SUMMARY OF SOME IMPORTANT CASES IN MEDICINE

(Presenting features, D/D, Investigations, Treatments and others)

Medicine, Paper-I
GASTROENTEROLOGY

Case: GI Bleeding
Presented with- Investigations- Treatment-
(i) hematemesis & melaena (i) Full Blood count (A) Immediate:
Causes- (ii) Urea and electrolytes (i) IV access, (ii) Blood transfusion, (iii) O2 Therapy, (iv) Urgent endoscopy if shock, (v) continue to
(i) Bleeding PUD (iii) Liver function test monitor pulse, BP, urine output, (vi) surgery if bleeding persist
(ii) Rupture Oesophageal varices (iv) Prothrombin time (B) Subsequent:
(iii) Gastric erosions (v) Blood grouping and cross matching (i) TT of peptic ulcer
(iv) Gastric carcinoma (vi) Upper GI endoscopy (ii) Control of portal hypertension if bleeding occurs due to oesophageal varices
(v) Oesophagitis (iii) Avoidance of alcohol
(iv) Proper taking of NSAIDs with PPI
Case: Peptic Ulcer Disease (PUD)
Presented with- Investigations- Treatment:
(i) anorexia, nausea, vomiting, dyspepsia (i) Upper GI endoscopy (A) H. pylori eradication (1st line)
(ii) recurrent upper abdominal pain (ii) Test for H. Pylori- - Omeprazole 20mg 12 hourly
(iii) hematemesis, melaena (bleeding PUD) (a) Non-invasive- Serology, urea breath test 2 of the following antibiotics
D/D- (b) Invasive- Histology, rapid urease tests - Clarithromycin 500mg 12 hourly; Amoxicillin 1 gm 12 hourly; Metronidazole 400mg 12 hourly
(i) Chronic pancreatitis Common Site- (B) Maintenance treatment-
(ii) Chronic cholecystitis (i) 1st part of duodenum - not necessary after successful H. pylori eradication - lowest effective dose of PPI
Aetiology- (ii) Stomach (C) Surgical treatment
H. Pylori, Smoking, Alcohol, Stress, (iii) Lower oesophagus - Partial gastrectomy - Vagotomy & drainage: gastroenterostomy
NSAIDS (iv) Within the margins of gastro-jejunostomy
Case: Abdominal TB/Intestinal TB
Presented with- Investigations- Treatment-
(i) chronic diarrhea, weight loss (i) CBC with ESR- raised ESR (i) Anti-TB therapy
(ii) low grade fever, ascites (ii) USG & CT scan of abdomen (ii) Treatment should be last for 1 year
(iii) altered bowel habit (iii) Ascitic fluid study
D/D- (iv) S. Alkaline phosphatase- increased
(i) Intestinal malignancy, (ii) AIDS (v) Confirmation- endoscopy, laparoscopy or liver biopsy
Case: Inflammatory Bowel Disease
Presented with- Investigations- Treatment-
(A) Ulcerative Colitis (i) Full Blood count- Anemia (A) Ulcerative Colitis-
- Bloody diarrhea (ii) S. Albumin conc.- Low Medical- Aminosalicylates (Mesalazine), Corticosteroids (Prednisolone), Methotrexate, Ciclosporin,
- lower abdominal discomfort, fever, (iii) ESR & CRP- raised Anti-TNF antibodies, Antibiotics, Anti-diarrheal agents, Nutritional support, Blood transfusion
anorexia, weight loss (iv) Stool & blood culture Surgery- Panprotocolectomy with ileostomy
(B) Crohn’s Disease (v) Sigmoidoscopy (U. colitis) / Colonoscopy (Crohn’s D) with biopsies (B) Crohn’s Disease-
- abdominal pain, weight loss, vomiting, (vi) Barium Studies Medical- Budesonide (1st choice), Prednisolone (2nd choice), Ca & Vit-D supplement
diarrhea, anemia (vii) X-ray Or MRI Surgery- For fistula & perianal disease
 Case: Acute Pancreatitis
Presented with- Investigations- Treatment- Complications-
(i) severe upper abdominal pain radiates (i) Serum amylase, Urinary amylase (i) Analgesics- pethidine (i) Hypoxia
to back (ii) Serum lipase (ii) Correction of hypovolemia- normal saline (ii) Hyperglycemia
(ii) Nausea and vomiting (iii) CRP (iii) NG aspiration if needed (iii) Hypocalcemia
(iii) Marked epigastric tenderness (iv) CBC with ESR (iv) Correction of electrolyte imbalance (iv) Upper GI bleeding
D/D- (v) Blood glucose (v) Enteral feeding (v) Variceal hemorrhage
(i) Acute cholecystitis (vi) Serum Ca (vi) Prophylactic treatment (vi) Obstructive jaundice
(ii) Perforated PUD (vii) Blood urea & Serum electrolytes (vii) Treatment of cause
(iii) Gastric Outlet Obstruction (viii) USG or CT scan
(iv) Acute inferior MI (ix) Plain X-ray

HEPATOLOGY

Case: Acute Liver Failure

Presented with- Investigations- Treatment- Complications-
(i) jaundice, anorexia, nausea, vomiting (i) LFT- S. Bilirubin, SGPT, SGOT, Alkaline phosphatase, S. albumin (i) Should be observed in ICU (i) Hepatic encephalopathy, cerebral edema
(ii) unconscious state, icteric (ii) Viral markers- HBsAg, IgM anti-HBc; IgM anti HAV; Anti-HEV, HCV (ii) Fluid & electrolyte balance (ii) Hypoglycemia
(iii) flapping tremor (asterixis) (iii) Autoantibodies: ANF, ASMA, LKM (iii) Broad spectrum antibiotic (iii) Metabolic acidosis
(iv) Immunoglobulins (iv) Avoid sedative & diuretics (iv) Infection
(v) N-Acetylcysteine therapy (v) Renal failure
(vi) Liver transplantation
Case: Hepatic Encephalopathy
Presented with- Investigations- Treatment- Precipitating factors-
(i) disoriented state, unconscious state (i) The diagnosis can be made clinically (i) Should be observed in ICU (i) Constipations
(ii) apathy, flapping tremor, icteric (ii) EEG shows diffuse slowing of the normal alpha waves (ii) Treatment or removal of precipitating cause (ii) Anti-depressants and sedative drugs
(iii) edema, ascites, splenomegaly (iii) The arterial ammonia is usually increased (ii) Suppression of production of neurotoxin: (iii) Dehydration (diuretics)
D/D- - Lactulose/Neomycin by NG tube (iv) Hypokalemia
(i) Intracranial Bleeding (iii) Fluid & electrolyte balance (v) Infection
(ii) Delirium tremens (iv) Broad spectrum antibiotic (vi) Porto-systemic shunting
(iii) Wernicke’s encephalopathy (v) Avoid sedative & diuretics (vii) Protein load
(iv) Wilson’s disease (neurology) (vi) Specific- Liver transplantation
Case: Chronic Liver Disease (CLD)
Presented with- Investigations- Treatment- Complications-
(i) Jaundice, Ascites, Hepatomegaly (i) LFT- Plasma albumin, A:G ratio, Prothrombin Time (i) TT of underlying cause (i) Portal Hypertension
(ii) Anemic, icteric (ii) S. electrolytes (ii) Maintenance of underlying cause (ii) Hepatic encephalopathy
(iii) Hematemesis, melaena (ROV) (iii) S. creatinine (iii) TT of complications of cirrhosis (iii) SBP
(iv) Engorged vein (P. hypertension) (iv) Hepatitis B surface antigen, Hepatitis C antibody (Screening test) (iv) Control of Ascites: Na & H2O restriction, Diuretic drugs (iv) Renal failure
D/D- (v) Autoantibodies: ANA, Anti-mitochondrial antibody (Screening test) (v) Orthotopic liver transplantation (v) Hepatocellular carcinoma
(i) Intra-abdominal malignancy (vi) Immunoglobulins (Screening test)
(ii) Lymphoma (vii) USG of whole abdomen, Endoscopy of upper GIT, CT/MRI of liver
(iii) Disseminated TB (viii) Liver biopsy
 Case: Portal Hypertension/Variceal bleeding
Presented with- Investigations- Treatment-
(i) Splenomegaly, Ascitis, icteric (i) Endoscopic examination of upper GIT (A) Primary Prevention- (i) β-blocker- Propranolol, (ii) Prophylactic banding- unable to tolerate β-
(ii) Caput medusae (ii) USG of whole abdomen blocker therapy
(iii) Hematemesis, melaena (ROV) (iii) CT/MRI to detect hepatic vein patency (B) Acute Variceal bleeding- (i) Restore hemodynamic state (ii) Pharmacological reduction of portal
(iv) Pulse- rapid, BP- low (iv) Portal venous pressure measurement venous pressure, (iii) Prophylactic antibiotic, (iv) PPI, (v) Balloon tamponade, (vi) Phosphate enema
(v) To see hypersplenism- TC & DC of WBC, platelet count & Hb% (C) TT to the complications (Variceal bleeding, Hypersplenism, Ascites, IDA, RF, H. encephalopathy)
Case: Acute Viral Hepatitis
Presented with- Investigations- Treatment-
(i) Fever, anorexia, vomiting (i) LFT: S. bilirubin- High, SGPT, SGOT- High; (ii) Viral Markers (i) Supportive: Bed rest, Normal diet, Adequate fluid and electrolyte balance, Follow up
(ii) Dark urine, pale stool (iii) USG of hepatobiliary system; (iv) Urine for bilirubin & urobilinogen (ii) Sedative, Analgesic, Alcohol avoided
(iii) Jaundice, tender hepatomegaly (v) WBC count (iii) TT of complications (Acute liver failure, Cholestatic hepatitis, Aplastic anemia, CLD)
Case: Pyogenic Liver Abscess
Presented with- Investigations- Treatment-
(i) H/O cholangitis/septicemia (i) CBC with ESR; (ii) CT scan/USG of liver (i) Antibiotic- Combination of Ampicillin, Gentamicin and Metronidazole
(ii) High grade fever with chill & rigor (iii) Needle aspiration under ultrasound guidance (Confirmatory) (ii) Aspiration/drainage by catheter if abscess is large or antibiotic is not responding
(iii) right upper abdominal pain (iv) Pus for culture and sensitivity; (v) Chest X-ray (iii) Hepatic resection may be indicated in chronic persistent abscess
(iv) Jaundice, tender hepatomegaly (vi) Plasma alkaline phosphatase, S. albumin; (vii) Blood culture
Case: Amoebic Liver Abscess
Presented with- Investigations- Treatment-
(i) H/O amoebic dysentery (i) CBC with ESR; (ii) CT scan/USG of liver (i) Metronidazole 800mg 8 hourly 5-10 days
(ii) High grade fever (iii) Needle aspiration under ultrasound guidance (Confirmatory) (ii) Luminal amoebicide to eliminate luminal cyst
(iii) right upper abdominal pain (iv) Pus for culture and sensitivity; (v) Chest X-ray (iii) Aspiration- if abscess is large or antibiotic is not responding
(iv) Tender hepatomegaly (vi) Plasma alkaline phosphatase, S. albumin; (vii) Serological test
Case: Hepatocellular Carcinoma
Presented with- Investigations- Treatment-
(i) weight loss, anorexia (i) Serum markers: AFP is produced by 60% of HCC (i) Hepatic resection- treatment of choice in for cirrhotic patient
(ii) jaundice, abdominal pain (ii) USG, CT, MRI (ii) Liver transplantation
(iii) hard & irregular hepatomegaly (iii) Liver biopsy & Histopathology (iii) Percutaneous ablation
(iv) hematemesis, melaena (iv) Trans-arterial chemo-metabolism
(v) Chemotherapy

HAEMATOLOGY

Case: Aplastic Anemia

Presented with- Investigations- Treatment-
(i) weakness, pallor, gum bleeding (i) Blood picture- Hb%- Reduced, (i) Supportive- Blood product support and aggressive management of infection
(ii) no organomegaly & no lymphadenopathy RBC count- Reduced, TC & DC of WBC- Reduced, (ii) Allogenic Bone marrow transplantation
D/D- Platelet count- Reduced, ESR- high (iii) Immunosuppressive therapy
(i) Acute leukemuia (ii) Bone marrow- (Confirmatory) A hypocellular or aplastic bone
(ii) ITP marrow with increased fat spaces
 Case: Thalassemia
Presented with- Investigations- Treatment-
(i) H/O repeated blood transfusion (i) Blood picture- Hb%- Reduced, RBC- Microcytic hypochromic with (i) Supportive: Blood transfusion, Folic acid, Iron chelating agent, Splenectomy if needed
(ii) Anemia, Jaundice, Splenomegaly anisocytosis & poikilocytosis, Plenty of target cell with fragmented RBC (ii) Specific: Allogenic Bone Marrow transplantation
Reticulocyte count- increased (iii) Genetic counseling
(ii) Hb electrophoresis (Confirmatory): For HbF, HbA2, Hb-Barts and HbH
(iii) X-ray skull- ‘hair on end’ appearance
(iv) Biochemical: S. Bilirubin- Increased
S. Iron Profile:
S. iron, S. ferritin, Percent saturation- Normal or increased, TIBC- Decreased
Case: Acute Leukemia
Presented with- Investigations- Treatment-
(i) fever, purpura, bony tenderness, gum (i) CBC- Hb%- reduced, WBC- Usually raised, sometimes low. (i) Supportive: Blood transfusion, Platelet transfusion, Antibiotic
bleeding Platelet- low (ii) Specific: Chemotherapy, Bone marrow transplantation
(ii) hepatosplenomegaly & lymphadenopathy (ii) PBF- Blast cell (only test or dx of leukemia)
D/D- (iii) Bone marrow examination- done for typing of leukemia
(i) Aplastic Anemia, (ii) ITP
Case: Multiple Myeloma
Presented with- Investigations- Treatment-
(i) Bone pain, fracture (i) Full Blood count- Degree of bone marrow failure (i) Immediate: High fluid intake, Analgesic for bone pain, Allopurinol for urate nephropathy
(ii) Anemia, Impaired renal function (ii) ESR- Very High (ii) Chemotherapy with/without HSCT: Thalidomide & Bortezomib – 1st line treatment
(iii) Spinal cord compression (iii) X-ray: Skeletal lytic lesion* (iii) Radiotherapy: For localized bone pain & pathological fracture. Also emergency treatment for spinal
D/D- (iv) Bone marrow aspiration & trephine: Presence of plasma cell* cord compression
(i) Spinal TB (Pott’s disease) (v) Serum and/or urinary M protein: Presence of paraprotein* (iv) Bisphosphonates: long term therapy reduce bone pain and skeletal events.
(ii) Metastatic malignancy to the spine (vi) MRI spine: Spinal cord compression
(vii) Blood Ca & albumin: Presence of hypercalcemia
* Diagnostic criteria of multiple myeloma. (require 2 of them)
Case: ITP
Presented with- Investigations- Treatment-
(i) purpuric spots, gum bleeding (i) CBC- Thrombocytopenia (i) Patient with platelet count >30,000/cmm generally require no treatment unless they undergo a
(ii) afebrile, no organomegaly, no (ii) PBF- Reduced platelet surgical procedure
lymphadenopathy, no bony tenderness (iii) Bone marrow examination- Increased number of megakaryocytes (ii) 1st line therapy: Prednisolone 1 mg/kg body weight daily, IV Ig therapy, Platelet transfusion
D/D- (iv) Anti-platelet Antibody detection (iii) 2nd line therapy: Splenectomy
(i) Aplastic Anemia, (ii) Acute leukemia (iv) 3rd line therapy: Immunosuppressants (rituximab)
(iii) Dengue hemorrhagic fever, (iv) DIC

RHEUMATOLOGY

Case: Osteoarthritis
Presented with- Investigations- Treatment-
(i) pain and swelling of both knee joints (i) CBC with ESR: Normal ESR (i) Education of the patient about the disease
(ii) joint tenderness in knee joint (ii) Plain X-ray: Focal narrowing of joint space and osteophyte formation (ii) Life style Advice: Weight loss, Aerobic exercise, Pacing of activities
(iii) coarse crepitation of knee joint (iii) Synovial fluid aspiration (iii) Non-Pharmacological Therapy: Local physical therapy (heat/cold>temporary relief)
(iv) restricted movement (iv) Radioisotope bone scan (iv) Pharmacological Therapy: Topical NSAIDs, Oral NSAIDs
(v) morning stiffness (v) Surgery- Osteotomy, Joint replacement
 Case: Rheumatoid Arthritis
Presented with- Investigations- Treatment-
(i) polyarthritis (i) CBC with ESR: Anemia- may be present, ESR & CRP- raised (i) Drug Therapy: NSAIDs, DMARDs, Corticosteroids
(ii) pain, swelling of small joint (ii) X-ray: Joint space narrowing (ii) Patient education, counselling
(iii) morning stiffness (iii) Synovial fluid aspiration (iii) Surgery: Synovectomy, Osteotomy (later stage)
Extra-articular features- (iv) RA factor DMARDs-
(i) fever, weight loss, fatigue (v) Anti-citrullinated peptide antibodies (ACPA) (Confirmatory) (i) Methotrexate: Nausea, mucosal ulcer
(ii) muscle wasting (ii) Sulfasalazine: GIT upset
(iii) anemia (iii) Hydroxychloroquine: Irreversible ototoxicity, Retinopathy
(iv) Leflunomide: GIT upset
Case: Ankylosing Spondylitis
Presented with- Investigations- Treatment-
(i) low back pain (i) CBC with ESR: ESR & CRP- raised (i) Education
(ii) Morning stiffness (ii) RA factor- Negative (ii) Appropriate physical activity- exercise, avoidance of inactivity and poor posture
Extra-articular features- (iii) HLA-B27: Positive (iii) Drugs: Long acting NSAIDs, Local corticosteroid injections, Oral steroid
(i) Anterior uveitis, conjunctivitis (iv) MRI of affected joints: More sensitive than X-ray (iv) Surgery: May be require in severe cases
(ii) Prostatitis (v) X-ray: Findings-
(iii) Pericarditis a) Sacroiliac joint: Fusion of both sacroiliac joints
(iv) Amyloidosis b) Lateral thoraco-lumber spine:
Extra-spinal features- - Bridging syndesmophytes
(i) Pleuritic chest pain - Squaring of vertebral bodies
(ii) Peripheral arthritis - Ossification of the anterior longitudinal ligament
Case: Reactive Arthritis
Presented with- Investigation- Treatment-
(i) H/O infection (Diarrhea, UTI) (i) CBC with ESR: ESR & CRP- raised (i) Rest to the joint
(ii) Oligoarthritis (ii) Synovial fluid aspiration (ii) NSAIDs and analgesics
(iii) Swelling of lower limb joints (iii) Urine R/E (iii) Intra-articular steroids for monoarticular disease
Extra-articular features- (iv) RA factor (iv) Systemic steroids for polyarticular disease
(i) Mouth ulcer (ii) Conjunctivitis (v) X-ray of affected joint- (in recurrent/chronic arthritis) (v) DMARDs- persistent marked symptoms, recurrent arthritis
(iii) Uveitis (iv) Nail Dystrophy (vi) For DMARDs-recalcitrant cases- anti-TNF therapy
Case: Gout
Presented with- Investigations- Treatment-
(i) Acute monoarthritis which affect first (i) Aspiration from joint (Confirmatory): Identification of MSUM crystals Acute Attack-
MTP joint (50% cases) (ii) CBC with ESR: ESR & CRP- raised (i) Fast acting oral NSAIDs
(ii) Severe pain and swelling in great toe (iii) X-ray: Assess the degree of joint damage (ii) Oral prednisolone
D/D- (iv) Biochemical screen: Renal Function, Blood glucose, S. lipid profile (iii) Local ice-pack for symptomatic relief
(i) Reactive arthritis (iv) Aspiration of the joint fluid
(ii) Septic arthritis Long term
(iii) Infective cellulitis (i) Correction of any predisposing factors
(ii) Drugs- Allopurinol, Febuxostat
Case: Septic Arthritis
Presented with- Investigations- Treatment-
(i) pain and swelling in joint (i) CBC with ESR- Neutrophilic leukocytosis, ESR & CRP raised (i) Parenteral antibiotics- IV Flucloxacillin 2g 6 hourly
(ii) joint is hot, red and tender (ii) Aspiration of joint fluid: usually turbid or blood stained (ii) Pain relief by NSAIDs & local ice packs
(iii) commonly affected- knee, hip joint (iii) Physiotherapy
 Case: Osteoporosis
Presented with- Investigations- Treatment-
(i) H/O early menopause (i) Measurement of BMD (i) Explanation & reassurance; (ii) Reduction of risk factors
(ii) H/O smoking, alcohol intake (ii) Searching for secondary cause (iii) Non-pharmacological: Smoking cessation, Moderation of alcohol, Adequate Ca intake, Exercise
(iii) Fragility fracture, back pain, (iii) X-ray- Radiological osteopenia, Osteoporotic fractures (iv) Pharmacological: Calcium & Vit-D supplements, Bisphosphonates, HRT
kyphosis (v) Surgery: For fixation of osteoporotic fractures
Case: SLE
Presented with- Investigations- Treatment-
(i) Migratory Arthralgia, oral ulcer (i) CBC with ESR- Hb%-low, ESR-raised (i) Education to the patient, control of symptoms
(ii) Butterfly facial rash (ii) CRP- usually normal, elevated in serositis/infection (ii) Avoiding sun & UV light exposure
(iii) Fever, pain, weight loss (iii) Urine R/M/E: Proteinuria (iii) Mild to moderate: Analgesics & NSAIDs for joint pain, Hydroxychloroquine
D/D- (iv) ANA: if negative very unlikely to have SLE unless they are extractable (iv) Severe & life threatening: Methylprednisolone plus cyclophosphamide
(i) Sarcoidosis nuclear antigen (Ro) positive (v) Maintenance therapy: Prednisolone (typical), methotrexate
(ii) Vasculitis (v) Anti-ds-DNA antibodies occur in only 30-50% of patients

NEPHROLOGY

Case: Acute Glomerulonephritis (AGN)

Presented with- Investigations- Treatment- Complications-
(i) Generalized body swelling/ puffiness of face (i) Urine analysis (RBC, RBC Cast, mild proteinuria) (i) Salt & fluid restriction (i) Acute Renal Failure
(ii) Scanty micturition, high colored urine (ii) CBC- Polymorphonuclear leukocytosis (ii) Diuretics (ii) Hypertensive encephalopathy
(iii) edema, HTN (iii) S. Creatinine- Raised (iii) Antihypertensive (iii) ALVF
(iv) H/O streptococcal infection (Post- (iv) Blood urea- Raised (iv) Dialysis if necessary (iv) Hyperkalemia, Hyponatremia
streptococcal AGN) (v) S. electrolyte- Hyperkalemia (v) Correction of electrolyte imbalance (v) Metabolic Acidosis
(vi) S. C3 level- Reduced (vi) Treatment of complications, if any
(vii) Evidence of streptococcal infection (vii) Antibiotic treatment for streptococcal infection
Case: Nephritic Syndrome (NS)
Presented with- Investigations- Treatment- Complications-
(i) Oliguria, Swelling, Weakness (i) Urinary findings- Massive proteinuria, Hyaline cast (A) Supportive - Balanced diet (i) Pneumococcal sepsis, UTI
(ii) Pitting edema, BP-Normal (ii) S. Cholesterol- Increased - Food & salt are not restricted unless edema is severe (ii) Hypercoagulability
(iii) Massive Proteinuria (iii) S. Albumin- Hypoalbuminemia - Edema sever—diuretics (iii) Hypercholesterolemia
(iv) Respiratory distress (sometimes) (iv) A:G ratio- Altered - Prophylactic daily oral penicillin against infection (iv) Iron Deficiency Anemia
(v) Renal Biopsy in steroid resistant case (B) Specific - Prednisolone 60 mg/m2 body surface (v) Rickets/Osteomalacia
area (duration depends on initial attack or relapse)
Case: Acute Renal Failure (ARF)
Presented with- Investigations- Treatment-
(i) Anuria, oliguria (i) Blood urea & S. creatinine; (ii) S. electrolytes; (iii) Urinalysis; (i) Fluid balance; (ii) Treatment of hyperkalemia; (iii) Correction of acidosis
(ii) H/O diarrhea (iv) Full blood count and clotting screen; (v) CRP-High; (iv) Stopping of nephrotoxic drugs; (v) Treatment of underlying cause
(iii) Body swelling (vi) Renal Ultrasound; (vii) Blood & Urine culture; (viii) CXR; (ix) ECG (vi) Antibiotic for infection control;(vii) Renal replacement therapy
Case: Chronic Kidney Disease (CKD)
Presented with- Investigations- Treatment-
(i) H/O DM, HTN, Drug (NSAIDs) intake (i) Blood urea & S. creatinine; (ii) S. electrolytes; (iii) Urinalysis; (i) Identification & treatment of underlying cause; (ii) Control of HTN- ACEi or ARBs
(ii) Anorexia, Nausea, Vomiting, Weakness (iv) Full blood count; (v) Plasma lipids; (vi) S. Albumin; (iii) Correction of anemia; (iv) Reduction of proteinuria; (v) Dietary and lifestyle interventions
(iii) Anemia, Raised JVP, BP-High (vii) Renal Ultrasound; (viii) Blood Glucose; (ix) ECG; (vi) Maintenance of fluid & electrolyte imbalance; (vii) Active Vit-D & Ca supplement
(x) Hepatitis and HIV serology (viii) Lipid lowering therapy; (ix) Renal Replacement Therapy, if indicated
 CARDIOLOGY

Case: Acute Left Ventricular Failure (ALVF)

Presented with- Investigations- Treatment- Causes of ALVF-
(i) Sudden severe breathlessness, Frothy sputum (i) ECG- features of MI, ischemia, LVH (i) Immediate hospitalization (i) MI
(ii) Orthopnea, Bilateral basal crepitation (ii) CXR PA view- Pulmonary edema, Cardiomegaly (ii) Propped up position (ii) Systemic HTN
(iii) High BP, Rapid pulse, Cold periphery (iii) Echocardiography (iii) High flow O2 (iii) Cardiomyopathy
Cardinal signs- (iv) Blood test- S. Creatinine, Blood urea, CBC with ESR, CRP (iv) IV GTN 10-200 μg/min upwards every 10 mins (iv) Aortic Stenosis
(i) Bilateral basal crepitations (v) IV Frusemide 50-100 mg (v) Mitral Stenosis & Mitral
(ii) Gallop Rhythm; (iii) Orthopnea (vi) IV opiates (Morphine/Pethidine) with anti-emetics Regurgitation
(iv) Pulsus alternans (vii) Treatment of specific cause
Case: Congestive Cardiac Failure (CCF)
Presented with- Investigations- Treatment-
(i) Exertional dyspnea, Raised JVP (i) CXR-PA view: Reticular shadowing of alveolar edema, Prominence (i) General Measure- Education, Diet, Alcohol consumption, Stop smoking, Exercise, Vaccination
(ii) Swelling in leg, abdomen or whole body of upper lobe blood vessels, Enlarged hiller vessels (ii) Drug Therapy- Diuretics (1st line), Vasodilators, ACEi, ARBs, B-blockers, Digoxin, Amiodarone
(iii) Bilateral petal edema, Tender hepatomegaly (ii) ECG (iii) Implantable cardiac defibrillators
Cardinal signs- (iii) Echocardiography (iv) Resynchronization devices
(i) Dependent edema; (ii) Raised JVP (iv) S. Creatinine, Blood urea & electrolytes (v) Revascularization- Coronary artery bypass surgery
(iii) Tender hepatomegaly (vi) Heart Transplantation
Case: Myocardial Infarction (MI)
Presented with- Investigations- Treatment- Complications-
(i) Sudden severe central chest pain, low BP (i) ECG- ST elevation followed by T-wave inversion, then pathological (i) Immediate Hospitalization (i) Arrythmia
(ii) Sweating, nausea, vomiting, anxiety Q wave development (ii) High flow O2 (ii) Cardiogenic shock
Assessment of History, Examination & Inv- (ii) Plasma biochemical marker- Troponin I, CK-MB (iii) IV access (iii) ALVF
H/O- Age, sex, smoking, alcohol, HTN, DM, (iii) CXR- features of pulmonary edema if LVF presents (iv) ECG monitoring (iv) Heart block
Hypercholesterolemia, Type-I personality, (iv) Leukocytosis, raised ESR and CRP (v) Aspirin 300mg chewed & Clopidogrel 300mg oral (v) Post-infarct angina
Physical inactivity, Dietary habit, past H/O IHD (v) Echocardiography; (vi) Coronary Angiography (vi) Sublingual GTN (vi) Pericarditis
E/O- Obesity, HTN, Xanthelasma (vii) IV analgesia (vii) Mechanical- MR, cardiac tamponade
Inv- Blood sugar level, HbA1C, Fasting Lipid (viii) B-blockers (viii) Embolism
Profile (ix) If ST elevated MI- Thrombolysis with Streptokinase (ix) Impaired ventricular function,
If not-ST elevated MI- LMW heparin remodeling and ventricular aneurysim
(x) If PCI is available, patient should be prepared for it
(xi) Coronary bypass surgery when indicated
Case: Angina
Presented with- Investigations- Treatment-
(A) Stable Angina- (A) Stable Angina- Stable Angina Unstable Angina
(i) Central chest pain, breathlessness (i) Resting ECG- Reversible ST elevated or depressed with or without T (i) Bed rest (i) Bed rest
(ii) Pain precipitated by exertion inversion. Features of previous MI may be found (ii) Sublingual GTN (ii) Sublingual GTN
(iii) Promptly relieved by rest (ii) Exercise ECG- Exercise induce ST depression (iii) Antiplatelet therapy- Low dose aspirin daily (iii) Aspirin 300mg followed by 75mg daily
(iv) H/O- Smoking, HTN, DM, Obesity etc. (iii) Echocardiography; (iv) Coronary Angiography (iv) B-blockers- Atenolol 50-100mg daily (iv) B-blockers- Atenolol 50-100mg daily
(B) Unstable Angina- (B) Unstable Angina- (v) Ca channel blocker- Verapamil (v) Ca channel blocker- Nifedipine/Amlodipine
(i) Substernal or epigastrium chest pain (i) ECG; (ii) Cardiac markers (vi) K channel activators- Nicorandil 10-30mg bd (vi) Anticoagulant- UF/F heparin
(ii) Pain radiates to neck, left shoulder, left arm (iii) Exercise tolerance test (vii) Correcting exacerbating factors (vii) Morphine/Pethidine
(iv) Echocardiography; (v) Coronary Angiography (viii) PCI or CABG- when indicated (viii) Treatment of risk factors
 Case: Atrial Fibrillation (AF)
Presented with- Investigations- Treatment-
(i) Palpitation, breathlessness, fatigue (i) 12-Lead ECG: Absent P-wave with irregular rhythm (i) Rhythm control & restoration of normal rhythm- Anticoagulant drug
(ii) Pulse- irregularly irregular, BP- hypertensive (ii) Echocardiogram (ii) Ventricular rate control- B-blockers, verapamil, diltiazem or digoxin
(iii) Thyroid function test (iii) Prevention of thromboembolism- Warfarin, Aspirin
(iv) Exercise Testing (iv) Treatment of cause
Case: Secondary HTN
Presented with- Investigations- Treatment-
(i) vertigo, palpitations, breathlessness, sweating (A) Baseline (for all patient)- (A) Non-drug Therapy- Correction of obesity, Stop smoking, reducing alcohol intake, restricting salt
Assessment of History, Examination- (i) Urinalysis for blood, protein & glucose intake, taking regular exercise, increasing consumption of fruits and vegetables
H/O- family, lifestyle (exercise, salt intake, (ii) Blood urea, electrolytes and serum creatinine (B) Anti-hypertensive Drug-
smoking), drug/alcohol intake etc.) (iii) Blood glucose (iv) Serum total & HDL cholesterol (i) A-ACEi- Enalapril 20mg daily, ARBs- Losartan 50-100mg daily
E/O- radio-femoral delay, enlarged kidney, (v) 12 Lead ECG (ii) B- Beta blockers- Atenolol 50-100mg daily
abdominal bruits, central obesity & (B) Others (selective patient) (iii) C- Ca channel blockers- Amlodipine 5-10mg daily
hyperlipidemia, evidence of atheroma, (i) CXR- to detect cardiomegaly, HF, coarctation of aorta (iv) D- Diuretics- Frusemide 40mg daily, Hydrochlorothiazide 12.5-25mg daily
ophthalmoscopy etc. (ii) Ambulatory BP- to assess borderline HTN (v) Others-
(iii) Echocardiogram- to detect left ventricular hypertrophy -Both alpha & beta blocker (Labetalol)
(iv) Renal ultrasound- to detect possible renal disease -Alpha blocker (Prazosin)
(v) Renal angiography- to detect or confirm renal artery stenosis -Direct vasodilators (Hydralazine)
(vi) Urinary catecholamines- to detect possible pheochromocytoma -Centrally acting (Methyl dopa)
(vii) Urinary cortisol & Dexamethasone Suppression test- Cushing Synd. (C) Adjuvant drug therapy- Aspirin 75mg daily, Atorvastatin 10-20mg daily
(viii) Plasma Renin activity & aldosterone- to detect P. aldosteronism
(ix) Thyroid function test- for thyrotoxicosis or hypothyroidism
Case: Rheumatic Fever
Presented with- Investigations- Treatment- Diagnostic Criteria
(i) Migratory joint pain (i) Evidence of systemic illness (not specific)- (i) Antibiotic- Benzathine Penicillin (Cephalosporin in (A) Major- Carditis, Polyarthritis, Chorea, Erythema marginatum,
(ii) Fever, anorexia, lethargy Leukocytosis, Raised ESR & CRP penicillin-allergic patient) Subcutaneous nodule
(iii) H/O- Sore throat, Scarlet Fever (ii) Evidence of streptococcal infection (specific)- (ii) Bed rest & supportive therapy (B) Minor- Fever, Arthralgia, Previous rheumatic fever, Raised ESR
Throat swab culture (iii) Aspirin- relieves the symptoms of arthritis rapidly & CRP, Leukocytosis, 1st degree AV block
(iii) Evidence of carditis- CXR, ECG, Echocardiography (iv) Corticosteroids- indicative in carditis or severe arthritis Plus- Supporting evidence of preceding streptococcal infection
Case: Mitral Stenosis (MS)
Presented with- Investigations- Treatment- Complications-
(i) Exertional breathlessness, fatigue (i) ECG- Lt atrial hypertrophy (if not in AF), Rt ventricular hypertrophy, (A) Medical- (i) AF
(ii) Edema, dyspnea, palpitation Features of AF (i) If AF, Anticoagulant therapy (warfarin) (ii) Systemic embolism
(iii) Cough, Chest pain, hemoptysis (ii) CXR- Enlarged Lt atrium, Signs of pulmonary edema (ii) If Dyspnea, Diuretics (iii) Pulmonary HTN
(iv) Loud 1st heart sound with mid-diastolic (iii) Echocardiogram- Reduced rate of diastolic filling of LV (iii) Antibiotic prophylaxis for infective endocarditis (iv) Pulmonary edema
murmur (iv) Doppler- Pulmonary artery pressure, Lt ventricular function (B) Intervention & Surgical- (v) Pulmonary infarction
(v) AF present when pulse irregularly irregular (v) Cardiac Catheterization- Assessment of coexisting coronary artery (i) Mitral Balloon valvuloplasty; (ii) Closed Valvotomy (vi) Hemoptysis
disease and MR (iii) Open Valvotomy, (iv) Mitral Valve replacement (vii) Right ventricular failure
Case: Infective Endocarditis
Presented with- Investigations- Treatment-
(i) Fever, malaise, rash, purpura, clubbing (i) Blood culture (crucial) (A) Medical-
(ii) Heart failure, Murmur (ii) Echocardiography- to detect vegetations (i) Viridans streptococci- Benzyl Penicillin IV + Gentamicin IV
(iii) Arthralgia, Pyrexia (iii) CBC: ESR & CRP- Raised, Leukocytosis & Thrombocytopenia (ii) Enterococci- Amoxicillin IV + Gentamicin IV
(iv) Splenomegaly (iv) ECG- AV block (iii) Staphylococci- Flucloxacillin IV or Vancomycin IV
(v) CXR- Cardiac failure and cardiomegaly (B) Surgery- Cardiac Surgery
 RESPIRATORY

Case: Pneumothorax
Presented with- Investigations- Treatment-
(i) Sudden pleuritic chest pain, breathlessness (i) CXR- (i) O2 Inhalation
(ii) H/O COPD, TB, Lung abscess - Hyper-translucent lung field with absent Broncho-vascular markings (ii) Management of shock
(iii) Percussion- hyper resonant and collapsed lung margin in the affected side (iii) Percutaneous needle aspiration
(iv) Breath sound- Diminished - Trachea is shifted to the opposite side (iv) Water Sealed intercostal drainage (in 2nd intercostal space anteriorly in mid clavicular line)
(v) Features of Shock (ii) CT scan of chest- (v) Treatment of the underlying cause
Case: Bronchial Asthma
Presented with- Investigations- Treatment-
(i) Breathlessness, Chest tightness (i) PEFR- Diurnal variation (i) High concentration of Oxygen
(ii) Wheezing, Cough, Cyanosis (ii) FEV1 & VC- by spirometry (ii) High dose of inhaled bronchodilators
(iii) H/O allergy, drug (iii) CXR- normal findings; hyperinflation & lobar collapse in acute case (iii) Systemic corticosteroids- Oral Prednisolone 30-60mg daily
(iv) Measurement of allergic status (iv) IV fluid- to correct dehydration
(v) Assessment of airway inflammation (v) Subsequent management (if severe)- IV aminophylline
(vi) Monitoring of the patient
Case: COPD
Presented with- Investigations- Treatment- Complications-
(i) Severe respiratory distress, Hemoptysis (i) CXR- hypertranslucent lung field (i) Smoking should be stopped (i) Pneumothorax
(ii) Cough with sputum, Ronchi (ii) ECG (ii) In acute exacerbation, low conc. Oxygen therapy (ii) Recurrent Pulmonary Infection
(iii) Barrel shaped chest (iii) Arterial blood gas analysis (iii) Bronchodilators- Ipratropium Bromide (iii) Pulmonary HTN
(iv) Increased Respiratory rate (iv) Full blood count (iv) Corticosteroids- Oral Prednisolone 30mg for 10 days (iv) Cor-pulmonale
(v) Often a smoker (v) Spirometry (v) Antibiotic- Aminopenicillin or a Macrolides, Co-Amoxiclav (v) Type-2 Respiratory Failure
D/D- (vi) Measurement of lung volume (vi) Non-invasive ventilation (vi) Secondary Polycythemia
Bronchial asthma, Bronchiectasis, CCF, PTB (vii) CT scan of chest- characterization and quantification of emphysema (vii) Diuretics if peripheral edema has developed
Case: Community Acquired Pneumonia (CAP)
Presented with- Investigations- Treatment-
(i) Pleuritic Chest pain (i) CBC- neutrophilic leukocytosis, ESR & CRP- raised (A) Uncomplicated CAP-
(ii) Fever, Cough, Hemoptysis (ii) CXR- Radio-opaque shadow with air brochogram (i) Amoxicillin 500mg 8 hourly orally
(iii) Rusty sputum (pneumococcal infection) (iii) Sputum study- microscopic and culture (ii) If patient allergic to penicillin, Clarithromycin 500mg 12 hourly orally
(iv) Pulse Oximetry- to see atrial O2 saturation (iii) If Staphylococcus is cultured/suspected,
Flucloxacillin 1-2g 6 hourly IV + Clarithromycin 500mg 12 hourly IV
(B) Severe CAP-
Clarithromycin 500mg 12 hourly IV + Co-Amoxiclav 1-2gm 8 hourly IV
Case: Bronchiectasis
Presented with- Investigations- Treatment- Complications-
(i) Chronic, productive, foul smelling cough (i) CXR- not usually apparent (i) Chest Physiotherapy- Postural drainage (i) Pneumonia
(ii) Copious purulent sputum (ii) High resolution CT scan of chest- (ii) Antibiotic- same as COPD (ii) Pneumothorax
(iii) Coarse crepitation, clubbing (iii) Sputum examination- Microscopic & culture (iii) Bronchodilators (iii) Empyema
D/D- (iv) X-ray of paranasal sinuses- concomitant rhino-sinusitis (iv) Anti-inflammatory agents- Inhaled or oral steroids (iv) Metastatic cerebral abscess
Lung Abscess (v) Serum immunoglobulin- antibody deficiency (v) Surgical Treatment- rarely (v) Recurrent infection
(vi) Assessment of ciliary function (vi) Pulmonary HTN
(vii) Cor-pulmonale
 Case: Lung Abscess
Presented with- Investigations- Treatment-
(i) Swinging fever & malaise (i) CBC- neutrophilic leukocytosis, ESR & CRP- raised (i) Postural drainage
(ii) Cough & large amount foul smelling sputum (ii) CXR- cavitation with air fluid level (ii) Antibiotic treatment- combination of antibiotics up to 4-6 weeks
(iii) Digital clubbing (iii) Sputum Examination- Microscopic & culture Amoxicillin + Metronidazole + Gentamicin
D/D- (iv) Blood culture (iii) Surgical treatment if no improvement
Bronchiectasis (iv) Removal or treatment of any obstructive endobronchial lesion
Case: Bronchial Carcinoma
Presented with- Investigations- Treatment-
(i) H/O smoking (i) CXR-Mass lesion, Lobar collapse, Pleural effusion, Mediastinal (i) Surgery- In stage-I & stage-II disease
(ii) Chronic cough, chest pain widening, Rib destruction (ii) Radiotherapy
(iii) Hoarseness of voice, shortness of breath (ii) CT scan of chest; (iii) CT guided FNAC (iii) Chemotherapy
(iv) Weight loss, malaise, low grade fever (iv) Fiberoptic bronchoscopy; (iv) Combined radiotherapy & chemotherapy
(v) Clubbing, Cervical lymphadenopathy (v) Bronchoscopic biopsy & histopathology (v) Adjuvant chemotherapy & radiotherapy after surgery
D/D- (vi) Lymph node biopsy & histopathology
Pulmonary TB (vii) Pleural fluid study; (viii) CBC with ESR- Anemia, ESR raised
(ix) Others- S. Ca level, LFT, S. electrolytes, PET etc.

ENDOCRINOLOGY

Case: Thyrotoxicosis & Hyperthyroidism

Presented with- Investigations- Treatment-
(i) Heat intolerance and sweating (A) Specific- (i) Anti-thyroid drugs-
(ii) Weight loss & increased appetite (i) Serum T3 & T4- increased Carbimazole 40-60mg daily in 3 divided doses, Propylthiouracil 400-600mg daily
(iii) Palpitations, fatigue, weakness, anxiety (ii) Serum TSH- Decreased/undetectable in primary, raised in secondary (ii) Subtotal Thyroidectomy
(iv) Diarrhea, muscle weakness (iii) Thyroid Antibody- Antibody to TSH receptor (iii) Radioactive Iodine
(v) Warm periphery, tachycardia, HTN (iv) Isotope scanning (iv) Symptomatic treatment- non-selective beta-blocker
(B) Non-specific-
(i) ECG shows sinus tachycardia; (ii) Raised bilirubin, (iii) Mild
hypercalcemia, (iv) Glycosuria
Case: Hypothyroidism
Presented with- Investigations- Treatment-
(i) Cold intolerance, Hoarseness of voice (A) Specific- (i) Serum T3, T4, TSH- Levothyroxine
(ii) Weight gain & poor appetite - Low T3 & T4, elevated TSH- primary hypothyroidism 50 μg should be given for 3 weeks, increasing thereafter to 100 μg per day for a further 3 weeks
(iii) Puffiness of face, delayed tendon reflex - Low T3 & T4, TSH low or normal- secondary hypothyroidism Finally, maintenance dose is 100-150 μg day for life long
(iv) Constipation, Menorrhagia (female) (B) Non-specific-
(v) Cold periphery, Anemic, Hypertensive (i) ECG shows sinus tachycardia; (ii) Raised Serum enzymes (CK, AST),
(iii) Hypercholesterolemia, (iv) CBC-normochromic normocytic anemia,
(v) USG of thyroid gland
Case: Addison’s Disease
Presented with- Investigations- Treatment-
(i) Pigmentary change, low BP (i) Assessment of glucocorticoids- ACTH stimulation test (i) Correction of volume depletion- IV saline
(ii) Anorexia, nausea, vomiting, Diarrhea (ii) Assessment of mineralocorticoids- Plasma electrolyte measurement (ii) Glucocorticoid replacement; (iii) Mineralocorticoid replacement
(iii) Hypotension, hyponatremia, Hypoglycemia, (iii) Others- Thyroid function test, Full blood count, Plasma calcium, CT (iv) Androgen replacement; (v) Correction of other metabolic abnormality
Hyperkalemia scan or MRI to identify malignancy (v) Identification and treatment of underlying cause
 DIABETES MELLITUS & DIABETIC COMPLICATIONS

Case: Diabetes Mellitus (DM)

Presented with- Investigations- Treatment-
(i) H/O weight gain/loss, exercise, HTN, IHD, (i) Blood glucose level- (i) Dietary modification
smoking, alcohol use etc. RBG, FBG (≥7 mmol/L), (ii) Lifestyle modification- Exercise, stopping smoking & alcohol intake
(ii) Polyuria, Polydipsia, Polyphagia Post-prandial Blood glucose (2 hours after meal)- ≥11.1mmol/L, OGTT (iii) Drugs-
(iii) Weight loss, weakness (ii) Urine examination- for glucose, protein - Oral Antidiabetic Drug (type 2 DM)- Tolbutamide, Tolazamide, Glipizide, Gliclazide, Metformin
Clinical Evaluation- (iii) HbA1c: >6.5% - Insulin therapy
Pulse, BP, Weight, Peripheral pulse, Bowel & (iv) Others- Fasting lipid profile, Blood urea & creatinine, S. electrolytes
Bladder habit, Foot examination etc.
Case: Diabetic Ketoacidosis (DKA)
Presented with- Investigations- Treatment-
(i) Abdominal pain, shortness of breath (i) Blood glucose (i) Correction of dehydration-
(ii) Loss of consciousness, Hypotension (ii) Urinalysis for ketones 0.9% saline (NaCl) IV, add 10% glucose 125ml/hour IV when blood glucose is <14 mmol/L
(iii) Fever, Dehydration, Cold extremities (iii) Urea & electrolytes (ii) Correction of blood glucose level-
(iv) Plasma Bicarbonate Administration of short acting soluble insulin 0.1 U/kg body weight/hour IV infusion (by infusion
(v) Arterial blood gas analysis pump) or 10-20 units Insulin IM stat and then 5 units IM hourly
(vi) ECG for hypo or hyperkalemia (iii) K level correction-
(vii) Infection screen: CBC, blood & urine culture, CXR K level >5.5mmol/L- no correction needed, K level 3.5-5.5- 40mmol/L K added per liter of infusion,
K level <3.5- Senior review necessary
(iv) Administration of antibiotics if infection are present
Case: Hyperglycemic Hyperosmolar State (HHS)
Presented with- Investigations- Treatment-
(i) Sudden unconsciousness, fever (i) Blood glucose > 30mmol/L (i) Fluid replacement with 0.9% NaCl IV
(ii) Marked dehydration (ii) Urinalysis for ketones- Absent ketone bodies (ii) Initiate Insulin IV infusion
Precipitating factors- (iii) Urea & electrolytes (iii) Treatment of co-existing condition
Infection, MI, Cerebrovascular events, (iv) Plasma Bicarbonate- no evidence of acidosis (iv) Prophylactic anti-coagulations
Corticosteroids drugs (v) Measurement of plasma osmolarity Complications- Thromboembolism
Case: Hypoglycemic Coma
Presented with- Investigations- Treatment-
(i) Sweating, tremor, loss of consciousness (i) Blood glucose (A) Mild Hypoglycemia (self-treated)- Oral fast acting carbohydrate 10-15g
(ii) Rapid pulse, Stable BP (ii) Urinalysis for ketones (B) Severe Hypoglycemia (External help required)
(iii) Urea & electrolytes - If semiconscious/unconscious, parenteral treatment is required. IV 75ml 20% dextrose, IM Glucagon
(iv) Plasma Bicarbonate - If conscious/able to swallow, Oral refined glucose as drink or sweets. Apply glucose gel/jam/honey
(v) Arterial blood gas analysis to buccal mucosa.
(vi) ECG for hypo or hyperkalemia
(vii) Infection screen: CBC, blood & urine culture, CXR

Prepared By-
PARTHA SAROTHI SINGHA
AMUMC-7
 SUMMARY OF SOME IMPORTANT CASES IN MEDICINE
(Presenting features, D/D, Investigations, Treatments and others)
Medicine, Paper-II
PAEDIATRICS

Case: Perinatal Asphyxia

Presented with- Investigations- Treatment- Complications-
(i) Pale color, No respiration, No Cry (i) CBC, (ii) CXR, (iii) ECG, (iv) IT ratio, (A) Immediate Resuscitation- (i) Cerebral palsy
(ii) Absent or Poor Respiratory effort (v) Arterial Blood gas analysis, (vi) Blood urea & creatinine, (i) Keep the baby warm, (ii) Opening and maintaining airway, (ii) Mental retardation
(iii) HR- Bradycardia (vii) Serum glucose, (viii) Serum electrolytes, (iii) Supporting breathing, (iv) Maintenance circulation & oxygenation (iii) Epilepsy
D/D- (ix) Cranial ultrasound & CT scan (B) Post Resuscitation- (iv) Cranial nerve palsy
RDS, Transient tachypnea of newborn, Different methods of O2 inhalation techniques- (i) Maintain body temperature, (ii) Support respiration by supplement O2 Immediate-
Acute intracranial hemorrhage, (i) Nasal canula, (ii) Simple mask, (iii) Venturi Mask, (iii) Mechanical ventilation, (iv) Treatment of other specific situations (i) Respiratory failure,
Meconium Aspiration Syndrome (iv) Oxygen hood, (v) Oxygen tent, (vi) AMBU Bag (ii) Convulsion, (iii) Coma
Case: Neonatal Sepsis
Presented with- Investigations- Treatment-
(i) Refuse to suck, Less active/alert (A) Sepsis screening- (A) Supportive care-
(ii) Lethargy, Less movement (i) Total leukocyte count (<5000/cmm), (ii) Differential count: low, (i) Maintenance of temperature, (ii) Hypoglycemia by 10% dextrose, (iii) Breast feeding,
(iii) Hypothermia/fever, vomiting (iii) IT ratio >0.2, (iv) Micro ESR >15mm in 1 st hour, (v) Elevated haptoglobin (iv) Treatment of shock- Dopamine, (v) Assess hypoxia & initiate O2 therapy
Causative agents- (B) Other investigations- (B) Anti-microbial- Ampicillin + Gentamicin or Ampicillin + Cefotaxime, usually 7-10 days
Group B Streptococci, E. Coli, (i) CBC with PBF, (ii) Blood for C/S, (iii) Blood for pro-calcitonin, (C) Host-defense modulation- (i) Granulocyte transfusion, (ii) Immunoglobulin therapy
Pseudomonas (iv) Urine for R/M/E & C/S, (v) X-ray chest & abdomen (D) Follow up every 4-6 hourly the vital signs, primitive reflex, skin, anterior fontanelle, abdomen
Case: Neonatal Jaundice
Presented with- Investigations- Treatment-
Yellow discoloration of eye & body (i) S. Bilirubin- Total, direct, indirect (i) Only exclusive breast feeding & follow up sufficient for physiological jaundice
H/O- (ii) Blood grouping & Rh typing of baby & mother (ii) Pathological jaundice is treated by Photo therapy & Exchange transfusion
(i) Age of appearance of jaundice (iii) CBC- Hb%, TC & DC of WBC, CRP Complications-
(ii) Order of pregnancy (iv) PBF (i) Kernicterus
(iii) Jaundice of previous child (v) Comb’s test- Direct & Indirect (ii) Hemoglobinuria
(iv) Death of any baby due to Jaundice (vi) Other as individualized (iii) Renal failure
Case: Protein Energy Malnutrition (PEM)
Presented with- WHO Classification of PEM 10 step management- Complications-
(A) Marasmus- Moderate Malnutrition Severe Malnutrition (i) Treat/Prevent Hypoglycemia (i) Infections both overt and hidden
Well alert face, sever muscle wasting, Weight for height -2 to -3 SD <-3 SD (<70%) (ii) Treat/Prevent Hypothermia (ii) Dehydration
Good appetite (70-79%) Severe wasting (iii) Treat/Prevent Dehydration (iii) Hypoglycemia
(B) Kwashiorkor- Height for age -2 to -3 SD <-3 SD (<85%) (iv) Correction of electrolyte imbalance (iv) Hypothermia
Rounded face, Bilateral pedal edema, (85-89%) Severe wastign (v) Treat/Prevent infection (v) Anemia
Skin change, Mental change, (vi) Correct micronutrient deficiency (vi) CCF
Hepatomegaly (vii) Start feeding cautiously (vii) Bleeding
Severe Acute Malnutrition (SAM) is (viii) Achieve catch up growth (viii) Sudden infant death syndrome
defined by presence of severe wasting (ix) Provide sensory stimulation & emotional support
and or bipedal edema. (x) Prepare for discharge & follow up after recovery
 Case: Dehydration/Diarrhea
Assessment of Dehydration Treatment- Complication of Diarrhea:
Points No Dehydration Some Dehydration Severe Dehydration (A) No Dehydration- (i) Hypokalemia
1. Look at- (i) Rehydration- at home with ORS; (ii) Hyponatremia
i) Condition/appearance Well alert Restless, irritable* Lethargic, unconscious, floppy <2 years: 50-100ml, ≥2 years: 100-200ml (iii) Metabolic acidosis
ii) Eyes Normal Sunken Very sunken & very dry (ii) Zinc supplementation- (iv) Paralytic Ileus
iii) Tears Present Absent Absent <6 months: 5mg/day 10-14 days, ≥6 months: 10mg/day for 10-14 days (v) Acute Renal Failure
iv) Mouth & tongue Moist Dry Very Dry (iii) Continue feeding (vi) Growth failure
v) Thirst Drinks normally, Thirsty, drinks eagerly* Drinks poorly or unable to drink* (B) Some dehydration- (vii) GBS
but thirsty (i) Rehydration- ORS 75 ml/kg within 4 hours (viii) Shock
2. Feel: Skin Pinch Goes back quickly Goes back slowly* Goes back very slowly* (ii) Reassess after 4 hours (iii) Zinc supplementation (iv) Continue feeding
3. Decide: Patient If the patient has If the patient has 2 or more signs, If the patient has 2 or more signs, (C) Severe dehydration-
no signs of including at least one *sign* - including at least one *sign* - (i) Rehydration: Rapid IV rehydration (100ml/kg) & close monitoring
dehydration SOME DEHYDRATION SEVERE DEHYDRATION <12 months: 1st give 30 ml/kg in 1 hour, then give 70 ml/kg in 5 hours
>12 months: 1st give 30 ml/kg in 30 mins, then give 70 ml/kg in 2.5 hours
(ii) Monitoring (iii) Zinc supplementation (iv) Continue feeding
Case: Ventricular Septal Defect (VSD)
Presented with- Investigations- Treatment-
(i) H/O repeated respiratory tract inf. (i) ECG- Normal in small defects (A) Medical-
(ii) Shortness of breath, Dyspnea (ii) CXR PA- Enlargement of main pulmonary artery, LA, LV (i) No exercise restriction, (ii) Maintenance of good dental hygiene, antibiotic prophylaxis,
(iii) Cyanosis (iii) Echocardiography- LA, LV enlargement; Defect may be directly (iii) CCF & Chest infection should be treated if present, (iv) Adequate nutrition should be maintained
(iv) Systolic thrill & Pansystolic murmur visualized (B) Surgical indications-
in lower left parasternal area (i) Not controlled medically, (ii) Large VSD & CCF not controlled by decongestive therapy,
(iii) After 1 year of age, significant LR shunt with QP/QS >2:1, (iv) Older children with large VSDs
Case: Tetralogy of Fallot (TOF)
Presented with- Investigations- Treatment- Complications-
(i) Dyspnea, fatigue (i) ECG- Right ventricular hypertrophy (A) Medical- (i) Cerebral thrombosis
(ii) Breathlessness on exertion (ii) Chest X-ray P/A view: ‘boot-shaped’ heart (i) Correction of Anemia, (ii) Treatment of Polycythemia (ii) Brain Abscess
(iii) Cyanosis, clubbing (iii) Echocardiography: VSD, overriding of aorta, RVH (iii) Prevention of dehydration, (iv) Prophylactic antibiotic (iii) Bacterial endocarditis
(iv) Systolic murmur in pulmonary area (iv) Cardiac Catheterization (B) Surgical- (iv) Heart Failure
(i) Palliative shunt, (ii) Total corrective surgery (v) Cerebral Accident
Case: Pneumonia
Investigations- Treatment-
(i) CXR- consolidation (A) Antibiotic-
(ii) WBC- elevated with predominant neutrophil Parenteral Amoxicillin (50mg/kg 8 hourly) for 5 days.
(iii) Arterial blood sample- Hypoxia with hypercapnia If improved, switched to oral Amoxicillin (30mg/kg 8 hourly). Total duration of treatment 7-10 days
(iv) Blood or lung aspirate (diagnostic)- Isolation of the bacteria (B) Supportive-
(i) O2 therapy, (ii) Paracetamol for fever,
(iii) Salbutamol for wheeze,
(iv) Clearing nose e- normal saline
Case: Bronchiolitis
Presented with- Investigations- Treatment-
(i) Severe respiratory distress (i) CXR- Hypertranslucency, Hyperinflation (i) Counselling, (ii) Home care in mild case
(ii) Wheeze, Low grade fever (ii) CBC- unremarkable (iii) Severe case- Hospitalization, Humidified O2 therapy, Nebulized with 7%, 3% NaCl/normal saline,
(iii) Runny nose with cough NPO & IV fluid, Monitoring of SpO2, Drugs- Steroids and antibiotics if infection is suspected.
 Case: Bronchial Asthma
Presented with- Investigations- Treatment-
(i) Recurrent respiratory distress (i) Blood & Sputum examination- Eosinophilia (i) Nebulization with salbutamol, if not improved nebulized with Ipratropium bromide
(ii) Cough, Wheeze, Low grade fever (ii) Bronchial reversibility & spirometry (less feasible in children) (ii) O2 inhalation; (iii) Inj. Hydrocortisone; (iv) Inj. Aminophylline
(v) In refractory cases, ICU support
Case: Febrile Convulsion
Presented with- Investigations- Treatment-
(i) Fever, Generalized tonic clonic (A) CSF study- Indications- (A) Acute episode-
convulsion (i) Any doubt of meningitis, (ii) 1 st attack is at <12 months of age, (i) Explanation & reassurance of parents about the natural history of disease & prognosis
Physical examination- (iii) Age 12-18 months associated with complex seizure (ii) Maintain airway, breathing & circulation, (iii) Reduce fever by paracetamol
Temperature, Pulse & BP, Respiratory (B) Other to find out the cause of fever- RBS, S. Calcium, S. electrolytes, CBC (iv) Termination of seizure by Inj. Diazepam or Inj. Midazolam
rate, GCS, Signs of meningeal irritation, with ESR, Blood culture, Throat swab C/S, CXR, Urine R/M/E (B) Prevention of recurrence-
Motor, sensory & cranial nerve exam (i) Intermittent prophylaxis- Oral diazepam, (ii) Continuous prophylaxis- not recommended
Case: Pyogenic Meningitis/Meningoencephalitis
Presented with- Investigations- Treatment-
(i) Fever, Restlessness (i) Blood for CBC, C/S (A) Antibiotic: Duration generally 10-14 days
(ii) Several episodes of Generalized (ii) CSF study, cytology, gram stain, culture (i) In 1st 3 months of life- Inj. Ampicillin + Inj. Ceftriaxone
convulsions (iii) Serological (Antigen detection) test (ii) Beyond 3 months of age- Inj. Ampicillin + Inj. Chloramphenicol
(iii) Photophobia, Bulge fontanels (iv) Cranial ultrasound scan (B) Anti-inflammatory- IV dexamethasone, should be given 15 min before antibiotic treatment
D/D- (v) CT Scan (C) Symptomatic- Paracetamol & Diazepam
Febrile convulsion, Encephalitis (D) Treatment of complications, (E) General Care
Case: Guillain Barre Syndrome (GBS)
Presented with- Investigations- Treatment-
(i) Distal paresthesia with limb pain (i) CSF study (should be done after 10 days)- Protein is elevates some stages (i) Supportive- to prevent pressure sores and DVT
(ii) Ascending muscle weakness (ii) Electrophysiological studies- Most evident proximally as delayed F waves (ii) Regular monitoring of respiratory function
(iii) Miller Fisher Syndrome triad- (iii) Antibodies to the ganglions GMI- found in 25% cases (iii) Plasma exchange & IV immunoglobulin therapy
Ophthalmoplegia, Ataxia, Areflexia (iv) S. electrolytes
Case: Nephrotic Syndrome (NS)
Presented with- Investigations- Treatment-
(i) Facial puffiness, massive periorbital (i) 24 hours urinary total protein- Massive proteinuria, Hyaline cast (A) Supportive - Balanced diet
swelling (ii) S. Cholesterol- Increased (iii) S. Albumin- Hypoalbuminemia - Food & salt are not restricted unless edema is severe
(ii) Generalized edema (iv) S. Creatinine, S. Electrolytes - Edema sever—diuretics
(iii) Massive Proteinuria (v) Blood for CBC, HbSAg - Prophylactic daily oral penicillin against infection
(iv) Scanty micturation (v) USG of chest/abdomen/kidney, (vi) Renal Biopsy (B) Specific - Prednisolone 60 mg/m2 body surface area (duration depends on initial attack or relapse)

Case: Acute Glomerulonephritis (AGN)

Presented with- Investigations- Treatment-
(i) Generalized body swelling/ puffiness (i) Urine analysis (RBC, RBC Cast, mild proteinuria) (i) Salt & fluid restriction
of face (ii) CBC- Polymorphonuclear leukocytosis (ii) Diuretics
(ii) Scanty micturition, high colored (iii) S. Creatinine- Raised (iii) Antihypertensive
urine (iv) Blood urea- Raised (iv) Dialysis if necessary
(iii) edema, HTN (v) S. electrolyte- Hyperkalemia (v) Correction of electrolyte imbalance
(iv) H/O streptococcal infection (Post- (vi) S. C3 level- Reduced (vi) Treatment of complications, if any
streptococcal AGN) (vii) Evidence of streptococcal infection (vii) Antibiotic treatment for streptococcal infection
 Case: Measles
Presented with- Investigations- Treatment-
Fever, Malaise, Rash Diagnosis by clinical & by detection of antibody (serum IgM) (i) Normal immunoglobulins attenuate the disease in the immunocompromised/non-immune pregnant
D/D- Complications- women, but must be given within 6 days of exposure
Dengue, Rubella Otitis media, Laryngitis, Diarrhea, Vit-A deficiency, Septicemia, GBS, (ii) Vaccination can be used in outbreaks, (iii) Vitamin-A may improve the condition
Encephalitis, Keratitis, Corneal ulceration (iv) Antibiotic therapy is reserved for bacterial complications
Case: Congenital Hypothyroidism
Presented with- Investigations- Treatment-
(i) Prolong neonatal jaundice, lethargy (i) Serum FT4, TSH: (i) Counseling
(ii) Constipation, Coarse facies Low FT4 & high TSH- Primary, Both TSH & FT4 low- Secondary (ii) Drugs- Sodium L. thyroxine
(ii) Thyroid scan; (iii) Thyroid ultrasonography (iv) Skeletal survey Newborn: 10-15 microgram/kg/day; Children: 4 microgram/kg/day
Case: Rheumatic Fever
Presented with- Investigations- Treatment- Diagnostic Criteria
(i) Migratory joint pain (i) Evidence of systemic illness (not specific)- (i) Counselling (A) Major- Carditis, Polyarthritis, Chorea, Erythema
(ii) Fever, anorexia, lethargy Leukocytosis, Raised ESR & CRP (ii) Supportive- Bed rest, Rest to affected joint marginatum, Subcutaneous nodule
(iii) H/O- Sore throat, Scarlet Fever (ii) Evidence of streptococcal infection (specific)- (iii) Antibiotics- Erythromycin 40mg/kg/day 6 hourly (B) Minor- Fever, Arthralgia, Previous rheumatic fever, Raised
Throat swab culture (iv) Anti-inflammatory- ESR & CRP, Leukocytosis, 1st degree AV block
(iii) Evidence of carditis- CXR, ECG, Polyarthritis, Carditis without CCF/cardiomegaly- Aspirin; Plus- Supporting evidence of preceding streptococcal infection
Echocardiography With CCF/cardiomegaly- Prednisolone
(v) Treatment of Sydenham chorea- Phenobarbitone
Case: Juvenile Rheumatoid Arthritis
Presented with- Investigations- Treatment-
(i) polyarthritis (i) CBC: Hb%-low, neutrophilic leukocytosis (i) Drug Therapy: NSAIDs, DMARDs, Corticosteroids
(ii) pain, swelling of small joint (ii) X-ray: soft tissue swelling, periarticular osteoporosis (ii) Patient education, counselling
(iii) morning stiffness (iii) ESR & CRP- raised (iii) Surgery: Synovectomy, Osteotomy (later stage)
Extra-articular features- (iii) Synovial fluid aspiration & synovial biopsy DMARDs-
(i) fever, weight loss, fatigue (iv) Arthroscopy, Arthrography (i) Methotrexate, (ii) Sulfasalazine, (iii) Hydroxychloroquine, (iv) Leflunomide
(ii) muscle wasting, (iii) anemia (v) Urine R/M/E to exclude SLE
Case: Acute Viral Hepatitis
Presented with- Investigations- Treatment-
(i) Fever, anorexia, vomiting (i) LFT: S. bilirubin, SGPT, SGOT, PT, Alkaline phosphatase- Elevated (i) Supportive: Bed rest, Normal diet, Adequate fluid and electrolyte balance, Follow up
(ii) Epigastric discomfort (ii) Viral Markers-Anti HAV IgM, Anti HEV IgM, HbSAg, Anti HCV (ii) Vitamin-K; if PT is High
(iii) Jaundice, tender hepatomegaly (iii) USG of hepatobiliary system (iii) Purgatives, gut sterilizer or lactulose
Case: Thalassemia
Presented with- Investigations- Treatment-
(i) H/O repeated blood transfusion (i) Blood picture- Hb%- Reduced, RBC- Microcytic hypochromic with (i) Supportive: Blood transfusion, Folic acid, Iron chelating agent, Splenectomy if needed
(ii) Anemia, Jaundice, Splenomegaly anisocytosis & poikilocytosis, Plenty of target cell with fragmented RBC (ii) Specific: Allogenic Bone Marrow transplantation
Reticulocyte count- increased (iii) Genetic counseling
(ii) Hb electrophoresis (Confirmatory): For HbF, HbA2, Hb-Barts and HbH
(iii) X-ray skull- ‘hair on end’ appearance
(iv) Biochemical: S. Bilirubin- Increased
S. Iron Profile:
S. iron, S. ferritin, Percent saturation- Normal or increased, TIBC- Decreased
 Case: Hemophilia
Presented with- Investigations- Treatment-
(i) Joint swelling, Swelling in muscle & (A) Screening- (i) In hemophilia A- IV infusion of factor VIII concentrate
soft tissue after trauma CT- greatly prolonged, BT- normal, APTT-prolonged, PT-normal, TT-normal, (ii) In hemophilia B- IV infusion of factor IX concentrate
(ii) Prolong bleeding after injury Routine blood test-Anemia, Platelet count-normal (iii) Resting of the bleeding site by either bed rest or a splint reduces continuing hemorrhage
(B) Confirmatory- (i) Factor VIII assay- reduced in hemophilia A,
(ii) Factor IX assay- reduced in hemophilia B
Case: Acute Lymphoblastic Leukemia
Presented with- Investigations- Treatment-
(i) fever, anorexia, weight loss, gum (i) CBC: Hb%- reduced, WBC- Usually raised, sometimes low, Platelet- low (i) Supportive: Blood transfusion, Platelet transfusion, Antibiotic
bleeding (ii) PBF- Blast cell, Smear Cell (ii) Specific: Chemotherapy, Bone marrow transplantation
(ii) hepatosplenomegaly & (iii) Bone marrow examination- Hypercellular, M/E Ratio-Increased,
lymphadenopathy Erythropoiesis- depressed, Leukopoiesis-increased, Megakaryopoiesis-reduced
Case: ITP
Presented with- Investigations- Treatment-
(i) purpuric spots, gum bleeding (i) CBC- Thrombocytopenia (i) Patient with platelet count >30,000/cmm generally require no treatment unless they undergo a
(ii) afebrile, no organomegaly, no (ii) PBF- Reduced platelet surgical procedure
lymphadenopathy, no bony tenderness (iii) Bone marrow examination- Increased number of megakaryocytes (ii) 1st line therapy: Prednisolone 1 mg/kg body weight daily, IV Ig therapy, Platelet transfusion
D/D- (iv) Anti-platelet Antibody detection (iii) 2nd line therapy: Splenectomy
(i) Aplastic Anemia, (ii) Acute leukemia (iv) 3rd line therapy: Immunosuppressants (rituximab)
(iii) Dengue hemorrhagic fever, (iv) DIC

INFECTIOUS DISEASES

Case: Dengue
Presented with- Investigations- Treatment-
(i) Fever, backache, arthralgia (i) CBC- Leukopenia & Thrombocytopenia (i) Symptomatic treatment
(ii) Maculo-papular rash (ii) ELISA to detect NS1 antigen (ii) Aspirin should be avoided due to bleeding risk
(iii) Anorexia, nausea, vomiting (iii) Antibody Titer- Four-fold rise in IgG titer (iii) Volume replacement and blood transfusion may be indicated in patients of shock
(iv) Isolation of dengue virus from blood (iv) Corticosteroids have not been shown to help
(v) Detection of dengue virus RNA by PCR (v) No existing antivirals are effective
Case: Tuberculosis
Presented with- Investigations- Treatment: H= Isoniazid
(i) Chronic cough, often with (i) CBC with ESR- High ESR, lymphocytosis, anemia Category-1: New cases of smear positive pTB R= Rifampicin
hemoptysis, Cachectic (ii) CXR- patchy opacity Initial phase- 2 months HRZE/HRZS; Continuation phase- 4 months HR E= Ethambutol
(ii) Pyrexia, Anorexia, Weight loss (iii) Sputum for AFB- may be found in Z-N staining Catergory-2: Previously treated smear positive pTB Z= Pyrazinamide
(iii) Cervical & other lymphadenopathy (iv) PCR- Nucleic Acid Amplification, (v) Tuberculin Test Initial phase- 2 months HRZES+1 month HRZE; Continuation phase- 5 month HRE S= Streptomycin
Case: Cerebral Malaria
Presented with- Investigations- Treatment:
(i) Diminished consciousness, confusion (i) Thick & thin blood films for malarial parasite (A) Supportive Treatment, (B) Treatment of complications
(ii) H/O high grade fever e chills & rigor (ii) RDT for P. falciparum (C) Anti-malarial drug-
(iii) Mild icteric, splenomegaly (iii) Hb%-Anemia - Quinine: LD- 20mg/kg body wt by IV infusion over 4 hours in 500ml 5% DA
(iv) Bilateral flexor planter reflex (iv) Blood glucose- Hypoglycemia MD- 8 hours after the start of LD, Quinine salt 10mg/kg IV over 4 hours in 500ml 5% DA (Total 7 days)
(v) Lumber puncture to exclude meningitis Or, Artesunate: LD- 2.4mg/kg IV, MD- 1.2mg/kg 12 hourly then 1.2mg/kg daily for 6 days
Or, Artemether: LD- 3.2mg/kg IM. MD- 1.6mg/kg daily for 5 days
 SEXUALLY TRANSMITTED DISEASES

Case: Gonorrhea
Presented with- Investigations- Treatment:
(i) Purulent urethral discharge (men), (i) Microscopic examinations of smears from infected sites: G-ve diplococci (i) Uncomplicated infection: Cefixime 400mg stat
vaginal discharge (women) (ii) Culture of specimen in Thayer Martin media (ii) Quinolone resistance: Ceftriaxone 250mg IM stat
(ii) Dysuria, H/O exposure (iii) Urine for routine & microscopic examination (iii) Pregnancy & Breastfeeding: Cefixime 400mg stat or Ceftriaxone 250mg IM stat
Case AIDS
Presented with- Investigations- Treatment-
(i) Diarrhea, Weigh loss (i) Screening: ELISA kit that detects p24 antigen (i) NRTI- Abacavir, (ii) NNRTI- Efavirenz
(ii) Fever, Arthralgia, Lymphadenopathy (ii) Confirmatory: Western blot, Nuclei Acid amplification test PCR (iii) Protease inhibitors- Lopinavir, (iv) Integrase inhibitors- Raltegravir
(iii) CXR PA, CBC, CD4 count, Colonoscopy, Microscopic exam of stool (v) Chemokine receptor inhibitors- Maraviroc

DERMATOLOGY

Case: Psoriasis
Presented with- Investigations- Treatment-
(i) Erythema (i) Biopsy- Irregular thickening of epidermis (i) Explanation, reassurance and removal of precipitating cause
(ii) Dry silver-white scale (ii) Throat swab culture (ii) Topical agents- Emollients, corticosteroids, Vit-D agonists
(iii) Well defined margin (iii) Joint symptoms require a formal rheumatology assessment (iii) UV therapy
(iv) Systemic agents- Methotrexate, Retinoids
Case: Scabies
Presented with- Investigations- Treatment-
(i) Itching, worsen at night (i) Skin scapings of a lesion and examining a potassium hydroxide preparation (A) Scabicidal drugs-
(ii) Red papules, Burrows for the mite and/or its eggs by microscopy (i) Topical- Permethrin (5%), Benzyl Benzoate lotion, Crotamiton, Malathion, (ii) Systemic- Ivermectin
(iii) Secondary eczematization (ii) Sometimes mites and eggs can be seen with a dermatoscope (B) Symptomatic- Antihistamine or topical steroid for itching, (C) Treatment of complications
Case: Ring Worm/Dermatophytosis/Tineasis/Tinea corporis
Presented with- Investigations- Treatment-
(i) Red Scaly rash Microscopic examination (with KOH solution) of- (i) Topical Terbinafine or miconazole or econazole cream
(ii) Erythematous, annular lesion (i) Skin scrapping, (ii) Nail clipping, (iii) Hair plucking (ii) Systemic Terbinafine or fluconazole or itraconazole

POISONING

Case: OPC Poisoning

Presented with- Clinical features- Treatment-
(i) Pin point pupil (i) GIT- nausea, vomiting, abdominal cramp, diarrhea (i) Further exposure should be prevented, (ii) Contaminated clothing & lenses should be removed
(ii) Increased all secretion (Salivation, (ii) Respiratory- Bronchorrhea, (iii) CVS- Bradycardia, hypotension (iii) The skin washed with soap & water, eye irrigated, (iv) The airway should be cleared & O 2 therapy
Sweating, Urination, Broncho secretion) (iv) Eye- Diplopia, Miosis, lacrimation, (v) Mouth- Salivation, (v) The IV access should be obtained, (vi) Gastric lavage may be considered within 1 hour of ingestion
(iii) Bradycardia, hypotension (vi) Urinary- Frequency, (vii) Skin- Sweating (viii) Skeletal muscle- Twitching (vii) IV Atropine 2mg, doubled every 5-10 mins until improved,
(ix) CNS- Restlessness, Tension, Anxiety, Slurred speech, Apathy, Drowsiness Atropinization should be maintained up to 48-72 hours
(viii) IV Pralidoxime 2 mg over 4 mins (specific antidote) repeated 4-6 times daily
(ix) Ventilatory support
(x) Treatment of convulsion by diazepam 10-20mg
 Case: Paracetamol Poisoning
Presented with- Investigations- Treatment-
(i) Phase-I (0-24 hours): Nausea, (i) Liver Function test (i) Gastric lavage in adult
vomiting, abdominal pain, Bradycardia (ii) Prothrombin time (ii) Emesis in children
(ii) Phase-II (24-72 hours): (iii) Full blood count (iii) Activated charcoal 50-100gm in 200ml of water
Hepatotoxicity, Rt upper abdominal pain (iv) Urine analysis (iv) IV N-Acetyl Cystine (NAC) 150mg/kg in 200ml of 5% dextrose over 15 mins followed by 50mg/kg
(iii) Phase-III (72-96 hours): Hepatic (v) Renal function test in 500ml dextrose over 4 hours, followed by 100mg/kg in 1000ml dextrose over 16 hours
necrosis, bleeding manifestations, Portal (vi) Blood glucose (v) If IV NAC is not available, give 140mg/kg oral NAC as a loading dose, followed 4 hours later with
HTN, H. encephalopathy, Pancreatitis, (vii) S. electrolytes 70mg/kg given every 4 hours for an additional 17 doses
Hypoglycemia, Hypokalemia, DIC Mechanism of hepatotoxicity- Toxicity results from formation of an (vi) If NAC is not available, Give Methionine 2.5gm orally, followed by 3 doses of 2.5gm 4 hourly
(iv) Phase-IV (96 hours-2 weeks): intermediate reactive metabolite that binds covalently to cellular proteins, (vii) Treatment of complications
Hepatic failure & Death causing cell death. This results in hepatic & occasionally renal failure. (viii) Maintenance of fluid & electrolyte balance
Case: Kerosene Poisoning
Presented with- Investigations- Treatment-
(i) Burning sensation in the mouth & (i) CXR- evidence of pneumonitis, consolidation and/or pleural effusion (i) Hospitalized for at least 24 hours irrespective of severity
pharynx (ii) Pulse Oximetry- O2 saturation (ii) Admit for observation and discharge after 24 hours if no symptoms develop.
(ii) Nausea, vomiting, abdominal pain (iii) Total count of WBC- Leukocytosis (iii) Emesis & Gastric lavage are contraindicated for fear of aspiration
Fatal dose: 30ml (iv) Evaluation & maintenance of ventilatory status
Fatal period: 24 hours usually (v) O2 administration to all patients of respiratory symptoms
(vi) Nutritional Support
Case: Arsenic Poisoning
Presented with- Investigations- Treatment-
(i) Hyperpigmentation, Alopecia (i) Measurement of arsenic in bone, hair & nail (i) No benefit in chronic arsenic toxicities
(ii) Palmar & Plantar keratosis (ii) Measurement of arsenic in tube well water (ii) Recovery from the peripheral neuropathy may never be complete
(iii) Multiple epitheliomas (iii) CBC, (iv) Serum ferritin level Complications-
(iv) Mae’s line (i) Increased risk of malignancy
D/D- (ii) Aplastic anemia
Hemochromatosis, Pityriasis versicolor, (iii) Peripheral neuropathy
Amyloidosis (iv) Corneal necrosis & ulceration
Case: Snake Venom Poisoning
Presented with- Investigations- Treatment:
(A) Local- Fang marks, bleeding, bruise, (i) Coagulations tests- 20 mins whole blood clotting time (A) First Aid-
laceration, pain & swelling at bite site (ii) CBC (i) Reassurance, (ii) Immobilize the bitten limb with a splint
(B) Neurotoxic- Ptosis, Diplopia, (iii) ECG (iii) Bite is in lower limb- Do not walk, Bite is in upper limb- Do not move the limb
Bulbar palsy, Facial paralysis, Broken (iv) Blood grouping & Rh Typing (iv) Pressure Immobilization
neck sign (v) Blood urea & S. creatinine (B) Treatment in Hospital-
(C) Hematological- Persistent bleeding, (vi) Urine R/E (i) Rapid clinical assessment & resuscitation- Airway, Breathing, Circulation
Gum bleeding, hemoptysis, hematuria (vii) Serum CPK (ii) Antibiotic
(D) Renal- Scanty/no urine, Dark color (viii) Immunodiagnostic (by ELISA) (iii) Tetanus prophylaxis
urine, Signs of fluid overload (iv) Observe for 24 hours if no sign of poisoning
(E) Myotoxicity- Muscle weakness, (v) Antivenom (Polyvalent antivenom)- 10 vials. Each vial is diluted with 10 ml of distilled water. Give
Respiratory failure, Renal failure a loading dose of IV antihistamine
(vi) Neostigmine-Atropine combination is indicated neurotoxic features only
(vii) Respiratory support, (viii) Fresh blood transfusion
 NEUROLOGY

Case: Parkinson’s Disease

Presented with- Investigation- Treatment-
(i) Tremor, rigidity, bradykinesia (i) The diagnosis is made clinical, as there is no test for it. (A) Drug-
(ii) Apathetic look, Slowness of (ii) Imaging CT or MRI of the head may be needed if there are any features (i) Levodopa with Carbidopa (ii) Anti-cholinergic: Procyclidine
movement suggestive of pyramidal, cerebellar or autonomic involvement. (iii) Amantadine (iv) MAO inhibitor- Selegiline (v) COMT inhibitor- Entacapone
(iii) Hypertonia, Loss of postural reflex (vi) Dopamine receptor agonists- Bromocriptine
D/D- (B) Surgery- Stereotactic thalamotomy
(i) Motor neuron disease (C) Physiotherapy & Speech therapy
(ii) Recurrent stroke
Case: ICSOL
Presented with- Investigations- Treatment-
(i) Severe headache worse in morning (i) CT scan and MRI of brain (i) May need ICU care
(ii) Intractable vomiting, Papilledema (ii) Biopsy & histopathology from the lesion (ii) For raised ICP- IV dexamethasone 8-20mg orally or IV 12 hourly
(iii) Bradycardia, Arterial hypertension (iii) Screening from the primary site (iii) Surgery, (iv) Radiotherapy/Chemotherapy
Case: Guillain Barre Syndrome (GBS)
Presented with- Investigations- Treatment-
(i) Distal paresthesia with limb pain (i) CSF study (should be done after 10 days)- Protein is elevates some stages (i) Supportive- to prevent pressure sores and DVT
(ii) Ascending muscle weakness (ii) Electrophysiological studies- Most evident proximally as delayed F waves (ii) Regular monitoring of respiratory function
(iii) Miller Fisher Syndrome triad- (iii) Antibodies to the ganglions GMI- found in 25% cases (iii) Plasma exchange & IV immunoglobulin therapy
Ophthalmoplegia, Ataxia, Areflexia (iv) S. electrolytes
D/D- Hypokalemic periodic paralysis
Case: Pyogenic Meningitis
Presented with- Investigations- Treatment-- Complications-
(i) Headache, High grade fever (i) CSF study unless there are common contra-indications (i) Adults (18-50 years) without meningococcal rash: Ceftriaxone 2g IV 12 hourly (i) Death
(ii) Disorientation, Drowsiness (ii) Blood culture (ii) Penicillin resistant: Ceftriaxone 2g IV 12 hourly + Vancomycin 1g IV 12 hourly (ii) Shock
(iii) Purpuric rash (meningococcal) (iii) PCR in Blood or CSF (iii) Adults (>50 years) with Listeria monocytogenes infection: (iii) Renal failure
(iv) Neck stiffness, Kernig’s sign Ceftriaxone 2g 12 hourly + Ampicillin 2g 4 hourly (iv) Arthritis
(iv) Clear H/O anaphylaxis to B-lactam: (v) Pericarditis
Chloramphenicol 25mg/kg IV 6 hourly + Vancomycin 1g IV 12 hourly (vi) Peripheral
(v) With typical meningococcal rash: Benzylpenicillin 2.4g IV 6 hourly gangrene
(vi) Adjunctive: Dexamethasone 0.15mg/kg 4 times daily for 2-4days
Case: Tubercular Meningitis
Presented with- Investigations- Treatment-
(i) Headache, vomiting, low grade fever (i) CSF study- Increased pressure, Clear appearance, Rise in protein, Marked (i) Anti TB drugs: Initial 2 months 4 drugs (HRZE), continuation by 2 drugs (HR) for 1 year
(ii) Confusion, Disorientation fall in glucose, Predominant cell- Lymphocyte (ii) Corticosteroid: Improves mortality but not focal neurological damage
(iii) Neck stiffness, Kernig’s sign (ii) Brain Imaging- Hydrocephalus (iii) Surgical ventricular drainage may be needed if obstructive hydrocephalus develops
Case: Pott’s Disease/Tuberculous Spondylitis
Presented with- Investigations- Treatment-
(i) Low grade fever, marked weight loss (i) CBC with ESR (i) Straight posture & prohibition of forward bending, (ii) No weight lifting
(ii) Progressive spastic paraplegia (ii) X-ray of effected spine (iii) Anti-TB drugs for 12 months, (iv) Immobilization of spinal region by rod
(iii) Back pain, Bilateral planter extensor (iii) CXR-PA view (v) Drainage of cold abscess (if present)
(vi) General management of paraplegia- Passive exercise to prevent DVT, Antibiotic (if catheterized)
 Case: Stroke
Presented with- Investigations- Treatment-
(i) Weakness (hemiplegia/hemiparesis) Routinely- (i) CT scan- Hyperdense (white) in hemorrhagic stroke, Hypodense (A) General: (i) Maintenance of airway, breathing, circulation, (ii) Maintenance of intake-output chart.
(ii) Headache, ataxia, seizure (black) in ischemic stroke (ii) ECG, (iii) Blood Glucose (iv) S. electrolyte, (v) (iii) Care of the bladder, bowel, skin, eye, oral cavity, (iv) Feeding, (v) Control of infection
(iii) Exaggerated jerk, High BP S. creatinine, (vi) Plasma lipid profile (B) Specific for ischemic stroke- Anti-platelet drug- Aspirin, Clopidogrel
(iv) Planter response- Extensor at In Special situation- (i) Echocardiogram, (ii) Lumber puncture, (iii) CT (C) Specific for hemorrhagic stroke- (i) Intracerebral- Suction of hematoma by bar hole operation
contralateral side angiography, (iv) Magnetic resonance angiography (ii) Subarachnoid- Nimodipine 360mg daily in divided doses for 21 days

PSYCHIATRY

Case: Anxiety Disorder

Features- Treatment-
(A) Psychological- Apprehension, Irritability, Worry, Fear of impending disorder, Poor concentration (A) Psychological- Explanation & reassurance, Relaxation, Graded exposure, Cognitive Behavioral Therapy
(B) Somatic- Palpitations, Fatigue, Tremor, Dizziness, Sweating, Diarrhea, Chest pain, Insomnia, Breathlessness (B) Drug-
D/D- (i) Anti-Depressants: TCA: Amitriptyline, SSRI: Fluoxetine, MAO: Phenelzine
Thyrotoxicosis, Hypoglycemia, IHD, Paroxysmal arrythmia, Pheochromocytoma (ii) Benzodiazepines (Diazepam), (ii) Beta-blockers (Propranolol)
Case: Depressive Disorder
Features- Treatment-
(A) Psychological- Depressive mode, Reduced self-esteem, Guilt, Loss of interest & enjoyment, Suicidal thinking (A) Immediate- Electroconvulsive therapy
(B) Somatic- Reduced appetite, Weight change, disturbed sleep, Fatigue, Loss of libido, Bowel disturbance (B) Psychological- Cognitive Behavioral Therapy (CBT), Interpersonal psychotherapy
D/D- Bipolar disorder, Hypothyroidism, Neurosyphilis, Schizophrenia (negative symptoms) (C) Drug- Anti-Depressants: TCA: Amitriptyline, SSRI: Fluoxetine, MAO: Phenelzine; Newer: Venlafaxine
Case: Mania, Bipolar Disorder
Features of Mania- Treatment-
(i) Elevated mood, (ii) Talk- fast, pressurized, (iii) Excessive energy, (iv) Grandiose, Self-confidence, (i) Immediate treatment- Electroconvulsive therapy (Major depressive)
(v) Insomnia, (vi) Disinhibition, (vii) Increased sexual activity, (viii) Hallucinations (ii) Depression should be treated with Anti-Depressants
Features of Bipolar Disorder- (iii) Manic episodes usually respond well to antipsychotic drug.
(i) Features of Mania, (ii) Features of depression (iv) Prophylaxis of prevent recurrent episode using drugs- Lithium, Carbamazepine, Sodium Valproate
Side effect: (1) Lithium- Tremor, Ataxia, Altered test, (2) Carbamazepine- Dizziness, Weakness, Drowsiness
(3) Long term use of Lithium carbonate- Nephrogenic Diabetes insipidus, Hypothyroidism, Renal failure
Case: Schizophrenia
First Rank Symptoms of acute Schizophrenia: Treatment-
A= Auditory Hallucination, B= Broadcasting, insertion/withdrawal of thoughts, C= Controlled feelings, impulses, (i) First episode requires admission to hospital
D= Delusional perception (ii) Subsequent acute relapse and chronic schizophrenia managed in community
Symptoms of Chronic Schizophrenia (negative symptoms) (iii) Drug- Antipsychotic agents are effective against the positive symptoms. To prevent relapse, should be
Flattened effect, Apathy & loss of drive, Social isolation, Poverty of speech, Poor self-care continued for several years
(iv) Psychological- General Support, CBT, Personal/Family education
(v) Social TT- Social rehabilitation, Accommodation & Occupational rehabilitation, Housing & employment
Case: Conversion Disorder/Hysteria
Features- Treatment-
Gait disturbance, Loss of function in limbs, Aphonia, Non-epileptic seizure, Sensory loss, Blindness (i) Reassurance, (ii) Explanation about the symptoms of disease
Investigation- (iii) Advice to avoid stressful social problems.
It depends upon presenting complaints of patient. (iv) Psychological- CBT, (v) Drug- Co-existing depression should be treated with anti-depressant drugs

Prepared By-
PARTHA SAROTHI SINGHA
AMUMC-7