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* some helpfull notes
 #556224  
  sami2004 - 12/22/10 15:35
 
  Cram-Facts:
CARDIOLOGY:
1. Stable angina – chest discomfort, can be felt in back/arms/jaw/abdm, occurs c stress/emotion, relief c rest, dx c stress test. Tx c nitrates, bb, Cabs, heparin, aspirin, if 3 vessels or L main do CABG
2. Unstable angina – unpredictable at rest or abruptly worsening pattern of angina, prolonged duration (>20), dx c ECG (st depression/t inversion) or cath shows CAD, but negative cardiac markers, tx c nitrates, cabs, bb, heparin
3. Variant/Prinzmetal Angina – chest pain at rest, ST elevation (note the 3 causes of ST elevation are MI (inferior (LDA) is II, III AVF; lateral (circumflex a)is I, AVL, V5, V6; anterior is V1-V4), Pericarditis (diffuse, meaning every lead has it), and Variant Angina) with negative markers. Treat with Ca-channel blockers (Cabs) or nitrates.
4. Acute MI – chest discomfort, crushing pain without warning (females and diabetics get atypical chest pain, which is abdm pain, fatigue, neck pain or weakness), prolonged duration (hours), ECG may be abnormal (st elevation or depression), increased markers, tx c MONA, ACEI, heparin, bb, tPA’s if 60, subtract one). >2 risk factors: diet if >160, drugs if >190; 2 or more risk factors: diet if >130, drugs if >160, pt has CHD: diet if >100, drugs if >130.
6. Causes of high output heart failure – severe anemia, thyrotoxicosis, acute beriberi, paget’s dz, large AV fistula
7. Acute Pulmonary edema – tx – 1st upright position and O2, 2nd loops, nitrates, morphine, and 3rd intubate if severe.
8. HOCM – tx – 1st avoid dehydration, 2nd strenuous activity prohibited, 3rd BB, 4th Cab’s, 5th surgical myectomy. Best dx is history (screen family) and physical, then Echo.
9. Restrictive CM – JVD, edema and ascites, dx c echo, tx 1st diuretics/ decrease salt
10. Myocarditis – history or URI (coxsackie) then fever, dyspnea, CP, edema, tachy
11. Acute Pericarditis – positional CP, tx c NSAIDS
12. Pericardial effusion – pericardial friction rub, tx c pericardiocentesis
13. Tamponade – becks triad (JVD, muffled heart sounds, pulsus paradoxicus c hypotension), tx c pericardiocentesis
14. Constrictive pericarditis – pericardial knock, kussmaul breathing, CXR shows pericardial calcification, tx c diuretics
15. Acute RF – PECCS (polyarthrtitis, erythema marginatum, carditis, chorea, subQ nodules) in kids 5-15yo due to group A strep. Tx is Abx, bed rest, salicylates, sedatives for chorea, steroids for carditis.
16. Mitral stenosis – most associated c RHD, LA enlargement à hoarseness, dysphagia, and A.fib, diastolic rumble at LV apex, tx c diuretics, coumadin for a.fib, endocarditis prophylaxis, balloon vulvoplasty
17. Mitral regurge – a/w marfans, RHD, myxomatous change, high-pitched holosystolic murmur at left sternal border, tx c diuretics, dilators, endocarditis prophylaxis, mitral valve respacement/repair
18. Aortic regurge – congenital, marfans, trauma, aortitis, high-pitched decrescendo diastolic murmur at left sternal border and/or apex and wide pressure, tx c valve diuretics, dilators, endocarditis prophylaxis, valve replacement (last)

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

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


SKIN:

42. HSV – type 1 at mouth, type 2 in genitalia. Recurrent erythema nodosum is characteristic. Dx c Tzank, tx c acyclovir
43. Herpes zoster (shingles) – dermatomal, reactivated at dorsal nerve root, tx c acyclovir
44. Varicella (chickenpox) – lesions in all stages of development, tx c benadryl. In 1st TM, causes microcephaly, chorioretinitis, IUGR and cataracts. Treat neonates with VZIG if mom contracted varicella within 5 days of delivery.
45. Impetigo – honey-crusted lesions. S aureus and B-hemolytic strep. Tx c muciprocin
46. Rubella – 3 days of cervical/suboccipital/postauricular node enlargement, prevention best c immunization before 1st TM to prevent triad: visual (cataracts), hearing loss, heart (PDA) defects.
47. Measles (Rubeola) – looks like spilled red paint over your head (rash spread beind ears and over forehead to neck to trunk and extremities), prevent c immunization
48. Roseola – 3-5 days of fever, and THEN rash after (never together). No tx
49. Erythema infectiosum – 5th dz – slapped cheek appearance, parvo B19, causes aplastic crisis in sickle cell patients, no tx
50. Rocky Mountain Spotted Fever – fever, rash on wrists then palms and soles, dx c weil-felix test, tx c tetracycline (chloramphenicol if pregnant)
51. Lyme dz – erythema chronicum migrans c central clearing, tx is doxycycline (amoxicillin if pregnant and children 60yo, large tense blisters, - nikolsky, IgG/C3 at dermal-epidermal junction, tx c prednisone, tetracycline, azathioprine (remember BCDE – Bullous pemphigoid, C3 at Dermal Epidermal junction)
57. Pemphigus Vulgaris – 40-60yo, multiple flaccid bullae, + nikolsky, biopsy shows acatholysis, antibodies to epidermal Ag, tx is prednisone, fluids, tetracycline
58. Dermatitis herpetiformis – itchy papulovesicular eruption usually on shins, - nikolsky, a/w celiac sprue, tx c gluten-free diet and dapsone (r/o G6PD first)
59. Factitial Dermatitis – no rash in nonreachable areas (midback, butterfly sign)
60. Acne Vulgaris – common acne. Tx c 1st benzoyl peroxide, 2nd topical/oral Abx, 3rd Topical retinoids, 4th Isoretinoin (r/o pregnancy first)
61. Hereditary angioedema – AD, C1 esterase inhibitor deficiency, subQ/mucosal edema
62. Pilonidal cyst – swelling, tender sacral mass, tx c antibiotics, I&D
63. Epidermoid cyst – contains keratin, asymptomatic, if infected (I&D, abx), if not excise
64. Capillary Hemangioma – strawberry nevus, reddish-purple hemangioma, tx c pulse dye laser therapy
65. Cavernous Hemangioma – purplish vascular anomaly, tx c reassurance, compression
66. Seborrheic keratosis – benign skin tumor in elderly, brown flat macule that appears “stuck-on”. Observe unless eruption is multiple then do shave excision and curettage, cryotherapy
67. Port-wine stain – a/w sturge-weber syndrome, brain calcfications, seizures
68. Actinic Keratosis – precursor to SCC, sun induced kyperkeratotic coarse lesions that are hard to remove. Tx c cryosurgery, 5FY, excision
69. Squamous cell ca – generally from the lower lip down. Ulcer that won’t heal. Tx c surgery or radiation
70. Basal cell ca – generally from upper lip up. Pearly nodule c rolled border. Surgical removal has high cure rate.
71. Melanoma – ABCD (asymmetry, borders irregular, color variation, diameter >6mm), MC is superficial spreading type, dx c total excision, loves to metastasize
72. Behcet’s syndrome – apthous ulcers, genital ulcers and uveitis, tx c d/c abx, chlorambucil
73. Dermatomyositis – difficulty rising from chair, proximal weakness, gottrons sign (purple papules on knees and knuckles), dx c mucle biopsy, tx c prednisone
74. Lofgren Syndrome – fever, erythema nodosum (LE nodules), and sarcoidosis.
75. Amyloidosis – macroglossia, waxy papules on face, congo red stain on biopsy
76. Scleroderma – raynauds, dysphagia, masklike face, tight skin, dx c skin bx, tx symptomatically or c D-Penicillamine, a/w CREST syndrome
77. Tuberous sclerosis – retinal phacomas, seizures, MR, sebaceous adenomas, ash-leaf hypopigmented macules, tx c seizure control.
78. Porphyria Cutanea Tarda – no abdm pain, but + red urine and vesicles on back of hand after having alcohol, drugs, estrogens, a/w Hep C, tx c 1st stop EtOH then phlebotomy
79. Acute Intermittend Porphyria – abdm pain, weakness in shoulders/arms, change in behavior. Blocks porphobilinogen deaminase, high ALA in the stool.
80. Acathosis Nigrans – black axillary/neck patches, a/w PCOS, DM, obesity and abdm adenocarcinoma. Next step is get fasting glucose to rule out insulin resisitance.
81. TTP – fever, thrombocytopenia (causing petechia/purpura), MAHA, renal problems (hematuria) and CNS symptoms (depression, HA, psychosis). Tx c plamapheresis
82. DIC – all labs messed up (BT, PT, PTT, fibrinogen, fibrin split products) causing cutaneous hemorrhage and ecchymosis. Tx – 1st treat primary cause, 2nd heparin
ENDOCRINE:
83. Thyroid nodule – 1st do TSH, then do FNA (preferred) or scan to see if its hot or cold (cold is malignant, if hot, observe – do not biopsy). MC benign is follicular adenoma, MC malignant is papillary (psammoma bodies), must as h/o radiation, worse if pt is male, >40 or young, distant mets. If results turn out that it’s a cyst, aspirate it and follow-up, if cancer, surgery c radioiodine (if papillary or follicular).
84. Goiter – high or low iodine uptake, lithium/amiodorone use, familial, tx c levothyroxine. Do not d/c drug, just continue the drug and add levothyroxine.
85. De Quervains (subacute) thyroiditis – painful thyroid, tx is NSAIDS
86. Sick Euthyroid Synd – low T4/T3, normal TSH. No s/s, just a goiter. Tx - nothing
87. Riedel’s – tracheal compression due to sclerosing fibrosis (rare)
88. Hashimoto’s – antimicrosomal ab, tx c levothyroxine
89. Congenital hypothyroidism (cretinism) – jaundice, lethargy, umbilical hernia, low T4, high TSH, tx c synthroid (levothryoxine)
90. Adult hypothyroidism – fatigue, myxedema, cold intolerant, wt gain, eyebrow thinning, high tsh, low T4, MCC is hashimotos, but also d/t prior graves tx, sheehan’s, amiodorone, lithium, tx c synthroid
91. Graves – low tsh, high T4, tachy, palpitations, weight loss, opthalmopathy, smooth goiter, A. fib, tx c BB’s (tremor and tachy), PTU, methimazole, radioactive iodine or subtotal thyroidectomy. In pregnancy, PTU can be used, as well as surgery if appropriate. Pt 40yo get radioactive iodine.
92. Toxic Nodule – high RIAU, no eye s/s, nodular goiter, on scan there is ONE area of increased uptake, whereas the rest its decreased (in toxic multinodular goiter (plummers disease), there are several areas of increased uptake and in Graves the entire gland has increased uptake)
93. Thyroid storm – very high fever, delirium, n/v, abdm pain, high t4, low tsh, tx c supportive care first (decrease temp, arrhythmia, BP), BB, glucocorticoids
94. Type 1 DM – polyuria/dypsia/phagia, islet cell ab, HLA DR3/4, low C-peptide, tx c insulin. If having surgery, give 10 units insulin in AM, and then 0.1U/kg/hr infusion.
95. Type 2 DM – polyuria/dypsia. Fasting glucose >126, random >200 on 2 visits. Tx first with diet/weight changes (decrease calories and carbs), oral agents, insulin. HBA1c to monitor glucose over 2-3 months. For retinal neovascularization, give laster photocoagulation therapy. For nephropathy, check for microalbuminuria (1st sign) and give ACEI. For neuropathy, give foot care and analgesia.
96. DKA – lethargy, n/v, polyuria, abdm pain, confusion, kussmaul breathing, fruity breath, glucose 400-600, anion gap met acidosis. Tx Isotonic fluids with insulin, replace K+ if needed (prevent cerebral edema).
97. Hyperosmolar coma – dehydration, lethargy, confusion, coma, high glucose without ketones, tx c fluids, insulin and electrolyte replacement.
98. Lactic Acidosis – coma, confusion, hyperventilation, no ketones, anion gap met acidosis, rare a/w metformin, tx etiology (starvation).
99. Pt with high blood glucose in the morning? Get 4AM blood glucose. If its high (Dawn effect), then increase morning NPH, if its low (Samogi effect) then decrease night-time NPH.
100. Insulinoma – lethargy, diplopia, HA, glucose 50yo every 3-5yrs; FOBT - >50 annually; DRE - >40 annually; PSA - >50 annually in normal risk, >40 annually in high risk; Pap smear – onset of sexual activity or 18yo annually for 3 consecutive years then however often; Pelvic exam – 18-40yo every 1-3yr, >40 annually; Endometrial biopsy – menopause/high risk annually; Self breast exam - >20 monthly; Clinical breast exam – 20-40 every 3 years, >40 annually; Mammogram – 40-49 every 1-2 yrs, >50 annually.
168. Cancerous Occupation Hazards – aromatic amines c bladder ca, arsenic c lung/skin/liver ca, asbestos c mesothelioma (bronchogenic MC), benzene c leukemia, mustard gas c lung/larynx/sinus cancer, vinyl chloride c liver cancer
169. Hodgkin’s – fever, night sweats, chills, weight loss (like TB), and painless cervical adenopathy. Dx c CT chest/abdm and then lympangiography and then biopsy (for treatment purposes). Reed-sternberg cells. Tx – If no B s/s (fever, wt loss, sweats) give radiation alone. If B s/s give chemotherapy (MOPP or ABVD)
170. Non-Hodgkin’s – variable nodes, monoclonal B/T-cell proliferation, dx c CT chest/abdm/pelvis then other stuff like BM bx, PET scan, gallium scan. Tx c radiation and chemo (CHOP) c Rituximab (CD20 Ab).
171. Acute Lymphocytic Leukemia – kids, blasts, tx c intrathecal chemo (MTX)
172. Acute Myelogenous Leukemia – M3 causes DIC, Aeur rods, blasts, add All-trans retinoic acid (Vit A) to tx.
173. CML – high WBCs, high PMNs, splenomegaly, LUQ pain, fullness and early satiety, decreased LAP, dx c phili chromosome (t9;22 of brc:abl) in BM, tx c Imatinib (Gleevac).
174. CLL – elderly, high WBCs, high lymphocytes, splenomegaly, dx c smudge cells, no tx if no lymphocytosis, if + lymphocytosis give fludarabine or chlorambucil.
175. Hairy Cell Leukemia – CD10+ and TRAP+ (tartrate-resistant acid phosphatase), tx c cladribine
176. Mycosis fungoidis – cutaneous T-cell lymphoma (look at 1st aid picture), lion-like facies, tx c PUVA chemotherapy. If affecting peripheral blood, its Sezary syndrome.
177. Multiple Myeloma – high calcium, high OAF, high uric acid. Best initial test is X ray if bone pain or electrophoresis if high protein. Most accurate test is >10% plasma cells. Tx: 70yo get Meiphelen or Thalidomide
178. Aplastic Anemia – low rbc/wbc/platelet, drugs (chloramphenicol), parvo-B19 (sickle cell), tx: 50yo get cyclosporine + anti-thymocyte globulin
179. If pt has neck + pelvic mass after chemo the mass gets smaller, wheat test checks content of the lymph node? PET scan. So in a nutshell, a lymphoma gets excisional biopsy of the node, then PET scan, and chemo if they have B symptoms.
180. Adverse effects of chemo: Vincristine/blastine – peripheral neuropathy, cyclophosphamide – hemorrhagic cystitis, Busulfan/Bleomycin – Irreversible Pulmonary Fibrosis (that’s why Lance Armstrong refused it), Cysplatin – renal dz, ototoxicity, anemia. Overall MC adverse effect with chemo drugs is sterility.
181. Lung cancer – chronic cough (MC s/s), wt loss, smoker, hemoptysis. Dx: 1st CXR, then biopsy. Tx: Small cell get chemo only, Non-small cell – chemo c radiation. Horner’s syndrome – unilateral ptosis, meiosis, anhidrosis due to compression of ipsilateral superior cervical ganglion by lung tumor, particularly SCC. SVC syndrome – obstruction of SVC causes facial swelling/plethora, dyspnea, cough, JVD. Pancoast syndrome – tumor of the superior sulcus causes brachial plexus s/s. Small cell causes Cushings syndrome (ACTH) and SIADH, SCC causes hypercalcemia (PTH-like peptide)
182. Solitary nodule – 1st step get old x-ray. If present and same size, its benign (send home), if increase in size its probably cancer. If it wasn’t there, assess risk (high is smoker and >35, low risk is nonsmoker and 35 except if B/L, lumpy and s/s only occur c menses. If 35yo. If mammo was already done, get FNA. If after biopsy, mass goes away, send pt home. Tx: tamoxifen, mastectomy, radiation, axillary dissection, chemotherapy (c platinum) if + nodes.
184. Prostate cancer – s/s of BPH c hematuria, high PSA (only to screen/monitor, not for dx), irregular/boggy, back pain. Tx c surgery. If +mets, then do orchiectomy, leuprolide, flutamide, DES, but no chemo. Only do TURP and radiation of mets is local (bone).
185. Colon cancer – R sided bleeds (bloody stools), L sided obstructs (constipation), wt loss. Dx c colonoscopy. Tx c surgery and 5-FU and then f/u CEA levels. If mets (MC is liver) to liver do surgery, but anywhere else do chemo.
186. Pancreatic cancer – 40-80yo male smoker c jaundice, wt loss and vague abdm pain. May have migratory thromboplebitis (Trousseau’s syndrome) or palpable, nontender gallbladder (Courvoisier’s sign). Dx c CT, then FNA. Tx c whipples.


HEMATOLOGY:

187. Microcytic (MCV 10,000), granulocytes (post chemo), FFP (bleeding diathesis like DIC, warfarin poisoning, liver failure), cryoprecipitate (vWD and DIC). MCC of transfusion rxn is lab error. If it occurs, 1st step is stop transfusion.
205. Platelet problems = skin, gums, nose, gingival (ALL SUPERFICIAL), GI, CNS and vaginal bleeding; Factor problems – bleeding into join and muscles (DEEP), GI, CNS.
206. von Willebran Dz – high PTT, normal PT, high BT, normal plt/rbc count, AD (look for family history) (a platelet type of bleeding c a normal platelet count). Best initial test is bleeding time, then ristocetin level. Best tx c desmopressin (DDAVP)
207. Hemophilia A/B – really high PPT, normal PT, normal BT/plt/RBC, looking for delayed hemarthrosis in males only (A is factor 8, B is factor 9).
208. DIC – high PT/PTT/BT, low plt, low RBC, low factor 8.
209. Liver failure – high PT, normal/high PTT, normal BT, normal/low plt/RBC, jaundince, normal factor 8, do not give vitamin K (ineffective), give FFP’s.
210. Heparin – high PTT, thrombocytopenia. Tx c d/c drug
211. Warfarin – high PT, vit K antagonist (2,7,9,10), tx c FFP (fast) or vit K (slow), skin necrosis
212. ITP –low platelets, high BT, h/o URI, next step is steroids (just treat it), auto-platelet Ab, if platelets fall 15 in pt c no risk facts. If PPD is positive, proceed to CXR, if (-) take INH for 9 months, if + get sputum AFB. If PPD is negative, repeat it in 1-2 weeks to rule out false negatives. If pt had PPD in the past that was +, don’t do PPD again (it will always be positive), go right to CXR.
240. Endocarditis – fever and a murmur is key, h/o IVDA is s.aureas at tricuspid valve, #1 dx is blood culture (not ECHO), #2 dx is ECHO (TTE type, not TEE). For dental procedures (must be dental procedure c blood, cant be dental fillings) give amoxicillin or clinda if allergic, for GI/GU (strep bovis) procedure give amox + genta, or vanco + genta if allergic. Strongest indication for surgery is ruptured valve. So, 1st step is blood culture, 2nd step is start abx while waiting for results.
241. Thrush – oral candida, removable white mouth patches (Candida CAN come off, hairy leukoplakia cant). Tx c nystatin mouth rinse.
242. Lyme Disease –problems in joints, CNS (b/l bells palsy), heart (3 degree AV block). If its just a tick bite and no s/s, do nothing. If it’s a bite c lyme rash give amox (pregnant or kids) or doxy (not serology). If pt has b/l bells palsy get serology. If av block c cns s/s (except bells palsy) give ceftriaxone next.
243. HIV – 1st ELISA, 2nd western blot (in kids, 1st is PCR). Peripheral neuropathy c stavudine/didanosine, anemia c zidovudine, rash c tmp/smx (start dapsone), nephrolithiasis c indinavir. MC overall adverse effect is increase lipids and glucose levels. Prophylaxis: 5days, Edema, Erythema, Lymphadenopathy, Myositis, Conjunctivitis). Next step is Echo (r/o coronary aneurysms). Tx c Aspirin + IVIG
264. Takayasu arteritis – Chinese 30-50yo female c pulselessness on 1 side. Dx c angiogram of aortic arch (coronaries to r/o stroke). Tx c steroids, cyclophosphamide
265. Wegeners – nasal (sinusitis), lung (hemoptysis, dyspnea), kidney (hematuria), c-ANCA, tx c cyclophosphamide
266. Fibromyalgia – young female with pain all over, multiple points of tenderness, irregular sleep pattern, anxiety, exams all normal. Tx c antidepressant, NSAIDS
267. Polymyalgia Rheumatic – old female c pectoral/pelvic pain/stiffness, elevated ESR, normal biopsy, a/w temporal arteritis. Tx c steroids.
268. Polymyositis – 40-60yo female c proximal muscle weakness, elevated ESR/CPK, abnormal muscle biopsy, dx c 1st muscle biopsy, then EMG. Tx c steroids
269. Dermatomyositis – same as above, but c rash (heliotrope rash around eyelid).
270. Paget’s disease - >40yo male c pevic/skull damage, hats don’t fit anymore, deafness, paraplegia, bone pain, very high alk phos, normal calcium/phos, increased risk of osteosarcoma. X-ray shows thickened bones. Tx c NSAIDS, bisphophonates (Etidronate) and calcitonin.
271. Herniated disk – most at L4-5 (weak big toe), and L5-S1 (reduced Achilles reflex), positive straight leg test.
272. Carpal Tunnels – median nerve compression (thumb, pointer, middle finger), Tinnels sign (tapping wrist causes numbing), Phalens sign (flexing wrist), tx c rest, splint, workplace modifications, then NSAIDS.
273. Osgood-Shlatter – inflammation of tibial tubercle in boys. Tx c rest and immobilization.
274. Slipped Capital Femoral Epiphysis – Obese kid c painful limp. Dx c xray. Tx c surgical pinning >5yo.
275. Legg-Calve-Perthes – non-obese kid c a limp (d/t avascular necrosis @ hip). Tx c observation and pain relief, 2nd is bracing, 3rd is surgery.
276. Osteoporosis – risks include early menopause, alcohol, Caucasian, thin body, tobacco. Dx c DEXA >-2.5 (-1 to -2.5 is osteopenia). Tx 1st weight-bearing exercise, 2nd lifestyle (smoking, alcohol cessation), 3rd calcium/vit D, bisphosphonates, etc.
277. Patellar tendonitis – an NBME 3 test question, aka jumper’s knee, patellar tenderness due to overuse and jumping sports resulting in quadriceps contraction. Tx c rest, nsaids, quadriceps stretching.
278. Osteosarcoma – 10-25yo c knee pain, mass, limping, high alk phos. X-ray c sunburst appearance. Tx c surgery and chemotherapy
279. Osteoid Osteoma – bone pain worse at night and relieved c NSAIDS. Tx c nsaids
280. Osteochondroma – bone pain, xray shows pedunculated metaphyseal tumor at distal femur. Tx c surgery.
281. Ewing sarcoma – fever, pelvic/femur bone pain, swelling, xray shows onion skinning. Tx c radiation, chemo, surgery.
282. Reflex Sympathetic Dystrophy – burning pain, skin changes (color/temp), edema in a pt who had prior injury to that area. Tx c pain management (hard to do).
283. Nursemaids Elbow – from pulling your childs arm, he develops severe pain at elbow and will not use that arm. Tx c pushing back the head of the radius while the arm is supinated and flexed. Kid will feel much better immediately.

NEUROLOGY:

284. Migraine HA – 70% unilateral, throbbing, aura, photophobia, family history, possible risk of stroke, worse c OCPs/EtOH/chocolate. Tx c NSAIDS, triptans (contraindicated in heart disease), ergots. Prevent c BB 1st, cab’s 2nd, sodium valproate/SSRI/TCAs.
285. Cluster headache – same time every month/year, males mostly, tearing, redness, pain, rhinorrhea, feels like an ice-pick is shoved in your eye (old question). Tx c 100% oxygen 1st, steroids 2nd.
286. Temporal Arteritis – >50yo c unilateral temporal HA, scalp tenderness, vision changes, high ESR. 1st step is give steroids, 2nd step temporal artery biopsy.
287. Pseudotumor Cerebri – aka Benign Intracranial HTN – increased ICP, HA, visual changes, obese female, papilledema, no focal CNS findings, a/w vitamin A toxicity. Dx c MRI 1st then LP 2nd, tx c azetazolamide.
288. Trigeminal Neuralgia – pain whenever you touch your face @ 5th cranial nerve distribution. Tx c carbamazapine. Definitive treatment with surgical rhizotomy.
289. Essential Tremor – at rest and motion. Tx c propranolol. (Tremor at rest only is Parkinson’s or hyperthyroidism, tremor c motion only is cerebellar dysfunction)
290. Nystagmus/Vertigo – if + focal defecits, the problem is central (vertical nystagmus): cerebellum (CT/MRI), M. Gravis (MRI), Stroke (MRI/CT), phenytoin without an hearing loss or tinnitus. If no focal defecits, the problem is peripheral (in the ears), so pt will have hearing loss and tinnitus. If pt only has vertigo, its benign positional vertigo. If pt has hearing loss and tinnitus with it: Miniere’s disease (chronic disease), Acoustic Neuroma (look for ataxia), Labyrinthitis (acute viral infxn)
291. Epilepsy (as per Kaplan on what is important): do not treat 1st time seizures unless there is a family history, EEG is positive or pt has status epilepticus.
292. Status Epilepticus – Dx: 1st sodium, 2nd glucose, 3rd calcium, 4th hypoxia, toxicology, CT-head, EEG (last!). Tx: 1st Benzo (lorazepam IV), 2nd Phenytoin, 3rd Barbiturate, 4th Anesthesia (succinylcholine/propofol – these will just stop the shaking, wont stop the seizure).
293. Absence seizures – kid stares into space, doing poorly in school, eye blinking, lip smacking, EEG c 3/sec spike and wave pattern. Tx c ethosuximide.
294. TIA – focal, abrupt onset lasting less than 1 hour, symptoms resolve after 1 day. Risk of stroke in days to weeks. Amorosis fugax (curtain over an eye due to retinal dysfunction) needs Doppler U/S of carotids or MRA. Give heparin acutely (if no contraindications), then long term aspirin. If stenosis >70%, amaurosis fugax/TIA or small, non-disabling stroke do CEA (carotid endarterectomy) and give aspirin. If stenosis 50yo, high risk (COPD, cardiovascular, renal), women who WILL become pregnant in winter, household contacts of high-risk pt (to protect the high-risk pt). Pneumococcal - >65, comorbidities.
341. Formulas: [A = True Positive; B = False positive; C = False negative; D = True Negative] (positives always on top) Sensitivity = TP/TP+FN; Specificity = TN/TN+FP; PPV = TP/TP+FP; NPV = TN/TN+FN; Attributable risk (attrib = subtract) = (a/a+b) – (c/c+d); Relative risk (only for propective studies like cohort study)= (a/a+b) / (c/c+d); Odds ratio (only for retrospective studies like case-control) = ad/bc; attack rate (how many ppl get attacked c dz) = a+c/b+d.
342. Power = rejecting the null when its false (a good thing, like saying Viagra does not treat constipation, which it doesn’t do). However, sometimes FDA may not always make the right choice and end up approving something that doesn’t work, or not approving something that works. Type 1 error – rejecting the null when it’s true (saying Viagra does not treat erectile dysfunction). Type 2 error = acceptance of the null hypothesis when it is false (saying Viagra treats constipation). Generally, the only way to increase power is to increase the sample size.
343. Mean = average; Median = middle #, Mode = MC #.
344. Confidence Interval = [mean +/- Z score x standard error of mean], where Z is the standard score (If confidence interval is 95%, Z is 2, if CI is 99%, Z is 2.5) and standard error of mean is (S / square root of N), where S is the standard deviation and N is the sample size. For example, old TQ said the mean was 67%, standard deviation was 8% in a sample size of 16, calculate a 95% CI: (67 +/- 2 (8 / square root of 16) = (67 +/- 2 (8/4)) = 64 +/- 4. The answer was 63-71.
345. When they give you a chart with different confidence intervals, just look for the one that has 1 within the range (ie. 0.89-2.3, not 1.12-2.25 or 0.56-0.93). That one is NOT statistically significant, meaning the risk is the same. If 1 is not within the range, is is statistically significant. If it was over 1 (1.12-2.25 used above), there is an increased risk. If it was under 1 (0.56-0.93 used above), there is a decreased risk.
346. When given statistical scales and asked for the statistical test: Nominal is categorical (how many you can split into groups, like genders, ethnicities, etc), Interval is a measurement (height, wt, BP, etc.). Pearson correlation = 2 intervals; Chi-square = 2 nominals; t-test = 1 nominal + 1 interval. For example, if you want to find out if men do better than women on step 2. Men vs women is nominal, Step 2 is an interval, therefore one of each makes it a t-test.
347. If given the following data: After surgery: 90% survive 1year, 75% survive 2years, 50% survive 3years, 40% survive 40%, and asked: what is the life expectancy after surgery? Always pick closest to 50%, so the answer would be 3 years. If asked, if a pt survives 2 years, what is the chance of surviving 3 years? Always put the # ending on top, # starting on bottom, so it will be 50/75, or 67%.
348. Cohort study (think – Cohort to Go Forth) – a prospective study where people are followed for a period of time. Advantages are that incidence (# of new cases) can be determined, there is an accurate relative risk (remember RR with cohort), and less control group bias. Disadvantages are that it takes too long, expensive, the sample size can get too large, and you might run into an ethical problem.
349. Case-control study – a retrospective study where you start with an outcome and then check backwards to evaluate the risk or cause. Advantages are that it’s cheap and easy, small sample size and minimal ethical risk is involved. Disadvantages are that incidence (new cases) are not determined, RR is just approximated (not exact, just taking odds, remember OR c case-control) and that there is some control group bias. Kaplan says, if you have no idea which type of study it is, pick this one.
350. Confounding bias – when hidden factors affect the results. For example, an experimenter measures the # of ashtrays owned and incidence of lung cancer and finds that people c lung cancer have more ashtrays. He or she then concludes that ashtrays cause lung cancer. Smoking is the confounding bias here, because it increases both ashtrays and lung cancer. So how can you prevent this? Do multiple studies.
351. Lead-time bias – when you confuse the facts that early screening will increase life expectancy. Look for false estimates of survival rates. For example, if I diagnosed you with cancer at 18 and you lived until 30, you will think I treated you for 22 years. However if I didn’t diagnose you until 25 and didn’t treat you after, and then you lived until 30, you will think that you only survived 5 years. The difference is not that my drug treats you better, but that I am diagnosing you earlier, thus getting a good lead on time. The solution here is to measure the “back-end” survival (ie. Getting the age 30 as the age that they both die at, whether they were treated or not).
352. Recall bias – subjects can’t remember events in the past. Solution is to make them confirm information with other sources.
353. Late-look bias – subjects die before the end of the survey, so your information gets distorted. For example, a survey finds that AIDS pts only get mild symptoms. This is wrong because they die before the really bad symptoms occur. Solution here is to stratify the disease by severity.
354. Experimenter/Interviewer bias – aka Pygmalion effect - when the experimenters expectations are inadvertently communicated to subjects, who then produce the desired effect. Solution is to make the study a double-blind one.
355. Selection bias – aka sampling bias – when the sample selected is not a representative of the population. For example, taking the people from a health club and doing a survey on the lungs in the general population. Another cause is when a study uses hospital records to estimate population prevalence (Berkson’s bias). For example, a doctor says all the people in NY are sick because all day he works with sick patients in NY.
356. Measurement bias – aka Hawthorne effect – when being observed makes you change how you answer to questions. Also, when the way the information is presented makes you answer in a certain way. For example, asking a pt “you don’t like your doctor, do you?” The pt is likely to say no because of the way the question was presented. In the law world, its termed “leading.” Prevent this by having a control/placebo group.

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OB:
357. Numbers to note: How many weeks in each trimester? 13; what is so special about 37 weeks? Lungs are muture b/c lethicin/sphingomyelin ratio is 2:1; what is the risk of having Down’s if mom is 35? 1/350; risk @ 40? 1/100; risk @ 45? 1/50, so you absolutely must recommend amniocentesis. Pregnancy weight gain is about 25 pounds (5 in first 20 weeks, 1 pd every week after). Uterine height: 8 weeks @ iliac, 14 weeks @ pubic symphisis, 20 weeks @ umbilicus, 38 weeks @ xiphoid process.
358. Dates to note: 6-8wks is prenatal workup. 15-18 weeks is triple screen. 18 weeks is ultrasound. 26 weeks is glucose challenge test for DM. 35 weeks is GBS culture.
359. Diagnostics: Ultrasound (noninvasive, no adverse effects, done at 18-20 weeks), Chorionic villus sampling (“CVS,” invasive, done at 9-12 weeks, best for early gestation so mom has the chance to choose an abortion, may be fatal, f/u c triple screen after), Amniocentesis (done at 15-20 weeks for genetic purposes or high risk patients, done at 24 weeks for Rh isoimmunization, done at 34 weeks for gestation age, pregnancy loss about 0.5%)
360. Diabetes workup: Done at 24-28 weeks in normal pt. Done c prenatal workup (6-8 weeks) if pt is obese or has h/o macrosomic baby, h/o DM or family h/o DM. The pt will come to your office fasting for 1 hour, her blood sugar should be >140. If 2cm (if none, pt has false (Braxton-hicks) contractions and send her home). MC risk factor is previous preterm labor. Dx c fetal fibronectin (if +, tocolytics and steroids, if (-), send home). Management: 1st L lateral decubitus position, bed reast, O2 and IVF. 2nd Start tocolytics (useless >4cm dilatation, r/o contraindications first), get cervical/urine culture before giving IV Pen G (for GBS), IM betamethasone and send home.
394. Tocolytics – 1st Mg Sulfate (calcium blocker that may cause resp depression, loss of DTRs and pulmonary edema. If so, give IV calcium gluconate). 2nd Ritodrine/Terbutaline (B-adrenergic agonists that may cause hypotension and tachycardia so don’t give in pt c heart disease or DM). 3rd Nifedipine (calcium blocker that may cause hypotention). 4th Misoprostol (prostaglandin inhibitor that may cause in utero ductus arteriosus closure, so don’t give if gestation age >32 weeks). Some contraindications to tocolytics include (conditions where you may need to deliver) abruption placenta, ROM, chorioamnionitis, fetal demise, late decelerations, eclampsia, severe eclampsia and cervical dilatation >4cm.
395. Post-date pregnancy (>40wk): complications include increased perinatal mortality, macrosomia, need for c-section, dysmaturity syndrome (mother’s support runs out). 1st step is to check dates (if dates still unsure, continue c conservative treatment and biweekly NSTs), 2nd step is induction of labor. If cervix is favorable (soft), begin aggressive tx c oxytocin and artificial ROM. If cervix is unfavorable (hard), give prostaglandins c oxytocin and wait for spontaneous delivery.
396. Transient HTN – unsustained high BP without proteinuria or edema. No tx.
397. Chronic HTN – high BP before 20 weeks gestation. Tx c methydopa, hydralazine.
398. Mild preeclampsia – mild HTN (140/90), petal edema, 2+ proteinuria after 24 weeks gestation. Management: 36 wk – deliver
399. Severe preeclampsia – sustained BP >160/110, >3+ proteinuria, edema, epigastric pain, HA, blurred vision, thrombocytopenia (r/o HELLP synd). Tx: prompt vaginal delivery c oxytocin, MgSO4 (to prevent convulsions) and IV hydralazine/lobetolol.
400. Eclampsia – HTN, proteinura, edema, seizures. Tx: 1st ABC’s, 2nd MgSO4 to stop seizure (do not deliver 1st, you can never attempt delivery if pt is seizing), 3rd aggressive prompt vaginal delivery c oxytocin and hydralazine to decrease BP.
401. HELLP syndrome – hemolysis (schistocytes), elevated LFTs, low platelets. No CNS or renal problems (r/o TTP), no h/o URI/GI infection (r/o HUS). Tx c steroids and prompt delivery.
402. Never recommend termination of pregnancy, unless: 1 – pulmonary HTN in mom, 2 – Marfan’s syndrome c an aortic aneurysm >4cm, 3 – Eisenmengers syndrome (pulm HTN c bidirectional shunt, 4 – peripartum cardiomyopathy.
403. If they ask about rheumatic heart disease in the context of pregnancy, know about mitral valve stenosis management (diuretics 1st, vasodilators, then balloon vulvoplasty). Management of cardiac disease in pregnancy is bed rest, decreased physical activity, decrease weight, correct anemia, analgesics, vacuum delivery.
404. Management of hyperthyroid disease in pregnancy is to stay on PTU to prevent thyroid storm, but warn mom that baby might be mentally retarded or have IUGR.
405. DM in pregnancy – a/w fetal NTD (most common fetal anomaly), hypoglycemia (d/t maternal insulin, tx c IV glucose), hypocalcemia (failure of PTH synthesis after birth), polycythemia (d/t increased erythropoietin from intrauterine hypoxia), respiratory distress (to check lung maturity, phosphatidylglycerol is a better choice than L:C ratio), hyperbilirubinemia.
406. Prolonged latent phase – cervical dilatation 20hrs in primipara, >14rhs in multipara). MCC is analgesia, so tx is bedrest and sedations.
407. Prolonged active phase – cervical dilatation >3cm, but slow/no rate (40,000, brain/liver mets, >6 months of D&C) do radiation and chemotherapy (MAC: MTX, Adenomycin, Cytotoxin). If good prognosis, give MTX only and f/u hCG every week for 3months while on OCPs.
430. Uterine prolapse – loss of uterine support due to cardinal ligament dysfunction. MCC is childbirth. Best tx is vaginal hysterectomy c ant/post repair (yes, first!), but if pt refuses surgery, do Kegel exercises, estrogen HRT and pessaries.
431. Stress Incontinence – weak pelvic floor causes you to urinate whenever you sneeze/cough, none at night. Dx c Q-tip test. Tx c Kegel exercises, then surgery (Marshall-Marcheli-Kranz procedure).
432. Urge Incontinence – involuntary detrusor contractions causing spurts of urine to fall at any time. Dx c cystometric studies. Tx c anticholinergics (Ditropan)
433. Overflow Incontinence – denervated bladder (DM, MS, CVA) causes bladder to keep filling up, thus high residual volume even after urination. Tx c cholinergics (bethanecol).
434. Endometriosis – dymenorrhea, dyspareunia, infertility, uterosacral ligament nodularityin the cul-de-sac, chocolate cysts. Dx c laparoscopy. Tx: 1st OCP, 2nd Danazol and Leuprolide (best tx, but not 1st because of side-effects), 3rd surgical resection, 4th pregnancy (however hard, d/t infertility), 5th TAH/SBO. If endometriosis is present, and pt has no s/s, do nothing.
435. Chancroid – painful chancre (H. ducreyi – you cry c ducreyi) c ragged, rolled edges. Tx c Azithromycin
436. LGV – painless ulcer that heals and then forms painful nodes. Tx c erythromycin.
437. Granuloma inguinale – painless, beefy-red ulcer. Dx c Donovan-bodies on smear. Tx c Azithromycin.
438. Chlamydia – MC bacterial STD, can be asymptomatic or mild mucopurulent cervical discharge c or w/o cervical motion tenderness (CMT), (+) Cx/Ab test, (-) stain. Tx c azithromycin (1 dose) or oral doxycycline (7 days).
439. Gonorrhea – Lower GU causes d/c, itching, burning, dysuria; Upper GU causes abdo/pelvic pain. Disseminated when there is dermatitis, polyarthritis or tenosynovitis. Pt has vulvovaginitis c mucopurulent d/c c CMT on bimanual exam. Dx c chocolate agar, Gram (-) diplococci on stain. Tx (for GC and Chlamydia) Ceftriaxone + Doxycycline.
440. PID – lower abdominal pain, adnexal tenderness, CMT and fever 1 week after menses in a sexually active female. Cervicitis (only vaginal D/C, no pain – tx G/C), Salpingo-oophoritis (b/l lower abdo/pelvic pain c CVA tenderness – tx G/C), Tubo-ovarian abscess (pt will look septic, severe pain, n/v, dyschezia, fever – tx c Ampicillin, Gentamycin and Flagyl. If ruptured, ex-lap is done). Tx for G/C in these cases are: outpatient: ceftriaxone + doxycycline, inpatient: clindamycin + gentamycin
441. Gardnerella Vaginosis – fishy odor on whiff test, pH 6, clue cells, tx c metronidazole (clindamycin if pregnant in 1st TM)
442. Trichomonas vaginalis – frothy, green smelly discharge c strawberry cervix, pH 5. Tx c metronidazole for pt and partner (if pt pregnant, tx c vaginal betadine).
443. Candida yeast infection – itchy, burning, dyspareunia, cottage-cheese discharge, that sticks to the vaginal wall, pseudohyphae, pH 4, tx c nystatin or Amp B.
444. Contraception: remember effects of estrogen (increases BP, cholelithiasis, LFTs, HDL, art/venous thrombosis and decreases LDL) and progesterone (affects mood, increase weight, acne, increase LDL, decrease HDL). Absolute CI: pregnancy (causes VACTERL), liver dz, vascular dz (DVT, SLE, CVA) and hormonally-dependent cancers like breast). Benefits include decreased risk of ovarian/endometrial cancer, decreased dysmenorrhea/DUB/PID/ectopics.
445. IUD – put it in 1 week after menses and f/u in 1 week. Does not affect risk of STDs. Absolute contraindications include pregnancy, pelvic cancer, salpingitis, steroid use (pt on Crohns, asthma), h/o PID. Increased risk of ectopics and PID when placed.
446. Abnormal vaginal bleeding: Pre-menarchal (52yo - endometrial cancer). A neonate c vaginal bleeding is normal due to maternal estrogen, thus reassure mom.
447. Precocious Puberty – normally: breast development @ 9yo, pubic/axillary hair @ 10yo, growth @ 11yo, menarche @ 12yo. If only 1 stage occurs early, this is Incomplete isosexual precocious puberty, next step is CT brain/abdo/pelvis. If all stages occur early, this is complete isosexual precocious puberty, next step is tx c constant GnRH stimulation (to decrease estrogen). If pt has bone lesions and café-au-lait spots, pt has McCune-Albright Syndrome. If pt has high estrogen c a pelvic mass, they have a granulose-theca cell tumor, tx c surgery.
448. Dysfunctional Uterine Bleeding – MCC is anovulation d/t unopposed estrogen, so no secretory phase (d/t lack of progesterone) c unstable endometrial thickening. Pt will have h/o irregular, unpredictable menstrual bleeding without cramps. Next step is endometrial biopsy to r/o cancer. Tx c NSAIDS if she desires children, cyclic progestin therapy or daily combined OCPs if she doesn’t desire children or has menorrhagia.
449. Primary Amenorrhea – 1st step is pregnancy test (whether she says she is sexually active or doesn’t), 2nd step is physical exam: (+) breasts and (+) uterus -> check prolactin, if normal r/o imporferate hymen (cyclic menstrul pain c bulging hymen, predisposition to endometriosis, tx c surgery) and tx c progesterone. (+) breasts and (-) uterus -> get karyotype, if 46 XY, pt has Androgen Insensitivity Syndrome (Testicular Feminization, no pubic hair, next step is remove testes from abdm), if 46XX, pt has Rokitanky-Hausen syndrome (she will have pubic hair). (-) breast and (+) uterus -> gonadal dysgenisis, so next step is get karyotype to r/o Turners syndrome (45XO, webbed neck, far spaced nipples, streak ovaries, premature ovarian failure, needs estrogen).
450. Secondary Amenorrhea – 1st step is r/o pregnancy, 2nd r/o prolactinoma (if prolactin level is high, next step is MRI of head. If abnormal, pt has pituitary tumor, if normal, pt has drug-induced prolactinoma) and hypothyroidism, 3rd progesterone challenge test. If pt bleeds after 2 weeks (estrogen is adequate), check LH. If elevated pt has PCOS, if normal/low check TSH/prolactin again. If pt does not bleed after 2 weeks (inadequate estrogen) check FSH, if high pt has premature ovarian failure (next step is karyotype to r/o Turners vs Ovarian failure due to congenital adrenal hyperplasia), if normal/low pt has craniopharyngioma, next step is MRI. If MRI is insufficient, pt has Ahsermann’s syndrome (scarring due to prior D&C/D&E. Tx by surgically removing scarred tissue then giving high-dose estrogen for 1 month to regenerate lining). Again, if LH/FSH are high, next step is karyotype. If XO, pt has turners, if XX pt has ovarian failure (now r/o autoimmune dz versus CAH). If LH/FSH are normal or low, next step is MRI of head. If abnormal pt has pituitary tumor/destruction or hypothalamic dz (may be a/w Kallman’s syndrome (anosmia, amenorrhea), anorexia, exercise, tx c estrogen). If normal, pt has Asherman’s syndrome.
451. Breast mass in a female intraductal papilloma. Next step is galactogram-guided excision.
454. Polycystic Ovarian Synd – female, hirsutism, amenorrhea, infertility (MCC of infertility in women 1yo, tet spells, boot-shaped heart
488. Transposition of great vessels – cyanosis in 1st 24hrs, aorta from RV, pulm artery from LV, egg on a string heart, tx c balloon atrial septostomy, then arterial switch
489. Total anomalous pulm venous return – pulmonary veins drain into systemic venous circulation (partial or total), snowman heart. 1st medications, 2nd surgery
490. Truncus arteriosis – single great artery is origin of aorta and pulm arter and coronary artery, listen for truncal valve click. Tx: 1st treat CHF, 2nd surgery
491. VSD – MC CHD, holosystolic murmur at 1-2months, tx c subacute bacterial endocarditis prophylaxis
492. ASD – pulmonary ejection murmur plus wide, fixed split S2, no SBE prophylaxis, usually presents after infancy
493. Coarctation of aorta – HTN in UE, low BP in LE, poor femoral pusles, Turners synd, rib notching on CXR, tx c balloon angioplasty
494. PDA – premature babies, congenital rubella, continuous machinery murmur c wide pulse pressure.
495. Hypoplastic left heart – underdeveloped LV and aorta, vascular collapse in 1st week of life, ductus dependent, tx: 1st prostaglandin E, 2nd Norwood or transplant
496. Hydrocephalus – communicating (obstruction of arachnoid villi) or noncommunicating (Aqueduct of Sylvius stenosis, Chiari malformation at cerebellar tonsils or Dandy-walker cyst of 4th ventricle). Baby c rapid increase in head circumference, split sutures, bulging anterior fontanelle, setting-sun sign (of eyes), 6th nerve palse, papilledema, dx c CT scan (do not do LP in risk of herniation). Tx: 1st hyperventilate and elevate head, 2nd mannitol, 3rd ventriculoperitoneal shunt
497. Congenital cataracts – rubella, CMV, toxo, galactosemia, tx c surgery right away to prevent permanent visual impairment.
498. Congenital glaucoma – tearing, corneal clouding, photophobia, sturge-weber synd (facial port-wine stain, seizures, CNS calcifications), neurofibromatosis, rubella, tx c surgery.
499. Congenital deafness – Alports (nephritis c deafness), CMV, rubella, maternal drugs.
500. Osteogenesis Imperfecta – brittle bones cause multiple fractures in a kid, blue sclera, osteoporosis, family history, type I collagen disorder, teeth deformities.
501. Developmental Dysplasia of the Hip – subloaxation of femoral head from the acetabulum, causing asymmetric thigh creases, clicking sound, + Ortolani sign (hip reducibility), + Barlow sign (hip dislocatability), dx c ultrasound. Tx c harness, then closed reduction, then open reduction (>6mo age) if closed reduction failed.
502. Talipus Equinovarus – toes face medially, forefoot adduction. Tx c manipulative casting, then surgery if needed.
503. Transesophageal Fistula – dx c failure to pass nasal catheter to stomach, AXR shows air-distended proximal esophagus. Tx: 1st NGT, 2nd surgery
504. Duodenal atresia – bilious projectile emesis, a/w Downs syndrome, abdominal distention, double bubble on AXR (air-distended stomach and proximal duodenum). Tx: 1st correct fluids/electrolytes, 2nd surgery
505. Pyloric stenosis – nonbilious projectile emesis, olive-shaped RUQ mass, dehydration c hypochloremic alkalosis. Tx:1st fluid/electrolyte correction, 2nd pyloromyotomy
506. Meckel’s Diverticulum – 2yo c painless rectal bleeding and abdm pain. Dx c technetium-labeled nuclear scan (Meckel’s scan), tx: 1st correct life-threatening anemia, 2nd surgical excision.
507. Hirschsprung’s Disease – congenital megacolon causing obstruction, absense of Auerbach’s and Messner’s plexus, failure to pass meconium in 1st week, dx c 1st barium enema (shows transitional zone) rectal biopsy (aganglionosis). Tx: 1st fluid/electrolyte correction, 2nd Abx if enterocolitis suspected, 3rd surgical excision of ganglionic segment.
508. Hyaline membrane Disease – RSD, surfactant insufficiency, early onset (hours after birth) baby has tachypnea, grunting, nasal flaring and retractions. Early problems include breathing difficulty, metabolic disturbances and infection. Late problems include broncopulmonary dysplasia. Risk factors include prematurity, maternal DM and multiple pregnancies. Dx: 1st CXR (shows fine reticular granularity in b/l lungs), 2nd L:S ratio (should be >2:1) and phosphatridylglycerol. Tx: Prevention is the best tx (prevent prematurity, give maternal steroids 48-72 hours antepartum if 5yo c inappropriate voiding of urine. Tx: 1st behavioral techniques (bell, buzzer, bed time fluid restriction), 2nd Imipramine (last resort).
522. Dementia vs Delerium: Delerium (rapid onset, fluctuating consciousness, often reversible, perceptual disturbances, incoherent speech). Dementia (insidious onset, clear consciousness (until late in course), irreversible).
523. Alzheimer’s vs Vascular (Multi-Infarct) Dementia: Alzheimers dementia (women, older, chrom 21, linear/progressive, no focal defecits (key), supportive tx). Vascular dementia (men, younger than alzheimers, HTN, stepwise/patchy pattern, (+) focal deficits (key), tx underlying condition).
524. Alcohol – intoxication includes slurred speech, ataxia, disinhibition, impaired judgement, coma and blackouts. Withdrawal includes tremor, agitation, irritability, n/v, fever, seizures, delirium tremens (onset of delirium, vivid auditory/tactile/visual hallucinations, paranoid delusions 2-3 days post cessation of long-term heavy use). Tx intoxication supportively. Tx withdrawal c vital sign/electrolytes/Mg/thiamine/vit B12/folate/glucose monitoring. 2nd Hydration c thiamine before glucose (prevent Wernicke), 3rd benzodiazepine (chlordiazepoxide). Tx dependence c confrontation of denial and rehab (AA). Specific managements: Alcohol hallucinations (chlordiazepoxide, IVF, haloperidol), Wernicke’s encephalopathy (sudden ataxia, confusion, nystagmus, lateral rectus palsy from thiamine deficiency. Tx c thiamine) Korsakoff’s syndrome (severe anterograde/retrograde amnesia, confabulations and polyneuritis from thiamine defiency).
525. Opioids – intoxication includes euphoria, analgesia, hypoactivity, anorexia, drowsiness, n/v, constipation, pin-point pupils, hypotension and bradycardia. Overdose includes CNS/respiratory depression, pinpoint pupils, pulm edema, seizure, coma and death. Withdrawal includes (not deadly) rhinorrhea, yawning, diarrhea, sweating, dilated pupils, tachycardia and HTN. Tx overdose c naloxone. Tx dependence c abstinence through methadoes titration.
526. Stimulants – amphetamines/cocaine, rapid dependence of tolerance, IVDA risks, paranoid psychosis. Intoxication includes euphoria, alertness, increased energy, anxiety, talkativeness, mydriasis, tactile hallucinations (crawling bugs), HTN and tachycardia. Withdrawal includes (non-deadly) fatigue, hypersomnia, anxiety, dysphoria, suicidal ideation, craving. Tx intoxication symptomatically (antiarrhythmic, benzo for agitation, haloperidol). Tx withdrawal supportively (observe for suicidality). Tx dependence c rehab.
527. Sedatives – benzo/barbs – intoxication causes slurred speech, drowsiness, impaired attention, disinhibition. (Flumetrazepam is the date-rape drug). Overdose c barbs for suicide, (not so much benzo b/c of high therapeutic index, unless taken with another drug or alcohol). Both cause resp depression, coma, death. Withdrawal causes anxiety and insomnia. Severe withdrawal is a medical emergency (n/v, autonomic hyperactivity, photophobia, tremor, hyperthermia, delerium, seizures, death) most severe c short-acting drugs. Overdose benzo c flumazenil (does not reverse resp depression), barbs c charcoal, gastric lavage. Tx barbiturate withdrawal c pentobarbital challenge test to get daily dose, and taper off. Tx benzo withdrawal c long-acting benzo (diazepam, clonazepam) and gradually withdraw.
528. Nicotine – acetylcholine (nicotinic) agonist. Withdrawal causes irritability, wt gain, and difficulty c concentration. Tx: 1st obtain specific date to stop, 2nd educate/counsel.
529. PCP – paranoia, assaultiveness, impulsiveness, vertical and/or horizontal nystagmus (dead give-away), diaphoresis, resp depression, seizures, normal size pupils. Tx symptomatically
530. Hallucinogens – LSD, Ecstacy – sympathomimetic effects (mydriasis, tachycardia, sweating, diarrhea, urination), panic reactions, illusions, paranoia. Later on, pt may not be using drug anymore and reexperience intoxication (flashback).
531. Cannabinoids – Marijuana/THC – intoxication has euphoria, bad judgement, slowed reactions, dry mouth, conjunctival injection (dead give-away). Chronic use causes amotivational syndrome and memory impairment.
532. Hallucination is a disturbed sensory perception (visual, tactile, auditory). Delusion is a fixed, false belief (even if people prove to you otherwise). Psychosis is inability to judge boundary between real and unreal.
533. Schizophrenia – presence of >2 s/s of the following for >6months: delusions, hallucinations (generally auditory, link visual c alcohol withdrawal), disorganized speech/behavior, negative s/s (flat affect, no speech, no motivation, anhedonia). Better prognosis (NBME 3 question) if acute, late onset, good social/occupation hx, positive s/s, medication compliance, married, female gender. Symptoms due to altered dopamine activity (newer antipsychotics affect serotonin also). Negative s/s have enlargement of cerebral ventricles and hypoactive frontal lobe. Tx: 1st assess if pt needs hospitalization (protect self/others), 2nd Antipsychotics (Risperidone), 3rd Psychosocial tx. [Timeline: 6mo = schizophrenia]
534. Delusional (Paranoid) Disorder – persistent, nonbizarre, well-systematized delusion. Erotomanic (on is loved by a famous other, NBME 3 TQ), grandiose (one possesses great talent), jealous (conviction that lover is unfaithful), persecutory (one is conspired against, MC), somatic (one has a physical abnormality like odor). Tx: 1st hospitalization for inability to control suicidal/homicidal impulses or danger a/w delusions, 2nd psychotherapy, 3rd antipsychotics/antidepressants.
535. Schizophreniform – schizophrenia 4days.
540. Major depression disorder (MDD)– 2 of SIGECAPS in >2wks– sleep changes (delayed sleep onset, decreased REM. Note the difference: Anxiety has increased REM latency, depression and narcolepsy have decreased REM latency), interest loss, guilt, energy loss, concentration decreased, appetite (up or down), psychomotor (retardation or agitation), suicidality. Decreased serotonergic activity a/w violence and suicide. Tx: Hospitalize if suicide risk, 2nd Antidepressant (SSRI 1st) for 6-12 months (not that it takes 4-6wks to start effects), 3rd ECT (rapid response in pregnancy, elderly, medically ill), 4th psychotherapy, 5th antipscyhotic + antidepressant for psychotic pts, 5th Phototherapy if depression is seasonal, 6th treat comorbid psychopathology (anxiety, substance abuse, personality d/o, ADHD).
541. Depression vs Bereavement – Depression (mood pervasive/unremitting, constant low self-esteem/worthlessness, suicidal, sustained psychotic s/s, no improvement c treatment, social withdrawal). Bereavement (mood fluctuates, self-reproach regarding deceased, not suicidal, transient visual/auditory hallucinations or deceased, s/s improve c time and usually gone by 6 months, often welcomes social support). It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, while an MDD pt thinks its real. Other clues to MDD that are not normal are feeling of worthlessness, suicidality and psychomotor retardation.
542. Bipolar Disorders: Type I is full-blown mania c MDD. Type II is hypomania c MDD. Tx: 1st assess risk of suicide, assaultiveness, dangerous poor judgement. 2nd For acute mania give mood stabilizer (lithium). For depression – modd stabilizer c or w/o antidepressant if necessary.
543. Cyclothymia – numerous hypomanic episodes c depressive episodes for >2yrs. (Cyclo is a psycho, while dysthymia is just depression for >2yrs).
544. Panic Disorder – minutes to hours of unexpected, sudden intense anxiety, dyspnea, parasthesia, CP, fear of dying. A/w agoraphobia (fear of places where escape is difficult such as bridges, public transportation, large crowds, traveling). Tx: 1st If acute, emergent case, give reassurance and benzo (alprazolam, clonazepam). 2nd R/o MI, PE, CVA, hypoglycemia, 3rd Antidepressants (SSRI is tx of choice for long-term management), 4th Cognitive-behavioral therapy (CBT) for agoraphobia.
545. Obsessive-Compulsive Disorder – recurrent intrusive images, impulses, thoughts (obsessions) and ritualistic behaviors (compulsions) that produce anxiety and affect way of life. A/w Tourette syndrome. Abnormality is serotonin system. Tx c SSRIs (fluvoxamine), but if you only see TCA’s pick clomipramine.
546. Specific Phobia – irrational, excessive fear and avoidance of a specific object or situation. Tx: Systemic desensitization.
547. Social Phobia – fear of embarrassment, scrutiny of others (public speaking, eating in public, public bathrooms). Tx: 1st CBT, 2nd BB (propranolol) for stage fright, 3rd Antidepressants (not TCAs) and high-potency benzodiazepines.
548. Posttraumatic Stress Disorder – >1 month, must have 3: reexperiencing (flashbacks), emotional numbing (avoidance), autonomic arousal (insomnia, irritability). Tx: 1st hospitalize for acute suicide, violence risk. 2nd CBT, 3rd Antidepressants.
549. Acute Stress Disorder - 6months. Muscle tension, restlessness, poor concentration, fatiguability, irritability, loss of sleep. Tx: 1st psychotherapy, 2nd Antidepressants (Buspirone).
551. Somatorofrm Disorders – unlike factitious disorder and malingering, the symptoms are not intentionally produced but are strongly linked to psychological factors. Examples include somatization disorder (multiple somatic complaints, tx c regularly scheduled visits c PMD), conversion disorder (neurologic s/s), pain disorder (pain in absence of adequate physical findings, tx c psychotherapy), hypochondriasis (fear of specific disease, tx c regular medical visits), and body dysmorphic disorder (preoccupation c defect in appearance, tx c psychotherapy and SSRI’s after you assess suicide risk).
552. Factitious disorder – “Munchausen syndrome.” Intentional production of s/s for unconscious psychological reasons (need to assume sick role) usually in someone in medical occuption or c history of illness. If s/s produced by parent, this is Munchausen’s by proxy. Tx c psychiatric consult, confrontation may be helful.
553. Malingering – intentional production of symptoms for a recognized gain (money, drugs, avoid work/military/prison).
554. Dissociative Identity disorder – multiple personalities, which take over life and pt may or may not be aware of each other. Tx c intensive psychotherapy.
555. Amnestic Disorder – 2 types: psychogenic fugue (sudden, unexpected travel c amnesia of old identity and assumption of new identity that lasts hours to months, pt is unaware of loss) and psychogenic amnesia (sudden inability to recall important personal information of a traumatic or stressful event, but aware of loss). Recovery usually returns spontaneously. If not, try hynosis, amobarbital or psychotherapy.
556. Depersonalization disorder – recurrent feeling of detachment from one’s body or self (feel like you’re in an outside world).
557. Anorexia Nervosa – must have 3: amenorrhea, minimal normal body weight, fear of gaining weight. Tx: 1st hospitalize for dehydration, starvation, hypotension, electrolyte, hypothermia, suicide risk. 2nd treatment contract for wt gain, 3rd CBT.
558. Bulimia Nervosa – binge eating, normal weight, overconcerned c wt/diet/exercise, self-induced vomiting, laxatives/diuretics, a/w kleptomania. Tx: 1st hospitalize for ECG (hypokalemia-induced arrhythmia is MCCOD), electrolytes, amylase, LFTs, esophageal/gastric rupture, suicide risk. 2nd psychotherapy, nutritional counseling, SSRI for binging (do not give buproprion for risk of seizures).
559. Old, classic USMLE TQ: Mom finds her son having sex c another boy, is this normal or homosexuality? Normal (unless they say he enjoys it). Another TQ is a man, who knows he is a man and likes women, dresses up like a woman and acts like a woman, what is his sexual orientation? Heterosexual (b/c he likes women).
560. Projection – attributing your own wishes to someone else. A/w paranoid personality d/o (p for p – paranoia c projection)
561. Denial – if they deny having a disease, next step is do nothing! (because it usually does not interfere c treatment, but if it does, next step is confront the pt).
562. Splitting – all is good or bad. a/w borderline d/o. If they only say all is good, its idealization. If they only say all is bad, its devaluation. Splitting must have both.
563. Regression – look for h/o bedwetting in a kid >5yo (3.0 is a medical emergency that needs IV saline or hemodialysis.
580. Electroconvulsive therapy – increases serotonin for conditions like MDD, mania and schizophrenia. No absolute contraindications. Only relative CI is high intracranial pressure (brain tumors). Who gets it? Suicidal pt (tx of choice), those who don’t respond to meds, pregnancy, h/o benefit c ECT, medication complications. MC adverse effect is memory loss.
581. Benzodiazepines – all work on CP450 exams OTL (Oxazepam, Temazepam, Lorazepam), so remember OTL for Outside The Liver.
582. Suicide – if pt mentions it, next step is to ask more questions (attempt, ideations), then admit. Risks: h/o attempt (best indicator of eventual success), hopelessness, psychiatric/physical illness, drug abuse, elderly, social isolation (living alone is worse than single, they are not the same thing!), low job satisfaction. MC method in males are guns, females are guns. MC attempt in males are guns, females are pills.

PULMONARY:

583. When to intubate? pO250, pH65yo and pt c comorbidities, tx c 3rd generation cephalosporins). Atypical (>3days, HA, aches, dry cough, 65yo, anyone (>2yo) c COPD/DM/alcoholism/ immunocompromised (HIV/AIDS, cancer, steroid-use, chemotherapy)/post-splenecomy.
600. Influenza vaccine – children 6-23months, >65 (Dr. Fisher says >50yo) c chronic medical conditions, residents of nursing homes, health care workers c pt contact, children (2-18) c chronic aspirin use (Kawasaki’s), caregivers of kids 0.6, Pleural fluid LDH more than 2/3 of the upper limits of normal serum value. What if they don’t give you the serum levels? Then exudates is when pleural fluid cholesterol >45 mg/dL and pleural fluid protein > 2.9. If you think it is malignancy (old guy, wt loss, smoker, etc) then look for LDH >1000, glucose 30-50, and lymphocytes 50-70%. However, if you worry about parapneumonic effusion, look for LDH >1000, glucose >30, pH 10%, CNS s/s, SVC syndrome (JVD c facial discoloration d/t SCC) or tumor at the trachea/esoph/pericardium. For small-cell Ca, tx c chemotherapy (VP16-etoposide and platinum). For non-small cell Ca give radiation and chemo (CAP – Cyclophosphamide, Adriamycin, Platinum).

RENAL/UROLOGY:

629. Prostatitis – dysuria, chills, fever, low back pain, perineal pain, frequency, prostate may feel boggy and large but is always tender. E.coli. Tx c levaquin and hydrate.
630. Epididymitis – tender (relieved c scrotal elevation, opposite of torsion), enlarged testicle, fever, scrotal thickening. Caused by neisseria, e.coli, chlamydia. Tx c abx (tetracycline, levaquin), nsaids, scrotal support.
631. Orchitis – fever, increase testicular size, scrotal pain/erythema, a/w mumps and TB. Tx c same as above.
632. Urethritis – urethral d/c, dysuria. Next step is culture/gram stain (r/o STD). Tx c abx.
633. Testicular torsion – MCC of scrotal swelling in kids, causing severe pain (especially when scrotum is lifted, opposite of epididymitis), abdm pain (sometimes this is their only s/s, so must check scrotum), vomiting. Urologic emergency for blood supply must be regained within 6 hrs to prevent loss of testicle.
634. Cryptorchidism – no s/s. Dx c CT. Tx: Orchiopexy at age 1 to prevent cancer.
635. Any testicular mass needs to have cancer ruled out, so excise and biopsy it.
636. Benign Prostatic Hypertrophy – enlargement of prostat gland causing obstruction (hesitancy, dribbling, weak/low stream), urgency, nocturia and frequency. Dx: 1st DRE, 2nd U/S. Tx: 1st a-blocker (terazosin, remember tamsulosin (flomax) has the least adverse effects), 2rd 5-a-reductase inhibitors (finasteride), 3th Surgery (TURP). However, if pt is in ER in pain, 1st foley (if it wont pass, do suprapubic tap), 2nd TURP (skip meds).
637. Hypospadia – meatus below penis tip, so you pee on your feet. Pt may have chordee (ventral penile curve causing penis to curve 90degrees). Tx:1st observe until 1yo (do not circumcise), 2nd surgery
638. Hydrocele – fluid around the testis due to patent processus vaginalis. Dx c + transillumination. Tx c observation.
639. Varicocele – pampiniform plexus vein dilation due to inefficient pampiniform valves. Disappears in supine position (no venous pooling). Dx c (-) transillumination. Tx c surgery.
640. Cystitis – bladder infection causing dysuria, frequency, nocturia, urgency. Dx c UA/Ucx/Urine dip. MCC is E.coli. Tx:1st abx, 2nd IVP, cystoscopy (if recurrent).
641. UTI – urgency, dysuria, low balck pain, low fever. Dx c midstream urine Cx to show high nitrates and leukocytes. Tx c TMP/SMX, amoxicillin, nitrofurantoin, levaquin. Any kid 25cc residual volume). Dx c renal u/s (shows hydronephrosis). MCC is BPH (then b/l renal stones). Tx c catheterization, then TURP.
655. Minimal Change Disease – kids, glomerulus looks normal, but may have fusion of podoyctes. Dx c 24hr urine protein (no need for biopsy). Tx c steroids.
656. Membranous Glomerulonephritis – elderly Caucasian c amyloidosis. No need to do biopsy for diagnosis.
657. Focal Segmental Glomerulonephritis – h/o IVDA, 50% get ESRD, dx c biopsy
658. Membranoproliferative Glomerulonephritis – a/w hepatitis C (give ribavirin) and endocarditis, dx c biopsy.
659. When do you choose dialysis? Acidosis
 
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* Re:some helpfull notes
#2295801
  sami2004 - 12/22/10 15:45
 
  emergency orders:
head of bed elevation
PEFR
finger stick blood glucose
pulse ox
oxygen
ekg
iv access
ivf
npo
cardiac monitor
bp monitor
drugs:
morphine
phenargan
tylenol
thiamine
glucose
naloxone

trauma:
airway and C spine
breathing
circulation
and then all emergency orders


labs for both office/ER:
cbc
bmp/cmp/lft
abg
preg test
UA/urine and blood culture
stool studies
iron studies
csf studies
urine drug screen
cardiac enz
lipase/amylase/ldh
esr/RF/ANA
echo
cxr/axr
usg
ct/mri
Pre op tests-PT/INR/PTT and type and cross
tumor markers

admit orders: pneumonic ADCVAANDIMPLE
A-admit to/location change(very impt as we always forget)
Diagnosis
Condition
Vitals every 2/4 hours
Activity-bed rest with BRP or ambulate etc
antibiotics-incl pre op antibiotics
nursing-intake and output/foley/NGT etc
Diet-NPO/Cardiac/diabetic etc
IVF
Meds-Remember to discontinue or keep home meds here
Labs-daily monitoring of labs or labs every 8 hours orpulse ox every hour etc
Extra-counsel, consult, vaccinations esp in kids and elderly, rehab, suicide contract, blood transfusion etc...






























uncomplicated sinus infection amoxicilin 40 -50 mg/kg
septic arthiritis in child nafcilin iv and 3th. Generation cephalosporin
conjuntivitis gonococal ceftriaxone
chlamydia conjuntivitis erytromicin
gestational listeria ampi/genta
meningitis profilaxis rifampine, ceftraiaxone, ciprofloxacine
endometritis 9ana,neg and positive clinda micin, gentamicin
actinomyces oral cavity abscess penicillin
lyme less than 9 y/old amoxicilin 40 -50 mg/kg/dia tid for 21 days
lyme more than 9 years old doxicilin 100 mg bid for 21 days
lyme in children can not take amoxi or doxi cefuroxime or eritromicin 21 days/azytro. Early 1st stage
lyme stage 3 ceftriaxone of penicilin G for 14 - 21 days IV
HIV pneumocistis carini pneumonia trimetropin sulfamethoxazole
RMSF in adults and children doxycycline. Some prefer cloramphenicol for children
rhizopus infection. Mucormicosis amphotericin B plus surgical debridemnt ( both)
sifilis penicilin
sifilis patient allergic to peniciiin tetracicline or doxyxycxline
sifilis patient who is pregnant erytromycin
cat scrach…B. henselae 5 days azytromicin
cat scrach…B. henselae alternate tx; claritro, rifam. Smx,tmp 5 to 7 days
actinomyces israeli in diabetic patient high dose of penicilin or erythromycin 6 - 12 week
chemoprophylaxis of tuberculosis isoniazide plus pyridoxin for 9 months
alternative chemoprophylaxis fo Tb pyrazinamide plus rifampicin for 2 months
alternate chemo tb pt can not tolerate pzn rifampicine alone for 4 months
cytomegalovirus cholitis in HIV patient ganciclovir..alternativae is foscarnet
HIV lung cavity with nocardia (weak acid fast branch) trimetropin sulfamethoxazole
chlamydia in pregnant azytromicin one single dose
gonorrhea in pregnant same as in non pregnant: ceftriaxone plus eritro
HIV candida esophagitis ( disphagia) fluconazol 1- 2 weeks. Resistant strain: itraconzaol
HIV CMV esophagitis ( odynophagia) ganciclovir IV…alternative is forscarnet
ehrlichiosis doxycilin
RMSF in pregnant cloramphenicol
HIV profilaxis MAC if CD4 less than 50 azytromycin or claritromicin.Alt: rifabutin
HIV profilaxis histoplasm. in endemic and lss 100 CD4 itraconazol
febrile neutropenia. Usually pseudomona monotherapy: ceftazidime,cefepime,imipenem, mero
lyme prophylaxis in pregnant oral amoxicilin
gonorrhea pharingeal ciprofloxacin, ofloxacin, ceftriaxone (if not allerg to ceph)
cryptococal meningitidis amphotericine and flucitocine
chlamydia uretritis in men azithromycin (1 dose) or doxycylin
lyme. Early localized doxycilin due to risk of ehrlichiosis concomitat
lyme. Early diseminate or late lyme ceftraixone or cefotaxime
meningitis acute in older than 60 and inmunocompr. ceftraixone + vanco (pneumoresitant) + ampici (listeria)
meningitis in hospitalized or after neurosurgery staph aureus (vancomycin),pseudomona(ceftazidime)
nocardia Tx. and prevention: TMP SMX. Minocilin 2nd. Choice
malaria: general chemoprophylaxis cloroquine
malaria india pakistan banglad resistan to cloroquine mefloquine use as prophylaxis
malaria vivax and oval primaquine
malria treatment in areas resistant to cloroquine fansidar
nosocomial neumonias or neumonias in ventilated cephalosp. 4th gen: cefepime,ceftazidime. Pseudomone
pseudomone nosocomial infection dime, pime, imip/cilastin,cirpofloxa, aztreonam, tobra
nosocomial MRSA vancomycin
nosocomial anaerobs clindamycin
human bite amoxicilin/clavulanate
endocarditis in IV abuser: empiric treatment vancomycin and gentamicin
endocarditis in pat that is not iv abuser: empiric tx nafcilin iv and 3th. Generation cephalosporin
lyme pregnant,lactating or children amoxicilin
mycobacterium avium complex profilax if cd less 40 azytromycin
mycobacterium avium complex treatment claritro y etambutol
limb threating infection/ulcer in diabetic patient empiric:cefotetan or ampi/sub, or clinda+fluorquinolone
limb threating infection/ulcer in diabetic that no heal if empiric tx fail do vano (MRSA) and ticarcilin (pseudom)
babesiosis 2 regimens: quinine/clinda and atovaquone azytromicin
HIV diseminated histoplasmosis iv amphotericin B and lifelong itraconazole
shyphilis in pt allergic to penicilin docycilin or tetraciclin for 14 days
shyphilis pregnant patient allergic to penicilin eritromycin
neuroshypliis IV aqueous crystalline penicillin
pneumonia in cystic fibrosis children(severe=pseudom) penicilin antiseudomone (piperacilin) +aminogluc (genta)
pneumonia in cystic fibrosis children alternative to penicilin is cefalosporine (pime or dime)
pneumonia in adults suspectin pseudomona fluorquinolone: ciprofloxacine can be used istead aminog
pneumonia: cystic fibrosis children (no severe:staph) antiestaphilococal medication ( pseudomone and stphylo
HIV patient with cryptococal infection in SNC amphotericin B (IV) plus flucytosine….later: fluconazole
influenza a and b oseltamivir and zanamivir
influenza a and b in pt with asthma avoid zanamivir
influenza a amantadina and rimantidina
HIV and hepatitis B together lamivudine, efavirenz, tenofovir
pseudomembranous cholitis plus ileo rectal vancomycin plus oral vanco and iv metron
pneumonia in pt w/ bronchiectasia. Think pseudomone cefepime/dime
RSV infection in children rivabirin
CMV gastric ulcers in transplanted patient ganciclovir valganciclovir
meningitis for streptococcus pneumoniae vancomycin plus ceftriaxone and dexamethasone
african tick bite fever (mc ricketsial infection in human doxycilin
meningitis by listeria ampicilin
meningitis by listeria in pt allergic to penicilin smx. Tmp
necrotizing fasciitis by MRSA vancomycin
tuberculosis latent alternate treatments rifam and piraz for 2 months or rifamp for 4 months
tuberculosis latent . Recommended treatment isoniazide for 9 months
meningitis after neurosurgical procedures staphylo and pseudomone vancomycin and cefepime
brain abscess after otitis media.contiguous spread multibugs: ceftriaxone and metronidazol (empiric tx)
strep or staphilo shock toxic (foreign bodies) vancomicine mrsa and clindamycin
septic arthritis in rheumatic patiet (>90%staph aureus) nafci if sensitive or vanco if mrsna
osteomyelitis in sickle cell. Empiric treatment vancomycne and ceftriaxone (vanco for stap and cef sallmonella)
neuroshyphilis penicilin, if allergic, desensitization is mandatory
pneumonia: community aquiredd. Empiric tx ceftraixone plus azytromicin
gonococal infection diseminated: empiric tx ceftriaxone (pacific rim and hawaii strains are resistant to cirpfloxa
pneumonia by strep neumonia resistant to penicilin fluoroquinolones, also vanco and linezolid.
HIV pat with sudden lost of vision and pain. acute reitnal necrosis: herpez or varicella virus: intravenous acyclovir
cryptococal infection in transplanted patients flucytosine and ampho b are the best choices
candidemias (pt with catehters chronically) caspofungines
dermatophytosis terbinafine
clenched-fist injury of the hand( punch a mouth) ampicilin sulbactam (anaerob strepto, eikenella corrodens) IV
herpes simplex v. infection w/o systemic complication oral valacyclovir
herpez infection complicated with meningitis iv acyclovir
vancomycin resistant enterococus bacteria linezolid: risk of severe trombocitopenia
pyelonephritis empiric treatment in ambulatory pt oral levofloxacin if pt is compliant, if not compliant iv levofloxacin
cystitis uncomplicated tmp.smx, .Avoid tmp/smx in pyelonephritis due to resistance to tmp.
cat bite in a pt allergic to penicilin tmp. Sulfamethoxazole plus clindamycin (covaer past.strep and staph
cholangitis piperacilin/tazo or ampi/sulbact or ticar/clavul
cholangitis in allergic to penicilin patient aztreonam + metro …or cephalosp 3th generation +metronidazol
spontaneous bacterial peritonitis: e coli or strept cefotaxime doc, also piper/tazo or ampi/sulbact
divertriculitis ciprofloxacin plus metronidazol
dermatophytosis miconazol, ketokonazol, ekonazol
dermatophytosis ( nails and hair) itraconaqzol or terbinafine
dermatophytosis (nail and harir ) in children griseofulvine, since itra or terbinafien is not FDA approved for child
lyme: meningitis encephalitis ceftriaxone intravenous
lyme: only facial palsy can be treated with oral doxycilin
lyme; cardiac involvement ceftraiaxone intravenous
lyme arthritis: doxyciclin
brain abscess empiric tx. Cover gram +, gram -, anaero penicilin, cefalosp 3 th generation and metronidazol
brain abscess post traumatic or post neurosurgery has to cover staph aureus:oxa/nafc , if allergy or resistant; vanco
brain abscces in drug abuse or pt with shunts: staph resistant (MRSA) or staph epidermitis: go with vanco as 1s.choice
brain abscess with edema and midline shift beside antibiotic, use manitol and steroids
 
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* Re:some helpfull notes
#2295813
  sami2004 - 12/22/10 15:56
 
  Record # 1

Question/Fact:

A 39-year-old Polish man comes to the clinic for painful calves after walking long distances and for discoloration of the fingers with changes in temperature. He says his symptoms started two months ago, and he gets no relief from the ibuprofen. He has previously been healthy. He currently smokes a pack a day and drinks socially. He has no history of drug abuse. On physical examination, his blood pressure is 140/90 mm Hg, heart rate is 68/min, and he is afebrile. Examination of the hands reveals distal digital ischemia and trophic changes in the nails of both hands. Radial pulses are absent bilaterally, but all other pulses are present. His right calf shows evidence of a superficial thrombophlebitis. Laboratory studies show: white cell count 9,600/mm3, hematocrit 38.6%, MCV 89 μm3, ESR 40 mm/h, and C-ANCA as negative. The rheumatoid factor and ANA are negative. Which of the following should be done next for this patient?

(A) Heparin
(B) Prednisone
(C) Arterial bypass
(D) Cyclophosphamide
(E) Abstention from tobacco

Answer:

(E) Abstention from tobacco

Explanation:

This patient has thromboangiitis obliterans (Buerger's disease), which is an inflammatory occlusive disorder involving small and medium-sized arteries and veins in the distal and upper extremities. The prevalence is highest in men of Eastern European descent under the age of 40. Although the cause is unknown, there is a definite relationship to cigarette smoking and an increased incidence of HLA-B5 and -A9 antigens in patients with this disorder. Clinical features of thromboangiitis obliterans often include a triad of claudication of the affected extremity, Raynaud's phenomenon, and migratory superficial thrombophlebitis. Claudication is confined to the lower calves and feet or forearms and hands because this disorder primarily affects the distal vessels. Hand examination can reveal severe digital ischemia, trophic nail changes, ulceration, and gangrene at the tips of the fingers. Brachial and popliteal pulses are usually present, but radial, ulnar, and/or tibial pulses may be absent. Smooth, tapering, segmental lesions in the distal vessels are present on angiography. The diagnosis can be confirmed by excisional biopsy of an involved vessel. There is no specific treatment, except abstention from tobacco. The prognosis is worse in those who continue to smoke, but results are relatively good in those who stop. C-ANCA antibodies are usually found in Wegener's granulomatosis. Arterial bypass may be indicated in disease confined to larger vessels. The hand abnormalities effectively exclude peripheral vascular disease. If these measures fail, amputation may be required. Cyclophosphamide and prednisone do not help. Again, the management is to stop smoking.
==============

Topic:

Rheumatology

Record # 2

Question/Fact:

A 25-year-old woman with Crohn's disease presents to your office with recurrent abdominal pain and diarrhea. She has been taking mesalamine 4 grams per day for the last year. Last fall, after developing diarrhea and pain, she was placed on prednisone 60 mg daily. She had a complete remission and, after a 3-month tapering of the prednisone, suffered a relapse. Prednisone was restarted 2 months ago at 60 mg daily, and now as the dose has decreased to 20 mg per day, the diarrhea has recurred. She is having 6 to 8 water stools per day, crampy pain, and some weight loss. What would be the best next step?

(A) Restart the prednisone and plan to maintain the dose at 40-60 mg indefinitely
(B) Restart the prednisone with 6-mercaptopurine and plan on prednisone taper in 2 months
(C) Stop the prednisone and add cyclosporine
(D) Admit to the hospital and give high-dose intravenous steroids to induce remission
(E) Stop the mesalamine and add methotrexate

Answer:

(B) Restart the prednisone with 6-mercaptopurine and plan on prednisone taper in 2 months

Explanation:

Prednisone is effective in treating active Crohn's disease for short durations (3-6 months). Long-term use for maintenance is not indicated. 6-Mercaptopurine and azathioprine are steroid-sparing medications used to limit the need for prednisone. Prednisone, like other corticosteroids, has numerous side effects and should only be used for treating active flares of disease, not maintenance of remission. Cyclosporine and methotrexate have limited roles in the management of Crohn's disease.


Topic:

Gastroenterology

Record # 3

Question/Fact:

A 65-year-old man presents to the emergency room with complaints of weakness, generalized swelling in his extremities, and right leg pain. At the time of presentation, he appears to be in moderate distress from the leg pain. The patient states that his symptoms started two days ago. The patient also has frequent urination and increased thirst. He states that he has felt weak for the past few months. Physical examination reveals a tender, erythematous, and swollen right calf. He also has 2+ pitting edema in all extremities. Blood pressure is 107/55 mm Hg, and temperature is 100.3 F. Venous ultrasound is positive for lower extremity deep vein thrombosis. Laboratory studies reveal:

White cell count 11,000/mm3; hematocrit 32.3%; platelets 105,000/mm3; K 4.0 mEq/L; BUN 24 mg/dL; creatinine 1.7 mg/dL. The PT/PTT are normal.

Total bilirubin 0.4 mg/dL, AST 28 U/L, albumin l.9 g/dL, cholesterol 326 mg/dL; triglycerides 425 mg/dL.

Urine dipstick shows protein 3+, hemoglobin 1+, white cells 1+; 24-hour urine shows 6.2 grams of protein.

What is the next step in the treatment of this patient?

(A) Renal biopsy
(B) Plasmapheresis
(C) Anticoagulation
(D) Cyclophosphamide
(E) Prednisone

Answer:

(C) Anticoagulation

Explanation:

This patient has nephrotic syndrome based on the presence of edema, hyperproteinuria, hypoproteinemia, and hyperlipidemia. Such patients are predisposed to developing a hypercoagulable state secondary to the renal losses of proteins C and S and antithrombin III, as well as increased platelet activation. Patients with evidence of venous thrombosis should be anticoagulated for at least 6 months. Recurrent thrombosis and renal vein thrombosis warrant lifelong anticoagulation.

Although he may need a renal biopsy, he needs to have his thrombus treated first as the "next" step. The same is true of using cyclophosphamide and prednisone. This patient most likely has membranous glomerulonephritis simply because he is an adult with nephrotic syndrome, and this is the most common cause in adults. Colonoscopy should also be done in a patient like this because there is a strong association of glomerulonephritis with solid tumors, such as colon and breast cancer.
Topic:

Nephrology

Record # 4

Question/Fact:

A 42-year-old man from Vietnam, who had been a bus driver in Thailand, presents to the emergency department after having shortness of breath while playing soccer with his son this morning. Over the last several months, he has been having several episodes of shortness of breath. Several of the episodes were associated with chest pain. He denies any significant medical history. He has a 25-pack-year use of tobacco, and he has a sedentary lifestyle. His father had a myocardial infarction at the age of 59. His heart rate is 72/min, blood pressure is 140/66 mm Hg, and respiratory rate is 14/min. His examination shows mild jugulovenous distention with a collapsing carotid arterial pulse. His cardiac examination reveals a point of maximal impulse that is displaced laterally and inferiorly and a mild diastolic blowing murmur at the base while he sits up. His sensory examination shows loss of vibration sense in all extremities, and an abnormal Romberg test. EKG shows normal sinus rhythm with left axis deviation and ST-segment depression and T-wave inversion in leads I, aVL, V5, and V6. The chest x-ray shows an enlarged heart with dilatation of the proximal aorta. The CBC, chemistries, and cardiac enzymes are negative. The echocardiogram shows an ejection fraction of 60%. What is the next best step in the management of this patient?
(A) Treat with digitalis
(B) Exercise stress test
(C) Cardiac catheterization
(D) VDRL and lumbar puncture, followed by penicillin therapy
(E) Aortic valve replacement

Answer:

(D) VDRL and lumbar puncture, followed by penicillin therapy

Explanation:

This patient has a murmur of aortic regurgitation (AR) and an abnormal neurological examination, suggesting syphilis. Therefore, this patient needs a VDRL and a lumbar puncture. Syphilis of the aorta involves the intima of the coronary arteries and may narrow the coronary ostia, leading to myocardial ischemia. There is also destruction of the medial muscle layers of the aorta, leading to aortic dilation. Myocardial ischemia in AR happens because oxygen requirements are elevated secondary to left ventricular (LV) dilatation and elevated LV systolic wall tension. Coronary blood flow is normally during diastole when the diastolic arterial pressure is subnormal. This leads to decreased coronary perfusion pressure.

Nifedipine or ACE inhibitors are only used once the patient develops severe AR. Digoxin is of very limited use at any time. An exercise stress test is not indicated because of the baseline EKG abnormalities. You normally detect the presence of ischemia on a stress test by looking for the development of ST-segment depression. This patient already has baseline ST-segment depression. A thallium or sestamibi scan would be required in a case like this. If you were investigating for ischemia, surgical treatment does not restore normal LV function. Patients with AR and normal LV function are followed until surgery is indicated. This is when the patient has LV dysfunction but before the development of symptomatic congestive failure. Valve replacement is also indicated in asymptomatic patients when the ejection fraction falls to 55 mL/m2. Although catheterization may be useful before surgery, it would not be done before a specific diagnosis of syphilitic aortitis has been confirmed and treatment with penicillin has been given.

Topic:

Cardiology

Record # 5

Question/Fact:

A 40-year-old woman is brought to the emergency department by her daughter who states that she found her mother at home several hours ago, confused, lethargic, and unable to get up from her chair or speak. Her mother has a seizure disorder for which takes an antiseizure medication. She also has a history of alcohol abuse in the remote past. For the past several weeks, her mother has been complaining of difficulty sleeping and anxiety. The patient is stuporous and unresponsive to verbal stimuli. Her blood pressure is 100/60 mm Hg, heart rate is 50/min, and respiratory rate is 9/min. The pupils are pinpoint, and there is horizontal nystagmus. Asterixis is present.

Laboratory examinations reveal: white cell count 9,800/mm3, sodium 150 mEq/L, BUN 18 mg/dL, creatinine 0.9 mg/dL, glucose 50 mg/dL, calcium 5 mg/dL, ammonia 100 μg/dL, albumin 3.0 g/dL, AST 100 U/L, ALT 80 U/L. The urinalysis and lumbar puncture are normal. A CT scan of the brain shows cerebral edema. Arterial blood gas shows a pH of 7.20, a pCO2 of 46 mm Hg, and a pO2 of 79 mm Hg. Osmolar gap is zero. The toxicology screen is negative for benzodiazepines and opioids. What is the most likely substance that this patient overdosed on?

(A) Phenytoin
(B) Carbamazepine
(C) Valproic acid
(D) Ethanol
(E) Valium

Answer:

(C) Valproic acid

Explanation:

This patient most likely is intoxicated with valproic acid. This drug is widely used in the management of seizure and mood disorders. Valproic-acid intoxication produces a unique syndrome consisting of hypernatremia, metabolic acidosis, hypocalcemia, elevated serum ammonia, and mild liver aminotransferase elevation. Hypoglycemia may occur as a result of hepatic metabolic dysfunction. Coma with small pupils may be seen, and this can mimic opioid poisoning. Encephalopathy and cerebral edema can occur.

Phenytoin and carbamazepine are also commonly used antiseizure medications. Phenytoin intoxication can occur with only slightly increased doses. The overdose syndrome is usually mild. The most common manifestations are ataxia, nystagmus, and drowsiness. Hepatic encephalopathy would be unusual. Choreoathetoid movements are occasionally seen. Carbamazepine is a first-line agent for temporal lobe epilepsy, as well as trigeminal neuralgia. Intoxication causes drowsiness, stupor, coma, or seizures. However, dilated pupils and tachycardia are more common.

Signs of ethanol intoxication are similar to the signs of anticonvulsant medication. In addition, it causes a high osmolar gap. Valium is an unlikely cause of intoxication because this patient's blood benzodiazepine levels are negative.

Topic:

Poisoning

Record # 6

Question/Fact:

A 52-year-old woman presents to the emergency department with fever, weakness, and abdominal pain for the past three days. It has been associated with nausea and three episodes of vomiting. Her husband states that her temperatures have been as high as 103.5 F and that she has not been herself lately, appearing confused and lethargic. She has a history of hypothyroidism and migraine headaches. She appears lethargic, dehydrated, and is oriented only to person. Her blood pressure is 75/50 mm Hg, temperature is 102.9 F, and pulse is 108/min. She has dry oral mucosa and hyperpigmented areas of her skin spread diffusely over the posterior neck, hands, and knuckles. Rales are heard over the right lower lung field, and the chest x-ray shows a right lower lobe infiltrate. The EKG is normal. The patient is placed on intravenous hydration. Laboratory studies show a white cell count of 6,300/mm3, and the differential shows 82% neutrophils, 7% lymphocytes, and 9% eosinophils. The sodium level is 112 mEq/L, with a potassium of 5.9 mEq/L and a chloride of 92 mEq/L. Bicarbonate level is 20 mg/dL, and BUN is 32 mg/dL. The creatinine level is normal. The glucose level is 60 mg/dL, and the urinalysis is normal. What is the best initial test to diagnose this disorder?

(A) Immediate cortisol and assess ACTH level
(B) Metyrapone stimulation test
(C) Early morning cortisol
(D) A cosyntropin stimulation test
(E) 24-hour urine cortisol

Answer:

(A) Immediate cortisol and assess ACTH level

Explanation:

In the context of acute adrenal crisis, the most appropriate initial diagnostic test is to obtain a random cortisol level before initiating treatment with intravenous hydrocortisone. In a patient who is hypotensive and hemodynamically unstable, it is inappropriate to perform any diagnostic maneuvers that require several steps to obtain a diagnosis. (The metyrapone stimulation and the cosyntropin stimulation are such tests.) The early-morning cortisol is diagnostically useful if it is very low, which confirms adrenal insufficiency, or very high, which excludes adrenal insufficiency. A 24-hour urine for cortisol is a test used to confirm the diagnosis of the hypersecretion of cortisol, also known as Cushing's syndrome, which is the opposite of adrenal insufficiency.

Topic:

Endocrinology

Record # 7

Question/Fact:

A 45-year-old woman presents to your office after developing a pruritic rash and a fever. She first noticed it on her wrists two weeks ago but states that it has now spread to her feet as well. Her past medical history is significant for a seizure disorder following the removal of a meningioma. She has been treated with Dilantin. Physical examination is significant for icteric sclera. There are polygonal, flat-topped, violaceous papules limited to her wrists and her ankles. A white, reticulated, lacy lesion is also evident on examination of her buccal mucosa. Her liver is enlarged and is nontender to palpation. Laboratory analysis reveals: PT 11 seconds, albumin 3.6 g/dL, alkaline phosphatase 160 U/L, AST 700 U/L, ALT 960 U/L, ANA 1:160. Anti-hepatitis C virus (second generation) is negative; anti-hepatitis-B surface antibody (HBs) is positive; and anti-hepatitis-B core antibody (Hbc)is negative. She has an erythrocyte sedimentation rate of 20 mm/h and a cholesterol of 160 mg/dL. Anti-smooth muscle antibody test is negative, and an ultrasound of the abdomen is normal. What would you do next?

(A) Start prednisone
-2b therapya(B) Initiate interferon-
(C) Administer N-acetylcysteine
(D) Stop Dilantin
(E) Start methotrexate

Answer:

(D) Stop Dilantin

Explanation:

The patient has Dilantin-induced hepatitis. Drug-induced hepatitis may resemble autoimmune hepatitis, including the presence of hypergammaglobulinemia and positive antinuclear antibodies (ANAs). This can result in a false-positive anti-HCV ELISA test. The liver biopsy confirms the picture of drug-induced cholestatic hepatitis. Prednisone and/or azathioprine are the initial treatments of choice for autoimmune hepatitis. Although this patient had a positive ANA, additional tests, such as anti-smooth muscle antibody and anti-LKM (liver, kidney, microsomes), are needed to confirm the diagnosis of autoimmune hepatitis.

Topic:

Gastroenterology

Record # 8

Question/Fact:

A 28-year-old female comes to the emergency department with a headache and fever. She has not had any recent infections, nor has she been exposed to any drugs. Her medical history is unremarkable. On examination, the patient appears lethargic. Her temperature is 100.5 F, pulse is 100/minute, blood pressure is 130/85 mm Hg, and respirations are 18/min. Her conjunctivae are yellowish, and scattered petechiae are noted on the lower extremities. The liver and spleen are not enlarged.

Laboratory studies show the following results: WBC 12,000/mm3; hematocrit 27%; platelets 14,000/mm3; bilirubin 4.5 mg/dL; direct bilirubin 0.5 mg/dL; BUN 40 mg/dL; creatinine 3.5 mg/dL. PT, fibrinogen, and PTT are all normal. Her peripheral blood smear shows fragmented red blood cells.

What is the most effective treatment for this patient?

(A) Splenectomy
(B) Glucocorticoids
(C) Plasmapheresis
(D) Intravenous immunoglobulins
(E) Platelet transfusion

Answer:

(C) Plasmapheresis

Explanation:

This woman has a combination of hemolytic anemia with fragmented RBCs on peripheral smear; thrombocytopenia; fever; neurologic symptoms; and renal dysfunction -- a classic pentad of symptoms that characterizes thrombotic thrombocytopenic purpura (TTP). Approximately 90% of patients will respond to plasmapheresis. Patient should be emergently treated with large-volume plasmapheresis. Sixty to 80 mL/kg of plasma should be removed and replaced with fresh-frozen plasma. Treatment should be continued daily until the patient is in complete remission. Platelet transfusions in patients with TTP are contraindicated and can be associated with acute clinical deterioration. Antiplatelet agents, splenectomy, intravenous immunoglobulin, and immunosuppressive agents have not been of reliable benefit to patients with TTP. Each is less effective than plasmapheresis. Glucocorticoids are useful in patients if plasmapheresis does not work.

Topic:

Hemotology-Oncology

Record # 9

Question/Fact:

A 58-year-old woman comes to your office. She is currently in atrial fibrillation and is asymptomatic. Her rate is 70/min. She denies hypertension, diabetes, and congestive failure. There is no other past medical history. What is the most appropriate management of this patient?

(A) Warfarin and clopidogrel
(B) Heparin followed by warfarin
(C) Low-molecular-weight heparin
(D) Aspirin (325 mg) daily
(E) Warfarin to maintain an INR of 2 to 3

Answer:

(D) Aspirin (325 mg) daily

Explanation:

This is a young patient who has an episode of atrial fibrillation in the absence of other preexisting conditions. The American College of Chest Physicians has established guidelines for anticoagulation in nonrheumatic atrial fibrillation. Patients with risk factors for the formation of thrombi such as a previous stroke, transient ischemic attack, systemic thromboembolism, left ventricular dysfunction, recent congestive heart failure, systemic hypertension, or diabetes should be placed on warfarin to an INR of 2 to 3. Patients with no risk factors who are younger than 65 years are considered to be low risk and should take one aspirin daily. Aspirin is also suitable for patients with a contraindication to warfarin therapy. The efficacy of other antiplatelet agents has not been proven in patients with atrial fibrillation.

Topic:

Cardiology

Record # 10

Question/Fact:

A 62-year-old man presents to your clinic complaining of four days of dysuria, frequency, and urgency. He feels slightly feverish and has had dull, lower-back pain for the past few months. He has had several episodes of the dysuria over the last several months. Each time he was given antibiotics for one week, and the symptoms resolved. Currently his temperature is 100.4 F. The genital examination is unremarkable, and the digital rectal examination reveals a nontender prostate, which is normal in size and consistency, with no palpable masses. After gentle massage of the prostate, a small amount of purulent discharge is extruded from the urethral meatus. The urine culture grows 100,000 colonies/mL of E. coli. Urine cultures from his prior symptomatic episodes also grew E. coli but only 10,000 colonies/mL. Which of the following is most appropriate?

(A) Cystoscopy
(B) Ciprofloxacin and azithromycin orally once now
(C) Trimethoprim/sulfamethoxazole for one week
(D) Renal ultrasound
(E) Ciprofloxacin for 4 to 6 weeks

Answer:

(E) Ciprofloxacin for 4 to 6 weeks

Explanation:

This patient has chronic bacterial prostatitis. Chronic prostatitis can present with lower abdominal pain, perineal pain, or low back pain. There is usually no dysuria unless there is accompanying cystitis. On physical examination, the prostate usually feels normal and is nontender. As in this patient, chronic prostatitis may manifest as a recurrent urinary tract infection (UTI). The key to the diagnosis is culture of urine or urethral discharge. Pathogens for chronic prostatitis in older men are the same as for a UTI, with E. coli being the most common organism identified. One may extrude purulent discharge by massaging the prostate, which will grow the offending organism. One can also culture the urine post massage of the prostate, which should grow ten times more colonies than premassage urine. This patient cultured 10,000 colonies of E. coli in prior cultures, and currently he grew 100,000 colonies postprostatic massage. Ciprofloxacin for 7 days would be appropriate treatment if this were just a UTI. Therapy for one week is not long enough to clear chronic bacterial prostatitis. Most antibiotics don't have good penetration into the prostate, and it takes at least four weeks of therapy with ciprofloxacin to clear the infection. Ciprofloxacin and azithromycin for a single dose would be the treatment for urethritis. This patient does have a urethral discharge, which may be confused with urethritis. However, since the discharge is extruded only on palpation of the prostate, this strongly suggests that the prostate is the source of infection. Cystoscopy would be useful in a patient with recurrent UTIs in whom you suspected a structural malformation of the genitourinary tract. This patient's UTIs are originating from his chronically infected prostate. Trimethoprim/sulfamethoxazole for 12 weeks is an acceptable alternative for treating chronic prostatitis.

Topic:

Infectious Diseases

Record # 11

Question/Fact:

A 29-year old man comes to your office for a routine visit. His only complaint is leg pain after walking a three-block distance. He states that six months ago he was able to walk a longer distance without having to stop. His father died of a heart attack at the age of 44. His mother had diabetes mellitus, and she too died of a heart attack at the age of 47. His older brother, who is now 35 years old, had a stroke and underwent a carotid endarterectomy last year.

The patient presents as a thin individual with a blood pressure of 135/70 mm Hg and a heart rate of 78/min. Physical examination findings are remarkable for the presence of multiple xanthelasmas on the face, chest, and upper back. There is bilateral, irregular, firm, and nodular thickening in the Achilles tendons and extensor tendons of the hands. This patient's medications include atorvastatin, gemfibrozil at maximum doses, and niacin, which was added to the regimen six months ago. He is maintaining a fat-free diet and exercises regularly. Laboratory test results show: total cholesterol 815 mg/dL, triglycerides 515 mg/dL, and HDL 55 mg/dL. The level of total cholesterol has increased by 15% since the last visit.

What would you recommend to this patient?

(A) Nutritionist consult
(B) Stress test for detection of silent ischemia
(C) Plasmapheresis
(D) Liver transplantation
(E) Increase the dose of statins as long as transaminases are within the normal range

Answer:

(C) Plasmapheresis

Explanation:

This patient presents with familial hypercholesterolemia (FH), which is a common autosomal dominant disorder due to absent or defective LDL receptors and resulting in a decreased capacity to remove plasma LDL. LDL cholesterol levels are markedly increased. It is associated with characteristic xanthomas in the Achilles, patellar, and extensor tendons of the hands and by the presence of xanthelasma. Corneal arcus is frequently seen. It is frequently associated with early coronary artery disease (CAD), peripheral vascular disease, and cerebral vascular disease. The plasma cholesterol level is generally in the range of 300 to 500 mg/dL, and in some patients homozygous for FH, it can exceed 800 to 1,000 mg/dL. Triglyceride levels are usually normal, but in 10% of patients, they may be mildly elevated.

Because of the risk of CAD, these patients need especially vigorous therapy. A low-fat and low-cholesterol diet should be initiated, although it gives only a moderate result and will not be enough to control the problem by itself. Effective therapy can be achieved with HMG-CoA reductase inhibitors (statins) as first-line therapy. They lower LDL by 20 to 45%. When they are combined with a bile acid-binding resin, levels of LDL may be decreased by 50 to 60%. In some patients, triple therapy with a statin, a bile acid-binding resin, and niacin may be necessary. Patients homozygous for FH may not be responsive to these measures. For them, measures such as plasmapheresis or LDL apheresis are indicated. Liver transplant is the last resort when all else fails as treatment.

This patient is already on maximum doses of statins and bile acid-binding agent. The addition of niacin did not help. There is very little chance that any additional medical therapy will solve this patient's problem; that is why plasmapheresis is indicated.



Topic:

Cardiology

Record # 12

Question/Fact:

A 37-year-old, HIV-positive man comes for evaluation of generalized weakness, diffuse muscle pain, and frequent headaches that began eight weeks after the start of new HIV medications. He has never had any symptoms from his HIV infection, and he has a CD4 of 255/μL and an HIV RNA viral load of 25,000 (by PCR). He was recently started on zidovudine, lamivudine, and ritonavir/lopinavir. His past medical history is significant for hypertension and hypercholesterolemia. His medications include simvastatin and metoprolol. His physical examination is significant for diffuse muscle tenderness of the extremities. The range of motion is decreased because of pain with movement. His potassium level is 5.4 mEq/L, serum bicarbonate is 16 mEq/L, BUN is 35 mg/dL, creatinine is 1.6 mg/dL, and his viral load is RNA 40,000. The genotyping test result is pending. What will you do while waiting for this result?

(A) Switch zidovudine and lamivudine to didanosine and stavudine, and continue ritonavir
(B) Switch zidovudine, lamivudine, and ritonavir/lopinavir to didanosine, stavudine, and indinavir, and stop simvastatin
(C) Continue all medications but stop simvastatin
(D) Continue zidovudine and lamivudine, and switch ritonavir/lopinavir to efavirenz
(E) Switch to didanosine, stavudine, and efavirenz, and stop simvastatin

Answer:

(E) Switch to didanosine, stavudine, and efavirenz, and stop simvastatin

Explanation:

This patient presents with a drug interaction between the protease inhibitors and the HMG-CoA reductase inhibitor. In this case, it is with ritonavir and simvastatin. This can produce significant toxicity from the statin. Ritonavir can increase the serum concentration of simvastatin, causing severe myalgias, rhabdomyolysis, and potential renal insufficiency. The next necessary step is to stop simvastatin or change the protease inhibitor to a non-nucleoside reverse-transcriptase inhibitor, such as efavirenz. However, in this case, the patient also presents with failure to achieve a reduction in HIV viral load of 1 log after eight weeks of therapy. In the event of inadequate treatment of HIV infection, the best choice would be to start two new nucleoside reverse-transcriptase inhibitors (NRTIs) and use efavirenz instead of ritonavir, in addition to discontinuing the simvastatin. It is not enough to change ritonavir to indinavir because high-level cross-resistance is very likely. Genotyping guides the therapeutic choice of all treatment failures. The best thing to do when treatment is insufficient is to use as least two, and preferably three, new drugs.

Topic:

Infectious Diseases

Record # 13

Question/Fact:

A 55-year-old man presents with abdominal pain and diarrhea for the past 3 months. He has also noticed a weight loss of 10 lb during this period. He denies nausea, vomiting, melena, or hematochezia. He consumes five to six beers each weekend, smokes half a pack of cigarettes a day, but has never used intravenous drugs. The past medical history is significant for osteoarthritis, newly diagnosed diabetes on a trial diet for 2 months, and recurrent duodenal ulcers found on four separate upper endoscopies. He takes diclofenac/misoprostol and famotidine 40 mg bid. Three years ago, he had taken triple antibiotics to treat H. pylori. He also tells you that tumors run in his family. His vital signs are normal. Physical examination is significant for mild epigastric tenderness to deep palpation without radiation. Routine labs ordered show: WBC 8,500/mm3, hemoglobin 13.4 g/dL, hematocrit 40.1%, platelets 256,000/mm3, amylase 155 U/L, sodium 141 mEq/L, potassium 4.2 mEq/L, chloride 106 mEq/L, CO2 23 mm Hg, BUN 15 mg/dL, creatinine 1.0 mg/dL, glucose 188 mg/dL, and calcium 11.2 mg/dL (elevated). What test would you order next?

(A) Serum lipase
(B) Upper endoscopy with biopsy
(C) Abdominal ultrasound
(D) Fasting serum gastrin level
(E) Liver enzyme studies

Answer:

(D) Fasting serum gastrin level

Explanation:

This patient's history of "tumors in the family" is consistent with MEN-1 (hyperparathyroidism, gastrinomas, and pituitary tumors). He presents with symptoms of gastrinoma, such as recurrent ulcer refractory to multiple treatments (H. pylori regimen and high-dose H2 blockers) and diarrhea. He also has an incidental hypercalcemia most likely secondary to his underlying diagnosis of MEN-1. The diagnosis of gastrinoma requires the demonstration of fasting hypergastrinemia and an increased basal gastric output.

Topic:

Gastroenterology

Record # 14

Question/Fact:

A slim, healthy 30-year-old woman is scheduled for a dental prosthodontic procedure and was sent for medical evaluation of a known history of mitral valve prolapse (MVP). The patient is a highly active individual and denies palpitations, chest pain, or shortness of breath. She admits to having a family history of heart disease, notably her father, who had died of a heart attack in his forties, and her mother, who had mitral valve prolapse. On physical examination, the patient is comfortable and has normal vital signs. Auscultation of the heart reveals a normal S1 and S2 and a prominent midsystolic click, which is accentuated in the standing position. No systolic murmur is appreciated. What is your overall assessment and plan for this patient?

(A) Get an echocardiogram to evaluate mitral valve motion and blood flow prior to clearing her for the procedure
(B) Prescribe empiric antibiotics for endocarditis prophylaxis and clear her for the procedure
(C) Get a cardiology consultation prior to medical clearance because the patient has a significant family history of heart disease
(D) Clear her for the procedure without endocarditis prophylaxis
(E) Clear her for the procedure with endocarditis prophylaxis

Answer:

(D) Clear her for the procedure without endocarditis prophylaxis

Explanation:

Mitral valve prolapse (MVP) is a commonly diagnosed valvular disorder affecting women more often than men in a 3:1 ratio. MVP is most commonly diagnosed in people between the ages of 20 and 40. Most people have no presenting symptoms. There is myxomatous degeneration of the valve leaflets, resulting in a stretching of the leaflets and chordae tendinae. Because of the disproportionate size of the left ventricle and mitral valve, there is uneven closure of the valve during each heartbeat and subsequent prolapse of the leaflets into the left atrium. The prolapse is similar to the opening of a parachute. The prolapse causes the classic mid-to-late systolic click. If there is regurgitation of blood back into the atrium, an apical systolic murmur can often be appreciated upon auscultation.

This patient is generally healthy and has a known history of MVP. On examination, she is found to have the midsystolic click but no systolic murmur. The lack of a murmur indicates that blood is not being regurgitated into the atrium. In this setting, the patient does not require antibiotics for endocarditis prophylaxis prior to the dental procedure. Prophylaxis for patients with MVP is recommended if a murmur is present or if evidence of nontrivial mitral regurgitation is found on the echocardiogram. Because the patient has a known history of MVP, she would not require a cardiology consultation or echocardiogram to reconfirm the diagnosis. In fact, an echocardiogram is not a required study to diagnose MVP because dynamic auscultation can be more reliable. Furthermore, the fact that she has remained symptom- and complaint-free would indicate that her condition is stable, and so no study should be warranted at this time. Besides all this, dental prosthodontic procedures do not need antibiotic prophylaxis.

Topic:

Cardiology

Record # 15

Question/Fact:

A 40-year-old man comes to the office because of pain in his right knee for the past three days. The patient denies fever, vomiting, or dysuria. He has no history of trauma but admits to prior episodes of pain, especially after binge drinking. It usually occurs in the knee, ankle, or big toe and is relieved somewhat by ibuprofen. He takes no medications and has no allergies. He has a 25-pack-year smoking history and drinks about half a case of beer when hanging out with friends. His mother developed the same symptoms at the age of 50. On examination, the right knee appears swollen, red, and tender to palpation and has a limited range of motion. You decide to aspirate the knee joint. Which of the following is most consistent with his diagnosis?

(A) Positively birefringent, rhomboid-shaped crystals and 200 white cells/μL
(B) Bipyramidal crystals and 2,000 white cells/mL
(C) Negatively birefringent, rhomboid-shaped crystals and 20,000 white cells/μL
(D) Cloudy and watery fluid with weakly positive birefringent crystals and 20,000 white cells/μL
(E) Watery fluid with strongly negative birefringent crystals and 20,000 white cells/μL

Answer:

(E) Watery fluid with strongly negative birefringent crystals and 20,000 white cells/μL

Explanation:

Gout is a metabolic disease that most often occurs in men at middle age or older. It rarely occurs in women until they are postmenopausal. The acute gouty episode typically happens at night and is brought on by excessive alcohol use, trauma, surgery, dietary excess, or glucocorticoid withdrawal. The joint fluid aspirate appears cloudy because of the numerous white cells. They typically range in number from 5,000 to 50,000/μL. The cell count in this range can be found in any kind of inflammatory arthritis, such as gout, pseudogout, or rheumatoid arthritis. Crystal analysis is required to distinguish them. Gout will have negatively birefringent, needle-shaped crystals, whereas pseudogout will have weakly positive, rhomboid-shaped crystals. Rheumatoid arthritis should have no crystals. Septic arthritis from infection usually gives >50,000/μL white cells in the synovial fluid. The inflammatory process causes breakdown of hyaluronate in the joint fluid and makes it become watery.

Topic:

Rheumatology

Record # 16

Question/Fact:

A 35-year-old man comes to the hospital after an episode of syncope. There were no preceding symptoms, and the patient recovered rapidly and completely with no residual effects. The patient did not have seizure activity during the episode. There is no history of heart disease and no previous episodes of syncope. The patient lives in rural Connecticut. His only previous medical problem was bilateral facial palsy several months ago. Currently, the physical examination is normal, except for a heart rate of 52/min. His blood pressure is normal. An EKG shows a sinus rhythm with Mobitz II second-degree heart block with a PR interval of 0.34 seconds. Echocardiogram is normal. He has a positive VDRL and a negative FTA. What is the most appropriate management of this patient?

(A) Doxycycline in addition to electrophysiological studies
(B) Ceftriaxone in addition to pacemaker
(C) Ceftriaxone in addition to prednisone
(D) Ceftriaxone
(E) Doxycycline in addition to permanent pacemaker

Answer:

(B) Ceftriaxone in addition to pacemaker

Explanation:

This patient seems to have second-degree heart block secondary to Lyme disease. He lives in Connecticut, which is an endemic area. (The city of Lyme is in Connecticut.) Facial palsy is the most common neurological manifestation of Lyme disease. The false positive VDRL is characteristic as well. Besides, the patient is very young and has no other reason to have heart block, such as ischemic heart disease. In Lyme disease, high-grade AV block with a PR interval of >0.3 seconds is an indication for intravenous therapy with either ceftriaxone or penicillin. A pacemaker should be placed at least temporarily in those with a Mobitz II heart block because of the risk of progressing on to third-degree block. This patient is also severely symptomatic from his heart block and has had syncope. Prednisone was used in the past but is inferior to an antibiotic alone. Steroids would only be used in those for whom the heart block does not improve with antibiotics. More minor forms of Lyme disease can treated with oral doxycycline. Doxycycline can be used with those who have just the rash, joint symptoms, facial palsy, or first-degree heart block.

Topic:

Cardiology

Record # 17

Question/Fact:

A 21-year-old man with no significant past medical history presents to office with complaints of blood in his urine and mucosal bleeding while brushing his teeth. The patient complains of intermittent "ringing in the ears." He denies any drug or alcohol use. He has no family history of bleeding disorders. Petechiae are noted in the oral cavity, as is dried blood in the nostrils.

Laboratory studies show the following:

Hematocrit 32%; white blood cell count 8,000/mm3 with 60% neutrophils; platelet count 13,000; PT 13 seconds; PTT 28 seconds; LDH 1,200 U/L; elevated indirect bilirubin.

Coombs' test is positive; abdominal examination is normal; and the peripheral smear shows spherocytes.

What is the most likely diagnosis?

(A) Alport's syndrome
(B) Bernard-Soulier syndrome
(C) Felty's syndrome
(D) Thrombotic thrombocytopenic purpura
(E) Evans' syndrome
(F) Idiopathic thrombocytopenic purpura (ITP)

Answer:

(E) Evans' syndrome

Explanation:

Evans' syndrome is the association of autoimmune hemolysis with autoimmune thrombocytopenia. It is treated initially with steroids and may occasionally need splenectomy to control the disease.

Alport's syndrome is the congenital association of glomerulonephritis with sensorineural hearing loss and ocular problems.

Bernard-Soulier syndrome is a functional platelet disorder presenting with platelet-related bleeding with a normal platelet count.

Felty's syndrome is the association of rheumatoid arthritis with neutropenia and splenomegaly. It is occasionally associated with thrombocytopenia. This patient has no history of rheumatoid arthritis, and the spleen and neutrophil count are normal.

ITP would not give the evidence of hemolysis that is present here, such as an increased bilirubin, positive Coombs' test, high LDH, or anemia. This patient does not have the renal failure or fever associated with TTP. In addition, TTP should give fragmented red cells on peripheral smear.

Topic:

Hemotology-Oncology

Record # 18

Question/Fact:

A 31-year-old woman presents to the emergency department with three hours of shortness of breath. She had been walking her dog this afternoon and had not been outside for more than a few minutes before she began to feel chest tightness, wheezing, and a cough. She has not had any relief from her bronchodilators or steroid inhalers that she uses daily. She states that her daily activities have become affected by frequent episodes of shortness of breath that recur a few times during each week. These attacks can last days at a time, and she is afraid that her current medications are no longer of assistance to her. On physical examination, she has a temperature of 98.8 F, a pulse of 98/min, a blood pressure of 136/90 mm Hg, and a respiratory rate of 23/min. There is some evidence of hyperemia and secretions in the nasal passages bilaterally. She is using her accessory muscles to breathe, and wheezing is audible. Pulmonary function testing reveals an FEV1 of 68% of predicted, with a reduced FEV1/FVC ratio. This increases by 14% after high-dose bronchodilators are administered. Her peak expiratory flow was 158 L/min before bronchodilators were given. Arterial blood gases on room air are: pH 7.36, pCO2 48 mm Hg, and pO2 60 mm Hg. Chest x-ray shows evidence of hyperinflated lungs. The severity of this patient's clinical condition corresponds with which of the following classifications of asthma?

(A) Moderate intermittent
(B) Severe intermittent
(C) Mild persistent
(D) Moderate persistent
(E) Severe persistent

Answer:

(D) Moderate persistent

Explanation:

This patient presents with an acute attack of asthma, likely precipitated by allergens from the environment. Her symptoms are suggestive of moderate persistent asthma, as she requires the daily use of an inhaled short-acting β2-agonist, the exacerbations are affecting her daily activities, and they recur at a frequency of more than twice per week, lasting days at a time. Other parameters consistent with moderate persistent asthma are the occurrence of nocturnal symptoms more than once per week. Her FEV1 value of 68% is consistent with the criteria for the FEV1 to fall between 60 and 80% of predicted, a reduced ratio of FEV1/FVC to 80%
2. Mild persistent -- symptoms greater than 2×/week but less than l×/day with FEV1 >80%
3. Moderate persistent -- daily symptoms greater than 2×/week with FEV1 >60 and 90%. Tissue examination is far more sensitive than pleural-fluid culture. A PPD would be completely nonspecific in a man from Russia who would almost certainly have a positive test anyway. Adenosine deaminase is elevated in third-space fluid collections from tuberculosis, such as the pleural, peritoneum, and pericardium. It is not as sensitive or specific as the pleural biopsy.

Topic:

Pulmonary

Record # 72

Question/Fact:

A 56-year-old Caucasian woman presents to your office complaining of progressive, right upper quadrant abdominal pain of one week's duration. The pain is accompanied by nausea, fatigue, joint pain, and dyspnea on exertion over the past month. She has a past medical history of type 2 diabetes mellitus and chronic renal insufficiency. She denies fever, chills, or diarrhea. On physical examination she appears thin and has a bronze coloration of her skin. Vital signs are normal. Examination of her neck reveals a steadily rising jugular venous pressure during inspiration. Cardiac examination is remarkable for an S3 gallop. The lungs are clear to auscultation, and the liver is nontender and palpable 3 cm below the costal margin. She has a bilateral 1+ pitting edema of the extremities. Chest x-ray reveals pulmonary congestion with an enlarged heart. The EKG shows a normal sinus rhythm with a rate of 86/min, nonspecific ST-T wave abnormalities, and low QRS voltage in all leads. Echocardiogram reveals mildly reduced left ventricular function. Laboratory studies show: amylase 34 U/L, AST 98 U/L, ALT 60 U/L, total bilirubin 1.0 mg/dL, direct bilirubin 0.2 mg/dL, and glucose 260 mg/dL. What would be the next appropriate diagnostic test to order?

(A) CT scan of the chest to evaluate the pericardium
(B) Ferritin, total iron-binding capacity (TIBC)
(C) Persantine thallium test
(D) Cardiac catheterization

Answer:

(B) Ferritin, total iron-binding capacity (TIBC)

Explanation:

This patient most likely has cardiomyopathy from hemochromatosis. The patient is presenting with signs of both liver dysfunction and congestive heart failure. Her liver is enlarged but nontender with a mild elevation in her transaminases. In addition, she has signs of biventricular cardiac dysfunction. The signs of right-sided heart failure, beside the dyspnea, are the edema and an elevation of jugular venous pressure on inspiration, or Kussmaul's sign. The left ventricle has diminished function on the echocardiogram, as well as an S3 gallop, and congestion is seen on the chest x-ray. Hemochromatosis leads to the accumulation of iron in the liver, heart, joints, pancreas, pituitary gland, skin, and gonads. Although hemochromatosis leads to restrictive cardiomyopathy, the most common cause of death is from cirrhosis and hepatic carcinoma. Iron also accumulates in the pancreas, leading to diabetes. The term "bronze diabetes" is highly suggestive of hemochromatosis.

Although a CT scan of the chest can be used to detect constrictive pericarditis, this disorder would not lead to diminished left ventricular dysfunction on the echocardiogram. A Persantine thallium test is excellent for detecting ischemia in a patient who is unable to exercise. The information obtained by this test in a patient with cardiomyopathy is nonspecific. Cardiac catheterization for biopsy is not necessary because other tests of iron stores are far less invasive and strongly suggest the diagnosis; therefore, the ferritin and total iron-binding capacity (TIBC) are most useful to order next. You should expect to see a transferring saturation rate of >50% and an elevated serum ferritin. A liver biopsy looking for iron stores would be the most specific test.

Topic:

Cardiology

Record # 73

Question/Fact:

A 28-year-old woman comes in for routine management of her hypothyroidism, which has been controlled with levothyroxine 100 μg per day. She does not use either alcohol or tobacco products. She feels fine but thinks she is pregnant. The physical examination is unremarkable, and the urine pregnancy test is positive. What is the next best step in the management of this patient?

(A) Increase her levothyroxine to 150 μg/day
(B) Check the free T4 and thyroid-stimulating hormone (TSH) levels
(C) Maintain the same dose of levothyroxine throughout the pregnancy
(D) Decrease the levothyroxine to 50 μg/day

Answer:

(B) Check the free T4 and thyroid-stimulating hormone (TSH) levels

Explanation:

This question focuses on the relationship between hypothyroidism and pregnancy. When a woman with hypothyroidism becomes pregnant, her requirement for the hormone increases. Usually, one may have to increase the dose of levothyroxine by 50%. You should then adjust it according to the levels of thyroid-stimulating hormone (TSH). You should first check a baseline level of the free T4 and TSH in order to know where you stand at baseline to guide your therapy. In pregnancy, there is an increase in the level of thyroid-binding globulin, which can artificially elevate the level of T4; this is why we should use the free T4 level to evaluate the true function of the gland. Postpartum, all dose requirements usually return to their prepregnancy levels.

Topic:

Endocrinology

Record # 74

Question/Fact:

A 30-year-old woman comes to the clinic because of an inflamed and painful right eye. She states that she was fine until three days ago, when she noticed that her vision was blurry. She usually wears contact lenses and thought they may be the source of her complaints. Physical examination shows a very teary, uncomfortable person. There is some inflammation of the conjunctiva and chemosis. Fluorescein staining reveals a corneal dendritic ulcer. What is the most appropriate therapy?

(A) Topical steroids
(B) Switch brands of contact lens cleaning solution
(C) Systemic steroids
(D) Topical trifluridine
(E) Topical polymyxin

Answer:

(D) Topical trifluridine

Explanation:

This patient presents with a dendritic ulcer, which is almost always caused by a herpes infection. Sometimes they can be caused by corneal abrasions or excessive use of contact lenses. If this were simply a reaction to the contact lens solution, there would not be a dendritic pattern visible on fluorescein staining. A herpetic, dendritic ulcer usually presents with a painful eye, visual blurring, and conjunctival inflammation. The treatment is with ophthalmic trifluridine and acyclovir for about 10 days. Corticosteroids are absolutely contraindicated because they may worsen it. These patients should be referred to an ophthalmologist.

Topic:

Infectious Diseases

Record # 75

Question/Fact:

A 38-year-old, HIV-positive woman finds out that someone at her workplace has tuberculosis. Her PPD at employee health is negative. Her chest x-ray is now normal, and her PPD last year was negative. What should you do next for her?

(A) Nothing further is required
(B) Repeat the PPD in three months
(C) Start isoniazid and stop in three months if the tuberculosis skin test (PPD) is negative
(D) Start isoniazid for a full nine months
(E) Yearly chest x-rays

Answer:

(D) Start isoniazid for a full nine months

Explanation:

If a patient has been exposed to tuberculosis (TB), and the tuberculosis skin test (PPD) is negative, you do not have to do a chest x-ray. The PPD should be repeated at three months. Most patients who have been exposed to TB and who are going to develop a positive PPD will do so within three months of the exposure, and the PPD should be repeated at 12 weeks. So, she should have the repeat test. However, it is more important to start treatment with isoniazid. There is no reason to give isoniazid to most patients if the PPD is negative. The only exception to this rule is in small children under two years of age who can have a serious exposure but still have a negative PPD because of immature T cells. The other exception is an HIV-positive patient with profound immunosupression and a very low T-cell count who has a serious exposure, such as someone in their own household. There is no routine indication for yearly chest x-rays in any population. Any person with a newly positive PPD should get a chest x-ray. This person's test, however, was negative.

Topic:

Pulmonary

Record # 76

Question/Fact:

A 50-year-old man comes in for management of gout that was originally diagnosed six months ago He has gouty attacks approximately once a month in his left great toe. He was started on daily colchicine several months ago and was told to avoid high-purine foods. He has a history of insulin-dependent diabetes for 20 years, which has been well maintained. Laboratory studies show: BUN 42 mg/dL; creatinine 2.6 mg/dL; uric acid level 8 mg/dL (normal 2.5-7.5 mg/dL) one month ago. What additional medication may be indicated in light of his history?

(A) Probenecid
(B) Allopurinol
(C) Methotrexate
(D) Ibuprofen
(E) Prednisone

Answer:

(B) Allopurinol

Explanation:

Allopurinol is a xanthine-oxidase inhibitor that promptly lowers plasma-urate and urinary uric-acid concentrations. It is of special value in uric acid overproducers, tophaceous gout, and in patients unresponsive to uricosuric agents. Allopurinol is also helpful in patients with uric-acid renal stones. It should be used in low doses in patients with renal insufficiency. The patient is already on low-dose colchicine on a daily basis. He should be continued on this medicine because in an older patient with occasional attacks, this may be all that is needed to prevent recurrences. Colchicine should be used once a day in moderate renal insufficiency, such as in this patient's case.

Probenecid is a uricosuric drug that is contraindicated in this patient because the creatinine level is elevated above 2 mg/dL. Probenecid and sulfinpyrazone are two uricosuric drugs that may be used with normal renal function. NSAIDs are used for the treatment of an acute attack and are relatively contraindicated with impaired renal function, as in this case. Steroids should be used in the case of an acute attack for those patients unable to take NSAIDs. Methotrexate does not help at all.

Topic:

Rheumatology

Record # 77

Question/Fact:

A 29-year-old man comes to see you because of difficulty with drooling and a unilateral dry eye. On physical examination, he has unilateral facial palsy. He lives in Massachusetts and frequently goes trekking in the mountains. His serologic test is positive for an IgM antibody to Borrelia burgdorferi. What is the most appropriate management?

(A) Repeat the serology in four weeks
(B) Perform a lumbar puncture
(C) Oral doxycycline for three weeks
(D) Intravenous ceftriaxone

Answer:

(C) Oral doxycycline for three weeks

Explanation:

The patient has facial palsy because of Lyme disease. Facial palsy is adequately treated with oral doxycycline. The positive IgM antibody test for Borrelia burgdorferi has sufficient specificity in this case to indicate the need for therapy. A repeat test is not necessary. In the absence of other neurologic abnormalities, a lumbar puncture is not necessary. Intravenous therapy does not give a greater efficacy when compared with oral doxycycline.

Topic:

Infectious Diseases

Record # 78

Question/Fact:

A 62-year-old woman with a 10-week history of rheumatoid arthritis presents with persistent pain and swelling of her hands and knees. She also has generalized fatigue and weakness. She reports a mild improvement of her symptoms after starting rofecoxib, prednisone, and physical therapy but still has more than 1 hour of stiffness upon awakening each morning. She has a history of macular degeneration and peptic ulcer disease. On physical examination, she has tenderness and soft-tissue proliferation of the proximal interphalangeal and metacarpophalangeal joints. This is symmetrical bilaterally, with limited flexion and extension of both wrists. There is fluid in each knee and soft-tissue swelling. Laboratory tests show a hemoglobin concentration of 10.2 g/dL, and the erythrocyte sedimentation rate is 45 mm/h. Kidney and liver function tests are normal. What therapy should be started in this patient?

(A) Naproxen
(B) Methotrexate
(C) Hydroxychloroquine
(D) Infliximab
(E) Intra-articular glucocorticoids

Answer:

(B) Methotrexate

Explanation:

The first step in medical management of rheumatoid arthritis is the use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) to control the symptoms and signs of the local inflammatory process. COX-2-specific inhibitors, such as celecoxib and rofecoxib, suppress the signs and symptoms of rheumatoid arthritis as effectively as does classic COX-nonspecific NSAIDs, such as naproxen or ibuprofen, but are associated with a significantly reduced incidence of gastrointestinal ulceration. This suggests that COX-2-specific inhibitors might be considered instead of classic COX-nonspecific NSAIDs in persons with an increased risk of NSAID-induced upper gastrointestinal side effects, such as those with a history of peptic ulcer disease and persons receiving glucocorticoids or anticoagulants. The patient in this question has a history of peptic ulcer disease, and that is why she is on rofecoxib.

Disease-modifying agents appear to have the capacity to decrease elevated levels of acute-phase reactants and, therefore, are thought to modify the inflammatory component of rheumatoid arthritis. Most rheumatologists recommend the use of methotrexate as the initial DMARD in individuals with evidence of aggressive rheumatoid arthritis. Aggressive disease is characterized by fever, weight loss, or joint erosions on x-rays. Cyclophosphamide appears to be no more effective than other DMARDs and causes a variety of toxic side effects. Cyclophosphamide also appears to predispose the patient to the development of a malignant neoplasm. It is used only for patients who have clearly failed therapy with the other DMARDs (i.e., methotrexate or hydroxychloroquine). Infliximab is also remarkably effective at controlling the signs and symptoms of rheumatoid arthritis in patients who failed DMARD therapy, and it has far less adverse effects than cyclophosphamide. Intra-articular glucocorticoids can often provide transient symptomatic relief when systemic medical therapy has failed to resolve inflammation. Hydroxychloroquine can be used as a DMARD as well. It should not be used in this specific patient because she has severe disease and a history of macular degeneration. Hydroxychloroquine can cause additional retinal lesions.

Topic:

Rheumatology

Record # 79

Question/Fact:

A 76-year-old woman comes to the emergency department after falling in her house. The daughter witnessed the episode and states that her mother fell on her left side but did not pass out or hit her head. Her mother had a hard time getting to her feet and had to be helped up. The patient denies dizziness, palpitations, or loss of consciousness. She also has hypertension, diabetes with gastroparesis, and peripheral vascular disease. She has had occasional urinary incontinence and memory loss. Her medications are aspirin, atenolol, lisinopril, glyburide, metformin, metoclopramide, and cilostazol. The patient is alert but has decreased concentration and a markedly impaired memory. She has normal language function. The cranial nerves are intact, and there is increased tone in the lower extremities bilaterally with 4/5 motor strength in all muscle groups. The deep-tendon reflexes and cerebellar function are normal. She has a broad-based stance, hesitant initiation of walking, and a shuffling, ataxic gait. What is the next step in the management of this patient?

(A) Discontinue metoclopramide
(B) CT scan of the head
(C) Lumbar puncture
(D) Start levodopa/carbidopa (Sinemet)
(E) Donepezil
(F) Ventriculo-peritoneal shunt

Answer:

(B) CT scan of the head

Explanation:

Even if you have no clue about the diagnosis, the first step in managing a patient with severe CNS-related abnormalities is a CT scan of the head in virtually any question you encounter on the boards. This patient has normal-pressure hydrocephalus (NPH). The gait disorder is usually characteristic and is the most reliable feature. Typically, the family describes the subacute onset of progressive intellectual deterioration accompanied by slowness and restriction of movement, particularly of the gait. There should also be the presence of bladder incontinence. In a way, it can be thought of as Parkinson's disease of the lower extremities. The disease is slowly progressive over weeks, months, or sometimes years. Parkinson's disease has many clinical features that are not present in NPH, such bradykinesia, rigidity, rest tremor, freezing, and postural instability. All of these are absent in this patient. In addition, NPH will not have a response to Sinemet. Although metoclopramide can cause a secondary parkinsonism, it should not cause cognitive decay or urinary incontinence. And even though donepezil may be useful for Alzheimer's disease, it will not help the memory loss of NPH. Ventriculo-peritoneal shunting would not be appropriate, unless a CT scan of the head is performed first. In short, don't start disease-specific therapies until you have confirmed a specific disease. Lumbar puncture is not a useful prognostic test. The only proof of shunt efficacy is to perform the shunt. Success is more likely if the shunt is done before the onset of severe cognitive problems.

Topic:

Neurology

Record # 80

Question/Fact:

A 43-year-old obese man is referred to you by his corporate masters for a cardiac evaluation prior to beginning an exercise program that mostly consists of playing intense games of racquetball with the boss. He denies any cardiac risk factors and has no history of coronary disease. His parents are robustly healthy, and he does not smoke. You find a blood pressure of 110/70 mg/dL. Laboratory tests show an LDL of only 140 mg/dL. His EKG is normal. In order to clear him for exercise, you order a thallium stress test, which shows a small reversible defect in his inferior wall. How would you manage him?

(A) Clear him for racquetball
(B) Tell him he will have no problem as long as he loses 10% of body weight prior to beginning exercise
(C) Start aspirin alone
(D) Start statins

Answer:

(D) Start statins

Explanation:

Although he has no cardiac risk factors, he has an LDL above 130 and a sestress test showing ischemia. Once you have the presence of coronary disease, risk factors such as hypertension, tobacco smoking, low HDL, family history, and the patient's age become irrelevant. Although obesity is certainly a risk for an increase in all-cause mortality, obesity is not specifically a risk factor in the evaluation of who needs lipid-lowering therapy. Statin therapy would be combined with a dietary restriction on fat intake, as well as weight loss.



Topic:

Cardiology




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practical exam 2
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brainX Digital Learning System
Study Session of KnowledgeBase: Practice Exam 2

Record # 1

Question/Fact:

A 55-year-old man with a past medical history significant for diabetes for 15 years presents to your office complaining of increasing shortness of breath over the past few months. Although he is pain-free today, he has had angina-like chest pain over the last several months. There is no radiation of the pain or nausea, vomiting, or diaphoresis. The patient's medications consist of metformin, glyburide, and lisinopril. He denies alcohol, tobacco, or illicit drug use.

On physical examination, the patient appears as an age-appropriate obese male. Blood pressure is 130/170 mm Hg, and heart rate is 66/min. Jugulovenous distention is present. There is an S3 gallop with lateral displacement of the point of maximal impulse and some minimal rales at the lung bases. There is no peripheral edema. An EKG reveals a normal sinus rhythm at a rate of 64/min with no ST elevation and no T wave inversions. Anterior and inferior leads have QS waves. An echocardiogram reveals four chamber dilatation, global hypokinesis, and an ejection fraction of 35%.

What is the next diagnostic step for this patient?

(A) Coronary angiography
(B) 24-hour Holter monitor
(C) Transesophageal echocardiogram
(D) Thallium stress test
(E) Endomyocardial biopsy

Answer:

(A) Coronary angiography

Explanation:

In the patient described, the physical examination and history paint a picture of dilated cardiomyopathy, although one should not come to a precise diagnosis until the EKG and echocardiogram are done. The patient denies any previous alcohol use, and there is no medical history suggesting the use of cardiotoxic drugs. The QS waves on the EKG probably represent previous ischemic events, such as a myocardial infarction. These might have gone unnoticed because of the patient's diabetes, leading to a "silent" myocardial infarction. Because this patient is symptomatic with anginal pain and dyspnea, the next diagnostic step in the management of this patient should be coronary angiography. An endomyocardial biopsy has a very limited role in restrictive cardiomyopathy, where you would want to distinguish between a primary versus an infiltrative process. The Holter is not a part of the routine evaluation of ischemic heart disease. A transesophageal echocardiogram would not reveal any additional information, which would be useful in the management of a patient with probable ischemic heart disease. Stress testing is used when there is a question of the possibility of coronary disease. Between the patient's symptoms of pain and shortness of breath, as well as an EKG consistent with a previous infarction, there is little doubt that he has ischemic disease. His history is more important that this test. Even with the injection of thallium, there is still only a 90 to 95% sensitivity. Even in the unlikely event that the test is negative, you would still want to perform angiography because, in a case like this, it would be one of the false negatives.

Topic:

Cardiology

Record # 2

Question/Fact:

A 55-year-old man complains of epigastric burning. The burning is nonradiating but lasts for hours and is worsened by meals. An upper gastrointestinal series is performed, which reveals a benign-appearing, 1-cm ulcer in the antrum. There is no melena, hematochezia, fever, chills, dysphagia, odynophagia, or weight loss. He is treated with omeprazole and describes an immediate relief of pain. Which of the following should be performed?

(A) Obtain an H. pylori antibody to determine if he should be treated with antibiotics
(B) Arrange a repeat endoscopy in 4 to 6 weeks to verify healing of the ulcer
(C) He should avoid aspirin and NSAIDs
(D) No dietary restrictions are necessary
(E) All of the above are appropriate recommendations

Answer:

(E) All of the above are appropriate recommendations

Explanation:

Verification of the presence of H. pylori and treatment will prevent a recurrence of H. pylori.. An endoscopy to verify healing should be performed in 4 to 6 weeks because gastric ulcers are malignant till proven otherwise. Aspirin and NSAIDs will delay healing and should be avoided, and diet has little role in the causation and treatment of peptic ulcers.

Topic:

Gastroenterology

Record # 3

Question/Fact:

A 25-year-old man comes to your office complaining of pain in the right eye, which started three days ago. The pain was associated with blurred vision and hypersensitivity to light on Day 1. The problem increased gradually and was associated with redness of the eye and increased lacrimation. The patient denies a problem of this type in the past. He has been having some bilateral, deep, and dull pain in the gluteal region with mild lower backache and stiffness, which is worse in the morning and improves by the time he starts working in his office 1 to 2 hours later. The patient uses analgesics for the backache. He has been married for the last year, is a computer programmer, and goes to the gym three days a week. On physical examination, the patient is healthy-looking but anxious. He has a hazy cornea in the right eye with precipitates on the corneal endothelium and yellowish spots on the iris with indistinct margins. Funduscopy, after dilation, shows a grossly normal retina and choroid. His left eye is normal. The rests of the physical examination shows some limitation in the range of movement of the lumber spine in all directions and vague tenderness deep in the gluteal region. The ESR is 60 mm/h, and the urinalysis and chemistries are normal. An x-ray shows slightly blurred cortical margins of the subchondral bones in the sacroiliac joints bilaterally. Which of the following would be most appropriate next action?

(A) Culture from the urethra
(B) Serological test for syphilis
(C) HLA-B27 typing
(D) Methylprednisolone
(E) Steroid eye drops

Answer:

(E) Steroid eye drops

Explanation:

The most important initial step is to treat the patient's visual loss and photophobia. This patient has ankylosing spondylitis (AS). Uveitis is an ocular manifestation of several systemic diseases, such as AS, Reiter's syndrome, syphilis, and many other diseases. Uveitis is the most common extra-articular manifestation of AS. In addition to the uveal tract, both Reiter's syndrome and syphilis affect joints, but the patterns of joint involvement in these diseases are different. Sacroiliac involvement is extremely uncommon in syphilis. In a sexually active man with uveitis, a serological test for syphilis should be considered. Arthritis may be secondary to gonococcal infection, but this patient does not have symptoms now, and he has not had recent urethritis. Although AS is strongly associated with HLA-B27, the test is not used for the diagnosis of either AS or Reiter's syndrome. This is because HLA-B27 lacks specificity. All forms of seronegative spondyloarthropathies can have it, as well as 8% of the general population. HLA-B27 testing adds nothing when there is buttock pain and an abnormal x-ray of the sacroiliac joint. Physical examination of the right eye reveals an anterior uveitis, which should be treated with local steroids. Intravenous steroids are used when there is involvement of the ciliary body, choroid, or retina. Decreased chest expansion is not a problem at this stage of the disease. Although a decrease in the ability of the chest to expand results in an increased residual volume and decreased vital capacity, the ventilatory function is well maintained in the earlier stages of the disease.

Topic:

Rheumatology

Record # 4

Question/Fact:

A 38-year-old man presents to the emergency department with shortness of breath and chest tightness. He has a past medical history of nephrotic syndrome and is currently taking prednisone. He just completed a 5-day course of azithromycin for an upper respiratory infection but still has a cough. On physical examination, his temperature is 100.8 F, pulse is 118/min, blood pressure is 115/70 mm Hg, and he appears to be in respiratory distress. The lung examination reveals right-sided splinting. The heart examination is normal. Laboratory examination reveals: white blood cell count 16,000/mm3 with 88% neutrophils. An arterial blood gas on room air shows a pH of 7.44, a pCO2 of 32 mm Hg, a pO2 of 79 mm Hg, and a 95% oxygen saturation. The chest x-ray reveals atelectasis and a right lower lobe infiltrate. Which of the following is the most likely cause of this patient's problem?

(A) Amyloidosis
(B) Focal segmental glomerular sclerosis
(C) Membranous nephropathy
(D) Diabetic nephropathy
(E) Minimal change disease

Answer:

(C) Membranous nephropathy

Explanation:

Nephrotic syndrome, particularly due to membranous glomerulonephropathy, is associated with a 50% risk of venous thrombosis. Patients also have a high incidence of renal vein thrombosis. There are several causes of thrombophilia in nephrotic syndrome. Antithrombin III, proteins C and S, and alpha-2 antiplasmin are natural anticoagulants that are lost in the urine. This patient has both the signs and symptoms of pulmonary embolism. He is in respiratory distress, and his ABG is consistent with respiratory alkalosis with an increased A-a gradient. The most common cause of nephrotic syndrome in adults is membranous glomerulonephropathy. This form of nephrotic syndrome is also associated with cancers of the colon and breast, as well as lymphoma. This patient must first receive heparin to inhibit growth of the clot. D-dimers are a very sensitive test for the presence of pulmonary embolus, but they are not specific and may become elevated with any form of increased clotting. In the acute setting with a high clinical suspicion, treatment should be instituted even before a V/Q scan or CT angiogram is obtained.

Topic:

Pulmonary

Record # 5

Question/Fact:

A 40-year-old man presents to your office after a syncopal episode at work today. He has high blood pressure but has not been adherent with his medical appointments. He also has a history of diet-controlled diabetes. Review of systems is remarkable for dyspnea on exertion with intermittent lightheadedness. The episodes last for 2 to 5 minutes. His medications include an anxiolytic medication prescribed by a friend. His blood pressure is 160/94 mm Hg, and his pulse is 78/min. Cardiac examination is remarkable for a sustained point of maximal impulse and a IV/VI systolic ejection murmur loudest at the lower left sternal border. The murmur increases with Valsalva. An EKG in your office shows left ventricular hypertrophy. What would be the most appropriate management of his hypertension?

(A) Beta-blocker
(B) ACE inhibitor
(C) Diuretic
(D) Calcium-channel blocker
(E) Angiotensin-receptor blocker

Answer:

(A) Beta-blocker

Explanation:

The patient presents with what seems to be hypertrophic obstructive cardiomyopathy. He has episodes of lightheadedness combined with the new episode of syncope. Dyspnea is a far more common presentation of this cardiomyopathy than sudden death, which is one of the rarer presentations. The only two left-sided cardiac lesions leading to a murmur that increases in intensity with Valsalva are mitral valve prolapse and obstructive cardiomyopathy. Beta-blockers are appropriate for both the blood pressure and cardiomyopathy. They decrease the force of contraction and thus decrease the obstruction. In addition, by slowing the heart rate, they increase diastolic filling time and thus decrease the obstruction.

Although ACE inhibitors are always good for hypertension in a diabetic patient, the more important issue in this patient is to prevent hemodynamic compromise. ACE inhibitors will increase ventricular emptying. They will therefore worsen the obstruction in a patient who already has serious signs of left ventricular outflow obstruction that are severe enough to make him pass out and become dyspneic. The same is true of the angiotensin-receptor blockers. Diuretics will only worsen ventricular filling and the signs of obstruction. Calcium-channel blockers are an alternative to those not responsive to, or are intolerant of, beta-blockers. They would not the first-line therapy.

Topic:

Cardiology

Record # 6

Question/Fact:

A 78-year-old white woman is brought to the emergency department unconscious and intubated by paramedics. The patient was found lying unresponsive on the bathroom floor with a heart rate of 30/min. She was apneic and hypotensive with a systolic blood pressure of 60 mm Hg. They gave atropine 1 mg intravenously in the field. The family arrives and tells you that she has a history of congestive heart failure, coronary heart disease, and hypertension and takes furosemide, metoprolol, digoxin, and enalapril. On admission to the emergency department, she has a temperature of 100 F, a heart rate of 35/min, and a blood pressure of 60/40 mm Hg. You give another dose of atropine 1 mg intravenously without any change in the heart rate or blood pressure. Her potassium is 3.6 mEq/L, with a bicarbonate of 22 mEq/L, BUN of 50 mg/dL, and a creatinine of 2.3 mg/dL. An EKG shows third-degree AV block at a ventricular rate of 35/min. Her toxicology screen is negative. What would you do next?

(A) Gastric lavage using activated charcoal
(B) Digibind
(C) Lidocaine
(D) Potassium
(E) Transcutaneous pacing

Answer:

(E) Transcutaneous pacing

Explanation:

This patient has life-threatening digitalis toxicity. Digoxin has a parasympathetic action on the AV and sinus nodes, causing slowing and nodal inhibition. Digoxin is primarily excreted through the urine, so this patient's elevated creatinine is a clue to the etiology of the toxicity. Patients may complain of nausea, vomiting, confusion, vertigo, and greenish yellow scotomata presenting as halos around lights. Hypokalemia occurs when patients are on chronic diuretic treatment, and this leads to a greater likelihood of developing toxicity. When the potassium level falls, the heart is sensitized more to arrhythmias caused by digoxin. The most common arrhythmia associated with digoxin is paroxysmal atrial tachycardia with variable block. The patient in this case has refractory third-degree AV block and hypotension, even after being given atropine twice. In this instance, a transcutaneous pacemaker should be applied to sustain an adequate blood pressure while other measures can be initiated. Certainly, activated charcoal should be given as soon as possible because digoxin is slowly absorbed and distributed. Lidocaine is used for ventricular tachyarrhythmias, such as ventricular tachycardia. The correction of hypokalemia is also a key part in stabilizing the myocardium from dysrhymias but is not the immediate priority in this patient because the potassium level is near normal. Digibind, which is a digoxin-specific antibody, would be a reasonable treatment after the pacemaker or in a patient so severely toxic that he or she develops arrhythmias.

Topic:

Poisoning

Record # 7

Question/Fact:

A 64-year-old man presents to your office for his yearly physical. This is his first visit to your office, and he admits that he has not been to a physician in over a decade. He takes no medications and denies tobacco or alcohol use. He is a recently retired accountant and started "health walks" three times a week, for 45 minutes at a time. He has been keeping salt out of his diet, going to yoga classes, and trying to lose weight for the last six months. At a local mall, his blood pressure was read as 160/80 mm Hg at a free screening booth.

On physical examination, his weight is 80 kg (176 lbs), and he stands 58" tall. Blood pressure taken in the office is 154/88 mm Hg, heart rate is 74/min, and temperature is normal. The physical exam shows AV nicking on funduscopic evaluation. The EKG has normal sinus rhythm at 74/min with no ST changes. The following lab results are available:

Sodium 143 mEq/L, potassium 5.0 mEq/L, bicarbonate 24 mEq/L, BUN 10 mg/dL, creatinine 1.1 mg/dL, glucose 96 mg/dL; cholesterol (total) 210 mg/dL, HDL 50 mg/dL, triglycerides 180 mg/dL, LDL 124 mg/dL, VLDL 36 mg/dL. Urinalysis is normal.

What is the next appropriate step regarding the management of this patient?

(A) ACE inhibitor
(B) Atenolol and simvastatin
(C) Advise further lifestyle modification and recheck blood pressure in 4 to 6 weeks
(D) Hydrochlorothiazide
(E) Repeat the blood pressure

Answer:

(D) Hydrochlorothiazide

Explanation:

This patient has sufficient evidence to clinically define hypertension. Although there have only been two readings, he has physical evidence of long-standing hypertension in the AV nicking on the funduscopic examination. Repeating the blood pressure is not necessary.

For isolated systolic hypertension, first-line medical therapy would be a diuretic. He comes to you having already tried to alter his lifestyle in terms of exercise, sodium restriction, and weight loss for the last six months. Even though he has an elevated cholesterol, the mortality benefit of the diuretics far outweighs any concern about increasing his lipid levels with the thiazide. An ACE inhibitor is recommended as first-line therapy for patients with diabetes, congestive heart failure, or persons postmyocardial infarction with systolic dysfunction. Beta-blockers are currently recommended as first-line therapy for patients who are postmyocardial infarction or who have known coronary disease. Simvastatin is not necessary because the patient has an LDL of 45 years) and being a male with hypertension. Statins are used in patients with two or more risk factors if diet and exercise do not get the LDL under 130 mg/dL.

Topic:

Nephrology

Record # 8

Question/Fact:

A 42-year-old woman presents to the hospital with the sudden onset of shortness of breath associated with chest pain. The pain does not radiate and increases on inspiration. On physical examination, blood pressure is 110/80 mm Hg, pulse is 116/min, and respirations are 22/min. She is 125 pounds. An EKG reveals sinus tachycardia at 120 beats per minute, and the chest x-ray is normal. Baseline prothrombin time (PT) is 12 seconds, and the partial thromboplastin time (PTT) is 28 seconds. The patient is bolused with 5,000 units of heparin and then started on a drip of 1,000 units per hour. The V/Q scan gives a high probability for a pulmonary embolus.

Six hours later, the repeat PT is 12.5 seconds, and the PTT is 30 seconds. She is rebolused with 5,000 units of heparin, and the drip is raised to 1,100 units per hour. Six hours later, the PT is 12.4 seconds, and the PTT is 31 seconds.

What is the most likely reason for this scenario?

(A) Lupus anticoagulant
(B) Anticardiolipin antibodies
(C) Factor V mutation
(D) Antithrombin III deficiency
(E) Protein S deficiency

Answer:

(D) Antithrombin III deficiency

Explanation:

All of the disorders in the answer could account for thrombophilia (hypercoagulable state). The clue to this patient's diagnosis is the fact that she is unresponsive to heparin. There was no elevation of the PTT to the initial bolus of heparin, and no response to a rebolus or raising the rate of the drip. Heparin works through potentiating the effect of antithrombin on the clotting cascade. If there is a limited amount of antithrombin, the heparin will not work as effectively.

Lupus anticoagulant and anticardiolipin antibodies are two types of antiphospholipid syndromes that can cause thrombophilia. They give the opposite presentation. They start with an elevated PTT that can't be brought down with mixing the patient's plasma with normal plasma. Even a first episode of thrombosis with antithrombin III deficiency should be treated with lifelong coumadin.

Topic:

Hematology-Oncology

Record # 9

Question/Fact:

A 47-year-old man with a history of diabetes mellitus and a 40-pack-per-year smoking history presents to the emergency department at 6 A.M. with the acute onset of nausea, vomiting, and diaphoresis that woke him up from sleep. An EKG is done and shows ST elevation in leads II, III, and aVF. His vital signs are: temperature 98.5 F; pulse 72/min; respirations 22/min, and blood pressure 70/50 mm Hg. A Swan-Ganz (pulmonary artery) catheter is placed emergently. Which of the following readings would you expect to see?



Answer:



Explanation:

The patient has right ventricular failure secondary to a right ventricular infarction. The EKG shows ST elevation in the inferior leads. The inferior wall is supplied by the right coronary artery (in the majority of patients), which also supplies the right ventricle. Inferior-wall myocardial infarctions can be associated with a right-ventricular infarction in as many as 30 to 40% of patients. This results in the cardiac output and pulmonary capillary wedge pressure (PCWP) being decreased while the right atrial pressure is elevated. The best treatment is to give fluids until the blood pressure returns to normal. Choice C shows equal diastolic pressures in both sides of the heart, which is suggestive of cardiac tamponade or constrictive pericarditis.

Choice D shows a pulmonary artery diastolic pressure more than PCWP by more than 20 mm Hg. These findings, along with an elevated right atrial pressure, are diagnostic for pulmonary hypertension.

Choice E shows a low cardiac output with a high right atrial pressure and a high PCWP. These findings suggest biventricular failure with cardiogenic shock. Treatment involves diuretics, preload and afterload reducers, and possibly positive inotropic agents, if needed.

Choice A is consistent with sepsis with a low PCWP and increased cardiac output.

Topic:

Cardiology

Record # 10

Question/Fact:

A 36-year-old woman comes to the cardiology clinic with complaints of shortness of breath on minimal exertion, which has been getting progressively worse over the past seven months. Six months ago, she delivered twins. For the last month of pregnancy, she felt short of breath after walking one block and noticed mild ankle edema, which she attributed to the natural course of pregnancy. After delivery, these symptoms became progressively worse. Now she also describes nocturnal dyspnea and states that lately she uses at least three pillows to sleep and cannot lie down flat at all. This was her fourth pregnancy, and her past medical history is unremarkable. She is trying to be compliant with fluid restriction. Her medications at this time are carvedilol, lisinopril, and furosemide.

The patient presents as an obese female, who is mildly short of breath at rest. Physical examination findings are positive for distended jugular veins, the presence of an S3 gallop, and a III/VI systolic ejection murmur radiating to the axilla. There are mild crackles at both lung bases, as well as a 1+ lower extremity edema. Echocardiogram was done three months ago, and showed an ejection fraction of 27% and a moderately dilated left ventricle and left atrium.

What would be most effective way to improve this patient's prognosis?

(A) Increase dose of diuretics
(B) Add hydralazine
(C) Cardiac catheterization
(D) Myocardial biopsy
(E) Cardiac transplantation

Answer:

(E) Cardiac transplantation

Explanation:

This patient presents with peripartum cardiomyopathy. This is a left ventricular myocardial dysfunction that occurs during the third trimester of pregnancy and up to six months postpartum without a definitive cause. Mothers of older age with increased parity, a delivery of twins, malnutrition, toxemia, and hypertension are at increased risk. It occurs most commonly at two months postpartum. The incidence is 1:1,300 to 1:15,000 births. Lymphocytic myocarditis has been found in 30 to 50% of biopsy specimens, suggesting an immune component and possible cross-reactivity between uterine and cardiac myocyte proteins. The presentation is usually with orthopnea and exercise-induced dyspnea. Approximately 50% of patients recover spontaneously within the first six months, after which recovery is unlikely. Diuretics should be used to facilitate diuresis as needed. It is not known if therapy with ACE-inhibitors improves recovery. Patients who do not recover eventually have a dismal prognosis if they don't undergo cardiac transplantation. Transplantation is indicated in this case as the most definitive treatment option.

Cardiac catheterization would be a useful study if we suspected ischemia as a cause of heart failure. Myocardial biopsy can give us information about the absence or presence of myocarditis, but this would not change the management in terms of the need for transplantation. Cardiac transplantation still stays as the most definitive choice of treatment. The question specifically asks about an effect on prognosis. There is no benefit to adding hydralazine to a patient who is already on ACE inhibitors in any circumstance. This patient has had no improvement in her symptoms at all after six months. Although peripartum cardiomyopathy has a high degree of reversibility, if this patient had any chance of recovery, it would have already started. That is why the transplantation is necessary.

Topic:

Cardiology

Record # 11

Question/Fact:

What is the appropriate mode of colorectal cancer screening for the following case?

A 51-year-old -man with no family history of colon cancer and who is asymptomatic.

(A) Colonoscopy now and every 10 years
(B) Flexible sigmoidoscopy now and every 5 years
(C) Colonoscopy at age 50 and every 10 years
(D) Colonoscopy now and every 10 years
(E) Stool occult cards every year; colonoscopy if positive
(F) Colonoscopy at age 40 and every 5 years
(G) Colonoscopy in 3 years
(H) Colonoscopy in 1 year
(I) Colonoscopy every 1 to 2 years

Answer:

(A) Colonoscopy now and every 10 years

Explanation:

Colonoscopy is the preferred method of screening for colon cancer. Average-risk persons should undergo colonoscopy at age 50, and if normal, every 10 years. If a polyp is found, the colonoscopy should be repeated after 3 years. When there is a family history of colon cancer, screening should begin at age 40 or ten years prior to the age of the family member. The earlier date is respected. Follow-up examinations for persons with family histories of colon cancer should occur at 5-year intervals. When there are multiple family members, screening colonoscopy should be performed at age 25 and every 1 to 2 years (characteristic of persons with hereditary nonpolyposis colorectal cancer (Lynch syndrome). Colonoscopy is recommended 1 year after a hemicolectomy for colon cancer to verify the absence of recurrence and the presence of new lesions.

Topic:

Gastroenterology

Record # 12

Question/Fact:

A 69-year-old woman with a history of severe coronary artery disease and a permanent pacemaker for tachybrady syndrome is admitted for dyspnea secondary to congestive heart failure. Her medications include digoxin, amiodarone, metoprolol, and furosemide. While in the telemetry unit, she develops torsades de pointes. She is initially treated with magnesium, atropine, and potassium. Her resting heart rate now is in the 40s. However, she continues having intermittent runs of torsade. The QT interval is 610 milliseconds. What is the next step in treating this dysrhythmia?

(A) Increase the atrial rate of the pacemaker
(B) Isoproterenol
(C) Procainamide
(D) Change oral amiodarone to intravenous
(E) Defibrillation at 200 Joules (J)

Answer:

(A) Increase the atrial rate of the pacemaker

Explanation:

Torsades de pointes is defined as a polymorphic ventricular tachycardia in which the morphology of the QRS complexes vary from beat to beat, with the ventricular rate varying from 150 to 250 per minute. The QT interval is also markedly increased and is usually 600 milliseconds or greater. It occurs in nonsustained bursts. Women are more likely to have QT prolongation secondary to drug therapy. Acquired conditions that predispose toward torsades include hypomagnesemia, hypokalemia, classes IA and III drugs, and interactions between antihistamines and azole or macrolide antibiotics.

Acute treatment includes discontinuation of the offending agent, administration of magnesium, and increasing the resting heart rate with either atropine or overdrive pacing up to a rate of 140/min to prevent the ventricular pauses that allow torsades to originate. Speeding the heart rate with a pacemaker shortens the QT interval and effectively helps reverse the torsade. Isoproterenol is rarely indicated and is dangerous in patients with coronary artery disease because of the positive inotropic effect and an increase in myocardial oxygen consumption. Class IA drugs (e.g., procainamide) and class III drugs (e.g., amiodarone) are also contraindicated because they can prolong the QT interval. Torsades with hemodynamic compromise is an indication for electrical cardioversion.

Topic:

Cardiology

Record # 13

Question/Fact:

A 62-year-old man presents to the emergency department with complaints of fever, chills, nausea, and pain on urination. On admission the patient appears dehydrated. He has not been eating or drinking for the past few days because he fears urination. He has been having progressively worsening dysuria and rectal pain on defecation for the past week. He denies urinary hesitance or incontinence. He has a low-grade fever that started two days before admission. On examination, the patient is noted to have suprapubic tenderness. Rectal examination reveals severe tenderness with a diffusely enlarged and boggy prostate. The stool is brown and negative for occult blood. He has a temperature of 101.9 F. The urinalysis shows 2+ blood, 1+ protein, 3+ white cells, and is positive for nitrites. His white blood cell count is 18,000/mm3. What is most appropriate for this patient?

(A) Ampicillin and gentamicin
(B) Cystoscopy
(C) Gentle prostate massage
(D) Increase fluid intake and administer one week of oral trimethoprim/sulfamethoxazole
(E) Prostrate-specific antigen (PSA) level

Answer:

(A) Ampicillin and gentamicin

Explanation:

The goal of this question is to test your understanding of the diagnosis and treatment of acute bacterial prostatitis. The patient presents with the typical symptoms of acute prostatitis, which include fever, chills, dysuria, and rectal pain. He has also become dehydrated secondary to poor fluid intake. At this point, hospitalization with the prompt administration of intravenous fluid resuscitation, as well as parenteral therapy with ampicillin and an aminoglycoside, is indicated. This antibiotic regiment should be continued until sensitivity testing of the organism is available. The patient may be switched to oral antibiotic therapy if he remains afebrile for a period of 24 to 48 hours after the start of the intravenous antibiotics. Oral therapy may consist of trimethoprim/sulfamethoxazole or a quinolone for a full course of 4 to 6 weeks. However, this patient is so ill that intravenous therapy is more appropriate. Prostate massage or urinary tract instrumentation is contraindicated in acute bacterial prostatitis because it may induce septicemia, and the diagnosis already seems abundantly clear. Obtaining a prostrate-specific antigen (PSA) at this time is not indicated because of its propensity to be falsely elevated with an acute infection of the prostate. PSA would not change the initial management.

Topic:

Infectious Diseases

Record # 14

Question/Fact:

A 57-year-old woman presents to the clinic for a follow-up visit. She complains of swelling in her extremities and generalized headaches, which she has noted for the past few weeks. She also reports an elevated blood pressure during her last visit to her pharmacy, which has an automated blood-pressure machine. Her past medical history is significant for Addison's disease, atrophic gastritis, and hypercholesterolemia. Her current medications include prednisone 5 mg, simvastatin, and ranitidine. She was recently started on fludrocortisone acetate 0.3mg daily. The patient states that she has been compliant with her medications. Her blood pressure is 182/91mm Hg, temperature is 96.9 F, and pulse is 70/min. Laboratory studies show: white blood cell count 6,200/mm3, sodium l56 mEq/L, potassium 2.6 mEq/L, chloride 102 mEq/L, bicarbonate 28 mg/dL, BUN 16 mg/dL, creatinine 0.9 mg/dL, and glucose 80 mg/dL. Which of the following is the next best step in the management of this patient?

(A) Advise the patient to limit free water intake to one liter per day and to weigh herself daily
(B) Add stress-dose hydrocortisone to the current regiment of prednisone
(C) Decrease the dose of fludrocortisone
(D) Start spironolactone therapy
(E) Order a panel of thyroid function testing

Answer:

(C) Decrease the dose of fludrocortisone

Explanation:

Most patients with adrenal insufficiency will require some mineralcorticoid therapy in the form of fludrocortisone. Excess doses of fludrocortisone results in edema, hypertension, and hypokalemia. Postural hypotension, weight loss, and hyperkalemia are signs of inadequate mineralcorticoid replacement. In this question, the patient is described as suffering from hypertension and hypokalemia. Therefore, the most appropriate next step in the management of this patient is to reduce the dose of the mineralcorticoid.

Topic:

Endocrinology

Record # 15

Question/Fact:

A 24-year-old woman is being evaluated in the emergency room for occasional, self-resolving headaches. In the triage area, the patient has a continuous, generalized tonic-clonic seizure. According to her family, the patient has no prior history of a seizure disorder. The patient continues to be in tonic-clonic state. Her pulse is 118/min, with a blood pressure of 138/64 mm Hg and a normal temperature. The patient appears cyanotic, and she is intubated. She weighs 60 kg. The patient is given three milligrams of lorazepam intravenously but continues to have seizures. The medical resident physician orders the nurse to give another 3 mg of lorazepam, which has no effect. The patient continues to have seizures. What is next step in management?

(A) Lumbar puncture
(B) Antibiotics
(C) Additional doses of lorazepam until the seizures stop
(D) Intravenous fosphenytoin
(E) Intravenous phenobarbital

Answer:

(D) Intravenous fosphenytoin

Explanation:

Phenytoin is the standard of care in treating patients with status epilepticus who do not respond to initial therapy with benzodiazepines. If 6 mg of lorazepam was not effective, it is unlikely that more will help. There is no history of fever or neck stiffness that would make either the lumbar puncture or antibiotics useful. Phenobarbital would only be used if phenytoin were ineffective. Fosphenytoin has certain advantages when compared with standard phenytoin. Fosphenytoin is less often associated with hypotension or arrhythmias.

Topic:

Neurology

Record # 16

Question/Fact:

A 19-year-old Caribbean woman is admitted to the gynecology service because of an ectopic pregnancy. She has a history of bacterial endocarditis. She is allergic to penicillin. In addition to her left lower quadrant pain and fever, her physical exam is significant for a grade III/VI diastolic murmur. Blood pressure is 120/80 mm Hg. The EKG is normal, and the echocardiogram shows mitral stenosis with no visible vegetations. What is your recommendation for antibiotic prophylaxis prior to surgically removing the ectopic pregnancy?

(A) Vancomycin and gentamicin
(B) Amoxicillin
(C) Clindamycin
(D) Ampicillin and gentamicin
(E) No antibiotics indicated

Answer:

(E) No antibiotics indicated

Explanation:

This patient does not require endocarditis prophylaxis. Although both the murmur of mitral stenosis and the history of previous endocarditis would be indications for prophylaxis, it is not necessary to use prophylaxis in generally sterile surgical procedures. Preparation of the skin for surgery involves a local sterilization method that eliminates most organisms. This is done for catheterization procedures as well. Surgery and catheterization procedures do not shower the body with bacteria. You are only at increased risk for endocarditis if you have both a significant underlying cardiac defect, as well as undergoing a procedure that causes a bacteremia. Procedures that do not need prophylaxis are minor dental procedures, such as filling cavities and routine teeth cleaning; flexible endoscopies (neither bronchoscopy nor colonoscopy); vaginal delivery or caesarean section; cardiac catheterization; or pacemaker placement.



Topic:

Cardiology

Record # 17

Question/Fact:

A 31-year-old man was sent to your clinic by his dentist to be evaluated for gingival bleeding prior to tooth extraction. For the past two months the patient has been experiencing bleeding from his gums while brushing. He admits to several episodes of nosebleeds throughout his lifetime, which were somewhat severe and once required a visit to the emergency department. He denies melena, hematochezia, joint pain, or swelling. His father died at an early age of an unknown cause, and patient recalls that he also had nosebleeds.

His vitals in your office are stable. His physical examination is unremarkable. No petechiae or purpura are seen on the skin. The oral mucosa is normal. The spleen is not palpable, and there are no joint deformities.

Laboratory studies show the following:

WBC 6,200/mm3; hematocrit 38%; platelets 360,000/mm3; PT 11.6 seconds; PTT 48.0 seconds; INR 1.3.

Peripheral smear is normal, and bleeding time is mildly prolonged. The ristocetin cofactor activity is abnormal.

What would you do to make the dental extraction safe?

(A) Desmopressin
(B) No therapy
(C) Aminocaproic acid
(D) Factor VIII concentrate infusion
(E) Cryoprecipitate

Answer:

(A) Desmopressin

Explanation:

This patient presents with spontaneous mucosal bleeding and a history of epistaxis. He also has a family history of bleeding. The diagnosis of von Willebrand's disease (vWD) is based on the abnormal bleeding time with a normal platelet count. In vWD, the PT is always normal, but the PTT can be abnormal in approximately half of the cases. This is because the von Willebrand's factor stabilizes the factor VIII coagulant portion. Ristocetin acts as an artificial endothelial surface. It is abnormal when there is no von Willebrand's factor (vWF) for the platelets to bind to. Desmopressin is the treatment of choice. It increases the level of von Willebrand's factor two- to three-fold by causing the release of stored vWF. This patient most likely has type I, which is a quantitative decrease in vWF and which responds to desmopressin. It would not be safe to proceed without treatment given that he has a history of increased bleeding, which might be severe during the extraction.

Cryoprecipitate also contains vWF, but it is a pooled blood product and therefore has a risk of transmitting disease. It would only be appropriate if desmopressin and factor VIII concentrates were not effective. Factor VIII is sometimes used in those not responding to desmopressin. Remember, because factor VIII travels bound to vWF, it makes sense that you are giving vWF when you infuse factor VIII as well. Aminocaproic acid is an antifibrinolytic agent sometimes used in disseminated intravascular coagulation.

Topic:

Hemotology-Oncology

Record # 18

Question/Fact:

A 39-year-old woman presents to your office complaining of worsening fatigue and malaise over the past 4 weeks. She says that she came to your office today because she has noticed that her eyes have become yellow and yesterday her skin became very itchy. She denies any history of alcohol use. She takes no medications but was treated for a urinary tract infection 6 weeks ago with a 7-day course of nitrofurantoin. Her only other complaints are of some mild occasional arthralgias in the small joints of her hands. Vitals are remarkable for a low-grade fever, but blood pressure and pulse are normal. Physical examination is remarkable for icteric sclera. The liver is palpated 3 cm below the costal margin and is slightly tender. There is no splenomegaly. Laboratory tests reveal: WBC 12,100/mm3, hematocrit 39%, platelets 245,000/mm3, albumin 3.8 g/dL, PT 12.0 seconds, PTT 22.5 seconds, AST 762 U/L, ALT 846 U/L, alkaline phosphatase 194 U/L, and total bilirubin 5.9 mg/dL. ANA test is positive with a titer of 1:640. Serum gamma globulin is 5.9 g/dL, and testing for anti-hepatitis C virus (HCV) antibody is negative.. Testing for hepatitis-B surface antigen is also negative. She refuses liver biopsy. What is the best next step in the treatment of this patient?

(A) Prednisone and azathioprine
(B) Cyclosporine
(C) Methotrexate
(D) Liver transplant evaluation
(E) Interferon-alpha and ribavirin

Answer:

(A) Prednisone and azathioprine

Explanation:

This patient has autoimmune hepatitis. The ANA is positive, and she has an elevated serum gamma globulin. Onset of autoimmune hepatitis is often triggered by a recent viral illness, such as hepatitis A, Epstein-Barr, measles, or from exposure to drugs like nitrofurantoin, as seen in this case. The patient is icteric, as is reflected in her total bilirubin, and she has elevated transaminases. The patient was placed on the correct first-line therapy for autoimmune hepatitis, prednisone, and/or azathioprine, and she responded well. However, there is a very high rate of relapse (50-90%). Patients who fail this treatment may try cyclosporine or methotrexate, and patients who have further treatment failures are candidates for liver transplants. Disease may recur in the transplanted liver.

Topic:

Gastroenterology

Record # 19

Question/Fact:

A 32-year-old woman came to the hospital with complaints of recurrent syncope for the last five years. She had her last syncopal episode two hours ago, which lasted for several seconds and was associated with chest discomfort, palpitations, and diaphoresis. She has history of Graves' disease for three years and for which she was originally treated with propylthiouracil and maintained on propranolol. The patient claims that her father had a heart attack at the age of 78 and her mother died suddenly at the age of 42. Telemetry during the current hospitalization shows multiple episodes of nonsustained, polymorphic ventricular tachycardia (VT) with an undulating amplitude and a prolonged QT interval during which she experienced lightheadedness followed by syncope. What is the best management for this patient?

(A) Amiodarone
(B) Implantable cardioverter/defibrillator
(C) Stop propranolol
(D) Cervicothoracic sympathectomy
(E) Quinidine

Answer:

(B) Implantable cardioverter/defibrillator

Explanation:

Torsades de pointes refer to ventricular tachycardia (VT) that is characterized by polymorphic QRS complexes that change in amplitude and cycle length, giving the appearance of oscillations around the baseline. This rhythm is associated with QT prolongation. For patients with congenital, prolonged, QT-interval syndrome, beta-adrenergic blocking agents have been the mainstay of therapy. Implantable cardioverter/defibrillators (ICDs) with dual-chambered pacing capability have become the treatment of choice for patients with recurrent episodes despite beta-blockers. ICD devices have been developed that will promptly recognize and terminate life-threatening ventricular arrhythmias. Clinical trials testing the function of these devices in patients with drug-refractory ventricular arrhythmias have demonstrated survival from sudden death at 1 year ranging between 92 and 100%. Currently, ICDs should be considered for patients with VT that is not hemodynamically tolerated. This is either if the VT occurs spontaneously, resulting in syncope or sudden death, or at induction in the laboratory with the development of symptoms. ICDs are also useful for patients with spontaneous, sustained VT and depressed, left ventricular function. Sustained or nonsustained VT at electrophysiological study is an indication for ICD placement if there is evidence or coronary artery disease, left ventricular dysfunction, or a prior infarction. Cervicothoracic sympathectomy has been proposed as a form of therapy for congenital prolonged QT syndrome, but it is not often effective as the sole therapy. Some investigators have used pacing in combination with sympathectomy when beta-blockers fail, but it is not uniformly successful and can result in Horner's syndrome. Class IA agents such as quinidine may induce QT prolongation and so is contraindicated for patient with prolonged QT syndrome.

Topic:

Cardiology

Record # 20

Question/Fact:

A 52-year-old man presents to your office with shortness of breath, which has been progressively worsening, especially on exertion, over the past 6 months. He also awakens at night with shortness of breath and occasionally sleeps sitting up in a chair because of it. He denies chest pain, palpitations, diaphoresis, syncope, fever, cough, or night sweats. His past medical history is significant for hypertension, hypercholesterolemia, and childhood asthma. He has smoked one pack of cigarettes per day for the past 30 years and drinks 5 to 6, 8-ounce cans of beer each evening after work for the past 20 years. Current medications include atorvastatin 10 mg, hydrochlorothiazide 25 mg, and Tylenol occasionally for headaches. He denies any significant history of heart disease, diabetes, cancer, or renal disease.

The patient's blood pressure is 169/92 mm Hg, respiratory rate is 18/min, heart rate is 90/min, and there is no presence of fever. Physical examination reveals a moderately obese male, who is well developed and well nourished. Significant findings include xanthelasma, jugulovenous distention, bibasilar crackles on lung auscultation, and a grade III/VI systolic murmur at the apex. Chest x-ray reveals cardiomegaly and pulmonary vascular congestion. An in-office echocardiogram reveals an enlarged and diffusely hypokinetic left ventricle with an ejection fraction of 30 to 35% and moderate mitral regurgitation.

Which of the following statements is most accurate?

(A) The cause of this patient's condition has been linked to a hereditary syndrome.
(B) Cardiac auscultation is most likely to reveal a fourth heart sound.
(C) Stopping alcohol is the most important measure in the management of this patient.
(D) The role of chronic anticoagulation should be considered in this patient.
(E) Cardiac catheterization is indicated as the next step in the management of this patient.

Answer:

(C) Stopping alcohol is the most important measure in the management of this patient.

Explanation:

This patient presents with alcoholic cardiomyopathy. The most important measure in the management is to completely stop alcohol intake. Stopping alcohol will not only prevent further deterioration, but there may even be some regression of the heart disease.

A fourth heart sound is usually heard in hypertrophic cardiomyopathy. The S4 is caused by atrial systole against a noncompliant left ventricle. Chronic anticoagulation is used when there is evidence of cardiac thrombosis or systemic embolus. Cardiac catheterization is of limited value because the diagnosis is established from the history, physical examination, and echocardiogram. There is no history of ischemic heart disease to suggest that ischemia is the cause of the cardiomyopathy.

Topic:

Cardiology

Record # 21

Question/Fact:

A 26-year-old woman with bipolar disorder comes to your office feeling "fatigued and down" for the past month. She claims that she has been compliant with her lithium therapy for the past six months. She denies using alcohol, tobacco, or illicit drugs. She claims that she has been having trouble having bowel movements for a few weeks and that she has been using an over-the-counter fiber supplement. On examination, she has a temperature of 96.5 F, a heart rate of 60/min, and a blood pressure of 110/70 mm Hg. Her skin is dry, and there is minimal neck swelling. There are delayed deep-tendon reflexes in the knees bilaterally. Her white blood cell count is 6,500/mm3 with a hematocrit of 33%.



What is the best treatment for this patient?

(A) Stop the lithium and restart at a lower dose when the thyroid normalizes
(B) Switch lithium to valproic acid
(C) Add fluoxetine and a laxative and monitor the TSH level closely
(D) Add levothyroxine 50 μg/day and monitor symptoms and TSH level
(E) Start methimazole 30 mg/day until the symptoms abate

Answer:

(D) Add levothyroxine 50 μg/day and monitor symptoms and TSH level

Explanation:

In a patient who is placed on lithium for bipolar disorder, it is important to get baseline thyroid-function tests because of the effect lithium has on the thyroid itself. Lithium has been shown to cause a goiter in 15 to 20% of patients and hypothyroidism in 5% of patients. Lithium causes a defect in the biosynthesis of thyroid hormone. In a patient who develops hypothyroidism while on lithium, the proper step in management is to start levothyroxine at a therapeutic dose. Lithium can also cause a transient increase in parathyroid hormone levels, simulating hyperparathyroidism. These levels will return to normal after stopping the lithium.

Topic:

Endocrinology

Record # 22

Question/Fact:

A 27-year-old woman presents to the emergency department complaining of shortness of breath for the last few hours that is not related to exertion or body position. The patient states that she is 22 weeks pregnant and this is her first pregnancy. She has never had an episode like this before. She denies fever, cough, or chest pain. The patient appears tachypneic and in moderate distress. Her temperature is 100.9 F, heart rate is 120 mm Hg, and the blood pressure is 110/60 mm Hg, with a respiratory rate of 30/min. The lungs are clear to auscultation, and the heart examination is unremarkable. She has moderate edema of the lower extremities with the left slightly worse than the right. An arterial blood gas on room air shows: pH 7.51, pCO2 26 mm Hg, pO2 62 mm Hg, and 92% saturation. The EKG shows sinus tachycardia at a rate of 126/min with no ST-T abnormalities. The chest x-ray shows clear lungs fields bilaterally. What is the most appropriate test to confirm the diagnosis?

(A) V/Q scan
(B) Spiral CT
(C) Impedance plethysmography
(D) D-Dimers
(E) 125I fibrinogen scan

Answer:

(A) V/Q scan

Explanation:

The V/Q scan is the appropriate test to confirm the possibility of a pulmonary embolus, even in a pregnant woman. The radiation exposure to the fetus is minimal and far less than that of a spiral CT scan. Although impedance plethysmography has no radiation exposure, it is very limited in its sensitivity. D-Dimers are very nonspecific. The 125I fibrinogen scan is very rarely, if ever, used anymore. When you see it in a question, it is always wrong.

Topic:

Pulmonary

Record # 23

Question/Fact:

A 57-year-old man presents to your office with complaints of multiple episodes of severe, unilateral, periorbital headaches over the last two weeks, as well as right now. The patient states that these headaches last approximately one hour and usually occur at night. They wake him from sleep. Sometimes they are accompanied by nasal stuffiness and lacrimation. He denies nausea or vomiting. He noticed that occasional alcohol intake or emotional stress at work precipitates his headache. He tried a large dose of acetaminophen with no significant relief. The patient also complains of periodic episodes of squeezing chest pain after walking 4 to 5 blocks. There is no recent change in the character of the chest pain. His pulse is 72/min, and his blood pressure is 130/80 mm Hg. Physical examination reveals Horner's syndrome on the left side. Which of the following is the most appropriate management for his headache?

(A) Ibuprofen
(B) Prednisone
(C) Ergotamine
(D) Propranolol
(E) Sumatriptan

Answer:

(B) Prednisone

Explanation:

This patient presents with cluster headaches. Cluster headaches predominantly affect middle-aged men in a 10:1 male-to-female ratio. The cause is unclear but may be related to the disturbance of serotonergic mechanisms. There is often no family history of headache or migraine. Cluster headaches are characterized by multiple episodes in a single day for several weeks with pain-free intervals that usually last a year or longer. The pain peaks in a few minutes in cluster headache, whereas it takes several hours to peak in a migraine. They are often accompanied by ipsilateral nasal congestion, rhinorrhea, and Horner's syndrome. Spontaneous remission then occurs, and the patient remains well for weeks or months. Many patients report that alcohol triggers an attack. Others report that stress or ingestion of specific foods occasionally precipitates attacks. Physical examination reveals no abnormality, except Horner's syndrome, which either occurs transiently during an attack or remains residual between them. Treatment is often with dihydroergotamine (DHE) or sumatriptan. DHE can be used intravenously or intramuscularly, and it is effective within 5 to 30 minutes. Sumatriptan 6 mg subcutaneously relieves a headache in 15 minutes in 75% of patients. Because this patient most likely has a history of coronary artery disease, both DHE and sumatriptan are less desirable choices. Both of these can cause vasospasm and potentially worsen coronary disease. High-flow oxygen for 15 minutes may be also acutely effective.

Because large doses of acetaminophen were not effective in this patient, it is unlikely that ibuprofen will solve the problem. Prednisone can be used acutely to treat cluster headaches as well. Prednisone can be used like 100% oxygen as abortive therapy. Several agents can be used to prevent attacks such as lithium, verapamil, prednisone, and beta-blockers. None of them, except prednisone, can be used to treat acute attacks. Methylsergide is no longer used because it is associated with fibrosis of the pleura, pericardium, and retroperitoneal area.

Topic:

Neurology

Record # 24

Question/Fact:

A 55-year-old man comes in to your office complaining of diarrhea. He states that he has had a history of Crohn's disease for many years, and it has been particularly aggressive over the past two years. Five months ago, he underwent a small bowel resection (250 cm of bowel) for a severe relapse of Crohn's that was not responsive to medical therapy. Shortly after this past surgery, he states that he has been experiencing diarrhea. He has about five bowel movements per day and he describes them as bulky, light-colored, and foul-smelling. He describes a weight loss of 30 lb over the past five months with no change in appetite. He appears to be slightly wasted and has several superficial hematomas on the skin. Otherwise, the physical examination is unremarkable. Laboratory studies show: WBC 8,200/mm3, hemoglobulin 11.3 g/dL, hematocrit 33.7%, platelets 238,000/mm3, and a mean corpuscular volume 104 µm3. Chest x-ray shows clear lung fields. However, diffuse osteopenia is noted. Which of the following is the best way to treat this patient?

(A) Oral vitamin B12
(B) Oral vitamin B12 and oral vitamins A, D, E, and K
(C) Intramuscular (IM) vitamin B12 and oral vitamins A, D, E, and K
(D) IM vitamin B12 and vitamins A, D, E, and K
(E) IM vitamin B12, oral vitamins A, D, E, and K, and medium-chain triglycerides

Answer:

(E) IM vitamin B12, oral vitamins A, D, E, and K, and medium-chain triglycerides

Explanation:

This patient suffers from short bowel syndrome as a result of his small bowel resection. We can assume that during his surgery, much of the terminal ileum was resected because of the nature of his symptoms and laboratory findings. His macrocytic anemia suggests B12 deficiency, and his visible hematomas and osteopenia suggest deficiencies of vitamins K and D, respectively. Furthermore, the patient describes steatorrhea. All of these symptoms and signs are consistent with the loss of the terminal ileum because both B12 and bile salts are absorbed in the terminal ileum. This leads to B12 deficiency, and the loss of bile salts leads to fat malabsorption, steatorrhea, and with it, the malabsorption of fat-soluble vitamins. Because he lacks the ability to absorb enteric B12, it must be replaced intramuscularly. As for the fat-soluble vitamins, they may be given orally with supplemented medium-chain triglycerides, which do not require micellar solubilization.

Topic:

Gastroenterology

Record # 25

Question/Fact:

Patients undergoing chemotherapy with doxorubicin (adriamycin) can develop damage to the myocardium as the cumulative dose of the drug rises. There is an irreversible effect upon left-ventricular contractility and ejection fraction. Oncologists often have a critical decision to make between limiting the dose of the chemotherapeutic agent versus causing symptomatic congestive failure over time. What is the most accurate method of assessing the effect of the drug upon the patient?

(A) Transthoracic echocardiogram
(B) Transesophageal echocardiogram
(C) Left heart catheterization
(D) Right heart catheterization (Swan-Ganz)
(E) Nuclear ventriculogram (MUGA)

Answer:

(E) Nuclear ventriculogram (MUGA)

Explanation:

The most accurate method of assessing the ejection fraction is the nuclear ventriculogram, or MUGA scan. This technique assesses ejection fraction by determining how much of a nuclear isotope is ejected from the ventricle with each beat. It is not based on a two-dimensional, cross-sectional image and extrapolation, such as in the case of an echocardiogram or traditional contrast ventriculography by catheterization. Swan-Ganz catheters measure cardiac output, not the ejection fraction: It is the only method listed in the answer choices that doesn't actually measure ejection fraction at all.

Topic:

Cardiology

Record # 26

Question/Fact:

A 39-year-old Japanese man comes to your office after he has developed a festinating gait and poverty of voluntary movement. On physical examination, he has cogwheel rigidity of the limbs and a pill-rolling type of tremor at rest. His symptoms are moderate and do not interfere with his ability to dress himself or to care for himself in general. He started noticing these symptoms seven years ago, and they have been getting progressively worse. Over the past year, his face has become mask-like. An MRI and CT scan of the head show nothing abnormal. Which of the following would be appropriate for this patient?

(A) Levodopa
(B) Pramipexole or ropinirole
(C) Sinemet (carbidopa and levodopa)
(D) Benztropine (Cogentin)
(E) Amantadine

Answer:

(B) Pramipexole or ropinirole

Explanation:

This patient has the gait and movement abnormalities, tremor, and cogwheeling consistent with Parkinson's disease (PD). Patients who develop severe functional impairment that interferes with daily living should be treated with Sinemet (levodopa/carbidopa). Younger patients seem to be at higher risk of developing complications with long-term levodopa treatment, such as motor fluctuations, choreiform dyskinesias, and painful "on/off" dystonias. These complications are sometimes as disabling as the tremor and bradykinesia of the actual disease and may persist despite changes in the medications. The initial therapy as per current guidelines is to start with a dopamine agonist and add Sinemet later if dopamine agonists (such as pramipexole or ropinirole) at high doses don't improve function or if the patient can't tolerate the adverse effects of these medications. There is some evidence that dopamine agonists may have a protective effect upon neural tissue.

Tremor and drooling are common problems in PD that may respond particularly well to anticholinergics, such as benztropine or trihexyphenidyl. Anticholinergics are particularly useful when the patient is young and has mild parkinsonian symptoms. Amantadine is used in older patients with mild disease for tremor, rigidity, and bradykinesia. Older patients have a hard time tolerating the side effects of the anticholinergics, such as urinary retention and constipation. These adverse effects are less common with amantadine.

Fatigue may represent bradykinesia and may require levodopa or dopamine agonists, such as ropinirole, pergolide, or pramipexole. Bromocriptine is rarely used anymore because of a higher rate of adverse effects. These drugs are not as potent as levodopa, but they can be used in a younger patient to defer the need to start levodopa (therefore avoiding the adverse effects of levodopa). Dopamine agonists may be poorly tolerated in elderly patients with cognitive impairment. Selegiline, which is an MAO inhibitor, may slow down the progression of the disease. The early use of selegiline may delay the need for levodopa in patients with very mild PD. When administered as monotherapy, dopamine agonists have a very low risk of producing motor fluctuations or dyskinesias. After several years of treatment, the majority of patients may require a combination of both levodopa and a dopamine agonist. Levodopa is always used in combination with carbidopa to enhance its passage into the central nervous system.

Topic:

Neurology

Record # 27

Question/Fact:

A 44-year-old-man presents for evaluation of increased abdominal girth. There has been no fever, chills, weight loss, or abdominal pain. He has also noted increased lower-extremity edema. Physical examination reveals that he is mildly icteric. The abdomen is nontender, but tense ascites are noted. There is lower extremity edema, spider angioma, and palmar erythema. Laboratory analysis reveals: WBC 2,500/mm3, hematocrit 33%, platelets 77,000/mm3, sodium 123 mEq/L, albumin 2.2 g/dL, bilirubin 3.3 mg/dL, AST 121 U/L, and ALT 88 U/L. Which of the following statements regarding this patient is false?

(A) The patient has end-stage liver disease, Child's class C cirrhosis
(B) If the ascites albumin is greater than 1.1, a malignancy may exist
(C) The low platelet count is typically due to portal hypertension
(D) Viral hepatitis A, B, or C could have caused this problem
(E) The low sodium portends a poor prognosis

Answer:

(A) The patient has end-stage liver disease, Child's class C cirrhosis

Explanation:

The clinical picture is consistent with end-stage liver disease, Child's Class C cirrhosis (albumin less than 2.5 g/dL, tense ascites, etc.). The serum albumin minus the ascites albumin, if less than 1.1 typically means that a malignancy exists as the cause of the ascites. Portal hypertension from the cirrhosis typically leads to splenomegaly, platelet sequestration, and thrombocytopenia. Hyponatremia is a poor prognosticating sign in patients with end-stage liver disease. Hepatitis A does not cause end-stage liver disease.

Topic:

Gastroenterology

Record # 28

Question/Fact:

An 88-year-old man with a past history of hypertension and a previous myocardial infarction is admitted for syncope. His family says he was in a store and collapsed to the floor while looking at some books. He then proceeded to have a few jerking movements of both arms and legs, which disappeared spontaneously after a few seconds. A minute or so later, the patient awoke and could not recollect the event. He denies any chest pain, dizziness, or palpitations preceding the collapse. Current medications include aspirin, metoprolol, and hydrochlorothiazide. On examination, the blood pressure is 142/98 mm Hg, pulse is 65/min, and temperature is normal. His chest and abdomen are also normal. He has a 2/6 holosystolic murmur at the apex. An EKG shows a normal sinus rhythm at 62/min, with Q waves in leads V3-V6. There are no ST- or T-wave abnormalities. An echocardiogram shows segmental left ventricular systolic dysfunction and moderate mitral regurgitation. What is the most likely diagnosis for this patient's syncope?

(A) Neurocardiogenic (vasovagal)
(B) Paroxysmal ventricular tachycardia
(C) Orthostatic hypotension
(D) Tonic clonic seizure
(E) Hypovolemia

Answer:

(B) Paroxysmal ventricular tachycardia

Explanation:

Paroxysmal ventricular tachycardia is a relatively common cause of syncope, particularly in patients with structural heart disease. These tachycardias can be associated with an abrupt loss of consciousness without premonitory symptoms. More often than not, the patient is unaware of palpitations, and recovery following an episode is usually prompt and complete without residual neurologic or cardiac sequelae. The presence of pathological Q waves on the EKG, indicative of a prior infarction, is strongly associated with ventricular tachycardia as a cause of syncope in patients with ischemic heart disease. A few clonic jerks of the limbs and face are commonly seen in all forms of fainting. They may be difficult to differentiate from the tonic-clonic jerks of a generalized seizure.

Neurocardiogenic (vasovagal) syncope is commonly precipitated by emotional stress, fear, extreme fatigue, or pain. In its classic form, neurocardiogenic syncope is composed of hypotension, bradycardia, nausea, pallor, and diaphoresis. Orthostatic hypotension occurs in those with a chronic defect or instability of the vasomotor reflexes. The effect of posture is its cardinal feature. Sudden rising from a recumbent position or standing still are precipitating circumstances if there were no sudden changes in posture in this patient. Tonic-clonic seizures can be long lasting and can be associated with loss of bladder and bowel sphincter control, as well as tongue biting. Most commonly, generalized seizures are followed by a postictal state of confusion and sleepiness. The patient described in this question has a rapid recovery of full consciousness, which is not consistent with a seizure.

Hypovolemia can be caused by an acute hemorrhage of the gastrointestinal tract. In the absence of pain and hematemesis, the cause of weakness, faintness, or even unconsciousness may remain obscure until the passage of a black stool. There is nothing in this case to suggest hypovolemia. He has a slow pulse and no evidence of sudden blood or volume loss.

Topic:

Cardiology

Record # 29

Question/Fact:

A 56-year-old woman comes to the clinic with pain in the wrists, knees, and fingers for several weeks. She has been taking ibuprofen for these symptoms. She has also begun noticing that she is unable to withstand staying out in the sun because the light bothers her eyes and she develops a rash on her cheeks. She has recently been found to have a reactive PPD skin test, and she was started on isoniazid several months ago. She has hypertension, diabetes, and gout. Her medications are metoprolol, metformin, and allopurinol. There has been no recent change in these medications. The physical examination shows a blood pressure of 129/84 mm Hg, a temperature of 37.0 F, and the rash on her face. Which of the following is most appropriate action?

(A) Change her pain medications
(B) Change her antigout medication
(C) Change her antituberculosis medications
(D) Corticosteroids

Answer:

(C) Change her antituberculosis medications

Explanation:

This patient most likely has drug-induced SLE. The most likely cause is her isoniazid. Lupus is definitely associated with isoniazid, chlorpromazine, methyldopa, hydralazine, procainamide, interferon, and quinidine. Although this patient has clinical manifestations, many patients simply develop a positive ANA test without symptoms. The treatment is to remove the offending agent. There are four features of drug-induced SLE that are different from idiopathic SLE. In drug-induced lupus, the sex ratio is nearly equal, whereas in idiopathic SLE, women are affected much more commonly. Nephritis and neurological features are not usually present, complement levels are normal, and anti-DNA antibodies are absent. The clinical and laboratory findings usually revert to normal when the offending agent is removed.

Topic:

Rheumatology

Record # 30

Question/Fact:

You are asked to see a 68-year-old white male in the intensive care unit who was admitted the previous night from a nursing home. He has increasing dyspnea, a fever, and leukocytosis. He was found to have a right lower lobe infiltrate on chest x-ray. He developed respiratory distress shortly after arrival to the emergency department and required mechanical ventilatory support. A left subclavian central venous line was placed. Two sets of blood cultures grew gram-negative rods. The patient was started on piperacillin/tazobactam 3.375 g intravenously every 6 hours. The ICU resident shows you multiple 2- to 3-cm ecchymosed areas on the upper and lower extremities. The patient is on the ventilator and is unresponsive to questions. The vital signs when you see him are: temperature 100 F, heart rate 110/min, respiratory rate 16/min, and blood pressure 100/60 mm Hg. When the patient was admitted, his hemoglobin was 10 g/dL, and the hematocrit was 30%.

Today's labs were drawn and are as follows:

WBC 15,000/mm3; hematocrit 27%; platelets 80,000/mm3
Differential: 90% neutrophils, 5% lymphocytes, and 5% monocytes
PT 25 seconds (control 11 to 14 seconds), PTT 50 seconds (control, 25 to 35 seconds)
Fibrinogen level is
 
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* Re:some helpfull notes
#2295816
  sami2004 - 12/22/10 15:58
 
  1. Upper gastrointestinal endoscopy is the diagnostic study of choice when a patient presents with acute alkali ingestion.
2. Quantitative CT of the spine is the most sensitive diagnostic test for osteopenia but it is not a gold standard because of its poor reproducibility. The test of choice in most settings is dual-energy X-ray absorptiometry of spine
3. Despite of other risks, HRT is still the best form of therapy for osteoporosis in postmenopausal women
4. Pap smear: If 3 consecutive pap smears are normal, screening may be performed less frequently (every three years) in a low-risk patient. Screening is usually started at 18 and stopped at 60-75 years.
5. If a woman has undergone a hysterectomy for cancer or cervical dysplasia she needs yearly Pap smear screening of the vaginal epithelium and inspection of the vulvar and perianal epithelium.
6. Learn the Hepatitis-B prevention. Know when to give vaccine and when to give HBIG. If someone is exposed to HBV and has a documented response to HBV vaccination, he does not need anything else but reassurance
7. Human studies have demonstrated a significant association between type A personality and exaggerated cardiovascular response.
8. Pneumococcal vaccine contains capsular polysaccharides and it produces T cell independent B cell response
9. Racemic epinephrine decreases the need for intubation in patients with croup and should always be tried before any invasive procedure
10. Adolescent onset of hirsutism and virilism, with normal menstruations and elevated 17-hydroxyprogesterone, are diagnostic of congenital adrenal hyperplasia

11. Spontaneous hemarthrosis raises the suspicion for hemophilia for which factor VIII assay is diagnostic
12. Decreased tympanic membrane mobility is specific for the diagnosis of acute otitis media.
13. Tetralogy of Fallot, the most common cyanotic congenital disease in children of less than 4 years of age, presents with cyanotic spells and pansystolic murmur on examination.
14. Neonatal sepsis is suspected when a baby develops jaundice after the 3rd day and within the first week, especially if he is feeding poorly and lethargic; work-up with blood cultures and lumbar puncture is the next step.
15. Rubella is characterized by low-grade fever, lymphadenopathy (sub-occipital and posterior auricular) and rash
16. The prodrome of measles may show Koplik sign, a pathognomonic finding, which appears as bluish white lesions on the erythematous buccal mucosa opposite to the first and second upper molars, and sometimes on the inner conjunctivae and vaginal mucosa.
17. An epiglottis rolling in from side to side is the diagnostic finding of laryngomalacia, and all such babies should be fed in the upright position.
18. Bedwetting is a normal phenomenon until the age of 5.
19. Severe dehydration in a neonate in the presence of hyponatremia, hyperkalemia, hypoglycemia and metabolic acidosis suggests the diagnosis of congenital adrenal hyperplasia.


20. First step in the management of an infant with suspected congenital diaphragmatic hernia is the placement of orogastric tube.
21. Kawasaki’s disease is a disease of blood vessel walls leading to aneurysm formation. It is usually self-limited though it can be fatal because of aneurysm formation, thrombosis or rupture of the coronary arteries, leading to myocardial infarction.
22. Moderate to severe degree of slipped capital femoral epiphysis requires surgery
23. Ileo-ileal intussusceptions, which may be caused by Henoch-Schonlein purpura, require surgical reduction.
24. Friedreich Ataxia is an autosomal recessive condition and genetic counseling is recommended for prenatal diagnosis for parents with one affected child.
25. Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which may be complicated by Volkmann’s ischemic contracture
26. Fragile X syndrome is characterized by low to normal IQ with learning disabilities, generalized language disability, short attention span, autism, large head, prominent jaw, large low set ears and macroorchidism.
27. Meningitis may be complicated by regression of developmental milestones
28. Cerebral anoxia is the most common cause of cerebral palsy
29. Fetal alcohol syndrome is characterized by irritability, mild to moderate mental retardation, hypoplastic maxilla, long philtrum, thin upper lip border, and microcephaly
30. Deficiency of sphingomyelinase causes Niemann-Pick's disease, which is characterized by cherry red macula, protruding abdomen, hepatosplenomegaly, lymphadenopathy, and regression of developmental milestones.

31. Bed rest with hip joint in the position of comfort is the treatment of choice for transient synovitis of the hip
32. Arthrocentesis and empiric treatment with IV nafcillin are the most appropriate measures for the management of suspected septic arthritis in a child
33. Aspirin therapy with monitoring of liver enzymes are the mainstay of the treatment of systemic juvenile rheumatoid arthritis
34. Presence of dermatitis herpetiformis and chronic non-bloody diarrhea in a child of 12-15 months, suggests the diagnosis of celiac disease
35. Positive anti-Smith antibodies and/or anti-double stranded DNA antibodies is specific and confirmatory for the diagnosis of systemic lupus erythematosus
36. Duodenal atresia presents with bilious vomiting, and its typical radiographic finding is the ‘double bubble sign’
37. Sudden onset of respiratory distress may be caused by foreign body aspiration, and rigid bronchoscopy is the procedure of choice, both for diagnostic and therapeutic purposes
38. Recurrent self-limiting episodes of vomiting and nausea in children, in the absence of any apparent cause, suggest the diagnosis of cyclical vomiting.
39. The 24-hour esophageal pH monitoring is the gold standard for the diagnosis of gastroesophageal reflux disease
40. Mast cell stabilizers are the drugs of choice for asthmatic patients who also have evidence of other allergic disorders


41. Increased gastric residues in a preterm neonate are highly suspicious for necrotizing enterocolitis.
42. Unilateral flank mass in a child more than 3 years is most likely due to Wilm’s tumor, which arises from the metanephros.
43. Nodular swellings in the irises of patients with neurofibromatosis are hamartomas.
44. The investigation of choice, for the diagnosis as well as the follow-up, in cases of Sturge-Weber syndrome is CT scan of the head. The cerebral lesions in Sturge-Weber syndrome are histologically similar to the facial lesions.
45. Turner's syndrome with 46 XY karyotype is associated with a higher incidence of gonadoblastoma, and hence, prophylactic bilateral gonadectomy is indicated.
46. Revise the management of hyponatremia from SIADH.
Mild (asymptomatic with sodium 120-130 meq/L) = Fluid restriction
Moderate (asymptomatic with sodium 110-120 meq/L) = Loop diuretic + normal saline
Severe (symptomatic) = hypertonic saline
47. NSAIDs can cause SIADH, which results in euvolemic, hypotonic, hyponatremia
48. Radioactive Iodine is the treatment of choice for Grave’s disease
49. Propylthiouracil can cause agranulocytosis, which should be suspected in patients presenting with sore throat and fever while on the drug
50. Hashimoto’s may rarely cause hyperthyroidism but the radioactive Iodine uptake is low thus distinguishing it from Grave’s disease


51. Indication for parathyroidectomy in asymptomatic patients with hyperparathyroidism are S. calcium 1 mg/dL above upper limit with urine calcium excretion over 50mg/24hr, urine calcium excretion over 400mg/24hr, cortical bone density more than 2SD below normal, under age 50-60, pregnancy, follow up difficulty.
52. Primary adrenocortical deficiency is associated with hyperpigmentation of the skin due to increased levels of ACTH that helps to differentiate from secondary adrenal insufficiency, which is due to pituitary failure.
53.
When Addison’ s disease is suspected clinically, the short cosyntropin (ACTH) stimulation test is performed to make a diagnosis
54. Failure to suppress 24-hour urine cortisol level following high dose dexamethasone suppression test suggests ectopic ACTH production rather than Cushing’s syndrome.

55. Know how to differentiate between primary and secondary hyperaldosteronism. Plasma rennin activity is low in primary hyperaldosteronism and is high in secondary hyperaldosteronism
56. Suspect DKA in stuperous patients with rapid breathing and history of weight loss, polydypsia and polyuria.
57. The single best screening test for virilizing neoplasm is to obtain serum testosterone and DHEA
58. Know the importance of fluid replacement in the treatment of acute hypercalcemia. Loop diuretics are indicated only after adequate rehydration.
59. Dehydration in Diabetes insipidus is managed with isotonic saline until the volume deficit is restored
60. Know that detection of microalbuminuria is the best screening test for diabetic nephropathy
61. Management of DKA includes restoration of intravascular volume with normal saline and correction of ketosis with regular insulin
62. In non-ketotic hyperglycemic hyperosmolar coma: ketones are not found in the serum; blood glucose levels are very high (greater than 600 mg/dl); there is no acidosis; anion gap is not elevated and serum bicarbonate level is either normal or mildly decreased; neurological manifestations including coma are often present; serum osmolality is greater than 310 mOsm/kg
63. Fluid replacement is the most important step in the management of non-ketotic hyperglycemic coma
64. Waning of insulin dose results in hyperglycemia at 3 AM and 7 AM whereas in Dawn phenomena the hyperglycemia occurs only at 7 AM.
65. Insulinomas secrete excessive amounts of insulin, C peptide, and pro insulin
66. Arterial pH or anion gap is the most reliable indicator of metabolic recovery in patients with diabetic ketoacidosis
67. Know the management of diabetic nephropathy. Protein restriction to 0.8 g/kg of body weight has a beneficial effect on the course of diabetic nephropathy.
68.
Thyroiditis is associated with hyperthyroidism and low radioactive Iodine uptake
69. In the management of type 2 diabetes mellitus, if one oral hypoglycemic agent becomes ineffective then often another agent from a different group is added to achieve better glycemic control.

70. Treatment of choice for streptococcal pharyngitis is single injection of IM Benzathine penicillin G.


71. TMJ syndrome often presents with unilateral and chronic pain in the muscles of mastication. Pain is described as a dull ache worsened by chewing. Recognise the radiation to the ear, jaw, and posterior cervical region.

72. Know the clinical features and management of peritonsillar abscess or quinsy, which is a suppurative complication of acute tonsillitis
• Contralateral deviation of the uvula
• Throat pain markedly more severe on the affected side and occasionally referred to the ipsilateral ear.
• Exudates on the tonsil AND Erythema of the tonsil



73. Fibreoptic laryngoscopy establishes the diagnosis of epiglottitis but it must be performed in the operating room with preparations already made to perform endotracheal intubation
74. While breaking bad news, physicians have to begin with an appropriate initial sentence, which would help the patient feel at ease
75. D-xylose absorption is abnormal both in bacterial overgrowth and Whipple’s disease. However, with bacterial overgrowth, the test becomes normal after antibiotic treatment.
76. When a motility disorder of esophagus is suggested by contrast studies, the next step is usually esophagoscopy to exclude mechanical causes of dysphagia like stricture or esophageal cancer
77
Esophagoscopy is indicated when a patient with gastroesophageal reflux disease (GERD) fails to respond to empiric treatment or when patient has features of complicated disease.

78. Hepatitis B virus immune globulin plus lamivudine treatment is the most effective treatment to prevent recurrent HBV infection after liver transplantation.
79. When diarrhea caused by clostridium difficile is severe, administration of metronidazole is also needed along with discontinuation of the offending antibiotic
80. Increased intragastric pressure during vomiting could cause tears in the mucosa of the cardia and sometimes of the distal esophagus- called Mallory-Weiss tears.
81. CT scan is the best test for the diagnosis of diverticulitis in acute setting
82. Fulminant colitis is a serious complication of ulcerative colitis and plain radiography shows distended colon. Proctosigmoidoscopy with biopsy establishes the diagnosis of ulcerative colitis and it can be performed in acute settings.
83. Always suspect Crohn’s disease as a cause for chronic diarrhea in a young patient
84. Migratory thrombophlebitis and atypical venous thromboses are suggestive for chronic DIC, most probably due to some visceral malignancy.
85. Abdominal CT scan is the next diagnostic test when abdominal ultrasound does not explain cholestatic jaundice
86. Gastro-intestinal (GI) blood loss without GI complaints in an elderly patient is most probably caused by colon cancer and needs a colonloscopy
87. Recurrent peptic ulcers with hypercalcemia are best explained by MEN type 1
88. Barium swallow is the initial test of choice for all patients with dysphagia
89. Manometry establishes the diagnosis of diffuse esophageal spasm
90. Recognize Zenker’s diverticulum. Barium esophagogram is the investigation of choice for confirmation


91. Know how to manage severe
symptomatic bradycardia. IV atropine is usually the first step.

92. Recognize the hemodynamic features of mediastinal hemorrhage and know how to differentiate it from pericardial tamponade
93. Recognize mesenteric arterial stenosis in a patient that presents with abdominal angina
94. 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.
95. Think of PE in a postoperative patient with JVD and new onset RBBB.
96
. Recognize the classic presentation of a tension pneumothorax. Remember the hypotension shortness of breath jugular venous distension and decreased breath sounds

97. Recognize the clinical presentation of pulmonary edema. Iatrogenic fluid overload is one of the common causes of pulmonary edema in perioperative patients
98. MI is one of the differential diagnoses of acute abdominal pain and should be ruled out in patients with risk factors.
99.
Learn the clinical presentation of mesenteric artery thrombosis.Always consider abdominal angina in a patient with risk factors for atherosclerotic vascular disease. Postprandial pain typically shortly after 20-30 mins Pain Last 60- 90 mins. Wt loss because fear of food might cause pain. Abdo pain and blood in stool. Sudden onset. Tx. Laparotomy and prophylaxis antibiotics.



100. Antihypertensive management should be the first step in patients with aortic dissection with hypertension
101. Thiazide diuretics are the initial antihypertensive of choice in patients with osteoporosis.
102. Learn how to differentiate ischemic angina from aortic stenosis angina. Echocardiogram should be the next step in suspected AS.
103. Know the natural history and complications of Marfan's syndrome in pregnancy. Every woman with Marfan’s syndrome who is contemplating pregnancy must be screened by echocardiography to determine the size of her aortic root.
104. Know how to recognize and treat right ventricular infarction. IV NS to increase the outflow from right ventricle should be considered in these patients
105. Sudden onset of shortness of breath (SOB), bibasilar rales, and an 'apical' murmur radiating to the axilla are quite characteristic of new onset mitral regurgitation. Papillary muscle dysfunction, or rupture, is the most common cause of MR in this setting
106. Choose the appropriate initial antihypertensive therapy in a patient with asthma. HCTZ is the initial drug of choice in patients with chronic persistent asthma
107. IV adenosine is the drug of choice for paroxysmal SVT. Know how to recognize the rhythm on ECG
108. Any patient who presents with sudden onset of chest pain, SOB, and has evidence of hypoxia and the new onset right bundle branch block should be considered as having a PE until proven otherwise. Therefore, the next best step from the choices offered is to get a V/Q scan
109. IV nafcillin is the treatment of choice for cellulitis with systemic signs.
110. Lithium precipitates and exacerbates psoriasis which is characterized by sharply defined erythematous areas with whitish, silvery and scaly plaques
111. Look for electrolyte abnormalities and correct them in patients with arrhythmias
112. Know how to differentiate between primary hyperparathyroidism and familial hypocalciuric hypercalcemia in a patient with increased serum calcium, decreased serum phosphorus, and increased PTH levels. Calcium excretion is decreased in familial hypocalciuric hypercalcemia and is normal or elevated in primary hyperparathyroidism
113. In a patient with hypochloremic metabolic alkalosis due to gastric outlet obstruction, potassium is usually low and needs to be supplemented
114. Parathyroidectomy is the only effective treatment for primary hyperparathyroidism
115. Plummer-Vinson syndrome is characterized by atrophic glossitis, stomatitis, and upper esophageal webs associated with iron-deficiency anemia. Usually these webs don’t regress with conservative treatment and require dilatation
116. Paracentesis provides useful diagnostic information in patients with ascites
117. Slow tapping of ascitic fluid balanced with infusion of albumin per liter tapped, is the final conservative measure for the treatment of acsites secondary to cirrhosis that has to be attempted before surgery.
118. Hypotension, hyponatremia, azotemia, and oliguria with normal urinalysis in a patient with severe liver disease are suggestive of hepato-renal syndrome. Measures are taken to withhold all possible precipitating factors and initial management includes careful volume load.
119. Patients with carcinoid syndrome are at risk of developing niacin deficiency owing to increased formation of serotonin from tryptophan.
120. Varicoceles that fails to empty when the patient is recumbent raises the suspicion for renal cell carcinoma for which abdominal CT scan is the investigation of choice.

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121. Suspect medullary cystic disease in adults with recurrent UTI or renal stones and contrast filled cysts demonstrated by IVP
122. Know the different causes of nephrotic syndrome and their likelihood in a given patient. Focal segmental glomerulosclerosis (FSGS) is the most common cause of nephrotic syndrome in African American adults. It also occurs in patients with HIV and IV drug abuse.
123. Indications for dialysis includes uremic symptoms such as pericarditis, encephalopathy, coagulopathy, and fluid overload unresponsive to diuresis, hyperkalemia not amenable to standard therapy, and pH less than 7.20
124. Know the factors that have been shown to delay the progression of chronic renal disease. Protein restriction and use of ACE inhibitors are two such factors.
125. Acute pyelonephritis presents with fever, chills, flank pain, pyuria, and bacteriuria. CVA tenderness may be present. Sometimes WBC casts may be seen.
126. Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic evaluation is not needed when a patient presents with their first renal stone.
127. Colicky flank pain with radiation to groin indicates renal colic. Small bowel disease such as surgical resection or chronic diarrhea, leading to the malabsorption of fatty acids and bile salts can predispose calcium oxalate stones
128. Know the differential diagnosis of microscopic hematuria, and know to differentiate myoglobinuria from hematuria. Alcoholism can cause rhabdomyolysis; the resulting myoglobinuria causes a positive dipstick analysis for blood and a negative microscopic examination for RBC‘s.
129. IgA nephropathy is the most common cause of glomerulonephritis in adults. Suspect IgA nephropathy in patients with gross hematuria associated with upper respiratory infection, GI symptoms, or flu-like illness
130. Any patient with recurrent sinusitis, cavitary lung lesions, pulmonary hemorrhages and glomerulonephritis will most likely have Wegener’s glomerulonephritis
131. The common presentation of cryoglobulinemia includes palpable purpura, glomerulonephritis, non-specific systemic symptoms, arthralgias, hepatosplenomegaly, peripheral neuropathy, and hypocomplementemia. Most of these patients have evidence of Hepatitis C.
132. Suspect Alport’s syndrome in patients with recurrent episodes of hematuria, sensorineural deafness and family history of renal failure.
133. Oral trimethoprim-sulfamethoxazole is the preferred empiric treatment for acute uncomplicated cystitis.
134. When isolated proteinuria occurs, the evaluation of the patient should begin by testing the urine on at least two other occasions
135. Chlamydial urethritis is suggested by the presence of mucopurulent urethral discharge, sexual history with multiple partners, and absence of bacteriuria on urinalysis
136. Patients with prostatodynia are afebrile and have irritative voiding symptoms. Expressed prostatic secretions show normal number of leukocytes and culture of these secretions is negative for bacteria.
137. Ultrasound or other imaging techniques should be done in patients with pyelonephritis whose symptoms do not respond 48 -72 hours after appropriate antibiotics
138. 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.
139. Know how to recognize and treat nonbacterial prostatitis. Rule out bladder cancer in all elderly patients with irritative voiding symptoms and have negative urine culture.
140. Acute post streptococcal glomerulonephritis occurs 10-20 days after streptococcal throat or skin infection. It presents with hematuria, hypertension, red cell casts, and mild proteinuria.
141. Renal vein thrombosis is an important complication of nephrotic syndrome, which is the most commonly caused by membranous glomerulonephritis in adults.
142. 70% of cases with interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAID’s, Rifampin, phenytoin, and allopurinol. Discontinuing the offending drug is the treatment of drug-induced interstitial nephritis.
143. Patients with nephrotic syndrome are at increased risk for developing hypercholesterolemia, hypertriglyceridemia, and hypercoagulable state.
144. Acalculous cholecystitis occurs in critically ill patients and imaging studies show diagnostic findings of thickening of the gall bladder wall and presence of pericholecystic fluid.
145. 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
146. Accidental ingestion of battery into esophagus warrants its immediate removal.
147. Warfarin induced skin necrosis is a complication seen in patients with protein C or S deficiency especially when it is started in high doses without heparin coverage
148. Gentamicin causes vestibular toxicity
149. Spherocytosis is due to RBC membrane defect mostly from spectrin deficiency
150. Aortic dissection is an acute emergency and its medical management includes prompt blood pressure lowering with IV nitroprusside and short-acting beta-blocker.
151. Vitamin A and its derivatives taken in large doses can lead to pseudotumor cerebri as a complication. The presentaion includes headache, nausea, vomiting, papilledema, and elevated CSF opening pressures, which is characteristic of pseudotumor cerebri.
152. Patients who are on high doses of vitamin D and calcium should have a close eye on serum calcium levels. Signs of toxicity include nause, vomiting, constipation, polyuria, and mental status changes.
153. 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
154. Hypercarotenemia is commonly seen in patients with anorexia, diabetes & hypothyroidism.
155. Excessive use of vitamin C in patients with renal insuffiency can cause oxalate stones
156. 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).
157. Patients who eat heated food all the time, such as toast and tea are more likley to develop folic acid deficiency.
158. Vitamin K deficiency is usually manifested by prolonged PT, normal platelet count and normal bleeding time. PTT is variable.
159. Vitamin B 12 deficiency: Subacute combined degeneration of the dorsal and lateral spinal columns is the classic neurologic manifestation. Symmetrical neuropathy, ataxia with loss of vibration and position sense is the clinical clues.
160. Penile fracture is a medical emergency and needs prompt surgical repair, but it should always be preceded by retrograde urethrogram to rule out urethral injury which is very common with penile fracture
161. Removal of impacted esophageal foreign body is mandatory
162. Pressure sores are common over the sacrum, heels and hips. Frequent turning of the patient is the only best method to prevent these
163. 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
164. 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.
165. Rapid cooling of the patent is the cornerstone of management of heat stroke and should be done in adjunction of stabilizing treatment. Evaporation cooling is the preferred modality.
166. Think of Conversion disorder in a female patient with sudden onset neurological symptoms preceded by an obvious stressor. The treatment of choice would be Psychotherapy
167. Zinc deficiency is associated with alopecia, mental changes, diarrhea, and dysgeusia, smell abnormalities, maculopapular rash around the mouth and eyes, and impaired wound healing.
168. Severe, excruciating pain should be treated with IV opioids even if the patient has a history of drug abuse
169. Lithium toxicity presents with tremulousness, headache, confusion, GI distress, fatigue and, in extreme cases, with seizures, coma, hyperreflexia and opisthotonus
170. Hypothyroidism should always be considered in patients with an unexplained elevation of serum CK concentration and myopathy.
171. For frostbite injuries, the best treatment is rapid re-warming with warm water. Whenever frostbite or cold injuries are diagnosed, no attempt should be made to débride any tissue initially. Rapid re-warming with dry heat (like a fan) is not effective for frostbite.
172. Beta blockers decrease the risk of perioperative myocardial infarction, and thus do decrease mortality in perioperative patients with vascular disease undergoing noncardiac surgery. Beta 1 selective agents are the drugs of choice for this purpose.
173. Wiskott Aldrich syndrome is one of the immunodeficiency syndromes, characterized by recurrent pyogenic infections, atopic eczema and thrombocytopenia. IgM levels will be decreased, but IgA, & IgG will be within normal limits
174. In a HIV patient, bilateral interstitial pneumonia is most likley due to Pneumocystis carinii infection.
175. Flumazenil, a benzodiazepine antagonist, is antidote for acute benzodiazepine intoxication.
176. Glucagon is used to treat beta-blocker toxicity
177. Mucormycosis requires aggressive surgical debridement plus early systemic chemotherapy with amphotericin B.
178. Association of diabetes mellitus and Mucor-mycosis is frequently tested in the examination.
179. Empiric antibiotic therapy with either ceftazidime or cefepime should be started in febrile neutropenic patients
180. Invasive aspergillosis occurs in immunocompromised patients like those with neutropenia, those who are taking cytotoxic drugs like cyclosporine or those who are taking very high doses of glucocorticoids. Invasive pulmonary disease presents with fever, cough, dyspnea or hemoptysis. Chest x-ray may show cavitary lesion. CT scan shows pulmonary nodules with halo sign or lesions with air crescent.
181. Treatment of disseminated Histoplasmosis in HIV patients is IV amphotericin B followed by lifelong treatment with itraconazole
182. Lymphocutaneous Sporotrichosis is the most common form and presents with painless papule at the site of inoculation which later on ulcerates.
183. Always remember Blastomycosis is big-based budding yeast. Blastomycosis is endemic in south central and north central USA.
184. Know the epidemiology of the fungal infections. Patient from Arizona should make you think of Coccidioidomycosis
185. Whenever there is suspicion of HSV encephalitis, IV acyclovir should be started without delay
186. Always suspect Infectious mononucleosis in a young patient presenting with sore throat and nonspecific spectrum of symptoms. Recognise the role of steroids in treating complications.
187. In both infants and children, Staphylococcus aureus is the most common organism responsible for osteomyelitis.
188. S. Epidermidis is a frequent cause of osteomyelitis associated with prosthetic devices.
189. Gram-negative rods like Klebsiella or Pseudomonas cause osteomyelitis when patients have a history of urinary tract infection (UTI) or urinary instrumentation
190. Three phase technetium scan is the test of choice for acute osteomyelitis and it is very sensitive.
191. Learn the clinical presentation, pattern of organ involvement and the complications in a case of mumps. Orchitis is one of the most frequent complications of mumps in adults.
192. Always consider the risk of splenic rupture in case of infectious mononucleosis and advise the patient to avoid contact sports to prevent this hazard.
193. Amoxicillin-clavulanate is the antibiotic of choice for prophylaxis against infections caused by human bite
194. Cat-scratch disease that usually occurs after scratch or bite by a cat and is caused by Bartonella.
195. Strep viridans is a frequent case of infective endocarditis in patients with damaged heart valves
196. Failure to respond to herpes simplex with acyclovir indicates resistance. The patient most likely requires foscarnet.
197. Babesiosis should be suspected in any patient from an endemic area who presents with a tick bite. Remember 'splenectomized patient'
198. The herpes simplex virus (HSV) esophagitis ulcers are usually multiple, well circumscribed and have a "volcano" (small and deep) like appearance, whereas the ulcers seen in CMV infection tend to be large, shallow and superficial.
199. Skin lesions of Kaposi sarcoma usually occur on the trunk, face and the extremities. Usually these lesions are papules that later on become plaques or nodules. The color changes from light brown to pink to dark violet.
200. So far there has been no case reports of congenital rubella syndrome in women inadvertently vaccinated during early pregnancy.
201. Pyridoxine (Vitamin B6) is an antidote for isoniazid
202. Duration of QRS complex is the best measure for assessment of severity of tricyclic antidepressant toxicity.
203. All chemical injuries to eyes should be immediately washed with plain water or saline.
204. Impaired concentration and conjunctival injection are important features of marijuana use.
205. Calcium is useful in reversing cardiac effect of calcium channel blocker.
206. Tyramine contained in aged cheese reacts with monoamine oxidase inhibitors to produce hypertensive crisis
207. Dextromethorphan interacts with monoamine oxidase inhibitors and can produce severe hyperthermia.
208. Decision of use of N acetyl cysteine as an antidote for acetaminophen overdose is generally based on 4 hour post-ingestion acetaminophen levels
209. Bromocriptine is used in the treatment of neuroleptic malignant syndrome, which is characterized by marked hyperthermia, muscular rigidity, tremors, altered mental status, and diaphoresis.
210. First step in the management of pesticide poisoning is to remove the source of poison.
211. Phenothiazines cause hypothermia by causing vasodilatation and by inhibition of shivering
212. Sodium bicarbonate prevents the development of arrhythmia in patients with tricyclic antidepressant toxicity by alleviating cardio-depressant action on sodium channels
213. Recognize the affect of alcohol intake on acetaminophen induced hepatic injury
214. In case of suspected osteomyelitis, blood cultures and x-rays should be taken and the patient should be started on intravenous antibiotics. If the x-rays 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.
215. Cervicofacial actinomycosis classically presents as slowly progressive, non-tender, indurated mass, which evolves into multiple abscesses, fistulae, and draining sinus tracts with sulfur granules, which appear yellow. Treatment is high dose penicillin for 6-12 weeks.
216. Cauda equina is an acute compression syndrome presenting with acute motor and sensory loss, loss of rectal tone and urinary retention. It has to be treated urgently
217. Neurofibromatosis is a neurocutaneous syndrome, which has a tendency to form tumors of the central nervous system (CNS), peripheral nervous system, skin and viscera
218. CT scan showing hyperdense (White) area suggests hemorrhage. The infarcts on CT are seen as hypodense (Black) parenchymal areas.
219. Asymptomatic patients with carotid artery stenoses of 60 to 99 percent are considered to have a proven indication for CEA. Complete occlusion (100 percent stenosis) of the carotid artery is a contraindication to surgery
220. When a patient presents with painless visual loss lasting a few seconds, a duplex ultrasound of the carotids should be the first test of choice.
221. Petit mal seizures may present with a sudden cessation of mental activity, which occur repeatedly. There are not associated with complex automatisms or tonic clonic activity. Diagnosis can be best confirmed by EEG studies
222. Primidone is an anticonvulsant agent, which can be used to treat benign essential tremor. However, it can also precipitate acute intermittent porphyria. Diagnosis of porphyria is made by assessing urine for porphobilinogen.
223. Itch, redness and fissuring in swimmers is typical of athlete’s foot. The condition is best treated with antifungal creams such as tolnaftate.
224. In a child who has been to the ER several times and has bruises of unknown origin on his/her body, child abuse should always be suspected and reported to the appropriate authorities.
225. Gonorrhea is a common organism, which causes sexually transmitted disease. It is also a common cause of pharyngitis, generally acquired from oral sex.
226. Postherpetic neuralgia can cause significant pain along the nerve dermatomal distribution. The best treatment is with the anti viral agent, acyclovir
227. Urethral cultures have higher yield than synovial or blood culture in cases of suspected gonococcal purulent arthritis.
228. Always suspect endocarditis whenever a patient is febrile and has other constitutional features in the presence of a new heart murmur.
229. Patients with trichinosis, presents with gastrointestinal (GI) complaints followed by muscle pain, swelling, and weakness. Presence of subungual splinter hemorrhages, conjunctival and retinal hemorrhages, periorbital edema and chemosis should make you think about trichinosis.
230. Always suspect rubella when a febrile patient with rash has occipital or posterior cervical lymphadenopathy and arthritis.
231. Vibrio parahaemolyticus is usually transmitted by ingestion of seafood. Patients having symptoms of food poisoning after intake of seafood should be suspected for this.
232. Group A beta-hemolytic streptococcus is the most frequent cause of erysipelas and cellulitis.
233. Proteus is the most likely cause of urinary tract infection in patients with alkaline urine.
234. Facial nerve palsy and classical Erythema migrans (EM) indicate Lyme disease, which is a tick borne disease.
235. Pseudomonas aeruginosa is the most frequent cause for malignant otitis externa.
236. Mefloquine is the drug of choice for chemoprophylaxis of chloroquine resistant malaria
237. Amoxicillin is used for treatment of pregnant/lactating patients with early-localized Lyme disease
238. Doxycycline is used to treat primary syphilis in penicillin allergic patients
239. Pneumococcal vaccine is recommended in all HIV infected patients whose CD4 count is > 200 cells/micro-L.
240. IV amphotericin plus flucytosine is the antibiotic regimen of choice for central nervous system cryptococcal infection in AIDS patients.
241. Bacillary angiomatosis, a great mimicker of Kaposi sarcoma, is caused by gram-negative rod Bartonella and is successfully cured with antibiotic treatment. They are highly vascular, initially are smooth and in the form of small papules that gradually become enlarged and pedunculated or nodular.
242. Azithromycin or clarithromycin is the drug of choice for MAC prophylaxis in HIV patients with CD4 cell count below 50/microL.
243. 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.
244. Any patient from southwestern region with history of tick bite developing systemic symptoms along with leukopenia and thrombocytopenia should make you think about Ehrlichiosis.
245. HIV patients are at a high risk for tuberculosis and require prophylactic treatment to prevent an active disease. PPD is done to verify this. Skin induration of greater than 5 mm with PPD testing in HIV patients requires prophylaxis with isoniazid for 9 months
246. Listeria monocytogenes is a frequent cause of meningitis in patients older than 55 and therefore in such patients ampicillin should be added to the empiric antibiotic regimen.
247. Presence of erythema chronicum migrans in a patient with tick bite history warrants immediate treatment without waiting for serology of Lyme's disease.
248. Lyme disease prophylaxis is given in pregnant patients who have history of tick bite and have anxiety about acquiring disease.
249. Methanol intoxication is associated with visual loss.
250. 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.
251. Pinpoint pupils and respiratory depression are the hallmark features of acute opioid toxicity for which naloxone is the drug of choice
252. Heterophil antibody test is sensitive and specific for diagnosis of IM. EBV specific antibody test is used in patients with high suspicion for IM and have negative heterophil antibody test.
253. Albendazole or mebendazole is the first line of treatment for E. vermicularis infection. Pyrantel palmate is an alternative.
254. Consider CMV pneumonitis as a late complication in post BMT recipients with dyspnea and cough.
255. Serotonin agonists (triptans) are the drugs of choice to abort acute attacks of migraine when simple analgesics or NSAIDs fail.
256. Pregnancy testing should be considered in patients with high risk of being pregnant prior to starting treatment with sumatriptan
257. The choice of prophylactic agent for migraine depends upon any associated medical condition. In patients with coexistent depression, antidepressants should be used for prophylaxis of migraine.
258. Rupture of saccular aneurysm is the most frequent cause of non-traumatic subarachnoid hemorrhage (SAH). Know the CT appearance of SAH.
259. Campylobacter jejuni is the most frequent precipitant of Guillain-Barré Syndrome (GBS).
260. Atrophy of the caudate nucleus is a characteristic feature of Huntington’s chorea. Recognize the classic clinical presentation of Huntington’s chorea.
261. Acetazolamide is the first line medical treatment for idiopathic benign intracranial hypertension.
262. Acute exacerbations of MS are treated with corticosteroids. Beta-interferon or Glatiramer acetate is used to decrease the frequency of exacerbations in patients with relapsing-remitting or secondary progressive form of MS.
263. Oligoclonal bands are present in 85-90% of cases of multiple sclerosis. CSF pressure, protein and cell count is grossly normal in patients with MS.
264. Initial presentation of multiple sclerosis with optic neuritis or sensory symptoms carries a good prognosis.
265. Cutaneous larva migrans is a common cause of dermatological disease in travelers from tropical regions, and is characterized by pruritic elevated serpiginous lesion on the skin.
266. Always consider malaria in patients from endemic areas with high-grade periodic fever and chills. Anemia and splenomegaly are the clinical clues.
267. 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.
268. It is recommended that all patients with atherothrombotic TIA should receive an antiplatelet agent if there is no contraindication to its use and antiplatelet agent of initial choice for this purpose is aspirin.
269. Anticoagulation is considered when TIA is due to emboli arising from the heart.
270. Anticholinergics are useful treatment for Parkinsonism patients who are younger than 70 with disturbing tremor and minimal bradykinesia. Parkinsonism tremor is a resting tremor.
271. Oral anticholinesterase is usually the initial treatment of choice for myasthenia gravis and all patients should have evaluation for thymectomy
272. First step in all patients suspected of having stroke is CT scan without contrast. If they have evidence of ischemic stroke, then carotid Doppler and TEE are performed to evaluate the possible source of embolism.
273. Presence of cord cavity is the most characteristic feature of syringomyelia that typically presents with areflexic weakness in the upper extremities and dissociated anesthesia in a "cape" distribution. Other features like caudal displacement of fourth ventricle or cerebellar tonsils or focal cord enlargement may or may not be present.
274. CT/MRI picture of heterogenous and serpiginous contrast enhancement is typical of high-grade astrocytoma. Recognize the classic butterfly appearance.
275. Patient with cerebellar hemorrhage presents with ataxia, vomiting, occipital headache, gaze palsy, and facial weakness. There is no hemiparesis. It is crucial to make early and correct diagnosis, as urgent surgical decompression may be life saving in such cases.
276. Treatment of myasthenia crisis consists of endotracheal intubation and withdrawal of anticholinesterases for many days.
277. The most common site of hypertensive hemorrhage is putamen (35%). Internal capsule that lies adjacent to putamen is almost always involved leading to hemiparesis.
278. All those patients who are on warfarin treatment and develop serious bleeding need rapid reversal of anticoagulation and fresh-frozen plasma is the most appropriate first choice for this purpose.
279. Untreated LGV may progress to a severe and chronic disease causing ulceration, proctocolitis, rectal stricture, rectovaginal fistulas and elephantiasis.
280. Riluzole is a glutamate inhibitor and is currently approved for its use in amyotrophic lateral sclerosis.
281. Intravenous cefotetan, ampicillin/sulbactam, or the combination of clindamycin and a fluoroquinolone is the appropriate empirical treatment for limb-threatening infections in diabetics, whereas mild, or non-limb-threatening, infections can be treated with oral antibiotics like cephalosporin, clindamycin, amoxicillin/clavulanate and fluoroquinolones.
282. The majority of human infections with E. granulosus are asymptomatic. Hydatid cysts can be found in almost any part of the body but liver (MC) is involved in two-thirds of patients and the lungs are involved in 25 percent of patients. It is most commonly seen in areas where sheep are raised.
283. Neurocysticercosis is the most common parasitic infection of the brain and highest prevalence seen in rural areas where pigs are raised and there are poor sanitary conditions
284. Streptococcus bovis endocarditis is associated with colorectal cancer and colonoscopy is advisable in such patients.
285. Condylomata acuminata are skin colored or pink, verrucous and papilliform skin lesions present around the anus and podophyllin is one of the available treatment options.
286. Eaton–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.
287. Immunocomplex disease is primarily responsible for glomerulonephritis, Roth spots and Osler’s nodes. Janeway lesions result from septic embolism.
288. MRI is the test of choice to support the clinical diagnosis of multiple sclerosis
289. Multiple observational studies have demonstrated that patients with hypertension have about four times the risk of stroke when compared to non-hypertensive subjects
290. Understand the concept of lead-time bias in screening tests. The concept of lead-time bias includes prolongation of apparent survival in patients to whom this test was applied, without changing prognosis for the disease.
291. Confounding is referred to the bias that can result when the exposure-disease relationship is mixed up with the effect of extraneous factors called confounders.
292. Know the concept of positive predictive value; positive predictive value depends on the prevalence of the disease of interest in the population to which the test is applied. PPV increases with an increase in prevelance of disease in the study population. For NPV, the inverse is true.
293. Thymectomy may induce remission in patients with myasthenia gravis and should be considered in all patients who are between puberty and 60 and whose disease is not confined only to the extraocular muscles.
294. Incidence is the measure of new cases, the rapidity with which they are diagnosed. Prevalence is the measure of the total number of cases at a particular point of time.
295. 68% - within 1 standard deviation from the mean
95% - within 2 standard deviations from the mean
296. 99.7% - within 3 standard deviation from the mean
297. Observer bias occurs when the decision as to whether outcome is present is adversely affected by the knowledge of the exposure status.
298. 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.
299. Dihydropyridine Ca-channel antagonists can cause peripheral edema and should always be considered in the differential diagnosis of this condition, along with other causes, such as heart failure, renal disease and venous insufficiency.
300. Elderly patients with depression often present with memory loss (Pseudodementia.), which can mimic other causes of dementia, including Alzheimer’s dementia, while the CT will be normal in these patients, the DST may be of value.
301. In cross-sectional study, exposure and outcome are measured simultaneously at a particular point of time (you can remember it as a ‘snapshot’ study). In other study designs, a certain time period separates exposure and outcome.
302. Situational syncope should be considered in the differential diagnosis 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.
303. Recognize normal pressure hydrocephalus by the triad of gait disturbance, dementia and urinary incontinence. Other features are normal CSF pressures on lumbar puncture and enlarged ventricles on MRI
304. VDRL testing, PPD skin testing, Hepatitis A and B serology and antibody titer for Toxoplasma are indicated as a part of initial work-up in all newly diagnosed HIV-positive patients.
305. Primary polydypsia is a disorder in which the patient drinks fluids in excess of 5 L per day and both plasma and urine are diluted.
306. SIADH results in hyponatremia, low serum osmolality and inappropriately high urine osmolality.
307. Diabetes insipidus presents with polyuria and polydypsia and urine osmolality is less than serum osmolality.
308. Several well-organized and well-controlled clinical trials demonstrated that ACE inhibitors could slow the progression of diabetic nephropathy and reduce albuminuria
309. Somogyi effect refers to early morning hyperglycemia caused by counter regulatory hormones following nocturnal hypoglycemia
310. Acute respiratory alkalosis (increase in extracellular pH) causes a fall in ionized plasma calcium by increasing the affinity of albumin to calcium
311. There are various mechanisms by which malignancy produces hypercalcemia. These are: the production of cytokines, parathyroid hormone related peptide, calcitriol and ectopic PTH
312. Remember when albumin is low, serum calcium concentration falls in the ratio of 0.8-1 mg of calcium to 1 g of albumin.
313. Always suspect surreptitious vomiting as a cause of hypokalemic alkalosis in a normotensive patient and distinguish it from other entities like diuretic abuse and Bartter’s syndrome on the basis of urine chloride concentration
314. Distinguish primary hyperaldosteronism from renovascular hypertension based on low plasma renin activity in the former and high plasma renin activity in the later.
315. Patients with Bartter’s syndrome have hypokalemia, metabolic alkalosis, normal blood pressure and elevated urine chloride concentration.
316. Patients with primary hyperaldosteronism show persistent elevation of BP, hypokalemia, metabolic alkalosis, mild hypernatremia, very low plasma renin activity and absence of edema
317. Measurement of glycosylated hemoglobin provides good evidence of how well the glucose has been controlled over the past 100-120 days (RBC survival time)
318. Hypercholesterolemia is the most frequent lipid abnormality in patients with hypothyroidism.
319. Hyperlipidemia, unexplained hyponatremia and elevated serum muscle enzymes are indications for thyroid function tests
320. Whenever a patient presents with thyroid nodule, first step is assessment of thyroid function.
321. Hyperplastic colloid nodule is the most frequent cause of thyroid nodule. Majority of thyroid nodules are benign, not malignant.
322. Patients with generalized resistance to thyroid hormones have high serum free T4 and T3 and normal or high serum TSH. Patients typically have features of hypothyroidism despite of having elevated free thyroid hormones
323. Agranulocytosis is a serious side effect of propylthiouracil
324. Radioiodine is more likely to cause permanent hypothyroidism in patients with Graves’ disease than multinodular goiter or toxic adenoma
325. Patients with osteomalacia have low or low-normal serum calcium, low serum phosphate and increased serum parathyroid hormone.
326. Osteomalacia is characterized by defective mineralization of bone
327. Always suspect hypophosphatemic rickets in patients of rickets who has normal serum calcium, normal serum alkaline phosphatase and normal 25-OH vitamin D.
328. Dopamine agonists like bromocriptine or cabergoline are the mainstay of treatment for patients with prolactinoma
329. Mucosal neuromas are the most distinctive feature of multiple endocrine neoplasia type 2b and are present in more than 90% of cases
330. Prolactinoma is the most common pituitary tumor
331. The most common thyroid hormone pattern in sick euthyroid patients is a fall in total and free T3 levels and normal levels of T4 and TSH. Remember ‘low T3 syndrome’
332. Antiperoxidase antibodies are the most prevalent antibodies in patients with Hashimoto’s thyroiditis.
333. Patients with Hashimoto’s thyroiditis are at an increased risk for developing lymphoma of thyroid
334. Papillary carcinoma of thyroid is the most common thyroid malignancy. Invasion of tumor capsule and blood vessels is the hallmark feature of follicular carcinoma of thyroid.
335. Subacute lymphocytic thyroiditis presents with painless enlargement of thyroid gland and hyperthyroidism. Duration is less than 2 months, goiter is small, no ophthalmopathy, and radioactive iodine uptake is low in such patients.
336. Asymptomatic patients with Paget’s disease generally don’t require any treatment. Symptomatic patients are best treated with bisphosphonates
337. MEN II consists of a medullary carcinoma of the thyroid, hyperparathyroidism and pheochromocytoma
338. In Leydig cell tumors, the estrogen production can be increased with secondary inhibition of LH and FSH
339. Male secondary hypogonadism is characterized by low levels of testosterone and low normal gonadotropins
340. DHEA and DHEA-S are produced by the adrenal glands and are used as markers for the adrenal tissue
341. 21-hydroxylase deficiency is the most common form of CAH. It presents with virilism, salt wasting, and increased 17-alpha-hydroxyprogesterone levels.
342. Most significant clinical impact of GH excess in acromegaly occurs on cardiovascular system, which accounts for 38-62 percent of deaths in acromegaly patients, CHF being the most common
343. In central DI, urine osmolality becomes greater than that of serum on arginine vasopressin administration while it remains lower than that of plasma when etiology is nephrogenic in origin. Treatment of choice for central DI is desmopressin, which is usually administered intranasally.
344. Fasting blood glucose measurement is now the recommended test for screening high-risk individuals for diabetes mellitus
345. Know the risk factors for development of foot ulcers in diabetics. Neuropathy is found in about 80% of diabetics with foot ulcers
346. Symmetric distal sensorimotor polyneuropathy is the most commonly seen neuropathy in diabetes and is characterized by classic "stocking glove" pattern sensory loss. The most common cranial nerve involved in diabetes is cranial nerve III. The most commonly involved peripheral mononeuropathy is the median nerve.
347. Diabetic cystopathy manifests as overflow incontinence. The pathology involves weak detrusor contraction secondary to autonomic neuropathy. Treatment is usually started with strict voluntary urinary scheduling and bethanechol; if no response, then the use of intermittent catheterization is advised.
348. GI manifestations of diabetic neuropathy include gastroparesis, constipation and diarrhea. Metoclopramide (drug of choice), bethanechol and erythromycin are useful in the management of gastroparesis
349. Diabetic neuropathy can be accompanied by acute or chronic pain. Treatment options for chronic diabetic neuropathic pain are gabapentine and TCAs (amitriptyline or desipramine).
350. Know the management of diabetic ulcers. Good wound care and debridement is key to the management. Antibiotics alone do not cure diabetic ulcers
351. Fasting blood glucose measurement is now the recommended test for screening high-risk individuals for diabetes mellitus. When fasting plasma glucose is 126 mg/dL or greater, repeat it, and if it is still elevated, diagnosis of diabetes mellitus is established and treatment is started.
352. The first test in all patients with unexplained hypertension and hypokalemia is measurement of plasma renin activity and plasma aldosterone concentration. If it is consistent with primary hyperaldosteronism, do an aldosterone suppression test for confirmation; once confirmed, perform a CT scan of the adrenals to look for a mass; but, if there is no mass on CT scan, do adrenal vein sampling
353. Nocturnal penile tumescence helps differentiate psychogenic causes of male erectile dysfunction from organic causes. It is positive in psychogenic causes and negative in organic causes
354. Glasgow coma scale is used to assess the severity of head injury but it does not indicate the presence or absence of increased intracranial pressure (ICP).
355. Patients with mild head injury can be discharged with a “head sheet” if they have a normal CT scan.
356. Pain relief should be the prime objective in management of rib fracture in elderly
357. In reference to neck trauma, neck can be divided into three zones and the treatment depends on the zone involved
358. Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound below the 4th intercostal space (level of nipple) is considered to involve the abdomen.
359. Hypotension not responsive to fluid administration is suggestive of ongoing blood loss and such patients with abdominal trauma need an exploratory laparotomy.
360. All the patients with acute carbon monoxide poisoning should be treated with 100% oxygen via a facemask.
361. Delayed emergency from anesthesia is characterized by hypoventilation, which is evident by decrease in respiratory rate, hypertension progressing to hypotension, tachycardia progressing to bradycardia, restlessness and pallor/cyanosis.
362. 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.
363. Hyperventilation helps to prevent and treat intracranial hypertension by causing cerebral vasoconstriction and thus decreasing cerebral blood flow.
364. Orotracheal intubation and surgical cricothyroidectomy are preferred way to establish an airway in apneic patient with head injury
365. Nasoethmoidal fractures may be associated with injuries to ethmoidal roof, lacrimal system, medial canthal tendons, cribriform plate and vasculature of nose. Associated injuries of these structures can give rise to cerebrospinal fluid rhinorrhea, epistaxis, anosmia, epiphoria or telecanthus
366. Beck's triad of hyotension, elevated JVP, and muffled heart sounds confirms the diagnosis of pericardial tamponade
367. Primary resuscitation of any trauma patient is based on establishing airway, breathing and circulation (ABC of resuscitation).
368. An airway is needed in all unconscious patients and in emergency room an orotracheal intubation is the best option. Hemodynamically unstable trauma patients should be started on IV crystalloids immediately.
369. 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. Confirmatory test is angiography or spiral CT scan.
370. Saphenous vein cut down or percutaneous femoral vein catheterization are alternatives to have an intravenous access in trauma patients with collapsed veins.
371. 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.
372. Acute subdural hematoma has a classic presentation of unconsciousness followed by a lucid interval followed by gradual deterioration of consciousness. CT scan is diagnostic and it shows a biconvex hematoma.
373. Treatment of acute subdural hematoma is essentially conservative if no midline shift is present on CT scan.
374. CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages with blurring of grey-white interface.
375. Hemothorax is most commonly managed by a tube thoracotomy in lower part of chest. Surgery is seldom necessary
376. 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.
377. Fat embolism presents with dyspnea, confusion and petechiae in the upper part of the body and occurs after multiple fractures of long bones
378. Know the tetanus immunization.
379. An exploratory laparotomy is needed in all the patients with blunt trauma to abdomen with signs of peritoneal irritation.
380. Patient with head injury can never have hemorrhagic shock due to intracranial bleeding
381. USG or DPL are the procedures of choice to diagnose intra abdominal bleeding in an unstable trauma patient.
382. Posterior urethral injury is associated with pelvic fractures and presents with blood at meatus, high riding prostrate, scrotal hematoma and inability to void in spite of sensation to void.
383. Retrograde urethrogram should be the first step in management of suspected posterior urethral injury
384. Intraperitoneal bladder rupture can occur in trauma patient with full bladder
385. Retrograde cystogram with post void film is the investigation of choice for patients with suspected bladder trauma
386. Penile fracture is a medical emergency and needs prompt surgical repair
387. Rule out vascular injuries in case of penetrating wound near the site of important vessels
388. 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
389. All the patients with traumatic wound should be assessed for need of Tetanus toxoid and/or tetanus immunoglobulin
390. Pelvic X ray should be routinely done in all patients with trauma to screen for pelvic injury.
391. Vital signs, hemodynamic stability, and need for blood transfusion are important determinant for surgical v/s non-surgical management of patient with splenic trauma.
392. Rhabdomyolysis can occur with severe crush injuries and should be managed with IV fluids, osmotic diuretics and alkalinization of urine
393. Infection is the most common cause of death in burns patients
394. Body surface involved in burn injury is calculated with the help of “Rule of Nines.
395. Burns patients need 4 ml / kg / % of the body area involved of fluids in first 24 hours, half of which is given in the first 8 hours
396. Inhalation injury is common in burns patients and may take several days to manifest. Diagnosis is best done with a bronchoscopy.
397. When circumferential full-thickness burns involving the extremities or chest are present, escharotomy may be necessary
398. Know the injuries suggestive of child abuse and report such cases to child safety services
399. Superficial and erythematous burns while painful do not require any special wound care. Topical or oral analgesics agents can be prescribed.
400. 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
401. Know the type of burn injuries and difference between burns and scalds. Scalds are the burn injuries secondary to contact with liquids. The type of burn injury in case of scalds depends on the type of liquid and duration of contact.
402. 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.
403. Chronic renal failure is the most common cause of death in systemic lupus erythematosus patients.
404. Inflammatory myopathies are best treated with corticosteroids
405. Presence of fever, inflammatory signs, no crepitus or bullae and signs of overlying skin necrosis all suggest that the patient has cellulitis. This patient also had toe web tinea pedis, which is one of the most common portals of entry for the microorganisms, causing cellulitis.
406. Osteoarthritis is a degenerative bone disease involving mainly the weight bearing joints. Know the pattern of joint involvement, x-ray findings and the differentiating features of this disease.
407. The demonstration of negatively birefringent needle shaped urate crystals in the synovial fluid is suggestive of gout.
408. Prophylactic allopurinol is the most effective method to prevent gout in patients at risk for tumor lysis syndrome.
409. 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
410. Hyperparathyroidism and hemochromatosis patients are more prone for pseudogout. Joint fluid aspirates reveal rhomboid shaped calcium pyrophosphate crystals, with positive birefringence
411. Asymmetric migratory polyarthralgia, followed by monoarticular arthritis, in a sexually active patient with a characteristic skin rash suggests gonococcal arthritis.
412. In patients with frequent attacks of acute gouty arthritis not controlled by colchicine, 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
413. Obesity is a major risk factor for osteoarthritis. Hence weight loss is the most effective measure in osteoarthritis management.
414. Leriche syndrome occurs as a result of atherosclerotic vascular disease and is characterized by impotence and intermittent claudication.
415. The cauda equina syndrome occurs as a result of compression of lumbosacral nerve roots by infection or tumor. Usual presentation is with urinary retention or overflow incontinence.
416. Thoracic aortic aneurysm is a serious complication of giant cell arteritis, which can be fatal so such patient must be monitored continuously
417. Regular exercise/physiotherapy is the only beneficial treatment that halts the disease progression in ankylosing spondylitis
418. Giant cell arteritis must be treated immediately with glucocorticoids once the clinical diagnosis is made. Temporal artery biopsy can be done within several days after treatment, for confirmation of the disease.
419. Anterior uveitis is the most common cause of red eye in patients with ankylosing spondylitis
420. Plain X-ray of the Sacroiliac joint is the next best step in a suspected patient of ankylosing spondylitis
421. Frozen shoulder should be suspected when a patient presents with stiffness and limited range of motion
422. Bladder carcinoma is a recognized complication of long-term use of cyclophosphamide
423. MRI is the definitive diagnostic study for rotator cuff tear
424. Joint involvement in Parvovirus infection is symmetrical. Hands, wrists, knees and feet are the most frequently involved joints. Rash may or may not be present. Patient may have arthralgias or arthritis. Joint involvement most frequently occurs in adult females.
425. Eye examinations at 6 months to 1 year intervals should be performed in all patients who are taking hydroxychloroquine
426. Anti-B19 IgM is the diagnostic study of choice when Parvovirus infection is clinically suspected
427. Diffuse proliferative glomerulonephritis is the severest form of glomerular disease in patients of systemic lupus erythematosus
428. Lofgren’s syndrome is an acute form of sarcoidosis and consists of triad of bilateral ankle arthritis (some times knees, wrists or elbows), erythema nodosum and bilateral hilar adenopathy
429. Systemic steroids are the drugs of choice in sarcoidosis
430. Thoracic outlet syndrome occurs with signs and symptoms of neurovascular bundle compression
431. Fibromyalgia is a chronic widespread pain disorder associated with fatigue, poor sleep, and depression. Patients have multiple trigger points of tenderness
432. Nerve conduction studies are very useful in diagnosing the carpal tunnel syndrome
433. Dupuytren’s contracture manifests as nodular thickening of the third and the fourth fingers with inability to extend completely
434. Amitriptyline and cyclobenzaprine have been shown to be effective in the treatment of fibromyalgia
435. Arthritis in systemic lupus erythematosus (SLE) is non-erosive and arthritis in rheumatoid arthritis is erosive.
436. Anti-DsDNA antibodies are primarily involved in the pathogenesis of lupus nephritis
437. Heliotrope rash, Gottron’s sign, and proximal muscle weakness are the classical features of dermatomyositis
438. Muscle biopsy is the best diagnostic study for polymyositis
439. Total knee replacement is indicated in patients with severe restriction of walking and nocturnal and rest pain
440. Low back pain in patients with history of malignancy should always raise the suspicion of bone metastasis
441. Reflex sympathetic dystrophy is a syndrome of pain and swelling associated with vasomotor instability.
442. Anserine bursitis presents with medial knee pain just below the joint line.
443. The most common cause of asymptomatic elevation of alkaline phosphatase in an elderly patient is Paget’s disease.
444. Hemochromatosis is an important condition that has been found to be associated with pseudogout.
445. Young patients with high spiking fevers associated with characteristic salmon colored evanescent rash, arthralgias, and leukocytosis most likely have adult stills disease.
446. Keratoderma blennorrhagicum is a typical skin manifestation of Reiter’s syndrome
447. Relapsing polychondritis is an idiopathic disorder characterized by recurrent inflammation of cartilaginous structures and other internal organs.
448. Whipple disease presents with joint pain, abdominal pain, diarrhea, and weight loss. Periodic Acid-Schiff positive material on small intestinal biopsy establishes the diagnosis.
449. Bucket handle tear of medial meniscus is the most common meniscus injury at knee and leads to locking of the knee joint during terminal extension.
450. Lachman's test is the most sensitive physical test for diagnosis of anterior cruciate ligament injury. Recognize the clinical presentation of ACL tear.
451. 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.
452. Most of the fractures of shaft of femur can be managed with closed intramedullary fixation of fracture.
453. 10% of calcaneal fractures secondary to fall from height is associated with compression fracture of thoracic or lumber vertebra.
454. Stress fracture or March fracture or insufficiency fracture is commonly seen in young active adults involved in vigorous and excessive exercises.
455. Elderly patients with displaced femoral neck fractures should be treated with primary arthroplasty.
456. Internal fixation with sliding screw and plate and early mobilization is the treatment of choice for intertrochanteric fractures.
457. Nonunion and avascular necroses are common complications seen in scaphoid fracture.
458. If a scaphoid fracture is suspected, even without a visible fracture on x-ray, it must be treated as if there was a fracture.
459. When clavicle injuries occur and a bruit is present, an arterial injury must be ruled out with an angiogram.
460. When a patient presents with a pulsatile abdominal mass and hypotension, a presumptive diagnosis of ruptured abdominal aortic aneurysm must be entertained and the patients should be taken straight to the operating room
461. Ludwig’s angina is infection of the submaxillary and sublingual glands. The source of the infection is from an infected tooth.
462. For carcinoid tumors locate at the tip of the appendix, appendectomy is sufficient treatment
463. The treatment of a tension pneumothorax is immediate chest tube placement
464. After placement of a central line, a chest x-ray must be obtained to ensure proper line placement.
465. Cardiac contusion can be associated with various arrhythmias and is best monitored by continuous ECG monitoring
466. Once an esophageal perforation has been diagnosed, primary repair of the esophagus should be done immediately
467. Nasopharyngeal cancer usually presents initially as a painless neck mass.
468. Fever occurring in the first 1-2 days after surgery is usually due to atelectasis
469. The presence of pulses does not rule out compartment syndrome and suspicion should be high for this diagnosis. Fasciotomy is the treatment and must be done urgently
470. 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.
471. Ulcers on the medial aspect of the leg are generally from venous disease. Venous hypertension may be due to vein varicosities and incompetent perforators.
472. In patients who present with ulcers on the soles of the foot, neuropathic ulcers from diabetes should be suspected
473. In a patient who undergoes bowel resection and then develops kidney stones, one should always suspect oxalate as the culprit
474. After rhinoplasty, if there is a whistling noise during respiration, one should suspect nasal septal perforation.
475. In a young individual who present with a fleshy immobile mass on his hard palate, the most likely diagnosis is torus palatinus. No medical or surgical therapy is required
476. Diagnostic peritoneal lavage, CT scan, ultrasound or local wound exploration has no role in the management of patients with a direct gunshot wound to the abdomen; laparotomy should be done
477. When there is an intimal flap of the carotid artery, surgery is recommended to repair the vessel. Intimal flap injury can lead to vessel occlusion and symptoms and signs of ischemia. Today, with the availability of stenting, this may be an alternative option to surgery
478. Subluxation of radial head is a common condition in preschool children and needs closed reduction by flexion and supination of forearm
479. Cast immobilization is recommended in the treatment of all non-displaced scaphoid fractures (fractures < 2 mm displacement and no angulation).
480. Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the dead muscle has been replaced with fibrous tissue.
481. Radial nerve is the most commonly injured nerve in association with fracture of midshaft humerus.
482. The treatment of choice for isolated diaphyseal humeral fracture is by closed methods
483. Monteggia and Galeazzi fractures need open reduction and internal fixation
484. Colles fracture is the most common fracture of distal radius characterized by dorsal displacement and dorsal angulation
485. Axillary nerve is the most commonly injured nerve in anterior dislocation of shoulder
486. Clavicle is one of the most commonly fractured bones and is treated with figure of eight bandage.
487. Pain on passive extension of fingers is the most sensitive physical sign of compartment syndrome
488. Adolescent onset idiopathic scoliosis is the most common type of scoliosis and is commonly seen in adolescent girls. (< 20 degree-Observe; >30-Bracing; >40-Surgery)
489. Osgood Schlatter disease is an apophysitis of tibial tubercle seen in young teenagers due to overuse.
490. Legg Calve Perthes disease is serious but self-limiting condition of young children characterized by avascular necrosis of femoral head.
491. Slipped femoral capitis is an emergency condition and should be promptly corrected with external screws.
492. USG is the most sensitive investigation for the diagnosis of DDH for infants less than 6 months of age.
493. Most of the snakes are not poisonous and even when bitten by a poisonous snake it does not necessarily mean that envenomation has occurred (Only 1/3 rd of the patients bitten with poisonous snakes develop envenomation). Antivenom should be given to all patients with significant symptoms.
494. Bee and Hymenoptera stings account for more deaths in the United States than any other envenomation. Anaphylactic shock should be promptly treated with subcutaneous epinephrine.
495. Brown recluse spider bite causes deep necrotic ulcer at the bite site.
496. Unique fracture patterns like green stick fracture, torus fracture and plastic deformation are seen in children because their bones are more porous and less brittle.
497. In case of amputation injury, amputated parts should be retrieved and brought to the emergency department. 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.
498. Atelectasis on chest-x ray can be confused with pneumonia and pleural effusion. However, it is more common after surgery in smokers and requires bronchoscopy to remove the mucus plug.
499. 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.
500. 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
501. Isolated duodenal hematoma is treated conservatively with nasogastric tube and parenteral nutrition.
502. 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.
503. The second part of the duodenum is the most commonly injured portion of the duodenum and needs a high degree of suspicion for diagnosis, especially in the presence of retroperitoneal air or blunting of the right psoas shadow on x-ray.
504. After an AAA repair, diarrhea with blood in the stools should raise the suspicion of ischemic colitis. If the CT scan is inconclusive a sigmoidoscopy/colonoscopy is recommended.
505. Diphenhydramine toxicity produces seizures as well as anti-cholinergic effects.
506. 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.
507. Know the different kind of bias, which can decrease the validity of study results. Hawthorne effect is the tendency of the study population to affect the outcome, due to the fact that they are being studied.
508. Know how to interpret odds ratio. To be clinically significant, odds ratio should be greater than or less than 1. OR > 1 means that the factor under study is a risk factor for the outcomes, whereas the OR < 1 means that the factor under study is a protective factor in respect to the outcome. OR = 1 means there is no significant difference in outcomes in either the exposed or the unexposed.
509. 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.
510. Toxicity with tricyclic antidepressants is characterized by anticholinergic effects and QRS widening on EKG
511. Calcium gluconate is used to treat black widow spider bite
512. Phencyclidine (PCP) is an hallucinogenic drug and its intoxication is characterized by disorientation, agitation, dizziness, ataxia, combativeness, sensory dissociation and nystagmus
513. Phencyclidine causes psychotic symptoms.
514. Deferoxamine is an antidote for iron toxicity that causes hemorrhagic gastroenteritis with acidosis and hypotension
515. Magnesium is an effective treatment for torsade de pointes.
516. Sodium bicarbonate is effective for the treatment of cardiac dysfunction induced by thioridazine toxicity
517. Chlordiazepoxide is the treatment of choice for delirium tremens that is characterized by disorientation, hallucination, tachycardia, hypertension, and agitation.
518. Tuberculosis is the most common cause of constrictive pericarditis, in immigrant population. It should be considered in patients with unexplained elevation of JVP and history of predisposing condition
519. In a patient with an MI who develops a cold leg, one has to get an ECHO to rule out a thrombus in the left ventricle.
520. Dressler syndrome typically occurs two-to-four weeks after an MI and presents with a low-grade fever, malaise and pleuritic chest pain. ECG will reveal 'non specific' ST elevations and there may be a pericardial effusion. NSAIDs are the agents of choice.
521. Amiodarone has the potential to cause lung fibrosis and should be avoided in patients with history of pulmonary fibrosis
522. Digoxin-specific antibody Fab fragments are indicated when adults ingest more than 10 mg of digoxin or when serum digoxin level is greater than 10 ng/ml.
523. . Statin intolerance should be suspected if the patient develops myalgias and elevated serum transaminases. Symptoms usually develop within few weeks to few months of starting statin therapy
524. Beta blockers are the initial drugs of choice for the treatment of isolated left ventricular diastolic dysfunction as they improve diastolic filling by lowering the heart rate and increasing the diastolic filling time
525. Recognize the clinical features of cardiogenic shock. Elevated PCWP is the most important finding to concentrate.
526. ST segment depression, T wave inversion and first degree AV block can occur at therapeutic levels of digoxin and they do not represent digitalis toxicity and therefore there is no need for discontinuation of the drug.
527. Whenever a patient of chronic aortic regurgitation develops symptoms of LV dysfunction, he should undergo aortic valve replacement after his congestive symptoms are relieved by intense medical treatment with digoxin, diuretics, and vasodilators
528. Infective endocarditis prophylaxis and repeated regular follow-ups are recommended for all patients of aortic stenosis even if they are asymptomatic
529. The majority of patients who have a mild degree of mitral stenosis can tolerate pregnancy without any complications.
530. Procainamide or disopyramide are the drugs of choice for atrial fibrillation in the context of WPW syndrome. Remember digoxin and calcium channel blockers should not be used.
531. Any patient, who has undergone genitourinary instrumentation, has a history of IV drug abuse, or a history of prosthetic valves should be suspected for infective endocarditis if they have fever, chills, weakness, and/or a new onset murmur.
532. Any patient who comes from South America and have findings suggestive of cardiomyopathy should make you think about Chaga’s disease.
533. The classic findings of pericarditis on EKG are:
a. Diffuse ST segment elevation with upward concavity at ‘J’ point.
b. No new ‘Q’ waves
c.'PR’ segment elevation in aVR with ‘PR’ depression in other leads
534. Once sick sinus node syndrome has been diagnosed, the best treatment is placement of a permanent pacemaker.
535. Wenckebach or Mobitz type I heart block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped, and then the sequence is repeated. It is a benign arrhythmia and is transient. Unless the patient is symptomatic, it requires no treatment.
536. First-degree heart block is a completely benign arrhythmia and requires no treatment
537. Torsades de pointes is an arrhythmia of gradually changing QRS morphology and most often caused by Quinidine
538. Ventricular tachycardia in the presence of a stable blood pressure does not warrant cardioversion. The best treatment is loading with lidocaine or amiodarone
539. Coarctation can present with rib notching on the chest-x ray. A “3” sign is typically seen with coarctation of longer duration, implying proximal aortic dilation, constriction and descending aorta dilatation
540. Mobitz type 2 block is a dangerous arrhythmia which can progress to complete heart block and requires a permanent pacemaker
541. 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.
542. Premature atrial beats are benign and neither requires any follow up nor treatment.
543. When atrial fibrillation is associated with hemodynamic compromise, cardioversion is the treatment of choice.
544. The treatment of ventricular fibrillation is STAT defibrillation with 200-360 joules. If defibrillation fails, lidocaine or amiodarone (drug of choice) can be loaded and the patient shocked again. Epinephrine can sensitize the heart and lower the threshold for conversion.
545. Anytime if the patient is hemodynamically unstable, treatment of choice is electrical cardioversion. If the patient is hemodynamically stable, then you have to think whether it is an acute process? or a chronic process?. If it is an acute process then you can choose to convert the patient to sinus rhythm by either cardioversion or you can keep the patient under rate control. If it is a chronic process then it is best managed with rate control along with anticoagulation. Rate control is best achieved with diltiazem or metoprolol.
546. Complete heart block is a dangerous condition, which can cause sudden cardiac death. It requires immediate placement of permanent pacemaker.
547. Amiodarone is a class III antiarrhythmic agent and is well known to cause lung fibrosis. Also, remember thyroid dysfunction (both hypo and hyper), hepatotoxicity, cornel deposits and bluish-slate gray discoloration of the skin.
548. Bluish discoloration and cool fingers in the ICU are a common finding after use of norepinephrine for hypotension
549. Amoxicillin is the drug of choice for prophylaxis of infective endocarditis in dental and respiratory procedures. In patients who are allergic to penicillin, alternatives include cefazolin, clarithromycin or clindamycin.
550. 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 plus gentamycin is used in high-risk patients
551. 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.
552. Patients with artificial pacemakers and defibrillators do not require prophylaxis for infective endocarditis.
553. Aspirin, beta-blockers, ACE inhibitors and spiranolactone improve survival in patients with heart failure, while digoxin and loop diuretics does not provide any survival benefit
554. 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.
555. Isolated premature ventricular arrhythmias generally do not require any medical treatment; observation is usually the treatment of choice.
556. It is better to keep systolic pressure < 130 mmHg to slow end-organ damage in patients with diabetes and chronic renal failure
557. Syncopal episode without following disorientation (post-episode confusion is more characteristic for a seizure), hearing impairment, normal physical exam, and family history of sudden cardiac death should make you think of congenital long ‘QT’ syndrome. Beta-blockers are the drugs of choice
558. It is important to recognize that oral contraceptives can be a potential cause of hypertension, and simply discontinuing its use can correct the problem
559. In all cases of ST elevation MI, reperfusion therapy with thrombolytics or PTCA(PCI) with or without stenting must be performed as soon as possible. PTCA(PCI) is preferred over thrombolytics.
560. 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.
561. Suspect aortic dissection as a cause of tearing chest pain in the setting of HTN and BP difference in the 2 arms.
562. Recognize the high risk of arterial thromboembolism associated with anterior wall MIs
563. The most common cause of aortic dissection is systemic HTN
564. CK-MB fraction has a high specificity for an acute MI (slightly lower than cardiac troponins). It begins to rise within 4-6 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 diagnosis of a recurrent MI.
565. 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
566. Electrical alternans is an important EKG finding for the diagnosis of pericardial tamponade. Other findings include sinus tachycardia and low voltage QRS complexes.
567. Viral infection is the most common cause of myocarditis that results in idiopathic dilated cardiomyopathy. The most frequently implicated virus is Coxsackie’s B virus.
568. Exercise testing is indicated in the risk stratification of patients with coronary artery disease. Understand the indications of other non-invasive tests for the diagnosis of coronary artery disease
569. Know how to treat acute pulmonary edema in the setting of acute MI. Loop diuretics should be given to treat pulmonary edema.
570. Tobacco and alcohol are reversible risk factors for the development of atrial premature beats.
571. A detailed medical history and physical examination is the most effective way to screen a low risk population for the presence of underlying cardiac disease
572. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in young athletes
573. HCM follows autosomal dominant inheritance
574. Know how to manage symptomatic HCM. Beta-blockers are usually the first line of medication.
575. Total abstinence from alcohol is the mainstay of alcoholic cardiomyopathy management and it may reverse this condition if it is employed earlier in the course of the disease
576. Know the physiology of HCM and be able to correctly identify the factors that increase or decrease the intensity of the murmur in HCM. Valsalva maneuver and standing-Increase; Handgrip, Phenylephrine and Leg elevation; Decrease the murmur.
577. Screening should be done in all first-degree relatives of the patients of hypertrophic cardiomyopathy and the most effective way of screening these people is echocardiography
578. Mitral valve prolapse is the most common cause of mitral regurgitation in USA
579. Restrictive cardiomyopathy is characterized by severe diastolic dysfunction due to a stiff ventricular wall.
580. Beta blockers are used to treat chest pain, palpitations, and autonomic symptoms of MVP.
581. Know how to diagnose mitral valve prolapse based on clinical findings. Remember the ‘systolic click’
582. . The presence of a tapping apex beat, a loud first heart sound, and a mid-diastolic rumble at the apex suggest the diagnosis of mitral stenosis in this patient.
583. Atrial fibrillation in MS is due to left atrial dilatation.
584. 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.
585. Know how to manage a case of CHF exacerbation due to atrial fibrillation with a rapid ventricular response. Digoxin is the drug of first choice in this situation
586. S. Aureus is the most frequent cause of IE in IV drug abusers
587. Transesophageal echocardiography or computed tomographies are the diagnostic studies of choice for suspected aortic dissection.
588. The typical radiographic abnormalities and PaO2/FiO2 ratio of 91.6 (which is less than 200) in the setting of absent clinical evidence of elevated left atrial pressures (or PCWP 50, do yearly digital rectal plus PSA (Prostate Specific Antigen)
749. In Waldenström’s Macroglobulinemia, IgM is produced in excess amounts which causes hyperviscosity of the blood. IgM spike on electrophoresis and hyperviscosity are two important diagnostic clues for this disorder.
750. Eradication of H. pylori by antibiotics is the most accepted and recommended next best step in the management of gastric mucosa-associated lymphoid tissue lymphoma without any metastasis.
751. Adenocarcinoma of lung has the least association with smoking. It is usually located peripherally and consists of columnar cells growing along the septa. It presents as a solitary nodule and may be detected incidentally.
752. Squamous cell carcinoma of mucosa of head and neck may present with palpable cervical lymph node. The best test for such patients is panendoscopy to detect the primary tumor.
753. There is no evidence that ultrasound of abdomen can help in decreasing mortality from ovarian cancer.
754. For a breast mass that disappears completely with FNA and fluid aspirated is clear, next step is to observe for 4 weeks.
755. Tamoxifen reduces the risk of breast cancer in patients who are at an increased risk of developing breast cancer.
756. Paget’s disease presents as a persistent dermatitis of the nipple. There is a red, oozing, crusted lesion, which is often unresponsive to topical steroid and antibiotics. Biopsy shows malignant cells that invade the epidermis and have abundant pale staining cytoplasm surrounding a hyper-chromatic nucleus, with prominent nucleoli.
757. Tamoxifen increases the risk of two types of cancer that can develop in the uterus: endometrial cancer, which arises in the lining of the uterus, and uterine sarcoma, which arises in the muscular wall of the uterus.
758. Recognize migratory thrombophlebitis and consider appropriate investigation to find out the possible occult malignancy.
759. Ondansetron is the drug of choice for chemotherapy-induced emesis.
760. Melanoma should be on the top of the list if a metastatic mass bleeds inside brain.
761. In low risk patients (i.e. < 40 years and non smokers) a solitary pulmonary nodule is not a sign of immediate alarm. The best approach is to ask for an old x-ray.
762. The best way to handle bone tumor is to recognize it and leave it for experts.
763. Amphotericin should be started in febrile neutropenic patients if they are persistently febrile despite of 5-7 days of ceftazidime/cefepime plus vancomycin.
764. Febrile neutropenia is a medical emergency; patient should be admitted in hospital and started on broad-spectrum antibiotics preferably 3rd generation cephalosporins after obtaining blood cultures.
765. Radiologically, Ewing's sarcoma is associated with a lamellated or "onion skin" periosteal reaction. The lesion is usually lytic and central. Endosteal scalloping is often present.
766. Any contrast enhancing, heterogeneous, irregular mass on kidney is a malignancy until proven otherwise. Through workup by an urologist is recommended
767. Hypercalcemia and hilar mass in a smoker of more than 45 years is most likely from a squamous cell carcinoma of the lungs.
768. Hypercalcemia and intractable ulceration can be due to MEN syndromes.
769. Syndrome of inappropriate antidiuretic hormone secretion is often seen with small cell carcinoma of the lung.
770. CT chest should be done to look for thymoma in all newly diagnosed myasthenia gravis patients.
771. IV normal saline is the first step in managing acute hypercalcemic crisis.
772. An increase in serum levels of both insulin and C-peptide and hypoglycemia is diagnostic of insulinoma.
773. Acanthosis nigricans might be a manifestation of occult gastrointestinal malignancy.
774. Water restriction is the first step in managing hyponatremia in patients with syndrome of inappropriate antidiuretic hormone secretion.
775. Hypocalcemia is an important component of Tumor Lysis Syndrome. It is believed to be due to the release of intracellular products by cell lysis. There are a number of metabolic abnormalities associated that include hyperphosphatemia, hypocalcemia, hyperkalemia, and hyperuricemia.
776. Any adolescent boy who presents with epistaxis and has localized mass with bony erosion on the back of the nose has an angiofibroma until proven otherwise.
777. Patients with Peutz-Jeghers syndrome have a high risk of developing ovarian tumors.
778. Hyperglycemia, necrolytic migratory erythema and diarrhea should make you think about glucagonoma.
779. Know how to diagnose osteosarcoma. Codman’s triangle and sunburst appearance are the two classic radiologic features of this entity.
780. Spironolactone is the diuretic of choice for managements of ascites.
781. The drug of first choice for cancer-associated anorexia is Megestrol acetate.
782. Recognize acute monocytic (FAB M5) leukemia based on the smear and positive ‘alpha-naphthyl esterase’
783. Chronic lymphocytic leukemia is almost always seen in elderly patients; presence of marked leukocytosis with predominant lymphocytosis and smudge cells are the diagnostic features.
784. Multiple myeloma is a plasma cell disorder and often presents with lytic lesions, hypercalcemia, and renal failure.
785. Know about the typical presentation of infectios mononucleosis and always keep in mind that heterophil antibody test is usually positive after 3 weeks of infection.
786. Recognize the importance of tartrate resistant acid phosphatase stain in the diagnostic of hairy cell leukemia.
787. Acute lymphoblastic leukemia is predominantly a disease of children and recognize the importance of periodic acid schiff positive staining in diagnosis.
788. Know the blood indices in various types of anemias. Megaloblastic anemias are characterized by elevated MCV, 90% of the times elevated MCH, and normal MCHC.
789. Patients with high MCV should be tested for vitamin B12 and folic acid levels. Know how to differentiate between various causes of megaloblastic anemia.
790. In a patient with increased reticulocyte count, increased bilirubin, negative Coombs test and spherocytes on peripheral blood films, the diagnosis of Hereditary Spherocytosis (HS) is top on the list
791. PA is the most common megaloblastic anemia and is the prototype of the group. In PA, Vitamin B12 deficiency is caused by reduced Intrinsic factor (IF) secondary to gastric atrophy. In majority of the cases antibodies to parietal cells have been reported.
792. Microcytic anemia and basophilic stippling in a child should make you think about lead poisoning.
793. In Paroxysmal Nocturnal Hemoglobinuria , a red cell membrane defect causes increased binding of complement to the red cell leading to increased intravascular hemolysis.
794. Know the iron studies in various types of microcytic anemias. Low serum iron, ferritin, and increased TIBC indicates iron deficiency anemia.
795. Polycythemia can present with hypertension. Know various presentations of polycythemia vera and try to identify it from other causes of hypervolemia.
796. Presence of antibodies to ds-DNA is specific for the diagnosis of systemic lupus erythematosus
797. New onset diabetes, arthropathy, and hepatomegaly should alert you about the possibility of hemochromatosis.
798. In P. Vera urinary erythropoetin assay reveals the absence of measurable erythropoetin in the urine.
799. In CLL, presence of thrombocytopenia is a poor prognostic factor.
800. Try to identify chronic lymhpocytic leukemia from clinical picture and hematological findings. Lymph node biopsy not bone marrow biopsy confirms the diagnosis.
801. Know that leukocyte alkaline phosphatase score is high in leukemoid reactions and usually low in chronic myeloid leukemia.
802. The hallmark of Bernard –Soulier syndrome is the Giant platelets. There is mild thrombocytopenia but the major defect is of membrane glycoprotein Ib. This defective platelet membrane lacks the receptor site for vWF so the platelets can’t adhere to vascular subendothelium.
803. Glazmann’s Thrombasthenia is a qualitative platelet defect with normal platelet count but prolonged bleeding time and abnormal aggregation test with ADP.
804. Elderly patient with anemia, renal failure, and hypercalcemic should make you think of multiple myeloma
805. Imatinib has changed the prognosis in patients with chronic myelogenous leukemia.
806. Know the diagnostic features of Hairy Cell Leukemia and that Cladribine is the drug of choice for it.
807. Know the presentation of thrombotic thrombocytopenic purpura and its differentiating features from disseminated intravascular coagulation, idiopathic thrombocytopenic purpura and hemolytic uremic syndrome.
808. Folic acid supplementation is encouraged in patients with high risk for developing aplastic crisis.
809. Bone marrow iron stain is the most definite way to diagnose iron deficiency anemia.
810. Recognize the pathology of B12 deficiency anemia. B12 stores are available for 3-4 years.
811. Supplementation with folic acid may correct anemia but will not correct neurological complications in patients with vitamin B12 deficiency.
812. Consider macro vascular hemolysis as a cause of microcytic anemia in patients with artificial heart valves or severely calcified aortic valves.
813. Always consider G6PD deficiency in patients who develop acute hemolysis following ingestion of primaquine or sulfa drugs. Also, G6PD levels are often normal during the hemolytic episode.
814. Acute cord compression in cancer patient is a medical emergency and needs prompt administration of intravenous steroids as the first step.
815. Radiation therapy is useful in managing bone pain in patients with prostate cancer who have undergone orchiectomy.
816. Vitamin K deficiency can occur following chronic diarrhea or broad-spectrum antibiotic use, manifesting with bleeding disorders in the form of easy bruisability, mucosal bleeding, etc. PT is prolonged. If the PT is not corrected with administration of vitamin K, it should make you think that this is not the result of vitamin K deficiency and liver disease should be suspected.
817. Recognize HUS in a child who has recently recovered from a diarrheal illness and presents with acute renal failure, microangiopathic hemolytic anemia, fever, thrombocytopenia and characteristic peripheral smear finding of schistocytes.
818. 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.
819. 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.
820. Reye’s syndrome or acute fatty liver with encephalopathy can lead to fulminant hepatic failure in children.
821. Pancreatic pseudocyst is a complication of both acute and chronic pancreatitis and is diagnosed by ultrasound.
822. Anti mitochondrial antibodies are present in 90% of patients with primary biliary cirrhosis.
823. Liver disease should be evaluated on the basis of tests to assess both the function and the structural integrity of the liver.
824. Hyperestronism in cirrhosis leads to gynecomastia, testicular atrophy, decrease bodily hair, spider nevi and palmar erythema.
825. Suspect spontaneous bacterial peritonitis (SBP) in cirrhotic patients with fever and ascites.
826. High serum AFP (>500 ng/ml) in an adult with liver disease and without an obvious G.I. malignancy is strongly suggestive of hepatocellular carcinoma.
827. Abdominal ultrasound is the best initial investigation for gallbladder pathology.
828. The triad of sudden onset right upper abdominal pain, fever, and leucocytosis is highly suggestive of acute cholecystitis.
829. Newborns of mothers with active hepatitis B should be passively immunized at birth with hepatitis B immunoglobulin followed by active immunization with recombinant HBV vaccine.
830. Risk factors for non alcoholic hepatic steatosis are obesity, diabetes mellitus, hyperlipidemia, total parental nutrition and bypass surgery for obesity.
831. Hemochromatosis is an autosomal recessive disorder characterized by increased skin pigmentation, diabetes, cirrhosis and arthralgia.
832. Checking for anti HBcAg and HBsAg is the best screening of the acute hepatitis B.
833. HCV RNA is the single most sensitive serological marker to screen for HCV infection.
834. Hepatitis E has a very high rate of progression to fulminant hepatitis in pregnant women.
835. Acute liver failure or fulminant hepatitis is most commonly due to acetaminophen toxicity.
836. Persons who received blood transfusions before 1992 should be screened for Hepatitis C and those with blood transfusions before 1986 should also be screened for hepatitis B.
837. Isoniazid causes idiosyncratic liver injury with histology similar to viral hepatitis.
838. Primary sclerosing cholangitis is caused by inflammatory destruction of both the intrahepatic and extrahepatic biliary channels. It is often associated with ulcerative colitis.
839. Alpha-1 Antitrypsin deficiency can cause panlobular emphysema and cirrhosis.
840. Non-selective B blockers are used in primary and secondary prevention of variceal bleeding in cirrhotic patients who have portal hypertension with varices.
841. The first step in the treatment of acute variceal bleeding is to get vascular access with two large bore intravenous needles.
842. C-J 1 is characterized by:

1. Unconjugated hyperbilirubinemia of 8-30mg/dl.
2. Normal liver enzymes and histology.
3. High rates of kernicterus
4. No response to Phenobarbital

C-J 2 is characterized by:

1. Unconjugated hyperbilirubinemia of 1000mg/dl can cause acute pancreatitis.
878. Endoscopic retrograde cholangiopancreatography is the investigation of choice for patients with recurrent pancreatitis with no obvious cause.
879. Paracentesis can be used for both diagnostic and therapeutic purposes in patients with ascites.
880. Hydatid cysts in the liver are due to infection with Echinococcus granulosus.
881. Transjugular intrahepatic portosystemic shunt procedure is used in cirrhotic patient for refractory ascites, refractory hydrothorax, and surgical management of acute recurrent variceal bleeding.
882. Entamoeba histolytica is a protozoan, which can cause amebic liver abscess. Remember the Mexico trip.
883. Factors independently associated with high rates of liver fibrosis in chronic hepatitis C patients are:
1. Male gender.
2. Acquiring infection after age of 40.
3. Alcohol intake: alcohol intake in any amount can hasten the progression of fibrosis in patients with chronic hepatitis C.
884. ERCP with sphincterotomy is the treatment of choice for sphincter of oddi dysfunction
885. The treatment of acute cholangitis is to give supportive care, broad-spectrum antibiotics, and biliary drainage with an endoscopic retrograde cholangiopancreatography.
886. Checking for urinary excretion of bilirubin is an easy and effective way of determining whether the cause of jaundice is conjugated or unconjugated bilirubin. So the presence of bilirubin in urine is indicative of conjugated hyperbilirubinemia.
887. Conjugated hyperbilirubinemia is mainly because of intrahepatic or extrahepatic obstruction or congenital impaired hepatic excretion of bilirubin.
888. Acute pancreatitis is one of the conditions causing acute abdomen, which is managed conservatively.
889. About 10% of patients on isoniazid develop a mild elevation of aminotransferases within first few weeks of the treatment. However, this elevation of aminotransferases returns to normal despite continued use of isoniazid in most of the patients.
890. Orthotopic liver transplantation remains the only effective mode of treatment of fulminant hepatic failure and should be considered in any patient presenting with fulminant hepatic failure, regardless of the etiology.
891. Liver biopsy is the most reliable way to distinguish chronic active from chronic persistent hepatitis.
892. Benign intrahepatic cholestasis can develop after a major surgery in which hypotension, extensive blood loss into tissues and massive blood replacement are notable.
893. 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).
894. Porcelain gall bladder is an entity usually diagnosed on an abdominal x- ray. The condition predisposes individuals to gall bladder carcinoma and requires resection.
895. In a patient with primary amenorrhoea and no breasts, estrogen is low and FSH measurement should be ordered: if it is decreased, GnRH stimulation test is the next step; if it is increased, karyotype is the next step.
896. In any woman of childbearing age with amenorrhea, first rule out pregnancy.
897. DUB is the most common cause of abnormal uterine bleeding, but owing to its benign nature, it is a diagnosis of exclusion. About 70% of cases are caused by anovulatory cycles. After menarche and before menopause it is considered physiologic. IV estrogen is the drug of choice for uncontroled bleeding.
898. When to perform endometrial biopsy to rule out endometrial carcinoma in patients with DUB? If the patient is older than 35 years, obese, diabetic or with chronic hypertension.
899. OCPs have been shown to decrease the risk of ovarian and endometrial carcinoma. As for breast cancer, the risk does not seem to change with their use. Beside hypertension, OCPs expose to other complications such as thromboembolism, cerebrovascular disease, MI, gallblader disease and benign hepatic tumors.
900. Postcoital or emergency contraception has become necessary because it is estimated that around 60% of pregnancies in the US are unplanned. It can be given upto 72 hours.
901. Presence of dysmenorrhea, heavy menses, and enlarge uterus is almost diagnostic of either adenomyosis or fibroid uterus.
902. Primary dysmenorrhea usually appears 6 to 12-months after menarche. NSAIDs are highly effective for treatment; oral contraceptive pills inhibit ovulation and are also effective.
903. Patients with polycystic ovarian disease (PCOD) 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.
904. Treatment for overflow incontinence includes cholinergic agents and intermittent self-catheterization.
905. External hordeolum or stye is a common staphylococcal abscess of eyelid, which is treated with warm compresses and if the resolution doesn’t begin in next 48hrs, with incision and drainage.
906. Age related macular degeneration is usually seen in patients above 50yrs of age, presents with progressive and bilateral loss of central vision with preservation of navigational vision.
907. Congenital cataract is the most common cause of white reflex in pediatric population.
908. Allergic conjunctivitis is an acute hypersensitivity reaction caused by environmental exposure to allergens and characterized by intense itching, hyperemia, tearing, conjunctival edema and eyelid edema.
909. Cataract is a vision-impairing disease, due to progressive thickening of lens and characterized by blurred vision and glare.
910. Angle Closure Glaucoma occurs predominantly in people aged 55-70 yrs and presents with acute onset of severe eye pain and blurred vision associated with nausea and vomiting.
911. Open Angle Glaucoma is more common in African Americans, is generally asymptomatic in intial stages and characterized by gradual loss of peripheral vision over a period of years resulting into tunnel vision.
912. Postoperative endophthalmitis is the most common form of endophthalmitis, usually occurs within six weeks of surgery.
913. Vesicular rash in the terminal distribution with dendriform corneal ulcers is suggestive of Herpes zoster opthalmicus.
914. CMV retinitis occurs when CD4 count is less than 50/ul; may be asymptomatic and is diagnosed by the characteristic fundoscopic findings of yellow white patches of retinal opacification and hemorrhages.
915. Optic neuritis presents with changes in color perception and decreased visual acuity. Afferent pupillary defect and central scotoma should make you think of optic neuritis. Remember the association between optic neuritis and multiple sclerosis.
916. Trachoma presents as follicles in the conjunctiva and signs of nasopharyngeal infection.
917. Dacryocystitis presents with inflammatory changes in the medial canthal region of the eye.
918. Hordeolum is a painful, tender swelling localized to the eyelid.
919. Corneal vesicles and dendritic ulcers characterize Herpes simplex keratitis.
920. Amaurosis fugax is transient loss of vision due to embolic phenomena
921. Recognize the clinical presentation of retinal detachment; it usually presents with sudden onset of photopsia and floaters.
922. Vitreous hemorrhage occurs in patients with diabetic retinopathy and the fundus is hard to visualize.
923. When an individual with acute glaucoma is diagnosed, all agents, which can dilate the pupil, like atropine, should be avoided.
924. Spontaneous subconjunctival hemorrhage is a benign finding and does not require any treatment.
925. In any patient less than 3 years old and presenting with impairment in social interactions and communication, delayed language development, and stereotypical behaviors, always thinks of autism.
926. Thus, in any patient with symptoms of short attention span, impulsivity, and hyperactivity, for more than 6 months in more than one setting, ADHD should be considered as the most probable diagnosis.
927. Infant botulism is transmitted by ingestion of food contaminated with C. botulinum. The germ grows in the gut and produces a toxin, which is responsible for the clinical signs.
928. Ventricular septal defects are common in patients with Edward’s syndrome, which is characterized by micrognathia, microcephaly, rocker bottom feet, overlapping fingers, and absent palmar creases.
929. Hirschsprung’s disease occurs with increased frequency in patients with Down’s syndrome.
930. Cystic fibrosis may presents with meconium ileus, which is characterized by bilious vomiting, failure to pass meconium at birth, and ground glass appearance on abdominal X-rays.
931. Midgut volvulus usually presents in a child less than one month with bilious vomiting, abdominal distension and bloodstained stools.
932. In a neonate who presents with bloody diarrhea, the presence of eosinophils in the stools and positive family history of atopy suggest the diagnosis of milk protein intolerance.
933. Painless melena in a 2 to 3-year-old child is most likely due to Meckel's diverticulum.
934. Fiberoptic laryngoscopy in the operating room is the most appropriate next step when diagnosis of acute epiglottitis is suspected.
935. Pyloric stenosis presents with non-bilious vomiting in a 4 to 8-week-old child, and abdominal ultrasound confirms the diagnosis.
936. Gaucher’s disease is diagnosed based on the radiological appearance of Erlenmeyer flask deformity of the distal femur, and characteristic Gaucher cells with their wrinkled paper appearance in bone marrow examination.
937. Children with a parental history of elevated total cholesterol levels (>240 mg/dL), or risk factors for coronary artery disease should get a screening test for total cholesterol level.
938. Peroxisomal disorders such as Zellweger's syndrome should be considered in neonatal seizures, especially if the neonate presents with typical facial dysmorphism.
939. Patients with classic phenylketonuria present with fair skin, blue eyes, musty body odor and eczema, and labs show elevated plasma phenylalanine levels.
940. Cri-du-chat syndrome is due to 5p deletion and it presents with features of hypotonia, short stature, and a characteristic cat-like cry.
941. Edwards' syndrome commonly presents with microcephaly, prominent occiput, micrognathia, closed fists with index finger overlapping the 3rd digit and the 5th digit overlapping the 4th, and rocker bottom feet.
942. Down’s syndrome, or trisomy 21, presents with flat face, upward and slanted palpebral fissures, epicanthal folds, simian crease, short and broad hands, hypoplasia of the middle phalanx of the 5th fingers, and high arched palate.
943. Vitamin D deficiency rickets is more common in dark skinned infants who are less exposed to sunlight and are 1-2 years of age. It presents with craniotabes, rachitic rosary, and thickening of the lower end of long bones, all due to defective mineralization.
944. Birth injuries such as clavicular fracture are common complications in mothers with GDM and large babies.
945. Mongolian spots are flat blue or gray lesions, characteristically well demarcated, seen more commonly in the sacral or presacral areas, and disappear by the first few years of life.
946. Conduct disorder is characterized by disruptive behavioral patterns that violate basic social norms present for more than one year, in patients less than 18 years old.
947. Suspect Vitamin A deficiency in any child 2 to 3 years of age presenting with dry eyes and skin, photophobia, and impaired dark adaptation.
948. Iron supplementation in the form of iron-fortified milk formula or medicinal iron, should be started at 6 weeks in all premature and low birth weight babies.
949. Maternal HIV infection is an absolute contraindication to breast-feeding.
950. Heroin withdrawal usually presents within the first 48 hours of life, with tremors and hyperirritability as the most prominent symptoms.
951. Surgery is advised in umbilical hernia if the hernia persists to the age of 3-4 years, exceeds 2 cm in diameter, causes symptoms, becomes strangulated, or if it enlarges progressively after the age of 1 to 2 years.
952. Physiological jaundice usually presents after 24 hours of birth. Any jaundice in the first 24 hours of birth, or a direct hyperbilirubinemia, needs detailed evaluation for the cause of jaundice.
953. Neonatal necrotizing enterocolitis should be suspected in any preterm or low birth weight infant with fever, vomiting, abdominal distension, and roentgenographic finding of pneumatosis intestinalis.
954. Hyaline membrane disease should be suspected in preterm infants with respiratory distress and hypoxia not responding to oxygen therapy, and is treated early with mechanical ventilation and surfactant
955. Cephalohematoma is a subperiosteal hemorrhage, presents few hours after birth as scalp swelling limited to one cranial bone.
956. Absence seizure is a generalized seizure of childhood and is characterized by sudden and brief lapses of consciousness without loss of postural control. It usually presents with multiple 'daydreaming' episodes and decline in school performance.
957. Intussusception, the most common cause of intestinal obstruction in the first two years of life, presents with intestinal obstruction and red currant jelly stools containing blood and mucus.
958. Calcified lesion above the sella requires an evaluation for craniopharyngioma.
959. Sturge-Weber syndrome is a neurocutaneous syndrome and is characterized by congenital unilateral cavernous hemangioma along the trigeminal nerve distribution; radiography shows characteristic intra-cranial calcifications that resemble a tramline.
960. Supportive care is the mainstay of treatment in cases of infant botulism.
961. The treatment of Kawasaki's disease consists of aspirin and IV immunoglobulins.
962. Always suspect pyloric stenosis in a neonate who presents with non-bilious, projectile and persistent vomiting, and order abdominal ultrasound to establish the diagnosis.
963. Osgood-Schlatter disease is generally a disease of children age around 10-17 years, which presents with knee pain at the tibial tuberosity, that is, at the site of insertion of the quadriceps tendon.
964. Recognize fetal alcohol syndrome and know that it is the most common cause of mental retardation in children. Remember the midfacial abnormalities.
965. Guthrie test is a qualitative (coloration) test which can detect the presence of metabolic products of phenylalanine in the urine.
966. The healthy appearance of the neonate, the evanescent nature of the rash, and the distinctive red halo surrounding the lesions support the diagnosis of erythema toxicum. The presence of eosinophils in the skin lesions is diagnostic.
967. Galactosemia should be considered for the newborn or young infant who has failure to thrive, bilateral cataract, jaundice and hypoglycemia. Early diagnosis and treatment by elimination of galactose from the diet are mandatory.
968. Aplastic anemia should be suspected in any patient with pancytopenia following drug intake, exposure to toxins or viral infections.
969. American Academy of Pediatrics advises against the use of cow's milk in the first year of life. Infants should receive breast milk or iron fortified formulas for the first year of life, and iron-fortified cereal should be added at the age of 4-6 months.
970. Any patient with recurrent or unusual lymphadenitis, hepatic abscesses, osteomyelitis at multiple sites, or unusual infections with catalase-positive organisms (e.g., S. aureus) requires clinical evaluation for chronic granulomatous disease.
971. Severe combined immune deficiency is a life-threatening syndrome presenting with recurrent bacterial, viral and fungal infections, and diagnosed by absence of lymph nodes and tonsils, lymphopenia, and absence of a thymic shadow on chest X-rays.
972. Hyper-IgM syndrome (HIM) is characterized by high levels of IgM with deficiency of IgG, IgA and poor specific antibody response to immunizations.
973. Bruton’s agammaglobulinemia classically presents in a male infant of 6-9 months of age with recurrent pneumonia and otitis media. Level of all classes of immunoglobulins and circulating B-lymphocytes are decreased.
974. Salicylates are contraindicated in young children with viral infections. Recognize the clinical presentation of Reye’s syndrome.
975. Hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia, in the presence of liver and kidney enlargement, are hallmarks of Type I glycogen storage disease (deficiency of Glucose-6-phosphatase).
976. Kawasaki's disease is characterized by fever, conjunctival vascular injection, cracked lips, polymorphous erythematous rash, diffuse erythema of palms and soles and unilateral lymphadenitis.
977. In patients suspected of epiglottitis, visualization of the epiglottis should not be attempted. Securing the airways as soon as possible is the first and foremost step in management of these patients.
978. Croup is caused by Parainfluenza virus and commonly presents in children younger than 3 years with hoarseness, a barking cough, and varying degrees of respiratory distress.
979. Myotonic dystrophy, a slowly progressive, dominantly inherited disorder, usually manifests itself in the third or fourth decade but occasionally appears early in childhood. The genetic defect has been localized to the long arm of chromosome 19 in the type 1 disorder. Myotonia leads to complaints of muscle stiffness and is evidenced by the marked delay that occurs before affected muscles can relax after a contraction. This can often be demonstrated clinically by delayed relaxation of the hand after sustained grip or by percussion of the belly of a muscle.
980. Streptococcal pharyngitis is the most common cause of pharyngitis in children, and the first step in any case of pharyngitis is to do a rapid strep test. Oral penicillin for 10 days is the treatment of choice.
981. Streptococcus pneumonia is the most common cause of acute sinusitis in childhood, followed by Haemophilus influenzae and Moraxella catarrhalis.
982. Sinusitis is a clinical diagnosis in children and is treated with oral amoxicillin in uncomplicated cases.
983. Acute lymphoblastic leukemia is the most common leukemia in children. Diagnosis is mainly based on more than 25% lymphoblasts in the bone marrow.
984. Immune thrombocytopenic purpura typically presents in early childhood after a viral infection with easy bruisability and petechiae. Labs show thrombocytopenia and normal Hb, WBC, PT and PTT.
985. A positive Coombs' test points towards autoimmune hemolytic anemia, and a positive osmotic fragility test points towards hereditary spherocytosis.
986. The intraosseous technique is an excellent site for IV access in children.
987. In children who develop thrombocytopenia after a viral infection, one should suspect immune thrombocytopenia, which is a relatively benign condition.
988. In a newborn in the NICU, abdomen distension, bloody diarrhea, elevated WBCs, that occur after feeding, usually represents necrotizing enterocolitis.
989. The organ system with the highest morbidity and mortality after HUS is the kidneys.
990. In a child who presents with a sudden onset of abdominal pain, bloody diarrhea, and a triad of anemia, thrombocytopenia and renal failure, one should suspect the hemolytic uremic syndrome.
991. In a febrile child who presents an isolated seizure, one has to think of a febrile seizures. They are benign and need to be adressed with reassurance and antipyretics.
992. Trachoma, caused by Chlamydia trachomatis is the most common cause of blindness in the world. The diagnosis is usually made by the presence of lymphoid follicles on the conjunctiva, scarring and limbal follicles.
993. In a patient with sickle cell trait, some protection against malaria is obtained.
994. Asthma when it cannot be controlled by medications, should be an indication for mechanical ventilation. Know when to intubate a patient.
995. Bordetella pertussis presents in children with paroxysms of cough, which can last up to two weeks. The coughing spells are so severe that rectal prolapse and pneumothoraces can ensue.
996. In a patient with severe bouts of coughing and subcutaneous emphysema, a pneumothorax must be ruled out by obtaining chest X-rays.
997. In a patient who presents with symptoms of an upper respiratory tract infection and later develops a rash after exposure to ampicillin, one should think of infectious mononucleosis caused by Epstein-Barr virus
998. When a child presents with chorea, sore throat, fever, pericarditis and subcutaneous nodules, one should suspect Group A streptococcus. It is the leading cause of rheumatic fever.
999. In an infant with meningitis from Neisseria meningococcus, a sudden vasomotor collapse and skin rash is due to adrenal hemorrhage, known as the Waterhouse-Friderichsen syndrome.
1000. In a neonate with signs of meningitis and a petechial rash, one should suspect meningococcemia.
1001. Pyloric stenosis is a surgical condition. However, surgery should be undertaken only after the infant has been resuscitated and electrolytes replaced.
1002. In a young child of 2-5 years age with a localized abdominal mass and hematuria, one has to think of Wilms tumor. If the child age is less than 1 year think of neuroblastoma.
1003. The drug of choice for nocturnal enuresis is DDAVP. Bed-wetting is considered normal until the age of 4-5 years. But if it persists either DDAVP or imipramine is used.
1004. Childhood obesity is a risk factor for development of type 2 diabetes later in life.
1005. Most cardiac murmurs in childhood are benign and require only observation
1006. DiGeorge syndrome is associated with cyanotic heart disease, craniofacial anomalies, thymic hypoplasia, cognitive impairment and hypoparathyroidism. It is essential to monitor the calcium levels in these infants.
1007. In a child who has proximal muscle weakness and exhibits a Gower’s sign, with depressed reflexes and pseudohypertrophy, a muscular dystrophy must be suspected
1008. Turner syndrome is associated with a higher incidence of coarctation and bicuspid aortic valve. The clinical presentation is that of short stature, short webbed neck and a low posterior hairline. The chest is broad with widely spaced nipples.
1009. Duodenal atresia can present with bilious vomiting and 2 large air bubbles on an x-ray. Remember its association with Down syndrome
1010. A typical presentation of TOF individuals is squatting, which increases the systemic vascular resistance and forces blood into the lungs, thus improving cyanosis.
1011. Gall Stone Ileus: Plain abdominal x-rays revealed distended loops of small bowel consistent with partial small bowel obstruction, and gas in the biliary tree and gallbladder. US confirmed gas in the biliary tree, but could not identify the gallbladder and could not determine the cause of intestinal obstruction.
1012. The treatment of recurrent aortic coarctation is balloon angioplasty.
1013. Down syndrome patients are prone to endocardial cushion defects, which can rapidly cause pulmonary hypertension.
1014. In a child presenting with failure to thrive and steatorrhea, with a history of neonatal jaundice, cystic fibrosis must be ruled out. The diagnosis of cystic fibrosis is made after evaluating the sweat chloride.
1015. In a young child who presents with recurrent upper respiratory tract infections and bilateral nasal polyps, cystic fibrosis must be ruled out.
1016. The most common cause of amblyopia is strabismus. Other causes include errors of refraction, and opacity of media along the visual axis. The standard of treatment is occlusion of the normal eye.
1017. Thyroid dysgenesis is the most common cause of congenital hypothyroidism in United States.
1018. Mongolian spots could most commonly be found in dark-skinned populations, present from birth and usually fades and then disappears in several years.
1019. Neonatal chlamydial conjunctivitis is treated with systemic erythromycin because of the risk of pneumonia.
1020. Anemia of prematurity is the cause of anemia in premature and low birth weigh infants. The pathology involves a combination of diminished RBC production, shortened RBC life span, and blood loss. Iron supplementation does not prevent falling hemoglobin and is not the cause of anemia of prematurity.
1021. Vaginal discharge in newborn is due to the effects of maternal estrogens and reassurance of the mother is all that is required.
1022. Osteogenesis imperfecta is caused by mutations in type 1 collagen and its typical features are blue sclera and recurrent fractures.
1023. Painless gross hematuria is the most common presentation of sickle cell trait.
1024. Hydroxyurea is indicated in patients with frequent, acute, painful episodes, as it tends to increase Hb F levels.
1025. Dactylitis is the earliest manifestation of vaso-occlusive disease in sickle cell anemia.
1026. Pubertal gynecomastia is seen in about one-half of adolescent boys, at an average age of 14 years; it is often asymmetric or transiently unilateral, frequently tender, and just needs observation.
1027. All children with recurrent episodes of nocturnal vulvar itching should be examined for pinworms and may be treated empirically.
1028. Neonatal tetanus is generally seen in infants born to unimmunized mothers, frequently following umbilical stump infection, and is characterized by poor suckling and fatigue, followed by rigidity, spasms and opisthotonus in first two weeks of life.
1029. DBS is a macrocytic pure red aplasia associated with several congenital anomalies including short stature, webbed neck, cleft lip, shielded chest and triphalangeal thumbs.
1030. Lesch-Nyhan syndrome is secondary to deficiency in HRPT. It presents with self-mutilation and neurologic features including mental retardation, dystonia, choreoathetosis and spasticity. Gout is usually seen in patients of above 50 years of age. If you see a boy with gout, suspect this.
1031. Iron poisoning presents with nausea, vomiting, diarrhea, abdominal pain, gastrointestinal bleeding and metabolic acidosis. As iron is radio-opaque, the tablets can be seen in the stomach on abdominal x-ray. Diagnosis is confirmed by measuring serum iron levels. Deferoxamine, an iron chelator, is used IV in moderate to severe intoxications.
1032. Neuroblastoma is the third most common cancer in the pediatric population (after leukemia and CNS tumors). It arises from neural crest cells which secondarily populate sympathetic ganglia and adrenal medulla. The most common site is the abdomen.
1033. Features of Prader-Willi syndrome (obesity hypogonadism syndrome) include hypotonia, hypogonadism and obesity. Also, try to remember the mental retardation and dysmorphic craniofacial features.
1034. In patients with sickle cell disease, acute severe anemia with absent reticulocytes in peripheral blood is due to aplastic crisis.
1035. Beckwith-Wiedemann syndrome is characterized by macrosomia, macroglossia, visceromegaly (liver and kidneys) and omphalocele, in addition to the neonatal hypoglycemia and hyperinsulinemia.
1036. The three most common organisms that cause pneumonia in patients with cystic fibrosis are:
1. Hemophilus. 2. Pseudomonas. 3. Staphylococcus
1037. Rotavirus is the most common cause of acute diarrhea in children, especially in those between 6 months and 2 years.
1038. Meconium aspiration syndrome occurs most commonly in low birth weight and post-mature infants. It is characterized by respiratory distress at birth, rales and rhonchi on auscultation, hyperinflation, coarse streaking and patchy opacities on chest x-ray.
1039. Mouth burns with drooling of saliva and difficulty in swallowing are classic indicators of caustic acid or alkali ingestion. The patient is often conscious, but in severe pain.
1040. Replacement of diarrheal loss of fluid with lots of low solute fluid like water can lead to water intoxication, hyponatremia and even seizures.
1041. Esophageal atresia presents with choking, regurgitation and coughing associated with the first feeding of the newborn infant.
1042. Premature adrenarche and thelarche often have no clinical significance. Pubarche requires a thorough evaluation, as it may be due to a CNS disorder in 50% of cases.
1043. Hypocomplementemia (low C3, CH50) in post streptococcal glomerulonephritis resolves in 8 - 12 weeks.
1044. In the presence of a cyanosis, aggravated by feeding and relieved by crying, think of choanal atresia.
1045. McCune-Albright syndrome is characterized by precocious puberty, pigmentation (cafe au lait spots) and polyostotic fibrous dysplasia.
1046. Sudden infant death syndrome is the leading cause of mortality in infants between 1 month and 1 year of age, and the third most common cause of mortality in infants < 1 year.
1047. For prevention of SIDS, infants should be placed on their backs while sleeping. Home monitors do not decrease the risk of SIDS
1048. For pertussis prevention, all close contacts should be given erythromycin for 14 days, regardless of age, immunizations, or symptoms.
1049. Individuals who are exposed to tick-infested areas should wear light-colored clothing with long-sleeved shirts and long pants tucked into socks or boot tops.
1050. Cystic fibrosis presents with failure to thrive, which occurs due to fat and protein malabsorption from a pancreatic insufficiency.
1051. COA patients have hypertension in the upper part of the body and relative hypoperfusion of the lower part of the body. A mild, continuous murmur heard all over the chest is due to the development of collaterals between the hypertensive and hypoperfused vessels. Rib notching, caused by the dilatation of the collateral chest wall vessels, is specific for coarctation.
1052. 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.
1053. Know how to manage various manifestations of exacerbation of COPD. Recognize collapse of the lung on chest-x ray. Bronchoscopic removal of mucus pugging is crucial.
1054. Always consider candida albicans as a cause of infection in a patient with uncontrolled diabetes mellitus.
1055. Tuberculosis occurs early in the course of HIV when the CD 4 counts are greater than 200/microL. Upper lobe consolidation and/or cavitation is the typical X-ray finding.
1056. Suspect acute bronchopulmonary aspergillosis in asthmatics with worsening asthma symptoms, coughing brownish mucous plugs, recurrent infiltrates and peripheral eosinophilia.
1057. 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.
1058. 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.
1059. Know the three major complications of too high a PEEP: Alveolar damage, Tension pneumothorax and Ventricular failure.
1060. 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.
1061. Suspect pulmonary embolism in any patient who presents with sudden onset of SOB, pleuritic chest pain, normal lung exam, hypoxic, and have tachypnea, tachycardia and hypotension. New onset atrial fibrillation is seen in few patients with PE.
1062. Always consider the risk of fat embolism in patients with multiple complicated fractures. Fat embolism is a clinical diagnosis usually characterized by a triad of respiratory insufficiency, neurological impairment and a petechial rash. Early immobilization and operative fixation of fractures reduces the chances of fat embolism.
1063. BAL (bronchoalveolar lavage) is > 90% effective in diagnosing pneumocystis carini pneumonia in HIV positive patients, especially when CD4 count is less than 200.
1064. Identify occupational interstitial lung diseases: i.e. Hypersensitivity Pneumonitis, Organic dusts (Byssinosis) and inorganic dusts (asbestosis, silicosis, berylliosis and coal worker’s pneumonitis).
1065. Identify allergic granulomatosis of Churg-Strauss and remember that leukotreine antagnoists are known to cause CSS.
1066. Know the pathophysiology of ARDS and how to differentiate between ARDS and cardiogenic pulmonary edema. Criteria for ARDS diagnosis is:

1. A pulmonary capillary wedge pressure less than 18 mmHg favors ARDS over cardiogenic pulmonary edema.
2. PaO2 to FiO2 ratio of 200 mmHg or less, regardless of the level of PEEP.
3. Diffuse, bilateral infiltrates on chest-X ray.
1067. Acute bronchopulmonary aspergillosis (ABPA) is characterized by transient recurrent pulmonary infiltrates, peripheral eosinophilia, asthma and immediate wheal and flare reaction to Aspergillus fumigatus and presence of antibodies in the serum against Aspergillus fumigatus.
1068. Remember bronchogenic carcinoma is the most common 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.
1069. A radiographic finding of pleural plaques is the hallmark of asbestos exposure
1070. There is strong association between silicosis and tuberculosis; therefore, steps should be taken to prevent tuberculosis in all patients who have developed silicosis. Patients who have already developed silicosis or they have been exposed to silica for more than 25 years, should be tested yearly by PPD.
1071. The common diagnostic features of ABPA include:
1.Asthma like symptoms
2.Elevated IgE
3.Hypereosinophilia
4.Central bronchiectasis
5.Positive Aspergillus Skin test
1072. When it is unclear whether the patient has nocturnal asthma or gastroesophageal reflux disease, a trial of proton pump inhibitors is both diagnostic and therapeutic.
1073. Patients who are on high doses of beta-2 agonists may develop hypokalemia and patient should be monitored with daily electrolytes. The other side affects of beta-2 agonists are tachycardia, tremor, and peripheral edema.
1074. Know the association of Leukotriene inhibitors with Churg Strauss vasculitis.
1075. Use of prophylactic inhaled corticosteroids is beneficial in the long term out come of chronic persistent asthma.
1076. Due to high incidence of lung cancer among smokers, it should be suspected in any smoker presenting with recurrent pneumonia.
1077. Suspect alpha-1 anti-trypsin deficiency in non-smoker with early onset emphysema.
1078. Obstructive sleep apnea is a common condition among obese population. With never ending pandemic of obesity in US, this is getting wider clinical attention. So, know the causes and management of this condition.
1079. Know the symptoms, clinical and X-ray findings of idiopathic pulmonary fibrosis. IPF is a diagnosis of exclusion. It almost universally progresses and the prognosis is worse.
1080. A sudden drop in oxygen saturation, restlessness, and agitation in a patient on mechanical ventilation in IPPV mode is suggestive of barotrauma. Chest-x ray should be the next step.
1081. High resolution CT scan of the lung is the diagnostic modality of choice for bronchiectasis.
1082. Remember Blastomyces blasts the lungs, skin and bone.
1083. The triad of meningoencephalitis, pneumonia, and spleenomegaly suggests Chlamydia psittaci pneumonia.
1084. 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.
1085. After quitting smoking, home oxygen therapy is the only modality known to prolong survival in COPD.
1086. 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 immunocompetent individuals who are 65 years and older or otherwise at increased risk for pneumococcal disease.
1087. A-a gradient is increased in interstitial lung disease due to poor oxygenation. In restrictive lung diseases, 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.
1088. Bilateral hilar adenopathy and non-caseating granulomas on biopsy suggests sarcoidosis.
1089. Increased ventilatory rate in patients on mechanical ventilation leads to auto PEEP and it can be corrected by reducing the ventilatory rate.
1090. In Goodpasture’s blood studies usually show antibodies against the glomerular basement membrane; it primarily involves the lungs and kidneys.
1091. Remember pneumonia, hyponatremia and diarrhea are almost classic for Legionella.
1092. Know how to manage various clinical situations in exacerbation of chronic obstructive pulmonary disease.
1093. Learn the practical significance of various tests in predicting the usefulness of lung resection in a patient with end stage lung disease.
1094. Know the role of beta agonists and mast cell stabilizers in the management of exercise-induced asthma.
1095. ARDS can present with dyspnea, tachypnea and bilateral fluffy infiltrates on a chest x-ray. It is a condition where hypoxemia persists and it becomes difficult to oxygenate the patient.
1096. When PEEP is increased, its major drawback is a decrease in cardiac output.
1097. Patients who are maintained on PEEP should be monitored with a Swan-Ganz catheter
1098. In ARDS, the one treatment that can improve oxygenation is the addition of PEEP.
1099. In any patient who presents with a lung lesion on a chest x ray, it is best to get old chest x rays and compare the lesion. The lesion may have been present for along time and may be benign.
1100. In a young thin male who smokes and suddenly becomes dyspneic with chest pain, think of pneumothorax.
1101. The most serious complication of bronchiectasis is hemoptysis.
1102. In a patient who has had recent surgery and presents with shortness of breath and tachycardia, the diagnosis of pulmonary embolus must always be suspected.
1103. The most common cause of superior vena cava syndrome today is bronchogenic carcinoma. Benign causes of SVCS are rare and relatively easily diagnosed.
1104. In pulmonary embolism, there can be numerous presentations on a chest x-ray, but the most frequent is a normal x-ray.
1105. IPF is a diagnosis 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.
1106. The triad of upper respiratory tract disease, lower respiratory tract disease, and glomerulonephritis defines Wegener’s granulomatosis. The demonstration of anti neutrophil cytoplasmic antibodies confirms the diagnosis of Wegener’s granulomatosis. The cytoplasmic pattern (C-ANCA) is highly specific
1107. Serologic assays for measurement of anti glomerular basement membrane antibodies further help in confirming the diagnosis and monitoring treatment in patients with Goodpasture’s syndrome.
1108. Proximal (above knee veins) deep vein thrombosis of lower extremities is the most frequent source of pulmonary embolism.
1109. Therapeutic INR for most clinical indications of warfarin is 2.0 to 3.0.
1110. Patients with DVT in whom anticoagulation is contraindicated require placement of inferior vena cava filter for the prevention of pulmonary embolism.
1111. The most common locations of post aspiration lung abscess in recumbent position are apical segment of right lower lobe and posterior segment of right upper lobe.
1112. If you suspect a pulmonary embolism clinically, and chest-x ray, ABG and EKG results rule out other differential diagnoses then you should begin treatment with heparin without waiting for a V/Q scan to confirm your diagnosis.
1113. Two modalities that can decrease mortality in patients with COPD are home oxygen therapy and smoking cessation.
1114. A lung mass with cartilage is most likely a hamartoma and can be observed.
1115. In a drug abuser, presence of well-circumscribed lung opacity is most likely due to embolism of infected vegetation causing a pulmonary infarct.
1116. Primary spontaneous pneumothorax which occurs in young males is almost always due to rupture of subpleural blebs.
1117. In a smoker with arm pain, cough and weight loss, a mass in the lung apex is a Pancoast tumor until otherwise proven.
1118. Anterior mediastinal mass along with elevated AFP and HCG indicates nonseminomatous tumor.
1119. Subcutaneous emphysema in an asthmatic is a benign disorder. A chest-x ray must be ordered to ensure that there is no pneumothorax.
1120. Adverse effects of low-dose inhaled corticosteroids are limited to topical problems like dysphonia and thrush. However, systemic toxicity may occur in patients who are on high-dose inhaled steroids for prolonged periods of time.
1121. Patients with suspected pulmonary embolism should have a chest-x ray and ABG, followed by EKG and V/Q scan.
1122. An enlarged left atrium in mitral stenosis can cause a persistent cough and elevation of the left main stem bronchus.
1123. Always consider lung abscess as an etiology of fever and foul- smelling productive cough in patients predisposed to aspiration.
1124. Electrical alternans is an important EKG finding for diagnosis for pericardial tamponade. Other findings include sinus tachycardia and low voltage QRS complexes.
1125. Know how to manage a case of CHF exacerbation due to atrial fibrillation with a rapid response. Digoxin is the drug of first choice in this situation.
1126. The best test to confirm CSF leakage is the β-2-transferrin.
1127. Often ICU and burn unit support is required in patient with Toxic Epidermal Necrolysis secondary to TMP-SMX.
1128. In an intravenous drug abuser the most frequent cause of skin abscesses is Staphlocccus; however in users of black-tar heroin, Clostridium is the predominant organism. Crepitus is an ominous sign suggesting gas forming organisms and deep infections.
1129. In atopic dermatitis keeping the skin moist with the over-the counter skin moisturizers immediately after bathing/showering is one of the mainstays of therapy.
1130. Liver abscess complicating biliary tract disease is described as “pyogenic” abscess and require drainage.
1131. The most dreaded consequence of pancreatitis is pancreatic necrosis. The biggest risk associated with necrosis is superinfection. Necrotic pancreatic tissue is not always superinfected, and before heroic measures such as surgical debridement are used, the tissue should be sampled.
1132. The most accurate test in patients with a left sided murmur on auscultation is left heart catheterization and angiography because these test accurately delinates the position and nature of the vulvular lesion, as well as determining the ejection fraction and left heart pressures.
1133. Panic disorders can be treated with benzodiazepines such as clonazepam
1134. In erysipelas a superficial cellulitis of the skin topical antifungals are applied for upto 2 weeks before clinical cure, and meticulous foot hygiene should be exercised to prevent recurrences of the fungal infections.
1135. Adrenoleukodystrophy is an X linked disorder characterized by neurologic deficits and adrenal insufficiency. It is caused by accumulation of very long chain fatty acid esters and gangliosides in neurons and gangliosides in the neurons and adrenocortical cells.
1136. A step wise management is required for the management of fibromyalgia. According to this approach, initial therapy includes TCA (amitriptyline) or cyclobenzaprone. If this management is unsuccessful then addition of SSRIs is recommended.
1137. The most common association of optic neuritis is with a demyelinating disease such as multiple sclerosis therefore a MRI of the brain should be performed looking for multiple white matters.
1138. For patients with pneumonia whoa re admitted to the general medical ward the drug of choice is IV β-lactam ( cefotaxime, ceftriaxone, ampi-sulbactum) this will cover atypical pneumonia- mycoplasma, Chlamydia, and legionella. The newer qunilones such as gatifloxacin are the other options for empiric therapy of pneumonia.
1139. In acute angle closure glaucoma the trabecular meshwork becomes blocked at the iridocorneal junction. The iris then creates a block at the border of the lens, obstructing transit and removal of vitreous fluid and rapidly increasing intraocular pressure. Definitive treatment is iridotomy.
1140. In a parotid tumor only a formal parotidectomy can provide complete removal with permanent cure and sparing of facial nerve.
1141. A recommended age appropriate screening is that atleast every 5 years a random cholesterol level should be checked. A fasting lipid profile is checked only if the screening test shows a cholesterol of > 240mg/dl
1142. Sinus tachycardia is the most common ECG change seen in PE.
1143. The tidal volume for a person is calculated as 10mL/kg of weight.
1144. Multiple myeloma results in hypercalcemia which is associated with apathy, decreased interest, psychomotor retardation and depression.
1145. Ulcerative colitis confined to the distal colon also known as proctosigmoiditis. Since the disease is limited to the distal colon topical mesalamine is effective.
1146. Multiple endocrine neoplasia I is associated with gastrinomas, gastrin levels are often elevated and it should be the first test to evaluate. Gastrin producing cells are functionally part of endocrine cells.
1147. Type 1 autoimmune hepatitis is characterized by female predominance, extra hepatic autoimmune disease, hypergammaglobulinemia and positive ANA and ASMA. This disease usually responds to low dose steroids, or a combination of steroid and azathioprine.
1148. The appropriate treatment for Mycoplasma Pneumonia is oral doxycycline.
1149. The most common congenital vulvular disease is mitral valve proplase.
1150. Dopamine blocking and depleting agents are effective in decreasing the involuntary movements of Huntington’s disease. Haloperidol is a dopamine receptor blocker and is commonly used for control of chorea in Huntington disease. There is no specific treatment for Huntington disease.
1151. The diagnosis of a urethral stricture can be made with a combination of direct visualization and radiography. A retrograde urethrogram is performed by injecting dye through a catheter placed just inside the tip of the penis, such that the urethra is outlined with radio-opaque contrast.
1152. Patients with a pulmonary embolus need prolong (6 months) of anticoagulant therapy.
1153. Primary biliary cirrhosis is associated with RA, Sjogren’s syndrome and scleroderma.
1154. Statins are associated with a 1-2 % incidence of marked persistent increase in transminases which resolves with statin discontinuation. It is recommeded that liver transaminases be tested at intitation of therapy at 6 and 12 weeks and periodically thereafter.
1155. For comedones the topical preparation are effective: benzoyl peroxide gels, retinoic acid, adapelene, and topical antibiotics.
1156. For mild papulopustular disease, use topical gel preparation of benzoyl peroxide combined with a topical antibiotic or an oral antibiotic with a topical retionoid.
1157. For severe papulopustular disease, use of an oral antibiotic with a topical retinoid;and for nodulocystic that had not responded, consider isotretinoin.
1158. When a patient presents with a history of acute coronary syndrome, the next step will be aspirin regardless of whether it is NSTEMI, STEMI or unstable angina. Early administration of aspirin has shown to have a statistically significant decrease in mortality in those patients presenting with a history of acute coronary syndrome.
1159. Pseudocyst may be asymptomatic or they may be infected or exert a mass effect on surrounding structures such as the portal vessels, the GI tract, or the biliary tree. If any of these complication occur drainage of pseudocyst is warranted.
1160. Shortness of breath is the most common presentation for those patients HOCM because of decreased compliance, decreased end diastolic volume and back pressure to the lungs.
1161. The most common cause of type 1 diabetes is autoantibidy production against pancreatic antibodies such as glutamic acid antobodies. These antibodies are present in over 70% of the patient and can be used to help confirm the mechanism of disease in unclear cases.
1162. An infected pleural effusion or empyema can only be determined from a thoracocentesis.
1163. An acute exacerbation of chronic bronchitis in a patient with COPD that result from S. Pneumonia and M. Catarrhalis should be treated with amoxicillin/clavunlate.
1164. Only when the patient is at term (36-38 weeks) should the cerclage be removed.
1165. Ganglion cyst is a cystic swelling on the dorsal aspect of the wrist and are usually attached to tendon sheath and joint capsule.
1166. Serotonergic can develop with concomitant use of MAO inhibitor and serotonergic agents, or if there has been a too short a period of wash out in crossing over from one agent to other. Atleast 10 days after MAO discontinuation and 5 weeks after discontinuation of fluoxetine should pass to avoid possible complication.
1167. In water intoxication, movement of water across the cellular membrane is passive and follows a tonicity gradient.
1168. MRI with gadolinium is considered the most effective test for detecting microadenoma. The test can reveal microadenoma in 20% of normal women.
1169. Spontaneous bacterial peritonitis should be suspected in all patients with ascites, mild, diffuse abdominal pain, altered mental status, and low grade fever.
1170. Cerebral venography is the most effective method to identify the cerebral veins and dural sinuses.
1171. The current recommendation of ACOG is that cesarean section is recommended for all women with genital herpes lesions or symptoms. Some studies have shown that administration of acyclovir to pregnant with a history of herpes outbreak during pregnancy can decrease the likelihood of the women developing the outbreak and hence the need for cesarean section.
1172. In suspected CML, bcr;abl gene may be detected in the peripheral blood with the PCR; this is now done over cytogenetic studies.
1173. In incomplete abortion, the cervix is dilated; there is incomplete evacuation of the conceptus with fragments retained in the uterine cavity.
1174. Abrupt onset of hypoxia with respiratory failure, cardiogenic shock, DIC, in a patient who has undergone amniocentesis or delivered, is most likely due to amniotic fluid embolism. Respiratory support is always the first step in the management.
1175. In chlamydial infection, empiric treatment of gonorrhea is not recommended, but in gonorrheal infection empiric therapy therapy of Chlamydia is recommended. A single dose of azithromycin is the treatment of choice for genital Chlamydial infection. 7 days of doxycycline can also be used for Chlamydia but because of the compliance issue single dose azithromycin is preferred.
1176. All patients who take metronidazole should abstain from drinking alcohol, as it is associated with disulfiram like reaction.
1177. A menstrual diary of atleast 3 cycles is a useful aid for confirming the diagnosis in a suspected case of premenstrual syndrome.
1178. OC pills are the first line agents in the treatment of endometriosis in young women desiring future pregnancies.
1179. Semen analysis is a simple test that helps to identify male factor as the cause of infertility. Semen analysis should be performed early in the evaluation of the infertile couple, usually as a screening test.
1180. A child’s blood group frequently differs from the mother’s blood group, but this fact does not create a potential for alloimmunization-related fetal damage. Antibodies to ABO antigens belong to the IgM class and do not cross the placenta.
1181. Fetal alcohol syndrome presents with IUGR, microcephaly and facial dysmorphology, which involves midfacial hypoplasia, micrognathia, flattened philtrum, microphthalmia, short palpebral fissure, and thin vermillion border of the upper lip.
1182. BPP score of 39 C, nausea and vomiting and signs of ileus) adolescent, nulliparous, wome with low socio-economic status and women who fail to respond to oral antibiotic therapy. It is most commonly caused by N.gonorrhea, C.trachomatis and genital mycoplasma. In hospitalized regimes include cefoxitin/ doxycycline, cefotetan/doxycycline and clindamycin/gentamycin.
1207. In case of post term pregnancy (42-43 weeks), the NST and BPP should be performed twice weekly and if there is oligohydramnios or if spontaneous decelerations are noted, delivery has to be accomplished.
1208. ZDV is administered orally during pregnancy after first trimester, intravenously during labor and delivery, orally to the neonate for the first 6 weeks of life.
1209. Major complication of ovulation induction are OHSS and multiple gestation. Symptoms of Ovarian Hyper Stimulation Syndrome include abdominal pain, abdominal distention, nausea, vomiting, diarrhea, weight gain, hypotension and pleural effusion. OHSS may be complicated with ovarian torsion, ovarian rupture, thrombophlebitis and renal insufficiency. Treatment is supportive.
1210. Lupus anticoagulant seen in SLE patients leads to recurrent abortion and thromboembolic disease.
1211. Metformin is indicated in PCOD with impaired glucose tolerance. It helps in preventing type 2 diabetes mellitus and correcting obesity, hirsutism, menstrual irregularity, and infertility.
1212. A search should be undertaken to determine the cause after the first episode of intrauterine fetal demise.
1213. If Pap smear reveals a dysplasia, perform colposcopy. If it reveals an inflammatory atypia (ASCUS) repeat after 4-6 months.
1214. Hypertrophic dystrophy of vulva is most commonly seen in postmenopausal women and is treated with local application of 1% corticosteroid ointment three times a day for 6 weeks. Hyperplastic dystrophy cannot be distinguished clinically from cancer of the vulva and biopsy is therefore required every time the diagnosis is suspected.
1215. In severe preeclampsia, the patient has to be evaluated and stabilized before management decisions are made. Bed rest and salt reduced diets are mandatory; patient with BP >160/110 mm Hg necessitates antihypertensive therapy. If the response to treatment is prompt and the patient is stabilized, the decision will then depend on 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.
1216. Amenorrhea during lactation is due to high levels of prolactin, which have an inhibitory effect on the production of the hypothalamic hormone GnRH, preventing ovulation.
1217. The classic presentation of acute abruption placenta includes vaginal bleeding, abdominal pain, uterine contractions and uterine tenderness. The absence of hemorrhage does not rule out this condition because retroplacental bleeding may be concealed.
1218. Think of trichotillomania in patients with uncontrollable urges to pull out their hair, resulting in alopecic patches.
1219. Tubo-ovarian abscesses are usually managed with triple antibiotic therapy. Drainage is indicated if there is no antibiotic therapy after 24-48 hours.
1220. Vaginismus is managed with kegel exercise and gradual dilatation.
1221. In the case of amenorrhea-hyperprolactinemia first rule out hypothyroidism by measuring serum TSH.
1222. Ectopic pregnancy should be suspected in any patient of child bearing age, presenting with a triad of amenorrhea, abdominal pain and vaginal bleeding.
1223. Patients with endometriosis present with dysmenorrhea, dyspareunia, dyschezia and the physical examination shows tender adnexal mass and firm nodularity located in the broad ligament, the uterosacral ligament, or in the cul-de-sac.
1224. Prolactin production is stimulated by serotonin and TRH and inhibited by dopamine. Hypothyroidism may result in amennorhea and galactorrhea.
1225. Infertility in premature ovarian failure is treated with egg donation.
1226. The peritoneal factor is the most common cause of female infertility.
1227. The risk factors include: thin body habitus, smoking, alcohol intake, steroid use, menopause, malnutrition, family history of osteoporosis, and asian and Caucasian race.
1228. The most commonly used regimen for emergency contraception is a combination of ethinyl estradiol and norgesterol: 2 tablets taken within 72 hoursof intercourse, and 2 other 12 hours later.
1229. Treatment of luteal phase defect is first attempted with progesterone supplement; clomiphene citrate or hMG can be tried if progesterone gives no results.
1230. The treatment of choice for bacterial vaginosis in a pregnant ladi is clindamycin cream or metronidazole.
1231. The major source of estrogen in menopausal women is from the peripheral conversion of adrenal androgens by fat tissues.
1232. Abdominal pain in a young female in the middle of her cycle with a benign history and clinical examination is most likely Mittelschmerz.
1233. Vulvar papillomatosis, or condylomata acuminate, are genital lesions caused by HPV 6 and 11. Condylomas present as exophytic lesions with a raised papillamatous or spiked surface and may grow into large and cauliflower-like formations.
1234. The chancre of primary syphilis is painless, indurated ulceration with a punched out base and rolled out edge.
1235. 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.
1236. In presence of antepartum hemorrhage pelvic examination must not be done before ruling out placenta previa.
1237. Uterine rupture presents with an intense abdominal pain associated with vaginal bleeding which can range from spotting to massive hemorrhage.
1238. Fetal hydantoin syndrome can present with a small body size with microcephaly, hypoplasia of the distal phalanx of the fingers and toe, nasal hypoplasia, low nasal bridge, cleft palate and rib anomalies.
1239. Most of the breech presentation assumes cephalic presentation by 36 weeks.
1240. The most appropriate test to confirm the diagnosis of IUFD is real time sonography.
1241. The most common cause of abnormal serum Alfa-feto protein is gestational –age error.
1242. 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 absence of frank chorioamnionitis.
1243. Patients with polycystic ovarian disease are at the risk of developinh type II diabetes.
1244. Ovarian solid tumors discovered incidentally in a multiparous African-american pregnant womed: think of preganancy leutoma. It is often asymptomatic, benign and self self limited condition and requires no treatment.
1245. Mid pelvic contraction which is indicated by prominent ischial spines is an important cause of arrest disorder of dilation.
1246. Lichen sclerosis is usually seen in postmenopausal women but may develop at any age. It presents with pruritis, burning and dyspareunia and is treated with ‘superpotent topical corticosteroid’ such as clobetasol or halobetosol.
1247. Granuloma inguinale is a STD caused by the bacterium Dovonian granulomatis and characterized by an initial papule, which rapidly evolves into papules, which rapidly evolves into a painless ulcer with irregular borders and beefy-red granular base.
1248. Delivery is the definitive treatment of HELLP syndrome in women beyond 34-weeks gestation.
1249. In cases of IUGR, presence of oligohydramnios is an indication for delivery.
1250. Patients with severe placental abruption in labor have to be managed aggressively to insure a rapid vaginal delivery.
1251. Preeclampsia is defined as hypertension occurring in the second trimester of pregnancy and associated with proteinuria. Risk factors include first conception, diabetes, renal failure and extreme of age. The hypertension regresses after delivery.
1252. The most common organism associated with mastitis is S. aureus.
1253. The combination of primary amennorhea, bilateral inguinal masses, and breast development without pubic or axillary hair is strongly suggestive of androgen insensitivity syndrome. A blind vaginal pouch and karyotype of 46XY are other clues. A gonadectomy should be performed to avoid the risk of testicular carcinoma.
1254. Benign glycosuria is a very common finding in pregnant women because of decreased renal threshold. However causes o fdecreased renal threshold have to be ruled out first, which is done with fasting urine glucose measurement.
1255. Contraceptive methods that can be used in the post partum period include sterilization, condoms and minipills.
1256. Early decelerations are secondary to fetal head compression.
1257. Variable decelerations are secondary to umbilical cord compression.
1258. Late decelerations are secondary to uteroplacental insufficiency.
1259. A granulocytic leukocytosis called lochia rubra is characteristic of first few days postpartum. After 2-3 days the color becomes paler and the discharge is then named lochia serosa. It then turn yellow or white called lochia Alba.
1260. Diagnosis of lutuael phase defect is confirmed by endometrial biopsy.
1261. Kegel exercise and urethropexy are treatment of stress incontinence.
1262. Reassurance and outpatient follow up is the standard of care in threatened abortion patient.
1263. HCG is hormone secreted by the synctiotrophoblast and is responsible for maintenance of progesterone secretion by preservation of the corpus luteum until the placenta starts producing progesterone on its own.
1264. β2 agonist may worsen the edema by decreased water clearance, tachycardia, and increased myocardial workload.
1265. The major cause of death in eclampsia is hemorrhagic stroke.
1266. Vasa previa necessitates immediate C section.
1267. Renal calculi in pregnancy require special consideration because most of the standard investigatory modalities will expose the fetus to radiation. The modality of choice is abdominal or pelvic sonography.
1268. Endometrial biopsy is required in selected patients with DUB to rule out endometrial cancer. These include age >35 years, obese, diabetic or has chronic hypertension.
1269. 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 % cases. Treatment consists of -10 days of nitrofurantoin, ampicillin or first generation cephalosporin.
1270. HRT is now only recommended for the short term use of controlling menopausal symptoms. Large studies have shown that the long term use of HRT can slightly increase the risk of coronary heart disease and stroke.
1271. The initial test to assess the ovulatory function is BBT and midluteal progesterone level.
1272. Adenomyosis occurs most frequently in women above 40 and typically presents with severe dysmenorrhea and menorrhagia. The physical exam reveals an enlarged and generally symmetrical uterus.
1273. Endometritis is caused 70% of times by anaerobes. The most appropriate antibiotic combination is clindamycin with either aminoglycoside or ampicillin.
1274. Hypertension in a pregnant female in a setting of massive proteinuria, malar rash, and positive ANA titer is most likely due to SLE which frequently causes glomerulonephritis.
1275. CVS is the best test for detection of for fetal chromosomal abnormalities in the first trimester of pregnancy.
1276. Myocardial perfusion scintigraphy is indicated when the resting ECG makes an exercise test difficult to interpret, if the exercise is contrary to the clinical impression, to localize the region of ischemia, to distinguish ischemic from infarcted myocardium, to assess vascularization after bypass or angioplasty, and as a prognostic indicator in patients with coronary.
1277. The main pathophysiologic mechanism of Duchenne muscle dystrophy is a mutation in the dystrophin gene that is responsible for the production of the dystrophin.
1278. Muscle phosphorylase is seen in McArdle’s disease, which is inherited in an autosomal recessive pattern. Patients with this condition typically have a history of exercise intolerance in childhood follosed by recurrent cramps, fatigue and myoglobulinuria in adolescence or early adulthood.
1279. A hexagonal crystal point towards the diagnosis of cystine stones.
1280. If a patient has a history of mania or hypomania, depression should be considered bipolar rather than unipolar, the patient should be started on a mood stabilizer before beginning treatment with an antidepressant.
1281. A simple cyst in the head of the epididymis is a spermatocoele or a epididymal cyst and does not require any intervention if the patient is asymptomatic.
1282. In factitious there is low TSH, low thyroglobulin and a low radioactive iodine uptake.
1283. High radioactive iodine indicates Graves’s disease or toxic multinodular goiter, depending on the pattern of the uptake.
1284. Metabolic disturbances such as hypoglycemia and hypocalcemia are common and readily treatable causes of neonatal seizures in the newborn.
1285. Otosclerosis is an autosomal dominant disease in which new, immature bone with abundant vascular channels cause ankylosis of stapedial foot plate. Pregnancy may cause the condition to progress more rapidly.
1286. The length and intensity of an acute exacerbation of MS can be reduced with the administration of glucocorticoids.
1287. ALS is a progressive motor neuron disease that presents with a combination of UMN and LMN. The median survival after diagnosis is 3 to 5 years, with death occurring from respiratory failure.
1288. CMV causes diarrhea in AIDS patient in wherein distal bowel is involved
1289. Rx Webs in plummer vinson : dilation
1290. Rx Intimal flap of carotid artery: surgery
1291. Rx Ant wall MI: risk of arterial thrombo ; full doses heparin + 3 months of warfarin.
1292. Rx Acute ill and toxic pt with UC : proctosigmo + biopsy
1293. Rx Heat stroke : rapid cooling
1294. Rx progressive back pain + myelopathy: IV dexa --> MRI --> Rx
1295. Metastatic cord compression : Radiotherapy
1296. Rx refractory hydrothorax due to cirrohis : TIPS
1297. Rx Ref ascitis : TIPS
1298. Rx recurrent variceal bleading not responsive to medical Rx : TIPS
1299. Rx TCA poisoning : NaHCO3
1300. Rx diabetic cystopathy: 1- oral bethancol , 2- intermittent catheter
1301. Rx chlamydia : single dose of Azithromycin OR 7 days doxycyclin
1302. Rx neuromalignant syn : Dantrolene or Bromocriptine
1303. Rx atopic dermatitis : prevention of Rx , take short baths.
1304. Rx presbyopia : convex lenses
1305. Rx amblyopia : cover better eye
1306. Rx hyperopia : convex lenses
1307. Rx myopia : concave lenses
1308. Rx beta blocker posioning : recent ingestion= emesis , bradycardia : Atropine--> Isoproterenol--> glucagon-->pace
1309. Rx beta blocker poisioning : severe bronchospasm : aminophylline or Beta2 agonist.
1310. Rx Isolated duodenal hematoma: NG + parentral nutrition.
1311. Rx for preventing recurrence of HBV after liver transplant : HBV Ig + Lamivudine.
1312. Rx Seizure due to INH toxicity : Pyriodoxine
1313. Rx hyponatremia due to SIADH : water restriction.
1314. Rx Girl infant < 3 months w vaginal bleeding : observation
1315. Rx Slow down progression of DM nephropathy : AceI
1316. Rx epiglottitis : Fiberoptic laryngoscopy in OR ( not in ER)
1317. Rx acute attacks of migrains : Rizatriptan
1318. Rx acute attack of migrains lasts for longer than 48 hours or r frequently recurrent: ergotamine.
1319. Rx anorexia nervosa : hospitalization
1320. Rx prophlaxy against human bites : Amoxi / calvulanate
1321. Rx rhabdomyolysis : osmotic diuresis + bicarbonate
1322. Rx Afib + HF : digoxin
1323. Rx acute rejection: high dose IV steroides.
1324. Rx bipolar disorder: lithium, valporate, OLANZAPINE.
1325. Rx PCP: cotri.
1326. Rx PCP + PaO2 no answer --> esophagoscopy + cytology + biopsy
1330. Rx psuedotumor cerebri : 1-acetazolamide --> no answer --> 2- shunt.
1331. Rx struvite stones : eradication of UT infections.
1332. Rx persistantly elevated ALT level w detectable HBs Ag , HBe Ag and HBV DNA : INF and lamivudine.
1333. Rx febrile neutropenic pt : ceftazidime or cefepime ( add vanco if pt is hypotensive or there is high suspiscion of MRSA)
1334. Rx Isolated systolic HTN: thiazides .
1335. Rx acute attack of cluster headaches : 100% oxygen
1336. Rx prevention of cluster headaches : verapamil
1337. Rx reversing cardiac effects of ca channel blockers : Ca!
1338. Rx Viterous hemorrhage : immediate ophthlamo consultation.
1339. Rx Battery in esophagus : remove it immediatly
1340. Rx Battery in intestine : observe it.
1341. Rx acute bleeding in pts with liver failure : FFP.
1342. Rx OtoSclerosis : Surgery + Sodium Fluoride .
1343. Rx non infalm comedones : topical retionides.
1344. Rx mild inflam acne : benzoyl peroxide , topical antibiotics.
1345. Rx Refractory mania, severe dep , dep in pregnancy , neuroleptic malig synd, catatonic schizo : ECT
1346. Rx Acute attack of hepatic encephalopathy : All dietary protein withheld , oral or rectal lactulose , oral NEOMYCIN.
1347. Rx white reflex in infant : refer to ophthalmo
1348. Rx ST elevation>1 mm in 2 contiguous leads : thrombolytic therapy OR PTCA
1349. Rx New LBBB: thrombolytic therapy.
1350. Rx Trachoma: ORAL tetra or erythromycin.
1351. Rx diabetic nephropathy : protein restriction ( 0.8 g/kg) , don't use AceI if Cr> 2,2.5
1352. Rx Zenker : excision and frequently cricophayngeal myotomy
1353. Rx porcelain gall bladder : cholecystectomy ( risk of carcinoma)
1354. Rx conversion disorder : psychotherapy ( long term benefit )
1355. Rx Dyspepsia w positve breath test : erad H.pylori
1356. Rx Dyspepsia w/o positive breath test : H2 blocker / PPI
1357. Rx fibromuscular dysplasia: percutaneous angioplasty w stent placement.
1358. Rx prophylaxis against MAC : Azithro or clarithro
1359. Rx PBC: ursodeoxycholic
1360. Rx Orbital cellulitis: imm admin of IV antibiotics.
1361. Rx carcinoid synd: can u remove it?( Remove it ) , u can't remove it ? ( use octerotide )
1362. Rx vaginismus: relaxation, Kegel exercise, insertion training.
1363. Rx Hypertrophic dystrophy of Vulva: steroides.
1364. Rx lichen scleroris : steroids
1365. Rx atrophic vaginitis : estrogen
1366. Rx stable angina + HTN: Beta blocker.
1367. Rx Tremor and rigidity in parkinson : Antichol ( benzotropines)
1368. Rx exercise induced asthma: Beta agon, mast cell stabilizer.
1369. Rx Reiter syn : NSAIDS .
1370. Rx Chronic HCV (HCV RNA presents , ALT inc , chornic hepatitis of at least moderate grade): INF+ Ribaverin.
1371. Rx Lactation Suppression: tight fitting bra, ice packs , analgesics.
1372. Rx non-complinat schizophrenic pt: long acting injectable antipsychotics like fluphenazine and haloperidol.
1373. Rx TIA due to atherosclrosis: ASA
1374. Rx TIA due to emboli from heart: Anticoagulation.
1375. Rx Nocardiosis: sulfonamides.
1376. Rx prophylaxis of getting UTI after intercourse: voiding after intercourse.
1377. Rx met prostate cancer: palliative radiation + anti androgen therapy ( leuprolide )
1378. Rx Actinomycosis : high dose penicillin
1379. Rx RA with erosive joint disease : DMARDS ( MTX, hydroxychlorquine , sulfasalazine , etanercept, azathio)
1380. Rx Met brain tumor: surgery + whole brain radiation.
1381. Rx Dressler: NSAIDS --> no answer: short course of steroides.
1382. Rx PMR : low dose pred
1383. Rx Giant cell: high dose.
1384. Rx cocaine intox: Benzo + ASA + nitrates.
1385. Rx effect of PEEP on CO: inotropic agent or fluids.
1386. Rx RMSF: Doxycycline
1387. Rx De Quervain’s tensosynovitis: Long acting steroids.
1388. Rx HSV encephalitis: IV acyclo without delay.
1389. Rx ALS: Riluzole
1390. Rx Subdural hematoma w/o midline shift : head elevation , hyperventilation , acetazolamide
1391. Rx Subdural hematoma w midline shift : craniotomy
1392. Rx early syph : Single IM Benz Peni , if allergic Doxy or tetra for 14 days . in pregnancy use peni with desintizator
1393. Rx Acute attack of Gout : use NSAIDs, there may be an option of colchicine but do not mark this option.
1394. Rx prevention of gout attack : allopurinol
1395. Rx GAD: Buspirone
1396. Rx post-term preg : NST + BPP ( twice/weekly ) „³ oligo or late dece or >43 w „³ delivery
1397. Rx Kawasaki in children : ASA ( the only disease u give child ASA inspite of fear of Reye syn)
1398. Rx massive hemoptysis : RIGID broncho
1399. Rx acute vaso-occlusive crisis in sicke cell : Exchange transfusion
1400. Rx Acute dystonia : antihistamine or anticholinergic
1401. Rx Parkinsonism as a result of antipsychotic: Benzo
1402. Rx Akathesia : beta blockers
1403. Rx HEAVY UNREMITTING ENDO HEMORRHAGE : high dose conjugated estrogens
1404. Rx Stress Fx : restricting weight bearing + short leg casts (3 to 4 W)
1405. Rx Met breast cancer + lytic bone disease : IV pamidronate
1406. Rx intertrochanteric Fx of femur : internal fix with sliding screw and plate , early mobilization
1407. Rx Cholangitis : Drain biliary tree with ERCP
1408. Rx Lambert Eaton : plasmapheresis + immunosuppression
1409. Rx Emphysematous cholecystitis : Imm fluid + electrolyte correction + antibiotics + early surgical cholecystectomy
1410. Rx Acute exacerbation of MS: Steroides
1411. Rx Umblical hernia : mostly Observe ( look for few indection of intervention)
1412. Rx Cholestoma: surgical removal
1413. Rx GBS: IVIg, plasmaphresis
1414. Rx Hordeoulum/stye : warm compress„³ no answer after 48 hours „³ incision and drainage
1415. Rx Erysipelas : Peni
1416. Rx Fever in neutropenic pt : Cetazidime / Cefepime
1417. Rx MG crisis: plasmapheresis
1418. Rx Sarcoidosis : systemic steroids.
1419. Rx for prevention of recurrence of renal stone : know them well and also remember that Ca intake must be NORMAL or even INCREASED.
1420. Rx Osgood Schlatter disease: Rest, NSAIDs , brief casting
1421. Rx Molluscum : curettage or application of luquid nitrogens
1422. Rx Amebic liver abscess: metro
1423. Rx Hypochlo met alkalo : 0.9% Nacl , NG suction „³ K supp
1424. Rx Anorexia asso w chemotherapy : Megestro acetate
1425. Rx Tension pneumothorax : needle thoraco
1426. Rx Sensory neuropathy w DM : TCA , Gabapentin , NSAIDs
1427. Rx acute pyeloneph : IV ampi + genta ( empiric )
1428. Rx VT hemo stable : Lido or Amio
1429. Rx prevention of variceal bleeding : beta blocker
1430. Rx pul infection if CF : aminoglyco + antipseudomona
1431. Rx Hydatid cyst : Surgery under cover of Albendazole ( Plz do not aspirate these cysts )
1432. Rx Reflex sympathetic dystrophy: physical therapy, prednisone , ganglion block
1433. Rx Chorioamnionitis :Ampi+ Genta
1434. Rx PCO: combines estro/prog or cyclic prog
1435. Rx Perforation of esophagus: primary closure of esophagus , drainage of mediastinum w/i 6 hours to prevent mediastinitis
1436. Rx Rotator cuff tendonitis : Lido injection
1437. Rx Megacolon: Iv fluids , Antibiotics , bowel rest , Iv cortico
1438. Rx Disseminated histoplasmosis in HIV: IV ampho B + LIFE LONG itraconazole
1439. Rx Pseudomonas : cefepim/ceftazidime
1440. Rx Dystonia : Anti hista , anti chol
1441. Rx AIDS with Dysphagia : 1-2 w of oral fluconazole „³ no answer „³ biopsy
1442. Rx Vipoma : correct dehydration slow diarrhea surgery
1443. Rx Ewing’s sarcoma : radio/chemo surgery
1444. Rx Croup : use racemic epinephrine before intubating your pt.
1445. Rx Free air under diaphragm : go to OR
1446. Rx Abnormal hemostasis due to uremia : DDAVP, Cryoper, conjugated estro
1447. Rx Pancreatic pseudocyst : only drain them if persist more then 6W or > 5 cm.
1448. Rx Capillary hemangioma: mostly regress by age of 7
1449. Rx Acute torsade de points: Mg replacement
1450. Rx MgSo4 tox: stop MgSo4, give Ca gluconate
1451. Rx CAD + EF30: Bracing.
1530. Rx Scoliosis >40: surgery
1531. Rx Shaft of humerus: closed reduction + hanging cast .
1532. Rx dirty looking wound in pt w less then 3 doses of tet tox: toxoid +Tig ( only situation which u give pt Tig)
1533. Rx uncomplicated Basilar skull fx : head elevation , fluid restriction.
1534. Rx Ludwig Angina: IV peni w coverage for anaerobes
1535. Rx Meconium plug syn : Water soluble contrast enema
1536. Rx Ovarian torsion : surgery
1537. Rx Tubo-ovarian abscess: surgery
1538. Rx volvulus or malrotation: immediate surgery
1539. Rx Transposition of great vessels: keep ductus arteriosus open, go for surgery.
1540. Patients who have Otitis media with effusion lasting longer than 3 months need an audiometry test ot objectively assess the loss of hearing.
1541. The combination of upper thigh and buttock claudication and impotence is highly suggestive of Leriche syndrome. Aortography is the modality of choice to diagnose the condition.
1542. Treatment with penicillin during labor and delivery has shown to be beneficial in the prevention of GBS disease if indicated.
1543. The first line agent for stage 1 hypetension with no other comorbidities is diet, exercise and hdrocholthiazide.
1544. Differentiate schizoaffective disorder and bipolar disorder or major depression with psychotic symptoms. The distinction is made by a required element for diagnosis of schizoaffective symptoms in the absence of mood symptoms for atleast 2 weeks.
1545. Low level of 5-HIAA have been consistently found in the CSF fluid of victims of violent suicide attempts.
1546. Acyclovir inhibits viral DNA synthesis.
1547. Turner’s syndrome is characterized by primary ovarian failure, multiple congenital anomalies, short stature and bilateral streaked ovaries. FSH elevation, greater than LH elevation, is classic for primary ovarian failure ovarian failure in Turner syndrome.
1548. OCP’s have been shown to decrease the risk of ovarian and endometrial cancer. Breast cancer does not seem to change with their use. Besides hypertension, OCP’s may be associated with other complications including thromboembolism, cerebrovascular disease, MI, gallbladder disease and benign hepatic tumors.
1549. Patients with chorioamnionitis exhibit fever greater than 38 C, uterine tenderness and irritability, elevated WBC count and fetal tachycardia. It is frequently associated with preterm or prolonged rupture of membrane.
1550. Labor should be allowed to proceed in patients with severe congential anomaly incompatible with life.
1551. Depressed DTR is the earliest sign of Mg sulfate toxicity which requires stopping of the Mg Sulfate and administration of calcium gluconate.
1552. Advanced stages of premature labor should be managed more aggressively and tocolysis has to be instituted at once. Mg Sulfate is the drug of choice for tocolysis.
1553. Septic abortion is managed with cervical and blood sampling, IV antibiotics, and gentle suction curettage.
1554. The screening test for diabetes is 50 gm OGTT.
1555. Local heat, bed rest and NSAID’s are the mainstay of treatment of superficial thrombophelibitis. Anticoagulants are indicated only when clot extends into the deep vein system.
1556. After a thorough history and physical examination, the forst step in the male infertility work up is the sperm count. If the sperm count is abnormal, an endocrine evaluation is carried out.
1557. Estrogen is the treatment of choice for atrophic vaginitis. It should be balanced with progesterone if the uterus is present.
1558. Secondary amennorhea is relatively common in elite female athletes and results from estrogen deficiency.
1559. Management of placenta previa depends on the severity of bleeding and the age of pregnancy. Know how each factor intervenes in management decision. Complete placenta previa needs C. section.
1560. Suction curettage is the treatment of choice for inevitable abortion.
1561. Oral hypoglycemic agents and ACE inhibitors are contraindicated in pregnancy and hydralazine, methyldopa and labetolol are used for hypertension in pregnancy
1562. Uric acid stone dissolve in alkaline medium. The treatment of choice is to alkanize the urine with potassium citrate or potassium bicarbonate.
1563. Patients with Paget’s disease or osteitis deformans are often asymptomatic but may present with gross skeletal abnormalities, deafness, nerve compression syndrome, or simply an abnormal alkaline phosphatase level. Treatment is bisphosphonates.
1564. Patients with herpes zoster with significant pain should be given TCA such as desparamine in addition to Herpes Zoster.
1565. Amyloidosis is a syndrome described in drug users who pop their skin with drugs and have resurrent infections. These patients with a nephrotic syndrome with bland urine. They usually have large kidneys.
1566. Lye ingestion can lead to esophageal stricture and carcinoma.
1567. The symptoms of pneumaturia are specific for colovesical fistula.
1568. DiGeorge is best confirmed with PCR based genotyping.
1569. The most common side effect of narcotics is constipation.
1570. Depression is a side effect of interferon in Hep C. It is important to rule out the presence of sucicidal ideation and monitor the symptoms carefully.
1571. All pregnant women should be screened for asmptomatic bacteriuria in pregnancy, and women who demonstrate bacteriuria (defined as a clean catch, midstream urine specimen with 25,000 to 100,000) should be treated with oral antibiotics.
1572. In adult polycystic disease, two genotypes are encountered, with a majority having a defect at the PKD1 locus on chromosome 16 and the minority having a defect at the PKD2 locus on chromosome 4. The latter had a better prognosis.
1573. Oral hypoglycemic agents and ACE inhibitors are contraindicated in pregnancy. Insulin is used in diabeted mellitus in pregnancy and hydralazine, methyldopa and labetolol are used for hypertension in pregnancy.
1574. Arrest disorder resulting from midpelvic contraction is treated with C-section.
1575. Forceps cannot be used until the cervis is fully dilated.
1576. Therpaeutic rest is advised for prolonged latent phase.
1577. Active phase arrest occurs when dilation fails to progressin the active phase of labor over a period of atleast 2 hours.This may be due to abnormal fetal lie, fetopelvic disproportion, inadequate uterine contractions or cervical anomalies. C section will be the treatment.
1578. ERT increases the requirement for L-thyroxine in patients receiving ERT. The potential cause may include induction o fliver enzymes, increased level of TBG, and an increased volume of the distribution of thyroid hormones. In pregnancy, also, thyroid hormone requirement will be increased, and the patients should be monitored every 4-6 weeks for dose adjustment.
1579. Know the criteria for hospitalization in PID. A common regime for PID includes cefotetan, cefoxitin plus doxycycline. Criteria for hospitalization are surgical emergency cannot be ruled out, pregnancy, failure to respond to outpatient treatment, suspected noncompliance, nulligravid, severe illness (includes nausea, vomiting) suspected TOA and pelvic abscess.
1580. The management of breech presentation depends on several maternal and fetal factors. And for vaginal delivery to be decided, the mother as well as the fetus should meet strict criteria:

1. Fetus in frank or complete breech.
2. G. age of atleast 36 weeks.
3. Estimated fetal weight between 2500g or 3800g.
4. Flexed fetal head.
5. Adequately large fetal maternal pelvis, as assessed by pelvimetry or tested by a prior delivery.
6. No maternal or fetal indications for cesarean section.
7. Experienced obstretician.

1581. Hypotension is the most common side effect of epidural anesthesia. The cause of hypotension is blood redistribution to lower extremities and venous pooling.
1582. Treatment for overflow incontinence includes cholinergic agents and intermittent self catheterization.
1583. The first step in a patient with secondary ammenorhea is to rule out common situation; that is, pregnancy, then hypothyroidism, and hyperprolactinemia. The subsequent step should be the determination of the patient’s estrogen status with progestin challenge test.
1584. After the events that are associated with excessive feto-maternal bleed, the failure to correct the dose of anti-D immune globulin may result in maternal alloimmunization.
1585. Lymphogranuloma venerum is a STD caused by Chlamydia trachomatis serotypes L1, L2 and L3 and manifest with generalized malaise, headache and fever with papule, which sunsequently transforms into a painless ulcer and reactive inguinal adenitis. Classic ‘groove sign’ is usually seen in men and in second stage of the disease.
1586. Prolonged latent phase may be seen in twin pregnancy probably caused by overstretching of the uterus by large uterine content. Oxytocin is administered because of hypocontractile dysfunction.
1587. Painful third trimester vaginal bleeding with normal ultrasound is most likely due to placental abruption.
1588. In placenta previa of the bleeding is still continuing; perform C section as soon as possible even if the pregnancy is not at term.
1589. Edema of the lower extremity in pregnancy is most commonly a benign problem. Preeclampsia should be suspected if the edema is associated with hypertension or proteinuria, or if it is located on the hands and/or face. Know when to order Duplex.
1590. Primary dysmennorhea usually appears 6-12 months after menarche. NSAID’s (increase prostaglandins) are highly effective for treatment; OC pills inhibit ovulation and also effective.
1591. Neonates of patients with Graves disease treated with surgery are at risk of thyrotoxicosis because of the passage of thyroid stimulating immunoglobulin across the placenta.
1592. In a post menopausal women with vulvar itch and dryness, lichen sclerosis must be suspected. However, vulvar carcinoma in situ must also be differentiated and a biopsy obtained if suspicion is high.
1593. In false labor, progressive cervical changes are absent and all such patient need assurance.
1594. BUN, serum creatinine, and hematocrit are often decreased in pregnant patients, and it is due to a dilutional affect.
1595. Asymptomatic bacteruria occurs when the urine culture grow >100,000 CFU per ml of a single organism in an asymptomatic patient. It is important to promptly treat the infection the infection to prevent progression to pyelonephritis in the pregnant patients.
1596. 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.
1597. DUB is the most common cause of abnormal uterine bleeding. Due to its benign nature, it is a diagnosis of exclusion. The most common case of DUB in adolescent women is anovulation. After menarche and before menopause it is considered physiologic. IV estrogen is the drug of choice for uncontrolled bleeding.
1598. In pregnant lady with Toxoplasmosis, Spiramycin is the drug of choice in first trimester; however combination of pyrimethamine and sulfadiazine is preferred in second and third trimester. Elective termination of pregnancy is an option in the first trimester of pregnancy.
1599. In complete abortion, the whole conceptus passed through the cervix. The cervix then closes, and pain and uterine contraction subside.
1600. Missed abortion involves a dead fetus that is still retained in the uterus. The diagnosis is suspected when there is disappearance of the nausea and vomiting of early pregnancy, and an arrest of uterine growth.
1601. Risk factors of cervical cancer include young age at first coitus, first pregnancy, high parity, multiple sex partners, a sexual partner with multiple sexual partners, smoking, and low socio-economic status.
1602. Lithium is associated with congenital anomalies, classically Ebstein’s anomaly. When a woman is treated with isotretonoin, she should receive strict contraception. Inhaled steroids are okay in pregnancy.
1603. The most common cause of mucopurulent cervicitis is C trachomatis.
1604. Retinal hemorrhage is an extremely ominous sign of preeclampsia.
1605. Patients with placental abruption in labor have to be managed aggressively to insure a rapid vaginal. C section is used only when there are obstrectical indications, or when there is a rapid deterioriation of the state of either the mother or the fetus, and labor is an early stage.
1606. Steroids are used to enhance fetal lung maturity when premature of membranes occur less then 34 weeks of gestation.
1607. The increase in blood pressure that appears before 20 weeks gestation is either chronic hypertension or H mole.
1608. In cases of mild preeclampsia, if pregnancy is remote from term and/or fetal lungs are not mature yet, the patient is managed with bed rest, salt reduced diet, and close observation.
1609. Cervical dysplasia in a hig risk patient should be investigated with colposcopy.
1610. Excessive use of oxytocin may cause water retention, hyponatremia, and seizures.
1611. Grave’s disease and migraine headache improve in pregnancy.
1612. Raloxifene is a mixed agonist/antagonist of estrogen receptors. 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 thromboembolism.
1613. Patients with testicular feminization syndrome presents with amenorrhea, developed breasts, absent pubic and axillary hair, absent internal reproductive organs and a 46 XY karyotype.
1614. MRKH is the result of mullerian agenesis. Patients have normal secondary sexual chrarcteristics, amennorhea, absent or rudimentary uterus, and a 46, XX karyotype.
1615. Premenopausal women with simple or complex hyperplasia without atypia usually respond to therapy with cyclic progestins. However, all patients should undergorepaet biopsy after 3-6 months. Even if this patient does not want more children, hysterectomy is not indicated.
1616. Clomiphene citrate acts by binding to hypothalamic estrogen receptors and suppressing the inhibitory effect estrogen has on GnRH production.
1617. Epidural anesthesia may cause overflow incontinence as a transient side effect. It is best treated with intermittent catheterization.
1618. RhoGAM is indicated in previously unsensitized Rh-negative women at 28 weeks of gestation, and within 72 hours after any procedure or incident and delivery.
1619. PCOD is characterized by an unbalanced estrogen secretion that may result in endometrial hyperplasia. Patients are treated with combined OC pills or cyclic progestins.
1620. Low back pain is a very common complaint in the third trimesterof preganancy. It is believed to be caused by increase lumbar lordosis and the relaxation of the ligaments supporting the joints of the pelvic girdle.
1621. All patients with a PPD should undergo a chest x ray in order to exclude active TB before prescribing isoniazid prophylaxis.
1622. If MSAFP are found to be abnormal in pregnancy, the next step is USG.
1623. Labor should be induced in patients with IUFD who develop coagulation abormalities.
1624. Transvaginal ultrasound is more accurate than transabdominal ultrasonogram in diagnosing ectopic pregnancy, and should be performed when beta-HCG levels are below 1500 to 2000.
1625. A young woman with a breast lump can be asked to return after her menstrual period for reexamination if no obvious sign of malignancy are present.
1626. Abdominal circumference is the most effective parameter for estimation of fetal weight in cases of suspected IUGR.
1627. Female offsprings of women who ingested DES during their pregnancy are at increased risk of developing clear cell adenocarcinoma of vagina and cervix, as well as cervical anomalies and uterine malformations.
1628. In inevitable abortion, cervix is dilated without passage of the conceptus. It manifests with vaginal bleeding, lower abdominal cramps that may radiate to the back and perineum.
1629. Bed rest and hydration are the first step in stopping uterine contractions in early stages of preterm labor and if the measures fail, tocolytics are indicated.
1630. Tamoxifen decreases the overall mortality in patients with breat cancer by preventing recurrences, and cancer development in the opposite breast. It acts as an agonist on the endometrium and thus increases the risk of endometrial carcinoma.
1631. Grave’s disease is the most common cause of maternal hyperthyroidism. New onset, significant arrhythmia in a pregnant patient could be from hyperthyroidism. TSH should be ordered as a next step.
1632. All patients with a primary amenorrhea and high FSH levels need to have a karyotype determination.
1633. Granulosa cell tumors produce excessive amounts of estrogen, and can present with precococcious 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.
1634. The increased incidence of UTI seen in females is due to shorter length of the urethra.
1635. Anethesia may reduce uterine activity if administered in latent phase.
1636. Patients with Kallman’s syndrome have a normal karyotype, and present hypogonadotrophic hypogonadism, eunuchoid stature and anosmia.
1637. In a patient with primary amennorhea: a) FSH measurement should be ordered if there is no breast development b) GnRH stimulation test is the next step if breast development is decreased c) Karyotyping is the next step if breast development is increased.
1638. A decrease in MSAFP and estriol, and an increase in beta-hCG is typical of Down’s syndrome.
1639. Presence of heavy menses, dysmennorhea and enlarged uterus is almost diagnostic of either adenomyosis or fibroid uerus.
1640. In presence of decreased fetal movements, fetal compromise should be suspected, and the best next step in the management in such cases is the performance of a NST.
1641. If any patient has grossly visible, bleeding cervical lesion biopsy should be performed. Pap smear alone is not appropriate. Know and understand the utility and indications of each procedure aimed at screening or diagnosing cervical pre-malignancies.
1642. GnRh stimulation test serves to differentiate between true isosexual and pseudoisosexual precocious puberty.
1643. Once the diagnosis of missed abortion is confirmed, surgical evacuation (D & C) of the uterus has to be performed to avoid serious complications, such as DIC and sepsis and to minimize the extent of the hemorrhage.
1644. Primary ovarian failure results in decreased estrogen and increased FSH and LH as a result of loss of feedback inhibition of estrogen and inhibin on these hormones. FSH elevation, more than LH elevation, is diagnostic of primary ovarian failure.
1645. Endoscopy is the next step in evaluation of a patient with GERD and painful swallowing.
1646. Gallium scintigraphy has a higher positive predicitive value than CT in detection of lymphoma.
1647. Hypoplastic left heart will have the following: No murmur, precordial hyperactivity, loud second heart sound.
1648. The presence of hemangioblastomas and an angiomatous lesion of retina are diagnostic of von Hippel-Lindau syndrome.
1649. Psychogenic seizures are characterized by lack of organized bilateral clonic jerks. Patients usually have asynchronous, alternating limb movement with suggestive pelvic thrusting.
1650. The tuberculoid form of leprosy is characterized by a vigorous form of immune response. Nerve involvement in leprosy is usually present before skin involvement.
1651. In relapsing polychondritis, chronic inflammation causes destruction of the supportive matrix around the tracheobronchial tree, and collapse on expiration is exaggerated. The result on pulmonary flow loop is slow flow on expiration.
1652. In tuberous sclerosis, during infancy, the common presentation is with infantile spasm. The characteristic EEG pattern is called hypsarrythmia. The use of ACTH may be effective in decreasing infantile spasm due to overproduction of CRH leading to excess excitability.
1653. Major veins at the base of neck have negative pressure during inspiration and, if injured at that moment, will suck air rather than bleed. The air embolism then leads to sudden death.
1654. Peritonitis in a patient with CAPD (Continous Ambulatory Peritoneal Dialysis) is usually due to Gram Positive organism.
1655. ARDS is characterized by PaO2 /FiO2 of less than 200.
1656. Diabetic cardiomyopathy is one of the causes of left ventricular hypertrophy and diastolic dysfunction.
1657. Normal labor and delivery is characterized by a lowering of fetal pH as the labor progresses. pH of 7.04, 7.05 and 7.06 are considered indications for immediately delivery.
1658. Erosio interdigitalis blastomycetica, a form of candiasis seen as an oval shaped area of macerated area white skin on the webs between and extending on the side of the fingers, is cuased by prolonged exposure to water.
1659. The major extra renal complications of APKD are: cerebral aneurysm, hepatic cyst, cardiac valve disease, colocin diverticula and abdominal and inguinal hernia.
1660. Ectopia lentis is a condition in which the lens is displaced upward, occurs in 50-70% of patients with Marfan’s.
1661. Onychomycosis is extremely difficult to treat with topical agents, the most effective agents are oral terbinafine or itraconozole
1662. Modern definition of agoraphobia is a fear of panic attacks in situations from which it would be difficult to remove oneself.
1663. In a patient with hemarthosis, with low factor VIII levels and an elevated PTT the possible diagnoses are congential hemophilia A and acquired anti-factor VIII antibodies. In order to differentiate between these two entities, a mixing study should be performed. In this test, the PTT is measured after the patient’s serum is mixed with normal serum. In the case of congenital hemophilia A, a mixing study will normalize the PTT because the normal serum has factor VIII. In the acquired anti-factor VIII antibody patient, the PTT will normalize with mixing.
1664. Atypical chest pain is the most common symptom associated with mitral valve prolapse.
1665. The first-line pharmacological agents of choice for the management of AOP (Apnea of Prematurity) are methylxanthines (caffine and theophylline) which acts to stimulate respiratory neurons.
1666. Treatment of any at risk pregnancy for 21-Hydroxylase deficiency is to start the administration of dexamethasone to the mother no later than the sixth week of pregnancy, and then perfom chorionic villus sampling between 10 and 12 weeks.
1667. Antibiotics are indicated for a cat bite at any location and any hand bite. For prophylaxis, one would use dicloxacillin for 3-5 days for a cat bite or penicillin V for 3-5 days for a cat bite on hand. If the wound is infected (pasturella multocida), then either penicillin or tetracycline is used.
1668. RTA 4 is frequently seen in patients with mild to moderate renal insufficiency due to diabetic nephropathy. Other causes include primary adrenal insufficiency, diabetes mellitus, renal insufficiency, effects of NSAID’s and ACE inhibitors, and potassium sparing diuretics.
1669. Chronic type A gastritis is immunologically mediated and is associated with an elevated level of parietal cell antibody. Thus, acid secretion is reduced.
1670. HOCM management: a) No symptoms: echocardiography and exercise testing b) Chest pain or dyspnea: echocardiography and exercise testing, then medical therapy (beta blockers, ca channel blocker); if symptoms persists coronary angiography c) Syncope and presyncope: echocardiography, holter monitoring, and cardiac angiography; consider electrophysiologic study d) Cardiac arrest: Full cardiac evaluation echocardiography, Holter monitoring, electropysiologic testing, and cardiac catheterization.
1671. Primary open angle glaucoma has several risk factors, including elevated intraocular pressure, black race, family history, and diabetes mellitus. Screening for individuals who have any of these risk factors should occur every year after the age of 40 years, according to the America Ophthalmology Society.
1672. The most common cause of mumps in pre-pubertal children is meningoencephalitis.
1673. Surgical management is the definitive treatment of toxic megacolon.
1674. Alkaptonuria is a deficiency in the enzyme homogentistic acid dioxygenase. The pigmented, polymerized form of homogentisic acid has a propensity for joints, especially the lumbar spine. It causes degenerative changes of these joints and can lead to significant morbidity. This accumulation in connective tissue is called as ochronosis.
1675. In spinal motor atrophy or Werdnig-Hoffman disease the simplest most definitive diagnostic test is molecular genetic marker in the blood for the survivor motor neuron gene (SMN).
1676. A spinal cord disorder should be considered in any patient with bilateral motor and sensory dysfunction in the extremities in the absence of signs or symptoms of brain or brainstem dysfunction.
2. Spinal cord compression due to epidural metastasis is a neurologic emergency for which urgent MRI of the entire spine is appropriate.
3. Vertebral artery dissection typically presents with neck or head pain, Horner's syndrome, dysarthria, dysphagia, decreased pain and temperature sensation, dysmetria, ataxia, and vertigo.
4. Magnetic resonance angiography is a sensitive diagnostic test for vertebral artery dissection as a cause of stroke.
5. Juvenile myoclonic epilepsy is a primary, genetic, generalized epilepsy that typically manifests with myoclonic jerks followed by a generalized tonic–clonic seizure
6. Guillain–Barré syndrome is characterized by proximal and distal weakness, autonomic symptoms, cranial nerve involvement, and respiratory failure.
7. Treatment of Guillain–Barré syndrome with either intravenous immunoglobulin or plasmapheresis is indicated in patients who cannot walk independently or who have impaired respiratory function or rapidly progressive weakness.
8. Small, stable, asymptomatic meningiomas can be followed with serial neuroimaging.
9. In large, symptomatic, or progressive meningiomas, surgical resection offers an 80% chance of cure.
10. Personality change, lost initiative, and slowing of thought, with relative preservation of recent memory, suggest frontotemporal dementia.
11. Frontotemporal dementia is usually associated with disproportionate atrophy of the anterior frontal and temporal lobes, a finding that is usually clearly demonstrated on MRI.
12. Elevation of the cerebrospinal fluid 14-3-3 protein in a patient with rapidly progressive dementia and normal structural imaging suggests Creutzfeldt–Jakob disease.
13. Treatment with interferon-beta decreases the incidence of additional attacks in patients with monosymptomatic demyelination, including optic neuritis and myelopathy.
14. Propranolol and primidone are first-line drugs in the treatment of essential tremor (postural and action tremor).
15. The diagnosis of Parkinson's disease requires the presence of at least two of the following: tremor at rest, bradykinesia, rigidity, and postural reflex abnormality.
16. The characteristics of migraine headache without aura include worsening of the headache with movement, limitation of activities, and photo- and phonophobia
17. Transverse myelitis is an acute or subacute demyelinative or inflammatory disorder of the spinal cord that causes motor, sensory, and autonomic dysfunction below a spinal cord level.
18. High-dose intravenous corticosteroids are indicated for initial treatment of acute transverse myelitis.
19. Secondary prevention of cardioembolic stroke consists of warfarin with a target INR of 2.0 to 3.0.
20. Heparin has no established role in the acute treatment of stroke.
21. The manifestations of partial seizures depend on their neuroanatomic location.
22. Frontal seizures are brief and are usually not associated with aura or postictal confusion.
23. Hereditary sensorimotor neuropathy is an autosomal dominant disorder that usually presents with clumsiness or difficulty running in the first decade of life.
24. Hereditary sensorimotor neuropathy is characterized by distal muscle atrophy, weakness, and sensory loss associated with high arches (pes cavus) and hammertoes
25. Cell type and tumor grade are the most important determinants of survival in glioma.
26. Higher-grade gliomas are more aggressive than lower grade.
27. Alzheimer's disease is characterized by primary dementia with prominent amnesia.
28. Dementia with Lewy bodies, characterized by fluctuating cognition, parkinsonism, and/or visual hallucinations, often coexists with Alzheimer's disease.
29. All patients with relapsing multiple sclerosis should be considered for immunomodulatory therapy with either a form of interferon-beta or glatiramer acetate.
30. Adult-onset idiopathic dystonia is usually focal or segmental and does not generalize to other parts of the body.
31. Botulinum toxin injections can correct the abnormal posture and alleviate the pain associated with cervical dystonia.
32. Approximately 20% of patients with migraine have headache with aura, that is, neurologic problems such as visual hallucinations or numbness or tingling before or during headache.
33. Lhermitte's sign, an “electric shock”–like sensation down the neck, back, or extremities occurring with neck flexion, is a helpful historical clue to a cervical spinal cord disorder.
34. Cervical spondylosis is a chronic disorder of degenerative and hypertrophic changes of the vertebrae, ligaments, and disks that may narrow the spinal canal and cause cervical spinal cord compression.
35. In patients with stroke not eligible for thrombolytic therapy, aspirin modestly reduces both the short-term risk of recurrent stroke and the long-term risk of stroke-related death and disability.
36. In patients with acute stroke, thrombolytic therapy must be started within 3 hours of the onset of symptoms or of the time the patient was last known to be well.
37. Elderly patients may be particularly sensitive to the cognitive, motor, and coordination side effects of phenytoin, even if the serum phenytoin level is in the therapeutic range.
38. Gabapentin, lamotrigine, and carbamazepine are equally effective at controlling partial onset seizures in the elderly, but gabapentin and lamotrigine are better tolerated.
39. Peripheral nervous system vasculitis usually presents with asymmetric weakness and sensory loss in specific nerve distributions.
40. In an elderly patient with recurrent glioblastoma and poor performance status, referral for hospice care is preferable to additional antitumor treatment.
41. The three specific criteria for dementia with Lewy bodies are fluctuating encephalopathy, parkinsonism, and visual hallucinations.
42. A centrally acting anticholinesterase agent may alleviate the inattention, hallucinations, and fluctuating encephalopathy of dementia with Lewy bodies.
43. Women taking immunomodulatory treatment for multiple sclerosis should use effective contraception, or if they want to become pregnant, stop therapy several months before attempting to conceive.
44. Involuntary brief, irregular, unpredictable movements fleeting from one body part to another are hallmarks of chorea.
45. Chorea can occur as a hereditary and degenerative disease or secondary to drugs, metabolic disorders, infections, immune-mediated diseases, and vascular lesions.
46. Tension-type headache is distinguished from migraine by the fact that patients with tension headache are not disabled and can carry out activities of daily living in a normal, expedient manner.
47. Vitamin B12 deficiency can cause dysfunction of the posterior columns and corticospinal tracts of the spinal cord, causing paresthesias, loss of vibration and position sense, sensory ataxia, weakness, and upper motor neuron signs.
48. Neurologic signs of vitamin B12 deficiency may manifest in the absence of hematologic signs of vitamin B12 deficiency.
49. In a patient with a transient ischemic attack, carotid artery ultrasonography showing a >50% stenosis of the internal carotid artery may be an indication for carotid endarterectomy.
50. A single antiepileptic drug should be used in pregnant women with epilepsy; multiple drug therapy increases the risk for birth defects.
51. Chronic inflammatory demyelinating polyneuropathy, the chronic form of Guillain–Barré syndrome, is characterized by proximal and distal weakness, areflexia, and distal sensory loss.
52. Chronic inflammatory demyelinating polyneuropathy progresses in a stepwise or relapsing course for at least 8 weeks and can occur early in the course of HIV infection.
53. In a young patient with totally resected low-grade glioma, postsurgical management consists of observation with serial neuroimaging.
54. Vascular dementia is suggested by a history of vascular risk factors, abrupt onset with subsequent improvement, periventricular white matter ischemia on imaging, and focal neurologic findings.
55. Intravenous methylprednisolone therapy followed by an oral prednisone taper speeds recovery of visual acuity in optic neuritis
56. The restless legs syndrome consists of abnormal sensations in the legs and restlessness relieved by movement.
57. Patients are at risk for developing analgesic overuse headache if they use prescription or over-the-counter medication for headache more than 2 days a week.
58. Pseudotumor cerebri is characterized by papilledema, postural change with headache, visual changes, recent report of rapid weight gain, or introduction of oral contraceptives or tetracycline.
59. Infarction of the spinal cord typically presents as sudden spinal cord dysfunction.
60. Spinal cord infarction usually affects the territory of the anterior spinal artery, causing weakness and pinprick loss of sensation with sparing of vibration and position sense.
61. CT scan may miss subarachnoid hemorrhage, especially when there is a delay in presentation after the initial hemorrhage.
62. Focal neurologic symptoms 3 to 7 days after a subarachnoid hemorrhage may be due to vasospasm with cerebral ischemia.
63. Patients with epilepsy who are most likely to remain seizure free after medication withdrawal are those with no structural brain lesion, no epileptiform or focal abnormalities on electroencephalogram, a sustained seizure-free period, and no abnormalities on neurologic examination.
64. Patients with epilepsy who discontinue antiepileptic medication should stop driving for at least 3 months and preferably 6 months from the start of the taper.
65. Critical illness polyneuropathy is a common cause of failure to wean from a ventilator in a patient with associated multiorgan failure and sepsis.
66. Critical illness polyneuropathy is characterized by generalized or distal flaccid paralysis, depressed or absent reflexes, and distal sensory loss with sparing of cranial nerve function.
67. Patients with primary central nervous system lymphoma should be evaluated for vitreal or uveal involvement before therapy is begun.
68. Aggressive resection is not recommended in primary central nervous system lymphoma; methotrexate chemotherapy is primary therapy.
69. Donepezil, an acetylcholinesterase inhibitor, may cause mild peripheral cholinergic side effects, including increased vagal tone, with bradycardia, and occasionally atrioventricular block.
70. In at least 50% of patients with relapsing–remitting multiple sclerosis, disease will evolve to a secondary progressive course.
71. In at least 50% of patients with relapsing–remitting multiple sclerosis, disease will evolve to a secondary progressive course.
72. Metoclopramide, which blocks dopamine receptors both in the periphery and inside the central nervous system, can induce parkinsonism.
73. Prednisone is the most appropriate treatment for episodic cluster headache.
74. Acute cervical spinal cord compression due to hyperextension injury is common in elderly patients.
75. Emergent MRI of the cervical spinal cord is indicated in any patient with quadriparesis after a fall.
76. The classic symptoms of cerebellar stroke are headache, vertigo, and ataxia.
77. Patients with epilepsy who fail to respond to three trials of antiepileptic drugs are unlikely to ever become seizure free with drug therapy.
78. Treatment-resistant patients with epilepsy should be evaluated for a surgically remediable epilepsy syndrome.
79. Myasthenia gravis is an autoimmune disease caused by antibodies against the acetylcholine receptor, which results in impaired neuromuscular transmission.
80. Myasthenia gravis is characterized by fatigable weakness with a predilection for ocular, bulbar, proximal-extremity, neck, and respiratory muscles.
81. Leptomeningeal spread of systemic carcinoma manifests as a cranial neuropathy or spinal polyradiculopathy, or as encephalopathy, diffuse brain infiltration, or communicating hydrocephalus.
82. Creutzfeldt–Jakob disease is suggested by subacute progression of dementia with myoclonus and other motor signs and a normal brain MRI.
83. In the setting of subacutely progressive dementia, the presence of 14-3-3 protein in cerebrospinal fluid, or electroencephalography showing periodic sharp waves, can be diagnostic of Creutzfeldt–Jakob disease.
84. Mitoxantrone therapy is of modest benefit in slowing progression of secondary progressive or severe relapsing–remitting multiple sclerosis.
85. The primary concern about mitoxantrone therapy is the risk for cardiotoxicity.
86. Progressive supranuclear palsy is characterized by parkinsonism with early gait and balance involvement, vertical gaze palsy, severe dysarthria, and dysphagia.
87. Normal pressure hydrocephalus is characterized by the classic triad of gait impairment, cognitive decline, and urinary incontinence.
88. Patients with idiopathic intracranial hypertension present with signs and symptoms of increased intracranial pressure without a mass lesion on brain imaging.
89. In patients with possible idiopathic intracranial hypertension, a diagnostic and potentially therapeutic lumbar puncture is indicated after brain imaging excludes a mass lesion.
90. Severe cerebral anoxia from cardiac arrest can cause severe diffuse cerebral hemispheric cortical injury with relative preservation of brainstem function, leading to the development of a vegetative state.
91. A vegetative state is a condition of complete unawareness of self or the environment, accompanied by sleep–wake cycles and preservation of brainstem and hypothalamic functions.
92. Intracerebral hemorrhage with extensive subarachnoid hemorrhage is the hallmark of a ruptured arteriovenous malformation.
93. Conventional angiography is the definitive diagnostic procedure for detecting arteriovenous malformations and berry aneurysms.
94. In a patient with status epilepticus, after the airway is stabilized and plasma glucose determined to be normal, parenteral antiepileptic medications should be started.
95. Lorazepam is the preferred benzodiazepine for initial therapy for a patient in status epilepticus.
96. Myasthenia gravis crisis is characterized by dysphagia requiring nasogastric feeding and/or severe respiratory muscle weakness necessitating ventilation.
97. Myasthenia gravis crisis is treated with either plasmapheresis or intravenous immunoglobulin.
98. Radiation-induced leukoencephalopathy is a subcortical process affecting white matter and characterized by the triad of gait apraxia, dementia, and urinary incontinence.
99. Radiation-induced leukoencephalopathy may occur months to years after radiation and is more common after whole-brain compared with focal brain irradiation.
100. Mild cognitive impairment consists of isolated mild amnesia with no impairment of interpersonal, occupational, or daily living activities.
101. The conversion rate from mild cognitive impairment to mild dementia is 10% to 15% per year.
102. Amantadine is the first-line pharmacologic agent for treatment of multiple sclerosis-related fatigue.
103. Multiple system atrophy is characterized by orthostatic hypotension, neurogenic bladder, constipation, and impotence, with gait-predominant parkinsonism and corticospinal tract signs.
104. Carbamazepine is the appropriate treatment for trigeminal neuralgia.
105. Patients with the locked-in syndrome are quadriplegic, have paralysis of horizontal eye movements and bulbar muscles, and can communicate only by moving their eyes vertically or blinking.
106. The locked-in state is due to a lesion of the base of the pons, usually from pontine infarction due to basilar artery occlusion.
107. Antiplatelet therapy, statins, and ACE inhibitors each reduce the risk of recurrent stroke even in the absence of chronic hypertension or a lipid disorder.
108. Headache may be a limiting factor in the use of the combination of aspirin and extended-release dipyridamole for secondary stroke prevention.
109. Nonepileptic seizures of psychogenic origin can be differentiated from epilepsy by their longer duration, normal electroencephalogram findings, and maintenance of consciousness.
110. Nonepileptic psychogenic seizures are often associated with moaning, crying, and arrhythmic shaking of the body.
111. Absence seizures are characterized by a brief loss of awareness with no movement or very subtle movements of the lips and fingers.
112. Juvenile myoclonic epilepsy is characterized by myoclonic seizures and often accompanied by absence and generalized tonic–clonic seizures.
113. Amyotrophic lateral sclerosis is characterized by pathologic hyperreflexia, spasticity, extensor plantar responses, along with atrophy, fasciculations, and weakness.
114. Muscle weakness in amyotrophic lateral sclerosis usually begins distally and asymmetrically in the upper or lower extremities or may be limited initially to the bulbar muscles, resulting in dysarthria and dysphagia.
115. Surgical resection is indicated for an accessible solitary brain metastasis in patients with limited or no systemic tumor.
116. Cholinesterase inhibitors have modest efficacy on cognitive and global function in mild to moderate Alzheimer's disease.
117. Vitamin E and selegiline may delay the progression of Alzheimer's disease, but do not alleviate cognitive or psychiatric symptoms.
118. In patients with possible multiple sclerosis, new MRI white-matter lesions or new gadolinium-enhancing lesions on serial brain or spinal cord MRI at least 3 months after an initial scan, indicate dissemination of demyelination, even without a new clinically evident attack.
119. Carbidopa-levodopa is the first-line treatment for patients older than 70 years with new-onset Parkinson's disease.
120. Complications associated with the use of dopamine agonists, such as somnolence, drug-induced psychosis, and dizziness, are more common in patients older than 70 years.
121. The risk of rupture of a small intracranial aneurysm is less than the risk of complications with clipping or endovascular coiling of the aneurysm.
122. Incidentally discovered small aneurysms should be re-evaluated periodically for enlargement.
123. Oxcarbazepine is effective monotherapy for partial onset seizures.
124. Risk factors for recurrent seizures include multiple previous seizures, a history of significant head trauma, focal electroencephalogram abnormalities, and structural abnormality on MRI.
125. Amyotrophic lateral sclerosis causes progressive respiratory muscle weakness that may present with supine dyspnea, frequent arousals, daytime fatigue, or morning headache.
126. Noninvasive positive-pressure ventilation should be started in patients with amyotrophic lateral sclerosis whose forced vital capacity is
1677. 160. Right ventricular infarction should be suspected in patients with inferior myocardial infarction who present with hypotension, clear lung fields, and elevated jugular venous pressure.
161. An echocardiogram establishes the diagnosis of right ventricular infarction by demonstrating right ventricular enlargement and hypokinesis.
162. Implantable cardioverter-defibrillator therapy reduces risk of sudden death in survivors of cardiac arrest due to ventricular tachycardia or ventricular fibrillation without a reversible cause.
163. Spontaneous coronary dissection may occur during pregnancy.
164. In patients with ST-elevation myocardial infarction, successful fibrinolysis is suggested by resolution of chest pain and ST-segment elevation and/or transient ventricular arrhythmias early after reperfusion.
165. In patients with ST-elevation myocardial infarction, reperfusion arrhythmias, typically manifested as a transient accelerated idioventricular arrhythmia, usually do not require additional antiarrhythmic therapy.
166. Thrombosis of mechanical valves may present with valve dysfunction rather than embolic events.
167. Intravenous heparin should be started immediately while diagnostic evaluation is in progress.
168. Chest CT scan with contrast is indicated to detect acute aortic dissection.
169. In patients at risk for radiocontrast nephropathy and contraindication to MRI, transesophageal echocardiography is the test of choice for possible aortic dissection.
170. Breast and lung carcinoma are the most common causes of malignant pericardial disease.
171. The epicardium is the most common location of metastatic cardiac neoplasm.
172. An ACE inhibitor and a β-blocker are indicated in all patients with systolic heart failure, including asymptomatic patients.
173. Spironolactone and digoxin are not indicated in patients with asymptomatic systolic heart failure.
174. Fixed splitting of the S2 is the auscultatory hallmark of atrial septal defect.
175. A divergence between electrocardiography showing low-voltage and echocardiography demonstrating a substantial increase in left ventricular wall thickness is a useful diagnostic clue for cardiac amyloidosis.
176. Abdominal fat aspiration biopsy is a safe and reasonably sensitive test for the diagnosis of amyloidosis.
177. Physical examination is helpful is identifying the presence, but not the severity, of valve disease.
178. The most sensitive sign on physical examination to exclude the diagnosis of severe aortic stenosis is a physiologically split S2.
179. Most patients with peripheral vascular disease have an ABI grade 3/6 in intensity, continuous murmurs, or any diastolic murmur.
192. Surgery for native valve endocarditis is indicated if there is significant hemodynamic instability or evidence of paravalvular extension.
193. Factors favoring earlier timing of surgery include significant congestive heart failure, resistant infections, and large mobile vegetations.
194. Even if active bacteremia is still present or if the antibiotic treatment course is ongoing, surgery for endocarditis should not be delayed if surgical criteria are met.
195. Medical therapy for acute, recent myocardial infarction includes β-blockers, aspirin, angiotensin-converting enzyme inhibitors, and statins.
196. Smoking cessation is the single most effective intervention for patients with peripheral vascular disease.
197. β blockade does not promote clinical claudication.
198. Cilostazol is relatively contraindicated in patients with congestive heart failure.
199. Patients with heart failure who have severe symptoms and evidence for ventricular dyssynchrony benefit from implantation of a biventricular pacemaker.
200. Biventricular pacing improves cardiac performance and quality of life and may also improve survival.
201. Glycoprotein receptor blockade is indicated for patients with acute coronary syndrome who will undergo coronary angiography and intervention.
202. Patients with ST-elevation myocardial infarction treated with stents require aspirin and clopidogrel at discharge.
203. Patients with ST-elevation myocardial infarction treated without stents may be managed with aspirin alone or with warfarin if indicated for atrial fibrillation or anterior akinesis or aneurysm.
204. In low-risk patients with lone atrial fibrillation, warfarin anticoagulation is not required. Aspirin or no therapy is recommended.
205. A systolic murmur, an S3 gallop, and mild peripheral edema are normal findings during pregnancy.
206. In the absence of significant mitral regurgitation, primary mitral valve prolapse has a benign prognosis.
207. Antibiotic prophylaxis for endocarditis is indicated in mitral valve prolapse if there is more than mild mitral regurgitation, if a murmur is heard on auscultation, or if the patient has high-risk echocardiographic features.
208. Initial management of acute coronary syndrome related to a systemic process, such as anemia, is treatment of the precipitating factor.
209. Medical therapy for NSTEMI in patients with TIMI low-risk status has acceptable outcomes.
210. Patients with atrial fibrillation and risk factors for stroke require anticoagulation with warfarin.
211. Risk factors for stroke in nonrheumatic atrial fibrillation include prior embolic event or stroke, hypertension, advanced age, congestive heart failure, coronary artery disease, and diabetes mellitus.
212. β-blockers should not be initiated in heart failure patients who are acutely decompensated or volume overloaded.
213. Patients with atrial fibrillation and minimal symptoms can usually be managed with rate control alone (without rhythm control).
214. Echocardiography is indicated when a new murmur, a systolic murmur ≥grade 3/6, or any diastolic murmur is heard.
215. Physiologic valvular regurgitation does not pose a risk of endocarditis and does not require antibiotic prophylaxis.
216. Antibiotic prophylaxis for endocarditis is tailored to the risk of the procedure and the risk of the patient.
217. Although pericardiectomy is the most effective treatment for constrictive pericarditis, it is unnecessary in patients with early disease.
218. Atrial flutter is characterized by saw-tooth pattern flutter waves most noticeable in the inferior leads.
219. The preferred treatment for recurrent atrial flutter is radiofrequency catheter ablation.
220. Aspirin-allergic patients with ST-elevation myocardial infarction can be treated with clopidogrel as part of postinfarction medical therapy.
221. Angiotensin-converting enzyme inhibitors are indicated for all patients with systolic heart failure, regardless of ejection fraction or functional status, barring contraindications.
222. Patients with STEMI should undergo coronary reperfusion in the most expeditious manner.
223. STEMI patients who cannot be reperfused by direct coronary intervention within 90 to 120 minutes should receive fibrinolytic therapy if there are no contraindications.
224. The decision to implant a pacemaker for sinus node dysfunction depends on the presence of symptoms rather than heart rate alone.
225. Subacute cardiac tamponade may be caused by acute viral pericarditis.
226. Echocardiography is a useful diagnostic modality for the delineation of pericardial hemodynamics.
227. • Papillary muscle dysfunction or rupture should be suspected in patients with clinical signs of acute mitral regurgitation in the setting of a myocardial infarction.
228. • An echocardiogram should be performed if papillary muscle dysfunction is suspected.
229. • Mitral regurgitation due to papillary muscle dysfunction often improves following coronary revascularization
230. Syncope in a patient with cardiomyopathy may be due to potentially fatal ventricular arrhythmia.
231. An ICD is indicated for patients with left ventricular dysfunction and hemodynamically significant ventricular arrhythmias.
232. Coronary artery bypass grafting improves survival in patients with obstructive left main and/or multivessel coronary artery disease.
233. Coronary artery bypass grafting improves survival in comparison to percutaneous intervention in diabetic patients with multivessel coronary artery disease.
234. Atrioventricular nodal re-entrant tachycardia is characterized by a narrow QRS complex and lack of visible P waves.
235. The first treatment of choice for atrioventricular tachycardia is carotid sinus massage.
236. If carotid sinus massage is unsuccessful, adenosine is the drug of choice for the termination of narrow-complex supraventricular tachycardias.
237. The murmur of hypertrophic cardiomyopathy increases after a Valsalva maneuver and decreases after a sit-to-squat maneuver, performing passive recumbent leg lifts, or performing handgripping exercises.
238. Ascending aortic dissection may involve the coronary arteries, most commonly the right coronary artery.
239. Ascending aortic dissection may lead to disruption of the aortic valve, leading to aortic regurgitation.
240. Noonan syndrome is characterized by short stature, intellectual impairment, unique facial features, neck webbing, and congenital heart defects.
241. Noonan syndrome should always be considered in a patient with pulmonary valve stenosis.
242. The recommended initial treatment for acute viral pericarditis is a high-dose nonsteroidal anti-inflammatory medication, such as indomethacin.
243. Anticoagulation therapy is contraindicated in pericarditis because of the risk of hemopericardium.
244. Perioperative β blockade decreases cardiovascular risk in patients undergoing noncardiac surgery.
245. Hypertension (blood pressure >180/110 mm Hg) is a relative contraindication to fibrinolysis in patients with STEMI.
246. Revascularization should proceed expeditiously with concomitant medical therapy for hypertension complicating STEMI.
247. Restrictive cardiomyopathy is a late complication of radiation therapy.
248. A normal left ventricular wall thickness in radiation-induced restrictive cardiomyopathy helps to differentiate this entity from other cardiomyopathies characterized by ventricular hypertrophy.
249. In asymptomatic patients with chronic aortic regurgitation, surgery should be considered when left ventricular ejection fraction drops below 60% or the left ventricular systolic dimension reaches 55 mm.
250. In asymptomatic patients with aortic regurgitation, nifedipine may delay the timing of surgical intervention.
251. Aortic coarctation is associated with a continuous murmur (often posterior thorax) and elevated but equal blood pressure in both upper extremities.
252. A bicuspid aortic valve is often seen in association with aortic coarctation, presenting with aortic regurgitation or aortic stenosis.
253. Physical findings of mitral regurgitation include holosystolic murmur at the apex radiating to the axilla, without respiratory variation.
254. In healthy adults, premature ventricular contractions are common and are not a cause for concern.
255. Suppression of premature ventricular contractions is indicated only in patients with severe and disabling symptoms.
256. Smoking, hypertension, advanced age, and male sex are risk factors for abdominal aortic aneurysm.
257. Most abdominal aortic aneurysms are asymptomatic, but abdominal pain is the most common symptom.
258. Patients at high risk for a subsequent coronary event after a myocardial infarction include those with multivessel coronary artery disease, anterior myocardial infarction, or a left ventricular ejection fraction 0.5 cm/year) increase in aneurysm size.
307. Severe hemolytic anemia in a patient with a mechanical valve suggests paravalvular leakage due to partial dehiscence of the valve or infection.
308. Prosthetic valve dehiscence or dysfunction should be suspected in patients that develop symptoms of congestive heart failure, particularly if these symptoms occur in the first 6 months following surgery.
309. Right ventricular infarction is a cause of hypotension following inferior infarction and typically requires appropriate volume infusion.
310. Right ventricular infarction should be suspected as a cause of hypotension when findings of right heart failure coincide with an absence of evidence of pulmonary congestion.
311. Implantation of a cardioverter-defibrillator is an important prophylactic treatment in patients with hypertrophic cardiomyopathy and high risk for sudden death.
312. Clinical features that predict high risk for sudden death in patients with hypertrophic cardiomyopathy include family history of sudden death, syncope, marked left ventricular septal hypertrophy, nonsustained ventricular tachycardia, and exertional hypotension.
313. Papillary muscle rupture and ventricular septal defect are recognized mechanical complications that occur early after myocardial infarction.
314. Both papillary muscle rupture and ventricular septal defect present with hypotension and acute dyspnea.
315. Annual echocardiography is appropriate in a patient with asymptomatic severe mitral regurgitation.
316. The timing of surgery for severe mitral regurgitation is based on symptoms and measures of left ventricular size and systolic function.
317. Classic features of Marfan's syndrome includes tall stature, high arched palate, joint hypermobility, scoliosis, and positive “wrist sign.”
318. Patients with Marfan's syndrome are at increased risk for asymptomatic thoracic aortic aneurysm and associated aortic valve incompetence.
319. Intravenous amiodarone is the drug of choice for shock-resistant ventricular fibrillation.
320. The risk of coronary artery disease in diabetic patients is 2 to 4 times higher than in nondiabetic patients.
321. The pretest likelihood of disease should be calculated using available algorithms in patients with coronary risk factors.a
322. In patients with chest pain and intermediate risk of coronary artery disease, non-invasive testing is indicated.
323. Patients with chest pain and low coronary artery disease risk with a normal electrocardiogram and a normal exercise electrocardiogram can be discharged without coronary angiography.
324. Although uncommon, left atrial myxoma should be considered in young patients with embolic stroke.
325. Echocardiography is an important imaging modality for diagnosis of an intracardiac tumor.
326. Women with Marfan syndrome are at increased risk of aortic dissection during pregnancy.
327. Aortic dissection should be considered in the differential diagnosis of chest pain in pregnancy.
328. The tachycardia rate in atrioventricular nodal reentrant tachycardia is typically 160–180/min with the P wave buried in the QRS complex.
329. • If atrioventricular nodal reentrant tachycardia does not respond to vagal maneuvers, adenosine is the treatment of choice
330. Continuous effective anticoagulation is needed throughout pregnancy in women with mechanical heart valves.
331. Radiofrequency catheter ablation is the most effective treatment for atrioventricular nodal reentrant tachycardia.
332. Calcium-channel blockers may be used for prophylaxis of recurrent atrioventricular nodal reentrant tachycardia but are less effective than radiofrequency catheter ablation.
333. The cardiac output is low in primary cardiogenic shock, and inotropic agents may be needed to augment myocardial contractility and thus cardiac output.
334. Exercise (or pharmacologic) stress testing is the most sensitive noninvasive method to establish the diagnosis of coronary artery disease.
335. Exercise (or pharmacologic) stress cardiac imaging can be used to evaluate for coronary artery disease if the resting electrocardiogram is abnormal.
336. The role of electron-beam CT coronary calcium scores is not yet established in the assessment of coronary artery disease.
337. Prolonged immobility followed by a stroke or transient ischemic attack should raise the suspicion of a paradoxical embolism.
338. Transesophageal echocardiography is the test of choice to confirm the diagnosis of a suspected patent foramen ovale or cardiac source of embolus.
339. • Systemic lupus erythematosus is a cause of premature atherosclerotic coronary disease.
340. • Other causes of acute myocardial infarction in young persons include coronary spasm, embolic coronary occlusion, and Kawasaki's disease.
341. High risk patients that require a heparin anticoagulation bridge after stopping warfarin prior to surgery include those with a mitral mechanical valve, atrial fibrillation, or previous embolism.
342. Low risk patients do not require a heparin bridge after stopping warfarin prior to surgery and include patients with a bileaflet aortic valve and no other high risk features.
343. Aspirin alone is not a sufficient replacement for warfarin, and is used only as a chronic adjunct in patients who manifest systemic emboli despite therapeutic warfarin therapy.
344. Radial-femoral delay is a characteristic physical finding in aortic coarctation.
345. Bicuspid aortic valves are common in patients with aortic coarctation and are associated with a systolic ejection click and systolic murmur noted over the aortic area.
346. Elevated B-type natriuretic peptide levels occur with renal failure, acute coronary syndrome or myocardial infarction, and acute volume or pressure overload.
347. Adenosine is the treatment of choice for narrow-complex tachycardia.
348. Neither adenosine nor other atrioventricular nodal blocking agents should be given to patients with preexcited tachycardias.
349. Procainamide is the drug of choice for wide-complex tachycardia of unclear etiology.
350. Coronary angiography is indicated in patients with a history of unstable angina or non-ST-elevation myocardial infarction.
351. In patients with a high pretest probability of coronary artery disease, a negative stress test result is most likely to be false.
352. Spinal stenosis is characterized by pain with standing or walking that is relieved by sitting or bending forward and is further supported by a normal ABI.
353. Leg ischemia is characterized by pain with exertion and with a decrease in ABI of at least 20 % with exercise.
354. The use of angiotensin-converting enzyme inhibitors should be avoided during pregnancy.
355. Hydralazine and nitrates are the vasodilators of choice to treat heart failure during pregnancy.
356. Induction of mild hypothermia improves outcomes in comatose survivors of out-of-hospital cardiac arrest.
357. Aortic valve replacement is recommended once symptom onset occurs, regardless of patient age.
358. Symptom onset in aortic stenosis is often insidious and may include exertional dyspnea.
359. Alcoholic cardiomyopathy is a dilated cardiomyopathy.
360. Therapy for alcoholic cardiomyopathy must include total abstinence from alcohol.
361. In chronic angina, coronary artery bypass graft surgery is indicated for patients refractory to medical therapy; a large area of ischemic myocardium; high-risk coronary anatomy; and reduced left ventricular systolic function.
362. Atrial tachycardia with variable block is a classic electrocardiographic finding in digitalis toxicity.
363. The first-line treatment for life-threatening digitalis toxicity is administration of digoxin-specific antibody fragments.
364. Iron deficiency is a common cause for dyspnea and fatigue in patients with cyanotic heart disease.
365. The most common cause of iron deficiency in patients with cyanotic heart disease is recurrent phlebotomy.
366. Mitral valve surgery is indicated for symptomatic patients with chronic, severe mitral regurgitation.
367. In asymptomatic patients with chronic, severe mitral regurgitation, criteria for mitral valve surgery include an end-systolic dimension >45 mm, an end-diastolic dimension >60 mm, and an ejection fraction
 
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* Re:some helpfull notes
#2295828
  sami2004 - 12/22/10 16:10
 
  USMLE WORLD NOTES * ENDOCRINE SYSTEM

►DIABETES MELLITUS: Tight glycemic control DECREASES risk of developing NEW peripheral neuropathy

1-DM diagnosis => fasting glucose in 2 separate times > 126
2-Pts with uncontrolled impaired fasting blood glucose [B/w 100 – 126] are at risk for => CAD- CORONARY ARTERY DISEASE [even with a normal lipid profile] and progression to evident DM
3-Fasting blood glucose < 100 is normal
DM: HYPOGLYCEMIA => Glucose < 60
► For the diagnosis of DM = use fasting blood glucose levels [> 126 /x2]
Or= Random blood sugar > 200
♥ RISK OF DM TYPE 1 IN OFFSPRING :
Mother with DM type 1 = RISK is 3%
Father with DM type 1 = RISK is 6%

►DM: Antihypertensive drugs that have been shown to reduce risk of development of type 2 DM:
o ACEIs [reduce insulin resistance] + lifestyle modifications
o Metformin
►Causes of hyperglycemia:
Stress due to any illness can increase in insulin resistance causing a poor glycemic control and aggravating hyperglycemia
Example –acute attack of gout, and not diet or medication compliant

►Polyglandular Autoimmune failure type II [Schmidt’s syndrome] => Addison disease, type I DM, Autoimmune thyroid disease and other autoimmune disorders like: pernicious anemia, premature ovarian failure, vitiligo, celiac disease.

►DM -Type I=> do not have appreciable endogenous insulin production, ketoacidosis when deprived of insulin treatment. [High blood sugar, ketonuria, increased anion gap]

►Sulfonylurea induced hypoglycemia [is severe and prolonged], RX:
-Admission
-Bolus of D50% followed by dextrose infusion + Octeotride
[Because bolus of dextrose lead to elevation in the blood glucose level increasing secretion of insulin->severe rebound hypoglycemia later]
> Add OCTEOTRIDE [somatostatin analogue that inhibits insulin secretion]

►Causes of hypoglycemia with increased plasma insulin level:
1. Insulinoma {Elevated serum Insulin and ↑ C-Peptide
2. Sulfonylurea use {Elevated serum Insulin and ↑ C-Peptide
3. Exogenous insulin [Elevated serum Insulin and LOW ↓ C-Peptide

Diabetes Mellitus/complications-
►Diabetic Retinopathy needs some years to develop => poor glycemic control and blurry vision can be due to swelling in the optical lens secondary to osmotic changes. => Best next step is => Improve glycemic control
►In a patient with Diabetic Retinopathy => how avoid further retinal damage? => Add insulin to the regimen to tighten glucose control.-

►Autonomic neuropathy/delayed gastric emptying -> advice small frequent meals- Metoclopramide, Erythromycin -> Cisapride x long term and severe refractory gastropathy
►Diabetic gastroparesis
Gastroparesis (D.M autonomic neuropathy, delayed gastric emptying -> food remaining in the stomach for a longer period of time than normal.) -symptoms: Postprandial bloating, postural dizziness, abnormal sweating, constipation => Delayed gastric emptying cause postprandial hypoglycemia
♣DX: x rays, manometry, BEST TEST: Nuclear studies to study gastric emptying => Gastric emptying scan
♣RX: Dietary changes (Low-fiber and low-residue diets, restrictions on fat and/or solids), oral medications [pro-kinetic] such as Metoclopramide (Reglan, Maxolon, Clopra). Erythromycin and Domperidone (Motilium); adjustments in insulin dosage for those with diabetes,
♠ For long term management: Cisapride (Propulsid), jejunostomy tube, parenteral nutrition, implanted gastric neurostimulators ("stomach pacemakers"), or botulinum toxin.
♣Complications: Bacterial infection due to overgrowth in undigested food, also, the food can intestinal obstruction; malnutrition,harden into solid masses called bezoars WT loss, diff. controlling glucose.

►DM: Tight glucose control => decreases risk for development of ‘microvascular’ complications [retinopathy, nephropathy, neuropathy]. No effect/control on macrovascular risks: MI, PVD, Stroke, etc
Diabetic patient should maintain their LDL cholesterol < 100 mg/dL -> Statins are the DOC**
►Diabetes Mellitus
►Diabetic poly-neuropathy –affects lower limbs in a stocking-glove pattern, decreased ankle reflexes, ↓ sensitivity to pain or light touch, paresthesias progressing to motor weakness and pain.
BEST screening and diagnostic test x D. Neuropathy is => NERVE conduction studies [axonal pattern of nerve damage]
► Diabetic peripheral neuropathy -> pain management.-
TCAs nortriptyline or amitriptyline [but are contraindicated in pts with HEART disease]
Alternative: Gabapentin

DM management during delivery and labor/surgery
**Insulin administration should not be stopped [to prevent DKA] in a type 1 DM patient even if they are not eating.- Insulin requirement DECREASES following delivery of a pregnant diabetic.
“Take normal insulin dose on the night before surgery and start on insulin drip and infusion of D5% with KCL 40 mEq [to keep blood sugar < 160]

DKA: Most common complication/mistake= incorrect fluid management
-Understand that glucose infusion and potassium replacement are important components in DKA, aside from insulin and NSS

1- Initial fluid: NSS 0.9% until the blood sugar reaches 250 mg/dl + Insulin infusion

2- Then: Decrease Insulin infusion to 1-2 U/hr and change to D5% ½ NSS + KCL
[Dextrose infusion is very important to decrease ketone levels]
3- Switch to SQ Insulin [Rapid acting] [when pt is stable, normal anion gap, HCO3 is > 10, able to tolerate food and precipitating factors are under control] then to oral route feeding.

 DKA – another common mistake: stopping IV Insulin w/o overlapping dose of SQ Insulin
Result= rapid recurrence of DKA
-When change to SQ insulin= this route takes time to be absorbed, so, it should be administered 30-60 minutes before insulin infusion is stopped => fails to do this = rapid recurrence of DKA.

►Diabetes Mellitus / HONKC
**Diabetes type 2 patient presenting with a Hyperosmolar nonketotic coma => hyperglycemic crisis precipitated by infection and steroid use =>
-Requires high doses of IV insulin due to insulin resistance induced by infection, steroid and hyperglycemia.
-Then insulin is reduced once blood sugar and infection are controlled
-SQ insulin is started once the patient starts to EAT consistently:
Regular insulin [rapidly acting] is required to cover meals
And basal insulin (NPH or Glargine) insulin required to cover the period b/w meals
-AVOID oral hypoglycemic agents

►Metformin is especially useful in DM patient OBESE
Metformin, Pioglitazone and Rosiglitazone => Decreases Triglycerides, improves NASH and increases HDL
Insulin, thiazolidinediones, sulfonylureas [glyburide] -> cause WT gain
►Metformin can be continued in patients with PCOD UNTIL PREGNANCY IS DOCUMENTED. Then, advice her to STOP Metformin and prescribe INSULIN

► Metformin is contraindicated in:
 CHF
Alcoholism
Renal failure
USE Insulin for these cases
►Pt with uncontrolled DM and renal failure => Stop Metformin and other sulfonylureas [Stop Glyburide] and Start Insulin [Renal failure is an indication to treat DM with insulin]
• Glyburide is metabolized in the kidney, stop this drug; and Metformin.
• Since Rosiglitazone is metabolized by the liver =. No need to stop Rosiglitazone

► Metformin & lactic acidosis => in the elderly, pt with renal failure, hepatic or heart failure…
=>Other causes of lactic acidosis: hypoperfusion and tissue hypoxia [sepsis, hypovolemic shock, and hypoxemia
=> Look always the anion gap.- AG= Na – (CL + HCO4) Normal: 8-12

High Anion gap metabolic acidosis: Lactic acidosis [metformin], renal failure, DKA, intoxications, ASA, ethylene glycol or methanol.

►Patients with type 1 DM or any autoimmune disease are in risk or predisposed to get other autoimmune disorders such as: Addison disease, hypothyroidism, pernicious anemia, atrophic gastritis; etc [MEN or PAS].
 If a patient with DM type 1 has symptoms of Addison disease; or adrenal failure [WT loss, asthenia, eosinophilia, hyperkalemia, borderline sodium levels, mild anion gap acidosis, prerenal azotemia, low blood glucose].
THE next step is: Check Cosyntropin stimulated cortisol levels

►Effects of Exercise on glycemic control – [principally DM type 2]
-“Hypoglycemic effect of exercise” for hrs after completion of exercise=> Exercise decreases blood glucose by improving insulin sensitivity and increasing non-insulin mediated uptake of glucose by the muscles => serious problems in glycemic management [can lower blood glucose in the presence of high insulin or increase blood glucose when insulin is low]
-Pt needs to check blood glucose before exercise, advice to eat a snack if glucose is in low normal range
-Most reasonable option is: => Start patient on insulin pump [free to vary the timing of their exercise and food intake]
►The role of exercise control in DM type 1 [is not as clearly defined as for the DM type 2]
**Type 1 DM achieve glycemic control with a lower dose of insulin when they exercise regularly or participate in sports
Make a appropriate schedule in order to make appropriate insulin adjustments
Should decrease dose of insulin prior to their most active time of the day or when participating in sports
**Exercise in early afternoon=> morning dose of NPH should be reduced
**Patient on insulin pumps => has more flexibility for changing their insulin dose and may participate in unplanned activities.
**AVOID exercise when blood sugar is > 250 => because risk of DKA

►Glucagonoma
---Pancreatic tumor associated to mild Diabetes and a classic skin rash “Necrolytic migratory Erythema”
--High Glucagon level in serum--Can have metastasis, mainly in liver at the time of diagnosis
--Can secrete other peptides: VIP, calcitonin, GLP1
--RX: Surgery
►Pancreas-
Classic triad of Somatostinoma [tumor, Delta cells of pancreas; majority are cancerous]
Gallstones [by inhibitory effect of somatostatin on gallbladder motility]
Malabsorption [by inhibition of pancreatic secretion]
Diabetes Mellitus [inhibition of insulin secretion by somatostatin]
DX/ Next step: Fasting somatostatin levels [> 160]

Incidentalomas:

►Incidentaloma=unilateral Adrenal mass => require further workup for hormone secretion or malignancy => evaluate hormone production is the first step
►Incidentaloma [Adrenal mass] work up:
Serum electrolytes
Dexamethasone suppression testing
24 hr urine catecholamine, metaneohrine, VMA
17-ketosteroid measurement
All masses should be managed conservatively with SERIAL ABDOMINAL IMAGING
Remove if masses increase in size
All functional mass with radiographic evidence of malignancy or masses > 4 cm in size should be removed

► Pituitary Incidentaloma-
Patients with a small mass [5 mm] or lesion without any hormonal dysfunction can be safely followed by periodic assessment of the pituitary gland with MRI [Repeat MRI of pituitary in 6-12 months]

If first episode of proximal DVT in leg, symptomatic pt => Need Anticoagulation / the primary goal of RX is to prevent clot extension and prevent acute PE!
 RX: Unfractioned Heparin IV /or LMWH x 5 days and add WARFARIN 24 hr after heparin starting. Heparin continued until INR is in 2.0-3.0 for at least 2 days.
If pt is a woman taking HRT => urged to stop HRT and continue WARFARIN for at least 3 months
After a 1st thromboembolic event in the presence of a reversible risk factor = should be treated with anticoagulation for at least 3 months
After a 1st IDIOPATHIC thromboembolic event [no risk factor] or recurrent thromboembolic event => should be treated for a prolonged period of time.

PARATHYROID:
►Indications of parathyroidectomy [pts with 2ry or 3ry hyperparathyroidism]
-Calcium > 10.5 not responding to conservative management
-Moderate/severe hyperphosphatemia, not responding to medical management
-PTH of > 1000 pg/mL
-Intractable bone pain
-Intractable pruritus
-Episode of calciphylaxis -Soft tissue calcification
-It is very important to rule out low bone turnover or adynamic bone disease before a parathyroidectomy => if ALP is very high { indicates that bone turnover is increased, so the surgery is safe.

► Indications of parathyroidectomy in patients with 1ry hyperparathyroidism
-Bone mineral density T score < 2.5 SD
-Complications of 1ry hyperparathyroidism like= kidney stone, evidence of bone disease
-Serum calcium > 1 mg/dl above upper limit of normal
-History of life threatening hypercalcemia
-Urinary Calcium > 400 mg/day
-Creatinine clearance decreased 30%
-younger than 50 y/o

Bone loss after delivery => exaggerated bone loss if predisposing factor like Heparin use combined with increased bone loss during postpartum state. => Discontinuation of breastfeeding during post-partum -> can preserve or improve bone mineral density because decrease calcium loss and decrease in the level of parathyroid hormone rP [PTHrP] which is important in calcium transfer into breast milk, and levels are increased during nursing.

►Celiac disease or gluten induce enteropathy can present w/o signs of malabsorption; in a pt with iron and vitamin D deficiency despite consuming a nutritious diet –and can be suggested by family history of autoimmune diseases and vitiligo.-
Celiac disease screening= Anti-endomysial and Anti-tissue transglutaminase antibody level
Gold standard => Small Intestinal biopsy

Familial Hypocalciuric Hypercalcemia [FHH]
-Can be managed with moderation of calcium intake, adequate hydration and regular physical activity
-Has: => LOW Urine Calcium [ 10
Osteopenic =T score 1.0-2.5
Oteoporosis = T score < 2.5
Optimal intake of calcium and vitamin D

►Excessive bone resorption after prolonged immobilization => leads to hypercalcemia. Seen in patient with a very high turnover [adolescent, older pt with Paget’s] [days to weeks following immobilization
Management: Biphosphonates are useful in decreasing bone resorption

►MEN 1 with 3 “P” = hyperparathyroidism, pancreas tumor [gastrinoma…] and pituitary tumor => Next step in the management => require refer to a surgeon for parathyroidectomy

► Sarcoidosis => hypercalcemia => Overproduction of 1,25-dihydroxyvitamin D => Increased Calcium uptake
Sarcoid produce the enzyme 1-alpha-hydroxylase [convert 25 hydroxyvitamin D to 1,25 dihydroxyvitamin D leading to an increase in GI absorption of calcium. => Resulting hypercalcemia leads a suppressed PTH secretion and an increased urinary calcium excretion.
►Sarcoidosis / hypercalcemia => RX: Glucocorticoids + hydration

►Hypercalcemia
1-Primary hyperparathyroidism
2-Malignancy induced hypercalcemia [calcium is very ↑↑↑]
3-Vitamin D induced hypercalcemia
**In hyoercalcemia due to malignancy [exe; lung tumors, smokers]=> SERUM Calcium levels is much higher than in primary HP.

►Hypercalcemia classification
1-Parathyroid dependent {primary, terciary HP, lithium induced hypercalcemia, familial hypocalciuric hypercalcemia}
2-Parathyroid independent {Malignancies, vitamin D toxicity, granulomatous diseases [sarcoidosis], milk alkali syndrome
Malignancy: due to secretion of PTHrP and other causes
Next step => Serum PTH measurement


►Pseudo-Hypoparathyrodism
Long standing hypocalcemia, hyeprphosphatemia, bilateral catarats and calcification of basal ganglia
Cause: resistance of PTH on its target tissues
Type 1A: Albright hereditary osteodystrophy AHO [short stature, round facies, short 4th – 5th metacarpals and a short neck]
Type 1B: Does not have features of 1A AHO
►Pseudo-Pseudo hypoparathyroidism [PPHP]: do not have hypocalcemia and hyperphosphatemia because resistance to PTH is mild but has features of Albrights

►Following gastric bypass surgery => malabsorption => DX: Measure 25-hydroxyvitamin D serum
RX: need higher doses of vitamin D supplementation to prevent osteomalacia

►Paget’s disease: RX: Biphosphonates
Treatment is indicated when:
Bone pain
Involvement of weightbearing bones
Neurological compromise
Hypercalcemia
 Hypercalciuria
CHF

►When pt does not respond to treatment for osteoporosis [biphosphonates] despite being compliant and has rapid bone loss => suspect secondary causes [MM]*
=> NEXT STEP: Serum Urine protein electrophoresis**

►Long term management for chronic hypoparathyroidism: Vitamin D + Calcium
**Borderline serum calcium and high urinary calcium [due to low PTH levels, PTH increases renal calcium absorption]. => Add a Thiazide diuretic [increase serum calcium and decrease loss of calcium through urine]

ADRENALS

CORTISOL DEFICIENCY = hypotension
=>LONG TERM USE OF GLUCOCORTICOIDS => Patients with chronic suppression of hypothalamic-pituitary-adrenal axis => 2ry or 3ry Adrenal insufficiency => ↓ Cortisol, ↓ ACTH
►Since ACTH does not control secretion of mineralocorticoids from the zona glomerulosa of adrenal gland, patients have can developnormal plasma aldosterone and are normotensive, but IF STRESS vascular collapse under a stressful situation [infection] [ACUTE ADRENAL INSUFFICIENCY] due to decrease of cortisol [hormone responsible for keep vascular tone] and since cortisol promotes synthesis of catecholamines in adrenal medulla, cortisol deficient patients are unable to grow a good pressor response to stress.
♥Hypotension in these pts responds to administration of a stress dose of glucocorticoids and hydration.
♥In secondary and tertiary adrenal failure, there are no significant abnormal mineralocorticoid levels [no need fludrocortisone]

Goal of treatment in ACUTE ADRENAL INSUFFICIENCY

** Reverse hypotension -> Hydration IV NSS 0.9%
**Correct electrolyte abnormalities ->
**Replace cortisol => IV Dexamethasone followed by Cosyntropin Stimulation test

► Dexamethasone is preferred because does not interferes with the measurement of ACTH or Cosyntropin test or with urinary steroids.

Spontaneous hypokalemia, hypertension
-Screen for hyperaldosteronism => Plasma/aldosterone to plasma/renin activity

►Pheochromocytoma = biochemical confirmation is required before imaging is performed to localize tumor => Screening test: - Urinary metanephrine and catecholamine levels.
=>Next step: Alpha blocker {Phenoxybenzamine} and liberal salt/fluid intake to control HTN and restore intravascular volume [for 10-14 days before surgery]
=>Then: Imaging to localize tumor before surgery {CT or MRI
=> Intraoperative hypotension -> IV bolus of NS followed by continuous NS infusion.

Screen for Pheochromocytoma in pts with Medullary thyroid cancer => measure plasma free metanephrine {MEN 2A

USE OF GLUCOCORTICOIDS => HIGH DOSES, > 7.5 MG/D, FOR MORE OF 3 WEEKS => can cause suppression of the hypothalamic-pituitary-adrenal- axis -> Lead to tertiary ADRENAL insufficiency

►Cushing syndrome
**Cushing with ADRENAL etiology is biochemically characterized by a non-suppressible or non-response high dose dexamethasone suppression test and low plasma ACTH levels.=> Next step => Do a CT scan of the adrenal glands

►Young patient with diabetes and HTN, osteoporosis, hypokalemia and metabolic alkalosis => Screening for Cushing syndrome => Overnight Dexamethasone suppression test [or 24 hr urinary free cortisol]

PITUITARY:

Nelson’s syndrome: Bitemporal hemianopsia, hyperpigmentation following bilateral adrenalectomy x Cushing’s disease is suggestive of => Nelson’s syndrome. [pituitary enlargement due to loss of feedback by adrenal glucocorticoids; hyperpigmentation and visual defect after adrenalectomy]
Diagnosis: MRI of the brain = Mass lesion in the sellar and suprasellar region and high plasma ACTH
RX: Surgery and pituitary radiation

►Untreated Acromegaly => Increased RISK of C/V disease [leading cause of death in acromegaly]
50% acromegalic pt has HTN, LV dysfunction, others has asymmetrical septal atrophy, conduction defects, atherosclerosis, etc
Increased risk for COLON cancer

►Hypogonadism, high prolactin and low gonadotropin LH/FSH levels; increased ↑ serum alpha subunits => Classic non-functioning pituitary adenoma
[Arises from gonadotropin secreting cells or gonadotrophs in the pituitary]
►First line of Transphenoidal surgerytherapy












THYROID GLAND:

►Pt taking Amiodarone and with WT gain, swelling on feet, tiredness. =>
Next step => “check TSH in serum” [Amiodarone => Thyroid dysfunction, corneal deposits, skin discoloration, pulmonary fibrosis [lipoid Pneumonitis] and liver toxicity]

►Amiodarone effect on thyroid functions
--Pt on amioradone due to Atrial fibrillation => thyroid side effects
--Causes decrease in conversion of T4 to T3 => in turn decrease T3 levels and elevated T4

►Nodules, Thyroid:
Thyroid nodules > 1 cm should be subjected to FNA and biopsy
Thyroid nodules < 1 cm should be followed by thyroid U/S YEARLY
Radionuclide scan is useful in Toxic adenoma [thyrotoxic state]
► A toxic thyroid nodule is charactherized by signs and symptoms of hyperthyroidism and the RIAU is increased focally [focal uptake]

Thyroid
Papillary thryroid cancer = NTT Near total Thyroidectomy is the TOC. Than use RAI to destroy any residual thyroid -> then total body scan

►Symptomatic tachycardia in hyperthyroid patient => use B-blockers / -> Propranolol

►Subclinical hypothyroidism =mild elevation of TSH [5 – 10] with normal FT4
►Subclinical hypothyroidism + depression and ovulatory dysfunction [irregular heavy painless menstrual cycles] with *only mild elevated TSH
*Next step: => Low dose Levothyroxine [start 50 mcg of levothyroxine or L4]
*Resolves depression and menstrual irregularities
►ASYMPTOMATIC Subclinical hypothyroidism => does not requires treatment
►Subclinical hypothyroidism = Treatment is required if:
Antithyroid antibodies [Anti-TPO]
Abnormal lipid profile
 Symptoms of hypothyroidism
Ovulatory and menstrual dysfunction
When TSH > 10
§ RX: Levothyroxine

►Subclinical hyperthyroidism or EVIDENT hyperthyroidism
HAS increased risk for Chronic ATRIAL FIBRILLATION
Primary goal of treatment: Rate/Rhythm control with B-blockers or CCC
And to prevent systemic embolization with anticoagulation- Heparin
► HRT => increases the risk of DVT venous thromboembolism and for PE [can lead to increased risk of forming blood clots] – It’s not indicated for primary or secondary prevention of CAD. [indicated to prevent osteoporosis and vasomotor symptoms]

►Subclinical hyperthyroidism /or/ thyrotoxicosis: Next step…
Subclinical thyrotoxicosis:When Suppressed TSH levels with normal thyroid hormones [Normal FT4]
MCC: treatment with levothyroxine, nodular thyroid disease, Grave’s disease and thyroiditis
♥ Subclinical thyrotoxicosis induced by levothyroxine RX: reduce the dose
♥ Recheck TSH after 6-8 wks [etiology no determined, TSH becomes normal if repeated in a few weeks]
♥ No treatment is necessary: Patient with no symptoms, mildly decreased TSH, normal bone density

►Calcium carbonate and iron preparations, OTC vitamins => can impair absorption of Levothyroxine
=> Pt with unexplained increased TSH
Pt should be instructed to take L4 on an empty stomach, in the morning, separately from other medications

►Thyroglobulin => Their only source in the body is the thyroid gland, thus the presence of EXOGENOUS Thyroid hormones would suppress the thyroid gland, inhibiting TG release into the circulation
Exogenous Thyroid hormone => “Undetectable levels of Thyroglobulin”
Some OTC weight loss pills contain thyroid hormones and can lead to pill induced thyrotoxicosis but decreased TG


►Thyroid LYMPHOMA [Rare thyroid malignancy in pts with Hashimoto’s]
-Suspected if a patient with longstanding Hashimoto’s thyroiditis presents with a rapid enlarging and compressive symptoms [dysphagia] and a firm thyroid gland or goiter
DX: large fine needle aspiration/biopsy
RX: Radiation and chemotherapy, => the response is good

►Hashimoto’s thyroiditis diagnosis => High titers of anti TPO
Other studies => U/S, Radionuclide thyroid scan, aspiration biopsy

►Thyroid lymphoma => needs => large needle aspiration biopsy

►Primary hypothyroidism => have hyperlipidemia [isolated elevation of LDL or combined elevation in LDL and triglycerides]

PREGNANCY AND THYROID
►Thyroid hormones and contraception or HRT:
Estrogen replacement therapy/contraception => increases requirements for L-thyroxine in hypothyroid patients taking this medication.- [due to induction of liver enzymes, increased level of TBG and increased volume of distribution of the thyroid hormones]
Next step: “Increase dose of levothyroxine”

►Thyroid and pregnancy:
-T4 [Total T4] and total T3 are elevated due to increased levels of TBG => induced by estrogens

**The total serum thyroxine (T4) and triiodothyronine (T3) levels are increased in pregnancy due to high levels of estrogen which, in turn, increase the thyroid hormone-binding protein concentrations
-Free T4, Free T3 and TSH are normal in pregnancy
-In the post-partum period T4 and T3 return to normal [unless postpartum thyroiditis]


►Post partum thyroiditis [Thyrotoxicosis followed by hypothyroidism]
By autoimmunity, has triphasic course=>
1st phase: Thyrotoxic phase= Low Radioactive iodine uptake [1-3 months after delivery] -anxiety, insomnia, palpitations (fast heart rate), fatigue, weight loss, and irritability
2nd phase: Hypothyroid phase = 4-8 months after delivery- fatigue, weight gain, constipation, dry skin, depression and poor exercise tolerance.
3rd phase: Recovery phase [within 12-18 months of the onset]
**Permanent hypothyroidism develops only in 20% cases

►Pregnant pt with thyrotoxicosis
Needs to be treated with PTU => if not response or intolerance => Surgery is indicated
Treatment can’t wait until postpartum period [risk of thyroid storm is high]

►Pregnancy + Hyperthyrodism => Discontinue Methimazole [scalp defect or aplasia cutis in the fetus]
Prescribe: Propylthiouracil

►Pregnant woman with hypothyrodism:
***> Very important to be treated to avoid fetal mental retardation, low IQ
**During the first trimester: INCREASE dose of levothyroxine!

►Most appropriate course of action in GRAVE’S disease in USA:
1- Radioiodine ablation + concurrent prednisone administration
[to avoid worsening of ophthalmopathy]
Contraindications:
* Large retrosternal goiter [due to post-procedure swelling of the gland may compromise airways]

►Thyroid storm
-Diagnosis is med clinically -> Treatment can be started ASAP without waiting for Labs
-Glucocorticoids are used in thyroid storm because they inhibit the conversion of T4 to T3
-Iodine can not be administered before antithyroid drugs because excess iodine can serve as a substrate for the formation of more thyroid hormones, worsening the problem

**Other drugs that inhibit the conversion of T4 to T3=> B-blockers, amiodarone, PTU, iopanoic acid

►THYROID CANCER
**Post-operative patient [total thyroidectomy] of Medullary thyroid cancer=> ↑ persistently of calcitonin => Indicates Residual metastatic thyroid cancer => NEXT step => CT-scan of the neck and chest [with or w/o high resolution U/S]

►Thyroid cancer in remission => Suppressive doses of levothyroxine are needed
-Papillary thyroid cancer in remission => dose of levothyroxine is adjusted to suppress the TSH below normal range (0.1 and 0.3 mU/mL) => Then, the dose can be increased to bring TSH to WNL goal range
--Patient with distant metastasis => even lower levels [complete suppression] is required
--Remember: This “Suppressive doses of levothyroxine’ puts pt at risk of=> Bone loss and Atrial fibrillation

►Important concept:
**Hypothyroidism, even it is severe; it not a contraindication to emergency surgical procedures!
Example-cardiac catheterization


►MEN II:
 Medullary thyroid cancer
Pheochromocytoma
Hyperparathyroidism
MEN II b: Pheochromocytoma and Medullary carcinoma of thyroid + Marfanoid habits with mucocutaneous and GI neuromas

►Patient with medullary thyroid cancer and symptoms of pheochromocytoma like palpitations, headaches and sweating; surgery for thyroid cancer is scheduled => What is the NEXT STEP in Remember MEN II =management? > Alpha blocking agent for at least 10-14 days before ANY surgical procedure + liberal fluid/salt intake to restore intravascular balance

Remember: Suspecting pheochromocytoma and any surgery scheduled-> next step is=> Alpha blocking agent to avoid intraoperative complications with fluids/salt intake to restore intravascular volume

►Iodine induce thyrotoxicosis after angiography; next step-> Thyroid function tests
=>Secondary to iodine administration during coronary angiography => extreme fatigue, shakiness, WT loss, palpitations, firm irregular thyroid [possible multinodular] and tachycardia despite B-Blockers after coronary angiography.—
RX: Self limited disorder [can persist for months, is usually refractory to antithyroid medication]
--For mild symptoms: B-Blockers
--Moderate/severe symptoms: Antithyroid drugs => Refractory cases: Potassium perchlorate
*****Ineffective Radioactive iodine ablation because RAIU is low****

►Subacute thyroiditis: => Very low RAIU***Decreased uptake!!
Classical symptoms of thyrotoxicosis, heat intolerance, palpitations, SOB; thyroid gland enlarged, painful and tender.

►Lymphocytic thyroiditis: => with symptoms of thyrotoxicosis are treated with B-blockers [Propranolol]

►Hashimoto thyroiditis: => High titers of Anti-TPO => hypothyroid state => RX: replacement with levothyroxine

►Central hypothyroidism =>”EVALUATION OF THE ADRENAL STATUS [Cosyntropin stimulation test] is the best next step in patients with central hypothyroidism””
***A patient with Central hypothyroidism has => Borderline elevated TSH, low FT4 ***But this TSH is not biologically active
***-> NEED to rule out concomitant central adrenal insufficiency [Addison disease] that can increase TSH levels without hypothyroidism [due to loss of an inhibitory effect of glucocorticoids on TSH secretion].
***=> Next step: “Measurement of CORTISOL” with Cosyntropin stimulation test
(Treating pt with central hypothyroidism and concomitant adrenal insufficiency or Addison => could precipitate adrenal crisis)

 Combination of elevated T3, T4 and TSH can be seen in:
1- TSH secreting pituitary adenoma and in
2- Thyroid hormone resistant syndrome
The difference: Hyperthyroidism central/pituitary adenoma has ELEVATED Alpha subunits

►TSH secreting pituitary adenoma
**Clinical features of thyrotoxicosis with: ↑ T3 ↑ T4 and ↑ TSH + ↑ serum alpha subunits
►Similar: Thyroid hormone resistant syndrome
**Clinical features of thyrotoxicosis with: ↑ T3 ↑ T4 and ↑ TSH BUT: Normal serum alpha subunits

►Euthyroid sick syndrome [Low T3 syndrome]
-Commonly seen in hospitalized pts due to another condition
-LABS: Decreased total T3 [↓Total T3] with Normal T4 and TSH
-If patient is extremely sick=> can be reduced T4 and TSH too [bad prognosis]
-TSH transiently increases above normal limits when pt recovers
►RX or next step: Repeat thyroid function test in 8 weeks [because recovery phase], do not use thyroid hormone

►Elder people with mental status change => Order Thyroid function tests
MCC of mental status change in elderly:
#1- Medication, polypharmacy
#2- Infections UTI, pneumonia, etc
#3- Metabolic abnormalities=> hypothyroidism, thyrotoxicosis [with depression]

USMLE WORLD STEP-3 INTERNAL MEDICINE
Cardiology
CAD
Multiple risk factors increase the risk of acute CAD.
The risk can be significantly reduced by decreasing LDL cholesterol and, to a lesser degree, by adequately controlling the blood pressure (in diabetic patients, as well as in patients with previous CAD, a blood pressure lower than 130/80 mmHg is recommended). The contribution of other interventions such as smoking cessation, diabetes control, exercise, and HDL increase is also beneficial, but not as critical as the first two measures.
♥In patients with hypercholesterolemia and hypertriglyceridemia ► a statin is the best initial drug of choice. The primary target of therapy is normalizing LDL-cholesterol; the secondary target is normalizing non-HDL cholesterol(total cholesterol – HDL cholesterol).
♥If the statin fails to control hypertriglyceridemia► gemfibrozil or niacin can be added.

In prospective studies of healthy patients, those with higher plasma fibrinogen concentrations developed coronary heart disease more frequently. Fibrinogen levels decrease only 20 years after smoking cessation; while certain drugs such as atorvastatin and lovastatin can produce hyperfibrinogenemia. Even though it is uncertain how dangerous hyperfibrinogenemia can be, it is currently recommended to maintain fibrinogen levels as low as possible and to discontinue any medication that can increase them, unless the benefits outweigh the risks.
Exercise electrocardiography should be the initial test of choice for evaluation of suspected CAD in patients with a normal resting EKG and the ability to exercise.
Exercise stress testing is useful for the diagnosis and risk stratification of patients with stable angina. Exercise testing is useful to identify a high-risk group that will benefit from coronary angiography.

♥Patients at high risk have one of the following findings on exercise testing:
1. failure to increase their blood pressure with exercise
2. Inability to complete stage I of Bruce protocols
3. Appearance of horizontal or down sloping ST segment during exercise

♥Pharmacological stress testing is an alternative to exercise stress testing, and is indicated in the setting of CAD, when the patient is unable to exercise due to some underlying medical disorder (amputation), when an exercise stress test is relatively contraindicated (MI, unstable angina), or in patients in whom interpretation of an EKG is difficult because of preexisting changes, such as left bundle branch block, baseline ST/T changes from left ventricular hypertrophy, etc.
♠Both adenosine and dipyridamole scans are contraindicated in patients with COPD because they can induce bronchospasm.
♥The American College of Cardiology/American Heart Association (ACC/AHA) defines a positive exercise stress test as ►1 mm or more of down sloping or flat ST segment depression during exercise or during the recovery period.
♥Exercise echocardiography is more sensitive than the resting echocardiogram or stress EKG, and is also commonly done in patients with stable angina.
♥Resting echocardiography or EKG is useless in stable angina when the patient has no active chest pain.
-Principles and practice of stress testing are based on the relative development of manifestations of myocardial ischemia as the stress to the myocardium is increased. Regional wall motion defects are the first to appear (detected by stress echocardiography). This is followed by significant perfusion defects (detected by perfusion scans), pulmonary capillary wedge elevation, ST segment changes on electrocardiogram, and finally, anginal pain.
-Stress imaging should therefore be pursued if there are no EKG changes during or after the stress test. It is also the modality of choice in patients with bundle branch block, WPW syndrome, paced ventricular rhythm, and baseline ST changes before exercise (ventricular hypertrophy, digitalis therapy, etc.). A positive stress test result in a patient with symptoms warrants further intervention, preferably with a coronary angiogram.
-Nuclear scans should be performed in subsets of patients with baseline ST segment changes.
-It is important to recognize the advantages and limitations of different available testing modalities for the evaluation of myocardial ischemia.
--Adenosine, along with dipyridamole and dobutamine, is one of the most frequently used pharmacologic agents to induce ischemia in patients with poor functional status.
--Sestamibi test is one of the three available technetium-99m labeled tracers used frequently for radionuclide imaging.
-In patients with angina and a prior history of revascularization (PTCA or CABG), technetium-99m (sestamibi) and thallium perfusion imaging are the two types of radionuclide perfusion imaging modalities used for characterizing the ischemia, establishing the functional effects of lesions, and determining the viability of myocardium.
-The two modalities are also used in patients with complete left bundle branch block (LBBB), electronically-paced ventricular rhythm, preexcitation (WPW) syndromes, > 1 mm ST segment depression at rest, LVH with repolarization changes, and in patients who are unable to exercise.
♥Coronary angiography is indicated in the setting of stable angina pectoris when the angina is refractory to medical treatment, or when exercise testing identifies the patient as high-risk.

►Studies have shown that compared to angioplasty, Coronary artery bypass graft (CABG) improves long-term survival in diabetic patients with multivessel disease and recent Q-wave infarction.
-Good, perioperative control of the blood glucose levels is advocated during CABG. An insulin drip achieves better blood glucose control during CABG, and decreases the incidence of sternotomy wound infections.
-According to the ACC/AHA guidelines, patients who are unable or unfit to exercise should undergo adenosine or dipyridamole myocardial perfusion imaging for the diagnosis and risk stratification of CAD. Adenosine, along with dipyridamole and dobutamine, is one of the most frequently used pharmacologic agents to induce ischemia in patients with poor functional status.

►All patients with chronic stable angina should undergo an exercise stress test for prognostic and risk stratification.

►All patients with coronary artery disease and stable angina should be referred for an exercise stress test for further risk stratification.
♥Patients with a low risk treadmill score (able to exercise more with a normal EKG) have less than 1% annual mortality rate.
♥On the other hand, patients who have a high-risk treadmill score (presence of chest pain or EKG changes with minimal exercise) have greater than 3% annual mortality rate and require more aggressive management.

►Metformin use is contraindicated in patients with renal failure, sepsis, hepatic dysfunction, and severe heart failure. It should also be stopped in patients who are at risk to develop renal failure, such as those who will undergo angiography, a procedure that involves infusion of a high load of contrast agent

►In patients whose chest pain may be ischemic in origin, supplemental oxygen and ASA aspirin should be administered immediately, followed by Nitroglycerin, Morphine, and Beta-blockers (presuming no contraindications exist).

►Calcium channel blockers can be harmful in patients with acute MI.

►Beta blockers, ACE inhibitors, and statins have significant effects on the secondary prevention of coronary artery disease, and should be continued indefinitely unless absolutely contraindicated.

►The only indications of calcium channel blockers in the setting of acute myocardial infarction include:
♥Intolerance to beta blockers, post-infarction angina refractory to beta blockers and nitrates, and rapid atrial fibrillation with contraindications to beta-blocker use (COPD, pulm. disease)
♠Peripheral edema is a well-known side effect of calcium antagonist therapy. It is more common with dihydropyridine agents (e.g. nifedipine, amlodipine), but also occurs in 2 to 15% of patients taking diltiazem [cardizem]. The exact mechanism of calcium antagonist-associated edema is not known; arteriolar dilatation seems to be responsible for increased interstitial fluid accumulation in these patients



Acute pericarditis
Acute pericarditis (infarct associated or infarction pericarditis) can occur within one to four days as a direct complication of a transmural myocardial infarction. The recurrence of chest pain three days after a myocardial infarction, which gets worse with position changes and deep inspiration, is suggestive of infarction pericarditis. It is usually a clinical diagnosis, and is supported by the presence of pericardial friction rub and EKG changes of pericarditis (sinus tachycardia, diffuse ST segment elevations with PR segment depression).
-A pericardial rub is usually heard over the left sternal border and can be present during any of the phases of the cardiac cycle. It is heard as a superficial scratchy or grating sound, which gets more pronounced when the patient leans forward.
-The EKG changes of pericarditis are not always seen, but usually resemble that of an acute myocardial infarction.

Infarction pericarditis
-Is seen less frequently in patients with early and complete reperfusion. It is usually a transient episode and does not affect the management of acute myocardial infarction, unless it is complicated by a large pericardial effusion or tamponade.
>>It should be managed with close clinical observation and adequate pain control.
>>Nonsteroidal anti-inflammatory medications (NSAIDs) are effective in alleviating the pain associated with acute pericardial inflammation, although there are some concerns that they may increase the risk of myocardial rupture after a transmural MI.

D/DX:
1. Chordae tendineae or papillary muscle rupture is a life threatening mechanical complication of an acute myocardial infarction. It usually occurs two to seven days after the infarction and causes acute hemodynamic instability. Patients also develop acute pulmonary edema.

2. Dressler’s syndrome, or post-cardiac injury syndrome, occurs in patients with myocardial infarction and after cardiac surgery. It is an autoimmune mediated syndrome, which usually develops weeks to months after an acute MI. It usually presents with fever, leukocytosis, pleuritic chest pain, and a pericardial rub.

3. A left ventricular aneurysm usually occurs as a late complication of a transmural myocardial infarction (usually a large anterior wall MI). It may result in heart failure, ventricular arrhythmias, or peripheral arterial embolization due to the formation of a left ventricular thrombus. It develops over a longer period of time, and is usually not associated with chest pain. Persistent ST elevation can be present in these patients.

►Sinus bradycardia is commonly seen as a complication of an inferior wall myocardial infarction.
-It is usually present transiently, immediately after or within the first six hours, and resolves within 24 to 48 hours of acute myocardial infarction. Most of the episodes are asymptomatic, and resolve without any therapy or intervention.
>>BUT: Active intervention is required in patients with sinus bradycardia after myocardial infarction, if the patient exhibits signs and symptoms of hemodynamic compromise.
>>The definite treatment is by reperfusion of the infarcted myocardium, either with thrombolysis or percutaneous transluminal coronary angioplasty (PTCA).
>>If bradycardia persists after reperfusion, the patients can still respond to the administration of intravenous Atropine.
>>VERY HD UNSTABLE: Temporary transvenous cardiac pacing is usually required in patients with persistent bradycardia and hemodynamic instability after myocardial infarction, despite the above measures.

►Recent myocardial infarction and atrial fibrillation are two most common causes of arterial thromboembolism.
►The single most important step in the early management of the patients with acute arterial occlusion diagnosed by history and physical examination is immediate IV heparin therapy followed by continuous heparin infusion.
►Heparin therapy will prevent further propagation of thrombus, and inhibit thrombosis distally in the arterial and venous systems due to low flow and stasis.
♥An important issue for many patients after a myocardial infarction is when sexual activity can be safely resumed
-Therefore, this should be addressed in all sexually active patients before hospital discharge.
-A consensus panel concluded that patients resuming sexual activity 6 weeks after an uncomplicated myocardial infarction are at low risk for future myocardial events.
On the other hand, those resuming sexual activity within six weeks are at intermediate risk, and those resuming activity within two weeks are at high risk.
•Patients with complications such as post-infarction chest pain, evidence of arrhythmias, or heart failure are also at intermediate or high risk
•Patients at intermediate risk should receive further evaluation and subsequent reclassification into the low-risk or high-risk category, while patients at high risk should be stabilized with appropriate therapy before resuming sexual activity.
•Consultation with a cardiologist prior to resuming sexual activity is recommended in all high-risk patients

Radionuclide ventriculography [RVG]
-The anthracyclines (doxorubicin, daunorubicin, idarubicin, epirubicin, and mitoxantrone) are the most common cause of cardiovascular complications in cancer patients.
-Patients who are about to receive such cardiotoxic chemotherapy are therefore recommended to undergo baseline testing and serial reevaluation of systolic function to identify early signs of cardiotoxicity.
-Noninvasive serial monitoring of cardiac function with radionuclide ventriculography (RVG) has been the most effective way to detect early toxicity and reduce the risk of anthracycline toxicity.
-Radionuclide ventriculography [also known as radionuclide angiography (RNA) or multiple-gated cardiac blood pool imaging (MUGA scan)] is performed by labeling a patient’s red cells with a radioactive tracer and measuring radioactivity over the anterior chest with a gamma camera.
-It is the ideal and most reproducible test for providing longitudinal quantitative assessment of LV systolic function in patients receiving doxorubicin or other anthracyclines. It should be used when detection of slight changes in the ejection fraction are of importance, such as during chemotherapy, before and after cardiac transplantation, and severe CHF

HTN
-According to the new JNC VII guidelines, thiazide diuretics are the initial drugs of choice for the treatment of essential hypertension.
-Approximately 90% of patients with secondary HTN will have an unidentified cause. Of the remaining, around 3% will be due to renovascular HTN. Other less common causes account for less than 1% each, and are comprised of the following: primary hyperaldosteronism, drug-induced HTN, acute stress, and renal parenchymal disease.
-Abdominal or flank bruits are present in 50% of the patients with renovascular HTN. This makes this clinical finding the most common and expected clinical finding in a patient with suspected secondary HTN.
-Almost all guidelines recommend non-pharmacologic measures that can be preventive, adjunctive or sometimes definitive in the treatment of hypertension.
-Weight loss enhances the effect of anti-hypertensive drugs. It is the single most effective non-pharmacologic measure to decrease blood pressure in overweight individuals, and it is believed to reduce the overall cardiovascular risk in such patients.
♥ Note: Smoking cessation is an important component of lifestyle modification that reduces the risk of future cardiovascular events.
CHF
►Ischemic heart disease is the most common cause of congestive heart failure (CHF), especially dilated cardiomyopathy, in the United States. Approximately 50 to 75% of the patients with heart failure (HF) have coronary disease as the etiology.
-Other known etiologies are: hypertension (13%), valvular disease (10-to12%), renovascular disease, and very rare causes, such as obstructive sleep apnea, myocarditis, alcohol or cocaine abuse, etc.
-In a new case of CHF with unknown etiology, efforts must first be made to rule out the presence of coronary lesions which may be corrected by an angioplasty.
-Congestive heart failure is a clinical syndrome that results from impaired or inadequate ventricular emptying (systolic dysfunction) or impaired ventricular relaxation (diastolic dysfunction).
-It is characterized by specific symptoms that are either due to reduced cardiac output (fatigue, weakness) or excessive fluid retention (peripheral or pedal edema, dyspnea).
-All symptoms are exacerbated by exertion, and the degree of these symptoms helps in assessing the severity of heart failure.
♥Heart failure is primarily a clinical diagnosis and is based on a detailed history and physical examination. A detailed history and physical examination can also provide clues to the specific cause of heart failure.

♥CHF: The major criteria include the presence of paroxysmal nocturnal dyspnea, orthopnea, raised jugular venous pressure, pulmonary rales, presence of third heart sound, increased cardiac silhouette, and pulmonary vascular congestion on chest x-ray.
♥CHF: The minor criteria include the presence of bilateral lower extremity edema, nocturnal cough, dyspnea on exertion, tachycardia, presence of pleural effusion, and hepatomegaly.

►The diagnosis of heart failure is based on the presence of two major criteria or one major and two minor criteria, provided the minor criteria cannot be explained by the presence of any concurrent medical illness.
♥Chest radiograph findings suggestive of congestive heart failure include cardiomegaly, pulmonary vascular congestion (especially in the upper lobes), Kerley B lines and bilateral pleural effusions.
-The presence or absence of such findings will help to differentiate heart failure from dyspnea secondary to a primary pulmonary pathology.
-Plasma B type natriuretic peptide levels are useful at times to differentiate between cardiogenic versus non-cardiogenic causes of dyspnea.

♥Rupture of chordae tendineae should be suspected in healthy individuals who develop flash pulmonary edema (heart failure) associated with an acute mitral regurgitation.
-The differential diagnosis of this condition includes infective endocarditis, papillary muscle rupture secondary to ischemia, and mitral valve rupture secondary to trauma.

♥ACE inhibitors are the main therapy for CHF. ]They are indicated even in the asymptomatic phase. Although there is currently insufficient data to show its benefits to the mortality rate of African-Americans and women, their use in CHF is always recommended.

♥The only reasons for not giving ACE inhibitors are=
(1) Poor tolerance to the drugs (presence of severe adverse effects) and
(2) The presence of contraindications, such as renal failure
(Creatinine greater than or equal to 3 mg/dL) or hyperkalemia)
♥ Hydralazine and isosorbide combination is frequently used in the management of congestive heart failure in patients intolerant of ACE inhibitors.
-Patients should be informed regarding the possible adverse reactions that may result from the use of these drugs, and instructed to stop the medication if they develop any of these reactions.

♣The development of drug-induced lupus-like syndrome
-has been associated with the use of hydralazine.
-Other drugs that have been associated with lupus include procainamide, penicillamine, isoniazid, minocycline, diltiazem, methyldopa, chlorpromazine, and interferon-alfa.
-Patients with drug-induced lupus can develop a variety of flu-like symptoms such as fever, malaise, arthralgias, myalgias, and maculopapular facial rash. They can also develop lymphadenopathy, splenomegaly, pleurisy, and pericarditis. An important immunological marker of drug-induced lupus is the presence of antihistone antibodies.
Remember:
All patients with flash pulmonary edema of unknown etiology should be evaluated with an Echocardiogram.
Patients with acute pulmonary edema are initially managed with oxygen, morphine and loop diuretics (IV furosemide).
The two most commonly used antihypertensive agents in the management of hypertensive crisis complicated by acute pulmonary edema are => IV nitroglycerine and IV nitroprusside.
Marfans
Marfan or Ehlers-Danlos syndrome must be suspected in patients with connective tissue abnormalities and an acute mitral regurgitation secondary to chordae tendineae rupture, although a primary, pre-existing mitral valve prolapse (MVP) is the most common cause.
Some cases may be idiopathic (individuals who experience rupture of the chordae tendineae without previous MVP or connective tissue disease), but an etiology can be found in most occasions.

Cardiac risk factors
-Diabetes mellitus is the single most important predictor of adverse cardiovascular outcomes, especially in women. It is considered to be an equivalent of coronary heart disease (CHD).
-The role of glycemic control in the development of macrovascular disease in patients with type-2 diabetes is not firmly established.
=Hypertension is a well-established risk factor.
=The blood pressure should be kept below 130/85 mmHg in diabetics, unlike non-diabetic individuals whose target blood pressure is below 140/90 mmHg.
=Smoking is an important modifiable risk factor. The risk of cardiovascular events declines rapidly after smoking cessation, and approaches that of non-smokers in several years

MAT
Multifocal or multiform atrial tachycardia (MAT) is characterized by the presence of:
3 or more P waves of different morphologies
The QRS complexes are narrow
While the PR segments and the R-R intervals are variable
The heart rate can reach up to 200 beats per minute.

MAT is usually secondary to the following conditions:
1) hypoxia
2) chronic obstructive pulmonary disease (COPD)
3) hypokalemia
4) hypomagnesemia
5) coronary/ hypertensive/ valvular disease
6) medications (i.e., theophylline, aminophylline, isoproterenol)
Treatment M A T:
#1= Correct cause: Do ABGs because Hypoxia and COPD are the most common etiologies that affect mainly elderly patients. -Therapy is aimed at correcting the underlying cause.
#2-If the patient fails to improve >>electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia) should be wanted.
If therapy is not effective and there are no contraindications, beta-blockers can be used successfully. In patients with asthma or COPD, verapamil is the drug of choice.

-SVT and sinus tachycardia are the most frequent types of tachyarrhythmias.
--Narrow and regular QRS complexes, and absent P waves >> suggest supraventricular tachycardia.
--Narrow and regular QRS complexes, and presence of P waves >> Sinus tachycardia

WPW Syndrome can be identified in around 0.2% of the population.
=It is characterized by a short PR interval (less than 0.12sec), a delta wave at the beginning of the QRS complex, QRS duration of 0.12sec or wider, and non-specific ST segments or T wave abnormalities.
=Although WPW Syndrome is not common, its diagnosis is important because it can present as SVT.
=If verapamil or beta-blockers are given, AV nodal conduction will be slow, and the accessory pathway conduction will increase.
=These can lead to ventricular fibrillation (especially if the patients already have atrial fibrillation) and death.



♦ Blocks:
-In comparison to Mobitz I, second-degree AV Block (Wenckebach’s), the PR does not prolong progressively, {PR is fixed] but QRS complexes are suddenly lost periodically
-Mobitz II AV Block can cause dizziness, episodes of syncope, or transient altered mental status, thus explaining the symptoms of the patient. Because Mobitz II can progress to third-degree AV Block, it needs to be managed with a permanent pacemaker. Even if the patient is asymptomatic, the AHA/ACC (American Heart Association/American College of Cardiology) consensus advises the use of a permanent pacemaker inserted through a venous access.

Nonsustained ventricular tachycardia
-Is defined as the presence of three or more consecutive ventricular beats with a heart rate greater than 120 beats/min, and with the episode lasting for less than 30 seconds. It is seen most commonly in patients with some form of structural heart disease, possibly because structural abnormalities lead to ventricular arrhythmia.
-Some structural abnormalities that can lead to nonsustained ventricular tachycardia include scarred myocardium from prior myocardial infarctions (coronary artery disease), ventricular hypertrophy (LVH or hypertrophic obstructive cardiomyopathy), dilated left ventricle (dilated cardiomyopathy), and valvular abnormalities such as mitral valve prolapse.
Although nonsustained ventricular tachycardia can also be seen in patients without any evidence of structural heart disease, it is important to recognize that structural heart disease is the most common cause, and a 2D-echocardiogram and stress test should be obtained to rule out ischemia.
-Patients with multiple risk factors for developing cardiac arrhythmias need proper evaluation for possible implantable cardiac defibrillator placement to prevent sudden cardiac death.

Atrial fibrillation
◘ Treatment of atrial fibrillation in a hemodynamically stable patient is different from one who is unstable.
1-If the patient is hemodynamically unstable (low BP, patient not responding to commands), the treatment of choice is electrical cardioversion.
2-If the patient is hemodynamically stable, the atrial fibrillation has to be categorized first as either an acute or a chronic process.
►If it is an acute process, the patient may undergo either Cardioversion [electrical or pharmacological with anti arrhythmic drugs class III agents (amiodarone, sotalol, ibutilide, etc.).
] or Rate control [B-blocker or CCB] to convert his arrhythmia to sinus rhythm. [If > 48 hrs, cardioversion need 1 month of anticoagulation in high risk pt]
►If it is a chronic process, then the patient should be managed with Rate control and Anticoagulation –heparin/Warfarin
Cardioversion -can be either electrical or chemical.

►Electrical cardioversion is indicated in hemodynamically unstable patients.

►Synchronized cardioversion (electrical shock administered in synchrony with the ‘R’ wave) is the procedure of choice.
-Electrical cardioversion should not be performed without 3-4 weeks of anticoagulation first in chronic atrial fibrillation (> 48 hours), as the risk of embolization is high. -The required joules are about 100-200 joules.
-Atrial fibrillation is generally more resistant to convert to normal sinus rhythm than atrial flutter, and the energy required is much higher.
-If you choose to do chemical cardioversion, the drugs of choice are class III agents (amiodarone, sotalol, ibutilide, etc.).

Lone atrial fibrillation in a patient younger than 60 years of age and without structural or functional cardiac abnormalities [CHF, valvular disease…] does not increase the risk of stroke. However, small studies suggest that there can be some risk, especially if the patient has other risk factors, such as advanced age, diabetes, or hypertension.
For this reason, ASA Aspirin is recommended as prophylactic therapy. The risk of anticoagulation with Coumadin outweighs the benefits in this setting.

♥Amiodarone interacts with Warfarin, prolonging its effect and increasing the risk of bleeding. Its clinical response is predictable; it is known that the Warfarin dose needs to be decreased about 25% in order to avoid over coagulation.

♥ Strokes and Warfarin use:
-The use of FFP or intravenous vitamin K is only necessary if the patient is bleeding or has an INR greater than 20.
-If the INR is supratherapeutic, but not higher than 5, it is enough to hold the Coumadin or decrease its dose.
-All other cases of excessive anticoagulation with Coumadin can be successfully managed with oral vitamin K

TCA toxicity
-TCA overdose is the leading cause of hospitalization and death. The signs of TCA overdose include hypotension, anticholinergic effects, CNS manifestations, and cardiac arrhythmias.
-Cardiotoxic effects are responsible for most of the mortality in patients with TCA overdose.
-TCAs inhibit fast sodium channels, which result to slowing of the phase 0 depolarization in His-Purkinje tissue and the myocardium.
-This may lead to QRS prolongation and reentrant arrhythmias, like ventricular tachycardia, ventricular fibrillation, and torsades de pointes.
►Sodium bicarbonate is the most effective agent for the management of TCA-induced cardiotoxic effects.
►Lidocaine is the antiarrhythmic drug of choice for TCA-induced ventricular dysrhythmias.

Valvular disorders
-Mitral stenosis is a narrowing of the outflow tract from the left atrium to the left ventricle, resulting in increased pressure in the left atrium, pulmonary vasculature, and right side of the heart.
-It is more common in women, and is most commonly linked to a remote episode of rheumatic fever, though congenital mitral stenosis may be found as well.
-On physical examination, mitral stenosis produces a diastolic thrill palpable over the apex and a low-pitched, rumbling diastolic murmur best heard over the apex when the patient is lying in a left lateral decubitus position.

Mitral regurgitation causes an apical holosystolic murmur, and is most often secondary to myocardial infarction, mitral valve prolapse, rheumatic heart disease, or coronary artery disease.

Aortic stenosis causes a crescendo-decrescendo systolic murmur with a normal S1, a diminished A2, and a paradoxical splitting of S2. It is most often secondary to senile degenerative calcification, or congenital malformation.

An aortic valve area of less than 1.0 cm2 is considered severe stenosis. The onset of symptoms markedly affects the prognosis in patients with aortic stenosis; therefore, prompt intervention is recommended in patients who have cardinal symptoms of aortic stenosis (dyspnea of heart failure, anginal pain, and syncope). Aortic valve replacement is associated with marked reduction in symptoms and mortality in patients with symptomatic aortic stenosis, and is considered the treatment of choice.

Critical aortic stenosis and angina at rest >> Highest risk factors for peri-operative cardiac risk

Aortic insufficiency causes a diastolic murmur best heard adjacent to the sternum in the second to fourth intercostal space. It is most often secondary to infective endocarditis, congenital malformation, connective tissue disorders, or rheumatic heart disease.

Pulmonic stenosis causes a systolic crescendo-decrescendo ejection murmur in the left upper sternal border. It is most often secondary to congenital malformation, rheumatic heart disease, or carcinoid.

COA: This is usually associated with a congenital bicuspid aortic wall.
-In a previously undiagnosed patient, the classic presenting sign is hypertension. Most patients are asymptomatic unless severe hypertension is present, which can lead to headaches, epistaxis, heart failure, or dissecting aneurysm. The major clinical manifestation in children and adults with COA is a difference in the systolic blood pressure between the upper and lower extremities. In most cases, the diastolic blood pressures are similar.
-The classic findings are hypertension in the upper extremities, diminished or delayed femoral pulses, and lower unobtainable arterial blood pressures in the lower extremities.
♦ Magnetic resonance imaging (MRI) is the best noninvasive modality to diagnose COA because it can usually clearly define the location of severe coarctation of the aorta. MRI can also detect associated cardiac abnormalities and can be used for serial follow-up after surgical repair or balloon angioplasty.

Delirium
-Acute infections are a common cause of delirium, especially in elderly patients being admitted to the hospital. An important goal of treatment in such patients is to avoid the use of medications that can potentially worsen the acute delirious state.
-Diuretics, ACE inhibitors, spironolactone, beta-blockers, and digoxin are all a part of standard therapy for patients with heart failure or cardiomyopathy due to any cause. ACE inhibitors (lisinopril) have consistently been shown in multiple, large, randomized trials to have a significant beneficial effect on patients with heart failure. They have a very low incidence of central nervous system (CNS) side effects, and do not cause worsening of confusional states or delirium. Lisinopril can be safely started in this patient without the risk of exacerbating his confusion and agitation.
-Digoxin is a cardiac glycoside frequently used in patients with congestive heart failure due to systolic dysfunction and atrial dysrhythmias; however, its use has been associated with significant CNS side effects.
-These include blurred vision, dizziness, confusion, mental disturbances, anxiety, delirium, and hallucinations. Its use should be avoided in patients with ongoing acute mental confusion or delirium.
-Spironolactone is a useful adjunct in the management of patients with congestive heart failure, especially in patients with a low ejection fraction; however, its use can also cause CNS disturbances such as drowsiness, lethargy, and mental confusion.
♥Digoxin toxicity is characterized by nausea, vomiting, anorexia, fatigue, confusion, visual disturbances, and cardiac abnormalities. Verapamil, quinidine, and amiodarone can potentially cause digoxin toxicity.

Syncope
Vasovagal syncope is associated with prodromal symptoms of nausea, lightheadedness, pallor and diaphoresis. It usually occurs when the patient is erect, and recovery occurs in the supine position. Patients are usually young and otherwise healthy. Precipitating events include prolonged standing, exertion, venipuncture, or a painful stimulus.
-Cardiovascular syncope is due to arrhythmia or obstructive lesions such as aortic stenosis or HOCM.
-Syncope may be associated with a prodrome of palpitations. Arrhythmias usually occur without warning, with the patient in a supine or resting position, and lasts for a few seconds. Patients will have risk factors such as left ventricular dysfunction, prior myocardial infarction or conduction system disease.
-Physical examination may show the murmur of aortic stenosis or HOCM. EKG/Holter monitoring may detect an arrhythmia.
-Neurological syncope is due to atherosclerotic disease of the cerebral circulation, and is associated with a history of focal neurological deficits.
DDX: A seizure may mimic syncope; however, patients usually have a history of tonic-clonic movements, urinary or fecal incontinence, and a postictal state. Jerky movements similar to tonic-clonic movements can occur in any patient with syncope, but the postictal confusion is very unlikely with other conditions except seizures.

Orthostatic hypotension
Orthostatic hypotension is defined as a significant drop in blood pressure upon assuming a standing position, causing symptoms of cerebral hypoperfusion. Orthostatic hypotension is diagnosed if there is a fall of at least 20 mmHg of systolic blood pressure, or a fall of at least 10 mmHg of diastolic blood pressure, within two to five minutes of standing from a supine or sitting position.
-A fall in the blood pressure with/after standing or eating (postprandial hypotension) is a commonly encountered clinical situation, especially in the elderly population. It is usually caused by autonomic dysfunction or failure, or intravascular volume depletion from various causes.
-Almost all the patients suffering from orthostatic hypotension experience a sensation of dizziness or lightheadedness, especially after rapid changes in position (i.e. from supine or sitting to standing position). In some severe cases, it can lead to a fall (presyncope), angina, acute stroke, or loss of consciousness (syncope).
-The symptoms of orthostatic hypotension are primarily caused by a rapid decrease in cerebral perfusion.
-There are multiple causes of orthostatic hypotension in elderly patients>>The two major mechanisms of orthostatic hypotension are autonomic dysfunction/failure and intravascular volume depletion. Autonomic dysfunction is caused by various neurological disorders, systemic disorders (diabetes mellitus, amyloid neuropathy) or medications. Common drugs causing orthostatic hypotension include antihypertensives, antianginal drugs, vasodilators (nitrates, calcium channel blockers), antidepressants (especially tricyclic antidepressants), and opiate analgesics.
-When a patient stands up from a supine position, there is pooling of 500 to 1000 cc of blood in the lower extremities and mesenteric circulation. This causes a decrease in the venous return to the heart, which decreases ventricular filling pressures. A drop in the cardiac output and blood pressure occurs, causing decreased cerebral perfusion. This is a normal response seen in all patients, and is counteracted by a reflex increase in sympathetic discharge, which causes vasoconstriction and an increase in cardiac output. Nitrates may cause excess vasodilation, which could reduce the venous return to and cardiac output of the heart.
-An excess drop in blood pressure and cerebral perfusion may occur, and lead to symptoms of orthostatic hypotension.
-RX->>
>>The first step in reducing the frequency and symptoms of orthostatic hypotension is to recognize and remove the potential offending medications; therefore, isosorbide nitrate should be discontinued, and the patient should be observed for any recurrence of symptoms.
>>Fludrocortisone is a synthetic mineralocorticoid. It is used as a first-line agent for most patients whose orthostatic hypotension is not controlled by nonpharmacologic measures. It causes an increase in salt and water retention, which increases the effective circulating blood volume.

Cardiac temponade
Pericardial effusion may occur in response to any cause of pericarditis or from malignancies. The pericardial effusion may develop slowly or rapidly. However, sudden filling of the pericardial space with fluid can have catastrophic consequences by limiting ventricular filling.
-Patients with pericardial tamponade often complain of shortness of breath. It is accompanied by typical physical signs and symptoms that arise from the limited filling of the ventricle. The classic Beck’s triad is hypotension, muffled or distant heart sounds, and elevated jugular venous pressure. Arterial systolic blood pressure normally drops 10 -12 mmHg with inspiration.
-Marked inspiratory drop in systolic blood pressure (> 20 mmHg) is an important physical finding in cardiac tamponade, but can also be seen in severe obstructive pulmonary disease and constrictive pericarditis. In pericardial tamponade, low limb voltage with alternating size of QRS complex due to swinging of the heart is seen.
♦CXR in cardiac tamponade will show an enlarged cardiac silhouette. When a chest
x-ray shows an enlarged heart with pulmonary edema, congestive heart failure should be suspected. In cardiac tamponade, usually, there is no pulmonary edema.
Cardiac tamponade is a surgical emergency, and an ECHO should be obtained urgently. The ECHO will reveal the large pericardial effusion, with prominent collapse of the right atrium and ventricle during diastole. Cardiac catheterization can confirm the diagnosis by showing equalization of diastolic pressures in all chambers. However, if the patient is collapsing, one should not wait for an ECHO. Rapid pericardiocentesis is life saving.

Mechanical valves
The following are the recommendations from the Sixth ACCP Consensus Conference for a mechanical valve:
A goal INR of 2.5 (range 2 to 3) is recommended for patients with AVR with bileaflet mechanical valve, provided that the patient is in sinus rhythm, left atrium is of normal size, and the left ventricular ejection fraction is normal, as in this patient.
A goal INR of 3 (range 2.5 to 3.5) is recommended for patients with MVR with bileaflet mechanical valve or for patients with a bileaflet mechanical aortic valve who have atrial fibrillation
A goal INR of 3 (range 2.5 to 3.5) in combination with low dose aspirin is recommended for patients with mechanical prosthetic valves who suffer a systemic embolism despite adequate anticoagulant therapy.
However, more data is coming in favor of a higher level of anticoagulation (target INR >3.0) for both aortic and mitral prosthetic mechanical valve

Respiratory

TB
Even though it is not common, a new pleural effusion in a patient already on anti-tuberculosis treatment may occur and must be studied, because this can progress despite the clinical improvement of the patient. There is no need to change therapy, unless there is proof of a new infection or drug resistance. Some authors advocate the use of steroids in this setting, but this is not a universally accepted practice.

Chronic Eosinophilic Pneumonia (CEP)
Chronic Eosinophilic Pneumonia (CEP) is the most common eosinophilic pneumonia in the USA. Patients with chronic eosinophilic pneumonia present with systemic symptoms such as fever, malaise, anorexia, and weight loss for several weeks to months.
Pulmonary symptoms include cough and breathlessness.
Sometimes, patients may give a history of bronchial asthma or allergic rhinitis.
-Chest auscultation shows crackles or wheezing.
-Chest x-ray reveals peripheral infiltrates that are the "photographic negative" of pulmonary edema, and this radiographic finding is pathognomonic for the disease.
♥Bronchoalveolar lavage (BAL) that reveals eosinophils greater than 40% is suggestive of the diagnosis. Glucocorticoid therapy results in rapid resolution of the symptoms and radiographic clearing.

Acute bronchopulmonary aspergillosis ABPA:

This hypersensitivity reaction to Aspergillus antigens is seen in patients with underlying asthma. When the airways of such patients become colonized with Aspergillus, the intense IgE and IgG mediated immune response leads to the characteristic recurrent episodes of fever, malaise, cough with brownish mucoid expectoration, wheezing, and symptoms of bronchial obstruction.
There is no single diagnostic test to confirm the diagnosis of ABPA.


►The diagnosis is usually made by clinical, radiographic, and immunologic criteria, which include the following:
1. A history of asthma.
2. Immediate skin test reactivity to Aspergillus antigen.
3. Precipitating serum antibodies to Aspergillus fumigatus.
4. Serum total IgE concentration of greater than 1000 ng/mL.
5. Peripheral blood eosinophilia greater than 500 per cubic millimeter.
6. Lung infiltrates, usually involving the upper lobes.
7. Central bronchiectasis.

==A skin prick test for Aspergillus should be performed initially in all asthmatic patients suspected of having ABPA.
If the skin prick test is positive, serum total IgE levels and precipitating serum antibodies to Aspergillus fumigatus should be measured. If the skin prick test is negative, the diagnosis of ABPA is extremely unlikely.
Recurrent episodes of airway inflammation and bronchial obstruction in patients with ABPA can lead to bronchiectasis and lung fibrosis; therefore, it is important to diagnose and treat such patients early to reduce the risk of progressive lung damage.
Corticosteroids are the mainstay of therapy for patients with ABPA.
Treatment with corticosteroids is effective in controlling the episodes of acute inflammation and preventing progressive lung fibrosis.
The clinical response to treatment is measured by the reduction of serum total IgE concentration, clinical improvement and resolution of radiographic findings.

Churg Strauss syndrome (CCS): is a multisystem vasculitic disorder of unknown etiology that affects the skin, kidney, nervous system, lungs, gastrointestinal tract, and heart. It is characterized by allergic rhinitis, asthma, and prominent peripheral blood eosinophilia.

A CSS-like syndrome has been noted in patients who have been successfully treated for chronic steroid-dependent asthma with leukotriene receptor antagonists.
Up to 75% of the patients have evidence of peripheral neuropathy. The disease is severe, and requires treatment with glucocorticoids and sometimes with immunosuppressants. There have been significant reports which associate the use of leukotriene inhibitors with Churg-Strauss vasculitis. To date, there are more than 28 cases of Churg Strauss vasculitis associated with its use.

ARDS:
ARDS can occur secondary to sepsis, pneumonia, severe trauma, burns, drowning, or pancreatitis. The presentation is sudden. Oxygen requirements increase very rapidly.

 Criteria for ARDS diagnosis are:
1. A pulmonary capillary wedge pressure less than 18 mmHg
2. PaO2 to FiO2 ratio of 200 mmHg or less, regardless of the PEEP level
3. Diffuse bilateral infiltrates on chest x-ray

In contrast to heart failure, patients with ARDS will typically have clear lungs on exam but will show diffuse, bilateral infiltrates on the chest x-ray results.
The management of ARDS through mechanical ventilation involves the interplay of the following settings:
1. PEEP (positive pressure at the end of expiration)
2. oxygen concentration
3. tidal volume
The PEEP attempts to expand the collapsed alveoli in ARDS in order to decrease the high oxygen requirement. It also prevents the development of atelectasis.

Although the physiologic PEEP is around 5 cmH2O, the mechanical ventilator settings of ARDS patients are usually around 9 cmH2O. Oxygen is set at high concentrations, while the tidal volume is set to the lowest possible value.

ARDS is associated with a mortality rate of 35-40%. Among the different strategies, mechanical ventilation that delivers lower tidal volumes (< 6 ml/kg) and limits plateau pressure (< 30 CmH2O) has been shown to be relatively more effective.
Studies comparing the effects of low tidal volume and limited plateau pressure to that of high tidal volume and plateau pressure have shown a significant reduction in mortality in the first group (32% vs. 40%).

 Mechanical ventilation in the management of ARDS is a dynamic process.
When the patient improves, FiO2 and PEEP should be decreased stepwise, as tolerated.

The objective is to maintain the patient on the following settings: a PaO2 more than 60mmHg, an oxygen saturation more than 90%, and a normal or slightly acidic pH (permissive hypercapnia).

Once this is achieved, the patient should be weaned as soon as possible, in order to avoid complications such as barotrauma, ventilator-associated pneumonia, prolonged sedation, and hypotension.


PE:
Pulmonary thromboembolism is difficult to diagnose, and usually requires the combination of several diagnostic modalities. It is therefore important to know the order in which to order these diagnostic tests.
=The first test that is usually employed is ventilation/perfusion scanning.
►If the results reveal the classic pattern of mismatched perfusion; it is advisable to proceed directly with treatment.
►If the scan is normal, significant pulmonary thromboembolism should be ruled out; however, ventilation/perfusion scanning results are inconclusive in a substantial number of patients. Since the usual source of emboli causing this condition is deep venous thrombosis (DVT) of the lower extremities, ►the next best step in this case is Venous ultrasonography to reveal DVT or CT angiogram of the chest. A diagnosis of DVT makes the probability of pulmonary thromboembolism very high, and warrants immediate treatment.
►Pulmonary angiogram is the gold standard test for the diagnosis of pulmonary embolism (PE); however, this procedure is rarely being performed since it is invasive and CT angiogram is readily available.
♥ Mild fever and leukocytosis can be seen in the setting of PE.
-Pulmonary embolism (PE) is generally treated by starting the patient on heparin first, and then adding warfarin (Coumadin) after 24-48 hours.

 The recommended duration of pharmacotherapy depends on the setting in which the PE occurred, as indicated below:
1. Occurrence of PE in the setting of reversible risk factors (e.g., use of oral contraceptive pills, immobilization, or surgery) should be treated with 3-6 months of warfarin therapy.
2. If the first episode of thromboembolism occurs in a setting that involves an underlying malignancy, anticardiolipin antibody, and antithrombin deficiency, the patient should be treated with at least 12 months of warfarin therapy.
3. Patients with a first episode of idiopathic thromboembolism should be treated for at least six months with warfarin; three months of therapy is inadequate in this patient group.
4. Patients with recurrent thromboembolism or a continuing risk factor should be treated indefinitely.

The indications for an inferior vena caval (IVC) or Greenfield filter insertion include patients with:

1. a documented recurrent venous thromboembolism while on therapeutic anticoagulation
2. a recurrent venous thromboembolism and absolute contraindications to anticoagulation
3. a history of massive pulmonary embolism in whom a recurrent episode may be life-threatening
4. Chronic recurrent pulmonary embolism and a history of pulmonary hypertension

►It is also considered prophylactically in patients with severe chronic obstructive pulmonary disease, cor pulmonale, or a previous history of venous thromboembolism who develop a predisposing risk factor for pulmonary embolism, such as an acute fracture or cancer.
►A chest x-ray should be obtained in all post-operative patients who complain of shortness of breath before performing more specific tests that will determine or exclude the diagnosis of PE. Chest x-ray findings may suggest the presence of PE and may help exclude other chest pathology.
►Septic pulmonary emboli may result from septic thrombophlebitis and/or tricuspid endocarditis.

Asthma:
♫ the allergen most frequently associated with asthma is house dust mites.
♥Cough induced by forced expiration is characteristic of airway hyperreactivity, and is usually suggestive of asthma; however, this presentation has also been described in some patients with COPD who can occasionally have an overlapping condition with asthma.
♥It is important to recognize and initiate early interventions in a patient with acute exacerbation of asthma. Early recognition, rapid assessment and treatment are crucial in preventing significant morbidity and mortality.
♥Measurement of the peak expiratory flow rate with a peak flow meter is an excellent method to assess the degree of severity of airflow limitation, and subsequent serial measurements of the peak flow rate are useful in assessing the response to therapy.
►The goal of treatment is to rapidly correct the airflow obstruction. This is most rapidly achieved by the administration of inhaled beta-2 adrenergic agonists, either by continuous nebulization or with the use of metered dose inhalers with a spacer.
►Systemic corticosteroids should also be administered early in the treatment of acute asthmatic exacerbation; however, their effect is usually not apparent in the first few hours. Their use should be preceded or accompanied by inhaled beta-2 agonist therapy.
♥In a patient with an acute, severe, asthma exacerbation, it is important to periodically assess the response to initial therapy during the first few hours. Failure to recognize early signs of clinical deterioration and impending respiratory failure is responsible for majority of the morbidity and mortality seen in patients with status asthmaticus.
♥Some of the clues to a patients clinical deterioration and poor outcome include a history of prior intubation, exhaustion or extreme fatigue, diaphoresis, change in consciousness (confusion and drowsiness), use of accessory muscles, presence of suprasternal retractions, depressed respiratory drive, marked tachycardia, pulsus paradoxus, PaCO2 greater than 40 mmHg, and a peak expiratory flow rate less than 25% of the normal predicted.
►Any patient with the above signs and symptoms of impending respiratory failure should be immediately intubated to secure and protect the airways.
Patients with hypoxemia due to an acute asthma exacerbation should be immediately managed with oxygen inhalation, followed by administration of an inhaled beta-2 agonist, which is the mainstay of therapy.
►Hospital admission for asthma exacerbation is recommended if the peak flow reading is 40-50% lower than the patient’s baseline, if there are signs of respiratory distress, if oral steroid therapy fails, or if the patient’s clinical condition worsens. Ipratropium nebulization may be given in the emergency department, but this is not the mainstay of therapy. For any acute exacerbation, oral or parenteral steroid therapy with prednisone, prednisolone, methylprednisolone, or hydrocortisone is essential for therapeutic success.

Solitary pulmonary nodule
Solitary pulmonary nodules represent a common clinical problem in the primary care setting. They are usually detected in an asymptomatic patient and present a clinical dilemma for the primary care physician.
The clinical and diagnostic workup of a solitary pulmonary nodule is aimed towards differentiating between a benign lesion from a malignant lesion (lung cancer).
►Some of the factors that suggest a malignant cause of a solitary pulmonary nodule include:
Age greater than 50 years,
History of smoking or asbestos exposure, presence of another primary cancer elsewhere in the body (malignant melanoma, colon, breast, kidney, testis),
Size greater than 3 cm, irregular or speculated borders of the nodule, and certain patterns of calcification within the lesion (eccentric calcification).
Another important clue is the growth of the pulmonary lesion over time.
Malignant lesions usually have a doubling time of 20-400 days, whereas the doubling time of benign lesions is either less than 20 days (infectious cause) or greater than 450 days.

►As a general guideline, any solitary pulmonary nodule with the absence of any changes in size over the last two years is strongly suggestive of a benign lesion; therefore, a comparison of the pulmonary nodule on chest x-ray with the previous chest radiographs to document any changes in the size of the lesion is a critical initial part of the diagnostic workup of this patient.

►A chest CT scan should be obtained to characterize the pulmonary nodule before performing any invasive procedures. It demonstrates the pattern of calcification within the nodule, and identifies any mediastinal lymph node involvement and small pleural effusions. Particular CT scan findings that suggest malignant lesions include an irregular or speculated border and the presence of eccentric, reticular or punctate calcifications within the lesion. Such findings can help distinguish between a benign from a malignant cause of the solitary nodule.
►BENIGN: Certain patterns of calcification within the pulmonary nodule, as seen on chest x-ray or CT scan, are strongly suggestive of a benign cause of the lesion or nodule. These include popcorn calcifications, concentric or laminated calcifications, central calcifications and diffuse homogenous calcifications. Popcorn calcifications are characteristically seen on radiographic imaging in patients with pulmonary hamartoma.

►Any patient with a solitary peripheral lung nodule suspicious for malignancy should undergo video-assisted thoracoscopic surgery (VATS) and excisional biopsy of the lesion. This is the procedure of choice in most patients for the removal and definite diagnosis of a peripherally located pulmonary nodule. It is a relatively safe procedure and has a low risk of complications if performed by a skilled surgeon.


Sarcoidosis
Sarcoidosis is a chronic granulomatous disease seen more frequently in young African-American patients. It is characterized by the formation of non-caseating granulomas in various involved tissues and organs. It usually involves the lungs, but can also involve other organ systems including the skin, lymph nodes, liver, spleen, eyes, exocrine glands (salivary and lacrimal glands), heart, kidneys, and central nervous system. It is usually asymptomatic and is frequently detected as an incidental finding on a routine chest x-ray.
Patients with pulmonary sarcoidosis usually present with cough, chest pain, or dyspnea. Some other nonspecific features include generalized weakness, lethargy, fever, and weight loss.


-Sarcoidosis- Initial test/screening:
-The chest radiograph in patients with pulmonary sarcoidosis classically reveals
Bilateral hilar adenopathy with or without right paratracheal lymph node enlargement
Serum ACE levels are elevated [screening test] in more than half of the patients with sarcoidosis, but this is a nonspecific finding. Although serum ACE levels have little role in diagnosing the disease, these may prove to be useful in monitoring disease activity
CONFIRMATORY TESTS:
-The biopsy of accessible tissues [not erythema nudosum] for confirmation of the diagnosis is not required in an asymptomatic patient with the typical history and chest x-ray findings.
-Hypercalciuria occurs in 50% of cases of sarcoidosis. Macrophages in the sarcoid granulomas produce calcitriol, which is the active form of vitamin D, and as a result, calcium absorption from the gut increases.
-Nephrocalcinosis may result in chronic renal failure (CRF) and end stage renal disease.
-Hypercalcemia occurs in 10-20% of cases of sarcoidosis [high vitamin D].
-Thrombocytopenia may occur in patients with sarcoidosis.
►Definitive diagnosis of sarcoidosis can be made from the biopsy of the easily accessible lesions, including:
1. Any palpable lymph node
2. Skin lesion [except erythema nodosum]
3. Enlarged parotid
4. Lacrimal glands
NEXT STEP IF NOT ACCESSIBLE LESION ►LUNG BIOPSY with fiberoptic bronchoscopy and transbronchial lung biopsy is the procedure of choice.
•Nerve and liver biopsies are not recommended unless all other approaches fail.
♥Hypercalcemia, non-caseating granulomas, depressed-cell mediated immunity, and activated humoral immunity are characteristic features of sarcoidosis.
♥Asymptomatic pulmonary sarcoidosis generally does not need treatment.
-Hilar adenopathy associated with erythema nodosum represents a very favorable variant of sarcoidosis that is associated with a high rate of spontaneous remission and good prognosis.
♥Symptomatic pulmonary disease is usually an indication for corticosteroid therapy in patients with sarcoidosis, especially if it is accompanied by systemic symptoms such as severe fatigue, fever and hypercalcemia. Severe extrapulmonary manifestations of sarcoidosis such as cardiac, ocular and neurologic involvement may require high-dose corticosteroid therapy.
-Alternative agents (e.g. methotrexate) may be indicated if corticosteroids are not effective or if intolerable side effects of corticosteroid therapy occur.

OSA:
Although there are no specific physical findings consistent with obstructive sleep apnea (OSA), some general observations can contribute to the diagnosis. Truncal obesity and a large neck circumference (collar size > 17.5 inches) are common, and the oropharynx may be visibly "crowded." In some patients, the uvula is enlarged.
-Systemic hypertension is seen in approximately half of the patients with OSA.
-Hypothyroidism should be screened for, especially in older patients or those with symptoms suggestive of hypothyroidism (e.g., constipation and hair loss, as seen in this patient). Therefore, physical examination and thyroid function testing should be performed next.
-Sleep studies are typically performed to confirm the diagnosis of OSA.
-Polysomnography in particular is considered the gold standard for diagnosis.
-After completing the physical and laboratory evaluation of the patient, polysomnography is indicated.


PPH:
►The diagnosis of primary pulmonary hypertension is made when there is evidence of increased pulmonary arterial pressure in the absence of other identifiable causes.
-Pulmonary hypertension may be primary or secondary to interstitial lung disease, chronic venous thromboembolism, valvular or myocardial disease, connective tissue disease, or congenital heart disease.
-All patients with primary pulmonary hypertension should receive anticoagulation therapy because of an increased risk of pulmonary thromboembolism. This increased risk is due to slow pulmonary blood flow, a dilated right heart, and venous stasis.
-The anticoagulant of choice for this purpose is warfarin, and a target INR of 2 should be achieved.
-Oral vasodilators prolong survival and provide hemodynamic and clinical benefit in those patients of primary pulmonary hypertension who show vasoreactivity to nitric oxide and other vasodilators.
Patients who do not show vasoreactivity may experience an acute cardiopulmonary decompensation if oral vasodilators are used. It is therefore recommended that all patients with primary pulmonary hypertension be tested for vasoreactivity before starting therapy with oral vasodilators.
==Untreated primary pulmonary hypertension ►can lead to cor pulmonale.

COPD:
It is important to recognize that some patients with COPD will be oxygen dependent at some point of their disease. Oxygen therapy in this setting will decrease mortality and delay the development of pulmonary hypertension or cor pulmonale as a consequence of chronic hypoxia.
►The current recommendations to use home oxygen therapy are:
1. PaO2 less than or equal to 55 mmHg or an arterial oxygen saturation (SaO2) less than or equal to 88 percent.
2. PaO2 between 56 to 59 mmHg (or) a SaO2 of 89 percent, if there is evidence of cor pulmonale, right heart failure, or erythrocytosis (hematocrit above 55 percent).

HY:
♥Recurrent pneumonia in an elderly smoker may be the first manifestation of bronchogenic carcinoma.
►Flexible bronchoscopy is a primary diagnostic tool to evaluate patients with persistent or nonresolving pneumonia or pulmonary infiltrates (HRCT scan is an alternative, but it does not provide confirmatory information).
►The best diagnostic test for endobronchial obstructive lesions is flexible bronchoscopy. If the question had asked for the next best step in management, then the answer would have been CT scan.
►Syndrome of inappropriate antidiuretic hormone (SIADH) is associated with normovolemic hyponatremia and can be caused by small cell carcinoma of the lung.
Water restriction (with the possible inclusion of salt administration) is the preferred means of correcting mild to moderate hyponatremia associated with SIADH.
♥Postoperative complications:
-Are a common cause of perioperative morbidity and mortality. Some of the factors that increase the risk of developing postoperative complications are upper abdominal and thoracic surgeries, underlying chronic lung disease, a history of smoking within the last eight weeks, baseline PaCO2 > 45 mmHg, duration of surgery of more than 3-4 hours, and the use of general anesthesia.
♥The most common complications include atelectasis, bronchospasm, worsening of the underlying lung disease, postoperative pneumonia, and prolonged need for mechanical ventilation.
♥All patients undergoing upper abdominal or thoracic surgery with one or more additional risk factors are at a high risk for postoperative complications. These patients should be the target of risk reduction strategies. Antibiotics should be given prior to surgery only in patients with clinically apparent respiratory infection. These include patients with purulent sputum or a recent change in the color of the sputum.
They should not be used routinely in stable COPD patients.

Silicosis:
Is pneumoconiosis caused by exposure to silica crystals.
-There are three patterns of disease: acute, accelerated, and chronic silicosis. High-risk professions include glass making, pottery working, underground mining, and working with abrasives. Pertinent radiographic findings of chronic silicosis are small nodules with predominance in the upper lung lobes. The presence of eggshell calcifications in hilar lymph nodes is a very characteristic finding. For all these reasons, a tentative diagnosis of silicosis in this patient can be made.
There is a strong association between silicosis and tuberculosis; therefore, measures such as yearly PPD testing should be taken to prevent tuberculosis in all patients who have developed silicosis

USMLE WORLD NOTES STEP 3
DERMATOLOGY
►Melanoma
It‘s important to recognize the presence of a melanoma, because excision can be curative if the lesion is identified early. Melanoma lesions are usually asymmetric, with color variegation, and usually more than 5 mm in diameter.
An excisional biopsy is the next best step in patients with a suspected malignant melanoma.
A complete excision is the treatment of choice.
Interferon alfa-2b is used as an adjutant therapy in patients with a high risk of developing metastatic disease.
Malignant melanoma most often arises in fair-skinned people who are intermittently exposed to intense amounts of sunlight, especially during childhood or adolescence.
Wearing protective clothing will reduce the risk of developing malignant melanoma.
While sunscreen usage is of theoretical benefit, it has not been scientifically proven to prevent malignant melanoma.

DDX:
1. Basal cell carcinoma is usually pink or red in color. It is more frequent in males, and it rarely appears before the age of 40
2. Keratoacanthoma is common on the cheek. It is a low-grade malignancy that pathologically resembles squamous cell carcinoma. It appears as a solitary, firm, round, skin-colored or reddish plaque that develops into a nodule with a central keratin plug.
3. Seborrheic keratosis is rare before the age of 30. It also has a "stuck on" appearance, with a "warty" form
4. Verruca vulgaris has the same warty appearance as seborrheic keratosis, and it is a well-demarcated lesion.

 Actinic keratosis
Actinic keratosis is a pre-malignant condition that develops from the sun-damaged (due to its UV component) clone of squamous cells in the skin. Further UV damage to "gene repair mechanisms" in these cells can lead to the development of squamous cell carcinoma (SCC). 1 out of 1,000 cases of AK progresses to SCC, while 60% of SCC arises from AK.
 Photoaging
Photoaging is a phenomenon that arises from intrinsic aging and damage caused by ultraviolet light. While intrinsic aging tends to result in fine wrinkles on an otherwise smooth skin surface, photodamage tends to result in coarse, deep wrinkles on a rough skin surface. Photoaged skin is often marked with actinic keratoses, telangiectasias and brown "liver" spots)
Cigarette smokers have been shown to have more and deeper wrinkles than do nonsmokers.
Tretinoin is an emollient cream approved by the FDA for reduction of fine wrinkles, mottled hyperpigmentation, and roughness of the facial skin. Tretinoin is also successful in reducing actinic keratoses and in improving the appearance of brown spots, regardless of etiology.
DDX
1. Erythrasma is an infection of the skin that occurs most often in intertriginous spaces and is caused by Corynebacterium minutissimum. The appearance of erythrasma includes a confluence of pruritic, reddish brown, finely wrinkled papules. The use of a Wood lamp reveals a coral-red fluorescence caused by the Corynebacterium porphyrins.

2. Pityriasis rosea is a self-limited condition of unknown etiology that first manifests as a single primary plaque ("herald patch") with a fine collarette scale. A generalized eruption develops 1 to 2 weeks later, with fine, scaling papules and plaques in the "Christmas tree" distribution.

3. Rosacea is a chronic inflammatory disease that causes erythema of the central face. It first manifests as easy flushing and later results in persistent erythema and telangiectasia. Patients are sensitive to chemical or physical insults and should limit exposure to sunlight.
 Metronidazole is an antibiotic prescribed for treatment of rosacea

4. Seborrheic dermatitis is a chronic, superficial, inflammatory process that arises in areas rich in sebaceous glands. The condition worsens during infancy and puberty, when the sebaceous glands are more active.
In adults with seborrheic dermatitis, erythema with fine scale is evident on the scalp ("dandruff"), eyebrows, eyelids, nasolabial creases, ears, sternal area, axillae, umbilicus, groin, and gluteal crease.
Tar-based creams and shampoos are used in the treatment of seborrheic dermatitis.

Alopecia areata:

It is a relatively common disease and is characterized by discrete, smooth and circular areas of hair loss over the scalp. There is typically no associated scaling or inflammation present in the area of hair loss. The hair loss usually develops over a few weeks and has a recurring pattern. Most of the patients will have regrowth of the hair in the involved areas over time.

The exact etiology of alopecia areata is unknown. An autoimmune process is thought to play at least a partial role in its pathogenesis. This is supported by the finding of T-cell infiltration around the hair follicles and the association of other autoimmune conditions (i.e., pernicious anemia, vitiligo, and thyroid diseases) with alopecia areata. The disease can recur in up to one-third of these patients. Some factors associated with the higher chance of relapse include a longer duration of the disease, a more extensive disease, involvement of peripheral areas, and onset prior to puberty.
RX-Topical or intralesional corticosteroids are the treatment of choice for patients with alopecia areata. Patient education and information is also the key part of treatment.
Patients should be made aware that:
(1) The disease is usually benign,
(2) They can have multiple relapses in spite of treatment, and
(3) Most patients have normal hair growth within the next one to two years even without treatment. They should also be informed that treatment with steroids, either intralesional or topical, can restore normal hair growth but does not cure the disease. After a steroid injection, new hair growth is usually seen in the next four to six weeks.
DDX
1. Patients with tinea capitis have an associated scaling and inflammation of the scalp in the areas of hair loss.
2. Localized discoid lupus erythematosus of the scalp causes hair loss, scaling, inflammation, scarring, and hypopigmentation of the skin. There may be associated lesions present over the face or extremities.
3. Areas of hair loss in secondary syphilis are not smooth and discrete. The lesions usually have a "moth-eaten" appearance and are associated with significant scarring.
4. Hair loss in men with androgenetic alopecia starts in the frontal or temporal areas and progresses gradually (male pattern baldness).
5. Drug hair loss-Numerous drugs can produce hair loss.
Lithium, thallium, and chemotherapeutic agents are between the most common ones; however, they characteristically do not affect the hair shaft, produce split-ends, or other lesions.
6-Traumatic alopecia, caused by traction, hair eating (trichotillomania), or chemical reactions, usually produces lesions on the hair strand or shaft itself, and is manifested as split-ends, trichoclasis, or fractured hair.
Sporotrichosis
Sporotrichosis is a subacute infection caused by a dimorphic fungus, Sporothrix schenckii.
The infection usually arises when the soil or other organic matter containing the fungus is inoculated in the skin or subcutaneous tissue. It is usually seen in persons involved in outdoor activities or occupations. The infection initially manifests as a papular lesion over the site of inoculation.
The lesion usually ulcerates over time with non-purulent discharge from the lesion.
Similar lesions are seen along the lymphatic channels proximal to the original lesion.
Diagnosis is by clinical presentation and culture of the tissue or aspirated material from the lesion.
Rx-Itraconazole for three to six months is the treatment of choice for lymphocutaneous sporotrichosis.

 Psoriasis
Psoriasis is a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick, silvery scales. These lesions are typically seen over the scalp, knees, elbows, back, and nail plates. Patients are often asymptomatic, but some may complain of mild pruritus. Once diagnosed, most patients tend to have the disease for life.
Spontaneous remissions and marked variations in the severity of symptoms are observed throughout the course of the disease.
Psoriasis results from hyperproliferation and abnormal differentiation of the epidermal layer of the skin. Although the exact pathophysiology of these changes is not understood, immunologic and genetic factors are both thought to play significant roles.
Physicians should be wary when prescribing medications to patients with psoriasis because several drugs may exacerbate psoriatic lesions. The most common of these drugs are beta-blockers, antimalarial drugs, nonsteroidal antiinflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, and lithium.
Bacterial and viral infections, especially HIV infection, have also been associated with worsening of psoriasis.
As a general rule, all drug-induced skin rashes or eruptions should be managed by complete discontinuation of the offending drug.
Beta-blockers are one of the most common classes of drugs known to exacerbate or unmask psoriatic lesions in patients predisposed to develop psoriasis; therefore, the use of such drugs should be completely stopped and substituted with another class of antihypertensive agents.
A variety of different treatment options, both local and systemic, are available for the treatment of psoriasis
-Mild, asymptomatic psoriasis without any joint or nail involvement does not need aggressive treatment. Some patients may request treatment only for cosmetic reasons.
Topical corticosteroid creams are the mainstay of therapy for localized skin lesions.
High-potency agents (betamethasone 0.05%) should be initially used for thick plaques on extensor surfaces, and should be started as a twice-daily application for at least two to three weeks. The lesions should be covered with a plastic wrap or occlusion tape after steroid cream application to maximize its effects.
Phototherapy with ultraviolet-B radiation is only used in patients with extensive disease (more than 30% of the body surface area).
a combination of cold tar-Severe lesions may be treated with application and exposure to ultraviolet-B light (Goeckerman regimen).
 Methotrexate is very effective in severe psoriasis, psoriatic arthritis, and psoriasis involving the nails. It is typically used as a weekly low-dose regimen.
Note: Systemic corticosteroids should not be used because of the concerns of inducing pustular psoriasis.

Acne
-although there are no definitive evidence-based guidelines on the treatment of acne, some general principles are observed by most clinicians. Treatment regimens usually progress through several stages, based upon how severe the acne is at presentation and how effective the treatment options are in resolving the symptoms.
Mild acne is initially treated with topical products (e.g., retinoid, benzoyl peroxide, antibiotics).
Moderate acne (or refractory mild acne) is treated with topical retinoid and either benzoyl peroxide or a topical antibiotic.
 More severe acne (or refractory moderate acne) is treated with:
1) Topical retinoid, benzoyl peroxide, and topical antibiotic [erythromycin] or
2) Systemic antibiotic [tetracycline] plus topical retinoid or benzoyl peroxide.
Note that systemic antibiotics are not typically used exclusively.
3) systemic antibiotic andThe most severe cases of acne should be treated with a if there is no response after 3-6 months,topical retinoid or benzoyl peroxide; then Oral isotretinoin is indicated.

Microcomedones take eight weeks to mature, so any acne therapy regimen must be continued for at least this length of time before determining its efficacy.
The more severe forms of acne vulgaris warrant treatment with an oral antibiotic in conjunction with topical retinoid or benzoyl peroxide.
Oral antibiotics frequently used for this purpose include tetracycline, doxycycline, minocycline, erythromycin, trimethoprim-sulfamethoxazole, and clindamycin.
Tetracycline is considered a first-line agent because it is inexpensive and highly effective.
 Doxycycline and minocycline are second-line agents prescribed in patients who have failed therapy with tetracycline.
Doxycycline is a phototoxic agent in that it permits light-activated compounds to damage cell membranes and DNA. It can also cause esophageal ulcerations if insufficient liquid accompanies Phototoxic reactions can develop in users of doxycyclineingestion of the pill. who are exposed to sufficient quantities of both sunlight and medication. ►Typically, the phototoxic reaction manifests as an exaggerated sunburn response. RX: In general, treatment for sunburns includes replenishment of lost fluids and relief for pain or pruritus. NSAIDs (e.g., oral or topical indomethacin, ibuprofen) have been shown to reduce pain and erythema and can minimize the damage to the epidermis if administered immediately after sun exposure. Diphenhydramine or hydroxyzine may be used for relief of itching.
 Isotretinoin is known to cause hypertriglyceridemia in up to 25% of individuals. This hypertriglyceridemia, if unrecognized and untreated, can cause acute pancreatitis.
Topical retinoids have been shown to have teratogenic effects; therefore, all patients on topical retinoids should be advised to avoid pregnancy.

Tinea versicolor
-Tinea versicolor is a fungal infection of the skin that is caused by the dimorphic yeast Pityrosporum orbiculare (also known as Malassezia Furfur).
-The clinical picture is usually very characteristic: multiple small circular maculae are observed that may vary in color (white, pink or brown). The rash is typically more prominent in the summer time because the yeast inhibits pigment transfer to keratinocytes and makes the affected skin more demarcated from unaffected tanned skin. The lesions are usually asymptomatic, although mild pruritus may be present. The typical location of the lesions is the upper trunk, but the rash may also involve the upper arms, neck and abdomen.
The treatment of choice for patients with tinea versicolor is topical anti-fungal therapy. Any anti-yeast topical agent can be used, including terbinafine, clotrimazole and ketoconazole. The success rate with topical anti-fungal agents exceeds 80%.
With extensive disease Oral antifungals are preferred (ketoconazole,or recalcitrant infection, itraconazole or fluconazole).
-DDX: Pityriasis rosea is characterized by the presence of a herald patch, confinement of the lesions to the central trunk, orientation of the lesion along the lines of cleavage of the skin, and a typical pink color of the lesions. RX-Oral erythromycin is effective in patients with pityriasis rosea.

Onychomycosis
-Onychomycosis is a fungal infection of the toenails or fingernails. The most common form of onychomycosis is distal subungual onychomycosis, which is caused by the dermatophyte Trichophyton rubrum. Because nail dystrophies caused by other diseases (e.g., psoriasis, lichen planus, eczematous conditions) can mimic the appearance of onychomycosis, many insurance companies require diagnostic confirmation of the condition before reimbursing treatment costs.
The diagnosis is typically established with KOH examination of nail bed scrapings. If KOH examination is negative, then evaluation by culture is appropriate.
Oral terbinafine is one of the newest medications available for treating this condition, and is considered superior in terms of efficacy. Infection of the fingernails requires 6 weeks of therapy with terbinafine, while infection of the toenails requires 12 weeks of therapy.
Ciclopirox is a topical antifungal nail lacquer recently approved for the treatment of mild to moderate onychomycosis. Although ciclopirox is considered safe, studies show its efficacy to be minimal.

Tinea pedis
-Tinea pedis is the most common dermatophyte infection and is usually accompanied by tinea manuum, onychomycosis, or tinea cruris (infection of the hand, nails, or groin). It presents as slowly progressive pruritic erythematous lesions usually between the toes and extends to the sole and side of the foot. There is typically a sharp border between the involved and uninvolved skin. It is a self-limiting, but recurrent infection and is usually associated with activities causing excessive sweating.
RX- Treatment of tenia pedis is with a topical antifungal cream for about two to four weeks (not a combination of antifungal and steroid cream).
DDX:
1. Scabies is due to skin infestation by a mite, sarcoptes scabiei. It presents with intense pruritus, which is usually worse at night. Examination of the skin reveals multiple, small, erythematous papules and characteristic burrows.
-The diagnosis is typically made by the characteristic distribution of the lesions.
-They usually involve the sides and webs of fingers, flexor aspects of the wrists, extensor aspects of the elbow, axillary folds, periumbilical areas and waist, lower half of the buttocks, and adjacent thighs.
Treatment of scabies is with topical 5% permethrin cream or topical lindane.

2. Dyshidrotic eczema or dermatitis (pompholyx)
-is an intensely pruritic, chronic, and recurrent dermatitis of unknown etiology. It typically involves the palms, soles, and lateral aspects of the fingers and toes. The patients present with multiple small and pruritic vesicles which desquamate over time, leaving erosions and fissures.
RX-Topical steroids can usually control the lesions in mild cases. A short course of oral corticosteroids may be required in severe cases.

3. Tinea versicolor is a superficial infection of the skin caused by Pityrosporum orbiculare, also known as Malassezia furfur. It is usually seen in adolescents and young adults. The lesions can be mildly pruritic, hypopigmented and light brown or salmon colored macules and are seen on the upper trunk, extremities, and face.
Rx-Treatment of choice is topical antifungals for a limited disease. Oral agents, like ketoconazole, may be used for extensive lesions.

Trichophyton tonsurans vs Microsporum canis
Unlike Trichophyton tonsurans infection, Microsporum canis infection is characterized by a bright green fluorescence when the lesion is observed under Wood’s ultraviolet (UV) lamp.

Poison Ivy
-Poison Ivy contact dermatitis presents as pruritic linear lesions, which are usually papular. When the reaction is severe, the papules may evolve into vesicles, which can exude a serous fluid. The lesions have a linear or curvilinear appearance, showing the points of contact with the leaves or stems of the plant. New lesions can appear two to three days later if the poison ivy resin was transported to other skin surfaces by the patient before washing the primary lesion.
DDX
1. Dyshidrotic dermatitis, also known as pompholyx, is chronic and usually affects the palms and soles.See detail above
2. Detergent contact dermatitis is composed of papules found mainly on the hands, and sometimes, the face.

 Porphyria cutanea tarda
-Porphyria cutanea tarda is a condition that arises from the deficiency of uroporphyrinogen decarboxylase, an enzyme in the heme synthesis pathway.
-This condition is characterized by painless blisters, an increased fragility of the skin on the dorsal surfaces of the hands, and facial hypertrichosis and hyperpigmentation.
-It can be triggered by the ingestion of certain substances (e.g., ethanol, estrogens) that should be discontinued if suspect.
Diagnosis is confirmed with an elevation of the urinary uroporphyrins.
Phlebotomy or hydroxychloroquine may provide relief, as can interferon alpha in those patients simultaneously infected with Hepatitis C virus.
DDX
1. Allergic contact dermatitis results from direct skin contact with chemicals or allergens. It is characterized by pruritus, erythema, and edema, often followed by the development of vesicles and bullae in the irritated region.
2. Herpes zoster is characterized by painful vesicular lesions clustered unilaterally along the course of a nerve. The lesions are typically found on the face or trunk, and will be Tzanck smear positive.
3. Dermatitis herpetiformis is characterized by pruritic papules and vesicles that appear mainly on the elbows, knees, buttocks, posterior neck, and scalp. The condition arises in the context of gluten-sensitive enteropathy, which may be subclinical.
4. Impetigo is characterized by pruritic and honey-colored macules, vesicles, and bullae on the face and other exposed parts. The condition is caused by Staphylococcus aureus or group A streptococcus.


 Pressure ulcers
Pressure ulcers are typically categorized into four stages.
Stage 1 ulcers are characterized by nonblanchable erythema of intact skin.
Stage 2 ulcers are superficial ulcers causing a partial thickness loss of the epidermis, dermis, or both. Stage 3 ulcers are deeper ulcers causing a full thickness loss with damage to subcutaneous tissue that may extend to, but not through, any underlying fascia.
Stage 4 ulcers are very deep ulcers causing a full thickness loss with extensive tissue destruction that may damage adjacent muscle, bone, or supporting structures.
Stage 3 or 4 pressure ulcers should be loosely packed with saline-moistened gauze to preserve the moist wound environment.

Seborrheic dermatitis
-It is characterized by erythematous, scaling plaques and patches with indistinct margins. The most common sites affected are the scalp, central face (eyebrows, nasal bridge, and nasolabial folds), ears, chest, upper back, axilla, and pubic area. Dandruff of the scalp is a form of seborrheic dermatitis with minimal inflammation. Diagnosis is usually made by physical examination alone.
Seborrheic dermatitis is common in HIV infection and can be a presenting feature. The reported frequency of seborrheic dermatitis varies from 40-80% in AIDS patients. It usually presents with a greater severity in these patients.
Physicians should consider the possibility of HIV infection in patients presenting with a new onset of severe seborrheic dermatitis. *********

 Tattooing

-Tattooing is a relatively common practice and most of the tattoos are seen in adolescents and young adults (13 to 25 years of age). The tattooing process involves repeated skin punctures using solid bore needles to place the tattoo pigment into the dermis.
-The pigment is taken up by macrophages in the dermis, which allows it to remain in the skin permanently.
-People who have had these marks for a long time sometimes desire tattoo removal. It is an expensive and complicated procedure but is certainly possible. It has no relation with the age of the tattoo marks.

Some of the common techniques used to remove tattoo marks include dermabrasion, cryosurgery, thermal cautery, surgical resection, and, more recently, laser removal. These techniques can be used to remove the marks on any part of the body.
Dermabrasion involves removal of the superficial layer of the epidermis, allowing the pigment to leach out of the skin.
Laser removal is a more recent advancement and it involves the use of lasers of different wave lengths. It is thought that the laser breaks up the pigments into smaller molecules, which are taken up and cleared by macrophages in the skin.
Although it is a safe procedure, laser removal can leave scar marks and cause skin hypo- or hyper-pigmentation.

Infectious disease USMLE WORLD NOTES
Non gonococcal urethritis/ or non-gococcocal cervicitis:
Preferred RX=> Azythromycin 1 g single dose [to assure patient adherence]
Alternative: Doxycycline 100mg twice/day PO x 7 days
10 days later no response
Rule out re-exposure and non-adherence to treatment => next step is give: Metronidazole 2 g single dose followed by: Erythromycin 500 mg Q/6 hrs x 7 days

Osteomyelitis: Initial step: X Rays [are positive 2-3 weeks after changes in bone]
TEST of choice:
► Un-complicated osteomyelitis:
=3-phase technetium 99-m bone scan [+ 2-3 days after the onset of infection] or
=Indium-labeled white cell scan and gallium citrate scan
►Complicated /Early stages of osteomyelitis/ Vertebral osteomyelitis, diabetic foot ulcer/osteomyelitis:
=MRI or CT-scan [MRI contraindicated if metal implants, prosthesis or pacemakers]
► Bone biopsy=gold standard [used when index of suspicion s high, after less invasive tests]

Osteomyelitis of diabetic foot lesion/ulcer => MRI => Most useful to obtain microbiologic diagnosis => Culture of deep tissue obtained by curettage

Rabies= universally fatal once pt is symptomatic
RABIES post-exposure prophylaxis: Rabies vaccine for active immunization and Rabies immunoglobulin [IG] for passive immunization
=> In pts previously vaccinated who has been re-exposed to rabies => should receive only ACTIVE immunization: rabies vaccine

Community Acquired pneumonia => ADMIT when: > 65 y/o, DM, chronic lung disease, others comorbities, tachypnea, hypoxia, multilobular involvement, hypotension.
♦ RX: Cover s. pneumoniae and atypical agents => Ceftriaxone IV + Macrolide: Azithromycin

Meningitis:
CSF Bacterial Cryptococcal Viral
Opening pressure [10-20 cm H20] ↑ [ > 180 mmH2O] ↑↑ [>200 mmH2O] Normal or mild ↑ [>100-300]
WBC < 5 ↑ [>100 cells/L] Low [< 40 cells/L] ↑ [25-500 cells/L]
Predominance Polymorphonuclear leukocytosis Mononuclear /Lymphocytes [>90%] Lymphocytic pleocytosis
Glucose [40-70] Low [< 40] Low [< 40] Normal
Protein [15-45] ↑ [ > 45 ] ↑ [ > 45 ] Normal or mild ↑

- PML=Progressive multifocal leukoencephalopathy [opportunistic infection in Immunocompromised pt x JC virus, multiple focal neuro deficits => MRI = non enhancing, demyelinating lesions with no mass effect
Cryptococcal meningitis [elevated intracranial pressure, severe headaches, altered sensorium; blurred vision => increased opening pressure=Do repeated or serial LP to relief symptoms]
RX- Cryptococcal meningitis=> Amphotericin B + Flucytosine x 10-14 days
Then: Start FLUCONAZOLE life long [maintenance therapy] in HIV + patients
Meningococcus prophylaxis to contacts => Rifampin [alternatives=fluoroquinolone, sulfonamide, ceftriaxone, minocycline]
Meningococcal meningitis:
Prophylaxis:
**Oral Rifampin
**Alternatives: SD oral Ciprofloxacin or SD IM Ceftriaxone
Chlamydia pscittaci pneumonia => TRIAD:
1. Meningoencephalitis
2. Splenomegaly
3. Pneumonia
► In an Immunocompromised host => Suggest Chlamydia pscittaci pneumonia until proven otherwise
► Other- important clues: Community acquired pneumonia in veterinarian, poultry farmer, bird raiser
► CXR: Consolidation of one of the lower lobes
► Confirmation: Serology
► RX: Doxycycline 100 mg 2/day x 21 days
If Outpatient therapy: Give empiric Doxycycline awaiting for serologic results and follow up
If hospitalized: Give empiric Doxycycline awaiting for serologic results, re-evaluate in an in-patient basis
Hospitalization criteria in community acquired pneumonia:
1. Age > 65 y/o
2. Comorbities: DM, immuno-compromise, sickle cell anemia, malignancy, steroid use, HIV
3. Presence of pleural effusion
4. Pulse > 120 or 30
6. BP < 100/systolic
7. P. Oximetry 3 episodes per year] who have a high probability of intercourse-related UTI: #1- Post-coital prophylaxis [voiding] #2- Continuous antibiotic therapy and then short course of antibiotics

Patient with symptoms of intestinal parasitosis /diarrhea/malabsorption/eosinophilia and a history of family visit from Central America; or traveling => Give Albendazole

GIARDIASIS= Metronidazole* [TOC] but its category B in pregnancy => FDA approved this drug in pregnancy if severe infection and dehydration.
Giardiasis in pregnancy:
♥ Mild to moderate infection, especially occurring in the 2nd trimester => use “Paramomycin”, alternative drug category C, resolves 70% of the cases
♥ Pregnancy + Severe infection, malabsorption, dehydration => DOC: Metronidazole [category B]
In the first and 3rd trimester

Latent TB and healthcare workers => should be counseled about the risk of developing active TB and offered preventive therapy with: Isoniazid + Vit B6 x 6-12 months or 9 months.
-They should not be excluded from the workplace if they refuse to accept recommended therapy or further intervention [document on chart this advice or discussion with the patient, decision and make a written agreement to continue regular follow up appointments]
Suspected Rocky mountain fever [petechial rash on ankles, wrists to palms and soles, central body-> to fulminant disease, complications] => clinical diagnosis -> immediately treated empirically with Doxycycline

Influenza Rx: Immediately in vulnerable patients
-> In the first 30-36 hrs => Zanamivir / Oseltamivir [neuraminidase inhibitors]
-> In the first 48 hrs => Rimantadine / Amantadine
-> After 48 hrs => symptomatic therapy or support, acetaminophen
The four Centor Criteria for the diagnosis of Acute pharyngitis in adults:
1. ♦ Fever
2. ♦ Tonsillar exudates
3. ♦ Tender anterior cervical adenopathy
4. ♦ Absence of cough
If ‘0’ criteria => no further testing or treatment
If 1 – 2 criteria => Rapid antistreptococcal antigen testing => if positive => Rx with antibiotic
If 3 – 4 criteria => immediately empiric antibiotics
Herpes zoster [reactivation of a latent varicella zoster virus in the sensory/dorsal nerve root ganglion
It’s a clinical diagnosis => RX immediately within 48 hrs of the onset and clinical suspicion => Acyclovir. Diagnostic workup is not necessary [Tzanck test, skin biopsy or serologies]
Transmitted from person to person by droplets and close contact => Should be isolated untilAll pt with disseminated infection lesions are crusted
All healthcare workers w/o history of varicella zoster infection are encouraged to=AVOID close contact with VZV or herpes zoster virus patients
If only local lesion => cover lesion with a scarf until lesions are crusted
Staph and Strep:
Erisipelas: MC site is lower extremities, and face is 5-20 % of the cases
Facial Erisipelas:
MCC: #1: B-hemolytic strep*, Group A, and less frequently Staph Aureus or Penicillin resistant strep [PRS]
♥Facial erysipelas needs to be treated immediately due to this location = if not open blisters or exudates
=> No need skin cultures
♥ DOC or current management => Penicillin G IM/IV
♥ Pt predisposed to Staph Aureus or to PRS: healthcare workers, nursing home resident, IV drug abuser:
 Antistaphylococcal penicillin {Nafcillin, Oxacillin, Methicillin, Cloxacillin…

Necrotizing fasciitis = Group A streptococci
-Fulminant infection of SQ tissue that spreads along fascial planes -> extensive tissue necrosis-> HD collapse and shock
1. Type I: [aerobic and anaerobic organisms] -> Group A Strepcococci, Staph Aureus, E. coli, bacteroides, prevotella ->Seen in pt with underlying DM and PVD

2. Type II: Rapidly spreading infection* => Group A Streptococci [pyogenes]***
-No underlying condition; but has a history of laceration, blunt trauma, surgical procedure, IV drug abuse
-Erythema, blister and bullae, fever, malaise, systemic toxicity and shock
Treatment: Urgent surgical exploration and debridement -> got tissue samples C & S, cytology…
♦ Empiric antibiotics= Clindamycin is the DOC*

Central venous catheter related systemic infection: Staph aureus**
1. Local infection = at the insertion site, exit site or SQ tunnel with erythema, induration, tenderness, pus from the exit site
2. Systemic infection= systemic symptoms, fever, chills, altered mental status-immuno-compromised pt with a tunneled catheter
1-Remove catheter, put new line in another site, make culture of catheter tip and blood cultures
2-IV empiric antibiotics w/o delay: Vancomycin [gram +] and Gentamicin [gram negative bacilli]

Pseudomona aeruginosa bacteriemia = common in immuno-compromised pt, with indwelling urinary catheter or Central venous catheter, infection of traumatic or surgical wound; severe nosocomial infections
=>P. Aeruginosa bacteriemia => Frequently develop “Ecthyma gangrenosum” infection of skin or mucous membranes worsening to nodular patches with hemorrhage, ulcer and necrosis [yellow-green exudates, purulent fluid…
RX= IV Empiric Antibiotics = 2 drug regimen:
1- Aminoglycoside [Tobramycin or Amikacin]
2- Stended spectrum Anti-pseudomonal penicillin [Piperacillin]
3- Or/ a Antiseudomonal Cephalosporin [Cefepime or Ceftazidime]
TSS [Staph Aureus] =history of tampon [vaginal or nasal] =>fever, chills, myalgias-> progressing to systemic hypotension, shock, rash….
Bacterial [Staphylococcal] exotoxin production; called: TSS toxin-1 -> widespread activation of T-cells by exotoxin acting as superantigens which leads to massive release of cytokines->SYSTEMIC TOXICITY
RX: IV fluids and antibiotic therapy => [Clindamycin/Vancomycin with/w/o Nafcillin [anti-staphylococcal penicillin]

HIV clues
HIV suspicion = young pt, with unintentional WT loss, vague symptoms, rash dry and itchy over face/axilla [seborrheic dermatitis] => Screen for HIV, detailed sexual history and drug use [IV drug abuser]

HIV [+] patient with Typical pneumonia => consider entire C/P => Typical pneumonia [acute onset, purulent rusty sputum, lobular infiltration, etc => Strep pneumoniae]
HIV pt with Atypical pneumonia=> subacute onset, gradual, non-productive cough, exertional dyspnea, interstitial infiltrates on CXR=> PCP, Mycoplasma…

Widespread disseminated candidiasis = ‘Candida Endophthalmitis’ => Risk factors: central venous catheters, total parenteral nutrition, immuno-compromised, AIDS, neutropenia, chronic corticosteroid therapy, IV drug abuser, broad spectrum Atb therapy, prior abdominal surgery.
CAUSE= esophageal / oropharyngeal candidiasis disseminated or hematogenous seeding [spreading to eye]
Rx: When have chorioretinitis and vitreal involvement=> Vitrectomy and systemic antifungal therapy [Amphotericin B]

PHAT= HIV patient with bleeding disorder=thrombocytopenia in all stages of the disease => Primary /HIV associated thrombocytopenia [PHAT] and only 20% has spontaneous remission **Mainstay of RX is: Zidovudine [reduce occurrence of opportunistic infections and Kaposi’s sarcoma]
Pt started with HAART => HIV viral load should be measured at 4 weeks and again at 8-12 weeks [Q/6-8 weeks until viral load is undetectable: 0-50 copies/L after 6 months of treatment]

HIV testing, post-exposure:
# 1: HIV/ELISA [HIV antibody testing] at initial visit and repeated at 6, 12, 24 weeks (1 ½ month, 3 months, 6 months)
♥ If HIV/ELISA is (+) => Order a Western blot
♥ If HIV/ELISA is (-)/indeterminate and C/P suggestive of HIV => Order a viral load test: HIV RNA PCR assay [confirming a high viral load]
HIV + patients not already on HAART => Should measure CD4 count every 3-4 months
When to start HAART:
♦Asymptomatic pt with CD4 < 300-350 and HIV viral load of > 55.000 or 60.000
♦Symptomatic or with AIDS defining illness

HIV postexposure prophylaxis/within the first 48 hrs is successful preventing HIV in:
○ Healthcare workers
○ Infants [perinatal transmission]
○ Unprotected sex with an individual HIV (+) [within 72 hrs of sexual intercourse]
RX => Zidovudine and Lamivudine x 4 weeks
Post-Exposure to body fluid of HIV (+) => requires antiretroviral prophylaxis:
- Zidovudine and lamivudine /or/ zidovudine, lamivudine and Indinavir

HIV post-exposure prophylaxis and healthcare workers
-All cases of occupational transmission have been due to transmission via exposure to BLOOD and certain body fluids [semen, vagina and any other body fluid containing visible blood.
-Standard precautions DO NOT apply to: urine, saliva, sweat, sputum, tears, vomitus, nasal secretion, or feces as long as there is no gross visible blood
=> The exposure to urine w/o visible blood is not considered a significant exposure => does not need further intervention

HIV pt, with Progressive multifocal leukoencephalopathy PML=> JC virus or human papilloma virus => no specific treatment but => regressions of well over two years treated with: HAART
Without treatment => majority of pts with PML will die within 3-6 months of the onset
HIV pt, homosexual with low CD4 count=>HBV vaccine
Esophagitis /HIV pt, aphthous ulcers => Fluconazole -> no improvement => Prednisone

Life threatening reactions associated with HIV therapy:
1. Crystal induced nephropathy => side effect of INDINAVIR [protease inhibitor]
2. Pancreatitis =Didanosine
3. hypersensitivity syndrome = Abacavir
4. NRTIs = lactic cidosis
5. NNRTIs = Stevens-Johnson syndrome
6. Liver failure = Nevirapine
IRIS = Immune Reconstitution Inflammatory Syndrome
-Paradoxical worsening of pre-existing and sub-clinical infections in HIV + individuals
-DAYS TO WEEKS OF initiation of HAART, secondary to the rapid improvement of immune function
-It is SELF Limited, best management: Provide Reassurance; continue HAART and antibiotic treatment of underlying pathogen

HAART can lead to: => HIV Lipodystrophic syndrome [redistribution of fat and insulin resistance and significant hyperlipidemia => Rx: Gemfibrozil

ACUTE RETROVIRAL SYNDROME:
- Is another term for Primary HIV infection [2-3 weeks after exposure, precedes seroconversion by 10-21 days, illness similar to I. mononucleosis, low grade fever, fatigue, maculopapular rash, face-trunk-extremities], G/I symptoms, LAD, myalgias and arthralgias, oral thrust, etc.
- HIV/ELISA is often negative initially -> can be supplemented by testing for HIV RNA or p24 Antigen if high suspicion.

PCP –in pts with defects in cell mediated immunity, HIV, CD4 < 200
**Fever, non productive cough, progressive dyspnea and tachypnea
**CXR= diffuse bilateral ground lgass or alveolar infiltrates
**DX: Fiberoptic Bronchoscopy and BAL Bronchoalveolar lavage and transbronchial biopsy
**RX:
- Admission / TMP/SMX [IV] /alternative: aerolized pentamidine
- Adjunctive treatment with corticosteroids ->when Alveolar-to-Arterial gradient of > 35 mmHg on room air.
PCP and HIV pt, allergic to sulfas: IV pentamidine [may have several electrolytic disturbances] next step= finger stick glucose to detect hypoglycemia

Do not test a patient’s HIV status => w/o obtaining ‘ a formal consent’

CD4 count => is an indicator or current level of immunosupression ‘immunologic damage that has already occurred’

HIV patient with Syphilis of unknown duration [or late latent Syphilis] => Best management: - should have a Lumbar Puncture and CSF examination before syphilis treatment [since results will determine the optimal RX]
RX: Benzathine penicillin G [IM] /week x 3 weeks
Jarish-Herxheimer reaction or ACUTE Febrile reaction developing within 24 hrs after start RX for Syphilis. Fever-malaise-chills-headache-myalgias /immunological reaction to the rupture of spirochetes. => RX: No effective prevention is available; pt should be advised of the possible signs and the need to contact the Dr if any symptom

HIV infected pt with late/latent syphilis and normal CSF analysis: Benzathine penicillin G, IM for 3 weeks

IRIS = Immune Reconstitution Inflammatory Syndrome
-Paradoxical worsening of pre-existing and sub-clinical infections in HIV + individuals
-DAYS TO WEEKS OF initiation of HAART, secondary to the rapid improvement of immune function
-It is SELF Limited, best management: Provide Reassurance; continue HAART and antibiotic treatment of underlying pathogen

Pharyngeal gonorrhea => Ceftriaxone DOC, if allergic to cephalosporins [ceftriaxone] => alternative is: => Ofloxacin and Ciprofloxacin

• Infectious mononucleosis:
1st test: If negative or inconclusive =Monospot test [heterophile antibodies] > EBV-specific antibodies
**RX of IM: bed rest and NSAIDs
**If severe complication of IM; airway obstruction, aplastic anemia, thrombocytopenia =>Rx is Admit pt and IV steroids
**Ampicillin associated maculo-papular rash => in pts with I.M, it’s a vasculitic rash immune mediated [Circulating immune complexes] [IgG and IgM antibodies vs. penicillin derivatives]
**Rx: Discontinue antibiotic and observe, supportive treatment [acetaminophen/NSAIDs, nutrition, fluids, bed rest.
♥ Adult vaccination more common: Influenza, pneumococcal and TT
♥ Indications Influenza vaccine:
1. 50 y/o and older
2. chronic resp, cardiac or metabolic conditions
3. Immunosupressed state
4. Resident of long care term facilities
5. Healthcare worker and people in prolonged contact with adults in this high risk categories

♥Indications pneumococcal vaccine:
1. 65 y/o and older
2. Younger 65 who were vaccinated more than 5 years ago

♥Indications TT:
1. Serious dirty wound, puncture wound, contaminated with saliva, soil, feces] and who received last dose > 5 years ago
2. Clean minor wound, last dose more than 10 years ago

Chronic prostatitis: => Antibiotics for 6 to 12 weeks
♦ For chronic infection: DOC => Quinolones ‘Ciprofloxacin’ and Levofloxacin
♦ Alternative: TMP/SMX

Transverse myelitis –Rapidly developed transverse myelopathy
-Rapid progressive weakness of lower extremities following a URI
-Sensory loss
-Urinary retention
-Dull back pain, muscle flaccidity / hyporeflexia and spasticity with hypereflexia thereafter
-Diagnosis: MRI

SALMONELLOSIS
Salmonella enteritidis, symptomatic pt => it’s a self limited disease
-RX: Supportive therapy, observe, fluids, electrolytes

Clostridium Difficile associated colitis: limited sigmoidoscopy is more useful than stool cytotoxin in severe cases [is more quickly]
Medication provoking CD colitis: Clindamycin, Ampicillin, Amoxicillin, Cephalosporins


Hepatic encephalopathy may be the only manifestation of SBP in chronic hepatitis pts / cirrhosis or nephritic syndrome => tremors is suggestive of stage 2 of HE
-Spontaneous bacterial peritonitis SBP -> When > 250 neutrophils/mm3 in ascitic fluid
-RX => 1st step- diagnostic testing, paracentesis and take blood cultures and ascitic fluid analysis
*** Lactulose
*** Antibiotics -Hospital admission for intravenous antibiotics (Cefotaxime or Ceftriaxone)
*** Albumin
***Once patients have recovered from SBP, they require regular prophylactic antibiotics (e.g. Septra DS, Cipro, norfloxacin) as long as they still have ascites.
Cirrhosis secondary to chronic hepatitis C => liver damage if -> PT remains prolonged, hepatic enzymes elevated AST and higher ALT, hyperbilirubinemia and hypoalbuminemia

CPT score- Child Turcotte Pugh score of liver damage [candidate for liver transplant]
Points 1 2 3
Bilirubin [mg/dL] < 2 2 - 3 > 3
Ascites Absent Slight responsive Moderate severe
PT < 15 sec 15-17 sec > 17 sec
Albumin
> 3.5 2.8-3.5 < 2.8
Encephalopathy None Stage 1-2 Stage 3-5
For cholestatic disorders=> Bilirubin are: < 4, 4-10 and > 10
Class A = CTP = 6
Class B = CTP = 7-9
Class C = CPT > 10
Liver transplantation => CTP > 7

Asymptomatic bacteriuria => in elderly patient, does not requires oral antibiotic therapy if urine WBC is < 20 WBC/HPF => Reassurance pt and repeat urine culture in 2 months

FUO: infectious disease** is the most common cause

Diphtheria is a serious condition, pharyngitis, cervical adenopathy, low grade fever. Throat culture (+) -> Give D. Antitoxin
Diphtheria antitoxin: High risk of anaphylaxis!
- > It’s made with horse serum => HIGH RISK of hypersensitivity or ‘serum sickness’ -> and risk of anaphylaxis => RX: Epinephrine

DkA patient is predisposed to Rhinocerebral Mucormycosis => RX: Surgical debridement and IV Amphothericin B
Cryptococcal cutaneous infection= early manifestation of CM / HIV patient with multiple discrete, redist colored papules with central umbilication; DX: histopathologic exam of the biopsy

Lyme disease/arthritis –can not be confirmed by Serologic tests
Serology identify too previous exposures
=> Best test= “ELISA antibody in Synovial fluid”
Lyme arthritis in children= 30 day of Amoxicillin or parenteral Ceftriaxone. In adults: Doxycycline -> Ceftriaxone. Allergic to penicillin => Erythromycin
Prognosis for children= Good => more than 905 of the children are disease free 1 year after therapy.
If not treatment => have recurrent episodes of arthritis even 8 years after the onset

Lyme disease and prophylaxis in pregnant woman:
Prophylaxis after tick bite can be done with Amoxicillin in pregnant woman
Use Doxycycline single dose if: Immuno-depression and other debilitating conditions

BACTERIEMIA:
Systemic manifestations of bacteriemia [abrupt temperature elevation, chills] occur 30-90 min after bacteria enter blood stream.
When best to drawn blood cultures? => one hour before the anticipated fever or spiking of a temperature and chill.

‘Quantitative jejunal cultures’ or The demonstration of “Excessive bacterial concentration in a jejunal aspirate” =>is the Gold standard test for diagnosis of bacterial overgrowth [“Quantitative jenunal cultures”]

TB: Sputum microscopy [AFB smear] -> is the quick/easy test to confirm pulmonary TB.
Sputum Culture is the gold standard or most useful for diagnosis
Sputum microscopy for AFB [is a marker of infectivity] => ‘’If 3 consecutive negative smears’’=> the pt can be considered: Non infectious
PPD is a screening test- used to assess previous exposure; is the first step if suspicion of TB. If PPD is (+) => CXR is the next step; then => Sputum smear and culture

Pt with a (+) PPD, but w/o any evidence of active TB => Considered to have ‘ latent TB’ and they are at increased risk of develop TB
PPD > 10 cm is (+) if immigrant from high incidence TB country within the past 5 years
Latent TB treatment=> Isoniazid daily x 6-12 months [for prevention]
LTB latent TB infection => PPD > 15 mm and normal CXR => INH monotherapy x 9 months

Tuberculin test [PPD] => initially performed in all persons exposed to patients with TB

Isoniazid /INH => Side effect => Hepatotoxicity [RX: discontinue drug]

Rifampin = Red-orange colored body fluids [urine, feces, sweat…]

Infective endocarditis
-Complication: Conduction system abnormalities if involved of => Aortic valve endocarditis
-Because of it is close proximity to proximal ventricular conduction system.

Bone marrow Transplant patient-high risk of Aspergillosis, invasive fulgal infection affecting sinuses and lungs principally.
Risk factors: Allogeneic transplantation vs. autologous transplantation, older age, acute graft versus host disease, corticosteroid therapy.

Hepatitis B:
Anyone who has received 2 rounds of HBV vaccine and still has a titer < 10 mlU/mL is considered a “Vaccine non-responder” and should be given hepatitis B immune globulin when exposed to HBsAg positive blood.

Pearly penile papules are a normal variant and not a STD. Common in uncircumcised male

Due to high incidence of lung cancer in smokers, if they presents with recurrent pneumonia = next step => Admit to the hospital and workup= CXR => CT-scan chest next

USMLE world NOTES STEP 3
PEDIATRICS
Precocious puberty:
-It is very important to distinguish between the two most common presentations and causes of precocious pubarche in order to facilitate the proper treatment.
-Precocious puberty is caused by premature activation of the hypothalamus-pituitary-gonad (HPG) axis.
-Precocious pseudo-puberty is caused by a gonadotropin-independent process, typically an excess of sex steroids (severe cystic acne, significant growth acceleration). It can be caused by late-onset congenital adrenal hyperplasia.
-Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation.
-Sequential development of the following is typically present: testicular enlargement, penis enlargement, pubic hair growth, and lastly, a growth spurt.

Benign premature thelarche:
-Is characterized by bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty.
-These other signs of precocious puberty include rapid increase in height, increase in bone maturity, appearance of axillary and pubic hair, and menstrual bleeding.
o The treatment for benign premature thelarche is expectant because majority of the patients remain stable or have reversal of the breast enlargement in a few months.
-Patients with benign premature thelarche have a normal hormone profile. Their final height is generally not compromised.
DD:
1. Hypothalamic hamartomas secrete GnRH and cause central isosexual precocious puberty in both males and females. Central precocious puberty is characterized by rapid acceleration of height, increase in bone age, thelarche, adrenarche, pubarche, and menarche. Lab investigations in patients with hypothalamic hamartoma reveal gonadotropin levels in the pubertal range and elevated estrogen levels. Majority of these patients will require treatment with a GnRH analog.
2. Estrogen production from an ovarian tumor can lead to peripheral precocious puberty. This syndrome has similar clinical features as hypothalamic hamartoma, and is characterized by accelerated height and bone age, and menstrual bleeding. Hormonal profile reveals elevated estradiol in the presence suppressed LH and FSH. Treatment is usually surgical.
3. McCune-Albright syndrome consists of "café au-lait" spots, fibrous dysplasia of the bone, and precocious puberty. This patient does not have any features to suggest McCune-Albright syndrome. The cause of precocious puberty in McCune-Albright syndrome is excessive production of estrogen from ovarian cysts.

Nocturnal enuresis
-can be categorized as primary or secondary, with secondary enuresis accounting for roughly ¼ of all cases. If the child was continent for at least 6 months prior to the onset of bed-wetting, then the enuresis is considered secondary. While psychological problems are very rarely the cause of primary nocturnal enuresis, they are quite frequently the cause of secondary nocturnal enuresis.
o Nocturnal enuresis is more common in boys. Prevalence declines slowly throughout childhood; almost ¼ of 5-year-old children (such as the boy in this case) continue to have nocturnal enuresis.
o Typically, the condition resolves of its own accord between the ages of 5 and 7. By age 10, prevalence of nocturnal enuresis has dropped to under 5% of all children.
o To increase the likelihood of success, parents should maintain a caring, patient approach, and may wish to try behavioral modification with positive reinforcement.
o If the child’s nocturnal enuresis persists alarm therapy or a prescription for Desmopressin may be worthfor some time, trying.
RX**First line management for primary nocturnal enuresis for children less than 7 seven years of age is to reassure the patient’s parents that the child usually outgrows this phase and spontaneously recovers.
►Other options for treatment, however, are the use of alarms, along with behavioral therapy, such as limiting the child’s fluid intake before bedtime. In the alarm method, a sensor is placed in the child’s underwear or in the bed padding. Once the child voids and moisture is detected, the alarm is activated, waking up the child so that he could go to the toilet before he continues to empty his bladder. Although alarms have been shown to be less immediately effective than desmopressin use, the former is still more effective in preventing relapses. Alarms are more effective than treatment with tricyclics during and after treatment.

♥When giving an opinion about a patient’s diagnosis, the physician must be cautious and try to avoid giving false reassurance or a premature diagnosis that cannot be supported by adequate clinical evidence. In cases wherein the patients’ history or physical findings do not point to a specific diagnosis, the physician can correctly state that it is "probably a medical condition", and then begin the work up in order to arrive at a more specific diagnosis.

Chronic adrenal insufficiency:
-It must be suspected in patients with the corresponding signs and symptoms: fatigue, weight loss, myalgias, increased pigmentation, and a decreased amount of axillary and pubic hair. Hyponatremia, hyperkalemia and hyperchloremic metabolic acidosis are characteristic laboratory findings. The most common etiology of this condition is primary adrenal insufficiency (Addison’s disease).
-Diagnosis can be made through the ACTH stimulation test, or by the measurement of early morning serum cortisol level (A level less than 10 mg/dl indicates a high probability of the disease).
DD: Hyperthyroidism shares some similar clinical manifestations with Addison’s disease (weight loss, asthenia,); however, the presence of other findings, such as fatigue, androgen deficit signs, hyponatremia and hyperkalemia, cannot be explained by hyperthyroidism alone. Hypothyroidism, not hyperthyroidism, is usually related to fatigue and hyponatremia (although the other symptoms still cannot be explained by hypothyroidism).

Sickle cell disease:
-In children, the most common initial symptom of sickle cell disease is dactylitis, which develops in 40% of patients.
-Splenic sequestration is the second most common, and occurs in about 20% of patients.
-Other complications, such as ischemic events, are not as frequent, and are seen mainly in the adult population.
-Salmonella is an uncommon cause of hematogenous osteomyelitis in the general population; however, it is the most common cause of osteomyelitis in patients with sickle cell disease. Long bones are usually affected, and multiple foci are often present. Sickle cell anemia should be strongly suspected in child who has a history of anemia and an episode of Salmonella osteomyelitis. Interestingly, only about 30% of cases of sickle cell anemia are diagnosed at the age of 1 year.
-DX-Hemoglobin electrophoresis will confirm the diagnosis.

Acute otitis media:
The most common complication after an episode of acute otitis media is another episode of otitis media. Approximately 75% of early recurrences are due to different bacteria, while other recurrent episodes are caused by the same agents (usually Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis).
Children who have had more than two episodes are especially at risk.
Some authors recommend prophylactic antibiotic therapy in such cases.
Contrary to popular belief, pneumonia is not a complication of acute otitis media. Both conditions can coexist, but one is not a risk factor for the other.
While adults have wide, steeply angled Eustachian tubes, infants have shorter, almost horizontal Eustachian tubes. This fact makes fluid accumulation and infection quite common in young children; however, not all children develop acute otitis media (AOM).
require further exploration►Recurrent episodes by the clinician.
-Exposure to cigarette smoke has been shown to alter mucosa, cilia, and adenoid structures, in addition to increasing the risk of developing AOM and upper respiratory tract infections.
-An increase in the level of smoke exposure is paralleled by an increase in the number of AOM episodes. Exposure to cigarette smoke is one of the most important risk factors for developing acute otitis media. Parents should be urged to quit smoking.
o Initial clinical treatment failure (failure of acute otitis media to respond clinically to amoxicillin by day 3 of treatment) and who has not received antibiotics in the month prior to the initiation of treatment are:
- High doses of amoxicillin/clavulanate or certain second or third generation cephalosporins.
The rationale is to enhance activity against penicillin-resistant S. pneumoniae (drug resistant S. pneumoniae or DRSP) found in an increasing percentage (30-60%) of cases of pneumococcal AOM in the US.
►If the patient has an initial clinical treatment failure and has received antibiotics in the month prior to beginning the current treatment. (Prior antibiotics in the month preceding AOM increase the likelihood that AOM is due to DRSP):
1- Discontinue amoxicillin, begin IM ceftriaxone, and 2- refer the boy to an otolaryngologist for urgent tympanocentesis.
o Under these conditions, the patient would also have been initially treated with high dose amoxicillin, high dose amoxicillin/clavulanate, or certain second or third generation cephalosporins.
o These regimens are reported to be more effective against DRSP than the usual dose of amoxicillin. IM ceftriaxone is even more effective against DRSP.
►Moreover, immediate tympanocentesis allows culture and sensitivity testing which can provide invaluable guidance in selected difficult cases not responding to empiric treatment.
►Tympanostomy and tubing is generally reserved for chronic otitis media (COM) with effusion persisting for more than 3 months, or recurrent AOM (greater than six episodes in 6 months) which is not prevented by prophylactic antibiotics (half of normal dose amoxicillin or sulfisoxazole).
-It might be considered in AOM if the TM bulging, earache, fever, vomiting, and/or diarrhea were unusually severe or persistent.

►**Post OM management:
-A normal appearing tympanic membrane with decreased mobility on pneumatic otoscopy is suggestive of an effusion in the middle ear. An effusion commonly persists up to three months after an acute episode of otitis media (OM) has been treated.
-If no other watchful waiting is all that is necessary.symptoms are present in such cases,
-If other symptoms are present, the effusion is bilateral, or has persisted further therapy should be considered.for more than three months,
o Switching to a second-line antibiotic should be considered if there is inadequate improvement of symptoms or appearance of the tympanic membrane, or when there is persistence of a purulent nasal discharge. According to the CDC, three drugs can be used as alternatives.
o These are amoxicillin-clavulanate, cefuroxime axetil, and intramuscular ceftriaxone.
o Tympanocentesis or myringotomy with culture are indicated in children in whom the clinical response to a second-line treatment has been unsatisfactory.
o Hearing should be assessed if effusion has persisted for more than three months.
o Myringotomy and insertion of tympanostomy tubes should be considered for patients with otitis media and effusion after antibiotic therapy and an ample period of watchful waiting.

Gynecomastia
-is very common (up to 70%) in pubertal males.
-Its occurrence during puberty is associated with the relative excess production of estrogens from the testes. In majority of subjects, gynecomastia regresses in about 18-24 months; however, this may persist in some patients, and although rare, it could be cosmetically disfiguring.
o Surgical resection is required in very large, cosmetically disfiguring gynecomastia which has not responded to medical therapy.
o Liver cirrhosis is associated with gynecomastia. This is mainly due to an increased aromatization of circulating androgens.

o Methamphetamine (MF): therapy is associated with decreased weight and height.
-Sadness and irritability can be seen in up to 22% of children at therapeutic doses.
-MF overdose has similar effects as dextroamphetamine, that is: anorexia, nausea, vomiting, tachycardia, increased blood pressure, palpitations, dizziness, headache, nervousness, euphoria, agitation, and aggressive or violent behavior.
-It is very important to remember that MF cannot be stopped abruptly because of the high prevalence of psychological dependence to the drug.
-MF must therefore be slowly tapered.
-DD: MF use in childhood has been associated with an increased probability of drug abuse problems in adulthood. Illicit drug overdose, especially cocaine, may be difficult to differentiate from MF or amphetamine overdose.
-A urine toxicology test may be useful in most cases.


Exercise-induced bronchoconstriction
Is usually seen after strenuous activities or exercises
Bronchodilation initially occurs during exercise, followed by bronchoconstriction, which begins after 3 to 5 minutes, and rapidly peaks within 10 to 15 minutes of cessation of exercise. This is extremely common in patients with a history of symptomatic asthma, and the patient"s response correlates with the degree of airway hyperresponsiveness.
o The first step in the management of patients with exercise-induced bronchoconstriction is to control the underlying asthma effectively.
o Patients with well-controlled asthma and a history of exercise-induced bronchoconstriction should have prophylactic treatment with inhaled beta-2 agonists (e.g., albuterol) approximately 5 to 10 minutes before the initiation of exercise.
o Patients with less severe or less frequent attacks, along with their close contacts, must be taught how to recognize and treat the acute attack with inhaled beta-2 agonists.
o It is important to realize that exercise is not the cause of asthma, but it induces bronchoconstriction in patients with underlying asthma. The patient should not be instructed to avoid exercise. In contrast, exercise should be encouraged to reduce the minute ventilation for any given level of exercise, and to prevent the recurrence of exercise-induced bronchoconstriction

♥ Capillary (strawberry) hemangioma:
Superficial, bright, red, strawberry-like round lesion is a benign vascular lesion.
Most capillary hemangiomas are evident at birth.
They may undergo subsequent growth for a period of several months (proliferation phase). Spontaneous regression usually follows (involution phase).
It is estimated that 70% of superficial lesions will disappear by seven years of age, although residual skin changes may be left.
For lesions that are small, do not affect normal functioning, and do not constitute a significant cosmetic problem, observation is the best approach.
Laser treatment should be considered in patients with lesions on the face, and at sites of potential functional impairment (orbital area).
Imaging studies are usually indicated in infants with multiple superficial lesions to exclude visceral involvement.
Oral corticosteroids, and sometimes subcutaneous interferon, are indicated for the treatment of rapidly growing lesions.

Anorexia nervosa :
Anorexia nervosa is a complex medical condition, which is difficult to treat. There are some indications to admit a patient with anorexia nervosa to the hospital.
The Society for Adolescent Medicine (SAM) has developed some guidelines.

o The indications for admission of Anorexia nervosa are:
♥Dehydration, electrolyte abnormalities (hypokalemia, hyponatremia), bradycardia (less than 50 beats per minute), hypotension (BP < 80/50 mmHg)
-Hypothermia (under 96ºF), orthostatism, acute food refusal
-Severe malnutrition (weight < 75% of the average for her age, height and sex)
-Acute medical or psychiatric emergencies (pancreatitis, seizures, syncope, suicidal ideation, psychosis), and cardiac arrhythmias
o If the patient meets any of these criteria, she must be admitted immediately.
o All other medical and psychiatric evaluations may be done after the patient is admitted to the hospital.
Hypocalcemia is common in patients with anorexia nervosa because of the presence of hypoalbuminemia.
►Refeeding syndrome can develop during the second or third week of nutritional therapy of patients with anorexia nervosa. It is characterized by edema and heart failure, and can lead to delirium and cardiac arrest.
Phosphate must be replaced immediately, and the patient should be managed in the intensive care unit

►Neonatal sepsis:
The diagnosis of neonatal sepsis is suspected when an infant has poor appetite, decreased reactivity to external stimuli, diminished oral intake, and lassitude or depressed sensorium.
►Neonatal sepsis -The most common etiologic agents are Group B Streptococcus, Escherichia coli, Klebsiella and Enterobacter species.
Although Listeria infections are rare in the United States, ampicillin is recommended as part of the antibiotic regimen.
Cefotaxime, ceftriaxone or antipseudomonal penicillins are used in combination with the aforementioned drug.
The type of bilirubinemia involved also affects the approach in management of septic infants. Indirect hyperbilirubinemia is usually physiologic in nature and persists, while direct hyperbilirubinemia is probably induced by sepsis-related cholestasis.
 Ceftriaxone should not be used if there is hyperbilirubinemia, because it will increase both types of bilirubin.
Moxalactam and sulfonamides are not recommended due to their capability of increasing indirect bilirubin levels.

♥Sydenham’s chorea (SC; also known as Saint Vitus dance), one of the classic manifestations of rheumatic fever.
SC is more common in girls, especially between 5 and 13 years of age.
SC is usually preceded by a period of emotional lability, manifested by a tendency to cry or laugh, as well as deterioration of school performance. SC starts with distal hand movements, later progressing to facial jerking and grimacing, as well as abnormal feet movement.
Chorea usually develops several (one to eight) months after the onset of acute rheumatic fever, whereas carditis and arthritis typically develop within 21 days.
The presence of carditis is diagnostic. Approximately one third of the patients have carditis; mitral regurgitation is the most common cardiac finding.
Patients may not remember a prior sore throat, and cultures are also usually negative.
Patients usually have hypotonia, and the relaxation phase of the patellar reflex is usually delayed. When the patient is examined with the arms stretched out, the arms move from the prone to the supine position (positive pronator sign).
DD:
1. Gilles de la Tourette syndrome starts between 2 and 15 years of age, and is four times more frequent in boys. Pronator sign, carditis and hypotonia are not present.
2. Attention deficit disorder is a chronic condition with no abnormal findings on physical examination.
Rx-Sydenham’s chorea (SC) should be treated immediately with oral penicillin for ten days. If patient adherence is an issue, an alternative is a single dose of intramuscular
Benzathine penicillin. In patients who are allergic to penicillin, weight based erythromycin, divided in 2-4 doses, and should be given. SC usually resolves within 12 to 15 weeks; however, prophylaxis should be continued into adulthood.
If the motor function is severely valproic acid, phenobarbital or haloperidol can be started, and thecompromised patient must be referred to a neurologist.

Atopic dermatitis:
The characteristic (red, oozing) rash may involve the face and the scalp in children.
Scaly, dry cheeks, especially in the winter, are also typical. Atopic dermatitis is believed to have a strong allergic/immunologic component because many patients demonstrate allergies to food and inhalant allergens. 80-85% of patients have elevated IgE levels, and there is a strong family predisposition to the disease.
o The condition promptly responds to topical steroids and calcineurin inhibitors such as topical tacrolimus and pimecrolimus.

Diarrhea diet:
-In a child with diarrhea and no clinical signs of dehydration, preferred intake includes fluids low in sugar and the resumption of a normal, age-appropriate diet with plenty of complex carbohydrates with limited fats and sugars.
-Foods containing excessive sugar can increase the osmolarity of the stool in the intestinal lumen, and fatty foods are known to delay gastric emptying. Both can worsen diarrhea.
-The previously popular BRAT diet is no longer recommended for refeeding children with diarrhea because it is quite low in calories and protein. Moreover, the bananas and applesauce in the BRAT diet add excessive sugar.
Of greater concern is loperamide’s linkage with paralytic ileus, toxic megacolon, CNS depression, coma, and death in children.

Rabies prophylaxis:
In a case of exposure to bats, immediate vaccination is recommended if the person was not aware of the presence of the animal.
 Postexposure prophylaxis consists of the administration of one dose of anti-rabies IG immunoglobulin and five doses of anti-rabies vaccine.
If treatment is postponed for no more than five days (if the patient did not immediately report the exposure), effectiveness will be the same, although there have been reports of rabies in persons not vaccinated in the first 72 hours when the bite was in the head or the neck.

Ethics:
Permission to treat a child can only be granted by the parent or legal guardian.
As an exception to this rule, adolescents are typically allowed to give consent for their own care in regards to pregnancy, contraception, sexually transmitted diseases, substance use, and emotional illness.
When providing medical care, clinicians must seek to balance the autonomy of the family with the welfare of the child.
-In true emergency situations requiring imminent treatment of a child, most medical teams choose to proceed with treatment despite the parental refusal of care.
-Very rarely do courts uphold charges against physicians in such cases.

Homosexual parents:
Homosexuality was classified as a sexual disorders in the DSM I and II, but was removed from the revised DSM III. Multiple studies of both biological and adopted children of homosexual parents have been performed, and the general consensus is that these children experience normal childhood development.
-Among children of homosexual parents, adolescent concerns about identity and peer approval are becoming less intense as variance in the American family unit grows more common and socially accepted.
-The majority of children adopted by homosexuals consider themselves to be heterosexual, though some do describe themselves as homosexual or bisexual.
-Homosexual parents have not been proven to be more passive than heterosexual parents, and there is no documentation of increased violence or antisocial behavior in their children. Studies of domestic violence suggest it is similarly prevalent in homosexual and heterosexual relationships.
-Although at least one study has suggested that certain learning disabilities (e.g., dyslexia, stuttering) are more common in homosexuals than in heterosexuals, there is no evidence that this tendency translates to increased learning disabilities in the children of homosexual parents.

Bacterial conjunctivitis:
-Characterized by redness and copious, purulent discharge - No fever or blurred vision.
-Examination shows conjunctival erythema and yellow exudates. - It is usually a self-limited disease; however, it must be treated because there is a small, but real risk of keratitis, which can lead to visual impairment.
-RX- Erythromycin ointment or sulfa drops are the first line of therapy for uncomplicated bacterial conjunctivitis, as they cover most organisms.
-Fluoroquinolone eye drops are preferred for contact lens wearers and corneal ulcers because of the activity against pseudomonas. -They should not be used in uncomplicated bacterial conjunctivitis as first line therapy because of the risk of the emergence of resistance.
-Primary care physicians should not prescribe corticosteroids, as they can cause sight-threatening complications in patients with bacterial conjunctivitis and herpes keratitis. Bacterial conjunctivitis is very contagious.
-The best thing to do is to keep the child at home until the discharge is cleared.
-However, in many patients who work outside, this may not be feasible. In those patients, at least 24-hours of topical antibiotic therapy should be applied before returning to work.

Delayed puberty:
-The earliest sign of puberty is nocturnal increase in the LH surge. This is followed by a daytime increase in the levels of gonadotrophins, and increase in testosterone levels. On physical examination, enlargement of testes is one of the earliest signs of onset of puberty.
-A patient is diagnosed with delayed puberty if he does not have testicular enlargement by 14 years of age, or if his testicles are 2.5 cm or less in diameter. -Another criterion is a delay in the development for 5 years or more from the onset of genitalia enlargement.
o The most common cause of delayed puberty is constitutional delay.
The initial evaluation involves the use of an imaging test to determine bone age.
Bone age that is older or equal to the chronological age warrants further testing to rule out chromosomal abnormality and endocrine causes
DD:
►Constitutional pubertal delay is characterized by delayed puberty, retarded bone age, and a positive family history without any evidence of systemic disorder. These patients develop puberty without any intervention.
-The development of secondary sexual characteristics can be enhanced in patients with constitutional pubertal delay by using small doses of testosterone for a short time.
-The use of testosterone for a short period of time does not compromise the final adult height.
►Kallman’s syndrome consists of anosmia with hypogonadotropic hypogonadism, and sometimes there are associated midline facial defects. This syndrome is due to a genetic defect which leads to the defective migration of GnRH-secreting and olfactory neurons to their final adult positions.

♥Neurofibromatosis:
To meet the diagnostic criteria NF 1, two or more of the following are required: a first degree relative with NF 1, the development of more than six CALS of 5 mm in greatest diameter (if children) or 15 mm (if adult), or the presence of more than two neurofibromas, Lisch nodules, optic glioma, bone dysplasia, or axillary freckling. If the patient is a child, there is a 15% possibility of development of optic nerve gliomas.
o Current recommendations include having a detailed ophthalmologic evaluation for early detection of this problem and for search of Lisch nodules (iris hamartoma).
-As primary care physicians have a lack of expertise in such an evaluation, immediate ophthalmologic referral is advised.-If there are any ophthalmologic or neurologic abnormalities, other tests such as MRI, head CT scan, EMG, or neurosurgery evaluation may be needed.
DD:
Hypopigmented spots, in combination with a family history of bilateral deafness, strongly suggest neurofibromatosis type 2 (NF-2), an autosomal-dominant disorder. The spots described actually represent café-au-lait spots that are usually hypopigmented (unlike the hyperpigmented café-au-lait spots found in NF-1).
-Deafness is caused by bilateral acoustic neuromas, a characteristic neurologic manifestation of the syndrome.

Herpes zoster or varicella:
-The diagnosis of herpes zoster or varicella is made clinically. -No further laboratory tests are needed
In immunosuppressed patients (e.g., HIV), the rash can be atypical and can be confused with herpes simplex.
-If the patient is critical and antiviral therapy needs to be started, lesions can be scraped for PCR or immunofluorescence studies.

Vaccination:
►True contraindications for DTaP vaccination:
1) Anaphylaxis within seven days of administration of a previous DTP or DTaP vaccine, and
2) Encephalopathy within seven days of administration of a previous DTP or DTaP vaccine.
►-If high fever (>104.8F), shock, inconsolable crying for three or more hours, or seizure occur within 24 hours of receiving a dose of DTaP vaccine, then subsequent doses should be given with caution.

►Temporary contraindications to receipt of the DTaP vaccine include:
1) Moderate or severe illness, with the vaccine administered as soon as the illness resolves.
2) Mild acute illness with or without fever is not a contraindication to vaccine administration.
-There are no significant contraindications to receipt of vaccinations against Hib, poliovirus, and pneumococcus; therefore, a four-month-old child with otitis media should be vaccinated against DTaP, Hib, IPV, and PCV.
**Varicella vaccination of household contacts of transplant recipients is relatively safe and is currently recommended by the American Association of Pediatrics (AAP). It is advisable for all patients to receive pre-transplantation immunization, although this is not always possible and durable protection is reached in less than 50% of patients. Transmission of vaccine-associated VZV is not typical, except for some cases when post-vaccination rash appears; therefore, this child should be monitored for the appearance of a rash and isolated if a rash appears

TB:
All patients with sputum-positive pulmonary or laryngeal tuberculosis can transmit the infection to other household contacts or healthcare workers via infectious aerosols containing Mycobacterium tuberculosis bacilli. The acts of coughing, sneezing, singing, and even speaking can all produce microscopic aerosols containing the organism.
-All such patients should be placed in respiratory isolation until they are confirmed to be non-infectious.
-Patients are rendered non-infectious if they are receiving effective antituberculous therapy and have had three consecutive negative results on sputum acid-fast smears performed on different occasions.
-Non-infectivity should be documented by serial negative acid-fast smears, and not by the duration of therapy. A patient can still be infectious after prolonged drug therapy if he has a drug-resistant infection.
-Resolution of chest x- ray findings in patients with pulmonary tuberculosis typically lag behind the clinical response. Chest radiograph changes can persist for longer periods of time after the patient has been rendered non-infectious, and may even become permanent.
**Multi-drug resistant TB: is an emerging problem in the USA. If the organisms are resistant to both rifampin and INH, we call it a multi-drug resistant TB (MDR-TB).
-In case of exposure to MDR-TB, chemoprophylaxis with pyrazinamide and ethambutol or quinolone with anti-mycobacterial activity, like ofloxacin or levofloxacin is recommended.
-But, if it is resistant to INH only, then the standard recommendations are to give the chemoprophylaxis with Rifampicin alone for four months or Rifampicin plus PZA for two months. The problem with the rifampin plus PZA combination in an immunocompetent host is liver toxicity. The patient needs careful monitoring.

**Tuberculous meningitis:
Is one of the forms of extrapulmonary tuberculosis. It is associated with high morbidity and mortality rates. Patients usually present with an insidious onset of symptoms such as malaise, headache, and low-grade fever. If left untreated, these symptoms can rapidly progress to persistent headaches, vomiting, cranial nerve involvement, confusion, seizures, coma, and eventually, death within six to eight weeks of the onset of illness. All patients with suspected tuberculous meningitis (based on initial history and CSF examination) should be immediately started on empiric antituberculous therapy, pending the results of confirmatory tests. The prognosis of the patient with tuberculous meningitis greatly depends on the stage in which the treatment is initiated. Early diagnosis and treatment of the patients is critical to prevent adverse clinical outcomes.
All patients with tuberculous meningitis should be initially treated with a combination of isoniazid, rifampin, and pyrazinamide (bactericidal agents) for the first two months, followed by treatment with INH and rifampin for the succeeding months. These three agents have good CSF penetration, and can achieve adequate therapeutic levels in the cerebrospinal fluid. Based on the current guidelines, all infants and children with drug-sensitive tuberculous meningitis should be treated for at least 12 months. In a patient with drug-resistant infection, the therapy may be extended to 18-24 months, depending on the clinical response and severity of the illness.

Summary:
1. Specific antituberculous therapy should be initiated early in all patients with clinically suspected tuberculous meningitis.
2. Infants and children with tuberculous meningitis, miliary TB, and tuberculous osteomyelitis should receive 12 months of antituberculous therapy.

kyphosis:
a) Flexible:
Scenario: Physical examination shows a postural round back that is corrected by voluntary hyperextension. Forward bending reveals no lateral deformity and no angulation. Neurological examination of the lower extremities is normal. You order x-ray of the spine that shows a convex alignment of the thoracic spine at 35 degrees.
-It is typically noticed by parents or teachers who observe adolescents sitting or standing in a slouched position. On lateral radiographs, the angle of thoracic kyphosis is normal or slightly increased (normal 20-40 degree). Interestingly, contrary to common belief, there is no evidence that flexible kyphosis leads to adverse physical effects or permanent deformity.
b) Scheuermann disease (structural kyphosis )
Scenario: Physical examination reveals thoracic curving of the spine that is not corrected with voluntary hyperextension of the spine. On forward bending, sharp angularity is observed in the thoracic region, but no lateral deformity is present. Neurological examination of the lower extremities is normal. X-ray of the spine shows a convex alignment of the thoracic spine at 55 degrees.
Unlike flexible kyphosis, structural kyFphosis is not corrected with voluntary efforts, and a sharp angulation is commonly seen on forward bending.
-The typical treatment for structural kyphosis that is not severe (less than 70-80 degrees) includes the use of a Milwaukee brace. In more severe cases (significant angulation, intractable pain, neurological abnormalities), surgical correction is used.


Turner syndrome (45,XO):
-dorsal feet and hands edema, short webbed neck, and a cardiac murmur) is typical for Turner syndrome. It represents monosomy for the X chromosome (45, X), that is why no Barr body is revealed on the buccal smear. Less common chromosomal abnormalities that can be present in patients with Turner syndrome include X chromosome mosaicism and Xp deletion. Interestingly, the risk of having an infant with monosomy for the X chromosome does not increase with advance maternal age, unlike Down’s syndrome and Klinefelter’s syndrome (47, XXY). Moreover, no increased recurrence risk is present after having an infant with Turner syndrome.
All patients who are initially diagnosed must be screened for the presence of other associated somatic abnormalities.
-The most important of these are the cardiac defects, which include coarctation of the aorta, bicuspid aortic valve, mitral valve prolapse, and hypoplastic heart. Since some of these defects cannot be picked up by clinical examination, an echocardiogram is necessary.
-The other associated defects are: visual and hearing deficits, kidney malformation (including horseshoe shaped kidney), and an increased predisposition for autoimmune endocrinopathy (especially primary hypothyroidism); therefore, in addition to an echocardiogram, all patients initially diagnosed with Turner syndrome require visual and hearing assessment, renal ultrasound, and TSH level measurement.
-Patients with Turner syndrome develop moderate to severe insulin resistance and diabetes when they are older. Blood sugar screening is performed based on the patient"s clinical manifestations.
-Patients with Turner syndrome have hypogonadism, and eventually require estrogen replacement; however, if estrogen therapy is given at an early age, there may be premature fusion of the epiphysis, which will potentially decrease the patient"s final height. Most physicians begin prescribing hormone replacement therapy when the patient reaches 14 years of age. Growth hormone is approved for use in patients with Turner’s syndrome to improve their final height.

Imaging studies in UTI:
Imaging studies are recommended in the following patients:
1. children under the age of five years with a febrile UTI
2. males of any age with a first UTI
3. females under the age of three years with a first UTI
4. children with UTI who do not promptly respond to antibiotic therapy
5. children with recurrent UTI
Voiding cystourethrogram is routinely recommended, and is considered by most authors as an important imaging study to demonstrate vesico-ureteral reflux (VUR).

►Infantile hypertrophic pyloric stenosis (IHPS):
-Usually presents in infants who are three to six weeks old. 83% of affected patients are boys. Postprandial, non-bilious vomiting is characteristic. Peristaltic waves can sometimes be detected just before vomiting. These occur as wavy movements traveling from left to right across the upper abdomen. A palpable "olive-like" mass in the right upper quadrant is pathognomonic of the disease, but is actually detected by only 49% of physicians, since most cases are diagnosed at an early stage (usually between the third and fourth week).
-Historically, laboratory evaluation will show hypokalemia and a hypochloremic, metabolic alkalosis secondary to the loss of gastric hydrochloric acid, although electrolyte imbalances are seen less often now that the diagnosis is made earlier.
-The imaging modality used most commonly to diagnose IHPS is ultrasound, though an upper gastrointestinal (UGI) contrast study is preferred in some medical centers.
-Electrolyte derangements and dehydration must be corrected before proceeding with surgical correction of infantile hypertrophic pyloric stenosis.
-Studies have shown that children who undergo surgery without first correcting the electrolyte imbalances are at increased risk for postoperative apnea.
Rx: pyloromyotomy
Endoscopically guided balloon dilation has been studied, but is not often used because of inconsistent success in opening the muscular ring of the pylorus.
This approach is typically reserved for patients who are not otherwise good surgical candidates.
Studies have documented an association between the development of infantile hypertrophic pyloric stenosis and the usage of oral erythromycin, which is typically given as postexposure prophylaxis for pertussis. In addition, there is some indication that the usage of macrolides in breastfeeding women is linked to the development of infantile hypertrophic pyloric stenosis, especially in infant girls.

Constipation:
The normal frequency of passage of stools in the infant is around six to eight times daily. This approximates to one stool passage per episode of breastfeeding. On the fourth week of life, the pattern changes. The stool frequency decreases to one or two episodes daily or even less, such as three episodes per week. This has to be differentiated from true constipation in order to avoid exaggerated concern.
DD: Hirschsprung’s disease usually presents earlier in life (failure to pass meconium in first 48 hours) as intestinal obstruction or enterocolitis. Notwithstanding, some patients will be diagnosed later, but will have a history of chronic constipation and failure to thrive. For this reason, observation is required to determine if the constipation persists.
**While constipation can signify a serious disorder (e.g., Hirschsprung’s disease, cystic fibrosis, hypothyroidism) in select circumstances, most children who are constipated are normal.
-Children with a history of resisting toilet training are at increased risk for developing constipation, as are those children whose dietary intake is high in dairy products and low in fiber. If dietary modification fails to relieve constipation, usage of a laxative is the next best step. Once the child’s bowel begins to operate properly on its own, the laxatives should be discontinued gradually.
Magnesium hydroxide, also known as milk of magnesia, is a mild saline laxative that causes the osmotic retention of fluid in the gut lumen. It can be titrated to produce soft, but non-liquid stool, and is safe for use in young children. In a child experiencing moderate constipation and no encopresis, magnesium hydroxide is an excellent treatment choice.
RX-
-Bisacodyl suppositories are powerful stimulant laxatives that cause increased peristalsis. Usage of these suppositories commonly results in abdominal cramping, diarrhea, and nausea, and is best reserved for short-term "rescue therapy" in children with severe constipation.
-Phosphate enemas are highly effective at relieving impaction, and act by distending the rectum and stimulating the muscles of the colon; however, frequent use of these enemas can cause electrolyte imbalances, and is therefore discouraged. This form of treatment is best reserved for relieving impaction or for bowel preparation prior to medical procedures.

Tick bite:
The risk of acquiring Lyme disease after being bitten by a tick is less than 1.5%. The most common complication of tick bites is local inflammation or infection.
In order to be infected with Lyme disease, the patient must have been exposed to the tick for more than 36 hours, because the transmission of the infectious agent - Borrelia burgdorferi - takes place only after the tick is firmly attached to the skin and has suctioned a certain amount of blood which gives it an engorged appearance. If a tick is found and it is not engorged with blood, there is no risk of Lyme disease, as ticks take at least 24 hours to firmly attach to their victims.
The majority of patients have a transitory skin reaction in the first 24-72 hours on the site of contact with the tick; this lesion must not be confounded with erythema chronicus migrans, which develops later.
The tick that transmits Lyme disease is brown, while the one that transmits RMSF is black

Epiglottitis:
With the introduction of the Haemophilus influenzae type b vaccine in 1985, epiglottitis has become much less common in recent years. When it does occur, it causes an inflammatory edema of the epiglottis that impinges upon the airway. Respiratory arrest is easily provoked at this stage, and treatment should be focused on relieving any airway obstruction and treating the infection. The threshold for performing intubation should be very low. Since the outpatient setting is inadequate for such procedures, it is imperative that an ambulance be called so the child’s condition can be properly addressed by emergency personnel. Frequently, epiglottitis is diagnosed solely by the clinical presentation.
-However, if a lateral neck radiograph is deemed necessary, it will reveal a swollen epiglottis (the "thumbprint sign") in classic epiglottitis.
-Endotracheal intubation should be performed before the radiograph is obtained, because patient is at great risk for respiratory arrest.

Lead intoxication:
Lead intoxication remains a common preventable environmental hazard, although its prevalence is declining in developed countries. Early recognition of lead poisoning helps to prevent the development of long-term irreversible neurological sequelae.
The two main factors contributing to lead poisoning in industrialized countries are exposure to old, lead-based paints which are usually found in old houses, and non-nutritive hand-to-mouth activities of young children.
Children with a blood lead level greater than 10 ìg/dL should be comprehensively evaluated by obtaining a CBC, serum electrolyte levels, and urinalysis. Environmental/behavioral interventions are crucial in the management of patients with lead intoxication. Ideally, these include identifying the source of exposure, removing the family from the lead-containing dwelling, cleansing of the environment, and educating the family in an effort to reduce hand-to-mouth activitiesof the children. High-risk populations must be screened for lead intoxication.
This includes children who live in or frequently visit old houses, and children whose sibling was diagnosed with lead poisoning.
Measurement of the blood lead level is the gold standard in lead intoxication screening. A blood lead level greater than 10 ìg/dL is diagnostic. Venous sampling is always preferred to capillary sampling because the former is more accurate.
**Mild lead poisoning (blood lead level < 45 µg/dL) can be treated by DMSA or d-penicillamine, although this approach is not evidence-based. Moderate lead poisoning (blood lead level between 45 and 70 µg/dL) requires the treatment with EDTA IV or oral DMSA. Continuous IV infusion of EDTA is preferred to IM injection
Severe lead intoxication (blood lead level > 70 µg/dL and/or acute encephalopathy) is a medical emergency and prompt chelation therapy with dimercaprol and EDTA is necessary.

 Afebrile pneumonia syndrome (APS):
-Causative organisms of APS include Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma, CMV, RSV, Parainfluenza virus, Adenovirus, and Pneumocystis carinii.
-The fever may either be absent or low grade. Other symptoms include cough, tachypnea, irritability, and poor feeding. Because of the lack of specificity of symptoms and radiologic findings, the causative organism cannot be determined solely by the clinical presentation. However, some organisms have characteristic features which may aid in the differential diagnosis and direct the necessary work-up of the patient.
-The age of onset (between 2 and 19 weeks) and the presence of staccato cough are suggestive of Chlamydia pneumonia. This diagnosis can further be supported if there is a history of conjunctivitis in the neonatal period. Conjunctivitis is present in half of cases and may present either in the neonatal period or be concurrent with the pulmonary infection. Additional characteristics include auscultatory and radiologic findings that are out of proportion to the overall healthy appearance of the infant. Chest-x ray shows hyperinflation, peribronchial thickening, and bilateral, symmetrical, interstitial infiltrates.
-The WBC count is usually normal, but the eosinophil count is elevated.
-The diagnosis can be confirmed by tissue culture isolation of the organism from nasopharyngeal specimens, direct fluorescent antibody tests, enzyme-linked immunoassays, or polymerase chain reaction.

Delayed speech development:
May indicate an underlying hearing impairment and should prompt referral of the patient for audiologic assessment. Other candidates for hearing evaluation include children with a family history of hereditary childhood hearing loss, history of meningitis, history of recurrent or persistent otitis media with effusion for more than three months, documented intrauterine infections, craniofacial anomalies, and use of ototoxic medications such as aminoglycoside.
Hearing loss early in life, even mild or unilateral, may affect speech and language development, social and emotional development, and academic achievements. Early identification is thus mandatory for a better prognosis; hence, screening programs have been widely and strongly advocated. Although the American Academy of Pediatrics endorses universal screening, at present, systematic screening is implemented in 32 states only.
The etiology of hearing impairment depends on whether the hearing loss is conductive or sensorineural.
The most common cause of conductive hearing loss in children is presence of fluid in the middle ear. Other causes include tympanic membrane perforation (trauma or infection), ossicular discontinuity (infection, cholesteatoma, and trauma), tympanosclerosis, and congenital anomalies of the external ear canal or middle ear components. As for sensorineural hearing loss (SNHL), it may be congenital or acquired.
-The most common infectious cause of congenital SNHL is CMV.
-Other less common congenital infectious causes include toxoplasmosis, syphilis, and rubella.
-Postnatal infectious causes include group B streptococcus and bacterial meningitis. Hearing loss can also be genetically determined; it may be autosomal dominant or recessive, isolated or in a syndromic association with other anomalies.

Downs syndrome:
Endocardial cushion defect is the most common congenital heart lesion in patients with Down’s syndrome. Other malformations that are frequent in Down’s syndrome include duodenal atresia, Hirschsprung’s disease, atlanto-axial instability, and hypothyroidism.
-Echocardiography is the most useful test for diagnostic evaluation of this condition. Cardiac catheterization is evidently more accurate than echocardiography for diagnostic evaluation, but this modality is reserved for cases in which the size of the shunt is uncertain, laboratory data and clinical findings are equivocal, or when pulmonary vascular disease is suspected.
-Patients with Down’s syndrome are at increased risk of developing acute leukemia later in life.
-Other conditions which occur with a higher frequency in Down"s syndrome include Alzheimer-like dementia, autism, ADHD, depressive disorder, and seizure disorder.

Infectious mononucleosis:
Suspect IM in any adolescent who presents with fever, pharyngitis, tonsillitis, lymphadenopathy, splenomegaly, and rash. The recognition of "atypical lymphocytes" in the peripheral smear can be a clue to its identification, but these can also be seen in toxoplasmosis, CMV infection, or lymphocytic leukemia.
**It is infrequent to find posterior cervical adenopathy in a case of common bacterial pharyngitis. The development of rash after administration of amoxicillin is also one of the characteristics of the disease. Even though the spleen and liver are not always palpable, the former is constantly increased in size and friable. Since there is an increased risk of splenic rupture, especially if the patient is actively involved in sports, a patient who is highly suspicious for IM must be recommended to avoid practicing sports while waiting for the test results. Despite this fact, almost 50% of the cases of splenic rupture associated with IM can occur spontaneously, without evidence of previous trauma or excessive exercise.

Smoking cessation:
-Nicotine is a highly addictive drug. It is extremely difficult for even the highly motivated to stop smoking. Numerous factors may elicit the urge to smoke. Studies have shown that smokers who attempt to quit while working or living with people who continue to smoke are much more likely to relapse.
-Smoking cessation is difficult to accomplish if the smoker remains subject to environmental triggers, including friends and family who continue to smoke. Parents who want their children to stop smoking should quit themselves. -Prescriptions for nicotine replacement (e.g., nicotine patch, nicotine gum) should be offered to those smokers interested in quitting.

Rash:
Due to the success of immunization campaigns, infection with the rubella virus (Choice B) is now very rarely seen in the United States; cases today typically arise in non-immunized foreign born populations. Infection with rubella is most often asymptomatic, but can cause German measles, a mild illness classically characterized by low-grade fever, lymphadenopathy involving the posterior cervical and occipital lymph nodes, and a maculopapular rash that begins on the face and spreads caudally.
-The rash is similar in appearance to that caused by measles, but patients are usually much less sick upon presentation with rubella. Supportive treatment is sufficient when the illness is self-limited. Of primary concern is the congenital rubella syndrome, which has devastating effects on the unborn child, especially when a non-immune pregnant woman is exposed to the virus in the first trimester.
-Varicella, commonly known as chickenpox, is an illness characterized by a low-grade fever, malaise, and a macular rash that appears in crops which progress through several stages, including papules, vesicles, pustules, and crusts. The rash is considered distinctive because it includes a variety of lesions at different stages.

Rubeola, commonly known as measles, is an illness characterized by the three C’s: cough, conjunctivitis, and coryza. Fever and photophobia are also common. The blue-white Koplik spots found on the buccal mucosa precede the appearance of the maculopapular rash, which starts on the face and spreads caudally to the trunk and extremities.
Roseola is a mild illness characterized by a high fever that rapidly resolves. The fever is followed by the eruption of a characteristic rosy nonpruritic rash originating on the trunk and spreading to involve the extremities.
Rocky Mountain Spotted Fever is a rickettsial disease transmitted by tick bite. It is characterized by fever, myalgias, headache, and a petechial rash.
-Classically, the rash first involves the distal extremities (especially the palms and soles) and subsequently spreads to involve the trunk.

Henoch-Schönlein purpura
Classical clinical manifestations of Henoch-Schönlein purpura include abdominal pain, arthralgias, skin lesions, and renal involvement. An antecedent upper respiratory infection is present in 50% of patients. Abdominal pain is a presenting symptom in 10-15% of patients. The skin lesions are symmetric, involve dependent parts of the body, and classically progress from an erythematous, macular rash to papular purpura. The joints and kidneys are also commonly involved.

Thrombotic thrombocytopenic purpura (TTP) is a serious disorder characterized by the following classical pentad:
1. Severe thrombocytopenia
2. Microangiopathic hemolytic anemia (RBC fragments)
3. Fluctuating neurological signs
4. Renal failure
5. Fever
-Patients with TTP generally present with fever, pallor, petechiae, and confusion. The peripheral smear shows RBC fragments. PT and PTT are usually normal. The LDH is elevated due to hemolysis. Hemolytic uremic syndrome (HUS) and TTP comes under a spectrum of diseases. If a patient has more neurologic symptoms and less renal failure, the disease is considered TTP. On the other hand, if a patient has significant renal failure and less neurologic symptoms, the disease is considered HUS. Both TTP and HUS are very serious conditions, and require emergent plasmapheresis.

Idiopathic thrombocytopenic purpura
Platelet-specific autoantibodies are the presumed pathogenesis of idiopathic thrombocytopenic purpura. In children, the condition is typically characterized by a sudden onset of bleeding, manifested as petechiae, purpura, epistaxis, and gingival bleeding. More severe bleeding is rare. Commonly, there is a history of infection in the several weeks prior to presentation. Symptomatic patients with moderate to severe thrombocytopenia
►DD- Diaper rash (diaper dermatitis): is a type of irritant contact dermatitis that is caused by a combination of factors: overhydration, friction, maceration and prolonged contact with excretions. The appearance of the rash after an episode of diarrhea is very characteristic. Management includes keeping the diaper area of the skin as dry as possible. This involves: frequent changing of diapers, avoiding tight-fitting diapers, exposing the skin to air, using diapers with super absorbent surfaces, and applying barrier creams such as zinc oxide or petrolatum. An uncomplicated diaper rash resolves quickly if the abovementioned measures are performed. Otherwise, a low-potency corticosteroid ointment may be prescribed.
DD:
Candidal diaper rash: Tomato-red plaques and satellite papules are characteristic of candidal intertrigo and perineal infection. This infection is common in infants who have recently received antibiotic therapy because the decrease in the normal bacterial flora favors yeast proliferation.
The condition can be confounded with diaper dermatitis, which affects the same area but usually spares the crural folds. Treatment of candidal diaper rash involves the application of an antimycotic cream such as clotrimazole or nystatin, while zinc oxide is the preferred treatment for diaper dermatitis.
Intestinal parasitosis: due to Helminths (hookworms, roundworms, pinworms, or whipworms) is the most frequent cause of chronic diarrhea, iron-deficiency anemia, and eosinophilia in patients coming from endemic countries. The prognosis is excellent with adequate therapy. Since the disease is easily transmitted, prophylactic treatment should be given to the rest of the household members.

Hemophilia:
-Is an X-linked recessive disorder that occurs almost exclusively in males.
-Females are usually the carriers of the disease. A female may acquire hemophilia, an extremely rare possibility, only when her father is a hemophiliac, and her mother is a carrier who transmits the abnormal allele to her. -When a father is a hemophiliac, he will transmit his abnormal X gene to all his daughters, and consequently, they will all be carriers of the disease. -When the mother is a carrier, her daughters have 50% chances of being carriers and her sons have 50% chances of getting the disease.

Childhood absence epilepsy (CAE):
-Age of onset (4-8 years), no neurologic signs, typical EEG pattern, and no myoclonic activity.
-This condition is usually responsive to ethosuximide or valproate, although high doses may be required to control it effectively. Interestingly, many traditional anti-epileptic drugs are not effective in absence epilepsy, and can even exacerbate the condition (e.g. gabapentin).
-The prognosis in patients with CAE, especially if generalized tonic-clonic seizures are absent, is good.
-Staring spells will disappear in the teenage years. The risk of persistence of the condition is higher in patients who develop generalized tonic-clonic seizures.
-Unlike CAE, juvenile myoclonic epilepsy (JME) is characterized by a late onset of absence seizures with myoclonic activity, and is associated with life-long seizures.

Candidiasis:
-The first-line therapy for oral candidiasis is a topical antifungal - nystatin suspension or clotrimazole troches. Oral fluconazole can be used in resistant cases.

 Child abuse:
-Always maintain a high index of suspicion for physical/sexual abuse in children (especially females) with sudden behavioral problems, especially if the family has an unstable economic background or if the child’s parents have a history of drug/alcohol abuse.
**Whenever you suspect child abuse, it is strongly recommended that you inform the social services of your hospital or to call the child protection agency. Even if you are proved wrong later on, you do not owe any liability legally and, perhaps, it is the most important step in the management of suspected child abuse.

Allergic rhinitis:
Dog or cat dander is one of the most common identifiable allergen in patients with perennial allergic rhinitis.
Allergen avoidance is traditionally considered the first step in the management. If the allergen is not identified or the symptoms persist after the avoidance measures, nasal corticosteroids should be the first-line therapy.
Second-generation antihistamines and cromolyn are less effective than topical steroids.
 Nasal decongestive sprays are not recommended because tachyphylaxis usually develops and rebound phenomena may result.

♥Thalassemia major:
Patients with this disorder usually die early in life due to relentless anemia and catastrophic expansion of erythroid precursors.
Hypertransfusion therapy has a great role in treated patients (i.e. the child may survive several years after the diagnosis).
Hypertransfusion regimen can suppress the effects of chronic severe anemia and extramedullary hematopoiesis, but result in significant iron overload and resultant organ damage.

Failure to thrive (FTT):
Is not a diagnosis in itself; rather, it is a term used to describe failure to gain weight in children younger than two years old. Children categorized as FTT weigh less than the 5th percentile for their age; more severe cases involve a slowing of linear growth and head circumference as well.
The three causes of FTT are
1- inadequate calorie intake,
2- inadequate calorie absorption, and
3- Increased calorie requirements.
Newborn infants need 110 kcal/kg/day, while children up to twelve months need 100 kcal/kg/day to grow at a normal pace.
-Psychosocial factors are very commonly involved in cases of FTT; this is why the clinician must explore whether there are stressors in the home environment.
-Organic causes of FTT, while less common, may include feeding problems, milk-protein intolerance, and inborn errors of metabolism, infection, cystic fibrosis, gastroesophageal reflux, or renal tubular acidosis.
RX-Dietary modification is the first-line of treatment in an otherwise well-appearing child with FTT.
The anxiety caused to the family by admitting the child to the hospital should not be underestimated. Although admitting a child with FTT for hyperalimentation was a common practice in the past, it is now considered unnecessary unless the child is severely malnourished, or if the child is at risk for neglect or abuse.
If oral feedings doDietary modification is the first-line of treatment supplementalnot result in appropriate weight gain within four to six weeks, feeding by nasogastric tube is preferred to the intravenous route.
-If the history and physical examination are suggestive of an organic cause for the then laboratory evaluation is warranted. Appropriate tests includechild’s FTT, urinalysis and culture, hematocrit, blood urea nitrogen, calcium, electrolyte levels, HIV ELISA test, and Mantoux tuberculin skin testing.
-Note that unless there is clinical evidence suggestive of thyroid disturbance, thyroid hormone levels are not typically tested.

Cat bites:
Get infected most of the time. Furthermore, the lesion is usually deeper than when produced by a dog, because the cat’s teeth are smaller and sharper. Pasteurella multocida, the major causative organism, is transmitted by the cat’s bite. However, this is often a polymicrobial infection.
-Adequate prophylaxis can be obtained by using amoxicillin and clavulanic acid.
-In adults, especially those allergic to penicillin, the second alternative is doxycycline. More ill patients can be treated with intravenous ampicillin-sulbactam combination.
** The incidence of infection complicating a cat bite is close to 50%; therefore, antibiotic prophylaxis is usually recommended, especially in high-risk situations (a hand bite is considered a high-risk situation) wherein the potential infection could extend to the bone and joint. The first dose of antibiotics (e.g. ampicillin/sulbactam) is usually given parenterally, and covers a broad spectrum of cat mouth flora, including Pasteurella multocida. An oral antibiotic (e.g. amoxicillin/clavulanate) is administered subsequently for 3-5 days.

Cat-scratch disease:
Is an infection that usually affects the young immunocompetent population. It is produced by Bartonella henselae. Around 10% of the patients with cat-scratch disease can develop suppuration of the lymph nodes. Other complications are: visual loss due to neuroretinitis, encephalopathy, fever of unknown origin, and hepatosplenomegaly.

Gastroesophageal reflux (GER) is a clinical diagnosis.
Reassurance should be offered to the mother that the "spitting up" is a normal occurrence in infants up to 24 months old. It typically requires no intervention if the child is otherwise healthy and developing appropriately (the "happy spitter").
-Children with mild GER symptoms, should be initially addressed with reassurance and thickening of formula with cereal, which usually results in decreased emesis, decreased cry, and better weight gain.
-Prone positioning is another conservative treatment that may alleviate symptoms; however, this treatment method is of some concern, because of the correlation between prone positioning and SIDS.
-Formula thickening should be attempted first.
-H2 receptor antagonists such as ranitidine are appropriate in those infants with a more severe GER presentation and who have failed conservative treatment.
-Surgery is reserved for cases of GER that do not respond to medical management.

Pneumonia:
-It can be difficult to distinguish between bacterial and viral pneumonia, and indeed viral pneumonia is very common in previously healthy children and adults.-Classically, bacterial pneumonias are sudden in onset, associated with high fevers, and cause the child to look very ill if not toxic.
-Auscultatory findings are typically focal and distinctive. -Chest radiographs may demonstrate a lobar consolidation. In contrast, viral pneumonias are gradual in onset and cause the child to look mildly ill.
-Auscultatory findings are more diffuse and bilateral. -Chest radiographs may also demonstrate a more diffuse, bilateral infiltrate. Both forms of pneumonia are frequently preceded by an upper respiratory tract infection.
►Community-acquired bacterial pneumonia in children is most commonly caused by S. pneumoniae. Amoxicillin is the drug of choice for the outpatient treatment of patients younger than five years of age
►Group B streptococcus pneumonia occurs most often in neonates.
►Mycoplasma causes respiratory infection most often in school-aged children and young adults. The clinical presentation is usually gradual (although it may be abrupt) and is characterized by malaise, headache, fever, rhinorrhea, and sore throat with progression to lower respiratory symptoms.
►Pneumocystis carinii pneumonia (PCP) is seen in patients with defects in cell-mediated immunity, especially in HIV-infected patients. It is usually seen in HIV patients when the CD4 cell count decreases to less than 200 cells/cubic mm. It has an insidious onset, and usually presents with low-grade fever, cough, dyspnea, and tachypnea.
-Chest x-ray results of patients with PCP reveal diffuse, bilateral ground-glass opacity.
-Trimethoprim-sulfamethoxazole is the initial drug of choice for treatment in patients with suspected or proven Pneumocystis carinii pneumonia.


Respiratory syncytial virus
-Are the most important respiratory pathogen of early childhood, and the major cause of bronchiolitis and pneumonia in children < 1 year. The illness manifests in annual outbreaks, appearing in winter with peaks in January, February, or March. Although this disease affects all age groups, lower respiratory symptoms appear mainly in children. Apnea is an important clue for this condition, as up to 25% of infants presenting with RSV infection will have this. How it causes significant apnea is not clearly known. The illness tends to be more severe, with a higher frequency of complications in preterms and infants with chronic medical conditions such as congenital heart disease, chronic lung disease, and immune deficiencies.
-Diagnosis of RSV is quickly made by detection of RSV antigen in nasal or pulmonary secretions by ELISA.
-RX-**
-In healthy infants and young children, bronchiolitis is usually a self-limited disease; however, patients who are hypoxic or cannot feed because of distress should be hospitalized.
-These children should be kept in respiratory isolation. Humidified oxygen andTherapy in most cases consists of supportive measures. tube or intravenous feedings are indicated.
-Although there is no strong evidence that inhaled bronchodilators are effective in patients with bronchiolitis, it is a routine practice to administer these (nebulized albuterol or epinephrine) and observe the patient for any effect. If no prompt clinical response is seen, most clinicians discontinue these drugs.
-Although ribavirin is a nucleoside analogue with good in vitro activity against RSV, studies examining its effect in children have been conflicting, and the cost for a course of therapy is substantial. It is usually reserved for patients with severe disease.
COMPLICATIONS, RISKS:
-A secondary bacterial infection of the middle ear and future risk of bronchial hyperreactivity are the most common complications of RSV bronchiolitis.

Congenital toxoplasmosis:
The consumption of undercooked meat during pregnancy may be associated with congenital toxoplasmosis, which can manifest as microcephaly or other abnormalities, such as chorioretinitis, mental retardation, deafness, and seizures. Domestic cats are definite hosts for T. gondii. Humans can acquire the infection by:
(1) the consumption of raw or undercooked meat of infected animals (including lamb, beef, or game), or
(2) Contact with cat feces. Other congenital infections of the TORCH group can also result in microcephaly.

Rheumatic disease prophylaxis:
The benefits of antibiotic therapy in a child with acute pharyngitis include:
(1) Reduction of the severity and duration of the symptoms,
(2) Prevention of rheumatic fever, and
(3) Prevention of local suppurative complications.
Interestingly, antibiotic therapy does not decrease the risk of acute glomerulonephritis because cutaneous (not pharyngeal) infection is typically implicated as its cause.
Disease associations:
o Meconium ileus
Is usually the earliest manifestation of cystic fibrosis (CF), and is almost pathognomonic for the disease. Uncomplicated meconium ileus is characterized by distal intestinal obstruction, wherein the terminal ileum is dilated and filled with thick, tar-like, inspissated meconium. Plain abdominal x-ray findings (dilated, gas-filled loops of small bowel, absent air-fluid levels, and a meconium mass within the right side of the abdomen) are usually suggestive of the diagnosis. Since CF is inherited in an autosomal recessive pattern, a family history of recurrent respiratory infections (or other manifestations of CF) is an important clue to the diagnosis of this patient.
o Duodenal atresia is associated with Down’s syndrome and polyhydramnios
-A family history of severe constipation is sometimes present in patients with Hirschsprung’s disease.
Patients with pyloric stenosis are typically firstborn males.
-Even though most cases of muscular dystrophy such as Duchenne’s, Becker’s, or myotonic dystrophy present around 10-12 years of age, some cases can be diagnosed when the child is 2-3 years old. Limb-girdle or facioscapulohumeral muscular dystrophies can be detected at this age; while congenital dystrophies and glycogen-storage diseases are evident soon after birth, and have early mortality.
-Muscular dystrophy can be a cause of inability to walk or limping in the infant or toddler, even though the more common cause of this problem is spasticity, a condition amenable to rehabilitation therapy. Hypothyroidism, MSUP and phenylketonuria must be screened for at birth, and are almost always accompanied by mental retardation and global delays in development.

o Neonatal screening for hypothyroidism
-Is performed by obtaining a small sample (few drops) of blood from the heel pad and using a piece of filter paper to absorb the blood sample. This test may be done within two to five days following delivery. It is performed after the first 24 hours of life because there is a normal physiologic TSH surge following delivery. After 24 hours, the TSH levels gradually drop to normal levels or may remain slightly elevated for the next few days. It is very important to avoid any delays in the diagnosis and treatment to avoid permanent neurological deficits.
Most centers in the United States use total T4 measurement as a primary tool for screening for neonatal hypothyroidism. If the total T4 levels are low, TSH levels of the same sample is measured, and if the TSH levels are over 20 U/L, repeat testing (measurement of both Free T4 and TSH levels) is performed from a regular blood draw to confirm the diagnosis.
Some programs use TSH as a primary screening tool.
☻Once the diagnosis of neonatal hypothyroidism is confirmed by measuring the Free T4 and TSH levels from a regular blood draw, other ancillary procedures such as thyroid ultrasonography, radioactive iodine scanning and urinary iodide levels are performed to investigate the etiology of the hypothyroid state. Radioactive iodine uptake and scanning are useful to determine the location, size and function of the thyroid gland.
Levothyroxine is the treatment of choice for hypothyroidism, and the dose in the neonate is higher than the adult dose; however, levothyroxine therapy should be started once the diagnosis is confirmed with a regular blood draw. The clinical features of hypothyroidism in neonates can be subtle and unreliable.
-Levothyroxine therapy in neonates is therefore started once the biochemical confirmation is obtained, even if the clinical features of hypothyroidism are not present.

Febrile seizures
The generally accepted criteria for febrile seizures are:
1. Age less than six years
2. No past history of afebrile seizures
3. Temperature greater than 38 C
4. No evidence of CNS infection / inflammation
5. No metabolic disturbances present which may produce seizures

**Febrile seizures may be subdivided into 2 forms: simple and complex.
A simple febrile seizure is characterized by the absence of focal features, duration of less than 15 minutes for an isolated event, and for seizures occurring in series, a cumulative duration of less than 30 minutes. This form of seizures is more common, and is associated with only a mild elevation of the risk for subsequent epilepsy (i.e. afebrile seizures) in latter life, compared to the general population,contrary to previous thinking.
It is important to note that the question specifically asks about prognosis, and not recurrence. If the question particularly asks about the recurrence of febrile seizures during childhood, then the answer would be “significantly elevated risk”, regardless if this case was a simple or complex febrile seizure for the first time.
Febrile seizures often occur on the first day of a mild illness as the child’s temperature is rising, and may be the first manifestation of illness.
-Generally, studies are not necessary for the evaluation of the simple febrile seizure, although it may be appropriate to explore the cause of the fever in children with other symptoms (e.g., severe diarrhea).
►Parents should be reassured that it is not an indication of future neurologic dysfunction or disease.
Complex febrile seizures, on the other hand, are characterized by focal features (i.e. postictal paresis), a duration of more than 15 minutes, and if occurring in series, a cumulative duration of greater than 30 minutes.

Congenital adrenal hyperplasia (CAH)
Is a group of disorders characterized by a deficiency in one of the enzymes involved in steroid synthesis. In 90% of cases, the deficiency concerns 21-hydroxylase, which is necessary in mineralocorticoid and glucocorticoid synthesis.
In addition to a low production of mineralocorticoids and glucocorticoids, the deficiency of 21-hydroxylase results in an excess of its substrates.
These excess substrates are shunted towards androgen synthesis, resulting in ambiguous genitalia and virilization in females, and precocious puberty in males.
-ACTH levels are also evidently elevated, and lead to hyperplasia of the adrenal glands, further contributing to the increased production of androgens.
-Salt wasting syndrome occurs in severe deficiencies. It presents in the first 2-4 weeks of life with emesis, dehydration, and shock. Laboratory work-up reveals hyponatremia and hyperkalemia (from lack of aldosterone), and hypoglycemia (from lack of cortisol).
-Diagnosis confirmation of 21-hydroxylase deficiency is carried out by documenting the elevation of 17 alpha-hydroxyprogesterone, a substrate of 21-hydroxylase.
-Other biologic disturbances occurring in 21-hydroxylase deficiency include elevated corticotropin and renin levels, and a serum aldosterone level that is inappropriately low for the renin level.
-RX-The treatment principle for 21-hydroxylase deficiency is based on supplementation of deficient hormones (mineralocorticoids and glucocorticoids). This supplementation will decrease corticotropin (ACTH) production, and consequently correct androgen levels.
11-hydroxylase deficiency is a far less frequent cause of CAH than 21-hydroxylase deficiency. It is characterized by:
(1) Decreased aldosterone and cortisol, and
(2) increased androgens and deoxycorticosterone.
-A deficiency in 11-hydroxylase results in an excess in its substrate, 11-deoxycorticosterone. This substrate has mineralocorticoid activity.
-Patients with this condition present with hypertension, hypernatremia, and hypokalemia.
3-beta-hydroxysteroid dehydrogenase is a rare cause of CAH. It involves:
(1) a decrease in testosterone, mineralocorticoids and glucocorticoids, and
(2) an increase in DHEA-S.
-Consequently, males fail to acquire normal external genitalia because of a lack of testosterone, and females are slightly masculinized because of DHEA-S excess.

Marfan syndrome (MFS):
A disease characterized by arachnodactyly, increased arm span relative to height, and valvular (mitral or aortic) insufficiency.
♥ Associations:
1-Dural ectasia is the most common finding, although frequently overlooked (present in more than 90% of patients), and usually requires an MRI of the lumbar spine for the confirmation of the diagnosis.
2-Other characteristics that can affect up to 80% of the patients with MFS are ectopia lentis, aortic dilatation (more frequent in adults), and mitral valve prolapse.
-The risk of aortic dissection is high in patients with MFS.
-For this reason, corrective surgery is recommended when the aortic root reaches 45 mm.
-About 80% of the patients will have mitral insufficiency, which can lead to CHF.
-These patients will benefit from mitral valve replacement.

Diaphragmatic paralysis in a newborn
-usually results from phrenic nerve injury
-The two most common causes of phrenic nerve injury are birth injury and cardiothoracic injury
-It is typically accompanied by the signs of brachial plexus injury, like Erb’s palsy.
-Other causes of diaphragmatic paralysis (diaphragmatic hypoplasia, neural and neuromuscular disorders) are very rare.

Myelomeningocele:
-In 80% of myelomeningocele cases, the lumbar region is involved.
-Almost all these patients will have bladder dysfunction, which can ultimately lead to upper urinary tract involvement and renal dysfunction.
-Children with S2-S3 involvement can have external anal sphincter dysfunction that can lead to fecal incontinence.
-This is a much less common complication than bladder involvement, and is specifically associated with S2-S3 involvement.

 Giardiasis
-Have several routes of transmission: person-to-person, food-borne and waterborne.
-Person-to-person transmission occurs in two settings:
(1) In institutions where there is fecal incontinence and poor hygiene (e.g., some daycare centers), and
(2) In male homosexuals.
-Symptomatic patients with giardiasis should receive appropriate treatment.
=Asymptomatic carriers of Giardia lamblia are not usually treated, except in specific instances such as in outbreak control and for prevention of household transmission by toddlers to pregnant women and patients with hypogammaglobulinemia or cystic fibrosis.


Severe malnutrition:
-Remains as one of the major health problems in developing countries
-The initial treatment of patients with severe malnutrition should address the following issues:
-temperature control (warming), possible infection, dehydration and malnutrition (feeding)
-Dehydration should be treated with oral rehydration whenever possible.

Posterior urethral valves
Are predominantly found in males and is the most common cause of severe obstructive uropathy in children. The abnormal development of the valves in utero can obstruct urinary flow, leading to detrusor hypertrophy and, eventually, vesicoureteral reflux and hydronephrosis. Hallmarks of PUV include a distended bladder and a weak urine stream.
Voiding cystourethrogram (VCUG) is a radiographic examination of the bladder and lower urinary tract. The bladder is filled with contrast material by catheter and multiple radiographic images of the bladder and urethra are obtained as the patient empties the bladder. VCUG is especially helpful in evaluating young children for vesicoureteral reflux and posterior urethral valves.

Foreign body aspiration:
Never forget your ABCs of resuscitation no matter what the nature of emergency is.
The Heimlich maneuver is recommended in kids older than one year. ==.Below that age, give blows on the back with chest thrusts.
If the child is unconscious, do it while the patient is lying down.
-After the abdominal thrusts, examine the airway for a foreign body. If visualized, it should be removed.

Transient synovitis (also known as toxic synovitis)
Is a common condition that causes pain in the hip, thigh, or knee in boys aged 3-10 years old. Up to 25% of children with transient synovitis will have bilateral effusions. The disorder may be preceded by a respiratory infection, although the erythrocyte sedimentation rate (ESR) and white blood count (WBC) are typically normal. If the clinical presentation suggests transient synovitis and plain radiographs are unremarkable, an ultrasound should be performed. Ultrasonography is the preferred technique for identifying small joint effusions, and may demonstrate widening of the joint space of the hip. This modality is also useful in guiding aspiration of the joint, a procedure that is warranted in a febrile child with hip effusion.

Breastfeeding issues:
-Every primary care physician It is recommended that the infant be fed atshould encourage breastfeeding. least every 4 four hours. The mother should be able to identify early signs of hunger, like suckling of the hand or fingers or arm movements towards the mouth, as preterm or debilitated infants may not be able to cry vigorously or show agitation. Cry is a late sign of hunger!
-It is a good practice to feed the newborn using both breasts, as complete emptying of the breast will increase the milk’s nutritional qualities. Unfortunately, sometimes there may be a decreased production of milk, and the baby has to be fed using artificial formula. BUT; Feeding the baby using both breasts will therefore not guarantee the infant’s satiety.

Neonatal jaundice
♥ If Appearing in the first 24 hours of is always pathologic.birth
- Immune or non-immune hemolysis is frequently present in such patients.
G-6-PD deficiency is the most common red cell enzymopathy that can lead to hemolysis. It is an X-linked disorder, and should be suspected in a male infant of African, Mediterranean, or Asian descent.
-No triggering agent is usually present, although those infants who develop severe jaundice with G6PD deficiency usually have Gilbert"s syndrome as well.
Physiologic jaundice manifests 24 hours after birth.-

 Enterovirus and Arbovirus infections
-Is the most common cause of viral meningitis or encephalitis in the pediatric population.
-These infections are more frequent during summer, late spring, and early fall. Most arbovirus infections are zoonosis (transmitted through animal vectors); for this reason, these infections are more common in the rural areas. -Herpes simplex virus is the most common cause of viral meningitis in the adult population, not in children.


Sickle cell disease
-Is an inherited disorder that results from the presence of hemoglobin S.
-The most severe and common form is sickle cell anemia, in which only hemoglobin S is present (HbSS).
-TRAIT: HbS, HbA
-Clinical manifestations rarely present prior to 6 months of age, when fetal hemoglobin levels decline and functional asplenia typically develops. Dactylitis (pain in the hands and feet) is common in the first 18 months of life. The best diagnostic test is hemoglobin electrophoresis because it precisely determines which form of sickle cell disease is present.

 Acute severe anemia
May be superimposed on chronic anemia in patients with sickle cell disease
When this occurs, it is a life-threatening condition.
Clinical manifestations include weakness, pallor and lethargy. The three typical causes of acute anemia are splenic sequestration crisis, aplastic crisis, and hyperhemolytic crisis.

Aplastic crisis
Represents a transient failure of erythropoiesis with an abrupt reduction in the blood hemoglobin and the number of erythroid precursors in the bone marrow. A very important finding during a crisis is the virtual absence of reticulocytes. The typical cause is an infection; parvovirus B19 infection is the most common cause in children.

Intussusception
Occurs when a part of the small bowel is telescoped into itself
The most frequent vicinity is the ileocecal region. Almost 60% of the cases occur in children younger than 1 year of age, while 80% present before 2 years of age.
The classic presentation is a sudden onset of colicky abdominal pain followed by vomiting, and the vomitus rapidly changes from alimentary to bilious.
The child usually draws up his legs towards the abdomen because of the pain.
Hematochezia is present in 70% of the cases; 15% of the patients have the characteristic "currant jelly" stools. Initially, the child is irritable, but he may eventually become apathetic when he is no longer able to eat, and he gets dehydrated.
Palpation of a sausage-shaped abdominal mass on the right side is characteristic.
Abdominal x-ray reveals generalized distension of the bowel loops or another evidence of obstruction. An enhanced density that projects into the air level of the large bowel can be identified in 25% of the cases. This density represents the invaginated bowel loop, and is known as the "crescent sign."
DD: Acute gastroenteritis (AGE) presents with fever that precedes abdominal pain and diarrhea. AGE will not explain the presence of the abdominal mass and the massive bowel distention seen in the abdominal x-ray of this patient.

Meckel’s diverticulum
Usually presents in toddlers and older children, generally between five and ten years of age, and in young adults.
The most common location of pain is in the right lower quadrant.
Hematochezia is also present, but the stool is non-mucoid, and there is no palpable abdominal mass.

Erb’s palsy:
The classical scenario of Erb’s palsy is described. It is the most common form of obstetrical brachial plexus injury and involves the upper roots (C5, C6, and sometimes C7) of the plexus resulting in an adducted and internally rotated right arm with forearm pronation and flexed wrist. -A serious complication is diaphragmatic paralysis due to phrenic nerve involvement.
-Symmetric palmar grasp reflex indicates that lower roots of the brachial plexus are intact and is a good prognostic sign. The prognosis of Erb’s palsy is typically good with an 80% chance of full or near-full recovery.
Horner’s syndrome may be associated with the injury of lower roots of the brachial plexus.

Gastrointestinal foreign bodies
-Occur typically in toddlers, because exploring objects by putting them into the mouth is a characteristic behavior pattern in that age group. Coins are the most common GI foreign bodies.
-Foreign bodies can become lodged in any of the areas of esophageal physiologic narrowing. They require attention and frequently removal in that case. Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty.
-Pyloric obstruction is rare and manifests as persistent vomiting.
Up to 90% of foreign bodies that have made it into the stomach will be passed without difficulty; therefore, no intervention is usually necessary.

Cellulitis:
Is characterized by its irregular and elevated borders, as well as increased local temperature, tenderness, and erythema.
-It is an infection located between the subcutaneous tissue and the fat, therefore local anesthesia will not be useful in this situation. Pain can be treated by oral analgesics.

 Cleft lip with or without cleft palate
-Is typically a multifactorial disorder but can have autosomal dominant, autosomal recessive, and X-linked inheritance, as well as be associated with teratogenic agents.
-Reconstruction of a cleft lip is generally performed at approximately three months of age according to the rule of ‘10:’ 10 lbs of weight, 10 weeks of age, and 10 g of hemoglobin.

The reticulocyte count is an index of RBC production by the bone marrow.
Increased destruction of RBCs (hemolytic anemia) prompts the normal bone marrow to compensate for the loss by increasing the rate of erythropoiesis, which results in an increased reticulocyte count. On the other hand, nonhemolytic anemias, due to a decreased production of RBCs, will result in a low reticulocyte count. The reticulocyte count is therefore increased in hemolytic anemia, and decreased in nonhemolytic anemia.

Diabetic ketoacidosis (DKA)
Must be suspected in any child with dehydration, metabolic acidosis, nausea, vomiting, tachypnea without oxygenation problems, abdominal pain, and hyperglycemia.
Patients must be immediately admitted to the Intensive Care Unit for correction of the metabolic acidosis and dehydration.
Treatment involves intravenous fluids and insulin administration, as well as adequate potassium supplementation (to avoid hypokalemia).

Botulism:
Giving honey to the child is the main clue to the diagnosis.
Constipation is typically the first manifestation of the disease, and is followed by lethargy, poor sucking and weak crying.
Gag reflex is frequently impaired.
This may result in aspiration if airways are not protected.

►Neonatal conjunctivitis is classically due to one of three causes (though typical adult bacterial and viral etiologies are also possible during the neonatal period):
1. ChemicaI reaction. Silyer nitrate. erythromycin or tetracycline drops are given prophylactically to newborns to prevent gonorrheal conjunctivitis, The drops may cause a chemical conjunctivitis (with no purulent discharge). wllich develops within 6-12 hours of instilling the drops and resolves within 48 hours. Chemical reaction is "always the answer if conjunctivitis in the first 24 hours of lives
2. Gonorrhea. Look for symptoms of gonorrhea in the mother. The infant has an purulent discharge that start 2-5 days off a birth.
-Treatment is topical (erythromycin ointment) plus IV or 1M third-generation cephalosporin (e.g .. ceftriaxone).
-lnfants who are given prophylactic drops should not develop gonorrheal conjunctivitis.
3. Chlamydial infection
The mother often reports no symptoms. The infant has mild-to-severe conjunctivitis.
Prophylactic eye drops do not effectively prevent Chlamydia conjunctivitis.

USMLE WORLD STEP 3 NOTES
Surgery

Normally, the parents or legal guardian of a minor must provide voluntary, informed consent for treatment and most medical tests or procedures. However, if immediate medical care is necessary to prevent serious harm or death, consent is always assumed.

Prostate Ca
Patients with PSA levels greater than 4 ng/ml, should be referred to an urologist for biopsy.
Radical prostatectomy is a treatment option for early prostate cancer. Pretreatment tests include biopsy of the tumor and a CT scan.
Urinary incontinence and erectile dysfunction are two common complications of radical prostatectomy, which is used for the treatment of early prostate cancer.
Retrograde ejaculation is the most frequent complication of transurethral resection of the prostate, and all patients should be made aware of this

►Suprapubic resection of the prostate is the currently accepted therapy for patients whose prostate cancer was diagnosed through TURP, needle biopsy, or cytology. This procedure is accompanied by lymph node resection, which can be preceded by sentinel lymph node identification through technetium radio labeling for a higher yield.
►Radiotherapy, estrogens, and chemotherapy are measures reserved for more advanced stages of the disease.

Testicular Ca
-The differential diagnosis of testicular swelling includes entities such as epididymitis, hydrocele, testicular torsion, varicocele, hernia or hematoma.
-A painless testicular mass is considered as cancer unless proven otherwise.☻
-The first step in the evaluation of males with testicular swelling is a scrotal Ultrasound, which helps in differentiating intra- and extra- testicular lesions. Cystic or fluid-filled lesions are unlikely to be cancerous.
►If the lesion appears suspicious on ultrasound, it is followed with:
1. -CT scan of the abdomen and pelvis (to detect retroperitoneal lymph nodes metastasis)
2.- Measurement of serum tumor marker levels (alpha fetoprotein, beta hCG).
►If scrotal ultrasound and Radical inguinal orchiectomy is doneserological tests confirm the suspicion to provide a histological diagnosis.

Epididymitis
-is an infection characterized by testicular pain and tenderness, hydrocele, and a tender, swollen epididymis.
-No irritative voiding symptoms are usually present, and urinalysis is normal.
-Dramatic presentation characteristics for acute bacterial epididymitis with severe scrotal pain, fever, and voiding symptoms are less common.
The most common cause of epididymitis is Chlamydia trachomatis.
Prehn"s sign (decrease in pain on testicular elevation) is usually present [but not universally present] and cremasteric reflex is intact.
When there is an apparent increase in testicular size, transillumination of the testicle can be done to determine the presence of a hydrocele or malignancy.
Treatment of epididymitis is done with ceftriaxone and doxycycline because Chlamydia trachomatis and Neisseria gonorrhoeae are the usual pathogens involved. In any case, antibiotic therapy must not be started until transillumination is done, and the possibility of a malignancy is ruled out.

Testicular torsion
-Is characterized by sudden development of moderate-to-severe pain
-High-riding testis can usually be palpated on the affected side.
-Cremasteric reflex is usually absent.
-In equivocal cases, color Doppler ultrasonography is helpful.

Varicocele
-presents as dull scrotal pain relieved by recumbency.
-A soft scrotal mass can be palpated (’bag of worms’) that disappears in the recumbent position.
-Besides that, varicocele is left-sided or bilateral in a vast majority of cases.

Cryptorchidism
-Cryptorchidism (undescended testis) is a common problem. It affects 4% of newborn infants, but the majority of cases resolve spontaneously during the first several months of life.
-Spontaneous descent is rare after six months of age.
-The complications of undescended testis include decreased fertility, increased risk of testicular torsion, inguinal hernia, and malignant transformation.
-RX-Early orchiopexy helps to prevent testicular torsion and infertility.
-Risk of malignancy: Although the risk of malignant transformation may decrease a little after the surgery, it remains higher than that of the general population. At the same time, the surgery makes it easier to examine the testis.
-Orchiopexy can be performed as early as six months of age, but definitely before two years of age
oral lesion

The most common cause of oral lesions in elderly patients is trauma.
-People who wear dentures all the time are more prone to develop such lesions.
-The most appropriate next step is to advise the patient to remove her dentures for one to two weeks, after which reevaluation is necessary.
►If the lesion does not subside, the patient should have a biopsy to rule out malignancy.

Intravenous nutrition
-The most dangerous metabolic complication, hyperglycemia, is most commonly caused by too rapid initiation of the infusion. This complication is best prevented by initiation of the infusion at 40-60 ml per hour, and slowly increasing the rate at 20 cc/hour every 24 hours, while monitoring glucose. Patients with normal glucose tolerance may manifest glycosuria for the first 48 hours of parenteral nutrition. Before initiating insulin, one must verify that the glucose level is high, and that glycosuria is not secondary to a reduced renal threshold for glucose.
The most common cause of sudden hyperglycemia is sepsis, and hyperglycemia may antedate other signs of sepsis within 24 hours. The sudden appearance of hyperglycemia should initiate a thorough search for the source of infection. The infection may be due to line sepsis, pneumonia, wound infection, or another process. Blood cultures and a thorough examination of the patient are required
Hypophosphatemia
-Is reported to occur in 30% of patients receiving intravenous nutrition. The mechanism is enhanced phosphate uptake into cells associated with enhanced glucose uptake. The consequences of hypophosphatemia include respiratory weakness, hemolysis, and impaired oxygen release from hemoglobin. These may be particularly prominent when serum phosphate falls below 1.0 mg/dL. Phosphate supplementation in the diet will prevent these complications.
A fatty liver can be seen when glucose infusions exceed the daily caloric requirements. This is because of the production of fatty acids from excess glucose and the impaired ability to mobilize the fat for energy needs. Fat accumulation eventually leads to abnormal liver enzyme elevations in the serum, particularly alkaline phosphatase.
Carbon dioxide retention can develop when excess glucose is given to patients with severe lung disease. Glucose metabolism produces a larger quantity of CO2 for each liter of O2 consumed than the other two nutrient substrates. When the ability to eliminate CO2 via alveolar ventilation is impaired, this enhanced CO2 production of carbon produces hypercapnia, and the impaired ability to wean from mechanical ventilation.

Acute cholangitis
-This condition is characterized by Charcot’s triad: right upper quadrant pain, fever and jaundice. Charcot’s triad is present in 50-75% of the cases of cholangitis.
-Hypotension and confusion may develop due to sepsis. When these two signs occur with Charcot’s triad, the patient is said to have Reynold’s pentad, which has a 50% mortality rate.
-Elevated levels of direct bilirubin and alkaline phosphatase, without a rise in the aminotransferases, confirms the presence of an extrahepatic obstruction.
Treatment of cholangitis is begun with adequate hydration, strict vital signs monitoring, and immediate antibiotic therapy.
A blood culture should be taken before starting antibiotics. The preferred empiric antibiotics are ampicillin + gentamicin or monotherapy with imipenem or levofloxacin.
In 80% of the cases, the cholangitis is controlled within 24 hours.
An elective endoscopic retrograde cholangiopancreatography (ERCP) is then scheduled. If the patient does not improve, an urgent biliary decompression is necessary.
Decompression is achieved through biliary drainage, and is usually done through ERCP due to its lower morbidity rate of 10% (compared with 50% morbidity rate via surgical drainage).

Rectal prolapse
-Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue slides through the anal orifice. It is usually associated with conditions causing increased intraabdominal pressure such as chronic straining with constipation, benign prostatic hypertrophy, and COPD.
-It usually presents with difficulty with defecation, diarrhea/fecal incontinence, pain in the anal area, rectal bleeding, and a protruding rectal mass.
-Untreated complete rectal prolapse can lead to strangulation and gangrene of the rectal mucosa.
-Uncomplicated prolapsed rectal mucosa can be reduced by gentle digital pressure.
-Adequate local anesthesia and sedation help reduce the prolapsed mucosa.
-Topical application of granulated sucrose helps reduce the mucosal edema and makes manual reduction easier.
-Irreducible prolapsed mucosa and gangrene of the mucosa warrant a prompt surgical consultation.
-The prognosis is generally good with prompt and appropriate care.

 Knee
-Medial collateral ligament injury is associated with tenderness and pain along the medial joint line. This common condition is most frequently caused by an injury involving valgus (abductor) stress to the partially flexed knee with the foot fixed.
-Such an injury can occur while skiing or during contact sports, when another person falls across the knee from the lateral to medial direction.

Anterior cruciate ligament injury
-Is associated with pain and laxity upon performance of the Anterior drawer or ‘Lachman maneuver’.
-This condition most frequently occurs after noncontact deceleration, a cutting movement, or hyperextension. It may be accompanied by a "popping" sound.

Posterior cruciate ligament injury
-Is associated with little pain or alteration in range of motion, but the posterior drawer test is positive.
-This uncommon condition occurs from a posteriorly directed force on a flexed knee (e.g., the dashboard being struck by the anterior of the flexed knee in a motor vehicle accident) or from hyperextension.

 Lateral collateral ligament injury
-Is associated with tenderness and pain along the lateral joint line.
-This uncommon condition is most frequently caused by an injury involving dramatic varus (adductor) stress.

 Meniscal injuries
-Principally occur after a twisting injury to the knee with one foot fixed to the ground (e.g. with sudden turning while running). The medial meniscus is more commonly injured, as compared to the lateral meniscus. A bucket handle tear is the most common type of medial meniscus tear.
-Patients generally complain of pain and swelling of the knee, and a popping sensation at the time of injury. In medial meniscus injuries, tenderness is generally felt along the medial side of the knee.
-Effusion with meniscus injuries takes about 24 hours to form, and is often not significantly bloody, unlike ACL or osteochondral injuries.
-Locking of the knee joint on extension is generally seen.
-McMurray’s sign is snapping felt with tibial torsion and the knee flexed at 90 degrees.

Prepatellar bursitis
-Is an inflammation of the largest knee bursa.
-This condition is most frequently caused by trauma from a fall or secondary to prolonged friction and pressure from repetitive kneeling ("housemaid’s knee").

O’ Donohue’s unhappy triad
-Typically occurs after a lateral knee injury, resulting in an Anterior cruciate ligament tear, a medial (Tibial) collateral ligament injury, and a Medial meniscal injury. Remember "MAT".

►Acute compartment syndrome
Acute compartment syndrome refers to ischemic tissue damage secondary to elevated pressures in the enclosed compartments of the lower legs or forearm. When the tissue pressure in an enclosed compartment exceeds the perfusion pressure, the resulting diminished tissue perfusion and compromised blood flow to the muscles and nerves inevitably lead to ischemic tissue necrosis.
Majority of the cases involving the lower extremities are due to a traumatic event, most commonly tibial fractures.
Other causes include a crush injury or other long bone fractures in a motor vehicle accident, a tight cast or dressing after trauma, and drug overdose.
Patients usually present with severe pain which is out of proportion to the extent of injury. The pain is typically worsened by passive movements of the involved muscles. Sensory nerves are usually affected earlier than the motor nerves, and the neurologic deficit presents as decreased vibration sense, decreased two-point discrimination, numbness or hypoesthesia.
extremity paralysis and Late features include  absent distal pulsation (pulseless paralysis). [Ominous sign]
 Complications: Rhabdomyolysis and subsequent development of acute renal failure is one of the most common and severe life-threatening complications of acute compartment syndrome.
►Laboratory studies
Typically reveal markedly elevated CK creatinine kinase levels and the presence of myoglobin in the urine (positive dipstick for blood in the absence of RBC’s in the urine).
Direct measurement of the compartment or tissue pressure is the diagnostic procedure of choice for patients with suspected acute compartment syndrome. The exact value for the tissue pressure at which blood flows to the muscle and nerve tissue stops is controversial. The current general consensus for the threshold value is greater than 30 mmHg. It is therefore important to measure the tissue or compartment pressure early in the course of management, especially if the diagnosis is in question.
►RX: Acute compartment syndrome is a surgical emergency. Any delay in treatment leads to irreversible muscle and nerve damage.
-A compartment pressures of 30 mmHg or greater warrants an emergent fasciotomy (also known as compartment release).
-Surgical decompression aims to relieve the pressure within the enclosed compartment and to restore the blood flow to muscles and other tissues within 6-10 hours of the initial symptoms. -Some patients may develop a persistent sensory or motor deficit after an episode of acute compartment syndrome despite early fasciotomy.

 Replantation
♥As a general rule, all amputated body parts should be retrieved and brought to the emergency room. Since the thumb or finger amputation can especially compromise the function of the hand, all attempts should be made to retrieve and replant the digit in the hope to preserve function.
►For transportation purposes, the amputated part should be wrapped in saline-moistened sterile gauze and sealed in a sterile plastic bag.
►After adequate steps have been taken to preserve the severed finger; it should be sealed in a plastic bag and placed on ice in a container.
►The severed part should never be placed directly on ice, as this could lead to injury to the vessels and other tissues. It should also not be immersed in water as this may make the replantation technically more difficult.


Breast mass
-Cysts that disappear completely, contain non-bloody fluid, and possess a characteristic diffuse nodularity, are most likely due to fibrocystic disease. Careful observation for recurrence of the mass is the standard follow-up therapy.
-A mammogram would be indicated if the mass didn’t disappear completely, or if its content was bloody.
-An ultrasound is indicated if the mass cannot be visualized using a mammogram because of dense, normal breast tissue (seen especially in young women).
-Ultrasound is also useful for the evaluation of cystic lesions, but not in the case that the cyst has already been drained.
Even though breast cancer is rare in women younger than 35 years, every breast lesion must be taken seriously.
Patients can be reevaluated 3 to 10 days after the menstrual period to look for regression.
If the lesion appears cystic, FNA should be done unless the patient declines.
If the mass looks solid, is too small, or cannot be felt, ultrasound is the next step to determine if biopsy is needed.

Breast lumps are a very common patient problem in the outpatient setting.
-They cause significant anxiety in most patients. A vast majority of breast lumps in women under age 35 are usually due to benign causes, most commonly benign cystic disease or fibroadenoma of the breast; however, any complaint of a breast mass or lump in a female patient should be evaluated thoroughly.
-All patients should be followed closely until a definite diagnosis is made.
A thorough history and physical examination is an important part of a complete evaluation. Benign cysts are most prominent just prior to the beginning of the menstrual cycle, and regress after the menstrual period is over. It is important to examine a young patient in the postmenstrual period to document any regression in the size of the breast lump.
Fine-needle aspiration biopsy should be performed in an easily palpable cystic breast mass in an anxious patient to obtain fluid or tissue for a specific diagnosis. Any blood-tinged fluid should be sent for cytologic examination. If the fluid obtained is not bloody, the patient should be reexamined in four to six weeks to look for any regression or recurrence of the lump.
Ultrasound of the breast is an alternative option for evaluation of breast masses in patients under age 35. It can differentiate a simple or complex cyst from a solid mass. It can also be used in patients who decline a fine-needle aspiration biopsy.
Mammograms are usually not indicated in women less than 35 years of age, as the normal breast tissue is too dense to evaluate the lump. Moreover, mammograms can miss up to 20% of palpable breast cancers and should be substituted or followed up with another diagnostic modality.

Silicone is a long-chain polymer derived from silicon.
-A silicone implant consists of an outer shell made of silicone, and is inflated with a saline solution. -They are most often used by women to "improve" their physical appearance (breast augmentation). -They are also used for breast reconstruction in women who have had a unilateral or bilateral mastectomy for various reasons, including breast cancer.
-There have been a lot of questions and concerns about the safety of silicone breast implants.
Women who have received breast implants have had local postoperative complications in the form of capsular contracture, causing pain and distortion of the shape, implant deflation, and rupture, requiring surgical removal of the implant. These local complications are the most common cause of morbidity associated with implants.
Silicone breast implants do not cause any major rheumatologic, autoimmune, or neurological disorder.
Silicone breast implants do not cause any disease or defects in the developing fetus.
Breast milk is the best source of nutrition for the babies. All women, even those with breast implants, should be encouraged to breast feed their babies. There is no risk in breast-feeding with a silicone breast implant.
Regular mammograms starting at age 40 years, or earlier if there are risk factors, have consistently been shown to reduce morbidity and mortality from breast cancer. It plays an important role in detecting the lesions in early stages, thereby improving the chances of a complete cure. It is recommended that all women, including those with breast implants, obtain regular screening mammograms as per the guidelines.

Klinefelter’s syndrome
-Is a chromosomal abnormality caused by an additional X chromosome (47, XXY). It is characterized by hypogonadism, low testosterone levels, gynecomastia due to an increased testosterone-to-estrogen ratio.
-Klinefelter’s syndrome is the strongest known risk factor for male breast cancer.
-It carries a 50-fold increase in the risk of breast cancer compared to men with a normal genotype.

 Porcelain gallbladder
-Porcelain gallbladder is a condition characterized by calcium salt deposits in the wall of a chronically inflamed gallbladder. The calcifications can be thin or faintly visible, or may be amorphous, patchy, and thick. -The gallbladder is generally large, but its size can vary considerably. Most porcelain gallbladders are associated with gallstones.
►A plain radiograph generally detects these, but computed tomography (CT) has a higher specificity; therefore, a CT scan is performed to confirm the diagnosis.
►Due to their high risk of gallbladder carcinoma, all patients with porcelain gallbladder should have an Elective cholecystectomy.

 Gallstones
Multiple therapies are available for individuals with gallstones.
Asymptomatic patients require no further intervention.
Patients with mild symptoms and small cholesterol stones may respond to ursodeoxycholic acid.
Extracorporeal lithotripsy may be used for those with bigger cholesterol stones.
The most effective therapy for symptomatic gallstones is cholecystectomy;
High-risk patients, especially those with non-cholesterol Endoscopic electrohydraulic lithotripsy.stones

Morphine overdose
-Morphine overdose is a common scenario in the hospitalized patients, postoperative patients receiving high doses of morphine for acute pain control. Opiate naive patients with renal insufficiency are at a much higher risk.
-The usual manifestations of overdose are lethargy, drowsiness, miosis, bradycardia, hypotension, respiratory depression, and apnea.
-The first and initial priority in the management of overdose is always to check for and maintain a patent airway. It is important to ensure adequate respiratory exchange at all times before instituting specific therapy.
-Specific therapy with naloxone should be given after ensuring adequate gas exchange.

In digital injuries
►Tendons are more likely to be injured than arteries, veins, or nerves due to their relative, vulnerable, anatomic location.

Even in cases where the risk is high, only the absence of benefits may prompt the physician to refuse a procedure; therefore, a physician must always look at the entire clinical picture and prognosis before suggesting or refusing a surgical intervention.
-The patient’s age, presence of comorbidities, functional status, quality of life, and personal values must all be considered to determine if the patient will benefit from hip surgery.
-If the patient is already bedridden, the benefit of surgery is minimal.
-If the patient has other serious medical problems, the risks may outweigh the benefits.
-Pain alone is not an indication for surgery, as conservative therapy can also effectively control this symptom.

Management of retrosternal goiter with compressive symptoms is surgical.

Tachycardia is the earliest sign of hypovolemia.

Most shoulder / clavicle fractures are treated with:
♥Sling or a figure-of-eight brace placement, along with rest and pain control; however, some lesions, such as ♥Compound, distal comminuted, or need surgical intervention.severely displaced fractures,

Complex Regional Pain Syndrome (CRPS) Type I, AKA Reflex Sympathetic Dystrophy (RSD)
International Association for the Study of Pain Diagnostic Criteria
1. The presence of an initiating noxious event or a cause of immobilization.
2. Continuing pain, allodynia (pain elicited by a normally non-noxious stimulus, particularly if repetitive or prolonged) or hyperalgesia (pain disproportionate to the inciting event)
3. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the painful region
4.Absence of other conditions that could account for the degree of pain and dysfunction.
At least one half of the patients meeting these diagnostic criteria have sympathetically maintained pain (SMP), which is defined as pain that is maintained by sympathetic efferent nerve activity or by circulating catecholamines.
Normally, the sympathetic reflex after injury results in vasoconstriction to prevent excessive blood loss or swelling
 Ordinarily, this reflex shuts off after an appropriate period. In the patient who develops CRPS Type I with SMP, the normal sympathetic reflex does not shut off, but continues unabated in a pathologic positive feedback mechanism. The intense vasoconstriction causes localized ischemia, which in turn causes pain that further initiates the sympathetic "pain reflex," etc.
Pharmacologic sympathetic blockade or sympathectomy may interrupt this vicious cycle and reduce long-term periarticular skin and muscle atrophy, flexion contractures, and osteoporosis.
There is evidence that such treatment for CRPS- I with SMP is most or only effective during the first three months after onset.
In CRPS-I of the knee, the most favorable prognostic indicators are early diagnosis, early interruption of the abnormal sympathetic activity (e.g., via alpha blockers, chemical or surgical sympathectomy), and early institution of aggressive physical therapy).
DDX: acute pyogenic arthritis usually presents with a tense joint effusion, and the patient generally cannot tolerate weight-bearing or joint motion.

Plica syndrome of the knee
-Is pain, crepitus, snapping, popping, or effusion related to patellofemoral joint motion.
-The clinical picture mimics a torn medial meniscus or a maltracking patella, and is due to a prominent medial plica (synovial fold) which impinges against the medial patellofemoral articular surface and may become inflamed.
PE
Pulmonary embolism may still occur in patients who are receiving DVT prophylaxis due to their high risk. ►V/Q scan

 Osteoporosis
-While less common in men than in women, osteoporosis is associated with significant morbidity. It is estimated that a 60-year-old male has a 25% chance of suffering an osteoporotic fracture.
-Bone mineral density depends on peak bone mass and the rate of bone mass loss. The peak bone mass is higher in men than in women; therefore, they present with osteoporotic fracture about 10 years later than women. The rate of bone mineral content loss after 30 years of age is approximately 0.5 – 1%/year.
Age is considered to be the most important single risk factor for osteoporosis and osteoporotic bone fracture. Other contributing factors are important, for example, family history, smoking, and alcohol consumption
Medications predisposing to osteoporosis include glucocorticoids, anti-androgens, and some anticonvulsants. Caucasian males are more susceptible to osteoporosis than African-Americans.
 Raloxifene is a selective estrogen receptor modulator (SERM) which selectively stimulates estrogen receptors on bone cells. It has been shown to improve bone mineral density at both the hip and lumbar spine. Studies have not shown that it reduces the risk for vertebral fractures. Side effects include hot flashes and an increased risk for deep venous thrombosis and pulmonary embolism.
►Raloxifene should therefore be discontinued at least 72 hours prior to an elective surgical procedure to prevent DVT deep venous thrombosis. It can be restarted after the patient is fully ambulatory.

Meckel’s diverticulum
-Acute abdominal pain with rectal bleeding in children between five and ten years of age can be due to Meckel’s diverticulum bleeding, inflammatory bowel disease or appendicitis.
-A technetium-99 nuclear scan is highly specific for Meckel’s diverticulum.

Dumping syndrome
-Dumping syndrome is a common complication of gastrectomy.
-Treatment is aimed at decreasing the speed of the passage of fluids and food into the small gut.
►A high-protein and low-carbohydrate diet is advised, as well as smaller but more frequent meals throughout the day.

DVT
-patients undergoing surgery can be classified into four levels of risk for postoperative deep venous thrombosis (DVT), depending upon age, type of surgery, and presence of clinical risk factors for DVT

Low risk—
-uncomplicated minor surgery in patients younger than 40 years with no clinical risk factors
Moderate risk-- any surgery in patients aged 40-60 years with no additional risk factors; major surgery in patients younger than 40 years with no additional risk factors; minor surgery in patients with risk factors
High risk—
-Major surgery in patients older than 60 years without additional risk factors or patients aged 40-60 years with additional risk factors; patients with MI; medical patients with risk factors
Highest risk—
Major surgery in patients older than 40 years with prior venous thromboembolism, malignant disease, or hypercoagulable state - patients with elective major lower extremity orthopedic surgery, hip fracture, stroke, multiple trauma, or spinal cord injury
Clinical risk factors for deep venous thrombosis include the following
Age (>40 y)
Prolonged immobility (>4 h) or paralysis
Prior DVT or PE
 Obesity
Hypercoagulable states (e.g. factor V Leiden mutation, protein S deficiency, protein C deficiency, antithrombin III deficiency, antiphospholipid antibodies or lupus anticoagulant, plasma hyperhomocystinemia)
Major surgery or fractures (especially abdominal, pelvic, lower extremities)
 Malignancy
Varicose veins
Heart failure
Myocardial infarction (MI)

-RX: The modalities recommended preventing such DVT, assuming prophylaxis is only begun postoperatively, are, in approximate (decreasing) order of effectiveness
1.- Full-dose therapeutic IV heparin
2. Either:
* Adjusted-dose oral Warfarin (goal INR 2.5) (or)
* Low dose heparin (unfractionated) 5000 U administered SC q8h to q12h (or)
* Adjusted (low dose) heparin (unfractionated)- 3500 U administered SC q8h adjust ± 500 U to maintain 1.5-2 times the reference range aPTT (or)
* Low molecular weight heparin SC [for example Enoxaparin (Lovenox) 3000 U (30 mg) SC q12h]
Adjuvant: *Calf-length elastic stockings (ES) with early ambulation (or) *Intermittent pneumatic compression devices (IPC

►Highest/high-risk patients without contraindications require anticoagulation via modalities 1 or 2.
►#1 [Full dose therapeutic IV heparin] is generally reserved for patients with MI.
►Warfarin is recommended mainly as a possible alternative to low dose or low molecular weight heparin for highest risk orthopedic patients undergoing lower extremity procedures.
►Modality 3 is adequate for low risk patients and some moderate risk patients, although most moderate risk patients should receive low dose or low molecular weight heparin.
►ES and/or IPC may be used adjunctively in higher risk patients.
LMWH is considered to be the prophylactic therapy of choice for preventing deep vein thrombosis in patients at high risk. ►Then coumadin and then aspirin. -Pressure stockings as adjuvant
Cardiopulmonary resuscitation
-Remember and follow the "ABC"s" of cardiopulmonary resuscitation.
-After the airway has been secured by endotracheal intubation, it is important to confirm its correct placement in the trachea by checking for lung expansion and auscultating for breath sounds on both sides.
-Emergent large-bore needle decompression ► should be performed in a patient with suspected tension pneumothorax causing hemodynamic instability and cardiovascular collapse.

Stress fractures
-Stress fractures most commonly occur on the lower one-third of the tibia, fibula, lateral metatarsals, and sometimes the tarsal bones of the foot.
-These are usually seen in athletes and military recruits with a history of excessive running or training.
-Patients often complain of pain that occurs with exercise or running, and improves with rest.
-Physical examination reveals localized tenderness and swelling over the fracture site.
-It is important to distinguish a stress fracture from the other common tendon and ligament injuries in order to provide specific therapy.
►DX:
-Plain radiographs are often unremarkable in the first two to four weeks after the injury or fracture.
-Magnetic resonance imaging or triple phase bone scans with technetium are highly sensitive and accurate imaging modalities used to confirm the diagnosis of stress fracture.
►RX:
-Most of the stress fractures of the lower extremities can be managed with conservative treatment.
-This includes complete cessation of aggravating activities for at least four to six weeks, with a gradual return to activity.
-Other general measures include pain control with nonsteroidal antiinflammatory drugs and support with crutches or a brace while walking.

Fat embolism
-Always consider the risk of fat embolism in patients with multiple complicated fractures.
-Fat embolism is a clinical diagnosis that is usually characterized by a triad of respiratory insufficiency, neurological impairment, and a petechial rash.
-Early immobilization and operative fixation of fractures reduce the chances of fat embolism.

 Mesenteric ischemia
A sudden onset of severe periumbilical pain that is out of proportion to the physical examination findings, along with metabolic acidosis, and occurs in a setting with risk factors such as atrial fibrillation, congestive heart failure, and peripheral vascular disease, should always raise the suspicion for acute mesenteric ischemia.
This condition is frequently overlooked initially.
All radiological studies may be initially normal.
Laboratory data may show a mild to moderate metabolic acidosis.
 Leukocytes and elevated Hb and Hct% in the CBC may occur secondary to hemoconcentration.
The ischemia may be due to an occlusion secondary to thrombosis, embolism and/or vasospasm.
The most common cause is superior mesenteric artery (SMA) occlusion secondary to an embolism.
The SMA is the most common site involved because it runs off at a minimal angle from the aorta and has a wide diameter. The origin of the embolus is commonly from the left atrium, left ventricle or cardiac valves.
Risk factors are cardiac arrhythmias, recent MI and abdominal malignancy.
The patient may later develop abdominal distention and signs of acute peritonitis.
If not treated promptly, consequences may be very serious. Untreated mesenteric ischemia may cause bowel infarction, sepsis and death. Mortality in this case may be as high as 60%.
DDX:
1. Patients with acute colonic ischemia usually have a more lateralized abdominal pain with tenderness, along with a history of bloody diarrhea or hematochezia.
This usually results from hypovolemic states or transient ischemia to the bowel.
This is not because of the obstruction of flow to the colon.
2. Patients with intestinal obstruction usually have a history of absolute constipation.
Plain abdominal radiographs will show air fluid levels.

CREMASTERIC REFLEX
-The cremasteric reflex is regulated at the L1-L2 level of the spinal cord.
-This reflex can be diminished or lost secondary to diabetic autonomic neuropathy.

Superficial suppurative thrombophlebitis ►requires drainage if the antibiotic therapy alone is ineffective.

A multilocular pancreatic cyst in a patient without a history of pancreatitis should be malignant until proven otherwise.considered

Obesity
The National Institute of Health (NIH) recommends that severe obesity (BMI of more than 40 Kg/m2) is an indication for surgery.
Other indications are:
(1) A significant decrease in the quality of life
(2) Serious medical problems such as obstructive sleep apnea, movement limitations, or brittle diabetes.

Abdominal gunshot wounds
-Most abdominal gunshot wounds will require laparotomy for further exploration and immediate management of intra abdominal injuries, unless the wounds are only superficial or tangential to the skin.
The absolute indications for an urgent laparotomy are:
-presence of peritoneal signs, spinal cord damage
-intra abdominal vessels or bladder damage, and hollow viscus perforation
►If the patient is hemodynamically the procedure must be doneunstable or has lost a great amount of blood, immediately.
♥Early transportation can be life-saving for patients with penetrating abdominal trauma secondary to gunshots.
♥Transfer to a regional trauma center is required if there is no surgeon or operating room available, if the patient has multiple injuries, or if he needs procedures that are not available (e.g., hemodialysis, organ transplantation, neurosurgery, etc.).
♥Air transport (life flight) is recommended for patients who are potentially unstable, or who are in rural areas or places where ground transportation may take more than 20 minutes.

Epidural abscess
-An epidural abscess should be suspected in a susceptible patient who presents with fever and back pain.
-Patients who are susceptible are the elderly, immunocompromised individuals (i.e., patients with AIDS, IV DRUG ABUSER, cancer, diabetes mellitus, chronic renal failure, or alcoholism), and patients who were recently involved in trauma, spinal surgery, or administration of epidural anesthesia.

The diagnosis must be made immediately because delays in treatment increase the risk of permanent neurologic damage or death.
A gadolinium-enhanced MRI is the preferred imaging modality to confirm the diagnosis because it adequately demonstrates inflammatory changes in the soft tissue.
CT with myelography is an alternative. When MRI is not available, 
Antibiotic therapy should be guided by Once the diagnosis is made,  obtaining a culture specimen via CT-guided aspiration or open biopsy. The most common etiologic agent is Staphylococcus aureus.
RX: Spinal epidural abscesses is a surgical emergency
-Early surgical decompression and drainage, preferably within the first 24 hours, is the most important part of management to improve the ultimate prognosis.

Subarachnoid hemorrhage:
-The constellation of a headache of sudden onset, nausea, and nuchal rigidity is characteristic.
-Cranial nerve III palsy (ptosis and anisocoria) is a typical finding in patients with a posterior communicating artery aneurysm. It is also characteristic for cavernous-carotid aneurysms, but they are uncommon.

Posterior inferior cerebellar artery aneurysms frequently result in ataxia and bulbar dysfunction.

Brainstem glioma presents with signs and symptoms of progressive brainstem involvement as ataxia, cranial nerve palsies, motor, and sensory abnormalities.
Lacunar stroke manifests as relatively limited neurologic dysfunction (e.g., ‘pure motor stroke’), but headache and nuchal rigidity are not present.



Varicose veins
-Varicose veins refer to visible, palpable, and tortuous superficial veins of the legs, usually on the calf or medial thigh. Most of the patients with varicose veins are asymptomatic. Some patients may complain of leg cramping, heaviness, fatigue, and swelling. The symptoms are generally worse in the evening with prolonged standing, and improve with leg elevation.
-Treatment of varicose veins is aimed at alleviating symptoms, although some patients may seek a physician"s attention due to cosmetic reasons.
-Various treatment options for varicose veins include leg elevation, compression stockings, sclerotherapy, and surgical ligation.
-Most patients with symptomatic varicose veins should initially be treated with conservative measures such as leg elevation and compression stockings.
Compression decrease the venousstockings along with leg elevation and weight reduction pressures in the lower extremities by direct compression and improves the patient’s symptoms- Compression stockings should not be used in patients with an underlying arterial insufficiency
Injection sclerotherapy with or without anesthetics is used in patients with symptomatic, small, varicose veins who have failed at least three to six months of conservative treatment. It involves the injection of a sclerosing agent into the affected vein. It causes endothelial damage and sclerosis of the involved vein, thus preventing further vein filling.
Surgical ligation and stripping is used in patients with large symptomatic varicose veins with ulcers, bleeding, or recurrent thrombophlebitis of the veins

Bites
-An animal bite is an extremely common problem encountered in the emergency department. Most of the bites are due to the animal known to the victim and are unprovoked. Sometimes the bites can be from the stray and wild animals as well. It is important to obtain an accurate and complete history from the patient for appropriate management.
-The most important piece of information to get is to find out the exact location of the animal in the zoo.
The bite in the zoo should not be presumed to be from the animals kept under observation. It can still happen from an animal in the surroundings. This is important, as these animals are not vaccinated and are not under observation. This can change the whole management strategy for a particular patient and will warrant a more aggressive approach to the management.
Animal bites can lead to a wide spectrum of injuries, ranging from minor scratches or abrasions to deep puncture wounds or lacerations. The extremities, especially the upper extremities, are common sites of injury in older children or adult patients.

All animal bites, regardless of the site, should be thoroughly cleaned and irrigated with normal saline, and all devitalized tissues should be débrided.

A plain radiograph should be obtained if a patient is suspected of having a foreign body or has a bite occurring close to a bone.
Most open lacerations can be closed primarily within a few hours of injury.
This is especially true for injuries of the face where infections are less common due to a good vascular supply
Primary closure is not recommended in the hands [should not be sutured or closed primarily due to a high risk of subsequent wound infection]. These should be left open to drain and examined frequently for signs of infection.
Primary puncture wounds, cat and human bites (high riskclosure is not recommended in of infection), and patients presenting late after the bite.
Cat and dog bites should be treated prophylactically with amoxicillin/clavulanate.
 Tetanus toxoid must be given to individuals with dirty wounds who have received a booster >5 years ago and to individuals with clean wounds who have received a booster >10 years ago.
Tetanus immune globulin should be given to any individual with a dirty wound and an unclear or insufficient immunization history.
A second dose of tetanus toxoid must be given in one month, and a third dose in twelve months.

Subphrenic abscess
-Typically develops 14-21 days after abdominal surgery.
-Clues to this diagnosis are a history of abdominal surgery, swinging fever, and leukocytosis.
Cough and shoulder-tip pain may be the presenting symptoms.
Abdominal ultrasound is the best diagnostic test for a suspected subphrenic or other abdominal abscess.

Thyroglossal duct cyst
-About one-third of patients with a thyroglossal duct cyst present after the age of 20.
-They present with a midline neck mass that moves with protrusion of the tongue.
-The thyroid is formed as an outpouching from the base of the tongue, and then descends to the base of the anterior neck. The thyroglossal duct connects the tongue and the thyroid gland, and a cyst can develop from the epithelial remnants within the duct.
►Ectopic thyroid tissue is present in a large number of patients within the thyroglossal duct cysts, but sometimes this is the only functional tissue present.
Therefore, imaging studies, like a thyroid nuclear scan, ultrasound, or CT is mandatory before subjecting the patient to surgery.
A CT scan is thought to be more useful because it not only delineates the normal thyroid gland, but also clarifies the anatomy of the thyroglossal duct cyst in relation to the surrounding structures.
Preoperative assessment of thyroid function is also required.
A fine needle aspiration biopsy is not generally required unless there is high suspicion of malignancy.

Flail chest
-The patient has tachypnea, shallow breathing, tachycardia, anterior chest bruises and peripheral cyanosis.
-Flail chest is usually the result of double rib fractures in more than one site, and is present in 10-20% of trauma admissions.
-The main pathophysiologic feature of flail chest is the increased work of breathing due to muscular spasm and pain. Hypoxia develops frequently due to associated pulmonary contusions.

Acute appendicitis
-McBurney’s sign (tenderness at McBurney’s point, the site two-thirds between the umbilicus and right anterior superior iliac spine)
-Rovsing’s sign (transmission of pain from the left to the right lower quadrant), and iliopsoas sign (RLQ pain on passive extension of the right hip). There is a left shift in the white blood cell count (true for 95% of diagnosed cases)
In a third trimester pregnant woman, there is a minimal risk of premature delivery; however, if rupture of the appendix occurs, peritonitis can lead to fetal death, abscess formation and pylephlebitis (infectious thrombosis of the portal veins).
These complications are rare but feasible, especially if therapy is not offered within the first 24 hours of the initiation of symptoms


Desmoid tumors [slow-growing muscle masses]
-Desmoid tumors are locally aggressive neoplasms arising from fibroplastic elements within the muscle or fascial planes. Since these are locally invasive and slowly infiltrate the surrounding tissues and structures, these only cause local complications. These usually present as painless or minimally painful, slow-growing muscle masses over the extremities, shoulder girdle, and hip-buttock area, although these may occur at all body sites.
The diagnosis is generally confirmed with a tissue biopsy.
Surgical excision with a wide margin of resection is the treatment of choice for patients with an easily approachable and resectable mass.
There is a high rate of local recurrence, even after adequate resection.

DDX:
1. Abdominal aortic aneurysms usually present as a painless pulsatile mass.
2. Ventral or incisional hernia can develop at the site of previous surgical scars; however, this is generally reducible, and pain is an unusual symptom of ventral hernia, unless it is strangulated.

Aortic dissection
-Aortic dissection is an uncommon but potentially life threatening cause of severe and sudden chest pain. It has the same predisposing risk factors as an acute coronary syndrome (unstable angina and myocardial infarction), including age greater than 55 years, hypertension, hyperlipidemia, and chronic smoking.
The diagnosis of aortic dissection is usually based on the history and the physical examination findings.
Patients with acute aortic dissection typically present with a sudden onset of severe or "tearing" chest pain radiating to the back. The pain is usually not relieved by sublingual nitroglycerine.
Other clinical clues favoring the diagnosis of an aortic dissection include the blood pressure difference in the two arms, an early diastolic murmur (reflecting aortic insufficiency
And the presence of mediastinal widening on chest x-ray.

Burns
-The majority of burn center deaths are due to inhalation injuries.
►COMPLICATION: Supraglottic damage [EDEMA] is one of the most alarming types of inhalation injuries and stems from inhaling hot air, steam, or smoke. The ensuing inflammatory response results in edema of surrounding soft tissues and significant narrowing of the airway.
►Fiberoptic laryngoscopy or bronchoscopy may be necessary to properly assess the extent of airway involvement.

Tetanus
-For those patients with a contaminated wound and unknown immunization status, both tetanus antitoxin and tetanus immune globulins are indicated. The situations in which only tetanus antitoxin is given are the following:
1. when the patient has a clean wound but unknown immunization status, or if he has received less than
three doses of tetanus antitoxin
2. when the patient has a clean wound and has received three or more doses of tetanus antitoxin with
the last dose received more than ten years ago
3. when the patient has a contaminated wound and has received three or more doses of tetanus
antitoxin with the last dose received more then five years ago


Avascular necrosis or osteochondritis dissecans
A variety of disorders and disease processes can cause osteonecrosis. Among all the causes, corticosteroid use and excessive alcohol intake are responsible for about 90% of the cases.
Some other disorders associated with the development of osteonecrosis include systemic lupus erythematosus (SLE), sickle cell disease, antiphospholipid antibody syndrome, chronic renal insufficiency and hemodialysis, trauma, Gaucher’s disease, HIV infection, following renal transplantation, and Caisson’s disease.
Patients with SLE on chronic high-dose corticosteroid therapy are at greatest risk (more than 15 to 20 mg/day).
Osteonecrosis usually occurs in the anterolateral femoral head, though it can also affect the humeral head, femoral condyles, vertebrae, proximal tibia, and small bones of hand and foot.
Early diagnosis of osteonecrosis is important to prevent bone collapse and the need for joint replacement.
Physical findings are usually nonspecific, making it necessary to obtain sensitive imaging.
MRI scanning is far more sensitive than plain films or bone scanning. Focal lesions are well demarcated and changes can be seen early in the course of the disease when other studies are negative.

The goal of therapy of osteonecrosis is to preserve the native joint for as long as possible.
The main modalities of treatment include conservative therapy, core decompression, osteotomy, and joint replacement.
Total hip replacement is the therapy of choice for stage-4 disease of the femoral head (flattening of the femoral head with joint space narrowing).

Aortic injury
-The most common cause of sudden death after a steering wheel injury from motor vehicle accident is aortic injury. Patients typically die at the scene before an ambulance service arrives.
Rapid deceleration produces a shearing force along the aortic arch where the aorta is firmly attached. It is usually observed in the area of the ligamentum arteriosum, the aortic root, and the diaphragmatic hiatus.

Hernia
-A hernia is a small area of weakness or defect in the overlying muscular or fibrous wall through which abdominal contents pass. Groin hernias are either inguinal or femoral hernias.
-The most common presentation is the dull sensation of heaviness or discomfort that is more pronounced with prolonged standing or straining (increased intraabdominal pressure).
-These are easily reducible in most cases, and symptoms are relieved with lying flat.
A dreaded complication is incarceration or strangulation. It occurs when a tight constriction ring forms around the herniated contents and the hernia then becomes irreducible. Patients typically present with a constant pain that gets worse over time.
If left untreated, it leads to necrosis and gangrene of the contents, and can be life-threatening.
A femoral hernia is much more predisposed to strangulation than an inguinal hernia.
►The effective treatment for all types of hernias is surgical repair.
Risks of delaying the surgery are mainly those related to incarceration and strangulation.
-Inguinal hernias in the pediatric age group should be surgically repaired as early as possible [FIRST MONTHS OF LIFE] -These will not resolve with age.
-The risk of potential complications, including incarceration, is particularly high if it remains unrepaired during the first months of life.
Rupture of the Achilles tendon
-Rupture of the Achilles tendon may occur after abrupt calf muscle contraction.
-This typically occurs in men over the age of 40 who do not perform a regular leg-conditioning program.
The most common symptoms are severe pain in the calf and the inability to stand up on the toes. The patient may note an audible snap at the time of injury.
A positive Thompson test is further evidence of rupture. This test is performed with the patient kneeling on a chair or lying prone on an examination table and the feet hanging over the edge.
►When the examiner squeezes the calf muscle on the normal side, the foot responds with plantar flexion.
there is no foot response after squeeze►On the affected side gastronemius
Treatment consists of immediate immobilization of the lower leg and surgical repair of the tendon as soon as possible.

Neck trauma
-Whenever there is an accident with possible neck trauma, the airway must be secured through the jaw lift maneuver to avoid further strain in the neck area.
Cricothyrotomy may be necessary if there is complete obstruction of the airway.
If the patient is unconscious, completely he orunresponsive, unable to protect the airway, not breathing or coughing, she will need to be intubated.

Infectious mononucleosis
Is a viral illness caused by the Epstein-Barr virus. It classically presents with marked fatigue, fever, tonsillar pharyngitis, and generalized lymphadenopathy. Acute symptoms usually resolve in one to two weeks.
The infection is usually seen in adolescents and young adults, although most of them are asymptomatic.

Lymphadenopathy
-Is typically symmetric, and usually involves posterior cervical nodes.
-It peaks in the first week of infection, and subsides over the next 2-3 weeks.
RX: -Patients with localized lymphadenopathy can be observed for 3-4 weeks.
-A biopsy should be performed if the abnormal nodes fail to resolve after that time, or earlier, if there are other signs of malignancy.
-Abnormal and persistent lymphadenopathy is sometimes the first clinical manifestation of an underlying lymphoma.
►Persistent and localized abnormal lymph nodes should be biopsied.

Scrotal trauma
-The utility of ultrasound in scrotal trauma is controversial.
-Some studies report excellent sensitivity, while others do not recommend it because of its unreliability. In any case, a sonogram is a useful adjunct to physical examination, but normal results should not preclude surgical exploration when the testis is grossly abnormal.
Several studies have demonstrated a significant increase in orchiectomy rates when surgical repair was delayed.
►Surgical exploration and repair should therefore be performed without delay if there is evidence of significant trauma on physical examination.
Nerve injury
Femoral:
-On examination, patients with significant femoral neuropathies develop weakness involving the quadriceps muscle group with sparing of leg adduction (this is a function of the obturator nerve).
-This leads to the inability to extend the knee against resistance.
In addition to muscle weakness, sensory loss over the anterior thigh and most of the medial thigh is typical.
-The sensory loss extends down the medial shin to the region of the arch of the foot due to saphenous nerve dysfunction (saphenous nerve is a branch of femoral nerve).
-The knee jerk also decreases in amplitude or becomes absent.

Patients with significant injury to the Sciatic nerve
-Complain of weakness affecting most of the lower leg musculature, including the hamstrings.
-Hip flexion, extension, abduction and adduction, and knee extension are usually normal. ►There is sensory loss involving the lower leg.
►However, in contrast to the femoral nerve injury, the medial calf and arch of the foot may be spared secondary to innervation by the preserved saphenous nerve (a branch of the femoral nerve).
-Sensation is also spared above the knee both anteriorly and posteriorly. -The knee jerk is normal, but the ankle jerk is unobtainable.
☺6The most common cause for compression or injury to the sciatic nerve in this region is trauma, including hip dislocation, fracture, or replacement.
►Other etiologies include wayward buttock injections, compression by external sources, such as prolonged bed rest and any deep-seated mass in the pelvis (hematomas).
An obturator nerve injury presents with: Pain, weakness in leg adduction, and sensory loss over a small area in the medial thigh Obturator neuropathy is often secondary to pelvic trauma or surgery.

 The clinical presentation of common peroneal nerve injury is usually acute foot drop, with weakness in foot dorsiflexion and eversion. Patients may also complain of paresthesias and/or sensory loss over the dorsum of the foot and lateral shin (superficial peroneal nerve territory). It is usually injured at the knee at the lateral aspect of the fibular head.

Renal or ureteral stones
-Renal or ureteral stones are a common presenting problem in the emergency department.
-Most of the patients present with a sudden onset of pain and hematuria.
-The pain is usually colicky in nature (waxing and waning) and can vary from a mild ache to severe discomfort requiring narcotic analgesics.
-The location of the pain can sometimes give clues to the site of the stone.
o Upper ureteral or renal stones usually cause pain in the flank, whereas a lower or distal ureteral stone causes pain which radiates to the ipsilateral groin area.
o Initial management is usually conservative, and includes intravenous hydration and pain control.
o Stones that are less than 5 mm in size usually pass spontaneously.
o On the other hand, stones greater than 8 to 10 mm are unlikely to pass spontaneously and require removal.
o Stone removal is also indicated in patients with persistent pain, acute renal failure, or signs of urosepsis.
There are three common techniques that have been employed to facilitate stone removal or passage from the ureters.
o These include extracorporeal shockwave lithotripsy (ESWL), flexible ureteroscopy, and percutaneous ureterolithotomy.
o The choice of procedure usually depends on the location of the ureteral stone.
o Shockwave lithotripsy is the treatment of choice for small symptomatic proximal ureteral calculi (less than 5 – 10 mm in size).
o For large (more than 10 mm) proximal ureteral stones, flexible ureteroscopy combined with laser lithotripsy is the preferred initial therapy.

Any case of acute urinary obstruction in which there is no evidence of pelvic or urethral trauma, or no history of urethral strictures, must be managed immediately through urethral catheterization in order to decompress the bladder, alleviate the pain, and avoid further renal compromise.

Suprapubic catheterization should never be done on an empty bladder, and should preferably be performed by the urologist when the aforementioned conditions are present, or if Foley catheter placement is difficult.

Intracranial hypertension
o Patients with intracranial hypertension have been classically described to have bradycardia, hypertension and respiratory depression (Cushing"s triad).
In the early stages, patients complain of headaches, vomiting, blurred vision, and have papilledema on funduscopic examination.
Further elevation in the intracranial pressure leads to transtentorial herniation of brain tissue, causing altered levels of consciousness (stupor progressing to coma), dilation of the ipsilateral pupil, third cranial nerve palsy, hemiparesis, decerebrate posturing, and eventually, respiratory arrest.
The most important next step in the management is to rapidly intubate the patient to protect and maintain her airway, in case of a respiratory arrest
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* Re:very useful review notes for step 3
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fullofgrace - 06/08/09 13:13

USMLE world notes step 3 - OB/GYN

Chlamydial infection
-This newborn most likely has conjunctival and pulmonary chlamydial infection. Chlamydia may have been transmitted from the mother during the neonate"s passage through the birth canal. Cervical carriage in the mother has been associated with a higher incidence of preterm labor, PROM, and late post-term endometritis.
-Chlamydia is the most common causative agent of infectious neonatal conjunctivitis. Infected infants have a 25-50% risk of developing conjunctivitis and a 5-20% risk of developing pneumonia.
♥Chlamydial conjunctivitis develops a few days to several weeks after birth and manifests with conjunctival congestion, edema, and mucoid or frank purulent discharge.
♥Pneumonia usually appears 3-19 weeks after birth, and symptoms include cough, tachypnea, rales, and absence of fever. Wheezing is rare. The latter two features differentiate chlamydial pneumonia from RSV bronchiolitis.
♥Neonatal disease is best prevented by early detection and treatment in pregnant women.
♥Screening is recommended in high-risk individuals such as single mothers, adolescents, patients with low socioeconomic status, and promiscuous patients. And in < 25 y/o
►Erythromycin is the drug of choice in pregnancy and should be given to both the patient and her sexual partner. Another test should be performed later in pregnancy, and a positive result warrants a second course of antibiotics. Infants should also be treated with oral erythromycin for 14 days, as topical agents are ineffective.
-Colonization takes place during delivery, when the newborn comes in contact with the vaginal secretions of the mother.

Rh – incompatibility: Hemolytic disease of the newborn due to Rh-incompatibility
-Is possible only when the mother is Rh-negative and the father is Rh-positive.
-Hemolytic disease is very unlikely in the first pregnancy, as the mother is not sensitized. The mother becomes sensitized as a result of fetomaternal hemorrhage at or near the end of pregnancy. This risk of sensitization can be reduced by a RhoGAM injection within 72 hours of the delivery.
-Anti-D immune globulin should be administered intramuscularly at 28 weeks’ gestation to all Rh (D) negative women if no anti-D isoimmunization is detected by antibody screening.
-Antenatal prophylaxis is not necessary only if the father of the child is known with certainty to be Rh (D) negative . Antenatal prophylaxis helps to reduce significantly the risk of Rh (D) isoimmunization during pregnancy.
-Peripartum anti-D immune globulin is also indicated to reduce the risk of isoimmunization due to fetomaternal transfusion during the delivery.
-Early antenatal anti-D immune globulin prophylaxis is indicated in case of the events and procedures that can increase the risk of isoimmunization (e.g., spontaneous abortion, ectopic pregnancy, and amniocentesis). Otherwise, the risk of isoimmunization before the 28th week of pregnancy is very low.

►Failure to adjust the dose of anti-D immune globulin after events that are associated with excessive feto-maternal hemorrhage (e.g., placental abruption) may result in maternal alloimmunization.
Events that are associated with feto-maternal hemorrhage (such as placental abruption) may require adjustments in the dosage of anti-D immune globulin; therefore, the presence and the amount of feto-maternal transfusion should have been determined in this patient during her first pregnancy.
The rosette test is a qualitative test that helps determine the presence of feto-maternal hemorrhage.
◘If negative, the standard dose of anti-D immune globulin should be administered.
◘If positive, the amount of hemorrhage can be evaluated using Kleihauer-Betke stain or fetal red cell stain using flow cytometry, and the dose of anti-D immune globulin should be corrected accordingly.

♣ Pregnancy Facts and conditions:
Screening for group B strep should be done 36-37 week gestation and positive cases should be tx with Penicilline G during labor, even in the absence of risks.
Low back pain is very common in thrid trimester. It’s caused by lumbar lordosis and relaxation of ligament to the joints.
Both Graves dis and Migraine will improve in Pregnancy.
Excessive use of oxytocin may cause water retention (acts like ADH), hyponatremia and seizures (water intoxication).
ACE inhibitors and Oral hypoglycemic agents (Glibenclamide) are C/I in pregnancy. Stop them and give Insulin for DM, and Methyldopa (most commonly used), Hydralazine and Labetalol for HT control in pregnancy.
Pregnancy has protective effect on both MS and PUD
In pregnancy both BUN and Creatinine are decreased to half of prepregnancy levels. Amoxicilin has no effect on them.
RENAL:
Asymptomatic Bacteriuria of Pregnancy, increases risk of developing cystitis and pyelonephritis. E coli are the cause 70% of the times.
TX- UTI in pregnancy: Cephalexin [first gen Cephalos] or Ampicillin or7-10 days “CAN” Nitrofurantoin
Ceftriaxone or CefazolinPyelonephritis/pregnancy: TX: “CAG” or Ampicillin or Gentamicin
Neonates of pts with Graves disease treated with surgery are at risk for Thyrotoxoicosis because of the passage of thyroid stimulating immunoglobin across the placenta.
Hypotension is a common se of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling.
Pregnancy and EXERCISE:
-it’s recommended to CONTINUE exercise as you were doing before, like an aerobic instructor.
-Aerobic is Ok, scuba diving are contraindicated
Edema of lower extremities (Bilateral) in pregnancy is most commonly a benign problem. Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria, no need to do ECG or DVT (presents unilateral and fever).
Oxytocin is like ADH so it causes water retention and Water toxicity due to decrease in Na concentration ( 123 ). So it could cause seizure post partum.
Screening cultures should be performed at week 36-37 and positive cases should be treated with IV penicillin therapy during labor to prevent the new born from getting infected.
If hypertension sets in before 20 weeks, its either Mole or CHRONIC hypertension.
If it sets in after 20 weeks, its either Preeclampsia (Proteinuria, >300mg) or TRANSIENT hypertension (not accompanied by proteinuria)
Antibodies to ABO antigens belong to IgM antibody class so they don’t cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies that are responsible for Rh alloimmunization belong to IgG class and do cross placenta.
All pregnant drivers should wear seatbelts while driving. Seat belts have been shown to improve both fetal and maternal outcomes in automobile accidents. Pregnant drivers who do not wear seat belts while driving are more likely to have excessive internal bleeding and fetal death if they are involved in a car accident.

The current recommendation is that both lap and shoulder straps should be used. The lap strap should be placed under the abdomen, and the shoulder strap should be placed diagonally across the chest and abdomen

Epilepsy:
-Although anti-epileptic drug use during pregnancy is associated with an increased risk of congenital abnormalities, over 90% of women with epilepsy have normal pregnancy. There is currently no agreement about which anti-epileptic drug is most or least teratogenic; therefore, the drug that works best for the patient should be used.
-Early detection of neural tube defects by serum alpha-fetoprotein screening, amniocentesis or ultrasonography is important.
►If major abnormalities are present, the pregnancy can be terminated or an optimal management strategy can be planned.
♠ switching to another drug is not usually recommended for the patient taking anti-epileptic drugs during pregnancy.

According to the American Academy of Pediatrics (AAP) and should be encouraged inAmerican Academy of Neurology (AAN), breastfeeding women with epilepsy. This is due to the belief that the benefits of breastfeeding outweigh the risk of exposure of the infant to antiepileptic drugs.

Ethics:
♥Expectant teenage mothers are legally entitled to give consent for procedures related to the management of their pregnancies, including the performing of cesarean sections.
-Adolescents do not need consent from their parents for contraceptive services.
-Barrier methods should be used by all sexually active adolescents even if an additional method of contraception is being used.
-Most states have implemented laws that allow for a physician to provide certain types of medical care to adolescents without parental consent.
♥Elective abortions are typically protected under these laws. ►Therefore, a teenaged girl would have the authority to provide legal consent for an abortion.
-When deciding ethical issues such as this, it is important to focus on the principles of patient autonomy and beneficence. Patients have the right to seek, accept, or refuse care.
-With the mentally disabled, it may be impossible to obtain informed consent, but at the least simple assent should be strenuously pursued. If sterilization is not wanted, it should not be performed against the patient’s will. Involuntary sterilization violates a woman’s right to privacy, her reproductive rights, and her bodily integrity.
►Advice long time hormonal contraceptives

-Lesbian women often conceal their sexual orientation from their primary care physicians. Recent developments and legislations regarding same sex marriages have encouraged more homosexual couples to "come forward" or reveal their sexual orientation. It is important for primary care physicians to be sensitive and knowledgeable to their special needs and concerns.
►Advice taking her Pap smears yearly

♠Emergency Contraception:
☻Levonorgestrel is the recommended method of emergency contraception if used soon enough after an unprotected sexual intercourse. It has maximal efficacy when used within the first 12 hours after intercourse, good efficacy within 48 hours, and appears to work up to 120 hours after intercourse.
One controlled trial showed that levonorgestrel prevents 85% of expected pregnancies (compared to 57% prevented by estrogen/progesterone combination).
☻The copper IUD intrauterine device is an effective emergency contraception tool that can be used if a patient presents more than 120 hours after unprotected intercourse.

☻The most effective reversible contraceptive methods are injectable contraceptives (97 to 98% in 1 year) and Oral contraceptives (92%).
►Oral contraceptives (OC) are contraindicated in patients with a history of thrombosis, estrogen-dependant tumors, or liver disease, as well as those who are heavy smokers or older than 35 years. They are also not recommended for patients who are younger, on anticonvulsant medication, have a heavy smoking history, have migraines, or uncontrolled hypertension.
The absolute contraindications to the use of Oral contraceptives are the following:
1. history of thromboembolic event or stroke
2. Active liver disease
3. History of estrogen dependent tumor
4. Pregnancy
5. Abnormal uterine bleeding
6. Heavy smokers who are older than 35
7. hypertriglyceridemia
Relative contraindications are the following:
1. migraine headaches
2. Poorly controlled hypertension
3. Anticonvulsant drug therapy
☻Depot medroxyprogesterone is ideal for women with heavy menstrual loss, fibroids, a history of PID, or heavy smoking > 35 y/o.
☻Implantable and injectable contraceptives, including implantable levonorgestrel and depot medroxyprogesterone acetate, have the lowest rate of pregnancy (does not exceed 2-3%) among nonpermanent methods of contraception.
☻"Norplant" consists of six capsules of levonorgestrel which are placed sub-dermally, generally in the upper arm. It offers contraceptive protection for about five years. ►The most common complication is menorrhagia (prolonged vaginal bleeding during each period), which occurs in about 28% of the cases.

Numerous commonly used anti seizure medications (e.g., phenytoin, carbamazepine, ethosuximide, phenobarbital, topiramate) are known to decrease the efficacy of OCs oral contraceptives.
Alternative anti seizure medications that do not decrease oral contraceptive efficacy include Gabapentin and Valproate.
Combination oral contraceptive pills (OCPs) are the most reliable form of reversible contraception; however, the use of these hormonal drugs may affect a person"s TBG, total T4, and free T4 levels.
The estrogen component of the combination pill increases Thyroxine Binding Globulin (TBG) an increase in the total T4 levels and decrease inlevels, which may result in free T4 levels.
Check with: total T4, Free T4, Total T3 and TSH
A person with an intact and normal thyroid gland may compensate for these changes by increasing thyroid hormone production, which normalizes the free T4 levels.
On the other hand, a hypothyroid patient cannot compensate for these possible physiologic changes since she is unable to produce sufficient amounts of thyroid hormone and is dependent on levothyroxine therapy.
The dosage of levothyroxine may therefore be increased in hypothyroid patients who are taking OCPs to compensate for the mentioned physiologic responses.
After starting combination OCPs in well-controlled patients with hypothyroidism, TSH levels should be checked in 12 weeks, and the dose of levothyroxine should be adjusted accordingly.

♥ Studies have shown that adolescents in a private practice setting are very concerned about the prospect of gaining weight secondary to oral contraceptive (OCP) use. However, available data has demonstrated that OCPs do not cause an increase in body weight or percent body fat. Occasionally adolescents voice other concerns about OCP use, including fears of developing blood clots, birth defects, and infertility, but these concerns are more common in the lower socioeconomic groups.
Chronic OCP can cause hypertension, discontinue it and problem goes away.
SLE pts with increased risk of thrombosis (antiphospholipid and nephritic synd) and pts with active renal involvement should avoid OCP.
Pt with Migraine should avoid OCP due to increased risk for Stroke.
Breast cancer has NO assoc with COP.
Endometrial and Ovarian cancers risk is decreased with use if OCP.
When you 1st start taking it could cause irregular bleeding and that is the mcc of incompliance. Tell the pt to keep taking it and it will be OK.
The accidental usage of oral contraceptives during the first trimester of pregnancy is not associated with an increased risk of fetal malformation.

Human papilloma virus (HPV): infection
-Is a sexually transmitted infection strongly linked with the development of cervical intraepithelial neoplasia (CIN) and cervical cancer. -Early initiation of sexual activity, multiple new sexual partners, and high-risk partners (partners with HPV infection), are the main risk factors for the acquisition of HPV infection and cervical cancer.
◘ Sexual intercourse, especially with multiple new partners, is the main risk factor for the acquisition of HPV infection.
◘Screening for cervical cancer by cytologic examination/Pap smear is an effective way of detecting early pre-invasive and invasive carcinoma.
◘ The risk of acquiring HPV infection (and, hence, CIN/cervical cancer) is much lower in lesbian women if they do not engage in sexual intercourse with men.
BUT: Lesbian women still need to undergo routine screening for cervical cancer
►The risk of acquiring HPV infection (and CIN/cervical cancer) is lower in lesbian women if they do not engage in sexual intercourse with men.
►The risk of cervical neoplasia is highest in lesbian women who have had sex with more than one male sexual partner, have an early age at first coitus with men, have been infected with HPV, and have been treated for an abnormal cervical cytology test in the past. ►The risk is also increased with cigarette smoking.

►Annual screening by Papanicolaou smear is recommended for all women approximately three years after the onset of vaginal intercourse, or at the age of 21, whichever is earlier.
♥ According to the guidelines, screening for cervical intraepithelial neoplasia (CIN) or cancer should be started three years after the onset of sexual intercourse, or at the age of 18 years (recently changed to 21 years) whichever is earlier. This is due to the fact that high-grade cervical cytologic abnormalities due to HPV usually do not occur until three to five years after HPV exposure.

Colposcopy, Endo♥After a Pap abnormal cervical curettage and Ecto cervical curettage. RESULTS:
-A colposcopic examination is Satisfactory when an entire lesion and a transformation zone are visualized.
-If there is progression during the follow-up, or lesions are treatment is indicated.persistent after one year

-When the colposcopic the next step is always excision as this allows forexam is Unsatisfactory histological examination. Even if colposcopic examination is satisfactory, treatment may be indicated if the patient is anxious about her disease, or if she seems to be non-compliant with follow-up.
-If the patient opts for ablation or excision.treatment, available modalities are either
►Ablation with cryosurgery or lasercan be done
with knife►Excision can be done conization, laser conization, or Loop Electrosurgical Excision Procedure (LEEP).


1. - ASCUS. Atypical squamous cells of unknown significance
HPV DNA testing from sample is the best test to evaluate atypical squamous cells of unknown significance. In this method, samples are collected both for cytology and HPV DNA
►If cytology results are negative the sample for HPV DNA is discarded
HPV►If cytology results are positive, DNA testing is performed, and if this test is positive for high-risk HPV type, an immediate colposcopy is performed.
►If the test is negative for high-risk HPV type, the Pap smear is repeated after one year.

2. HGSIL -High-grade squamous intraepithelial lesions include:
- CIN II, CIN III, moderate and severe dysplasia, and CIS carcinoma in situ
-High-grade squamous intraepithelial lesions are more likely to be progressive than low-grade lesions, and these should always be treated with ablation or excision.
Cryosurgery or laser☻Ablation
knife conization, Laser☻Excision conization or Loop Electrosurgical Excision Procedure (LEEP)
- Loop Electrosurgical Excision Procedure (LEEP) is the treatment of choice for high-grade squamous intraepithelial lesion.***LEEP is preferred because of its low cost, accuracy, and easiness to perform. It is a very successful procedure and can be performed in an office setting.
- A HGSIL revealed on Pap smear indicates a 1-2% probability of already having invasive cervical cancer and a 20% probability of acquiring invasive cervical cancer if left untreated.
►Immediate referral to colposcopy and endocervical curettage is indicated.
a Diagnostic excisional procedure should be►If colposcopy suggests HGSIL performed.

3. LSIL- Low-grade squamous intraepithelial lesions or low-grade cervical intraepithelial neoplasia (CIN I)
-Regress spontaneously; therefore
Expectant management is preferred for biopsy proven CIN 1 with satisfactory colposcopic examination.
repeatExpectant management includes cytology at 6 and 12 months, or HPV DNA testing at 12 months.

Bleeding
• -is the most common short-term complication after cervical conization (cone biopsy), both cold knife conization and LEEP. The causes of bleeding include inadequate intraoperative hemostasis and vasodilatation after the effect of the local vasoconstrictor wears off. Usually, the bleeding can be easily controlled by conservative measures. Surgical hemostasis is rarely required.
• All women at high risk of HPV infection and a normal Pap smear have annual Pap smear tests.should

Cervical stenosis and cervical incompetence from LEEP surgery
• Surgical treatment of cervical intraepithelial neoplasia before conception increases the incidence of cervical incompetence and preterm birth 200-300%. It is thought that the risk is proportional to the amount of tissue removed during the procedure.
• ►Frequent cervical examinations in the second trimester will aid in determining if either cerclage is necessary in the short term or cesarean section is necessary in the long term.

HIV/pregnancy:
• All HIV-positive adults are normally counseled to receive HAART (highly active antiretroviral therapy), which is a combination of two nucleoside analogue reverse transcriptase inhibitors and one protease inhibitor or one non-nucleoside reverse transcriptase inhibitor.
• An HIV-positive woman who is already receiving HAART should be counseled to continue her treatment regimen if her pregnancy is after the first trimester. (Zidovudine in particular is consideredidentified an essential component of the treatment regimen as it has been demonstrated to significantly decrease the vertical transmission of HIV.)
• For those HIV-positive women whose pregnancies are identified Early on in the first alternative is to discontinue HAART for the remaindertrimester, an acceptable of the first trimester and then resume it thereafter.
• Ultimately, the preferred mode of delivery in all HIV-positive women is elective cesarean section.
• Efavirenz and Delavirdine are thought to have some teratogenic qualities and are best avoided during pregnancy if other options are available.
• Studies have shown that HIV can be transmitted through breast milk. Worldwide, it is estimated that one of every eight babies born to HIV-positive women will acquire the virus through breastfeeding.
• For this reason, HIV-positive women in the United States and other industrialized countries who have ready access to commercially prepared formula are advised to feed their infants with formula instead of breast milk.
• Most antiretroviral drugs are passed through breast milk in significant quantities, which is thought to decrease HIV transmission by indirectly providing the drugs to the infant. This understanding – accompanied by the concern that formula is often too difficult or expensive to obtain in developing countries – is the justification for suggesting that HIV-positive women in developing countries be given HAART while breastfeeding their children. However, the recommendation in the United States remains that HIV-positive women feed their infants with formula instead of breast milk, regardless of therapy given to the mother or infant.

Condyloma acuminata:
• This is the dermatologic manifestation of an infection with the human papilloma virus, with over 90% of such condylomas arising from HPV subtypes 6 and 11 specifically. HPV is primarily transmitted through sexual contact, and the areas affected include the penis, vulva, vagina, cervix, perineum, and perianal region. Less frequently, HPV may be found in the oropharynx, larynx, or trachea secondary to oral-genital contact or secondary to vertical transmission from mother to infant during childbirth.
• One relatively common benign laryngeal tumor in children, recurrent respiratory papillomatosis, is caused by the acquisition of HPV during passage through the vaginal canal.
• However, since HPV is thought to be contracted by the infant in less than 1% of all childbirths to women who have condylomas, no intervention is usually undertaken

Pelvic inflammatory disease (PID): The risk factors for PID include the following:
1. Oral contraception
2. No barrier contraception
3. Multiple sexual partners
4. Age < 35 years
5. History of previous episodes
6. African-American ethnicity
-Studies have shown that among all the PID risk factors, having multiple sexual partners is the one associated with the highest increase in risk for occurrence of PID (4.6 to 20 fold increase in risk).
-The presence of fever, chills, bandemia, leukocytosis, as well as nausea and vomiting, indicates that the infection is severe. PID can be a serious condition that needs to be treated immediately.
►Treatment of severe PID is aimed at obtaining high blood concentrations of the antibiotics as soon as possible. For this reason, all therapy should be intravenous.
►Combinations that can be used are: cefoxitin + doxycycline or ceftriaxone + doxycycline.
►If a tubo-ovarian abscess is diagnosed, surgical evaluation is immediately needed.

• Tubo-varian abscess
-Is seen in 10% of pt w PID. Admit the pt, Broad spectrum antibiotics should be started immediately AFTER taking cultures. Gentamycin+Clindamycin+Ampicillin. In absence of obvious response w/i 48 hours , do Laparoscopy.drainage should be considered. If there is doubt regarding Dx
If rupture we need to do exploratory Laparotomy.

• Vaginitis,
-Candida it’s not an STD. It may appear in presence of risk factors like DM, OCP, pregnancy and immunosupresive therapy. It can also trigger by Alkaline pH of the vagina during menses that is favorable for growth of Candida.
-Symptoms are vaginal and vulvar pruritus, burning and dyspareunia.
-Discharge has cottage cheese appearance. It’s NOT malodorous and pH is 4-4.5.
-Dx is by KOH wet mount preparation and visualization of pseudohypha and spores.
Tx is Imidazole cream or 10 day oral Ketoconazole (especially if recurrent). Fluconazole is the new drug with fewer SE. Give 2 doses, a week apart. Most recurrences are due to non-compliance. If that is OK, then suspect another organism and culture on Saboraud. 50% of recurrence is due to other organism like like T. Glabrata and Candida tropicalis. In addition, 35% of pt with recurrent yeast infection and who have negative cultures, have HPV on biopsy.
DD: Trichomonas (Metro)

• Gardenella Vaginitis (Metro).


Mittelschmerz:
-It’s a mid-cycle (LMP was 2 weeks ago) abdominal pain that typically presents in young females. If there is no fever it’s not PID.

Vaginismus:
-Involuntary spasm of the perineal musculature that interferes with sexual intercourse.
Unlike Dysparunia, Vaginismus is not due to any medical cause. In ALL cases it’s due to ignorant of women's anatomy, huge apprehension about penetration, and an uncontrollable fear of pain. Tx includes relaxation, Kegel excercise (to relax vaginal muscle), and graduation dilation (penetration).

Chlamydia trachomatis:
-Genitourinary infection caused by Chlamydia trachomatis is extremely common, and results in insidious and often chronic unrecognized disease. The large majority of women (up to 70 percent) are asymptomatic.
-It is a major cause of infertility, pelvic inflammatory disease (PID), and ectopic pregnancy in women.
-Some of the risk factors associated with the development of Chlamydia trachomatis infection include younger age with multiple sexual partners, inconsistent use of barrier contraceptives, and a history of prior sexually transmitted disease (STD).
-The Centers for Disease Control recommend that all pregnant women be screened for Chlamydia at the first prenatal visit.
-Women under age 25 and those at increased risk for chlamydial infection should have repeat testing in the third trimester.
-Chlamydia endometritis during pregnancy can lead to chorioamnionitis and premature delivery of the fetus. -Untreated infection during pregnancy can also lead to conjunctivitis (ophthalmia neonatorum) and pneumonia in the newborn baby.
-Chlamydia infection is a sexually transmitted disease. Pregnant women under age 25 and those at increased risk for have repeat testing in the thirdchlamydial infection should trimester.
►Chlamydia infections are susceptible to tetracyclines, macrolides, and fluoroquinolones. Azithromycin (1 g PO as a single dose) and doxycycline (100 mg PO BID for 7 days) are the two most commonly used and recommended treatment regimens in the general population. Some of the other less frequently used alternative regimens include seven days of an erythromycin base (500 mg PO QID), erythromycin ethylsuccinate (800 mg PO), ofloxacin (300 mg PO BID), or levofloxacin (500 mg PO QD).
►Presumptive treatment of the partners is crucial in the management of these patients to prevent recurrence/reinfection.
-Doxycycline, the fluoroquinolones, and erythromycin estolate are contraindicated for use in pregnant women.
-The recommended regimens during pregnancy include erythromycin base (500 mg PO QID for 7 days) and amoxicillin (500 mg PO TID for 7 days).
-Azithromycin (1 gm as a single dose) is an alternative, though it has not been well tested in pregnancy.

• Lymphoganuloma Venereum
-It’s a STD caused by C. Trachomatis. Serotype L1L2L3. Initially there is headache and fever, then a papule appears that turns in to an ulcer typicaly in vulvovaginal region. Ulcer is painless and disease may go unnoticed until inguinal adenitis develops a month after.
becomes chronic causing►If untreated at this stage LGV ulceration, PROCTATITIS, rectal stricture rectovaginal fistulas and elephantiasis.
Tx is Doxycycline or Erythromycin .
DD: Granuloma Inguinale is caused by Donovania granulomatis, Unlike LGV the ulcer and lymphadenopahty present simultaneously. Also the ulcer here has irregular borders and beefy red granular base.
-Recommended Tx include azithromycin, doxycycline, erythromycin.

• Trichomoniasis:
-Trichomoniasis is a sexually transmitted infection caused by the protozoa Trichomonas vaginalis. The infection may be entirely asymptomatic or may be characterized by a copious frothy gray-green vaginal discharge, fishy odor, vulvar and vaginal pruritus, or dysuria.
-Treatment is indicated for all women diagnosed with trichomoniasis and their sexual partners, and metronidazole is considered the treatment of choice.
-Metronidazole is known to enter breast milk in significant concentrations, but few adverse effects have been reported in infants. Therefore most physicians recommend that lactating women be treated with
• Metronidazole 2g PO for 1 dose and that breastfeeding be discontinued for 12-24 hours only.

• Vulvovaginitis:
-is an extremely common condition in the sexually active age group. The etiology of symptoms includes infection of the vulva, vagina, and cervix, and the noninfectious causes are chemicals and irritants, hormonal disorders, and, rarely, some systemic disorders. Common infectious causes are vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis.
-Most of the symptoms of vaginitis are nonspecific, and self-diagnosis and treatment by the patient is unreliable. Even diagnosis by history and physical examination by a physician is not reliable and should always be confirmed in the office by microscopy. This is important to avoid frequent misdiagnosis and inappropriate treatment.
-Most common techniques used are saline and KOH preparation for microscopy. The vaginal secretions have characteristic pseudohyphae in candidiasis.
-Bacterial vaginosis is confirmed by the presence of clue cells in the smear.
-Motile trichomonads and an abundance of polymorphonuclear cells are found in patients with trichomoniasis.

• Pelvic cystic mass:
-A pregnant woman with a pelvic cystic mass needs to be observed carefully. If the mass is larger than 5 cm in size and persists beyond the first trimester or shows no regression in subsequent visits, surgical intervention is indicated.
-Removal of the cyst is recommended during the second trimester to avoid acute complications that lead to preterm delivery or abnormal labor.

• Ascites:
-Abdominal paracentesis and ascitic fluid analysis is the most reliable way to differentiate between the different causes of ascites. The most common cause of ascites in the United States is hepatic cirrhosis.
-Some of the other causes are cancer, congestive heart failure, peritoneal tuberculosis, nephrotic syndrome, and pancreatic disease.
The differential diagnosis of ascites can be narrowed down by calculating the serum to ascitic fluid albumin gradient (SAAG).
==This is done by subtracting the ascitic fluid albumin value from the serum albumin value. SAAG value is useful in identifying the presence or absence of portal hypertension.
>SAAG value of > or = 1.1 g/dL indicates the presence of portal hypertension. Clinical conditions associated with high SAAG (> 1.1 g/dL), include cirrhosis, congestive heart failure and alcoholic hepatitis.
-Conditions associated with low (< 1.1 g/dL) albumin gradient; include peritoneal carcinomatosis, peritoneal tuberculosis, nephrotic syndrome, pancreatitis, and serositis

Premenstrual syndrome (PMS):
-Abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido 7 to 10-days before the start of each menstrual cycle.
-The presence of symptoms such as this patient is presenting, after menstrual cycle begins or after ovulation, points out to the diagnosis of premenstrual syndrome (PMS).
-Symptoms usually disappear near menses and the patient is symptom free until her next ovulation.
-Psychological symptoms may include anxiety, mood swings, difficulty concentrating, decreased libido and irritability.
-PMS has to be differentiated primarily from major depression because there is an association between puerperal depression, menopausal depression and PMS.
-A menstrual diary for at least 3 cycles is a useful aid for confirming the diagnosis in suspected cases; PMS is confirmed when one or several particular symptoms occur repeatedly at the same time of the several cycles.
-Once the diagnosis is confirmed, treatment depends on the patient's complaints.
-There is no universally accepted treatment.
-Reduction of caffeine intake may reduce breast symptoms.
-Exercise program may be effective in improving the general well being.
-Recently, selective serotonin reuptake inhibitors have been shown to be beneficial in double blind controlled trials and now the drug of choice for mood decline.

Amenorrhea:
-Amenorrhea is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended.
-Women athletes with this condition have been shown to have decreased levels of luteinizing hormone (LH) and gonadotropin-releasing hormone (GnRH), resulting in an estrogen deficiency.
-These amenorrheic women are therefore at increased risk for all conditions associated with estrogen deficiency, including infertility, vaginal atrophy, breast atrophy, and osteopenia.

Females who maintain a lower weight or body mass index (BMI) due to the sport or activity that they regularly engage in (e.g. ballet dancers, gymnasts, and runners)
-may become hypoestrogenic and present with exercise-induced amenorrhea.
-They are at special risk of developing osteopenia, and even osteoporosis.
-Spontaneous fractures have been reported in these types of patients, with osteoporosis or osteopenia confirmed through bone densitometry.
-Treatment consists of improving caloric intake; if this is not possible, patients are started on hormonal replacement with oral contraceptives and supplementation with calcium and vitamin D.
-The most common cause of secondary amenorrhea is pregnancy.
-Drugs that inhibit or induce the cytochrome P450 system can reduce oral contraceptive efficacy.

1. Infertility:
-The first step in WOMEN is to check Basal Body Temperature and mid luteal PROGESTERONE. The ovulatory factor involves defects in the hypo-thalamic pituitary ovarian axis, and related infertility maybe due to impairment of follicular maturation ovulation or endometrial development. BBT assess the DURATION luteal finction and MLP asseses LEVEL of lutal function.
-Endometrial biposy is done to confirm luteal phase defect. Rather than initial evaluation.

• MALES:
-According to the recent studies, male factors account for 20-30% of the infertility causes.
-Semen analysis is therefore performed early in the evaluation of the infertile couple. It is usually the initial screening test, and it evaluates sperm concentration, motility, and morphology.
-Identification of azoospermia and severe oligospermia are likely causes of infertility. Although cutoff values for semen analysis exist, there is a broad overlap in the values of the semen measurements in fertile and infertile samples; therefore, borderline results should be interpreted with caution.
-If sperm analysis is normal then an endocrine hormonal evaluation is carried out. It includes:
1-TFT (since increased TSH inhibits GnRH and then decrease FSH.
2-Testosterone levels to indicate the presence or not of Gonadism
3-Gonadotropin to determine whether hypogonadism is central or testicular and
4-Prolactin levels

• Causes of infertility in females falls in 4 factors:
1-Peritoneal factor
2-Ovulatory
3-Cervical
4-tubo-uterine
►Peritoneal is the mc type and includes Endometriosis and peritoneal adhesions.
-Laparoscopy is the procedure of choice for dx and tx.
-Mild forms of endometriosis usually respond to meds like GnRH agonists, Danazol and Medroxyprogesterone.

2-Ovulatory factor involves hypothalamus-pit-ovary axis and infertility might be due to impairment of follicular maturation, ovulation,or endometrial development. ovulatory abnormality may initially be screened by Basal body temp and midluteal phase level of progesterone, the former assesses Duration and later LEVEL of luteal function.
♥If luteal phase shows low progesterone, hence infertility, then tx is suppository progesterone deposition.

3-Tubo0uterine is seldom a cause. It involves Fibroids, endometrial polyps, tubal occlusion (2ary to IUD or endometriosis).
-Investigation is hysterosalpingography or laparoscopy.

4-Cervical involves cervical structure abnormalities and abnormal mucus production. In 5-10% infertility remains unidentified. Intrauterine insemination is the tx.

Clomiphene Citrate is an antiesterogen that acts by competitively inhibiting estrogen receptors at hypo-thalamus, thus inhibiting the negative feed back estrogen has on GnRH production and consequently increasing LH & FSH secretion and improving ovulation.
Along with HCG and HMC it’s indicated for chronic anovulation. Side effects include large ovaries, hot flashes, abdominal bloating, breast discomfort and abnormal uterine bleeding.


►A Retroverted uterus
-It’s a common condition found in 11% of the female population
-If this condition is secondary to chronic PID or endometriosis, it can be associated with infertility. It is also related to dyspareunia, low back pain, and dysmenorrhea.
-If it is not spontaneously corrected during pregnancy before the second trimester, it can lead to uterus incarceration and be life-threatening. It is not an etiologic cause of abortion.


• Chances of infertility in a female with cystic fibrosis are 20% percent. ►This increased risk is due to secondary amenorrhea caused by malnutrition, and is also due to thick, tenacious cervical mucus.
• Chances of infertility in a male with cystic fibrosis are 95%. ►Spermatogenesis is normal in a patient with cystic fibrosis, but sperm transport is impaired because of impaired development of the Wolffian duct.

A defect in the luteal phase:
-A defect in the luteal phase refers to a relatively low progesterone secretion by the corpus luteum.
-Progesterone is important for embryo implantation and maintenance of pregnancy, so a defect in its secretion may cause infertility even if ovulation takes place. The defect may affect the level or duration of production of progesterone.
-Luteal phase defect is suggested by short cycles, history of spontaneous abortion, abnormal basal body temperature (BBT) or low levels of midluteal progesterone.
-The diagnosis is confirmed by endometrial biopsy, which demonstrates a lag in endometrial maturation of 2 days or more as compared with normal states.
-RX- Luteal phase defect is treated with progesterone vaginal suppositories.
-Clomiphene citrate or human menopausal gonadotropin (hMG) may be used if progesterone suppositories give no results; they increase serum FSH level and thus correct follicular maturation and oocyte expulsion
-As mentioned above, luteal phase defect refers to a deficiency in progesterone production; therefore, combined oral contraceptive pills are not appropriate.
Danazol is an androgen derivative that has a gonadotropin inhibitory effect. It is indicated in endometriosis, fibroids and fibrocystic breast disease.

Polycystic ovarian syndrome (Stein-Leventhal syndrome):
-infertility, menstrual irregularity, obesity, hirsutism, and increased ovarian volume measured by ultrasonography.
-Anovulation is the principal cause of infertility in patients with polycystic ovarian syndrome. Interestingly, several studies have demonstrated that weight reduction in overweight or obese patients with this syndrome is associated with restoration of ovulation, decrease in androgen production, and pregnancy. Furthermore, the data from these studies indicate that even a moderate reduction in weight may restore fertility.

Insulin-resistant hyperinsulinemia is a common finding in patients with PCOD.
-PCOD is an important risk factor for development of DM-2 in women. About 10% of diabetes in premenstural women is POS related.
A two hour test►Thus a glucose tolerance test is needed in all POS pts. with > 140 is Dx and needs further action.
►RX: Life style modification and Metformin is then indicated.
Metformin helps in following ways:
1-prevents DM,
2-Causes anorexia and prevents obesity,
3-corrects hirsutism mildly, 4-menstural irregularity and infertility
☻The treatment of PCOS is directed primarily at the problems of hirsutism, menstrual irregularity, and infertility. ♣Treatment modalities for hirsutism include ovarian and adrenal antiandrogen therapy, and local depilatory measures. Oralsuppression, contraceptives are a simple and relatively safe method of ovarian suppression and will often normalize the menstrual cycle. The estrogen component in oral contraceptives increases the sex hormone binding globulin with a resultant decrease in free testosterone. This reduces the symptoms of excessive hair growth and acne.
♣Clomiphene citrate is the drug most commonly used to induce ovulation in patients with polycystic ovary syndrome (PCOS).
-This condition should be suspected in any pt who has menstrual irregularities, and evidence of Hyperandrogenism (facial hair). Presence f these establishes the dx.50% of pts are obese and are at risk of DM-II.
do Oral glulcose►The next step is to tolerance test
Characterized by unbalanced Estrogen secretion resulting in Endometrial Hyperplasia.

• Ovarian HyperStimulation Synd
-Major complications of ovulation induction are multiple gestation and OHSS. OHSS occurs in 1-3% of pts. It develops 5-7 days after administration of hMG or hcg and refers to acute increase in vascular permeability of enlarged ovaries. Symptoms include abdominal pain, distension, nausea, vomiting diarrhea, weight gain, hypotension and pleural effusion.
-Ovaries are large in US. OHSS maybe complicated with ovarian torsion, ovarian rupture, renal insufficiency.
- Symptoms resolve in 1-2 weeks, but may persist longer is pregnancy is successful.
-Tx is supportive.

• Androgen insensitivity syndrome:
-The combination of primary amenorrhea, bilateral inguinal masses (one removed earlier and one palpable in this case), and breast development without pubic or axillary hair is strongly suggestive of androgen insensitivity syndrome.
-This condition is related to a mutation of the androgen receptor (AR) gene, making peripheral tissues unresponsive to androgens that are typically available in normal concentrations in these patients. Although the genotype is 46, XY, a female phenotype develops.
-Breast development is present, because testosterone is converted to estrogen; however, there is no pubic or axillary hair.
-No mullerian structure is present (uterus, fallopian tube), and the vagina ends with a blind pouch.
-Primary amenorrhea is usually due to chromosomal abnormalities and physiologic delay of puberty (45% and 20% of causes, respectively). In both cases, development of secondary sexual characteristics is delayed.
-Imperforate hymen presents as cyclic, pelvic or abdominal pain with primary amenorrhea. Sometimes, a small suprapubic mass (the uterus containing retained menstrual blood) can be palpated. Perineal exam will reveal a bulging, bluish membrane between the labia.
This bluish or violaceous discoloration is due to blood sequestration behind the imperforate hymen, and is also known as hematocolpos.

• Testicular feminization
-defect or absence of androgen receptor results in feminine phenotype with 46XY genotype
- MIF is produced by gonads, so uterus and vagina are absent.
-Breast develop because peripheral production of estrogen, whereas axillary hair and pubic hair does not.
-Tx is testicular resection at puberty and creation of a neo-vagina. Pt presents with amenorrhea, developed breasts, absent pubic and axillary’s hair, absent internal reproductive organs and a 46XY karyotype.

• Turner syndrome:
-Ovarian function and morphology is highly variable in patients with Turner syndrome. Most patients do not undergo puberty, and present with primary amenorrhea. Some patients may develop normally and undergo spontaneous menarche, but secondary amenorrhea may occur after some time. Such patients may become pregnant without medical assistance before developing secondary amenorrhea; however, most women are infertile. In one retrospective study of 522 patients, three women became pregnant spontaneously.
Summary: Pregnancy is almost impossible, but there still remains a very small chance, in patients with Turner syndrome.

• Endometriosis:
-is a progressive disease typically diagnosed in women aged 25 to 29 years, and is thought to affect 5-10% of all women. It is characterized by the presence of endometrial tissue in the ovaries, fallopian tubes, or other abnormal sites, and commonly causes significant pelvic pain and infertility.
-Typically pt presents with Dysmenorrhea, Dyspareunia (when endometriomas is in cul-de-sac), Dyschezia (Pain on defecation), hematochezia, hematuria, and pre post menstrual spotting.
-Endometriosis should be considered a strong likelihood in women who experience dysmenorrhea after years of painless menstruation.
-Diagnosis
-Is difficult and is best done with direct visualization of the implants by laparoscopy or, less commonly, laparotomy. Laparoscopy is GOLD standard which shows powder burns.
-The hemorrhage of endometriomas into the ovaries results in formation of cystic cavity filled with blood with dark color, hence the name 'Chocolate cyst'. To complicate matters, there may be little correlation between the clinical manifestations and the actual extent of endometrial implants.
-The most frequent sites of involvement are the ovaries, cul-de-sac, broad ligaments, uterosacral ligaments, uterus, fallopian tubes, and sigmoid colon.
Endometriosis may also involve intestinalthe appendix, cecum, and colon, which may lead to obstruction.
-Endometriosis can be treated medically or surgically.
RX-The first line of tx is OCP. They cause a state of pseudo pregnancy and causing an "exhaustion atrophy" of the endometriomas.
-If OCP fails or not Danazole, its an androgen derivative that causestolerated then we give Pseudomenopause state. -SE is acne; hirsutism deep voice.
-GnRh agonists have an inhibitory action of LH & FSH when given continually which produces temporary castration. It’s also a 2nd line of choice.
-Surgical treatment involves removal of lesions through bipolar coagulation or laser vaporization, while severe cases may require hysterectomy and bilateral salpingo-oophorectomy.
-In patients with severe or unresponsive symptoms (including infertility), the standard of care requires that confirmatory laparoscopy be performed to definitively establish the diagnosis of endometriosis before instituting treatment.
DDX:
-Vaginismus, use Vaginal dialators. -Pain disorder, pain in one or more anatomical site, pain management training.
-Somatization disorder, tx is follow up visits regularly scheduled.
-Endometriosis is the location of tissue outside uterine cavity so hysterosalpingogram can’t see it.

• Dysfunctional uterine bleeding (DUB):
=Heavy unremitting endometrial hemorrhage through the menarche and peri-menopause requires:
► 1- (IV) high dose conjugated estrogens to suppress bleeding, and to ensure cardiovascular stability.
► 2- Once cardiovascular stability is achieved D&C should be performed.
The most common cause of dysfunctional uterine bleeding (DUB) in adolescent women is anovulation. So, endometrial biopsy is not required in these patients.
Uterine ablation:►Once the bleeding is stopped advice the patient to: take 25 mg of oral conjugated estrogen daily for 25 days; add 10 mg of medroxypreogesterone for the last 10 to 15 days of treatment; then allow 5-7 days for withdrawal bleeding. All this in order is to mimic the menstrual cycle.
In which pts with DUB do you perform endometrail biopsy to rule out endometrial carcinoma? When a pt is >35, obese, DM or has chronic HT

• Menopause: high FSH*
-Most females rapidly lose considerable bone mass following menopause.
-Lifestyle modification, including weight bearing exercises and optimum calcium and vitamin D supplementation, prevents postmenopausal bone mass loss and possibly reduces the risk of fragility fractures.
☺ The National Academy of Science recommends daily supplementation of elemental calcium (1200 mg) and vitamin D (400 to 800 international units) in women after 50 years of age.
-This can be easily achieved by taking one multivitamin tablet (which contains 400 international units of vitamin D) with two tablets of calcium/vitamin D (containing 600 mg of elemental calcium and 200 international units of vitamin D) everyday.
Short-term use of low-dose estrogen for menopausal symptoms does not appear to be harmful; however, hormone replacement therapy fell out of favor following a recently published study of the women’s health initiative because of increased, undesirable cardiovascular and other side effects.
-Exercise with weight bearing leads to improvement in bone mass -However, exercise should be individualized in patients with significant osteoporosis, since they have a higher risk of fracture. In such patients, stressful exercises should be avoided as much as possible.
►Recently published women’s health initiative studies show that older postmenopausal women on hormone replacement therapy are at an increased risk for myocardial infarction, deep venous thrombosis, strokes, and breast cancer.
-The findings of this study do not apply to younger patients with premature ovarian failure
♥RX -Hormone replacement therapy in the form of conjugated equine estrogen and medroxyprogesterone with careful monitoring can be safely used in younger patients without any excessive cardiovascular risk.
-The use of bisphosphonates in older, postmenopausal women has been extensively studied, and has been shown to be very useful in the treatment of low bone density.
-On the other hand, bisphosphonates are not very well studied in younger patients with low bone density. The long-term effects of bisphosphonates such as alendronate or etidronate are unknown in younger patients.
-Furthermore, although risedronate (bisphosphonates) may improve bone mineral density in this patient, it will not improve her hypoestrogenic symptoms; therefore, it is not the preferred drug regimen.

• Premature ovarian failure:
Premature ovarian failure refers to a failure of estrogen production by the ovaries that occur in women less than 35 years. It may be secondary to an increased atresia or a reduced number of primordial follicles. It is most commonly idiopathic but may also be due to mumps, oophoritis, irradiation or chemotherapy.
-It can be associated with disorders such as Hashimoto's thyroiditis, Addison's disease, type I diabetes mellitus and pernicious anemia, which supports the hypothesis of an autoimmune origin.
-Diagnosis is confirmed by increased FSH serum levels and in patients less than 30 years.
-A chromosomal analysis becomes necessary in order to rule out the presence of a Y chromosome.
-Since patients with premature ovarian failure lack viable oocytes, measures of ovulation induction, such as clomiphene citrate, hCG and hMG, will be useless, and the only option such patients have to restore fertility is egg or embryo donation.
Ovarian failure, chemo induced chemotherapy causes failure of follicular cells of the ovary resulting in decreased production of estrogen and inhibin. This result in loss of feedback inhibition of estrogen on FSH and LH , causing their high levels. Inhibin causes feedback inhibition of FSH only, so in the absence of inhibin, FSH levels are higher than LH which is pathognomonic of ovarian failure.
-Clinically, pts have Amenorrhea, hot flashes. They might develop anxiety, depression and irritability.
-Loss of estrogen results in atrophy of breast, vagina, myometrium.

• Postmenopausal bleeding:
-The most common cause of postmenopausal bleeding is atrophic vaginitis (50-60%).
-However, one should always rule out the most serious conditions, such as endometrial carcinoma (less than 10%) by obtaining endometrial biopsy.

Atrophic vaginitis
-is characterized by vaginal dryness, burning, dyspareunia, reduced vaginal secretions, and vulvar pruritus. Occasionally, urinary symptoms such as dysuria, hematuria, and discomfort are also seen. Pelvic examination typically reveals loss of labial fullness, pallor of the vaginal epithelium, and decreased vaginal secretions. The condition commonly occur secondary to declining estrogen levels in postmenopausal women.
-In nonmenopausal women, estrogen production can be countered by radiation therapy, chemotherapy, immunologic disorders, oophorectomy, and lactation.
-RX: Atrophic vaginitis is treated with hormonal replacement therapy, transvaginal estrogen replacement (e.g., creams, hormone-releasing rings), or lubricants.
DD: -Vulvar cancer most often occurs in women aged 65-75 and is characterized by a long history of pruritus. Vulvar bleeding, discharge, dysuria, and pain are reported less often.
-A raised vulvar lump or mass is apparent on pelvic examination, and may be fleshy, ulcerated, leukoplakia, or warty in appearance. -Cervical cancer most often occurs in women aged 40-60.
-Women at increased risk for developing cervical cancer include smokers and those with a history of sexually transmitted diseases, human papillomavirus infection, low socioeconomic status, two or more lifetime sexual partners, or immunosuppression (e.g., AIDS). -Cervical cancer is responsible for less than 1% cases of postmenopausal bleeding.

• Breast mass:
-Most of the palpable breast masses in young patients (less than 35 years of age) are due to benign etiology, most commonly benign fibrocystic disease or fibroadenoma of the breast.
-The symptoms of fibrocystic disease may get worse during pregnancy due to the hormonal changes in the body. Despite these facts, any complaints of a dominant mass in the breast should be thoroughly evaluated to exclude malignancy.
-A dominant breast mass characterized by a hard, single, and immobile mass with irregular borders should raise the suspicion for malignancy.
-A cystic breast mass should be evaluated with fine needle aspiration biopsy to obtain tissue or fluid for a more specific diagnosis. The goal of aspiration is complete drainage of the cyst and collapse of the cyst wall.
►Clear cyst fluid may be discarded, with a follow up exam in 4-6 weeks.► If the mass persists at that time it may be -Any blood-tinged fluidre-aspirated and further workup may be warranted. obtained should be sent for cytologic analysis. If the fluid is non-bloody, the patient should be reassured and reexamined in four to six weeks to check for any signs of recurrence.
-Excisional biopsy is invasive and does not need to be the first step in a breast cyst evaluation. If the mass persists, definitive evaluation with a biopsy would be an appropriate next step.

• Fibroadenoma:
1x1 cm firm rubbery freely mobile round mass in a 35 yo women w/o axillary nodes palpable. Best initial step is Mammogram.


• Breast Carcinoma:
Inflamatory beast cancer: Erythema and edema of non lactating breast could be due to locally advanced cancer, biopsy should be done first to rule out that dx. Tx is 2-3 weeks of combination chemotherapy to shrink the tumor allowing sybsequent extended resection.
-Metastatic Breast Cancer has a poor prognosis. With little chance of cure=its important to choose Local (Surgery) vs. Systemic (Systemic Chemotherapy) tx in pt with metastatic breast cancer. Tumor burden, based on TNM staging, is considered the single most important prognostic consideration in treating pts with breast cancer. ER+ and PR+ are good prognostic factors. Over expression of Her2/Neu oncogene is worst prognosis.
-Breast cancer is the leading cause of metastatic skin disease in women. These lesions are erythematous that present as erosions covered by necrotic skin. Tx is palliative radiation therapy with aggressive wound care.
Two prohibitions when having breast cancer in pregnant: No chemo in 1st trimester, and no Radiotherapy anytime in pregnancy. Also Lumpectomy is not a good choice for 1st trimester cause it needs Radiation afterwards. So the only Tx for 1st trimester is Modified Radical Mastectomy.

• Nipple discharge:
-Nipple discharge is a relatively common problem, and is due to a benign cause in most cases. A detailed history and physical examination can essentially determine the differential diagnoses and necessary diagnostic work-up.
-It is important to determine whether the discharge is spontaneous or provoked, and whether it is unilateral or bilateral.
►Patients with a malignant cause have a spontaneous, unilateral and guaiac positive or grossly bloody discharge.
►Patients with endocrine, medication-induced or other physiologic causes tend to have a bilateral nipple discharge.
♥ All patients with a unilateral spontaneous nipple discharge should be screened for breast cancer with a mammogram. Patients with evidence of a mass or suspicious finding on mammogram should have further evaluation such as fine needle aspiration biopsy or open breast biopsy. The discharge should also be examined for the presence of occult or gross blood; positive results are then sent for cytologic analysis.

• Intraductal Papiloma:
-A benign tumor of lactiferous ducts. Clinically manifest as serous bloody discharge.
-Mamogram won’t show it, too small. Resection has to be done to relief pain guided by galactogram.

• Lactation suppression: Tight fitting bra and ice packs. Bromocriptine is no longer used.
• Mastitis Infection of breast with S. Aureus. It must be ddx with Breast Engorgement (heavy,tender,firm and warm breasts bilaterallyin women who not nursing. Its managed with tight fitting bras, analgesics and ice pack, breast feeding should be resumed). Mastitis is tx with oral Dicloxacillin. Breast feeding should be suspended but milk has to be pumped until infection clears. If it involves abscess, incision and drainage is required.
• Raloxifene Is a Selective Estrogen Receptor Modulator (SERM) used for prevention of osteoporosis. Unlike Estrogen, it doesn’t increase risk of endometrial cancer. It decreases risk of Breast cancer. It has no effect on Ovarian cancer. Ts most important SE is it increase the risk of Pulmonary Thromboembolism and its C/I in pt with hx of DVT. It may also worsen hot flashes and vaginal dryness.
• Tamoxifen:
-An antiestrogen drug used for breast cancer. When used as adjuvant therapy for early stage disease it reduces the risk of recurrence of original cancer and new cancer in other breast.
-However it increases the risk of 2 types of cancer, 1-endometrial (lining of Uterus) and Uterine Sarcoma.
It reduces the risk of breast cancer in those who are at increased risk for developing breast cancer, ITS PROVEN. SEE RALOXIFEN.
-It increased the risk for endometrial cancer by 1% and ONLY in postmenopasusal women. It decreased risk of breast cancer, so overall it reduces mortality rate. It also decreases risk facto in the opposite breast. It protects against osteoporosis. However it does cause hot flashes and vaginal dryness due to its antiesterogenic effect. Remember its mixed agonist-antagonist on estrogen receptors.
Maternal substance abuse
1-Herion abuse:
Newborn will show tremors, increased weakness, frequent loose stool, high pich cry, fist sucking, poor feeding and tachypnea, Hyperirritability. Symptoms manifest w/I 24/48 after birth, Exclude hypocalcemia and hypoglycemia.
2-Mthadone withdrawal: presents at the 2nd to6th wek of life with seizure.
3-Cocaine: assoc w IUGR, intracranial hemorrhages, and premature labor or abrupta placenta. Its not common.
4-Alcohol withdrawal: presents with tremors, agitation, lethargy and seizures .Its rare.


Urinary incontinence:
Urinary incontinence is a common problem in the elderly population which causes significant functional and psychological morbidity. It frequently leads to a decline in self-confidence and a diminished quality of life in the elderly population.
It is important to distinguish between the three main types of urinary incontinence to devise a proper treatment plan. A detailed history and physical examination is the most important step to differentiate between the various types of urinary incontinence. A thorough history is also useful to identify various reversible causes of urinary continence, such as excessive fluid intake, urinary tract infection, atrophic vaginitis, stool impaction, and the use of various drugs causing or contributing to urinary incontinence.
►The three major types of urinary incontinence are stress incontinence, urge incontinence, and overflow urinary incontinence. Stress incontinence is the most common cause of urinary incontinence in younger females and occurs due to inadequate urethral support from the fascia and muscles. An increase in the intraabdominal pressure leads to urethral sphincter opening, which causes urinary leakage in the absence of bladder contraction. A detailed history, physical examination, and clinical stress test can provide the diagnosis of stress urinary incontinence in almost all the patients. In a clinical stress test, the patient is asked to relax and give a single vigorous cough. Leakage that occurs instantaneously with coughing is virtually diagnostic of stress urinary incontinence. Aggrevating factors are Obesity, pregnancy, COPD and Smoking. Postvoid cystometry is normal. Tx include Kegel excercise, esterogen in post menopausal women. Surgical tx is Burch and Sling procedures.
It is important to differentiate stress urinary incontinence (urethral hypermobility) from urge incontinence (detrusor overactivity). Pelvic floor exercises should always be the first line of treatment in patients with stress urinary incontinence.
URGE Incontinence: Detrusor instability, bladder irritation form neoplasm, and interstitial cystitis result in UI, which causes sudden and frequesnt loss of moderate to large amount of urine. Often accommodated with Nocturia.
OVERFLOW: Diabetic Nephropathy causes OI. Characterized by loss of small amount of urine from an over extended bladder and a markedly increased residual volume. There is hx of DM which is not controlled. CC are certain medications (Ibuprofen), Diabetic nephropathy, MS and spinal cord injury. NSAIDs have an inhibitory action on the detruser, so the first step is to stop NSAID. Then cholinergic drug (Bethanechol) should be added afterwards to improve detruser action . Intermittent self catheterization can be used.
One of effects of epidural anesthesia is urinary retension due to denervation of bladder. When bladder presure is > sphingter pt urianates until balace is achieved again. This incontinence is transient. PE may show distended blader. Postvoidal vol is high. Tx is by Intermittant cathaterization until control is regained. Oxybutyrin is used for Urge incontinence. Urethroplexy is for stress incontinence.

Uterine prolapse:
-Uterine prolapse is typically seen in multiparous, postmenopausal woman with a history of multiple vaginal deliveries. The injury to the pelvic ligaments and loss of estrogen weakens the endopelvic fascia.
-The uterus and cervix descend down the vaginal canal towards the vaginal orifice (introitus).
-Patients usually complain of a sensation of pressure or heaviness in the pelvic area, which is relieved by lying down and aggravated by prolonged standing or exertion.
-Some patients may complain of low back pain, dyspareunia, or a visible mass at the introitus.
-In chronic cases, patients may have bleeding or discharge from ulcerative, superficial epithelium.
►All symptomatic patients (constant sensation of heaviness, pain, or bleeding) should have surgical correction of the defect in the pelvic support. The aim of surgical treatment is to completely relieve the symptoms and prevent any future relapse.
►Conservative treatment with the insertion of a pessary to hold the pelvic organs in place should be only used in patients who are poor candidates for surgical intervention.
-It does not correct the underlying defect, and there is a higher chance of relapse in active patients.
Alkaline phosphatase:
-Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women, provided there is no associated symptoms or signs. Hence, reassuring the patient and explaining this observation is adequate and no further investigation is necessary.

Cervical cancer :
Risk factors: Young age at first coitus


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* Re:very useful review notes for step 3
#1780138
fullofgrace - 06/08/09 13:19

USMLE WORLD NOTES –HEMATOLOGY/Oncology

Multiple brain metastasis => whole brain radiation therapy [improves survival]
ESCC=Epidural Spinal Cord Compression: common complication of cancer => pain [classic thoracic radicular pain] and neurological dysfunction => metastatic tumor from any 1ry site can cause ESCC.
Symptomatic epidural spinal cord compression => Emergency => High dose corticosteroids {dexamethasone} and radiation therapy => Order MRI of spine [to confirm the diagnosis]
Primary CNS lymphoma [PCNSL] is a common malignancy in pts with HIV, related to EBV, and the major determinant of the survival is the significant degree of immunosupression [CD4 < 50]. The best prognostic sign for PCNSL is a increase in CD4 count and a decrease in viral load => management: HAART therapy improve prognosis
 Sickle cell crisis => acute painful episode, vasooclusive type, with splenomegaly; triggers: infection, cold, menses, dehydration, alcohol, etc. First step in management [especially in children] => is IV fluids to ensure optimal hydration. Then analgesia => Ketorolac or Morphine. **Next step after management of acute abdominal pain crisis is undertaken => CBC [remember spleen sequestration crisis in children and hypovolemic shock]
Transfusion order => first test: ABO and RH => then screen for antibodies [pretransfusion antibody screen] looking for RBC antibodies => if positive => further testing
Major reason for incompatibility or difficulty finding cross-match blood is patients with a history of multiple transfusions is= ALLOANTIBODIES thah make finding compatible blood even more difficult [example in pts with sickle-cell anemia or myelodysplasia] **MC implicated RBC antigen => E, L, K
Anemia of chronic disease can be difficult to differentiate from iron def. anemia in the setting of an acute bacterial infection [like pneumonia] => The best test to CONFIRM diagnosis of Anemia of chronic disease and rule our iron def. is => BONE MARROW BIOPSY
ITP: Most likely cause of the drop in platelet count => autoimmune phenomena involving formation of antiplatelet antibodies [platelet destruction by spec. antibodies]
ITP management: self limited in children, but may be chronic in adults. RX: is only necessary in severe or symptomatic thrombocytopenia => Corticosteroid therapy => if no response -> IV- IGs => refractory cases -> Splenectomy
Pancoast tumor /metastatic => with Horner syndrome and hoarseness, local invasion of paravertebral symp. Chain and RLN [MC tumor is small cell lung cancer] => RX: Radiation therapy with surgical resection. If distant metastatic disease= radiation therapy alone as palliative.
 Normocytic normochromic anemia: 1) Diseases with decreased RBC production and 2) Hemolytic disorders. To determine the mechanism of this anemia => Reticulocyte count [elevated if hemolysis]
Elevated Reticulocyte count:= Hemolysis sign = RC elevated, Indirect bilirubin elevated, LDH elevated, decreased haptoglobin; and splenomegaly
Low Reticulocyte count:= hypoproliferative state renal disease, aplastic anemia, hypothyroidism, and late stage anemia of chronic disease when chronic bleeding become in microcytic anemia due to iron deficiency]
HIT: Arterial thrombosis to left arm following administration of UFH => Heparin induced thrombocytopenia
o TYPE 1: within 2 days, lesser degree in fall of PC, after stop heparin, PC return to WNL
o TYPE 2: more serious, formation of antibodies vs. heparin platelet factor 4 complex, spontaneous bleeding is usual, with thrombosis, PE, venous limb gangrene, cerebral sinus thrombosis, strokes, MI, organ ischemia; etc
 RX: Discontinue heparin, warfarin and initiate argatroban or lepidurin [direct thrombin inhibitor]
Most useful strategy in preventing HIT=> Substitution of UFH with LMWH or heparinoids [Danaparoid], or use heparin less than 5 days in order to prevent any antibody response

Metastatic prostate cancer with spread to vertebral column [osteoblastic lesions in skeleton] Best test for new bony metastasis => Radionuclide bone scan or Radioisotope bone scan

Best treatment for metastatic prostate cancer => palliative => Leuprolide and flutamide [androgen depletion]

 Leuprolide is a LH releasing hormone agonist-> binds LHRH receptors in ant pituitary ->initial release of LH and FSH, rising testosterone transiently [symptoms can worsen] but after 1 week there is a down regulation of LHRH receptors causing decrease of LH and decrease of testosterone. LHRH agonist therapy is contraindicated in pts with painful vertebral metastasis and urethral obstruction because in the first week the symptoms can worsen; so give: Flutamide [antiandrogen] for 1 week before starting LHRH agonist [leuprolide, goserelin or zoladex, etc] to block effects of testosterone surge or initial symptom flare.

If after hormone treatment the pt has a progressive cancer despite leuprolide/flutamide or chemotherapy => Next step: REFER pt for RADIATION therapy

If spinal cord compression emergency, neuro signs, pain to 2ry compression or visceral distention => Admit pt and IV Corticosteroids

SVC syndrome -> in pt with high risk of malignancy [smoker] neck pain swelling, cervical and upper extremities venous dilation => CT scan neck and chest with contrast

Factor V Leiden mutation =MC heredity thrombophilia –predisposes to venous thromboembolism
Long term management=>life long Warfarin

Neutropenic fever is an emergency=please take pt to the local ER immediately [pt can have a serous life threatening infection even in the absence of typical signs and symptoms.

Venogram indicating=Recurrent DVT [2nd] with a more proximal extension into IVC and internal iliac vein => due to inadequate anticoagulation with warfarin [INR=1.4] => next step=>pt requires higher doses of warfarin to bring INR within therapeutic range =with serial monitoring of PT/INR. Maybe pt is in high diet of vit k [green leafy vegetables] or is taking any medicatin metabolize in the liver P450 cytochrome isoenzyme.

 IVC filter= indicated hen contraindicated anticoagulation or recurrent venous thromboembolism despite a correct and adequate anticoagulation.

 Posttransfusion platelet count should be measured 10-60 min after transfusion=> each unit of platelet should cause immediate post-transfusion rise in PC => ‘platelet refractoriness’ due to alloimmunization should be considered if platelet transfusion fail to cause expected increment in PC. -> Alloantibodies can cause a rapid destruction of transfused platelets and cause refractoriness.

Doxorubicin based chemo causing extrapiramidal symptoms, unstable gait => Due to metochlopramide [dopamine blocker] => for chemo induced emesis => next step=> > Change to Ondansetron [5HT3 serotonin rec. antagonist

Lobular carcinoma in situ LCIS [incidental finding of mammography] bilateral and multicentric => is not considered to be a direct precursor of invasive breast cancer , but the risk factor is important, the risk is increased in both the ipsilateral and contralateral regardless of the side where its present => Management =>> 1) regular close observation and mammogram, if any problem: tamoxifen and bilateral prophylactic mastectomy

Methotrexate, trimethoprim and phenytoin=> interfere w folate metabolism->folic acid def. anemia
RX=folinic acid or Leucovorin rescue is the DOC [more potent than folic acid] when folic def. is due to MTX. Folinic acid is more potent rescuing RBC from the deficiency bypassing the block on DHFR enzyme

Greatest RISK FACTOR for developing COLON CANCER=> 1] Alcohol intake 2] cigarette smoking

PROTECTIVE factors for COLON Cancer=> NSAIDs, ASA, regular exercise, fibrous diet rich in fruits/vegetables, HRT

Anemia of chronic disease due to ESRD –due to EPO def. => RX: EPO but you need to rule out other causes of anemia before stat treatment with EPO

o If after 6 weeks of treatment the HCT fails to increase adequately =>next step-> measure transferring saturation and ferritin levels [to rule out iron deficiency] and iron def. should be treated by weekly IV iron

RENAL failure, anemia-> tendency to bleed, due to platelet dysfunction [prolonged bleeding time in uremic coagulopathy] PT, PTT, PC are normal. RX= correct anemia, Desmopressin dialysis, estrogen treatment, DOC=Desmopressin if prolonged bleeding time.cryoprecipitate infusion.
 Desmopressin simplest and least toxic acute treatment of a prolonged bleeding time, acts by releasing factor VIII, von willebrand factor multimers from endothelium [vWF is ligant for platelet adhesion in a damaged vessel and is a cofactor of factor VIII, too.
Other coagulopathies using Desmopressin= Von Willebrand’s disease, Hemophilia A, Bernard Soulier, Renal failure coagulopathy

Cancer of the head / neck of the pancreas [60%] are advanced at the time of diagnosis, and are INOPERABLE => most appropriate treatment option => Combined Radiotherapy and Chemotherapy
Most effective strategy in pt management in CML => { Philadelphia chromosome and LOW leukocyte ALP } => ‘Refer pt to hematologist for bone marrow transplantation’ [allogeneic hematopoietic cell transplantation] *Requirements for success/good candidate:=> < 50 y/o, less than 1 yr diseased, stable chronic phase, have not taken busulfan (cumulative dose lead to pulmonary toxicity]
CML= other management: oral chemotherapy [busulfan, hydroxyurea]; parenteral Interferon alpha; newer oral thyrosine kinase inhibitors =Imanitib

Secondary polycythemia = CBC => High EPO to compensate for hypoxemia [due to pulmonary disease, cardiac disease or chronic hypoxic stimulus, OSA, smoking [carboxyhemoglobin], COPD, RT to LT cardiac shunt, high altitude], high HB, high RBC, but PC and WBC are normal [unlike polycythemia vera]

Polycythemia vera = Low EPO [Erythroid production is independent of EPO]; normal SaO2; increased erythrocyte mass, increased HCT, WBC, increased plasma volume. Mutations in JAK-2 gene. Thrmbotic events! Due to hyperviscosity=> daily ASA; increased histamine [prurutus] -> Diphenhydramine, SSRIs; increased PC or thrombocytosis -> Anagrelide; Phlebotomy to lower HCT, Hydroxyurea and for hyperuricemia-> Allopurinol
 Best next step= Diagnose secondary polycythemia due to chronic hypoxic stimulus or lung disease=> Pulse oximetry or oxygen saturation measurement [taken after minimal exertion], and ABGs => Then: Sleep studies => to determine presence of nocturnal oxygen desaturation
MM= Best next step => Serum protein electrophoresis, skeletal survey and bone marrow biopsy
Best test to reveal any potential skeletal lesion => ‘A complete skeletal series [skull, long bones, spine] ‘Whole body x rays’ [bone-scan are not useful]’
 Hyperviscosity syndrome= due to high protein content [MM*] and in WM*

 Anemia of chronic disease= next step is => ‘treat underlying disease’ [infection, organ failure, RA, SLE…] and follow ups.
When anemia of chronic disease is severe=>’periodic Blood transfusions’ with PRBC are necessary
If Hb < 10 and EPO serum < 500 [N=500-3.600] => ‘’Give EPO’’

Pancoast tumor/superior sulcus tumor => Dangerous sign => ‘’Chest movement asymmetry and asymmetric lower extremity DTRs’’ [indicates phrenic nerve involvement and possible invasion of intervertebral foramina-> spinal cord compromise]

Anti IF antibody testing very sensitive/specific in detecting pernicious anemia
Autoimmune metaplastic atrophic gastritis, pernicious anemia caused by autoimmune aggression vs. gastric mucosa. Most likely findings: ‘’Absent rugae in the fundus’’ or glandular atrophy; intestinal metaplasia and inflammation.

Mononulear antibodies to HER-2 neu oncogene can be added to the RX of pts with breast carcinoma who over express this oncogene=> good response and improve sensitivity to chemotherapy. [Over expression of HER-2/neu is a worse prognosis in breast carcinoma and resistance to alkilating agents in treatment]

 Lung cancer, initial step in the optimal management => CT-scan of the chest as the initial staging workup=> accurate histological identification and staging of tumor along with pre-operative assessment of lung function. => RX: surgery is the 1st line of choice

Systemic mastocytosis suspected if unexplained peptic ulcer disease, malabsorption, eosinophilia, unexplained flushing or anaphylaxis, sclerotic bone lesions, diarrhea => RX: ‘H1 rec. antagonists, PPIs, Cromolyn sodium

Eaton Lambert syndrome= associated with small cell lung carcinoma= from antibodies vs. the voltage gated calcium channels in the presynaptic motor nerve terminal. Next step=> Chest x rays; if negative do a CT scan. RX: plasmapheresis and immunosuppressive drug therapy

Best next step in management of a MALE pt with microcytic anemia, anisocytosis [iron deficiency] The GI tract is the major source of blood loss leading to iron deficiency in males; in women GU tract with menorhagia => Fecal occult blood
 
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* Re:some helpfull notes
#2823945
  toyotacorolla - 02/03/13 23:28
 
  good to know for exam  
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