Y3M QUIZ 3 - SOME EXPLANATIONS

The quiz 3 is yet to be marked. Marks will be published after the EOPE. Meanwhile read below. Some of the difficult items are explained here.

Skin is not the best place to look for the pallor of anaemia. Palms can be pale due to increased skin thickness. Look at mucous membranes to assess anaemia.

There is collapsing pulse in severe anaemia. Remember, the essential ingredients for collapsing pulse are: large stroke volume and leak back into LV or peripheral run off. In anaemia both these are fulfilled - large stroke volume and fast peripheral run off. Vasodilation leads to fast peripheral run off of the blood.

SOB is invariably present in anaemia as there is decreased O2 carrying capacity of the blood. The CVS and RS have to work harder to meet the demands of the tissues. Dyspnoea is usually experienced on exertion.

Angina will be worsened in anaemia. This is due to decreased O2 supply to the myocardium, also experienced during exertion.

Koilonychia is a late feature of iron deficiency. It first appears on toe nails. The nails will be brittle and easily breakable. Splenomegaly has nothing to do with iron deficiency anaemia. Dysphagia can be experienced - Plummer-Vinson syndrome - due to web formation in the oesophagus.

Thrombocytopaenia causes skin and mucous membrane bleeding, deep tissue bleeding is not a feature of ITP. It is usually seen in coagulopathies like haemophilia.

Spleen moves anteromedially on inspiration. It is superficial and not covered by intestines, so is dull on percussion. It is not ballotable - a differentiating feature from kidney. Friction rub on the spleen can be heard if there is splenic infarct.

In Dengue haemorrhagic syndrome, there is plasma leak into extravascular spaces leading to haemoconcentration and increase in haematocrit - significant when there is 20% rise in Hct. Hct will drop back when the patient is rehydrated. So a rise in Hct of 20% with treatment, is also significant.

Primary tuberculosis in immunocompetent individuals can go unnoticed. Advanced PTBs you usually find are all post-primary. The bacilli can remain dormant after the primary focus is healed. Post primary results from a reactivation of primary or a reinfection. Manifestations depend, again, on the immune status of the host. In HIV/AIDS, there is extensive TB - pulmonary as well as extrapulmonary. Miliary TB has no predilection for any particular lobe of the lung, it is seen as milletseed lesions all over the lungs, and also affecting other organs.

Enteric fever spreads by fecal-oral route. Humans are the only host for enteric fever, Salmonella. Leptospira comes through rodents' urine, usually found in ponds - not flowing water. The microbes can enter the body through mucosae. So, even washing face in pond water can be the source of infection.

Vertical transmission is from mother to foetus, usually occurs during the third trimester or peripartum in HIV. Also Hep B

There is no loss of tendon reflexes in meningitis. Plantar reflex may be bilaterally extensor, if the patient is unconscious. Flexing neck will be painful in mengitis - neck stiffness.

PUO - FUO is fever of three weeks' duration with no known cause after routine investigations and observation in the hospital. Antibiotics and some drugs also can cause fever - drug fever. Sometimes one needs to stop all medications to exclude this condition. Repeated physical examination is very useful as some signs may appear later in the course.

GORD is due to loss of tone of the lower oesophageal sphincter. Any posture or process that increases intraabdominal pressure will aggravate the symptoms - mainly heartburn. Some patients also get chronic cough due to acid getting into the respiratory tract. Treatment is mainly acid neutralizing drugs.

Jaundice affects all tissues. Bilirubin has special affinity for elastin in the sclerae, that is why sclera is the best place to look for jaundice. It is not only sclera that is jaundiced, it is the patient that is jaundiced.

Finger (digittal) clubbing is found in only 30% cases of cirrhosis. Palmar erythma is a possible sign of excess oestrogen leading to erythema. It is found in several other conditions including normal pregnancy, rheumatoid arthritis, thyrotoxicosis, etc.

Hepatitis A virus spreads through fecal contamination of water and food. Vertical transmission is known to occur in Hepatitis B. Loss of appetite is one of the earliest symptoms. Hep A does not lead to chronic infection. It usually subsides leaving life-long immunity in the host. Hep B and Hep C infection lead to chronic liver disease.