Thiazides are recommended for patients with CKD stages 1 to 3 (GFR ≥30 mL/min), and have been established as effective agents for BP and CVD risk reduction.[22] Loop diuretics are recommended for patients with CKD stage 4 or 5 (GFR <30 mL/min), as they have been shown to be more effective in reducing extracellular fluid volume in patients with severely reduced GFR.[1

most common cause of postpartum fever is endometritis, which is inflammation in the lining of the uterus, in this case from infection.[

Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect.

antipakinsonism drugs may cause  acute cilonic psudo obstuctuin.

The causes of ACPO are multifactorial. The 3 most common associations are the following:

Trauma (especially retroperitoneal)

Serious infection

Cardiac disease (especially myocardial infarction and congestive heart failure)

Other conditions commonly associated with colonic pseudo-obstruction are as follows:

Recent surgery (abdominal, urologic, gynecologic, orthopedic, cardiac, or neurologic)

Spinal cord injury

Old age

Neurologic disorders

Hypothyroidism

Electrolyte imbalances ( hyponatremia , hypokalemia , hypocalcemia , hypercalcemia , or hypomagnesemia )

Respiratory disorders

Renal insufficiency

Medications (eg, narcotics, tricyclic antidepressants, phenothiazines, antiparkinsonian drugs, and anesthetic agents)

Severe constipation [18]

The term intestinal pseudo-obstruction denotes a syndrome characterized by a clinical picture suggestive of mechanical obstruction in the absence of any demonstrable evidence of such an obstruction in the intestine

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis.

Ultrasonographic findings that are suggestive of acute cholecystitis include the following: pericholecystic fluid, gallbladder wall thickening greater than 4 mm, and sonographic Murphy sign. The presence of gallstones also helps to confirm the diagnosis.

after mi unstable patient cholycystitis ....p paper

For patients at high surgical risk, placement of a sonographically guided, percutaneous, transhepatic cholecystostomy drainage tube coupled with the administration of antibiotics may provide definitive therapy.[35] Results of studies suggest that most patients with acute acalculous cholecystitis can be treated with percutaneous drainage alone,[36, 37] but the SAGES guideline describes radiographically guided percutaneous cholecystostomy as a temporizing measure until the patient can undergo cholecystectomy.[

warfarine reversal by

1.ffb

2.vit K

de novo meaning is starting f4om beging.. ekaiyanne cancer ekak vage ekak aluthenma hata gannava..

ca colon usually start from adenomas... not de novo  ... ekiyanne aluthenma ethi venne nee

tumour deposision in peritoneal tissues and omentum can caus3 irritation if that tissue and  secreat fluid..it cause ascitis

Cushing's disease is not the same as Cushing's syndrome. Cushing's syndrome refers to the general state characterized by excessive levels of cortisol in the blood. Elevated cortisol levels can occur for reasons other than a pituitary tumor, including: Tumors of the adrenal glands producing cortisol.

Cushing's syndrom, is a collection of signs and symptoms due to prolonged exposure to cortisol.

 Signs and symptoms may include: high blood pressure,

cenyral obesity,

reddish stretch marks,

 a round red face,

a fat lump between the shoulders, weak muscles,

weak bones,

acne,

and fragile skin that heals poorly.

 Women may have more hair and irregular menstruation. Occasionally there may be changes in mood, headaches, and a chronic feeling of tiredness.

Cushing's syndrome is caused by either excessive cortisol-like medication such as prednisone or a tumor that either produces or results in the production of excessive cortisol by the adrenal glands.

Cases due to a pituitary adenoma are known as Cushing's disease. It is the second most common cause of Cushing's syndrome after medication.

cushing syndrom

pitutiry adenoma which cause to cushing disease

pitutary adeanoma which cause to cushing syndrome  unlike to cause  bitemporal hemi anopia.

most of thebtume micro adenomas

ACTH level in ACTH-independent Cushing syndrome is low due to the negative feedback to pituitary corticotroph cells from a high level of serum cortisol. ACTH-dependent Cushing syndrome is characterized by elevated ACTH levels.

Elevated ACTH levels are usually due to an anterior pituitary tumor, which is classic Cushing disease (60-70%

Nonpituitary ectopic sources of ACTH, such as small-cell lung carcinoma (oat cell carcinoma), carcinoid tumor, medullary thyroid carcinoma, or other neuroendocrine tumors can result in high ACTH levels and sequentially hypercortisolism.

ACTH-independent Cushing syndrome

Primary adrenal lesions

Overproduction of glucocorticoids may be due to an adrenal adenoma, adrenal carcinoma, or macronodular or micronodular adrenal hyperplasia. The zona fasciculata and zona reticularis layers of the adrenal cortex normally produce glucocorticoids and androgens

In general, excess androgen secretion is suggestive of an adrenal carcinoma rather than an adrenal adenoma

. Exposure to excess glucocorticoids results in multiple medical problems, including hypertension, cardiovascular disease, obesity, osteoporosis, fractures, impaired immune function, impaired wound healing, glucose intolerance, and psychosis.

Bulimia nervosa includes regularly occurring compensatory behaviors that are intended to rid the body of the excess calories consumed during eating binges. The disorder has two major variants, as follows:

Purging - Compensation by means of self-induced vomiting and/or excessive ingestion of laxatives to induce diarrhea

Nonpurging - Binge eating associated with the use of nonpurging compensatory measures such as excessive exercise, stimulant substances, and/or fasting

Cushing's syndrome (cortisol-producing adrenal tumor)

Diagnosis and Radiological tests

There are three main questions to answer to determine if a patient has Cushing's syndrome:

Is the patient producing too much cortisol?

Collecting the urine for 24 hours and measuring the cortisol (i.e. 24 hour urine cortisol level) can tell you how much cortisol was made over the day.

Does the patient have a low cortisol level in the late evening?

Checking a midnight salivary cortisol level measures this late evening level. This is done by asking the patient to take a saliva sample with a cotton swab just before going to bed. The swab is placed in a special tube and returned to the laboratory the next day.

Does the patient decrease the amount of steroid produced in the body normally after giving a dose of artificial steroid?

The low dose dexamethasone suppression test will check if the body responds normally. This test is performed by giving the patient 1 mg of dexamethasone at 11 PM and measuring the blood cortisol level the next morning at 8 AM. Patients with Cushing's syndrome will not lower the amount of steroid made in the body (i.e. dexamethasone will not suppress steroid production).

Figure 6: Algorithm For Determining the Cause of Cushing's Syndrome

Once the diagnosis is made, the next step is to determine the cause of the Cushing's syndrome. The blood ACTH (adrenocorticotropic hormone) level will be tested to see if the patient's disease is ACTH-independent (i.e. caused by adrenal disease) or ACTH-dependent (i.e. caused by a pituitary adenoma or an ectopic ACTH-producing tumor). If the patient has a low ACTH (i.e. suppressed), then the adrenal glands are causing the Cushing's syndrome and the patient should have an MRI or CAT scan of the abdomen. If the ACTH level is high, the patient will have additional tests to determine if there is a pituitary adenoma or ectopic tumor.

High dose dexamethasone suppression test –

The high dose dexamethasone suppression test will check if the body lowers the cortisol production in response to large doses of artificial steroid. This test is performed by giving the patient 8 mg of dexamethasone at 11 PM and measuring the blood cortisol level the next morning at 8 AM. Patients with Cushing's disease (i.e. pituitary adenoma) may lower the amount of steroid made in the body while patients with an ectopic tumor usually will not.

CRH stimulation test –

The CRH stimulation test will see if the body can increase the amount of cortisol and ACTH made by the body in response to corticotropin releasing hormone (CRH). Patients with Cushing's disease (i.e. pituitary adenoma) should be able to increase the levels of cortisol and ACTH while patients with an ectopic tumor usually cannot.

Inferior petrosal venous sinus sampling –

This test involves threading a long, tiny plastic tube or catheter up through the veins of the body to measure the blood levels of ACTH directly from the veins that come from the pituitary. This is done through a small needle-stick in the groin area and is generally not painful.

The results of the laboratory evaluation will determine what type of imaging is needed. If the patient has adrenal Cushing's syndrome, then an abdominal CAT scan or MRI will be ordered. If a pituitary adenoma is suspected, then a CAT scan or MRI of the brain will be ordered.1-3 If an ectopic ACTH-producing tumor is suspected, then a CAT scan or MRI of the chest, abdomen, and pelvis will be ordered to locate it.

most important things to understand cushing syn investigation

Cushing

cushing syndrome easily understand

CS can be due to exaogenus steroid or endogenus excess storoid

endogenus CS  can be due to

1. excess cortisol produce by adrenal tumour

2.excess ACTH produce by   pitutary tumour

3.excess ACTH produce by extra pitutary Tumour such as small cell carcinoma, medullary ca of thyroid..ect

all the blood test plan to identify the suspected  place whre high ACTH or cortosol produce.

depend on that result do do imaginge like MAI or CAT (axial ct)

A papilloma is a noncancerous (benign) tumor that can be associated with bloody discharge. It appears spontaneously and involves a single duct. A

Possible causes of nipple discharge include:

Abscess

Breast cancer

Breast infection

Ductal carcinoma in situ (DCIS)

Excessive breast stimulation

Fibroadenoma — a solid, benign mass most common in young women

Fibrocystic breasts — lumpy or rope-like breast tissue

Galactorrhea

Hormone imbalance

Injury or trauma to the breast

Intraductal papilloma

Mammary duct ectasia

Medication use

Menstrual cycle hormone changes

Paget's disease of the breast

Pregnancy and breast-feeding

Prolactinoma

Loop diuretics are diuretics that act at the ascending loop of Henle in the kidney. They are primarily used in medicine to treat hypertension and edema often due to congestive heart failure or renal insufficiency. While thiazide diuretics are more effective in patients with normal kidney function, loop diuretics are more effective in patients with impaired kidney function.

promethazine=phenergan... its a antihistamine

Diskitis is an inflammation of the vertebral disk space often related to infection. Infection of the disk space must be considered with vertebral osteomyelitis,

commnly seen is HIv patien.. iv drug abise abuse patients...renal impaierd patiend like immunocompromise situation

usually direct trauma noy cause to discitis

Spinal shock following a spinal cord injury SCI) is a specific term that relates to the loss of all neurological activity below the level of injury. This loss of neurological activity include loss of motor, sensory, reflex and autonomic function.

Mechanism for Spinal Shock

The mechanism for spinal shock involves the sudden loss of conduction in the spinal cord as a result of the migration of potassium ions from the intracellular to extracellular spaces. This is associated with a transient loss of somatic and automatic reflex activity below the level of spinal cord segment damage. The spinal cord reflex arcs that are immediately above the injury may also be severely disrupted.

Spinal shock following a spinal cord injury results in flaccid paralysis, areflexia and anaesthesia below the level of injury. The return of the reflexes indicates the end of spinal shock. Assessment of the end of spinal shock is based on the return of reflexes, with the bulbocavernosus reflex typically being the first to return

buulbocavanus reflex ..

when squees pinis or clitoris contaction of the anul splinter

S2 ro S4 involve

initial treatment for for spinal shock is isotonic cristoloid up to 2 litter.

oxigen comes second

if sever bradicardia give aropine

buerolohic bladder should be decompress

inotrops rarly indicated

Thursday, December 17, 2015

4:27 PM

vaccination over 65 years

at risk group

1.influenza

2.pneumociccal polysaccharide

very important

The DTPa (it is sometimes written as DPaT) is given as part of the Australian childhood vaccination schedule at: 2, 4 & 6 months of age, then again at 4 years of age or just before a child starts school. An adult triple antigen shot, Boostrix, was licensed in Australia in 2005 and is recommended for all adults, especially those who are in close contact with infants under 1 year of age.

Clinical Practice Guidelines

 Toggle section navigation

Management of tetanus-prone wounds

The new Immunisation Schedule recommends that 10-yearly tetanus boosters are no longer required up until the age of 50, provided that the primary series of 3 vaccinations plus 2 boosters have been given.

The recommendations for the management of tetanus-prone wounds remain the same.

Types of wounds likely to favour the growth of tetanus organisms include:

compound fractures

deep penetrating wounds

wounds containing foreign bodies (especially wood splinters)

wounds complicated by pyogenic infections

wounds with extensive tissue damage (eg. contusions or burns)

any wound obviously contaminated with soil, dust or horse manure (especially if topical disinfection is delayed more than 4 hours).

Re-implantation of an avulsed tooth is also a tetanus-prone event, as minimal washing and cleaning of the tooth is conducted to increase the likelihood of successful re-implantation.

Wounds must be cleaned, disinfected and treated surgically if appropriate.

History of tetanus vaccinationType of woundTetanus vaccine booster

(see below)Tetanus immunoglobulin

3 or more doses< 5 years since last doseAll woundsNONO

5-10 years since last doseClean minor woundsNONO

All other woundsYESNO

> 10 years since last doseAll woundsYES        NO
< 3 doses or uncertain        Clean minor wounds        YES        NO
All other wounds        YES        YES
A combination vaccine should be used in order to boost community protection against pertussis:

Please note that CDT and Tetanus Toxoid vaccine are no longer available.

< 8 years old DTPa-IPV (Infanrix-IPV®)
> 8 years old dTpa (Boostrix®)
Can use a diphtheria/ tetanus toxoid vaccine (ADT® ) if pertussis vaccination is contraindicated

ankle brachial presure index

si nerver route give siatic nerve .si supply ankle refle

hip refles L2

knee reflex L3 and L4

Capture Dec 17, 2015

Thursday, December 17, 2015

5:03 PM

exam question

Paget–Schroetter disease, also known as Paget–von Schrötter disease, is a form of upper extremity deep vein thrombosis (DVT), a medical condition in which blood clots form in the deep veins of the arms.

pain and swetting of arm

bara veda kalata passe enen... chain saw

treated wuth anticoagulant and tronbolisis

classical triad of congenital Rubella

1.sensonieronal defness

2.eye abnormalitiea(cateractretinopathy...microopthalmia)

3.congenital Heart dieases

treayment for akathasia

1.reduce drug dose..eg.lithiam

2.strat bensodiazipine...propanalol and anticholinergic

treatment for bleeding peptic ucer after 2 faild endoscopic attentbis Sx

The indications for urgent surgery include failure to achieve hemostasis endoscopically, recurrent bleeding despite endoscopic attempts at achieving hemostasis (many advocate surgery after 2 failed endoscopic attempts), and perforation. Many authorities recommend simple oversewing of the ulcer with treatment of the underlying H pylori infection or cessation of NSAIDs for bleeding PUD. Additional surgical options for refractory or complicated PUD include vagotomy and pyloroplasty, vagotomy and antrectomy with gastroduodenal reconstruction (Billroth I) or gastrojejunal reconstruction

Several modalities of endoscopic therapy are available, such as injection therapy, coagulation therapy, hemostatic clips, argon plasma coagulator, and combination therapy.[28] Injection therapy is performed with epinephrine in a 1:10,000 dilution or with absolute alcohol. Thermal endoscopic therapy is performed with a heater probe, bipolar circumactive probe, or gold probe.

evaluation of aortic injury after RTA

Gigantism refers to abnormally high linear growth (see the image below) due to excessive action of insulinlike growth factor I (IGF-I) while the epiphyseal growth plates are open during childhood. Acromegaly is the same disorder of IGF-I excess but occurs after the growth plate cartilage fuses in adulthood.

acromegaly

GH acts indirectly, by stimulating the formation of IGF hormones (also called somatomedins

acromegaly Fx

acromegaly - Google Search

acromegaly fx

acromegaly - Google Search

acromegaly

Breast tissue becoming atrophic; galactorrhea ..due to prolactin

High blood pressure

acromevaly lab diagnosis

Laboratory studies used in the diagnosis of growth hormone (GH)/IGF-I excess include the following:

Oral glucose: To determine the extent to which the patient can suppress GH concentration after the consumption of oral glucose

GH: Clearly elevated GH levels (>10 ng/mL) after oral glucose, combined with the clinical picture, secure the diagnosis of acromegaly

IGF-I: Elevated IGF-I values in a patient whose symptoms prompt appropriate clinical suspicion almost always indicate GH excess

aceomegaly treatment

For pituitary adenomas, transsphenoidal surgery is usually considered the first line of treatment,

thiroiditis

thyroid nucler scan use to distingish thyrotoxucosis from subacute thyroiditis where radio active iodine reduce in thyroiditis.

A thyroid scan is a nuclear medicine test that uses a radioactive iodine tracer to examine the structure and function of the thyroid gland. This test is often done together with a radioactive iodine uptake test.

prolactine secrestion

stimulate by antagonistic of dopamine recepter

1.phenithiazines

2.butyrophenones

3.3.methildopa

4.reserpine

5.oestrogen

thiazide diuratics use in patient with highturn over ostioporosis assocuated with hypercalciuria and hyperlarathyroidism

ABO incomplete bld transfusion cause to BACKPAIN

Many patients with chronic leukemias are asymptomatic. Other patients present with splenomegaly, fever, weight loss, malaise, frequent infections, bleeding, thrombosis, or lymphadenopathy

n children with ALL, 90% of patients achieve a complete remission, and up to 80% can remain disease free at 5 years following treatment. In adults with ALL, remissions occur in 60-80%, while 20-35% will maintain a leukemia-free survival.

Currently, 65-70% of patients with AML attain remission. The 5-year survival rate during the period 1989-1994 was 43%.

leukaemia

ALL is accounts for 80%of pead leukamia

most of remainde is AMLor ANLL

peak age of ALL is 2to 5 years

allopurinol and addiyional hydrations are given b4 chemotherapy to prevent ARF

during chemi Co_trimexazole is given

Many patients with chronic leukemias are asymptomatic

Many patients with chronic leukemias are asymptomatic. Other patients present with splenomegaly, fever, weight loss, malaise, frequent infections, bleeding, thrombosis, or lymphadenopathy.

Acute lymphocytic leukemia (ALL) is a malignant clonal disorder of the bone marrow lymphopoietic precursor cells

Acute myelogenous leukemia (AML) is a group of neoplastic disorders of the hematopoietic precursor cells of the bone marrow

Leukemic retinopathy

Retinal lesions are the most common ocular manifestation of leukemia. They are found most often in adults and in patients with myeloid leukemia.

Currently marketed beta lactamase inhibitors are not sold as individual drugs. Instead they are co-formulated with a a beta lactam that has a similar serum half-life. This is done not only for dosing convenience, but also to minimize resistance development that might occur as a result of varying exposure to one or the other drug. The main classes of beta lactam antibiotics used to treat Gram-(-) bacterial infections include (in approximate order of intrinsic resistance to cleavage by beta lactamases) penicillins (especially aminopenicillins and ureidopenicillins), 3rd generation cephalosporins, and carbapenems. Individual beta lactamase variants may target one or many of these drug classes, and only a subset will be inhibited by a given beta lactamase inhibitor.[9] Beta lactamase inhibitors expand the useful spectrum of these beta lactam antibiotics by inhibiting the beta lactamase enzymes produced by bacteria to deactivate them.[10]

Clavulanic acid or clavulanate, usually combined with amoxicillin (Augmentin) or ticarcillin (Timentin)

Sulbactam, usually combined with ampicillin (Unasyn) or Cefoperazone (Sulperazon)

Tazobactam, usually combined with piperacillin (Zosyn) (Tazocin)

Avibactam, approved in combination with ceftazidime (Avycaz), currently undergoing clinical trials for combination with ceftaroline

Macrocytosis is a term used to describe erythrocytes that are larger than normal, typically reported as mean cell volume (MCV) greater than 100 fL

same as megaloblastic aneamia

macrocytosis

1.vit B12 def_ all the problem of illeum where vB12 absobtion occur

2.folate def

3.alcoholism

4.liver dx

5.hypothyroidism

6.anti epileptic specially phenytoin

6.B12 deficiency.... =cyanocobalamine def

7.

8.drugs that cause macrocytosis

Folate antagonists (eg, methotrexate [10] )

Purine antagonists (eg, 6-mercaptopurine [6-MP])

Pyrimidine antagonists (eg, cytosine arabinoside [ara-C])

Alkylating agents (eg, cyclophosphamide)

Zidovudine (AZT)

Trimethoprim

Oral contraceptive pills

Phenytoin

Arsenic

9.

8.cronic giadiaais like inection

CHA2DS2–VASc score

For other uses, see Chad (disambiguation).

ConditionPoints

 C  Congestive heart failure

1

 H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)

1

 A Age ≥75 years

1

 D Diabetes mellitus

1

 S2 Prior Stroke or TIA or Thromboembolism
2
The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF), a common and serious heart arrhythmia associated with thromboembolic stroke.

Intrahepatic cholestasis of pregnancy (ICP) is a reversible type of hormonally influenced cholestasis. It frequently develops in late pregnancy in individuals who are genetically predisposed.[1] It is the most common pregnancy-related liver disorder.[2, 3] It is characterized by generalized itching, often commencing with pruritus of the palms of the hands and soles of the feet, with no other skin manifestations. It most often presents in the late second or early third trimester of pregnancy.

most commen liver disoder in pregnacy

1%

increse GGT

pregnacy cholestasis

most common liver Dx in pregnacy

presented with pluritis and jaundice

presen late2nd trimester and or 3rd trimester

Ix

most specificand sensitive Ix is  bile acid

ALp and ASt increase mildly or up to 25%

increase bilirubine

Mx

drugs of choice ursodeoxycholic acid

other drugs for for pluritis

phenobabitol

dexamethazone

ect

Acute cholycystitis

. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic is adequate. Some options include the following:

The current Sanford guide recommendations include piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or meropenem (Merrem, 1 g IV q8h). In severe life-threatening cases, the Sanford Guide recommends imipenem/cilastatin (Primaxin, 500 mg IV q6h).

Alternative regimens include a third-generation cephalosporin plus metronidazole (Flagyl, 1 g IV loading dose followed by 500 mg IV q6h).

Bacteria that are commonly associated with cholecystitis include Escherichia coli and Bacteroides fragilis and Klebsiella, Enterococcus, and Pseudomonas species.

Sertraline is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors (SSRIs

endicarditis

streptococus bovis is a normal flora of gut.

assocuate with colonic CA and through that endocarditis

clostridium septicum also wark as same

hyphema

hyphema - Google Search

A hyphema is a collection of blood inside the front part of the eye (called the anterior chamber, between the cornea and the iris). The blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye

Hypopyon is inflammatory cells in the anterior chamber of the eye.

It is a leukocytic exudate, seen in the anterior chamber, usually accompanied by redness of the conjunctiva and the underlying episclera.

- Wikipedia, the free encyclopedia

iritis..... irreguler iris

iritis pictures - Google Search

glucoma fix and dialated pulils

Sjögren syndrome is a systemic chronic inflammatory disorder characterized by lymphocytic infiltrates in exocrine organs. Most individuals with Sjögren syndrome present with sicca symptoms, such as xerophthalmia (dry eyes), xerostomia (dry mouth), and parotid gland enlargement, which is seen in the image below.

Laboratory test results may indicate the following:

Elevated erythrocyte sedimentation rate (ESR)

Anemia

Leukopenia

Eosinophilia

Hypergammaglobulinemia

Presence of antinuclear antibodies, especially anti-Ro and anti-La

Presence of RF

Presence of anti–alpha-fodrin antibody (reliable diagnostic marker of juvenile Sjögren syndrome)

Creatinine clearance may be diminished in up to 50% of patients

common bile duct  more than 6mm valata vada vedinam anjva ERCP karanna oona.

atypical pneuminia

1.macroloids

2.levoflox

3.doxa

Premenstrual syndrome (PMS) refers to physical and emotional symptoms that occur in the one to two weeks before a woman's period.

e acne,tender breasts ,bloating ,feeling tired ,irritability ,and mood changes 

treatment

1.supportuve..low caffainminimal stress

excesice

cognitiv3 behavioralbtgeraly

2.naids...

diuratics

SSRI

OCP

homonal patche

women also use evening primrose oil for premenstrual syndrome (PMS), breast pain, endometriosis, and symptoms of menopause such as hot flashes. In foods, evening primrose oil is used as a dietary source of essential fatty acids. In manufacturing, evening primrose oil is used in soaps and cosmetics.

According to the DSM-IV criteria for alcohol dependence, at least three out of seven of the following criteria must be manifest during a 12-month period:

Tolerance

Withdrawal symptoms or clinically defined alcohol withdrawal syndrome

Use in larger amounts or for longer periods than intended

Persistent desire or unsuccessful efforts to cut down on alcohol use

Time is spent obtaining alcohol or recovering from effects

Social, occupational and recreational pursuits are given up or reduced because of alcohol use

Use is continued despite knowledge of alcohol-related harm (physical or psychological)[2]

dications for oral GTT include the following:

Equivocal fasting plasma/random plasma glucose results

To screen for gestational diabetes mellitus at 24-28 weeks of gestation in all pregnant women not known to have diabetes

To screen for diabetes mellitus at 6-12 weeks postpartum in women with a history of gestational diabetes mellitus, using nonpregnant oral GTT criteria

retinal atery oclusion

cherry red spot of retinal atery occlusion

retinal atery oclusion

Painless loss of monocular vision is the usual presenting symptom of retinal artery occlusion (RAO). Ocular stroke commonly is caused by embolism of the retinal artery, although emboli may travel to distal branches of the retinal artery, causing loss of only a section of the visual field. Retinal artery occlusion represents an ophthalmologic emergency, and delay in treatment may result in permanent loss of vision.

treatmet of  retinal atery occlusion

1.acetazolamide IV  is drug of choice

2.hyperbaric o2

other drugs

3.sympathomimatic

4.beta blocker..tmalol

4.coticosteroid

Ocular massage

Apply direct pressure for 5-15 seconds, then release. Repeat several times.

Increased IOP causes a reflexive dilation of retinal arterioles by 16%.

A sudden drop in IOP with release increases the volume of flow by 86%.

Ocular massage dislodges the embolus to a point further down the arterial circulation and improves retinal perfusion.

bed wetting

bed wetting is normal up to 7 years

Haemophillia

Heamophilia A  =fac 8def

Heamophilia b=fac 9 def

both aew X link recessive

1/3 due to mutation of gene

von willebrand Dx pressentat tge age of puberty and with menorehhegia.

Malaria-associated maternal illness and low birth weight is mostly the result of Plasmodium falciparum infection and occurs predominantly in Africa.

fetal bither weight reducion... IUGR and fetal heart rate abnomalitis are occur with malaria infection

hand foot nad mouth disease

hand foot amd mouth disease due group of entero virus call coxackie virus  A.

DNARS that continue in pregnacy

1.hydrixycholroqnine

2.azothiaprine

3.suphersalcin

mcrocytic aneamia in pregnancy due to inadequate intake of falate

a drug used in the treatment of gastric and duodenal ulcers. It is a complex of aluminium hydroxide and a sulphate derivative of sucrose.

glanduler fever

is due to EBV

same name= glanduler fever

infectious mononuleosis

The incubation period of EBV infectious mononucleosis is 1-2 months.

infectous mononecleosis

Early signs include fever, lymphadenopathy, pharyngitis, rash, and/or periorbital edema. Relative bradycardia has been described in some patients with EBV mononucleosis, but it is not a constant finding.

Later physical findings include hepatomegaly, palatal petechiae, jaundice, uvular edema, splenomegaly, and, rarely (1-2%), findings associated with splenic rupture.

CNS findings associated with EBV mononucleosis are rare but usually occur later in the course of the illness.

Splenic tenderness may be present in patients with splenomegaly.

Pulmonary involvement is not a feature of EBV infectious mononucleosis.

The classic presentation of EBV infectious mononucleosis in children and young adults consists of the triad of fever, pharyngitis, and lymphadenopathy.

classic tried of infectious mononecleosis of children and young adult  are fever ,lympadenopathy and phyryngitis

Epstein-Barr virus (EBV) infection induces specific antibodies to EBV and various unrelated non-EBV heterophile antibodies. These heterophile antibodies react to antigens from animal RBCs.

Sheep RBCs agglutinate in the presence of heterophile antibodies and are the basis for the Paul-Bunnell test.

Agglutination of horse RBCs on exposure to heterophile antibodies is the basis of the Monospot test.

Heterophile test antibodies are sensitive and specific for EBV heterophile antibodies, they are present in peak levels 2-6 weeks after primary EBV infection, and they may remain positive in low levels for up to a year.

The latex agglutination assay, which is the basis of the Monospot test using horse RBCs, is highly specific. Sensitivity is 85%, and specificity is 100%.

The heterophile antibody test (eg, the Monospot test) results may be negative early in the course of EBV infectious mononucleosis. Positivity increases during the first 6 weeks of the illness.

eosinophilia suggeat a paracitic infection

abnormal liverfuntion test without jaundice sugest EBV infection

Cold agglutinins are typical of mycoplasma infection

vasopressin =ADH=arginine vasopressin

Vasopressin, also known as antidiuretic Homone..ADH.

also called arginine vasopressin (AVP) or argipressin.help for 2 majir funtions.

1.retain water in the body

2. constrict blood vessels.

Vasopressin regulates the body's retention of water by acting to increase water reabsorption in the kidney's collecting ducts, the tubules

 Vasopressin is a peptide hormone that increases water permeability of the kidney's collecting duct.

 It also increases peripheral vascular resistance, which in turn increases arterial blood pressure. It plays a key role in homeostasis, by the regulation of water, glucose, and salts in the blood. It is derived from a preprohormone precursor that is synthesized in the hypothalamus and stored in vesicles at the posterior pituutary

sterile pyuria ....eg..prostitis..anlgesic nepropathi..vuR..ect

The normal value for the serum anion gap is 8-16 mEq/L.

patient with vomiting developa low K+

,lowHCO3, and  alkalosis

low PaCO2 and Low HCO3 usually due to metabolic acidosis

commenwst causes for end stage renal failure

1.DM

2.glomerulonephritis

3.HTN

most common caus3 in Autralia is chronic glomerulonehritis

hypokaleamia cause impaired renal tubulerfintions and polyuria

sacidosis cause alow onset meningitis .

cryptococcosis cause cryptococal meningutis

cryptoccocal meningitis

Infection with the encapsulated yeast Cryptococcus neoformans can result in harmless colonization of the airways, but it can also lead to meningitis or disseminated disease, especially in persons with defective cell-mediated immunity.

With pulmonary cryptococcosis, radiographic findings in patients who are asymptomatic and immunocompetent may include the following:

Patchy pneumonitis

Granulomas ranging from 2-7 cm

Miliary disease similar to that in tuberculosis

cryptococcosis

infestation with a yeast-like fungus, resulting in tumours in the lungs and sometimes spreading to the brain. It occurs chiefly in the United States.

pulmonary cryptococosis

pulmonary cryptococcosis - Google Search

Immunocompetent patients with endobronchial Cryptococcus colonization who have no evidence of tissue invasion do not need antifungal therapy.

sacoidosis

Sarcoidosis is a multisystem inflammatory disease of unknown etiology that manifests as noncaseating granulomas, predominantly in the lungs and intrathoracic lymph nodes

presented with lung signs, sking manifestations like erythema nodosum and HF and other cadiac causes arw rare

sacoidosis of eye can cause to blindness

Tretment for sarcoidosis

1.Rhumatic joint pain-NSAID

2.mild lung involvement-no need of corticosteroid

3.extra pulmonary involment-cirticisterois

4.corticiteroid resistent disease

   azithiaprine

cloroqinine

cylophospomid

and so on

agn

Acute poststreptococcal glomerulonephritis (APSGN) results from an antecedent infection of the skin (impetigo) or throat (pharyngitis) caused by nephritogenic strains of group A beta-hemolytic streptococci

rheumatic fever and acute poststreptococcal glomerulonephritis (both nonsuppurative complications of streptococcal infections) did not simultaneously occur in the same patient and differ in geographic location

POST STREPTOCOCUS AGN

averegae 10days later to pharingitis or impatigo...(7-21)

Haematuria...hipertention ..mild oedema...circulatory congetion..hypertensive encephalopathy is rare

strap

most common oganism cause to septic atheritis under 5 year

Staphylococcus aureus

Q fever =coxiella burnetii

Q fever is a zoonosis caused by Coxiella burnetii, an obligate gram-negative intracellular bacterium.

primary reserver- Cattle, sheep, and goats

  Transmission to humans occurs primarily through

1.inhalation of aerosols from contaminated soil or animal waste.(moat common)

 Other rare modes of transmission include tick bites,

ingestion of unpasteurized milk or dairy products,

 human-to-human transmissio

Fx-pneumonia,headache,malaise,

drug of choice is Doxacyllin

if patient less than 8 years you would try trimeyhoprim /sulfamethozole or shoter duration of doxa

Diagnosis of chronic Q fever requires demonstration of an increased phase I IgG antibody (≥1:1024) and an identifiable persistent infection (e.g., endocarditis)

PCR, immunohistochemistry, or culture of affected tissue can provide definitive confirmation of infection by Coxiella burnetii.

Tabes dorsalis

tabea dosalis is a varient of tertiary syphilis

posterior collom demyelinationbcause to loss of vibration and position sense

Syphilis is a sexually transmitted disease caused by Treponema pallidum, with human beings as the only host   Treponemes are spirochetes, which are thin, delicate, helically coiled organisms

Neurosyphilis, quite directly, is defined as a CSF WBC count of 20 cells/µL or greater or a reactive CSF Venereal Disease Research Laboratory (VDRL) test resul

syphilis

syphilis - Google Search

congenital siphylis ocur due to transmission of spirochet gram negative bacteria to fetus IN UTERO

syphilis - Google Search

gumma in tertiary siphylis

neurosyphilis - Google Search

ampicillin increase colonisation of clostridium difficile in the colon and cause to psudomembranes colitis

Toxoplasma gondi treated with

sulfadiazine

clindamivin

pyrimethamine

ceftriaxone effective on penicillinase producing Neisseria gonorrhoea

tetacylin and erythromycin response to M.pneumoniae and Chlamydia trachomatis

metronidazole respose to Gardenerella vaginalis and Giardia lamblia

Psittacosis is an infection caused by the obligatory intracellular bacterium Chlamydia psittaci. trrated with tetracyclin

cimetadine

cimetadine reduce the hepatic metabolism of proponalol,phenytoin,warfarin,thiophylin

anticonvulsant increse birtj defect in 3 fold.

phenytoin cause to gingival hyperplasia.

status epilapsicas cand treated vith dia...mida.clona..or phenytoin

petit mal seizurer treated with Na valproate

NSAID Cause to Li toxicity

NSAID reduce Na secretion .

Li also excrete same mechanism as Na

So NSAID cause Li toxicity.

Fx..ataxia..anirexia..nausia..tremulouness

tremulosness mean shaking...

eosinophills are more in nasal smear who has allergic rhinitis

smooth muscle antibodies can see in chronic active helatitis

Sturge-Weber syndrome (SWS), also called encephalotrigeminal angiomatosis, is a neurocutaneous disorder with angiomas that involve the leptomeninges (leptomeningeal angiomas [LAs]) and the skin of the face, typically in the ophthalmic (V1) and maxillary (V2) distributions of the trigeminal nerve. The hallmark of SWS is a facial cutaneous venous dilation, also referred to as a nevus flammeus or port-wine stain (PWS).

Developmental delay/mental retardation

Learning problems

Attention deficit-hyperactivity disorder

seizur

cerebral calcification

initial focal seizurs  become worst with time

PWS

Macrocephaly

Ocular manifestations

Soft-tissue hypertrophy

Hemiparesis

Visual loss

Hemianopsia

gluecoma

psorisis

psoriasis medscape - Google Search

Psoriasis is a complex, chronic, multifactorial, inflammatory disease that involves hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate (see the image below). Environmental, genetic, and immunologic factors appear to play a role.

The diagnosis of psoriasis is clinical

oculer and musculerskelital changers might be there in psorisis

lithiam,antimalarial drug,beta adrenergic blocker ,NSAID could worse psorisis

treatment of psorisis

Keratolytic agents

Vitamin D analogs (eg, calcitriol ointment,

  betamethasone topical ointment

Topical retinoids

Antimetabolites (eg, methotrexate)

Immunomodulators (eg, tacrolimus topical 0.1%,

cyclosporine, alefacept, ustekinumab)

TNF inhibitors (eg, infliximab, etanercept, adalimumab)

Phosphodiesterase-4

cyclophosphamid

Combination therapy

Continuous therapy for patients receiving biologic agents

Switching biologic agents: If due to lack of efficacy, perform without a washout period; if for safety reasons, a treatment-free interval may be required

Other therapies

Management of psoriasis may also involve the following nondrug therapies:

Light therapy with solar or ultraviolet radiation

Stress reduction

Climatotherapy

Vertebrobasilar insufficiency is a condition characterized by poor blood flow to the posterior (back) portion of the brain, which is fed by two vertebral arteries that join to become the basilar artery. Blockage of these arteries occurs over time through a process called atherosclerosis, or the build-up of plaque.

Vertebrobasilar (posterior) circulation constitutes the arterial supply to the brainstem, cerebellum, and occipital cortex.

Vertebrobasilar ischemic disease encompasses a vast spectrum of clinical syndromes, extending from subclinical to lethal brainstem infarctions.

ventribulobasiller insuficiency cause B/L medial temporal lobe ischemia

complex partial seizur

Complex partial seizures last 1 to 2 minutes.

These seizures may have an aura (or warning).

Complex Partial Seizures include automatisms (such as lip smacking, picking at clothes, fumbling), unaware of surroundings or may wander.

Vigabatrin is already approved as adjunctive therapy, but not first-line treatment,

Vigabatrin is already approved as adjunctive therapy, but not first-line treatment,

during a complex partial seizure, the patient is unresponsive and does not remember events that occurred

All current antiepileptic drugs (AEDs), with the exception of ethosuximide, can be used in the treatment of complex partial seizures

Vigabatrin is already approved as adjunctive therapy, but not first-line treatment,

2 major neuropathologic findings in Parkinson disease are loss of pigmented dopaminergic neurons of the substantia nigra pars compacta and the presence of Lewy bodies and Lewy neurites.

Signs and symptoms

Initial clinical symptoms of Parkinson disease include the following:

Tremor.......UNILATERAL

Subtle decrease in dexterity

Decreased arm swing on the first-

Rapid eye movement (REM) behavior disorder (RBD; a loss of normal atonia during REM sleep)

Decreased sense of smell

DRIBLLING AND SALIVATION

Symptoms of autonomic dysfunction (eg, constipation, sweating abnormalities, sexual dysfunction, seborrheic dermatitis)

Slowness in thinking

Onset of motor signs include the following:

Typically asymmetric

The most common initial finding is a resting tremor in an upper extremity

Over time, patients experience progressive bradykinesia, rigidity, and gait difficulty

Axial posture becomes progressively flexed and strides become shorter

Postural instability (balance impairment) is a late phenomenon

Clinical diagnosis requires the presence of 2 of 3 cardinal signs:

Resting tremor

Rigidity

Bradykinesia

tre

atment of Pakinsons Dx

Symptomatic drug therapy

Usually provides good control of motor signs of Parkinson disease for 4-6 years

Levodopa/carbidopa: The gold standard of symptomatic treatment

Monoamine oxidase (MAO)–B inhibitors: Can be considered for initial treatment of early disease

Other dopamine agonists (eg, ropinirole, pramipexole): Monotherapy in early disease and adjunctive therapy in moderate to advanced disease

Anticholinergic agents (eg, trihexyphenidyl, benztropine): Second-line drugs for tremor only

a neurological disorder caused by thiamine deficiency, typically from chronic alcoholism or persistent vomiting, and marked by mental confusion, abnormal eye movements, and unsteady gait

Thiamine (vitamin B-1) deficiency can result in Wernicke's Encephalopathy (WE),

A myoclonic jerk is the brief, involuntary twitching of a muscle or group of muscles. It may be caused either by a sudden muscle contraction, or a sudden lapse of contraction.

eg...

epilepsy

normal sleep

subacute encephalitis

uremia

creutzfeldt_Jacob Dx