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* SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Doctors)
  skan - 03/23/06 07:50

Collection from Different Forums

I also recommend the following

1. USMLE World MCQ’s and CCS (Must Do)

2. 1,470 Online Free MCQs with Answers. (Subject to Availability of Time)


3. All or any of these books are good.

First Aid, Crush the Boards, Kaplan Step2, Kaplan Step3, Premier Review Notes, Swanson’s, Blue Prints, MAKSAP, CMDT, Harrisons etc etc. ( Subject to Time Since Step 2, specialty in residency)

(Step3 needs understanding of American Medical System, especially the Guidelines in different clinical situations and Ethical Issues.)


Gastrointestinal System:
1. Gastro-esophageal Reflux Disease
2. Gastroenteritis
3. Erosive Gastritis
4. Gastric Carcinoma
5. Duodenal Ulcer
6. Duodenal Ulcer, Perforated
7. Upper GI Bleed
8. Acute Cholecytitis
9. Acute Pancreatitis
10. Appendicitis
11. Carcinoma Colon
12. Constipation
13. Intestinal Obstruction
14. Irritable Bowel Syndrome
15. Lower GI Bleed
16. Acute Diverticulitis
17. Sigmoid Volvulus
18. Ulcerative Colitis
19. Crohn’s Disease
20. Hepatitis A
Endocrine System:
21. Diabetes Mellitus Type 2, chronic uncontrolled
22. Diabetes Mellitus Type 2, new onset
23. Diabetic Ketoacidosis with UTI
24. Hyper-Osmolar Non-Ketotic Coma
25. Hyperthyroidism
26. Hypothyroidism
27. Hypothyroidism with Iron Deficiency Anemia
Musculoskeletal System:
28. Acute Gout Attack
29. Cellulitis
30. Rheumatoid Arthritis
31. Septic Arthritis
Cardiovascular system:
32. Acute Pericarditis
33. Aortic Dissection
34. Atrial Fibrillation
35. Congestive Heart Failure
36. Congestive Heart Failure with Dilated Cardiomyopathy
37. Congestive Heart Failure with Hypertension
38. Congestive Heart Failure with Pulmonary Embolism
39. Infective Endocarditis
40. Myocardial Infarction
41. Pericardial Tamponade
42. Unstable Angina
43. Chemotherapy-Induced Febrile Neutropenia
44. DVT
45. G6PD Deficiency
46. Folic Acid Deficiency Anemia
47. Iron Deficiency Anemia
48. Sickle Cell Patient with Acute Chest Syndrome
49. Sickle Cell Patient with Cholelithiasis
50. ITP
51. TTP
52. Hemophilia
53. Von Willebrand’s Disease with easy bruising
54. Von Willebrand’s Disease with menorrhagia
Renal System:
55. Acute Cystitis
56. Acute Prostatitis
57. Acute Renal Failure
58. Chronic Renal Failure
59. Nephrotic Syndrome
60. Polycystic Kidney Disease in adult
61. Post-op ATN/Interstitial Nephritis due to medication
62. Renal Cell Carcinoma
Pulmonary System:
63. Asthma Exacerbation
64. Community Acquired Pneumonia
65. COPD Exacerbation
66. Lung Carcinoma
67. Lung Carcinoma with Obstructive Pneumonia
68. Maxillary Sinusitis
69. Pneumocystis Carinii Pneumonia
70. Pleural Effusion
71. Pulmonary Embolism
72. Solitary Pulmonary Nodule
73. Tuberculosis
Nervous System:
74. Alzheimer’s Dementia
75. Headache
76. Meningitis
77. Sub-arachnoid Hemorrhage
78. Temporal Arteritis
79. Transient Ischemic Attack
80. Antenatal care
81. Bacterial Vaginosis
82. Candida Vaginitis
83. Trichomonas Vaginitis
84. Breast Lump
85. Dysfunctional Uterine Bleeding
86. Ectopic pregnancy
87. Menopause
88. Menopause with Osteoporosis
89. Ovarian Carcinoma, abdominal mass
90. Ovarian Torsion
91. PCOD
92. Pelvic Inflammatory Disease
93. Premature Labor
94. Toxic Shock Syndrome
95. Tubo-ovarian abscess
96. Turner’s syndrome
97. UTI in pregnancy
98. Iron Deficiency Anemia in Pregnancy
99. Hyperthyroidism in Pregnancy
100. Bronchiolitis
101. Child Abuse
102. Croup
103. Cystic Fibrosis
104. Diarrhea in an Infant
105. Down’s syndrome with Duodenal Atresia
106. Foreign-body Aspiration
107. Infant with Sepsis
108. Iron deficiency anemia due to cow’s milk intake
109. Lead Poisoning
110. Meningitis in Infant
111. Neonatal Hyperbilirubinemia secondary to cephalhematoma reabsorption
112. Obesity and hypertension in adolescent boy
113. Otitis Media
114. Pneumonia in an Infant
115. Seizures in a child
116. Unknown Poisoning
117. Alcohol Withdrawal in an Alcoholic
118. Depression
119. Panic Attack
120. MVA with Complete Heart Block
121. MVA with Epidural Hematoma
122. MVA with Rhabdomyolysis
123. MVA with Splenic Rupture
124. MVA with Rib Fractures
125. Angioedema/Anaphylaxis
126. Hypertension, New Onset
127. Hypertensive Emergency
128. Lead Poisoning
129. Military Recruit Physical
130. Narcotic Overdose
131. Barbiturate Overdose
132. TCA Overdose
133. Spousal Abuse


Bence Jones Protein · · multiple myeloma free light chains (either kappa or lambda) · · Waldenstrom’s macroglobinemia
· Bilateral breast cancer · Lobular carcinoma
· Bilateral renal cell carcinoma · Von Hippel-Lindau
· Birbeck Granules · · histiocytosis X (eosinophilic granuloma)
· Bladder trabeculation · BPH
· Bloody nipple discharge · Intraductal papilloma
· Blueberry muffin baby · Rubella
· Blue Bloater · · Chronic Bronchitis
· Blue Sclera · Osteogenesis imperfecta
· Boot-Shaped Heart · · Tetralogy of Fallot
· Bouchard’s Nodes · · osteoarthritis (PIP)
· Boutonniere’s Deformity · · rheumatoid arthritis
· Bronze Diabetes · Hemochromatosis
· Brown Tumor · · hyperparathyroidism
· Brudzinski sign · meningitis
· Brushfield Spots · · Down’s, on iris
· Call-Exner Bodies · · granulosa cell tumor
· Carbon monoxide poisoning · Hyperemia, edema and necrosis of globus
· Cardiomegaly with Apical Atrophy · · Chagas’ Disease
· Central Nuclei in Muscle · Muscular dystrophies
· Chancre · · 1° Syphilis, painless firm ulcers
· Chancroid · · Haemophilus ducreyi, painful soft ulcers
· Charcot Triad · · multiple sclerosis (nystagmus, intention tremor, scanning speech)
· Charcot-Leyden Crystals · · bronchial asthma
· Cherry-red spot on macula · Tay-Sachs, 50% of Niemann-Pick
· Cheyne-Stokes Breathing · · cerebral lesion
· Chocolate Cysts · · endometriosis
· Cholesterol clefts · atherosclerosis
· Chordae tendinae short and fused · Rheumatic heart disease
· Chronic staph infections · Chronic granulomatous disease, a deficiency of NADPH oxidase, can’t kill catalase positive bugs
· Chvostek’s Sign · · Hypocalcemia facial spasm in tetany
· Clear nuclei · Thyroid papillary carcinoma (Orphan Annie’s eyes)
· Clue Cells · · Gardnerella vaginitis
· Codman’s Triangle · · osteosarcoma
· Coin Lesions in Lung · Pulmonary Hamartoma
· Cold Agglutinins · · Mycoplasma pneumoniae · · infectious mononucleosis
· Cold thyroid nodules · Colloid cyst or thyroid adenoma
· Concentric laminar intimal fibrosis of small arteries of lung · Primary pulmonary hypertension
· pernicious anemia (antibodies to intrinsic factor or parietal cells ® ¯IF ® ¯Vit B12 ® megaloblastic anemia)
· Albright’s Syndrome · · polyostotic fibrous dysplasia, precocious puberty, café au lait spots, short stature, young girls
· Alport’s Syndrome · · hereditary nephritis with nerve deafness, Type 4 collagen defect (basement membranes)
· Alzheimer’s · · progressive dementia; tau proteins, neurofibrillary tangles, apolipoprotein E4 allele, narrow gyri and wide sulci (atrophy), occipital sparing, hydrocephalus ex vacuo, plaques in hippocampus and cortex, ¯ Acetylcholine, Hiramo bodies (inrtacellular inclusion bodies in hippocampal cells)
· Argyll-Robertson Pupil · · loss of light reflex constriction (contralateral or bilateral) · · “Prostitute’s Eye” - accommodates but does not react · · Pathognomonic for 3°Syphilis
· Arnold-Chiari Malformation · · cerebellar tonsil herniation
· Barrett’s · · columnar metaplasia of lower esophagus ( risk of adenocarcinoma)
· Bartter’s Syndrome · · hyperreninemia
· Becker’s Muscular Dystrophy · · similar to Duchenne, but less severe (deficiency in dystrophin protein)
· Bell’s Palsy · · CNVII palsy (entire face; recall that UMN lesion only affects lower face)
· Berger’s Disease · · IgA nephropathy
· Bernard-Soulier Disease · · defect in platelet adhesion (abnormally large platelets & lack of platelet-surface glycoprotein)
· Berry Aneurysm · · circle of Willis (subarachnoid bleed) · · often associated with ADPKD
· Bowen’s Disease · · carcinoma in situ on shaft of penis ( risk of visceral ca)
· Briquet’s Syndrome · · somatization disorder · · psychological: multiple physical complaints without physical pathology
· Broca’s Aphasia · · Motor Aphasia intact comprehension
· Bronchiolitis · RSV
· Brown-Sequard · · hemisection of cord (contralateral loss of pain & temp / ipsilateral loss of fine touch, UMN)
· Bruton’s Disease · · X-linked agammaglobinemia
· Budd-Chiari · · post-hepatic venous thrombosis
· Buerger’s Disease · · acute inflammation of small, medium arteries ® painful ischemia ® gangrene
· Burkitt’s Lymphoma · · small noncleaved cell lymphoma EBV · · 8:14 translocation
· Caisson Disease · · gas emboli
· Carpal Tunnel Syndrome · Median nerve entrapment
· Chagas’ Disease · · Trypansoma infection sleeping disease, cardiomegaly with apical atrophy, achlasia
· Chediak-Higashi Disease · · Phagocyte Deficiency: neutropenia, albinism, cranial & peripheral neuropathy · · repeated infections
· Congenital adrenal hyperplasia · 21-hydroxylase deficiency: virilism, no cortisol, salt loss, hypotension · 11-hydroxylase deficiency: virilism, no cortisol, salt retention, hypertension
· Conn’s Syndrome · · primary aldosteronism
· Cori’s Disease · · glycogen storage disease (debranching enzyme deficiency)
· Creutzfeldt-Jakob · · prion infection ® cerebellar & cerebral degeneration
· Crigler-Najjar Syndrome · · congenital hyperbilirubinemia (unconjugated) · · glucuronyl transferase deficiency
· Crohn’s · · IBD; ileocecum, transmural, skip lesions, lymphocytic infiltrate, granulomas · (contrast to UC: limited to colon, mucosa & submucosa, crypt abscesses, pseudopolyps, colon cancer risk)
· Croup · Parainfluenza
· Curling’s Ulcer · · acute gastric ulcer associated with severe burns
· Cushing’s · · Disease: hypercorticism 2° to ACTH from pituitary (basophilic adenoma) · · Syndrome: hypercorticism of all other causes (1° adrenal or ectopic)
· Cushing’s Ulcer · · acute gastric ulcer associated with CNS trauma
· de Quervain’s Thyroiditis · · self-limiting focal destruction (subacute thyroiditis)
· DiGeorge’s Syndrome · · thymic hypoplasia ® T-cell deficiency · · hypoparathyroidism
· Down’s Syndrome · · trisomy 21 or translocation
· Dressler’s Syndrome · · Post-MI Fibrinous Pericarditis autoimmune
· Dubin-Johnson Syndrome · · congenital hyperbilirubinemia (conjugated) · · striking brown-to-black discoloration of the liver
· Duchenne Muscular Dystrophy · · deficiency of dystrophin protein ® MD X-linked recessive
· Edwards’ Syndrome · · trisomy 18 · · rocker-bottom feet, low ears, heart disease
· Ehler’s-Danlos · · defective collagen
· Eisenmenger’s Complex · · late cyanotic shunt (R®L) pulmonary HTN & RVH 2° to long-standing VSD, ASD, or PDA
· Erb-Duchenne Palsy · · trauma to superior trunk of brachial plexus Waiter’s Tip
· Ewing Sarcoma · · undifferentiated round cell tumor of bone
· Eyrthroplasia of Queyrat · · carcinoma in situ on glans penis
· Fanconi’s Syndrome · · impaired proximal tubular reabsorption 2° to lead poisoning or Tetracycline (glycosuria, hyperphosphaturia, aminoaciduria, systemic acidosis)
· Felty’s Syndrome · · rheumatoid arthritis, neutropenia, splenomegaly
· Gardner’s Syndrome · · adenomatous polyps of colon plus osteomas & soft tissue tumors
· Gaucher’s Disease · · Lysosomal Storage Disease glucocerebrosidase deficiency · · hepatosplenomegaly, femoral head & long bone erosion, anemia · Crinkled tissue paper cells in marrow
· Gilbert’s Syndrome · · benign congenital hyperbilirubinemia (unconjugated

GIST · Tumor arising in cells of Cajal (pacemakers of gut)
· Glanzmann's Thrombasthenia · · defective glycoproteins on platelets
· Goodpasture’s · · autoimmune: ab’s to glomerular & alveolar basement membranes; linear immunofluorescence
· Grave’s Disease · · autoimmune hyperthyroidism (TSI)
· Guillain-Barre · · idiopathic polyneuritis (ascending muscle weakness & paralysis; usually self-limiting)
· Hamman-Rich Syndrome · · idiopathic pulmonary fibrosis
· Hand-Schuller-Christian · · chronic progressive histiocytosis
· Hashimoto’s Thyroiditis · · autoimmune hypothyroidism (antimicrosomal or antithyroglobulin); Hurthle cells, thyroid germinal centers,
· Ha****oxicosis · · initial hyperthyroidism in Hashimoto’s Thyroiditis that precedes hypothyroidism
· Henoch-Schonlein purpura · · hypersensivity vasculitis · · hemmorhagic urticaria (with fever, arthralgias, GI & renal involvement) · · associated with upper respiratory infections
· Hereditary Spherocytosis · RBC cytoskeletin defect, most commonly spectrin
· Hirschprung’s Disease · · aganglionic megacolon
· Horner’s Syndrome · · ptosis, miosis, anhidrosis (lesion of cervical sympathetic nerves often 2° to a Pancoast tumor)
· Huntington’s · · progressive degeneration of caudate nucleus, putamen & frontal cortex; AD
· Hunter’s · Decreased iduronosulfate sulfatase
· Hurler’s · Decreased alpha-L-iduronidase
· Jacksonian Seizures · · epileptic events originating in the primary motor cortex (area 4)
· Job’s Syndrome · · immune deficiency: neutrophils fail to respond to chemotactic stimuli
· Kaposi Sarcoma · · malignant vascular tumor (HHV8 in homosexual men)
· Kartagener’s Syndrome · · immotile cilia 2° to defective dynein arms infection, situs inversus, sterility
· Kawasaki Disease · · mucocutaneous lymph node syndrome (lips, oral mucosa)
· Keratoconjunctivitis · adenovirus
· Klinefelter’s Syndrome · · 47, XXY
· Kluver-Bucy · · bilateral lesions of amygdala (hypersexuality; oral behavior)
· Krabbe Disease · Beta-galactosidase deficiency
· Krukenberg Tumor · · adenocarcinoma with signet-ring cells (typically originating from the stomach) metastases to the ovaries
· Laennec’s Cirrhosis · · alcoholic cirrhosis
· Lesch-Nyhan · · HGPRT deficiency · · gout, retardation, self-mutilation
· Letterer-Siwe · · acute disseminated Langerhans’ cell histiocytosis
· Libman-Sacks · · endocarditis with small vegetations on valve leaflets · · associated with SLE
· Lou Gehrig’s · · Amyotrophic Lateral Sclerosis degeneration of upper & lower motor neurons
· Mallory-Weis Syndrome · · bleeding from esophagogastric lacerations 2° to wretching (alcoholics)
· Marfan’s · · elastin defect, floppy mitral valve, arachnodactyly, cystic medial necrosis, subluxed lens
· McArdle’s Disease · · glycogen storage disease (muscle phosphorylase deficiency)
· Meckel’s Diverticulum · · rule of 2’s: 2 inches long, 2 feet from the ileocecum, in 2% of the population · · embryonic duct origin; may contain ectopic tissue (gastric, pancreatic, etc.)
· Meig’s Syndrome · · Triad: ovarian fibroma, ascites, hydrothorax
· Menetrier’s Disease · · giant hypertrophic gastritis (enlarged rugae; plasma protein loss)
· Monckeberg’s Arteriosclerosis · · calcification of the media (usually radial & ulnar aa.), pipestem arteries
· Munchausen Syndrome · · factitious disorder (consciously creates symptoms, but doesn’t know why)
· Meningioma · Arachnoid cap cells, whorls of cells
· Mesothelioma · Asbestos exposure
· Nelson’s Syndrome · · 1° Adrenal Cushings ® surgical removal of adrenals ® loss of negative feedback to pituitary ® Pituitary Adenoma
· Niemann-Pick · · Lysosomal Storage Disease sphingomyelinase deficiency · · “foamy histiocytes”
· Osler-Weber-Rendu Syndrome · · Hereditary Hemorrhagic Telangiectasia
· Osteogenesis imperfecta · Type I collagen defect
· Paget’s Disease · · abnormal bone architecture (thickened, numerous fractures ® pain) , woven and lamellar bone mosaic
· Pancoast Tumor · · bronchogenic tumor with superior sulcus involvement ® Horner’s Syndrome
· Parkinson’s · · dopamine depletion in nigrostriatal tracts; Cogwheel rigidity
· Peutz-Jegher’s Syndrome · · melanin pigmentation of lips, mouth, hand, genitalia plus hamartomatous polyps of small intestine
· Peyronie’s Disease · · subcutaneous fibrosis of dorsum of penis
· Pick’s Disease · · progressive dementia similar to Alzheimer’s, knife-edged gyri
· Plummer’s Syndrome · · hyperthyroidism, nodular goiter, absence of eye signs (Plummer’s = Grave’s - eye signs)
· Plummer-Vinson · · esophageal webs & iron-deficiency anemia, SCCA of esophagus
· Pompe’s Disease · · glycogen storage disease (acid maltase deficiency) ® cardiomegaly
· Pott’s Disease · · tuberculous osteomyelitis of the vertebrae
· Potter’s Complex · · renal agenesis ® oligohydramnios ® hypoplastic lungs, defects in extremities
· Raynaud’s · · Disease: recurrent vasospasm in extremities · · Phenomenon: 2° to underlying disease (SLE or scleroderma)
· Reiter’s Syndrome · · urethritis, conjunctivitis, arthritis non-infectious (but often follows infections), HLA-B27, polyarticular
· Reye’s Syndrome · · microvesicular fatty liver change & encephalopathy · · 2° to aspirin ingestion in children following viral illness
· Riedel’s Thyroiditis · · idiopathic fibrous replacement of thyroid
Rotor Syndrome · · congenital hyperbilirubinemia (conjugated) · · similar to Dubin-Johnson, but no discoloration of the liver
· Sezary Syndrome · · leukemic form of cutaneous T-cell lymphoma (mycosis fungoides)
· Shaver’s Disease · · aluminum inhalation ® lung fibrosis
· Sheehan’s Syndrome · · postpartum pituitary necrosis
· Shy-Drager · · parkinsonism with autonomic dysfunction & orthostatic hypotension
· Simmond’s Disease · · pituitary cachexia
· Sipple’s Syndrome · · MEN type IIa (pheochromocytoma, thyroid medulla, parathyroid)
· Sjogren’s Syndrome · · triad: dry eyes, dry mouth, arthritis risk of B-cell lymphoma
· Spitz Nevus · · juvenile melanoma (always benign)
· Stein-Leventhal · · polycystic ovary
· Stevens-Johnson Syndrome · · erythema multiforme, fever, malaise, mucosal ulceration (often 2° to infection or sulfa drugs)
· Struma Ovarii · Thyroid teratoma of ovary
· Still’s Disease · · juvenile rheumatoid arthritis (absence of rheumatoid factor)
· Takayasu’s arteritis · · aortic arch syndrome · · loss of carotid, radial or ulnar pulses
· Tay-Sachs · · gangliosidosis (hexosaminidase A deficiency ® GM2 ganglioside)
· Tetralogy of Fallot · · تVSD, ثoverriding aorta, جpulmonary artery stenosis, حright ventricular hypertrophy
· Tourette’s Syndrome · · involuntary actions, both motor and vocal
· Turcot’s Syndrome · · adenomatous polyps of colon plus CNS tumors
· Turner’s Syndrome · · 45, XO
· Typhoid Fever · Bradycardia and in white people rose spots on abdomen
· Vincent’s Infection · · “trench mouth” - acute necrotizing ulcerative gingivitis
· von Gierke’s Disease · · glycogen storage disease (G6Pase deficiency)
· von Hippel-Lindau · · hemangioma (or hemangioblastoma) · · adenomas of the viscera, especially renal cell carcinoma · defect in VHL tumor suppressor
· von Recklinghausen’s · · neurofibromatosis & café au lait spots & Lisch nodule (iris hamartomas)
· von Recklinghausen’s Disease of Bone · · osteitis fibrosa cystica (“brown tumor”) 2° to hyperparathyroidism
· von Willebrand’s Disease · · defect in platelet adhesion 2° to deficiency in vWF; increased bleeding time and PTT
· Waldenstrom’s macroglobinemia · · proliferation of IgM-producing lymphoid cells
· Wallenberg’s Syndrome · · Posterior Inferior Cerebellar Artery (PICA) thrombosis “Medullary Syndrome” · · Ipsilateral: ataxia, facial pain & temp; Contralateral: body pain & temp
· Waterhouse-Friderichsen · · catastrophic adrenal insufficiency 2° to hemorrhagic necrosis (eg, DIC) · · often 2° to meningiococcemia
· Weber’s Syndrome · · Paramedian Infarct of Midbrain · · Ipsilateral: mydriasis; Contralateral: UMN paralysis (lower face & body)
· Wegener’s Granulomatosis · · necrotizing granulomatous vasculitis of paranasal sinuses, lungs, kidneys, etc.
· Weil’s Disease · · leptospirosis
· Wermer’s Syndrome · · MEN type I (thyroid, parathyroid, adrenal cortex, pancreatic islets, pituitary)
· Wernicke’s Aphasia · · Sensory Aphasia impaired comprehension
· Wernicke-Korsakoff Syndrome · · thiamine deficiency in alcoholics; bilateral mamillary bodies (confusion, ataxia, ophthalmoplegia)
· Whipple’s Disease · · malabsorption syndrome (with bacteria-laden macrophages) & polyarthritis
· Wilson’s Disease · · hepatolenticular degeneration (copper accumulation & decrease in ceruloplasmin)
· Wiskott-Aldrich Syndrome · · immunodeficiency: combined B- &T-cell deficiency (thrombocytopenia & eczema)
· Wolff-Chaikoff Effect · · high iodine level (-)’s thyroid hormone synthesis
· Zenker’s Diverticulum · · esophageal; cricopharyngeal muscles above UES
· Zollinger-Ellison · · gastrin-secreting tumor of pancreas (or intestine) ® acid ® intractable ulcers

Bloody Mary

Adhesive arachnoiditis · Caused by bacterial meningitis, leads to obstructive hydrocephalus
· Albumino-Cytologic Dissociation · · Guillain-Barre (markedly increased protein in CSF with only modest increase in cell count)
· AFP increase · Neural tube defects, hepatocellular carcinoma, yolk sac and embryonal carcinoma
· AFP decrease · Down’s
· Amnion nodosum · Renal agenesis
· Amyloid in thyroid · Thyroid medullary carcinoma (calcitonin)
· Analgesic abuse · Papillary necrosis, esp. in diabetics
· Anasarca · Minimal change disease
· Aneurysmal nodules · Polyarteritis nodosa
· Angiomyolipoma · Tuberous sclerosis
· Anosmia · Kallman’s syndrome
· Anterior vermian atrophy · alcoholism
· Anti-centromere antibody · Limited scleroderma (CREST)
· Anti-DNA topoisomerase antibody · Diffuse scleroderma
· Anti-endomysial antibody · Celiac sprue
· Anti-jo antibody · polymositis
· Anti-mitochondrial antibody · Primary biliary cirrhosis
· Antiplatelet Antibodies · · idiopathic thrombocytopenic purpura
· Anti-sacharommyces cervisiae antibody · Crohn’s
· Anti-Smith antibodies · Specific for SLE, anti-ribonulceoprotein
· Anti-smooth muscle antibody · Autoimmune hepatitis type I
· Arachnodactyly · · Marfan’s
· Aschoff Bodies · · rheumatic fever
· Ashleaf spots (skin) · Tuberous sclerosis
· Atypical lymphocytes · EBV
· Auer Rods · · acute promyelocytic leukemia (AML type M3)
· Autosplenectomy · · sickle cell anemia
· Babinski · · UMN lesion
· Bacterial conjuntivitis · S. aureus, strep. pneumo, Hemophilus aegyptius
· Basophilic Stippling of RBCs · · lead poisoning
· Condyloma Lata · · 2° Syphilis · · new coffee flavor at Bagel & Bagel
· Congenital Hepatic Fibrosis · Polycystic Kidney Disease, juvenile autosomal recessive form
· Contraction Band Necrosis · MI
· Cotton Wool Spots · · HTN
· Councilman Bodies · · dying hepatocytes
· Crescents In Bowman’s Capsule · · rapidly progressive (crescentic glomerulonephritis)
· Crushed ping pong balls · · Pneumocystis carinii
· Crypt abscesses · Ulcerative colitis
· Currant-Jelly Sputum · · Klebsiella
· Curschmann’s Spirals · · bronchial asthma
· Cystathioine synthase deficieny · homocystinuria
D-dimers · DIC
· Depigmentation Of Substantia Nigra · · Parkinson’s
· Dew drop on rose petal · Chicken pox
· Diaphragmatic pleural plaques · Asbestosis
· Donovan Bodies · · granuloma inguinale (STD)
· Double bubble sign on ultrasound · Down’s syndorme – duodenal atresia
· Duret Hemorrhages · Uncal herniation
· Eburnation · · osteoarthritis (polished, ivory-like appearance of bone)
· Eccentric intimal fibrosis with medial hypertrophy · Chronic transplant rejection
· Ectopia Lentis · · Marfan’s
· Embolizing endocarditis · Infectious, marantic (fibrin deposits in hypercoagulable states)
· Erythema Chronicum Migrans · · Lyme Disease
· Excavation of Optic Cup · Glaucoma
· Exopthalmos · hyperthyroid
· FAT RN · TTP (fever, anemia, thrombocytopenia, renal failure, neuro problems)
· Fatty Liver · · Alcoholism
· Fecalith · Acute appendicitis
· False positive VDRL · SLE, Treponema pertenue (non-STD tropical infection)
· Ferruginous Bodies · · asbestosis
· Fish-mouthed mitral valve · Rheumatic heart disease
· Flea-bitten Kidney · Malignant Hypertension
· Frontal bossing · Sickle cell anemia
· Fungus ball in lung · Apergillus
· galactosemia · Galactose-1-phosphate uridyl transferase deficiency or galactokinase deficiency
· Garlic odor on breath · Arsenic (or lasagna)
· Ghon Complex · · Tuberculosis, primary
· Gold Pneumonia · Lipid pneumonia, exogenous (aspiration) or endogenous (obstruction
· Gower’s Maneuver · · Duchenne’s MD use of arms to stand
· Gray discoloration of skin · Argyria (silver poisoning)
· Hat size increase · Paget’s disease of bone
· Heart Failure Cells · CHF; hemosiderin-laden macrophages in lungs
· Heberden’s Nodes · · Osteoarthritis (DIP)
· Heinz Bodies · · G6PDH Deficiency
· Hemarthrosis · Coagulation factor deficiency
· Hemorrhagic Temporal Lobe Lesion · HSV
· Hemorrhagic Urticaria · · Henoch-Schonlein
· Heterophil Antibodies · · infectious mononucleosis (EBV)
· Hirano Bodies · · Alzheimer’s
· HLA B27 · Ankylosing spondylitis
· ochronosis (dark pigment of fibrous tissue) · Alkaptonuria –homogentisic acid oxidase deficiency
· Honeycomb lung · Pulmonary fibrosis
· Howell Jolley Bodies · Splenectomy, remnant of nuclear DNA
· H shaped vertebrae · Sickle cell anemia
· Human placental lactogen increase · Placental site trophoblastic tumor
· Hyaline thrombi · TTP
· Hydrosalpinx · Chronic pelvic inflammatory disease
· Hypersegmented PMNs · · Megaloblastic anemia
· Hypochromic Microcytic RBCs · · iron-deficiency anemia
· IgM against IgG · Rheumatoid arthritis (rheumatoid factor)
· ¯ Immunoglobulins · X-linked Brutons agammaglobulinemia, and common variable immunodeficiency
· Index finger overlapping 3rd and 4th · Edward’s (Trisomy 18)
· Jarisch-Herxheimer Reaction · · Syphilis over-aggressive treatment of an asymptomatic pt. that causes symptoms 2° to rapid lysis
· Joint Mice · · osteoarthritis (fractured osteophytes)
· Kaussmaul Breathing · · acidosis
· Keratin Pearls · · SCCA
· Kernig’s sign · meningitis
· Keyser-Fleischer Ring · · Wilson’s
· Kimmelstiel-Wilson Nodules · · diabetic nephropathy
· Koilocytes · · HPV
· Koplik Spots · · measles
· Lacunar cells · Variant of Reed-Sternberg cell seen in nodular sclerosing Hodgkin’s Disease
· Lacunar infarct · Chronic hypertension
Lamellar bodies · Contain surfactant in Type II pneumocytes
· Langhans giant cells · Tuberculosis, other including coccidioides
· Lemon yellow skin color · Pernicious anemia
· Lemon sign · Ultrasonographic finding in Neural Tube Defects
· Leukocoria · Retinoblastoma
· Lewy Bodies · · Parkinson’s (eosinophilic inclusions in damaged substantia nigra cells)
· Leukocyte alk. Phos. Positive · Leukemoid rxn.
· Lines of Zahn · · arterial thrombus
· Lisch Nodules · · neurofibromatosis (von Recklinhausen’s disease)
· Loss of grey-white junction · Tuberous sclerosis
· Low set ears · Downs, DiGeorge, Trisomy 18 (Edwards)
· Lumpy-Bumpy IF Glomeruli · · poststreptococcal glomerulonephritis
· Machine-like murmur · Patent ductus arteriosus
· Macronodular cirrhosis · Wilson’s, viral hepatitis, alpha-1-antitrypsin
· Malignant pustule · Anthrax (black skin lesion)
· Mallory Bodies · Alcoholic liver disease: intermediate filaments of hepatocyte cytoskeleton
· Maple syrup/burnt sugar urine · Alpha-ketoacid dehydrogenase deficiency; valine, leucine and isoleucine build up (branched)
· McBurney’s Sign · · appendicitis (McBurney’s Point is 2/3 of the way from the umbilicus to anterior superior iliac spine)
· Meconium ileus · Cystic Fibrosis
· Mees lines · Arsenic (parallel lines on fingernails)
· Melanosis coli · Laxative abuse
· Mental probs. with heart defect · Mitral prolapse
· Michealis-Gutmann Bodies · · Malakoplakia, an abnormal tissue response to kidney infection
· Microglial nodules · HIV
· Micrognathia · DiGeorge
· Micronodular cirrhosis · Wilsons, alcoholic, hemochromatosis, primary biliary cirrhosis
· Microsatellite instability · HNPCC (right-sided colon cancer), but also possible in other cancers
· Mid-systolic click · Mitral prolapse
· Monoclonal Antibody Spike · · multiple myeloma this is called the M protein (usually IgG or IgA) · · MGUS
· Mousy / musty odor · PKU
· Mucosal bleeding · Platelet problem (qualitative or quantitative)
· Myxedema · · hypothyroidism
· Necrolytic migratory erythema dermatitis · a-cell islet tumor
· Negri Bodies and hydrophobia · · rabies
· Neuritic Plaques · · Alzheimer’s
· Neurofibrillary Tangles · · Alzheimer’s
· Night pain relieved by aspirin · Osteoid osteoma
· Non-embolizing endocarditis · Rheumatic, Libman-Sacks (with SLE)
· Non-pitting Edema · · Myxedema · · Anthrax Toxin
· Notching of Ribs · · Coarctation of Aorta
· Nutmeg Liver · · CHF, right heart
· Onion skin kidney arterioles · Malignant nephrosclerosis (malignant hypertension)
· Oligoclonal band · Multiple sclerosis
· Osteoid production · osteosarcoma
· Painless Jaundice · · pancreatic CA (head)
· Palatal Petechaie · Strep pharyngitis
· Palpable purpura · Hypersensitivity vasculitis (Henoch-Schonlein, serum sickness)
· Pancarditis · Rheumatic fever
· Pannus · · rheumatoid arthritis
· PAS positive macrophages · Whipple’s disease
· Patent ductus arteriosus · Maternal rubella and prematurity
· Pautrier’s Microabscesses · · mycosis fungoides (cutaneous T-cell lymphoma)
· Periductal edema · Gynecomastia
· Periventricular Calcifications · Congenital CMV (brain ventricles, that is)
· Phenylalanine hydroxylase deficiency · PKU
· Philadelphia Chromosome · · CML
· Pick Bodies · · Pick’s Disease
· Piecemeal Necrosis · Chronic active hepatitis (periportal hepatocytes)
· Plexiform lesions · Pulmonary HTN (aneurysmal expansion of vessel wall)
· Pink, foamy lung exudate · Pneumocystis carinii pneumonia
· Pink Puffer · · Emphysema Centroacinar – smoking Panacinar - a1-antitrypsin deficiency
· Podagra · · gout (MP joint of hallux)
Porcelain gallbladder · Chronic cholecystitis (scarring)
· Porcelain gallstones · Associated with gallbladder adenocarcinoma
· Port-Wine Stain · · Hemangioma
· Posterior Anterior Drawer Sign · · tearing of the ACL
· Proliferating bile ducts · Obstructive jaundice
· Psammoma Bodies · · Papillary adenocarcinoma of the thyroid · · Serous papillary cystadenocarcinoma of the ovary · · Meningioma · · Mesothelioma
· Pseudohypertrophy · · Duchenne muscular dystrophy
· Pseudopoyps · Ulcerative colitis
· Pulmonary atherosclerosis · Cor pulmonale
· Punched-Out Bone Lesions · · multiple myeloma
· Punched-out esophageal lesions · herpes
· Rash on Palms & Soles · · 2° Syphilis · · RMSF
· RBC poikilocytosis · Beta-thalassemia
· Rectangular RBC’s · Hemoglobin SC
· Red hyalin globules · Alpha-1-antitrypsin deficiency (in liver)
· Red Morning Urine · · paroxysmal nocturnal hemoglobinuria
· Reed-Sternberg Cells · · Hodgkin’s Disease
· Reid Index Increased · · chronic bronchitis
· Reinke Crystals · · Leydig cell tumor
· Rhomboid crystals · Pseudogout
· Rim pattern · SLE, staining pattern with anti-double stranded DNA antibodies
· Rockerbottom feet · Patau (Trisomy 13), Edward’s (Trisomy 18)
· Rose thorns · Sporotrichosis
· Rouleaux Formation · · multiple myeloma RBC’s stacked as poker chips
· Rugae loss · Pernicious anemia (atrophic gastritis)
· S3 Heart Sound · · L®R Shunt (VSD, PDA) · · Mitral Regurg · · LV Failure
· S4 Heart Sound · · Pulmonary Stenosis · · Pulmonary HTN
· Scalloped colloid · Grave’s disease
· Schwartzman Reaction · · Neisseria meningitidis impressive rash with bugs
· Shagreen patches · Tuberous sclerosis
· Simian Crease · · Down’s
· Smith Antigen · · SLE (also anti-dsDNA)
· Smudge cells · CLL (delicate cells easily destroyed on peripheral smear)
· Soap Bubble on X-Ray · · giant cell tumor of bone
· Soldiers plaque · Clinically insignificant remnant of healed pericarditis
· Spider telangiectasia · Hyperestrinism: liver faillure, pregnancy
· Spike & Dome Glomeruli · · membranous glomerulonephritis
· Splinter hemorrhages · Infective endocarditis
· Strawberry tongue · Scarlet fever, Kawasaki’s
· Strawberry cervix · Trichomonas vaginalis
· Strawberry gallbladder · cholesterolosis
· String Sign on X-ray · · Crohn’s bowel wall thickening
· Sugar icing on spleen · Portal hypertension
· Sulfer granules · Collection of actinomyces or nocardia organisms in chronic abscessing bronchopneumonia
· Swiss cheese brain · Clostridia (gas forming)
· Syncitia · RSV, measles
· Tamm-Horsfall protein · Hyaline casts (non-specific)
· Target Cells · · Thalassemia
· Teardrop RBCs · Myelofibrosis
· Temporal lobe encephalitis · Herpes
· Tendinous Xanthomas · · Familial Hypercholesterolemia
· Tethered cord · Arnold-Chiari malformation (tonsilar herniation)
· Tetrahydrobiopterin cofactor def. · PKU
· Thymidine dimers · Xeroderma pigmentosum
· Thymus, parathyroid agenesis · Digeorge (3rd and 4th pharyngeal pouch)
· Thyroidization of Kidney · · chronic pyelonephritis
· TIBC increase · Anemia of chronic disease
· Tingible Bodies · Macrophage in lymph node germinal centers
· Tophi · · gout
· Tram-Track Glomeruli · · membranoproliferative glomerulonephritis
· Tree bark aorta · Syphilis

Piña Colada

1.If a patient has a fever, give acetaminophen (unless it is contraindicated)
2. If a patient is on a statin or you order a statin, get baseline LFTs and check frequently
3. If a patient is found to have abnormal LFTs, get a TSH
4. If a patient is going to surgery (including cardiac catheterization), make them NPO
5. All NPO patients must also have their urine output measured (type "urine output")
6. If a woman is between 12 and 52 years old and there is no mention of a very recent menses (that is, < 2 weeks ago), order a beta-hCG
7. Don't forget to discontinue anything that is no longer required (especially if you are sending the patient home)
8. When a patient is stable, decide whether or not you should change locations (if you anticipate that the patient could crash in the very near future, send the patient to the ICU; if the patient just needs overnight monitoring, send to the ward; if the patient is back to baseline, send home with follow-up)
9. In any diabetic (new or long-standing), order an HbA1c as well as continuous Accuchecks.
10. If this is a long-standing diabetic, also order an ophthalmology consult (to evaluate for diabetic retinopathy)
11. In any patient with respiratory distress (especially with low oxygen saturations), order an ABG
12. In any overdose, do a gastric lavage and activated charcoal (no harm in doing so, unless the patient is unconscious or has risk for aspiration)
13. In any suicidal patient, admit to ward and get "suicide contract" and "suicide precautions"
14. Patients who cannot tolerate Aspirin get Clopidogrel or Ticlopidine
15. Post-PTCA patients get Abciximab
16. In any bleeding patient, order PT, PTT, and Blood Type and Crossmatch (just in case they have to go to the O.R.)
17. In any pregnant patient, get "Blood Type and Rh" as well as "Atypical Antibody Screen"
18. In any patient with excess bleeding (especially GI bleeding), type "no aspirin" upon D/C of patient
19. If the patient is having any upper GI distress or is at risk for aspiration, order "head elevation" and "aspiration precautions"
20. In any asthmatic, order bedside FEV1 and PEFR (and use this to follow treatment progress)
21. Before you D/C a patient, change all IV meds to PO and all nebulizers to MDI
22. In any patient who has GI distress, make them NPO
23. All diabetic in-patients get Accuchecks, D/C oral hypoglycemic agents, start insulin, HbA1c, advise strict glycemic control, recommend diabetic foot care
24. All patients with altered mental status of unknown etiology get a "fingerstick glucose" check (for hypoglycemia), IV thiamine, IV dextrose, IV naloxone, urine toxicology, blood alcohol level, NPO
25. If hemolysis is in the differential, order a reticulocyte count
26. If you administer heparin, check platelets on Day 3 and Day 5 (for heparin-induced thrombocytopenia), as well as frequent H&H
27. If you administer coumadin, check daily PT/INR until it is within therapeutic range for two consecutive days
28. Before giving a woman coumadin, isotretinoin, doxycycline, OCPs or other teratogens, get a beta-hCG
29. If you give furosemide (Lasix), also give KCl (it depletes K+)
30. All children who are given gentamycin, should have a hearing test (audiometry) and check BUN/Cr before and after treatment
31. Don't forget about patient comfort! Treat pain with IV morphine, nausea with phenergan, constipation with PO docusate, diarrhea with PO loperamide, insomnia with PO temazepam
32. ALL ICU patients get stress ulcer prophylaxis with IV omeprazole or ranitidine
33. If you put a patient on complete bedrest (such as those who are pre-op), get "pneumatic compression stockings"
34. If fluid status is vital to a patient's prognosis (such as those with dehydration, hypovolemia, or fluid overload), place a Foley catheter and order "urine output"
35. If a CXR shows an effusion, get a decubitus CXR next
36. If you intubate a patient you ALSO have to order "mechanical ventilation" (otherwise the patient will just sit there with a tube in his mouth!)
37. With any major procedure (including surgery, biopsy, centesis), you MUST type "consent for procedure" (typing consent will not reveal any results)
38. With any fluid aspiration (such as paracentesis or pericardiocentesis), get fluid analysis separately (it is not automatic). If you don't order anything on the fluid, it will just be discarded.
39. With high-dose steroids (such as in temporal arteritis), give IV ranitidine, calcium, vitamin D, alendronate, and get a baseline DEXA scan.
40. In all suspected DKA or HHNC, check osmolality and ketone levels in the serum.
41. In ALCOHOLIC ketoacidosis, just give dextrose (no need for insulin), in addition to IV normal saline and thiamine
42. All patients over 50 with no history of FOBT or colonoscopy should get a rectal exam, a FOBT, and have a sigmoidoscopy or colonoscopy scheduled.
43. All women > 40 years old should get a yearly clinical breast exam and mammogram (if risk factors are present, start at 35)
44. All men > 50 years old should get a prostate exam and a PSA (if risk factors are present, start at 45)
45. If a patient has a terminal disease, advise "advanced directives"
46. In any patient with a chronic disease that can cause future altered mental status, type "medical alert bracelet" upon D/C
47. Any patient with diarrhea should have their stool checked for "ova and parasites", "white cells", "culture", and C.diff antigen (if warranted)
48. Any patient on lithium or theophylline should have their levels checked
49. All patients with suspected MI should be given a statin (and check baseline LFTs)
50. All suspected hemolysis patients should get a direct Coombs test
51. Schedule all women older than 18 for a Pap smear (unless she has had a normal Pap within one year)
52. Pre-op patients should have the following done: “NPO”, “IV access”, “IV normal saline”, “blood type and crossmatch”, “analgesia”, “PT”, “PTT”, “pneumatic compression stockings”, “Foley”, “urine output”, “CBC”, and any appropriate antibiotics
53. If a patient requires epinephrine (such as in anaphylaxis), and he/she is on a beta-blocker, give glucagon first
54. If lipid profile is abnormal, order a TSH
55. All dementia and alcoholic patients should be advised “no driving”
56. To diagnose Alzheimer’s, first rule out other causes. Order a CT head, vitamin B12 levels, folate levels, TSH, and routine labs like CBC, BMP, LFT, UA. Also, if the history suggests it, order a VDRL and HIV ELISA as well
57. Also rule out depression in suspected dementia patients
58. For all women who are sexually active and of reproductive age, give folate. In fact, you should give ALL your patients a multivitamin upon D/C home
59. All pancreatitis patients should be made NPO and have NG suction so that no food can stimulate the pancreas
60. Send patients home on a disease-specific diet: diabetics get a “diabetic diet”, hypertensives get a “low salt diet”, irritable bowel patients get a “high fiber diet”, hepatic failure patients get “low protein diet”, etc
61. Do not give a thrombolytic (tPA or streptokinase) in a patient with unstable angina patient
62. Patients who are having a large amount of secretions, order “pulmonary toilet” to reduce the risk of aspiration
63. Every patient should be advised to wear a “seatbelt”, to “exercise”, and advised about “compliance”
64. In any patient who presents with an unprotected airway (as in overdoses, comatoses), get a CXR to rule out aspiration
65. In any patient with one sexually transmitted disease (such as Trichomonas), check for other STDs as well (Gonorrhea, Chlamydia, HIV, syphilis, etc.) and do a Pap smear in all women with an STD
66. Remember to treat children with croup with a “mist tent” and racemic epinephrine
67. Any acute abdomen patient with a suspected or proven perforation, give a TRIPLE antibiotic: Gentamycin, Ampicillin, Metronidazole
68. Get iron studies in patients with microcytic anemia if the cause is unknown. Order “iron”, “ferritin”, “TIBC”
69. Women with vaginal discharge should get a KOH prep, saline (wet) prep, vaginal pH, cervical gonococcal, chlamydia culture
70. If a woman is found to have vaginal candida, check her fasting glucose
71. When the 5 minute warning screen is displayed, go through the following mnemonic (RATED SEX). I know it probably is not the best mnemonic, but it is difficult to forget!:
Recreational drugs / Reassurance
Diet (eg. high protein, no lactose, low fat, etc.)
Seat belt / Safety plan / Suicide precautions
Education (“patient education”)
X (stands for safe seX)
72. All suspected child abuse patients should be admitted and you should order THREE consults: consult “child protection services”, consult “ophthalmology” (to look for retinal hemorrhages), consult “psychiatrist” (to examine the family dynamics)
73. When a woman reaches menopause, she should have a “fasting lipid profile” checked (because without estrogen, the LDL will rise and the HDL will drop), a DEXA scan (for baseline bone density), and of course, FOBT and colonoscopy (if she is over 50)
74. If colon cancer is suspected, order a CEA; if pancreatic cancer, order CA 19-9; if ovarian cancer, order CA 125.
75. Remember to give “phototherapy” to a newborn with pathologic unconjugated bilirubinemia (it is not helpful if it is predominantly conjugated). Also, with phototherapy, keep the neonate on IV fluids (the heat can dehydrate them), and give erythromycin ointment in their eyes
76. Before giving a child prednisone, get a PPD
77. If a patient is found to have high triglycerides, check “amylase” and “lipase” (high triglycerides can cause pancreatitis)
78. Remember that any newborn under 3 weeks of age who develops a fever is SEPSIS until proven otherwise. Admit to the ward and culture EVERYTHING: “blood culture”, “urine culture”, “sputum culture”, and even “CSF culture”. And give antibiotics to cover EVERYTHING.
79. If you get a high lead level in a child, you have to check a “venous blood lead level” to confirm. If the value is > 70, admit immediately and begin IV “dimercaprol” and “EDTA”. Order “lead abatement agency” and “lead paint assay” upon discharge.
80. If you perform arthrocentesis, send the synovial fluid for “gram stain” and the 3 Cs: “crystals”, “culture”, and “cell count”
81. If a patient has exophthalmos with hyperthyroidism, it is not enough to just treat the hyperthyroidism (as the eye findings may worsen). You should give prednisone.
82. If any patient has cancer, get an “oncology consult”.
83. In a patient with rapid atrial fibrillation, decrease the heart rate first (then worry about converting to sinus rhythm). Use a CCB (diltiazem) or a beta-blocker (metoprolol) for rate control.
84. In any patient with new-onset atrial fibrillation, make sure you check a TSH
85. In any patient with suspected fluid volume depletion, order “postural vitals” to detect orthostasis
86. Before a colonoscopy or a sigmoidoscopy, you should prepare the bowel: make the patient NPO, give IV fluids (if necessary) and order “polyethylene glycol”.
87. Any patient with Mobitz II or complete heart block gets an immediate “transcutaneous pacemaker”. Then order a cardiology consult to implant a “transvenous pacemaker”
88. If calcium level is abnormal, order a “serum magnesium”, “serum phosphorus”, and “PTH”
89. Treat both malignant hyperthermia and neuroleptic malignant syndrome with “dantrolene”
90. All splenectomy patients get a “pneumovax”, an “influenza” vaccine, and a “hemophilus” vaccine if not previously given.
91. If you give INH (for Tb), also give “pyridoxine” (this is vitamin B6)
92. If you give pyrazinamide, get baseline “serum uric acid” levels
93. If you give ethambutol, order an ophthalmology consult (to follow possible optic neuritis)
94. If you perform a thoracocentesis (lung aspirate), send the EFFUSION as well as a peripheral blood sample for: LDH and protein (to help differentiate a transudate versus an exudates) and pH of the effusion
95. Give sickle cell disease children prophylactic penicillin continuously until they turn 5 years old
96. Any patient with a recent anaphylactic reaction (for any reason), should get “skin test” for allergens (to help prevent future disasters) and consult an allergist
97. Do not give cephalosporins to any patient with anaphylactic penicillin allergies (there is a 5% cross-reactivity)
98. Order Holter monitor on patients who have had symptomatic palpitations.
99. Any patient with a first-time panic attack gets a “urine toxicology” screen, a TSH, and “finger stick glucose”
100. All renal failure patients get: “nephrology consult”, “calcium acetate” (to decrease the phosphorus levels), “calcium” supplement, and erythropoeitin

Strawberry Daiquiri

(CCS Approach)
Take a deep breath and select ‘Start Case’ button to begin.
You will see the case introduction. Wait! Note on the erasable board:
Age of the patient
Race of the Patient
Sex of the patient

Then click ‘OK’ and you will see the initial vital signs. Wait! Note on the erasable board:
Stable or unstable?

Then click ‘OK’ and you will see the initial history. Wait! Think and write on the erasable board:
Differential Diagnosis :
Habits – smoking , alcohol , drugs , etc. Anything worrisome?

Then ask:
Is the patient stable or is it an emergency? A clue to this would be in the history - for emergency cases, you will see only the basic history of present illness and not the detailed history (social, past, etc). All other history will be ‘unobtainable’.
If unstable, do a EMERGENT physical exam. No emergency case should get a full physical exam - it’s an emergency!!
For the EMERGENT physical, choose the 'general appearance' and the relevant system. If needed, add one or two relevant systems.
After you note the results of the EMERGENT physical, stabilize patient immediately:
Airway – Intubation?
Breathing – Oxygen mask? Chest tube?
Circulation – IV fluids? Dopamine?
Drugs – Naloxone? Dextrose? Thiamine?
IV Access?
Then ask:
Does the patient’s condition correlate to the setting?
Emergency or unstable patient in office needs to go to the ER immediately!! Change location if necessary.
After the patient is stable and in the right setting, proceed to ‘Interval/follow-up history’ and a more detailed RELEVANT physical exam.
If the patient is already a stable case in the right setting, proceed straight to the RELEVANT physical exam.
Then ask:
Is the case limited to one particular system? Like Asthma or MI?
Choose the particular system and a few related systems, based on the most likely diagnosis.
Is the case not limited to one particular system?
Choose a COMPLETE physical exam. This option is available on the top of the physical exam choices. Examples of such cases include Case for Annual Physical Exam, Child Abuse, Depression, Asymptomatic Hypertensive for Office Management, etc.
Note the significant findings on the physical exam and go back to your erasable paper and revise your Differential Diagnosis. Strike out those which are less likely and add those are more likely.
Then keeping the Differential Diagnosis in mind, consider the labs to be done.
When considering labs use this mnemonic:
I – Imaging –> X-Rays, CT, USG, MRI, Echo, Scopy, VQ Scan, etc.
B – Blood –> CBC, Basic Metabolic Panel, Lipid Profile, LFT, Smears, Cultures, etc.
U – Urine –> Urinalysis, Toxicology Screen, Ketones, etc.
O – Others –> Other tests which do not fall under IBU, like EKG, PEFR for Asthma, Pulse Oximetry, Biopsies, etc.
P – Pregnancy test –> For any female of reproductive age presenting with abdominal or pelvic symptoms, or trauma.

When ordering labs, consider:
Is this test time-effective/time-consuming? Choose time-effective.
Is this test initial screening/confirmatory? Choose initial screening.
Is this test cheap/expensive? Choose cheap.
Is this test non-invasive/invasive? Choose non-invasive.

Then ask:
Will this test tell me anything useful? Tests like CBC, ESR, Chem 7, etc might satisfy the above criteria but will not tell you anything useful.
Are there any specific tests for this condition? Examples are Cardiac Enzymes for MI, Sweat Chloride test for Cystic Fibrosis, etc.
Are the tests in the right order? Example – Pulse Oximetry before ABG, CT before Spinal Tap, etc.

Order the labs using the Order button.
Then advance clock to the ‘Next Available Result’.
Understand the results. Ask:
Is the diagnosis clear or do I need any confirmatory tests?
If diagnosis is clear, start treatment.
If confirmation is needed, order confirmatory tests and then start treatment.

Treatment :
Determine if the patient is in the right setting. If patient is in office and needs to be admitted, change location to ward. If patient is in ward and is in a serious condition, change location to ICU.
If case is admitted, order:
IV access (unless IV drugs are not indicated) – Type ‘IV Access’.
Vital Signs – Type Vitals and click on ‘Every 1,2, 4 or 6 hours’ depending on the condition of patient.
Activity – Type ‘Bed Rest’ and choose ‘Complete bed rest’ or ‘Bed rest with bathroom privileges’ or type restrain and choose ‘Restrain patient in bed’.
Diet – Normal, liquid, NPO, 2 gram Sodium, ADA, etc. Order ‘Diet’ and you will see the list of options, choose which is the best for this case.
Tubes – NG Tube? Foley’s catheter?
Fluids – Saline, Ringer, etc. Type ‘Fluids’ and choose which is the best for this case.
Urine output – Type ‘Urine Output’ and choose frequency. There is no option for Input/output chart.
Medications :
Stop! Check for allergies on erasable board!
Order standard drugs for this case.
Decide IV or Oral. Decide bolus or continuous. Decide frequency.
Labs :
Additional labs to confirm diagnosis?
Labs to monitor? Cardiac Monitor? Pulse Oximetry?
Consults :
Order consults if necessary. GI, Ophthalmology, Psychiatry, Genetics, Social worker, etc.

Then move clock!
Depending on severity of case, move by 30 minutes/1 hour/2 hours/3 hours/6 hours/12 hours/1 day/2 days/1 week.
Do Interval/follow-up history.
Understand the results of the labs.
Then ask:
Has the patient’s condition changed significantly?
If yes, change locations.
If the condition has improved, move the patient to the next location in the order ER --> ICU --> Ward --> Office/Home.
If the condition has worsened, move the patient to the next location in the order Home/Office --> Ward/ER or Ward/ER --> ICU.

If you are changing location from inpatient (ER/ICU/Ward) to outpatient (Office/Home):
Stop unnecessary medications and change IV medications to oral.
Discontinue IV fluids.
Remove tubes.
Remove IV access.
Schedule followup visit in 1 or 2 weeks as relevant.
Patient education or counseling or diet specific and vital to this case. Type ‘patient education’ and ‘counsel’ and see if anything is relevant to this specific case. Type ‘Diet’ and see if anything is relevant to this specific case.

By this time, the 5 minute screen will appear!
Then type ‘counsel’ and choose the relevant things. You can choose multiple things at a time. See your erasable board for any worrisome habits like alcohol or smoking!
Type ‘patient education’ and choose the relevant things. You can choose multiple things at a time

VODKA (41%) Stolichnaya

Critical aortic stenosis:
virtually zero chance of successful CPR.
Gout with h/o peptic ulcer disease:
Rx of choice – colchicine (not indomethacin)
<6w: external rainage >6w: internal drainage
St. John's Wort:
is a herbal medication with some efficacy in treatment of depression
(no FDA Approval)
PKU screen
can be negative at 48hrs of life
(requires a repeat screen after 48 hrs. to confirm)
Maternal Solvent Abuse:
assoc. with nail hypoplasia
Transplacental spread is highest in primary HSV,
very low in recurrent HSV
Infants of Diabetic Mothers with proteinuria, hematuria:
? Renal Vein Thrombosis (gluteal. with maternal DM)
HyperTG Rx: Gemfibrozil
Hypercholesterolemia (Drug Rx):
>190: 0-1 risk factors
>160: >= 2 risk factors
>130: CAD equivalent / CAD
if > 15% reduction reqd: “statins”
if < 15% reduction reqd: (Low HDL) Niacin
(normal HDL) Cholestyramine
Obesity in Children Triceps Skin Fold Thickness
OCP induced hepatic adenomas : tendency to rupture
(Surgical resection)
ELISA â-hCG (Urine) is (+) 14 d post conception
RIA â-hCG (Serum) is (+) 14 d post conception
Lobular Ca in situ is not premalignant
Digitalis Toxicity is enhanced by:
HYPERcalcemia, HYPOkalemia, HYPOmagnesemia
Finkelstein Test: Chr. Stenosing Tenosynovitis (deQuervain's Disease)
Rx for Chlamydial Ophthalmia: ORAL Erythromycin
(to prevent chlamydial pneumonia)
Commonest Hernia: Indirect Inguinal Hernia
T4 / RTU / FT4-I move up or down together unless there is a derangement in TBG
CPK-MM is increased in hypothyroidism (proximal myopathy)
Fetal Weight Determination:
Fetal Age Determination:
Transcerebellar Diameter
RA: associated with atlanto-axial subluxation
(“drop” attacks)
PTE: (A-a) O2 gradient is always abnormal
even if PaO2 is normal [highly sensitive]
CSF Leak
Pneumococcal Vaccination is required
Nephrotic Syndrome: Fatty Casts
Pyelonephritis: WBC Casts
Cystitis: WBCs
GN (PSGN): RBC Casts
CRF: Broad Casts
Cold Antibody: IgM - Inravascualr Hemolysis
Warm Antibody: IgG - Extravascular Hemolysis
Addison's: ACTH Simulation Test
Cushing's: Dexamethasone Suppresion Test
Conn's: Salt Loading Response
Diabetes Insipidus: Water Deprivation Test
Mx of Myesthenia Gravis: PYRIDOSTIGMINE
(not PHYSOSTIGMINE cuz of CNS effects)
Alcoholic Cirrhosis: â-gamma bridge
d-xylose test: abnormal in small bowel malabsorption, normal in pancreatic disease
screening for malabsorption: 24 hour fecal fat
? Penicillamine increases survival in Scleroderma
Abciximab: decreases restenosis rates post-PTCA
PTCA: no effect on morbidity or mortality

Obesity: BMI>27g/m2 or 120% of ideal body weight
Caloric Intake increase:
300 Cal (Pregnancy); 50 Cal (Lactation)

COPD excacerbation: H.flu, Pneumo., Moraxella
Long term stabilization of exercise induced asthma: Salmetrol & Zafirlukast
Severe acute asthma: < 50% best PEFR
Moderate acute attack: 60-80% best PEFR
Mild acute attack: >80% best PEFR

Ideal sputum sample: <10 epi./HPF & many PMNs

GERD: Transient relaxation of LES
Always perform an EKG for any adult with chest pain (esp. with risk factors for CAD)

Esophageal Ca.: most common type is AdenoCa. (Barrett's Esophagus)
Sulfasalazine: effective in UC & Crohn's colitis / ileocolitis
Celiac Sprue: villous atrophy & reactive crypt hyperplasia
Dermatitis Herpetiformis (Mx: Dapsone)

H. pylori association:
.Serology (Past or Present Infection)
.Fecal Antigen Detection (False [-] with PPI)
.Urease Breath Test (False [-] with PPI)
Triple Therapy, esp. for non-NSAID ass. ulcers
1st episode of PUD: emperical therapy (H2 -> PPI)
Recurrent PUD: H. pylori eradication

â blockers decrease variceal bleed in portal HTN

Ascites: Salt Restriction, Diuretic: Spironolactone

narcotic analgesic switching
use 1/5 equianalgesic dose

Graves': Rx – Radioactive Iodine
children & pregnant: Propylthiouracil

Ca. ass. cachexia & anorexia: Prednisone, Magestrol
Agitated Depression Rx: sedating TCA (not SSRI)
Rx of choice for narcotic induced costipation: Lactulose

Nephropathy Incidence: IDDM (40%) > NIDDM (20%)
but #1 cause of Diab. Nephropathy is NIDDM
('cuz NIDDM prevalence is much higher than IDDM)
Prevalence Inreases: PPV of test increases
(NPV of negative test decreases)
Screening for GDM
Oral 50g Glucose: Bl. Glu. @ 1 hr. > 140mg% (+)
F/U with Oral 100g Glu. 3 hour GTT
values > 105 (0h) / 190 (1h) / 165 (2h) / 145 (3h)
Obese Diabetic: Diet/Wt.Loss -> Metformin
(ass. With Lactic Acidosis)
Insulin in DM
Initial dose: 15-20 U
2/3 of total : AM dose (2/3 regular, 1/3 intermediate)
1/3 of total : PM dose (2/3 regular, 1/3 intermediate)

Conn's syndrome Mx
Adenoma: Sx resection
B/L hyperplasia: Spironolactone

Multiple Sclerosis:
2 attacks more than 24 hours apart
> 1 area of damage (Oligodendrocyte damage)
m/c variant: relapsing-remitting type
CSF mononuclear pleocytosis, CSF IgG increase
Oligoclonal Banding of CSF IgG
Myelin Breakdown Metabolites
Headache on stopping NSAIDs:
Analgesic withdrawl headache

Aspirin in febrile children: Reye's Syndrome
Continue anticonvulsants till seizure free for 4 years
Menorrhagia with hemodynamic compromise:
i/v conjugated estrogen
normal Hb in women: 12.0
normal Hb in pregnancy: 11.0 (1st & 3rd trimester)
10.5 (2nd trimester)
m/c variant of Hodgkin's : Nodular Sclerosis
Hodgkin's: Supraclav. node
NHL: epitrochlear node / likely to be extranodal
Joint space narrowing
subchonral cysts
osteophytes (mere osteophytes are not OA)
OA: Isometric exercizes are better than isotonic
CFS: T cell activation -> CNS effect of cytokines
nonREM sleep anomaly
(also seen in Fibromyalgia)
Gout prophylaxis: required for recurrent attacks
(not indicated after first attack)
Strep Sore Throat Rx: can prevent Rh. Fever
Potassium sparing diuretics can cause severe
hyperkalemia in CRF
SULINDAC: NSAID with no nephrotoxicity
Asymp. Bacteruria in Pregnancy : Treat with antibiotics [Amoxycillin is safe] (high risk of
Give Chlamydia Rx in Gonorrhea
-> i/m Ceftriaxone + PO Doxycycline
Biophysical Profile : TBMAN
Tone, Body Movements, Breathing, AFI, NST
Early Deceleration: Head Compression
Variable Deceleration: Cord Compression
Late Deceleration: Uteoplacental insufficiency
GU+NGU: 1 g Azithromycin stat
.Benzoyl Peroxide
.Topical Tretinoin
.Topical Antibiotics
.Systemic Antibiotics
.Systemic Isotretinoin
Acne Rosacea Mx
Topical Metronidazole -> Systemic Antibiotic
[Benzoyl peroxide & Tretinoin can aggravate rosacea]

Female Infertility (Hormonal)
Hyper-estrogenic: CLOMIPHENE CITRATE
Hyper-PRL: Bromocriptine (PIH)

Narcotic Dependence: Methadone replacement
External Hemorrhoids: Excision with elliptical incision
Internal Hemorrhoids: Banding
Amniotomy: perform after enagement of fetal head
Rx of HTN in preg.: á-methyldopa, hydralazine
BP reduction goal in pre-eclampsia:
Lower diastolic to 90-100 mmHg (lowering to 80mmHg could jeopardize placental perfusion)
#1 maternal disease causing IUGR: Maternal HTN
#1 cause for 1st tri. abortions: Chromosomal ab(n)
Postpartum Blues: < 2 weeks
Postpartum Depression: > 2 weeks
Major Depression: >= 5 symptoms for > 2 weeks
Mania: >= 3 symptoms for > 1 week
Primary Type 1 Osteoporosis: # vertebrae
Primary Type 2 Osteoporosis: # neck femur
Progesterone required only if uterus is present
Estrogen: dec. LDL, inc. HDL
Progesterone: inc. LDL, dec. HDL
Estrogen's cardioprotective effects of estrogen are not mediated through cholesterol.
Estrogen promotes EDRF synth. In vascular endothelium
Repeat Pap: if reqd., no sooner than 6 weeks
Hormonal contraception if h/o DVT/PE (+):
Norplant & DMPA (Progesterone based), not OCPs
Jarisch Herxheimer reaction: Syphilis Rx (chills)
HPV: condyloma acuminata
HPV 18: fastest progression to Ca. Cx

Acute Epididymitis:
#1 cause: Chlamydia trachomatis
#1 bacterial cause: E. coli (m/c in >40 y age)

Depression: Cognitive Psychotherapy + SSRI

Atypical Antipsychotics are especially useful for negative symptoms of Schizophrenia

Mx of DTs
.Intermediate acting BZDs (Diazepam)
.IV saline (no glucose containing fluids)
.IV thiamine
BZD in Hepatic Enceph.: Oxazepam

Fluid Deficit in Burns
= 4mL/kg x %BSA (Parkland Formula)
1st degree:
2nd degree: clean, sulfadizine, nonadhesive dressing
3rd degree: refer to plastic surgeon for escharotomy

Heat Cramps: ORS
Heat Exhaustion: IV Fluids
Heat Stroke: neurological dysfunction & absence of sweating (may not be dehydrated), Temp. >104
Mx- cooling fan/blank, check CPK

Hypothemia: Osborne (J) wave on EKG
Mild: (32-35 C) Passive External Rewarming
Moderate: (27-32 C) Active External Rewarming
Severe: (< 27C) Active Core Rewarming

Depression: Cognitive Psychotherapy
Anxiety Dsorders: Behavioral Psychotherapy
Adjustment Disorder: Supportive Psychotherapy
Social phobia: bea blockers & assertive training
Specific phobia: systematic desensitization
Panic: SSRI & Alprazolam (short T1/2)
.Na Lactate can mimic a panic attack
.use alprazolam for panic, not GAD
.may be associated with rebound anxiety
OCD: (associated with anxiety) SSRI
OC PD: insight-oriented psychotherapy

Depression: SSRI + Cognitive Psychotherapy
Sexual Dysfunction
Young Males: Premature Ejaculation
(Mx: start and stop penile stimulation, not SSRIs)
Older Males: #1 Erectile Dysfunction
Females: #1 Hypoactive Sexual Desire
Young males with sexual dysfunction: Psychogenic
Older males with sexual dysfunction: Organic

ADHD associated with:
Conduct Disorder and Oppositional Defiant Disorder
(also with Tourette's Syndrome)
ADHD with (+) h/o or F/H tics

Elderly: higher chances of perforation
Appendiceal abscess: Delay surgical intervention
If on lap., some other cause is found – do an appendectomy anyway, to prevent confusion in future

Oral Dissolution of Gallstones URSODIOL
single floating cholesterol stones in functioning g.b.

#1 complication of Lap Chole: Bile Duct Injury

indications of ERCP:
.small stones
.dilated CBD
.palpable stones in CBD
Plantar Warts: Cryosurgery
Venereal Warts: Podophyllin (not in pregnancy)
#1 radiological signs in pancreatic disease

Crucifer intake reduces Colon Ca.

Ca. risk of polyps is dependent on villous content
#1 risk factor for pancreatic ca. : smoking

#1 cause for chronic low back pain: idiopathic
.bed rest has no role
.no need for imaging (X-Ray / CT / MRI)
.prescribe an exercize program (can temporarily excacerbate symptoms)

Acetohydroxamic acid: urease inhibitor
(acidifies urine in patients with struvite stones)

HTN with BPH: Terazocin (á blocker)
Vestibular Neuronitis: NO hearing loss

Meniere's Diseass: Tinnitus, Vertigo, Hearing Loss
Ac. Labrynthitis: Ac Hearing Loss, Nystagmus, Vertigo

no role of imaging (Dx by h/o & PE)
? antibiotics – PO Amox x 7-10 days

Antidep. of choice in depresion in elderly: TCA (Nortryptaline) - minimal side effects cf. other TCAs

Alzheimer's Rx: DONEPEZIL (OD) & Tacrine Cholinesterase Inhibitors

Polymyalgia Rheumatica: Oral Steroids

Elderly black HTN: CCB & Thiazide Diuretics

Parkinson's with Tremor has a better prognosis than pts. with symptoms of Postural Instability & Gait Disturbance

Perform Postvoid Residual Urine measurement on every elderly patient with Urinary incontinence to r/o Urinary Retention

Alzheimer's & Parkinson's cause Detrusor Hyperreflexia:

@ high risk for pressure ulcers: reposition q2h
low-risk patients: reposition q6h
.prenatal ultrasound not mandatory
.? role of PSA & DRE in screening of asymptomatic individuals

á-FP estimation at 5-17 weeks to r/o NTD
.increased: ultrasound (can detect 80% anomalies)
.decreased: does not necessarily indicate Downs'

QUIT SMOKING before starting Nicotine replacement
Transdermal Nicotine Replacement:
21mg -> 14mg -> 7mg
[Pts. with CAD, start with 14 mg.]
[Nicotine is vasoconstrictor, risk of MI]

Pesticide exposure has been linked to Prostate Cancer

HTN increases the risk of stoke > CAD
2% reduction in CAD for every 1% decrease in serum cholesterol
Cancer mortality is increasing
stroke/CAD mortality is decreasing

HAART drug interactions
“statins”, Antihistaminics, Ergot alkaloids
AIDS in infants: better prognosis cf. adults

d/o/c for malaria prophylaxis: MEFLOQUIN
once-a-week (1 w before travel & 6 weeks after)

Influenze A: adults
Influenza B: children
Influenza epidemics: Influenza A
Influenza vaccine: A & B
Amantidine protects only against “A”
(Rimantidine preferred in patients with renal failure)
Oseltamivir (Tamiflu®) protects against both “A” & “B”
Annual influenza vaccination for age > 65 y

#1 cause of traveler's diarrhea: ETEC

Cardiac Arrest: 1st step – initiate 911 call
Cardiac Arrest in Children: Assess, 1 min. on CPR
Initiate 911 call

Mx of Respiratory Acidosis: Increase Ventilation
(Use of NaHCO3 is not wise to Mx Respi. Acidosis)
1-person CPR: 15:2
2-person CPR: 15:2
symptom to treatment time: <60 minutes
ED to needle time: <30 minutes

A. Fib.: (Unstable): Sync. Cardioversion
V. Fib.: Async. Defib. [200 -> 300 -> 360 mJ]
SVT: Vagal Maneuvres -> Adenosine
V.Tac.: Lidocaine, Procainamide, Bretylium
V.Tac.: (Unstable): Cardiovert

Immediate transcutaneous pacing
Epinephrine -> Atropine -> Consider Bicarbonate
Use intra-osseous route in age < 6 years

m/c cause of abdo. Pain in elderly: CONSTIPATION
Use activated charcoal with 70% sorbitol in poisonings
Cuffed ETT for age > 7yrs
#1 Poisoning: OTC Analgesics
Naloxone: Short acting
Naltrexone: Long acting
(used in rehab programs, not acute overdose)

Urticaria: Subcutaneous edema
Angioedema: Mucosal edema
Colles' #: Dinner Fork abnormality
(Splint in Neutral position)

Suspected Scaphoid # & X-Ray (-)

Ankle Inversion Injury
- Lateral Ligament Sprain
- Anterior Talofibular Ligament

McMurray Test:
.Meniscal Tear
.Joint Line Tenderness

Lachman Test:
Anterior Cruciate Ligament Injury

Dislocation of Shoulder:
.associated with axiallry artery injury

NBT (-) : CGD (SXR) -> IFN-gamma


(Bone Scan is useless, does not detect lytic lesions)

#1 cause of death in myeloma: Pulmonary or UTI
Duration of Maintenance Pharmacotherapy for depression (even for single episode) should be at least 6-9 months.

Desert Rheumatism: C immitis
Mx – Conservative
Rx required only for dissemination / lung lesions

#1 Kidney stones: Calcium Oxalate (radiopaque)
[Square Crystals]
CYSTINE crystals in urine are always pathological

Crohn's: associated with gallstones & kidney stones
[increased absorption of oxalates from the gut]

#1 complicatin of chickenpox: 2º skin infection

Postop Fever @ 24 hours: atelectasis
Postop Fever @ 5-10 days: wound infection
(early wound infection: clostridia / pesudomonas)

Neonatal Meningitis: S. agalactiae (Gp B Strep)

C1 esterase inhibitor deficiency:
.hereditary angiodema
.depleted C4 levels
.Mx: FFP/e-ACA/Stanozolol
.Maintain: ANDROGENS (inc. synthesis)

Suspect endometrial cancer:
gynecological referral for enometrial biopsy
Pap misses 60% of endometrial Ca.

Cryoprecipitate: replaces Fibrinogen & Factor VIII
FFP: replaces all coagulation factors
Reversal of warfarin action: FFP (chronic: Vit. K)
Reversal of heparin action: Protamine
sterile subdural effusions: H. influenzae meningitis
pneumonia with effusion / empyema: Staph. aureus

osteomyelitis after foot puncture wound:

.Inability to supress glucose
.no stimulation of GH with levodopa
.paradoxical increase of GH with TRH

#1 intracranial mass lesion: METASTASIS

#1 brain malignancy (adult): Glioblastoma multiforme

#1 brain malignancy (child): Astrocytoma
adult: supratentorial
children: infratentorial (#1 supratentorial in children is craniopharyngoma)

Hairy Cell Leukemia: TRAP+ (Rx: Cladribine)

Rocky Mountain Spotted Fever:
Dx – Indirect IF
Rx – DOXYCYCLINE (< 8y: Chloramphenicol)

> 6 cafe au lait spots [or 1 spot > 5cm]

Tuberous Sclerosis:
Cardiac Rhabdomyomas
Angiomyolipoma of Kidney
Subungal Fibromas

Decreased Haptoglobin:
Intravascular Hemolysis
Very Severe Extravascular Hemolysis

3- are normal

Testicular Torsion: affected testis lies horizontally
Mx – Surgical Fixation of BOTH Testes

Torsion of Testicular Appendix: BLUE DOT
Mx – Exploration of other scrotum not required
m/c Thyroid Malignancy: Papillary Ca. Thyroid

MEN Syndrome: Medullary Syndrome
Hematogenous Spread: Follicular Ca.
Patella dislocates laterally
Mx PTSD with Group Psychotherapy
(not BZD : high risk of BZD abuse)

Fever without Focus:
#1 cause: Occult Bacteremia
due to Pneumococcus
due to Otitis Media

Signs of Occult Bacteremia:
Temp > 40C
WBC < 5000 or WBC > 15000

Recurrent Otitis Media:
–definition: >3 in 6 months or >4 in 1 year
–Amox prophylaxis -> Myringotomy & Tubes

Indications of Tonsillectomy:
–1 episode of Quinsy (Peritonsillar abscess)
–> 7 proven streptococcal pharyngitis
–airway obstruction
decreases recurrent sore throat, not URI

Simple Diarrhea
No role of Stool Culture:
Stool Culture indicated only if:
–bloody diarrhea
–persistent diarrhea
–(+) tenesmus
–h/o foreign travel
Mx: Oral Rehydration Solution
(not juices or carbonated beverages)
Children with no dehydration – age-appropriate diet

Gp A â-hemolytic Streptococci are usually susceptible to Penicillin (this is not the case with Staphylococci)

Strep viridans sensitive to Ampicillin + Gentamycin
German Measles (Rubella)
Measles (Rubeola)
Roseola infantum (Exanthem subitum) HHV 6
high fever, rash appears after fever subsides
Lead levels > 10 : environmental abatement
start chelation therapy @ higher levels (? > 25)
single umbilical artery associated with renal ab(n)

HbS Disease: Prophylactic Penicillin till 5y age
Stranger Anxiety: 6-9m
Separation Anxiety: 12-15m
Encopresis: >4 y
Enuresis: >5 y

Simple Febrile Seizures:
–Single Seizure
–< 15 minutes durations
–associated with high fever
–Rx: antipyretics (NOT ANTICONVULSANTS)
–F/H (+)
–Can recur
Meningococcal Contacts: Rifamp/Cipro prophylaxis
(#1 cause) Seasonal Allergic Rhinitis-Ragweed
(#1 cause) Perennial Allergic Rhinitis-House Dust Mite
Choanal Atresia
–cyanosis with feeding
–relieved by crying
Dog & Cat Bite: P multocida (Rx: Amox-Clav)
Cat scratch disease: Bartonella henselae
Cushing's Syndrome: #1 Iatrogenic
Cushing's Disease: #1 Pituitary Microadenoma
Dx: 24 hour urinary free cortisol
to diff. Pituitary & adrenal cause: Overnight DST
Pick's Disease:
Dementia / atrophy of frontal & anterior temporal lobes
[early psychiatric manifestations]
Dementia with Lewy bodies:
(Alzheimer's + Parkinsonism features)
[they can excecerbate parkinsonism features]
Dialysis Dysequilibrium Syndrome:
associated with rapid correction of uremia
HTN in elderly African Americans: CCB + Diuretics
HTN in young African Americans: Diuretics
Paget's Disease of the bone:
extent is delineated by Tc 99 scan
Wounds < 12 hours old, clean: primary closure
Wounds > 12 hours old, contaminated: debridement and secondary closure
concomitant use of I/v heparin with thrombolysis:
Ac. anterior MI & Left Venticular Thrombus
Pts. with non-Q wave MI & previous CABG do not benefit considerably from
High risk features post-MI
1. Post MI angina
2. Non Q Wave MI
3. CHF
4. LVEF < 40%
5. > 10 PVCs / min
e/o Significant Ischemia on Exercize Stress Test:
1.ST segment depression
2.< 6 METS work
3.@ < 70% predicted maximum heart rate
4.Hypotensive Response
LDL is the most important “lipid” risk factor for CAD
Cholesterol: < 200, 200-240, > 240
LDL: < 130, 130-160, > 160
treatment of choice for hypercholesterolemia: DIET
Basilar & Hemiplegic Migraine
(also c.i. in IHD/MI, Pts on SSRI/MAOI/Li)
Acute A. Fib.:
(Stable) â-blockers & CCB
(Unstable) Sync. Cardioversion
Obesity is a risk factor for Endometrial Ca.
Surgical intervention for obesity : BMI > 40 kg/m2
Heparin: keep PTT 1.5-2.0 x control
Warfarin: keep PT 1.5-1.8 x control
Enoxaparin (LMWH): No PTT monitoring required
COPD : smooth muscle hyperplasia (as in asthma), but Methacholine challenge test is
REID INDEX: ratio of thickness of bronchial glands to bronchial wall thickness
(increased in chronic bronchitis)
Nicotine enhances growth of H. flu
Most effective long term pharmacotherapy for COPD: Ipratropim bromide
COPD excecacerbations: H. flu, Pneumococcus, Moraxella
Only Rx in COPD that enhances survival
–Resting PaO2 < 55 mmHg
–Resting PaO2 < 60 mmHg with tissue hypoxia
(cor pulmonale / polycythemia)
Acute Bronchitis in healthy non-smoker:
no Investigations, no treatment (no antibiotics)
Early phase of asthma: primary mediators
Late phase of asthma: secondary mediators
Prophylaxis of exercize induced asthma: Albuterol
Long term stabilization of exercize induced asthma: Salmetrol (long acting) +
Mycoplasma pneumonia:
–minimum physical findings
–B/L lower lobe infiltrates
–Cough (+)
–Mx: Macrolide
Cold Agglutinins (IgM) Inravascular hemolysis
Pnenumonia in elderly debilitated alcoholic:
Lower Lobe: Strep pneumoniae
Upper lobe: Klebsiella
(currant jelly sputum, hemoptysis, cavitatory lesion)
Normal Semen analysis
vol. 2-5 mL
sperm conc. > 20 million / mL
morph > 30% normal
motile > 50% motile
#1 cause of dysphagia: lower esophageal ring
(in the absence of risk factors for esophageal cancer)
Systemic Sclerosis associated with severe GERD
UC (Dx): Colonoscopy
Crohn's (Dx) : air contrast barium enema
Alcoholic Hepatitis: AST >> ALT (ratio > 2.0)
Malignant Neuropathic Pain
Sharp Stabbing: Rx anticonvulsants (Carbamazepine)
Dull Aching: Rx TCA (Desipramine)
Mx of Chemotherapy induced Emesis: ONDANSETRON
Pain control : round-the-clock dosing > cf. PRN
TPN: no mortality/morbidity benefit in cancer pts.
Vestibular Nausea Rx: Cyclizine
Radiotherapy assoc. diarrhea: Loperamide / Codeine
Narcotic induced constipation: LACTULOSE
#1 symptom in avanced cancer is weakness (ASTHENIA)
SSRIs can make agitated depression worse
(Use sedating TCA & Anxiolytic PRN)
#1 metabolic derangement with advanced malignancy:
–hyperCa++ (long PR, decreased QT, wide T waves)
Type 1 DM is HLA DR3/DR4 associated
Type 2 DM - Obesity & Family History
decrease Glucose production & increase peripheral utilization (Metformin)
stimulate Insulin release (Glibenclamide)
–á-glucosidase inhibitors
decrease carbohydrate absorption (Acarbose)
–pts. are normal to underweight
–< 40 years age
–AD inheritance
–F/H (+) in 50%Dx of DM
Diagnosis of Diabetes Mellitus
–FBS (2 values) > 126 mg%
–RBS (1 value) > 200 mg%
–GTT (100g oral glucose): 2 hour value > 200 mg%
Li induced NDI : stop Li -> start Carbamazepine
#1 feature of Cushing's: Truncal Obesity (90%)
Pathophysiology of Migraine:
CNS Platelet aggregation with Serotonin release
Very Severe Migraine (abortive): SUMATRIPTAN
Moderately severe Migraine (abortive): DHE
Status migrainous: migraine lasting > 72 hours
Cluster Headaches: Sumatriptan / O2 inhalation
New onset seizure
< 40 y age: #1 Idiopathic
> 40 y age: #1 Brain Tumor
Discontinue anticonvulsants after seizure-free for 4y
(confirmed by absence of epileptiform activity on EEG)
Grand mal: Phenytoin
Petit mal: Ethosuximide
Thrombotic Stroke: slow and continuing (m/c variety)
Embolic Stroke: sudden
#1 risk factor for CVA: HTN
CEA for Symptomatic Carotid Artery stenosis > 70%
Fe deficiency anemia (most sensitive Ix): S. Ferritin
#1 inherited bleeding disorder: vWD
Inherited hypercoagulable state
Factor V Leyden (most common)
Prot C def. / Prot. S def.
Anti-thrombin III deficiency
Anti-PL antibodies: can cause arterial thrombosis
TTP: do NOT give platelet transfusion
vWD: Factor VIII (cryoppt.)
COX-2 (Celecoxib): less GI side effects cf. NSAIDs
Exercize program in OA
Graded, Active Exercize, Isometric
–tenderness in 11 of 18 defined points
–r/o comorbid depression
–ass. with sleep disorder
(á-nonREM sleep anomaly) -> also in CFS
Mx of Chronic Fatigue Syndrome:
–nonsedating TCAs
GOUT prophylaxis: only for recurrent attacks
(> 2-3 attacks) [not after first atack]
#1 cause of Chr. Renal Failure: DM
Mx of uncomplicated UTI: 3 days of TMP-SMX
Artificial Donor Insemination
–Store semen for 6 months
–Check donor for HIV @ 6 m
–If still (-), proceed with insemination
#1 step in Obstructive Sleep Apnea: Weight Reduction
BZD can worsen Obstructive Sleep Apnea
Narcolepsy Mx:
–Mazindol (TCA)
Long T1/2 BZD are associated with lower incidence of rebound anxiety (e.g.
Oral - to be taken in the morning on empty stomach with 8 oz of water (to prevent
Alendronate (FDA approved)
Etidronate (less efficacious)
Pamidronate (I/V infusion)
SERMs (Raloxfene):
–Estrogenic on Bone / Lipids
–Anti-estrogenic on Uterus & Breats
Marjolin Ulcers: squamous cell ca. in old scars
Immunosuppression is a risk facor for Sq Cell Ca.
PRCA (Pure red cell aplasia) may be associated with thymoma
Aplastic Anemia causes <3% fall in Hct / week
[>3% fall in Hct / week: Hemolysis / Hemorrhage]
Hereditary Spherocytosis:
–increased MCHC, increased Osmotic Fragility
–Lifelong FOLATE supplementation
–acquired defect in DAF
–Dx: Sugar Water Test
–prone to hepatic & mesenteric vein thrombosis
–may progress to Aplastic Anemia / AML
Blody Nipple d/c: DUCT EXCISION
(no role of ductography)
G6PD def.: older RBCs are deficient in enzyme, hemolysis is self-limited
G6PD def. (Mediterranean Variant): all cells are deficient - severe and chronic
–giant abnormal platelets
–dry bone marrow tap
“Clustered Polymorphic Microcalcification” on Mammography is s/o Breast Cancer
Mammography is never a substitute for BIOPSY. Mammo is for detection of other
lesions and screening the contralateral bereast. It does not rule-in or rule-out cancer
HbSC disease:
–increased incidence of Proliferative Retinopathy
–decreased vaso-occlusive and pain crisis
Fever in Neutropenia: consider infectious
Rx of acute promyelocytic leukemia: RETINOIC ACID
Serum LDH is a prognostic marker in Lymphomas
multiple myelomas with no paraprotein : 1%
(very aggressive)
TTP & HUS: normal coagulation studies (cf. DIC)
Uremia is asscoaited with qualitative platelet defect
Hemophilia with low platelet count:
??? HIV associated immune-thrombocytopenia
Hemophilia with no improvement with Factor VIII infusion: ??? suspect Factor VIII
Inhibitor activity
[Serum Mixing Test]
Mx: Steroids or Cyclophosphamide
Vit. K dep. factors:
Factor II, VII, IX, X
(Vit. K def.: corrected by Vit. K administration)
Liver Disease:
decreased vit. K dependent factors & Factor V
(coagulopathynot corrected by Vit. K administration)
1 Unit of Packed Red Cells
300 mL volume = 200 mL of Red Cells
raises Hc by 4%
When Typo “O” blood is being used (universal donor): use packed red cells, not
whole blood
<50y: increase fiber or osmotic laxatives
>50y: FOBT
If (+), Colonoscopy (Sigmoido/Ba enema)
Mayonnaise/Salad Dressing: S. aureus food poisoning
Small Bowel Diarrhea: Voluminous, Bloating
Large Bowel Diarrhea: small volume, LLQ Cramps
Methylene Blue stain of stool detects Fecal Leukocytes
Follow-up Rx of DKA with ANION GAP
(not serum Ketones)
–ketone estimation detects only acetate and acetoacetate
–the predominant ketone in DKA is b-HAP
–as DKA Rx progresses, b-HAP converts to acetoacetate and estimation of serum
ketones might suggest "paradoxical" worsening ketonemia
Osmotic Diarrhea: decreases with fasting
Fecal Fat > 10g/24hours : s/o Malabsorption
#1 Peptic Ulcer
#2 Variceal Bleed (#1 cause of death from UGIH)
#1 (>50y) Diverticulosis (#2: Angiodyslasia)
<50y: Anoscopy or Sigmoidoscopy
>50y: Colonoscopy (Sigmoido/Ba enema)
Ascitic Flluid: SAAG > 1.1 [Portal HTN]
Spontaneous Bacterial Peritonitis
–> 500 cells / ìL
–> 250 PMNs / ìL
–Total Protein < 1g / dL
–Mx: i/v Ceftriaxone (no anaerobic cover required)
–prophylactic FLUOROQUINOLONES to
prevent recurrences
Familial Mediterranean Fever:
–Turks, Armenians, Arabians
–recurrent abdominal pain (resembles acute surgical abdomen)
–attacks resolve in 24-48 hours
–associated with serositis & pleuritis
–recurrent attacks cause secondary amyloidosis
Uncomplicated GERD: H2 blockers (1st line) -> PPI
Complicated GERD: PPI (1st line)
Preferred procedure for portal decompression is TIPS (Transvenous Inrahepatic
Portosystemic Shunt)
–associated with maximum decrease in rebleeding rate (> banding, sclerotherapy, âblockers)
Non-invasive tests for H. pylori
–serology (past & present infection)
–fecal antigen detection
–urea breath testing
PPI can cause False (-) fecal antigen & breath test
Duodenal ulcers heal faster than gastric ulcers
Long term PPI Rx not required in PUD
Long term PPI Rx required in GERD
H. pylori eradication: PPI / Amox / Clarithromycine
50% of H pylori isolates are Metronidazole-resistant
•10-14 days of H. pylori eradication followed by 4-8 weeks of PPI for Rx of PUD
Rx of Whipple's Disease: TMP-SMX for 1 year
Giardiasis can cause Lactase deficiency
Ogilvie's: acute colonic pseudo-obstruction
Gastric malignancy
#1 Gastric adenocarcinoma
#2 B-cell lymphoma
Celiac Sprue
increased incidence of intestinal T-cell lymphomas
Carcinoid Syndrome: small bowel carcinoid with hepatic metastasis (increased urinary
•increased right sided valvular lesions
Abdominal Pain relieved by defecation: IBS
Cl. difficile: watery diarrhea (Dx: Toxin Assay)
high potency steroid
low systemic side efects
(due to high first pass metabolism)
useful in nflammatory bowel disease
When UC/CD diff. is difficult
UC: pANCA (+)
CD: ASCA (antbodies to s. cerevisiae)
UC: assoc. with PSC (PSC is an independent risk factor for colonic malignancy in UC)
APC Gene:
–Polyps -> Adenomatous Polyps -> Ca
–small bowel polyps (low malignant potential) & gastric polyps (no malignant potential)
may also be found
FPC: begin screening colonoscopy @ 12-20 y age
Peutz Jeghers:
–colonic polyps have no malignant potential
–increased extraintestinal malignancies
(Breast, Gonads, Pancreas)
–Colorectal Ca (+)
(few, flat, fast-progressing adenomas)
–40% lifetime risk of endometrial cancer
Right sided Colon Ca: Bleeding
Left sided Colon Ca: Obstruction
Hep D superinfection is more severe than co-infection
HAV infection: may have relapses
Acute Hepatic Failure: Encephalpathy in < 8w
Subacute Hepatic Failure: Enceph. in 8w - 6m
Chr. Hepatitis: > 6m
Anti-HCV: EIA -> if (-) -> confirmatory test RIBA
Chronic HCV infection:
gluteal. with cryoglobulinemia and Type2 DM (NIDDM)
Individuals with Hemachromatosis are susceptible to V. vulnificus, Listeria, Y
enterocolitica infections
Dx of Budd Chiari syndrome: Duplex Doppler U/S
Left Heart Failure:
increased liver enzymes (ischemic injury)
Right Heart Failure:
increased Bilirubin & Ascites (>> periph. edema)
Gastric Varices without Esophageal Varices: Splenic Vein Thrombosis
Mx: Splenectomy
#1 organism causing pyogenic liver abscess: E. coli
OCP associated Liver Adenoma
(Mx: RESECTION even for asymptomatic cases)
Meperidine: least Sphincter of Oddi spasm
UC with pruritus: consider PSC
S. amylase can be increased in MUMPS ue to salivary gland involvement without
involvement of pancreatic gland [but S. Lipase would be normal in cases of
extrapancreatic elevation of amylase]
Antibiotic of Choice in Pancreatic Infections: IMIPENEM
decreases Breast Ca. / increases Endometrial Ca.
SERMs (Raloxifene):
decreases Breast Ca. / decreases Endometrial Ca.
Medical Adrenalectomy
Aminoglutethemide + Corticosteroids
HRT after Breast Ca. -> Raloxifene
IgE is not involved in anapylactoid reactions
(e.g. radiocontrast allergy)
CD3 : pan B cell marker
CD19: pan T cell marker
Dx of CREST syndrome is clinical
(not based on anti-centromere antibody)
Of all HLAs - HLA-DR compatibility is essential for long term graft survival
decreases CMI & decreases IL-2 (T-cell activation)
Steroids: decrease CMI
Cyclophosphamide: decreases CM as well as HMI
IFN-á: HCL, HepB & C, Kaposi's, CML
IFN-â: Multiple Scerosis
Acidosis due to Organic Acids is not assoc. with HyperK+ (cuz they freely permeate the
cell membrane)
Renal Glycosuria, Hyphosphatemia, Hypouricemia: FANCONI's
Commonest TA: Type IV RTA
(Hyperchloremic Hyperkalemic metabolic acidosis)
Thyroid Scan: I-123
Thyroid Ablation: I-131
Prerenal Azotemia: BUN/Cr > 20.0
L4: Knee Jerk & Sensory on Medial Calf
S1: Akle Jerk & Lateral Foot
PIVD L5 compression:
DORSIFLEXION of foot affected
PIVD S1 compression:
PLANTAR FLEXION of foot affected
[Ca][PO4] > 64 : predictive of metastatic calcification
Mx of Myedema Coma:
300-500 microg bolus of i/v thyroid hormone
followed by 50 microgram daily
Panhypoptuitarism presenting with Myxedema coma:
(to prevent Adrenal Crisis)
Allopurinol potentiates the action of Azathioprine: if used together, reduce
Azathioprine dose by 75%
Routine PIVD: MRI not indicated
(conservative Mx – resolve in 1-4 weeks)
PIVD with neurological deficits: MRI
Lumbar Spinal Stenosis:
–Discomfort in Thighs on walking / standing
–pedal pulses preserved (PSEUDOCLAUDICATION)
–Ix: MRI
Urinary Catecholamines: sensitive
Urinary Metanephrine: specific
Urinary VMA: least useful
Mx of Fibromyalgia: TCA (NSAIDs are ineffective)
#1 functional pituitary adenoma: PROLACTINOMA
Pain in sole of foot after getting up in he morning: Plantar Fascitis (Mx: Arch Support /
ANA- sensitive
Anti-Sm: specific
Ant-dsDNA: correlates with disease activity
#1 vitamin deficiency: Vit. D
Polymyositis associated dysphagia:
oropharyngeal (striated muscle)
Scleroerma associated dysphagia:
esophageal (smooth muscle)
Muscle Biopsy findings in Dermatomyositis:
lymphoid infiltrate AROUND muscle fascicles
Muscle Biopsy findings in Polymyositis:
lymphoid infiltrate INSIDE muscle fascicles
Ix of choice: Muscle Biopsy (not EMG/NCV)
Woman with Joint Pains and Dental Caries : Sjogren's syndrome
GCA: associated with increased incidence of
Thoracic Aortic Aneurysms
Ank. Spond. vs. SI joint involvement in Psoriasis:
lack of calcification in Psoriasis
Prompt Rx of NGU:
associated with decreased indcidence of REITER's
Whipple's: Joint symptoms precede GI symptoms
Synovial Fluid WBC count
< 200 normal
< 2000 noninflammatory (OA)
2000-50000 Rheumatoid Arthritis
50000-100000 Septic / Gout
> 100000 Septic
#1 Septic Arthritis: N gonorrheae
#1 non-gonococcal arthritis: S. aureus
#1 with IVDU/arthroscopy/prosthesis: S epidermidis
Recurrent Gonococcal Arthritis:
? C5-C8 deficiency
#1 cause of Osteomyelitis: S. aureus
#1 renal involvement after URI:
IgA nephropathy (1-2 days after URI)
PSGN occurs 1-3 weeks after Strep. infection
Nephrotic Syndrome:
#1 (Children): MCD
#1 (Adults): MGN
Dialysis :acquired renal cysts (? malignant pot.)
inflammation of Ligaments / Tendons
(Ankylosng spondylosis / Reactive Athritis)
Polycystic Kidney Disease:
associated with Berry aneurysms in circle of Willis
Multile Myeloma & Kidney:
Myeloma Kidney - LIGHT CHAIN Renal Toxicity
(light chains are not detected by urine protein dipstick)
Renal Amyloidosis - Heavy Chains excreted
(heavy chains are detected by urine protein dipstick)
Aging: decreasd GFR but S. Cr. remains constant ('cuz Lean Body Muslce Mass
decreases too)
Initial Hematospermia: Prostate
Terminal Hematospermia: Seminal Vesicle
RBCs: Hematuria
WBCs: Cystitis
RBC Cast: GN
WBC Cast: APN, Pyelonephritis
Acute Bacterial Prostatitis:
NO Prostatic Massage or Catheterization
Chronic Bacterial Prostatitis:
Prostatic massage -> C/S of expressed secretions
Ureteral Stones < 6mm:
Conservative Mx for 6 weeks
Asymptomatic Renal Stones: Conservative
F/U with serial X-Rays
Symptomatic Renal stones (Fever/Pain/UTI):
–< 3cm: ESWL
–> 3cm: PCNL
Urinary Incontinence:
Total: Sx
Stress: Sx is curative (Kegel/Pessary/Estrogen)
Urge: Antispasmodic / Anti-Ach / TCA
Overflow: Catheterize
Sildenafil (Viagra) c.i. in patients on Nitroglycerine
Right Ventricular Infarction:
Nitroglycerine precipitates HYPOTENSION
Mx: I/V Fluids
70y old man with urinary obstruction and backache:
? Prostatic Ca with mets
Prostatic Biopsy: U/S guided biopsy > finger-guided
Prostatic Ca: Transrectal U/S = MRI for staging
(CT has no role)
Prostatic Mets: Radionuclide Bone Scan > X-Ray
Ix for suspected Bladder Ca.: CYSTOSCOPY
MEN II: hyperparathyroidism is due to HYPERPLASIA, not PARATHYROID
Testicular Neoplastic Mass:
Children: Embryonal Cell Ca.
Adult: Seminoma
> 50y: Lymphoma
Intracranial H'age (< 48h. duration):
CT without contrast is superior to MRI
Cerebellar Vermis:
Axial ataxia
Cerebellar Hemisphere:
“IPSILATERAL” Appendicular Ataxia
Frontal Lobe Lesions:
Personality Changes
Temporal Lobe Lesions:
Hallucinations/ deja vu / emotional changes
Parietal Lobe Lesions:
cortical sensory loss (astereognosis)
Occipital Lobe Lesions:
macular sparing field defects &
Acoustic Neuroma:
first symptom is IPSILATERAL hearing loss
To measure severity of ASTHMA attack:
Peak Expiratory Flow Rate [PEFR] (not ABG)
Alcohol can temporarily decrease symptoms in BENIGN ESSENTIAL TREMOR
(intention tremor)
Myerson's Sign:
2 per second tap on nose -> sustained blinking
(seen in Parkinsonism)
Parkinsonism + Autonomic Insufficiency + Neurological Deficits
Progressive Bulbar Palsy (CN Motor nuclei): TONGUE WASTED
Pseudobulbar Palsy (UMN):
Peripheral Neuropathy:
AXONAL (NCV normal)
TT Leprosy: Neuropathy in area of skin lesions
LL Leprosy: Neuropathy > Skin Lesions
Tarsal Tunnel Syndrome
Pain, Paraeshesiae on bottom of foot
(Sparing of the HEEL)
Cervical Rib:
–Thenar Wasting
–Pain & Numbness on medial 2 fingers
(ulnar side of forearm)
Myotonic Dystrophy:
Mx - Quinine, Phenytoin, Procainamide
Neuropathy: DISTAL ± Sensory Loss
NM Junction: Fluctuating Deficits
Myopathy: PROXIMAL weakness (NO sensory loss)
non-enhancing white matter lesions without mass effect (in AIDS): PML
Ix of Valvular Ht. Disease:
ECHO foll. by Catheterization (definitive Dx)
–Non-productive Cough
–Exertional Dysnea
–Fine Expiratory Crackles
–decreased DLCO
–increased A-a gradient
–gold standard for diagnosis: LUNG BIOPSY
Dx of Malignant Mesothelioma: Pleural Biopsy
100% of small cell ca. occur in smokers
Complicated Parapneumonic Effusions
–Gross Pus
–Gram Stain (+)
–Glucose < 50 mg%
–Pleural Fluid pH < 7.0
Severe Hyperkalemia Mx: Calcium Gluconate
Mx of Mg toxicity: Calcium Gluconate
1st test in asymptomatic hematuria:
1st test in suspected pneumonia:
CXR -> Sputum C/S
Currant jelly sputum: Klebsiella
Rusty sputum: Pneumococcus
Smokers / COPD: H. influenzae
Interstitial infiltrates: Mycoplasma
Empyema / Rapidly progressive: Staph. aureus
Pneumonia Rx:
Community acquired: Macrolide
> 60y or COPD/smoker: 2nd gen cephalosporin
Nosocomial: 2nd / 3rd gen cephalosporin
ICU (severe): Macrolide + Antipseudomonadal
Uncomplicated UTI: 3 day course of TMP-SMX
Native Valve Endocarditis - S. viridans
[â-lactam + aminoglycoside]
Prosthetic Valve Endocarditis (Early) - S. epidermidis [Vancomycin + Aminoglycoside]
Prosthetic Valve Endocarditis (Late) - S. viridans [Vancomycin + Aminoglycoside]
IVDU - S. epidermidis / S. aureus
[Vancomycin + Aminoglycoside]
IE prophylaxis:
- Amox 2g 1 hr. before Dental / GI / GU procedures
- penicillin allergy -> Clarithromycin
Don't delay antibiotics in Meningococcal meningitis
(even if LP is not done)
HAART: AZT+3TC & Indinavir
AIDS - avoid all live vaccines except MMR
Abdo. Pain: 1st investigation - AXR
UC: Pseudopolyps, Crypt Abscesses
CD: Skip Lesions, Fistulae
ddI can cause Pancreatitis
RA: PIP involvement (DIP sparing)
OA: DIP involvement
Ix of choice in Osteoporosis: DEXA scan
Vaginal Candidiasis:
Topical Miconazole / Systemic Fluconazole (recurrent)
(Oral agents eliminate rectal reservoir of yeast)
PO Metronidazole 2g stat (Rx male partner also)
Bacterial Vaginosis:
PO Metronidazole 250-500mg x 7 days
(cf. single dose in Trichomoniasis)
Pap shows LGSIL (F/U reliable):
repeat Pap 4-6 months later
Women Smokers should always have annual Pap
Primary Dysmenorrhea: within 2 years of menarche
–inreased Prostaglandins
–arteriolar spasm
–uterine hypoxia
–Mx: (sexually active): OCP's
–Mx (sexually inactive / OCP c.i.): NSAIDs
#1 cause of DUB: Anovulatory Cycles
Mx: Hormonal Therapy===>Endometrial Ablation
Severe acute DUN with orthostatic hypotension
I/V Conjugated Estrogen
#1 STD: Chlamydia trachomatis
Ectopic (hemodynamically stable / no rupture):
Ectopic (Unstable / rupture):
Salpingectomy or Salpingotomy
decrease Gonococcal STD
may increase Chlamydial STD (cervical ectropion)
Vaginal Spermicides:
decrease Gonococcal & Chlamydial STD
(no effect on HIV transmission)
Breastfeeding & OCPs: can use. Use low-dose OCPs
('cuz of effect on milk production, not because of infant safety consideration. Estrogens
do pass into milk in small quantity, but they are safe)
Hormonal Contraception for h/o DVT/PE:
Norplant & Depo-Provera [no OCP's]
I/V Cefoxitin or Cefotetan + Doxycycline
I/M Ceftriaxone + PO Probenecid + PO Doxycycline
Depression: Cognitive Psychotherapy
Adjustment Disorder: Supportive Psychotherapy
Anxiety Disorder: Behavioral Psychotherapy
Antidepressant Ladder:
–another antidepressant (except MAOIs)
–best tolerated agent + LiCO3
Lab Test for Cocaine:
Urine Benzoylecgonine (Cocaine metabolite)
Genital Herpes transmission occurs even in asymptomatic state
(Acyclovir decreases freq. of recurrences)
H'agic crust on "molluscum" like lesions in HIV pts. : Cutaneous Cryptococcosis
HPV (Genital Warts)
Heaperd up lesions flesh colored lesions on penis
female partner has increased risk of Ca. Cx
Leprosy with painful red patches on extremities that become nectrotic and ulcerate:
LUCIO REACTION (seen in unreated leprosy, responds to Steroids)
Excessive use of Aluminium containin laxatives:
risk factor for postmenopausal osteoporosis
KOH Prep "meatball-and-spaghetti" appearance: Tinea versicolor
binge eating and purging behavior
(even without depression) : SSRI
Factitious Disorder : assoc. with child abuse
Somatoform Pain Disorder:
limit analgesic use
best managed in a multi-disciplinary pain clinic
Rx of choice for Panic Disorder: PAROXETINE [dependence might develop with
Mx of Social Phobia:
Mx of OCD: SSRI [Fluvoxamine]
Clomipramne is no longer the first line drug
Mx of PTSD: >1m; assoc. with life-threatening event
Group Psychotherapy
Anorexia nervosa:
75% have Depression, 25% have OCD
Buckman's 6 steps of Breaking Bad News
1. Getting started
2. find out how much the pt. knows
3. find out how much the pt. wants to know
4. share the info. a) Give Warning Shot
5. respond to pt.'s feelings
6. Plan F/U - give hope
most appropriate initial investigation in â-Thalassemia: CBC with red cell indices
SLE: decreased C3/C4
Dumping Syndrome post-Bilroth II
- Dietary modification
- Octrotide
- (fails) Bilroth I conversion
75%-95% of AAAs are infra-renal
- Dx: U/S abdo.
Food poisoning: < 6 hrs. after food intake
- S. aureus (mayonnaise / salad dressing)
- B. cereus (fried rice)
> 16 hours / poultry consumption: C. jejuni
Carbamazepine intoxication
- QRS prolongation : predisposes to
- QT lengthening
Defib. followed by pulseless electrical activity
- Hypovolemia
- Hypoxia
- cardiac tamponade
- pneumothorax
- massive pulmonary embolism
- drug toxicity
- hyperkalemia
- acidosis
- massive MI
Coarctation of aorta is associated with
Bicuspid aortic valve in 70% cases
#1 cause of GI h'age following AAA repair is:
Colonic Ischemia (not stress gastritis)
Early onset wound infections: Strep / Clostridium
Visuospatial: Alzheimer's
Gait disturbance / Urinary Incontinence: NPH
Delayed DTR: Hypothyroidism
Myoclonus: CJD (Creutzfeld Jacob Disease)
Alzheimer's with agitation: use HALOPERIDOL
(not BZDs -> they can aggravte agitation)
Testicular tumors
–#1 seminoma
–increased incidence in cryptorchidism
–metastatize to retroperitoneal nodes
–inguinal nodes involved only with scrotal spread
–Children: Embyonal Cell Ca.
–Adults: Seminoma
–> 50 y: Lymphoma
–Dx: Testicular Ultrasound (no BIOPSY)
Mx: Inguinal exploration & cross clamping of cord
& Orchiectomy
–increased tidal volume
–decreased BP (decreased TPR – progesterone)
–Hb decreases (dilutional effect)
TV U/S > sensitive cf. Abdo. Scan for ectopic preg.
Fat Embolism: associated with Eosinophilia & Lipiduria
Shoulder Pain
Rotator Cuff Injury:
best elicited by positioning of the reater tubercle of humerus beneath acromion
Subacromion bursitis:
elicited by palpation over deltoid
Biceps tendinitis:
aggravated by flexion or supination of elbow
Acromioclavicular arthritis:
elicited by crossed arm adduction against resistance
at admn. @ 48 hours
Age > 55 Fall in Hct > 10%
WBC > 16000 Fluid deficit > 6L
Bl. Glu > 200 S. Ca++ < 8.0
LDH > 350 PaO2 < 60 mmHg
AST > 250 BUN increase > 5 mg/dL
Base deficit > 4 mEq/L
Rx of sigmoid volvulus: Sigmoidoscopy
(Sx required if s'copy fails)
Hemodialysis in CRF
–Unresponsive Volume Overload
AIDS Chemoprophylaxis
CD4 < 200: PCP
CD4 < 100: Cryptococcus
CD4 < 50: MAIC
Cryptococcal Meningitis: very high CSF pressure
(serial lumbar punctures may be warranted)
#1 cause of inracranial mass lesions:
Metastasis (not primary brain tumor)
#1 benign liver neoplasm:
HEMANGIOMA (not Hepatic Adenoma)
Propylthiouracil: can cause agranulocytosis
smoking is a relative c.i. to OCPs - not absolute
#1 cause for osteomyelitis: S. aureus
Bed Rest has no proven benefit in chronic low back pain & threatened abortion
Significant Hematuria: > RBCs/HPF
Significant Pyuria: > 10 WBCs/HPF
increased PEEP causing hypotension/hypoxemia -> consider pneumothorax
Confirm erythema nodosum by SKIN BIOPSY (Conservative Mx) -> Steroids for
persistent Pain
Change in Antipsychotics should be done
within 2-4 weeks, if no desired effect
Ice should not be applied on snake bite site ->
can delay efflux of venom by causing vasoconstriction
Severity of AS: late peaking murmur & delayed and weak carotid upstroke
Hymenoptera anivenom is not available
Even after treating anaphylaxis with S/Q Epinephrine -> monitor patient in ED
(patient is not risk-free, complications can develop)
#1 cause of fever in AIDS, without overt symptoms: MAC (Rx Ethambutol +
#1 cause of Seizures in AIDS: TOXOPLASMOSIS
#1 cause of dysphagia in AIDS:
Candidal Esophagitis
Suspected child abuse:
inform child protective services
(Hospitalize only if child's conition requires it)
ITP : improvement with splenectomy but platelet counts falls again (Ix:
radionuclide spleen scan for splenic remnant)
HSP: usually remits in 1 week (Mx is conservative) - Leukocytoclastic vasculitis
#1 cause of hematuria after URI: IgA nephropathy
ABI < 0.4 - sever vaso-occlusive disease
Mx: surgical revascularization
Oliguria in hospitalized pt. -> assess pulmonary wedge pressure (to diff. hypovolemia
and ATN)
Fibrinogen is the most abundant acute phase reactant (responsible for increased ESR)
Age, Myeloma, Macroglobulinemia, Hypoalbuminemia increase ESR
Number-needed-to-screen is reciprocal of absolute risk reduction
Celiac Sprue: dermatitis herpetiformis Mx: Dapsone
Localization of extra-adrenal phaeo: MIBG scan
suspected phaeo
1.catecholamine levels
2.if levels elevated, Imaging
(imaging, done first, will lead to detection of incidental adrenal masses – high
Preop prep in Phaeo
full á blockade followed by â blockade (not vice versa)
Antidote for Mg toxicity is Calcium Gluconate
Mild pre-eclampsia: Bed Rest and Monitoring
Severe pre-eclampsia: Hospitalization,
Control of HTN, MgSO4 infusion
Dx of Hemachromatosis (Gold Standard):
Hepatic Iron Index (not HFE Gene analysis)
#1 cause of TEN : Adverse Drug Reaction
Rapid Correction on HypoNa: CPM
Frozen shoulder = adhesive capsulitis
takes months to regain full function
(steroid injections can hasten recovery)
Orchiopexy in Cryptorchidism @ 1 year age
Orchiopexy deceases the proportion of seminomatous malignancies - but total risk of
malignancy stays the same
Urine dipstick only detects albumin,
24 urinary protein assessment detecs all proteins
(Myeloma light chains will not be detected by dipstick)
Bone scan has no role in lytic lesions of myeloma
Hypotension in Meningococcemia:
Waterhouse-Frederrikson syndrome
Macrolide antibiotics prolong QT interval:
Sinusitis / Bronchiectasis / Infertility / Situs inversus
Disulfiram : slow excretion from the ody. Adverse reactions can occur even 1-2 weeks
after cessation of therapy. Disulfiram is not an option for long term alcohol abstinence
Statin therapy: monitor LFTs regularly
(CPK only if rhabdmyolysis is suspected)
Intravascular Catheter related infection :
Staph. epidermidis / S. aureus
(use Vancomycin, cultures pending)
Arterial Clots: Anti-PL antibody
Venous Clots: #1 inh. cause: Factor V Leyden
Postcoital contraception: is not 100% effective
(Progestin-only Pills are safer than OCPs)
HIRUDIN: is a direct thrombin inhibitor approved for use in pts. with Heparin-induced
Pulmonary Embolism: CXR is usally NORMAL
#1 finding on EKG: Sinus Tachycardia
- Hampton's Hump: seen in Pulmonary Infarction
- Westermark's Sign: sign of Pulmonary Oligemia
Meningococcemia: seen in C5-C8 deficiency
Meningococcal vaccine: Polysaccharide vaccine (A,C,Y,W135)
Neutropenia with Fever: (Neutropenia = < 500/mcL)
suspect Pseudomonas
Piperacillin/Tazobactam & Gentamycin
(or Ceftazidime)
if central line is present: Add Vancomycin
[Continue antibiotics even if cultures are negative]
Indomethacin: can decrease amniotic fluid production
Indications for CONIZATION
1. non-visualization of transformation zone
2. "pap" worse than bopsy
3. AdenoCa.
4. (+) endocervical cuerettage
5. Microinvasion on Bx
(+) F/H is not a risk factor for Ca. Cx
Neuroblastoma metastasis:
can cause periorbital ecchymosis / proptosis
- increased urinary VMA
- N-myc gene
PEPTO-BISMOL: affects platelet function
(can prolong bleeding time)
"popcorn" calcification in SPN : Hamartoma
Mx of SIADH: Fluid Restriction
Mx of malignant SIADH: Demeclocycline
"pop" or snap in knee : ACL tear
[Knee Immobilization / Crutches]
post-URI abdo pain / vomiting / RUQ mass in a child: ? Intussusception [Barium Enema
- Rx & Dx]
Legitimate Vanco. use :
â-Lactam resistant Staph. Epidermidis
Vit. A toxicity can cause Hypercalcemia
Gatsric ulcers: located on lesser curvature
within 1cm of gastric antrum
Adrenal Mass > 4cm & High Hounsfiled Values:
high chance of being malignant
Most ensitive test for Cushing's:
24 hour urinary cortisol
(levels are subject to diurnal variation)
Bilroth II:
Afferent Loop Syndrome (Pain after meal ingeston) Mx: Bilroth I conversion, roux-en-y
Blind Loop syndrome (bacerial overgrowth, malabs.) Mx: antibiotics
â-Thalassemia major: HbF increased
â-Thalassemia trait: HbA2 increased
Risk of Postop DVT
#1 Elective Knee Arthroplasty
#2 Elective Hip Arthroplasty
#3 Hip # Repair
Cocaine use assoc. MI:
combination of spasm and plaque rupture
(don't assume spasm is the cause, do angiography)
Pappenheimer's Bodies: Iron inclusions in RBCs
Hypocalcemia, Hyperkalemia, Hyperphosphatemia
Diverticulosis: #1 complication - BLEEDING
85% bleeds stop spontaneously
(#1 complication is not Diverticultis)
–Broad spectrum antibiotics
–no barium enema / colonoscopy
h/o Malig. Hyperthermia with succinylcholine:
use NITROUS OXIDE in future anesthesia
Chronic Fatigue with normal physical exam: DEPRESSION INVENTORY -> Thyroid
IE -> Mycotic Aneurysm -> Bleeding -> SAH
[embolization of bacteria to the brain)
IFN-â: decreases relapse frequency in MS
First Episode of DVT:
Heparinize -> Warfarin for 3-6m (INR 2.0-3.0)
Recurrent DVT:
Lifelong "Warfarin"
[if Warfarin is not tolerated : ENOXAPARIN]
Fever / Sore Throat / Atypical Lymphocytes
(without LN / Splenomegaly / MonoSpot) : CMV
Colles' #: splinting in NEUTRAL postion
(not in FLEXED position)
PSA levels in Prostatic Ca. correlate with lymphatic spread
Antibiotics in postpartum endometritis:
I/V Imipenem / Cilastatin
Vaginal Delivery in Breech
2. Fetal Weight between 2000-3000g
3. Gynecoid Pelvis
Rx of Catatonia: Lorazepam
Incisions done for pre-existing infections and abscesses are considered INFECTED
Severe Depression with Psychosis: Mx with ECT
Hypertensive Heart Disease: S4 Gallup (LVH)
Depo-provera: - associated with Irregular bleeding
(use conjugated estrogen x 7 days to control bleeding)
Peak CPK levels:
give idea about size of an infarct
(no prognostic value)
Nephrolithiasis with increased Creatinine:
IVP can not be done
(No I/V CONTRAST in the setting of renal dysfn.)
Renal and Bladder Ultrasound Scan, instead
HTN in Graves' disease: Rx with â-blockers
Anti-Ro: associated with neonatal Lupus
(resolves in 6 months) and Congenital Heart Block
Lupus anticoagulant
–recrrent abortions
–thrombotic state (arterial + venous)
–"in vitro" increased PTT
(doesn't correct with mixing)
–Russel Viper Venom Time
Doxepin (a TCA) is useful in chronic urticaria
suspected ADHD: get psychometric tests
Misleading Low Sodium is caused by Hyperglycemia
Mx of acute mountain sickness: acetazolamide
Dx of Sarcoidosis:
–Kveim test is obsolete
–ACE levels are elevated in 50% pts.
Rx of Brown Recluse Spider Bite: DAPSONE
Middle Ear Effusion persisting for 4-6 months following an adequate
antibiotics, with significant hearing loss (especially bilateral), is an indication for
myringotomy and insertion of tympanostomy tubes.
Chlamydial Ophthalmia:
(to prevent chlamydial pneumonia)
Appropriate Initial Test for suspected B12 def:
Serum B12 levels
(many patients have normal CBC and normal indices)
fruity breath odor: ketosis
prolonged latent phase of labor :
–therapeutic rest & sedation (usually morphine).
–No Oxytocin / No Amniotomy
DtaP contra-indications:
1.previous febrile reaction: fever > 105 F
2.h/o seizures
(F/H of seizures is not a contra-indication)
Rx of choice for SVC syndrome:
First HiB vaccine @ 2 months age
Female > 40y with abnormal vaginal bleeding Endometrial Bx to r/o Endo. malig.
Atrial Flutteris not a serious arrhythmia, but cardioversion should be attempted in the
presence of CHF.
Atrial Flutter due to Digitalis toxicity:
Anorexia nervosa:
BUN increase
Low Platelet Count
Leukopenia with relative lymphocytosis
elevated serum carotene levels
Legionaire's disease:
Aster's USMLE Step3 Notes
Person-to-person spread has not been documented
Childhood obesity is not a predictor for adult obesity
long-term Rx of obesity in children : usually fails
Thoracic outlet syndrome:
appearance on numbness and paraesthesiae
with arm abducted to 90 degrees and externally rotated
(not defined by the disappearance of radial pulse)
Postmenopausal with stress incontinence:
Kegel exercizes, pessary, estrogen replacement
Retractile Testes:
–exaggerated cremasteric reflex
–resolves in adolescence
–no increased risk of malignancy
Flail Chest: Intubation & Assisted ventilation
(Strapping of Chest may lead to hypoxia & atelectasis)
Vaginismus is involuntary contraction
Behcet's: cutaneous hypersensitivity
60-70% will develop a sterile pustule within 48 hours of any aseptic injection
epidydimitis -> check age of pt.
< 35: Chlamydia, Gonococcus
> 35: E.coli
Gold stadard for diagnosis of melanoma:
Treatment of alcoholism in wife-batterers does not treat battering behavior
Pt. with hemoptysis and normal chest film:
Fibre-optic bronchoscopy
(PPD is not indicated)
F/U COPD progression with FEV1
Tick paralysis (neuro-toxin mediated): 10% mortality
prompt resolution if tick is identified and removed
Let children attend funerals, if they want to. They should be accompanied by adults who
can provide comfort and support
Hyperparathyroidism: inc. incidence of Pseudogout
NIACIN: can be associated with hepatotoxicity
rear-facing infant seats should be on the back seat.
< 12 y children: ride secured on car backseat
Headache onset with exertion, such as weight-lifting:
serios sign (look for CNS malformations & vascular malformations)
Minocycline: has anti-inflammatory action
(has been used in Rheumatoid Arthritis)
Gynecomastia in adolescence: Observation
Long standing Gynecomastia: SURGERY
HCM: EKG is abnormal (LVH, WPW, abnormal Q wves)
Ticlopidine: has been associated with neutropenia
Immediate gastric lavage is ot indicated in strychnine poisoning
Continuous gastric lavage: PCP overdose
Not all persons with anaphylaxis will have a repeat
reaction when exposed again to the agent. Repeat reactions are usually less severe.
Head, Neck, Face sutures:
leave in place for 3-5 days (rapid healing)
Eclampsia: MgSO4
(no role of anticonvulsants)
Clonidine withdrawl: Hypertensive Crisis
The woman's need for physical intimacy often increases during pregnancy.
Abstention from intercourse in the last month of normal pregnancy is not necessary
Valsalva maneuver decreases the venous return to the heart, thereby decreasing
cardiac output. This decreases murmurs due to AS, MR, PS, but increases the
murmur due to HCM
FOBT testing does not decrease the mortality from colorectal carcinoma
#1 symptom in vaulvar carcinoma: Pruritus
Of the anticonvulsant, VAPROATE has the least effect on hepatic enzymes and
therefore has the least impact on decreasing the efficacy of OCP's
Gilbert's syndrome: lower levels of unconjugated bilirubin cf. Crigler Najjar (6-45 mg/dL)
Menopause: Serum FSH increased
Estradiol decreases, and Estone becomes predominant estrogen.
Infiltration of local anesthetic agents (less pain):
–warm solution
–small needles
–slow infiltration
–addition of bicarbonate to the mixure
Mg-containing antacids in CRF:
can cause magnesium toxicity
Postherpetic neuralgia: higher incidence in older pts.
ANA titre < 1:160 is common in healthy older people
Orthostatic hypotension:
Drop in Systolic > 20 mmHg
Drop in Diastolic > 10 mmHg
Mx: discontinue any drugs that might be responsible
-> arise slowly -> elastic stockings -> Fludrocortisone
B pertussis is being recognized as a cause of
persistent cough in adults. (associated with dysnea, tingling sensation in throat)
d/o/c for Giardiasis in children: Furazolidone
Tinea capitis: Oral Griseofulvin
poor response to topical medication
Males with impotence, decreased libido & decreased testosterone: order a prolactin
(r/o pituitary adenoma)
Pre-term infants: normal response to immunization
(although they have relative immunodeficiency)
Drug indiced LE: anti-histone antibodies
[ANA (+), Anti-dsDNA absent]
–hydralazine, isoniazid, procainamide, penicillamine
–Mx: discontinue medication + short-course of glucocorticoids
–disease lasts < 6 months
–ANA may remain (+)
–most lupus inducing drugs can be safely used in SLE, if no alternative exists
HCM: sudden death in athletes
Dx: Echo Rx: â-BLOCKERS
Valsalva maneuver increases murmur
ITP: low platelet, BM aspiration shows numerous megakaryocytes
Risk of suicide: Female Physicians > general females
Physicians' risk of suicide
Psychiatrists > Ophthalmologist > Anesthesiologist
Anaphylaxis: Epinephrine
Juvenile Rheumatoid Arthritis:
very few patients are left with disabilty / deformity. At least 50% remit fully and majority
regain normal function
Urticaria > 48 h :
Skin Biopsy to r/o Urticarial Vasculitis
Mobitz Type II Heart Block: Mx is PACEMAKER
Stage IA Hodgkin's: Radiotherapy alone is effective
Total Hip replaement:
–immediate relief
–perioperative anticoagulation
–successful (no need for revision in 90%)
–bone resorption is a major concern for long-term stability of implant
Pressure Ulcers:
Stage I: Nonblanching Erythema
Stage II: Broken Skin with partial thickness skin loss
Stage III: Full tickness skin loss (extension into subcutaneous fat)
Stage IV: Extension into Muscle or Bone
"kennel cough" is produced by a canine Bordetella
Risk factor for domestic abuse: female gender
Trochanteric bursitis
–presents with a deep, dull, aching pain
–burning & tingling in lateral upper thigh
–worse with activity
–excacerbated by sitting cross-legged with affected leg
The mortality rate for pneumococcal pneumonia is same for the past 50 years
SKIN SWELLING with Bee sting: local reaction
[not anaphylaxis]
Rx of Restless Leg Syndrome: Clonazepam
Alendronate: Pill-induced esophagitis
TCA withdrawl symptoms (cholinergic symptoms) : best managed with Benzotropine
Aspartame is c.i. in children with PKU
Diaphragm & spermicidal jelly:
insert upto 2 hrs before intercourse
and leave in place for 6 hrs after intercourse
(for repeated intercourse, re-apply jelly)
Asthmatics who require â2-agonists > once/day; can be prescribed inhaled
Psoriasis in infancy: begins n diaper area (the area of greatest trauma)
Labia minora adhesions:
–not present @ birth
–acquired condition
–no urinary retention
–not assoc. with other anomalies
–surgical correction has a 100% recurrence rate
–estrogen cream can lyse the adhesions
Carbidopa/Levodopa do not alter the progression of Parkinson's disease
Chronic Choleystitis with Cholelithiasis is frequently non-visualized on ultrasound.
Umbilical hernia in a child < 6m
Mx: Conservative [Strapping is ineffective]
(usually disappear by 1 year of age)
Surgery for strangulated hernia; persisting beyond 4y
Increased Postop Cardiac Death
–S3 Gallop
–h/o MI in the past 6 months
–Frequent PVCs
–Aortic Stenosis
Supression of lactation: breast inder & cold pack
[Bromocriptine is not approved for this purpose]
Cardiac Pacemaker: does not warrant IE prophylaxis
Pubertal development in an adolescent girl:
Thelarche, Pubic Hair, Growth spurt, Menarche
(Growth spurt precedes Menarche)
Most sensitive and specific means of diagnosing appendicitis is history and physical
(not CT or U/S)
In stroke, overzealous antihypertensive medications can reduce cerebral perfusion and
increase tissue damage.
Scabies in young children:
[Lindane not approved]
Wheezing in children may also be due to GERD
A single sexual encounter with a person with genital warts carries a 60% chance of
transmission. Transmission occurs in asymptomatic state too.
Hydrocephalic children:
–increased developmental disabilities
–lower IQ
–learning deficits
–defective verbal abilities
–memory and visual problems
Chlamydial infections:
Azithromycine & Doxycycline have equal efficacy
#1 cause of hematemesis in healthy newborn:
comiting of swallowed maternal blood
Clinical privileges to physicians are granted by the GOVERNING BODY of the hospital
New onset LBBB may be an indication for thrombolysis even in the absence of
characteristic ST elevation of MI
Dexfenfluramine: 1º Pulmonary Hypertension
Transdermal NTG Patches: Rapid Tolerance
Oropharyngeal dysphagia in elderly:
? early Parkinson's
Paget's disease of bone:
–Head Enlargement
–Nerve compression
–increased urinary hydroxyproline
–increased alkaline phosphatase
HIDA scan: Cholecystitis (+)
–nonvisualization of the GB
–visualization of CBD & Bowel
Leading cause fo mental retardation in US:
Fetal Alcohol Syndrome
Rotavirus G/E: decreased incidence in breast fed infants. None of the antibodies that
develop after the first attack are protective
Grade 1 Vesico ureteral reflux:
prophylactic antibiotics and double voiding of urine
Sodium Nitroprusside infusion:
may increase Thiocyanate levels to toxic range (delirium, tinnitus, blurred vision)
Allergic bronchopulmonary aspergillosis is treated by corticosteroids (not
Childhood autism:
Echolalia, minimal eye contact, repetitive behavior
serum digoxin levels elevation can be seen in pts. treated with oral verapamil
Recurrent Zoster is rare
Cocaine > Coronary Spasm
(free basing can lead to loss of eyebrows/eyelashes)
Measles vaccine significantly reduces the chances of developing SSPE
Influenza A is usually sensitive to Amantidine
(resistance occasionally seen in institutionalized pts.)
Synovial Fluid in OA : High Viscosity
Children with diarrhea who are not dehydrated should be give age appropriate diet
Loperamide: contra-indicated in children
Secondary Amenorrhea: give Progestin Challenge
Rapidly Progressive Periodonitis (with good dental hygiene) might be suggestive of
Hyperosmolar nonketotic coma:
–require less insuin for correction (cf. DKA)
–Fluid deficit is larger (cf. DKA) (10 L)
–patients are older
–can also occur in Type 1 DM
The hypochondriac believes that his fears about disease are totally realistic. He also
believes that physicians are not acting in his best interests by disputing the reality of
these fears.
poor response to antidepressants
Old age:
Vital Capacity decreases
Functional Residual Capacity increases
Arterial Oxygen Tension slowly declines with age
Pasturella multocida:
Rx Amox-Clav
(Pn allergy: Doxycycline) [NOT ERYTHROMYCIN]
Place PPD on all individuals being admitted to a nursing home. Persons with doubtful
reactions should be tested a second time within 1-2 weeks (boosted reaction). This
second reading should be taken as the baseline reading for that person.
Tennis Elbow : Lateral Epicondylitis
(usually acquired occupationally)
Obesity lowers aminoglycoside volume of distribution necessitating decrease in
Primary indication of joint replacement in OA:
Severe Pain
Postcoital test : best done in midcycle
Adhesive bands are now the most common cause of intestinal obstruction for all age
(strangulated hernias are the m/c cause in children)
Rx for ANUG (acute necrotizing ulcerative gingivitis) PENICILLIN
Vasoldilators of choice for CHF
Use of TCAs in patients with glaucoma can precipitate acute angle-closure attacks (antcholinergic
The only absolute contra-indication to breast feeding is
Major abdominal trauma in 3rd trimester pregnancy:
evaluate for placental abruption & preterm labor
[electronic fetal monitoring: obtain reactive NST]
Transient cortical blindness due to mild head traums usually recovers (benign outcome)
Pneumococcal vaccine: not before 2 years of age
#1 cause of microscopic hematuria in elderly is BPH
Polychlorinated Biphenyls: skin rash called Chloracne
Ludwig's angina: infection of the deep fascial space of the submandibular space (early
airway compromise)
Mx: Intravenous steroid cover
Wilson's disease confirmed by inability to incorp. a copper isotope into Ceruloplasmin
Patients with procaine allergy usually tolerate Lidocaine (amide group) well
Always inject insulin in skin of non-exercized areas (to prevent exercize-induced
hypoglycemia). If the lefg is used as injection site, insulin absorption will be enhanced
with running leading to hypoglycemia.
Celecoxib: not to be used in patients with SULFA allergy
Passengers with stable medical conditions requiring low-flow oxygen cannot bring their
own oxygen on aircrafts according to Federal Air Regulations concerning hazardous
cargo. Most air carriers will provide O2 for a fee
Do not fly within 3 weeks of a MI
No air travel with term pregnancy
–Response prevention & in vitro exposure
Don't give OPV to a child whose sibling is immunodeficient
Post MI Risk Stratification is done with an Exercize Stress Test (for patients who can
exercize). For patients who can not exercize, a Pharmacological stress testing or
Dobutamie Echo is indicated (both are less sensitive than Exercize Stress Testing)
Continue ASPIRIN in the post-MI period
Antiplatelet agent Post-stent placement:
Clopidogrel (ADP receptor inhibitor)
Abciximab (anti-IIb/IIIa)
(decrease restenosis rates)
The choice of agents in asthma therapy is determined by frequency of asthma
The presentation & management of acute cholecystitis in pregnant patients is the same
as in non-pregnant population (Lap Cholecystectomy). Fetal otcome is the best in 2nd
Hyperactive children: hypoperfusion in frontal lobes
NPH: order CT scan head to r/o ICSOL
(confirm NPH by documentation of improvement in symptoms with serial lumber
Severe pre-eclampsia:
–delivery @ term
–MgSO4 for seizure prophylaxis
–antihypertensives for BP control
–MgSO4 is not an antihypertensive.
–Control of BP alone does not obviate the need for seizure prophylaxis
Suspected PCP in AIDS: Obtain a Chest X-Ray
Migraine prophylaxis: â-blockers
Migraine treatment: Sumatriptan
Somatization disorders: 1st step in Mx
avoid un-necessary Ix & medical/surgical treatment
Community acquired pneumonia: S pneumoniae
Rx: Macrolide (Clarithromycin)
Patient presents to the office with unstable angina:
1st step: Chew & Swallow Aspirin
Vaginal douching > 3-4 times / month:
associated with alteration of vaginal flora and increased incidence of PID
Prolonged survival in CHF: ACEI's
A fecal gram stain is always positive for bacteria and is not indicative of any pathology.
Inflammatory Bowel Disease: Fecal Leukocytes(+)
Gold standard for Dx of IBD: COLONOSCOPY
Critical Aortic Stenosis: Valve Repair Surgery
(Valvuloplasty in high risk due to other co-morbidity)
Spinal metastasis: Emergent Radiotherapy
COPD patient who still smokes:
#1 step is smoking cessation
(immediate effect on declining lung function)
COPD patients should receive annual influenza vaccine (not HiB vaccine, it is only
given to children)
Dx of Adenomyosis: MRI (most accurate)
(U/S has lower sensitivity and specificity)
Abnormal Vaginal Bleeding:
Periodic, abnormal flow: Anatomic cause
Irregularly Irregular: Endocrine cause
Routine screening of asymptomatic population for dyslipidemia:
Screening of population with CAD/risk factors:
(non fasting random spot cholesterol not indicated)
Patient must have quite smoking 15 years ago
for it to not count as a risk factor for CAD
Digoxin with or without a nodal blocking agent (beta-blocker) is effective in
achieving rate control in Atrial Fibrillation
Chronic A.Fib.:
associated with enlarged Left atrium
Medical emergency in a physician's office:
1st step is to initiate call to “911”
beta-blockers improve outcome in patients at cardiac risk undergoing noncardiaovascular
Mx of HTN in patients with migraine: â-blockers
Renal Failure: is associated with calcium wasting & secondary
hyperparathyroidism (Calcium supplementation is beneficial)
Patient with syphilis & penicillin allergy:
Do a penicillin skin test to confirm & perform desensitization if necessary
uncomplicated UTI:
–perform urinalysis
–Oral TMP-SMX (3 days)
–no need for urine cultures
The occurrence of PVCs post-MI is associated with increased mortality &
morbidity. Treatment of asymptomatic PVC's with anti-arrhythmics is not
indicated. (Such treatment is itself associated with increased mortality)
No role of prophylactic anti-arrhythmics post-MI
Initiate Calcium supplementation even in cases of prolonged secondary
Exercize-induced amenorrhea
–low adipose tissue
–estrogen biosynthesis shifts to 2-hydroxylation with increased synthesis of catechol
–catechol estrogens compete with catecholamines for COMT
–results in inreased dopamine
–dopamine decreases GnRH release
–results in secondary amenorrhea
–whatever the age, OCPs (for HRT) & calcium supplementation are required to prevent
bone loss
Mx of psychotic depression: ECT
Post-void urinary volume estimation:
Straight Urinary Catheterization
(U/S is inaccurate in estimating bladder volumes)
All GDM patients should be tested @ 6w post-partum with 2-hr (75g Glucose) Oral
GDM is a risk for DM unrelated to pregnancy (regardless of glycemic control in
Klebsiella penumonia
–necrotizing pnemonia
–hospitalized patients / aspiration / post-stroke & alcoholics
–currant-jelly sputum (bloody)
Staph aureus: causes cavitatory pneumonia
(associated with rapidly progressive effusions & empyema)
Colon Cancer screening:
–FOBT annually
–Colonoscopy q10y
–Sigmoidoscopy q5y
PSA estimation is not recommended for Prostatic cancer screening (if at all one test has
to be done, it should be Digital Rectal Examination)
Chronic Uterine prolapse:
–first fit a pessary
–prescribe estrogen cream
–later proceed to surgery (surgical failure rate is high when performed in the presence
of dry atrophic mucosa)
In any patient with pain of cardiac origin: EKG
(to differentiate between Ischemia & Infarction)
Inhaled corticosteroids:
long-term stabilization of severe asthma
(beta-agonists provide only symptomatic relief)
Hypotensive response to NTG drip in patients with inferior ischemia: Right Ventricular
(Mx: Stop NTG, Start I/V crystalloids)
suspected anemia: 1st Ix – CBC
suspected Fe deficiency anemia: Serum Ferritin levels
Normocytic anemia: 1st Ix – Reticulocyte count
h/o GI bleeds with DVT: not a candidate for anticoagulation
Alcohol induced dilated cardiomyopathy:
#1 step – stop alchol intake to halt progression
Polycythemia vera: increased risk of stroke
Valsalva maneuvre: decreases pre-load
Jedrassik maneuvre: decreases after-load
Valsalva decreases HCM murmur,
Jedrassik increases HCM murmur
Ankle – Brachial Index:
< 0.5 suggests severe ischemia
(surgical revascularization required)
MVP without MR: no IE prophylaxis required
[absence of MR to be documented by Echo]
Pilonidal Cyst: infection of hair follicles in sacrococcygeal area. Mx: removal of hair /
Elderly with Knee “locking”: Medial Meniscal Tear
“pop” in he knee: ACL tear
pain in lateral knee, athlete: Iliotibial Band Syndrome
COPD @ any stage, smoking cessation in beneficial
Painless Testicular Enlargement
–? Malignancy [Embryonal/Seminoma/Lymphoma]
–Ultrasound, no Biopsy
–spreads to retroperitoneal nodes, if inguinal nodes (+), suspect scrotal invasion
–Sx: Inguinal approach, not Scrotal (Orchiectomy)
Evaluation of lung malignancy: CECT (IV contrast)
Dermatomyositis: search for occult malignancy
Most testicular varicoceles are on the left side
Neomycine allergy: 5% of population (Treat with Steroids). It is a Type IV
hypersensitivity reaction
SCC Lip Risk factor: Smoking > Sunlight exposure
Hydrocele: typically idiopathic (No Rx required).
Persistent hydrocele: Refer to Urology for Sx
Tuberous Sclerosis: Skull X-Ray to look for intracranial calcifications
AFP increase: NSGCT
b-hCG increase: Seminoma & NSGCT
Li-induced hypothyroidism: Mx – levothyroxine
(not discontinuation of Lithium)
Latest recommendation advise Influenza vaccination for >50y instead of >65y
suspected Pseudotumor cerebri:
LP (inc. CSF pressure)
complex partial seizure:
aura, behavioral arrest, automatisms
Myesthenia gravis: CT Chest to r/o Thymoma
Propranolol is associated with depression
Fluoxetine takes 6-8 weeks to act !
Asplenia: PneumoVax / HiB / Influenza vaccine
Headache excacerbated by position & exertion:
increased ICT (? mass lesion)
Mitral Regurgitation
1.Transthoracic Echocardiography
2.If quantification reqd.: TEE
3.Gold Standard for any valvular disease:
Cardiac Catheterization
Suspected Anemia: next step – CBC
MICROCYTIC ANEMIA, to Dx Fe.-def anemia:
SERUM FERRITIN (Gold. Std.: Bone Marrow Bx)
GI side effects are common with oral FeSO4. They are not an indication for
discontinuing therapy. Always assess response (% Retics) after Iron Therapy.
OCPs can prevent anemia, they do not treat established Iron deficiency anemia. (Rx:
ABI < 0.5: s/o significant PVD (Sx revascularization)
Steroid Rx in suspected GCA: start without waiting for ESR / Temporal Artery Bx results
Excessive Cow's Milk Intake: Fe. Def. Anemia
Pericarditis: Diffuse ST elevation
Factor V Leyden: Lifelong Warfarin Prophylaxis
beta-blockers in stable CHF: decrease mortality
DVT with h/o UGIH: no prophylaxis (?IVC Filter)
Critical Aortic Stenosis: Mx – Valve Repair (Valvulopalsty only for high risk cases)
Esophageal Varices: BANDING
TIPS is for portal decompression before Transplant. Not used as a primary procedure
only for Eso. Varices
Chronic Malabsorption in Pancreatitis: Mx – non-enteric coated Pancreatic enzyme with
H2 blockers
Child < 2 years with symp. Inguinal Hernia:
Contralateral Exploration indicated
–non-pharmacological measures
–emperical pharmacological measures (H2 / PPI)
–if fail, do Esophageal 24 hr. pH monitoring
probe kept 5 cm proximal to LES
pH<4 for >5 minutes or >9% of total time
–followed by UGIE & Surgical Mx if needed
Irritable Bowel Syndrome is a Dx of exclusion
12 weeks of GI symp. In preceding 12 months
Gilbert's: jaundice may only be noticed in the times of stress / infection or fasting
Anal Fissure: Steroid Cream & Sitz Bath
Stress is a trigger of IBS, not cause
Biliary colic: RUQ pain following meals
Cholecystitis: RUQ Pain / Murphy's / Fever / Leuko.
Cholangitis: RUQ Pain / Fever / Jaundice
False (+) Guaiac stools: meats & vegetables containing peroxidases (Inorganic Iron
does NOT cause False (+))
F/H Duodenal Ulcers with Hypercalcemia:
HNPCC: Mx – subtotal colectomy with TAHBSO
Child with Constipation: Mx prune / pear juice (sorbitol)
Rectum devoid of stool: Hirschsprung's
Rectum full of hard stool: Fecal Impaction
Graves': Cigarette smoking increases ophthalmic involvement (advise patients to quit
Smoking Cessation:
1.success usually takes 5-6 attempts
2.associated with weight gain
3.counsel patients at each visit
4.pharmacotherapy should be offered to all
5.relapse rates decrease after 6m of abstinence
suspected Phaeo: first step is alpha-blockade with phenoxybenzamine (before Bx /
#1 side effect of radioactive Iodine: hypothyroidism
Glitazones – asociated with liver toxicity (LFT's)
Hypothyroidism with macrocytosis & hyperlipidemia:
1st step is THYROID hormone replacement
(might correct macrocytic anemia & decrease lipid levels)
Infection in suppressed adrenal axis due to chronic use of exogenous steroids
(refractory hypotension) :
administer stress dose of i/v steroids
Cholesteatoma: CT scan of temporal bone (Mx: Sx)
CN III palsy with pupillary involvement: MRI
Child attending day care with viral conjunctivitis:
remove from daycare till symptoms subside
Fifth Disease: child is infectious before onset of rash
Mx of epistaxis: pressure, no need to tilt head upwards
Alk. Phosphatase is norally increased in pregnancy
Med. Mx of Ectopic: MTX
(b-hCG sample on Day 4 & 7, 15% decrease in level)
LGSIL = CIN I (most lesions resolve spontaneously)
Newborns can lose upto 10% of their weight in 1st wk
Breast – Cystic Mass
clear : discard
bloody : send for cytology
Delayed age at 1st preg: increased risk of Ca. Breast
Polycystic Ovaries: 1st step: OCP's
Churg-Strauss: (+) pANCA
#1 extra-renal manifestation of adult PCKD:
Colonic Diverticular Disease
(not Intracranial Berry Aneurysms: seen in 15%)
Nephrotic Syndrome in adult with recurrent hematuria:
IgA nephropathy
HSP: self limiting. Do urinanalysis (r/o kidney involv.)
Cisplatin: nephrotoxic
Never prescribe prescription drugs over the phone, especially if the patient is “new”
(call for evaluation)
F/H (+) of HTN: ? Adult PCKD
Biopsy has no role for Diagnosis of RCC. If suspected, refer for Sx management (Bx
only if e/o metastasis present)
Nephrotic Syndrome with HTN: start ACEI's
(no role of high-protein diet in nephrotic syndrome)
T-score: cf. Normal healthy young population
Z-score: cf. Age matched conrols
Osteoporosis is defined by the T-score
Rx (HRT + Bisphosphonates) indicated if:
–T < 2.5 or
–T < 1.5 with presence of risk factors
Smallpox Rx: Cidofovir
Smoking cessation: Mortality reduced to ½ in first year and smoking caeses to be a risk
factor 15 years after quitting
Infants: always rear facing on backseat
< 12y: always on rear seat
Fertility returns as early as 1-2 weeks after cessation of OCP use.
Tinea capitis: KOH prep (Ix)
not Wood's lamp, all species don't show fluorescence
Postherpectic neuralgia: Mx – TCA
(Acyclovir decreases PHN when given prophylactically)
Toxic megacolon in U/C:
–high mortality rate
–Ix: AXR
–Mx: NPO/NG/Rectal Tube/Antibiotics
–Sx if doesn't resolve in 2-5 days
Peptic Ulcer disease with Gout: acute Rx – colchicine
(NSAIDs can not be used)
Necrobiosis Lipoidal Diabeticorum: DM
plaques with depressed atrophy on anterolateral leg
Parkinson's patients hould be referred to neurologist
Anosmia: r/o neoplasm/#/sinusitis (CT/MRI)
–abdominal pain
–painful defecation
–GI upset with periods
–Ix: Laparoscopy
Influenza vaccine is indicated in healthcare workers @ any age
alpha-1-AT def.: avoid smoking & alcohol
(to prevent emphysema & cirrhosis)
Pruritic Urticarial Papules & Plaques of Pregnancy
–no umbilical involvement
–Mx: conservative
Impetigo herpetiformes:
rare form of pustular psoriasis
–acute onset
–erythematous plaques surrounded by sterile pustules
Herpes Gestationis:
–2nd or 3rd trimester onset
–involves umbilicus
–recurs in subsequent pregnancies
Routine rectal examination does not lead to elevation of PSA (levels can be done on the
same visit as DRE)
Uncomplicated varicella in preg., Conservative Mx
Hematuria without UTI: next step – contrast study
LiCO3 can excacerbate psoriasis
TT in past 5y: No Rx reqd.
TT in past 5-10y:
prone wound: T toxoid
clean wound: No Rx
TT > 10y ago
prone wound: T toxoid
clean wound: No Rx
Post-PE: maintain INR between 2.0 & 3.0
If > 3.0 (no e/o ICH):
admit / give Vit. K (heparinize if INR falls to 2.0)
If e/o ICH: give FFP to replenish clotting factors
Thioridazine: prolongation of QT interval
PPD(+): obtain CXR to r/o active infection before starting INH prophylaxis
Chronic Steroid Use:
–Avascular Necrosis of Femoral Head (not due to osteopenia) avoid trauma, slow taper
of steroids
Relapsing Polychondritis
–Ear (Painful external ear)
–Larngeal Inflammation (focal narrowing) with airway obstruction
–can be associated with aortic aneurysms
Avascular Necrosis of Scaphoid: Sx Pinning
(X-Ray: sclerosis)
#1 cause of U/L vocal cord paralysis: Lung Ca.
Prostatic Mets.: respond to andrigen deprivation for the first 2-3 years and then
become resistant
>6m with exclusive b.f. : Iron Supple.
Breast Feeding (Hormonal Contra.): Progestin-only
minimal effect on milk quality & quantity
Uterus & Cx reach normal size:
6 wks post-partum (IUCD & Diaphragm can be used)
If one FBS > 126, send another sample (Dx of DM)
MMR immunization is assoc. with simple febrile reaction. Can be associated with
seizures too.
Gingko biloba used with warfarin:
severe bleeding tendency
Give MMR to children with egg allergy (contains cross-reacting egg protein but in
very small quantity)
Varicella vaccine @ 12 months
suspected Giardiasis: send stool for ova/parasite before starting treatment
Shell fish intake: associated with Hep. A
Rx of Clostridial infection: Penicillin & Clindamycin
Neonatal Sepsis: Ampicillin + Cefotaxime
Meningococcal disease with persistent hypotension: Give I/V hydrocortisone
SBP prophylaxis: Levofloxacin
Acute post-infectious cerebellar ataxia:
–ataxia / nystagmus
–post varicella infection (1m later)
–acute onset, resolves
–Mx: conservative
Pulmonary Coccidiomycosis:
Pap smear of fresh expectorate is diagostic
Meningococcal prophylaxis:
Immunosuppressed: increased risk of fungal sinusitis
(high mortality rate, intracranial compli., Ampho-B)
After toilet, wipe front to back (decreases UTI inci.)
Candida Diaper Rash: Topical Nystatin
Primary Irritant Dermatitis: Zinc Oxide
Rx of viral pericarditis: NSAIDs
Rotavirus vaccine is no longer FDA approved (due to incidence of intussusception in
Ant-HCV is (+) 18 weeks after infection
Newborn with (+) TB contact should be given
INH prophylaxis for 3 months irrespective of CXR/PPD status.
If at 3 months PPD(+), continue for 6 more months (else stop INH)
Pruritus ani: E.vermicularis (Mebendazole)
Mandatory seat belt laws decrease MVA mortality
Smoking cessation counseling should be provided to all patients regardless of age,
duration, previous attemps. (decreases cardiovascular mortality)
HSV transmission may not be prevented by condoms: skin-to-skin transmission occurs
G(-) diplococci in Otitis: Moraxella
(usually Penicillin resistant, use penicillinase resistant antibiotics)
MMR is not contra-indicated in AIDS
Dog Bite infection
Rx with Amox-clav for puncture wounds or bites on hand (for non-infected wounds: local
Home air humidifiers favor growth of house dust mite
Post GA Sx hoarseness of voice:
evaluate by ENT
Mx aspiration pneumonia:
Clindamycin (anaerobic cover)
Breastfeeding mother with Trichomoniasis:
Give MNZ one dose stat, discard milk for 24 hours
Air Travel: decreased cabin pressure
–decreased pO2 can cause hypoxemia, CAD patients have increased risk of MI
–decreased pressure leads to expansion of gases. (problematic for patients with
volvulus, GI surgery, recent intestinal obstruction)
Female patients with CF may be infertile (plugging of fallopian tubes)
Inpatient Rx for community acquired pneumonia:
Malignancy, AIDS, cardiopulmonary/renal/liver disease
PSA is not present in ejaculate. Butejaculation can increase PSA levels transiently for
48 hours
Hemoptysis workup:
–Chest X-Ray
Chlamydial/Gono. Epidydimitis can be treated with a 10 day course of Ofloxacin
PSA > 4.0ng/mL: required prostatic biopsy
(esp. with F/H prostatic Ca.; 30% risk of Prostatic Ca. When PSA levels are >
4.0ng/mL). But no evidence that screening with PSA is beneficial
suspected esophageal perf.:
esophagoscopy with water soluble contrast
Anabolic Steroids:
Acne/Testicular Atrophy/Liver Dyfn./Depression
IV contrast is contra-indicated in renal dysfn.
Contrast nephropathy can be prevented by prior administration of N-acetylcysteine
Dx of Sarcoidosis: Skin / Transbronchial Bx
[Kveim is obsolete, Ca/ACE levels unreliable]
Postop Sensory loss: EMG (Ix)
Physiotherapy has role in motor weakness only
Occupational Vitiligo: affects persons who work in rubber clothes, rubber gloves or
handle phenolic or antioxidant chemicals
Seborrheic Keratosis: Stuck-on appearance
100's of Seborrheic keratoses (Leser-Trelat sign)
search for internal malignancy
BZD in OLD patients: Oxazepam (hepatic excretion)
BZD in Liver Disease: Lorazepam (renal excretion)
Severe pain in OA is indication for joint replacement
Hyperpigmented lesions with velvety appearance on nape & axillae: Acanthosis
[associated with DM, obesity, Cushing's]
Nursemaid's elbow: Mx – supination of forearm with elbow flexed (No cast
Blackheads: open comedones
Whiteheads: closed comedones
Supraclavicular node: BIOPSY
Axillary node in female: Mammography -> Bx
3-10% of patients with spina bifida are hypersensitive to latex (also to foods like
banana, chestnut, avocado, kiwi): SPINA BIFIDA – LATEX ALLERGY
Osler Weber Rendu: epistaxis, GI bleed
(lesions on lips/nose/tongue/palatepalm/sole)
(chronic blood loss anemia)
Chronic plaque psoriasis: Scale Bx
Mx of autoimmune vitiligo: Steroids+Phototherapy
Time released oxycodone: can be abused by drug-seekers (snorting or injecting
crushed pill)
prevention of recurrent erythema multiforme minor:
Bullae / Papules on Hand with Naproxen intake:
r/o Porphyria cutanea tarda / pseudo-porphyria
(order urine porphyrin & hepatic panel)
Kyphosis with thoracic vertebrae wedging:
Scheurmann's Kyphosis
Tracheal deviation with impinging neck mass:
consult thoracic surgery for securing airway
Agitation in Delirium: d/o/c low dose Haloperidol
When giving i/v high-dose Haloperidol, add Benzotropine to prevent Parkinson's
Benzotropine is c.i. In Malignant Neurolept Syndrome
(anticholinergic, leads to worsening of hyperthermia)
If a child is to be given long-term salicylates, prior Influenza vaccination is
(to prevent Reye's syndrome)
Post-MI: chest pain (aggravated by supine posture, relieved by sitting and leaning
forward): Dressler's
Emergent Pericardial Drainage: V5 EKG guided
Postpartum psychosis: increased risk of infanticide
Pt. with A.Fib.:
require anticoagulation before cardioversion
(if anticoag. c.i.: TEE to r/o mural thrombus)
AIDS: primary CNS lymphoma
CSF EBV PCR estimation is highll sensitive & specific
If patient with altered sensorium has no DPAHC:
do not use relatives for consent
Post-SAH deterioration: mediated by vasospasm
(prevent by NIMODIPINE)
diffuse osteoporosis despite HRT / inc. infections
??? Myeloma
MVA with Quadriplegia with h/o recent Sx:
DVT prophylaxis required but anticoag. c.i.
(use IVC Filter)
absolute bedrest required only for 12 hours.
Patients can begin graded activity after 12 hours.
Submaximal EST @ discharge
Maximal EST @ 2-4 weeks
Sexual activity after 2-4 weeks
#1 complication of vascular Sx: MI
No Verapamil / Diltiazem in WPW gluteal. SVT
(sync. Cardioversion)
tPA use in stroke: monitor neuro. Q1h
(high risk of intracranial h'age)
suspected Conn's in 2º HTN: 1st step – CT abdo.
(not Renal Vein Renin Levels), CT yields more info.
Definitive Mx of Hepatorenal Synd.: Liver Transplant
Diverticulitis with Pneumaturia: Mx – Sx
(Colovesical Fistula)
<50y Diverticulitis: Sx after 1st episode
> 50y Diverticulitis: Sx after 3rd episode
UGIH: i/v Octreotide (Splanchnic vaso-constriction)
Malignant Otitis Externa: CT scan of temporal bone
(Mx: i/v antibiotics)
Rapid Rx of DKA: risk of cerebral edema
Radio. Dx of Pleural Effusion: X-Ray in decubitus view
Elderly with Bloody Diarrhea & patchy mucosal depigmentation (with other e/o
Ischemic colitis (Mx - Bowel Rest & Hydration)
Dural Venous Sinus Thrombosis (headache/seizure):
Ix: CT Mx: Anticoag.
Infants of GBS (+) mothers who received <2 doses of ampicillin: Take CBC/Bl.Culture &
observe for 48hrs.
Nephrolithiasis with Hydronephrosis with Urosepsis:
Percutaneous Nephrostomy Tube Insetion
(Antibiotics alone will not help)
Mx of Neonatal UTI:
i/v Ampi + Genta
Neonatal Adrenal H'ages (B/L):
sign of birth trauma (F/U with rpt. U/S in 1-2 weeks)
Urinary retention with Renal Dysfn.: Catheterize (Decompress tract)
Competent pregnant female may refuse diagnostic or surgical procedure that may be
therapeutic, even life-saving, for the fetus (Patient autonomy)
Previous abortion & OCP use are not risk factors for ectopic pregnancy
Breast engorgement: Continue breast feeding
(Use warm compresses) – antibiotics not needed
An intact pulse distal to injury DOES NOT R/O compartment syndrome
Ix – measure compartment pressure
Mx – fasciotomy
Lap Chole in Pregnancy: best results in 2nd trimester
discoloration of synovial fluid indicates infection
Acute onset of renal dysfn. - look at BUN/C
next step: estimate electrolytes
Children, with delayed passage of meconium, born to mothers who recv'd MgSO4
“bubbly” appearance on radiographs
(not synonymous with meconium ileus)
Ix & Mx: Water-soluble contrast
Biliary vomiting in infant: VOLVULUS until proved otherwise (Mx – Sx)
Muddy Brown Casts in urine: ATN
(Contrast nephropathy is a common cause, prevent by prior administration of Nacetylcysteine)
#1 Sensitive test for proper intubation:
End-tidal colume CO2 detection (colorimetric)
1st step after insertion of ETT (>7y):
inflate cuff, auscultate (or check end-tidal CO2)
Any anatomical defect in airway, get thoracic surgery consult before securing airway
Ix for Latent TB: PPD
Ix for Active TB: Sputum AFB Stain
RA+Splenomegaly = Felty's
severe disease, might require immunosuppressive agents like cyclophosphamide /
azathiprine for Rx
Patient on ventilator:
acidosis & hypercarbia: increase Tidal Volume
hypoxic respi.failure (ARDS, cardiogenic pulmonary edema): increase PEEP
Apiration penumonia:
Right Lower Lobe, foul smelling, anaerobic cover reqd.
Selective pulmonary vasodilator: NO (Nitric Oxide)
Evaluation of TMJ: MRI
Heliox: mixture of Helium + Oxygen
(used for oxygen delivery in severe bronchoconstriction, it has better laminar flow)
Cystic Fibrosis with pneumonia:
Aggressive chest physiotherapy to clear secretions
Steroid acne: papules & pustules
–steroid induced
–atypical site
–Mx: Tretinoin (no need to stop steroids)
–also with: anabolic steroids, Iodide, Bromides, Li
If unable to intubate after repeated attempts:
Surgical Airway Access (No Resusci. without airway)
Increased survival with ARDS:
ventilator setting of TV < 6cc/kg bdy weight
Alkali ingestion:
–UGI study with water soluble contrast
–if (-) can be repeated with Barium
–Early endoscopy (endoscopy in acute ingestion might cause perforation)
post-AAA repair, loss of sensation but intact proprioception: Anterior Spinal Artery
(posterior cord spared)
Catheter associated sepsis:
Remove catheter, start broad spectrum antibiotics
if still spiking fever (add fungal cover)
Post-heart transplant chest pain / dysnea / fever
? Mediastinitis (Mx: broad-spectrum antibiotics)
Post-thyroidectomy STRIDOR:
? Arterial bleed (call vascular surgeon, will open neck @ bedside – do ot attempt to
open neck yourself)
Post-thyroidectomy hoarseness of voice:
Recurrent Laryngeal Nerve injury
IJV line: associated with Carotid Bleed (if bleed occurs, and neck is tense, call vascular
Subclavian Line: associated with pneumothorax
Guide wire loss while inserting central line:
#1 complication – arrhythmia (call interventional cardiologist or radiologist for guide wire
post-GI Sx, ileus, LLQ mass, localized tenderness with some air under diaphragm
(Pelvic Abscess)
–some air under diaphragm post-op may be normal, does not necessarily indicate
perforated viscus
TURP syndrome: associated with hyonatremia
(aborption of irrigating fluid)
Alcohol withdrawl: Day 3
Fat Embolism: shortly after Long Bone #
DVT: risk increases with duration of immobilization
Nitroprusside : CN toxicity (Mx-Na thiocyanate)
Mx of MethHb: Methylene Blue
Rib #: shallow rapid respiration (due to chest pain): associated with higher incidence
of atelectasis
Patients receiving epidural narcotics should not receive I/V narcotics till epidural
narcotics have stopped
#1 cause of wound dehiscence: poor surgical closure
DPL may not reveal retroperitoneal processes
LGV: suppurative inuinal adenitis
(1º lesion: herpetiform vesicle or erosion on glans)
Chancroid: Painful punched out lesion
–Syphilitic chancre can appear after appearance of chancroid 'cuz the incubation period
of syphilis is longer than chancroid
–Mx: Ceftriaxone / Azithromycin
Granuloma inguinale:
–seprenginous ulceration of groin/genitalia/anus
–granulomatous tissue
–beefy red / bleeds easily
Acute suppurative parotitis:
–S aureus
–high mortality rate
–seen in post-op patients with poor oral hygiene
–fever with preauricular swelling
Fastest way to achieve androgen deprivation (for prostatic mets.) is B/L orchiectomy
(castrate level testosterone in 3 hours) – Leuprolide can take 30 days to achieve
castrate level testosterone
INR > 3.0, dysnea, no fever/leuko, increased Dlco:
Dx is Pulmonary Hemorrhage
AIDS with PML: start HAART (improves survival)
–no Rx for PML (caused by JC virus)
Post-LP: c/o postural headache
–Post-LP headache
–Mx: remain horizontal
Broca's aphasia: broken speech, comprehension intact
Wernicke's: “word salad”
1st episode of vasovagal syncope: reassure (get EKG)
recurrent vasovagal syncope: TILT TABLE TEST
Neuro. deficits in hypoglycemia: give I/V Dextrose
SAH: Early CT can be normal, if CT does not agree with clinical suspicion – do CSF
TIA: 1st step – auscultate carotid
If bruit (+): do Duplex U/S
If Stenosis > 70% - CEA
TCA overdose: admit to ICU
(high risk of arrhythmia)
Bell's palsy: Mx ?Conserv. / Acyclovir & Prednisone
Li levels > 4.0mEq/L – urgent hemodialysis
Bifrontal headache, OK when supine, worse on getting up : Intracranial Hypotension (?
Dural tear – exertion)
Meningitis with Papilledema: No LP
Pt. with A.Fib
on warfarin with increased INR with stroke:
CT Head : if non-h'agic – tPA
CT Head : h'agic – administer FFP & Vit.K
Acute arterial occlusion:
start i/v heparin + prepare for Sx embolectomy
Pt. in ED with asystole: Transcutaneous pacing
severe CAD & brady alternating with tachy:
Sick Sinus Syndrome
Pt. with uncontrolled HTN with chest pain & unequal blood pressure in R & L arm:
Acute Aortic Dissection (Dx: CT)
Mx - 1st step – lower systolic to < 100-120 mmHg
HbS disease with fever: ADMIT (high risk of sepsis)
CT can detect pericardial effusion, only ECHO can detect cardiac tamponade
Dx of IE: isolation of organism from 2 separate sites
FFP transfusion is also blood group matched
anemia, t'penia, fever, renal dysfn., neuro ab(n):
TTP (Mx: Plasmapheresis)
Sigmoid volvulus: forms an omega loop
can be reduced with sigmoidoscopy
Abdo exam: 1st step is AUSCULTATION
eavluation of any acute abdomen: check hernial sites
DM with hearing loss / pain / granulation in external auditory canal: Malignant
Otitis Externa
(Pseudomonas) Mx – I/V Antibiotics
Frontal sinusitis: can lead to a subperiosteal abscess (Pott's puffy tumor)
Adult PCKD: cysts are found in kidneys, aso in liver
PID with severe pain / guarding / mass:
TOA ? Ruptured
Child < 1 m with fever > 100F
send Blood / Stool / CSF to r/o Sepsis
Epiglottitis: Intubate (in OR by Anesthetist)
Avoid NSAID use in renal insufficiency
Acute Gout with PUD / recent Bleed:
Acute Gout with Renal Failure
(NSAIDs and Colchicine are both unsafe)
Intra-articular steroids
HZ Ophthalmicus: ORAL Acyclovir
Rx human bites with antibiotics
Rx rat bites with Penicillin (rat bite fever)
Pain remover: absorbed by skin, metabolized to CO in liver, can lead to CO poisoning
100% O2 vs Hyperbaric Oxygen therapy
Indications for Hyperbaric O2 therapy in
Carbon Monoxide poisoning
–CarboxyHb > 40%
–CarboxyHb > 25% with neuro. Symptoms
CarboxyHb > 15% in pregnancy (HbF has a high affinity for CO and fetal CO levels are
10-15% higher than maternal levels)
to detect small pneumothoarx: end-expiratory CXR
Radial Head #: heals faster with early mobilization
Clearing Cx Spine: X-Rays and Examination
Clearing involves response from patient. Therefore, a patient in altered sensorium with
suspected Cx spine injury can not have hi Cx spine cleared !!!
Antibiotics improve outcome in COPD flare
A Living Will with DNR orders needs to be verified by the hospital's legal / social work
Penile chordee: CONGENITAL, fibrosis of tunica albuginea – increased curvature of
Peyronie's disease: ACQUIRED, fibrosis of tunica albuginea – increased curvature &
palpable plaques
evaluation of rotator cuff injuries:
Diabetic Foot Ulcer: X-Ray to detect air
Mx: Debridement
DVT/PE: start i/v heparin & warfarin. Stop heparin 2 days after attaining therapeutic
Pemphigus: acantholysis, Nikolsky sign (+)
In patients @ high-risk for aspiration, apply cricoid pressure while intubating
Fall from height & landing on feet:
increased incidence of calcaneal & vertebral #'s
Mx of acute prostatitis: Fluoroquinolones / TMP-SMX
–no prostatic massage / no catheterization

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* Re:SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Docto
  marx - 04/05/06 16:44
  I love it man. I have been looking for Aster notes and found so many other in this collections. Who ever has taken time to do it and let us have it is really appreciable and wonderful person.
I have tried step3 once and dont have time... I am in psych residency. I hope these notes help me.
Thank you Doc.
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* Re:SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Docto
  docespy - 04/07/06 03:30
  LAZY? Its more like CRAZY to me, the sources are huge the summary is also very long, this is an excellent review, but its definitely not for lazy doctors.  
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* Re:SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Docto
  runika - 04/07/06 20:06
a big help
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* Re:SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Docto
  maskin - 04/08/06 07:23
  I just read these notes. Especially when commuting to work. These notes are a real high yeald summary for step 3. UW CCS cases combined with skans cocktail I think you really dont need any other books. I wish you all success in tests.
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* Re:SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Docto
  maskin - 03/24/06 06:05
  thanks a lot for this fantastic summary. I am going to make a copy of it and raed 10 pages evey day. yeh and the cocktails is heavy with VODKA in it.
any way god bless you.
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* Re:SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Docto
  maskin - 03/26/06 15:56
  Last part looks like aster notes but I am not sure which ones are Fishers notes. Are they included in it.
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* Re:SKAN'S-STEP3 COCKTAIL (For Lazy But Smart Docto
  sfq - 03/23/06 10:30
  I can't access the family practice questions at What is a good time to access these questions?  
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