---

Exam Diagnostic Tactics: Paediatrics, Obs/Gynae, Internal Medicine & Surgery

---

PART 1: THE UNIVERSAL DIAGNOSTIC FRAMEWORK

Step 1: History (Build Your Clinical Picture)

• Site, Onset, Character, Radiation, Associating symptoms, Timing, Exacerbating/relieving factors, Severity

• Past medical/surgical history
• Drug history (including allergies)
• Family history
• Social history (smoking, alcohol, occupation, travel)
• In paeds: birth history, developmental milestones, immunisation
• In obs/gynae: LMP, parity, gravidity, contraception

---

Step 2: Examination (Confirm Your Suspicion)

---

Step 3: Form a Differential Diagnosis

• Vascular, Infective, Traumatic, Autoimmune, Metabolic, Iatrogenic, Neoplastic, Congenital, Degenerative

---

Step 4: Investigations (Prove Your Diagnosis)

• Urine dipstick, ECG, blood glucose, pulse oximetry, urine pregnancy test (women of reproductive age)

---

PART 2: PAEDIATRICS

High-Yield Conditions

1. Meningitis (Bacterial)

• Task/Presentation: Fever + headache + neck stiffness + photophobia. Babies: bulging fontanelle, high-pitched cry, poor feeding
• Key signs: Kernig's sign (+), Brudzinski's sign (+), non-blanching rash (meningococcal)
• Investigations to prove:
  • LP: CSF - turbid, WBC >1000 (neutrophils), protein high, glucose low
  • Blood cultures, FBC, CRP, PCR
  • CT head BEFORE LP if signs of raised ICP
• Treatment:
  • IV Ceftriaxone (3rd gen cephalosporin) IMMEDIATELY
  • Dexamethasone (reduces inflammation)
  • Contact prophylaxis: Rifampicin or Ciprofloxacin

2. Pneumonia

• Task/Presentation: Fever + cough + tachypnoea + reduced air entry/crackles
• Investigations: CXR (lobar consolidation), FBC, CRP, blood cultures, sputum culture
• Treatment:
  • Community-acquired: Amoxicillin (PO or IV)
  • Atypical (Mycoplasma): Azithromycin/Clarithromycin
  • Severe: IV Co-amoxiclav or Ceftriaxone

3. Febrile Seizure

• Task: Child 6m-5y with fever + generalised tonic-clonic seizure (<15 min, resolves spontaneously)
• Prove it's simple febrile seizure: Single episode, <15 min, generalised, full recovery
• Investigations: FBC, glucose, electrolytes; LP if <18 months (exclude meningitis)
• Treatment: Paracetamol/Ibuprofen for fever; Diazepam (rectal/IV) if prolonged

4. Asthma

• Task: Wheeze + cough + breathlessness, worse at night or with exercise
• Prove: Peak flow (<80% predicted), spirometry (FEV1/FVC <0.7, reversible with bronchodilator)
• Treatment (stepwise):
  • SABA (Salbutamol) - reliever
  • Inhaled corticosteroid (Beclometasone) - preventer
  • LABA (Salmeterol) added if uncontrolled
  • Acute: Nebulised salbutamol + O2 + IV hydrocortisone

5. Dehydration (Gastroenteritis)

• Task: Diarrhoea + vomiting + sunken eyes + decreased skin turgor + dry mucous membranes
• Classify: Mild (<5%), Moderate (5-10%), Severe (>10% = shock)
• Investigations: U&E, blood glucose, stool MCS
• Treatment: ORS (oral rehydration salts) first choice; IV 0.9% NaCl if severe

6. Neonatal Jaundice

• Task: Yellow discolouration in newborn
• Danger signs: Within 24h = pathological (Rh/ABO incompatibility, G6PD); Physiological peaks day 3-4
• Investigations: Serum bilirubin, Coombs test, FBC, blood group, G6PD level
• Treatment: Phototherapy (most cases); Exchange transfusion (severe)

---

PART 3: OBSTETRICS & GYNAECOLOGY

High-Yield Conditions

1. Pre-eclampsia

• Task: Pregnant woman >20/40 with hypertension (BP ≥140/90) + proteinuria (>300mg/24h)
• Symptoms: Headache, visual disturbances, RUQ pain, oedema
• Investigations to prove:
  • Urine dipstick (protein 2+), 24h urine protein
  • FBC (thrombocytopenia in HELLP), LFTs, U&E, serum uric acid
  • USS - fetal growth, Doppler
• Treatment:
  • Antihypertensive: Labetalol (first-line), Nifedipine, Methyldopa
  • MgSO4 (prevent eclamptic seizures)
  • Definitive = delivery (timing depends on severity/gestation)

2. Ectopic Pregnancy

• Task: Woman with amenorrhoea + unilateral lower abdominal pain + PV bleeding. May have haemodynamic instability
• Prove:
  • Urine/serum bHCG positive
  • Transvaginal USS: no intrauterine gestational sac + adnexal mass
  • If ruptured: haemoperitoneum on USS
• Treatment:
  • Unstable → Immediate laparotomy (salpingectomy)
  • Stable + small → Methotrexate (IM) or laparoscopic salpingotomy

3. Placenta Praevia vs Abruption

4. Labour and its Complications

• Normal labour: Regular contractions + cervical effacement/dilatation + fetal descent
• Prolonged labour: Diagnose by partogram (slow progress line)
• Foetal distress: Cardiotocography (CTG) - late decelerations, decreased variability
• Treatment: Augmentation with Oxytocin; Caesarean section if fails

5. Gynaecological - PCOS

• Task: Young woman with oligomenorrhoea + hirsutism + acne + obesity
• Prove (Rotterdam criteria - 2 of 3):
  • Oligo/anovulation
  • Clinical/biochemical hyperandrogenism (testosterone, DHEAS)
  • Polycystic ovaries on USS
• Treatment:
  • OCP (regulate cycle)
  • Metformin (if insulin resistant)
  • Clomiphene (if wanting fertility)

6. Cervical Cancer

• Task: Post-coital bleeding + vaginal discharge + pelvic pain
• Prove: Speculum (visible lesion), colposcopy + biopsy (gold standard)
• Staging: Clinical (MRI/CT for advanced)
• Treatment: Surgery (stage I), Chemoradiotherapy (Cisplatin + radiotherapy) for stage II+

---

PART 4: INTERNAL MEDICINE

High-Yield Conditions

1. Myocardial Infarction (STEMI/NSTEMI)

• Task: Central crushing chest pain, radiation to arm/jaw, sweating, nausea
• Investigations to prove:
  • ECG: ST elevation (STEMI) or depression (NSTEMI), T-wave changes
  • Troponin I/T (rises 3-6h, peaks 24h) - gold standard biomarker
  • CK-MB (earlier marker)
  • Echo (wall motion abnormality)
• Treatment (MONA+):
  • Morphine (pain), Oxygen (if <94%), Nitrates, Aspirin 300mg
  • STEMI → Primary PCI within 90min (or thrombolytics if PCI unavailable)
  • NSTEMI → LMWH + Clopidogrel/Ticagrelor + PCI within 72h

2. Heart Failure

• Task: Dyspnoea on exertion, orthopnoea, PND, peripheral oedema, raised JVP, basal crackles
• Classify: Left (pulmonary oedema) vs Right (peripheral oedema) vs biventricular
• Investigations:
  • CXR: Cardiomegaly, Bat wings, Kerley B lines, pleural effusion (ABCDE on CXR)
  • BNP/NT-proBNP (elevated, diagnostic)
  • Echo (EF <40% = HFrEF; >50% = HFpEF)
  • ECG, U&E
• Treatment (HFrEF):
  • ACE inhibitor (Ramipril) or ARB (Valsartan)
  • Beta-blocker (Bisoprolol, Carvedilol)
  • Aldosterone antagonist (Spironolactone)
  • Loop diuretic (Furosemide) for symptoms
  • SGLT2 inhibitor (Dapagliflozin) - newer addition

3. Pneumonia (CAP)

• Task: Fever + productive cough + pleuritic chest pain + crackles/dullness
• CURB-65 score (severity): Confusion, Urea >7, RR >30, BP <90/60, age ≥65
• Investigations:
  • CXR: Consolidation (lobar = pneumococcal, bilateral = atypical)
  • Sputum culture, blood cultures, FBC, CRP
  • Pneumococcal/Legionella urinary antigen
• Treatment:
  • Mild (CURB 0-1): Amoxicillin PO
  • Moderate (CURB 2): Amoxicillin + Clarithromycin
  • Severe (CURB 3-5): IV Co-amoxiclav + Clarithromycin (or Levofloxacin)

4. Diabetes Mellitus

• Prove diagnosis (any one):
  • Fasting glucose ≥7.0 mmol/L (≥126 mg/dL)
  • Random glucose ≥11.1 mmol/L with symptoms
  • OGTT 2h glucose ≥11.1 mmol/L
  • HbA1c ≥48 mmol/mol (≥6.5%)
• Complications: Retinopathy, nephropathy, neuropathy, vasculopathy
• Treatment:
  • Type 1: Insulin (basal-bolus regimen)
  • Type 2: Metformin first, then add SGLT2i, GLP-1 agonist, DPP-4i, sulfonylurea
  • Hypos: Glucose oral → IM Glucagon if unconscious

5. Stroke

• Task: Sudden focal neurological deficit (FAST: Face/Arm/Speech/Time)
• Investigations:
  • CT head (non-contrast) IMMEDIATELY - to exclude haemorrhage
  • MRI DWI (more sensitive for ischaemic stroke)
  • ECG (AF → cardioembolic source), carotid Doppler
  • FBC, coagulation, glucose, cholesterol
• Treatment:
  • Ischaemic: IV Alteplase (tPA) within 4.5h + aspirin 300mg; thrombectomy within 24h
  • Haemorrhagic: Reverse anticoagulants, BP control, neurosurgical opinion

6. Pulmonary Embolism (PE)

• Task: Sudden dyspnoea + pleuritic chest pain + haemoptysis + risk factors (DVT, immobility, surgery, OCP)
• Wells Score to pre-test probability
• Investigations:
  • D-dimer (if low probability + negative = rule out)
  • CTPA (gold standard)
  • CXR: Westermark sign, Hampton's hump
  • ECG: Sinus tach, S1Q3T3 pattern
• Treatment:
  • LMWH (Enoxaparin) or DOAC (Rivaroxaban/Apixaban)
  • Massive PE (haemodynamic instability): IV Alteplase (thrombolysis)

7. Sepsis

• qSOFA (quick screening): Confusion + RR ≥22 + SBP ≤100
• Sepsis-3 definition: Life-threatening organ dysfunction due to dysregulated host response to infection
• Sepsis 6 Bundle (within 1 hour):
  1. Oxygen
  2. Blood cultures (before antibiotics)
  3. IV antibiotics (broad spectrum - Piperacillin/Tazobactam)
  4. IV fluid (500mL crystalloid bolus)
  5. Lactate measurement
  6. Urine output monitoring

---

PART 5: SURGERY

High-Yield Conditions

1. Acute Appendicitis

• Task: Periumbilical pain migrating to RIF + fever + anorexia + nausea
• Signs: McBurney's point tenderness, Rovsing's sign, Psoas sign, Dunphy's sign
• Investigations:
  • FBC: WBC elevated
  • CRP elevated
  • USS abdomen (first-line, especially in females/children)
  • CT abdomen (gold standard in adults, if USS equivocal)
  • Alvarado score (scoring system)
• Treatment:
  • Appendicectomy (laparoscopic preferred)
  • IV Cefuroxime + Metronidazole (peri-operative antibiotics)

2. Bowel Obstruction

• Task: Colicky abdominal pain + vomiting + absolute constipation + abdominal distension
• Small vs Large:
  • Small: central/diffuse, vomiting early, less distension
  • Large: lower abdomen, vomiting late, marked distension
• Investigations:
  • AXR: Dilated loops (small = valvulae conniventes; large = haustra)
  • CT abdomen: Confirms level + cause (adhesions, hernia, tumour)
• Treatment:
  • Drip and suck (IV fluids + NG tube decompression)
  • Surgery if strangulation/ischaemia suspected

3. Peptic Ulcer Disease / Perforated Peptic Ulcer

• Task: Epigastric pain + relationship to food. Perforation = sudden onset severe generalised pain, rigid abdomen
• Investigations:
  • OGD (endoscopy) - gold standard, allows biopsy + H. pylori test
  • H. pylori: Urea breath test, stool antigen, CLO test on biopsy
  • Erect CXR: Free air under diaphragm (perforation)
  • CT abdomen (if diagnosis uncertain)
• Treatment:
  • H. pylori eradication: Triple therapy = PPI + Amoxicillin + Clarithromycin (1 week)
  • Perforation: Emergency laparotomy (Graham patch repair)

4. Cholecystitis / Biliary Disease

• Task: RUQ pain after fatty food + fever + Murphy's sign positive
• Investigations:
  • LFTs (raised ALP/bilirubin in obstruction)
  • USS abdomen: Gallstones + thick-walled gallbladder + pericholecystic fluid
  • MRCP (if CBD stones suspected)
  • ERCP (therapeutic - stone removal)
• Treatment:
  • Cholecystitis: Analgesia + IV antibiotics (Coamoxiclav) → Laparoscopic cholecystectomy
  • CBD stone: ERCP + sphincterotomy, then cholecystectomy

5. Thyroid Conditions (Surgical Relevance)

• Thyroid swelling (goitre): Moves with swallowing
• Investigations:
  • TFTs (TSH, fT4, fT3)
  • Ultrasound (nodule characterisation)
  • FNAC (Fine Needle Aspiration Cytology) - cytology of nodule
  • Radioisotope scan (hot vs cold nodule - cold = higher cancer risk)
• Treatment:
  • Hypothyroidism: Levothyroxine
  • Hyperthyroidism: Carbimazole/Propylthiouracil; Radioiodine; Thyroidectomy
  • Malignant nodule: Total thyroidectomy + RAI

6. Hernia

• Task: Groin/abdominal lump, may be reducible, may cause pain
• Inguinal vs Femoral:
  • Inguinal: Above and medial to pubic tubercle (direct/indirect)
  • Femoral: Below and lateral to pubic tubercle (more likely to strangulate)
• Investigations: Clinical diagnosis mainly; USS if uncertain
• Treatment: Elective mesh repair; Emergency surgery if strangulated

---

PART 6: COMMON DRUGS QUICK REFERENCE

---

PART 7: IMAGING QUICK GUIDE

---

KEY EXAM MEMORY AID: "TIDE"

• Task - What does the patient need right now? (Is it an emergency?)
• Investigate - What tests will confirm your diagnosis?
• Diagnose - What is the most likely diagnosis + differentials?
• Explain + treat - What is the management plan?

"Frameworks for Internal Medicine" (Lippincott) and "Symptom to Diagnosis: An Evidence-Based Guide" (McGraw-Hill) in your library are excellent resources to read case by case in this exact format.

---

---

Additional High-Yield Topics - Complete Exam Guide

---

PAEDIATRICS - Additional High-Yield Topics

7. Diabetic Ketoacidosis (DKA) in Children

• Task: Known or new-onset T1DM child with vomiting, abdominal pain, polyuria, polydipsia, Kussmaul breathing, fruity breath, altered consciousness
• Diagnostic criteria (all three):
  • Blood glucose >11 mmol/L
  • Ketonaemia (blood ketones >3 mmol/L or urine ketones 2+)
  • Metabolic acidosis (pH <7.3 or HCO3 <15)
• Investigations:
  • ABG (pH, bicarb, pCO2)
  • Blood glucose, blood ketones
  • U&E (Na, K - pseudohyponatraemia common; K total body depleted despite normal serum level)
  • FBC, blood cultures (if infection trigger suspected)
  • ECG (peaked T waves = hyperkalaemia)
• Treatment (strict protocol):
  • Do NOT give bolus insulin first - fluids first
  • IV 0.9% NaCl 10ml/kg bolus (if shocked)
  • Slow rehydration over 48h (cerebral oedema risk in children)
  • Insulin infusion 0.05-0.1 units/kg/hr ONLY after 1h of fluid
  • Potassium replacement once urine output confirmed
  • Bicarbonate NOT routinely given (only if pH <6.9)
  • Monitor neurological status hourly - cerebral oedema is #1 cause of death

---

8. Kawasaki Disease

• Task: Child (usually <5y) with prolonged fever (>5 days) + rash
• Diagnostic criteria (CRASH mnemonic - 4 of 5 + fever):
  • Conjunctivitis (bilateral, non-purulent)
  • Rash (polymorphous, trunk)
  • Adenopathy (cervical, >1.5 cm)
  • Strawberry tongue / lip changes (red, cracked lips)
  • Hands/feet (erythema, oedema, desquamation)
• Key risk: Coronary artery aneurysm (main complication)
• Investigations:
  • FBC: High WBC, high platelets (thrombocytosis in 2nd week)
  • CRP/ESR markedly elevated
  • ECHO (coronary artery dimensions) - essential
  • UA (sterile pyuria)
• Treatment:
  • IVIG 2g/kg single dose (within 10 days)
  • Aspirin (high dose initially, then low dose for antiplatelet)

---

9. Bronchiolitis

• Task: Infant <2 years with wheeze + cough + tachypnoea, often after URTI (RSV most common)
• Distinguish from asthma: Age <1y, first episode, seasonal (winter), preceded by cold
• Investigations: Largely clinical; O2 sat, CXR (hyperinflation), NPA for RSV PCR
• Severity indicators (hospital admission): SpO2 <92%, RR >60, poor feeding (<50% of feeds), apnoeas
• Treatment (supportive only):
  • Oxygen (main intervention)
  • Nasogastric feeds if poor oral intake
  • Salbutamol/steroids/antibiotics - NOT routinely recommended
  • No specific antiviral (Ribavirin not routine)

---

10. Congenital Heart Disease (CHD)

• Cyanotic vs Acyanotic:

• Tetralogy of Fallot (most common cyanotic):
  • PROV: Pulmonary stenosis + RVH + Overriding aorta + VSD
  • Tet spells (hypercyanotic): squat, propranolol, morphine, O2, IV fluids
  • CXR: "Boot-shaped heart"
  • Echo confirms diagnosis
  • Treatment: Surgical repair
• VSD (most common CHD overall):
  • Harsh pansystolic murmur (lower left sternal edge)
  • CXR: Cardiomegaly, plethoric lung fields
  • Echo confirms; small VSDs close spontaneously
  • Large: Diuretics (Furosemide) + surgical closure

---

11. Developmental Dysplasia of the Hip (DDH)

• Task: Newborn/infant hip abnormality (risk: female, breech, first-born, family history)
• Tests:
  • Barlow test (dislocates hip)
  • Ortolani test (reduces dislocated hip)
• Investigations: USS hip (under 6 months); X-ray (>6 months)
• Treatment: Pavlik harness (if <6 months); surgical reduction if older

---

12. Neonatal Sepsis

• Task: Neonate with temperature instability, poor feeding, bulging fontanelle, jaundice, apnoeas, lethargy
• Risk factors: PROM, maternal GBS, premature delivery
• Investigations: FBC, CRP, blood culture, LP, urine culture, CXR
• Treatment: IV Ampicillin + Gentamicin (empirical); duration 7-14 days

---

OBSTETRICS & GYNAECOLOGY - Additional High-Yield Topics

7. Postpartum Haemorrhage (PPH)

• Definition: Blood loss >500ml after vaginal delivery; >1000ml after C-section
• The 4 Ts mnemonic:
  • Tone (uterine atony - 80% of PPH)
  • Trauma (lacerations)
  • Tissue (retained placenta)
  • Thrombin (coagulopathy)
• Investigations: FBC, coagulation screen, crossmatch, fibrinogen
• Treatment (stepwise):
  1. Bimanual uterine compression
  2. IV Oxytocin (10 units IM or infusion)
  3. Ergometrine (Syntometrine)
  4. Carboprost (15-methyl PGF2α) - IM; avoid in asthma
  5. Misoprostol (rectal/sublingual)
  6. Tranexamic acid (within 3h)
  7. Bakri balloon tamponade
  8. Uterine compression sutures (B-Lynch)
  9. Hysterectomy (last resort)

---

8. Preterm Labour

• Definition: Regular contractions + cervical changes at <37 weeks
• Investigations:
  • Fetal fibronectin (fFN) swab (if negative = very unlikely to deliver in 7-14 days)
  • Cervical length USS (transvaginal) - <25mm = high risk
  • Amniocentesis if PPROM (infection screen)
• Treatment:
  • Tocolysis (to delay delivery 48h for steroids): Nifedipine, Atosiban (oxytocin antagonist)
  • Betamethasone (12mg IM x2, 24h apart) - fetal lung maturity (<34 weeks)
  • Magnesium sulphate - neuroprotection (<32 weeks)
  • GBS prophylaxis: IV Benzylpenicillin

---

9. Gestational Diabetes (GDM)

• Screening: 75g OGTT at 24-28 weeks
• Diagnosis (WHO 2013 - any one):
  • Fasting glucose ≥5.1 mmol/L
  • 1h glucose ≥10.0 mmol/L
  • 2h glucose ≥8.5 mmol/L
• Risks: Macrosomia, shoulder dystocia, polyhydramnios, stillbirth, neonatal hypoglycaemia
• Treatment:
  • Dietary modification first
  • Metformin if diet fails
  • Insulin if Metformin fails or contraindicated
  • Post-natal: 6-week OGTT (50% develop T2DM later)

---

10. Endometriosis

• Task: Young woman with dysmenorrhoea + dyspareunia + subfertility + cyclical pelvic pain
• Investigations:
  • CA-125 (elevated but non-specific)
  • Pelvic USS (chocolate cysts/endometriomas)
  • MRI pelvis
  • Gold standard: Laparoscopy + biopsy (endometrial glands and stroma outside uterus)
• Treatment:
  • Analgesia (NSAIDs)
  • Hormonal suppression: Combined OCP, Progestins, GnRH agonist (Leuprolide)
  • Surgical: Laparoscopic excision/ablation

---

11. Molar Pregnancy (Gestational Trophoblastic Disease)

• Task: Early pregnancy + heavy bleeding + uterus larger than dates + hyperemesis + no fetal heart
• Types:
  • Complete mole: 46XX, no fetus, "snowstorm" on USS, very high hCG
  • Partial mole: 69XXX/69XXY, fetal parts may be present
• Investigations: βhCG (very high), USS (snowstorm/bunch of grapes appearance), CXR
• Treatment: Suction evacuation + hCG monitoring weekly until normal
• Malignant transformation (choriocarcinoma): Treated with Methotrexate ± Actinomycin D

---

12. Ovarian Cyst Torsion

• Task: Sudden severe unilateral lower abdominal pain, nausea/vomiting, may have known cyst
• Investigations: USS Doppler (absent/reduced ovarian flow), FBC, βhCG
• Treatment: Emergency laparoscopy (detorsion or salpingo-oophorectomy)

---

13. Dystocia / Shoulder Dystocia

• Task: Head delivered but shoulders impacted (turtle-neck sign)
• HELPERR mnemonic:
  • Help (call for)
  • Episiotomy
  • Legs (McRobert's manoeuvre - hyperflex hips)
  • Pressure (suprapubic, NOT fundal)
  • Enter (internal rotational manoeuvres - Rubin, Woods screw)
  • Remove posterior arm
  • Roll patient (Gaskin manoeuvre)

---

INTERNAL MEDICINE - Additional High-Yield Topics

8. Nephrotic Syndrome

• Classic triad: Proteinuria >3.5g/day + hypoalbuminemia + oedema (+ hyperlipidaemia, lipiduria)
• Common causes:
  • Adults: Membranous nephropathy (most common), FSGS, Minimal Change Disease
  • Children: Minimal Change Disease (most common - steroid sensitive)
  • Secondary: Diabetes, SLE, Amyloid, Hepatitis B/C
• Investigations:
  • Urine dipstick (3-4+ protein), 24h urine protein, PCR (protein:creatinine ratio)
  • Serum albumin, cholesterol
  • U&E, creatinine
  • Complement (C3/C4 - low in lupus nephritis)
  • ANA, anti-dsDNA, ANCA, anti-GBM, hepatitis serology
  • Renal biopsy (gold standard for classification)
• Treatment:
  • Minimal Change: Prednisolone (80% respond)
  • Membranous: Steroids + Cyclophosphamide or Rituximab
  • Oedema: Low-salt diet, Furosemide
  • Hypertension: ACE inhibitor (also reduces proteinuria)
  • Anticoagulation if albumin <20g/L (DVT/PE risk)

---

9. Rheumatoid Arthritis (RA)

• Task: Young/middle-aged woman with symmetrical small joint arthritis (MCP, PIP), morning stiffness >1h, systemic features
• ACR/EULAR 2010 Criteria (score ≥6 = definite RA): Joint involvement, serology (RF, anti-CCP), acute phase reactants (CRP/ESR), duration
• Key investigations:
  • RF (positive 70%), anti-CCP antibody (more specific, 95%)
  • FBC (normocytic anaemia), ESR/CRP
  • X-ray hands/feet: Periarticular osteoporosis, joint space narrowing, erosions (late)
  • USS/MRI: Synovitis, early erosions
• Treatment (pyramid, escalate):
  • NSAIDs (symptom control)
  • DMARDs: Methotrexate (anchor drug) ± Hydroxychloroquine ± Sulfasalazine
  • Biologics (TNF inhibitors: Adalimumab, Etanercept) if inadequate response
  • Corticosteroids (bridge therapy or flares)

---

10. Chronic Obstructive Pulmonary Disease (COPD)

• Task: Middle-aged/elderly smoker with chronic productive cough, exertional dyspnoea, barrel chest, hyperresonance, reduced breath sounds
• Diagnose: Spirometry post-bronchodilator: FEV1/FVC <0.70 (non-reversible, unlike asthma)
• Severity (GOLD): Mild (FEV1 ≥80%), Moderate (50-79%), Severe (30-49%), Very severe (<30%)
• Investigations:
  • Spirometry (essential for diagnosis)
  • CXR: Hyperinflation, flat diaphragm, bullae
  • CT chest: Emphysema, bronchiectasis
  • ABG (type 2 respiratory failure: low pO2, high pCO2)
  • ECHO (Cor pulmonale)
• Treatment (stable):
  • Smoking cessation (#1 intervention)
  • SABA (Salbutamol) PRN
  • LAMA (Tiotropium) - long-acting anticholinergic
  • LABA + ICS if FEV1 <60% + exacerbations
  • Pulmonary rehab, flu vaccine
• Acute exacerbation: Controlled O2 (target 88-92%), Nebulised salbutamol + ipratropium, IV hydrocortisone, Doxycycline/Amoxicillin, NIV if type 2 respiratory failure

---

11. Liver Cirrhosis and its Complications

• Task: Jaundice, ascites, spider naevi, caput medusae, leukonychia, palmar erythema, hepatomegaly/splenomegaly
• Causes: Alcohol, NASH, Hepatitis B/C, Autoimmune, PBC, Wilson's
• Investigations:
  • LFTs: Low albumin, raised bilirubin, raised PT
  • FBC: Pancytopenia (hypersplenism), thrombocytopenia
  • AFP (hepatocellular carcinoma screen)
  • USS abdomen: Liver texture, portal hypertension, spleen
  • Fibroscan (liver stiffness)
  • Liver biopsy (gold standard staging)
• Complications and their management:

---

12. Hypothyroidism

• Task: Fatigue, cold intolerance, weight gain, constipation, bradycardia, dry skin, hair loss, delayed ankle reflexes
• Cause: Hashimoto's thyroiditis (most common - autoimmune), post-thyroidectomy/RAI, iodine deficiency
• Investigations to prove:
  • TSH (raised in primary hypothyroidism - most sensitive test)
  • fT4 (low)
  • Anti-TPO antibody (Hashimoto's)
  • Lipid profile (secondary dyslipidaemia)
• Treatment: Levothyroxine (T4) - start low, increase slowly; monitor TSH 6-8 weekly until stable; annual TSH thereafter
• Myxoedema coma (rare emergency): IV T3 + hydrocortisone + warming blanket

---

13. Atrial Fibrillation (AF)

• Task: Palpitations + irregularly irregular pulse + possible haemodynamic compromise
• Types: Paroxysmal (<7d, self-terminating), Persistent (>7d), Permanent
• Investigations: 12-lead ECG (absent P waves, irregular RR), Echo, TFTs, FBC, U&E
• Rate vs Rhythm control:
  • Rate control: Beta-blocker (Bisoprolol) or Rate-limiting CCB (Diltiazem/Verapamil) or Digoxin (elderly/heart failure)
  • Rhythm control: DC cardioversion, Flecainide/Amiodarone
• Anticoagulation (CHA2DS2-VASc score ≥2 in men, ≥3 in women):
  • DOACs (Apixaban, Rivaroxaban, Dabigatran) preferred over Warfarin
  • Do NOT anticoagulate if <48h onset without TOE (thrombus risk)

---

14. UTI / Pyelonephritis

• Task: Dysuria + frequency + urgency (UTI); + loin pain + fever + rigors (pyelonephritis)
• Investigations:
  • Urine dipstick (nitrites + leukocytes = UTI)
  • Urine MCS (culture before antibiotics)
  • FBC, CRP, blood cultures (if pyelonephritis)
  • USS renal tract (if recurrent, obstruction suspected)
• Treatment:
  • Uncomplicated UTI (female): Trimethoprim x3 days or Nitrofurantoin x5 days
  • Pyelonephritis: Oral Ciprofloxacin or Co-amoxiclav x7-14 days; IV if severe
  • Pregnancy: Nitrofurantoin or Cefalexin (avoid trimethoprim in 1st trimester, nitrofurantoin near term)

---

SURGERY - Additional High-Yield Topics

7. Pancreatitis (Acute)

• Task: Severe epigastric pain radiating to back, nausea/vomiting, reduced bowel sounds, may have jaundice
• Causes: Gallstones (most common) + Alcohol (GET SMASHED mnemonic for causes)
• Investigations:
  • Serum amylase >3x normal (diagnostic; lipase more sensitive/specific)
  • FBC, LFTs, U&E, Ca2+, glucose (Glasgow/Ranson criteria markers)
  • USS abdomen (gallstones)
  • CT abdomen with contrast (Balthazar score for severity - gold standard for complications)
• Severity scoring (Glasgow-Imrie - PANCREAS mnemonic, ≥3 = severe):
  • PaO2 <8kPa, Age >55, Neutrophils (WBC >15), Calcium <2mmol/L, Renal (urea >16), Enzymes (LDH/AST raised), Albumin <32, Sugar (glucose >10)
• Treatment:
  • Aggressive IV fluids (crystalloid, 250-500ml/hr)
  • Analgesia (IV morphine, NG decompression)
  • NBM → reintroduce early enteral feeding (EN better than TPN)
  • ERCP within 72h if gallstone pancreatitis with obstruction
  • Antibiotics ONLY if infected necrosis (Imipenem/Meropenem)

---

8. Upper GI Bleed

• Task: Haematemesis + melaena (coffee-ground vomit) ± haemodynamic instability
• Causes: Peptic ulcer (most common), oesophageal varices, Mallory-Weiss tear, gastric cancer
• Rockall Score (pre-endoscopy): Age, shock, comorbidity, diagnosis, stigmata of recent haemorrhage
• Investigations:
  • FBC, U&E, LFTs, coagulation, crossmatch (group and save/crossmatch)
  • OGD (endoscopy) within 24h (within 12h if haemodynamically unstable)
• Treatment (ABCDE first):
  • 2 wide-bore IV cannulae + aggressive fluids + blood transfusion (target Hb >80)
  • IV PPI (Omeprazole/Pantoprazole) before endoscopy
  • Endoscopic treatment: Adrenaline injection, clips, thermal coagulation
  • Varices: Terlipressin + Octreotide (vasoconstriction), band ligation, Sengstaken-Blakemore tube (salvage), TIPSS
  • H. pylori eradication if peptic ulcer

---

9. Colorectal Cancer

• Task: Change in bowel habit + PR bleeding + weight loss + anaemia (right-sided: iron deficiency anaemia; left-sided: obstruction)
• "Red flag" symptoms → urgent 2-week referral
• Investigations:
  • FBC (iron deficiency anaemia)
  • CEA (tumour marker - monitoring, not diagnosis)
  • Colonoscopy + biopsy (gold standard)
  • CT chest/abdomen/pelvis (staging)
  • MRI rectum (rectal cancer - T staging)
• Staging: Duke's / TNM
• Treatment:
  • Resectable: Surgical resection (hemicolectomy / anterior resection / APER)
  • Rectal cancer: Neoadjuvant chemoradiotherapy → surgery
  • Metastatic: Palliative chemo (FOLFOX, FOLFIRI) ± Bevacizumab/Cetuximab

---

10. Deep Vein Thrombosis (DVT) & Post-op Care

• Task: Unilateral swollen, warm, red, tender leg post-operation/immobility
• Wells Score: >2 = high probability DVT
• Investigations:
  • D-dimer (if low Wells + negative D-dimer = rule out)
  • Compression Doppler USS (gold standard)
  • In unprovoked DVT: Thrombophilia screen, malignancy screen (FBC, CA125, PSA, CXR, CT)
• Treatment:
  • Anticoagulation: DOAC (Rivaroxaban, Apixaban) minimum 3 months
  • Cancer-associated: LMWH or Edoxaban
  • Bilateral leg elevation, TED stockings
• Prophylaxis (post-op): LMWH (Enoxaparin) + TED stockings + early mobilisation

---

11. Peripheral Arterial Disease (PAD)

• Task: Intermittent claudication (calf pain walking, relieved by rest) or critical ischaemia (rest pain + ulceration)
• 6 Ps of acute limb ischaemia: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishing cold
• Investigations:
  • ABPI (Ankle-Brachial Pressure Index): <0.9 = significant PAD; <0.5 = critical ischaemia
  • Duplex Doppler USS
  • CT/MR Angiography (pre-intervention planning)
• Treatment:
  • Claudication: Supervised exercise, risk factor modification (statin, aspirin, stop smoking)
  • Critical ischaemia: Urgent revascularisation (angioplasty/stenting vs bypass)
  • Acute ischaemia: IV heparin + embolectomy/thrombolysis (within 6h)
  • Amputation if non-viable

---

12. Wound Complications (Post-surgical)

• Wound infection: Erythema + heat + discharge + fever; WBC/CRP raised; swab for culture; antibiotics + wound opening
• Wound dehiscence: "Seropurulent/pink fluid" leaking from wound on day 5-8; cover with saline-soaked dressing; return to theatre
• Anastomotic leak: Post bowel surgery, fever + tachycardia + peritonism day 3-5; CT abdomen confirms; urgent re-exploration

---

13. Trauma - Primary Survey (ATLS)

• Tension pneumothorax: Needle decompression (2nd ICS, midclavicular line) → chest drain
• Massive haemothorax: Chest drain; thoracotomy if >1500ml initial or >200ml/hr
• Cardiac tamponade: Beck's triad (hypotension + muffled heart sounds + raised JVP); USS; pericardiocentesis

---

SUMMARY: INVESTIGATIONS THAT PROVE SPECIFIC DIAGNOSES

---

HIGH-YIELD DRUGS BY MECHANISM (Exam Favourites)

---

BONUS: SCORING SYSTEMS TO MEMORISE