USMLE Review Notes

Bioethics Website

2011-11-21T12:04:00.002-05:00

http://depts.washington.edu/bioethx/topics/index.html

Procedure Notes Template

2011-06-29T18:59:00.000-04:00

Approach to CCS

2011-03-23T13:40:00.033-04:00

Step I: Stablize the patient

Step II: Physical Examination: complete vs. focus

Step III: Diagnostic Workup: time is the key
Pulse oxy
CXR, portable
EKG
Finger tip glucose
CT head
cardiac enzymes
PEFR in asthma patients
drug levels
serum amylase and lipase levels
blood alcohol level
coagulation studies
LFTs

Step IV: triage the patient
Vitals
Activities
Is/Os
Diets
Daily weights
Monitoring

Labs
IV fluids
Medications
1. change IV to PO whenever possible
2. Nebulizer to MDI when pt is stable
3. FOBT before initiation of heparin/warfarin
4. PRN meds
5. adjust doses

Step V:
educate patients and family
counsel patient on excercise, no smoking, no alcohol, no drug use, safe driving, safe sex, etc.

Pharmacology Quizzes

2011-03-20T19:22:00.001-04:00

Click Here to Access the Quizzes

Rotator Cuff

2010-11-18T13:43:00.000-05:00

Critical Care

2010-11-11T22:06:00.003-05:00

RSBI

Weaning and Extubation

Weaning Protocol

Surviving sepsis campaign guideline

Management of sepsis and septic shock

Septic shock PPT

High Speed Railway in China: How is it made

2010-11-07T11:04:00.002-05:00

How is the high speed railway made in China?

Paracentesis

2010-11-03T18:20:00.001-04:00

Thoracentesis

2010-11-03T18:19:00.000-04:00

Chest tube placement

2010-11-03T18:06:00.000-04:00

Lumbar Puncture

2010-11-03T18:04:00.002-04:00

Central line placement

2010-11-03T18:04:00.001-04:00

Surgical knot tying

2010-11-03T17:59:00.000-04:00

Arterial Line Placement

2010-11-03T17:58:00.000-04:00

Interview

2010-11-01T21:24:00.001-04:00

Interview Tips 002

2010-11-01T21:22:00.001-04:00

Interview Tips 001

2010-11-01T21:20:00.000-04:00

Impingement syndrome

2010-10-08T23:06:00.000-04:00

Impingement syndrome is a special category of supraspinatus tendinitis caused by irritation of the subacromial bursa or rotator cuff tendon from mechanical impingement between the humeral head and the coracoacromial arch, which includes the acromion, coracoacromial ligament, and the coracoid process. Chronic overhead activity may contribute to narrowing of this space, which can lead to recurrent microtrauma and chronic local inflammation of rotator cuff tendons. Pain on the Hawkins test that resolves with injection of lidocaine into the subacromial space helps establish the diagnosis. Initial treatment is similar to rotator cuff tendinitis; however, persistence of symptoms after 3 months, which occurs in 10% to 25% of patients, may warrant an orthopedic referral.

A good website for infectious disease

2010-06-13T11:12:00.001-04:00

http://prod.hopkins-abxguide.org/

A look at the health care overhaul bill

2010-03-22T10:24:00.000-04:00

The Associated Press, On Monday March 22, 2010, 4:43 am EDT

Congressional Democrats released a final version of President Barack Obama's health care overhaul bill in advance of passage Sunday by the House. Some features of the legislation, which makes changes to the bill the Senate passed on Christmas Eve:

COST: $940 billion over 10 years, according to the Congressional Budget Office.

HOW MANY COVERED: 32 million uninsured. Major coverage expansion begins in 2014. When fully phased in, 95 percent of eligible Americans would have coverage, compared with 83 percent today.

INSURANCE MANDATE: Almost everyone is required to be insured or else pay a fine. There is an exemption for low-income people. Mandate takes effect in 2014.

INSURANCE MARKET REFORMS: Starting this year, insurers would be forbidden from placing lifetime dollar limits on policies, from denying coverage to children because of pre-existing conditions, and from canceling policies because someone gets sick. Parents would be able to keep older kids on their coverage up to age 26. A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion goes into high gear. Major consumer safeguards would also take effect in 2014. Insurers would be prohibited from denying coverage to people with medical problems or charging them more. Insurers could not charge women more.

MEDICAID: Expands the federal-state Medicaid insurance program for the poor to cover people with incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014. The federal government would pay 100 percent of costs for covering newly eligible individuals through 2016. A special deal that would have given Nebraska 100 percent federal financing for newly eligible Medicaid recipients in perpetuity is eliminated. A different, one-time deal negotiated by Democratic Sen. Mary Landrieu for her state, Louisiana, worth as much as $300 million, remains.

TAXES: Dramatically scales back a Senate-passed tax on high-cost insurance plans that was opposed by House Democrats and labor unions. The tax would be delayed until 2018, and the thresholds at which it is imposed would be $10,200 for individuals and $27,500 for families. To make up for the lost revenue, the bill applies an increased Medicare payroll tax to the investment income and to the wages of individuals making more than $200,000, or married couples above $250,000. The tax on investment income would be 3.8 percent.

PRESCRIPTION DRUGS: Gradually closes the "doughnut hole" coverage gap in the Medicare prescription drug benefit that seniors fall into once they have spent $2,830. Seniors who hit the gap this year will receive a $250 rebate. Beginning in 2011, seniors in the gap receive a discount on brand name drugs, initially 50 percent off. When the gap is completely eliminated in 2020, seniors will still be responsible for 25 percent of the cost of their medications until Medicare's catastrophic coverage kicks in.

EMPLOYER RESPONSIBILITY: As in the Senate bill, businesses are not required to offer coverage. Instead, employers are hit with a fee if the government subsidizes their workers' coverage. The $2,000-per-employee fee would be assessed on the company's entire work force, minus an allowance. Companies with 50 or fewer workers are exempt from the requirement. Part-time workers are included in the calculations, counting two part-timers as one full-time worker.

SUBSIDIES: The proposal provides more generous tax credits for purchasing insurance than the original Senate bill did. The aid is available on a sliding scale for households making up to four times the federal poverty level, $88,200 for a family of four. Premiums for a family of four making $44,000 would be capped at around 6 percent of income.

HOW YOU CHOOSE YOUR HEALTH INSURANCE: Small businesses, the self-employed and the uninsured could pick a plan offered through new state-based purchasing pools called exchanges, opening for business in 2014. The exchanges would offer the same kind of purchasing power that employees of big companies benefit from. People working for medium-to-large firms would not see major changes. But if they lose their jobs or strike out on their own, they may be eligible for subsidized coverage through the exchange.

GOVERNMENT-RUN PLAN: No government-run insurance plan. People purchasing coverage through the new insurance exchanges would have the option of signing up for national plans overseen by the federal office that manages the health plans available to members of Congress. Those plans would be private, but one would have to be nonprofit.

ABORTION: The proposal keeps the abortion provision in the Senate bill. Abortion opponents disagree on whether restrictions on taxpayer funding go far enough. The bill tries to maintain a strict separation between taxpayer dollars and private premiums that would pay for abortion coverage. No health plan would be required to offer coverage for abortion. In plans that do cover abortion, policyholders would have to pay for it separately, and that money would have to be kept in a separate account from taxpayer money. States could ban abortion coverage in plans offered through the exchange. Exceptions would be made for cases of rape, incest and danger to the life of the mother.

GOP HEALTH CARE SUMMIT IDEAS: Following a bipartisan health care summit last month, Obama announced he was open to incorporating several Republican ideas into his legislation. But two of the principle ones -- hiring investigators to pose as patients and search for fraud at hospitals and increasing spending for medical malpractice reform initiatives -- did not make it into the legislation released Thursday. The legislation incorporates only one, an increase in payments to primary care physicians under Medicaid, an idea mentioned by Sen. Charles Grassley, R-Iowa.

Affordable and Doable Observerships

2010-03-20T09:40:00.000-04:00

http://www.okmed.org/index-2_internationalsection.html 250+950

http://www.griffinmeded.org/primary-links/clinical-observership 500

http://my.clevelandclinic.org/florida/education/observerships.aspx 500

http://www.msmc.com/body.cfm?oTopId=0&id=318 800

http://www.jhsmiami.org/body.cfm?id=9270 200

http://facultyaffairs.med.miami.edu/x135.xml

http://ob-gyn.med.miami.edu/x150.xml 250 obgyn

http://pathology.med.miami.edu/x76.xml pathology

http://rehabmed.med.miami.edu/x46.xml PMR

Subclinical Hyperthyroidism: Controversies in Management

2010-03-19T08:17:00.002-04:00

This subject was tested in the UW qbank. Therefore, I found two links here for both hyperthyroidism and hypothyroidism.

Subclinical Hyperthyroidism

Subclinical Hypothyroidism

CCS synopsis

2010-03-07T18:01:00.000-05:00

PREPARED BY SANTOSH DHUNGANA

CCS synopsis.

First always see the sex and age of the patient, and keep in mind all the preventive aspects you are going to prescribe for him at the end, like vaccines and cancer screening, besides the no smoking, alcohol, drugs, safe sex, seat belt, medication compliance, medication side effect and patient counseling that we prescribe for all patients.

- Iv access

- Iv NSS

- Pulse oxy

- O2 inhalation at 4-6 l/min

- Cardiac monitoring

- Bp monitoring

- Admit to floors

- Vitals q 4-6 hrs

- Output msmt in all admitted patients, with Foleys if in ICU, or if complete bed rest is advised

- Bed rest

- Pneumatic compression stockings

- Don’t forget to examine the pt every day if he is in wards, and every 4-6 hrs if in ICU

- Neurochecks q2-4 hrs, for SAH, trauma, poisoning, etc, ie almost anybody in ICU

- Npo

- Cbc

- Bmp

- Don’t forget daily cbc/bmp for patients in ward, and every 4-6hrs for those in ICU

- UA

- HCG in all females

- Cxr

- Counsel patient

- Educate patient

- Safe sex counselling

- Seat belt

- Stop alcohol

- Stop smoking

- Stop illegal drugs

- Medication compliance

- Medication side effects

- Pap smear

- Fasting lipid

- DEXA scan

- FOBT

- Sigmoidoscopy, flexible

- Colonoscopy

- Mammogram

- Influenza and pneumo vacccine in elderly

- Vaccinations in child: DTP, polio, pneumo, influenza, varicella in >12 yrs

- Counsel parents

- Educate parents

- Home safety instructions

- Fasting lipid, lipid profile

- Fingerstick glucose in those in coma or with DKA- and not BMP, as it takes 20 min for reporting.

- BT has to be ordered separately, and doesn’t come with coagulation profile.

- Inall pts on heparin, PTT q6h; in pts on warfarin PT q1day till therapeutic INR is reached, then discharge home, and PT twice weekly is needed. Do baseline PT/PTT and FOBT before starting any of those.

- Don’t forget interval hx and c/e in pts in theward- every day, if in ICU, every 6 hrs or so. Use your judgement. Also don’t forget to monitor daily CBC/BMP for patients in the ward.

- H &H means Hb and HCT- in all actively bleeding patients, like splenic trauma, AAA, neonatal jaundice, G6PD acute hemolysis, etc.

- Treatment of severe mania- start with haloperidol, then olanzapine or risperidone with lithium.

- Use RL and not NS in patients with shock and acidosis. Use D5 ¼ NS in infants and children for maintenance fluid while NPO.

- Lead poisoning- don’t forget lead abatement agency or home lead paint assay, erythrocyte porphyrin, blood lead levels, calcium and iron supplement which will decrease absorption of lead, and succimer as DOC, use only behave modification if blood lead level <45,>45 and 2 drugs if >65, use docusate initially if constipation, parent education, do iron profile if pt has anemia, continue chelation therapy for 3 wks only, orally.

- Pregnancy- do BT, PTT, PT, Pap, TVS, HBsAg, HIV, RPR, TORCH, blood grouping and cross matching, DirectCoombs ifRh-, repeat in 24-28 wks if initially negative, Rubella Ab, Chlamydia and Gonorrhea cervical culture, urine R/M and C/S, counseling-pregnancy, counseling-breastfeeding in 2/3 trimester, 50gm OGTT in 24-28 wks, iron, folic acid, calcium after first trimester, flu shot in 2/3 trimester, exercise, high fiber diet,

- Alzheimers- TFT, B12, Folic acid level serum, Olanzapine for agitation (haloperidol not good in elderly), buspirone for anxiety, SSRI for depression, Temazepam for sleep problem (short acting Triazolam causes confusion),Donepezil,

- Very imp in elderly with Alzheimer’s- Advance Directives, Safety plan, Supportive care(consult social services),counsel pt- no driving

- Also in all elderly- flu vax, pneumovax, lipid profile, FOBT, DRE and PSA, colonoscopy

- HIV testing, ELISA in those with STD or multiple partners

- Ulcerative colitis- dx is by colonoscopy and biopsy, with GI consult. Give loperamide and dicyclomine for diarrhea along with disease modifying drugs.

- Irritable bowel syndrome- do TSH, FOBT, ESR, stool R/M, c/s, 72 hr fecal fat and lactose breath hydrogen test. Order lactose free diet, high fiber diet, avoid caffeine, relaxation technique, biofeedback, reassurance, dietary counseling, loperamide for diarrhea, psyllium(Metamucil) for constipation

- Depression- don’t forget TSH, psych consult, suicide contract, patient education, and1-2wkly f/u initially after starting SSRI. Use lorazepam initially for insomnia then withdraw.

- Mania- do urine toxicology screen, suicidal contract, psychotherapy (consult psychiatry), olanzapine or risperidone with lithium.

- Any malignancy diagnosis- CT head/chest/abdomen/pelvis as per need for staging, consult oncology, consult surgery, counsel cancer diagnosis, skeletal survey.

- Serum amylase and lipase in all abd pain- also urine, USG abd, LFT, AXR, Pt/PTT and NPO for immediate surgery can be needed, FOBT, HCg infemale, morphine with phenergan, consult surgery,

- In DKA- ABG, ketone level, serum osmolality, infection screen with CXR, urine and blood c/s

- Babies with resp bronchiolitis- sucition q1h, epinephrine and albuterol nebulisation, RSV antigen, chest physio, cardiac monitor, humidified oxygen, infant Tylenol

- Dexamet in Croup, and epinephrine if severe only.

- In septic arthritis (which can be gonococcal), do c/s of urethra, rectum, throat, blood, joint.

- All patients who come with chest pain, first give aspirin and sl nitroglycerine to all, in case there is coronary spasm.

- Pericarditis- ANA, RA, HIV, PPD, don’t tap even if fluid seen on Echo unless there is tamponade, NSAIDs and don’t use routine steroids.

- Low salt diet, low fat, diet in those with high lipids/ HTN

- Exercise program in obese, DM, HTN

- In almost all pts admitted to ward, think about vitals q4h, iv access, cardiac monitor in most, urine output, diet (normal or low sodium) and ambulation (at will) or bed rest with or without bathroom privileges.

- In ICU settings, elevate head end to prevent aspiration, vitals q2hrs, urine output q4hrs, pulse oximetry q 4 hrs, check cardiac monitor, check BP monitor q 4 hrs, pneumatic compression stockings, heparin q6hrs, npo, omeprazole or ranitidine iv for all

- Unconscious patients- fingerstick glucose test, 50%D with thiamine and naloxone cocktail in all, check airway first, suction airway (eg in narcotic overdose), blood alcohol and urine toxicology screen, CXR for aspiration,CT head as needed, charcoal if needed, NG with ETT and lavage as per needed, Suicide contract and Psych consult.

- Counsel for safe sex and contraception in all female, and all get PAP.

- CF patient- sputum Gram stain and culture, sinus XR, sweat chloride, 72 hr fecal fat, blood culture if needed, albuterol, chest physio, multivitamins due to malabsorption, influenza vaccine, pneumovax, consultdietitian,genetic counseling, pancreatic enzymes oral, high protein and high calorie diet,

- Accucheck at home for DM, Diabetic education,Diabetic foot care counseling,Diabetic diet, Exercise and wt reduction, medication compliance and mediaction s/e for DM

- HBA1C for DM when in hospital. Sliding scale insulin if admitted for severe infection, and stop metformin to prevent lactic acidosis.

- Examine extremities for DVT and swelling, and HEENT for LN, and rectal exam for occult blood in almost all cases.

- Dexamet prior to Antibiotics in pts with meningitis.

- Type’ obtain consent for procedure’ to get consent for certain procedures.

- surgeries, tube thoracostomy, thoracotomy, depression, suicide attempt, drug overdose, cardiac catheterization, ptca, ST elevation MI, Orthopaedic procedures, eye procedures, ENT stuff, EGD, Colonoscopy – get appropriate consults

- VERY IMP ( you can do this only on 5 min screen) • enter follow-up tests at a later date i.e; following drug toxic effects (LFTs, cbc etc), following the drug efficacy (lipid panel, INR monitoring etc), following disease activity ( follow up TSH etc)

- Enter elective screening tests for a LATER date in an inpatient i.e; colonoscopy, pap smear, mammogram ,Enter age appropriate and disease appropriate vaccines if not entered before

- In all patients in the ICU, order bed rest, Foleys, pneumatic compression, urine output, omeprazole, npo, cardiac monitor, bp monitor, o sat q 2hrly, vitals q2h, cbc/bmp daily in most patients, and swan ganz in pts with pericardial tamponade, myo infarction, etc.

- pregnancy with UTI- should check for pregnancy before initiating antibiotics for UTI. All pregnant women should be sent for urine culture, Chlamydia and GC culture, and pap smear. After treatment of UTI, usu with 7d of amoxy, always do repeat CS to document eradication. When such patient comes to office, send ua and hcg, then f/u after 30 min. ua will show uti. Send home on antibiotics, prenatal vitamins and f/u in 2 wks, and send for urine culture. Do repeat cs after the pt comes in 2 wks.

- Pt with dyspepsis- if alarm symptoms or if age more than 50, do EGD with biopsy.

- Type only ‘counsel’ or vaccine or synovial fluid analysis, and then press control and select multiple entries. Also works for blood culture and gram and fungal stain, csf, arthrocentesis, etc.

- HUS: Supportive theray as initial choice ,Monitor CBC and BMP , If Clinical picture worsens, get plasmapheresis ,If BMP worsens, get HD

- CCF patient: cardiac enzymes, ABG, shift to ICU, telemetry, elevate head, lasix, low Na diet, output monitor, fluid restriction, daily wt, heparin, kcl, digoxin, enalapril, metoprolol, morphine, daily BMP, consult cardiology, pepcid continuous, ETT if patient desaturates, lastly after discharge Cardiac Rehabilitation Program.

- PCOD: estrogen, DHEAS, androstenedione, LH, FSH, testosterone, prolactin, TSH, urine cortisol and urine 17 ketosteroids to rule out CAH, TVS, OGTT, lipid profile, exercise, metformin,wt loss, OCP, low fat diet,

- Postmenopausal: pap, DEXA, mammo, lipid, FOBT, colonoscopy, glucose; HRT for hot flashes, or estrogen vaginal cream, diet-calcium enriched, exercise very imp, stopping smoking v imp, counseling-HRT (order if pt is on HRT),

- Pt with fatigue or weaknes: PPD, HIV, ESR, FOBT, EKG, CXR, GTT,

- Rhabdomyolysis: monitor BMP esp K and Ca, Mg, PO4, uric acid and CPK every 12 hrs or so. Alkalinise urine with NaHCO3 and monitor urine pH till its >6.5, use NS to increase urine output to >300ml/hr, start half NS and mannitol after urine output has been established.

- PTB: don’t forget to do optho consult and LFT before starting DOTS, and don’t forget B6 with INH. f/u with sputum and CXR. Also do LFT on f/u. When the patient comes with symptoms of TB, there is no use of doing PPD- its done only for detecting latent TB.

- Do blood c/s in acute prostatitis, and treat with oral cotrim or cipro if mild, or admit and treat with ampi and genta if severe infection with sepsis.

- Pleural effusion: do coagulation/bleeding profile and Decubitus CXR(layering of 1cm is needed to tap) before tapping. Draw serum LDH and protein at the same time when sending pleural fluid for analysis. Do ANA, RA if no cause can be found for effusion. If positive, do Rheum consult. If ANA is positive, only then confirm with dsDNA. If pH of parapneumonic effusion is <7.2,>

- Sickle cell with Acute Chest syndrome: do sputum and blood culture, type and crossmatch blood in case transfusion is needed, iv morphine and phenergan for pain, D5 ¼ Ns for hydration, iv cefuroxime or xone plus azithro, incentive spirometry, chest physio, albuterol nebulisation, exchange transfusion may be needed (esp if sickling crisis like priapism and stroke), H&H q4h. On discharge, penicillin V oral prophylaxis, pneumovax, flu shot, and hydroxyurea can be given to decrease the acute crises frequency.

- Anaphylaxis: give all of these- ranitidine, diphenhydramine, epinephrine sc if mild or iv if severe( first thing to order should be this), albuterol and hydrocortisone. Later, dopamine in ICU if the BP doesn’t come up. Consult Allergy and Immunology. Medical alert bracelet and counsel- avoid allergen. RAST can be done too. If pt is already on beta blocker, then epinephrine maynot work, so give glucagon before epinephrine to neutralize the beta blocker.

- Panic attack: urine toxicology, ECG, cardiac enzymes and TSH are imp; rebreathing in a bag, alprax, reassurance, psych consult only if recurrent for cognitive behavioral therapy, SSRI if recurrent (ie panic disorder), avoid caffeine, nicotine and alcohol.

- CRF: treat hyperkalemia with all of the following- calcium gluconate, NaHCO3, 50%D with insulin, kayexalate, salbutamol; do iron studies to confirm ACD, then start EPO, control HTN with ACEI if mild RF and CCB if severe, renal diet (low Na, low K and low PO4), use calcium acetate as PO4 binder if PO4 is high, consult nephrology

- Osteoporotic Vertebral fracture: ESR is imp to rule out other pathology, do XR and MRI if s/s of compression of nerves are present, SPEP/CXR/mammo to rule out mets, DEXA, TSH to rule out hyperthyroidism induced osteoporosis. IF its postmenopausal, then all fragility fractures warrant alendronate or raloxifen (biphosphonates preferred) in addition to vitamin D and calcium supplement.

- Toxic Shock syndrome: order tampon removal stat, do sepsis workup like blood and urine culture, CXR protable AP, ABG, Coagulation profile to rule out DIC; then start Clindamycin which is the DOC as it directly inhibits toxin production, start Dopamine if BP is low. Discharge the patient on oral Clinda after his condition improves. There can be pancytopenia, hypocalcemia and hypoalbuminemia on lab studies.

- Order TVS in all gynobs cases, even if virgin or if placenta previa too!

- Temporal Arteritis with PMR: do Ct head to rule out other causes, Baseline DEXa before starting steroids, CXR to rule out thoracic aneurysm as this is common in GCA patients re! Put patient on PPI, calcium and vitamin D while starting steroid.

- leaking AAA: stop metoprolol and aspirin if the pt is already on it. If unstable(eg SBP <90),>

- Intussusception: don’t forget pediatric surgery consult before enema, morphine for pain, NG decompression of stomach, and USG for diagnosis.

- Sinusitis: naphazoline intranasal or pseudoephedrine po.

- Alcoholic withdrawl seizure- iv lorazepam, oral chlordiazepoxide (Librium) only after the pt’s consciousness improves, glucose with thiamine, folic acid, soft restraint, elevate head, serum Mag and PO4 (and supplement both after results come), LFT, coagulation (vit K if deranged), ABG, urine toxicology and blood alcohol level (repeat daily till normal), CXR for aspiration, haloperidol for agitation, consult substance abuse unit, neurocheck q 2h, seizure precautions, ETT if Osat deteriorates. Lastly before discharge, alcohol rehab and Alcoholics anonymous, and psych consult (may be suicidal).

- Do direct coomb’s in all pregnant ladies with blood group O.

- Nephrotic syndrome in child- lipid profile, 24 hr urine protein estimation, complement level (c3, c4, CH50), albumin infusion f/by lasix for ascites (can be repeated next day), coagulation profile, renal USG, low Na and high protein diet, daily wt, output msmt, Nephrology consult, repeat BMP everyday, pneumovax, Meningo and HI vaccine also if feasible

- In all babies- after discharge, counsel parent, counsel breast feeding,counsel safety plan, vaccine

- HTN patient- repeat BP msmt in 2 followup before labeling as HTN, do investigations in the meantime, like lipid profile; start HCTZ, stop smoking/alcohol, wt reduction, low salt diet, low fat diet, exercise

- Turner: do TVS to see streak gonads even in virgins, karyotype, FSH, LH, estrogen, TSH, prolactin, blood sugar, lipids, LFT,skeletal survey to see other anomaly, renal USG, Echo, TSH, Audiometry, Ophthalmo consult, consult dietitian, consult obsgyn, consult genetic, consult psychiatry for IQ determination,

- Child abuse: skeletal survey very important, coagulation study, BT has to be ordered separately, bone scan for fractures, ophthalmo consult, CPS consult, psychiatry consult, LFT/Pan enzymes for abd trauma, USG abd, Urinalysis, Stool R/M , FOBT, CT head if symptomatic.

- PE: aspirin as in all chest pain cases, avoid nitroglycerine though as these patients have hypotension, cardiac enzymes, portable CXR stat AP, ABG, coagulation profile, cardiac enzymes, FOBT, VQ as it is faster than CT, D dimer stat, cardiac/BP/oximetry monitoring q1-2h, PTT q6h after starting heparin, PT q24h after starting warfarin, heparin for 5 days, start warfarin in second day, stop heparin after INR is therapeutic, send home and do INR monitoring twice weekly, Plt count on day 3 to rule out HIT

- SAH: ICU, neurocheck q1h, consult neurosx, 4 vessel cranial angiogram, BMP q24h to rule out electrolyte anomaly, docusate, nimodipine, omeprazole as in all ICU patients, Percocet or ketorolac or tramadol for pain( morphine causes constipation), water restriction if hyponatremia, followed by NS infusion, iv labetalol if malig HTN, ventriculostomy if hydrocephalus develops.

- Febrile Neutropenia- avoid DRE as it can cause mucosal injury and introduce organism into the blood, culture urine, stool, catheter tip, blood, CSF (not in all), sputum; empiric treatment with ceftazidime or piperacillin/tazo/gentamicin; GCSF only if ANC <100;>

- Infective endocarditis in drug user: TEE better, blood culture 3 times 10 min apart (advance clock and order), order urine toxicology, HBV/HCV serology, HIV ELISA, central line placement for antibiotic, start vancomycin and gentamycin presuming its Staph, continue vanco for 6 wks, and stop genta after 5 days (if non drug user, start xone and genta- continue xone for 4 wks and genta for 2 wks if viridians, both for 6 wks if Enterococcus).Always reconfirm eradication by repeat blood culture. Can also order blood antibiotic level to see if MBC is reached or not.

- Graves: 24 hour RAIU scan for diagnosis, TSI antibody, control with ppnl and PTU or methimazole for 4 weeks, then stop methimazole for a few days to increase RAI uptake, then do RAI ablation therapy once (order, RI, once), then again start ppnl and PTU to prevent flares during RI therapy, steroids to prevent progression of opthalmopathy with RI if pt has signs of eye disease. f//u in 4 wks with T4 (not TSH re), can repeat second dose of RI if still hyperthyroid. Do baseline CBC and LFT before starting the patient on PTU.

- Lung Ca- sputum cytology, HRCT chest, consult pulmonary medicine for bronchoscopy, CT guided transthoracic biopsy, Pul function test, CT chest/abd/head and bone scan for staging, LFT, consult surgery and oncology and radiotherapy.

- Ovarian Ca- CT chest/abd and mammogram to rule out Krukenberg, Pap, CA 125, ascetic fluid tap, endoscopy if needed, endomet biopsy if needed, colonoscopy if FOBT+, consult obgyn and oncology.

- Meningitis- take blood culture, advance clock 1 min, then start antibiotics, do LP then (antibiotics don’t affect LP), CT needed before LP only if pt is obtunded or has FND, else there is no need, coagulation profile for DIC, interim hx and examination q4h till patient improves, then q12h.

- AF- IF Pt come to ER with acute AF, diltiazem iv is the DOC to control the acute symptoms, followed by oral diltiazem after the heart rate drops to 80; digoxin can be used but only for maintenance, the loading dose of digoxin for acute symptom control is a thing of the past, because of the fast action of diltiazem compared to digoxin.

- AF- also do TSH, ECG, cardiac enzymes, urine toxicology, ECHo, cardiac consult, coagulation profile, heparin and warfarin after one day, PTT monitoring q6h while on heparin, and PT q24 hr while on warfarin, after INR is reached, discharge and follow up in anticoagulation clinic with INR twice weekly.

- AF of less than 48 hrs can be cardioverted with amiodarone or dofetilide or synchronized cardioversion under heparin cover,and then discharged from ER itself, but if longer duration AF, then we need 4-6 wks anticoagulation with warfarin before cardioversion, and we have to admit the patient. Cardioversion is preferred to rate control in those with acute coronary syndrome, heart failure or hemodynamic instability.

- Pericardial tamponade: swan ganz catheter for monitoring, CTVS consult before pericardiocentesis, send pericardial fluid for tests, ABG, ECHO, a catheter may be placed after centesis, and thoracotomy might be needed if patient is unstable or centesis doesn’t work. Do repeat CXR and ECHO for reaccumulation after 24 hrs.

- Pancreatitis- if febrile and has developed abscess, order CT, CT guided aspiration and culture, debridement or percut drainage, imipenem, TPN.

- Pseuocysts <6cm>

- UGIB- monitor Ca and Pt with multiple transfusion, may need FFP if INR is raised. In EGD, clean base ulcer- can be discharged within 24 hr, if clots present, keep for 2-3 days, if visible vessels or if bleeding, apply local epi, and admit for longer in ICU. After pt is sent home on PPI, repeat EGD and biopsy after 4-8 weeks for gastric ulcer, no need for DU.

- Order postural vitals in GI bleeding.

- LGIB- do colon preparation with polyethylene glycol before doing colonoscopy,

- All DM patients- on hospitalization, stop OHA, start insulin with 4-6 hrly accucheck.

- start statin directly after LFT if patient has high LDL but is unlikely to respond to diet and exercise due to multiple risk factors;

- HIV positive on ELISA- don’t forget to do western blot, CD4 count, PCR for viral load before starting HAART, VDRL, HBsAg, HCV RNA, Toxoplasma serology, pap smear, flu vaccine, pneumovax, HIV support group, PPD, LFT before starting HAART

- All patients with anemia- do iron studies, even if there is an apparent cause for it.

- All patient with hyperCa- PTH level, SPEP,, CXR, USG or CT abdomen to see for tumor, Alp to see bone formation, bone scan to see for mets.

- Pt with HTN, hypokalemia and leg cramps- do plasma renin activity, plasma aldosterone:renin ratio, spironolactone, do CT, then surgery consult and adrenalectomy if required.

- DKA - Initial Tx is Regular Insulin + IV NSS (0.9%) + KCL + accucheck 1 hrly, S.K 2 hrly and ABG 2 hrly and gradually increased to 4 hrly. Once the Glucose level is 250, change the IV fluid to D5+0.45%Saline (rest conintue). Now once the pt is no more vomiting and ABG is <>

- in all pts with polytrauma, order C spine immobilization before doing any examinations. ABG in all to rule out lactic acidosis. Blood ethanol level and urine toxicology in almost all MVA patients. Spine, Chest, Pelvic XR in almost all- including abd CT (preferred over USG if the patient is stable) and head CT if symptoms so dictate. Cardiac and BP monitor, Foleys and urine output measurement, ICu admission, iv morphine with iv phenergan, and order H and H (ie serial hb and hct) in those with suspected intracorporal bleeding. LFT, amylase and lipase if associated abdominal injury. NPO in case surgery is needed, and blood crossmatch in case transfusion is needed. Cancel C spine immobilization once the XRs clear the spine.

- Any pt comes with unconsciousness, fingerstick glucose is a must (its fast than bmp), 50%glucose, with thiamine iv, and naloxone iv are also indicated. Aspiration precautions, neurocheck q2hrs, etc

- In all pts with abd pain, don’t forget lipase, amylase, urine analysis, usg abd, axr, lft.

Perinatal Infections

2010-02-28T18:22:00.007-05:00

GBS
Prevention: Intrapartum Penicillin G or Clindamycin/Erythromycin

All women with positive GBS urine culture
Previous neonatal sepsis
Trimester vaginal culture positive
Preterm gestation
Membranes rupture > 18 h
Maternal fever

Toxoplasmosis

Chorioretinitis
Intracranial calcification
Symetrical IUGR
Hepatosplenomegaly
Thrombocytopenia
Primary infection cause problems

Treatment:

Pyrimethamine and sulfadiazine
Spiramycin to prevent vertical transmission

Varicella

Microphthamia
Extremity hypoplasia
Zigzag rashes
Greatest risk if rashes occur 6 days antepartum or 2 days postpartum

Prevention: VZIG, attenuated VZ
Treatment: Acyclovir

Rubella

Congenital deafness
Congenital cataracts
Congenital heart disease
Primary infection causes problems

Prevention: all pregnant women should be screened for IgG. Active vaccination after delivery

CMV

Nonimmune hydrops
Symmetric IUGR
Periventricular calcification
Congenital deafness

Treatment: Ganciclovir

HSV

If genital herpes presents, C-section
Acyclovir

Pregnancy with Tuberculosis

2010-02-27T21:32:00.002-05:00

If PPD positive, do chest X-ray with abdominal shielding.

Treatment: INH + Rifampin + Pyridoxine (+ethambutol if resistant)

Contradiction: streptomycin, pyrazinamide, ethionamide

Prevention: INH for 6 months after delivery

USMLE Step 3: Dr. Ziggy's Notes

2010-02-19T22:57:00.002-05:00

Cram-Facts:
CARDIOLOGY:
1. Stable angina – chest discomfort, can be felt in back/arms/jaw/abdm, occurs c stress/emotion, relief c rest, dx c stress test. Tx c nitrates, bb, Cabs, heparin, aspirin, if 3 vessels or L main do CABG
2. Unstable angina – unpredictable at rest or abruptly worsening pattern of angina, prolonged duration (>20), dx c ECG (st depression/t inversion) or cath shows CAD, but negative cardiac markers, tx c nitrates, cabs, bb, heparin
3. Variant/Prinzmetal Angina – chest pain at rest, ST elevation (note the 3 causes of ST elevation are MI (inferior (LDA) is II, III AVF; lateral (circumflex a)is I, AVL, V5, V6; anterior is V1-V4), Pericarditis (diffuse, meaning every lead has it), and Variant Angina) with negative markers. Treat with Ca-channel blockers (Cabs) or nitrates.
4. Acute MI – chest discomfort, crushing pain without warning (females and diabetics get atypical chest pain, which is abdm pain, fatigue, neck pain or weakness), prolonged duration (hours), ECG may be abnormal (st elevation or depression), increased markers, tx c MONA, ACEI, heparin, bb, tPA’s if <12 hrs after onset of pain, complications include MR, VSD, cardiac rupture and ventricular aneurysm.
5. CAD risk factors: smoking, HTN, family h/o premature CAD (<55 in male, <65 in female), male >45, female >55, HDL <40, LDL >100. (If HDL >60, subtract one). >2 risk factors: diet if >160, drugs if >190; 2 or more risk factors: diet if >130, drugs if >160, pt has CHD: diet if >100, drugs if >130.
6. Causes of high output heart failure – severe anemia, thyrotoxicosis, acute beriberi, paget’s dz, large AV fistula
7. Acute Pulmonary edema – tx – 1st upright position and O2, 2nd loops, nitrates, morphine, and 3rd intubate if severe.
8. HOCM – tx – 1st avoid dehydration, 2nd strenuous activity prohibited, 3rd BB, 4th Cab’s, 5th surgical myectomy. Best dx is history (screen family) and physical, then Echo.
9. Restrictive CM – JVD, edema and ascites, dx c echo, tx 1st diuretics/ decrease salt
10. Myocarditis – history or URI (coxsackie) then fever, dyspnea, CP, edema, tachy
11. Acute Pericarditis – positional CP, tx c NSAIDS
12. Pericardial effusion – pericardial friction rub, tx c pericardiocentesis
13. Tamponade – becks triad (JVD, muffled heart sounds, pulsus paradoxicus c hypotension), tx c pericardiocentesis
14. Constrictive pericarditis – pericardial knock, kussmaul breathing, CXR shows pericardial calcification, tx c diuretics
15. Acute RF – PECCS (polyarthrtitis, erythema marginatum, carditis, chorea, subQ nodules) in kids 5-15yo due to group A strep. Tx is Abx, bed rest, salicylates, sedatives for chorea, steroids for carditis.
16. Mitral stenosis – most associated c RHD, LA enlargement à hoarseness, dysphagia, and A.fib, diastolic rumble at LV apex, tx c diuretics, coumadin for a.fib, endocarditis prophylaxis, balloon vulvoplasty
17. Mitral regurge – a/w marfans, RHD, myxomatous change, high-pitched holosystolic murmur at left sternal border, tx c diuretics, dilators, endocarditis prophylaxis, mitral valve respacement/repair
18. Aortic regurge – congenital, marfans, trauma, aortitis, high-pitched decrescendo diastolic murmur at left sternal border and/or apex and wide pressure, tx c valve diuretics, dilators, endocarditis prophylaxis, valve replacement (last)

19. Aortic stenosis – calcific in elderly, bucuspid in congenital, angina, dyspnea, syncope, mid-late systolic murmur at base radiating to carotids, tx c replacement (1st step)

20. Endocarditis – if dental procedure give amoxicillin (clindamycin if allergic), if GI/GU procedure give amoxicillin c gentamycin (vanco with gentamycin in allergic)
21. VSD – membranous septum, harsh systolic murmur at L sternal border, spontaneous closure in 30-50%, tx – for small vsd observe, for large vsd and significant shunt, surgical repair and endocarditis prophylaxis.
22. ASD – wide, fixed splitting S2, tx – if small observe, if large surgery
23. PDA – machinery murmur, wide systemic pulse pressure, tx c indomethacin then surgery
24. Aortic Coarctation – UE HTN c LE hypotension, rib notching, LE claudication, HA, dx with MRA or contrast aortography, tx is surgery (best at 4-8yo).
25. Tetralogy of Fallot – PROVe (Pulm HTN, RVH, Overriding aorta, VSD), kid squats to increase systemic resistance, thus decreased R to L shunt, cyanosis in kid >1yo, CXR c boot shaped heart, confirm dx with cath, tx is surgery, endo prophylaxis
26. Transposition of great vessels – MCC of cyanosis in 24hrs of birth, tx c surgery
27. Initial Tx’s: CHF à thiaz, bb, acei, arb, aldo ant; Post-MI à bb, acei, aldo ant; DM àacei, bb, thiaz, arb; recurrent strokes à thiaz, acei
28. Hyperaldosteronism – hypokalemic met alkalosis, PRA ratio, captopril-suppression test, high aldo level, 24hr urinary aldo, salt loading test
29. Pheochromocytoma – 24hr urine collection for VMA, MRI to visualize adrenal tumors, MIBG if chemistries positive by CT/MRI are negative.
30. Renal artery stenosis – renal U/S c Doppler, captopril scanning, CT/MRA, high renin, ACEI contraindicated if B/L
31. Urgent v Emergent HTN – Urgent is just one high reading (give nitroprusside or lobetolol, wait til BP goes down and d/c home). Emergent is when there are signs of end-organ damage (must admit and do workup).
32. PAD – claudication, rest pain, ulceration at medial ankle, dx c ankle-brachial index before/after exercise, angiography, MCC is atherosclerosis, tx c meds (pentoxyfylline, cilastazol, cab’s), angioplasty/stenting, avoid constricting drugs (bb)
33. Temporal Arteritis - >55yo pt c HA, scalp tenderness, visual s/s, next step is low-dose steroids (before temporal a biopsy or getting ESR).
34. Polyerteritis – HTN, abdominal pain, numbness in legs, skin findings, cns s/s, dx c biopsy, tx with steroids.
35. AV Fistula – thrill/bruit over fistula (buzzing sound), dx c angiography, tx c surgical excision, if congenital do conservative management instead.
36. Varicose veins – pain, pigmentation, superficial ulcer, tx c elastic stockings
37. Superficial thrombophlebitis – pain, erythema, embolism is rare, tx c warm compression, limb elevation and NSAIDS.
38. Deep vein thrombophlebitis – pain, swelling, fever, + Homans sign, PE is risk, so must do plethysmography or Doppler, tx c heparin/warfarin, filter if recurrent.
39. Dissecting aortic aneurysm – sharp CP radiating to back, dx c CT, TEE or MRI, tx – 1st decrease BP (nitroprusside), 2nd - If ascending aorta (up to aortic arch) do surgery, if descending aorta use meds
40. Abdominal aortic aneurysm – bruit, dx with U/S, see abdominal notes
41. Aneurysm of thoracic aorta (nondissecting) – may compress adjacent structures causing CP, dysphagia, hoarseness, dx c aortography, Atherosclerosis is MCC, also due to cystic medial necrosis. Tx c surgical graft replacement.

SKIN:

42. HSV – type 1 at mouth, type 2 in genitalia. Recurrent erythema nodosum is characteristic. Dx c Tzank, tx c acyclovir
43. Herpes zoster (shingles) – dermatomal, reactivated at dorsal nerve root, tx c acyclovir
44. Varicella (chickenpox) – lesions in all stages of development, tx c benadryl. In 1st TM, causes microcephaly, chorioretinitis, IUGR and cataracts. Treat neonates with VZIG if mom contracted varicella within 5 days of delivery.
45. Impetigo – honey-crusted lesions. S aureus and B-hemolytic strep. Tx c muciprocin
46. Rubella – 3 days of cervical/suboccipital/postauricular node enlargement, prevention best c immunization before 1st TM to prevent triad: visual (cataracts), hearing loss, heart (PDA) defects.
47. Measles (Rubeola) – looks like spilled red paint over your head (rash spread beind ears and over forehead to neck to trunk and extremities), prevent c immunization
48. Roseola – 3-5 days of fever, and THEN rash after (never together). No tx
49. Erythema infectiosum – 5th dz – slapped cheek appearance, parvo B19, causes aplastic crisis in sickle cell patients, no tx
50. Rocky Mountain Spotted Fever – fever, rash on wrists then palms and soles, dx c weil-felix test, tx c tetracycline (chloramphenicol if pregnant)
51. Lyme dz – erythema chronicum migrans c central clearing, tx is doxycycline (amoxicillin if pregnant and children <9yo).
52. Scabies – burrows in hands, axillae, genitalia, highly contagious, tx c permethrin to the whole family.
53. Allergic contact dermatitis – type 4 (cell-mediated) hypersensitivity like poison ivy
54. Psoriasis – a T-cell mediated epidermal hyperproliferation, scaling plaques on knees, elbows, a/w clubbing of fingers, worsened by antimalarial drugs, lithium, bb’s, tx c steroids, calcipotriene.
55. Seborrheic Dermatitis – on scalp is dandruff, on kids is cradle cap. Tx c ketoconazole (pt on chronic azoles need to have LFTs monitored) If generalized, r/o histiocytosis X; if severe, r/o AIDS.
56. Bullous Pemphigoid – >60yo, large tense blisters, - nikolsky, IgG/C3 at dermal-epidermal junction, tx c prednisone, tetracycline, azathioprine (remember BCDE – Bullous pemphigoid, C3 at Dermal Epidermal junction)
57. Pemphigus Vulgaris – 40-60yo, multiple flaccid bullae, + nikolsky, biopsy shows acatholysis, antibodies to epidermal Ag, tx is prednisone, fluids, tetracycline
58. Dermatitis herpetiformis – itchy papulovesicular eruption usually on shins, - nikolsky, a/w celiac sprue, tx c gluten-free diet and dapsone (r/o G6PD first)
59. Factitial Dermatitis – no rash in nonreachable areas (midback, butterfly sign)
60. Acne Vulgaris – common acne. Tx c 1st benzoyl peroxide, 2nd topical/oral Abx, 3rd Topical retinoids, 4th Isoretinoin (r/o pregnancy first)
61. Hereditary angioedema – AD, C1 esterase inhibitor deficiency, subQ/mucosal edema
62. Pilonidal cyst – swelling, tender sacral mass, tx c antibiotics, I&D
63. Epidermoid cyst – contains keratin, asymptomatic, if infected (I&D, abx), if not excise
64. Capillary Hemangioma – strawberry nevus, reddish-purple hemangioma, tx c pulse dye laser therapy
65. Cavernous Hemangioma – purplish vascular anomaly, tx c reassurance, compression
66. Seborrheic keratosis – benign skin tumor in elderly, brown flat macule that appears “stuck-on”. Observe unless eruption is multiple then do shave excision and curettage, cryotherapy
67. Port-wine stain – a/w sturge-weber syndrome, brain calcfications, seizures
68. Actinic Keratosis – precursor to SCC, sun induced kyperkeratotic coarse lesions that are hard to remove. Tx c cryosurgery, 5FY, excision
69. Squamous cell ca – generally from the lower lip down. Ulcer that won’t heal. Tx c surgery or radiation
70. Basal cell ca – generally from upper lip up. Pearly nodule c rolled border. Surgical removal has high cure rate.
71. Melanoma – ABCD (asymmetry, borders irregular, color variation, diameter >6mm), MC is superficial spreading type, dx c total excision, loves to metastasize
72. Behcet’s syndrome – apthous ulcers, genital ulcers and uveitis, tx c d/c abx, chlorambucil
73. Dermatomyositis – difficulty rising from chair, proximal weakness, gottrons sign (purple papules on knees and knuckles), dx c mucle biopsy, tx c prednisone
74. Lofgren Syndrome – fever, erythema nodosum (LE nodules), and sarcoidosis.
75. Amyloidosis – macroglossia, waxy papules on face, congo red stain on biopsy
76. Scleroderma – raynauds, dysphagia, masklike face, tight skin, dx c skin bx, tx symptomatically or c D-Penicillamine, a/w CREST syndrome
77. Tuberous sclerosis – retinal phacomas, seizures, MR, sebaceous adenomas, ash-leaf hypopigmented macules, tx c seizure control.
78. Porphyria Cutanea Tarda – no abdm pain, but + red urine and vesicles on back of hand after having alcohol, drugs, estrogens, a/w Hep C, tx c 1st stop EtOH then phlebotomy
79. Acute Intermittend Porphyria – abdm pain, weakness in shoulders/arms, change in behavior. Blocks porphobilinogen deaminase, high ALA in the stool.
80. Acathosis Nigrans – black axillary/neck patches, a/w PCOS, DM, obesity and abdm adenocarcinoma. Next step is get fasting glucose to rule out insulin resisitance.
81. TTP – fever, thrombocytopenia (causing petechia/purpura), MAHA, renal problems (hematuria) and CNS symptoms (depression, HA, psychosis). Tx c plamapheresis
82. DIC – all labs messed up (BT, PT, PTT, fibrinogen, fibrin split products) causing cutaneous hemorrhage and ecchymosis. Tx – 1st treat primary cause, 2nd heparin
ENDOCRINE:
83. Thyroid nodule – 1st do TSH, then do FNA (preferred) or scan to see if its hot or cold (cold is malignant, if hot, observe – do not biopsy). MC benign is follicular adenoma, MC malignant is papillary (psammoma bodies), must as h/o radiation, worse if pt is male, >40 or young, distant mets. If results turn out that it’s a cyst, aspirate it and follow-up, if cancer, surgery c radioiodine (if papillary or follicular).
84. Goiter – high or low iodine uptake, lithium/amiodorone use, familial, tx c levothyroxine. Do not d/c drug, just continue the drug and add levothyroxine.
85. De Quervains (subacute) thyroiditis – painful thyroid, tx is NSAIDS
86. Sick Euthyroid Synd – low T4/T3, normal TSH. No s/s, just a goiter. Tx - nothing
87. Riedel’s – tracheal compression due to sclerosing fibrosis (rare)
88. Hashimoto’s – antimicrosomal ab, tx with levothyroxine
89. Congenital hypothyroidism (cretinism) – jaundice, lethargy, umbilical hernia, low T4, high TSH, tx - synthroid (levothryoxine)
90. Adult hypothyroidism – fatigue, myxedema, cold intolerant, wt gain, eyebrow thinning, high tsh, low T4, MCC is hashimotos, but also d/t prior graves tx, sheehan’s, amiodorone, lithium, tx - synthroid
91. Graves – low tsh, high T4, tachy, palpitations, weight loss, opthalmopathy, smooth goiter, A. fib, tx -BB’s (tremor and tachy), PTU, methimazole, radioactive iodine or subtotal thyroidectomy. In pregnancy, PTU can be used, as well as surgery if appropriate. Pt <25yo get surgery, pt >40yo get radioactive iodine.
92. Toxic Nodule – high RIAU, no eye s/s, nodular goiter, on scan there is ONE area of increased uptake, whereas the rest its decreased (in toxic multinodular goiter (plummers disease), there are several areas of increased uptake and in Graves the entire gland has increased uptake)
93. Thyroid storm – very high fever, delirium, n/v, abdm pain, high t4, low tsh, tx c supportive care first (decrease temp, arrhythmia, BP), BB, glucocorticoids
94. Type 1 DM – polyuria/dypsia/phagia, islet cell ab, HLA DR3/4, low C-peptide, tx- insulin. If having surgery, give 10 units insulin in AM, and then 0.1U/kg/hr infusion.
95. Type 2 DM – polyuria/dypsia. Fasting glucose >126, random >200 on 2 visits. Tx first with diet/weight changes (decrease calories and carbs), oral agents, insulin. HBA1c to monitor glucose over 2-3 months. For retinal neovascularization, give laster photocoagulation therapy. For nephropathy, check for microalbuminuria (1st sign) and give ACEI. For neuropathy, give foot care and analgesia.
96. DKA – lethargy, n/v, polyuria, abdm pain, confusion, kussmaul breathing, fruity breath, glucose 400-600, anion gap met acidosis. Tx Isotonic fluids with insulin, replace K+ if needed (prevent cerebral edema).
97. Hyperosmolar coma – dehydration, lethargy, confusion, coma, high glucose without ketones, tx - fluids, insulin and electrolyte replacement.
98. Lactic Acidosis – coma, confusion, hyperventilation, no ketones, anion gap met acidosis, rare a/w metformin, tx etiology (starvation).
99. Pt with high blood glucose in the morning? Get 4AM blood glucose. If its high (Dawn effect), then increase morning NPH, if its low (Samogi effect) then decrease night-time NPH.
100. Insulinoma – lethargy, diplopia, HA, glucose <40, high proinsulin, high c-peptide (low c-peptide if exogenous insulin used). Tx - surgery, if emergency then first give 50mL of 50% dextrose IV.
101. Primary Hyperparathyroidism – kidney stones, osteitis fibrosa cystica, muscle weakness, high calcium, low phosphate, high PTH, a/w MEN. Tx c surgery if adenoma, but if pt has severe hypercalcemia, 1st tx - saline, then furosemide, calcitonin and/or pamidronate.
102. Hypoparathyroidism – low calcium (chvostek’s sign, trousseau’s sign, tetany), high phosphate, normal renal function. Tx - vitamin D and calcium
103. Diabetes Insipidus – water loss, polyuria, nocturia, thirst, craving for ice, low urine osm (<250), high serum osm. Dx – Give vasopressin, if corrected its central, if still getting worse its nephrogenic (can be due to demecyclone or lithium), if no change in urine osm its primary polydipsia. Tx – if central give vasopressin (DDAVP), if nephrogenic give diuretic (thiazides, amiloride).
104. SIADH – low Na, low serum osm, high urine osm, a/w small cell ca/morphine/ chlorpropramide/oxytocin, tx - 1st fluid restriction, 2nd demeclocycline or hypertonic saline if Na is really low. Do not treat too rapidly to avoid central pontine myelinosis.
105. Acromegaly – enlarging hands, feet, coarse features, deep voice, large tongue, hat/wedding ring doesn’t fit anymore (hat don’t fit anymore can be Paget’s), due to high GH, dx with glucose suppression test, then IGF-1, then MRI to confirm adenoma, tx - surgery (transphenoidal), or radiation/meds (bromocriptine, octreotide) if surgery doesn’t work.
106. Acute adrenocortical insufficiency – shock, fever, abdm pain, low sugar, dx - cosyntropin testing, tx c hydrocortisone sodium succinate.
107. Chronic adrenocortical insufficiency (Addisons) – MCC is US is autoimmune, MCC in world is TB. Lethargy, skin pigmentation, hypotension, low Na, high K+, low cortisol, high ACTH is primary, normal/low ACTH is secondary. Dx - ACTH stimulation test (cortisol should increase, but remains low in Addisons). Tx - hydrocortisone (glucocorticoid) and fludrocortisone (mineralcorticoid)
108. Cushing’s syndrome – obesity, purple striae, HTN, hirsutism, buffalo hump, wakness, osteoporosis, dx c 1st 24hr urine free cortisol, then DXM suppression test (if suppressed that means its pituitary caused (Cushing disease), if not its adrenal or ectopic ACTH like small cell ca or carcinoid). Tx – if iatrogenic use smallest effective steroid dose possible, if cushing disease do surgery/radiation of pituitary adenoma.
109. Adrenogenital syndrome – hirsutism, amenorrhea, high urinary 17-OH, MCC is 21-OH deficiency in kids, MCC in adults is PCOS or adrenal disease. Tx is surgery if ambiguous genitalia in girls), then estrogen spironolactone, meformin (if PCOS), gluco/mineralocorticoid if CAH.
110. Conn’s synd – high aldo, low K+, high Na, High BP, low renin, tx is adrenalectomy c spironoloactone preop.
111. Secondary Hyperaldosteronism – MCC is renal artery stenosis – high Na, low K, high rennin, renal bruit. Dx - aldo:renin ration, then CT Abdm.
112. Prolactinoma – milky d/c from breast, if prolactin level 20-100 then r/o dopamine antagonist drugs (haloperidol, metaclopramide) and r/o hypothyroidism, if prolactin level >100, then do MRI of brain. Tx – if CNS s/s (bitemporal hemianopsia) do surgery, if not give bromocriptine.
113. Pheochromocytoma – sudden episodes of flushing, HTN, HA, sweating, feeling of doom, a/w MEN II/III, dx c urinary VMA or catecholamines, then if + do CT of abdomen and tx - give phenoxybenzamine (then BB) followed by surgery.
114. PCOS and Premature ovarian failure – see obgyn notes
115. Hemochromatosis – AR, hepatomegaly, bronze skin, cardiomegaly, DM, dx c liver biopsy, tx - phlebotomy 1st, then deferoxamine (if needed).
116. Gestational DM – measured at 26-28wks, glucose checked 1 hour after 50g load, if abnormal, check 3 hours after 100g load (fasting should be <95, 1hr <180, 2hr <155, 3hr <140). Tx - diabetic diet and insulin if needed.
117. Carcinoid syndrome – diarrhea, flushing, bronchospasm, low bp, R heart valve lesions, dx - urinary 5HIAA, tx c surgery. MC is at appendix, but if symptomatic, MC is at small bowel.

GI:

118. Upper GI bleed – hematemisis, dx c EGD, tx (in order) – If bleeding ulcer: PPI, transfuse, urgent endoscopy when possible, epinephrine into vessel, surgery if needed. If esophageal varices: Octreotide, banding/sclerotherapy, ET intubation, TIPS (for esophageal varices, prevent next bleed with BB’s)
119. Lower GI bleed – MCC of BRBPR is diverticulosis, then angiodysplasia. Dx c colonoscopy if bleeding stops, blood scan if bleeding continues and if +, angiography. Tx – replace blood, vasopressin at site.
120. what is the cutoff between upper and lower GI bleeding? Ligament of Trietz.
121. Crohn’s – all gi tract (usually rectal sparing), fistula, skipped lesions, all layers of bowel (transmural), fistula, abscess, noncaseating granuloma, gallstones, calcium oxalate kidney stones, extraintestinal manifestations, dx c colonoscopy and biopsy. Tx using infliximab (must do PPD before starting it), sulfasalazine, metronidazole, prednisone.
122. Ulerative Colitis – rectum mainly (unless backwashing present), continuous, just mucosa/submucosa, crypt abscesses, toxic megacolon, small/frequent bloody diarrhea c tenesmus. Tx c azulfidine, sulfasalazine
123. Toxic Megacolon – emergency, a/w UC, tx: NPO, NGT, IVF, D/C meds, Abx, surgery only if + perforation (free air on AXR)
124. Peptic Ulcer – Duodenal decreases c food, Gastric increases with food, gastic is more a/w cancer, duodenal is more a/w H.pylori. Dx 1st c H.pylori testing, then endoscopy with biopsy to r/o cancer. Risks for NSAIDS: >70, h/o prior PUD, only available tx is misoprostol. H.pylori: breath test, gastric biopsy, urease. Dx for PUD: 1st Upper GI endoscopy, then biopsy for gastric ulcers to r/o cancer. Tx with amox, clarithro and omprazole. Follow-up with urea breath tests after 1 month of tx. Complications: hemorrhage (MC), perforation – do AXR to see free air in a pt c peritoneal s/s and tx c abx and laparatomy. After surgery (antreceomy, vagotomy, billroth I and II), watch out for Dumping Syndrome (weakness, n/v after eating), Afferent loop syndrome (bilious vomiting relieves abdm pain after meal), Iron/B12 deficiency.
125. ZE syndrome – severe, non-healing ulcers. Get gastric levels and r/o ca (MEN).
126. Oropharyngeal dysphagia – swallowing impaired d/t lack of neuromuscular control from prior CVA/Parkinsons/Alzheimers. Dx c barium swallow. Tx underlying dz.
127. Achalasia – aperistalsis, incomplete LES relaxation c high LES pressure, dysphagia for solids and liquids, no regurge, dx c barium (dilated distal 2/3rd) then manometry (bird beak), then endoscopy to r/o cancer. Tx c pneumatic dilatation, then botox, then surgical Nissen’s fundoplication.
128. Chagas Disease – achalasia, cardiomegaly, hepatomegaly in a south American.
129. GERD – heartburn, CP, epigastric pain, older guy, MCC of nocturnal cough. Dx c 24hr pH, upper GI endoscopy to r/o barrett’s or ulcers. If you suspect it, treat it without doing any diagnostics. Tx c lifestyle changes, PPI, H2 blockers. If pt still has symptoms then do 24hr pH. If pt says drugs used to work but don’t work anymore, do EGD to rule out cancer.
130. Zenker’s Diverticulum – a motility disorder, causing halitosis, dx c barium, tx c Sx.
131. Esophagitis – painful swallowing (odynophagia), Candida so start c flucanazole.
132. Diffuse Esophageal Spasm (Nutcracker) – Cp due to strong intermittent contractions. Dx c barium (corkscrew pattern) first, then manometry (shows nonperistaltic uncoordinated contractions), tx c calcium channel blockers or nitrates.
133. Scleroderma Esophagus – younger guy with GERD symptoms, raynauds, heartburn, dysphagia for solids and liquids, dx c manometry (low LES pressure (unlike achalasia which is high), absent contractions in the smooth muscle esophagus, normal peristalsis in the striaghted muscle, normal UES). Tx c same things as GERD.
134. Schatzki Ring – young pt with episodic difficulty (not pain) swallowing. Dx c barium, tx c pneumatic dilatation of LES
135. Plummer vinson synd – hypopharyngeal web c iron deficiency. Risk of SCC. Middle-aged female c dysphagia immediately after meals. Dx c barium, tx c surgery.
136. Barett’s Esophagus – 5yrs of dysphagia, weight loss, no reflux, s/s visible on EGD so do biopsy. If biopsy shows no dysplasia then repeat in 2-5yrs, if bx shows low dysplasia, repeat in 3-6 months, if bx shows high grade dysplasia – resection
137. Esophageal CA – progressive dysphagia for solids and eventually liquids, wt loss, CP, hypercalcemia (SCC), dx c barium, then comfirm c EGD and biopsy. Tx c surgery, chemotherapy (cisplatin, 5-FU) and radiation.
138. Gastroparesis – delayed gastric emptying causing n/v, bloating and upper abdm discomfort, common in DM, tx c metoclopramide
139. When you suspect GI perforation, use gastrograffin (not barium), when you suspect aspiration, use barium (not gastrograffin).
140. Diarrhea – see ID notes
141. Irritable Bowel Syndrome – alternating constipation/diarrhea, pain relieved c defacation. Tx c increased fiber in diet.
142. Diverticulosis – d/t low fiber/high fat diet. LLQ pain, fever, tenderness. Dx c colonoscopy. Tx c increased fiber.
143. Diverticulitis – peritonitis, fever due to micro/macro-perforations, do CT scan. Tx c NPO, IVF and abx (cipro/metro or cefoxitine or ampicillin/sulbactam)
144. Pseudomembranous Colitis – C.difficile overpopulation due to prior use of Abx weeks ago, dx c C.diff in stool. Colonoscopy shows yellow adherent plaques on mucosa. Tx: d/c drug, start metronidazole, if still +, vancomycin.
145. Colorectal CA – 2nd MCCOD d/t cancer, rectal bleeding, change in BM, weight loss, sometimes asymptomatic (found incidentally on colonoscopy). Dx: FOBT yearly after age 50, flexible sigmoidoscopy every 4 years, colonoscopy at 50 then 53 then every 5 years, but start 10 years earlier than the age of which family relative was diagnosed with it. Tx – surgical resection of primary tumor.
146. Chronic Liver Disease – causes include autoimmune hepatitis, hemochromatosis, chronic alcohol use, fatty liver dz (non-alcoholic stateohepatitis), wilsons dz, viral (HBV, HCV), s/s include fatigue, increased abdm girth, jaundice, spider angiomas, palmar erythema, HSM, gynecomastia, testicular atrophy, labs c high AST/ALT/PT/INR, thrombocytopenia, hyponatremia, hypoalbuminemia.
147. Autoimmune hepatitis – 20-40yo female c +ANA, +anti-smooth muscle Ab, everything else normal. Tx c steroids.
148. Wilson’s disease – young guy with parkinsonism due to hepatilenticular degeneration, kayser-Fleischer ring, hemolytic anemia, dx c low serum ceruloplasmin, low total copper (not free), high urine copper. CT shows hypdense regions in the basal ganglia. Confirm dx c liver biopsy. Tx c D-penicillamine.
149. Ascites – U/S, CT and then paracentesis. Tx c Na/fluid restriction, diuretics, then furosemide, then large-volume paracentesis, then TIPS.
150. Spontaneous bacterial peritonitis - >250polys in 3 bedside cultures, tx c cefotaxime
151. Encephalopathy – tx c protein restriction and lactulose.
152. HAV – shellfish, fecal-oral, dx c + anti-HAV IgM (IgG shows previous infxn)
153. HBV – HbsAg is earliest marker, >6months is chronic, if vaccinated = +HbsAb, -HbcAb, if exposed in the past = +HbsAb, +HbcAb. Window period has anti-HBc IgM only. Prevent with vaccine + HBIG. Treat c Interferon alpha and lamivudine. Give vaccine at 0-2mo, 4-6mo, 13-18 months. If mom has +HbsAg, give baby vaccine + HBIG within 12 hours of birth.
154. HCV – dx c anti-HCV Ab/IgG/IgM and HCV RNA by PCR. Tx – Inf-a c ribavirin
155. Drug-induced – Tylenol, isoniazid, halothane, carbon tetrachloride, tetracycline. Dx c very high AST/ALT levels. Tx – D/C med
156. Acute fatty liver of pregnancy – develops in 3rd TM. Tx – immediate surgery
157. Primary Biliary Cirrhosis – antimitochondrial Ab in serum, pruritis, fatigue, hepatomegaly, high alk phos, destruction of intrahepatic and extrahepatic ducts. Tx c ursodeoxycholic acid, cholestyramine.
158. Primary Sclerosing Cholangitis – young man c IBD (UC), destruction on extrahepatic ducts only (shows beading effect d/t fibrosis).
159. Gallstones – female, fat, 40, fertile, RUQ or epigastric pain, worsened c food, radiates to midscapular area. Dx c U/S, then HIDA scan if negative. Tx c lap chole. ERCP if pt still has symptoms after (stone is in CBD).
160. Mesenteric Ischemia – severe abdm pain/tenderness with paucity of clinical findings. Pt will usually have extensive ischemic history (MI, DM, etc), dx c angiography, tx with prompt laparotomy to reestablish arterial flow
161. Acute Pancreatitis – MCC is gallstones, then alcohol. Epigastric pain radiating to midback, alleviated c sitting up, jaundice sometimes fever. High amylase/lipase. Dx c CT. Tx c NPO, NGT, analgesia, and then begin to consider ERCP and surgery if perforated, bleeding, abscess, pseudocyst or peritonitis.
162. Pacreatic Pseudocyst vs Abscess – worsening of pain, n/v, fever high WBC and positive blood culture after initial improvement. Dx c CT. Tx c Abx, then surgical drainage of abscess. Pseudocyst is generally asymptomatic.
163. Pancreatic CA – vague abdm pain (doesn’t have to radiate to the back anymore), anorexia and weight loss with jaundice, n/v. Dx c CT. If negative do ERCP. Check CA 19-9. Tx: If only at pancreatic head c no spread, try resection. If not, do Whipple (pancreaticoduodenectomy) procedure.
164. Malabsorption – Steatorrhea (dx c Sudan stain – 1st test). Then dx c D-xylose, if abnormal, suggests small bowel disease. Normal value suggests focus on pancreatic dz: CT of abdm, serum amylase, AST/ALT. If overgrowth considered, note response to malabsorption to Abx. Celiac sprue panel: antiendomysial/antigliadin Ab, tissue transglutaminase, total serum IgA, antigliadin Ab IgA and IgG; at least 3 biopsy specimens from distal duodenum is gold standard.
165. Whipple’s – malabsorption, arthralgia and CNS symptoms (dementia). Dx c small bowel biopsy (shows foamy macrophages on PAS stain). Tx c TMP-SMX
PEDS GI:

NAME AGE VOMITUS FINDINGS
Pyloric Stenosis 0-2mo Nonbilious, projectile M>F, olive-shaped mass, low K
Intestinal Atresia 0-1wk Bilious, projectile Double bubble sign, a/w Downs
TE Fistula 0-2wk Food regurgitation Resp problems c feeding, asp pneumo, dx via cant pass NGT
Hirschsprung 0-1yr Feculent Distention, obstipation, no ganglia on biopsy
Anal Atresia 0-1wk Late, feculent Seen on initial exam in nursery
Choanal Atresia 0-1wk - Cyanosis c feeding, relieved c crying, CHARGE synd, cant pass NGT
Intussusseption 4mo – 2yo Bilious Currant jelly stool, palpable abdm mass, kid draws up legs, dx c barium enema
Nec Enterocolitis 0-2mo Bilious Premies, fever, rectal bleeding, air in bowel wall, tx c NPO/IVF
Meconium Ileus 0-2wk Feculent, Late Cystic Fibrosis
Midgut Volvolus 0-2yw Bilious D/t malrotation, sudden pain/n/v. dx c upper Gi, tx c Sx
Meckel’s Diverticulum 0-2yw Varies GI ulcer/bleed, dx c Meckels (Technetium) scan, tx c Sx
Strangulated Hernia Any Bilious Bowel loops in inguinal canal

ONCOLOGY:

166. Tumor markers – Bhcg – testicular cancer, choriocarcinoma, mole; AFP – hepatocellular carcinoma testicular ca; CEA – GI cancers; PSA – prostate ca; CA-125 – Ovarian ca; CA 19-9 – colorectal/GI/pancreatic cancer
167. Sigmoidoscopy - >50yo every 3-5yrs; FOBT - >50 annually; DRE - >40 annually; PSA - >50 annually in normal risk, >40 annually in high risk; Pap smear – onset of sexual activity or 18yo annually for 3 consecutive years then however often; Pelvic exam – 18-40yo every 1-3yr, >40 annually; Endometrial biopsy – menopause/high risk annually; Self breast exam - >20 monthly; Clinical breast exam – 20-40 every 3 years, >40 annually; Mammogram – 40-49 every 1-2 yrs, >50 annually.
168. Cancerous Occupation Hazards – aromatic amines c bladder ca, arsenic c lung/skin/liver ca, asbestos c mesothelioma (bronchogenic MC), benzene c leukemia, mustard gas c lung/larynx/sinus cancer, vinyl chloride c liver cancer
169. Hodgkin’s – fever, night sweats, chills, weight loss (like TB), and painless cervical adenopathy. Dx c CT chest/abdm and then lympangiography and then biopsy (for treatment purposes). Reed-sternberg cells. Tx – If no B s/s (fever, wt loss, sweats) give radiation alone. If B s/s give chemotherapy (MOPP or ABVD)
170. Non-Hodgkin’s – variable nodes, monoclonal B/T-cell proliferation, dx c CT chest/abdm/pelvis then other stuff like BM bx, PET scan, gallium scan. Tx c radiation and chemo (CHOP) c Rituximab (CD20 Ab).
171. Acute Lymphocytic Leukemia – kids, blasts, tx c intrathecal chemo (MTX)
172. Acute Myelogenous Leukemia – M3 causes DIC, Aeur rods, blasts, add All-trans retinoic acid (Vit A) to tx.
173. CML – high WBCs, high PMNs, splenomegaly, LUQ pain, fullness and early satiety, decreased LAP, dx c phili chromosome (t9;22 of brc:abl) in BM, tx c Imatinib (Gleevac).
174. CLL – elderly, high WBCs, high lymphocytes, splenomegaly, dx c smudge cells, no tx if no lymphocytosis, if + lymphocytosis give fludarabine or chlorambucil.
175. Hairy Cell Leukemia – CD10+ and TRAP+ (tartrate-resistant acid phosphatase), tx c cladribine
176. Mycosis fungoidis – cutaneous T-cell lymphoma (look at 1st aid picture), lion-like facies, tx c PUVA chemotherapy. If affecting peripheral blood, its Sezary syndrome.
177. Multiple Myeloma – high calcium, high OAF, high uric acid. Best initial test is X ray if bone pain or electrophoresis if high protein. Most accurate test is >10% plasma cells. Tx: <70yo get stem cell transplant, >70yo get Meiphelen or Thalidomide
178. Aplastic Anemia – low rbc/wbc/platelet, drugs (chloramphenicol), parvo-B19 (sickle cell), tx: <50yo get BMT, >50yo get cyclosporine + anti-thymocyte globulin
179. If pt has neck + pelvic mass after chemo the mass gets smaller, wheat test checks content of the lymph node? PET scan. So in a nutshell, a lymphoma gets excisional biopsy of the node, then PET scan, and chemo if they have B symptoms.
180. Adverse effects of chemo: Vincristine/blastine – peripheral neuropathy, cyclophosphamide – hemorrhagic cystitis, Busulfan/Bleomycin – Irreversible Pulmonary Fibrosis (that’s why Lance Armstrong refused it), Cysplatin – renal dz, ototoxicity, anemia. Overall MC adverse effect with chemo drugs is sterility.
181. Lung cancer – chronic cough (MC s/s), wt loss, smoker, hemoptysis. Dx: 1st CXR, then biopsy. Tx: Small cell get chemo only, Non-small cell – chemo c radiation. Horner’s syndrome – unilateral ptosis, meiosis, anhidrosis due to compression of ipsilateral superior cervical ganglion by lung tumor, particularly SCC. SVC syndrome – obstruction of SVC causes facial swelling/plethora, dyspnea, cough, JVD. Pancoast syndrome – tumor of the superior sulcus causes brachial plexus s/s. Small cell causes Cushings syndrome (ACTH) and SIADH, SCC causes hypercalcemia (PTH-like peptide)
182. Solitary nodule – 1st step get old x-ray. If present and same size, its benign (send home), if increase in size its probably cancer. If it wasn’t there, assess risk (high is smoker and >35, low risk is nonsmoker and <35). If low risk follow up later, if high risk do biopsy.
183. Breast Cancer – biopsy everyone c palpable mass >35 except if B/L, lumpy and s/s only occur c menses. If <35 its probably fibroadenoma (rubbery moveable mass, observe pt). After bx, get mammogram if >35yo. If mammo was already done, get FNA. If after biopsy, mass goes away, send pt home. Tx: tamoxifen, mastectomy, radiation, axillary dissection, chemotherapy (c platinum) if + nodes.
184. Prostate cancer – s/s of BPH c hematuria, high PSA (only to screen/monitor, not for dx), irregular/boggy, back pain. Tx c surgery. If +mets, then do orchiectomy, leuprolide, flutamide, DES, but no chemo. Only do TURP and radiation of mets is local (bone).
185. Colon cancer – R sided bleeds (bloody stools), L sided obstructs (constipation), wt loss. Dx c colonoscopy. Tx c surgery and 5-FU and then f/u CEA levels. If mets (MC is liver) to liver do surgery, but anywhere else do chemo.
186. Pancreatic cancer – 40-80yo male smoker c jaundice, wt loss and vague abdm pain. May have migratory thromboplebitis (Trousseau’s syndrome) or palpable, nontender gallbladder (Courvoisier’s sign). Dx c CT, then FNA. Tx c whipples.

HEMATOLOGY:

187. Microcytic (MCV <80): Iron deficiency, Thalassemia, Anemia of Chronic Dz, Sideroblastic Anemia (lead poising, isoniazid, alcohol-induced)
188. Normocytic (MCV 80-100): Check Reticulocyte count(should be <2% c anemia, otherwise marrow isn’t responding properly): <2% is acute blood loss (<5-7days), early iron deficiency, aplastic anemia, early AOCD, renal disease. >3% is due to either Intrinsic RBC defect (MAD: Membrane defects (Spherocytosis, PNH), Abnormal hemoglobins (Sickle cell), Deficient enzymes (G6PD, pyruvate kinase deficiency)) or Extrinsic RBC defect (Autoimmune hemolytic anemia, MAHA, blood loss >1 week)
189. Macrocytic (MCV >100): B12 def, folate def, Myelodysplastic syndrome, drug-induced, hepatic dysfunction (d/t alcohol), reticulocytosis.
190. Red Cell Morphologies: Rouleaux (myeloma), Burr cells (uremia), Tear drops and nucleated red cells (myelofibrosis), hypochromic/microcytic (iron def), target cells (HALT: Hemoglobinopathies, Asplenia, Liver dz (obstructive jaundice), Thalassemia), Oval macrocytes (B12/Folate def), basophilic stippling (Lead, B12 def), spherocytes (HS), Schistocytes (MAHA, AIHA, DIC), bite cells and Heinz bodies(G6PD), Howell-Jolly bodes (Asplenia like SCD).
191. Iron deficiency – low MCV, high TIBC, low ferritin, low iron (<60), high RDW (why? Because some are normocytic and some are microcytic so the range of width will be high), pica kid who eats sand and ice, plummer-vinson (web, low iron, glossitis), cow milk before age 1, exclusive breast-feeding, pregnancy. Tx – 1st is to find the source of iron loss and fix that (before you give iron!), 2nd transfusion (if needed fast) or oral iron supplements for 6-12 months.
192. Anemia of Chronic Dz – (how does this work? The body knows diseases (RA, TB, SLE, cancer) love iron, so it will hide iron away in stores (high ferritin) but keep it out of the serum (low serum iron and high TIBC)) if anemia is a/w chronic renal dz, look for Burr cells.
193. Thalassemia – normal iron (so don’t give iron), target cells, nucleated rbc, x-ray shows crew-cut appearance of skull, dx c Hb electrophoresis, no tx for traits. Thal major gets transfusion 1st and deforoxamine to prevent iron overload, spelenectomy (now give pneumovax, penicillin prophylaxis, folate supplement).
194. Lead Poisoning – pica kids who have ABCD (Anemia/Ataxia/Abdm pain, Basophillic stippling/Behavioral changes, Constipation, Drops (foot/wrist)/Death), high free erythrocyte protoporphyrin. Dx c blood Pb level and x-ray (pb visible in bones). Tx c EDTA or dimercaprol.
195. B12 Deficiency – MCC is pernicious anemia (anti IF/parietal Ab), also d/t gastrectomy, terminal ileus resection, vegetarian, chronic pancreatitis and diphyllobothrium latum infection. Look for CNS s/s (symmetric parethesia in feet/fingers, disturbed proprioception and vibratory sense, irritability, somnolence, abnormal taste/smell, central scotomas, positive babinski) and achlorhydria (no stomach acid secretion so pH in stomach is high). Check serum B12. Schilling test (never used in real world). Hypersegmented PMN. High methylmalonic acid level. Tx c cobalamin. Folate may worsen the CNS s/s.
196. Folate – usually d/t dietary lack (green vegetables, liver, kidney, yeast, mushrooms), alcoholism, pregnancy, celiac sprue, phenytoin, bactrim, MTX, 5-FU, OCPs. Tx c folate supplements.
197. Autoimmune Hemolytic Anemia – Ab/complement binds to RBC mmb. Two types IgM (agglutination at colder temp like Mycoplasma) and IgG (warm agglutination like SLE, penicillin, methyldopa). Dx c direct Coomb’s positive. If hemolysis is mild, observe, if hemolysis is severe, give glucocorticoids. If recurrent, do splenectomy.
198. Paroxysmal Nocturnal Hburia – Hypoventilate at night, so acidosis causes RBC burst d/t low DAF, therefore complement comes right off (CD 55/59). May die in 10 yrs d/t thrombosis. Best test is Sugar water test or Hams test (Acidic sounds like Hacidic, Hacidics don’t like Ham). s/s include Hburia in the morning time (not at night, that would be a prostate problem), increase risk of AML. Give steroids.
199. G6PD Deficiency – MCC is infection (they usually wont say Greek, primaquine, fava beans, Dapsone). Hemolysis, jaundice abdm/back pain 1-3 days after exposure. Heinz bodes, bite cells. Best tx c avoiding offending agents.
200. Spherocytosis – increased osmotic fragility, AD, low spectrin, splenomegaly. Dx c osmotic fragility test, tx c splenectomy (defer until 6yo), pneumo vaccine and folate
201. Sickle Cell Disease – African descent, AR, s/s >6mo d/t HbF, if trait only gets UTI, best initial test is smear, most accurate test is Hb electrophoresis, for crisis 1st give fluids/pain management, if fever (d/t autosplenectomy) give Abx (Ceftriaxone), if eye/CNS/chest/Priapism give exchange transfusion, to prevent next aplastic crisis give folate, to prevent next vaso-occlussive pain crisis (they will just say “crisis”) give hydroxyurea, if Hct drops suspect Aplastic anemia d/t Parvovirus. Give prophylactic penicillin, Pnumococcal/Haemophilus influenza vaccine @ childhood.
202. Aplastic Anemia – low rbc/wbc/platelets, chloramphenicol, parvovirus, benzene, acute leukemia, AZT/zidovudine. Tx c 1st stop drug, then give antithymocyte globulin
203. Myelophthisic anemia (Myelofibrosis) – malignant invasion of BM, anisocytosis (aniso = any size), poikilocytosis (shape), teardrop-shaped RBC, dx c BM biopsy showing no cells (dry tap).
204. Transfusions: Whole blood (poisoning, TTP), Packed RBC (post-surgery/trauma transfusion or instead of whole blood), washed RBC (IgA deficiency), Platelets (>10,000), granulocytes (post chemo), FFP (bleeding diathesis like DIC, warfarin poisoning, liver failure), cryoprecipitate (vWD and DIC). MCC of transfusion rxn is lab error. If it occurs, 1st step is stop transfusion.
205. Platelet problems = skin, gums, nose, gingival (ALL SUPERFICIAL), GI, CNS and vaginal bleeding; Factor problems – bleeding into join and muscles (DEEP), GI, CNS.
206. von Willebran Dz – high PTT, normal PT, high BT, normal plt/rbc count, AD (look for family history) (a platelet type of bleeding c a normal platelet count). Best initial test is bleeding time, then ristocetin level. Best tx c desmopressin (DDAVP)
207. Hemophilia A/B – really high PPT, normal PT, normal BT/plt/RBC, looking for delayed hemarthrosis in males only (A is factor 8, B is factor 9).
208. DIC – high PT/PTT/BT, low plt, low RBC, low factor 8.
209. Liver failure – high PT, normal/high PTT, normal BT, normal/low plt/RBC, jaundince, normal factor 8, do not give vitamin K (ineffective), give FFP’s.
210. Heparin – high PTT, thrombocytopenia. Tx c d/c drug
211. Warfarin – high PT, vit K antagonist (2,7,9,10), tx c FFP (fast) or vit K (slow), skin necrosis
212. ITP –low platelets, high BT, h/o URI, next step is steroids (just treat it), auto-platelet Ab, if platelets fall <7000 give IVIG or RhoGam.
213. TTP – high BT, low plt, low RBC, hemolysis, CNS, renal, fever, thrombocytopenia (petechia, purpura). Tx c plasmapheresis
214. HUS – like TTP but no renal failure or CNS s/s, h/o infection, E. coli 015H7.
215. Scurvy – all studies normal. Fingernal/gum/bone/perifollicular hemorrhage, poor diet (only eats hot dogs and soda or tea and toast). Tx c vitamin C.
216. Neutropenia – PMN <2.0 x 10_9. Dx c bone marrow aspirate/bx. Tx: 1st determine the cause, 2nd Abx, 3rd steroids, 4th GM-CSF.
217. Polycythemia Rubra Vera – 4 H’s (Hypervolemia, Hyperviscosity (thrombosis is MCCOD), Hyperuricemia, Histaminemia (itch all over after a hot shower)). Tx c phlebotomy.
________________________________________________________________________

ID:

218. Toxic Shock Syndrome – preformed toxin, prolonged tampon placement, hypotension, fever, dequamated rash (peeling of palms/soles), S.aureas
219. Conjunctivitis – 1st 24 hours is chemical, 2-5 days is Neisseria, 4+ is Chlamydia. If they say painful conjunctivitis, that’s viral (HSV) so treat c acyclovir.
220. External Otitis – pain, drainage, itchy swimmer’s ear, Pseudomonas.
221. Otitis Media – 40% s.pneumo, 30% h.influenza, 30% m.catarrhalis, dx: 1st step is pneumatic otoscopy showing immobility of tympanic mmb, 2nd step is tympanocentesis, tx c amoxicillin.
222. Sinusitis – same % as above. Yellow green d/c, sinus tenderness, best initial step – empiric abx (amox + decongestant), then X-ray, then Sinus biopsy (most accurate)
223. Meningitis – 0-1mo – GBS, E.coli, Listeria, 2mo-2yo – S.pneumo, 2-18yo – Neisseria, 18+ - S.pneumo; Kernigs/Brudzinski sign, lethargy, fever, bulging fontanelle, photophobia, nuchal rigidity, n/v, dx c LP (bacteria: low glucose, high prtn, PMN’s; viral: normal glucose, slightly high prtn, low WBC, lymphocytes). If bacterial, give ceftraixone, vanco or steroids. Give ampicillin (listeria) if immunocompromised. If neisseria suspected (2-18yo c rash) next step is respiratory isolation and tx him and family members c rifampin. If >100 lymphocytes: Cryptococcus (r/o HIV, best initial test is India ink, most accurate test is crypt ag, tx c Amp B), Viral (no specific test), TB (pulm s/s, high CSF protein, give RIPE + steroids), Lyme Dz (serology, h/o bite, target rash, doxycycline, or if CNS s/s like cranial nerve 7 effects, give Ceftriaxone), RMSF (serology, rash on wrists/ankes moving centrally, h/o camping or hiking, tx c Doxycycline, chloramphenicol if pregnant). The MC sequela is hearing loss.
224. Encephalitis – look for acute febrile confusion (if they say confusion, its encephalitis not meningitis), MCC is herpes (blood in csf), best initial test is CT (temporal lope), if negative do PCR (most accurate). Tx c acyclovir, then foscarnet if resistant.
225. Brain Abscess – look for focal neurologic findings c ring/contrast enhancing lesions. If HIV (-), do biopsy, if HIV +, start sulfadiazine-pyrimethamine tx for Toxo and repeat CT.
226. Spinal Abscess – local severe back pain that becomes radicular pain, then weakness c fever. Next step is CT, then surgical drainage c abx.
227. Tetanus – rictus sardonicus (facial sneer), tonic muscle spasms (jaw, trismus), clostridium tetani, tx c tetanus IG and penicillin G.
228. Diptheria – gray pharyngeal pseodommb c sore throat, tx c diphtheria antitoxin (DAT) and penicillin or erythromycin.
229. Croup – aka acute laryngotracheitis – barking cough in a 1-2yo. Parainfluenza virus. Frontal neck x-ray shows steeple sign. Tx c racemic epinephrine.
230. Epiglottitis – 2-5yo kid unimmunized (H.influenza) c rapid progression of high fever, drooling and respiratory distress c no coughing. X ray shows thumb sign. Do not examine throat or irritate the kid (worsen airway obstruction). Tx c airway assessment, then cephalosporins.
231. Bronchiolitis – 0-18month old kid in the fall/winter gets expiratory wheezing due to RSV. Tx c ribavirin. (In a nutshell, 0-2yo c wheezing is bronchiolitis, 1-2yo c barking cough is croup, 2-5yo c drooling is epiglottitis)
232. Pertussis – whooping inspiratory wheeze.
233. Lung abscess – fever for weeks, bad teeth, alcoholic, aspiration, stroke pt, intubated pt, next step is CXR, best way to prevent it is to remove all teeth, how do you differentiate from TB? The smell (very bad in abscess), most accurate test is biopsy, tx c clindamycin
234. Bronchitis – mild cough c sputum, negative CXR, tx c azithro, levaquin or doxy
235. Pharyngitis – sore throat, exudes, lymph nodes, no cough, no hoarseness, best test is rapid strep test, tx c penicillin
236. Influenza – ahces, pains, tired, cough, HA, no fever. Best tx is oseltamivir or zanamivir (note the Ivir (for Influenze), not Ovir like acyclovir/famcyclovir for HSV or Avir like ritonavir/nelfinavir for AIDS)
237. Pneumonia – outpt tx is same as bronchitis (azithro, levaquin, doxy), inpatient tx include ceftriaxone. In young healthy pt, think mycoplasma (get serologies) or if inpt, think S.pneumo. If CNS and GI symptoms, pick Legionella. If AIDS c CD<200 pick PCP (TMP-SMX tx). If exposed to sheep placenta, pick Coxiella burnetti. If lobar pneumonia (s.pneumo is MC) then stain and culture next. When do you give steroids? PO2 <75, A-a gradient <35. When do you admit and give pneumovax? Hypoxia, >65, splenectomy, hypotensive c high pulse, comorbidities, confusion, low Na (SIADH).
238. TB – homeless, alcoholic, immigrant, HIV, health care worker, prisoner, fever, cough, sputum, wt loss, night sweats, first thing to do is CXR (NOT PPD – when do you choose PPD first? Screens asymptomatic pts!), 2nd step is AFP and then give RIPE c isolation for 2 months, then isoniazid and rifampin for another 4 months (6 months total). Adverse effects are Isoniazid is neurotoxic (less c B6), Rifampin c red urine, pyrizinimide c high uric acid (do not treat it, it will pass) and ethambutol with eye problems.
239. PPD –Positive if: >5mm in HIV, steroid users, close contacts; >10mm in immigrants, health care workers (me!), >15 in pt c no risk facts. If PPD is positive, proceed to CXR, if (-) take INH for 9 months, if + get sputum AFB. If PPD is negative, repeat it in 1-2 weeks to rule out false negatives. If pt had PPD in the past that was +, don’t do PPD again (it will always be positive), go right to CXR.
240. Endocarditis – fever and a murmur is key, h/o IVDA is s.aureas at tricuspid valve, #1 dx is blood culture (not ECHO), #2 dx is ECHO (TTE type, not TEE). For dental procedures (must be dental procedure c blood, cant be dental fillings) give amoxicillin or clinda if allergic, for GI/GU (strep bovis) procedure give amox + genta, or vanco + genta if allergic. Strongest indication for surgery is ruptured valve. So, 1st step is blood culture, 2nd step is start abx while waiting for results.
241. Thrush – oral candida, removable white mouth patches (Candida CAN come off, hairy leukoplakia cant). Tx c nystatin mouth rinse.
242. Lyme Disease –problems in joints, CNS (b/l bells palsy), heart (3 degree AV block). If its just a tick bite and no s/s, do nothing. If it’s a bite c lyme rash give amox (pregnant or kids) or doxy (not serology). If pt has b/l bells palsy get serology. If av block c cns s/s (except bells palsy) give ceftriaxone next.
243. HIV – 1st ELISA, 2nd western blot (in kids, 1st is PCR). Peripheral neuropathy c stavudine/didanosine, anemia c zidovudine, rash c tmp/smx (start dapsone), nephrolithiasis c indinavir. MC overall adverse effect is increase lipids and glucose levels. Prophylaxis: <200 for PCP (tmp/smx), <50 MIA (azithromycin). What if pt finds out she has HIV during pregnancy? Continue all meds except effavirenz. When do you only continue c AZT? If she has high CD count, give it in end of pregnancy and to newborn for 6 weeks. If pt gets stuck c needs, start 2 nucleosides and 1 PI or 2 nucleosides c effavirenz. Must you start tx if pt got splashed in eyes? Yes. Kissing? No.
244. If pt is stuck c HBV needle, now has +HBsAg, what do you do? If vaccinated, do nothing. If not vaccinated, give IVIG + vaccine. If pt got stuck c HCV needle do nothing.
245. How can you tell urethritis from cystitis? Urethritis has discharge. For both conditions, 1st step is swab, then stain, then DNA probe then tx. For urethritis tx GC (Ceftriaxone), for cervicitis, tx for Chlamydia (Azithro or Doxy)
246. Genital ulcers and + Lymph could be syphilis, LGV or chancroid
247. Syphilis – painless genital ulcer, skin rash (lata), CNS/aortitis. 1st step is Darkfield microscopy (not rpr/vdrl). DOC is penicillin. If allergic give doxycyline. If allergic and pregnant, desensitize c penicillin. If pt gets immediate allergic rxn to penicllin, give aspirin.
248. LGV – painless ulcer c painful nodes. 1st step is serology (Chlamydia is culture negative), tx c doxycycline
249. Chancroid – painful ulcer, 1st step is culture, tx c azithromycin
250. Genital vesicles, next step is acyclovir (not Tzank because you already have dx), if resistant give foscarnet. When do you choose PCR? HSV in the brain.
251. If they show or describe a vesicle (but don’t say vesicle), then do Tzank test
252. If they describe or show warts, next step is remove (no tests needed).
253. Septic Arthritis – 1st step is arthrocentesis (>50,000 wbc). If you suspect gonorrhea (look for tenosynovitis, rash or migratory polyarthritis), next step is culture pharynx, rectum, cervix, etc.
254. Osteomyelitis – 1st step is xray (periosteal elevation), 2nd is MRI, 3rd is biopsy. When do you choose bone scan? If you cant do MRI (metal, pacemaker, hearing tubes, etc). After bx you can make dx: S.aureaus (nafcillin), MRSA (vanco, linezolid), E.coli (quinolones for bones) and then f/u ESR. When do you choose culture or sinus drainage? Never!

RHEUMATOLOGY:

255. Osteoarthritis – stiff, not red, not hot. DIP (Heberdens node), PIP (Bouchards), worse in PM (not in AM like RA). X-ray shows osteophytes and joint narrowing. Tx c weight loss 1st, then NSAIDS.
256. Rheumatoid Arthritis – red, hot, swollen, fever, subQ nodules, +RF, pericarditis, pleural effusion, uveitis, long morning stiffness, swan neck, PIP/MCP (not DIP). Xray shows pannus. Tx c NSAIDS (1st if mild), methotrexate (1st if severe), 2nd is TNF (infliximab – r/o TB 1st), then steroids.
257. Gout – podagra, tophi (subQ uric acid deposits c punched-out bone lesions), (-) birefrigent crystals, a/w alcohol/aspirin/HCTZ use. Tx: Acute: 1st c NSAIDS (Indomethacin), then colchicines, then steroids (1st if renal dz). Chronic: If oversecretor give allopurinol (allo for ppl who make a lot), undersecretors get propenecid.
258. Pseudogout – calcium rhomboid shaped crystals, + birefringence, chondrocalcinosis, a/w 4 H’s (hemochromatosis, hyperparathyroidism, hypophosphatemia, hypomagnesemia). MC @ knees/elbows.
259. Psoriasis – scaly skin lesions, finger clubbing, RF negative. Tx c NSAIDS, MTX
260. Ankylosing spondylitis – HLA-B27 (not diagnostic), family hx, back pain, bent over (bamboo spine), worse c rest (key), better c exercise, dx c 1st Sacral X-ray (sacroiliitis). Tx c exercise and NSAIDS
261. Reiters Synd – HLA-B27, can’t see (conjunctivitis), pee (uvieitis), climb a tree (arthritis). Tx c NSAIDS, eye drops, STD treatment.
262. Behcet’s syndrome – 20-40yo c painful oral/genital ulcers and arthritis. Tx c steroids.
263. Kawasaki’s – (FEEL My Conjunctiva – Fever >5days, Edema, Erythema, Lymphadenopathy, Myositis, Conjunctivitis). Next step is Echo (r/o coronary aneurysms). Tx c Aspirin + IVIG
264. Takayasu arteritis – Chinese 30-50yo female c pulselessness on 1 side. Dx c angiogram of aortic arch (coronaries to r/o stroke). Tx c steroids, cyclophosphamide
265. Wegeners – nasal (sinusitis), lung (hemoptysis, dyspnea), kidney (hematuria), c-ANCA, tx c cyclophosphamide
266. Fibromyalgia – young female with pain all over, multiple points of tenderness, irregular sleep pattern, anxiety, exams all normal. Tx c antidepressant, NSAIDS
267. Polymyalgia Rheumatic – old female c pectoral/pelvic pain/stiffness, elevated ESR, normal biopsy, a/w temporal arteritis. Tx c steroids.
268. Polymyositis – 40-60yo female c proximal muscle weakness, elevated ESR/CPK, abnormal muscle biopsy, dx c 1st muscle biopsy, then EMG. Tx c steroids
269. Dermatomyositis – same as above, but c rash (heliotrope rash around eyelid).
270. Paget’s disease - >40yo male c pevic/skull damage, hats don’t fit anymore, deafness, paraplegia, bone pain, very high alk phos, normal calcium/phos, increased risk of osteosarcoma. X-ray shows thickened bones. Tx c NSAIDS, bisphophonates (Etidronate) and calcitonin.
271. Herniated disk – most at L4-5 (weak big toe), and L5-S1 (reduced Achilles reflex), positive straight leg test.
272. Carpal Tunnels – median nerve compression (thumb, pointer, middle finger), Tinnels sign (tapping wrist causes numbing), Phalens sign (flexing wrist), tx c rest, splint, workplace modifications, then NSAIDS.
273. Osgood-Shlatter – inflammation of tibial tubercle in boys. Tx c rest and immobilization.
274. Slipped Capital Femoral Epiphysis – Obese kid c painful limp. Dx c xray. Tx c surgical pinning >5yo.
275. Legg-Calve-Perthes – non-obese kid c a limp (d/t avascular necrosis @ hip). Tx c observation and pain relief, 2nd is bracing, 3rd is surgery.
276. Osteoporosis – risks include early menopause, alcohol, Caucasian, thin body, tobacco. Dx c DEXA >-2.5 (-1 to -2.5 is osteopenia). Tx 1st weight-bearing exercise, 2nd lifestyle (smoking, alcohol cessation), 3rd calcium/vit D, bisphosphonates, etc.
277. Patellar tendonitis – an NBME 3 test question, aka jumper’s knee, patellar tenderness due to overuse and jumping sports resulting in quadriceps contraction. Tx c rest, nsaids, quadriceps stretching.
278. Osteosarcoma – 10-25yo c knee pain, mass, limping, high alk phos. X-ray c sunburst appearance. Tx c surgery and chemotherapy
279. Osteoid Osteoma – bone pain worse at night and relieved c NSAIDS. Tx c nsaids
280. Osteochondroma – bone pain, xray shows pedunculated metaphyseal tumor at distal femur. Tx c surgery.
281. Ewing sarcoma – fever, pelvic/femur bone pain, swelling, xray shows onion skinning. Tx c radiation, chemo, surgery.
282. Reflex Sympathetic Dystrophy – burning pain, skin changes (color/temp), edema in a pt who had prior injury to that area. Tx c pain management (hard to do).
283. Nursemaids Elbow – from pulling your childs arm, he develops severe pain at elbow and will not use that arm. Tx c pushing back the head of the radius while the arm is supinated and flexed. Kid will feel much better immediately.

NEUROLOGY:

284. Migraine HA – 70% unilateral, throbbing, aura, photophobia, family history, possible risk of stroke, worse c OCPs/EtOH/chocolate. Tx c NSAIDS, triptans (contraindicated in heart disease), ergots. Prevent c BB 1st, cab’s 2nd, sodium valproate/SSRI/TCAs.
285. Cluster headache – same time every month/year, males mostly, tearing, redness, pain, rhinorrhea, feels like an ice-pick is shoved in your eye (old question). Tx c 100% oxygen 1st, steroids 2nd.
286. Temporal Arteritis – >50yo c unilateral temporal HA, scalp tenderness, vision changes, high ESR. 1st step is give steroids, 2nd step temporal artery biopsy.
287. Pseudotumor Cerebri – aka Benign Intracranial HTN – increased ICP, HA, visual changes, obese female, papilledema, no focal CNS findings, a/w vitamin A toxicity. Dx c MRI 1st then LP 2nd, tx c azetazolamide.
288. Trigeminal Neuralgia – pain whenever you touch your face @ 5th cranial nerve distribution. Tx c carbamazapine. Definitive treatment with surgical rhizotomy.
289. Essential Tremor – at rest and motion. Tx c propranolol. (Tremor at rest only is Parkinson’s or hyperthyroidism, tremor c motion only is cerebellar dysfunction)
290. Nystagmus/Vertigo – if + focal defecits, the problem is central (vertical nystagmus): cerebellum (CT/MRI), M. Gravis (MRI), Stroke (MRI/CT), phenytoin without an hearing loss or tinnitus. If no focal defecits, the problem is peripheral (in the ears), so pt will have hearing loss and tinnitus. If pt only has vertigo, its benign positional vertigo. If pt has hearing loss and tinnitus with it: Miniere’s disease (chronic disease), Acoustic Neuroma (look for ataxia), Labyrinthitis (acute viral infxn)
291. Epilepsy (as per Kaplan on what is important): do not treat 1st time seizures unless there is a family history, EEG is positive or pt has status epilepticus.
292. Status Epilepticus – Dx: 1st sodium, 2nd glucose, 3rd calcium, 4th hypoxia, toxicology, CT-head, EEG (last!). Tx: 1st Benzo (lorazepam IV), 2nd Phenytoin, 3rd Barbiturate, 4th Anesthesia (succinylcholine/propofol – these will just stop the shaking, wont stop the seizure).
293. Absence seizures – kid stares into space, doing poorly in school, eye blinking, lip smacking, EEG c 3/sec spike and wave pattern. Tx c ethosuximide.
294. TIA – focal, abrupt onset lasting less than 1 hour, symptoms resolve after 1 day. Risk of stroke in days to weeks. Amorosis fugax (curtain over an eye due to retinal dysfunction) needs Doppler U/S of carotids or MRA. Give heparin acutely (if no contraindications), then long term aspirin. If stenosis >70%, amaurosis fugax/TIA or small, non-disabling stroke do CEA (carotid endarterectomy) and give aspirin. If stenosis <70%, severely disabling stroke, or TIA/stroke in evolution give daily aspirin alone.
295. CVA – 1st test is CT without contrast (although, if ischemic, it will show negative), 2nd is MRI. Heparin is not given until hemorrhagic stroke is ruled out. If ischemic, give tPA’s if less than 3 hours of onset. If hemorrhagic, control BP and ICP.
296. Ischemic Stroke Locations: MCA – contralateral hemiplegia, hemianopsia, Broca’ s (nonfluent, babbling)/Wernicke’s (fluent but doesn’t make sense) aphasia. ACA – contralateral leg paralysis, sphincter incontinence (they cant kick you, so they pee on you); Posterior – cortical blindness, hemianopsia; Vertebrobasilar – ataxia, horizontal gaze, nystagmus; Cerebellar – ataxia and dizziness; As for hemorrhagic, remember that in the thalamus its only sensory loss, in the pontine/internal capsule/putamen its only motor loss.
297. Multiple Sclerosis – insidious onset of CNS s/s in a woman aged 20-40 with exacerbations and remissions of numbness, parasthesia, weakness, optic neuritis, gait disturbance, incontinence and emotional/mental status changes. Look for classic b/l internuclear opthalmoplegia (lesion @ MLF so you cannot adduct in horizontal gaze) and scanning speech. Babinski may be positive. Entirely CNS (M.gravis and G-Barre are entirely PNS). 1st step is MRI, 2nd test is LP (oligoclonal bands). Tx acute exacerbation c steroids. Prevent next attack c ABC (Avonex (Inf-B), Betaseron (Inf-B) and Copaxone (Glatiramer acetate)). If stuck in 1 position all day, give baclofen or Tizanidine. If incontinent give oxybutinin or bethanacol.
298. Guillain-Barre Syndrome – h/o URI of GI infection (campylobacter jejuni) or immunization 1 week before develops onset of symmetric, assending progressive weakness or paralysis and loss of DTRs. 1st step is PFTs (MCCOD is respiratory dysfunction due to paralysis, so monitor the pt’s NIF (negative inspiratory force) and if it keeps decreasing, consider intubation). Most accurate test is EMG. When do you choose LP? Last (shows elevated CSF protein). Tx c IVIG or plasmapheresis (not steroids!).
299. Myasthenia Gravis – Ab against Ach receptors in women 20-40yo. Look for ptosis, diplopia, difficulty swallowing and weakness c repetition (at the end of they day they are exhausted). Best initial test is Ach Ab (NOT edrophonium test, which is 2nd or if they already mention the Ach Ab). Most accurate test is EMG. Tx Myasthenia crisis (breathing problems) c D/C anitchonergics and give IVIG and Plasmapheresis (NOT steroids). Tx for chronic disease: <60 gets thymectomy (do CXR, Chest CT), >60 gets neostigmine and steroids, then azathiopine/cyclosporine/tacrolimus. What abx is contraindicated? Aminoglycosides.
300. Eaton-Lambert – Ab against presynaptic calcium channels causing limb weakness that gets stronger c repetitive stimulation (opposite of gravis),no loss of DTRs or extraocular manifestations, a/w small cell lung cancer, tx c guanidine. (cab’s are contraindicated).
301. Neurosyphilis – tertiary treponema pallidum disease. Treat c high dose penicillin. After giving penicillin, pt may develop hypotension, fever, HA, chills and tachycardia within 24 hours of treatment due to treponemal products (Jarisch-Herxheimer reaction, this is not a penicillin reaction). Tx c aspirin.
302. Myotonic Dystrophy– 20-30yo guy grabs something and cant let go (impaired relaxation) d/t mutations in chloride channel. Tx c phenytoin.
303. Duchenne Muscular Dystrophy – XLR, boys 3-7 have muscle weakness, very high CK, calf pseudohypertrophy, Gower’s sign (kid climbs his legs to stand, look at it in google videos its so sad). Kid is in wheelchair by teenager and dead by 20. Dx c muscle biopsy.
304. Mitochondrial Myopathy – aka Lever’s hereditary optic atrophy – every mom gives to all overspring (no male transmission). Look for ragged red fibers on biopsy.
305. Botulism – infant ingests honey and develops floppy baby syndrome. 1st step is intubate if needed, 2nd step is antitoxin. Spontaneous recovery in 1 week.
306. Amyotrophic lateral Sclerosis – aka Lou Gehrig’s dz – 55yo male upper (spasticity, hyperreflexia, babinski) and lower motor neuron (fasciculations, atrophy, flaccidity) problem. Only motor problems, no sensory/sexual/bowel problems. Tx c Riluzole.
307. Huntington’s Disease – AD (father had it, you have it at a younger age) c CAG repeats, chorea, personality change, psychiatric syndromes, progressive dementia. Dx c CT/MRI showing caudate nucleus and cerebral cortex atrophy, causing decreased Ach and GABA (thus causing increased dopamine). Tx c antipsychotics (haloperidol) When you see a movement disorder, dementia and emotional problems, think of Huntington’s. When you see dementia and emotional problems (no chorea), pick Pick’s disease.
308. Parkinson’s – 60yo c extrapyramidal movement disorder (pill-rolling resting tremor, cogwheel rigidity, shuffling gait, bradykinesia, masked facies). Caused by loss of dopaminergic neurons in substantia nigra. Tx: Mild s/s (can still take care of themselves): <60yo c Anticholinergic (cabergeline/benztropine/trihexylphenidyl), >60yo c Amantidine. If Severe s/s: 1st Levo/Carbidopa, 2nd is DA agonist (primapexole, ropinirole, pergolide), 3rd COMT-inhibitors (Talcopone), 4th MAOI (selegiline). Some antipsychotics (haloperidol, risperidone, MPTP) can cause parkinson-like symptoms, tx c anticholinergics (benztropine/ trihexylphenidyl/ cabergeline). Young guy c Parkinsonism, but not on meds, think of Wilson’s disease.
309. Alzheimer’s – progressive dementia (memory, language, visuospatial, mood, hallucinations, personality/behavior) in mid-late life. a/w Down’s syndrome (amyloid precursor protein). Dx c MRI showing cortical atrophy, senile plaques, neurofibrillary tangles. Tx c donepezil, rivastigmine and galantamine to increase Ach just in brain.
310. Pick’s – early aged (40) personality change, dementia. CT/MRI shows frontetemporal atrophy, argyrophilic neuronal (Pick) bodies in frontal and temporal lobe, sparing superior temporal gyrus (generally no memory problems).
311. Multi-infarct Dementia – stepwise dementia in a pt c bad medical history (HTN, DM, etc.). They will describe the pt as progressively getting worse, little-by-little. Dx c PET/SPECT scan showing multifocal decreases in cerebral blood flow. Tx c aspirin
312. Normal Pressure Hydrocephalus - “wet, wacky, wobbly” (incontinent, dementia, ataxia). Dx c CT scan, tx c ventriculoperitoneal shunt.
313. Creutzfeldt-Jakob - young guy c rapidly progressive dementia, myoclonus due to abnormal isoform of prion protein. Dx c biopsy (nothing else). No treatment.
314. Narcolepsy – daytime sleep attacks c cataplexy, hynogogic (going to sleep)/hypnopompic (waking up) hallucinations, sleep paralysis. Rapid onset of REM sleep. Tx c amphetamines for sleepiness, clomipramine for cataplexy.
315. Obstructive sleep apnea – overweight, HTN, arrhythmia, gasping for air. Dx c polysymnography. Tx c CPAP.
316. Central sleep apnea – old, non-obese pt c loss of respiratory drive. Tx c azetazolamide.
317. Epidural Hematoma - + head trauma, + HA, + LOC, lucid intervals after brief LOC followed by increasing obtundation, middle meningeal artery. Dx c CT without contrast showing convex hematoma. Tx c 1st hyperventilate and elevate head, 2nd evacuate, 3rd mannitol
318. Subdural Hematoma - +head trauma, + HA, + LOC, bridging veins injured, can be acute (CT showing concave or crescent-shaped hematoma), days (MRI), or gradual deterioration (MRI). Tx c same as above.
319. Subarachnoid Hemorrhage - +HA, + LOC, no head trauma, spontaneous, sudden onset of meningitis (stiff neck, photophobia, kernig’s, brudzinski), worst HA of my life, a/w polycystic kidney disease, CSF c blood. Best initial test is Head CT, most accurate test is LP. Tx supportively (bed rest, analgesia)
320. Concussion – + head trauma, + LOC, no focal CNS defecits. Tx – go home.
321. Contusion – + head trauma, + LOC, blood/bruise on head. Tx – go home.
322. Neuroleptic malignant syndrome – high temperature, muscular rigidity, confusion, high CPK, high K+, no sweating, tx c IV dantrolene or bromocriptine.
323. Malignant hyperthermia – high temperature, confusion, high CPK, high K+, no sweating, h/o anesthesia (halothane). Tx c IV dantrolene
324. Heat Stroke – high temperature, confusion, no sweating, normal CPK, normal K. Tx c fanning them (don’t overcool them) and water.
325. Closed-angle Glaucoma – sudden eye pain, n/v, vision loss. Tx c surgical iridectomy
326. Open-angle Glaucoma – progressive peripheral vision loss, disc cupping, no pain. Treat with bb (timolol), acetazolamide, eye drops and prostaglandins (latanoprost).

Growth/Development/ Preventative Medicine:

327. Gestational Age – fundus at pubic symphysis @ 8 wks, above symphysis @ 14wks, umbilicus @ 20wks, xiphoid @ 38wks.
328. Naegele’s rule – assuming 28 day cycle, subtract three months, add 7 days (if more than 28 days, add the remaining days to the 7)
329. Infant size – gains back birth weight by 2 weeks of age, double weight by 6 months, triples weight by 1 year.
330. Lactation – estrogen makes mammary duct tissue grow, progesterone stimulates alveolar glands. Postportum, they both drop, prolactin increases (inhibiting ovulation) and oxytocin, via nipple stimulation, allows milk letdown. Contraindicated with HIV, CMV or certain meds.
331. Newborn care: “Caput succedaneum” is a hematoma across the suture line, caphalohematoma is a hemotoma that does not cross the suture line. Mongolian spot is a bluish discoloration at the sacrum, always benign (do not assume abuse). Check for red eye reflex (r/o retinoblastoma and congenital cataracts), Orolani/Barlow maneuver (r/o DDH), abdm masses (ARPKD, Wilm’s tumor, neuroblastoma, umbilical hernia (r/o hypothyroidism))
332. Development: 1 month – head lag/social smile; 3 months – lifts head, 6 months – rolls over/sits up alone/stranger anxiety, 9 months – crawls/takes steps if hands held, 12 months – walks if you hold one hand, speaks three words; 15 months – walks alone/separation anxiety, two-block tower; 2yo – six cube tower/poison-proof home.
333. At 4 years old, must get objective hearing and visual exam.
334. Puberty: Females sequence (estrogen): ovary growth, breat bud, growth spurt, then pubic hair. Male sequence (testosterone): testicular growth, growth spurt, then pubic hair.
335. When to keep child-physician confidentiality? Drugs, EtOH, OCP, STD prevention.
336. OCP – Barrier Method (condoms help prevent STDs, diaphragms might be annoying to prepare, thus inhibiting use), hormonal contraceptives (combined est/prog (safe, effective), minipill (more pregnancy/bleeding), or injectable and implanted progestins), vaginal spermicides, IUD, surgical sterilization.
337. #1 stressor is death of a spouse, # 2 is divorce.
338. Normal Aging: cardiac (decreased CO), musculoskeletal (decreased bone mass), pulmonary (decreased strength and compliance), immunity (thymus involution), senses (decreased visual, auditory, tactile and taste), endocrine (decreased insulin-secreting cells, glucose intolerance), mental (decreased memory, learning ability and calculation speed).
339. Exceptions to informed consent: emergency, imcompetent pt, minors.
340. Influenza - >50yo, high risk (COPD, cardiovascular, renal), women who WILL become pregnant in winter, household contacts of high-risk pt (to protect the high-risk pt). Pneumococcal - >65, comorbidities.
341. Formulas: [A = True Positive; B = False positive; C = False negative; D = True Negative] (positives always on top) Sensitivity = TP/TP+FN; Specificity = TN/TN+FP; PPV = TP/TP+FP; NPV = TN/TN+FN; Attributable risk (attrib = subtract) = (a/a+b) – (c/c+d); Relative risk (only for propective studies like cohort study)= (a/a+b) / (c/c+d); Odds ratio (only for retrospective studies like case-control) = ad/bc; attack rate (how many ppl get attacked c dz) = a+c/b+d.
342. Power = rejecting the null when its false (a good thing, like saying Viagra does not treat constipation, which it doesn’t do). However, sometimes FDA may not always make the right choice and end up approving something that doesn’t work, or not approving something that works. Type 1 error – rejecting the null when it’s true (saying Viagra does not treat erectile dysfunction). Type 2 error = acceptance of the null hypothesis when it is false (saying Viagra treats constipation). Generally, the only way to increase power is to increase the sample size.
343. Mean = average; Median = middle #, Mode = MC #.
344. Confidence Interval = [mean +/- Z score x standard error of mean], where Z is the standard score (If confidence interval is 95%, Z is 2, if CI is 99%, Z is 2.5) and standard error of mean is (S / square root of N), where S is the standard deviation and N is the sample size. For example, old TQ said the mean was 67%, standard deviation was 8% in a sample size of 16, calculate a 95% CI: (67 +/- 2 (8 / square root of 16) = (67 +/- 2 (8/4)) = 64 +/- 4. The answer was 63-71.
345. When they give you a chart with different confidence intervals, just look for the one that has 1 within the range (ie. 0.89-2.3, not 1.12-2.25 or 0.56-0.93). That one is NOT statistically significant, meaning the risk is the same. If 1 is not within the range, is is statistically significant. If it was over 1 (1.12-2.25 used above), there is an increased risk. If it was under 1 (0.56-0.93 used above), there is a decreased risk.
346. When given statistical scales and asked for the statistical test: Nominal is categorical (how many you can split into groups, like genders, ethnicities, etc), Interval is a measurement (height, wt, BP, etc.). Pearson correlation = 2 intervals; Chi-square = 2 nominals; t-test = 1 nominal + 1 interval. For example, if you want to find out if men do better than women on step 2. Men vs women is nominal, Step 2 is an interval, therefore one of each makes it a t-test.
347. If given the following data: After surgery: 90% survive 1year, 75% survive 2years, 50% survive 3years, 40% survive 40%, and asked: what is the life expectancy after surgery? Always pick closest to 50%, so the answer would be 3 years. If asked, if a pt survives 2 years, what is the chance of surviving 3 years? Always put the # ending on top, # starting on bottom, so it will be 50/75, or 67%.
348. Cohort study (think – Cohort to Go Forth) – a prospective study where people are followed for a period of time. Advantages are that incidence (# of new cases) can be determined, there is an accurate relative risk (remember RR with cohort), and less control group bias. Disadvantages are that it takes too long, expensive, the sample size can get too large, and you might run into an ethical problem.
349. Case-control study – a retrospective study where you start with an outcome and then check backwards to evaluate the risk or cause. Advantages are that it’s cheap and easy, small sample size and minimal ethical risk is involved. Disadvantages are that incidence (new cases) are not determined, RR is just approximated (not exact, just taking odds, remember OR c case-control) and that there is some control group bias. Kaplan says, if you have no idea which type of study it is, pick this one.
350. Confounding bias – when hidden factors affect the results. For example, an experimenter measures the # of ashtrays owned and incidence of lung cancer and finds that people c lung cancer have more ashtrays. He or she then concludes that ashtrays cause lung cancer. Smoking is the confounding bias here, because it increases both ashtrays and lung cancer. So how can you prevent this? Do multiple studies.
351. Lead-time bias – when you confuse the facts that early screening will increase life expectancy. Look for false estimates of survival rates. For example, if I diagnosed you with cancer at 18 and you lived until 30, you will think I treated you for 22 years. However if I didn’t diagnose you until 25 and didn’t treat you after, and then you lived until 30, you will think that you only survived 5 years. The difference is not that my drug treats you better, but that I am diagnosing you earlier, thus getting a good lead on time. The solution here is to measure the “back-end” survival (ie. Getting the age 30 as the age that they both die at, whether they were treated or not).
352. Recall bias – subjects can’t remember events in the past. Solution is to make them confirm information with other sources.
353. Late-look bias – subjects die before the end of the survey, so your information gets distorted. For example, a survey finds that AIDS pts only get mild symptoms. This is wrong because they die before the really bad symptoms occur. Solution here is to stratify the disease by severity.
354. Experimenter/Interviewer bias – aka Pygmalion effect - when the experimenters expectations are inadvertently communicated to subjects, who then produce the desired effect. Solution is to make the study a double-blind one.
355. Selection bias – aka sampling bias – when the sample selected is not a representative of the population. For example, taking the people from a health club and doing a survey on the lungs in the general population. Another cause is when a study uses hospital records to estimate population prevalence (Berkson’s bias). For example, a doctor says all the people in NY are sick because all day he works with sick patients in NY.
356. Measurement bias – aka Hawthorne effect – when being observed makes you change how you answer to questions. Also, when the way the information is presented makes you answer in a certain way. For example, asking a pt “you don’t like your doctor, do you?” The pt is likely to say no because of the way the question was presented. In the law world, its termed “leading.” Prevent this by having a control/placebo group.

________________________________________________________________________

OB:
357. Numbers to note: How many weeks in each trimester? 13; what is so special about 37 weeks? Lungs are muture b/c lethicin/sphingomyelin ratio is 2:1; what is the risk of having Down’s if mom is 35? 1/350; risk @ 40? 1/100; risk @ 45? 1/50, so you absolutely must recommend amniocentesis. Pregnancy weight gain is about 25 pounds (5 in first 20 weeks, 1 pd every week after). Uterine height: 8 weeks @ iliac, 14 weeks @ pubic symphisis, 20 weeks @ umbilicus, 38 weeks @ xiphoid process.
358. Dates to note: 6-8wks is prenatal workup. 15-18 weeks is triple screen. 18 weeks is ultrasound. 26 weeks is glucose challenge test for DM. 35 weeks is GBS culture.
359. Diagnostics: Ultrasound (noninvasive, no adverse effects, done at 18-20 weeks), Chorionic villus sampling (“CVS,” invasive, done at 9-12 weeks, best for early gestation so mom has the chance to choose an abortion, may be fatal, f/u c triple screen after), Amniocentesis (done at 15-20 weeks for genetic purposes or high risk patients, done at 24 weeks for Rh isoimmunization, done at 34 weeks for gestation age, pregnancy loss about 0.5%)
360. Diabetes workup: Done at 24-28 weeks in normal pt. Done c prenatal workup (6-8 weeks) if pt is obese or has h/o macrosomic baby, h/o DM or family h/o DM. The pt will come to your office fasting for 1 hour, her blood sugar should be >140. If <140, get her fasting glucose (should be <90) and proceed to a 3 hour 100g glucose tolerance test: 1hr <180, 2hr <155, 3hr <140.
361. Embryology: Week 1 – implantation, week 2 – 2 layers formed (epiblast and hypoblast) and b-hCG is produced by syncytiotrophoblast, week 3 – 3 layers formed, week 4 – major organs formed. Note that weeks 3-8 are the period of greatest teratogenicity.
362. Teratogens: Infections (TORCH), Radiation (>20 rads), Chemotherapy (In first TM, cant give MTX, Adrinomycin), Environmental (smoking causes IUGR, alcohol causes microcephaly, flat philtrum, thin upper lip), Recreational drugs (cocaine causes placental abruption and intraventricular hemorrhage, marijuana causes prematurity), Medications (DES (vaginal/cervical cell CA), Dilantin (gingival hyperplasia, nystagmus, craniofacial dysmorphism), Warfarin (Stippled epiphysis), Isoretinoin (deafness, CNS), Lithium (ebstein anomaly), Streptomycin (CN 8), Tetracycline (black teeth), Thalidomide (small limbs), Valproic acid (spina bifida)).
363. B-hCG – 3 purposes: maintains corpus luteum (which keeps making progesterone) until placenta takes over at 9th week, regulates steroid production, stimulates testosterone production in fetal male testes. Levels may be too high (incorrect dates (MC), twins, hydatidiform mole, choriocarcinoma, ebryonal CA) or too low (incorrect dates (MC), ectopic, threatened/missed abortions). If levels are high or low, next step is to recheck the dates.
364. Human Placental lactogen (HPL) – chemically similar to GH and prolactin, thus antagonizing insulin which will contribute to gestational diabetes if too high.
365. Estrogens: Estradiol (nonpregnant reproductive years, made from granulose cell from testosterone via aromatase), estriol (pregnancy, made from DHEA via sulfatase in the placenta), estrone (menopause, made from adrenal adrostenedione in adipose).
366. Changes in pregnancy: Skin (striae gravidarum (stretch marks), chadwick’s sign (bluish cervix), linea nigra, chloasma. Note the only cancer that increases c pregnancy is melanoma), CVS (decreased BP in 1st TM, highest CO in L lateral decubitus position, systolic ejection murmur is normal, diastolic murmur is abnormal), GI (progesterone causes increased salivation, gum hyperplasia, GERD/aspirations, decreased gastric motility, constipation), pulmonary (generally, most increase except tidal volume causing resp alkalosis), renal (increased GFR, decreased BUN/Cr, decreased uric acid, glycosuria is normal, proteinuria is not), pituitary (size increases, contributing to possible Sheehan’s syndrome), thyroid (increase in TBG and total T3/T4, not free T3/T4 thus not causing s/s of hyperthyroidism, blood (increase RBC/WBC, normal platelets. Note low platelets c HELLP syndrome d/t preeclampsia, MCC of anemia is iron deficiency, then folate deficiency).
367. Prenatal workup: done at 6-8 weeks. Check CBC, UA (r/o asymptomatic bacteruria where >1000 E.Coli will be found, treat c ampillin or nitrofurantoin if allergic), Rubella (worst at 1st TM), RPR, HBV, Rh blood typing, sickle cell prep (if (+), proceed to Hb electrophoresis). If pt is a teenager, do Chlamydia and gonorrhea cultures.
368. Triple Screen – AFP, hCG, estriol (currenty inhibin-A makes for quad screen). If AFP is low, think of Down’s/Edwards synd. If AFP is high think of NTDs, gastrocele, omphalocele. Again, if AFP is high/low, next step is to get vaginal u/s to check dates. If dates are correct and U/S is non-explanatory (did not show nuchal fold thickening of Down’s), get amniocentesis for karyotype, amniotic fluid-AFP and acetylcholinesterase activity (both high in NTD). Down’s syndrome – high hCG, low AFP, low estriol. Edwards syndrome – all 3 are low.
369. Mom says she doesn’t feel the baby move anymore. Next step is U/S. If it shows fetal cardiac activity, get non-stress test. If it doesn’t show fetal cardiac activity, this is fetal demise and the next step is D&E AT 12-16wk (not D&C (<12wk), not C/S, induce labor <16wk) followed by cervix/placental culture, autopsoy, karyotyping and total body x-ray (r/o osteochondroplasia). Non-stress test (done in high risk, or if pt says she doesn’t feel the baby move anymore): reactive is good (2 accelerations in 20 minutes), nonreactive is bad (<2 accel/20 minutes)
370. Nonstress test (NST): if reactive baby is ok (monitor). If non-reactive, baby may be sleeping or in danger, so do vibroacoustic stimulation (VAS) and repeat NST. If NST is now reactive, baby was sleeping and is now ok (monitor). If still non-reactive, get a Biophysical profile (BPP) c U/S. If BPP is 8-10, baby is ok (repeat in 4 days); if BPP is 6-4, do a stress test (check for decelerations). If BPP is 0-2, deliver immediately.
371. BPP – measures 5 components (each worth 2): NST, amniotic fluid volume (normal is 5-15,<5 is oligohydramnios, >15 is polyhydramnios), fetal gross body movements, fetal extremity tone, fetal breathing movements.
372. Stress test – checks for decelerations. Go in order (head, then cord, then placenta). Early deceleration means head compression, Variable deceleration means cord compression, Late deceleration means utero-placental insufficiency. Treatment for decelerations in a stress test: 1st D/C oxytocin, 2nd Give oxygen and fluids, 3nd position her to L lateral decubitus position, 4th get scalp pH (normal 7.25 – 7.4, if <7.2 go right to C-sxn).
373. Group B Strep (GBS) – not a disease or pathogen to the mother, but if transmitted to the newborn during delivery can cause pneumonia, sepsis or meningitis. Prophylaxis c IV penicillin G (if allergic, give clinda, erythro of cefazolin) is given for +GBS culture @ 37 weeks, h/o previous child c infection, preterm gestation (even if culture negative), PROM >18 hours (must give enough time for penicillin to reach fetus), or maternal fever.
374. Toxoplasma gondii – cat feces, raw goat milk, undercooked meat. Worst in 2/3rd TM. In neonate it can cause seizures, in fetus look for intracranial calcifications. Tx c pyrimethamine-sulfadiazine.
375. Varicella – kid c “zigzag” lesions (due to nerve distribution), cataracts, chorioretinitis. Worst if mom has the pruritic vesicles 5 days antepartum-2 days postpartum. Prevent c VZIG 96 hours prior to birth. Tx c acyclovir.
376. Rubella – worst in 1st TM. Prevent 3 months before conceiving. Look for triad: deafness, cataracts and PDA. Sometimes “blue-berry muffin” rash. No treatment.
377. CMV – look for cerebral calcifications, deafness and microphthalmia. Blood shows intranuclear inclusions. Tx c ganciclovir, or foscarnet if resistant.
378. Syphilis – Dx c darkfield microscopy (rpr/vdrl may be negative until secondary disease). Child will have Hutchinson’s teeth, saber shins, saddle nose and 8th cranial nerve deafness. Tx c Penicillin, if allergic then desensitize penicillin.
379. HSV – if vesicular lesions are present in vulvar area at time of delivery, do C/S. If lesions are only on legs, none of vulva/labia, cover with towel and proceed c vaginal delivery (never done in real world). If history of lesions of culture 1 week before delivery, do C/S.
380. Hepatitis B – worst in 3rd TM. If mom has +HBsAg, next step is to get LFT’s (if high, she has active disease, if normal she may just be a carrier). Upon delivery, give baby vaccine and HbIG within 12 hours of birth. Give mom Inf-a c lamivudine.
381. HIV – ELISA then western blot. If (+), get viral load and CD-4 count. If viral load >1000 or CD <500, give all the drugs except efavirenz. If CD>500, only give AZT throughout pregnancy (starting at 14 weeks) and 6 weeks postpartum. After 6 weeks, dx HIV c PCR (cant use ELISA yet). Mom must avoid breastfeeding.
382. 4 big causes of 1st TM bleeding: Incomplete/Complete abortion, Threatened abortion, Ectopic pregnancy, Mole. Use Apt test to make sure blood is from fetus, not from mom.
383. 1st TM bleeding: 1st step is speculum exam. If cervical os is open, pt had an incomplete/complete (depending how much products of conception passed), next step is D&C. If cervical os is closed, next step is vaginal U/S c hCG. If vaginal U/S shows an intrauterine pregnancy, pt had a threatened abortion, next step is bed rest. If vaginal U/S shows no intrauterine sac and hCG >1500, pt has an ectopic pregnancy and the next step salpingostomy or MTX treatment followed by serial hCG levels until zero. If vaginal U/S shows a snowstorm appearance, pt has a mole and the next step is D&C followed by serial hCG levels to zero (also put pt on OCP’s to prevent birth, which would increase hCG and not be able to allow you to monitor hCG appropriately).
384. Ectopic – amenorrhea, vaginal bleeding, abdm pain, hCG>1500, no IUP on vaginal U/S. If unstable c peritonitis, do laparascopic salpingectomy. If stable and does not want surgery, give methotrexate and follow-up hCG levels until zero.
385. Mole – preeclampsia before 3rdTM, very high hCG, in 1st TM you will see expulsion of grapes and a uterine size that’s too big for gestation age. Vaginal U/S shows snow-storm appearance. Complete (46XX, all from dad) have no fetal tissue, incomplete does. Tx c D&C and f/u hCG while pt is on OCP’s. If hCG still doesn’t fall, pt has choriocarcinoma and needs MTX and actinomycin.
386. 3rd TM bleeding: 1st step is ultrasound (absolutely not pelvic exam). Possible choices are placenta previa, vasa previa, abruption placenta, uterine rupture.
387. Placenta previa – painless bleeding c ultrasound showing placental implantation over the lower uterine segment. Pt may say she woke up in a pool of blood. Treatment: If preterm gestation, pt is stable and bleeding stops: 1st admit, then bedrest, get vital signs/labs, transfuse if needed and put on steroids (for lung maturity) c magnesium sulfate. If pt is >37 weeks, do C-section (whether she is still bleeding or not).
388. Vasa previa – look for triad: rupture of membranes (gush of fluid), bright red painless vaginal bleeding and fetal bradycardia. Next step is C-section.
389. Abruptio placenta – painful vaginal bleeding (if bleeding stops, it may be collecting in retroperiteal area), uterine tenderness and increased uterine tone with hyperactive contraction pattern. May even cause DIC. If mild to moderate, give fluids and deliver vaginally. If severe, pt will have acute abdm (rock hard) c profound hypotension, next step is immediate C-section.
390. Uterine rupture – sudden abdm pain c profuse vaginal bleeding and abnormal fetal heart rate. Treat c immediate C-section and then uterine repair if mom wants kids in future, or hysterectomy if she doesn’t.
391. Rh Isoimmunization – mom is Rh(-), dad is Rh (+), second baby is affected c erythroblastosis fetalis. Prevent c RhoGAM at 28 weeks and 72 hours of delivery, D&C or CVS. If mom already has Rh antibodies, RhoGAM is useless (only for prevention) and so the next step is to get Rh titers. If >1:8, do amniotic fluid spectrophotometry to assess severity of hemolysis.
392. Premature rupture of membranes – sudden gush of fluid. Next step is fern test, nitrazine test. Risk of chorioamnionitis (maternal fever, uterine tenderness, PROM, culture/gram stain amniotic fluid, treat c ampicillin while awaiting results and if (+), deliver). Management: if infection present, deliver. If no infection present and fetus is <24 weeks, outcome is dismal (induce labor c bedrest at home). If baby is 24-35 weeks c no fever, hospitalize, IM betamethasone, Cx, Abx. If baby is >36 weeks, prompt vaginal delivery.
393. Preterm Labor – must have cervical change >2cm (if none, pt has false (Braxton-hicks) contractions and send her home). MC risk factor is previous preterm labor. Dx c fetal fibronectin (if +, tocolytics and steroids, if (-), send home). Management: 1st L lateral decubitus position, bed reast, O2 and IVF. 2nd Start tocolytics (useless >4cm dilatation, r/o contraindications first), get cervical/urine culture before giving IV Pen G (for GBS), IM betamethasone and send home.
394. Tocolytics – 1st Mg Sulfate (calcium blocker that may cause resp depression, loss of DTRs and pulmonary edema. If so, give IV calcium gluconate). 2nd Ritodrine/Terbutaline (B-adrenergic agonists that may cause hypotension and tachycardia so don’t give in pt c heart disease or DM). 3rd Nifedipine (calcium blocker that may cause hypotention). 4th Misoprostol (prostaglandin inhibitor that may cause in utero ductus arteriosus closure, so don’t give if gestation age >32 weeks). Some contraindications to tocolytics include (conditions where you may need to deliver) abruption placenta, ROM, chorioamnionitis, fetal demise, late decelerations, eclampsia, severe eclampsia and cervical dilatation >4cm.
395. Post-date pregnancy (>40wk): complications include increased perinatal mortality, macrosomia, need for c-section, dysmaturity syndrome (mother’s support runs out). 1st step is to check dates (if dates still unsure, continue c conservative treatment and biweekly NSTs), 2nd step is induction of labor. If cervix is favorable (soft), begin aggressive tx c oxytocin and artificial ROM. If cervix is unfavorable (hard), give prostaglandins c oxytocin and wait for spontaneous delivery.
396. Transient HTN – unsustained high BP without proteinuria or edema. No tx.
397. Chronic HTN – high BP before 20 weeks gestation. Tx c methydopa, hydralazine.
398. Mild preeclampsia – mild HTN (140/90), petal edema, 2+ proteinuria after 24 weeks gestation. Management: <36 wk – conservative (no meds). >36 wk – deliver
399. Severe preeclampsia – sustained BP >160/110, >3+ proteinuria, edema, epigastric pain, HA, blurred vision, thrombocytopenia (r/o HELLP synd). Tx: prompt vaginal delivery c oxytocin, MgSO4 (to prevent convulsions) and IV hydralazine/lobetolol.
400. Eclampsia – HTN, proteinura, edema, seizures. Tx: 1st ABC’s, 2nd MgSO4 to stop seizure (do not deliver 1st, you can never attempt delivery if pt is seizing), 3rd aggressive prompt vaginal delivery c oxytocin and hydralazine to decrease BP.
401. HELLP syndrome – hemolysis (schistocytes), elevated LFTs, low platelets. No CNS or renal problems (r/o TTP), no h/o URI/GI infection (r/o HUS). Tx c steroids and prompt delivery.
402. Never recommend termination of pregnancy, unless: 1 – pulmonary HTN in mom, 2 – Marfan’s syndrome c an aortic aneurysm >4cm, 3 – Eisenmengers syndrome (pulm HTN c bidirectional shunt, 4 – peripartum cardiomyopathy.
403. If they ask about rheumatic heart disease in the context of pregnancy, know about mitral valve stenosis management (diuretics 1st, vasodilators, then balloon vulvoplasty). Management of cardiac disease in pregnancy is bed rest, decreased physical activity, decrease weight, correct anemia, analgesics, vacuum delivery.
404. Management of hyperthyroid disease in pregnancy is to stay on PTU to prevent thyroid storm, but warn mom that baby might be mentally retarded or have IUGR.
405. DM in pregnancy – a/w fetal NTD (most common fetal anomaly), hypoglycemia (d/t maternal insulin, tx c IV glucose), hypocalcemia (failure of PTH synthesis after birth), polycythemia (d/t increased erythropoietin from intrauterine hypoxia), respiratory distress (to check lung maturity, phosphatidylglycerol is a better choice than L:C ratio), hyperbilirubinemia.
406. Prolonged latent phase – cervical dilatation <3cm (>20hrs in primipara, >14rhs in multipara). MCC is analgesia, so tx is bedrest and sedations.
407. Prolonged active phase – cervical dilatation >3cm, but slow/no rate (<1.2cm/hr in primipara, <1.5cm/hr in multipara). Causes include the 3 P’s (passenger (macrosomia), pelvis (cephalopelvic disproportion) or power insufficiency). Tx: If contractions are hypotonic (<200MVU in 2hrs), give oxytocin. If contractions are hypertonic, give morphine and consider C-section.
408. Prolonged 2nd stage – failure to deliver head (1hr in primi, 2hrs in multi). Causes are the same as above (3 P’s). If head is engaged, vacuum deliver. If head is not engaged, do C-section.
409. Prolonged 3rd stage – failure to deliver placenta within 30 minutes. Causes include placenta accreta (A for A, accreta adheres to uterine wall, MCC is placenta previa), placenta increta (In for In, increta goes into uterine wall), placenta percreta (invades uterine wall). Tx c 1st manual placental removal, 2nd curettage in the OR and 3rd hysterectomy.
410. Prolonged 4th stage: Postpartum hemorrhage: >500 in vaginal delivery, >1000 in C-section. MCC is uterine atony (tx: 1st massage uterus, 2nd pitocin, 3rd PGE, 4th methergin, 5th hysterectomy), then lacerations, retained placenta (tx c sedation, then ex-lap for b/l uterine and hypogastric artery ligation and hysterectomy), DIC, uterine inversion (from pulling).
411. Prolapsed umbilical cord – emergency d/t cord compression. Do not hold the cord or attempt to reinsert it into the uterus. 1st step is place pt in knee-chest position, 2nd elevatate the presenting cord (avoid palpating), 3rd emergency c-section.
412. Shoulder Dystocia – MCC is macrosomia (DM). 1st step is McRobert’s maneuver (maternal thigh flexion c suprapubic (not fundal) pressure). 2nd C-section.
413. Postpartum Fever – Day 0 is atelectasis (d/t anesthesia), Day 1-2 is UTI, Day 2-3 is Endometritis (this is what they will ask, causes include C-sections, prolonged PROM, prolonged labor. Tx c ampicillin, gentamycin, metronidazole). Day 4-5 is wound infection, Day 5-6 is pelvix abscess/septic thrombophlebitis (they will say, pt still spikes fever despite antibiotics. 1st step is CT scan, if there is an abscess drain it, if there is no abscess, pt has thrombophlebitis, tx c heparin). It is normal to have discharge (first red, then white lochia) up to 10 days postpartum. If there is a bad smell, fever or tenderness, suspect endometritis.
414. Mastitits – fever, unilateral breast tenderness, erythema and edema due to lactational nipple trauma. Treat c oral cloxacillin and continued breast feeding from that breast. If the same symptoms occur, but the woman was not lactating, think of cancer.
415. If woman does not want to breast feed, tell her to wear tight-fitted bras c ice-packs and analgesia. If that is not enough, give bromocriptine or estrogens.
416. In a pregnant female c antiphospholipid syndrome and recurrent abortions, tx c aspirin (otherwise, avoid aspirin in pregnancy).
417. Cholestasis c pregnancy – jaundice, itchiness, increase LFT’s, tx c deliver baby. Acute Fatty liver of Pregnancy is more serious because it can progress to hepatic coma. Tx AFLP c fluids, IV glucose and FFPs.
418. Amniotic Fluid Embolism - postpartum female c dyspnea, tachypnea, chest pain, hypotension and/or DIC.

GYN:

419. Cervical Dysplasia – firstly, note the word dysplasia (its not cancer, its precancer that has not yet invaded the basement membrane or affected lymphatics) asymptomatic or lesions on cervix. MCC is HPV 16/18 (6+11 are benign). Risk factors are early aged intercourse, smoking, multiple partners and immunosuppression. Screening c Pap smear (shows dysplasia at transformation zone). Start pap smears annually at 18yo or age of sexual activity onset for 3 consecutive years, and then every 3 years thereafter. If pt has risk factors, pap smear annually. In order: 1st Pap, 2nd colposcopy (abnormal findings include mosaicism and white epithelium; colposcopy tells you where the disease is, so if a pt comes to you with a lesion on her cervix, you can skip pap smear and skip this phase because you already know where the lesion is and go right to stage 3), 3rd Ectocervical biopsy and Endocervical curettage (ECC should not be done on pregnant pts), 4th Cone biopsy and treat with cryotherapy (mild CIN) or LEEP (loop electrodiathermy excision procedure for moderate CIN). Remember, its not cancer, do not choose chemo, surgery or radiation for dysplasia.
420. ASCUS – Pap smear may show atypical squamous cells of undetermined significance, which is basically the step right before HPV (so you would not yet find koilocytosis). The next step would be HPV/DNA testing. If the smear returns c HPV 6 or 11, proceed with colposcopy and biopsy/ECC. If the smear returns (-) HPV 11/16, then just repeat pap smear in 1 year.
421. Invasive Cervical cancer – now it has penetrated the BM. Look for postcoital vaginal bleeding. Dx c cervical biopsy 1st (don’t pick pap or colposcopy). Only a pelvic exam and IVP can be used to stage cervical cancer. Tx: Stage Ia1 (<3mm invasion) do TAH (total abdominal hysterectomy). Stage Ia2 (3-5mm invasion) do modified radical hysterectomy. Stage Ib (>5mm) or IIa (upper 2/3 vagina) do radical hysterectomy, para-aortic lymphadenectomy and radiation. All patients with cervical cancer should be followed-up c pap smears every 3months for 2 years after tx, then every 6 months thereafter. MC site of metastasis is liver. MCCOD is uremia d/t ureteral obstruction.
422. Cervical cancer in pregnancy – colposcopy and biopsy, but no ECC. If CIN (no invasion), pap every 3mo then repeat colposcopy and pap 2 months postpartum. If microinvasion (3-5mm), do cone biopsy (r/o frank invasion) and if (+), tx c LEEP and cryotherapy 2 months later. If invasive cancer, 1st punch biopsy, 2nd if <24wk give radiation c radical hysterectomy; if >24wks do C/S at 37wks then hysterectomy.
423. Uterine/Endometrial Cancer – postmenopausal bleeding. Dx c endometrial biopsy. If it comes back negative, pt is assumed to have bled from atrophy and is treated c HRT (estrogen AND progesterone, not estrogen alone). If it shows cancer, do TAH/SBO. If prognosis is poor (nodes affected, metastasis past the cervix into the uterus and beyond) give radiation and chemotherapy as well.
424. Leiomyoma uterine – submucosal fibroids cause menometorrhagia, pain, infertility, visceral obstruction (causing urinary retention and constipation). Treat c leuprolide (GnRH anolog therapy), then myomectomy (if pt wants fertility) or hysterectomy (if pt is anemic or does not want to be fertile anymore). Leiomyomas are assymetrical and bumpy.
425. Adenomyosis – endometrial glands and stroma located in the myometrium. Enlarged, symmetrical, tender uterus in the absence of pregnancy. Only definitive dx is histological sampling confirmation. Tx c hysterectomy.
426. Ovarian Cancer – look for adnexal mass, abdm pain and ascites in a postmenopausal woman. Prevent c OCPs. Screen c bimanual pelvic exams. Dx (generally hard to dx) c U/S first, then CA-125. In kids, suspect germ cell tumors (teratoma, choriocarcinoma), in adults suspect epithelial tumor (mucinous, serious, clear cell). Tx c debulking (TAH, BSO, omentectomy) and chemotherapy (carboplatin and taxol).
427. Vulvar cancer – vulvar itching in a 65yo. Dx c biopsy. Tx c surgery.
428. Germ Cell Tumors – Teratoma/Dermatoid cyst (skin, hair, teeth and pelvic calcifications on X-ray), Sertoli-leydi cell tumor (high testosterone causing virilization), Granulose-theca cell tumor (high estrogen causing feminization and precocious puberty), Meig’s syndrome (ovarian fibroma, asicets and R hydrothorax), Krukenberg tumor (stomach cancer c metastasis to ovaries).
429. Gestational Trophoblastic Neoplasia – s/s: very high hCG, large uterus, pregnancy c bleed, no fetal heart tones, high BP in 1st TM, hyperemesis, hyperthyroidism (must to TSH in a pt c GTN), snowstorm u/s. Can be benign (mole) or malignant (choriocarcinoma). Complete mole is an empty egg fertilized c single X-sperm (46XX so sperm duplicated), no fetus, uterus filled c grape-like vesicles (same description as sarcoma botyroides in young girls). Incomplete mole is a normal egg c 2 sperm (causing 69XXX), + fetus/cord, but fetus dies. For either mole, treatment is D&C, f/u hCG, start OCPs. If choriocarcinoma, 1st step is CT head/chest/abdo/pelvis to r/o METS. If poor prognosis (hCG >40,000, brain/liver mets, >6 months of D&C) do radiation and chemotherapy (MAC: MTX, Adenomycin, Cytotoxin). If good prognosis, give MTX only and f/u hCG every week for 3months while on OCPs.
430. Uterine prolapse – loss of uterine support due to cardinal ligament dysfunction. MCC is childbirth. Best tx is vaginal hysterectomy c ant/post repair (yes, first!), but if pt refuses surgery, do Kegel exercises, estrogen HRT and pessaries.
431. Stress Incontinence – weak pelvic floor causes you to urinate whenever you sneeze/cough, none at night. Dx c Q-tip test. Tx c Kegel exercises, then surgery (Marshall-Marcheli-Kranz procedure).
432. Urge Incontinence – involuntary detrusor contractions causing spurts of urine to fall at any time. Dx c cystometric studies. Tx c anticholinergics (Ditropan)
433. Overflow Incontinence – denervated bladder (DM, MS, CVA) causes bladder to keep filling up, thus high residual volume even after urination. Tx c cholinergics (bethanecol).
434. Endometriosis – dymenorrhea, dyspareunia, infertility, uterosacral ligament nodularityin the cul-de-sac, chocolate cysts. Dx c laparoscopy. Tx: 1st OCP, 2nd Danazol and Leuprolide (best tx, but not 1st because of side-effects), 3rd surgical resection, 4th pregnancy (however hard, d/t infertility), 5th TAH/SBO. If endometriosis is present, and pt has no s/s, do nothing.
435. Chancroid – painful chancre (H. ducreyi – you cry c ducreyi) c ragged, rolled edges. Tx c Azithromycin
436. LGV – painless ulcer that heals and then forms painful nodes. Tx c erythromycin.
437. Granuloma inguinale – painless, beefy-red ulcer. Dx c Donovan-bodies on smear. Tx c Azithromycin.
438. Chlamydia – MC bacterial STD, can be asymptomatic or mild mucopurulent cervical discharge c or w/o cervical motion tenderness (CMT), (+) Cx/Ab test, (-) stain. Tx c azithromycin (1 dose) or oral doxycycline (7 days).
439. Gonorrhea – Lower GU causes d/c, itching, burning, dysuria; Upper GU causes abdo/pelvic pain. Disseminated when there is dermatitis, polyarthritis or tenosynovitis. Pt has vulvovaginitis c mucopurulent d/c c CMT on bimanual exam. Dx c chocolate agar, Gram (-) diplococci on stain. Tx (for GC and Chlamydia) Ceftriaxone + Doxycycline.
440. PID – lower abdominal pain, adnexal tenderness, CMT and fever 1 week after menses in a sexually active female. Cervicitis (only vaginal D/C, no pain – tx G/C), Salpingo-oophoritis (b/l lower abdo/pelvic pain c CVA tenderness – tx G/C), Tubo-ovarian abscess (pt will look septic, severe pain, n/v, dyschezia, fever – tx c Ampicillin, Gentamycin and Flagyl. If ruptured, ex-lap is done). Tx for G/C in these cases are: outpatient: ceftriaxone + doxycycline, inpatient: clindamycin + gentamycin
441. Gardnerella Vaginosis – fishy odor on whiff test, pH 6, clue cells, tx c metronidazole (clindamycin if pregnant in 1st TM)
442. Trichomonas vaginalis – frothy, green smelly discharge c strawberry cervix, pH 5. Tx c metronidazole for pt and partner (if pt pregnant, tx c vaginal betadine).
443. Candida yeast infection – itchy, burning, dyspareunia, cottage-cheese discharge, that sticks to the vaginal wall, pseudohyphae, pH 4, tx c nystatin or Amp B.
444. Contraception: remember effects of estrogen (increases BP, cholelithiasis, LFTs, HDL, art/venous thrombosis and decreases LDL) and progesterone (affects mood, increase weight, acne, increase LDL, decrease HDL). Absolute CI: pregnancy (causes VACTERL), liver dz, vascular dz (DVT, SLE, CVA) and hormonally-dependent cancers like breast). Benefits include decreased risk of ovarian/endometrial cancer, decreased dysmenorrhea/DUB/PID/ectopics.
445. IUD – put it in 1 week after menses and f/u in 1 week. Does not affect risk of STDs. Absolute contraindications include pregnancy, pelvic cancer, salpingitis, steroid use (pt on Crohns, asthma), h/o PID. Increased risk of ectopics and PID when placed.
446. Abnormal vaginal bleeding: Pre-menarchal (<12yo - foreign body, trauma, sarcoma botyroides, precocious puberty), reproductive (13-52yo - pregnancy, fibroids/adenomyosis, DUB), postmenopausal (>52yo - endometrial cancer). A neonate c vaginal bleeding is normal due to maternal estrogen, thus reassure mom.
447. Precocious Puberty – normally: breast development @ 9yo, pubic/axillary hair @ 10yo, growth @ 11yo, menarche @ 12yo. If only 1 stage occurs early, this is Incomplete isosexual precocious puberty, next step is CT brain/abdo/pelvis. If all stages occur early, this is complete isosexual precocious puberty, next step is tx c constant GnRH stimulation (to decrease estrogen). If pt has bone lesions and café-au-lait spots, pt has McCune-Albright Syndrome. If pt has high estrogen c a pelvic mass, they have a granulose-theca cell tumor, tx c surgery.
448. Dysfunctional Uterine Bleeding – MCC is anovulation d/t unopposed estrogen, so no secretory phase (d/t lack of progesterone) c unstable endometrial thickening. Pt will have h/o irregular, unpredictable menstrual bleeding without cramps. Next step is endometrial biopsy to r/o cancer. Tx c NSAIDS if she desires children, cyclic progestin therapy or daily combined OCPs if she doesn’t desire children or has menorrhagia.
449. Primary Amenorrhea – 1st step is pregnancy test (whether she says she is sexually active or doesn’t), 2nd step is physical exam: (+) breasts and (+) uterus -> check prolactin, if normal r/o imporferate hymen (cyclic menstrul pain c bulging hymen, predisposition to endometriosis, tx c surgery) and tx c progesterone. (+) breasts and (-) uterus -> get karyotype, if 46 XY, pt has Androgen Insensitivity Syndrome (Testicular Feminization, no pubic hair, next step is remove testes from abdm), if 46XX, pt has Rokitanky-Hausen syndrome (she will have pubic hair). (-) breast and (+) uterus -> gonadal dysgenisis, so next step is get karyotype to r/o Turners syndrome (45XO, webbed neck, far spaced nipples, streak ovaries, premature ovarian failure, needs estrogen).
450. Secondary Amenorrhea – 1st step is r/o pregnancy, 2nd r/o prolactinoma (if prolactin level is high, next step is MRI of head. If abnormal, pt has pituitary tumor, if normal, pt has drug-induced prolactinoma) and hypothyroidism, 3rd progesterone challenge test. If pt bleeds after 2 weeks (estrogen is adequate), check LH. If elevated pt has PCOS, if normal/low check TSH/prolactin again. If pt does not bleed after 2 weeks (inadequate estrogen) check FSH, if high pt has premature ovarian failure (next step is karyotype to r/o Turners vs Ovarian failure due to congenital adrenal hyperplasia), if normal/low pt has craniopharyngioma, next step is MRI. If MRI is insufficient, pt has Ahsermann’s syndrome (scarring due to prior D&C/D&E. Tx by surgically removing scarred tissue then giving high-dose estrogen for 1 month to regenerate lining). Again, if LH/FSH are high, next step is karyotype. If XO, pt has turners, if XX pt has ovarian failure (now r/o autoimmune dz versus CAH). If LH/FSH are normal or low, next step is MRI of head. If abnormal pt has pituitary tumor/destruction or hypothalamic dz (may be a/w Kallman’s syndrome (anosmia, amenorrhea), anorexia, exercise, tx c estrogen). If normal, pt has Asherman’s syndrome.
451. Breast mass in a female <35yo – Fibrocystic Dz (b/l, tender esp with menses, multiple, tx c reassurance and f/u later), Fibroadenoma (painless, rubbery, mobile, tx c observe but try not to stare too long), Mastitis/Abscess (lactating, painful, red, tx c clocacillin, if still there, I&D), Fat Necrosis (h/o trauma, tx c observation). Avoid mammogram in women <35yo (tissue too dense) and if suspicious of cancer go right to biopsy.
452. Breast mass in a female >35yo –Fibrocystic Dz (same as above, but this time you must aspirate it and do a mammogram. If mass resolves, observe. If FNA shows blood or if cyst recurs quickly, do biopsy), Fibroadenoma (mobile, get mammogram. If pt is low risk, observe, if high risk get biopsy). If pt is postmenopausal and has a mass, go right to biopsy.
453. If bloody discharge from the nipple -> intraductal papilloma. Next step is galactogram-guided excision.
454. Polycystic Ovarian Synd – female, hirsutism, amenorrhea, infertility (MCC of infertility in women <30yo c abnormal menses, while PID is MCC if normal menses) and insulin resistance (DM). Next step is U/S to show multiple cysts, then LH and FSH (ration should be 2:1), then testosterone and DHEA levels. Unopposed estrogen will increase risk of endometrial cancer. Tx c OCP’s, cyclic progestins, Metformin, Spironolactone and clomiphene if she wants kids.
455. Congenital Adrenal Hyerplasia – overproduction of adrogens causing virlization and amenorrhea. Young girls get clitoromegaly. 90% is 21-OH deficiency (salt-wasting, high K, low BP, high urinary 12-hydroxyprogesterone). Tx c steroids + IVF (to prevent death). Must do karyotype to figure out gender.
456. Review of hirsutism (excessive sexual hair) versus virilization (excess androgen, thus acne, balding, deep voice, clitoromegaly, amenorrhea): Hirsutism c high testosterone, normal DHEAS, CT shows enlarged ovaries is PCOS. Virilization c normal testosterone, high DHEAS, CT shows enlarged adrenals is Adrenal Tumor (CAH, tx c DXM suppression). Virilization c high testosterone, normal DHEAS, CT shows enlarged ovaries is ovarian tumor (tx c OCPs, GnRH analogs and surgery). Hirsutism c normal testosterone, normal DHEA, normal CT is familial hirsutism (a/w 5-alpha reductase defiency, tx c spironolactone, flutamide).
457. Menopause – high LH/FSH, low estrogen/progesterone. Hot flashes, osteoporosis, atrophic vaginitis, abnormal lipi profile, atherosclerosis/CAD. Tx c HRT for <5years and then calcium, exercise, and lubricants for sexual activity. HRT increases risk of CAD, invasive breast cancer, memory loss, stroke, PE. Decreased osteoporosis and colon cancer. Contraindicated in breast and endometrial cancer (must do endometrial biopsy before giving it), acute liver dz, active thrombosis, vaginal bleeding. If contraindicated, give SERMS (Tamoxifen, Raloxifen, which still increase risk of endometrial cancer).
458. Infertility: 1st step is semen analysis (tx c sperm injection), 2nd step is ovulation analysis (basal body temperature, endometrial biopsy, serum estrogen level to r/o anovulation. Tx c clomiphene), 3rd step is Hyterosalpingogram for tubal blockage, 4th step is laparoscopy.

CONGENITAL ANOMALIES/PERINATAL MEDICINE:

459. Down’s Synd – trisomy 21, 1/700 births (1/350 if >35yo), MR, endocardial cushing defect/ASD/VSD, duodenal atresia, simian crease, Alzheimers @ 40yo, epicanthal folds. Prenatal dx: high hCG, low AFP, low estriol, increased maternal age, amniocentesis, u/s shows thickened nuchal folds, CVS @ 9-12wk. Neonatal: 1st step is echo, then genetic counseling.
460. Edwards Synd – trisomy 18, IUGR, rocker-bottom feet, clenched hands, PDA/VSD
461. Patau’s Synd – trisomy 13 (P for P: cleft liP, cleft Palate), holoprosencephaly, renal and ocular malformations.
462. Cri du Chat Synd – Chrom 5p deletion, cat-like cry, MR so tx c special schooling
463. Turners Synd – Gonadal dysgenesis 45XO, 1/2000 newborn girls, short webbed neck, horseshoe kidney, coarctation of aorta, primary amenorrhea. Estrogen replacement
464. Klinefelters Synd – seminiferous tubule dysgenesis 47XXY, hypogonadism, gynecomastia, tall stature, infertility, give testosterone replacement starting at 12yo.
465. Fragile X Synd – macro-orchidism, MR
466. Achondroplasia – AD, short limbs, hydrocephalus (must monitor closely)
467. Xeroderma Pigmentosa – sunlight sensitivity from 1st exposure, conjunctitis leading to blindness, dx c skin biopsy and tx c strict sun avoidance (they will say kid only comes out at night).
468. Fetal Alcohol Synd – MR, flat philtrum, thin upper lip, worst in 1st TM
469. Tobacco in pregnancy – IUGR
470. Cocaine in pregnancy – CNS damage, placental abruption
471. Fetal Warfarin synd – epiphyseal stippling, CNS malformations, MR
472. Thalidomide – phocomelia (absence of long bones in extremities)
473. Syphilis – treponema pallidum, snuffles, palm/sole rash, anemia, hepatosplenomegaly, periostitis, Hutchinson’s teeth, sabir shings, saddle nose, tx c penicillin
474. Toxoplasmosis – oocytes from cat litter and meat, hydrocephalus, chorioretinitis, scattered CNS calcifications, tx: 1st avoidance, 2nd pyrimethamine, 3rd shunt for hydrocephalus
475. Rubella – blueberry muffin rash, PDA, deafness, cataracts
476. CMV – deafness, perventricular CNS calcifications, microcephaly
477. Herpes – aquired at birth (prevent c C-sxn), seizures (temporal lobe), encephalitis, vesicles, overwhelming sepsis, hepatitis, tx c acyclovir
478. HIV – all meds (except efavirenz) if CD <500, AZT only if CD>500 in 2nd/3rd TM and 6 weeks postpartum. Dx in kid c PCR (not ELISA).
479. Hypospadias – pee on your feet (ventral urethral opening), hooded prepuce, chordee (ventral curving of penis), tx c 1st avoid circumcision to save foreskin for reconstruction, 2nd surgery at 1yo
480. Omphalocele/Gastrocele – absence of anterior wall (gastrocele has no sac, omphalocele does). Tx: 1st cover c plastic wrap, 2nd surgery within 24 hours.
481. Posterior urethral valves – cause of UTI in young boys, a/w potters synd, dx c VCUG
482. Undescended testicle – cryptorchidism, rarely descent after 1yo, must differentiate from retractable testis, tx: if testes is palpable – wait for descent and do orchieplexy after 1 year. If testes are not palpable – consider hCG trial if b/l. 2nd – Orchiectomy for atrophied testis due to risk of malignancy and infertility for other testis.
483. Congenital Adrenal Hyperplasia – adrenogenital syndrome, no steroidogenisis due to 21-OH deficiency, ambiguous genitalia, clitoromegaly, salt-wasting, hyperkalemia. Tx: 1st fluids for low BP, 2nd treat hyperkalemia (calcium, alkalinization, insulin/glucose, kayexalate).
484. Choanal atresia – respiratory distress/cyanosis relieved by crying, a/w CHARGE synd (Colobama of eye, Heart defect, Atresia of choanae, Retardation, Genital hypoplsia, Ear anomalies). Tx c respiratory support.
485. Laryngomalacia – flexible larynx collapses causing obstruction on inspiration. Dx c fluoroscopy or direct laryngoscopy. Airway support if needed, otherwise self-limited.
486. Diaphragmatic Hernia – either at foramen of Bochdalek (left sided (b/c R side has liver), severe newborn respiratory distress, scaphoid abdm, mediastinal shift, pulmonary hypoplasia) or at foramen of Morgagni (presents later c bowel obstruction). Tx c 1st aggressive rescucitation, 2nd extracorporeal membrane oxygenation (ECMO), 3rd surgery.
487. Tetralogy of Fallot – PROVe (pulm HTN due to RV outflow obstruction, RVH, Overriding aorta, VSD), MC cyanotic CHD, presents >1yo, tet spells, boot-shaped heart
488. Transposition of great vessels – cyanosis in 1st 24hrs, aorta from RV, pulm artery from LV, egg on a string heart, tx c balloon atrial septostomy, then arterial switch
489. Total anomalous pulm venous return – pulmonary veins drain into systemic venous circulation (partial or total), snowman heart. 1st medications, 2nd surgery
490. Truncus arteriosis – single great artery is origin of aorta and pulm arter and coronary artery, listen for truncal valve click. Tx: 1st treat CHF, 2nd surgery
491. VSD – MC CHD, holosystolic murmur at 1-2months, tx c subacute bacterial endocarditis prophylaxis
492. ASD – pulmonary ejection murmur plus wide, fixed split S2, no SBE prophylaxis, usually presents after infancy
493. Coarctation of aorta – HTN in UE, low BP in LE, poor femoral pusles, Turners synd, rib notching on CXR, tx c balloon angioplasty
494. PDA – premature babies, congenital rubella, continuous machinery murmur c wide pulse pressure.
495. Hypoplastic left heart – underdeveloped LV and aorta, vascular collapse in 1st week of life, ductus dependent, tx: 1st prostaglandin E, 2nd Norwood or transplant
496. Hydrocephalus – communicating (obstruction of arachnoid villi) or noncommunicating (Aqueduct of Sylvius stenosis, Chiari malformation at cerebellar tonsils or Dandy-walker cyst of 4th ventricle). Baby c rapid increase in head circumference, split sutures, bulging anterior fontanelle, setting-sun sign (of eyes), 6th nerve palse, papilledema, dx c CT scan (do not do LP in risk of herniation). Tx: 1st hyperventilate and elevate head, 2nd mannitol, 3rd ventriculoperitoneal shunt
497. Congenital cataracts – rubella, CMV, toxo, galactosemia, tx c surgery right away to prevent permanent visual impairment.
498. Congenital glaucoma – tearing, corneal clouding, photophobia, sturge-weber synd (facial port-wine stain, seizures, CNS calcifications), neurofibromatosis, rubella, tx c surgery.
499. Congenital deafness – Alports (nephritis c deafness), CMV, rubella, maternal drugs.
500. Osteogenesis Imperfecta – brittle bones cause multiple fractures in a kid, blue sclera, osteoporosis, family history, type I collagen disorder, teeth deformities.
501. Developmental Dysplasia of the Hip – subloaxation of femoral head from the acetabulum, causing asymmetric thigh creases, clicking sound, + Ortolani sign (hip reducibility), + Barlow sign (hip dislocatability), dx c ultrasound. Tx c harness, then closed reduction, then open reduction (>6mo age) if closed reduction failed.
502. Talipus Equinovarus – toes face medially, forefoot adduction. Tx c manipulative casting, then surgery if needed.
503. Transesophageal Fistula – dx c failure to pass nasal catheter to stomach, AXR shows air-distended proximal esophagus. Tx: 1st NGT, 2nd surgery
504. Duodenal atresia – bilious projectile emesis, a/w Downs syndrome, abdominal distention, double bubble on AXR (air-distended stomach and proximal duodenum). Tx: 1st correct fluids/electrolytes, 2nd surgery
505. Pyloric stenosis – nonbilious projectile emesis, olive-shaped RUQ mass, dehydration c hypochloremic alkalosis. Tx:1st fluid/electrolyte correction, 2nd pyloromyotomy
506. Meckel’s Diverticulum – 2yo c painless rectal bleeding and abdm pain. Dx c technetium-labeled nuclear scan (Meckel’s scan), tx: 1st correct life-threatening anemia, 2nd surgical excision.
507. Hirschsprung’s Disease – congenital megacolon causing obstruction, absense of Auerbach’s and Messner’s plexus, failure to pass meconium in 1st week, dx c 1st barium enema (shows transitional zone) rectal biopsy (aganglionosis). Tx: 1st fluid/electrolyte correction, 2nd Abx if enterocolitis suspected, 3rd surgical excision of ganglionic segment.
508. Hyaline membrane Disease – RSD, surfactant insufficiency, early onset (hours after birth) baby has tachypnea, grunting, nasal flaring and retractions. Early problems include breathing difficulty, metabolic disturbances and infection. Late problems include broncopulmonary dysplasia. Risk factors include prematurity, maternal DM and multiple pregnancies. Dx: 1st CXR (shows fine reticular granularity in b/l lungs), 2nd L:S ratio (should be >2:1) and phosphatridylglycerol. Tx: Prevention is the best tx (prevent prematurity, give maternal steroids 48-72 hours antepartum if <33 weeks to women who do not have toxemia, DM or renal disease), 2nd – correction of hypoxia, acidosis, hypercapnea, hypotension, hypothermia and anemia. 3rd neonatal surfactant (via ETT) at delivery but avoid uneccessary pulmonary barotraumas or oxygen toxicity.
509. Chlamydia – conjunctivitis 4-7 days after birth, staccato cough, tx c erythromycin.
510. Gonorrhea – conjunctivitis 3-5 days after birth, disseminated infxn, chocolate agar, Thayer-martin media, tx c parenteral abx.
511. GBS – early onset (<3days old) has resp distress, pneumonia, meningitis; late onset (7days-3mo) has meningitis, osteomyelitis, septic arthritis and occult bacteremia. Prevent c culture at 35-37wk and penicillin at birth. Neonates given abx if febrile.

PSYCHIATRY

512. If you see a question about the best next test and one of the answers is “mini-mental exam,” pick that one.
513. Autism – starts by 3yo. Impaired social interactions (unaware of surroundings), impaired verbal/nonverbal communication (if verbal is okay, dx is Asperger’s syndrome), and restrictive activities and interest (head banging, strange movements). Linked to congenital rubella. Tx c 1st structured classroom training, behavioral modifications, family support, 2nd halorperidol, risperidone, SSRI’s. If child has normal development and then deteriorates into this condition or worse, that is Rett’s syndrome.
514. Learning disorder – impairment in reading (80%), math, language, written expression with no mental retardation or lifestyle anomalies. Tx c educational intervention.
515. ADHD – dx <7yo. Boy is hyperactive, impulsive and has a short memory span, but is not cruel. Tx: 1st individual/family therapy and behavioral modifications, 2nd methylphenidate (Ritalin) or dextroamphetamine, both of which may cause insomnia, abdm pain, HA, anorexia, exacerbations of tics, weight loss or growth suppression. Tx c 1st atimoxitine (but must be given everyday, so if mom says kid only has s/s Monday thru Friday, then you cannot give this, give tx #2), 2nd Methylphenidate or amphetamine.
516. Conduct Disorder – violates society norms, pediatric form of antisocial disorder. Look for fire setting (if only this, dx is pyromania), cruelty to animals, lying, stealing, fighting. Must have this disorder in order to make diagnosis of antisocial d/o as adult. Tx: 1st evaluate suicide/violence potential, 2nd containment by parents, schools, legal system or hospital, 3rd tx aggression c SSRI or haloperidol, 4th individual/group/ family therapy.
517. Oppositional Defiant Disorder – negative, hostile and defiant behavior towards authority figure. Note the different between this and conduct d/o is that here, the kid is just bad to adults behaves with peers and is not a cruel, lying criminal. Tx c individual/family therapy
518. Separation anxiety Disorder – look for a kid who refuses to go to school or sleep alone or away from home by claiming sickness, stomachache, HA or temper tantrums. Must be >6months old (might ask about 8mo baby who cries when he sees grandma for 1st time = separation anxiety, but if kid was under 6mo, its normal) School refusal is a psychiatric emergency and needs prompt evaluation and treatment involving parents, school and peers.
519. Tourette’s Disorder – (only 10-30% curse), look for males c motor tics (blinking, grunting, throat clearing, grimacing, barking, shrugging) that are exacerbated by stress and remit c activity or sleep. Linked to ADHD and OCD. Tx: 1st Haloperidol (improves 80% but watch for EPS, mental dulling and tardive dyskinesia). 2nd Pimozide or Clonidine
520. Encopresis – >4yo c passage of feces into inappropriate places (clothing, floor). r/o Hirschsprungs disease. Tx c behavioral techniques, individual therapy.
521. Enuresis - >5yo c inappropriate voiding of urine. Tx: 1st behavioral techniques (bell, buzzer, bed time fluid restriction), 2nd Imipramine (last resort).
522. Dementia vs Delerium: Delerium (rapid onset, fluctuating consciousness, often reversible, perceptual disturbances, incoherent speech). Dementia (insidious onset, clear consciousness (until late in course), irreversible).
523. Alzheimer’s vs Vascular (Multi-Infarct) Dementia: Alzheimers dementia (women, older, chrom 21, linear/progressive, no focal defecits (key), supportive tx). Vascular dementia (men, younger than alzheimers, HTN, stepwise/patchy pattern, (+) focal deficits (key), tx underlying condition).
524. Alcohol – intoxication includes slurred speech, ataxia, disinhibition, impaired judgement, coma and blackouts. Withdrawal includes tremor, agitation, irritability, n/v, fever, seizures, delirium tremens (onset of delirium, vivid auditory/tactile/visual hallucinations, paranoid delusions 2-3 days post cessation of long-term heavy use). Tx intoxication supportively. Tx withdrawal c vital sign/electrolytes/Mg/thiamine/vit B12/folate/glucose monitoring. 2nd Hydration c thiamine before glucose (prevent Wernicke), 3rd benzodiazepine (chlordiazepoxide). Tx dependence c confrontation of denial and rehab (AA). Specific managements: Alcohol hallucinations (chlordiazepoxide, IVF, haloperidol), Wernicke’s encephalopathy (sudden ataxia, confusion, nystagmus, lateral rectus palsy from thiamine deficiency. Tx c thiamine) Korsakoff’s syndrome (severe anterograde/retrograde amnesia, confabulations and polyneuritis from thiamine defiency).
525. Opioids – intoxication includes euphoria, analgesia, hypoactivity, anorexia, drowsiness, n/v, constipation, pin-point pupils, hypotension and bradycardia. Overdose includes CNS/respiratory depression, pinpoint pupils, pulm edema, seizure, coma and death. Withdrawal includes (not deadly) rhinorrhea, yawning, diarrhea, sweating, dilated pupils, tachycardia and HTN. Tx overdose c naloxone. Tx dependence c abstinence through methadoes titration.
526. Stimulants – amphetamines/cocaine, rapid dependence of tolerance, IVDA risks, paranoid psychosis. Intoxication includes euphoria, alertness, increased energy, anxiety, talkativeness, mydriasis, tactile hallucinations (crawling bugs), HTN and tachycardia. Withdrawal includes (non-deadly) fatigue, hypersomnia, anxiety, dysphoria, suicidal ideation, craving. Tx intoxication symptomatically (antiarrhythmic, benzo for agitation, haloperidol). Tx withdrawal supportively (observe for suicidality). Tx dependence c rehab.
527. Sedatives – benzo/barbs – intoxication causes slurred speech, drowsiness, impaired attention, disinhibition. (Flumetrazepam is the date-rape drug). Overdose c barbs for suicide, (not so much benzo b/c of high therapeutic index, unless taken with another drug or alcohol). Both cause resp depression, coma, death. Withdrawal causes anxiety and insomnia. Severe withdrawal is a medical emergency (n/v, autonomic hyperactivity, photophobia, tremor, hyperthermia, delerium, seizures, death) most severe c short-acting drugs. Overdose benzo c flumazenil (does not reverse resp depression), barbs c charcoal, gastric lavage. Tx barbiturate withdrawal c pentobarbital challenge test to get daily dose, and taper off. Tx benzo withdrawal c long-acting benzo (diazepam, clonazepam) and gradually withdraw.
528. Nicotine – acetylcholine (nicotinic) agonist. Withdrawal causes irritability, wt gain, and difficulty c concentration. Tx: 1st obtain specific date to stop, 2nd educate/counsel.
529. PCP – paranoia, assaultiveness, impulsiveness, vertical and/or horizontal nystagmus (dead give-away), diaphoresis, resp depression, seizures, normal size pupils. Tx symptomatically
530. Hallucinogens – LSD, Ecstacy – sympathomimetic effects (mydriasis, tachycardia, sweating, diarrhea, urination), panic reactions, illusions, paranoia. Later on, pt may not be using drug anymore and reexperience intoxication (flashback).
531. Cannabinoids – Marijuana/THC – intoxication has euphoria, bad judgement, slowed reactions, dry mouth, conjunctival injection (dead give-away). Chronic use causes amotivational syndrome and memory impairment.
532. Hallucination is a disturbed sensory perception (visual, tactile, auditory). Delusion is a fixed, false belief (even if people prove to you otherwise). Psychosis is inability to judge boundary between real and unreal.
533. Schizophrenia – presence of >2 s/s of the following for >6months: delusions, hallucinations (generally auditory, link visual c alcohol withdrawal), disorganized speech/behavior, negative s/s (flat affect, no speech, no motivation, anhedonia). Better prognosis (NBME 3 question) if acute, late onset, good social/occupation hx, positive s/s, medication compliance, married, female gender. Symptoms due to altered dopamine activity (newer antipsychotics affect serotonin also). Negative s/s have enlargement of cerebral ventricles and hypoactive frontal lobe. Tx: 1st assess if pt needs hospitalization (protect self/others), 2nd Antipsychotics (Risperidone), 3rd Psychosocial tx. [Timeline: <1month = brieft psychotic d/o, 1-6months = schizophreniform, >6mo = schizophrenia]
534. Delusional (Paranoid) Disorder – persistent, nonbizarre, well-systematized delusion. Erotomanic (on is loved by a famous other, NBME 3 TQ), grandiose (one possesses great talent), jealous (conviction that lover is unfaithful), persecutory (one is conspired against, MC), somatic (one has a physical abnormality like odor). Tx: 1st hospitalization for inability to control suicidal/homicidal impulses or danger a/w delusions, 2nd psychotherapy, 3rd antipsychotics/antidepressants.
535. Schizophreniform – schizophrenia <6months. Good prognosis c acute onset, confusion, disorientation, full affect, tx c antipsychotics for at least 6 months.
536. Brief Psychotic Disorder – sudden onset of psychotic s/s c emotional turmoil and confusion, often following obvious stressor, duration <1month. Suicide risk, thus tx 1st hospitilization as needed, 2nd antipsychotics/antianxiety agent, 3rd psychotherapy
537. Schizoaffective – schizophrenia c depression or mania for at least 2 weeks.
538. Shared Psychotic disorder – submissive, dependent isolated relationship with person c established delusion. Suicide/homicide pacts. Tx: 1st separate the 2 people, 2nd antipsychotics.
539. Mania – >1wk of elevated, expansive, irritable mood c grandiosity, no sleep, talkativeness, impulsitivity (shopping sprees, gambling, promiscuity) , racing thoughts, distractibility, agitation. Hypomania is less severe and lasts >4days.
540. Major depression disorder (MDD)– 2 of SIGECAPS in >2wks– sleep changes (delayed sleep onset, decreased REM. Note the difference: Anxiety has increased REM latency, depression and narcolepsy have decreased REM latency), interest loss, guilt, energy loss, concentration decreased, appetite (up or down), psychomotor (retardation or agitation), suicidality. Decreased serotonergic activity a/w violence and suicide. Tx: Hospitalize if suicide risk, 2nd Antidepressant (SSRI 1st) for 6-12 months (not that it takes 4-6wks to start effects), 3rd ECT (rapid response in pregnancy, elderly, medically ill), 4th psychotherapy, 5th antipscyhotic + antidepressant for psychotic pts, 5th Phototherapy if depression is seasonal, 6th treat comorbid psychopathology (anxiety, substance abuse, personality d/o, ADHD).
541. Depression vs Bereavement – Depression (mood pervasive/unremitting, constant low self-esteem/worthlessness, suicidal, sustained psychotic s/s, no improvement c treatment, social withdrawal). Bereavement (mood fluctuates, self-reproach regarding deceased, not suicidal, transient visual/auditory hallucinations or deceased, s/s improve c time and usually gone by 6 months, often welcomes social support). It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, while an MDD pt thinks its real. Other clues to MDD that are not normal are feeling of worthlessness, suicidality and psychomotor retardation.
542. Bipolar Disorders: Type I is full-blown mania c MDD. Type II is hypomania c MDD. Tx: 1st assess risk of suicide, assaultiveness, dangerous poor judgement. 2nd For acute mania give mood stabilizer (lithium). For depression – modd stabilizer c or w/o antidepressant if necessary.
543. Cyclothymia – numerous hypomanic episodes c depressive episodes for >2yrs. (Cyclo is a psycho, while dysthymia is just depression for >2yrs).
544. Panic Disorder – minutes to hours of unexpected, sudden intense anxiety, dyspnea, parasthesia, CP, fear of dying. A/w agoraphobia (fear of places where escape is difficult such as bridges, public transportation, large crowds, traveling). Tx: 1st If acute, emergent case, give reassurance and benzo (alprazolam, clonazepam). 2nd R/o MI, PE, CVA, hypoglycemia, 3rd Antidepressants (SSRI is tx of choice for long-term management), 4th Cognitive-behavioral therapy (CBT) for agoraphobia.
545. Obsessive-Compulsive Disorder – recurrent intrusive images, impulses, thoughts (obsessions) and ritualistic behaviors (compulsions) that produce anxiety and affect way of life. A/w Tourette syndrome. Abnormality is serotonin system. Tx c SSRIs (fluvoxamine), but if you only see TCA’s pick clomipramine.
546. Specific Phobia – irrational, excessive fear and avoidance of a specific object or situation. Tx: Systemic desensitization.
547. Social Phobia – fear of embarrassment, scrutiny of others (public speaking, eating in public, public bathrooms). Tx: 1st CBT, 2nd BB (propranolol) for stage fright, 3rd Antidepressants (not TCAs) and high-potency benzodiazepines.
548. Posttraumatic Stress Disorder – >1 month, must have 3: reexperiencing (flashbacks), emotional numbing (avoidance), autonomic arousal (insomnia, irritability). Tx: 1st hospitalize for acute suicide, violence risk. 2nd CBT, 3rd Antidepressants.
549. Acute Stress Disorder - <1month of the same 3 symptoms. Tx c psychotherapy.
550. Generalized Anxiety Disorder – unrealistic, persistent anxiety for >6months. Muscle tension, restlessness, poor concentration, fatiguability, irritability, loss of sleep. Tx: 1st psychotherapy, 2nd Antidepressants (Buspirone).
551. Somatorofrm Disorders – unlike factitious disorder and malingering, the symptoms are not intentionally produced but are strongly linked to psychological factors. Examples include somatization disorder (multiple somatic complaints, tx c regularly scheduled visits c PMD), conversion disorder (neurologic s/s), pain disorder (pain in absence of adequate physical findings, tx c psychotherapy), hypochondriasis (fear of specific disease, tx c regular medical visits), and body dysmorphic disorder (preoccupation c defect in appearance, tx c psychotherapy and SSRI’s after you assess suicide risk).
552. Factitious disorder – “Munchausen syndrome.” Intentional production of s/s for unconscious psychological reasons (need to assume sick role) usually in someone in medical occuption or c history of illness. If s/s produced by parent, this is Munchausen’s by proxy. Tx c psychiatric consult, confrontation may be helful.
553. Malingering – intentional production of symptoms for a recognized gain (money, drugs, avoid work/military/prison).
554. Dissociative Identity disorder – multiple personalities, which take over life and pt may or may not be aware of each other. Tx c intensive psychotherapy.
555. Amnestic Disorder – 2 types: psychogenic fugue (sudden, unexpected travel c amnesia of old identity and assumption of new identity that lasts hours to months, pt is unaware of loss) and psychogenic amnesia (sudden inability to recall important personal information of a traumatic or stressful event, but aware of loss). Recovery usually returns spontaneously. If not, try hynosis, amobarbital or psychotherapy.
556. Depersonalization disorder – recurrent feeling of detachment from one’s body or self (feel like you’re in an outside world).
557. Anorexia Nervosa – must have 3: amenorrhea, minimal normal body weight, fear of gaining weight. Tx: 1st hospitalize for dehydration, starvation, hypotension, electrolyte, hypothermia, suicide risk. 2nd treatment contract for wt gain, 3rd CBT.
558. Bulimia Nervosa – binge eating, normal weight, overconcerned c wt/diet/exercise, self-induced vomiting, laxatives/diuretics, a/w kleptomania. Tx: 1st hospitalize for ECG (hypokalemia-induced arrhythmia is MCCOD), electrolytes, amylase, LFTs, esophageal/gastric rupture, suicide risk. 2nd psychotherapy, nutritional counseling, SSRI for binging (do not give buproprion for risk of seizures).
559. Old, classic USMLE TQ: Mom finds her son having sex c another boy, is this normal or homosexuality? Normal (unless they say he enjoys it). Another TQ is a man, who knows he is a man and likes women, dresses up like a woman and acts like a woman, what is his sexual orientation? Heterosexual (b/c he likes women).
560. Projection – attributing your own wishes to someone else. A/w paranoid personality d/o (p for p – paranoia c projection)
561. Denial – if they deny having a disease, next step is do nothing! (because it usually does not interfere c treatment, but if it does, next step is confront the pt).
562. Splitting – all is good or bad. a/w borderline d/o. If they only say all is good, its idealization. If they only say all is bad, its devaluation. Splitting must have both.
563. Regression – look for h/o bedwetting in a kid >5yo (<5yo is normal).
564. Reaction formation vs Undoing – rxn formation is a thought, undoing is an action. Both are classically a/w obsessive compulsive d/o, where rxn formation is the obsession, and undoing is the compulstion.
565. Reaction formation vs sublimation – sublimation does something good for mankind.
566. Primary insomnia – disturbance in initiating, maintaining or feeling rested after sleep. Tx: 1st hygeine treatment: regularize sleep hours, use of bed only for sex/sleep, if not asleep in 30 minutes then leave bed and return only when drowsy, no napping, regular exercise but not immediately prior to bedtime, reduce/eliminate alcohol/caffeine/smoking, relaxation exercise. 2nd sedative-hypnotics (benzo, zolpidem) for short-term relief
567. Narcolepsy – daytime drowsiness, irresistible sleep attacks c hypnagogic/hympopompic hallucinations, sleep paralysis, cataplexy (loss of muscle control c strong emotions). Tx c short daytime naps, 2nd stimulants for sleep attacks and TCAs for cataplexy.
568. Sleep apnea – obstructive type d/t occlusion of upper airway during sleep in an obese pt. Central type is d/t reduced nocturnal resp drive). Dx c polysomnography. Tx:1st wt reduction, 2nd CPAP for obstructive type, Acetazolamide or protriptyline for central type.
569. Restless Legs Synd – agonizing, deep creeping sensations in leg/arm muscles relieved by moving or massage. Pt has trouble falling asleep at night because of it. Tx c benzodiazepam.
570. Intermittent Explosive – discreet episodes of loss control of aggressive impulses, but otherwise not aggressive. Tx c benzo (causes disinhibition) and CBT.
571. Kleptomania – failure to resist stealing unnecessary and unneeded things. a/w Bulimia.
572. Pyromania – deliberate fire setting and fascination c fire, usually in kids. Make sure the guy is not getting paid to do it and that it is completely for self-satisfaction.
573. Trichotillomania – recurrent pulling out of one’s own hair. Tx c psychotherapy, SSRI.
574. Adjustment Disorder –excessive emotional/behavioral responses that occur within 3 months of a stressor that is within range of normal experience (unlike PTSD), such as school problems, marital discord, job loss or illness. Does not persist after 6 months of stressor. Lacks sufficient evidence to make for other diagnosis (MDD). Tx:1st evaluate suicide risk. 2nd psychotx, antianxiety, antidepressants, 3rd stress reduction.
575. Personality Disorders - Cluster A (Weird: Paranoid, Schizoid (pt wants to be alone), Schizotypal (peculiar ideations/appearance/behavior magical thinking)), Cluster B (Wild: Antisocial (exploitative, destructive, impulsive behavior c no remorse. Childhood h/o conduct d/o essential for dx. Tx c SSRI), Borderline (instability of self-image, identity, relationships and mood. Does crazy things and still feels empty inside. h/o child abuse. Tx c pschotx (long-term), SSRI for mood stability and impulsitivity, haloperidol for psychosis. Avoid benzo), Histrionic (attention seeking, hits on the doctor, needs praise and reassurance), Narcissistic (grandiose, mad if humiliated, lack of empathy). Cluster C (Worried: Obsessive-compulsive (tx c fluvoxamine), Dependent, Avoidant (does not want to be alone (unlike schizoid), but fears rejection)
576. Antipsychotics (Neuroleptics): Low-doses (thioridazine, chlorpromazein), high-doses/long-acting (haloperidol, fluphenazine. Highest risk of EPS, NMS), atypical (clozapine, risperidone, olanzapine, quetiapine, ziprasidone). Typicals block dopamine (D2) receptors, thus used for positive symptoms only and have many side-effects, while Atypicals block serotonin (5-HT), D2 and D4, thus can be used for positive and negative symptoms and have fever side-effects. Adverse-effects: Hours-Days: Dystonia (spasms), Torticollis and oculogyric crisis (eyes stay looking up). Tx c benztropine, diphenhydramine or trihexylphenidate. Weeks: Akathisia (restlessness). Tx c lowering drug-dose, benzo, BB, or switch to atypical (best). Months: Tardive dyskinesia (lip-smacking). Tx c switching to atypical. Neuroleptic malignant syndrome: MC c high-potency drugs, increased risk if used c lithium, fever, rigidity, autonomic instability, very high CPK levels, high K+, tx c IV dantrolene or bromocriptine. Clozapine causes agranulocytosis (must do weekly CBC if taking), thioridazine causes retinal pigment deposits, chlorpromazine causes jaundice and photosensitivity.
577. Newer Atypicals Adverse Effects: Risperidone (less sedative, but increases prolactin, incrase risk of movement d/o), Olanzepine (love to ask about. weight gain (MC), risk of DM), Ziprasidone (prolonged QT), Quetiapine (risk of movement d/o)
578. Antidepressants: block NE, 5-HT, Dopamine. MAOIs (bad b/c of Tyramine food reaction (cheese, red wine, chocolates, sausages). Must stop MAOI at least 2 weeks before starting TCAs or SSRI. Tx of choice for atypical depression (increased sleep/weight/appetite or Leaden paralysis)). TCAs (best ones are nortryptilline and desipramine, worst is amitriptylline. Causes hypotension, anti-cholinergic s/s, conduction defect (MCCOD, MC is sinus tachy, but USMLE loves widened QRS, tx c bicarb), sexual problems, changes in wt, sedation). SSRI (1st choice for MDD (fluoxetine, sertraline, peroxitine, citalopram, escitalopram), Anxiety (fluoxetine, sertraline, peroxitine) and OCD (fluvoxamine only). Causes headache (MC), GI upset, sedation, agitation, sexual dysfunction (worst s/s), weight gain). Others include Venlafaxine (MDD, anxiety), Duloxetine (MDD, pain d/o), Bupropion (MDD, smoking cessation), Mirtazipine (weight good (good for anorexia), sedation), Trazodone (priapism). In a nutshell, always answer SSRI unless: 1- pt c MDD and neuroleptic (spinal) pain, give duloxetine; 2 – pt c MDD and has sexual changes/weight gain, give bupropion (not buspirone for GAD).
579. Mood stabilizers – Depressed pt (lithium or lamotrigine) or Mixed/Manic (Lithium, valproic acid, antipsychotics). Either way, lithium is 1st line. It causes tremors, GI upset, hypothyroidism, nephrotoxic, teratogenic, acne, wt gain, leukocytosis, ataxia, and seizures. Must get weekly blood levels and must get TSH, BUN/Cr, hCG before starting it. If renal disease, pick valproic acid, if very acute mania pick haloperidol, otherwise always go with lithium first. Never discontinue lithium abruptly and levels >3.0 is a medical emergency that needs IV saline or hemodialysis.
580. Electroconvulsive therapy – increases serotonin for conditions like MDD, mania and schizophrenia. No absolute contraindications. Only relative CI is high intracranial pressure (brain tumors). Who gets it? Suicidal pt (tx of choice), those who don’t respond to meds, pregnancy, h/o benefit c ECT, medication complications. MC adverse effect is memory loss.
581. Benzodiazepines – all work on CP450 exams OTL (Oxazepam, Temazepam, Lorazepam), so remember OTL for Outside The Liver.
582. Suicide – if pt mentions it, next step is to ask more questions (attempt, ideations), then admit. Risks: h/o attempt (best indicator of eventual success), hopelessness, psychiatric/physical illness, drug abuse, elderly, social isolation (living alone is worse than single, they are not the same thing!), low job satisfaction. MC method in males are guns, females are guns. MC attempt in males are guns, females are pills.

PULMONARY:

583. When to intubate? pO2<50, pCO2>50, pH<7.3 @ room air. Remember if pt becomes fatigued, this is a bad sign, don’t assume he’s just tired, intubate him.
584. Common cold – rhinitis, sneezing, headache, malaise and cough (no fever). Rhinovirus is MCC (also adenovirus, RSV, influenze). Tx: keep well hydrated, NSAIDS for fever, warm salt water gargles for pharyngitis (fever, dry/sore throat) and laryngitis, pseudoephedrine/phenylephrine for nasal congestion, avoid aspirin in children
585. Pharyngitis (strep throat) – although viruses can be a common cause, r/o bacterial infection (group A strep, aka strep pyogenes) c rapid strep test. Clues to strep throat include cervical lymphadenopathy, fever, pharyngeal and tonsillar exudates and the absence of cough. Tx c penicillin/erythromycin is given to prevent complications (peritonsillar/retropharyngeal abscess, meningitis, endocarditis, acute RF and glomerulonephritis). If viral etiology, supportive care only.
586. Peritonsillar abscess – dysphagia, fever, pain and trismus (hard to open mouth). Uvula displaced by swelling, tx c surgical drainage and antibiotics.
587. Thrush – candidal infection that has removable white patches in the mouth (rememeber, candida CAN come off, hairy leukoplakia cant). Tx c nystatin, fluconazole.
588. Sinusitis – facial pain/pressure, fever, greenish purulent rhinitis. If suspected, go ahead and begin tx c amoycillin, then get x-ray, then CT-scan of sinus. Only maxillary and ethmoid sinuses are present in children. Ethmoid sinusitis is more frequent in children. Cavernous sinus thrombosis is a complication that includes facial edema, meningitis and opthalmoplegia.
589. Allergic rhinitis – sneezing, itchy/water eyes, nose blocked and/or runny. Tx c corticosteroids and cromolyn sodium, antihistamines, decongestants, allergy shots.
590. Nasal polyps – swollen mucosa/submucosa polypoid tissue causing obstruction of nasal cavity. A/w allergic rhinitis, cystic fibrosis and aspirin intolerance.
591. Croup – (laryngotracheobronchitis) an acute viral illness in young kids who get cold s/s at onset, then barking cough, slight fever and inspiratory/expiratory stridor. X-ray shows steeple sign. Tx c humidified air then racemic epinephrine.
592. Epiglottitis – kid c drooling, high fever, resp obstruction, dyspnea, dysphagia, inspiratory stridor, lateral x-ray shows thumb sign. Do not irritate the kid or maneuver epiglottis as that would worsen obstruction. MCC is H. influenza type B. Tx c cephalosporins and intubation if needed.
593. Pertussis – 3 stages: catarrhal (coryza for 1-2wk), paroxysmal (whooping cough, 2-4wk), convalescent stage weeks later. Tx c erythromycin in catarrhal stage, otherwise supportive care.
594. Acute Bronchitis – large airway inflammation, productive cough, fever, mild dyspnea, CXR is clear (if there was an infiltrate, then its pneumonia). Tx c abx, hydration, expectorants, bronchodilators.
595. Bronchiolitis – small airway inflammation, tachypnea, wheezing, fever, cough in a child <2yo. Caused by RSV. Tx c ribavirin and oxygen.
596. Pulmonary Nodule – 1st step is get old xray. 2nd step If lesion was present and is the same size, its benign (hamartoma, discharge home). If the lesion was there and has gotten bigger, assume cancer. However, if the lesion was not in the old-xray, then classify his risk. If he is low risk (<40yo, nonsmoker) then its probably benign (hamartoma, CXR every 3mo for 2yrs). If he is high-risk (>50, smoker), assume cancer (do open-lung biopsy).
597. Pneumonia – Typical (<2days prodrome, fever >102, >40yo, one lobe involved) is d/t strep pneumo (gram + diplococci, tx c levaquin, prevent c vaccine in >65yo and pt c comorbidities, tx c 3rd generation cephalosporins). Atypical (>3days, HA, aches, dry cough, <40yo, multiple lobes, diffuse) in a young, otherwise healthy adult c atypical pneumonia is Mycoplasma/H. Influenza/Chlamydia and tx c Azithromycin. College student c dry cough, think of Mycoplasma (cold agglutinins) or Chlamydia. An elderly pt c COPD likely has bacterial pneumonia, or if in the winter, possible influenza. An AIDS pt c low CD4 and subacute illness has PCP (tx c bactrim (if allergic, give dapsone) or prophylax when CD<200). A pt whose mentation is altered (postop from anesthesia, demented, intoxicated) or who have swallowing dysfunction (CVA) has aspiration pneumonia. An alcoholic will likely have Klebsiella. If you see CNS (headache), GI (diarrhea) and pneumonia, its Legionella so give erythromycin (1st test is urine legionella Ag test, most accurate test is direct fluorescent antibody from sputum). If cystic fibrosis or hospitalized for a long time, think pseudomonas (though S.aureus is still a big one here) and tx c piperacillin/tazobactam or ceftazidime. If pt is a farmer (cattle, sheep, goats) or veterinarian, think of Coxiella burnetti (tx c doxycyline) or chlamydia psitacci (bird-exposure, tx c doxycycline). (Pediatric Wheezing: <1yo is RSV, 2-5yo is Croup (barking) or epiglottitis (drooling), >6yo is Asthma)
598. Influenza – fever, chills, cough, sore throat c positive throat/nasal swabs in the winter-time. For prophylaxis, give Amantidine (influenza A only) or vaccine (>50yo or high-risk pt). If discovered <2days, give Oseltamivir. If >2days, rest/fluids/symptomatic tx c analgesics/antipyretics.
599. Pneumococcal vaccine – everyone >65yo, anyone (>2yo) c COPD/DM/alcoholism/ immunocompromised (HIV/AIDS, cancer, steroid-use, chemotherapy)/post-splenecomy.
600. Influenza vaccine – children 6-23months, >65 (Dr. Fisher says >50yo) c chronic medical conditions, residents of nursing homes, health care workers c pt contact, children (2-18) c chronic aspirin use (Kawasaki’s), caregivers of kids <6mo.
601. TB – caseating granulomas, transmission by aerolized droplets (overcrowded areas, poor ventilation, health-care workers, immunocompromised, homeless), fever, productive cough, night sweats, chills, wt loss. If symptomatic, next step is CXR then AFB. If asymptomatic, next step is PPD (refer to ID notes for Mantoux reaction margins), then CXR then AFB. Tx c RIPE until culture sensitive.
602. Histoplasma – Ohio/Mississipi river bird/bat droppings in soil grow spores, which are inhaled. If mild, no tx. If more ill give ketoconazole or amphotericin B. If disseminated (AIDS pt) then 1st step is blood/bone marrow culture, 2nd Ampho B.
603. Coccidiomycosis – flulike s/s, arthralgia, erythema nodosum/multiforme rash. If mild, no tx. If severe, give Ampho B.
604. Cryptococcus – AIDS or steroid-use pt gets infected c encapsulated yeast found in soil/pigeon droppings in NY area causing s/s in the lungs and CNS (meningitis). Tx c Ampho B + flucytosine for severe disease.
605. Lung Abscess – purulent/putrid sputum, cough, chest pain, fever, pt c poor dentition and aspiraton, CXR shows cavities and air-fluid level. Tx c IV penicillin G.
606. A-a gradient: 150 – (1.25 x PCO2) – PaO2. (NL = 5-15, high c all hypoxemia causes except hypoventilation and high altitude)
607. Obstructive – low FEV1, low FVC, low FEV1/FVC, low DLCO in emphysema, normal DLCO in Chronic bronchitis/Asthma. FEV1 determines severity of disease (60-70% is normal-moderate COPD, <50% is severe COPD). Decreased lung flow.
608. Restrictive – FEV1, FVC both decreased, but FEV1/FVC is normal. TLC is reduced. Decreased lung volume.
609. COPD – what are the only things that decrease mortality? Home O2 (when PaO2 <60mmHg) and smoking cessation. If tx is not sufficient c bronchodilators, give theophylline (decreased clearance if also given c erythro, cipro, cimetidine). Tx 1st Anticholinergics (ipratropium bromide MDI), 2nd Albuterol, 3rd Theophylline. What is the best predictor of survival? FEV1. Vacccines? Influenza annually and pneumococcus every 5 years.
610. Chronic Bronchitis – blue bloaters (due to cyanosis), productive cough, recurrent pulm infections.
611. Emphysema – pink puffer, progressive dyspnea, low DLCO, less cough, cachexic, barrel chest, sits in tripod position, hyperresonant lungs, distant heart sounds, CXR shows huge lungs c bullae,. If in a young pt c no smoking history, pick alpha-1-antitripsyn (AAT) deficiency, tx c purified human AAT.
612. Asthma – for attacks: 1st give oxygen, 2nd peek flow, 3rd Albuterol, 4th Steroids for 14 days (no abx). What if pt has attack secondary to BBs? Give anticholinergics (ipratropium bromide). For exercise-induced asthma, give cromolyn and albuterol before exercising. Chronic tx: daily inhaled steroids, albuterol as needed (other drugs depend on type of asthma). For acute evaluation get ABG (resp alkalosis, if it gets normal that’s bad), Pulse ox, CXR. For chronic evaluation, get PFTs, methacoline challenge, bronchodilator (test reversibility). Tx of choice for nocturnal cough is long acting B-agonist (Salmeterol).
613. Bronchiectasis – cupfuls of purulent/malodorous productive cough, wt loss, hemoptysis, clubbing, a/w cystic fibrosis and kartegener’s syndrome (immotile cilia). Dx c CXR 1st then CT (best, but not 1st). For acute management, tx for pseudomonas (ticar/pipercillin, quinolones, ceftazidine). For chronic tx, give bronchodilators, postural drainage, rotate abx (prevent resistance), surgery and vaccines.
614. Pulmonary Fibrosis – interstitial inflammation, exertional dyspnea (MC s/s), crackles, clubbing, cor pulmonale. Dx: 1st CXR (shows ground-glass appearance), 2nd CT, 3rd Lung biopsy (gold standard). Tx c steroids for 6months, then transplant if needed and f/u PFTs.
615. Allergic Bronchopulmonary Aspergillosis (ABPA): must have 6 of the following 7: h/o asthma, peripheral eosinophilia, pulm infiltrates, + skin test to Aspergillus, high serum IgE, +IgE/IgG for Aspergillus, central bronchiectasis. Tx c prednisone.
616. Atelectasis – MCC of postop fever after 1-2 days. Tx: 1st incentive spirometry, 2nd Deep breathing exercises, 3rd out of bed, 4th chest physical therapy, 5th CPAP, 6th Bronchoscopy (if atelectasis is severe and spontaneous-due to mucus plug).
617. Hemothorax – blood in pleural space. Dyspnea c massive shock. Tx: if very small, observe. All others need a chest tube. Some need thoracotomy (bleeding >200mL/hr)
618. Asbestosis – exposure to remoal sides, pipe maintenance, etc. Takes >20 years to develop mesothelioma, but much less to develop bronchogenic CA (esp if smoking). Dx c lung biopsy showing ferruginous bodies (not CXR or CT). No tx.
619. Silicosis – increased risk of TB (must do annual PPD). Upper lob nodules c eggshell hilar node calcification.
620. Caplan Synd – rheumatoid nodules in lung periphery c coal-workers pneumoconiosis.
621. Sarcoidosis – blacks, females, biopsy shows non-caseating granulomas (most accurate), fever, dyspnea, skin (erythema nodosum)/eye (iritis)/CNS (nerve palsy)/cardiac (arrhythmia) s/s. CXR shows b/l enlarged hilar adenopathy, dx c biopsy, elevated ACE, high calcium. Tx c steroids.
622. Acute Resp Distress Synd (ARDS) – acute lung damage from increased pulmonary (alveolar) permeability. Pt c dyspnea, tachypnea, tachycardia, no improvement c oxygen, arterial hypoxemia (PaO2/FiO2 ratio <300), hypercapnea, CXR shows b/l whited out lungs. H/o infection, aspiration, near-drowning, drugs, shock, burns, and pancreatitis. Tx c PEEP.
623. Pulmonary Embolism – venous stasis/thrombosis, hypercoagulable state (pregnancy, SLE, cancer, prtn C/S def, OCP, antithrombin III def, Factor V leidin). Sudden onset of dyspnea, pleuritic CP, hemoptysis, syncope, split S2 sound. Clear CXR. EKG shows sinus tachycardia or S1Q3T3. ABG shows resp alkalosis c hypoxia and increased A-a gradient. Mostly from deep leg vein thrombi (above knee is not possible, must be below knee). Dx c spiral CT or V/Q scan (esp if pregnant). Definitive dx c pulmonary angiography. Tx c 1st anticoagulation c heparin(LMW-heparin if pregnant) c O2 if stable, 2nd thrombolytics (tPA) if unstable, 3rd embolectomy (if severe like a saddle embolism), 4th filter (if recurrent or if anticoagulation is contraindicated).
624. Pulmonary HTN – CP, dyspnea, lethargy, shortened S2 split c louder P2, weak peripheral pulses/coldhands. Tx c oxygen and vasodilators.
625. Goodpastures – renal c pulm so pt c hemoptysis and hematuria, anti-GBM Abs, tx:1st prednisone, 2nd cyclophosphamide, 3rd plasmapharesis.
626. Wegeners – Upper airway, pulmonary, renal so pt c sinusitis, hemoptysis, hematuria, c-ANCA. Tx: 1st cyclophosphamide, 2nd prednisone.
627. Pleural Effusion – once you see it on CXR, next step is tap (thoraentesis) to see if it is transudative (CHF, PE, nephrotic syndrom, atelectasis) or exudate (parapneumonic, cancer, PE, chylothorax, esophageal rupture, rheumatoid arthritis). For it to be exudates: Pleural fluid to serum protein ratio > 0.5, Pleural fluid to serum lactate dehydrogenase (LDH) ratio > 0.6, Pleural fluid LDH more than 2/3 of the upper limits of normal serum value. What if they don’t give you the serum levels? Then exudates is when pleural fluid cholesterol >45 mg/dL and pleural fluid protein > 2.9. If you think it is malignancy (old guy, wt loss, smoker, etc) then look for LDH >1000, glucose 30-50, and lymphocytes 50-70%. However, if you worry about parapneumonic effusion, look for LDH >1000, glucose >30, pH <7.2, next step is chest tube drainage.
628. Lung Cancer – no available screening test. Squamous cell (central cavitation, a/w hypercalcemia d/t PTH-like peptide, dx c bronchoscopy), Small cell (central cavitation, a/w SIADH, Eaton-Lambort and Cushings syndrome, dx c bronchoscopy), Adenocarcinoma (peripheral lesion, MC is bronchoalveolar CA, increased hyaluronidase levels, dx c FNA then thoracotomy c pleural bx). When is it unresectable? Hoarseness, METS, wt loss >10%, CNS s/s, SVC syndrome (JVD c facial discoloration d/t SCC) or tumor at the trachea/esoph/pericardium. For small-cell Ca, tx c chemotherapy (VP16-etoposide and platinum). For non-small cell Ca give radiation and chemo (CAP – Cyclophosphamide, Adriamycin, Platinum).

RENAL/UROLOGY:

629. Prostatitis – dysuria, chills, fever, low back pain, perineal pain, frequency, prostate may feel boggy and large but is always tender. E.coli. Tx c levaquin and hydrate.
630. Epididymitis – tender (relieved c scrotal elevation, opposite of torsion), enlarged testicle, fever, scrotal thickening. Caused by neisseria, e.coli, chlamydia. Tx c abx (tetracycline, levaquin), nsaids, scrotal support.
631. Orchitis – fever, increase testicular size, scrotal pain/erythema, a/w mumps and TB. Tx c same as above.
632. Urethritis – urethral d/c, dysuria. Next step is culture/gram stain (r/o STD). Tx c abx.
633. Testicular torsion – MCC of scrotal swelling in kids, causing severe pain (especially when scrotum is lifted, opposite of epididymitis), abdm pain (sometimes this is their only s/s, so must check scrotum), vomiting. Urologic emergency for blood supply must be regained within 6 hrs to prevent loss of testicle.
634. Cryptorchidism – no s/s. Dx c CT. Tx: Orchiopexy at age 1 to prevent cancer.
635. Any testicular mass needs to have cancer ruled out, so excise and biopsy it.
636. Benign Prostatic Hypertrophy – enlargement of prostat gland causing obstruction (hesitancy, dribbling, weak/low stream), urgency, nocturia and frequency. Dx: 1st DRE, 2nd U/S. Tx: 1st a-blocker (terazosin, remember tamsulosin (flomax) has the least adverse effects), 2rd 5-a-reductase inhibitors (finasteride), 3th Surgery (TURP). However, if pt is in ER in pain, 1st foley (if it wont pass, do suprapubic tap), 2nd TURP (skip meds).
637. Hypospadia – meatus below penis tip, so you pee on your feet. Pt may have chordee (ventral penile curve causing penis to curve 90degrees). Tx:1st observe until 1yo (do not circumcise), 2nd surgery
638. Hydrocele – fluid around the testis due to patent processus vaginalis. Dx c + transillumination. Tx c observation.
639. Varicocele – pampiniform plexus vein dilation due to inefficient pampiniform valves. Disappears in supine position (no venous pooling). Dx c (-) transillumination. Tx c surgery.
640. Cystitis – bladder infection causing dysuria, frequency, nocturia, urgency. Dx c UA/Ucx/Urine dip. MCC is E.coli. Tx:1st abx, 2nd IVP, cystoscopy (if recurrent).
641. UTI – urgency, dysuria, low balck pain, low fever. Dx c midstream urine Cx to show high nitrates and leukocytes. Tx c TMP/SMX, amoxicillin, nitrofurantoin, levaquin. Any kid <6yo c UTI needs VCUG (MCC is vesicureteral reflux and posterior urthral valves).
642. Nephrolithiasis – severe flank pain radiating to the groin c hematuria. Dx: 1st Xray (uric acid stones not visibile), 2nd CT scan abdo/pevis without contrast. Tx: 1st Hydration c analgesia, 2nd (remember, ureter is 8mm wide, so a small stone (<5mm) will pass c supportive measures, but larger stones may completely obstruct) extracorporeal lithotripsy if upper GU tract, or ureteroscopy if lower GU tract.
643. Anytime you suspect urethral injury (high riding prostate or blood at urethral meatus), next step is retrograde urethrogram (not foley!).
644. We give cyclosporine for graft rejection, but cyclosporine itself is nephrotoxic. How do you differentiate renal graft rejection from cyclosporine toxicity? Do percutaneous needle biopsy. Also, if situation occurs, trying increasing cyclosporine: if kidney function worsens, its nephroxicity. If kidney function improves, its graft rejection (however try percutaneous needle biopsy first in risk of worsening kidney).
645. Incontinence – discussed in Gyn notes. Functional/Overflow (nerve dysfunction, DM/MS, high voiding residual volume, tx c self-catheterization if pt cannot empty or anticholinergics if pt cannot store), Stress (weak pelvic floor, aggrevated by coughing/sneezing/laughing, tx c kegel exercises, then surgical MMK procedure), Urge (detrusor hyperreflexia causing spontaneous contractions, tx c anticholinergics).
646. Hydronephrosis – kidney/ureter damage from ureter obstruction (in men, think BPH) causing flank/back pain and oliguria. Dx c ultrasound. Tx c 1st foley catheter to relieve distal obstruction, 2nd cystoscopy and ablation of stones.
647. Pyelonephritis – ascending infection into kidney causing fever/chills, n/v, flank pain and anorexia. If pt is not seriously ill, tx c abx. If pt has severe n/v and appears ill (dehydration, hypotension) give IV hydration and abx for 2 weeks.
648. Glomerulonephritis – hematuria, proteinuria, HTN, edema. If acute, give bed rest, anti-HTN. Causes include HIV, HBV, poststreptococcal, SLE, Goodpastures, Wegeners, RA, Polyareteritis nodoa, penicillamine, hydralizine, allopurinol and rifampin. If rapid progression give steroids, cytotoxics, plasmapharesis.
649. Berger’s Disease – IgA nephropathy, gross hematuria after viral URI. Dx c biopsy (immune deposits of IgA in glomeruli). No tx. (Don’t confuse c Buerger’s disease, which is a problem of the fingers in smokers).
650. Diabetic Nephropathy – microvascular glomerular damage (thickened GBM) and Kimmelsteil-Wilson lesions (nodular deposits in glomeruli). Best tx is prevention.
651. Acute Renal Failure – rales, JVD, hyponatremia. Causes include prerenal, renal and postrenal. See below.
652. Prerenal Failure – hypovolemia (dehydration) BUN/Cr >15:1, Tx c IVF. Causes include sepsis, CHF (tx c diuretic), Liver Failure (Hepatorenal Synd, which has no tx)
653. Renal Failure – MCC is ATN (muddy-brown casts) due to: IV contrast (avoid in DM, renal dz, asthma, shellfish allergy), Rhabdo/Myoglobinuria (high CPK, tx c IVF and diuretics), SLE, Chronic NSAID use (papillary necrosis), aminoglycosides, cyclosporine, Goodpastures (anti-GBM Ab, linear on bx, tx c steroids and cyclophosphamide), Wegeners (tx c cyclophosphamide). ATN usually resolves in 6 weeks so just try to keep them alive (dialysis) until then. 2nd MCC is AIN (acute interstitial nephritis – look for wbc casts and eosinophilia. d/t drugs (B-lactam), calcium crystals, oxalate (antifreeze), chemotx (uric acid), tx c d/c stressor). 3rd MCC is Glomerulonephritis (RBC casts, dx c biopsy immediately) and 4th MCC is vasculitis (HUS< TTP, Multiple Cholesterol Emboli Syndrome (s/p cardiac cath pt gets blue feet, HTN and eosinophilia).
654. Postrenal Failure – Anuria (no urine output with >25cc residual volume). Dx c renal u/s (shows hydronephrosis). MCC is BPH (then b/l renal stones). Tx c catheterization, then TURP.
655. Minimal Change Disease – kids, glomerulus looks normal, but may have fusion of podoyctes. Dx c 24hr urine protein (no need for biopsy). Tx c steroids.
656. Membranous Glomerulonephritis – elderly Caucasian c amyloidosis. No need to do biopsy for diagnosis.
657. Focal Segmental Glomerulonephritis – h/o IVDA, 50% get ESRD, dx c biopsy
658. Membranoproliferative Glomerulonephritis – a/w hepatitis C (give ribavirin) and endocarditis, dx c biopsy.
659. When do you choose dialysis? Acidosis <7.25, Uremic encephopathy (1st give DDAVP, then dialysis), Increased K+ and creatinine, pericarditis, heart failure.
660. Polycystic Kidney Disease – family history, HTN, hematuria, palpable flank mass, Dx c CT of abdo (shows multiple cysts).
661. Chronic Renal Failure – azotemia (high BUN/Cr), metabolic acidosis, high K, hypervolemia (HTN, CHF, edema), low calcium/high phosphate. Tx c dialysis 1st, then water-soluble vitamins (lost in dialysis), calcium, EPO and anti-HTN meds.
662. Hyponatremia: 3 types: Hypovolemic Hyponatremia (tx c saline), Hypervolemic Hyponatremia (pt c cardiomyopathy and edema, tx c correcting underlying cause), and Euvolemic Hyponatremia (Hypothyroidism (tx c thyroxine), SIADH (high urine osmolarity, tx c fluid restriction), Psychogenic polydipsia (low urine osmolarity, tx c fluid restriction)).
663. Never give IV Potassium unless: 1- K+<2.8, 2 – pt on digoxin, 3 – arrhythmia.
664. Only 2 conditions in Anion-gap acidosis (MUDPILES) where you do NOT give bicarb: DKA and Lactic acidosis.
665. Vomiting vs Conn’s Synd – in vomiting (lose K and Cl, thus Cl is low) you treat c saline. In Conn’s synd (lose K, not Cl, thus Cl is normal) tx c Spironolactone and ACEI.
666. Renal Artery Stenosis – high rennin HTN. 1st test is captopril imaging, 2nd test is Angiogram. Tx c angioplasty.
Most common cause:
MCC of Aortic Dissection is systemic HT by degeneration of aortic media and elastic /collagen tissue

MC pituitary adenoma hormone secreted = prolactin

MCC of unilateral oculomotor palsy = diabetes mellitus

MCC bilateral oculomotor palsy = increase of intracranial pressure

MCC of urethral obstruction in males = posterior urethral valves

MC bone tumor in adolescents = osteosarcoma

MC etiologic agent of meningitis = Streptococcus pneumoniae

MC neurological manifestation of vit. B12 deficiency = peripheral neuropathy

MC complication of mumps = meningoencephalitis

MC skin cancer = basal cell carcinoma

MC cancer in urinary tract = bladder

MC urological cancer = prostate

MCC of stridor in children = laryngomalacia

MCC of acute abdominal pain that leads to surgery = hernia

MC bllod-borne infection = hepatitis C

MCC of immediate death post motor vehicle accident = aortic rupture

MCC of blindness in USA= prolipherative diabetic retinopathy

MCC of constipation in neonates and infants = Hirschsprung disease

MC congenital adrenal hyperplasia = 21 hydroxilase defficiency

MCC epistaxis = nose picking

MCC of ARDS = sepsis

MCC of death by poisoning in USA = carbon monoxide

MCC of drug induced SLE = procainamide

MCC of pleural effusion = CHF

MC etiology of viral meningitis = enteroviruses

MC site for anal cancer metastases = liver

MCC of neutropenia = medications

MCC of subarachnoid hemorrhage in children = arteriovenous malformation

MCC of cerebral palsy = cerebral anoxia

MCC low GI bleeding in elderly = diverticulosis

MCC of acute liver failure = acetaminophen toxicity

MC adrenal insufficiency in world.... TB
..................................in USA.......AUTO IMMUNE
MC palpable mass in the neonate = POLYCYSTIC KIDNEY
No 2 = bladder
most frequent cause of rhabdomyolysis in US: alcoholism.

most effective way to dec woman's risk of osteoprosis during postmenopause: HRT.

most effective treatment for stress incontinence: urethropexy

MC nasal tumors: Nasal polyps.
MCC of white reflex in ped population: congential cataract.
Most frequent cause of "non traumatic" SAH: rupture of saccular aneurysm , mostly in Ant circulation of willis.
MC site of atherosclerosis in carotids: origin of internal carotid A( first 2cm)
MC intracranial brain tumor: Met Brain tumor.
MC site of hemorrhagic stroke: basal ganglia.
MCC of "asymp" isolated elevation of AlkP in elderly: Paget's disease.
MCC of anemia in elderly: Iron def anemia.
M frequent respiratory condition in post term fetuses : meconium aspiration.
M frequent percipitant of GBS: campylo
MC site for Sialolithiasis: submandibular gland.
M imp test to assess liver function :PT

most common viral infection of hand: Herpetic witlow.

most common pathology seen in anagesics nephropathy: papillary necrosis and chronic tubulointersitial nephritis.

most common risk factor for abruptio placenta : maternal HTN

most common neuropathy w DM; sym distal sensori-motor polyneuropathy.

most common cause of isolated mitral regurg in US: MVP
most common complication of measles infection Otitis media

MCC of infant mortality in US is Congenital abnormalities

MCC of maternal mortality in US is Pulmonary Embolus
MC germ cell tumor Benign cystic teratoma

MC malignant ovarian tumor Serous Cystodadenocarcinoma

mc nosocomial infection ... uti
no 2 .............................. wound infection
no 3............................... nosocomial pneumonia
mc fever in post op day 1....atelectasis

Intussusseption is the most common cause of bowl obstruction in the first 2 years of life.
MCC of hemolysis in G6 Pd def is infection, not drugs.
most common cause of anaemia in sickle cell pts is chronic hemolysis.

-thyroid dysgenesis is most common cause of congenital hypothyroidism in USA..
-iodine defficiency or endemic goitre is the most common cause of congenital hypothyroidism worldwide..
Most common STD in women------ HPV
second Most common STD in women----- trichomoniasis
Most common bacterial STD in women----- chlamydia
Most common cause of osteomyelitis in sickle cell pts is --- staph aureus
salmonella osteomyelitis is exclusively in sickle cell patients
MCC of Death in Freidrich Ataxia is Cardiomyopathy and Respiratory Complication
MCC of Congenital hypothyroidism is Thyroid Dysgenesis - i.e. aplasia, hypoplasia, ectopic gland
Most common acid-base disorder hospitalized in US ====>>>METABOLIC ALKALOSIS

Obstructive sleep apnea ,OSA, is the most common type of sleep apnea, and it has been implicated in some cases of Sudden Infant Death Syndrome
MCC of Mitral regurgitation is MVP (Mitral Valve Prolapse)
MCC of death in Ac. MI is reentry ventricular arythmia (V.Fibb.)

Most common cause of Anemia in End stage renal disease is deficiency of erythropoeitin - normocytic normochromic anemia

Most common cause of Anemia in End stage renal disease is deficiency of erythropoeitin - normocytic normochromic anemia
And most common side effect of erythropoeitin therapy to control ESRD anemia is worsening of hypertension, if you ask how -- I don't know exactly how does that happen , please explain
COD in potter's sequence is pulm hypoplasia and not renal failure.
MCC inherited mental retardation = fragile x
MC congenital malformation is down syn
MC single cause of hypogonadism and infertility = klinefelter
MCC thyroid nodule = colloid nodule
2nd mcc = follicular adenoma
mycop pneum = mcc bact bronchitis + pneum in teenagers and young adults.

treatment = erythromycin
mc cod in alpha1antitrypsin def is emphysema
2nd mc cod is liver cirrhosis
MCC nephrotic syn in adult is membranous GN

renal v thrombosis occurs most commonly with memb GN
MC site of hypertensive hemorhagic stroke is putamen

3 major complications of PEEP
pneumothorax
alveolar damage
ventricular failure

MCC of post fossa tumor in kids

1. cerebellar astrocytoma

2. AVM

MCC of death in SLE? chronic renal failure

most common cause of corneal blindness in US: HSV

most common germ of endometritis : strepto

most common site of aortic aneurysm: ascending aorta (~ cystic medial necrosis)

most common predisposing factor to native valve endocarditis: MVP

most common form of melanoma: superficial spreading form

most common form of melanoma in black pts: acral lentigo.

most common cause of viterous hemorrhage : Diabetic retinopathy.

most common type of testicular sex cord stromal tumors: Leydig cell tumors.

most common acid/base abnormality in chronic liver dis: Res alkalo

most common cause of diastolic HTN in children : renal (fibromuscular dysplasia
MCC of community acquired Meningitis - Pneumoccocus

MCC of Meningitis in :
0-1 month (Newborn) - GBS
1 month - 2 year - Strep. pneumonia
2 year - 18 year - Neisseria meningitis
18 year and above - Strep. pneumonia

Most common laryngeal abnorlmality
LARYNGOMALACIA
Most common nasal malformation
?Choanal atresia

Most common cancer associated with Asbestosis is Bronchogenic Carcinoma

VSD is most common congenital heart defect.
-Transposition is most common cyanotic heart disease of infancy.
-Teratology is the most common cyanotic heart disease of childhood

most common cause of death from poisoning in children is iron poisoning
Most common poisoning overal in USA is CO poisoning

Most common cause of drug poisoning from OTC drugs = acetaminophen

Most common cause of poisoning from prescription drugs = TCAs
most common STD in America: chlamydia
Most common viral Hepatitis in Homosexuals is Hepatitis A
MCC of perinatal morbidity and mortality? preterm delivery..
MC head injury in children...cerebral concussion
In male athletes = IHSS ---------> cardiac arrythmias

In females = MVP --------------> Cardiac arrythmias

In Marfan syndrome patient = MVP -----------> Cardiac arrythmias

In anorexia nervosa patients = Cardiac arrythmias due to hypokalemia

in infants = OSA

MC location of post aspiration lung abscess is post segment of RUL or apical segment of RLL in recumbent position
MCC conjuctivitis within 24hrs of birth is chemical conjuctivitis caused by instillation of AgN03.

MCC of infectious neonatal conjuctivitis = chlamydia
MCC female infertility is peritoneal factors

Otitis media
MC Complication = hearing loss
MC Intracranial complication = meningitis

MC aspirated food is peanuts ( is the rule still 'dont give peanuts to children less than 6yrs? )
MCC of amblyopia is strabismus

MCC of death in infants 1 -12mo = SIDS ( PREVENTION = 'back to bed')

MC inherited hemolytic anemia= herid spherocytosis
mc childhood cancer = leukaemia
2n mc cancer is brain ca
3rd is lymphoma
mc solid tumour is brain tumour
MC genetic neuropathy = charcot marie tooth disease (hered motor-sensory neuropathy)

MC hereditary neuromuscular disease = duchenne's

head injury is the most common cause of death in child abuse

more than 95% serious intracranial injuries in <1yr are due to child abuse

1.The typical presentation of a thrombosed external hemorrhoid is an acute onset of very severe perianal pain, particularly when walking and sitting.2. You know that external hemorrhoid is below the dentate line. internal hemorrhoids arise above the dentate line.
3. thrombosed external hemorrhoid requires immediate incision and evacuation of the clot to provide symptomatic relief. Pressure by compression is usually all that is needed to control the bleeding. 4..Sitz baths, applying a topical steroid cream, and increasing fiber intake are the usual treatment for symptomatic external hemorrhoids that are not thrombosed.5..as a rule alwayes remember that external hemorrhoid s hurts but donot bleeding(opossit internal hemorrhoids)
6.typical picture of pyloric stenosis.,Projectile non-bilious vomiting is seen in virtually all patients. Patients also often develop a hypokalemic, hypochloremic metabolic alkalosis from the persistent vomiting. remeber if they give a child with intermittent spitting up think about pyloric stenosis.
7.abrupt onset of colicky abdominal pain in childeren <2 years ,think about intussusception! what's the etiology? The exact cause is unknown. However, it is associated with Meckel's diverticulum, cystic fibrosis, polyps, and Henoch-Schonlein purpura. remeber A barium enema or air enema is both diagnostic and therapeutic. 8.Remember In any patient with dysphagia that is progressive for only solids, it suggests a growing and obstructive lesion. The history of tobacco and alcohol use, puts person at a much higher risk of carcinoma. The two ways to diagnose this are a barium swallow study, which will show the mucosal mass, or an upper endoscopy study to directly visualize and biopsy the lesion.9.Remember Esophageal manometry is used to evaluate dysphagia caused by motility disorders. These typically present with dysphagia for solids and liquids and may or may not be progressive.
10.Incarcerated or strangulated hernias in an elderly patient can cause acute abdomen, dehydration, and altered mental status.11.. Frequent, greasy, malodorous stools are a result of steatorrhea from chronic pancreatitis. This happens from the lack of pancreatic enzymes. Non-enteric coated pancreatic enzyme supplements with concurrent H2 blockers will deliver active enzymes to the proximal small bowel and help reduce malabsorption and steatorrhea.12.. Acute acalculous cholecystitis is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder. BUT
biliary colic, which is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound.
13.Acute cholangitis is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad). 14.The hallmark of mesenteric ischemia is pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely in a patient with known vascular disease and a history of cigarette smoking. The next diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most often compromised vessel.15. Patients with ulcerative colitis are at high risk for toxic megacolon, which is also associated with Clostridium difficile colitis16.. Toxic megacolon presents clinically as abdominal distension and bowel motility disturbances. The next step in evaluation is an abdominal radiograph which will demonstrate a distended large bowel.

17.spontaneous bacterial peritonitis. This diagnosis should be first on your list in any patient with ascites who presents with fevers, abdominal pain, change in mental status, or with other non-specific complaints. These patients need to have a paracentesis. This fluid is then sent to the lab for a cell count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a positive peritoneal fluid culture. Patients with SBP need to be started on a third-generation cephalosporin
18.. Lead levels over 10 mg/dL are considered abnormal.19.Remeber Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects.20.congenital diaphragmatic hernia, which is when the abdominal contents herniate into the left hemithorax through a congenital defect in the left hemidiaphragm. This causes displacement of the heart into the right hemithorax and pulmonary hypoplasia.21 key finding for Esophageal atresia with distal tracheoesophageal fistula usually presents with a history of polyhydramnios, cyanosis with feeding, and increased oropharyngeal secretions.22.Remember in a traumatic lumbar puncture even though the CSF is initially red, the supernatant of the centrifuged cerebrospinal fluid is clear. This means that the red blood cells have not yet had a chance to lyse and release their intracellular contents into the cerebrospinal fluid.
BUT in subarachnoid hemorrhage there would be blood in the CSF, the supernatant of the centrifuged fluid would be xanthochromatic (yellow) due to the lysis of red blood cells and the release of their intracellular contents into the cerebrospinal fluid.23.The symptoms of crampy abdominal pain and watery, explosive, secretory diarrhea are consistent with enterotoxic E. coli. the cause of traveler's diarrhea ,treatment ciprofloxacin if symptoms persistent.24.The symptoms of Giardiasis, which usually occur about a week after exposure, include flatus, loose stools, diarrhea, abdominal pain, bloating, and vomiting. The usual scenario for a healthy person that develops this infection is the onset of these symptoms after a camping trip. tx:metronidazole
25.infectious mononucleosis typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur.26.Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor.
27.Remember sudden onset of right upper quadrant pain associated with nausea and vomiting and history right upper quadrant and epigastric pain before, associated with food intake. These symptoms are classical for a perforated peptic ulcer. In a perforated peptic ulcer, a patient can still have right upper quadrant localized tenderness, a thickened gallbladder wall, and pericholecystic fluid from the perforated ulcer. Hence, with any abdominal pain associated with signs, abdominal x-rays both erect and supine are very essential in the initial evaluation to rule out any free air.28.The first line in treatment of panic disorder is selective serotonin reuptake inhibitors (SSRIs), a group of medications including sertraline, paroxetine, fluoxetine, and citalopram. .
29.Remember Surveillance colonoscopies are generally recommended every 6 months for 2 years beginning after 8 to 10 years duration of ulcerative colitis.
30.The presence of endocervical cells on a Pap test is regarded as evidence of adequate sampling of the transformation zone during cytologic screening of the cervix. When these cells are absent, it indicates that this area may not have been sampled. This is considered a satisfactory, but limited smear. In patients with no known risk factors (i.e., prior abnormal Pap test, multiple sexual partners, smoking) the American College of Obstetricians and Gynecologists recommends that the physician may defer to repeating the Pap test in 12 months even if the sample is not adequ
31.in superior vena cava syndrome (SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS.
32.Remember in patients with known lung cancer, a biopsy of the mass causing the SVCS is usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis).33.Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women.
34.Acneiform eruptions is characterized by papules and pustules resembling acne lesions. The eruptions are distinguished by their sudden onset.
Oral medications such as iodides, bromides, testosterone, cyclosporine, antiepileptic medications, lithium, and systemic corticosteroids are common agents that can lead to acneiform eruption. When medium or high doses of corticosteroids are taken for as short a time as 3-5 days, a distinctive eruption may occur, known as steroid acne. It is a sudden out-cropping of inflamed papules, most numerous on the upper trunk and arms, but also seen on the face. The lesions typically present as papules rather than comedones. Tretinoin cream applied once or twice daily may clear the lesions within 1-3 months, despite the continuation of high doses of corticosteroid.
35.The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma.
36. Remeber anterior uveitis is associated with sarcoidosis. Anterior uveitis is usually marked by the abrupt onset of pain and photophobia. Specifically anterior uveitis causes iritis and iridocyclitis. Constriction of the pupil causes increased pain. Slit-lamp examination is diagnostic, showing inflammatory cells in the aqueous humor or deposited along the corneal endothelium.37.Many diseases are associated with anterior uveitis, including sarcoidosis and the seronegative spondyloarthropathies, including ankylosing spondylitis, psoriasis, inflammatory bowel disease, and Behçet's disease. Infectious disease may also cause uveitis. Some of the associated infections include herpesviruses, tuberculosis, onchocerciasis, and leprosy. In the majority of cases, uveitis is idiopathic. Treatment should include topical corticosteroids to decrease inflammation and mydriatics because dilation of the pupil decreases pain and the formation of synechiae.
38. hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.(tingling sensation in the fingertips.)39.Remember treatment of CMV retinitis in HIV if Gancyvlovier dosen't work is FOSCARNET(can cuase renal toxicity).40.Asperger disorder
it's characterized by defecits in interpersonal development,restricted patterns of interest&behaivior,and normal cognitive and speech development. 41.Spondylolysis is a defect seen in the pars interarticularis portion of the lamina.Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level.Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point(with hyperextension maneuvers)42.Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific.

43..Remember The sudden onset of tachycardia and hypotension in a patient who is being mechanically ventilated with positive pressure, is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax,44.young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis. 45.Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations. 46.Still disease is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis. 47.whenever the terms "coin-shaped" or "discoid" are used to describe a patient's skin lesions in a question you should think about nummular dermatitis.48.Remeber symptoms of congestive heart failure and possible atrial fibrillation, as demonstrated by irregularly irregular heartbeat in question(they never mention stright forward A.F). In addition, are at high risk for the development of an embolic occlusion of the superior mesenteric artery. These patients will present with severe pain out of proportion to their objective physical findings. The diagnosis should be suspected clinically, and immediate superior mesenteric arteriogram should be performed. If evidence of ischemia is confirmed, the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia and possible gangrenous bowel.

49.BUT Ischemic colitis will usually present as diarrhea, often bloody, in elderly patients with known atherosclerotic heart disease.50.malignant external otitis, This form is specifically caused by Pseudomonas aeruginosa, and tends to affect elderly diabetics and AIDS patients, causing the findings in the severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor.

51.Headache of sudden onset ("thunderclap" headache), rapid deterioration of mental status and blood in the CSF are virtually diagnostic of ruptured berry aneurysms. Note the characteristic hyperdensity on CT of the suprasellar cistern, indicating blood in the subarachnoid space. Rupture of a berry aneurysm is the most common cause of subarachnoid bleeding. 52.PBC is due to an autoimmune destruction of intrahepatic bile ductules, and the diagnosis is made by liver biopsy. The serology that should be checked is the antimitochondrial antibody. Primary biliary cirrhosis is often seen in individuals with other autoimmune diseases, such as Sjögren syndrome, pernicious anemia, and Hashimoto thyroiditis.53.Myasthenia gravis is an autoimmune disease in which antibodies directed against the acetylcholine receptor of the muscle side of the neuromuscular junction block the ability of the receptor to bind to acetylcholine. Remember insulin resistance is also produced by a similar mechanism, i.e. antibodies to insulin receptors block the receptors' ability to bind to insulin54.The first step in the approach to a patient with a community-acquired pneumonia is to categorize condition according to the American Thoracic Society guidelines (1993), which are based on severity of illness, age, comorbidities, and the need for hospitalization. the criteria for hospitalization (one of the following is needed: respiratory rate > 30 breaths/min, room air PaO2< 60 mm Hg, O2 saturation less than 90% on room air, or bilateral or multiple lobes involved), and older than 60 years.
55.normal value for the anion gap is 12 ± 4 mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes mellitus, alcoholism, starvation), renal failure with retained sulfate and phosphate, drugs or metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of protein anions, and dehydration (hemoconcentration).
56.Remember Subcutaneous unfractionated heparin is used for prevention of DVT in immobile patients or in hospitalized patients unable to ambulate. However, after orthopedic surgery, especially after joint procedures, its efficacy is very poor, given the increased venous stasis ,you should use warfarin.57.Remember Both chronic laxative use and chronic diuretic use can produce hypokalemia. Severe hypokalemia, with plasma potassium <3 mEq/L, can markedly affect skeletal, smooth, and cardiac muscles. Skeletal muscle effects can include weakness, cramping, fasciculations, paralysis (with risk of respiratory failure), tetany, and rhabdomyolysis. Smooth muscle effects include hypotension and paralytic ileus. Cardiac muscle effects include premature ventricular and atrial contractions, tachyarrhythmias, and AV block. Additional ECG changes can include ST segment depression, increased U wave amplitude, and T wave amplitude less than U wave.
58.Basal cell carcinoma affects sun-exposed areas, particularly the mid and upper face, in patients lacking protective pigmentation. One of its morphologic forms is that of a raised, waxy, pale lesion that grows very slowly and doesn't metastasize to lymph nodes. 59.Key for Keratoacanthoma : grows very rapidly in a matter of weeks and has a scaly, rough appearance, with a core of keratin. If untreated, it eventually sloughs off. 60.Squamous cell carcinoma is usually an ulcer, rather than a nodule. In the face, it favors the lower lip. If present for several years, lymph node metastasis can sometimes occur. 61.euthyroid sick syndrome, which occurs in many seriously ill patients who do not have clinical hypothyroidism. especially in ICU 61. The TSH level is usually most helpful in distinguishing euthyroid sick syndrome from true hypothyroidism, as it often above 30 mU/mL in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick syndrome. Disproportionately decreased T3 is also typical of euthyroid sick syndrome, and T4 may be normal or decreased. 62.Remember hepatorenal syndrome occurs during the end stages of cirrhosis and is characterized by diminished urine output and low urinary sodium. In the setting of end-stage liver disease, renal vasoconstriction occurs, and the distal convoluted tubule responds by conserving sodium. Unless the renal function is allowed to deteriorate further, liver transplantation will reverse this vasoconstriction and kidney function will return to normal.
then when ever you have cirrhosis with reanal faiuler the most appropriate treatment is LIVER TRANSPALNTION!63.In beta thalassemia, a reduced production of beta chains occurs with normal amounts of alpha production64.A shock-like pain upon percussion on the volar aspect of the wrist (Tinel sign) is a characteristic sign of Carpal tunnel syndrome ,,is most often idiopathic, but may represent a manifestation of underlying disorders such as rheumatoid arthritis, sarcoidosis, amyloidosis, acromegaly, and leukemia.
65.Fibrositis , also known as fibromyalgia, refers to a poorly understood syndrome of widespread musculoskeletal pain associated with tenderness in multiple trigger points. Fatigue, headache, and numbness are also common. Women between 20 and 50 years of age are most commonly affected. Neck, shoulders, low back and hips are usually involved.66.Reflex sympathetic dystrophy describes a syndrome of pain and swelling of one extremity (most commonly a hand), associated with skin atrophy. It is thought to be secondary to vasomotor instability. Sometimes, it follows injuries to the shoulder (shoulder-hand variant). 67.Femoral pseudoaneurysms represent an important vascular complication of cardiac catheterization. The combination of a pulsatile mass, femoral bruit, and compromised distal pulses make this diagnosis likely. The diagnosis can be confirmed by ultrasound of the groin.(it was exam question of one of my friend).68.Cholesterol emboli syndrome is also an important complication to recognize in the post-catheterization patient. It usually presents, however, with skin findings in the distal extremities of livedo reticularis, ischemic ulcerations, cyanosis, gangrene, or subcutaneous nodules. 69.Remember Another important complication of cardiac catheterization via the femoral artery is a retroperitoneal bleed . This complication presents, however, as either new back pain, an unexplained drop in the hematocrit, or purpura over the flanks.70.what is piriformis syndrome??
As you may recall from your anatomy, the piriformis is the small muscle that crosses the greater sciatic foramen, cutting it into two spaces as the muscle passes from the edge of the sacrum to the greater trochanter. The sciatic nerve comes out of the greater sciatic foramen below the piriformis, and is liable to compression by the muscle. Symptoms are as described above; bicycle riding and running may also set off the symptoms, which may take the form of chronic nagging ache, pain, tingling, or numbness. Treatment is usually to teach the patient to avoid maneuvers that set off the symptoms. Some patients have been helped by corticosteroid injection near the site where the piriformis muscle crosses the sciatic nerve; this therapy is thought to work by reducing the fat around the muscle and thereby increasing the available space in the area.71.in Adison disease Laboratory findings include hyponatremia (due to aldosterone deficiency), hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement.
72.HIV encephalitis, clinically known as AIDS dementia complex, . The pathologic substrate is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS. 73. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion. MRI studies and CSF analysis are useful in excluding other CNS diseases .74.HIV myelopathy manifests mainly with spastic paraparesis. It is a complication similar in pathologic substrate to vitamin B12 deficiency, i.e., vacuolar degeneration of the posterior and lateral columns of the spinal cord.
75.Progressive multifocal leukoencephalopathy consists of multifocal areas of myelin destruction. These changes would be visible on MRI. This complication is due to JC virus, a papovavirus that causes asymptomatic infections in immunocompetent individuals. 76.Patients with longstanding extensive ulcerative colitis for at least 10 years' duration are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia77.Individuals with herpes zoster are contagious and can spread the VZV virus.78.Decreased esophageal peristalsis and decreased LES pressure :SCLERODERMA , These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's esophagus.
79.Patients with this erythema infectiosum (Fifth disease) are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death. 80.If a pergnant woman was in contact with a patient with fifth disease during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy.81.Most authorities think that it is appropriate to initiate a progestin-only method of contraception immediately postpartum. It has no impact on lactation or the quality of breast milk.
82.The triad of miosis, respiratory depression, and coma is suggestive of opioid intoxication83.Phenelzine is an antidepressant monoamine oxidase inhibitor (MAOI) that causes hypertensive crises and the serotonin syndrome (hypertension, tachycardia, fever, coma, and possibly death) when combined with tyramine-containing food (cheese) and serotonin-altering drugs.Pseudoephedrine and other nasal decongestants, bronchodilators, amphetamines can cause severe hypertension when monoamine oxidase is inhibited and should be avoid.84.the classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles. 85.Fiberoptic bronchoscopy is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation.
then remeber if you have a patient with hemoptysis with past history of smoking ,your first step is CXR even if he/she is normal right now!but!!!!!!!Keep in mind that a chest x-ray is not part of a routine physical examination of an asymptomatic smoker.
86.Complications of ovarian torsion include infection, peritonitis, sepsis, adhesions, chronic pelvic pain, and infertility due to the loss of the viability of the torsed ovary.87.Remember One of the most important considerations in evaluating patients with conjunctivitis is to rule out any vision-threatening conditions such as iritis, keratitis, glaucoma, or a corneal ulceration. Symptoms such as marked photophobia, decreased visual acuity, or globe pain suggest that ocular structures other than the conjunctiva are involved and should trigger immediate ophthalmologic evaluation.88.The pathophysiology of ITP:
involves antibody (IgG or IgM) binding to platelets. These antibody- coated platelets are subsequently destroyed in the spleen.89.Remember an extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients.90.Multifocal glioblastoma multiforme (GBM) , the most frequent malignant primary brain neoplasm, manifests as an ill-defined mass in the white matter. 91.Wernicke encephalopathy is characterized by nystagmus progressing to ophthalmoplegia, truncal ataxia and confusion. 92.Korsakoff syndrome refers to alcohol-related amnesia and confabulation. Wernicke-Korsakoff syndrome is due to vitamin B1 deficiency, which is often seen in chronic alcoholics. This deficiency results in degeneration of periaqueductal gray matter.93.Remember Huntington disease autosomal dominant condition is caused by an unstable expansion of a CAG trinucleotide repeat and MRI examination of the brain reveals hyperintensity in the region of the caudate on T2-weighted images.94.The pathologic substrate of this condition(Huntington disease ) is degeneration of the striatal neurons, especially those in the caudate nucleus. 95.the pathogenesis of stress-induced gastritis iffuse gastric mucosal vasoconstriction 96.Right-sided endocardial fibrosis, with pulmonary stenosis and tricuspid regurgitation, is common in carcinoid patients and is the result of toxic damage to the heart97.Ondansetron, a 5-hydroxytryptamine3 antagonist, is the most potent antiemetic available for chemotherapy-induced vomiting.It has side effects only infrequently, the most common being constipation. 98.Copper deficiency can present with anemia and neutropenia, Zinc deficeincy will present with alopecia, impaired wound healing , dermaititis, selenium def will present with dilated cardiomyopathy99.Bernard-Soulier syndrome is an autosomal recessive disease of platelet adhesion which causes prolonged bleeding times in the presence of normal platelet counts. These patients' platelets cannot bind to subendothelial collagen properly because of a deficiency or dysfunction of the glycoprotein Ib-IX complex. Clinically the patients have impaired hemostasis and recurrent severe mucosal hemorrhage. The only treatment for an acute episode is a transfusion of normal platelets. This patient has a slightly decreased hemoglobin due to blood loss.100.Von Willebrand's disease causes increased bleeding times with normal platelet counts. It is the most common inherited bleeding disorder, caused by a defect in von Willebrand factor, which aids the binding of platelets to collagen. Even though the platelets themselves are normal, binding is impaired, thus a platelet transfusion would not correct the problem. Cryoprecipitate, a plasma fraction rich in von Willebrand factor, would help in the case of von Willebrand's disease, but would not help with Bernard-Soulier syndrome.
Coarctations account for approximately 7% of congenital cardiac abnormalities, occur more frequently (2x) in men than in women, and are associated with gonadal dysgenesis and bicuspid aortic valves. Adults will present with hypertension, manifestations of hypertension in the upper body (headache, epistaxis), or leg claudication. Physical examination reveals diminished and/or delayed lower extremity pulses, enlarged collateral vessels in the upper body, or reduced development of the lower extremities.101..Lymphoma is well known to develop specifically in the late stage of Sjögren's syndrome. Common manifestations of this malignant condition include persistent parotid gland enlargement, purpura, leukopenia, cryoglobulinemia, and low C4 complement levels.102.if they give you a farmer patient presents with acute-onset pulmonary symptoms, including wheezing, with no other medical problems and was recently handling hay.think about farmer's lung, a hypersensitivity pneumonitis caused by Actinomyces. In this disorder moldy hay with spores of actinomycetes are inhaled and produce a hypersensitivity pneumonitis. The disorder is seen most commonly in rainy periods, when the spores multiply. Patients present generally 4 to 8 h after exposure with fever, cough, and shortness of breath without wheezing. Chest radiograms often show patchy bilateral, often upper lobe infiltrates. The exposure history will differentiate this disorder from other types of pneumonia.
103.The Women's Health Initiative (WHI) demonstrated that estrogen-progestin therapy in Postmenopausal can reduce the risk of hip fractures by 34%. However, the WHI also demonstrated that estrogens are associated with a 30% increase in myocardial infarction, a 40% increase in stroke, a 100% increase in venous thromboembolism, and a 25% increase in breast cancer. In the WHI study there was no overall effect of estrogen-progestin therapy on mortality, probably because of the balance between the detrimental cardiovascular effects and the beneficial effects (in addition to fractures, there was a beneficial effect on the development of colon cancer).harrison new eddition!

104. Remember Pain, loss of function (without clear-cut sensory or motor deficits), and a localized autonomic impairment are called reflex sympathetic dystrophy (also known as shoulder-hand syndrome or causalgia). Precipitating events in this unusual syndrome include myocardial infarction, shoulder trauma, and limb paralysis. In addition to the neuropathic-type pain, autonomic dysfunction, possibly resulting from neuroadrenergic and cholinergic hypersensitivity, produces localized sweating, changes in blood flow, and abnormal hair and nail growth as well as edema or atrophy of the affected limb. Treatment is difficult; however, anticonvulsants such as phenytoin and carbamazepine may be effective, as they are in other conditions in which neuropathic pain is a major problem.
101. Remember when a patient has acute attacke with Renal faiuler the best drug for treatment would be either oral prednisone or steroids injected into the joint. He should not receive NSAIDs because he has renal insufficiency. Rofecoxib, a COX-2 inhibitor, can also be detrimental to renal function and should not be used in this setting.
102.remember Typical radiographic findings in osteoarthritis include joint space narrowing, subchondral bone sclerosis, subchondral cysts, and osteophytes (bony spurs). In the small interphalangeal joints of the fingers, central erosions may be seen within the joint space105.HTN+Glocuma treatment?B blocker106.Remember Addiction has identifiable risk factors, including genetic factors. The most well-established risk factors for addiction are family history and male sex. 105 in cocain toxi serum and urine tests are useful when they are positive, but they are of limited utility when they are negative because of the short duration of detectability of cocaine (6 to 8 hours) and cocaine metabolites (2 to 4 days). Cocaine does not produce compensatory adaptations in brain regions that control somatic functions and therefore does not produce dependence. Dependence and, therefore, withdrawal are not produced by highly addictive compounds such as cocaine. 107.The benzodiazepines (e.g., chlordiazepoxide, diazepam, lorazepam, and oxazepam) are the safest and most effective medications for treatment of alcohol withdrawal108.glucagonoma and gastric adeno ca are associated with acanthosis nigric109.nasopharyngeal ca also
burkitts lymphoma t8:14are associated with EBV110.Findings in Von Recklinghausen's disease: ... café-au-lait spots, neural tumors, Lisch nodules (pigmented iris hamartomas), skeletal disorders (scoliosis), and increased tumor susceptibility 111.Findings of Cri-du-chat syndrome: ... microcephaly, severe MR, high pitched crying/mewing -(Cri-du-chat is French for cry of the cat), cardiac abnormalities 112.Pathogenesis of Cystic Fibrosis: ... defective Cl- channel --> secretion of abnormally thick mucus that plugs lungs, pancreas, and liver --> recurrent pulmonary infections (Pseudomonas species and Staph aureus), chronic bronchitis, bronchiectasis, pancreatic insufficiency (malabsorption and steatorrhea), meconium ileus in newborns. 113.Which gene is affected in Fragile X? ... methylation and expression of the FMR 1 gene is affected in this X-linked disorder
114.2 skin conditions in AIDS patients one is a bacterial infection and another viral cause both look similar?kaposi's sarcoma-HHV 8 AND BACILLARY ANGIOMATOSIS-caused by bartonella henselea115.urticaria you get subcutaneous edema and angioedema you get mucosal edema116.Genetic anticipation of Fragile X syndrome may be shown by what?
Triplet repeat (CGG)n117.Huntington gene involved and triplet repeat CAG ,chromosome 4p118.: Kidney cancer is a neoplastic condition that can initially appear with many different paraneoplastic manifestations. The initial presentation may include hypertension, flank mass, gross or microscopic hematuria, hypercalcemia, fever, weight loss, and/or polycythemia. This polycythemia is the presenting sign in 3% of cases of kidney cancer. In kidney cancer, polycythemia is secondary to a hypersecretion of tumor cytokines, including renin. The patient's erythropoietin level is usually high. Surgical removal of the cancer resolves the polycythemia.
, full evaluation is important in patients presenting with polycythemia and hematuria. Kidney cancer is an important differential diagnosis of secondary polycythemia.
119.Remember esophagitis in HIV often presents with belly or epigastric pain that could be caused by CMV or herpes simplex, but Candida most common (80%-90%); treat empirically with fluconazole 100 to 200 mg/day 120.Cryptococcal meningitis in HIV minority of patients have meningeal signs; most have only fever and headache; obtain head CT and lumbar puncture (LP); elevated opening pressure most common abnormality; cerebrospinal fluid (CSF)—can be normal; most have normal glucose; only 50% of patients have elevated protein; minority of patients have white blood cells in CSF; india ink simple test that detects 75% of cases; cryptococcal antigen >90% sensitive, but results take 1 to 2 days at most institutions how do you treat?Treatment: treat with amphotericin B; flucytosine added in patients with severely elevated pressures; fluconazole as maintenance for rest of life 121.Remember LDH: nonspecific test; appears to be consistently greatly elevated in PCP; PCP unlikely if LDH normal (in HIV )122.Remember Pneumocystis carinii pneumonia (PCP) less common now because many patients receiving medical care get prophylaxis for this organism; P carinii now considered closer to fungi than to protozoa; bacterial pneumonia now more common than PCP123.Antiretroviral treatment for HIV: no consensus on when to start; indications include acute HIV infection, symptomatic HIV infection, CD4 count <350 cells/µL, high viral load (ie, >55,000 copies/mL124.Kaposi’s sarcoma: reddish/purplish lesions can be located anywhere (internal or external); characteristic appearance of sharp demarcation (HSV8)
Hairy leukoplakia: tends to occur on side of tongue; cannot be spooped off like thrush; related to Epstein-Barr virus 125.What 2 neoplasms are associated with AIDS? ... 1. Aggressive malignant lymphomas (non-Hodgkins) 2. Kaposi's sarcoma 126.What 2 neoplasms are associated with Tuberous sclerosis (facial angiofibroma, seizures, and mental retardation)? ... 1. Astrocytoma 2. Cardiac rhabdomyoma 127.What are a common histopathological finding of meningiomas? ... Psammoma bodies. These are spindle cells concentrically arranged in a whorled pattern
128.What are ependymomas? ... Ependymal cell tumors most commonly found in the 4th ventricle. May cause hydrocephalus 129.Reason why Pregnant women get more chances of UTI: Increase in ventilation rate causes respiratory alkalosis: This causes renal compensation for and causes alkaline urine. This provides a good growth media130. Remember the normal values of Non pregnant women does not apply to pregnant women. In pregnant women, the upper limts of BUN and Serum creatinine should be 10 and 0.5 respectively. If a pregnant woman has a serum creatinine of 1.5, then it can only mean 2 things: Either she has a kidney disease or it could be due to hyper coagulation which is seen only in Preeclampsia131: What constitutes a positive SLR sign to diagnose radiculopathy?
SLR is positive if the maneuver REPRODUCES THE PATIENT'S USUAL PAIN .The patient may describe pain in the low back,buttocks, post. thigh or lower leg. But the key feature is reproduction of the patient's usual pain.
Other factors such as muscle stiffness can mimic radicular pain.
SLR is used to detect lesions of L5 and S1 roots and sciatic nerve.
Reverse SLR (passive extension of leg with patient standing)-for L2-L4 roots and femoral nerve
Crossed SLR-Performance of maneuver on one leg produces pain in the opposite leg or buttocks-The nerve or nerve root lesion is always on the side of the pain.
For all these tests, the key feature is REPRODUCTION OF PATIENT'S ORIGINAL PAIN.
(source: Harrison')132.How do you manage a patient with non massive9less than 100 cc in 24 hour) hemoptysis? The work-up begins with history and physical examination. A chest x-ray and laboratory studies should be ordered initially.
If the chest x-ray is normal and the patient has risk factors for cancer, like smoking a bronchoscopy should be ordered to localize the bleeding site and look for an endobronchial mass. If none is found, a high resolution CT scan should be considered. If a mass is found on a study, referral to a thoracic surgeon is necessary.133.Remember Once a biopsy diagnosis of cervical intraepithelial neoplasm has been made, an appropriate treatment option is a loop electrosurgical excision procedure, and the most common complication being postoperative bleeding.134.Remember Patients with dural sinus and cerebral venous thrombosis can present with headaches, stroke-like symptoms, and/or seizures. There are multiple etiologies including dehydration, sepsis, and trauma. In addition, hypercoagulable states such as sickle cell disease, leukemia, and pregnancy are also predisposing factors. Because the symptomatology of a dural sinus thrombosis is nonspecific, imaging studies play a critical role in the diagnosis. On non-contrast enhanced head CT, a cord sign or tubular hyperdensity may be seen in the acute setting along with cortical and subcortical hemorrhage due to venous stasis and infarction. The treatment of choice during pregnancy is intravenous heparin. Unfractionated heparin and low molecular weight heparin (LMWH) do not cross the placenta and are considered safe for the fetus, but must be administered parenterally.
135.alwayes remember Children with sickle cell disease, despite splenomegaly, have reduced function of the reticuloendothelial system, (functional asplenia). Therefore, in a sickle cell patient with a fever, it is important that broad spectrum antibiotics are instituted as soon as possible to protect against septicemia from encapsulated organisms such as H. influenzae, Pneumococcus, and Neisseria.136.Heat stroke can occur in athletes who exert themselves in conditions of high humidity and temperatures. Clinical signs of this condition include a core body temperature of >40.5 C (or 105 F), profuse sweating, and mental status changes. Patients with exertional heat stroke are at risk for disseminated intravascular coagulation and rhabdomyolysis137.Treatment for rhabdomyolysis involves intravenous saline infusions to maintain a high urine output and alkalization of urine with a target pH of 7-8 to prevent myoglobin deposition.138.remember aortic dissecting aneurysm caused by degeneration of tunica media-cystic medial necrosis139.Remember cardiac rupture most common 4-7 days post MI. ventricular free wall rupture leads to cardiac tamponade140.Remember New onset serous discharge from a laparotomy wound should raise the suspicion of wound dehiscence.141.Remember acute angle-closure glaucoma, which is an ocular emergency that requires immediate treatment to prevent blindness: Immediate treatment includes mannitol (to reduce vitreous volume), acetazolamide and topical beta-blockers, such as timolol (to block aqueous production), and pilocarpine (to facilitate aqueous outflow). Ophthalmologic consultation should also be sought as soon as possible. A peripheral laser iridectomy is the definitive procedure and is usually performed after the IOP is controlled.142.treatment of Acne rosacea,avoiidng exogenouse factor,topical metronidazole ,no response give tetracycline
143.Risk factors for TOA include IUD use, multiple sexual partners, and previous episodes of pelvic inflammatory disease.ntravenous cefoxitin is used because it is an antimicrobial agent that is active against Gram-negative and anaerobic organisms, the predominant bacteria found in these abscesses
what wwill you see in sono?trasonography of the pelvis demonstrates a complex, cystic mass containing multiple septations and internal echoes in the left adnexa. 144.A tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way valve mechanism and compromises the contralateral lung and the venous return to the chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the pressure 145.A pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion scan.in trension pneumothorax The ventilation perfusion scan demonstrates lack of ventilation and perfusion .
146.how do you manage a syncopal episode in a yaoung healthy adult?
when a young, healthy, athletic patient had a syncopal episode, which can be cardiogenic or neurogenic in origin. After the history and physical, blood work is usually sent to rule out anemia, infections, hypocalcemia, or hypomagnesemia and an EKG must be performed. An EKG may show evidence of cardiac abnormalities such as Wolf-Parkinson-White syndrome (r wave slurring), idiopathic hypertrophic subaortic stenosis, or congenital prolonged QT syndrome.147. Remember,Higher prevalence enhances positive predictive value. Simply put, if more people actually have the disease, then a positive test result has a higher probability of being true. Note that for the reasons described here, diagnostic tests always have a higher positive predictive value than screening tests.148.Remember The definition of chronic sinusitis is a sinus infection greater than 3 months. The most common etiology is infectious and the organisms most responsible are rhinovirus, H. influenza, S. pneumoniae, and influenza. The hallmark of acute sinusitis compared with sinus inflammation is total ostial obstruction. Once obstructed, fluid accumulates and becomes infected. The diagnosis is suggested by clinical signs and symptoms although certain imaging studies are very useful. The only imaging study to consider is a sinus CT. If positive, the maxillary or ethmoid sinuses will be opacified.149.Remember Women who have very low body fat and/or participate in intense exercise are known to have a decrease in gonadotropin releasing hormone (GnRH), which in turn results in a diminished release of follicle stimulating hormone (FSH) and leuteinizing hormone (LH). Ovulatory dysfunction is responsible for approximately 20-25% of infertility cases.150.Septic shock is characterized by decreased blood pressure despite euvolemia and is often seen with severe infection, especially with Gram-negative organisms. Release of inflammatory mediators is responsible for decreasing SVR. Patients are thought to be in a hyperdynamic state with increased cardiac output. Volume status is reflected by PAWP and is classically normal but can be normal, low, or high depending on the aggressiveness of hydration.
151.Decreased CI, increased SVR, and normal PAWP is an example of cardiogenic shock. This is common with cardiac tamponade or myocardial infarction. It should be thought of as pump failure. The cardiac index is low because the heart is not pumping well. The SVR is increased in an effort to maintain blood pressure. The PAWP is normal in these patients since volume is typically not the primary problem152.Hypovolemic shock is demonstrated by a low cardiac index, an increased SVR, and a decreased PAWP. Simply, CI and PAWP are low because there isn't enough blood volume to be pumped by the heart (low volume = low pre-load). SVR is elevated to attempt to increase blood pressure.
153.Obstructive shock, characterized decreased CI and normal SVR and PAWP , is typically caused by massive pulmonary embolus. Supportive care with IV fluids and vasoconstrictors along with possible embolectomy is indicated. Note: The only indication for embolectomy is hemodynamic instability.154.Remember the presentation of painless jaundice is highly suspicious for a pancreatic head mass and in particular adenocarcinoma of the pancreas. Adenocarcinoma of the pancreas accounts for more than 90% of pancreatic malignancies and jaundice is present in about 65% of patients. Risk factors for pancreatic adenocarcinoma include smoking and diabetes. The best initial evaluation for pancreatic masses is by CT of the abdomen and pelvis.155.Remember Lorazepam is a short acting benzodiazepine with no active metabolites. Lorazepam is metabolized to the glucuronide form and excreted by the kidneys. The drug is tapered over 4-6 days for detoxification purposes. It is safe in patients with severe liver damage, and it won't compromise respiration in severe COPD156.Chlordiazepoxide is a long-acting benzodiazepine that is used for detoxification from alcohol in uncomplicated cases. It has several metabolites that are long acting, thus making it difficult to efficiently manage the detoxification without risking the accumulation of drug and its metabolites because of impaired liver metabolism. In patients with severe COPD, it can compromise respiration secondary to sedative effects.
157.Remember renal vein thrombosis. Most commonly occurs in Membranous glomerulonephritis.158. Excessive friction between the iliotibial band and the lateral femoral condyle can lead to iliotibial band tendonitis. This overuse syndrome commonly occurs in runners and cyclists, although it may develop in any person subsequent to activity involving repetitive knee flexion. Tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial torsion are predisposing factors. 159.The patient with iliotibial band tendonitis reports pain at the lateral aspect of the knee joint. The pain is aggravated by activity, particularly running downhill and climbing stairs. On physical examination, tenderness is present at the lateral epicondyle of the femur, approximately 3 cm proximal to the joint line. Soft tissue swelling and crepitus also may be present, but there is no joint effusion. Radiographs are not indicated. 160.Remember he two live vaccines, MMR and the varicella vaccine, are not recommended for use before the first birthday, but should be given the first time the child sees the doctor after 12 months of age.161.Remember The findings of diffuse osteoporosis in a patient on hormone replacement therapy are suspicious for a multiple myeloma. 161. Laboratory data for multiple myeloma includes anemia, an elevated creatinine from secondary renal dysfunction, and elevated IgA and IgG levels and hypercalcemia.162.alwyes remember bone scan has a low sensitivity for myeloma lesions and has no role in its workup. Do not confuse a bone survey which is a series of x-rays evaluating all of the bones with a bone scan which is a nuclear medicine scan.NO!NO!NO!NO BONE SCANE FOR MULTIPLE MYELOMA!!!!!!!!!!!!!!!!!!!!!!163. a postoperative pelvic abscess: This condition may occur after abdominal surgery, and presentation usually occurs after postoperative day 7. Diarrhea is frequently the earliest manifestation of abscess formation. . A fluctuant mass is a common finding on physical exam, and a rectal exam should be performed on all postoperative patients who are at risk for developing an abscess. A postoperative abscess will frequently cause an ileus, as manifested by vomiting, abdominal distention, decreased bowel sounds, and radiographic findings. Although the clinical grounds may provide you with the diagnosis of abscess, imaging studies should be undertaken to localize the fluid collection and aid in drainage. A CT scan probably has the highest yield compared to the other imaging modalities. Besides localizing the abscess, a CT scan will aid in the drainage of the fluid collection.164.APGAR is a named after Virginia Apgar, M.D. who came up with a rating system for neonates at delivery. One helpful mnemonic is A: appearance, P: pulse, G: grimace or response to catheter in nostril, A: activity or tone, and R: respiratory effort. Each category is rated from 0-2. 165.Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections.166.After a myocardial infarction, normal sexual activity can typically be resumed 2-4 weeks after discharge from the hospital.167.some of the most common anomalies associated with congenital rubella are intrauterine growth retardation, microcephaly, microphthalmia, cataracts, glaucoma, retinopathy, patent ductus arteriosus, hepatomegaly, jaundice, thrombocytopenia, metaphyseal lucency, and a purpuric rash also known as a "blueberry muffin" rash. Infants may be asymptomatic at birth, but the earlier in pregnancy the mother is infected with the rubella virus, the more likely the baby is to have defects. For example, if a mother is infected in the first 8 weeks of pregnancy, the baby has an 85% chance of having a defect.168.Remember Toxoplasma gondii is another organism that can cause congenital infection, but 70-90% of infants with congenital infection are asymptomatic at birth. It is important to note that a large percentage of the infants that are asymptomatic at birth will develop visual impairment, learning disabilities, or mental retardation months to years later. Signs of congenital toxoplasmosis include: hydrocephalus, microcephaly, cerebrospinal fluid abnormalities, intracranial calcifications, chorioretinitis, hepatosplenomegaly, generalized lymphadenopathy, and a maculopapular rash.169.Varicella-zoster infection in a mother causes different syndromes in a baby depending on the time of the infection. If the mother is infected in the first trimester or early in the second trimester, the baby may develop varicella embryopathy which is characterized by microphthalmia, cataracts, chorioretinitis, cutaneous and bony aplasia/atrophy, and scarring of the skin of the extremity. If the mother is infected during the second 20 weeks of pregnancy, the baby may show no clinical manifestations of varicella, but may develop zoster later in life without ever having extrauterine infection. If the mother develops varicella from 5 days before delivery until 2 days after delivery, the child may develop severe infection, which may lead to death.170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%.
The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%.171.Remember when ever you use niacin you should monitor liver function and plasma glucose carefully.
when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL
172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.
173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.
174. Remember white cells generally indicate active inflammation. The presence of leukocytes in a stool sample would be highly suggestive of IBD.
175.The treatment of unstable atrial fibrillation (atrial fibrillation associated with hypotension, myocardial ischemia, congestive failure, etc.) is immediate synchronous cardioversion, in an attempt to immediately restore sinus rhythm.
176.Churg-Strauss vasculitis: Prednisone should be started at a moderate dose, along with a bisphosphonate to prevent osteoporotic fractures,in initial therapy no cyclophosphamid,...
177.Remember Major depression need not present as classic dysphoria or sadness.It may present as irritability particularly in children and adolescent.
178.know pictures of fundoscopy ( glaucoma, DM, and cmv)
skin (herpes zoster)
ecg (1st degree block) preop.
179.IN DM with sports this is what we do… check ketone.. if positive ,, he cant participate until ketones are gone… in DM insulin is decreased with snacks during break….check glucose before and after sports is also a recoomendation
180.black male with HTN + DM .what HTsive med do u give?
…..Ace inhibitor….*htn plus diabetes

181.“BILATERAL”renal a. stenosis with HTN, what med do you use to tx HTN…
Answer is calcium channel blocker…. If it was unilateral stenosis then ACE inhibitors
182.A male pt with thumb base pain what is dxa.
De querene tensovitis is the answer… treatment is nsaid and intrathecal steroids.
183.a pregnant rh- do not know father what is next?
test rh titer now
184.primigravida 28 weeks, rh negative ,husband positive anti ***** antibody positive what next
1)give anti rhd
2.dont give anti rhd
3.do amniocentesis,
answer,,,, DON’T DO ANYTHING…
185.During a flu. Season, a pt who did got get flu. Shot and had a flu.s/s for 4 days came in for treatment. You provide for him:
1. amantadine 2. zanamivir 3. only symptomatic support including (Tyleno)
Symptomatic treatment ( amantadine or zanamivir is given within 72 hours of influnza… ZANAMIVIR is the best treatment it covers both A and B)
186.Know exact inetrvals for pap smear (cervical cancer screening), breast cancer screeing, prostate cancer screening and colorectal cancer.
This is very important topic many Q in this topic

187.How do you treat Cocaine abuser with 210/115 BP?
Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV
No beta blockers like propranolol

188. Remember Bilious vomiting in an infant means that there is a malrotation with volvulus until proven otherwise. The radiographic findings of the cecum in the left upper quadrant confirms this clinical diagnosis. An upper gastrointestinal series would likely show a bird-beak deformity of the midgut where there is volvulus of the gut around a mesenteric "Ladd" band.

189.Remember about 20% of malrotation with volvulus is associated with duodenal atresia, annular pancreas, or a duodenal diaphragm. About 33% of cases present in the first week of life and 85% present in the first year of life. The hallmark of malrotation is ischemia of the midgut as the superior mesenteric vein and the superior mesenteric artery are occluded by the twisting mesentery. Immediate surgery is necessary to prevent death or the loss of much of the bowel.
190.Intussusception typically presents in infants from 4 months to 2 years of age, with alternating lethargy and irritability, colicky abdominal pain, and currant jelly stools. In addition, there is usually a right lower quadrant mass on abdominal x-ray.
191. The presence of tamponade is suggested by the presence of diminished heart sounds and pulsus alternans (a beat to beat variability in the QRS amplitude) on EKG.
192.It 's useful to note that the shock typically associated with sepsis, anaphylaxis, and neurogenic shock is associated with vasodilation, and hence, with warm extremities.
193.complication of polycytemia vera:
1.Hyperuricemia due to increased rbc turnover is common in patients with polycythemia vera, and these patients are at increased risk of gout.
2.Both arterial and venous thrombosis are common in polycythemia vera. The Hct is directly related to the risk of thrombosis. This association between Hct and risk of thrombosis forms the basis for the treatment recommendation to keep the Hct less than 46%. The platelets are derived from the neoplastic clone and may not function normally
3.Approximately 15-20% of patients with Polycythemia vera eventually develop myeloid metaplasia. Myeloid metaplasia is characterized by gradual replacement of the marrow space with fibrosis, and movement of hematopoiesis into the spleen and liver. The spleen and liver become massively enlarged, and the patient becomes progressively pancytopenic

194. Polycythemia vera :Neoplastic hematopoietic stem cell,CBC in Polycythemia vera: Hct and often WBC and platelets are increased ,reatment: Phlebotomy or hydroxyurea or 32P to keep Hct below 46% ,Decreased or low normal erhtropoitine
195. Secondary Polycythemia: disorder Due to tissue hypoxia causing an appropriate increase in Epo production, or to renal or hepatic disease causing an inappropriate increase in Epo production ,Only Hct is increased ,Treatment is usually not required,Normal or increased erhtropoithine
196.Hyperuricemia: An elevated uric acid level can result from gout, renal failure or an increased production of uric acid secondary to high rates of cell turn over such as in patients with hematologic malignancies. it may also be seen during treatment of these malignancies with chemotherapy when the rapid destruction of cells releases large amounts of uric acid into the blood, so called "tumor lysis."

197.Whenever u see an HIV positive patient on pentamidine with seizure think ((pentamidine induced hypoglycemia..and check bld glc!!))
198. Efavirenz contraindicated in pregnancy
199.Hypocalcemia, hypomagnesemia, hyperphosphatemia. Renal impairment progressing to renal failure. side effect of foscarnet also remember other drugs like Other drugs that affect the kidneys like amphotericin B and pentamidine should be avoided.

200.). The CT scan can be normal in 5% of patients with a subarachnoid hemorrhage within the first 12 hours of headache onset. Between 24 and 72 hours from onset of headache, up to 25% of CT scans can be normal. Therefore, if one suspects a subarachnoid hemorrhage from the patient's history, it is imperative to perform a lumbar puncture to evaluate the CSF for xanthochromia and red blood cells. Xanthochromia is not seen in a traumatic tap and may be more specific than RBC analysis.

201.the age of 18 months, most children will have developed a specific set of skills which can be divided into: social, self-help, gross motor, fine motor, and language. Social skills at this age include greeting people by saying "hi" or something similar, giving hugs and kisses, and playing patty-cake. Self-help involves drinking from a cup and feeding self with a spoon. Gross motor skills include walking without help and beginning to run. Fine motor skills would include scribbling with a crayon and stacking 2 blocks. Language skills should encompass talking in single words, asking for food or drink with words, and following simple instructions.

202.Histoplasma capsulatum is a dimorphic fungus ,it is endemic to the Ohio, Missouri, and Mississippi River valleys ,
T lymphocytes are crucial in limiting the extent of infection. Susceptibility to dissemination is increased markedly with impaired cellular host defenses.
A thorough social and occupational history is essential in the initial evaluation. Travel or residence in an endemic area or activities involving bats or birds, whether recent or remote, should aid in the differential. Determine if the patient has a drug history or comorbid condition that is contributing to an immunocompromised state.
203.temporomandibular joint (TMJ) disorder, which is a very common disorder that can usually be detected by palpating the area just in front of the tragus. Joint clicking may be found when the patient opens and closes his mouth. Symptoms of TMJ include orofacial pain, a noisy joint, and restricted jaw function.
204.remember treatment for preventing recurrence of HBV after liver transplant is HBV Ig + Lamivudine
205.Hairy-cell leukemia: B-cell leukemia
-tartrate resistant acid phosphatase
-give cladribine for treatmen.
206. Rx acute attacks of migrains : Rizatriptan
207.Rx acute attack of migrains lasts for longer than 48 hours or r frequently recurrent : ergotamine
208.Rx rhabdomyolysis : osmotic diuresis + bicarbonate
209.Low Ca, high P, high PTH=secondary hyperPTH due to renal failure
-lung cancer: high PTH-related peptide, high Ca, low P
-primary hyper PTH: high Ca, low P, high PTH
-multiple mieloma: high Ca, low to normal PTH

210.HIV patient pneumonia-MC is still pneumococcus
In PCPpneumonia=>no pleural effusions
In PCPpneumonia=>no pleural effusions

211.A new born with central cynosis ,apex palpated on the rt and scaphoid abdomen,neonatologist suspects diaphragmatic hernia? whats the next step to do?

do orogastric suction and can operate after 2/3 days because the lungs are hypoplastic and u allow them to be mature

212.42 yo M, repeated LL clots ? Dx? (factor V laiden deficiency)
213.. M with superficial varicose veins, discoloration of LL ? cause? (increased hydrostatic pressure in the v/s)
214.M fall off a ladder & hit with the ladder, 3-4 Ds later comes with abd pain, tense & tender, abd XR shows fluid under both side diaphragm ? Dx ?( splenic rupture)
215.9 mo, said to be fell off couch, have different color bruises all over, withdrawn, can’t sit or stand without support, <5th % ? what next? (skeletal survey)
216.. The treatment of choice for lithium levels greater than 4.0 mEq/L is hemodialysis.
217.In the 2001 update of their screening recommendations, the U.S. Preventive Services Task Force strongly recommended routine screening for chlamydia in all sexually active women aged 25 and younger, as well as in asymptomatic women older than 25 who are at high risk.
218.intermittent claudication, which is a sign of peripheral vascular disease. Patients often complain of pain during exertion that is relieved by rest. Noninvasive evaluation is usually recommended initially and consists of determining the ratio of ankle to brachial arterial pressures. The ankle/brachial artery ratio is determined by measuring and comparing the 2 blood pressures. If the ratio is less than 1 (greater than or equal to 1 is considered normal), peripheral artery disease is present
219. Remember Vancomycin is used in febrile and neutropenic patients in addition to ceftazidime when the patient has an indwelling central vascular catheter
220. Chest pain, fever, tachycardia, subcutaneous emphysema, dysphagia, and dyspnea are suggestive of an esophageal perforation. An esophageal perforation may result from endoscopic procedures, external trauma, esophageal disease, and spontaneous perforation from violent bouts of emesis. Prompt recognition of an esophageal perforation is necessary to prevent delayed complications. Whenever a perforation is suspected, a contrast study should be performed with water-soluble contrast material. If this study does not demonstrate the perforation, it should be repeated with barium. Barium is more accurate for a delineating esophageal leakage. Contrast studies not only help in diagnosing esophageal rupture but also document the level of injury, which has important implications for treatment.

221.Topical steroid and phototherapy are the two main therapeutic modalities in treating vitiligo.
222.the presence of a central venous catheter for 6 days in an intensive care unit (ICU) dictates strong consideration of catheter-associated sepsis, for which staphylococci are the most common cause. The absence of inflammatory changes at the site of catheter insertion is not uncommon in the presence of catheter-associated bacteremia. Because methicillin-resistant strains of staphylococci are common in many ICUs, vancomycin must be a component of the antibiotic regimen to cover these pathogens. Genta-micin is used to cover the less frequent possibility of gram-negative catheter-associated sepsis and is indicated because the patient is in septic shock.
223.The diagnosis of common variable immunodeficiency (CVI) should be suspected in any patient with abnormally recurrent or severe bacterial infections of the upper or lower respiratory tract. Early diagnosis of CVI is important because immunoglobulin replacement therapy can prevent recurrent infections and associated chronic tissue damage. It is important to consider other conditions that may predispose a patient to recurrent respiratory tract infections, such as allergies and anatomic abnormalities, when evaluating a patient for suspected humoral immunosuppression. The laboratory tests for CVI consist of measuring serum immunoglobulin levels, including subclasses of IgG. In addition to quantitative measurements of serum immunoglobulins, it is important to evaluate the patient’s ability to produce specific IgG antibodies to protein and polysaccharide antigens. The decision to treat patients with immunoglobulin replacement therapy is based on the frequency and severity of recurrent infections and a demonstrated failure to mount functional antibody responses, rather than on the absolute level of serum IgG.
224. Adrenoleukodystrophy:
1.X linked ds
2.cha by visual loaa,spasticity,mental retardation.
3.there is failure of meta of long chain fatty acid.
Rx-Dietary restriction of long chain fatty acid
225.Remember The psychiatric manifestations of hypothyroidism include fatigue, depression, lethargy, psychomotor retardation, poor concentration, and forgetfulness.
226.Remember Spironolactone has an anti-aldosterone effect and therefore predisposes a patient to hyperkalemia. (Remember that hyperkalemia is an important stimulus for the secretion of aldosterone.)
227.Remember Acetaminophen can predispose susceptible patients to renal failure through tubular injury (acetaminophen is a metabolite of phenacetin, a known tubular toxin.
228.Remember MRI with gadolinium is considered the most sensitive test for detecting microadenoma. The test can reveal microadenomas in 20% of normal women.
229.Achalasia is a neurogenic esophageal disorder thought to be caused by a malfunction of the myenteric plexus of the esophagus. The result is denervation of the distal esophageal muscle with resulting impaired esophageal peristalsis. The characteristic findings on esophageal manometry are diminished or absent peristalsis in the body of the esophagus and a high resting lower esophageal pressure
230.remember To rapidly assess for the possibility of antifreeze ingestion, the physician can evaluate the patient's urine under a Wood's lamp for fluorescence. Manufacturers of ethylene glycol-containing antifreezes typically add fluorescein to the mix, which will fluoresce under a Wood's lamp
231.Remember Evaluating the optic discs for hyperemia is typically reserved for suspected methanol toxicity, since methanol is metabolized to formic acid, which can cause irritation of the optic nerve
232.Remember whenever they asked about vulvar heart disease ,look at BP ,if it's wide,you should consider AR!
233.Mitral stenosis presents with a diastolic rumbling murmur heard at the apex of the heart
AR:blowing diastolic murmur heard loudest at the left sternal border
234.Acute cholecystitis is the result of cystic duct obstruction, and this would be best demonstrated by a HIDA scan.
235.Remember skin tags, more formally known as acrochordons
236.Remember silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. Intravenous pyelogram (IVP) will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer. Thus, both procedures are needed.
237.Remember There is no need for prophylaxis for IE when the cardiac lesion is due to prior coronary artery surgery, mitral valve prolapse without regurgitation, prior rheumatic fever or Kawasaki disease without valvulopathy, presence of a pacemaker, isolated secundum atrial septal defect, surgically repaired septal defect or patent ductus arteriosus, or physiologic heart murmurs.
238.remember some procedures require no prophylaxis for endocarditis regardless of the type of cardiac lesion. These include dental procedures that do not induce bleeding, endotracheal intubation, tympanotomy tube insertion, cesarean section, uncomplicated uterine procedures in the absence of infection, and cardiac catheterization.
239.Remember Increasing anemia in a previously well-maintained immunosuppressed patient is suggestive of parvovirus B19 infection, especially with an associated reticulocytopenia. Occasionally giant pronormoblasts may be seen on the peripheral blood smear. A bone marrow examination may confirm the absence of erythroid progenitor cells and exclude other pathology, but is not required to diagnose parvovirus B19 infection. The diagnosis should be confirmed by the detection of parvovirus B19 antigen or significant levels of parvovirus B19 DNA in serum by (PCR).
240.Remember paitent with kawasaki have conjunctival involvment but in scarlet fever no conjunctival !!
241.HHv6:Roseola
HHV7 itrias rosea
HHv8:kaposi sarcoma
242.Erythema multiforme,exfoliative dermatitis& the *******-Johnson syndrome r potentially life-threatening drug reactions of sulfa agent.
243.Remember The risk of contracting meningococcal disease among household members and childcare and nursery school contacts is considered high enough to warrant chemoprophylaxis. Rifampin, ceftriaxone, and ciprofloxacin r the 3 recommended agents used as chemoprophylaxis for invasive meningococcal disease.
244.inhalant intoxication is characterized by euphoria,belligerence,apathy,impaired judgment,dizziness,nystagmus,incoordination,slurre d speech,unsteady gait,lethargy,depressed reflexes,psychomotor retardation,tremor,muscle weakness,diplopia.Stupor,coma may occur.
245.Good q:A 48 yo woman has a 3yr history of gradually progressive writhing movements of her extremities,emotional lability,aggressive outbursts& memory impairment.Mental status exam reveals a withdrawn& irritable woman who speaks only in monosyllables.Which of the following is the most appropriate pharmacologic intervention?
A:benztropine
B:carbamazepine
C:chlorpromazine
D:haloperidol
E:lorazepam
D:haloperidol
Case of Huntington dementia
246.A preterm infant required positive pressure ventilation for 3mo,and developed bronchopulmonary dysplasia.After discharge from the hospital,the child was noted to have intermittent episodes of acute respiratory distress& wheezing unresponsive to bronchodilator therapy.The most appropriate diagnostic test in this case is:
a:Cxray
b:a serum theophyline level
c:an ABG determination
d:an echocardiogram
e:bronchoscopy

A. e:bronchoscopy
It’s the diagnostic test of choice,characteristic findings on bronchoscopy in this infant include narrowing of the airway by abnormal growth of tissue,tracheomalacia or bronchomalacia or both
247.Remember Steroids, especially intraarticular steroids,r very effective when NSAIDs and Colchicine (which are the treatment of choice for acute gout)r contraindicated.In this pt,CRF is a relative contraindication to NSAID & rofecoxib use.So,intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects.
248.Neuromelanin are found in substantia nigra & locus ceruleus and they disappear in Parkinson's dz.
249.which type of brain tumor can be spread by CSF ?
medulloblastoma
250.Remember germinoma, as common in pineal gland area, give Parinaud's. Brain stem glioma give (usually benign pilocytic astrocytoma) may give locked-in syn.

251.which lesion can be induced by aneurysm of Posterior communicating artery of Circle of Willis ?
which lesion can be induced by aneurysm of Anterior communicating artery of Circle of Willis ?
1.3rd nerve palsy
2.bitemporal lower quandrantinopia

252.)CHF due to aortic regurgitation=>give diuretics, ACE inhibitors, digoxin, NOT Beta-blockers-which prolong the diastole=>increased regurgitation
253.Malaria-P.vivax-fever every 48h
P.ovale-fever every 72h
P. falciparum=>no periodicity
-starts with intens chills, then the hot phase, then 2-6h later-vomitting, low BP, tahicardia
-anemia, splenomegaly
-hystory of past similar complaints when in Africa
254.Babesiosis-RBC cell parasite
-from ticks
-varies frrom asymptomatic to severe anemia, jaundice and renal failure
-seen in splenectomised patients or with HbSS diseases
255.)TB can appear in HIV patients even with CD4>200/ul
-no need of hystory of close contacts
256.Case of SYSTEMIC MASTOCYTOSIS
which there's proliferation of mast cells in the skin,liver,spleen,BM&lymph nodes.
It can occur at any age,no FH+,and atopy is not increased in these pts.
the cutaneous lesions of urticaria pigmentosa respond to trauma with urtication and erythema(Darier's sign)
diagnosis with clinical findings&Ph.E,and lab findings:A 24 hr urine collection for histamine,histamine and PGD2 metabolites is the most common noninvasive procedure.confirmtion of diagnosis with tissue diagnosis.
Rx:symptom/sign directed approach:H1&H2 antihistamines
257.an associated hypogammaglobulinemia is an underlying cause for infection &
,serum beta2-microglobulin is the single most powerful predictor of survival and can substitute for staging:
SEEN IN MM
258.Remember Pts with DM&CRF and multiple organ failure can develop acalculous cholecystitis.Acalculous cholecystitis is characterized by the absence of gallstones and sometimes even biliary sludge.These pts may not present with classical signs of cholecystitis, because of associated diabetes mellitus and multiple organ failure.US may fail to show evidence of gallstones or obvious signs of cholecystitis.A CT scan of the abdomen and pelvis will reveal a thickened gallbladder wall, pericholecystic fluid, gas within the gallbladder wall, and evidence of surrounding inflammation.
259.Afetr abdom. aortic aneurysm repair and blood in the stool=>suspect ischemic colitis=> do sigmoidoscopy/colonoscopy to assess coloniv viability, if CT scan is inconclusive, BUT NOT Barium enema=>can cause perforation
260.In SLE=> non-erosive arthritis
In RA=erosive arthritis:indication for starting Methotrexate
261.Patient of IPPV who deteriorates=>do CXR to rule out barotrauma
262.Kallmann's syndrome-46,XX
-anosmia
-hypogonadotropic hypogonadism
-absent pubic, axillary hair
-absent breasts
-amenorrhea
263.Acute liver failure-appears within 8 weeks from the start of the injury
Fulminant hepatitis=acute liver failure+hepatic encephalopathy
264.factor XI deficiency
it's largely confined to Ashkenazi-Jewish populations.Spontaneous bleeding may occur in homozygotes:epistaxis,menorrhagia or bleeding after dental procedures or surgery.Hemarthroses as in hemophilia A or B r unusual
265.ts with factor XIII defeciency usually bleed in the neonatal period from their umbilical stump or circumcision
266.Remember i t’s recommended that during nursing home outbreaks of influenza,both amantadine& immunization should be given to those who haven’t received annual immunization
267.remember whenever you suspect venous sinus thrombosis.MRV is the best noninvasive test to confirm this diagnosis.Pregnancy& postpartum state r RFs for it.
268.In neurofibromatosis type 2, when suspect acoustic neuroma=> first do MRI with gadolinium=best test, then surgery to remove the tumor
269.Solitary brain metastasis=>surgical resection, followed by whole brain irradiation
Multiple brain metastasis=>palliative brain irradiation
270.)Eaton-Lamber Syndrome=>auto-antib. against gated Ca channels
-small-celllung cancer
-treat by plasmapheresis+immunossupressive therapy
271.To diagnose lutheal phase defect=>endometrial biopsy which shows loss of endometrial maturation by more than 2 days as compared to normal
272.Remember Juvenile angiofibroma is a highly vascular fibrous tumor that classically affects adolescent males and appears to be related to androgenic stimulation. It manifests with recurrent epistaxis.
273.Mutation of an X-linked gene coding for a tyrosine kinase is the underlying molecular mechanism leading to X-linked agammaglobulinemia of Bruton, a syndrome characterized by inability of pre-B cell precursors to mature into B-lymphocytes. Humoral immune deficiency thus manifests
274. Mutations of the autosomal gene encoding adenosine deaminase represent the most common cause of the recessive form of severe combined immunodeficiency disease (SCID), encompassing a heterogeneous group of conditions characterized by deficiency of both T- and B-cell mechanisms. SCID may be autosomal dominant, autosomal recessive, or X-linked. Mutations of the X-linked gene coding for a cytokine receptor subunit represent the most common cause of the autosomal dominant form of SCI.
275.Remember Children with hypospadias are prone to urinary tract infections and other urinary tract anomalies.don't forget U/A and Sono

276.Remember One of the most important reasons for steatorrhea in newborns is bile acid deficiency. Bile acids are very important in normal absorption of fat, which constitutes a major portion of an infant's calories intake. Unfortunately, the bile acid pool in neonates is very small when compared with that in adults. In addition, neonates often lose an excessive amount of bile acids in their stools. This results in physiologic steatorrhea because of poor absorption of fat. Preterm infants, have an even smaller bile acid pool and are more likely to have steatorrhea because of poor fat absorption. This will result in poor weight gain. The solution to this problem is to substitute medium-chain triglycerides (MCTs) in the formula for long-chain triglycerides (LCTs), because, unlike LCTs, MCTs do not require bile acids for absorption.
277. Inhalant abuse such as model glue, correction fluid, spray paint, and gasoline, to achieve an altered mental state. It is a common health problem in adolescence. The effect of inhaling a large quantity of hydrocarbons has been described as "quick drunk" because it resembles alcoholic intoxication. Initially, euphoria develops; then, lightheadedness and agitation. Disorientation, ataxia, and dizziness might develop with increasing intoxication. In extreme cases, generalized weakness, hallucinations, and nystagmus can occur. Abusers often show deterioration in school performance, disturbance of family relationships, and increased risk-taking behaviors.
278.Remember Encephalopathy is the major chronic morbidity following chronic inhalant abuse. and also keep in mind that a good history is essential because there is no drug screen test that can detect inhalant hydrocarbons.
279.Atrial myxoma=>systemic signs, dyspnea, like mitral stenosis, but no opening snap, murmur changes with position=>high risk of embolization
28o.A 2 month old infant can lift its head to 45 degrees, eyes follow to the midline, vocalizes, smiles and has a state of half-waking consciousness
281.The ability to lift the head to 90 degrees, eyes crossing the midline, laughing and slight awareness of the caregiver are characteristic childhood development landmarks of a 4 month old infant.
282. 6-month old infant can roll over, grasp a rattle, turn to voice, feed self and separate the world into a "parent" and "not parent" world.
283.Remember The combination of female sex and breech presentation results in developmental dysplasia of the hip in 1 in 35 such births.
284.Remember PCP is a hallucinogen that causes CNS stimulation (hypertension, tachycardia, brisk reflexes, hyperthermia). Other hallucinogens such as LSD and mescaline cause dilated pupils but PCP has an effect of constricting pupils. Seizures and coma are more common with PCP and intracranial hemorrhages have been reported.
285.Marijuana ingestion or inhalation(toxication) causes relatively benign symptoms that include euphoria, hunger, tachycardia and injected conjunctivae. Pupils usually remain normal.
286.Screening for prostate cancer:
->40 years=yearly rectal exam
->50 years=PSA=rectal exam
-if abnormal=>transrectal US, then niddle biopsy, then bone scan for staging
287.Intelectualization=transforming an unpleasant event into a purely intellectual problem
Rationalization=offering rational explanations in an attempt to justify undesirable attitudes, impulses, beliefs-ex. a guy is rejected from getting jobs at various interviews says that he saved money because the commute was paid by his interogators...
288.Internuclear ophtalmoplegia=demyelinization of medial longit. fasciculus
-sign of MS
289.Cervical spondylosis-chronic neck pain, limited rotation and lateral bending of head
-sensory deficit due to osteophyte-induced radiculopathy
290.Constitutional delay of growth is suggested by a child who is growing at a normal or mildly decreased rate. The patient is delayed in pubertal development, and the bone age significantly lags behind the chronologic age.
291.Familial short stature is characterized by a child with short parents, by a bone age consistent with the chronologic age, and by a growth curve that follows the normal pattern even though it is significantly below the 3rd percentile.
292.Malrotation is usually caused by the presence of a volvulus, which presents with sudden onset of bilious vomiting, abdominal distention, rectal hemorrhage, peritonitis, and shock. It is a surgical emergency.
293 . Pyloric stenosis :It is caused by hypertrophy and hyperplasia of the antrum of the stomach, resulting in obstruction.
294.The most common cause of urethral obstruction in males is posterior urethral valves. It typically results in urinary obstruction and vesicoureteral reflux.it will cause bedwetting day and night,FTT, enlarge bladder!Voiding cystourethrogram is the definitive diagnostic test.
295. Marfan syndrome is an autosomal-dominant disorder The genetic defect results in abnormal synthesis and secretion of fibrillin, Patients with Marfan syndrome often have involvement in the skeletal, ocular, and cardiovascular systems. Most of the morbidity and mortality with this disease are related to the cardiovascular manifestations; patients develop aortic root dilatation. This may be associated with aortic insufficiency and aortic arch dissection. They may also have mitral valve prolapse . Aortic root, aortic valve, and mitral valve replacement may be needed during the lifetime of the patient. Patients with Marfan syndrome may frequently complain of chest pain; these patients must be viewed as having aortic dissection until proven otherwise. In this population, a spontaneous pneumothorax is another potential cause of chest pain.
296. beta-blockers clearly slow the progression of aortic root dilatation in those with mild aortic root dilatation in Marfan syndrom.. Exercise should be limited to aerobic activities. Patients must avoid contact sports that cause acceleration-deceleration injury and isometric maneuvers that tend to increase central blood pressure. Aerobic activity is encouraged, but those with established aortic root dilatation should have adequate heart rate control with beta-blockers.

297.)Brown recluse spider-deep bite, ulcer with a necrotic center and erythematous halo, treat by local excision
Black widow spider=>abdominal rigidity, muscle cramps, nausea, vomitting, no local ulcer
-treat by Ca gluconate, muscle relaxants
298.Pneumonia post bone marrow transplant=>think CMV
-not immediate, comes in about 2 weeks to 2 years post-transplant
299.Asymptomatic Paget disease=>no treatment
-symptomatic (lytic lesions or skullinvolvement)=>biphosphonates=CHOICE
300.If isolated proteinuria detected=>repeat distick testing at least twice more; then if still (-)=>reassurance; if (+)=>check 24h urinary proteins, BUN, Cr
301.Venous ulcers=>medial aspect of foot
Arterial ulcers=>lateral........................
302.Disseminated gonococcal infection-rash, tenosynovitis, polyarthralgia (migratory)
-mediated by immune complexes from gonococcemia
303.Foreign body aspiration=sudden onset of resp. distress, afebrile, interstitial retractions
-do direct laryngoscopy+rigid brochoscopy
-one lung is hyperinflated, the other is hypoinflated
304.Remember throwing a ball overhead is most consistent with the motor development of a 24-month-old child
305. Building a tower is a good way to assess a child's motor function.3 cubs 15
4 cubs 18
7 cubs 24
306.Osteoid osteoma is a small benign tumor of the bone that frequently affects the tibia. The tumor is usually unilateral and manifests with nocturnal pain, which awakens the child and is promptly relieved by aspirin or NSAIDs
307.Stress fractures affect small bones that normally have a thin cortical bone. When subjected to repeated mechanical stress, such as marching, skiing, ballet dancing, etc., the bone accumulates microfractures that eventually result in chronic pain and swelling. Metatarsal bones are the most frequently affected.
308.Osteosarcoma is a malignant bone tumor affecting children and adolescents. Unilateral bone pain in the segment involved (usually proximal tibia or distal femur) or pathologic fracture is the usual mode of presentation
309.Remember In children, the most common cause of stridor is laryngomalacia.
310.Renovascular disease is the most frequent cause of hypertension in young children. Ailments such as polycystic kidney disease, congenital vascular disease, tumors and infections can all lead to hypertension, and a urologic evaluation is imperative.
311.ALwayes remember For patients with persistent asthma symptoms, inhaled corticosteroid is the treatment of choice
312.In acute CHF, treatment should begin immediately. IV furosemide is the drug of choice because its onset is very rapid. It can provide quick symptomatic relief and improve respiratory distress. Angiotensin-converting enzyme inhibitors are used for the long-term management of patients with CH.
313.Measles is associated with subacute sclerosing panencephalitis, a chronic encephalitis of the central nervous system manifested by progressively bizarre behavior and decline in cognitive function.
314.Bell palsy, a postinfectious allergic or immune demyelinating facial neuritis. Epstein-Barr virus is the preceding infection in approximately 20% of cases.However, herpes simplex virus, Lyme disease caused by Borrelia burgdorferi and mumps have been associated with Bell palsy too.
315.microhematuria after trivial trauma in children may be a sign of a congenital anomaly that makes the urinary tract unusually vulnerable. The warning should be heeded, and an anomaly sought. The first, noninvasive test should be the sonogram.
316.Neurofibromatosis is a multisystem genetic disorder. The features of this condition are more than six café-au-lait spots, two or more neurofibromas, axillary freckling, optic gliomas, iris hamartomas (Lisch nodules), and osseous lesions. There is almost always a first-degree relative with neurofibromatosis.
317.An infant with HLH(hypoplastic left heart) syndrome has a hyperdynamic precordium because the enlarged right ventricle is contracting against systemic pressure. The infant also has a loud, or even palpable, second heart sound (S2) because the pulmonary artery acts as the aorta by pumping blood to the systemic circulation through the ductus arteriosus. The high end-systolic pressure markedly enhances S2. The flow from the right ventricle to the pulmonary artery is not turbulent; therefore, there is usually no significant murmur heard on auscultation. When the ductus closes, or when the pulmonary vasculature resistance falls, the flow to the systemic circulation will decrease, causing greatly diminished peripheral pulses. Management includes infusion of prostaglandin E1 and administration of room air while on a ventilator. Prostaglandin E1 may open the ductus arteriosus and restore systemic blood flow. Administration of room air or even hypobaric oxygen (FiO2 less than 21%) and the use of muscle relaxants can prevent hyperventilation and subsequent pulmonary vasodilation, thus reversing systemic hypoperfusion and metabolic acidosis.
318. Osteoid osteoma usually affects patients between the ages of 5 and 24 years. This lesion can occur in almost any bone, although it is most common in the lower extremities. Osteoid osteoma also may occur in the posterior elements of the spine. Patients usually present with pain, which is characteristically worse at night and relieved with aspirin. the pain is now managed with naproxen or ibuprofen. The process may cause growth disturbances, such as leg length discrepancy or bowing of an extremity, or scoliosis. Radiographs usually show a sclerotic lesion and sometimes a localized lytic defect or nidus (<1 cm in diameter) within the sclerotic bone. The nidus is best demonstrated with CT.
319.Ewing sarcoma is a malignant tumor of bone arising in medullary tissue. It most often occurs in cylindrical bones. Prominent symptoms include pain, fever, and leukocytosis. Radiographs have a typical "onion skin appearance."

320.Attention deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, and inattention lasting at least 6 months. To make the diagnosis, the disorder must have started before age 7, and six signs each of inattention and impulsivity/hyperactivity need to be present in both home and school.
321.the presence of IgG against hepatitis A could mean a previous infection and is not diagnostic of a current infection. there is no chronic hep A.
322.CMV infection : Heterophile Ab test is negative
323.-Cyclophosphamide: ovarian fibrosis in 1/5 femals. Also bladder problems
324.Reloxafine: drug use for osteoprosis, inc HDL, dec LDL, doesn’t tx hot flash
325.Remember CLL : stage I (lymphocytosis & lymphadenopathy) req no tx
326.Membranous nephropathy : . Among infections, cuases #1 is Hep B #2 syphilis
327.Remember whenever you see MI in yuong age think :-Familial hypercholesterolemia Fam hx, xanthoma, AD mutation in LDL receptor gene .
327.Autoimmune Hep : liver biopsy shows lymphocytic portal inflammation w/ early bridging necrosis. Type I (classic) assoc. w/ antinuclear & antismooth Ab. Type II (common in W European descent) has Ab to circulating liver-kidney microsomes
328.Wiskott Aldrich synd: XR immunodef triad of thrombocytopenia, eczema, recurrent infection. T & B cell defect. Inc risk of ALL & lymphoma. Tx is splenectomy, continued antibiotics, IVIG, bone marrow transplant
329.Poststreptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. Itusually follows a streptococcal pharyngitis by 1-2 weeks and a streptococcal skin infection by 2-3 weeks
Laboratory values are usually significant for markedly decreased complement levels (C3 and C4), hypo- or hypernatremia, and a blood urea nitrogen elevated disproportionately to the creatinine. In order to diagnose poststreptococcal glomerulonephritis with certainty, there needs to be evidence of a preceding streptococcal infection such as an elevated ASO or streptozyme.

33o.Total anomalous pulmonary venous return is characterized by the pulmonary veins forming a confluence behind the left atrium, and draining into the right atrium. Complete mixing takes place in the right atrium, with a right-to-left shunt through the foramen ovale to the left side of the heart. Often, no murmur is heard on cardiac examination, although a short systolic murmur is sometimes heard. ECG often reveals right atrial enlargement and right ventricular hypertrophy. The chest roentgenogram often shows a normal heart size with pulmonary edema. If there is obstruction to pulmonary venous return, as is almost always present with veins draining inferior to the diaphragm, cyanosis can be very prominent. Definitive treatment is surgical anastomosis of the pulmonary vein to the left atrium. don't forget figure 8 or snow man!
331.Hypoplastic left heart syndrome is characterized by underdevelopment of the left ventricle and the ascending aorta. Typically, there is obstruction at the mitral valve, causing all pulmonary venous blood to shunt through either an ASD or a patent ductus arteriosus (PDA) into the right atrium. Total systemic blood flow is channelled through the ductus arteriosus from the pulmonary artery. As the ductus closes, these infants present with shock because systemic blood flow is significantly reduced.
these paitents have ,HEPAtO SPLENEMEGALLY,CARDIOMEGALLY,DYSPENEA,CYANOSIS
332.PDA causes symptoms of pulmonary congestion, dyspnea, widened pulse pressure, and bounding arterial pulsation because aortic blood flow is shunted from left to right.
333.PS causes a harsh systolic murmur easily audible over the upper left sternal border. There is a significant right-to-left shunt because the large VSD allows unrestricted flow from the right ventricle to the left ventricle, causing cyanosis.
334.In which disease polymerisation of microtubules in leukocytes is the primary defect and what are its effects?
Cheideck-Higashi
Phagolysosome defect leads to infection with Staph,
335.Acid base disorder seen in a case of cardiorespiratory arrest?

first, resp acidosis becos of arrest of resp
after a time later, metabolic acidosis as tissue hypoxia going on
336.Gaucher's: glucocerebroside
Tay-Sachs': ganglioside
Niemann-Pick's: sphingomyelin
337.actinic keratoses (AK), which are common lesions seen on sun-exposed skin. AKs are a cutaneous dysplasia of epidermis that may undergo malignant transformation. They typically occur in middle-aged and elderly adults. AKs can be macules or papules, and often have a hyperkeratotic, adherent scale. The "cutaneous horn" is caused by an abnormal growth pattern of the cells within the AK, that resembles an animal horn. The treatment includes cryosurgery, surgical excision, pathologic evaluation, and topical therapy.
338.keratoacanthoma is a rapidly growing nodule that has keratinous debris in the center. It is related to squamous-cell carcinoma.
339.Because of its toxicity, especially in elderly patients and patients with liver and renal dysfunction, colchicine is not used frequently to treat acute gout.
340.High levels of cisapride (or astemizole, among other drugs) can cause prolonged QT intervals, torsades de pointes, ventricular tachycardia, and death. cisapride levels can be especially high when their metabolism is inhibited by ritonavir.
341.The patient with trichomoniasis often has a purulent vaginal discharge and some vaginal and cervical erythema (strawberry cervix). Wet smear is the most useful test and is approximately 80% sensitive for Trichomonas
342.Bacterial vaginosis presents as a gray, homogeneous, foul-smelling vaginal discharge with a pH exceeding 4.5, an amine odor when sodium or potassium hydroxide is added to the discharge, and clue cells in the exudate (vaginal epithelial cells coated with bacteria
343.remember Patients with suspected sexually transmitted diseases are good candidates for HIV serologic screening, but HIV infection does not appear to increase the risk of vulvovaginal candidiasis, trichomoniasis, or bacterial vaginosis.
344. Escherichia coli (EHEC): Bloody diarrhea, abdominal cramping, and absence of fever are common, and the disease tends to occur in previously healthy people who consumed underheated ground beef
345.From most transmissible to least transmissible, the pathogens are: hepatitis B (e antigen-positive)—about 30% to 40% of needlesticks; hepatitis C—about 3%; HIV—about 0.25%; and hepatitis A—almost never (transmission can occur during the initial viremic phase of infection only).
346..Remember Cryptococcal meningitis can occur in immunologically normal patients with no underlying disease.
347.Patients with moderately advanced to advanced immunosuppression from HIV may develop a syndrome of fever, mild hepatitis, and elevated angioma-like skin lesions cause by Bartonella henselae.The skin lesions can resemble Kaposi’s sarcoma, but the biopsy specimen shows characteristic findings of Bartonella infection, including Warthin-Starry–stained organisms.
348.The evaluation of health-care workers at the time of exposure to blood should include an HIV antibody test (ELISA) and testing for protection against hepatitis B.
349.Remember In 60% of patients with cervical intraepithelial neoplasm (CIN) the lesion resolves spontaneously; only 1% of patients have lesions that progress to cancer. The remaining patients have a chronic infection. HPV infection leading to CIN is acquired by sexual intercourse, although the male partner is usually not aware of a penile lesion, and HPV can be transmitted to new sexual partners.
350.Alwayes remember Some patients with rapidly progressive meningococcemia and meningococcal meningitis may have a normal cerebrospinal fluid examination on first presentation. !!!then suspect clinically start ceftriaxone and don't care the CSF!!!
351.what is the pathophys of idiopathic pulm fibrosis?
its the immune complex mediated activation of alverolar macrophages .....probably related to locally generated immune comples, alveolar macrogphages become activated and the produce several mediatores that recruite and induce fibroblast proliferationand ca .
clues which are imp are chest auscultation reveals coarse dry crackes and on chest x ray retucilar or reticulonodular disease..ct ground glass apperarance....pft's restrictive pattern
352.hypersen pneumonitis is type III hypersentsitivity
352.Remember Like their younger counterparts, patients older than 60 years who are not immunosuppressed contract pneumonia caused by the usual pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae. More important, advanced age is associated with infections due to Staphylococcus aureus and enteric gram-negative bacilli. Empiric antibiotic coverage for pneumonia among persons in this age group should include agents active against these pathogens.

353.Remeber Sarcoptes scabiei: The most effective way to confirm the diagnosis is to place a drop of mineral oil on a suspected area, and unroof the burrow hole with a needle or scalpel and examine the spoopings under the microscope. The patient should be treated with permethrin cream and close contacts should be treated, even if asymptomatic.
after DIAgnosis establish now you can treat and ......but not before spooping the lesions and evaluating them under the microscope.IT IS NOT A CLINICAL DIAGNOSIS!
354.2 situation that you can see WBC cast:
pyelonephritus and alergic interstial nephritus
355.by which mechanism cyclosperin cuase HTN?and what's the treatment of HTN in this situation?
renal vasoconstriction& sodium retention.RX--ca+ blockers
356.giving ACE and NSAID with each other can cuase decrease in GFR and RF,by which mechanism??
angiotensin II causes constriction at efferent arteriole.
ACEI causes dilatation of that arteriole.
so that renal blood flow is increased. But GFR and Filtration fraction are decreased as there is decreased filtration pressure.
renal PG dilate afferent arterial tone.
NSAID causes afferent arteriolar constriction.
so that decreased Renal bld flow and GFR => renal shut down
357.pathogenes of Alport syndrome: collegen type IV for GBM
358.which diuretic cuase dissolved uric acid stones?
uric acid is less soluble than its urate salt,and decreasing the urinary PH increase concentration of the uric acid form,becuase ACTAZOLAMID increase urinary PH ,it can be used to dissolved uric acid stone.
359.what's Tx(treatment) of Goodpasture's syndrome?
tx wegner granolomatosis?
plasmapharesis - gotta get rid of antiglomerular basement membrane antibodies, steroids+cyclophosphamid for Wegners granulomatosis
360.)Impaired consciousness, even following a first seizure=>do CT scan without contrast
361.Guillain-Barre syndrome is an acquired demyelinating neuropathy that usually follows a viral respiratory infection or immunizations. It is characterized by ascending weakness. Sensation is intact. A main diagnostic clue is absent deep tendon reflexes
-not EEG
361.Alwayes Remember Heart size is usually normal early in the course of common congenital heart diseases. This is true of coarctation of the aorta, aortic stenosis, pulmonic stenosis, tetralogy of Fallot, and tricuspid atresia. In transposition of the great vessels, however, a roentgenogram will show a large, egg-shaped heart with a narrow supra-cardiac stalk
362.Pneumonia that does not respond to beta-lactamines=>suspect Legionella
-diagnose by urinary Legionella antigen (ELISA)
363.Remember most common cause of hematuria in children is infection, which should be ruled out by culture unless the history strongly suggests another cause. Other causes include post-streptococcal glomerulonephritis, neoplasms, stones
364.Remember A hydrocele of the tunica vaginalis testis occurs frequently at birth but usually resolves in a few weeks or months. No treatment is indicated during the first year of life unless there is a clinically evident hernia. A simple scrotal hydrocele without communication with the peritoneal cavity and no associated hernia should be excised if it has not spontaneously resolved by the age of 12 months.
365.The current mainstay of treatment for metastatic prostate cancer is androgen deprivation therapy using a leuteinizing hormone-releasing hormone (LHRH) agonist such as leuprolide or goserelin or by performing a bilateral orchiectomy.
366.Remember hep B with membranous and hep c with membrano proliferative
367.Neurological Features of Sjogren’s Syndrome:
Small vessel strokes
Encephalitis
Dementia
Peripheral neuropathy – may be sensory, motor or mixed
Seizures
Aseptic meningitis
368.alwyes remember one of the important neurologic manifestaion of Vasculitis is peripheral neuropathy,especially in CSS!
369.asthma+eosinophilia +peripheral neuropaythy DX??
CSS(UW).
369.Differentiating Parkinson’s disease and essential tremor
Age – Parkinson’s tends to come on later in life
Location – Essential tremor is more generalised and symmetrical. It often affects the head and voice.
First degree relatives – More commonly affected in essential tremor
Associated neurological signs – rigidity, bradykinesia in Parkinson’s, usually none in essential tremor.
Response – Parkinson’s will respond to L-Dopa, anticholinergics and dopamine agonists. Essential tremor is often responsive to alcohol, benzodiazepines and beta-blockers
Writing – Parkinson’s sufferers often demonstrate micrographia, while essential tremor often involves tremulous writing.
370.which malignancy you can see in wiskott aldrich syndrme?NHL
371 .what is the cuase of death in NF1 in future?
Sarcoma
372.remember recent trials have indicated that a combination of unfractionated heparin plus a platelet glycoprotein IIb/IIIa inhibitor is superior to heparin alone in reducing morbidity and mortality in patients with acute coronary syndromes.
373.The asymptomatic patient with Descending thoracic aortic aneurysms is treated medically until the size of the aneurysm is 5 to 6 cm or symptoms present. Medical management includes aggressive blood pressure control,(B blocker and nitroproside), serial imaging for evaluation of size (diameter), and close follow up for symptom onset.
374.Remember there is a increase incidence of CAD in premenopuse women with SLE!(due to imune complex)
also chronic use of corticosteroid can cuase hyperglycemia and hyperlipedemia!
375.S. epidermidis, is the single most common cause of catheter-acquired sepsis and the most usual coagulase-negative staphylococcus,cover it with Vancomycin
376.Rifampin is an inducer of cytochrome P-450 enzyme systems and causes to decrease the plasma concentrations of protease inhibitors in HIV paitent!!BE CAREFUL!!
377. MCcune albright sd recocius puberty, aromatase enz def, cystis in bone
+ cafe auliat spots
378.Remember The diagnosis of pesudo tumor cerebri can be made only after intracranial causes for increased intracranial pressure have been excluded by MRI (tumor, venous sinus thrombosis, ventricular outflow obstructive lesions) and a lumbar puncture documents an elevated opening cerebrospinal fluid pressure.
379.Remember Carbidopa is combined with levodopa to minimize peripheral side effects of levodopa, with nausea being the most common side effect.
380.Toxoplasmosis is the most common cause of intracranial mass lesions in patients with AIDS. It typically develops subacutely over several days with the onset of fever, headache, mental status changes, and focal neurologic signs. The diagnosis of cerebral toxoplasmosis relies on a high index of clinical suspicion, neuroimaging, serologic studies, and response to a therapeutic drug trial. MRI with gadolinium is the neuroimaging test of choice to detect small lesions. Multiple lesions with ring enhancement, edema, and mass effect suggest a diagnosis of toxoplasmosis. However, no clinical or radiologic feature absolutely differentiates cerebral toxoplasmosis from a primary central nervous system lymphoma, which is the other major cause of intracranial mass lesions in patients with AIDS,put the paitent on empiric therapy with pyrimethamine, folinic acid, and sulfadiazine for 8 weeks,no response!!!do biopsy!
381.Remember Premonitory symptoms in patients with syncope include a sensation of impending unconsciousness, often accompanied by nausea, a sense of warmth, and diaphoresis. Syncope often results in atonia and collapse; however, opisthotonic posturing and clonic jerks can also occur. Pallor is a characteristic feature. Syncope usually lasts 10 to 30 seconds. Recovery of cognition is relatively rapid following syncope compared with recovery following a generalized tonic-clonic seizure.
382.good example of ethics:Old Spanish lady with CHF, she doesn’t speak English, has a care-giver daughter speaking English & a clergyman visiting her for religious talks speaking both E & S? How would u discuss with her for further Mx?answer: (get a fluent translator not a friend or family member
383. Giant cell arteritis (temporal arteritis) is a relatively common necrotizing granulomatous systemic arteritis t. The diagnosis should be considered in any person older than 50 years of age who has a new form of headache, abrupt loss of vision, polymyalgia rheumatica, unexplained fever or anemia, and an elevated erythrocyte sedimentation rate. Visual loss, which is preceded by amaurosis in only 15% of patients, occurs in up to 40% of those with giant cell arteritis if left untreated.
384.The clinical manifestations of dermatomyositis include proximal muscle weakness that evolves over weeks or months and an erythematous, violaceous rash over the eyelids, bridge of the nose, and cheeks. About one third of patients have violaceous papules over the dorsal interphalangeal joints known as Gottron’s papules. Dermatomyositis appears to be associated with a malignancy in 6% to 45% of patients, especially patients over 40 years of age.Based on available information, there appears to be a temporal association between dermatomyositis and malignancy. In women with dermatomyositis and ovarian carcinoma, the tumor is at an advanced stage and of uniform epithelial origin. In children, dermatomyositis is often associated with vasculitis,not malignancy!!!!!!!!!!!!!!!!!!!!
385. Remembber The exact pathophysiology of hepatic encephalopathy is unknown, but patients frequently respond to measures that lead to a reduction of hyperammonemia. Such measures include dietary protein restriction and lactulose administration. Gastrointestinal bleeding is an important precipitant of hepatic encephalopathy and should be ruled out by upper endoscopy.
385.Keep on back of your mind Although hypoglycemia should be avoided in patients with hepatic encephalopathy,
but if you see for example BG - 56 ,don't rush to give Glucose ,,thiamine should be administered prior to any glucose load in an alcoholic or otherwise malnourished patient to avoid precipitating Wernicke’s encephalopathy.
386.Remember Hypertonic saline should not be administered to patients with chronic liver disease and hyponatremia because of the risk of central pontine myelinolysis in this population.

387. weakness , dizziness, dysarthria, and dysphagia. These symptoms are highly suggestive of posterior circulation ischemia involving the brain stem. In addition, evidence of bilateral pyramidal tract findings (bilateral extensor plantar responses), oculovestibular dysfunction (unilateral nystagmus), and cranial nerve involvement (unilateral tongue weakness). The basilar artery and its branches supply most of the brain stem.
388.The posterior cerebral artery supplies the ipsilateral occipital lobe and medial temporal lobe.
389. Remember Patients with ALS generally present with muscle weakness and commonly note “muscle twitches” representing fasciculations. An electromyogram (EMG) is the most important confirmatory test for ALS.

390.The clinical triad of Wernicke’s encephalopathy is confusion, ataxia, and abnormalities of eye movement. However, the complete triad is uncommonly noted. Although the disorder is usually associated with chronic alcoholism, Wernicke’s encephalopathy can occur in any malnourished individual. It has been described in patients with anorexia nervosa, in patients with cachexia secondary to underlying malignancy, as a complication of gastrectomy and gastric stapling, and in patients receiving chronic hemodialysis. Once the diagnosis is suspected, thiamine, 100 mg intravenously, should be administered promptly. It is important to administer thiamine prior to or during a glucose load in a malnourished patient, as exacerbations of Wernicke’s encephalopathy can occur if thiamine is not administered first.
391.Essential tremor causes a posture- or action-related tremor that usually involves the upper extremities, the head, or the voice. Other family members may have a similar disorder. A positive response to ethanol ingestion is often noted. Treatment options include beta-blocking agents such as propranolol. Primidone, an anticonvulsant medication, is also effective. Patients should be told that primidone, even at low doses, may cause an idiosyncratic reaction that is similar to an influenza syndrome. Nausea, vomiting, and significant malaise may occur for 24 to 48 hours and then rapidly dissipate. Other treatment options for essential tremor include clonazepam and gabapentin
392.Remember the contrast used in catheterization procedure contains iodine!
and iodine tends to worsen hyperthy cuased by autonomous nodules, wheres it inhibits the release of thyroid hormon in patients with autoimmune thyroid disease such as Graves.
393.Middle cerebral artery (MCA) occlusion: "Difficulty with A-B-Cs in M-C-A"
A-Apraxia
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
394.A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D
-Dizziness
-Diplopia
-Dysarthria
-Dysphagia
395.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
396.Argyle Robertson Pupil
• Accomodation Reflex Present - Pupillary Reflex Absent.
397.Amantadine and rimantadine are active against influenza A only. A new class of compounds, the neuraminidase inhibitors, is active against influenza A and B viruses. The neuraminidase inhibitors are also effective for prophylaxis of influenza A and B infections.
398.Remeber CA125 level is a useful parameter for assessment of the response of ovarian cancer patients to chemotherapy and for detection of relapse. not for helping in diagnose
399. extensionof inflammed synovium in the popliteal space:mechanism of baker cyst
400.Focal glomerulosclerosis is the most common pattern of idiopathic nephrotic syndrome in black Americans, and treatment with a prolonged course of glucocorticoids is successful in up to 50% of patients
401. Recent studies have shown that classic Bartter’s syndrome is often due to a genetic mutation in the Na-K-2Cl transporter located in the thick ascending limb of Henle. This is the transporter that is inhibited by loop diuretics. Gitelman’s syndrome has a similar clinical presentation but is due to a genetic defect in the neutral Na-Cl transporter in the distal tubule. Thiazide diuretics inhibit this transporter. These two disorders are clinically distinguished by the presence of hypercalciuria in Bartter’s syndrome and hypo-calciuria in Gitelman’s syndrome.
402.Remember As with other metastatic tumors, breast cancer tends to produce multiple lesions that are most commonly located at the junction of the white matter and gray matter. These lesions are characteristically surrounded by a significant amount of edema; occasionally, the edematous area is out of proportion with the size of the metastasis
403.Remember Both astrocytomas and oligodendrogliomas are tumors situated within the brain parenchyma. Both types tend to present as solitary masses without clearly defined margins. Edema, although frequently present, is less significant than the cerebral edema associated with metastatic disease.
404.Remember Meningiomas arise from the dura and the arachnoid villa of intracranial and spinal spaces. These are slow-growing tumors; patients usually present with either symptoms of a space-occupying lesion or seizures of new onset. Radiologically, these tumors are characterized by their extraparenchymal location and the fact that they have a density similar to that of surrounding brain tissue. Of interest, women with breast cancer are known to have an increased incidence of meningiomas. Prognosis of meningiomas is in general excellent; surgical excision tends to be curative. Meningiomas that are difficult to excise completely (e.g., those located at the base of the brain) or that have anaplastic features are more likely to recur. For such patients, postsurgical radiation therapy is recommended.
405.Remember Prostate cancer almost never metastasizes to the brain
406.The red cell mass of less than 36 ml/kg, reduced oxygen levels, and low-normal plasma volume seen in this patient suggest a diagnosis of Gaisböck syndrome.(secendory polycytemia) Gaisböck syndrome, or relative polycythemia, is often seen at an earlier age (45 to 55 years) than polycythemia vera. In the male population in the United States, 5% to 7% have Gaisböck syndrome. Those affected are usually middle-aged, obese, hypertensive men who may also be heavy smokers.
407.Remember There are several mechanisms by which drugs can induce hemolysis; two well-recognized mechanisms are immunologic mediation (e.g., hemolysis caused by penicillin and methyldopa) and an increase in oxidative stress on red cells. Oxidative stress can occur as a result of hemoglobins becoming unstable or through a decrease in reduction capacity (as would result from G6PD deficiency).
407.understand that patients with polycythemia vera who are older than 70 years should be treated with a myelosuppressive agent such as hydroxyurea in combination with phlebotomy ,, combination of hydroxyurea and phlebotomy has been demonstrated to be an effective therapeutic regimen in controlling the hematocrit in most patients with polycythemia vera and in lowering the risk of thrombosis that occurs with use of phlebotomy alone.
408.then remember hydroxyurea is generally used for (PV) in patients older than 70 years or for those who have previously had a thrombotic event or who require high-maintenance phlebotomy.
409.If exposed to measles, all HIV-infected infants, children, and adolescents, as well as children of unknown infectious status born to HIV-infected women, should receive 0.5 mL/kg (maximum dose, 15 mL) of immune globulin intramuscularly, regardless of their immunization status, because it is impossible to know in a timely fashion if the child has protective antibody. If the person exposed to measles is receiving intravenous immune globulin (IGIV) (400 mg/kg) and 3 weeks have elapsed since the last dose, the person should receive IG (0.5 mL/kg) or IGIV (400 mg/kg) as soon as possible.
410. Isoniazid deprees the GABA neurotransmiters R in the brane=seizure.Pyrydoxon work opposite
411.Osteoarthritis of lumbar spine.:
Referred pain from the lower lumbar facet joints or intervertebral discs is often reported by the patient as hip pain, with localization to the buttock and lateral thigh. The pain is characteristically aggravated by maneuvers that increase the force brought to bear on these joints, particularly spine extension as well as lateral bending or rotation toward the painful side. Pain over the spine may or may not be present, but even in its absence, there may be paravertebral muscle spasm contributing to reduced spine motion
412.Pain resulting from hip joint pathology is usually felt in the groin and anterior thigh. Hip motion, particularly rotation, is usually painful
413.Remember mitral regurgitation secondary to left ventricular dilatation(cardiomypathy dilated) and systolic dysfunction. The mechanism of mitral regurgitation in this setting appears to be lateral displacement of the papillary muscles, resulting in inadequate leaflet coaptation. Afterload reduction therapy with an angiotensin-converting enzyme inhibitor results in a decrease in ventricular dimension and improvement in papillary muscle alignment, so that many patients have a substantial reduction in regurgitant severity
414. Rapid exclusion (or diagnosis) of aortic dissection is essential. Transesophageal echocardiography has a high sensitivity and specificity for aortic dissection and can be performed rapidly at the patient’s bedside. Therapy with a b-blocker to decrease blood pressure and heart rate should be initiated immediately and continued during the transesophageal examination. If an ascending aortic dissection is present, prompt surgical intervention is indicated;
415. putament hemorrhage cause deviation of both eyes to the side of the lesion (away from hemiparesis), but the sizes of pupils are normal
416.thalamus hemorrhage, although the sizes of the pupils are small; both eyes are deviated inward and look at nose
417.patients with cerebellum hemorrhage have a normal size of pupils and they are unable to look toward the side of the lesion
418.Remember Prochlorperazine (Compazine) is frequently used to treat nausea and emesis in some patients. Side effects of this medication, including extrapyramidal reactions (e.g., catatonia), are treated best by antiparkinsonian medications such as benztropine
419.Remember Bupropion is the antidepressant of the choices listed that has the fewest adverse sexual side effects
420. Concrete thinking is described as literal thinking that shows a lack of understanding of the nuances of meaning. These individuals lack the ability to use metaphors. for example if asks the patient what the proverb "Don't cry over spilled milk" means what??. The patient answers that if you spill what you cook, you have to do it all over again.
421.what do u find in bipsy of wilms?
spindl shaped cell, striated muscle, anaplasia, fibrillar inclusions in histo of nephroblastoma
422.Pathophysiology: In Graves disease, B- and T-lymphocyte–mediated autoimmunity are known to be directed at 4 well-known thyroid antigens, thyroglobulin, thyroperoxidase, sodium-iodide symporter, and the TSH receptor. However, the TSH receptor itself is the primary autoantigen of Graves disease and is responsible for the manifestation of hyperthyroidism. In this disease, the antibody and cell-mediated thyroid antigen-specific immune responses are well defined. The transference of hyperthyroidism by TSH receptor antibodies in (1) healthy subjects by transfer of serum from patients with Graves disease and (2) the passive transfer of TSH receptor antibodies to the fetus in pregnant women are direct proof of an autoimmune disorder mediated by autoantibodies

423.Physical findings that are unique to Graves disease but not associated with other causes of hyperthyroidism include ophthalmopathy, acropachy, and pretibial myxedema
424.During pregnancy, both T-cell and B-cell function are diminished, and the rebound from this immunosuppression is thought to contribute to the development of postpartum thyroid syndrome
also
Acute stress-induced immunosuppression may be followed by immune system hyperactivity, which could precipitate autoimmune thyroid disease.
This may occur during the postpartum period, in which Graves disease may occur 3-9 months after delivery.

425.VERY HIGH YIELD:
A summary of the differential diagnosis of thyrotoxicosis is a follows:
Graves disease: Special features include diffusely enlarged thyroid, thyroid bruits, ophthalmology, pretibial myxedema, and the presence of TSIs.
Subacute thyroiditis: Special features include a history of antecedent respiratory tract infection, neck tenderness, elevated sedimentation rate, low or absent radioactive iodine uptake, and a self-limited course.
Silent thyroiditis: Special features include painless thyroiditis, which may be seen in postpartum women (postpartum thyroiditis); a self-limited course; and low radioiodine uptake.
Multinodular toxic goiter: Special features include a propensity to occur in elderly individuals and multiple nodules palpated or observed after thyroid scans.
Toxic adenoma: Special features include a solitary palpable nodule and a "hot" nodule observed after a thyroid scan.
Factitious thyrotoxicosis: Special features include no goiter, a low thyroglobulin level, and low radioiodine uptake.
Iatrogenic thyrotoxicosis: The special feature is a history of thyroid hormone intake.
Iodide-induced thyrotoxicosis: The special feature is a propensity to occur in patients with a history of nodular thyroid disease who have been exposed to iodine-containing contrast agents or drugs such as amiodarone.
TSH-secreting pituitary adenoma: Special features include inappropriately elevated or normal TSH levels in the face of elevated free levothyroxine (T4) and free triiodothyronine (T3) levels, evidence of other pituitary hormone deficiencies, elevated alpha subunit level, and compressive symptoms.
Beta human choriogonadotropin–induced thyrotoxicosis: Special features include a positive pregnancy test result, a history of hydatidiform mole, choriocarcinoma, and embryonal carcinoma of the testis. Also, rarely, it may be observed in normal gestation.
426.How do u diff Toxic epidermal necrolysis from SSSS?
TEN is more benign than SSSS
biopsy diff them: in ssss: split granular layer....in TEN full thickness involvem
427.Intraoperative and postoperative hemorrhage is a significant problem in the patient with polycythemia vera. Despite thrombocytosis, these patients have a hemorrhagic tendency generally ascribed to a qualitative deficiency of the platelets. Elective surgery should be postponed until the hematocrit and platelet count reach normal levels. Alkylating agents, such as busulfan or chlorambucil, are effective in this regard. In the emergency situation, phlebectomy should
be performed prior to operation and also an especially careful hemostatic technique should be employed
428.Significant drop in estrogen leves right after delivery, can cause all changes in women mood- so called postparatum blues.

429.remember forceps may be used in face presentation with a mentum anterior presentation(chin facing toward the maternal pubic symphysis.) ; in such a case, vacuum is contraindicated BUT opposed to forceps, the vacuum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissues.
430.Remember When unvaccinated susceptible personnel are exposed to varicella, they are potentially infectious 10 to 21 days after exposure, and exclusion from duty is indicated from the tenth day after the first exposure through the 21st day after the last exposure, or until all lesions are dry and crusted if varicella occurs.
431.if vaccinated health care personnel are exposed to varicella, they may be serotested immediately after exposure to assess the presence of antibody. If they are seronegative, they may be excluded from duty or monitored daily for development of symptoms. Exclusion from duty is indicated if symptoms (fever, upper respiratory tract symptoms, or rash) develop.
432.The routine postexposure use of VZV immune globulin (VZIG) is not recommended among immunocompetent health care personnel. VZIG can be costly, does not necessarily prevent varicella, and may prolong the incubation period by a week or more, thus extending the time that personnel will be restricted from duty. The use of VZIG may be considered for immunocompromised (e.g., HIV infected) or pregnant health care personnel.
433.It is essential to detect and treat chlamydial infection during pregnancy because maternal chlamydial infection is associated with several complications of pregnancy including preterm premature rupture of the membranes (PPROM) and preterm labor.
434. Remember Rh isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother's immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother's immune system may "attack" the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death.

435. Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin):
1. at 28 weeks of gestation,
2.within 72 hours after the birth of an Rh-positive infant, 3.after a spontaneous abortion,
4. after invasive procedures such as amniocentesis. 5.threatened abortion,
6.antenatal bleeding,
7.external cephalic version, or abdominal trauma.

436.The amount that is usually given after the delivery of an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL-especially in cases such as manual removal of the placenta or placental abruption (as this patient had). To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given.
437. An apt test is used to differentiate fetal from maternal blood. It can be used in the diagnosis of vasa previa or with neonatal melena.
438.Among adults with acute community-acquired bacterial meningitis, Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, and Listeria monocytogenes are the most common pathogens. The possibilities of highly penicillin-resistant S. pneumoniae and L. monocytogenes should be considered (especially if the patient has underlying diabetes and liver disease). Although ceftriaxone is appropriate for susceptible S. pneumoniae, it would not be adequate for highly penicillin-resistant strains; thus, vancomycin should be given until definitive microbiologic results are available. The patient's advanced age and underlying medical conditions (i.e., diabetes, liver disease) predispose him to L. monocytogenes infection. Ampicillin is the antibiotic of choice for Listeria infections and should also be given empirically
then Alwyes remember elderly paitent >60 years especially if with Diabet and liver disease comes with bacterial mengitis COVER HIM WITH AMPI+VANCO+CEFTRIX
439.keep in your mind!! Listerial meningitis typically occurs in elderly patients, immunocompromised persons, or patients with serious underlying medical conditions (e.g., liver disease or diabetes).The CSF Gram stain is positive in only approximately 30% of patients with listerial meningitis (as compared to 60% to 90% of patients with meningitis caused by other bacteria). In addition, approximately 25% of patients with listerial meningitis have a lymphocytic predominance in the CSF (an uncommon finding in meningitis caused by other types of bacteria). The antibiotic of choice for listerial meningitis is ampicillin (or trimethoprim-sulfamethoxazole for the penicillin-allergic patient
440.Spinal epidural abscess must be considered early in any patient with fever and localized back pain, because delay in diagnosis and treatment can lead to serious neurologic sequelae. Injection drug users are at increased risk .your next step??
MRI (if available) is the best choice for delineating an epidural abscess. If MRI is unavailable, CT should be performed
441.Remember Although many patients with spinal epidural abscess have concomitant vertebral osteomyelitis, spinal x-rays are not sensitive enough to exclude the diagnosis. and also A bone scan would not adequately differentiate vertebral osteomyelitis from epidural abscess.
442.Remember In addition to I.V. antibiotics, the most important element of therapy for spinal epidural abscess is urgent surgery for drainage of pus and removal of granulation tissue

443.Remember The low-probability ventilation-perfusion scan results do not alter the probability of PE. Therefore, further diagnostic workup is necessary. Lower-extremity ultrasound should be the next step before empirical anticoagulation therapy or more invasive testing such as pulmonary arteriography is administered.
444.Vena cava filter placement is more effective than heparin anticoagulation in preventing recurrent VTE in the short-term
it is best reserved for patients with recurrent VTE whose anticoagulation therapy is inadequate at the time; in patients with significant risk of bleeding; and in patients with a life expectancy of less than 2 years.
445.mechanism by which chronic disease can cause anemia :
Anemia of chronic disease is generally associated with conditions that release cytokines (tumor necrosis factor-a, interleukin-1, and other inflammatory cytokines). These cytokines decrease erythropoietin production, decrease the levels of iron released from the reticuloendothelial system, and increase serum ferritin levels
446.Remember Alcohol abuse can cause a reversible form of sideroblastic anemia, and stopping alcohol is an important aspect of patient care.
447.AVM is the most common subarachnoid space hemorrhage in children and history of seizure or migrain like headache is characterestic.
448.keratoacanthoma, Mimics skin cancer (especially Squamous cell carcinoma) rapid onset and growth (1 month) almost never happens is SCC. Lesion spont involutes in a few months and requires no treatment
449.Rhinoviruses, which cause about 50% of colds, and coronaviruses, which cause 10% to 20%, are the most important pathogens with regard to the common cold.
450Adenoviruses : pharyngoconjunctival fever, which is often contracted while swimming in contaminated water. In addition to transmission by direct contact with respiratory secretions or infectious aerosols, fecal-oral transmission can occur. Infection may be acquired by pharyngeal inoculation or conjunctival inoculation from contaminated water. The incubation period for adenovirus infection of the respiratory tract is usually 4 to 7 days. Adenovirus respiratory disease typically causes moderate to severe, sometimes exudative, pharyngitis and tracheobronchitis. Fever and systemic symptoms are often prominent, and rhinitis, cervical adenitis, and follicular conjunctivitis are common.
451.Name 3 possible findings in non-REM sleep.?
Sleepwalking, night terrors, and bedwetting
452.Name 4 physiological actions found in REM sleep.?
Increased/variable pulse, rapid eye movements, increased/variable blood pressure, and penile/clitoral tumescence
453.Lung cancer=>think of paraneoplstic syndrome=>muslce strengh diminuished bilaterally, more proximal than distal
-normal reflexes
-increase in CK, (+) EMG
-pathology is located in the muscle membrane.
454.Disseminated gonococcal infection-rash, tenosynovitis, polyarthralgia (migratory)
-mediated by immune complexes from gonococcemia.
455.)Pneumonia post bone marrow transplant=>think CMV
-not immediate, comes in about 2 weeks to 2 years post-transplant
456.To detect the benefit of lung resection=>do PFT, especially FEV1
457.)Status epilepticus=> treat by general anesthesia+intubation
458.when u have P value > .1 means u r power ( p value ) is LOW!
mean ur number of samples r LOW !
cause ur power is low!!
459.HSP is an IgA-mediated autoimmune vasculitis, which can cause tissue damage as a result of immune complex formation. Deposition of these immune complexes in the kidneys can lead to nephritis, which is the leading cause of permanent sequelae from HSP. End-stage renal disease is an uncommon but possible outcome. It is important to perform frequent urinalyses for early detection of kidney involvement.
460.Pathogenes of A Zencker's diverticulum is a pharyngoesophageal pulsion diverticulum that occurs at the point of transition between the oblique fibers of the thyropharyngeus muscle and the horizontal fibers of the cricopharyngeus muscle. A hypertrophied cricopharyngeus muscle is thought to predispose the development of the diverticulum at this transition point.
461.cardiac output = 3-7 liters/ min
CO in cardiogenic shock is decreased; whereas CO in overload (eg. bld transfusion) will increase by increasing the mean circulatory filling pressure but it does not cause enhanced performance of heart.
Ref : Kaplan Q bank
462.Remember Some antibiotics should not be used during pregnancy :. These include tetracyclines (adverse effects on fetal teeth and bones, congenital defects), quinolones (various congenital defects), trimethoprim in the first trimester (facial defects, cardiac abnormalities), and chloramphenicol and sulfonamides in the last trimester (Gray syndrome; hemolytic anemia in mothers with glucose-6-phosphate dehydrogenase [G-6-PD] deficiency, jaundice, and kernicterus, respectively).
463.how should we manage truma to neck zone!
be careful about 2 things!
first is it gunshot or stab wound?
odes he stabe or unstable!?
NOW RULE!
.if you have a penetrating truma to neck(can be gun shot or stab wound) + UNSATBLE paitent go for surgery without any doubt and forget any ZONE!
2,if you have a GUNSHOT to middle ZONE don't think the paitent is stable or not send him for surgery!
3.If you have a STAB WOUND to MIDDLE ZONE!first look the paitent is stable or not!
if stable just observe for 12 hours no need for surgery or any expensive workup!
ok middle Zone is clear?!we talked about both gunshot and stab wound in middle ZONE!
now let's go to upper zone!
GUN shot to upper zone first do arterigraphic diagnosis and managment! if paitent is stable!
if paitent is not stable you know the rule!
now stab wound to upper zone paitent stable and asymptomatic!just observe!
if unsatble surgery!
now move to base of the neck!
GUNSHOT and stable! do arterography,esophagogram,esophagoscopy,broncoscop y ,then surgery!
if unstable you know ,surgery!
stab wound in neck of zone I have no idea becuause kaplan didn't mention!
464.Remember TSH levels are very helpful in confirming the diagnosis of the hyperthyroid state, but are not the best parameter to follow in patients undergoing treatment for thyrotoxicosis.Serum T4 levels are the best parameter to follow; they are readily available and relatively inexpensive, and allow for careful monitoring of the effects of antithyroid drug therapy.
465.The appropriate evaluation of the hypothalamic–pituitary–adrenal axis is a post-cosyntropin measurement of serum cortisol; cortisol levels fluctuate widely due to the pulsatility of this hormone, and therefore random measurements are not useful. The appropriate evaluation of the hypothalamic–pituitary–thyroid axis is a free thyroxine index (or dialysis free T4) because the TSH concentration is often normal in central hypothyroidism. The hypothalamic–pituitary–gonadal axis in men is best evaluated by measuring serum total testosterone
466.Alwyes remember There is significant variation in sperm counts on semen analysis, and a single abnormal test should never be used to document infertility.Repeat it again!!!!before you say he is infertile!!!!!!
467.Treatment for Gonococcal conjunctivitis =>>> Ceftriaxone
Prevention =>>> erythro topical
468.Adrenal Leukodystrophy (ALD)
USMLE LOVE TO ASK!!!!!!!
Clinical Sx:
The disease usually presents in males age 5-10 years old with a gradual disturbance in gait and slight intellectual impairment. There is usually rapid progression with hypotension, seizures, visual complaints, and difficulty in swallowing appearing with time. Abnormal skin pigmentation or other signs and symptoms of adrenal insufficiency may become apparent before CNS symptoms. In some cases, adrenal symptoms never appear.
Etiology/Pathophysiology:
Classic ALD and the adult variant adrenomyeloneuropathy (AMN) are X-linked diseases in which there is deficiency of lignoceroyl-CoA ligase, a perioxisomal enxyme needed for the degradation of very long chain fatty acids (VLCFA).
Pathology:
White matter diseases are usually classified as demyelinating or dysmyelinating diseases. Dysmyelinating diseases such as ALD are inherited enzymatic deficiencies that cause abnormal formation or increased breakdown of myelin. Demyelinating diseases result in the loss of normally formed myelin by processes such as infection, chemotherapy, radiation, and autoimmune disorders such as multiple sclerosis.
The diagnosis of ALD is made by the assay of plasma, red cells, or cultured fibroblasts for increased amounts of VLCFA.
Imaging:The classic presentation on CT is low attenuation in the central occipital white matter that extends into the splenium of the corpus callosum.

USMLE Step 3: Day 3

2010-02-11T09:22:00.002-05:00

Completed GI review. O yeah ...

The snow storm is really historical. The total amount of snow I shoveled from my driveway is nearly ten tons. Most of my time yesterday was spent on fighting snow.

Today I'll review all available texts for GI and tomorrow will move on to nephrology.

USMLE Step 3: Day 2

2010-02-10T09:21:00.002-05:00

Still doing GI questions. The overall correct rate is 59% for today. My feeling is that Step 3 has no big difference as Step 2 at least for GI. I also realize that FA Step 3 needs a lot of details for colon cancer. Maybe I should find some family medicine reference to study colon cancer.
Due to the snow, I came back home at around 8 pm. After dinner, it's almost 9:30 pm and then started to study till 12 am.
Day 2: so far so good.

USMLE Step 3: my first day!

2010-02-09T10:40:00.000-05:00

Yesterday was my first day on the journey to the USMLE Step 3 exam. With great excitement, I registered for the UW course and attempted the first 34 problems for GI. The overall correct rate is 61%. Not bad as a start. My plan for Step 3 is to do the UW questions by subject first. Every night (my study time can only be from 8 pm to 10 pm), finish 30 questions and then review these questions and make notes on FA Step 3. My first goal is to finish the UW qbank in about 6 weeks. I know it’s hard, but what I felt yesterday was that I really like doing the medical questions. Every question is a great intellectual stimulation and I really enjoyed the whole process, which really helps me a lot to distract myself from the anxiously waiting for the match!

Coney Island IM Interview

2010-02-08T10:04:00.002-05:00

When I got there, their pre-matches have all been sent. So, if you like this hospital, schedule the interview as early as possible. There is very limited information about this program on the Internet. What I can tell you is that this is a big IM program. The hospital has a new building and the vast majority of the IM wards are in the new building. The facilities are the best among all the hospitals I visited. According to the chief, it's a very busy program but has plenty of opportunities to learn. The case given in the morning report is also interesting and it reflects the complexed diseases the residents here can handle.

The interview itself is quite easy. It's a panel interview. No hard medical questions were asked. In summary, this program is much better than my first impression.

USMLE Step 3

2010-02-08T10:00:00.002-05:00

Finally, I made up my mind to go for it. From today, I'll officially start to prepare for the USMLE Step 3. From many others, it seems Step 3 is the most difficult part of the three steps. Let's see how hard it could be! :)

Brooklyn Hospital Center - Preliminary Surgery

2010-01-31T19:39:00.002-05:00

There is a paid parking space beside the hospital, $14 a day. If from New York, it's easily accessible by subway. The hospital is located in downtown Brooklyn. The hospital itself is safe and has a relatively nice neighborhood. The interview started very early: yes, 7 am. The candidates meet the PC in the cafeteria. The breakfast is provided: very nice actually. Then all go up to the 8th floor. The PD is new and very nice too. He introduced the program first and then start to interview each candidate. One other faculty does interview too. There are no medical questions during the interview. After interview, lunch was provided and then the hospital tour. During my interview, every faculty member and resident was very very nice and happy.

Step 3 Experience from usmleforum

2010-01-02T12:39:00.001-05:00

* Step 3 Experience - i will miss the USMLE
#467994
delmar - 12/03/09 07:11

exam: nov 9/10
result: dec 1 midnight (dec 2 @12 am)
Score: 250 -99
not in residency
prep : 4 months

TIPS:
1- step 3 does not ask the depth of medicine as much as the width of knoweldge
it tests u as a primary care giver, focusing on answering real questions that u will get from patients, no single book has this information

2- exam questions are long, practice under pressure, u should anticepate what the question will ask u by the 2nd line

3- focus on advice to the patients, side effects of meds, interactions, peds and rashes, obgyn = what a PCP knows, they will not ask sofistacted question, but the simpler the fact, the more likely u'll get it wrong

4- read a family practice book or questions

5- dont let the anxiety of other froum members to reflect on you

6- if u plan to take NBME, UWSA , take them at least 2 weeks before the exam or earlier to have the time to work on ur weak areas

7- they are not designed to foretell or predict ur score, that is a misuse and dangerous, the only help u see ur weak areas.

8- no single material source is perfect, live with that.

9- CCS, take care not to do the same stuff too much, u will have a predetermined path to the case and that might be very dangerous.

10- while studying topics, write ur ccs plan for each topic even if it is not likely to come, by this u will do at least 1000 ccs in the same time ur doing mcqs, the big plus, ur going to be a better doctor

11- material i used: due to the problems on this forum i will not advise either with or against any material, just FYI ; nothing is complete

Good luck

IM Interview at Interfaith Hospital at Brooklyn

2010-01-02T11:57:00.002-05:00

There is nominally no parking space for visitors and you have to park your car on the street. Neither is there a PC to register you. You simply wait in the lobby and around 11:45, you will be called in the offices one after another. Each interview is about 15 minutes. After the interview for all the candidates, you'll be given a brief tour of the hospital. Then you are dismissed with a very hungry stomach.

Hospitals offer externship

2009-11-28T13:38:00.001-05:00

We are compiling a list of hospitals in the United States that offer Externships to medical graduates/medical students with an emphasis on those programs that accept IMG's. Externships are learning opportunities, similar to internships, offered by hospitals to give you short practical experiences. For a list of observerships, click on the link below http://www.residentscafe.com/list_of_hospitals_offering_observerships You have hands on clinical experience working with patients and can get useful LOR's and meets the requirements for most hospitals that require USCE or US clinical experience. However, you have to pay the hospital or institution a fee for the previlege of being an extern. This is an ongoing effort to find the best hospitals that offer externships, so please add more to the list and we will update the main post. List of Hospitals Offering Exterships Organized By State California
Hospitals in California (accept IMGs) Natividad Medical Center Program
Salinas, CA
http://www.natividad.com/fprp Arrowhead Regional Medical Center Program
Colton, CA
http://www.arrowheadmedcenter.org/Residency.asp Cedars-Sinai Medical Center
Specialty: Psychiatry
URL: http://www.csmc.edu/2813.html Colorodo
University of Colorado Health Science Center
Specialty: Anesthesia / Anesthesiology
Contact Information Health South Rehab Hospital, Colorado Springs, CO
Phone: (719) 630-8000 URL: http://www.uchsc.edu/anes/ResInfo/requirements.htm Washington DC St. Elizabeth Hospital
Specialty: Psychiatry
Duration: 4 Months or more
URL: http://www.stelizabethshospitalresidency.org/ Providence Hospital, DC
Specialty: Internal Medicine
Cost: Free
Contact: Program Coordinator: (202) 269-7747
Duration: 3 Months
Requirements: ECFMG Certification, GOOD USMLE scores, 3 LORs, Copies of Medical Diploma, ECFMG Certificate AND your Resume
Address: Program Director (Internal Medicine Residency Program)
Providence Hospital, 1150 Varnum Street, N.E., Washington, DC 20017 - 2180
URL: http://www.provhosp.org/Physicians/Medical_Int/Medical_Int.htm Illinois
Chicago Jackson park hospital - Family medicine
Address:
7531 S. Stony Island Ave.
Chicago, Illinois 60649
Telephone: 773-947-7500 - ask for the department of family medicine and enquire about externship opportunities. URL: http://www.jacksonparkhospital.org/index-1.html Indiana Indiana University School of Medicine
Specialties: Obstetrics and Gynecology and Family Practice
Requirements: ECFMG Certification, At least one US LOR
Allow Visitors, Student (F1) and even J1 visas
URL:http://housestaff.iusm.iu.edu/externs_temporarys/extern.pdf Kansas University of Kansas School of Medicine-Wichita (KUSM-W) at Veteran Affairs Hospital (VA hospital)
Specialty: Internal Medicine
Contact: Internalmed-wichita@kumc.edu
Application Requirements: * Universal Application (Download PDF from NRMP)
* ECFMG Certificate
* Dean's Letter
* USMLE scores: Step 1 & Step 2 CK
* Medical School Transcript Mail / Courier all the above material to: Kansas School of Medicine-Wichita
Internal Medicine Residency Program
Attention: Externship
1010 North Kansas
Wichita, KS 67214-3319 URL for application forms: http://www.nrmp.org/res_match/about_res/univappl.pdf URL for program's website"
http://wichita.kumc.edu/im/
Maryland Dr. Barry Mehta
Specialties: Internal Medicine, Family Medicine, Surgery, Pediatrics, Ob-Gyn
Duration: Minimum 7 weeks tp get a Letter Of Recommendation. Schedule
Cost: $4,400 for 7 weeks (Training + Staying)
Call: 410-730-3961, 443-285-9563 (cell)
This program seems to be organized by a commercial service via fmgaffordable, according to the following url, http://fmgaffordable.com/Schedule.aspx
"The standard program of 6 weeks has two mini-sessions of 3 weeks each. We enroll students for standard sessions only (6 weeks minimum), after which you will have earned two LOR's. Your first assignment will be partially at a teaching physician's office, but mostly hospital-based. Your second assignment can be 100% hospital-based if the student so chooses. Use the URL http://fmgaffordable.com/Schedule.aspx for schedule dates Harbor Hospital, Baltimore
Specialty: Internal medicine
Contact Program Coordinator at: 410-350-3565
URL: http://www.harborhospital.org/ Massachusetts - Cambridge
Harvard Medical school program The harvard program is only for those who did not graduate yet. Contact: hone: 617-732-5775
Address: 75 Francis Street, Boston, MA 02115 Ask for externship opportunities Not sure if they offer both externships and observerships but for sure offer observerships as per the following url
http://www.mgh.harvard.edu/vep/observerships.html Ohio Columbus Community Hospital, Columbus Specialty: Pediatrics Unsure, call (614) 445-5000 and speak with somebody in the department of pediatrics to confirm Huron Hospital Specialty: Internal Medicine Policy Statement: The Internal Medicine Program offers externships, observerships to candidates meeting our minimum criteria, but it is not required to be a resident. We do not schedule externships in the months of June or July. Externships are for one month only and must be approved a minimum of three months prior to starting. University of Cincinnati Academic Medical Center Specialty: E.N.T. (Otolaryngology) NB: Application are considered on an individual basis by contacting Robert Keith, PhD, Director of Medical Education at robert.keith@uc.edu, Department of Otolaryngology-Head and Neck Surgery, PO Box 670528, Cincinnati OH 45267-0528. Oklahoma Oklahoma State Medical Association (OSMA) Specialties:- Family medicine, Internal Medicine, Anesthesiology etc.
Application: To Apply, you should fill the Application Form from OSMA Telephones: 405-843-9571 OR 800-522-9452 Application Form available at
URL: http://www.okmed.org/index-2_internationalsection.html Tennessee East Tennessee State University (ETSU), Johnson City Specialty: Internal Medicine - Not too sure, need to confirm URL: http://www.etsu.edu/com/intmed/ Contact Department of Internal Medicine East Tennessee State University VA Bldg. 1, Box 70622 Johnson City, TN 37614-0622 423- 439-6282 and ask if they have any externship opportunities. Texas North Richland Hospital, North Richland,TX Specialty: Pediatrics
Needs further confirmation Contact:
North Hills Hospital
4401 Booth Calloway Road
North Richland Hills, TX 76180 Telephone: (817) 255-1000 and ask to speak with the secretary for the department of Pediatrics, ask for any possibilities for Externships. Url: http://www.northhillshospital.com/