very useful mnemonics

Discussion in 'MRCP Forum' started by Guest, Sep 2, 2007.

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    Causes of acute Pancreatitis


    Black scorpion bite
    Alcohol ( or autoimmune : PAN )
    Drugs ( tetracycline, azothioprin, sulfa, diuretics )
    Stones ( gallstones or steroid )
    Infection ( mumps )

    Small Bowel Obstruction


    S - Stone (gallstone ileus)
    H - Hernia
    A - Adhesions
    V - Volvulus
    I - Intussusception
    T - Tumor

    Non-GI Causes of Vomiting

    ABC's of Non- GI causes of vomiting

    Acute renal failure
    Brain (Increased ICP)
    Cardiac (Inferior MI)
    Ears (labyrinthitis)
    Foreign substances (Tylenol, theo, etc)
    Hyperemesis Gravidarum
    Infections (pyelonephritis, meningitis)

    Extraintestinal manifestations of I. B. D. are A PIE SAC -
    Aphthous ulcers, Pyoderma gangrenosum, Iritis, Erythema nodosum, Sclerosing cholangitis, Arthritis, clubbing.

    Which I. B. D. has C-obblestones on endoscopy - C-rohn's.

    If QRS complex is wide, consider bundle branch block. LBBB causes a "W" pattern in V1-2 and a "M" pattern in V5-6. RBBB is the other way round. Remember as WiLLiaM MaRRoW.

    Basal Systolic Murmur: Aortic Stenosis (AS)
    -The mnemonic key is Arthur Shawcross (AS), a cannibalistic murderer, a key which immediately follows the symbol.


    Angina pectoris despite normal coronary arteries
    Arthur Shawcross represents the Angel of death [Angina].

    Exertional syncope
    His victims Swooned [Syncope] with fear when they saw him.

    Exertional dyspnea of congestive heart failure
    Arthur Shawcross claims he left the crime scenes whistling Dixie [Dyspnea].

    Sudden cardiac death
    Arthur Shawcross causes Sudden Death.

    -Physical findings

    Loud, harsh, systolic ejection murmur at the upper right sternal border, usually
    associated with a palpable systolic thrill.

    Arthur Shawcross is a Base [Basal] Thrill-murderer [Thrill].
    He is a Harsh Hardened criminal, who attributed his grotesque actions to
    incest with his Sister [Systolic].

    S4 gallop is common and represents left ventricular hypertrophy and increased
    left ventricular pressure.
    His ghoulish tales read like the Four [S4] Horsemen of the Apocalypse.

    S3 when left ventricular failure is present.
    As a child, AS displayed the classic homicidal Triad [S3]: animal torture,
    fire-setting, and bed-wetting.

    Delayed upstroke in the carotid pulse. Parvus et tardus carotid pulse.
    His last victim still had a Small but palpable pulse. However, the ambulance was
    Delayed [upstroke], and, it soon became too Little, too Late [Parvus et Tardus].

    Paradoxical splitting of S2
    AS sent his victims to Paradise [Paradoxical].

    Apical Diastolic Murmur: Mitral Stenosis (MS)

    -The mnemonic key is MicroSoft (MS), a key which immediately follows the symbol.

    -Physical findings:

    The thrill at the apex is the diastolic murmur.
    >> Hopeful applicants at the Apex of their careers are Thrilled to be hired by

    The left ventricle (LV) is of normal pressure and size, so the point of maximum impulse
    is not displaced to the left.
    >> MS owns a Healthy Windows [Vented: Normal LV] environment, and is Not willing
    to be Displaced from its location.

    High-pitched opening snap [OS] following S2, heard best between the second to
    fourth left intercostal space.
    >> The new Windows98 Operating System [OS] sold at a High-pitched pace.

    S1 is loud and snapping.
    >> MicroSoft 1-sound is Bill Gates [S1], who barks out Loud Snapping orders.

    -Chest x-ray:

    Kerley B lines (dilated interlobular septa or septal edema) are horizontal, nonbranching
    lines at the peripheral lower lung fields.
    >> The Curly-haired [Kerley B lines] computer geek...

    The large left atrium straightens the left heart border and is suggested by a double
    density right-heart border, by the posterior displacement of the esophagus, and
    by an elevated left mainstem bronchus.
    >> ...stole Double Density [CXR] diskettes to be sold in Los Angeles [large LA].


    The left atrial (LA) pressure pulse reveals a prominent "a wave (LA contraction
    against the mitral valve).
    >> Those trying to enter the ranks of MS had to show Prominent A grades ["a wave]
    at the Apex [Apical diastolic murmur] of their class.

    Symptoms of aortic stenosis are SAD or ASD - Syncope, Angina, Dyspnea.

    For Causes of A-Fib/Flutter

    H = cHf, other cardiomyopathies
    E = Enlargement of the atria
    A = Alcohol binge drinking
    R = Rheumatic heart disease
    T = hyperThyroid

    "3 Hypo's & 3 Hyper's"
    Hyper H (Acidosis)
    Hyper Rx (Drugs/OD)
    Submitted by Tag Filley, M.D.

    H - hypoglycemia hypoxia
    E - epilepsy
    A - anxiety [the "swoon"]
    D - dysfunction of brain stem [i.e. brain stem TIA]
    H - heart attack
    E - embolism of pulmonary artery
    A - aortic obstruction [ Aortic stenosis, myxoma, IHSS ]
    R - rhythm disturbance
    T - tachycardia esp VT
    V - vasovagal
    E - ectopic i.e. hemorrhage obvious or not
    S - situational [micturation, defecation...]
    S - subclavial steal
    L - low SVR [eg: anaphalaxis]
    S - sensitive carotid sinus
    of M.I. is BOOMAR - Bed rest, Oxygen, Opiate, Monitor, Anticoagulate, Reduce clot size Proven MI.. should be met by M.O.N.A.

    M = morphine
    O = oxygen
    N = nitrates
    A = aspirin

    suspected right ventricular MI suspected .. hold the Nitrates. submitted by Chris

    Mnemonic for remembering antiarrhythmics

    Class Drug Mnemonic Read as: Professor Quackers "dissed" - Lydia's penny Mexican tacos. - Feeling profaned, - proper Bertha Butt - (amiable British socialite) - virtually dismembered 'im. or Professor Quackers dissed Lydia's Penny Mexican Tacos. Feeling profaned, proper Bertha Butt, (amiable British socialite), virtually dismembered 'im.*Note: "Dissed" is used here as the slang term "dis" - from dismiss. I.e., "Don't 'dis' me, man!"
    Class IA Procainamide Professor
    Quinidine Quackers
    Disopyramide "dissed" *
    Class IB Lidocaine Lydia's
    Phenytoin penny
    Mexiletine Mexican
    Tocainide Tacos
    Class IC Flecainide feeling
    Propafenone profaned
    Class II Propranolol proper
    Beta Blockers Bertha Butt
    Class III Amiodarone amiable
    Bretylium British
    Solatol socialite
    Class IV Verapamil virtually
    Diltiazem dismembered 'im

    F - FEVER
    A - ANEMIA
    M - MURMUR

    Causes of pericarditis are CARDIAC RIND - Collagen vascular disease, Aortic aneurysm, Radiation, Drugs eg. hydralazine, Infections, Acute renal failure, Cardiac infarction, Rheumatic fever, Injury, Neoplasms, Dressler's syndrome.

    5 T's of early cyanosis in congenital heart disease
    • Tetralogy, Transposition, Truncus, Total anomalous, Tricuspid atresia
    Sumbitted by Ben Humphreys

    95% of hypertension is primary (idiopathic). 5% is secondary and causes include CHAPS - Cushing's syndrome, Hyperaldosteronism (Conn's syndrome) , Aorta coarctation, Pheochromocytoma, Stenosis of the renal arteries.

    Takayasu's disease is also called pulseless disease, therefore I can't Tak'a ya's pulse.

    Henoch-Schonlein Purpura
    J - Joints
    A - Abdominal pain
    R - Renal
    S - Skin

    Compartment Syndrome

    "6 p's"

    Predisposing Conditions for Pulmonary Embolism TOM SCHREPFER
    • T--trauma
    • O--obesity
    • M--malignancy
    • S--surgery
    • C--cardiac disease
    • H--hospitalization
    • R--rest (bed-bound)
    • E--estrogen, pregnancy, post-partum
    • P--past hx
    • F--fracture
    • E--elderly
    • R--road trip

    (Cot)Caught by Sin : Cottonà BySSinosis

    Shortness of Breath


    H: History of any pulmonary disease
    A: Activity at onset
    P: Pain upon inspiration
    I: Infections fever/chills
    S: Smoker years/packs
    O: Orthopnea
    C: Cough (Persistent)
    S: Sputum Productive/color

    Non-Cardiogenic Pulmonary Edema
    P - Phosgene, paraquat, phenothiazines
    O - Opioids/organophosphates
    N - Nitrous dioxide
    S - Salicylates

    Treatment of acute pulmonary edema
    As Easy as 'LMNOP' : Remember the mnemonic LMNOP when treating a patient with acute pulmonary edema
    • Lasix¢ç (furosemide) intravenous (IV), one to two times the patient's usual dose, or 40 mg if the patient does not usually take the drug.
    • Morphine sulfate. Initial dose, 4 to 8 mg IV (subcutaneous administration is effective in milder cases); may repeat in 2 to 4 hours. Avoid respiratory depression. Morphine increases venous capacity, lowering left atrial pressure, and relieves anxiety, which reduces the efficiency of ventilation.
    • Nitroglycerin IV, 5 to 10 ug/min. Increase by 5 ug/min q 3 to 5 minutes. Reduces left ventricular preload. Caution: may cause hypotension.
    • Oxygen, 100% given to obtain an arterial PO2>60 mm Hg.
    • Position patient sitting up with legs dangling over the side of the bed. This facilitates respiration and reduces venous return.

    Beta-1 receptors are in the heart (you have 1 heart) and beta-2 receptors are in the lungs (you have 2 lungs).

    Decreased Pleural fluid Glucose : "IRAN"
    • I=Infections
    • RA=Rheumatoid arthritis
    • N=Neoplasia

    Anterior Mediastinal Mass
    "4 T's"
    T - Thymoma
    T - Teratoma
    T - Thyroid tumor/goiter
    T - Terrible lymphoma

    Middle Mediastinal Mass
    H - Hhernia, hematoma
    A - Aneurysm
    B - Bronchogenic cyst/duplication cyst
    I - Inflammation (sarcoid, histo, coccidio, TB)
    T5 - Tumors (lung, lymphoma, leukemia, leiomyoma, lymph node hyperplasia)

    Bilateral Hilar Adenopathy
    "Please Helen Lick My Popsicle Stick"
    P - Primary TB
    H - Histoplasmosis
    L - Lymphoma
    M - Metastases
    P - Pneumoconiosis
    S - Sarcoidosis



    E-Erythema nodosum
    R-Restrictive lung defect (PFTs)
    M-Multiple systemic manifestations
    A-Asteroid bodies (inclusions)
    N-Noncaseating granuloma, Negative TB test

    ACE - Angiotensin converting enzyme levels monitor disease activity and response to therapy.

    Schaumann's bodies (inclusions)

    B-Bell's palsy, Bilateral hilar lymphadenopathy, Black females O-Optic nerve dysfunction is a common manifestation of neurosarcoid.
    E-Eyes: uveitis
    K-Kveim skin test

    Rat Poisons

    "RATS PANIC" I'm sure that you'll easily remember this one!
    R - Red squill
    A - Arsenicals
    T - Thallium
    S - Strychnine
    P - PNU/Phosphorus/zn Phosphide
    A - Alpha naphtha thiurea (ANTU)
    N - Norbormide
    I - Indanediones
    C - Coumadin/cholcalciferol

    Anion Gap Acidosis:
    M - Methanol
    U - Uremia
    D - DKA/AKA
    P - Paraldehyde/phenformin
    I - Iron/INH
    L - Lactic acidosis
    E - Ethylene glycol
    S - Salicylates

    Normal Gap Acidosis
    H - Hyperalimentation/hyperventilation
    A - Acetazolamide
    R - RTA
    D - Diarrhea
    U - Ureteral diversion
    P - Pancreatic fistula/parenteral saline

    Osmolar Gaps
    "ME DIE"
    M - Methanol
    E - Ethanol
    D - Diuretics (mannitol, sorbitol, glycerol)
    I - Isopropanol
    E - Ethylene glycol

    Respiratory Alkalosis: Asthmatic Sally poisoned POPE's HEN
    • Asthma
    • Salicylate poisoning
    • PO= Pulmonary Oedema
    • PE= Pulmonary Embolism
    • HEN= Hepatic Encephalopathy

    R - renal failure
    EX - exogenous
    P - pituitary
    L - liver failure
    A - alcohol
    I - insulinoma/infection
    N - neoplasm

    Hypoglycemia [By Sung Kim]

    Hypoglycemia - H-U-N-G-E-R: B-E-S-T S-A-U-C-E I-S M-S-G

    H-Hepatic failure (advanced), Hypothermia
    U-Uremia/renal failure
    N-Nausea, vomiting
    G-Growth hormone deficiency
    E-Ethanol metabolism blunts gluconeogenesis
    R-Reye's syndrome

    B-Beta blockers
    E-Enzyme defects (glycogen storage diseases)
    T-Tumors: Islet beta cell tumors (pancreatic): Insulinomas
    Non-islet cell tumors: Large mesenchymal tumors

    A-Adrenal insufficiency
    U-Under 0.3 (insulin/glucose ratio) to make the diagnosis C-C-peptide measurement to rule out factitious hypoglycemia
    E-Endocrine: Epinephrine, glucagon deficiencies (counterregulatory hormone deficiencies)

    I-Immune disease with insulin or insulin receptor antibodies
    S-Sarcomas: large retroperitoneal sarcomas

    M-Maple syrup urine disease, severe Malaria
    S-Salicylates in children
    G-Galactosemia (with milk ingestion), disorders of Gluconeogenesis

    Symptoms of hyperthyroidism
    • Remember the following mnemonic when evaluating patients for hyperthyroidism:
    S : Sweating
    T : Tremor or Tachycardia
    I : Intolerance to heat, Irregular menstruation, and Irritability N : Nervousness G : Goiter and Gastrointestinal (loose stools/diarrhea).

    • DISEASE is
    • Dependent on (Pituitary) and
    • Depresses ( Cortisol) on
    • Daddy Doses of Dexa(High doses of Dexamethasone).

    S - Sarcoidosis
    H - Hyperparathypoidism, Hyperthyroidism
    A - Alkali-milk syndrome
    M - Metastases, myeloma
    P - Paget disease
    O - Osteogenesis imperfecta
    O - Osteoporosis
    D - Vitamin intoxication
    I - Immobility
    R - RTA
    T - Thiazides

    Hypercalcemia symptoms are Bones (pain), Stones (renal), abdominal Groans (pain) and psychic moans (confusion).

    Multiple endocrine neoplasia
    MEN I is 3 P's (Pituitary, Parathyroid, Pancreas). MEN II is 2 C's (Catecholamines ie. pheochromocytome, carcinoma of medulla of thyroid) and Parathyroid (IIa) or Mucocutaneous neuromas (IIb).

    The most common thyroid carcinoma is P-apillary (P-opular). It also has P-sammona bodies on histology. It causes P-alpable lymph nodes (lymphatic spread).

    The most common symptoms of PHEochromocytoma begin with the first 3 letters - Palpitations, Headache, Episodic diaphoresis (sweating).

    Tumors that go to bone
    "Kinds Of Tumors Leaping Primarily To Bone"
    K - Kidney
    O - Ovarian
    T - Testicular
    L - Lung
    P - Prostate
    T - Thyroid
    B - Breast

    Causes of joint pain are SOFTER TISSUE - Sepsis, Osteoarthritis, Fractures, Tendon/muscle, Epiphyseal, Referred, Tumour, Ischaemia, Seropositive arthritides, Seronegative arthritides, Urate, Extra-articular rheumatism (eg. polymyalgia).

    Ossification centers of the elbow

    There are two that I know of (most people use "CRITOE"):
    C - Capitellum
    R - Radial head
    I - Internal (medial epicondyle)
    T - Trochlea
    O - Olecranon
    E - External (lateral epicondyle)
    These appear at 2, 4, 6, 8, 10, and 12 years of age in order and go away two years later.
    The other mnemonic I know for the ossification centers is "Come Rub My Tree Of Love" where the "M" is medial epicondyle and the "L" is the lateral epicondyle.

    Wrist Bones
    "Never Loosen Tillies Pants, Mother Might Come Home"
    Proximal row:
    N - Navicular
    L - Lunate
    T - Triquetrium
    P - Pisiform
    Distal row:
    M - greater Multiangular (trapezium)
    M - lesser Multiangular (trapezoid)
    C - Capitate
    H - Hamate
    Also: "Some Lovers Try Positions That They Can't Handle"

    Rotator Cuff Muscles
    S - Supraspinatus
    I - Infraspinatus
    T - Teres minor
    S - Subscapularis

    The Salter Classification:
    S - Slip of physis
    A - Above physis
    L - Lower than physis
    T - Through physis
    R - Rammed physis

    NEPHROTIC SYNDROME (NS) is characterized by the following: [By Shweta]

    N = Na + water retention
    This occurs due to several factors, including compensatory secretion of aldosterone in response to hypovolemia-mediated release of ADH.

    E = Edema
    Due to hypoproteinemia + Na, water retention. Edema is soft, pitting and starts in the periorbital region.

    P = Proteinuria >3.5gm/1.74sq. ml/24hrs

    H = Hypertension + hyperlipidemia (due to increased lipoprotein synthesis in liver, abnormal transport of circulating lipoproteins, decreased catabolism.)

    R = Renal vein thrombosis

    O = "Oval fat bodies" in the urine. Lipiduria follows hyperlipidemia. Albumin as well as lipoproteins are lost. Lipoproteins are reabsorbed by tubular epithelial cells and they shed along with degenerated cells- this appears as "oval fat bodies" in urine.

    T = Thrombotic + thromboembolic complications owing to loss of anticoagulant factors (eg. anti-thrombin III )

    I = Infection. These patients are prone to infection, especially with staphylococci and pneumococci. Vulnerability is due to loss of immunoglobulins.

    C = hyperCoagulable state

    Henoch-Schonlein Purpura
    J - Joints
    A - Abdominal pain
    R - Renal
    S - Skin

    Causes of hematuria
    • Use the mnemonic SITTT as an aid in evaluating the cause of hematuria:

    S: Stone
    I: Infection
    T: Trauma
    T: Tumor
    T: Tuberculosis

    Causes of secondary nephrotic syndrome ie. not of direct renal origin are DAVID - Diabetes mellitus, Amyloidosis, Vasculitis, Infections, Drugs.

    Causes of acute and reversible forms of urinary incontinence The following mnemonic aids in remembering the causes of acute and reversible forms of urinary incontinence - DRIP

    D: Delirium
    R: Restricted mobility, retention
    I: Infection, inflammation, impaction (fecal)
    P: Polyuria, pharmaceuticals

    Hereditary cystic disorders: Polycystic kidney disease

    Autosomal dominant polycystic kidney disease (ADPKD) is associated with cysts in the kidneys and, in many cases, in the brain (berry aneurysms), liver, spleen, pancreas, and lungs.

    ¡°Halley Berry AKA Dorothy (Dandridge) Portrayed Carmen Jones.¡±

    Halley ?Hematuria: Gross and microscopic
    Berry -Berry aneurysms


    D-Dominant (autosomal) inheritance
    O-Obstruction of the urinary tract by stones, blood clots R-Renal failure
    O-Oxalate: calcium oxalate and uric acid stones
    T-renal Tubular defects
    H-Hemorrhagic cysts
    Y-Year 1 - Most cases are diagnosed in the first year of life, presenting as bilateral abdominal masses.

    Portrayed ?Polycystic: continued enlargement of the cysts often leads to progressive renal failure.

    Carmen ?CT scanning: Enlarged kidneys with multiple bilateral cysts are diagnosed using ultrasound, IVP,
    or CT scanning.
    Jones - Juvenile nephronophthisis (JN) and medullary cystic disease (MCD) are in the DDx.

    -Cardiac valvular disorders: Mostly mitral valve prolapse (MVP) and aortic regurgitation -Salt-wasting nephropathy, renal tubular acidosis (RTA) -Chronic flank pain due to the mass effect of the enlarged kidneys

    Lusty Carmen Jones powdered her nose, using her Bivalve [MVP] mirror compact, ¡¦ -then she slowly raised her Salt-rimmed [Salt-wasting nephropathy] MargaRiTA [RTA], and seductively
    placed her other hand on her Hip [Flank pain].

    -Hyperchloremic acidosis
    -Salt-wasting nephropathy causing hyponatremia

    It was said that Dorothy was not allowed to swim in the hotels Chlorinated pool [Hyperchloremic acidosis].
    When she defiantly swam in the pool, they Drained it [Salt-wasting nephropathy, Hyponatremia].

    -End-stage renal disease (ESRD)

    Dorothy was forced to enter through the back door, even while she was contracted to sing under The Big
    Tent [Hypertension].
    Dorothy was only 41 when she was found DEAD [ESRD].


    Dx: Positive family history (autosomal dominant inheritance)
    Gross and microscopic hematuria
    Ultrasound, IVP, or CT scanning detect the enlarged kidneys with multiple bilateral cysts

    Renal Pathology Buzz words

    Lupus = wire LOOP lesion (LUPUS=LOOP)

    goodPASTURE = a pasture is FLAT so is the immunoflouresence for GP

    Membraneous GN = spike and DOME appearance (think membrane = dome)
    (held up by spikes)

    Membranoproliferative GN = M P GN = Tram Track
    think of MP's (military police riding on Trams)

    Post streptococcal GN= Lumpy Bumpy
    think Strep aerobics
    Lumpy people Bumping
    around doing aerobics

    WBC Count
    "Never Let Mom Eat Beans" and "60, 30, 6, 3, 1"
    • Neutrophils 60%
    • Lymphocytes 30%
    • Monocytes 6%
    • Eosinophils 3%
    • Basophils 1%

    Hem - PT, PTT:

    To remember the intrinsic and extrinsic pathways in relation to what blood test is affected:

    PiTT (I for Intrinsic pathway) - PiTTsburgh
    PeT (E for Extrinsic pathway)

    Vitamin K-dependent proteins and warfarin sodium [by Sung Kim and S. Levine, MD, PhD.]

    Warfarin sodium is a vitamin K antagonist.

    -Vitamin K-dependent proteins C and S.
    -Vitamin K-dependent clotting factors II, VII, IX, and X of the extrinsic pathway.

    --> The Korean [vitamin K] War [Warfarin] was fought Outdoors [Extrinsic
    --> pathway]. The American PT boats [PT, Protime, or prothrombin time],
    --> whose access had been limited
    by the rough Seas [protein C], quickly sent out SOS [protein S] messages.

    Microcytic Anemia
    Iron deficiency
    Chronic disease
    Sideroblastic anemia

    Submitted by Jeff Rodgerson M.D.
    HCMC Medical Center

    N - Neoplasm
    A - Allergy
    A - Addison's
    C - Cirrhosis, CVD
    P - Parasite (visceral larva migrans), Periarteritis nodosa
    Submitted by Tag Filley, M.D.

    Thalassemia major is the most Severe ©-thalassemia [B-Beta-Bad].

    -Major B-A-D M-A-F-I-A guys have the typical gangster appearance:
    Short [Microcytic hypochromic anemia] and
    Ugly [distortion of facial, skull, and long bones]

    B-Basophilic stippling
    A-Anemia, Anisocytosis

    M?MCV is low
    A-HbA is decreased
    F-HbF is increased
    I-Ineffective erythropoiesis
    A?HbA2 is increased

    Cooley's anemia (beta-thalassemia major) is the homozygous state.

    -The key is Denton A. Cooley, M.D., Texas Heart Institute (THI).

    D-Deferoxamine therapy to prevent hemochromatosis
    A-Anemia - In beta-thalassemia major or intermedia, anemia is due to a combination of ineffective erythropoiesis
    and hemolysis of circulating cells. C-Congestive heart failure is a cause of death in the first years of life if the patient is not transfused.

    M-MCV is low; Microcytic hypochromic anemia
    D-Diagnosis, prenatal

    T-Tower skull (also frontal bossing, chipmunk facies, and distortion of long bones) H-Hemolytic anemia with Hepatosplenomegaly in the first year of infant life I-Intermedia - Beta-thalassemia intermedia presents with abnormalities similar to those of thalassemia major.

    Increased susceptibility to infections

    Peripheral blood smear: Basophilic stippling
    Helmet cells
    Nucleated target cells
    Anisocytosis (RBCs of different size/volume)

    X-ray: Hair-on-end skull

    Serum hemoglobin electrophoresis: HbA is decreased.
    HbA2 is increased.
    HbF is increased

    --> Dr. Cooley performed Major surgery [thalassemia Major] as a
    --> Cardiothoracic surgeon [Cardiac failure] live
    on the Internet [Infections].

    --> His skilled hands can perform Microsurgery [Microcytic hypochromic
    --> anemia] on Fetuses [HbF].

    --> His surgical cap [Helmet cells] fit loosely over his Crew cut
    --> [Hair-on-end skull].

    --> He proceeded to make an incision along the Blue Stippled line
    --> [Basophilic Stippling] drawn on the skin.

    --> Dr. Cooley's Target [Target cells] academic score had always been an
    --> A+ [HbA2 is increased].

    --> He would Not accept a simple A [HbA is decreased].

    --> The surgical staff is a close knit community, like a B-A-D M-A-F-I-A
    --> (see below), quick to dispose of weak,
    Ineffective [Ineffective erythropoiesis] residency candidates.

    Disseminated intravascular coagulation (DIC)


    D-Dx: D dimer
    I-Immune complexes
    S-Snakebite, shock, heatstroke
    E-Eclampsia, HELLP syndrome
    M-Massive tissue damage
    I-Infections: viral and bacterial
    A-Acute promyelocytic leukemia
    T-Tumor products: Tissue Factor (TF) and TF-like factors released by carcinomas of pancreas, prostate, lung,
    colon, stomach
    E-Endotoxins (bacterial)
    D-Dead fetus (retained)

    Characteristic features of multiple myeloma on X-ray are ABCDE - Asymmetry, Border irregular, Colour irregular, Diameter usually > 0.5cm, Elevation irregular.

    æ 9 Àå þ¾ç Ãúȯ

    Chronic lymphocytic leukemia (CLL) is a monoclonal malignancy, usually of B lymphocytes.

    -Incidence: CLL is the most common adult leukemia in the United States.
    50-70 years of age

    Songwriter Phil CoLLins [CLL] is Male and probably over 50 years of age. He recently won an
    Oscar for his "Tarzan" song.

    Clinical and diagnosis

    Lymphocytosis >15,000/mm3
    Generalized lymphadenopathy

    Tarzan can spring from Limb [Lymphocytosis] to Limb [Lymphadenopathy] above the tree

    Splenomegaly, hepatomegaly
    Low serum immunoglobulins (immunosuppression)

    --> where the Splendid [Splenomegaly] Moonlight [imMunosuppression]
    --> streams through the

    Diffuse bone marrow infiltration and replacement of cellular elements cause:

    --> Walt Disney Pictures produced the Animated Animal [Anemia] adventure
    --> "Tarzan".

    --> The "Tarzan" [Thrombocytopenia] song earned CoLLins an Oscar [Osteo,
    --> bone marrow failure]
    award for the best original song.

    --> Tarzan had Little need for Plates [Platelets <100,000/¥ìL] in the
    --> jungle.

    --> Phil CoLLins is a Grammy [Granulocytopenia] Award-winning singer and
    --> songwriter.

    Occasionally extravascular hemolysis: warm-antibody autoimmune hemolytic anemia (AHA)

    --> An African jungle [Autoimmune extravascular] APE [AHA] had Warmly
    --> [Warm-antibody]
    adopted baby Tarzan.

    Differential diagnosis
    Malignant lymphoma
    Infectious mononucleosis

    --> Tarzan is Lord [Lymphoma] of the Jungle and friend of the Monkeys
    --> [Mononucleosis]. Phil CoLLins was born in London [Lymphoma].

    Chlorambucil (an alkylating agent), with or without prednisone

    --> Some may imagine a Ram [ChloRambucil] scrambling about, but others
    --> will¡¦

    --> recall that Clayton [Chlorambucil] is the villainous jungle guide
    --> who was hired by
    Professor [Prednisone] Porter, not knowing that¡¦

    --> ¡¦Clayton [Chlorambucil] had his captured Prey [Prednisone]
    --> immediately Flown
    [Fludarabine] out for profit.

    1. Harrison's Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998. 2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999. 3. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.

    Hodgkin's lyphoma classification - A = Asymptomatic, B = Bad.

    Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40 etc.

    Malignant Monoclonal Gammopathies: Multiple myeloma

    -The mnemonic key for multiple myeloma (MM) is Marilyn Monroe (MM), a key which immediately follows the >> symbol.


    Weakness and fatigue due to normochromic normocytic anemia.
    >> MM's original name was Norma [Normochromic normocytic] Jean.

    Bone pain and pathologic fractures: predominantly osteolytic tumors and osteoporosis.
    >> MM's name was illuminated in marquee Lights [osteoLytic], but she
    >> secretly longed for
    an Oscar award [Osteoporosis].

    Susceptibility to bacterial infections.
    >> MM was Susceptible to Toxic [infections] relationships.

    Acute renal failure (ARF) due to the effects of filtered light-chain proteins,
    hypercalcemia, and amyloid deposits in the kidney.
    >> MM's Lightly-Chained ARF dog barked when MM's death was said to be
    >> related to her
    JFK Army-Lord [Amyloid].


    >> MM fluffed White Talcum [hypercalcemia] powder on her delicate white
    >> skin...

    >> protect it from the movie industry's Large hot Camera
    >> lights[hyperGammaglob].

    Serum electrolytes: Low anion gap
    >> MM wore gowns with Low [Low anion gap] revealing necklines.

    Rouleaux on peripheral blood smear.
    Occasionally Coombs(+) hemolytic anemia.
    >> MM used hair Rollers [Rouleaux] and Combs [Coombs] to create her
    >> famous hairdo.

    Leukocyte alkaline phosphatase (LAP) staining reaction: High LAP score.
    >> MM used her Great LAP to her advantage because....

    Normal levels of Serum Alkaline Phosphatase (SAP)
    >> ...she was Not a SAP.

    Antineoplastic agents & Adverse effects

    Male testicular tumors: "S-E-C sac T-I-C-S¡±

    S-Seminoma: most common
    E-Embryonal carcinoma

    Sac-Yolk sac tumor (endodermal sinus tumor)

    T-Teratoma, Teratocarcinoma
    I-C-Interstitial (Leydig) cell tumor
    S-Sertoli cell tumor

    Paraneoplastic syndromes and their associated cancers:

    Your diagnosis can be "Highly S-C-R-A-M-B-L-E-D."

    Highly-Hypercalcemia (squamous cell carcinoma)

    S-SIADH, hyponatremia (SCLC)
    C-Clubbing (adenocarcinomas)
    R-Retinal blindness (SCLC)
    M-Myasthenia gravis (thymoma)
    B-Bone - hyperosteoarthropathy (adenocarcinomas)
    L-Limbic encephalitis (SCLC)
    E-Eaton-Lambert myasthenic syndrome (SCLC)
    D-Dermatomyositis (cancer of the lung, ovary, breast, stomach; NHL)

    SIADH: Syndrome of inappropriate antidiuretic hormone secretion
    SCLC: Small cell lung cancer
    NHL: non-Hodgkin's lymphoma


    The first two mnemonics are modifications of well-known mnemonics.

    -Gram-positive, spore-forming, rods: Bacillus and Clostridium

    Some love stay home forming spores:
    Basically Claustrophilic (Bacilli and Clostridia)

    -Other gram-positive rods:

    Others love to belong: C-L-A-N


    All species within the Enterobacteriaceae family are gram-negative enteric bacilli and are facultative anaerobes that can ferment glucose to acid.

    When microorganisms compete with humans for glucose, they are Nasty CURSESS."

    Nasty-Neisseria (N. gonorrhoeae and N. meningitides)

    C-Curved: Vibrio and C-Campylobacter species
    SS-Salmonella, Shigella

    Urease(+): Y. enterocolitica, Y. pseudotuberculosis, P. mirabilis, P. vulgaris, M. morgani

    Clinically significant Anaerobes "A Closed Box For Pepsi."

    A-Actinomyces G+
    C-Clostridia- G+
    B-Bacteroides G-
    For Fusobacterium G-
    Pepsi Peptostreptococci G+

    Bloody diarrhea

    Bloody diarrhea may be caused by invasive bacteria or parasites, including:

    Campylobacter, Shigella, Salmonella, Yersinia, and Trichuris (whipworm).

    The Cutting edge of the Campbell's [Campylobacter] soup can was Bloody.

    The Shaggy [Shigella] surface was Abrasive [Bloody].

    The Salmon [Salmonella] scales were Abrasive [Bloody].

    The Jersey [Yersinia] sweatshirt was rough and Abrasive [Bloody].

    The Bullwhip [Whipworm] drew Blood.

    Bordetella pertussis: Whooping cough

    Bordetella pertussis is the etiologic agent of whooping cough.


    Absolute lymphocytosis in children (a reportedly recent USMLE Step 2 question).

    >> Many crossed the Border [Bordetella] for their Green* cards [lymphocytosis].
    *In our color-coding scheme of mnemonics, green will represent lymphocytes.


    B-Bordet-Gengou agar culturing a nasopharyngeal swab is the standard diagnostic test ordered during the
    first 2 weeks of onset.
    O-whOoping cough
    R-Rod: B. pertussis is a small, gram-negative pleomorphic rod

    D-DFA - Direct fluorescent antibody test of nasopharyngeal secretions results in frequent false-positives.

    E-Erythromycin for therapy and prophylaxis.

    T-Trimethoprim-sulfamethoxazole is an alternative antibiotic choice.

    E-ELISA is the diagnostic test ordered after the first 2 weeks of onset.

    L-Leukocytosis: 10,000 - 50,000 cells/uL with 50-75% mature lymphocytes

    L-Lymphocytosis in children

    A-Adult lymphocytosis is rare.

    Organisms that Spread from Blood to Urine
    C - candida
    A - aureus staph
    S - salmonella
    H - histoplasma
    C - cytomegalo virus
    M - mycobacteria
    L - leptospira
    Submitted by Ousama Dabbagh M.D


    "scream fever"
    S - sausage fingers
    C - conjunctival redness
    R - rash
    E - extremity involvement
    A - adenopathy
    M - mucosal erythema
    FEVER - fever

    Causes of post op fever
    Remember the following mnemonic when determining the possible cause(s) of fever in a patient who has recently undergone a surgical procedure: the 5 W's (or 6 W's)

    Wind : the pulmonary system is the primary source of fever in the first 48 hours. ( Atelectasis, pneumonia ect.)
    Wound : there might be an infection at the surgical site.
    Water : check intravenous access site for signs of phlebitis.
    Walk : deep venous thrombosis and pulmonay embolism can develop due to pelvic pooling or restricted mobility
    Whiz : a urinary tract infection is possible if urinary catheterization was required.
    Also Wonder drugs - drug fevers. (added by Calvin Lee)

    Classification of hypersensitivity reactions
    Type I Anaphylaxis
    Type II Cytotoxic - mediated
    Type III Immune - complex
    Type IV Delayed hypersensitivity

    Criteria for Lupus
    Serositis (pleuritis, pericarditis)
    Oral Ulcers
    Blood (all are low - anemia, leukopenia, thrombocytopenia)
    Renal (protein)
    Immunologic (DS DNA etc.)
    Neurologic (psyc, seizures)
    Submitted by Mike Ritter, MD FAAEM, San Diego, CA

    Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40 etc.

    Blue Sclera: "MIXED"
    • M = Marfans ,
    • I = Imperfecta ( Osteogenesis )
    • XE =(pseudo) Xanthoma elasticum
    • ED = Ehlers Danlos
    Altered Mental Status
    A - Alcohol/drugs
    E - Endocrine
    I - Insulin
    O - Opiates
    U - Uremia
    T - Toxins/trauma
    I - Infections
    P - Psych/porhyria
    S - SAH, shock, stroke, seizure, space occupying lesion

    MIDAS : States to exclude as cause of coma.
    • Meningitis
    • Intoxication
    • Diabetes
    • Air - respiratory failure
    • Subdural or subarachnoid hemorrhage.

    Level of consciousness

    A - alert
    V - resonds to verbal stimuli
    P - responds to painful stimuli
    U - unconscious

    Vertebral/Basilar Ischemia
    dizziness (nystagmus)
    diplopia (skew deviation)
    Submitted by: Ronald H. Miller, OD, The Ohio State University

    Cerebellar lesions lead to VANISHeD - Vertigo, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonic reflexes, Dysdiadochokinesia. ( or Dementia )

    Marcus Gunn Pupil

    Marcus Welby, M.D. "knows". Robert Young was also in "Father Knows Best".

    D-R K-N-O-W-S

    D-Deafferentation of the pupillary light reflex
    R-Retrobulbar optic neuritis

    K-Kan't kick inward: afferent limb defect
    N-No constriction to direct light stimulation
    O-Optic nerve (CN II) damaged unilaterally
    W-swinging flashlight test
    S-consensual reflex intact

    Subarachnoid hemorrhage (SAH): Rupture of an aneurysm releases blood directly into the cerebrospinal fluid (CSF) under arterial pressure.

    Clinical manifestations:

    CSF ~ FDR

    F-D-R's Last Words: O! CAN'T W-H-I-P 'E-M

    F-Focal signs: limb weakness, dysphagia, CN III palsy
    D-Depression of consciousness with headache
    R-Retinal (subhyaloid) hemorrhage

    Last-Lucidity with headache is the usual pattern of onset.

    Words-Warning leak sign of impending rupture (controversial sign).

    O-(looks like eyes) CN III palsy

    Can't extend knees (Kernig's sign)

    W-circle of Willis
    H-Headache: sudden onset of severe headache ("the worst headache of my life")
    I-Increased ICP

    E-Epileptic seizures

    Subarachnoid hemorrhage : Ruptured berry aneurysm

    A-Adult polycystic kidney disease, Anterior communicating artery
    B-Berry aneurysm
    C-Circle of Willis
    D-Danlos-Ehlers and Marfan's syndromes

    Causes of Syncope: F-A-D-E-O-U-T

    F-Faint simple vasovagal fainting
    A-Arrhythmia causing cardiac syncope
    D-Drugs: alcohol, illicit drugs, nitrates, antihypertensives, sympathetic blockers
    E-Eyeball pressure
    O-Orthostatic hypotension: dysautonomias
    U-Undiagnosed seizures
    T-Takayasu's arteritis: reduced cerebral blood flow due to involvement of the carotid and vertebral arteries.

    Causes of Vertigo: revolving, P-I-V-O-T-I-N-G M-E-N

    P-Petrositis, benign Positional vertigo
    I-Ischemic attacks: transient vertebrobasilar ischemic attacks
    V-Vestibular neuronitis
    O-Other Otogenic causes: Otosclerosis, herpes zoster Oticus, Obstructed external auditory canal
    T-Tumors of the middle ear, labyrinth, pons, cerebellopontine angle, CN VIII
    I-Internal auditory artery occlusion
    N-Neuronitis: acute vestibular neuronitis
    G-Giant cell arteritis - internal auditory artery occlusion

    M-Meniere's disease
    E-Ear: otitis media, labyrinthitis, barotrauma
    N-Neuromas: acoustic neuromas

    Headache: S-T-O-I-C M-P

    S-Sentinel headache that precedes a major subarachnoid hemorrhage (SAH)
    T-Temporomandibular joint dysfunction, Tension-type headache, Tumors
    O-Other: pressure, traction, or displacement of extracerebral structures.
    I-Indomethacin-responsive headache
    C-Cluster headache

    M-Meningitis, Migraine headache
    P-Posttraumatic headache, Paranasal sinuses


    Intracerebral hemorrhage: T-I-P Ur H-A-T to M-Ds

    P-Penia ? thrombocytopenia


    A-Amyloid angiopathy
    T-Tumors associated with bleeding

    M-Malformations: AV
    D-blood Dyscrasias

    Subdural hemorrhage: subconsciously dying¡±

    -Slowly dying
    -Brain injury


    Cerebrovascular I-N-F-A-R-C-T-S

    I-Infections: septic heart valve vegetations
    N-Neoplasms; Nonbacterial thrombotic endocarditis
    F-Fracture of the long bone
    A-Atherosclerosis, Atrial fibrillation-related emboli
    R-Reperfusion -> infarct -> hemorrhage
    C-Carotid atheromas or mural thrombi
    T-Thrombotic occlusions
    S-Sylvan fissure: MCA is a particularly common site.

    Lacunar infarct: "Lacunar" from the Latin for G-A-P or- D-I-S-P-A-R-I-T-Y

    G-deep Gray matter: basal ganglia

    D-Dysarthria and a contralateral clumsy hand or arm due to infarction in the base of the pons or in the genu
    of the internal capsule. (20%)
    I-Internal Capsule: Lacunae in the posterior limb of the Internal capsule may cause pure motor hemiplegia
    involving the face, arm, leg, foot. (60%)
    S-Subcortical, capsular, or thalamic lacunae
    P-Pontine lesions
    A-Ataxic hemiparesis due to an infarct in the base of the pons
    R-Rare: Lacunae in the anterior limb of the Internal capsule may cause severe dysarthria with facial weakness.
    I-Ipsilateral ataxia (arm/leg) with leg weakness: Pontine lesion (rare)
    T-Thalamus: Lacunae in the Thalamus may cause pure sensory stroke (10%)
    y-V-Ventrolateral Thalamic lacunae

    Anterior cerebral artery (A*C*A) occlusion:

    *C*-Contralateral Crural (leg) monoplegia
    *C*-Crest of Cerebral hemispheres and medial hemispheric walls represent the leg area of the motor strip

    Middle cerebral artery (MCA) occlusion: "Difficulty with A-B-Cs in M-C-A"

    B-Blindness in corresponding half of the visual field (contralateral homonymous hemianopsia)
    C-Contralateral Clumsiness of arm, face. -- Leg is somewhat spared.

    M-Memorization difficulties
    C-Calculation difficulties
    A-Aphasia with language-dominant hemispheral involvement.

    Posterior cerebral artery (PCA) occlusion: P-O-S-T

    P-Proximal fling movements
    O-Occipital lobe infarction results in contralateral homonymous hemianopsia which may be complete
    S-Speech and Spelling maintained, but unable to read fluently
    T-Thalamic syndrome


    A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D



    Types of Stroke

    Stroke "H-I-T" you!

    T-TIA (Transient Ischemia Attack)

    T.I.A (Transient Ischemic attack)

    Patients often describe it as a shade being pulled over their eyes: S-H-A-D-E-D

    S-Sensory loss; TIA may herald a stroke
    H-Hypertension, Hyperlipidemia
    A-Amaurosis fugax (transient monocular blindness)
    D-DDx: seizures, neoplasms, migraine, vertigo
    E-Extrinsic factor is monitored for warfarin administration; E-Endarterectomy

    Root values of reflexes are 1,2,3,4,5,6,7,8 - S1-2 ankle, L3-4 knee, C5-6 biceps/supinator, C7-8 triceps.

    Argyle Robertson Pupil
    • Accomodation Reflex Present - Pupillary Reflex Absent.

    Neurosyphilis [By jsara]

    -Symptomatic Neurosyphilis: The small, irregular Argyll Robertson pupil reacts to accommodation but
    not to light.
    -Tabes dorsalis:
    Argyl-Robertson Pupil (ARP) in syphlis - Accomodation Reflex Present (ARP)
    but the light reflex is absent, so ARP=ARP.
    -General paresis: P-A-R-E-S-I-S*
    R-Reflexes are hyperactive
    E-Eye: Argyll Robertson pupils
    S-Sensorium: illusions, delusions, hallucinations
    I-Intellect: decrease in recent memory, orientation, calculations

    *From Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.

    Pattern of Weakness in UMN lesions
    • FLUE weakness FUELs Contractures
    • F=Flexion,L=Lower Limb,U=Upper Limb E= Extensors

    Normal Pressure Hydrocephalus
    • Demented (Memory Loss)
    • Dribbles (Urinary Incontinence)
    • Disbalanced (Gait disorder)

    TRAP to identify parkinson's disease
    • Tremor at rest (pill-rolling tremor)
    • Rigidity
    • Akinesia
    • Posture typical of a Parkinson's patient

    Progressive Cerebellar Ataxias: Bassen-Kornzweig Acanthocytosis (Abetalipoproteinemia)

    Abetalipoproteinemia is a rare autosomal recessive disorder that occurs primarily in Ashkenazi
    Jews during their childhood years (6-12 years of age).

    -The key is Bette [aBeta] Midler, who is Jewish [Ashkenazi Jews] by birth, but hardly shy or


    Lack of intestinal apolipoprotein B causes mild malabsorption (notably of fat-soluble
    vitamins A, D, E, K), steatorrhea, and low serum chylomicrons, VLDL, IDL, and LDL.

    - Did you know that Bette is computer-savvy? Know that she created her own web page
    on a PC, and Not on an Apple [No Apolipoprotein-B] computer.

    Progressive neuromuscular disease of the peripheral nervous system (PNS) and of the
    cerebellum (ataxia of gait, trunk, and limbs).

    - Bette wanted to be featured on serious PBS [PNS] television, but instead her trash
    with flash persona was interviewed for E! Celebrity [Cerebellum] Profile.

    - Bette paid heavy Taxes [aTaxia] after starring in "That Old Feeling" [sensory ataxia] with
    Dennis Farina.

    - The concert tour: As the tail-wagging mermaid, Bette motored around the stage in a
    Wheelchair [muscle weakness].

    Retinitis pigmentosa
    -Then she donned her mermaid Goggles [retinitis pigmentosa] and grinned.


    Ataxia plus acanthocytes in peripheral blood smear. The low cholesterol gives rise to
    deformed or spiky red blood cells called acanthocytes.
    Low apolipoprotein B, low vitamin E
    Low plasma triglyceride (TG) and cholesterol levels

    - The Jewish Cantor [aCanthocytosis] disapproved of the bawdy stiletto Spike [Spiky
    RBC] heels she wore to holy day services.

    Small bowel biopsy: Foamy epithelial cells and lacy villus tips.
    - The mermaid character was set in a Foamy [epithelial cells] sea backdrop.
    - Under her Lacy [Lacy villus tips] mermaid costume, Bette had to wear a tightly laced
    corset. She was still No Twiggy [low TGs].


    Low fat diet, fat-soluble vitamins such as vitamins A and E.
    - Bette tried to lose weight on a Low Fat Diet in preparation for her A&E [vitamins A and
    E] interview.

    Radiopaque Ingestants
    C - Cocaine condoms/ chloral hydrate/ calcium
    H - Heavy metals
    I - Iron/ iodides
    P - Psychotropics (TCA, phenothiazines)
    E - Enteric coated/BA
    S - Solvents (CCl4)

    Drugs that can go into an ET tube

    L - lidocaine
    A - atropine
    N - naloxone
    E - epi
    Some like NAVEL, which includes Valium. Others have commented that valium should not go in an ET tube.

    History taking in EMS

    S - signs/symptoms
    A - allergies
    M - medications
    P - past medical history
    L - last oral intake
    E - events leading to injury or illness

    Pain scale:


    O - onset
    P - provocation
    Q - quality
    R - radiation
    S - severity
    T - time

    Pain Scale (Revisited)
    P - palliates/provokes
    Q - quality
    R - region/radiation
    S - severity (on a 1-10 scale)
    T - timing (onset, frequency, duration)
    A - associated symptoms
    P - prior
    P - persists
    P - progression (stable, better, worse)
    Submitted by Omar A. Blanco

    More on Pain Evaluation
    LOCI" (Latin for places) and the "Daughters of the American Revolution"
    L - Location
    O- Onset
    C- Character
    I- Intensity
    D- Duration
    A- Aggravation
    A- Alleviation
    A - Association
    R - Radiation

    One More Pain Mnemonic
    P - period of pain
    A - area of pain
    I - intensity of pain
    N - nullify ( what makes pain go away, if any)
    Submitted by Greg Van Hook

    "Big Mess"
    B - Barbituates
    I - Iron
    G - Glutethemide
    M - Meprobamate
    E - Extended release theophylline
    SS - Salicylates

    X linked
    • Bleeder, Blind, Becker and Duch, B cell
    • others : G6PD,NDI,SCID,CGD
  2. Guest

    Guest Guest

    wat a gr8 help
    thx alot
  3. Guest

    Guest Guest

    u r welcome

    u r welcome brother
  4. Guest

    Guest Guest

    great information,

    thanks :)
  5. Guest

    Guest Guest

    thanks brother its very useful for me. :)
  6. Guest

    Guest Guest

    thanks, its useful.... :)
  7. Guest

    Guest Guest


    dr. ali u ve done mind blowing job, very helping.
  8. Guest

    Guest Guest

    nice one..thanks.. :D
  9. Guest

    Guest Guest

    HEHE,,, U R A GENIUS...!!! THUMBS UP!!!
  10. Guest

    Guest Guest

    excellent, many thanks
  11. adelali34

    adelali34 Guest


    thanks man
    for ett drugs NAVEL V for Vasopressin
  12. Thanx

    Thanx alot
  13. Guest

    Guest Guest

    great! u r a genius
  14. Guest

    Guest Guest

    This is dr. Rifat graduate 2005,.my problem is that i m in riyadh and though i hav cleared fcps1 ,saudi r not offering residencies to foreigners....
    plz somene kindly clear situation 4 me.
    ..can any anyone plz tell me tht the 2 yr experince which is required 4 elgibilty is it any experice as a medical officer or it must b a residency?
    also when i will b a medical officer i dont think i wil hav a supervisor what shall i do in tht case? or any consultant will willingly write refrence for me?
    if they accept experince from any big hospital who r not authorized for post graduate training ...or should i specifically try in those who give post grduate training like king fahd or king faisal etc...but i dont think these hospitals will offer us job ..

    plz plz plz ans my query ...A lot of thanks in advace
  15. Guest

    Guest Guest

    Lichen planus is of unknown aetiology. Its association with autoimmune diseases like vitiligo, alopecia areata and ulcerative colitis suggests that it too can be mediated immunologically. Typical lesions are violaceous or lilac-coloured intensely itchy flat-topped papules arising on the extremities. Genital skin is similarly affected in the absence of oral, nail or other skin findings. In 50% of patients there are oral lesions e.g. white asymptomatic lacy lines, dots or plaques. In 10% of patients there are nail changes e.g. longitudinal ridging and destruction of the nail bed. Potent topical steroids are the treatment of choice.
    Dermatomyositis is an autoimmune skin condition characterised by insidious, symmetrical, proximal muscle weakness resulting from muscle inflammation. Autoantibodies to striatal muscle are found. The skin signs are characteristic:

    • heliotrope rash: lilac discolouration around eyes
    • malar erythema and facial oedema
    • Gottren’s papules (seen in picture): lilac atrophic papules over knuckles
    • erythema and telangiectasia of nail folds.

    The skin signs can appear much earlier than the muscle symptoms. Malignancy is associated with dermatomyositis in up to 30% of patients above the age of 40 years. The neoplasias most commonly seen are breast, lung, ovary and stomach. In this gentleman it probably coincides with a stomach malignancy. Treatment is with high-dose steroids and immunosuppressants. Management of the driving malignancy often leads to resolution of the cutaneous symptoms.
    Drug hypersensitivity syndrome is a serious hypersensitivity reaction pattern that tends to occur 3–6 weeks after commencing certain drugs, particularly anticonvulsants and antimicrobials with fever, facial oedema, generalised papulopustular or exanthematous rash, lymphadenopathy, or hepatitis. This is sometimes associated with nephritis, pneumonitis, myocarditis and hypothyroidism with eosinophilia and mononucleosis.

    Toxic epidermal necrolysis (TEN) secondary to the carbamazepine. Toxic epidermal necrolysis is a potentially life-threatening skin disorder that most commonly is drug induced. However, other etiologies, including infection, malignancy, and vaccinations, may exist. Toxic epidermal necrolysis is idiosyncratic, and its occurrence is not predicted easily. Some authors believe Stevens-Johnson syndrome (SJS) is a manifestation of the same process, with the latter representing more extensive necrotic epidermal detachment. The risk of death in patients with toxic epidermal necrolysis can be accurately predicted by the toxic epidermal necrolysis-specific severity-of-illness score (SCORTEN). A score of 0-1 indicates a mortality risk of 3.2%; score of 2, 12.1%; score of 3, 35.3%; score of 4, 58.3%; and a score of 5 or more, 90%. Each of the following independent prognostic factors is given a score of one:Age of greater than 40 years; Heart rate of greater than 120 beats per minute; Cancer/hematologic malignancy; Involved body surface area of greater than 10%; Serum urea level of more than 10 mmol/L; Serum bicarbonate level of more than 20 mmol/L; Serum glucose level of more than 14 mmol/L. The condition requires intensive therapy with nursing on air-fluidised mattresses, as the skin is so fragile. Any potentially responsible drug should be withdrawn as quickly as possible: one observational study showed a reduction in mortality from 26% to 5% when the implicated drugs with short elimination half-lives were withdrawn no later than the day the blisters or erosins first developed. Routine use of prophylactic broad-spectrum antibiotics and steroid therapy remains controversial, as does the use of IV immunogloblins. Plasmapheresis may have a role in the management of some cases.
    Behçet’s disease is a chronic multisystem disease, most prevalent in the Mediterranean, Middle East and Japan. It is largely a diagnosis of exclusion and can often be confused with Crohn’s disease and therefore the latter must be excluded. It is a systemic vasculitic disorder involving arteries and veins with a tendency to thrombosis. In over 90% of cases there are painful oral aphthous ulcers, in over 70% genital aphthous ulcers and in over 50% ocular inflammation occurs. Other features include arthritis, central nervous system involvement and skin lesions e.g. erythema nodosum, folliculitis and acneiform lesions on the face. It commonly takes on a relapsing and remitting course. Treatment is largely symptomatic, and in the case of eye disease it is aimed at reducing the progression of disease.
    Impetigo is a common superficial infection of the epidermis occurring mainly in children. It is usually due to Staphylococcus aureus, a group A beta-haemolytic streptococcus or a mixture of both. It is very contagious. It typically starts as vesicles which then break down to form honey-coloured crusts.
    Herpes simplex infection caused by herpes simplex virus type I is often recurrent and always recurs at the site at which the primary infection was e.g. the mouth. Most patients experience a prodromal sensation of itching, burning or tingling. A few hours later small grouped vesicles appear, burst, crust and then heal in 7–10 days. These episodes can be precipitated by fever, hence the name ‘cold sore’. Herpes simplex can be differentiated from impetigo by the history of recurrent episodes, prodromal pain and initial vesicles containing clear fluid. In adults certainly it is more likely than impetigo. If in doubt viral polymearse chain reaction (PCR) will confirm the diagnosis

    Rhinophyma – localised swelling of soft tissue with variable combinations of sebaceous hyperplasia, fibrosis and lymphoedema.

    Rosacea is a rash which although more common in females occurs in males and is associated with rhinophyma. It is an erythema of the face with telangiectasia. It is similar to acne in that there are papules and pustules but no comedones. Complications such as blepharitis, chronic lymphoedema of the face and rhinophyma occur more commonly in men.

    Retention hyperkeratosis. The treatment for varicose eczema in the past with bandages that were changed infrequently interferes with the normal process of desquamation and results in this condition – a build up of keratin. It is a benign but malodorous condition that can be treated very well with gentle debridement after soaking in arachis oil, revealing normal skin underneath. Recurrence can be prevented by skin care with emollients.
    Herpes zoster occurs in people who have previously had chickenpox. The virus Herpes varicella-zoster lies dormant in the dorsal root ganglion following chicken pox, and later travels down the cutaneous nerves to infect the epidermal cells. The prodromal period is followed by a rash consisting of a group of vesicles on an erythematous background, followed by weeping and crusting; healing takes 3–4 weeks. The rash is nearly always unilateral and confined to one or two dermatomes. Oral antiviral agents such as aciclovir at a high dose are only beneficial if given in the first 48 h of the development of blisters. Regular analgesics are important, but in the elderly particularly if given as soon as the rash appears, prophylactic amitriptyline at night starting at 25 mg and increasing to 75 mg can help prevent post-herpetic neuralgia. Topical aciclovir is of no benefit at all.

    BCCs or rodent ulcers most commonly occur in middle-aged or elderly fair-skinned individuals who have experienced extensive sun exposure regardless of the form. Most occur on the face, but they do sometimes occur on the limbs and trunk. It usually starts as a small translucent papule with obvious telangiectasia over the surface. It gradually increases in size when the centre may ulcerate and crust. Treatment is complete excision with a margin of normal skin.

    Dermatitis herpetiformis is a disease of young adults and presents with severe itching especially at night. Lesions in dermatitis herpetiformis have a characteristic distribution very similar to that of psoriasis, involving the extensor aspects of limbs, the buttocks and the nasal cleft. Often the blisters are not obvious and the disease may present as excoriated papules. It can easily be confused with eczema on examination. It is important to diagnose as it is associated with a gluten-enteropathy. The diagnosis can be confirmed by finding anti-gliadin antibodies in the blood and characteristic immunoglobulin A (IgA) deposits on the upper surface of the dermis on immunofluorescence of normal skin. Initial treatment is with dapsone which will stop the itching within a few hours. A gluten-free diet will eradicate the IgA from the dermal papillae in 9–12 months and the itching will stop

    Lupus vulgaris as a result of mycobacterium tuberculosis infection. It is a chronic tuberculous infection of the skin. It is exceedingly rare these days. Treatment is the same as that for pulmonary tuberculosis.

    Impetigo which is a very superficial infection of the epidermis due to Staphylococcus aureus, a group A beta-haemolytic streptococcus or a mixture of both. Children are mainly affected since the organisms gain entrance through broken skin (cuts and grazes). It is very contagious. Typically it starts as vesicles, which rapidly break down to form honey-coloured crusts; less commonly there may be just a glazed erythema. Because the infection is very superficial, topical antibiotics are more effective than systemic. Once thick crust is removed, topical antibiotics such as 2% mupirocin (Bactroban), 2% fusidic acid (Fucidin) or 0.3% neomycin ointment should be used. It should also be applied to the anterior nares at the same time. Oral penicillin V is useful in parts of the world where impetigo is due to a group A beta-streptococcus, to prevent acute glomerulonephritis occurring.

    A malignant melanoma is a malignant tumour of the melanocytes. Two-thirds arise from normal skin and one-third arise from a pre-existing mole. Superficial spreading malignant melanomas occur as malignant melanocytes migrate laterally along the dermo-epidermal junction, and have a good prognosis. It is important to diagnose melanomas while they are thin so that removal results in cure

    Hereditary haemorrhagic telangiectasia which is an autosomal dominantly inherited condition. Small red macules and papules occur on the lips, tongue and fingers, associated with nose bleeds and gastrointestinal bleeding. Anaemia due to bleeding is treated with oral iron. The skin lesions do not need any treatment although pulse dye laser is very effective at removing them if unsightly.

    Peutz–Jegher’s syndrome is another rare genetically determined condition which is characterised by brown macules on the lips, the skin around the mouth and the fingers and toes, occurring early in childhood. It is associated with small bowel polyps which can cause intussusception.

    Tinea corporis. This is due to dermatophyte fungi of the Microsporum, Trichophyton and Epidermophyton species. It presents with an asymmetrical erythema and itching with a well-defined edge. It is very important to obtain mycological confirmation of the diagnosis from skin scrapings before starting treatment. Since the infection of dermatophytes is in the keratin layer on the surface of the skin, topical treatment works better than systemic therapy. Fungicidal drugs such as terbinafine or imidazoles (e.g. ketoconazole, clotrimazole) are effective.

    Scabies is an infestation with the human scabies mite Sarcoptes scabei. It is transmitted by prolonged skin-to-skin contact with someone who has it. A fertilised female has to be transferred for the infestation to take place. She will then find a place to lay her eggs (a burrow); 4–6 weeks later a secondary hypersensitivity rash occurs. This is characterised by intense itching particularly at night. The diagnosis is confirmed by finding one or more ‘burrows’ in the finger web spaces. These are linear S-shaped papules 3–5 mm in length along the sides of the fingers or the front of the wrists. Treatment is with 0.5% malathion lotion (Derbac-M). It is necessary to treat all those in close contact even if asymptomatic, which means the entire residential home would need to be treated in the same way.

    Lesions in lichen planus in Caucasians are small, mauve flat-topped, shiny papules which sometimes have white streaky areas on the surface (Wickham’s striae). They characteristically occur on the flexor aspect of the wrist but are often widespread on the trunk and limbs and may occur at sites of trauma. As the rash gets better the papules will change colour from purple to brown. The rash tends to last 9–12 months before disappearing. In type V skin however, the lesions look different and they are often hyperpigmented. The residual post-inflammatory hypopigmentation occurs as a result of scratching. It is often a difficult diagnosis to make in these patients.

    Pityriasis versicolor – a scaly rash of varying colours. In different skin types it may be white, orange–brown or dark brown. The lesions are small, less than 1 cm in diameter, usually round and always scaly when scratched. It is a disease of young adults and occurs predominantly on the upper trunk. It is due to an infection with a yeast, Pityrosporum orbiculare, which we all have on our skin as a harmless commensal. Under certain conditions, the yeast produces hyphae and becomes pathogenic when it is known as Malassezia globosa. The depigmentation in darker skin types is caused by suppression of melanin production by the pityrosporum yeast.

    Recurrent cellulitis secondary to herpetic whitlow, a self-limiting disease with a reported incidence of 3 cases per 100 000 per year! Young adults are typically affected by HSV-2 (herpes simplex virus type 2) where a prodromal phase of up to 72 h is followed by a recurrence of 7–10 days’ duration. Lymphangitis and lymphadenitis secondary to HSV infection is a recognised complication. Lymphoedema of the hand and forearm may rarely develop. Acute infection should be treated with high dose oral aciclovir followed by lower doses (400 mg bd) as prophylaxis. Although this is not common it is very important to remember in cases of unexplained recurrent cellulitis.

    OHL- oral mucosal disease first described in 1984; it is associated with Epstein–Barr virus (EBV) and occurs almost exclusively in patients who are immunocompromised, particularly those infected with HIV. As well as being a sign of AIDS, it has also been described in association with inflammatory bowel disease and Behcet’s. It is non-painful and the appearance of the white plaque may change slightly from day to day. Smoking more than a pack of cigarettes a day is correlated positively with development of OHL in men who are HIV positive. The risk of developing OHL doubles with each 300-unit decrease in CD4 count. Diagnosis is clinical, though biopsy may be helpful in some cases to exclude dysplasia or malignancy. Treatment is of the underlying disorder, most often with anti-retroviral therapy.

    Seborrhoeic keratoses are very common harmless skin growths that first appear during adult life – they are the commonest benign tumour in older individuals. They may also be called basal cell papillomas, senile warts or brown warts. They can itch, grow, and become cosmetically unattractive. Scratching seborrhoeic keratoses or trying to pick them off the skin can result in a secondary infection. People sometimes have many seborrhoeic keratoses, and they may obscure the detection of a dysplastic nevus or malignant melanoma. Squamous cell carcinoma or basal cell carcinoma can rarely develop in association with a seborrhoeic keratosis.

    DLE- chronic, scarring, photosensitive dermatosis. A small number of patients with DLE may later develop systemic lupus erythematosus (SLE) and DLE can occur as a feature of SLE. DLE usually occurs as a skin manifestation alone without significant systemic features; however some cases will have positive autoantibodies (Rh factor) +/– low complement levels. Arthralgia may occur, and pruritis at the site of the lesions, but patients are often asymptomatic. DLE may be localised (head and neck) or widespread as in this case. Treatment is with sun protection, topical corticosteroids, oral antimalarial agents, and in severe cases systemic immunosuppressive therapy.
    Alopecia areata (AA) is a condition characterised by recurrent non-scarring patches of hair loss that can affect any hair-bearing area of skin. In the areas affected, the skin is normal in appearance but there may be short, broken hairs that taper at the proximal end (exclamation point hairs) — this is a pathognomonic sign but is not always present. Patients may also complain of pruritus or a burning sensation in the affected skin areas. A positive pull test at the periphery of an affected area indicates that the disease is active and that further hair loss may occur. AA can occur at any age and affects both sexes equally. The natural history of the condition is unpredictable with no correlation existing between the number of patches at onset and the subsequent severity of the disease. Precipitating factors, such as a major life event, a febrile illness, drugs and pregnancy, can be found in some patients with AA but most patients fail to report a triggering factor preceding their episode of hair loss.

    Tinea cruris, also known as jock itch or ringworm of the groin, is a dermatophytoses that is more commonly seen in men. It is transmitted via both direct contact between infected individuals and indirect contact with contaminated objects such as towels, bed linens and clothing. The affected area is sharply demarcated and has a scaly raised red border that spreads down the inner thighs from the groin in a symmetrical fashion, but asymmetrical involvement may occur. The scrotum is usually spared in distinct contrast with infections of this area by Candida. In acute infections, the rash may be moist and exudative and patients may complain of intense pruritus. Microscopic examination of a potassium hydroxide (KOH) treated skin scraping is diagnostic and reveals the typical long branch-like structure of the fungus.

    Oculocutaneous albinism type 1 (OCA 1) presents with the complete absence of melanin in the hair, the skin and the eyes. This subtype is called OCA 1A. Other problems with the eyes in these patients include photophobia, moderate to severe reduction in visual acuity and nystagmus. However, a subgroup of OCA 1 can present with moderate pigmentation in these same tissues (OCA 1B) and therefore their associated eye problems are not as apparent.
    Three categories used to describe human papilloma virus infections based on their clinical manifestations: anogenital and/or mucosal, nongenital cutaneous and epidermodysplasia verruciformis. The cutaneous variety usually produces benign, self-limiting warts which are usually found on the hands and fingers. The term ‘kissing warts’ has been applied to this kind of infection due to the autoinoculation that may occur from a wart on one finger causing the occurrence of warts on an adjacent finger. The virus can be spread by direct or indirect contact and can resist desiccation, freezing and prolonged storage outside of host cells. The diagnosis is made primarily on the clinical findings.
    Herpes simplex virus (HSV) infection can cause a variety of clinical symptoms. HSV type 1 is normally associated with orofacial infections. On the eyelids, it typically presents as a rash consisting of between three and five vesicles on the eyelids that may have been preceded by a prodrome of pain, tingling, burning or itching, which usually lasts up to 6 hours. The eyelid may be oedematous, erythematous and the patient may complain of localised pain and tenderness. These vesicles become pustular or ulcerative with formation of crusts within 72–96 hours and heal over 8–10 days. It is important to ask if the patient has had a recent cold sore infection of the mouth or has been in contact with anyone who has had a cold sore infection, since direct spread from the mouth to the eye can occur via contact with infected saliva. It is imperative that the eye is also examined, both externally (the cornea looking for the classic dendritic ulcer on the surface) and internally (to exclude acute retinal necrosis, a very rare complication of HSV infection that may result in blindness).
  16. Guest

    Guest Guest

    Impetigo is an acute and highly contagious superficial infection of the skin that commonly occurs in children, and consequently outbreaks in nurseries and schools are not rare. There are two forms of the condition, bullous and non-bullous, with the former being caused almost exclusively by Staphylococcus aureus whereas the latter can be caused by S. aureus, group A streptococcus (Streptococcus pyogenes), or a combination of both. The non-bullous form tends to affect children whereas the bullous form can affect all ages. Culture of the skin lesion is required to confirm the diagnosis and determine the causative organism. Treatment can consist of topical therapy (topical mupirocin) alone or in combination with systemic therapy (penicillin or erythromycin for S. pyogenes, and clindamycin or cephalexin for S. aureus).
    Oral leukoplakia is a condition characterised by a white patch that cannot be rubbed off — it is a diagnosis of exclusion. It is a potentially malignant condition and is more common in men. The patches are white and well defined. Patients tend not to be symptomatic. Causes for this condition include smoking, alcohol consumption, ill-fitting dentures and malocclusion of teeth.
    Pityriasis rosea (PR) is an acute exanthem that initially presents with a primary plaque (herald patch) followed, 1–2 weeks later, by a generalised rash which can last up to 6 weeks. Prodromal symptoms may precede the herald patch and the symptom of pruritus may be intense. The herald patch measures 1–2 cm in diameter and is usually located on the trunk. The secondary rash is symmetric and again localised to the trunk and the adjacent areas of the neck and limbs. The rash is typically described as being in a Christmas tree pattern.
    NF1- Criteria for diagnosis are:

    • six or more café-au-lait spots
    • two or more neurofibromas
    • axillary freckling
    • two or more Lisch nodules (iris hamartoma)
    • optic glioma
    • a parent or sibling with neurofibromatosis

    associated abnormalities are:
    • skeletal rib notching and other bony defects
    • honeycomb lung
    • intellectual disability
    • kyphoscoliosis
    • hypertension (renal artery stenosis, phaeochromocytoma)
    • Lisch nodules (iris hamartoma).
  17. Guest

    Guest Guest

    Erythema multiforme. He shows the classical target lesions. These have three zones: a central area of dusky erythema, a middle paler zone of oedema and an outer erythematous ring. The lesions preferentially involve the extremities and trunk. 
They usually appear in successive crops and fade in 1 to 2 weeks. There are multiple triggering factors although the cause is not determined in up to 50% of cases. The most common association is with preceding herpes simplex or mycoplasma infection, although drugs such as sulphonamides and penicillins are also frequently implicated.

    This lady has developed erythema nodosum, which is characterised by painful erythematosus nodules, which generally appear on the anterior aspect of the leg. The rash appears most commonly in young women and can either be idiopathic or secondary to various disorders or drugs. The most common cause is infection, typically group A beta haemolytic Streptococcus, therefore an antistreptolysin titre should be requested. Although less common, sarcoid and tuberculosis should not be missed and therefore a chest X-ray is essential. Other common causes include medications such as sulphonamides, pregnancy and inflammatory bowel disease.

    Erythroderma is the term that applies to any inflammatory skin disease that affects more than 90% of the body surface. It is often accompanied with fever, shivering and malaise. Forty per cent of erythroderma is secondary to eczema and 25% secondary to psoriasis. These are the two most common conditions. Other precipitants include lymphoma, drugs and pityriasis rubra pilaris. Erythroderma is often associated with metabolic disturbances, and patients may develop hypothermia or high-output cardiac failure. Treatment in hospital is advisable with careful monitoring of fluid balance and temperature. The condition may continue for months or years and may also relapse.

    Isotretinoin is the most clinically effective treatment for acne, and frequently produces long-term remission. It significantly reduces elevated sebum production, comedogenesis and colonisation with Propionibacterium acnes. Isotretinoin should be prescribed for patients with moderate acne who are failing to respond to conventional therapy. It does however have many side-effects. In particular it is very teratogenic. A negative pregnancy test must be obtained prior to treatment, and counselling must be given regarding contraception. Liver function tests and lipids should be checked in patients as these frequently become elevated with treatment. Patients generally complain of dryness of the mouth and lips, and should be advised to use regular moisturisers.

    Multiple neurofibromas are part of neurofibromatosis type 1 or von Recklinghausen’s disease. It is characterised by the presence of six or more café au lait spots, axillary freckling and Lisch nodules (pigmented iris hamartomas). The inheritance is autosomal dominant and the gene is located on chromosome 17. Neurological manifestations are seen in around 40% of patients, most commonly an optic nerve glioma. Neurofibromatosis type 2 (NF2) is characterised by bilateral acoustic neuromas and other central nervous system tumours. Café au lait spots and cutaneous neurofibromas are much less common in NF2 and are usually fewer in number.

    A heliotrope rash around the eyes and violaceous papules (Gottron’s papules) over the hands is characteristic of dermatomyositis. Part of the disorder includes a polymyositis, which affects the proximal muscles, eg brushing hair, standing up from a chair. There are two peaks of onset, one in childhood and the other between the ages of 40 and 60 years. Dermatomyositis occurs twice as frequently in women as it does in men. There is an association with malignancy, commonly of the lung, breast, female genital tract, stomach and rectum. Dermatomyositis precedes the neoplasm in 40% of cases, both conditions occur together in 26%, and in 30% the neoplasm occurs first. Anti-Jo are the most common circulating antibodies and are seen more commonly in patients with pulmonary fibrosis.

    Porphyria cutanea tarda (PCT) is the most common of the porphyries. It is characterised by fragility and blistering of exposed skin. PCT is generally acquired and is the result of deficiency of uroporphyrinogen decarboxylase. Other features include scarring alopecia following resolution of bullae on the scalp, hypertrichosis and hyperpigmentation. Risk factors for the development of PCT include alcohol and sun, both of which this lady may have been exposed to in Cyprus.

    Humans are unable to synthesise ascorbic acid, and vitamin C deficiency leads to a condition known as scurvy. The initial typical skin changes are of follicular keratosis with coiling of hair. Later, patients develop perifollicular haemorrhages, bleeding gums and purpura over the legs. Patients often have an associated anaemia and their plasma ascorbic acid levels will be low. There is a rapid response to treatment.

    Acanthosis nigrans is a diffuse velvety thickening and hyperpigmentation of the skin. It occurs mainly in the axillae and other body folds. It may be linked with various endocrine disorders associated with insulin resistance such as diabetes, acromegaly and Cushing’s syndrome. It can also occur as a complication of obesity. More rarely it is a paraneoplastic manifestation particularly of the gastrointestinal tract

    Behçet’s syndrome is most common in young Turkish males and presents with recurrent oral and genital ulcers. It is also associated with eye problems eg anterior and posterior uveitis and an asymmetrical migratory non-erosive oligoarthritis. Patients may also present with neurological complications, in particular meningoencephalitis. The above differentials may all present with oral and genital ulcers.
  18. Guest

    Guest Guest

    Scarring alopecia. Rashes that lead to this condition include discoid lupus erythematosus, lichen planus and kerion from fungal infection. All the other disorders lead to non-scarring alopecia. Alopecia areata is an autoimmune condition, which leads to localised hair loss without inflammation. Alopecia totalis describes loss of all scalp hair and eyebrows, while alopecia universalis describes complete loss of body hair. Trichotillomania describes a psychological disorder where patients are compelled to pull out their hair.

    rythema multiforme (EM) is an acute mucocutaneous hypersensitivity reaction of variable severity characterised by a symmetrically distributed skin eruption, with or without mucous membrane lesions. The more common form, EM minor, consists of skin lesions with involvement of no more than one mucosal surface. EM major, or Stevens–Johnson syndrome, is more severe, involving two or more mucous membranes with more variable skin involvement. It may involve internal organs and typically is associated with systemic symptoms. 
EM appears to involve a hypersensitivity reaction that can be triggered by a variety of stimuli, particularly bacterial, viral, or chemical products. Infectious agents are often the cause in children. Drugs are the major culprits in adults or in EM major. The most common bacterial precipitant is Mycoplasma pneumoniae. Approximately 50% of cases however are idiopathic, with no precipitating cause identified.

    Pemphigus refers to a group of autoimmune blistering diseases of the skin and mucous membranes. These include pemphigus vulgaris (PV), pemphigus foliaceus and paraneoplastic pemphigus. 
PV is an autoimmune, intraepithelial, blistering disease affecting the skin and mucous membranes and is mediated by circulating autoantibodies directed against keratinocyte cell surfaces. 
PV presents with oral lesions in the majority of patients, and most patients develop cutaneous lesions. The primary lesion of PV is a flaccid blister. 
The cause of PV remains unknown but there is a recognised association with the human leucocyte antigen DR4 (DRB1*0402) and human leucocyte antigen DRw6 (DQB1*0503) alleles. Patients are often suffering from other autoimmune diseases, particularly myasthenia gravis and thymoma. 

Other differentials for intraepidermal blistering include : 

• friction 
• eczema – multilocular 
• infection 
• toxic epidermal necrolysis. 

Causes of subepidermal blistering include : 

• burns 
• pemphigoid – characterised by tense, haemorrhagic, unilocular bullae which arise on abnormal(erythematous, urticated) skin. Mucosal involvement is uncommon. Nikolsky’s sign is negative 
• dermatitis herpetiformis – very itchy grouped vesicles, most frequent on the extensor surface of the knees, elbows, buttocks and shoulders. 

• erythema multiforme – ‘target’ lesions, precipitated by viral infection or drugs 
• insect bites 
• porphyria cutanea tarda – light sensitivity, fragile, scarred skin and hypertrichosis, usually seen in middle-aged alcoholic men 
• epidermolysis bullosa – many different inherited diseases, of varying severity.

    alopecia areata (AA) which is a condition of unknown aetiology associated with other autoimmune diseases, such as Hashimoto’s thyroiditis (hence the importance of checking the TFTs), vitiligo and myasthenia gravis. There is no curative treatment currently available and, although systemic steroids do induce remission, the AA recurs on discontinuation and the risk of long-term therapy precludes its use. Patients find this condition very distressing, and although it often spontaneously remits, psychological support from family, doctor and support groups is extremely important.

    ERTYTHEMA NODUSUM Peak incidence 20–30 year of age, females: males 3–6:1. There are many causes : infections: bacterial (strep, TB), fungal, viral (infectious mononucleosis), drugs (OCP, penicillin, sulphonamides), malignancies (lymphoma), sarcoidosis, inflammatory bowel disease – Crohn’s and ulcerative colitis

    pyoderma gangrenosum – these are recurrent nodulo-pustular ulcers with a tender red/blue necrotic edge and healing with scarring. It is associated with ulcerative colitis and Crohn’s disease, rheumatoid arthritis, Wegener’s granulomatosis, myeloma, hyperthyroidism and Type 1 diabetes. Treatment is with high dose steroids +/– cyclosporin.

    eiter’s syndrome and the rash is keratoderma blenorrhagica. It occurs secondary to Clamydia trachomatis (which may also cause circinate balanitis as in this case), salmonella, shigella, Campylobacter jejuni and yersinia. Stool should be cultured if diarrhoea is present and a urethral swab/sexual review should be made, as urethritis may be asymptomatic. The arthritis is managed with rest, NSAIDs +/– steroids and does not tend to respond to treatment of the causative organism.

    ichen planus (LP) characteristically affects flexor surfaces, particularly the wrists. There are fine white streaks on the surface of the lesions if viewed through a hand lens (Wickham’s striae). It demonstrates the Koebner phenomenon (as does psoriasis) – a linear pattern along scratch marks or scars. There are often asymptomatic lacy white lesions in the buccal mucosa. Certain drugs may cause an LP-like eruption, particularly thiazides, β-blockers, phenothiazines, antimalarials and methyldopa. LP usually resolves spontaneously in a few months, but steroids may be required if pruritus is severe.

    Zinc deficiency leads to well-demarcated psoriasiform and eczematous-like plaques, initially occurring in perioral and anogenital areas.

    erythema multiforme and Stevens–Johnson syndrome. This is a mucocutaneous drug-induced (or sometimes idiopathic) reaction pattern characterised by skin tenderness, erythema of skin and mucosa, followed by extensive epidermal necrosis and sloughing. Nicolsky’s sign is described. It is potentially life-threatening due to multi-system involvement. Early diagnosis and withdrawal of suspected drug(s) is very important. Most frequently associated drugs include: sulfasalazine, co-trimoxazole, carbamazepine, barbiturates, aminopenicillins.

    ellow nail syndrome, which is usually associated with lymphatic hypoplasia (check for lymphoedema of extremities). The syndrome can be associated with a number of pulmonary conditions including bronchiectasis, pleural effusion COPD or neoplasm. It is also associated with nephrotic syndrome and penicillamine use.

    Erythema gyratum repens (EGR) is believed to be a paraneoplastic process. Characteristic concentric erythematous bands forming a wood-grain appearance help distinguish EGR from other erythemas, such as erythema annulare centrifugum, erythema migrans, and erythema marginatum. 
EGR is associated with malignancy in up to 80% of patients. Lung cancer is the most common association, particularly in a patient who is a smoker. It is also associated with breast, bladder, cervical, stomach, and prostate cancer. 
Most patients with EGR develop the eruption before the symptoms of underlying malignancy. The time interval for this may be up to 6 years. 
EGR is associated with some non-malignant conditions, including pulmonary tuberculosis, systemic lupus erythematosus (SLE), CREST (calcinosis, Raynaud phenomenon, oesophageal motility disorder, sclerodactyly, and telangiectasia) syndrome, psoriasis, and as a drug reaction to azathioprine in a patient with type I autoimmune hepatitis. There are some cases with no associated conditions exist.

    Thyroid storm is a sudden, life-threatening exacerbation of thyrotoxicosis. Some series suggest a mortality rate of between 30 and 75%. Its manifestations are due to the action of excess thyroid hormone. Fever is the most characteristic feature, with the temperature often rising above 41°C. There may be evidence of organ damage. The clinical picture is frequently clouded by a secondary infection such as pneumonia or a viral infection. Death may be caused by cardiac arrhythmia, congestive heart failure, hyperthermia or other unidentified factors.
    The diagnosis of thyroid storm is made entirely on clinical grounds. The results of thyroid function tests will rarely be available soon enough to make the diagnosis.
    Propylthiouracil followed by a stable iodine preparation (eg Lugol’s iodine) is usually given. Propanolol, intravenous fluids, dexamethasone and cooling are also often required. Finally, one must remember to treat the precipitating cause.

    Multiple endocrine neoplasia (MEN) 1 should be suspected here, which may be a combination of a pituitary tumour (often a macroadenoma), hyperparathyroidism and a pancreatic islet tumour.

    Addison’s disease. Over 90% of patients diagnosed complain of weakness, hyperpigmentation, anorexia, nausea, vomiting and hypotension.

    The combination of a high ACTH concentration (> 80 ng/l) and a poorly responsive Synacthen test is diagnostic of Addison’s disease.

    Phaeochromocytoma is a rare catecholamine-producing tumour. The ‘rule of tens’ applies to this tumour: 10% are familial, 10% are bilateral, 10% are outside the adrenal medulla and 10% are malignant. There is an association with multiple endocrine neoplasia type–2 in the familial cases, and also with the von Hippel–Lindau syndrome. The von Hippel–Lindau syndrome predisposes patients to renal-cell carcinoma, phaeochromocytoma and retinal and cerebellar haemangioblastomas. As a result, patients may have a raised haemoglobin due to a secondary increase in erythropoietin production. This patient does have a raised haemoglobin and therefore needs to be screened for the von Hippel–Lindau syndrome.

    Patients present with a variety of symptoms including episodic hypertension, chest tightness, abdominal pain, vomiting, sweating, restlessness, anxiety, pallor and weakness. Symptoms are precipitated by sneezing, stress, surgery and by agents such as cheese, alcohol and tricyclic antidepressants. Glycosuria occurs during attacks in 30% of cases.

    Tests that help in diagnosis include 24-hour catecholamine measurement, metaiodobenzylguanidine (MIBG) and CT/MRI of the adrenal glands.
  19. Guest

    Guest Guest

    Dear Dr Ali

    Many thanks and JazakAllah for this favour to all of us.

    Kind regards
  20. Guest

    Guest Guest

    Dr. mohamed, very helpful mnemonics.
    This would help those people who wants
    to learn more about acute pancreatitis.
    Thanks for posting it.
  21. Guest

    Guest Guest

    Thank you very much for your great efforts,
    Friends please, keep this post for MNEMONICS ONLY
  22. Ampicillin

    Ampicillin Guest

    Dr Rifat

    I have just saw your message.
    Have you already got reply to it, as I can answer the questions you have asked.

    Dr Ahmed
  23. Guest

    Guest Guest

    thanks a lot
  24. Guest

    Guest Guest

  25. Guest

    Guest Guest


    Dr. Mohammed Ali,
    Thank you very much.


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