drtanvir
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MASTER DOC UW NOTES
propranolol=drug of choice for HTN+beningn essential tremor
)Reccurent chalazion=> do histopathologic examination because of risk of Squamous cellular carcinoma (SCC)
)PH=7.23, HCO3=16, PCO2=40-what is it?
=mixed metabolic+respiratory acidosis, because if it were simple metabolic acidosis, then PCO2 would have been=1.5*HCO3+8=1.5*16+8=32mmHg and in this case it is 40mmHg, so there is also a respiratory acidosis
Know the formula for calculating the compensation in acidosis: PC02= 1.5*HCO3+8
Ex.: a diabetic suffering from COPD treated with metformin may have mixed acidosis, metabolic from metformin, respiratory from COPD.
)NSAID can give SIADH (innapropriate secreation of ADH)
)Quinsy=peritonssilar abcess
)Tamsulosin=blocks alpha1-receptors only in prostate and bladder=>no side effects like hypoTN, headache, rhinitis as other alpha 1 blockers
)Sideroblastic anemia-high Fe, high TIBS, may be hypocromic and normocromic anemia in the same time=HIGH YIELD
)Streptoccocus bovis endocarditis-asoc. with colorectal cancer=>do colonoscopy
)Treatment of MG crisis=intubation+withdrawl of anticholinesterasic drugs for many days, then do plasmapheresis and iv IG
)Foreign body in the eye=>first pen light exam=>fluoresceine exam, if still (-)=>CT or US, never MRI (it can dislocate the foreign body)
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)patient with XYY karyotype=severe acne, but not precocious puberty
21-hydroxylase deficiency=precocious pseudo-puberty, independent of the hypotalamic-hypophyseal-gonadal axe
)Black widow spider bite=>treat with narcotics, muscle relaxants and Ca gluconate
)Women with CIN (cervical intraepithelial neoplasia):
a) imunocpmpromized
b) in utero exposure to DES
c) hystory of CIN II/III
will have annual PAP smear done, regardless the normal previous ones.
)In severly depressed patient, even suffering from terminal illness with suicidal thoughts=>start antidepressant therapy
)Systemic steroids=drug of choice in sarcoidosis with disabling symptoms, if not responding=>cyclosporine
if asymptomatic sarcoidosis=>no treatment
)Lachman test is more sensitive than anterior drawer test in ACL rupture (anterior cruciate ligament)
)Primary polydipsia=increased thrist first, can be given by antipsyhotic medication (phenotiazines) because they give a dry mouth. Look for a patient in the psychiatric ward on antipsychotics who gets diarhhea, polyuria and thrist
Insipid diabetes=increased polyuria first
)HTN+peripheral vascular disease=>give Ca channel blocker
)BCC (basal cell carcinoma)=most common tumor of the eyelid
=pearly, indurated
=>treat by chemosurgery of frozen section control excision
)Respiratory alkalosis-in liver insufficiency because of increased levels of progesterone (not metabolized anymore)
)Hashimoto thyroiditis-can be eu/hypo/hyper thyroid
-anti preoxidase Antibodies are diagnostic
-risk (6 times) of thyroid lymphoma
)Nasopharingeal carcinoma-appears in all age groups
)Colonic villous adenoma, sessile adenoma or size>2.5 cm=> increased risk of malignancy=HIGH YIELD
No further work-up for hyperplastic polyps
)US of KUB (kidney, ureter, bladder)=first step in evaluating BPH (benign proastate hypertrophy) with elevated Creatinine and normal urinalysis
)MALT gastric lymphoma and no metastasis=>eradicate H.pylori infection, if this fails, then give chemotherapy (CHOP)
)Athlete's foot (in swimmers too)=fungal infection, treat with tolnaftate
)Excessive bleeding (like abruptio placenta) in pregnant woman Rh (-)=>give higher dose of anti-D globulin
)If HDL>60mg%=>it removes one risk factor for CV disease
)Alcohol withdrawl=>first-line give chlordiazepoxide (librium), then lorazepam=second-line
)Sjogen syndrome=>diagnosis confirmed by lip biopsy (lymphoid foci in accessory salivary glands)=most specific
)Allergic contact dermatitis=erythema, edema, pruritus, tiny vesicles, weepy&crusted lesions 24-48h after contact with the allergen-cell mediated hypersensitivity
)Psammoma bodies=thyroid papillary cancer
Invasion of tumor capsule and blood vessels=folicular cancer
Hurtle cells-appears in both the above types (rarely)
)Carcinoid syndrome=>develop deficiency of niacine (dermatitis, diarhea dementia) because Trp is mainly converted to serotonine and 5HIAA
Hyper Ca crisis=vomiting, oliguria/anuria, dizziness, coma
)Invasive aspergillosis="halo sign" on CT scan of lung
=in imunocompromized people
=on CXR-cavitary nodule
)Miastenia gravis=>thymectomy if:
-between age of puberty and 60
-if <12 years of age=>frecquent spontaneous remissions
-if>60 years of age=>give corticosteroids
-if only ocular disease=>no thymectomy
)Defect in Le adhesion=reccurent bacterial infections
-characteristic are: delayed separation of umbilical stump
necrotic periodontal infections
)Defect in opsonisation=asplenia (infections with S. Pneumoniae are frecq)
)Acute ingestion of masssive alcohol=> reduces the toxic effect of acetaminophen by inhibiting CYP2E1 like in suicide attemps with alcohol and acetaminophen together, but
Chronic ingestion of alcohol reduces glutathion=>increases the toxicity of acetaminophen like in an alcoholic patient with some kind of fever due to common cold
)Egg allergy=>contraindication to influenza vaccine and Q fever vaccine, and relative c.i. to MMR (which is however still recommended)-HIGH YIELD
)ACE inhibitors=>increase renin and kinin derivates=>cough
)Dermatomiositis=Gottron's sign=scaly patches on MCP and IP joints
=heliotrop rash (periorbital edema+purplish suffusion)
=proximal muscle weakness
)Vertebral osteomyelitis-lumber area frecq.=>back pain
- low fever, high ESR, local tenderness, spasm
Do MRI=of choice for diagnosis
-Complications=epidural abcess, spinal cord compression
)Pale lesions, velvet-pink or whitish that do not tan and are not scaly=tinea versicolor (Malassezia furfur)
-thick budding spores, large blunt hyphae="spaghetti and meatballs"
-treat=>Se sulfid shampoo and ketoconazole
)Loss of gastric fluid by NG suction in intestinal obstruction=>metabolic alkalosis (contraction alkalosis) even if initially it was a metabolic acidosis from the obstruction
)Hypophosphatemic rickets-only P is low, the rest are normal (PTH, Ca)
)Migratory trombophlebitis-due to cancer=> do CT of chest abdomen and pelvis; can be pancreatic, lung, prostate, stomach cancer
)Acyclovir=nephrotoxic=>renal tubular obstruction, gives crystalluria
)Deficiency of Iron=most common anemia in the elderly=HIGH YIELD
)Anemia of chronic disease is given by inflamatory joint disease not degenerative joint disease
)Pseudomonas osteomyelitis (punctures through snikers in the foot)=>give quinolones+surgical debridement
) Anemia of prematurity-normocitic, normochromic, low reticulocytes, few precursors of red line, normal WBC, T, normal Bilirubin, , no other abnormalities
)Isoniazide=>lowers the levels of GABA in the brain=>seizures in 1h after administration, treat by Vit. B6
)For screening use=total cholesterole+HDL
For treament use=LDL+Risk assessment
)Undiagnosed pleural effusion=best evaluated by thoracocentesis, except in CHF (here give diretics and see what happens-it will disappear)-HIGH YIELD
Varicose veins with incompetent perforating veins- can give:
-non-pitting edema
-medial leg ulcer
-fatigue
-brown discoloration of the ankles
)Warfarin induces skin necrosis=>mostly in patients with deficiencies of prot C or S or when it is started in high doses without prior heparin coverage (like in Atrial fibrillation)
)Larger Confidence interval (CI)=wider range of possible effects for a tested drug (efficient drug in some patients, non efficient in others)
If CI of 2 groups overlap=>no statistical significance
If they don't overlap=> statistical significant differences
)Niacine treatment=> raises HDL, but gives pruritus and flushing (release of Prostaglandines)=>prevent this by giving aspirin 30 min. prior to taking niacine
)Pulmonary embolism (PE)-post surgery in pacients with JVD and new RBBB; also dilated pupils=ominous sign
)Post-ictal (after seizures) lactic acidosis is transient=> no treatment, it resolves by itself in 60-90 min.
HCO3 is given in acidosis only if PH<7.2
)In primary hyper aldosteronism, there's no edema, but hyper Na
)Retinal vein occlusion=disk swelling, venous dilation and tortuosity, retinal hemorrhages, cottol-wool spots
)Retinal artery occlusion=pale disk, cherry-red fovea, boxcar segmentation of blood in the retinal veins
)Celiac disease-diarrhea, pallor (anemia), bone pain (osteomalacia), easy buising (low vit.K), hyperkeratosis (low vit. A), Ig A Antib. to gliadine, to endomissium and to tissue transglutaminase
=malabsortion+Iron def. anemia
)Overflow incontinence-can be given by: TCA, antichol., antipsychotics, sedative-hypnotics
)Spinal cord compression=>first give STEROIDS, then do MRI of the spine, if not available do=>CT myelogram=> give radiotherapy for malignancies=HIGH YIELD
) Diagnosis of Bartonella Henselae is clinical, confirm by Warthin-Starry stain of tissue specimen or Antib.
treat by azytromycin for 5 days and only in regional lymphadenopathy or systemic symptoms (also can give claritromycin, rifampin, TMP/SMX, cipro or Doxi)
)Shy-Dragger syndrome=Parkinson +autonomic instability (HypoTN...)
-can have bulbar dysfunction or laringeal stridor
-treat by iv expansion (fludrocortisone), salt, alpha agonists
Riley-Day Syndrome-AR disease, in Askenazi Jews
=autonomic dysfunction +severe hypoTN
)Prepubertal vulvo-vaginitis=>pruritus mainly in the night=>do scotch tape test to detect pinworm (do not answer stool examination)
)Treatment for low HDL=>Choice=fibrates, the niacine
)Treatment of choice for anorexia=hospitalisation
)Subcutaneous emphysema in patients on 100% O2 on mask=> do first CXR to rule out pneumotorax; if (-) this is a benign condition=>no furthet treatment
)Thoracic outlet syndrome-after MVA, playing with musicalinstruments, chronic illnesses, cervical ribs, congenital muscle band...=has signs of neuro-muscular bundle compression
-do EAST test for screening (elevated arm stress test), and CXR, MRI or angiography for confirming the diagnosis
)Medial meniscus tear-C shaped meniscus (the lateral is O-shaped)
by twisting the leg, effusion forms in 24h and is not as bloody as in ACL tear, tenderness on the medial part on the knee
=characteristic=bucket handle tear and locking of the knee joint in extension
(+)McMurray sigh=snapping felt with tibial torsion, knee flexed at 90 degrees
-trea by immobilization+bracing
ACL tear=hystory of hyperextension
(+) Lachman test, ant. drawer test, pivot shift test
)CI=1.02-2.15
RR=1.6 What does it mean? Well, the CI does not include value of where RR=1, then it means that the result is statistical significant
RR=1=> no effect or association
)Low cardiac output + high PCWP+high SVR=left ventricular failure (cardiogenic shock)=HIGH YIELD, I got some similar questions on actual exam, know this type of Q for cardilogy very well!!!
)Eczema herpeticum=HSV infection associated with atopic dermatitis, there are vesicles over the areas of atopic dermatitis
treat by acyclovir in infants
)Causes of altered mental status in the elderly patients:
low+high Na, Ca, low Mg, low P, low glucose, stroke, cardaic events, infections
-risk of dehydration by:WATER ACCESS IS DENIED=main mechanism in:
a)nursing homes
b)post-surgery
c)intubation in ICU
)To slow down the progression of Diabetic nephropathy=>restrict proteins and give ACE inhibitors (even if normal TN, but not if Clearance of Creatinine>2)
) Treat of both acute and chronic anal fissures=> starts with dietary modifications+stool softner+local anesthetics; in refractory cases do lateral sphincterotomy or gradual dilatation=>risk of incontinence and disruption of sphincter
)Paroxismal nocturnal hemoglobinuria-may cause pancitopenia
-like hemolytic anemia (High reticulocytes)
-intravascular process (high LDH, total billirubin, low haptoglobin)
-splenomegaly, Cooms (-)
-loss of iron in the urine=>microcytes, hyprocromia
-bone marrow=hypocellular
-flow cytometry=absence of CD59 -used for confirmation of disease
)Screen for hepatitis C if blood transfusion was before 1992 and for hep. B is before 1986
)To supress lactation=>tight-feeting bra+ice packs, no longer bromcriptine
)First step in organo-phosphoric poisoning=remove clothes and wash patient, then atropine
)Use CA-125+vaginal US for screening the intermediate risk of ovarian cancer in women with family hystory of ovarian cancer (not other type of cancer); otherwise, there's no screening done for ovarian cancer
)Avascular hip necrosis-given by steroids, scikle cell disease, alcoholism, SLE, Gaucher's disease
=hip pain with normal range of motion and normal X-rays. Do MRI=GOLD STANDARD for diagnosis
)Intraperitoneal rupture of bladder in MVA=previous full baldder in a patient who drank water (2l) and didn't urinated for 8h
Extraperitoneal rupture=more common
)Treat Ig A deficeincy:-prophilactic TMP/SMX, donor erytrocytes washed five times or bloodfrom other IgA def.patients
)HTA+osteoporosis=first choice are THIAZIDIC DIURETICS
)Vitiligo=pale macules with pigmented borders-acral or peri-orificial areas, autoimmune distrcution of melanocytes
Piebaldism=absence pf melanocyes, obvious from birth
Infection with M. Leprae=areas of hypopigmentation+anesthesia
)Metabolic alkalosis:
a) Cl sensitive (Urinary Cl<20mEq/l)-causes;vomiting,diurectics...=ECF contraction; treatable by NaCl infusion
b) Cl resistant (U Cl>20mEq/l)=ECF expansion, not correctede by Na Cl infusion; causes ersistent mineralocorticoid stimulation
)Nerve IX neuralgia-associated with Multiple Sclerosis (MS)
)Nephrotic syndrome-associated with arterial+venous thrombosis (freq. renal vein thrombosis and even PE
-anemia microcytes, hypocromia, resistant to iron therapy (loss of transferine)
-vit D deficiency, low Thyroxine levels
)Angiofibroma in the nose-can give bony erosions
Chondroma of nasal cartillage-is very rare in young patients
)Lyme disease in pregnancy and in children<9 years of age=>give AMOXI, not Doxi; also can give Azytromycin or cefuroxime
)Sympathetic ophtalmia-ant. uveitis, panuveitis, papillary edema, blindness
-by uncovering of "hidden antigens" (auto-Antib, cell-mediated reaction)
)Diphenilhydramine toxicity-seizures+cholinergic effects
Mercury overdose=vomitting, abdom. pains, bloddy diarrhea, renal insufficiency
)Best prevention of osteoporosis=HRT, c.i. if hystory of endometrial/breast cancer, but not if only family hystory
)Pulmonary nodule with cartillage in it=hamartoma=>observe
Radiotherapy-use it emergently in Superior Cava Vein syndrome
)Dupuytren contracture-associated with alcoholism, epilepsy, DM, TB, Peyronnie disease, Riedel thyroiditis; over 50 years of age
)Perforated retro-cecal appendix, edematous cecum, pus behind the ascending colon=>do right hemicolectomy+ileo-transverse anastomosis=best post-surgical results
)Excruciating pain from femur fracture=>give iv. Morphine (even in patients with hystory of drug abuse), then give PCA (patient controlled analgezia)
Give methadone in chronic severe pain syndromes
) If a test is (-)=> probability of the disease is =1-NPV
)HCO3 if given in lactic acidosis can depress the myocardium and increase the production of lactic acid by stimulating the phosphofructokinase enzyme
)Most common location of ischemic colitis is splenic flexure, than recto-sigmoid area
)MCC of bleeding in patients with renal failure is platelet dysfunction; treat by DDAVP
)Bacterial meningitis-treat empirically with ceftriaxone+vancomycine
Give iv dexamethasone in intracranial HTN and bacterial meningitis in infants
)The decision of using N-acetyl-cysteine for acetaminophen overdose is based on the drug levels taken at 4h post-ingestion. But if taken>7.5g acetaminophen or levels are not available at 8h of ingestion=>start treatment
)COPD exacerbation with: ph=7.32, pco2=52, po2=60=> give NIPPV (non-invasive positive pressure ventilation)-the indications are:
ph<7.35
pc02>45mmHg
Resp. rate>25/min.
)Adult Still's disease-variant of RA
-at 20-30 years of age
-high spiking fever
-salmon colored rash along with thye fever
-arthralgias, lymphadenopathy, high Le
)Any gunshot under the 4th i.c. space=>do laparotomy of the abdomen
)Latex allergy-associated with spina bifida
-gives anaphilactic reaction to "sex and surgery" (because of condoms and surgical gloves)
)Selection bias=loss of follow-up in a prospective study
)Reccurent myocardial infarction-detect by serial CK-MB levels
)RTA 1-assoc. with Sjogren syndrome
-urine ph>5.5
low HCO3
low K+
RTA 2-osteomalacia
-urinary ph<5.5
low HCO3 levels
-low K+
)Corrected Ca=measured Ca+0.8 (4.5-measured albumin)
For each 1g of lost albumin, Ca goes down by 0.8-1mg%
)Cavernous sinus thrombosis-like orbital cellulitis but with cranial nerves involvement (III,IV,V, VI) and bilateral
-treat by Antibiotics, then anticoagulation and corticosteroids
)Acute pancreatitis and non-alcoholic=>suspect gall-stones=>do US=first step; do CT only if Le>20000/ml and suspect necrotising pancreatitis
)DM foot ulcer-treat by cephalosporine, ampi/sulbactam, clidamycine+fluoroquinolone
)Syringomyelia=areflexic weakness + dissociated anesthesia in a "cape" distribution in the upper extremities
)Emergent contraception=estradiol+norgestrol, 2 tb taken in no later than 72h, 12h apart
)HIV individuals-give Td vaccine
)Aspirin sensitivity syndrome=pseudo-allergic reaction; treat with leukotriene inhibitors=drug of choice
)To confirm Ankilosing spondilitis=>do X-ray of the sacro-iliac joint, if not conclusive=>do CT
)Splenic rupture- the need of surgery determined by:
a)vital sighns+hemodynamic stability
b)change in hematocrit over time
c)need for blood transfusion
)NTG-dilates the capacity vessels not the resistance vessels=>reduces preload
)Molluscum contagiosum-poxvirus
-diseminated in HIV patients
-central umbilicated, dome shaped
resolves spontaneous in 1 year
)Bullous myringitis-painful vesicles on the timpanic membrane
-mycoplasma or viral infection
)Drug-induced pancreatitis: valproic acid, diuretics (loop and thiazidic), 5-ASA, sulfasalazine, imunosuppressive (L-asparaginase, azathioprine), AIDS-patient (didanosine, pentamidine), metronidazole, tetracycline
)Cystinuria-reccurent stones since childhood
-family hystory
-hexagonal crystals, hard stones which are radio-opaque
-screening test=urinary cyanide nitroprusside test
)Antiphospholipid syndrome-reccurent fetal losses, reccurent artery+vein thrombosis
-types-I has false (+) VDRL
-II has lupic anticoagulant=>false + APTT
-III-has anticardiolipin antibody
treat in pregnancy by: heparin+aspirin and measure factor X activity and not APTT for treatment
)Gilbert syndrome-associated with fasting, alcohol, stress, complete reversal with phenobarbital
Crygler Naijar 1-billirubin=8-30mg%, kernicterus, no response to phenobarbital
Crygler Naijar 2-billirubin<20mg%, no kernicterus, 25% response to phenobarbital
)In gonochoccal arthritis=>do urethral culture to identify the gonococcus
)Common variable imunodeficiency=15-35 years of age
-normal B and T cells
-frecq. sino-pulmonary infections
-low IgG, Ig M, Ig A
Wiskot-Aldrigh=has low IgM, but high Ig A, IgE
)Acute appendicitis-can perforate and give pelvic abcess with diarrhea, fever, tender mass on rectal exam, low abdom pain and not the usual sighns of appendicitis
)PTCA=has better outocme than thrombolysis
)NPV is high and PPV is low if the pre-test probability of the disease is low
)Microalbuminuria in DM=>start ACE inihibitors even if no HTN
)Motility disorder of the oesophagus=>do contrast study=>then oesophagoscopy to exclude mecanic causes (strictures,cancer)=>only then manometry
)Chronic headaches+painless hematuria=>think analgesic nephropathy due to papillary necrosis
)Terminal patients with severe pain=>give short-acting morphine, then long-acting narcotics
)Campylobacter jejuni-MCC of diarrhea
-in undercooked poultry
-diarrhea is watery or hemorrhagic
)Craniopharingiomas-bimodal distribution:
-children (gives growth problems)
-55-65 age group (gives sexual dysfunction, bitemporal hemianopsia-think of a truck driver who has to turn his head all over when looking sideways
)Chlamydia screening-do it in all women under 25 years of age if sexually active
)Nonseminomatous tumor-may give ant.mediastinal mass, high AFP, HCG; treat by cysplatinum for 6 weeks; use the above two markers to monitor the therapy
)Signs of high ICP: dilated pupils, anisocoria
flaccidity, decerebrate or decorticate posturing
papilledema
NOT Glasgow coma scale=it assesses the severity of head injury only
)Matching=tool that makes cases and controls have similar distribution of some important confounding variables; it's an efficient mean to control confounding
)Warfarin induced skin necrosis-pain, bullae, skin necrosis; use heparin until they heal
)Furosemid-is ototoxic
)SLE-has-low T supressor cells, high T helper cells>B-cell hyperactivity>high serum Antib and Ig G auto-anitbodies which form the immune complexes
)Hyperlipidemia 1 and 5=associated with pancreatitis
)In PCP in HIV patients give steroids, besides TMP/SMX if:
-Pa O2<70mmHg
-A-a gradient>35=150-(1.25*PCO2)-PO2
sat O2<75%
)Amantadine-dual drug=anti-viral+anti-Parkinson
)Granulosa cell tumors-precocious puberty
-postmenopausal bleeding
)Trachoma-given by chlamydia trachomatis (A-C)
-cause of blindness by neovascularisation=pannus
-follicular conjunctivitis
-treat by oral erytro or tetracycline
)Anserine bursitis-medial knww pain below the joint line, hystory of trauma
-valgus stess test is (-), it's (+) in medial collateral ligament strain
-X-ray of tibia is normal
Patellofemural syndrome-in females <45 years
-ant. knee pain aggravated by flexion
-retropatellar tenderness and crepitation
)A narrower CI=>the study is more precise
)If DM type II is not controlled by one hypoglicemic agent, add another one from another class; give insulin only if BUN and Cr are abnormal
)In acute bacterial prostatitis=>get urnie sample for culture before starting empirical antibiotics
)Acute variceal bleeding-give octreotid; beta-blockers are for prophylaxis
)Mucormicosis-treat by surgical debridement and amphotericin B
)Labetalol=drug of choice in pregnancy if HTN+DM nephropathy
)Open-angle gluacoma-cupping of optic disk
-loss of peripheral vision=tunnel vision
-more frecq. in African-Americans
Macular degeneration=central vision loss
)Give MMR to all HIV patients (except those severly compromized)
)Patients with impaired consciousness, advanced dementia=>predisposed to aspiration pnemonia due to impaired epiglotic function
)In patients with frecq. attacks of gout=>first step is to measure 24h urinary uric acid level
-<800mg/day=>under-secretion (probenecid)
->800mg/day=>over-production (allopurinol)
)Ulnar nerve syndrome=MC site of entrapment is: medial epicondilar groove; think of counter clerks who sit with their elbows on the table all day
)In CHF-improved survival by: aspirin, beta-blockers, ACE inhib., spironolactone
-don't improve survibal: digoxin and loop diuretics
)What acid-base disorder is this?
ph=7.53
pco2=30mmHg
HCO3=24
Cl=85
Na=138
Well, tough one: we have alkalosis and is respiratory because Pco2 is low;
AG=Na-(Cl+HCO3)=29=>metabolic acidosis;
But a change in the AG (increase) is accompanied by a similar change in the levels of HCO3 (decrease). Here HCO3 is normal=> metabolic alkalosis.
Scenario (all three together): pneumonia=>respiratory alkalosis
vomiting=>metabolic alkalosis
DKA (from ketones)=>metabolic acidosis
)Any patient with bone pains, renal failure and hypercalcemia has Multiple Mieloma until proven otherwise
)Sudden RUQ pain+rise in hematocrit levels with hepatomegaly, splenomegaly and ascites=>think Budd-Chiari syndrome (from polycitemia vera)=>first step=hepatic venogram or liver biopsy
)Carotid stenosis of >60%-99%=> do CEA even if asymptomatic; complete occlusion= c.i. to surgery
)Lichenus sclerosis-dryness, severe itch, vaginal soreness
-may give vaginal cancer
-do biopsy to rule out cancer
-treat by topical steroids
)Retinal artery occlusion-treat with occular massage+high flow O2
-give thrombolytics within 4-6 hours of visual loss
)TCA- cardiotoxic potential=>because they inhibit fast Na channels
-to asses the severity of the toxicity=>get QRS duration
)Pneumovax-has capsular polysacharrides and gives T-cell independent B cell response; live vaccines give T-cell dependent......
)All uncouncious patients, even those breathing need airway established by:
-intubation in the ICU
-cricothyroidectomy in the field
)In unstable angina=> no thrombolytics; give aspirin, heparin, NTG, beta-blockers
)In MI, give thrombolytics after sublingual NTG to rule out vasospasm.
)VF=is a reentrant ventricular arrythmia
)Superficial spreading melanoma=MC
-increased intraepithelial atypical melanocytes
Acral lentiginous melanoma-on palms, soles, beneath nail plate
Lentigo melanoma-head, neck, arms of fair skinned older people
)Diuretic use (also thiazidic)=>gives metabolic alkalosis
)Euthyroid sick syndrome: low T3, Normal T4, normal TSH; in severe disease: low T4+T3, normal TSH
)Cholesterol embolism-follows surgical or intervention on arterial tree
-livedo reticularis, gangrene, ulcer or mottling of toes
-systemic eosinophilia, low complement levels
-renal failure (eosinophiluria)
)If an ulcer is seen on colonoscopy=>do biopsy to rule out cancer
)Subconjunctival hemorrhage-benign condition, observe only; think of a person with a red eye on awakening in the morning
)Parvovirus infection=>arthralgias of small joints with 5-10 min morning stiffness, normal ESR, no signs of inflamation locally
-joint involvement is symmetrical+-rash
)Intermitent claudication-give aspirin and exercise program
-do angiogram only pre-op,otherwise do duplex arterial study if you want imaging
)Acantosis nigricans-insulin resistance (DM)-in young people
-gastro-intestinal malignancy in the older
-symmetrical, hyperpigmented, velvety palques in axilla, groin, neck
)Drug-induced acute allergic interstitial nephropathy:
a)antibiotics (meticilline, cephalosporine, sulfonamides...)
b)NSAID
c)thiazides
d)phenytoin
e)allopurinol
)Epiglotitis-given MC by H.influenzae type B and strep. group A
)Food droolong out of the mouth and nose during meals=Zenker diverticulum=> can give aspiration pneumonia
-diagnose by oesopphagography
)Chronic diarrhea=>oxalate stones (due to malabs. of fatty acids, they bind Ca and oxalate is free for absortion)
)Gardner syndrome:colonic polyps+lipoma, nasal angiofibroma, gastric polyps, osteomas, epidermoid cysts, more teeth
)Amebic hepatic abcess-"anchovy paste" in the liver
-treat by oral metronidazole (not percutaneous drainage)
-in the tropics acquired
)Cluster headache=>treat by 100%O2 and s.c. sumatriptan; prophilaxis: verapamil, Li, ergotamine
)Vaginal delivery in breech:
-frank or complete breech
->36 weeks of gestation
-weight:2500-3800g
-adequate maternal pelvis
External cephalic version-converts breech into cephalic presentation=>use over 37 weeks until the onset of labor
Internal podalic version-in twin delivery (from transverse/oblique to breech)
)Friedrich ataxia-ataxia, dysarthria, skeletal deformities (scoliosis, hammer toes, pes cavus), cardiomyopathy; three words: neurologic, cardiac and skeletal problems
)Pseudogout-can be triggered by surgery or trauma
-may have 100000 Le/ml in joint fluid
)Nosocomial infections-UTI
-surgical wound infection
-pneumonia
)Know the X-ray appearance of descented aorta aneurysm-well circumscribed lesion=>due to aterosclerosis
)For acute aortic dissection=>use first TEE or CT(only if hemodynamically stable)
)Herpetic withlow-HSV 1 and 2
-in health care workers
-pain in the finger pulp with vesicles and systemic symptoms
-treat by acyclovir+topical bacitracin (to prevent secondary infection)
Felon-appears in tailors
-from needle injuries
-it's a bacterial abcess (tense abcess)=>do drainage+cephalosporine
)Urinary diversion procedure (ureter implanted in the ileum for example)=>gives Hyper Cl metabolic acidosis because the colon absorbs NH4+ derived from ureea under the action of intestinal bacteria
-also the pum Cl/HCO3 functions like this: absorbs Cl, lets HCO3 go!
)Tinitus-by aspirin, quinine
-also in Meniere disease, acoustic neuroma and ...depressed patients=>give TCA
)Chronic myelogenous leukemia=>give IMATINIB (Gleevec)=Tyrosine kinase inhibitor; side effects are: nausea, diarrhea, cramps, rash, face swelling, temporary reduction in blood cell production
)Post-herpetic neuralgia=>give acyclovir
-follows acute herpetic-zoster infection
)Intra-uterine fetal demise (IUFD)-death in utero>20weeks
-Beta-HCG remaind eleveted
-confirm with US
-first do a coagulation profile to assess the risk of DIC
<=>between 13-28 weeks, no DIC=>watchful expectancy
<=>between 13-28 weeks, with DIC=>induction of labor with PG suppositories
<=>after 28weeks, with/out DIC=>induction of labor with oxytocin and laminaria tents
-can use vaginal delivery
So, in case of DIC=>deliver immediately by induction of labor
)Acute retinal necrosis in HIV patients
-pain, keratitis, uveitis
-peripheral pale lesions+central retinal necrosis
-given by HSV or VZV
CMV retinitis=hemorrhages+granular lesions around the retinal vessels
)Pneumonia after upper GI endoscopy=>suspect anaerobic bacteria=> give clindamycine or ampi+metronidazole
Ampi+genta=used almost NEVER for pneumonia, they are used for abdominal infections+-metronidazole
)Cyclophosphamide=> can give bladder cancer
-prevent by lots of fluids and mesna
)Stress fracture (March fracture) or insufficiency fracture:
-young adults who exercise a lot
-X-ray=normal, dignose it with CT or MRI
-dull pain increased by exercise
-point tenderness
-at metatarsal, navicular, neck of femur/tibia
)Hypothyroidism-consider in patients with unexplained high CK levels
)Bicuspid aortic valves=>can give aortic stenosis later in life (4-5th decade)=MCC of aortic stenosis in middle-aged adults
)Seborrheic keratosis-in the elderly
-0.3-2cm large
-slow enlargement
-greasy surface, stuck on appearance-HIGH YIELD these words
-varies in color
-anywhere on the body, except palms and soles
-can itch or rub
-do shave biopsy (DON'T DO IT FOR MELANOMA)
)Aspirin toxicity-gives metabolic acidosis and respiratory alkalosis (not normal compensation, but two distinct processes)
)Gastroparesis-treat in order by: metoclopramide, bethanecol, erythromycine; also cysapride-but it gives cardiac arrythmias
-confirm study=Nuclear Medicine Scintigraphy
)To determine the type of jaundice (conjugated or unconjugated) do:
-check urnary excretion of billirubin
-Van der Bergh test
)Lyme disease prophylaxis-do it only in pregnant women with hystory of tick bite in order to RELIEVE ANXIETY by Amoxi
-give vaccine to people living in moderate/high risk areas
-to the rest of the population=NO PROPHYLAXIS
)MCC of SAH (subarahnoid hemorrhage) syndrome in children is AVM rupture
-may have a case with hystory of seizures and migraine-like headaches
)Screen patients for lipid abnormalities:
-men>35 years
-women>45 years, if in good health or
between 20-35 (M) and 20-45 (W) if they suffer from:
a)DM
b)family hystory of hyperlipidemia
c)personal risks of CAD
d)family hystory of cardiac disease<50 years (M) or <60 years (W)
)Gout attacks-give:
-low-purine diet
-no alcohol=>metabolises to lactic acid=>impairs renal excretion of uric acid by acidifying the ph
-avoid diuretics, pyrazinamide=>they compete with uric acid for renal excretion
)Penile fracture=emergency
-penis deviated to one side due to the rupture of albugineea of a cavernous body
-first do retrograde urethrogram, then surgical exploration of the penis
)Hypercarotinemia-in anorexia, DM, hypothyroidism
)A confounder (ex.smoking), to be considered so, needs to be linked to the:
-exposure (ex.people who drink alcohol are more likely to smoke)
-outcome (ex. smoking is associated with oral cavity cancer)
So smoking can be a confounder if a study concludes that alcohol alone is responsable for oral or oesophageal cancer!!!
)Effect modification=the effect of exposure (ex.drugs) on outcome (a disease) is modified by another variable ( ex.family hystory). This effect is not BIAS!!!
)Amiodarone=> don't give it if low BP
)Lesion suspicious of melanoma=>do excisional biopsy with narrow margins
)Radioactive iodine=treat of choice for Grave's disease
Antithyroid drugs-give in pregnancy+Grave's
-pre-op for surgery on Grave's
Iodinated contrast agents=>treat thyrotoxicosis
-give them if intolerant to anthytiroid drugs
Surgery-if:
-very large goiters
-antithyroid drugs do not control thyrotoxicosis in pregnancy
-increased risk of malignancy
-if next year scheduled pregnancy
)Petrous apicitis-triad=retro-orbital pain, paralysia of lateral rectus, otorrhea
)Anoscopy/proctoscopy=first step for blood per rectum in patients <50 years of age, without risk factors for colon cancer (here's not included blood mixed with stool=this is a risk factor)
)Sickle cell disease-aplastic crisis-prevent by folic acid administartion and NOT by vaccination against parvovirus (which is a nother cause)
)Exercise level in pregnancy=keep it at the same level as before preganancy
)Phenothiazine-gives hypothermia, inhibit shivering-think of a schizo wandering in the streets in winter and is found lying in a park
)If someone exposed to HBV is vaccinated already and HAS a documented response to HBV (by prior adequate titer of antibodies)=>do nothingm, just reassure!!!
)If in 2 weeks from the beginning of a pneumonia, the CXR is still pathologic=> do bronchoscopy and CT scan to rule out abcess or tumor and to take cultures, to drain...
)A reliable test gives similar results on repeat measurements
A valid (accurate) test gives results that can be compared with a gold standard test!!!
)Graft versus host disease=> affects skin (rash), intestin (blood+diarrhea), liver (abnormal LFT)
-by activation of donor T-cells, so it's cell-mediated immune response
)In DKA there's a paradoxycal hyper K+ from acisosis, because the reserves of K+ are actually depleted=> so give K+ in your treatment plan
)FIRST sign of colo-rectal cancer under 40 years of age=Rectal Bleeding
)Removal of K+ from the body=cation-exchange resin (kayexalate), diuretics, dialysis; NOT Ca gluconate, NOT insulin (these create only a shift intracellularly)
)Roth spots and Osler nodulesm in IE are from immune complex deposition (immune vasculitis)
Janeway lesions=septic embolism
)Optic neuritis=rapid vision decrease
-marked changes in color perception
-pain on eye movements
-central scotoma
-afferent pupillary defect
-swollen disk
)Myotonic muscular dystrophy
-begins in childhood (~13 years)
-AD disease
-muscle weakness, wasting in distal hands, post. forearms, ant. compartment of legs
-myotonia=delayed relaxation
-associated with testicular atrophy, DM, frontal balldness, hypothyroidism
)Matitis-in nursing
-treat by anti-Staph penicillin
-continue nursing to decrease breast engorgement and observe
-drainage only if there'sa fluctuating mass (=abcess)
)Atracurium-metabolized in plasma, by serum esterases
-use it safe in renal and liver dysfunctions
Pancuronium+mivacuronium=>not good in renal disease
Rocuronium=>not good in liver disease
Succinylcholine-in renal disease gives Hyper K+ and apneea
)Randomization=similarities in the baseline characteristics of patients in both placebo and treated groups. It controls known/unknown confounders!!!
)Mild acne=>topical retinoids; if reactivation occurs, give topical antibiotics
Moderate to severe acne (papular or inflamatory acne)=>oral antibiotics
Nodulocystic, scarring acne=>oral isotretinoin
)IMPORTANT!!!
In any metabolic acidosis=>first step=get AG (Na-Cl-HCO3); normal is 6-12 (or 8-14 depends on the author)
a)Normal AG metabolic acidosis-usually hyper Cl-2 causes:
-renal loss of HCO3 by RTA, moderate renal failure (GFR>20ml/min), carbonic anhidrase inhibitors
-GI loss of HCO3 by diarrhea, pancreatic fistula, ureterosigmoidostomy
To differentiate between them, get next step=urine AG(Na+K-Cl); normal is from -50 to 0.
If (+)=> defective urine acidification, lower urinary Cl, like RTA 1,2 and 4
If (-)=> higher urinary Cl=>adecquate NH4+ production=> GI causes
Then, urine PH differentiates different types of RENAL causes of acidosis!!!
b)High AG metabolic acidosis:
-lactic acidosis
-ketoacids (DM, starvation, alcohol ingestion)
-methanol ingestion
-ethjylen glycol ingestion
salycilate poisoning
uremia (GFR<20ml/min)
Here, next step is to calculate the osmolar gap (especially if toxicity is suspected)
)Paget disease=disordered skeletal remodelling
Osteoporosis=low bone mass with normal mineralization
Rickets=defective mineralization of bone and cartillage of the growth plate
)Malignant otitis externa-by pseudomonas (in DM, imunocompromized)
-granulations of the ear canal
-involvement of CN VII, IX to XII
-erosion of bone
-foul smelling discharge
-deep otalgia
Rhizopus+Aspergillus are fungal infections that give external otitis, (not malignant), but don't make granulations
)Suspect Zollinger-Elisson syndrome if refractory ulcers are associated with renal stones and there's a + family hystory of PUD
)HIGH-YIELD:
Erythopoietin in dialysed patients-side effects:
-raises BP, even HTN encephalopathy
-headaches
-flu-like syndromes
-red-cell aplasia (rare)
Start treatment at Hematocrit<30% or Hb<10g%
)Gall-bladder pathology-First use US
HIDA scan-for diagnosis of acalculous cholecystitis or suspected on US
)Trichinosis-2 phases:
a)GI upsetsain, nausea, vomit, diarrhea
b)splinter hemorrhages, retinal&conjunctival hemorrhages, periorbital edema, chemosis, muscle pain, tenderness, swelling, weakness
)Eato-Lamber syndrome-earliest manifestation is hip-girdle weakness, later shoulder girdle involvement
)Thioridazine toxicity-cardiac arrythmias, prolonged QRS, low BP, tahicardia; treat by NaHCO3
)Sputum gram stain of pneumonia-purulent specimen if >25 neutrophils and <10 epithelial cells/field
)Respondent bias=when outcome is obtained by patient's response (ex.migraine) and not by objective means of diagnosis (ex.biopsy)
)Tinea corporis infection-itching
-ring-shaped scaly patches with centralclearing and distinct borders
-caused most frecq. by Trichophyton rubrum
-treat by topical terbinafine
-use griseofulvine if only extensive disease (this drug is usually not used today)
)Salivary glands inflamation-from drugs such as: tioureea, iodine, cholinergic drugs
)Hepatitis B-associated with membranous GN
Carrierrs of Hep. B virus-associated with membrano-proliferative GN
)Vit.K deficiency:
-NPO patient
-receiving antibiotics
-high PT, then high PTT (prolongation of PT>> prolongation of PTT)
)Primary sclerosing cholangitis-in Ulcerative Colitis
-complication of it is cholangiocarcinoma=contraindication to transplant
So any severe stricture of the biliary tree MUST BE BIOPSIED!!!
)Mitral regurgitation=MC valvular abnormality in patients with IE
)Hollenhorst bodies=cholesterol particles, signs of impending stroke
)Benzodiazepines-can cause paradoxycal agitation in the elderly
)Congenital cataract=MCC of white reflex in pediatric population
)Any nocturnal, newly diagnosed asthma in middle-aged patients=>suspicion of GERD if associated laryngitis; to differentiate between asthma and GERD give a trial of proton pump inhibitors which can be both dignostic anf therapeutic
)CREST syndrome-may have pulmonary HTN (loud P2 sound)
)Mechanical symptoms in patients with meniscal problems=>evaluate by arthroscopy or MRI, then correct by surgery (arthroscopic or open)
)Latent period-in chronic disease epidemiology; is NOT BIAS
=extended time of continuous exposure is needed to affect the outcome (ex. 2 years of continuous multivitamins administration is needed to give a protective effect against cancer)
)Nitrates are c.i. for at least 24h after taking sildenafil (viagra)
)SCC-scaly plaque, central ulceration, 1.5cm, on the forearm
-polygonal cells, atypical nuclei at all levels of epidermis, zones of keratinization; sometimes is difficult to tell it apart from BCC
)Hypo K+ metabolic alkalosis:
-vomiting=>low urine Cl
-S. Bartter
-S. Gitelmann
-diuretic abuse; all three have high urine Cl
)Otosclerosis-AD disease
-Women>>men
-more in Caucasian race
-treat by NaF
)Lactose intolerance-diagnose with Lactose Breath H+ Test or (+) Clinitest for stool reducing substances
-high osmotic stool gap=290-2(stool Na+stool K)>50mosm/kg
)Goodpasture's syndrome-give emergent plamapheresis!!!
)Metastatic bleeding brain mass=> FIRST think MELANOMA
Tumors that don't metastisize to the brain are:
a) non-melanomatous skin cancer
b) oropharingeal cancer
c) oesophageal cancer
d) prostate cancer
)Parkinson's tremor=>gibe benztropine
Choreea Huntington=>give haloperidol
)Vitreous hemorrhage-sudden, acute loss of vision
-sudden onset of floaters
-fundus is hard to visualize, floating debris, dark red glow
-treat conservatively-sleep in upright position
)Prematurity-cause of intraventricular hemorrhage
)Mamography-do it annually between 50-75 years
FOBT-anually; 50-80 years
sigmoidoscopy-every 5 years between 50-80 years
Pap smear-until the age of 65 years, not after
Lipid screening-men>35y
-women>45y
-not >75y
-??unknown recommendations between 65-75y
)Alpha-1 antitrypsine deficiency in non-smoker, 3rd decade of life, lower lobe emphysema, neonatal jaundice in hystory
)Relapsing polychondritis
-recurrent inflamation of cartillaginous structures: ear=MC,spares the lobules; eye (conjunctivitis, episcleritis); joints (diffuse joint pains); skin; CNS.
)Fracture of calcaneum due to fall=> evaluate for other potetial fractures by X-ray of head, chest, abdomen, lumber area and pelvis
It's a very painful fracture and prior taken narcotics may alter pain perception
-so give morphine in severe pain, but after investigating for potential injuries (head and neck first)!!!
)Li-can cause seizures, opisthotonus, hyperreflexia, coma
)Attributable risk percent (ARP)=risk in exposed-risk in unexposed/risk in exposed=1-risk in unexposed/risk in exposed=1-1/RR=RR-1/RR
-it's the excess risk in the exposed population attributable to the risk factor!!!
)Impaired NH4+ excretion=main mechanism of metabolic acidosis in renal failure
)Hypo K+ periodic paralysis-by stress or medication
-sudden drop in K+ levels
-renin=normal, BP=normal
-familial condition or thyrotoxicosis
)Bartter syndrome=hypoK+ metabolic alkalosis
-impaired Na absortion in Henle ascending loop=hypovolemia=>activate RAA syste
-polyuria, polydipsia, growth abnormalities
-high urine Cl
)Serous otitis media=>air bubbles seen in the middle ear
Cholesteatoma-marginal tympanic membrane perforation, ear canal filled with mucus, pus, granulation tissue, destroys bone; remove surgically
)All patients suspencted of Zollinger-Elisson syndrome should have checked:
-first: serum gastrin levels (if>1000pg/ml are diagnostic); if not diagnostic,
-then:secretin stimulation test, if (-),
-then: Ca infusion study
Also measure gastric PH once to exclude hypergastrinemia from achlorhydria
)Chlamydial urethritis-dysuria, urinary frecquency
-mucopurulent urethral discharge
-sexual hystory of multiple partners
-pyuria+absence of bacteria on urialysis (colonies<100/ml)
In gonochoccal, the discharge is purulent!!!
)Differentiate CML from leukemoid reaction by measuring Leukocyte Alkaline Phosphatase (LAP); low in CML, high in leukemoid reaction!!!
)Lewy body dementia-fluctuating cognitive impairement
-reccurent visual halucinations
-motor features of Parkinson
Pick's disease-fronto-temporal
-personality changes (euphoria, dezinhibition,apathy)
compulsive behaviour
-peculiar eating habits, hyperorality
-impaired memory
-visuo-spatial function=intact
)Transient synovitis of the hip:
-X-ray=normal
-2 weeks after URI
-high ESR
-pain of joint movements
-treat by bed rest and hip joint in the position of comfort
)Beta-blockers intoxication-treat by:
-atropine, if fails
-isoproterenol, if fails
-glucagon
)Gold standard for osteoporosis is DEXA scan
)Increased ventilatory rates onmechanical ventilation=>can lead to auto-PEEP=>lowers BP
-treat by decreasing the ventilator rate
)Erythema nodosum-may be the first sign of sarcoidosis
-goes with flare-ups of IBD
-appears in TB too
)Osgood-Schaltter disease-treat with rest, NSAID, brief casting
)Beta-blockers-selective beta 1 are agents of choice for perioperative MI risk decrease
)Cocaine abuse-young, venous trace marks, EKC with ischemia (ST depression), tahicardia, HTN
-treat-first line: Benzodiazepine, then nitrates, aspirin
-do catheterisation only if MI is obvious!!!
)Use aspirin in children only in:
a)Kawasaki disease
b)Juvenile rheumatoid arthritis
)Patients on both Mg(OH)2 and Kayexalate can get metabolic alkalosis due to the fact that Kayexalate bind Mg, so HCO3 remains in access and can be reabsorbed from GI tract!!!
)Treatment of hypo Na (SIADH):
-mild, asymptomatic, Na=120-130: fluid restriction
-moderate, asymptomatic, Na=110-120: normal saline+loop diuretic
-severe, symptomatic: hypertonic saline (3%)+loop diuretic
)Laxative abuse-10-20 evacuations/day and night,cramps=cause of factitious diarrhea
-on colonoscopy you see melanosis coli, because of the use of anthraquinone-laxatives (bisacodyl) and is dark-brown discoloration of the colon with shining limph follicles as pale patches
)Cyclosporine side effects=HIGH YIELD:
a)nephrotoxicity, high K+
b)HTN-tret with Ca channel blocker
c)neurotoxicity-tremors
d)glucose intolerance
e)infections
f)malignancy
g)gingival hypertrophy, hirsutism
h)GI complaints
Tacrolimus-same side effects except no gingival hypertr. and no hirsut.
Mycophenolate=>bone marrow suppression
Azathioprine=>bone marrow suppression,hapatotoxicity, diarrhea, leukopenia
)Pernicious anemia=>has high levels of LDH
)Nosocomial pneumonia in intubated patients=>think Pseudomonas=>give cefepime or ceftazidime (4th generation)
)A definite diagnosis for Alzheimer's disease can be made only post-mortem by brain biopsy!!!
)Chronic fatigue syndrome-like fibromialgia,but no trigger-points+symptoms of at least 6 months duration
)Barton's fracture-intraarticular, carp+distal margi of radius
Chauffeur's fracture-of radial styloid
Galeazzi's fracture-anywhere on the radius+radio-ulnar junction
Smith's fracture-reverse Colles fracture
)Null-hypothesis for cross-sectional study:
There's no association between elevated ESR level and colon cancer!
Null-hypothesis for cohort study:
The risk of colon cancer is the same for the subjects with and without elevated ESR level
)Descending aortic aneurysm in a young male is frecq. due to blunt trauma to the chest!!!
HIGH-YIELD:
)Bullous penphigoid=IgG+C3 deposits at the dermal-epidermal junction
-no oral lesions
-tense blisters in flexural areas
->60 years of age
-pruritus precipitated by UV, NSAID, antibiotics
Pemphigus vulgaris-intraepidermal blistering disease with auto-antibodies to adhesion molecules
-Ig G deposits intracellularly in the epidermis
Cicatricial pemphigoid-affectsmucous membrames
-Ig G deposits in linear band at the deromo-epidermal junction
Herpes gestationis-2nd trimester
-sub-epidermal blisters
-deposits of C3 at the basement membrane zone
)Amphotericine=>can give hypoK+
)Hshimoto thyroiditis:
-low TSH, high T4, T3, high T3 resin uptake
-low radioactive iodine uptake
-high thyroglobilin level
-non-tender goiter
-dry mouth&eyes
)Leukoplakia:
-increased risk of SCC
-from tabacco, vit. A, B deficiencies, syphilis
-do incisional biopsy or exfoliative citology examination!!!
)Soemtimes UC can involve the terminal ileum=>backwash ileitis
)Adult PKD complications:
-hepatic cysts
-valvualr heart disease (MVP, AR)
-colonic diverticula
-abdominal wall and inguinal hernia
)Thrombastenia Glanzmann-RA disease
-defect in GP IIb-IIIa
-increased BT
-trombocytes=normal, vWF=normal
-clot retraction is decreased
-epinephrine, colagen, thrombin and ADP fails to induce aggrgation
-normal response to ristocetin test
Bernar-Soulier syndrome-giant trombocytes, bleeding tendencies
-lack of aggrgation to vWF and ristocetin
-normal responde to ADP
-abnormality in GP Ib
)Acalculous cholecytitis:
-extensive burns
-severe trauma
-prolonged TPN
-prolonged fasting
-mechanical ventilation
)HIV patients with esophagitis-give fluconazole against Candida; if it donesn't cure, then and only then do esophagoscopy, cytology, biopsy, culture!!!
)In alkali ingestion(ex. lye)=>do contrast study with gastrografin+endoscopy as easrly as possible
-don't give charcoal=ineffective!!!
)Bupropion-can be given with nicotin patches, monitor BP=>risk of HTN
-causes weight loss
-risk of seizures=>don't give to anorexic patients as antidepressant
)In tumor lysis syndrome=>give allopurinol+hydration!!! If on allopurinol, give only 25% of purine antagonists (mercaptopurine, azathioprine)!
)In heat stroke=>rapid cooling with evaporating cooling=choice,then gastrci lavage or imersion in cold water
)Dermatitis herpetiformis=>dapsone
)In metab acidosis=>look for compensation (PaCo2)=>look at AG=>look at variation of AG and HCO3; one goes up and the other should go down, if this is the only acid-base problem, so the divisation of their variations is equal to 1!!!
)Prevalence high=>high PPV, low NPV
)Nickel jewelry, poison ivy=allergic contact dermatitis (type IV reaction)
)Do thyroid function tests if:
-hyperlipidemia
-unexplained low Na
-high CK levels
)Treat strep.pharingitis with one shot of benzatin-penicilline G i.m.
)MC complication of PUD=hemorrhage
)MC drug causing priapism=prazosin
)Asymptomatic lymphocytosis in older=>suspect CLL=> lymphadenopathy=>hypogamaglobulinemia=infections!
-Smudge cells are characteristic
-lymph node biopsy is not required for diagnosis, but it confirms it!
)In primary billiary cirrhosis-give ursodeoxycolic acid=first line, second-line=cholestiramine; ultimate cure=liver transplant
)Actinomycosis-anaerobic gram (+) branching bacteria
-draining infection, indurated area
-sulfur granules
-treat by high dose penicilline or erythromycine 6-12 weeks!!!
Another cause of draining face/neck infection=scrofula!
)Scoliosis-Cobb's angle
-mild curve<20degrees=>careful follow-up to assess the rate of progression
-20-30 degrees=>choice between observation and bracing is made on the presence of rotational deformity and + family hystory
->30 degrees=>bracing
->40degrees=> surgery
)Unacceptability bias=participants' response with desirable answers which leads to underestimation of the risk factors-ex. medical students are asked to complete a survey about whether they smoke or not...some may say that they don't smoke just because they know that smoke is bad for health!!!
)Hystory of normal skin at birth+gradual progression to dry scaly skin=ichthyosis
-dry skin with horny plates over the extensor surfaces of the limbs
-worsens in winter due to increased dryness=lizard skin!
)Markers of adrenal tissue: DHEA, DHEA-Sulfate
Testosterone+androstendione coem equally from ovaries and adrenal glands
)Symple renal cyst on CT=>reassurance (know the CT appearance), but investigate if:
-multilocular mass
-thcikened irregular walls and septae within the mass
-contrast enhancement
)In mononucleosis, patients can play sports only when physical exam is normal (no splenomegaly)
)TIA-give anticoagulation if embolic
-in the rest, give aspirin; if fails, give clopidogrel, if fails, give ticlopidine
-aspirine+dipiridamole-if there's a hystory of TIA on aspirin alone
)Zellweger's syndrome-defect in peroxisomes
-neonatal seizures
-facial dysmorphism
-hypotonia, wide open sutures, cloudy cornea, glaucoma
-they live only a few months
Neonatal adrenoleukodystrophy-no dysmorphic features
-enlarged liver, abnormal LFT, pigmentary degeneration of retina, impaired hearing
X-linked adrenoleukodystrophy
-accumulation of fatty acids (log chain ones)=>pregressive adrenal cortex dysfunction and CNS white matter
Infantile Refsum disease
-gait problems, hearing loss, pigmentary degen. of retina, dysmorphic features
Classic Refsum disease-young adulthood
-visual problems (night blindness), ataxia, cardiac arrythmia, ichthyosis, peripheral neuropathy
)Osteoporosis-acute backpain with noobvious preceding trauma in the elderly women=compression fractures of the vertebrae
)More than 5 days of symptoms of appendicitis with RLQ findings=>give iv. hydration, antibiotics (cover gram (-)), bowel rest
)Chronic therapy with Vit. D=>hyper Ca
-stop vit.D, low Ca diet, acidify urine, give corticosteroids!
)To control confounding-means:
-matching
-randomization
-restriction
Selection bias=>controlled by selecting a representative sample of the population for the study+high rates of follow-up
Ascertainment bias=>avoided by a strict protocol of case ascertainment
Observer's bias=>controlloed by blinding
)Patients with dyspepsia and <45 years of age without alarm symptoms (bleeding, anemia, dysphagia, weight loss)=>first step=Non-invasive test for H.pylori (breath test or serologic test)
-if +=>eradication therapy of H.pylori
-if -=>empirical trial of H2 blockers or PPI or prokinetics
If >45 years or with alarming symptoms=>do endospcopy+H.pylori testing
)Hematuria+irritative or voiding symptoms=>suspect bladder cancer, even in a patient with large, firm prostate
-associated factors: cigarette smoking, suprapubic pain, long hystory of analgezic use
)Chronic ITP-can be a feature of SLE; that's why in chronic cases of ITP=> do BM biopsy
)In conjugated hyper bilirubinemia=> first do LFT, then US of CT scan
)Dubin-Jonhsons+Rotor syndromes=> have normal ALP
)Hawthorne effect=tendency of the studied population to affect the outcome due to the fact that they are being studied!!!
Sample distorsion bias=when the sample is not representative for the whole population in "exposure" and "outcome"
Information bias=imperfect assessment of association between exposure and outcome as a result of errors in the measurement of exposure and outcome-it's minimized by standard techniques for surveillance and measurement+trained observers
)HIGH-YIELD:
Left ventricle dysfunction: high RA and PCWP pressure
Septic shock: low PCWP and RA pressure, low SVR, high debit
In pericarditis, tamponade=>RA pressure=PCWP and both are high
RV infarct=> low PCWP, low BP
)Post-prandial worsening pain+avoidance of food+risk factors for atherosclerosis=abdominal angina
)Hydatid cysts-Echinococcus granulosus
-asymptomatic
-mostly in the liver, but also lung
-comes from sheep
=fluid-filled cyst with numerous secondary daughter cysts
Pig farmers=> get neurocysticercosis
Commercial sex-worker=>can get perihepatitis from STD (gonorrhea)
)Congenital adrenal hyperplasia-hirsutism, virilization+very high levels of 17-HO-progesteron, normal Testosteron and DHEA
Idiopatic hirsutism-from excessive peripheral conversion of testosteron=>dihidro-testosteron
)If bleeding >25-30% of blood volume (or 1500ml)=>give blood transfusion
In trauma, usually give 2l of crystalloid solution in 10 min=>if still hypovolemic=>give blood
Give blood also if:
-Ht<25%
-Ht<30%+ COPD, Ischemic Heart, chronic renal failure
-unexplained acidosis in anemic patients
)Epiglotitis=>first do fiberoptic laryngoscopy to establish a diagnosis, then do nasotraheal intubation (alternative=traheostomy)
)HIGH-YIEDL-Know this thouroughly!!!
low PCWP, normal MV02 (mixed venous O2 concentration)=>is septic shock; also: low RA pressure, high debit, low SVR
low PCWP, low MVO2=>is volume depletion or neurogenic shock
)Atopic dermatitis-infants<6 months
-pruritus
-symmetrical-scalp, cheeks, trunk, extensor areas
-unknowun etiology
-in acute attacks give low-moderate potency corticosteroids
-spares diaper area (contact dermatitis does not)
Exfoliative dermatitis-over 40 years of age
-prior dermatological condition, systemic illness, new medication
)Dehydration in diabetes insipidus=>give normal saline; once the volume deficit is replaced, can switch to 0.45% saline to restore water deficit
)HIGH-YIELD
CT scan=>use it to evaluate the extent of newly diagnosed gastric cancer; treat by surgery
)In dialysis-persist or worsen the followings: anemia, HTN, bone disease, autonomic neuropathy
)Intrahepatic cholestasis of pregnancy
-3rd trimester with jaundice
-marked pruritus, high AST, ALT(<200), very high bile acid levels, ALP<200, PT=normal
)If suspect IUFD=>GET US, then coagulation profile
)Spontaneous hemarthrosis=>think hemophilia
)Osteogenesis imperfecta=>get type 1 collagen assay
)If one parent gives consent for the treatment of a minor is sufficient 9even if the other one disagrees)=>go ahead with the treatment!!!
If both parents refuse treatment=>get a court order if the situation is not emergent!!! If it's emergent=>treat as you see fit; you are protected by the law that you act in the best interest of the child!!!
)Inhaled steroids=> can give dysphonia, thrush
)In a ureteral colic, one can have intestinal ileus=>do CT scan or IVP; treat by ureterolithiasis
Enteroclysis=used to diagnose small bowel tumors or other pathology which cause intestinal obstruction
)In case-control studies, if prevalence of the disease is low=>odd ratio=~RR (this is rare disease assumption). They love these questions, try to understand them, though they are difficult!!!
)Study of choice for abdominal aortic aneurysm=abdominal US
)Malignant melanoma-MC as a changing mole
-hystory of sun exposure
3 major crteria:
change in-color
-shape
-size
4 minor criteria:
inflamation
bleeding/crusting
>7mm
sensory changes
)In metabolic alkalosis from vomitting=> give K, not Ca which is normal in total, only ionized is decreased
)In acute respiratory alkalosis=>PH raisis the afinity of Ca for albumin=>decreased ionized Ca, increased albumin-bound Ca, normal total Ca and normal Ca bound to inorganic anions
)Chronic pancreatitits with central duct>1cm and severe pain=>do lateral pancreatico-jejunostomy
)Alcoholism=>can cause rhabdomyolysis (drunk man lying in a park)=> urine dipstick is + for blood but (-) for RBC=>from myoglobinuria
)IE of drug users: give vanco+genta because of high incidence of meticillin-resistant Staph
-if not drug abuser=>give naph+genta
)Acarbose (alpha glucosidase inhibitor)=> don't allow carbohydrate breakdown in the intestin=>high carbohydrates in the stool!
-indicated in late onset type II DM
)Dysphagia to both solids&liquids=>achalasia=>domanometry, but alsoendoscopy to rule out cancer
)Acute monicitic leukemia- M5A in young (~16 years)
- M5B-middle age(~49 years)
-(+) alpha-naftyl esterase
-numerous promonocytes and monocytes
M3 leukemia-assoc. with DIC
)Post-op benign intrahepatic cholestasis
-after major sugery
-low BP
-extensive blood loss
-or after massive blood replacement
Halothane toxicity-type 1-mild elevation of LFT, no jaundice
-type 2-acute liver failure
)Kaposi sarcoma-on the trunk, face, extremities
-papules>plaques/nodules
Bacillary angiomatosis-like Kaposi sarcoma, but with systemic signs (malaise, headaches, fever)
)Prolactin is (+) by TRH, serotonin and (-) by dopamine
Hyperprolactinemia=>(-)GnRH=>amenorrhea
=>galactorrhea
Both of them appear in hypothyroidism due to high TRH
)Idiopathic pulmonary fobrosis-treat by steroids; lung transplant is not an option since it must be bilateral and there's a shortage a donors!
)In fibromyalgia=>check thyroid tests and CK levels
Diffuse axonal injuries-from deceleration
-at the gray-white matter junction
-looses consciousness on the spot=>then persistent vegetative state
MRI is more sensitive than CT for detecting the axonal injuries
)Lumbosacral strain-pain after exertion
-absence of radiation
-(+) paravertebral tenderness
-(-) straight-leg raising test
-normal neurologic exam
)Situational syncope: middle-aged, old male, losses counsciousness immediately after urination or during coughing fits
)Hypocalcemia-after major surgery, extensive transfusions
-due to volume expansion, hypoalbuminemia
Mypo Mg-alcoholism
-diarrhea, diuretic abuse
-prolonged NG suction
)Management of DM foot ulcer from mild to severe forms:
-off-loading
-debridement
-wound dressing
-antibiotics
-revascularization
-amputation
)In refractory ascites=>do tapping of up to 2l/day+give 10g albumin/liter taped as a last resort before any surgical procedure you may think!!!
Spleno-renal shunt-will worsen ascites
Side to side porto-caval shunt-improves ascites, worsens encephalopathy
Peritoneo-jugular shunt-for the treatment of ascites only; risks IC, sepsis, peritonitis
iv furosemide therapy=>worsens encephalopathy, precipitates hepato-renal syndrome
)Treat Ca-oxalate stone lithiasis by:
a)increased fluid intake>3l
b)normal or increased Ca intake-yes!!! you read fine!!! (1000mg)
c)low Na diet
d)low oxalate diet (no chocolate, vit C)
e) low dietary proteins (meat, eggs)
)Soap-bubble appearance in the distal femur on x-ray with knee pain, some mass, in 20-40 years old=>think giant-cell tumor of the bone=>refer to orthopedic surgeon; don't do bone scan=this is for solid tumor metastasis identification
)Choledocal cyst=congenital anomaly of the biliary tree
-dilatation of the intra/extra hepatic ducts
-jaundice, acholic stools
-reccurent attacks of pancreatitis
-can degenerate into cholangiocarcinoma
-First do US, then CT or MRI
Caroli'ssyndrome=congenital
-intrahepatic dilation of bile ducts
)In transplant patients=> give TMP/SMX to prevent PCP pneumonia; alternatives:dapsone or aerosolized pentamidine
)Lumbar pain in the 3rd trimester=> due to lumbar lordosis and relaxation of the ligaments of the sacro-iliac joints
)Dystonia-treat by benztropine or diphenilhydramine
)90% of PE come from emboli in the ileo-femoral veins
)Pseudogout under 50 years=>think any of:
hypo Mg, hypo P, hyper PTH, hypothyroidism, hemochromatosis
)Treat fractures of the humeral shaft by: closed reduction and immobilization of the arm in a hanging cast
)Cystic fibrosis-may develop Cl sensitive metabolic alkalosis
Barter'syndrome-Cl resistant metab. alkalosis
)In GERD=> give empirical treatm. with PPI or H2 blockers=>if it fails or there are features of complicated disease=>esophagoscopy=>if (-)=>PH monitoring
)HIGH-YIELD
Acute tubular necrosis-muddy-brown cast
GN-RBC cast
Pyelonephritis, interstitial nephritis-WBC cast
Nephrotic syndrome-fatty cast
Chronic renal failure-broad, waxy cast
)Febrile reaction to transfusion=
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| DrVirgo
Forum Hero
Topics: 1085
Posts: 3,476
|
 WOW! Thats a LOT! This topic should be pinned somewhere.
___________________
Our greatest glory is not in never falling, but in rising every time we fall.
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| drtanvir
Forum Junior
Topics: 15
Posts: 49
|
Its not the complete yet. IA soon u will see the complete version of high yield from UW, kaplan new, Aster notes and mayo clinic review all in one place. this would be power package.
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| peraspera
Forum Elite
Topics: 38
Posts: 233
|
Good job drtanvir
Thankx
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| aig8
Forum Newbie
Topics: 0
Posts: 2
|
You da MAN Drtanvir. Tha man!!
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| lakshya_0_7
Forum Elite
Topics: 24
Posts: 314
|
great dr tanvir.....thanx a lot...
few days back i was going through,step-3 qs *kaplan*,just out of curiosity...and to my surprise i found many qs were very similar to UWqbank for step-2........my exam is just 1 month from now...can u please do a favour...please make notes of step-3 kaplan q bank too???
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| anastamosis
Forum Senior
Topics: 34
Posts: 167
|
thats awesome collection !
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THE HIGHER YOU AIM, THE HIGHER YOU REACH !! My contacts are as follows ==> yahoo id --> anastamosis_e2e;gmail id --> anastamosis;Skype id --> anastamosis
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| SIARA
Forum Newbie
Topics: 3
Posts: 46
|
Thank you so much drtanvir..
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| Drtweetie
Forum Elite
Topics: 17
Posts: 301
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Awesome job, drtanvir! Thanks...
___________________
"Our greatest glory is not in never falling but in rising every time we fall." --Confucius
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| dr_puma
Forum Senior
Topics: 5
Posts: 121
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mindblower this stuff....thanks
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| yarab99
Forum Elite
Topics: 15
Posts: 260
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wow,,good work,,,thx
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| falcon
Forum Junior
Topics: 5
Posts: 210
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Great work, Thanks very much
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| TEFAZ7
Forum Newbie
Topics: 0
Posts: 3
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U R VERY GOOD MAN U KNOW
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