Approach to CCS

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.

Subclinical Hyperthyroidism: Controversies in Management

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

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

GBS
Prevention: Intrapartum Penicillin G or Clindamycin/Erythromycin

1. All women with positive GBS urine culture
2. Previous neonatal sepsis
3. Trimester vaginal culture positive
4. Preterm gestation
5. Membranes rupture > 18 h
6. Maternal fever

Toxoplasmosis

• Chorioretinitis
• Intracranial calcification
• Symetrical IUGR
• Hepatosplenomegaly
• Thrombocytopenia
• Primary infection cause problems
  

Treatment:

1. Pyrimethamine and sulfadiazine
2. 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

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: Day 3

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

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!

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!

USMLE Step 3

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! :)

Step 3 Experience from usmleforum

* 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

adeno:技术贴step ３ CCS 99 05 2009

adeno (天夺其魄) 于 (Wed May 6 16:22:43 2009) 提到:

成绩出来了，涉险挤入了９９队伍。总的来说，准备的不是很充份，详见以前贴的＂我
的step ３经历＂，主要是在吃CK的老本；其他乏善可陈，成绩单里唯一的一个星号是
给了CCS，这里就说一说CCS好了。

以前总把CCS和CS混淆，其实这两个有一个共同点就是open choices和uncertainty。在
这总场合，最重要的可能就是要有一个严格的protocol，这样可以尽量避免遗漏。考过
CS的同学都知道LIQOR AAA和PAMHUGSFOSS的重要性。CCS也一样。网上比较流行的是
Neeraj的protocol，用google一搜就能找到。非常有用。我把他的protocol稍微整理了
一下，自以为是更加简洁有条理一些。给几个朋友用了用，有的朋友觉的没有时间应用
，有的朋友用了觉的还成，让我贴出来，最后的决定是如果考出来还行就贴，要不就不
出来吓人了。

象CS一样这个protocol充满了mnemonics，开始考试之前第一件事就是把所有的mnemonics写下来。下面９个case都可以用，这点比CS强。

（１） what＇s to be managed？

知己知彼百战不殆。第一件事是要知道有什么是需要处理的。在读病史的时候要把这些要点记下来。这个mnemonic不make sense，就是好念： VASCODAL

V: abnormal vitals
A: age
S: sex
C: chief complaint
O: other symptoms to be managed
D: Diabetes
A: Allergy
L: Lifestyle to be modified (eg, smoking/alcohol/drug, etc)

（２） Emergency orders

如果病人不stable，在体检之前你要先stablize。下面是Emergency orders的checklist。当然不是每个人都要全套，你根据病人的需要，不要遗漏就是了。

I am so mean！

IVA
Airway suction,
Mechanical ventilation （of course, preceded by tracheal intubation）,
Sat,
O2,
Monitor (enter monitor, then select bp and cardiac),
EKG,
Accuchek,
Naloxone cocktail (naloxone, thiamine and D50)

（３） Physical examination

PE没啥特殊的。原则是： if the patient is in any distress (SOB, severe pain, not necessary unstable), do a focused PE； Otherwise, do a complete one

（４） Diagnostic orders

Neeraj的原版是boupi，对俺们老中来说还是BUOPI更血淋淋一些。诊断嘛，就是要刺刀见红。

Blood: cbc, bmp, LFT, Mg, P, TSH, fT4, fT3, Cardiac enzyme,
PT/PTT, Blood Culture, Lipid profile, etc
Urine: UA, culture，etc
Other: EKG, FEV1, PEFR
Pregnancy：育龄女性不可缺少！
Imaging: CXR， KUB， CT， etc

5. Treatment plan


ADMIT P ICU (Admit Patient to ICU)

Activity: bed rest, ambulate, etc
Diet: low salt, low fat, NPO, soft food, blahblah
Modification of Lifestyle (Avoid Caffeine, etc )
IV fluids
Treatment (Medication/Procedure)

Precaution: Seizure precaution, aspiration precaution, skin care, DVT and stress ulcer

Intake/Output
Compressive stocking
upper GI protection (or ulcer prevention, whatever) (ranitidine, pantoprazole, etc)

(These 3 are for ICU only)



7. Monitor: 下了order后要注意治疗效果。根据病情关注下列指征。

History&Physical, Urine output, BP, Sat, H&H (bleeding) CBC (infection), BMP (Electrolyte), ABG, PT/INR/PTT, LFT, etc, neuro check (for altered mental status)


8. Discharge: Rated SexPM

RatedSex see Neeraj
Prevention (screening and vaccination, age appropriate)
Medication side effects and adherence

就这些。有一点很重要的没有提到，就是location。什么时候换，换哪里没有一定之规，自己用common sense吧。Neeraj有更详细的讨论。

=============================

附录： empirical antibiotic use （stripped from UW８８ and Shaher CD）

Common ID and abx use:

AOM and sinusitis: amoxicillin
IE: Vancomycin + Gentamycin
cholecystisis, ampicillin + gentamycin, or cefuroxime monotherapy
cholangitis or necrotizing pancreatitis: Imipenem
appendicitis, diverticulitis: cipro + flagyl
perforation: Ampicillin + Gentamycin + Metronidazole
Pyelonephritis, urosepsis: ceftriaxone
PID: Cefoxitin + Doxycycline
infant sepsis/meningitis: ampicillin + cefotaxime
COPD exacerbation: levoquin
pneumonia: CAP outpatient: azithro
CAP inpatient: levoquin
hospital acquired levo + pipera
fibrile neutropenia: vanco + ceftazidime. Or piperacillin + tobra if G+ is not a concern
prostatitis: ofloxacin
meningitis: vancomycin + ceftriaxone
arthritis: Gono -- Cetriaxone
non-gono -- nafcillin + cipro
cystitis: TMP/SMZ, amoxicillin, cipro, nitrofurantoin
diabetes cellulitis: cefazolin
trichomonas vaginalis and bacterial vaginosis: metranidazole
mastitis: nafcillin
bronchial foreign body after brochoscope retrieval:
Methylprednisolone, IV, one time
Cefazolin, IV, one time

抱歉的是里面有很多缩写。你考到step ３就明白是什么了，我就不一一翻译了。

USMLE step 3 application website

http://www.fsmb.org/usmle_applonline.html