---

🏥 GENERAL MEDICINE - COMPLETE PYQ ANSWER GUIDE

For Physiotherapy Students

---

📌 TOPIC 1: URINARY TRACT INFECTION (UTI)

Definition

Classification

• Upper UTI: Pyelonephritis (kidney infection)
• Lower UTI: Cystitis (bladder), Urethritis (urethra)
• Complicated vs Uncomplicated: Complicated = structural/functional abnormality, pregnancy, immunocompromised state

Causes (Organisms)

• Female sex (short urethra)
• Sexual activity ("honeymoon cystitis")
• Urinary obstruction (stones, BPH)
• Catheterization
• Diabetes mellitus
• Pregnancy
• Vesicoureteral reflux

Clinical Picture

• Dysuria (burning/pain on urination)
• Frequency and urgency of micturition
• Suprapubic discomfort
• Haematuria (blood in urine)
• Cloudy, foul-smelling urine
• No fever (or low-grade)

• All of the above PLUS:
• High fever with chills and rigors
• Loin/flank pain (costovertebral angle tenderness)
• Nausea and vomiting
• Systemic signs of infection

Investigations

• Urine routine microscopy: Pyuria (>5 WBC/hpf), bacteriuria, RBCs
• Urine culture and sensitivity (gold standard) - midstream clean catch
• Blood tests: CBC (leukocytosis), blood culture if sepsis suspected
• Ultrasound KUB: to rule out obstruction, abscess
• IVP/CT urogram: recurrent UTIs

Management/Treatment

• Trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days
• Nitrofurantoin for 5-7 days
• Ciprofloxacin for 3 days
• Increase fluid intake

• Oral fluoroquinolones (Ciprofloxacin) for 7-14 days
• Hospitalization if severe: IV antibiotics (Ceftriaxone, Gentamicin)
• IV fluids, antipyretics

• Low-dose prophylactic antibiotics
• Post-coital prophylaxis
• Treat underlying cause

---

📌 TOPIC 2: HYPERTENSION

Definition

• Primary (Essential): 90-95% - no identifiable cause
• Secondary: 5-10% - due to renal disease, endocrine causes, drugs

Clinical Features

• Headache (occipital, worse in morning)
• Dizziness and vertigo
• Blurred vision
• Epistaxis (nosebleed)
• Palpitations
• Shortness of breath

• Elevated BP on measurement
• Retinal changes (hypertensive retinopathy): AV nicking, flame hemorrhages, papilledema in severe cases
• Loud S2 (aortic component)
• LV hypertrophy - apex displaced laterally

Complications (REMEMBER: "REACH-H")

• Hypertensive nephrosclerosis
• Chronic kidney disease (CKD)
• Proteinuria, haematuria

• Hypertensive retinopathy grades I-IV
• Grade IV: papilledema (malignant hypertension)
• Retinal vein occlusion

• Coronary artery disease (angina, MI)
• Left ventricular hypertrophy
• Heart failure
• Aortic dissection and aneurysm

• Stroke (ischaemic or haemorrhagic) - most deadly complication
• Transient ischaemic attacks (TIA)
• Hypertensive encephalopathy

• Left ventricular hypertrophy (LVH)
• Cardiac failure (initially diastolic, then systolic)
• Atrial fibrillation

Management

• DASH diet (low salt, <2.3g/day)
• Weight reduction
• Regular aerobic exercise
• Reduce alcohol
• Stop smoking
• Stress management

• ACE inhibitors (Enalapril, Lisinopril): especially in diabetics, CKD
• ARBs (Losartan, Valsartan): if ACE inhibitor intolerant
• Calcium channel blockers (Amlodipine): elderly, isolated systolic HTN
• Thiazide diuretics (Hydrochlorothiazide): first-line in many patients
• Beta-blockers (Atenolol): with CAD, heart failure, tachycardia

---

📌 TOPIC 3: DIABETES MELLITUS

Definition

Diagnostic Criteria

• Fasting plasma glucose ≥ 126 mg/dL
• 2-hour glucose ≥ 200 mg/dL (OGTT)
• Random glucose ≥ 200 mg/dL + symptoms
• HbA1c ≥ 6.5%

Type I vs Type II Diabetes - Key Differences

Complications of Type II Diabetes Mellitus

1. Hyperosmolar Hyperglycaemic State (HHS/HONK): Very high blood sugar, severe dehydration, altered consciousness, NO significant ketosis
2. Hypoglycaemia: Due to insulin/drug overdose - sweating, tremors, palpitations, confusion

1. Diabetic Nephropathy: Proteinuria → nephrotic syndrome → CKD → end-stage renal disease
2. Diabetic Retinopathy: Background → proliferative → blindness (leading cause of blindness in working-age adults)
3. Diabetic Neuropathy: Peripheral (glove & stocking sensory loss), autonomic (postural hypotension, gastroparesis, impotence), mononeuropathy

---

📌 TOPIC 4: DIABETIC FOOT

Definition

Pathophysiology (Triad)

1. Peripheral neuropathy → loss of sensation → unnoticed injury
2. Peripheral vascular disease (ischaemia) → poor healing
3. Infection → rapid spread due to impaired immunity

Clinical Features

• Painless ulcers (typically plantar, pressure points)
• Charcot's neuropathic joint (deformed, Rocker-bottom foot)
• Cold, pulseless foot (ischaemia)
• Gangrene (dry or wet)
• Cellulitis, abscess
• Discoloration, callus formation
• Wagner's Classification: Grade 0 (intact skin at risk) to Grade 5 (extensive gangrene)

Management

• Strict glycaemic control (HbA1c < 7%)
• Wound debridement
• Antibiotics (broad spectrum - aerobic + anaerobic coverage)
• Offloading pressure (total contact cast, special footwear)
• Vascular surgery / revascularization if ischemic
• Amputation as last resort
• Patient education: Daily foot inspection, proper footwear

---

📌 TOPIC 5: ANAEMIA & IRON DEFICIENCY ANAEMIA

Definition

• Males: Hb < 13 g/dL
• Females: Hb < 12 g/dL
• Children: Hb < 11 g/dL (WHO)

Classification of Anaemia

1. Blood loss (acute/chronic)
2. Decreased production (nutritional, aplastic, bone marrow suppression)
3. Increased destruction (haemolytic anaemia)

Iron Deficiency Anaemia (IDA)

• Increased demand: Pregnancy, infancy, adolescence
• Decreased intake: Poor diet (vegetarians, poverty)
• Decreased absorption: Coeliac disease, gastrectomy, antacids
• Chronic blood loss: Menorrhagia (most common in women), GI bleed (peptic ulcer, colorectal cancer), hookworm infestation

Clinical Features

• Pallor (conjunctival, palmar, nail bed)
• Fatigue, weakness, easy fatigability
• Breathlessness on exertion
• Palpitations and tachycardia
• Headache, difficulty concentrating
• Pedal oedema in severe cases

• Koilonychia (spoon-shaped nails)
• Angular stomatitis (cracking at corners of mouth)
• Glossitis (smooth, sore tongue)
• Dysphagia (in Plummer-Vinson syndrome)
• Pica (craving for chalk, mud, ice)
• Blue sclerae

Investigations

• CBC: Low Hb, Low MCV, Low MCH, Low MCHC
• Peripheral smear: Microcytic, hypochromic RBCs, target cells, pencil cells
• Serum ferritin: Low (best marker of iron stores)
• Serum iron: Low
• TIBC (Total Iron Binding Capacity): High
• Transferrin saturation: Low (<16%)
• Reticulocyte count: Normal or slightly raised

Management

1. Treat the underlying cause (e.g., treat menorrhagia, hookworm)
2. Oral iron: Ferrous sulphate 200mg TDS (3 times daily) for 3-6 months
   • Take on empty stomach with Vitamin C (for absorption)
   • Side effects: constipation, black stools, nausea
3. Parenteral iron: IV/IM when oral not tolerated or absorption impaired
4. Blood transfusion: Only if severe or cardiac compromise
5. Dietary advice: Red meat, green leafy vegetables, legumes, fortified foods
6. Response: Reticulocytosis in 5-10 days; Hb rises ~1g/dL/week

---

📌 TOPIC 6: COMMUNICABLE DISEASES - MODES OF TRANSFER

Definition

Modes of Transmission

• Skin-to-skin: Scabies, ringworm, impetigo
• Sexual contact: HIV/AIDS, gonorrhoea, syphilis, Hepatitis B
• Droplet infection (large droplets, <1m): Influenza, common cold, mumps, meningococcal meningitis

• Mother to fetus: Rubella, CMV, HIV, Syphilis (TORCH infections)

---

• Fomites (contaminated inanimate objects): Smallpox, diphtheria, trachoma
• Water: Cholera, typhoid, hepatitis A, dysentery
• Food: Salmonella, staphylococcal food poisoning, E. coli
• Blood/blood products: HIV, Hepatitis B and C
• Soil: Tetanus, hookworm, anthrax

• Biological vectors (pathogen multiplies in vector):
  • Mosquito (Anopheles): Malaria
  • Mosquito (Aedes): Dengue, yellow fever, chikungunya
  • Mosquito (Culex): Filariasis, Japanese encephalitis
  • Sandfly: Kala-azar (Leishmaniasis)
  • Tsetse fly: African sleeping sickness
  • Louse: Typhus
• Mechanical vectors (no multiplication): Housefly carrying typhoid/cholera

• Pulmonary tuberculosis
• Measles
• Chickenpox
• COVID-19

• Tetanus (Clostridium tetani spores)
• Hookworm (larvae penetrate skin)
• Anthrax

---

📌 TOPIC 7: SCHIZOPHRENIA - SALIENT FEATURES

Definition

Salient (Key) Features - Schneider's First Rank Symptoms

1. Hallucinations: Perceptions without external stimuli
   • Auditory (most common in schizophrenia): hearing voices commenting, arguing
   • Visual, olfactory, tactile less common
2. Delusions: Fixed false beliefs not amenable to reason
   • Persecutory (paranoid): being followed, poisoned
   • Grandiose: believing one has special powers
   • Reference: events refer to self
   • Thought insertion/withdrawal/broadcasting
3. Disorganized Thinking (Formal Thought Disorder):
   • Loose associations (derailment)
   • Tangential thinking
   • Word salad (incoherence)
4. Disorganized or Catatonic Behavior:
   • Unpredictable agitation
   • Catatonic posturing (waxy flexibility)
   • Catatonic stupor

1. Affective flattening - diminished emotional expression
2. Alogia - poverty of speech
3. Avolition - lack of motivation
4. Anhedonia - inability to feel pleasure
5. Asociality - social withdrawal

• Poor working memory, attention deficits
• Poor executive function

Diagnosis (DSM-5 Criteria)

• Delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms
• At least 1 must be delusions, hallucinations, or disorganized speech
• Social/occupational dysfunction for ≥6 months

Management

• Antipsychotics (first-line):
  • Typical (older): Haloperidol, Chlorpromazine
  • Atypical (newer, fewer side effects): Risperidone, Olanzapine, Clozapine
• Psychosocial:
  • Cognitive Behavioral Therapy (CBT)
  • Family therapy
  • Social skills training
  • Occupational rehabilitation

---

📌 TOPIC 8: HYPOTHYROIDISM - CLINICAL FEATURES

Definition

Causes

• Primary: Hashimoto's thyroiditis (most common, autoimmune), iodine deficiency, radioiodine treatment, thyroidectomy
• Secondary: Pituitary failure (low TSH)
• Tertiary: Hypothalamic failure

Clinical Features (Remember: EVERYTHING SLOWS DOWN)

• Fatigue, lethargy, excessive sleepiness
• Weight gain despite poor appetite
• Cold intolerance
• Constipation
• Dry, coarse, rough skin
• Hair loss (coarse, brittle hair), loss of outer 1/3 of eyebrow (Hertoghe sign)

• Puffy face (periorbital puffiness/oedema)
• Macroglossia (enlarged tongue)
• Hoarse voice (myxoedematous infiltration of larynx)
• Goitre (enlarged thyroid gland)
• Dull, expressionless facies

• Bradycardia
• Hypertension (diastolic)
• Pericardial effusion
• Cardiomegaly

• Slowed speech, slow thinking
• Depression
• Psychosis (rare - "myxoedema madness")
• Delayed relaxation of deep tendon reflexes (hallmark sign)
• Carpal tunnel syndrome
• Cerebellar ataxia (rare)

• Proximal myopathy (muscle weakness)
• Myalgia, muscle cramps
• Arthralgia

• Menorrhagia (heavy periods)
• Infertility

• TSH: High (primary hypothyroidism) - most sensitive test
• Free T4: Low
• Thyroid peroxidase antibodies (TPO-Ab): Positive in Hashimoto's
• Lipid profile: High cholesterol, high LDL

---

📌 TOPIC 9: HYPERTHYROIDISM - CLINICAL FEATURES

Definition

Causes

• Graves' disease (most common, autoimmune - TSH receptor antibodies)
• Toxic multinodular goitre
• Toxic adenoma
• Excessive thyroxine intake

Clinical Features (EVERYTHING SPEEDS UP)

• Weight loss despite increased appetite
• Heat intolerance, excessive sweating
• Tremors (fine tremor of hands)

• Tachycardia, palpitations
• Atrial fibrillation
• Wide pulse pressure
• Cardiac failure (high-output)

• Anxiety, irritability, emotional lability
• Insomnia
• Hyperreflexia

• Increased appetite
• Diarrhoea

• Exophthalmos (proptosis) - eyes pushed forward
• Lid lag, lid retraction
• Ophthalmoplegia

• Proximal myopathy

• Oligomenorrhoea (scanty/infrequent periods)

---

📌 TOPIC 10: CIRRHOSIS

Definition

Causes

• Chronic alcohol abuse (most common in western countries)
• Viral hepatitis B and C (most common worldwide)
• Non-alcoholic fatty liver disease (NAFLD/NASH)
• Autoimmune hepatitis
• Primary biliary cirrhosis/cholangitis
• Wilson's disease, Haemochromatosis (metabolic)
• Drugs (Methotrexate, Amiodarone)

Clinical Features

• Often asymptomatic
• Mild fatigue, anorexia
• Spider naevi (spider angiomata) - on upper body
• Palmar erythema
• Hepatosplenomegaly
• Parotid enlargement (in alcoholics)
• Clubbing, leukonychia (white nails)

1. Jaundice: Yellow discoloration of sclera, skin, urine
2. Ascites: Fluid in abdomen (portal hypertension + low albumin)
3. Oedema: Peripheral pitting oedema
4. Hepatic Encephalopathy: Confusion, altered consciousness, asterixis (flapping tremor), coma
5. Variceal Haemorrhage: Bleeding from oesophageal/gastric varices → haematemesis (bloody vomit), melaena
6. Spontaneous Bacterial Peritonitis (SBP): Infection of ascitic fluid
7. Hepatorenal Syndrome: Renal failure in advanced cirrhosis
8. Coagulopathy: Bruising, bleeding tendency (low clotting factors)

• Splenomegaly
• Oesophageal varices
• Caput medusae (distended veins around umbilicus)
• Rectal varices

• Treat underlying cause (stop alcohol, antiviral for hepatitis)
• Ascites: Salt restriction, diuretics (spironolactone + furosemide), therapeutic paracentesis
• Encephalopathy: Lactulose, Rifaximin, protein restriction
• Varices: Propranolol (prophylaxis), endoscopic band ligation, TIPS
• Liver transplant (definitive)

---

📌 TOPIC 11: HEPATITIS B

Definition

Transmission

• Sexual contact (most common in developed countries)
• Parenteral route: Blood transfusion, IV drug use, contaminated needles
• Vertical: Mother to child (perinatal - most important in endemic areas like India)
• Healthcare workers: Needlestick injuries
• NOT transmitted by casual contact, food, water

Incubation Period

Clinical Features

• Pre-icteric phase: Fatigue, malaise, anorexia, nausea, vomiting, fever, arthralgia, right upper quadrant pain (1-2 weeks)
• Icteric phase: Jaundice (yellow eyes/skin), dark urine (tea-colored), pale stools, hepatomegaly, tender liver, splenomegaly
• Post-icteric phase: Gradual recovery over weeks

• 95% adults: Full recovery → immunity
• 5% adults → Chronic Hepatitis B
• 90% neonates → Chronic HBV (high vertical transmission)

Serology Markers

• HBsAg: Marker of infection (positive in acute + chronic)
• Anti-HBs: Marker of immunity (vaccination or recovery)
• HBeAg: Marker of high infectivity/replication
• Anti-HBe: Seroconversion (decreasing infectivity)
• Anti-HBc IgM: Acute infection (window period)
• HBV DNA: Viral load (most sensitive for active replication)

Management

• Acute: Supportive (rest, fluids, nutrition)
• Chronic: Antiviral therapy - Tenofovir (TDF), Entecavir (first-line)
• Prevention: HBV Vaccine (most important - 3 doses: 0, 1, 6 months)
• Post-exposure prophylaxis: Hepatitis B Immunoglobulin (HBIG) + vaccine

---

📌 TOPIC 12: HEPATITIS C

Risk Factors

• IV drug use (most common route in developed countries)
• Blood transfusion (pre-screening era)
• Healthcare worker needlestick injuries
• Sexual transmission (less efficient than HBV)
• Vertical transmission (less common than HBV)
• Tattoos, body piercing with contaminated equipment

Clinical Features

• Most (80%) are asymptomatic in acute phase
• Acute: Mild jaundice, fatigue, nausea (if symptomatic)
• 80% of HCV infections become chronic (vs 5% for HBV)
• Chronic HCV: Slowly progressive liver damage over 20-30 years
• → Cirrhosis → Hepatocellular carcinoma

• Cryoglobulinaemia (vasculitis, purpura)
• Membranoproliferative glomerulonephritis
• Sjögren-like syndrome

Treatment

• Direct Acting Antivirals (DAAs): Sofosbuvir + Ledipasvir/Daclatasvir/Velpatasvir
• Cure rate >95%, oral treatment for 8-12 weeks
• No vaccine available for HCV

---

📌 TOPIC 13: CORONARY ARTERY DISEASE (CAD) & MYOCARDIAL INFARCTION

Definition

Risk Factors

• Age (men >45, women >55)
• Male sex
• Family history of premature CAD
• Genetics

• Dyslipidaemia: High LDL, low HDL, high triglycerides
• Hypertension (most common risk factor in India)
• Diabetes mellitus
• Cigarette smoking
• Obesity (BMI >30)
• Physical inactivity
• Metabolic syndrome
• Stress (Type A personality)

Clinical Features of CAD

• Central chest pain/pressure on exertion
• Radiates to left arm, jaw, back
• Relieved by rest or GTN (nitroglycerine) in <5 minutes
• Precipitated by exercise, cold, stress, meals

1. Unstable Angina: Pain at rest or increasing pattern, no enzyme rise
2. NSTEMI: Partial blockage, elevated troponin, no ST elevation
3. STEMI (Myocardial Infarction): Complete coronary artery occlusion

Features of Myocardial Infarction (STEMI)

• Severe crushing/squeezing central chest pain - worse than angina
• Radiation to left arm, jaw, back
• NOT relieved by GTN
• Sweating (diaphoresis), cold and clammy skin
• Nausea, vomiting
• Dyspnoea
• Feeling of impending doom
• In diabetics/elderly: Silent MI (no pain)

• Tachycardia (or bradycardia if inferior MI)
• Hypotension (cardiogenic shock in severe cases)
• Signs of heart failure

• ECG: ST elevation, pathological Q waves, T wave inversion
• Troponin I/T: Rises in 3-6 hours, peaks 24-48h (most specific marker)
• CK-MB: Rises in 3-6h, normalises in 48-72h
• ECHO: Wall motion abnormality

Management of MI

• MONA (immediate): Morphine, Oxygen, Nitrates, Aspirin
• Dual antiplatelet: Aspirin + Clopidogrel/Ticagrelor
• Anticoagulants: Heparin
• Reperfusion (most important):
  • Primary PCI (percutaneous coronary intervention): within 90 minutes (preferred)
  • Thrombolysis (streptokinase, tPA): if PCI not available within 2 hours
• Long-term: Statins, ACE inhibitors, Beta-blockers, aspirin

---

📌 TOPIC 14: TUBERCULOSIS (TB)

Organs Affected by Tuberculosis

1. Lungs (most common - 85%) - Pulmonary TB
2. Lymph nodes (TB lymphadenitis) - most common extrapulmonary
3. Pleura (pleural effusion)
4. Bones and joints (Pott's disease - vertebral TB)
5. Meninges (TB meningitis)
6. Kidneys and genitourinary tract
7. Bowel (intestinal TB)
8. Liver, spleen (miliary TB)
9. Pericardium
10. Skin (lupus vulgaris)
11. Adrenal glands
12. Eyes (uveitis)

Pulmonary Tuberculosis - Clinical Features

• Chronic cough (>3 weeks) - initially dry, then productive
• Haemoptysis (blood in sputum) - important feature
• Fever - low-grade, especially evening rise
• Night sweats - drenching night sweats
• Weight loss and anorexia - significant weight loss
• Fatigue and weakness
• Chest pain (pleuritic)
• Breathlessness (in extensive disease)

• Cachexia (muscle wasting)
• Pallor
• Clubbing (chronic)
• Dullness to percussion (consolidation/effusion)
• Bronchial breathing, crepitations
• Cervical lymphadenopathy

Diagnosis

• Sputum AFB smear (Ziehl-Neelsen stain): Simple, quick - direct smear for acid-fast bacilli
• Sputum culture: Gold standard (but slow - 4-8 weeks on Lowenstein-Jensen medium)
• GeneXpert MTB/RIF: Rapid molecular test, also detects rifampicin resistance
• Chest X-ray: Upper lobe infiltrates, cavitation, calcification, hilar adenopathy
• Tuberculin skin test (Mantoux): Induration ≥10mm = positive
• IGRA (Interferon Gamma Release Assay): QuantiFERON test

Management (RIPE)

• First-line drugs: Rifampicin (R), Isoniazid (H/I), Pyrazinamide (Z/P), Ethambutol (E)
• Intensive phase: 2 months of RHZE
• Continuation phase: 4 months of RH
• Total duration: 6 months (non-severe); 9-12 months for severe/extrapulmonary

---

📌 TOPIC 15: HIV/AIDS

Modes of Spread of HIV

1. Sexual transmission (most common worldwide)
   • Unprotected sexual intercourse (anal > vaginal > oral)
   • Homosexual/heterosexual
2. Parenteral (Blood-borne)
   • IV drug users sharing needles
   • Blood and blood product transfusion
   • Organ transplantation
   • Needlestick injuries (healthcare workers)
3. Vertical (Mother to Child)
   • During pregnancy (transplacental)
   • During delivery (intrapartum - most common)
   • Breastfeeding (postnatal)

• Casual contact, hugging, sharing utensils
• Mosquitoes or other insects
• Coughing, sneezing
• Toilet seats, swimming pools

Clinical Features of AIDS

• Asymptomatic
• Persistent generalized lymphadenopathy (PGL)
• CD4 >500 cells/mm³

• Minor weight loss (<10%)
• Recurrent URTI
• Herpes zoster
• Angular cheilitis
• Oral ulcers

• Weight loss >10%
• Chronic diarrhoea >1 month
• Oral candidiasis
• Pulmonary TB
• CD4 200-350 cells/mm³

• Opportunistic infections:
  • PCP (Pneumocystis jirovecii pneumonia) - most common AIDS-defining illness
  • CMV retinitis → blindness
  • Cryptococcal meningitis
  • Toxoplasmosis (brain abscess)
  • Disseminated Mycobacterium avium complex (MAC)
  • Esophageal candidiasis
• HIV wasting syndrome: >10% weight loss
• AIDS-defining malignancies:
  • Kaposi's sarcoma (skin purple lesions)
  • Non-Hodgkin's lymphoma
  • Cervical cancer
• CD4 <200 cells/mm³

Management

• Antiretroviral Therapy (ART): Lifelong, started regardless of CD4 count
• First-line regimen (India): Tenofovir + Lamivudine + Efavirenz (TLE)
• Prophylaxis: Co-trimoxazole (for PCP when CD4 <200)
• Prevention: Safe sex (condoms), clean needles, blood screening, PMTCT (Prevention of Mother to Child Transmission)
• No cure; treatment controls viral replication

---

📌 TOPIC 16: SWINE FLU (H1N1 Influenza)

Definition

Spread (Transmission)

• Droplet transmission: Coughing, sneezing (main route)
• Direct contact: Touching contaminated surfaces then touching face
• NOT from eating cooked pork
• Spreads person to person
• Incubation period: 1-7 days (average 3 days)

Clinical Features

• Fever (>38°C) - sudden onset
• Cough (often dry)
• Sore throat
• Runny or stuffy nose
• Body aches and myalgia
• Headache
• Chills
• Fatigue
• Diarrhoea and vomiting (more common than seasonal flu)

• Dyspnoea/breathlessness
• Bluish skin (cyanosis)
• Persistent vomiting, dehydration
• Confusion/altered mental status
• Chest pain

• Elderly, young children, pregnant women
• Chronic diseases (diabetes, heart disease, lung disease)
• Immunocompromised patients

Prevention

• Oseltamivir (Tamiflu) vaccine - annual vaccination recommended
• Hand hygiene (frequent washing with soap)
• Covering mouth/nose when coughing/sneezing
• Avoiding crowded places during outbreaks
• Wearing masks (N95)
• Isolation of suspected cases

Treatment

• Oseltamivir (Tamiflu): 75mg twice daily for 5 days (antiviral)
• Zanamivir (inhaled) as alternative
• Supportive: rest, fluids, antipyretics, analgesics
• Hospitalization for severe cases

---

📌 TOPIC 17: COPD (Chronic Obstructive Pulmonary Disease)

Definition

Causes

• Cigarette smoking (most important cause - 90%)
• Air pollution (outdoor and indoor - biomass fuel)
• Occupational dust and chemicals
• Alpha-1 antitrypsin deficiency (genetic, rare)
• Recurrent childhood respiratory infections

Types

1. Chronic Bronchitis - "Blue Bloater": productive cough for ≥3 months/year for ≥2 consecutive years, cyanosis, oedema
2. Emphysema - "Pink Puffer": destruction of alveolar walls, barrel chest, pursed-lip breathing, little cyanosis

Clinical Features

• Chronic cough (productive)
• Increased sputum production
• Progressive breathlessness on exertion (main complaint)
• Wheeze
• Barrel chest (increased AP diameter)
• Pursed-lip breathing
• Use of accessory muscles of respiration
• Reduced breath sounds
• Cyanosis (blue lips, fingertips)
• Finger clubbing
• Cor pulmonale (right heart failure): raised JVP, ankle oedema, hepatomegaly

Management

• Smoking cessation (most important intervention - slows progression)
• Pulmonary rehabilitation
• Oxygen therapy (long-term in severe hypoxaemia - >15 hours/day)
• Vaccinations: Influenza, Pneumococcal

• Bronchodilators (first-line):
  • Short-acting beta-2 agonist (SABA): Salbutamol
  • Long-acting beta-2 agonist (LABA): Salmeterol, Formoterol
  • Long-acting anticholinergic (LAMA): Tiotropium
• Inhaled Corticosteroids (ICS): Fluticasone (added if frequent exacerbations)
• Oral theophylline: Add-on therapy
• Roflumilast: PDE-4 inhibitor for severe COPD

• Increased bronchodilators
• Systemic corticosteroids (Prednisolone 30-40mg for 5-7 days)
• Antibiotics if infection suspected

• Smoking cessation and prevention
• Reducing indoor air pollution
• Occupational health measures
• Vaccinations
• Early detection and treatment

---

📌 TOPIC 18: BRONCHIAL ASTHMA

Definition

Precipitating Factors (Triggers)

1. Allergens: Dust mites, pollen, mould, pet dander, cockroach
2. Respiratory infections: Viral URI (most common trigger in children), bacterial
3. Exercise (Exercise-induced asthma)
4. Cold air
5. Air pollutants: Tobacco smoke, traffic fumes, occupational chemicals
6. Drugs: Aspirin/NSAIDs (Samter's triad), beta-blockers
7. Emotional stress and anxiety
8. GERD (gastroesophageal reflux)
9. Occupational agents: Isocyanates, flour, latex
10. Hormonal changes: Menstruation, pregnancy
11. Food additives: Sulphites (in wine, dried fruit), tartrazine

Clinical Features

• Episodic breathlessness (dyspnoea)
• Wheeze (expiratory wheeze)
• Chest tightness
• Cough (especially nocturnal/early morning)
• Symptoms worsen at night or in early morning

• Bilateral expiratory wheeze
• Prolonged expiration
• Use of accessory muscles
• Tachypnoea

Management

• Reliever: SABA (Salbutamol) - used as needed for acute symptoms
• Controller/Preventer: Inhaled corticosteroids (ICS) - Beclomethasone
• LABA + ICS combination for persistent asthma
• Leukotriene receptor antagonists: Montelukast
• Biologics for severe asthma: Omalizumab (anti-IgE)
• Acute attack: Nebulised Salbutamol + Ipratropium, systemic steroids, O2, IV Magnesium if severe

---

📌 TOPIC 19: SKIN CONDITIONS

A. Classification of Skin Lesions

• Scale, crust, erosion, ulcer, fissure, scar, atrophy, excoriation

B. Urticaria (Hives)

• Allergic (IgE-mediated - Type I hypersensitivity): drugs (penicillin, aspirin), foods (nuts, seafood, eggs), insect stings
• Physical: cold urticaria, heat, pressure, dermographism (skin writing), exercise
• Infections: viral, bacterial, parasitic
• Autoimmune
• Idiopathic (50% cases)
• Chronic urticaria: >6 weeks duration

• Intensely itchy wheals/hives
• Multiple raised erythematous plaques with central pallor
• Lesions come and go (transient - each lesion <24 hours)
• No scarring
• Can be accompanied by angioedema (deeper swelling of lips, tongue, throat - dangerous if airway involved)
• Dermatographism: writing on skin produces wheal

• Remove/avoid triggering cause (most important)
• Antihistamines (first-line):
  • Non-sedating (2nd generation): Cetirizine, Loratadine (preferred)
  • Sedating (1st generation): Chlorphenamine (for acute/severe)
• Corticosteroids (short course): for severe/resistant cases
• Anaphylaxis with urticaria: Adrenaline (Epinephrine) 0.5mg IM - EMERGENCY
• Anti-IgE (Omalizumab): for chronic refractory urticaria
• Avoid aspirin, NSAIDs, alcohol (can worsen)

C. Acne Vulgaris

1. Increased sebum production (androgens)
2. Follicular hyperkeratosis (plugging)
3. Cutibacterium acnes (bacteria) proliferation
4. Inflammation

• Comedones (open = blackheads, closed = whiteheads)
• Papules and pustules
• Nodules and cysts (severe)
• Scarring
• Mainly face, chest, upper back

• Mild: Topical retinoids, benzoyl peroxide, topical antibiotics (clindamycin)
• Moderate: Oral antibiotics (doxycycline, minocycline) + topical
• Severe (nodular/cystic): Oral isotretinoin (Accutane) - most effective
• Hormonal (females): Combined OCP, spironolactone

D. Psoriasis

• Well-demarcated, erythematous plaques with silvery-white scales
• Mainly on extensor surfaces (elbows, knees), scalp, lower back
• Koebner's phenomenon (lesions appear at trauma sites)
• Auspitz sign (pinpoint bleeding when scale removed)
• Nail changes: pitting, onycholysis, subungual hyperkeratosis
• Psoriatic arthritis (15-20% cases)

• Topical: Corticosteroids, vitamin D analogues (calcipotriol), tar, retinoids
• Phototherapy: Narrowband UVB, PUVA
• Systemic (severe): Methotrexate, Cyclosporine, Acitretin
• Biologics: Anti-TNF (Adalimumab, Infliximab), anti-IL-17 (Secukinumab)

E. Fungal Infections of Skin

1. Tinea (Dermatophytosis):
   • Tinea capitis (scalp - ringworm of scalp)
   • Tinea corporis (body - ringworm)
   • Tinea cruris (groin - "jock itch")
   • Tinea pedis (foot - "athlete's foot")
   • Tinea unguium (nails = Onychomycosis)
   • Features: Circular, red, scaly ring-shaped lesion with central clearing
2. Candidiasis:
   • Oral thrush (white plaques in mouth)
   • Vaginal candidiasis (curdy white discharge, itching)
   • Intertrigo (skin folds)
   • Risk factors: Diabetes, antibiotics, immunosuppression
3. Pityriasis versicolor: Malassezia furfur; hypo/hyperpigmented patches, fine scaling on trunk

---

📌 TOPIC 20: UROLITHIASIS (KIDNEY STONES) & HEMATURIA

Hematuria - Definition

• Gross/macroscopic: Visible to naked eye
• Microscopic: >3 RBC/HPF on microscopy

Urolithiasis - Clinical Features

• Renal colic: Severe, colicky (wave-like) pain - originates in loin, radiates to groin, inner thigh, labia/scrotum
• Haematuria (blood in urine)
• Nausea and vomiting
• Restlessness (unable to find comfortable position)
• Fever if infection superimposed (urosepsis)
• Symptoms of obstruction: oliguria, anuria

• Urinalysis: RBCs, WBCs if infection, pH
• CT-KUB (non-contrast) - gold standard for stone diagnosis
• Ultrasound abdomen (first-line, especially for renal stones)
• X-ray KUB: radio-opaque stones (calcium, struvite)
• IVU (Intravenous Urography)
• Stone analysis

• Conservative (stones <5mm usually pass spontaneously):
  • High fluid intake (>2-3L/day)
  • Analgesia (NSAIDs, opioids for colic)
  • Alpha-blockers (Tamsulosin) for ureteric stones
• Interventional:
  • Extracorporeal Shock Wave Lithotripsy (ESWL): non-invasive, for small-medium renal stones
  • Ureteroscopy (URS) + laser lithotripsy: ureteric stones
  • Percutaneous Nephrolithotomy (PCNL): large/complex renal stones (>2cm)
  • Open surgery: rarely needed

---

📌 TOPIC 21: GERD (Gastroesophageal Reflux Disease)

Definition

Clinical Features

• Heartburn (pyrosis) - burning sensation in chest, behind sternum, worse after meals, lying down, bending
• Regurgitation - sour/acid taste in mouth, fluid coming back up
• Waterbrash - excess saliva due to esophageal acid irritation

• Chronic cough (acid aspiration)
• Hoarse voice (laryngopharyngeal reflux)
• Asthma exacerbation
• Dental erosions
• Chest pain (non-cardiac)

• Oesophagitis
• Oesophageal stricture (dysphagia)
• Barrett's oesophagus (metaplasia - risk of adenocarcinoma)

• Lifestyle: Weight loss, avoid precipitants (fatty food, coffee, alcohol, spicy food), elevate head of bed, small frequent meals, avoid lying down after meals
• Proton Pump Inhibitors (PPIs): Omeprazole, Pantoprazole - first-line pharmacotherapy
• H2-receptor antagonists: Ranitidine (second-line)
• Antacids: Symptom relief
• Surgery: Fundoplication (Nissen) for resistant cases

---

📌 TOPIC 22: LUNG ABSCESS

Definition

Causes

• Aspiration (most common): Anaerobic organisms, in patients with impaired consciousness (alcoholics, seizures, post-anaesthesia)
• Pneumonia (secondary lung abscess - Staphylococcus aureus, Klebsiella)
• Septic emboli (IV drug users, endocarditis)
• Obstruction (tumour, foreign body)
• Amoebic abscess (right lower lobe, rupture from liver)
• Immunocompromised (TB, Nocardia, fungi)

Clinical Features

• Fever with chills and sweats
• Putrid, foul-smelling sputum (in anaerobic infections - hallmark)
• Productive cough with copious sputum
• Haemoptysis
• Chest pain (pleuritic)
• Weight loss, malaise
• Clubbing (if chronic)
• On auscultation: bronchial breathing, amphoric breath sounds over cavity

Investigations

• Chest X-ray: Cavity with air-fluid level (hallmark)
• CT chest: More detail
• Sputum culture
• Bronchoscopy: if obstruction suspected or to obtain cultures

Management

• Prolonged antibiotics (4-6 weeks minimum):
  • Anaerobic: Metronidazole + Penicillin or Amoxicillin-clavulanate
  • If Staphylococcus: Flucloxacillin or Vancomycin (MRSA)
• Postural drainage and chest physiotherapy (IMPORTANT for physiotherapists!)
• Surgical drainage or resection: if no response to medical treatment

---

📌 TOPIC 23: LIVER ABSCESS

Types

1. Pyogenic (Bacterial) Liver Abscess: E. coli, Klebsiella (usually multiple, right lobe)
2. Amoebic Liver Abscess: Entamoeba histolytica (single, right lobe, "anchovy paste" pus)

Clinical Features

• Fever with chills
• Right upper quadrant pain
• Tender hepatomegaly
• Jaundice (mild)
• Weight loss
• Referred right shoulder tip pain (diaphragm irritation)

Management

• Aspiration or drainage (ultrasound-guided)
• Antibiotics: Metronidazole (for amoebic), broad-spectrum for pyogenic

---

📌 TOPIC 24: PROTEIN DEFICIENCY DISEASES

A. Kwashiorkor (Protein Deficiency with adequate calories)

• Age: Typically 1-3 years (weaned child)
• Cause: Adequate carbohydrate but protein-deficient diet

• Oedema (pitting, most characteristic) - due to hypoalbuminaemia
• Growth retardation
• Muscle wasting (hidden by oedema)
• Moon face (puffy face)
• Hepatomegaly (fatty liver)
• Skin: Dermatosis - "flaky paint" depigmentation, "crazy-paving" appearance
• Hair changes: Sparse, fine, depigmented, easily pluckable (Flag sign - alternating bands)
• Apathetic, irritable, miserable child
• Serum albumin: Very low

B. Marasmus (Protein-Energy Malnutrition)

• Age: <1 year typically
• Cause: Severe deficiency of both protein AND calories

• Severe muscle wasting - "skin and bones" appearance
• "Old man face" (senile facies)
• Loss of subcutaneous fat - "baggy pants" skin folds
• No oedema (distinguishes from kwashiorkor)
• Severe weight loss (>60% expected weight)
• Alert and hungry but weak
• Hair and skin relatively normal

C. Marasmic Kwashiorkor

• Combined features of both

Management

• WHO 10-step protocol for severe malnutrition
• F-75 formula (low protein, low energy initially) → F-100 (catch-up growth)
• Therapeutic Ready-to-Use Food (RUTF): Plumpynut
• Micronutrient supplementation (zinc, Vitamin A, folate, iron)
• Treat infections

---

📌 TOPIC 25: OLIGURIA

Definition

Causes (Pre-renal, Renal, Post-renal)

• Hypovolaemia: dehydration, hemorrhage, burns
• Reduced cardiac output: Heart failure, cardiogenic shock
• Decreased vascular tone: Septicaemia, anaphylaxis, liver failure

• Acute tubular necrosis (ATN) - most common intrinsic cause
• Glomerulonephritis
• Interstitial nephritis (drugs)
• Vascular: Renal artery/vein thrombosis

• Bladder outlet obstruction: BPH, urethral stricture
• Bilateral ureteric obstruction: Stones, tumour, retroperitoneal fibrosis
• Blocked urinary catheter

Management

• Identify and treat underlying cause
• Fluid challenge (250-500ml NS) - for pre-renal
• Catheterize (for post-renal/monitoring)
• Dialysis if renal failure severe
• Monitor urine output, creatinine, electrolytes

---

📌 TOPIC 26: HOARSE VOICE - CAUSES AND MANAGEMENT

Definition

Causes

• Acute laryngitis (most common) - viral/bacterial, excessive voice use
• Chronic laryngitis - smoking, chronic irritants
• Vocal cord nodules (singer's nodules, "screamer's nodules")
• Vocal cord polyps
• Vocal cord cysts
• Functional dysphonia

• Hypothyroidism (myxoedema infiltration of vocal cords)
• GERD (laryngopharyngeal reflux)
• Reinke's oedema (smokers)

• Recurrent laryngeal nerve (RLN) palsy:
  • Left RLN: Mediastinal lymphoma, lung cancer (Pancoast), aortic aneurysm
  • Right RLN: Thyroid surgery, subclavian vessel disease
• Upper motor neurone lesions

• Laryngeal carcinoma (most important to exclude)
• Thyroid carcinoma invading larynx
• Metastatic lymph nodes compressing RLN

• Intubation injury
• Neck trauma

Management

• History: Duration, progression, smoking, voice use, dysphagia, weight loss
• Investigation: Laryngoscopy (direct or indirect - essential investigation)
• Treat underlying cause
• Voice rest for acute laryngitis
• Speech therapy for vocal cord lesions/functional dysphonia
• Surgery: Microlaryngoscopy for polyps, nodules, laryngeal cancer

---

📌 TOPIC 27: ECT (Electroconvulsive Therapy)

Definition

Indications (IMPORTANT)

1. Severe depression with psychotic features or suicidal risk
2. Severe depression not responding to antidepressants
3. Bipolar disorder - severe manic or depressive episode
4. Schizophrenia - catatonic type
5. Post-partum psychosis
6. Rapid response needed (suicidal, refusing food/water)

Contraindications

• Recent MI or stroke
• Raised intracranial pressure
• Aortic aneurysm
• Phaeochromocytoma

Procedure

• Written informed consent
• Pre-ECT: Fasting, ECG, blood tests
• General anaesthesia + muscle relaxant (to prevent injury during seizure)
• Electrode placement (bilateral/unilateral)
• Brief electrical stimulus (0.5-2 seconds) induces grand mal seizure (30-90 seconds)
• Monitoring: ECG, EEG, SpO2
• Typically: 6-12 sessions (2-3 times/week)

Side Effects

• Short-term: Confusion, headache, muscle aches
• Memory loss (most common complaint): retrograde and anterograde amnesia (usually temporary)
• Cardiovascular: Bradycardia, hypertension (transient)
• Bone fractures (prevented by muscle relaxants)

---

📌 TOPIC 28: HEART MALFORMATIONS (Congenital Heart Disease)

Classification

1. VSD (Ventricular Septal Defect) - most common CHD overall
   • Harsh pansystolic murmur at left sternal border
   • Can cause Eisenmenger's syndrome (reversal of shunt → cyanosis)
2. ASD (Atrial Septal Defect)
   • Ejection systolic murmur, fixed split S2
   • Often asymptomatic in childhood
3. PDA (Patent Ductus Arteriosus)
   • Continuous "machinery" murmur
   • More common in premature infants, rubella
4. Coarctation of Aorta
   • Hypertension in arms, weak pulses in legs
   • Rib notching on CXR

1. Tetralogy of Fallot (TOF) - most common cyanotic CHD
   • Four features: VSD + Right Ventricular Hypertrophy + Pulmonary Stenosis + Overriding Aorta
   • Tet spells (hypercyanotic spells), squatting relieves symptoms
   • Boot-shaped heart on CXR
2. Transposition of Great Arteries (TGA)
   • Aorta from RV, pulmonary artery from LV
   • Cyanosis at birth
   • Egg-on-string CXR appearance
3. Tricuspid Atresia

---

📌 QUICK REFERENCE: IMPORTANT DRUG NAMES & TREATMENTS

---

📝 EXAM TIPS FOR PHYSIOTHERAPY STUDENTS

1. Most repeated topics (prepare first): UTI, Diabetes (Type I vs II + complications), Hypertension complications, Iron deficiency anaemia, Communicable diseases, Schizophrenia, Hypothyroidism, TB
2. For long questions (15 marks): Use proper headings - Definition → Causes → Clinical features → Investigations → Management. Each heading gets marks.
3. Comparisons/tables: Always draw a comparison table for Type I vs Type II DM - examiners love it.
4. Remember mode mnemonics:
   • Communicable disease: Direct, Indirect (Vehicle, Vector, Airborne, Soil)
   • TB management: RHZE (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol)
   • Anaemia "5 A's" of IDA symptoms: Anaemia, Angular stomatitis, Atrophic glossitis, Achlorhydria, Alopecia
5. Physiotherapy relevance: For conditions like COPD and lung abscess, mention chest physiotherapy (postural drainage, breathing exercises, vibration) as part of management - this shows your clinical thinking!
6. Diagrams: Draw wherever possible - skin lesion classifications, TB X-ray (cavity with air-fluid level), ECG changes in MI.