1. UTI, 2. Hypertension, 3. Diabetes mellitus (Type I vs II, complications, diabetic foot), 4. Anaemia / Iron deficiency anaemia, 5. Communicable diseases / modes of transfer, 6. Schizophrenia, 7. Hypothyroidism / Hyperthyroidism, 8. Cirrhosis, 9. Hoarse voice, 10. Bronchial asthma, 11. Hepatitis B & C, 12. Coronary Artery Disease / Myocardial infarction, 13. Skin lesions / Urticaria, 14. Swine flu, 15. COPD, 16. Hematuria / Urolithiasis, 17. Acne, 18. GERD, 19. Heart malformations, 20. HIV/AIDS, 21. Tuberculosis (pulmonary), 22. Protein deficiency diseases, 23. Fungal infection of skin, 24. Liver abscess, 25. Lung abscess, 26. Oliguria, 27. Psoriasis, 28. ECT (Electroconvulsive Therapy)

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📚 GENERAL MEDICINE - COMPLETE PYQ ANSWER GUIDE

(For Physiotherapy Students)

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QUESTION 1: URINARY TRACT INFECTIONS (UTI)

Definition

Classification

• Upper UTI: Pyelonephritis (kidney involvement) - more serious
• Lower UTI: Cystitis (bladder), Urethritis (urethra) - more common

Causes (Etiology)

• Female sex (short urethra, proximity to anus)
• Sexual activity ("honeymoon cystitis")
• Urinary catheterization
• Urinary obstruction (stones, BPH)
• Pregnancy
• Diabetes mellitus
• Immunosuppression
• Vesicoureteral reflux

Clinical Picture (Signs and Symptoms)

• Dysuria (painful urination) - most common
• Frequency and urgency of urination
• Suprapubic pain/discomfort
• Haematuria (blood in urine) - may be visible
• Cloudy, foul-smelling urine
• Nocturia
• No fever (or low-grade only)

• All symptoms of lower UTI PLUS:
• High fever (>38.5°C) with chills and rigors
• Flank pain / loin pain (costovertebral angle tenderness)
• Nausea and vomiting
• Headache
• Systemic signs of sepsis in severe cases

Investigations

• Urine dipstick: Nitrites positive, leucocyte esterase positive
• Urine microscopy: Pyuria (>10 WBCs/HPF), bacteriuria
• Urine culture & sensitivity: Gold standard - confirms organism and antibiotic sensitivity
• Blood tests: CBC (elevated WBC in pyelonephritis), blood cultures if sepsis suspected
• Ultrasound: For recurrent UTI - to detect stones, obstruction, structural abnormalities
• DMSA scan: For renal scarring assessment

Management (Principles of Treatment)

• First-line antibiotics: Nitrofurantoin 100mg BD x 5-7 days, OR Trimethoprim 200mg BD x 7 days
• Alternatives: Cefalexin, Amoxicillin-clavulanate, Fosfomycin
• Increased fluid intake
• Urinary alkalinizers for symptomatic relief (e.g., potassium citrate)

• Mild-moderate: Oral ciprofloxacin 500mg BD x 7-14 days
• Severe/hospital admission: IV Ceftriaxone or IV Gentamicin
• Analgesia, antipyretics
• IV fluids for hydration
• Treat predisposing factors (e.g., stones)

• Adequate fluid intake (>2L/day)
• Post-coital voiding
• Proper perineal hygiene (front-to-back wiping)
• Avoid urinary catheterization unless necessary; remove early
• Cranberry products (limited evidence)
• Low-dose prophylactic antibiotics in recurrent UTI

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QUESTION 2: HYPERTENSION

Definition

• Normal: <120/80 mmHg
• Pre-hypertension: 120-139/80-89 mmHg
• Stage 1 HTN: 140-159/90-99 mmHg
• Stage 2 HTN: ≥160/≥100 mmHg
• Hypertensive Crisis: >180/120 mmHg

Classification

• Primary (Essential) Hypertension: ~95% of cases - no identifiable cause
• Secondary Hypertension: ~5% - due to renal disease, endocrine causes (Cushing's, Conn's, phaeochromocytoma), coarctation of aorta, drugs (OCP, NSAIDs, steroids)

Clinical Features

• Headache (especially occipital, early morning)
• Epistaxis (nosebleeds)
• Dizziness / vertigo
• Visual disturbances (blurring)
• Palpitations
• Fatigue, breathlessness on exertion
• Nocturia (in advanced disease)

• Elevated BP on repeated measurements
• Retinal changes (hypertensive retinopathy) - A-V nipping, silver wiring, papilloedema
• Loud A2 (aortic component of S2)
• Left ventricular heave
• Signs of end-organ damage (see complications)

Complications ("Target Organ Damage")

1. Cardiac Complications

• Left ventricular hypertrophy (LVH) - compensatory, eventually leads to heart failure
• Coronary artery disease / Angina / Myocardial infarction
• Heart failure (Hypertensive Heart Disease)
• Cardiac arrhythmias (especially AF)

2. Cerebrovascular Complications

• Stroke (ischaemic or haemorrhagic) - most important cause of morbidity/mortality
• Transient Ischaemic Attack (TIA)
• Hypertensive encephalopathy (in hypertensive crisis)
• Vascular dementia

3. Renal Complications

• Nephrosclerosis - hypertensive nephropathy
• Proteinuria
• Chronic Kidney Disease (CKD) / Renal failure

4. Ocular Complications

• Hypertensive retinopathy (Keith-Wagener-Barker grading)
  • Grade I: Arterial narrowing
  • Grade II: A-V nipping
  • Grade III: Flame haemorrhages, cotton wool spots
  • Grade IV: Papilloedema (malignant hypertension)

5. Vascular Complications

• Aortic aneurysm (abdominal/thoracic)
• Aortic dissection
• Peripheral vascular disease

Management

• Lifestyle modifications: Weight loss, DASH diet (low sodium, high K+), exercise, quit smoking, limit alcohol
• Drug therapy: ACE inhibitors, ARBs, calcium channel blockers, thiazide diuretics, beta-blockers
• Target BP: <130/80 mmHg (general), <140/90 (elderly)

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QUESTION 3: DIABETES MELLITUS

Definition

• Fasting plasma glucose ≥ 7.0 mmol/L (126 mg/dL), OR
• 2-hour glucose ≥ 11.1 mmol/L (200 mg/dL) after OGTT, OR
• Random glucose ≥ 11.1 mmol/L (200 mg/dL) with symptoms, OR
• HbA1c ≥ 6.5% (48 mmol/mol)

Differences Between Type I and Type II Diabetes

Main Complications of Type II Diabetes

Acute Complications

• Hypoglycaemia - due to excess insulin/drugs
• Hyperosmolar Hyperglycaemic State (HHS/HONK) - severe hyperglycaemia without ketosis, high mortality
• Diabetic Ketoacidosis (DKA) - less common in Type II but possible

Chronic Complications

Microvascular

1. Diabetic Nephropathy - leading cause of chronic kidney disease worldwide
   • Microalbuminuria → proteinuria → CKD → end-stage renal disease
2. Diabetic Retinopathy - leading cause of blindness in working-age adults
   • Background (non-proliferative): dot/blot haemorrhages, microaneurysms
   • Proliferative: neovascularization - risk of vitreous haemorrhage, retinal detachment
3. Diabetic Neuropathy - most common complication
   • Peripheral sensorimotor neuropathy (stocking-glove pattern)
   • Autonomic neuropathy: postural hypotension, gastroparesis, erectile dysfunction, bladder dysfunction, cardiac arrhythmias

Macrovascular

1. Coronary Artery Disease - 2-4x increased risk
2. Stroke - 2x increased risk
3. Peripheral Vascular Disease - claudication, critical limb ischaemia

Others

1. Diabetic Foot (see below)
2. Increased susceptibility to infections (TB, UTI, skin infections)
3. Lipid abnormalities (Dyslipidaemia)
4. Non-alcoholic fatty liver disease (NAFLD)

DIABETIC FOOT (Short Note)

• Result of neuropathy + peripheral vascular disease + infection
• Neuropathy causes loss of protective sensation → minor trauma goes unnoticed
• PVD causes poor healing
• Presentation: Painless ulcers (usually plantar surface), gangrene, Charcot joint
• Wagner Classification: Grade 0-5 (0=at-risk foot, 5=extensive gangrene)
• Management: Debridement, antibiotics, offloading pressure, vascular surgery, amputation if necessary
• Prevention: Daily foot inspection, proper footwear, regular podiatry

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QUESTION 4: ANAEMIA AND IRON DEFICIENCY ANAEMIA

Definition

• Men: Hb < 13 g/dL
• Women: Hb < 12 g/dL
• Pregnant women: Hb < 11 g/dL
• Children 6-14 years: Hb < 12 g/dL

Classification of Anaemia

A. By Morphology (RBC Size)

B. By Mechanism (Pathophysiological)

1. Decreased RBC production: Iron deficiency, B12/folate deficiency, aplastic anaemia, bone marrow infiltration
2. Increased RBC destruction (Haemolysis): Hereditary spherocytosis, G6PD deficiency, sickle cell, autoimmune haemolytic
3. Blood loss: Acute (trauma, GI bleed) or chronic (menorrhagia, peptic ulcer)

Iron Deficiency Anaemia (IDA)

Causes

• Dietary deficiency (vegetarians, poor diet, infants)
• Increased demand (pregnancy, growing children, adolescence)
• Chronic blood loss - most common in adults:
  • GI: Peptic ulcer, colorectal cancer, haemorrhoids
  • Gynaecological: Menorrhagia
  • Urological: Haematuria
• Malabsorption: Coeliac disease, Crohn's, post-gastrectomy

Clinical Features

• Fatigue, tiredness, weakness
• Breathlessness on exertion (dyspnoea)
• Palpitations
• Headache, dizziness
• Poor concentration
• Cold intolerance

• Pica - craving for non-food items (earth/clay = geophagia, ice = pagophagia)
• Koilonychia - spoon-shaped nails (classic sign)
• Angular stomatitis - cracks at corners of mouth
• Glossitis - smooth, red, painful tongue
• Dysphagia (Plummer-Vinson/Paterson-Kelly syndrome) - from oesophageal web
• Brittle hair and nails

• Pallor (conjunctival, palmar, nail bed)
• Tachycardia
• Systolic flow murmur (if severe)
• Koilonychia
• Glossitis

Investigations

• CBC: Low Hb, low MCV (microcytic), low MCH (hypochromic), elevated RDW
• Blood film: Microcytic hypochromic red cells, target cells, pencil cells
• Serum ferritin: Low (<12 µg/L) - best single test for iron store depletion
• Serum iron: Low
• TIBC (Total Iron Binding Capacity): Elevated
• Transferrin saturation: <16%
• Reticulocyte count: Low/normal
• Bone marrow biopsy: Absent iron stores (gold standard but rarely needed)

Management

1. Treat the underlying cause (most important - find the source of blood loss)
2. Oral iron supplementation:
   • Ferrous sulphate 200mg TDS (3x/day) x 3-6 months
   • Take with vitamin C (enhances absorption), avoid tea/coffee/antacids
   • Continue for 3-6 months after Hb normalizes (to replenish stores)
   • Side effects: Constipation, nausea, black stools
3. IV iron: When oral not tolerated, malabsorption, or rapid repletion needed
4. Blood transfusion: Only in severe symptomatic anaemia (Hb <7 g/dL) or pre-surgery
5. Dietary advice: Red meat, green leafy vegetables, legumes, iron-fortified foods

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QUESTION 5: COMMUNICABLE DISEASES - MODES OF TRANSFER

Definition of Communicable Disease

Modes of Transfer

1. DIRECT TRANSMISSION

• Person-to-person physical contact
• Examples:
  • STIs (HIV, syphilis, gonorrhoea) - via sexual contact
  • Ringworm, scabies - via skin-to-skin contact
  • Conjunctivitis (viral) - via contact with infected eye discharge

• Infectious droplets (>5 µm) expelled during coughing, sneezing, talking
• Travel short distances (<1 metre); fall quickly
• Examples:
  • Influenza (flu)
  • Whooping cough (Pertussis)
  • Meningococcal disease

• Very small particles (<5 µm) that remain suspended in air for long periods; travel >1 metre
• Examples:
  • Tuberculosis (TB)
  • Measles
  • Chickenpox (Varicella)
  • COVID-19

2. INDIRECT TRANSMISSION

• Transmission via contaminated inanimate objects (bedding, clothing, utensils, toys)
• Examples:
  • Hepatitis B (via shared needles/syringes)
  • Clostridium difficile (via contaminated surfaces)
  • Hepatitis A (via contaminated food utensils)

• Single contaminated source infects multiple people
• Food-borne examples:
  • Salmonellosis (food poisoning)
  • Typhoid fever (Salmonella typhi)
• Water-borne examples:
  • Cholera (Vibrio cholerae)
  • Dysentery (Shigella, E. coli)
  • Hepatitis A, E

• Via living intermediate hosts (insects/arthropods)
• Mechanical: Organism does not multiply in vector (e.g., housefly carrying E. coli)
• Biological: Organism multiplies in vector
  • Examples:
    • Malaria - Anopheles mosquito
    • Dengue fever - Aedes mosquito
    • Plague - rat flea
    • Kala-azar (Leishmaniasis) - sandfly
    • Filariasis - Culex mosquito

• Mother to child during pregnancy, childbirth, or breastfeeding
• Examples:
  • HIV
  • Rubella (German measles) - congenital rubella syndrome
  • Hepatitis B
  • Syphilis - congenital syphilis
  • Toxoplasmosis

• Through medical procedures, blood transfusion, needle-stick injuries
• Examples:
  • HIV
  • Hepatitis B and C
  • Malaria (transfusion malaria)

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QUESTION 6: SHORT NOTES

(a) SALIENT FEATURES OF SCHIZOPHRENIA

Positive Symptoms (excesses or distortions of normal function):

• Hallucinations - most commonly auditory (hearing voices); also visual, tactile, olfactory
  • Voices commenting on actions, or two voices arguing, are pathognomonic
• Delusions - fixed, false, unshakeable beliefs not in keeping with culture
  • Delusions of persecution (paranoia) - most common
  • Delusions of reference, grandeur, control ("made" experiences)
• Thought disorder:
  • Loosening of associations (knight's move thinking)
  • Thought insertion, thought withdrawal, thought broadcasting
  • Neologisms, word salad, tangentiality
• Disorganized/bizarre behaviour

Negative Symptoms (diminution of normal function):

• Alogia - poverty of speech
• Avolition - lack of motivation and goal-directed activity
• Anhedonia - inability to feel pleasure
• Affective flattening - reduced emotional expression
• Asociality - social withdrawal
• Attention impairment

Cognitive Symptoms:

• Poor executive function, working memory deficits

Subtypes (DSM-IV, still used in exams):

• Paranoid, Disorganized (Hebephrenic), Catatonic, Undifferentiated, Residual

Diagnosis (ICD-10 criteria): 1+ first-rank symptom OR 2+ second-rank symptoms for >1 month

Schneider's First Rank Symptoms:

• Auditory hallucinations (running commentary, third-person voices)
• Thought insertion, withdrawal, broadcasting
• Made feelings/actions/impulses (passivity experiences)
• Delusional perception

Management:

• Antipsychotics (haloperidol, risperidone, olanzapine, clozapine for refractory cases)
• Psychosocial rehabilitation
• Family therapy, CBT
• Long-term maintenance treatment essential

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(b) CLINICAL FEATURES OF HYPOTHYROIDISM

Symptoms (by system):

Signs:

• Goitre (enlarged thyroid gland) - may or may not be present
• Bradycardia
• Dry, coarse skin and hair
• Periorbital puffiness (myxoedematous facies)
• Loss of outer 1/3 of eyebrows (Queen Anne's sign)
• Delayed relaxation of deep tendon reflexes (very characteristic)
• Hoarse, deep voice
• Low temperature
• Non-pitting oedema of hands, feet, face

Investigations:

• TSH elevated - most sensitive and specific test
• Free T4 low
• Dyslipidaemia (high LDL, high cholesterol)
• Anaemia (normocytic)
• Anti-TPO antibodies (Hashimoto's)

Treatment:

• Levothyroxine (T4) - oral, once daily, lifelong
• Start low dose (50 µg), titrate based on TSH levels
• Monitor TSH every 6-12 weeks initially, then annually

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CLINICAL FEATURES OF HYPERTHYROIDISM

Clinical Features:

Diagnosis: TSH low, free T4 elevated, TSH receptor antibodies (Graves')

Treatment: Antithyroid drugs (carbimazole, propylthiouracil), radioiodine (I-131), thyroidectomy

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(c) CIRRHOSIS

Definition

Causes

• Alcoholic liver disease (most common in Western countries)
• Viral hepatitis B and C (most common globally)
• Non-alcoholic fatty liver disease (NAFLD/NASH)
• Autoimmune hepatitis
• Primary biliary cholangitis (PBC)
• Haemochromatosis (iron overload)
• Wilson's disease (copper overload)
• Biliary obstruction (secondary biliary cirrhosis)

Clinical Features

• Often asymptomatic
• Fatigue, anorexia, weight loss
• Mild hepatomegaly initially, then small shrunken liver

• Skin: Spider naevi (>5 = significant), palmar erythema, jaundice, leukonychia (white nails), Terry's nails, Dupuytren's contracture
• Face: Parotid enlargement, jaundice, xanthelasma
• Hands: Clubbing, asterixis (liver flap - in encephalopathy), Dupuytren's
• Abdomen: Hepatomegaly/small liver, splenomegaly, caput medusae (dilated abdominal veins), ascites
• Hormonal: Gynaecomastia, testicular atrophy, loss of axillary/pubic hair (in males - due to hyperoestrogenaemia)

1. Ascites - most common complication
2. Oesophageal/Gastric varices → life-threatening haemorrhage
3. Spontaneous Bacterial Peritonitis (SBP)
4. Hepatic Encephalopathy - asterixis, confusion, coma
5. Hepatorenal Syndrome - functional kidney failure
6. Hepatocellular Carcinoma (HCC) - 1-5% per year in cirrhosis
7. Coagulopathy - due to failure to synthesize clotting factors
8. Portal Hypertension

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(d) HOARSE VOICE - CAUSES AND MANAGEMENT

Definition

Causes

• Acute laryngitis - most common; due to viral URTI
• Chronic laryngitis - smoking, gastro-oesophageal reflux (GORD)
• Vocal cord nodules (Singer's nodules) - repeated vocal trauma/overuse
• Vocal cord polyps
• Laryngeal carcinoma - persistent hoarseness >3 weeks → must exclude malignancy
• Laryngeal oedema - allergic, angioedema

• Left RLN palsy - much more common due to its longer course through chest
  • Lung cancer (apical/hilar)
  • Mediastinal lymphadenopathy / lymphoma
  • Aortic aneurysm
  • Oesophageal cancer
• Thyroid surgery (RLN damage)
• Neck surgery

• Hypothyroidism - deep, hoarse voice (myxoedema voice)
• Acromegaly

• Functional dysphonia / voice abuse

Red Flags (Urgent Referral):

• Age >40, hoarseness >3 weeks
• Smoker
• Dysphagia, odynophagia
• Neck mass
• Haemoptysis, unexplained weight loss

Management

• Treat underlying cause
• Acute laryngitis: Voice rest, hydration, steam inhalation; antibiotics if bacterial
• Vocal cord nodules: Voice therapy (speech therapy); surgery if persistent
• Laryngeal carcinoma: Surgery (partial/total laryngectomy), radiotherapy, chemotherapy
• RLN palsy: Treat the underlying cause (e.g., treat lung cancer)
• Hypothyroidism: Levothyroxine
• Reflux-related: PPI therapy, lifestyle changes
• Voice therapy for functional causes

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(e) PRECIPITATING FACTORS OF BRONCHIAL ASTHMA

Definition

Precipitating/Triggering Factors:

• House dust mites (Dermatophagoides species) - most common indoor allergen
• Animal dander (cat, dog)
• Cockroach allergen
• Moulds/fungi (Aspergillus)
• Pollen (tree, grass, weed)

• Viral URTIs (rhinovirus, RSV) - most common trigger in children
• Bacterial infections less common

• Cold, dry air during exercise
• More common in children; "exercise-induced bronchospasm"

• Isocyanates (spray painting), flour dust, animal proteins, latex
• "Occupational asthma" - resolves with removal from exposure

• Cigarette smoke (active and passive)
• Air pollution (ozone, particulate matter)
• Strong odors (perfumes, chemical fumes)
• Cold air

• Aspirin / NSAIDs (Samter's triad: asthma + nasal polyps + aspirin sensitivity)
• Beta-blockers (including eye drops) - contraindicated in asthma
• ACE inhibitors (cause cough which can trigger wheeze)

• Stress, anxiety, laughter, crying

• Sulphites (in wine, dried fruits)
• Food colouring agents (tartrazine)
• Nuts, shellfish (IgE-mediated)

• Premenstrual worsening
• Pregnancy (variable effect)
• Thyrotoxicosis

• Microaspiration triggers bronchospasm

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QUESTION 7: HEPATITIS B AND C

HEPATITIS B

Causes/Transmission:

• Bloodborne and sexually transmitted:
  • Sexual contact (most common route globally)
  • Mother-to-child (perinatal) - most common in high-prevalence areas
  • Blood-to-blood: IV drug use, needlestick injuries, blood transfusion
• NOT spread by casual contact, saliva, coughing, or faeces

Clinical Features:

• Incubation period: 1-6 months (average 3 months)
• Prodromal phase (pre-icteric): Malaise, anorexia, nausea, vomiting, fever, arthralgia, urticaria, right upper quadrant pain
• Icteric phase: Jaundice, dark urine (bilirubinuria), pale stools (acholic), hepatomegaly, tender liver
• Recovery phase: Gradual improvement

• 90-95% adults: Complete recovery
• 5-10% adults: Chronic infection (>6 months)
• Neonates: 90% develop chronic infection

• Asymptomatic carrier
• Chronic active hepatitis → cirrhosis → hepatocellular carcinoma (HCC)
• HCC risk: 100x increased in HBsAg carriers

• Polyarteritis nodosa
• Membranous glomerulonephritis
• Cryoglobulinaemia

Serology Markers:

• HBsAg - surface antigen; positive = current infection
• Anti-HBs - protective antibody; positive = recovery or vaccination
• HBeAg - high infectivity marker; active viral replication
• HBV DNA - best marker of viral replication

Treatment:

• Acute: Supportive (no specific antivirals usually needed)
• Chronic: Tenofovir or Entecavir (antivirals); pegylated interferon-alpha

Prevention:

• HBV vaccine (highly effective, 3-dose schedule)
• Safe sex, avoid shared needles
• Screening of blood products
• Universal birth vaccination

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HEPATITIS C

Risk Factors:

• IV drug use - most common in developed countries
• Blood transfusion / blood products (before 1990s screening)
• Needlestick injuries (healthcare workers)
• Tattooing, body piercing with unsterile equipment
• Sharing razors, toothbrushes
• Sexual transmission (less efficient than Hep B, but possible)
• Mother-to-child (rare, ~5%)
• No effective vaccine available

Clinical Features:

• Usually silent/asymptomatic (~80% cases)
• Incubation: 2 weeks - 6 months
• Mild flu-like illness, mild jaundice if symptomatic
• Only ~20% clear the virus spontaneously

• Usually asymptomatic for decades
• Fatigue - most common symptom
• Gradual progression: chronic hepatitis → cirrhosis (over 20-30 years)
• ~20% develop cirrhosis within 20 years

• Cirrhosis (20-30% over 20 years)
• Hepatocellular carcinoma (1-3% per year in cirrhotics)
• Portal hypertension, ascites, variceal bleeding
• Extra-hepatic: Cryoglobulinaemia, membranous glomerulonephritis, B-cell lymphoma, porphyria cutanea tarda, lichen planus

Treatment:

• Direct-Acting Antivirals (DAAs): Sofosbuvir, Ledipasvir, Daclatasvir, Glecaprevir/Pibrentasvir
• Cure rates >95% with 8-12 weeks of treatment (revolution in HCV management)
• No HCV vaccine available

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QUESTION 8: CORONARY ARTERY DISEASE (CAD) / MYOCARDIAL INFARCTION

Definition

Risk Factors

Non-Modifiable:

• Age (men >45, women >55)
• Male sex
• Positive family history (first-degree relative with CAD <55 in men, <65 in women)
• Genetic factors

Modifiable (Major):

• Hypertension - most important modifiable risk factor
• Diabetes mellitus - 2-4x increased risk
• Dyslipidaemia (high LDL, low HDL, high triglycerides)
• Cigarette smoking - doubles risk; carbon monoxide + nicotine damage
• Obesity (especially central/abdominal obesity)
• Physical inactivity
• Unhealthy diet (high saturated fat, low fibre)

Other Risk Factors:

• Metabolic syndrome
• Chronic kidney disease
• Inflammatory conditions (SLE, RA)
• Stress, Type A personality
• Oral contraceptive pill
• Cocaine use
• Elevated homocysteine, Lipoprotein(a)

Clinical Features of CAD / Angina

• Chest pain: Central/substernal, crushing/tight/heavy, radiates to left arm, jaw, shoulder, back
• Provoked by exertion, cold, emotion, heavy meal
• Relieved by rest or GTN within minutes
• Duration: <20 minutes

MYOCARDIAL INFARCTION (MI / Heart Attack)

Definition

Clinical Features of MI:

• Severe central chest pain - crushing, squeezing, "elephant sitting on chest"
• Radiation to left arm, jaw, neck, back, epigastrium
• Onset at rest; NOT relieved by GTN or rest
• Duration: >20-30 minutes
• Sweating (diaphoresis)
• Nausea and vomiting
• Breathlessness
• Sense of impending doom
• Painless MI (silent MI) - in diabetics, elderly, women

• Pallor, sweating, distress
• Tachycardia or bradycardia
• Hypo- or hypertension
• S4 gallop, signs of heart failure
• Low-grade fever

ECG Changes:

• STEMI: ST elevation, Q waves (later), T-wave inversion
• NSTEMI: ST depression, T-wave changes, no Q waves

Investigations:

• Troponin I or T - gold standard; rises 3-6 hrs after onset, peaks at 12-24 hrs
• ECG
• CXR
• Echocardiogram
• Coronary angiography

Complications of MI:

• Arrhythmias - most common cause of early death (VF most dangerous)
• Heart failure / Cardiogenic shock
• Pericarditis (Dressler's syndrome - weeks later)
• Papillary muscle rupture → acute mitral regurgitation
• Ventricular septal rupture
• Cardiac rupture (rare but fatal)
• Ventricular aneurysm
• Deep vein thrombosis / pulmonary embolism

Management (STEMI):

• Primary PCI (angioplasty + stent) - preferred reperfusion within 90 min
• Thrombolysis if PCI not available within 120 min
• Aspirin + Clopidogrel (dual antiplatelet)
• Anticoagulation (heparin)
• Beta-blockers, ACE inhibitors, statins (long-term)
• Morphine for pain, O2, nitrates

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QUESTION 9: SKIN LESIONS / URTICARIA

Classification of Skin Lesions

Primary Lesions (Arise on normal skin):

Secondary Lesions (Arise from change in primary lesions):

• Scale (psoriasis), crust (impetigo), erosion, ulcer, fissure, lichenification, scar, keloid, excoriation

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URTICARIA (Hives)

Definition

Classification:

• Acute urticaria: <6 weeks duration - usually allergic
• Chronic urticaria: >6 weeks duration - often idiopathic (chronic spontaneous urticaria)
• Physical urticaria: Triggered by physical factors (cold, heat, pressure, dermographism, exercise)

Causes:

• Allergic (IgE-mediated): Foods (peanuts, shellfish, eggs, milk), drugs (penicillin), insect stings, latex
• Drugs (direct mast cell degranulation): Aspirin, NSAIDs, codeine, morphine, ACE inhibitors (angioedema)
• Infections: Viral (EBV, hepatitis), bacterial (Helicobacter pylori), parasites
• Physical stimuli: Dermographism (stroking), cold urticaria, solar urticaria, cholinergic (heat/exercise)
• Systemic diseases: SLE, thyroid disease, malignancy
• Idiopathic: ~50% chronic urticaria cases

Clinical Features:

• Wheals: Transient, raised, erythematous, intensely pruritic
• Each wheal lasts <24 hours and resolves without marks
• Can occur anywhere on body
• Angioedema (in ~50% of urticaria): deeper swelling of lips, eyes, tongue, throat - can cause airway compromise
• No systemic features usually (unless anaphylaxis)

Management:

• Second-generation antihistamines (H1-blockers): Cetirizine, loratadine, fexofenadine - first-line, non-sedating, take regularly (not just when itching)
• First-generation: Chlorphenamine (useful for its sedating effect at night)

• IM Adrenaline (epinephrine) 0.5 mg - first-line for anaphylaxis
• IV hydrocortisone
• IV chlorphenamine
• Nebulised salbutamol (bronchospasm)

• Regular antihistamines (higher doses may be needed - up to 4x standard dose)
• Omalizumab (anti-IgE monoclonal antibody) - licensed for refractory chronic urticaria
• Short course oral corticosteroids for flares

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QUESTION 10: SWINE FLU (H1N1 Influenza)

Definition

Spread / Transmission

• Primary route: Respiratory droplets (coughing, sneezing, talking - within 1-2 metres)
• Contact transmission: Touching contaminated surfaces then touching nose/mouth
• Airborne (fine droplet nuclei) in enclosed poorly ventilated spaces
• Highly contagious; incubation 1-4 days
• Person is infectious 1 day before symptoms to 5-7 days after onset
• Seasonal peaks (winter in temperate regions)

Clinical Features

• Fever - usually >38.5°C, sudden onset - most common
• Cough (dry, persistent)
• Sore throat
• Runny/blocked nose (rhinorrhoea)
• Body aches and myalgia (severe) - characteristic
• Headache
• Fatigue, malaise
• Chills
• Gastrointestinal symptoms (nausea, vomiting, diarrhoea) - more common than seasonal flu (especially in children)
• No symptoms in some (asymptomatic infection)

• Viral pneumonia (bilateral, rapid progression)
• Secondary bacterial pneumonia (Staphylococcus aureus, Streptococcus)
• Respiratory failure / ARDS
• Myocarditis, encephalitis (rare)
• Septic shock

• Pregnant women, children <5 years
• Elderly >65 years
• Obese (BMI >40)
• Chronic medical conditions (CVD, diabetes, asthma, CKD, immunosuppression)
• Indigenous populations

Prevention

• Annual influenza vaccination (trivalent or quadrivalent - covers H1N1)
• Hand hygiene (frequent handwashing with soap/sanitizer)
• Respiratory etiquette (cover mouth/nose, use tissues)
• Avoid touching face (eyes, nose, mouth)
• Avoid close contact with ill people
• Social distancing during outbreaks
• Wearing masks in high-risk settings
• Chemoprophylaxis: Oseltamivir (Tamiflu) for post-exposure in high-risk contacts

Management

• Mild disease: Rest, fluids, paracetamol/ibuprofen for fever and pain
• Antiviral therapy: Oseltamivir (Tamiflu) 75mg BD x 5 days - effective if started within 48 hours of symptom onset
  • Indicated for: severe/hospitalised disease, high-risk groups
  • Zanamivir (Relenza) - alternative
• Hospitalised patients: IV oseltamivir, respiratory support, ICU if ARDS
• Antibiotics if secondary bacterial pneumonia

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QUESTION 11: COPD (Chronic Obstructive Pulmonary Disease)

Definition

Causes

• Cigarette smoking - most important cause (accounts for ~85-90% of cases)
• Other tobacco (pipes, cigars, hookah)
• Biomass fuel exposure (indoor cooking fires - major cause globally, especially in women in developing countries)
• Occupational dust and chemicals (coal dust, cotton dust, grain dust, isocyanates)
• Air pollution
• Alpha-1 antitrypsin deficiency (genetic - rare, ~1%)
• Recurrent childhood respiratory infections

Types:

• Chronic bronchitis (Blue Bloater): Cough with sputum for >3 months in >2 consecutive years; chronic airway inflammation, mucus hypersecretion; hypoxic and hypercapnic, cyanosed, oedematous
• Emphysema (Pink Puffer): Destruction of alveolar walls, air trapping, hyperinflation; breathless, pink, thin, using accessory muscles; less hypoxia initially

Clinical Features:

• Chronic productive cough (white/grey sputum; yellow/green in exacerbations)
• Progressive breathlessness (dyspnoea) on exertion → at rest
• Wheeze
• Chest tightness
• Barrel chest (hyperinflation - increased AP diameter)
• Reduced breath sounds, prolonged expiratory phase
• Accessory muscle use (sternocleidomastoid)
• Pursed-lip breathing
• Peripheral oedema (in cor pulmonale)
• Cyanosis (in severe disease)
• Exacerbations: acute worsening of symptoms, often triggered by infections

Investigations:

• Spirometry (Gold standard): FEV1/FVC <0.7 post-bronchodilator
• CXR: Hyperinflation, flattened diaphragm, bullae
• CT chest: Emphysematous changes
• ABG: Hypoxia, hypercapnia (in severe disease)
• Alpha-1 antitrypsin level (in young patients)

Management:

• Short-acting bronchodilators (SABA/SAMA): Salbutamol, ipratropium - for rescue/PRN use
• Long-acting bronchodilators (LABA/LAMA): Salmeterol, tiotropium - maintenance
• Inhaled corticosteroids (ICS) + LABA: For frequent exacerbations (combined inhalers - Seretide, Symbicort)
• Oral theophylline: Add-on therapy
• Roflumilast: PDE-4 inhibitor, for severe COPD with frequent exacerbations

• Pulmonary rehabilitation (exercise training, education) - most effective non-drug intervention
• Long-term oxygen therapy (LTOT): PaO2 <7.3 kPa (55 mmHg) at rest; ≥15 hours/day - proven survival benefit
• Vaccination (annual influenza, pneumococcal)
• Nutritional support

• Bullectomy, lung volume reduction surgery (LVRS), lung transplantation (selected cases)

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QUESTION 12: HEMATURIA AND UROLITHIASIS

HEMATURIA - Definition

• Macroscopic (Gross) hematuria: Visible blood - urine appears pink, red, or brown
• Microscopic hematuria: ≥3 RBCs per HPF on urine microscopy; urine appears normal

• Upper urinary tract: Stones (urolithiasis), glomerulonephritis, polycystic kidney disease, renal tumour (hypernephroma), trauma, TB
• Lower urinary tract: Bladder cancer (most important in >40 painless hematuria), UTI, prostate disease (BPH, prostate cancer), urethritis
• Non-urological: Anticoagulants, ITP, haemophilia, sickle cell disease
• "Pseudohaematuria": Beetroot, rifampicin, myoglobinuria (not true RBCs)

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UROLITHIASIS (Kidney Stones / Renal Calculi)

Definition

Composition of Stones:

• Calcium oxalate - most common (70-80%)
• Calcium phosphate
• Struvite (magnesium ammonium phosphate) - infection stones; Proteus, Klebsiella
• Uric acid - radiolucent on plain X-ray; associated with gout, hyperuricaemia
• Cystine - rare; cystinuria (genetic)

Clinical Features:

• Severe, sudden-onset loin pain - colicky (comes and goes in waves)
• Radiates from loin (flank) to groin, inner thigh, genitals ("loin-to-groin radiation")
• Patient is restless, cannot find comfortable position (distinguishes from peritonitis where patient lies still)
• Nausea and vomiting
• Haematuria (macroscopic or microscopic)
• Fever if associated infection (urological emergency - stone + infection)

• Tenderness over the affected flank (renal angle tenderness)
• No guarding/peritonism

Investigations:

• Non-contrast CT KUB - gold standard (detects all stones except indinavir stones)
• Urine dipstick: blood, white cells
• Urine culture (R/O infection)
• Serum: FBC, urea/creatinine, electrolytes, calcium, uric acid
• Plain X-ray KUB: Radiopaque stones (calcium oxalate visible, uric acid invisible)
• Ultrasound: hydronephrosis, large stones

Management:

• Adequate analgesia: NSAIDs (diclofenac) - first-line for renal colic
• Opioids (morphine, pethidine) for severe pain
• High fluid intake (>2L/day)
• Medical expulsive therapy: Alpha-blockers (tamsulosin) to help passage

• ESWL (Extracorporeal Shock Wave Lithotripsy): For stones <2cm in kidney/proximal ureter; shock waves break up stones
• URS (Ureteroscopy) + Laser Lithotripsy: For ureteric stones
• PCNL (Percutaneous Nephrolithotomy): For large stones >2cm

• High fluid intake (>2.5 L/day) - most important
• Diet: Reduce oxalate (spinach, nuts, chocolate), moderate calcium intake
• For uric acid stones: Allopurinol, alkalinize urine (potassium citrate)

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QUESTION 13: ACNE VULGARIS

Definition

Pathogenesis (4 key factors):

1. Increased sebum production (androgens stimulate sebaceous glands)
2. Follicular keratinization (abnormal desquamation → comedone formation)
3. Colonization by Cutibacterium acnes (C. acnes) (formerly P. acnes) - anaerobic bacterium
4. Inflammation (C. acnes activates inflammatory cascade)

Clinical Features:

• Open comedones (blackheads) - dilated follicle with oxidized melanin
• Closed comedones (whiteheads) - follicle opening blocked, white appearance

• Papules (small, red, raised)
• Pustules (papules with pus)
• Nodules (>5mm, deep, painful)
• Cysts (fluctuant, large, deep; most likely to scar)

Management:

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QUESTION 14: GERD (Gastro-Oesophageal Reflux Disease)

Definition

Pathophysiology:

• Lower Oesophageal Sphincter (LOS) incompetence - most important
• Transient LOS relaxations
• Hiatus hernia (stomach hernia through diaphragm) - predisposes

Risk Factors:

• Obesity (most important)
• Pregnancy
• Hiatus hernia
• Fatty foods, chocolate, caffeine, alcohol, spicy food
• Smoking
• Drugs: Calcium channel blockers, nitrates, anticholinergics, benzodiazepines
• Lying flat after meals

Clinical Features:

• Heartburn (pyrosis) - burning sensation behind sternum, worse after meals, lying down, bending; relieved by antacids - most common
• Acid regurgitation - sour/bitter taste in mouth
• Belching, bloating
• Waterbrash (sudden filling of mouth with saliva - reflex salivation)

• Chronic cough (especially nocturnal)
• Hoarse voice / laryngitis
• Dental erosions (acid)
• Chest pain (can mimic cardiac pain)
• Globus sensation (lump in throat)
• IMPORTANT for physiotherapy: GERD can worsen asthma symptoms

• Oesophagitis (erosive)
• Barrett's Oesophagus - metaplasia of squamous to columnar epithelium (premalignant)
• Oesophageal stricture (benign peptic stricture - dysphagia)
• Oesophageal adenocarcinoma (Barrett's → cancer; 0.1-0.3%/year)
• Aspiration pneumonia

Management:

1. Lifestyle modifications (first-line):
   • Weight loss
   • Small, frequent meals; avoid eating 3 hours before bed
   • Elevate head of bed
   • Avoid trigger foods (fatty, spicy, chocolate, coffee, alcohol)
   • Stop smoking
2. Drug therapy:
   • Proton pump inhibitors (PPIs): Omeprazole, lansoprazole, pantoprazole - gold standard; most effective; take 30 min before meals
   • H2-receptor antagonists: Ranitidine, famotidine - second-line
   • Antacids: Symptomatic relief (aluminium/magnesium hydroxide)
   • Prokinetics: Metoclopramide, domperidone
3. Surgical:
   • Laparoscopic Nissen fundoplication - for severe/refractory GERD; wrap fundus of stomach around LOS

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QUESTION 15: HIV/AIDS

Spread of HIV Virus

Modes of Transmission:

• Unprotected vaginal, anal, or oral sex
• Anal sex carries highest risk (receptive partner)
• STIs increase transmission risk (disrupt mucosal barriers)

• IV drug use (sharing needles/syringes) - most common in developed countries
• Blood transfusion or blood products (before 1986 screening)
• Needlestick injuries (healthcare workers - 0.3% risk per injury)
• Organ/tissue transplantation
• Sharing razors, tattooing with unsterile equipment

• During pregnancy (transplacental - especially last trimester)
• During childbirth (intrapartum - most common)
• Via breastfeeding

• Casual contact (hugging, shaking hands)
• Coughing, sneezing, saliva, tears
• Food, water, toilet seats
• Mosquitoes or other insects

Clinical Features of AIDS

Stage 1 - Primary HIV Infection (Acute Retroviral Syndrome):

• 2-4 weeks after infection
• Flu-like illness: fever, sore throat, lymphadenopathy, rash (maculopapular), myalgia
• Usually self-limiting; extremely high viral load and infectious
• Often missed / goes undiagnosed

Stage 2 - Asymptomatic Stage (Clinical Latency):

• Weeks to years (average ~10 years untreated)
• No symptoms, but viral replication continues
• CD4 count gradually declining

Stage 3 - Symptomatic HIV:

• Persistent Generalised Lymphadenopathy (PGL)
• Constitutional: Weight loss (>10%), night sweats, chronic fever, diarrhoea
• Oral candidiasis (thrush), hairy leukoplakia
• Herpes zoster (recurrent or disseminated)
• Kaposi's sarcoma (early skin lesions)

Stage 4 - AIDS-Defining Illnesses (CD4 <200):

• Pneumocystis jirovecii Pneumonia (PCP) - most common OI in AIDS
• Toxoplasma gondii encephalitis - brain abscess in AIDS
• Cryptococcal meningitis
• CMV retinitis → blindness
• MAC (Mycobacterium avium complex)
• Oesophageal candidiasis
• Disseminated TB
• Cryptosporidium - chronic diarrhoea

• Kaposi's Sarcoma (HHV-8) - violaceous skin lesions
• Primary CNS Lymphoma
• Non-Hodgkin's Lymphoma
• Cervical carcinoma (invasive)

• HIV dementia (AIDS dementia complex)
• Peripheral neuropathy

Treatment:

• Antiretroviral Therapy (ART) - combination of 3+ drugs (HAART)
• Two NRTIs + one integrase inhibitor or NNRTI or PI
• Goal: Viral load <50 copies/mL, CD4 recovery
• Lifelong treatment
• Pre-exposure prophylaxis (PrEP): Tenofovir/Emtricitabine in high-risk individuals
• Post-exposure prophylaxis (PEP): Within 72 hours of exposure

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QUESTION 16: TUBERCULOSIS (TB)

Organs Affected by Tuberculosis

Pulmonary Tuberculosis - Clinical Features and Diagnosis

Causative Organism:

Transmission:

• Airborne via droplet nuclei (1-5 µm)
• Generated by coughing, sneezing, speaking by an infectious person
• Risk increases with: prolonged close contact, crowding, poor ventilation, HIV co-infection, malnutrition

Clinical Features:

• Cough (>2 weeks) - initially dry, becomes productive
• Haemoptysis (coughing blood) - classic but not always present
• Night sweats (drenching)
• Fever (low-grade, evening rise of temperature)
• Weight loss and anorexia
• Fatigue, malaise

• Reduced expansion affected side
• Dullness on percussion (consolidation, fibrosis)
• Bronchial breathing (consolidation)
• Coarse crackles (cavities)
• Signs of pleural effusion

Diagnosis:

1. Sputum smear microscopy (Ziehl-Neelsen stain): AFB positive; quick but less sensitive; cannot speciate
2. Sputum culture (Gold standard): LJ medium - takes 6-8 weeks; MGIT liquid culture (2-3 weeks)
3. GeneXpert MTB/RIF (Xpert): Rapid molecular test (2 hrs); detects MTB + rifampicin resistance; WHO recommended first-line
4. Chest X-ray: Upper lobe infiltrates, cavitation, fibrosis, lymphadenopathy; not diagnostic alone
5. Tuberculin Skin Test (Mantoux/TST): Induration ≥10mm = positive; screens for exposure; not diagnostic for active disease
6. IGRA (Interferon-Gamma Release Assay): QuantiFERON-TB Gold; detects latent TB
7. Bronchoscopy + BAL: For smear-negative / non-productive cough cases

Treatment:

• Intensive phase (2 months): HRZE (Isoniazid + Rifampicin + Pyrazinamide + Ethambutol)
• Continuation phase (4 months): HR (Isoniazid + Rifampicin)
• Total: 6 months (2HRZE/4HR)
• Pyridoxine (B6) given with isoniazid (prevents peripheral neuropathy)
• Drug-resistant TB (MDR-TB, XDR-TB): Second-line drugs, longer treatment (18-24 months)

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QUESTION 17: PROTEIN DEFICIENCY DISEASES

Protein Energy Malnutrition (PEM) - Two Main Types:

1. KWASHIORKOR

• Primary deficiency: Protein deficient but energy adequate
• Age: 1-3 years (after weaning from breast milk)

• Oedema (hallmark) - bilateral pitting oedema of legs, face; "moon face" - due to low albumin
• Growth retardation
• Characteristic skin changes: "Flaky paint" dermatitis, hypopigmented patches
• Hair changes: Depigmented (reddish), "flag sign" (alternating bands), easily plucked
• Hepatomegaly (fatty liver)
• Apathy, misery, irritability
• Muscle wasting (may be hidden by oedema)
• Pot belly (ascites)
• Normal or slightly above normal weight

2. MARASMUS

• Primary deficiency: Both protein AND calorie deficient
• Age: <1 year usually

• Severe wasting (very thin - "skin and bones" - "old man face")
• No oedema
• Growth failure
• Loose, wrinkled skin (loss of subcutaneous fat)
• Very irritable, alert child
• No hepatomegaly
• "Monkey facies" - prominent eyes, wrinkled face

3. MARASMIC KWASHIORKOR

• Features of both: wasting + oedema

Management of PEM:

• Stabilization: Treat infections, hypoglycaemia, hypothermia, correct electrolytes
• Transition phase: Gradual refeeding (avoid "refeeding syndrome")
• Rehabilitation: Therapeutic feeding (F-75 then F-100 formula, RUTF - Ready to Use Therapeutic Food)
• Follow-up: Growth monitoring, nutritional counselling

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QUESTION 18: FUNGAL INFECTIONS OF SKIN (DERMATOPHYTOSIS / TINEA)

Common Superficial Fungal Infections:

• Candidiasis (Candida albicans) - oral thrush, vaginal candidiasis, skin fold infections
• Cryptococcosis (HIV)
• Aspergillosis (immunocompromised)

Treatment:

• Topical: Clotrimazole, miconazole, terbinafine (for most skin fungal infections)
• Oral: Fluconazole, itraconazole, terbinafine (for nail/scalp/resistant infections)
• Keep area dry, avoid occlusive clothing

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QUESTION 19: LIVER ABSCESS

Definition

Types:

• Cause: Entamoeba histolytica
• Most common in tropical/developing countries
• Route: Faeco-oral → intestinal infection → portal vein → liver
• Features: Single, large abscess (right lobe, "anchovy paste" pus)
• Clinical: Fever, right upper quadrant pain, hepatomegaly, tenderness; may rupture into pleural space
• Diagnosis: Serology (amoebic antibodies), ultrasound
• Treatment: Metronidazole 800mg TDS x 10 days (highly effective)

• Causes: E. coli, Klebsiella, Streptococcus, anaerobes
• Sources: Biliary tract (most common - cholangitis, cholecystitis), portal vein (diverticulitis, appendicitis), hepatic artery (septicaemia), trauma
• Features: Multiple small abscesses or single; "pus smells offensive"
• Clinical: Fever, rigors, jaundice, tender hepatomegaly; often more severe than amoebic
• Diagnosis: Ultrasound/CT, blood cultures, aspiration
• Treatment: IV antibiotics (cefuroxime + metronidazole) + percutaneous drainage under ultrasound guidance; surgical drainage if needed

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QUESTION 20: LUNG ABSCESS

Definition

Causes:

• Aspiration (most common) - oropharyngeal contents especially in:
  • Altered consciousness (anaesthesia, alcohol, seizures, stroke)
  • Dysphagia
  • Dental/gum disease
  • Poor oral hygiene
• Pneumonia (S. aureus, Klebsiella, anaerobes)
• Obstruction (bronchogenic carcinoma, foreign body)
• Haematogenous spread (septic emboli from right-sided endocarditis, IV drug users)
• Immunocompromised (Nocardia, Aspergillus)

Clinical Features:

• Symptoms develop gradually over weeks
• Cough - initially dry, then productive
• Foul-smelling, purulent sputum (classically with putrid odour - anaerobic infection)
• Haemoptysis (may be massive)
• Fever, night sweats, rigors
• Weight loss, anorexia, malaise
• Pleuritic chest pain
• Finger clubbing (if chronic)

Signs:

• Dullness on percussion over affected area
• Bronchial breathing
• Cavitating sounds (amphoric breathing)

Investigations:

• CXR: Cavity with fluid level (air-fluid level) - characteristic
• CT chest: Better delineation, helps plan drainage
• Sputum culture and sensitivity
• Bronchoscopy (if obstruction suspected/foreign body)

Management:

• Prolonged antibiotics (4-6 weeks) - IV initially, then oral
  • Cover anaerobes and aerobic bacteria: Metronidazole + Amoxicillin-clavulanate; or Clindamycin
• Postural drainage (physiotherapy!) - positioning to drain the abscess (e.g., head-down position)
• Chest physiotherapy - vibration, percussion, breathing exercises
• Surgical drainage/lobectomy - if medical treatment fails, or massive haemoptysis

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QUESTION 21: OLIGURIA

Definition

Causes:

• Inadequate perfusion of kidneys
• Hypovolaemia: dehydration, haemorrhage, burns, diarrhoea/vomiting
• Reduced cardiac output: heart failure, cardiogenic shock
• Sepsis (distributive shock)
• Hepatorenal syndrome
• Response to decreased BP: hypotension, renal artery stenosis

• Acute Tubular Necrosis (ATN) - most common intrinsic cause
  • Ischaemic ATN (following pre-renal failure)
  • Nephrotoxic ATN (aminoglycosides, contrast media, NSAIDs, rhabdomyolysis)
• Glomerulonephritis (acute)
• Interstitial nephritis
• Renal vasculitis

• Bladder outflow obstruction (BPH, prostate cancer, stricture)
• Bilateral ureteric obstruction (stones, tumour, retroperitoneal fibrosis)
• Bladder stone / clot retention
• Catheter blockage

Clinical Assessment:

• Urine dipstick, microscopy, culture
• Catheterise the bladder (if not already done - rules out retention)
• Serum urea, creatinine, electrolytes
• Blood glucose, FBC
• Fluid chart review (was patient hypovolaemic?)
• Renal ultrasound (hydronephrosis = post-renal)

Management:

• Pre-renal: IV fluid resuscitation; treat cause
• Renal (ATN): Stop nephrotoxins; fluid/electrolyte management; renal replacement therapy (dialysis) if severe
• Post-renal: Relieve obstruction (catheterisation, nephrostomy, ureteric stenting)

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QUESTION 22: PSORIASIS

Definition

Epidemiology: Affects ~2-3% of population; equal in males and females

Pathogenesis:

• T-lymphocyte mediated autoimmune process
• Accelerated keratinocyte proliferation (turnover 3-4 days vs. normal 28 days)
• TNF-alpha, IL-17, IL-23 play key roles

Clinical Features:

• Classic lesion: Well-demarcated, salmon-pink plaques with overlying silver-white scales
• Distribution: Extensor surfaces (elbows, knees), scalp, lower back, umbilicus, natal cleft
• Auspitz sign: Pinpoint bleeding on scraping scales (removal of scale reveals bleeding points)
• Koebner phenomenon (isomorphic response): New lesions appear at sites of skin trauma
• Itching (variable - less than eczema)
• Nail changes (20-40%): Pitting (most common), onycholysis, subungual hyperkeratosis, "oil drop" sign

Types:

• Plaque psoriasis - most common (90%)
• Guttate psoriasis - "rain drop" lesions after streptococcal throat infection (common in children)
• Pustular psoriasis - palmoplantar or generalized
• Erythrodermic psoriasis - generalized redness, serious
• Psoriatic arthritis - in ~20-30%

Triggers:

• Stress (psychological)
• Streptococcal throat infection
• Drugs (lithium, beta-blockers, antimalarials, NSAIDs)
• Alcohol
• Trauma (Koebner)
• HIV infection

Management:

• Emollients (first step - moisturize)
• Corticosteroids (moderate-potent) - most commonly used
• Vitamin D analogues (calcipotriol/calcitriene)
• Coal tar preparations
• Dithranol
• Topical retinoids (tazarotene)

• UVB (narrowband UVB) - for moderate-extensive disease
• PUVA (psoralen + UVA)

• Methotrexate - gold standard systemic therapy
• Ciclosporin - rapid effect; short-term use
• Acitretin (retinoid)
• Biologics: TNF inhibitors (adalimumab, etanercept), IL-17 inhibitors (secukinumab), IL-23 inhibitors (guselkumab) - for severe/refractory psoriasis

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QUESTION 23: ECT (Electroconvulsive Therapy)

Definition

Indications:

• Severe, treatment-resistant major depression (most common indication) - failed 2+ adequate antidepressant trials
• Severe depression with psychotic features
• Depression with imminent suicide risk (fastest-acting treatment)
• Severe depression with refusal to eat/drink (life-threatening)
• Severe mania refractory to pharmacotherapy
• Catatonia (regardless of diagnosis) - ECT is highly effective

• Neuroleptic Malignant Syndrome (NMS)
• Parkinson's disease (refractory motor symptoms and depression)
• Severe puerperal (postpartum) psychosis
• Schizophrenia (catatonic, acute)

Contraindications:

Procedure:

1. Informed consent (or consent from legal guardian)
2. Full medical and anaesthetic assessment
3. Patient fasts (NPO from midnight)
4. Premedication: Atropine (to reduce secretions, prevent bradycardia)
5. General anaesthesia (short-acting - thiopentone/propofol)
6. Muscle relaxant (succinylcholine) - prevents musculoskeletal injury during seizure
7. Oxygenation, monitoring (ECG, EEG, SpO2, BP)
8. Brief electrical stimulation (bilateral or unilateral electrode placement)
9. Generalized seizure (30-60 seconds) - therapeutic
10. Recovery

Course:

• 6-12 sessions over 3-4 weeks (typically 3x/week)
• Maintenance ECT: Monthly sessions to prevent relapse

Side Effects:

• Most common: Temporary memory loss (retrograde and anterograde amnesia) - usually resolves
• Confusion after each session
• Headache, muscle aches
• Nausea
• Rare: Prolonged seizure, cardiovascular complications (related to anaesthesia)

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SUMMARY TABLE: HIGH-PRIORITY TOPICS BY FREQUENCY

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QUICK EXAM STRATEGY

1. UTI - know causes (E. coli most common), symptoms (dysuria, frequency), management (antibiotics)
2. Schizophrenia - Schneider's first rank symptoms, positive vs. negative symptoms
3. Hypothyroidism - TSH elevated, cold intolerance, bradycardia, delayed reflexes, Levothyroxine treatment
4. Diabetes Mellitus - Type I vs II table, complications (micro/macrovascular), Diabetic foot
5. IDA (Iron Deficiency Anaemia) - koilonychia, ferritin low, TIBC high, ferrous sulphate treatment
6. Communicable diseases - all modes (airborne, droplet, contact, vector, fecal-oral, vertical, blood-borne) + 2 examples each

• Always start with a definition (2-3 marks)
• Use tables for comparisons (Type I vs II DM, anaemia classification)
• Draw diagrams where applicable (the question paper says "draw wherever necessary")
• Use subheadings to organize long answers
• End with management for every clinical topic - examiners love it
• For 5-mark short notes: Definition → Causes/Features → Management (3-part structure)