drbcshah
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i have copy pasted above notes so may have mistakes. They are made by Dr. Jiggy So thank him / her not me
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| drbcshah
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Topics: 48
Posts: 227
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KaplanQbankNotes:Neeraj 15
• Thyroid nodule? Benign or malignantnodule large enough to cause airway or digestive tract obstruction emergent thyroid surgery without further evaluation.
Step-1:TSHDecreased =hyperactive nodule=typically benignA
Step-2:TSHNormal or elevated TSH = non-functioning or normally functioning nodule.
Step-3:Imaging and/or a biopsy to obtain a tissue diagnosisultrasoundmost useful diagnostic tool fine needle aspirate (FNA)result from an FNA
1. First, the sample can represent benign lesions= no further treatment (unless the lesion continues to grow causing obstruction to breathing or eating, or causing unacceptable cosmetic disfigurement in the neck).
2. Second, the specimen can be a follicular lesion = treated with a surgical removal of part or all of the thyroid gland to determine whether it is a benign or malignant type.
3. Third, the biopsy can show a clearly malignant lesion = treated with surgical removal of the thyroid gland.
4. Finally, the sample can be nondiagnostic = requires a repeat FNA. However, after three nondiagnostic biopsies, a surgical removal of the affected thyroid lobe is usually recommended.
• Approach towards Breast Lump:
1. Nipple discharge: Pathologic discharges are spontaneous, bloody or associated with a mass. These discharges are usually unilateral. The most common cause of pathologic nipple discharge is intraductal papilloma, followed by duct ectasia.10 If a palpable mass is present in association with a discharge, the likelihood of cancer is greatly increased.
2. Dominant breast mass Dx macrocyst (clinically evident cyst), fibroadenoma, prominent areas of fibrocystic change, fat necrosis and cancer. KaplanQbankNotes:Neeraj 16
(a)Solid Masses in Women Less Than 40 Years of Age
1. Physical Examination No evidence of mass reassured and instructed in breast self-examination.
2. Physical Examination physical finding is uncertain directed ultrasound examinationnot demonstrate a massRepeat physical examination?mammogram (35 to 40 years not in younger)
3. Physical Examination dominant mass (? suspicious mass is solitary, discrete, hard and often, adherent to adjacent tissue) mammographypathologic diagnosis.
4. Physical Examination dominant mass (? Not a suspicious mass or clinically benign) discus options of surgical excision or follow-up with the patientpatient desires surgical excisionno additional testing is donepatient opts for further work-upan ultrasound examination and fine-needle aspiration are performed to confirm that the mass is benign. "Triple test" (clinical examination, ultrasonography [or mammography] and fine-needle aspiration).
• The size of the lesion must be measured with a ruler at presentation and on subsequent visits to allow an accurate assessment of size over time.
• patient is examined every three or four months for one year to ensure stability of the mass.
(B)Solid Masses in Women More Than 40 Years of Age.
1. Abnormalities detected on physical examination in older women should be regarded as possible cancers until they are documented to be benign.
2. mammography is a standard part of the evaluation of a solid breast mass.
3. In the presence of a dominant breast mass, a normal mammogram should never be considered proof of the absence of breast cancer.
• Premenstrual dysphoric disorder: constellation of physical and emotional symptoms occurring during the late luteal phase of the menstrual cyclesymptoms must be present during most cycles in the past year and during at least two subsequent cyclesat least five of the following symptoms: depressed mood, marked anxiety, affective lability, decreased interest, decreased energy, sleep disturbance, craving food, feeling overwhelmed, and difficulties concentratinginterfere with social or occupational functioning and are not due to other psychiatric or medical disorders.
• Exposure therapya type of behavior therapymost commonly used treatment of specific phobia desensitizes the patient by a gradual exposure to the phobic stimulusRelaxation and breathing control are important parts of the treatment.
• Alprazolam belongs to the group of short-acting benzodiazepines. Even though it has a short half-life, it can produce confusion, disinhibition, and amnestic problems like blackouts in the elderly population. The risk is increased if it is combined with CYP3A inhibitors.
• In pseudodementia of depression, the patient often tends to emphasize disability related to memory loss much more than patients experiencing true dementia.
• Olanzapine is an atypical antipsychotic indicated for the management of psychotic disorders. It is said to be associated with weight gain.
• HIV dementia is characterized by affective, cognitive, behavioral, and motor symptoms and signs. It presents as a subcortical process and is most likely to occur in patients with a CD4 count below 200/mm3. It usually has a slow onset, and, after a period of stability, there can be a precipitous decline. The diagnosis is made when other causes of delirium are excluded; the disease may present with psychosis within HIV dementia. The symptoms are controlled with low doses of neuroleptics.
• Circumstantiality refers to speech that is delayed from reaching the point, characterized by overinclusion of details.DDxTangentiality : patient never gets to the desired goal from the starting point of discussion.
• Patients with disorganized type schizophrenia are likely to exhibit disorganized speech, disorganized behavior, and flat or inappropriate affect. Examples of disorganized thoughts and speech include: loosening
KaplanQbankNotes:Neeraj 17
of associations or derailment, flight of ideas, tangentiality, circumstantiality, word salad, neologisms, and clang associations.
• The newer atypical antipsychotics have minimal, if any effect on plasma prolactin concentrations, except for risperidone, which is associated with elevated prolactin.
• A Papanicolaou smear should ideally be a sampling of the transformation zone(adequate sample should show endocervical cells)endocervical cells not present?whether the transformation zone was fully sampledRepeat the sample if high risk individual or after 1 yr if with no high risk and had all earlier pap normalEvery woman should have yearly pap smear after first intercourse or 18yrs whatever comes earlier
• Rarely struma ovarii is a cause of hyperthyroidism and patients with this manifestation may have symptoms of hyperthyroidism, as well as elevated levels of thyroid hormones and decreased levels of thyroid stimulating hormone (TSH).
• There is no evidence that breast-feeding increases HCV transmission to the baby.
• Postpartum endometritis Cesarean section is the major risk factorOrganisms ascending from the vagina and causing a polymicrobial infection of the endometrium fever and chills, lower abdominal pain, a foul-smelling vaginal discharge and malaise abdominal tenderness, and uterine tendernessRx clindamycin and gentamicin ( prophylactic antibiotics are recommended in all cases of nonscheduled cesarean delivery i.e. a cesarean delivery that is not anticipated like with membranes broke but non-progressing/Breech etc and are given before or after the umbilical cord is clamped)
• Discharge criteria patient should be alert, able to ambulate (if this was her preoperative level of function), able to tolerate adequate oral intake(Patient on IV intake should not be discharged), have stable vital signs, and have satisfactory bowel and urinary tract function.
• Chorioamnionitis (can develop at any time before and during delivery)fever and uterine tendernessRx ampicillin or penicillin with gentamicin.
• Asymptomatic bacteriuria in pregnant womenassociation with preterm delivery/low birth weight Rx trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexinfollow-up urine culture after 10 days of completing the medicationtest-of-cure.
• Gestational diabetesusually diagnosed by means of oral glucose tolerance testingPatients with gestational diabetes and normal fasting glucosetwo major risksfetal macrosomia & eventual development of overt diabetes(within the next 20 years)with gestational diabetes and abnormal fasting glucose increased risk of stillbirth.
• Significant mitral stenosis during pregnancy should be monitored invasively using a Swan-Ganz catheter second stage of labor be shortened using forceps or vacuum to prevent excess maternal Valsalva efforts and maternal tachycardia.
• HIV Positive mother combination of ZDV therapy + cesarean delivery decreases the risk of transmission to approximately 2% Amniocentesis should be avoided, if possible, in the HIV-positive woman.
1. 2% vertical transmission with ZDV + Scheduled CS prior to the onset of labor or rupture of membranes
2. 8% antiretroviral therapy in mother + Infant
3. 25% when none used
• Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is 12 1/2 years, but it may be delayed until 16 or may begin as early as age 10.
• Current recommendations are that pregnant women who will be in the second or third trimester during the flu epidemic season should be given the influenza vaccination.
• "once a cesarean, always a cesarean." This is no longer the case. Some women are allowed to approximately 70% of all women attempt vaginal birth after a prior cesarean delivery will be successful.
KaplanQbankNotes:Neeraj 18
• Face presentationCauses: anencephalic fetus, pelvic contraction, and high parityvaginal delivery is possible when the fetus is in a mentum anterior position (i.e., the fetal chin is oriented toward the maternal pubic symphysis.)Fetus can flex its head, thereby allowing delivery Vacuum delivery /Forceps delivery with a non-vertex presentation would be contraindicated.
• The presence of a classic uterine scar (vertical incision into the uterus that extends from the lower uterine segment up into the active myometrial portion toward the fundus of the uterus) mandates elective repeat cesarean delivery when the fetus is mature as patients with a previous classic cesarean delivery have roughly a 10% risk of uterine rupture.
• Oxytocin or Prostaglandin (PGE2) gel is an effective agent to use for labor inductionshown to improve the Bishop's score, to shorten the length of labor and delivery, to decrease the amount of oxytocin needed, and to decrease the cesarean delivery ratemain complication from its use is uterine hyperstimulationincreased frequency of contractions (greater than 5 every 10 minutes) or an increased length of each contraction (greater than 2 minutes) or contractions of normal duration occurring within 1 minute of each other and a non-reassuring fetal heart rate tracing Rx IV or subcutaneous terbutaline or IV magnesium sulfate(MgSo4 also most effective medication for seizure prophylaxis in women with preeclampsia) in case of PGE2 or discontinuing the oxytocin (bradycardia to the 80s) or reducing its dosage (where the fetal heart rate tracing is not as non-reassuring)
• Home uterine activity monitoring (HUAM) women are monitored at home with a tocodynamometer (a way to measure uterine contractions)will allow for preterm labor to be recognized and treated in its earliest stagesto prevent preterm birthsIn practice not been proven to prevent preterm birthpossible benefit early recognition of preterm laborwould allow for the administration of corticosteroids to bring about fetal pulmonary maturity (Steroid administration in a Diabetic mother may lead to increased dosage of Insulin).
• Fetal scalp sampling (FSS):method of fetal assessment with fetal blood pH When the fetal heart rate tracing is not reassuring, FSS can be used to determine the acid-base status of the fetus, which will help with management of the laborpH is > 7.25 then the patient may be managed expectantly pH is between 7.20 and 7.25:repeat in 15 to 30 minutespH is < 7.20, steps should be taken to bring about delivery(Acidemia likely to cause damage to the fetus appears to occur at values < 7.00, by using a cutoff of 7.20, there is a margin for error to protect the fetus)
• Forceps and the vacuum extractorTo expedite the deliveryindications:
1. non-reassuring fetal heart rate tracing,
2. maternal exhaustion
3. maternal contraindications to pushing (such as maternal cardiac disease.
Choice of forceps or vacuum ? Forceps may be used in face presentation with a mentum anterior presentation(vacuum is contraindicated) Vaccum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissuesBoth the vacuum and forceps should preferably be used only in low- or outlet- situations (i.e., with the fetal vertex at +2 station or lower.)
• A major advantage of chorionic villus sampling is that it can be performed at 10-12 weeks, as opposed to amniocentesis, which is performed in the second trimester. CVS thus allows a woman to undergo an earlier termination than amniocentesis allows for. However, there is some evidence that one subtype of limb defect, called transverse digital deficiency, is more common with CVS.
• The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the vagina at the 5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the posterior vagina.They undergo rapid growth during the process of puberty and they shrink after the menopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst resultscyst becomes infectedBartholin's abscesspolymicrobial /gonococcus implicated in 25% Rx placement of a Word catheter.( This is a small balloon-tipped catheter)allows drainage of the cyst and the formation of an epithelialized tract that will allow continued drainage once the catheter is removedtract should prevent the cyst from reformingIf Bartholin's cysts continue to form in spite of the use of the Word catheter, a marsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding skin to prevent re-closure and re-formation of the cystinterestingly; one cannot make this assumption in a postmenopausal patientcystic mass on the vulva in a postmenopausal woman must be biopsied(as there is a higher likelihood that this lesion represents a Bartholin's gland carcinoma)
• High-grade squamous intraepithelial lesion (HGSIL) will progress to invasive cervical cancercolposcopically directed biopsydiagnosis of HGSIL is confirmedthe distribution of the lesion
KaplanQbankNotes:Neeraj 19
is known, removal or destruction of the entire transformation zone should be performeddone with a loop electrode excision procedure (LEEPa thin-wire loop electrode is used to excise the entire transformation zoneLEEP can thus be used as both a diagnostic and therapeutic procedure immediate risks of LEEP are bleeding and infection. The possible long-term risks include cervical incompetence and cervical stenosis.
• The American Heart Association guidelines for the prevention of bacterial endocarditisantibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery Except patient with "high risk" cardiac conditions, which include women with a history of endocarditis, or who have prosthetic heart valves, complex cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts Mitral valve prolapse if associated with mitral regurgitation (demonstrated by Doppler or a murmur) is considered a moderate risk condition and therefore antibiotic prophylaxis is not necessary.
• Physiologic leukorrhea can be seen during 2 different periods of childhood. Some female neonates develop a physiologic leukorrhea shortly after birth as maternal circulating estrogens stimulate the newborn's endocervical glands and vaginal epithelium. Physiologic leukorrhea can also be seen during the months preceding menarche. During this time, rising estrogen levels lead to a whitish discharge not associated with any symptoms of irritation or infection.
• With each uterine contraction, blood flow to the placenta decreases, and the fetus is exposed to transient hypoxia. As the labor progresses and more and more contractions occur, this hypoxia can eventually lead to a change from aerobic to anaerobic metabolisfetal academiamost fetuses tolerate the stressprotective mechanismsincluding a blood buffering system and the diving reflex (a lowering of the heart rate in times of hypoxic stress)Electronic fetal monitoring is used to determine whether the fetus is becoming dangerously acidemic or "stressed"? But many fetuses with a non-reassuring fetal heart rate tracing do not have academiaThus, the delivery of many fetuses is expedited because of the concern for fetal acidemia when, in fact, the fetus is not acidemic at all!
• Group B Streptococcus part of the normal bacterial colonization of many women which women will receive antibiotics during labor? likelihood of infection is increased if following risk factors are present:
1. The five risk factors are: 1. History of a GBS-affected neonate. 2. Urine culture with GBS (GBS bacteriuria) 3. Preterm labor (<37 weeks). 4. Membranes ruptured for greater than eighteen hours in labor. 5. Temperature greater than 38.0 C (100.4 F) in labor. A woman with any one of these five risk factors should receive antibiotics in labor.
2. also provide antibiotic if pregnant women being screened for GBS and found positive at 35 to 37 weeks with a culture of the vagina, perineum, and anus.
Rx penicillin.
• Needle prick injury may transmit HBV>HIV during operative procedures etc
• BRCA1 is associated with high risk for breast and ovarian cancer.
BRCA2 is associated with a high risk of female and male breast cancer.
But total number of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentage of the total number Therefore, screening of the general population is not recommended.
• RhoGAM (anti-D immune globulin) is given at 28 weeks' gestation, within 72 hours after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis, threatened abortion, antenatal bleeding, external cephalic version, or abdominal traumaThe amount is 300 μg (covers a fetal to maternal hemorrhage of 30 mL or 15 mL of fetal cells)when fetal to maternal hemorrhage in excess of this 30 mL like with manual removal of the placenta (like this patient had) or placental abruption. To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test This acid-dilution procedure allows fetal red blood cells to be identified and counted.
• Aspiration pneumonitis is a major cause of anesthesia-related death in obstetrics Rx treatment positive-pressure ventilation with 100% oxygen administered through an endotracheal tube when an epidural is going to be placed, the patient should be given an antacid
• Two of the major risk factors for uncomplicated UTI are sexual intercourse and hypoestrogenism. Hypoestrogenism is believed to be a risk factor for UTI because it is known that postmenopausal women not receiving estrogen replacement therapy (ERT) are at greater risk for developing a UTI compared with those women who do use ERT.
KaplanQbankNotes:Neeraj 20
• There is no effective screening test for endometrial cancer .It is not cost-effective to screen asymptomatic women for endometrial cancer.
• Cancer screening should be an essential part of an annual examination. Colorectal cancer screening should begin at age 50 with no significant family history. Screening consists of a digital rectal examination with fecal occult blood testing. This can be performed at the same time that pelvic examination is performed. Sigmoidoscopy should be performed every 3-5 years.
• Various studies have also shown that rates of preeclampsia, placental abruption, and heart failure may be increased in pregnant patients with hypothyroidism. Pregnancy often leads to an increased requirement for thyroid hormone replacement (thyroxine) as the pregnancy progresses.
• Coumadin is contraindicated during the first trimester because of the risk of birth defects. Coumadin embryopathy is a syndrome consisting of nasal hypoplasia and stippled vertebral and femoral epiphyses. Second- and third-trimester exposure to Coumadin can lead to hydrocephaly, microcephaly, ophthalmologic abnormalities, fetal growth retardation, and developmental delay. Low-molecular-weight heparin has been shown to be an excellent anticoagulant because it has a longer half-life and a more predictable dose-response relationship,also less likely to cause thrombocytopenia and hemorrhagic complications than unfractionated heparin.
• Tubal ligation failure may result from many factors including recannalization of the tube and poor surgical technique. The most commonly quoted failure rate is about 1 in 100, although a more accurate figure may be closer to 1 in 300.
• Raloxifene is selective estrogen receptor modulators (SERMs) have pro-estrogenic effects in some tissues and anti-estrogenic effects in other tissuesapproved for prevention of osteoporosisno effect on hot flashes.
• Patient post-hysterectomy for Endometrial CA asking for HRT? if any neoplasm is remaining in body it will grow and recur earlier! +Standard risk of venous thrombosis
• Hot flashes can respond to estrogen or progestin bothWhen both are contraindicated(like H/o pulmonary embolus for estrogen or depression for progestin) Rx alternative treatment Clonidine in low doses.
• Vitamin A supplementation during pregnancy is not needed or recommended for most women. In fact, vitamin A supplementation has been associated with birth defects, including cranial neural crest malformations. Most commonly used prenatal vitamins contain 5000 IU or less, and this is considered acceptable.
• Ovarian hyperstimulation syndrome (OHSS)in patients undergoing ovulation induction mild OHSS (ovaries <5 cm) mild weight gain and pelvic discomfortmoderate OHSS, (up to 10 cm)least a 10-pound weight gain, nausea, and vomitingsevere OHSS, (>10 cm) with ascites, hydrothorax, hemoconcentration, and oliguria Rx mild cases: conservatively, more severe cases: paracentesis, thoracentesis, or surgery. Pelvic or abdominal examinations can lead to rupture of the ovarian capsule hence ultrasound examination is preferred.
• During pregnancy: gastric acid secretion & motility is reduced and mucus secretion increased Reduced peptic ulcer disease Similarly 70% of women with migraines will have improvement(Rx acetaminophen and antiemetics or Codeine or meperidine may be given for severe headachesErgotamine preparations should be avoided in pregnancy) safety of sumatriptan during pregnancy has not been established?
• Mode of delivery with twin gestations:
1. Vertex-vertex twins are generally allowed to have a vaginal delivery.
2. presenting twin that is non-vertex are generally advised to have a cesarean delivery
3. Presenting twin vertex and the non-presenting twin non-vertex may decide which mode of delivery they would preferOnce the presenting (vertex) twin has deliveredfirst option is an external cephalic version, in which the head of the second twin is guided into the pelvis so that it becomes a vertex presentationsecond option is a breech extraction of the second twin(Breech extraction may be performed so long as there is an adequate pelvis, a fetal weight greater than 2,000g, an experienced physician, a flexed fetal head, and available general anesthesia)
KaplanQbankNotes:Neeraj 21
• DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed on cultured amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliable for the diagnosis of fragile X syndrome because of different methylation patterns in the trophoblast compared with the fetus.
• Kallmann syndrome (i.e., isolated gonadotropin deficiency or familial hypogonadotropic hypogonadism) can present with primary amenorrhea ,anosmia or hyposmia, color blindness, and cleft lip or cleft palate(during embryogenesis the GnRH neurons originally develop in the epithelium of the olfactory placode and normally migrate into the hypothalamusThus exists the link between the midline defects and the amenorrhea)Rx exogenous estrogen and progestin replacement therapyIf pregnancy is desired, ovulation induction can be brought about with the pulsatile administration of exogenous GnRH.
• In case of PID: The partner of the patient must be treated as well as the patient herself in order to prevent reinfection. A test of cure (TOC) should be performed 4 to 6 weeks after treatment is given to ensure that the organism has been completely eradicated from the patient and her partner or partners.
• PID in preganacyRx Clindamycin + gentamycin
• Meperidine can be used as a systemic analgesic during labor. It is an opioid and readily crosses the placenta; therefore, the fetus is exposed to the medication. As an opioid, it causes respiratory depression. Neonates are at greatest risk for respiratory depression when delivery occurs approximately 2 to 3 hours after meperidine is administered to the mother.Rx nalaxone
• Compound presentation:when an extremity prolapses alongside the fetal presenting partbrought about when the pelvic inlet is not completely occluded by the fetal head(Most often with premature fetuses) compound presentation can be allowed to undergo a normal labor and delivery.
• Women of child-bearing age should consume 0.4 mg/day of folic acid starting preconceptionally and continuing for the first 3 months of pregnancy.
• Molar preganancy: Once there is pathologic confirmation of the diagnosis, it is essential that the patient continued to be followed weekly until the beta-hCG value returns to 0. The patient should then be followed monthly for an additional year to ensure that the values stay at 0 and that there is no evidence of persistent or metastatic disease.
• Syphillis in preganancy :Only Rx is penicillin as no other drug permits safe and effective treatment of the fetus as well as the motherIn a patient who is allergic to penicillin, oral desensitization must be performed first in a hospital setting with appropriate facilities.
• Genital herpes: no "cure" for herpes genitalis. Acyclovir can be used to shorten the duration of symptoms. In patients who have more than 6 outbreaks per year, daily oral acyclovir is recommended to prevent these frequent outbreaks.
• In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be sought.
• Fluid replacement in a case of burns the Parkland calculations made by standard formulas are only an educated guess. Once fluid administration begins, we judge its adequacy by the information provided by urinary output and central venous pressure, aiming for an output of 1-2 mL/kg/hr, while not exceeding a venous pressure of 10 or 15.
• Parkland formula: 4 mL of Ringer's lactate x body weight in Kg x percentage of the body surface burned + 2000 mL of dextrose 5% in water
• The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions: no chemotherapy during the first trimester, and no radiation therapy during the pregnancy. It is not necessary to terminate the pregnancy. The surgical option could be mastectomy or lumpectomyas per the size.Should axillary nodes be positive, systemic therapy should be done later.
KaplanQbankNotes:Neeraj 22
• 2nd postoperative day after an operative procedureurinary output in the past 2 hours has been zero (ARF ruled out as some urine is still produced in ARF, although it is a small volume)Rule out catheter block?
• Lumpectomy alone has an unacceptably high incidence of local recurrenceAlways add local radiation therapyIf metastatic disease found in axillary nodesAdd systemic therapy. As a rule, chemotherapy is preferred for premenopausal women & receptor positive.
• Never operate a patient under GA if liver function marginal would be tipped into overt liver failure by an anesthetic and an operation
• Any gunshot wound below the nipples involves the abdomen, and the management of all gunshot wounds of the abdomen requires exploratory laparotomy.
• Compartment syndrometriggered by prolonged ischemia followed by reperfusion (the arm pressed against the park bench until he woke up and changed position), and located in one of the two most common sites (forearm and lower leg)reliable physical finding pain on passive extension and the diagnosis is not ruled out by normal pulses. Only a fasciotomy will solve his problem.
• Amputed finger under transportmust be kept from drying outmust not be injured with any direct chemical agentsmust not be placed in direct contact with ice or allowed to freeze.
• There is some evidence that high-dose corticosteroids administered as soon as possible after the injury will result in a better ultimate outcome
• A rough guideline to quantify water loss every 3 mEq/L that the serum sodium concentration is above normal, represents about 1 L of water deficit E.g Na+ 155 = excess of 15 = water deficit of about 5 L. While correcting hypernatremia the tonicity correction should not happen with the same speed with which the volume is going to be corrected (Brain should adapt with osmolality changes) That delay is achieved by choosing a fluid that is not pure water, but one that has some sodium in it to dampen the effect on tonicityE.g Dextrose with half NS
• Severe head trauma sufficient to produce coma + facial injuriesalways evaluate with CT to R/o bleed and include Neck also
• All failed regimen in anal fissure Opt for Forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections
• Abdominal compartment syndromethe life-saving massive fluid infusions produce severe edema in the surgical fieldForced closure would compromise ventilation and venous returnA temporary plastic coverage, or a mesh, allows the bowel to be protected without undue pressure.
• Pelvic bone fracture Falling BP but no free fluid within abdomen Pelvic fractures can bleed massively, and often the source is torn veins that are not easily controlledMinimizing the motion of the bone fragments by external fixation can be helpful Comminuted fractures of the femurs are also known to be one of the few places in the body where enough occult blood loss may occur to lead to hypovolemic shock.
• Hyperthyroid state But the thyroid gland normalRadioactive iodine uptake should be high if her gland is indeed hyperfunctioning but it will be near zero if it is suppressed by the exogenous hormone.
• Breast mass found after trauma not regressing after week might not be a hematoma or fat necrosistrivial trauma sometimes brings to the attention of the patient an area of the body that had not been examined beforeA breast mass in a >40-year-old woman requires a mammogram and biopsy.
• Gunshot wounds to the base of the neck may injure major vessels, the tracheobronchial tree, and the esophagus diagnostic studies should precede surgical intervention if time allows
• Several months after sustaining a crushing injury to armconstant, burning, agonizing pain in that armNot responding to usual analgesic medications aggravated by the slightest stimulation of the area, such as rubbing from the shirt sleevesarm not swollen and pulses normalneurologic function of major
KaplanQbankNotes:Neeraj 23
nerves intactcausalgia (reflex sympathetic dystrophy)If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy.
• Small umbilical hernias can close spontaneously up to the age of 2 years.
• Enucleation of EyeOften done for two malignant tumorsretinoblastoma and melanomamelanoma may present as metastatic tumour after even 20-some yearsA patient with a glass eye or missing toe and a liver full of tumor is classic examples to illustrate the unpredictable behavior of melanoma.
• Suspected Skin CA Always perform biopsy edge of the lesion offers the best information for the pathologistAn excision before pathologic diagnosis risks doing too much (a basal cell cancer needs only 1 or 2 mm of margins) or too little (a melanoma should have at least 2 cm).
• most important thing that can be done for caustic chemical burns is to wash away the caustic agent as soon as possible
• When coagulopathy develops during operative procedure provide fresh frozen plasma and platelet packs. when hypothermia complicates the pictureClose the abdomen immediately bleeding surfaces have to be packed, waiting for a more propitious time in which to attempt hemostasis, once coagulation function and body temperature have improved
• Diffuse esophageal spasm v/s Nutcracker esophagus on manometry there is a mean distal esophageal peristaltic amplitude of more than 180 mm Hg, including an elevated baseline pressure in the lower sphincter in Nutcracker (Normal pressure and relaxation in diffuse esophageal spasm).
• De Quervain's tenosynovitis: Tenosynovitis of the abductor or extensor tendons of the thumb positive Finkelstein sign (the pain produced by ulnar deviation to stretch the affected tendons).
• Advanced breast CARad/chemo to make it operable
• A high spinal anesthetic can produce vasomotor shock by inducing widespread vasodilation. Vasoconstrictors are the appropriate therapy, but since the capacity of the vascular tree is also increased under these circumstances, filling it up with additional volume is also helpful.
• Follicular thyroid cancers can metastasize by way of the blood stream to the liver, lung, brain, or bones. Because the tumor has rudimentary functional capability, it can be traced with and ablated by radioactive iodine; however, the tumor cannot compete successfully with normal thyroid tissue for the capture of iodine. After removal of the entire gland, the tumor becomes the most effective iodine trapper in the body.
• Very tender spot in the third interspace foot(between the third and fourth toes)no redness, limitation of motion, or signs of inflammationclassic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve.
• A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely cause would be a lytic lesion from metastatic breast cancer.
• Post-traumatic hemothoraxcriteria to perform thoracotomy if the initial blood recovery exceeds 1000 mL, or if subsequent drainage adds up to 600 mL or more, over the ensuing 6 hours.
• wound dehiscence after abdominal surgerydraining copious amounts of clear pink fluid from his midline laparotomy woundcould have been handled by taping the wound securely Immediate surgical repair is mandatoryNot allowed to strain abdomen or move aroundOnce the bowel came out, the problem became an evisceration
• Acute ‘Senility’ within short periods of weeks Suspect chronic SDH.
• In case of Pheochromocytoma presence of catabolites from epinephrine indicates that the tumor is in the adrenal glands, and not at an extra-adrenal site.
KaplanQbankNotes:Neeraj 24
• When hitting the knees against the dashboard, the femurs can be driven backward and out of the acetabulum, resulting in posterior dislocation of the hips. Because of the tenuous blood supply of the femoral heads, such injury must be promptly recognized and treated.
• Postoperative complications:
1. Atelectasis : seen on day 1
2. Fever day 3 is usually from the urinary tract infection.
3. Deep thrombophlebitis 5-7 days after surgery
4. Intra-abdominal abscess 7-10 days
• Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is prolonged hypotension. Furthermore, the mortality greatly surpasses that of a myocardial infarction de novo (ie, unrelated to surgery), reaching upto 50-90%
• heel pain every time foot strikes the groundworse in the mornings, preventing him from putting any weight on the heelwhen the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation plantar fasciitis.
• central cord syndrome:mechanism of injury (hyperextension)relative sparing of the lower extremities in the presence of upper extremity deficits are classic
• Anterior cord syndrome all functions are lost, except for positional and vibratory sense. Those injuries occur with blowout of the vertebral bodies.
• Posterior cord syndrome is quite rare, and it would show loss of positional and vibratory sense.
• Anorectal signs and mass with Inguinal nodes has to be anal SCCAdenoCa of rectum will never metastasize to inguinal nodes.
• Ogilvie syndrome is the acute pseudoobstruction and dilation of the colon in the absence of any mechanical obstruction in severely ill patients
• Brain tumor with increased intracranial pressuredevelopment of hypertension and bradycardia (Cushing's reflex) signifies that the brain has run out of compensatory mechanisms to minimize the intracranial pressure elevation generated by increased intracranial volume. When that point is reached, brain perfusion suffers and death is imminent.
• Posterior dislocation of the shoulder: Can be missed in AP view mechanism of injury (massive contraction of all muscles in the area)
Axillary view x-ray films are needed to make the diagnosis.
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| docnikki
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Topics: 93
Posts: 680
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thanks alot for this input...Im sure it will be very useful.
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| damian33
Forum Junior
Topics: 5
Posts: 91
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Great notes thanks a lot
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Expect the worst and you won't be disappointed
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| werther
Forum Senior
Topics: 11
Posts: 110
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In that long list something is wrong:
NO NEED TO ROUTINE BIOPSY IN WOMEN ON TAMOXIFEN.
he American College of Obstetricians and Gynecologists has developed the following recommendations for monitoring women on tamoxifen [94]:
* Premenopausal women have no known increased risk of uterine cancer with tamoxifen, and require no additional monitoring beyond routine gynecologic care.
* For postmenopausal women, perform an annual gynecologic examination.
* Monitor for symptoms of endometrial hyperplasia or cancer. Women should be educated to report any abnormal vaginal symptoms (eg, bloody discharge, spotting, staining, leukorrhea).
* Investigate any abnormal vaginal symptoms.
* Limit tamoxifen use to five years duration because benefit beyond this time has not been demonstrated.
* If atypical endometrial hyperplasia develops, the use of tamoxifen should be reassessed and appropriate gynecologic management should be initiated. Hysterectomy should be considered for women with atypical endometrial hyperplasia in whom tamoxifen therapy must be continued.
Endometrial protection from the effects of tamoxifen may be possible with local application of intrauterine levonorgestrel, a progestational agent. In one randomized trial, 122 women receiving at least one year of adjuvant tamoxifen treatment for breast cancer were randomly assigned to endometrial surveillance alone, or endometrial surveillance before and after the insertion of a levonorgestrel-releasing intrauterine device for 12 months [95]. There were no new polyps in women fitted with the intrauterine device, and 13 percent fewer fibroids than in controls. Further evaluation of this method is warranted.
Guys be careful with what you post, whenever is not checked by yourself, it lowers the forum resource trustfulness.
There are a few more to check.
Thanks!
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| profane76
Forum Newbie
Topics: 0
Posts: 10
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Why not, I'll bite...
USMLE Step 3 Nuggets
UGI bleeding in HIV is either related to Kaposi’s or Lymphoma. LGI bleeding is usu. CMV, or HSV, or bacteria.
Kaposis is usu characterized by purplish lesions (macules, papules, tumors etc.) most commonly on face, LN, lungs and GI tract.
Basal cell Ca is characterized as a papule w/ central ulcerations and a "pearly" border.
Squamous cell ca is characterized by an indurated and hyperkeratotic plaque w/ crusting and ulceration.
Actinic keratosis may undergo malignant transformationà charact as macules or papules, hyperkeratotic, adherent scale with a "cutaneous horn".
A keratoacanthoma is a rapidly growing nodule w/ keratinous debris in middle and is related to squamous cell ca.
seborrheic keratoses usu has a waxy "stuck on" appearance.
In pedsà set hot water heaters to less than 130 F
Always think of fungal infxn w/ immunocompromised pts’.
In pts’ in DKA, if you lower the blood glc level to quickly you will get cerebral edema.
In pregnancy you will see increased elevated Alk phos secreted by the placenta, so just reassure pts and there is no need for a work-up.
Abd wound dehiscence typically occurs 7-10d post-op; look for new onset serous d/c. tx is to re-do the laparotomy.
For chlamydia positive females, tx them and their partners; pt’s w/ gonorrhea need tx for both chlamydia and gonorrhea.
classic EKG for PEà S wave in I, Q wave and T wave inversion in III, or ST-T wave changes in V1-4.
In family thryroid ca, think of medullary thyroid Ca.
Acute glaucoma (elevation of intraocular pressure) often presents w/ abd pain, n/v and is an emergency which can lead to blindness. Dx it by measuring intraocular pressure and possibly give acetazolamide, topical BB, mannitol or pilocarpine.
cocaine is contraindicated during breastfeeding.
SE’s of testosterone tx (for erectile dysfxn) are increase in PSA, erythrocytosis and exacerbation of sleep apnea.
Skin necrosis will happen in a pt w/ deficiency of protein C and who is started on Coumadin without heparin at the same time.
u/s of molar pregnancyà "Snowstorm" pattern. The content of the uterus are hydropic villi and are grapelike in appearance. They are at risk for choriocarcinoma, thus monitor their BhCG for one year afterwards, therefore they can’t get pregnant and thus need to be on OCPs.
A pt w/ an LDL >160 and >2 risk factors should be started on drug tx as well as diet/exercise.
Prinzmetal’s angina is a variant angina charact by coronary vasospasm that causes reversible ST elevation. Tx is CCB and nitrates.
"Nursemaids elbow"(sublaxation of radial head)à tx is supination of the forearm w/ the elbow flexed.
Do not do a percutaneous needle bx of a suspected renal cell Ca, just do a nephrectomy. You can seed the tumor.
Esophageal rupture is a complication of EGD. The first step is to get an esophagram w/ a water soluble agent. A thoracotomy is the tx.
Screening w/ mammograms and annual clinical breast exams should begin at 40yo. In woman w/ FmHx (1st degree), screening w/ annual mammograms should begin 10 years b/f the age of the youngest affected pt.
pt post-op an ortho procedure needs to be on warfarin or LMWHep post op for 6wks to 6 months.
A modified radical mastoidectomy spares the tympanic membrane (a bad case of cholesteatoma).
Do a direct coombs test to test for blood incompatability of mother and fetus when you get hyperbilirubinemia in an infant soon after being born. When the level of unconjugated bili reaches >20 worry about kernicturus (deposit in the basal ganglia).
A woman should get mammograms yearly.
In treating DKA, pt’s can get cerebral edema if the glc level drops to rapidly which presents as acute change in MS, vomiting and HA. Give mannitol and dexamethasone. If this doesn’t work, hyperventilate pt. A CT scan makes the dx.
In a pt who had a subarachnoid bleed and who got treated but then declines in MS, think of a vasospasm (blood in csf is an irritant) and give nimodipine (no other CCB works).
Ulcerating granulomatous lesions of the upper and lower resp tract is the hallmarks for Wegener’s granulomatosis as are cavitating lesions.
An IVP is performed to est the presence or absence of both kidneys, to define renal outlines and cortical borders, and to outline the collecting system and ureters.
A retrograde urethrogram is used for pts suspected of having a urethral injury. They typically have blood at the meatus, high-riding prostate, perineal hematoma, pelvic fx,
A varicocele is the most common cause of male factor infertility.
...Keep 'em coming...
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