drtanvir
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Page 1 of 94 May 19, 2003
Critical aortic stenosis: virtually zero chance of successful CPR.
Gout with No peptic ulcer disease: Rx of choice - colchicine (not indomethacin)
pseudocyst
<6w: external rainage >6w: internal drainage
St. John's Wort: is a herbal medication with some efficacy in treatment of depression (no FDA Approval)
Vaginal d/c pH < 4.5 : Consider Candida
ph > 4.5 : Consider Bacterial Vaginosis
Maternal Smoking / Alcohol: Symm IUGR Maternal HTN: Symm IUGR
Physiological Jaundice / Exaggerated Physio / Breast Milk Jaundice: no risk of Kernicterus
Kernicterus occurs @ 1% x Birth Wt. (in grams) [Bilirubin Level]
PKU screen can be negative at 48hrs of life (requires a repeat screen after 48 hrs. to confirm)
Maternal SLE: Congenital Lupus & 3rd degree Ht. Block (Anti-Ro) Respi Failure: <60 mmHg 02 >60mHg C02
Maternal Solvent Abuse: assoc. with nail hypoplasia
PDA closure achieved by Indomethacin
NEC: Pneumatosis Intestinalis
Neonatal CMV: confirm by isolation of virus from urine
Transplacental spread is highest in primary HSV,
very low in recurrent HSV
Breast Milk (cf. Cow's Milk)
high carboydrate
low protein
low iron, but more bioavailable
inadequate Vit. D, Vit. K
supplement Iron @ > 6 m in exclusively breast fed
Infants of Diabetic Mothers with proteinuria, hematuria: ? Renal Vein Thrombosis (ass. with maternal DM)
Transfusion Reactions:
Febrile Reaction: WBCs in Donor Blood (Acetaminophen)
Anaphylaxis: Proteins in donor blood (Antihistaminics, SQ Epinephrine) Hemolysis: Mismatch (Hydration & Diuresis)
Infantile Colic: (Wessel Criteria)
3 m child; 3 hrs/day; >3 days/week; > 3 wks. duration
ADHD:
1.Methylphenidate / Dextroamph / Mg Pemoline 2.TCA / SRI (second line)
3.Don't use Benzodiazepines
4.consider "drug holiday" on weekends
ACEIs contraindicated in preg. HyperTG Rx: Gemfibrozil
Hypercholesterolemia (Drug Rx): >190: 0-1 risk factors
>160: >= 2 risk factors
>130: CAD equivalent / CAD
if > 15% reduction reqd: "statins"
if < 15% reduction reqd: (Low HDL) Niacin
(normal HDL) Cholestyramine
Obesity in Children Triceps Skin Fold Thickness
OCP induced hepatic adenomas : tendency to rupture (Surgical resection)
ELISA a-hCG (Urine) is (+) 14 d post conception RIA a-hCG (Serum) is (+) 14 d post conception
Symptomatic Gallstones: Lap Cholecstectomy Ca. Tail of Pancreas: Poorest Prognosis Lobular Ca in situ is not premalignant
Digitalis Toxicity is enhanced by:
HYPERcalcemia, HYPOkalemia, HYPOmagnesemia
Infant of HIV + mother (steps to derease transmission) 1.Intrapartum IN AZT
2.LSCS delivery
3.AZT prophylaxis to child x 6 m
4.No breastfeeding
5.HIV test at 6m - 12 m
Finkelstein Test: Chr. Stenosing Tenosynovitis (deQuervain's Disease)
Rx for Chlamydial Ophthalmia: ORAL Erythromycin (to prevent chlamydial pneumonia)
Commonest Hernia: Indirect Inguinal Hernia
T4 / RTU / FT4-I move up or down together unless there is a derangement in TBG CPK-MM is increased in hypothyroidism (proximal myopathy)
Fetal Weight Determination: HC, BPD, AC, FL
Fetal Age Determination: Transcerebellar Diameter
RA: associated with atlanto-axial subluxation ("drop" attacks)
PTE: (A-a) 02 gradient is always abnormal even if PaO2 is normal [highly sensitive]
Fever 24-48 hrs. Postop: #1 Atelectasis
(D)EH / (B)CP / BR
Pneumococcal Vaccination is required in CSF Leak
Nephrotic Syndrome: Fatty Casts Pyelonephritis: WBC Casts
Cystitis: WBCs
GN (PSGN): RBC Casts
CRF: Broad Casts
Cold Antibody: IgM - Inravascualr Hemolysis Warm Antibody: IgG - Extravascular Hemolysis
Addison's: ACTH Simulation Test
Cushing's: Dexamethasone Suppresion Test Conn's: Salt Loading Response
Diabetes Insipidus: Water Deprivation Test
Hemophilia A: aPTT increased, BT normal vWD: aPTT increased; BT increased (Ristocetin Cofactor Assay)
Factor VII def.: PT increased, BT normal Aspirin: prolonged BT, no effect on CT
spiking fever despite antibiotics, 1 wk. postLSCS ?Septic Pelvic Thrombophlebitis (Mx: i/v Heparin)
Mx of Myesthenia Gravis: PYRIDOSTIGMINE (not PHYSOSTIGMINE cuz of CNS effects)
vWD & Aortic Stenosis: ass. with Angiodysplasia
Alcoholic Cirrhosis: a-gamma bridge
d-xylose test: abnormal in small bowel malabsorption, normal in pancreatic disease screening for malabsorption: 24 hour fecal fat
? Penicillamine increases survival in Scleroderma
Congenital Syphilis may be associated with severe osteochondritis. Child may refuse to move limbs (Pseudoparalysis of PARROT)
Abciximab: decreases restenosis rates post-PTCA
PTCA: no effect on morbidity or mortality
Diabetes Mellitus : assocation with hyperTG
First line management of newly diagnosed diabetic: DIET (not drugs) DM+HTN: ACEIs
Hypercalcemia: IN Hydration + Loop Diuretics
Obesity: BMI>27g/m2 or 120% of ideal body weight
Caloric Intake increase:
300 Cal (Pregnancy); 50 Cal (Lactation)
Pulmonary Embolism: i/v Heparin
COPD excacerbation: H.flu, Pneumo., Moraxella
Long term stabilization of exercize induced asthma: Salmetrol & Zafirlukast
Severe acute asthma: < 50% best PEFR Moderate acute attack: 60-80% best PEFR Mild acute attack: >80% best PEFR
#1 community acq. pneumonia: S. pneumoniae Ideal sputum sample: <10 epi./HPF & many PMNs GERD: Transient relaxation of LES
Always perform an EKG for any adult with chest pain (esp. with risk factors for CAD) Esophageal Ca.: most common type is AdenoCa. (Barrett's Esophagus)
Sulfasalazine:
effective in UC & Crohn's colitis / ileocolitis
(not small-bowel Crohn's)
Celiac Sprue:
villous atrophy & reactive crypt hyperplasia Dermatitis Herpetiformis (Mx: Dapsone)
H. pylori association:
DUODENAL > GASTRIC
Serology (Past or Present Infection)
Fecal Antigen Detection (False [-] with PPI) Urease Breath Test (False [-] with PPI)
Triple Therapy, esp. for non-NSAID ass. ulcers
1st episode of PUD: emperical therapy (H2 -> PPI) Recurrent PUD: H. pylori eradication
Infectious mononucleosis
EBV, Sore Throat, LN, Splenomegaly
Atypical Lymphocytes (also in CMV)
Monospot (+): positivity wanes with time
Serology: increased Anti-EA; increased Anti-VCA IgM
a blockers decrease variceal bleed in portal HTN Ascites: Salt Restriction, Diuretic: Spironolactone
narcotic analgesic switching
use 1/5 equianalgesic dose
Graves': Rx - Radioactive Iodine children & pregnant: Propylthiouracil
WHO analgesic stepladder
1st LINE
Aspirin, Acetaminophen, NSAIDs
2nd LINE
Hydrocodone Codeine
3rd LINE
Page 7 of 94 May 19, 2003
Morphine Sulfate Hydromorphone Fentanyl
Methadone
Ca. ass. cachexia & anorexia: Prednisone, Magestrol Agitated Depression Rx: sedating TCA (not SSRI)
Rx of choice for narcotic induced costipation: Lactulose
Nephropathy Incidence: IDDM (40%) > NIDDM (20%) but #1 cause of Diab. Nephropathy is NIDDM ('cuz NIDDM prevalence is much higher than IDDM)
Prevalence Inreases: PPV of test increases (NPV of negative test decreases)
Screening for GDM
Oral 50g Glucose: BI. Glu. @ 1 hr. > 140mg% (+) F/U with Oral 100g Glu. 3 hour GTT
values > 105 (Oh) / 190 (1 h) / 165 (2h) / 145 (3h)
Obese Diabetic: Diet/Wt.Loss -> Metformin (ass. With Lactic Acidosis)
Insulin in DM
Initial dose: 15-20 U
2/3 of total : AM dose (2/3 regular, 1/3 intermediate) 1/3 of total : PM dose (2/3 regular, 1/3 intermediate)
Conn's syndrome Mx
Adenoma: Sx resection
B/L hyperplasia: Spironolactone
"cold nodules" on thyroid scan: ? Malignant
#1 Thyroid Study: Serum TSH (yields max. info.)
Multiple Sclerosis:
2 attacks more than 24 hours apart
> 1 area of damage (Oligodendrocyte damage) m/c variant: relapsing-remitting type
CSF mononuclear pleocytosis, CSF IgG increase Oligoclonal Banding of CSF IgG
Myelin Breakdown Metabolites
Headache on stopping NSAIDs: Analgesic withdraw) headache
Jaw Claudication & Scalp Tenderness: GCA ESR increased
Visual Loss
Start Glucocorticoids without waiting for Bx results
Aspirin in febrile children: Reye's Syndrome Continue anticonvulsants till seizure free for 4 years
Menorrhagia with hemodynamic compromise: i/v conjugated estrogen
normal Hb in women: 12.0
normal Hb in pregnancy: 11.0 (1st & 3rd trimester) 10.5 (2nd trimester)
m/c variant of Hodgkin's : Nodular Sclerosis
Hodgkin's: Supraclav. node
NHL: epitrochlear node / likely to be extranodal
Osteoarthritis
Joint space narrowing
sclerosis
subchonral cysts
osteophytes (mere osteophytes are not OA)
OA: Isometric exercizes are better than isotonic
CFS: T cell activation -> CNS effect of cytokines nonREM sleep anomaly
(also seen in Fibromyalgia)
Gout prophylaxis: required for recurrent attacks (not indicated after first attack)
Strep Sore Throat Rx: can prevent Rh. Fever NOT PSGN!!!
Potassium sparing diuretics can cause severe hyperkalemia in CRF SULINDAC: NSAID with no nephrotoxicity
Asymp. Bacteruria in Pregnancy : Treat with antibiotics [Amoxycillin is safe] (high risk of pyelonephritis)
Give Chlamydia Rx in Gonorrhea
-> i/m Ceftriaxone + PO Doxycycline
Biophysical Profile : TBMAN
Tone, Body Movements, Breathing, AFI, NST
Early Deceleration: Head Compression Variable Deceleration: Cord Compression Late Deceleration: Uteoplacental insufficiency
GU+NGU: 1 g Azithromycin stat
ACNE Mx
Benzoyl Peroxide Topical Tretinoin
Topical Antibiotics Systemic Antibiotics Systemic Isotretinoin
Acne Rosacea Mx
Topical Metronidazole -> Systemic Antibiotic [Benzoyl peroxide & Tretinoin can aggravate rosacea]
Female Infertility (Hormonal)
Hyper-estrogenic: CLOMIPHENE CITRATE Hyper-PRL: Bromocriptine (PIH)
Narcotic Dependence: Methadone replacement
External Hemorrhoids: Excision with elliptical incision Internal Hemorrhoids: Banding
2nd trimester eclampsia: Molar pregnancy Molar pregnancy: hyperemesis gravidarum
Most important obstetric measurement: Diagonal Conjugate (at least 11.5 cm)
Amniotomy: perform after enagement of fetal head Rx of HTN in preg.: a-methyldopa, hydralazine
BP reduction goal in pre-eclampsia:
Lower diastolic to 90-100 mmHg (lowering to 80mmHg could jeopardize placental perfusion)
#1 maternal disease causing IUGR: Maternal HTN
#1 cause for 1st tri. abortions: Chromosomal ab(n)
Postpartum Blues: < 2 weeks Postpartum Depression: > 2 weeks
Major Depression: >= 5 symptoms for > 2 weeks Mania: >= 3 symptoms for > 1 week
Primary Type 1 Osteoporosis: # vertebrae Primary Type 2 Osteoporosis: # neck femur
HRT
Progesterone required only if uterus is present
Estrogen: dec. LDL, inc. HDL
Progesterone: inc. LDL, dec. HDL
Estrogen's cardioprotective effects of estrogen are not mediated through cholesterol. Estrogen promotes EDRF synth. In vascular endothelium
Repeat Pap: if regd., no sooner than 6 weeks
Hormonal contraception if No DVT/PE (+):
Norplant & DMPA (Progesterone based), not OCPs
Jarisch Herxheimer reaction: Syphilis Rx (chills)
HPV: condyloma acuminata
HPV 18: fastest progression to Ca. Cx
Acute Epididymitis:
#1 cause: Chlamydia trachomatis
#1 bacterial cause: E. coli (m/c in >40 y age)
Depression: Cognitive Psychotherapy + SSRI
Drug Rx of Bipolar Disorder: Li, Carbamazepine, Valproate, Gabapentin, Lamotrigine (ass. With SJS)
Lithium: Hypothyroidism, NDI
Atypical Antipsychotics are especially useful for negative symptoms of Schizophrenia Drug Dependence: WITHDRAWL & TOLERANCE
Mx of DTs
Intermediate acting BZDs (Diazepam) IV saline (no glucose containing fluids) IV thiamine
BZD in Hepatic Enceph.: Oxazepam
Fluid Deficit in Burns
= 4mL/kg x %BSA (Parkland Formula)
1st degree:
2nd degree: clean, sulfadizine, nonadhesive dressing 3rd degree: refer to plastic surgeon for escharotomy
Heat Cramps: ORS
Heat Exhaustion: IV Fluids
Heat Stroke: neurological dysfunction & absence of sweating (may not be dehydrated)
Hypothemia: Osborne (J) wave on EKG Mild: (32-35 C) Passive External Rewarming
Moderate: (27-32 C) Active External Rewarming Severe: (< 27C) Active Core Rewarming
Depression: Cognitive Psychotherapy
Anxiety Dsorders: Behavioral Psychotherapy Adjustment Disorder: Supportive Psychotherapy Social phobia: bea blockers & assertive training Specific phobia: systematic desensitization
Panic: SSRI & Alprazolam (short T1/2) Na Lactate can mimic a panic attack use alprazolam for panic, not GAD
may be associated with rebound anxiety
OCD: (associated with anxiety) SSRI OC PD: insight-oriented psychotherapy
Somatization Disorder:
4 Pain, 2 GI, 1 sexual symptoms (associated with abuse in childhood)
Depression: SSRI + Cognitive Psychotherapy "Atypical" depression: MAOIs are first-line
Generalized Anxiety: Buspirone (selective anxiolytic)
Sexual Dysfunction
Young Males: Premature Ejaculation
(Mx: start and stop penile stimulation, not SSRls) Older Males: #1 Erectile Dysfunction
Females: #1 Hypoactive Sexual Desire
Young males with sexual dysfunction: Psychogenic Older males with sexual dysfunction: Organic
The PATIENT is the head of the healthcare team
ADHD associated with:
Conduct Disorder and Oppositional Defiant Disorder (also with Tourette's Syndrome)
ADHD with (+) No or F/H tics DO NOT USE STIMULANTS
Phototherapy isomerizes bilirubin to a state that can be excreted in urine & bile unchanged. (does not enhance conjugation)
Water Supply > 1 ppm fluoride: No supplementation Retrocecal Appendicitis: poorly localized pain
Appendicitis
#1 cause : lymphoid hyperplasia
Mx: Surgery
Yersnia enterocolitis can mimic appendicitis
Painkillers & antibiotics can alter presentation
Preg. With appendicitis: atypical location of pain
Elderly: higher chances of perforation
Appendiceal abscess: Delay surgical intervention
If on lap., some other cause is found - do an appendectomy anyway, to prevent confusion in future
Oral Dissolution of Gallstones
URSODIOL
single floating cholesterol stones in functioning g.b.
Asymp. Gallstones: DO NOTHING
Symptomatic Gallstones: Lap. Cholecystectomy #1 complication of Lap Chole: Bile Duct Injury
Choledocholithiasis: ERCP with sphincterotomy
idications of ERCP:
small stones
dilated CBD
palpable stones in CBD jaundice
Plantar Warts: Cryosurgery
Venereal Warts: Podophyllin (not in pregnancy)
Cullen's Sign: periumbilical discoloration Grey Turner Sign: flank discoloration
#1 radiological signs in pancreatic disease acute pancreatitis: sentinel bowel loop chronic pancreatitis: pancreatic calcification
Crucifer intake reduces Colon Ca.
Ca. risk of polyps is dependent on villous content #1 risk factor for pancreatic ca. : smoking
#1 cause for chronic low back pain: idiopathic
bed rest has no role
no need for imaging (X-Ray / CT / MRI)
prescribe an exercize program (can temporarily excacerbate symptoms)
Acetohydroxamic acid: urease inhibitor (acidifies urine in patients with struvite stones)
HTN with BPH: Terazocin (a blocker)
Vestibular Neuronitis: NO hearing loss
Meniere's Diseass: Tinnitus, Vertigo, Hearing Loss Ac. Labrynthitis: Ac Hearing Loss, Nystagmus, Vertigo
Acute Bacterial Sinusitis:
Pneumococcus
no role of imaging (Dx by No & PE) ? antibiotics - PO Amox x 7-10 days
Antidep. of choice in depresion in elderly: TCA (Nortryptaline) - minimal side effects cf. other TCAs
Alzheimer's Rx: DONEPEZIL (OD) & Tacrine Cholinesterase Inhibitors
Polymyalgia Rheumatica: Oral Steroids GCA: IN Seroids
Elderly black HTN: CCB & Thiazide Diuretics
Parkinson's with Tremor has a better prognosis than pts. with symptoms of Postural Instability & Gait Disturbance
Perform Postvoid Residual Urine measurement on every elderly patient with Urinary incontinence to r/o Urinary Retention
Alzheimer's & Parkinson's cause Detrusor Hyperreflexia : URGE INCONTINENCE
@ high risk for pressure ulcers: reposition q2h low-risk patients: reposition q6h
USPSTF
prenatal ultrasound not mandatory
? role of PSA & DRE in screening of asymptomatic individuals
Hyperlipidemia screening:
NONFASTING SERUM CHOLESTEROL if elevated: do a FASTING LIPID PROFILE
a-FP estimation at 5-17 weeks to r/o NTD
increased: ultrasound (can detect 80% anomalies) decreased: does not necessarily indicate Downs'
QUIT SMOKING before starting Nicotine replacement
Transdermal Nicotine Replacement: 21 mg -> 14mg -> 7mg
[Pts. with CAD, start with 14 mg.] [Nicotine is vasoconstrictor, risk of MI]
Pesticide exposure has been linked to Prostate Cancer HTN increases the risk of stoke > CAD
2% reduction in CAD for every 1% decrease in serum cholesterol
Cancer mortality is increasing stroke/CAD mortality is decreasing
HAART drug interactions
"statins", Antihistaminics, Ergot alkaloids
AIDS in infants: better prognosis cf. adults
d/o/c for malaria prophylaxis: MEFLOQUIN once-a-week (1 w before travel & 6 weeks after)
Influenze A: adults
Influenza B: children
Influenza epidemics: Influenza A
Influenza vaccine: A & B
Amantidine protects only against "A"
(Rimantidine preferred in patients with renal failure)
Oseltamivir (Tamiflu®) protects against both "A" & "B" Annual influenza vaccination for age > 65 y
#1 cause of traveler's diarrhea: ETEC
Cardiac Arrest: 1st step - initiate 911 call
Cardiac Arrest in Children: Assess, 1 min. on CPR Initiate 911 call
Mx of Respiratory Acidosis: Increase Ventilation (Use of NaHCO3 is not wise to Mx Respi. Acidosis)
1-person CPR: 15:2 2-person CPR: 5:1
symptom to treatment time: <60 minutes ED to needle time: <30 minutes
A. Fib.: (Unstable): Sync. Cardioversion
V. Fib.: Async. Defib. [200 -> 300 -> 360 mJ]
SVT: Vagal Maneuvres -> Adenosine V.Tac.: Lidocaine, Procainamide, Bretylium V.Tac.: (Unstable): Cardiovert
V. Fib:
Defibrillate,
Epinephrine
Defibriallate again Lidocaine
2nd line antiarrhythmic
Asystole:
Immediate transcutaneous pacing
Epinephrine -> Atropine -> Consider Bicarbonate
Use intra-osseous route in age < 6 years
DKA
Insulin 0.1 U/kg/hr + NS
Add K+
when Blood Glucose approaches 250, shift to 5%D
m/c cause of abdo. Pain in elderly: CONSTIPATION Use activated charcoal with 70% sorbitol in poisonings Cuffed ETT for age > 7yrs
#1 Poisoning: OTC Analgesics
Naloxone: Short acting
Naltrexone: Long acting
(used in rehab programs, not acute overdose)
Urticaria: Subcutaneous edema Angioedema: Mucosal edema
Colles' #: Dinner Fork abnormality (Splint in Neutral position)
Suspected Scaphoid # & X-Ray (-) APPLY THUMB SPICA CAST anyway
Ankle Inversion Injury
- Lateral Ligament Sprain
- Anterior Talofibular Ligament
McMurray Test:
Meniscal Tear
Joint Line Tenderness
Lachman Test:
Anterior Cruciate Ligament Injury
Dislocation of Shoulder: Anterior
Page 18 of 94 May 19, 2003
associated with axiallry artery injury NBT (-) : CGD (SXR) -> IFN-gamma
Prostatic Mets.: BONE SCAN > SKELETAL SURVEY MYELOMA: SKELETAL SURVEY
(Bone Scan is useless, does not detect lytic lesions)
#1 cause of death in myeloma: Pulmonary or UTI
Duration of Maintenance Pharmacotherapy for depression (even for single episode) should be at least 6 months.
Desert Rheumatism: C immitis
Mx - Conservative
Rx required only for dissemination / lung lesions
#1 Kidney stones: Calcium Oxalate (radiopaque) [Square Crystals]
URIC ACID stones are radiolucent
CYSTINE crystals in urine are always pathological
Crohn's: associated with gallstones & kidney stones [increased absorption of oxalates from the gut]
#1 complicatin of chickenpox: 2° skin infection
Postop Fever @ 24 hours: atelectasis
Postop Fever @ 5-10 days: wound infection (early wound infection: clostridia / pesudomonas)
Neonatal Meningitis: S. agalactiae (Gp B Strep)
Cl esterase inhibitor deficiency: hereditary angiodema
depleted C4 levels
Mx: FFP/e-ACA/Stanozolol
Maintain: ANDROGENS (inc. synthesis)
Suspect endometrial cancer:
gynecological referral for enometrial biopsy
Pap misses 60% of endometrial Ca.
Cryoprecipitate: replaces Fibrinogen & Factor VIII FFP: replaces all coagulation factors
Reversal of warfarin action: FFP (chronic: Vit. K) Reversal of heparin action: Protamine
sterile subdural effusions: H. influenzae meningitis pneumonia with effusion / empyema: Staph. aureus
Lipase is more sensitive and specific than amylase
Serum amylase elevated for 2-4 days Urinary amylase elevated for 7-10 days
#1 cause of sensorineural hearing loss: PRESBYACUSIS
#1 cause of conductive hearing loss: OTOSCLEROSIS
osteomyelitis after foot puncture wound: Pseudomonas
Acromegaly
Inability to supress glucose
no stimulation of GH with levodopa paradoxical increase of GH with TRH
#1 intracranial mass lesion: METASTASIS
#1 brain malignancy (adult): Glioblastoma multiforme #1 brain malignancy (child): Astrocytoma
adult: supratentorial
children: infratentorial (#1 supratentorial in children is craniopharyngoma)
SVC Syndrome: Think Bronchogenic Ca.
AML with DIC: M3 variant of AML
AML with gum chloromas: M5 variant of AML
Hairy Cell Leukemia: TRAP+ (Rx: Cladribine)
Page 20 of 94 May 19, 2003
Port Wine Stain: Sturge Weber Syndrome
CSF has a higher CI- content compared to plasma
Rocky Mountain Spotted Fever:
Dx- Indirect IF
Rx - DOXYCYCLINE (< 8y: Chloramphenicol)
Neurofibromatosis:
> 6 cafe au lait spots [or 1 spot > 5cm]
Tuberous Sclerosis:
Cardiac Rhabdomyomas Angiomyolipoma of Kidney Subungal Fibromas
Decreased Haptoglobin:
Intravascular Hemolysis
Very Severe Extravascular Hemolysis
OSTEOPOROSIS: Serum Ca++ & PO43- are normal
Testicular Torsion: affected testis lies horizontally Mx - Surgical Fixation of BOTH Testes
Torsion of Testicular Appendix: BLUE DOT Mx - Exploration of other scrotum not required
m/c Thyroid Malignancy: Papillary Ca. Thyroid MEN Syndrome: Medullary Syndrome Hematogenous Spread: Follicular Ca.
Patella dislocates laterally
Mx PTSD with Group Psychotherapy (not BZD : high risk of BZD abuse)
Fever without Focus:
#1 cause: Occult Bacteremia due to Pneumococcus
due to Otitis Media
Signs of Occult Bacteremia: Temp > 40C
WBC < 5000 or WBC > 15000
Acute Otitis Media: Strep. pneumoniae (Amoxicillin)
#1 Pediatric Gastroenteritis: Rotavirus
#1 Pediatric (Bacterial) Gastroenteritis: C. jejuni
Recurrent Otitis Media:
definition: >3 in 6 months or >4 in 1 year Amox prophylaxis -> Myringotomy & Tubes
Indications of Tonsillectomy:
l episode of Quinsy (Peritonsillar abscess) > 7 proven streptococcal pharyngitis airway obstruction
decreases recurrent sore throat, not URI
Suspected Strep Sore Throat:
Sore throat, fever, cervical LN, tonsillar exudates Only 15% of sore throats are streptococcal Rapid Strep. Test (HIGH SPECIFICITY)
even If (-), start treatment & perform a throat swab
Simple Diarrhea
No role of Stool Culture:
Stool Culture indicated only if: bloody diarrhea
persistent diarrhea
(+) tenesmus
h/o foreign travel
Mx: Oral Rehydration Solution
(not juices or carbonated beverages)
Children with no dehydration - age-appropriate diet
Gp A a-hemolytic Streptococci are usually susceptible to Penicillin (this is not the case with Staphylococci)
Strep viridans sensitive to Ampicillin + Gentamycin German Measles (Rubella)
Measles (Rubeola)
Roseola infantum (Exanthem subitum) HHV 6 high fever, rash appears after fever subsides
Lead levels > 10 : environmental abatement start chelation therapy @ higher levels (? > 25)
single umbilical artery associated with renal ab(n) Caput crosses midline; cephalhematoma does not HbS Disease: Prophylactic Penicillin till 5y age
Stranger Anxiety: 6-9m Separation Anxiety: 12-15m
Encopresis: >4 y Enuresis: >5 y
Simple Febrile Seizures:
Single Seizure
Nonfocal
< 15 minutes durations
associated with high fever
Rx: antipyretics (NOT ANTICONVULSANTS) F/H (+)
Can recur
Meningococcal Contacts: Rifamp/Cipro prophylaxis
(#1 cause) Seasonal Allergic Rhinitis-Ragweed
(#1 cause) Perennial Allergic Rhinitis-House Dust Mite
Choanal Atresia
cyanosis with feeding relieved by crying
Dog & Cat Bite: P multocida (Rx: Amox-Clav) Cat scratch disease: Bartonella henselae
Cushing's Syndrome: #1 latrogenic
Cushing's Disease: #1 Pituitary Microadenoma
Dx: 24 hour urinary free cortisol
to diff. Pituitary & adrenal cause: Overnight DST
Pick's Disease:
Dementia / atrophy of frontal & anterior temporal lobes [early psychiatric manifestations]
Dementia with Lewy bodies:
(Alzheimer's + Parkinsonism features)
DO NOT USE ANTIPSYCHOTICS
[they can excecerbate parkinsonism features]
Dialysis Dysequilibrium Syndrome: associated with rapid correction of uremia
HTN in elderly African Americans: CCB + Diuretics HTN in young African Americans: Diuretics
Paget's Disease of the bone: extent is delineated by Tc 99 scan
Wounds < 12 hours old, clean: primary closure
Wounds > 12 hours old, contaminated: debridement and secondary closure
concomitant use of I/v heparin with thrombolysis: Ac. anterior MI & Left Venticular Thrombus
Pts. with non-Q wave MI & previous CABG do not benefit considerably from thrombolysis
High risk features post-MI
1. Post MI angina
2. Non Q Wave MI
3. CHF
4. LVEF < 40%
5. > 10 PVCs / min
e/o Significant Ischemia on Exercize Stress Test: 1.ST segment depression
2.< 6 METS work
3.@ < 70% predicted maximum heart rate
4. Hypotensive Response
LDL is the most important "lipid" risk factor for CAD
Cholesterol: < 200, 200-240, > 240 LDL: < 130, 130-160, > 160
treatment of choice for hypercholesterolemia: DIET
Basilar & Hemiplegic Migraine
DO NOT use SUMATRIPTAN
(also c.i. in IHD/MI, Pts on SSRI/MAGI/Li)
Acute A. Fib.:
(Stable) a-blockers & CCB (Unstable) Sync. Cardioversion
Obesity is a risk factor for Endometrial Ca. Surgical intervention for obesity : BMI > 40 kg/m2
Heparin: keep PTT 1.5-2.0 x control Warfarin: keep PT 1.5-1.8 x control
Enoxaparin (LMWH): No PTT monitoring required
COPD : smooth muscle hyperplasia (as in asthma), but Methacholine challenge test is negative
REID INDEX: ratio of thickness of bronchial glands to bronchial wall thickness (increased in chronic bronchitis)
Nicotine enhances growth of H. flu
Most effective long term pharmacotherapy for COPD: Ipratropim bromide COPD excecacerbations: H. flu, Pneumococcus, Moraxella
LONG TERM HOME OXYGEN THERAPY Only Rx in COPD that enhances survival indications:
Resting PaO2 < 55 mmHg
Resting PaO2 < 60 mmHg with tissue hypoxia (cor pulmonale / polycythemia)
Acute Bronchitis in healthy non-smoker:
no Investigations, no treatment (no antibiotics)
Early phase of asthma: primary mediators Late phase of asthma: secondary mediators
Prophylaxis of exercize induced asthma: Albuterol
Long term stabilization of exercize induced asthma: Salmetrol (long acting) + Zafirlukast
Mycoplasma pneumonia:
minimum physical findings
B/L lower lobe infiltrates
Cough (+)
Mx: Macrolide
Cold Agglutinins (IgM) Inravascular hemolysis
Pnenumonia in elderly debilitated alcoholic: Lower Lobe: Strep pneumoniae
Upper lobe: Klebsiella
(currant jelly sputum, hemoptysis, cavitatory lesion)
Normal Semen analysis vol. 2-5 mL
sperm conc. > 20 million / mL morph > 30% normal
motile > 50% motile
#1 cause of dysphagia: lower esophageal ring
(in the absence of risk factors for esophageal cancer)
Systemic Sclerosis associated with severe GERD
UC (Dx): Colonoscopy
Crohn's (Dx) : air contrast barium enema
Alcoholic Hepatitis: AST >> ALT (ratio > 2.0)
Malignant Neuropathic Pain
Sharp Stabbing: Rx anticonvulsants (Carbamazepine)
Dull Aching: Rx TCA (Desipramine)
Page 26 of 94 May 19, 2003
Mx of Chemotherapy induced Emesis: ONDANSETRON Pain control : round-the-clock dosing > cf. PRN
TPN: no mortality/morbidity benefit in cancer pts.
Vestibular Nausea Rx: Cyclizine
Radiotherapy assoc. diarrhea: Loperamide / Codeine Narcotic induced constipation: LACTULOSE
#1 symptom in avanced cancer is weakness (ASTHENIA)
SSRIs can make agitated depression worse (Use sedating TCA & Anxiolytic PRN)
#1 metabolic derangement with advanced malignancy: hyperCa++ (long PR, decreased QT, wide T waves)
Type 1 DM is HLA DR3/DR4 associated Type 2 DM - Obesity & Family History
OHAs
Biguanides
decrease Glucose production & increase peripheral utilization (Metformin) Sulfonylureas
stimulate Insulin release (Glibenclamide)
Glitazones
DECREASE INSULIN RESISTANCE
(Troglitazone) a-glucosidase inhibitors
decrease carbohydrate absorption (Acarbose)
MODY
opts. are normal to underweight
< 40 years age AD inheritance
F/H (+) in 50%Dx of DM
Diagnosis of Diabetes Mellitus
FBS (2 values) > 126 mg%
RBS (1 value) > 200 mg%
GTT (100g oral glucose): 2 hour value > 200 mg%
Li induced NDI : stop Li -> start Carbamazepine #1 feature of Cushing's: Truncal Obesity (90%)
Pathophysiology of Migraine:
CNS Platelet aggregation with Serotonin release
Very Severe Migraine (abortive): SUMATRIPTAN Moderately severe Migraine (abortive): DHE
Status migrainous: migraine lasting > 72 hours Cluster Headaches: Sumatriptan / 02 inhalation
New onset seizure
< 40 y age: #1 Idiopathic
> 40 y age: #1 Brain Tumor
Discontinue anticonvulsants after seizure-free for 4y (confirmed by absence of epileptiform activity on EEG)
Grand mal: Phenytoin Petit mal: Ethosuximide
Thrombotic Stroke: slow and continuing (m/c variety) Embolic Stroke: sudden
#1 risk factor for CVA: HTN
CEA for Symptomatic Carotid Artery stenosis > 70% Fe deficiency anemia (most sensitive Ix): S. Ferritin
#1 inherited bleeding disorder: vWD Inherited hypercoaqulable state Factor V Leyden (most common) Prot C def. / Prot. S def.
Anti-thrombin III deficiency
Page 28 of 94 May 19, 2003
Anti-PL antibodies: can cause arterial thrombosis TTP: do NOT give platelet transfusion
vWD: Factor VIII (cryoppt.) DIC: FFP
COX-2 (Celecoxib): less GI side effects cf. NSAIDs
Exercize program in OA
Graded, Active Exercize, Isometric
Fibromyalgia
tenderness in 11 of 18 defined points r/o comorbid depression
ass. with sleep disorder
(a-nonREM sleep anomaly) -> also in CFS
Mx of Chronic Fatigue Syndrome: NSAIDs
nonsedating TCAs
Both FIBROMYALGIA & CHRONIC FAIGUE SYNDROME have a-nonREM sleep anomaly
GOUT prophylaxis: only for recurrent attacks (> 2-3 attacks) [not after first atack]
#1 cause of Chr. Renal Failure: DM
Mx of uncomplicated UTI: 3 days of TMP-SMX
Artificial Donor Insemination Store semen for 6 months
Check donor for HIV @ 6 m
lf still (-), proceed with insemination
#1 step in Obstructive Sleep Apnea: Weight Reduction BZD can worsen Obstructive Sleep Apnea
Narcolepsy Mx: Methylphenidate
Aster's USMLE Step3 Notes
Dextroamphetamine Mazindol (TCA)
Long T1/2 BZD are associated with lower incidence of Flurazepam)
Bisphosphonates
Oral - to be taken in the morning on empty stomach with 8 esophagitis)
Alendronate (FDA approved)
Etidronate (less efficacious)
Pamidronate (IN infusion)
SERMs (Raloxfene):
Estrogenic on Bone / Lipids
Anti-estrogenic on Uterus & Breats rebound anxiety (e.g.
oz of water (to prevent
Marjolin Ulcers: squamous cell ca. in old scars
Immunosuppression is a risk facor for Sq Cell Ca.
PRCA (Pure red cell aplasia) may be associated with thymoma
Aplastic Anemia causes <3% fall in Hct / week
[>3% fall in Hct / week: Hemolysis / Hemorrhage]
Hereditary Spherocytosis:
AD
Spectrin
Microcytosis
increased MCHC, increased Osmotic Fragility Lifelong FOLATE supplementation
Rx: SPLENECTOMY
PNH:
acquired defect in DAF
Dx: Sugar Water Test
prone to hepatic & mesenteric vein thrombosis may progress to Aplastic Anemia / AML
Blody Nipple d/c: DUCT EXCISION (no role of ductography)
Page 30 of 94 May 19, 2003
G6PD def.: older RBCs are deficient in enzyme, hemolysis is self-limited G6PD def. (Mediterranean Variant): all cells are deficient - severe and chronic hemolysis
MYELOFIBROSIS:
poikilocytosis
giant abnormal platelets dry bone marrow tap
"Clustered Polymorphic Microcalcification" on Mammography is sic Breast Cancer
Mammography is never a substitute for BIOPSY. Mammo is for detection of other lesions and screening the contralateral bereast. It does not rule-in or rule-out cancer
HbSC disease:
increased incidence of Proliferative Retinopathy decreased vaso-occlusive and pain crisis
Fever in Neutropenia: consider infectious
Rx of acute promyelocytic leukemia: RETINOIC ACID Serum LDH is a prognostic marker in Lymphomas
multiple myelomas with no paraprotein : 1% (very aggressive)
TTP & HUS: normal coagulation studies (cf. DIC) Uremia is asscoaited with qualitative platelet defect
Hemophilia with low platelet count:
??? HIV associated immune-thrombocytopenia
Hemophilia with no improvement with Factor VIII infusion: ??? suspect Factor VIII Inhibitor activity
[Serum Mixing Test]
Mx: Steroids or Cyclophosphamide
Vit. K dep. factors:
Factor II, VII, IX, X
(Vit. K def.: corrected by Vit. K administration)
Liver Disease:
decreased vit. K dependent factors & Factor V (coagulopathynot corrected by Vit. K administration)
1 Unit of Packed Red Cells
300 mL volume = 200 mL of Red Cells raises He by 4%
When Typo "0" blood is being used (universal donor): use packed red cells, not whole blood
Constipation
<50y: increase fiber or osmotic laxatives >50y: FOBT
If (+), Colonoscopy (Sigmoido/Ba enema)
Mayonnaise/Salad Dressing: S. aureus food poisoning
Small Bowel Diarrhea: Voluminous, Bloating Large Bowel Diarrhea: small volume, LLQ Cramps
Methylene Blue stain of stool detects Fecal Leukocytes
Follow-up Rx of DKA with ANION GAP
(not serum Ketones)
ketone estimation detects only acetate and acetoacetate
the predominant ketone in DKA is b-HAP
as DKA Rx progresses, b-HAP converts to acetoacetate and estimation of serum ketones might suggest "paradoxical" worsening ketonemia
Osmotic Diarrhea: decreases with fasting Fecal Fat > 10g/24hours : s/o Malabsorption
UGIH
#1 Peptic Ulcer
#2 Variceal Bleed (#1 cause of death from UGIH)
LGIH
#1 (>50y) Diverticulosis (#2: Angiodyslasia) LGIH Dx
<50y: Anoscopy or Sigmoidoscopy
>50y: Colonoscopy (Sigmoido/Ba enema)
Ascitic Flluid: SAAG > 1.1 [Portal HTN]
Spontaneous Bacterial Peritonitis
> 500 cells / iL
> 250 PMNs / iL
Total Protein < l g / dL
Mx: i/v Ceftriaxone (no anaerobic cover required) prophylactic FLUOROQUINOLONES to
prevent recurrences
Familial Mediterranean Fever:
Turks, Armenians, Arabians
recurrent abdominal pain (resembles acute surgical abdomen) attacks resolve in 24-48 hours
associated with serositis & pleuritis
recurrent attacks cause secondary amyloidosis
Rx: COLCHICINE
Uncomplicated GERD: H2 blockers (1st line) -> PPI Complicated GERD: PPI (1st line)
Preferred procedure for portal decompression is TIPS (Transvenous Inrahepatic Portosystemic Shunt)
associated with maximum decrease in rebleeding rate (> banding, sclerotherapy, ablockers)
Non-invasive tests for H. pylori
serology (past & present infection)
fecal antigen detection
urea breath testing
PPI can cause False (-) fecal antigen & breath test
Duodenal ulcers heal faster than gastric ulcers
Long term PPI Rx not required in PUD Long term PPI Rx required in GERD
H. pylori eradication: PPI / Amox / Clarithromycine
50% of H pylori isolates are Metronidazole-resistant
10-14 days of H. pylori eradication followed by 4-8 weeks of PPI for Rx of PUD
Rx of Whipple's Disease: TMP-SMX for 1 year Giardiasis can cause Lactase deficiency
Ogilvie's: acute colonic pseudo-obstruction
Gastric malignancy
#1 Gastric adenocarcinoma
#2 B-cell lymphoma
Celiac Sprue
increased incidence of intestinal T-cell lymphomas
Carcinoid Syndrome: small bowel carcinoid with hepatic metastasis (increased urinary 5-H IAA)
increased right sided valvular lesions
Abdominal Pain relieved by defecation: IBS Cl. difficile: watery diarrhea (Dx: Toxin Assay)
Budesonide:
high potency steroid
low systemic side efects
(due to high first pass metabolism) useful in nflammatory bowel disease
When UC/CD diff. is difficult
UC: pANCA (+)
CD: ASCA (antbodies to s. cerevisiae)
UC: assoc. with PSC (PSC is an independent risk factor for colonic malignancy in UC)
APC Gene:
AD
Polyps -> Adenomatous Polyps -> Ca
small bowel polyps (low malignant potential) & gastric polyps (no malignant potential) may also be found
FPC: begin screening colonoscopy @ 12-20 y age
Peutz Jeghers:
colonic polyps have no malignant potential increased extraintestinal malignancies
(Breast, Gonads, Pancreas)
HPNCC:
Colorectal Ca (+)
(few, flat, fast-progressing adenomas) 40% lifetime risk of endometrial cancer
Right sided Colon Ca: Bleeding Left sided Colon Ca: Obstruction
Hep D superinfection is more severe than co-infection HAV infection: may have relapses
Acute Hepatic Failure: Encephalpathy in < 8w Subacute Hepatic Failure: Enceph. in 8w - 6m
Chr. Hepatitis: > 6m
Anti-HCV: EIA -> if (-) -> confirmatory test RIBA
Chronic HBV: IFN-a or LAMIVUDINE Chronic HCV: IFN-a or RIBAVARIN
Chronic HCV infection:
ass. with cryoglobulinemia and Type2 DM (NIDDM)
Individuals with Hemachromatosis are susceptible to V. vulnificus, Listeria, Y enterocolitica infections
Dx of Budd Chiari syndrome: Duplex Doppler U/S
Left Heart Failure:
increased liver enzymes (ischemic injury) Right Heart Failure:
increased Bilirubin & Ascites (>> periph. edema)
Gastric Varices without Esophageal Varices: Splenic Vein Thrombosis Mx: Splenectomy
#1 organism causing pyogenic liver abscess: E. coli
OCP associated Liver Adenoma
(Mx: RESECTION even for asymptomatic cases)
Meperidine: least Sphincter of Oddi spasm UC with pruritus: consider PSC
S. amylase can be increased in MUMPS ue to salivary gland involvement without involvement of pancreatic gland [but S. Lipase would be normal in cases of extrapancreatic elevation of amylase]
Antibiotic of Choice in Pancreatic Infections: IMIPENEM
Tamoxifen:
decreases Breast Ca. / increases Endometrial Ca. SERMs (Raloxifene):
decreases Breast Ca. / decreases Endometrial Ca.
Medical Adrenalectomy Aminoglutethemide + Corticosteroids
HRT after Breast Ca. -> Raloxifene
IgE is not involved in anapylactoid reactions (e.g. radiocontrast allergy)
CD3 : pan B cell marker CD19: pan T cell marker
Dx of CREST syndrome is clinical
(not based on anti-centromere antibody)
Of all HLAs - HLA-DR compatibility is essential for long term graft survival
Cyclosporin:
decreases CMI & decreases IL-2 (T-cell activation) Steroids: decrease CMI
Cyclophosphamide: decreases CM as well as HMI
IFN-a: HCL, HepB & C, Kaposi's, CML IFN-a: Multiple Scerosis
IFN-a: CGD
Acidosis due to Organic Acids is not assoc. with HyperK+ (cuz they freely permeate the cell membrane)
Renal Glycosuria, Hyphosphatemia, Hypouricemia: FANCONI's
Commonest TA: Type IV RTA
(Hyperchloremic Hyperkalemic metabolic acidosis)
Thyroid Scan: 1-123 Thyroid Ablation: 1-131
Prerenal Azotemia: BUN/Cr > 20.0
L4: Knee Jerk & Sensory on Medial Calf SI: Akle Jerk & Lateral Foot
PIVD L5 compression: DORSIFLEXION of foot affected
PIVD SI compression:
PLANTAR FLEXION of foot affected
[Ca][PO4] > 64 : predictive of metastatic calcification
Mx of Myedema Coma:
300-500 microg bolus of i/v thyroid hormone followed by 50 microgram daily
Panhypoptuitarism presenting with Myxedema coma: first give HYDROCORTISONE
then THYROID REPLACEMENT
(to prevent Adrenal Crisis)
Allopurinol potentiates the action of Azathioprine: if used together, reduce Azathioprine dose by 75%
Routine PIVD: MRI not indicated (conservative Mx - resolve in 1-4 weeks)
PIVD with neurological deficits: MRI
Lumbar Spinal Stenosis:
Discomfort in Thighs on walking / standing
pedal pulses preserved (PSEUDOCLAUDICATION) Ix: MRI
Phaeochromocytoma
Urinary Catecholamines: sensitive Urinary Metanephrine: specific Urinary VMA: least useful
Mx of Fibromyalgia: TCA (NSAIDs are ineffective) #1 functional pituitary adenoma: PROLACTINOMA
Pain in sole of foot after getting up in he morning: Plantar Fascitis (Mx: Arch Support / NSAIDs)
SLE
ANA- sensitive
Anti-Sm: specific
Ant-dsDNA: correlates with disease activity
#1 vitamin deficiency: Vit. D
Polymyositis associated dysphagia: oropharyngeal (striated muscle)
Scleroerma associated dysphagia: esophageal (smooth muscle)
Muscle Biopsy findings in Dermatomyositis: lymphoid infiltrate AROUND muscle fascicles Muscle Biopsy findings in Polymyositis: lymphoid infiltrate INSIDE muscle fascicles
Ix of choice: Muscle Biopsy (not EMG/NCV)
Woman with Joint Pains and Dental Caries : Sjogren's syndrome
GCA: associated with increased incidence of Thoracic Aortic Aneurysms
Ank. Spond. vs. SI joint involvement in Psoriasis: lack of calcification in Psoriasis
Prompt Rx of NGU:
associated with decreased indcidence of REITER's
Whipple's: Joint symptoms precede GI symptoms
Synovial Fluid WBC count
< 200 normal
< 2000 noninflammatory (OA)
2000-50000 Rheumatoid Arthritis
50000-100000 Septic / Gout
> 100000 Septic
#1 Septic Arthritis: N gonorrheae
#1 non-gonococcal arthritis: S. aureus
#1 with IVDU/arthroscopy/prosthesis: S epidermidis
Recurrent Gonococcal Arthritis: ? C5-C8 deficiency
#1 cause of Osteomyelitis: S. aureus
#1 renal involvement after URI:
IgA nephropathy (1-2 days after URI)
PSGN occurs 1-3 weeks after Strep. infection
Nephrotic Syndrome: #1 (Children): MCD #1 (Adults): MGN
Dialysis :acquired renal cysts (? malignant pot.)
Enthesopathy:
inflammation of Ligaments / Tendons (Ankylosng spondylosis / Reactive Athritis)
Polycystic Kidney Disease:
associated with Berry aneurysms in circle of Willis (SAH)
Multile Myeloma & Kidney:
Page 39 of 94 May 19, 2003
Myeloma Kidney - LIGHT CHAIN Renal Toxicity (light chains are not detected by urine protein dipstick) Renal Amyloidosis - Heavy Chains excreted (heavy chains are detected by urine protein dipstick)
Aging: decreasd GFR but S. Cr. remains constant ('cuz Lean Body Muslce Mass decreases too)
Initial Hematospermia: Prostate
Terminal Hematospermia: Seminal Vesicle
RBCs: Hematuria
WBCs: Cystitis
RBC Cast: GN
WBC Cast: APN, Pyelonephritis
Acute Bacterial Prostatitis:
NO Prostatic Massage or Catheterization
Chronic Bacterial Prostatitis:
Prostatic massage -> C/S of expressed secretions (Mx: TMP-SMX)
Ureteral Stones < 6mm: Conservative Mx for 6 weeks
Asymptomatic Renal Stones: Conservative F/U with serial X-Rays
Symptomatic Renal stones (Fever/Pain/UTI): < 3cm: ESWL
> 3cm: PCNL
Urinary Incontinence:
Total: Sx
Stress: Sx is curative (Kegel/Pessary/Estrogen) Urge: Antispasmodic / Anti-Ach / TCA
Overflow: Catheterize
Sildenafil (Viagra) c.i. in patients on Nitroglycerine
Right Ventricular Infarction:
Nitroglycerine precipitates HYPOTENSION
Mx: IN Fluids
70y old man with urinary obstruction and backache: ? Prostatic Ca with mets
Prostatic Biopsy: U/S guided biopsy > finger-guided Prostatic Ca: Transrectal U/S = MRI for staging (CT has no role)
Prostatic Mets: Radionuclide Bone Scan > X-Ray
Ix for suspected Bladder Ca.: CYSTOSCOPY
MEN II: hyperparathyroidism is due to HYPERPLASIA, not PARATHYROID ADENOMA
Testicular Neoplastic Mass: Children: Embryonal Cell Ca. Adult: Seminoma
> 50y: Lymphoma
Intracranial H'age (< 48h. duration):
CT without contrast is superior to MRI
Cerebellar Vermis: Axial ataxia
Cerebellar Hemisphere: "IPSILATERAL " Appendicular Ataxia
Frontal Lobe Lesions: Personality Changes
Temporal Lobe Lesions:
Hallucinations/ deja vu / emotional changes
Parietal Lobe Lesions:
cortical sensory loss (astereognosis)
Occipital Lobe Lesions:
macular sparing field defects &
UNFORMED VISUAL HALLUCINATIONS
Acoustic Neuroma:
first symptom is IPSILATERAL hearing loss
To measure severity of ASTHMA attack: Peak Expiratory Flow Rate [PEFR] (not ABG)
Alcohol can temporarily decrease symptoms in BENIGN ESSENTIAL TREMOR (intention tremor)
Myerson's Sign:
2 per second tap on nose -> sustained blinking (seen in Parkinsonism)
Shy-Drager:
Parkinsonism + Autonomic Insufficiency + Neurological Deficits
Progressive Bulbar Palsy (CN Motor nuclei): TONGUE WASTED
Pseudobulbar Palsy (UMN): TONGUE SPARED
ALS : UMN + LMN
Peripheral Neuropathy:
AXONAL (NCV normal)
DEMYELINATION (NCV decreased)
TT Leprosy: Neuropathy in area of skin lesions LL Leprosy: Neuropathy > Skin Lesions
Tarsal Tunnel Syndrome
Pain, Paraeshesiae on bottom of foot (Sparing of the HEEL)
Cervical Rib:
Thenar Wasting
Pain & Numbness on medial 2 fingers (ulnar side of forearm)
Myotonic Dystrophy: AD
stiffness
cataracts
Page 42 of 94 May 19, 2003
baldness
Mx - Quinine, Phenytoin, Procainamide
Neuropathy: DISTAL ± Sensory Loss
NM Junction: Fluctuating Deficits
Myopathy: PROXIMAL weakness (NO sensory loss)
non-enhancing white matter lesions without mass effect (in AIDS): PML
Ix of Valvular Ht. Disease:
ECHO foil. by Catheterization (definitive Dx)
ILD
Non-productive Cough Exertional Dysnea
Fine Expiratory Crackles decreased DLCO
increased A-a gradient
gold standard for diagnosis: LUNG BIOPSY
Dx of Malignant Mesothelioma: Pleural Biopsy 100% of small cell ca. occur in smokers
Complicated Parapneumonic Effusions Gross Pus
Gram Stain (+)
Glucose < 50 mg%
Pleural Fluid pH < 7.0
Severe Hyperkalemia Mx: Calcium Gluconate Mx of Mg toxicity: Calcium Gluconate
st 1 test in asymptomatic hematuria: URINE CULTURE -> IVP
1st test in suspected pneumonia: CXR -> Sputum C/S
Currant jelly sputum: Klebsiella Rusty sputum: Pneumococcus Smokers / COPD: H. influenzae
Page 43 of 94 May 19, 2003
Interstitial infiltrates: Mycoplasma
Empyema / Rapidly progressive: Staph. aureus
Pneumonia Rx:
Community acquired: Macrolide
> 60y or COPD/smoker: 2nd gen cephalosporin
Nosocomial: 2nd / 3rd gen cephalosporin
ICU (severe): Macrolide + Antipseudomonadal
Uncomplicated UTI: 3 day course of TMP-SMX
Native Valve Endocarditis - S. viridans [a-lactam + aminoglycoside]
Prosthetic Valve Endocarditis (Early) - S. epidermidis [Vancomycin + Aminoglycoside] Prosthetic Valve Endocarditis (Late) - S. viridans [Vancomycin + Aminoglycoside]
IVDU - S. epidermidis / S. aureus [Vancomycin + Aminoglycoside]
IE prophylaxis:
- Amox 2g 1 hr. before Dental / GI / GU procedures - penicillin allergy -> Clarithromycin
Don't delay antibiotics in Meningococcal meningitis (even if LP is not done)
HAART: AZT+3TC & Indinavir
AIDS - avoid all live vaccines except MMR
Abdo. Pain: 1st investigation - AXR
UC: Pseudopolyps, Crypt Abscesses CD: Skip Lesions, Fistulae
ddl can cause Pancreatitis
RA: PIP involvement (DIP sparing) OA: DIP involvement
Ix of choice in Osteoporosis: DEXA scan
Vaginal Candidiasis:
Topical Miconazole / Systemic Fluconazole (recurrent) (Oral agents eliminate rectal reservoir of yeast)
Trichomoniasis:
PO Metronidazole 2g stat (Rx male partner also)
Bacterial Vaginosis:
PO Metronidazole 250-500mg x 7 days (cf. single dose in Trichomoniasis)
Pap shows LGSIL (F/U reliable): repeat Pap 4-6 months later
Women Smokers should always have annual Pap
Primary Dysmenorrhea: within 2 years of menarche inreased Prostaglandins
arteriolar spasm
uterine hypoxia
Mx: (sexually active): OCP's
Mx (sexually inactive / OCP c.i.): NSAIDs
#1 cause of DUB: Anovulatory Cycles
Mx: Hormonal Therapy===>Endometrial Ablation
Severe acute DUN with orthostatic hypotension IN Conjugated Estrogen
#1 STD: Chlamydia trachomatis
Ectopic (hemodynamically stable / no rupture): Methotrexate
Ectopic (Unstable / rupture):
Salpingectomy or Salpingotomy
OCPs:
decrease Gonococcal STD
may increase Chlamydial STD (cervical ectropion)
Vaginal Spermicides:
decrease Gonococcal & Chlamydial STD (no effect on HIV transmission)
Breastfeeding & OCPs: can use. Use low-dose OCPs
('cuz of effect on milk production, not because of infant safety consideration. Estrogens do pass into milk in small quantity, but they are safe)
Hormonal Contraception for No DVT/PE: Norplant & Depo-Provera [no OCP's]
PID
in-patient:
IN Cefoxitin or Cefotetan + Doxycycline
out-patient:
I/M Ceftriaxone + PO Probenecid + PO Doxycycline
Depression: Cognitive Psychotherapy
Adjustment Disorder: Supportive Psychotherapy Anxiety Disorder: Behavioral Psychotherapy
Antidepressant Ladder:
SSRI
another antidepressant (except MAOIs) best tolerated agent + LiCO3
MAOIs ECT
Lab Test for Cocaine:
Urine Benzoylecgonine (Cocaine metabolite)
Genital Herpes transmission occurs even in asymptomatic state (Acyclovir decreases freq. of recurrences)
H'agic crust on "molluscum" like lesions in HIV pts. : Cutaneous Cryptococcosis
HPV (Genital Warts)
Heaperd up lesions flesh colored lesions on penis female partner has increased risk of Ca. Cx
Leprosy with painful red patches on extremities that become nectrotic and ulcerate: LUCID REACTION (seen in unreated leprosy, responds to Steroids)
Excessive use of Aluminium containin laxatives: risk factor for postmenopausal osteoporosis
KOH Prep "meatball-and-spaghetti" appearance: Tinea versicolor
binge eating and purging behavior (even without depression) : SSRI
Factitious Disorder : assoc. with child abuse
Somatoform Pain Disorder:
limit analgesic use
best managed in a multi-disciplinary pain clinic
Rx of choice for Panic Disorder: PAROXETINE [dependence might develop with Alprazolam]
Mx of Social Phobia:
a-blockers + ASSERTIVE TRAINING
Mx of OCD: SSRI [Fluvoxamine] Clomipramne is no longer the first line drug
Mx of PTSD: >1 m; assoc. with life-threatening event Group Psychotherapy
Anorexia nervosa:
75% have Depression, 25% have OCD
Buckman's 6 steps of Breaking Bad News
1. Getting started
2. find out how much the pt. knows
3. find out how much the pt. wants to know
4. share the info. a) Give Warning Shot
5. respond to pt.'s feelings
6. Plan F/U - give hope
Skew: depends on direction of tail (not hump)
± 1 SD 68% ± 2 SD 95%
± 3 SD 99.7%
To increase power of a test: inrease sample size
Nominal or Ordinal Data: Non-parametric Tests [Chi Square]
Interval or Ratio Data:
Parametric Tests [T-test, Z-test, F-test]
Correlation coefficient
Ordinal Data: Spearman Rank Order
Interval or Ratio Data: Pearson product-moment
r=correlation coeeficient
r2 (square)=coefficient of determination
(proportion of variation in one variable explained by variation in other)
Causality is only proven by properly conducted experimental studies
A test can only be 100% sensitive and specific if there is no overlap between measurements in normal and diseased states
Higher the prevalence of a disease: Higher the PPV of a (+) test
Lower the NPV of a (-) test
Untreated apendicitis in young female can cause infertility (peritoneal adhesions)
Appendiceal abscess: delay
Sx till inflammation has subsided
[the acute process has been walled off]
Cholangitis (ass. with CBD stones): ERCP with Sphincterotomy + Lap Chole.
Skin Suture: cutting needle
Deeper Layer Suture: Taper Needle
Ingrown Toe Nail
first episode:
antibiotics, elevation of edge -> wedge resection recurrent:
Nail Removal
Anal Fissure: Local Steroid Cream / Sitz Bath
Anaesthetic of choice for skin lesion removal: Lidocaine + Adrenaline (No Adrenaline for fingers and nails)
#1 type of breast Ca.: Infiltrating Ductal Ca. (80%)
Mx of Fibrocystic Disease: Low Dose OCP Mx of Fibroadenoma: Biopsy (Excisional)
Danger Signs in Chronic Low Back Pain
- Bowel or Bladder dysfunction
- Impotence
- Ankle clonus - NIGHT PAIN - Weight Loss
- Lymph Node enlargement
- Buttock claudication
- New Onset in age > 50 y
No imaging for routine chronic low back pain
Mx of Chronic LBP:
TCA's have the best cost/benefit ratio
[Muscle relaxants and NSAIDs have low effectiveness]
Dx of Childhood PCKD: > 2 cysts in EITHER Kidney Dx of Adult PCKD: > 5 cysts in EACH Kidney
C/I to thrombolysis
- Sx < 2 weeks
- Unconrolled HTN
- Aortic Dissection
- h/o CVA / 'aic stroke / CNS tumor / AVM - prolonged traumatic CPR
- allergy to thrombolytic agents
Page 49 of 94 May 19, 2003
- pregnancy
Risk Stratification in Unstable Angina
fOutpt.) Low - Onset < 2 weeks
iTelemetry) Medium - Onset < 2 weeks, Pain > 20 minutes but resolved @ present (CCU) High - Rest Pain > 20 minutes and not resolved @ present
(CHF / Pulm. Edema / ST changes / Mitral Regurg.)
st 1 episode of syncope / low risk of heart disease: NO FURTHER EVALUATION
Emperical Rx for IE:
Nafcillin + Ampi + Genta
(add Rifampin for Prosthetic Valve)
IE prophylaxis not reqd. for: 1. small ASD of secundum type 2.MVP without Mitral Regurg.
Acute Asthma:
Give Albuterol, 02, steroids -> assess response (PEFR, 02 sat.) Good Response
PEFR > 80% of best (discharge with a-agonist)
Moderate Response
PEFR 60-80% of best
(hospitalize and continue medications, 02)
Poor Response
PEFR < 50% of best
(ICU admission)
(prepare for Intubation if silent chest, altered sensorium, respiratory failure)
Chronic Asthma
Mild Intermittent:
<2/week, nocturnal symp. < 2/month (Inh a2-agonist)
Mild Persistent:
>2/week, nocturnal symp. >2/month (Inh a2-agonist + Anti-LT)
Moderate Persistent:
Daily, PF 60-80%
(Inh a2-agonist + Inh. Steroids/Inh. long acting a2-agonist)
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Severe Persistent:
Continuous, PF<60%
(Inh a2-agonist + Inh. Steroids + Inh. long acting a2 / Anti LT)
SPN: Conservative Mx
Age < 45, nonsmoker, no inrease in size, size < 4cm
Psoriasis:
Pustular: ACITRETIN
Plaques:
Emollients / Keratolytics / Corticosteroids Tar / Calcipotriol / Anthracin
UVB
PUVA
Methotraxeate / Cyclosporin
Hyd roxyu rea
Rx of Onychomycosis: PO Terbinafine
Acute Mastoiditis develops 2-3 w after acute otitis Mx: Ceftriaxone / Sx drainage
Acute Bacterial Sinusitis: Pneumococcus Chronic Bacterial Sinusitis: S. aureus
most serious form of sinusitis: FRONTAL sinusitis
d/o/c for Alzheimer's :
DONEPEZIL (OD dosing, no liver toxicity)
Upper Lips: BCC > SCC Lower Lips: SCC > BCC
RCA stenosis: Saphenous grafts
Anterior Duodenal Ulcers: Perforation Posterior Duodenal Ulcers: Bleeding
Acute Meseteric Ischemia: Embolization Chronic Mesenteric Ischemia: Atherosclerosis
Page 51 of 94 May 19, 2003
Carcioid: Appendix > heal
(Heal have higher chances of metastasis)
#1 GI malignancy: HCC (not colorectal Ca.) #1 Liver neoplasm: Cavernous hemangioma
#1 Breast Lesion: Fibrocystic Disease #1 Breast Malig.: Infiltrating Ductal Ca.
Indications for Hormonal Therapy for Breast Ca. - Postmenopausal
- Nodes -
- ER +
Aortic Aneurysms Thoracic:
Type A: Sx
Type B:Sxif>6cm Abdominal:
Sx if > 5cm
#1 Congenital Heart Disease: VSD #1 Cyanotic Heart Disease: TOF
ASD: Fixed Splitting of S2
Biliary Atresia:
Jaundice @ 2 wks of life, dark urine & acholic stools Rx: Surgery (Roux-en-y portoenterostomy)
Neck Injuries:
Zone I : Arteriography -> Sx Zone II : Sx
Zone III : Arteriography -> Sx
Mortality in Burns = Age + % BSA
1st degree: Leave Open
2nd degree: Clean,Sulfadiazine,nonadhesive dressing 3rd degree: Escharotomy + Skin Grafting
Sprain: Ligament Pull
Page 52 of 94 May 19, 2003
Strain: Muscle Pull
# Neck Humerus: Axillary Nerve Damage
# Shaft Humerus: Radial Nerve Damage
Quick Neuro Exam
AVPU:
Alert
Responds to Verbal Stimulus Responds to Pain
Unresponsive
Rescusitation:
02, 2 large bore IV lines, IV fluids, EKG
- 100 mg Thiamine
- 1 amp 50% Dextrose
- 0.4 mg Naloxone
C/I to Foley's Catheter: (do retrograde urethrogram)
1. Blood at tip of urethral meatus
2. Perinea) Eccymoses
Abdo. Trauma
#1 Injury in Blunt Trauma: Spleen
#1 Injury in Penetrating Trauma: Small Bowel
Indications for Exploratory Laparatomy in Abdo. trauma
1. Shock with Abdo. Injury
2. Pneumoperitoneum
3. Gunshot
4. (+) DPL
- Blood
- RBC > 100,000/mL
- WBC > 500/mL
- Food
- Bile
- Bacteria
Referral for Burns
- 3rd degree burns > 10% BSA, < 10 y, > 50 y
- 2nd degree burns > 20% BSA
- Electrical burns / Chemical burns
Page 53 of 94 May 19, 2003
- Inhalation Injury
- Perinea) burns
- Radiation burns
#1 symptom of Parkinsonism: Tremor (Resting)
Benign Essential Tremor
Intention Tremor
Familial
Head Nodding
temporary decrease with alcohol intake
S. pneumoniae: Rx - Macrolide or newer Quinolone (Levofloxacin / Gatifloxacin)
Majority of elderly patients with sepsis: URINARY TRACT is the culprit
#1 cause of death in hospitalized elderly: UTI
#1 cause of death in institutionalized pts.: Bacterial Pneumonia
#1 cause of Urinary Incontinence: Urge Incontinence
Clean pressure ulcers with Normal Saline (avoid Povidone-lodine, Hydrogen Peroxide etc.)
Unimmunized with infected wounds 3 TT + 1 ATS
Stroke mortality is higher in WHITES than in BLACKS
indications for pneumococcal vaccine
1. Splenectomy
2. Sickle Cell
3.>65y
4. Chr. Cardio / Pulmonary / Renal Disease 4. Hodgkin's Disease
Continued Gastric Lavage for : PCP overdose
#1 Foods causing angioedema: Nuts / Seafood #1 Drug causing allergy: Aspirin
Electronic Fetal Monitoring & Intermittent Auscultation of Fetal Heart have similar outcomes
Page 54 of 94 May 19, 2003
NST (Non-stress Test)
> 2 accelerations (in 20 minutes) 15 bpm lasting > 15 sec
CST
>= 3 consecutive late decelerations in 10 minutes
< 20w. POG with HTN: Essential HTN (not PIH or pre-eclampsia)
Pre-eclampsia:
Bed Rest / (L) lateral position /
pharmacotherapy [a-methyldopa / labetalol]
#1 indicator of perinatal outcome in IUGR is: presence of vertical pocket of Amniotic Fl > 3 cm
0-8 weeks : Embryo 8w-term : Fetus
0-14 weeks: 1st Trimester [Routine Ix] 14-28 weeks: 2nd Trimester [GDM Screen] 28-40 weeks: 3rd Trimester [GBS Culture]
<24 weeks: Previable 24-27 weeks: Preterm 37-42 weeks: Term
> 42 weeks: Post-term
Cervical Incompetence:
- Cerclage @ 12-14 weeks, till 36-38 weeks POG
Bishop Score:
<= 5: Prime (with Prostaglandins)
> 8: Induce Labor
#1 cause of PPH: Uterine Atony Preterm ROM: @ < 37 weeks POG
Premature ROM: > 1 hr before onset of labor
Prolonged ROM: > 18 hours before onset of Labor (Mx: Antibiotics)
Mastitis in breasftfeeding: continue breastfeeding, Cloxacillin
Early Breast Milk Jaundice
Exaggerated Physiological Jaundice Onset < 4 days of life
Late Breast Milk Jaundice
Breast Milk Jaundice
Onset 4-14 days
competitive inhibition of glucuronyl ransferase by nonesterified long chain fatty acids in reast milk
Mx: Stop breastfeeding for 2-3 days /
Give Formula Milk [Jaundice comes down quickly] -> Resume Breastfeeding
Any jaundice @ Birth is PATHOLOGICAL
Success of Contraceptives Norplant > OCPs > Barrier
Norplant: quick return to fertility DMPA: 18 months for fertility to return
Complete Mole:
Diploid; 46, XX; has higher malignant potential
Kernicterus never occurs with:
physiological jaundice
exaggerated physiological jaundice breast milk jaundice
Features of Pathological Jaundice:
present @ birth
increase in bili. > 5 mg/dL/day on first day
Bill. >12 mg/dL [term] or Bili. >14mg/dL [preterm] persists > 1 week of life
Conjugated Bili. > 1 mg/dL @ any time
Page 56 of 94 May 19, 2003
Wessel Criteria for Infantile Colic
Unexplained Crying:
>3hr/day,>3d/week,>3 weeks, 3 m old child Do Urinanalysis
Reassure
No treatment necessary
Bottle-fed infants have higher incidence Dicyclomine: risk of apnea
After a feed, allow "burping" and lay the child on (R) side of abdomen
Introduce Solid Foods @ 6 months age
Vaginal pH < 4.5: Candida
Vaginal pH > 4.5: Bacterial Vaginosis
Transfusion Reactions
Fever: Leukoagglutination (donor WBCs) Mx: acetaminophen
Anaphylaxis (donor proteins,severe in IgA-deficiency)
Mx: Epinephrine, Steroids
Hemolysis (ABO mismatch)
Mx: stop transfusion, hydration & diuresis
Familial Short Stature: NORMAL BONE AGE Constitutional Delay: DELAYED BONE AGE
Short Stature with Webbed Neck is seen both in Turner's (XO) & Noonan's (normal Sex chromosomes)
Budesonide has proven to be beneficial in Croup (along with racemized epinephrine)
Rx of choice for AOM in primary practice: Amox =__> Cefaclor (if no response to Amox)
Transmission of Common Cold:
Indirect Spread is more important than Aerosol spread
Absolutely no antibiotics in common cold (even if patient demands it!)
Erysipelas: Gp. A a-hemolytic Srep. Impetigo: Staph. or Strep. [Bullous - Staph.]
Coxsackie A16: Hand Foot Mouth Disease Pitryasis rosea: Herald Patch
PNEUMONIA
2 wks: GBS
2 wks - 4 m: Chlamydia trachomatis
#1 Bacterial: Strep. pneumoniae
4 months - 4 years: Mycoplasma pneumoniae
#1 Bacterial: Strep. pneumoniae > 4 years: VIRAL
#1 bacterial: Strep. pneumoniae
Antibiotic Rx of Occult Bacteremia
does not decrease the occurence of meningitis
Yersenia entercolitica: can mimic acute appendicitis (no Rx necessary - self limiting) ROTAVIRUS G/E is preceded by URI symptoms
Rec. Abdo. Pain Syndrome - 10% prevalence
- school phobia
- no organic signs
- no Rx necessary
Growing Pains
- B/L deep pains
- can awaken child from sleep Mx: exercize program
SCFE
overweight and sedentary "teenage" BOY Groin Pain/ Knee Pain
Dx: X-Ray
Mx: Surgical fixation
Page 58 of 94 May 19, 2003
Avascular necrosis of femoral head LIMP
hip pain or referred knee pain
(knee is NOT TENDER to palpation)
Osgood Schlatter
tenderness over tibial tubercle
aggraveated by activity
occurs in pysically actve males around puberty Mx: Limit activity, NSAIDs;
(if severe) Knee immobilization splint
Teenager with knee pain aggravated by climbing stairs: Patellofemoral Syndrome
Child with Limp / Hip Pain
- preceded by URI
- Fever (+)
- normal ESR
TOXIC SYNOVITIS [Sterile Hip Effusion] Mx: Rest / NSAIDs (NO ANTIBIOTICS)
Foot dorsiflexes easily
banana shaped sole: Congenital calcaneovalgus kidney bean shaped sole: Metatarsus adductus
Intoeing
patella points forward: Internal Tibial Torsion
patella points medially: Excessive Femoral Anteversion (#1 cause of intoeing in children)
CTEV: inability to dorsiflex Mx: progressive serial casts,
posteromedial release of heel cord
#1 substance of abuse: Alcohol
Nocturnal Enuresis
> 4 years
majority of children do NOT have any physical or psychiatric disorder Mx: Behavioral modification
Bell / Buzzer system
d/o/c: dDAVP (no longer IMIPRAMINE)
Page 59 of 94 May 19, 2003
Encopresis: > 4 y. Enuresis: > 5 y.
Allergic Rhinitis:
Hyperemic Nasal Mucosa
Clear Discharge
Bluish-purple rings around eyes (SHINERS) Ix: Nasal smear for Eosinophils
Mx: elimination / inra-nasal corticosteroids
Child with rash on introduction of "whole milk": Atopic Dermatitis
Mx: Cow Milk ----> Formula Milk ----> Soy Milk
(Cow milk allergic might show allergy to soy milk, too)
Diaper Rash
Candidal: Satellite lesions Seborrheic
Primary Irritant Dermatitis:
maceration with sparing of henitocrural folds
(Mx: frequent changing, washing,
no occlusive plastic pants, ZINC OXIDE,
NO ANTIBIOTICS)
Innocent Murmur in Children
prevalence: 50%
accentuated by sitting, anxiety, fever, tachycardia mid to low sternal border
systolic
no thrill
vibratory or musical in quality
[Still's Murmur]
Common Cold: Steam Inhalation provides superior relief of nasal congestion cf. antihistaminics
Decongestants (sympathomimetics) :
can use CNS overstimulation
Cough Suppressants (Dextromethorphan) :
can cause respiratory depression in children #1 complication of sickle cell disease Painless Hematuria (Paillary Necrosis)
Page 60 of 94 May 19, 2003
Priapism in Sickle Cell Disease > 6 hrs.: Hospitalize
no eff
Edited by drtanvir on 07/27/07 - 09:53 AM
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| GOGETA
I'm Dr. GOGETA
Topics: 298
Posts: 2,616
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thanks they are very nice
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As a general rule, the better it felt when you said it, the more trouble it's going to get you into.
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