Paper II — Infection, rheumatology, bone and prescribing

APPENDIX

Consolidated Night-Before Master Sheets

The three original rapid-recall grids, retained in full. Question numbers in these sheets refer to the original question sets; use the Table of Contents to map them to the numbering used in this volume.

Night-Before Master Sheet — Questions 63 to 75

A. The single highest-yield line for each topic

Q Topic The one sentence that earns the mark

63 Herpes zoster / PHN Antiviral within 72 hours for 7 days; PHN = pain beyond 3 months; prevention is the recombinant zoster vaccine from age 50.

64 CAUTI All chronic catheters are bacteriuric — treat the patient, not the culture; the best prevention is early removal.

65 Asymptomatic bacteriuria Do not screen and do not treat, except before urological procedures with mucosal bleeding.

66 IPC and AMS Hand hygiene is the most effective IPC measure; NAP-AMR 2.0 (2025–29) makes IPC mandatory in every Indian facility.

67 Leptospirosis and dengue In dengue the elderly die of fluid overload as often as of shock; in leptospirosis, doxycycline early, dialysis early.

68 COVID-19 Delirium and silent hypoxia are the presentations to know; antiviral within 5 days, steroids only if hypoxic.

69 PMR Girdle pain with a normal CK and a dramatic response to 12.5–25 mg prednisolone; watch for GCA.

70 Psoriatic arthropathy Seronegative arthritis with dactylitis, enthesitis, nail disease and pencil-in-cup; avoid JAK inhibitors over 65.

71 Systemic vasculitides GCA above 50, MPA at 65–75; start steroids before the biopsy; infection kills more older patients than the vasculitis.

72 Sjögren's syndrome Anti-Ro/La, Schirmer ≤5 mm, focus score ≥1; the commonest cause of dry mouth in an older person is a drug.

73 Osteoporosis / DEXA / FRAX T ≤ −2.5; FRAX gives 10-year probability; never stop denosumab without a follow-on bisphosphonate.

74 Pressure ulcers Four stages plus unstageable and DTPI; never reverse-stage; prevention beats dressings.

75 Beers / STOPP-START / ACB STOPP the wrong, START the missing, score the anticholinergics (ACB ≥3).

B. Steroid-sparing agents — the whole rheumatology block on one line each

Condition First line Steroid-sparing / advanced

Polymyalgia rheumatica Prednisolone 12.5–25 mg/day Sarilumab preferred (EULAR 2025); tocilizumab; methotrexate Giant cell arteritis Prednisolone 40–60 mg (IV if visual Tocilizumab or upadacitinib 15 mg (SELECT-GCA: 46% loss) vs 29%)

ANCA-associated vasculitis Steroids + rituximab (preferred in Avacopan; reduced-dose steroid regimen (PEXIVAS) elderly)

Psoriatic arthritis Methotrexate (peripheral only) IL-17 / IL-23 inhibitors; apremilast if frail; avoid JAKi over 65 Sjögren's syndrome Symptomatic + hydroxychloroquine Rituximab for systemic disease; ianalumab / nipocalimab emerging C. Numbers most likely to be asked Number What it belongs to 72 hours / 7 days / 3 months Zoster antiviral window, course, PHN definition 51% and 66% Zostavax reduction in herpes zoster and PHN ≥105 CFU/mL Significant bacteriuria (voided specimen)

45 minutes / >40 mm/h / >75 mm/h PMR morning stiffness; PMR ESR; ESR raising suspicion of GCA 12.5–25 mg vs 40–60 mg Prednisolone in PMR vs GCA 16–21% PMR patients who develop GCA 46% vs 29% SELECT-GCA sustained remission, upadacitinib vs placebo T ≤ −2.5 / −1 to −2.5 / ≤ −3.0 Osteoporosis / osteopenia / very high risk threshold 800–1200 mg and 800–1000 IU Daily calcium and vitamin D 5 years oral / 3 years IV Bisphosphonate review point before a drug holiday 30–35 kcal/kg, 1–1.5 g/kg protein, 1 mL/kcal Nutrition target in pressure injury >90% / >30 minutes / 2–4 hourly Lower-body ulcers, Stage 1 erythema, repositioning interval 91% vs 48% STOPP vs Beers detection of ADRs 57.9% and 72.2% Prescribing omission, all ages ≥65 and over 85 133 + 57 / ACB ≥3 STOPP/START v3 criteria; anticholinergic burden threshold D. Indian policy and programme hooks to drop into any answer Programme / instrument Where it fits NAP-AMR 2.0 (2025–2029), launched 18 CAUTI, asymptomatic bacteriuria, IPC and stewardship (Q64, 65, 66)

Nov 2025

ICMR AMRSN and ICMR AMSP guidelines Hospital antibiogram, stewardship programme structure (Q66) NCVBDC dengue and leptospirosis Dengue and leptospirosis (Q67)

programmes; TAK-003 approved 2026 for ages 4–60 NPHCE — geriatric clinics, district and Vaccination access, falls and osteoporosis services, chronic care (Q63, 68, 73) regional geriatric centres ISBMR position statements; Indian FRAX Osteoporosis (Q73)

model; ICMR-NIN calcium recommendation MWPSC Act 2007 and Elder Line 14567 Neglect presenting as a Stage 3–4 pressure injury (Q74) Schedule H1; AYUSH–allopathy co- Prescribing safety and stewardship (Q66, 75)

prescribing; irrational fixed-dose combinations AB-PMJAY, Rashtriya Vayoshri Yojana, Financing of fracture surgery, mobility and assistive devices (Q73, 74)

ADIP-ALIMCO

FIVE SENTENCES WORTH MEMORISING VERBATIM

B. Numbers most likely to be asked

Number What it belongs to

1–2% over 55; rare below 40; M:F 3:2 Paget's disease epidemiology SQSTM1 in 40–50% familial, 5–10% sporadic Paget's genetics; P392L mutation 70–80% asymptomatic; osteosarcoma <1% Paget's presentation and worst complication >15–20% of skeleton Threshold for high-output cardiac failure Zoledronate 5 mg once; remission ~90%; retreat Paget's drug of choice ≥12 months Risedronate 30 mg × 2 months; alendronate 40 Oral alternatives in Paget's mg × 6 months Onset ≥60 (or 65); one-third of RA LORA definition and burden F:M 3:1 versus ~1:1 YORA versus LORA sex ratio PMR-like in ~25%; >20% of PMR reclassified LORA phenotypes and the PMR overlap ACR/EULAR 2010 score ≥6/10; eGFR <30 RA classification; methotrexate cut-off C. Two trials and two guidelines to name Trial / guideline What to say about it PRISM / PRISM-EZ Intensive bisphosphonate therapy to normalise turnover gave no reduction in fracture, orthopaedic surgery, deafness or quality of life, with a signal of harm — treat symptoms, not the number.

ZiPP Prophylactic zoledronic acid in SQSTM1 carriers modified new lesion development but did not change clinical outcomes — genetic screening with pre-emptive treatment is not routine. Endocrine Society / UK Paget's Both name single 5 mg IV zoledronate first-line; X-ray to confirm, bone scan to define extent.

Association

ORAL Surveillance JAK inhibitors not first-line over 65 — MACE, VTE, malignancy, herpes zoster.

THREE SENTENCES WORTH MEMORISING VERBATIM

THE LINK BETWEEN THE TWO QUESTIONS

Both are diseases of bone and joint in old age that are frequently missed because the presentation is constitutional rather than musculoskeletal. Paget's is usually found through an isolated raised alkaline phosphatase; LORA is usually found through weight loss, fatigue and a very high ESR. In each case the examiner is testing whether you will work systematically through the differential — the metabolic bone table for one, the OA-versus-inflammatory-arthritis table for the other — rather than jumping to the diagnosis in the question.

Night-Before Master Sheet — Questions 103 to 116 A. The single highest-yield line for each topic Q Topic The sentence that earns the mark 103 DOTS and DR-TB BPaLM for 6 months is the preferred MDR/RR-TB regimen; XDR (2021) = pre-XDR + resistance to bedaquiline or linezolid.

104 GeneXpert Cartridge PCR detecting MTB + rifampicin resistance in 2 hours via the rpoB hot-spot; never use for test of cure.

105 FUO In over-65s, GCA/PMR is the commonest identifiable cause; the highest-yield "tests" are the repeated examination and the drug chart.

106 Shock and septic shock Septic shock = vasopressor-dependent MAP <65 plus lactate >2; no antibiotic substitutes for source control.

107 Procalcitonin Suppressed by interferon-γ, so it stays low in viral infection; best proven role is shortening antibiotic duration.

108 Cerebral malaria IV artesunate 2.4 mg/kg at 0, 12, 24 h then daily; exclude and correct hypoglycaemia; no steroids.

109 Chikungunya Lymphopenia (not thrombocytopenia); no NSAIDs until dengue is excluded; chronic arthritis in 40–50%.

110 Scrub typhus Hunt for the eschar in hidden moist sites; doxycycline 100 mg BD with defervescence in 48 hours.

111 Ebola Death is from hypovolaemic shock, not haemorrhage; Ervebo ring vaccination and Inmazeb/Ebanga for Zaire only.

112 C. difficile Fidaxomicin first-line; soap and water, not alcohol gel; test only diarrhoeal stool, never a test of cure.

113 Influenza High-dose/adjuvanted/recombinant vaccine from 65; oseltamivir 30 mg BD if CrCl 30–60.

114 Vaccination Immunosenescence drives the schedule: influenza annually, PCV20/21 from 50, RZV ×2 from 50, RSV from 75.

115 Acute pyelonephritis Classic triad may be absent — delirium and falls may be the only features; white cell casts mean parenchymal disease.

116 Recurrent UTI Vaginal oestrogen first, methenamine second, antibiotics last; systemic HRT does not work.

B. The geriatric principles that run through the whole module (quote these anywhere)

C. Numbers most likely to be asked

Number What it belongs to

BPaLM 6 months; bedaquiline 400 mg → 200 mg MDR/RR-TB regimen and dosing thrice weekly 81-bp rpoB; 2 hours; 16 CFU/mL (Ultra) GeneXpert target, turnaround, Ultra limit of detection >38.3 °C, >3 weeks; LTC fever >37.8 °C FUO definition and its geriatric modification SOFA ≥2; MAP <65; lactate >2; mortality >40% Sepsis-3 and septic shock 30 mL/kg in 3 h; antibiotics <1 h; MAP 60–65 if Septic shock bundle and SSC 2026 ≥65 y Rises 2–4 h, peaks 12–24 h; >0.5 ng/mL Procalcitonin kinetics and antibiotic threshold Artesunate 2.4 mg/kg at 0, 12, 24 h; GCS ≤11 Cerebral malaria Eschar in 20–50%; doxycycline 100 mg BD × 7 Scrub typhus d; response in 48 h Incubation 2–21 days; semen persistence ≥18 Ebola months WBC ≥15,000 or creatinine >1.5 mg/dL; C. difficile severity and recurrence recurrence 20–25% then 40–60% HR 0.75 hospitalisation, 0.52 death; oseltamivir Influenza vaccine benefit and antiviral dosing 30 mg BD if CrCl 30–60 PCV from 50; RZV ×2 from 50; RSV all ≥75 Current adult immunisation schedule 2 in 6 months or 3 in 12 months; methenamine 1 Recurrent UTI g BD; fluids 1.5 L D. Indian policy and programme hooks Programme / instrument Where it fits NTEP, Ni-kshay portal, Ni-kshay Poshan DOTS and drug-resistant TB (Q103)

Yojana ₹1000/month, Pradhan Mantri TB

Mukt Bharat Abhiyaan

Universal drug susceptibility testing; GeneXpert and TB diagnostics (Q103, 104)

CBNAAT; indigenous Truenat

NAP-AMR 2.0 (2025–2029); ICMR Sepsis, procalcitonin, C. difficile, pyelonephritis, recurrent UTI (Q106, 107, 112, 115, 116) treatment guidelines and AMRSN NCVBDC; National Framework for Malaria Cerebral malaria, chikungunya, scrub typhus (Q108–110)

Elimination; pre-referral rectal artesunate

NPHCE geriatric clinics; API / Geriatric Vaccination delivery — no adult UIP in India (Q113, 114)

Society of India adult immunisation guidance

AB-PMJAY and Ayushman Vay Vandana Financing of hospitalisation for sepsis, TB and severe infection Card THE THREAD THAT LINKS THIS WHOLE MODULE Every answer in this block turns on the same three geriatric facts: (i) the febrile and leucocyte responses are unreliable, so the presentation is delirium, falls and functional decline rather than fever; (ii) the pathogen spectrum shifts towards Gram-negative organisms, so empirical cover and local antibiograms matter more; and (iii) the greatest iatrogenic risks are over-treatment of colonisation, unadjusted drug doses, and fluid overload during resuscitation. If you open any answer in this module with those three points and close it with the relevant Indian programme, you will have framed it as a geriatrics answer rather than a general medicine one.