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* Conrad Fischer's lectures on Internal Medicine
 #243644  
  mira1978 - 11/17/07 01:08
 
  http://rapidshare.com/files/34351286/Abd.Pain.mp3
http://rapidshare.com/files/34351850/Arrhythmia.mp3
http://rapidshare.com/files/34352255/Bl.-CA_1-2.mp3
http://rapidshare.com/files/34352768/Bl.-CA_2-2.mp3
http://rapidshare.com/files/34353985/CHF.mp3
http://rapidshare.com/files/34563866/CXR.mp3
http://rapidshare.com/files/34563804/DDx.chest_pain.mp3
http://rapidshare.com/files/34564239...Aller_Inf..mp3
http://rapidshare.com/files/34563785/Derm.CA_Acne.mp3
http://rapidshare.com/files/34563745/Diarrhea-colon.mp3
http://rapidshare.com/files/34563891/Dx.chest_pain.mp3
http://rapidshare.com/files/34563808/EKG_notes.mp3
http://rapidshare.com/files/34564076...ENT_Pneumo.mp3
http://rapidshare.com/files/34564107/Esophgous.mp3
http://rapidshare.com/files/34563878/GI_Bleeding.mp3
http://rapidshare.com/files/34564264...hts01-M.I..mp3
http://rapidshare.com/files/34564253/hilights02-CHF.mp3
http://rapidshare.com/files/34563862...ntibiotics.mp3
http://rapidshare.com/files/34563982...infections.mp3
http://rapidshare.com/files/34563946...hts_05-INH.mp3
http://rapidshare.com/files/34563981...hts_06-HIV.mp3
http://rapidshare.com/files/34563953...cro-Anemia.mp3
http://rapidshare.com/files/34564073...cro-Anemia.mp3
http://rapidshare.com/files/34564100...-Hemolysis.mp3
http://rapidshare.com/files/34564084...al_Failure.mp3
http://rapidshare.com/files/34564260...1-Na___ADH.mp3
http://rapidshare.com/files/34564098/hilights_12-K.mp3
http://rapidshare.com/files/34564096..._poisoning.mp3
http://rapidshare.com/files/34544198/IBD.mp3
http://rapidshare.com/files/34544112/Inf.bone_heart.mp3
http://rapidshare.com/files/34544095/Inf.GU_Skin.mp3
http://rapidshare.com/files/34543985/Inf.liver_STD.mp3
http://rapidshare.com/files/34715963/Inf.lung_GI.mp3
http://rapidshare.com/files/34714837/Inf.lyme_HIV.mp3
http://rapidshare.com/files/34544132...Meningitis.mp3
http://rapidshare.com/files/34723607/Macro-Anemia.MP3
http://rapidshare.com/files/34722981...mplication.mp3
http://rapidshare.com/files/34722329/Micro-Anemia.mp3
http://rapidshare.com/files/34721760...ease_Liver.MP3
http://rapidshare.com/files/34721158/Plt._Bleeding.mp3
http://rapidshare.com/files/34720371...of_CNS_GIT.mp3
http://rapidshare.com/files/34719013..._lipids_MI.mp3
http://rapidshare.com/files/34718146...ericardium.mp3
http://rapidshare.com/files/34716962/VolvDis_IHSS.mp3

A must have for everyone!!
 
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* Re:Conrad Fischer's lectures on Internal Medic
#1061782
  fragilemed - 11/23/07 22:29
 
  bump..to the top.
Thank u mira. Wonderful work
 
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* Re:Conrad Fischer's lectures on Internal Medic
#1061870
  hpv - 11/24/07 01:22
 
  http://egymedicine.com/forums/thread2784.html

(different way to download)
 
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* Re:Conrad Fischer's lectures on Internal Medic
#1062477
  k80 - 11/24/07 18:24
 
  my second time bump  
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* Re:Conrad Fischer's lectures on Internal Medic
#1062695
  mira1978 - 11/24/07 23:19
 
  1. A 25- year old mother refused immunization for her 2-month old son. The social worker spoke to the mother. (Important for Board examination)
Next step in management: immunization should be given for the benefit of the child.
2. A 30-year old mother refused surgery for suspected appendicitis for her 6-year old daughter. The social worker spoke to the mother. (Important for Board examination)
Next step in management: surgical removal of the appendix should be preformed for the benefit of the child.
3. A 16-year old boy was diagnosed with osteosarcoma of the right thigh. The surgeon recommended amputation. The boy refuses amputation. He is doing very well otherwise. He is aware that death is certain without surgery. (Important)
Next step in management: amputation should NOT be preformed.
Adolescent patients or adults who are competent in making decisions have an absolute right to determine what shall be done with their own bodies. However, most pediatric patients are not competent to make their own decisions. Please remember, children (15 years or older) are usually able to give a genuinely informed consent. Therefore physicians may respond to their request, except in a case of irreversible sterilization.
4. A 17-year old girl is a Jehovah's Witness. She refuses a lifesaving blood transfusion. She is aware of the consequences. She spoke to the social worker. (Important)
Next step in management: blood transfusion should NOT be given because she is competent to make the decision.
5. A 5-year old girl is a Jehovah's Witness. She requires emergency blood transfusion. Her mother refuses blood transfusion. A social worker along with two physicians spoke to the mother. (Important)
Next step in management: blood transfusion should be given because the patient is not competent. Mother cannot refuse her daughter's treatment.
6. A 2-year old boy was brought to the ER by his parents for an injury. Physicians made the diagnosis of child abuse. There are three other children living in the same household. Both parents confess to child abuse but request the physician to keep it confidential. Social worker was involved. (Important)
Next step in management: the case should be reported to Child Welfare Agency (CWA). All children should be removed from the parents.
7. A 15-year old boy with STD (sexually transmitted disease) came to see a physician. He asked the physician not to tell his parents. (VERY IMPORTANT)
Next step in management: the physician should treat the patient and notify the appropriate health authority, but should not tell his parents.
8. A 16-year old boy wants to use a condom. He comes to the clinic for free samples. He requested the physician, however, not to tell his parents. (Important)
Next step in management: condom should be given and physician should not tell his parents.
9. A 30-year old male patient is recently diagnosed with HIV. He lives with his wife and two other children but is promiscuous. He requested the physician not to tell his wife. He lost his job recently. Social worker spoke to the patient. (Very Important)
Next step in management: physician should notify the appropriate authority (e.g. department of health) for the safety of other specific persons who are engaged in unsafe sexual practices. The physician however, should ask the patient to divulge the diagnosis to his wife and other sexual partners.
10. A very small premature infant was born in the delivery room by NSVD (normal spontaneous vaginal delivery). The attending physician decided not to resuscitate the newborn. Physician spoke to the mother. Mother started to cry. Newborn expired after 30 minutes. Is the physician liable for the newborn's death?
Answer: NO. Please remember, no physician in the USA has ever been found liable for withholding or withdrawing any life sustaining treatment from any patient for any reason.
11. A physician picked up a car accident victim from the street and brought him to the ER in his car. He did not want to wait for an ambulance because the patient's condition was critical. Physical examination in the ER reveals quadriplegia. Is the physician liable for this consequence? (Very Important)
Answer: YES, because the physician did not protect the neck of the patient resulting in quadriplegia.
12. A policeman brought an alcoholic patient to the ER. The policeman asked the physician to give him a sample of gastric contents by putting a nasogastric tube for laboratory study. The patient refused insertion of a nasogastric tube. (Very Important)
Next step in management: nasogastric tube should not be placed. Blood alcohol level however should be preformed. The policeman should not give orders to a physician.
13. A 60-year old man with a history of myocardial infarction (MI) suddenly develops ventricular tachycardia. A physician from another department was present. The patient needs resuscitation. (Very Important)
Next step in management: the physician must resuscitate that patient. Physician should not refuse treatment because he belongs to another department.
14. A 15-year old homosexual boy wanted to change his sexual orientation. He was not successful. He needed help. He requested the physician not to tell his parents. (Important)
Next step in management: physician should help him avoid homosexual activities. Physician should not tell his parents about his homosexual activities.
15. A 15-year old homosexual boy is brought by his parents to a physician. His parents do not accept their son's sexual orientation. The boy refuses to change. (Important)
Next step in management: physician should tell his parent that homosexual activity is considered as an alternative life style. Parents should talk to his son but should not force him to change his homosexual activities.
16. A 16-year old girl becomes pregnant. Her mother wanted her to abort this pregnancy. The girl wanted to continue her pregnancy despite difficulties. Her boyfriend is a high school drop out. (Important)
Next step in management: physician should advise to continue this pregnancy because the girl is competent to make this decision.
17. A 15-year old girl recently becomes pregnant. She went to a doctor for abortion. She told the doctor not to tell her parents about this pregnancy. (Important)
Next step in management: abortion should be done and parents should not be notified. Please remember, strict requirements for parental consent may deter many adolescents from seeking health care.
18. Can a physician provide sterile needles for intravenous drug abusers? (Important)
Answer: YES. It reduces the risk of acquiring HIV or hepatitis. The patients should be referred to appropriate health facilities.
19. A 26-year old pregnant woman went for antenatal check up. Sonogram revealed a 27-week old fetus with erythroblastosis fetalis. Doctor recommended intrauterine fetal blood transfusion. She refused the procedure. Social worker discussed the case with the mother. (Important)
Next step in management: doctor should receive a court to do the procedure which will help the fetal condition.
20. A 20-year old man tells his doctor that he is going to kill girlfriend. She lives in the university dormitory. Doctor called the university and alerted them about the threat. However, university security people did not protect her. She was killed by her boyfriend. Who should be responsible for this killing? (Important)
Answer: the 20-year old man is responsible. Doctor did the right thing by notifying the university or the police. The university is also responsible because they did not take any preventive measures.
21. A 20-year old pregnant woman refuses cesarean section for complete placenta previa. Fetus is full-term and healthy. Social worker spoke to mother. (Important)
Next step in management: doctor can go to court to get permission for cesarean section for the benefit of the fetus.
22. A 30-year old pregnant woman ingested alcohol and illicit drugs (e.g., cocaine, crack) which are harmful to the fetus. What should a physician do? (Important)
Answer: the physician should be careful in reporting this case because the pregnant woman may not come back for prenatal care, which is important for both the mother and the fetus. However, if the baby's urine toxicology test is positive for illicit drugs, case should be reported to CWA (child welfare agency). CWA suggests separate custody for the child.
23. A physician wants to study a group of children aging from 10-12 year old. Physician already got the consent from the parents. However, he didn't discuss the study with the children. A child refused to participate. Should the physician force the child to participate? (Important)
Answer: no, because a child can refuse to participate in a research study.
24. A 40-year old schizophrenic patient needs hernia repair. Surgeon discussed the procedure with the patient who understood the procedure. Can the patient give consent? (Important)
Answer: yes. If a psychiatric patient understands the procedure, he or she can give the consent.
25. A 65-year old schizophrenic patient needs coronary angiography because of suspected myocardial infarction. Cardiologists explained the procedure to the patient who did not understand the procedure. Who can give the consent on behalf of the patient? (Important)
Answer: the patient's relative can give the consent. If nobody is available to give the consent, court order should be obtained. If a psychiatric patient does not understand the procedure, he or she cannot give the consent.
26. A 25-year old woman developed postpartum psychosis. The newborn developed cyanosis due to congenital heart disease. The newborn needs cardiac surgery. Surgeon discussed the procedure with the mother. She understood the procedure. Can she give the consent? (Important)
Answer: yes, because she understood the procedure.
27. A newborn is diagnosed with either trisomy 18 or 13 with TE (tracheoesophageal) fistula which requires suregery. Mother request surgeon to repair the TE-fistula. What should a surgeon do? (Important)
Answer: surgeon should refuse to do the reparative surgery because these conditions (trisomy 18 or 13) are nonviable. If the patient survives, surgeon can put a gastrostomy feeding tube for nutrition. However, please remember that a patient with trisomy 21 (Down syndrome) with TE fistula should be operated on.
28. A 45-year old terminally ill patient wanted to die. He has pancreatic cancer and has been suffering from constant pain. He asked the physician to give him some medication which can expedite his death. What should a physician do? (Very Important)
Answer: physician cannot give any medication which will expedite the death. However, physician can prescribe medication to minimize the pain. The dose should be appropriate. Physician-assisted suicide is illegal everywhere (except in the state of Oregon).
29. A 47-year old man came to a doctor for chronic low back pain and dysuria. The diagnosis of metastatic prostate cancer was made after appropriate investigation. Should the doctor tell the bad news to the patient? (Important)
Answer: yes physician must tell the truth to the patient.
30. A surgeon wanted to perform cholecystectomy on a patient. The surgeon is not sure whether the patient has decision-making capacity. What is the next appropriate step? (Important)
Answer: consultation with a psychiatrist or neurologist may be helpful. Sometimes it is necessary to discuss the case with hospital attorneys, ethic committees, or ethic consultants. In a difficult case, the ultimate judge of a patient's competency is a court.
31. A 45-year old widow was admitted to an ICU (intensive care unit) with ruptured intracranial aneurysm. She is comatose and is placed on a mechanical ventilator. She has a 20-year old son who did not keep any relation with his mother. However, he came to see his mother. His mother made a written proxy advance directive which indicates that her 50-year old female neighbor should make the substitute decision. Who is the right person to make the substitute decision in this situation? (Important)
Answer: 50-year old neighbor should make the substitute decision. Please remember, the most appropriate person to make the substitute decision is someone designated by the patient while still competent, either orally or through a written proxy advance directive. Other substitute decision makers, in their usual order of priority, include a spouse, adult child, parent, brother or sister, relative, or concerned friend. For a patient who has no other decision maker available, a public official may serve as a decision maker.
32. The right of patients to refuse medical intervention: patients can refuse dialysis, cardiopulmonary resuscitation, mechanical ventilation, and artificial nutrition and hydration, even if such a decision results in the patient's death. A patient's decision to withdraw (discontinue) or to withheld (not to initiate) life-sustaining treatment is not considered suicide and physician participation is not considered physician-assisted suicide. Physicians do not have any legal risk.
33. Can a medical student introduce himself or herself as a 'doctor' to the patient? (Important)
Answer: no. a patient can refuse a medical student from performing any procedure. However, medical students are allowed to perform a procedure under appropriate supervision If the patient agrees to that.
34. Should a bus driver hide history of epilepsy from his employer? (Important)
Answer: no. He has requested his physician not to mention his epilepsy to the employer because this would result in the loss of his job. The physician is obligated not only to his patient but to the community. The patient should notify his employer and try to find a non-driving job in the company. If the patient disagrees, physician may notify the appropriate authority for the safety of the patient and the community.
35. A 50-year old make is diagnosed with stomach cancer. He requested the physician not to tell his wife. The following day, the wife calls to inquire about her husband's diagnosis. (Important)
Answer: the physician should not divulge the husband's diagnosis. However, the physician should encourage the patient to reveal his diagnosis to his wife.
36. A 29-year old man is diagnosed with presymptomatic Huntington's disease. This disease is an autosomal dominant (50% chance of having the disease in each pregnancy). He requested his physician not to tell the diagnosis to his wife. The wife wants to have children. (Important)
Answer: physician should ask the patient to seek genetic counseling and to urge him to discuss the matter with his wife. Since there is a risk of harm to the future children, physician can divulge the diagnosis to protect the future children.
37. A 18-year old man is diagnosed to have suspected bacterial meningitis. He refuses therapy and returns to the college dormitory. What should a physician do in this situation? (Very Important)
Answer: physician should report to the college authority and recommend that the suspected individual should be isolated during the course of his illness.
38. A 39-year old nurse is diagnosed with hepatitis B antigen-positive. She is working in a dialysis unit. She told her doctor. However, she did not tell the hospital authority because she is afraid to lose her job. (Very Important)
Answer: physician should ask the nurse to divulge her medical condition to the hospital authority. If she refuses, physician should notify the hospital authority for the protection of patients.
39. A 20-year old man with severe head injury was admitted to a small hospital. The patient needs neurosurgical intervention which is available in a nearby university hospital. Hospital refused to accept a patient who has no medical insurance.
Answer: university hospital must accept the patient.
40. A 30-year old man needs a second prosthetic valve. He is a drug addict. Surgeon does not want to perform surgery because the patient does not take care of himself. Is this the right decision? (Important)
Answer: no. Surgery should be performed if it is medically indicated.
41. A newborn male is diagnosed with anencephaly. His 1-year old sibling needs a kidney. His parents requested the physician to remove the kidney from the anencephalic child and to transplant that kidney in the 1-year old sibling. What should a physician do?
Answer: surgeon should perform the kidney transplant.
42. A 50-year old man is in a persistent vegetative state. Physician decided to discontinue nutrition and hydration for that patient. Is this the right decision?
Answer: yes. This is an acceptable practice in most states. Few states require clear evidence that the patient would have chosen this course.
43. A medical student requested his attending to perform a pelvic examination on a patient who is anaesthetized for appendectomy. Is this ethically acceptable?
Answer: no. The patient did not give consent to perform a pelvic examination.
44. A 20-year old woman slashed her wrists and wanted to die. She was unconscious and was brought to the ER. What should a physician do? (Important)
Answer: physician should take care of the patient. Psychiatric consultation and social worker evaluation are indicated. A suicide attempt is very often a 'cry for help'.
45. A 90-year old man was diagnosed with having Alzheimer's disease 10 years ago. It is difficult to feed him. He cannot recognize his family members. He developed recurrent aspiration pneumonia. What should a physician do?
Answer: physician should discuss this with the family and should respect their decision.
46. A 1-day-old infant was diagnosed with hypoplastic left heart syndrome. The patient is stabilized with the use of prostaglandin. Physician discussed this case in detail with the parents. What should the parents decide in this situation?
Answer: the parents can choose a staged surgical repair of the heart, a final heart transplantation if the organ is available, or allow the infant to die.
47. A 55-year old woman with severe developmental disability recently is diagnosed with breast cancer. Her mental age is estimated at a 2-year old level. Her family members do not want any more intervention. What should physician do?
Answer: physician should discuss this case with the hospital ethics committee members. The usual consensus is 'not to do anything' because of her severe mental disability.
48. A 49-year old woman with cervical cancer has a history of noncompliance. She had surgery a month ago. She missed several appointments. Can a physician force her for chemotherapy? (Important)
Answer: no. Physician can talk to her regarding the importance of chemotherapy. However, the patient must make the final decision.
49. An internist has been managing a diabetic patient for the last 10 years. The patient's condition is progressively getting worse. The patient is also not happy with the physician's management. What should a physician do in this situation?
Answer: physician should find another physician (e.g., endocrinologist) who might be more successful with the patient in this particular circumstance.
50. An internist recently refused to see a patient who he has been seeing for the last 5 years. Internist stated that the patient was rude to him. The patient went to see another physician who requested the patient's medical record. What should the internist do in this situation?
Answer: internist should provide the medical records of the patient to the new physician.
51. An internist refused to see a complicated hypertensive patient who he has seen for the last 10 years. Internist did not give any notice to that patient. The patient was angry with the physician. The patient was recently admitted to a hospital with the diagnosis of stroke. Is the internist responsible for the patient's condition?
Answer: yes. The legal charge of abandonment can arise when the physician without giving timely notice, ceases to provide care for a patient who is still in need of medical attention. Internist is not obligated to find him another physician. However, patient should have sufficient time to arrange for another physician.
52. A physician went to vacation for 2 weeks. He did not find another physician to cover him. He is very sincere. One of his patients with hypertension developed severe headache. The patient has an appointment with the doctor as soon as he comes back from vacation. The patient did not look for another physician and decided to wait. The patient suddenly collapses and was diagnosed to have intracranial hemorrhage. Is the physician responsible for this patient? (Important)
Answer: yes. The physician has a legal obligation to arrange for coverage by another physician.
53. An ophthalmologist performed a cataract surgery on a patient who went home after the operation. In the evening, the patient started vomiting and complained of severe headache. The ophthalmologist refused to accept that the symptoms were due to postoperative complications. The patient wanted to see the doctor immediately but he refused to see that patient. The patient went to the nearest ER and was diagnosed to have dislocation of the lens and partial retinal detachment. Is the physician responsible for the patient's condition?
Answer: yes ophthalmologist failed to judge the patient's condition seriously enough to warrant attention.
54. A 70-year old Chinese man is diagnosed to have severe osteoarthritis. He told his doctor that he is using Chinese herbal medicine. He is feeling better. However, he had two episodes of dizzy spells since he started that herbal product. What should a doctor suggest to this patient? (Important)
Answer: the doctor should suggest to discontinue the herbal product which may be causing the dizzy spells.
55. A 35-year old woman is diagnosed to have chronic throat infection. She is frustrated with the conventional medicine. She told her doctor that she is using an alternative homeopathic medicine. She is feeling much better and she has no other complications. What should a doctor suggest to this patient?
Answer: the patient can continue an alternative homeopathic medicine. Alternative medicine therapy is accepted in the society and is also used along with conventional therapy.
56. A 45 year old woman is diagnosed to have UTI (urinary tract infection). She told her doctor that she could not afford to purchase antibiotics. However, she is using herbal medicine that is cheaper. She is complaining of fever and dysuria. What should a doctor suggest to this patient? (Important)
Answer: the patient should discontinue the herbal medicine immediately and should start antibiotics as soon as possible.
57. A 13-year old boy with suspected meningitis refuses therapy. His parents also support that decision because they are supposed to go on vacation the following day. What should a physician do in this situation? (Important)
Answer: the patient should be admitted and treated in the hospital. If they refuse, legal action should be taken.
58. A 2-year old girl is admitted with the diagnosis of intestinal obstruction. Her mother has a psychiatric problem. Her mother is not capable of giving the consent. Her father died one year ago. What should a surgeon do in this situation?
Answer: legal steps may be taken to provide a surrogate decision-maker.
59. A 67-year old widow has been using hypnotics for the last 5 years. She is addicted. Her doctor wants to withdraw her from her present medication by trial on placebos. Is the physician making a right decision? (Important)
Answer: no. The physician cannot use placebos because his decision is deceptive. The problem of addiction should be discussed directly with the patient. The use of deceptive placebo is indicated in the following conditions:
(a) the patient insists on a prescription;
(b) the patient wishes to be treated;
(c) the alternative to placebo is either continue illness or the use of a drug with know toxicity;
(d) high response rates to placebo ( e.g., postoperative pain, mild mental depression).
60. A 50-year old man is diagnosed to have multiple sclerosis. In the morning, the surgeon asked the man his opinion on the surgical procedure and he agreed. In the evening, the man refused to give consent for the same surgical procedure. He is also disoriented to place and time. Is the patient capable of making the decision?
Answer: no the patient has impaired capacity.
61. A 55-year old woman with diabetes is diagnosed to have gangrene on both feet. She was brought to the hospital. She told the doctor the she is feeling fine and she has no medical problems. Can she give consent for the amputation of both legs?
Answer: no. The appointment of a surrogate should be sought to get the consent for the surgery.
62. A 17-year old boy came to a surgeon for bilateral vasectomy. He is the father of one child and does not want to have any more children. He does not want to tell his girlfriend and parents. He lives with his parents. What should a surgeon do in this situation? (Important)
Answer: surgeon should not perform bilateral vasectomy and should offer him less radical alternatives. Please remember, a mature minor may not comprehend the implications of this procedure.
63. A 16-year old girl came to a doctor for bilateral tubal ligations. She is a mother of one child and does not want to have any more children. She does not want to tell her boyfriend and parents. She lives with her parents. What should a doctor do in this situation? (Important)
Answer: obgyn doctor should not perform bilateral tubal ligation and should offer her less radical alternatives.
64. A 16-year old boy wants to donate one of his kidneys to his friend who is suffering from ESRD (end stage renal disease). The boy's parents did not agree with his decision. What should a physician do in this situation? (Important)
Answer: the physician cannot accept his kidney. However, he can donate one of his kidneys if his parents agree.
65. A 15-year old boy wants to participate in a research study. He told his parents who did not agree. He lives with his parents. Can this boy participate in the research study?
Answer: no the boy needs consent from his parents to participate in a research study.
66. A 17-year old boy lives independently. He is married and has one child. He wants to participate in a research study. Does he need his parents permission? (Important)
Answer: no. He is an emancipated minor who lives independently from his parents physically and financially.
67. A 70-year old man is diagnosed with terminal esophageal cancer and requires an insertion of a gastrostomy tube. He has signed a DNR (Do Not Resuscitate) order about a month ago. Should the preexisting DNR order stand or be suspended during the surgical procedure? (Very Important)
Answer: attending physician, surgeons, and the patient or surrogate should discuss the matter and either affirm or suspend the order in anticipation of surgery. If a patient is competent and wishes a preexisting DNR order to stand, resuscitation should not be performed in the event of an intrasurgical arrest.
68. An infant, born at 30 weeks gestation, appears to be SGA (small for gestational age) with multiple malformations. Amniocentesis study was not performed. Infant needs resuscitation at birth. What should a physician do in this situation? (Important)
Answer: physician must resuscitate the patient in the delivery room because the diagnosis is uncertain.
69. A 60-year old man is diagnosed with terminally ill colon cancer and needs resuscitation. He did not sign a DNR order. The physician has decided to perform a 'slow code' on his own. Is this the right decision? (Important)
Answer: no. Please remember, a performance of 'slow code' or 'show code' is not acceptable to the patient. This decision by the doctor represents the failure to come to a timely and clear decision about the patient's resuscitation status.
70. A 20-year old man is diagnosed with suspected bacteremia and meningitis. He refuses antibiotic therapy. He collapses and requires resuscitation. What should a physician do in this situation?
Answer: the physician should resuscitate the patient despite the patient's refusal to antibiotic therapy.
71. A 50-year old woman is diagnosed with severe aortic stenosis. She collapsed in a doctor's office and is required resuscitation. She is waiting for valve replacement surgery. What should a physician so in this situation?
Answer: this condition is called 'physiological futility'. In severe aortic stenosis, vigorous resuscitation is highly unlikely to restore adequate cardiac output. Therefore, the physician might reasonably refrain from resuscitation.
72. A 14-year old boy is diagnosed with terminally ill cancer. He is not responding to chemotherapy. His parents want to continue the treatment. However, the boy does not want to continue his suffering. The physician told the parents that chemotherapy will not be helpful. What is the appropriate decision at this point? (Important)
Answer: the boy's decision should be respected because the treatment is futile.
73. A surrogate pregnant mother made a surrogacy contract with a couple in which she will give the baby to the couple. She developed complications in the first trimester and wanted to abort. Is she allowed to do that? (Important)
Answer: yes. If her life or health becomes threatened from continuing the pregnancy, she should retain her right to abortion.
74. A physician became sexually involved with a current patient who initiated or consented to the contact. Is it ethical for a physician to become sexually involved?
Answer: no. Sexual involvement between physicians and former patients raises concern. The physician should discuss with a college or other professional before becoming sexually involved with a former patient. The physician should terminate the physician-patient relationship before initiating a romantic or sexual relationship with a patient.
75. A physician decided to take care of his own family members and relatives. He is a very smart physician. Is this a right decision?
Answer: no. The physician should encourage all friends and family members to have their own personal physician.
76. A male patient wants to have a copy of his medical records. What should a physician do in this situation?
Answer: the physician should retain the original of the chart. Information should only be released with the written permission of the patient or the patient's legally authorized representative ( e.g., attorney).
77. A 30-year old female wants to have an abortion. Her physician objects to abortion on moral, religious, or ethical grounds. What should a physician do in this situation? (Important)
Answer: physician should not offer advice to the patient.
78. A physician sees patients at a reduced fee. He spends very little time with each patient. Is the physician doing the right thing?
Answer: no. The physician is not providing optimal care.
79. A surrogate pregnant mother signed a surrogacy contract with a couple. Male partner gave sperms which were artificially inseminated to the surrogate mother. Surrogate mother has a genetic relation to the child. She wants to void the contract after the baby is born. Is she allowed to breach the contract? (Important)
Answer: yes. Surrogate contracts, while permissible, should grant the birth mother the right to void the contract within a reasonable period of time after the birth of the child.
80. A surrogate pregnant mother signed a surrogacy contract with a couple. Both male and female parents gave sperm and ovums respectively. The surrogate mother wants to void the contract and she has no genetic relation. Is she allowed to breach the contract? (Important)
Answer: no. Genetic parents have exclusive custody and parental rights.
81. A surrogate pregnant mother signed a surrogacy contract with a couple. The couple got divorced. Male partner gave sperms and the female partner gave ovums. They do not want to continue the surrogate pregnancy. What should be the decision at this point? (Important)
Answer: the couple is genetically related to the fetus. They have the right not to continue with this pregnancy.
82. A surrogate pregnant mother signed a surrogacy contract with a couple. The couple got divorced. Male partner gave sperms but the female partner could not give ovums. They do not want to continue the surrogate pregnancy. What should be the decision at this point? (Important)
Answer: female partner has no right to terminate this pregnancy because she has no genetic relation. Surrogate mother has genetic relation and she has the right to continue this pregnancy even if the male partner disagrees.
83. A 3-year old girl is diagnosed with blood cancer. She has been waiting for an umbilical cord transfusion. Her mother delivered a newborn baby girl. Umbilical cord blood was obtained and was transfused to the 3-year old sibling. What is the duty of the physician?
Answer: physician should obtain an informed consent of the risks of donation and he or she should follow the normal umbilical cord clamping protocol. Physician should protect both the children.
84. A 31-year old man has decided to donate one of his kidneys for a large amount of money. Is this the right decision?
Answer: no. However, the donor can receive some payment to cover his medical expenses. Only the potential donor not the donor's family or another third party may accept financial incentive. Payment should occur only after the organs have been retrieved and judge medically suitable for transplantation.
85. A couple has decided to have a child through artificial insemination. They asked the physician for sex selection of the child. What should a physician advise in this situation? (Important)
Answer: physician should not participate for sex selection for reasons of gender preference. However, sex selection of sperm for the purpose of avoiding a sex-linked inheritable disease is appropriate.
86. A 30-year old man has donated his sperms which were kept frozen. He died in a car accident. He did not leave any specific instructions regarding sperm donations. His wife wants to make use of them. A woman requested her to donate his sperms. What is the appropriate decision? (Important)
Answer: the donor's wife can use the semen for artificial insemination but not to donate it to someone else. The donor should give clear instructions at the time of donation. The donor has the power to override any decision.
87. The donor and recipient of sperms are not married. Who would be considered the sole parent of the child? (Important)
Answer: the recipient. Except in cases where both donor and recipient agree to recognize a paternity right.
88. The residents and medical students were asked by an attending to follow certain orders for a patient. The residents and medical students believe the orders reflect serious errors in clinical or ethical judgment. What is the appropriate way to handle the situation? (Important)
Answer: The residents and medical students should not follow those orders. They should discuss with the attending issuing those orders. They should also discuss the situation with a senior attending physician, a chief of staff, or a chief resident.
89. A physician used a newly prescribed drug to his patient. The patient got sick after the drug was ingested and required hospitalization. Should the physician report this drug's side effect to FDA (Food and Drug Administration)? (Important)
Answer: yes. FDA should be notified only if the drug causes serious adverse events such as those resulting in death, hospitalization, or medical or surgical intervention.
90. A 39-year old female has been suffering from chronic cholecystitis. The surgeon advised cholecystectomy. The patient wants a second opinion. The surgeon agreed. The patient went to another surgeon and has decided to be operated by the second surgeon. What should the second surgeon do in this situation? (Important)
Answer: the second surgeon should accept the patient because the patient has the right to choose the surgeon. First surgeon should accept the patient's decision.
91. A 45-year old male was admitted to the hospital with mild chest pain. He wants to leave the hospital before completion of therapy. How do you manage the patient? (Important)
Answer: The patient is asked to sign a statement that he is leaving against medical advice (AMA). The patient may however leave without signing that statement. This document is a legal evidence that the patient was warned by the physician about the risk of leaving. Please remember, discharge AMA does not apply to children.
92. A 55-year old man requested his physician to misrepresent his medical condition to receive disability or insurance payment. What is the appropriate response of the physician in this situation?
Answer: The physician must refuse that request.
93. What is the responsibility of a fellow physician who is aware of drug abuse, alcohol abuse, or psychiatric illness of his colleagues or of a medical condition that is harmful to patients? (Very Important)
Answer: the physician should protect the patients. The fellow physician should report to the appropriate authority ( i.e., report to the hospital authority; report to the Dean for a medical student's problem).
94. A 60-year old male has been suffering from severe pain due to terminal prostate cancer. The patient is receiving lower doses of narcotics and sedatives. How can a physician relieve his suffering? (Important)
Answer: The physician should increase the dosage of narcotics and sedatives up to the maximum recommended amount. The suffering can be reduced by listening, spending more time with him, and reducing psychological distress.
95. A 25-year old female medical student or resident noticed a mistake made by a junior attending physician during rounds. She is afraid of that attending physician. What is the appropriate way to handle the situation? (Important)
Answer: She should discuss the situation with a more senior attending physician for appropriate interpretation, advice, and assistance.
96. A 26-year old male medical student or resident made a mistake during patient care. He is afraid of what might result. What is the appropriate way to handle the situation?
Answer: He should disclose the mistake to the attending physician and try to learn from that mistake. The patient should be notified as well.
97. A 63-year old female health care worker is concerned about taking care of patients with HIV infection or multidrug-resistant tuberculosis. What is the appropriate way to handle the situation? (Important)
Answer: The physician should provide appropriate care to patients despite personal risk. Institutions should reduce the risk of infection by appropriate equipment, supervision, and training. Her concern should be taken seriously.
98. A 30-year old male physician has an opportunity for financial incentive if he sees more patients and refers them unnecessarily. What is you opinion about this?
Answer: The physician should provide only care that is in the patient's best interest.
99. Two physicians are discussing a case inside the elevator of a hospital. What is your opinion about this?
Answer: They should not do that because they have to maintain the patient's confidentiality.
100. The patient's confidentiality should be maintained except in the following situations:
Physicians should override third parties in case of domestic violence, child abuse, elderly abuse, gunshot wounds, syphilis, and tuberculosis. They should report these cases to appropriate governmental authorities.
101. A physician is experiencing a very difficult ethical issue regarding a complicated case. He is confused. What should be the next step?
Answer: he should discuss the matter with other faculty members in his health care team, colleagues, or hospital ethics committee.
102. What is the final plan of action in an ethical issue?
Answer: Both patient and physician should agree regarding final management. The patient should be well-informed about the medical condition. The physician should be sympathetic and knowledgeable regarding the relevant medical condition.
103. DNR (do not resuscitate) order. This is appropriate if the patient or surrogate signed that order or if CPR (cardiopulmonary resuscitation) would be futile. Physicians should write DNR orders and the reason for them in the chart. Please remember, "slow" or "show" codes are not acceptable. Foods and fluids are considered therapies that should be stopped. (Important)
104. (A)Brain death (adult): (Important)
(i) Definition by the President's Committee:
Death is an irreversible cessation of circulation and respiratory functions or irreversible cessation of all functions of the entire brain and brain stem.
(ii) The criteria of brain death by the staff of Massachusetts General Hospital and the Harvard Committee:
Death occurs when there is absence of all signs of receptivity, responsivity, and all brainstem reflexes, and the EEG is isoelectric. Sometimes metabolic disorders and intoxications may mimic the above findings.
(iii) The guidelines of brain death:
(a) The diagnosis should be made also by another physician and confirmed by clinical findings and EEG.
(b) The family should be notified. They should not make the decision about discontinuing medical treatment except in a situation where the patient has directed the family to make the decision.
(c) The physician should discuss with another physician before removing supportive measures (e.g., ventilators).
(d) Family members may request organ donation, and in many states physicians may request the family to make an organ donation.
(B) Brain death (children):
(i) Definition: same as in adults.
(ii) Criteria: similar in children and adults, but the period of observation is longer in children.
Children 1wk-2mo of age: two separate examinations 48 hours apart
Children 2mo-1yr of age: two separate examinations 24 hours apart
Children more than 1 yr of age: two separate examinations 12 hours apart
Spontaneous movements must be absent, with the exception of spinal cord reflex withdrawal and myocolnus.
Generalized flaccidity should be present. The presence of clinical criteria for 2 days in term and 3 days in preterm infants indicates brain death in majority of asphyxiated newborns. The absence of cerebral blood flow on radionuclide scan and silence of electrical activity on EEG are not always observed in brain-dead newborns. There is no universal consensus about the definition of neonatal brain death. The decision is made after discussion with the family and health care team. If there is difference of opinion, the ethics committee should be consulted. The decision is made on the basis of what is in the best interest of the infants and children.
105. Practice guidelines for physicians:
(i) The best way to practice medicine is to select useful diagnostic techniques and therapeutic measures which are most appropriate to a particular patient and clinical condition.
(ii) Practice guidelines can reduce the health care costs, which improves health care to patients who even do not have adequate health care benefits.
(iii) Please remember, guidelines do not and should not be the only way of managing an individual patient.
106. Some important points about patients:
(i) For a patient with an incurable disease, the major goal of therapy should be the enhancement of the quality of life.
(ii) The patient care begins with a personal relationship between the patient and the physician. If a patient has confidence on the physician, reassurance may be the best therapy. The patient must understand that the physician is giving the best possible care available.
107. Patients who do not have decision-making capacity about their medical care:
The patients who do not have decision-making capacity usually arrange for surrogates who make decisions for them. Their choices depend on their values. Psychiatrists are helpful in mentally impaired patients. Family members are usually the surrogates, because they know the patients very well
Advanced directives: statements made in advance in case patients lose their decision-making capacity in the future. These directives indicate the names of surrogates and which interventions are acceptable or not acceptable to them. These are achieved by oral conversation (most common form), living will, health care power of attorney, or physicians can ask the patient in advance.
Absence of advance directives and surrogates: physicians can make the decision using all information and should respect the patient's values. Physicians must know the laws of the state in which they practice.
Patient preferences are known:
The decision is made with the patient's best interest in mind.
Disagreements between potential surrogates or between the physician and surrogate: Physicians can consult with the hospital ethics committee or with other physicians. The courts should be only the last resort.
108. Down syndrome with different medical conditions: (Very Important)
(a) Duodenal atresia at birth: surgical repair is recommended as it is done regularly.
(b) VSD (ventricular septal defect) in newborn period: initial conservative medicals management is followed by surgical repair as it is done regularly.
(c) Cyanotic heart disease at birth: immediate medical management, which is followed by surgical repair as it is required routinely.
(d) Cosmetic surgical condition (e.g., rhinophyma or big nose): there is no urgency to repair the underlying condition, but it can be done as it is performed regularly.
(e) Neural tube defects (e.g., meningomyelocele): surgical repair is recommended as it is done regularly.
Please remember, a patient's management should be discussed with his/her parents and the decision made with the best interest of the patient in mind.
109. A healthy male patient with Down Syndrome lives independently. He went to a doctor for facial cosmetic surgery. Can he make his own decision? (Important)
Answer: yes. The patient can make his decision if he understands the procedure and the consequences. He lives independently which indicates that he is capable of making his own decision.
110. A patient went to the doctor due to throat pain. The doctor asked the patient what her problem was. The patient said that she woke up at six o'clock in the morning, went to the bathroom, ate breakfast, and went to drop her children at school. She then came back home, stared cooking and continues to talk about irrelevant things. What should the doctor do to stop the patient from rambling? (Important)
Answer: the doctor should ask the patient to tell him what problems she has related only to her throat.
111. A patient went to a doctor for abdominal pain but remained quiet throughout the visit. He did not tell the doctor enough about his symptoms. What should the doctor do? (Important)
Answer: the doctor must ask the patient detailed questions about his abdominal pain. It is the doctor's obligation to find out as much as he can about the patient. Without enough information, the doctor will not be able to make an accurate diagnosis.
112. A patient walked into his doctor's office with acute abdominal pain. He has been suffering from ulcerative colitis. The patient is noncompliant and did not visit for the past six months. What should the doctor do in this situation? (Very Important)
Answer: The doctor should find out more about the patient's abdominal pain before making any other decision. The doctor should always be responsible with the patients.
113. A terminally ill pancreatic cancer patient with multiple metastasis is admitted to the hospital. He is in critical condition. The patient wants to know his prognosis. What should the doctor say?
Answer: the doctor should tell the patient politely that he will discuss his condition with him and his family. The doctor should never specify the longevity of the patient. The doctor should tell the truth even when the patient is a child. The doctor should not hide any medical information from the patient.
114. A patient is recently diagnosed with cancer. He is nervous but is eager to know about his medical diagnosis. What should the doctor's reply be? (Important)
Answer: the doctor should gently tell the patient his condition.
115. A patient is recently diagnosed with cancer. Previously, he had an episode of a nervous breakdown after hearing a family death and had to be admitted to a hospital. He loves his family members and tends to be very open with them on all issues. How should the doctor tell the patient about his current state? (Important)
Answer: the doctor should call his family members and discuss the patient's medical condition openly and politely.
116. A male patient was admitted with severe myocardial infarction. He was admitted to the ICU and his condition is very critical. He does not know the reason for his admission. The patient is unstable. What should the doctor tell the patient? (Important)
Answer: the doctor should wait until the patient is stabilized and then gently tell him his medical condition.
117. A mother gave birth to a premature baby who was admitted to the NICU (neonatal intensive care unit). The baby is on a mechanical ventilator. The mother wants to hold the baby. What should the doctor do in this situation? (Important)
Answer: the mother should be allowed to hold the baby.
118. A male patient is recently diagnosed with HIV. Should the doctor ask about his sexual orientation (i.e., male, female, or both)? (Important)
Answer: yes, the doctor should ask the patient directly but politely about his sexual orientation.
119. A homosexual male patient went to a doctor. The patient's partner was recently diagnosed with HIV. Should the doctor ask the patient whether he is being penetrated by his partner or he penetrates his partner?
Answer: yes, because the person who is being penetrated has a higher incidence of HIV due to trauma in perianal area.
120. A 6-year old boy comes to the ER after drowning. He expired in the ER despite appropriate resuscitations. The family members became angry which is a reflection of a sense if guilt and helplessness. What is the appropriate way of giving information to the family members?
Answer: the physician should give the information clearly and compassionately when there is no hope for survival. Parents need to know that everything was done to save the child.
121. A pregnant woman who is Rh(-)ve became sensitized. She had H/O induced abortions. Her husband is not aware of his wife's previous abortions. He wants to know from the physician how she became sensitized. (Very Important)
Answer: the physician should tell the man to ask his wife. The physician should not mention anything about the patient's H/O abortions.
122. A mother brought her infant to the ER. The radiologist test reveals old fractures of the ribs. She did not know anything about that. (Very Important)
Answer: this is a case of child abuse. This case should be reported to child welfare agency.
123. A physician is examining a child with respiratory distress. The child's mother became anxious during the physical examination. Please remember, a patient's management should be discussed with his/her parents and the decision made with the best interest of the patient in mind. (Important)
Answer: child abuse.
124. A mentally retarded patient became pregnant. The patient does not want an abortion. Her mother and husband want an abortion. What should a physician do in this situation? (Important)
Answer: abortion should not be performed.
125. A male physician is examining an adolescent or adult female patient. What should a physician do in this situation? (Important)
Answer: a chaperone should be present during the physical examination. The same rules apply when a physician is examining a patient who appears to be seductive. (Important)
126. A female physician is examining an adolescent or adult male patient. What should a physician do in this situation? (Important)
Answer: a chaperone should not be present during the physical exam.
127. A suspected HIV patient expired in a car accident. He signed for organ donations. What should a physician do in this situation?
Answer: his HIV status is not certain. The organs can be preserved until the HIV status is confirmed. If the test for HIV is positive, organs should be discarded.
128. A patient who expired in a car accident signed in his license foe organ donations. His license has expired. He always wanted to donate his organs. What should a physician do in this situation? (Important)
Answer: physican cannot accept organs because the signed consent has expired.
129. A male physician sexually harassed a female patient during the physical examination. The patient complained to a nurse. What should the nurse do in this situation?
Answer: the nurse should tell the patient to make an official report to the hospital authority or to an appropriate agency.
130. A chronic male smoker comes to the physician for his heart problems. The physician wanted his patient to quit smoking. What should the physician advise in this situation?
Answer: the physician should ask the patient to quit smoking immediately because patients are usually more responsive when they are ill. The physician should assist the smoker to move one step closer to quitting.
131. A terminally ill patient did not sign a DNR (do not resuscitate) order, however, he signed a DNI (do not intubate) order. What should the physician do in this situation?
Answer: the physician should follow his orders i.e., the patient should be resuscitated but should not be intubated, despite severe hypoxic condition of the patient.
132. A terminally ill patient signed a DNR order, however, he did not sign a DNI (do not intubate) order. He wants to be intubated but not resuscitated. What should a physician do in this situation?
Answer: the physician should follow his orders i.e., the patient should be intubated but should not be resuscitated.
133. An adolescent car accident victim was brought to the ER in an unconscious state. The patient needs immediate surgical interventions. The surgeon was unable to contact any family member to obtain consent. What should a surgeon do in this situation? (Important)
Answer: the surgeon should do the procedure without waiting to obtain a consent for the benefit of the patient.
134. An obgyn doctor is recently diagnosed with HIV infection. He is receiving medication for HIV. His physical and mental conditions are normal. Should he tell his patients or fellow physicians about his HIV status?
Answer: no, however, the doctor should take appropriate precautions for infection control. He does not have to tell his fellow physicians about his HIV status including the physicians who are referring patients to him. The doctor is allowed to see patients if he takes appropriate precautions. However, he should notify the hospital authority.
135. A physician is scared of seeing an HIV patient with an open wound. Can a physician refuse to see a patient?
Answer: yes, however, a physician's refusal to see a patient is unethical but is legal.
136. An elderly semicomatose patient may require surgical intervention. His family members are confused about the surgery. They asked the surgeon for his opinion. What should the surgeon's response be?
Answer: the surgeon can give his opinion and act as a moral surrogate for the benefit of the patient. (Very Important)
137. A 12-year old boy is diagnosed with a terminal illness (e.g., malignancy). He asked the doctor about his prognosis. His parents requested the doctor not to tell him the bad news. What should the doctor do in this situation? (Very Important)
Answer: the doctor should tell the truth politely and compassionately to the patient.
138. A 55-year old woman is recently diagnosed with right breast cancer. The doctor told the patient that she will require surgery for removal of the right breast. She started to cry. What should a doctor do in this situation?
Answer: first, the doctor should give her some tissue paper for wiping her tears. Then, the doctor should be sympathetic to her and console her. He might tell her that similar reactions are usually expected from other patients with breast cancer. Please do not mention that she will be fine with a breast implant or without a right breast because she is already 55-years old.
139. A mother is carrying a 500 gram premature fetus which develops acute fetal distress. The physician wanted to perform a cesarean section. Mother refused cesarean section. What should the doctor do in this situation?
Answer: the physician should arrange a bedside conference with the mother along with other physicians, social worker, and administrator to discuss the matter.

ETHICS PROBLEMS
 
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* Re:Conrad Fischer's lectures on Internal Medic
#1062696
  mira1978 - 11/24/07 23:21
 
  RADIOLOGY
http://www.med-ed.virginia.edu/courses/rad/headct/index.html
http://www.neuroanatomy.wisc.edu/natbrdrev/nbrbase1.htm
 
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* Re:Conrad Fischer's lectures on Internal Medic
#1062700
  mira1978 - 11/24/07 23:36
 
  UW notes..these are not mine, but ere very useful!!

Pediatrics:

1. With supracondylar fractures, the brachial artery can be compromised, resulting in the loss of the radial artery pulse; therefore, the radial artery pulse must be assessed when the fracture is reduced. Supracondylar fractures are the MC fractures in the pediatric population.

2. Pure riboflavin (vit. B2) deficiency is unusually in industrialiaed nations, but has been documented in regions of the world with severe food shortages. The condition is typically mild and nonspecific in presentation, but symptoms may include sore throat, hyperemic and edematous oropharyngeal mucous membranes, cheilitis, stomatitis, glossitic, normocytic-normochromic anemia, seborrheic dermatitis, and photophobia.

3. Ascorbic acid deficiency (Vit C): ecchymoses, petechiae, bleeding gums, hyperkeratosis, Sjogren’s syndrome, arthralgias, impaired wound healing. Systemic manifestations include: weakness, malaise, joint swelling, arthralgias, edema, coiled hair, depression, neuropathy, vasomotor instability.

4. Pellagra: (niacin deficiency): symmetric reddish rash present in exposed areas of skin, a red tongue, nonspecific symptoms such as diarrhea, vomiting, insomnia, anxiety, disorientation, delusions, dementia, encephalopathy. May be observed in alcoholics, long-trem users of isoniazid, and those stricken with carcinoid syndrome or Hartnup disease.

5. Leiomyomas: MCC of hysterectomy, Malignant transformation is extremely rare.

6. Depression: is a valid reason for a patient to be considered incompetent to make decisions. Refer the patient for psychiatric evaluation of depression first, then treat the patient.

7. Retinal detachment: usually painless, sudden onset, seeing flashes of light, seeing floaters of black spots in the field of vision, unilateral involvement.

8. Asthma:
 Acute attack: β2-antagonist
 Chronic obstructive pulmonary disease exacerbation: Ipratropium
 Prophylaxis: cromolyn and zafirlukast
 Prednisone doesn’t provide immediate relief but reduce inflammation several hours later and often are useful adjuncts to β2-antagonist

9. Thiamine deficiency: associated with beriberi, Wernicke-Korsakoff syndrome. Manifestations of infantile beriberi appear between the ages of 2 and 3 months, and include a fulminant cardiac syndrome with cardiomegaly, tachycardia, cyanosis, dyspnea, and vomiting.

10. Adult beriberi: is categrorized as dry or wet.
 Dry beriberi is characterized by a symmetrical peripheral neuropathy accompanied by sensory and motor impairments, especially of the distal extremities.
 Wet beriberi includes neuropathy in addition to cardiac involvement (e.g. cardiomegaly, cardiomyopathy, congestive heart failure, peripheral edema, tachycardia)

11. Stranger anxiety: is the normal anxiety experienced by infants when they are exposed to unfamiliar individuals. It peaks at 12-15 months.

12. Acute post-streptococcal GN: is the MC form of GN in children. It may occur following pharyngitis or pyoderma.
 HTN+edema
 ↓ C3 and CH50, but C4 is normal (this indicates the activation of the alternate complement pathway).-hypocomplementemia resolves in 8-12 weeks.
 hematuria, proteinuria (renal function returns to normal in 1-2 weeks)
 ↑ ASO titer.

13. Bed rest with the hip joint in a position of comfort is the Tx of choice for transient synovitis of the hip. (the condition will get better in 3-4 days)

14. Meingococcemia: suspect ~ in a neonate with signs of meningitis and a petechial rash. H.Influenza may cause meningitis but without the rash. Listeria can cause meningitis but without the rash either. GBS can casue meningitis and with a rash, but it is very rare in 18 M infant, but shortly after birth.


15. Myotonic muscular dystrophy (MMD): an AD disease which is known as Steinert disease. The 2nd MC muscular dystrophy in the U.S. The pathology is distinct in that all types of muscles (ie. Smooth, striated, cardiac) are involved. Presentations: muscle weakness, progressive muscle wasting, posterior forearm muscles, anterior compartment of the lower legs. Temporal wasting, thin cheeks, an upper lip in the shape of an inverted V. Myotonia is defined as delayed muscle relaxation, and the classic example is the inability to release the hand after a handshake.

16. Causes of amblyopia: --std Tx: occlusion of the normal eye.
 Strabismus (MCC)
 Errors of refraction
 Opacity of media along the visual axis

17. Clubfoot is initially managed with stretching and manipulation of the foot, followed by serial plaster casts, malleable splints, or taping. Surgical Tx is indicated if conservative management gives unsatisfactory results, and is preferably performed between 3 and 6 months of age. (mild atrophy of the calf, calcaneum and talus are in equines and varus positions, midfoot is in varus position, forefoot in adduction. Dorsiflexion and plantar flextion of the ankles are limited. Normal neurologic examination.)

18. Todd’s paralysis: represents a postictal condition that usually rapidly improves with restoration of motor function within 24 hours. (hemiparesis. Sudden loss of consciousness with following disorientation and slow gain of consciousness is a characteristic description of a seizure, if the convulsive episode was missed.) It may follows a generalized as well as focal seizures.

19. Neuroblastoma: the 3rd MC cancer in the pediatric population (after leukemia and CNS tumors). Arise from neural crest cells, which are also the precursor cells of the sympathetic chains and adrenal medulla. Calcifications and hemorrhages are seen on plain X-ray and CT scan. The levels of HVA and VMA are usually elevated. May arise from adrenal or any location along the paravertebral sympathetic chains. Easy to metastasize.

20. Psoriasis: more common in white, positive family history, pitting of the fingernails, arthritis (DIPs always involved).

21. Whenever IV access can’t be obtained in emergent pediatric cases, intraosseous access should be attempt next.


22. Guillain-Barre syndrome: suspect ~ in a child who presents with an ascending polyneuropathy one week after apparent viral infection. The underlying pathology involves mainly the peripheral motor nerves, although sensory and automomic nerves may also be affected. Associated with Campylobacter jejuni enteritis. Tx. plasmapheresis, immunoglobin (IV), no prednisone here (ineffective and may prolong recovery.

23. Child developments:
Language development:
 Social smiles: 2 M
 Babbles: 6 M
 2-words, obeys 1-step command: 1 Y
 2-3 phrases, obeys 2-step command: 2 Y

Gross motor development:
 Holds head: 3M
 Rolls back to front and front to back: 4 M
 Sits well unsupported: 6 M
 Walks alone: 1 Y
 Walks up and down stairs without help: 2 Y

Fine motor development:
 Raking grasp: 6 M
 Throw object: 1 Y
 Build tower of 2 blocks: 15 M
 Build tower fo 6 blocks/turn pages of books: 2 Y

Social development:
 Recognizes parents: 2 M
 Recognizes strangers (stranger anxiety): 6 M
 Imitates action/comes when called: 1 Y
 Plays with other children : 18 M
 Parallel play: 2 Y

24. Osgood-Shlatter disease: typical patient is a 10-17 yo boy with knee pain at the tibial tuberosity, which is the site of insertion of the quadriceps tendon.

25. Septic joint in a child is a true surgical emergency and needs immediate surgical drainage. A delay of even 4-6 hours can lead to avascular necrosis of the femoral head.

26. Subarachnoid hemorrhage (SAH): can be cuased by an intraventricular hemorrhage, which is common in premature infants. Accumulation of the blood in the subarachnoid space may lead to destruction of the arachnoid villi and cisterns, thereby blocking the flow or decreasing the absorption of CSF and leading to communicationg hydrocephalus. SAH is the MCC of communicating hydrocephalus.

27. MCC of syncope: vasovagal.

28. Sudden infant death syndrome (SIDS): is the leading cause of mortality in infants between 1 M and 1 Y, and the 3rd MCC of mortality in infants <1 Y.

29. Perinatal problems: is the leading cause of mortality in infants < 1 M.

30. Drugs/diseases associated with hirsutism:
 Minoxidil (anti HTN agent, used to treat alopecia)
 Polycystic ovary syndrome
 Cushing syndrome
 cyclosporine

31. Pyloric stenosis: a 4-6 week old infant with projectile vomiting that worsen over time. Peristaltic waves are seen over the upper abdomen, and an olive-sized mass is palpated. Tx: surgical correction.

32. Vesicourteral reflux: Reflux is a risk factor for UTI. Repeated attacks can lead to progressive renal scarring, which is the major cause of end stage renal disease and HTN in children. Dx of VUR is best made with a voiding cystourethrogram (VCUG) or a radionucleide cystogram (RNC). Suggested after 1st UTI.

33. Bedwetting: is considered normal until the age of 4-5 yrs. If nocturnal enuresis persists, DDAVP (DOC) or imipramine may be used.

34. Mild protein intolerance: should be suspected when a neonate presents with bloody diarrhea (maroon-colored), eosinophils in the stool, and a positive family history of atopy. (e.g. mom is asthmatic)

35. Precocious pubarche with signs of severe androgen excess is suggestive of precocious pseudo-puberty that is casued by a gonadotropin-independent process (typically an excess of sex steroid, such as in a late onset congenital adrenal hyperplasia-21 hydroxylase deficiency)

36. Tuberous sclerosis (infantile spasm): best Tx is im ACTH. Presents with: episodes of jerkey movements of the neck, arms, and legs onto the trunk, occur in clusters, last for a few minutes, often preceded by a cry. Multiple small 1-2 cm oval irregular hypopigmented macules, ash-leaf spots, shagreen spots (orange peel lesions, sebaceous adenomas on her trunk and extremities. A head CT: cortical tubers in the cerebral cortex and multiple subependymal nodules in the lateral ventricles. EEG: hypsarrhythmia. Chromosome 9 & 16

37. An immediate anaphylactic reaction, an encephalopathy, or any CNS complication within 7 days of administration of the vaccine is a contraindication for further administration of DTaP. In these instances, DT should be substituted for DTaP since the adverse reactions are usually attributed to the pertussis component of the vaccine. *extremely HY Q for USMLE*

38. Congenital anomalies are the 2nd leading cause of death in infants < 1 Y.

39. Cyclical vomiting: recurrent self-limiting episodes of vomiting and nausea in children, in the absence of any apparent cause, suggest the Dx. Its incidence is high in children whose parents have a history of migraine.

40. Chlamydia: is the MC causative agent of infectious neonatal conjunctivitis. Chlamydial pneumonia can develop in infected infants (congenital chlamydial infection).

41. Friedreich Ataxia (FA): autosomal recessive disease. (triplet repeats-tocopherol transfer protein abnormality): progressive with poor prognosis. ↓ vibratory and position sense in the lower extremities, feet are deformed with high plantar arches. MRI of the brain and spinal cord shows marked atrophy of the cervical spinal cord and minimal cerebellar atrophy. Nerve conduction velocity normal. EKG shows T-wave inversions in the inferior and lateral chest leads.

42. T wave inversion differentials:
 MI
 Myocarditis
 Old pericarditis
 Myocardial contusion
 Digoxin toxicity

43. Tx of choice for local impetigo: topical mupirocin, or, oral erythromycin.

44. Febrile seizure: Consider the Dx of ~ when an otherwise healthy child presents with a fever and isolated seizure. These seizures are benign and mangaged with antipyretic therapy.

45. Pubertal gynecomastia: is seen in approximately one-half of adolescent boys, at an average age of 14 years. It is often asymmetric or transiently unilateral, and frequently tender. In prebubertal males the testicular size is normally 2 cm in length and 3 mL in volume. The initial management involves reassurance and watchful waiting/observation. *extremely HY Q for USMLE*

46. APGAR:
Color of the newborn:
0 body and extremities are blue/pale
1 body is pink and extremities are blue
2 body and extremities are pink

Heart rate:
0 heart shows no activity
1 HR <100
1 HR > 100

Reaction to nasal stimulation:
0 no response
1 grimace
2 active cough

Tone/Activity
0 limp
1 some flextion of extremities
2 active flextion of extremities

Respirations:
0 completely absent
1 slow and irregular
2 good respiratory effort

47. Craniopharyngioma: a young boy with symptoms of increased intracranial pressure (headache, vomiting), bitemporal hemianopsia, and a calcified lesion above the sella has a ~ until proven otherwise. Presence of a cystic calcified parasellar lesion on MRI is diagnostic of craniopharyngioma.

48. Tetralogy of Fallot: the MC cyanotic congenital disease in children less than 4 yo, presents with cyanotic spells and pansystolic murmur on examination.
 Overringding aorta
 Right ventricular hypertrophy
 Subpulmonary stenosis (single S2)
 VSD (pansystolic murmur)

49. Turner’s syndrome with 46 XY karyotype: is associated with a higher incidence of gonadoblastoma; hence, prophylactic bilateral gonadectomy is indicated in the management of such patients.
50. Endocrinology:

1. A 35yo white male presents with fatigue, decreased appetite, weight gain, constipation and cold intolerance. He can’t recall any stressful event. He does not take any medications. No smoking no alcoholic. HR 47, BP:145/91mmHg.PE revels cool, pale skin, coarse hair, and brittle nails. There is delayed relaxation of DTR. The thyroid gland is normal on palpation. Lab studies reveal increased serum free T3 and T4 level, and normal serum TSH level. Which of the following is the most likely Dx.?
A. Primary hypothyroidism
B. Secondary hypothyroidism
C. Subclinical hypothyroidism
D. Generalized resistance to thyroid hormones.
E. Graves’ disease

Answer is D. Patients with generalized resistance to thyroid H. have high serum T4 and T3 levels with normal to mildly elevated TSH levels. Patients typically have features of hypothyroidism despite having elevated free thyroid hormones.

2. Elevated serum DHEA-S (Dehydroepiandrosterone-sulfate) levels are specifically seen in patients with androgen-producing adrenal tumors.

3. A 40 yo asymptomatic male comes to the office for a routine physical examination. His serum chemistry panel shows:
Sodium:140 mEq/L, Potassium 4.0 mEq/L, Bicarbonate 25 mEq/L, chloride 101 mEq/L Calcium 11.6 mg/dL Phosphorus 2.2 mg/dL
24-hr urine collection reveals a calcium level of 200 mg, and creatinine level of 1.5 g. Bone mineral density by dual energy X-ray absorptiometry (DXA) shows normal bone mineral density. Neck examination reveals no masses. What is the most appropriate next step in the management of this patient?
A. Bisphosphonate therapy
B. Surgical exploration of the neck
C. Medical surveillance
D. Loop diuretics
E. Thiazide diuretics
Explanation: B. The patient most likely has asymptomatic primary hyperparathyroidism. Laboratory findings of hypercalcemia, hypophosphatemia and elevated PTH levels are very suggestive of the Dx. Asymptomatic primary hyperPTH is a common disorder, particularly in females over 60 yo. Most patients are usually identified during routine chemistry screening. While surgical intervention is needed for all patients with symptomatic primary hyperPTH, not all asymptomatic patients require such as. The indication for surgery in asymptomatic patients is the presence of at least one of the following features:
1. Serum Cacium level at least 1mg/dL above the upper normal limit with urinary calcium excretion greating than 50mg/24hr
2. Urinary calcium excretion greater than 400 mg/24hr.
3. Young patients (<50 yro)
4. Bone mineral density lower than T-2.5 at any site.
5. Difficulty in follow-up of the patient.

4. Spot urine collection and times urine collection for the measurement of urine microalbumin to creatinine ratio are generally accepted as good screening methods for microalbuminuria. Although 24-hr urine collection is slightly more accurate in screening for microalbuminuria, its inconvenience to patients makes it less preferred by physicians.

5. Suspect DKA in stuporous patients with rapid breathing and a history of weight loss, polydipsia and plyuria.

6. Hyperpigmentation of the skin and mucous membranes is characteristic of primary adrenocortical deficiency, and is due to the increased levels of ACTH (MSH like). This clinical feature is not seen in patients with secondary adrenal insufficiency, which is due to hypothalamo-pituitary failure.

7. The most likely Dx. In a patient who presents with clinical features of adrenal insufficiency and calcifications in the adrenal glands is adrenal tuberculosis. Adrenal tuberculosis continues to be the prominent cause of primary adreanal insufficiency in developing countries. In contrast, autoimmune adrenalitis is currently the MCC of primary adrenal insufficiency in developed countries.

8. Suspect the following conditions whenever a patient presents with hypokalimia, alkalosis and normotension.
Surreptitous vomiting
Diuretic abuse
Bartter syndrome
Gitelman’s syndrome
Physical findings that are characteristic of surreptitious vomiting are scars/calluses on the dorsum of the hands, and dental erosions, hypovolemia and hypochloremia, which in turn lead to a low urine cl concentration.

Always suspect surreptitious vomiting as a cause of hypokalemic alkalosis in a normotensive patients, and be able to distinguish it from other entities (e.g. diuretic abuse, Bartter’s syn.) using the urine chloride concentration.

9. .Diabetes insipidus presents as poly uria, polydipsia, and excretion of dilute urine in the presence of elevated serum osmolarity.
. Primary polydipsia is due to excessive water drinking; both plasma and urine are diluted.
. SIADH results in hyponatremia, low serum osmolality and inappropriately high urine osmolality.

10. α-glucosidase inhibitors block dietary carbohydrate breakdown in the intestinal tract. The most significant side effects are GI disturbances due to the increased undigested carbohydrate concentration in the stool.

11. Metabolic acidosis observed during diabetic ketoacidosis is typically accompanied by hyperkalemia; this is sometimes called paradoxical hyperkalemia because the body potassium reserves are actually depleted. (extremely HY Q for the USMLE!)

12. The serum albumin level should always be measured simultaneously with the serum calcium level in order to calculate the correct total serum calcium value. With every 1 g/dL change in serum albumin, serum calcium changes by 0.8 mg/dL.

13. Nonketotic hyperosmolar syndrome (NKHS) occurs in type 2 DM because the level of insulin in these patients is sufficient to prevent ketosis, but not hyperglycemia. In most cases, severe hyperglycemia develops, thereby resulting in glycosuria and severe dehydration. The severe hyperosmolality is also responsible for lethargy, weakness, altered mental status, focal neurological deficits and eventual coma.

14. Fasting blood glucose measurement is now the recommended screening test for DM. 126 mg/dL on two separate occasions is diagnostic of DM.

15. Untreated hyperthyroid patients are at risk for rapid bone loss resulting from increased osteoblastic activity in the bone cells. Untreated hyperthyroid patients are also at risk for cardiac tachyarrhythmias, including atrial fibrillation.

16. Increased extracellular pH levels (e.g. respiratory alkalosis) can cause an increase in the affinity of serum albumin to calcium, thereby increasing the levels of albumin-bound calcium, and consequently decreasing the level of ionized calcium. Ionized calcium is the only physiologically active form, which means that decreased levels of this form can result in clinical manifestations of hypocalcemia.

17. Important causes of thyrotoxicosis with low radioactive iodine uptake include:
 subacute painless thyroiditis
 subacute granulomatous thyroiditis
 iodine-induced thyroid toxicosis
 levothyroxine overdose
 struma ovarii

18. Arterial pH or anion gap is the most reliable indicator of metabolic recovery in patients with diabetic ketoacidosis.

19. Suspect primary hyperaldosteronism in a young patient with hypertension, muscle weakness and numbness; the most specific lab value for the patient with primary hyperaldosteronism is high aldosterone/rennin ratio, indicating automomic aldosterone secretion.

20. MEN II consists of medullary carcinoma of the thyroid (MTC), hyperparathyroidism and pheochromocytoma. The serum calcitonin level is elevated in patients with medullary thyroid cancer. Virtually 100% of patients with MENII have c-cell hyperplasia or MTC, 50% have pheo, and 20-30% have hyperparathyroidism.

21. In the treatment of a patient using both sildenafil and an alpha-blocker, it is important to give the drugs with at least a 4-hour interval to reduce the risk of hypotension.

22. In patients with MEN IIa syndrome, genetic testing has replaced biochemical measurement of serum calcitonin as the recommended screening test. If genetic analysis is positive for a RET proto-oncogene mutation, total thyroidectomy is indicated.




GIT
a. Laxative abuse is characterized by very frequent (10-20), watery, nocturnal diarrhea. The Dx. can be confirmed with the characteristic biopsy finding of dark brown discoloration of the colon with lymph follicles shining through as pale patches (melanosis coli)

b. CT scan is the best test for the Dx. of diverticulitis in acute setting.

c. Suspect ischemic colitis in patients who have evidence of atherosclerotic vascular disease, present with abdominal pain followed by bloody diarrhea, and have minimal abdominal exam findings. The most commonly involved segment of the colon is the splenic flexure, because it is supplied by end arteries.

d. Always suspect Crohn’s disease in a young patient with chronic bloody diarrhea.

e. Know the stepwise approach of the Tx for ascites:

1. Sodium and water restriction
2. Spironolactone
3. Loop diuretic (not more than 1 L/day of diuresis)
4. Frequent abdominal paracentesis (2-4 L/day, as long as the renal function is okay)

b. Most colon cancers develop from polyps. The risk factors for a polyp progressing into malignancy are villous adenoma, sessile adenoma, and size >2.5 cm. Only adenomatous polyps are clearly premalignant, but <1% of such lesions progress to malignancy. Hyperplastic polyps are non-neoplastic and do not require further work-up. (extremely HY for USMLE)

c. Suspect celiac disease in any patient who presents with malabsorption and iron deficiency anemia. Celiac disease (sprue) is associated with anti-endomysial antibodies.

d. D-xylose absorption is abnormal both in bacterial overgrowth and Whipple’s disease. However, with bacterial overgrowth, the test becomes normal after antibiotic Tx.

e. Bacterial overgrowth is a malabsorption syndrome which can be associated with a history of abdominal surgery.

f. The initial Tx of both acute and chronic anal fissures includes dietary modification (e.g. high-fiber diet and large amounts of fluids), a stool softener, and a local anesthetic.

g. Suspect tropical sprue in patients with malabsorption, along with a history of living in endemic areas for more than one month. Tropical sprue involves the small intestine; the typical biopsy is characterized by blunting of villi with infiltration of chronic inflammatory cells, including lymphocytes, plasma cells and eosinophils.

h. The two MCC of painless GI bleeding in an elderly patient over 65 years of age are diverticulosis and angiodysplasia (vascular ectasia). There is a well defined association between aortic stenosis and angiodysplasia.

i. Iron deficiency anemia is one of the MC presentation of celiac sprue. Upt to 24% of cases of celiac disease is associated with dermatitis herpetiformis.

j. Drug-induced pancreatitis is mild and usually resolves with supportive care. CT scan is diagnostic for pancreatitis. Remember the following scenarios for drug-induced pancreatitis:
 Patient on diuretics? Furosemide, thiazides
 Pateint with inflammatory bowel disease? Sulphasalazine, 5-ASA
 Patient on immunosuppressive agents? Azathioprine, L-asparaginase
 Patient with a history of seizures or bipolar disorder? Valproic acid
 AIDS patient? Didanosine, pentamidine
 Patient on antibiotics? Metronidazole, tetracycline

k. The BUN level is often elevated in patients with upper GI bleeds because the bacterial breakdown of Hb in the GI tract results in the absorption of urea. A BUN level > 40 in the presence of a normal serum creatinine level may include an upper GI bleed. The other common scenario where you can see elevated BUN without increased creatinine levels is the administration of steroids.

l. Currently, quantitative estimation of stool fat is the gold std for the Dx of steatorrhea. (72 hrs fecal fat collection)

m. Esophagoscopy is indicated when a patient with gastroesophageal reflux disease (GERD) fails to respond to empiric Tx., or when a patient has features of complicated disease.

n. Abdominal CT scan is the next Dx test when abdominal ultrasound doesn’t explain cholestatic jaundice.

o. No matter what the underlying disease of the patient is, remember that the management of any patient arriving in the ED begins with assessment of the patients’ “ABCs”.

p. Noninvasive tests for H. pylori should be the first step in the management of patients with dyspepsia under age 45 who do not have alarming symptoms.

q. Manometry (esophageal motility studies) establishes the Dx of diffuse esophageal spasm.

r. Carcinoids are most commonly found on the appendix; however, patients who present with carcinoid syndrome usually have carcinoids located in the small bowel.

s. Recognize when to order upper endoscopy in GERD:
 Nausea/vomiting
 Weight loss, anemia or melena/blood in the stool
 Long duration of symptoms (>1-2 yrs), especially in Caucasian males >45 yo
 Failure to respond to proton pump inhibitors

t. Remember the pancreatic cholera-VIPoma

u. A combination of hepB virus immune globulin and lamivudine is the most effective measure to prevent recurrent HBV infection after liver transplantation. But it is not effective in fulminant hepatitis.

v. Whipple’s disease can mimic many illnesses, such as hyperthyroidism, connective tissue disease, alcoholism and AIDS. It should be suspected in all patients with fever of unknown origin (FUO), generalized lymphadenopathy, arthralgias, weight loss, abdominal pain and diarrhea. Dx of Whipple’s disease can be readily made using upper gastrointestinal endoscopy and PAS-staining of the obtained small intestinal biopsies. The classical findings are PAS-+ material in the lamina propria and villous atrophy.

w. Painless jaundice in an elderly patient should make you think about pancreatic head carcinoma.

x. Increased intragastric pressure during vomiting can cause tears in the mucosa of the cardia, and sometimes of the distal esophagus. These are called Mallory-Weiss tears

y. Lactose intolerance is characterized by a positive hydrogen breath test, a positive Clinitest of stool for reducing substances, and an increase stool osmotic gap.

z. The extent of a malignancy determines the most appropriate, timely, and individualized patient care. CT is a std Dx tool employed in patients with newly diagnosed gastric ca. to evaluate the extent of the disease. Surgical removal of the affected tissueds remains as the mainstay of therapy.

aa. MI is one of the differential Dx of acute abdominal pain and should be ruled out in patients with risk factors. (ECG)

Infectious Diseases

1. Mitral regurgitation is the most common valvular abnormality observed in patients with infective endocarditis not related to IV drug abuse.

2. Any HIV-positive patient with bloody diarrhea and normal stool examination should have a colonoscopy and biopsy done to look for CMV colitis. CMV colitis is characterized by bloody diarrhea with abdominal pain, multiple ulcers and mucosal erosions on colonoscopy; biopsy shows characteristic cytomegalic cells with inclusion bodies.

3. Diarrhea, in HIV-infected patients, can be due to multiple etiological agents therefore; and etiologic Dx must be made before starting antibiotic therapy. (stool examination for Salmonella, Shigella, Campylobacter, Clostridium difficile, Giardia, Cryptosporidium, Mycobacterium avium complex and CMV.

4. A 32 yo male comes to his physician with a 2week history of fatigue, fever, muscle and joint pains. His vitals are, BP:115/75 mmHg;T: 37.7 C; RR: 14/min; PR: 75/min. Physical examination is unremarkable, except for splenomegaly. Lab studies show: Hb: 13 gm/dL; WBC count: 15,000/microL; Neutrophils: 42%; Lymphocytes: 50%, monocytes: 5%, Basophils: 1%; Eosinphils: 2%; Platelet count: 300,000/microL. Large basophilic lumphocytes with vacuolated appearance are seen. Monospot test is negative. What is the most likely cause of this patient’s symptoms?
a. chronic fatigue syndrome
b. CMV infection
c. Acute toxoplasmosis
d. Acute retroviral syndrome
e. Chronic lymphocytic leukemia
Explanation: The patient described in this vignette has a mononucleosis-like syndrome in which atypical lymphocytes are found in the blood. Atypical lymphocytes are large basophilic cells with a vacuolated appearance. They may be found in CMV infection, acute toxoplasmosis, and acute retroviral syndrome, but CMV infection is the MC of all the listed causes.

For a Dx of chronic fatigue syndrome to be made symptoms must be present for over 6 months.

In CML, lymphocytes are small, mature, and they constitute 70-80% of WBCs.

Educational objective:
Blood smear with atypical lymphocytes should make you rank CMV higher on the list in a patient with mononucleiosis-like symptoms.

5. Condyloma Lata and bilaterally symmetrical maculopapular rash involving the entire trunk and extremities are characteristic of second stage of syphilis. Remember the rash is present on palms and soles. Serological tests are positive in secondary syphilis.

6. IV cefotetan, ampicillin/sulbactam, or the combination of clindamycin and a fluoroquinolone is the appropriate empirical Tx for limb-threatening infections in diabetics, whereas mild, or non-lim-threatening, infections can be treated with oral antibiotics like cephalosporin, clindamycin, amoxicillin/clavulanate and fluroquinolones.

7. Always consider malaria in patients from endemic areas with high-grade periodic fever and chills. Anemia and splenomegally are the clinical clues.

8. Proteus is the most likely cause of urinary tract infection in patients with alkaline urine.

9. In a HIV patient, bilateral interstitial pneumonia is most likely due to Pneumocystis carinii infection.

10. VDRL testing, PPD skin testing, Hep A and B serology and ab titer for Toxoplasma are indicated as a part of initial work-up in all newly diagnosed HIV-positive patients.

11. A nail puncture wound in an adult resulting in osteomyelitis is most likely due to Pseudomonas aeruginosa. (Clostridium tetani doesn’t cause ostomyelitis)

12. Mucormycosis requires aggressive surgical debridement plus early systemic chemotherapy with amphotericin B.

13. Whenever a health care worker is exposed to HIV, baseline HIV testing should be performed immediately and postexposure prophylaxis with combination of two or three antiretroviral drugs should be started without any delay.

14. In case of suspected oestomyelitis, blood cultures and x-rays should be taken and the patient should be started on IV antibiotics. If the x-ray are negative, three-phase technetium bone scan should be considered. Needle biopsy can be done to identify the organism if the blood cultures are negative.

15. Streptococcus bovis endocarditis is associated with colorectal cancer and colonoscopy is advisable in such patients.

16. Untreated LGV (lymphogranuloma venereum) caused by Chlamydia trachomatis serotypes L1-3) may progress to a severe and chornic disease causing ulceration (painless), proctocolitis (inflammation of colon and rectum), rectal stricture, rectovaginal fistulas and elephantiasis.

17. Any patient from southwestern region with history of tick bite developing systemic symptoms along with leucopenia and thrombocytopenia should make you think about Ehrlichiosis. (Tx. Doxycycline)

18. Enterotoxigenic E. coli is the most frequent offender causing travelers diarrhea. Travelers with abdominal cramps, diarrhea and malaise should be suspected for infection by this organism.

19. Always consider the risk of splenic rupture in case of infectious monomucleosis (IM) and advise the patient to avoid contact sports to prevent this hazard. (no exercises till PE is normal)-atypical lymphocytes, EBV. Heterophil antibody test is sensitive and specific for Dx. of IM

20. Cutaneous larva migrans (creeping eruption, is a helminthic disease casued by infective stage larva of dog or cat hookworm, also called Ancylostoma braziliense.) is a common cause of dermatological disease in travelers from tropical regions, and is characterized by pruritic elevated serpiginous lesion on the skin.*Remember sand box handling*

21. Urethral cultures have higher yield than synovial or blood culture in cases of suspected gonococcal purulent arthritis.

22. Consider CMV pneumonitis as a late complication in post BMT recipients with dyspnea and cough (CT: ground glass attenuation and innumerable small nodules.)

23. Osteomyelitis in DM that involves the bone adjacent to the foot ulcers is explained by the contiguous spread of infection.

24. Intermittent catheterization is an effective measure to reduce the risk of UTI in patients with neurogenic bladder.

25. Patients with hemochromatosis are vulnerable to listeria monocytogenes infections and some other bacterial infections. Know the various bugs that are likely to jeopardize such patients.

26. Campylobacter is the MCC of bloody diarrhea in USA. Presence of severe abdominal pain along with diarrhea is a helpful clue.

27. Albendazole or mebendazole is the first line Tx. For E. vermicularis infection (pinworm). Pyrantel palmate is an alternative.

28. Vibro paraheamolyticus is usually transmitted by ingestion of seafood. Patients having symptoms of food poisoning after intake of seafood should be suspected for this.

29. Steptococcus pneumoniae is the MC pathogen causing pneumonia in nursing home patients.

30. Patients with trichinosis, presents with GI complaints followed by muscle pain, swelling, and weakness. Presence of subungual splinter hemorrhages, conjunctival and retinal hemorrhages, periobital edema and chemosis should make you think about trichinosis.

31. Pseudomonas is commonly responsible for nosocomial pneumonia in intubated patients. Cefepime or ceftazidime are the commonly used medications.

32. HIV infected patients who develop esophagitis are first started on fluconazole directed against candidiasis.

33. Glucocorticoids are indicated in a case of IM complicated by upper airway obstruction, autoimmne hemolytic anemia, and thrombocytopenia.

34. Gonorrhea is a common organism,which causes STD. It is also a common cause of pharyngitis, generally acquired from oral sex.

35. Immunocomplex disease is primarily responsible for glomerulonephritis, Roth spots and Osler’s nodes. Janeway lesions result from septic embolism. * Extrememly HY Q for USMLE.

36. The Tx. Of PCP is always triemthoprim-sulfamethoxazole. However, the second choice agent is pentamidine.

37. Always suspect endocarditis whenever a patient is febrile and has other constitutional features in the presence of a new heart murmur

38. Anti TB therapy should always be supplemented with vitamin (pyridoxine) to avoid neurological complications.






Poisoning

1. Duration of QRS complex is the best measure for assessment of severity of tricyclic antidepressant toxicity. (Toxicity with TCA is characterized by anticholinergic effects and QRS widening on EKG.)

2. Pyridoxine (Vit. B6) is an antidote for isoniazid.

3. Bromocriptine is used in the Tx. of neuroleptic malignant syndrome, which is characterized by marked hyperthermia, muscular rigidity, tremors, altered mental status, and diaphoresis.

4. Phenothiazine cause hypothermia by causing vasodilatation and by inhibition of shivering.

5. Methanol intoxication is associated with visual loss. Ethylene glycol poisoning is associated with renal failure and crystalluria. Methanol is not hepatotoxic.

6. Suspect caustic poisoning in a conscious patient with a white tongue, heavy salivation, mouth burns, drooling of saliva and dysphagia. The patient is usually in severe pain.

7. Impaired concentration and conjunctival injection are important features of marijuana use. Also, it causes behavioral changes and 2 or more of the followings: dry mouth, tachycardia, increased appetite.

8. Spider bites:
 Acute abdomen is a feature of black widow bite and is best treated with a combination of calcium gluconate and musle relaxants.

 Brown recluse spider bites produce an extensive localized skin necrosis resembling a pyoderma gangrenosum. Dapsone is used to reduce the extent of local necrosis in patients who have been screened for glucose-6-phosphate dehydrogenase (G6PD) deficiency.

9. Sodium bicarbonate prevents the development of arrhythmia in patients with TCA by alleviating cardio-depressant action on sodium channels.

10. Calcium is useful in reversing cardia effect of calcium channel blocker.

11. Flumazenil, a benzodiazepine antagonist, is antidote for acute benzodiazepine intoxication.

12. Alcohol competes with CYP2E1, so in acetaminophen intoxication, results in decrease production of toxic metabolite.

13. Decision of use of N acetyl cysteine as an antidote for acetaminophen overdose is generally based on 4 hour post-ingestion acetaminophen levels. Gut emptying procedures are best effective if carried out in the first hour.

14. Dextromethorphan interacts with monoamine oxidase inhibitors and can produce severe hyperthermia.

15. Diphenhydramine toxicity produces seizures as well as anti-cholinergic effects.

16. Chlordiazepoxide is the treatment of choice for delirium tremens that is characterized by disorientation, hallucination, tachycardia, hypertension, and agitation (such as alcohol withdrawal).

17. Magnesium is an effective Tx for torsade de pointes.

18. First step in the management of pesticide poisoning is to remove the source of poison.

19. Sodium bicarbonate is effective for the Tx of cardiac dysfunction induced by thioridazine toxicity.

20. Pinpoint pupils and respiratory depression are the hallmark features of acute opioid toxicity for which naloxone is the drug of choice.

21. Contrast studies with gastrograffin are indicated in addition to upper gastrointestinal endoscopy when a patient with acute alkali ingestion is suspected of having esophageal perforation.


Preventive Medicine

1. Bupropion has been approved by FDA for smoking cessation program.

2. Dysthymia= depressed mood for most days for at least two years.

3. Pap smear: if 3 consecutive pap smears are normal, screening may be performed less frequently (every 3 years) in a low-risk patient. Screening is usually started at 18 and stopped at 60-75 years.

4. Patients with egg allergy can have severe allergic reaction or anaphylaxis with influenza, yellow fever or MMR vaccine.

5. Hepatocellular cancer is a vaccine-preventable cancer (hepatitis B vaccine)

6. Hepatitis A is the MC vaccine-preventable disease among travelers. It should be considered in people who are planning to visit developing countries.

7. The USPSTF recommends that screening for lipid disorders should include measurement of total cholesterol (TC) and HDL with fasting or non-fasting samples.

8. USPSTF recommends the use of total cholesterol and HDL cholesterol for the purpose of screening, however, for treatment purposes, the recommendations are based on total risk assessment and LDL cholesterol levels.

9. Female patients over the age of 50 are required to undergo annual mammograms until the age of 75. In general, screening studies are not routinely recommended for people older than 80.

10. All adults should be immunized against diphtheria and tetanus every 10 years.

11. USPSTF strongly recommendes routine screening of male at/above 35, and females at/above 45 for lipid disorders. * HY Q for USMLE.

12. Human studies have demonstrated a significant association between type A personality and exaggerated cardiovascular response.

13. Women who (1)are immunocompromised, (2) had in utero exposure to DES, or (3) have a history of CIN II/III or cancer should have annual Pap smear, even if their prior Pap smears are negative.* HY Q for USMLE.

14. Influenza vaccine is recommended on an annual basis for all adults above 65 yo, and adults of any age who are at risk for developing complications from influenza infection (as listed above).

15. Even though MMR is a live attenuated vaccine, it should be given to all HIV patients who are not severely immunocompromised.


Cardiology

1. The hyperdynamic type of septic shock is characterized by
an elevated cardiac output
low systemic vascular resistance, right artrial pressure and pulmonary capillary wedge pressure, (PCWP)
a frequently normal mixed venous oxygen concentration.

2. Diagnose right ventricular infarct, which should always be suspected in the setting of an inferior wall MI, with hypotension. Understand its pathophysiology and hemodynamics.

3. A clear association has been found between excessive alcohol intake and development of HTN. ( greater than smoking effect).

4. Clopidogrel should be included as secondary prevention following UA/NSTEMI for at least 12 months. It should also be prescribed for 30 days (bare metal stent) to one year (drug eluting stents) following PCI, as it has been shown to help prevent subacute stent thrombosis.

5. Clopidogrel + apspirin: is more effective than aspirin alone for the first 30 days following percutaneous coronary interventions (PCI), as it helps prevent subacute stent thrombosis. Patients who receive drug-eluting stents need a longer duration because epithelialization occurs slowly.

6. Know how to Dx restrictive cardiomyopathy in the setting of amyloidosis. Speckled pattern on echocardiogram is very specific for amyloidosis.

7. Restrictive cardiomyopathy: characterized by severe diastolic dysfunction due to a stiff ventricular wall. Chest X-ray shows only mild enlargement of the cardiac silhouette. Echo usually shows a symmetrically thickened ventricle wall, normal or slightly reduced LV size and normal or near normal systolic function. Kussmaul’s sign may also be present. The apical impulse is easily palpable in restrictive cardiomyopathy as opposed to constrictive pericarditis.

8. Restrictive cardiomyopathy is difficult to differentiate from constrictive pericarditis. With constrictive pericarditis, chest X-rays may show pericardial calcifications and the CT scan usually shows increased thickness of pericardium. Kussmal’s sign may be positive in both contitions. With constrictive pericarditis, the thickness of myocardium will be normal.

9. Mitral valve prolapse (MVP) is the MCC of mitral regurgitation in U.S.A.

10. MVP symptoms: substernal chest pain not related to exertion or ingestion of food. Palpitation, Murmur type: mid systolic click with late systolic crescendo-decrescendo murmur. Click and murmur occurs earlier with Valsava maneuver and it disappears with squatting. EKG is normal. Best Tx for this chest pain: β-blockers.

11. β-blockers are used to treat chest pain, palpitation, and autonomic symptoms of MVP. ‘

12. Murmur of MVP: mid systolic click with late systolic crescendo-decrescendo murmur. Click and murmur occurs earlier with Valsalva maneuver and it disappears with squatting. EKG can be normal.

13. The mechanism of mitral regurgitation in HOCM is the systolic anterior motion of mitral valve leaflet.

14. First-degree heart block is a completely benign arrhythmia and requires no Tx. (eg. HR 68, PR interval >0.2)

15. Know how to manage a case of CHF exacerbation due to A. Fib with a rapid ventricular response. Digoxin is the DOC in this situation. Also anticoagulant should be given, as this is one of the most important interventions in reducing the morbidity and mortality associated with atrial fibrillation.

16. Atrial fibrillation in MS is due to left atrial dilatation. (history of Rhematic fever, mid diastolic rumble, and loud S1) Left atrial enlargement that results from MS predisposes the patient to the development of AFib.

17. The hallmark of MS: elevated left atrioventricular pressure gradient.

18. Antihypertensive management should be the first step in patients with aortic dissection with HTN. Transesophageal echocardiogram (TEE) is the initial investigation of choice to Dx suspected aortic dissection. But it is indicated after HTN Tx is initiated.

19. Recognize infective Endocarditis in a patient who has recently undergone GU instrumentation (cytoscopy).

20. It’s better to keep systolic pressure<130 mmHg to slow end-organ damage in patients with diabetes and chronic renal failure. 120/80 mmHg is considered optimal in DM patients.

21. Even though IV β-blockers improve mortality in acute MI, they are contraindicated in the presence of pulmonary edema. (severe shortness of breath, bilateral crackles half way up to the lungs. Obvious jugular venous distension and 2+ pedal edema bilaterally). This case, DOC is furosemide.

22. Thiazide diuretics have some unfavorable metabolic side effects including hyperglycemia, increased LDL cholesterol, and plasma triglycerides. Electrolyte abnormalities that can be induced by thiazide diuretics include hyponatremia, hypokalemia, and hypercalcemia (good for kidney stone patient, though).

23. The diagnosis of ventricular septal rupture can be made if there is evidence of left to right shunting on Swan-Ganz catheter readings, when a 2D-echo is not available.

24. Recognize the clinical presentation of pulmonary edema. Iatrogenic fluid overload is one of the common causes of pulmonary edema in perioperative patients. (increased urine volume is an evidence)

25. Emphasize the importance of CK-MB for the Dx of recurrent myocardial infarction. It begins to rise within 4-5 hours after MI and returns to baseline within 48-72 hours. It’s high specificity and rapid return to the baseline makes it the biomarker of choice for the Dx. of a recurrent MI. (CK-MB fraction has a high specificity for an acute MI (slightly lower than cardiac troponins).

26. Primary biochemical tests used for the Dx of acute MI: Cardiac troponins T and troponins I. They begin to rise 4-6 hours after an MI, and remain elevated for 10 days. They have also replaced LDH for the retrospective Dx of MI. But because of their persistent elevation for 10 days after an MI, they can’t be used to establish the Dx of re-infarction within 1-2 weeks after an MI.

27. Tobacco and alcohol are reversible risk factors for the development of atrial premature beats.

28. GI endoscopy is a low-risk procedure for infective endocarditis. For GI endoscopy, prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients.
High risk to develop infective endocarditis:
 All prosthetic heart valves.
 Any history of previous bacterial endocarditis
 Complex cyanotic congenital heart disease and surgical constructed systemic pulmonary shunts.
Moderate risk to develop infective endocarditis:
 Congenital cardiac malformations not falling into the high or negligible risk categories (such as PDA, VSD, Ostium primum ASD, bicuspid aortic valve and coarctation)
 Acquired valvular heart disease (such as rheumatic heart disease, valvular stenosis and reguregitation)
 MVP with regurgitation and/or myxomatous leaflets.
 Hypertrophic cardiomyopathy.

Conditions that do not require IE prophylaxis include:
 Isolated ostium secundum ASD and surgically-reparied ASD, VSD and PDA (beyond six months and without sequelae)
 MVP without mirtral regurgitation and without thickened leaflets.
 Innocent or physiologic murmurs (echo required in the adult population to rule out valvular lesion).
 Cardiac pacemakers and defibrillators.
 History of isolated bypass surgery, history of Kawasaki disease without valvular dysfunction and history of rheumatic fever without valvular dysfunction.

29. Syncopal episode without following disorientation (post-episode confusion is more characteristic for a seizure), hearing impairment, normal PE, and family history of sudden cardiac death should make you think of congenital long QT syndrome. Beta-blockers are the DOC.

30. Aspirin, ACEIs and beta-blockers have been shown to reduce mortality in the setting of acute MI.

31. Know how to recognize and treat right ventricular infarction. IV NS to increase the outflow from right ventricle should be considered in these patients (avoid lowering preload, stop nitrate, give a normal saline bolus).

32. Recognize the early complications of an acute anterior wall MI: mitral regurgitation-- papillary muscle dysfunction, or rupture, is the MCC of MR in this setting.

33. When A. fib is associated with hemodynamic compromise, cardioversion is the treatment of choice.

34. Thrombolytic therapy is not indicated for unstable angina or non-ST elevation (non Q wave) MI. The treatment of unstable angina primarily includes aspirin, beta-blockers, heparin and nitroglycerin.

35. In all cases of ST elevation MI, reperfusion therapy with thrombolytics or PTCA (PCI) with or without stenting must be performed ASAP. PTCA (PCI) is preferred over thrombolytics.

36. Reentrant ventricular arrhythmia (ventricular fibrillation) is the MCC of death in patients with acute myocardial infarction.

37. The Tx of ventricular fibrillation is STAT defibrillation with 200-360 joules. If defibrillation fails, lidocaine or aminodarone (DOC) can be loaded and the patient shocked again. Epinephrine can sensitize the heart and lower the threshold for conversion.

38. Think of PE in a postoperative patient with JVD and new onset RBBB.

39. Amiodarone has the potential to cause lung fibrosis and should be avoided in patients with history of pulmonary fibrosis.

40. Beta-blockers have been shown to decrease the risk of perioperative coronary events.

41. It is important to recognize that oral contraceptives can be a potential cause of HTN, and simply discontinuing its use can correct the problem. It causes hypercoagulable stage too.

42. The MCC of aortic dissection is systemic HTN.

43. Calcium channel blockers do not improve survival in patients with acute MI (such as nifedipine). On the other hand, aspirin, thrombolytics, ACEIs and β-blockers have been shown to improve survival in patients with acute MI.

44. First degree heart block is characterized by a prolonged constant PR interval (>0.2s). There will not be any dropped beat.


45. Wenckebach or Mobitz type I heart block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped, then the sequence is repeated. It is a benign arrhythmia and is transient. Unless the patient is symptomatic, it requires no Tx.

46. Mobitz type II heart block is a dangerous arrhythmia which can progress to complete heart block and requires a permanent pacemaker.

47. Morbitz type II block, the PR interval remained unchanged prior to the “P” wave and it suddenly failed to conduct to ventricles. So you will see a dropped “QRS” complex with normal “PR” interval.

48. In third degree AV block, no atrial impulses will travel to ventricles. So atria and ventricles beat independently and have their respective rates.

49. In AFib, the heart rate is irregular and you will not see any P waves.

50. Suspect aortic dissection as a cause of tearing chest pain in the setting of HTN and BP difference in the 2 arms.

51. The measurement of serum BNP can help distinguish between CHF and other causes of dyspnea. A value>100 pg/mL Dx CHF with a sensitivity, specificity, and predictive accuracy of 90,76, and 83 percnet, respectively.

52. Choose the appropriate initial antihypertensive therapy in a patient with asthma. Hydrochlorothiazide is the initial DOC in patients with chronic persistent asthma.

53. Recognize the high risk of arterial thromboembolism associated with anterior wall MIs (LAD, left anterial descending branch). Inferior wall MI is associated with a right ventricular infarction in more than 1/3 of cases. Lateral wall MIs, posterior wall MIs, and right ventricular infarctions are not associated with an increased risk of arterial thromboembolism.

54. TB is the MCC of constrictive pericarditis, in immigrant population. It should be considered in patients with unexplained elevation of JVP and history of predisposing condition.

55. High-dose niacin therapy that is used to treat lipid abnormalities frequently produces cutaneous flushing and pruritis. This side effect is explained by prostaglandin-induced peripheral vasodilation and can be reduced by low-dose aspirin.

56. Descending aortic aneurysm in a young male is usually due to blunt trauma to the chest.

57. Decrease in the synthesis of non-cholesterol products may be responsible for some adverse effects of statin therapy; for example, reduced CoQ10 production is implicated in the pathogenesis of statin-induced myopathy.

58. In the treatment of cocaine-related cardiac ischemia, the first-line drugs are benzodiazepines, nitrates, and aspirin. (IV diazepam)

59. Systolic heart failure is characterized by depressed cardiac index (CI) accompanied by increased total peripheral resistance (TPR) and left ventricular end-diastolic volume (LVEDV).

60. Stress EKG or an exercise echocardiogram should be considered for risk stratification in patients with stable angina.

61. It is important to look for and treat hemochromatosis early in patients who present with restrictive cardiomyopathy, because this intervention significantly improves prognosis in these patients. (avoid restrictive cardiomyopathy if early Tx is started).

62. Always suspect malignant HTN in patients with very high BP (>=200140 mmHg). Presence of papilledema on ophthalmoscopy confirms the Dx. The pathologic change responsible for end-organ damage in malignant HTN is fibrinoid necrosis of small arterioles.

63. Think of cocaine intoxication in a young patient presenting with chest pain/myocardial infarction or stroke. Features of cocaine intoxication are cocaine bugs, agitation, decreased appetite, dilated pupils, elevated or decreased BP, tachycardia or bradycardia, and sweating.

64. Patients with artificial pacemakers and defibrillators do not require prophylaxis for infective endocarditis.

65. Suspect aortic dissection in a patient with acute retrosternal pain and a normal EKG. Check BP in both arms and auscultate for DM of aortic regurgitation. Transesophageal echocardiography is the preferred diagnostic tool. Before performing the TEE, HTN should be controlled.

66. Lidocaine is not used prophylactically in patients with acute coronary syndromes. Although its use decreases the risk of ventricular fibrillation, it may increase the risk of asystole.

67. Electrical alternans is an important EKG finding for the Dx of pericardial tamponade. Other findings include sinus tachycardia and low voltage QRS complexes.

68. EKG:
 T wave inversions occur with ischemia of the myocardium.
 ST segment depression occurs with subendocardial infarcts and unstable angina.
 Prolonged PR interval occurs in cases of first-degree heart block and it is not an EKG finding of cardiac tamponade.
 Delta waves are present in Wolff-Parkinson-White syndrome.
 New onset of RBBB is seen in right ventricular strain, especially with massive pulmonary thromboembolism.

69. Dihydropyridine CCA can cause peripheral edema and should always be considered in the DD of this condition, along with other causes, such as heart failure, renal disease and venous insufficiency.


70. The investigation of choice for the Dx of HCM is echocardiography.

71. Murmur type of HCM( hypertrophic cardiomyopathy)-a harsh crescendo-decrescendo grade III SM heard most prominently along the left lower sternal border. The murmur is intensified ↑ by Valsalva maneuver and attenuated ↓ by leg elevation)-less blood, more murmur; more blood less murmur----characteristic of HCM.

72. Bicuspid aortic valves represent the MCC of aortic stenosis in middle age adults.

73. Senile calcific aortic stenosis is the MCC of aortic stenosis in elderly (60-80 yo).

74. Presence of hypokalemia and HTN warrants investigations for secondary cause. Measure plasma renin activity and serum aldosterone level.

75. Elderly patients are particularly sensitive to fluid loss, and even mild hypovolemia may predispose them to orthostatic syncope, especially upon getting up in the morning. BUN/Creatinine ratio is a useful indicator of dehydration.

76. Left ventricular aneurysm can cause CHF in a patient who sustained an anterior wall MI in the past. A double apical beat and persistent elevation of the ST segment are important diagnostic clues.

77.

78. Bluish discoloration and cool fingers in the ICU are a common finding after use of norepinephrine (pressor Tx.) for hypotension.

79. Manage a patient with ST segment elevation MI with immediate angiography and PTCA when thrombolytic are contraindicated. Even if the patient has no contraindications for thrombolytic therapy and a catheterization lab is available in the hospital, or within 30 mins of the hospital, PTCA with stent placement has been shown to have better outcomes than thrombolytic therapy in acute ST elevation MI.

80. Prophylaxis drugs for IE:
 Amoxicillin is the DOC for prophylaxis of IE in dental and respiratory procedure. In patients who are allergic to penicillin, alternatives include cefazolin, clarithromycin or clindamycin.
 For genitourinary and GI procedures, other than esophageal procedures, the regimen of choice is ampicillin plus gentamicin in high-risk patients. If the patient is allergic to penicillin, a combination of vancomycin + gentamycin is used in high-risk patients. (if allergic to penicillin, give no ampicillin or amoxicillin?)

81. Hypertrophic cardiomyopathy is the MCC of sudden cardiac death in young athletes.

82. Isolated systolic HTN is an important cause of HTN in elderly patients. It is created by decreased elastic properties of the arterial wall. Always treat isolated systolic HTN, in spite of the fact that diastolic BP is not elevated. The DOC would be hydrochlorothiazide.

83. Isolated diastolic dysfunction: secondary to hypertrophic cardiomyopathy. The cause of hypertrophy cardiomyopathy (essential HTN caused). Features suggesting isolated diastolic dysfunction of the LV are the normal cardiac size, the normal ejection fraction and normal LV EDV, as well as the presence of an S4 gallop. DOC: β-blockers as they improve diastolic filling by lowering the HR and increasing the diastolic filling time. They also reduce the myocardial oxygen demand and cause regression of LV hypertrophy due to reduction of BP.

84. Vasovagal syncope is the MCC of syncope. It is frequently recurrent. Upright tilt table testing may be indicated to confirm the Dx if the syncope is recurrent.

85. The most likely culprit lesion for acute inferior wall myocardial infarction is right coronary artery (RCA) occlusion, especially if it is complicated by right ventricular infarction (hypotension) and bradycardia.

86. Cacium channel blockers (diltiazem) are the DOC for variant angina.

87. Nitrates are contraindicated when a patient is continuously or intermittently taking sildenafil (Viagra). Should not be given to the patient within 24 hours of the last dose of sildenafil. Otherwise, nitrate will cause syncope, MI or sudden death. They both induce nitric oxide mediated vasodilatation.

88. Clopedogrel should be included as secondary prevention following UA/NSTEMI for at least 12 months. It should be prescribed for 30 days (bare metal stent) to one year (drug eluting stents) following PCI, as it has been shown to help prevent subacute stent thrombosis.

89. Inferior wall myocardial infarction: can result from the occlusion of either the right coronary artery or the left circumflex artery. (RCA: bradycardia and hypotension, involvement of SA node and right ventricle.)

90. The earliest EKG finding in acute MI is peaked (hyperacute) T waves, followed by ST segment elevation, followed by the inversion of T waves, followed by the appearance of Q waves. The earliest changes of hyperacute T waves are frequently not seen in clinical practice because by the time the patient present they already have ST elevation.

91. Diffuse ST segment elevation is seen in: pericarditis, pulmonary edema

92. Acute pericarditis: typical findings are
 chest pain, worsened by breathing and improved by leaning forward,
 presence of a pericardial friction rub
 Diffuse ST segment elevation that is concave upwards.

93. Depressed CO combined with elevated PCWP (an indicator of left atrial pressure, and most of the times left ventricular end diastolic pressure) is indicative of left ventricular failure.--à cardiogenic shock.

94. Age-dependant idiopathic sclerocalcific changes are the MCC of isolated aortic stenosis in elderly patients. These changes are common and usually have minimal hemodynamic significance, but sometimes may be severe.

95. Aortic stenosis: systolic ejection murmur and soft S2, displaced apical impulse is due to the hypertrophied LV. Most appropriate investigation would be and echocardiogram to confirm the Dx.

96. Torsades de pointes is an arrhythmia of gradually changing QRS morphology and most often caused by Quinidine. In the acute setting magnesium replacement is the cornerstone of the Tx.

97. Heparin should be started in all unstable angina patients. Immediate angiography and possible revascularization are indicated when ischemia is refractory to optimal medical Tx or when there is evidence of hemodynamic compromise. A decision for PTCA can’t be made unless angiography provides specific indications for this procedure.

98. Infective endocarditis prophylaxis and repeated regular follow-ups are recommended for all patients of aortic stenosis even if they are asymptomatic.

99. Renal artery stenosis is a common cause of resistant HT in a patient with advanced atherosclerosis. Carefully auscultate the periumbilical area of such a patient to reveal continuous (or systolic with diastolic component) murmur characteristic of renal artery stenosis.

100. Atrial myxomas can present with systemic features and findings similar to MS.

101. TEE (transesophageal echocardiography) or computed tomography are the Dx studies of choice for suspected aortic dissection.

102. EKG manifestations of digitalis toxicity: atrial tachycardia with AV block. (more specific).

103. Digoxin causes ST segment depression, T wave inversion, first degree AV block at therapeutic levels and they do not represent digitalis toxicity and therefore there is no need for discontinuation of the drug.

104. MVP is the MCC of isolated mitral regurgitation in North America.

105. Controlling the rhythm or rate in patients with prolonged tachysystolic atrial fibrillation usually improves the LV function significantly, sometimes even dramatically.

106. Presence of hypotension, pulsus paradoxus, and pulseless electrical activity in a patient with a recent acute MI should make you think of free ventricular wall rupture.

107. The Tx of verntricular fibrillation is STAT defibrillation with 200-360 joules. If defibrillation fails, lidocaine or amiodarone (DOC) can be loaded and the patient shocked again. Epinephrine can sensitize the heart and lower the threshold for conversion.

108. Premature atrial beats are benign and neither require any follow up nor Tx.

109. Pulsus paradoxus: (paradoxic pulse) an exaggeration of the normal variation in the systemic arterial pulse volume with respiration, becoming weaker with inspiration and stronger with expiration; characteristic of cardiac tamponade, rare in constrictive pericarditis; so called because these changes are independent of changes in the cardiac rate as measured directly or by EKG.

110. A patient who develops a cold leg after an MI should be suspected of throwing an embolus. An angiogram is diagnostic and an embolectomy is required. (The patient has to get an ECHO to rule out a thromus in the left ventricle)

111. Any patient who comes from S. America and have findings suggestive of cardiomyopathy should make you think about Chaga’s disease (Trypanosoma Cruzi). Can cause new onset RBBB.

112. Thiazide diuretics are the initial antihypertensive of choice in patients with osteoporosis (due to the fact that it decrease the excretion of Calcium in urine, hence increase the blood Calcium.

113. Restrictive cardiomyopathy: Sarcoid, amyloid, hemochromatosis, cancer and fibrosis-------severe diastolic dysfunction is the pathophysiology.

114. Severe systolic dysfunction and increased left ventricle size are features of dilated cardiomyopathy.

115. V/Q scan is to rule out PE (pulmonary embolism)

116. LV aneurysm can cause CHF in a patient who sustained and anterior wall MI in the past. A double apical beat and persistent elevation of the ST segment are important diagnostic clues. (Chest X-ray shows a characteristic prominence of the left border of the heart.)

117. Look for electrolyte abnormalities and correct them in patients with arrhythmias. (when someone is having recurrent VT, first thing to do after stabilizing the patient is to search for underlying cause. e.g. electrolyte imbanlance due to diuretics (furosemide---hypokalemia)-----lead to digoxin toxicity.

118. The study of choice for diagnosis and follow-up of abdominal aneurysms is an abdominal ultrasound.

119. Aortic insufficiency Tx: diuretics, ACEIs, digoxin, then surgery replacement of the aortic valve.

120. Prevention of recurrent attacks of rheumatic fever with antibiotic prophylaxis may slow down the progression of MS in adolescents. Asymptomatic MS do not require any Tx except penicillin prophylaxis.

121. Elevated PCWP (normally should be <12) is the most important finding in cardiogenic shock.

122. Dipyridamole (and adenosine are coronary vasodilators) can be used during myocardial perfusion scanning to reveal the areas of restricted myocardial perfusion. The redistribution of the coronary blood flow to “non-diseased” segments induced by this drug is called coronary steal phenomenon.-used to diagnose ischemic heart disease.

123. The main mechanism responsible for pain relief in patients with anginal pain treated with nitroglycerin is dilation of veins and decrease in ventricular preload. (effect on veins>on arteries) ---------dilation of capacitance vessels.

124. Hyponatremia is a bad prognostic factor in heart failure. It indicates the presence of severe heart failure and a high level of neurohumoral activation.
Other important electrolyte abnormalities in patients with heart failure include hypo-and hyperkalemia that may reflect the activity of rennin angiotensin-aldosterone system or may be due to different drugs and drug combinations.

125. As a result, a patient’s survival is significantly reduced if the serum Na+ level is <137 mg/dL. Decreasing the intake of water, not increasing the sodium intake, can help to control the electrolyte abnormalities.

126. Propranolol is the DOC in patients who presents with HTN and a benign essential tremor.

127. β-blocker can worsen severe peripheral vascular disease while helping for BP.

128. Dressler syndrome typically occurs 2-4 weeks after an MI and presents with a low-grade fever, malaise and pleuritic chest pain. EKG will reveal “non specific” ST elevations and there may be a pericardial effusion. NSAIDs are the agents of choice.

129. Know that prevention of recurrent attacks of rhematic fever with antibiotic prophylaxis may slow down the progression of mitral stenosis in adolescents. Asympomatic MS do not require any Tx except penicillin prophylaxis. (history of RF, apex beat is tapping, a loud S1, opening snap and mid diastolic rumble at the apex. Lungs are clear, can have normal EKG and chest x ray.)f

130. Exercise EKG testing is recommended for patients with an intermediate pre-test probability of angina based on clinical features and risk factors. Medications that should be withheld prior to testing include anti-ischemic medications, digoxin and medications that slow the heart. (e.g. beta-blockers).

131. Once sick sinus node syndrome has been Dx, the best Tx is placement of a permanent ventricular pacemaker.

132. Situational syncope should be considered in the differential Dx of syncopal episodes. The typical scenario would include a middle age or older male, who loses his consciousness immediately after urination, or a man who loses his consciousness during coughing fits.

133. Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using transthoracic Doppler echocardiography. Midsystolic soft murmurs (grade I-II/IV) in an asymptomatic young patient are usually benign and need no further work-up.

134. IV adenosine is the DOC for paroxysmal SVT. Know how to recognize the rhythm on EKG.(narrow complex QRS morphology. SVT is usually recognized by a HR of >140/min, regular loss of P waves and narrow QRS complex.) If the patient is hemodynamically unstable, electrical cardioversion should be performed immediately. If stable, vagal maneuvers should be attempted initially. If these fails to convert him to normal sinus rhythm, IV adenosine push is DOC.Verapamil can be a second line drug in this case.

135. Tx of unstable angina in the setting of anemia due to massive GI hemorrhage: blood transfusion.

Rheumatology

1. Muscle biopsy is the best diagnostic study for polymyositis. ( shows endomysial infiltration of the inflammatory infiltrate.)

2. The axillary nerve: is the most commonly injured nerve in anterior dislocation of the shoulder. Its palsy leads to loss of sensation over the lateral aspect of the deltoid.

3. Gouty arthritis: gout can present with nodular swelling of the digits resulting in significant deforming arthritis. Rheumatoid nodules predominantly occur over pressure points such as the elbow and extensor surface of the proximal ulna.

4. Diffuse proliferative glomerulonephritis is the severest form of glomerular disease of SLE. 6 types of SLE related glomerular injury:
 Type 1: normal
 Type 2: mesangial
 Type 3: focal proliferative
 Type 4: diffuse proliferative
 Type 5: membranous
 Type 6: sclerosing

5. Most specific test for Sjogren’s syndrome: Lip biopsy.

6. Acute inflammatory monoarticular arthritis in a previously damaged joint suggests septic arthritis. Leukocyte counts in synovial fluid exceeding 50,000 or even 100,000/ul should make you think of septic arthritis.

7. Lyme arthritis is a late manifestation of Lyme infection; suspect this in patients with history of travel to endemic areas. Intermittent inflammatory arthritis is a typical presentation.

8. Relapsing polychondritis is an idiopathic disorder characterized by recurrent inflammation of cartilaginous structures and other internal organs.

9. Thoracic outlet syndrome occurs with signs and symptoms of neurovascular bundle compression. (compression of the neurovascular structures supplying the upper extremities: compression by scalene muscles, cervical ribs or congenital fibro muscular band.) Predisposing factors also include: motor vehicle accidents, playing musical instruments (music teacher) and chronic illness.

10. Regular exercise/physiotherapy is the only beneficial Tx that halts the disease progression in ankylosing spondylitis.

11. Low back pain in patients with history of malignancy should always raise the suspicion of bone metastasis.

12. Disc herniation: presents as low back pain radiating down the buttock and below the knee. The pain is cuased due to impingemed nerve. A positive straight leg suggests nerve root irritation due to impingement. The cross straight leg test is very specific for disc herniation.

13. Though OCPs are safe in most patients with SLE, patients with the increased risk of thrombosis (anti phospholipids and nephritic syndrome) and active renal involvement should avoid its use.

14. Next best step in a suspected patient of ankylosing spondylitis: Plain X-ray of the sacroiliac joint.

15. Typical skin manifestation of Reiter’s syndrome: Keratoderma blennorrhagicum.

16. Thoracic aortic aneurysm is a serous complication of giant cell arteritis (Temporal arteritis), which can be fatal so such patients must be monitored continuously.

17. Rheumatoid factor is usually negative in Reiter’ syndrome and other spondyloarthropathies,60-80% patients are HLA-B27 (+)

18. DOC in sarcoidosis: systemic steroids (prednisone)

19. De Quervain’s tenosynovitis is characterized by tendonitis of abductor pollicis longus and extensor pollicis brevis as they pass beneath the retinacular pulley. ( pain over the lateral side of her wrist, pain is severe when she lifts her baby from the crib.)

20. What antibody is primarily involved in the pathogenesis of lupus nephritis: anti-dsDNA

21. Kidney biopsy is indicated to guide the Tx in all SLE patients with renal involvement.

22. Erosive joint disease in RA is a clear-cut indication for the use of diseases modifying anti-rheumatic drugs (DMARD) and methotrexate is the intitial DOC for this purpose.

23. Diagnostic of pseudogout: the presence of positively birefreingent crystals in joint aspiration.

24. Erythema nodosum, arthralgias, diarrhea, and positive P-ANCA in a young patient are highly suggestive of inflammatory bowel disease (IBD).

25. Amitriptyline and cyclobenzaprine have been shown to be effective in the Tx of fibromyalgia.

26. Fibromyalgia: a chronic widespread pain disorder associated with fatigue, poor sleep, and depression. Patients have multiple trigger points of tenderness.

27. Always consider fibromyalgia in a patient with diffuse muscle aches and excessiove fatigue with non-restorative sleep.

28. Arthritis in SLE is non-erosive and arthritis in RA is erosive.

29. A compression fracture of the vertebrae is a common complication of advanced osteoporosis. It usually manifests as acute back pain without an obvious preceding trauma in a predisposed patient. Neurologic examinationg will be normal.

30. Whipple disease presents with joint pain, abdominal pain, diarrhea, and weight loss. Periodic Acid-Schiff positive material on small intestinal biopsy establishes the Dx.

31. Tennis elbow: lateral epicondylitis, is epicondylitis about the origin of extensors of forearm; know who to differentiate it from radial tunnel syndrome.

32. Anterior uveitis is the MCC of red eye in patients with ankylosing spondylitis.

33. Dissenminated gonococcal infection is a syndrome of rash, tenosynovitis and polyarthralgia.

34. Classic triad of Buerger’s disease: occlusive disease of the arteries, migratory superficial thrombophlebitis, Raynaud’s phenomenon.

35. Parvovirus can be an important causative agent in acute small joint arthritis or arthralgia (note daycare employees)

36. Eye examinations at 6 months to 1 year intervals should be performed in all patients who are taking hydroxychloroquine.

37. The MCC of death in SLE: chronic renal failure.

38. HCV infection is associated with 80% cases of mixed essential cryoglobulinemia.

39. MRI is the definitive Dx study for rotator cuff tear! Not X-ray shoulder!

40. Presence of anti RNP is diagnostic of mixed connective tissue disease. Recognize the overlapping features.

41. Lofgren’s syndrome: an acute form of sarcoidosis and consists of triad of bilateral ankle arthritis (sometimes knees, wrists or elbolws), erythema nodosum and bilateral hilar adenopathy.

42. In patients with frequent attacks of acute gouty arthritis not controlled by colchicines, a 24-hour uric acid levels in urine is determined. This evaluates whether hyperuricemia is due to over production or under secretion of uric acid:
< 800 mg/day, suggests under secretion;àadd a uricosuric drug
>800 mg/day, suggests over production. àadd xanthine oxidase inhibitor

43. The MCC of asymptomatic elevation of alkaline phosphatase in an elderly patient is Paget’s disease. Asymptomatic Paget’s disease generally do not require any Tx. Symptomatic patiens are best treated with oral or intravenous bisphosphonates.

44. Hyperparathyroidism and hemochromatosis patients are more prone for pseudogout. Joint fluid aspirates reveal rhomboid shaped calcium pyrophosphate crystals, with positive birefringence.

45. Nerve conduction studies are very useful in diagnosing the carpal tunnel syndrome. (not carpal compression test---reproduce the symptoms, but not diagnostic)

46. Classical features of dermatomyositis: Heliotrope rash(periorbital edema with a purplish suffusion), Gottron’s sign(scaly patches over the dorsum of proximal interphalangeal and metacarpophalangerl joints),and proximal muscle weakness.

47. Low back pain in patients with history of malignancy should always raise the suspicion of bone metastasis.

48. Side effect of long-trem use of cyclophosphamide: bladder carcinoma.

49. MRI is the investigation of choice for suspected lumbar spinal stenosis.

50. Cessation of alcohol and staying on a low purine diet are important measures in the prevention of future attacks in patients with acute gouty arthritis. * extremely HY Q for USMLE.

51. Big toe Qs:
Atherothrombotic plaques: blue toe syndrome. Characterized by intact pulses, painful cyanotic toe along with features of ischemic lesions in distal limbs, such as livedo reticularis. Toe is tender, cold, cyanotic. (calf discomfort and tenderness, secondary to small vessel problems) Lab: significant for ↑ ESR, hypocomplementemia, eosinphilia.
Gout: big toe is red, tender, and inflamed (classic USMLE misleading, be careful)
Erythromelalgia: a paroxysmal disorder of peripheral blood vessel dilation with bilateral burning pain on palms and soles. It then progresses to the entire extremity. The area becomes red and warm.

52. Young patients with high spiking fevers associated with characteristic salmon colored evanescent rash, arthralgias, and leukocytosis most likely have adult still disease. (a variant of RA). Rheumatoid factor and ANA are usually negative.

53. Reflex sympathetic dystrophy is a syndrome of pain and swelling associated with vasomotor instability. Any extremity may be involved but is more common in the hand. Tx: physical therapy, prednisone, stellate ganglion block.

54. Psoriatic arthritis (PA) is asymmetrical and oligo-articular and such patients usually have typical features (silvery scales on erythematous plaques over flexural surfaces) of psoriasis present for years. Think of PA when pitting nails is present in the history. Skin rash may not be present all the time. Can present in 5 different forms:
 DIP involvement
 Asymmetric oligoarthritis
 Symmetric polyarthritis, similar to RA
 Spondyloarthropathy, including both sacroiliitis and spondilitis

55. Prophylactic allopurinol is the most effective method to prevent gout in patients at risk for tumor lysis syndrome.

56. Tx of choice for Reiter’s syndrome: NSAIDs. (reactive arthritis)

57. In patients with acute “mechanical” back pain without significant neurologic dedicit, conservative approach is preferred for a period of 4-6 weeks. This includes early mobilization, muscle relaxants, and NSAIDs. Bed rest and physical therapy has not been shown to be helpful.

58. Cortisteroid-induced avascular necrosis of the femoral head usually presents as progressive hip or groin pain without restriction of motion range and normal radiograph on early stages. MRI is gold std for the Dx of avascular necrosis of hip.

59. Behcet’s syndrome is a multi-systemic inflammatory condition characterized by recurrent oral and genital ulcers,skin lesions, seen most commonly in the Turkish, Asian and Middle Eastern population.

60. Obesity is a major risk factor for osteoarthritis. Hence weight loss is the most effective measure in OA management.

61. Keeping the back straight while lifting objects.-àvery helpful in protecting the back from recurrent injury.

62. Frozen shoulder: should be suspected when a patient presents with stiffness and limited range of motion. This is a result of pericapsulitis. Arthroscopy establishes the Dx by showing ↓ joint space volume, and loss of normal axillary pouch. Tx: NSAIDs, corticosteroid injection into the joint space, and physical therapy.

63. Rotator cuff tear or Rotator cuff tendonitis presents with severe pain and weakness of the shoulder abduction. Movements of shoulder like positioning the arm above the shoulder aggravate pain. Range of motion is limited only on active movement but is normal on passive flexion. A positive drop arm sign, with inability to actively maintain 90 degree of passive abduction, may be present in large tears.

64. Rotator cuff tendonitis: can be distinguished from rotator cuff tear by injecting lidocaine that will result in improvement in range of motion in cases of rotator cuff tendonitis but no effect in range of motion in cases of rotator cuff tear.

65. herniated disc: pain becomes worsened with sitting and lumbar flexion and therefore is different from pain of spinal stenosis.

66. Cauda equine syndrome: compression of lumbosacral nerve root by infection or tumor. Usual presentation is with urinary retention or overflow incontinence. Important physical findings include saddle anesthesia around the anus or perineum and decreased tone of anal sphincter.

67. Leriche syndrome: occurs as a result of atherosclerotic vascular disease and is characterized by impotence and intermittent claudication.

68.

69. Reiter’s syndrome/ reactive arthritis: polyarthritis reactive to genitourinary infection by Chlamydia. (a form of seronegative spondyloarthropathy). Other enthesopathy evidences: heel pain, sausage digits in the patient. Tx of choice: NSAIDs. Tetracycline. If refractory to the above Tx, then sulfasalazine, infliximab and methotrexate.

70. In patients with acute mechanical back pain without significant neurologic deficit, conservative approach is preferred for a period of 4-6 weeks. This includes early mobilization, muscle approach is preferred for a period of 4-6 weeks. This includes early mobilization, muscle relaxants, and NSAIDs.

71. Anti-B19 IgM is the diagnostic study of choice when Parvovirus infection is clinically suspected. (school teacher, suffering from acute ~. Joint involvement is symmetrical. Hands, wrists, kness and feet are the MC involved joints. Rash may or may not be present. Arthralgias or arthritis. Joint movement most frequently occurs in adult female.) IgG persists for life. Persistence of IgM indicates chronic infection.

72. Painful legs:
 Cellulitis of calf: difficult to DD from DVT. However presence of high-grade fever, lymphangitis, absence of any risk factor such as orthopedic surgery, or prolonged immobilization make DVT less likely. (web tinea pedis is one of the MC portals of entry for the microorganisms, causing cellulites-diffuse infection of deep layers of skin .
 Baker’s cyst: complication of RA.
 Necrotizing fasciitis: a deep-seated cellulites. Should be suspected in a patient who has evidence of overlying skin necrosis, bullae, with anesthesia due to destruction of nerves, crepitus due to gas producing organism, and fever.
 Sclerosing panniculitis: acute tender lesion over the medial malleolus. Usually occurs in a patient with venous stasis of lower limb.
 Erysipelas: a superficial cellulites. Usually affects cheek. The area involved become erythematous, tender, sharply demarcated and with vesicles or bullae. Fever is usually present, no element of lymphangitis.
 Erysipeloid is an edematous, purplish plaque with central clearing. It is caused by Erysipelothrix insidiosa. It usually on the hands of fishermen and meat handlers. Not very painful like cellulites. Fever is not present.


Respiratory diseases

1.The common diagnostic features of ABPA (allergic broncho pulmonary aspergillosis) include:
 Astham like symptoms
 Elevated IgE
 Hypereosinophilia
 Central bronchiectasis
 Positive Aspergullus skin test

2. Theophylline toxicity usually manifests as CNS stimulation (headache, insomia), GI disturbance (nausea, vomiting), and cardia toxicity (arrhythmia). The mechanisms responsible for the toxicity may include phosphodiesterase inhibition, adenosine antagonism, and stimulation of epinephrine release.

3. Triad of Wegener’s granulomatosis: (cytoplasmic -ANCA +)
 Upper respiratory tract disease
 Lower respiratory tract disease
 Glomerulonephritis

4. Atypical pneumonia presents with headache, malaise, low-grade fever, and dry cough. Patient complaints exceed the physical findings since exam findings are often minimal. The most common X-ray abnormality is peribronchial pneumonia pattern and have predilection for the lower lobes. Erythema multiforme is one of the extra pulmonary manifestations of mycoplasma pneumonia.

5.Use of prophylactic inhaled corticosteroids is beneficial in the long term out come of chronic persistent asthma. Know the clinical decisions one has to take in various scenarios of asthma. This is big in USMLE.

6. In a patient who has had recent surgery and presents with SOB and tachycardia, the Dx of Pulmonary embolus must always be suspected. And order a V/Q scan.

7. Any patient who presents with sudden onset of chest pain, SOB, and has evidence of hypoxia and the new onset RBBB should be considered as having a PE until proven otherwise. Best next step: V/Q scan.

8. Excessive alcohol intake can lead to aspiration pneumonia. (key cue: foul-smelling sputum, right lower lobe pneumonia)

9. The important risk factors for aspiration pneumonia are:
Altered consciousness-Seizures, alcoholism, drug overdose, etc
Dysphagian- esophageal reflux, diverticula, obstruction, etc.
Neurologic disorder- advanced dementian, PD, myasthenia, etc.
Sedation to procedures, such as bronchoscopy, intubation, endoscopy

10. Any chronic smoker with hypertrophic osteoarthropathy should have a chest x-ray to rule out malignancy. Hypertrophic osteoarthropathy is associated with chronic proliferative periostitis of the long bones, clubbing, and synovitis.

11. Identify allergic granulomatosis of Churg-Strauss and remember that leukotreine antagonists are known to cause CSS.Tx: corticosteroids and immunosupressnts.

12. Patients with DVT in whom anticoagulation is contraindicated require placement of inferior vena cava filter for the prevention of pulmonary embolism.

13. Blood in the chest, if it is not evacuated, can get infected. The majority of patients will present with a low-grade fever, dyspnea, and chest pain. Surgery is required to remove the clotted blood and fibrinous peel.

14. The Dx of cystic fibrosis is made on the basis of compatible clinical findings with laboratory confirmation. Sweat chloride test (>60 mEq/L) is the gold std test for Dx of CF and preferred over direct mutation analysis as more than 1,250 mutations in CFTR can lead to CF.

15. Suspect acute bronchopulmonary aspergillosis in asthmatics with worsening asthma symptoms, coughing brownish mucous plugs, recurrent infiltrates and peripheral eosinophilia. Tx. oral prednisone

16. Always consider lung abscess as an etiology of fever and foul-smelling productive cough in patients predisposed to aspiration.

17. The MCC of pulmonary complications in patients with systemic sclerosis is interstitial fibrosis.

18. All COPD patients with PaO2<55 mmHg or SaO2<88% are candidates for long-term home oxygen treatment. Patient with signs of pulmonary HTN or hematocrit >55% should be started on home oxygen when the PaO2<60 mmHg.

19. When an acute pulmonary embolus occurs with hemodynamic compromise, the best Tx is fibrinolytic therapy. But, if the patient has contraindications, an embolectomy is the treatment of choice

20. Criteria for ARDS:
 A pulmonary capillary wedge pressure less than 18 mmHg favors ARDS over cardiogenic pulmonary edema.
 PaO2 to FiO2 ratio of 200 mmHg or less, regardless of the level of PEEP
 Diffuse, bilateral infiltrates on chest-X ray

21. A bronchodilator response test is used to demonstrate reversible of air way obstruction. It helps to differentiate between COPD and asthma, although a subset of patients with COPD may also demonstrate airway reactivity.

22. A mobile cavitary mass in the lung, which presents with intermittent hemoptysis, is usually indicative of aspergilloma.

23. Glucocorticoids cause neutrophilia by increasing the bone marrow release and mobilizing the marginated neutrophil pool. Eosinophils and lymphocytes are decreased. (Extremely HY Q for USMLE)

24. In patients with fever and cough after upper GI endoscopy suspect anaerobic lung infection. Clindamycin and ampicillin plus metronidazole are the commonly used agents for this infection.

25. Suspect choriocarcinoma in any postpartum women who presents with shortness of breath and hemoptysis. The next step is chest X-ray, pelvic exam, and beta-hCG.

26. An enlarged left atrium in mitral stenosis can cause a persistent cough and elevation of the left main stem bronchus.

27. Always consider ACEI therapy as a potential cause of chronic cough. Simple discontinuation of the drug should precede any Dx testing in patients with chronic dry cough who are taking an ACEI.

28. The MC locations of post aspiration lung abscess in recumbent position are apical segment of right lower lobe and posterior segment of right upper lobe.

29. TB occurs early in the course of HIV when the CD4 counts are greater than 200/microL. Upper lobe consolidation and/or cavitation is the typical X-ray finding.

30. Anterior mediastinal mass along with elevated AFP and HCG indicates Nonseminomatous tumor.

31. Remember Blastomyces blasts the lungs, skin and bone.

32. The MCC of superior vena cava syndrome today is bronchogenic carcinoma. Benign causes of SVCS are rare and relatively easily diagnosed. These lung cancers usually arise from the right hilar region and invade the superior vena cava. (venous congestion of the face and arms. Tx: angioplasty with stenting is the std. of care.)

33. Rigid bronchoscopy is indicated in patients with massive hemoptysis as it allows rapid visualization of the bleeding site and to control bleeding through cauterization or other means.

34. When the pH of the pleural fluid is less than 7.2, the probability is very high that this fluid needs to be drained. Glucose of less than 60 mg/dL in pleural fluid is also an indication for tube thoracostomy. Infected pleural space is usually initially drained with a chest tube.

35. In ventilation/perfusion scan is inconclusive in patients undergoing diagnostic work-up for pulmonary thromboembolism, order venous ultrasonography to reveal DVT or CT angiogram. Pulmonary angiography is an invasive procedure and should be employed only if venous ultrasonography or CT angiogram is negative.

36. DVT is not a clinical Dx and therefore all suspected cases of DVT should be evaluated with noninvasive testing and the test of choice for this purpose is compression ultrasonography.

37. Proximal (above knee veins) DVT of lower extremities is the most frequent source of PE. (such as: clot in ileofemoral veins)

38. PE: an area of perfusion defect without ventilation defect. (V/Q scan mismatch).

39. In any patient who presents with a lung lesion on a chest X-ray, it is best to get old chest X-ray and compare the lesion. The lesion may have been present for a long time and may be benign.

40. Patients who are on high dose of beta-2 agonists may develop hypokalemia and patients should be monitored with daily electrolytes. The other side affects of beta-2 agonists are tachycardia, tremor, and peripheral edema.

41. BAL (bronchoalveolar lavage) is >90% effective in diagnosing pneumocystis carini pneumonia in HIV positive patients, especially when CD4 count is less than 200.

42. The most serious complication of bronchectasis is hemoptysis.

43. Obstructive sleep apnea is a common condition among obese population. With never ending pandemic of obesity in USA, this is getting wider clinical attention, know the management of this condition. Dx: nocturnal polysomnography.

44. Factor V Leiden is the MC inhirited disorder causing hypercoagulability and predisposition to thromboses, especially DVT of lower extremities. (Factor V Leiden is the result of a point mutation in a gene coding for the coagulation factor V. As a result of this mutation, Factor V becomes resistant to inactivation by protein C, an important counterbanlance factor in hemostatic cascade.)

45. All patients withsuspected bacterial pneumonia should have a chest X-ray done as the first step, and antibiotics should be administered ASAP without waiting for sputum gram stain or cultures.

46. A non-productive cough is observed in 5-20% of patients receiving ACEIs. It is caused by an accumulation of kinins (bradykinins), and possibly by the activation of the arachidonic acid pathway.

47. The most typical findings of a pulmonary embolism on arterial blood gas sampling are hypoxemia and hypocarbia.

48. High resolution CT scan of the lung is the diagnostic modality of choice for bronchiectasis.

49. Suspect cystic fibrosis in patients with bronchiectasis and symptoms suggestive of intestinal malabsorption due to pancreatic insufficiency. CF is often tested on USMLE and must be covered thoroughly.

50. Always consider infective endocarditis in any patient who is an IV drug abuser and comes with fever and heart murmurs heard on examination. Empiric antibiotic therapy: IV vancomycin and gentamycin.

51. Remember bronchogenic carcinoma is the MC lung cancer associated with asbestos exposure while malignant mesothelioma is almost exclusively associated with asbestos exposure but is not the most common malignancy after asbestos exposure. (plumber)

52. Cough can be a presenting symptom of GERD. A 24-hour pH recording is the most specific test available for acidic gastroesophageal reflus. It is usually employed to Dx the cause of chest pain or supra esophageal complications of GERD in patients with negative esophagoscopy.

53. Acute exacerbation of COPD is treated with a combination of inhaled/nebulized bronchodilators and systemic steroids.

54. Cor Pulmonale is a term for right-sided heart failure most commonly due to pulmonary disease. Signs of right-sided heart failure include: jugular venous distension, right-sided S3, right ventricular heave, hepatomegaly, ascites, and dependent edema.

55. Any elderly patient who presents with pneumonia, abdominal pain, confusion and hyponatremia should be suspected for Legionella pneumonia. This should also be suspected in patients who failed to respond to beta-lactam antibiotics and Gram stain showing many polymorphs with few visible organisms. The Tx of choice for Legionella pneumonia is high dose erythromycin or azithromycin.
Remember pneumonia, hyponatremia and diarrhea are almost classic for Legionella.

56. IPF is a Dx of exclusion. Idiopathic pulmonary fibrosis is best treated with steroids. Most patients will have a positive response in the first six months but they fail to have sustained response.

57. Klebsiella is an encapsulated gram-negative bacillus and can cause pneumonia in subjects with debilitating conditions, especially alcoholics. Friedlander’s pneumonia generally affects the upper lobe and is characterized by current jelly-like sputum.

58. A-a gradient is increased in interstitial lung disease due to poor oxygenation. In restrictive lung disease, total lung capacity (TLC), functional residual capacity and residual volume are all reduced. Flow volumes are also reduced but the ratio of FEV1/FVC is either normal or increased.

59. After quitting smoking, home oxygen therapy is the only modality known to prolong survival in COPD.

60. If you suspect a PE clinically, and chest X-ray, ABG and EKG results rule out other differential diagnoses then you should begin Tx with heparin without waiting for a V/Q scan to confirm your Dx.

61. When pneumonia fails to heal after two weeks of appropriate antibiotics, a CT scan of the chest followed by bronchoscopy is indicated to ensure that the bronchus is not blocked and there is no lung abscess.

62. Annual influenza vaccine is recommended for all persons aged 65 and older and persons in selected high-risk groups. Pneumococcal vaccine is recommended for all immunocometent individuals who are 65 years and older or otherwise at increased risk for pneumonococcal disease ( post-splenectomy, myeloma).

63. Identify occupational interstitial lung diseases: i.e. Hypersensitivity pneumonitis, Organic dust (Byssinosis) and inorganic dusts (asbestosis, silicosis, berylliosis and coal worker’s pneumonitis).

64. Know the role of beta agonists and mast cell stabilizers in the management of exercise-induced asthma.

65. Always consider candida albicans as a cause of infection in a patient with uncontrolled DM. Dx: KOH preparation.

66. In a smoker with arm pain, cough and weight loss, a mass in the lung apex is a Pancoast tumor until proven otherwise.

67. When it is unclear whether the patient has nocturnal asthma or GERD, a trial of proton pump inhibitors is both diagnostic and therapeutic.

68. Suspect alpha-1 anti-trypsin deficiency in non-smoker with early onset emphysema. Dx: estimate alpha-1 anti-trypsin level.

69. Know the 3 major complications of too high a PEEP:
 Alveolar damage
 Tension pneumothorax
 Ventricular failure

70. Indicators of a severe asthma attack include normal to increased PCO2 values, speech difficulty, diaphoresis, altered sensorium, cyanosis, and silent lungs.

71. Due to high incidence of lung cancer among smokers, it should be suspected in any smoker presenting with recurrent pneumonia. Admit the patient and order a high resolution CT scan.

72. A lung mass with cartilage is most likely a hamartoma and can be observed.

73. Congestive heart failure is the MCC of pleural effusion. In patients with this condition, pleural fluid analysis is consistent with transudative effusion. (pH of 7.35, pH <7.3 indicate pleural inflammation)

74. Patients with impaired consciousness, advanced dementia, and other neurologic disorders are predisposed to aspiration pneumonia due to impaired epiglottic function.

75. Aspirin sensitivity syndrome is believed to be a pseudo-allergic reaction. It results from aspirin-induced prostaglandin/leukotriene misbanlance in susceptible individuals. Tx includes avoidance of NSAIDs and the use of leukotriene receptor antagonists (DOC). Extremely HY Q for USMLE

76. Patients with suspected PE should have a chest X-ray and ABG, followed by EKG and V/Q scan. Pulmonary embolism Risk factors include:
 Venous stasis
 Hypercoagulable states (cancer, protein C deficiency, protein S deficiency, antithrombin III deficiency, malignancy, pregnancy, etc)
 Obesity
 Prior history of pulmonary embolus
 Malignancy
 Pregnancy
 Estrogen and tamoxifen
 Prolonged immobilization
 Trauma of lower extremities

77. ARDS can present with dyspnea, tachypnea and bilateral fluffy infiltrates on a CXR. It is a condition where hypoxemia persists and it becomes difficult to oxygenate the patient.



Miscellaneous
1. MRI is the imaging procedure of choice in patients with suspected vertebral osteomyelitis. (back pain + low grade fever + elevated ESR+local tenderness on percussion over the affected vertebrae and paravertebral muscular spasm)

2. Think of conversion disorder in a female patient with sudden onset neurological symptoms preceded by an obvious stressor. The Tx of choice would be Psychotherapy.

3. The MCC site of ulnar nerve entrapment is the elbow where the ulnar N. lies at the medial epicondylar groove. (decreased sensations over the 4th and 5th fingers and a weaker grip)-cubital tunnel syndrome

4. Severe, excruciating pain (such as motor vehicle accident) should be treated with IV opioids even if the patient has a history of drug abuse.

5. Atracurium is a neuromuscular blocking agent that is metabolized in plasma and hydrolysed by serum esterases. Its use is safe in patients with renal and liver dysfunction. Pancuronium and mivacurium---excreted mostly unchanged in urine. Succinylcholine-in renal dysfunction, may casue apnea and hyperkalemia.

6. An epidural abscess presenting with neurologic symptoms of spinal compression requires urgent surgery.

7. Removal of impacted esophageal foreign body is mandatory (through endoscopy).

8. Primary polydypsia (psychogenic polydypsia) is characterized by primary increase in water intake. Patients taking phenothiazines have this problem due to dry mouth caused by anticholinergic action of phenothiazines.

9. Hepato-jugular reflex is a useful tool that can be used to differentiate between heart and liver disease-related causes of lower extremity edema.

10. Mild manifestations of a drug allergy (e.g. urticaria and pruritus without systemic symptoms) are usually treated with antihistamines and discontinuation of the offending drug.

11. Nasal eosinophila is characteristic for allergic rhinitis, although this finding is not specific. Nasal eosinophilia is absent in patients with infectious causes and vasomotor rhinitis. (Do a nasal cytology to distinguish them)

12. Vit. K deficiency is usually manifested by prolonged PT, normal platelet count and normal BT. PTT is variable.

13. Beta-blockers decrease the risk of perioperative myocardial infarction, and thus does decrease mortality in perioperative patients with vascular disease undergoing noncardiac surgery. Beta 1 selective agents are the DOC for this purpose.

14. Patients who are on high dose of Vit. D and calcium should have a close eye on serum calcium levels. Signs of toxicity include nausea, vomiting, constipation, polyuria, and mental status changes.

15. Heat exhaustion, also known as heat prostration is a syndrome characterized by volume depletion under the conditions of heat stress. It can be distinguished from heat stroke by T<40 °C and lack of severe CNS symptoms.

16. Pellagra, a niacin deficiency syndrome is characterized by a triad of 3 Ds of Diarrhea, Dermatitis, and Dementia and if untreated eventually leading to Death (4th D).

17. Wernicke’s encephalopathy is a syndrome characterized by ataxia, ophthalmoplegia, nystagmus and altered mental status. Wernicke’s encephalopathy is seen in chronic alcoholics with thiamine deficiency.

18. Lumbosacral strain is the MCC of acute back pain. The typical clinical scenario includes acute onset of the back pain after physical exertion, absence of radiation, presence of paravertebral tenderness, negative straight-leg raising test, and normal neurologic examination.

19. Zinc deficiency is associated with alopecia, mental changes, diarrhea, smell abnormalities, maculopapular rash around the mouth and eyes, and impaired wound healing. (usually seen in patients receiving long term TPN, total parenteral nutrition).

20. Excessive use of vit C in patients with renal insufficiency can cause oxalate stones.

21. Chloride depletion in patients with vomiting is a common cause of metabolic alkalosis. It is due to the loss of chloride in vomiting. (GI loss).

22. An aortic aneurysm of the descending aorta may appear on a CXR as a well-circumscribed lesion. These aneurysms are due to atherosclerosis.

23. Latex allergy can manifest as an anaphylactic reaction during exposure to latex-containing products (gloves, condoms etc).

24. Hypothyroidism should always be considered in patients with an unexplained elevation of serum CK concentration and myopathy. (Do a serum TSH test).

25. Hypercarotenemia is commonly seen in patients with anorexia, DM & hypothyroidism.

26. Consider IgA deficiency in patients with recurrent sionpulmonary and GI infections, and anaphylactic transfusion reaction. Dx of IgA deficiency is made if the serum IgA concentration is less than 7 mg/dL with normal serum IgM and IgG levels.

27. Lithium toxicity presents with tremulousness, headache, confusion, GI distress, fatigue and, in extreme cases, with seizures, coma, hyperreflexia and opisthotonus.

28. For frostbite injuries, the best Tx is rapid re-warming with warm water. Whenever frostbite or cold injuries are diagnosed, no attempt should be made to debridge any tissue initially. Rapid re-warming with dry heat (like a fan) is not effective for frostbite.

29. Fibreoptic laryngoscopy establishes the Dx of epiglottitis but it must be performed in the OR with preparations already made to perform endotracheal intubation.

30. Pressure sores are common over the sacrum, heels and hips. Frequent turning of the patient is the only best method to prevent these.

31. Heat stroke is a life threatening catastrophic medical emergency due to failure of thermoregulatory center leading to severe hyperthermia with body temperature generally greater than 105 F. Patients will have CNS symptoms.

32. Warfarin induced skin necrosis is a complication seen in patients with protein C or S deficiency especially when it is started in high dose without heparin coverage.

33. Vit B12 deficiency: subacute combined degeneration of the dorsal and lateral spinal columns is the classic neurologic manifestation. Symmertrical neuropathy, ataxia with loss of vibration and position sense are the clinical clues.

34. Aortic dissection is an acute emergency and its medical management includes prompt BP lowering with IV nitroprusside and short-acting beta blocker.

35. Aortic dissection may cause impaired consciousness. Neurological deficits may develop later in the course of disease.

36. Prolonged placement of central lines can lead to subclavian vein thrombosis and result in arm swelling. Catheters should be removed and duplex ordered to document the thrombus and for the need of anticoagulation.

37. Gentamicin causes vestibular toxicity (Romberg’s sign +). Some of the drugs (especially aminoglycosides) commonly associated with ototoxicity are as follows:
 Streptomycin
 Minocycline
 Neomycin
 Quinine
 Kanamycin
 Quinidine
 Tobramycin
 Salicylates
 Amikacin
 Cisplantin
 Netilmicin
 Ethacrynic acid
 Vancomycin
 Furosemide
Genitourinary

1. Renal transplant dysfunction in the early post-operative period can be explained by a variety of causes, including ureteral obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, and acute tubular necrosis. Radiosotope scanning, renal ultrasound, MRI, and renal biopsy can be employed in conducting a differential diagnosis. Acute rejection is best treated with IV sterioids. (biopsy: heavy lymphocyte infiltration, and vascular involvement with swelling of the intima)

2. Rule out bladder cancer in all elderly patients with irritative voiding symptoms and have negative urine culture.

3. The major cause of anemia in patients with end stage renal disease is deficiency of erythropoietin. The anemia is normocytic and normochromic. The Tx of choice is recombinant erythropoietin, which is started if the Hb is <10 g/dL. The MC side effects are worsening of HTN (30% of patients), headaches (15% patients) and flu-like symptoms (5% of patients)

4. Focal segmental glomerulosclerosis (FSGS) is the MCC of nephritic syndrome in African American adults. It also occurs in patients with HIV and IV drug abuse.

5. The classic findings in patients with amyloidosis (eg. In RA patients) are renal amyloid deposits that show apple-green birefringence under polarized light after staining with congo red.

6. 70% of cases with interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and allopurinol. Discontinuing the offending agent is the Tx of drug-induced interstitial nephritis.

7. IgA nephropathy is the MCC of glomerulonephritis in adults. Patients have recurrent episodes of gross hematuria, beginning 1-3 days after an upper respiratory infection. Serum complement levels are normal.

8. Ultrasound of the kidney, ureter and bladder should be done in patients of benign prostatic hyperplasia whose serum creatinine is elevated.

9. Memranoproliferative glomerulonephritis, type II, is a unique glomerulopathy that is caused by persistent activation of the alternative complement pathway. (IgG and C3 deposit at basement membrane)

10. Pulmonary-renal syndrome include a variety of disorders with simultaneous involvement of the lung and kidney. Quick DD is important because the management differs per disease. Emergency plasmapheresis is required in patients with Goodpasture’s syndrome. Wegener’s granulomatosis is treated with a combination of cyclophophamide and steroids.

11. Routine urine cultures are not indicated in women with uncomplicated cystitis. Oral trimethoprim-sulfamethoxazole is the preferred empiric Tx.

12. When isolated proteinuria occurs, the evaluation of the patient should begin by testing the urine on at least two other occasions. (transient proteinuria is a common cause of isolated proteinuria and can occure during stress or any febrile illness.

13. Acute allergic interstitial nephropathy is a drug-induced hypersensitivity reaction characterized by rash, renal failure, eosinophilia, and eosinophiluria (Hansel stain). The common medications:
 Antibiotics (MC is methicillin group)
 NSAIDs (often cause heavy proteinuria)
 Thiazides
 Phenytoin
 Allopurinol

14. Cholesterol embolization usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low complement levels should make you think of cholesterol embolism. (HY Q)

15. Suspect Alport’s syndrome in patients with recurrent episodes of hematuria, sensorineural deafness and a family history of renal failure.

16. The Tx of choice for fibromuscular dysplasia: percutaneous angioplasty with stent placement. (The usual cause of renal artery stenosis in young adults is fibromuscular dysplasia: headache, elevated BP, renal bruit)

17. Collapsing focal and segmental glomerulosclerosis is the most common form of glomerulopathy associated with HIV. Typical presentation of focal segmental glomerulosclerosis includes nephritis range proteinuria, azotemia, and normal sized kidneys. (HY Q)

18. Drug induced interstitial nephritis is usually caused by cephalosporins, penicillins, sulfonamides, NSAIDs, rifampim, phenytoin and allopurinol. Patients present with arthralgias, rash, renal failure and the urinalysis will show eosinophiluria.

19. Suspect medullary cystic disease in adults with recurrent UTI or renal stones and contrast filled cysts demonstrated by IVP.

20. Acute post-streptococcal glomerulonephritis occurs 10-20 days after streptococcal throat or skin infections. It presents with hematuria, HTN, red cell casts, and mild proteinuria.

21. Tamsulosin is alpha-1a receptor blocker and it has the least side effects of all the alpha-1 blocker used for the tx of BPH.

22. Several medications can cause hyperkalemia. Examples of these are: ACEIs, NSAIDs, and potassium-sparing diuretics, such as spironolactone and amiloride.

23. Calcium gluconate is the most appropriate initial Tx for hyperkaliemic patients with significant EKG abnormalities.

24. Patients with prostatodynia are afecrile and have irritative voiding symptoms. Expressed prostatic secretions show a normal number of leukocytes and culture of these secretions is negative for bacteria.

25. Simple renal cysts are almost always benign and do not require further evaluation. Know how to recognize these on a CT scan.

26. Allergic interstitial nephritis is a type 4 hypersensitivity reaction commonly seen following the ingestion of nephrotoxic drugs. The triad of fever, petechial, rash, and peripheral eosinophilia in an azotemic patient is highly suggestive of the Dx.

27. Patients with acute pyelonephritis usually present with fever, chills, nausea, vomiting and flank or suprapubic pain. Physical examination shows costovertebral angle tenderness. Hospitalization and intravenous antibiotics are indicated in complicated acute pyelonephritis.

28. Finasteride acts on epithelium and alpha-1 blockers act on smooth muscles of prostate and bladder base.

29. Acyclovir can cause crystalluria with renal tubular obstruction during high-dose parenteral therapy, especially in inadequately hydrated patients.

30. Rifampin causes red to orange discoloration of body fluid. “Red urine” in a patient taking rifapin is usually a benign drug effect.

31. Autonomic neuropathy may lead to a denervated bladder, resulting in overflow incontinence. This condition is characterized by a high post-void residual volume.

32. Struvite stones almost always occur in the presence of alkaline urine that is persistently infected with urease-producing bacteria.

33. Renal stones are predominantly of 4 types:
 Calcium oxalate/phosphate (75%)
 Uric acid (10-15%)
 Struvite/triple phosphate (10-15%)
 Cysteine (<1%)

34. Platelet dysfunction is the MCC of abnormal hemostasis in patient with CRF,PT, PTT, and platelet count are normal. BT is prolonged. DDAVP (desmopressin) is usually the Tx of choice, if needed. DDAVP increases the release of factor VIII: von Willebrand factor multimers from endothelial storage sites. Platelet transfusion is not indicated because the transfused platelets quickly become inactive. (HY Q)

35. The symptoms of BPH are weak urinary stream, urgency, frequency, and sensation of incomplete voiding. Unlike prostate cancer, BPH starts in the center of the prostate. Placement of a Foley catheter is the most appropriate initial step in patients who present with acute renal failure. The obstruction should be reversed within the first two weeks to prevent permanent kidney damage.

36. Autosomal dominant polycystic kidney disease (ADPKD) is a potential cause of HTN. Hepatic cysts are the MC extrarenal manifestations. Intracranial berry aneurysms are seen in 5 to 7% of the cases. Although such aneurysms are common and dangerous when coupled with HTN, routine screening for intracranial aneurysms is not recommended.

37. The other major extra-renal complication of ADPKD are:
 Hepatic cysts-MC common extrarenal manifestations of ADPKD
 Valvular heart disease-most often mitral valve prolapse and aortic regurgitation
 Colonic diverticula
 Abdominal wall and inguinal hernia

38. Patients with recurrent hypercalciuric renal stones should be treated with increased fluid intake, sodium restriction, and a thiazide diuretic. Calcium restriction is not advised. The Tx of a first uncomplicated calcium stone is hydration and observation.


39. The MCC of calcium stones are:
 Idiopathic hypercalciuria
 Hypercalciuria due to systemic disorders (e.g., primary hyperparathyroidism, sarcoidosis, etc.)
 Hyperuricosuria
 Hyperoxaluria: The cause may be hereditary, dietary (i.e. due to ingestion of a large amount of vit. C or green leafy vegetables), or secondary to IBD or short bowel syndrome.
 Decreased urinary citrate
 Renal tubular acidosis: typically, nephrocalcinosis is seen
 Chronic decrease in urine output: this helps the precipitation of calcium salts.

40. The dietary recommendations for patients with renal calculi are:
 Decreased dietary protein and oxalate
 Decreased sodium intake
 Increased fluid intake
 Increased dietary calcium

41. Elderly patients are particularly predisposed to dehydration after even minor insults (e.g., a minor febrile illness). Know the classic signs of dehydration (i.e., dry mucosa, marginally high values for hematocrit and serum electrolytes, BUN/creatinine ratio >20). The Tx is administration of intravenous sodium-containing crystalloid solutions (usually 0.9% NaCl= normal saline).

42. Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic evaluation is not needed when a patient presents with his first renal stone.

43. In hyperkalemia, removal of K+ from the body can be achieved with dialysis, cation exchange resins (Kayexalate) or diuretics.

44. Dx criteria of ATN:
 Urine osmolality of 300-350 mOsm/L (but never <300)
 Urine Na of >20 mEq/L
 FENa >2%
 Prolonged hypotension from any cause can lead to ATN.
 Hallmark findings on urinalysis: muddy brown granular casts consisting of renal tubular epithelial cells.

45. Educational Objective: (extremely HY Q)
 Muddy brown granular-Acute tubular necrosis (ATN)
 RBC casts- Glomerulonephritis
 WBC casts- Interstitial nephritis and pyelonephritis
 Fatty casts- Nephrotic syndrome
 Broad and waxy casts- Chronic renal failure

48. Acute pyelonephritis can potentially result in gram-negative sepsis. Urine and blood cultures should be routinely obtained prior to administering antibiotics.

49. Presence of hematuria in a patient with irritative or obstructive voiding should alert the physician to the possibility of bladder cancer.

50. in elderly patients, E.coli is the MC causative organism of acute bacterial prostatitis. Prostatic massage and urethral catheterization are contraindicated due to the risk of septicemia.

51. Any elderly patient with bone pain, renal failure, and hypercalcemia has multiple myeloma until proven otherwise. Approximately 50% of multiple myeloma patients develop some degree of renal insufficiency; this is most likely due to obstruction of the distal and collecting tubules by large laminated casts containing paraproteins (mainly Bence Jones protein).

52. Membranous glomerulonephritis is the most likely Dx in patients with both hepatitis B infection and nephritic syndrome.

53. Acute epididymitis in younger patients is usually caused by sexually transmitted organisms such as C. trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is caused by gram-negative rods.

54. Rhabdomyolysis should be suspected in the following situation:
 Presence of risk factors such as alcoholism, cocaine use, and electrolyte abnormalities (e.g. hypokalemia, hypophosphatemia)
 Disproportionate elevation of creatinine as compared with BUN.
 Urine dipstick positive for blood but no RBC on microscopic examination.
The underlying pathology is acute tubular necrosis. Serum CK should be measure in suspected patients. The Tx is aggressive intravenous hydration and alkalinazaion of urine. In some cases, forced diuresis with mannitol may be required.

55. Uric acid stones are highly soluble in alkaline urine; therefore, alkalinization of urine to pH >6.5 with oral sodium bicarbonate or sodium citrate is the treatment of choice.

56. Consider three possibilities when a flat film of the abdomen and pelvis does not show a stone in a patient with typical renal colic:
 Radiolucent stone disease (uric acid stones)
 Calcium stones less than 1 to 3 mm in diameter
 Non-stone causes (e.g., obstruction by a blood clot or tumor)
OBGYN

1. Vasa previa or fetal vessel rupture necessitates immediate C. section.

2. Meigs’ syndrome: ovarian fibroma + ascites + right hydrothorax.

3. Krukenberg’s tumor: metastasis of stomach cancer to both ovaries.

4. Advanced stage of premature labor should be managed more aggressively and tocolysis has to be institute at once. Magnesium sulfate is the DOC for tocolysis. (bed rest, cervical cultures, antibiotics, steroid, Magnesium)

5. HCG is a hormone secreted by the syncytiotrophoblast and is responsible for maintenance of progesterone secretion by preservation of the corpus luteum until the placenta starts producing progesterone on its own.

6. Toxoplasmosis in pregnancy:
 DOC in first trimester: spiramycin
 DOC in 2nd -3rd trimester: pyrimethamine and sulfadiazine.
 Elective termination of pregnancy is an option in 1st trimester.

7. Hypotension is a common side effect of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling.

8. HELLP: combination of thrombocytopenia, microangiopathic hemolytic anemia and increased liver enzymes in a patient with preeclampsia is defined as HELLP syndrome.

9. Severe preeclampsia is defined as a BP> or = 160/110, and / or the presence of one or more of the following signs:
 Oliguria (<500 mL/day)
 Altered consciousness, headache, scotoma or blurred vision
 Pulmonary edema or cyanosis
 Epigastric or right upper quadrant pain
 Microangiopathic hemolysis
 Altered liver function tests
 Elevated serum creatinine levels
 IUGR, or oligohydramnios

10. In which patients with DUB do you perform endometrial biopsy to rule out endometrial carcinoma? When the patient is older than 35 yo, obese, diabetic or has chronic HTN.

11. DUB is the MCC of abnormal uterine bleeding. Due to its benign nature, it is a Dx of exclusion. The MCC of DUB in adolescent women is anovulation. IV estrogen is the DOC for uncontrolled bleeding.

12. All patients with positive PPD should undergo a chest Xray. Should be given INH for a period of 9 months.

13. Endometritis: typically occurs on the 2nd -3rd day postpartum. Predisposing risk factors:
 Prolonged labor
 Prolonged and premature rupture of membranes
 Manual removal of the placenta
 Repeated pelvic examinations
 More frequent after C section or operative vaginal delivery (episiotomy)
Tx: antibiotics ASAP: covering the aerobic and anaerobic ------clindamycin +
aminoglycoside/ ampicillin.

14. Fetal hydantoin syndrome presents with a small body size with microephaly, hypoplasia of the distal phalanx of the fingers and toes, nail hypoplasia, low nasal bridge, hirsutism, cleft palate and rib anomalies. (due to fetal exposure to hydantoin anticonvulsants, such as diphenylhydantoin, usually taken by epileptic mothers.)

15. Hypertrophic dystrophy of vulva is most commonly seen in postmenopausal women and is treated with local 1% corticosteroid ointment 3 times a day for 6 weeks. DD: biopsy to differentiate from vulva cancer.

16. Granuloma inguinale: is a STD caused by the bacterium Donovania granulomatis and characterized by an initial papule, which rapidly evolves into a painless ulcer with irregular borders and a beefy-red granular base. (microscopic exam reveals Donavan bodies: Giemsa stain of tissue smears reveals reddish encapsulated bipolar staining organisms that are found within large mononuclear cells.). Tx. tetracycline

17. The most appropriate next step in managing variable deceleration is mask oxygen and change in maternal position.

18. Lithium is associated with the congenital anomalies, classically Ebstein’s anomaly. When a woman with isotretinoin, she should receive strict contraception. Inhaled steroid are okay in pregnancy.

19. Idiopathic precocious puberty is managed with GnRH agonist therapy in order to prevent premature fusion of the epiphyseal plates.

20. In pregnant patients, asymptomatic bacteriuria increases the risk of developing cystitis and pyelonephritis more than in the non-pregnant state. E.coli accounts for more than 70% of cases. Tx in pregnancy consists of a 7-10 day courses of nitrofurantoin, ampicillin or first generation cephalosporin.

21. Lichen sclerosis is usually seen in postmenopausal women but many develop at any age. It present with pruritus, burning and dyspareunia and is treated with superpotent topical corticosteroids such as clobetasol or halobetasol. *Itchy spot in a postmenopausal women needs biopsy.

22. In a postmenopausal female who has vulvar itch and dryness, Lichen sclerosis must be suspected. However, vulvar carcinoma in situ must also be in the DD and a biopsy obtained if suspicion is high.

23. The chancre characterizes the primary stage of syphilis: painless, indurated ulceration with a punched-out base and rolled edges. Serologic testing is not reliable at this stage and includes a high rate of false-negatives, so Dx in the first stage is made via spirochete identification on dard field microscopy.

24. Fetal distress (repetitive late decelerations) is an indication for emergency C. section.

25. Physicians have to maintain their obligation to a patient’s right to confidentiality, even in the event of a pregnant minor wanting to withhold the Dx from her parents.

26. GnRH stiulation test serves to differentiate between true isosexual and pseudoisosexual precocious puberty.

27. Presence of dysmenorrheal, heavy menses, and enlarged uterus is almost diagnostic of either adenomyosis or fibroid uterus.

28. Hormone replacement therapy is now only recommended for the short-term use of controlling menopausal symptoms. Large studies, such as the WHI, have shown that the long-term use of combined HRT can slightly increase the risk of coronary heart disease and stroke.

29. Abrupt onset of hyposia with respiratiory failure, cardiogenic shock and DIC when doing amniocentesis or delivery, ---amniotic fluid embolism. Respiratory support is always the 1st step of management.

30. The indicence of vertical transmission of HIV can be reduced from 25% to 8% by admistrationg ZDV to pregnant women and their offspring. ZDV is administered orally after 1st trimester, IV during labor, and orally to the neonate for the first 6 weeks of life.

31. Vulvar papillomatosis, or condylomata acuminate, are genital lesions caused by HPV serotype 6 and 11. Condylomas present as exophytic lesions with a raised papillomatous or spiked surface and may grow into large and cauliflower-like formations.

32. Low back pain is a very common complaint in the 3rd trimester of pregnancy. It is believed to be caused by the increase in lumbar lordosis and the relaxation of the ligaments supporting the joints of the pelvic girdle.

33. The first step in a patient with secondary amenorrhea is to rule out common situations; that is, pregnancy, then hypothyroidism (TRH increases-prolactin increases-GnRH inhibited) and hyperprolactinemia. The subsequent step should be the determination of the patients’s estrogen status with progestin challenge test.

34. The MCC of mastitis: staph. Aureus.

35. Active phase arrest: occurs when dilation fails to progress in the active phase of labor over a period of at least 2 hours. In the primigravida, cervical dilatation in the active phase progresses at a speed of 1.2 cm/hr. So after 2 hours the patient (originally with cervix dilated to 5 cm) must be at 7.4 cm. If less than that, Dx is made. Tx.: C-section

36. Prolonged latent phase: therapeutic rest.

37. In incomplete abortion, the cervix is dilated; there is an incomplete evacuation of the conceptus with fragments retained in the uterine cavity.

38. Labor should be induced immediately in patients with intrauterine fetal demise who develop coagulation abnormalities.

39. Patients with testicular ferminization syndrome present with amenorrhea, developed breast (why? Because testes secret some estrogen, unopposed to testosterone), absent pubic and axillary hair, absent internal reproductive organs, and a 46XY karyotype. (lower part of girl thingy exists, sine it is from urogenital sinus, not from Mullerian tube:give rise to uterus, tubes,upper part of girl thingy). Presence of MIF is the casue.

40. Tx of luteal phase defect is first attempted with progesterone supplements; clomiphene citrate or hMG can be tried if progesterone gives no results.

41. Dx of luteal phase defect is confirmed by emdometrial biopsy.

42. beta-2 agonist may worsen the edema by decreased water clearance, tachycardia and increased myocardial workload.

43. Pregnancy is associated with an increase in total T4 (normal free T4), an increase in TBG, and a normal TSH. (extremely HY Q for USMLE)

44. Pseudocyesis is a rare condition in which a woman presents with nearly all signs and symptoms of pregnancy; however, ultrasound reveals a normal endometrial stripe. All patients with ~ need psychiatric evaluation.

45. Edema of the lower extremities in pregnancy is most commonly a benign problem. Pre-eclampsia should be suspected if the edema is associated with HTN or proteinuria, or if it is located on the hands and/or face. Know when to order Duplex. (reassurance in regular edema)

46. Bed rest and hydration are the first step in stopping uterine contractions in early stages of preterm labor and if these measures fail, tocolytics are indicated.

47. Total abodominal hysterectomy is the Tx of choice for uterine rupture. However, debridement and closure of the site of rupture can be considered in women with low parity or who desire more children.

48. Even though ACEIs /ARBs retard the progression of diabetic nephropathy, they are strictly contraindicated in pregnant women. Labetalol is a perfect substitute for enalapril in pregnant women with diabetic nephropathy. The goal is to bring the protein excretion to less than 500-1000 mg/day and blood pressure to less than 130/80 mmHg.

49. In chlamydial infection, empiric Tx of gonorrhea is not recommended. But in Gonococcal infections empiric Tx of Chlamydia is recommended. A single dose of azithromycin is Tx of choice for genital Chlamydia infections. 7 days of doxycycline can also be used for Chlamydia but because of the compliance issues single dose azithromycin is preferred. (treat patient and partner)

50. Clotrimazole cream is an effective Tx for Candidal vaginitis, and partner need not be treated.

51. In the ovulatory phase of the menstrual cycle, cervical mucus is profuse, clear and thin.

52. Neuroblastomas have been shown to be associated with exposure to phenytoin and other hydantoins in utero.

53. Think of trichotillomania in patients with uncontrollable urges to pull out their hair, resulting in alopecic patches.

54. The most appropriate test to confirm the Dx of intra uterine fetal demise (IUFD) is real time ultrasonography.

55. Reassurance and outpatient follow up is the std of care for threatened abortion.

56. In severe preeclampsia, the patient has to be evaluated and stabilized before management decisions are made. Bed rest and salt reduced diet are mandatory; patients with BP >160/110 mmHg necessitate antiHTN therapy. If the response to Tx is prompt and the patient is stabilized, the decision will then depend on the term: if the patient is at term or fetal lungs are mature, delivery must be done. In the opposite case, delivery can be delayed until 34 weeks’ gestation or until fetal lungs become mature.

57. Diabetes screening is performed between 24 and 28 weeks of gestation. The screening test is the 1 hour 50 gram oral glucose tolerance test. After 1 hour, if the blood glucose value is less than 140 mg/dL, the gestational diabetes is ruled out. If the blood glucose value is >140mg/dL, the 3 hour OGTT is used for confirmation.

58. Patients with Kallmann’s syndrome have a normal karyotype, and present with hypogonadotropic hypogonadism, eunuchoid stature and anosmia (can’t smell).

59. Down syndrome: a decrease in MSAFP and Estriol, and an increase in beta-hCG level is typical.

60. Asymmetrical IUGR is a result of a late exposition to the insult past 28 weeks and is characterized by a normal or almost normal head size and a reduced abdominal circumference. It is usually caused by maternal factors such as HTN, preeclampsia and chronic renal disease.

61. Abdominal circumference is the most effective parameter for estimation of fetal weight in cases of suspected IUGR.

62. In cases of IUGR, presence of oligohydramnios (amniotic fluid index:<7) is an indication for delivery.

63. MRKH (Mayer-Rokitansky-Kuster-Hauser syndrome) is the result of a mullerian agenesis. Patients have normal secondary sexual characteristics, amenorrhea, absent or rudimentary uterus, and a 46 XX karyotype.

64. Physical exercise can be beneficial during pregnancy and is helpful in maintaining a feeling of well being. It is usually recommended to keep it at the same level as before pregnancy.

65. OHSS (ovarian hyperstimulation syndrome) is a complication that occurs in 1-3% of patients under ovulation induction. OHSS may be complicated with ovarian torsion, ovarian rupture, thrombophlebitis and renal insufficiency.

66. Labor:
 First stage: latent phase(2-3CM)àactive phase (considered prolonged if exceeds 20 hours in the primiparous, and 14 hours in the multiparous.) Normal dilating rate: primiparous: 1 cm/hr, multiparous: 1.2cm/hr.
 Second stage:
 Third stage: starts with the delivery of the baby, and ends with the delivery of the placenta.
 Fourth stage: from delivery of the placenta until 6 hours postpartum. (the mother should be closely observed during this stage because of the risk of postpartum hemorrhage.

67. Screening cultures for GBS should be performed at 36-37 weeks gestation, and positive cases should be treated with penicillin G during labor, even in the absence of frank chorioamnionitis, thus reducing the risk of neonatal infections.

68. Epicural anesthesia may cause overflow incontinence as a transient side effect. It is best treated with intermittent catheterization.

69. PID Tx: inpatient Tx with cefotetan plus doxycycline.

70. Penicillin desensitization is considered to be the Tx of choice for the pregnant patients with syphilis and having penicillin allergy.

71. Asymptomatic bacteriuria occurs when the urine culture grows>100,000 CFU per ml of a single organism in an asymptomatic patient. It is important to promptly treat the infection to prevent progression to pyelonephritis in the pregnant patient.

72. Suction curettage is the Tx of choice for inevitable abortion.

73. Most of the breech presentations assume cephalic presentation by 34-weeks gestation. External cephalic version should not be tried unless the fetus has not assumed the cephalic presentation past 37 wks.

74. Once the Dx of missed abortion is confirmed, surgical evacuation (dilation and curettage) of the uterus has to be performed to avoid serious complications, such as DIC and sepsis and to minimize the extent of the hemorrhage.

75. In cases of post-term pregnancy (42-43 weeks), the NST and biophysical profile should be performed twice weekly and if there is oligohydramnios or if spontaneous decelerations are noted, delivery has to be accomplished.

76. Biophysical profile (BPP) is a scoring system designed to evaluate fetal well being. It is indicated in high risk pregnancies, or in case of maternal or physician concern, decreased fetal movements, or an NST. It includes the NST in addition to four parameters assessed by ultrasonography: 1/fetal tone; 2/fetal movements (3/10 min); 3/fetal breathing (30/10min); 4/amniotic fluid index, (5-20). Each of these five variables is given a score of two when present, and a score of 0 when absent or abnormal. A total of score of 8-10 is considered normal, and should only be repeated once or twice weekly until term for high risk pregnancies.

77. Primary dysmenorrheal: due to increased prostaglandins level. Tx: NSAIDs are highly effective, oral contraceptive pills inhibit ovulation and are also effective.

78. Candida vaginitis is not considered a STD and occurs in presence of risk factors such as DM, oral contraceptive pills, pregnancy and immunosuppressive therapy.

79. Atrophic vaginitis is treated with estrogen, this latter should be balanced with medroxyprogesterone (provera) if the uterus is still present. If the patient is not willing to use oral hormones, premarin (estrogen) cream twice daily may be used.

80. Septic abortion is managed with cervical and blood sampling, IV antibiotics and gentle suction curettage.

81. The increased in BP that appears before 20 weeks gestation is either chronic HTN or hydatiform mole.

82. Midplevic contraction which is indicated by prominent ischial spines is an important cause of arrest disorder of dilation (cervical dilation has been the same for over 2 hours, or the descent has not progressed for more than 1 hour). Causes of arrest disorder: hypotonic contractions, conduction anesthesia, excessive sedation, cephalopelvic disproportion or malpresentation.

83. In the presence of decreased fetal movements, fetal compromise should be suspected, and the best next step in management in such case is the performance of a non-stress test (NST).

84. An antepartum hemorrhage with fetal heart changes, progressing from tachycardia, to bradycardia, to a sinusoidal pattern occurring suddenly after rupture of membranes suggests the diagnosis of vasa previa.

85. Transvaginal ultrasonogram is more accurate than transabdominal one in diagnosing ectopic pregnancy, and should be performed when beta-hCG levels are below 1500-2000 mIU/mL.

86. Grave’s disease is the MCC of maternal hyperthyroidism. New onset, significant arrhythmias (not premature beats) in a pregnant patient could be from hyperthyroidism. TSH should be ordered as the next step.

87. Increased HCG seen with hyperemesis gravidarum, H. mole, and choriocarcinoma can cause hyperthyroidism during pregnancy too.

88. CVS (chorionic villus sampling) is the best test for detection of fetal chromosomal abnormalities in the first trimester of pregnancy (earliest)

89. Primary dysmenorrheal usually appears 6-12 months after menarche. NSAIDs are highly effective for Tx; OCPs inhibit ovulation and are also effective. They have high levels of prostaglandins than normal women.

90. Tx for superficial thrombophlebitis postpartum: local heat, bed rest, and NSIDs. Anticoagulants are indicated only when clot extends into the deep vein system.

91. Thrombophlebitis: a condition predisposed by the pelvic venous stasis usually present after delivery and occurs when there is a large inoculum of anaerobic pathogen on that level. It is suspected in the setting of a persistent spiking fever for 7 to 10 days postpartum, which fails to respond to antibiotic therapy. When suspected, heparin should be added promptly to antibiotics and maintained for 2 to 3 wks.

92. Patients with placental abruption in labor have to be managed aggressively to insure a rapid vaginal delivery. C. section is used only when there are obstetrical indications, or when there is a rapid deterioration of the state of either the mother or the fetus, and labor is in an early stage.

93. All patients with primary amenorrhea and high FSH levels need to have a karyotype determination.

94. If maternal serum AFP levels are found to be abnormal in a pregnant patient, the next step is ultrasonography.

95. Clomiphene citrate acts by binding to hypothalamic estrogen receptors and suppressing the inhibitory effect estrogen has on GnRH production.

96. Variable decelerations are secondary to umbilical cord compression.

97. OCP are first line agents in the Tx of endometriosis in young women desiring future fertility.

98. The risk factors for osteoporosis include: thin body habitus, smoking, alcohol intake, steroid use, menopause, malnutrition, family history of osteoporosis, and Asian or Caucasian race.

99. Laparoscopy is the gold std for the Dx of endometriosis

100. Lupus anticoagulant, seen in SLE patients, leads to recurrent abortions and thromboembolic disease. (antiphospholipid AB, such as lupus anticoagulant and anticardiolipin Ab, cause placental infarction leading to fetal growth restriction or death.) These Ab are also associated with thromboembolic disease.

101. NST: a test is considered reactive (good), and therefore normal, if in 20 minutes, 2 accelerations of fetal heart rate of at least 15 beats per minute above the baseline, lasting at least 15 seconds each, are noted. If less than 2 accelerations are noted in 20 mins, the test is said to be non-reactive (bad) and further assessment is required. The MCC of non reactive NST is sleeping baby; If acceleration (>15bpm for >15 sec) is noted after exposure to the vibroacoustic stimulus, the test is considered positive, and reassuring. If the NST is abnormal either BPP or CST should be considered.

102. Standard of care for threathened abortion: reassurance and outpatient follow ups.

103. OCPs have been shown to decrease the risk of ovarian and endometrial carcinoma. Breast cancer risk does not seem to change with their use. Besides HTN, OCP may be associated with other complications including thromboembolism, cerebrovascular disease, MI, gallbladder disease and benign hepatic tumors.

104. The initial tests to assess the ovulatory function are BBT and midluteal progesterone level.

105. Patients with severe placental abruption in labor have to be managed aggressively to insure a rapid vaginal delivery.
Risk factors of abruption placenta include:
 Maternal HTN
 Placental abruption in a previous pregnancy
 Trauma
 Rapid decompression of a hydramnios
 Short umbilical cord
 Tobacco use and cocaine abuse
 Folate deficiency

106. Secondary amenorrhea is relatively common in elite female athletes and results from estrogen deficiency. (excessive exercises, excessive weight loss)

107. Endometiral hyperplasia: cyclic progestins

108. Major complication of ovulation induction are multiple gestation and OHSS

109. Pap smear schedule: from 18 yo on, or onset of sexual activity: annually. After 3 normal results 1 year apart, perform the screening every 2-3 yrs.

110. Granulosa cell tumors produce excessive amounts of estrogen, and can present with precocious puberty in younger children and postmenopausal bleeding in elderly patients. This has to be differentiated from heterosexual precocious puberty or virilizing symptoms which are usually produced by excessive androgens.

111. In the presence antepartum hemorrhage, pelvic examination must not be done before ruling out placenta previa (ruled out by ultrasound). Placenta previa presents with painless third trimester vaginal bleeding.

112. Arrest disorder resulting from midpelvic contraction is treated with C. section. (low-transverese C. section)

113. The chancre characterizeds the primary stage of syphilis: it is a painless, indurated ulceration with a punched-out base and rolled edges. Serologic testing is not reliable at this stage and includes a high rate of false-negative, so Dx in the first stage is made via spirochete identification on dark field microscopy.

114. Behcet’s disease is a rare multisystem disorder with an autoimmune etiology and manifests with recurrent ulceration in the mouth and genital area associated with uveitis.

115. Metronidazole is the Tx of choice for Trichomonas vaginitis and should be given to both the patients and the partners.

116. Bacterial Vaginosis: Tx of choice is metronidazole cream or clindamycin cream (not orally). An STD caused by the bacteria Gardnerella vaginalis. Presents with a profuse ivory to gray malodorous discharge with a pH of 5 -6.5. When add KOH-fishy odor. Itching and burning are not usual, Identifying “clue cells” on a wet mount preparation of the discharge makes the Dx.

117. Clue cells: characteristic epithelial cells diffusely coated with the organism.

118. The MCC of abnormal AFP is gestational age error.

119. The major cause of death in eclampsia is hemorrhagic stroke.

120. Adenomyosis occurs most frequently in women above 40 and typically presents with severe dysmenorrheal and menorrhagia. The physical exam reveals an enlarged and generally symmetrical uterus.

121. Excessive use of oxytocin may cause water retention, hyponatremia and seizures (water intoxication).

122. A young woman who presents with a breast lump can be asked to return after her menstrual period for reexamination (which may reveal regression of the mass) if no obvious signs of malignancy are present.

123. 1° ovarian failure results in decreased estrogen, and increased FSH and LH (loss of negative feedback of estrogen).FSH elevation > LH, diagnostic

124. Metformin is indicated in PCO patients with impaired glucose tolerance. It helps in preventing Type 2 DM and correcting obesity, hirsutism, menstrual irregularity, and infertility.

125. Patients with PCO are at risk of developing type II DM and the best next step in the management once Dx ed is oral glucose tolerance test.

126. PCO patient usually have elevated DHEA levels. Although ACTH levels are normal in these women, ACTH stimulation test produces an exaggerated response of DHEA because of increased sensitivity of the adrenal gland to ACTH.

127. The MCC of mucopurulent cervicitis is : Chlamydia trachomatis. Besides, cervical ectopy created by OCPs may preferentially predisposed to colonization with C. trachomatis.

128. Tubo-ovarian abscesses are usually managed with triple antibiotic therapy. Drainage is indicated if there is no response to antibiotic therapy after 24 to 48 hours.

129. Raloxifene is a mixed agonist/antagonist of estrogen receptor. In breast tissue and vaginal tissue, it is an antagonist, whereas in bone tissue, it is an agonist and may be used to treat osteoporosis. It increases the risk of DVP.

130. Retinal hemorrhage is considered to be an extremely ominous sign of preeclampsia.

131. The most effective agent used for the Tx and prevention of seizures in eclampsia is: magnesium sulfate.

132. Depressed deep tendon reflexes is the earliest sign of magnesium sulfate toxicity which requires stopping of the magnesium sulfate infusion and administration of calcium gluconate.

133. Before 37 weeks of gestation, fetuses in breech presentation need no intervention as they may convert to vertex automatically.

134. Magnesium sulfate is the DOC of tocolysis.

135. Ovarian solid tumors discovered incidentally in a multiparous African-American pregnant woman: think of pregnancy luteoma. If in non pregnant woman, it is almost always malignant and demand immediate and aggressive evalution and Tx in all age groups.

136. In pregnant lady with toxoplasmosis (recognize contact with cats), Spiramycin is DOC in first trimester, however combination of pyrimethmine and sulfadiazine is preferred in second and third trimester. Elective termination of pregnancy is an option in 1st trimester.

137. In a pregnant lady in her first trimester, who presents with severe and persistent vomiting, one has to think of hyperemesis gravidarum. (measure HCG)

138. Voiding after intercourse has been shown to decrease the risk of UTI in sexually active females.

139. If Pap smear reveals a dysplasia, perform colposcopy. If it reveals an inflammatory atypia, repeat after 4-6 months.

140. Radiation levels used for Dx exams are not associated with teratogenicity.

141. Suppression of lactation: tight fitting bra and ice packs. (testosterone + estrogen will do it too. No bromocriptine for lactation suppression anymore

142. BUN, serum creatinine, and hematocrit are often decreased in pregnant women, and it is due to dilutional effect.

143. ABO antibodies: IgM, don’t cross the placenta
Rh antibodies: Ig G, do cross the placenta.

144. Emergency contraception: up to 72 hours after coitus. Ethinyl estradiol (estrogen) and levonorgestrol -progesterone(now and after 12 hours).

145. Testosterone level increased in female: androgen comes from ovary
DHEAs level increased in female: androgen comes from adrenal.

146. Maternal risk factors:
 Infection (Rubella virus, Listeria, CMV, and Treponema)
 Environmental factors: alcohol consumption, cigarette smoking can increase up to 4 times the risk. Advanced maternal age and low socioeconomic status. Women above 40 yo exceeds 10%, and can be as high as 50% in women above 45
 Systemic disorders: DM, hypothyroidism, SLE. Up to 40% of pregnancies in patients suffering from SLE are lost.
 Local maternal factors: cervical incompetence, uterine anomalies

Fetal factors:
Genetic abnormalities (MCC)

147. Diseases improve in pregnancy:
 Grave’s disease (due to the relative immunotolerance of pregnancy)
 Migraine (especially during 2nd trimester, avoid β-blockers, it decreases placental blood flow and cause growth retardation. In the 3rd trimester, imitriptyline or doxepin may be used in low dose)
 Peptic ulcer (pregnancy associated with increased prostaglandins which protect the gastric mucosal barrier.)
 Multiple sclerosis

148. Puerperal fever: is defined as an increase in temperature 38C for more than 2 consecutive days in the first 10 days of postpartum. It occurs in approximately 6-7% of women after vaginal delivery but its incidence is twice as high after a C. section. When thrombophlebitis is suspected, heparin is required.

149. Risk factors of gynecologic cancers:
 Endometrial cancer-HTN and DM
 Breast cancer- late childbirth and pauciparity
 Cervical cancer-smoking, HPV
 OCPs reduce the risk of ovarian and endometrial cancers, as well as benign breast disease
Hepatology

1. Liver founctions can be divided into three distinct categories:
 Synthetic (clotting factors, cholesterol, proteins)
 Metabolic (of drugs and steroids, including detoxification)
 Excretory (bile excretion)

2. All chronic hepatitis C patients with elevated ALT, detectable HCV RNA and histologic evidence of chronic hepatitis of at least moderate grade are candidates for antiviral therapy with interferon and ribavirin.

3. Tx for Chronic hepatitis B with persistently elevated ALT levels, detectable serum HBsAg, and HBV DNA: interferon or lamivudine.

4. HyperTG>1000 mg/dL can cause acute pancreatitis.

5. Characteristic of alcoholic hepatitis: AST: ALT>2 It is thought that this transaminase imbalance occurs in alcoholics secondary to a heptic deficiency of pyfidoxal-6-phosphate (a cofactor for ALT enzymatic activity). The absolute values of serum AST and ALT are almost always less than 500 IU/L in alcoholic liver disease. (Mallory bodies are often observed in severe cases, but are not specific for the Dx of alcoholic hepatitis)

6. Jaundice in the 3rd trimester of pregnancy should be evaluated specifically for those hepatic disorders associated with pregnancy. Marked pruritis and elevated of total bile acids are suggestive of intrahepatic cholestasis of pregnancy.

7. Benign intrahepatic cholestasis can develop after a major surgery in which hypotesion, extensive blood loss into tissues and massive blood replacement are notable.

8. Hydatid cysts in the liver are due to infection with Echinococcus granulosus.

9. Dubin-Johnson and Rotor syndrome are two familial disorders of hepatic bile system that result in conjugated hyperbilirubinemia. A dark granular pigment is present in the hepatocytes of patients with Dubin-Johnson syndrome, but is not seen in association with Rotor syndrome.

10. Acute pancreatitis is one of the conditions causing acute abdomen, which is managed conservatively (analgesics, IV fluids, nothing by mouth)

11. Cigarette smoking is the most consistent reversible risk factor for pancreatic cancer.

12. Risk factors for pancreatic cancers are:
 Male sex
 Increasing age (50yo)
 Black race
 Cigarette smoking
 Chronic pancreatitis
 Long-standing diabetes
 Obesity
 Familial pancreatitis
 Pancreatic cancer in a close relative

13. The following are not risk factors for pancreatic cancer:
 Alcohol consumption
 Gall stones
 Coffee intake

14. Tx for coagulopathy in patients with liver failure: fresh frozen plasma

15. Emphysematous cholecystitis is a common form of acute cholecystitis in elderly diabetic males. It arises due to infection of the gallbladder wall with gas-forming bacteria.

16. Conjugated hyperbilirubinemia is mainly because of intrahepatic or extrahepatic obstruction or congenital impaired hepatic excretion of bilirubin.(ultrasonogram will help)

17. Abdominal CT scan is a very sensitive and specific tool used in the Dx of pancreatic carcinoma.

18. Cholecystectomy is indicated in all patients with symptomatic gallstones who are medically stable enough to undergo surgery.

19. Asymptomatic gallstones should not be treated. Laparoscopic cholecystectomy is the Tx of choice for symptomactic gallstone disease.

20. Abdominal ultrasound is the best tool for the initial investigation of gallbladder pathology. While asymptomatic patients typically do not require Tx, laparoscopic cholecystectomy (not open cholecystectomy) is the Tx of choice for those with symptomatic gallbladder disease.

21. Acute acalculous cholecystitis is an acute inflammation of the gallbladder in the absence of gallstones, most commonly seen in hospitalized and severely ill patients.

22. Fatty liver (steatosis), alcoholic hepatitis and early fibrosis of the liver can be reversible with the cessation of alcohol intake. True cirrhosis (with regenerative nodules) is irreversible, regardless of alcohol abstinence.

23. Cholangiocarcinoma can complicate primary sclerosing cholangitis, especially in patients who smoke and have ulcerative colitis.

24. Ursodeoxycholic acid is a medication used to dissolve small radiolucent gallstones in patients with normal, functional gallbladders who are poor surgical candidates. However, this medication is very costly and associated with a high risk of relapse when therapy is halted.

25. Ursodeoxycholic acid is the most commonly used drug for primary biliary cirrhosis as it relieves symptoms and improves the transplant free survival time.

26. Post cholecystectomy pain most commonly occurs due to one of three reasons: common bile duct stone, sphincter of Oddi dysfunction, or functional causes.

27. PSC (primary sclerosing cholangitis) is caused by inflammation and fibrosis of the intrahepatic and extrahepatic biliary ducts. It is frequently associated with ulcerative colitis.

28. Insuline resistence plays a central role in the pathophysiology of non-alcoholic fatty liver disease by increasing the rate of lipolysis and elevation the circulating insulin levels.

29. Predominantly found in children who were given aspirin for virus-induced fever, Reye syndrome can lead to fulminant hepatic failure. Elevation of ammonia levels and transaminases, vomiting, and mental status changes are the more common clinical manifestations of this syndrome (extensive fatty vacuolization of liver)

30. Paracentesis can be used for both diagnostic and therapeutic purposes in patients with ascites.

31. Individuals who received blood transfusions before 1992 should be screened for hepatitis C. Those who received blood transfusion before 1986 should be screened for hepatitis B.

32. Wilson’s disease is Dx by decreased serum ceruloplamin, increased urinary copper, and Kayser-Fleischer rings seen on slit lamp examination of the eye.

33. Gallbladder carcinoma is a rare malignancy that most often arises in Hispanic and Southwestern Native American females who have a history of gallstones. It is typically Dx during or after cholecystectomy. No more Tx other than cholecystectomy is needed.

34. Hepatic adenoma is a benign tumor most often seen in young and middle-aged women who are taking OCPs. Severe intra-tumor hemorrhage and malignant transformation are the most dreaded complications.

35. Pain management in patients with chronic pancreatitis: perform an ERCP with removal of the stone and stent insertion.

36. ERCP is the investigation of choice for patients with recurrent pancreatitis with no obvious cause.

37. Studies have shown that patients with chronic hepatitis C who show persistently normal liver enzymes on multiple occasions have minimal histological abnormalities, therefore they do not need to be treated with interferon or antiviral drugs at this stage.

38. Non-selective beta blockers are used for the primary and secondary prevention of variceal bleeding in cirrhotic patients who have portal HTN with esophageal varices.

39. Choledochal cysts are congenital abnormalities of the biliary tree characterized by dilation of the intra and/or extra hepatic biliary ducts.

40. Alpha-1 antitrypsin deficiency is associated with panacinar emphysema and cirrhosis.

41. Most reliable way to distinguish chronic active from chronic persistent hepatitis: liver biopsy.

42. Lab tests in the evaluation of liver disease either assess liver functionality (eg, PT, bilirubin, albumin, cholesterol) or structural integrity and cellular intactness (eg, AST, ALT, gamma glutaryl transferase, alkaline phosphatase). A progressive decrease in transaminase levels signals either recovery from liver injury or that few hepatocytes are functional. (progression to fulminant hepatitis).

43. HCV RNA is the single most sensitive serological marker used in screening for HCV infection.

44. Orthotopic liver transplantation remains the only effective mode of Tx of fulminant hepatic failure and should be considered in any patient presenting with fulminant hepatic failure, regardless of the etiology.

45. In U.S.A., acute liver failure and fulminant hepatitis are most commonly due to acetaminophen toxicity. Remember that acute hepatic failure is defined as the development of liver failure within 8 weeks of hepatocellular injury onset. If hepatic encephalopathy is also seen, then the syndrome is described as fulminant hepatic failure.

46. Porcelain gall bladder is an entity usually diagnosed on an abdominal X-ray. The condition predisposes individuals to gall bladder carcinoma and requires resection.

47. Sudden onset right upper quadrant abdominal pain, fever, vomiting, and leukocytosis are highly suggestive of acute cholecystitis.(impaction of gallstone in cystic duct).

48. In evaluating the asymptomatic evaluation of aminotransferases, the first step is to take a thorough history to rule out the more common hepatitis risk factors (eg. Alcohol or drug use, travel outside of the country, blood transfusion, high risk sexual practices)

49. Hepatitis A vaccine or serum immune globulin should be given to all non-immunized travelers to endemic countries. If travel will occur in less than 4 weeks, serum immune globulin should be given. If travel will occur in greater than four weeks, hepatitis A vaccine should be given instead as it offers long-term protection.

50. Known risk factors for the development of pancreatic cancer include:
 family history
 chronic pancreatitis
 smoking
 DM
 Obesity
 Diet high in fat
(Alcoholism is not a risk factor for pancreatic cancer)

51. Checking for urinary excretion of bilirubin is an easy and effective way of determing wheter the cause of jaundice is conjugated or unconjugated bilirubin. The presence of biirubin in urine is indicative of conjugated hyperbilirubinemia. A more precise way is to do the Vandenberg test.

52. 95% of blood bilirubin is due to unconjugated fraction.
 The unconjugated fraction of bilirubin is insoluble as it is bound to the albumin and therefore cannot be filtered by the glomerulus and is not excreted in urine.
 The conjugated fraction is soluble in plasma, can be filtered by the glomerulus and excreted in the urine.

53. Anti-mitochondrial Ab are present in 90% of patients with primary biliary cirrhosis, a chronic liver disease characterized by autoimmune destruction of the intrahepatic bile ducts and cholestasis.

54. Alcoholism is the MCC of cirrhosis in the United States. Infection with HCV is the second MCC of cirrhosis in the U.S.

55. Tx for acute cholangitis:
 Supportive care
 Broad-spectrum antibiotics
 Biliary drainage with an ERCP

56. Budd Chiari syndrome or hepatic vein occlusion is most commonly associated with polycythemia vera and other myeloproliferative diseases.

57. Spironolactone is the diuretic of choice in treating cirrhotic ascites.

58. Common indications for TIPS:transjugular intrahepatic portalsystemic shunt
 Refractory cirrhotic hydrothorax.
 Refratory ascites (defined as diurectic resistant or diuretic refractory ascites)
 Recurrent variceal bleed not controlled by other minimal invasive means.
 Patients waiting for liver transplantation and needing portocaval shunts.

59. Tx of cirrhotic ascites:
 Diagnostic paracentesis, with examination for cell count and culture and ascetic albumin level. The latter allows calculation of the serum-ascites albumin gradient (serum albumin minus ascetic albumin) SAAG level >1.1 suggest portal HTN
 Salt-restricted diet, which may allow for complet resolution of the ascites without additional therapy in a subset of patients.
 Spironolactone, generally in conjunction with furosemide, for patients who do not improve with salt restriction. Spironolactone is an aldosterone-receptor antagonist and is the diurectic of choice in ascites secondary to cirrhosis
 Patients with massive ascites, regractory ascites, or respiratory compromise may benefit from early larg-volume paracentesis
 Recalcitrant ascites may require a transjugular intrahepatic portosystemic shunt (TIPS) procedure

60. Patients with cirrhosis develop ascites as a result of multiple mechanisms:
 Portal HTN
 Hypoalbuminemia
 Peripharl vasodilation
 Limited hepatic inactivation of aldosterone
 Increased aldosterone secretion (due to ↑ renin production)-this 2° hyperaldosteronism is considered most responsible for cirrhotic ascites)

61. Hepatic venogram or a liver biopsy is the diagnostic test of choic for the evaluation of congestive hepatomegaly secondary to hepatic vei occlusion (Budd Chiari syndrome)

62. Spotaneous bacterial peritoneal (SBP) should be suspected immediately in cirrhotic patients with ascites who develop fever or abdominal pain. The diagnosis of SBP is confirmed by a positive ascetic bacterial culture and an elevated ascetic fluid absolute neutrophil (PML) count of more than 250 cells/mm3

63. ERCP with sphincterotomy is the Tx of choice for sphincter of oddi dysfunction.

64. Endoscopy is the preferred screening tool for esophageal varices in patients with cirrhosis.

65. Entamoeba histolytica is a protozoan, which can cause amebic liver abscess. Remember the Mexico trip. Amebic abscess is characterized by an “anchovy paste” collection in the liver. Tx is with oral metronidazole.

66. Gallstones and alcoholism are the two most common causes of acute pancreatitis in the United States. Abdominal ultrasound should be used to search for gallstones in all patients experiencing a first attack of acute pancreatitis. Abdominal CT scan is used to confirm the Dx. of acute pancreatitis.

67. The first step in the Tx. of acute variceal bleeding is to establish vascular access with two large bore intravenous needles or a central line.

68. Chronic liver disease or cirrhosis from almost any cause is a risk factor for hepatocellular cancer. Hepatocellular cancer is responsible for 30% of deaths in patients with hemochromatosis

69. Hemochromatosis is an autosomal recessive disorder characterized by increased skin pigmentation, diabetes, cirrhosis and arthralgia in the later stages.

70. About 10% of patients on INH (isoniazid) develop a mild elevation of aminotranserases within first few weeks of the Tx. However, this elevation of aminotranserases returns to normal despite continued use of INH in most of the patients. (so do nothing except for regular follow ups).

71. Uncomplicated pseudopancreatic cysts < 5 cm should be observed for 6 weeks before any further therapeutic intervention.

72. Hepatic encephalopathy is a central nervous system complication of liver failure secondary to accumulation of ammonia in blood because of inability of liver to detoxify ammonia into urea.
Pathogenic factors involved in the development of hepatic encephalopathy
 Accumulation of ammonia in blood
 Production of false neurotransmitters
 Increased sensitivity of the CNS to inhibitory neurotransmitters like GABA.
 Zinc deficiency

Some of the precipitating factors for hepatic encephalopathy:
 High protein diet
 Alkalosis
 Diuretic therapy
 Extensive gastro intestinal bleeding
 Narcotics, hypnotics, and sedatives
 Medication containing ammonium or amino compounds
 High volume paracentesis
 Hepatic or systemic infection
 Portocaval shunts

Hepatic encephalopathy is characterized by
 reversal of sleep cycle,
 asterixis,
 progressive coma,
 characteristic delta waves on EEG.

73. Tx for acute hepatic encephalopathy: protein free diet, lactulose, neomycin
Hepatic encephalopathy is a reversible condition. Tx principles:
 During acute attack all the dietary protein should be withheld. Later on patient should be started on low protein diet of 20g/day.
 Give oral or rectal lactulose. Bacterial action on lactulose results in acidification of the colon contents, which converts the absorbable ammonia into nonabsorbable ammonium ion (ammonia trap)
 Oral neomycin a nonabsorbable antibacterial agent kills the colonic bacteria producing ammonia

74. Risk factors for non-alcoholic steatohepatitis includeLliver biopsy reveals macrovesicular steatosis, polymorphonuclear cellular infiltrates,necrosis)
 Obesity
 DM
 Hyperlipidemia
 Total parenteral nutrition
 The usage of certain medications

75. One of the known complications of ERCP is an iatrogenic biliary enteric fistula characterized by the presence of air in the biliary tree. Other complications include
 Iatrogenic biliary enteric fistula
 pancreatitis,
 biliary peritonitis,
 sepsis,
 hemorrhage,
 adverse effects from the contrast, sedative, or anticholinergic agents.

76. Hyperestrogen in cirrhosis leads to (due to decreased its metabolites)
 Gynecomastia
 Testicular atrophy,
 Decreased body hair,
 Spider angiomas
 Palmar erythema

77. Progression of liver disease in patients with chronic hepatitis C is relatively more rapid in following conditions:
 Male sex
 Acquiring infection after age of 40
 Longer duration of infection
 Co infection with HBC or HIV
 Immunosuppression
 Liver co mobidiities like alcoholic liver disease, hemochromatosis, alpha-1 anti trypsinase deficiency

Factors in chronic hepatitis C patients associated with high rates of liver fibrosis:
 Male gender
 Acquiring infection after age 40
 Alcohol intake: in any amount can hasten the progression of fibrosis in patients with chronic hepatitis C

78. Vitiligo is characterized by skin depigmentation of unknown etiology. Associated with other autoimmune conditions such as pernicious anemia, hypothyroidism, Addison’s disease, type I DM. Patients often have Ab to melanin, parietal cells, thyroid, or other factors.

79. Chronic hepatitis C is associated with number of extra hepatic complications like:
 Cryoglobulinemia
 B cell lymphomas
 Plasmacytomas
 Autoimmune disease like Sjogren’s syndrome and thyroiditis
 Lichen planus
 Porphyria cutanear Tarda
 Idiopathic thrombodytopenic purpura (ITP)
 Membranous glomerulonephritis

80. The decision to treat a patient of chronic hepatitis C depends on :
 Natural history of disease
 Findings of liver biopsy
 Stage of the disease
 The levels of liver enzymes
 Presence of HCV RNA
 Efficacy and adverse effects of the drugs in the patient
Psychiatry

1. When child abuse is suspected, the following steps should be performed:
 Complete physical examination
 Radiographic skeletal survey, if needed
 Coagulation profile ( if multiple bruise are present)
 Report to child protective services
 Admit to hospital if necessary
 Consult psychiatrist and evaluate family dynamics

2. Patients who are extremely agitated, psychotic, or manic should be initially managed with haloperidol.

3. Lithium exposure in the 1st trimester of pregnancy causes a twenty-fold increase in the risk of Ebstein’s anomaly, a cardiac malformation. In the later trimester, goiter and transient neonatal neuromuscular dysfunction are of concern.

4. Always have a high index of suspicion for physical/sexual abuse in children (especially females) with sudden behavioral problems, families with unstable economic backgrounds, or parents with a history of drug/alcohol abuse.

5. Altered levels of the neurotransmitter serotonin play an important role in the development of obsessive-compulsive disorder.

6. The Tx for bulimia nervosa include
 pharmacotherapy (SSRI antidepressants),
 cognitive therapy,
 interpersonal psychotherapy,
 family therapy,
 Group therapy.

7. For the general population, the lifetime risk of developing bipolar disorder is 1%. However, an individual with a first-degree relative who suffers from bipolar disorder has a 5-10% risk of developing the condition in his lifetime.

8. Always rule out hypothyroidism in patients who present with symptoms of depression. (order blood test for TSH)

9. Pyromania is characterized by intentional, repeated fire setting with no obvious motive. Although a history of arson may be documented in individuals with conduct disorder, other features will be present as well. (e.g. lying, theft, cruelty).

10. Clozapine’s serious side effect: agranulocytosis.

11. In severely depressed patients with active suicidal thoughts, antidepressants should be started immediately. This is also true for depressed patients suffering from terminal illnesses.

12. Marijuana ((Cannabis) abuse causes behavioral changes and 2 or more of the following symptoms: dry mouth, tachycardia, increased appetite, or conjunctival injection.

13. Tx of choice for social phobia: assertiveness training, which is a component of cognitive-behavioral psychotherapy (CBT). SSRI drugs are the 1st line drugs in the management of these patients, either alone or in combination with CBT.

14. Odd behavior, magical thinking, and a lack of close friends are common features of schizotypal personality disorder. While individuals with schizoid personality disorder also lack close friends and have a restricted range of emotional expression, they do not have eccentric behavior or odd thinking. Those with avoidant personality disorder want friends but fear ridicule.

15. All depressed patients should be screened for suicidal ideation. Suicidal patients who can’t contract for safety should be hospitalized for stabilization.

16. Patients with somatization disorder benefit from regularly scheduled appointments intended to reduce the underlying psychological distress.

17. Cocaine and amphetamine intoxication present in a similar manner, but psychosis is more commonly associated with amphetamine use. Common symptoms of stimulant intoxication include dilated pupils, HTN, and tachycardia.

18. Cocaine abuse should be suspected in an individual presenting with weight loss, behavioral changes, and erytham of the turbinate and nasal septum (hallmark).

19. Sleep terror disorder is characterized by multiple episodes of sudden, fearful waking at night that cause the patient to be highly agitated and inconsolable. Later, the details of the event can’t be recalled. The disorder typically occurs in children ages 3 to 8 years, and is more common in boys than girls.

20. Patients with sleep terror disorder report complete amnesia for the event. In contrast, patients with nightmare disorder can provide detailed descriptions of their dreams.

21. Unlike patients with anorexia nervosa, patients with bulimina nervosa maintain a normal body weight and are not amenorrheic.

22. The antidepressant of choice in depressed patients suffering from sexual dysfunction (whether as a side effect of medication or as a pre-existing condition) is bupropion.

23. Bupropion has been found to be effective in treating major depression, attention deficit disorder, and the craving and withdrawal symptoms associated with smoking cessation. Bupropion may be used in conjunction with nicotine replacement agents, but such a combination necessitates frequent monitoring of BP because of the risk of developing emergent HTN.

24. In most states, adolescents do not require parental consent when they seek a physician’s care for:
 Contraception
 Pregenancy
 STD Tx
 Drug abuse
 Mental health concerns
If a rape is suspected, the doctor is obliged to report his findings to
local law enforcement and child protective services.

25. Hirschsprung disease is considered life-threatening in a neonate. Abdominal radiograph and barium emema are necessary.

26. Large ears, long face with a prominent jaw, voice is high pitched, mental retardation--------Fragile X syndrome.-can be taught some basic self-care skills and perform simple tasks with close supervision.

27. Propranolol is the DOC for treating performance-related anxiety.

28. Childhood disintegrative disorder is a rare pervasive developmental disorder that occurs more commonly in males. It is characterized by a period of normal development for at least two years, followed by a loss of previously acquired skills in at least two of the following areas: expressive or receptive language, social skills, bowel or bladder control, or play and motor skills.

29. Schizophrenic patients have increased ventricular size as shown on CT scan of the brain.

30. Circadian rhythm sleep disorder is a likely diagnosis in a patient with insomnia who often travels between different time zones.

31. Benzodiazepines are used for the acute Tx of panic attacks. An SSRI or TCA should be substituted for long-term symptom relief. (Diazepam, lorazepam, triazolam, oxazepam, midazolam, chlordiazepoxide, valium) Facilitate GABAA action by ↑ Cl- channel opening. Contraindicated in patients with breath-related sleep disorders. (panic attack-hyperventilation-respiratory alkalosis-numbness and tingling of the lips)

32. Benzodiazepines may cause sudden onset memory disturbance or other cognitive impairment in the elderly and should therefore be used with extreme caution in this patient population.

33. Olanzapine, an atypical antipsychotic, has been demonstrated to lead to weight gain in many patients with schizophrenia. It affects the 5HT2 serotonin receptor in the brain, which is also thought to control satiety, in addition to decreasing auditory hallucinations and controlling mood symptoms.

34. The likelihood a schizophrenic patient will relapse is decrease if conflicts and stressors in the home environment are kept to a minimum.

35. A physician is authorized to provide emergent life-saving Tx to the unconscious patient. This remains true even if the patient’s spouse requests that the Tx not be given because it contraindicts a belif system.

36. The extrapyramidal symptoms (EPS) frequently seen with typical antipsychotics include dystonia, Parkinsonism, tardive-dyskinesia, akathisia, and neuroleptic malignant syndrome. The atypical antipsychotic medication most likely to cause EPS is risperidone. TD is characterized by involuntary perioral movements such as biting, chewing, grimacing, and tongue protrusions.

37. Patients who develop dystonia from the use of antipsychotics should be treated with benztropine or diphenhydramine.

38. A phobia is a fear related to a specific object or experience, and is best treated with cognitive behavioral therapy that includes repeated exposure to the object or experience.

39. Low doses of TCAs such as imipramine or desmopressin can be used to treat enuresis.

40. When breaking bad news, physicians should begin with exploratory general statements such as “How are you feeling right now?” to help the patient feel at ease.

41. If a patient presents with refractory mania despite therapy with a mood stabilizer (liuthium, for example), a urine toxicology screen and mood stabilizer drug levels should be obtained in the initial evaluation.

42. Older individuals may frequently awaken from sleep and spend less time sleeping overall. These changes are considered a normal part of aging.

43. Bereavement is the normal reaction to the loss of a loved one. Symptoms are similar to those seen with major depression but are less intense and usually significantly taper within two months.

44. First-line therapy for major depression is prescription of a SSRI (eg. Sertraline).

45. When treating a single episode of major depression, Tx should be continued for another 6 months following the patient’s response. If multiple episodes occur, maintainece Tx should be continued for a longer period of time.

46. Side effect of olanzapine: weight gain

47. Vaginismus is a voluntary spasm of the perineal musculature that interferes with sexual intercourse.

48. Bispirone is the DOC for generalized anxiety disorder.

49. Pathological gambling is an individual with a chronic history of gambling and a seeming inability to stop. Significant financial losses or damaged relationships are common consequences of this behavior.

50. Contraindication to the use of bupropion: a history of seizure disorder. (epilepsy)

51. The dissociative disorders are characterzed by forgetfulness and dissociation. Dissociative fugue is the only condition within this group that is associated with travel.

52. The most concerning MAOI side effects include hypertensive crisis and serotonin syndrome. The HTN crisis is a malignant HTN caused when food rich in tyramine (wine or cheese) are ingested by an individual taking an MAOI. Serotonin syndrome is caused by the interaction of an MAOI with an SSRI, pseudoephendrine, or meperidine. The syndrome is characterized by hyperthermia, muscle rigidity, and altered mental status. Therefore fluoxetine is a contraindicated medication for MAOI (eg. Phenelzine).

53. If a patient’s family disagrees with his living will and demands care that contradicts the patient’s written wishes, the best initial step is to discuss the matter with the family. If a discussion fails to resolve the situation, then the hospital’s ethics committee should be consulted.

54. Lithium should not be given to patients with renal dysfunction. Valproate or carbamazepine are suitable alternatives for the long-term Tx of bipolar disorder in this patient group.

55. Lithium and valproic acid are first-line tx of bipolar disorder. Carbamazepine is an occasionally used alternative.

56. Borderline personality disorder is characterized by splitting, unstable relationships, and impulsivity. Angry outbursts and suicidal gestures are common.

57. A pregnant woman has the right to refuse Tx, even if it places her unborn child at risk.

58. Somatization disorder is characterized by multiple recurrent somatic complaints that have persisted for several years and that have been evaluated by healthcare providers to no avail. The condition presents before the age of 30 and most frequently occurs in females.

59. Methylphenidate (a mild CNS stimulant) is frequently used to treat ADHD. Common side effects include nervousness, decreased appetite, weight loss, insomnia, and abdominal pain.

60. Altruism: involves minimizing internal fears by serving others.

61. Severe symptoms of Tourette syndrome are best treated with typical antipsychotics such as haloperidol or pimozide.

62. Adjustment disorder results in marked distress in excess of what is expected from exposure to the triggering stressor. (usually within 3 months, rarely lasts 6 months)

63. PCP (phencyclidine) and LSD (Lysergic acid) intoxication present similarly, but agitation and aggression occur more often in patients using PCP. Visual hallucinations and intensified perceptions are hallmarks of LSD use.

64. One of the MC side effects of electroconvulsive therapy (ECT) is amnesia.

65. The Tx of choice for adjustment disorder is cognitive or psychodynamic psychotherapy.

66. Kleptomania is characterized by an inability to resist the impulse to steal objects that either are of low monetary value or are not needed for personal use. The condition is more prevalent in females and is occasionally associated with bulimia nervosa.

67. Most antidepressants must be taken for 4-6 weeks before they provide symptomatic relief.

68. Abrupt cessation of alprazolam, a short-acting benzodiazepine, is associated with significant withdrawal symptoms such as generalized seizures and confusion.

69.

70. Differentiation of Delirium and Dementia:
 Onset: Acute in delirium vs. gradual in dementia
 Consciousness: impaired in delirium vs intact in dementia
 Course: fluctuating symptoms in delirium vs. progressive decline in dementia
 Prognosis: reversible symptoms in delirium vs. irreversible in dementia
 Memory impairment: global in delirium vs remote memory spared in dementia.

71. Individuals with schizoid personality disorder are socially detached and aloof but do not have bizarre cognition. Those with schizotypal personality disorder are also socially detached but typically demonstrate “magical thinking” and a more eccentric thought process. Individuals with shcizophreniform disorder have full-blown schizophrenic symptoms (eg. Hallucinations, delusions) that have been present for one to six months.

72. Atypical antipsychotics such as risperidone are particularly effective in the Tx of negative symptoms of schizophrenia.

73. Sertraline is an SSRI used for treating depression.

74. Chlordiazepoxide is predominantly used for the Tx. of alcohol withdrawal.

75. Vascular dementia (also called multi-infarct dementia) is a Dx to consider in patients given old age and the finding of a carotid bruit. However, the absence of any focal neurological signs should also be present.

76. Suspect herorin withdrawal in patients with papillary dilation, rhinorrhea, muscle and joint aches, abdominal cramping, nausea, and diarrhea. The symptoms are severe and out of proportion to physical findings. Tx. clonidine.

77. Fantasy is an immature defense mechanism that substitutes a less disturbing view of the world in place of reality as a means of resolving conflict.

78. Antisocial personality disorder is diagnosed in those aged 18 or older who engage in illegal activities and disregard the rights of others. These individuals display evidence of conduct disorder as minors.

79. Patients have the legal right to obtain copies of their medical records.

80. Acute distress disorder and post-traumatic stress disorder present with identical symptoms (recurrent nightmares and flashbacks, potential memory loss, and exaggerated startle response). Acute distress can last no more than 4 weeks, however, while PTSD lasts longer than 4 weeks.

81. Avoid benzodiazepine use in patients with PTSD. Tx of PTSD is best accomplished with a combination of SSRIs and exposure or cognitive therapy.

82. Alcohol withdrawal is best treated with long-acting benzodiazepines such as chlodiazepoxide (Librium). Withdrawal symptoms should be correlated with the time of the last alcoholic drink

83. . Manic episode (mnemonic: DIGFAST)
 Distractibility
 Insomnia
 Grandiosity
 Flight of ideas
 Activity increased
 Speech (extremely talkative)
 Thoughlessness (high risk behavior)


84. Remember the common findings in anorexic patients (important):
 Osteoporosis
 Elevated cholesterol and carotene levels
 Cardiac arrhythmias (prolonged QT interval)
 Euthyroid sick syndrome
 Hypothalamic-pituitary axis dysfunction resulting in anovulation, amenorrhea, and estrogen deficieny
 Hyponatremia secondary to excess water drinking is often the only electrolyte abnormality, but the presence of other electrolyte abnormalities indicates purging behavior.

85. Physical abuse should be suspected in a woman with multiple bruises and frequent injuries. In these cases, the following steps should be carried out:
 Confront the patient gently, in a non-judgmental way.
 Assure her about confidentiality.
 Emphasize that she should not allow abuse to happen to her
 Ensure safety of the patient and children, if any.
 Ask her if she has a plan to escape.
 Suggest talking to a women’s group dealing with these problems.
 Assure her of your continuing support.

86. The following signs and symptoms are indications that psychiatric hospitalization is necessary:
 Homicidal ideation
 Suicidal ideation
 Grave disability
 Gross disorganization
 Agitated
 Threatening behavior
 Severe symptoms of substance intoxication or withdrawal


87. Tx options for narcolepsy include:
 Scheduled daytime naps
 Psychostimulants (eg. Modafinil, methylphenidate), or
 A combination of antidepressant and psychostimulant

Surgery

1. Hypotension not responsive to fluid administration is suggestive of ongoing blood loss and such patients with abdominal trauma need an immediate exploratory laparotomy.

2. Vital signs, hemodynamic stability, and need for blood transfusion are important determinant for surgical v/s non-surgical management of patient with splenic trauma.

3. Choledocholithiasis symptomatic of biliary colic and without any systemic toxicity is treated with analgesic and spasmolytics and elective surgery is done at a later date.

4. Tetanus prophylaxis depends upon whether the patient had his 3 doses or not. If yes, it depends upon when did he have it. For any wound, clean or minor, patients should be administered tetanus toxoid if the last dose was administered 5 years ago. However, if the patient has clean wound & he has previously received 3 or more doses, but received the last dose 10 years ago, then again he should receive the tetanus toxoid.

5. Transient submandibular gland swelling may occur during feeding due to partial obastruction of its duct and further evaluation is required if swelling is persistent or recurrent.

6. In a young individual who present with a fleshy immobile mass on his hard palate, the most likely Dx is torus palatinus. No medical or surgical therapy is required.

7. Technetium pertechnetate scintigraphy is the best diagnostic test for Meckel’s diverticulum.

8. Colonoscopy is difficult and rarely performed in settings of active bleeding. If the bleeding stops, however, it should be done.

9. Angiodysplasia may be seen as cherry-red spots that may be coagulated.

10. Labeled erythrocyte scintigraphy, although not a very precise study, could be helpful to define the site of bleeding.

11. The diaphragmatic rupture is more common on the left side, since the right side is protected by the liver. The leakage of intraabdominal contents into the chest causes compression of the lungs and mediastinal deviation. Elevation of the hemidiaphragn on the chest X-ray may be the only abnormal finding. Sometimes, there may be evidence of small bowel in the thoracic cavity.

12. Approximately 5-10% of unconscious patients who present to the ED as result of a motor vehicle accident or fall, have a major injury to the cervical spine. One third of injuries occur at the level of C2, and one half of the rest occur at the level of C6 or C7. Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction, C1 or C2.

13. It is important to rule out a fracture or dislocation of cervical spine as the first priority because of grave consequences of missing a cervical spine injury.

14. Cast immobilization is recommended in the tx of all non-displaced scaphoid fractures (fractures < 2mm displacement and no angulation).

15. Varicose veins with incompetent perforators may present with non-pitting edema, medial leg ulcers, fatigue, and a brown discoloration at the ankles. The MC symptoms from varicose veins are fatigue, tiredness in the leg, aching, swelling and occasional cramps at night.

16. History of a traumatic event and presence of crunching are compatible with fracture of metatarsal.

17. Anterior cord syndrome is commonly associated with burst fracture of the vertebra and is characterized by total loss of motor function below the level of lesion with loss of pain and temperature on both sides below the lesion and with intact proprioception.

18. Central cord syndrome is characterized by burning pain and paralysis in upper extremities with relative sparing of lower extremities. It is commonly seen in elderly secondary to forced hyperextension type of injury to the neck. (rear end collision)

19. central cord syndrome may result from hyperextension injuries and is characterized by weakness that is more pronounced in the upper extremities than in the lower extremities.

20. Brown Sequard syndrome is acute hemisection of cord and is characterized by ipsilateral motor and proprioception loss and contra lateral pain loss below the level of lesion. (should be suspected when there is unilateral paralysis.

21. Posterior cord syndrome: is usually associated with signs and symptoms of posterior columns.

22. Patients with mild head injury can be discharged with a “head sheet” if they have a normal CT scan.

23. Axillary nerve is the most commonly injuried nerve in anterior dislocation of shoulder. (symptoms:numbness over the lateral aspect of the right shoulder).

24. Acute disk prolapse will be characterized by severe radicular pain with positive straight leg raising test.

25. Cauda equine syndrome is characterized by paraplegia, variable sensory loss, urinary and fecal incontinence.

26. With posterior dislocation of the shoulder (Tonic clonic seizures may result in posterior dislocation of the shoulder joint), patient shows internally rotated arm, inability for external rotation and intact sensations and reflexes.

27. The 2nd part of the duodenum is the most commonly injured portion of the duodenum and needs a high degree of suspicion for Dx, especially in the presence of retroperitoneal air or blunting of the right psoas shadow on X-ray. (*Remember the bicycle injury*)-the 2nd portion of the duodenum, being retroperitoneal and the least mobile, is most commonly injured.

28. Duodenal injuries are best diagnosed with CT scan of the abdomen with oral contrast or an upper GI study with gastrograffin, followed by barium, if necessary.

29. Muffled heart sounds are common in severe hypovolemia and do not necessarily indicate pericardial fluid. Moreover, cardia tamponade is unlike without distention of the neck veins.

30. Whenever a patient is in decompensated hemorrhagic shock most probably from rupture abdominal organ bleeding, next step is diagnostic peritoneal lavage or abdominal ultrasound once the resuscitative efforts are begun.

31. Bee and hymenoptera stings account for more deaths in the U.S. than any other envenomation. Anaphylactic shock should be promptly treated with subcutaneous epinephrine. Then remove the bee stinger ASAP.

32. Acalulous cholecystitis occurs in critically ill patients and imaging studies show diagnostic findings of thickening of the gall bladder wall and presence of pericholecystic fluid.

33. Diverticulosis is the MCC of bleeding in an elderly patient. Chronic constipation is the single most predisposing factor to develop diverticulosis.

34. Whenever an open wound fails to heal after a prolonged period, biopsies have to be obtained to ensure that the ulcer has not degenerated into a squamous cell carcinoma. These ulcers are known as Marjolin’s ulcers.

35. A long-standing cycle of repeated healing and breaking down my eventually give rise to a squamous cell carcinoma of the skin, know as Marjolin’s ulcer. Biopsy is need for diagnosis.

36. In stable patients with abdominal trauma, CT scan with contrast is the single best study to evaluate solid organ damage.

37. Nosocomial infections are defined as infections acquired as a result of hospitalization, and they manifest at least 48 hours after hospitalization. A urinary tract infection is the MC type of nosocomial infection; however, it is easy to treat and has the best prognosis. *The case didn’t specify the source or cause of infection. That means you have to select the MC nosocomial infection.*

38. Widening of the mediastinum: Mediastinittis, hemorrhage, large pericardial effusion.

39. Recognize the mediastinitis, a post CABG (coronary artery bypass grafting) complication by systemic signs of inflammation, chest pain, breathlessness and mediastinal widening on chest X-ray; it is a serious condition and it requires thoracotomy for debridement and drainage + antibiotics.

40. Mastitis associated with breast-feeding is treated with antibiotics and continuation of breast-feeding from the affected breast is recommended.

41. When blunt chest trauma occurs with a widened mediastinum on chest x-ray, aortic injury must be suspected. Either a CT scan or ECHO will be diagnostic.

42. Ludwig’s angina (rapidly spreading bilateral cellulites to the submaxillary and sublingual glands) is infection of the submaxillary and sublingual glands. The source of the infection is from an infected tooth.

43. Recognize the classic presentation of a tension pneumothorax. Remember the hypotension, shortness of breath, jugular venous distension and decreased breath sound.

44. Absent bowel sounds with gaseous distention of both small and large bowel indicates paralytic ileus. (secondary to retroperitoneal hematoma, dropped hematocrit, that affects paraspinal ganglia.)

45. Dumping syndrome is common postgastrectomy complication. The symptoms usually diminish over time and dietary changes are helpful to control the symptoms. In resistant cases, octreotide should be tried. Reconstructive surgery is reserved for intractable cases.

46. Pneumomediastinum: may accompany a spontaneous pneumothorax: the air from ruptured alveoli or bulla dissects along the vessels into the hilum and mediastinum. Pneumomediastinum associated with tension pneumothorax usually responds to chest tube drainage and it does not usually require surgical decompression. (Tx: chest tube + observation)

47. Heroin overdose: deep coma, bradypnea, hypotension.

48. Clavicle is one of the most commonly fractured bones and is treated with figure of eight bandage.

49. After an AAA repair (abdominal arterial aneurysm), diarrhea with blood in the stools should raise the suspicion of ischemic colitis. If the CT scan is inconclusive a sigmoidoscopy/colonoscopy is recommended.

50. Oratracheal intubation and surgical cricothyroidectomy are preferred way to establish an airway in apneic patient with head injury (who is unconscious).

51. If tachyneic conscious patient, to secure the air way, chin lift with face mask.

52. Aortic rupture should be ruled out in all the chest trauma patients with hypotension. Screening for aortic trauma can best be done with a chest X-ray. Confirmation test is angiography or spiral CT scan.

53. Pain on passive extension of fingers is the most sensitive physical sign of compartment syndrome.

54. After placement of a central line, a chest x-ray must be obtained to ensure proper line placement. A central line is an intravenous catheter or IV placed into a large vein.

55. Where is a central line placed:
 Subclavian vein (chest)
 Femoral vein (groin)
 Jugular vein (neck)

56. Percutaneus drainage is the standard Tx approach for pelvic abscess.

57. Penile fracture is a medical emergency and needs prompt surgical repair. But should be always be preceded by a retrograde urethrogram to rule out a urethral injury which is very common with penile fracture.

58. Circumcision is the treatment of choice for paraphimosis.

59. Atelectasis is not uncommon after abdominal surgery and can be responsible for early postoperative fever.

60. Fever occurring in the first 1-2 days after surgery is usually due to atelectasis.

61. Treatment of acute subdural hematoma is essentially conservative if no midline shift is present on CT scan.

62. The direction of force that produces a fracture often predicts the possibility of other less obvious injuries. The vertical fall depicted in this vignette classically results in compression fractures of thoracic and lumbar vertebral bodies. (Do X-ray films of thoracic and lumbar spine)

63. Acute epidural hematoma has a classic presentation of unconsciousness followed by a lucid interval followed by gradual deterioration of consciousness. CT scan is diagnostic and it show a biconvex hematoma.

64. Hypoventilation is a frequent occurrence after abdominal hernia repair and early physiotherapy and respiratory exercises are mandatory.

65. Neutralization of gastric pH should be considered for severely ill patients to prevent gastric stress erosions. Gastric pH measured through nasogastric tube should be 5 or above.

66. Patients with head injury should be triaged according to the Glasgow Coma Scale (GCS): can’t tell if there is ICP by GCS.
Eye opening:
Spontaneous 4
To verbal command 3
To pain (or shout) 2
None 1

Verbal response:
Oriented 5
Confused 4
Inappropriate 3
Incomprehensible sounds 2
None 1

Motor response:
Obeys 6
Localization 5
Flexion 4
Abnormal flexion (Decorticate) 3
Extension (Decerebrate) 2
None 1
Total:15

67. Clinical signs of increased intracranial pressure (ICP) include:
 Papillary findings like bilaterally dilated pupils, anisocoria, or non-reactivity of one or both pupils.
 Flaccidity or decerebrate or decorticate motor posturing, or progressing neurological deterioration not attributable to other causes.
 papilledema

67. Intubation with mechanical ventilation and administration of IV fluid, analgesics and sedatives should be done in all the patients with severe head trauma as indicated by GCS.

68. The most rapid method available to lower ICP is hyperventilation to lower PaCO2, which leads to decreased cerebral blood flow and ICP

69. When suspecting pulmonary embolism, order an arterial blood gas first. Confirmation is by ventilation-perfusion scan.

70. The rule of abdominal gunshot wounds is simple: an exploratory laparotomy should be done in every case, before there are obvious signs of either bleeding or peritonitis.

71. A crescent-shaped hematoma: seen in acute subdural hematoma

72. A biconvex, lens-shaped hematoma: seen in acute epidural hematoma.

73. Radial nerve is the MC injured nerve in association with fracture of midshaft humerus.

74. Child abuse is very likely in following conditions:
 Scalds and burns on feet or buttocks indicative of forceful immersion.
 Circular burn marks indicative of cigarette burns.
 Incoherent story of the event.
 Delay in seeking care after the injury.
 Torsional fracture of lower limbs
 Bruises and fractures in various stage of healing. Bruising on normally non bruised areas like thighs, abdomen, cheeks and genitalia.
 Subdural hematoma and retinal hemorrhages in very young infant

What to do in a suspected child abuse?
 Admit the patient to ensure further safety
 Skeletal survey is mandatory in children less than 2 yo
 For children older 2 yo a decision is to be made depending on the strength of suspicion.
 A thorough physical examination to look for other associated injuries should also be done.
 Report to child safety services.

75. Mesenteric thrombosis (arterial or venous) or non-occlusive ischemia can lead to massive fluid sequestration in the bowels. Hypovolemic shock and hemoconcentration usually ensue. The extreme elevation of CK suggesting massive ischemia is characteristic. The intensive abdominal pain out of proportion to the physical findings and diarrhea, which may contain occult blood, further support the Dx. Poor neurologic condition in this patient is probably due to brain hypoperfusion as a consequence of shock.

76. Recognize the clinical presentation of mesenteric thrombosis. Severe abdominal pain out of proportion to the physical findings along with bloody diarrhea should make you think about this.

77. Colles fracture is the MC fracture of distal radius characterized by dorsal displacement and dorsal angulation. Tx: closed reduction and casting. Also can be associated with a fracture of the ulnar styloid.

78. Smith fracture: is reverse Colles fracture and is characterized by fracture of distal radius metaphysic with dorsal angulation of distal radius and hand, and the wrist displaced volarly with respect to the foremarm.

79. Barton’s fracture: is a fracture of radial styloid process and is commonly seen in persons operating automobiles that require cranking to start.

80. In patients who present with ulcers on the soles of the foot, neuropathic ulcer from diabetes should be suspected.

81. Scoliosis:
 Idiopathic scoliosis: no cause is determined. MC type, and right thoracic curve is most commonly seen. It can be further classified as:
-infantile type: age<3
-juvenile type: 3-10
-adolescent type: >10
 Neuromuscular scoliosis: secondary to neuromuscular disturbance or muscle disease.
 Congenital scoliosis: secondary to structural bony deformities.

82. Highest detection rate of prostatic carcinoma in early stages---PSA+digital rectal examination

83. Kidney stones:
 Oxalate stones: in a patient who undergoes bowel resection and then develops kidney stones, one should always suspect oxalate.
 Cystine stones: rare and occurs as part of a rare inherited disorder of defective renal transport resulting in over-excretion of cystine. Sone formation begins in childhood and are a rare cause of staghorn calculi.
 Uric acid stones: occur when urine is saturated with uric acid in the presence of an acidic urine and dehydration. Seen in gout, myeloproliferative disorders and diarrhea. Tx: fluid, alkalinization of urine, allopurinol.
 Struvite stones: form in the collecting system and become infected with urea splitting organisms. Condicitons required for formation of struvite stones are presence of high urine pH, magnesium, ammonium and carbonate levels.
 Calciu phosphate stones: associated with hypercalciuria (sarcoidosis, immobilization, Cushing’s syndrome, renal tubular acidosis.) std Tx: fluid, thiazide.(note Furosemide in CI).

84. Acute appendicitis: Rovsing’s sign +. Requires immediate surgery.

85. Acute appendicitis may be complicated by pelvic abscess that presents with lower abdominal pain, malaise, low-grade fever and tender pelvic mass on rectal examination. (most of the pelvic abscesses are due to perforation of appendix. Tx. Drainage of the abscess).

86. Laxatives should not be given in the setting of intestional obstruction.

87. Intestinal obstruction with metabolic acidosis and shock indicates serious disease and it requires laparotomy. (suggesting bowel ischemia or necrosis).

88. In case of simple mechanical obstruction, there would be metabolic alkalosis.

89. Patients who present more than 5 days after the onset of symptoms of appendicitis, and have localized right lower quadrant findings, should be treated with IV hydration, antibiotic and bowel rest. Antibiotics should cover enteric gram-negative organisms and anaerobes (cefotetan)

90. Cefotetan: has a good coverage of gram-negative organisms and anaerobes; therefore, this can be used as monotherapy in complicated appendicitis.

91. Erythromycin and vancomycin are effective against gram-positive organisms, they do not cover gram-negative organisms or anaerobes.

92. Persistent symptoms (e.g. mechanical symptoms) in patients with probable meniscal injury should be further evaluated by MRI or arthroscopy. Surgery (arthroscopic or open) is often necessary to correct the problem.

93. Boerhaave’s syndrome is esophageal perforation due to severe vomiting and it produces pneumomediastinum.

94. Saphenous vein cut down or percutaneous femoral vein catheterization are alternatives to have an intravenous access in trauma patients with collapsed veins.

95. Interosseous membrane cannulation is an alternative route in children <4 yo but not in adults.

96. Cardiac contusion can be associated with various arrhythmias and is best monitored by continous ECG monitoring. ECHO is used only if murmurs are detected on auscultation.

97. Pulmonary contusion: is not uncommon after high-speed car accidents. The symptoms usually develop in the first 24 hours and a patchy alveolar infiltrate on chest X-ray is typical.

98. Necrotized surgical infection: characterized by intensive pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. Early surgical exploration is essential.

99. Enterolysis: is used to diagnose small bowel tumors and other pathology, which can cause intestinal obstruction.

100. Colonoscopy: is not indicated for the right-sided pathology and shoul not be performed in acute pathology of the bowel wall because of the risk of perforation.

101. Ileus: sometimes is due to a vagal reaction due to ureteral colic. Needle shaped crystals on urinalysis indicate uric acid stones. Uric acid stones, which are radiolucent, have to be evaluated by either CT of the abdomen or intravenous pyelography. CT of the abdomen is also useful to diagnose other pathology such as appendicular abscess etc.

102. Isolated duodenal hematoma: is treated conservatively with nasogastric tube and parenteral nutrition.

103. Stress fracture or March fracture or insufficiency fracture: is commonly seen in young active adults (like a dancer) involved in vigorous and excessive exercise.

104. Osgood schlatter disease: is an epiphysitis of the tibia tubercle and is characterized by pain over tibial tubercle, which is exacerbated by contraction of quadriceps muscle. Almost exclusively seen in young men and women of less than 19 years age whose growth centers are still active. The typical patients is a 13-14 yo boy or 11-12 yo girl who has had recent rapid growth spurt.

105. The characteristic findings of tear of patellar tendon: proximal displacement of patella.

106. Intraductal papilloma: a benign tumor of major lactiferous ducts and clinically manifests as serous or bloody discharge. Mammogram does not show papilloma, as they are too small. Mammogram is not useful for young women, since their breast tissue is dense. Resection has to be done to provide relief and is guided by a galactogram.

107. Esophageal perforation due to iatrogenic cause is very frequent and radiography with water-soluble contrast is the best way to diagnose esophageal perforation.

108. The presence of pulses does not rule out compartment syndrome and suspicion should be high hence fasciotomy is the Tx and must be done urgently. (surgical emergency)

109. 10% of calcaneal (heel, most commonly fractured tarsal bone) fractures secondary to fall from height is associated with compression fracture of thoracic or lumber vertebra.

110. Pain relief should be the prime objective in management of rib fracture in elderly. Local nerve block can be used if oral or systemic analgesics are not useful. (intercostals nerver blocks provide pain relief without affecting respiratory function, although it carries some risk of pneumothorax.

111. Brown recluse spider bite causes deep necrotic ulcer at the bite site.

112. Breast mass that produces non-bloody aspirate and disappears completely on aspiration does not need any further evaluation other than observation. (cyst)

113. In acute pancreatitis patient who is septic, the cystic lesion must be regarded as abscess, until proven otherwise. An abscess anywhere in the body of the pancrease needs to be drained and external drainage is preferred for pancreatic abscess.

114. Pseudocyst engaging tail of the pancreas could be resected.

115. Galactogram guide resection is the Tx of choice for intraductal papilloma which presents with serous or bloody nipple discharge.

116. In right ventricular infarction, consider IV normal saline and do not give diuretics or nitrate.

117. The usual sequence of management of injury to bone, artery and nerve is to stabilize the bone followed by repair of vasculature followed by the nerve repair. (B-A-N)

118. CT scan is the investigation of choice to diagnosis intraabdominal abscess

119. Ulcers on the medial aspect of the leg are generally from venous disease. Venous HTN may be due to vein varicostities and incompetent perforators.

120. Bladder rupture can be classified into the following types:
 Type 1: bladder contusion
 Type 2: extra peritoneal rupture is more common than intra peritoneal rupture and usually occurs at lateral border or base
 Type 3: intraperitoneal rupture is less common but is commonly seen in patients with full bladder at accident due to rupture of dome of bladder.
 Type 4: combined intra and extra peritoneal rupture: it accounts for 10% of bladder injury.

118. Fixation:
 Closed intramedullary nailing: preferred over open nailing in closed femoral shaft fractures (associated with less chances of infection, less soft tissue disruption and do not compromise periosteal circulation)
 External fixation: indicated in certain cases of open fracture but not in closed fracture.
 Plate and screw fixation: needs soft tissue dissection and would disrupt fracture hematoma. It may be used in cases of fracture of femoral neck.
 Most of fractures of shaft of femur can be managed with closed intramedullary fixation of fracture.
 Lower limb skin traction would significantly increase the immobilization duration and its complications. Also the fracture union is not satisfactory in most cases. It can be used as a Tx. option in pediatric patients.

121. Preoperative DVT prophylaxis is dependent on the patients individual risk factors and the type of surgery being performed. The best DVT prophylaxis for high-risk surgical patients who are undergoing an orthopedic operation includes either oral warfarin or LMWH.

122. Risk of DVT in surgical patients:
 Low risk: minor surgery in a patient <40 yo with no additional risk factors present. Without prophylaxis, the risk of DVT <2%
 Moderate risk: patients >40 yo, one or more additional risk factors, minor/non-major surgery. The risk of DVT is 2-10%.
 High risk: patients > 40 yo, additional risk factors, major operation (e.g. orthopedic procedures of the lower extremity). The risk of DVT in these patients is between 10-20%.

123. Bucket handle tear of medial meniscus is the MC meniscus injury at knee and leads to locking of the knee joint during terminal extension.

124. Lachman’s test is the most sensitive physical test for Dx of anterior cruciate ligament injury. (A popping or snapping sensation is commonly felt at the time of ACL injury, ACL prevents anterior gliding of the tibia under the femoral condyles). Patients complain of instability of the knee. Commonly associated with injury to medial meniscus and medial collateral ligament of the knee (terrible triad). Lachman’s test: is done with knee flexed at 20 degrees, and pulling the proximal tibia with one hand while stabilizing the femur with the other hand.

125. Anterior cruciate ligament: prevents anterior glinding of the tibia under the femoral condyles. Isolated injury is seen after hyperextension of the knee. A “popping or sanpping” sensation is commonly felt at the time of injury. Patients complain of instability of the knee (giving out, looseness etc.) It is commonly associated with injury to medial meniscus and medial collateral ligament of the knee. (terrible triad)

126. Osgood Schlatter disease: is an apopysitis of tibial tubercle seen in young teenager due to overuse. (swelling and marked tenderness over the tibial tubercle. Pain increases on contraction of quadriceps muscle.)

127. Slipped femoral capitis: is an emergency condition and should be promptly corrected with external screws. (Dx is made by a high degree of clinical suspicion in presence of limited range of hip movements. Loss of abduction and internal rotation are very characteristic and external rotation of thigh is seen when hip is flexed. Frog-leg lateral view X-ray of hip joint is the imaging technique of choice for Dx.)

128. Lateral collateral ligament injury: tackled while playing football, knee pain, swollen, direct palpation over the lateral aspect of the knee elicit pain. Anterior drawer and posterior drawer test, and Lachman test are all negative.

129. Anterior drawer test: is also used for Dx of ACL injury but is less sensitive. It is done in supine position with the knee flexed at 90 degrees and hips flexed at 45 degrees, while tibia is pulled forward over femur to note the degree of displacement.

130. Posterior drawer test: is used for Dx of posterior cruciate ligament injury. It is similar to anterior drawer test except that posterior pressure is exerted on tibia to note posterior displacement.

131. McMurray’s test: is used for Dx of meniscus injury. In case of meniscus injury a click is heard on forced flexion and rotation of the knee. (popping sound on passive flexion/extenstion of the joint)-specific for meniscal injury.

132. Valgus stress test: is used for Dx of medial collateral ligament injury in which case valgus stress leads to marked angulation of knee joint as compared to the normal knee.

133. The immediate management of splenic trauma caused by blunt abdominal injury depends on the patient’s hemodynamic status and response to IV fluids. If the patient is initially hemodynamically unstable but improves with fluid administration, the best next step is to obtain an abdominal CT scan. If the patient is initially hemodynamically unstable and is unresponsive to fluid administration, then emergent exploratory laparotomy is required.

134. Intermittent claudication is best treated with aspirin and an exercise program.

135. MRI is now the investigation of choice for ligamentous injuries of the knee with an accuracy rate of 95%. Surgery is rarely necessary for MCL tear.

136. Non-communicating hydrocele disappears spontaneously by 12 months of age and it is therefore managed expectantly.

137. CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages with blurring of grey-white interface. It is the most significant cause of morbidity in patients with traumatic brain injuries.

138. A sternal fracture is very likely to be complicated by myocardial contusion, serial ECG is needed.

139. Paget’s disease of the nipple: Dx-mammogram and punch biopsy.

140. Tx. of Mitral stenosis: cardiovascular surgeons prefer to repair the patient’s own mitral valve, rather than replacing it. Stenosis is due to fusion at the commissures---commissurotomy can correct.

141. As a rule: internal hemorrhoids bleed but do not hurt, wherears external hemorrhoids hurt but do not bleed. (discomfort could be pain, or itchy)

142. Brain examinations:
 CT scan is our best tool when intracranial bleeding is suspected.
 MRI is our choice when brain tumor is suspected..
 Duplex scanning is our choice if transient ischemic attack is suspected.

143. Fogarty balloon tipped catheters: an embolectomy used in treating embolic occlusion of the artery. Heparin etc anticoagulants are an adjunct to vascular procedures, but are not the primary Tx for a clot that has already traveled from the atrial appendage to the lower extremity. Anticoagulants cannot dissolve existing clots.

144. The urinary retention is extremely common in the immediate postoperative period after lower abdominal inguinal or perineal surgery. Tx: in and out bladder catheterization. (don’t use indwelling Foley catheter unless in and out fails twice to resolve the urinary retention.)

145. If a scaphoid fracture is suspected, even without a visible fracture on X-ray, it must be treated as if there was a fracture. (long arm cast)---fall on an outstretched hand. Pain with wrist movement, tenderness in the anatomical snuffbox. 10% go on to develop avascular necrosis due to tx error.

146. Spinal cord ischemia with lower spastic paraplegia is a rare complication of abdominal aneurism surgery.

147. Acute adrenal insufficiency is a potentially lethal postoperative complication. Preoperative steroid use is the main cause. A high index of suspicion is required. Commonly, they present with nausea, vomiting, abdominal pain, hypoglycemia, and hypotension.

148. Burns:
 1st degree: superficial burns, confined to the epidermis with minimal skin damage. The skin is mildly erythematous and pain is the chief complaint. (such as sunburn, heals without scaring.)
 2nd degree: partial thickness burns-involves the entire epidermis and various layers of the dermis. Skin is painful, red, edematous and blistered.
 3rd degree: full thickness burns-no dermal appendages remain, all epidermis and dermis is completely destroyed. (flame burn)

149. Patients have obvious signs of hemorrhagic shock (loss of about 25-30%, 1500 mL blood), can only occur with intraabdominal bleeding, intrathoracic bleeding, and fracture of femur, pelvic, extremities or bleeding in neck. USG and DPL are the procedure of choice to diagnose intra abdominal bleeding in an unstable trauma patient. (ultrasonogram, diagnostic peritoneal lavage).

150. In case of amputation injury, amputated parts should be retrieved and brought to the ED. The amputated part should be wrapped in a saline-moistened gauze sponge placed in a plastic bag. The plastic bag should be sealed and placed on ice.

151. Cirrhotic patients with ascites may develop spontaneous primary bacterial peritonitis, which gives a “mild picture of acute abdomen”, Dx: culture of the ascetic fluid.

152. Sigmoid volvulus, a common condition in elderly patients. The endoscopic instrument (proctosigmoidoscopy) can untwist the bowel from the inside, relieve the obstruction, and allow placement of a long rectal tube.

153. Nerves of the lower extremities:
Femoral N.:innervated the muscles of the anterior compartment of the thigh, and is therefore responsible for knee extension and hip flexion. It provides sensation to the anterior thigh and medial leg via the saphenous branch.
Tibial nerve: supplies the muscles of the posterior compartment of the thigh, posterior compartment of the leg, and plantar muscles of the foot. The tibial nerve provides sensation to the leg (except medial side) and plantar foot.
The obturator nerve: innervated the medial compartment of the thigh (ie, gracilis adductor longus, adductor brevis, anterior portion of adductor magnus), and controls adduction of the thigh. It provides sensation over the medial thigh.
The common peroneal nerve: gives rise to the superficial and deep peroneal nerves. These two nerves supply the muscle of the anterior and lateral leg. These nerves provide sensation to the anterolateral leg and dorsum of the foot.

154. Current Tx. to full thickness burn: immediate excistion, grafting

155. DDH:
Ultrasound is the most sensitive investigation for DDH (developmental dysplasia of the hip) for infants less than 6 months of age.
X-ray of hip is not useful in young infants, as the cartilage and epiphysis are not ossified.
However, in older infants and children, plain radiography is the preferred modality of investigation.
MRI of hip joint though sensitive is reserved for complicated cases
CT though sensitive is not the first investigation of choice. It is particularly used for evaluating complicated dislocations and for postoperative evaluation of the hip.
156. After rhinoplasty, if there is whistling noise during respiration, one should suspect nasal septal perforation.

157. Unless strangulation or perforation is suspected, bowel obstruction is treated conservatively with fluids, nasogastric suction and enemas.

158. Retrograde cystogram with post void film is the investigation of choice for patients with suspected bladder trauma.

159. Retrograde urethrogram should be the first step in management of suspected posterior urethral injury. (inability to void, trauma history, high riding prostate)

160. Anterior urethral injury due to injury to urethra anterior to the perineal memebrane. Anterior urethral injuries are most commonly due to blunt trauma to the perimeum (straddle injuries), and many have delayed manifestation.

161. Posterior urethra consists of the prostatic urethra and memebranous urethra. Posterior urethral injuries are most commonly associated with pelvic fracture. (presents with blood at meatus, high riding prostate, scrotal hematoma and inability to void in spite of sensation to void).

162. When suspecting a urethral injury, do a retrograde urethrogram, inject the dye directly into the urethra. Inserting a Foley catheter is absolutely contraindicated in suspected urethral injury, you may change a partial urethral disruption into a complete transaction.

163. Retrograde ejaculation occurs in up to 90% patients undergoing transurethral resection of the prostate (TURP).

164. TUIP (transurethral incision of the prostate) involves incision of the periurethral prostate without resection of any tissue. This procedure is minimally invasive and can be performed on an outpatient basis. It frequently results in symptomatic relief without the adverse effects of TRP.

165. The disease with the highest incidence of perioperative death or cardiac event is a recent myocardial infarction. (other causes: coronary disease, worsened or poor baseline exercise tolerance, recent infarction)

166. Postoperative period, patient has persistent difficulty swallowing solids and even more difficulty swallowing liquids. Any attempts to do so results in violent coughing ans aspiration.Lesion: ----------sensory fibers of the 9th (glossopharyngeal) nerve.

167. When a patient presents with a pulsatile abdominal mass and hypotension, a presumptive Dx of ruptured abdominal aortic aneurysm must be entertained and the patient should be taken straight to the operating room.

168. Aortic aneurysm rupture, best diagnostic exam: Spiral CT scan or MRI angiogram.

169. Ureteropelvic junction obstruction and profuse diuresis: a congenital narrowing at the ureteropelvic junction allows normal passage of urine at a normal flow rate, but the lumen can’t accomadate a suddenly increased flow rate. (remember, beer is a wonderful diuretic.)

170. Most common nontraumatic casue for SAH is: berry aneurysm in the anterior portion of the circle of Willis.

171. Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound below the 4th intercostals space (level of nipple) is considered to involve the abdomen.

172. Subluxation of radial head is a common condition in preschool children and needs closed reduction by flexion and supination of forearm.

173. Small amount of intraperitoneal bleed that is not visible on abdominal ultrasound can be detected by diagnostic peritoneal lavage.

174. Consider bowel ischemia and infarction as an early complication of operation on the abdominal aorta.

175. Hallmark triad of urethral injury is:
 Blood at urethral meatus
 Inability to void
 Distended bladder

176. For carcinoid tumors located at the tip of the appendix, appendectomy is sufficient Tx. Carcinoids do not have the tendency to spread and have a good prognosis. When carcinoid spreads to the liver, it may produce the carcinoid syndrome, which is characterized by flushing, diarrhea, cramping, and valvular heart lesions.

177. Rule out vascular injuries in case of penetrating wound near the site of important vessels. (arteriogram)

178. Monteggia fracture: an isolated fracture of proximal third of ulna, with anterior dislocation of radial head. May be associated with injury to radial nerve, so careful neurovascular examination at the time of evaluation is mandatory. Tx: open reduction and internal fixation in adults, closed reduction and casting are optimal for children.

179. Galeazzi fracture: an isolated radial shaft fracture, associated with disruption of distal radio ulnar joint also need open reduction and internal fixation.

180. Osteogenic sarcoma usually presents with painful swelling around the knee without any systemic signs and radiographic findings are osteolytic lesions with periosteal reaction.

181. Hyperventilation helps to prevent and treat intracranial hypertension by causing cerebral vasoconstriction and thus decresing cerebral blood flow. (goal: to have pCO2 in the range of 30-35 mmHg.)

182. Harvesting team’d evaluate any dying patient as a potential donor.

183. Typical history for fracture of the posterior lateral talar tubercle: standing on a chair and falls backward, a cracking sound -develop pain and swelling behind the ankle. Pain is exacerbated by plantar flexion and dorsiflexion of the hallus (big toe).Tx: with immobilization in a cast for 4-6 weeks. Dx: lateral x-ray film of the ankle.

184. After rectal surgery, patient experience impotence, cause?-erectile nerve damage.

185. In cirrhotic patient with hepaticencephalopathy, porto-systemic shunt may worsen the encephalopathy.

186. Patient with cirrhosis may have upper GI bleeding due to:
 Erosive gastritis
 Varices
 PUD (peptic ulcer disease)
 Mallory-Weiss tears.

187. In cases of bleeding esophageal varices, need for 5 or more units of blood transfusion in a period of 24 hours is considered an indication for surgery and transjugular intrahepatic portosystemic shunt is the best choice in emergency situations.

188. When clavicle injuries occur and a bruit is present, an anterial injury must be ruled out with an angiogram.

189. Atelectasis on chest X-ray can be confused with pneumonia and pleural effusion. However, it is more common after surgery in smoker and requires bronchoscopy to remove the mucus plug.

190. Fever on the first postoperative day is almost invariably from atelectasis, the Tx of which requires active participation and cooperation from the patient. If atelectasis does not resolve, it leads to the development of pneumonia, which can be identified in chest x-ray and confirmed with sputum cultures.

191. Sclerotherapy and surgery are indicated after first variceal bleeding, but not prophylactically. (sclerotherapy may have complications such as perforation, stenosis, and bleeding.)

192. Pelvic X-ray should be routinely done in all patients with trauma to screen for pelvic injury.

193. Fibrocystic disease: (mammary dysplasia) typically seen in women aged 20-40. It is characterized by painful breasts and recurrent formation of cysts.

194. Malrotation: 3 week old infant, protracted bilious vomiting. With double bubble sign with a little gas beyong is highly suggestive. Dx must be promptly confirmed by barium enema or contrast study from above. Tx: emergency surgery.

195. A patient must be left with at least 800mL in FEV1 to live a semi-decent life.

196. Even being left with at least 800 mL in FEV1, a patient with SCC in lung still needs to do a CT scan of the chest and upper abdomen to rule out lymph metastasis before a pneumonectomy can be done.

197. The best initial therapy for rhabdomyolysis is infusion of copious amounts of alkalinized saline to assist the kidneys in clearing the myoglobin from the blood. Alkalinizing the urine allows the renal tubules to retain the myoglobin and excrete it in the urine. (saline+bicarbonate)

198. Percutaneous lithotomy: used for large renal sontes located within the pelvicaliceal system. Smaller stones located in this position are best treated with ESWL.

199. Extracorporeal shock wave lithotripsy (ESWL): particularly effective on stones impacted in the distal ureter that have failed to pass spontaneously with conservative management.

200. Testicular torsion needs immediate de-torsion if the testis is to be saved. No time should be wasted doing further studies.

201. In patients sustaining trauma, there is a chance of bony cervical spine injury-lateral cervical spine x-ray can rule it out.

202. A COPD patient with a 1100 mL in FEV1, suffers from a SCC at the hilar. What to do? ---only radiation + chemotherapy. If surgery and have the bad lung removed, then only leave him 40% FEV1 (440 mL).

203. Expectant therapy is a rule for all patients with uncomplicated basilar skull fracture. Clinical signs of basilar skull fracture includes rhinorrhea, raccoon eyes (black eyes), and ecchymosis behind the ears and otorrhea. Patient’s head should be elevated and fluid intake should be restricted to 1200 mL/day. Patient should also be cautioned against the maneuvers that increase the intracranial pressure like blowing the nose.

204. Legg calve Perthes disease (avascular necrosis) is serious but self-limiting condition of young children characterized by avascular necrosis of femoral head. Can be painless. But hip pathology can present as referred knee pain. Also named: avascular necrosis of the capital femoral epiphysis.

205. The Tx of choice for isolated diaphyseal humeral fracture is by closed methods.

206. Scaphoid fracture: nonunion and avascular necrosis are common complications. The proximal third of the scaphoid is prone to avascular necrosis in fractures involving the wrist or proximal pole.

207. Gentle traction to attempt alignment of the fragments of a fractured long bone is important to prevent further vascular and neurological damage and it should be attempted immediately.

208. Nasopharyngeal cancer usually presents initially as a painless neck mass. (other symptoms: epistaxis, hearing loss, nasal blockage)

209. Warfarin treated patients should be given fresh frozen plasma instead of vitamin K when emergency surgical procedure is to be performed.

210. Intravenous pyelography is very useful for the Dx of renal stones.

211. Open fractures should not be closed primarily because of the associated increased risk of infection and subsequent osteomyelitis.

212. Rhabdomyolysis can occur with severe crush injuries and should be managed with IV fluids, osmotic diuretics and alkalinization of urine.

213. Hyperkalemia due to crush injuries needs IV calcium gluconate (acts as a membrane-stabilizing agent to balance against the imminent hyperkalemia-induced global depolarization of the myocardium.

214. Elderly patients with displaced femoral neck fractures should be treated with primary arthroplasty.

215. Tx of choic for intertrochanteric fracture: internal fixation with sliding screw and plate and early mobilization.

216. Patients treated with high-dose methylprednisolone within eight hours of spinal cord injury have significant and sustained neurological improvement, thus its use is warranted as the first priority after stabilizing the patient. *important Q.!!!*

213. Garden classification for femoral neck fracture:
 Type 1: valgus impaction of femoral head commonly seen with stress fracture
 Type 2: complete but non-displaced femoral neck fracture.
 Type 3: complete fracture with displacement <50%
 Type 4: complete fracture with displacement >50%

217. Delayed emergency from anesthesia is characterized by hypotension, which is evident by decreased in respiratory rate, HTN progressing to hypotension, tachycardia progressing to bradycardia, restlessness and pallor/cyanosis.

218. After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a mass in the left lower chest, one should suspect a diaphragmatic perforation.(Dx. barium swallow)

219. Patient with head injury can never have hemorrhagic shock due to intracranial bleeding.

220. Beck’s triad of hypotension, elevated JVP, and muffled heart sounds confirms the Dx of pericardial tamponade.

221. Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the dead muscle has been replaced with fibrous tissue. Tx: immediate fasciotomy.

222. Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which may be complicated by Volkmann’s ischemic contracture.

223. Presence of brachial pulse on the fracture side can’t rule out the possibility of vascular compromise because of collateral flow.

224. Two locations in the body have the highest risk for development of the dreaded compartment syndrome: the forearm and the lower leg.

225. Hirschsprung’s disease in neonate presenting with obstruction: diverting ileostomy +appendectomy (for Dx. of the disease). Definite repair can be done when the child is older.

226. A known complication of ling-standing use of birth control pills is the development of hepatic adenomas that may rupture and bleed. (acute onset of abmominal pain, followed by a faint)

227. The MC site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial epicondylar groove. *extremely HY Q for USMLE* (decreased sensation over the 4th and 5th fingers of the hand and a weaker grip compared to the normal side.) Prolonged, inadvertent compression of the nerve by leaning on the elbows while working at a desk or table is the typical scenario.

228. APKD (adult onset polycystic kidney disease) diagnosed, you should order an MRA (magnetic resonance angiogram) of the brain to rule out berry aneurysms. (10%-20% incidence of this in APKD).

229. Virtually all solid testicular masses are malignant tumors. The best way to avoid dissemination is to open the inguinal canal, do a high ligation of the cord, and pull the testicle out.(radical inguinal orchiectomy)

230. Mixed connective tissue disease represents the over lapping symptoms of SLE, scleroderma and myositis. It is associated with autoantibody to ribonuclear protein.

231. The rule is that lymph nodes that progressively enlarge over several months are malignant.

232. Lymph nodes which are in the supraclavicular area, typically harbor metastasis from a primary tumor below the clavicles (i.e., not in the head and neck).

233. Inhalation injury is common in burns patients and may take several days to manifest. Diagnosis is best done with a bronchoscopy.

234. Body surface involved in burn injury is calculated with the rule of 9:
 Each arm: 9%
 Each lower extremity: 18%
 Anteiror torso: 18%
 Posterior torso: 18%
 Face 9%
 Perineum: 1%

235. Burns patients need 4 ml/kg/% of the body area involved of fluid in first 24 hours, half of which is given in the first 8 hours. Plus 2000 mL dextrose 5% in water.

236. Infection is the MCC of death in burns patients.

237. Burns:
 Superficial and erythematous burns while painful do not require any special wound care (not even antibiotics)
 Early excision therapy is indicated for extensive partial-thickness and full-thickness burns, as they do not heal spontaneously. Also, it allows for early skin grafting and lesser complications.
 Prophylactic systemic antibiotic is not indicated in all the patients. However, topical antibiotics should be used for burn wound care.
 The most commonly used topical anti bacterial agent: silver sulphadiazine. Mafenide sulphate is only used if deep penetration is required in case of wound with eschar. Mafenide sulfate is associated with severe pain and acidosis.
 Eschar is dead rigid tissue formed in burns wounds. The eschar restricts outward expansion of the compartment as edema occurs in the injured extremity following the burns. As a result, interstitial pressure rised to the point that vascular flow is compromised. This can be relieved by performing an escharoctomy.
 Tetanus prophylaxis should be considered in all the burns wound patients using std guidelines as burn wounds are prone to tetanus infection.
238. Cholesteatoma is an epithelial cyst that contains desquamated keratin. Patients generally present with chronic ear discharge and granulation tissue that are unresponsive to antibiotic treatment. (This is not a tumor)

239. Carcinoids are most commonly found on the appendix; however, patients who present with carcinoid syndrome usually have carcinoids located in the small bowel.

240. Dog bite:
 May result in rabies (fatal disease)
 Post exposure prophylaxis: active and passive immunization.
 Capture the dog, if fails to do so, the dog is assued to be rabid and post exposure prophylaxis is indicated.
 If the dog is available and it does not show any features of rabies, observed it for the development of rabies (10 days). If it shows rabies, it is killed and its brain is examined to confirm the presence of rabies and post exposure prophylaxis is given when rabies in dog is confirmed by FA.(fluorescent antibody)

241. When isolated proteinuria occurs, the evaluation of the patient should begin by testing the urine on at least two other occasions. (transient proteinuria is a common cause of isolated proteinuria and can occur during stress or any febrile illness).

242. Glanzmann’s thrombasthenia: an autosomal recessive disease that results in deficient glycoproteins IIb-IIIa complex so fibrinogen will not cross-connect. The patient presents with increased bleeding episodes for some time. Platelet counts may be normal, but on the peripheral blood stream, platelets remain isolated and do not exhibit clumping that is normally seen. BT is markedly increased. Epinephrine, collagen, ADP and thrombin fail to induce aggregation. VWF is normal.

243. Chediak Higashi syndrome: is a storage granulocyte abnormality resulting in hepatosplenomegaly, lymphadenopathy, anemia, thrombocytopenia, roentgenological changes of bones, lungs and heart, skin andn psychomotor abnormalities, and susceptibility to infection, usually resulting in death in childhood.

244. Bernard Soulier syndrome: is a bleeding disorder characterized by thrombocytopenia, giant platelets, and a bleeding tendency, which is typically greater than expected bleeding for the degree of thrombocytopenia.

245. skin pigmentation, polydypsia, polyuria, serume ferritin ↑↑, transferring saturation ↑, blood glucose ↑, ALT and AST ↑─hemochromatosis. If left untreated, 30% of deaths in patients will be due to hepatocellular cancer (hepatoma).

246. AlZheimer’s disease is the MCC of dementia in the western world. It is initially characterized by memory loss, language difficulties and apraxia, followed by impaired judgement and personality changes. CT scan shows generalized cortical atrophy.

247. Eczema herpeticum is a form of primary herpes simplex virus infection associated with atopic dermatitis. Numerous vesicles over the area of atopic dermatitis are typical. The infection can be life-threatening in infants; thus, prompt treatment with acyclovir should be initiated.

248. Unrecognized bowel ischemia is one of the common causes of lactic acidosis in patients with severe atherosclerotic disease.

249. Seborrheic keratosis: is commonly referred to as “the barnacles of old age.” Suspect seborrheic keratosis in an elderly person with benign plaques that are 3-20 mm in size, and have a greasy surface and stuck-on appearance.*extremely HY Q*

250. Churg Strauss syndrome (CSS): is a multisystem vasculitic disorder of unknown etiology that affects the skin, kidney, nervous system, lungs, GI tract and heart. It is characterized by allergic rhinitis, asthma and prominent peripheral blood eosinophilia. Up to 75% of CSS patients have evidence of peripheral neuropathy (mononeuritis multiplex). Tx: glucocorticoid and sometimes immunosuppressant. (it is a severe disease)

251. Identify allergic granulomatosis of Churg-Strauss syndrome (CSS) and remember that leukotreine antagonist (asthma agent) are known to cause CSS.

252. Job syndrome: is characterized by recurrent bacterial infections and markedly elevated IgE levels. Bacterial infections in Job syndrome are usually caused by staphylococci and the skin is the most frequent site of involvement. Neutrophils exhibit impaired chemotaxis. Some patients have coarse features while others are fair. Other allergic disorders like eczema, asthma, allergic rhinitis may be present. Tx: intermittent or continuous antibiotics.

253. Indications for the Tx of Paget’s disease include:
 Bone pain
 Hypercalcemia of immobilization
 Neurological deficit
 High output cardiac failure
 Preparation for orthopedic surgery
 Involvement of weight-bearing bones (to prevent deformities)

254. Asymptomatic patients with Paget’s Disease generally do not require any Tx. Symptomatic ones are best treated with oral or IV bisphosphonates.

255. Bisphophonates (Zoledronic acid) are the DOC for mild to moderate hypercalcemia due to malignancy.

256. Excessive use of oxytocin may cause water retention, hyponatremia and seizure (water intoxication). Oxytocin has ADH effect.

257. Intensive axillary freckling and café-au-lait spots are suggestive of neurofibromatosis type I. Optic glioma is a well-known complication of it. ( presenting as pallor of the optic disk). Optic glioma occurs in 15% of patients with neurofibromatosis, type 1.

258. Retinal hamartoma is typical for tuberous sclerosis, mulberry lesions.

259. Optic neuritis is frequently the early manifestation of multiple sclerosis.

260. Prophylactic allopurinol is the most effective method to prevent gout in patients at risk for tumor lysis syndrome.(it is a competitive inhibitor of xanthine oxidase, prevents the conversion of soluble hypoxanthine and xanthine to insoluble uric acid).

261. Loss to follow-up in prospective studies creates a potential for selection bias.

262. Post-ictal (post seizure) lactic acidosis is transient and resolves without Tx within 60-90 minutes.

263. Primary hyperPTH is the MCC of hypercalcemia in ambulatory patients. Hepercalcemia due to primary hyperPTH is associated with elevated or inappropriately normal serum PTH level.

264. Retropharyngeal abscess presents with posterior pharyngeal edema, nuchal rigidity, cervical adenopathy, and fever.

265. Palliative radiation, along with anti-androgen therapy, is the Tx. of choice for metastatic prostate cancer. Anti-androgen therapy consists of Leuprolide. (LHRH analogues) Flutamide is considered inferior to LHRH analogues.

266. Hydatid cysts in the liver are due to infection with Echinococcus granulosus. (contact from the close and intimate contacts with dogs. Mostly asymptomatic and generally diagnosed on screening for some other problem. “Eggshell” calcification of a hepatic cyst on CT scan is highly suggestive of hydatid cyst.

267. Marfan’s features + mental retardation+ thromboembolic event + downward dislocation of the lens= Homocystinuria. It is an autosomal recessive disease casued by cystathionine synthase deficiency. Tx: mainly involves administration of high doses of vit B6.

268. PCOD (polycystic ovarian disease) patients are at risk of developing type II DM. So once diagnosed PCOD, do an oral glucose tolerance test.

269. Erosive joint disease in RA is a clear-cut indication for the use of diseases modifying anti-rheumatic drugs (DMARD) and methotrexate is the initial DOC for this purpose.

270. Nasal polyps: recurrent episodes of rhinitis, chronic nasal obstruction, altered taste sensation, diminished sense of smell, and persistent postnasal drip.

271. Severe, excruciating pain should be treated with IV opioids (like morphine) even if the patient has a history of drug abuse.

272. Tricuspid atresia is a cyanotic congenital heart disease characterized clinically by cyanosis that appears early in life and left axis deviation. Most cases (90%) are associated with VSD, and 30% are associated with TGA (transposition of the great arteries). Interestingly, the associated heart defects (eg. ASD, VSD and PDA) are necessary for survival. (presents as: cyanotic, holosystolic murmur at the left, lower sternal border, and a single S2. No rales or rhonchi heard, decreased pulmonary vascular markings and a normal sized heart)

273. VSD-holosystolic murmur.

274. Anticholinergics are useful for PD patients younger than 70 years with disturbing tremors and minimal bradykinesia. PD tremor is a resting tremor.

275. Progestin is chosen over estrogen as contraceptive method postpartum because it has no effects on milk production and does not pass into the milk. (e.g. minipill)

276. Sodium bicarbonate is effective for the Tx of cardiac dysfunction induced by thioridazine toxicity. (which presents with low BP, seizure, miosis, confused state, ataxia)

277. Patients with mild head injury can be discharged with a “head sheet” if they have a normal CT scan.

278. Pneumococcal vaccine is recommended:
 For adults over age 65
 All individuals with immunosuppression and DMChronic alcoholics, and individuals in chronic-care facilities, should also receive this
vaccination.

270. Pneumococcoal vaccine contains capsular polysaccharides and it
produces T cell independent B cell response. (only peptides can be
presented by macrophages/B cell to T cell in association with MHC II.
Polysaccharides and other antigens induce T cell independent response
By B cells.

271.Influenza immunization is recommended on annual bases for:
 All individuals aged 65 years and older.
 Individual of any age with chronic debilitating illnesses like: cardiovascular, renal or pulmonary disorders, DM.
 All immunocompromised adults.
 Pregnant women in the second or third trimester during influenza season.
 Nursing home residents
 Other high-risk individuals such as physicians, nurses, employees of nursing homes, and family members of patients infected with influenza.



272. HSV and VZV can cause severe, acute retinal necrosis associated with pain, keratitis, uveritis, and funduscopic findings of peripheral pale lesions and central retinal necrosis.In contrast, CMV is PAINLESS.(HSV, VZV -painful)

273. MAOI (phenelzine) can’t be taken with tyramine (cheese, wine etc.). Other side effects include interaction with serotonergic drugs to produce serotonin syndrome, sexual dysfunction, hypotension, and insomnia.

274. The antidepressant of choice in depressed patients suffering from sexual dysfunction (whether as a side effect of medication or as a pre-existing condition ) is bupropion. (inhibits NE and DA reuptake)

279. Newer antipneumococcal quinolones, like levofloxacin or gatifloxacin, are the DOC for in-patient Tx. of community-acquired pneumonia. For out-patient therapy, either azithromycin or doxycycline can be used.

280. NG tube placements may lead to the loss of large amounts of acidic gastric fluid leading to contraction alkalosis, even in patients with preexisting metabolic acidosis. This phenomenon should not be confused with a normalization of the acid base status.

281. Polymyositis and Dermatomyositis: are inflammatory myopathies, which are characterized by proximal muscle weakness, and ultimately wasting. Dermatomyositis involve typical skin changes: heliotrope rash around the eyes associated with periorbital edema, and Gottron’s papules, which are red scaly patches over the emtacarpophalangeal joints. These conditions may occur along or in association with a variety of neoplasms such as breast, ovary, lung, prostate, or colon cancer. Unlike myasthenia, facial or ocular muscle weakness is uncommon. Unlike scleroderma, which affects the lower smooth muscle of esophagus, it involves striated muscle of the upper pharynx and can make deglutition difficult. Suspected patients should have measurement of serum CK and aldolase levels. Specific Dx is usually made by muscle biopsy. Tx: oral corticosteroid.

282. Bactrim (trimethoprim-sulfamethoxazole) is the DOC for uncomplicated cystitis and sinusitis.

283. Always consider thyroid abnormalities or fibromyalgia in a patient with diffuse muscle aches and excessive fatigue with non-restorative sleep. (do a thyroid function test and CK level)

284. Nasopharyngeal cancer usually presents initially as a painless neck mass.

285. In patients with hyperthyroidism-related tachysystolic atrial fibrillation, a beta-blocker is the DOC.

286. Hairy cell leukemia is characterized by lymphocytes with fine, hair-like irregular projections and a TRAP stain (tartrate-resistant acid phosphatase). The bone marrow may become fibrotic; thus leading to dry taps. DOC for hairy cell leukemia: cladribine.

287. DOC for CLL: chlorambucil and prednisone.

288. Acanthosis nigricans is characterized by symmetrical, hyperpigmented, velvety plaques in the axilla, groin, and neck. It is associated with DM (insulin resistance) in younger patients, and GI malignancy in older individual.

289. Amphotericin use is associated with hypokalemia. Potassium levels should routinely be monitored when administrating this agent. The presence of “U” wave and flat T wave in the ECG indicates hypokalemia.

290. Bromocriptine is useful in neuroleptic malignant disorder, which is characterized by marked hyperthermia, muscular rigidity, tremors, altered mental status, and diaphoresis.

291. Patients suffering from panic disorder have an increased incidence of depression, agoraphobia, generalized anxiety and substance abuse. (extremely important).

292. Immediate anticoagulation with heparin and surgical intervention (ie, embolectomy) are crucial to prevent tissue death in a patient with ongoing ischemia of the limb.

293. Cholesterol embolization usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low competent levels should make you think of cholesterol embolism. (extremely important for USMLE)

294. Patients with osteomalacia have low-normal serum calcium, low serum phosphate and increased serum PTH level. (after surgery of inflammatory bowel disease-Vit D deficiency-osteomalacia)

295. Acute allergic interstitial nephropathy is a drug-induced hypersensitivity reaction characterized by rash, renal failure (eosinophilia in urine), eosinophilia. Common offending drugs:
 Methicillin (penicillin, etc)
 NSAIDs
 Thiazides
 Phenytoin
 Allopurinol

296. Suspect aortic dissection as a cause of tearing chest pain in the setting of HTN and BP difference in the 2 arms.

297. Suspect optic neuritis in a patient with central scotoma, afferent papillary defect, changes in color perception (colors like washed out) and decreased visual acuity. Remember the association between optic neuritis and multiple sclerosis (The USMLE love this topic!)

298. CHD (coronary heart disease) equivalents, which are the risk factors that place the patient at similar risk for CHD events as a history of CHD itself include:
 DM
 Symptomatic carotid artery disease
 Abdominal aortic aneurysm
 Multiple risk factors that confer a ten year risk of CHD of more than 20%

295. Major CHD risk factors other than LDL are:
 Age, male >=45 yo and female >=55 yo
 HTN (BP>140/90 mmHg or antihypertensive drugs)
 Smoking
 Low HDL (<40 mg/dL)
 Family history of premature CHD (males<55 yo, females<65 yo)

299. Infective endocarditis is common among IV drug abusers. It can be fatal if Tx. is delayed so IV vancomycin + gentamycin is empiric Tx.

300. Angioedema is characterized by the rapid onset of non-inflammatory edema. It is due to deficiency in C1 esterase inhibitor, which results in elevated levels of the edema-producing factors, C2b and bradykinin. Episodes of angiodedema usually follow an infection, dental procedure, or trauma.

301. Sympathetic ophthalmia is characterized by damage of one eye (the sympathetic eye) after a penetrating injury to the other eye. It is due to an immunologic mechanism involving the recognition of “hidden” antigens.

302. Laryngomalacia or congenital flaccid larynx is the MCC of chronic inspiratory noise in infants. It is a self-limiting condition in most cases, and generally subsides by 18 months of age. Hold the baby in an upright position for half an hour after feeding, and never feed the baby when he is lying down.

303. Condylomata acuminate are skin colored or pink, verrucous and papilliform skin lesions present around the anus and podophyllin is one of the available Tx.

304. Diammond-Blackfan anemia: a macrocytic pure red aplasia associated with several congenital anomalies such as short stature, webbed neck, cleft lip, shielded chest and triphalangeal thumbs.

305. Always suspect sickle cell trait in a young black male who presents with painless hematuria. (due to papillary ischemia, which is due to the relatively low local oxygen partial pressure, and which predisposes the diseased RBCs to sickling.)

306. Pharyngoesophageal (Zenker’s) diverticulum develops immediately above the upper esophageal sphincter by herniating posteriorly between the fibers of cricopharyngeal muscle. Motor dysfunction and incoordination are responsible for the problem. *The surgical Tx of the disorder includes excision and frequently cricopharyngeal myotomy.* *extremely HY Q for USMLE*

307. Therapeutic INR ( international normalized ratio) for most clinical indications of warfarin is 2-3 .
 Thromboembolism
 Valvular heart disease
 Atrial fib
A higher INR of 3-4 is required only in certain clinical settings like prosthetic heart valves.

308. The risk of bleeding in patients treated with warfarin correlateds with the degree of anticoagulation and it increases substantially when INR is greater than 4.

309. Due to high incidence of lung cancer among smokers, it should be suspected in any smoker presenting with recurrent pneumonia. (admit the patient and order a high resolution CT of the chest)

310. Mast cell stabilizers are the DOC for asthmatic patients who also have other allergic disorders. (inhale sodium cromolyn)

311. Pinpoint pupils and respiratory depression are the hallmark features of acute opioid toxicity for which naloxone is the DOC.

312. Sialolithiasis presents as post-prandial pain and swelling in a patient with history of recurrent sialadenitis.

313. Reversible acetylcholinesterase inhibitors such as donepezil, rivastigmine, galantamine, and tacrine are of benefit in slowing the cognitive decline associated with Alzheimer’s disease.

314. Contraindications of triptans are as follows:
 Familial hemiplegic migraine
 Uncontrolled HTN
 CAD
 Prinzmetal angina
 Pregnancy
 Ischemic stroke
 Basilar migraine

315. Pregnancy testing should be performed in women of child-bearing age before starting Tx. with sumatriptan (serotonin agonists)

316. Neutralization of gastric pH should be considered for severely ill patients of pancreatitis to prevent gastric stress erosions.

317. Turcot’s syndrome: refers to an association between brain tumors (primarily medulloblastomas and gliomas) and FAP (familial adenomatous polyposis) or HNPCC.

318. Catatonic schizophrenia: best treated with benzodiazepines or ECT. (lorazepam, not clozapine).

319. Antidote for acute benzodiazepine intoxication: flumazenil, a benzo antagonist. (presents with drowsy, slurred speech)-hint: elderly patients on sleeping pills.

320. Fibromuscular dysplasia: can present as new onset HTN in children (renal HTN). Bruit or venous hum may be heard at the costovertebral angle. Angiogram reveals the “string of beads” sign of the renal artery.

321. Tx of choice for fibromuscular dysplasia: percutaneous angioplasty with stent placement.

322. Patients with a leukocyte adhesion defect suffer from recurrent bacterial infections. Delayed separation of the umbilical cord and necrotic periodontal infections are characteristic.

323. A history of seizure disorder is an absolute contraindication to the use of bupropion.

324. Patients with chronic liver disease most commonly have respiratory alkalosis.(progesterone accumulation-stimulatory effect on the respiratory center-leads to tachypnea causing respirary alkalosis.

325. Primary polydypsia (psychogenic polydypsia) is characterized by primary increase in water intake. Patients taking phenothiazines have this problem due to dry mouth caused by anticholinergic action of phenothiazines.

326. Lithium exposure in the 1st trimester of pregnancy causes a 20 fold increase in the risk of Ebstein’s anomaly, a cardiac malformation. In later trimesters, goiter and transient neonatal neuromuscular dysfunctions are of concern.

327. Central retinal artery occlusion is emergency treated with an ocular massage and high-flow oxygen administration. (thrombolytic is effective if initiated within 4-6 hours of visual loss, but always perform the former ones first)

328. Idiopathic pulmonary fibrosis is best treated with steroids. Most patients will have a positive response in the first 6 months but they fail to have sustained response.

329. All patients with unstable angina should be hospitalized and treated with aspirin, IV heparin, and IV nitroglycerin. Once the patient is free of chest pain, an angiography can be performed non-emergently.

330. HIV-infected patients have lower than normal immunity for diphtheria. These individuals should receive the tetanus and diphtheria vaccine as per the routine recommendations. (Td vaccine.)

331. Leukopalkia presents as hard to remove whitish patches in the oral mucosa and may lead to squamous cell carcinoma.

332. Toxic epidermal necrolysis is a severe mucocutaneous exfoliative disease. It is characterized by an erythematous morbilliform eruption that rapidly evolves into exfoliation of the skin.

333. Always suspect X-linked hypophosphatemic rickets in patients of rickets who has normal serum calcium, normal serum alkaline phosphatase and normal 25-OH vit D.

334. In type II vit D dependent rickets, there is mutation of vit D receptor. Therefore these patients have normal serum levels of calcitriol but it is ineffective and as a result osteomalacia occurs.

335. MCC of toxic megacolon: ulcerative colitis. This is medical emergency. Tx: prompt administration of IV steroids, nasogastric decompression and fluid management are required.

336. Delirium tremens: presents with seizures, headache, confusion and tremors. Due to alcohol withdrawal. Usually occur 2-4 days after the last drink. Hallucinations, autonomic instability (tachycardia and fever)

337. Alcohol withdrawal: is best treated with long-acting benzodiazepines such as chlordiazepoxide, diazempam. Withdrawal symptoms should be correlated with the time of the last alcohol drink. It is important to rule out other medical conditions that could be responsible (electrolyte abnormalities, infection, or hypoxia) before making a Dx.

338. Lithium toxicity: tremulousness, headache, confusion, GI distress, fatigue, in extreme cases, with seizures, coma, hyperreflexia and opisthotonus.

339. Tricyclic antidepressant intoxication: includes sodium bicarbonate. This drug not only helps to correct the acidosis, but also helps to narrow the QRS complex prolongation. Benzodiazepine (eg. Diazepam) is given when the patient presents with seizures that require treatment.*Extremely HY Q for USMLE*

340. Riley-Day syndrome: (familial dysautonomia), is an autosomal-recessive diseae seen predominantly in children of Ashkenazi Jewish ancestry. It is characterized by gross dysfunction of the autonomic nervous system with severe orthostatic hypotension.

341. The management of diabetic gastroparesis includes: secondary to diabetic GI automomic neuropathy.

 Improved glycemic control
 Small, frequent meals
 A dopamine antagonist (eg. Metoclopromide, domperidone) before meals
 Bethanechol
 Erythromycin: this drug interacts with motilin receptors and can promote gastric emptying
 Cisapride: is effective, but it is currently available only through the manufacturer. It is issued only after providing adequate documentation of the need for the drug, and after a thorough assessment of the individual’s risk factors for cardiac arrhythmias.

338. Cryoglobulinemia:
Palpable purpura
Glomerulanephritis
Non-specifi systemic symptoms
Arthralgias
Hepatosplenomegaly
Peripheral neuropathy
Hypocomplementemia
Most patients also have hepatitis C

339. Whipple’s disease: is a multi-systemic illness characterized by arthralgias, weight loss, fever, diarrhea and abdominal pain. PAS-positive material in the lamina propria of the small intestine is a classical biopsy finding of Whipple’s disease. PAS positive material in the lamina propria of the small intestine is a classical biopsy finding.

340. Whipple’s disease: D-xylose absorption is abnormal both in bacterial overgrowth and whipple’s disease. However, with the bacterial overgrowth, the test becomes normal after antibiotic treatment.

341. Dxylose: is a simple sugar. It does not need to undergo any digestive process before it can be absorbed. Its absorption requires an intact mucosa only.

342. Sensory distribution of dermatomes:
 A lesion in the upper thoracic spinal cord results in paraplegia, bladder and fecal incontinency, and absent sensation from the nipple downwards.
 A lesion in the cerebellum causes posterior fossa sympotoms (nausea, vomiting, ataxia).
 A lesion in the lower thoracic spinal cord causes absent sensation from the umbilicus downwards.
 A lesion located supratentorially produces partial or complete hemiparesis.

343. The main substrate of gluconeogenesis are: alanine, lactate and G-3-P. Pyruvate is an intermediate of alanine during the process of gluconeogenesis.

344. Painless jaundice in an elderly patient should make you think about pancreatic head carcinoma.

345. Bladder rupture can be classified into the following types:
 Type 1-Bladder contusion
 Type 2-Extra peritoneal rupture is more common than intra peritoneal rupture and usually occurs at lateral border or base.
 Type 3- Intraperitoneal rupture is less common but is commonly seen in patients with full bladder at accident due to rupture of dome of bladder.
 Type 4- Combined intra and extra peritoneal rupture: it accounts for 10% of bladder inuries.

346. Intraperitoneal bladder rupture can occur in trauma patient with full bladder.


1. NIPPV (non-invasive positive pressure ventilation) is an excellent option for patients with COPD exacerbation. It should be tried before intubation and mechanical ventilation in COPD patients with CO2 retention.

2. Amoxicillin is used for Tx of pregnant/lactating patients with early-localized Lyme disease.

3. Tx. of limb-threatening infections in Diabetic: IV cefotetan, ampicillin/sulbactam, or the combination of clindamycin and a fluoroquinolone is the appropriate empirical method. Mild or non-limb-threatening infections can be treated with oral antibiotics like cephalosporin, clindamycin, amoxicillin/calvalanate and fluoroquinolones.

4. Cholangiocarcinoma can complicate primary sclerosing cholangitis, especially in patients who smoke and have ulcerative colitis. (order biopsy of the prominent stricture)

5. Mastoiditis: is the MC complication of otitis media. It presents as erythema, edema, and tenderness over the mastoid area (the area behind the ear). Examination of the involved ear reveals a protruded auricle. CT imaging may be used to confirm the clinical Dx.

6. Suspect Creutzfeldt-Jacob disease in an old patient (50-70 yo) with rapidly progressive dementia, myoclonus and periodic synchronous bi or triphasic sharp wave complexes on EEG.

7. Trachoma presents with follicular conjunctivitis and pannus (neovascularization) formation in the cornea.

8. Paget’s disease is characterized by excessive bone resorption and repair. Its features are normal serum calcium and an elevated alkaline phosphatase. A small number of patients will develop sarcomatous changes over 10 yrs and third will present as a new lytic lesion and a sudden increase in alkaline phosphatase.

9. The earliest ECG finding in acute MI is peaked T waves (hyperacute), followed by ST segment elevation, followed by the inversion of T waves, followed by the appearance of Q waves (this do not occur in 20-50% cases of acute infarcts)

10. Delayed emergency from anesthesia is characterized by hypoventilation, which is evident by decrease in respiratory rate, HTN progressing to hypotension, tachycardia progressing to bradycardia, restlessness and pallor/cyanosis.

11. Triad of renal faiure, microangiopathic hemolytic anemia and thrombocytopenia occurs in hemolytic uremic syndrome.

12. Elderly patients with dehydration-hypernatremia, common in nursing home-altered mental status.

13. Recognized the common causes of altered mental status in elderly patients. The major causes include:
 Hyponatremia and hypernatremia
 Hypocalcemia and hypercalcemia
 Hypomagnesemia
 Hypophosphatemia
 Hypoglycemia
 Stroke
 Cardiac events
 Infections (chest x ray and urinalysis is routine)
*Since altered mental status is one of the common cuases of
hospitalization in the U.S. USMLE expects you to know everything
possible)

14. Pyloric stenosis presents with non-bilious vomiting in a 4 to 8 week old infant, and an abdominal ultrasound confirms the Dx.

15. The blood supply of the brain can be expained as follows:
Anterior vasculature-comprised of the internal carotid artery and its branches, especially the paired anterior and middle cerebral arteries.
Posterior circulation- comprised of paired vertebral arteries, which unite to form the basilar artery, which further divides into the paired posterior cerebral arteries.

16. Internal carotid artery dissection is a potential cause of strokes in children. The history of a fall on a pencil in a child’s mouth within 24 hours of the onset of symptoms is typical. (The injury produces a tear in the intima of the internal carotid A. and dissection and thrombosis may follow-hemiplegia of sudden onset, hemianesthesia, mild motor aphasia)

17. Most definite way to Dx iron deficiency anemia: bone marrow iron stain.

18. Patients with hemochromatosis and cirrhosis are vulnerable to listeria monocytogenes and some other bacterial infections.

19. Iron overload is also a risk factor for infection with Yersina enterocolitica and septicemian from Vibrio vulnificus both of which are iron-loving bacteria.

20. Duchenne muscular dystrophy : CK levels are used for screening the muscular dystrophies. Muscle biopsy can confirm the Dx in most cases. The gold std is genetic studies, which is required in atypical cases.

21. Dx. of Whipple’s disease: can be confirmed with upper GI endoscopy and biopsy of the small intestine, followed by PAS staining of the sample.

22. Multiple myeloma Tx: melphalan, prednisone, interferon, combination chemotherapy and autologous bone marrow transplantation.

23. Most specific test for Sjogren’s syndrome: lip biopsy. (shows lymphoid foci in accessory salivary glands)

24. Unless strangulation or perforation is suspected, bowel obstruction is treated conservatively with fluids, nasogastric suction and enemas.

25. Monoclonal gammopathy of undetermined significance (MGUS): characterized by lab findings of an M component (IgA, or IgG, or IgM)<3000 mg/dL, and fewer than 10% plasma cells in the bone marrow. Patients initially do not require any Tx, but proper education and counseling are necessary. Regular follow-up visits are recommended, and all patients are instructed to promptly obtain medical evaluation if any clinical symptoms occur.

26. Rhabdomyolysis should be suspected in the following situations:
o Presence of risk factors such as alcoholism, cocaine use, and electrolyte abnormalities (eg. Hypokalemia, hypophosphatemia)
o Disproportionate elevation of creatinine as compared with BUN
o Urine dipstick positive for blood but no RBC on microscopic examination.
o (The underlying pathology is acute tubular necrosis. Serum CK should be measured in
o suspected patients. The Tx is aggressive IV hydration and alkalinzation of urine. Forced
o diruesis with mannitol may be required.)

27. Moderation of alcohol intake to 1-2 drinks per day has been shown to have a cardioprotective effect (BP reduction).

1. Manometry establishes the Dx of diffuse esophageal spasm. (esophageal motility studies)

2. Alzheimer’s disease: A MMSE score of <24 is suggestive of dementia (total maximum is 30). Alzheimer’s disease is the MCC of dementia in the western world. Etiology is unknown, but the following mechanisms have been implicated:
 Degeneration of the basal nucleus of Meynert (in the forebrain), which secretes acetylcholine (Ach). (diffused cortical and subcortical atrophy on CT scan)
 Deficiency of choline acetyltracnsferase and its product, Ach, in the brain.
 Abnormal amyloid gene expression

3. Infectious mononucleosis is an infection caused by the EBV, and is sometimes detected only when the patient develops a characteristic polymorphous rash after taking ampicillin for an apparent upper respiratory tract infection.

4. Orthotopic liver transplantation remains the only effective mode of Tx of fulminant hepatic failure and should be considered in any patient presenting with fulminant hepatic failure, regardless of the etiology.

5. The Dx of PCP is likely if an HIV patient has a non-productive cough, exertional dyspnea, fever, severe hypoxia, bilateral interstitial infiltrates on chest X-ray, and a normal white count. TMP-SMX is DOC. Steroids have been shown to decrease the mortality in patients with severe PCP.

6. Indication of steroid use in PCP includes:
o PaO2<70 mmHg
o A-a gradient >35; (A-a gradient= (150-(1.25xpCO2))-PO2)

7. PID tx: inpatient Tx with cefotetan + doxycycline

8. Aspirin intoxication in adults initially causes increased respiratory drive leading to respiratory alkalosis and then uncouples oxidative phosphorylation leading to metabolic acidosis.

9. Hairy leukoplakia is a white, painless lesion that appears “hairy” and is often found in AIDS patient on the lateral aspect of tongue. It is caused by EBV.

10. CT of the chest should be done to look for a thymoma in all newly diagnosed myasthenia gravis patients.

11. Reversible acetylcholinesterase inhibitors such as donepezil, rivastigmine, galantamine, and tacrine are of benefit in slowing the cognitive decline associated with Alzheimer’s disease.

12. Consider 3 possibilites when a flat film of the abdomen and pelvis doesn’t show a stone in a patient with typical renal colic:
o Radiolucent stone disease (uric acid stones)
o Calcium stones less than 1 to 3 mm in diameter
o Non-stone causes (eg. Obstruction by a blood clot or tumor)

13. Uric acid stones are highly soluble in alkaline urine; therefore alkalinzation of urine to pH>6,5 with oral sodium bicarbonate or sodium citrate is the Tx of choice.

14. Clinical scenario describing a woman with chronic headaches who presents with painless hematuria is typical for analgesic nephropathy. Papillary necrosis is the cause of hematuria.(vasoconstriction of medullary blood vessels, vasa recta)

15. Hypercarotenemia is commonly seen in patients with anorexia, diabetes & hypothyroidism.

16. Impaired ammonia ion (NH4+) excretion is the principal mechanism of metabolic acidosis in chronic renal disease.

17. Situational syncope should be considered in the DD of syncopal episodes. The typical scenario would include a middle age or older male, who loses his consciousness immediately after urination, or a man who loses his consciousness during coughing fits.

18. Primary pulmonary HTN can be seen in middle-aged patients, and it presents with exertional breathlessness. Lungs will be clear to auscultation. Chest X-ray would show enlargement of the pulmonary arteries with rapid tapering of the distal vessels (pruning) and enlargement of the right ventricle.

19. Pyromania is characterized by intentional, repeated fire setting with no obvious motive. Although a history of arson may be documented in individuals with conduct disorder, other features will be present as well. (lying, theft, cruelty, etc.)

20. Tx for E. vermicularis infection (pinworm):
First line: Albendazole or mebendazole
Alternative: pyrantel palmate

21. Subcutaneous emphysema in an asthmatic is a benign disorder. A chest X-ray must be ordered to ensure that there is no pneumothorax.

22. Dapsone is an effective Tx for dermatitis herpetifomis. Dermatitis herpetiform occurs in association with celiac sprue. (will improve within hours after applying the drug)

23. The presence of dermatitis herpetiformis (erythematous vesicles symmetrically distributed over the extensor surfaces for elbows and knees) and chronic non-bloody diarrhea in a child of 12-15 months is suggestive of celiac disease. (microcytic anemia too).

24. Rigid bronchoscopy is indicated in patients with massive hemoptysis as it allows rapid visualization of the bleeding site and to control bleeding through cauterization or other means.

25. Triad of juvenile angiofibroma: (a markedly vascular fibrous tumor in nasopharynx of males, usually in the 2nd decade of life.)
 Nasal obstruction
 Nasopharyngeal mass
 Recurrent epitaxis

26. Endoscopic retrograde cholangiopancreatography (ERCP) is the investigation of choice for patients with recurrent pancreatitis with no obvious cause.

27. Rotator cuff tear:presents with shoulder pain aggravated by movements like pushing, pulling and positioning the arm above the shoulder as well as weakness of shoulder resulting in functional impairment. Dx: MRI of the shoulder, or arthrography.

28. Subacromial bursitis: injury to rotator cuff is a common casue of shoulder pain and disability in athelets. Prolonged, repetitive overhead activity as in tennis, swimming, pitching or golf can compromise the space between the humeral head and coracoacromial arch leading to impingement syndrome. Subacromial bursitis results from impingement syndrome. It refers to inflammation of the subacromial bursa. Rotator cuff tendon tear and supraspinatus tendonitis can also occur as a part of impeachment syndrome.

29. Normal pressure hydrocephalus: is characterized by the triad of gait disturbance, dementia and urinary incontinence. Lumbar puncture reveals the normal CSF pressures, and MRI shows the enlarged ventricles (not like in pseudotumor cerebri, the ventricles shrink) Tx.: CSF shunting procedure.

30. Psedotumor cerebri: suspect this in a young obese female with a headache that is suggestive of a brain tumor, but with normal neruoimaging and elevated CSF pressure (papilledema). Tx: weight reduction, acetazolamide. Shunting or optic nerve sheath fenestration may be performed to prevent blindness. (if left untreated-> blindness)

31. Membranous nephropathy is the MC nephropathy associated with carcinoma.

32. Nephrotic syndrome is a well-known complication of Hodgkin’s lymphoma, usually casued by minimal change disease *extremely HY Q for the USMLE*

33. pressure sores are common over: (mostly parts below the waist)
 hips
 sacrum
 heels

34. Hepatic venogram or a liver biopsy is the diagnostic test of choice for the evaluation of congestive hepatomegaly secondary to hepatic vein occlusion (Budd Chiari syndrome)-elevated hematocrit with organomegaly, polycythemia rubra vera (at risk of hepatic vein occlusion)

35. Patients treated with high-dose methylprednisolone within 8 hours of spinal cord injury have significant and sustained neurological improvement, thus its use is warranted as the first priority after stabilizing the patient. *important Q!!!*

36. ECG manifestations of digitalis toxicity: atrial tachycardia with AV block.

37. Basal cell carcinoma presents as a slow-growing, pearly and indurated lesion. It is the most common malignant tumor of the eyelid. (eyelid swelling, loss of lashes)

38. Cataract is the MCC of leukocoria (not retinoblastoma). The causes of cataract include familial, congenital infection (rubella), metabolic conditions (eg, DM, galactosemia), genetic disorders (eg. Down’s syndrome, Turner’s syndrome), and long-term/high dose glucocorticoid use. (extremely HY Q!)

39. Effective in preventing pneumocystis carinii in transplant patients:
oral Trimethoprim-sulfamethoxazole.
If sulfa allergic, use aerosolized pentamidine and Dapsone

40. Biophysical profile score of <2 is alarming and baby should be delivered immediately.

41. Cat bites Tx: prophylactically with a 5-day course of amoxicillin/clavulanate.

42. Suspect rosacea in 30-60 yo patients with telangiectasia over the cheeks, nose, and chin. Flushing of these areas is typically precipitated by hot drinks, heat, emotion, and other causes of rapid body temperature changes. Topical antibiotic such as metronidazole is the most frequrently prescribed initial therapy.

43. Lofgren’s syndrome: is an acute form of sarcoidosis and consists of triad of bilateral ankle arthritis(sometimes knees, wrists or elbow), erythema nodosum and bilateral hilar adenopathy.

44. Erythema nodosum (EN): pink to reddish painful, subcutaneous, nodules that usually develop in a pretibial location. Resolve without scarring over a 2-6 week period. Histologically, this is a panniculitis involving inflammation of septa in the subcutaneous fat tissue. EN is commonly associated with recent streptococcal infection.

45. Causes for painless hematuria:
 Glomerulonephritis
 Hb S trait
 Kidney stones
 Tumor

46. Intravenous pyelography (IVP) is very useful for the Dx of renal stones.

47. DOC for Variant angina: calcium channel blockers (eg. Diltiazem)

48. Chronic supraphysiological doses of glucocorticoids suppress CRH release, thereby causing central adrenal insufficiency. Aldostorone secretion is relatively preserved. Lab studies typically show low ACTH and low cortisol levels.

49. The most serious complication of bronchiectasis is: hemoptysis.

50. Oligoclonal bands are present in 85-90% of cases of multiple sclerosis. CSF pressure, protein and cell counts are grossly normal. (may present as: paraplegia, urinary incontinence, urgency. Trigenminal neuralgia, spasticity, hyperreflexia in the lower extremities, impaired vibration and proprioception in one arm. (high immunoglobulin levels, especially IgG)

51. Suspect pulmonary embolism in any patient who presents with sudden onset of shortness of breath, pleuritic chest pain, normal lung exam, hypoxic, and have tachypnea, tachycardia, and hypotention. New onset A fib (ECG: reveals irregular RR intervals, with no definite P waves and narrow QRS complexes) is seen in few patients with PE. Pulmonary vascular disease includes PE.

52. Tumor burden is the single most important prognostic consideration in the Tx of patients with breast cancer. It is based on TNM staging.

53. Early excision therapy is indicated for extensive partial-thickness and full-thickness burns, as they do not heal spontaneously. Also, it allows for early skin grafting and lesser complications.

54. Meningitis and empirical antibiotic regimens:
 In children, Listeria monocytogenes: ampicillin + cefotaxime
 In hospitalized patients, staph. Aureus and pseudomona: vancomycin (to cover Staph.) and ceftazidime (3rd generation cephalosporins to cover pseudomonas)
 Pneumococci: vancomycin + ceftrizxone (third generation cephalosporin)

55. Radial Tunnel syndrome: can be confused with lateral epicondylitis as both the conditions can coexist. It is a compression neuropathy of radial nerve in radial tunnel characterized by tenderness over mobile muscle mass distal to the radial head. Also, the pain is reproduced by simultaneously extending the wrist and fingers while the long finger is passively flexed by the examiner and also by resisted forearm supination.

56. Rupture of long head of biceps: commonly occurs in bicipital groove and would lead to a bulging muscle mass in the middle arm

57. Lateral epicondylitis: also know as tennis elbow is epicondylitis about the origin of extensors of forearm, know how to differentiate it from radial tunnel syndrome.

58. Transmission of HIV by breastfeeding is well documented; therefore, the presence of maternal HIV infection is an absolute contraindication to breastfeeding.

59. Performance-related anxiety: prophylactic propanolol.

60. Generalized anxiety disorder (GAD): Buspirone is a first line drug. (it does not cause the physical dependence and withdrawal symptoms associated with benzodiazepines)

61. Pericardial cysts are usually found in the middle mediastinum. Thyoma is usually found in the anterior mediastinum. All neurogenic tumors (menigocele, enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors and aortic aneurysms) are located in the posterior mediastinum. It is benign, and can be aspirated and will shrink.

62. Middle mediastinal masses include:
 Bronchogenic cysts
 Lymphoma
 Lymph node enlargement
 Aortic aneurysms of the arch.
 Pericardial cysts

63. TCA (i.e. imipramine) intoxication: Sodium bicarbonate (single most effective intervention). It prevents the development of arrhythmia in patients with TCA toxicity by alleviating cardio-depressant action on sodium channels.

64. Antibiotic therapy is the most accepted and recommended management for the eradication of H. pylori in patients with gastric MALT without any metastasis. (PPI, clarithromycin, amoxicillin)

65. Drug-induced pancreatitis is mild and usually resolves with supportive care. CT scan is diagnostic for pancreatitis. (presents as abdominal pain, nausea, vomiting, low-grade fever, loss of appetite)

66. In patients presenting with significant peripheral vascular disease, calcium channel blockers are preferred as anti-HTN agents. (such as amlodipine)

67. Granuloma inguinale is an STD caused by the bacterium Donovania granulomatis and characterized by an initial papule, which rapidly evolves into a painless ulcer with irregular borders and a beefy-red granular base. Tx: tetracycline 500 mg every 6 hours for 10-21 days

68. Children with occupational defiant disorder are disobedient and argumentative. Although they may be hostile, they do not seriously violate the rights of others.

69. MCC of hypercalcemia in admitted patients: malignancy. Due to multiple reasons:
 PTHrP secretion
 Osteolytic metastasis
 Increased formation of 1,25-dihydroxyvitamin D
 Increased interleukin 6 levles
 (normal calcium level: 8.4-10.2, thiazide will cause mild hypercalcemia, won’t reach 14)

70. How to manage unstable angina in the setting of anemia due to a massive GI hemorrhage?---blood transfusion.

71. When PEEP is increased, its major drawback is a decrease in cardiac output. Patients who are maintained on PEEP should be monitored with a Swan-Ganz catheter. This Q is based on simple physiology. It is expected in USMLE.

72. DOC for early syphilis: benzathine penicillin G and a single IM injection is required. For those who are allergic to penicillin, doxycycline or tetracycline is given orally for 14 days.

73. DOC for patient with neurosyphilis: IV aqueous crystalline penicillin. IM procaine penicillin is a good alternative.

74. A complex partial seizure is characterized by brief episodes of impaired consciousness, failure to respond to various stimuli during the episode, staring spells, automatisms, and postictal confusion. The EEG pattern is usually normal or may show brief discharges. *Remember the automatisms.*

75. Patients with a leukocyte adhesion defect suffer from recurrent bacterial infections. Delayed separation of the umbilical cord and necrotic periodontal infections are characeteristic. (normal NBT test, increased gamma globulin level)

76. In cases of intrauterine growth retardation, (IUGR), presence of oligohydraminos ( AFI < 5, amnionic fluid index) is an indication for delivery.

77. When hemorrhage occurs, the pulse pressure is the first physiological change.

78. Anserine bursitis presents with medial knee pain just below the joint line.history of trauma, well-defined area of tenderness over the medial tibial plateau just below the joint line. Valgus stress test doesn’t aggravate the pain. X ray of tibia is normal.

79. Test of choice for lumbar spinal stenosis: MRI. Symptoms: associated with aging, >60 yo. Narrowing of the spinal canal results from encroaching osteophytes at the facet joints, hypertrophy of the ligamentum flavum and protrusion of intervertebral disks. Gait disturbance can be so prominent that they complain of having spaghetti legs or walking like a drunken sailor. The preservation of pedal pulses helps distinguish from vascular claudication.

80. Decision of use of N-acetyl cysteine as an antidote for acetaminophen overdose is generally based on 4 hour post-ingestion acetaminophen levels. (ingested >7.5 gm of acetaminophen: give antidote)

81. Any elderly patient who presents with pneumonia, abdominal pain, confusion and hyponatremia should be suspected for Legionellar pneumonia. This should also be suspected in patitents who fail to respond to beta-lactam antibiotics and gram stain showing many poly with few visible organisms. (they are intracellular ones). Tx. of choice for Legionella pneumonia: high dose erythromycin or azithromycin.

82. Cholesterol embolization usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic esosinophilia, and low complement levels should make you think of cholesterol embolism. *extremely HY Q*

83. Aortic dissection is an acute emergency and its medical management includes prompt blood pressure lowering with IV nitroprusside and short-acting beta-blocker.

84. Unacceptability bias refers to participants’s response with desirable answers which leads to underestimation of the risk factors.(eg. Medical school students know the risk of smoking and may not care to reveal their smoking status, especially to the public health department. Therefore a lower number of smoker may be reported, than actual.)

85. The MC esophageal anomaly is esophageal atresia with a tracheoesophageal fistula. This is characterized by an atretic esophageal pouch that communicates distally with the trachea just above the carina. Pneumonitis and atelectasis occur frequently.

86. The mechanism of action of antipsychotic drugs (such as haloperidol) is primarily blockade of the dopamine-D2 receptors. The added serotonin antagonism of atypical antipsychotic drugs (such as resperidone) reduces the likelihood of extrapyramidal side effects.

87. Parinaud’s syndrome (paralysis of vertical gaze that may be associated with papillary disturbances) and Collier’s sign (eyelid retraction) usually indicate a lesion in the rostral midbrain, most likely pinealoma or germinoma.

88. Fluid overload can lead to pulmonary edema and heart strain (elevated CVP, like 30 cmH2O and an S3 gallop).

89. Acute exacerbations of MS are treated with corticosteroids. Beta-interferon or glatiramer acetate is used to decreased the frequency of exacerbations in patients with relapsing-remitting or secondary progressive form of MS.

90. CT scan is the best test for the Dx of diverticulitis in acute setting.

91. Hyaline memebrane disease should be suspected in preterm infants with respiratory distress and hypoxia not responding to oxygen therapy. The characteristic chest X-ray findings of HMD demonstrates fine granularity of the lung parenchyma, and fine rales, hypoxemia and metabolic acidosis. Tx includes early mechanical ventilation and surfactant administration.

92. Magnesium is an effective Tx for torsade de pointes (i.e. side effect of quinidine)

93. Lidocaine: is a class 1 anti arrhythmic agent, used in the Tx of ventricular tachycardia and fibrillation. Always given IV.

94. Hemodynamically unstable: low BP, patient not responding to commands, etc.

95. Common causes of Atrial flutter:
 Mitrial valve stenosis
 HTN
 Pulmonary embolism
 CAD (coronary artery disease)
 Pericarditis
 Post cardiac surgery
 COPD

123. Atrial flutter Tx:
 Atrial flutter with unstable hemodynamics is best treated with cardioversion.
 Acute atrial flutter with stable hemodynamics can be treated with cardioversion or can be managed with rate control.
 Chronic stable atrial flutter is best treated with rate control, which is best achieved with either calcium channel blockers or beta-blockers.

96. Plain X-ray of the sarcroiliac joints is the next best step in a suspected patient of ankylosing spondylitis.

97. Always suspect malignant HTN in patients with very high BP. Presence of papilledema on ophthalmoscopy confirms the Dx. The pathologic change responsible for end-organ damage in malignant HTN is fibrinoid necrosis of small arterioles.

98. Parathyroidectomy is the only effective Tx for primary hyperPTH.

99. Budd Chiari syndrome or hepatic vein occlusion is most commonly associated with polycythemia vera and other myeloproliferative disease. (severe RUQ pain, icteric sclera, hepatomegaly, splenomegaly, free fluid in abdomen. Centrilobular congestion)

100. Treatment for narcolepsy include:
 Scheduled daytime naps.
 Psychostimulants (eg modafinil)
 Or a combination of antidepressants and psychostimulants (methylphenidate)

101. A nail puncture wound in an adult resulting in osteomyelitis is most likely due to Pseudomonas aeruginosa.

102. Excessive use of vit C in patients with renal insufficiency can cause oxalate stones. (radioopaque)

103. Elderly patients are particularly predisposed to dehydration after even minor insults (e.g., a minor febrile illness). Know the classic signs of dehydration (ie. Dry mucosa, marginally high values for hematocrit and serum electrolytes, BUN/creatinine ratio >20.) The Tx is administration of IV sodium-containing crystalloid solutions (usually 0.9% NaCl= normal saline).

104. Tinea versicolor is characterized by pale, velvety pink or whitish, hypopigmented macules that do not tan and do not appear scaly, but scale on scraping. Topical Tx with selenium sulfide lotion and ketoconazole shampoo is recommended. (extremely HY Q)

105. Any elderly patient with bone pain, renal failure, and hypercalcemia has multiple myeloma until proven otherwise. 50% MM paitents develop some degree of renal insufficiency; this is most likely due to obstruction of the distal and collecting tubules by large laminated casts containing paraproteins (mainly Bence Jones protein).

106. Anesthesia may reduce uterine activity if administered in the latent phase (too soon to use anesthesia)

107. Anti-smith antibodies are present only in 30-40% SLE patients (but is very specific). A case of SLE presents with: pain and swelling of joints of her right hand and wrist, low-grade fever, malaise, difficult to rise from the chair. APTT slightly increased. Oral cavity shows painless ulcer on the buccal mucosa. (+) ANA, (+) RA, (-) anti-smith Ab. Lupus procoagulant (+)

108. Anti phospholipids antibody syndrome: may be either primary or associated with other autoimmune disorders like SLE. Characterized by recurrent arterial or venous thrombosis or recurrent fetal losses in the presence of anti phospholipids antibodies.

109. There are 3 types of anti phospholipids antibodies:
o The 1st is responsible for false-positive syphilis serology. (VRDL)
o The 2nd is responsible for lupus anticoagulant, which falsely elevated APTT.
o The 3rd is anticardiolipin antibody.

110. The Tx for an acute severe exacerbation of lung disease in a cystic fibrosis patients is intravenous antibiotic therapy with coverage against Pseudomonas aeruginosa (usually a combination of two drugs, such as penicillin/cephalosporin + aminoglycoside). The example I met is :IV ceftazidime and gentamicin.

111. Thiazide (HCTZ) is the initial DOC for treating HTN in patients with chronic persistent asthma.

112. Anti-thyroid peroxidase antibodies (namely antimicrosomal Ab) are present in more than 90% of patients with Hashimoto’s thyroiditis.

113. Choanal atresia: It is the MC nasal malformation. It may be isolated or part of a dysmorphic syndrome. Suspect choanal atresia in an infant who presents with cyanosis that is aggravated by feeding and relieved by crying.

114. Choledochar cysts: are congenital abnormalities of the biliary tree characterized by dilation of the intra and/or extra hepatic biliary ducts. ( abdominal pain, yellow urine, icteric sclerase, abdominal tenderness with a mass palpable in RUQ. Mild elevated amylase and lipase, ultrasonography: shows a cystic extra hepatic mass and a gall bladder separated from the mass.

115. Migratory thrombophlebitis and atypical venous thromboses: are suggestive for chronic DIC, most likely due to some visceral malignancy.

116. Seborrheic dermatitis: is characterized by dry scales, central face, presternal region, interscapular areas, umbilicus and body folds. It may be associated with Parkinsonism, acutely ill patients who have been hospitalized, and HIV positive individuals.

117. Suspect an HIV infection in a young patient with seborrheic dermatitis.

118. Suspect hepatitis C infection in patients with lichen planus.

119. Atracurium is a neuromuscular blocking agent that is metabolized in plasma and hydrolysed by serum esterases. Its use is safe in patients with renal and liver dysfunction.

120. Early deceleration: defined as a decrease in fetal heart rate by 15 beats/sec from baseline for at least 15 sec, occurring at the same time as the uterine contraction.

121. Early deceleration is due to fetal head compression.

122. Fetal cord compression presents with variable decelerations.

123. Uteroplacental insufficiency presents with late decelerations. (most worrisome)

124. An epidural abscess presenting with neurologic symptoms of spinal compression requires urgent surgery.

125. Be overly suspicious for an intraocular foreign body in patients with high-velocity injuries (drilling, grinding, etc). If the initial pen light examination does not reveal any conjunctival and corneal abrasions or foreign bodies, proceed with fluorescein examination.

126. Know how to treat acute pulmonary edema in the setting of an acute MI. Loop diuretics should be given to treat pulmonary edema.(furosemide)------symptoms described for this case: sudden onset of severe substernal chest pain asoociated with SOB, radiating to the left arm. Pain not respond to baby aspirin and nitroglycerine. EKG has shown diffuse ST elevation in the inferior and lateral leads. JVD, 2+ pedal edema bilaterally.

127. With posterior dislocation of the shoulder, patients shows internally rotated arm, inability for external rotation and intact sensation and reflexes.

128. Local therapy (eg. Resection of metastases, local irradiation) is rarely curative in paients with metastatic breast cancer, but it can be tried in patients with a respectable solitary metastatic focus without signs of systemic involvement.

129. The MC locations of post aspiration lung abscess in recumbent position are apical segment of right lower lobe and posterior segment of right upper lobe.

130. Lung abscess is commonly seen in patients with predisposition to aspiration and those with periodontal disease. (seizure), Mouth anaerobes are responsible for most of the lung abscesses.

131. DOC for variant angina: calcium channel blockers. Variant anginas are different from classic angina patients. They are younger, and do not exhibit the classic cardiovascular risk factors. (due to vasospastic condition, they may also have other related conditions like migraine headaches or Raynaud’s phenomena.)

132. Hemorrhage in HTN patients:
 MC site of HTN hemorrhage: putamen (35%). The internal capsule lies to the putamen and is almost always involved, thereby leading to hemiparesis. Other signs: hemi-sensory loss, homonymous hemianopsia, stupor and coma. The eyes are deviated away from the paralytic side.
 Pontine hemorrhage accounts for 5-12%. Presents with deep coma, paraplegian that developed within a few minutes. The pupils are pinpoint and reactive to light. There is decerebrate rigidity. There are no horizontal eye movements.
 Subarachnoid hemorrhage: sudden dramatic onset of severe headache, no focal neurological signs. The MCC are saccular aneurysm and vascular malformations.
 Cerebellar hemorrhage: ataxia, vomiting, occipital headache, gaze palsy, and facial weakness. There is no hemiparesis. (emergency decompression may be life-saving in such cases)

133. P value shows the probability of obtaining the result of a study by chance alone. When the P value is less than 0.05, this is usually considered statistically significant. It is very important to know the interpretation of the P value and its relationship with confidence interval.

134. Many patients with influenza are treated with bed rest and simple analgesia (eg, acetaminophen). Antiviral medications can reduce the duration of influenza symptoms by 2-3 days; however, these drugs are only effective if administered within 48 hours of the onset of illness. Amantadine and rimantadine are only active against influenza A. The neuraminidase inhibitor (ie, zanamivir and oseltamivir) are active against both influenza A and influenza B. *extremely HY Q for the USMLE*

135. Chlamydial urethritis is suggested by mucopurulent urethral discharge, absent bacteriuria, and history of multiple sexual partners.

136. Herpes mainly affects the temporal lobe of the brain and may present acutely (<1 week duration) with focal neurological findings. The characteristic CSF findings are lymphocytic pleocytosis, increased number of erythrocytes, and elevated protein. HSV PCR analysis is the gold standard.

137. Be ware of the potential for the development of metabolic alkalosis in patients taking both Kayexalate and magnesium hydroxide. Kayexalate is a cation binding resin.

138. MC acid base disorder encountered in the hospitalized patient in the U.S.: metabolic alkalosis.

139. DA-agnoist such as bromocriptine or cabergoline are the mainstays of Tx for most patients with prolactinoma (for <10mm, over that size, surgery)

140. Imatinib mesylate: has changed the prognosis of patients with chronic myelogenous leukemia. (It is a tyrosine kinase inhibitor and works by blocking signals within cancer cells and preventing a series of chemical reactions that cause the cancer cells to grow and divide)

141. Infliximab, etanercept: TNF receptor inhibitors, used to treat RA.

142. Premenopausal women with simple or complex hyperplasia without atypia usually respond to therapy with cyclic progestins. However, all patients should undergo repeat biopsy after 3-6 months of Tx. Even if the patient does not want more children, a hysterectomy is not warranted.

143. Hyper-IgM syndrome (HIM) is characterized by high levels of IgM with deficiency of IgG, IgA and poor specific antibody response to immunizations.

144. Always rule out hypothyroidism in patients who present with symptoms of depression. Once ruled out, prescribe fluoxetine. For severe, refractory depression, ECT is helpful.(also helpful in pregnant women)

145. When treating patients with Pheochromocytoma: do not give beta-blockers without alpha-blockers. Always give an alpha-blocker first, followed by a beta-blocker; doing this in the wrong order can precipitate a very dangerous increase in BP. (α-blocker first then β-blocker) i.e.: phentolamine, phenoxybenzamine.

146. Glucocorticoids are indicated in a case of infectious mononucleosis complicated by upper airway obstruction, autoimmune hemolytic anemia, and thrombocytopenia.

147. Monospot test (+): is sufficient to Dx infectious mononucleosis.

148. Brain death is clinical Dx. The characteristic findings are absent cortical and brain stem functions. The spinal cord may still be functioning; therefore deep tendon reflexes may be present.

149. Secondary amenorrhea is relatively common in elite female athletes and results from estrogen deficiency.

150. Spondylolisthesis is a developmental disorder characterized by a forward slip of vertebrae (usually L5 over S1) that usually manifests in preadolescent children. In the typical clinical scenario, back pain, neurologic dysfunction (eg. Urinary incontinence-bed wetting), and a palpable “step-off” at the lumbosacral area are present if the disease is severe.

151. Intermittent claudication is best treated with aspirin and an exercise program.

152. Controlling the rhythm or rate in patients with prolonged tachysystolic atrial fibrillation usually improves the LV function significantly, sometimes even dramatically.

153. Kallmann syndrome: hypogonadic hypogonadism, + decreased sense of smell. (secondary hypogonadism, low LH, FSH). Tx: testosterone.

154. Klinefelter syndrome: 20 times higher risk for developing breast cancer. Mostly are not mental retarded.

155. SLE pregnant women: treated with LMWH or aspirin to avoid spontaneous abortions during the 2nd and 3rd trimester.

156. All SLE pregnant patients should be screened for SSA/anti-Ro antibodies. Since they cross the placenta and cause neonatal lupus and rarely permanent heart block.

157. Anti-dsDNA Ab positive---very specific for the Dx of SLE, also increase the likelihood of lupus nephritis, and when they are ↑, they point to currently active SLE.

158. Schober test: a measure of lumbar spine motion in which parallel horizontal lines are drawn 10 cm above and 5 cm below the lumbosacral junction in the erect subject; with maximum forward flexion, the distance between the lines increases at least 5 cm in normal patients but far less in patients with anklylosing spondylitis

159. Ankylosing spondylitis: stiffness in the morning >1 hr, improved as exercises. The Dx of AS is based on clinical and X-ray findings (sacroiliitis, fusing of the sacroiliac joint, bamboo spine and squaring of the vertebral bodies), not based on HLA-B27.

160. Septic arthritis:
 In young man/women, consider gonorrhea, Tx: ceftriaxone (3rd generation cephalosporin, to cover gonorrhea)
 In older patients with RA, consider staph. Aureus, Tx. nafcillin or vancomycin

161. Capsaicin cream: used in Tx of osteoarthritis (OA). Depletes local sensory nerve endings of substance P.

162. Prophylatic for malaria in pregnancy: combination of atovaquone & proguanil.

163. Smoking cessation: nicotine patches/gums, or the oral antidepressant bupropion.

164. Bupropion: is dopaminergic and adrenergic, it not only improves depression but also improves cognitive funcitong related to OCD.

165. Nephrogenic DI: treated with thiazides. The mechanism is incompletely understood. It is possible that the natriuretic action of thiazides and resulting depletion of extracellular fluid volume plan an important role in the thiazide-induced antidiuresis. In this regard, whenever ECF volume is reduced, compensatory meachnisms increase reabsorption of NaCl in the proximal tubule, reducing the volume delivered to the distal tubule.(From Harrison online.)

166. Osteoarthritis: obesity is a major risk factor for osteoarthritis. Hence weight loss is the most effective measure in osteoarthritis management.

167. Suspect peritonsillar abscess or quinsy in an ill-appearing patient with fever, sore throat, dysphagia, trismus, pooling of saliva, and muffled voice. Management includes needle drainage (patient should be in the Trendelenburg position), close monitoring, and IV antibiotics. MCC- β hemolytic streptococcus.(group A streptococcus)

168. Respiratory synscytial virus infection may increase the risk of asthma later in life.

169. Open angle glaucoma: usually asymptomatic in the earlier stages, more common in African Americans, and has an ↑ prevalence in those with a family history of glaucoma and diabetes. There is a gradual loss of peripheral vision over a period of years, and eventual tunnel vision. (Intraocular pressure is high, cupping of the optic disc with loss of peripheral vision.) Tx: beta-blockers, (timolol eye drops), laser trabeculopalsty, surgical trabeculectomy.

170. Angle closure glaucoma: is characterized by a sudden onset of symptoms such as blurred vision, severe eye pain, nausea, and vomiting. Examination reveals a red yee with a hazy cornea and a fixed, dilated pupil.

171. Macular degeneration: affects central vision

172. Cataract: is a vision-impairing disease characterized by progressive thickening of the lens. Oxidative damage of the lens occurs with aging and leads to cataract formation. Patients usually complain of blurred vision, problems with nighttime driving, and glare. Definitive Tx: lens extraction.

173. Acetaminophen intoxication:
 4 hour post-ingestion acetaminophen levels are determined to decide whether the patient will benefit from N acetyl cysteine, or not.
 If patient (adult) has ingested >7.5 gm of acetaminophen and levels will not be available within 8 hours after ingestion, he should be given the antidote.
 Gut emptying procedures are best effective if carried out in the first hour.

174. Remember the following when Tx with phosphodiesterase inhibitors:
 Sildenafil is contraindicated in patients on nitrates, and in those who are hypertensive to dildenafil.
 Sildenafil is used with precaution in conditions predisposing to priapism
 Concurrent use of drugs which interfere with the metabolism of sildenafil (e.g. erythromycin, cimetidine) may predispose to adverse reactions by prolonging its plasma half life.
 While combining with an alpha-blocker, it is important to give the drugs with at least 4 hour interval to reduce the risk of hypotension.

175. Vasovagal syncope (common faint): neurally mediated or neurocardiogenic syncope. Presents with prodome (lightheadness, weakness, and blurred vision), provocation by an emotional situation, and rapid recovery of consciousness. Dx: upright tilt table testing with or without pharmacologic provocation (isoproterenol) may be indicated to confirm the Dx.

176. Sick sinus node syndrome: once diagnosed, the best Tx is placement of a permanent ventricular pacemaker.

177. Porcelain gall bladder: is an entity usually diagnosed on an abdominal Xray. The condition predisposes individuals to gall bladder carcinoma and requires resection.

178. The overall incidence of vertical transmission of HCV is approximately 2-5%. All patients including pregnant patients, with chronic hepatitis C should receive vaccinations against Hepatitis A and B if not already immuned. *extremely important Q for USMLE*

179. Tx of hepatitis C: interferon-alfa and ribavirin. But they are contraindicated in pregnancy. Ribavirin is particularly highly teratogenic.

180. HCV sexual transmission incidence is extremely low, so no recommended barrier precautions between stable monogamous sexual partners.

181. Suspect choriocarcinoma in any postpartum women who presents with shortness of breath, chest pain and hemoptysis. The next step is chest X ray, pelvic exam, and β-hCG.

182. Suspect hemoochromatosis in a patient with new-onset DM, arhtropathy, and hepatomegaly.

183. Painless gross hematuria is the MC presentation of sickle cell trait (characterized by a Hb S concentration ranging from 35-40%)

184. Dactylitis: is common in patients with sickle cell anemia. (hand-foot syndrome, symmetric painful swelling of the feet and hands)

185. Frequent UTIs occur in pregnant individuals with sickle cell trait.

186. Type A personality: is characterized primarily by time pressure (ie. Feeling rushed most of the time) and competitiveness. Patients of type A personality are not at special risk for cardiovascular disease.

187. Insulin resistance plays a central role in the pathophysiology of non-alcoholic fatty liver disease by increasing the rate of lipolysis and elevating the circulating insulin levels.

188. Arthrocentesis followed by empiric Tx with IV nafcillin are the most appropriate measures for the management of suspected septic arthritis in a child.

189. Osteomyelitis in DM patients that involves the bone adjacent to the foot ulcers is explained by the contiguous spread of infection.

190. Tumor lysis syndrome: hyperphosphatemia, hypocalcemia, hyperkalemia, hyperuricemia (increased phosphate binds to calcium and causes hypocalcemia)

191. Idiopathic precocious puberty is managed with GnRH agonist (Lupron, Synarel, Busrelin) therapy in order to prevent premature fusion of the epiphyseal plates.

192. Factor V Leiden is the MC inherited disorder causing hypercoagulability and predisposition to thromboses, especially DVT of lower extremities.

193. McCune-Albright syndrome: 3 Ps: precocious puberty, pigmentation (café au lait spots) and polystotic fibrous dysplasia.(Cushing’s syndrome can occur in patient). (light-brown spots with irregular contours on the back of the shoulders and left side of the neck.)

194. Amitriptyline and cyclobenzaprine have been shown to be effective in the Tx of fibromyalgia

195. An airway is always patent (secure) in a patient who is conscious and able to speak. Chin lift and oxygen by a face mask to clear the airway and cut down the RR.

196. Tumors that are metastatic to bone cause local osteolysis by production of cytokines, such as IL-1 or TNF. The most frequent tumors that produce hypercalcemia by this mechanism are lung cancer and breast cancer.

197. The MCC of hypercalcemia in patients with nonmetastatic solid tumors is production of PTHrP. In such cases, PTH is typically low.

198. Hypercalcemia in Hodgkin’s disease is almost always produced by calcitriol (2nd step in the biological conversion of Vit D3 to its active form, more potent than calcidiol).

199. Aplastic anemia should be suspected in any patient with pancytopenia following drug intake, exposure to toxins or viral infections.

200. Peutz-Jeghers syndrome is characterized by GI polyposis and mucocutaneous pigmentation. It may also involve the development of an estrogen-secreting tumor, leading to precocious puberty.

201. Sturge-Weber disease: is a sproradic phakomatosis characterized by mental retardation, seizures, visual impairment and a characteristic port-wine stain over the territory of the trigeminal nerve.

202. Most thyroid nodules are benign colloid nodules.

203. Fibromuscular dysplasia: can present as new onset HTN in children. Bruit or venous hum (due to well-developed collaterals) may be heard at the costovertebral angle. Angiogram reveals the “string of beads” sign. The right renal artery is more affected than the left.

204. Mitral regurgitation is the MC valvular abnormality observed in patients with infective endocarditis not related to IV drug abuse.

205. Non-communicating hydrocele disappears spontaneously by 12 months of age and it is therefore managed expectantly.

206. Checking for urinary excretion of bilirubin is an easy and effective way of determining whether the cause of jaundice is conjugated or unconjugated bilirubin.

207. A very simple and convenient method is to measure the urinary excretion of bilirubin by urine dipstick method. Normally more than 95% of blood bilirubin is due to unconjugated fraction. The unconjugated fraction of bilirubin is insoluble as it is bound to the albumin and therefore cannot be filtered by the glomerulus and is not excreted in urine. Thus normally urine has no detectable bilirubin. However, the conjugated fraction is soluble in plasma, can be filtered by the glomerulus and excreted in the urine. Patients with conjugated hyperbilirubinemia have >50% of bilirubin in form of conjugated bilirubin so enough of it remains unbound to be filtered and excreted by kidney.A more precise way is to do the Vandenbergh test.

208. The single MCC of asymptomatic isolated elevation of alkaline phosphatase in an elderly patient is Paget’s disease.

209. Glucocorticoid deficiency: weakness, fatigue, depression, irritability, hypotension, lymphocytosis, eosinophilia and hypothyroidism (i.e., cold intolerance, constipation, dry and rough skin, bradycardia), aldosterone production is intact. ----à pituitary tumor, low ACTH ( no hyperpigmentation)

210. aton-Lambert syndrome is associated with small cell carcinoma of the lung, and results from autoantibodies directed against the voltage-gated calcium channels in the presynaptic motor nerve terminal.-leads to defect release of Ach. Electrophysiological studies confirm the Dx. Tx: plasmapheresis and immunosuppressive drug therapy.

211. Autoantibodies against postsynaptic receptors cause myasthenia gravis. Reduction of postsynaptic acetylcholine receptors leads to muscle weakness. The muscle weakness is provoked by repetitive or sustained use of the muscles involved, unlike myasthenic syndrome. Deep tendon reflexes are usually preserved, and may be somewhat brisk in clinically weak muscle.

212. Boerhaave’s syndrome: is esophageal perforation due to severe vomiting and it produce pneumomediastinum.

213. Beckwith-Wiedemann syndrome: characterized by macrosomia, macroglossia, visceromegaly (liver and kidneys), omphalocele, hypoglycemia and hyperinsulinemia.

214. Think of Cocaine intoxication in a young patient presenting with chest pain/myocardial infarction or stroke. Features of cocaine intoxication are cocaine bugs, agitation, decreased appetite, dilated pupils, elevated or decreased BP, tachycardia or bradycardia, and sweating.

215. Acute lymphoblastic leukemia: is the MC leukemia in children. Dx is mainly based on more than 25% lymphoblasts in the bone marrow. Dx is suggested by the presence of anemia, thrombocytopenia and blast cells on a peripheral blood smear, but is confirmed by examination of the BM. (history of viral infection, pallor, hepatosplenomegaly, petechiae, and/or lymphadenopathy.

216. Multifocal leukoencephalopathy: suspect it in an HIV-infected patient with focal neurological signs and multiple non-enhancing lesions with no mass effect on the CT scan.

217. Primary CNS lymphoma: is the second MCC of mass lesion in HIV infected patients. It also presents as a ring-enhancing lesion on MRI, but is usually solitary, weakly enhancing and periventricular. The presence of EBV DNA in CSF is quite specific for the Dx.

218. Most colon cancer develops from polyps: the risk factors for a polyp progressing into malignancy are villous adenoma, sessile adenoma, and size >2.5 cm Only adenomatous polyps are clearly premalignant, but <1% of such lesions progress to malignancy. Hyperplastic polyps are non-neoplastic and do not require further work-up. *extremely HY Q*

219. Cerebral toxoplasmosis: is the MCC of ring-enhancing mass lesion in HIV-infected patients. MRI reveals lesions that are usually multiple, spherical, and located in the basal ganglia. This is unlikely if the patient is receiving TMX-SMX. A positive Toxopalsma serology is quite common in normal subjects in the U.S., and is therefore not specific for this condition.

220. Indications for hemodialysis:
 Refractory hyperkalemia
 Prefractory metabolic acidosis (pH<7.2)
 Uremic pericarditis
 Uremic encephalopathy or neuropathy
 Coagulopathy due to renal failure

221. HIV infected patients who develop esophagitis are first started on fluconazole directed against candidiasis

222. Oral acyclovir is used to treat HSV esophagitis

223. Oral famotidine is used in cases of GERD.

224. Metabolic alkalosis can occur in hemodialysis patients who receive citrate.

225. Elevated PT/INR levels in a patient with hepatic failure may be due to vit. K deficiency or liver cirrhosis. Regardless of the cause, the first step in this setting is empiric administration of vit. K, since there is usually an underlying vit. K deficiency due to several comorbidities. Fresh frozen plasma is indicated if the patient is actively bleeding, or if the patient needs immediate surgery or an invasive procedure.


226. Post-exposure prophylaxis for chicken pox can be provided with VZIG (varicella Zoster immune globulin) or acyclovir. Post exposure prophylaxis with VZIG is preferred and indicated in susceptible high-risk persons exposed to varicella within 96 hours (preferably 72 hours) of exposure.
High risk persons:
 Immunocompromised susceptible children
 Immunocompetent susceptible adolescent (>15 yo) and adults, especially pregnant women
 Newborn of mother with onset of chicken pos <5 days before or <2 days after delivery
 Hospitalized premature infants.

Exposure criteria---Exposed to a case by:
 Continuous household contact
 Palymate for >1 hour indoor
 Hospital contact
 Mother with onset of chicken pox <5 days before or <2 days after delivery

Time of administration:
 Preferably within 72 hours of exposure (within 96 hours at most)
 Efficacy after 96 hours is not known.
High risk persons might have a rash within a week or two.


227. A significant granulocytic leukocytosis may be seen in immediate postpartum period (sweetish smelling). This patient has a normal Lochia rubra, which is characteristic of the first few days postpartum. After 3-4 days, the color becomes paler and the discharge is then named lochia serosa. It turns afterwards white or yellow and becomes lochia alba. If a foul smelling odor is noted, endometritis should be suspected. (reassurance is all that needed)

228. Blood smear with atypical lymphocytes should make you rank CMV higher on the list in a patient with mononucleosis-like symptoms, but monospot test negative.(large basophilic lymphocytes with vacuolated appearance are seen)

229. Acalulous cholesystitis occurs in critically ill patients and imaging studies show diagnostic findings of thickening of the gall bladder wall and presence of pericholecystic fluid.

230. An ACEI is contraindicated in a patient with hyperkalemia.

231. The concept of latent period is an important issue in chronic disease epidemiology. Exposure must be continuously present for a certain period of time (called latent period) to influence the outcome.

232. Lactose intolerance is characterized by a + hydrogen breath test, a + clinitest of stool for reducing substances, and an ↑ stool osmotic gap.

233. When to order endoscopy in GERD:
 Nausea/vomiting
 Weight loss, anemia or melena/blood in the stool
 Long duration of symptoms (>1-2 yrs), especially in Caucasian males >45 yo
 Failure to respond to proton pump inhibitors.

233. The Dx of achalasia is made by manometry, however, endoscopy is required to ensure that there is no malignancy.

234. Currently, quantitative estimation of stool fat is the gold std for the Dx of steatorrhea. (fat malabsorption).

235. Chronic mesenteric ischemia: is suspected in patients with unexplained chronic abdominal pain, weight loss, and food aversion. Evidence of associated atherosclerotic disease is usually present. Physical findings are usually nonspecific. Abdominal examination may reveal a bruit.

236. Zollinger-Ellison syndrome: Dx is fasting serum gastrin level. Greater than 1000 pg/mL is diagnostic of the disorder. Patient with non-diagnostic fasting serum gastrin level should have a secretin stimulation test done.

237. Bacterial overgrowth: is a malabsoption syndrome which can be associated with a history of abdominal surgery.

238. In these cases, CHF (congestive heart failure) is most likely the cause of worsening dyspnea in elderly patients: (BNP will be increased)
 Orthopnea (breathlessness worse while lying flat)
 Lower extremity edema
 S3,
 Bibasilar crackles
 Jugular venous distention
 hepatomegaly

239. B-type natriuretic peptide (BNP) is a natriuretic hormone similar to ANP; however, in contrast to ANP, which is released from the atria, BNP is released from the cardiac ventricles in response to volume overload.

240. The measurement of serum BNP can help distinguish between CHF and other causes of dyspnea. A value >100 pg/mL disgnoses CHF.

241. Depressed CO combined with elevated PCWP(normally <12) ( an indicator of left atrial pressure, and most of the times left ventricular end diastolic pressure) is indicative of left ventricular failure.

242. ACEIs improve prognosis in post-MI patients with subnormal EF by decreasing ventricular remodeling.

243. β-blockers decrease mortality after MI and the incidence of recurrent MI in post-MI patients. They decrese the risk of ischemia and arrhythmic episodes by decreasing the influence of the sympathetic nervous system on the heart.

244. Mediastinal hemorrhage due to coagulation abnormality caused by warfarin: The blood accumulated in the mediastinum causes compression of the surrounding structures leading to cardio-vascular compromise i.e. mediastinal tamponade. (lungs are clear, no pericardiac fluid, heart sounds somewhat muffled, chest pain, dyspnea, ecchymoses, ↑ PCWP), widening of the mediastinum.

245. Large cell carcinoma of the lung: may produce hCG resulting in gynecomastia, milky discharge, and elevated levels of serum hCG. (false + pregnancy test).

246. Schizoaffective disorder: is characterized by the presence of schizophrenia and mood symptoms.

247. connversion disorder: characterized by the sudden onset of pseudoneurologic symptoms or deficits involving the sensory or voluntary motor systems. Common triggers include relationship conflicts or other stressors with an intense emotional component, but the symptoms are not feigned or purposefully produced. Patient with conversion disorder may be hysterical or strangely indifferent (“la belle indifference”) to their symptoms. Sodium amytal may show improvement. Tx. psycotherapy

248. Pityriasis rosea: usually starts out with the classic “herald” patch 1 week before the generalized eruption that tends to affect the trunk. The scaly, erythematous patches are classically in a Christmas tree pattern on the back, following the skin lines of Langerhans. Usually remit spontaneously in about 1 month and supportive Tx (e.g. antihistamine for itching) is all that usually is required.

249. Aztreonam: has a spectrum of antimicrobial activity limited to gram negative organisms, which cause UTIs (e.g., E. coli, Serratia, Pseudomonas, Proteus, Klebsiella). It is not effective against anaerobic, atypical, or gram positive organisms.

250. Alternating pulse: mechanical alternation; a pulse regular in time but with alternate beats stronger and weaker, often detectable only with the sphygmomanometer or other pressure measurement and usually indicating serious myocardial disease. Syn: pulsus alternans. It is because of severe left ventricular dysfunction. The right side of the heart would not be expected to affect the pulse in this way.

251. Vit B12 is mainly from animal products. Strict vegan will have a deficiency of it.

252. Courvoisier’s sign: a nontender, palpable gallbladder, usuallyu caused by pancreatic cancer. (not in chronic cholecystitis, not in cholelithiasis, or acute cholecystitis, or cholangitis.)

253. Factors increase the risk of transitional cell carcinoma of the bladder:
 Smoking
 Long-term exposure to cyclophosphamide
 Chronic ingestion of phenacetin
 Industrial exposure to aromatic amines.

254. Factors increase the risk of squamous cell carcinoma of the bladder: chornic Schistosoma haematobium infestation.

255. Priapism: estrongen therapy sometimes is effective as prophylaxis in repeated episodes. May be caused by trazodone, sickle cell disase etc. Prolonged cases lasting more than several hours commonly result in impotence.

256. Stress incontinence: is the MC type of urinary incontinence in women and usually is associated with aging, multiparity, and pelvic relaxation.

257. Blood transfusion: O is universal donor type, AB is universal receiver type. Rh negative can only receive Rh negative blood; while Rh positive can receive from both negative and positive.

258. IUD: is most suited for older, monogamous women. The risk of PID, infertility, and ectopic pregnancy are increased with the use of this from of contraception, and most physicians hesitate to use this from birth control in a young, mulliparous, promiscuours woman with eventual plans to have children.

259. Hegar’s sign: softening and compressibility of the lower uterine segment and is suggestive of pregnancy.

260. Chadwick’s sign: is a dark discoloration of the vulva and vaginal walls and also is suggestive of pregnancy.

261. Normal newborn heart rate: 95-180/min.

262. Risks factors of premature delivery:
 Maternal pelvic infection
 Premature rupture of the membrane
 Multiple gestation
 Maternal smoking

263. Anencephaly is associated with prolonged gestation (>42 weeks) probably due to lack of normal fetal hormone production because of abnormal CNS development in the fetus.

264. Naloxone can reverse dramatically the effects of opioids on the central nervous system and can precipitate acute withdrawal symptoms.

265. Urethroceles: located in the lower anterior vaginal wall

266. Rectoceles: located in the lower posterior vaginal wall

267. Cystoceles: located in the upper anterior vaginal wall

268. Enteroceles: located in the upper posterior vaginal wall

269. MC hernia: indirect hernias are the MC type of hernias in any age group and both sexes. (hernia sac travels throught the inner and outer inguinal rings, protusion begins lateral to the inferior epigastric vessels) and into the scrotum as result of a patent processus vaginalis.

270. Restrictive cardiomyopathy : sarcoidosis, amyloidosis, hemochramatosis, cancer and fibrosis.

271. Dilated cardiomyopathy:
 Alcohol
 Coronary artery disease
 Myocarditis
 Doxorubicin An antineoplastic antibiotic isolated from Streptomyces peucetius; also used in cytogenetics to produce Q-type chromosome bands. Syn: adriamycin.

272. A Fib Tx:
 Synchronized cardioversion (not unsynchronized one, this is reserved for V tach)
 Amiodarone for chemical cardioversion
 Quinidine for chemical cardioversion
 Procainamide for chemical cardioversion
 Ibutilide for chemical cardioversion
 Β-blockers to slow the ventricular rate.
 Digoxin to slow the ventricular rate.
 Centrally acting calcium channel blockers (verapamil or diltiazem), to slow the ventricular rate.
 Anticoagulation with heparin

273. Best way to increase power is to increase the sample size.

274. MC primary tumor of the liver-hemangioma.

275. MC primary malignant tumor of the liver in adults-hepatocellular carcinoma.

276. MC primary malignant tumor in the pediatric age group-hepatoblastoma.

277. Relative risk can’t be calculated from a retrospective study. The odds ratio, an approximation of the RR, can be calculated from retrospective data.
278. Schistosoma mansoni: causes Katayama fever (schistosomiasis). Tx of choice: Praziquantel.

279. Eyesights:
 Myopia
 Hyperopia
 Presbyopia
 Amblyopia

280. List of disease we should think when we see oral pigmentations:
 Peutz Jeghers syndrome
 Addison’s (because of á ACTH and MSH like effect)
 Pb poisoning.

281. Tx. for uterine atony: diluted oxytocin infusion, bimanual compression with massage of the uterus. If fails, second-line drugs, such as ergonovine, may be tried, but a hysterectomy may be required if medical management fails.

282. Risk of uterine atony:
 Multiple gestation
 Polyhydramnios
 Macrosomia
 Prolonged labor
 Oxytocin usage
 Grandmultiparity
 Precipitous labor

283. Omphaocele: is in the midline, the sac generally contains multiple abdominal organs, the umbilical ring is absent, and other physical anomalies are common.

284. Gastroschisis: is to the right of the midline, only small bowel is exposed (there is no true hernia sac), the umbilical ring is present, and other anomalies are rare.

285. Congenital diaphragmatic hernia: more common on the left side, with bowel that has herniated into the left thorax. Main complication: pulmonary hypoplasia that develop on the side of the lesion and sometimes both sides becasues of bowel compressing the developing lungs. Tx: surgical correction.

286. Most likely cause of an isolated oculomotor palsy with a normal and reactive pupil on the affected side in a 57 yo man with HTN and DM: microvascular complications of DM, HTN, or both.

287. β-thalathemia:
Mediterranean descent
A microcytic, hypochromic anemia
Reticulocytosis
Elevated Hb A2 level.

288. Lower the cut-off value for Dx: increase sensitivity, decrease specificity, decrease PPV, increase NPV.

289. Acne Tx: (blockage of pilosebaceous gland and the bacteria Propionibacterium acne are thought to be responsible for it)
 First topical benzoyl peroxide
 Then topical or oral antibiotics
 Topical vitamin A derivatives
 A last resort is oral isotretinoin

290. Folate: is the only B-complex vitamin deficiency that has not been associated with peripheral neuropathy.

291. Left sided heart failure: orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales, and toher respiratory symptoms, as fluid backs up into the lungs.

292. Right sided heart failure: fluids back up into the peripheral systemic circulation, causing JVD, peripheral edema, hepatomegaly, and abdominal fullness or ascites.

293. Phenylephrine and handgrip: increase afterload, so will intense murmur in VSD, mitral regurgitation, will decrease the murmur in Aortic stenosis, HOCM

294. Bartter’s syndrome: a disorder due to a defect in active chloride reabsorption in the loop of Henle; characterized by primary juxtaglomerular cell hyperplasia with secondary hyperaldosteronism, hypokalemic alkalosis, hypercalciuria, á renin or angiotensin levels, normal or low blood pressure, and growth retardation; edema is absent. Autosomal recessive inheritance, caused by mutation in either the Na-K-2Cl cotransporter gene (SLC12A1) on chromosome 15q or the K(+) channel gene (KCNJ1) on 11q.

295. Henoch-Shoonlein purpura (HSP): abdominal pain with guaiac-positive stools, prominent rash (mostly on lower extremities), hematuria and joint pains (ankles, knees, wrists and elbows). Rash starts out as an urticarial rash and progresses to become petechial and purpuric.

296. Normal ejection fractions value: 60%±5%

297. Reference values:
 CO (cardiac output): normal 3.5-5.5
 CVP: normal 0-8
 PCWP: normal 4-12 (if á, Left ventricular dysfunction)
 SVR: normal 800-1200

298. Kussmaul’s sign (+), pulsus paradoxus (-): constrictive pericarditis

299. Kussmaul’s sign (-), pulsus paradoxus (+): cardiac temponade

300. Kussmaul’s sign: may be present in restrictive cardiomyopathy, Apical impulse is palpable in restrictive cardio as opposed to constrictive pericarditis

301. Hypercortisolism: new onset HTN, dermal striae, easy bruisability, glycosuria→next step is to do dexomethasone suppression test→if cortisol level is high, then determine if this is due to ACTH (do a measurement of baseline ACTH)

302. Tx.to slow the progression of osteoporosis: aldendronate

303. In rate control of A.Fib,: Digoxin alone works better than β-blocker alone.

304. Exercise-induced asthma is best prevented by inhalation of a β2 agonist immediately before exercise.

305. "growing" pains. Although such pains are most likely unrelated to growth, they do affect children between 3 and 10 years. Growing pains are most commonly bilateral, involve the lower leg and knees, manifest with pain during rest (usually at bedtime), and are relieved by massaging or rubbing. Children awaken the next morning feeling fine. Physical activity is not impaired. Limb pains produced by organic disease will usually be unilateral (except for rheumatoid arthritis) or associated with physical signs (swelling, warmth, etc.). The child with physical injuries or disease cannot bear to have the affected area touched. Growing pains often have a familial predisposition.

306. DDAVP: 1-Desamino-8-D-arginine-vasopressin.

307. Testicular ferminzation syndrome: androgen insensitivity syndrome, 46 XY, has very shallow, blind ending girl thingy, palpable mass in the labia (testicles). During early fetal life, MIF was presented.

308. DOC for HTN Tx:
 HTN with stable angina: a β-blocker
 HTN with a benign essential tremor: β-blocker
 HTN with BPH and an unfavorable metabolic profile (dyslipidemia, glucose intolerance): α-blockers are preferred.
 HTN with significant peripheral vascular disease: calcium channel blockers (almodipine, nimodipine etc.)
 Isolated systolic HTN: hydrochlorothiazide
 Isolated diastolic dysfunction HTN: β-blockers.
 HTN in a post-MI patient: β-blockers and ACEIs are preferred over diuretics and calcium channel blockers. (ACEIs are indicated when EF is decreased, EF normally is 2/3)
 HTN with chronic asthma: Hydrochlorothiazide
 HTN due to renal vascular disease: should not use ACEIs, will precipitate acute renal failure.
 HTN with A.fib: verapamil.
 
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* Re:Conrad Fischer's lectures on Internal Medic
#1062704
  mira1978 - 11/24/07 23:44
 
  This is what Dr. Fischer believes is absolute high yield for seizures. Try to think of the answer before looking at it, its sth only way you remember it:

1 - Dx and Tx of Absent seizures -
2 - Pregnant c seizures tx -
3 - Adverse effect of phenytoin -
4 - Adverse effect of Lamotrigine -
5 - Driver c h/o seizures, next step -
6 - Diagnostic test to stop seizure meds -
7 - Must be seizure free for how long before stopping meds - 8 - Do NOT treat first time seizures unless:
9 - Another disease you where use Carbamazepine -
10 - Status Epilepticus Diagnostic tests (IN ORDER) -
11 - Status Epilepticus Tx (In order) -

Answers:
1 - kid staring in space, blinking eyes/lip smacking, 3 waves, tx c ethosuximide
2 - Carbamazepine (or MgSO4)
3 - gingival hyperplasia, teratogenicity
4 - Steven-Johnson syndrome
5 - advise to stop (thats all you do, do not report him)
6 - Sleep-deprived EEG
7 - >2 years
8 - 1 - family h/o seizures, 2 - status epilepticus, 3 - EEG abnormality
9 - Trigeminal Neurolgia
10 - 1st - Serum Sodium, 2nd Serum Glucose, 3rd low calcium, 4th low O2, 5th Toxicology (TCA, Cocain, Benzo, barbs), 6th CT head, 7th EEG (LAST RESORT)
11 - 1st benzo, 2nd Phenytoin, 3rd barbiturate, 4th General anasthesia (does not stop seizure, just stops the shaking)

 
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* Re:Conrad Fischer's lectures on Internal Medic
#1062707
  mira1978 - 11/24/07 23:50
 
  HY Notes: CK(Q-bank)
• Familial short stature: normal birth weight and length 􀃎 age of 2-3 years growth decelerate and drops to 5th percentile 􀃎 The onset and progression of puberty normal : Bone age is typically consistent with the chronologic age.
• Immunizations: Hep B vaccine- At birth, 1 month, and 6 months DTaP- At 2, 4, and 6 months, 15-18 months, and 4-6 years Td booster- 11-12 years, and then every 10 years Hib- At 2, 4, and 6 months, and 12-15 months
IPV- At 2 and 4 months, 6-18 months, and 4-6 years
MMR- At 12-15 months and 4-6 years
Varicella- 12 months
• Chemo-prophylaxis tuberculosis: The usual agent isoniazid. Indicated in the following groups:
1) tuberculin skin test has converted from negative to positive within the previous 2 years;
2) all small children (<4 years of age)exposed by known close contact to a person with untreated tuberculosis or who have a positive PPD; In young children, not to delay chemoprophylaxis until the PPD test becomes positive in child,
3) all HIV patients with positive PPD;
4) elderly patients with a definite conversion of PPD;
5) PPD positive persons with apical scars;
6) PPD positive persons with significant risk of recurrence due to diabetes mellitus, prolonged corticosteroid therapy, gastrectomy, end-stage renal disease, or gastric stapling.
• CHARGE syndrome: colobomas, heart defects, choanal atresia, retardation, genitourinary abnormalities/ cryptorchidism and ear anomalies,not genetically transmitted and is not associated with a teratogenic effect of any substance.
• Amount of Factor VIII to hemophiliac A patients: weight in pounds x 20 x desired plasma level in units. (Not applicable in hemophiliac B patients because Factor IX tends to bind to the endothelium of the vessel walls.Monitor the patient for cessation of bleeding or check clotting times before assuming that a calculated dose of Factor IX had its intended effect)
• Ataxia-telangiectasia: autosomal recessive disease.Ataxia,Choreoathetoid movements, slurred speech, ophthalmoplegia, and progressive mental retardation,Telangiectasias.Recurrent sinopulmonary infections. lack of IgA and IgE, cutaneous anergy and a progressive cellular immune defect. predisposition for certain cancers (leukemias, brain cancer, and gastric cancer). Most of these patients die of their neurologic deterioration by age 30.
• Irreversible muscle weakness in Duchenne muscular dystrophy seen after ventilator put for respiratory distress due to pneumonia etc 􀃎hypoventilation on weaning 􀃎tracheostomy will reduce the dead space and airway resistance.
• Infants usually double their birth weight by 6 months
Infants are triple their birth weight by the age of 12 months. Infants usually quadruple their birth weight by 24 months. Infants usually double their length by 4 years.
• Most patients with ALL are significantly granulocytopenic = like aplastic anemia associated with bone pain & fever = features like ecchymoses & infections
• Orthostatic proteinuria:very common 􀃎protein excretion rate is higher while the child is in an upright position 􀃎obtain a "first morning" urine before the child has had much time in an upright position. DDx Minimal change ds = Edema, hypercholesterolemia & hypoproteinemia
• Neonate with pneumonia and h/o conjunctivitis on the fourth day of life. The leukocyte count is elevated at 15,000 with 40% eosinophils = suspect Chlamydia
• Corrossive ingestion: ingestion can cause severe esophageal necrosis of the liquefaction type. Full-thickness injury is common. In severe cases, it can cause esophageal perforation and mediastinitis. Acid ingestion causes coagulation necrosis and eschar formation. The eschar tends to protect the esophagus from full-thickness injury and corrosive perforation. Perform an esophagoscopy within 24 hours of exposure for the following patients following alkali ingestion:
1. Small children
2. Symptomatic older children and adults
3. Patients with abnormal mental status
Esophagoscopy should not be performed in patients with evidence of gastrointestinal perforation, significant airway edema, or necrosis and in those who are hemodynamically unstable.
KaplanQbankNotes:Neeraj 1
• Children with sickle cell disease are at risk of serious bacterial infection and sepsis because they have impaired splenic function. Intravenous ceftriaxone is the most commonly used antibiotic in a febrile child with sickle cell disease. It is effective against both S. pneumoniae and H. influenzae.
• Red urine = hematuria, hemoglobinuria, myoglobinuria, certain foods or medications (e.g., rifampin, nitrofurantoin, chloroquine, azo dyes, beets, and blackberries), and the presence of urates.
+ Strip-test for blood in a urinalysis = red blood cells, hemoglobin or myoglobin = perform microscopic analysis to DDx Raised serum creatinine phosphokinase = rhabdomyolysis = admit for aggressive IV hydration and treatment with sodium bicarbonate to alkalinize the urine to prevent precipitation of the myoglobin in the renal tubules.
• Nightmares:frightening dreams that awaken the child from REM sleep recall details of the dream.
Nightterror: Stage 3 or 4 sleep,not recalled Rx simply let it go but prevent injury
• Functional abdominal pain is pain that lasts for more than 3 months and often interferes with normal activity. The pain is periumbilical and often hard to describe. The pain typically does not awaken patients from sleep or interfere with pleasant activities. The pain is real and is the result of the regulation of gastrointestinal motility in response to either psychological or physical stress.
• Fragile X male = Adv Cytogenetic testing in female siblings = Heterozygous females frequently have developmental and behavioral problems such as ADHD. They may also have borderline or mild mental retardation.
• Rx Acne vulgaris: retinoid (tretinoin, adapalene, and the new yeast-derived agent azaleic acid).S/E skin irritation & photosensitivity. Frequent face washing with strong soap will probably cause exacerbation of acne. Gentle face washing once or twice daily with mild soaps is recommended.
• Toxicities tricyclic antidepressant ingestion: 1. A prolongation of the QRS interval is highly predictive of both cardiac and CNS toxicities
2. Right deviation of the QRS axis (greater than 120 degrees) is very predictive of cardiac toxicity from tricyclics.
• Fat embolism brain = multimodal petechiae in the white matter represent the most common pathologic change. Corpus callosum and cerebral peduncles small petechiae = Diffuse axonal injury = coma a few hours to days after head trauma. Multiple cortical infarcts, usually of the hemorrhagic type = Septic embolism / white matter is spared.
• Prostatic abscess:Infecting organisms include aerobic gram-negative bacilli and Staphylococcus aureus.
• Hyper IgM immunodeficiency = increased susceptibility to major gram-positive pathogens and opportunistic infections (such as the patient's Pneumocystis infection). The biochemical basis defect in a receptor on the T cell membrane that helps to trigger B cell switching from IgM to IgA, IgG, and IgE.
• The tidal volume for a patient on respirator is generally estimated as 10 mL/kg of weight.
• Screening every 5 years, a random cholesterol level should be checked = > 240 mg/dL =fasting lipid profile
• Scaling skin on back and extensor surfaces of the extremities/flexor surfaces are uninvolved. Cracking of the skin is prominent on the palms and soles. + atopy = ichthyosis vulgaris, Rx minimizing bathing with use of soaps only in the intertriginous areas. Bathing limited to 10-minute periods (to hydrate the stratum corneum), followed by immediate application of an emollient such as petrolatum, can help to control the scaling. In addition, 50% propylene glycol in water under occlusion by thin plastic film or bags during the night is helpful in adults, but is not usually used in children.
• Nummular dermatitis: chronic inflammation / etiology unknown. Coin-shaped/discoid itchy patches of vesicles and papules (ooze serum and crust over)numerous on the extensor surfaces of the extremities and on the buttocks. Heal and then reappear at the same sites. Microscopically, localized spongiosis (corresponding to edema) of the epidermis, which may also contain minute fluid-filled holes that correspond to the tiny KaplanQbankNotes:Neeraj 2
vesicles seen clinically in early lesions. Treatment of these patients is problematic, and numerous regimens involving corticosteroids or antibiotics have been recommended, each of which appears to work with some but not all patients.

• Euthyroid sick syndrome: seriously ill patient with low T4 /T3, but below normal, normal, or minimally elevated TSH and clinically do not have clinical hypothyroidism.DDx true hypothyroidism (significantly raised TSH).
• End-stage liver disease/Cirrhosis 􀃎 renal vasoconstriction occurs worsening fatigue and confusion 􀃎 distal convoluted tubule responds by conserving sodium 􀃎 diminished urine output and low urinary sodium 􀃎 Deranged BUN/creatinine 􀃎 hepatorenal syndrome 􀃎 Rx Liver transplantation 􀃎 reverse this vasoconstriction and kidney function will return to normal.
• HIV encephalitis (AIDS dementia complex): most common CNS complication in AIDS = cognitive impairment, incontinence, impairment of motor skills, and confusion = sub acute inflammatory infiltration of the brain caused by direct spread of HIV = diagnosis of exclusion = MRI studies and CSF analysis are useful in excluding other CNS diseases.
• Patient with respiratory distress due to pneumonia 􀃎 oxygen saturation is 80% on room air 􀃎Hypoxia puts at significant risk for delirium, cardiac arrhythmias, and cardiopulmonary arrest 􀃎 Oxygen should first be administered noninvasively 􀃎starting with a non-rebreather face mask 􀃎Failed 􀃎 go for invasive methods like endotracheal intubation.
• Hospitalization in community-acquired pneumonia :Criteria for hospitalization: one of the following is needed:
1. respiratory rate > 30 breaths/min,
2. room air PaO2< 60 mm Hg,
3. O2 saturation less than 90% on room air,
4. or bilateral or multiple lobes involved
• The normal value for the anion gap is 12 ± 4 mEq/L
• Gaucher disease: deficiency of the enzyme glucocerebrosidase (Ashkenazi Jews ) 􀃎progressive accumulation of glucocerebroside within lysosomes of histiocytes 􀃎 Gaucher cells, large histiocytes with their cytoplasm engorged with glycolipid = "crumpled tissue paper" appearance 􀃎most common adult variant (type I) =most severely affected organs are the bone marrow, liver, and spleen 􀃎 Bone marrow involvement =progressive pancytopenia and bone fractures 􀃎 Glucocerebrosidase levels in circulating leukocytes: diagnostic. In the US, the disease is Rx glucocerebrosidase named alglucerase(safe but expensive)
KaplanQbankNotes:Neeraj 3
• an erythematous, slightly raised, 2-cm patch of skin on sun-exposed area (Face mostly) 􀃎 area has a rough, very adherent, yellow-brown scale 􀃎 Actinic keratosis 􀃎Rx application of 5-fluorouracil cream twice daily x 4 one-week cycles alternated with no treatment weeks 􀃎heal without scarring.
• Ventilator delivering high concentrations of oxygen 􀃎 lead to irreversible pulmonary fibrosis 􀃎Use positive-end expiratory pressure (PEEP) to prevent the development of oxygen toxicity 􀃎But PEEP does increase the risk of both barotrauma and hypotension by impairing right-sided heart filling.
• Secondary hyperparathyroidism developed in renal failure in an attempt to correct the hypocalcaemia 􀃎 bone calcium deficits and pathologic bone lesions 􀃎Rx Calcium supplementation in Renal failure
• Atypical nevus(Dysplastic):size from 5 to 12 mm 􀃎most commonly on sun-exposed skin 􀃎round in color, but some have subtly notched borders or are slightly asymmetrical 􀃎 intermediate category between obviously benign nevi and malignant melanoma 􀃎increased rate of progression to melanoma􀃎 Isolated dysplastic nevi are often excised to remove the melanoma risk􀃎cases with large numbers 􀃎 careful monitoring with serial photographs can identify any changing lesions which may be undergoing malignant transformation.
• Post-MI patients: Ejection fraction near or minimally subnormal Rx Beta blockers 􀃎decreasing both oxygen demand and the incidence of ventricular arrhythmia 􀃎 Improved survival But if ejection fractions less than 40% 􀃎 Rx Angiotensin-converting enzyme (ACE) inhibitors
• Tension headache: headache often triggered or worsened by stressful situations, anxiety and fatigue Rx NSAIDs
• Eosinophilic fasciitisrange peel skin on the anterior aspects of the extremities= scleroderma-like disorder involving the arms, legs, and sometimes face and trunk, but not usually the hands and feet 􀃎 lead to eventual restriction of arm and leg motion related to inflammation and fibrosis of fascia 􀃎Biopsy of the skin or fascia shows cellular infiltrates with histiocytes, plasma cells, lymphocytes and (in only some cases, despite the name) eosinophils 􀃎 Rx high dose prednisone followed by tapering and maintenance for 2 to 5 years on low dose prednisone.
• Pulsus paradoxus: significant fall in systolic blood pressure with inspiration = severe asthmatic attack 􀃎 Look for associated accessory muscles of respiration, i.e., the internal intercostal muscles and the sternocleidomastoid muscles.
• Traumatic hemolytic anemias: repeatedly compressed tiny blood vessels, causing fragmentation of some red cells (triangle and helmet shapes)􀃎 e.g. forced march DDx rhabdomyolysis: high creatine kinase
• Atrial fibrillation (in CHF) 􀃎causes cardiovascular embarrassment and pulmonary edema 􀃎adequate management of atrial fibrillation is rate control 􀃎 Rx Digoxin with or without a nodal agent such as a beta blocker.However,in sinus tachycardia seen with hyperthyroidism DOC is propanolol alone.
KaplanQbankNotes:Neeraj 4
• Bleeding in diverticular 􀃎 usually due to the disruption of an often single arteriole or small artery in a diverticulum 􀃎vessel can be sufficiently stretched by the diverticulum that it cannot undergo contraction.
• Sheehan syndrome: panhypopituitarism due to intrapartum necrosis of the pituitary 􀃎insulin challenge 􀃎Measuring plasma levels of growth hormone and cortisol and evaluating thyroid hormones and TSH levels 􀃎Rx hydrocortisone (IV not oral like prednisolone) and thyroid hormones.
• Blood supply from 1978 to 1985 was likely to be tainted with HIV positive blood 􀃎patients with a history of blood transfusions during these years even if currently asymptomatic, should be screened.
• Hyperkalemia 􀃎First to give: IV calcium gluconate 􀃎 to counteract the effect of the high potassium on the heart and muscle
• Hypercalcemia 􀃎 Rx IV saline and furosemide 􀃎rapid and safe way to lower serum.
• hemochromatosis = total body iron load >5 g; (hemosiderosis = milder iron overload)
• cirrhosis and portal hypertension 􀃎 Rx Propanolol (to reduce his portal pressure) and Frusemide to relieve ascites 􀃎 dehydration (dry mucous membranes) related to his diuretic 􀃎 BUN elevated 􀃎may exacerbate hepatic encephalopathy􀃎 but pulse does not demonstrate a reflex tachycardia because of the propranolol.
• In portal hypertension strictly restrict or entirely avoid any medications with a sedative effect, e.g., benzodiazepines as they may ppt an encephalopathy.
• Silent lymphocytic thyroiditis: common disorder of postpartum women,autoimmune reaction to the thyroid gland 􀃎produce transient hyperthyroidism (related to follicle destruction) followed by hypothyroidism (that may be either permanent or resolve within 1 year).
• Seborrhic Keratosis: This lesion is characterized by light brown to black papules or plaques with an adherent waxy, greasy scale. The "stuck-on" appearance is very characteristic. It is most often found on the face and trunk.
• The findings of a coagulopathy or of an encephalopathy confer the worst prognosis in patients with acute viral hepatitis.These findings, in fact; suggest the possibility of fulminant hepatic failure.
• IgA type heavy chain diseas:centered in the Middle East ,ages of 10-30􀃎present with abdominal mass and malabsorption (behaves like an abdominal lymphoma but not mailgnant)􀃎confined to the gut and mesenteric lymph nodes 􀃎may represent an aberrant reaction to some sort of bacterial infection 􀃎 Rx corticosteroids, cytotoxic drugs and broad-spectrum antibiotics.
KaplanQbankNotes:Neeraj 5
• Pemphigus vulgaris:uncommon autoimmune skin disorder characterized by blistering and erosions involving the mucous membranes and skin 􀃎 autoimmune attack is on the junctions between epithelial cells in the epidermis 􀃎 blisters occur high in 􀃎the epithelium and can rupture easily(Nikolsky's sign) 􀃎 begin in the mouth 􀃎 rapid rupture of the blisters may lead to the impression that the initial lesion is an ulcer rather than a blister 􀃎 IgG deposition on epithelial cell surfaces 􀃎life-threatening as a result of fluid/electrolyte imbalance, secondary infection, or complications of the high-dose corticosteroid therapy.
• Marrow fibrosis suggests myelofibrosis. The marrow in aplastic anemia is fatty, rather than fibrotic
• Excess vitamin C supplementation can lead to uricosuria and the development of calcium oxalate stones.
• The perfusion territory of the anterior spinal artery includes the anterior horn cells and part of the pain and temperature pathways. Thrombosis of this artery causes flaccid paralysis, loss of bowel and bladder function and loss of pain and temperature sensation
• Infectious Mononucleosis: Ampicillin therapy leads to a maculopapular rash. An antibiotic should not be given.
• 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.
• Paroxysmal nocturnal hemoglobinuria(Marchiafava-Micheli syndrome):genetic defect in glycosyl-phosphatidyl-inositol "anchor 􀃎 marked sensitivity of RBC to serum complement factor C3 􀃎 Hemolysis triggered by infection, iron use (prescribed to treat the anemia), vaccination, or menstruation 􀃎predisposed for thrombotic disease, including Budd-Chiari Syndrome 􀃎Ham test:classic but non-specific:acid incubation causes red cell lysis􀃎flow cytometric analysis using CD 55 and CD 59 (most definitive).Prognosis good only a few require allogenic bone marrow transplant.
• AMI : Thrombolytic therapy is indicated in patients up to 75 years of age .Absolute contraindications include a bleeding diathesis, major surgery or trauma within 6 months, gastrointestinal bleeding, or the presence of aortic dissection or a known intracranial tumor.
• Whenever you see ‘Lewy’s Body’ think of relation with Parkinson’s􀃎 dementia with visual hallucinations and extrapyramidal signs 􀃎dementia with Lewy bodies 􀃎 Like parkinsons it shows fluctuating clinical course with alternating periods of improvement and deterioration 􀃎DDx Pick dementia =Personality changes & disinhibition,affecting younger than 65 􀃎striking atrophy of the frontal and anterior temporal lobes.
• Suspected lung carcinoma 􀃎hoarseness􀃎metastatic disease to the recurrent laryngeal nerve􀃎incurability by surgical means.
• Charcoal is DOC within 4 hrs of toxic ingestion in any case 􀃎 also applicable to Acetominophen 􀃎Give charcoal + N-acetylcysteine within 4hrs of ingestion 􀃎If >4 hrs but <10 hrs = N-acetylcysteine alone 􀃎 continue oral treatment for 72 hours.
• Tangier disease:alpha-lipoprotein deficiency 􀃎very low high-density lipoprotein (HDL)􀃎recurrent polyneuropathy, lymphadenopathy, and hepatosplenomegaly due to storage of cholesterol esters in KaplanQbankNotes:Neeraj 6
reticuloendothelial cells 􀃎orange-yellow tonsillar hyperplasia (due to the cholesterol ester deposits) is a distinctive clue
• HIV patient with bloody diarrhea + tensmus + urgency/fecal incontinence 􀃎 Sigmoidoscopy showing proctosigmoiditis with deep ulcers 􀃎 suspect CMV
• Obese patient? in postop state 􀃎 developing respiratory distress 􀃎 think about PE
• Nephritic syndrome with bland urine in drug users who "skin pop" their drugs and have recurrent infections 􀃎 Enlarged kidneys 􀃎 ?Amyloidosis DDx Heroin Nephritis=Small kidneys
• Idiopathic hypertrophic subaortic stenosis (Earlier name of Hypertrphic cardiomyopathy):frequent cause of syncope or near syncope in young patients 􀃎characteristic murmur by its increase with the Valsalva maneuver (Any maneuver that decreases left ventricular size will increase the murmur because the obstructive component increases as the left ventricular cavity shrinks 􀃎 systolic ejection murmur is diminished when the patient lies down (This increases cardiac size by increasing venous return and tends to diminish the intensity of the murmur.This increases the ventricular size and diminishes the murmur).Rx Beta-blockers, such as propanolol, help relax the left ventricular smooth muscle and reduce ventricular outflow obstruction.
• Mesalamine (active ingredient 5-aminosalicylic acid) rectal suspension, suppositories, delayed release oral tablets and controlled release oral capsules 􀃎not absorbed and acts topically 􀃎 modulation of arachidonic acid metabolites, including prostaglandins, leukotrienes, and hydroxyeicosatetraenoic acids 􀃎well tolerated except sulfite sensitivity.
• Hypertensive emergency (Raised both systolic & diastolic BP)may lead to increased Intracranial tension(Blurry vision/Papilledema) subarachnoid hemorrhage and end-organ failure (Like renal manifesting as ‘cola’ colored urine) 􀃎Rx Control BP but the blood pressure should not be lowered too far 􀃎 systolic pressure in the range of 160-170 mm Hg because some of the elevated pressure may represent a compensatory mechanism to maintain cerebral perfusion pressure in the face of increased intracranial pressure or cerebral arterial narrowing (May lead to watershed infarcts)􀃎IV nitroprusside is a good agent because it can be titrated with the blood pressure. If the pressure drops too low, the IV can be turned off.
• IgG subclass deficiency: minor forms of immunodeficiency disease 􀃎deficiency may involve either or both IgG2 and IgG3 with or without IgG4 deficiency 􀃎 (IgG1 is the major form, and its deficiency leads to a deficiency of total IgG (by definition not considered a "subclass" deficiency)􀃎potentially clinically important point that patients with IgG2 deficiency may also have IgA deficiency and may develop anaphylaxis if given IgA-containing blood products.
• Chronic "autoimmune" hepatitis􀃎 young age & hypergammaglobulinemia􀃎biopsy demonstrating portal inflammation with lobular damage resulting in bridging necrosis
1. Type I(classic type: most frequent):associated with antinuclear and anti-smooth muscle autoantibodies
2. Type II(more common in women of Western European descent):associated with autoantibodies to circulating liver-kidney microsomes. insidious + amenorrhea.
• Chronic hepatitis C 􀃎 positive enzyme immunoassay test for HCV-antibodies(this test may be falsely positive in situations with hypergammaglobulinemia like seen in chronic autoimmune hepatitis)􀃎positivity should be confirmed by a more specific RIBA.
• Ganglion cyst: degenerative nontumourous/cystic swellings with gelatinous material having high hyaluronic acid content the center over dorsal aspect of the wrists, usually near or attached to tendon sheaths and joint capsules􀃎 Common sites:65%scapholunate joint,volar aspect of the radius and the flexor tendon sheath. 􀃎regress spontaneously or after needle aspiration of the contents. Recurrent ganglia or ganglia that are cosmetically unacceptable to the patient can be surgically excised, but may recur after excision.
• Strenuous exercise like swimming􀃎development of headache, dizziness, One sided arm clumsiness and leg weakness + loss of pain and temperature sensation on same side face and contra lateral body areas 􀃎 No prior illness 􀃎 ? lateral medullary syndrome 􀃎investigate vertebral artery dissection.
KaplanQbankNotes:Neeraj 7
• Diagnosis of Myocardial infarction requires either characteristic ST segment elevations on the ECG OR elevations in serum markers for cardiac injury. ‘Myocardial ischemia’ may or may not always manifest as MI(􀃎Angina). Diabetics often have silent ischemia.
• Propranolol is considered to be relatively contraindicated in patients with peripheral claudication & asthma.
• HIV/ lymphomas/organ transplants. 􀃎Evidence of destruction of myelin at multiple sites in the CNS 􀃎PML􀃎JC virus(papovavirus)􀃎 involves Oligodendrocytes in active lesions contain characteristic intranuclear inclusions.
• In constrictive pericarditis (calcification of the anterior pericardium) a pericardial knock is heard 0. 06-0. 12 seconds after the aortic valve closes. This corresponds to the sudden cessation of ventricular filling.
• Hypertrophic heart disease is the best recognized cause of diastolic dysfunction
• ECG 􀃎P waves preceding the QRS complex but no two P waves have the same morphology 􀃎 ‘Multifocal atrial tachycardia’􀃎Variable P wave morphology and PR and RR intervals 􀃎 associated with severe pulmonary disease􀃎control of this tachycardia comes with improved ventilation and oxygenation.
• HSV is thought to cause encephalitis following transport to the brain along the trigeminal nerve.
• HIV with pneumocystis showing respiratory distress oxygen saturation on room air is 71% 􀃎Rx intravenous trimethoprim-sulfamethoxazole and prednisone 􀃎given in any patient showing significant respiratory distress or room air oxygen saturation of less than 75 % 􀃎otherwise in HIV Steroids are only given if the question of adrenal insufficiency, a common complication of HIV, is suspected.
• HIV patient with watery diarrhea 􀃎typical small bowel-type diarrhea(weakness & weight loss)􀃎most common etiology cryptosporidiosis􀃎spores can be seen on the tips of the villi on biopsy.
• Hypotension always accompanied with Tachycardia but when it is associated with Bradycardia 􀃎It is vagal response 􀃎Rx Atropine.E.g: post AMI
• Amyotrophic lateral sclerosis is a progressive motor neuron disease that affects both upper and lower motor neurons. Patients present with a gradual onset of asymmetric weakness of the distal limb. Even in advanced disease, sensory and bladder function are preserved. On exam, there is hyperactivity of muscle stretch reflexes.
• If autonomic dysfunction is suspected in a diabetic patient, a useful maneuver on physical examination is to look for a decrease in heart rate in response to the Valsalva maneuver (forced expiratory effort against a closed airway).
• Meniere disease = tinnitus, vertigo, and progressive hearing loss􀃎 thought to be related to a degeneration of the vestibular and cochlear hair cells􀃎Rx includes bed rest, a low-salt diet, dimenhydrinate, cyclizine or meclizine.
• Heparin-induced thrombocytopenia (HIT) is the result of platelet aggregation (platelet count falls below 50,000/mm3) caused by heparin-induced antibodies􀃎lead to limb-threatening thromboses and constitutes a medical emergency (Arterial thrombosis is a manifestation of the HIT syndrome)􀃎 Rx discontinue heparin and use lepirudin.
• An atypical gastric upset, heartburn, indigestion may turn out to be a myocardial ischemia ++> Look for objective signs of sympathetic activation including sweating, anxiety, tachypnea, and tachycardia or light-headedness, dyspnea, orthopnea, cough, nausea and syncope. An ECG examination is imperative in any patient presenting with this symptomatology. A normal tracing is rare with acute MI.
• Cerebellar bleed Cerebral bleed
abrupt onset develops slowly
lucid patient early loss of consciousness
cerebellar tonsillar herniation No herniation
should be evacuated as soon as possible before coma ensues No such need
KaplanQbankNotes:Neeraj 8
• The most common cause of chronic AF is valvular disease, followed by congestive heart failure (CHF). The most common anatomic correlate seen in patients with AF (Framingham Heart Study) is an enlarged left atrium.
• Otosclerosis may progress more rapidly in pregnancy􀃎Rx hearing aids; severe cases may respond to removal of the stapes with implantation of a prosthesis
• Amylodosis: echocardiogram reveals ventricular walls with a "speckled pattern􀃎 restrictive cardiomyopathy􀃎 ventricular filling is impaired and the cardiac silhouette may be mildly enlarged􀃎ECG nonspecific arrhythmias􀃎 Like all restrictive ds develops into diastolic dysfunction.
• The pulmonary artery catheter/Swan-Ganz catheter allows direct, simultaneous measurement of pressures in the right atrium, right ventricle, pulmonary artery, and the filling pressure ("wedge" pressure) of the left atrium􀃎 elevated right-sided pressure and low wedge pressure 􀃎 Rt ventricular infarct? Causing backing up of venous blood and decreased forward flow, producing a decrease in left ventricular filling, 􀃎Rx aggressive fluid administration.
• A communication between an arteriole and venule in the cecum is a description of a vascular ectasia, also known as an arteriovenous (AV) malformation. This a common cause of painless colonic bleeding in the elderly and may present with acute gastrointestinal bleeding,chronic gastrointestinal bleeding, or iron-deficiency anemia. These lesions may be difficult to demonstrate, as the bleeding may be intermittent or the colon may be so full of blood that the site of origin is obscured. Techniques used to demonstrate bleeding AV malformations include colonoscopy, intraoperative endoscopy, and visceral angiography. Treatment of these lesions is problematic because many patients will subsequently develop new or recurrent bleeding vessels.
• Having difficulty holding and using a writing instrument due to hand and forearm spasms 􀃎no medications, dizziness or loss of consciousness or any history suggestive of a seizure 􀃎 focal dystonia of unknown cause.
• Cardioversion􀃎Synchronized electrical cardioversion is the process by which an abnormally fast heart rate or cardiac arrhythmia is terminated by the delivery of therapeutic dose of electrical current to the heart at a specific moment in the cardiac cycle as determined by a compute0r(Pharmacologic cardioversion uses medication) 􀃎Synchronized electrical cardioversion is used to treat hemodynamically significant supraventricular (or narrow complex) tachycardias, including atrial fibrillation and atrial flutter. It is also used in the emergent treatment of wide complex tachycardias, including ventricular tachycardia, when a pulse is present. Pulseless ventricular tachycardia and ventricular fibrillation are treated with unsynchronized shocks referred to as defibrillation.
So,hemodynamically unstable(loss of consciousness)vetricular tachcardia 􀃎treat with asynchronous cardioversion.
• Hypertension􀃎eye tries to protect itself from the hypertension 􀃎 arteriolar constriction􀃎thickening of the arteriolar walls (producing the broad light reflex)􀃎 arterioles squeeze down too hard􀃎 superficial foci of retinal ischemia(cotton wool spots)􀃎 hemorrhage and deposits occur because of vessel damage with leakage of contents.Hypertensive retinopathy seen in chronic essential hypertension, malignant hypertension, and toxemia of pregnancy. Rx control of the hypertension. (Practically, progression can be stopped and the hemorrhages will resolve, but the vessel changes remain.)
• Nonproliferative diabetic retinopathy= hemorrhage and exudates in the retina + microaneurysms (visible as red dots).
• Proliferative diabetic retinopathy = nonproliferative diabetic retinopathy +neovascularization with vessel growth into the vitreous.
• Brain-death 􀃎no electrical activity and no clinical evidence of brain function on physical examination (no response to pain, absent cranial nerve reflexes ,pupillary response:fixed pupils, oculocephalic reflex, corneal reflexes), absent response to the caloric reflex test and no spontaneous respirations. But patient without such criteria but with no purposeful activity one week after an anoxic brain injury bodes poorly for a meaningful neurological recovery!(Not a brain death but recovery not meaningful).
• Whenever you see a case with a link to water reservoir/source like cruise/hospital/air-conditioner system and patient developed mental changes + diarrhea + Pneumonia = DDx Legionnaires pneumonia Rx Erythromycin
KaplanQbankNotes:Neeraj 9
• Yersinia enterocolitica: Right lower quadrant pain mimicking appendicitis with symptoms of an acute ileitis and diarrhea (In appendicitis patient typically have difficulty moving their bowels). Acquired through the fecal-oral route and diagnosis is based on clinical suspicion and the finding of the organism in stool cultures.
• Campylobacter jejuni: acute onset of either watery or bloody diarrhea consistent with colitis, severe fecal urgency, nocturnal bloody diarrhea 􀃎sigmoidoscopy reveals continuous, symmetric inflammation from the anal verge to the proximal sigmoid colon 􀃎 diarrhea in all age groups/peak of incidence is in young children􀃎Fecoral spread
• Intentional inhalation of volatile hydrocarbons(model glue, correction fluid, spray paint and gasoline) in a large quantity = "quick drunk": resembles alcoholic intoxication􀃎very high dose ataxia, hallucinations, and nystagmus 􀃎Encephalopathy is the major chronic morbidity (Hydrocarbons are highly lipophilic leading to CNS damage) 􀃎high level of suspicion is needed 􀃎no drug screen test that can detect inhalant hydrocarbons.
• Rubella vaccine 􀃎Gap of 3 months to be pregnant(theoretical risk of exposure to the rubella virus through vaccination)􀃎But if pregnancy occurs within 3 months after vaccination􀃎not an indication or a reason to terminate the pregnancy(Simply woman should be counseled about the theoretical risk).
• Neonatal especially preterm steatorrhea due to smaller bile acid pool 􀃎substitute medium-chain triglycerides (MCTs) in the formula for long-chain triglycerides (LCTs)􀃎MCTs do not require bile acids for absorption.
• Milestones:
1. 4-years 􀃎 draw a four-sided figure (i.e., a square), count to 4, identify four colors, say a four-to five-word sentence, and draw a picture of a person with at least four parts. (Easily remembered as 4-year-olds do things in 4's.)
2. 5 yrs 􀃎Drawing a triangle,count to 10, repeat a 10-syllable sentence, and draw a picture of a person with 8-10 parts
3. 6 yrs 􀃎Building a staircase with cubes,can perform simple addition and draw a person with 12-15 parts.
4. 7- yrs 􀃎ability to repeat five digits,can repeat three digits backward, draw a diamond shape, and draw a person with 18-22 parts.
• Mitral valve prolapse =An apical click followed by a late systolic murmur 􀃎Rx antibiotic before Dental procedure Mitral and tricuspid regurgitation = produce holosystolic murmurs with relatively uniform intensity. Mitral regurgitation is heard at the apex while tricuspid regurgitation is best heard along the lower left sternal border. Mitral stenosis= mid-diastolic murmur heard after an opening snap.
• nasal foreign body: frequent sneezing and obstruction(Often misinterpreted as a common cold or allergy) 􀃎infection develops 􀃎resulting in a purulent and malodorous discharge􀃎unilateral involvement
• A saturation of 90% corresponds to an oxygen partial pressure of around 60 mm Hg =Hypoxia needs oxygen
• hepatitis A diagnosis is best made by determination of IgM levels against hepatitis A virus􀃎acute infection(antibody peaks at 4-6 weeks and does not persist beyond 6 months)while IgG is produced in the primary infection, but for most viral infections, including hepatitis A, it persists for a life time.
• Attention deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, and inattention lasting at least 6 months and disorder must have started before age 7.
• Cardiac defects:
1. Hypoplastic Lt heart syndrome: underdevelopment of the left cardiac chambers(left atrium and ventricle often exhibit endocardial fibroelastosis), atresia or stenosis of the aortic and/or the mitral orifices, and hypoplasia of the aorta􀃎 No murmur, precordial hyperactivity(enlarged right ventricle is contracting against systemic pressure), loud second heart sound (because the pulmonary artery acts as the aorta by pumping blood to the systemic circulation through the ductus arteriosus). When the ductus closes, or when the pulmonary vasculature resistance falls, the flow to
KaplanQbankNotes:Neeraj 10
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.
2. Total anomalous pulmonary venous return:pulmonary veins forming a confluence behind the left atrium, and draining into the right atrium 􀃎Complete mixing takes place in the right atrium 􀃎 right-to-left shunt through the foramen ovale to the left side of the heart􀃎 Often, no murmur is heard 􀃎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.
3. Neonate becomes cyanotic then lost consciousness following feeding or when crying vigorously 􀃎 baby picked her up and held 􀃎infant regained 􀃎 hypercyanotic spells or "Tet spells"􀃎TOF
DDx Frequent cyanosis and difficult breathing following birth but improves while crying􀃎Choanal atresia Rx intubation via oropharynx
• Post infectious Bells palsy:Mostly EBV
• CHF in infant: respiratory distress, tachycardia and/or hyperdynamic precordium, and cardiac enlargement evidenced by echocardiogram. DDx left-to-right shunt (ASD, VSD, PDA, atrioventricular canal, or AV fistula), left-sided obstruction leading to myocardial dysfunction (severe coarctation or AS), or intrinsic myocardial dysfunction (myocarditis, cardiomyopathy, or infarct due to anomalous coronary artery). Rx IV furosemide provide quick symptomatic relief and improve respiratory distress.
• Rx streptococcal pharyngitis is oral penicillin V for 10 days. However, Benzathine penicillin G can be given as a single dose intramuscularly. It is a long-acting antibiotic and can complete the treatmentrevention of Rheumatic heart Ds in a noncompliant patient
• Patients with sickle cell disease are at risk for infection by Salmonella and other gram-negative bacteria increased risk for acute recurrent Salmonella osteomyelitis. However, even in patients with sickle cell disease, Staphylococcus aureus is still the most common pathogen for osteomyelitis.
• Children <3 years with harsh, barking cough(sounds like a seal),runny nose but no fever or drooling + hoarse with inspiratory stridor 􀃎 Acute laryngotracheobronchitis (viral croup) DDx
1. Epiglossittis 􀃎fever, drooling, muffled voice, cyanosis, and soft stridor.
2. Laryngomalacia 􀃎persistent stridor that is first noted early in infancy
• Tanner stages:
1. Stage I (0-15yrs): preadolescent breast development with no pubic hair.
2. Stage II(8-15 yrs)breast budding or thelarche + small pubic hair near the labia + growth spurt
3. Stage III :more pubic hair
4. Stage IV (10-17yrs) breast and nipple enlargement with some contour separation of the areola is noted. Hairs adult quality but not distribution.
5. Stage V (12-18 yrs) complete breast enlargement with no contour separation of the areola. Pubic hair is of adult quality and distribution.
• Neonatal Group B Streptococcus (GBS): Early-onset / first week of life: involve the respiratory tract causing pneumonia .Late-onset (weeks 2 and 4): meningitis.
• Long Q-T syndrome (LQTS):50% familial: syncope and sudden death from torsades de pointes (TDP).
1. Romano-Ward syndrome has autosomal-dominant transmission;
2. Jervell-Lange-Nielsen syndrome has autosomal-recessive transmission.(High Mortality)
On ECG 􀃎 QT prolongation (QTc averages 0. 49 seconds).
Rx beta-blocker or implantable cardiac defibrillator in resistant cases.
• Child's recurrent leg pains􀃎Bilateral(Organic pain :Unilateral) 􀃎occurring soon after going to bed􀃎relieved from rubbing his legs and knees􀃎 no limp and is able to participate in sports activities 􀃎"growing" pains but unrelated to growth(affect 3-10 years).
• Metabolic alkalosis in cystic fibrosis due to excess sweating (summer)infants & dehydration􀃎 hyponatremic, hypochloremic, metabolic alkalosis
KaplanQbankNotes:Neeraj 11
• Breast-feeding jaundice􀃎decreased intake and increased enterohepatic circulation.
• Any ingested toxic substance/overdose presented within 60 mints􀃎 Gastric lavage+ Add charcoal if possible
• Hypernatremic dehydration: hypotonic fluid loss (history of diarrhea or vomiting),inadequate supply of mother's milk or high concentration of sodium in mothers milk 􀃎 irritable,lethargic infant and have a high-pitched cry 􀃎Complication like intracranial hemorrhage
• Intussusception usually occurs within the 6 to 12-month-old age group
• Conscious Sedation􀃎 minor procedures like suturing laceration 􀃎 able to maintain airway patency, protective airway reflexes and responses to physical stimuli􀃎Use short-acting or long-acting benzodiazepine (midazolam or diazepam, respectively) by the oral or rectal route for (Intravenous midazolam or diazepam can be used for procedures that produce more intense pain or discomfort, such as repair of complex lacerations, bone marrow aspiration, and reduction of fractures)
• "Do's" and "Don't's." during the seizure episode􀃎don't Put any object into the patient's mouth,do Place the patient on the side,Put a pillow or other soft object under the patient's head,Loosen tight clothing around the neck,Remove sharp objects from the surroundings.After the seizures, caretakers or parents should remain with the patient until he/she is fully alert and allow him/her to go back to the usual activities.
• Child with ecchymoses􀃎Eliminate bleeding abnormalities by coagulation studies 􀃎Normal study􀃎Think about Abuse!
• Triad of thrombocytopenia (hemorrhage may be the presenting complaint), eczema, and recurrent infections (often respiratory)􀃎 Wiskott-Aldrich syndrome(X-linked recessive)􀃎 defects in both T and B cell function􀃎vulnerable to pyogenic bacteria, viruses, fungi and Pneumocystis carinii􀃎often died by age 15 and survivors have increased incidence of cancer (lymphoma /ALL) 􀃎Rx splenectomy, continuous antibiotic therapy, IV immunoglobulin, and bone marrow transplantation.
• Severe combined immunodeficiency (Autosomal recessive) 􀃎 "bubble boy" disease because its victims are extremely vulnerable to infectious diseases􀃎adenosine deaminase deficiency (purine salvage enzyme and deficiency leading to turn off DNA synthesis)􀃎Low T/B cells counts.
• X linked SCID􀃎mutations in gene encoding the common gamma chain (γc),shared by the receptors for multiple interleukins􀃎 affects development and differentiation of T and B cells􀃎All males with the defective gene will have SCID􀃎 Females are carriers.
• Bruton agammaglobulinemia􀃎Cellular immunity is intact􀃎 mature B-lymphocytes do not form􀃎germinal centers are absent in lymph nodes 􀃎infections after about six months (maternal antibodies have decreased)􀃎recurrent pyogenic infections, particularly of the lungs, sinuses, and bones.
• Common variable immunodeficiency syndrome􀃎Clinically same as Bruton’s but onset in late adolescence/young adulthood􀃎hypogammaglobulinemia with markedly decreased IgM􀃎failure of B-lymphocytes to differentiate into plasma cells 􀃎patients have an increased risk for B-cell lymphomas, gastric carcinoma, and skin cancer
• Meconium =fetal stool(desquamated cells from the gastrointestinal tract admixed with enough bile to give the soft stool a greenish color)􀃎distressed fetus will pass meconium into the amniotic fluid and then may aspirate it􀃎In maternal preeclampsia, hypertension, or postmaturity􀃎aspirated meconium is very irritating to the lungs and causes a chemical pneumonitis􀃎Rx prompt suction of the nasopharynx and mouth
• Kawasaki disease:systemic vasculitis of unknown origin􀃎mucocutaneous lymph node syndrome􀃎Clinical and echocardiographic features remain the basis for diagnosis􀃎An (unidentified) infectious origin and a T-cell immune activation 􀃎Fever, bilateral non-exudative conjunctivitis, mucous membrane changes (injected pharynx, cracked lips, or strawberry tongue), extremity changes (edema, desquamation, erythema, or rash), and cervical adenopathy 􀃎myocarditis, valvular insufficiency, arrhythmias, pericardial effusion, and congestive heart failure􀃎Leukocytosis and an elevated C-reactive protein are associated with the development of coronary artery aneurysms􀃎Rx aspirin ,IV immune globulin & Corticosteroids(Controversial:Reduces coronary artery aneurysm?).
KaplanQbankNotes:Neeraj 12
• The most commonly abused drug by pregnant mothers is cocaine􀃎Infants small for gestational age (SGA) and sometimes,microcephaly and neurodevelopmental abnormalities􀃎irritable and cries in high-pitch􀃎. increased risk of sudden infant death syndrome & Periventricular leukomalacia.
• Interesting facts that pancreatitis may show normal amylase(Rely more on lipase)
• Interesting facts that Gullain Barre synd may rarely have sensory involvement
• Listeriosis acquired by mothers exposed to unpasteurized dairy products or raw vegetables exposed to cattle or sheep manure􀃎amnionitis􀃎abortion, stillbirth or neonatal sepsis􀃎brown, murky amniotic fluid 􀃎or Disseminated disease in the fetus can cause granuloma formation (with associated tissue destruction) in many tissues, including liver, adrenal glands, lymphatic tissue, lungs, and brain(granulomatosis infantiseptica)
• Prenatal toxoplasmosis􀃎Rx Treatment is with combination antibiotic therapy, including pyrimethamine, sulfadiazine, and leucovorin.
• Bupropion 􀃎 antidepressant with both dopaminergic and noradrenergic properties􀃎improve depression and cognitive functioning (term cognition is used in several loosely related ways to refer to a faculty for the human-like processing of information, applying knowledge and changing preferences)􀃎also used to reduce Nicotine craving/dependence 􀃎Any drug with anticholinergic properties might impair cognitive function(even SSRI)
• Propranolol known to occasionally lead to depressive symptoms
• Loosening of associations􀃎ideas are disconnected and seem to jump from one topic to an unconnected topic. Clang associations􀃎Words that rhyme are frequently associated. Concrete thinking 􀃎poor ability to think in abstract terms despite normal intelligence. Tangential thoughts􀃎thoughts that go off on a tangent, interviewer is commonly left with the sense that a question to the patient elicited a long string of thoughts that ended up having nothing to do with the original question. Thought blocking 􀃎occurs when thoughts and speech halt, often in mid-sentence, as if forgotten. The thought may be picked up later, after a period of apparent confusion.
• Cimetidine known to cause psychiatric effects like delusions and psychosis􀃎related to the effects of cimetidine on the H-2 histamine receptor in the brain.
• Electroconvulsive therapy (ECT) has been safely used in pregnancy. In case of psychotic depression with increased risk for suicide, the situation requires expeditious treatment to protect the mother and fetus, and ECT is the treatment of choice.
• Post-traumatic stress disorder􀃎Rx Sertaline
• Maternity blues is a normal state of sadness, dysphoria, frequent tearfulness, and dependence that about 20% to 40% of women experience in the postpartum period. It is thought to be derived from rapid changes in women's hormonal levels and the stress of childbirth associated with maternity
• Behavioral therapy is the most frequently used treatment in children with enuresis. Dry nights are recorded on a calendar and rewarded with a star as a gift.
• Agoraphobia(fear of open spaces or of the marketplace)is a fear of panic attacks in situations from which it would be difficult to gracefully remove oneself. Behavioral therapy is used to encourage patients to modify their activities.
• Generally conventional antipsychotic + prophylactic anticholinergic agent (benztropine, diphenhydramine, or trihexyphenidyl).is given together􀃎sudden ceassation of anticholinergic􀃎Ppt Extrapyramidal signs like dystonic reaction/torticollis􀃎Rx IM administration of an anticholinergic agent
• Although risperidone is an atypical antipsychotic, it is like conventional antipsychotics in its ability to cause significant elevations in plasma prolactin levels.
KaplanQbankNotes:Neeraj 13
• Psychomotor agitation is a series of unintentional and purposeless motions that stem from mental tension of an individual. This includes pacing around a room, wringing one's hands, pulling off clothing and putting it back on and other similar actions. In more severe cases, the motions may become harmful to the individual, such as ripping, tearing or chewing at the skin around one's fingernails to the point of bleeding DDx Psychomotor agitation in major depressive disorder > bipolar depression
• Catatonia include stupor, negativism(motiveless resistance to all attempts to be moved or to all instructions), rigidity, posturing, mutism, stereotypies, mannerisms, waxy flexibility, and catatonic excitement. Catatonia may be associated with schizophrenia (catatonic type), mood disorders (with catatonic features), or general medical condition or Extrapyramidal side effect of drug .
• Nihilistic delusions are false feelings that the self or others do not exist or are destroyed. It is typical for depression with psychotic features. At its extreme, it is called Cotard's syndrome.
• Prescribing antidepressants in bipolar depression may un-mask underlying mania 􀃎Start mood stabilizer before beginning treatment with an antidepressant
• Panic disorder Rx benzodiazepine like clonazepam or use of cognitive behavior therapy, which incorporates exposing the patient to disturbing stimuli in an attempt to develop coping mechanisms in response to the stimuli.
• Adjustment disorder is exemplified by a set of behavioral or emotional symptoms developing as a response to an identifiable stressor within 3 months after exposure to the stressor. The symptoms are excessive compared with what one would expect from the exposure, and they cause marked impairment in social functioning.
• Any event that affects the vasculature, such as a myocardial infarction or a cerebrovascular accident (CVA), has been shown to increase the risk of major depressive disorder in the months following such an event. Post-stroke mania is a rare phenomenon usually seen in infarctions of right frontal lobe and sometimes other parts of the right hemisphere.
• Pemoline is a sympathomimetic agent approved for the treatment of attention deficit/hyperactivity disorder. Given the rate of reported cases of hepatic failure. Dextroamphetamine is approved for the treatment of attention deficit/hyperactivity disorder. Its main adverse reactions involve the cardiovascular system, the CNS, the gastrointestinal system, and the endocrine system.
• Prevalence of ADHD is estimated to decline by 50 % every 5 years until the mid-20's i.e. older the children get without symptoms of ADHD, the less likely they have the disorder. (Generally manifest before 6-7yrs)
• Mini-Mental Status Examination (MMSE) is a brief instrument designed to grossly assess cognitive functioning. It assesses orientation, memory, calculation, reading and writing capacity, visuospatial ability, and language. The maximum score is 30. can be re-administered periodically to follow progression of dementia.
• prochlorperazine and haloperidol administration􀃎 feeling of restlessness & agitation(akathisia)􀃎Rx lorazepam given IV during administration of the neuroleptic drug.
• The most serious side effect of lamotrigine(adjunct in the treatment of refractory seizures and bipolar disorder) is rash (skin changes that looked like burns.)􀃎Stevens-Johnson syndrome
• Clozapine is an atypical agent more effective in resistant schizophrenia. It exerts an antagonistic effect on D1 and D4 receptors􀃎S/E agranulocytosis􀃎requires regular blood count monitoring
KaplanQbankNotes:Neeraj 14


KaplanQbankNotes:Neeraj 15
• Thyroid nodule? Benign or malignant􀃎nodule large enough to cause airway or digestive tract obstruction􀃎 emergent thyroid surgery without further evaluation.
Step-1:TSH􀃎Decreased =hyperactive nodule=typically benignA
Step-2:TSH􀃎Normal or elevated TSH = non-functioning or normally functioning nodule.
Step-3:Imaging and/or a biopsy to obtain a tissue diagnosis􀃎ultrasound􀃎most useful diagnostic tool fine needle aspirate (FNA)􀃎result from an FNA
1. First, the sample can represent benign lesions= no further treatment (unless the lesion continues to grow causing obstruction to breathing or eating, or causing unacceptable cosmetic disfigurement in the neck).
2. Second, the specimen can be a follicular lesion = treated with a surgical removal of part or all of the thyroid gland to determine whether it is a benign or malignant type.
3. Third, the biopsy can show a clearly malignant lesion = treated with surgical removal of the thyroid gland.
4. Finally, the sample can be nondiagnostic = requires a repeat FNA. However, after three nondiagnostic biopsies, a surgical removal of the affected thyroid lobe is usually recommended.
• Approach towards Breast Lump:
1. Nipple discharge: Pathologic discharges are spontaneous, bloody or associated with a mass. These discharges are usually unilateral. The most common cause of pathologic nipple discharge is intraductal papilloma, followed by duct ectasia.10 If a palpable mass is present in association with a discharge, the likelihood of cancer is greatly increased.
2. Dominant breast massDx macrocyst (clinically evident cyst), fibroadenoma, prominent areas of fibrocystic change, fat necrosis and cancer. KaplanQbankNotes:Neeraj 16
(a)Solid Masses in Women Less Than 40 Years of Age
1. Physical Examination􀃎 No evidence of mass 􀃎reassured and instructed in breast self-examination.
2. Physical Examination􀃎 physical finding is uncertain 􀃎 directed ultrasound examination􀃎not demonstrate a mass􀃎Repeat physical examination􀃎?mammogram (35 to 40 years not in younger)
3. Physical Examination􀃎 dominant mass (? suspicious mass is solitary, discrete, hard and often, adherent to adjacent tissue)􀃎 mammography􀃎pathologic diagnosis.
4. Physical Examination􀃎 dominant mass (? Not a suspicious mass or clinically benign)􀃎 discus options of surgical excision or follow-up with the patient􀃎patient desires surgical excision􀃎no additional testing is done􀃎patient opts for further work-up􀃎an ultrasound examination and fine-needle aspiration are performed to confirm that the mass is benign. "Triple test" (clinical examination, ultrasonography [or mammography] and fine-needle aspiration).
• The size of the lesion must be measured with a ruler at presentation and on subsequent visits to allow an accurate assessment of size over time.
• patient is examined every three or four months for one year to ensure stability of the mass.
(B)Solid Masses in Women More Than 40 Years of Age.
1. Abnormalities detected on physical examination in older women should be regarded as possible cancers until they are documented to be benign.
2. mammography is a standard part of the evaluation of a solid breast mass.
3. In the presence of a dominant breast mass, a normal mammogram should never be considered proof of the absence of breast cancer.
• Premenstrual dysphoric disorder: constellation of physical and emotional symptoms occurring during the late luteal phase of the menstrual cycle􀃎symptoms must be present during most cycles in the past year and during at least two subsequent cycles􀃎at least five of the following symptoms: depressed mood, marked anxiety, affective lability, decreased interest, decreased energy, sleep disturbance, craving food, feeling overwhelmed, and difficulties concentrating􀃎interfere with social or occupational functioning and are not due to other psychiatric or medical disorders.
• Exposure therapy􀃎a type of behavior therapy􀃎most commonly used treatment of specific phobia􀃎 desensitizes the patient by a gradual exposure to the phobic stimulus􀃎Relaxation and breathing control are important parts of the treatment.
• Alprazolam belongs to the group of short-acting benzodiazepines. Even though it has a short half-life, it can produce confusion, disinhibition, and amnestic problems like blackouts in the elderly population. The risk is increased if it is combined with CYP3A inhibitors.
• In pseudodementia of depression, the patient often tends to emphasize disability related to memory loss much more than patients experiencing true dementia.
• Olanzapine is an atypical antipsychotic indicated for the management of psychotic disorders. It is said to be associated with weight gain.
• HIV dementia is characterized by affective, cognitive, behavioral, and motor symptoms and signs. It presents as a subcortical process and is most likely to occur in patients with a CD4 count below 200/mm3. It usually has a slow onset, and, after a period of stability, there can be a precipitous decline. The diagnosis is made when other causes of delirium are excluded; the disease may present with psychosis within HIV dementia. The symptoms are controlled with low doses of neuroleptics.
• Circumstantiality refers to speech that is delayed from reaching the point, characterized by overinclusion of details.DDxTangentiality : patient never gets to the desired goal from the starting point of discussion.
• Patients with disorganized type schizophrenia are likely to exhibit disorganized speech, disorganized behavior, and flat or inappropriate affect. Examples of disorganized thoughts and speech include: loosening
KaplanQbankNotes:Neeraj 17
of associations or derailment, flight of ideas, tangentiality, circumstantiality, word salad, neologisms, and clang associations.
• The newer atypical antipsychotics have minimal, if any effect on plasma prolactin concentrations, except for risperidone, which is associated with elevated prolactin.
• A Papanicolaou smear should ideally be a sampling of the transformation zone(adequate sample should show endocervical cells)􀃎endocervical cells not present?whether the transformation zone was fully sampled􀃎Repeat the sample if high risk individual 􀃎or after 1 yr if with no high risk and had all earlier pap normal􀃎Every woman should have yearly pap smear after first intercourse or 18yrs whatever comes earlier
• Rarely struma ovarii is a cause of hyperthyroidism and patients with this manifestation may have symptoms of hyperthyroidism, as well as elevated levels of thyroid hormones and decreased levels of thyroid stimulating hormone (TSH).
• There is no evidence that breast-feeding increases HCV transmission to the baby.
• Postpartum endometritis 􀃎Cesarean section is the major risk factor􀃎Organisms ascending from the girl thingy and causing a polymicrobial infection of the endometrium 􀃎 fever and chills, lower abdominal pain, a foul-smelling vaginal discharge and malaise􀃎 abdominal tenderness, and uterine tenderness􀃎Rx clindamycin and gentamicin ( prophylactic antibiotics are recommended in all cases of nonscheduled cesarean delivery i.e. a cesarean delivery that is not anticipated like with membranes broke but non-progressing/Breech etc and are given before or after the umbilical cord is clamped)
• Discharge criteria 􀃎patient should be alert, able to ambulate (if this was her preoperative level of function), able to tolerate adequate oral intake(Patient on IV intake should not be discharged), have stable vital signs, and have satisfactory bowel and urinary tract function.
• Chorioamnionitis (can develop at any time before and during delivery)􀃎fever and uterine tenderness􀃎Rx ampicillin or penicillin with gentamicin.
• Asymptomatic bacteriuria in pregnant women􀃎association with preterm delivery/low birth weight 􀃎Rx trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin􀃎follow-up urine culture after 10 days of completing the medication􀃎test-of-cure.
• Gestational diabetes􀃎usually diagnosed by means of oral glucose tolerance testing􀃎Patients with gestational diabetes and normal fasting glucose􀃎two major risks􀃎fetal macrosomia & eventual development of overt diabetes(within the next 20 years)􀃎with gestational diabetes and abnormal fasting glucose 􀃎increased risk of stillbirth.
• Significant mitral stenosis during pregnancy should be monitored invasively using a Swan-Ganz catheter􀃎 second stage of labor be shortened using forceps or vacuum to prevent excess maternal Valsalva efforts and maternal tachycardia.
• HIV Positive mother 􀃎combination of ZDV therapy + cesarean delivery decreases the risk of transmission to approximately 2% 􀃎Amniocentesis should be avoided, if possible, in the HIV-positive woman.
1. 2% vertical transmission with ZDV + Scheduled CS prior to the onset of labor or rupture of membranes
2. 8% antiretroviral therapy in mother + Infant
3. 25% when none used
• Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is 12 1/2 years, but it may be delayed until 16 or may begin as early as age 10.
• Current recommendations are that pregnant women who will be in the second or third trimester during the flu epidemic season should be given the influenza vaccination.
• "once a cesarean, always a cesarean." This is no longer the case. Some women are allowed to 􀃎 approximately 70% of all women attempt vaginal birth after a prior cesarean delivery will be successful.
KaplanQbankNotes:Neeraj 18
• Face presentation􀃎Causes: anencephalic fetus, pelvic contraction, and high parity􀃎vaginal delivery is possible when the fetus is in a mentum anterior position (i.e., the fetal chin is oriented toward the maternal pubic symphysis.)􀃎Fetus can flex its head, thereby allowing delivery􀃎 Vacuum delivery /Forceps delivery with a non-vertex presentation would be contraindicated.
• The presence of a classic uterine scar (vertical incision into the uterus that extends from the lower uterine segment up into the active myometrial portion toward the fundus of the uterus) mandates elective repeat cesarean delivery when the fetus is mature as patients with a previous classic cesarean delivery have roughly a 10% risk of uterine rupture.
• Oxytocin or Prostaglandin (PGE2) gel is an effective agent to use for labor induction􀃎shown to improve the Bishop's score, to shorten the length of labor and delivery, to decrease the amount of oxytocin needed, and to decrease the cesarean delivery rate􀃎main complication from its use is uterine hyperstimulation􀃎increased frequency of contractions (greater than 5 every 10 minutes) or an increased length of each contraction (greater than 2 minutes) or contractions of normal duration occurring within 1 minute of each other and a non-reassuring fetal heart rate tracing 􀃎Rx IV or subcutaneous terbutaline or IV magnesium sulfate(MgSo4 also most effective medication for seizure prophylaxis in women with preeclampsia) in case of PGE2 or discontinuing the oxytocin (bradycardia to the 80s) or reducing its dosage (where the fetal heart rate tracing is not as non-reassuring)
• Home uterine activity monitoring (HUAM) 􀃎 women are monitored at home with a tocodynamometer (a way to measure uterine contractions)􀃎will allow for preterm labor to be recognized and treated in its earliest stages􀃎to prevent preterm births􀃎In practice not been proven to prevent preterm birth􀃎possible benefit early recognition of preterm labor􀃎would allow for the administration of corticosteroids to bring about fetal pulmonary maturity (Steroid administration in a Diabetic mother may lead to increased dosage of Insulin).
• Fetal scalp sampling (FSS):method of fetal assessment with fetal blood pH 􀃎When the fetal heart rate tracing is not reassuring, FSS can be used to determine the acid-base status of the fetus, which will help with management of the labor􀃎pH is > 7.25 then the patient may be managed expectantly 􀃎pH is between 7.20 and 7.25:repeat in 15 to 30 minutes􀃎pH is < 7.20, steps should be taken to bring about delivery(Acidemia likely to cause damage to the fetus appears to occur at values < 7.00, by using a cutoff of 7.20, there is a margin for error to protect the fetus)
• Forceps and the vacuum extractor􀃎To expedite the delivery􀃎indications:
1. non-reassuring fetal heart rate tracing,
2. maternal exhaustion
3. maternal contraindications to pushing (such as maternal cardiac disease.
Choice of forceps or vacuum ? 􀃎Forceps may be used in face presentation with a mentum anterior presentation(vacuum is contraindicated)􀃎 Vaccum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissues􀃎Both the vacuum and forceps should preferably be used only in low- or outlet- situations (i.e., with the fetal vertex at +2 station or lower.)
• A major advantage of chorionic villus sampling is that it can be performed at 10-12 weeks, as opposed to amniocentesis, which is performed in the second trimester. CVS thus allows a woman to undergo an earlier termination than amniocentesis allows for. However, there is some evidence that one subtype of limb defect, called transverse digital deficiency, is more common with CVS.
• The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the girl thingy at the 5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the posterior girl thingy.They undergo rapid growth during the process of puberty and they shrink after the menopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst results􀃎cyst becomes infected􀃎Bartholin's abscess􀃎polymicrobial /gonococcus implicated in 25% 􀃎Rx placement of a Word catheter.( This is a small balloon-tipped catheter)allows drainage of the cyst and the formation of an epithelialized tract that will allow continued drainage once the catheter is removed􀃎tract should prevent the cyst from reforming􀃎If Bartholin's cysts continue to form in spite of the use of the Word catheter, a marsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding skin to prevent re-closure and re-formation of the cyst􀃎interestingly; one cannot make this assumption in a postmenopausal patient􀃎cystic mass on the vulva in a postmenopausal woman must be biopsied(as there is a higher likelihood that this lesion represents a Bartholin's gland carcinoma)
• High-grade squamous intraepithelial lesion (HGSIL) will progress to invasive cervical cancer􀃎colposcopically directed biopsy􀃎diagnosis of HGSIL is confirmed􀃎the distribution of the lesion
KaplanQbankNotes:Neeraj 19
is known, removal or destruction of the entire transformation zone should be performed􀃎done with a loop electrode excision procedure (LEEP􀃎a thin-wire loop electrode is used to excise the entire transformation zone􀃎LEEP can thus be used as both a diagnostic and therapeutic procedure􀃎 immediate risks of LEEP are bleeding and infection. The possible long-term risks include cervical incompetence and cervical stenosis.
• The American Heart Association guidelines for the prevention of bacterial endocarditis􀃎antibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery 􀃎Except patient with "high risk" cardiac conditions, which include women with a history of endocarditis, or who have prosthetic heart valves, complex cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts􀃎 Mitral valve prolapse if associated with mitral regurgitation (demonstrated by Doppler or a murmur) is considered a moderate risk condition and therefore antibiotic prophylaxis is not necessary.
• Physiologic leukorrhea can be seen during 2 different periods of childhood. Some female neonates develop a physiologic leukorrhea shortly after birth as maternal circulating estrogens stimulate the newborn's endocervical glands and vaginal epithelium. Physiologic leukorrhea can also be seen during the months preceding menarche. During this time, rising estrogen levels lead to a whitish discharge not associated with any symptoms of irritation or infection.
• With each uterine contraction, blood flow to the placenta decreases, and the fetus is exposed to transient hypoxia. As the labor progresses and more and more contractions occur, this hypoxia can eventually lead to a change from aerobic to anaerobic metabolis􀃎fetal academia􀃎most fetuses tolerate the stress􀃎protective mechanisms􀃎including a blood buffering system and the diving reflex (a lowering of the heart rate in times of hypoxic stress)􀃎Electronic fetal monitoring is used to determine whether the fetus is becoming dangerously acidemic or "stressed"? 􀃎 But many fetuses with a non-reassuring fetal heart rate tracing do not have academia􀃎Thus, the delivery of many fetuses is expedited because of the concern for fetal acidemia when, in fact, the fetus is not acidemic at all!
• Group B Streptococcus part of the normal bacterial colonization of many women􀃎 which women will receive antibiotics during labor? 􀃎 likelihood of infection is increased if following risk factors are present:
1. The five risk factors are: 1. History of a GBS-affected neonate. 2. Urine culture with GBS (GBS bacteriuria) 3. Preterm labor (<37 weeks). 4. Membranes ruptured for greater than eighteen hours in labor. 5. Temperature greater than 38.0 C (100.4 F) in labor. A woman with any one of these five risk factors should receive antibiotics in labor.
2. also provide antibiotic if pregnant women being screened for GBS and found positive at 35 to 37 weeks with a culture of the girl thingy, perineum, and anus.
Rx penicillin.
• Needle prick injury may transmit HBV>HIV during operative procedures etc
• BRCA1 is associated with high risk for breast and ovarian cancer.
BRCA2 is associated with a high risk of female and male breast cancer.
But total number of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentage of the total number 􀃎Therefore, screening of the general population is not recommended.
• RhoGAM (anti-D immune globulin) is given at 28 weeks' gestation, within 72 hours after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis, threatened abortion, antenatal bleeding, external cephalic version, or abdominal trauma􀃎The amount is 300 μg (covers a fetal to maternal hemorrhage of 30 mL or 15 mL of fetal cells)􀃎when fetal to maternal hemorrhage in excess of this 30 mL like with manual removal of the placenta (like this patient had) or placental abruption. 􀃎To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test􀃎 This acid-dilution procedure allows fetal red blood cells to be identified and counted.
• Aspiration pneumonitis is a major cause of anesthesia-related death in obstetrics 􀃎Rx treatment positive-pressure ventilation with 100% oxygen administered through an endotracheal tube􀃎 when an epidural is going to be placed, the patient should be given an antacid
• Two of the major risk factors for uncomplicated UTI are sexual intercourse and hypoestrogenism. Hypoestrogenism is believed to be a risk factor for UTI because it is known that postmenopausal women not receiving estrogen replacement therapy (ERT) are at greater risk for developing a UTI compared with those women who do use ERT.
KaplanQbankNotes:Neeraj 20
• There is no effective screening test for endometrial cancer .It is not cost-effective to screen asymptomatic women for endometrial cancer.
• Cancer screening should be an essential part of an annual examination. Colorectal cancer screening should begin at age 50 with no significant family history. Screening consists of a digital rectal examination with fecal occult blood testing. This can be performed at the same time that pelvic examination is performed. Sigmoidoscopy should be performed every 3-5 years.
• Various studies have also shown that rates of preeclampsia, placental abruption, and heart failure may be increased in pregnant patients with hypothyroidism. Pregnancy often leads to an increased requirement for thyroid hormone replacement (thyroxine) as the pregnancy progresses.
• Coumadin is contraindicated during the first trimester because of the risk of birth defects. Coumadin embryopathy is a syndrome consisting of nasal hypoplasia and stippled vertebral and femoral epiphyses. Second- and third-trimester exposure to Coumadin can lead to hydrocephaly, microcephaly, ophthalmologic abnormalities, fetal growth retardation, and developmental delay. Low-molecular-weight heparin has been shown to be an excellent anticoagulant because it has a longer half-life and a more predictable dose-response relationship,also less likely to cause thrombocytopenia and hemorrhagic complications than unfractionated heparin.
• Tubal ligation failure may result from many factors including recannalization of the tube and poor surgical technique. The most commonly quoted failure rate is about 1 in 100, although a more accurate figure may be closer to 1 in 300.
• Raloxifene is selective estrogen receptor modulators (SERMs)􀃎 have pro-estrogenic effects in some tissues and anti-estrogenic effects in other tissues􀃎approved for prevention of osteoporosis􀃎no effect on hot flashes.
• Patient post-hysterectomy for Endometrial CA asking for HRT? 􀃎if any neoplasm is remaining in body it will grow and recur earlier! +Standard risk of venous thrombosis
• Hot flashes can respond to estrogen or progestin both􀃎When both are contraindicated(like H/o pulmonary embolus for estrogen or depression for progestin) 􀃎 Rx alternative treatment Clonidine in low doses.
• Vitamin A supplementation during pregnancy is not needed or recommended for most women. In fact, vitamin A supplementation has been associated with birth defects, including cranial neural crest malformations. Most commonly used prenatal vitamins contain 5000 IU or less, and this is considered acceptable.
• Ovarian hyperstimulation syndrome (OHSS)􀃎in patients undergoing ovulation induction 􀃎mild OHSS (ovaries <5 cm) mild weight gain and pelvic discomfort􀃎moderate OHSS, (up to 10 cm)least a 10-pound weight gain, nausea, and vomiting􀃎severe OHSS, (>10 cm) with ascites, hydrothorax, hemoconcentration, and oliguria􀃎 Rx mild cases: conservatively, more severe cases: paracentesis, thoracentesis, or surgery. 􀃎Pelvic or abdominal examinations can lead to rupture of the ovarian capsule hence ultrasound examination is preferred.
• During pregnancy: gastric acid secretion & motility is reduced and mucus secretion increased􀃎 Reduced peptic ulcer disease 􀃎Similarly 70% of women with migraines will have improvement(Rx acetaminophen and antiemetics or Codeine or meperidine may be given for severe headaches􀃎Ergotamine preparations should be avoided in pregnancy)􀃎 safety of sumatriptan during pregnancy has not been established?
• Mode of delivery with twin gestations:
1. Vertex-vertex twins are generally allowed to have a vaginal delivery.
2. presenting twin that is non-vertex are generally advised to have a cesarean delivery
3. Presenting twin vertex and the non-presenting twin non-vertex may decide which mode of delivery they would prefer􀃎Once the presenting (vertex) twin has delivered􀃎first option is an external cephalic version, in which the head of the second twin is guided into the pelvis so that it becomes a vertex presentation􀃎second option is a breech extraction of the second twin(Breech extraction may be performed so long as there is an adequate pelvis, a fetal weight greater than 2,000g, an experienced physician, a flexed fetal head, and available general anesthesia)
KaplanQbankNotes:Neeraj 21
• DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed on cultured amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliable for the diagnosis of fragile X syndrome because of different methylation patterns in the trophoblast compared with the fetus.
• Kallmann syndrome (i.e., isolated gonadotropin deficiency or familial hypogonadotropic hypogonadism) can present with primary amenorrhea ,anosmia or hyposmia, color blindness, and cleft lip or cleft palate(during embryogenesis the GnRH neurons originally develop in the epithelium of the olfactory placode and normally migrate into the hypothalamus􀃎Thus exists the link between the midline defects and the amenorrhea)􀃎Rx exogenous estrogen and progestin replacement therapy􀃎If pregnancy is desired, ovulation induction can be brought about with the pulsatile administration of exogenous GnRH.
• In case of PID: The partner of the patient must be treated as well as the patient herself in order to prevent reinfection. A test of cure (TOC) should be performed 4 to 6 weeks after treatment is given to ensure that the organism has been completely eradicated from the patient and her partner or partners.
• PID in preganacy􀃎Rx Clindamycin + gentamycin
• Meperidine can be used as a systemic analgesic during labor. It is an opioid and readily crosses the placenta; therefore, the fetus is exposed to the medication. As an opioid, it causes respiratory depression. Neonates are at greatest risk for respiratory depression when delivery occurs approximately 2 to 3 hours after meperidine is administered to the mother.Rx nalaxone
• Compound presentation:when an extremity prolapses alongside the fetal presenting part􀃎brought about when the pelvic inlet is not completely occluded by the fetal head(Most often with premature fetuses)􀃎 compound presentation can be allowed to undergo a normal labor and delivery.
• Women of child-bearing age should consume 0.4 mg/day of folic acid starting preconceptionally and continuing for the first 3 months of pregnancy.
• Molar preganancy: Once there is pathologic confirmation of the diagnosis, it is essential that the patient continued to be followed weekly until the beta-hCG value returns to 0. The patient should then be followed monthly for an additional year to ensure that the values stay at 0 and that there is no evidence of persistent or metastatic disease.
• Syphillis in preganancy nly Rx is penicillin as no other drug permits safe and effective treatment of the fetus as well as the mother􀃎In a patient who is allergic to penicillin, oral desensitization must be performed first in a hospital setting with appropriate facilities.
• Genital herpes: no "cure" for herpes genitalis. Acyclovir can be used to shorten the duration of symptoms. In patients who have more than 6 outbreaks per year, daily oral acyclovir is recommended to prevent these frequent outbreaks.
• In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be sought.
• Fluid replacement in a case of burns the Parkland calculations made by standard formulas are only an educated guess. Once fluid administration begins, we judge its adequacy by the information provided by urinary output and central venous pressure, aiming for an output of 1-2 mL/kg/hr, while not exceeding a venous pressure of 10 or 15.
• Parkland formula: 4 mL of Ringer's lactate x body weight in Kg x percentage of the body surface burned + 2000 mL of dextrose 5% in water
• The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions: no chemotherapy during the first trimester, and no radiation therapy during the pregnancy. It is not necessary to terminate the pregnancy. The surgical option could be mastectomy or lumpectomyas per the size.Should axillary nodes be positive, systemic therapy should be done later.
KaplanQbankNotes:Neeraj 22
• 2nd postoperative day after an operative procedure􀃎urinary output in the past 2 hours has been zero (ARF ruled out as some urine is still produced in ARF, although it is a small volume)􀃎Rule out catheter block?
• Lumpectomy alone has an unacceptably high incidence of local recurrence􀃎Always add local radiation therapy􀃎If metastatic disease found in axillary nodes􀃎Add systemic therapy. As a rule, chemotherapy is preferred for premenopausal women & receptor positive.
• Never operate a patient under GA if liver function marginal 􀃎would be tipped into overt liver failure by an anesthetic and an operation
• Any gunshot wound below the nipples involves the abdomen, and the management of all gunshot wounds of the abdomen requires exploratory laparotomy.
• Compartment syndrome􀃎triggered by prolonged ischemia followed by reperfusion (the arm pressed against the park bench until he woke up and changed position), and located in one of the two most common sites (forearm and lower leg)􀃎reliable physical finding pain on passive extension and the diagnosis is not ruled out by normal pulses. Only a fasciotomy will solve his problem.
• Amputed finger under transport􀃎must be kept from drying out􀃎must not be injured with any direct chemical agents􀃎must not be placed in direct contact with ice or allowed to freeze.
• There is some evidence that high-dose corticosteroids administered as soon as possible after the injury will result in a better ultimate outcome
• A rough guideline to quantify water loss 􀃎every 3 mEq/L that the serum sodium concentration is above normal, represents about 1 L of water deficit 􀃎 E.g Na+ 155 = excess of 15 = water deficit of about 5 L. While correcting hypernatremia the tonicity correction should not happen with the same speed with which the volume is going to be corrected (Brain should adapt with osmolality changes)􀃎 That delay is achieved by choosing a fluid that is not pure water, but one that has some sodium in it to dampen the effect on tonicity􀃎E.g Dextrose with half NS
• Severe head trauma sufficient to produce coma + facial injuries􀃎always evaluate with CT to R/o bleed and include Neck also
• All failed regimen in anal fissure􀃎 Opt for Forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections
• Abdominal compartment syndrome􀃎the life-saving massive fluid infusions produce severe edema in the surgical field􀃎Forced closure would compromise ventilation and venous return􀃎A temporary plastic coverage, or a mesh, allows the bowel to be protected without undue pressure.
• Pelvic bone fracture 􀃎Falling BP but no free fluid within abdomen 􀃎Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlled􀃎Minimizing the motion of the bone fragments by external fixation can be helpful􀃎 Comminuted fractures of the femurs are also known to be one of the few places in the body where enough occult blood loss may occur to lead to hypovolemic shock.
• Hyperthyroid state 􀃎 But the thyroid gland normal􀃎Radioactive iodine uptake should be high if her gland is indeed hyperfunctioning but it will be near zero if it is suppressed by the exogenous hormone.
• Breast mass found after trauma not regressing after week might not be a hematoma or fat necrosis􀃎trivial trauma sometimes brings to the attention of the patient an area of the body that had not been examined before􀃎A breast mass in a >40-year-old woman requires a mammogram and biopsy.
• Gunshot wounds to the base of the neck may injure major vessels, the tracheobronchial tree, and the esophagus 􀃎diagnostic studies should precede surgical intervention if time allows
• Several months after sustaining a crushing injury to arm􀃎constant, burning, agonizing pain in that arm􀃎Not responding to usual analgesic medications􀃎 aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleeves􀃎arm not swollen and pulses normal􀃎neurologic function of major
KaplanQbankNotes:Neeraj 23
nerves intact􀃎causalgia (reflex sympathetic dystrophy)􀃎If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy.
• Small umbilical hernias can close spontaneously up to the age of 2 years.
• Enucleation of Eye􀃎Often done for two malignant tumors􀃎retinoblastoma and melanoma􀃎melanoma may present as metastatic tumour after even 20-some years􀃎A patient with a glass eye or missing toe and a liver full of tumor is classic examples to illustrate the unpredictable behavior of melanoma.
• Suspected Skin CA 􀃎 Always perform biopsy 􀃎edge of the lesion offers the best information for the pathologist􀃎An excision before pathologic diagnosis risks doing too much (a basal cell cancer needs only 1 or 2 mm of margins) or too little (a melanoma should have at least 2 cm).
• most important thing that can be done for caustic chemical burns is to wash away the caustic agent as soon as possible
• When coagulopathy develops during operative procedure􀃎 provide fresh frozen plasma and platelet packs. 􀃎when hypothermia complicates the picture􀃎Close the abdomen immediately 􀃎 bleeding surfaces have to be packed, waiting for a more propitious time in which to attempt hemostasis, once coagulation function and body temperature have improved
• Diffuse esophageal spasm v/s Nutcracker esophagus􀃎 on manometry there is a mean distal esophageal peristaltic amplitude of more than 180 mm Hg, including an elevated baseline pressure in the lower sphincter in Nutcracker (Normal pressure and relaxation in diffuse esophageal spasm).
• De Quervain's tenosynovitis: Tenosynovitis of the abductor or extensor tendons of the thumb 􀃎positive Finkelstein sign (the pain produced by ulnar deviation to stretch the affected tendons).
• Advanced breast CA􀃎Rad/chemo to make it operable
• A high spinal anesthetic can produce vasomotor shock by inducing widespread vasodilation. Vasoconstrictors are the appropriate therapy, but since the capacity of the vascular tree is also increased under these circumstances, filling it up with additional volume is also helpful.
• Follicular thyroid cancers can metastasize by way of the blood stream to the liver, lung, brain, or bones. Because the tumor has rudimentary functional capability, it can be traced with and ablated by radioactive iodine; however, the tumor cannot compete successfully with normal thyroid tissue for the capture of iodine. After removal of the entire gland, the tumor becomes the most effective iodine trapper in the body.
• Very tender spot in the third interspace foot(between the third and fourth toes)􀃎no redness, limitation of motion, or signs of inflammation􀃎classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve.
• A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely cause would be a lytic lesion from metastatic breast cancer.
• Post-traumatic hemothorax􀃎criteria to perform thoracotomy 􀃎if the initial blood recovery exceeds 1000 mL, or if subsequent drainage adds up to 600 mL or more, over the ensuing 6 hours.
• wound dehiscence after abdominal surgery􀃎draining copious amounts of clear pink fluid from his midline laparotomy wound􀃎could have been handled by taping the wound securely􀃎 Immediate surgical repair is mandatory􀃎Not allowed to strain abdomen or move around􀃎Once the bowel came out, the problem became an evisceration
• Acute ‘Senility’ within short periods of weeks 􀃎Suspect chronic SDH.
• In case of Pheochromocytoma 􀃎 presence of catabolites from epinephrine indicates that the tumor is in the adrenal glands, and not at an extra-adrenal site.
KaplanQbankNotes:Neeraj 24
• When hitting the knees against the dashboard, the femurs can be driven backward and out of the acetabulum, resulting in posterior dislocation of the hips. Because of the tenuous blood supply of the femoral heads, such injury must be promptly recognized and treated.
• Postoperative complications:
1. Atelectasis : seen on day 1
2. Fever day 3 is usually from the urinary tract infection.
3. Deep thrombophlebitis 5-7 days after surgery
4. Intra-abdominal abscess 7-10 days
• Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is prolonged hypotension. Furthermore, the mortality greatly surpasses that of a myocardial infarction de novo (ie, unrelated to surgery), reaching upto 50-90%
• heel pain every time foot strikes the ground􀃎worse in the mornings, preventing him from putting any weight on the heel􀃎when the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation􀃎 plantar fasciitis.
• central cord syndrome:mechanism of injury (hyperextension)􀃎relative sparing of the lower extremities in the presence of upper extremity deficits are classic
• Anterior cord syndrome all functions are lost, except for positional and vibratory sense. Those injuries occur with blowout of the vertebral bodies.
• Posterior cord syndrome is quite rare, and it would show loss of positional and vibratory sense.
• Anorectal signs and mass with Inguinal nodes 􀃎has to be anal SCC􀃎AdenoCa of rectum will never metastasize to inguinal nodes.
• Ogilvie syndrome is the acute pseudoobstruction and dilation of the colon in the absence of any mechanical obstruction in severely ill patients
• Brain tumor with increased intracranial pressure􀃎development of hypertension and bradycardia (Cushing's reflex) signifies that the brain has run out of compensatory mechanisms to minimize the intracranial pressure elevation generated by increased intracranial volume. When that point is reached, brain perfusion suffers and death is imminent.
• Posterior dislocation of the shoulder: Can be missed in AP view 􀃎mechanism of injury (massive contraction of all muscles in the area)􀃎Axillary view x-ray films are needed to make the diagnosis.

 
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* Re:Conrad Fischer's lectures on Internal Medic
#1079161
  mira1978 - 12/06/07 23:39
 
  bump for newcomers
G.L
 
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* Re:Conrad Fischer's lectures on Internal Medic
#1079169
  watano_yo - 12/06/07 23:55
 
  great work!!!  
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