very high yield from for USMLE

1.Patients with DM, CRF and multiple organ failure can develop acalculous cholecystitis. Acalculous cholecystitis is characterized by the absence of gallstones and sometimes even biliary sludge. These patients may not present with classical signs of cholecystitis, because of associated diabetes mellitus and multiple organ failure. U/S may fail to show evidence of gallstones or obvious signs of cholecystitis. A CT scan of the abdomen and pelvis will reveal a thickened gallbladder wall, pericholecystic fluid, gas within the gallbladder wall, and evidence of surrounding inflammation.



2.After abdominal aortic aneurysm repair and blood in the stool =>suspect ischemic colitis => do sigmoidoscopy/colonoscopy to assess colon viability, if CT scan is inconclusive, do not use Barium enema=>can cause perforation.





3. In SLE => non-erosive arthritis; In RA =>erosive arthritis: indication for starting Methotrexate





4. Kallmann's syndrome-46,XX = anosmia, hypogonadotropic hypogonadism, absent pubic, axillary hair, absent breasts, amenorrhea.



5. Juvenile angiofibroma is a highly vascular fibrous tumor that classically affects adolescent males and appears to be related to androgenic stimulation. It manifests with recurrent epistaxis.





1. Euthyroid sick syndrome occurs in many seriously ill patients who do not have clinical hypothyroidism. especially in the ICU.



2. The TSH level is usually most helpful in distinguishing euthyroid sick syndrome from true hypothyroidism, as it is often above 30 mU/mL in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick syndrome. Disproportionately, decreased T3 is also typical of euthyroid sick syndrome, and T4 may be normal or decreased.



3. Hepatorenal syndrome occurs during the end stages of cirrhosis and is characterized by diminished urine output and low urinary sodium. In the setting of end-stage liver disease, renal vasoconstriction occurs, and the distal convoluted tubule responds by conserving sodium. Unless the renal function is allowed to deteriorate further, liver transplantation will reverse this vasoconstriction and kidney function will return to normal.Then when ever you have cirrhosis with renal failure the most appropriate treatment is LIVER TRANSPLANTION!



4. In B-thalassemia, a reduced production of beta chains occurs with normal amounts of alpha chain production.



5. A shock-like pain upon percussion on the volar aspect of the wrist (Tinel sign) is a characteristic sign of Carpal tunnel syndrome. It is most often idiopathic, but may represent a manifestation of underlying disorders such as rheumatoid arthritis, sarcoidosis, amyloidosis, acromegaly, and leukemia.







1. Fibrositis , also known as fibromyalgia, refers to a poorly understood syndrome of widespread musculoskeletal pain associated with tenderness in multiple trigger points. Fatigue, headache, and numbness are also common. Women between 20 and 50 years of age are most commonly affected. Neck, shoulders, low back and hips are usually involved.



2. Reflex sympathetic dystrophy describes a syndrome of pain and swelling of one extremity (most commonly a hand), associated with skin atrophy. It is thought to be secondary to vasomotor instability. Sometimes, it follows injuries to the shoulder (shoulder-hand variant).



3. Femoral pseudoaneurysms represent an important vascular complication of cardiac catheterization. The combination of a pulsatile mass, femoral bruit, and compromised distal pulses make this diagnosis likely. The diagnosis can be confirmed by ultrasound of the groin.



4. Cholesterol emboli syndrome is also an important complication to recognize in the post-catheterization patient. It usually presents, however, with skin findings in the distal extremities of livedo reticularis, ischemic ulcerations, cyanosis, gangrene, or subcutaneous nodules.



5. Another important complication of cardiac catheterization via the femoral artery is a retroperitoneal bleed . This complication presents as either new back pain, an unexplained drop in the hematocrit, or purpura over the flanks.







1. what is piriformis syndrome? As you may recall from your anatomy, the piriformis is the small muscle that crosses the greater sciatic foramen, cutting it into two spaces as the muscle passes from the edge of the sacrum to the greater trochanter. The sciatic nerve comes out of the greater sciatic foramen below the piriformis, and is subject to compression by the muscle. Symptoms are as described above; bicycle riding and running may also set off the symptoms, which may take the form of chronic nagging ache, pain, tingling, or numbness. Treatment is usually to teach the patient to avoid maneuvers that set off the symptoms. Some patients have been helped by corticosteroid injection near the site where the piriformis muscle crosses the sciatic nerve; this therapy is thought to work by reducing the fat around the muscle and thereby increasing the available space in the area.



2. In Addison disease, laboratory findings include hyponatremia (due to aldosterone deficiency), hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement.



3. HIV encephalitis is clinically known as AIDS dementia complex. The pathologic substrate is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS.



4. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion. MRI studies and CSF analysis are useful in excluding other CNS diseases.



5. HIV myelopathy manifests mainly with spastic paraparesis. It is a complication similar in pathologic substrate to vitamin B12 deficiency, i.e., vacuolar degeneration of the posterior and lateral columns of the spinal cord.







1/ warfarin better choice in hip surg



2. in euthyroid tsh is normal t3 is high and t4 n or high sick thyroid is in sickk icu bed

in hypo real one tsh reaches 30



3. piriformis preses sciatic



4.hiv encephalitis isdirect infiltration of brain by hiv virus causig adcomplex



5,hiv myelo is poste and lateral and like b12



6cardi cath by femoral artery cancause psedo and pulsatile anew ry and cholestral emboli syndro or blue toe and unexplain drop in hb and flank purpura



7 fibromyel amnd fibrocytis are same involve central big joint area but joints are niormal and incontrast to polymyelgia come in prime of women lif and need antidepressiv



8 sympathe dystrophy is actually ortho prob aith atrophy and vasom instablity



9inaddison adrenocortical def causing mineralo and glucocor def and need to supplement bith



10 in addiso n u do cosyntrophin or acth test to find out primary or secondary



in primary no response

in secondary cort i will increse

inaddison there will be hyper pigmen



11basalcell uper face



12 sqa is ulcer



12 keratoacanthoma is quick crust and benign and a good news



13. laxative also cause hypokalemia like diuretic ,u wave tetany



14 hypokale can cause rhabdo myelysis and rhabdo can cause hyper kalemia



15 tinel finkel sign carpal also in lekemia



16 in hepatorenal vasoconstiction do liver transplant and renal prob wii go away

17 b thale will hv normal alpha







1.Progressive multifocal leukoencephalopathy consists of multifocal areas of myelin destruction. These changes will be visible on MRI. This complication is due to JC virus, a papovavirus that causes asymptomatic infections in immunocompetent individuals.



2. Patients with longstanding extensive ulcerative colitis for at least 10 years are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia.



3. Individuals with herpes zoster are contagious and can spread the VZV virus.



4. Decreased esophageal peristalsis AND decreased LES pressure:SCLERODERMA , These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's esophagus.



5. Patients with erythema infectiosum (Fifth disease) are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death.







1. If a pregnant woman was in contact with a patient with fifth disease during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy.



2. Most authorities think that it is appropriate to initiate a progestin-only method of contraception immediately postpartum. It has no impact on lactation or the quality of breast milk.



3. The triad of miosis, respiratory depression, and coma is suggestive of opioid intoxication.



4. Phenelzine is an antidepressant monoamine oxidase inhibitor (MAOI) that causes hypertensive crises and the serotonin syndrome (hypertension, tachycardia, fever, coma, and possibly death) when combined with tyramine-containing food (cheese) and/or serotonin-altering drugs. Pseudoephedrine and other nasal decongestants, bronchodilators, amphetamines can cause severe hypertension when monoamine oxidase is inhibited and should be avoid.



5. the classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles.







1. Fiberoptic bronchoscopy is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray (CXR). It is the next step if a CXR shows a mass, if the CXR is normal and there are major risk factors for cancer, or if the CXR is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation. Then remember, if you have a patient with hemoptysis with past history of smoking ,your first step is CXR even if he/she is normal right now but keep in mind that a CXR is not part of a routine physical examination of an asymptomatic smoker.



2. Complications of ovarian torsion include infection, peritonitis, sepsis, adhesions, chronic pelvic pain, and infertility due to the loss of the viability of the torsed ovary.



3. One of the most important considerations in evaluating patients with conjunctivitis is to rule out any vision-threatening conditions such as iritis, keratitis, glaucoma, or a corneal ulceration. Symptoms such as marked photophobia, decreased visual acuity, or globe pain suggest that ocular structures other than the conjunctiva are involved and should trigger immediate ophthalmologic evaluation.



4. The pathophysiology of ITP involves antibodies(IgG or IgM) binding to platelets. These antibody coated platelets are subsequently destroyed in the spleen.



5. An extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients.







1. Multifocal glioblastoma multiforme (GBM) , the most frequent malignant primary brain neoplasm, manifests as an ill-defined mass in the white matter.



2. Wernicke encephalopathy is characterized by nystagmus progressing to ophthalmoplegia, truncal ataxia and confusion.



3. Korsakoff syndrome refers to alcohol-related amnesia and confabulation. Wernicke-Korsakoff syndrome is due to vitamin B1 deficiency, which is often seen in chronic alcoholics. This deficiency results in degeneration of periaqueductal gray matter.



4. Huntington disease, an autosomal dominant condition, is caused by an unstable expansion of a CAG trinucleotide repeat. MRI examination of the brain reveals hyperintensity in the region of the caudate on T2-weighted images.



5. The pathologic substrate of Huntington disease is degeneration of the striatal neurons, especially those in the caudate nucleus.







1. The pathogenesis of stress-induced gastritis: Diffuse gastric mucosal vasoconstriction.



2. Right-sided endocardial fibrosis, with pulmonary stenosis and tricuspid regurgitation, is common in carcinoid patients and is the result of toxic damage to the heart.



3. Ondansetron, a 5-hydroxytryptamine3 antagonist, is the most potent antiemetic available for chemotherapy-induced vomiting. It has side effects only infrequently, the most common being constipation.



4. Copper deficiency can present with anemia and neutropenia; Zinc deficiency will present with alopecia, impaired wound healing , dermaititis; Selenium deficiecny will present with dilated cardiomyopathy.



5. Bernard-Soulier syndrome is an autosomal recessive disease of platelet adhesion which causes prolonged bleeding times in the presence of normal platelet counts. These defective platelets can not bind to subendothelial collagen properly because of a deficiency or dysfunction of the glycoprotein Ib-IX complex. Clinically the patients have impaired hemeostasis and recurrent severe mucosal hemorrhage. The only treatment for an acute episode is a transfusion of normal platelets. This patient has a slightly decreased hemoglobin due to blood loss.









2; acalculous cholecystitis occu in dm immunosuppresed debilated icu and ct shows peri fluid and wall thickening and biliary sludge



3' sle has no erosion but rh. has, needing methotrex



atrial myxoma has a fixed mitra like murmur w/o opening snap



5.kallman has not only reduce smeell but hypogondotrophic gondism no brest no pubic axillary hai and has hypo thalam tumo.



6. cause primary amenorrha



7 ther is one syndrome in primary ;many in second lke ashermamn rokitsky and so one



8juvenile angiofibrma lik juv delequency occu in adolescent presnt w/t epistax



9. inhalant cause encephalopath and brain damage



10esophage atrsia and fistula r rel'd to polyhydra in fetus



1 untreated hyperthy cause abortion nd prematur deliv-y and treat with lowest taperi-ng propyl thyouracil.



12.hypospadis a/w the congeni defect ;do ua and usg



13 presense of endocervical tissue is must in smoker hige risk cevical pap but in low risk even limited is not considered inadequate rpt afte 1 yr but in hy risk repeat quick



1.Von Willebrand's disease causes increased bleeding times with normal platelet counts. It is the most common inherited bleeding disorder, caused by a defect in von Willebrand factor, which aids the binding of platelets to collagen. Even though the platelets themselves are normal, binding is impaired, thus a platelet transfusion would not correct the problem. Cryoprecipitate, a plasma fraction rich in von Willebrand factor, would help in the case of von Willebrand's disease, but would not help with Bernard-Soulier syndrome.



2. Coarctations account for approximately 7% of congenital cardiac abnormalities, occur more frequently (2x) in men than in women, and are associated with gonadal dysgenesis and bicuspid aortic valves. Adults will present with hypertension, manifestations of hypertension in the upper body (headache, epistaxis), or leg claudication. Physical examination reveals diminished and/or delayed lower extremity pulses, enlarged collateral vessels in the uppe r body, or reduced development of the lower extremities.



3. Lymphoma is well known to develop specifically in the late stage of Sjogren's syndrome. Common manifestations of this malignant condition include persistent parotid gland enlargement, purpura, leukopenia, cryoglobulinemia, and low C4 complement levels.



4. If they give you a farmer patient presenting with acute-onset pulmonary symptoms, including wheezing, with no other medical problems and was recently handling hay, think about farmer's lung; a hypersensitivity pneumonitis caused by Actinomyces. In this disorder moldy hay with spores of actinomycetes are inhaled and produce a hypersensitivity pneumonitis. The disorder is seen most commonly in rainy periods, when the spores multiply. Patients present generally 4 to 8 h after exposure with fever, cough, and shortness of breath without wheezing. Chest radiograms often show patchy bilateral, often upper lobe infiltrates. The exposure history will differentiate this disorder from other types of pneumonia.



5. The Women's Health Initiative (WHI) demonstrated that estrogen-progestin therapy in Postmenopausal can reduce the risk of hip fractures by 34%. However, the WHI also demonstrated that estrogens are associated with a 30% increase in myocardial infarction, a 40% increase in stroke, a 100% increase in venous thromboembolism, and a 25% increase in breast cancer. In the WHI study there was no overall effect of estrogen-progestin therapy on mortality, probably because of the balance between the detrimental cardiovascular effects and the beneficial effects (in addition to fractures, there was a beneficial effect on the development of colon cancer) - Harrison's new eddition!





1.Pain, loss of function (without clear-cut sensory or motor deficits), and a localized autonomic impairment are called reflex sympathetic dystrophy (also known as shoulder-hand syndrome or causalgia). Precipitating events in this unusual syndrome include myocardial infarction, shoulder trauma, and limb paralysis. In addition to the neuropathic-type pain, autonomic dysfunction, possibly resulting from neuroadrenergic and cholinergic hypersensitivity, produces localized sweating, changes in blood flow, and abnormal hair and nail growth as well as edema or atrophy of the affected limb. Treatment is difficult; however, anticonvulsants such as phenytoin and carbamazepine may be effective, as they are in other conditions in which neuropathic pain is a major problem.



2. Typical radiographic findings in osteoarthritis include joint space narrowing, subchondral bone sclerosis, subchondral cysts, and osteophytes (bony spurs). In the small interphalangeal joints of the fingers , central erosions may be seen within the joint space.



3. Addiction has identifiable risk factors, including genetic factors. The most well-established risk factors for addiction are family history and male sex.



4. HTN+Glocuma treatment? Beta-blocker



5. In cocaine toxicity, serum and urine tests are useful when they are positive, but they are of limited utility when they are negative because of the short duration of detectability of cocaine (6 to 8 hours) and cocaine metabolites (2 to 4 days). Cocaine does not produce compensatory adaptations in brain regions that control somatic functions and therefore does not produce dependence. Dependence and, therefore, withdrawal are not produced by highly addictive compounds such as cocaine.





1. The benzodiazepines (e.g., chlordiazepoxide, diazepam, lorazepam, and oxazepam) are the safest and most effective medications for treatment of alcohol withdrawal.



2. Glucagonoma and gastric adenocarcinoma are associated with acanthosis nigrans.



3. Nasopharyngeal carcinoma and burkitt's lymphoma t8:14 are associated with EBV.



4. Findings in Von Recklinghausen's disease: Cafe-au-lait spots, neural tumors, Lisch nodules (pigmented iris hamartomas), skeletal disorders (scoliosis), and increased tumor susceptibility.



5. Findings of Cri-du-chat syndrome: microcephaly, severe MR, high pitched crying/mewing (Cri-du-chat is French for cry of the cat), cardiac abnormalities.





1. Pathogenesis of Cystic Fibrosis: defective Cl- channel --> secretion of abnormally thick mucus that plugs lungs, pancreas, and liver --> recurrent pulmonary infections (Pseudomonas species and Staph aureus), chronic bronchitis, bronchiectasis, pancreatic insufficiency (malabsorption and steatorrhea), meconium ileus in newborns.



2. Which gene is affected in Fragile X ? methylation and expression of the FMR 1 gene is affected in this X-linked disorder.



3. Skin conditions in AIDS patients: one is a bacterial infection and the other is a viral cause; both look similar - kaposi's sarcoma-HHV 8 AND BACILLARY ANGIOMATOSIS-caused by bartonella henselea.



4. Genetic anticipation of Fragile X syndrome may be shown by what? Triplet repeat (CGG)n



5. Huntington's: gene involved and triplet repeat - chromosome 4p, CAG.

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1.Kidney cancer is a neoplastic condition that can initially appear with many different paraneoplastic manifestations. The initial presentation may include hypertension, flank mass, gross or microscopic hematuria, hypercalcemia, fever, weight loss, and/or polycythemia. This polycythemia is the presenting sign in 3% of cases of kidney cancer. In kidney cancer, polycythemia is secondary to a hypersecretion of tumor cytokines, including renin. The patient's erythropoietin level is usually high. Surgical removal of the cancer resolves the polycythemia. ull evaluation is important in patients presenting with polycythemia and hematuria. Kidney cancer is an important differential diagnosis of secondary polycythemia.



2. Esophagitis in HIV often presents with belly or epigastric pain that could be caused by CMV or herpes simplex, but Candida is most common (80%-90%); treat empirically with fluconazole 100 to 200 mg/day.



3. Cryptococcal meningitis in HIV: minority of p atients have meningeal signs; most have only fever and headache. Obtain head CT and lumbar puncture (LP); elevated opening pressure most common abnormality; cerebrospinal fluid (CSF)-can be normal; most have normal glucose; only 50% of patients have elevated protein; minority of patients have white blood cells in CSF; india ink simple test that detects 75% of cases; cryptococcal antigen >90% sensitive, but results take 1 to 2 days at most institutions. How do you treat? Treat with amphotericin B; flucytosine added in patients with severely elevated pressures; fluconazole as maintenance for rest of life.



4. LDH: nonspecific test; appears to be consistently greatly elevated in PCP; PCP unlikely if LDH normal (in HIV ).



5. Pneumocystis carinii pneumonia (PCP) less common now because many patients receiving medical care get prophylaxis for this organism; Pneumocystis carinii now considered closer to fungi than to protozoa; bacterial pneumonia now more common than PCP.

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1. Antiretroviral treatment for HIV: no consensus on when to start; indications include acute HIV infection, symptomatic HIV infection, CD4 count 55,000 copies/mL).



2. Kaposi\\\\\\\\\\\\\\\'s sarcoma: reddish/purplish lesions can be located anywhere (internal or external); characteristic appearance of sharp demarcation (HSV8).



3. Hairy leukoplakia: tends to occur on side of tongue; cannot be scraped off like thrush; related to Epstein-Barr virus.



4. What 2 neoplasms are associated with AIDS? Aggressive malignant lymphomas (non-Hodgkins) and Kaposi\\\\\\\\\\\\\\\'s sarcoma.



5. What 2 neoplasms are associated with Tuberous Sclerosis (facial angiofibroma, seizures, and mental retardation)? 1. Astrocytoma 2. Cardiac Rhabdomyoma.

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1. Treatment for rhabdomyolysis involves intravenous saline infusions to maintain a high urine output and alkalization of urine with a target pH of 7-8 to prevent myoglobin deposition.



2. Aortic dissecting aneurysm caused by degeneration of tunica media-cystic medial necrosis.



3. Cardiac rupture most common 4-7 days post MI.; ventricular free wall rupture leads to cardiac tamponade.



4. New onset serous discharge from a laparotomy wound should raise the suspicion of wound dehiscence.



5. Acute angle-closure glaucoma, which is an ocular emergency that requires immediate treatment to prevent blindness: Immediate treatment includes mannitol (to reduce vitreous volume), acetazolamide and topical beta-blockers, such as timolol (to block aqueous production), and pilocarpine (to facilitate aqueous outflow). Ophthalmologic consultation should also be sought as soon as possible. A peripheral laser iridectomy is the definitive procedure and is usually performe d after the IOP is controlled.

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1,benzo are good for withdrawal and delirium tremen



2 the glucagonama not only cauese that migratory dermatitis eczema like condition but also acanthosis nigrican; remember it s also in hair in syndrome



3 in young it is aw dm; in old -cancer



4.von reclihaushean is also aw scoliosis

5 ebv infectious mono and hair leuko



6.huntigton is cag repeat fragile x is cgg repeat. it is x linked



7 wht are othe x ; bruton gama hemophilia fabrys hunter mucopolysachridoses huntigyton g6pd pyruvate defi duchene muscle dystrophy



8. 8; polycythemia hematuria in rcc



9; cryptoccus w/o meningismus pressure m/b nl india ink 75% ANTIGEN 90% BLOOD IN CSF 100% AMPHOTERICIN + FLUCYTOCIN AND FLUCOCONAZOLE ALON FOR LIFE



10, no ldh no pcp in pcp no pleural effusion



11.hiv kaposhi and non hdk



12 kaposhi sharp demarcation



i2 hairy lukoplakia ebv



13 start hivrx in 350 andd 500000 copis



14 tuberous scelorisis brain tumo rhabdomyoma renal angiomyolipoma seizure facial angiofibroma and menta retardation



15rhabdomyelyssis can happen even when one is unconscious an in crush syndrome there is myoglobunaria and renal failure



16 rx is vigrous hydration osmotic diuresis and alkalinization target ph 7 8



7 cystic medial necrosi aortic aneurysm

8 car diac rupture on 5 days because necrosed wall is noncompliant and ld to tamponade.



9 \\\\\\\\\\\\\\\' new pink dcg in lap wound w; dehiscence



1o angle closure is emergency give acitazolamide mannitol to decrese volume in vitreous

11 an beta blocker to block production and pilocarpine only given later to facilliate the outflow



12. laser iridectomy is definite rx after crisis is over/





1. How do you manage a patient with non massive (less than 100 cc in 24 hour) hemoptysis? The work-up begins with history and physical examination. A chest x-ray and laboratory studies should be ordered initially. If the chest x-ray is normal and the patient has risk factors for cancer, like smoking, a bronchoscopy should be ordered to localize the bleeding site and look for an endobronchial mass. If none is found, a high resolution CT scan should be considered. If a mass is found on a study, referral to a thoracic surgeon is necessary.



2. Once a biopsy diagnosis of cervical intraepithelial neoplasm has been made, an appropriate treatment option is a loop electrosurgical excision procedure, and the most common complication being postoperative bleeding.



3. Patients with dural sinus and cerebral venous thrombosis can present with headaches, stroke-like symptoms, and/or seizures. There are multiple etiologies including dehydration, sepsis, and trauma. In addition, hypercoagulable states such as sickle cell disease, leukemia, and pregnancy are also predisposing factors. Because the symptomatology of a dural sinus thrombosis is nonspecific, imaging studies play a critical ro le in the diagnosis. On non-contrast enhanced head CT, a cord sign or tubular hyperdensity may be seen in the acute setting along with cortical and subcortical hemorrhage due to venous stasis and infarction. The treatment of choice during pregnancy is intravenous heparin. Unfractionated heparin and low molecular weight heparin (LMWH) do not cross the placenta and are considered safe for the fetus, but must be administered parenterally.



4. Children with sickle cell disease, despite splenomegaly, have reduced function of the reticuloendothelial system (functional asplenia). Therefore, in a sickle cell patient with a fever, it is important that broad spectrum antibiotics are instituted as soon as possible to protect against septicemia from encapsulated organisms such as H. influenzae, Pneumococcus, and Neisseria.



5. Heat stroke can occur in athletes who exert themselves in conditions of high humidity and temperatures. Clinical signs of this condition include a core body temperature of >40.5 C (or 105 F), profuse sweating, and mental status changes. Patients with exertional heat stroke are at risk for disseminated intravascular coagulation and rhabdomyolysis.

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1. Treatment of Acne rosacea: avoidng exogenous factors,topical metronidazole, no response give tetracycline.



2. Risk factors for tubo-ovarian abscess (TOA) include IUD use, multiple sexual partners, and previous episodes of pelvic inflammatory disease. Intravenous cefoxitin is used because it is an antimicrobial agent that is active against Gram-negative and anaerobic organisms, the predominant bacteria found in these abscesses. What will you see in sonogram? Trasonography of the pelvis demonstrates a complex, cystic mass containing multiple septations and internal echoes in the left adnexa.



3. A tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way valve mechanism and compromises the contralateral lung and the venous return to the chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the pressure.



4. A pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion scan. In trension pneumothorax the ventilation perfusion scan demonstrates lack of ventilation and perfusion.



5. How do you manage a syncopal episode in a young healthy adult? A young, healthy, athletic patient can have a syncopal episode which can be cardiogenic or neurogenic in origin. After the history and physical, blood work is usually sent to rule out anemia, infections, hypocalcemia, or hypomagnesemia and an EKG must be performed. An EKG may show evidence of cardiac abnormalities such as Wolf-Parkinson-White syndrome (r wave slurring), idiopathic hypertrophic subaortic stenosis, or congenital prolonged QT syndrome.

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1..Higher prevalence enhances positive predictive value. Simply put, if more people actually have the disease, then a positive test result has a higher probability of being true. Note that for the reasons described here, diagnostic tests always have a higher positive predictive value than screening tests.



2. The definition of chronic sinusitis is a sinus infection greater than 3 months. The most common etiology is infectious and the organisms most responsible are rhinovirus, H. influenza, S. pneumoniae, and influenza. The hallmark of acute sinusitis compared with sinus inflammation is total ostial obstruction. Once obstructed, fluid accumulates and becomes infected. The diagnosis is suggested by clinical signs and symptoms although certain imaging studies are very useful. The only imaging study to consider is a sinus CT. If positive, the maxillary or ethmoid sinuses will be opacified.



3. Women who have very low body fat and/or participate in intense exercise are known to have a decrease in gonadotropin releasing hormone (GnRH), which in turn results in a diminished release of follicle stimulating hormone (FSH) and leuteinizing hormone (LH). Ovulatory dysfunction is responsible for approximately 20-25% of infertility cases.



4. Septic shock is characterized by decreased blood pressure despite euvolemia and is often seen with severe infection, especially with Gram-negative organisms. Release of inflammatory mediators is responsible for decreasing SVR. Patients are thought to be in a hyperdynamic state with increased cardiac output. Volume status is reflected by PAWP and is classically normal but can be normal, low, or high depending on the aggressiveness of hydration.



5. Decreased CI, increased SVR, and normal PAWP is an example of cardiogenic shock. This is common with cardiac tamponade or myocardial infarction. It should be thought of as pump failure. The cardiac index is low because the heart is not pumping well. The SVR is increased in an effort to maintain blood pressure. The PAWP is normal in these patients since volume is typically not the primary problem.

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1.Hypovolemic shock is demonstrated by a low cardiac index, an increased SVR, and a decreased PAWP. Simply, CI and PAWP are low because there isn\\\\\\\\\\\\\\\'t enough blood volume to be pumped by the heart (low volume = low pre-load). SVR is elevated to attempt to increase blood pressure.



2. Obstructive shock, characterized decreased CI and normal SVR and PAWP , is typically caused by massive pulmonary embolus. Supportive care with IV fluids and vasoconstrictors along with possible embolectomy is indicated. Note: The only indication for embolectomy is hemodynamic instability.



3. The presentation of painless jaundice is highly suspicious for a pancreatic head mass and in particular adenocarcinoma of the pancreas. Adenocarcinoma of the pancreas accounts for more than 90% of pancreatic malignancies and jaundice is present in about 65% of patients. Risk factors for pancreatic adenocarcinoma include smoking and diabetes. The best initial evaluation for pancreatic masses is by C T of the abdomen and pelvis.



4. Lorazepam is a short acting benzodiazepine with no active metabolites. Lorazepam is metabolized to the glucuronide form and excreted by the kidneys. The drug is tapered over 4-6 days for detoxification purposes. It is safe in patients with severe liver damage, and it won\\\\\\\\\\\\\\\'t compromise respiration in severe COPD.



5. Chlordiazepoxide is a long-acting benzodiazepine that is used for detoxification from alcohol in uncomplicated cases. It has several metabolites that are long acting, thus making it difficult to efficiently manage the detoxification without risking the accumulation of drug and its metabolites because of impaired liver metabolism. In patients with severe COPD, it can compromise respiration secondary to sedative effects.

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1.Renal vein thrombosis. Most commonly occurs in Membranous glomerulonephritis.



2. Excessive friction between the iliotibial band and the lateral femoral condyle can lead to iliotibial band tendonitis. This overuse syndrome commonly occurs in runners and cyclists, although it may develop in any person subsequent to activity involving repetitive knee flexion. Tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial torsion are predisposing factors.



3. The patient with iliotibial band tendonitis reports pain at the lateral aspect of the knee joint. The pain is aggravated by activity, particularly running downhill and climbing stairs. On physical examination, tenderness is present at the lateral epicondyle of the femur, approximately 3 cm proximal to the joint line. Soft tissue swelling and crepitus also may be present, but there is no joint effusion. Radiographs are not indicated.



4. The two live vaccines, MMR and the varicella vaccine, are not recommended for use before the first birthday, but should be given the first time the child sees the doctor after 12 months of age.



5. The findings of diffuse osteoporosis in a patient on hormone replacement therapy are suspicious for a multiple myeloma.

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in 100 cc hemoptysis do cxry and bronchoscopy and coagulate the blleding point after localising it or take a biopsy and refer if there is amass.



2 biopsy diagnosed intraepithelial neoplasm -- leep



3 shock sepsis hemorrage and sickling can cuse stroke like condition due todural thrombosis presenting with neuro deficit and hedache and seizure and cranial nerve defecit.



5 decreased cardic index increased pawp and increasd svr is in cardiogenic shock,



6 adeno ca pancreas

7, obstructive shock due to massive PE HAS A NORMAL pawp



lorazepam is safe drug in detoxification programme dur to safety profile in liver and excreating through kidney



6 sicle cell having fever will be needing broad spectrum for encapsulted bacteria due to reduced functionally depressed RES mainly strep and hemophillus type b



7 septic shock is due to inflammatory mediator of sepsis reducing svr and cusing warm shock pawp is normal or low but can be high during overjealous hydration.



8 chlordizopoxide a good drug for detoxifying programme but becomes a bad drug in liver disese because its metabolites are long acting and difficult o clear and so accumulate and also in copd can compromise respiration in contrast to lorazepam which do not.



9 higher rhe prevalence higher the predective value so lower the prevalence lower the predective value . so lower the prevalence higher the predective value and higher the prevalence lower the predective values. but sensivity and specifity do not change wih predictability



10. sensitivity is about disease and sensibity is possibility that a diseased person will have a positive test



ii specifity is about NIH NORMAL IN HEALTH. IT IS THE POSSIBILITY THAT A HEALTHY PERSON WILL HAVE NEGATIVE TEST.



12, positive predictability is predictability that a person with positive test has actually the disease



13 negative predictability is the probability that a person with negative test has actually have no disease



14 heat stroke have 105 temp and can have dic





14. prevalence is pid \\\\\\\\\\\\\\\' that is. incidence with duration.



15. disease like influenza have higher incidence and disease like sle have higher prevalence



16. syncope in athlets may be due to hccm or arrahthymia like woollf parkinsonism syndrome and congenital long QT SYNDROME OR ELECTROLYTE CHANGES SUCH AS HYPERCALCEMIA HYPOMAGNESSIMIA POTASSIUM CHANGES. SO ECG AND ELECTROLYTE IS v important.



17 PE CAUSES VENTILATION PERFUSION MISMATCH. high ventilation low perfusion so ratio is infinity



18 pnemi=othorax causes both reduced



19 tubo ovarian abscess usg multiple septation and fluid in those loculi in the adenexal mass and occurs in stds multiple sexual partner and with iud and px. cefoxitin is DOC



20 ACNS ROSEAsea IS TREATED WITH topical metro ;get metro by metro./ no responce tetra/ of course avoid exogenous factor



membranous glomerulonepritis can cause renal v rhrombosis



iliotibial tendonitis causes frictional injury of iliotibial tract in cyclist runner due to overuse syndrome and there is lateral knee tenderness and even crepitus no xray is warrented.



mmr and varicella are given in first year not before that because the immune system is not mature enough to handle it,



diffuse osteoporosis in hrt will make you review the diagnosis in search of multiple myeloma



1. Laboratory data for multiple myeloma includes anemia, an elevated creatinine from secondary renal dysfunction, and elevated IgA and IgG levels and hypercalcemia.



2. Bone scan has a low sensitivity for myeloma lesions and has no role in its workup. Do not confuse a bone survey which is a series of x-rays evaluating all of the bones with a bone scan which is a nuclear medicine scan. NO BONE SCANE FOR MULTIPLE MYELOMA!



3. A postoperative pelvic abscess: This condition may occur after abdominal surgery, and presentation usually occurs after postoperative day 7. Diarrhea is frequently the earliest manifestation of abscess formation. A fluctuant mass is a common finding on physical exam, and a rectal exam should be performed on all postoperative patients who are at risk for developing an abscess. A postoperative abscess will frequently cause an ileus, as manifested by vomiting, abdominal distention, decreased bowel sounds, and radiographic findings. Although the clinical grounds may provide you with the diagnosis of abscess, imaging studies should be undertaken to localize the fluid collection and aid in drainage. A CT scan probably has the highest yield compared to the other imaging modalities. Besides localizing the abscess, a CT scan will aid in the drainage of the fluid collection.



4. APGAR is a named after Virginia Apgar, M.D. who came up with a rating system for neonates at delivery. One helpful mnemonic is A: appearance, P: pulse, G: grimace or response to catheter in nostril, A: activity or tone, and R: respiratory effort. Each category is rated from 0-2.



5. Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections.

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1. After a myocardial infarction, normal sexual activity can typically be resumed 2-4 weeks after discharge from the hospital.



2. Some of the most common anomalies associated with congenital rubella are intrauterine growth retardation, microcephaly, microphthalmia, cataracts, glaucoma, retinopathy, patent ductus arteriosus, hepatomegaly, jaundice, thrombocytopenia, metaphyseal lucency, and a purpuric rash also known as a \\\\\\\\\\\\\\\"blueberry muffin\\\\\\\\\\\\\\\" rash. Infants may be asymptomatic at birth, but the earlier in pregnancy the mother is infected with the rubella virus, the more likely the baby is to have defects. For example, if a mother is infected in the first 8 weeks of pregnancy, the baby has an 85% chance of having a defect.



3. Toxoplasma gondii is another organism that can cause congenital infection, but 70-90% of infants with congenital infection are asymptomatic at birth. It is important to note that a large percentage of the infants that are asymptomatic at birth w ill develop visual impairment, learning disabilities, or mental retardation months to years later. Signs of congenital toxoplasmosis include: hydrocephalus, microcephaly, cerebrospinal fluid abnormalities, intracranial calcifications, chorioretinitis, hepatosplenomegaly, generalized lymphadenopathy, and a maculopapular rash.



4. Varicella-zoster infection in a mother causes different syndromes in a baby depending on the time of the infection. If the mother is infected in the first trimester or early in the second trimester, the baby may develop varicella embryopathy which is characterized by microphthalmia, cataracts, chorioretinitis, cutaneous and bony aplasia/atrophy, and scarring of the skin of the extremity. If the mother is infected during the second 20 weeks of pregnancy, the baby may show no clinical manifestations of varicella, but may develop zoster later in life without ever having extrauterine infection. If the mother develops varicella from 5 days before delivery until 2 days after delivery, the child may develop severe infection, which may lead to death.



5. Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk, with the risks of the fracture and the surgery being additive. Some estimates place risk of DVT at greater than 80%. The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%.

_____________________________________________



1. Whenever you use niacin you should monitor liver function and plasma glucose carefully.



2. When do you use niacin? When a patient cannot tolerate statins and also it\\\\\\\\\\\\\\\'s the best choice for raising HDL.



3. An angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.



4. Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.



5. White cells generally indicate active inflammation. The presence of leukocytes in a stool sample would be highly suggestive of IBD.

________________________________________________



1. The treatment of unstable atrial fibrillation (atrial fibrillation associated with hypotension, myocardial ischemia, congestive failure, etc.) is immediate synchronous cardioversion, in an attempt to immediately restore sinus rhythm.



2. Churg-Strauss vasculitis: Prednisone should be started at a moderate dose, along with a bisphosphonate to prevent osteoporotic fractures,in initial therapy no cyclophosphamide.



3. Major depression need not present as classic dysphoria or sadness.It may present as irritability particularly in children and adolescent.



4. In DM with sports this is what we do… check ketone.. if positive patient can not participate until ketones are gone. In DM insulin is decreased with snacks during break. Checking glucose before and after sports is also a reccomendation



5. BILATERAL renal aa. stenosis with HTN: what med do you use to treat HTN Calcium channel blocker. If it was unilateral stenosis then ACE inhibitors.

____________________________________________



1.A male patient with thumb base pain: what is dx. De Quervain Tenosynovitis; treatment is NSAIDs and intrathecal steroids.



2. How do you treat Cocaine abuser with 210/115 BP? Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV. No beta blockers like propranolol.



3. Bilious vomiting in an infant means that there is a malrotation with volvulus until proven otherwise. The radiographic findings of the cecum in the left upper quadrant confirms this clinical diagnosis. An upper gastrointestinal series would likely show a bird-beak deformity of the midgut where there is volvulus of the gut around a mesenteric \\\\\\\\\\\\\\\"Ladd\\\\\\\\\\\\\\\" band.



4. About 20% of malrotation with volvulus is associated with duodenal atresia, annular pancreas, or a duodenal diaphragm. About 33% of cases present in the first week of life and 85% present in the first year of life. The hallmark of malrotation is ischemia of the midgut as the superior mesenteric vein and the superior mesenteric artery are occluded by the twisting mesentery. Immediate surgery is necessary to prevent death or the loss of much of the bowel.



5. Intussusception typically presents in infants from 4 months to 2 years of age, with alternating lethargy and irritability, colicky abdominal pai n, and currant jelly stools. In addition, there is usually a right lower quadrant mass on abdominal x-ray.

_____________________________________



1. The presence of tamponade is suggested by the presence of diminished heart sounds and pulsus alternans (a beat to beat variability in the QRS amplitude) on EKG.



2. It is useful to note that the shock typically associated with sepsis, anaphylaxis, and neurogenic shock is associated with vasodilation, and hence, with warm extremities.



3. Complication of polycytemia vera:

1.Hyperuricemia due to increased RBC turnover is common in patients with polycythemia vera, and these patients are at increased risk of gout.

2.Both arterial and venous thrombosis are common in polycythemia vera. The Hct is directly related to the risk of thrombosis. This association between Hct and risk of thrombosis forms the basis for the treatment recommendation to keep the Hct less than 46%. The platelets are derived from the neoplastic clone and may not function normally.

3.Approximately 15-20% of patients with Polycythemia vera eventually develop myeloid metaplasia. Myeloid metaplasia is characterized by gradual replacement of the marrow space with fibrosis, and movement of hematopoiesis into the spleen and liver. The spleen and liver become massively enlarged, and the patient becomes progressively pancytopenic.

Polycythemia vera :Neoplastic hematopoietic stem cell; CBC in Polycythemia vera: Hct and often WBC and platelets are increased; treatment: Phlebotomy or hydroxyurea or 32P to keep Hct below 46%, decreased or low normal erythropoietin

Secondary Polycythemia: disorder due to tissue hypoxia causing an appropriate increase in Epo production, or to renal or hepatic disease causing an inappropriate increase in Epo production , only Hct is increased , treatment is usually not required, normal or increased erythropoietin.



4. Hyperuricemia: An elevated uric acid level can result from gout, renal failure or an increased production of uric acid secondary to high rates of cell turn over such as in patients with hematologic malignancies. it may also be seen during treatment of these malignancies with chemotherapy when the rapid destruction of cells releases large amounts of uric acid into the blood, so called "tumor lysis."





1. Whenever u see an HIV positive patient on pentamidine with seizure think ((pentamidine induced hypoglycemia..and check blood glucose!!))



2. The CT scan can be normal in 5% of patients with a subarachnoid hemorrhage within the first 12 hours of headache onset. Between 24 and 72 hours from onset of headache, up to 25% of CT scans can be normal. Therefore, if one suspects a subarachnoid hemorrhage from the patient's history, it is imperative to perform a lumbar puncture to evaluate the CSF for xanthochromia and red blood cells. Xanthochromia is not seen in a traumatic tap and may be more specific than RBC analysis.



3. The age of 18 months, most children will have developed a specific set of skills which can be divided into: social, self-help, gross motor, fine motor, and language. Social skills at this age include greeting people by saying "hi" or something similar, giving hugs and kisses, and playing patty-cake. Self-help involves drinking from a cup and feedi ng self with a spoon. Gross motor skills include walking without help and beginning to run. Fine motor skills would include scribbling with a crayon and stacking 2 blocks. Language skills should encompass talking in single words, asking for food or drink with words, and following simple instructions.



4. Histoplasma capsulatum is a dimorphic fungus ,it is endemic to the Ohio, Missouri, and Mississippi River valleys , T lymphocytes are crucial in limiting the extent of infection. Susceptibility to dissemination is increased markedly with impaired cellular host defenses. A thorough social and occupational history is essential in the initial evaluation. Travel or residence in an endemic area or activities involving bats or birds, whether recent or remote, should aid in the differential. Determine if the patient has a drug history or comorbid condition that is contributing to an immunocompromised state.



5. Temporomandibular joint (TMJ) disorder, which is a very common disorder that can usually be detected by palpating the area just in front of the tragus. Joint clicking may be found when the patient opens and closes his mouth. Symptoms of TMJ include orofacial pain, a noisy joint, and restricted jaw function.





1. Treatment for preventing recurrence of HBV after liver transplant is HBV Ig + Lamivudine.



2. Rx acute attacks of migraines : Rizatriptan



3. Rx for acute attack of migraines lasting longer than 48 hours or that are frequently recurrent : ergotamine



4. Rx rhabdomyolysis : osmotic diuresis + bicarbonate



5. Low Ca, high P, high PTH =secondary hyperPTH due to renal failure

-lung cancer: high PTH-related peptide, high Ca, low P

-primary hyper PTH: high Ca, low P, high PTH

-multiple mieloma: high Ca, low to normal PTH



1. HIV patient pneumonia: Most Common is still pneumococcus; In PCP=>no pleural effusions



2. A new born with central cynosis ,apex palpated on the rt and scaphoid abdomen, neonatologist suspects diaphragmatic hernia? whats the next step to do? Do orogastric suction and can operate after 2-3 days because the lungs are hypoplastic and u allow them to be mature



3. 42 yo M, repeated Lower Leg clots: Dx? (factor V laiden deficiency)



4. M with superficial varicose veins, discoloration of Lower Limbs: cause? (increased hydrostatic pressure in the v/s)



5. M fall off a ladder & hit with the ladder, 3-4 days later comes with abd pain, tense & tender, abd XR shows fluid under both side diaphragm, Dx ?( splenic rupture)





1. in multiple myeloma do cbc for anaemia. ua for bence jones protenuria electrophoresi for igg oiga but xraya but no bone scan because it is apuredestructive lesion



2 bilious vomiting in neborn with obstruction almost due to malrotation



3. varicella in the pregnancy can cause microopthamia eye ear cataract entropathy brain and even skin scarring



4 polycythemia though causes venous thrombosis can cause arterial thrombosis



5. hyper uricemia can be in under secretor like in renalfailure and over secretor like in tumour lysis drugs and disease like lischnyhan syndrome can be with diabetes insipidus or even lead poisoning



it is also asociated alkalization of urine/



6. in chemotherapy allopurinol can be given because to prevent overproduction



7. in polycythemia platelets are derived from clone and may not function properly. phlebotomy and hydroxy urea can be used in it,



8 in cocaine cardiac ischemia giv benzo nitro glyserine phntolamine nitroprusside but not beta blok because it may cause overwhelming further vasoconstriction and further ischemia



--pteithe dsd witness or encounter for laveled as ptsd



--derealization and crzy dommed dyeing feeling are in panic



===terbinafine and itraconazole for weeks for onycholysis of toes and fingers



--topical agents are nt effectv



--tay sachs disease has no splenomegaly like spinghomyelinidase but both have cherry red



--asken jews

--healthy at birth but later die with incordinadion dementia become vegetative by 3 an di

-cottonwool patch or soft exudate in htn



roth spot in be



-- elevated intracranial space papilledema



--gray fold elevation of retina- retinaldetachment



glioblastoma buterfly shape in adulr worst prognosis of 6 month



---primary cns lypoma in aids

--cerebral metsasis gray whit area



--meningioma benign more in women calcification psammoma body

--scaphoid fracture treat urgent dont look for xray sign

--thumbsplint immobilization for three weeks

--pregnancy most be excluded in all ameniorrhaea



--asherman s. is the secondary amenorrhea related to d an c

--too much exercisecan cause amenorrhea like in anorexia nervosa

-bilaterally nonreactive pupil may e by bilateral optic lesion



--holmes adie pupil are unilateral but syphillis like presentation in ciliary ganglion lesion



--horner miosis anhydrosis and ptosis



--opiate ovedose pinpint pupil

-opiate withdrawal dilated pupil

--amphetamine cocaine atropine lsd marijuana amitryptaline dilated pupil

--malathon and parasympathetic constricted pupil

--argyll robertson pupil bilateral light reflex absent accomodation reflex present in tertiary sy.



--electrical radiating leg pain rectal spasm pain abdomen bladder spasm gait problem in tabes

-27 with firsrt time htn will have renal artery stenosis with fibrous dysplasia



--but atherosclerosis mcc of htn in older

--electrolyte abnormalitywill nt be expect in essentil htn



--in old age do not say coarctation as your diagnosis

--look for ps in pheochromocytoma

perspiration pressure givin headache

-pain in body

-palpitation

pallor and panicky



--hyperthyroidism with htn, tachycardia wt loss heat intolerance

--a fundoscopic exam and ct in meningitis b4 lp



--unhappy triad are mam that is medial collateral anterior cruciate and medial meniscys



--among these anterior cruciate need operation but other may or may not

--anterior drawe sign in anterior cruciate

--68 yr with no px of operation and no f/o cancer with sbo probly will have hernia

--incarcerated hernias are more common cause of sbo than cancer

-it is nt necessaryto treat a partner of candida



--douching is no good for std

--head xray no longer poor bcoz poor senstvy



--pet evaluate bran activty and r physiologic test

-eeg in non emergency and post seizure

--carotid r for evaluating the anterior blood flow not for intracranial flow as such

-broz dm need early phlebotomy they may hve acanthosis and pigmentataion and candida



--a 48 with recurrent vaginitis with global darkening may hve broz dm

--cholaerapromazine have more fall risk than haloperidol



haloperidol have more dystonia



--thioridazine causes retinal pigmentation

-clozapine causes agranulocytosis



--a 64 with paralytic ileus improved but his k is persistently low what you will do

ans;; i will check mg and correct it



--asplenic pt need pnemococcal vaccination other than other peoplle



--its normal for 9 yr to cry in front of stranger --s anxuety



--colicc in fussy babies and last to 3 month present at 3 weeks and



--imipramine in overdose convulsion coma cardic arrathymia rx na hco3



--bupripione is a good one except that it can cause seizure



--aortic stenosis need cardiac surgeon and refer after echo ; he will need valve replacement or valvuloplasty



--a 4 yr down syndrome pt is not walking suspect leukemia he may have leucocytosis







rubella is a torch vaccine and should not be given while in pregnancy



--rubella is not an indication of voluntary inturruption of pregnancy



--to distinguish between normal grief and depression , pt in depression tend to push away social contact . temporarily sx of grief are considered normal for upto one year.



--normal bereavement must first be excluded b4 diagnosis of depression



--to be a psychotic disorder there should be loss of reality testing , such as hallucination or delusion



----for ptsd ,there would have to be an actual experience of a traumatic event.



---adrenal crisis is the most likely diagnosis in a pt with a history of rheumatic arthritis likely treated with steroid.



--hypotension and mental status changes that do not respond with fluid challange are hall mark of addisons crisis



--do not use high potency steroid in face



--1% IS OK



--A PT OF GLUCOMA WILL HAVE PERIPHERAL VISION LOSS



--LOSS OF CENTRAL PORTION OF VISUAL FIELD IS CALLED -CENTRAL SCOTOMA



-central scotoma may occur in occipital lesion or if there is compression of nerve bundle in both eyes., as the nerves corrosponding to central vision are most vulnerable to compression



--optic neuritis will also cause central scotoma



--monoocular blindness is lesion of optic nerve



--bitemporal hemianopsia is classical of optic chiasma



--loss of right upper quadrant of both visual field is lesion in the temporal lobe where the optic radiation corrosponding to the right upper quadrant travel



--children with foreign body aspiration have hyperinflated lungs on cxray



--steeple sign in cxr of rsv



thumb printing in influenza



--epiglottitis should be intubated in or



--there is only 2% risk of biliary colic life time in asyptomatic gall stone



--sx resolve in 24 hr in tia unlike cva.



hypoglycemic can cause stroke like sx but that resolve with dextrose



--migraine can result in visual disturbance and dysarthia but complete hemiparesis is uncommon



--chemo is not curative for cll



--cll is indolent

--cll life expectancy 2 to 10 yrs.

- atypical lymphocyte are present in infectious mononucleosis



--a large pulsatile mass in abdomen and pt in orthostatic hypotension and decreased mental status== take him to or this is ihe case of AAA



--22 yr women in hystria, but if you find tremor basal ganglia sign and golden brown pigmentation in eyes -- she has wilson disease. the ring is kayser fleisher ring



-- a raised subconjunctival fatty structure growing in a horizontal band toward pupil is pterigym



---dots visible in cornea witout inflammation=fanconi syndrome which result in cystine deposit



--a gray band of opacity in the corne 1.5 mm that is seperated by a clear zone from the limbus--arcus senilis of old age



---22 yr old he has a murmur in heart and clubbing hx of rheumatic fever abd now has fever

what will you find in eyes--roth spot



---roth spot central white area surronded by hemorregic circle



---papilledema= elevatededematous disc with blurred margin and tortuous engorged vein =increased intracranial pressure



--gray folded elevation in the region of retina ==retinal detachment



--the presence of extranumerous blood vessel superimposed over the normal vasculature neovascularization in dm



--grayish white ovoid lesion with irregular wool like margin of varying sizes ,some just slightly smaller than the disc= hypertension.cotton wool soft exudate



--tender testis transeverssely lying cremastric reflex absend doppler no bllod flow--torsion testis



--epididymitis cannot be presumed without ruling out torsion



--testicular torsion is a surgical emergency and definitive treatment should not be delayed by testing



pregnant - substance abuse-contraception advice- std councelling and rx - in these cases minors are not minor . they can decide for their rx



--do not violate the confidentiality of a pt



--polycythemia vera - increased blood viscosity headache pruritus after shower blured vision plethora,splenomegaly and high hematocrit with normal morphology



--pruritus is due to incresed histamine released by excess histamine secreted by increased basophilia



--hepatic faliure also result in pruritus as well as obstructive jaundice and biliary cirrosis do.



--idiopathic myelofibrosis result in decreased hemoglobin and hemaytocrit and abnormal morphology . red cell are described as tear drop cell.



in polycythemia platelets are normal



-



--hepatic encephalopathy is diagnosed by hx and physical examination . astexis spider navi disruption of finger nose task and short term memory loss are important



--ammonia level is more prognostic ;higher the level worser is prognosis and a sign that pt is detioriating



--ct is not needed to diagnose this case . ct is good for hemorregic stroke



--eeg is not so valuable her as it is for the seizure



--cholestaeol screening is by hdl and total cholesteol



--a 23, has scaling rash in the extensor surface elbows and knees and has got dandruff too where else he may have lesion--actually this case is psoriasis and his lesion will be in the fingernail as oil spot pitting nail



--routine investigation of the patient who smoke with chest xray is not effective in detection of early lung cancer



--high resolution ct are good for these cases

--hydrocholrothiazide can prevent osteoporosis



--risk of osteoporosis are --fx / age/lack of estrogen/ menopause/dietary deficiency/caucacian race/ thin body built / female sex/smoking

drugs like steroid and tetracycline



--pt with chickenpox are contagious until the lesion crust over. pt may choose to expose their child to a contagious child, but the contagious child should not expose the other children in school or day care.

ideally the parent would not bring the child into the office to prevent transmission to others,.



---painless jaundice recent depressed mood anorexia loss of weight in the elderly is suggestive of pancreatic cancer



--gallbladder, though enlarged will be normal



--pancreatic pseudocyst will be well defined low density mass



--testicular enlargement will be first indication of puberty.you can advice your pt to first expect testicular enlargement.then increase in penile length,then pubic hair,then his growth spurt.approximately 2 yrs after testicular enlargement



--other thing like voice beard are indivualised

--total cholesterol and hdl are affected least by recent consumption of food. but both triglyceride and ldl can be grossly affected by recent eating



--ldl test will therefore require fasting

--psoriasis can cause arthritis\\\\\\\\\\\\\\\'it can give rise to auspit sign and koebners phenomenon

and munroes abscess



--face can be involved in acne and exanthematous rashes viral diseases bacterial diseases atopic dermatitis .sle.discoid lupus,leprosy and-----



--rashes for palm and soles include --rockey mountain spotted fever/syphillis/kawasaki disease;disseminated gonorrhea- actually not a rash



--in infant cradle cap seborrheic dermatitis can spread to the face/



--intertriginal area are are affected by scabies ,candida or tinea



--eczema is linked to asthma

--eczema is a rash that itches



--criteria for influenza vaccine is more than 50 yrs old and hospital worker and high risk pt and heart disease.



--contraindicated in egg allergy since the vaccine is made in egg.



---hand schuller christian disease ,the more chronic progression of histiocytosis x, has the classic triad of exopthalmos,skull finding,and diabetes insipidus



--lettere siwe disease is also a form of histiocytosis x but with splenomegaly ;these pt die in childhood



--nausea vomiting and tinnitus are consistent with salicylate poisoning



--respiratory alkalosis due to hyperventilation and anion gap metabolic acidosis is charactierstic of adult salicylate poisoning

--in children there will be primary metabolic acidosis with respiratory compensation



--respiratory compensation for a primary metabolic acidosis wil not overcorrect



---a young healthy person who is hyperventillating can have a po2 greater than 100mm of hg



SUSPICIAN OF MALIGNANCY SHOULD BE VERY HIGH IN THe PT WITH WEIGHT LOSS AnD SMOKING HISTORY



-PRIMARY BILIARY CIRROSIS IN WOMEN is ASOCIATED WITH ADDISON DISEASE PERNICIOUS ANEMIA,thyroiditisscleroderma sjogren syndrome. raynauds syndrome and inital alkaline po4 is high later bilirubin and ast and alt will be also high. it is characteiised by cholestasis and destruction of biliary ducts. it is dignosed by antimitochondrial antibody and confirmed by biopsy.



hemolysis induced hyperbilirubinemia will have elevated indirect bilirubin and acholuric jaundice because it is water insoluble and excecs urobilirubinogen in urine and very much yellowish urine. indirect bilirubin can be quiet toxic in immature baby because it can croos blood brain barrier being lipid soluble. hallmark of hemolysis is leucocytosis



--hemolytic anemia that coincides with the adminstration of drug with oxidative properties is usually glucose g6pd deficiency especially in black . it is observed with certain drugs like antimalarial like primaquine. quinine. sulfa.nitrofurantoin. red blood cell in g6pd deficiency unable to regenerate reduced glutathione, which protects hemoglobin from oxidative denuration. hall mark of g6pd defi is bite cells in rbc ,



--if you notice hemolysis in old people you can certainly exclude sickle cell anemia because it should have been presented earlier and with so many sequale.



--paoxymal nocturnal hemoglobunaria a deacclerating factor deficiency is an acquired stem cell disorder that predisposesred blood cell to lysis by complement . it is not a/w medication



-- folic acid deficiency causes macrocytic anemia but no hemolysis and no perepheral neuropathy. but in vitamin b12 defiiency there is perepheral neuropathy as wellas some hemolysis



--whenever you see heart failure and px of lung disease it may be cor pulmonale.



--treat shortness of breath sob with SOB s- That is supplemental o2/ beta blocker/steroid



-- digoxin is not indicated for right heart failure except for atrial fibrillation



--although there can be secondary role for diuretics in reducing fluid overload in right heart failure . this will not result in immediate improvement



--betablocker may exacerbate bronchoconstriction and pulmonary hypertension in copd pt

and cor pulmonale pt



--hiv and close contact 5mm ppd is positive







--diastolic murmur are not normal finding in pregnancy



--because of an increase inflow s3 can be a normal finding in pregnancy



--systolic ejection may be normal in prgnant



--s2 split can be a normal finding too due to increase flow and due to so many hemodynamic changes in pregnancy,

--for the same reason, distended neck vein can be a normal finding in pregnancy



---pills in nonambulating pt can give rise to pulmonary embolism.



--d- dimer levels have very low specifity fo DVT

--SARCOIDOSIS IS A systemic disease characterised by granulomatous inflammation of many organs. the etiology is idiopathic/

radiographic finding often show bilateral hilar lymphadenopathy and egg cell calcification of lymph nodes. biopsy is needed for diagnosis. elevated ace level aand hypercalcemia are observed in a majority of patients. steroid is the mainstay of therapy. it is commoner in African black, may be asmptomatic and at times self limiting,/ ppd will be negative



-- small cell lung cancer typically presents with unilateral lymphadenopathy and is very unlikely and uncommon in nonsmoker.



---miliary tuberculosis results with multiple small lung densities as a chest xry finding rather than hilar adenopathy, of courseprimary may present with hilal lymphnode so called ghons complex



--like miliary tuberculosis etrinsic allergic allevolitis normally result in multiple small lung densities on chest radiograph.



-- disease where aspirn can be given in pediatric pt are kawasaki disease in spite of fear of reys syndrome.

---many pt will be drowsy after a seizure and this would have no prognostic significance.



--typicals/sx of mi and cardiac enzymes will help in diagnosis of mi as wll as ecg finding.



--but ekg changes are not absolutely necessary for the diagnosis of myocardial infarction



-- you should answer coronary artery bypass graft so called caabg pronouced cabbage only if there is a facillity of coronary angiography for the obvious reason.



-- lidocaine drips are not beneficial as a prophylactic therapy in reducing the incidence of ventricular fibrillation in patient wiyh ectopy.



--hemorrage and anemia can give rise to mi because anemia decrease o2 supply to the myocardium and must be corrected ; in acute hemorrage blood transfusion should be given with goal of maintaining hemoglobin greater than 10 g/dl in pt with coronary artery disease.



-and if blood pressure permits ,beta blokade will help by decresing o2 demand and should be initiated.



thrombylytics are strictly contraindicated in hemorregic situation such as gi bleeding for the obvious reasons.



--4 extrmity blood pressure measurement is a good tool for coarctation of aorta where there is bp, pulse. o2 saturation discrepancy is seen between upper and lower limb.



--coarctation of aorta may be be born without murmur and later get it but some types present at birth as ccf.



--an egg shaped heart is seen in patients with transposition of great vessel where artery and vein switch their origin



--trnsposition presnt early with cyanosis and murmur;

--if we talk about infant .transposition is the commonest cause of cyanosis



--a boot shaped heart is seen in falot tetralogy



rib notching is seen in coarctation as wellas reverse 3 sign.



--hyper inflation is seen in asthma or foreign body aspiration.



macule and patch are flat / papule and plaque are raised/



--macule and patch are less than 1 cm / papule and plaque are more than 1 cm,



--drooling is a developmental step but watch out it may be te fistula. gerd, epiglottitis. upperairway obstruction botulism cretin child/ so watch out



--constipation may be a habit but watch out the combination with other thing which may be sinister/ intestinal obstruction/botulism meconium ileus /hirshsprung disease/pyloric stenosis/drugs



--80% of DVT occur postpartum



--pregnancy is a hypercoagulable state



--the degree of agitation may be consistent with PE

--IT IS TRUE THAT ALL WOMEN EXPERIENCE SOME DEGREE OF SHORTNESS OF BREATH in pregnancy RELATED TO THE DEGREE OF decrese in functional residual capacity by almost 20% but shortness of breath should be always taken as watchful sx.



--PCOS also called sten leventhal syndrome is the most common cause of hyper androgenism and hirsutism./ for a pt who hope to be pregnant weight loss is the first step in improving androgen excess and its associated effects. lh/fsh ratio here will be 3;1



---in pt who do not desire to be pregnant hormonal contraceptive can help interrupt the feedback cycle ,leading to decreased LH production.



--if dhea is increased and your diagnosis is congenital adrenal hyperplasia using glucocorticoid and mineralocorticoid help\\\\\\\\\\\\\\\'



--in sertoli leydig syndrome testerone is increased but LH/FSH ratio is decreased and here operation is indicated





1. 9 month old, said to fall off couch, has different color bruises all over, withdrawn, can’t sit or stand without support, what next? (skeletal survey)



2. The treatment of choice for lithium levels greater than 4.0 mEq/L is hemodialysis.



3. .In the 2001 update of their screening recommendations, the U.S. Preventive Services Task Force strongly recommended routine screening for chlamydia in all sexually active women aged 25 and younger, as well as in asymptomatic women older than 25 who are at high risk.



4. Intermittent claudication, which is a sign of peripheral vascular disease. Patients often complain of pain during exertion that is relieved by rest. Noninvasive evaluation is usually recommended initially and consists of determining the ratio of ankle to brachial arterial pressures. The ankle/brachial artery ratio is determined by measuring and comparing the 2 blood pressures. If the ratio is less than 1 (greater than or equal to 1 is considered normal), peripheral artery disease is present



5. Vancomycin is used in febrile and neutropenic patients in addition to ceftazidime when the patient has an indwelling central vascular catheter.

_________________________________________________________________



1. Chest pain, fever, tachycardia, subcutaneous emphysema, dysphagia, and dyspnea are suggestive of an esophageal perforation. An esophageal perforation may result from endoscopic procedures, external trauma, esophageal disease, and spontaneous perforation from violent bouts of emesis. Prompt recognition of an esophageal perforation is necessary to prevent delayed complications. Whenever a perforation is suspected, a contrast study should be performed with water-soluble contrast material. If this study does not demonstrate the perforation, it should be repeated with barium. Barium is more accurate for a delineating esophageal leakage. Contrast studies not only help in diagnosing esophageal rupture but also document the level of injury, which has important implications for treatment.



2. Topical steroid and phototherapy are the two main therapeutic modalities in treating vitiligo.



3. The presence of a central venous catheter for 6 days in an intensive care unit (I CU) dictates strong consideration of catheter-associated sepsis, for which staphylococci are the most common cause. The absence of inflammatory changes at the site of catheter insertion is not uncommon in the presence of catheter-associated bacteremia. Because methicillin-resistant strains of staphylococci are common in many ICUs, vancomycin must be a component of the antibiotic regimen to cover these pathogens. Genta-micin is used to cover the less frequent possibility of gram-negative catheter-associated sepsis and is indicated because the patient is in septic shock.



4. The diagnosis of common variable immunodeficiency (CVI) should be suspected in any patient with abnormally recurrent or severe bacterial infections of the upper or lower respiratory tract. Early diagnosis of CVI is important because immunoglobulin replacement therapy can prevent recurrent infections and associated chronic tissue damage. It is important to consider other conditions that may predispose a patient to recurrent respiratory tract infections, such as allergies and anatomic abnormalities, when evaluating a patient for suspected humoral immunosuppression. The laboratory tests for CVI consist of measuring serum immunoglobulin levels, including subclasses of IgG. In addition to quantitative measurements of serum immunoglobulins, it is important to evaluate the patient’s ability to produce specific IgG antibodies to protein and polysaccharide antigens. The decision to treat patients with immunoglobulin replacement therapy is based on the frequency and severity of recurrent infections and a demonstrat

ed failure to mount functional antibody responses, rather than on the absolute level of serum IgG.



5. The psychiatric manifestations of hypothyroidism include fatigue, depression, lethargy, psychomotor retardation, poor concentration, and forgetfulness.

___________________________________________________________



1. Spironolactone has an anti-aldosterone effect and therefore predisposes a patient to hyperkalemia. (Remember that hyperkalemia is an important stimulus for the secretion of aldosterone.)



2. Acetaminophen can predispose susceptible patients to renal failure through tubular injury (acetaminophen is a metabolite of phenacetin, a known tubular toxin.



3. MRI with gadolinium is considered the most sensitive test for detecting microadenoma. The test can reveal microadenomas in 20% of normal women.



4. Achalasia is a neurogenic esophageal disorder thought to be caused by a malfunction of the myenteric plexus of the esophagus. The result is denervation of the distal esophageal muscle with resulting impaired esophageal peristalsis. The characteristic findings on esophageal manometry are diminished or absent peristalsis in the body of the esophagus and a high resting lower esophageal pressure.



5. To rapidly assess for the possibility of antifreeze ingestio n, the physician can evaluate the patient\\\\\\\\\\\\\\\'s urine under a Wood\\\\\\\\\\\\\\\'s lamp for fluorescence. Manufacturers of ethylene glycol-containing antifreezes typically add fluorescein to the mix, which will fluoresce under a Wood\\\\\\\\\\\\\\\'s lamp.

____________________________________________________________________



1. Evaluating the optic discs for hyperemia is typically reserved for suspected methanol toxicity, since methanol is metabolized to formic acid, which can cause irritation of the optic nerve.



2. Whenever they ask about valvular heart disease , look at BP, if it\\\\\\\\\\\\\\\'s wide you should consider AR!



3. Mitral stenosis presents with a diastolic rumbling murmur heard at the apex of the heart; Aortic Regurge presents as blowing diastolic murmur heard loudest at the left sternal border.



4. Acute cholecystitis is the result of cystic duct obstruction, and this would be best demonstrated by a HIDA scan.



5. Skin tags, more formally known as acrochordons.

______________________________________________________________



1. Silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. Intravenous pyelogram (IVP) will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer. Thus, both procedures are needed.



2. There is no need for prophylaxis for IE when the cardiac lesion is due to prior coronary artery surgery, mitral valve prolapse without regurgitation, prior rheumatic fever or Kawasaki disease without valvulopathy, presence of a pacemaker, isolated secundum atrial septal defect, surgically repaired septal defect or patent ductus arteriosus, or physiologic heart murmurs.



3. Some procedures require no prophylaxis for endocarditis regardless of the type of cardiac lesion. These include dental procedures that do not induce bleeding, endotracheal intubation, tympanotomy tube insertion, cesarean section, uncomplicated uterine procedures in the absence of infection, and cardiac catheterization.



4. Increasing anemia in a previously well-maintained immunosuppressed patient is suggestive of parvovirus B19 infection, especially with an associated reticulocytopenia. Occasionally giant pronormoblasts may be seen on the peripheral blood smear. A bone marrow examination may confirm the absence of erythroid progenitor cells and exclude other pathology, but is not required to diagnose parvovirus B19 infection. The diagnosis should be confirmed by the detection of parvovirus B19 antigen or significant levels of parvovirus B19 DNA in serum by (PCR).



5. Paitent with kawasaki has conjunctival involvment but in scarlet fever no conjunctival involvement.

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1.HHV6: roseola, HHV7: pitrias rosea, HHV8: kaposi sarcoma



2. Erythema multiforme, exfoliative dermatitis and Stevens-Johnson syndrome are potentially life-threatening drug reactions of sulfa agent.



3. The risk of contracting meningococcal disease among household members and childcare and nursery school contacts is considered high enough to warrant chemoprophylaxis. Rifampin, ceftriaxone, and ciprofloxacin are the 3 recommended agents used as chemoprophylaxis for invasive meningococcal disease.



4. Inhalant intoxication is characterized by euphoria, belligerence, apathy, impaired judgment, dizziness, nystagmus, incoordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, tremor, muscle weakness, diplopia. Stupor, coma may occur.



5. Steroids, especially intraarticular steroids, are very effective when NSAIDs and Colchicine (which are the treatment of choice for acute gout) are contraindicated. In this patient, CRF is a relative contraindication to NSAID & rofecoxib use. So,intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects

__________________________________________



--CAUSES for post operative fever are atelactasis.pneumonia,uti.dvt.wond infection.abscess.drug fever



--in case of normal chest xray you do not do ct in suspected fever except in bronchectasis



---a 31 yr with all the hirsute family had lots of blister after coming from florida



--dx--here you suspect porphyrea cutenous tarda and perform urine wood lamp exam. urine

of these pt fluoresces an orange pink color under the woodlamp due to increased porphyrin



---though skin biopsy is a gold standard it will not be helpful for porphyria cutaneous tarda



--porphyria cutenous tarda is charactized by skin blistering ,increasd hair in temple and cheeks, and no abdominal pain . autosomal dominant pattern; thus the sibling will also get it.



chromosomal analysis is not a first choice in dermatology. diagnosis is usually done clinically and through biopsy and only confirmed by chromosomal analysis if needed



--pemphiguous vulgaris has immunofluroescence surrounding epidermal cell., showing a tombstone pattern .



--immunofluroscence in bullous pemphigoid shows a linear band around the basement membrane with increased eosinophil in dermis



--urine porphyllogin is the test for intermittent acute porphyria giving rise to acute abdomen



--in guillain -barre syndrome there is typically antecedent gastro or respiratory illness followed by steadily progressive paralysis with loss of reflexes that is lmn. the classic csf finding is albuminocytological dissociation, which basically mean high protein with few white blood cell



--amyotrophic lateral sclerosis also called lou gehrig disease aftere a baseball player who got it

is a more chronic and degenerative irreversible disease . it typically causes weakness with muscle fasciculation and often hyperreflexia.



---pulmonary alveolor proteinosis is a rare disease there is adult 30 YR OLD pt with diffuse infiltrate in cxray and present with hypoxia. pco2 normal/large A-a differance; marked hypoxia,improving with o2 adminstration and decrease diffusion limited carbonmonooxide DLCO/ -- IN THIS CASE CO2 WILL BE NORMAL BECAUSE THERE IS NO HYPOVENTILATION. pco2 changes linearly and inversely with hypoventilation ,so hypoventilation always cause co2 retention and vice versa.



--pt inspiring low fio2 do not have increased A-a differance, \\\\\\\\\\\\\\\' when are you ever going to see this clinically? rarely



--v/q mis match and diffusion impairment can only be distinguished by pulmonary function test .



--in your carrier you will see manymore pt with v/q mismatch than diffusion impairment



--hypoxia from shunt donot improve much with adminstration of exogenous o2



--10 mm ppd is positive in high risk pt including the son of richest beverly hill actor if he happens to be a medical student/







1. Neuromelanin are found in substantia nigra & locus ceruleus and they disappear in Parkinson\\\\\\\\\\\\\\\'s disease.



2. Which type of brain tumor can be spread by CSF ? Medulloblastoma



3. Germinoma, common in pineal gland area, gives Parinaud\\\\\\\\\\\\\\\'s. Brain stem glioma give (usually benign pilocytic astrocytoma) may give locked-in syndrome.



4. Which lesion can be induced by aneurysm of Posterior communicating artery of Circle of Willis ? 3rd nerve palsy



5. Which lesion can be induced by aneurysm of Anterior communicating artery of Circle of Willis ? Bitemporal lower quandrantinopia

_______________________________



TTFN



ewing sarcoma similar to osteomyelitis in that both have fever



but there is no weight loss in om



---ewing sarcoma involve the diaphyseal end osteomyelitis involve metaphyseal end



---benign bone tumours and eosinophillicgranuloma aere noy painful



--SCFE OCCUR IN OBESE ADOLESCENT MALE



--SCFE occur in hip joint



-scfe differ from leggcalves perthes by xray and age of occurance



--perthes occur in 5- 7/ scfe ocur in 13 -14



--om and septic arthritis are unlikely without fever



--osgood schlatter disease also occur in adolescent but it involve tibial tuberosity



--osd does not involve hip



--harsh holosystolic murmur is in vsd



--ccf sx in child are tachpnea diaphoresis during feeding in child and cardiomegaly in chest radiograph and hepatomegaly



--a systolic murmur at left upper sternal border will be consistent with either asd or pulmonic stenosis



--a systolic murmur at right uper sternal border will be consistent with aortic stenosis



--a continuous machinary heard bestin upper left sternal border and radiating to axilla will be patent ductus arteosusPDA





--nebulized bronchodilator are main stay of asthma therapy albuterol



--oral therapy and chromollyn are not in urgent therapy



--theophylline has fallen out of favor in emergent situation



--infants shud be placed on their back to prevent sids



--infant most be bot 1 yr and 20 pound to be in forward facing car seat





----for strong bases and hydrocarbon syrup of ipecac is contraindicated



---lead contained paint should be removed rather than painted over becoz of continued risk of ingestion of lead paint



--kawasaki has no lab test it is a clinical dx



--does kawa saki need echo -yes

--does kawasaki need --dialysis --no

--does yoy do electrolyte -no



--ivig helps decrese the incidence of coronary artery disese



--conjunctivitis/ oral ulcer/cervical unilateral lymphadenopathy/swelling of finger hand/fever are the feature f kawasaki





--kawasaki need aspirin in spite of fear of reye syndrome



--in petit mal seizure eeg will show the characteristic generalized symmetric 3 per second spike and wave pattern. other inv will be normal. it also called absent seizure and comes as spell and is confused with day dreaming





transposition of greatvesel egg shaped heart is due to switching of vessel and

typically ther are increased pulmonary vascularity in the xray



ther is no murmur in transposition of graeat arterities and there is intact ventricular septum



--there is asingle s2



--first of all do yperoxiaa test



--if pao2 is less than 50 firsry do cxr, then if there is massive cardiomegaly the ebstein anomaly is the most likely diagnosis



---if massive cardiomegaly is ruled out then see the pulmonary vascularity



--if pulmonary vascularity is increased it may be trasposition of great vessel

--if pulmonary edema is there it may indicate total anomalous pulmonary venous return



--but remaining diagnoses have decresed pulmonary vascularity and small cardiac silhoutte

these are tetalogy of fallot /tetralogy of fallot with pulmonary atresia pulmonary atrsia

tricuspid atrsia with normally elated great arteries



--these are differienciated by degrre of axis in ecg and by their murmur.



---metatarsusadductus is toeing of theforefoot without hindfoot abnormalities without and is commonandrelatively benigncondition

--metatarsus adductus are caused by intrauterine positioning. as opposed to talipes equinovarus ,range of motionat the ankle is unrestricted



--developmental hip dysplasia is in the first born girl child and may not be evident to the casual observer



--ortolani is the relocation test which relocates on abduction putting head of femur into the socket of acetabulum and relocates with a click



--barlows test is the dislocating the head by adducting and pushing and it snaps out.



--genuvarum is a knee deformity



--pt with dka may be hyperkalemic normokalemic and or hypokalemic at presentation



--but in real they are hypokalemic and potassium shud be given



--many pt with lyme disease donot give a hx of tickbite presumely they are unaware of it .



--case of lyme disease are clustered around the northeast , midwest,and westcoast and peak during the summer and early fall .



--the rash is like target lesion with central clearing

--the rash is fleeting occurs both at inoculation site and secondary areas

-- rocky mountainspotted fever produces maculopapular rash that begins at the wrist and at the ankle and spread proximally and centrally, and the lesion progresse to apetechial stage



--meniningococcemia can give rise to a petechial rash but that is different from erythema migrans



--eheerlichiosis doesnot cause a rash



--pyloric stenosis causes hypokalemic metabolic alkalosis and due to hcl loss and it is hypochloremic too because chloride also is lost and if chloride is lost bicarbonate is going to be high

--in pyloric stenosis na and k level are not usually affected until late in the presentation



--fever and new murmur may be consistent with with rheumatic heart disease or eendocarditis

-but presence of autoimmune phenomenon vasculitis that is splinter hemorrage/petechiae goes in favor of endocardiditis in presnce of new murmur



--kawasaki pt can present with fever and heart involvement r in the kid and there is rash but

murmur and splinter hemorrage are not noted



--dilated cardiomyopathy can present with a new murrmur but the murmur is of blowing quality and it is at the lower sternal border or apex,



shigella is most likely associated with aseizure with hx of bloody diarrhea



--children withseizure can present with neurologic manifestation including lethargy,seizure and mental status changes possibly as a result of neurotoxin elaborated by the organism



--cholera causes ricewater stool and lead quickly to hypovolumic shock and dehydration but not to mental status changes



--giardiasis most common parasitic disease in united states typically causes only diarrhea without fever



yersinia can cause pseudo appenciditis like feature



--salmonella can invade the bloodstream and can cause extraintestinal disease including meningitis meningitis arthritis and osteomyelitis



--both shigell and escherichia coli 0157;h7 produce enterotoxin shiga or shiga like toxin associated with hemolytic uremic syndrome



-hemolytic uremic syndrome is a serious complication that include microangiopathic hemolytic anemia nephropathy and thrombocytopenia



-pseudoappenciditis and erythema nodosum are associated with yersinia



--the child can have obstructive pneumonia due to enlarged tonsil or adenoid or both



-obstructive sleep apnea usually can be diagnosed with sleep study -polysomnography



-polysomnography can distinguish obstructive sleep apnea from central apnea



-removal of obstructing tissue is the rx of choice in obstructive sleep apnea



-continuous positive airway pressure is more appropriate in case of central sleep apnea.



--oxygen therapy will no help in a pt who is initially breathing in



--abx is not indicated in sleep apnea because there is no infection



-stimulants are not effective in sllep apnea



--syphillis in newborn is called congenital syphillis.

-congenital syhillis is systemic from the beginning, there is hepatomegaly splenomegaly jaundice,mucocutenous lesion,jaundice , lymphadenopathy and the characteristic snuffles.



--snuffles is a clear copious nasal discharge in congenital syphillis

fta abs is a true treponemal test and less likely to give false positive result



cbc and bllood culture are of no use in syphillis diagnosis



-vdrl and rpr can have false positive so must be confirmed by fta abs



--newborn infected with hepatitis b have a great likelihood of chronic disease at later part of life and moreover hepatocelluular carcinoma is more likely so that vaccination by recombinent vaccine is a must, and they shud get immunoglobulin too.







----givent he maternal hx of SLE congenital heart block is most likely caused by sle



----lyme disease can cause rash but look for endemic rea and travel hx to those endemic area



--look at the age also tick exposure in infant may be unlikely



---cardiomyopathy mostly they with cardiomegaly . so look for the cardiomegaly in cardiomyopathy



---sinus node dys function can cause heart block but ther sd have been sutureline post operative or atril dilation and atria dilation can be seen in cxr



--sinus bradycardia is a comon variant in athelets



----measles is caused by paramyxovirus and is characterized by cough ,coryza,conjunctivitis koplik spot an an erythematous maculopapular rash



--koplik spot are small irregular red spot with central grey blue or white speck that appear in buccal mucosa



measles is also called rubeola





---rubella is called german measles and also called 3 day fever , rubella is caused by rubella virus and is characterized by erythematous maculopapular rash with generalised lymphadenopathy especially of the posterior auricular,cervical and suboccipital lymphnode,





---roseola infantum is caused by herpesvirus 6 and the differance is it starts from the trunk and spread to the periphery .the fever typically resove as the rash appearr,





--erythema infectiiossosum is along name caused by parvovirus b19 and is characterized by slapped chick face



--and this even it causes slapped cheeks it is peculiar in that it starts in the arm and spreads towards trunk and leg



--handfoot mouth diseae is caused by coxsackie virus and is characterized by ulcer on the tongue and a maculopapularvesicular rash on the hands and feet but instead of going to the trunk it goes right into the mouth



--chickenpox is caused by varicella zoster virus and is characterised by pruritic papular pustular vesicular rash starting on the trunk and spreading to the extremities



--the infected child of varicella is infectious until the last lesion is crusted over.



--zoster or shingles is caused by reactivation of varicella zoster virus from the dorsal root ganglia and is characterised by fever and painful pruritic crops of vesicles along a dermatomal distribution



--electrocardiographic changes associated with significant hyperkalemia include loss of p wave peaked t wave and wide qrs and st segment depression.



--these changes may be seen in k of 7 or over



--ca gluconate doesnot get rid the body of potassium however it does stabilise the cardic cell membrane so that electrical activity is less likely to be disrupted



--dialysis is very effective in reducing hyperkalemia but it takes time to set up.



--atrial fibrillation is a narro complex tachycardia but it is an irregularly irregular narrow complex tachycardia



--wollff parkinsons syndrome is a narrow complex tachycardia it is orthrodromic is a reentrant tachycardia that travels down the atrioventricular node and up the bypass tract



--hepatotoxicity is manifested by increased liver enzyme and jaundice which may progress over days



--the blood acetaminophen at one hour is not predective of outcome because timely intervention can change the progression



--however blood actaminophen over 4 hour after ingestion is very predictive of outcome,because by then the drug has been absorbed andis passing through the liver ,the primry organ of toxicity



--cardiac arrythmia caoccur with anticholinergic or antiarrythmic ingestion



--acute iron overdose and cancause seizure.



--folic acid decreases ntd

--down syndrome has low level of alphafetoprotein

--but in neural defect there is high level of alphafetoprotein in maternal serum due to leakage through oprn neural tube,



---children with spinas bifida have wide variation in the level of loewer extremity involvement





You`re welcome,mazinmoodi and djyoti.

Jyoti,I really appreciate your efforts.It`s not a lazy job,on the contrary,it needs lot of your time,patience and as you said,big heart!!!!!

HAPPY STUDYING........:-)



1. CHF due to aortic regurgitation: give diuretics, ACE inhibitors, digoxin, NOT Beta-blockers, which prolong the diastole --> increased regurgitation



2. Malaria: P. Vivax - fever every 48h, P. Ovale -f ever every 72h, P. Falciparum --> no periodicity - starts with intense chills, then the hot phase, then presents 2-6h later with vomitting, low BP, tachicardia, anemia, splenomegaly -hystory of past similar complaints when in Africa



3. Babesiosis: RBC cell parasite from ticks, varies from asymptomatic to severe anemia, jaundice and renal failure; seen in splenectomised patients or with HbSS diseases



4. TB can appear in HIV patients even with CD4 count > 200/ul; no need of hystory of close contacts.



5. Case of SYSTEMIC MASTOCYTOSIS which there\\\\\\\\\\\\\\\'s proliferation of mast cells in the skin, liver, spleen, BM and lymph nodes. It can occur at any age, no +FH, and atopy is not increased in these pts. the cutaneous lesions of urticaria pigmentosa respond to trauma with urtication and erythema(Darier\\\\\\\\\\\\\\\'s sign) diagnosis with clinical findings, physical exam,and lab findings. A 24 hr urine collection for histamine and PGD2 metabolites is the most common noninvasive procedure.confirmtion of diagnosis with tissue diagnosis. Rx: symptom/sign directed approach, H1and H2 antihistamines.

________________________________________





--meconium ileus is highly associated with cystic fibrosis, anautosomal recessive disese



have a freqency of about 1 in 2500 birth



--infants with phenylketonuria are usually detected on state newborn screening tests;those who are not diagnosed by some reason present later with already mental retadation behaviour problem



--taysachs diseae in askenez zews is also autosomal recessive disorder a



--taysachs disease is a lipidosis



---taysachs disease presents developementall delay and seizure inthefirst year of life.



--galactosemia is a disorder of carbohydrae metabolisb wher there is jaundice and cataract



--galactosemia start from soon after feeding start.manifestating as vomiting growth failure and hepatomegaly



--wilsons disease does not present at birth /wilsons disease present with hepatitis usually after the age of 5



-the adjusted reticulocyte count= measured hematocrit/normal ematocrit for agex reticulocyte



--an arc less than 2 suggest ineffective erythropoiesis ,



--an arc greater than 2signifies effective erythropoisis



--so aplastic anemia or redcellaplasi will have an arc less than 2



--but anemia caused by chronic disese and and chronic bllod loss will have an arc greater than 2



--so anemia due to decresed hematopoietic procedure will also have arc more than 2



--bonemarrow failure will have also arc more than 2

--irondeficiency microcytic anemia is the most common cause of microcytic anemia

-it is not only most common microcytocanemia but also most common childhood anemia



--iron deficiency anemia is most commonly seen in 6 and 24 month



--thalessemia syndrome are also microcytic anemia but less common than irondeficiency anemia



--anemia of ch disease may be microcytic or normochromic



--transient erythrocytopenia can occur in childhood early



--transient erythro cytopenia of child hood is a normocytic anemia that in acquired red cellaplasia



-so in transient erythrocytopenia of childhood also arc will be more than 2



--parvovirus b19 aplastic crisi is a normocytic anemia that result from parvovirus myel suppression



--most common cause of rectal bleeding in toddlers is an anal fissure



-- if the child is having bleeding from peptic ulcer then the child would have melena not blood streaked stool



necrotising colitis can cause bleeding in childhood but very early like in neonate also in premature baby



--inflammatory bowel disese also can cause bleeding in childhood but not so early as 18 month



inflammatory bowel disese and necrotizing enterocolitis could both cause lower gi tract bleeding in the form of hematochezia or blood streaked stool



--a 5 yr child coming with facial handd feet swelling to yo will be probly minimal change disease and u treat with steroid



--same child with pain abdomen withhematuria will be iga nephropathy commonest one in childhood



--hemarthrosi in achild with similar hx inmaternal uncle wit ptt high and normal pt and normal platelets count is hemophilia



--inconsolable cry in a child every afternoon for several hours with normal / and baby looks and feed s well is colic

-

-premature baby apgar 5 and 7 at 1 and 5 minute got surfectant and was given empiric antibiotic got chest infection we will suspect gbs



--sepsis is the important cause of hypotension in children



--neuroblastoma doesnot cause distortion of calyces



1. What is a common histopathological finding of meningiomas? Psammoma bodies. These are spindle cells concentrically arranged in a whorled pattern.



2. What are ependymomas? Ependymal cell tumors most commonly found in the 4th ventricle. May cause hydrocephalus.



3. Reason why Pregnant women get more chances of UTI: Increase in ventilation rate causes respiratory alkalosis: This causes renal compensation which leads to alkaline urine. This provides a good growth medium.



4. The normal values of Non-pregnant women do not apply to pregnant women. In pregnant women, the upper limts of BUN and Serum Creatinine should be 10 and 0.5 respectively. If a pregnant woman has a serum creatinine of 1.5, then it can only mean 2 things: either she has a kidney disease or it could be due to hypercoagulation which is seen only in Preeclampsia.



5. What constitutes a positive Straight Leg Raise (SLR) sign to diagnose radiculopathy? SLR is positive if the maneuver R EPRODUCES THE PATIENT\\\\\\\\\\\\\\\'S USUAL PAIN .The patient may describe pain in the low back,buttocks, post. thigh or lower leg. But the key feature is reproduction of the patient\\\\\\\\\\\\\\\'s usual pain. Other factors such as muscle stiffness can mimic radicular pain. SLR is used to detect lesions of L5 and S1 roots and sciatic nerve. Reverse SLR (passive extension of leg with patient standing)-for L2-L4 roots and femoral nerve Crossed SLR-Performance of maneuver on one leg produces pain in the opposite leg or buttocks-The nerve or nerve root lesion is always on the side of the pain. For all these tests, the key feature is REPRODUCTION OF PATIENT\\\\\\\\\\\\\\\'S ORIGINAL PAIN.

___________________________________



--most of extraintestinal manifestation regress after rx of inflammatory disease except episcleritis



calcium oxalate nephrolithiasis occur in crohns



irriatable syndrome occurs in 10 to 20 % of population



--23 yr old guy burping all the time having fatty intolerance with negative investigation may have nonulcer dyspepsia



---steatorrehea is due to increse cyclic amp



---source of watery diarrea is small intestine



--after crohns disease operatio the diarrea occurs due to short gut sndrome but that response to cholecystaramine



--irritable bowel syndrome is due to inappropriate pain impulse



---large volume paracentensis is asafe and ffective way of quickly mobilizing clinically significant ascites



esophageal varies do not bleed below 12 mmof hg.



--trivial elevation of alt is in hepatitis c



--healing in chronic liverdisease is by regeneration andfibrosis



--stage 4 encephalopathy cause permanent neurological damage which will be contraindication for liver transplantation



--dont wait for sx colon cancer presnt late



--prefered route of nutrition is enteral thamn parenteral



risk of cancer is in villous tubular adenoma in that order and in sessile is more than peduncular



in primart hyperthyroidism both calcium and parathormone are incresed and it is mostly due to hypar plasia but 5 peret can be due to cabncer / a,lso associatedwit men 1 and 2



--in secondary hypothyrioidism there is hypocalcemia and increase parathormone. it is due to renal failure and there is lack of conversion of 25 to 1 25 dehydrochlecalciferol



--

simlest assesment of weight loss is at first questionimg about intennional or unintentional wt loss then only nutrition hx anthropometry. albumin tranferrin lymphocyte coumnt anergy



-- barbeque is bad



--too much cooking of meat is bad for it can cause cance/ too less for staph/toxoplasmosis/taenia



--environmental factor of cancer is al most 75% may be more





dysmorphic feature of down syndrome include flat facial profile.upslanted palpebral fissure, a flat nasal bridge with epicanthal folds a small mouth with a protruding tongue,micrognthia and short ears with down folding ear lobes. excess skini nthe back microcephaly a flat occiput short stature a short sternum small genitalia and a gap between first and scond toe. sandal gap toe.

anomalies of hand include single hand crease simian crease and short broad band hands with finger marked by incurved fifth finger clinodactyly



--features of trisomy 18 incclude hypertonia microcephaly.occipital defect iris coloboma microopthalmia. and cleft lip and palate and clenched hands . boys with klienfelter syndrome donot have physical feature identified at birth that could led too suspician of the disorder; girls with turner s syndrome have a webbed neck, widespaced nipple cubitus valgus wide carying angle and edema of hands and feet.





--functional and structural abnormalities in children with trisomy 21 include generalised hypotonia obstructive sleep apnea cardiac defect ; endocardial cushion defect, and septal defect are seen in 50% of cases. gastrointestinal anomalies like duodenal atresia, hirshsprung\\\\\\\\\\\\\\\'s disease . atlantoaxial insstability developmental delay.moderate mental retardation and hypothyroidism. there is a higher frequency of leukemia in children withtrisomy 21 than general population.



--isoimmune thrombocytopenic purpura is noted in newborn, not in children. isoimmune igg ntibodies are produced against the fetal platelets when the fetal platelets crosss the placenta . now the maternal antibody wil cros e placenta andattack thefetal platelets.



--leukemia sepsis, and hypersplenism may cancause thrombocytopenia



--sepsis is unlikely if childappearswell/



--hypersplenism is unlikely when the spleen is normal on palpation





reyes syndrome are not common these days now that theparents are instructed to avoid aspirin in children.



the most common consistintent laboratory abnormalities are hyperammoniaemia and elevated liverenzymes although glucose and electrolyte may be abnormal aswell.



-polyhydramnios is defined as amniotic fluid volume greater than 2 litres . chronic polyhydramnios is more common than acute polyhydramnios. polyhydramnios is associated with lesion that interferes with fetal swallowing such as neural tube defect \\\\\\\\\\\\\\\' aencephaly and myelomeningocele \\\\\\\\\\\\\\\' abdominal walldefect \\\\\\\\\\\\\\\'omphalocele and and gastrochesis duodenal atresia and cleft palate as well as gestational diabetes , immune or nonimmune hydrops fetalis. multiple gestation and trisomy 21 and 18.



--oligohydraamnios is a decreased amount of amniotic fluid and is associated with postmaturityamniotic fluidleak intra uterine growth retardation and congenital abnormalities of the fetal kidneys. bilateral renal agenesis results in potters syndrome which is associated with renal anomalies oligohydramnios and pulmonary hypoplasia .



--telescoping of a proximal segment of proximal segment to distal segment is called intussception. it has coiled spring appearance in ba enema in axr in rt lower quadrant. the barium enema or air enema results in hydrostatic reduction of intussception in sever cases.



voiding cystourethrogram will demonstrate vesicourteral reflux



-renal ultrasound and intravenous pyelography can demonstrate the mass



-nuclear scan may show area of scarring demonstrating a previous episode of pyelonephritis



-corticosteroid such as prednisone and methyl presinolone require a 4 to 6 hours to take theeffect. however they are very important in the treatment of exacerbation because they address the underlying inflammation and prevent the late phaseresponse.



--theophylline ., albuterol,and terbutaline are bronchodilators that virtually haave no inflammatory properties. cromylyn is amastcellstablizer that is not effectie in acuteexacerbaton



--the primary serious complication of kawasaki disease arecardic including vasculitis and aneuresm formation. prognosis is tied to cardici nvolvement cardiac instability can produce arrythmias infarction or congestative heart failure within days of presentation



--aneuresm and coronary rtery disease persist and may result in death months or year later.



-- hypsarathmia is the patten seen onelectroencephalogram in patients with infantile spasm .



--a characteristicly generalized symmetrical 3 per second spike and wave pattern would be expected in patient with absnet seizure.



--causes of increased cerebrospinal fluid protein level include guillain barre syndrome



--epinephrine is a very good drug epinephrine is used for asytole. bradycardia , and or ventricular fibrillation . lo dose epinephrine increases systmic vascularresistense chronotrophy and inotrophy,therby increasing cardiac output and systolic and diastolic blood pressure coronary pefusion is incresed. low dose epinephrine may change fine ventricular fibrillation to coarse ventricular fibrrilation and promote succssful defibrillation.



-- OPTHALMIANEONATURUM - caused by neisseria gonorrhea typically preent at two to 5 days of life with bilateral conjunctival injection , purulent discharge and eyelid edema, appropriate treatment consist of either intravenous ceftritaxone or penicillin plus saline salvage.



--conjunctivitis caused by chlymydia trachmatitis is treated with oral and topical erythromycin which is less important than oral.



--chemical conjunctivitis does not require specific therapy

--herpes simplex virus is treated with acyclovir.



---a 6 month old is able to sit wellsupported reach and transfer object witheither hand and babble.



--at 12 month a child will learn to walk alone, use a pincer grasp and be able to say few words



-a 24 month child walks will walk up and down stairs and follow two step command



--the 3 yr old child is able to rid e a tricycle draw a circle and use 3 word sentences.



--at 5 yrs old , a child will be able to hop and skip , tie shoes and recognise colors.



--in phago cytic disorder such as chronic granulomatous disease patient present with recurrent skn infection and abscess formation. the most common crgasism include styphylococcal aureus pseudomonas .



-- disorder of humoral immunity include involve frequent infection of sinus middle ear and lung.



--in complement deficiencies . patient preent with recurrent bacteria,l infections and increased risk of autoimmune disease. patient with cell mediated immunity will have infections with oppurtunisistic or low grade infection



-in patients with juvenile rhematoid arthritis a positive ana indicates an incresed risk for the incidence of chronoc uveitis, these patient require more frequent opthalmologic examination.





-turner syndrome occur relatively comon 1 ;2500



--low hair line , short stature . webbed neck due to cystic hygroma,coactation of aorta bicspid aortic valve, incresed carrying angle streaky ovary are present ther will be incresed fsh and decresed estrogen



--patient with cushing syndrome wil presnt with moon facies facial hair buffallo hump abdominal striae etc. the so called lemon with 4 stick appearance.



--in isolated growth hirmone deficiency and familial short stature pt will not have delayed puberty.



--patients with with addison\\\\\\\\\\\\\\\'s diseas prsent with nausea vomiting fatigue weaknes salt craving shock acidosis etc,



-----breast mlk is best but not always/ vitamin milk is found in smaller amounts in brest milk when compared with infant formula. infants who are exclucively breast fed need to have to be given vitamin supplementation--ramember what our parents say sunlight is good that s so true but dont forget to protect the infant eye if you take the infant to the sunlight .



--iron is also found in smaaller amount in breast milk but iron has greater bioavalability so supplementation is not required . premature born infant may need though.



--about breast milk having less in amounts it was vitamin d i was refering to.



--the astamatic who has persistnt sx need frequent rescue medication and visits to th e ER . inhaled corticosteroid have become the main tay of preventive medicine for moderate to severe asthma



--cromylyn sodium has been largely fallen out of favor because it requires frequent adminstration. 3 to 4 times daily and is not as effective as steroid



--theophylline is very difficult to dose because of its very narrow therapeeutic window



--leucotrine inhibitors are an effective second line agent shold be considered in addition to inhaled corticosteroid if greater symtom control is needed. long acting beta agonist llike salbtamol also play a role if a patient requires daily bronchodilators therapy in the face of other medication.



--giving fluid in a child is a challanging affair too little cause dehydration and electrolyte deficiency too mch cause overhydration fluid overload and heart failure.



--maintenance fluid almost always contain dextrose to try to prevent a catabolic state usually 5% dextrose althouhgh chldren require a10% solution.



--when the infant\\\\\\\\\\\\\\\'s bilirubinis is rising faster than 5mg/dlper 24 hr it is a pathologic jaundice rather than physiologic



--biliary atresia is a disorder of biliary secreation therefore causes conjugated hyper bilirubinemia .



--maternal antibody to infant\\\\\\\\\\\\\\\'s blood cell as seen in abo incompatibility ,is aeelatively common cause of unconjugated hyperbilirubinemia. this infant require phototherapy and close monitoring of his monitoring of hemolytic process.



---von hippel lindau disease is a disorder that is characterized by vascular haemartomas



--macrocephaly is descriptive term indicating a head cicumferance greater than two standard deviation above the mean.



--tuberous sclerosis and neurofibrostasiss are neurocutenous disorder with specific clinical criteria



--tuberous sclerosis has hemartomas like tubors in the brain rhabdomyoma inth left ventricle and shagreen patches in the skin



--neurofibromatosis may be bilateral or unilateral .

-nf2 is associated with acoustic neuroma which is associated with vertical progreessive continuous vertigo, tinnitus and hearing loss at the cerebellopontine tumour



--nf is a neurocutenous syndrome/



--nf 1 is also associated with brain tumour but other than acoustatic neuroma



--craniosyntosis is the fusion of coronal suture.



--oral rehydration is atechnique of frequent adminstrationof with smmall volume of fluid with balanced elecrolytes for mild to moderate dehydratio n but sever dehydration need iv fluid resucitation as timme is life here.



--pt with dehydration present with dehydration and hypernatremia. a child may present with tachcardia and listlesness and sx ansx of dehydration. bp may be late to decline dueto compensatory response of vasoconstriction so not reliable to asses a child in shock initially.



--a pt in shock should recieve fluid resucitation in the form of crystalloid such as normal saline and ringer lactate solutions. I t is not appropriate to give large amount of dextrose solution with water since this wter is going to dilute electrolyte further and also not going to stay in the vascular space as the crystalloid do.



--hypernatremia needs to be corrected slowly as 1 mg / hour otherwise sodium will enter brain and take water with it to cause pulmonary edema.



--most commoncause of seizure is idiopathic epilepsy



--presnce of aseizure in apatient in hyperpigmented macules should make the patient look for other signs of neurofibromatosis,including axillary freckling,neurofibromas,lisch nodules ,optic gliomas or bony abnormalities.



--tuberous sclerosis is another neurocutenous diasorder associated with seizure secondary to tubers found in the brain.



--the skin marking of tuberou scelerosis is hypopigmented rather than hyperpigmented ash leaf spots .



--sturge weber syndrome is generally a severe neurological disorrder characterized by a portwine stain on the face . mental retardation and visual impairment.



--cytomagalovirus is likely responsible for intra uterinr growth retadation. hepato splenomegaly and periventicular calcification. choriretinitis blueberry muffin rash anemia thrombocytopenia and jaundice may also be seen.



--cytomegalovirus is diagnosed by rapid antigen test in infant ;s urine.



--herpes virus is morelikely to be acquired perinatally rather than a congenital infection syndrome, and growth retardtion is not a likely feature.



--placental insufficiency is the most common cause of iugr



--chorioamnionitis is risk factor for early sepsis and demands delivery asap.



--trisomy 13 is associated with cleft lip cleft palate, polydactyly. overlaping finger.

hypotelorism, microphalmos and overlapping fingers.



--CEREBELLAR ASTROCYTOMA AND OTHER INFRATENTORIAL TUMOUR OFTEN PRESENT WITH DEFICIT OF BALANCE OR BRAINSTEM FUNCTION .



--HEAD TILT IS A COMPENSATION FOR LOSS OF BINOCULAR VISION AND NOTED WITH LOCAL DEFICIT OF CRANIAL NERVE 3 ,4 OR 6 WHICH CAUSE EXTRAOCULAR MUSCLE WEAKNESS



--CRANIOPHARYNGEOMA PRESENTS WITH BITEMPORAL HEMIANOPSIA AND PITUITARY DYSFUNCTION



--CHILDREN WITH NEUROBLASTOMA SOMETIMES PRESENT WITH OPSOCLONUS -MYOCLONUS SYNDROME OR DANCING EYE DANCING FET SYNDROME AND ALSO HAVE RACOON EYES AND CAN PRESENT WITH HORNER ;S SYNDROME



--CHILDREN WITH OPTIC GLIOMA HAVE NYSTAGMUS--EXOOPTHALAMUS, AND STRABISMUS



---HYDROXYUREA MAINTANANCE THERAPY HAS SHOWN TO REDUCE NUBER AND SEVERITY OF VASOOCCLUSIVE CRISIS IN SICKLE CELL ANEMIA



--CHILDREN WITH SICKLE CELL DISEASE LIKE ALL CHILDREN REQUIRE ALL ROUTINE CHILDHOOD VACCINATION



--despite penicillin prophylaxis children with sickle cell disese are still at high risk of sepsis caused by streptococcus pneumoniae as well as other capsulated bacteria. these children require both pnemococcal conjugate vaccine 7 valent during infancy and pnemococcal polysaccride vaccine 27 at 4 to 6 yrs of age



--gall stone typically develop dyuring adolescent and it is apigmented gall stone as a result of chronic hemolysis



---dactylitis or handfoot syndrome is the earliest manifestation of hand foot syndrome in vasoocclusive crisis of sickle cell disese.



--hand foot syndrome in vasoocclusive cerisis is caused by avscular nerosis of metacarpal and metatarsal bones



--hand foot syndrome requires analgesic not antibiotic



--acute chest syndrome of sickle cell disese needs supportative care in the form of supplemental oxygen red blood cell transfusion and antibiotic.







---COMPLICATION OF HIV -CANDIDIAOIS

=TB --PCP

TOXOPLASMOSIS

--COCI



HISTO

--CRYPTO

HAIRY LEUOPLAKIA

CNS LYMPHOMA

-CNS LYMPHOMA

--MAC

KAPOSHI

HERPES SIMPLEX ZOSTER



CAUSES OF WEIGHT GAIN

-- EXCESS FOOD

- SEDENDARY



---PCOS



---HYPOTHYROIDISM



---DEPRESSION

---CUSHINGS SYNDROME



--DRUG INDUCED WEIGHT GAIN



perform cbc

electrolyte

dexa supression test

thyroid



lipid

liver function

blood sugar

skin fold tahickness



albumin



in hiv



--cbc with dc

-cd4



hiv rna viral load



--cx--ppd



--rpr vdri



agg serology --toxo. cytomegalo



hepatitis b

--anal swab





1. Subcutaneous unfractionated heparin is used for prevention of DVT in immobile patients or in hospitalized patients unable to ambulate. However, after orthopedic surgery, especially after joint procedures, its efficacy is very poor, given the increased venous stasis ,you should use warfarin.



2. Both chronic laxative use and chronic diuretic use can produce hypokalemia. Severe hypokalemia, with plasma potassium 30 breaths/min, room air PaO2< 60 mm Hg, O2 saturation less than 90% on room air, or bilateral or multiple lobes involved, and older than 60 years.



5. Normal value for the anion gap is 12 ± 4 mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes mellitus, alcoholism, starvation), renal failure with retained sulfate and phosphate, drugs or metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of protein anions, and dehydration (hemoconcentration).

_____________________________________



1. Still disease is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis.



2. Whenever the terms \\\\\\\\\\\\\\\"coin-shaped\\\\\\\\\\\\\\\" or \\\\\\\\\\\\\\\"discoid\\\\\\\\\\\\\\\" are used to describe a patient\\\\\\\\\\\\\\\'s skin lesions in a question you should think about nummular dermatitis.



3. Symptoms of congestive heart failure and possible atrial fibrillation, as demonstrated by irregularly irregular heartbeat in question (they never mention straight forward A.F). In addition, there is high risk for the development of an embolic occlusion of the superior mesenteric artery. These patients will present with severe pain out of proportion to their objective physical findings. The diagnosis should be suspected clinically, and immediate superior mesenteric arteriogram should be performed. If evidence of ischemia is confirmed, the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia and possible gangrenous bowel.



4. Ischemic colitis will usually present as diarrhea, often bloody, in elderly patients with known atherosclerotic heart disease.



5. Malignant external otitis, This form is specifically caused by Pseudomonas aeruginosa, and tends to affect elderly diabetics and AIDS patients, causing the findings in the severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor.

_______________________________



1. Spondylolysis is a defect seen in the pars interarticularis portion of the lamina. Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level. Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point (with hyperextension maneuvers).



2. Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific.



3. The sudden onset of tachycardia and hypotension in a patient who is being mechanically ventilated with positive pressure, is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax.



4. Young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis.



5. Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations.

___________________________________









1.Anterior uveitis is associated with sarcoidosis. Anterior uveitis is usually marked by the abrupt onset of pain and photophobia. Specifically, anterior uveitis causes iritis and iridocyclitis. Constriction of the pupil causes increased pain. Slit-lamp examination is diagnostic, showing inflammatory cells in the aqueous humor or deposited along the corneal endothelium.



2. Many diseases are associated with anterior uveitis, including sarcoidosis and the seronegative spondyloarthropathies, including ankylosing spondylitis, psoriasis, inflammatory bowel disease, and Behçet\\\\\\\\\\\\\\\'s disease. Infectious disease may also cause uveitis. Some of the associated infections include herpesviruses, tuberculosis, onchocerciasis, and leprosy. In the majority of cases, uveitis is idiopathic. Treatment should include topical corticosteroids to decrease inflammation and mydriatics because dilation of the pupil decreases pain and the formation of synechiae.



3. Hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.(tingling sensation in the fingertips.)



4. Treatment of CMV retinitis in HIV is Gancyclovir, alternatively you can use FOSCARNET(can cause renal toxicity).



5. Asperger disorder is characterized by defecits in interpersonal development, restricted patterns of interest and behavior,and normal cognitive and speech development.

_______________________________

ca lung with sv obstruction do not loose time in imaging ; it is a clinical diagnosis;



2; but in other case you do it because it may happen with thyroid and thromobosis



3survellience colonoscopy every 6 month ?



4hematuria in adult trauma without hypotension observe closely imaging can wait



5, hematuria in kids trauma image because hypotension is late or compensted in children. in fact tachycardia is more reliable, so image quickly in kids



6 drugs like iodidide steroid cause acniformirruption rx is same retionin



thanks for these pearl.





1.Superior vena cava syndrome (SVCS) is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS.



2. Remember in patients with known lung cancer, a biopsy of the mass causing the SVCS is usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis).



3. Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women.



4. Acneiform eruptions is characterized by papules and pustules resembling acne lesions. The eruptions are distinguished by their sudden onset. Oral medications such as iodides, bromides, testosterone, cyclosporine, antiepileptic medications, lithium, and systemic corticosteroids are common agents that can lead to acneiform eruption. When medium or high doses of corticosteroids are taken for as short a time as 3-5 days, a distinctive eruption may occur, known as steroid acne. It is a sudden out-cropping of inflamed papules, most numerous on the upper trunk and arms, but also seen on the face. The lesions typically present as papules rather than comedones. Tretinoin cream applied once or twice daily may clear the lesions within 1-3 months, despite the continuation of high doses of corticosteroid.



5. The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma.

__________________________________



1. Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor.



2. Sudden onset of right upper quadrant pain associated with nausea and vomiting and history of right upper quadrant and epigastric pain before, associated with food intake. These symptoms are classical for a perforated peptic ulcer. In a perforated peptic ulcer, a patient can still have right upper quadrant localized tenderness, a thickened gallbladder wall, and pericholecystic fluid from the perforated ulcer. Hence, with any abdominal pain associated with signs, abdominal x-rays both erect and supine are very essential in the initial evaluation to rule out any free air.



3. The first line in treatment of panic disorder is selective serotonin reuptake inhibitors (SSRIs), a group of medications including sertraline, paroxetine, fluoxetine, and citalopram.



4. Surveillance colonoscopies are generally recommended every 6 months for 2 years beginning after 8 to 10 years duration of ulcerative colitis.



5. The presence of endocervical cells on a Pap test is regarded as evidence of adequate sampling of the transformation zone during cytologic screening of the cervix. When these cells are absent, it indicates that this area may not have been sampled. This is considered a satisfactory, but limited smear. In patients with no known risk factors (i.e., prior abnormal Pap test, multiple sexual partners, smoking) the American College of Obstetricians and Gynecologists recommends that the physician may defer to repeating the Pap test in 12 months even if the sample is not adequate.

________________________________



1. Key finding for Esophageal atresia with distal tracheoesophageal fistula usually presents with a history of polyhydramnios, cyanosis with feeding, and increased oropharyngeal secretions.



2. In a traumatic lumbar puncture even though the CSF is initially red, the supernatant of the centrifuged cerebrospinal fluid is clear. This means that the red blood cells have not yet had a chance to lyse and release their intracellular contents into the cerebrospinal fluid. BUT in subarachnoid hemorrhage there would be blood in the CSF, the supernatant of the centrifuged fluid would be xanthochromatic (yellow) due to the lysis of red blood cells and the release of their intracellular contents into the cerebrospinal fluid.



3. The symptoms of crampy abdominal pain and watery, explosive, secretory diarrhea are consistent with enterotoxic E. coli. the cause of traveler\\\\\\\\\\\\\\\'s diarrhea , tx: ciprofloxacin if symptoms persistent.



4. The symptoms of Giardiasis, which usually occur about a week after exposure, include flatus, loose stools, diarrhea, abdominal pain, bloating, and vomiting. The usual scenario for a healthy person that develops this infection is the onset of these symptoms after a camping trip. tx:metronidazole.



5. Infectious mononucleosis typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur.

_______________________________



1. Toxic megacolon presents clinically as abdominal distension and bowel motility disturbances. The next step in evaluation is an abdominal radiograph which will demonstrate a distended large bowel.



2. Spontaneous bacterial peritonitis. This diagnosis should be first on your list in any patient with ascites who presents with fevers, abdominal pain, change in mental status, or with other non-specific complaints. These patients need to have a paracentesis. This fluid is then sent to the lab for a cell count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a positive peritoneal fluid culture. Patients with SBP need to be started on a third-generation cephalosporin.



3. Lead levels over 10 mg/dL are considered abnormal.



4. Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects.



5. Congenital diaphragmatic hernia, which is when the abdominal contents herniate into the left hemithorax through a congenital defect in the left hemidiaphragm. This causes displacement of the heart into the right hemithorax and pulmonary hypoplasia.





1. Frequent, greasy, malodorous stools are a result of steatorrhea from chronic pancreatitis. This happens from the lack of pancreatic enzymes. Non-enteric coated pancreatic enzyme supplements with concurrent H2 blockers will deliver active enzymes to the proximal small bowel and help reduce malabsorption and steatorrhea.



2. Acute acalculous cholecystitis is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder. BUT...biliary colic, is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound.



3. Acute cholangitis is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad).



4. The hallmark of mesenteric ischemia is pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely in a patient with known vascular disease and a history of cigarette smoking. The next diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most often compromised vessel.



5. Patients with ulcerative colitis are at high risk for toxic megacolon, which is also associated with Clostridium difficile colitis.





1.Typical picture of pyloric stenosis: Projectile non-bilious vomiting is seen in virtually all patients. Patients also often develop a hypokalemic, hypochloremic, metabolic alkalosis from the persistent vomiting. If they give a child with intermittent spitting up think about pyloric stenosis.



2. Abrupt onset of colicky abdominal pain in childeren systemic signs, dyspnea, like mitral stenosis, but no opening snap, murmur changes with position=>high risk of embolization





3. A 2 month old infant can lift its head to 45 degrees, eyes follow to the midline, vocalizes, smiles and has a state of half-waking consciousness.





4. The ability to lift the head to 90 degrees, eyes crossing the midline, laughing and slight awareness of the caregiver are characteristic childhood development landmarks of a 4 month old infant.





1. Mutation of an X-linked gene coding for a tyrosine kinase is the underlying molecular mechanism leading to X-linked agammaglobulinemia of Bruton, a syndrome characterized by inability of pre-B cell precursors to mature into B-lymphocytes. Humoral immune deficiency thus manifests





2. Mutations of the autosomal gene encoding adenosine deaminase represent the most common cause of the recessive form of severe combined immunodeficiency disease (SCID), encompassing a heterogeneous group of conditions characterized by deficiency of both T- and B-cell mechanisms. SCID may be autosomal dominant, autosomal recessive, or X-linked. Mutations of the X-linked gene coding for a cytokine receptor subunit represent the most common cause of the autosomal dominant form of SCI.





3. Children with hypospadias are prone to urinary tract infections and other urinary tract anomalies. Don't forget U/A and Sono.





4. One of the most important reasons for steatorrhea in newborns is bile acid deficiency. Bile acids are very important in normal absorption of fat, which constitutes a major portion of an infant's calories intake. Unfortunately, the bile acid pool in neonates is very small when compared with that in adults. In addition, neonates often lose an excessive amount of bile acids in their stools. This results in physiologic steatorrhea because of poor absorption of fat. Preterm infants, have an even smaller bile acid pool and are more likely to have steatorrhea because of poor fat absorption. This will result in poor weight gain. The solution to this problem is to substitute medium-chain triglycerides (MCTs) in the formula for long-chain triglycerides (LCTs), because, unlike LCTs, MCTs do not require bile acids for absorption.





5. Inhalant abuse such as model glue, correction fluid, spray paint, and gasoline, to achieve an altered mental state. It is a common health problem in adolescence. The effect of inhaling a large quantity of hydrocarbons has been described as "quick drunk" because it resembles alcoholic intoxication. Initially, euphoria develops; then, lightheadedness and agitation. Disorientation, ataxia, and dizziness might develop with increasing intoxication. In extreme cases, generalized weakness, hallucinations, and nystagmus can occur. Abusers often show deterioration in school performance, disturbance of family relationships, and increased risk-taking behaviors.





---AASNCHRONOUS CARDIOVERSION OR DEFIBRILLATION AND DC SHOCK CAN BE USED SYNONYMEOULY



-Asychronous cardiovesion is given for ventricullar fibrrilation or unconscious unstable dieing pt with arrathmias /unstable or pulseless ventricular tachycardia



but synchronous is given in atrial fibrrillation or ventricular tachcardia and more stable patient brcause synchronous can be given after set up/ asychronous we cannot loose any time



--bipolar can have auditory hallucination kind of thing but he is infact not hallucinating but he thinks he is so powerful that he can talk to dead people



--bipolar have goal directed activity and decrease need for sleep







--75 yr old women having hypertrophy of metacrpometacarpal joint with also dip and pip involvement is having osteoarthritis



--ecg finding of hypocalcemia is qt prologtation-ecg finding of hypercalcemia is qt shortening but qrs will be long.



--a person who has loin to groin pain and hematuria annd have a calcium oxalate stone --advice him to take plenty of water-dont avice him to avoid calcium



---somatization and hypochondrissis cases are cofusing--but somatization will land with several chart and operation



--BRAT DIET -BANANA00RICE--APPLESAUCE AND TOAST



---CONTINUE BREAST FEEDING IN INFANT;S DIAAREEA



--A DIABETIC TYPE ONE WANT TO PARTICIPATE IN OLYMPIC DONT FORGE TO DO UA FOR KETONES



--remember nephrotic syndrome and hypothyroidism are related with high cholesterol



--screening for asyptomatic bactriuria has greatest significance for pregnant



--initial treatment of claudication is exercise and quitting and exercise



--tsh level is normal is 0.1 mcu/t4 level--0.6 to 2.9



--atrial fibrrillation is likelihood complication of hyper thyroidism..



in influenza preparation zanamavir is given which is effective given in very early period may be 72 hrs --not sure



--intralesional steroid is the rx for keloid



--32 african has uveitis with bilateral hilar lymphaeno--dx -sarcoidosis



yesterday i didnot write any thing because one guy really annoyed be by telling that i explain too much bla--- bla -- bla



-- but anyway it is for better





--first test in gyne with amenorrhea--hcg



--heavy bleeding during mens and in b/w mens --menometrorrhegia



--amenorrhea with normal prolactin , no response to estrogen progesterone challange and a hx of d and c--asher man syndrome



--therapy for pcos--ocps and weight loss sometimes metformin for insulin resistenance



--medi for ovulation--clomiphene



--postmeno with bleeding need endom. biopsy



--when pt is stable and ectopic is less than < 3.5 at less than 6 weks gestation--methotrexate can be tried.



---chocolate cyst powder burn as endoscopic finding in endometriosis



---medical options for endometriosis --ocps danazol gnrrh agonists



--diagnosi and follow up of leiomyoma is usg



-leiomyoma may be submucosal intramural intra fscial and



--natural hx of leimyo is --- it regresses after menopause



--the most common cause of bloody nipple discharge is intraductal papilloma - a benign condition



--increase vaginal discharge and petichial patches in the upper vagina and cervix --trichomonas vaginilis



--rx for bacterial vaginosis is metro and no need of rx of partner



--the contraceptive method that protect from pid is ocp and barrier cotraception



--unopposed estrogen is contraindicated in endometrial cancer and estrogen receptor positive cancer



--recent pid and rt upper quadrant pain --fitz hugh



--annual screening for women with a strong fx of ovaarian ca is ca125 and and transvaginl usg



--a 50 yr women leaks while laughing --rx kegel\\\\\\\\\\\\\\\'S --ESTROGEN -pessaries for stress incontinence



--a 30 yr unpredictable urine loss examination is normal --anticholinergic [oxybutrin]or beta adrenergic for stress incontinance.



--lab value suggestive of mnopause is incresed fsh



--the most common infertility--endometriosis



--two ascus in pap --colposcopy and endocevical curettage



--future risk of invasive brest ca - lobular ca in situ



--itching urning and erosion i n --paget disease





-teratogen will either kill or will have no effect within initial 2 weeks they may cause abnormal organ formation between 2 to 12 weeks







--women at risk of poor nutrition--



teenagers /low socioeconomic/ smoker/ alcoholics /drug abuser





--daily pregananY calorie--2500



--encourage exercise --to improve maternal felings of well being / improve symptoms due to positional effect of fetus / and to promote healthy blood sugar level



--work and travel to 36 week--ok



--sex ok unless high risk of abortion premature labour or placenta previa



-the triple screen is only valid if done if done during the correct gestational window 16 to 18



--alpha feto is incresed in neural tube defect and decrese in down 21 and trisom 18



gestational ddm --1 %



3rd trimester



if in first trimester it is nongestational dm





continue glucose monitoring after birth in dm because maternal glucose need will change suddenly for pt with gestational dm and because mother has alow risk of remaining diabetic after pregnancy





--ace i -risk of teratozenicity-



--HELLP syndrome is a form of preeclamsia 1% maternal mortality and poor fetal prognosis



--anti convulsant in pregnancy--phenobarbitone is the rx of choice in eary pregnancy because of lower risk of teratogenic effect

-clonazepam and carbamezepine may be used very carefully

-valproic acid should be never used -ebstein anomaly

diazepam may be used to break active seizure--80% effective



--BABY WHO IS CYANOSED AND IMPROVED ON CRYING --CHOANAL ATRESIA--DX IS TRY TO PASS A NASOGASTRIC TUBE YOU CANNOT



-BABY WHOSE MOTHER HAS SLE MAY HAVE HEART BLOCK



--PEA SOUP AMNIOTIC FLUID --MECONIUM ASPIRATION NEED SUCTION FIRST THEN O2



-- IN IMMATURE BABY YOU SEE EYES FOR RETINAL HEMORRAGE



-CYANOSIS IN THE FIRST DAY WITH SINGLE S2 IS TRANSPOSITION



--CYANOSIS 2 YR AND TET SPELL --BOOT SHAPED HEART --FALLOT



-HYPOTHERMIC BABY WILL HAVE NO SHIVERING BUT WILL HAVE INCREASED RESPIRATORY RATE



- V/Q SCAN HIGH PROBABILITY MEAN VERY GOOD VENTILATION WITH BLOCKED PERFUSION --A WASTED VENTILATATION





-GERD COMPLICATION--ESOPHAGITITIS/ESOPHAEGEAL ULCERATION/ STRICTURE/ BARRETS AND BAREETS CAN TURN INTO CANCER



--NISSENS FUNDOPLICATION ARE GOOD EARLY BEFORE BARRET



-ONCE BARRET HAS HIGH GRADE DYSPLASIA UPTO HALF OF ESOPHAGEUS REMOVED FOR SUCH HAVE FOCI OF INVASIVE CARCINOMA



--THERE IS NO EVIDENCE THAT H PYLORI IS INVOLVED IN GERD-ESOPHAGITIS





--EXTERNAL OTITIS EXTERNAL EAR PAIN ON PULLING ALSO





MASTODITIS IS COMPLICATION OF OTITIS MEDIA WILL DISPLACE PINNA



- CONTACT DERMATITIS WITH EAR RING IN PINNA



--DISEASE FROM WILD POLIO IS NO MORE IN USA / AND INJECTABLE FORM OF IPV IS USED



--ELISA WITHIN 4 TO 12 WEEKS BUT 95% POSITIVE BY ELISA IN 6 MONTH A WINDOW PERIOD--WESTERN LOT FOR CONFIRMING



--BENZENE BONE MARROW DEPRESSION



-IF A PATIENT IS BEING FOLLOWED UP BY A DOCTOR SAY FOR DM--WHAT IS HIS TYPE OF PREVENTION CALLED? --TERTIARY PREVENTION / IF THIS WAS A NEW PATIENT THEN IT WOULD HAVE BEEN CALLED SECONDARY PREVENTION



--IF THIS PT IS VACCINATED OR GENE MANIPULATON DONE HYPOTHETICALLY HERE THEN THAT WILL BE CALLEED PRIMARY PREVENTION



--SO TERTIARY PREVENTION ACTIVITIES INVOLVE THE CARE OF ESTABLISHED DISEASE





--PAP FOR ALL SEXUALLY ACTIVE



--ONCE SEULAL ACTIVITY STARTED IN ALL-- DO PAP



-AT LEAST-- 3 YRLY

PROBABLY CAN BE STOPPED AT 65 IF ALL ALL PREVIOUS PAP WERE NEGATIVE



--IF A WOMEN HAD HAD INVASIVE CA AND HYSTERCTOMY IS DONE OR SHE WAS EXPOSED TO DIETHYLSTIBESTEROL, PAP SHOULD BE DONE DESPITE ABSENCE OF CERVIX



--CPV -12 18 31 -PATH STRAIN--CANCER CERVIX







SILICA-QUARRY WORKER/ QUQRTZ/SANDSTONE GRANITE AND SLATE--HAS AADDED RISK FOR TB BUT NO SUCH ADDED RISK IN ASBESTOSIS



ASBESTOS IN ASBESTOS MINING OR MILLING



SIDEROSIS -IRON DUST



FOX RABID STILL PROBLEM IN USA/FOXES RSSRVOIR IN TEXAS/



FOR WILD RABID BITE --BOTH VACCINE AND IMMUNOGLOBULIN AND TETANUS ACCORDING TO TEATANUS STATUS



--LINEAR REGRESSION WITH CALCULATION OF THE COEEFICIENT IS COMMONLY USED TO ASSESS WHETHER THERE IS A RELATIONSHIP BEWEEN TWO VARIABLE AND TO ASSESS THE MAGNITUDE OF THAT TREND/IF THE LINE IS ESSENTIALLY HORIZONTAL THE SLOPE IS CLOSE TO ZERO AND VARIABLES HAVE LITLE RELATIONSHIP TO EACH OTHER

IT MUST BE REMEMBERED THAT HIGH LEVEL OF CORLATION INDICATES STRONG ASSOCIATION , BUT DOES NOT NECESSARILY MEAN THAT THERE IS CASUAL RELATIONSHIP BETWEEN THE TWO VARIABLE



--THE ODDS RATIO IS USED TO CONTRAST TWO PROPORTION





RESISTENSE TO PENICILLIN HAS INCREASED SIGNIFICANTLY IN THE LAST DECADE AND APPROACHES 20 TO 30 % IN SOME CASES . THIRD GENERATION CEPHALOSPORIN CEFTRIAAXONE ARE A PREFERRED ANTIBIOTIC FOR INITIAL TREATMENT/ AFTER STREPTOCOCCUS CULTURE SENSITIVITIES RETURN ANTIBIOTIC THERAPY CAN BE TAILORED DEPENDING UPON ANTIBIOTIC SUSCEPTIBILITIES



--ALTHOUGH TESTING OF ANIMAL SPECIMEN CAN GIVE A DX IN LESS THAN 24 HOUR IMMEDIATE TREATMENT IS INDICATED IF FOX BEHAVIOUR IS CLEARLY ABNORMAL--



5 SHOT SERIES --IN 28 DAYS--IG CALCULATED BY WEIGHT ONE HALF IN BEATEN AREA ONE HALF IN GLUTEUS/ NO CASE OF RABIES IN USA



CYSTIC FIBROSIS --IN WHITE GENE 7 Q3 1/ BLACK I IN 25/ RARE IN ASIAN



IT IS AN AUTOSOMMAL RECESSIVE DISORDER SO IF 1 IN 4 CHILDREN WILL HAVE CF IF BOTH PARENT CARRY A CF GENE/



AS CARRIER SCREENING BECOMES MORE AVAILABLE , ROUTINE TESTING FOR CF CARRIER STATUS IS BECOMING OF MORE OF STANDARD OF CAE FOR ALL PREGNANT WOMEN



1 IN 2500 CF



MORE THAN 150 GENE MUTATION CAUSING CF ARE IDENTIFIED





--REMEMBER PROSTAGLANDIN INHIBITION IS KEY TO CONTROL OF PRIMARY DYSMENNORRHEA / NSID SUCH AS IBUPROFEN



--PRIMARY DYSMENORRHEA IS PAIN WITH MENSTRUATION IN ABSENCE OF PELVIC PATHOLOGY



-INHIBITION OF OVULATION WITH ORAL CONTRACEPTIVE , DEPOT MEDROXYPROGESTERONE ACETATE OR A GONDOTROPHIC HORMONE AGONIST IS ALSO EFFECTIVE.



-ORAL CONTRACEPTIVE DECREASE PROSTAGLANDIN SYNTHESIS BY CAUSING ATROPHY AND DECIDUALIZATION OF THE ENDOMETRIUM , RELEF OF DYS MENORRHEA MAY BE ENHANCED BY ORAL CONTRACEPTIVE AND AN NSAID TAKEN ON SCHEDULED BASIS THAT IS NSAID IS TAKEN CONTINUOUSLY ON SCHEDULE DURING THOSE DAYS.



ALTHOUGH FLUOXETINE OR OTHER SELECTIVE SEROTININE UPTAKE INHIBITOR ARE USEFUL FOR PREMENSTRUAL SYNDROME OR THE PREMENSTRUAL DYSMORPHIC DISORDER PMDD THESE ARE INEFFECTIVE IN RELIEVING DYSMENORRHEA



--NODULARITY OF UTEROSACRAL LIGAMENT AND MASS -ENDOMETRIOMA-CHOCOLATE CYST POWDER BURN--IS SUGGESTIVE OF ENDOMETRIOSIS



--PREFERRED METHOD OF EVALUATION OF SUSPECTED PATHOLOGY IS DIAGNOSTIC LAPAROSCOPY





--REMEMBER PNEMOTHORAX CAN BE PRESENT SUDDENLY IN OTHERWISE HEALTHY ADOLESCENTS -IT PRESENTS VERY SUDDENLY WITH CHEST PAIN AND DYSPNEA/

PNEMONIA AND EMPYEMA CAN NOT APPEAR SO SUDDENLY WITHOUT PRODERMAL FEATURES/ASTHMA WILL HAVE WHHEGING OR DECREASED BREATHING SOUND/A FOREIGN BODY ASPIRATION IS UNLIKELY IN ADOLESCENTS--IT IS LIKELY IN DEBILATED , CHILDREN/DEBILATED ELDERLY AND DEBILITED WEAK UNCONSCIOUS PATIENTS AND POST SEIZURE STATUS/ ANAESTHESIA AND POSTOPERATIVE PATIENTS/



--REMEMBER IN PNEUMOTHORAX THERE WILL BE HYPERESONANCE DUE TO LEAKED AIR AND DECRESED VOCAL FREMITUS AS AIR IS LESS CONDUCTOR OF SOUND THAN SOLID



-IN SPONTANEOUS PNEMOTHORAX THERE WILL BE NO FEVER





--A 2 WEEK OLD BOY WITH SICKLE DISESE --WHAT IS THE MOST IMPORTANT THING FOR HIM/? --IT IS PENICILLIN PROPHYLAXIS



. PATIENT WITH SICKLE ARE AT INCRESED RISK FOR OVERWHELMING INFECTION ESPECIALLY WITH ENCAPSULATD ORGANISMS/ THIS IS USUALLY TRUE IN INFANTS AND YOUNG CHILDREN / PENICILLIN IS STARTED AS SOON AS DIAGNOSIS IS MADE



. HE WILL NEED A PNEMOCOCCAL VACCINATION BUT IS NOT EFFECTIVE INNEONATES/IT IS USUALLY GIVEN AT AGE 2 YRS?



.NEONATES WITH SICKLE DISESE ARE NOT AT ANY GREATER RISK FOR IRON DEFICIENCY THAN NORMAL INFANTS.



--FOLATE SUPPLEMENTATION IS NOT NEEDE THOUGH THEY HAVE GOT HIGHER RISK OF FOLATE DEFICIENCY THAN IRON--STUDIES HAVE SHOWN THAT



--THE SICKLE CELL PATIENT NEED TO BE CAUTIOUS IN INCREASE OF HEAT . WHEN EXPOSED TO HEAT , PATIENT NEED TO BE DILIGENT ABOUT FLUID INTAKE SO THAT THEY ARE NOT DEHYDRATED





A SICKLE CELL PT AT 6 MONTH AGE COMES WITH A LEFT QUADRANT MASS WITH HB OF 4 GM PLATELETS OF 10000O RETICULOCYTE OF 15% -WELL WHAT COMES TO YOUR MIND/?



ACUTE SPLENIC SEQUSTRATION --PT MAY BE IN SHOCK--THIS HAPPEN IN FIRST FEW YEARS OF LIFE BEFORE THE SPLEEN AUTO INFARCT



IF IT WERE APLASTIC CRISIS SAY DUE TO APLASTIC ANEMIA THERE WILL BE A VERY LOW LEUCOCYTE COUNT.



THE PREVALENCE OF SEVERE MENTAL RETARDATION IS SPREAD EQUALLLY ACROSS ALL SOCIAL CLASS



--MILD MENTAL RETATRDATION IS MORE COMMON IN CHILDREN IN LOWER SOCIAL CLASS



-BOYS SUFFER MORE--1,4 TO 1.1



ABOUT 30% OF MENTAL RETARDATION IS ATTRIBUTED TO TRISOMIES



ADVANCE MATERNAL AGE HAS SOME CORELATION-



THEIR LIFE EXPECTANCY IS COMPARITIVELY SHORTER





BOERHAAVE SYNDROME



---SPONTENOUS

--AFTER STRAINING AFTER SEVERE VOMITING

--SUBCUTENOUS EMPHYSEMA, FEVER HYPOTENSION TACHYCARDIA, AND DYSPNEA

INITIAL RX --FLUID

DIAGNOSTIC TEST OF CHOIICE--CONTRAST STUDY OF ESOPHAGEUS--NOT ESOPHAGOSCOPY

CT SCAN HELPFUL IN ATYPICAL PRESENTATION

TIME IS IMPORTANT

POORER SURVIVAL IN DELAY MORE THAN 24 TO 48 HOUR











ORDINAL SCALE --CATEGORIES HAVE A LOGICAL ORDER / BUT IT SEES DEGREE OF DIFFERENCE NOT THE AMOUNT

--LIKE 1 ,3 4 5 HOUR



BINARY SCALE HAS ONLY 2 --YES / NO OR MALE FEMALE



NOMINAL SCORE HAVE NO RANKING OR RELATIONSHIP TO EACH OTHER--BLUE BLACK BROWN -CATEGORIES TO EACH OTHER



CATEGORICAL IS SIMILAR TO EACH OTHER









AN INDIVIDUAL IS STUDYING LENTH OF SURVIVAL IN 25 INDIVIDUAL WHO HAVE SURVIVAL TIME RANGING FROM 2 MONTH TO 2 YEAR , THREE OF HIS STUDY PARTICIPITANT ARE STILL ALIVE SO THEIR TRUE SURVIVAL TIME ISS STILL UNKNOWN . WHICH ONE OF CENTRAL TENDANCY CAN BE USED AT THIS POINT TO ANALYZE THE DATA



MEAN /MODE/ MEDIAN



ANSWER--MEDIAN--MEDIAN IS USEFUL WHEN LOOKING AT HE LONGITUDINAL DATA WHEN THE DATA SET IS STILL INCOMPLETE. THE MEDIAN SURVIVAL TIME IS THE LENGTH OF SURVIVAL THAT IS MET OR EXCEEDED BY 50% OF THE STUDY POPULATION



THE MEDIAN DOES NOT ENCORPORATE THE VALUES OF EXTREMES AND THEREFORE WILL NOT BE INCORPORATED BY VALUES THAT ARE NOT STILL RECORDED .



THE MEAN TAKES INTO ACCOUNT ALL VALUES AND THEREFORE CANNOT BE CALCULATED AT THIS TIME.



THERE IS NOT ENOUGH NUMBER GIVEN TO SAY WHICH IS THE MODE --SINCE MODE IS MOST FREQUENTLY REPEATED NUMBER.





--ALPRAZOLAM WITHDRAWAL CAN CAUSE ANXIETY TREMOR IRRITABILITY NAUSEA DEPRESSION DELIRIUNSEIZURE, SLEEP DISRUPTION





TRAVELLERS DIARREA --ECOLI --CIPRO



SALMONELLA OCUR IN USA



VIBRIO FROM SEA FOOD



CAMPYLOBACTERIA --CHILDREN BELOW 6 AND COLLEGE AGED PEOPLE-COMMON DIAAREA IN MANY AREA







METHOD OF CALCULATING EDD--MINUS 3 MONTH FROM LMP AND THEN ADD 7 DAYS



OR PLUS 7 DAYS FROM LMP AND MINUS 3 MONTH



266 DAYS FROM THE ASSUMED DAY OF CONCEPTION OR 280 DAYS FROM THE LAST DAYS OF MENSTRUATION







UTERINE FUNDUS IN PREGNANCY



--DOES NOT GROW BEYOND THE PELVIS UNTIL AFTER 12 POSTMENOPAUSAL WEEKS.

GESTATIONAL AGE CAN BE INTERPRETEDED FROM FUNDAL HEIGHT BY TWO WAYS--



AT 14 UTERUS IS PALPABLE AT ONE FOURTH



AT 16 UTERUS IS PALPABLE AT ONE HALF



AND AT 18 UTERUS IS PALPABLE AT THREE FOURTH---OF THE DISTANCE BETWEEN SYMPHYSIS AND UMBILICUS



THIS WAY AT 20 WEEKS FUNDUS WILL BE AT THE UMBILICUS



INTRESTINGLY FROM THERE UPWARD DISTANCE FROM SYMPHYSIS TO PUBIS CAN BE CAL CULATED EASILY BECAUSE IT APPROXIMATES THE WEEKS GESTATION



SAY IF IT IS 1 CM ABOVE THE UMBILICUS IT MEANS IT IS 21 CM IF 5 CM ABOVE THE UMBILICUS IT IS 25 CM



CRECENT OR LENS SHAPED SUBDURAL HEMORRAGE DOES NOT CROSS THE MIDLINE AND GRADUALL Y GIVES THEM PROBLEM AND THERE WILL BE LESS FOCAL SIGN THAN IN EPIDURAL . IT RATHER PRESENT WITH GRADUALL HEADACHE CONFUSION AND COMA/ INITIALLY INCRESED INTRACRANIAL PRESSURE WILL DELAY ITS APPEARANCE OF SIGNS AND SYMPTOM MAKING IT A RATHER GRADUAL PROCESS



ALTERED MENTAL STATUS IS MOR PROMINENT THAN ITS FOCAL SIGN







ABSTINENCE OR HAVING SEX WITH AN UNINFECTED PARTNER IN A MUTUAL MONOGAMOUS RELATIONSHIP IS THE BEST FOR HIV PREVENTION



LATEX CONDOM AND THEIR CONSISTENT USE AND CORRECT USE IS NECESSARAY



IF ADOLESCENT IS ALONE IT IS FINE --BECAUSE ONE OF THE MAJOR DEVELOPMENTAL TASKS OF ADOLESCENCE IS THE ACQUISITION OF INDIPENDANCE FROM THE PARENTS.



SPENDING TIME IN THEIR OWN SPACE IS PART OF THEIS



BUT THINK ABOUT DRUG ABUSE/PREGNANCY ADOLESCENT PROBLEM ALSO BECAUSE THAT CAN LEAD TO THEIR WITHDRAWAL FROM THE FAMILY



SYMPTOM OF CONDUCT DISORDER MUST BEGIN BEFORE THE AGE OF 13



3 OF 15 BEHAVIOUR MUST HAVE BEEN PRESENT INCLUDING



BULLYING

TRAUNCY

CRUELTY TO OR HUURTING ANIMALS THREATENING OR INTIMIDATING OTHERS , OFTEN INITIATING THE FIGHT/CRUELITY TO PEOPLE/STEALING OR RAPING PURPOSEFULLY FIRESETTING , LIES TO OR CONES OTHERS/STAYING OUT AT NIGHT DESPITE PARENT\\\\\\\\\\\\\\\'S PROHIBITING AND RUNNING AWAY FROM HOME



DIFFERNTIAL INCLUDE MOOD DISORDER/PSYCHOTIC DISORDER



CHILDREN WITH OPPOSITIONAL DISORDER DO NOT NECESSARILY VIOLATE THE RIGHT OF OTHERS--THEY JUST DEGEREE AND DO NOT TAKE ADVICE.



MORE LIKELY TO DEVELOP ANTISOCIAL PERSONALITY DISORDER BUT THIS DISOODER CANNOT BE DIAGNOSE UNTIL ADULTHOOD



OPPO



CONDUCT DISORDER IS HIGHER AND EARLIER IN BOYS



PARENTERALL ALCOHOLISM, SOCIOPATHY,NEGLECT, OR ABSENCE CAN PREDISPOSE TO DEVELOPMENT OF CONDUCT DISORDER



HYPERACTIVITY MAY PRECEDE



ADHD MAY COEXIST IN SOME CASE



THERE SEEN CHEMICAL BASIS ALSO --DOPAMINE DECARBOXYLASE IS SEEN LOW



AMENORRHEA AND GALACTORROHOREA IS A COMBINATION FOR PROLACTINOMA--PROLACTINOMA MORE THAN 100--PREGNANCY AND HYPOTHYROIDISM BEING EXCLUDED

OCCURS DUE TO CHRONIC SUPPRESSION OF DOPAMINE



SO DOPAMINE AGONIST IS THE TREATMENT --BROMOCRIPTINE -PARLODEL OR CABERGOLINE DOSTINEX



HYPERTENSION IN SEXUALLY INFANTILE CHILD WITH PRIMARY AMENORRHEA IS 17 ALPHA HYDROXYLASE DEFICIENCY UNTIL PROVEN OTHERWISE / 11 HYDROXY IS NOT IMPAIRED SO MINERALOCTICOID WILL BE FORMED AND THERE WILL BE HYPERTENSION/TREAMENT IS TO PROVIDE GLUCOCORTCOID IN HIGH DOSE TO SUPPRESS HIGH LEVEL OF ACTH





--IRREGULAR MENSTRUAL INTERVAL INWOMEN WITHH SIGN OF HYPERANDROGENISM [ HISUTISM,TEMPORAL BALDING, VOICE CHANGES, CLITORAL ENLARGEMENT AND SO FORTH} SUGGEST AFUNCTIONAL DISORDER RATHER THAN NEOPLASTIC DISORDER ESPECIALLY IF THE PROBLEM IS CHRONIC AND DATES FROM THE TIME OF PUBERTY



ABSENCE OF FAMILY HISTORY, NORMAL BP AND NORML DHEA LEVEL ELIMINATE 21 HYDROXYLASE DEFICIENCY



DEFICIENCY OF 17 HYDROXYLASE CAUSES SEXUAL INFANTALISM NOT HIRSUTISM



SERTOLI LEYDIG SYNDROME WILL BE ABRUPT ONSET OF AMENORRHEA AND UNILATERAL OVARIAN ENLARGEMENT





--diaper dermatitis is a common problem in infant





--the classic presentation of this illness is erythema of the skin follwed by bullae that will rupture



allergic dermatitis and irritants dermatitis are most prominent in convex area and intensely red



-candida dermatitis is red without bullae and satellite lesion in the margin



--in seborrheic dermatitis the children tend to have a rash on the scalp , neck, and face also and prominent in intertriginous area



-



pt should be given the option of observation in fibroadenoma

if if triple test --physical examination , imaging and fna are normal







erythema marginatum--lyme--after 3 week of bite, when systemic sign would have already developed / annular raised plaque



erythema marginatum alo red annular plaque mostly in the runk and the limbs in rheumatic fever



contact dermatitis follows the shape of the offending agent not annular





primary herpes can be transmitted in neonate from mother more



the characteristic lesion of herpes is vesicles in erythematous base/ they are likely to occur in the trumatized area say if the monitor was usd in the scalp





--varicella is also vesicular but you will see numerous vesicle which usually start in the trunk



--exanthem are common with enterovirus but thay are macular and all over the body



--staphylococcal and gbs can cause cellulitis in neonete but the rash would not be vesicular





kawasaki diagnosis is clinical





--measles 3 cs cough coryza and conjunctivitis and koplick spot





--folic acid dose can be brought to 1 mg by 12 weeks because by the time neural tube would have already foormed





--the primary reason of prescribing prenatal vitamin is to provide 60 mg of vitamin in stead of 25 mg in the over the counter







--obesity at 15 with almond shaped eyes and narrow bifrontal diameter severe neonataal hypotonia hypoplastic genitalia small hands and feet polyphagia mental retardation chromosome 15 inherited sporadically --prader willy --paternal imprint



- -PSORIASIS--IS A CHARACTERISTIC BY WELL , ERYTHEMATOUS PAPULES AND PLAQUES COVERED BY FLAKES OR SCALES / COMMON SITES OF INVOLVEMENT ARE THE SCALP , ELBOWS PERIANAL REGION AND GENITALIA / PSORIASIS IS ASSOCIATED WITH NAIL DYSTROPHY --PITS GROVES OR CRUMBLING/ ARTHRITIS USUALLY MONOARTHRITIS INVOLVING THE DIGIT/ AND ANTERIR UVETIITIS COMMON TO HLA 27 --





---ACUTE RADIATION SYNDROME--



HEMATOPOIIETIC FORM -2 TO 10 SIEVERTS---3 TO 6 WEEKS -WEAKNESS LEUCOPENIA AND THROMBOCYTOPENIA/ IF BONE MARROW SUPPRESSION IS SIGNIFICANT THEN RESULTING DEAH FROM INFECTION OR HEMORRAGE MAY OCCUR



THE CEREBRAL FORM OF ACUTE RADIATION SYNDROME--AT THE EXPOSURE OF GREATER THAN 50 SIEVERT--NAUSEA VOMITING HEADACHE COMA CONVULSION DEATH



GI FORM OCCUR IN 10 TO 20 SIEVERT--UP TO 2 WEEKS AFER THE EXPOSURE





PULMONARY FORM OCCURS AFTER EXPOSURE TO GREAER THAN 10 -EFFECT ARE SEEN AT THE 30 DAYS EXPOSURE AND IF SIGNIFICANTLY EXTENSIVE IT CAN RESULT IN RESSPIRATORY FAILURE PULMONARY FIBROSIS AND COR PULMONALE



RENALL FORM ARE NOT SO COMMON



prader willi syndrome paternal imprinting



angel man --happy puppet





--for varicella vaccine child be more than 12 month



--2/4 /6/12 --influenza vaccine



--within 7 days neuro sign --dtap -should not be given



ground glass appearance in ards



surfectant deficiency



--prolonged/ first day/ direct conjugated hyperbilirubinemia --pathological jaundice



--pnematolis intesyanalis --necrotising enterocolitis



boot shaped / decreased pulmonary vascularity --fallot



egg shaped silhoutte --transposition of great vessel



tavpr --from lungs blood come back to right atrium



ebstein anomaly --tricuspid stenosis pushed down



pda--a/w rubella



most common acynotic --congenital



abstein anomaly --lithium



woolf parkinson white --delta wave due to preexcitation



digoxin is contra in wolf -beta bloker is used



cystic fibrosis ch --7



-failur to thrive most common manifestation



nasal polyp/ pneumonia. clubbing/ malabsorption/ jaundice / cirrosis



oliguria/hematuria htn--acute gn



febril seizure/ maclopapuloar rash/hsv 6 -roseola subitum



sniffing dog tipoid position--epiglottitis



croup --recemic epinephrine-cold air



otitis media rx --high dose amoxycillin



emergent ntubation--epiglottitis



thumb sign--epiglottitis



stipple sign-



bulging tympanic decresed mobility --in otitis media





most common intetinal n less than 2 yr --intusception



painless rectal bleeding --mekel's / meckel scanis needed



risk of intussception --those what act as a lead point -weaning/ lymph node/ cystic fibrosis/meckels



cryptoorchidism risk--low sperm/ cancer prone





palpable purpura joint pain / pain abdomen / hematuria---henoch scolein syndrome





dka --fluid/ electrolye/insulin





type 1 --fatigue /abdominal pain/



complication of dka--cerebral edema





-growth curve velocity decrease and falls below 5th percentile



constitutional delay is only bone age velocity ok puberty is delayed



congenital adrenal hyperplasia



--ambiguous genitlia in female



shock saltcraving



elevation of 17 keto is diagnostic







iron defi mot common pediatric



priapism/ stroke i/ swollen fingers--sickle cell anemia



acute sickle--analgesia/ o2/exchange transfusion



-there is good availability of iron n breast milk



-sickle cell--autio infarction



infarction in lungs--acute chest syndrome



gall stone/ avascular necrosi f femoral head --sickle cell



ddavp -causes secretion of factor willebrand and help hemophilia and von willibrand



rx of von willibrand- ffp/ddavp/ cryoprep





acute lymphocytic anemia is commonest in childhood



lethrgy/malaise/bone pain/



petechiae / infection --bone marrow failure in leukemia



most common solid tumour will be central nervous system tumour



sign of increased intracranial pressure--papilledema/ha/cushings respiration/ bradycardia





osteosarcoma--at epiphysis or metaphysis



ewing --diaphysis





t cell defi--digeorge/ hereditary talengiectasia





hereditary --ataxia/ alibism/ talengectasia/t cell efi/low antibody level





at 6 month, b cell defi synd. present



b cell --urti/ abcess



total lack of antibody --wiskott



combined b and t cell deficiency--scid and wiskott





wiskott--igm decrese/ iga increase/ thrombocytopenia / eczema







phagocytic--cgd

---------------chediak higashi





cgd --oxidative burst is lacking





chediak higashi --chemotaxis defect



















tuberous sclerosis --shagren patch/ seizure



febrile seizure--bilateral simple



seizure in first 2 hour of fever



neurofibrmatosis --cafe au leit/ lisch nodule--at risk for hyper tension due to renal artery stenosis/optic glioma





tics paralysis may resemble guillain barre



congenital myasthenia gravis is life long--



but due to marnal body will be temporary and present as inability to shock and floppy baby







absence seizure 6 to 10/ girl/ 3 hertz spikes





rx of myoclonic seizure is valproic acid



rx of infantile seizure is acth and valproic acid--hypsarrathmia --in eeg









--a pt presenting with sore throat can have infectious mononucleiosis. viral /bacterial pharyngitis/acute hiv infecion /secondary syphillis



-bacterial tonsillitis may be streptococcall tonsillitis.scarlet fver





/ mycoplasma pneumona viral pharayngitis can be coxsackie/ cmv/herpes/ebv/ adenovirus/infleunza -or so many





test u like to do are cbc/ peripheral smear / monospot test/ strep rapid antigen test /throat culture /grams tain/--throat work up



then you will do--hiv elisa test/ westeren blot if necessary/ hiv viral load/ cd4 count



lAST/ALT/ALKALINE PHOPOTASE/BILIRUBIN



HEPATITIS PANEL



VDRL/RPR







REMEMBER TO ASK ABOUT RASH /NEEDLEARK/ IN SORETHROAT INADDITION TO ILL CONTACT



-remember to examine spleen in sore throat

-remember to counsil about avoiding sport till splenomegaly subsides







a case of shortness of breath /cough





tuberous sclerosis --shagren patch/ seizure



febrile seizure--bilateral simple



seizure in first 2 hour of fever



neurofibrmatosis --cafe au leit/ lisch nodule--at risk for hyper tension due to renal artery stenosis/optic glioma





tics paralysis may resemble guillain barre



congenital myasthenia gravis is life long--



but due to marnal body will be temporary and present as inability to shock and floppy baby







absence seizure 6 to 10/ girl/ 3 hertz spikes







rx of myoclonic seizure is valproic acid



rx of infantile seizure is acth and valproic acid--hypsarrathmia --in eeg



















--a pt presenting with sore throat can have infectious mononucleiosis. viral /bacterial pharyngitis/acute hiv infecion /secondary syphillis



-bacterial tonsillitis may be streptococcall tonsillitis.scarlet fver





/ mycoplasma pneumona viral pharayngitis can be coxsackie/ cmv/herpes/ebv/ adenovirus/infleunza -or so many





test u like to do are cbc/ peripheral smear / monospot test/ strep rapid antigen test /throat culture /grams tain/--throat work up



then you will do--hiv elisa test/ westeren blot if necessary/ hiv viral load/ cd4 count



lAST/ALT/ALKALINE PHOPOTASE/BILIRUBIN



HEPATITIS PANEL



VDRL/RPR







REMEMBER TO ASK ABOUT RASH /NEEDLEARK/ IN SORETHROAT INADDITION TO ILL CONTACT



-remember to examine spleen in sore throat

-remember to counsil about avoiding sport till splenomegaly subsides







a case of shortness of breath /cough



--when did it start//?



-how is it progressing -gettng worse or getting better



do you hve cough



what time of day or night it is more



acute /chronic



do you have shortness of breath



can you tell ore about it for me please



ask about postnasal drip/dyspnea/exacerbating/ alleviating factor/exposure/





dont forget medication--/exposure



smoking history/ hx of lung disease / allergies / medicines /







-30 yr male ith shortness of breath/cough aand wheezing that worsen in cold weather/ he has had several such episode in pase four month--this case is asthma but d/d are gerd/bronchitis/pneumonitis / foreign body/ tuberculosis



iwork up--chest xray/ peak flow measurement/pft/ methacholine challange test



u dont have to do ppd here--in asthma







--56 yr old f presents with cough with productive cough for three consecutive month for last three years. she is a heavy smoker



--d/d chronic bronchitis



-lung cancer



-tuberculosis



--cbc



work up --sputum gram sstain/ culture cxr/pft / ppd





57 y o M c/o pleuritic chest pain fever, cough with purulent yellow sputum. he is heavy smoker with COPD



D/D PNEUMONIA

BRONCHITIS LUNG ABSCESS LUNG CANCER

TB

PERICARDITIS



CBC/SPUTUM CULTURE -GRAM STAIN/CXR/ CT -CHEST ECG/PPD





-25 YO F PRESENTS WITH TWO WEEKS OF NONPRODUCTIVE COUGH. THREE WEKS AGO SHE HAD A SORE THROAT AND RUNNY NOSE



---atypical pneumonia

---reactive airways disease



ui associated-postinfectous

post nasal drip

gerd



work up



--cbc/induced sputum/gram stain and culture/cxr/ igm cold agglutinin detection for asthma/urine legionella antigen





65 yo M PRESENTS WITH WORSENING COUGH OVER PAST SIX MONTH TOGETHER WITH HEMOPTYSIS DYSPNEA AND WEAKNESS AND WEIGHT LOSS. HE IS A HEAVY SMOKER



D/D lung cancer

----copd/

--lung abscess vasculitis-wegner

--interstitil lug disese

--CHF



WORK UP



cbc/sputum gram stain and culture and cytology /cxr/ct-chest /ppd/ bronchoscopy



dont forget cytology





34 yo F nurse presents with worsenig cough of six week duration together with weight loss.fatigue night sweats and fever/ she has a history of contat with tuberculoss at work



d/d-tb

pneumonia

atypial pneumonia

lung abcess vasculitis

lymphoma

metastatic cancer

hiv/aids

sarcoidosis





--34 yo M presents with shortness of breath and cough . he has had unprotected sex with multiple sexual partner and was recently exposed to a patient of tuberculosis/ has no recent trvel history



-tb/ pneumonia includind pcp/bronchitis/chf -cardiomyopathy/asthma



work up

cbc/ ppd/ sputum gram stain--induced if necesary--acid fast stain-silver stain-ziehl nelson stain /culture / cxr /hiv atibody



dont forget hiv--mention ppd first







50 yo M presents cough that is exacerbated by lying down at night and elieved by propping up on three pillows. he also reports exertional dyspnea



dd--chf/ cardiac valvular defect gerd pulmonary disese copd post nasal drip



w/u--cbc/ cxr/ ecg / echo/ pft/ bnp



note; ecg and echo are mentioned b4 pft



thanks







--theophylline --poor clearnce in liver diseases/kidey disease



rifampicin and all -- increase the clearance



cimetidine and antibiotic--decrease the clearance





theophylline can cause headache/ nausea/ vomiting and ectopic beat





-breast feeding delays the onset of atopic allergy



egg and influenza vaccine do not go --feather of hen , does not matter





mild intermittent asthma



mild intermittent asthma



moderate persistent asthma



severe persistent asthma





hyper oxia test-- give 100 % oxygen



more than 200 po2 in 100 oxygen --there is no cyanotic heart disese



less than 150 cyanotic heart disease --



if less than 50--tavpr--parellel circulation





hydrops/aseptic meningitis bizzare but can be associated with kawasaki in addition to aneurysm



turner and coarctatatoion cystic hygroma --related



rx of rheumatic--penicillin/aspirin/prednisolone



koebner/auspit sign/pitted nail / gutted psoriasis/





trichotellemania --stress and ocd



alopeca totlis --can regrow



newborn pustules --usually normal



molluscum-pox -



lice--permethrin

never give lindane -in children



pyogenic granuloma --



tinea versicolar --koh --sphagetti meat ball --selenium shampoo is the rx



---moles --evacuation and curettage



--complete mole is diploid incomplete is triploid



-lamivudine\\\\\\\\\\\\\\\' interferon for hepatitis b



--ovaria vessel from aorta run ism infundibulopelvic--



--ovarian vein left renal rt to venacava



-twin hyperhydramnios/ multiparity can cause uterine atony and uterus may not contrac to stop the bleeding --give oxytocin then give methargina nd then give 0prostaglandin



--if that does not work --bilateral uterine artery ligation-they come from uterine artery --no problem--because pelvis is notorious for extensive metastasis



--if tha

t does not work --hypogastric both



unilatweral ligation is not going to be success full



-- last thing --hysterectomy







retrograde menstruation --samson theory of endometriosis



--rectocele -posterior colorraphy



--cystocele --anterior relaxation--urinary incontinence---anterior colporraphy





urinary stress continence --bladder pressure increases than sphincter and urine spills while golfing laughing--urethropexy --marshal / burtz operation



sx--pressure sensation back ache --sx--is uterine prolapse --





-phenylketonuria --mental retardation/ temper tantrum/ unpredictable be haviour/ bizzare move/twisting hand move





--neurogenic/urge/detrucor dyssynergia--it is medical rx urge--anticholinergic --oxybutrin -or antispsmodic--probanthin



-prader willi --hyperphagia /obesity/hypogonadism/small stature/hypotonia/





--cats cry --criu di chat--microcephaly /low set ears hypertelerosim oblique palpebral fissure



--micrognthia



diagnosis for mental retardation and preventin--cvs/amniocntesis





--q tipp test put qtipp ask to cough --if more than 30 degree --it is stress incontinence





--stress is most common



-neurogenic seond



-never operate neurogenic



-stress versus neurogenic hx/ q tipp / pessure study--250 pessure go up --stress incontinence have normal relationship of pressure and volume---



but in neurogenic relationship b/w volume and presure is deranged





-first degree episiotomy--vagina only



-secoond degree --vagina +PERINEAL BODY



THIRD DEGRE -VAGIna+ perineal body + sphincter



4 th degree --vagina =perineal body sphincter



u cut bulbocavenous superficial transversus -cut in both sphicterctomy



advantage of mediolateral--avoid rectum



dis advantage --painful a/w higher blood loss



common causeof rectovaginal fistula--4th degree laceration



common cause of vesicovaginal fistula--presenting leakage ---traumatic hysterectomy -be care ful









only time adenexal mass may be normal is reproductive age



-old age it should have atrophy and 8 yr should not have a active ovary





-at all age group --always usg --confirm it



rx of ovarian ca is debulking cavity and 6 courses of carboplatinum and taxol--



-reproductive age -- physiological cyst --common



old and young --cancer



physiological cyst --usg --2 month follow p --can give ocp



--physiological cyst are hollow like ballon--simple



but if they have --solid component -- teratoama -



then you have to do operation --laproscopy oe ovpen but do cystectomy --not oophrectomy because it may reoccur in other as a bilateral condition--you canot take out ovary in young -unless





in young person think of germ cell tumour and present as first stage -- do conservative



--there got to be volume of cyst for torsion--



--complex surgery --philosophy --conservative



rx of endometriosis is - to inactivate endometriosis and beat way to inactivate is to inhibit the hormonal axis--znrh analogue in a constant fashion/ ocp/



in young -the mass may be ectopic--spotting/ abdominal amenorrhea--



rupture --peritonitis



indication of methotrexate --3 .5 cm cm/ hcg less thal 6000 only / no fetal heart tone / no hx of folate replacement





salpingostomy --good one/ salpngectomy and salpingoporectomy





-sudden onset of severe pelvic pain--think of ovarian torsion--if there is ovarian mass --



-- correct torsion--see if blood supply come--do simple cystectomy--if ischemia not pink after even half hour --remove



--if she becomes pregnant in endometrisois -problem may be solved



laproscopy bluish discolaration --powderlike



uterosacral nodularity











lower abdominal/fever/about one week of pregnancy --blood good media



adenexal tenderness/ chandlier sign/fever--gono and chlamydia



rx-cephalosporin plus tetracycline



cefoxitin doxy





linig of tube --when inflammed --it will let all other vaginal floora in chronic --pid --chronic pid --tuboovarian abscess--adhesion



acute do not have tuboovarian abscess --so if chronic--for aerobes --penicillin genta or clindamycin for anaerobic



or u can give metro in place of --clindamycin





postmenopausal bleeding though --atrophy is commonest should be think of cancer until proved



premenache --first cause of bleeding is foreign body second sexual abuse third sarcoma butyroids



dont do speculum



exam under anaesthesia under anaesthesia



it may be a precocious puberty but look for axillay pubic hair



puberty is three to four of your life-



breast vagina growth adrenarche pubrche



maturation of axis -causes puberty



puberty is secondary sexual characteristic--homonal not chromosomal like primary





if all features of abuse/foreign body/tumour --absent -then it may be --precocious puberty



now she may have--estogen secreting tumour --do ct of brain --abdomen ct abdomen and pelvis --dont say usg -because usg o not see adrenal-



however most common cause of precocious puberty by ar is most idopathic--but that is diagnosis of exclusion--



what u do with idiopathic precocious puberty -- because she has to grow --so menarche fuses epiphyses--so u have to delay puberty --treat the cause if idiopathic also you have to treat because she has to grow---give or gnrh--continuous--leuprolide--downregulates pituitary--for 3 years --no problem



bone age goes ahed of their chronological age --in precocious puberty



abnormal bleeding menometrorregia -- use PAd



p= pregnancy r/out



a= anatomical-adenomyosis/leiomyoma



D == dysfunctional uterine bleeding





when u are pregnant u dont bleed --but u can be pregnant but u may be bleeding



stress / anxiety -can disrupt the cycle and can cause bleeding--cause dub



do hcg test/ bleeding profile/ usg/ pelvi exam --and endo biopsy and rx it --ocp/estrogen/progesterone





all pcos are dub--chronic problem



all dub are not pcos





pcos--stevein leventhal syndrome--higher risk ofendometrial cancer--



amenorrhea /insulin resistence/ anenia/ infertility--



hirsutism --facial hair growth--most common cause hirutism



ocp increase sex hormone binding problem and bind testerone and decrese free testerone



ocp --prevent endometrial hyperplasia --



if infertility -give clomiphen/pergonal/







when we describe fibroid --compare with pregnancy size-12 weeks --pelvis/ 20 weeks --umblicus





adenomycis --symmetrical boggy--endomyometrium in myometrium



fibroid --asyymetrical





fibroid --also called leiomyoma --shrink with menopause







--paranoid scizophrenia has formal thought disorder and hallucination --but paranoid personality is just paranoid



-leiomyoma can go red degeneration/ calcification/ anemia/ hurt means --degeneration



red in pregnancu --carneos --like meat



can cause obstruction --urinary



infertility--can block fallopian tube



can cause -urinary



behind --rectal problem



if they are growing after menopause --it may be leiomyosarcoma



leupran can work for 6 month ---





you need65oo hcg for abdominal sonography



you need only -1500 mg for vaginal sonogram



if it is an intrauterine pregnancy it shoild double by 48 hours --if it does not say today it was 1200 and do ot bevome 2400 after 2 days means it isnot an intra uterine pregnancy --so wht i am going to do --/ --laproscopy to see ectopic





--in bleeding biggest worry is ectopic pregnancy becuse that can kill----6 weeks it shold be in vagina--



if 1600 vaginal sono must be able to show -----intrauterine



snowstorm--mole



if vaginal is not positive--then go for serial quantitative hcg analysis--





anything in the axis disorder can give both dub or amenorrhea--stress/ hypothyroidism/



how do u diagnose --shhehans--give trh--there will be no secretion of prolactin





take a drug hx of amennorhea and they can have antidpamine effect -- caan inhibit gn rh --

and cause amennorrhea or bleeding --



if she has hypothyroidism give her synthroid



if she has hyperprolactinoma and give her dopaminergic drug --bromocriptine--



wih syntroid they have mens after 3 month -surprisingly good response





exerise/ anorexia nervosa stress and anxiety



--menopause--fsh is incresed



--savage syndrome --resistense ovary syndrome amennorrhea



--asheman syndome-- d and c



--how do u differnciate b/w --menopause and savage syndrome----in menopause there are no follicle





-to know the problem ovary --what i do fsh and lh ratio



if i want to asses endo metrium --give both esrogen / progesterone--o know that to see something wrong--if problenm --she is not bleeding



f i suspect pituitary do mri --if dont see --do ct---if no thing--do prolactin





wh dont do gnrh --because it is cyclical --so do mri



rx of savage give estrogen--follicle become more active





beta hcg/tsh/ prolactin



then axis--hypothalamus--gnrh



ovary -



give progesterone--



if not give



estrogen/progesterone



if bleeds --get fsh /lh





if doesnot bleed--- ashermans syndrome





to see savage or meopause --do usg--follicle savage











prmary amenorrhea





if ther is mullerian agenesis -there may be not only absence of uterus but urological abnormaly--so do ivp



testicular feminization or androgen insensitivity they ar actually --male but look lik e female

why they are breast positive because testis secrete small amount of estogen and there is no competition from testerone--lower vagina so operate it to elongate it

and take the testis away





mullerian agenesis have normal testerone/ but testicularfeminization has more but not working testerone



a girl should definitely have seconday secondary characteristic by 14 and mens by 16--if not do fsh and lh if high do mri brain



how do aproach infertility--in spite of frequent entercourse no fertilization --one year



so sperm count is the first test --if problem first refer to urologist--later gynecoogist come in the show for artificial inseminationa nd in vitro so on



if male factor is not ok then go for female factors of infertility--tubal blokage/ ovulation problem/ mucus problem/ antibody problem







rosacea treat ment is similar to acne -eccept it need metronidazole and clonidine--reduce flushing













d/d of uti



--pyelonephritis



vaginitis



pelvic inflammatory disesese



appendicitis



herpes simplex type 2



invesigation



--u/a



urine culture



bimanual pelvic examination



vaginal examination and vaginal culture



complete blood count







unstable angina



d/d



myocardial infarction



coronary artery spasm



pleuritis



pneumonia



musculoskletel pain



trauma



gerd



investigation



-ecg



--ck ck -mb tropinin



-cxr



--echo



stress test



lipid profile



-

counselling for smoking cesation







d/d of tuberculosis



--pneumonia



--lung abscess



-bronchitis



aspiration





ivestigation



tuberculin skin test ppd



cxr



sputum culture



ct



bronchoscopy





--respiratory isolation



ancohol withdeawal precaution



-alcohol counselling







transient ischemic attack --



d/d



cerebral vascular accident



hypoglycemia



brain tumour



cerebral abscess



subdural hematoma



drug abuse



-seizure disorder



follow up



=1, computed tomography scan



2. tissue plasminogen activator



3. heparin /tpa if appropriate



4. eeg



5 fasting blood glucose



ecg



toxicology screen [ drug screening]





stable angina



d/d



myocardial infarction



pleuritis



pneumonia



musculoskletel pain



trauma



follow up

-ecg



--cardiac enzymes ck ck mb tropinin



cxr



echo



stress test



lipid profile







differencial diagnois of



cough



--uri/ pnemonia/ broncitis and asthme/ emphysema



gerd/postnasal drip/lung abscess bronchiectasis/ aspergillosis/atypical pnemonia/interstial pnemonitis/ drugs like captropril





productive cough



-pneumonia



-bronchiectasis



lung abscess



-gerd

postnasl drip



aspergillosis

bronchitis exacerbation



tb





dry cough



pleuritis



atypical pneumonias



interstitial pnemonitis



legionella



chlymydia



mycoplasma







d/d of upper gi bleeding --aything above ligamnt of treitz



esophagitis/hiatus/esophegeal cancer



stomach -gastric ulcer leiomyoma



gastric erosion



cushing and curling uler



gastric cancer



angiodysplasia



duodenal ulcer



du divericula



hematobilia







aoroenteric fistula



pancretic aorto fistula/





bleeding disorder like--hemophilia von wille brand/ leukemia/drugs -heparin /warfarin/tpa







lower gi bleeding



commonest cause of lower gi bleeding is from upeer gi bleeding --funny but true comment



diverticulosis/ angiodysplasia



areteiovenous malformation



mekel \\\\\\\\\\\\\\\'s diveticulum



colon cancer



and hemorrhoids



anal fistula



sometimes--infection-shigella ecoli/ campylobacter



inflammatory bowel disease



in old age ischemic colitis





Additional facts





subdural hematoma is venous and slow but dangerous





epidural is rapid has lucid interval of course it is dangerous but if diagnosed and treated in time has best prognosis-- it is due to rupture of middle meningeal artery





epidural hematoma is bicovex shape in ct and subdural is crescent shape







hypertension is common cause of brain hemorrage



in younger av malformation is the common cause of brain hemorrage in older rupture subarachnoid hemorrage-the worst headche of my life--



first investigation is ct to rule out hemorrage / if it is hemorrage you cannot give aspirin or thrombolytics even the patient may have come their as early as three hours.





hypertension presents usually with headache







-rx for fracture of clavicle is just a sling most of the time

in infant no rx

moro reflex will be absent in that side





if there is painless bleeding in first trimester and size of uterus is greater than period of gestation and there is hyperemesis gravidarum simply suspect hydatiform mole and see hcg serum level which will be very high





in normal pregnancy hcg level should double by 24 hour /if it doesnot it may be ectopic do transvaginal usg if hccg is less than 2000??/ --for transabdominal usg to be positive hcg shoul d be as high as more tha,n 4000/ l--??





if there is papule and vesicle in the shin of tibia and some paralysis in the distribution of tibial nerve --suspect herpes zoster --especially if patient is taking prednisolone







1.Whenever you use niacin you should monitor liver function and plasma glucose carefully.



2. When do you use niacin? When a patient cannot tolerate statins and also it\\\\\\\\\\\\\\\'s the best choice for raising HDL.



3. An angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.



4. Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.



5. White cells generally indicate active inflammation. The presence of leukocytes in a stool sample would be highly suggestive of IBD.





1. What imaging study is most sensitive for detection of subarachnoid hemorrhage?

CT scan without contrast.



2. What are typical lumbar puncture (LP) findings in subarachnoid hemorrhage?

Gross blood in CSF, RBC count not declining from first tube to last tube and xanthochromia (pink/yellow coloration of CSF supernatant by heme pigments).



3. What are the signs/symptoms of anterior cerebral artery occlusion?

Contralateral lower limb hemiparesis/hemianesthesia.



4. What are the signs/symptoms of middle cerebral artery occlusion?

Aphasia (dominant hemisphere), apraxia, agnosis, hemi-neglect (non-dominant hemisphere), contralateral hemianesthesia, contralateral hemiparesis and contralateral homonomymous hemianopia or quadrantanopia.



5. What are the major causes of cerebrovascualar accidents?

Ischemia (thrombosis), embolism (typically cardioembolism), hypercoagulability, hypertension and hemorrhage

Causes of acute Pancreatitis

BAD ****

Black scorpion bite

Alcohol ( or autoimmune : PAN )

Drugs ( tetracycline, azothioprin, sulfa, diuretics )

Stones ( gallstones or steroid )

Hyperlipidemia

Infection ( mumps )

Trauma



Small Bowel Obstruction

\\\"SHAVIT\\\"

S - Stone (gallstone ileus)

H - Hernia

A - Adhesions

V - Volvulus

I - Intussusception

T - Tumor



Non-GI Causes of Vomiting

ABC\\\'s of Non- GI causes of vomiting

Acute renal failure

Brain (Increased ICP)

Cardiac (Inferior MI)

DKA

Ears (labyrinthitis)

Foreign substances (Tylenol, theo, etc)

Glaucoma

Hyperemesis Gravidarum

Infections (pyelonephritis, meningitis)



Extraintestinal manifestations of I. B. D. are A PIE SAC -

Aphthous ulcers, Pyoderma gangrenosum, Iritis, Erythema nodosum, Sclerosing cholangitis, Arthritis, clubbing.



Which I. B. D. has C-obblestones on endoscopy - C-rohn\\\'s.





Acute Rheumatic Fever

There are several for the major criteria, I use \\\"JONES\\\"

J - Joints

O - Obvious (cardiac) - sorry, I know this is kinda weak

N - Nodules (subcutaneous nodules)

E - Erythema marginatum

S - Syndeham\\\'s Chorea



Causes of ST Elevation

\\\"ELEVATION\\\"

E - Electrolytes

L - LBBB

E - Early Repolarization

V - Ventricular hypertrophy

A - Aneurysm

T - Treatment - Pericardiocentesis

I - Injury (AMI, contusion)

O - Osborne waves (hypothermia)

N - Non-occlusive vasospasm





Hyperkalamia causes large T waves on the ECG, Hypokalaemia causes small ones - ie. large pot - lots of tea, small pot - no tea.





If QRS complex is wide, consider bundle branch block. LBBB causes a \\\"W\\\" pattern in V1-2 and a \\\"M\\\" pattern in V5-6. RBBB is the other way round. Remember as WiLLiaM MaRRoW.



Elevation of cardiac enzymes after a M.I. is CPK, then AST, then LDH. Remember as - C AST Le.



Basal Systolic Murmur: Aortic Stenosis (AS)

-The mnemonic key is Arthur Shawcross (AS), a cannibalistic murderer, a key which immediately follows the symbol.



-Clinical:



Angina pectoris despite normal coronary arteries

Arthur Shawcross represents the Angel of death [Angina].



Exertional syncope

His victims Swooned [Syncope] with fear when they saw him.



Exertional dyspnea of congestive heart failure

Arthur Shawcross claims he left the crime scenes whistling Dixie [Dyspnea].



Sudden cardiac death

Arthur Shawcross causes Sudden Death.



-Physical findings



Loud, harsh, systolic ejection murmur at the upper right sternal border, usually

associated with a palpable systolic thrill.



Arthur Shawcross is a Base [Basal] Thrill-murderer [Thrill].

He is a Harsh Hardened criminal, who attributed his grotesque actions to

incest with his Sister [Systolic].



S4 gallop is common and represents left ventricular hypertrophy and increased

left ventricular pressure.

His ghoulish tales read like the Four [S4] Horsemen of the Apocalypse.



S3 when left ventricular failure is present.

As a child, AS displayed the classic homicidal Triad [S3]: animal torture,

fire-setting, and bed-wetting.



Delayed upstroke in the carotid pulse. Parvus et tardus carotid pulse.

His last victim still had a Small but palpable pulse. However, the ambulance was

Delayed [upstroke], and, it soon became too Little, too Late [Parvus et Tardus].



Paradoxical splitting of S2

AS sent his victims to Paradise [Paradoxical].









Apical Diastolic Murmur: Mitral Stenosis (MS)





-The mnemonic key is MicroSoft (MS), a key which immediately follows the symbol.



-Physical findings:



The thrill at the apex is the diastolic murmur.

>> Hopeful applicants at the Apex of their careers are Thrilled to be hired by

MicroSoft.



The left ventricle (LV) is of normal pressure and size, so the point of maximum impulse

is not displaced to the left.

>> MS owns a Healthy Windows [Vented: Normal LV] environment, and is Not willing

to be Displaced from its location.



High-pitched opening snap [OS] following S2, heard best between the second to

fourth left intercostal space.

>> The new Windows98 Operating System [OS] sold at a High-pitched pace.



S1 is loud and snapping.

>> MicroSoft 1-sound is Bill Gates [S1], who barks out Loud Snapping orders.



-Chest x-ray:



Kerley B lines (dilated interlobular septa or septal edema) are horizontal, nonbranching

lines at the peripheral lower lung fields.

>> The Curly-haired [Kerley B lines] computer geek...



The large left atrium straightens the left heart border and is suggested by a double

density right-heart border, by the posterior displacement of the esophagus, and

by an elevated left mainstem bronchus.

>> ...stole Double Density [CXR] diskettes to be sold in Los Angeles [large LA].



-Catheterization:



The left atrial (LA) pressure pulse reveals a prominent \\\"a wave (LA contraction

against the mitral valve).

>> Those trying to enter the ranks of MS had to show Prominent A grades [\\\"a wave]

at the Apex [Apical diastolic murmur] of their class.





Symptoms of aortic stenosis are SAD or ASD - Syncope, Angina, Dyspnea.



For Causes of A-Fib/Flutter



H = cHf, other cardiomyopathies

E = Enlargement of the atria

A = Alcohol binge drinking

R = Rheumatic heart disease

T = hyperThyroid



Asystole

\\\"3 Hypo\\\'s & 3 Hyper\\\'s\\\"

Hypoxia

Hypothermia

Hypokalemia

Hyperkalemia

Hyper H (Acidosis)

Hyper Rx (Drugs/OD)

Submitted by Tag Filley, M.D.



Syncope

\\\"HEAD, HEART and VESS\\\'LS\\\"

H - hypoglycemia hypoxia

E - epilepsy

A - anxiety [the \\\"swoon\\\"]

D - dysfunction of brain stem [i.e. brain stem TIA]

H - heart attack

E - embolism of pulmonary artery

A - aortic obstruction [ Aortic stenosis, myxoma, IHSS ]

R - rhythm disturbance

T - tachycardia esp VT

V - vasovagal

E - ectopic i.e. hemorrhage obvious or not

S - situational [micturation, defecation...]

S - subclavial steal

L - low SVR [eg: anaphalaxis]

S - sensitive carotid sinus

of M.I. is BOOMAR - Bed rest, Oxygen, Opiate, Monitor, Anticoagulate, Reduce clot size Proven MI.. should be met by M.O.N.A.



M = morphine

O = oxygen

N = nitrates

A = aspirin



suspected right ventricular MI suspected .. hold the Nitrates. submitted by Chris



Mnemonic for remembering antiarrhythmics



Class Drug Mnemonic Read as: Professor Quackers \\\"dissed\\\" - Lydia\\\'s penny Mexican tacos. - Feeling profaned, - proper Bertha Butt - (amiable British socialite) - virtually dismembered \\\'im. or Professor Quackers dissed Lydia\\\'s Penny Mexican Tacos. Feeling profaned, proper Bertha Butt, (amiable British socialite), virtually dismembered \\\'im.*Note: \\\"Dissed\\\" is used here as the slang term \\\"dis\\\" - from dismiss. I.e., \\\"Don\\\'t \\\'dis\\\' me, man!\\\"

Class IA Procainamide Professor

Quinidine Quackers

Disopyramide \\\"dissed\\\" *

Class IB Lidocaine Lydia\\\'s

Phenytoin penny

Mexiletine Mexican

Tocainide Tacos

Class IC Flecainide feeling

Propafenone profaned

Class II Propranolol proper

Beta Blockers Bertha Butt

Class III Amiodarone amiable

Bretylium British

Solatol socialite

Class IV Verapamil virtually

Diltiazem dismembered \\\'im

Atropine

Adenosine





Endocarditis

\\\"FAME\\\"

F - FEVER

A - ANEMIA

M - MURMUR

E - ENDOCARDITIS



Causes of pericarditis are CARDIAC RIND - Collagen vascular disease, Aortic aneurysm, Radiation, Drugs eg. hydralazine, Infections, Acute renal failure, Cardiac infarction, Rheumatic fever, Injury, Neoplasms, Dressler\\\'s syndrome.



5 T\\\'s of early cyanosis in congenital heart disease

• Tetralogy, Transposition, Truncus, Total anomalous, Tricuspid atresia

Sumbitted by Ben Humphreys





95% of hypertension is primary (idiopathic). 5% is secondary and causes include CHAPS - Cushing\\\'s syndrome, Hyperaldosteronism (Conn\\\'s syndrome) , Aorta coarctation, Pheochromocytoma, Stenosis of the renal arteries.





Takayasu's disease is also called pulseless disease, therefore I can't Tak'a ya's pulse.



Henoch-Schonlein Purpura

"JARS"

J - Joints

A - Abdominal pain

R - Renal

S - Skin



Compartment Syndrome



\\\"6 p\\\'s\\\"

pulselessness

pain

pallor

parasthesia

poikiolothermia

paralysis



Predisposing Conditions for Pulmonary Embolism TOM SCHREPFER

• T--trauma

• O--obesity

• M--malignancy

• S--surgery

• C--cardiac disease

• H--hospitalization

• R--rest (bed-bound)

• E--estrogen, pregnancy, post-partum

• P--past hx

• F--fracture

• E--elderly

• R--road trip







(Cot)Caught by Sin : Cottonà BySSinosis



Shortness of Breath



HAPISOCS



H: History of any pulmonary disease

A: Activity at onset

P: Pain upon inspiration

I: Infections fever/chills

S: Smoker years/packs

O: Orthopnea

C: Cough (Persistent)

S: Sputum Productive/color

Submitted by medmanRRT@aol.com



Non-Cardiogenic Pulmonary Edema

\\\"PONS\\\"

P - Phosgene, paraquat, phenothiazines

O - Opioids/organophosphates

N - Nitrous dioxide

S - Salicylates



Treatment of acute pulmonary edema

As Easy as \\\'LMNOP\\\' : Remember the mnemonic LMNOP when treating a patient with acute pulmonary edema

• Lasix¢ç (furosemide) intravenous (IV), one to two times the patient\\\'s usual dose, or 40 mg if the patient does not usually take the drug.

• Morphine sulfate. Initial dose, 4 to 8 mg IV (subcutaneous administration is effective in milder cases); may repeat in 2 to 4 hours. Avoid respiratory depression. Morphine increases venous capacity, lowering left atrial pressure, and relieves anxiety, which reduces the efficiency of ventilation.

• Nitroglycerin IV, 5 to 10 ug/min. Increase by 5 ug/min q 3 to 5 minutes. Reduces left ventricular preload. Caution: may cause hypotension.

• Oxygen, 100% given to obtain an arterial PO2>60 mm Hg.

• Position patient sitting up with legs dangling over the side of the bed. This facilitates respiration and reduces venous return.



Beta-1 receptors are in the heart (you have 1 heart) and beta-2 receptors are in the lungs (you have 2 lungs).



Decreased Pleural fluid Glucose : \\\"IRAN\\\"

• I=Infections

• RA=Rheumatoid arthritis

• N=Neoplasia



Anterior Mediastinal Mass

\\\"4 T\\\'s\\\"

T - Thymoma

T - Teratoma

T - Thyroid tumor/goiter

T - Terrible lymphoma



Middle Mediastinal Mass

\\\"Habit5\\\"

H - Hhernia, hematoma

A - Aneurysm

B - Bronchogenic cyst/duplication cyst

I - Inflammation (sarcoid, histo, coccidio, TB)

T5 - Tumors (lung, lymphoma, leukemia, leiomyoma, lymph node hyperplasia)



Bilateral Hilar Adenopathy

\\\"Please Helen Lick My Popsicle Stick\\\"

P - Primary TB

H - Histoplasmosis

L - Lymphoma

M - Metastases

P - Pneumoconiosis

S - Sarcoidosis



Sarcoidosis:



SARCOIDOSIS: G-E-R-M-A-N ACE \\\"SCHAUMANN\\\" B-O-E-K



G-Granulomas

E-Erythema nodosum

R-Restrictive lung defect (PFTs)

M-Multiple systemic manifestations

A-Asteroid bodies (inclusions)

N-Noncaseating granuloma, Negative TB test



ACE - Angiotensin converting enzyme levels monitor disease activity and response to therapy.



Schaumann\\\'s bodies (inclusions)



B-Bell\\\'s palsy, Bilateral hilar lymphadenopathy, Black females O-Optic nerve dysfunction is a common manifestation of neurosarcoid.

E-Eyes: uveitis

K-Kveim skin test



Rat Poisons



\\\"RATS PANIC\\\" I\\\'m sure that you\\\'ll easily remember this one!

R - Red squill

A - Arsenicals

T - Thallium

S - Strychnine

P - PNU/Phosphorus/zn Phosphide

A - Alpha naphtha thiurea (ANTU)

N - Norbormide

I - Indanediones

C - Coumadin/cholcalciferol



Anion Gap Acidosis:

\\\"Mudpiles\\\"

M - Methanol

U - Uremia

D - DKA/AKA

P - Paraldehyde/phenformin

I - Iron/INH

L - Lactic acidosis

E - Ethylene glycol

S - Salicylates



Normal Gap Acidosis

\\\"HARDUP\\\"

H - Hyperalimentation/hyperventilation

A - Acetazolamide

R - RTA

D - Diarrhea

U - Ureteral diversion

P - Pancreatic fistula/parenteral saline



Osmolar Gaps

\\\"ME DIE\\\"

M - Methanol

E - Ethanol

D - Diuretics (mannitol, sorbitol, glycerol)

I - Isopropanol

E - Ethylene glycol



Respiratory Alkalosis: Asthmatic Sally poisoned POPE\\\'s HEN

• Asthma

• Salicylate poisoning

• PO= Pulmonary Oedema

• PE= Pulmonary Embolism

• HEN= Hepatic Encephalopathy



Hypoglycemia

\\\"Reexplain\\\"

R - renal failure

EX - exogenous

P - pituitary

L - liver failure

A - alcohol

I - insulinoma/infection

N - neoplasm



Hypoglycemia [By Sung Kim]



Hypoglycemia - H-U-N-G-E-R: B-E-S-T S-A-U-C-E I-S M-S-G



H-Hepatic failure (advanced), Hypothermia

U-Uremia/renal failure

N-Nausea, vomiting

G-Growth hormone deficiency

E-Ethanol metabolism blunts gluconeogenesis

R-Reye\\\'s syndrome



B-Beta blockers

E-Enzyme defects (glycogen storage diseases)

S-Sepsis

T-Tumors: Islet beta cell tumors (pancreatic): Insulinomas

Non-islet cell tumors: Large mesenchymal tumors



S-Sulfonylureas

A-Adrenal insufficiency

U-Under 0.3 (insulin/glucose ratio) to make the diagnosis C-C-peptide measurement to rule out factitious hypoglycemia

E-Endocrine: Epinephrine, glucagon deficiencies (counterregulatory hormone deficiencies)



I-Immune disease with insulin or insulin receptor antibodies

S-Sarcomas: large retroperitoneal sarcomas



M-Maple syrup urine disease, severe Malaria

S-Salicylates in children

G-Galactosemia (with milk ingestion), disorders of Gluconeogenesis



Symptoms of hyperthyroidism

• Remember the following mnemonic when evaluating patients for hyperthyroidism:

S : Sweating

T : Tremor or Tachycardia

I : Intolerance to heat, Irregular menstruation, and Irritability N : Nervousness G : Goiter and Gastrointestinal (loose stools/diarrhea).



CUSHING\\\'S

• DISEASE is

• Dependent on (Pituitary) and

• Depresses ( Cortisol) on

• Daddy Doses of Dexa(High doses of Dexamethasone).



Hypercalcemia

\\\"SHAMPOO DIRT\\\"

S - Sarcoidosis

H - Hyperparathypoidism, Hyperthyroidism

A - Alkali-milk syndrome

M - Metastases, myeloma

P - Paget disease

O - Osteogenesis imperfecta

O - Osteoporosis

D - Vitamin intoxication

I - Immobility

R - RTA

T - Thiazides



Hypercalcemia symptoms are Bones (pain), Stones (renal), abdominal Groans (pain) and psychic moans (confusion).



Multiple endocrine neoplasia

MEN I is 3 P\\\'s (Pituitary, Parathyroid, Pancreas). MEN II is 2 C\\\'s (Catecholamines ie. pheochromocytome, carcinoma of medulla of thyroid) and Parathyroid (IIa) or Mucocutaneous neuromas (IIb).



The most common thyroid carcinoma is P-apillary (P-opular). It also has P-sammona bodies on histology. It causes P-alpable lymph nodes (lymphatic spread).



The most common symptoms of PHEochromocytoma begin with the first 3 letters - Palpitations, Headache, Episodic diaphoresis (sweating).



Tumors that go to bone

\\\"Kinds Of Tumors Leaping Primarily To Bone\\\"

K - Kidney

O - Ovarian

T - Testicular

L - Lung

P - Prostate

T - Thyroid

B - Breast



Causes of joint pain are SOFTER TISSUE - Sepsis, Osteoarthritis, Fractures, Tendon/muscle, Epiphyseal, Referred, Tumour, Ischaemia, Seropositive arthritides, Seronegative arthritides, Urate, Extra-articular rheumatism (eg. polymyalgia).



Ossification centers of the elbow



There are two that I know of (most people use \\\"CRITOE\\\"):

C - Capitellum

R - Radial head

I - Internal (medial epicondyle)

T - Trochlea

O - Olecranon

E - External (lateral epicondyle)

These appear at 2, 4, 6, 8, 10, and 12 years of age in order and go away two years later.

The other mnemonic I know for the ossification centers is \\\"Come Rub My Tree Of Love\\\" where the \\\"M\\\" is medial epicondyle and the \\\"L\\\" is the lateral epicondyle.



Wrist Bones

\\\"Never Loosen Tillies Pants, Mother Might Come Home\\\"

Proximal row:

N - Navicular

L - Lunate

T - Triquetrium

P - Pisiform

Distal row:

M - greater Multiangular (trapezium)

M - lesser Multiangular (trapezoid)

C - Capitate

H - Hamate

Also: \\\"Some Lovers Try Positions That They Can\\\'t Handle\\\"



Rotator Cuff Muscles

\\\"SITS\\\"

S - Supraspinatus

I - Infraspinatus

T - Teres minor

S - Subscapularis



The Salter Classification:

\\\"SALTR\\\"

S - Slip of physis

A - Above physis

L - Lower than physis

T - Through physis

R - Rammed physis



NEPHROTIC SYNDROME (NS) is characterized by the following: [By Shweta]



N = Na + water retention

This occurs due to several factors, including compensatory secretion of aldosterone in response to hypovolemia-mediated release of ADH.



E = Edema

Due to hypoproteinemia + Na, water retention. Edema is soft, pitting and starts in the periorbital region.



P = Proteinuria >3.5gm/1.74sq. ml/24hrs



H = Hypertension + hyperlipidemia (due to increased lipoprotein synthesis in liver, abnormal transport of circulating lipoproteins, decreased catabolism.)



R = Renal vein thrombosis



O = \\\"Oval fat bodies\\\" in the urine. Lipiduria follows hyperlipidemia. Albumin as well as lipoproteins are lost. Lipoproteins are reabsorbed by tubular epithelial cells and they shed along with degenerated cells- this appears as \\\"oval fat bodies\\\" in urine.



T = Thrombotic + thromboembolic complications owing to loss of anticoagulant factors (eg. anti-thrombin III )



I = Infection. These patients are prone to infection, especially with staphylococci and pneumococci. Vulnerability is due to loss of immunoglobulins.



C = hyperCoagulable state



Henoch-Schonlein Purpura

\\\"JARS\\\"

J - Joints

A - Abdominal pain

R - Renal

S - Skin



Causes of hematuria

• Use the mnemonic SITTT as an aid in evaluating the cause of hematuria:



S: Stone

I: Infection

T: Trauma

T: Tumor

T: Tuberculosis



Causes of secondary nephrotic syndrome ie. not of direct renal origin are DAVID - Diabetes mellitus, Amyloidosis, Vasculitis, Infections, Drugs.



Causes of acute and reversible forms of urinary incontinence The following mnemonic aids in remembering the causes of acute and reversible forms of urinary incontinence - DRIP



D: Delirium

R: Restricted mobility, retention

I: Infection, inflammation, impaction (fecal)

P: Polyuria, pharmaceuticals



Hereditary cystic disorders: Polycystic kidney disease



Autosomal dominant polycystic kidney disease (ADPKD) is associated with cysts in the kidneys and, in many cases, in the brain (berry aneurysms), liver, spleen, pancreas, and lungs.



¡°Halley Berry AKA Dorothy (Dandridge) Portrayed Carmen Jones.¡±



Halley ?Hematuria: Gross and microscopic

Berry -Berry aneurysms



AKA ?ADPKD



D-Dominant (autosomal) inheritance

O-Obstruction of the urinary tract by stones, blood clots R-Renal failure

O-Oxalate: calcium oxalate and uric acid stones

T-renal Tubular defects

H-Hemorrhagic cysts

Y-Year 1 - Most cases are diagnosed in the first year of life, presenting as bilateral abdominal masses.



Portrayed ?Polycystic: continued enlargement of the cysts often leads to progressive renal failure.



Carmen ?CT scanning: Enlarged kidneys with multiple bilateral cysts are diagnosed using ultrasound, IVP,

or CT scanning.

Jones - Juvenile nephronophthisis (JN) and medullary cystic disease (MCD) are in the DDx.



-Cardiac valvular disorders: Mostly mitral valve prolapse (MVP) and aortic regurgitation -Salt-wasting nephropathy, renal tubular acidosis (RTA) -Chronic flank pain due to the mass effect of the enlarged kidneys



Lusty Carmen Jones powdered her nose, using her Bivalve [MVP] mirror compact, ¡¦ -then she slowly raised her Salt-rimmed [Salt-wasting nephropathy] MargaRiTA [RTA], and seductively

placed her other hand on her Hip [Flank pain].



-Hyperchloremic acidosis

-Salt-wasting nephropathy causing hyponatremia



It was said that Dorothy was not allowed to swim in the hotels Chlorinated pool [Hyperchloremic acidosis].

When she defiantly swam in the pool, they Drained it [Salt-wasting nephropathy, Hyponatremia].



-Hypertension

-End-stage renal disease (ESRD)



Dorothy was forced to enter through the back door, even while she was contracted to sing under The Big

Tent [Hypertension].

Dorothy was only 41 when she was found DEAD [ESRD].



Review:



Dx: Positive family history (autosomal dominant inheritance)

Gross and microscopic hematuria

Ultrasound, IVP, or CT scanning detect the enlarged kidneys with multiple bilateral cysts







Renal Pathology Buzz words



Lupus = wire LOOP lesion (LUPUS=LOOP)



goodPASTURE = a pasture is FLAT so is the immunoflouresence for GP



Membraneous GN = spike and DOME appearance (think membrane = dome)

(held up by spikes)



Membranoproliferative GN = M P GN = Tram Track

think of MP\\\'s (military police riding on Trams)



Post streptococcal GN= Lumpy Bumpy

think Strep aerobics

Lumpy people Bumping

around doing aerobics



WBC Count

\\\"Never Let Mom Eat Beans\\\" and \\\"60, 30, 6, 3, 1\\\"

• Neutrophils 60%

• Lymphocytes 30%

• Monocytes 6%

• Eosinophils 3%

• Basophils 1%



Hem - PT, PTT:



To remember the intrinsic and extrinsic pathways in relation to what blood test is affected:



PiTT (I for Intrinsic pathway) - PiTTsburgh

PeT (E for Extrinsic pathway)



Vitamin K-dependent proteins and warfarin sodium [by Sung Kim and S. Levine, MD, PhD.]



Warfarin sodium is a vitamin K antagonist.



-Vitamin K-dependent proteins C and S.

-Vitamin K-dependent clotting factors II, VII, IX, and X of the extrinsic pathway.



--> The Korean [vitamin K] War [Warfarin] was fought Outdoors [Extrinsic

--> pathway]. The American PT boats [PT, Protime, or prothrombin time],

--> whose access had been limited

by the rough Seas [protein C], quickly sent out SOS [protein S] messages.



Microcytic Anemia

\\\"TICS\\\"-

Thalasemia

Iron deficiency

Chronic disease

Sideroblastic anemia



Submitted by Jeff Rodgerson M.D.

HCMC Medical Center



Eosinophilia

\\\"NAACP\\\"

N - Neoplasm

A - Allergy

A - Addison\\\'s

C - Cirrhosis, CVD

P - Parasite (visceral larva migrans), Periarteritis nodosa

Submitted by Tag Filley, M.D.



Thalassemia major is the most Severe ©-thalassemia [B-Beta-Bad].



-Major B-A-D M-A-F-I-A guys have the typical gangster appearance:

Short [Microcytic hypochromic anemia] and

Ugly [distortion of facial, skull, and long bones]



B-Basophilic stippling

A-Anemia, Anisocytosis

D-Deferoxamine



M?MCV is low

A-HbA is decreased

F-HbF is increased

I-Ineffective erythropoiesis

A?HbA2 is increased





Cooley\\\'s anemia (beta-thalassemia major) is the homozygous state.



-The key is Denton A. Cooley, M.D., Texas Heart Institute (THI).





D-Deferoxamine therapy to prevent hemochromatosis

A-Anemia - In beta-thalassemia major or intermedia, anemia is due to a combination of ineffective erythropoiesis

and hemolysis of circulating cells. C-Congestive heart failure is a cause of death in the first years of life if the patient is not transfused.





M-MCV is low; Microcytic hypochromic anemia

D-Diagnosis, prenatal



T-Tower skull (also frontal bossing, chipmunk facies, and distortion of long bones) H-Hemolytic anemia with Hepatosplenomegaly in the first year of infant life I-Intermedia - Beta-thalassemia intermedia presents with abnormalities similar to those of thalassemia major.





Increased susceptibility to infections



Peripheral blood smear: Basophilic stippling

Helmet cells

Nucleated target cells

Anisocytosis (RBCs of different size/volume)



X-ray: Hair-on-end skull



Serum hemoglobin electrophoresis: HbA is decreased.

HbA2 is increased.

HbF is increased



--> Dr. Cooley performed Major surgery [thalassemia Major] as a

--> Cardiothoracic surgeon [Cardiac failure] live

on the Internet [Infections].



--> His skilled hands can perform Microsurgery [Microcytic hypochromic

--> anemia] on Fetuses [HbF].



--> His surgical cap [Helmet cells] fit loosely over his Crew cut

--> [Hair-on-end skull].



--> He proceeded to make an incision along the Blue Stippled line

--> [Basophilic Stippling] drawn on the skin.



--> Dr. Cooley\\\'s Target [Target cells] academic score had always been an

--> A+ [HbA2 is increased].



--> He would Not accept a simple A [HbA is decreased].



--> The surgical staff is a close knit community, like a B-A-D M-A-F-I-A

--> (see below), quick to dispose of weak,

Ineffective [Ineffective erythropoiesis] residency candidates.





Disseminated intravascular coagulation (DIC)





D-I-S-S-E-M-I-N-A-T-E-D



D-Dx: D dimer

I-Immune complexes

S-Snakebite, shock, heatstroke

S-SLE

E-Eclampsia, HELLP syndrome

M-Massive tissue damage

I-Infections: viral and bacterial

N-Neoplasms

A-Acute promyelocytic leukemia

T-Tumor products: Tissue Factor (TF) and TF-like factors released by carcinomas of pancreas, prostate, lung,

colon, stomach

E-Endotoxins (bacterial)

D-Dead fetus (retained)



Characteristic features of multiple myeloma on X-ray are ABCDE - Asymmetry, Border irregular, Colour irregular, Diameter usually > 0.5cm, Elevation irregular.



Á¦ 9 Àå Á¾¾ç Áúȯ



Chronic lymphocytic leukemia (CLL) is a monoclonal malignancy, usually of B lymphocytes.



-Incidence: CLL is the most common adult leukemia in the United States.

Males>Females

50-70 years of age



Songwriter Phil ***** [CLL] is Male and probably over 50 years of age. He recently won an

Oscar for his \\\"Tarzan\\\" song.



Clinical and diagnosis



Lymphocytosis >15,000/mm3

Generalized lymphadenopathy



Tarzan can spring from Limb [Lymphocytosis] to Limb [Lymphadenopathy] above the tree

tops¡¦



Splenomegaly, hepatomegaly

Low serum immunoglobulins (immunosuppression)



--> where the Splendid [Splenomegaly] Moonlight [imMunosuppression]

--> streams through the

branches.



Diffuse bone marrow infiltration and replacement of cellular elements cause:

Anemia

Thrombocytopenia

Granulocytopenia



--> Walt Disney Pictures produced the Animated Animal [Anemia] adventure

--> \\\"Tarzan\\\".



--> The \\\"Tarzan\\\" [Thrombocytopenia] song earned ***** an Oscar [Osteo,

--> bone marrow failure]

award for the best original song.



--> Tarzan had Little need for Plates [Platelets jungle.



--> Phil ***** is a Grammy [Granulocytopenia] Award-winning singer and

--> songwriter.



Occasionally extravascular hemolysis: warm-antibody autoimmune hemolytic anemia (AHA)



--> An African jungle [Autoimmune extravascular] APE [AHA] had Warmly

--> [Warm-antibody]

adopted baby Tarzan.



Differential diagnosis

Malignant lymphoma

Infectious mononucleosis



--> Tarzan is Lord [Lymphoma] of the Jungle and friend of the Monkeys

--> [Mononucleosis]. Phil ***** was born in London [Lymphoma].





Treatment

Chlorambucil (an alkylating agent), with or without prednisone

Fludarabine



--> Some may imagine a Ram [ChloRambucil] scrambling about, but others

--> will¡¦



--> recall that Clayton [Chlorambucil] is the villainous jungle guide

--> who was hired by

Professor [Prednisone] Porter, not knowing that¡¦



--> ¡¦Clayton [Chlorambucil] had his captured Prey [Prednisone]

--> immediately Flown

[Fludarabine] out for profit.





References:

1. Harrison\\\'s Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998. 2. Maximum access to diagnosis and therapy (MAXX), Lippincott Williams & Wilkins, New York, 1999. 3. Scientific American Medicine (SAM-CD), Scientific American Inc, New York, 1997.



Hodgkin\\\'s lyphoma classification - A = Asymptomatic, B = Bad.



Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40 etc.



Malignant Monoclonal Gammopathies: Multiple myeloma



-The mnemonic key for multiple myeloma (MM) is Marilyn Monroe (MM), a key which immediately follows the >> symbol.



-Clinical:



Weakness and fatigue due to normochromic normocytic anemia.

>> MM\\\'s original name was Norma [Normochromic normocytic] Jean.



Bone pain and pathologic fractures: predominantly osteolytic tumors and osteoporosis.

>> MM\\\'s name was illuminated in marquee Lights [osteoLytic], but she

>> secretly longed for

an Oscar award [Osteoporosis].



Susceptibility to bacterial infections.

>> MM was Susceptible to Toxic [infections] relationships.



Acute renal failure (ARF) due to the effects of filtered light-chain proteins,

hypercalcemia, and amyloid deposits in the kidney.

>> MM\\\'s Lightly-Chained ARF dog barked when MM\\\'s death was said to be

>> related to her

JFK Army-Lord [Amyloid].



-Laboratory



Hypercalcemia

>> MM fluffed White Talcum [hypercalcemia] powder on her delicate white

>> skin...



Hypergammaglobulinemia

>> ...to protect it from the movie industry\\\'s Large hot Camera

>> lights[hyperGammaglob].



Serum electrolytes: Low anion gap

>> MM wore gowns with Low [Low anion gap] revealing necklines.



Rouleaux on peripheral blood smear.

Occasionally Coombs(+) hemolytic anemia.

>> MM used hair Rollers [Rouleaux] and Combs [Coombs] to create her

>> famous hairdo.



Leukocyte alkaline phosphatase (LAP) staining reaction: High LAP score.

>> MM used her Great LAP to her advantage because....



Normal levels of Serum Alkaline Phosphatase (SAP)

>> ...she was Not a SAP.







Antineoplastic agents & Adverse effects





Male testicular tumors: \\\"S-E-C sac T-I-C-S¡±



S-Seminoma: most common

E-Embryonal carcinoma

C-Choriocarcinoma



Sac-Yolk sac tumor (endodermal sinus tumor)



T-Teratoma, Teratocarcinoma

I-C-Interstitial (Leydig) cell tumor

S-Sertoli cell tumor



Paraneoplastic syndromes and their associated cancers:



Your diagnosis can be \\\"Highly S-C-R-A-M-B-L-E-D.\\\"



Highly-Hypercalcemia (squamous cell carcinoma)



S-SIADH, hyponatremia (SCLC)

C-Clubbing (adenocarcinomas)

R-Retinal blindness (SCLC)

A-ACTH (SCLC)

M-Myasthenia gravis (thymoma)

B-Bone - hyperosteoarthropathy (adenocarcinomas)

L-Limbic encephalitis (SCLC)

E-Eaton-Lambert myasthenic syndrome (SCLC)

D-Dermatomyositis (cancer of the lung, ovary, breast, stomach; NHL)





SIADH: Syndrome of inappropriate antidiuretic hormone secretion

SCLC: Small cell lung cancer

NHL: non-Hodgkin\\\'s lymphoma









Microbiology



The first two mnemonics are modifications of well-known mnemonics.



-Gram-positive, spore-forming, rods: Bacillus and Clostridium



Some love stay home forming spores:

Basically Claustrophilic (Bacilli and Clostridia)





-Other gram-positive rods:



Others love to belong: C-L-A-N



C-Corynebacterium

L-Listeria

A-Actinomyces

N-Nocardia







All species within the Enterobacteriaceae family are gram-negative enteric bacilli and are facultative anaerobes that can ferment glucose to acid.



When microorganisms compete with humans for glucose, they are Nasty CURSESS.\\\"



Nasty-Neisseria (N. gonorrhoeae and N. meningitides)



C-Curved: Vibrio and C-Campylobacter species

UR-Urease-positive

SE-Serratia

SS-Salmonella, Shigella



Urease(+): Y. enterocolitica, Y. pseudotuberculosis, P. mirabilis, P. vulgaris, M. morgani





Clinically significant Anaerobes \\\"A Closed Box For Pepsi.\\\"



A-Actinomyces G+

C-Clostridia- G+

B-Bacteroides G-

For Fusobacterium G-

Pepsi Peptostreptococci G+



Bloody diarrhea



Bloody diarrhea may be caused by invasive bacteria or parasites, including:



Campylobacter, Shigella, Salmonella, Yersinia, and Trichuris (whipworm).



The Cutting edge of the Campbell\\\'s [Campylobacter] soup can was Bloody.



The Shaggy [Shigella] surface was Abrasive [Bloody].



The Salmon [Salmonella] scales were Abrasive [Bloody].



The Jersey [Yersinia] sweatshirt was rough and Abrasive [Bloody].



The Bullwhip [Whipworm] drew Blood.







Bordetella pertussis: Whooping cough



Bordetella pertussis is the etiologic agent of whooping cough.



-Laboratory:



Absolute lymphocytosis in children (a reportedly recent USMLE Step 2 question).



>> Many crossed the Border [Bordetella] for their Green* cards [lymphocytosis].

*In our color-coding scheme of mnemonics, green will represent lymphocytes.



B-O-R-D-E-T-E-L-L-A



B-Bordet-Gengou agar culturing a nasopharyngeal swab is the standard diagnostic test ordered during the

first 2 weeks of onset.

O-whOoping cough

R-Rod: B. pertussis is a small, gram-negative pleomorphic rod



D-DFA - Direct fluorescent antibody test of nasopharyngeal secretions results in frequent false-positives.



E-Erythromycin for therapy and prophylaxis.



T-Trimethoprim-sulfamethoxazole is an alternative antibiotic choice.



E-ELISA is the diagnostic test ordered after the first 2 weeks of onset.



L-Leukocytosis: 10,000 - 50,000 cells/uL with 50-75% mature lymphocytes



L-Lymphocytosis in children



A-Adult lymphocytosis is rare.





Organisms that Spread from Blood to Urine

CASH CML

C - candida

A - aureus staph

S - salmonella

H - histoplasma

C - cytomegalo virus

M - mycobacteria

L - leptospira

Submitted by Ousama Dabbagh M.D



Acute Rheumatic Fever

There are several for the major criteria, I use \\\"JONES\\\"

J - Joints

O - Obvious (cardiac) - sorry, I know this is kinda weak

N - Nodules (subcutaneous nodules)

E - Erythema marginatum

S - Syndeham\\\'s Chorea



Kawasaki\\\'s



\\\"scream fever\\\"

S - sausage fingers

C - conjunctival redness

R - rash

E - extremity involvement

A - adenopathy

M - mucosal erythema

FEVER - fever



Causes of post op fever

Remember the following mnemonic when determining the possible cause(s) of fever in a patient who has recently undergone a surgical procedure: the 5 W\\\'s (or 6 W\\\'s)



Wind : the pulmonary system is the primary source of fever in the first 48 hours. ( Atelectasis, pneumonia ect.)

Wound : there might be an infection at the surgical site.

Water : check intravenous access site for signs of phlebitis.

Walk : deep venous thrombosis and pulmonay embolism can develop due to pelvic pooling or restricted mobility

Whiz : a urinary tract infection is possible if urinary catheterization was required.

Also Wonder drugs - drug fevers. (added by Calvin Lee)





Classification of hypersensitivity reactions

\\\"ACID\\\"

Type I Anaphylaxis

Type II Cytotoxic - mediated

Type III Immune - complex

Type IV Delayed hypersensitivity







Criteria for Lupus

SOAP BRAIN MD

Serositis (pleuritis, pericarditis)

Oral Ulcers

Arthritis

Photosensitivity

Blood (all are low - anemia, leukopenia, thrombocytopenia)

Renal (protein)

ANA

Immunologic (DS DNA etc.)

Neurologic (psyc, seizures)

Submitted by Mike Ritter, MD FAAEM, San Diego, CA



Risk of underlying malignancy with dermatomyositis or polymyositis is 30% at age 30, 40% at age 40 etc.



Blue Sclera: \\\"MIXED\\\"

• M = Marfans ,

• I = Imperfecta ( Osteogenesis )

• XE =(pseudo) Xanthoma elasticum

• ED = Ehlers Danlos

¯

Altered Mental Status

\\\"AEIOU TIPS\\\"

A - Alcohol/drugs

E - Endocrine

I - Insulin

O - Opiates

U - Uremia

T - Toxins/trauma

I - Infections

P - Psych/porhyria

S - SAH, shock, stroke, seizure, space occupying lesion



MIDAS : States to exclude as cause of coma.

• Meningitis

• Intoxication

• Diabetes

• Air - respiratory failure

• Subdural or subarachnoid hemorrhage.



Level of consciousness



\\\"AVPU\\\"

A - alert

V - resonds to verbal stimuli

P - responds to painful stimuli

U - unconscious



Vertebral/Basilar Ischemia

4Ds

dizziness (nystagmus)

diplopia (skew deviation)

dysarthria

dysphagia

Submitted by: Ronald H. Miller, OD, The Ohio State University



Cerebellar lesions lead to VANISHeD - Vertigo, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonic reflexes, Dysdiadochokinesia. ( or Dementia )



Marcus Gunn Pupil



Marcus Welby, M.D. \\\"knows\\\". Robert Young was also in \\\"Father Knows Best\\\".



D-R K-N-O-W-S



D-Deafferentation of the pupillary light reflex

R-Retrobulbar optic neuritis



K-Kan\\\'t kick inward: afferent limb defect

N-No constriction to direct light stimulation

O-Optic nerve (CN II) damaged unilaterally

W-swinging flashlight test

S-consensual reflex intact





Subarachnoid hemorrhage (SAH): Rupture of an aneurysm releases blood directly into the cerebrospinal fluid (CSF) under arterial pressure.



Clinical manifestations:



CSF ~ FDR



F-D-R\\\'s Last Words: O! CAN\\\'T W-H-I-P \\\'E-M



F-Focal signs: limb weakness, dysphagia, CN III palsy

D-Depression of consciousness with headache

R-Retinal (subhyaloid) hemorrhage



Last-Lucidity with headache is the usual pattern of onset.



Words-Warning leak sign of impending rupture (controversial sign).



O-(looks like eyes) CN III palsy



Can\\\'t extend knees (Kernig\\\'s sign)



W-circle of Willis

H-Headache: sudden onset of severe headache (\\\"the worst headache of my life\\\")

I-Increased ICP

P-Papilledema



E-Epileptic seizures

M-Meningismus





Subarachnoid hemorrhage : Ruptured berry aneurysm



A-Adult polycystic kidney disease, Anterior communicating artery

B-Berry aneurysm

C-Circle of Willis

D-Danlos-Ehlers and Marfan\\\'s syndromes





Causes of Syncope: F-A-D-E-O-U-T



F-Faint simple vasovagal fainting

A-Arrhythmia causing cardiac syncope

D-Drugs: alcohol, illicit drugs, nitrates, antihypertensives, sympathetic blockers

E-Eyeball pressure

O-Orthostatic hypotension: dysautonomias

U-Undiagnosed seizures

T-Takayasu\\\'s arteritis: reduced cerebral blood flow due to involvement of the carotid and vertebral arteries.







Causes of Vertigo: revolving, P-I-V-O-T-I-N-G M-E-N



P-Petrositis, benign Positional vertigo

I-Ischemic attacks: transient vertebrobasilar ischemic attacks

V-Vestibular neuronitis

O-Other Otogenic causes: Otosclerosis, herpes zoster Oticus, Obstructed external auditory canal

T-Tumors of the middle ear, labyrinth, pons, cerebellopontine angle, CN VIII

I-Internal auditory artery occlusion

N-Neuronitis: acute vestibular neuronitis

G-Giant cell arteritis - internal auditory artery occlusion



M-Meniere\\\'s disease

E-Ear: otitis media, labyrinthitis, barotrauma

N-Neuromas: acoustic neuromas





Headache: S-T-O-I-C M-P



S-Sentinel headache that precedes a major subarachnoid hemorrhage (SAH)

T-Temporomandibular joint dysfunction, Tension-type headache, Tumors

O-Other: pressure, traction, or displacement of extracerebral structures.

I-Indomethacin-responsive headache

C-Cluster headache



M-Meningitis, Migraine headache

P-Posttraumatic headache, Paranasal sinuses

Intracerebral hemorrhage: T-I-P Ur H-A-T to M-Ds



T-Trauma

I-Idiopathic

P-Penia ? thrombocytopenia



Ur-Vasculitis



H-Hypertension

A-Amyloid angiopathy

T-Tumors associated with bleeding



M-Malformations: AV

D-blood Dyscrasias





Subdural hemorrhage: subconsciously dying¡±



-Elderly

-Slowly dying

-Alcohol

-Brain injury



____________________________________________________________________________________________



Cerebrovascular I-N-F-A-R-C-T-S



I-Infections: septic heart valve vegetations

N-Neoplasms; Nonbacterial thrombotic endocarditis

F-Fracture of the long bone

A-Atherosclerosis, Atrial fibrillation-related emboli

R-Reperfusion -> infarct -> hemorrhage

C-Carotid atheromas or mural thrombi

T-Thrombotic occlusions

S-Sylvan fissure: MCA is a particularly common site.





Lacunar infarct: \"Lacunar\" from the Latin for G-A-P or- D-I-S-P-A-R-I-T-Y



G-deep Gray matter: basal ganglia

A-Atherosclerosis

P-hyPertension



D-Dysarthria and a contralateral clumsy hand or arm due to infarction in the base of the pons or in the genu

of the internal capsule. (20%)

I-Internal Capsule: Lacunae in the posterior limb of the Internal capsule may cause pure motor hemiplegia

involving the face, arm, leg, foot. (60%)

S-Subcortical, capsular, or thalamic lacunae

P-Pontine lesions

A-Ataxic hemiparesis due to an infarct in the base of the pons

R-Rare: Lacunae in the anterior limb of the Internal capsule may cause severe dysarthria with facial weakness.

I-Ipsilateral ataxia (arm/leg) with leg weakness: Pontine lesion (rare)

T-Thalamus: Lacunae in the Thalamus may cause pure sensory stroke (10%)

y-V-Ventrolateral Thalamic lacunae





Anterior cerebral artery (A*C*A) occlusion:



*C*-Contralateral Crural (leg) monoplegia

*C*-Crest of Cerebral hemispheres and medial hemispheric walls represent the leg area of the motor strip





Middle cerebral artery (MCA) occlusion: \"Difficulty with A-B-Cs in M-C-A\"



A-Apraxia

B-Blindness in corresponding half of the visual field (contralateral homonymous hemianopsia)

C-Contralateral Clumsiness of arm, face. -- Leg is somewhat spared.



M-Memorization difficulties

C-Calculation difficulties

A-Aphasia with language-dominant hemispheral involvement.



Posterior cerebral artery (PCA) occlusion: P-O-S-T



P-Proximal fling movements

O-Occipital lobe infarction results in contralateral homonymous hemianopsia which may be complete

S-Speech and Spelling maintained, but unable to read fluently

T-Thalamic syndrome



____________________________________________________________________________________________



A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D



-Dizziness

-Diplopia

-Dysarthria

-Dysphagia



____________________________________________________________________________________________



Types of Stroke



Stroke \"H-I-T\" you!



H-Hemorrhagic

I-Ischemic

T-TIA (Transient Ischemia Attack)







T.I.A (Transient Ischemic attack)



Patients often describe it as a shade being pulled over their eyes: S-H-A-D-E-D



S-Sensory loss; TIA may herald a stroke

H-Hypertension, Hyperlipidemia

A-Amaurosis fugax (transient monocular blindness)

D-DDx: seizures, neoplasms, migraine, vertigo

E-Extrinsic factor is monitored for warfarin administration; E-Endarterectomy

D-Diabetes



Root values of reflexes are 1,2,3,4,5,6,7,8 - S1-2 ankle, L3-4 knee, C5-6 biceps/supinator, C7-8 triceps.



Argyle Robertson Pupil

• Accomodation Reflex Present - Pupillary Reflex Absent.





Neurosyphilis [By jsara]



-Symptomatic Neurosyphilis: The small, irregular Argyll Robertson pupil reacts to accommodation but

not to light.

-Tabes dorsalis:

Argyl-Robertson Pupil (ARP) in syphlis - Accomodation Reflex Present (ARP)

but the light reflex is absent, so ARP=ARP.

-General paresis: P-A-R-E-S-I-S*

P-Personality

A-Affect

R-Reflexes are hyperactive

E-Eye: Argyll Robertson pupils

S-Sensorium: illusions, delusions, hallucinations

I-Intellect: decrease in recent memory, orientation, calculations

S-Speech



Reference:

*From Harrison Principles of Internal Medicine, 14/e Edition, McGraw-Hill, New York, 1998.





Pattern of Weakness in UMN lesions

• FLUE weakness FUELs Contractures

• F=Flexion,L=Lower Limb,U=Upper Limb E= Extensors



Normal Pressure Hydrocephalus

• Demented (Memory Loss)

• Dribbles (Urinary Incontinence)

• Disbalanced (Gait disorder)





TRAP to identify parkinson\'s disease

• Tremor at rest (pill-rolling tremor)

• Rigidity

• Akinesia

• Posture typical of a Parkinson\'s patient





Progressive Cerebellar Ataxias: Bassen-Kornzweig Acanthocytosis (Abetalipoproteinemia)





Abetalipoproteinemia is a rare autosomal recessive disorder that occurs primarily in Ashkenazi

Jews during their childhood years (6-12 years of age).



-The key is Bette [aBeta] Midler, who is Jewish [Ashkenazi Jews] by birth, but hardly shy or

Recessive.



-Clinical:



Lack of intestinal apolipoprotein B causes mild malabsorption (notably of fat-soluble

vitamins A, D, E, K), steatorrhea, and low serum chylomicrons, VLDL, IDL, and LDL.



- Did you know that Bette is computer-savvy? Know that she created her own web page

on a PC, and Not on an Apple [No Apolipoprotein-B] computer.



Progressive neuromuscular disease of the peripheral nervous system (PNS) and of the

cerebellum (ataxia of gait, trunk, and limbs).



- Bette wanted to be featured on serious PBS [PNS] television, but instead her trash

with flash persona was interviewed for E! Celebrity [Cerebellum] Profile.



- Bette paid heavy Taxes [aTaxia] after starring in \"That Old Feeling\" [sensory ataxia] with

Dennis Farina.



- The concert tour: As the tail-wagging mermaid, Bette motored around the stage in a

Wheelchair [muscle weakness].



Retinitis pigmentosa

-Then she donned her mermaid Goggles [retinitis pigmentosa] and grinned.



-Diagnosis:



Ataxia plus acanthocytes in peripheral blood smear. The low cholesterol gives rise to

deformed or spiky red blood cells called acanthocytes.

Low apolipoprotein B, low vitamin E

Low plasma triglyceride (TG) and cholesterol levels



- The Jewish Cantor [aCanthocytosis] disapproved of the bawdy stiletto Spike [Spiky

RBC] heels she wore to holy day services.



Small bowel biopsy: Foamy epithelial cells and lacy villus tips.

- The mermaid character was set in a Foamy [epithelial cells] sea backdrop.

- Under her Lacy [Lacy villus tips] mermaid costume, Bette had to wear a tightly laced

corset. She was still No Twiggy [low TGs].



-Treatment:



Low fat diet, fat-soluble vitamins such as vitamins A and E.

- Bette tried to lose weight on a Low Fat Diet in preparation for her A&E [vitamins A and

E] interview.











Radiopaque Ingestants

\"Chipes\"

C - Cocaine condoms/ chloral hydrate/ calcium

H - Heavy metals

I - Iron/ iodides

P - Psychotropics (TCA, phenothiazines)

E - Enteric coated/BA

S - Solvents (CCl4)





Drugs that can go into an ET tube



\"lane\"

L - lidocaine

A - atropine

N - naloxone

E - epi

Some like NAVEL, which includes Valium. Others have commented that valium should not go in an ET tube.





History taking in EMS



\"sample\"

S - signs/symptoms

A - allergies

M - medications

P - past medical history

L - last oral intake

E - events leading to injury or illness







Pain scale:



\"OPQRST\"



O - onset

P - provocation

Q - quality

R - radiation

S - severity

T - time







Pain Scale (Revisited)

PQRSTAPPP

P - palliates/provokes

Q - quality

R - region/radiation

S - severity (on a 1-10 scale)

T - timing (onset, frequency, duration)

A - associated symptoms

P - prior

P - persists

P - progression (stable, better, worse)

Submitted by Omar A. Blanco





More on Pain Evaluation

LOCI\" (Latin for places) and the \"Daughters of the American Revolution\"

L - Location

O- Onset

C- Character

I- Intensity

D- Duration

A- Aggravation

A- Alleviation

A - Association

R - Radiation







One More Pain Mnemonic

P - period of pain

A - area of pain

I - intensity of pain

N - nullify ( what makes pain go away, if any)

Submitted by Greg Van Hook



Concretions:

\"Big Mess\"

B - Barbituates

I - Iron

G - Glutethemide

M - Meprobamate

E - Extended release theophylline

SS - Salicylates





X linked

• Bleeder, Blind, Becker and Duch, B cell

• others : G6PD,NDI,SCID,CGD









Respond to this message













Uncomplicated cystitis-bactrim bid 3 days

Bv-metronidazole 7 days 500bid; but if pregnant 250tid

Gonorrhea-ceftriaxone125 IM one dose for women; 250 IM if epididymitis +doxy 100 po bid x 10 days.( rx for chlamydia also.)



If >35, allergic to doxy/cephelo sporin, enteric org suspected then for epididymitis give lovefloxacin bid x10day



Chancroid ceftriaxone 250 IM single dose or azythr po 1 g single dose.



Ocp’s [protect against gonorrhea)

CHLAMYDIA- AZYthromycin 1g po single dose

Sexual assault-metronidazole 2g PO( covers trichomonas) +azythro 1g PO + ceftriaxone 250 IM

Pid- if In patient, ceftriaxoxe 250 IM, Amp+clinda x 48 hrs + 14 day doxy bid+/- metro bid .

Syphilis- pen 2.4 IM single dose , if pencilin allergy then doxy 14 days bid like in pid

Travelers diaarhea- prophylaxis loperaamide and cipro 5 days bid to 7 days

Tularemia –cipro bid 14 days



Hydro morphone(dilaudid) iv/im 1= 5 po; hydro codone 1 po-= 1.5 po