Safe triangle for chest tube insertion; Anteriorly by pectoralis major, posteriorly by latissmus dorsi,

inferiorly by intercostals muscles, superiorly by axilla. Best at 5th intercostals space slightly anterior to
mid axillary line
Transpyloric plane
Knee bursa
9th costal cartilage correlates to fundus of gallbladder
Deep peroneal nerve compression from overuse of anterior leg muscles or ski boots (tight boots)
Obturator nerve: medial thigh
Biliary system
Ankle veins
Sacs / potential space for fluid leaks
Anatomy of heart / coronary vessels
Inferior alveolar nerve trauma from wisdom tooth removal/mandibular fractures
C1/2 = neck flexion/extension
C3 = lateral neck flexion + diaphragm (Dermatome: clavicle)
C4 = accessory nerve (shoulder shrug) + diaphragm (Dermatome: clavicle)
C5 = arm raise + elbow flexion + diaphragm (Dermatome: deltoid)
C6 = Ext. rotation + supination (arm) ; elbow extension ; wrist pronation (Dermatome: lateral arm,
forearm)
C7 = wrist flexion(Dermatome: middle finger)
C8 = finger extension, thumb abduction, thumb extension (Dermatome: little finger)
T1 = Finger abduction/adduction

OBGYN
- Normalization of menses as early as 4 weeks after delivery; reassure, NOT US
- Cryotherapy is the only Rx now for genital warts (podophylin, 5-FU, InF are now CONTRA)
- Pregnancy causes CTS, NOT median nerve entrapment (they are separate; Median nerve involvement
means +VE Tinel Test and thenar muscle wasting too, not just flexor retinaculum)
- Bladder drill (retraining) for detrusor instability or overflow incontinence
- For stress incontinence, pelvic floor exercises first -> vaginal tape
- IUS = LVNG/Mirena IUD
- IUD (UK) = Copper IUD
- Hb in pregnancy cutoff for iron: < 11 (1st tri), < 10.5 (2nd), < 10 (3rd)
- post-Molar pregnancy Rx : avoid intrauterine systems for contraception
- Endometriosis needs Laparoscopy to Dx -> US
- RPOC = Incomplete miscarriage
- Cervical os open and bleeding = Inevitable miscarriage
- Head retracting with labor contractions = turtle sign ; need episiotomy -> rotational maneuvers
- Prophylactic mastectomy if: strong family hx of breast CA, BRCA1/2 +Ve, prior hx of breast CA in pt,
biopsy confirmed LCIS or atypical hyperplasia or breast
- Mammogram q3yrs in 50-70 normally or annually in 40-69 if BRCA gene +ve
- Depo shot has dosing interval of 13-16 weeks, so not good for reversibility
- Nexplanon is the only contraceptive implant in UK (ETNG) (good if want reversibility, estrogen CONTRA
and not compliant/good with pills)
-Atonic uterus: soft uterus palpable over umbilicus
- Ovulation check for female fertility: Day 21 Progesterone (mid-luteal) (7days before expected period
on Day 28). If low, needs repeat as ovulation does not occur every month
- FSH checked for menopause only AFTER confirmed pattern; 2yrs of amenorrhea after age 45 OR 1yr of
amenorrhea after 50

Breast:
Ductal papilloma: age 20-40, bloody discharge, wart like growth, too small for XR/US, need galactogram
Duct Ectasia: green/brown nipple discharge + dilated large/intermediate breast subareolar ducts from
chronic inflammation and scarring, high assoc with smoking. breast or mammary duct ectasia or plasma
cell mastitis is a condition in which the lactiferous duct becomes blocked or clogged. This is the most
common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of
peri- or post-menopausal age
Duct Fistula/Mammilary fistula: Abnormal communication b/w mammary duct-skin near areola ->
discharge from para-areolar region
Pagets: eczema
Abscess: pus around nipple
Lobular Carcinoma: mammary duct CA

Young woman + not sexually active (do not need contraception)

+ menorrhagia only = tranexamic acid
+ dysmenorrhea = mefenamic acid
+ metrorrhagia (irregular menses) = Combined OCP

Young woman + sexually active (need contraceptive)

+menorrhagia/dysmenorrheal/non-uterus distorting fibroid/OCP contra = Mirena (IUS) (1st) (OCP
preferred usually if age <20)
+HbS = Depo IM

Emergency contraceptive
- 72hrs = LVNG
- 120hrs = IUCD/IUD or ellaone pill (ulipristal)

Cardiology
- Dilated Cardiomyopathy – highest arrhythmic risk with AFib
- PDA murmur best heard during systole at left infraclavicular area
- MS most common valve disorder from rheumatic fever
- SVT Rx (stable) = Valsalva/Carotic massage -> Adenosine
- Adenosine (6mg) -> CONTRA (asthma) -> give Verapamil instead
 -(fail)->12mg Adenosine –(fail) -> another 12mg Adenosine
-(fail)-> Cardioversion
-SVT Rx (unstable) = Cardioversion
- SVT Prevention: BB, Radioablation

BP Classification:
Class 1 up to 15% of blood volume lost: pulse <100; systolic BP normal; pulse pressure normal;
Respiratory rate 14-20; urine output greater than 30 ml/hour.

Class 2 15%-30% blood volume lost: pulse 100-120; systolic blood pressure normal; pulse pressure
decreased; respiratory rate 20-30; urine output 20-30 ml/hour.

Class 3 30%-40% blood volume lost: pulse 120-140; systolic BP decreased; pulse pressure decreased,
respiratory rate 30-40; urine output 5-15 ml/hr

Class 4, blood loss of greater than 40%: pulse rate >140; systolic BP decreased; pulse pressure
decreased’ respiratory rate >35; urine output negligible.

Endo:
- Co-amoxiclav (clavulanic acid) (high dose) = reduced biliary excretion = induced hepatitis/cholestasis
- HyperCa Dx: Corrected Ca (1st)
-> Check Albumin+Urea+↑corrected Ca = dehydration
-> Check AlkPO4 +↑corrected Ca = bony mets, sarcoidosis, thyrotoxicosis
-> Check ↑Calcitonin +↑corrected Ca = B-cell lymphoma

- DKA Rx: NS > IV insulin -> When [glucose] < 12, switch NS to D5W +/- KCl at all stages if <5
- Intrasurgical glucose should be b/e 4-9 on sliding scale insulin
- Thyroid nodule
- HyperK needs insulin+D5W if severe state only (>6.5)
- Checking blood glucose always BEFORE head CT in a fall/exhaustion
- ACE(-), NSAIDs (via renal damage) and K-sparing diuretics in combination can cause hyperkalemia
- CAH has salt wasting but less hypotension; mostly just hyponatremia!
- Addison's parts:
High ACTH: Hyperpigmentaion
Low aldosterone: hyponatremic, hyperkalemic, metabolic acidosis
Low cortisol: arterial hypotension + hypoglycemia

Rheum:
- RA has keratoconjunctivitis sicca > episcleritis (pain + red) > scleritis (less pain + red) > steroid induced
cataracts > uveitis
- AS Dx needs XR first for sacroiliitis > ESR for followup; HLAB27 useless for Dx
- AS has high association with IBD
- Temporal arteritis Rx: ASA 75 can reduce stroke and vision loss in Temporal arteritis/Giant cell
- Always check knee aspirate for WBC, cell, cultural sens. BEFORE crystal

ENT:
- Nasal septal hematoma must be immediately drained or becomes septic abscess
- Lymphangiomas: soft, nontender, translucent, lateral neck masses. grow rapidly in first weeks/mos. of
life, esp before age 2.
- External/superior laryngeal nerve damage: voice pitch changes
- HIV Hairy Leukoplakia : white lesions cannot be scraped off
- AOM: painful VS OM+effusion is painless (perforated TM)
- OM+ effusion = glue ear = congenital conductive loss mostly from parental smoking + flat
tympanogram + dull, grey or yellow TM. Rx best with observation -> grommet insertion if over 3 months
-> hearing aids is persistent B/L and surgery not an option
- Otosclerosis worsened with pregnancy, accelerated in females,
- Bell's palsy + vertigo = acoustic neuroma
- Hearing Tests:
<6mo: Otoacoustic emission, Audiologic Brainstem response
6mo-18mo: Distraction testing
2-4yrs: Conditioned response audiometry, speech discrimination
5 yrs: Pure tone audiogram
- Labyrynthitis: Loss of hearing VS Vestibular neuritis : Vomiting
- Submandibular abscess have fever but not prominent swelling while chewing VS
Sialadenitis have both

GIT:
Mallory Weiss outpatient criteria Admit/early endoscopy if:
- Blatchford score @ assessment Age >60
- Rockallscore after endoscopy Witnessed hematemesis/hematochezia
Urea<6.5 unstable vitals (SBP<110, Pulse > 100)
Hb>130 (male) / > 120 (female) Cirrhosis, unknown varices
SBP>110 Serious comorbidity
Pulse<100
Absent melena, syncope, cardiac failure, cirrhosis

- Celiac's has risk for intestinal lymphoma

- Gilbert's syndrome has high bilirubin (worsened with nicotinic acid test) but no excretion in urine
- Liver transplant criteria in acetaminophen OD: arterial ph<7.3, arterial lactate >3 despite fluids OR
3/3 in 24hrs: Cr>300, PT>100 (INR>6.5), Grade3-4 encephalopathy
- Anti-smooth muscle Ab: autoimmune hepatitis
- Constipation: High fibre diet -> Senna (stimulant) -> Lactulose/macrogol (osmotic) -> + prokinetic
(metoclopramide, domperidone, erythromycin) -> dantron containing laxative
- Acute pancreatitis does NOT have malabsorption or calcification on XR
- Carcinoma of head of pancreas usually blocks the CBD
- Ulcerative Colitis: p-ANCA positive; Dx with rectal biopsy, upper endoscopy, stool culture (r/o
infection), pediatric UC activity index (severity for peds)
Rx: Topical(enema)/oral mesalazine (1st) -> + prednisolone PO if ASA derivatives fail for 4 weeks
- If severe: infliximab (kids), cyclosporine (adult) +/- surgery

Ortho:
-Myofascial pain syndrome: repetitive muscle use/contraction causing regional muscle pain with
restricted painful regions or trigger points, aching, deep in nature, relief on changei n position
- More severe claw deformity of 4th/5th fingers if a more distal lesion of ulnar nerve
- Acetabular fractures/posterior hip dislocation: sciatic nerve injury (loss of sensation in posterior leg
and foot + loss of dorsiflexion from loss of deep peroneal branch)
- DeQuervain's = Washerwoman's sprain = Mummy thumb = Gamers thumb: Inflammed extensor pollicis
brevis, Abductor pollicis longus from repetitive stress. Usually in new mothers from the way babies held.
- Fibular neck fracture: lateral/superficial peroneal n. loss
- Femoral neck fracture: sciatic nerve loss

Optho:
- Acute angle closure glaucoma risks: long sightedness/hypermetropia, mydriasis
- Acetazolamide (IV 500mg -> 250mg PO slow release), BB (unless asthma), Pilocarpine 1-2%,
Steroids (prednisolone 15mg q15mn x 1 hr -> then hourly), antiemetic/analgesia
- Iridotomy (peripheral > surgical) (both eyes within 1 week of attack, when corneal edema is
cleared); the other eye is at risk now too
- Neovascularization means urgent referral for photocoag. VS cotton wool spots/exudate/hemorrhages
by themselves mean pre-proliferative (non-urgent referral)

Hematology
- Indirect Coombs best to check antigen reactions before transfusion
Direct Indirect Coombs
- Tests RBCs (Abs, complement system) - Tests serum
- Autoimmune hemolytic anemia DX - Pregnancy/pre-transfusion checks (Ab screening,
- Positive = ABO, RhD, HDN crossmatching)
- alloimmune hemolytic reactions - Antenatal Ab screening (IgG in placental transfer
- Cold Ag disease/Infectious mono causing HDN)
- penicillins, cephalosporins

- Paraneoplastic syndrome can include autoimmune neuropathy

Renal:
- ARF does not have hemolysis or thrombocytopenia ( = HUS)
- MCD can have severe proteinuria. Rx is steroids or if R/>3 episodes, cyclophosphamide
- Resp. alkalosis/panic attacks can have numbness, tingling (paroxysmal though). Need paper breathing
first, then BZ
-VUR DX
-UA+culture+sensitivity (1st) -> US -> micturating cystourethrogram (gold) -> Technetium scan
(DMSA) for scarring
- Daily Tmp-smx (Grade1-4)-> fail?/Grade 4-5/scarring present -> surgery + reimplant ureters

Pulmonology:
- Thoracoscopy for pleural lesions/drainage biopsy
- Bronchoscopy for central/perihilar mass biopsy

Neurology:
- CN3 damage: fixed dilated pupil
- Frontotemporal dementia has no Rx; Fix sexual disinhibition with cimetidine or spironolactone
- Wernicke's Encephalopathy: confusion + ataxia+ opthalmoplegia (+amnesia + confabulation =
Wernicke's-Korsakoff or Just Korsakoff's)
- Acute vertigo + neuro. Sx = Brain stem or Cerebellar stroke
- Brain stem specific = vertigo, ataxia, diplopia + dysarthria, facial numbness, LoC
- Cb specific = less likely to have limb numbness or diplopia unless inferior Cb also compromised
in a PCA stroke
- Weber syndrome (midbrain): I/L CN3 palsy + C/l hemiparesis or hemiplagia

Carotid artery divides to internal and external carotid of which internal continues as middle cerebral
ultimately. But just before it becomes middle cerebral internal carotid gives rise to ophthalmic branch.
So middle cerebral occlusion may give partial visual loss but not complete mono-ocular blindness. For
complete mono-ocular blindness occlusion should be proximal to ophthalmic artery i.e. either in internal
carotid or more proximally to carotid artery].
- Middle cerebral artery occlusion: paralysis or weakness of contralateral face and arm (faciobracheal).
Sensory loss of the contralatera face and arm.

- Anterior cerebral artery occlusion: paralysis or weakness of the contralateral foot and leg. Sensory loss
at the contralateral foot and leg.

Head CT (w/in 1hr) criteria: Head CT (w/in 8 hrs) if:

- GCS < 13 (initial assessment) / <15 @ 2hrs
- Open/depressed skull fracture
- Basal/Basilar skull fracture signs
- seizure
- prolonged vomiting (>1 episode)
- focal n. deficit
- Age >= 65
- clotting/bleeding disorder/ taking warfarin
- More than 30 min. retrograde amnesia of
events before trauma
- Fall more than 1 metre, 5 stairs, dangerous
trauma mode (MVA without seat belt, etc)

- TIA: - CVA
ASA (300mg Stat x 2 weeks) (unless already on it,
then just continue low dose)
Clopidogrel 75mg for long term (if contra, use
combo of ASA 81 + dipyrdiamole 200)
Statin stat
BP control after 48 hrs
ASA (300mg x 2 wks) AFTER CT confirms it is
ischemic only
BP control after 48 hrs
Thrombolytics within 4.5 hrs for ischemic strokes
Clopidogrel 75mg for long term (if contra, use
combo of ASA 81 + dipyrdiamole 200)
Statin stat
If hemorrhagic, clopidogrel or statin not given

ABCD2 = risk of future stroke in TIA case

CHA2DS2-VASc = risk of stroke in AFib case
Post CVA/TIA BP control
- Target 130/90 after first 48 hrs
- Age >/= 55 OR AA = CCB
- Age <55 = ACE(-)/ARB –(fail)-> + ACE(-), ARB, thiazide or CCB
- Carotid endarterectomy within 2 weeks if TIA (and US confirms ICA stenosis >50% in men, 70% in
women)

Post CVA/TIA cholesterol control

- Target 40% reduction in non-HDL cholesterol
- Lifelong atorvastatin 80mg

Post CVA/TIA anticoagulation

- ASA/clopidogrel protocol if AFib absent
- If + AFib, use for long term, Warfarin, Dagibatran, Rivaroxaban, apixaban, edoxaban @ Inr 2-3
INR 2-3 for prophylaxis/Rx of DVT or if AFib/valvular heart disease (3-4 if metallic valve)

Psych:
- Naloxone has shorter half life than methadone so opioid toxicity must be observed and treated with
repeated doses of naloxone
- Pain ladder: ASA, NSAIDs -> Weak opioid (codeine, tramadol, dihydrocodone) -> strong opioid
(morphine, oxycodone). Always go forward. Fentanyl patch is never for acute pain, only after stable
pain control in pt. unwilling to take/tolerate oral meds or if renal impairment
-SSRI of choice in MI: Sertraline, Citalopram, Mirtazapine

-Delusion of control: false belief that another group/person/force is controlling your thoughts
- Delusion of Persecution: harmful interference (tormented, followed, spied on)
- Delusions of Grandeur: famous, omnipotent, wealthy, special abilities
- Delusions of reference: Insignificant remarks, events or objects in environment have personal meaning
or significance (TV or newspaper talking to them)
- Thought insertion: Thoughts are being placed inside the head from outside
Infectious:
- CD4 cutoff for vaccine is 200 in adults, 750 in kids
- Always use 5% permethrin
- Paul Bunnell test = monospot test | Glandular fever = Mono

Onco
- Testicular CA Dx: US (1st) -> CT (Staging); Spread mostly to para-aortic lymph nodes rather than
inguinal, mets to prostate > lung
- Tumor lysis: Hyper-uricemia, kalemia, phosphatemia -> Hypocalcemia (phosphate-calcium
crystallization -> tetany)

Emerg:
- Only burns > 10% total body surface in kids / >15% in adults need IV fluids
- Fluid replacement in burns is 4 ml/ kg/BSA% in adults VS
100ml/kg (first 10kg) + 50ml/kg (next 10 kg) +20ml/kg (each kg after the first 20kg)
- Refer to special burn unit if:
Age<5/>60, injury to face, perineum, hands, neck, axilla, chemical burn >5% TBSA, steam or electrical
injury

Stats:
- Lack of followup or loss of patients in a study

Surgery
- Postsurgical fluid intake while gastric system is still in a state of ileus -> gastric dilation -> hypovolemic
shock, tender, full abdomen, nausea, abdominal fullness, heartburn
Needs NG decompression due to risk of gastric rupture
- Primary hemorrhage: Usually form unsecured blood vessel -> immediate post-op bleed or continued
surgical bleed
- Reactionary hemorrhage: Within first 24hrs postop; Venous bleed from slipped ligature from improved
circulation (NS/fluids improve circulation)
- Secondary: From 24hrs post-op to upto 10 days after surgery. Usually from infected wound, raw
surface degrading clot, bleed from exposed tissue