Medicine

Raynaud’s phenomenon is digital ischaemia induced by cold and emotion. It has three phases 
•     pallor: due to digital artery spasm and/or obstruction
•     cyanosis: due to deoxygenation of static venous blood
(this phase may be absent)
•    redness: due to reactive hyperaemia.

Reference: Acute upper gastrointestinal haemorrhage is the most common gastrointestinal emergency

Explanation: Iodine is required for synthesis of thyroid hormones

Reference: Davidson 23rd; P-626
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

For acute dissection, parenteral beta-adrenergic blockers (IV propranolol, metoprolol, labetalol or esmolol) should be administered to achieve a heart rate of ~60 beats/min. Sodium nitroprusside infusion is used to lower SBP to <120 mmHg. Verapamil, diltiazem or enalaprilat may be used parenterally. Isolated use of direct vasodilators like diazoxide and hydralazine is contraindicated because these agents can increase hydraulic shear and may propagate dissection.

Explanation: 12-lead ECG is the initial investigation for acute onset chest pain.

Explanation: Acromegaly is caused by growth hormone (GH) secretion from a pituitary tumour, usually a macroadenoma, and carries an approximate twofold excess mortality when untreated.

Chest pain on exertion suggests angina pectoris. The reproducibility, predictability and relationship to physical exertion (and occasionally emotion) of the chest pain are the most important features.

Reference: Davidson 23rd; P-775
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Clinical features

The typical presentation is for a reduced eGFR to be found incidentally during routine blood tests, often during screening of high-risk patients, such as those with diabetes or hypertension. Most patients with slowly progressive disease are asymptomatic until GFR falls below 30 mL/ min/1.73 m 2 and some can remain asymptomatic with much lower GFR values than this. An early symptom is nocturia, due to the loss of concentrating ability, but this is non-specific. When GFR falls below 15–20 mL/ min/1.73 m2 , symptoms and signs are common and can affect almost all body systems, but are often non-specific and may not immediately raise suspicion of kidney disease (Fig. 18.22). They typically include tiredness or breathlessness, which may, in part, be related to renal anaemia or fluid overload. With further deterioration in renal function, patients may suffer pruritus, anorexia, weight loss, nausea, vomiting and hiccups. In very advanced renal failure, respiration may be particularly deep (Kussmaul breathing) due to profound metabolic acidosis, and patients may develop muscular twitching, fits, drowsiness and coma.

Reference: Davidson 23rd; P-530

Explanation: persistent daily vomiting suggests gastric outlet obstruction.

Finger clubbing is due to overgrowth of soft tissue in the terminal phalanx, which increases the lateral and longitudinal curvature of the nail (see Fig. 3.8), raising the nail bed off the underlying bone. It is palpable as a boggy fluctuation of the nail when pressure is applied just proximal to the nail 

The most common respiratory causes of clubbing are chronic suppurative lung disease (such as bronchiectasis), lung cancer and pulmonary fibrosis. An additional rare complication of lung cancer is hypertrophic pulmonary osteoarthropathy, in which painful, tender swelling of
the wrists and ankles accompanies pronounced finger clubbing. X-rays of the distal forearm and lower legs show subperiosteal
new bone formation overlying the cortex of the long bones.
Other important signs of respiratory disease in the hands include:
•     cyanosis
•     tar staining of fingers from tobacco use (Fig. 5.8)
•     small-muscle wasting (see Fig. 13.22), which may indicate
T1 root damage by an apical lung tumour
•     rarely, yellow–brown discoloration of nails in yellow nail
syndrome

Reference: Davidson 23rd; P-576
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Explanation: Initial flushing faint macular rash in first 1–2 days. Maculopapular, scarlet morbilliform blanching rash from days 3–5 on trunk, spreading centrifugally and sparing palms and soles; onset often with fever defervescence. May desquamate on resolution or give rise to petechiae on extensor surfaces

Reference: Davidson 23rd, Fig-23.17

Reference: Davidson 23rd; P-800

In tuberculoid leprosy, ulnar and common peroneal nerves are typically affected.

Drugs causes gout are: Thiazide and loop diuretics, Low-dose aspirin, Ciclosporin & Pyrazinamide

Adrenal insufficiency & hypothyroidism may cause hyponatremia. Hypothyroidism decreases cardiac output and GFR and thus increased AVP secretion leading to hyponatremia.

Explanation: Acne usually affects the face and often the trunk. Greasiness of the skin may be obvious (seborrhoea). The hallmark is the comedone

Explanation: The most common cause of acute pancreatitis is Gallstones disease

Explanation: About 65% of the filtered sodium load is reabsorbed in the proximal renal tubule

Reference: Davidson 23rd; P-862
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

In PDA, severe pulmonary vascular disease results in reversal of flow through ductus thereby unoxygenated blood is shunted to descending aorta leading to cyanosis and clubbing of the toes, but not fingers. This is called differential cyanosis.

P. falciparum, P. knowlesi and P. malariae have no persistent exoerythrocytic phase but recrudescence of fever may result from multiplication of parasites in red cells that have not been eliminated by treatment and immune processes

Reference: Davidson 23rd; P-572

Reference: Davidson 23rd; P-432

Stem Breakdown:

Fatigue, pallor, and heavy menstrual periods: These symptoms suggest anaemia, and the history of heavy periods (menorrhagia) suggests blood loss as a likely cause.
Haemoglobin of 8.5 g/dL and MCV of 70 fL: The low haemoglobin indicates anaemia, and the low MCV (microcytosis) is characteristic of iron deficiency anaemia.
Option Analysis:

A) Iron deficiency anaemia: This is the correct diagnosis. Davidson and Harrison explain that iron deficiency anaemia is the most common cause of anaemia worldwide and is often due to chronic blood loss, particularly from menstruation in women. The microcytic, hypochromic anaemia (low MCV) is a hallmark finding.
B) Vitamin B12 deficiency: Vitamin B12 deficiency causes macrocytic anaemia (high MCV), not microcytic anaemia. Symptoms include neurological deficits, such as paraesthesia and balance problems, which are absent in this case.
C) Aplastic anaemia: Aplastic anaemia presents with pancytopenia (low red cells, white cells, and platelets) and a hypocellular bone marrow. It does not cause microcytosis and is not related to blood loss from menstruation.
D) Haemolytic anaemia: Haemolytic anaemia causes normocytic or macrocytic anaemia with increased reticulocytes and evidence of haemolysis (e.g., elevated bilirubin, LDH). There is no evidence of haemolysis in this case, and the low MCV points to iron deficiency.

Reference: Davidson 23rd; P-619

On liver biopsy, the characteristic early features of PSC are periductal ‘onion skin’ fibrosis and inflammation, with portal oedema and bile ductular proliferation resulting in expansion of the portal tracts (Fig. 24.34). Later, fibrosis spreads, progressing inevitably to biliary cirrhosis; obliterative cholangitis leads to the so-called ‘vanishing bile duct syndrome’.

EXplanation: The nephritic syndrome is characterised by the presence of haematuria in association with hypertension, oliguria, fluid retention and reduced/declining renal function

Reference: Davidson 23rd; P-798
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Davidson 23rd; P-637

Reference: Davidson 23rd; P-591

Stem Breakdown:

Confusion, ataxia, and nystagmus: This classic triad of symptoms is highly suggestive of Wernicke's encephalopathy, a neurological disorder associated with thiamine (vitamin B1) deficiency.
Chronic alcohol use: Chronic alcoholism is the most common cause of thiamine deficiency, leading to Wernicke's encephalopathy.
Rapid improvement with thiamine: This confirms that the symptoms were due to thiamine deficiency, which is rapidly reversible with appropriate supplementation.
Option Analysis:

A) Wernicke’s encephalopathy: This is the correct diagnosis. Davidson and Harrison both highlight that Wernicke’s encephalopathy is caused by thiamine deficiency, commonly seen in chronic alcoholics. The classic symptoms include confusion, ataxia, and ophthalmoplegia (nystagmus or other eye movement abnormalities). Rapid improvement with thiamine supports this diagnosis.
B) Korsakoff’s syndrome: Korsakoff's syndrome is a chronic sequela of untreated Wernicke’s encephalopathy, characterised by irreversible memory loss and confabulation. It does not cause rapid neurological improvement with thiamine administration.
C) Alcohol withdrawal: Alcohol withdrawal causes symptoms such as tremors, agitation, and hallucinations, but it does not typically present with the triad of confusion, ataxia, and nystagmus.
D) Hepatic encephalopathy: Hepatic encephalopathy occurs in patients with liver failure and is due to elevated ammonia levels. It presents with altered mental status but not with the other signs of Wernicke's (ataxia, nystagmus).

Reference: In pre-renal AKI, usually develops hypotension not hypertension. Davidson 23rd, Box-15.25

Explanation: Percussion-hyper-resonant is a feature of pneumothorax, Davidson 23rd page-547

Chancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated

Reference: Davidson 23rd, Box-3.4

Pyogenic liver abscesses are most commonly caused by ascending infection from the biliary tract (e.g., cholangitis, gallstones obstructing bile ducts), portal vein pylephlebitis from intra-abdominal infections (e.g., appendicitis, diverticulitis), or hematogenous spread from systemic infections. Amoebic liver abscesses are caused by Entamoeba histolytica but are less common than pyogenic abscesses in many parts of the world.

Explanation: Factor V Leiden mutation is the most common inherited thrombophilia. Davidson explains that this mutation renders Factor V resistant to inactivation by activated protein C, leading to a prothrombotic state. Harrison discusses that individuals with Factor V Leiden have a higher risk of venous thromboembolism, particularly in the presence of additional risk factors like surgery or immobility.

Left iliac fossa mass
• Sigmoid colon cancer
• Constipation
• Diverticular mass

Explanation: smoking is probably the most important modifiable risk factor.

Anti-CCP antibodies are associated with rheumatoid arthritis (highly specific)

Reference: Davidson 23rd: Box-17.13

Reference: Davidson 23rd; P-543
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Primary syphilis, caused by Treponema pallidum, presents with a painless chancre (ulcer) at the site of infection, typically on the genitals, which is highly infectious. Rash is seen in secondary syphilis, and gummas and tabes dorsalis are features of tertiary syphilis

Explanation: Cough is the most common early symptom

Explanation: Acute coronary syndrome almost always occurs in patients who have atherosclerosis, The culprit lesion.

Refractory hypertension refers to the situation where multiple drug treatments do not give adequate control of BP. Although this may be due to genuine resistance to therapy in some cases, a more common cause of treatment failure is non-adherence to drug therapy.

Reference: Davidson 23rd; P-841
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Due to severe neutropenia (a component of pancytopenia), patients with aplastic anemia are highly susceptible to infections, which can be life-threatening. Anemia leads to fatigue and pallor, while thrombocytopenia causes bleeding tendencies (e.g., petechiae, ecchymoses, mucosal bleeding).

Metronidazole is the drug of choice for invasive amoebiasis including liver abscess

Reference: Davidson 23rd; P-581

Explanation: see question no: 7