• Class II: Slight limitation, symptoms with moderate exertion
• Class III: Marked limitation, symptoms with minimal exertion
• Class IV: Symptoms at rest, cannot carry out any activity

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1. ACE-I / ARB (e.g., ramipril, enalapril)
2. Beta-blocker (carvedilol, bisoprolol, metoprolol)
3. MRA / Aldosterone antagonist (spironolactone, eplerenone)
4. SGLT2 inhibitor (dapagliflozin, empagliflozin)

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• Killip I: No heart failure (mortality ~6%)
• Killip II: Mild HF, basal crackles, S3 gallop (mortality ~17%)
• Killip III: Pulmonary edema (mortality ~38%)
• Killip IV: Cardiogenic shock, BP <90, cold clammy (mortality ~67%)

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• Prior intracranial hemorrhage
• Ischemic stroke within 3 months
• Active internal bleeding
• Aortic dissection
• Significant closed-head trauma <3 months

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• Dyspnea, orthopnea, PND
• Hemoptysis (rupture of dilated bronchial veins)
• Malar flush (mitral facies)
• Atrial fibrillation (common complication)
• Auscultation: Loud S1, opening snap (OS), mid-diastolic rumbling murmur at apex
• MDM: best heard in left lateral decubitus, with bell, in expiration
• Severity: shorter S2-OS interval = more severe stenosis

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RESPIRATORY SYSTEM

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• C - Confusion (new onset)
• U - Urea >7 mmol/L (BUN >19 mg/dL)
• R - Respiratory rate ≥30/min
• B - Blood pressure (SBP <90 or DBP ≤60)
• 65 - Age ≥65

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• Most common overall: Streptococcus pneumoniae
• Atypical (walking pneumonia): Mycoplasma pneumoniae (young adults)
• Elderly: S. pneumoniae, H. influenzae
• Aspiration: Anaerobes, gram-negatives
• HIV patients: PCP (Pneumocystis jirovecii)
• Nosocomial (HAP): Gram-negatives (Klebsiella, Pseudomonas), MRSA
• Legionella: Air conditioning/water towers; hyponatremia + diarrhea clue

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• Lobar consolidation - S. pneumoniae (air bronchograms)
• Bilateral interstitial / ground glass - Atypical (Mycoplasma, PCP)
• Upper lobe cavitation - TB, Klebsiella ("currant jelly sputum")
• Hilar adenopathy - TB, sarcoidosis, lymphoma
• RML / basal consolidation - Aspiration

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• Intensive phase: 2 months of HRZE (Isoniazid + Rifampicin + Pyrazinamide + Ethambutol)
• Continuation phase: 4 months of HR (Isoniazid + Rifampicin)
• Total: 6 months (2HRZE + 4HR)

• 2HRZES + 1HRZE + 5HRE (8 months total)

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• Isoniazid (H): Peripheral neuropathy (prevent with pyridoxine/B6), hepatitis, lupus-like syndrome
• Rifampicin (R): Orange urine/tears, hepatitis, induces CYP450 (reduces OCP efficacy)
• Pyrazinamide (Z): Hyperuricemia (gout), hepatitis
• Ethambutol (E): Optic neuritis (check color vision), retrobulbar neuritis
• Streptomycin (S): Ototoxicity, nephrotoxicity (aminoglycoside)

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• All patients: Smoking cessation, vaccinations (flu, pneumococcal)
• GOLD 1-2 (A/B): SABA (salbutamol) PRN → add LAMA (tiotropium) or LABA
• GOLD 3-4 (C/D): LAMA + LABA → add ICS if eosinophils >300 or frequent exacerbations
• Long-term O2 therapy (LTOT): PaO2 ≤55 mmHg at rest (>15 hrs/day)
• COPD exacerbation: Controlled O2 (target SpO2 88-92%), SABA nebulizer, steroids (prednisolone 40mg x5 days), antibiotics (amoxicillin/doxycycline) if purulent sputum

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1. Pleural fluid protein / serum protein > 0.5
2. Pleural fluid LDH / serum LDH > 0.6
3. Pleural fluid LDH > 2/3 upper limit of normal serum LDH

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1. High-flow O2 (target SpO2 >94%)
2. Nebulized SABA (salbutamol) back-to-back every 20 mins x3
3. Ipratropium nebulization (add to SABA)
4. IV/oral steroids (hydrocortisone IV or prednisolone oral)
5. IV MgSO4 (2g over 20 min) if severe
6. Heliox / IV aminophylline in refractory cases
7. ICU / intubation if PaCO2 rising (paradoxical normalization = impending arrest)

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GASTROENTEROLOGY

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• H. pylori (80% of duodenal ulcers, 60% of gastric ulcers)
• NSAIDs
• Zollinger-Ellison syndrome (gastrinoma)
• Smoking, alcohol, steroids

• PPI + Clarithromycin + Amoxicillin (OR Metronidazole if penicillin allergy)

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• Class A (5-6): Well-compensated, 1-yr survival 100%
• Class B (7-9): Significant compromise, 80%
• Class C (10-15): Decompensated, 45%

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• Portal hypertension → Varices, splenomegaly, caput medusae
• Ascites → treat with salt restriction, spironolactone ± furosemide
• Spontaneous Bacterial Peritonitis (SBP) → ascitic neutrophils >250/mm³ → IV cefotaxime
• Hepatic Encephalopathy → Lactulose + rifaximin + treat precipitant
• Hepatorenal Syndrome (HRS) → Cr rises without other cause → terlipressin + albumin
• Hepatocellular Carcinoma → AFP + USS surveillance every 6 months

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NEPHROLOGY

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• A - Acidosis (metabolic, pH <7.1, refractory)
• E - Electrolytes (hyperkalemia refractory to treatment)
• I - Intoxication (dialyzable poisons: methanol, salicylates, lithium, ethylene glycol)
• O - Overload (fluid overload refractory to diuretics)
• U - Uremia (encephalopathy, pericarditis, bleeding)

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• Children: Minimal Change Nephropathy (MCNS) - most common, responds to steroids
• Young adults: Focal Segmental Glomerulosclerosis (FSGS), Membranous Nephropathy
• Adults with DM: Diabetic nephropathy (Kimmelstiel-Wilson lesions)
• Secondary causes: SLE (membranous), amyloidosis, drugs (NSAIDs, penicillamine)

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ENDOCRINOLOGY

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1. Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L) - fasting = no caloric intake x8 hrs
2. 2-hr plasma glucose ≥ 200 mg/dL during 75g OGTT
3. HbA1c ≥ 6.5% (48 mmol/mol)
4. Random plasma glucose ≥ 200 mg/dL + symptoms (polyuria, polydipsia, weight loss)

• IFG: FPG 100-125 mg/dL
• IGT: 2-hr OGTT 140-199 mg/dL
• HbA1c 5.7-6.4%

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1. Fluids: 0.9% NaCl 1L over 1 hr → then 500ml/hr x2 → then slow down
2. Insulin: Fixed-rate IV insulin infusion (0.1 units/kg/hr) - do NOT start until K+ >3.5
3. Potassium: Add K+ to fluids once K+ <5.5 and urine output adequate (K+ falls when insulin given)
4. Monitor: Glucose hourly, U&E 2-hourly, blood gas 2-hourly
5. Switch to dextrose when glucose <14 mmol/L (keep insulin running)
6. Resolve DKA when: pH >7.3, bicarbonate >18, ketones <0.6 mmol/L
7. Treat precipitant (infection, missed insulin)

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• Fatigue, weight gain, cold intolerance
• Dry skin, hair loss, brittle nails
• Constipation, depression
• Bradycardia, diastolic hypertension
• Periorbital puffiness, goiter
• Delayed relaxation of tendon reflexes (best sign)
• Myxedema coma (severe): hypothermia, altered consciousness
• Labs: High TSH, Low free T4

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• Weight loss despite increased appetite
• Palpitations, AF, tachycardia
• Heat intolerance, sweating
• Tremor, anxiety, irritability
• Diarrhea
• Graves-specific: Exophthalmos (proptosis), pretibial myxedema, thyroid acropachy
• Labs: Low TSH, High free T3/T4, TSH receptor antibodies (TRAb)
• Treatment: Carbimazole/methimazole (first-line) or radioiodine or surgery

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1. PTU (blocks synthesis AND peripheral conversion) - preferred over carbimazole in storm
2. Lugol's iodine (given 1 hr AFTER PTU to block hormone release)
3. Propranolol (controls symptoms, blocks T4→T3 conversion)
4. Steroids (dexamethasone - blocks peripheral T4→T3)
5. Cooling, IV fluids, treat precipitant

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• Central obesity, moon face, buffalo hump
• Purple/violaceous striae (>1cm wide)
• Proximal myopathy (can't rise from squat)
• Hypertension, hyperglycemia
• Osteoporosis, easy bruising, poor wound healing
• Hirsutism, menstrual irregularity

1. Screening: 24-hr urinary free cortisol OR overnight low-dose dexamethasone suppression test (1mg at midnight, measure 8am cortisol - suppression to <1.8 µg/dL = normal)
2. Confirm: 48-hr low-dose DST
3. ACTH level: If ACTH high → pituitary (Cushing's disease) or ectopic; If ACTH low → adrenal adenoma
4. High-dose DST: Suppresses in pituitary Cushing's, NOT in ectopic or adrenal

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• Fatigue, weakness, weight loss
• Hyperpigmentation (buccal mucosa, skin creases, scars) - due to high ACTH/MSH
• Postural hypotension, hyponatremia, hyperkalemia
• Vitiligo (autoimmune association)

• Severe hypotension, shock, vomiting, abdominal pain
• Treat: IV hydrocortisone 100mg STAT → then 8-hourly; IV 0.9% saline 1L rapidly; IV dextrose if hypoglycemic; identify + treat precipitant

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HEMATOLOGY

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• T - Thalassemia
• A - Anemia of chronic disease (also normocytic)
• I - Iron deficiency (most common)
• L - Lead poisoning
• S - Sideroblastic anemia

• Acute blood loss, hemolysis, anemia of chronic disease, mixed deficiency, aplastic anemia, CKD

• B12 / Folate deficiency (megaloblastic)
• Alcohol, liver disease, hypothyroidism, drugs (methotrexate, hydroxyurea)

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• Simultaneous bleeding AND thrombosis
• Triggered by: Sepsis (most common), obstetric emergencies (abruption, APH), malignancy, trauma
• Labs: Low platelets, prolonged PT + aPTT, low fibrinogen, HIGH D-dimers, schistocytes on film
• Treatment: Treat underlying cause + fresh frozen plasma (FFP) + cryoprecipitate + platelet transfusion

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• Stage I: Single lymph node region
• Stage II: ≥2 regions, same side of diaphragm
• Stage III: Both sides of diaphragm
• Stage IV: Disseminated (liver, bone marrow, lung)

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NEUROLOGY

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• Ischemic stroke with measurable deficit
• Onset to treatment within 4.5 hours
• Age ≥18

• Intracranial hemorrhage on CT
• Prior stroke or head trauma <3 months
• BP >185/110 (must treat first)
• Active bleeding or bleeding diathesis
• Blood glucose <50 or >400 mg/dL
• INR >1.7 or platelets <100,000

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1. Dexamethasone 0.15 mg/kg IV qds x4 days (give BEFORE or with first antibiotic)
2. Antibiotics: IV Ceftriaxone 2g BD (or cefotaxime)
   • Add Ampicillin if Listeria suspected (elderly, immunocompromised, neonates)
3. Treat raised ICP if present (head elevation 30°, mannitol)
4. Isolate until 24 hrs of antibiotics given
5. Contacts: Rifampicin or ciprofloxacin prophylaxis for close contacts of meningococcal meningitis

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1. 0-5 min: ABCDE, IV access, glucose check
2. 5-10 min (Phase 1): Lorazepam 0.1 mg/kg IV (OR diazepam 0.15 mg/kg IV), can repeat x1
3. 20-30 min (Phase 2 - if still seizing): Levetiracetam 60mg/kg IV OR phenytoin 20mg/kg IV OR valproate 40mg/kg IV
4. >30 min (Refractory): Anesthetic agents - propofol / thiopental / midazolam infusion + ICU admission + EEG monitoring

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• T - Tremor (resting "pill-rolling" tremor, 4-6 Hz, worse at rest)
• R - Rigidity (cogwheel or lead-pipe)
• A - Akinesia / Bradykinesia (slow movements)
• P - Postural instability (late feature)

• First-line: Levodopa + Carbidopa (carbidopa prevents peripheral conversion, reduces side effects)
• Dopamine agonists: Pramipexole, ropinirole (used early, or in younger patients)
• MAO-B inhibitors: Selegiline, rasagiline
• COMT inhibitors: Entacapone (extend levodopa effect)

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• Ascending symmetric flaccid paralysis (starts legs, goes up)
• Areflexia (absent deep tendon reflexes)
• Preceded by URTI (Campylobacter jejuni most common trigger, also CMV, EBV)
• Autonomic involvement (BP swings, arrhythmias)
• Respiratory muscles → mechanical ventilation needed in 30%
• CSF: Albuminocytological dissociation (high protein, normal cells)
• NCS: Demyelinating pattern (slow conduction)
• Treatment: IVIG or plasmapheresis (equally effective, NOT steroids); supportive care

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INFECTIOUS DISEASES

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• Cerebral malaria (seizures, coma, altered consciousness)
• Renal failure (acute tubular necrosis)
• Anemia (severe, hemolytic)
• Pulmonary edema (ARDS)
• Euphylactic/metabolic (hypoglycemia)
• Spontaneous bleeding (DIC)
• Placental malaria (in pregnancy)
• Algid malaria (cardiovascular collapse)
• Decreased consciousness
• Electrolyte imbalance
• Blackwater fever = massive hemolysis → hemoglobinuria → dark urine → AKI

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• Artemisinin-based Combination Therapy (ACT): Artemether-lumefantrine (Coartem) OR Artesunate-amodiaquine

• IV Artesunate (drug of choice) → then switch to oral ACT when able

• Chloroquine (blood stage) + Primaquine (14 days, for liver hypnozoites)
• Check G6PD before primaquine (causes hemolysis in G6PD deficiency)

• Chloroquine only (no hypnozoites)

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• Week 1: Gradually rising fever (step-ladder pattern), headache, relative bradycardia
• Week 2: High sustained fever, Rose spots (pale-pink macules on trunk), hepatosplenomegaly, constipation → diarrhea
• Week 3: Complications (intestinal perforation, hemorrhage, encephalopathy)

• Gold standard: Blood culture (week 1-2), Stool culture (week 2-3)
• Widal test: Positive if TO ≥1:160, TH ≥1:160 (supports diagnosis, not definitive)

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• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding
• Lethargy or restlessness
• Liver enlargement >2cm
• Rapid decline in platelet with rise in hematocrit

1. Febrile (day 1-3): High fever, myalgia
2. Critical (day 4-6): Defervescence + plasma leakage (dangerous)
3. Recovery (day 7+): Fluid reabsorption

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• CD4 <200: PCP pneumonia, Toxoplasmosis, Cryptococcal meningitis
• CD4 <50: CMV retinitis, MAI (Mycobacterium avium), PML (JC virus)

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• Caused by Leptospira interrogans (spirochete)
• Contact with water/soil contaminated with rat urine
• Biphasic illness:
  • Phase 1 (Leptospiremic): Fever, myalgia (severe calf pain), conjunctival suffusion, headache
  • Phase 2 (Immune/Weil's): Jaundice, AKI, thrombocytopenia, uveitis, meningitis
• Weil's Disease = severe form: jaundice + AKI + bleeding
• Diagnosis: Microscopic Agglutination Test (MAT) - gold standard; IgM ELISA
• Treatment: Doxycycline (mild); IV Penicillin G (severe); Prophylaxis: Doxycycline 200mg weekly

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SUMMARY TABLES

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• M - Methanol
• U - Uremia (CKD)
• D - DKA / starvation ketosis
• P - Propylene glycol / Paracetamol
• I - Isoniazid / Iron
• L - Lactic acidosis (sepsis, shock)
• E - Ethylene glycol
• S - Salicylates

• Hyperchloremia, Addison's, RTA, Diarrhea (bicarbonate loss), Drugs (acetazolamide), Ureteroileostomy, Pancreatic fistula

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• A - Abscess (lung), Asbestosis
• B - Bronchiectasis, Bronchogenic carcinoma
• C - Congenital cyanotic heart disease (TOF, TGA), Crohn's, Cirrhosis
• D - Diarrhea chronic (IBD)
• E - Endocarditis (infective)
• F - Fibrosis (idiopathic pulmonary), Familial

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• CML (most common cause in India)
• Malaria (chronic, hyperreactive)
• Visceral Leishmaniasis (Kala-azar)
• Myelofibrosis
• Gaucher's disease

• Cirrhosis with portal hypertension
• Lymphoma, CLL

• Infectious mononucleosis (EBV)
• Typhoid, Viral hepatitis, SLE, ITP

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PRACTICE MCQs - GENERAL MEDICINE

3rd Term MBBS (2nd Year Clinical Postings)

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CARDIOVASCULAR SYSTEM

• A) Fever
• B) Elevated ESR
• C) Sydenham's chorea
• D) Prolonged PR interval

Fever, elevated ESR, and prolonged PR interval are all Minor criteria. Major criteria = Carditis, Polyarthritis, Chorea, Erythema marginatum, Subcutaneous nodules (CAPES).

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• A) Oral penicillin V daily
• B) Benzathine penicillin IM monthly
• C) Azithromycin daily
• D) Erythromycin weekly

Monthly IM Benzathine penicillin G is the gold standard for secondary prophylaxis. Oral agents have poorer compliance.

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• A) Painless and on palms
• B) Painful and on fingertip pads
• C) Painless and on soles
• D) Hemorrhagic and on nails

Osler nodes = painful, immune complex-mediated, on finger/toe pads. Janeway lesions = painless, embolic, on palms and soles.

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• A) Streptococcus viridans
• B) Staphylococcus epidermidis
• C) Staphylococcus aureus
• D) Streptococcus bovis

IV drug users classically get right-sided (tricuspid) endocarditis caused by S. aureus, introduced from skin flora during injection.

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• A) Amlodipine
• B) Ramipril
• C) Bisoprolol
• D) Furosemide

ACE inhibitors (e.g., ramipril) cause a dry cough due to bradykinin accumulation. Switch to an ARB or calcium channel blocker like amlodipine.

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• A) ACE inhibitors
• B) Beta-blockers
• C) Loop diuretics
• D) Spironolactone

Furosemide relieves symptoms (edema, dyspnea) but has no proven mortality benefit in HF. ACE-I, beta-blockers, and aldosterone antagonists all reduce mortality.

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• A) Wait for transfer to PCI center
• B) Give thrombolysis with streptokinase
• C) Start aspirin alone and observe
• D) Give heparin infusion and monitor

When PCI is unavailable within 120 min and onset is <12 hours, thrombolysis is indicated. Aspirin + streptokinase/alteplase is appropriate.

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• A) Anterior MI - LAD
• B) Lateral MI - LCx
• C) Inferior MI - RCA
• D) Posterior MI - LCx

Inferior MI affects leads II, III, aVF and is supplied by the Right Coronary Artery (RCA) in most patients.

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• A) Troponin I
• B) CK-MB
• C) LDH
• D) Myoglobin

Myoglobin rises in 1-3 hours (earliest) but is non-specific. Troponin is most specific. LDH rises last and stays elevated longest.

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• A) Sitting forward, in inspiration
• B) Left lateral decubitus, in expiration
• C) Supine, in inspiration
• D) Right lateral decubitus, in expiration

The low-pitched mid-diastolic rumble of MS is heard at the apex with the bell of the stethoscope, patient in left lateral decubitus position, in expiration.

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RESPIRATORY SYSTEM

• A) 2
• B) 3
• C) 4
• D) 5

Confusion (1) + Urea elevated (1) + RR ≥30 (1) + BP low (1) + Age ≥65 (1) = 5. Score 3-5 = ICU/severe pneumonia.

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• A) Mycoplasma pneumoniae
• B) Staphylococcus aureus
• C) Streptococcus pneumoniae
• D) Klebsiella pneumoniae

S. pneumoniae = most common CAP organism, causes lobar consolidation, rust-colored sputum (from lysed RBCs), herpes labialis.

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• A) S. pneumoniae pneumonia
• B) TB
• C) Mycoplasma pneumoniae pneumonia
• D) PCP pneumonia

"Walking pneumonia" = Mycoplasma. CXR looks worse than the patient. Treat with doxycycline or azithromycin (macrolides/tetracyclines - no cell wall so penicillin doesn't work).

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• A) 2 months of HRZE
• B) 4 months of HR
• C) 5 months of HRE
• D) 6 months of HR

Cat 1 regimen = 2HRZE (intensive) + 4HR (continuation) = 6 months total. Only Isoniazid + Rifampicin in the continuation phase.

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• A) Isoniazid
• B) Rifampicin
• C) Pyrazinamide
• D) Ethambutol

Ethambutol is the classic cause of optic neuritis - presents as reduced visual acuity and red-green color blindness. Monitor regularly.

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• A) GOLD 1
• B) GOLD 2
• C) GOLD 3
• D) GOLD 4

FEV1/FVC <0.7 confirms obstruction. FEV1 30-49% = GOLD Grade 3 (Severe).

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• A) Transudate
• B) Exudate
• C) Chylothorax
• D) Empyema

Meets ALL three Light's criteria for exudate: protein ratio >0.5, LDH ratio >0.6, pleural LDH >2/3 of upper normal serum LDH. One criterion is sufficient.

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• A) PaO2 of 70 mmHg
• B) PaCO2 rising to normal (40 mmHg)
• C) Peak expiratory flow <50%
• D) Tachycardia of 110 bpm

In an acute asthma attack, patients hyperventilate causing LOW PaCO2. A "normal" or rising PaCO2 means the patient is tiring and heading toward respiratory failure - a medical emergency requiring ICU.

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GASTROENTEROLOGY

• A) Class A (5 points)
• B) Class B (7 points)
• C) Class C (10 points)
• D) Class A (6 points)

Bilirubin 34-50 = 2 pts; Albumin 28-35 = 2 pts; PT prolonged 4-6s = 2 pts; No encephalopathy = 1 pt; Mild ascites = 2 pts. Total = 9? Let's recount: Bili (34-50µmol)=2, Albumin(28-35)=2, PT(4-6s)=2, Ascites(mild)=2, Enceph(none)=1 → Total = 9 = Class B.

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• A) Hepatitis A
• B) Hepatitis B
• C) Hepatitis C
• D) Hepatitis E

Hep E has a mortality of up to 20-25% in pregnant women (vs 1-2% generally), especially in the 3rd trimester. This is a classic exam fact.

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• A) Hepatorenal syndrome; terlipressin
• B) Spontaneous bacterial peritonitis; IV cefotaxime
• C) Tuberculous peritonitis; anti-TB drugs
• D) Malignant ascites; diuretics

SBP is diagnosed when ascitic PMN count ≥250/mm³. This patient has 350. Treat with IV cefotaxime (3rd gen cephalosporin). Add IV albumin to prevent hepatorenal syndrome.

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• A) It involves only the rectum and colon
• B) It causes continuous mucosal inflammation
• C) It has skip lesions and transmural inflammation
• D) Colectomy is curative

Crohn's = any part of GI tract, skip lesions, transmural, fistulae, non-caseating granulomas, cobblestone mucosa. NOT cured by surgery. UC = continuous, mucosal only, rectum always involved, cured by colectomy.

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NEPHROLOGY

• A) Acute tubular necrosis
• B) Pre-renal AKI
• C) Post-renal AKI
• D) Glomerulonephritis

Pre-renal AKI: urine Na <20, FENa <1% (kidneys are working hard to retain Na). ATN: urine Na >40, FENa >2% (tubules damaged, can't reabsorb).

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• A) Post-streptococcal GN
• B) Minimal change nephropathy
• C) IgA nephropathy
• D) Membranoproliferative GN

Classic nephrotic syndrome in children = Minimal Change Disease (MCNS). No hematuria or hypertension. Responds well to steroids. Electron microscopy shows effacement of podocyte foot processes.

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• A) Type 1 (Distal)
• B) Type 2 (Proximal)
• C) Type 3
• D) Type 4

Type 4 RTA = hypoaldosteronism (or aldosterone resistance) → HYPERKALEMIA + normal AG metabolic acidosis. Common in DM and adrenal insufficiency. Types 1 and 2 cause HYPOkalemia.

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• A) Creatinine of 8 mg/dL
• B) BUN of 90 mg/dL
• C) Hyperkalemia of 6.8 mEq/L with ECG changes
• D) Mild pedal edema

Hyperkalemia with ECG changes (peaked T waves, wide QRS) is the most immediately life-threatening indication for urgent dialysis among the AEIOU criteria. Cardiac arrest risk is imminent.

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ENDOCRINOLOGY

• A) Fasting glucose 118 mg/dL
• B) HbA1c 6.2%
• C) 2-hr OGTT glucose 185 mg/dL
• D) Fasting glucose 128 mg/dL

FPG ≥126 mg/dL = DM. Option A (118) = IFG (pre-diabetes 100-125). Option B (6.2%) = pre-diabetes (5.7-6.4%). Option C (185) = IGT (140-199 = pre-diabetes; ≥200 = DM).

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• A) Start insulin infusion immediately
• B) Give IV 0.9% NaCl fluid resuscitation
• C) Give IV sodium bicarbonate
• D) Check and correct potassium first

In DKA, IV fluids (0.9% NaCl) come FIRST. Do not start insulin until K+ is confirmed >3.5 mEq/L (insulin drives K+ into cells, worsening hypokalemia). Bicarbonate is NOT routinely given (only if pH <6.9).

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• A) Rules out Cushing's syndrome
• B) Is normal - no further testing needed
• C) Confirms Cushing's syndrome and indicates pituitary source
• D) Suggests failure to suppress - Cushing's likely

Normal suppression = 8am cortisol <1.8 µg/dL. A value of 22 µg/dL means cortisol was NOT suppressed, suggesting autonomous production = Cushing's syndrome. Further testing (ACTH levels, high-dose DST) is needed to find the source.

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• A) Oral fludrocortisone
• B) IV hydrocortisone 100mg STAT
• C) IV aldosterone replacement
• D) Oral prednisolone 40mg

Addisonian crisis = life-threatening. Give IV hydrocortisone 100mg STAT immediately + IV 0.9% saline. Do not delay for tests if clinical diagnosis is clear. Hydrocortisone has both glucocorticoid and mineralocorticoid effects at high doses.

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• A) Tachycardia
• B) Weight loss
• C) Pretibial myxedema
• D) Heat intolerance

Pretibial myxedema (non-pitting edema of shins), exophthalmos, and thyroid acropachy are specific to Graves' disease (TSH receptor antibody-mediated). All other features are common to any cause of hyperthyroidism.

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HEMATOLOGY

• A) Beta-thalassemia minor
• B) Iron deficiency anemia
• C) Sideroblastic anemia
• D) Anemia of chronic disease

Koilonychia (spoon-shaped nails), glossitis, and angular stomatitis are classic clinical features of IDA. Confirm with low serum ferritin, low serum iron, high TIBC.

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• A) ITP
• B) Hemophilia A or B
• C) DIC
• D) Von Willebrand disease

Hemophilia A (Factor VIII deficiency) and B (Factor IX deficiency) affect the intrinsic pathway → prolonged aPTT only, normal PT, normal platelets. VWD also prolongs aPTT but also prolongs bleeding time.

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• A) ALL
• B) AML
• C) CML
• D) CLL

Ph chromosome (t9;22) = BCR-ABL = CML hallmark. Treatment = Imatinib (TKI). Note: Ph+ ALL exists but is less common. CLL has smudge cells; AML has Auer rods.

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• A) Non-Hodgkin's Lymphoma
• B) CLL
• C) Hodgkin's Lymphoma
• D) Multiple Myeloma

Reed-Sternberg cells are pathognomonic of Hodgkin's lymphoma. They are large binucleated cells with prominent eosinophilic nucleoli resembling owl eyes.

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• A) Low PT, high platelets, high fibrinogen
• B) High PT, low platelets, high D-dimer, low fibrinogen
• C) Normal PT, low platelets, normal D-dimer
• D) Low PT, normal platelets, normal D-dimer

DIC = consumption of clotting factors + platelets + fibrinogen → prolonged PT/aPTT, thrombocytopenia, low fibrinogen, very HIGH D-dimers, schistocytes on blood film.

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NEUROLOGY

• A) Ischemic stroke - give tPA
• B) Hemorrhagic stroke - do NOT give tPA
• C) Normal CT - give tPA
• D) Subdural hematoma - give tPA

Hyperdense (white/bright) area on non-contrast CT = blood = hemorrhagic stroke. tPA is absolutely contraindicated. Ischemic stroke is isodense/normal on early CT.

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• A) CT scan of head
• B) Lumbar puncture
• C) IV Dexamethasone + IV Ceftriaxone
• D) Blood cultures only

In suspected bacterial meningitis, do NOT delay antibiotics for CT or LP. Give dexamethasone + ceftriaxone IMMEDIATELY (even before LP if there will be delay). Blood cultures should be taken before antibiotics if possible but must not delay treatment.

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• A) Transverse myelitis
• B) Guillain-Barre Syndrome
• C) Multiple sclerosis
• D) Myasthenia gravis

Classic GBS: ascending weakness, areflexia, autonomic features, preceded by Campylobacter jejuni GI infection, CSF shows albuminocytological dissociation (high protein, near-normal cells). Treat with IVIG or plasmapheresis.

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• A) Amantadine
• B) Selegiline
• C) Levodopa + Carbidopa
• D) Trihexyphenidyl (Artane)

Levodopa + Carbidopa (Syndopa/Sinemet) is the most effective treatment for Parkinson's disease and remains the gold standard first-line agent. Carbidopa inhibits peripheral decarboxylation of levodopa, reducing side effects and increasing CNS availability.

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INFECTIOUS DISEASES

• A) Blackwater fever
• B) Splenic rupture
• C) Cerebral malaria
• D) Renal failure

P. falciparum (banana-shaped gametocytes, multiple ring forms) causes the most severe malaria. Cerebral malaria (seizures, coma) is the most immediately life-threatening complication. Treat with IV Artesunate.

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• A) Sickle cell trait
• B) G6PD deficiency
• C) Renal function
• D) Liver function

Primaquine causes oxidative hemolysis in G6PD-deficient patients. Always check G6PD levels before prescribing. It is used for P. vivax/ovale liver hypnozoites (radical cure).

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• A) Splenic rupture
• B) Intestinal perforation
• C) Hepatic abscess
• D) Meningitis

Typhoid ulcers form in Peyer's patches of the terminal ileum in Week 2-3. Perforation causes peritonitis (sudden abdominal pain, rigidity, guarding). It is the most feared complication of typhoid fever.

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• A) Day 1-5 (febrile phase)
• B) Day 6-8 (critical phase)
• C) Day 9+ (recovery phase)
• D) Any time equally

NS1 antigen is present in blood during the febrile phase (day 1-5). After day 5, IgM antibody tests become more useful. NS1 is a direct viral antigen test - no antibodies needed.

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• A) CD4 <500 cells/µL
• B) CD4 <350 cells/µL
• C) CD4 <200 cells/µL
• D) CD4 <100 cells/µL

PCP (Pneumocystis jirovecii) prophylaxis with Co-trimoxazole (TMP-SMX) is started when CD4 <200 cells/µL. This is also the threshold that defines AIDS (along with AIDS-defining illnesses).

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• A) Malaria
• B) Leptospirosis (Weil's disease)
• C) Dengue hemorrhagic fever
• D) Hepatitis A

Classic scenario: flood water exposure, jaundice + AKI + bleeding (Weil's triad), conjunctival suffusion, severe calf pain (myositis). Treat with IV Penicillin G.

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MIXED / HIGH-YIELD SINGLE BEST ANSWERS

• A) India ink stain
• B) AFB smear
• C) BACTEC culture / Gene Xpert (nucleic acid amplification)
• D) Widal test

CSF BACTEC culture is the gold standard but takes weeks. Gene Xpert MTB/RIF provides rapid diagnosis (2 hours) and detects rifampicin resistance. AFB smear has very low sensitivity in CSF. India ink = Cryptococcus.

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• A) Vitamin B12
• B) Vitamin B6 (Pyridoxine)
• C) Vitamin C
• D) Folic acid

INH inhibits pyridoxine (B6) metabolism, causing peripheral neuropathy. Prevent with pyridoxine 25-50mg/day supplementation, especially in diabetics, malnourished patients, and pregnant women.

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• A) Normal anion gap metabolic acidosis
• B) High anion gap metabolic acidosis
• C) Metabolic alkalosis
• D) Respiratory acidosis

DKA = accumulation of ketoacids (beta-hydroxybutyrate, acetoacetate) → High AG metabolic acidosis. Remember MUDPILES - D = DKA. Kussmaul breathing is the compensatory respiratory alkalosis.

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• A) Acute myeloid leukemia; Daunorubicin + AraC
• B) Chronic myeloid leukemia; Imatinib
• C) Leukemoid reaction; treat the cause
• D) CLL; Chlorambucil

CML: Ph+ (t9;22), all myeloid stages on smear, basophilia, LOW LAP/NAP score (distinguishes from leukemoid reaction), massive splenomegaly. First-line = Imatinib (BCR-ABL tyrosine kinase inhibitor).

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SCORE YOURSELF

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CLINICAL BASICS - HISTORY TAKING & EXAMINATION

For 2nd Year MBBS Clinical Postings

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THE STRUCTURE OF A COMPLETE HISTORY

1. Biodata
2. Chief Complaint (CC)
3. History of Present Illness (HPI)
4. Past Medical History (PMH)
5. Drug History
6. Family History
7. Personal & Social History
8. Review of Systems (ROS)

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1. BIODATA

"Mr./Mrs. X, a __-year-old male/female, resident of __, occupation __, presented to the OPD/ward with..."

• Name, Age, Sex
• Occupation - important! (coal miner → pneumoconiosis; farmer → leptospirosis, organophosphate poisoning)
• Residence - urban/rural, endemic area (malaria belt, fluoride belt)
• Religion/Marital status - relevant in some contexts (diet, STIs)
• Date of admission

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2. CHIEF COMPLAINT

• The patient's OWN words, in order of duration
• Maximum 2-3 complaints
• Always mention duration

"Fever for 5 days, cough for 3 days, breathlessness for 1 day"

• Do NOT write diagnosis as CC (never say "fever due to malaria")
• List in chronological order (first symptom first)
• Keep it brief - 1 line per complaint

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3. HISTORY OF PRESENT ILLNESS (HPI)

The 7 Features of Every Symptom (MUST memorize)

1. Site
2. Onset (sudden / gradual)
3. Character / Quality
4. Radiation
5. Associated symptoms
6. Relieving factors
7. Aggravating factors
8. Duration & progression
9. Severity (scale 1-10 for pain)

• Timing - continuous/intermittent, time of day
• Previous similar episodes

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HOW TO DESCRIBE COMMON COMPLAINTS IN HPI

FEVER

• Onset: sudden or gradual?
• Pattern: continuous / remittent / intermittent / hectic/septic / periodic
• Height: high grade (>101°F) or low grade?
• Chills and rigors? (rigors = shivering with teeth chattering = bacteremia/malaria)
• Diurnal variation? (evening rise = TB)
• Associated: headache, rash, joint pain, dysuria, cough
• Relief: paracetamol? spontaneous defervescence?

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COUGH

• Onset and duration
• Dry or productive?
• If productive: sputum color, amount, smell, blood (hemoptysis)
• Timing: morning (bronchiectasis, COPD), night (asthma, GERD, ACE-inhibitor)
• Associated: fever, weight loss, breathlessness, wheeze
• Aggravating: lying down (GERD, CCF), cold air (asthma)

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BREATHLESSNESS (Dyspnea)

• Onset: sudden (pneumothorax, PE) vs gradual (CCF, COPD)
• On exertion or at rest? Progression?
• Orthopnea: breathless lying flat (CCF, massive ascites) - ask "how many pillows?"
• PND: wakes from sleep gasping (CCF)
• Platypnea: breathless sitting up, better lying (hepatopulmonary syndrome - rare)
• Wheeze? (asthma, COPD, cardiac asthma)
• Associated: ankle swelling, chest pain, cough, fever

• I: No symptoms with ordinary activity
• II: Symptoms with moderate exertion
• III: Symptoms with minimal exertion
• IV: Symptoms at rest

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CHEST PAIN

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ABDOMINAL PAIN

• Site - which quadrant?
• Character: colicky (waves) vs constant
• Radiation: RUQ to right shoulder (gallstones), loin to groin (renal colic), epigastric to back (pancreatitis, AAA)
• Relation to food: worse after meals (mesenteric ischemia, peptic ulcer = 2-3 hrs after meals), better after meals (DU), worse at night (DU)
• Vomiting: before or after pain? (surgical = pain before vomiting)
• Bowel habits: constipation/diarrhea, blood/mucus in stool
• Jaundice, fever, weight loss

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JAUNDICE

• Onset: sudden vs gradual
• Color of urine: dark urine = conjugated hyperbilirubinemia (hepatic/post-hepatic)
• Color of stool: pale/clay-colored = obstructive jaundice
• Itching (pruritus) = cholestatic/obstructive
• Associated fever + rigors = Charcot's triad (choledocholithiasis)
• Drug/alcohol history
• Contact with jaundiced persons, travel history
• Risk factors: IV drug use, blood transfusion (Hep B/C)

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EDEMA

• Site: ankle (dependent), face/periorbital (nephrotic, nephritic), sacral (bedridden)
• Pitting or non-pitting?
• Unilateral (DVT, lymphedema) or bilateral (systemic cause)
• Associated breathlessness (CCF), proteinuria (nephrotic), jaundice (cirrhosis)
• Time of day: worse in evening (cardiac), present morning (renal)

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HEADACHE

• Site: frontal (tension, sinusitis), occipital (hypertension, meningitis), unilateral (migraine, cluster)
• Onset: sudden thunderclap (SAH - EMERGENCY) vs gradual
• Character: throbbing (migraine, vascular), pressure band (tension)
• Associated: nausea/vomiting, photophobia, neck stiffness (meningism), aura, fever
• Triggers: stress, alcohol, menses, bright lights (migraine)
• Worse with: straining, coughing (raised ICP)

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4. PAST MEDICAL HISTORY (PMH)

• Previous similar illness
• Known comorbidities: Hypertension, Diabetes, Asthma, TB, Epilepsy, Heart disease, Kidney disease
• Previous hospitalizations / surgeries
• Previous blood transfusions
• Allergies (especially drug allergies)

In your presentation say: "There is no significant past history" OR "Patient is a known hypertensive on amlodipine for 3 years"

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5. DRUG HISTORY

• Current medications (name, dose, duration)
• Over-the-counter drugs (NSAIDs, antacids)
• Herbal/ayurvedic remedies (important in liver disease)
• Drug allergies - what reaction?
• Specifically ask about:
  • Steroids (immunosuppression, adrenal suppression)
  • NSAIDs (peptic ulcer, kidney disease)
  • ACE inhibitors (cough, hyperkalemia)
  • Anticoagulants (bleeding risk)
  • Oral contraceptive pill (DVT, stroke risk)
  • Anti-TB drugs (hepatotoxicity)

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6. FAMILY HISTORY

• Same illness in family members?
• Hereditary conditions: DM, HTN, IHD, TB, malignancy, bleeding disorders
• TB in household contacts (very important in India)
• Consanguinity (for genetic conditions)

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7. PERSONAL & SOCIAL HISTORY

Diet

• Vegetarian or non-vegetarian (B12 deficiency in strict vegans)
• Appetite: decreased (TB, malignancy), increased (DM, hyperthyroidism)

Habits (ALWAYS ASK - never assume)

Pack-years = (cigarettes per day ÷ 20) × years smoked

Occupational history

Socioeconomic and marital status

• Living conditions: crowding (TB)
• Sanitation and water supply (typhoid, cholera)
• Travel history (malaria endemic area, dengue belt)
• Sexual history (if relevant - STIs, HIV)

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8. REVIEW OF SYSTEMS (ROS)

• CVS: Palpitations, chest pain, ankle swelling, syncope
• Respiratory: Cough, wheeze, hemoptysis, breathlessness
• GI: Nausea, vomiting, dysphagia, abdominal pain, bowel changes, rectal bleeding
• Urinary: Dysuria, frequency, nocturia, hematuria, frothy urine
• Neuro: Headache, dizziness, fits, weakness, numbness, vision changes
• Musculoskeletal: Joint pain/swelling, muscle weakness
• Skin: Rash, itching, hair loss, nail changes
• Endocrine: Weight change, heat/cold intolerance, polyuria, polydipsia
• In women: Menstrual history (LMP, regularity, heavy periods), pregnancy history, contraception

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HOW TO PRESENT A HISTORY (What to say to the examiner)

"Mr. Ramesh, a 45-year-old male, farmer, resident of rural Maharashtra, was admitted with fever for 7 days, cough with yellow sputum for 5 days, and breathlessness for 2 days.

The fever was of sudden onset, high grade (>101°F), continuous in nature, associated with chills but no rigors. There was no diurnal variation. The cough was productive with approximately 2 teaspoons of yellow sputum per episode, with no blood or foul smell.

The breathlessness was of gradual onset, currently NYHA Grade II, with no orthopnea or PND. No chest pain or wheeze.

There is no past history of similar illness, tuberculosis, diabetes, or hypertension. He is not on any medications. He smokes 10 cigarettes per day for 20 years (10 pack-years). He does not drink alcohol.

Family history is non-contributory. There is no history of TB contact.

On review of systems, no significant findings."

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GENERAL PHYSICAL EXAMINATION - ORDER & WHAT TO LOOK FOR

1. General appearance
2. Built and nourishment
3. Vital signs
4. Lymph nodes
5. Skin, nails, hair
6. Eyes
7. Mouth & tongue
8. Hands
9. Neck (JVP, thyroid)
10. Lower limbs (edema)

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VITAL SIGNS (memorize normal values)

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PULSE - 7 CHARACTERS

1. Rate - beats per minute
2. Rhythm - regular / regularly irregular / irregularly irregular (AF)
3. Volume - normal / high / low
4. Character - normal / collapsing (AR) / plateau (AS) / bisferiens / pulsus paradoxus
5. Vessel wall - soft / thickened / beaded
6. Symmetry - compare both radials simultaneously
7. Radio-femoral delay - coarctation of aorta

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BLOOD PRESSURE

• Measure in both arms (difference >10 mmHg = subclavian stenosis, aortic dissection)
• Measure standing + lying (postural drop >20 systolic = orthostatic hypotension - Addison's, dehydration, autonomic neuropathy)
• Pulsus paradoxus: BP drops >10 mmHg on inspiration = cardiac tamponade, severe asthma

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JVP (Jugular Venous Pressure)

• Patient at 45°, look at the right side of the neck
• Normal JVP = <3-4 cm above sternal angle
• Raised JVP = Right heart failure, cardiac tamponade, SVC obstruction
• Kussmaul's sign: JVP RISES on inspiration (normally falls) = Constrictive pericarditis, cardiac tamponade
• Hepatojugular reflux: Press on liver → JVP rises = Right heart failure

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HANDS - What to look for

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EYES - What to look for

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LYMPH NODES - How to examine

• Cervical (anterior + posterior chain)
• Submandibular + submental
• Axillary
• Inguinal
• Epitrochlear (always check - raised in sarcoidosis, secondary syphilis, lymphoma)

• Site, size, shape
• Surface - smooth / irregular
• Consistency - soft / firm / hard / rubbery
• Tenderness - tender (infection) / non-tender (malignancy)
• Mobility - mobile / fixed (malignant fixation)
• Skin over it - normal / inflamed / sinuses

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EDEMA - How to examine

• Press firmly over tibial surface for 30 seconds
• Grading:
  • 1+ : Slight pitting, disappears rapidly
  • 2+ : Deeper pit, disappears in <15 sec
  • 3+ : Deep pit, disappears in 1-2 min
  • 4+ : Very deep pit, >2 min
• In bedridden patients: check sacral edema
• Non-pitting edema = lymphedema, myxedema (hypothyroidism)

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SYSTEMIC EXAMINATION ORDER (Respiratory example)

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Chest Inspection

• Shape: barrel chest (COPD), kyphoscoliosis, pectus excavatum
• Movement: symmetrical? Reduced on one side?
• Use of accessory muscles (intercostal, SCM = respiratory distress)
• Tracheal position: central / deviated?
• Any scars, sinuses, visible veins

Palpation

• Tracheal position (finger in suprasternal notch)
• Chest expansion: place hands on chest, thumbs meet in midline, watch them separate
• Vocal fremitus: say "99" - feel vibrations with palm
  • Increased = consolidation
  • Decreased = pleural effusion, pneumothorax

Percussion

• Always compare left and right at same level
• Resonant = normal
• Dull = consolidation, collapse, pleural thickening
• Stony dull = pleural effusion
• Hyper-resonant = pneumothorax, emphysema

Auscultation

• Breath sounds: vesicular (normal) / bronchial (consolidation)
• Added sounds:
  • Crackles (crepitations): Fine = pulmonary edema, fibrosis; Coarse = bronchiectasis, secretions
  • Wheeze (rhonchi): High-pitched = asthma; Low-pitched polyphonic = COPD
  • Pleural rub: Leathery creaking = pleurisy, PE
  • Vocal resonance: Increased over consolidation ("one-two-three" sounds clear = bronchophony, whisper sounds clear = whispering pectoriloquy)

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ABDOMINAL EXAMINATION - Key Steps

Inspection (patient supine, hands by side)

• Distension: generalized (ascites, gas, obesity, feces, fetus, fibroid, fat)
• Visible peristalsis (obstruction)
• Dilated veins: caput medusae (portal HTN), flow direction
• Scars, hernias, pulsations

Palpation

• Start from the quadrant AWAY from pain
• Superficial then deep palpation
• Look for guarding, rigidity (peritonism)
• Specific organs: liver, spleen, kidneys, bladder

• Start from RIF, move toward RUQ
• Comment on: size (cm below costal margin in MCL), surface (smooth/nodular), edge (sharp/rounded), consistency, tenderness, pulsatility

• Start from RIF, move toward LUQ
• Can't get ABOVE it (unlike kidney)
• Has a notch on medial border
• Moves with respiration
• Percuss Traube's space (dull = splenomegaly)

• Bimanual palpation (one hand posterior, one anterior)
• Ballotable (can ballot between two hands) = kidney
• Can get ABOVE it (unlike spleen)

Percussion

• Shifting dullness → fluid thrill = ascites
• Liver dullness, splenic dullness

Auscultation

• Bowel sounds: present / absent (obstruction, peritonitis) / hyperactive (early obstruction, diarrhea)
• Bruits over aorta, renal arteries (renal artery stenosis)

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HOW TO PRESENT YOUR EXAMINATION FINDINGS

"On general physical examination, the patient is conscious, oriented, and cooperative. He is moderately built and nourished. He is afebrile with a temperature of 98.6°F. Pulse is 88 bpm, regular, good volume. BP is 130/80 mmHg in the right arm. RR is 18/min. SpO2 is 97% on room air.

There is no pallor, icterus, cyanosis, clubbing, edema, or lymphadenopathy. JVP is not raised.

On systemic examination of the respiratory system: The chest is bilaterally symmetrical with equal expansion. Trachea is central. Vocal fremitus is increased in the right infrascapular area. Percussion note is dull in the right infrascapular area. On auscultation, bronchial breath sounds are heard with increased vocal resonance and whispering pectoriloquy in the right infrascapular region.

Provisional diagnosis: Right lower lobe consolidation - likely community-acquired pneumonia."

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QUICK REFERENCE - CLINICAL SIGNS BY CONDITION

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