Plab bedside

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HPI

1. When did it start

2. What was the first thing noticed

3. Progress since then

4. Ever had it before

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hands

5.Warm sweaty hands

Hyperthyroidism

6.Cold moist hands

Anxiety

7.Cold dry hands

hypothyroidism

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8.Pallor of palmer crease

Anemia

9.Palmer erythema

Cirrhosis pregnancy polycythemia

10.Pigmentation of creases

Normal in Asian/blacks Addison

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11.Fibrosis and contracture of palmer fasciaDupuytrens contracture

Liver disease trauma epilepsy aging

12.Swollen PIP joints with DIP joint sparingRA

13.Swollen DIP jointsOsteoarthritis gout psoriasis

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14.Distal and proximal nodesHeberden’s and Bouchard’s nodes

Osteoarthritis

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Nails

15.Spoon shape (koilonychias)

.Iron deficiency syphilis IHD

16.Destruction of nails (onycholysis)

Hyperthyroidism fungal infection psoriasis

17.Transverse furrows Beaus lines (temporary growth arrest due to severe illness)

Nail growth rate=0.1mm/day,measure stress date from cuticle

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18.Transverse bands white and parallel

Mees lines Hypoalbuminaemia

19.Pink/brown band on nail tip

Terry's lines-

cirrhosis CCF DM cancer aging

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20.Fine longitudinal streaks under nail

Splinter hemorrhages-Infective endocarditis

21.Pitting

Psoriasis Alopecia Areata

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22.Nail fold infarcts

Vasculitic disorders

13.Painful swollen nail with intermittent discharge

Chronic paronychia- chronic infection of nail fold

Rx. Dry erythro250mg/6hrPO Nystatin oint.

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clubbing

1.Thoracic causes1. 24.Bronchogenic CA(not small cell)2. 25.Chronic lung supporation

1. Empyma2. abscess3. Bronchiactesis4. Cystic fibrosis

3. 26.Fibrosing Alveolitis4. 27.mesothelioma

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2.GI causes

1. 28.Inflammatory bowl disease

2. 29.cirrohsis

3. 30.Malabsorption

4. 31.Lymphoma

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3.Cardiac causes

1. 32.Cyanotic congenital heart disease

2. 33.endocarditis

3. 34.Atrial myxoma

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4.Rare causes of clubbing;

35.Familial

36.Thyroid acropachy

5.Unilateral clubbing bc of

37.Axillary artery aneurysm

38.Brachial A-V malformation

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Abdominal distension

39.fat

40.faeces

41.fluid ( shifting dullness, fluid thrill)

42.fetus

43.flatus ( air is resonant on percussion)

44.food(malabsorption)

AD due to Air

45.GI obstruction (inc. faeces) ||

46. Aerophagy (air swollowing )

V

AD due to ascites

47. malignancy*

48. Hypoproteinaemia (nephrotic )

49. Right heart failure

50. Portal hypertension

qumber: any organ e.g liver, pancrease, kidney stomach colon*qumber: any organ e.g liver, pancrease, kidney stomach colon*

AD due to solids

51.Malignancy*

52.Lymph nodes

53.Aorta aneurysm

54.Cysts • renal

• pancrease

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qumber: any organ e.g liver, pancrease, kidney stomach colon*qumber: any organ e.g liver, pancrease, kidney stomach colon*

AD due to pelvic masses

55. Bladder• Full

• CA

56. Fibroid, fetus

57. Ovarian ( cyst, cancer)

58. Uterine cancer

qumber:u cant get below pelvic massesqumber:u cant get below pelvic masses

Right illiac fossa mass

59.appendix ( mass, abscess)

60.kidney mass

61.Caecum CA

62.Crohns or TB mass

63.Intussusceptions

64.Amoebic mass

65.Any of pelvic mass mentioned above

hepatomegaly

66.Right heart failure

67. Pulsatile hepatomegalyTricuspid incompetence

68.InfectionsGlandular feverHepatitisMalaria

s

69. Malignancy

Metastatic or primary

Myeloma

Leukemia

Lymphoma

70.misc

Sickle cell anaemia

Hemolytic anaemia

porphyria

.Ascities and portal hypertension

71.Cirrhosis

72.Portal nodes

73.Budd-chiari syndrome

74.IVC or portal vein thrombosis

DM

Lack of or diminished effectiveness of endogenous insulin and characterized by hypoglycemia

Two types

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defination

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defination

Glucose normal

Normal glucose range3.5 to 5.5 mmol/lit

Ketone breathKetoacidosis

Secoondary DM developing After some disease,drugs or pancreatic surgery

WHO criteria for labelling glucose

Fasting plasma venous glucose level

Equal to or >7mmol/lit

OGTT>? To label DM

11.1mmol?lit

HBA1c specifity n sensitivity

99.6% n 99%

Urine glycoseuria specificity and sensitivity

33% n 90%

Which diuretic u will use in renal impairment in DM

ACE inhibitors

What care to be taken in thyazolidine

LFTs monthly bc hepatotoxity

Thiazolidines and biguanides MOA?

Increase recetpor sensitivity

Alpha glycosidase inhibitors MOA

Stop starch conversion into glucose

Stop hepatic gluconeogenesis

Side effects of Alpha glucosidase inhibitors

Flatus abdominal distension

Cause of hypoglycemia in diabetics

Insulin and oral hyperglycemic

CAUSES

Cause of hypoglycemia in non diabeticEXPLAINExogenous drugs• Insulin• Oral hypoglycemics• Alcohol• Others quinine

sulphate,pentamidine,quinolones

( EXPLAIN )

Pitu insufficiency

Liver failure’

Addison’s disease

Islet cell tumor /insulinoma

Immune hypoglycemia

Nonpancreatic neoplasia

PRESENTATIONS

HI or norm insulin + no ketones = insulinoma , sulphonylurea, insulin auto anti bodies

Low or undetectable insulin + no ketones= non pancreatic neoplasia and ins rec antibodies

Ins low or undetected + hi ketones=adrenal or pitutary failure

Confirm test for insulinomas

Suppresive test = insulin iv inf and measure c – peptide

Investigations

BSR by lab or glucometer

Exclude liver failure or malaria• LFT and Mp slide

OGTT for post prandial hypoglycemia

72 hr fast and BSR monitoring for fasting hypoglycemia

TREATMENT

oral sugar 25-50g iv glucose stat as 25% D/W

Glucagon 0.5 – 1.5mg iv

Frequent CHO meals

Long acting starch for recurrence

Guar and pectin instead of CHO incase of recurrence after starch

limp

5.painful arthritis+macular rash+fever+lymphadenopathyJuvenile ideopathic arthritis

6.6yr+painless Ar+flattened epiphyseal endsPerthes disease

7.3 yr+painless limp+skin creaseCongenital dislocation of hip

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pediatrics

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pediatrics

Motor abnormalitis and drug

5.spastic diplegia

Cerebral palsy

6.Ataxia

Postvaricella infection

Mefloquine side effects

neuropsychiatric

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Biopsy 5.werdnig-Hoffman disease or spinal muscular atrophyMuscle biopsy

6.secondary sclerosing panencephalitisBrain bipsy

Celiac diseaseVillus atrophy on jejunal biopsy

Hirschsprungs diseaseRectal biopsy

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pediatrics

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pediatrics

stridor5.usually well but worse during nightALTB

Prevention of recurrent moderate asthmaPulmicort inhaler

Treatment of mild asthmaBricanyl inhaler

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pediatrics

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asthma

5.newborn+lymphedema of feet+low hairline+small chin

45XO, turner

6.15 gynocomestia +poorly developed testes

Klinefelter, 46XXXy

Small chin,mental retardation+abnormally shaped souls

Trisomy 18s

Cleft palatte aortic arch+Abnormal T function

Deletion of 22q11 Digeorge syndrome

Hypotonicnewborn brachycephaly and duodenal atresi

Trisomy, down syndromea

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pediatrics

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pediatrics

epilepsy .10 yr+twitching corner of his mouth,arm leg consious

Benighn rolandic epilepsy

Sixmonth+shortlived flexion neck&limbs

Infantile spasms

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pediatrics

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pediatrics

8.Pallor of palmer crease

Anemia

9.Palmer erythema

Cirrhosis pregnancy polycythemia

10.Pigmentation of creases

Normal in Asian/blacks Addison

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pediatrics

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pediatrics

Viral infections of childhoodRash+cervical lymphadenopathy+arthritisrubella

Rash Lymphadenopathy organomegalyEBV

Hand foot mouth diseaseCoxsackie A

Diarrhea URTI conjunctivitisAdenovirus

Roseola infantumHHV

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pediatrics

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pediatrics

Marking= wrong ones

9/24/04 30/38 =78%

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