done with step 3 - duloxetine

[ArchivalUser]

my score was high probably coz i knew uw too well !

i didnt take nbme (was tight on cash!!)

here is the synopsis of uw step 3, kaplan step 3 and some other ethics stuff

UWORLD SYNOPSIS FIRST: step 3 usmleworld.com
Cardiology
1. Decreasing LDL is more imp to prevent CAD than stopping smoking, DM control, HTN control or exercise. DM is the second most important.
2. Pt with CHF on amiodarone comes with desaturation and basal crackles- probably chronic interstitial pneumonitis, or organizing pneumonia due to amiodarone. It™s a cumulative dose effect, and not dependent on blood levels. Other adrs are liver, lungs, thyroid, BM toxicity and skin changes including Photosensitivity. Steroids can be used for severe pul disease.
3. Young patient with sec HTN, most common finding is abdominal bruit( 50%). Tachycardia if pheochromocytoma, but is less common.
4. In a patient with HTN, in absence of any known CAD, baby aspirin is useless.
5. All pts with stable angina should undergo stress EKG for risk stratification. High risk patients, ie those with failure to inc BP with exercise, inability to complete stage I of Bruce protocol,, or appearance of downsloping or horizontal ST segment during exercise >1mm, should undergo cor angiography, and thallium scan to see viable salvageable myocardium before PTCA or CABG.
6. Pt on warfarin is started on amiodarone- dec the warfarin dose by 25%
7. In a pt with h/o angioedema with ACEI, ARB are not the choice drugs- B blockers are, because ARB still have low risk of causing angioedema. Especially if the pt has no compelling indication to use ACEI, like Diabetic Nephropathy.
8. Stress Echo is always more sensitive than stress ECG, and can show wall motion abnormalities, but stress ECG is still the first choice for risk stratification in pts with stable angina. In patients who cannot exercise, eg due to OA, use dopamine stress EKG or Echo. Probably can use adenosine and dipyridamole stress EKG/Echo too.
9. Adenosine thallium/sestamibi scan, Dipyridamole thallium perfusion/viability scan both are c/I if the pt has COPD or asthma. These are used to see hypoperfused myocardium during stress.
10. Pharmacological stress testing (and probably radionuclide scan) are done in those who cant exercise eg due to OA or MI or unstable angina, and in those with abnormal baseline ECGs like LBBB, LVH, baseline ST changes, WPW, externally paced heart, etc.
11. Aortic sclerosis and ESM are normal finding in old patients.
12. Pt with CHF is given ACEI even in asymptomatic stage, ie if Echo shows low EF; B blockers and diuretics are added only if symptomatic. Isosorbide Dinitrate if evidence of pul edema. Low sodium diet and diuretics if pt has some fluid retention.
13. Orthostatic hypotension means fall of 20 mm in systolic and 10 mm in diastolic
14. Verapamil, quinidine, amiodarone and spironolactone can cause digoxin toxicity, so for eg a pt on digoxin comes with nausea, vomiting, confusion after starting verapamil.
15. In a pt with high LDL and TG, the first step is always targeting LDL with statin, then add fibrates if statin doesn™t decrease the TG. Cholestyramine can increase TG so is contraindicated.
16. Post CABG angina, with permanent ECG changes- do radionuclide perfusion imaging and not stress EKG or even stress Echo, as we cant interpret the Echo with previous wall motion abnormality due to previous MI or ischemic cardiomyopathy.
17. Inc fibrinogen >2.7 7 puts patient at high risk of MI; and lovastatin and atorva both increase fibrinogen. So if the patient has elevated levels of fibrinogen, change to either prava or simvastatin, as they have no effect on fibrinogen.
18. Wt loss is the single most imp measure to dec BP, more than stopping smoking, or dec salt or alcohol consumption or exercise
19. Preop cardiovascular risk assessment; age above 70 yrs 5 points, MI6 mo 5 points; angina on walking 1-2 blocks 10 points, angina at rest 20 points, and critical aortic stenosis 20 points
20. Drug lupus with hydralazine, mdopa, CPZ, IFN a, diltiazem, minocycline, penicillamine, procainamide, INH- starts with flu like symptoms, fever, malaise, arthralgia and facial rash.
21. Asymptomatic hypoNa in CHF patients- water restriction is the TOC, even if NA 1mm in 2 contiguous leads, after nitroglycerine is given to rule out coronary spasm. Also in pts with new LBBB. No benefit in NSTEMI. C/I with BP>180, recent surgery or ischemic stroke. ST depression occurs with ischemia, strain, digitalis, hypokalemia and hypomagnesemia, so is not an indication, unless it is due to posterior MI.
40. Poor R wave progression- if the R remains same through V1 to V4. Seen in COPD, RVH, LVH, ant infarction, blocks and cardiomyopathy.
41. Prolonged QT means more than half of RR, seen in antiarrythmic drugs, TCA, hypokalemia, seizure and stroke.
42. Metformin should be stopped before coronary angio or other dye related procedures that can harm kidney and cause lactic acidosis. Also in renal or hepatic failure, CCf, sepsis and alcoholics.
43. Aspirin should be stopped 7 d before most procedures, but needn™t be stopped for coronary angio or cath.
44. TCA overdose is treated with sod bicarb. Lidocaine is the DOC for any vent arythmia that occurs. Procainamide, disopyramide and quinidine are membrane stabilizer, hence increase TCA toxicity re. Also ppnl is contraindicated, as it dec conduction and inc arythmogenic potential of TCA re.
45. Pt can resume sexual activity 6 weeks after uncomplicated MI- ie if he recovers without any post MI chest pain, CCF or arythmia.
46. Severe symptomatic AS (area 10.
3. Immobility is a common cause of hypercalcemia, esp in adolescent and those with paget™s disease, who have high bone turnover, due to uncoupling of bone turnover, ie more resorption and less formation. Subsequent hypercalcemia will suppress PTH, and low PTH in turn suppresses D3 levels. Biphosphonates can be used in these patients to prevent this.
4. For every 1 g/dl decrease below 4 of serum albumin, add 0.8 mg to the total calcium level.
5. Paraproteinemia can increase the bound calcium, hence the total calcium in the serum.
6. Hypoglycemia with high C peptide can be both due to insulinoma and sulfonylurea overdose. History and context is imp. To differentiate, measure serum proinsulin levels. Also checking for sulfonylurea level in urine and plasma can be helpful.
7. Autoimmune hypoglycemia due to insulin antibodies which bind to insulin receptors, or release excess insulin into circulation
8. Diabetic for planned CS section- don™t stop regular dose of insulin night before, to prevent ketoacidosis, even if she is npo. Then start insulin infusion during the surgery, with D5,1/2NS and KCL. Insulin requirement will drop following delivery of the placenta. Switch to scheduled sc dosage as soon as the patient starts tolerating food.
9. DKA management- continue NS and insulin till blood glucose is 250, then change to DNS with KCL, and decrease the insulin infusion dose. Dextrose infusion is very imp to decrease ketone levels. Start KCL regardless of serum level. Switch to oral feed and sc insulin only after the anion gap has corrected, HCO3>10m and precipitating factor like infection is corrected. But always start sc insulin 1 hr before discontinuing iv insulin, as sc insulin needs time to act, so otherwise it might precipitate DKA again if we don™t overlap the insulin.
10. Pt with hyperthyroidism with chief complaints of palpitation- treatment is ppnl and not PTU
11. Preop patient for emergency surgery like CABG for unstable angina is found to have hypothyroidism- its not a contraindication for surgery, tho there is higher risk of ileus, hyponatremia and oversedation with narcotic. Only after the surgery, start with low dose T4 as the patient has CAD.
12. DM pt on metformin develops anion gap acidosis, and there is no leukocytosis or hyperamylasemia- implies its probably lactic acidosis and not DKA- so do ABG and blood lactate level, instead of ketone level and urinalysis, or instead of starting DKA treatment.
13. In patients with thyroid cancer in remission, T4 supplementation should be used to suppress TSH below normal range (ie between 0.1-0.3). If distant mets, even lower, to undetectable levels, tho that increases the risk of AF and bone loss. T3 is only used short term and never used for long term management of hypothyroidism. Hormone supplement should be taken on empty stomach.
14. Mental state change in elderly- always do TFT for diagnosing apathetic hyperthyroidism.
15. A pt on prednisone for RA develops infection and then hypotension- acute adrenal insufficiency. Administer fluid and dexamet, as it is long acting and doesn™t interfere with measurement of serum cortisols. Then do cosyntropin test. Mineralocorticoids aren™t used, because, one- they are not deficient, two- they take a longer time then just simply infusing saline.
16. Amiodarone- monitor patient™s TFT 6mthly; if it causes hypothyroid, no need to stop amiodarone. Just give larger dose of T4, as amiodarone prevents peripheral conversion of T4 into T3. But check TSH first. If hyperthyroid, it can be either due to induction of Graves disease, which is treated with PTU or methimazole, or it is due to induction of destructive thryoiditis, in which case the treatment is steroids.
17. Female on HRT for hot flashes develops DVT- should stop HRT, then give warfarin for 3 mo as this DVT has a precipitating cause and is the first episode. DVT without precipitating cause, or subsequent episode should get warfarin for 6 months. Increasing anticoagulation for continuing HRT is not justified, neither does tamoxifen help with postmenopausal symptoms.
18. Urinary metanephrines and catecholamines are better test then VMA for pheochromocytoma. Alpha blockade should be started only after the test, as it can falsely increase the level of the CA. Only after biochemical confirmation we do CT/MRI to confirm location. Both have equal sensitivity, but MRI is useful for extraadrenal foci, and also to differentiate benign from malignant ones. MIBG scan can be used if either of the above three tests are equivocal and we still suspect pheo, or one test shows pheo but the other doesn™t. Treatment is with alpha blockade, only then start beta blockade. Long acting phenoxybenzamine is used before surgery, along with liberal salt and fluid intake to increase the intravascular volume. The common complication after surgery is hypotension- use normal saline bolus and infusion. Dopamine doesn™t help as the alpha blockade will blunt the response to vasoconstrictors.
19. Pt with Hashimoto develops rapidly enlarging thyroid and SVCO- probably thyroid lymphoma. Treatment is RT.
20. Long acting sulfonylurea induced hypoglycemia- treat with D50 bolus, then D5 infusion is required to prevent rebound hypo due to the D50 induced insulin release. If refractory to this treatment, start octreotide sc. Somatostatin is iv and is short lived so not used. Giving D10 or D50 infusion for long time is not recommended as they can cause thrombophlebitis. Glucagon is also not recommended as it is short acting, plus increases insulin release causing reboud hypo. Glucagon is hence only used in acute mgmt of hypo with mental obtundation, and the patient is given readily absorbed carbo after gaining consciousness.
21. Pt on amiodarone can have inc T4 and low T3 due to decrease in conversion from T4 to T3. Ppnl also does that, but not atenolol. Aspirin displaces T4 from albumin, so don™t use it as an antipyretic in the treatment of thryotoxic storm.
22. AF due to Grave disease is treated like any other AF- with b blockers and anticoagulation. So antithyroid drug or RI ablation is not the answer.
23. Effect of tight glycemic control on microvascular complications is proved, but not macrovascular. It reduces the incidence of neuropathy, but there are conflicting evidence for reversing previous neuropathy.
24. Fahr syndrome: pseudohypoparathyroidism, with Albright hereditary osteodystrophy (short stature, round facies, short metacarpals and short neck); they have hypocalcemia with hyperphosphatemia, latter causing basal ganglia calcification and cataract. Their PTH is also elevated. Patients with hypopara will have low ca, high phosphorus and also low PTH. Vit D deficiency causes low ca and phosphorus both, and inc PTH. Acute hyperphosphatemia like with rhabdomyolysis, seizures, ARF can cause decrease in calcium, but no basal ganglia calcification and cataract like in chronic hyperphosphatemia.
25. Hypercalcemia due to sarcoidosis- , due to 1a hydroxylase enzyme, vit D increases, PTH is suppressed, hence urinary calcium is increased. Treatment is glucocorticoid and not pamidronate.
26. Exercise increases non insulin mediated glucose uptake by muscles, so can cause hypoglycemia in a patient on insulin. Avoid insulin injection to the exercising limb, and lower the dose of insulin.
27. Medullary Ca thyroid, post surgery rise in calcitonin level indicates residual metastatic disease- first step is HRCT of neck and chest with HRUSG of neck, with surgical resection if possible. If these don™t show any lesion, HRCT abdomen and bone scan, or iodine 111-octreotide scan and PET may be required. Total body iodine scan is for follicular and not medullary cancer, as the parafollicular cells don™t take iodine. Thallium scintiscan is also nonspecific.
28. Don™t take thyroxin with calcium or iron over the counter supplements.
29. Pt with amenorrhea, low FSH and LH with high alpha subunit, high prolactin and a pituitary mass- probably has gonadotroph adenoma, with lack of functioning beta subunit. Increase in prolactin is probably due to compression effect. Treatment is surgery as bromocriptine works only with GH or prolactin secreting tumor. RT is never the first choice due to delayed risk of hypopituitarism. Octreotide is also not much effective.
30. Pituitary incidentaloma with no symptoms shouldn™t be treated, only followed up with regular MRI.
31. To diagnose spurious hyperthryroidism due to external intake and to differentiate it from primary thyrotoxicosis, do the thyroglobulin level. It is decreased in external thyrotoxicosis. RAIU study doesn™t help, as the intake is decreased also in different thyroiditis, iodine or amiodarone induced thyrotoxicosis.
32. Subclinical hypothyroidism- treat if TPO AB present, as they have high rate of conversion to overt hypothyroidism. Also treat if symptomatic subclinical (ie inc TSH but normal T4).
33. HTN with hypokalemia- do aldosterone to renin ratio to differentiate hypo and hyperreninemic hyperaldosteronism. In Conn™s syndrome, the ratio is >30, with high aldosterone level also needed for diagnosis, as essential HTN can also suppress renin. Patients present with polyuria and polydipsia due to hypokalemia induced DI. If hyperreninemic, then do MR angio of renal arteries, with fibromuscular dysplasia giving a beaded appearance, and is the most common cause of RAS in young patients. Suppression of both renin and aldosterone in a pt with hypokal and HTN is probably due to apparent mineralocorticoid excess (AME), so obtain a serum cortisol level.
34. Pt with DM, NASH due to hyperTG, and obesity- TOC is metformin, as it causes wt loss,, and helpful in hyper TG and NASH. Glitazones are contraindicated as they cause wt gain, partly due to fluid retention, as well as they are hepatotoxic.
35. Subacute thyroiditis- thyrotoxicosis with painful thyroid enlargement. Tt is NSAID and beta blocker, and steroid rarely if severe. Since preformed thyroid hormones are the cause of the problem, antithyroid drugs and RI are not effective. Its not difficult to differentiate from bacterial suppurative thryoiditis, as in the latter case, people aren™t usually thyrotoxic as it involves the center of the gland, as well as USG will show multiple abscesses.
36. Hyperthyroidism in pregnancy- PTU is the TOC, as methimazole is teratogenic. If PTU doesn™t work, or cause neutropenia, surgery is indicated, else she can have thyroid storm during the stress of childbirth.
37. Asymptomatic thyroid nodules: first step is to, do TSH- if normal, and if 1cm need FNAC. If TSH is decreased, then RAIU study- if hot nodule, only observation. If symptomatic, then antithyroid drugs.. RAIU is seldom used in management of thyroid nodule, as most of cold nodules are benign, though most of malignant nodules are also cold. Since most of the nodules are benign, all nodules don™t need surgery, only FNAC is enough. Still, if we have done RAIU, then all cold nodules must be biopsied. IF the nodule is toxic or if there is carcinoma on FNAC, then the patient needs surgery.
38. CT of neck is less sensitive than USG for nodular thyroid diseases.
39. If pt has papillary cancer on FNAC, then he needs NTT- near total thyroidectomy, and then RI ablation therapy for residual tissue and mets, then RAIU study to see for remaining mets, then lifelong Thyroxine to suppress TSH. Also thyroglobulin can be followed up as a tumor marker. TSH should be suppressed below the normal range, tho this can risk AF and bone loss. Doing only subtotal thyroidectomy is ineffective, as it is difficult to ablate the remaining gland with RI, and we cant also use thyroglobulin as a marker when lot of thyroid tissue is still left in the body.
40. If medullary cancer, first test for RET to see for MENII syndrome, or do urine metanephrine/CA or abdominal CT to diagnose any concomitant pheochromo. Then start the pt on alpha blockade for a few weeks before surgery then beta blockade only after alpha blockade (else there will be vasomotor crisis), then do surgery- total thyroidectomy with central neck dissection.
41. DM with autonomic dysfunction, gastroparesis- its difficult to adjust insulin because due to delayed gastric emptying, pt will be hypoglycemic just after meal. Plus problems of postprandial bloating and constipation. Treatment is metoclopramide, or cisapride or erythromycin, and small frequent, low fat meals. Cisapride is especially shown to be beneficial, tho it is not freely available due to incidence of QT prolongation and Torsades. Last resort is feeding jejunostomy. Metoclopramide cant be used for long due to side effects and tachyphylaxis, so cisapride is the TOC re. High fiber diet will increase the constipation.
42. Octreotide can be given in intractable diarrhea in DM gastroparesis patient.
43. DM neuropathy- amitryptiline is the DOC, but since most patients have heart disease also, beware- use gabapentin instead.
44. Erectile dysfunction with normal morning erection- its psychological impotence. Erectile dysfunction is never a normal part of aging, so don™t tick that.
45. Pt of hypoparathyroidism- Tt is high dose of vit D( calciferol) and calcium; high dose because conversion to calcipotriol is defective. We don™t use calcipotriol as it is expensive. Calcipotriol has a rapid OOA, and can be used in hypercalcemic crisis, or if pt is refractory to calciferol. Pts thus treated with vit D and Ca for hypoPTH usually develop high urinary excretion of Ca, due to lack of PTH, which can lead to nephrocalcinosis. So adding THIAZIDE not only helps reduce urinary calcium, but also increases the serum calcium effectively.
46. Hypercalcemia with high PTH- can be either primary hyperPTH, lithium toxicity or familial hypocalciuric hypocalcemia. If hyperPTH, surgery is indicated if Bone mineral density is less than 2.5 SD (ie T score below -2.5), overt bone disease or fracture, kidney stone, reduced creatinine clearance, Ca level more than normal by 1, urinary calcium >400 mg/d, or if young than 50 years. For eg a postmenopausal woman with T score of -3 comes with hypercalcemia and high PTH, then she probably needs surgery. Alendronate is not as effective as surgery in preserving the BMD.
47. Those with hyperPTH who don™t need surgery are managed with periodic msmt of ca, Cr, and BMD. Pt can continue their vit D and Ca supplement, as research hasn™t shown any aggravation on calcium level with those.
48. Acromegaly: COD is cardiac- LV dysfunction, asymmetric septal hypertrophy, CAD, HTN and myocardial fibrosis; these changes may be reversible with treatment. Also increased risk of colon cancer.
49. Offspring of mother with DM I has 3% risk, if father then 6% risk of having DM I.
50. A patient with unknown goiter undergoes cardiac cath, then develops thyrotoxicosis- its iodine induced thyrotoxicosis. Treatment is b blocker, or Antithyroid drugs or KCLO4, but RAIU doesn™t help, as the iodine uptake is reduced in the gland.
51. Pt with inc TSH following say, pneumonia, with normal T4 but dec T3, its not subclinical hypothyroidism, its EUTHYROID SICK SYNDROME (low T3 syndrome). Just followup with TFT in a few weeks. No treatment needed, and no investigations for antibodies too.
52. T score in DEXA is calculated in comparison to healthy adult of age 25, while Z score is calculated in comparison with similar aged adults. WHO classifies T between -1 to -2.5 as osteopenia, and below that as osteoporosis. In a pt with osteoporosis, do CBC/Ca and PO4 levels for secondary causes; can do urinary calcium, SPEP, PTH, TSH, N telopeptide for bone resorption and AlP for bone formation. Pts with T score< -2, with low wt, smoking patient, or with fragility factures irrespective of T score, need antiresorptive therapy with alendronate or risedronate, in addition to vit D and Ca. Etidronate is old and not used, Pamidronate iv is used if pt cannot tolerate oral alendronate due to esophagitis. Calcitonin is not very effective, teriparatide (PTH) is very effective but needs daily injection and is expensive. HRT has fallen out of favor since 2002 due to report of inc MI, DVT, Stroke, and breast cancer. Pt who doesn™t respond with biphosphonates, has constitutional symptoms and pallor should be strongly suspected to have myeloma. Myeloma cells release OAF( osteoclast activating factor).
53. Medical therapy is the TOC in prolactinoma even if large and has effect on vision.
54. Pt with Addison™s disease develops diabetes I- its autoimmune polyglandular failure type II (Schmidt™s syndrome), which also has Graves, pernicious anemia, premature ovarian failure, vitiligo and celiac disease.
55. Postpartum patient on heparin for DVT comes with osteoporosis “ discontinuing breastfeeding can help re, increasing dose of vit D and Ca isnot as much helpful.
56. Old male comes with hip pain- XR shows thick outer cortex with sclerosis, and Tm scan shows increased uptake- its Paget™s disease. Biphosphonates are indicated if intolerable pain, involve wt bearing bones, hypercalcemia, or CCF. Calcitonin and steroids are not useful.

HAEM/ONC
1. Pt of NHL comes with epidural spinal cord compression( radicular pain)- give high dose steroid, obtain an MRI to confirm diagnosis, then start RT. If only back pain due to vertebral mets, only RT. If saddle anesthesia or bowel bladder involvement, immediate decompressive surgery.
2. Patient comes with metastatic ER/PR + cancer with occult primary in breast- no need for multiple core biopsy of breast or RM- only do chemo and hormonal therapy. Tamoxifen is preferred, with fulvestrant in those not responding to tamoxifen. Trastuzumab (HERceptin) in Her + ones.
3. Pt with AML gets multiple platelet transfusion, still the platelet count doesn™t increase- its called platelet refractoriness, due to alloimmunisation (formation of anti-platelet antibodies). If initial increase in platelet and then decrease within 24 hrs, think DIC or sepsis or active bleeding or antiplatelet drugs.
4. Pt with lung tumor with FEV1 and contribution of each lung given- the best next thing to do is still to do CT staging. PET/ bone scan can be used too. CT is best as it gives mediastinal and chest wall invasion, mets to adrenal and liver, and can also help in CT guided biopsy.
5. SVCO: dyspnea, persistent cough, hoarseness, dysphagia, syncope, chest and neck pain, cyanosis, collateral veins in thorax, ocular proptosis, lingual edema- best thing is CT with contrast. MRI only if dye cant be used.
6. If imatinib is not in the choices, then BMT is the TOC for CML, aka HCT( hematopoietic cell transplantation.) IFNa will lead to cytogenetic and not molecular remission. CPS is used to prepare for BMT to prevent GVHD.
7. HIT usually presents as thrombosis- very tricky- type I is less severe and occurs early, type II more severe and occurs after 4-10 days, due to heparin-platelet factor 4 complex antibody, decreases platelet upto 30,000, can lead to limb gangrene, mesenteric ischemia, cerebral sinus thrombosis. Prevention of HIT is by using LMWH or danaparoid, or using heparin for less than 5 days; while treatment is using DTI like lepirudin or argatroban. LMWH are not the treatment of HIT, as they can also rarely cross react with the antibodies and increase the problem.
8. Prostate cancer post treatment- f/u with PSA. If rising PSA or if skeletal complaints, do bone scan.
9. Pts on tamoxifen should be screened for endometrial hyperplasia with annual Pap and detailed history. TVS has a lot of false +ve leading to unnecessary endom biopsy, so not recommended.
10. Plt transfusion are useless in ITP, as they will also be rapidly destroyed. Only use in life threatening emergencies as intracerebral and massive GI hemorrhage. Steroid are the TOC in most cases, with IVIG in severe cases ( IVIG is not the first answer). Plasmapheresis is for HUS and TTP.
11. Alcohol and colon cancer are strongly linked than remote smoking history, so beware if the pt is smoking currently. NSAID and hormone replacement are protective. Alcohol probably causes the risk by interfering with folate absorption.
12. Among inherited thrombophilia, factor V leiden is the most common, don™t tick antiphospholipid syndrome, that is not inherited. Methyl tetrahydrofolate reductase gene mutation is related to homocystinemia, and is another risk factor. Any patient with inherited thrombophilia and spontaneous thrombosis should be on lifelong warfarin. Also those with life threatening VTE like massive PE, or unusual site like mesenteric or cerebral venous thrombosis should also be on lifelong warfarin.
13. Primary vs secondary polycythemia- WBC and platelet count will also increase in the former. If secondary cause is suspected, eg in a pt with COPD, first test is pulse oximetry after minimal exertion, and sleep study to determine nocturnal desaturation.
14. Pt with RA has pneumonia and found to have anemia- ferritin is high ( can be due to both infection or due to ACD), transferring and TIBC are low (can be due to both IDA and ACD). In these patients, do BM biopsy to differentiate ACD and IDA.
15. Pts requiring frequent transfusion might develop antibodies to RH, Kelly and other antigens, causing acute transfusion reaction. Rx is hydration, stopping transfusion. Dopamine and osmotic diuresis can be used.
16. Of all the features of Pancoast syndrome, chest movement asymmetry with asymmetric lower leg DTR is the most dangerous, as it signifies phrenic nv involvement with possible iv foramina invasion and imminent cord compression.
17. Pt of CRF comes with esophagitis and massive bleeding- Desmopressin is the TOC as it releases VIII/VWF from the endothelium, after that dialysis. Cryoppt can be used but associated with infections. Estrogen can be used too.
18. Pt with prostate cancer comes with back pain due to mets- TOC is hormonal therapy- LHRH analogue with flutamide to counter the initial flare, if back pain is unresponsive to this, then EBRT followed by chemotherapy. Radionuclide bone scan is the most effective diagnostic modality. DES reduces LHRH release from the hypothalamus too, but increases MI, PE and stroke.
19. SCC skin- surgery first line, RT if pt refuses surgery, and 5FU is the third line treatment.
20. Pancoast: RT with surgical resection is the TOC, but if there is evidence of distant mets, or brachial plexus involvement, or positive bone scan, then RT alone.
21. AIDS with PCNSL- best therapy is HAART itself, tho RT and corticosteroid help, they don™t increase life expectancy. The most important prognostic factor is the increase in CD4 count.
22. CholangioCa, even if Klatskin- if with mets, is inoperable, so the treatment is ERCP and stenting for the pruritus and jaundice. PTC only if ERCP fails. Ursodeoxycholic acid doesn™t help as it doesn™t relieve the obstruction.
23. Pt comes with diarrhea, sclerotic bone lesions, eosinophilia and peptic ulcer- Systemic mastocytosis.
24. Lobular CIS of breast- it is multicentric and bilateral, so the best treatment is close observation, annual mammogram and tamoxifen which has shown dec risk of progression to overt carcinoma. Surgery, If at all, has to be bilateral prophylactic mastectomy. Local excision is useless.
25. Pt with ACD- low iron, high ferritin, normal or low transferring and transferrin saturation. BM is diagnostic, and shows normal or increased iron in macrophages, and decreased no of sideroblasts. Do EPO level, if it is low, EPO is the treatment. If EPO is already high, then periodic blood transfusion is the treatment. Plus treatment of the underlying disease with close f/u might be the right answer.
26. Pt with ESRD and ACD, doesn™t respond to EPO- first thing is to do iron study to rule out iron deficiency. Then see for folate deficiency, systemic inflammation and Al toxicity. Avoid BT in them, as that can risk causing allogenic graft rejection after kidney transplant.
27. Advanced gallbladder Ca with neuropathic pain in right thigh- for sharp pain, DOC is carbamazepine, second line being valproate or gabapentin. For dull pain, desipramine is the DOC. Not narcotics.
28. Pt treated for SCLC comes with features of acoustic neuroma, its probably not neuroma but mets. Contrast MRI showing the multiple well circumscribed mass with local edema is the investigation of choice.
29. A pt with normocytic anemia- first thing to do is retic count- if high, its hemolysis, if low its hypoproliferative Electrophoresis and Coombs for earlier, BM for the latter.
30. Myaesthenic syndrome means Lambert Eaton- treatment is plasmapheresis and immunosuppressive therapy. Electrophysiological studies confirm incremental response with repetitive stimulation. DTR are lost unlike in myasthenia gravis or polymyositis re.
31. Breast cancer metastasis to brain- stereotactic surgery if single, EBRT if multiple. Chemo don™t penetrate, steroid help, and prophylactic anticonvulsant are not indicated.
32. Sickling crisis- during mens, alcohol, nocturnal hypoxemia- mainstay of treatment is hydration. Morphine or iv ketorolac for pain.
33. Sickling crisis with splenomegaly- beware of splenic sequestration- dramatic fall in hemoglobin causing hypovolemic shock. So CBC should be monitored in these pts. CXR, blood and urine culture are followed by iv antibiotics esp if the pt wasn™t on prophylactic penicillin. Avoid contact sports.

GASTRO
1. If polyps are found in sigmoidoscopy, next thing to do is colonoscopy to see for synchronous lesions and remove them. Double contrast enema is inferior, plus doesn™t allow intervention also.
2. TPN: average need is 30Kcal/d and protein 1g.kg.d, but in malnourished or critically ill patients, its 35-40 and 1.5 respectively. Overfeeding leads to hyperglycemia, hyperinsulinemia, inc TNF. PEG (percut gastrostomy) should be considered if pts need TPN for a long time.
3. LGIB: urgent colonoscopy is the procedure of choice due to diagnostic and therapeutic advantage. IF there is poor visualization due to bleeding, then do Tm tagged RBC scan, which is better than angio to localize the site. Vasopressin is inferior as bleeding recurs after stopping, and it can cause ischemic damage to organs and arythmia. Octreotide works only in variceal bleeding. Urgent colectomy might be needed, but only after localization of the site of bleeding.
4. Chronic pancreatitis: low fat diet is the most effective method to stop steatorrhea, while enzyme supplement is inferior.
5. Mallory Weiss tear that has stopped bleeding needs no intervention. Hiatal hernia is a very frequent predisposing factor for the tear, and can occur during blunt abd trauma, CPR and endoscopy too.
6. Mesentric angina- duplex USG is the screening test done first, as it has a high negative predictive value. Angiography is the gold standard, but is done only after duplex.
7. Mild pancreatitis- manage with pain control and iv fluid, npo, ng aspiration to prevent further pancreatic stimulation. Hypoechoic mass in pancreas doesn™t mean abscess unless there are systemic signs. Antibiotics have been shown to be useful prophylactically only in severe pancreatitis (Ranson criteria), or necrotizing pancreatitis or large peripancreatic fluid collection. Imipenem or cefuroxime penetrate pancreas well. No indication of daily CT scan or CT aspiration unless features suggestive of infected necrosis. Surgical debridement if severe necrosis, biliary pancreatitis, lack of response to therapy or complications. ERCP if concurrent dilatation of biliary system or elevated LFT.
8. If the patient with pancreatitis develops fever, then take blood culture and start imipenem, piperacillin, quinolones. IF pt fails to improve after 1 week of antibiotic therapy, a CT guided aspiration of the tissue for C/s is done.
9. Acute HepB needs only supportive treatment, as most resolve on their own. Only chronic active hepatitis needs lamivudine and adefovir. Conversion to chronic stage depends on age- 90% if perinatal, 20-50% if below 5 and 7, ie class B or C in child pugh classification. Class A is

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Interestingly, if PT remains normal during the acute infection, then the infection will likely resolve with no sequelae.
10. Isolated gastric varices without esophageal varices in a pt with chronic pancreatitis is due to splenic venous thrombosis. It may also present with noncirrhotic portal HTN, ascites, massive splenomegaly and hypersplenism. Portal vein thrombosis is similar, but will have esophageal varices also.
11. Hepatic venocclusive disease is due to occlusion of terminal hepatic venules and causes postsinusoidal portal HTN, with hypatomegaly, jaundice and ascites. This is similar to Budd Chiari, but in the latter there is thrombosis of major hepatic veins.
12. Pseudomembranous enterocolitis suspect: rapid immunoassay for C difficile toxin is very popular, but its sensitivity is low, so that if one is negative, repeat it if the pretest probability of infection is high. Stool cytotoxin test and stool culture are outdated. Culture is useless also because many nontoxigenic strains of C Difficile exist. Tt is metro. IF relapse, again metro, coz relapse is due to inadequate treatment more than resistance. Vanco if more than one relapse.
13. Febrile transfusion reaction can be prevented by washing the cells, using leukocyte depletion filter, and preferring packed RBC to whole blood.
14. First test in chronic diarrhea is stool examination for leucocytes, parasites, blood, fat, ph, osmotic gap.
15. Duodenal endoscopic biopsy is needed for diagnosing celiac disease, showing villus blunting and increased lymphocytic infiltrate in the mucosa. Avoid wheat, rye and barley. Can take soyabean, rice and corn and potatoes. Plus might need to supplement iron, folate and calcium.
16. Chronic constipation- bulk laxative like psyllium, methylcellulose and dietary fiber is the mainstay of treatment. Magnesia is c/I in CRF, castor oil and bisacodyl are laxatives and cause electrolyte imbalance. Docusate is a softner but not used long term.
17. Triple therapy for H pylori failed- give quadruple therapy. Best way to see eradication is urea breath test or fecal antigen test 4-6 wks after therapy. Fecal antigen test is best. Early testing might produce false negative, as Helicobacter can transform into urease negative coccoid form. Serology is uselss coz it doesn™t differentiate past and present infection. Endoscopic biopsy is not warranted to document care.
18. Complete resection of a 2cm sessile, or if poorly differentiated, f/u colonoscopy in 4-6 mon.
19. Scleroderma- atrophy of muscle layer with fibrosis on HPE, dec peristalsis wave and dec LES tone. Achalasia: dec peristalsis but inc tone, and hypertrophied muscle in HPE. Diffuse spasm: inc peristalsis and inc tone.
20. Kava can cause hepatitis and cirrhosis. Gingko can cause platelet dysfunction. Ginseng can cause SJ syndrome and psychosis.
21. Pt of celiac disease not improving with gluten free diet must be suspected to have intestinal T cell lymphoma. It can be nodular or ulcerative, leading to perforation peritonitis. Pain, wt loss, diarrhea are typical, with malabsorption and anemia. Tt is surgery and chemo, but prognosis is poor.
22. Post chole: no change in diet is needed, not even low fat diet. Giving CCK is useless, as it is already produced by duodenal mucosa.
23. ALS pts need PEG gastrostomy, and not TPN, as it is irreversible. It is better than NGT as it doesn™t interfere with breathing and speech, and it doesn™t cause sinusitis; tho risk of aspiration is the same with both.
24. Protease inhibitors can be used to prevent ERCP induced pancreatitis.
25. Child Pugh criteria:
i. Albumin- 3.5- score 1, 2 or 3 accordingly
ii. Bilirubin- 3
iii. Ascites- None mild and moderate
iv. Delayed PT- 17 sec
v. Encephalopathy, none, stage 1-2, or stage 3-4
b. Liver transplant if score is >7, ie class B or C in child pugh classification. Class A is

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SURGERY
1. A pt involved in MVA couldn™t be extricated from the car, is unconscious and he started coughing up blood- first thing to do is secure the airway without spinal manipulation by jaw lift manuver. Only then suction and stabilisation of neck. Intubation is not needed as the patient has spontaneous respiration.
2. Thompson test in Achilees tendon rupture: no foot plantarflexion on calf muscle compression.
3. Cholangitis: ampigenta or monotherapy with imipenem or levofloxacin. If not responsive, do decompression with ERCP.
4. MVA pt after intubation doesn™t have satisfactory oxygen saturation, and on examination has hypoventilation on one side of the chest. The first diagnosis should be bronchus intubation. So try to check the ETT placement, and withdraw it a few cm. If that doesn™t help the oxygen saturation, then think about pneumothorax, and do a needle decompression.
5. Pt with acute colonic ischemia are not due to embolism like mesentric ischemia, but due to hypotensive state. IT presents with lateralised abdominal pain (periumbilical pain in mesentric ischemia), and with hematochezia.
6. Pt who die due to lightning strike usually have asystole, so if they don™t respond to CPR, then epinephrine should be tried, atropine comes next. Defibrillation will not help in asystole patients.
7. All animal bites should be thoroughly cleaned with NS, debrided, Xred to see the presence of foreign body or bone involvement, and shouldn™t be primarily closed (except if dog bite on face, due to its vascularity infection and nonhealing is not common in the face). Also puncture wound, cat and human bites shouldn™t be closed primarily.
8. Only TT if contaminated would and 10 yrs since vaccination, no TT if clean wound and 10yrs since last dose, or if vaccination history is not known.
9. Scrotal trauma with hematoma formation on examination, surgical exploration should be done immediately, and not USG as USG has not been shown to be reliable.
10. Inhalation injury without any surface burn- the most dangerous complication is supraglottic edema. Fibreoptic laryngoscopy should be done, and intubation if necessary.
11. Laparoscopy can be used to evaluate tangential gunshot wound, but perforating GSW needs laparotomy. Exploration under local anaesthesia for stab wound.
12. Compound clavicle fracture should be repaired by ORIF
13. MVA patient with bradycardia, bradypnea and HTN has cushing reflex- and the first thing to do is secure an airway with ETT to prevent respiratory arrest. Hyperventilation to reduce ICP is contraindicated in those with head injury and ischemic stroke, as it can worsen the neurological injury due to vasoconstriction.
14. Polytrauma patient with shallow breathing, tachycardia, chest bruises, cyanosis with intact Breath sound probably has flail chest- hypoxia is caused due to associated pul contusion and inc work of breathing due to muscle spasm.
15. Pt comes with knife sticking in his head- first thing to do is not CT but coagulation profile and blood match and cross match.
16. Aortic injury is the most common cause of sudden death in steering wheels injury, and occurs in the area of lig arteriosum, aortic root and diaphragmatic hiatus.
17. Pt who underwent lidocaine injection for PIVD came with fever, and leg paralysis and anesthesia- he has epidural abscess. First step is MRI with gadolinium contrast. CT myelography is an alternative. Antibiotic should be started, guided by CT aspiration or biopsy culture. Immediate surgical exploration is needed.
18. Pneumatic compression alone is not sufficient in high risk patients to decrease risk of DVT, because they can still have pelvic vein DVT.
19. 1cm proximal stones.
20. Post communicating artery aneurysm- diplopia, ptosis and anisocoria. PICA aneurysm- ataxia and bulbar dysfunction.
21. Scaphoid fracture on presentation- first thing to do is not casting, but CT or bone scan to rule out fracture. If fracture is really present, then thumb spica cast with wrist in slight radial deviation and neutral flexion. Most common complication is nonunion and not AVN.
22. Sister cannot be considered legal guardian of a child- so in emergency if parents are not around, we should treat the child anyway, and we don™t take the sister™s consent.
23. Elderly with BPH comes with protruding rectal mucosa with bluish discoloration and fraibility- its rectal prolabpse with strangulation and gangrene- immediate surgery (rectosigmoidectomy) is needed. If not strangulated, can try digital reposition under sedation, or application of granulated sucrose to decrease the edema.
24. Reflex sympathetic Dystrophy, aka Complex Regional pain syndrome (CRPS)- immobilisation after sprain or fracture, causing allodynia, hyperalgesia, some edema, changes in skin blood flow and sudomotor activity (sweatin), later leading to atrophyof tissues. This is due to SMP (sympathetically mediated pain), causing vasoconstriction and ischemia. Early treatement with a blockers like phenoxybenzamine, chemical or surgical sympathectomy within 3 months and early physiotherapy helps to reduce its incidence.
25. Plica syndrome- crepitus, snapping and effusion related to prominent medial plica of synovium which gets trapped in the knee joint, presenting like torn medial meniscus or maltracking patella.
26. PSA over 4 needs urology referral for biopsy.
27. Proximal nonmetastatic rectal cancer can be treated with sphincter sparing surgery, while distal can be locally resected only if mobile, small and nonulcerated. Big tumors can be given neoadjuvant chemoradio to make them resectable.
28. Smooth, round, soft, mobile, mildly tender breast mass implies cyst and not fibroadenoma- so the best step is FNAC, if pt refuses it, then mammo if over 35 yrs of age, or USG if under 35.
29. Silicone breast implant haven™t been associated with any connective tissue disease, any problem in fetus or in breastfeeding. Only problem is contracture of the capsule, pain and sometimes rupture needing extraction. It also doesn™t affect the mammogram criteria, though the calcifications along its capsule can rarely lead to a false positive result. It doesn™t obscure mammogram or decrease its sensitivity.
30. Multinodular thyroid in a patient with short neck can be retrosternal and cause symptoms of dysphagia- treatement is surgery. Iodine or thyroxine don™t help, as there is already considerable fibrosis in the gland. RAIU and Antithyroid drugs can infact cause initial enlargement of the gland, so are contraindicated.
31. Undescended testis, or varicocele can cause infertility due to the effect of temperature on the spermatozoa, but not hypogonadism as the Leydig cells are not affected.
32. Pt with bilateral or right sided varicocele, or varicocele that doesn™t disappear in the supine position, should be investigated for clot or tumor obstructing the inferior venacava. Varicoceles are common in the left side due to the drainage of veins.
33. March fracture: XR can be unremarkable for 2-4 wks, so do bone scan or MRI
34. Pt showing multiloculated cyst in pancreas on Ct- no need to do CEA and CA 19-9, as they are very nonspecific. Directly send the patient to surgery.
35. Barometric surgery- if BMI >40, if decreased quality of life, eg OA and sexual dysfunction, OSAS, movement limitation or brittle diabetes. Benefits of gastric bypass or gastric banding include better DM control, better lipid levels, sleep improvement, depression decline, etc.
36. Pt with hard nontended scrotal mask suspected to be tumor- FNAC or biopsy are contraindicated. Referral to urology for radical inguinal orchiectomy is the TOC. Before that, CT of abd and pelvis to detect LN metastasis, and tumor markers can be done.
37. Testis usually descends spontaneously within 6 mths, else surgery is indicated, at most before 2 yrs. Even after surgery, the risk of malignancy is still high, but it makes it easier to examine the testis. Orchiopexy does decrease the risk of infertility.
38. Breast lumps can be examined 4-10 days after menstruation for regression in size, which implies fibrocystic disease. If palpable and patient is anxious, FNAC should be done, and fluid sent for HPE if bloody. Reexamine in 4-6 wks for any regression or recurrence.
39. Congenital hernia due to persistent processus vaginalsis should be repaired as early as possible to decrease the risk of incarceration.
40. CT or nuclear scan to see for remnant thyroid tissue is needed before Sistrunk operation for thyroglossal cyst, else we might remove the only functioning thyroid tissue inside the cyst. CT is preferred.
41. Epididymitis: mild pain, (severe in orchitis), usu due to Chlamydia these days, cremasteric reflex is absent, Prehn™s sign positive (ie pain subsides on elevation), testis is high riding, transillumination usually shows unilateral hydrocele due to reactive effusion, Doppler USG if equivocal, and treatment is xone and doxy.
42. Recurrent abdominal or thigh superficial tumor with mild pain is desmoid tumor. Excision with a wide margin of resection is the TOC.
43. ESWL for gallstone if only 3 or less stones, ursodeoxycholic acid if small stones with functioning gall bladder, electrohydraulic lithotripsy is very cumbersome, and surgery is the TOC.
44. Dumping syndrome: high protein diet in small doses and frequent interval is the TOC, low carb diet, alprazolam helps for neurovegetative symptoms (dizziness, sweating and dyspnea), metoclopramide increases gastric emptying and exacerbates the problem.
45. Retrograde ejaculation is the most common complication of TURP. Urinary incontinence and erectile dysfunction are the complications of nerve damage due to suprapubic radical prostatectomy, which should be done if the TURP specimen shows evidence of malignancy, even if only adenocarcinoma in situ ! It should be done with LN dissection following sentinel LN sampling using technetium radiolabelling. Chemo, bicalutamide antiandrogen therapy and radio are reserved for advanced lesions.
46. Raloxifen (SERM) used for osteoporosis, can cause hot flashes and more importantly DVt. So should be stopped 72 hrs before any elective surgery.
47. Klinefelter syndrome predisposes to male breast cancer, but not testicular cancer, tho the testis undergo atrophy.

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GYNAECOLOGY
1. Shoulder dystocia- first thing is to tell mother not to push, then reposition the fetus, and then suprapubic pressure. If it fails, McRobert™s maneuver, ie flexing the mother™s knee towards the abdomen; or Rubin or Wood™s maneuver or delivery of posterior arm first. Zavanelli maneuver is replacing the fetus head in the pelvis before performing a CS.
2. Lesbians- have lower risk of contracting all STD, including cervical cancer. They should still be given HBV vaccine.
3. After the first baby of a twin is born, then positioning and heart rate of the second should be assessed with USG. If labor is halted, start oxytocin. Forceps is c/I if second amniotic sac is intact. Internal podalic version can be done to revert breech into cephalic position re
4. HELLP syndrome- treatment is again Magsol, to prevent seizure. Plasma exchange transfusion in persistent HELLP.
5. LSIL on Pap- do colposcopy. IF colposcopy is satisfactory (ie entire lesion and transformation zone visible), expectant management with repeat cytology 6 mthly or HPVDNA testing at 1 yr. If the lesion is persistent after 1 yr, or there is progression, or if colposcopy is unsatisfactory, or if HSIL, treatment with either ablation or excision is needed. Ablation can be cryo or laser, and excision can be knife or laser conisation or LEEP (Loop Electrosurgical Excision procedure). LEEP is the most favored procedure. Ablation is done in low risk lesion, without evidence of invasion and satisfactory colposcopy.
6. Condyloma are not c/I for vaginal delivery, as long as they are not large enough to cause obstruction. HSV is an contraindication however.
7. Risk of repeat preeclampsia is atleast 7 times higher, or even more if the previous preeclampsia occurred earlier, or pt has chronic renal disease or HTN.
8. Most effective strategy for severe preeclampsia is delivery, tho the next best step is magsol, as preeclampsia has other complications besides seizures, and magsol only controls the seizures. IV hydralazine or labetalol for BP control. Even after eclampsia occurs, magsol is more beneficial than phenytoin in preventing seizure. Diazepam if magsol is c/I, eg due to myasthenia.
9. Retinal hemorrhage is considered the most ominous sign of preeclampsia. Also PGI2 dec, TXA2 inc, NO dec, Endothelin inc.
10. Fasting glucose target in GDM is 60-90 and postprandial 35 yrs, hyper TG. Relative c/I are migraine, poorly controlled HTN and anticonvulsant therapy. Diabetes and f/h/o malignancy are not c/i.
22. 20% women with CF are infertile, due to thick cervical mucus and amenorrhea due to malnutrition, 95% of male are infertile due to impaired development of Wolffian duct, and poor sperm transport.
23. Annual pap is recommended even in lesbian, tho the interval can be increased to 2 or 3 yrs after 3 or more consecutive normal pap.
24. Trichomonas in postpartum period- give 2g single dose of metron, and withheld breast feeding for one day. Also treat the partner. Local vaginal therapy are less efficacious coz it doesn™t reach the urethra and the periurethral glands.
25. Stress incontinence- alpha agonists like amitryptiline can help by increasing the sphincter tone. Anticholinergic like oxybutinin and biofeedback are for urge incontinence.
26. UTI in pregnancy- cephalexin, amoxicillin or nitrofurantion. Even asymptomatic bacteriuria has to be treated to prevent preterm birth and neonatal sepsis and endometritis, and risk of progression to pyelonephritis. After treatment, eradication should be documented with urine culture. Pyelonephritis is treated with 10-14 days xone or ampi/genta, followed by low dose nitrofurantion or cephalexin prophylaxis for the remainder of the pregnancy.
27. If Pregnancy is detected early in first trimester in HIV patients, its better to withheld HAART. If in second trimester already, continue HAART. HIV patients shouldn™t breastfeed, even if on treatment.
28. In pregnancy or if on OCP, the dose of Thyroxine has to be increased due to inc TBG in the body, plus increased body mass and VOD in pregnancy. Monitor TSH and try to keep it at normal level.
29. Subchorionic hematoma are diagnosed by USG, and should be observed with repeat USG in 1 week. The most common complication of such hematoma is spontaneous abortion. Preterm birth and IUGR are also possible.
30. Gabapentin and valproate are safe to be used in pts on OCP- other antiepileptics will decrease the efficacy of OCP.
31. Pregnancy is still possible in Turners, tho the chance is very small.
32. A lady with hemophiliac husband is worried and asks what is the risk of her child having hemophilia? The answer should be ˜none™, as the child will be only a carrier if a female, and normal if male.
33. Hyperreflexia is an ominous sign of severe preeclampsia and heralds eclampsia- treatment of severe preeclampsia is hydralazine or labetalol, plus magsol.
34. Physiologic changes of skin are the commonest cause of general body pruritus in pregnant wome. Other cause is herpes gestationis, aka pemphigoid gestationis, which manifests are urticarial veriscles around umbilicus, and is not due to viral infection. PUPPP (popular urticarial papules and plaques of pregnancy) is another and involves the stria gravidarum. Treatment is antihistamine, topical steroid, emollient, etc. Topical steroids are the DOC.
35. Contraindication of exercise in pregnancy are pul or cardiac disease, cervical incompetence, twin, abruption placenta, placenta previa, Premature labor, preeclampsia. Scuba is c/I as it can cause decompression sickness in the child
36. Limb reduction defect associated with CVS depends mostly on the age- higher risk with earlier age.
37. Weight reduction is the TOC for PCOD infertility. After that is clomiphene, and if it doesn™t work, then gonadotropins. Metformin is not studied enough, so is usually not the answer.
38. Adolescents dong comply with OCP mostly because of concern over wt gain, tho there is no hard evidence.
39. Testicular feminization- pt has breast development but no axillary or pubic hair, unlike in constitutional delay, where such asynchronous delay is not found.
40. Laparoscopy is always the first step in suspected endometriosis, to rule out other pathology, and to see the extent of the disease, plus it can be therapeutic too with bipolar coagulation.
41. Unilateral nipple discharge is cancer UPO, so do mammogram, even if it is serous. It can be f/by FNAC or biopsy, and cytology of the discharge if it is bloody.
42. CVS doesn™t help with detecting NTD, as it is only for cytogenetic studies and doesn™t measure AFP levels.
43. NTD needs immediate surgery to prevent infection of CNS, followed by orthopedic evaluation to correct patient™s posture and promote ambulation.
44. All pregnant women should be screened for Chlamydial infection in the first prenatal visit, and repeat in third trimester if the patient is below 25 yrs of age (donno why)- coz it can lead to endometritis, chorioamnionitis, conjunctivitis and pneumonia in the baby, preterm delivery, PID, ectopic. If positive, treat mother with erythromycin base (estolate is c/i)or amoxicillin for 7 days; and father with azithro single dose.
45. The MCC of postmenopausal bleeding is atrophic vaginitis, then endometrial ca, while cervical cancer is a very rare cause.
46. Rosette test can be done to detect fetal RBC in mother in cases of isoimmunisation, and if present, then quantify how much fetomaternal bleed has occurred by Kleihauer Betke test. Adjust the dose of anti RH globulin accordingly.
47. Sickle cell disease- OCP are not preferred due to thromboembolic risk, progesterone pills cause breakthrough bleeding and aggravate anemia, IUD also increases bleeding, so the best contraceptive is DMPA or norplant. Almost half of pregnancies are complicated by either acute crisis, endometritis, pyelonephritis or thromboembolism.
48. Pt on antiepileptic becomes pregnant- never change the drug. Add folate (though benefit has been shown only in animal studies) and offer screening for NTD with serum fetoprotein, amniocentesis and USG, and termination if affected. Also antiepileptic is not a c/I to breastfeeding, though Phenobarbital and diazepam can be stopped for a few weeks if the child becomes irritable or sleepy.
49. Eisenmenger syndrome is absolute contraindication to pregnancy- elective termination of pregnancy should be advised. The sudden drop in systemic vascular resistance with delivery will cause cyanosis in the mother. Also higher risk of spontaneous abortion and preterm delivery. Only treatment is heart lung transplant, or lung transplant with intracardiac repair.
50. Gestational transient thyrotoxicosis (GTT) has mild increase in free T4 and only slight decrease in TSH, due to the effect of hCG on thyroid stimulation. If TFT are normal, and pt has typical symptoms of hyperthyroidism, she probably has anxiety disorder or something else. Subacute lymphocytic (postpartum) thyroiditis causes only transient hyperthyroidism, and shows reduced RAIU test.
51. DMPA is the contraceptive of choice in pt with VWD or hemophilia, as it decreases the menstrual flow, unlike IUD or minipill which increases bleeding. It also dec risk of PID and endometrial cancer, and is useful in those with fibroid.
52. Downs diagnosis- increased nuchal translucency on USG in 10 wks, PAPP-A in the first trimester, quadruple testing ( with dimeric inhibin A) in second trimester, and karyotyping with CVS in 10 wks and amniocentesis in 16 wks.
53. A pt recently started on OCP comes with spotting, just reassure her that is normal breakthrough bleeding, and nothing needs to be done. Just continue the OCP. Some patient may complain that there is no withdrawl bleeding. That is normal too, initially. Advice her to use condoms if she forgot to take her pill for 2-3 days.
54. Clonidine is useful for hot flashes, esp if there are any c/I to the use of HRT. Progestin has also been shown to be effective for hot flashes, but causes mood disturbances.
55. Any preterm labor- always administer prophylactic penicillin for GBS. Also betamethasone if between 24 to 34 wks.
56. Intrahepatic cholestasis of pregnancy is associated with still birth, so in a ICP suspect, do LFT to rule out other causes, and then undergo fetal testing and early delivery.
57. Elderly with burning, dyspareunia and a butterfly like atrophic white lesion on the vulva, has lichen sclerosis. Treatment is potent topical testosterone !!
58. Breastfeeding suppresses estrogen release from ovary, and that can result in vaginal dryness and dyspareunia.
59. Air travel is c/I after 36 wks, or if h/o HTN, preterm delivery, poorly controlled DM or sickle cell anemia.
60. A pt comes with primary amenorrhea, no other symptoms like abd pain, and normal secondary sexual characteristics. This is probably uterine agenesis and not imperforate hymen (Mayer Rokitansky Kuster Hauser syndrome)
61. Meigs syndrome- TOC is unilateral oophorectomy and not TAHBSO, as it is caused by a benign ovarian fibroma. Tricky.
62. Regularly timed but heavy periods imply adenomyosis, endo hyperplasia or polyp or fibroid. Anovulatory DUB is characterized by irregular cycles.
63. If a pt comes with PROM at say 28 wks, then expedited delivery is not warranted, tho prophylactic antibiotics can help prevent amnionitis. Delivery should be delayed until sign of infection develops to promote further fetal growth and development.
64. c/I to daily aerobic exercise in pregnancy are significant heart disease, HTN, preeclampsia, preterm labor and PROM, restrictive lung disease, incompetent cervix, twins, placenta previa.
65. A pt with normal mens hx comes with abnormal bleeding. It is most probably due to pregnancy, and not anovulatory bleeding. PREGNANCY always comes first in d/d.
66. Pt comes with severe pv bleeding, hypotension and anemia- Tt is iv estrogen, vasopressin if needed, BT, followed by oral estrogen which is gradually tapered. If above 35 yrs, do endometrial sampling before starting estrogen to rule out endometrial hyperplasia or Ca.
67. Rapid onset virilisation with clitoromegaly and frontal balding- its probably ovarian or adrenal androgen secreting tumor and not PCOD. So the first investigation is USG pelvis.
68. LH:FSH ratio is not a very sensitive test for PCOD re. Amazing.
69. Below 40 yrs, breast lump if dismissed as having no abnormality by USG or mammo, has 1% chance of malignancy, so nothing needs to be done. But if more than 50 yrs, it has >40% probability of being cancer, so even if mammo is negative, still have to do biopsy or fine needle aspiration.
70. Postpartum telogen effluvium is common after 2-6 mo of delivery.
71. The preferred therapy for inpatient PID is iv cefoxitin and iv doxy, +/-metron if vaginal smear shows trichomonas. Alternative is iv clinda and iv genta. Beware of options with oral doxy. Admission is needed in pts with peritoneal signs, n/v precluding oral treatment, pregnancy, etc.
72. All SSRI are excreted in breast milk, so only short acting ones should be used in postpartum period, so that patient can refrain from breastfeeding till the drug is in her system.
73. Shoulder dystocia and obstructed labor- first thing to do is call for help. Then McRobert™s maneuver by pushing the mother™s leg as far back as possible. Then epi, supriapubic pressure, Wood™s corkscrew manuvre, heel knee position, and finally pushing back the fetal head and CS if everything else fails.
74. IUD protects against endometrial cancer
75. HRT increases HDL and lowers LDL, thus dec cardiovascular mortality long term, but it has been shown to increase coronary event in the short term.
76. After the first trimester, advise not to exercise in supine position, as it can compress IVC, dec CO and cause uterine hypoperfusion.
77. Fragile X is a X linked dominant syndrome due to triple repeat expansion, which is a type of mutation. If the permutation is transmitted from the mother, it has a higher chance of expansion than if from father. Huntington on the other hand is autosomal dominant.
78. Breastfeeding is usually successful after reduction or augmentation mammoplasty or breast implant.
79. If a pt is profusely bleeding pv, D&c gives a faster response to stop the bleeding than iv estrogen.
80. Screening for DM starts at 45 with three yearly RBS, for lipid disorder starts at 45 if no risk factor, but as early as age 18 if has risk factor like f/h of MI.
81. A pregnant mother is diagnosed with sec syphilis in her second trimester. The baby will be born with ? snuffles, rhagades and neurosyphilis (features of early congenital syphilis), not saber shin/Hutchinson teeth, as these are manifestation of late congenital syphilis. Also can have meningitis, hydrocephalus, optic atrophy.
82. Maternal obesity increases the risk of NTD, tho the reason is not known. It also increases the risk of GDM, macrosomia and stillbirth, so wt loss before conception is advised.
83. Tubal ligation: failure rate is 5% and not 0.1%, 5-20 % pts regret later doing the ligation.
84. The presence of endocervical cells on Pap is regarded as adequate sampling. If these cells are absent, then in a no risk patient, repeating may be deferred till next years Pap. If it is high risk patient, then repeat immediately.
85. After an episode of pyelonephritis in pregnancy, the pt should be put on prophylactic antibiotic for the rest of her pregnancy.
86. A pt comes with IUGR, ie

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86. A pt comes with IUGR, ie

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86. A pt comes with IUGR, ie

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IUGR, ie

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then the first thing to do is Doppler velocimetry of the umbilical artery. If the flow is absent or reversed, then immediate delivery is warranted, else not.
87. ER+ breast tumor needs tamoxifen for 5 yrs to reduce recurrence after surgery, chemo and radio. Lifelong tamoxifen is not used as it can cause endometrial cancer.
88. Pregnant women shouldn™t consume too much fish, due to risk of mercury poisoning, and ACOG has actually set limits on the amount of fish in a week a pregnant woman can take. Also carnivorous fishes like shark are c/i.
89. In a patient with partial spinal cord transaction, the biggest threat during pregnancy is developing autonomic dysreflexia. It can manifest with malignant HTN, brady, arythmia, sweating, resp distress, uteroplacental vasoconstriction, etc. Patients are unaware of labor due to absence of pain, and only way of knowing is abd or leg spasm and SOB that accompanies labor.
90. Cranberry juice prevents UTI by inhibiting E coli from adhering to the urinary epithelium.
91. None of the radioimaging are c/I in pregnancy except for radioactive imaging. The modality with highest exposure to the fetus is a barium enema, then a CT abdomen.
92. Ondansetron is effective only if given before chemo. For late onset emesis, metoclopramide is more effective.
93. No alteration in sexual practice is needed during pregnancy, except if pt has PROM, placenta previa or premature labor history. Even supine position is not c/I re.
94. Chronic vestibulitis is a cause of chronic vulvar pain and extreme tenderness. Tt is low dose amitryptiline.
95. IF a HIV elisa comes positive, the most important factor of the test that concerns the patient is the PPV of the test, ie how many with positive test actually have HIV.
96. Tt of condyloma in pregnancy is TCA. Podophyllin is c/I in pregnancy. IFN and laser ablation in case of resistant infection.
97. Bicornuate uterus needs no treatment before pregnancy. Septate uterus needs hysteroscopic excision of the septum, and didelphys needs reunification process.
98. Dysuria with low level WBC in urine, low bacteruria and negative leucocyte esterase is consistent with urethral syndrome. Interstitial cystitis has a normal examination of urine. Traumatic cystitis occurs sex, diaphragm use or catheterization, and presents with hematuria without pyuria.
99. pt with Anticardiolipin Ab can present with livedo vasulitis in the lower limb, which presents with painful purupura in the lower limb, which ulcerate and heal leaving atrophic scars, livedo reticularis with telangiectasia, erythema and hemosiderin hyperpigmentation. Livedo can occur with hep C, protein C deficiency also. Treatment is low dose aspirin, nifedipine, dipyridamole, pentoxiphylline or mini dose heparin. Heparin is preferred in pregnancy, with one dose every 2-3 days.
100. A pt with menarche comes with heavy bleeding and shock- its probably not DUB but VWD, so do ristocetin cofactor assay. Tt is OCP, desmopressin, antifibrinolytic and VWF concentrates.
101. Pt with bac vaginosis on pap don™t need treatment if they are asymptomatic, even during pregnancy, as the treatment hasn™t been shown to be effective. Metronidazole is okay for 2nd trimester use.
102. Gestational thrombocytopenia is one of the commonest cause.
103. DMPA is the best contraceptive in a pt with sickle cell anemia, as it has shown to decrease the pain crisis. Estrogen is relatively c/I as it increases the vasoocclusive crisis. IUDs are also not good, due to high rates of infection.
104. 80 yr female with stroke develops incontinence. Post void residual volume is 70ml (normal). This is functional incontinence due to impaired mobility so that the pt cant go to toilet. Best treatment is communicating with caregivers about accessing the toilet.
105. Young woman on ACEI should be using contraceptives.

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DERMATOLOGY
1. In pt with alopecia, if the hair shows split ends, aka trichoclasis, then it signifies traumatic alopecia, due to trichotillomania, or chemicals.
2. Psoriasis is treated with potent local steroid, and low potency steroid like hydrocort if on face or intertriginous area. Systemic steroids are not used as they can induce pustular psoriasis. Extensive disease is managed with UVB with or without coaltar (Goeckermann regimen). Severe or psoriatric arthritis is treated with MTX.
3. Pressure ulcers are treated with moist saline soaked gauze packing. Dry gauze is not used as the fluid is thought to contain growth factors needed for reepithelialisation.
4. Topical metron is the TOC of rosacea, with or without oral doxy, mino, erythro, tetra like in acne. Topical isotretinoin in popular or pustular lesions, and permethrin has shown to help, as demodex mites are frequently found in the lesions. Rosacea can be associated with conjunctivitis, keratitis, chalazion and scleritis.
5. Erythrasma caused by corynebac minutissimum, reveals coral red fluorescence in Wood lamp.
6. Photoaging causes coarse deep wrinkles (fine and superficial only due to aging), actinic keratosis, telangiectasis and brown liver spots. Treatment is isotretinoin, which will remove the brown spots also. Smoking exacerbates photoaging.
7. Tattoo removal- deramabrasion, laser, cryo, cautery- laser can cause scarring and hypo/hyperpigmentation.
8. Wearing protective clothing is more important than sunscreen since childhood to decrease the risk of melanoma. Sunscreen with SPF 15 have shown to reduce the incidence of only BCC and SCC, not melanoma.
9. Oral Terbinafine 6wks for fingernails and 12 for toenails are the TOC for tinea unguium. Itraconazole can be used. Oral fluconazole is once weekly and easy to take, but is not as effective.
10. Lindane used for scabies was found to cause aplastic anemia and seizures, and hence is replaced by permethrin.
11. A pt went hiking, was bitten by insect, and scratched with a wooden stick, followed by draining lesion- its sporotrichosis, as it is the only fungus which can get inoculated. Blastomyces and Coccidiodes both have to be inhaled.
12. Minocycline doesn™t cause photosensitivity, but can cause lupus like syndrome, pseudotumor cerebri, vertigo and tooth discoloration
13. NSAID and hydration are the treatment for sunburn, whether induced by drugs or otherwise. NSAID also limits the damage to the skin. Diphenhydramine for itchng, and topical steroids can be used
14. Oral Isotretinoin can cause hyperTG,so monitor LFT and lipid profile, and stop if severe hyperTG, as it can cause pancreatitis.
15. Psoriatic lesions are exacerbated by beta blockers, ACEI, lithium, NSAIDS- stop the medicine and replace from another group.
16. A pt on OCP with chronic HCV comes with painless blisters on hand, and hyperpigmentation, hypertrichosis and fragility of skin. Its porphyria cutanea tarda. Dx is by inc urinary uroporphyrins. Treatment is phlebotomy or hydroxychloroquine, or IFN alpha in those with HCV infection.
17. Mild acne is treated with topical retinoid. Moderate( or refractory mild) with topical retinoid and either benzoyl peroxide or topical antibiotic. More severe with all three of them, or systemic antibiotic with topical benzoyl peroxide or retinoid. If no response in 3-6mo, start oral isotretinoin. Microcomedones need 8 wks to mature, so wait for 2 months for any therapy to work before switching. Pregnancy is c/I with even topical isotretinoin, though no LFT and lipid monitoring needed with topical therapy.
18. Microsporum canis ectothrix infection is fluorescent in Wood™s lamp, unlike the endothrix infection with T tonsurans.
19. Trichotillomania is characterized by bizarre pattern of broken hair strands of varying length.

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PAEDIATRICS
1. DTaP vaccine c/I if anaphylaxis of encephalopathy within 7d. If high fever, shock, inconsolable crying and seizure within 24 hrs, then give under caution. There are no contraindications to pneumo, polio or Hib vaccines.
2. MMR c/i- severe febrile illness, anaphylaxis to neomycin or gelatin, severe immunodeficiency (not just HIV status), thrombocytopenia after first dose, previous IVIG administration within 3-11 mo, as it decreases the efficacy of the vaccine, pregnancy. f/h/o seizures, breastfeeding, TB, PPD conversion, asymptomatic HIV infection, allergy to mercury (thimerosal) and egg are not considered contraindications.
3. Chemoprophylaxis for PPD conversion following contact with MDR TB- if resistant to only INH, give rifampicin 4mo or RZ 2mo, if resistant to H and R, give ZE or Z with quinolone for 4 mths.
4. If neonate at birth has polycythemia in capillary heel blood test, then repeat in venous blood- if still elevated, repeat in 12 and 24 hrs, as it resolves on its own. If it persists, and the child develops drowsiness, jaundice, hypoglycemia, apnea, hypotonia, poor feeding, cyanosis, then hydration and exchange transfusion is needed.
5. Children need 1300 mg calcium daily, so apart from diet, 1gm calcium supplementation should be done in all. Adults typically need less, while the requirement in old age again increases.
6. Strawberry aka capillary hemangioma in places other than face can be left to regress by themselves, while face can be treated with laser for cosmetic reason. Steroid and interferon sc have also been useful in large hemangiomas.
7. Kawasaki disease- TOC is Aspirin and IVIG. HSP- supportive, steroids if severe. HUS supportive and IVIG, peritoneal dialysis. TTP- plasmapheresis. ITP- mild cases are self limiting, steroid short course for severe cases, and IVIG for very severe cases.
8. Diaper rash is due to overhydration and friction, eg following diarrhea, treatment is to keep dry by frequent change of diapers, and barrier creams like petrolatum and ZnO, or low potency steroid. Candidal infection involves skin fold, is painful, and is persistent after the above treatment. Bacterial superinfection presents with fever, pustular drainage and lymphangitis.
9. Flexible kyphosis is commonly seen in adolescent, and is correctable by voluntary extension and prone extention test, and doesn™t need treatment. If there is sharp angulation seen on forward bending, it is structural kyphosis, aka Scheuermann disease, and needs Milwaukee brace if angle 14 yrs of age. It can be constitutional if positive family history, and bone age is lower than true age, and other systemic illness are absent. Pt with Klinefelter has normal puberty, but then he develops testicular atrophy and hypogonadism. Constitutional puberty delay can be managed with testosterone mthly im injection for 3-6 mo (short therapy doesn™t affect bone growth), esp for psychological reason. HCG with HMG can be used in central hypogonadism like kallman™s syndrome- or GnRH pump.
16. Child with diarrhea should be given normal diet, with limited sugars and fat, which increases osmolality. Clear liquid like juice has sugar. Loperamide can cause paralytic ileus, toxic megacolon and CNS depression.
17. Normal Tympanic mb with decreased mobility signifies effusion, and can persist for 3 mo after an episode of AOM. So watchful waiting only is needed, unless if the effusion is bilateral, or has persisted for longer. First line therapy for AOM is amoxy, second line is clavam, cefuroxime axetil or im xone, tympanocentesis or myringotomy with culture if second line also fails. Hearing evaluation should be done if effusion lasts for more than 3 months.
18. Lead levels>44 needs oral chelatoin, and >70 needs hospitalization and iv chelation. Less than 44 needs only environmental and behavioral interventions. Blood lead levels are more sensitive than erythroporphyrin levels.
19. Criteria for admission of pts with anorexia nervosa- dehydration, electrolyte abn, brady, hypotension, hypothermia, acute food refusal, wt