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CARDIOLOGY:
1. Stable angina >>> chest discomfort, can be felt in back/arms/jaw/abdm, occurs c stress/emotion, relief c rest, dx c stress test. Tx c nitrates, bb, Cabs, heparin, aspirin, if 3 vessels or L main do CABG
2. Unstable angina unpredictable at rest or abruptly worsening pattern of angina, prolonged duration (>20), dx c ECG (st depression/t inversion) or cath shows CAD, but negative cardiac markers, tx c nitrates, cabs, bb, heparin
3. Variant/Prinzmetal Angina chest pain at rest, ST elevation (note the 3 causes of ST elevation are MI (inferior (LDA) is II, III AVF; lateral (circumflex a)is I, AVL, V5, V6; anterior is V1-V4), Pericarditis (diffuse, meaning every lead has it), and Variant Angina) with negative markers. Treat with Ca-channel blockers (Cabs) or nitrates.
4. Acute MI >>> chest discomfort, crushing pain without warning (females and diabetics get atypical chest pain, which is abdm pain, fatigue, neck pain or weakness), prolonged duration (hours), ECG may be abnormal (st elevation or depression), increased markers, tx c MONA, ACEI, heparin, bb, tPA’s if <12 hrs after onset of pain, complications include MR, VSD, cardiac rupture and ventricular aneurysm.
5. CAD risk factors: smoking, HTN, family h/o premature CAD (<55 in male, <65 in female), male >45, female >55, HDL <40, LDL >100. (If HDL >60, subtract one). >2 risk factors: diet if >160, drugs if >190; 2 or more risk factors: diet if >130, drugs if >160, pt has CHD: diet if >100, drugs if >130.
6. Causes of high output heart failure >>> severe anemia, thyrotoxicosis, acute beriberi, paget’s dz, large AV fistula
7. Acute Pulmonary edema >>> tx >>> 1st upright position and O2, 2nd loops, nitrates, morphine, and 3rd intubate if severe.
8. HOCM >>> tx >>> 1st avoid dehydration, 2nd strenuous activity prohibited, 3rd BB, 4th Cab’s, 5th surgical myectomy. Best dx is history (screen family) and physical, then Echo.
9. Restrictive CM >>> JVD, edema and ascites, dx c echo, tx 1st diuretics/ decrease salt
10. Myocarditis >>> history or URI (coxsackie) then fever, dyspnea, CP, edema, tachy
11. Acute Pericarditis >>> positional CP, tx c NSAIDS
12. Pericardial effusion >>> pericardial friction rub, tx c pericardiocentesis
13. Tamponade >>> becks triad (JVD, muffled heart sounds, pulsus paradoxicus c hypotension), tx c pericardiocentesis
14. Constrictive pericarditis >>> pericardial knock, kussmaul breathing, CXR shows pericardial calcification, tx c diuretics
15. Acute RF >>> PECCS (polyarthrtitis, erythema marginatum, carditis, chorea, subQ nodules) in kids 5-15yo due to group A strep. Tx is Abx, bed rest, salicylates, sedatives for chorea, steroids for carditis.
16. Mitral stenosis >>> most associated c RHD, LA enlargement hoarseness, dysphagia, and A.fib, diastolic rumble at LV apex, tx c diuretics, coumadin for a.fib, endocarditis prophylaxis, balloon vulvoplasty
17. Mitral regurge >>> a/w marfans, RHD, myxomatous change, high-pitched holosystolic murmur at left sternal border, tx c diuretics, dilators, endocarditis prophylaxis, mitral valve respacement/repair
18. Aortic regurge >>> congenital, marfans, trauma, aortitis, high-pitched decrescendo diastolic murmur at left sternal border and/or apex and wide pressure, tx c valve diuretics, dilators, endocarditis prophylaxis, valve replacement (last)
19. Aortic stenosis >>> calcific in elderly, bucuspid in congenital, angina, dyspnea, syncope, mid-late systolic murmur at base radiating to carotids, tx c replacement (1st step)
20. Endocarditis >>> if dental procedure give amoxicillin (clindamycin if allergic), if GI/GU procedure give amoxicillin c gentamycin (vanco with gentamycin in allergic)
21. VSD >>> membranous septum, harsh systolic murmur at L sternal border, spontaneous closure in 30-50%, tx >>> for small vsd observe, for large vsd and significant shunt, surgical repair and endocarditis prophylaxis.
22. ASD >>> wide, fixed splitting S2, tx >>> if small observe, if large surgery
23. PDA >>> machinery murmur, wide systemic pulse pressure, tx c indomethacin then surgery
24. Aortic Coarctation >>> UE HTN c LE hypotension, rib notching, LE claudication, HA, dx with MRA or contrast aortography, tx is surgery (best at 4-8yo).
25. Tetralogy of Fallot >>> PROVe (Pulm HTN, RVH, Overriding aorta, VSD), kid squats to increase systemic resistance, thus decreased R to L shunt, cyanosis in kid >1yo, CXR c boot shaped heart, confirm dx with cath, tx is surgery, endo prophylaxis
26. Transposition of great vessels >>> MCC of cyanosis in 24hrs of birth, tx c surgery
27. Initial Tx’s: CHF thiaz, bb, acei, arb, aldo ant; Post-MI bb, acei, aldo ant; DM acei, bb, thiaz, arb; recurrent strokes thiaz, acei
28. Hyperaldosteronism >>> hypokalemic met alkalosis, PRA ratio, captopril-suppression test, high aldo level, 24hr urinary aldo, salt loading test
29. Pheochromocytoma >>> 24hr urine collection for VMA, MRI to visualize adrenal tumors, MIBG if chemistries positive by CT/MRI are negative.
30. Renal artery stenosis >>> renal U/S c Doppler, captopril scanning, CT/MRA, high renin, ACEI contraindicated if B/L
31. Urgent v Emergent HTN >>> Urgent is just one high reading (give nitroprusside or lobetolol, wait til BP goes down and d/c home). Emergent is when there are signs of end-organ damage (must admit and do workup).
32. PAD >>> claudication, rest pain, ulceration at medial ankle, dx c ankle-brachial index before/after exercise, angiography, MCC is atherosclerosis, tx c meds (pentoxyfylline, cilastazol, cab’s), angioplasty/stenting, avoid constricting drugs (bb)
33. Temporal Arteritis - >55yo pt c HA, scalp tenderness, visual s/s, next step is low-dose steroids (before temporal a biopsy or getting ESR).
34. Polyerteritis >>> HTN, abdominal pain, numbness in legs, skin findings, cns s/s, dx c biopsy, tx with steroids.
35. AV Fistula >>> thrill/bruit over fistula (buzzing sound), dx c angiography, tx c surgical excision, if congenital do conservative management instead.
36. Varicose veins >>> pain, pigmentation, superficial ulcer, tx c elastic stockings
37. Superficial thrombophlebitis >>> pain, erythema, embolism is rare, tx c warm compression, limb elevation and NSAIDS.
38. Deep vein thrombophlebitis >>> pain, swelling, fever, + Homans sign, PE is risk, so must do plethysmography or Doppler, tx c heparin/warfarin, filter if recurrent.
39. Dissecting aortic aneurysm >>> sharp CP radiating to back, dx c CT, TEE or MRI, tx >>> 1st decrease BP (nitroprusside), 2nd - If ascending aorta (up to aortic arch) do surgery, if descending aorta use meds
40. Abdominal aortic aneurysm >>> bruit, dx with U/S, see abdominal notes
41. Aneurysm of thoracic aorta (nondissecting) >>> may compress adjacent structures causing CP, dysphagia, hoarseness, dx c aortography, Atherosclerosis is MCC, also due to cystic medial necrosis. Tx c surgical graft replacement.
SKIN:
42. HSV >>> type 1 at mouth, type 2 in genitalia. Recurrent erythema nodosum is characteristic. Dx c Tzank, tx c acyclovir
43. Herpes zoster (shingles) >>> dermatomal, reactivated at dorsal nerve root, tx c acyclovir
44. Varicella (chickenpox) >>> lesions in all stages of development, tx c benadryl. In 1st TM, causes microcephaly, chorioretinitis, IUGR and cataracts. Treat neonates with VZIG if mom contracted varicella within 5 days of delivery.
45. Impetigo >>> honey-crusted lesions. S aureus and B-hemolytic strep. Tx c muciprocin
46. Rubella >>> 3 days of cervical/suboccipital/postauricular node enlargement, prevention best c immunization before 1st TM to prevent triad: visual (cataracts), hearing loss, heart (PDA) defects.
47. Measles (Rubeola) >>> looks like spilled red paint over your head (rash spread beind ears and over forehead to neck to trunk and extremities), prevent c immunization
48. Roseola >>> 3-5 days of fever, and THEN rash after (never together). No tx
49. Erythema infectiosum >>> 5th dz >>> slapped cheek appearance, parvo B19, causes aplastic crisis in sickle cell patients, no tx
50. Rocky Mountain Spotted Fever >>> fever, rash on wrists then palms and soles, dx c weil-felix test, tx c tetracycline (chloramphenicol if pregnant)
51. Lyme dz >>> erythema chronicum migrans c central clearing, tx is doxycycline (amoxicillin if pregnant and children <9yo).
52. Scabies >>> burrows in hands, axillae, genitalia, highly contagious, tx c permethrin to the whole family.
53. Allergic contact dermatitis >>> type 4 (cell-mediated) hypersensitivity like poison ivy
54. Psoriasis >>> a T-cell mediated epidermal hyperproliferation, scaling plaques on knees, elbows, a/w clubbing of fingers, worsened by antimalarial drugs, lithium, bb’s, tx c steroids, calcipotriene.
55. Seborrheic Dermatitis >>> on scalp is dandruff, on kids is cradle cap. Tx c ketoconazole (pt on chronic azoles need to have LFTs monitored) If generalized, r/o histiocytosis X; if severe, r/o AIDS.
56. Bullous Pemphigoid >>> >60yo, large tense blisters, - nikolsky, IgG/C3 at dermal-epidermal junction, tx c prednisone, tetracycline, azathioprine (remember BCDE >>> Bullous pemphigoid, C3 at Dermal Epidermal junction)
57. Pemphigus Vulgaris >>> 40-60yo, multiple flaccid bullae, + nikolsky, biopsy shows acatholysis, antibodies to epidermal Ag, tx is prednisone, fluids, tetracycline
58. Dermatitis herpetiformis >>> itchy papulovesicular eruption usually on shins, - nikolsky, a/w celiac sprue, tx c gluten-free diet and dapsone (r/o G6PD first)
59. Factitial Dermatitis >>> no rash in nonreachable areas (midback, butterfly sign)
60. Acne Vulgaris >>> common acne. Tx c 1st benzoyl peroxide, 2nd topical/oral Abx, 3rd Topical retinoids, 4th Isoretinoin (r/o pregnancy first)
61. Hereditary angioedema >>> AD, C1 esterase inhibitor deficiency, subQ/mucosal edema
62. Pilonidal cyst >>> swelling, tender sacral mass, tx c antibiotics, I&D
63. Epidermoid cyst >>> contains keratin, asymptomatic, if infected (I&D, abx), if not excise
64. Capillary Hemangioma >>> strawberry nevus, reddish-purple hemangioma, tx c pulse dye laser therapy
65. Cavernous Hemangioma >>> purplish vascular anomaly, tx c reassurance, compression
66. Seborrheic keratosis >>> benign skin tumor in elderly, brown flat macule that appears “stuck-on”. Observe unless eruption is multiple then do shave excision and curettage, cryotherapy
67. Port-wine stain >>> a/w sturge-weber syndrome, brain calcfications, seizures
68. Actinic Keratosis >>> precursor to SCC, sun induced kyperkeratotic coarse lesions that are hard to remove. Tx c cryosurgery, 5FY, excision
69. Squamous cell ca >>> generally from the lower lip down. Ulcer that won’t heal. Tx c surgery or radiation
70. Basal cell ca >>> generally from upper lip up. Pearly nodule c rolled border. Surgical removal has high cure rate.
71. Melanoma >>> ABCD (asymmetry, borders irregular, color variation, diameter >6mm), MC is superficial spreading type, dx c total excision, loves to metastasize
72. Behcet’s syndrome >>> apthous ulcers, genital ulcers and uveitis, tx c d/c abx, chlorambucil
73. Dermatomyositis >>> difficulty rising from chair, proximal weakness, gottrons sign (purple papules on knees and knuckles), dx c mucle biopsy, tx c prednisone
74. Lofgren Syndrome >>> fever, erythema nodosum (LE nodules), and sarcoidosis.
75. Amyloidosis >>> macroglossia, waxy papules on face, congo red stain on biopsy
76. Scleroderma >>> raynauds, dysphagia, masklike face, tight skin, dx c skin bx, tx symptomatically or c D-Penicillamine, a/w CREST syndrome
77. Tuberous sclerosis >>> retinal phacomas, seizures, MR, sebaceous adenomas, ash-leaf hypopigmented macules, tx c seizure control.
78. Porphyria Cutanea Tarda >>> no abdm pain, but + red urine and vesicles on back of hand after having alcohol, drugs, estrogens, a/w Hep C, tx c 1st stop EtOH then phlebotomy
79. Acute Intermittend Porphyria >>> abdm pain, weakness in shoulders/arms, change in behavior. Blocks porphobilinogen deaminase, high ALA in the stool.
80. Acathosis Nigrans >>> black axillary/neck patches, a/w PCOS, DM, obesity and abdm adenocarcinoma. Next step is get fasting glucose to rule out insulin resisitance.
81. TTP >>> fever, thrombocytopenia (causing petechia/purpura), MAHA, renal problems (hematuria) and CNS symptoms (depression, HA, psychosis). Tx c plamapheresis
82. DIC >>> all labs messed up (BT, PT, PTT, fibrinogen, fibrin split products) causing cutaneous hemorrhage and ecchymosis. Tx >>> 1st treat primary cause, 2nd heparin
ENDOCRINE:
83. Thyroid nodule >>> 1st do TSH, then do FNA (preferred) or scan to see if its hot or cold (cold is malignant, if hot, observe >>> do not biopsy). MC benign is follicular adenoma, MC malignant is papillary (psammoma bodies), must as h/o radiation, worse if pt is male, >40 or young, distant mets. If results turn out that it’s a cyst, aspirate it and follow-up, if cancer, surgery c radioiodine (if papillary or follicular).
84. Goiter >>> high or low iodine uptake, lithium/amiodorone use, familial, tx c levothyroxine. Do not d/c drug, just continue the drug and add levothyroxine.
85. De Quervains (subacute) thyroiditis >>> painful thyroid, tx is NSAIDS
86. Sick Euthyroid Synd >>> low T4/T3, normal TSH. No s/s, just a goiter. Tx - nothing
87. Riedel’s >>> tracheal compression due to sclerosing fibrosis (rare)
88. Hashimoto’s >>> antimicrosomal ab, tx c levothyroxine
89. Congenital hypothyroidism (cretinism) >>> jaundice, lethargy, umbilical hernia, low T4, high TSH, tx c synthroid (levothryoxine)
90. Adult hypothyroidism >>> fatigue, myxedema, cold intolerant, wt gain, eyebrow thinning, high tsh, low T4, MCC is hashimotos, but also d/t prior graves tx, sheehan’s, amiodorone, lithium, tx c synthroid
91. Graves >>> low tsh, high T4, tachy, palpitations, weight loss, opthalmopathy, smooth goiter, A. fib, tx c BB’s (tremor and tachy), PTU, methimazole, radioactive iodine or subtotal thyroidectomy. In pregnancy, PTU can be used, as well as surgery if appropriate. Pt <25yo get surgery, pt >40yo get radioactive iodine.
92. Toxic Nodule >>> high RIAU, no eye s/s, nodular goiter, on scan there is ONE area of increased uptake, whereas the rest its decreased (in toxic multinodular goiter (plummers disease), there are several areas of increased uptake and in Graves the entire gland has increased uptake)
93. Thyroid storm >>> very high fever, delirium, n/v, abdm pain, high t4, low tsh, tx c supportive care first (decrease temp, arrhythmia, BP), BB, glucocorticoids
94. Type 1 DM >>> polyuria/dypsia/phagia, islet cell ab, HLA DR3/4, low C-peptide, tx c insulin. If having surgery, give 10 units insulin in AM, and then 0.1U/kg/hr infusion.
95. Type 2 DM >>> polyuria/dypsia. Fasting glucose >126, random >200 on 2 visits. Tx first with diet/weight changes (decrease calories and carbs), oral agents, insulin. HBA1c to monitor glucose over 2-3 months. For retinal neovascularization, give laster photocoagulation therapy. For nephropathy, check for microalbuminuria (1st sign) and give ACEI. For neuropathy, give foot care and analgesia.
96. DKA >>> lethargy, n/v, polyuria, abdm pain, confusion, kussmaul breathing, fruity breath, glucose 400-600, anion gap met acidosis. Tx Isotonic fluids with insulin, replace K+ if needed (prevent cerebral edema).
97. Hyperosmolar coma >>> dehydration, lethargy, confusion, coma, high glucose without ketones, tx c fluids, insulin and electrolyte replacement.
98. Lactic Acidosis >>> coma, confusion, hyperventilation, no ketones, anion gap met acidosis, rare a/w metformin, tx etiology (starvation).
99. Pt with high blood glucose in the morning? Get 4AM blood glucose. If its high (Dawn effect), then increase morning NPH, if its low (Samogi effect) then decrease night-time NPH.
100. Insulinoma >>> lethargy, diplopia, HA, glucose <40, high proinsulin, high c-peptide (low c-peptide if exogenous insulin used). Tx c surgery, if emergency then first give 50mL of 50% dextrose IV.
101. Primary Hyperparathyroidism >>> kidney stones, osteitis fibrosa cystica, muscle weakness, high calcium, low phosphate, high PTH, a/w MEN. Tx c surgery if adenoma, but if pt has severe hypercalcemia, 1st tx c saline, then furosemide, calcitonin and/or pamidronate.
102. Hypoparathyroidism >>> low calcium (chvostek’s sign, trousseau’s sign, tetany), high phosphate, normal renal function. Tx c vitamin D and calcium
103. Diabetes Insipidus >>> water loss, polyuria, nocturia, thirst, craving for ice, low urine osm (<250), high serum osm. Dx >>> Give vasopressin, if corrected its central, if still getting worse its nephrogenic (can be due to demecyclone or lithium), if no change in urine osm its primary polydipsia. Tx >>> if central give vasopressin (DDAVP), if nephrogenic give diuretic (thiazides, amiloride).
104. SIADH >>> low Na, low serum osm, high urine osm, a/w small cell ca/morphine/ chlorpropramide/oxytocin, tx c 1st fluid restriction, 2nd demeclocycline or hypertonic saline if Na is really low. Do not treat too rapidly to avoid central pontine myelinosis.
105. Acromegaly >>> enlarging hands, feet, coarse features, deep voice, large tongue, hat/wedding ring doesn’t fit anymore (hat don’t fit anymore can be Paget’s), due to high GH, dx with glucose suppression test, then IGF-1, then MRI to confirm adenoma, tx c surgery (transphenoidal), or radiation/meds (bromocriptine, octreotide) if surgery doesn’t work.
106. Acute adrenocortical insufficiency >>> shock, fever, abdm pain, low sugar, dx c cosyntropin testing, tx c hydrocortisone sodium succinate.
107. Chronic adrenocortical insufficiency (Addisons) >>> MCC is US is autoimmune, MCC in world is TB. Lethargy, skin pigmentation, hypotension, low Na, high K+, low cortisol, high ACTH is primary, normal/low ACTH is secondary. Dx c ACTH stimulation test (cortisol should increase, but remains low in Addisons). Tx c hydrocortisone (glucocorticoid) and fludrocortisone (mineralcorticoid)
108. Cushing’s syndrome >>> obesity, purple striae, HTN, hirsutism, buffalo hump, wakness, osteoporosis, dx c 1st 24hr urine free cortisol, then DXM suppression test (if suppressed that means its pituitary caused (Cushing disease), if not its adrenal or ectopic ACTH like small cell ca or carcinoid). Tx >>> if iatrogenic use smallest effective steroid dose possible, if cushing disease do surgery/radiation of pituitary adenoma.
109. Adrenogenital syndrome >>> hirsutism, amenorrhea, high urinary 17-OH, MCC is 21-OH deficiency in kids, MCC in adults is PCOS or adrenal disease. Tx is surgery if ambiguous genitalia in girls), then estrogen spironolactone, meformin (if PCOS), gluco/mineralocorticoid if CAH.
110. Conn’s synd >>> high aldo, low K+, high Na, High BP, low renin, tx is adrenalectomy c spironoloactone preop.
111. Secondary Hyperaldosteronism >>> MCC is renal artery stenosis >>> high Na, low K, high rennin, renal bruit. Dx c aldo:renin ration, then CT Abdm.
112. Prolactinoma >>> milky d/c from breast, if prolactin level 20-100 then r/o dopamine antagonist drugs (haloperidol, metaclopramide) and r/o hypothyroidism, if prolactin level >100, then do MRI of brain. Tx >>> if CNS s/s (bitemporal hemianopsia) do surgery, if not give bromocriptine.
113. Pheochromocytoma >>> sudden episodes of flushing, HTN, HA, sweating, feeling of doom, a/w MEN II/III, dx c urinary VMA or catecholamines, then if + do CT of abdomen and tx c give phenoxybenzamine (then BB) followed by surgery.
114. PCOS and Premature ovarian failure >>> see obgyn notes
115. Hemochromatosis >>> AR, hepatomegaly, bronze skin, cardiomegaly, DM, dx c liver biopsy, tx c phlebotomy 1st, then deferoxamine (if needed).
116. Gestational DM >>> measured at 26-28wks, glucose checked 1 hour after 50g load, if abnormal, check 3 hours after 100g load (fasting should be <95, 1hr <180, 2hr <155, 3hr <140). Tx c diabetic diet and insulin if needed.
117. Carcinoid syndrome >>> diarrhea, flushing, bronchospasm, low bp, R heart valve lesions, dx c urinary 5HIAA, tx c surgery. MC is at appendix, but if symptomatic, MC is at small bowel.
GI:
118. Upper GI bleed >>> hematemisis, dx c EGD, tx (in order) >>> If bleeding ulcer: PPI, transfuse, urgent endoscopy when possible, epinephrine into vessel, surgery if needed. If esophageal varices: Octreotide, banding/sclerotherapy, ET intubation, TIPS (for esophageal varices, prevent next bleed with BB’s)
119. Lower GI bleed >>> MCC of BRBPR is diverticulosis, then angiodysplasia. Dx c colonoscopy if bleeding stops, blood scan if bleeding continues and if +, angiography. Tx >>> replace blood, vasopressin at site.
120. what is the cutoff between upper and lower GI bleeding? Ligament of Trietz.
121. Crohn’s >>> all gi tract (usually rectal sparing), fistula, skipped lesions, all layers of bowel (transmural), fistula, abscess, noncaseating granuloma, gallstones, calcium oxalate kidney stones, extraintestinal manifestations, dx c colonoscopy and biopsy. Tx using infliximab (must do PPD before starting it), sulfasalazine, metronidazole, prednisone.
122. Ulerative Colitis >>> rectum mainly (unless backwashing present), continuous, just mucosa/submucosa, crypt abscesses, toxic megacolon, small/frequent bloody diarrhea c tenesmus. Tx c azulfidine, sulfasalazine
123. Toxic Megacolon >>> emergency, a/w UC, tx: NPO, NGT, IVF, D/C meds, Abx, surgery only if + perforation (free air on AXR)
124. Peptic Ulcer >>> Duodenal decreases c food, Gastric increases with food, gastic is more a/w cancer, duodenal is more a/w H.pylori. Dx 1st c H.pylori testing, then endoscopy with biopsy to r/o cancer. Risks for NSAIDS: >70, h/o prior PUD, only available tx is misoprostol. H.pylori: breath test, gastric biopsy, urease. Dx for PUD: 1st Upper GI endoscopy, then biopsy for gastric ulcers to r/o cancer. Tx with amox, clarithro and omprazole. Follow-up with urea breath tests after 1 month of tx. Complications: hemorrhage (MC), perforation >>> do AXR to see free air in a pt c peritoneal s/s and tx c abx and laparatomy. After surgery (antreceomy, vagotomy, billroth I and II), watch out for Dumping Syndrome (weakness, n/v after eating), Afferent loop syndrome (bilious vomiting relieves abdm pain after meal), Iron/B12 deficiency.
125. ZE syndrome >>> severe, non-healing ulcers. Get gastric levels and r/o ca (MEN).
126. Oropharyngeal dysphagia >>> swallowing impaired d/t lack of neuromuscular control from prior CVA/Parkinsons/Alzheimers. Dx c barium swallow. Tx underlying dz.
127. Achalasia >>> aperistalsis, incomplete LES relaxation c high LES pressure, dysphagia for solids and liquids, no regurge, dx c barium (dilated distal 2/3rd) then manometry (bird beak), then endoscopy to r/o cancer. Tx c pneumatic dilatation, then botox, then surgical Nissen’s fundoplication.
128. Chagas Disease >>> achalasia, cardiomegaly, hepatomegaly in a south American.
129. GERD >>> heartburn, CP, epigastric pain, older guy, MCC of nocturnal cough. Dx c 24hr pH, upper GI endoscopy to r/o barrett’s or ulcers. If you suspect it, treat it without doing any diagnostics. Tx c lifestyle changes, PPI, H2 blockers. If pt still has symptoms then do 24hr pH. If pt says drugs used to work but don’t work anymore, do EGD to rule out cancer.
130. Zenker’s Diverticulum >>> a motility disorder, causing halitosis, dx c barium, tx c Sx.
131. Esophagitis >>> painful swallowing (odynophagia), Candida so start c flucanazole.
132. Diffuse Esophageal Spasm (Nutcracker) >>> Cp due to strong intermittent contractions. Dx c barium (corkscrew pattern) first, then manometry (shows nonperistaltic uncoordinated contractions), tx c calcium channel blockers or nitrates.
133. Scleroderma Esophagus >>> younger guy with GERD symptoms, raynauds, heartburn, dysphagia for solids and liquids, dx c manometry (low LES pressure (unlike achalasia which is high), absent contractions in the smooth muscle esophagus, normal peristalsis in the striaghted muscle, normal UES). Tx c same things as GERD.
134. Schatzki Ring >>> young pt with episodic difficulty (not pain) swallowing. Dx c barium, tx c pneumatic dilatation of LES
135. Plummer vinson synd >>> hypopharyngeal web c iron deficiency. Risk of SCC. Middle-aged female c dysphagia immediately after meals. Dx c barium, tx c surgery.
136. Barett’s Esophagus >>> 5yrs of dysphagia, weight loss, no reflux, s/s visible on EGD so do biopsy. If biopsy shows no dysplasia then repeat in 2-5yrs, if bx shows low dysplasia, repeat in 3-6 months, if bx shows high grade dysplasia >>> resection
137. Esophageal CA >>> progressive dysphagia for solids and eventually liquids, wt loss, CP, hypercalcemia (SCC), dx c barium, then comfirm c EGD and biopsy. Tx c surgery, chemotherapy (cisplatin, 5-FU) and radiation.
138. Gastroparesis >>> delayed gastric emptying causing n/v, bloating and upper abdm discomfort, common in DM, tx c metoclopramide
139. When you suspect GI perforation, use gastrograffin (not barium), when you suspect aspiration, use barium (not gastrograffin).
140. Diarrhea >>> see ID notes
141. Irritable Bowel Syndrome >>> alternating constipation/diarrhea, pain relieved c defacation. Tx c increased fiber in diet.
142. Diverticulosis >>> d/t low fiber/high fat diet. LLQ pain, fever, tenderness. Dx c colonoscopy. Tx c increased fiber.
143. Diverticulitis >>> peritonitis, fever due to micro/macro-perforations, do CT scan. Tx c NPO, IVF and abx (cipro/metro or cefoxitine or ampicillin/sulbactam)
144. Pseudomembranous Colitis >>> C.difficile overpopulation due to prior use of Abx weeks ago, dx c C.diff in stool. Colonoscopy shows yellow adherent plaques on mucosa. Tx: d/c drug, start metronidazole, if still +, vancomycin.
145. Colorectal CA >>> 2nd MCCOD d/t cancer, rectal bleeding, change in BM, weight loss, sometimes asymptomatic (found incidentally on colonoscopy). Dx: FOBT yearly after age 50, flexible sigmoidoscopy every 4 years, colonoscopy at 50 then 53 then every 5 years, but start 10 years earlier than the age of which family relative was diagnosed with it. Tx >>> surgical resection of primary tumor.
146. Chronic Liver Disease >>> causes include autoimmune hepatitis, hemochromatosis, chronic alcohol use, fatty liver dz (non-alcoholic stateohepatitis), wilsons dz, viral (HBV, HCV), s/s include fatigue, increased abdm girth, jaundice, spider angiomas, palmar erythema, HSM, gynecomastia, testicular atrophy, labs c high AST/ALT/PT/INR, thrombocytopenia, hyponatremia, hypoalbuminemia.
147. Autoimmune hepatitis >>> 20-40yo female c +ANA, +anti-smooth muscle Ab, everything else normal. Tx c steroids.
148. Wilson’s disease >>> young guy with parkinsonism due to hepatilenticular degeneration, kayser-Fleischer ring, hemolytic anemia, dx c low serum ceruloplasmin, low total copper (not free), high urine copper. CT shows hypdense regions in the basal ganglia. Confirm dx c liver biopsy. Tx c D-penicillamine.
149. Ascites >>> U/S, CT and then paracentesis. Tx c Na/fluid restriction, diuretics, then furosemide, then large-volume paracentesis, then TIPS.
150. Spontaneous bacterial peritonitis - >250polys in 3 bedside cultures, tx c cefotaxime
151. Encephalopathy >>> tx c protein restriction and lactulose.
152. HAV >>> shellfish, fecal-oral, dx c + anti-HAV IgM (IgG shows previous infxn)
153. HBV >>> HbsAg is earliest marker, >6months is chronic, if vaccinated = +HbsAb, -HbcAb, if exposed in the past = +HbsAb, +HbcAb. Window period has anti-HBc IgM only. Prevent with vaccine + HBIG. Treat c Interferon alpha and lamivudine. Give vaccine at 0-2mo, 4-6mo, 13-18 months. If mom has +HbsAg, give baby vaccine + HBIG within 12 hours of birth.
154. HCV >>> dx c anti-HCV Ab/IgG/IgM and HCV RNA by PCR. Tx >>> Inf-a c ribavirin
155. Drug-induced >>> Tylenol, isoniazid, halothane, carbon tetrachloride, tetracycline. Dx c very high AST/ALT levels. Tx >>> D/C med
156. Acute fatty liver of pregnancy >>> develops in 3rd TM. Tx >>> immediate surgery
157. Primary Biliary Cirrhosis >>> antimitochondrial Ab in serum, pruritis, fatigue, hepatomegaly, high alk phos, destruction of intrahepatic and extrahepatic ducts. Tx c ursodeoxycholic acid, cholestyramine.
158. Primary Sclerosing Cholangitis >>> young man c IBD (UC), destruction on extrahepatic ducts only (shows beading effect d/t fibrosis).
159. Gallstones >>> female, fat, 40, fertile, RUQ or epigastric pain, worsened c food, radiates to midscapular area. Dx c U/S, then HIDA scan if negative. Tx c lap chole. ERCP if pt still has symptoms after (stone is in CBD).
160. Mesenteric Ischemia >>> severe abdm pain/tenderness with paucity of clinical findings. Pt will usually have extensive ischemic history (MI, DM, etc), dx c angiography, tx with prompt laparotomy to reestablish arterial flow
161. Acute Pancreatitis >>> MCC is gallstones, then alcohol. Epigastric pain radiating to midback, alleviated c sitting up, jaundice sometimes fever. High amylase/lipase. Dx c CT. Tx c NPO, NGT, analgesia, and then begin to consider ERCP and surgery if perforated, bleeding, abscess, pseudocyst or peritonitis.
162. Pacreatic Pseudocyst vs Abscess >>> worsening of pain, n/v, fever high WBC and positive blood culture after initial improvement. Dx c CT. Tx c Abx, then surgical drainage of abscess. Pseudocyst is generally asymptomatic.
163. Pancreatic CA >>> vague abdm pain (doesn’t have to radiate to the back anymore), anorexia and weight loss with jaundice, n/v. Dx c CT. If negative do ERCP. Check CA 19-9. Tx: If only at pancreatic head c no spread, try resection. If not, do Whipple (pancreaticoduodenectomy) procedure.
164. Malabsorption >>> Steatorrhea (dx c Sudan stain >>> 1st test). Then dx c D-xylose, if abnormal, suggests small bowel disease. Normal value suggests focus on pancreatic dz: CT of abdm, serum amylase, AST/ALT. If overgrowth considered, note response to malabsorption to Abx. Celiac sprue panel: antiendomysial/antigliadin Ab, tissue transglutaminase, total serum IgA, antigliadin Ab IgA and IgG; at least 3 biopsy specimens from distal duodenum is gold standard.
165. Whipple’s >>> malabsorption, arthralgia and CNS symptoms (dementia). Dx c small bowel biopsy (shows foamy macrophages on PAS stain). Tx c TMP-SMX
PEDS GI:
NAME AGE VOMITUS FINDINGS
Pyloric Stenosis 0-2mo Nonbilious, projectile M>F, olive-shaped mass, low K
Intestinal Atresia 0-1wk Bilious, projectile Double bubble sign, a/w Downs
TE Fistula 0-2wk Food regurgitation Resp problems c feeding, asp pneumo, dx via cant pass NGT
Hirschsprung 0-1yr Feculent Distention, obstipation, no ganglia on biopsy
Anal Atresia 0-1wk Late, feculent Seen on initial exam in nursery
Choanal Atresia 0-1wk - Cyanosis c feeding, relieved c crying, CHARGE synd, cant pass NGT
Intussusseption 4mo >>> 2yo Bilious Currant jelly stool, palpable abdm mass, kid draws up legs, dx c barium enema
Nec Enterocolitis 0-2mo Bilious Premies, fever, rectal bleeding, air in bowel wall, tx c NPO/IVF
Meconium Ileus 0-2wk Feculent, Late Cystic Fibrosis
Midgut Volvolus 0-2yw Bilious D/t malrotation, sudden pain/n/v. dx c upper Gi, tx c Sx
Meckel’s Diverticulum 0-2yw Varies GI ulcer/bleed, dx c Meckels (Technetium) scan, tx c Sx
Strangulated Hernia Any Bilious Bowel loops in inguinal canal
ONCOLOGY:
166. Tumor markers >>> Bhcg >>> testicular cancer, choriocarcinoma, mole; AFP >>> hepatocellular carcinoma testicular ca; CEA >>> GI cancers; PSA >>> prostate ca; CA-125 >>> Ovarian ca; CA 19-9 >>> colorectal/GI/pancreatic cancer
167. Sigmoidoscopy - >50yo every 3-5yrs; FOBT - >50 annually; DRE - >40 annually; PSA - >50 annually in normal risk, >40 annually in high risk; Pap smear >>> onset of sexual activity or 18yo annually for 3 consecutive years then however often; Pelvic exam >>> 18-40yo every 1-3yr, >40 annually; Endometrial biopsy >>> menopause/high risk annually; Self breast exam - >20 monthly; Clinical breast exam >>> 20-40 every 3 years, >40 annually; Mammogram >>> 40-49 every 1-2 yrs, >50 annually.
168. Cancerous Occupation Hazards >>> aromatic amines c bladder ca, arsenic c lung/skin/liver ca, asbestos c mesothelioma (bronchogenic MC), benzene c leukemia, mustard gas c lung/larynx/sinus cancer, vinyl chloride c liver cancer
169. Hodgkin’s >>> fever, night sweats, chills, weight loss (like TB), and painless cervical adenopathy. Dx c CT chest/abdm and then lympangiography and then biopsy (for treatment purposes). Reed-sternberg cells. Tx >>> If no B s/s (fever, wt loss, sweats) give radiation alone. If B s/s give chemotherapy (MOPP or ABVD)
170. Non-Hodgkin’s >>> variable nodes, monoclonal B/T-cell proliferation, dx c CT chest/abdm/pelvis then other stuff like BM bx, PET scan, gallium scan. Tx c radiation and chemo (CHOP) c Rituximab (CD20 Ab).
171. Acute Lymphocytic Leukemia >>> kids, blasts, tx c intrathecal chemo (MTX)
172. Acute Myelogenous Leukemia >>> M3 causes DIC, Aeur rods, blasts, add All-trans retinoic acid (Vit A) to tx.
173. CML >>> high WBCs, high PMNs, splenomegaly, LUQ pain, fullness and early satiety, decreased LAP, dx c phili chromosome (t9;22 of brc:abl) in BM, tx c Imatinib (Gleevac).
174. CLL >>> elderly, high WBCs, high lymphocytes, splenomegaly, dx c smudge cells, no tx if no lymphocytosis, if + lymphocytosis give fludarabine or chlorambucil.
175. Hairy Cell Leukemia >>> CD10+ and TRAP+ (tartrate-resistant acid phosphatase), tx c cladribine
176. Mycosis fungoidis >>> cutaneous T-cell lymphoma (look at 1st aid picture), lion-like facies, tx c PUVA chemotherapy. If affecting peripheral blood, its Sezary syndrome.
177. Multiple Myeloma >>> high calcium, high OAF, high uric acid. Best initial test is X ray if bone pain or electrophoresis if high protein. Most accurate test is >10% plasma cells. Tx: <70yo get stem cell transplant, >70yo get Meiphelen or Thalidomide
178. Aplastic Anemia >>> low rbc/wbc/platelet, drugs (chloramphenicol), parvo-B19 (sickle cell), tx: <50yo get BMT, >50yo get cyclosporine + anti-thymocyte globulin
179. If pt has neck + pelvic mass after chemo the mass gets smaller, wheat test checks content of the lymph node? PET scan. So in a nutshell, a lymphoma gets excisional biopsy of the node, then PET scan, and chemo if they have B symptoms.
180. Adverse effects of chemo: Vincristine/blastine >>> peripheral neuropathy, cyclophosphamide >>> hemorrhagic cystitis, Busulfan/Bleomycin >>> Irreversible Pulmonary Fibrosis (that’s why Lance Armstrong refused it), Cysplatin >>> renal dz, ototoxicity, anemia. Overall MC adverse effect with chemo drugs is sterility.
181. Lung cancer >>> chronic cough (MC s/s), wt loss, smoker, hemoptysis. Dx: 1st CXR, then biopsy. Tx: Small cell get chemo only, Non-small cell >>> chemo c radiation. Horner’s syndrome >>> unilateral ptosis, meiosis, anhidrosis due to compression of ipsilateral superior cervical ganglion by lung tumor, particularly SCC. SVC syndrome >>> obstruction of SVC causes facial swelling/plethora, dyspnea, cough, JVD. Pancoast syndrome >>> tumor of the superior sulcus causes brachial plexus s/s. Small cell causes Cushings syndrome (ACTH) and SIADH, SCC causes hypercalcemia (PTH-like peptide)
182. Solitary nodule >>> 1st step get old x-ray. If present and same size, its benign (send home), if increase in size its probably cancer. If it wasn’t there, assess risk (high is smoker and >35, low risk is nonsmoker and <35). If low risk follow up later, if high risk do biopsy.
183. Breast Cancer >>> biopsy everyone c palpable mass >35 except if B/L, lumpy and s/s only occur c menses. If <35 its probably fibroadenoma (rubbery moveable mass, observe pt). After bx, get mammogram if >35yo. If mammo was already done, get FNA. If after biopsy, mass goes away, send pt home. Tx: tamoxifen, mastectomy, radiation, axillary dissection, chemotherapy (c platinum) if + nodes.
184. Prostate cancer >>> s/s of BPH c hematuria, high PSA (only to screen/monitor, not for dx), irregular/boggy, back pain. Tx c surgery. If +mets, then do orchiectomy, leuprolide, flutamide, DES, but no chemo. Only do TURP and radiation of mets is local (bone).
185. Colon cancer >>> R sided bleeds (bloody stools), L sided obstructs (constipation), wt loss. Dx c colonoscopy. Tx c surgery and 5-FU and then f/u CEA levels. If mets (MC is liver) to liver do surgery, but anywhere else do chemo.
186. Pancreatic cancer >>> 40-80yo male smoker c jaundice, wt loss and vague abdm pain. May have migratory thromboplebitis (Trousseau’s syndrome) or palpable, nontender gallbladder (Courvoisier’s sign). Dx c CT, then FNA. Tx c whipples.
HEMATOLOGY:
187. Microcytic (MCV <80): Iron deficiency, Thalassemia, Anemia of Chronic Dz, Sideroblastic Anemia (lead poising, isoniazid, alcohol-induced)
188. Normocytic (MCV 80-100): Check Reticulocyte count(should be <2% c anemia, otherwise marrow isn’t responding properly): <2% is acute blood loss (<5-7days), early iron deficiency, aplastic anemia, early AOCD, renal disease. >3% is due to either Intrinsic RBC defect (MAD: Membrane defects (Spherocytosis, PNH), Abnormal hemoglobins (Sickle cell), Deficient enzymes (G6PD, pyruvate kinase deficiency)) or Extrinsic RBC defect (Autoimmune hemolytic anemia, MAHA, blood loss >1 week)
189. Macrocytic (MCV >100): B12 def, folate def, Myelodysplastic syndrome, drug-induced, hepatic dysfunction (d/t alcohol), reticulocytosis.
190. Red Cell Morphologies: Rouleaux (myeloma), Burr cells (uremia), Tear drops and nucleated red cells (myelofibrosis), hypochromic/microcytic (iron def), target cells (HALT: Hemoglobinopathies, Asplenia, Liver dz (obstructive jaundice), Thalassemia), Oval macrocytes (B12/Folate def), basophilic stippling (Lead, B12 def), spherocytes (HS), Schistocytes (MAHA, AIHA, DIC), bite cells and Heinz bodies(G6PD), Howell-Jolly bodes (Asplenia like SCD).
191. Iron deficiency >>> low MCV, high TIBC, low ferritin, low iron (<60), high RDW (why? Because some are normocytic and some are microcytic so the range of width will be high), pica kid who eats sand and ice, plummer-vinson (web, low iron, glossitis), cow milk before age 1, exclusive breast-feeding, pregnancy. Tx >>> 1st is to find the source of iron loss and fix that (before you give iron!), 2nd transfusion (if needed fast) or oral iron supplements for 6-12 months.
192. Anemia of Chronic Dz >>> (how does this work? The body knows diseases (RA, TB, SLE, cancer) love iron, so it will hide iron away in stores (high ferritin) but keep it out of the serum (low serum iron and high TIBC)) if anemia is a/w chronic renal dz, look for Burr cells.
193. Thalassemia >>> normal iron (so don’t give iron), target cells, nucleated rbc, x-ray shows crew-cut appearance of skull, dx c Hb electrophoresis, no tx for traits. Thal major gets transfusion 1st and deforoxamine to prevent iron overload, spelenectomy (now give pneumovax, penicillin prophylaxis, folate supplement).
194. Lead Poisoning >>> pica kids who have ABCD (Anemia/Ataxia/Abdm pain, Basophillic stippling/Behavioral changes, Constipation, Drops (foot/wrist)/Death), high free erythrocyte protoporphyrin. Dx c blood Pb level and x-ray (pb visible in bones). Tx c EDTA or dimercaprol.
195. B12 Deficiency >>> MCC is pernicious anemia (anti IF/parietal Ab), also d/t gastrectomy, terminal ileus resection, vegetarian, chronic pancreatitis and diphyllobothrium latum infection. Look for CNS s/s (symmetric parethesia in feet/fingers, disturbed proprioception and vibratory sense, irritability, somnolence, abnormal taste/smell, central scotomas, positive babinski) and achlorhydria (no stomach acid secretion so pH in stomach is high). Check serum B12. Schilling test (never used in real world). Hypersegmented PMN. High methylmalonic acid level. Tx c cobalamin. Folate may worsen the CNS s/s.
196. Folate >>> usually d/t dietary lack (green vegetables, liver, kidney, yeast, mushrooms), alcoholism, pregnancy, celiac sprue, phenytoin, bactrim, MTX, 5-FU, OCPs. Tx c folate supplements.
197. Autoimmune Hemolytic Anemia >>> Ab/complement binds to RBC mmb. Two types IgM (agglutination at colder temp like Mycoplasma) and IgG (warm agglutination like SLE, penicillin, methyldopa). Dx c direct Coomb’s positive. If hemolysis is mild, observe, if hemolysis is severe, give glucocorticoids. If recurrent, do splenectomy.
198. Paroxysmal Nocturnal Hburia >>> Hypoventilate at night, so acidosis causes RBC burst d/t low DAF, therefore complement comes right off (CD 55/59). May die in 10 yrs d/t thrombosis. Best test is Sugar water test or Hams test (Acidic sounds like Hacidic, Hacidics don’t like Ham). s/s include Hburia in the morning time (not at night, that would be a prostate problem), increase risk of AML. Give steroids.
199. G6PD Deficiency >>> MCC is infection (they usually wont say Greek, primaquine, fava beans, Dapsone). Hemolysis, jaundice abdm/back pain 1-3 days after exposure. Heinz bodes, bite cells. Best tx c avoiding offending agents.
200. Spherocytosis >>> increased osmotic fragility, AD, low spectrin, splenomegaly. Dx c osmotic fragility test, tx c splenectomy (defer until 6yo), pneumo vaccine and folate
201. Sickle Cell Disease >>> African descent, AR, s/s >6mo d/t HbF, if trait only gets UTI, best initial test is smear, most accurate test is Hb electrophoresis, for crisis 1st give fluids/pain management, if fever (d/t autosplenectomy) give Abx (Ceftriaxone), if eye/CNS/chest/Priapism give exchange transfusion, to prevent next aplastic crisis give folate, to prevent next vaso-occlussive pain crisis (they will just say “crisis”) give hydroxyurea, if Hct drops suspect Aplastic anemia d/t Parvovirus. Give prophylactic penicillin, Pnumococcal/Haemophilus influenza vaccine @ childhood.
202. Aplastic Anemia >>> low rbc/wbc/platelets, chloramphenicol, parvovirus, benzene, acute leukemia, AZT/zidovudine. Tx c 1st stop drug, then give antithymocyte globulin
203. Myelophthisic anemia (Myelofibrosis) >>> malignant invasion of BM, anisocytosis (aniso = any size), poikilocytosis (shape), teardrop-shaped RBC, dx c BM biopsy showing no cells (dry tap).
204. Transfusions: Whole blood (poisoning, TTP), Packed RBC (post-surgery/trauma transfusion or instead of whole blood), washed RBC (IgA deficiency), Platelets (>10,000), granulocytes (post chemo), FFP (bleeding diathesis like DIC, warfarin poisoning, liver failure), cryoprecipitate (vWD and DIC). MCC of transfusion rxn is lab error. If it occurs, 1st step is stop transfusion.
205. Platelet problems = skin, gums, nose, gingival (ALL SUPERFICIAL), GI, CNS and vaginal bleeding; Factor problems >>> bleeding into join and muscles (DEEP), GI, CNS.
206. von Willebran Dz >>> high PTT, normal PT, high BT, normal plt/rbc count, AD (look for family history) (a platelet type of bleeding c a normal platelet count). Best initial test is bleeding time, then ristocetin level. Best tx c desmopressin (DDAVP)
207. Hemophilia A/B >>> really high PPT, normal PT, normal BT/plt/RBC, looking for delayed hemarthrosis in males only (A is factor 8, B is factor 9).
208. DIC >>> high PT/PTT/BT, low plt, low RBC, low factor 8.
209. Liver failure >>> high PT, normal/high PTT, normal BT, normal/low plt/RBC, jaundince, normal factor 8, do not give vitamin K (ineffective), give FFP’s.
210. Heparin >>> high PTT, thrombocytopenia. Tx c d/c drug
211. Warfarin >>> high PT, vit K antagonist (2,7,9,10), tx c FFP (fast) or vit K (slow), skin necrosis
212. ITP >>> low platelets, high BT, h/o URI, next step is steroids (just treat it), auto-platelet Ab, if platelets fall <7000 give IVIG or RhoGam.
213. TTP >>> high BT, low plt, low RBC, hemolysis, CNS, renal, fever, thrombocytopenia (petechia, purpura). Tx c plasmapheresis
214. HUS >>> like TTP but no renal failure or CNS s/s, h/o infection, E. coli 015H7.
215. Scurvy >>> all studies normal. Fingernal/gum/bone/perifollicular hemorrhage, poor diet (only eats hot dogs and soda or tea and toast). Tx c vitamin C.
216. Neutropenia >>> PMN <2.0 x 10_9. Dx c bone marrow aspirate/bx. Tx: 1st determine the cause, 2nd Abx, 3rd steroids, 4th GM-CSF.
217. Polycythemia Rubra Vera >>> 4 H’s (Hypervolemia, Hyperviscosity (thrombosis is MCCOD), Hyperuricemia, Histaminemia (itch all over after a hot shower)). Tx c phlebotomy.
________________________________________________________________________
ID:
218. Toxic Shock Syndrome >>> preformed toxin, prolonged tampon placement, hypotension, fever, dequamated rash (peeling of palms/soles), S.aureas
219. Conjunctivitis >>> 1st 24 hours is chemical, 2-5 days is Neisseria, 4+ is Chlamydia. If they say painful conjunctivitis, that’s viral (HSV) so treat c acyclovir.
220. External Otitis >>> pain, drainage, itchy swimmer’s ear, Pseudomonas.
221. Otitis Media >>> 40% s.pneumo, 30% h.influenza, 30% m.catarrhalis, dx: 1st step is pneumatic otoscopy showing immobility of tympanic mmb, 2nd step is tympanocentesis, tx c amoxicillin.
222. Sinusitis >>> same % as above. Yellow green d/c, sinus tenderness, best initial step >>> empiric abx (amox + decongestant), then X-ray, then Sinus biopsy (most accurate)
223. Meningitis >>> 0-1mo >>> GBS, E.coli, Listeria, 2mo-2yo >>> S.pneumo, 2-18yo >>> Neisseria, 18+ - S.pneumo; Kernigs/Brudzinski sign, lethargy, fever, bulging fontanelle, photophobia, nuchal rigidity, n/v, dx c LP (bacteria: low glucose, high prtn, PMN’s; viral: normal glucose, slightly high prtn, low WBC, lymphocytes). If bacterial, give ceftraixone, vanco or steroids. Give ampicillin (listeria) if immunocompromised. If neisseria suspected (2-18yo c rash) next step is respiratory isolation and tx him and family members c rifampin. If >100 lymphocytes: Cryptococcus (r/o HIV, best initial test is India ink, most accurate test is crypt ag, tx c Amp B), Viral (no specific test), TB (pulm s/s, high CSF protein, give RIPE + steroids), Lyme Dz (serology, h/o bite, target rash, doxycycline, or if CNS s/s like cranial nerve 7 effects, give Ceftriaxone), RMSF (serology, rash on wrists/ankes moving centrally, h/o camping or hiking, tx c Doxycycline, chloramphenicol if pregnant). The MC sequela is hearing
loss.
224. Encephalitis >>> look for acute febrile confusion (if they say confusion, its encephalitis not meningitis), MCC is herpes (blood in csf), best initial test is CT (temporal lope), if negative do PCR (most accurate). Tx c acyclovir, then foscarnet if resistant.
225. Brain Abscess >>> look for focal neurologic findings c ring/contrast enhancing lesions. If HIV (-), do biopsy, if HIV +, start sulfadiazine-pyrimethamine tx for Toxo and repeat CT.
226. Spinal Abscess >>> local severe back pain that becomes radicular pain, then weakness c fever. Next step is CT, then surgical drainage c abx.
227. Tetanus >>> rictus sardonicus (facial sneer), tonic muscle spasms (jaw, trismus), clostridium tetani, tx c tetanus IG and penicillin G.
228. Diptheria >>> gray pharyngeal pseodommb c sore throat, tx c diphtheria antitoxin (DAT) and penicillin or erythromycin.
229. Croup >>> aka acute laryngotracheitis >>> barking cough in a 1-2yo. Parainfluenza virus. Frontal neck x-ray shows steeple sign. Tx c racemic epinephrine.
230. Epiglottitis >>> 2-5yo kid unimmunized (H.influenza) c rapid progression of high fever, drooling and respiratory distress c no coughing. X ray shows thumb sign. Do not examine throat or irritate the kid (worsen airway obstruction). Tx c airway assessment, then cephalosporins.
231. Bronchiolitis >>> 0-18month old kid in the fall/winter gets expiratory wheezing due to RSV. Tx c ribavirin. (In a nutshell, 0-2yo c wheezing is bronchiolitis, 1-2yo c barking cough is croup, 2-5yo c drooling is epiglottitis)
232. Pertussis >>> whooping inspiratory wheeze.
233. Lung abscess >>> fever for weeks, bad teeth, alcoholic, aspiration, stroke pt, intubated pt, next step is CXR, best way to prevent it is to remove all teeth, how do you differentiate from TB? The smell (very bad in abscess), most accurate test is biopsy, tx c clindamycin
234. Bronchitis >>> mild cough c sputum, negative CXR, tx c azithro, levaquin or doxy
235. Pharyngitis >>> sore throat, exudes, lymph nodes, no cough, no hoarseness, best test is rapid strep test, tx c penicillin
236. Influenza >>> ahces, pains, tired, cough, HA, no fever. Best tx is oseltamivir or zanamivir (note the Ivir (for Influenze), not Ovir like acyclovir/famcyclovir for HSV or Avir like ritonavir/nelfinavir for AIDS)
237. Pneumonia >>> outpt tx is same as bronchitis (azithro, levaquin, doxy), inpatient tx include ceftriaxone. In young healthy pt, think mycoplasma (get serologies) or if inpt, think S.pneumo. If CNS and GI symptoms, pick Legionella. If AIDS c CD<200 pick PCP (TMP-SMX tx). If exposed to sheep placenta, pick Coxiella burnetti. If lobar pneumonia (s.pneumo is MC) then stain and culture next. When do you give steroids? PO2 <75, A-a gradient <35. When do you admit and give pneumovax? Hypoxia, >65, splenectomy, hypotensive c high pulse, comorbidities, confusion, low Na (SIADH).
238. TB >>> homeless, alcoholic, immigrant, HIV, health care worker, prisoner, fever, cough, sputum, wt loss, night sweats, first thing to do is CXR (NOT PPD >>> when do you choose PPD first? Screens asymptomatic pts!), 2nd step is AFP and then give RIPE c isolation for 2 months, then isoniazid and rifampin for another 4 months (6 months total). Adverse effects are Isoniazid is neurotoxic (less c B6), Rifampin c red urine, pyrizinimide c high uric acid (do not treat it, it will pass) and ethambutol with eye problems.
239. PPD >>> Positive if: >5mm in HIV, steroid users, close contacts; >10mm in immigrants, health care workers (me!), >15 in pt c no risk facts. If PPD is positive, proceed to CXR, if (-) take INH for 9 months, if + get sputum AFB. If PPD is negative, repeat it in 1-2 weeks to rule out false negatives. If pt had PPD in the past that was +, don’t do PPD again (it will always be positive), go right to CXR.
240. Endocarditis >>> fever and a murmur is key, h/o IVDA is s.aureas at tricuspid valve, #1 dx is blood culture (not ECHO), #2 dx is ECHO (TTE type, not TEE). For dental procedures (must be dental procedure c blood, cant be dental fillings) give amoxicillin or clinda if allergic, for GI/GU (strep bovis) procedure give amox + genta, or vanco + genta if allergic. Strongest indication for surgery is ruptured valve. So, 1st step is blood culture, 2nd step is start abx while waiting for results.
241. Thrush >>> oral candida, removable white mouth patches (Candida CAN come off, hairy leukoplakia cant). Tx c nystatin mouth rinse.
242. Lyme Disease >>> problems in joints, CNS (b/l bells palsy), heart (3 degree AV block). If its just a tick bite and no s/s, do nothing. If it’s a bite c lyme rash give amox (pregnant or kids) or doxy (not serology). If pt has b/l bells palsy get serology. If av block c cns s/s (except bells palsy) give ceftriaxone next.
243. HIV >>> 1st ELISA, 2nd western blot (in kids, 1st is PCR). Peripheral neuropathy c stavudine/didanosine, anemia c zidovudine, rash c tmp/smx (start dapsone), nephrolithiasis c indinavir. MC overall adverse effect is increase lipids and glucose levels. Prophylaxis: <200 for PCP (tmp/smx), <50 MIA (azithromycin). What if pt finds out she has HIV during pregnancy? Continue all meds except effavirenz. When do you only continue c AZT? If she has high CD count, give it in end of pregnancy and to newborn for 6 weeks. If pt gets stuck c needs, start 2 nucleosides and 1 PI or 2 nucleosides c effavirenz. Must you start tx if pt got splashed in eyes? Yes. Kissing? No.
244. If pt is stuck c HBV needle, now has +HBsAg, what do you do? If vaccinated, do nothing. If not vaccinated, give IVIG + vaccine. If pt got stuck c HCV needle do nothing.
245. How can you tell urethritis from cystitis? Urethritis has discharge. For both conditions, 1st step is swab, then stain, then DNA probe then tx. For urethritis tx GC (Ceftriaxone), for cervicitis, tx for Chlamydia (Azithro or Doxy)
246. Genital ulcers and + Lymph could be syphilis, LGV or chancroid
247. Syphilis >>> painless genital ulcer, skin rash (lata), CNS/aortitis. 1st step is Darkfield microscopy (not rpr/vdrl). DOC is penicillin. If allergic give doxycyline. If allergic and pregnant, desensitize c penicillin. If pt gets immediate allergic rxn to penicllin, give aspirin.
248. LGV >>> painless ulcer c painful nodes. 1st step is serology (Chlamydia is culture negative), tx c doxycycline
249. Chancroid >>> painful ulcer, 1st step is culture, tx c azithromycin
250. Genital vesicles, next step is acyclovir (not Tzank because you already have dx), if resistant give foscarnet. When do you choose PCR? HSV in the brain.
251. If they show or describe a vesicle (but don’t say vesicle), then do Tzank test
252. If they describe or show warts, next step is remove (no tests needed).
253. Septic Arthritis >>> 1st step is arthrocentesis (>50,000 wbc). If you suspect gonorrhea (look for tenosynovitis, rash or migratory polyarthritis), next step is culture pharynx, rectum, cervix, etc.
254. Osteomyelitis >>> 1st step is xray (periosteal elevation), 2nd is MRI, 3rd is biopsy. When do you choose bone scan? If you cant do MRI (metal, pacemaker, hearing tubes, etc). After bx you can make dx: S.aureaus (nafcillin), MRSA (vanco, linezolid), E.coli (quinolones for bones) and then f/u ESR. When do you choose culture or sinus drainage? Never!
RHEUMATOLOGY:
255. Osteoarthritis >>> stiff, not red, not hot. DIP (Heberdens node), PIP (Bouchards), worse in PM (not in AM like RA). X-ray shows osteophytes and joint narrowing. Tx c weight loss 1st, then NSAIDS.
256. Rheumatoid Arthritis >>> red, hot, swollen, fever, subQ nodules, +RF, pericarditis, pleural effusion, uveitis, long morning stiffness, swan neck, PIP/MCP (not DIP). Xray shows pannus. Tx c NSAIDS (1st if mild), methotrexate (1st if severe), 2nd is TNF (infliximab >>> r/o TB 1st), then steroids.
257. Gout >>> podagra, tophi (subQ uric acid deposits c punched-out bone lesions), (-) birefrigent crystals, a/w alcohol/aspirin/HCTZ use. Tx: Acute: 1st c NSAIDS (Indomethacin), then colchicines, then steroids (1st if renal dz). Chronic: If oversecretor give allopurinol (allo for ppl who make a lot), undersecretors get propenecid.
258. Pseudogout >>> calcium rhomboid shaped crystals, + birefringence, chondrocalcinosis, a/w 4 H’s (hemochromatosis, hyperparathyroidism, hypophosphatemia, hypomagnesemia). MC @ knees/elbows.
259. Psoriasis >>> scaly skin lesions, finger clubbing, RF negative. Tx c NSAIDS, MTX
260. Ankylosing spondylitis >>> HLA-B27 (not diagnostic), family hx, back pain, bent over (bamboo spine), worse c rest (key), better c exercise, dx c 1st Sacral X-ray (sacroiliitis). Tx c exercise and NSAIDS
261. Reiters Synd >>> HLA-B27, can’t see (conjunctivitis), pee (uvieitis), climb a tree (arthritis). Tx c NSAIDS, eye drops, STD treatment.
262. Behcet’s syndrome >>> 20-40yo c painful oral/genital ulcers and arthritis. Tx c steroids.
263. Kawasaki’s >>> (FEEL My Conjunctiva >>> Fever >5days, Edema, Erythema, Lymphadenopathy, Myositis, Conjunctivitis). Next step is Echo (r/o coronary aneurysms). Tx c Aspirin + IVIG
264. Takayasu arteritis >>> Chinese 30-50yo female c pulselessness on 1 side. Dx c angiogram of aortic arch (coronaries to r/o stroke). Tx c steroids, cyclophosphamide
265. Wegeners >>> nasal (sinusitis), lung (hemoptysis, dyspnea), kidney (hematuria), c-ANCA, tx c cyclophosphamide
266. Fibromyalgia >>> young female with pain all over, multiple points of tenderness, irregular sleep pattern, anxiety, exams all normal. Tx c antidepressant, NSAIDS
267. Polymyalgia Rheumatic >>> old female c pectoral/pelvic pain/stiffness, elevated ESR, normal biopsy, a/w temporal arteritis. Tx c steroids.
268. Polymyositis >>> 40-60yo female c proximal muscle weakness, elevated ESR/CPK, abnormal muscle biopsy, dx c 1st muscle biopsy, then EMG. Tx c steroids
269. Dermatomyositis >>> same as above, but c rash (heliotrope rash around eyelid).
270. Paget’s disease - >40yo male c pevic/skull damage, hats don’t fit anymore, deafness, paraplegia, bone pain, very high alk phos, normal calcium/phos, increased risk of osteosarcoma. X-ray shows thickened bones. Tx c NSAIDS, bisphophonates (Etidronate) and calcitonin.
271. Herniated disk >>> most at L4-5 (weak big toe), and L5-S1 (reduced Achilles reflex), positive straight leg test.
272. Carpal Tunnels >>> median nerve compression (thumb, pointer, middle finger), Tinnels sign (tapping wrist causes numbing), Phalens sign (flexing wrist), tx c rest, splint, workplace modifications, then NSAIDS.
273. Osgood-Shlatter >>> inflammation of tibial tubercle in boys. Tx c rest and immobilization.
274. Slipped Capital Femoral Epiphysis >>> Obese kid c painful limp. Dx c xray. Tx c surgical pinning >5yo.
275. Legg-Calve-Perthes >>> non-obese kid c a limp (d/t avascular necrosis @ hip). Tx c observation and pain relief, 2nd is bracing, 3rd is surgery.
276. Osteoporosis >>> risks include early menopause, alcohol, Caucasian, thin body, tobacco. Dx c DEXA >-2.5 (-1 to -2.5 is osteopenia). Tx 1st weight-bearing exercise, 2nd lifestyle (smoking, alcohol cessation), 3rd calcium/vit D, bisphosphonates, etc.
277. Patellar tendonitis >>> an NBME 3 test question, aka jumper’s knee, patellar tenderness due to overuse and jumping sports resulting in quadriceps contraction. Tx c rest, nsaids, quadriceps stretching.
278. Osteosarcoma >>> 10-25yo c knee pain, mass, limping, high alk phos. X-ray c sunburst appearance. Tx c surgery and chemotherapy
279. Osteoid Osteoma >>> bone pain worse at night and relieved c NSAIDS. Tx c nsaids
280. Osteochondroma >>> bone pain, xray shows pedunculated metaphyseal tumor at distal femur. Tx c surgery.
281. Ewing sarcoma >>> fever, pelvic/femur bone pain, swelling, xray shows onion skinning. Tx c radiation, chemo, surgery.
282. Reflex Sympathetic Dystrophy >>> burning pain, skin changes (color/temp), edema in a pt who had prior injury to that area. Tx c pain management (hard to do).
283. Nursemaids Elbow >>> from pulling your childs arm, he develops severe pain at elbow and will not use that arm. Tx c pushing back the head of the radius while the arm is supinated and flexed. Kid will feel much better immediately.
NEUROLOGY:
284. Migraine HA >>> 70% unilateral, throbbing, aura, photophobia, family history, possible risk of stroke, worse c OCPs/EtOH/chocolate. Tx c NSAIDS, triptans (contraindicated in heart disease), ergots. Prevent c BB 1st, cab’s 2nd, sodium valproate/SSRI/TCAs.
285. Cluster headache >>> same time every month/year, males mostly, tearing, redness, pain, rhinorrhea, feels like an ice-pick is shoved in your eye (old question). Tx c 100% oxygen 1st, steroids 2nd.
286. Temporal Arteritis >>> >50yo c unilateral temporal HA, scalp tenderness, vision changes, high ESR. 1st step is give steroids, 2nd step temporal artery biopsy.
287. Pseudotumor Cerebri >>> aka Benign Intracranial HTN >>> increased ICP, HA, visual changes, obese female, papilledema, no focal CNS findings, a/w vitamin A toxicity. Dx c MRI 1st then LP 2nd, tx c azetazolamide.
288. Trigeminal Neuralgia >>> pain whenever you touch your face @ 5th cranial nerve distribution. Tx c carbamazapine. Definitive treatment with surgical rhizotomy.
289. Essential Tremor >>> at rest and motion. Tx c propranolol. (Tremor at rest only is Parkinson’s or hyperthyroidism, tremor c motion only is cerebellar dysfunction)
290. Nystagmus/Vertigo >>> if + focal defecits, the problem is central (vertical nystagmus): cerebellum (CT/MRI), M. Gravis (MRI), Stroke (MRI/CT), phenytoin without an hearing loss or tinnitus. If no focal defecits, the problem is peripheral (in the ears), so pt will have hearing loss and tinnitus. If pt only has vertigo, its benign positional vertigo. If pt has hearing loss and tinnitus with it: Miniere’s disease (chronic disease), Acoustic Neuroma (look for ataxia), Labyrinthitis (acute viral infxn)
291. Epilepsy (as per Kaplan on what is important): do not treat 1st time seizures unless there is a family history, EEG is positive or pt has status epilepticus.
292. Status Epilepticus >>> Dx: 1st sodium, 2nd glucose, 3rd calcium, 4th hypoxia, toxicology, CT-head, EEG (last!). Tx: 1st Benzo (lorazepam IV), 2nd Phenytoin, 3rd Barbiturate, 4th Anesthesia (succinylcholine/propofol >>> these will just stop the shaking, wont stop the seizure).
293. Absence seizures >>> kid stares into space, doing poorly in school, eye blinking, lip smacking, EEG c 3/sec spike and wave pattern. Tx c ethosuximide.
294. TIA >>> focal, abrupt onset lasting less than 1 hour, symptoms resolve after 1 day. Risk of stroke in days to weeks. Amorosis fugax (curtain over an eye due to retinal dysfunction) needs Doppler U/S of carotids or MRA. Give heparin acutely (if no contraindications), then long term aspirin. If stenosis >70%, amaurosis fugax/TIA or small, non-disabling stroke do CEA (carotid endarterectomy) and give aspirin. If stenosis <70%, severely disabling stroke, or TIA/stroke in evolution give daily aspirin alone.
295. CVA >>> 1st test is CT without contrast (although, if ischemic, it will show negative), 2nd is MRI. Heparin is not given until hemorrhagic stroke is ruled out. If ischemic, give tPA’s if less than 3 hours of onset. If hemorrhagic, control BP and ICP.
296. Ischemic Stroke Locations: MCA >>> contralateral hemiplegia, hemianopsia, Broca’ s (nonfluent, babbling)/Wernicke’s (fluent but doesn’t make sense) aphasia. ACA >>> contralateral leg paralysis, sphincter incontinence (they cant kick you, so they pee on you); Posterior >>> cortical blindness, hemianopsia; Vertebrobasilar >>> ataxia, horizontal gaze, nystagmus; Cerebellar >>> ataxia and dizziness; As for hemorrhagic, remember that in the thalamus its only sensory loss, in the pontine/internal capsule/putamen its only motor loss.
297. Multiple Sclerosis >>> insidious onset of CNS s/s in a woman aged 20-40 with exacerbations and remissions of numbness, parasthesia, weakness, optic neuritis, gait disturbance, incontinence and emotional/mental status changes. Look for classic b/l internuclear opthalmoplegia (lesion @ MLF so you cannot adduct in horizontal gaze) and scanning speech. Babinski may be positive. Entirely CNS (M.gravis and G-Barre are entirely PNS). 1st step is MRI, 2nd test is LP (oligoclonal bands). Tx acute exacerbation c steroids. Prevent next attack c ABC (Avonex (Inf-B), Betaseron (Inf-B) and Copaxone (Glatiramer acetate)). If stuck in 1 position all day, give baclofen or Tizanidine. If incontinent give oxybutinin or bethanacol.
298. Guillain-Barre Syndrome >>> h/o URI of GI infection (campylobacter jejuni) or immunization 1 week before develops onset of symmetric, assending progressive weakness or paralysis and loss of DTRs. 1st step is PFTs (MCCOD is respiratory dysfunction due to paralysis, so monitor the pt’s NIF (negative inspiratory force) and if it keeps decreasing, consider intubation). Most accurate test is EMG. When do you choose LP? Last (shows elevated CSF protein). Tx c IVIG or plasmapheresis (not steroids!).
299. Myasthenia Gravis >>> Ab against Ach receptors in women 20-40yo. Look for ptosis, diplopia, difficulty swallowing and weakness c repetition (at the end of they day they are exhausted). Best initial test is Ach Ab (NOT edrophonium test, which is 2nd or if they already mention the Ach Ab). Most accurate test is EMG. Tx Myasthenia crisis (breathing problems) c D/C anitchonergics and give IVIG and Plasmapheresis (NOT steroids). Tx for chronic disease: <60 gets thymectomy (do CXR, Chest CT), >60 gets neostigmine and steroids, then azathiopine/cyclosporine/tacrolimus. What abx is contraindicated? Aminoglycosides.
300. Eaton-Lambert >>> Ab against presynaptic calcium channels causing limb weakness that gets stronger c repetitive stimulation (opposite of gravis),no loss of DTRs or extraocular manifestations, a/w small cell lung cancer, tx c guanidine. (cab’s are contraindicated).
301. Neurosyphilis >>> tertiary treponema pallidum disease. Treat c high dose penicillin. After giving penicillin, pt may develop hypotension, fever, HA, chills and tachycardia within 24 hours of treatment due to treponemal products (Jarisch-Herxheimer reaction, this is not a penicillin reaction). Tx c aspirin.
302. Myotonic Dystrophy >>> 20-30yo guy grabs something and cant let go (impaired relaxation) d/t mutations in chloride channel. Tx c phenytoin.
303. Duchenne Muscular Dystrophy >>> XLR, boys 3-7 have muscle weakness, very high CK, calf pseudohypertrophy, Gower’s sign (kid climbs his legs to stand, look at it in google videos its so sad). Kid is in wheelchair by teenager and dead by 20. Dx c muscle biopsy.
304. Mitochondrial Myopathy >>> aka Lever’s hereditary optic atrophy >>> every mom gives to all overspring (no male transmission). Look for ragged red fibers on biopsy.
305. Botulism >>> infant ingests honey and develops floppy baby syndrome. 1st step is intubate if needed, 2nd step is antitoxin. Spontaneous recovery in 1 week.
306. Amyotrophic lateral Sclerosis >>> aka Lou Gehrig’s dz >>> 55yo male upper (spasticity, hyperreflexia, babinski) and lower motor neuron (fasciculations, atrophy, flaccidity) problem. Only motor problems, no sensory/sexual/bowel problems. Tx c Riluzole.
307. Huntington’s Disease >>> AD (father had it, you have it at a younger age) c CAG repeats, chorea, personality change, psychiatric syndromes, progressive dementia. Dx c CT/MRI showing caudate nucleus and cerebral cortex atrophy, causing decreased Ach and GABA (thus causing increased dopamine). Tx c antipsychotics (haloperidol) When you see a movement disorder, dementia and emotional problems, think of Huntington’s. When you see dementia and emotional problems (no chorea), pick Pick’s disease.
308. Parkinson’s >>> 60yo c extrapyramidal movement disorder (pill-rolling resting tremor, cogwheel rigidity, shuffling gait, bradykinesia, masked facies). Caused by loss of dopaminergic neurons in substantia nigra. Tx: Mild s/s (can still take care of themselves): <60yo c Anticholinergic (cabergeline/benztropine/trihexylphenidyl), >60yo c Amantidine. If Severe s/s: 1st Levo/Carbidopa, 2nd is DA agonist (primapexole, ropinirole, pergolide), 3rd COMT-inhibitors (Talcopone), 4th MAOI (selegiline). Some antipsychotics (haloperidol, risperidone, MPTP) can cause parkinson-like symptoms, tx c anticholinergics (benztropine/ trihexylphenidyl/ cabergeline). Young guy c Parkinsonism, but not on meds, think of Wilson’s disease.
309. Alzheimer’s >>> progressive dementia (memory, language, visuospatial, mood, hallucinations, personality/behavior) in mid-late life. a/w Down’s syndrome (amyloid precursor protein). Dx c MRI showing cortical atrophy, senile plaques, neurofibrillary tangles. Tx c donepezil, rivastigmine and galantamine to increase Ach just in brain.
310. Pick’s >>> early aged (40) personality change, dementia. CT/MRI shows frontetemporal atrophy, argyrophilic neuronal (Pick) bodies in frontal and temporal lobe, sparing superior temporal gyrus (generally no memory problems).
311. Multi-infarct Dementia >>> stepwise dementia in a pt c bad medical history (HTN, DM, etc.). They will describe the pt as progressively getting worse, little-by-little. Dx c PET/SPECT scan showing multifocal decreases in cerebral blood flow. Tx c aspirin
312. Normal Pressure Hydrocephalus - “wet, wacky, wobbly” (incontinent, dementia, ataxia). Dx c CT scan, tx c ventriculoperitoneal shunt.
313. Creutzfeldt-Jakob - young guy c rapidly progressive dementia, myoclonus due to abnormal isoform of prion protein. Dx c biopsy (nothing else). No treatment.
314. Narcolepsy >>> daytime sleep attacks c cataplexy, hynogogic (going to sleep)/hypnopompic (waking up) hallucinations, sleep paralysis. Rapid onset of REM sleep. Tx c amphetamines for sleepiness, clomipramine for cataplexy.
315. Obstructive sleep apnea >>> overweight, HTN, arrhythmia, gasping for air. Dx c polysymnography. Tx c CPAP.
316. Central sleep apnea >>> old, non-obese pt c loss of respiratory drive. Tx c azetazolamide.
317. Epidural Hematoma - + head trauma, + HA, + LOC, lucid intervals after brief LOC followed by increasing obtundation, middle meningeal artery. Dx c CT without contrast showing convex hematoma. Tx c 1st hyperventilate and elevate head, 2nd evacuate, 3rd mannitol
318. Subdural Hematoma - +head trauma, + HA, + LOC, bridging veins injured, can be acute (CT showing concave or crescent-shaped hematoma), days (MRI), or gradual deterioration (MRI). Tx c same as above.
319. Subarachnoid Hemorrhage - +HA, + LOC, no head trauma, spontaneous, sudden onset of meningitis (stiff neck, photophobia, kernig’s, brudzinski), worst HA of my life, a/w polycystic kidney disease, CSF c blood. Best initial test is Head CT, most accurate test is LP. Tx supportively (bed rest, analgesia)
320. Concussion >>> + head trauma, + LOC, no focal CNS defecits. Tx >>> go home.
321. Contusion >>> + head trauma, + LOC, blood/bruise on head. Tx >>> go home.
322. Neuroleptic malignant syndrome >>> high temperature, muscular rigidity, confusion, high CPK, high K+, no sweating, tx c IV dantrolene or bromocriptine.
323. Malignant hyperthermia >>> high temperature, confusion, high CPK, high K+, no sweating, h/o anesthesia (halothane). Tx c IV dantrolene
324. Heat Stroke >>> high temperature, confusion, no sweating, normal CPK, normal K. Tx c fanning them (don’t overcool them) and water.
325. Closed-angle Glaucoma >>> sudden eye pain, n/v, vision loss. Tx c surgical iridectomy
326. Open-angle Glaucoma >>> progressive peripheral vision loss, disc cupping, no pain. Treat with bb (timolol), acetazolamide, eye drops and prostaglandins (latanoprost).
Growth/Development/ Preventative Medicine:
327. Gestational Age >>> fundus at pubic symphysis @ 8 wks, above symphysis @ 14wks, umbilicus @ 20wks, xiphoid @ 38wks.
328. Naegele’s rule >>> assuming 28 day cycle, subtract three months, add 7 days (if more than 28 days, add the remaining days to the 7)
329. Infant size >>> gains back birth weight by 2 weeks of age, double weight by 6 months, triples weight by 1 year.
330. Lactation >>> estrogen makes mammary duct tissue grow, progesterone stimulates alveolar glands. Postportum, they both drop, prolactin increases (inhibiting ovulation) and oxytocin, via nipple stimulation, allows milk letdown. Contraindicated with HIV, CMV or certain meds.
331. Newborn care: “Caput succedaneum” is a hematoma across the suture line, caphalohematoma is a hemotoma that does not cross the suture line. Mongolian spot is a bluish discoloration at the sacrum, always benign (do not assume abuse). Check for red eye reflex (r/o retinoblastoma and congenital cataracts), Orolani/Barlow maneuver (r/o DDH), abdm masses (ARPKD, Wilm’s tumor, neuroblastoma, umbilical hernia (r/o hypothyroidism))
332. Development: 1 month >>> head lag/social smile; 3 months >>> lifts head, 6 months >>> rolls over/sits up alone/stranger anxiety, 9 months >>> crawls/takes steps if hands held, 12 months >>> walks if you hold one hand, speaks three words; 15 months >>> walks alone/separation anxiety, two-block tower; 2yo >>> six cube tower/poison-proof home.
333. At 4 years old, must get objective hearing and visual exam.
334. Puberty: Females sequence (estrogen): ovary growth, breat bud, growth spurt, then pubic hair. Male sequence (testosterone): testicular growth, growth spurt, then pubic hair.
335. When to keep child-physician confidentiality? Drugs, EtOH, OCP, STD prevention.
336. OCP >>> Barrier Method (condoms help prevent STDs, diaphragms might be annoying to prepare, thus inhibiting use), hormonal contraceptives (combined est/prog (safe, effective), minipill (more pregnancy/bleeding), or injectable and implanted progestins), vaginal spermicides, IUD, surgical sterilization.
337. #1 stressor is death of a spouse, # 2 is divorce.
338. Normal Aging: cardiac (decreased CO), musculoskeletal (decreased bone mass), pulmonary (decreased strength and compliance), immunity (thymus involution), senses (decreased visual, auditory, tactile and taste), endocrine (decreased insulin-secreting cells, glucose intolerance), mental (decreased memory, learning ability and calculation speed).
339. Exceptions to informed consent: emergency, imcompetent pt, minors.
340. Influenza - >50yo, high risk (COPD, cardiovascular, renal), women who WILL become pregnant in winter, household contacts of high-risk pt (to protect the high-risk pt). Pneumococcal - >65, comorbidities.
341. Formulas: [A = True Positive; B = False positive; C = False negative; D = True Negative] (positives always on top) Sensitivity = TP/TP+FN; Specificity = TN/TN+FP; PPV = TP/TP+FP; NPV = TN/TN+FN; Attributable risk (attrib = subtract) = (a/a+b) >>> (c/c+d); Relative risk (only for propective studies like cohort study)= (a/a+b) / (c/c+d); Odds ratio (only for retrospective studies like case-control) = ad/bc; attack rate (how many ppl get attacked c dz) = a+c/b+d.
342. Power = rejecting the null when its false (a good thing, like saying Viagra does not treat constipation, which it doesn’t do). However, sometimes FDA may not always make the right choice and end up approving something that doesn’t work, or not approving something that works. Type 1 error >>> rejecting the null when it’s true (saying Viagra does not treat erectile dysfunction). Type 2 error = acceptance of the null hypothesis when it is false (saying Viagra treats constipation). Generally, the only way to increase power is to increase the sample size.
343. Mean = average; Median = middle #, Mode = MC #.
344. Confidence Interval = [mean +/- Z score x standard error of mean], where Z is the standard score (If confidence interval is 95%, Z is 2, if CI is 99%, Z is 2.5) and standard error of mean is (S / square root of N), where S is the standard deviation and N is the sample size. For example, old TQ said the mean was 67%, standard deviation was 8% in a sample size of 16, calculate a 95% CI: (67 +/- 2 (8 / square root of 16) = (67 +/- 2 (8/4)) = 64 +/- 4. The answer was 63-71.
345. When they give you a chart with different confidence intervals, just look for the one that has 1 within the range (ie. 0.89-2.3, not 1.12-2.25 or 0.56-0.93). That one is NOT statistically significant, meaning the risk is the same. If 1 is not within the range, is is statistically significant. If it was over 1 (1.12-2.25 used above), there is an increased risk. If it was under 1 (0.56-0.93 used above), there is a decreased risk.
346. When given statistical scales and asked for the statistical test: Nominal is categorical (how many you can split into groups, like genders, ethnicities, etc), Interval is a measurement (height, wt, BP, etc.). Pearson correlation = 2 intervals; Chi-square = 2 nominals; t-test = 1 nominal + 1 interval. For example, if you want to find out if men do better than women on step 2. Men vs women is nominal, Step 2 is an interval, therefore one of each makes it a t-test.
347. If given the following data: After surgery: 90% survive 1year, 75% survive 2years, 50% survive 3years, 40% survive 40%, and asked: what is the life expectancy after surgery? Always pick closest to 50%, so the answer would be 3 years. If asked, if a pt survives 2 years, what is the chance of surviving 3 years? Always put the # ending on top, # starting on bottom, so it will be 50/75, or 67%.
348. Cohort study (think >>> Cohort to Go Forth) >>> a prospective study where people are followed for a period of time. Advantages are that incidence (# of new cases) can be determined, there is an accurate relative risk (remember RR with cohort), and less control group bias. Disadvantages are that it takes too long, expensive, the sample size can get too large, and you might run into an ethical problem.
349. Case-control study >>> a retrospective study where you start with an outcome and then check backwards to evaluate the risk or cause. Advantages are that it’s cheap and easy, small sample size and minimal ethical risk is involved. Disadvantages are that incidence (new cases) are not determined, RR is just approximated (not exact, just taking odds, remember OR c case-control) and that there is some control group bias. Kaplan says, if you have no idea which type of study it is, pick this one.
350. Confounding bias >>> when hidden factors affect the results. For example, an experimenter measures the # of ashtrays owned and incidence of lung cancer and finds that people c lung cancer have more ashtrays. He or she then concludes that ashtrays cause lung cancer. Smoking is the confounding bias here, because it increases both ashtrays and lung cancer. So how can you prevent this? Do multiple studies.
351. Lead-time bias >>> when you confuse the facts that early screening will increase life expectancy. Look for false estimates of survival rates. For example, if I diagnosed you with cancer at 18 and you lived until 30, you will think I treated you for 22 years. However if I didn’t diagnose you until 25 and didn’t treat you after, and then you lived until 30, you will think that you only survived 5 years. The difference is not that my drug treats you better, but that I am diagnosing you earlier, thus getting a good lead on time. The solution here is to measure the “back-end” survival (ie. Getting the age 30 as the age that they both die at, whether they were treated or not).
352. Recall bias >>> subjects can’t remember events in the past. Solution is to make them confirm information with other sources.
353. Late-look bias >>> subjects die before the end of the survey, so your information gets distorted. For example, a survey finds that AIDS pts only get mild symptoms. This is wrong because they die before the really bad symptoms occur. Solution here is to stratify the disease by severity.
354. Experimenter/Interviewer bias >>> aka Pygmalion effect - when the experimenters expectations are inadvertently communicated to subjects, who then produce the desired effect. Solution is to make the study a double-blind one.
355. Selection bias >>> aka sampling bias >>> when the sample selected is not a representative of the population. For example, taking the people from a health club and doing a survey on the lungs in the general population. Another cause is when a study uses hospital records to estimate population prevalence (Berkson’s bias). For example, a doctor says all the people in NY are sick because all day he works with sick patients in NY.
356. Measurement bias >>> aka Hawthorne effect >>> when being observed makes you change how you answer to questions. Also, when the way the information is presented makes you answer in a certain way. For example, asking a pt “you don’t like your doctor, do you?” The pt is likely to say no because of the way the question was presented. In the law world, its termed “leading.” Prevent this by having a control/placebo group.
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OB:
357. Numbers to note: How many weeks in each trimester? 13; what is so special about 37 weeks? Lungs are muture b/c lethicin/sphingomyelin ratio is 2:1; what is the risk of having Down’s if mom is 35? 1/350; risk @ 40? 1/100; risk @ 45? 1/50, so you absolutely must recommend amniocentesis. Pregnancy weight gain is about 25 pounds (5 in first 20 weeks, 1 pd every week after). Uterine height: 8 weeks @ iliac, 14 weeks @ pubic symphisis, 20 weeks @ umbilicus, 38 weeks @ xiphoid process.
358. Dates to note: 6-8wks is prenatal workup. 15-18 weeks is triple screen. 18 weeks is ultrasound. 26 weeks is glucose challenge test for DM. 35 weeks is GBS culture.
359. Diagnostics: Ultrasound (noninvasive, no adverse effects, done at 18-20 weeks), Chorionic villus sampling (“CVS,” invasive, done at 9-12 weeks, best for early gestation so mom has the chance to choose an abortion, may be fatal, f/u c triple screen after), Amniocentesis (done at 15-20 weeks for genetic purposes or high risk patients, done at 24 weeks for Rh isoimmunization, done at 34 weeks for gestation age, pregnancy loss about 0.5%)
360. Diabetes workup: Done at 24-28 weeks in normal pt. Done c prenatal workup (6-8 weeks) if pt is obese or has h/o macrosomic baby, h/o DM or family h/o DM. The pt will come to your office fasting for 1 hour, her blood sugar should be >140. If <140, get her fasting glucose (should be <90) and proceed to a 3 hour 100g glucose tolerance test: 1hr <180, 2hr <155, 3hr <140.
361. Embryology: Week 1 >>> implantation, week 2 >>> 2 layers formed (epiblast and hypoblast) and b-hCG is produced by syncytiotrophoblast, week 3 >>> 3 layers formed, week 4 >>> major organs formed. Note that weeks 3-8 are the period of greatest teratogenicity.
362. Teratogens: Infections (TORCH), Radiation (>20 rads), Chemotherapy (In first TM, cant give MTX, Adrinomycin), Environmental (smoking causes IUGR, alcohol causes microcephaly, flat philtrum, thin upper lip), Recreational drugs (cocaine causes placental abruption and intraventricular hemorrhage, marijuana causes prematurity), Medications (DES (vaginal/cervical cell CA), Dilantin (gingival hyperplasia, nystagmus, craniofacial dysmorphism), Warfarin (Stippled epiphysis), Isoretinoin (deafness, CNS), Lithium (ebstein anomaly), Streptomycin (CN 8), Tetracycline (black teeth), Thalidomide (small limbs), Valproic acid (spina bifida)).
363. B-hCG >>> 3 purposes: maintains corpus luteum (which keeps making progesterone) until placenta takes over at 9th week, regulates steroid production, stimulates testosterone production in fetal male testes. Levels may be too high (incorrect dates (MC), twins, hydatidiform mole, choriocarcinoma, ebryonal CA) or too low (incorrect dates (MC), ectopic, threatened/missed abortions). If levels are high or low, next step is to recheck the dates.
364. Human Placental lactogen (HPL) >>> chemically similar to GH and prolactin, thus antagonizing insulin which will contribute to gestational diabetes if too high.
365. Estrogens: Estradiol (nonpregnant reproductive years, made from granulose cell from testosterone via aromatase), estriol (pregnancy, made from DHEA via sulfatase in the placenta), estrone (menopause, made from adrenal adrostenedione in adipose).
366. Changes in pregnancy: Skin (striae gravidarum (stretch marks), chadwick’s sign (bluish cervix), linea nigra, chloasma. Note the only cancer that increases c pregnancy is melanoma), CVS (decreased BP in 1st TM, highest CO in L lateral decubitus position, systolic ejection murmur is normal, diastolic murmur is abnormal), GI (progesterone causes increased salivation, gum hyperplasia, GERD/aspirations, decreased gastric motility, constipation), pulmonary (generally, most increase except tidal volume causing resp alkalosis), renal (increased GFR, decreased BUN/Cr, decreased uric acid, glycosuria is normal, proteinuria is not), pituitary (size increases, contributing to possible Sheehan’s syndrome), thyroid (increase in TBG and total T3/T4, not free T3/T4 thus not causing s/s of hyperthyroidism, blood (increase RBC/WBC, normal platelets. Note low platelets c HELLP syndrome d/t preeclampsia, MCC of anemia is iron deficiency, then folate deficiency).
367. Prenatal workup: done at 6-8 weeks. Check CBC, UA (r/o asymptomatic bacteruria where >1000 E.Coli will be found, treat c ampillin or nitrofurantoin if allergic), Rubella (worst at 1st TM), RPR, HBV, Rh blood typing, sickle cell prep (if (+), proceed to Hb electrophoresis). If pt is a teenager, do Chlamydia and gonorrhea cultures.
368. Triple Screen >>> AFP, hCG, estriol (currenty inhibin-A makes for quad screen). If AFP is low, think of Down’s/Edwards synd. If AFP is high think of NTDs, gastrocele, omphalocele. Again, if AFP is high/low, next step is to get vaginal u/s to check dates. If dates are correct and U/S is non-explanatory (did not show nuchal fold thickening of Down’s), get amniocentesis for karyotype, amniotic fluid-AFP and acetylcholinesterase activity (both high in NTD). Down’s syndrome >>> high hCG, low AFP, low estriol. Edwards syndrome >>> all 3 are low.
369. Mom says she doesn’t feel the baby move anymore. Next step is U/S. If it shows fetal cardiac activity, get non-stress test. If it doesn’t show fetal cardiac activity, this is fetal demise and the next step is D&E AT 12-16wk (not D&C (<12wk), not C/S, induce labor <16wk) followed by cervix/placental culture, autopsoy, karyotyping and total body x-ray (r/o osteochondroplasia). Non-stress test (done in high risk, or if pt says she doesn’t feel the baby move anymore): reactive is good (2 accelerations in 20 minutes), nonreactive is bad (<2 accel/20 minutes)
370. Nonstress test (NST): if reactive baby is ok (monitor). If non-reactive, baby may be sleeping or in danger, so do vibroacoustic stimulation (VAS) and repeat NST. If NST is now reactive, baby was sleeping and is now ok (monitor). If still non-reactive, get a Biophysical profile (BPP) c U/S. If BPP is 8-10, baby is ok (repeat in 4 days); if BPP is 6-4, do a stress test (check for decelerations). If BPP is 0-2, deliver immediately.
371. BPP >>> measures 5 components (each worth 2): NST, amniotic fluid volume (normal is 5-15,<5 is oligohydramnios, >15 is polyhydramnios), fetal gross body movements, fetal extremity tone, fetal breathing movements.
372. Stress test >>> checks for decelerations. Go in order (head, then cord, then placenta). Early deceleration means head compression, Variable deceleration means cord compression, Late deceleration means utero-placental insufficiency. Treatment for decelerations in a stress test: 1st D/C oxytocin, 2nd Give oxygen and fluids, 3nd position her to L lateral decubitus position, 4th get scalp pH (normal 7.25 >>> 7.4, if <7.2 go right to C-sxn).
373. Group B Strep (GBS) >>> not a disease or pathogen to the mother, but if transmitted to the newborn during delivery can cause pneumonia, sepsis or meningitis. Prophylaxis c IV penicillin G (if allergic, give clinda, erythro of cefazolin) is given for +GBS culture @ 37 weeks, h/o previous child c infection, preterm gestation (even if culture negative), PROM >18 hours (must give enough time for penicillin to reach fetus), or maternal fever.
374. Toxoplasma gondii >>> cat feces, raw goat milk, undercooked meat. Worst in 2/3rd TM. In neonate it can cause seizures, in fetus look for intracranial calcifications. Tx c pyrimethamine-sulfadiazine.
375. Varicella >>> kid c “zigzag” lesions (due to nerve distribution), cataracts, chorioretinitis. Worst if mom has the pruritic vesicles 5 days antepartum-2 days postpartum. Prevent c VZIG 96 hours prior to birth. Tx c acyclovir.
376. Rubella >>> worst in 1st TM. Prevent 3 months before conceiving. Look for triad: deafness, cataracts and PDA. Sometimes “blue-berry muffin” rash. No treatment.
377. CMV >>> look for cerebral calcifications, deafness and microphthalmia. Blood shows intranuclear inclusions. Tx c ganciclovir, or foscarnet if resistant.
378. Syphilis >>> Dx c darkfield microscopy (rpr/vdrl may be negative until secondary disease). Child will have Hutchinson’s teeth, saber shins, saddle nose and 8th cranial nerve deafness. Tx c Penicillin, if allergic then desensitize penicillin.
379. HSV >>> if vesicular lesions are present in vulvar area at time of delivery, do C/S. If lesions are only on legs, none of vulva/labia, cover with towel and proceed c vaginal delivery (never done in real world). If history of lesions of culture 1 week before delivery, do C/S.
380. Hepatitis B >>> worst in 3rd TM. If mom has +HBsAg, next step is to get LFT’s (if high, she has active disease, if normal she may just be a carrier). Upon delivery, give baby vaccine and HbIG within 12 hours of birth. Give mom Inf-a c lamivudine.
381. HIV >>> ELISA then western blot. If (+), get viral load and CD-4 count. If viral load >1000 or CD <500, give all the drugs except efavirenz. If CD>500, only give AZT throughout pregnancy (starting at 14 weeks) and 6 weeks postpartum. After 6 weeks, dx HIV c PCR (cant use ELISA yet). Mom must avoid breastfeeding.
382. 4 big causes of 1st TM bleeding: Incomplete/Complete abortion, Threatened abortion, Ectopic pregnancy, Mole. Use Apt test to make sure blood is from fetus, not from mom.
383. 1st TM bleeding: 1st step is speculum exam. If cervical os is open, pt had an incomplete/complete (depending how much products of conception passed), next step is D&C. If cervical os is closed, next step is vaginal U/S c hCG. If vaginal U/S shows an intrauterine pregnancy, pt had a threatened abortion, next step is bed rest. If vaginal U/S shows no intrauterine sac and hCG >1500, pt has an ectopic pregnancy and the next step salpingostomy or MTX treatment followed by serial hCG levels until zero. If vaginal U/S shows a snowstorm appearance, pt has a mole and the next step is D&C followed by serial hCG levels to zero (also put pt on OCP’s to prevent birth, which would increase hCG and not be able to allow you to monitor hCG appropriately).
384. Ectopic >>> amenorrhea, vaginal bleeding, abdm pain, hCG>1500, no IUP on vaginal U/S. If unstable c peritonitis, do laparascopic salpingectomy. If stable and does not want surgery, give methotrexate and follow-up hCG levels until zero.
385. Mole >>> preeclampsia before 3rdTM, very high hCG, in 1st TM you will see expulsion of grapes and a uterine size that’s too big for gestation age. Vaginal U/S shows snow-storm appearance. Complete (46XX, all from dad) have no fetal tissue, incomplete does. Tx c D&C and f/u hCG while pt is on OCP’s. If hCG still doesn’t fall, pt has choriocarcinoma and needs MTX and actinomycin.
386. 3rd TM bleeding: 1st step is ultrasound (absolutely not pelvic exam). Possible choices are placenta previa, vasa previa, abruption placenta, uterine rupture.
387. Placenta previa >>> painless bleeding c ultrasound showing placental implantation over the lower uterine segment. Pt may say she woke up in a pool of blood. Treatment: If preterm gestation, pt is stable and bleeding stops: 1st admit, then bedrest, get vital signs/labs, transfuse if needed and put on steroids (for lung maturity) c magnesium sulfate. If pt is >37 weeks, do C-section (whether she is still bleeding or not).
388. Vasa previa >>> look for triad: rupture of membranes (gush of fluid), bright red painless vaginal bleeding and fetal bradycardia. Next step is C-section.
389. Abruptio placenta >>> painful vaginal bleeding (if bleeding stops, it may be collecting in retroperiteal area), uterine tenderness and increased uterine tone with hyperactive contraction pattern. May even cause DIC. If mild to moderate, give fluids and deliver vaginally. If severe, pt will have acute abdm (rock hard) c profound hypotension, next step is immediate C-section.
390. Uterine rupture >>> sudden abdm pain c profuse vaginal bleeding and abnormal fetal heart rate. Treat c immediate C-section and then uterine repair if mom wants kids in future, or hysterectomy if she doesn’t.
391. Rh Isoimmunization >>> mom is Rh(-), dad is Rh (+), second baby is affected c erythroblastosis fetalis. Prevent c RhoGAM at 28 weeks and 72 hours of delivery, D&C or CVS. If mom already has Rh antibodies, RhoGAM is useless (only for prevention) and so the next step is to get Rh titers. If >1:8, do amniotic fluid spectrophotometry to assess severity of hemolysis.
392. Premature rupture of membranes >>> sudden gush of fluid. Next step is fern test, nitrazine test. Risk of chorioamnionitis (maternal fever, uterine tenderness, PROM, culture/gram stain amniotic fluid, treat c ampicillin while awaiting results and if (+), deliver). Management: if infection present, deliver. If no infection present and fetus is <24 weeks, outcome is dismal (induce labor c bedrest at home). If baby is 24-35 weeks c no fever, hospitalize, IM betamethasone, Cx, Abx. If baby is >36 weeks, prompt vaginal delivery.
393. Preterm Labor >>> must have cervical change >2cm (if none, pt has false (Braxton-hicks) contractions and send her home). MC risk factor is previous preterm labor. Dx c fetal fibronectin (if +, tocolytics and steroids, if (-), send home). Management: 1st L lateral decubitus position, bed reast, O2 and IVF. 2nd Start tocolytics (useless >4cm dilatation, r/o contraindications first), get cervical/urine culture before giving IV Pen G (for GBS), IM betamethasone and send home.
394. Tocolytics >>> 1st Mg Sulfate (calcium blocker that may cause resp depression, loss of DTRs and pulmonary edema. If so, give IV calcium gluconate). 2nd Ritodrine/Terbutaline (B-adrenergic agonists that may cause hypotension and tachycardia so don’t give in pt c heart disease or DM). 3rd Nifedipine (calcium blocker that may cause hypotention). 4th Misoprostol (prostaglandin inhibitor that may cause in utero ductus arteriosus closure, so don’t give if gestation age >32 weeks). Some contraindications to tocolytics include (conditions where you may need to deliver) abruption placenta, ROM, chorioamnionitis, fetal demise, late decelerations, eclampsia, severe eclampsia and cervical dilatation >4cm.
395. Post-date pregnancy (>40wk): complications include increased perinatal mortality, macrosomia, need for c-section, dysmaturity syndrome (mother’s support runs out). 1st step is to check dates (if dates still unsure, continue c conservative treatment and biweekly NSTs), 2nd step is induction of labor. If cervix is favorable (soft), begin aggressive tx c oxytocin and artificial ROM. If cervix is unfavorable (hard), give prostaglandins c oxytocin and wait for spontaneous delivery.
396. Transient HTN >>> unsustained high BP without proteinuria or edema. No tx.
397. Chronic HTN >>> high BP before 20 weeks gestation. Tx c methydopa, hydralazine.
398. Mild preeclampsia >>> mild HTN (140/90), petal edema, 2+ proteinuria after 24 weeks gestation. Management: <36 wk >>> conservative (no meds). >36 wk >>> deliver
399. Severe preeclampsia >>> sustained BP >160/110, >3+ proteinuria, edema, epigastric pain, HA, blurred vision, thrombocytopenia (r/o HELLP synd). Tx: prompt vaginal delivery c oxytocin, MgSO4 (to prevent convulsions) and IV hydralazine/lobetolol.
400. Eclampsia >>> HTN, proteinura, edema, seizures. Tx: 1st ABC’s, 2nd MgSO4 to stop seizure (do not deliver 1st, you can never attempt delivery if pt is seizing), 3rd aggressive prompt vaginal delivery c oxytocin and hydralazine to decrease BP.
401. HELLP syndrome >>> hemolysis (schistocytes), elevated LFTs, low platelets. No CNS or renal problems (r/o TTP), no h/o URI/GI infection (r/o HUS). Tx c steroids and prompt delivery.
402. Never recommend termination of pregnancy, unless: 1 >>> pulmonary HTN in mom, 2 >>> Marfan’s syndrome c an aortic aneurysm >4cm, 3 >>> Eisenmengers syndrome (pulm HTN c bidirectional shunt, 4 >>> peripartum cardiomyopathy.
403. If they ask about rheumatic heart disease in the context of pregnancy, know about mitral valve stenosis management (diuretics 1st, vasodilators, then balloon vulvoplasty). Management of cardiac disease in pregnancy is bed rest, decreased physical activity, decrease weight, correct anemia, analgesics, vacuum delivery.
404. Management of hyperthyroid disease in pregnancy is to stay on PTU to prevent thyroid storm, but warn mom that baby might be mentally retarded or have IUGR.
405. DM in pregnancy >>> a/w fetal NTD (most common fetal anomaly), hypoglycemia (d/t maternal insulin, tx c IV glucose), hypocalcemia (failure of PTH synthesis after birth), polycythemia (d/t increased erythropoietin from intrauterine hypoxia), respiratory distress (to check lung maturity, phosphatidylglycerol is a better choice than L:C ratio), hyperbilirubinemia.
406. Prolonged latent phase >>> cervical dilatation <3cm (>20hrs in primipara, >14rhs in multipara). MCC is analgesia, so tx is bedrest and sedations.
407. Prolonged active phase >>> cervical dilatation >3cm, but slow/no rate (<1.2cm/hr in primipara, <1.5cm/hr in multipara). Causes include the 3 P’s (passenger (macrosomia), pelvis (cephalopelvic disproportion) or power insufficiency). Tx: If contractions are hypotonic (<200MVU in 2hrs), give oxytocin. If contractions are hypertonic, give morphine and consider C-section.
408. Prolonged 2nd stage >>> failure to deliver head (1hr in primi, 2hrs in multi). Causes are the same as above (3 P’s). If head is engaged, vacuum deliver. If head is not engaged, do C-section.
409. Prolonged 3rd stage >>> failure to deliver placenta within 30 minutes. Causes include placenta accreta (A for A, accreta adheres to uterine wall, MCC is placenta previa), placenta increta (In for In, increta goes into uterine wall), placenta percreta (invades uterine wall). Tx c 1st manual placental removal, 2nd curettage in the OR and 3rd hysterectomy.
410. Prolonged 4th stage: Postpartum hemorrhage: >500 in vaginal delivery, >1000 in C-section. MCC is uterine atony (tx: 1st massage uterus, 2nd pitocin, 3rd PGE, 4th methergin, 5th hysterectomy), then lacerations, retained placenta (tx c sedation, then ex-lap for b/l uterine and hypogastric artery ligation and hysterectomy), DIC, uterine inversion (from pulling).
411. Prolapsed umbilical cord >>> emergency d/t cord compression. Do not hold the cord or attempt to reinsert it into the uterus. 1st step is place pt in knee-chest position, 2nd elevatate the presenting cord (avoid palpating), 3rd emergency c-section.
412. Shoulder Dystocia >>> MCC is macrosomia (DM). 1st step is McRobert’s maneuver (maternal thigh flexion c suprapubic (not fundal) pressure). 2nd C-section.
413. Postpartum Fever >>> Day 0 is atelectasis (d/t anesthesia), Day 1-2 is UTI, Day 2-3 is Endometritis (this is what they will ask, causes include C-sections, prolonged PROM, prolonged labor. Tx c ampicillin, gentamycin, metronidazole). Day 4-5 is wound infection, Day 5-6 is pelvix abscess/septic thrombophlebitis (they will say, pt still spikes fever despite antibiotics. 1st step is CT scan, if there is an abscess drain it, if there is no abscess, pt has thrombophlebitis, tx c heparin). It is normal to have discharge (first red, then white lochia) up to 10 days postpartum. If there is a bad smell, fever or tenderness, suspect endometritis.
414. Mastitits >>> fever, unilateral breast tenderness, erythema and edema due to lactational nipple trauma. Treat c oral cloxacillin and continued breast feeding from that breast. If the same symptoms occur, but the woman was not lactating, think of cancer.
415. If woman does not want to breast feed, tell her to wear tight-fitted bras c ice-packs and analgesia. If that is not enough, give bromocriptine or estrogens.
416. In a pregnant female c antiphospholipid syndrome and recurrent abortions, tx c aspirin (otherwise, avoid aspirin in pregnancy).
417. Cholestasis c pregnancy >>> jaundice, itchiness, increase LFT’s, tx c deliver baby. Acute Fatty liver of Pregnancy is more serious because it can progress to hepatic coma. Tx AFLP c fluids, IV glucose and FFPs.
418. Amniotic Fluid Embolism - postpartum female c dyspnea, tachypnea, chest pain, hypotension and/or DIC.
GYN:
419. Cervical Dysplasia >>> firstly, note the word dysplasia (its not cancer, its precancer that has not yet invaded the basement membrane or affected lymphatics) asymptomatic or lesions on cervix. MCC is HPV 16/18 (6+11 are benign). Risk factors are early aged intercourse, smoking, multiple partners and immunosuppression. Screening c Pap smear (shows dysplasia at transformation zone). Start pap smears annually at 18yo or age of sexual activity onset for 3 consecutive years, and then every 3 years thereafter. If pt has risk factors, pap smear annually. In order: 1st Pap, 2nd colposcopy (abnormal findings include mosaicism and white epithelium; colposcopy tells you where the disease is, so if a pt comes to you with a lesion on her cervix, you can skip pap smear and skip this phase because you already know where the lesion is and go right to stage 3), 3rd Ectocervical biopsy and Endocervical curettage (ECC should not be done on pregnant pts), 4th Cone biopsy and treat with cryotherapy (mild CIN) or LEEP (loo
p electrodiathermy excision procedure for moderate CIN). Remember, its not cancer, do not choose chemo, surgery or radiation for dysplasia.
420. ASCUS >>> Pap smear may show atypical squamous cells of undetermined significance, which is basically the step right before HPV (so you would not yet find koilocytosis). The next step would be HPV/DNA testing. If the smear returns c HPV 6 or 11, proceed with colposcopy and biopsy/ECC. If the smear returns (-) HPV 11/16, then just repeat pap smear in 1 year.
421. Invasive Cervical cancer >>> now it has penetrated the BM. Look for postcoital vaginal bleeding. Dx c cervical biopsy 1st (don’t pick pap or colposcopy). Only a pelvic exam and IVP can be used to stage cervical cancer. Tx: Stage Ia1 (<3mm invasion) do TAH (total abdominal hysterectomy). Stage Ia2 (3-5mm invasion) do modified radical hysterectomy. Stage Ib (>5mm) or IIa (upper 2/3 vagina) do radical hysterectomy, para-aortic lymphadenectomy and radiation. All patients with cervical cancer should be followed-up c pap smears every 3months for 2 years after tx, then every 6 months thereafter. MC site of metastasis is liver. MCCOD is uremia d/t ureteral obstruction.
422. Cervical cancer in pregnancy >>> colposcopy and biopsy, but no ECC. If CIN (no invasion), pap every 3mo then repeat colposcopy and pap 2 months postpartum. If microinvasion (3-5mm), do cone biopsy (r/o frank invasion) and if (+), tx c LEEP and cryotherapy 2 months later. If invasive cancer, 1st punch biopsy, 2nd if <24wk give radiation c radical hysterectomy; if >24wks do C/S at 37wks then hysterectomy.
423. Uterine/Endometrial Cancer >>> postmenopausal bleeding. Dx c endometrial biopsy. If it comes back negative, pt is assumed to have bled from atrophy and is treated c HRT (estrogen AND progesterone, not estrogen alone). If it shows cancer, do TAH/SBO. If prognosis is poor (nodes affected, metastasis past the cervix into the uterus and beyond) give radiation and chemotherapy as well.
424. Leiomyoma uterine >>> submucosal fibroids cause menometorrhagia, pain, infertility, visceral obstruction (causing urinary retention and constipation). Treat c leuprolide (GnRH anolog therapy), then myomectomy (if pt wants fertility) or hysterectomy (if pt is anemic or does not want to be fertile anymore). Leiomyomas are assymetrical and bumpy.
425. Adenomyosis >>> endometrial glands and stroma located in the myometrium. Enlarged, symmetrical, tender uterus in the absence of pregnancy. Only definitive dx is histological sampling confirmation. Tx c hysterectomy.
426. Ovarian Cancer >>> look for adnexal mass, abdm pain and ascites in a postmenopausal woman. Prevent c OCPs. Screen c bimanual pelvic exams. Dx (generally hard to dx) c U/S first, then CA-125. In kids, suspect germ cell tumors (teratoma, choriocarcinoma), in adults suspect epithelial tumor (mucinous, serious, clear cell). Tx c debulking (TAH, BSO, omentectomy) and chemotherapy (carboplatin and taxol).
427. Vulvar cancer >>> vulvar itching in a 65yo. Dx c biopsy. Tx c surgery.
428. Germ Cell Tumors >>> Teratoma/Dermatoid cyst (skin, hair, teeth and pelvic calcifications on X-ray), Sertoli-leydi cell tumor (high testosterone causing virilization), Granulose-theca cell tumor (high estrogen causing feminization and precocious puberty), Meig’s syndrome (ovarian fibroma, asicets and R hydrothorax), Krukenberg tumor (stomach cancer c metastasis to ovaries).
429. Gestational Trophoblastic Neoplasia >>> s/s: very high hCG, large uterus, pregnancy c bleed, no fetal heart tones, high BP in 1st TM, hyperemesis, hyperthyroidism (must to TSH in a pt c GTN), snowstorm u/s. Can be benign (mole) or malignant (choriocarcinoma). Complete mole is an empty egg fertilized c single X-sperm (46XX so sperm duplicated), no fetus, uterus filled c grape-like vesicles (same description as sarcoma botyroides in young girls). Incomplete mole is a normal egg c 2 sperm (causing 69XXX), + fetus/cord, but fetus dies. For either mole, treatment is D&C, f/u hCG, start OCPs. If choriocarcinoma, 1st step is CT head/chest/abdo/pelvis to r/o METS. If poor prognosis (hCG >40,000, brain/liver mets, >6 months of D&C) do radiation and chemotherapy (MAC: MTX, Adenomycin, Cytotoxin). If good prognosis, give MTX only and f/u hCG every week for 3months while on OCPs.
430. Uterine prolapse >>> loss of uterine support due to cardinal ligament dysfunction. MCC is childbirth. Best tx is vaginal hysterectomy c ant/post repair (yes, first!), but if pt refuses surgery, do Kegel exercises, estrogen HRT and pessaries.
431. Stress Incontinence >>> weak pelvic floor causes you to urinate whenever you sneeze/cough, none at night. Dx c Q-tip test. Tx c Kegel exercises, then surgery (Marshall-Marcheli-Kranz procedure).
432. Urge Incontinence >>> involuntary detrusor contractions causing spurts of urine to fall at any time. Dx c cystometric studies. Tx c anticholinergics (Ditropan)
433. Overflow Incontinence >>> denervated bladder (DM, MS, CVA) causes bladder to keep filling up, thus high residual volume even after urination. Tx c cholinergics (bethanecol).
434. Endometriosis >>> dymenorrhea, dyspareunia, infertility, uterosacral ligament nodularityin the cul-de-sac, chocolate cysts. Dx c laparoscopy. Tx: 1st OCP, 2nd Danazol and Leuprolide (best tx, but not 1st because of side-effects), 3rd surgical resection, 4th pregnancy (however hard, d/t infertility), 5th TAH/SBO. If endometriosis is present, and pt has no s/s, do nothing.
435. Chancroid >>> painful chancre (H. ducreyi >>> you cry c ducreyi) c ragged, rolled edges. Tx c Azithromycin
436. LGV >>> painless ulcer that heals and then forms painful nodes. Tx c erythromycin.
437. Granuloma inguinale >>> painless, beefy-red ulcer. Dx c Donovan-bodies on smear. Tx c Azithromycin.
438. Chlamydia >>> MC bacterial STD, can be asymptomatic or mild mucopurulent cervical discharge c or w/o cervical motion tenderness (CMT), (+) Cx/Ab test, (-) stain. Tx c azithromycin (1 dose) or oral doxycycline (7 days).
439. Gonorrhea >>> Lower GU causes d/c, itching, burning, dysuria; Upper GU causes abdo/pelvic pain. Disseminated when there is dermatitis, polyarthritis or tenosynovitis. Pt has vulvovaginitis c mucopurulent d/c c CMT on bimanual exam. Dx c chocolate agar, Gram (-) diplococci on stain. Tx (for GC and Chlamydia) Ceftriaxone + Doxycycline.
440. PID >>> lower abdominal pain, adnexal tenderness, CMT and fever 1 week after menses in a sexually active female. Cervicitis (only vaginal D/C, no pain >>> tx G/C), Salpingo-oophoritis (b/l lower abdo/pelvic pain c CVA tenderness >>> tx G/C), Tubo-ovarian abscess (pt will look septic, severe pain, n/v, dyschezia, fever >>> tx c Ampicillin, Gentamycin and Flagyl. If ruptured, ex-lap is done). Tx for G/C in these cases are: outpatient: ceftriaxone + doxycycline, inpatient: clindamycin + gentamycin
441. Gardnerella Vaginosis >>> fishy odor on whiff test, pH 6, clue cells, tx c metronidazole (clindamycin if pregnant in 1st TM)
442. Trichomonas vaginalis >>> frothy, green smelly discharge c strawberry cervix, pH 5. Tx c metronidazole for pt and partner (if pt pregnant, tx c vaginal betadine).
443. Candida yeast infection >>> itchy, burning, dyspareunia, cottage-cheese discharge, that sticks to the vaginal wall, pseudohyphae, pH 4, tx c nystatin or Amp B.
444. Contraception: remember effects of estrogen (increases BP, cholelithiasis, LFTs, HDL, art/venous thrombosis and decreases LDL) and progesterone (affects mood, increase weight, acne, increase LDL, decrease HDL). Absolute CI: pregnancy (causes VACTERL), liver dz, vascular dz (DVT, SLE, CVA) and hormonally-dependent cancers like breast). Benefits include decreased risk of ovarian/endometrial cancer, decreased dysmenorrhea/DUB/PID/ectopics.
445. IUD >>> put it in 1 week after menses and f/u in 1 week. Does not affect risk of STDs. Absolute contraindications include pregnancy, pelvic cancer, salpingitis, steroid use (pt on Crohns, asthma), h/o PID. Increased risk of ectopics and PID when placed.
446. Abnormal vaginal bleeding: Pre-menarchal (<12yo - foreign body, trauma, sarcoma botyroides, precocious puberty), reproductive (13-52yo - pregnancy, fibroids/adenomyosis, DUB), postmenopausal (>52yo - endometrial cancer). A neonate c vaginal bleeding is normal due to maternal estrogen, thus reassure mom.
447. Precocious Puberty >>> normally: breast development @ 9yo, pubic/axillary hair @ 10yo, growth @ 11yo, menarche @ 12yo. If only 1 stage occurs early, this is Incomplete isosexual precocious puberty, next step is CT brain/abdo/pelvis. If all stages occur early, this is complete isosexual precocious puberty, next step is tx c constant GnRH stimulation (to decrease estrogen). If pt has bone lesions and café-au-lait spots, pt has McCune-Albright Syndrome. If pt has high estrogen c a pelvic mass, they have a granulose-theca cell tumor, tx c surgery.
448. Dysfunctional Uterine Bleeding >>> MCC is anovulation d/t unopposed estrogen, so no secretory phase (d/t lack of progesterone) c unstable endometrial thickening. Pt will have h/o irregular, unpredictable menstrual bleeding without cramps. Next step is endometrial biopsy to r/o cancer. Tx c NSAIDS if she desires children, cyclic progestin therapy or daily combined OCPs if she doesn’t desire children or has menorrhagia.
449. Primary Amenorrhea >>> 1st step is pregnancy test (whether she says she is sexually active or doesn’t), 2nd step is physical exam: (+) breasts and (+) uterus -> check prolactin, if normal r/o imporferate hymen (cyclic menstrul pain c bulging hymen, predisposition to endometriosis, tx c surgery) and tx c progesterone. (+) breasts and (-) uterus -> get karyotype, if 46 XY, pt has Androgen Insensitivity Syndrome (Testicular Feminization, no pubic hair, next step is remove testes from abdm), if 46XX, pt has Rokitanky-Hausen syndrome (she will have pubic hair). (-) breast and (+) uterus -> gonadal dysgenisis, so next step is get karyotype to r/o Turners syndrome (45XO, webbed neck, far spaced nipples, streak ovaries, premature ovarian failure, needs estrogen).
450. Secondary Amenorrhea >>> 1st step is r/o pregnancy, 2nd r/o prolactinoma (if prolactin level is high, next step is MRI of head. If abnormal, pt has pituitary tumor, if normal, pt has drug-induced prolactinoma) and hypothyroidism, 3rd progesterone challenge test. If pt bleeds after 2 weeks (estrogen is adequate), check LH. If elevated pt has PCOS, if normal/low check TSH/prolactin again. If pt does not bleed after 2 weeks (inadequate estrogen) check FSH, if high pt has premature ovarian failure (next step is karyotype to r/o Turners vs Ovarian failure due to congenital adrenal hyperplasia), if normal/low pt has craniopharyngioma, next step is MRI. If MRI is insufficient, pt has Ahsermann’s syndrome (scarring due to prior D&C/D&E. Tx by surgically removing scarred tissue then giving high-dose estrogen for 1 month to regenerate lining). Again, if LH/FSH are high, next step is karyotype. If XO, pt has turners, if XX pt has ovarian failure (now r/o autoimmune dz versus CAH). If LH/FSH are normal or low,
next step is MRI of head. If abnormal pt has pituitary tumor/destruction or hypothalamic dz (may be a/w Kallman’s syndrome (anosmia, amenorrhea), anorexia, exercise, tx c estrogen). If normal, pt has Asherman’s syndrome.
451. Breast mass in a female <35yo >>> Fibrocystic Dz (b/l, tender esp with menses, multiple, tx c reassurance and f/u later), Fibroadenoma (painless, rubbery, mobile, tx c observe but try not to stare too long), Mastitis/Abscess (lactating, painful, red, tx c clocacillin, if still there, I&D), Fat Necrosis (h/o trauma, tx c observation). Avoid mammogram in women <35yo (tissue too dense) and if suspicious of cancer go right to biopsy.
452. Breast mass in a female >35yo >>> Fibrocystic Dz (same as above, but this time you must aspirate it and do a mammogram. If mass resolves, observe. If FNA shows blood or if cyst recurs quickly, do biopsy), Fibroadenoma (mobile, get mammogram. If pt is low risk, observe, if high risk get biopsy). If pt is postmenopausal and has a mass, go right to biopsy.
453. If bloody discharge from the nipple -> intraductal papilloma. Next step is galactogram-guided excision.
454. Polycystic Ovarian Synd >>> female, hirsutism, amenorrhea, infertility (MCC of infertility in women <30yo c abnormal menses, while PID is MCC if normal menses) and insulin resistance (DM). Next step is U/S to show multiple cysts, then LH and FSH (ration should be 2:1), then testosterone and DHEA levels. Unopposed estrogen will increase risk of endometrial cancer. Tx c OCP’s, cyclic progestins, Metformin, Spironolactone and clomiphene if she wants kids.
455. Congenital Adrenal Hyerplasia >>> overproduction of adrogens causing virlization and amenorrhea. Young girls get clitoromegaly. 90% is 21-OH deficiency (salt-wasting, high K, low BP, high urinary 12-hydroxyprogesterone). Tx c steroids + IVF (to prevent death). Must do karyotype to figure out gender.
456. Review of hirsutism (excessive sexual hair) versus virilization (excess androgen, thus acne, balding, deep voice, clitoromegaly, amenorrhea): Hirsutism c high testosterone, normal DHEAS, CT shows enlarged ovaries is PCOS. Virilization c normal testosterone, high DHEAS, CT shows enlarged adrenals is Adrenal Tumor (CAH, tx c DXM suppression). Virilization c high testosterone, normal DHEAS, CT shows enlarged ovaries is ovarian tumor (tx c OCPs, GnRH analogs and surgery). Hirsutism c normal testosterone, normal DHEA, normal CT is familial hirsutism (a/w 5-alpha reductase defiency, tx c spironolactone, flutamide).
457. Menopause >>> high LH/FSH, low estrogen/progesterone. Hot flashes, osteoporosis, atrophic vaginitis, abnormal lipi profile, atherosclerosis/CAD. Tx c HRT for <5years and then calcium, exercise, and lubricants for sexual activity. HRT increases risk of CAD, invasive breast cancer, memory loss, stroke, PE. Decreased osteoporosis and colon cancer. Contraindicated in breast and endometrial cancer (must do endometrial biopsy before giving it), acute liver dz, active thrombosis, vaginal bleeding. If contraindicated, give SERMS (Tamoxifen, Raloxifen, which still increase risk of endometrial cancer).
458. Infertility: 1st step is semen analysis (tx c sperm injection), 2nd step is ovulation analysis (basal body temperature, endometrial biopsy, serum estrogen level to r/o anovulation. Tx c clomiphene), 3rd step is Hyterosalpingogram for tubal blockage, 4th step is laparoscopy.
CONGENITAL ANOMALIES/PERINATAL MEDICINE:
459. Down’s Synd >>> trisomy 21, 1/700 births (1/350 if >35yo), MR, endocardial cushing defect/ASD/VSD, duodenal atresia, simian crease, Alzheimers @ 40yo, epicanthal folds. Prenatal dx: high hCG, low AFP, low estriol, increased maternal age, amniocentesis, u/s shows thickened nuchal folds, CVS @ 9-12wk. Neonatal: 1st step is echo, then genetic counseling.
460. Edwards Synd >>> trisomy 18, IUGR, rocker-bottom feet, clenched hands, PDA/VSD
461. Patau’s Synd >>> trisomy 13 (P for P: cleft liP, cleft Palate), holoprosencephaly, renal and ocular malformations.
462. Cri du Chat Synd >>> Chrom 5p deletion, cat-like cry, MR so tx c special schooling
463. Turners Synd >>> Gonadal dysgenesis 45XO, 1/2000 newborn girls, short webbed neck, horseshoe kidney, coarctation of aorta, primary amenorrhea. Estrogen replacement
464. Klinefelters Synd >>> seminiferous tubule dysgenesis 47XXY, hypogonadism, gynecomastia, tall stature, infertility, give testosterone replacement starting at 12yo.
465. Fragile X Synd >>> macro-orchidism, MR
466. Achondroplasia >>> AD, short limbs, hydrocephalus (must monitor closely)
467. Xeroderma Pigmentosa >>> sunlight sensitivity from 1st exposure, conjunctitis leading to blindness, dx c skin biopsy and tx c strict sun avoidance (they will say kid only comes out at night).
468. Fetal Alcohol Synd >>> MR, flat philtrum, thin upper lip, worst in 1st TM
469. Tobacco in pregnancy >>> IUGR
470. Cocaine in pregnancy >>> CNS damage, placental abruption
471. Fetal Warfarin synd >>> epiphyseal stippling, CNS malformations, MR
472. Thalidomide >>> phocomelia (absence of long bones in extremities)
473. Syphilis >>> treponema pallidum, snuffles, palm/sole rash, anemia, hepatosplenomegaly, periostitis, Hutchinson’s teeth, sabir shings, saddle nose, tx c penicillin
474. Toxoplasmosis >>> oocytes from cat litter and meat, hydrocephalus, chorioretinitis, scattered CNS calcifications, tx: 1st avoidance, 2nd pyrimethamine, 3rd shunt for hydrocephalus
475. Rubella >>> blueberry muffin rash, PDA, deafness, cataracts
476. CMV >>> deafness, perventricular CNS calcifications, microcephaly
477. Herpes >>> aquired at birth (prevent c C-sxn), seizures (temporal lobe), encephalitis, vesicles, overwhelming sepsis, hepatitis, tx c acyclovir
478. HIV >>> all meds (except efavirenz) if CD <500, AZT only if CD>500 in 2nd/3rd TM and 6 weeks postpartum. Dx in kid c PCR (not ELISA).
479. Hypospadias >>> pee on your feet (ventral urethral opening), hooded prepuce, chordee (ventral curving of penis), tx c 1st avoid circumcision to save foreskin for reconstruction, 2nd surgery at 1yo
480. Omphalocele/Gastrocele >>> absence of anterior wall (gastrocele has no sac, omphalocele does). Tx: 1st cover c plastic wrap, 2nd surgery within 24 hours.
481. Posterior urethral valves >>> cause of UTI in young boys, a/w potters synd, dx c VCUG
482. Undescended testicle >>> cryptorchidism, rarely descent after 1yo, must differentiate from retractable testis, tx: if testes is palpable >>> wait for descent and do orchieplexy after 1 year. If testes are not palpable >>> consider hCG trial if b/l. 2nd >>> Orchiectomy for atrophied testis due to risk of malignancy and infertility for other testis.
483. Congenital Adrenal Hyperplasia >>> adrenogenital syndrome, no steroidogenisis due to 21-OH deficiency, ambiguous genitalia, clitoromegaly, salt-wasting, hyperkalemia. Tx: 1st fluids for low BP, 2nd treat hyperkalemia (calcium, alkalinization, insulin/glucose, kayexalate).
484. Choanal atresia >>> respiratory distress/cyanosis relieved by crying, a/w CHARGE synd (Colobama of eye, Heart defect, Atresia of choanae, Retardation, Genital hypoplsia, Ear anomalies). Tx c respiratory support.
485. Laryngomalacia >>> flexible larynx collapses causing obstruction on inspiration. Dx c fluoroscopy or direct laryngoscopy. Airway support if needed, otherwise self-limited.
486. Diaphragmatic Hernia >>> either at foramen of Bochdalek (left sided (b/c R side has liver), severe newborn respiratory distress, scaphoid abdm, mediastinal shift, pulmonary hypoplasia) or at foramen of Morgagni (presents later c bowel obstruction). Tx c 1st aggressive rescucitation, 2nd extracorporeal membrane oxygenation (ECMO), 3rd surgery.
487. Tetralogy of Fallot >>> PROVe (pulm HTN due to RV outflow obstruction, RVH, Overriding aorta, VSD), MC cyanotic CHD, presents >1yo, tet spells, boot-shaped heart
488. Transposition of great vessels >>> cyanosis in 1st 24hrs, aorta from RV, pulm artery from LV, egg on a string heart, tx c balloon atrial septostomy, then arterial switch
489. Total anomalous pulm venous return >>> pulmonary veins drain into systemic venous circulation (partial or total), snowman heart. 1st medications, 2nd surgery
490. Truncus arteriosis >>> single great artery is origin of aorta and pulm arter and coronary artery, listen for truncal valve click. Tx: 1st treat CHF, 2nd surgery
491. VSD >>> MC CHD, holosystolic murmur at 1-2months, tx c subacute bacterial endocarditis prophylaxis
492. ASD >>> pulmonary ejection murmur plus wide, fixed split S2, no SBE prophylaxis, usually presents after infancy
493. Coarctation of aorta >>> HTN in UE, low BP in LE, poor femoral pusles, Turners synd, rib notching on CXR, tx c balloon angioplasty
494. PDA >>> premature babies, congenital rubella, continuous machinery murmur c wide pulse pressure.
495. Hypoplastic left heart >>> underdeveloped LV and aorta, vascular collapse in 1st week of life, ductus dependent, tx: 1st prostaglandin E, 2nd Norwood or transplant
496. Hydrocephalus >>> communicating (obstruction of arachnoid villi) or noncommunicating (Aqueduct of Sylvius stenosis, Chiari malformation at cerebellar tonsils or Dandy-walker cyst of 4th ventricle). Baby c rapid increase in head circumference, split sutures, bulging anterior fontanelle, setting-sun sign (of eyes), 6th nerve palse, papilledema, dx c CT scan (do not do LP in risk of herniation). Tx: 1st hyperventilate and elevate head, 2nd mannitol, 3rd ventriculoperitoneal shunt
497. Congenital cataracts >>> rubella, CMV, toxo, galactosemia, tx c surgery right away to prevent permanent visual impairment.
498. Congenital glaucoma >>> tearing, corneal clouding, photophobia, sturge-weber synd (facial port-wine stain, seizures, CNS calcifications), neurofibromatosis, rubella, tx c surgery.
499. Congenital deafness >>> Alports (nephritis c deafness), CMV, rubella, maternal drugs.
500. Osteogenesis Imperfecta >>> brittle bones cause multiple fractures in a kid, blue sclera, osteoporosis, family history, type I collagen disorder, teeth deformities.
501. Developmental Dysplasia of the Hip >>> subloaxation of femoral head from the acetabulum, causing asymmetric thigh creases, clicking sound, + Ortolani sign (hip reducibility), + Barlow sign (hip dislocatability), dx c ultrasound. Tx c harness, then closed reduction, then open reduction (>6mo age) if closed reduction failed.
502. Talipus Equinovarus >>> toes face medially, forefoot adduction. Tx c manipulative casting, then surgery if needed.
503. Transesophageal Fistula >>> dx c failure to pass nasal catheter to stomach, AXR shows air-distended proximal esophagus. Tx: 1st NGT, 2nd surgery
504. Duodenal atresia >>> bilious projectile emesis, a/w Downs syndrome, abdominal distention, double bubble on AXR (air-distended stomach and proximal duodenum). Tx: 1st correct fluids/electrolytes, 2nd surgery
505. Pyloric stenosis >>> nonbilious projectile emesis, olive-shaped RUQ mass, dehydration c hypochloremic alkalosis. Tx:1st fluid/electrolyte correction, 2nd pyloromyotomy
506. Meckel’s Diverticulum >>> 2yo c painless rectal bleeding and abdm pain. Dx c technetium-labeled nuclear scan (Meckel’s scan), tx: 1st correct life-threatening anemia, 2nd surgical excision.
507. Hirschsprung’s Disease >>> congenital megacolon causing obstruction, absense of Auerbach’s and Messner’s plexus, failure to pass meconium in 1st week, dx c 1st barium enema (shows transitional zone) rectal biopsy (aganglionosis). Tx: 1st fluid/electrolyte correction, 2nd Abx if enterocolitis suspected, 3rd surgical excision of ganglionic segment.
508. Hyaline membrane Disease >>> RSD, surfactant insufficiency, early onset (hours after birth) baby has tachypnea, grunting, nasal flaring and retractions. Early problems include breathing difficulty, metabolic disturbances and infection. Late problems include broncopulmonary dysplasia. Risk factors include prematurity, maternal DM and multiple pregnancies. Dx: 1st CXR (shows fine reticular granularity in b/l lungs), 2nd L:S ratio (should be >2:1) and phosphatridylglycerol. Tx: Prevention is the best tx (prevent prematurity, give maternal steroids 48-72 hours antepartum if <33 weeks to women who do not have toxemia, DM or renal disease), 2nd >>> correction of hypoxia, acidosis, hypercapnea, hypotension, hypothermia and anemia. 3rd neonatal surfactant (via ETT) at delivery but avoid uneccessary pulmonary barotraumas or oxygen toxicity.
509. Chlamydia >>> conjunctivitis 4-7 days after birth, staccato cough, tx c erythromycin.
510. Gonorrhea >>> conjunctivitis 3-5 days after birth, disseminated infxn, chocolate agar, Thayer-martin media, tx c parenteral abx.
511. GBS >>> early onset (<3days old) has resp distress, pneumonia, meningitis; late onset (7days-3mo) has meningitis, osteomyelitis, septic arthritis and occult bacteremia. Prevent c culture at 35-37wk and penicillin at birth. Neonates given abx if febrile.
PSYCHIATRY
512. If you see a question about the best next test and one of the answers is “mini-mental exam,” pick that one.
513. Autism >>> starts by 3yo. Impaired social interactions (unaware of surroundings), impaired verbal/nonverbal communication (if verbal is okay, dx is Asperger’s syndrome), and restrictive activities and interest (head banging, strange movements). Linked to congenital rubella. Tx c 1st structured classroom training, behavioral modifications, family support, 2nd halorperidol, risperidone, SSRI’s. If child has normal development and then deteriorates into this condition or worse, that is Rett’s syndrome.
514. Learning disorder >>> impairment in reading (80%), math, language, written expression with no mental retardation or lifestyle anomalies. Tx c educational intervention.
515. ADHD >>> dx <7yo. Boy is hyperactive, impulsive and has a short memory span, but is not cruel. Tx: 1st individual/family therapy and behavioral modifications, 2nd methylphenidate (Ritalin) or dextroamphetamine, both of which may cause insomnia, abdm pain, HA, anorexia, exacerbations of tics, weight loss or growth suppression. Tx c 1st atimoxitine (but must be given everyday, so if mom says kid only has s/s Monday thru Friday, then you cannot give this, give tx #2), 2nd Methylphenidate or amphetamine.
516. Conduct Disorder >>> violates society norms, pediatric form of antisocial disorder. Look for fire setting (if only this, dx is pyromania), cruelty to animals, lying, stealing, fighting. Must have this disorder in order to make diagnosis of antisocial d/o as adult. Tx: 1st evaluate suicide/violence potential, 2nd containment by parents, schools, legal system or hospital, 3rd tx aggression c SSRI or haloperidol, 4th individual/group/ family therapy.
517. Oppositional Defiant Disorder >>> negative, hostile and defiant behavior towards authority figure. Note the different between this and conduct d/o is that here, the kid is just bad to adults behaves with peers and is not a cruel, lying criminal. Tx c individual/family therapy
518. Separation anxiety Disorder >>> look for a kid who refuses to go to school or sleep alone or away from home by claiming sickness, stomachache, HA or temper tantrums. Must be >6months old (might ask about 8mo baby who cries when he sees grandma for 1st time = separation anxiety, but if kid was under 6mo, its normal) School refusal is a psychiatric emergency and needs prompt evaluation and treatment involving parents, school and peers.
519. Tourette’s Disorder >>> (only 10-30% curse), look for males c motor tics (blinking, grunting, throat clearing, grimacing, barking, shrugging) that are exacerbated by stress and remit c activity or sleep. Linked to ADHD and OCD. Tx: 1st Haloperidol (improves 80% but watch for EPS, mental dulling and tardive dyskinesia). 2nd Pimozide or Clonidine
520. Encopresis >>> >4yo c passage of feces into inappropriate places (clothing, floor). r/o Hirschsprungs disease. Tx c behavioral techniques, individual therapy.
521. Enuresis - >5yo c inappropriate voiding of urine. Tx: 1st behavioral techniques (bell, buzzer, bed time fluid restriction), 2nd Imipramine (last resort).
522. Dementia vs Delerium: Delerium (rapid onset, fluctuating consciousness, often reversible, perceptual disturbances, incoherent speech). Dementia (insidious onset, clear consciousness (until late in course), irreversible).
523. Alzheimer’s vs Vascular (Multi-Infarct) Dementia: Alzheimers dementia (women, older, chrom 21, linear/progressive, no focal defecits (key), supportive tx). Vascular dementia (men, younger than alzheimers, HTN, stepwise/patchy pattern, (+) focal deficits (key), tx underlying condition).
524. Alcohol >>> intoxication includes slurred speech, ataxia, disinhibition, impaired judgement, coma and blackouts. Withdrawal includes tremor, agitation, irritability, n/v, fever, seizures, delirium tremens (onset of delirium, vivid auditory/tactile/visual hallucinations, paranoid delusions 2-3 days post cessation of long-term heavy use). Tx intoxication supportively. Tx withdrawal c vital sign/electrolytes/Mg/thiamine/vit B12/folate/glucose monitoring. 2nd Hydration c thiamine before glucose (prevent Wernicke), 3rd benzodiazepine (chlordiazepoxide). Tx dependence c confrontation of denial and rehab (AA). Specific managements: Alcohol hallucinations (chlordiazepoxide, IVF, haloperidol), Wernicke’s encephalopathy (sudden ataxia, confusion, nystagmus, lateral rectus palsy from thiamine deficiency. Tx c thiamine) Korsakoff’s syndrome (severe anterograde/retrograde amnesia, confabulations and polyneuritis from thiamine defiency).
525. Opioids >>> intoxication includes euphoria, analgesia, hypoactivity, anorexia, drowsiness, n/v, constipation, pin-point pupils, hypotension and bradycardia. Overdose includes CNS/respiratory depression, pinpoint pupils, pulm edema, seizure, coma and death. Withdrawal includes (not deadly) rhinorrhea, yawning, diarrhea, sweating, dilated pupils, tachycardia and HTN. Tx overdose c naloxone. Tx dependence c abstinence through methadoes titration.
526. Stimulants >>> amphetamines/cocaine, rapid dependence of tolerance, IVDA risks, paranoid psychosis. Intoxication includes euphoria, alertness, increased energy, anxiety, talkativeness, mydriasis, tactile hallucinations (crawling bugs), HTN and tachycardia. Withdrawal includes (non-deadly) fatigue, hypersomnia, anxiety, dysphoria, suicidal ideation, craving. Tx intoxication symptomatically (antiarrhythmic, benzo for agitation, haloperidol). Tx withdrawal supportively (observe for suicidality). Tx dependence c rehab.
527. Sedatives >>> benzo/barbs >>> intoxication causes slurred speech, drowsiness, impaired attention, disinhibition. (Flumetrazepam is the date-rape drug). Overdose c barbs for suicide, (not so much benzo b/c of high therapeutic index, unless taken with another drug or alcohol). Both cause resp depression, coma, death. Withdrawal causes anxiety and insomnia. Severe withdrawal is a medical emergency (n/v, autonomic hyperactivity, photophobia, tremor, hyperthermia, delerium, seizures, death) most severe c short-acting drugs. Overdose benzo c flumazenil (does not reverse resp depression), barbs c charcoal, gastric lavage. Tx barbiturate withdrawal c pentobarbital challenge test to get daily dose, and taper off. Tx benzo withdrawal c long-acting benzo (diazepam, clonazepam) and gradually withdraw.
528. Nicotine >>> acetylcholine (nicotinic) agonist. Withdrawal causes irritability, wt gain, and difficulty c concentration. Tx: 1st obtain specific date to stop, 2nd educate/counsel.
529. PCP >>> paranoia, assaultiveness, impulsiveness, vertical and/or horizontal nystagmus (dead give-away), diaphoresis, resp depression, seizures, normal size pupils. Tx symptomatically
530. Hallucinogens >>> LSD, Ecstacy >>> sympathomimetic effects (mydriasis, tachycardia, sweating, diarrhea, urination), panic reactions, illusions, paranoia. Later on, pt may not be using drug anymore and reexperience intoxication (flashback).
531. Cannabinoids >>> Marijuana/THC >>> intoxication has euphoria, bad judgement, slowed reactions, dry mouth, conjunctival injection (dead give-away). Chronic use causes amotivational syndrome and memory impairment.
532. Hallucination is a disturbed sensory perception (visual, tactile, auditory). Delusion is a fixed, false belief (even if people prove to you otherwise). Psychosis is inability to judge boundary between real and unreal.
533. Schizophrenia >>> presence of >2 s/s of the following for >6months: delusions, hallucinations (generally auditory, link visual c alcohol withdrawal), disorganized speech/behavior, negative s/s (flat affect, no speech, no motivation, anhedonia). Better prognosis (NBME 3 question) if acute, late onset, good social/occupation hx, positive s/s, medication compliance, married, female gender. Symptoms due to altered dopamine activity (newer antipsychotics affect serotonin also). Negative s/s have enlargement of cerebral ventricles and hypoactive frontal lobe. Tx: 1st assess if pt needs hospitalization (protect self/others), 2nd Antipsychotics (Risperidone), 3rd Psychosocial tx. [Timeline: <1month = brieft psychotic d/o, 1-6months = schizophreniform, >6mo = schizophrenia]
534. Delusional (Paranoid) Disorder >>> persistent, nonbizarre, well-systematized delusion. Erotomanic (on is loved by a famous other, NBME 3 TQ), grandiose (one possesses great talent), jealous (conviction that lover is unfaithful), persecutory (one is conspired against, MC), somatic (one has a physical abnormality like odor). Tx: 1st hospitalization for inability to control suicidal/homicidal impulses or danger a/w delusions, 2nd psychotherapy, 3rd antipsychotics/antidepressants.
535. Schizophreniform >>> schizophrenia <6months. Good prognosis c acute onset, confusion, disorientation, full affect, tx c antipsychotics for at least 6 months.
536. Brief Psychotic Disorder >>> sudden onset of psychotic s/s c emotional turmoil and confusion, often following obvious stressor, duration <1month. Suicide risk, thus tx 1st hospitilization as needed, 2nd antipsychotics/antianxiety agent, 3rd psychotherapy
537. Schizoaffective >>> schizophrenia c depression or mania for at least 2 weeks.
538. Shared Psychotic disorder >>> submissive, dependent isolated relationship with person c established delusion. Suicide/homicide pacts. Tx: 1st separate the 2 people, 2nd antipsychotics.
539. Mania >>> >1wk of elevated, expansive, irritable mood c grandiosity, no sleep, talkativeness, impulsitivity (shopping sprees, gambling, promiscuity) , racing thoughts, distractibility, agitation. Hypomania is less severe and lasts >4days.
540. Major depression disorder (MDD) >>> 2 of SIGECAPS in >2wks >>> sleep changes (delayed sleep onset, decreased REM. Note the difference: Anxiety has increased REM latency, depression and narcolepsy have decreased REM latency), interest loss, guilt, energy loss, concentration decreased, appetite (up or down), psychomotor (retardation or agitation), suicidality. Decreased serotonergic activity a/w violence and suicide. Tx: Hospitalize if suicide risk, 2nd Antidepressant (SSRI 1st) for 6-12 months (not that it takes 4-6wks to start effects), 3rd ECT (rapid response in pregnancy, elderly, medically ill), 4th psychotherapy, 5th antipscyhotic + antidepressant for psychotic pts, 5th Phototherapy if depression is seasonal, 6th treat comorbid psychopathology (anxiety, substance abuse, personality d/o, ADHD).
541. Depression vs Bereavement >>> Depression (mood pervasive/unremitting, constant low self-esteem/worthlessness, suicidal, sustained psychotic s/s, no improvement c treatment, social withdrawal). Bereavement (mood fluctuates, self-reproach regarding deceased, not suicidal, transient visual/auditory hallucinations or deceased, s/s improve c time and usually gone by 6 months, often welcomes social support). It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, while an MDD pt thinks its real. Other clues to MDD that are not normal are feeling of worthlessness, suicidality and psychomotor retardation.
542. Bipolar Disorders: Type I is full-blown mania c MDD. Type II is hypomania c MDD. Tx: 1st assess risk of suicide, assaultiveness, dangerous poor judgement. 2nd For acute mania give mood stabilizer (lithium). For depression >>> modd stabilizer c or w/o antidepressant if necessary.
543. Cyclothymia >>> numerous hypomanic episodes c depressive episodes for >2yrs. (Cyclo is a psycho, while dysthymia is just depression for >2yrs).
544. Panic Disorder >>> minutes to hours of unexpected, sudden intense anxiety, dyspnea, parasthesia, CP, fear of dying. A/w agoraphobia (fear of places where escape is difficult such as bridges, public transportation, large crowds, traveling). Tx: 1st If acute, emergent case, give reassurance and benzo (alprazolam, clonazepam). 2nd R/o MI, PE, CVA, hypoglycemia, 3rd Antidepressants (SSRI is tx of choice for long-term management), 4th Cognitive-behavioral therapy (CBT) for agoraphobia.
545. Obsessive-Compulsive Disorder >>> recurrent intrusive images, impulses, thoughts (obsessions) and ritualistic behaviors (compulsions) that produce anxiety and affect way of life. A/w Tourette syndrome. Abnormality is serotonin system. Tx c SSRIs (fluvoxamine), but if you only see TCA’s pick clomipramine.
546. Specific Phobia >>> irrational, excessive fear and avoidance of a specific object or situation. Tx: Systemic desensitization.
547. Social Phobia >>> fear of embarrassment, scrutiny of others (public speaking, eating in public, public bathrooms). Tx: 1st CBT, 2nd BB (propranolol) for stage fright, 3rd Antidepressants (not TCAs) and high-potency benzodiazepines.
548. Posttraumatic Stress Disorder >>> >1 month, must have 3: reexperiencing (flashbacks), emotional numbing (avoidance), autonomic arousal (insomnia, irritability). Tx: 1st hospitalize for acute suicide, violence risk. 2nd CBT, 3rd Antidepressants.
549. Acute Stress Disorder - <1month of the same 3 symptoms. Tx c psychotherapy.
550. Generalized Anxiety Disorder >>> unrealistic, persistent anxiety for >6months. Muscle tension, restlessness, poor concentration, fatiguability, irritability, loss of sleep. Tx: 1st psychotherapy, 2nd Antidepressants (Buspirone).
551. Somatorofrm Disorders >>> unlike factitious disorder and malingering, the symptoms are not intentionally produced but are strongly linked to psychological factors. Examples include somatization disorder (multiple somatic complaints, tx c regularly scheduled visits c PMD), conversion disorder (neurologic s/s), pain disorder (pain in absence of adequate physical findings, tx c psychotherapy), hypochondriasis (fear of specific disease, tx c regular medical visits), and body dysmorphic disorder (preoccupation c defect in appearance, tx c psychotherapy and SSRI’s after you assess suicide risk).
552. Factitious disorder >>> “Munchausen syndrome.” Intentional production of s/s for unconscious psychological reasons (need to assume sick role) usually in someone in medical occuption or c history of illness. If s/s produced by parent, this is Munchausen’s by proxy. Tx c psychiatric consult, confrontation may be helful.
553. Malingering >>> intentional production of symptoms for a recognized gain (money, drugs, avoid work/military/prison).
554. Dissociative Identity disorder >>> multiple personalities, which take over life and pt may or may not be aware of each other. Tx c intensive psychotherapy.
555. Amnestic Disorder >>> 2 types: psychogenic fugue (sudden, unexpected travel c amnesia of old identity and assumption of new identity that lasts hours to months, pt is unaware of loss) and psychogenic amnesia (sudden inability to recall important personal information of a traumatic or stressful event, but aware of loss). Recovery usually returns spontaneously. If not, try hynosis, amobarbital or psychotherapy.
556. Depersonalization disorder >>> recurrent feeling of detachment from one’s body or self (feel like you’re in an outside world).
557. Anorexia Nervosa >>> must have 3: amenorrhea, minimal normal body weight, fear of gaining weight. Tx: 1st hospitalize for dehydration, starvation, hypotension, electrolyte, hypothermia, suicide risk. 2nd treatment contract for wt gain, 3rd CBT.
558. Bulimia Nervosa >>> binge eating, normal weight, overconcerned c wt/diet/exercise, self-induced vomiting, laxatives/diuretics, a/w kleptomania. Tx: 1st hospitalize for ECG (hypokalemia-induced arrhythmia is MCCOD), electrolytes, amylase, LFTs, esophageal/gastric rupture, suicide risk. 2nd psychotherapy, nutritional counseling, SSRI for binging (do not give buproprion for risk of seizures).
559. Old, classic USMLE TQ: Mom finds her son having sex c another boy, is this normal or homosexuality? Normal (unless they say he enjoys it). Another TQ is a man, who knows he is a man and likes women, dresses up like a woman and acts like a woman, what is his sexual orientation? Heterosexual (b/c he likes women).
560. Projection >>> attributing your own wishes to someone else. A/w paranoid personality d/o (p for p >>> paranoia c projection)
561. Denial >>> if they deny having a disease, next step is do nothing! (because it usually does not interfere c treatment, but if it does, next step is confront the pt).
562. Splitting >>> all is good or bad. a/w borderline d/o. If they only say all is good, its idealization. If they only say all is bad, its devaluation. Splitting must have both.
563. Regression >>> look for h/o bedwetting in a kid >5yo (<5yo is normal).
564. Reaction formation vs Undoing >>> rxn formation is a thought, undoing is an action. Both are classically a/w obsessive compulsive d/o, where rxn formation is the obsession, and undoing is the compulstion.
565. Reaction formation vs sublimation >>> sublimation does something good for mankind.
566. Primary insomnia >>> disturbance in initiating, maintaining or feeling rested after sleep. Tx: 1st hygeine treatment: regularize sleep hours, use of bed only for sex/sleep, if not asleep in 30 minutes then leave bed and return only when drowsy, no napping, regular exercise but not immediately prior to bedtime, reduce/eliminate alcohol/caffeine/smoking, relaxation exercise. 2nd sedative-hypnotics (benzo, zolpidem) for short-term relief
567. Narcolepsy >>> daytime drowsiness, irresistible sleep attacks c hypnagogic/hympopompic hallucinations, sleep paralysis, cataplexy (loss of muscle control c strong emotions). Tx c short daytime naps, 2nd stimulants for sleep attacks and TCAs for cataplexy.
568. Sleep apnea >>> obstructive type d/t occlusion of upper airway during sleep in an obese pt. Central type is d/t reduced nocturnal resp drive). Dx c polysomnography. Tx:1st wt reduction, 2nd CPAP for obstructive type, Acetazolamide or protriptyline for central type.
569. Restless Legs Synd >>> agonizing, deep creeping sensations in leg/arm muscles relieved by moving or massage. Pt has trouble falling asleep at night because of it. Tx c benzodiazepam.
570. Intermittent Explosive >>> discreet episodes of loss control of aggressive impulses, but otherwise not aggressive. Tx c benzo (causes disinhibition) and CBT.
571. Kleptomania >>> failure to resist stealing unnecessary and unneeded things. a/w Bulimia.
572. Pyromania >>> deliberate fire setting and fascination c fire, usually in kids. Make sure the guy is not getting paid to do it and that it is completely for self-satisfaction.
573. Trichotillomania >>> recurrent pulling out of one’s own hair. Tx c psychotherapy, SSRI.
574. Adjustment Disorder >>> excessive emotional/behavioral responses that occur within 3 months of a stressor that is within range of normal experience (unlike PTSD), such as school problems, marital discord, job loss or illness. Does not persist after 6 months of stressor. Lacks sufficient evidence to make for other diagnosis (MDD). Tx:1st evaluate suicide risk. 2nd psychotx, antianxiety, antidepressants, 3rd stress reduction.
575. Personality Disorders - Cluster A (Weird: Paranoid, Schizoid (pt wants to be alone), Schizotypal (peculiar ideations/appearance/behavior magical thinking)), Cluster B (Wild: Antisocial (exploitative, destructive, impulsive behavior c no remorse. Childhood h/o conduct d/o essential for dx. Tx c SSRI), Borderline (instability of self-image, identity, relationships and mood. Does crazy things and still feels empty inside. h/o child abuse. Tx c pschotx (long-term), SSRI for mood stability and impulsitivity, haloperidol for psychosis. Avoid benzo), Histrionic (attention seeking, hits on the doctor, needs praise and reassurance), Narcissistic (grandiose, mad if humiliated, lack of empathy). Cluster C (Worried: Obsessive-compulsive (tx c fluvoxamine), Dependent, Avoidant (does not want to be alone (unlike schizoid), but fears rejection)
576. Antipsychotics (Neuroleptics): Low-doses (thioridazine, chlorpromazein), high-doses/long-acting (haloperidol, fluphenazine. Highest risk of EPS, NMS), atypical (clozapine, risperidone, olanzapine, quetiapine, ziprasidone). Typicals block dopamine (D2) receptors, thus used for positive symptoms only and have many side-effects, while Atypicals block serotonin (5-HT), D2 and D4, thus can be used for positive and negative symptoms and have fever side-effects. Adverse-effects: Hours-Days: Dystonia (spasms), Torticollis and oculogyric crisis (eyes stay looking up). Tx c benztropine, diphenhydramine or trihexylphenidate. Weeks: Akathisia (restlessness). Tx c lowering drug-dose, benzo, BB, or switch to atypical (best). Months: Tardive dyskinesia (lip-smacking). Tx c switching to atypical. Neuroleptic malignant syndrome: MC c high-potency drugs, increased risk if used c lithium, fever, rigidity, autonomic instability, very high CPK levels, high K+, tx c IV dantrolene or bromocriptine. Clozapine causes agranulocy
tosis (must do weekly CBC if taking), thioridazine causes retinal pigment deposits, chlorpromazine causes jaundice and photosensitivity.
577. Newer Atypicals Adverse Effects: Risperidone (less sedative, but increases prolactin, incrase risk of movement d/o), Olanzepine (love to ask about. weight gain (MC), risk of DM), Ziprasidone (prolonged QT), Quetiapine (risk of movement d/o)
578. Antidepressants: block NE, 5-HT, Dopamine. MAOIs (bad b/c of Tyramine food reaction (cheese, red wine, chocolates, sausages). Must stop MAOI at least 2 weeks before starting TCAs or SSRI. Tx of choice for atypical depression (increased sleep/weight/appetite or Leaden paralysis)). TCAs (best ones are nortryptilline and desipramine, worst is amitriptylline. Causes hypotension, anti-cholinergic s/s, conduction defect (MCCOD, MC is sinus tachy, but USMLE loves widened QRS, tx c bicarb), sexual problems, changes in wt, sedation). SSRI (1st choice for MDD (fluoxetine, sertraline, peroxitine, citalopram, escitalopram), Anxiety (fluoxetine, sertraline, peroxitine) and OCD (fluvoxamine only). Causes headache (MC), GI upset, sedation, agitation, sexual dysfunction (worst s/s), weight gain). Others include Venlafaxine (MDD, anxiety), Duloxetine (MDD, pain d/o), Bupropion (MDD, smoking cessation), Mirtazipine (weight good (good for anorexia), sedation), Trazodone (priapism). In a nutshell, always answer SSRI unless
: 1- pt c MDD and neuroleptic (spinal) pain, give duloxetine; 2 >>> pt c MDD and has sexual changes/weight gain, give bupropion (not buspirone for GAD).
579. Mood stabilizers >>> Depressed pt (lithium or lamotrigine) or Mixed/Manic (Lithium, valproic acid, antipsychotics). Either way, lithium is 1st line. It causes tremors, GI upset, hypothyroidism, nephrotoxic, teratogenic, acne, wt gain, leukocytosis, ataxia, and seizures. Must get weekly blood levels and must get TSH, BUN/Cr, hCG before starting it. If renal disease, pick valproic acid, if very acute mania pick haloperidol, otherwise always go with lithium first. Never discontinue lithium abruptly and levels >3.0 is a medical emergency that needs IV saline or hemodialysis.
580. Electroconvulsive therapy >>> increases serotonin for conditions like MDD, mania and schizophrenia. No absolute contraindications. Only relative CI is high intracranial pressure (brain tumors). Who gets it? Suicidal pt (tx of choice), those who don’t respond to meds, pregnancy, h/o benefit c ECT, medication complications. MC adverse effect is memory loss.
581. Benzodiazepines >>> all work on CP450 exams OTL (Oxazepam, Temazepam, Lorazepam), so remember OTL for Outside The Liver.
582. Suicide >>> if pt mentions it, next step is to ask more questions (attempt, ideations), then admit. Risks: h/o attempt (best indicator of eventual success), hopelessness, psychiatric/physical illness, drug abuse, elderly, social isolation (living alone is worse than single, they are not the same thing!), low job satisfaction. MC method in males are guns, females are guns. MC attempt in males are guns, females are pills.
PULMONARY:
583. When to intubate? pO2<50, pCO2>50, pH<7.3 @ room air. Remember if pt becomes fatigued, this is a bad sign, don’t assume he’s just tired, intubate him.
584. Common cold >>> rhinitis, sneezing, headache, malaise and cough (no fever). Rhinovirus is MCC (also adenovirus, RSV, influenze). Tx: keep well hydrated, NSAIDS for fever, warm salt water gargles for pharyngitis (fever, dry/sore throat) and laryngitis, pseudoephedrine/phenylephrine for nasal congestion, avoid aspirin in children
585. Pharyngitis (strep throat) >>> although viruses can be a common cause, r/o bacterial infection (group A strep, aka strep pyogenes) c rapid strep test. Clues to strep throat include cervical lymphadenopathy, fever, pharyngeal and tonsillar exudates and the absence of cough. Tx c penicillin/erythromycin is given to prevent complications (peritonsillar/retropharyngeal abscess, meningitis, endocarditis, acute RF and glomerulonephritis). If viral etiology, supportive care only.
586. Peritonsillar abscess >>> dysphagia, fever, pain and trismus (hard to open mouth). Uvula displaced by swelling, tx c surgical drainage and antibiotics.
587. Thrush >>> candidal infection that has removable white patches in the mouth (rememeber, candida CAN come off, hairy leukoplakia cant). Tx c nystatin, fluconazole.
588. Sinusitis >>> facial pain/pressure, fever, greenish purulent rhinitis. If suspected, go ahead and begin tx c amoycillin, then get x-ray, then CT-scan of sinus. Only maxillary and ethmoid sinuses are present in children. Ethmoid sinusitis is more frequent in children. Cavernous sinus thrombosis is a complication that includes facial edema, meningitis and opthalmoplegia.
589. Allergic rhinitis >>> sneezing, itchy/water eyes, nose blocked and/or runny. Tx c corticosteroids and cromolyn sodium, antihistamines, decongestants, allergy shots.
590. Nasal polyps >>> swollen mucosa/submucosa polypoid tissue causing obstruction of nasal cavity. A/w allergic rhinitis, cystic fibrosis and aspirin intolerance.
591. Croup >>> (laryngotracheobronchitis) an acute viral illness in young kids who get cold s/s at onset, then barking cough, slight fever and inspiratory/expiratory stridor. X-ray shows steeple sign. Tx c humidified air then racemic epinephrine.
592. Epiglottitis >>> kid c drooling, high fever, resp obstruction, dyspnea, dysphagia, inspiratory stridor, lateral x-ray shows thumb sign. Do not irritate the kid or maneuver epiglottis as that would worsen obstruction. MCC is H. influenza type B. Tx c cephalosporins and intubation if needed.
593. Pertussis >>> 3 stages: catarrhal (coryza for 1-2wk), paroxysmal (whooping cough, 2-4wk), convalescent stage weeks later. Tx c erythromycin in catarrhal stage, otherwise supportive care.
594. Acute Bronchitis >>> large airway inflammation, productive cough, fever, mild dyspnea, CXR is clear (if there was an infiltrate, then its pneumonia). Tx c abx, hydration, expectorants, bronchodilators.
595. Bronchiolitis >>> small airway inflammation, tachypnea, wheezing, fever, cough in a child <2yo. Caused by RSV. Tx c ribavirin and oxygen.
596. Pulmonary Nodule >>> 1st step is get old xray. 2nd step If lesion was present and is the same size, its benign (hamartoma, discharge home). If the lesion was there and has gotten bigger, assume cancer. However, if the lesion was not in the old-xray, then classify his risk. If he is low risk (<40yo, nonsmoker) then its probably benign (hamartoma, CXR every 3mo for 2yrs). If he is high-risk (>50, smoker), assume cancer (do open-lung biopsy).
597. Pneumonia >>> Typical (<2days prodrome, fever >102, >40yo, one lobe involved) is d/t strep pneumo (gram + diplococci, tx c levaquin, prevent c vaccine in >65yo and pt c comorbidities, tx c 3rd generation cephalosporins). Atypical (>3days, HA, aches, dry cough, <40yo, multiple lobes, diffuse) in a young, otherwise healthy adult c atypical pneumonia is Mycoplasma/H. Influenza/Chlamydia and tx c Azithromycin. College student c dry cough, think of Mycoplasma (cold agglutinins) or Chlamydia. An elderly pt c COPD likely has bacterial pneumonia, or if in the winter, possible influenza. An AIDS pt c low CD4 and subacute illness has PCP (tx c bactrim (if allergic, give dapsone) or prophylax when CD<200). A pt whose mentation is altered (postop from anesthesia, demented, intoxicated) or who have swallowing dysfunction (CVA) has aspiration pneumonia. An alcoholic will likely have Klebsiella. If you see CNS (headache), GI (diarrhea) and pneumonia, its Legionella so give erythromycin (1st test is urine legionella
Ag test, most accurate test is direct fluorescent antibody from sputum). If cystic fibrosis or hospitalized for a long time, think pseudomonas (though S.aureus is still a big one here) and tx c piperacillin/tazobactam or ceftazidime. If pt is a farmer (cattle, sheep, goats) or veterinarian, think of Coxiella burnetti (tx c doxycyline) or chlamydia psitacci (bird-exposure, tx c doxycycline). (Pediatric Wheezing: <1yo is RSV, 2-5yo is Croup (barking) or epiglottitis (drooling), >6yo is Asthma)
598. Influenza >>> fever, chills, cough, sore throat c positive throat/nasal swabs in the winter-time. For prophylaxis, give Amantidine (influenza A only) or vaccine (>50yo or high-risk pt). If discovered <2days, give Oseltamivir. If >2days, rest/fluids/symptomatic tx c analgesics/antipyretics.
599. Pneumococcal vaccine >>> everyone >65yo, anyone (>2yo) c COPD/DM/alcoholism/ immunocompromised (HIV/AIDS, cancer, steroid-use, chemotherapy)/post-splenecomy.
600. Influenza vaccine >>> children 6-23months, >65 (Dr. Fisher says >50yo) c chronic medical conditions, residents of nursing homes, health care workers c pt contact, children (2-18) c chronic aspirin use (Kawasaki’s), caregivers of kids <6mo.
601. TB >>> caseating granulomas, transmission by aerolized droplets (overcrowded areas, poor ventilation, health-care workers, immunocompromised, homeless), fever, productive cough, night sweats, chills, wt loss. If symptomatic, next step is CXR then AFB. If asymptomatic, next step is PPD (refer to ID notes for Mantoux reaction margins), then CXR then AFB. Tx c RIPE until culture sensitive.
602. Histoplasma >>> Ohio/Mississipi river bird/bat droppings in soil grow spores, which are inhaled. If mild, no tx. If more ill give ketoconazole or amphotericin B. If disseminated (AIDS pt) then 1st step is blood/bone marrow culture, 2nd Ampho B.
603. Coccidiomycosis >>> flulike s/s, arthralgia, erythema nodosum/multiforme rash. If mild, no tx. If severe, give Ampho B.
604. Cryptococcus >>> AIDS or steroid-use pt gets infected c encapsulated yeast found in soil/pigeon droppings in NY area causing s/s in the lungs and CNS (meningitis). Tx c Ampho B + flucytosine for severe disease.
605. Lung Abscess >>> purulent/putrid sputum, cough, chest pain, fever, pt c poor dentition and aspiraton, CXR shows cavities and air-fluid level. Tx c IV penicillin G.
606. A-a gradient: 150 >>> (1.25 x PCO2) >>> PaO2. (NL = 5-15, high c all hypoxemia causes except hypoventilation and high altitude)
607. Obstructive >>> low FEV1, low FVC, low FEV1/FVC, low DLCO in emphysema, normal DLCO in Chronic bronchitis/Asthma. FEV1 determines severity of disease (60-70% is normal-moderate COPD, <50% is severe COPD). Decreased lung flow.
608. Restrictive >>> FEV1, FVC both decreased, but FEV1/FVC is normal. TLC is reduced. Decreased lung volume.
609. COPD >>> what are the only things that decrease mortality? Home O2 (when PaO2 <60mmHg) and smoking cessation. If tx is not sufficient c bronchodilators, give theophylline (decreased clearance if also given c erythro, cipro, cimetidine). Tx 1st Anticholinergics (ipratropium bromide MDI), 2nd Albuterol, 3rd Theophylline. What is the best predictor of survival? FEV1. Vacccines? Influenza annually and pneumococcus every 5 years.
610. Chronic Bronchitis >>> blue bloaters (due to cyanosis), productive cough, recurrent pulm infections.
611. Emphysema >>> pink puffer, progressive dyspnea, low DLCO, less cough, cachexic, barrel chest, sits in tripod position, hyperresonant lungs, distant heart sounds, CXR shows huge lungs c bullae,. If in a young pt c no smoking history, pick alpha-1-antitripsyn (AAT) deficiency, tx c purified human AAT.
612. Asthma >>> for attacks: 1st give oxygen, 2nd peek flow, 3rd Albuterol, 4th Steroids for 14 days (no abx). What if pt has attack secondary to BBs? Give anticholinergics (ipratropium bromide). For exercise-induced asthma, give cromolyn and albuterol before exercising. Chronic tx: daily inhaled steroids, albuterol as needed (other drugs depend on type of asthma). For acute evaluation get ABG (resp alkalosis, if it gets normal that’s bad), Pulse ox, CXR. For chronic evaluation, get PFTs, methacoline challenge, bronchodilator (test reversibility). Tx of choice for nocturnal cough is long acting B-agonist (Salmeterol).
613. Bronchiectasis >>> cupfuls of purulent/malodorous productive cough, wt loss, hemoptysis, clubbing, a/w cystic fibrosis and kartegener’s syndrome (immotile cilia). Dx c CXR 1st then CT (best, but not 1st). For acute management, tx for pseudomonas (ticar/pipercillin, quinolones, ceftazidine). For chronic tx, give bronchodilators, postural drainage, rotate abx (prevent resistance), surgery and vaccines.
614. Pulmonary Fibrosis >>> interstitial inflammation, exertional dyspnea (MC s/s), crackles, clubbing, cor pulmonale. Dx: 1st CXR (shows ground-glass appearance), 2nd CT, 3rd Lung biopsy (gold standard). Tx c steroids for 6months, then transplant if needed and f/u PFTs.
615. Allergic Bronchopulmonary Aspergillosis (ABPA): must have 6 of the following 7: h/o asthma, peripheral eosinophilia, pulm infiltrates, + skin test to Aspergillus, high serum IgE, +IgE/IgG for Aspergillus, central bronchiectasis. Tx c prednisone.
616. Atelectasis >>> MCC of postop fever after 1-2 days. Tx: 1st incentive spirometry, 2nd Deep breathing exercises, 3rd out of bed, 4th chest physical therapy, 5th CPAP, 6th Bronchoscopy (if atelectasis is severe and spontaneous-due to mucus plug).
617. Hemothorax >>> blood in pleural space. Dyspnea c massive shock. Tx: if very small, observe. All others need a chest tube. Some need thoracotomy (bleeding >200mL/hr)
618. Asbestosis >>> exposure to remoal sides, pipe maintenance, etc. Takes >20 years to develop mesothelioma, but much less to develop bronchogenic CA (esp if smoking). Dx c lung biopsy showing ferruginous bodies (not CXR or CT). No tx.
619. Silicosis >>> increased risk of TB (must do annual PPD). Upper lob nodules c eggshell hilar node calcification.
620. Caplan Synd >>> rheumatoid nodules in lung periphery c coal-workers pneumoconiosis.
621. Sarcoidosis >>> blacks, females, biopsy shows non-caseating granulomas (most accurate), fever, dyspnea, skin (erythema nodosum)/eye (iritis)/CNS (nerve palsy)/cardiac (arrhythmia) s/s. CXR shows b/l enlarged hilar adenopathy, dx c biopsy, elevated ACE, high calcium. Tx c steroids.
622. Acute Resp Distress Synd (ARDS) >>> acute lung damage from increased pulmonary (alveolar) permeability. Pt c dyspnea, tachypnea, tachycardia, no improvement c oxygen, arterial hypoxemia (PaO2/FiO2 ratio <300), hypercapnea, CXR shows b/l whited out lungs. H/o infection, aspiration, near-drowning, drugs, shock, burns, and pancreatitis. Tx c PEEP.
623. Pulmonary Embolism >>> venous stasis/thrombosis, hypercoagulable state (pregnancy, SLE, cancer, prtn C/S def, OCP, antithrombin III def, Factor V leidin). Sudden onset of dyspnea, pleuritic CP, hemoptysis, syncope, split S2 sound. Clear CXR. EKG shows sinus tachycardia or S1Q3T3. ABG shows resp alkalosis c hypoxia and increased A-a gradient. Mostly from deep leg vein thrombi (above knee is not possible, must be below knee). Dx c spiral CT or V/Q scan (esp if pregnant). Definitive dx c pulmonary angiography. Tx c 1st anticoagulation c heparin(LMW-heparin if pregnant) c O2 if stable, 2nd thrombolytics (tPA) if unstable, 3rd embolectomy (if severe like a saddle embolism), 4th filter (if recurrent or if anticoagulation is contraindicated).
624. Pulmonary HTN >>> CP, dyspnea, lethargy, shortened S2 split c louder P2, weak peripheral pulses/coldhands. Tx c oxygen and vasodilators.
625. Goodpastures >>> renal c pulm so pt c hemoptysis and hematuria, anti-GBM Abs, tx:1st prednisone, 2nd cyclophosphamide, 3rd plasmapharesis.
626. Wegeners >>> Upper airway, pulmonary, renal so pt c sinusitis, hemoptysis, hematuria, c-ANCA. Tx: 1st cyclophosphamide, 2nd prednisone.
627. Pleural Effusion >>> once you see it on CXR, next step is tap (thoraentesis) to see if it is transudative (CHF, PE, nephrotic syndrom, atelectasis) or exudate (parapneumonic, cancer, PE, chylothorax, esophageal rupture, rheumatoid arthritis). For it to be exudates: Pleural fluid to serum protein ratio > 0.5, Pleural fluid to serum lactate dehydrogenase (LDH) ratio > 0.6, Pleural fluid LDH more than 2/3 of the upper limits of normal serum value. What if they don’t give you the serum levels? Then exudates is when pleural fluid cholesterol >45 mg/dL and pleural fluid protein > 2.9. If you think it is malignancy (old guy, wt loss, smoker, etc) then look for LDH >1000, glucose 30-50, and lymphocytes 50-70%. However, if you worry about parapneumonic effusion, look for LDH >1000, glucose >30, pH <7.2, next step is chest tube drainage.
628. Lung Cancer >>> no available screening test. Squamous cell (central cavitation, a/w hypercalcemia d/t PTH-like peptide, dx c bronchoscopy), Small cell (central cavitation, a/w SIADH, Eaton-Lambort and Cushings syndrome, dx c bronchoscopy), Adenocarcinoma (peripheral lesion, MC is bronchoalveolar CA, increased hyaluronidase levels, dx c FNA then thoracotomy c pleural bx). When is it unresectable? Hoarseness, METS, wt loss >10%, CNS s/s, SVC syndrome (JVD c facial discoloration d/t SCC) or tumor at the trachea/esoph/pericardium. For small-cell Ca, tx c chemotherapy (VP16-etoposide and platinum). For non-small cell Ca give radiation and chemo (CAP >>> Cyclophosphamide, Adriamycin, Platinum).
RENAL/UROLOGY:
629. Prostatitis >>> dysuria, chills, fever, low back pain, perineal pain, frequency, prostate may feel boggy and large but is always tender. E.coli. Tx c levaquin and hydrate.
630. Epididymitis >>> tender (relieved c scrotal elevation, opposite of torsion), enlarged testicle, fever, scrotal thickening. Caused by neisseria, e.coli, chlamydia. Tx c abx (tetracycline, levaquin), nsaids, scrotal support.
631. Orchitis >>> fever, increase testicular size, scrotal pain/erythema, a/w mumps and TB. Tx c same as above.
632. Urethritis >>> urethral d/c, dysuria. Next step is culture/gram stain (r/o STD). Tx c abx.
633. Testicular torsion >>> MCC of scrotal swelling in kids, causing severe pain (especially when scrotum is lifted, opposite of epididymitis), abdm pain (sometimes this is their only s/s, so must check scrotum), vomiting. Urologic emergency for blood supply must be regained within 6 hrs to prevent loss of testicle.
634. Cryptorchidism >>> no s/s. Dx c CT. Tx: Orchiopexy at age 1 to prevent cancer.
635. Any testicular mass needs to have cancer ruled out, so excise and biopsy it.
636. Benign Prostatic Hypertrophy >>> enlargement of prostat gland causing obstruction (hesitancy, dribbling, weak/low stream), urgency, nocturia and frequency. Dx: 1st DRE, 2nd U/S. Tx: 1st a-blocker (terazosin, remember tamsulosin (flomax) has the least adverse effects), 2rd 5-a-reductase inhibitors (finasteride), 3th Surgery (TURP). However, if pt is in ER in pain, 1st foley (if it wont pass, do suprapubic tap), 2nd TURP (skip meds).
637. Hypospadia >>> meatus below penis tip, so you pee on your feet. Pt may have chordee (ventral penile curve causing penis to curve 90degrees). Tx:1st observe until 1yo (do not circumcise), 2nd surgery
638. Hydrocele >>> fluid around the testis due to patent processus vaginalis. Dx c + transillumination. Tx c observation.
639. Varicocele >>> pampiniform plexus vein dilation due to inefficient pampiniform valves. Disappears in supine position (no venous pooling). Dx c (-) transillumination. Tx c surgery.
640. Cystitis >>> bladder infection causing dysuria, frequency, nocturia, urgency. Dx c UA/Ucx/Urine dip. MCC is E.coli. Tx:1st abx, 2nd IVP, cystoscopy (if recurrent).
641. UTI >>> urgency, dysuria, low balck pain, low fever. Dx c midstream urine Cx to show high nitrates and leukocytes. Tx c TMP/SMX, amoxicillin, nitrofurantoin, levaquin. Any kid <6yo c UTI needs VCUG (MCC is vesicureteral reflux and posterior urthral valves).
642. Nephrolithiasis >>> severe flank pain radiating to the groin c hematuria. Dx: 1st Xray (uric acid stones not visibile), 2nd CT scan abdo/pevis without contrast. Tx: 1st Hydration c analgesia, 2nd (remember, ureter is 8mm wide, so a small stone (<5mm) will pass c supportive measures, but larger stones may completely obstruct) extracorporeal lithotripsy if upper GU tract, or ureteroscopy if lower GU tract.
643. Anytime you suspect urethral injury (high riding prostate or blood at urethral meatus), next step is retrograde urethrogram (not foley!).
644. We give cyclosporine for graft rejection, but cyclosporine itself is nephrotoxic. How do you differentiate renal graft rejection from cyclosporine toxicity? Do percutaneous needle biopsy. Also, if situation occurs, trying increasing cyclosporine: if kidney function worsens, its nephroxicity. If kidney function improves, its graft rejection (however try percutaneous needle biopsy first in risk of worsening kidney).
645. Incontinence >>> discussed in Gyn notes. Functional/Overflow (nerve dysfunction, DM/MS, high voiding residual volume, tx c self-catheterization if pt cannot empty or anticholinergics if pt cannot store), Stress (weak pelvic floor, aggrevated by coughing/sneezing/laughing, tx c kegel exercises, then surgical MMK procedure), Urge (detrusor hyperreflexia causing spontaneous contractions, tx c anticholinergics).
646. Hydronephrosis >>> kidney/ureter damage from ureter obstruction (in men, think BPH) causing flank/back pain and oliguria. Dx c ultrasound. Tx c 1st foley catheter to relieve distal obstruction, 2nd cystoscopy and ablation of stones.
647. Pyelonephritis >>> ascending infection into kidney causing fever/chills, n/v, flank pain and anorexia. If pt is not seriously ill, tx c abx. If pt has severe n/v and appears ill (dehydration, hypotension) give IV hydration and abx for 2 weeks.
648. Glomerulonephritis >>> hematuria, proteinuria, HTN, edema. If acute, give bed rest, anti-HTN. Causes include HIV, HBV, poststreptococcal, SLE, Goodpastures, Wegeners, RA, Polyareteritis nodoa, penicillamine, hydralizine, allopurinol and rifampin. If rapid progression give steroids, cytotoxics, plasmapharesis.
649. Berger’s Disease >>> IgA nephropathy, gross hematuria after viral URI. Dx c biopsy (immune deposits of IgA in glomeruli). No tx. (Don’t confuse c Buerger’s disease, which is a problem of the fingers in smokers).
650. Diabetic Nephropathy >>> microvascular glomerular damage (thickened GBM) and Kimmelsteil-Wilson lesions (nodular deposits in glomeruli). Best tx is prevention.
651. Acute Renal Failure >>> rales, JVD, hyponatremia. Causes include prerenal, renal and postrenal. See below.
652. Prerenal Failure >>> hypovolemia (dehydration) BUN/Cr >15:1, Tx c IVF. Causes include sepsis, CHF (tx c diuretic), Liver Failure (Hepatorenal Synd, which has no tx)
653. Renal Failure >>> MCC is ATN (muddy-brown casts) due to: IV contrast (avoid in DM, renal dz, asthma, shellfish allergy), Rhabdo/Myoglobinuria (high CPK, tx c IVF and diuretics), SLE, Chronic NSAID use (papillary necrosis), aminoglycosides, cyclosporine, Goodpastures (anti-GBM Ab, linear on bx, tx c steroids and cyclophosphamide), Wegeners (tx c cyclophosphamide). ATN usually resolves in 6 weeks so just try to keep them alive (dialysis) until then. 2nd MCC is AIN (acute interstitial nephritis >>> look for wbc casts and eosinophilia. d/t drugs (B-lactam), calcium crystals, oxalate (antifreeze), chemotx (uric acid), tx c d/c stressor). 3rd MCC is Glomerulonephritis (RBC casts, dx c biopsy immediately) and 4th MCC is vasculitis (HUS< TTP, Multiple Cholesterol Emboli Syndrome (s/p cardiac cath pt gets blue feet, HTN and eosinophilia).
654. Postrenal Failure >>> Anuria (no urine output with >25cc residual volume). Dx c renal u/s (shows hydronephrosis). MCC is BPH (then b/l renal stones). Tx c catheterization, then TURP.
655. Minimal Change Disease >>> kids, glomerulus looks normal, but may have fusion of podoyctes. Dx c 24hr urine protein (no need for biopsy). Tx c steroids.
656. Membranous Glomerulonephritis >>> elderly Caucasian c amyloidosis. No need to do biopsy for diagnosis.
657. Focal Segmental Glomerulonephritis >>> h/o IVDA, 50% get ESRD, dx c biopsy
658. Membranoproliferative Glomerulonephritis >>> a/w hepatitis C (give ribavirin) and endocarditis, dx c biopsy.
659. When do you choose dialysis? Acidosis <7.25, Uremic encephopathy (1st give DDAVP, then dialysis), Increased K+ and creatinine, pericarditis, heart failure.
660. Polycystic Kidney Disease >>> family history, HTN, hematuria, palpable flank mass, Dx c CT of abdo (shows multiple cysts).
661. Chronic Renal Failure >>> azotemia (high BUN/Cr), metabolic acidosis, high K, hypervolemia (HTN, CHF, edema), low calcium/high phosphate. Tx c dialysis 1st, then water-soluble vitamins (lost in dialysis), calcium, EPO and anti-HTN meds.
662. Hyponatremia: 3 types: Hypovolemic Hyponatremia (tx c saline), Hypervolemic Hyponatremia (pt c cardiomyopathy and edema, tx c correcting underlying cause), and Euvolemic Hyponatremia (Hypothyroidism (tx c thyroxine), SIADH (high urine osmolarity, tx c fluid restriction), Psychogenic polydipsia (low urine osmolarity, tx c fluid restriction)).
663. Never give IV Potassium unless: 1- K+<2.8, 2 >>> pt on digoxin, 3 >>> arrhythmia.
664. Only 2 conditions in Anion-gap acidosis (MUDPILES) where you do NOT give bicarb: DKA and Lactic acidosis.
665. Vomiting vs Conn’s Synd >>> in vomiting (lose K and Cl, thus Cl is low) you treat c saline. In Conn’s synd (lose K, not Cl, thus Cl is normal) tx c Spironolactone and ACEI.
666. Renal Artery Stenosis >>> high rennin HTN. 1st test is captopril imaging, 2nd test is Angiogram. Tx c angioplasty.
667. Osteomyelitis >>> 1st step is xray (sometimes may show the characteristic periosteal elevation). Most questions will have given you the X-ray and asked for the next test. So the 2nd is MRI, 3rd step is biopsy (not so much for diagnostic purposes, but for treatment purposes rather). When do you choose bone scan? If you cant do MRI (metal, pacemaker, hearing tubes, etc). So to answer your question in the way you asked it...
1st test is X-ray, 2nd test is MRI, 3rd test is Biopsy
Most sensitive is MRI
Most specific is MRI
Gold Standard would probably still be MRI (unless pt cannot get one, then it would be Bone scan) jiggy_cram facts
INJURIES TO ELBOW
1. Lateral Epicondylitis (tennis elbow). A very common inflammatory process of the extensor origin of the lateral epicondyle. May be secondary to overuse/repetitive use. Pain at the lateral epicondyle, with referred pain to the extensor surface of the forearm is typical. The pain is exacerbated by resisted extension of the wrist or fingers. Treatment includes avoiding exacerbating activities, NSAIDs, and placing a constrictive \"tennis elbow\" band just distal from the elbow. Occasionally immobilization of the wrist in a volar splint is required. Local steroid injection or orthopedic referral may be advised in recalcitrant cases.
2. Medial Epicondylitis. This results from repeated flexion activities of the wrist and fingers. Pain is at the medial epicondyle and exacerbated by resistant flexion of the fingers. Treatment is the same as that of lateral epicondylitis.
3. Radial Head Subluxation (nursemaids elbow).
a. The mechanism is a sudden pull on the extended pronated elbow of a child less than 4 years of age (for example, when one picks up a child by the forearm or swings the child). The child holds his arm in pronation and usually refuses to move it with pain on supination and palpation of the radial head.
b. Although radiographic findings are usually normal, one must be sure to rule out undisplaced supracondylar fracture. Frequently, the subluxation spontaneously reduces from x-ray positioning.
c. Treatment is firm supination of the forearm, flexing the elbow gently to 90 degrees with pressure over the radial head. Reduction is achieved with a palpable click over the radial head, and the pain is immediately relieved. The patient should resume full activity within several minutes of reduction although some are hesitant. It may take an hour or so to resume full activity.
4. Little Leaguers Elbow. Results from overuse of an adolescents pitching elbow. On exam there is tenderness over the medial humoral epicondyle with mild swelling. An acute syndrome with sudden onset also occurs from the avulsion of a fragment of bone from the medial humeral epicondyle. Treatment includes rest for 3-6 weeks followed by rehabilitation. Loose bodies and locking elbow require referral.
5. Olecranon Bursitis (note: the same treatment and diagnostic modalities hold true for prepatellar bursitis as well).
a. Clinically there is tenderness and swelling over the olecranon bursa. Olecranon bursitis may be secondary to trauma (e.g., lying on carpet with elbows propped up while watching TV) or may be infectious (Staphylococcal). Frequently, traumatic bursitis leads to infectious bursitis.
b. Diagnosis. Must differentiate infectious from sterile bursitis. Tap the bursa and evaluate gram stain, cell count, crystals, and culture.
c. Treatment consists of repeated aspiration until fluid no longer re- accumulates. Start antistaphylococcal antibiotics (e.g., amoxicillin/ clavulanate, nafcillin) if an infectious etiology is likely. May require admission for IV antibiotics the patient is toxic or there are comorbid conditions (e.g., immunosuppression, diabetes). If the etiology is not infectious, treat with NSAIDS, aspiration and compression dressings. Occasionally, an olecranon bursa must be opened surgically.
RED EYE
Clinical clue table suggesting the possibility of serious eye disease causing the \"red eye\", clinical features that may necessitate immediate ophthalmologist consultation
Clinical features:
Severe eye aching: Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus thrombosis (CST)
Prominent photophobia: Iritis, keratitis
Impaired vision: Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST
Cloudy cornea: Keratitis, acute angle-closure glaucoma
Corneal opacification: Keratitis - chemical or infectious
Circumcorneal conjunctival injection: Iritis, keratitis
Cloudy anterior chamber: Iritis
Pain on eyeball palpation: Scleritis (+++), orbital cellulitis, CST
Proptosis: Orbital cellulitis, CST, posterior scleritis
Impaired, or painful, extraocular eye movements: Orbital cellulitis
Fever, toxic appearance: Orbital cellulitis (+), CST (++)
Hyperpurulent discharge from an \"angry\" eye: Gonococcal conjunctivitis/endophthalmitis
Prominent nausea and vomiting: Acute angle-closure glaucoma
Small, irregular, poorly-reactive pupil: Iritis
Fixed mid-dilated pupil: Acute angle-closure glaucoma
Increased intra-ocular pressure: Acute angle-closure glaucoma, iritis (secondary complication)
History of connective tissue disease, or granulomatous disease: Iritis, scleritis
Recall:
23 yo runner developed fracture of the medial malleolus...next step:
a-posterior splinting
b-medial splinting
c-lateral splinting
d-orthopedic referral
The answer to this question is posterior splinting..The trick here is to know the intervention and the position of splinting..
Think of the ankle as a \"ring\" composed of medial malleolus, deltoid ligamnet, calcaneous, lateral ligamnet, lateral malleolus.
DISRUPTION OF THE RING AT ONE POINT ONLY OF THE RING results in a stable ankle that can be treated by CONSERVATIVE means (POSTERIOR splinting+non-weight bearing)
DISRUPTION OF THE RING AT TWO OR MORE POINTS OF THE RING makes the ankle unstable and the treatment is immobilization and emergent referral..
Difference b/w Raloxifene and Tamoxifen:
Tamoxifen:
Often used in women over 50 years of age and younger women with ER + tumors. ER + respond better than ER -. Treatment for 5 years seems to be optimal duration. Side effects include, nausea, menopausal symptoms, thromboembolism and and a small increase in uterine cancer (mandating work for any abnormal uterine bleeding). Ovarian ablation is only beneficial as hormonal treatment in premenopausal women.
* women at high risk for the development of breast cancer may reduce their risk by taking tamoxifen.
* Tamoxifen appears to be antiestrogenic at the level of the breast but proestrogenic at other levels.
It causes endometrial changes, including polyp formation, hyperplasia NOT ATROPHY, and frank invasive carcinoma. Thus, women on tamoxifen need to be followed carefully, and prompt evaluation of abnormal vaginal bleeding should be conducted.
Tamoxifen, like estrogen, has been shown to lower blood levels of LDL cholesterol
Women on tamoxifen appear to be at no greater risk, and may be at a lower risk, for the development of myocardial infarction .
Tamoxifen, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis .
Raloxifene:
Raloxifene appears to function like estrogen in bone, acting to maintain bone strength and increase bone density.
In addition, raloxifene also resembles estrogen in its ability to lower LDL cholesterol levels, thereby decreasing the risk of heart disease.
Although information on the long-term risks and benefits of raloxifene is limited compared to tamoxifen, preliminary evidence suggests that raloxifene may exert these beneficial effects on bones, heart, and blood vessels without increasing a woman\'s risk of developing cancer.
Even if the STAR trial confirms the effectiveness of raloxifene in reducing the risk of breast and uterine cancer, raloxifene is still not the perfect drug. It does not reduce the frequency of hot flashes associated with menopause and, like estrogen, it increases the risk of blood clots. Just as tamoxifen was an important milestone, if a single SERM like raloxifene is found to protect women against osteoporosis, heart disease, breast cancer, and uterine cancer, it will represent an important milestone in women\'s health. For the recall question raloxifene if h/o breast ca is there.
Asymptomatic hematuria:
1)>50, + Risk factors(tob, dye, etc) or is consistent with underlying causes straight cystoscopy.
2) Think ischemic ulcer
If you see the ulcer at the heel ==> Think diabetic ulcer
If you see the ulcer above the malleolus ==> Think in stasis ulcer
Diabetic ulcers typically develop at pressure points, and the heel is a favorite location. The patient has evidence of neuropathy, and the correlation with the trauma inflicted by the new shoes is classic
Ischemic ulcers, whether due to arteriosclerosis or embolization are typically seen at the tip of the toes, as far away from the heart as one can get.
Stasis ulcers are seen above the malleolus, surrounded by edematous, hyperpigmented skin.
RECALLS:
1.pregnant exposed to a lacy rashed boy
a.it wonot affect u
b.u will get mild disease
c.u are vaccinated to this,no harm
d.u may lose your fetus
A. no longer infectious once rash appears.
2.pt heavy smoker,lost 8 lbs lately and serum ca=11.5
what do u do next;
a.recheck ca
b.check cxr
CXR.
3.14 yrs old girl never been vaccinated for varicella and she exposed to 5 yrs old her sister with varicella
how would u tx 14 yr one
a.varicella immuno
b.varicella ig g and vaccine
c.var vaccine now
d.va vaccine now and month later
edo nothing.she already exposed
Answer D ref CDC guidelines
4.4 yr old almost near drowing was cpr for 45 mts to get pulse and circulation.in er pt is on dopamine and intubated.he pronouned brain dead and ready for organ donation.what is the best time for this.
a.now
b.after 48 hrs
c.after good b.p. control
Answer NOW
5.56 yr man came to pmd he is s/p CABG 10 yrs back and c/o sob with exertion and chest pain what is next step:
a.thallium stress test
b.dobutamine test
c.ekg
Next step EKG
6.Pt with carbamezapine toxicity what should u monitor
a.cardiac
b.renal
Cardiac
7.what is definitive diagnosis for mi
a.ekg
b.enzyme
c.physical exam
Enzyme
8.cocaine induced htn what will be tx
a.nitropru
b.beta blocer
c.phentolamnine
Phentolamine
9.cocaine induced mi
a.thrombolytic
b.angioplasty
Angioplasty
10.which is not a risk factor for osteoporosis
a.smoking
b.etoh
c.caffinated product
d.white race
e.obesity
Obesity
11. woman on contraceptive > >>> became amenorrheic
a.let her be ameno
b.modify estro(increase)
c.progesterone (lower)?
Likely B
12. A child goes to picnic has redness in arms and legs What the dx:
Poison Ivy
Atopic dermatitis
Irritant contact dermatitis: Just local inflammation of the skin following contact of the skin with a noxious substance. NO immunologic reaction eg; Industrial and household detergents
Allergic contact dermatitis: Delayed type of hypersensitivity..Occurs when an external agent sensitizes T-cells, Poison ivy, poison oak, some metals (nickel), various preservatives in medications, ingredients in rubber industry, agents in finishing process for clothing or other naturally occurring or industry produced chemicals. MKSAP p 16
Atopic dermatitis: Atopy in the skin. Type I hypersensitivity ..Part of generalized atopic reaction. The Ig-E mediated immunity occurs in many parts of the body including the skin.
Having understood the type of hypersensitivity in each dermatitis.., timing here is very important. If the child develops the reactions of erythema and pruritis 24-72 hrs after the return of the picnic, .Poison ivy /allergic contact dermatitis will be choice, If the child develops the symptoms immediately, atopic dermatitis is the choice.
HTN High yield facts
Hypertension Rx
Trial of Lifestyle Change x6-12mos in Pt.\'s w/ NO Co-morbid Dz.
*** 1st LINE DRUGS ***
No Other Dz.
- Diuretic OR -blocker
- (Proven to Decr. Mortality)
Hyperthyroidism
- -blocker
- (Decreases HyperT3 Sx, also)
DM
- ACE Inh.
- (Proven to Decr Vasc & Kid Dz)
Blacks
- Ca Channel Blocker
Decr. Ejec. Frac.
- ACE Inh.
- (Proven to Decr. Mortality)
MI
- -blocker AND ACE Inh.
- (Proven to Decr. Mortality)
Atrial Fibrillation
- Diltiazem (Ca Chan. Blocker)
- (Controls Atrial Rate, also)
Osteoporosis
- Thiazides
- (Decr. Ca Excretion)
Prostatic Hypertrophy
- Alpha-blockers
(Ex.: PRAZOSIN, TERAZOSIN)
- (Treats HTN & BPH Concurrently)
HTN *** CONTRAINDICATIONS ***
-blockers
- COPD
- due to Bronchospasm
-blockers (Relative)
- DM
- due to alteration in insulin/glc homeostasis & blockade of
autonomic response to hypoglycemia
-blockers
- Incr. K
- due to risk of Incr.\'ing K even higher
ACE Inh.
- Preg.
- due to Teratogenicity
ACE Inh.
- Renal Artery Stenosis (B/l)
- due to precipitation of ARF
ACE Inh.
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
K Sparing Diuretics
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
Diuretics
- Gout
- due to causation of Hyperuricemia
Thiazides
- DM
- due to Hyperglycemia
See page 251 Katzung for uses and side effects of Diuretics.
Immunization Contraindications
No MMR:
if PREG / IC Pt / EGG ALLERGY
OK if HIV+ (Asymp)
No DPT:
if SEIZ / Any NS Dz.
if FEVER > 104 AFTER 1st DOSE
No OPV:
if IC Pt
(Use IPV, which is IV & Killed)
UPDATE:
- Last Polio Inf. in 1979 w/ ~8 cases/yr due to OPV (Live-attenuated)
- As of Jan. 2000, No more OPV. (ie.: IPV is only given)
NB: Live Vaccines
- MMR
- OPV (Replaced w/ IPV)
- Varicella
Oral Contraception Pill (OCP) Contraindications
PE, DVT
Cerebral vascular disease
Coronary artery disease
CA of breast
CA of endometrium
Cholestatic Jaundice in Preg.
Hepatic adenoma
Impaired liver function
Type II hyperlipidemia
Factor V Leiden mutation
Smoker (if > 35yo)
Varicella Vaccine
Live attenuate vaccine
- Given at 12 to 18 months in pt with no previous infection
*< 12 yo, only one injection is given
*>12 yo, two injection is given 1 to 2 months apart
Route of administration
-Subcutaneuosly
Complication:
-Erythema 20-25%
-Varicella < 1%.
WBC Shift
LEFT SHIFT:
- Increased Seg.\'d Neutrophils + Bands
- Bacterial
RIGHT SHIFT:
- Increased Lymphocytes
- Viral
Labor Induction (Indications)
Abruption
Chorioamnitis
IUFD
PIH / Pre-eclampsia
PROM
Post-term (42 wks)
Maternal Medical Conditions:
- Diabetes mellitus
- Renal disease
- Chronic pulmonary disease
- Chronic HTN
Fetal Compromise:
- Severe IUGR
- Isoimmunization
Contraindictions to Labour Induction
Vasa/Placenta previa
Transverse fetal lie
Umbilical cord prolapse
Previous uterine surgery
DKA Treatment
**LABS**
SMA-7 / Ketones / ABG / EKG
**TREATMENT**
1) FLUIDS -> 2L NS (500cc/hr x 4hr), then 250 cc/hr x 2hr
2) INSULIN -> Bolus 10U Reg, then run at 0.1U/kg/hr
Make sure drip is running
3) K -> in 1/2 NS 20-40mEq/L after 1-2L NS
4) Check Glc q1hr (until BS < 250)
5) Once BS < 250, add Dextrose (D5NS) to Insulin drip
6) Turn off drip when HCO3 > 22
ie.: Improvement of Anion Gap (AG)
AG = Na - (HCO3 + Cl) = 140 - (24 + 100) = ~8-16
7) Start SQ Insulin 1-2 hr before stopping Insulin drip
Amenorrhea Work Up:
Remember the definition of Primary Amenorrhea is either 14yo without secondary Sex characteristics OR 16yo without menses yet. Secondary Amenorrhea is NO menses for 6 months OR 3 cycles.
Progesterone Challenge test is needed after Preg Test(neg) / TSH (normal) / Prolactin (normal). If she bleeds with the progesterone, then she\'s anovulatory (Tx-> Progesterone). If she does not bleed, then test with Estrogen & Progesterone (OCP). If no bleeding still she has scarring in the uterus (Asherman\'s synd or TB). If bleeding occurs, then do LH/FSH level. If LH/FSH is low then repeat Prolactin level and do a Coned down view of Sella Tursica. She probably has a Prolactinoma (Tx-> Bromocriptine (may breastfeed)). If LH/FSH is normal, then she has Polycystic Ovarian Syndrome (PCO) and treatment is OCP (or Clomiphene if she desires pregnancy now). Testosterone is also high in these patients. If LH/FSH is high, she either has Menopause, Ovarian Failure, Testicular Feminization (46XY) or Turner\'s Syndrome (XO).
For PCOD LH/FSH ratio is greater than 2:1
Cervical cancer guidelines
ASC-US
-Repeat PAP in 4 mos
-HPV with reapeat PAP
-If (+), then Colpo
ASC-H
-Colpo
AGC
-Colpo + Endocervical Curretings (ECC)
-If >35yo also do Endometrial Biopsy (EMBx)
-If Endometrial cells present, do Colpo + ECC + EMBx
LGSIL
-Colpo +/- ECC
HGSIL
-Colpo with Cervical Biopsy + ECC
Endometrial Cells present
- EMBx if Postmenopausal and NOT on HRT
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mudpiles_jiggy_cram facts