09-21-2007, 09:41 AM
Pages: 1 2
09-21-2007, 10:29 AM
type cram-facts in search,u will get all facts
09-21-2007, 04:28 PM
yes, if that doesnt help reply to me but just as mahwishhah said, just type it in the search and you'll get everything i posted. good luck on your test.
09-21-2007, 04:37 PM
hey husayn
here the crams
Cram facts step 2 ck all in one till now
#219359
rehellohie - 09/13/07 12:03
Thanx to drjiggy and elba this thread is going to completeion. I put all the things in one thread. now surgery, obs gynae and psychatry left. if anyone can contirbute it will be appreciated.
Cardiology: Cram “ Facts:
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.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 <3hrs after onset of pain, complications include MR, VSD, cardiac rupture and ventricular aneurysm.
4.CAD risk factors: smoking, HTN, family h/o premature CAD (<55 in male, <65 in female), male >45, female >55, HDL <40, LDL >100. (If HDL >60, subtract one). >2 risk factors: diet if >160, drugs if >190; 2 or more risk factors: diet if >130, drugs if >160, pt has CHD: diet if >100, drugs if >130.
5.Causes of high output heart failure “ severe anemia, thyrotoxicosis, acute beriberi, paget™s dz, large AV fistula
6.Acute Pulmonary edema “ tx “ 1st upright position and O2, 2nd loops, nitrates, morphine, and 3rd intubate if severe.
7.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.
8.Restrictive CM “ JVD, edema and ascites, dx c echo, tx 1st diuretics/ decrease salt
9.Myocarditis “ history or URI (coxsackie) then fever, dyspnea, CP, edema, tachy
10.Acute Pericarditis “ positional CP, tx c NSAIDS
11.Pericardial effusion “ pericardial friction rub, tx c pericardiocentesis
12.Tamponade “ becks triad (JVD, muffled heart sounds, pulsus paradoxicus c hypotension), tx c pericardiocentesis
13.Constrictive pericarditis “ pericardial knock, kussmaul breathing, CXR shows pericardial calcification, tx c diuretics
14.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.
15.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
16.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
17.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)
18.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)
19.Endocarditis “ if dental procedure give amoxicillin (clindamycin if allergic), if GI/GU procedure give amoxicillin c gentamycin (vanco with gentamycin in allergic)
20.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.
21.ASD “ wide, fixed splitting S2, tx “ if small observe, if large surgery
22.PDA “ machinery murmur, wide systemic pulse pressure, tx c indomethacin then surgery
23.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).
24.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
25.Transposition of great vessels “ MCC of cyanosis in 24hrs of birth, tx c surgery
26.Initial Tx™s: CHF à thiaz, bb, acei, arb, aldo ant; Post-MI à bb, acei, aldo ant; DM à acei, bb, thiaz, arb; recurrent strokes à thiaz, acei
27.Hyperaldosteronism “ hypokalemic met alkalosis, PRA ratio, captopril-suppression test, high aldo level, 24hr urinary aldo, salt loading test
28.Pheochromocytoma “ 24hr urine collection for VMA, MRI to visualize adrenal tumors, MIBG if chemistries positive by CT/MRI are negative.
29.Renal artery stenosis “ renal U/S c Doppler, captopril scanning, CT/MRA, high ¬renin, ACEI contraindicated if B/L
30.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).
31.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 vasoconstricting drugs, bb™s.
32.Temporal Arteritis - >55yo pt c HA, scalp tenderness, visual s/s, next step is low-dose steroids (before temporal a biopsy or getting ESR).
33.Polyerteritis “ HTN, abdominal pain, numbness in legs, skin findings, cns s/s, dx c biopsy, tx with steroids.
34.AV Fistula “ thrill/bruit over fistula (buzzing sound), dx c angiography, tx c surgical excision, if congenital do conservative management instead.
35.Varicose veins “ pain, ¬pigmentation, superficial ulcer, tx c elastic stockings
36.Superficial thrombophlebitis “ pain, erythema, embolism is rare, tx c warm compression, limb elevation and NSAIDS.
37.Deep vein thrombophlebitis “ pain, swelling, fever, + Homans sign, PE is risk, so must do plethysmography or Doppler, tx c heparin/warfarin, filter if recurrent.
38.Dissecting aortic aneurysm “ sharp CP radiating to back, dx c CT, TEE or MRI, tx “ 1st ¯BP (nitroprusside), 2nd - If ascending aorta (up to aortic arch) do surgery, if descending aorta use meds
39.Abdominal aortic aneurysm “ bruit, dx with U/S, see abdominal notes
40.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.
ENDOCRINE:
41.Thyroid nodule “ must do FNA or scan to see if its hot or cold ( cold is malignant). 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.
42.Goiter “ high or low iodine uptake, lithium/amiodorone use, familial, tx c levothyroxine
43.De Quervains (subacute) thyroiditis “ painful thyroid, tx is NSAIDS
44.Sick Euthyroid Synd “ low T4/T3, normal TSH. Tx - nothing
45.Riedel™s “ tracheal compression due to sclerosing fibrosis (rare)
46.Hashimoto™s “ antimicrosomal ab, tx c levothyroxine
47.Congenital hypothyroidism (cretinism) “ jaundice, lethargy, umbilical hernia, low T4, high TSH, tx c synthroid (levothryoxine)
48.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
49.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 <25yo get surgery, pt >40yo get radioactive iodine.
50.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)
51.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
52.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.
53.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.
54.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).
55.Hyperosmolar coma “ dehydration, lethargy, confusion, coma, high glucose without ketones, tx c fluids and insulin.
56.Lactic Acidosis “ coma, confusion, hyperventilation, no ketones, anion gap met acidosis, rare a/w metformin, tx etiology (starvation).
57.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.
58.Insulinoma “ lethargy, diplopia, HA, glucose <40, high proinsulin, high c-peptide (low c-peptide if exogenous insulin used). Tx c surgery, if emergency then first give 50mL of 50% dextrose IV.
59.Primary Hyperparathyroidism “ kidney stones, osteitis fibrosa cystica, muscle weakness, high calcium, low phosphate, high PTH, a/w MEN. Tx c surgery if adenoma, but if pt has severe hypercalcemia, 1st tx c saline, then furosemide, calcitonin and/or pamidronate.
60.Hypoparathyroidism “ low calcium (chvostek™s sign, trousseau™s sign, tetany), high phosphate, normal renal function. Tx c vitamin D and calcium
61.Diabetes Insipidus “ water loss, polyuria, nocturia, thirst, craving for ice, low urine osm (<250), high serum osm. Dx “ Give vasopressin, if corrected its central, if still getting worse its nephrogenic (can be due to demecyclone or lithium), if no change in urine osm its primary polydipsia. Tx “ if central give vasopressin (DDAVP), if nephrogenic give diuretic (thiazides, amiloride).
62.SIADH “ low Na, low serum osm, high urine osm, a/w small cell ca/morphine/ chlorpropramide/oxytocin, tx c 1st fluid restriction, 2nd demeclocycline or hypertonic saline if Na is really low. Do not treat too rapidly to avoid central pontine myelinosis.
63.Acromegaly “ enlarging hands, feet, coarse features, deep voice, large tongue, hat/wedding ring doesn™t fit anymore (hat don™t fit anymore can be Paget™s), due to high GH, dx with glucose suppression test, then IGF-1, then MRI to confirm adenoma, tx c surgery (transphenoidal), or radiation/meds (bromocriptine, octreotide) if surgery doesn™t work.
64.Acute adrenocortical insufficiency “ shock, fever, abdm pain, low sugar, dx c cosyntropin testing, tx c hydrocortisone sodium succinate.
65.Chronic adrenocortical insufficiency (Addisons) “ MCC is US is autoimmune, MCC in world is TB. Lethargy, skin pigmentation, hypotension, low Na, high K+, low cortisol, high ACTH is primary, normal/low ACTH is secondary. Dx c ACTH stimulation test (cortisol should increase, but remains low in Addisons). Tx c hydrocortisone (glucocorticoid) and fludrocortisone (mineralcorticoid)
66.Cushing™s syndrome “ obesity, purple striae, HTN, hirsutism, buffalo hump, wakness, osteoporosis, dx c 1st 24hr urine free cortisol, then DXM suppression test (if suppressed that means its pituitary caused (Cushing disease), if not its adrenal or ectopic ACTH like small cell ca or sarcoid). Tx “ if iatrogenic use smallest effective steroid dose possible, if cushing disease do surgery/radiation of pituitary adenoma.
67.Adrenogenital syndrome “ hirsutism, amenorrhea, high urinary 17-OH, MCC is 21-OH deficiency in kids, MCC in adults is PCOS or adrenal disease. Tx is surgery, then estrogen spironolactone, meformin (if PCOS), gluco/mineralocorticoid if CAH.
68.Conn™s synd “ high aldo, low K+, high Na, High BP, low renin, tx is adrenalectomy c spironoloactone preop.
69.Secondary Hyperaldosteronism “ MCC is renal artery stenosis “ high Na, low K, high rennin, renal bruit. Dx c aldo:renin ration, then CT Abdm.
70.Prolactinoma “ milky d/c from breast, if prolactin level 20-100 then r/o dopamine antagonist drugs (haloperidol, metaclopramide) and r/o hypothyroidism, if prolactin level >1000, then do MRI of brain. Tx “ if CNS s/s do surgery, if not give bromocriptine.
71.Pheochromocytoma “ sudden episodes of flushing, HTN, HA, sweating, feeling of doom, a/w MEN, dx c urinary VMA or catecholamines, then if + do CT of abdomen and tx c surgery, but if emergent, give phenoxybenzamine.
72.PCOS and Premature ovarian failure “ see obgyn notes
73.Hemochromatosis “ AR, hepatomegaly, bronze skin, cardiomegaly, DM, dx c liver biopsy, tx c phlebotomy 1st, then deferoxamine (if needed).
74.Gestational DM “ measured at 26-28wks, glucose checked 1 hour after 50g load, if abnormal, check 3 hours after 100g load (fasting should be <95, 1hr <180, 2hr <155, 3hr <140). Tx c diabetic diet and insulin if needed.
75.Carcinoid syndrome “ diarrhea, flusing, bronchospasm, low bp, R heart valve lesions, dx c urinary 5HIAA, tx c surgery. MC is at appendix, but if symptomatic, MC is at small bowel
GI:
76. Upper GI bleed “ hematemisis, dx c EGD, tx (in order) “ If bleeding ulcer: PPI, transfuse, urgent endoscopy when possible, epinephrine into vessel, surgery if needed. If esophageal varices: Octreotide, banding/sclerotherapy, ET intubation, TIPS (for esophageal varices, prevent next bleed with BB™s)
77. Lower GI bleed “ MCC of BRBPR is diverticulosis, then angiodysplasia. Dx c colonoscopy if bleeding stops, blood scan if bleeding continues and if +, angiography. Tx “ replace blood, vasopressin at site.
78. what is the cutoff between upper and lower GI bleeding? Ligament of Trietz.
79. Crohn™s “ all gi tract (usually rectal sparing), fistula, skipped lesions, all layers of bowel (transmural), fistula, abscess, noncaseating granuloma, gallstones, calcium oxalate kidney stones, extraintestinal manifestations, dx c colonoscopy and biopsy. Tx using infliximab (must do PPD before starting it), sulfasalazine, metronidazole, prednisone.
80. Ulerative Colitis “ rectum mainly (unless backwashing present), continuous, just mucosa/submucosa, crypt abscesses, toxic megacolon, small/frequent bloody diarrhea c tenesmus. Tx c azulfidine, sulfasalazine
81. Toxic Megacolon “ emergency, a/w UC, tx: NPO, NGT, IVF, D/C meds, Abx, surgery only if + perforation (free air on AXR)
82. Peptic Ulcer “ Duodenal decreases c food, Gastric increases with food, gastic is more a/w cancer, duodenal is more a/w H.pylori. Dx 1st c H.pylori testing, then endoscopy with biopsy to r/o cancer. Risks for NSAIDS: >70, h/o prior PUD, only available tx is misoprostol. H.pylori: breath test, gastric biopsy, urease. Dx for PUD: 1st Upper GI endoscopy, then biopsy for gastric ulcers to r/o cancer. Tx with amox, clarithro and omprazole. Follow-up with urea breath tests after 1 month of tx. Complications: hemorrhage (MC), perforation “ do AXR to see free air in a pt c peritoneal s/s and tx c abx and laparatomy. After surgery (antreceomy, vagotomy, billroth I and II), watch out for Dumping Syndrome (weakness, n/v after eating), Afferent loop syndrome (bilious vomiting relieves abdm pain after meal), Iron/B12 deficiency.
83. ZE syndrome “ severe, non-healing ulcers. Get gastric levels and r/o ca (MEN).
84. Oropharyngeal dysphagia “ swallowing impaired d/t lack of neuromuscular control from prior CVA/Parkinsons/Alzheimers. Dx c barium swallow. Tx underlying dz.
85. Achalasia “ aperistalsis, incomplete LES relaxation c high LES pressure, dysphagia for solids and liquids, no regurge, dx c barium (dilated distal 2/3rd) then manometry (bird beak), then endoscopy to r/o cancer. Tx c pneumatic dilatation, then botox, then surgical Nissen™s fundoplication.
86. Chagas Disease “ achalasia, cardiomegaly, hepatomegaly in a south American.
87. GERD “ heartburn, CP, epigastric pain, older guy, MCC of nocturnal cough. Dx c 24hr pH, upper GI endoscopy to r/o barrett™s or ulcers. If you suspect it, treat it without doing any diagnostics. Tx c lifestyle changes, PPI, H2 blockers. If pt still has symptoms then do 24hr pH. If pt says drugs used to work but don™t work anymore, do EGD to rule out cancer.
88. Zenker™s Diverticulum “ a motility disorder, causing halitosis, dx c barium, tx c Sx.
89. Esophagitis “ painful swallowing (odynophagia), Candida so start c flucanazole.
90. Diffuse Esophageal Spasm (Nutcracker) “ Cp due to strong intermittent contractions. Dx c barium (corkscrew pattern) first, then manometry (shows nonperistaltic uncoordinated contractions), tx c calcium channel blockers or nitrates.
91. Scleroderma Esophagus “ younger guy with GERD symptoms, raynauds, heartburn, dysphagia for solids and liquids, dx c manometry (low LES pressure (unlike achalasia which is high), absent contractions in the smooth muscle esophagus, normal peristalsis in the striaghted muscle, normal UES). Tx c same things as GERD.
92. Schatzki Ring “ young pt with episodic difficulty (not pain) swallowing. Dx c barium, tx c pneumatic dilatation of LES
93. Plummer vinson synd “ hypopharyngeal web c iron deficiency. Risk of SCC. Middle-aged female c dysphagia immediately after meals. Dx c barium, tx c surgery.
94. Barett™s Esophagus “ 5yrs of dysphagia, weight loss, no reflux, s/s visible on EGD so do biopsy. If biopsy shows no dysplasia then repeat in 2-5yrs, if bx shows low dysplasia, repeat in 3-6 months, if bx shows high grade dysplasia “ resection
95. Esophageal CA “ progressive dysphagia for solids and eventually liquids, wt loss, CP, hypercalcemia (SCC), dx c barium, then comfirm c EGD and biopsy. Tx c surgery, chemotherapy (cisplatin, 5-FU) and radiation.
96. Gastroparesis “ delayed gastric emptying causing n/v, bloating and upper abdm discomfort, common in DM, tx c metoclopramide
97. When you suspect GI perforation, use gastrograffin (not barium), when you suspect aspiration, use barium (not gastrograffin).
98. Diarrhea “ see ID notes
99. Irritable Bowel Syndrome “ alternating constipation/diarrhea, pain relieved c defacation. Tx c increased fiber in diet.
100. Diverticulosis “ d/t low fiber/high fat diet. LLQ pain, fever, tenderness. Dx c colonoscopy. Tx c increased fiber.
101. Diverticulitis “ peritonitis, fever due to micro/macro-perforations, do CT scan. Tx c NPO, IVF and abx (cipro/metro or cefoxitine or ampicillin/sulbactam)
102. Pseudomembranous Colitis “ C.difficile overpopulation due to prior use of Abx weeks ago, dx c C.diff in stool. Colonoscopy shows yellow adherent plaques on mucosa. Tx: d/c drug, start metronidazole, if still +, vancomycin.
103. Colorectal CA “ 2nd MCCOD d/t cancer, rectal bleeding, change in BM, weight loss, sometimes asymptomatic (found incidentally on colonoscopy). Dx: FOBT yearly after age 50, flexible sigmoidoscopy every 4 years, colonoscopy at 50 then 53 then every 5 years, but start 10 years earlier than the age of which family relative was diagnosed with it. Tx “ surgical resection of primary tumor.
104. Chronic Liver Disease “ causes include autoimmune hepatitis, hemochromatosis, chronic alcohol use, fatty liver dz (non-alcoholic stateohepatitis), wilsons dz, viral (HBV, HCV), s/s include fatigue, increased abdm girth, jaundice, spider angiomas, palmar erythema, HSM, gynecomastia, testicular atrophy, labs c high AST/ALT/PT/INR, thrombocytopenia, hyponatremia, hypoalbuminemia.
105. Autoimmune hepatitis “ 20-40yo female c +ANA, +anti-smooth muscle Ab, everything else normal. Tx c steroids.
106. Wilson™s disease “ young guy with parkinsonism due to hepatilenticular degeneration, kayser-Fleischer ring, hemolytic anemia, dx c low serum ceruloplasmin, low total copper (not free), high urine copper. CT shows hypdense regions in the basal ganglia. Confirm dx c liver biopsy. Tx c D-penicillamine.
107. Ascites “ U/S, CT and then paracentesis. Tx c Na/fluid restriction, diuretics, then furosemide, then large-volume paracentesis, then TIPS.
108. Spontaneous bacterial peritonitis - >250polys in 3 bedside cultures, tx c cefotaxime
109. Encephalopathy “ tx c protein restriction and lactulose.
110. HAV “ shellfish, fecal-oral, dx c + anti-HAV IgM (IgG shows previous infxn)
111. HBV “ HbsAg is earliest marker, >6months is chronic, if vaccinated = +HbsAb, -HbcAb, if exposed in the past = +HbsAb, +HbcAb. Window period has anti-HBc IgM only. Prevent with vaccine + HBIG. Treat c Interferon alpha and lamivudine. Give vaccine at 0-2mo, 4-6mo, 13-18 months. If mom has +HbsAg, give baby vaccine + HBIG within 12 hours of birth.
112. HCV “ dx c anti-HCV Ab/IgG/IgM and HCV RNA by PCR. Tx “ Inf-a c ribavirin
113. Drug-induced “ Tylenol, isoniazid, halothane, carbon tetrachloride, tetracycline. Dx c very high AST/ALT levels. Tx “ D/C med
114. Acute fatty liver of pregnancy “ develops in 3rd TM. Tx “ immediate surgery
115. Primary Biliary Cirrhosis “ antimitochondrial Ab in serum, pruritis, fatigue, hepatomegaly, high alk phos, destruction of intrahepatic and extrahepatic ducts. Tx c ursodeoxycholic acid, cholestyramine.
116. Primary Sclerosing Cholangitis “ young man c IBD (UC), destruction on extrahepatic ducts only (shows beading effect d/t fibrosis).
117. Gallstones “ female, fat, 40, fertile, RUQ or epigastric pain, worsened c food, radiates to midscapular area. Dx c U/S, then HIDA scan if negative. Tx c lap chole. ERCP if pt still has symptoms after (stone is in CBD).
118. Mesenteric Ischemia “ severe abdm pain/tenderness with paucity of clinical findings. Pt will usually have extensive ischemic history (MI, DM, etc), dx c angiography, tx with prompt laparotomy to reestablish arterial flow
119. Acute Pancreatitis “ MCC is gallstones, then alcohol. Epigastric pain radiating to midback, alleviated c sitting up, jaundice sometimes fever. High amylase/lipase. Dx c CT. Tx c NPO, NGT, analgesia, and then begin to consider ERCP and surgery if perforated, bleeding, abscess, pseudocyst or peritonitis.
120. Pacreatic Pseudocyst vs Abscess “ worsening of pain, n/v, fever high WBC and positive blood culture after initial improvement. Dx c CT. Tx c Abx, then surgical drainage of abscess. Pseudocyst is generally asymptomatic.
121. Pancreatic CA “ vague abdm pain (doesn™t have to radiate to the back anymore), anorexia and weight loss with jaundice, n/v. Dx c CT. If negative do ERCP. Check CA 19-9. Tx: If only at pancreatic head c no spread, try resection. If not, do Whipple (pancreaticoduodenectomy) procedure.
122. Malabsorption “ Steatorrhea (dx c Sudan stain “ 1st test). Then dx c D-xylose, if abnormal, suggests small bowel disease. Normal value suggests focus on pancreatic dz: CT of abdm, serum amylase, AST/ALT. If overgrowth considered, note response to malabsorption to Abx. Celiac sprue panel: antiendomysial/antigliadin Ab, tissue transglutaminase, total serum IgA, antigliadin Ab IgA and IgG; at least 3 biopsy specimens from distal duodenum is gold standard.
123. Whipple™s “ malabsorption, arthralgia and CNS symptoms (dementia). Dx c small bowel biopsy (shows foamy macrophages on PAS stain). Tx c TMP-SMX
ONCOLOGY:
124. Tumor markers “ Bhcg “ testicular cancer, choriocarcinoma, mole; AFP “ hepatocellular carcinoma testicular ca; CEA “ GI cancers; PSA “ prostate ca; CA-125 “ Ovarian ca; CA 19-9 “ colorectal/GI/pancreatic cancer
125. Sigmoidoscopy - >50yo every 3-5yrs; FOBT - >50 annually; DRE - >40 annually; PSA - >50 annually in normal risk, >40 annually in high risk; Pap smear “ onset of sexual activity or 18yo annually for 3 consecutive years then however often; Pelvic exam “ 18-40yo every 1-3yr, >40 annually; Endometrial biopsy “ menopause/high risk annually; Self breast exam - >20 monthly; Clinical breast exam “ 20-40 every 3 years, >40 annually; Mammogram “ 40-49 every 1-2 yrs, >50 annually.
126. 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
127. 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)
128. 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).
129. Acute Lymphocytic Leukemia “ kids, blasts, tx c intrathecal chemo (MTX)
130. Acute Myelogenous Leukemia “ M3 causes DIC, Aeur rods, blasts, add All-trans retinoic acid (Vit A) to tx.
131. 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).
132. CLL “ elderly, high WBCs, high lymphocytes, splenomegaly, dx c smudge cells, no tx if no lymphocytosis, if + lymphocytosis give fludarabine or chlorambucil.
133. Hairy Cell Leukemia “ CD10+ and TRAP+ (tartrate-resistant acid phosphatase), tx c cladribine
134. Mycosis fungoidis “ cutaneous T-cell lymphoma (look at 1st aid picture).
135. Multiple Myeloma “ high calcium, high OAF, high uric acid. Best initial test is X ray if bone pain or electrophoresis if high protein. Most accurate test is >10% plasma cells. Tx: <70yo get stem cell transplant, >70yo get Meiphelen or Thalidomide
136. Aplastic Anemia “ low rbc/wbc/platelet, drugs (chloramphenicol), parvo-B19 (sickle cell), tx: <50yo get BMT, >50yo get cyclosporine + anti-thymocyte globulin
137. 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.
138. 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.
139. 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)
140. Solitary nodule “ 1st step get old x-ray. If present and same size, its benign (send home), if increase in size its probably cancer. If it wasn™t there, assess risk (high is smoker and >35, low risk is nonsmoker and <35). If low risk follow up later, if high risk do biopsy.
141. Breast Cancer “ biopsy everyone c palpable mass >35 except if B/L, lumpy and s/s only occur c menses. If <35 its probably fibroadenoma (rubbery moveable mass, observe pt). After bx, get mammogram if >35yo. If mammo was already done, get FNA. If after biopsy, mass goes away, send pt home. Tx: tamoxifen, mastectomy, radiation, axillary dissection, chemotherapy (c platinum) if + nodes.
142. 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).
143. 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.
144. 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.
Growth/Development/ Preventative Medicine:
Okay, as I promised. I wrote the preventative medicine/epidemiology/statistics notes to the way I best understand them. If you dont, thats understandable and you need to just think it out. Good luck...
HEMATOLOGY:
145. Microcytic (MCV <80): Iron deficiency, Thalassemia, Anemia of Chronic Dz, Sideroblastic Anemia (lead poising, isoniazid, alcohol-induced)
146. Normocytic (MCV 80-100): Check Reticulocyte count(should be <2% c anemia, otherwise marrow isn™t responding properly): <2% is acute blood loss (<5-7days), early iron deficiency, aplastic anemia, early AOCD, renal disease. >3% is due to either Intrinsic RBC defect (MAD: Membrane defects (Spherocytosis, PNH), Abnormal hemoglobins (Sickle cell), Deficient enzymes (G6PD, pyruvate kinase deficiency)) or Extrinsic RBC defect (Autoimmune hemolytic anemia, MAHA, blood loss >1 week)
147. Macrocytic (MCV >100): B12 def, folate def, Myelodysplastic syndrome, drug-induced, hepatic dysfunction (d/t alcohol), reticulocytosis.
148. Red Cell Morphologies: Rouleaux (myeloma), Burr cells (uremia), Tear drops and nucleated red cells (myelofibrosis), hypochromic/microcytic (iron def), target cells (HALT: Hemoglobinopathies, Asplenia, Liver dz (obstructive jaundice), Thalassemia), Oval macrocytes (B12/Folate def), basophilic stippling (Lead, B12 def), spherocytes (HS), Schistocytes (MAHA, AIHA, DIC), bite cells and Heinz bodies(G6PD), Howell-Jolly bodes (Asplenia like SCD).
149. Iron deficiency “ low MCV, high TIBC, low ferritin, low iron (<60), high RDW (why? Because some are normocytic and some are microcytic so the range of width will be high), pica kid who eats sand and ice, plummer-vinson (web, low iron, glossitis), cow milk before age 1, exclusive breast-feeding, pregnancy. Tx “ 1st is to find the source of iron loss and fix that (before you give iron!), 2nd transfusion (if needed fast) or oral iron supplements for 6-12 months.
150. Anemia of Chronic Dz “ (how does this work? The body knows diseases (RA, TB, SLE, cancer) love iron, so it will hide iron away in stores (high ferritin) but keep it out of the serum (low serum iron and high TIBC)) if anemia is a/w chronic renal dz, look for Burr cells.
151. Thalassemia “ normal iron (so don™t give iron), target cells, nucleated rbc, x-ray shows crew-cut appearance of skull, dx c Hb electrophoresis, no tx for traits. Thal major gets transfusion 1st and deforoxamine to prevent iron overload, spelenectomy (now give pneumovax, penicillin prophylaxis, folate supplement).
152. Lead Poisoning “ pica kids who have ABCD (Anemia/Ataxia/Abdm pain, Basophillic stippling/Behavioral changes, Constipation, Drops (foot/wrist)/Death), high free erythrocyte protoporphyrin. Dx c blood Pb level and x-ray (pb visible in bones). Tx c EDTA or dimercaprol.
153. B12 Deficiency “ MCC is pernicious anemia (anti IF/parietal Ab), also d/t gastrectomy, terminal ileus resection, vegetarian, chronic pancreatitis and diphyllobothrium latum infection. Look for CNS s/s (symmetric parethesia in feet/fingers, disturbed proprioception and vibratory sense, irritability, somnolence, abnormal taste/smell, central scotomas, positive babinski) and achlorhydria (no stomach acid secretion so pH in stomach is high). Check serum B12. Schilling test (never used in real world). Hypersegmented PMN. High methylmalonic acid level. Tx c cobalamin. Folate may worsen the CNS s/s.
154. Folate “ usually d/t dietary lack (green vegetables, liver, kidney, yeast, mushrooms), alcoholism, pregnancy, celiac sprue, phenytoin, bactrim, MTX, 5-FU, OCPs. Tx c folate supplements.
155. Autoimmune Hemolytic Anemia “ Ab/complement binds to RBC mmb. Two types IgM (agglutination at colder temp like Mycoplasma) and IgG (warm agglutination like SLE, penicillin, methyldopa). Dx c direct Coomb™s positive. If hemolysis is mild, observe, if hemolysis is severe, give glucocorticoids. If recurrent, do splenectomy.
156. Paroxysmal Nocturnal Hburia “ Hypoventilate at night, so acidosis causes RBC burst d/t low DAF, therefore complement comes right off (CD 55/59). May die in 10 yrs d/t thrombosis. Best test is Sugar water test or Hams test (Acidic sounds like Hacidic, Hacidics don™t like Ham). s/s include Hburia in the morning time (not at night, that would be a prostate problem), increase risk of AML. Give steroids.
157. G6PD Deficiency “ MCC is infection (they usually wont say Greek, primaquine, fava beans, Dapsone). Hemolysis, jaundice abdm/back pain 1-3 days after exposure. Heinz bodes, bite cells. Best tx c avoiding offending agents.
158. Spherocytosis “ increased osmotic fragility, AD, low spectrin, splenomegaly. Dx c osmotic fragility test, tx c splenectomy (defer until 6yo), pneumo vaccine and folate
159. Sickle Cell Disease “ African descent, AR, s/s >6mo d/t HbF, if trait only gets UTI, best initial test is smear, most accurate test is Hb electrophoresis, for crisis 1st give fluids/pain management, if fever (d/t autosplenectomy) give Abx (Ceftriaxone), if eye/CNS/chest/Priapism give exchange transfusion, to prevent next aplastic crisis give folate, to prevent next vaso-occlussive pain crisis (they will just say œcrisis) give hydroxyurea, if Hct drops suspect Aplastic anemia d/t Parvovirus. Give prophylactic penicillin, Pnumococcal/Haemophilus influenza vaccine @ childhood.
160. Aplastic Anemia “ low rbc/wbc/platelets, chloramphenicol, parvovirus, benzene, acute leukemia, AZT/zidovudine. Tx c 1st stop drug, then give antithymocyte globulin
161. Myelophthisic anemia (Myelofibrosis) “ malignant invasion of BM, anisocytosis (aniso = any size), poikilocytosis (shape), teardrop-shaped RBC, dx c BM biopsy showing no cells (dry tap).
162. Transfusions: Whole blood (poisoning, TTP), Packed RBC (post-surgery/trauma transfusion or instead of whole blood), washed RBC (IgA deficiency), Platelets (>10,000), granulocytes (post chemo), FFP (bleeding diathesis like DIC, warfarin poisoning, liver failure), cryoprecipitate (vWD and DIC). MCC of transfusion rxn is lab error. If it occurs, 1st step is stop transfusion.
163. Platelet problems = skin, gums, nose, gingival (ALL SUPERFICIAL), GI, CNS and vaginal bleeding; Factor problems “ bleeding into join and muscles (DEEP), GI, CNS.
164. 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)
165. 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).
166. DIC “ high PT/PTT/BT, low plt, low RBC, low factor 8.
167. 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.
168. Heparin “ high PTT, thrombocytopenia. Tx c d/c drug
169. Warfarin “ high PT, vit K antagonist (2,7,9,10), tx c FFP (fast) or vit K (slow), skin necrosis
170. ITP “low platelets, high BT, h/o URI, next step is steroids (just treat it), auto-platelet Ab, if platelets fall < <7000 give IVIG or RhoGam.
171. TTP “ high BT, low plt, low RBC, hemolysis, CNS, renal, fever, thrombocytopenia (petechia, purpura). Tx c plasmapheresis
172. HUS “ like TTP but no renal failure or CNS s/s, h/o infection, E. coli 015H7.
173. Scurvy “ all studies normal. Fingernal/gum/bone/perifollicular hemorrhage, poor diet (only eats hot dogs and soda or tea and toast). Tx c vitamin C.
174. Neutropenia “ PMN <2.0 x 10_9. Dx c bone marrow aspirate/bx. Tx: 1st determine the cause, 2nd Abx, 3rd steroids, 4th GM-CSF.
175. Polycythemia Rubra Vera “ 4 H™s (Hypervolemia, Hyperviscosity (thrombosis is MCCOD), Hyperuricemia, Histaminemia (itch all over after a hot shower)). Tx c phlebotomy.
My Infectious Disease Cram-Facts
#219813
drjiggy - 09/14/07 17:32
ID:
176. Toxic Shock Syndrome “ preformed toxin, prolonged tampon placement, hypotension, fever, dequamated rash (peeling of palms/soles), S.aureas
177. Conjunctivitis “ 1st 24 hours is chemical, 2-5 days is Neisseria, 4+ is Chlamydia. If they say painful conjunctivitis, that™s viral (HSV) so treat c acyclovir.
178. External Otitis “ pain, drainage, itchy swimmer™s ear, Pseudomonas.
179. Otitis Media “ 40% s.pneumo, 30% h.influenza, 30% m.catarrhalis, dx: 1st step is pneumatic otoscopy showing immobility of tympanic mmb, 2nd step is tympanocentesis, tx c amoxicillin.
180. Sinusitis “ same % as above. Yellow green d/c, sinus tenderness, best initial step “ empiric abx (amox + decongestant), then X-ray, then Sinus biopsy (most accurate)
181. Meningitis “ 0-1mo “ GBS, E.coli, Listeria, 2mo-2yo “ S.pneumo, 2-18yo “ Neisseria, 18+ - S.pneumo; Kernigs/Brudzinski sign, lethargy, fever, bulging fontanelle, photophobia, nuchal rigidity, n/v, dx c LP (bacteria: low glucose, high prtn, PMN™s; viral: normal glucose, slightly high prtn, low WBC, lymphocytes). If bacterial, give ceftraixone, vanco or steroids. Give ampicillin (listeria) if immunocompromised. If neisseria suspected (2-18yo c rash) next step is respiratory isolation and tx him and family members c rifampin. If >100 lymphocytes: Cryptococcus (r/o HIV, best initial test is India ink, most accurate test is crypt ag, tx c Amp B), Viral (no specific test), TB (pulm s/s, high CSF protein, give RIPE + steroids), Lyme Dz (serology, h/o bite, target rash, doxycycline, or if CNS s/s like cranial nerve 7 effects, give Ceftriaxone), RMSF (serology, rash on wrists/ankes moving centrally, h/o camping or hiking, tx c Doxycycline, chloramphenicol if pregnant). The MC sequela is hearing loss.
182. Encephalitis “ look for acute febrile confusion (if they say confusion, its encephalitis not meningitis), MCC is herpes (blood in csf), best initial test is CT (temporal lope), if negative do PCR (most accurate). Tx c acyclovir, then foscarnet if resistant.
183. Brain Abscess “ look for focal neurologic findings c ring/contrast enhancing lesions. If HIV (-), do biopsy, if HIV +, start sulfadiazine-pyrimethamine tx for Toxo and repeat CT.
184. Spinal Abscess “ local severe back pain that becomes radicular pain, then weakness c fever. Next step is CT, then surgical drainage c abx.
185. Tetanus “ rictus sardonicus (facial sneer), tonic muscle spasms (jaw, trismus), clostridium tetani, tx c tetanus IG and penicillin G.
186. Diptheria “ gray pharyngeal pseodommb c sore throat, tx c diphtheria antitoxin (DAT) and penicillin or erythromycin.
187. Croup “ aka acute laryngotracheitis “ barking cough in a 1-2yo. Parainfluenza virus. Frontal neck x-ray shows steeple sign. Tx c racemic epinephrine.
188. Epiglottitis “ 2-5yo kid unimmunized (H.influenza) c rapid progression of high fever, drooling and respiratory distress c no coughing. X ray shows thumb sign. Do not examine throat or irritate the kid (worsen airway obstruction). Tx c airway assessment, then cephalosporins.
189. Bronchiolitis “ 0-18month old kid in the fall/winter gets expiratory wheezing due to RSV. Tx c ribavirin. (In a nutshell, 0-2yo c wheezing is bronchiolitis, 1-2yo c barking cough is croup, 2-5yo c drooling is epiglottitis)
190. Pertussis “ whooping inspiratory wheeze.
191. Lung abscess “ fever for weeks, bad teeth, alcoholic, aspiration, stroke pt, intubated pt, next step is CXR, best way to prevent it is to remove all teeth, how do you differentiate from TB? The smell (very bad in abscess), most accurate test is biopsy, tx c clindamycin
192. Bronchitis “ mild cough c sputum, negative CXR, tx c azithro, levaquin or doxy
193. Pharyngitis “ sore throat, exudes, lymph nodes, no cough, no hoarseness, best test is rapid strep test, tx c penicillin
194. Influenza “ ahces, pains, tired, cough, HA, no fever. Best tx is oseltamivir or zanamivir (note the Ivir (for Influenze), not Ovir like acyclovir/famcyclovir for HSV or Avir like ritonavir/nelfinavir for AIDS)
195. Pneumonia “ outpt tx is same as bronchitis (azithro, levaquin, doxy), inpatient tx include ceftriaxone. In young healthy pt, think mycoplasma (get serologies) or if inpt, think S.pneumo. If CNS and GI symptoms, pick Legionella. If AIDS c CD<200 pick PCP (TMP-SMX tx). If exposed to sheep placenta, pick Coxiella burnetti. If lobar pneumonia (s.pneumo is MC) then stain and culture next. When do you give steroids? PO2 <75, A-a gradient <35. When do you admit and give pneumovax? Hypoxia, >65, splenectomy, hypotensive c high pulse, comorbidities, confusion, low Na (SIADH).
196. TB “ homeless, alcoholic, immigrant, HIV, health care worker, prisoner, fever, cough, sputum, wt loss, night sweats, first thing to do is CXR (NOT PPD “ when do you choose PPD first? Screens asymptomatic pts!), 2nd step is AFP and then give RIPE c isolation for 2 months, then isoniazid and rifampin for another 4 months (6 months total). Adverse effects are Isoniazid is neurotoxic (less c B6), Rifampin c red urine, pyrizinimide c high uric acid (do not treat it, it will pass) and ethambutol with eye problems.
197. PPD “Positive if: >5mm in HIV, steroid users, close contacts; >10mm in immigrants, health care workers (me!), >15 in pt c no risk facts. If PPD is positive, proceed to CXR, if (-) take INH for 9 months, if + get sputum AFB. If PPD is negative, repeat it in 1-2 weeks to rule out false negatives. If pt had PPD in the past that was +, don™t do PPD again (it will always be positive), go right to CXR.
198. 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.
199. Thrush “ oral candida, removable white mouth patches (Candida CAN come off, hairy leukoplakia cant). Tx c nystatin mouth rinse.
200. 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.
201. HIV “ 1st ELISA, 2nd western blot (in kids, 1st is PCR). Peripheral neuropathy c stavudine/didanosine, anemia c zidovudine, rash c tmp/smx (start dapsone), nephrolithiasis c indinavir. MC overall adverse effect is increase lipids and glucose levels. Prophylaxis: <200 for PCP (tmp/smx), <50 MIA (azithromycin). What if pt finds out she has HIV during pregnancy? Continue all meds except effavirenz. When do you only continue c AZT? If she has high CD count, give it in end of pregnancy and to newborn for 6 weeks. If pt gets stuck c needs, start 2 nucleosides and 1 PI or 2 nucleosides c effavirenz. Must you start tx if pt got splashed in eyes? Yes. Kissing? No.
202. If pt is stuck c HBV needle, now has +HBsAg, what do you do? If vaccinated, do nothing. If not vaccinated, give IVIG + vaccine. If pt got stuck c HCV needle do nothing.
203. How can you tell urethritis from cystitis? Urethritis has discharge. For both conditions, 1st step is swab, then stain, then DNA probe then tx. For urethritis tx GC (Ceftriaxone), for cervicitis, tx for Chlamydia (Azithro or Doxy)
204. Genital ulcers and + Lymph could be syphilis, LGV or chancroid
205. Syphilis “ painless genital ulcer, skin rash (lata), CNS/aortitis. 1st step is Darkfield microscopy (not rpr/vdrl). DOC is penicillin. If allergic give doxycyline. If allergic and pregnant, desensitize c penicillin. If pt gets immediate allergic rxn to penicllin, give aspirin.
206. LGV “ painless ulcer c painful nodes. 1st step is serology (Chlamydia is culture negative), tx c doxycycline
207. Chancroid “ painful ulcer, 1st step is culture, tx c azithromycin
208. Genital vesicles, next step is acyclovir (not Tzank because you already have dx), if resistant give foscarnet. When do you choose PCR? HSV in the brain.
209. If they show or describe a vesicle (but don™t say vesicle), then do Tzank test
210. If they describe or show warts, next step is remove (no tests needed).
211. Septic Arthritis “ 1st step is arthrocentesis (>50,000 wbc). If you suspect gonorrhea (look for tenosynovitis, rash or migratory polyarthritis), next step is culture pharynx, rectum, cervix, etc.
212. Osteomyelitis “ 1st step is xray (periosteal elevation), 2nd is MRI, 3rd is biopsy. When do you choose bone scan? If you cant do MRI (metal, pacemaker, hearing tubes, etc). After bx you can make dx: S.aureaus (nafcillin), MRSA (vanco, linezolid), E.coli (quinolones for bones) and then f/u ESR. When do you choose culture or sinus drainage? Never!
Rheumatology Cram-Facts
#219828
drjiggy - 09/14/07 18:43
RHEUMATOLOGY:
213. Osteoarthritis “ stiff, not red, not hot. DIP (Heberdens node), PIP (Bouchards), worse in PM (not in AM like RA). X-ray shows osteophytes and joint narrowing. Tx c weight loss 1st, then NSAIDS.
214. Rheumatoid Arthritis “ red, hot, swollen, fever, subQ nodules, +RF, pericarditis, pleural effusion, uveitis, long morning stiffness, swan neck, PIP/MCP (not DIP). Xray shows pannus. Tx c NSAIDS (1st if mild), methotrexate (1st if severe), 2nd is TNF (infliximab “ r/o TB 1st), then steroids.
215. Gout “ podagra, tophi (subQ uric acid deposits c punched-out bone lesions), (-) birefrigent crystals, a/w alcohol/aspirin/HCTZ use. Tx: Acute: 1st c NSAIDS (Indomethacin), then colchicines, then steroids (1st if renal dz). Chronic: If oversecretor give allopurinol (allo for ppl who make a lot), undersecretors get propenecid.
216. Pseudogout “ calcium rhomboid shaped crystals, + birefringence, chondrocalcinosis, a/w 4 H™s (hemochromatosis, hyperparathyroidism, hypophosphatemia, hypomagnesemia). MC @ knees/elbows.
217. Psoriasis “ scaly skin lesions, finger clubbing, RF negative. Tx c NSAIDS, MTX
218. Ankylosing spondylitis “ HLA-B27 (not diagnostic), family hx, back pain, bent over (bamboo spine), worse c rest (key), better c exercise, dx c 1st Sacral X-ray (sacroiliitis). Tx c exercise and NSAIDS
219. Reiters Synd “ HLA-B27, can™t see (conjunctivitis), pee (uvieitis), climb a tree (arthritis). Tx c NSAIDS, eye drops, STD treatment.
220. Behcet™s syndrome “ 20-40yo c painful oral/genital ulcers and arthritis. Tx c steroids.
221. Kawasaki™s “ (FEEL My Conjunctiva “ Fever >5days, Edema, Erythema, Lymphadenopathy, Myositis, Conjunctivitis). Next step is Echo (r/o coronary aneurysms). Tx c Aspirin + IVIG
222. 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
223. Wegeners “ nasal (sinusitis), lung (hemoptysis, dyspnea), kidney (hematuria), c-ANCA, tx c cyclophosphamide
224. Fibromyalgia “ young female with pain all over, multiple points of tenderness, irregular sleep pattern, anxiety, exams all normal. Tx c antidepressant, NSAIDS
225. Polymyalgia Rheumatic “ old female c pectoral/pelvic pain/stiffness, elevated ESR, normal biopsy, a/w temporal arteritis. Tx c steroids.
226. Polymyositis “ 40-60yo female c proximal muscle weakness, elevated ESR/CPK, abnormal muscle biopsy, dx c 1st muscle biopsy, then EMG. Tx c steroids
227. Dermatomyositis “ same as above, but c rash (heliotrope rash around eyelid).
228. 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.
229. Herniated disk “ most at L4-5 (weak big toe), and L5-S1 (reduced Achilles reflex), positive straight leg test.
230. 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.
231. Osgood-Shlatter “ inflammation of tibial tubercle in boys. Tx c rest and immobilization.
232. Slipped Capital Femoral Epiphysis “ Obese kid c painful limp. Dx c xray. Tx c surgical pinning >5yo.
233. 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.
234. 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.
235. 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.
236. Osteosarcoma “ 10-25yo c knee pain, mass, limping, high alk phos. X-ray c sunburst appearance. Tx c surgery and chemotherapy
237. Osteoid Osteoma “ bone pain worse at night and relieved c NSAIDS. Tx c nsaids
238. Osteochondroma “ bone pain, xray shows pedunculated metaphyseal tumor at distal femur. Tx c surgery.
239. Ewing sarcoma “ fever, pelvic/femur bone pain, swelling, xray shows onion skinning. Tx c radiation, chemo, surgery.
240. 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).
241. 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.
My Neurology Cram-Facts
#219994
drjiggy - 09/15/07 14:01
NEUROLOGY:
242. 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.
243. 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.
244. Temporal Arteritis “ >50yo c unilateral temporal HA, scalp tenderness, vision changes, high ESR. 1st step is give steroids, 2nd step temporal artery biopsy.
245. 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.
246. Trigeminal Neuralgia “ pain whenever you touch your face @ 5th cranial nerve distribution. Tx c carbamazapine. Definitive treatment with surgical rhizotomy.
247. 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)
248. 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)
249. 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.
250. 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).
251. 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.
252. TIA “ focal, abrupt onset lasting less than 1 hour, symptoms resolve after 1 day. Risk of stroke in days to weeks. Amorosis fugax (curtain over an eye due to retinal dysfunction) needs Doppler U/S of carotids or MRA. Give heparin acutely (if no contraindications), then long term aspirin. If stenosis >70%, amaurosis fugax/TIA or small, non-disabling stroke do CEA (carotid endarterectomy) and give aspirin. If stenosis <70%, severely disabling stroke, or TIA/stroke in evolution give daily aspirin alone.
253. CVA “ 1st test is CT without contrast (although, if ischemic, it will show negative), 2nd is MRI. Heparin is not given until hemorrhagic stroke is ruled out. If ischemic, give tPA™s if less than 3 hours of onset. If hemorrhagic, control BP and ICP.
254. Ischemic Stroke Locations: MCA “ contralateral hemiplegia, hemianopsia, Broca™ s (nonfluent, babbling)/Wernicke™s (fluent but doesn™t make sense) aphasia. ACA “ contralateral leg paralysis, sphincter incontinence (they cant kick you, so they pee on you); Posterior “ cortical blindness, hemianopsia; Vertebrobasilar “ ataxia, horizontal gaze, nystagmus; Cerebellar “ ataxia and dizziness; As for hemorrhagic, remember that in the thalamus its only sensory loss, in the pontine/internal capsule/putamen its only motor loss.
255. Multiple Sclerosis “ insidious onset of CNS s/s in a woman aged 20-40 with exacerbations and remissions of numbness, parasthesia, weakness, optic neuritis, gait disturbance, incontinence and emotional/mental status changes. Look for classic b/l internuclear opthalmoplegia (lesion @ MLF so you cannot adduct in horizontal gaze) and scanning speech. Babinski may be positive. Entirely CNS (M.gravis and G-Barre are entirely PNS). 1st step is MRI, 2nd test is LP (oligoclonal bands). Tx acute exacerbation c steroids. Prevent next attack c ABC (Avonex (Inf-B), Betaseron (Inf-B) and Copaxone (Glatiramer acetate)). If stuck in 1 position all day, give baclofen or Tizanidine. If incontinent give oxybutinin or bethanacol.
256. Guillain-Barre Syndrome “ h/o URI of GI infection (campylobacter jejuni) or immunization 1 week before develops onset of symmetric, assending progressive weakness or paralysis and loss of DTRs. 1st step is PFTs (MCCOD is respiratory dysfunction due to paralysis, so monitor the pt™s NIF (negative inspiratory force) and if it keeps decreasing, consider intubation). Most accurate test is EMG. When do you choose LP? Last (shows elevated CSF protein). Tx c IVIG or plasmapheresis (not steroids!).
257. Myasthenia Gravis “ Ab against Ach receptors in women 20-40yo. Look for ptosis, diplopia, difficulty swallowing and weakness c repetition (at the end of they day they are exhausted). Best initial test is Ach Ab (NOT edrophonium test, which is 2nd or if they already mention the Ach Ab). Most accurate test is EMG. Tx Myasthenia crisis (breathing problems) c D/C anitchonergics and give IVIG and Plasmapheresis (NOT steroids). Tx for chronic disease: <60 gets thymectomy (do CXR, Chest CT), >60 gets neostigmine and steroids, then azathiopine/cyclosporine/tacrolimus. What abx is contraindicated? Aminoglycosides.
258. Eaton-Lambert “ Ab against presynaptic calcium channels causing limb weakness that gets stronger c repetitive stimulation (opposite of gravis),no loss of DTRs or extraocular manifestations, a/w small cell lung cancer, tx c guanidine. (cab™s are contraindicated).
259. Neurosyphilis “ tertiary treponema pallidum disease. Treat c high dose penicillin. After giving penicillin, pt may develop hypotension, fever, HA, chills and tachycardia within 24 hours of treatment due to treponemal products (Jarisch-Herxheimer reaction, this is not a penicillin reaction). Tx c aspirin.
260. Myotonic Dystrophy“ 20-30yo guy grabs something and cant let go (impaired relaxation) d/t mutations in chloride channel. Tx c phenytoin.
261. Duchenne Muscular Dystrophy “ XLR, boys 3-7 have muscle weakness, very high CK, calf pseudohypertrophy, Gower™s sign (kid climbs his legs to stand, look at it in google videos its so sad). Kid is in wheelchair by teenager and dead by 20. Dx c muscle biopsy.
262. Mitochondrial Myopathy “ aka Lever™s hereditary optic atrophy “ every mom gives to all overspring (no male transmission). Look for ragged red fibers on biopsy.
263. Botulism “ infant ingests honey and develops floppy baby syndrome. 1st step is intubate if needed, 2nd step is antitoxin. Spontaneous recovery in 1 week.
264. Amyotrophic lateral Sclerosis “ aka Lou Gehrig™s dz “ 55yo male upper (spasticity, hyperreflexia, babinski) and lower motor neuron (fasciculations, atrophy, flaccidity) problem. Only motor problems, no sensory/sexual/bowel problems. Tx c Riluzole.
265. Huntington™s Disease “ AD (father had it, you have it at a younger age) c CAG repeats, chorea, personality change, psychiatric syndromes, progressive dementia. Dx c CT/MRI showing caudate nucleus and cerebral cortex atrophy, causing decreased Ach and GABA (thus causing increased dopamine). Tx c antipsychotics (haloperidol) When you see a movement disorder, dementia and emotional problems, think of Huntington™s. When you see dementia and emotional problems (no chorea), pick Pick™s disease.
266. Parkinson™s “ 60yo c extrapyramidal movement disorder (pill-rolling resting tremor, cogwheel rigidity, shuffling gait, bradykinesia, masked facies). Caused by loss of dopaminergic neurons in substantia nigra. Tx: Mild s/s (can still take care of themselves): <60yo c Anticholinergic (cabergeline/benztropine/trihexylphenidyl), >60yo c Amantidine. If Severe s/s: 1st Levo/Carbidopa, 2nd is DA agonist (primapexole, ropinirole, pergolide), 3rd COMT-inhibitors (Talcopone), 4th MAOI (selegiline). Some antipsychotics (haloperidol, risperidone, MPTP) can cause parkinson-like symptoms, tx c anticholinergics (benztropine/ trihexylphenidyl/ cabergeline). Young guy c Parkinsonism, but not on meds, think of Wilson™s disease.
267. Alzheimer™s “ progressive dementia (memory, language, visuospatial, mood, hallucinations, personality/behavior) in mid-late life. a/w Down™s syndrome (amyloid precursor protein). Dx c MRI showing cortical atrophy, senile plaques, neurofibrillary tangles. Tx c donepezil, rivastigmine and galantamine to increase Ach just in brain.
268. Pick™s “ early aged (40) personality change, dementia. CT/MRI shows frontetemporal atrophy, argyrophilic neuronal (Pick) bodies in frontal and temporal lobe, sparing superior temporal gyrus (generally no memory problems).
269. Multi-infarct Dementia “ stepwise dementia in a pt c bad medical history (HTN, DM, etc.). They will describe the pt as progressively getting worse, little-by-little. Dx c PET/SPECT scan showing multifocal decreases in cerebral blood flow. Tx c aspirin
270. Normal Pressure Hydrocephalus - œwet, wacky, wobbly (incontinent, dementia, ataxia). Dx c CT scan, tx c ventriculoperitoneal shunt.
271. Creutzfeldt-Jakob - young guy c rapidly progressive dementia, myoclonus due to abnormal isoform of prion protein. Dx c biopsy (nothing else). No treatment.
272. Narcolepsy “ daytime sleep attacks c cataplexy, hynogogic (going to sleep)/hypnopompic (waking up) hallucinations, sleep paralysis. Rapid onset of REM sleep. Tx c amphetamines for sleepiness, clomipramine for cataplexy.
273. Obstructive sleep apnea “ overweight, HTN, arrhythmia, gasping for air. Dx c polysymnography. Tx c CPAP.
274. Central sleep apnea “ old, non-obese pt c loss of respiratory drive. Tx c azetazolamide.
275. Epidural Hematoma - + head trauma, + HA, + LOC, lucid intervals after brief LOC followed by increasing obtundation, middle meningeal artery. Dx c CT without contrast showing convex hematoma. Tx c 1st hyperventilate and elevate head, 2nd evacuate, 3rd mannitol
276. Subdural Hematoma - +head trauma, + HA, + LOC, bridging veins injured, can be acute (CT showing concave or crescent-shaped hematoma), days (MRI), or gradual deterioration (MRI). Tx c same as above.
277. Subarachnoid Hemorrhage - +HA, + LOC, no head trauma, spontaneous, sudden onset of meningitis (stiff neck, photophobia, kernig™s, brudzinski), worst HA of my life, a/w polycystic kidney disease, CSF c blood. Best initial test is Head CT, most accurate test is LP. Tx supportively (bed rest, analgesia)
278. Concussion “ + head trauma, + LOC, no focal CNS defecits. Tx “ go home.
279. Contusion “ + head trauma, + LOC, blood/bruise on head. Tx “ go home.
280. Neuroleptic malignant syndrome “ high temperature, muscular rigidity, confusion, high CPK, high K+, no sweating, tx c IV dantrolene or bromocriptine.
281. Malignant hyperthermia “ high temperature, confusion, high CPK, high K+, no sweating, h/o anesthesia (halothane). Tx c IV dantrolene
Normal Development & Preventative Med Cram-Facts
#220050
drjiggy - 09/15/07 17:22
Growth/Development/ Preventative Medicine:
285. Gestational Age “ fundus at pubic symphysis @ 8 wks, above symphysis @ 14wks, umbilicus @ 20wks, xiphoid @ 38wks.
286. Naegele™s rule “ assuming 28 day cycle, subtract three months, add 7 days (if more than 28 days, add the remaining days to the 7)
287. Infant size “ gains back birth weight by 2
here the crams
Cram facts step 2 ck all in one till now
#219359
rehellohie - 09/13/07 12:03
Thanx to drjiggy and elba this thread is going to completeion. I put all the things in one thread. now surgery, obs gynae and psychatry left. if anyone can contirbute it will be appreciated.
Cardiology: Cram “ Facts:
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.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 <3hrs after onset of pain, complications include MR, VSD, cardiac rupture and ventricular aneurysm.
4.CAD risk factors: smoking, HTN, family h/o premature CAD (<55 in male, <65 in female), male >45, female >55, HDL <40, LDL >100. (If HDL >60, subtract one). >2 risk factors: diet if >160, drugs if >190; 2 or more risk factors: diet if >130, drugs if >160, pt has CHD: diet if >100, drugs if >130.
5.Causes of high output heart failure “ severe anemia, thyrotoxicosis, acute beriberi, paget™s dz, large AV fistula
6.Acute Pulmonary edema “ tx “ 1st upright position and O2, 2nd loops, nitrates, morphine, and 3rd intubate if severe.
7.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.
8.Restrictive CM “ JVD, edema and ascites, dx c echo, tx 1st diuretics/ decrease salt
9.Myocarditis “ history or URI (coxsackie) then fever, dyspnea, CP, edema, tachy
10.Acute Pericarditis “ positional CP, tx c NSAIDS
11.Pericardial effusion “ pericardial friction rub, tx c pericardiocentesis
12.Tamponade “ becks triad (JVD, muffled heart sounds, pulsus paradoxicus c hypotension), tx c pericardiocentesis
13.Constrictive pericarditis “ pericardial knock, kussmaul breathing, CXR shows pericardial calcification, tx c diuretics
14.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.
15.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
16.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
17.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)
18.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)
19.Endocarditis “ if dental procedure give amoxicillin (clindamycin if allergic), if GI/GU procedure give amoxicillin c gentamycin (vanco with gentamycin in allergic)
20.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.
21.ASD “ wide, fixed splitting S2, tx “ if small observe, if large surgery
22.PDA “ machinery murmur, wide systemic pulse pressure, tx c indomethacin then surgery
23.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).
24.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
25.Transposition of great vessels “ MCC of cyanosis in 24hrs of birth, tx c surgery
26.Initial Tx™s: CHF à thiaz, bb, acei, arb, aldo ant; Post-MI à bb, acei, aldo ant; DM à acei, bb, thiaz, arb; recurrent strokes à thiaz, acei
27.Hyperaldosteronism “ hypokalemic met alkalosis, PRA ratio, captopril-suppression test, high aldo level, 24hr urinary aldo, salt loading test
28.Pheochromocytoma “ 24hr urine collection for VMA, MRI to visualize adrenal tumors, MIBG if chemistries positive by CT/MRI are negative.
29.Renal artery stenosis “ renal U/S c Doppler, captopril scanning, CT/MRA, high ¬renin, ACEI contraindicated if B/L
30.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).
31.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 vasoconstricting drugs, bb™s.
32.Temporal Arteritis - >55yo pt c HA, scalp tenderness, visual s/s, next step is low-dose steroids (before temporal a biopsy or getting ESR).
33.Polyerteritis “ HTN, abdominal pain, numbness in legs, skin findings, cns s/s, dx c biopsy, tx with steroids.
34.AV Fistula “ thrill/bruit over fistula (buzzing sound), dx c angiography, tx c surgical excision, if congenital do conservative management instead.
35.Varicose veins “ pain, ¬pigmentation, superficial ulcer, tx c elastic stockings
36.Superficial thrombophlebitis “ pain, erythema, embolism is rare, tx c warm compression, limb elevation and NSAIDS.
37.Deep vein thrombophlebitis “ pain, swelling, fever, + Homans sign, PE is risk, so must do plethysmography or Doppler, tx c heparin/warfarin, filter if recurrent.
38.Dissecting aortic aneurysm “ sharp CP radiating to back, dx c CT, TEE or MRI, tx “ 1st ¯BP (nitroprusside), 2nd - If ascending aorta (up to aortic arch) do surgery, if descending aorta use meds
39.Abdominal aortic aneurysm “ bruit, dx with U/S, see abdominal notes
40.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.
ENDOCRINE:
41.Thyroid nodule “ must do FNA or scan to see if its hot or cold ( cold is malignant). 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.
42.Goiter “ high or low iodine uptake, lithium/amiodorone use, familial, tx c levothyroxine
43.De Quervains (subacute) thyroiditis “ painful thyroid, tx is NSAIDS
44.Sick Euthyroid Synd “ low T4/T3, normal TSH. Tx - nothing
45.Riedel™s “ tracheal compression due to sclerosing fibrosis (rare)
46.Hashimoto™s “ antimicrosomal ab, tx c levothyroxine
47.Congenital hypothyroidism (cretinism) “ jaundice, lethargy, umbilical hernia, low T4, high TSH, tx c synthroid (levothryoxine)
48.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
49.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 <25yo get surgery, pt >40yo get radioactive iodine.
50.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)
51.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
52.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.
53.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.
54.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).
55.Hyperosmolar coma “ dehydration, lethargy, confusion, coma, high glucose without ketones, tx c fluids and insulin.
56.Lactic Acidosis “ coma, confusion, hyperventilation, no ketones, anion gap met acidosis, rare a/w metformin, tx etiology (starvation).
57.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.
58.Insulinoma “ lethargy, diplopia, HA, glucose <40, high proinsulin, high c-peptide (low c-peptide if exogenous insulin used). Tx c surgery, if emergency then first give 50mL of 50% dextrose IV.
59.Primary Hyperparathyroidism “ kidney stones, osteitis fibrosa cystica, muscle weakness, high calcium, low phosphate, high PTH, a/w MEN. Tx c surgery if adenoma, but if pt has severe hypercalcemia, 1st tx c saline, then furosemide, calcitonin and/or pamidronate.
60.Hypoparathyroidism “ low calcium (chvostek™s sign, trousseau™s sign, tetany), high phosphate, normal renal function. Tx c vitamin D and calcium
61.Diabetes Insipidus “ water loss, polyuria, nocturia, thirst, craving for ice, low urine osm (<250), high serum osm. Dx “ Give vasopressin, if corrected its central, if still getting worse its nephrogenic (can be due to demecyclone or lithium), if no change in urine osm its primary polydipsia. Tx “ if central give vasopressin (DDAVP), if nephrogenic give diuretic (thiazides, amiloride).
62.SIADH “ low Na, low serum osm, high urine osm, a/w small cell ca/morphine/ chlorpropramide/oxytocin, tx c 1st fluid restriction, 2nd demeclocycline or hypertonic saline if Na is really low. Do not treat too rapidly to avoid central pontine myelinosis.
63.Acromegaly “ enlarging hands, feet, coarse features, deep voice, large tongue, hat/wedding ring doesn™t fit anymore (hat don™t fit anymore can be Paget™s), due to high GH, dx with glucose suppression test, then IGF-1, then MRI to confirm adenoma, tx c surgery (transphenoidal), or radiation/meds (bromocriptine, octreotide) if surgery doesn™t work.
64.Acute adrenocortical insufficiency “ shock, fever, abdm pain, low sugar, dx c cosyntropin testing, tx c hydrocortisone sodium succinate.
65.Chronic adrenocortical insufficiency (Addisons) “ MCC is US is autoimmune, MCC in world is TB. Lethargy, skin pigmentation, hypotension, low Na, high K+, low cortisol, high ACTH is primary, normal/low ACTH is secondary. Dx c ACTH stimulation test (cortisol should increase, but remains low in Addisons). Tx c hydrocortisone (glucocorticoid) and fludrocortisone (mineralcorticoid)
66.Cushing™s syndrome “ obesity, purple striae, HTN, hirsutism, buffalo hump, wakness, osteoporosis, dx c 1st 24hr urine free cortisol, then DXM suppression test (if suppressed that means its pituitary caused (Cushing disease), if not its adrenal or ectopic ACTH like small cell ca or sarcoid). Tx “ if iatrogenic use smallest effective steroid dose possible, if cushing disease do surgery/radiation of pituitary adenoma.
67.Adrenogenital syndrome “ hirsutism, amenorrhea, high urinary 17-OH, MCC is 21-OH deficiency in kids, MCC in adults is PCOS or adrenal disease. Tx is surgery, then estrogen spironolactone, meformin (if PCOS), gluco/mineralocorticoid if CAH.
68.Conn™s synd “ high aldo, low K+, high Na, High BP, low renin, tx is adrenalectomy c spironoloactone preop.
69.Secondary Hyperaldosteronism “ MCC is renal artery stenosis “ high Na, low K, high rennin, renal bruit. Dx c aldo:renin ration, then CT Abdm.
70.Prolactinoma “ milky d/c from breast, if prolactin level 20-100 then r/o dopamine antagonist drugs (haloperidol, metaclopramide) and r/o hypothyroidism, if prolactin level >1000, then do MRI of brain. Tx “ if CNS s/s do surgery, if not give bromocriptine.
71.Pheochromocytoma “ sudden episodes of flushing, HTN, HA, sweating, feeling of doom, a/w MEN, dx c urinary VMA or catecholamines, then if + do CT of abdomen and tx c surgery, but if emergent, give phenoxybenzamine.
72.PCOS and Premature ovarian failure “ see obgyn notes
73.Hemochromatosis “ AR, hepatomegaly, bronze skin, cardiomegaly, DM, dx c liver biopsy, tx c phlebotomy 1st, then deferoxamine (if needed).
74.Gestational DM “ measured at 26-28wks, glucose checked 1 hour after 50g load, if abnormal, check 3 hours after 100g load (fasting should be <95, 1hr <180, 2hr <155, 3hr <140). Tx c diabetic diet and insulin if needed.
75.Carcinoid syndrome “ diarrhea, flusing, bronchospasm, low bp, R heart valve lesions, dx c urinary 5HIAA, tx c surgery. MC is at appendix, but if symptomatic, MC is at small bowel
GI:
76. Upper GI bleed “ hematemisis, dx c EGD, tx (in order) “ If bleeding ulcer: PPI, transfuse, urgent endoscopy when possible, epinephrine into vessel, surgery if needed. If esophageal varices: Octreotide, banding/sclerotherapy, ET intubation, TIPS (for esophageal varices, prevent next bleed with BB™s)
77. Lower GI bleed “ MCC of BRBPR is diverticulosis, then angiodysplasia. Dx c colonoscopy if bleeding stops, blood scan if bleeding continues and if +, angiography. Tx “ replace blood, vasopressin at site.
78. what is the cutoff between upper and lower GI bleeding? Ligament of Trietz.
79. Crohn™s “ all gi tract (usually rectal sparing), fistula, skipped lesions, all layers of bowel (transmural), fistula, abscess, noncaseating granuloma, gallstones, calcium oxalate kidney stones, extraintestinal manifestations, dx c colonoscopy and biopsy. Tx using infliximab (must do PPD before starting it), sulfasalazine, metronidazole, prednisone.
80. Ulerative Colitis “ rectum mainly (unless backwashing present), continuous, just mucosa/submucosa, crypt abscesses, toxic megacolon, small/frequent bloody diarrhea c tenesmus. Tx c azulfidine, sulfasalazine
81. Toxic Megacolon “ emergency, a/w UC, tx: NPO, NGT, IVF, D/C meds, Abx, surgery only if + perforation (free air on AXR)
82. Peptic Ulcer “ Duodenal decreases c food, Gastric increases with food, gastic is more a/w cancer, duodenal is more a/w H.pylori. Dx 1st c H.pylori testing, then endoscopy with biopsy to r/o cancer. Risks for NSAIDS: >70, h/o prior PUD, only available tx is misoprostol. H.pylori: breath test, gastric biopsy, urease. Dx for PUD: 1st Upper GI endoscopy, then biopsy for gastric ulcers to r/o cancer. Tx with amox, clarithro and omprazole. Follow-up with urea breath tests after 1 month of tx. Complications: hemorrhage (MC), perforation “ do AXR to see free air in a pt c peritoneal s/s and tx c abx and laparatomy. After surgery (antreceomy, vagotomy, billroth I and II), watch out for Dumping Syndrome (weakness, n/v after eating), Afferent loop syndrome (bilious vomiting relieves abdm pain after meal), Iron/B12 deficiency.
83. ZE syndrome “ severe, non-healing ulcers. Get gastric levels and r/o ca (MEN).
84. Oropharyngeal dysphagia “ swallowing impaired d/t lack of neuromuscular control from prior CVA/Parkinsons/Alzheimers. Dx c barium swallow. Tx underlying dz.
85. Achalasia “ aperistalsis, incomplete LES relaxation c high LES pressure, dysphagia for solids and liquids, no regurge, dx c barium (dilated distal 2/3rd) then manometry (bird beak), then endoscopy to r/o cancer. Tx c pneumatic dilatation, then botox, then surgical Nissen™s fundoplication.
86. Chagas Disease “ achalasia, cardiomegaly, hepatomegaly in a south American.
87. GERD “ heartburn, CP, epigastric pain, older guy, MCC of nocturnal cough. Dx c 24hr pH, upper GI endoscopy to r/o barrett™s or ulcers. If you suspect it, treat it without doing any diagnostics. Tx c lifestyle changes, PPI, H2 blockers. If pt still has symptoms then do 24hr pH. If pt says drugs used to work but don™t work anymore, do EGD to rule out cancer.
88. Zenker™s Diverticulum “ a motility disorder, causing halitosis, dx c barium, tx c Sx.
89. Esophagitis “ painful swallowing (odynophagia), Candida so start c flucanazole.
90. Diffuse Esophageal Spasm (Nutcracker) “ Cp due to strong intermittent contractions. Dx c barium (corkscrew pattern) first, then manometry (shows nonperistaltic uncoordinated contractions), tx c calcium channel blockers or nitrates.
91. Scleroderma Esophagus “ younger guy with GERD symptoms, raynauds, heartburn, dysphagia for solids and liquids, dx c manometry (low LES pressure (unlike achalasia which is high), absent contractions in the smooth muscle esophagus, normal peristalsis in the striaghted muscle, normal UES). Tx c same things as GERD.
92. Schatzki Ring “ young pt with episodic difficulty (not pain) swallowing. Dx c barium, tx c pneumatic dilatation of LES
93. Plummer vinson synd “ hypopharyngeal web c iron deficiency. Risk of SCC. Middle-aged female c dysphagia immediately after meals. Dx c barium, tx c surgery.
94. Barett™s Esophagus “ 5yrs of dysphagia, weight loss, no reflux, s/s visible on EGD so do biopsy. If biopsy shows no dysplasia then repeat in 2-5yrs, if bx shows low dysplasia, repeat in 3-6 months, if bx shows high grade dysplasia “ resection
95. Esophageal CA “ progressive dysphagia for solids and eventually liquids, wt loss, CP, hypercalcemia (SCC), dx c barium, then comfirm c EGD and biopsy. Tx c surgery, chemotherapy (cisplatin, 5-FU) and radiation.
96. Gastroparesis “ delayed gastric emptying causing n/v, bloating and upper abdm discomfort, common in DM, tx c metoclopramide
97. When you suspect GI perforation, use gastrograffin (not barium), when you suspect aspiration, use barium (not gastrograffin).
98. Diarrhea “ see ID notes
99. Irritable Bowel Syndrome “ alternating constipation/diarrhea, pain relieved c defacation. Tx c increased fiber in diet.
100. Diverticulosis “ d/t low fiber/high fat diet. LLQ pain, fever, tenderness. Dx c colonoscopy. Tx c increased fiber.
101. Diverticulitis “ peritonitis, fever due to micro/macro-perforations, do CT scan. Tx c NPO, IVF and abx (cipro/metro or cefoxitine or ampicillin/sulbactam)
102. Pseudomembranous Colitis “ C.difficile overpopulation due to prior use of Abx weeks ago, dx c C.diff in stool. Colonoscopy shows yellow adherent plaques on mucosa. Tx: d/c drug, start metronidazole, if still +, vancomycin.
103. Colorectal CA “ 2nd MCCOD d/t cancer, rectal bleeding, change in BM, weight loss, sometimes asymptomatic (found incidentally on colonoscopy). Dx: FOBT yearly after age 50, flexible sigmoidoscopy every 4 years, colonoscopy at 50 then 53 then every 5 years, but start 10 years earlier than the age of which family relative was diagnosed with it. Tx “ surgical resection of primary tumor.
104. Chronic Liver Disease “ causes include autoimmune hepatitis, hemochromatosis, chronic alcohol use, fatty liver dz (non-alcoholic stateohepatitis), wilsons dz, viral (HBV, HCV), s/s include fatigue, increased abdm girth, jaundice, spider angiomas, palmar erythema, HSM, gynecomastia, testicular atrophy, labs c high AST/ALT/PT/INR, thrombocytopenia, hyponatremia, hypoalbuminemia.
105. Autoimmune hepatitis “ 20-40yo female c +ANA, +anti-smooth muscle Ab, everything else normal. Tx c steroids.
106. Wilson™s disease “ young guy with parkinsonism due to hepatilenticular degeneration, kayser-Fleischer ring, hemolytic anemia, dx c low serum ceruloplasmin, low total copper (not free), high urine copper. CT shows hypdense regions in the basal ganglia. Confirm dx c liver biopsy. Tx c D-penicillamine.
107. Ascites “ U/S, CT and then paracentesis. Tx c Na/fluid restriction, diuretics, then furosemide, then large-volume paracentesis, then TIPS.
108. Spontaneous bacterial peritonitis - >250polys in 3 bedside cultures, tx c cefotaxime
109. Encephalopathy “ tx c protein restriction and lactulose.
110. HAV “ shellfish, fecal-oral, dx c + anti-HAV IgM (IgG shows previous infxn)
111. HBV “ HbsAg is earliest marker, >6months is chronic, if vaccinated = +HbsAb, -HbcAb, if exposed in the past = +HbsAb, +HbcAb. Window period has anti-HBc IgM only. Prevent with vaccine + HBIG. Treat c Interferon alpha and lamivudine. Give vaccine at 0-2mo, 4-6mo, 13-18 months. If mom has +HbsAg, give baby vaccine + HBIG within 12 hours of birth.
112. HCV “ dx c anti-HCV Ab/IgG/IgM and HCV RNA by PCR. Tx “ Inf-a c ribavirin
113. Drug-induced “ Tylenol, isoniazid, halothane, carbon tetrachloride, tetracycline. Dx c very high AST/ALT levels. Tx “ D/C med
114. Acute fatty liver of pregnancy “ develops in 3rd TM. Tx “ immediate surgery
115. Primary Biliary Cirrhosis “ antimitochondrial Ab in serum, pruritis, fatigue, hepatomegaly, high alk phos, destruction of intrahepatic and extrahepatic ducts. Tx c ursodeoxycholic acid, cholestyramine.
116. Primary Sclerosing Cholangitis “ young man c IBD (UC), destruction on extrahepatic ducts only (shows beading effect d/t fibrosis).
117. Gallstones “ female, fat, 40, fertile, RUQ or epigastric pain, worsened c food, radiates to midscapular area. Dx c U/S, then HIDA scan if negative. Tx c lap chole. ERCP if pt still has symptoms after (stone is in CBD).
118. Mesenteric Ischemia “ severe abdm pain/tenderness with paucity of clinical findings. Pt will usually have extensive ischemic history (MI, DM, etc), dx c angiography, tx with prompt laparotomy to reestablish arterial flow
119. Acute Pancreatitis “ MCC is gallstones, then alcohol. Epigastric pain radiating to midback, alleviated c sitting up, jaundice sometimes fever. High amylase/lipase. Dx c CT. Tx c NPO, NGT, analgesia, and then begin to consider ERCP and surgery if perforated, bleeding, abscess, pseudocyst or peritonitis.
120. Pacreatic Pseudocyst vs Abscess “ worsening of pain, n/v, fever high WBC and positive blood culture after initial improvement. Dx c CT. Tx c Abx, then surgical drainage of abscess. Pseudocyst is generally asymptomatic.
121. Pancreatic CA “ vague abdm pain (doesn™t have to radiate to the back anymore), anorexia and weight loss with jaundice, n/v. Dx c CT. If negative do ERCP. Check CA 19-9. Tx: If only at pancreatic head c no spread, try resection. If not, do Whipple (pancreaticoduodenectomy) procedure.
122. Malabsorption “ Steatorrhea (dx c Sudan stain “ 1st test). Then dx c D-xylose, if abnormal, suggests small bowel disease. Normal value suggests focus on pancreatic dz: CT of abdm, serum amylase, AST/ALT. If overgrowth considered, note response to malabsorption to Abx. Celiac sprue panel: antiendomysial/antigliadin Ab, tissue transglutaminase, total serum IgA, antigliadin Ab IgA and IgG; at least 3 biopsy specimens from distal duodenum is gold standard.
123. Whipple™s “ malabsorption, arthralgia and CNS symptoms (dementia). Dx c small bowel biopsy (shows foamy macrophages on PAS stain). Tx c TMP-SMX
ONCOLOGY:
124. Tumor markers “ Bhcg “ testicular cancer, choriocarcinoma, mole; AFP “ hepatocellular carcinoma testicular ca; CEA “ GI cancers; PSA “ prostate ca; CA-125 “ Ovarian ca; CA 19-9 “ colorectal/GI/pancreatic cancer
125. Sigmoidoscopy - >50yo every 3-5yrs; FOBT - >50 annually; DRE - >40 annually; PSA - >50 annually in normal risk, >40 annually in high risk; Pap smear “ onset of sexual activity or 18yo annually for 3 consecutive years then however often; Pelvic exam “ 18-40yo every 1-3yr, >40 annually; Endometrial biopsy “ menopause/high risk annually; Self breast exam - >20 monthly; Clinical breast exam “ 20-40 every 3 years, >40 annually; Mammogram “ 40-49 every 1-2 yrs, >50 annually.
126. 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
127. 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)
128. 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).
129. Acute Lymphocytic Leukemia “ kids, blasts, tx c intrathecal chemo (MTX)
130. Acute Myelogenous Leukemia “ M3 causes DIC, Aeur rods, blasts, add All-trans retinoic acid (Vit A) to tx.
131. 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).
132. CLL “ elderly, high WBCs, high lymphocytes, splenomegaly, dx c smudge cells, no tx if no lymphocytosis, if + lymphocytosis give fludarabine or chlorambucil.
133. Hairy Cell Leukemia “ CD10+ and TRAP+ (tartrate-resistant acid phosphatase), tx c cladribine
134. Mycosis fungoidis “ cutaneous T-cell lymphoma (look at 1st aid picture).
135. Multiple Myeloma “ high calcium, high OAF, high uric acid. Best initial test is X ray if bone pain or electrophoresis if high protein. Most accurate test is >10% plasma cells. Tx: <70yo get stem cell transplant, >70yo get Meiphelen or Thalidomide
136. Aplastic Anemia “ low rbc/wbc/platelet, drugs (chloramphenicol), parvo-B19 (sickle cell), tx: <50yo get BMT, >50yo get cyclosporine + anti-thymocyte globulin
137. 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.
138. 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.
139. 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)
140. Solitary nodule “ 1st step get old x-ray. If present and same size, its benign (send home), if increase in size its probably cancer. If it wasn™t there, assess risk (high is smoker and >35, low risk is nonsmoker and <35). If low risk follow up later, if high risk do biopsy.
141. Breast Cancer “ biopsy everyone c palpable mass >35 except if B/L, lumpy and s/s only occur c menses. If <35 its probably fibroadenoma (rubbery moveable mass, observe pt). After bx, get mammogram if >35yo. If mammo was already done, get FNA. If after biopsy, mass goes away, send pt home. Tx: tamoxifen, mastectomy, radiation, axillary dissection, chemotherapy (c platinum) if + nodes.
142. 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).
143. 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.
144. 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.
Growth/Development/ Preventative Medicine:
Okay, as I promised. I wrote the preventative medicine/epidemiology/statistics notes to the way I best understand them. If you dont, thats understandable and you need to just think it out. Good luck...
HEMATOLOGY:
145. Microcytic (MCV <80): Iron deficiency, Thalassemia, Anemia of Chronic Dz, Sideroblastic Anemia (lead poising, isoniazid, alcohol-induced)
146. Normocytic (MCV 80-100): Check Reticulocyte count(should be <2% c anemia, otherwise marrow isn™t responding properly): <2% is acute blood loss (<5-7days), early iron deficiency, aplastic anemia, early AOCD, renal disease. >3% is due to either Intrinsic RBC defect (MAD: Membrane defects (Spherocytosis, PNH), Abnormal hemoglobins (Sickle cell), Deficient enzymes (G6PD, pyruvate kinase deficiency)) or Extrinsic RBC defect (Autoimmune hemolytic anemia, MAHA, blood loss >1 week)
147. Macrocytic (MCV >100): B12 def, folate def, Myelodysplastic syndrome, drug-induced, hepatic dysfunction (d/t alcohol), reticulocytosis.
148. Red Cell Morphologies: Rouleaux (myeloma), Burr cells (uremia), Tear drops and nucleated red cells (myelofibrosis), hypochromic/microcytic (iron def), target cells (HALT: Hemoglobinopathies, Asplenia, Liver dz (obstructive jaundice), Thalassemia), Oval macrocytes (B12/Folate def), basophilic stippling (Lead, B12 def), spherocytes (HS), Schistocytes (MAHA, AIHA, DIC), bite cells and Heinz bodies(G6PD), Howell-Jolly bodes (Asplenia like SCD).
149. Iron deficiency “ low MCV, high TIBC, low ferritin, low iron (<60), high RDW (why? Because some are normocytic and some are microcytic so the range of width will be high), pica kid who eats sand and ice, plummer-vinson (web, low iron, glossitis), cow milk before age 1, exclusive breast-feeding, pregnancy. Tx “ 1st is to find the source of iron loss and fix that (before you give iron!), 2nd transfusion (if needed fast) or oral iron supplements for 6-12 months.
150. Anemia of Chronic Dz “ (how does this work? The body knows diseases (RA, TB, SLE, cancer) love iron, so it will hide iron away in stores (high ferritin) but keep it out of the serum (low serum iron and high TIBC)) if anemia is a/w chronic renal dz, look for Burr cells.
151. Thalassemia “ normal iron (so don™t give iron), target cells, nucleated rbc, x-ray shows crew-cut appearance of skull, dx c Hb electrophoresis, no tx for traits. Thal major gets transfusion 1st and deforoxamine to prevent iron overload, spelenectomy (now give pneumovax, penicillin prophylaxis, folate supplement).
152. Lead Poisoning “ pica kids who have ABCD (Anemia/Ataxia/Abdm pain, Basophillic stippling/Behavioral changes, Constipation, Drops (foot/wrist)/Death), high free erythrocyte protoporphyrin. Dx c blood Pb level and x-ray (pb visible in bones). Tx c EDTA or dimercaprol.
153. B12 Deficiency “ MCC is pernicious anemia (anti IF/parietal Ab), also d/t gastrectomy, terminal ileus resection, vegetarian, chronic pancreatitis and diphyllobothrium latum infection. Look for CNS s/s (symmetric parethesia in feet/fingers, disturbed proprioception and vibratory sense, irritability, somnolence, abnormal taste/smell, central scotomas, positive babinski) and achlorhydria (no stomach acid secretion so pH in stomach is high). Check serum B12. Schilling test (never used in real world). Hypersegmented PMN. High methylmalonic acid level. Tx c cobalamin. Folate may worsen the CNS s/s.
154. Folate “ usually d/t dietary lack (green vegetables, liver, kidney, yeast, mushrooms), alcoholism, pregnancy, celiac sprue, phenytoin, bactrim, MTX, 5-FU, OCPs. Tx c folate supplements.
155. Autoimmune Hemolytic Anemia “ Ab/complement binds to RBC mmb. Two types IgM (agglutination at colder temp like Mycoplasma) and IgG (warm agglutination like SLE, penicillin, methyldopa). Dx c direct Coomb™s positive. If hemolysis is mild, observe, if hemolysis is severe, give glucocorticoids. If recurrent, do splenectomy.
156. Paroxysmal Nocturnal Hburia “ Hypoventilate at night, so acidosis causes RBC burst d/t low DAF, therefore complement comes right off (CD 55/59). May die in 10 yrs d/t thrombosis. Best test is Sugar water test or Hams test (Acidic sounds like Hacidic, Hacidics don™t like Ham). s/s include Hburia in the morning time (not at night, that would be a prostate problem), increase risk of AML. Give steroids.
157. G6PD Deficiency “ MCC is infection (they usually wont say Greek, primaquine, fava beans, Dapsone). Hemolysis, jaundice abdm/back pain 1-3 days after exposure. Heinz bodes, bite cells. Best tx c avoiding offending agents.
158. Spherocytosis “ increased osmotic fragility, AD, low spectrin, splenomegaly. Dx c osmotic fragility test, tx c splenectomy (defer until 6yo), pneumo vaccine and folate
159. Sickle Cell Disease “ African descent, AR, s/s >6mo d/t HbF, if trait only gets UTI, best initial test is smear, most accurate test is Hb electrophoresis, for crisis 1st give fluids/pain management, if fever (d/t autosplenectomy) give Abx (Ceftriaxone), if eye/CNS/chest/Priapism give exchange transfusion, to prevent next aplastic crisis give folate, to prevent next vaso-occlussive pain crisis (they will just say œcrisis) give hydroxyurea, if Hct drops suspect Aplastic anemia d/t Parvovirus. Give prophylactic penicillin, Pnumococcal/Haemophilus influenza vaccine @ childhood.
160. Aplastic Anemia “ low rbc/wbc/platelets, chloramphenicol, parvovirus, benzene, acute leukemia, AZT/zidovudine. Tx c 1st stop drug, then give antithymocyte globulin
161. Myelophthisic anemia (Myelofibrosis) “ malignant invasion of BM, anisocytosis (aniso = any size), poikilocytosis (shape), teardrop-shaped RBC, dx c BM biopsy showing no cells (dry tap).
162. Transfusions: Whole blood (poisoning, TTP), Packed RBC (post-surgery/trauma transfusion or instead of whole blood), washed RBC (IgA deficiency), Platelets (>10,000), granulocytes (post chemo), FFP (bleeding diathesis like DIC, warfarin poisoning, liver failure), cryoprecipitate (vWD and DIC). MCC of transfusion rxn is lab error. If it occurs, 1st step is stop transfusion.
163. Platelet problems = skin, gums, nose, gingival (ALL SUPERFICIAL), GI, CNS and vaginal bleeding; Factor problems “ bleeding into join and muscles (DEEP), GI, CNS.
164. 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)
165. 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).
166. DIC “ high PT/PTT/BT, low plt, low RBC, low factor 8.
167. 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.
168. Heparin “ high PTT, thrombocytopenia. Tx c d/c drug
169. Warfarin “ high PT, vit K antagonist (2,7,9,10), tx c FFP (fast) or vit K (slow), skin necrosis
170. ITP “low platelets, high BT, h/o URI, next step is steroids (just treat it), auto-platelet Ab, if platelets fall < <7000 give IVIG or RhoGam.
171. TTP “ high BT, low plt, low RBC, hemolysis, CNS, renal, fever, thrombocytopenia (petechia, purpura). Tx c plasmapheresis
172. HUS “ like TTP but no renal failure or CNS s/s, h/o infection, E. coli 015H7.
173. Scurvy “ all studies normal. Fingernal/gum/bone/perifollicular hemorrhage, poor diet (only eats hot dogs and soda or tea and toast). Tx c vitamin C.
174. Neutropenia “ PMN <2.0 x 10_9. Dx c bone marrow aspirate/bx. Tx: 1st determine the cause, 2nd Abx, 3rd steroids, 4th GM-CSF.
175. Polycythemia Rubra Vera “ 4 H™s (Hypervolemia, Hyperviscosity (thrombosis is MCCOD), Hyperuricemia, Histaminemia (itch all over after a hot shower)). Tx c phlebotomy.
My Infectious Disease Cram-Facts
#219813
drjiggy - 09/14/07 17:32
ID:
176. Toxic Shock Syndrome “ preformed toxin, prolonged tampon placement, hypotension, fever, dequamated rash (peeling of palms/soles), S.aureas
177. Conjunctivitis “ 1st 24 hours is chemical, 2-5 days is Neisseria, 4+ is Chlamydia. If they say painful conjunctivitis, that™s viral (HSV) so treat c acyclovir.
178. External Otitis “ pain, drainage, itchy swimmer™s ear, Pseudomonas.
179. Otitis Media “ 40% s.pneumo, 30% h.influenza, 30% m.catarrhalis, dx: 1st step is pneumatic otoscopy showing immobility of tympanic mmb, 2nd step is tympanocentesis, tx c amoxicillin.
180. Sinusitis “ same % as above. Yellow green d/c, sinus tenderness, best initial step “ empiric abx (amox + decongestant), then X-ray, then Sinus biopsy (most accurate)
181. Meningitis “ 0-1mo “ GBS, E.coli, Listeria, 2mo-2yo “ S.pneumo, 2-18yo “ Neisseria, 18+ - S.pneumo; Kernigs/Brudzinski sign, lethargy, fever, bulging fontanelle, photophobia, nuchal rigidity, n/v, dx c LP (bacteria: low glucose, high prtn, PMN™s; viral: normal glucose, slightly high prtn, low WBC, lymphocytes). If bacterial, give ceftraixone, vanco or steroids. Give ampicillin (listeria) if immunocompromised. If neisseria suspected (2-18yo c rash) next step is respiratory isolation and tx him and family members c rifampin. If >100 lymphocytes: Cryptococcus (r/o HIV, best initial test is India ink, most accurate test is crypt ag, tx c Amp B), Viral (no specific test), TB (pulm s/s, high CSF protein, give RIPE + steroids), Lyme Dz (serology, h/o bite, target rash, doxycycline, or if CNS s/s like cranial nerve 7 effects, give Ceftriaxone), RMSF (serology, rash on wrists/ankes moving centrally, h/o camping or hiking, tx c Doxycycline, chloramphenicol if pregnant). The MC sequela is hearing loss.
182. Encephalitis “ look for acute febrile confusion (if they say confusion, its encephalitis not meningitis), MCC is herpes (blood in csf), best initial test is CT (temporal lope), if negative do PCR (most accurate). Tx c acyclovir, then foscarnet if resistant.
183. Brain Abscess “ look for focal neurologic findings c ring/contrast enhancing lesions. If HIV (-), do biopsy, if HIV +, start sulfadiazine-pyrimethamine tx for Toxo and repeat CT.
184. Spinal Abscess “ local severe back pain that becomes radicular pain, then weakness c fever. Next step is CT, then surgical drainage c abx.
185. Tetanus “ rictus sardonicus (facial sneer), tonic muscle spasms (jaw, trismus), clostridium tetani, tx c tetanus IG and penicillin G.
186. Diptheria “ gray pharyngeal pseodommb c sore throat, tx c diphtheria antitoxin (DAT) and penicillin or erythromycin.
187. Croup “ aka acute laryngotracheitis “ barking cough in a 1-2yo. Parainfluenza virus. Frontal neck x-ray shows steeple sign. Tx c racemic epinephrine.
188. Epiglottitis “ 2-5yo kid unimmunized (H.influenza) c rapid progression of high fever, drooling and respiratory distress c no coughing. X ray shows thumb sign. Do not examine throat or irritate the kid (worsen airway obstruction). Tx c airway assessment, then cephalosporins.
189. Bronchiolitis “ 0-18month old kid in the fall/winter gets expiratory wheezing due to RSV. Tx c ribavirin. (In a nutshell, 0-2yo c wheezing is bronchiolitis, 1-2yo c barking cough is croup, 2-5yo c drooling is epiglottitis)
190. Pertussis “ whooping inspiratory wheeze.
191. Lung abscess “ fever for weeks, bad teeth, alcoholic, aspiration, stroke pt, intubated pt, next step is CXR, best way to prevent it is to remove all teeth, how do you differentiate from TB? The smell (very bad in abscess), most accurate test is biopsy, tx c clindamycin
192. Bronchitis “ mild cough c sputum, negative CXR, tx c azithro, levaquin or doxy
193. Pharyngitis “ sore throat, exudes, lymph nodes, no cough, no hoarseness, best test is rapid strep test, tx c penicillin
194. Influenza “ ahces, pains, tired, cough, HA, no fever. Best tx is oseltamivir or zanamivir (note the Ivir (for Influenze), not Ovir like acyclovir/famcyclovir for HSV or Avir like ritonavir/nelfinavir for AIDS)
195. Pneumonia “ outpt tx is same as bronchitis (azithro, levaquin, doxy), inpatient tx include ceftriaxone. In young healthy pt, think mycoplasma (get serologies) or if inpt, think S.pneumo. If CNS and GI symptoms, pick Legionella. If AIDS c CD<200 pick PCP (TMP-SMX tx). If exposed to sheep placenta, pick Coxiella burnetti. If lobar pneumonia (s.pneumo is MC) then stain and culture next. When do you give steroids? PO2 <75, A-a gradient <35. When do you admit and give pneumovax? Hypoxia, >65, splenectomy, hypotensive c high pulse, comorbidities, confusion, low Na (SIADH).
196. TB “ homeless, alcoholic, immigrant, HIV, health care worker, prisoner, fever, cough, sputum, wt loss, night sweats, first thing to do is CXR (NOT PPD “ when do you choose PPD first? Screens asymptomatic pts!), 2nd step is AFP and then give RIPE c isolation for 2 months, then isoniazid and rifampin for another 4 months (6 months total). Adverse effects are Isoniazid is neurotoxic (less c B6), Rifampin c red urine, pyrizinimide c high uric acid (do not treat it, it will pass) and ethambutol with eye problems.
197. PPD “Positive if: >5mm in HIV, steroid users, close contacts; >10mm in immigrants, health care workers (me!), >15 in pt c no risk facts. If PPD is positive, proceed to CXR, if (-) take INH for 9 months, if + get sputum AFB. If PPD is negative, repeat it in 1-2 weeks to rule out false negatives. If pt had PPD in the past that was +, don™t do PPD again (it will always be positive), go right to CXR.
198. 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.
199. Thrush “ oral candida, removable white mouth patches (Candida CAN come off, hairy leukoplakia cant). Tx c nystatin mouth rinse.
200. 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.
201. HIV “ 1st ELISA, 2nd western blot (in kids, 1st is PCR). Peripheral neuropathy c stavudine/didanosine, anemia c zidovudine, rash c tmp/smx (start dapsone), nephrolithiasis c indinavir. MC overall adverse effect is increase lipids and glucose levels. Prophylaxis: <200 for PCP (tmp/smx), <50 MIA (azithromycin). What if pt finds out she has HIV during pregnancy? Continue all meds except effavirenz. When do you only continue c AZT? If she has high CD count, give it in end of pregnancy and to newborn for 6 weeks. If pt gets stuck c needs, start 2 nucleosides and 1 PI or 2 nucleosides c effavirenz. Must you start tx if pt got splashed in eyes? Yes. Kissing? No.
202. If pt is stuck c HBV needle, now has +HBsAg, what do you do? If vaccinated, do nothing. If not vaccinated, give IVIG + vaccine. If pt got stuck c HCV needle do nothing.
203. How can you tell urethritis from cystitis? Urethritis has discharge. For both conditions, 1st step is swab, then stain, then DNA probe then tx. For urethritis tx GC (Ceftriaxone), for cervicitis, tx for Chlamydia (Azithro or Doxy)
204. Genital ulcers and + Lymph could be syphilis, LGV or chancroid
205. Syphilis “ painless genital ulcer, skin rash (lata), CNS/aortitis. 1st step is Darkfield microscopy (not rpr/vdrl). DOC is penicillin. If allergic give doxycyline. If allergic and pregnant, desensitize c penicillin. If pt gets immediate allergic rxn to penicllin, give aspirin.
206. LGV “ painless ulcer c painful nodes. 1st step is serology (Chlamydia is culture negative), tx c doxycycline
207. Chancroid “ painful ulcer, 1st step is culture, tx c azithromycin
208. Genital vesicles, next step is acyclovir (not Tzank because you already have dx), if resistant give foscarnet. When do you choose PCR? HSV in the brain.
209. If they show or describe a vesicle (but don™t say vesicle), then do Tzank test
210. If they describe or show warts, next step is remove (no tests needed).
211. Septic Arthritis “ 1st step is arthrocentesis (>50,000 wbc). If you suspect gonorrhea (look for tenosynovitis, rash or migratory polyarthritis), next step is culture pharynx, rectum, cervix, etc.
212. Osteomyelitis “ 1st step is xray (periosteal elevation), 2nd is MRI, 3rd is biopsy. When do you choose bone scan? If you cant do MRI (metal, pacemaker, hearing tubes, etc). After bx you can make dx: S.aureaus (nafcillin), MRSA (vanco, linezolid), E.coli (quinolones for bones) and then f/u ESR. When do you choose culture or sinus drainage? Never!
Rheumatology Cram-Facts
#219828
drjiggy - 09/14/07 18:43
RHEUMATOLOGY:
213. Osteoarthritis “ stiff, not red, not hot. DIP (Heberdens node), PIP (Bouchards), worse in PM (not in AM like RA). X-ray shows osteophytes and joint narrowing. Tx c weight loss 1st, then NSAIDS.
214. Rheumatoid Arthritis “ red, hot, swollen, fever, subQ nodules, +RF, pericarditis, pleural effusion, uveitis, long morning stiffness, swan neck, PIP/MCP (not DIP). Xray shows pannus. Tx c NSAIDS (1st if mild), methotrexate (1st if severe), 2nd is TNF (infliximab “ r/o TB 1st), then steroids.
215. Gout “ podagra, tophi (subQ uric acid deposits c punched-out bone lesions), (-) birefrigent crystals, a/w alcohol/aspirin/HCTZ use. Tx: Acute: 1st c NSAIDS (Indomethacin), then colchicines, then steroids (1st if renal dz). Chronic: If oversecretor give allopurinol (allo for ppl who make a lot), undersecretors get propenecid.
216. Pseudogout “ calcium rhomboid shaped crystals, + birefringence, chondrocalcinosis, a/w 4 H™s (hemochromatosis, hyperparathyroidism, hypophosphatemia, hypomagnesemia). MC @ knees/elbows.
217. Psoriasis “ scaly skin lesions, finger clubbing, RF negative. Tx c NSAIDS, MTX
218. Ankylosing spondylitis “ HLA-B27 (not diagnostic), family hx, back pain, bent over (bamboo spine), worse c rest (key), better c exercise, dx c 1st Sacral X-ray (sacroiliitis). Tx c exercise and NSAIDS
219. Reiters Synd “ HLA-B27, can™t see (conjunctivitis), pee (uvieitis), climb a tree (arthritis). Tx c NSAIDS, eye drops, STD treatment.
220. Behcet™s syndrome “ 20-40yo c painful oral/genital ulcers and arthritis. Tx c steroids.
221. Kawasaki™s “ (FEEL My Conjunctiva “ Fever >5days, Edema, Erythema, Lymphadenopathy, Myositis, Conjunctivitis). Next step is Echo (r/o coronary aneurysms). Tx c Aspirin + IVIG
222. 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
223. Wegeners “ nasal (sinusitis), lung (hemoptysis, dyspnea), kidney (hematuria), c-ANCA, tx c cyclophosphamide
224. Fibromyalgia “ young female with pain all over, multiple points of tenderness, irregular sleep pattern, anxiety, exams all normal. Tx c antidepressant, NSAIDS
225. Polymyalgia Rheumatic “ old female c pectoral/pelvic pain/stiffness, elevated ESR, normal biopsy, a/w temporal arteritis. Tx c steroids.
226. Polymyositis “ 40-60yo female c proximal muscle weakness, elevated ESR/CPK, abnormal muscle biopsy, dx c 1st muscle biopsy, then EMG. Tx c steroids
227. Dermatomyositis “ same as above, but c rash (heliotrope rash around eyelid).
228. 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.
229. Herniated disk “ most at L4-5 (weak big toe), and L5-S1 (reduced Achilles reflex), positive straight leg test.
230. 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.
231. Osgood-Shlatter “ inflammation of tibial tubercle in boys. Tx c rest and immobilization.
232. Slipped Capital Femoral Epiphysis “ Obese kid c painful limp. Dx c xray. Tx c surgical pinning >5yo.
233. 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.
234. 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.
235. 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.
236. Osteosarcoma “ 10-25yo c knee pain, mass, limping, high alk phos. X-ray c sunburst appearance. Tx c surgery and chemotherapy
237. Osteoid Osteoma “ bone pain worse at night and relieved c NSAIDS. Tx c nsaids
238. Osteochondroma “ bone pain, xray shows pedunculated metaphyseal tumor at distal femur. Tx c surgery.
239. Ewing sarcoma “ fever, pelvic/femur bone pain, swelling, xray shows onion skinning. Tx c radiation, chemo, surgery.
240. 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).
241. 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.
My Neurology Cram-Facts
#219994
drjiggy - 09/15/07 14:01
NEUROLOGY:
242. 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.
243. 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.
244. Temporal Arteritis “ >50yo c unilateral temporal HA, scalp tenderness, vision changes, high ESR. 1st step is give steroids, 2nd step temporal artery biopsy.
245. 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.
246. Trigeminal Neuralgia “ pain whenever you touch your face @ 5th cranial nerve distribution. Tx c carbamazapine. Definitive treatment with surgical rhizotomy.
247. 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)
248. 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)
249. 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.
250. 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).
251. 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.
252. TIA “ focal, abrupt onset lasting less than 1 hour, symptoms resolve after 1 day. Risk of stroke in days to weeks. Amorosis fugax (curtain over an eye due to retinal dysfunction) needs Doppler U/S of carotids or MRA. Give heparin acutely (if no contraindications), then long term aspirin. If stenosis >70%, amaurosis fugax/TIA or small, non-disabling stroke do CEA (carotid endarterectomy) and give aspirin. If stenosis <70%, severely disabling stroke, or TIA/stroke in evolution give daily aspirin alone.
253. CVA “ 1st test is CT without contrast (although, if ischemic, it will show negative), 2nd is MRI. Heparin is not given until hemorrhagic stroke is ruled out. If ischemic, give tPA™s if less than 3 hours of onset. If hemorrhagic, control BP and ICP.
254. Ischemic Stroke Locations: MCA “ contralateral hemiplegia, hemianopsia, Broca™ s (nonfluent, babbling)/Wernicke™s (fluent but doesn™t make sense) aphasia. ACA “ contralateral leg paralysis, sphincter incontinence (they cant kick you, so they pee on you); Posterior “ cortical blindness, hemianopsia; Vertebrobasilar “ ataxia, horizontal gaze, nystagmus; Cerebellar “ ataxia and dizziness; As for hemorrhagic, remember that in the thalamus its only sensory loss, in the pontine/internal capsule/putamen its only motor loss.
255. Multiple Sclerosis “ insidious onset of CNS s/s in a woman aged 20-40 with exacerbations and remissions of numbness, parasthesia, weakness, optic neuritis, gait disturbance, incontinence and emotional/mental status changes. Look for classic b/l internuclear opthalmoplegia (lesion @ MLF so you cannot adduct in horizontal gaze) and scanning speech. Babinski may be positive. Entirely CNS (M.gravis and G-Barre are entirely PNS). 1st step is MRI, 2nd test is LP (oligoclonal bands). Tx acute exacerbation c steroids. Prevent next attack c ABC (Avonex (Inf-B), Betaseron (Inf-B) and Copaxone (Glatiramer acetate)). If stuck in 1 position all day, give baclofen or Tizanidine. If incontinent give oxybutinin or bethanacol.
256. Guillain-Barre Syndrome “ h/o URI of GI infection (campylobacter jejuni) or immunization 1 week before develops onset of symmetric, assending progressive weakness or paralysis and loss of DTRs. 1st step is PFTs (MCCOD is respiratory dysfunction due to paralysis, so monitor the pt™s NIF (negative inspiratory force) and if it keeps decreasing, consider intubation). Most accurate test is EMG. When do you choose LP? Last (shows elevated CSF protein). Tx c IVIG or plasmapheresis (not steroids!).
257. Myasthenia Gravis “ Ab against Ach receptors in women 20-40yo. Look for ptosis, diplopia, difficulty swallowing and weakness c repetition (at the end of they day they are exhausted). Best initial test is Ach Ab (NOT edrophonium test, which is 2nd or if they already mention the Ach Ab). Most accurate test is EMG. Tx Myasthenia crisis (breathing problems) c D/C anitchonergics and give IVIG and Plasmapheresis (NOT steroids). Tx for chronic disease: <60 gets thymectomy (do CXR, Chest CT), >60 gets neostigmine and steroids, then azathiopine/cyclosporine/tacrolimus. What abx is contraindicated? Aminoglycosides.
258. Eaton-Lambert “ Ab against presynaptic calcium channels causing limb weakness that gets stronger c repetitive stimulation (opposite of gravis),no loss of DTRs or extraocular manifestations, a/w small cell lung cancer, tx c guanidine. (cab™s are contraindicated).
259. Neurosyphilis “ tertiary treponema pallidum disease. Treat c high dose penicillin. After giving penicillin, pt may develop hypotension, fever, HA, chills and tachycardia within 24 hours of treatment due to treponemal products (Jarisch-Herxheimer reaction, this is not a penicillin reaction). Tx c aspirin.
260. Myotonic Dystrophy“ 20-30yo guy grabs something and cant let go (impaired relaxation) d/t mutations in chloride channel. Tx c phenytoin.
261. Duchenne Muscular Dystrophy “ XLR, boys 3-7 have muscle weakness, very high CK, calf pseudohypertrophy, Gower™s sign (kid climbs his legs to stand, look at it in google videos its so sad). Kid is in wheelchair by teenager and dead by 20. Dx c muscle biopsy.
262. Mitochondrial Myopathy “ aka Lever™s hereditary optic atrophy “ every mom gives to all overspring (no male transmission). Look for ragged red fibers on biopsy.
263. Botulism “ infant ingests honey and develops floppy baby syndrome. 1st step is intubate if needed, 2nd step is antitoxin. Spontaneous recovery in 1 week.
264. Amyotrophic lateral Sclerosis “ aka Lou Gehrig™s dz “ 55yo male upper (spasticity, hyperreflexia, babinski) and lower motor neuron (fasciculations, atrophy, flaccidity) problem. Only motor problems, no sensory/sexual/bowel problems. Tx c Riluzole.
265. Huntington™s Disease “ AD (father had it, you have it at a younger age) c CAG repeats, chorea, personality change, psychiatric syndromes, progressive dementia. Dx c CT/MRI showing caudate nucleus and cerebral cortex atrophy, causing decreased Ach and GABA (thus causing increased dopamine). Tx c antipsychotics (haloperidol) When you see a movement disorder, dementia and emotional problems, think of Huntington™s. When you see dementia and emotional problems (no chorea), pick Pick™s disease.
266. Parkinson™s “ 60yo c extrapyramidal movement disorder (pill-rolling resting tremor, cogwheel rigidity, shuffling gait, bradykinesia, masked facies). Caused by loss of dopaminergic neurons in substantia nigra. Tx: Mild s/s (can still take care of themselves): <60yo c Anticholinergic (cabergeline/benztropine/trihexylphenidyl), >60yo c Amantidine. If Severe s/s: 1st Levo/Carbidopa, 2nd is DA agonist (primapexole, ropinirole, pergolide), 3rd COMT-inhibitors (Talcopone), 4th MAOI (selegiline). Some antipsychotics (haloperidol, risperidone, MPTP) can cause parkinson-like symptoms, tx c anticholinergics (benztropine/ trihexylphenidyl/ cabergeline). Young guy c Parkinsonism, but not on meds, think of Wilson™s disease.
267. Alzheimer™s “ progressive dementia (memory, language, visuospatial, mood, hallucinations, personality/behavior) in mid-late life. a/w Down™s syndrome (amyloid precursor protein). Dx c MRI showing cortical atrophy, senile plaques, neurofibrillary tangles. Tx c donepezil, rivastigmine and galantamine to increase Ach just in brain.
268. Pick™s “ early aged (40) personality change, dementia. CT/MRI shows frontetemporal atrophy, argyrophilic neuronal (Pick) bodies in frontal and temporal lobe, sparing superior temporal gyrus (generally no memory problems).
269. Multi-infarct Dementia “ stepwise dementia in a pt c bad medical history (HTN, DM, etc.). They will describe the pt as progressively getting worse, little-by-little. Dx c PET/SPECT scan showing multifocal decreases in cerebral blood flow. Tx c aspirin
270. Normal Pressure Hydrocephalus - œwet, wacky, wobbly (incontinent, dementia, ataxia). Dx c CT scan, tx c ventriculoperitoneal shunt.
271. Creutzfeldt-Jakob - young guy c rapidly progressive dementia, myoclonus due to abnormal isoform of prion protein. Dx c biopsy (nothing else). No treatment.
272. Narcolepsy “ daytime sleep attacks c cataplexy, hynogogic (going to sleep)/hypnopompic (waking up) hallucinations, sleep paralysis. Rapid onset of REM sleep. Tx c amphetamines for sleepiness, clomipramine for cataplexy.
273. Obstructive sleep apnea “ overweight, HTN, arrhythmia, gasping for air. Dx c polysymnography. Tx c CPAP.
274. Central sleep apnea “ old, non-obese pt c loss of respiratory drive. Tx c azetazolamide.
275. Epidural Hematoma - + head trauma, + HA, + LOC, lucid intervals after brief LOC followed by increasing obtundation, middle meningeal artery. Dx c CT without contrast showing convex hematoma. Tx c 1st hyperventilate and elevate head, 2nd evacuate, 3rd mannitol
276. Subdural Hematoma - +head trauma, + HA, + LOC, bridging veins injured, can be acute (CT showing concave or crescent-shaped hematoma), days (MRI), or gradual deterioration (MRI). Tx c same as above.
277. Subarachnoid Hemorrhage - +HA, + LOC, no head trauma, spontaneous, sudden onset of meningitis (stiff neck, photophobia, kernig™s, brudzinski), worst HA of my life, a/w polycystic kidney disease, CSF c blood. Best initial test is Head CT, most accurate test is LP. Tx supportively (bed rest, analgesia)
278. Concussion “ + head trauma, + LOC, no focal CNS defecits. Tx “ go home.
279. Contusion “ + head trauma, + LOC, blood/bruise on head. Tx “ go home.
280. Neuroleptic malignant syndrome “ high temperature, muscular rigidity, confusion, high CPK, high K+, no sweating, tx c IV dantrolene or bromocriptine.
281. Malignant hyperthermia “ high temperature, confusion, high CPK, high K+, no sweating, h/o anesthesia (halothane). Tx c IV dantrolene
Normal Development & Preventative Med Cram-Facts
#220050
drjiggy - 09/15/07 17:22
Growth/Development/ Preventative Medicine:
285. Gestational Age “ fundus at pubic symphysis @ 8 wks, above symphysis @ 14wks, umbilicus @ 20wks, xiphoid @ 38wks.
286. Naegele™s rule “ assuming 28 day cycle, subtract three months, add 7 days (if more than 28 days, add the remaining days to the 7)
287. Infant size “ gains back birth weight by 2
09-21-2007, 05:59 PM
did u see it husayn
09-21-2007, 07:23 PM
wow thats alot!! i thought if i just posted my notes at once like that, people would get overwhelmed and not read it.. looks like another textbook haha... but to me, its just bare essentials, to know more is better, to know less is inadequate.. hope you agree and hope there are no mistakes, forgive me if there are, im only human...
09-21-2007, 07:41 PM
i have been reading yoour notes. They are great drjiggy...yes you can make a book:
09-21-2007, 09:44 PM
I have got all of them jiggy...but the numbers that i am looking for,may have been missed by you while composing them. Any waz they are complete and extremely helpful.In case you have the particular numbers that i am looking for i.e item 315 to 354,457to 509, please mail me those particular ones.otherwise leave it jaani.Thanks again.
10-24-2007, 10:07 PM
hi,
please help ehat does "c" stand for in numbers1 and onward?
Thanks a ton
please help ehat does "c" stand for in numbers1 and onward?
Thanks a ton
10-24-2007, 10:07 PM
hi,
please help ehat does "c" stand for in numbers 1 and onward?
Thanks a ton
please help ehat does "c" stand for in numbers 1 and onward?
Thanks a ton
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