GOLJAN'S AUDIO TO WORD FILE

800 OTHER TOP SECRET USMLE FACTS

Cell injury:

- If the oxygen partial pressure (in the plasma) is decreased, the oxygen saturation (on

Hb) MUST also decrease.

- Thrombosis in a muscular artery is the most common cause of ischemia.

- Hypoxemia (decrease oxygen partial pressure) is a cause of hypoxia

- Respiratory acidosis ! CO2" ! pO2# ALWAYS (and vice versa).

- Hypoxemic patient that gets 100% oxygen and his pO2 didn’t increase ! shunt !

ventilation defect (ARDS, hyaline membrane disease).

- Perfusion defect (PE) ! "dead space (100% O2 will get the pO2 up)

- Diffusion defect (sarcoidosis, pulmonary edema)

- J reflex innervated by the Kent nerve, cause dyspnea (fluid in lung interstitium irritating

the J receptors).

- Anemia (Hb related problem) ! pO2 normal, saturation normal, Hb decreased !

exertional dyspnea.

- House fire produces tissue hypoxia in 2 ways: CO poisoning (! saturation!, give

100% oxygen) and CN poisoning. Both inhibit cytochrome oxidase.

- Cyanosis is the clinical evidence of decreased saturation. Red pigment hides the

cyanosis in CO poisoning (most frequent symptom is headache).

- MetHb ! saturation decreased because the Hb is Fe$ and not Fe% (chocolate color

blood) ! 100% oxygen doesn’t improve cyanosis. Treatment is IV methylene blue,

vitmamin C (also but not main)

- Sulfa and nitro drugs (oxidizing agent): 1. produce MetHb. 2. Hemolytic anemia, G6PD

deficiency.

- MetHb common in HIV, because we use sulfa drugs to treat pneumocystis carinii.

- Right shift curve: 2,3BPG", high altitude, acidosis, fever.

Left shift curve: CO, MetHb, HbF, 2,3BPG#, alkalosis.

- Uncoupling agents (mitochondrial membrane permeable to protons): dinitrophenol

(wood preserving), alcohol, salicylates. To compensate, NADH, FAD producing

systems (which produce protons) increase ! hyperthermia (alcoholics are more

susceptible to heatstroke).

- Respiratory acidodis = Hb normal, Saturation#, pO2#

Anemia = Hb decrease, saturation normal, pO2 normal

CO + MetHb = Hb normal, saturation#, pO2 normal

- Anaerobic glycolysis ! lactate acidosis ! denature proteins + enzymes (can’t even

auto digest itself) ! coagulation necrosis ! infarct.

Anaerobic glycolysis ! ATP pump malfunction, decrease ATP ! Na enters cells !

water follows ! cellular swelling (reversible!).

- Irreversible cell damage: ATP decrease ! Ca ATPase# ! intracellular Ca" !

activates nuclear enzymes (! pyknosis), phosphlipase (! cell membrane damage)

! pancreatitis.

- Cell death: CK, GOT, GLT, amylase increase.

2- Lipofuscin (wear and tear pigment) is a brown pigment in atrophic organs in elderly. It cannot be digested. Hemosiderin or bilirubin can also produce a brown pigment.

- Reperfusion injury (oxygen radicals) can be caused after giving TPA for coronary

thrombosis, then oxygenated blood go to the injured cardiac muscle.

- IRDS: retinopathy of prematurity (oxygen radicals destroying the retina, blindness) and bronchopulmonary dysplasia (fibrosis)

- Most common cancer of radiation is Leukemia

- Iron overload cause free radicals ! cirrhosis, restrictive cardiomyopathy, pancreas failure ! malabsorption + diabetes.

- Acetoaminaphen (Tylenol) is the #1 cause of drug induced fulminant hepatitis

(damage around central vein). Treatment: N-acetyl cystein ("glutathione)

- Neutralization of superoxide is by superoxide dismutase (turns into peroxide).

- PPP generates Glutathione and NADPH.

- CCL4 can also be converted to a free radial (CCL3) ! fulminant hepatitis.

- Acetoaminaphen (radicals) + Aspirin (#PG) ! kidney damage (renal medulla)

- Di-george syndrome: absence of thymus, cause tetany.

- Councilman body in Hepatitis: apoptotic eosinophilic cell with no nucleus.

- Coagulation necrosis - Pale infarct: Heart, kidney, spleen, liver

Hemorrhagic infarct: Bowel, testicle (torsion), lungs.

- Vegetation of acute rheumatic fever rarely embolize. Infective endocarditis does.

- Mitral stenosis can cause thrombi in left atrium ! atrial fibrillation.

- The arrhythmia most associated with systemic emboli is atrial fibrillation.

- Dry gangrene: no pus

- Most common cause of non traumatic amputation is diabetes ("ATH of popliteal artery)

- Most common cause of bowel infarction: #1: adhesions of previous surgery,

#2: piece of small bowel trapped in an indirect inguinal hernia.

- Liquefactive necrosis is related to an infection where neutrophils are involved (acuteinflammation, lung/brain abscess, cellulites by strep.) and also related to brain infarct.

- Granulmatose necrosis: caseous – mycobacteria or systemic fungal infection.

Non caseous – sarcoidosis.

- Epigastric distress with pain radiating to the back ! pancreatitis (retroperitoneal)

- Enzymatic fat necrosis (pancreas) or traumatic fat necrosis (breast, adipose) can both calcify (look like cancer on X-ray) but it’s painful unlike cancer.

- Calcium bound to fatty acid = saponification (chalky white areas on X-ray).

- Bluish discoloration on histologic sections is calcium (dystrophic calcification).

- Fibrinoid necrosis (looks like fibrin but isn’t): immunological diseases (rhematic fever,rheumatic arthritis, glomerulonephritis, SLE, vasculitis).

- Palpable purpura: small vessel vasculitis, hypersensitivity type 3.

Conditions that present with palpable purpura include: Henoch-Schönlein purpura,subacute bacterial endocarditis and Rocky Mountain spotted fever.

- Immune complex ! activate alternative complement system ! C5a ! chemotaxis of neutrophils that cause the actual damage.

- Yellow fever (Arbovirus) damages the liver zone 2 (mid-zone necrosis)

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- Alcoholics have fasting hypoglycemia, lactic acidosis ("NADH shift pyruvate to lactate so there is no substrate for GNG), keto-acidosis (& hydroxybutyrate).

- Restriciting CH will reduce the synthesis of VLDL (Glycolysis provides glycerol 3phosphate, which is the backbone of TAG which is incorporated into VLDL).

- Kwashiorkor: reduce protein intake ! no apo-proteins ! huge fatty liver Reduce protein intake ! no oncotic pressure ! Ascites.

- Ferritin (soluble iron storage) is a marker for diagnosing iron deficiency anemia or hemosiderosis, hemochromatosis.

Hemosiderin (insoluble iron storage), stored in MP and BM. Stained with Prussian blue.

- Dystrophic calcification: damaged tissue gets calcified (fat necrosis, ATH, aortic stenosis, hemolytic anemia), normal serum calcium.

Metastatic calcification: hypercalcemia or hyperphosphatemia ! calcium deposits in normal tissue.

- Congenital bicuspid aortic valve is the most common cause of aortic stenosis.

- Spectrin is needed to keep a bi-concave disc, if it’s defective ! spherocytosis.

- Ubiquination - Mallory bodies = alcoholic hepatitis

Neurofibrillaty tangles (tau protein) = Alzheimer, Creutzfeldt-Jakov disease.

Lewy body = Parkinson (substantia nigra, dopamine)

- Labile cells = division is via stem cells (BM, skin, intestinal crypts), in cell cycle.

Cell cycle specific or non specific drugs ! BM suppression, diarrhea, rash.

- Stable cells = mostly in G0, but can be stimulated to divide (liver, spleen, kidney,smooth muscle, endometrium)

- Permanent cells = can’t get into the cell cycle (striated and cardiac muscles, neurons),can go through hypertrophy.

- Hyperplasia = increase in number, hypertrophy = increase in size.

- The length of the cell cycle is decided by the length of the G1 stage.

- Glucagon is a phosphorylator, insulin is a dephosphorylator.

- Rb (chr.13) prevents the cell from going into S phase.

When phosphorylated by CDK, it’s inactive.p53 (chr.19) induces a CDK inhibitor, gives time to detect & correct defects before entry to S phase.

- HPV E6 suppresses p53, HPV E8 suppresses Rb.

- No Rb protein ! Retinoblastoma, osteogenic sarcoma, breast cancer.

- Codman’s triangle seen in: osteosarcoma, Ewing sarcoma, subperiosteal abscess.

- Vinca Alkaloids (periwinkle plant), Paclitaxel (chemotherapy, yew tree), Colchicine,Griseofulvin ! M phase

Etoposide ! G2 phase

MTX, Bleomycin ! S phase

- MTX, used in rheumatoid arthritis, inhibits DHF reductase ! can cause macrocytic anemia.

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- Atrophy = decrease in tissue mass, decrease cell size, less mitochondria.

- Hydronephrosis is mostly caused by renal stones ! increase pressure ! ischemia !

atrophy of renal tubules.

- ATH, Alzheimer (& amyloid protein, layers 3,5,6 destroyed), ALS ! brain atrophy,

neuron degeneration.

- Hypopituitarism ! adrenal gland atrophy (zona reticularis and fasiculata ONLY)

- Oral thyroid ! thyroid atrophy.

- CF (Chr.7) ! block lumen ! pancreas atrophy

- Renal vascular hypertension ! kidney atrophy, other kidney hypertrophy ("renin)

- If you block G2 phase, you have 4n chromosomes (no mitosis)

- Hyperplasia left unchecked is predisposing for cancer (EXCEPT prostate)

- Unopposed estrogen (no progesterone) causes endometrial hyperplasia ! atypical

hyperplasia ! cancer.

- Gravid uterus (after delivery): 50% hypertrophy, 50% hyperplasia.

- RBC hyperplasia in BM may be caused by COPD

- Erythropoetin is made in the endothelial cells of the peri-tubular capillary.

- Psoriasis is an unregulated proliferation of squamus cells in the skin (hyperplasia).

Treatment: MTX (works on the basal cells).

- All hormone stimulated glands go through hyperplasia, not hypertrophy.

- Urinary bladder goes through hypertrophy of smooth muscle cells related to afterload

caused by urethra narrowing.

- H. Pylori is the most common cause of adenocarcinoma of the stomach.

- Clonorchis Sinensis (Chinese liver fluke) is associated with cholangiocarcinoma Schistosome Haematubium causes squamus metaplasia (instead of transitional) in the

urinary bladder ! SCC.

- Dysplasia = atypical hyperplasia, precursor for cancer.

- Actinic (solar) keratosis is premalignant to SCC of the skin, related to chronic sun

exposure and excess keratin. If scraped off, it grows back.

- No premalignant lesion to basal cell carcinoma. It is more common.

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Inflammation:

- Histamine is responsible for the rubor, calor (both: vasodilatation on arterial end) and

tumor ("permeability on venular end) of acute inflammation.

- Bradykanin (degraded by ACE) and PGE2 are responsible for the dolor.

- C5A, LTB4 ! chemotaxis, make adhesion molecules.

- IgG, C3B ! opsonization

- C3A, C5A ! anaphylatoxins (stimulate mast cells to release istamine)

- I-cell disease (lysosomal storage disease): can’t add mannose 6 phosphate residues

to lysosomal enzymes ! no proper trafficking ! empty lysosomes.

- Oxygen dependant myeloperoxidase system: O2 is converted by NADPH oxidase in

cell membrane of neutrophils + monocyes (not MP) into superoxide (free radical), that

gives off energy ! oxygen burst – can be measured by radiation detector or NBT dye

test: if working ok ! bluish color, if not ! chronic granulomatous disease of childhood

(X-linked, no NADPH oxidase).

Superoxide is converted to peroxide which together with chloride (catalyzed by myeloperoxidase) to form bleach (kills bacteria).

- Microglial cells are the MP of the CNS.

Dendritic cells (MP outside CNS) are located in lymph nodes.

- Catalase (Staph. Aureus) breaks down peroxide and prevent its utilization in CGD.

Strep doesn’t have catalase, so it can be killed even in CGD patient.

- In Myeloperoxide deficiency (AR), there is a respiratory burst, but no bleach.

- Adhesion/& integrin defect ! impaired adhesion, phagocytosis ! umbilical cord doesn’t fall off (removed surgically), no neutrophils lining the small vessels.

- NO is used in treatment of pulmonaty hypertension, big role in septic shock.

- IL-1 ! stimulate hypothalamus to produce PG ! fever (reduced by aspirin).

- Corticosteroids inhibit PLA2 ! no release of retinoic acid from PL ! no PG, IL.

Decrease adhesion molecules (along with epi and NE) ! neutrophil count

increase (more circulating instead of being stuck to endothelium).

Lymphocytotoxic by apoptosis.

Decrease eosinophils.

- Addison’s disease ! #neutrophils, "eosinphils.

MI ! "epi ! "neutrophil

- Omega 3 (like aspirin) inhibits platelet aggregation.

- Zileuton inhibits 5 lipoxygenase, works in asthma.

- TXA2 made in platelets ! vasoconstrictor, bronchoconstrictor, platelet aggregation.

PGI2 made in endothelial cells ! vasodilator, inhibits platelet aggregation.

- PGE2 ! vasodilator in kidney, patent ductus arteriosus, mucus barrier in stomach,dismenorrhea, increases uterine contractility.

- Dipyridamole inhibits TX synthase, used in stress test in coronary artery disease.

- Alveolar MP have a lot of lysosomes which are seen as black dots on EM.

- Lamellar bodies (where lechitin is located) are seen in pneumocyte type 2.

- Vitamin E neutralizes oxidized LDL

- 60% of lymphocytes are T. Th:Tc ratio is 2:1.

- Plasma cell has a lot of ribosomes, because of Ig production. It is located in germinal

follicle.

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- Eosinophils have crystals in their cytoplasm. In asthma, degenerating eosinophils form

Charcot-Leyden crystals seen in sputum.

- Major basic proteins are released by eosinphils in type 2 H-S to kill helminths.

- Mast cells release histamine and eosinophil chemotactic factor in type 1 H-S.

Eosinophils here release histaminase and leukotriene neutralizing agents.

- CD3 = marker in antigen recognition site for all T cells

CD1 = antigen marker for histiocyte

CD10 = CALLA antigen (common ALL antigen)

CD15, 30 = Reed Sternberg

CD21 = B cell, EBV hooks on it

CD45 = all leukocytes

- Antipyretics reduce the oxygen in neutrophils (disturbs O2 dep. myelo system)

- Fever is not good for viral and bacterial reproduction.

- Pus coming out of lactiferous duct in post partum ! Staph. Aureus.

- Osteomyelitis (yellowish abscess) ! Staph. Aureus. In Sickle cell anemia, it is usually

cause by Salmonella Typhimurium. Hematogenous spread.

- Cellulitis ! Strep. Pyogens

- C. dyphteria toxin damages the sub/mucosa ! psedomembrane (like C. difficile)

- Bread and butter pericarditis = fibrinous inflammation ! SLE, MI, coxsackie

- Dressler’s syndrome: pericarditis which develops about 6 weeks after an MI or heart surgery.

- Most common organism causing infection in 3rd degree burns is Pseudomonas

Aeruginosa. Pus color is green due to pyocyanin.

- Fibronectin is an adhesion molecule and fibroblast chemotactic in healing process.

Granulation tissue starts at day 3, peak on day 5.

- Type 4 collagen in basement membrane.

Type 1 collagen is in bone, skin, tendons and ligaments

Type 3 collagen is in the initial stages of wound repair. Broken by type 3 collagenase.

Metalloenzyme (need zinc) helps turn type 3 into type 1.

- Maximal tensile strength in a wound by 3 months is 80%.

- Most common cause of poor wound healing is infection.

- Ehlers danlos syndrome: defect in collagen.

- Marfan syndrome: defect in fibrillin.

- Scurvy: defect in hydroxylation of proline and lysine ! no cross bridges ! weak

abnormal collagen ! hemorrhage, no wound healing, hemoarthrosis.

- Keloid (hypertrophied scar) = excess of type 3 collagen deposition.

- SCC is common in the setting of scars related to 3rd degree burns or chronically

draining sinus tracts (in osteomyelitis).

- IgM is the most potent activator of the complement system, because it had 10 antigen

recognition sites. Main Ig of Acute inflammation.

IgG complement activation doesn’t go beyond C3 (no C5A and so on). Main Ig of chronic inflammation.

- Pus is not a characteristic of chronic (only of acute) inflammation.

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- Granuloma: roundish and pink, multi nucleated giant cells. Type 4 H-S. Sometimes gets calcified. Epitheloid cells are activated MP, when they die they form multinucleated giant cells which are seen in granulomas.

- Tc killing neoplastic cells or virally infected cells is also Type 4 H-S.

- MP and Th are the key cells of TB.

- Th type 1 are involved in type 4 H-S. MP release IL-12 ! memory T cells.

- Langerhans cells are the MP of the skin, phagocytose PPD, process it and present it

to Th type 1 that has memory of previous exposure ! release cytokines that produces the inflammatory reaction which is part of the positive PPD.

- HIV: less/no type 4 H-S (Th##), no granuloma formation in HIV.

PPD of 5 cm is enough to say positive in HIV.

- Scar tissue: heart muscle, kidney (especially straight portion of PT, TAL).

- Na-K-Cl pump generates free water (80ml for those 4 ions). Blocked by lasix.

- Type 2 pneumocytes: 1. produce surfactant, 2. repair cells, even replace type 1.

- Astrocytes: can proliferate, cause gliosis (reaction to injury in the brain)

- Schwann cells myelinate PNS axons, Oligodendrocytes myelinate CNS axons.

- Schwannoma = acoustic neuroma (if involves VIII nerve), seen in neurofibromatosis.

- IgG and/or fibrinogen" ! ESR"

- IgM, cryoglobulin cause RBC to stick (cold agglutination ! Raynaud’s phenomenon).

High association of Hep.C with cryoglobulin.

- IgG ! MM, IgM ! macroglobulinemia (both increase ESR)

- Greater than 10% band neutrophils is left shift.

- Acute inflammation: absolute increase in neutrophils, toxic granulation, left shift.

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Fluid and hemodynamics:

- Non pitting edema: exudate (increase vessel permeability with pus) > 3g

Pitting edema: transudate (right heart failure) < 3g

Lymphatic fluid: initially pitting, later not

- Low albumin: nephrotic syndrome, malabsorption, cirrhosis, # protein intake.

- Kerley B lines: usually indicative of interstitial pulmonary edema (CHF), clinically present as dyspnea.

Kerley A lines: caused by distension of anastomotic channels between peripheral and central lymphatics of the lungs (less frequent than B)

- Cirrhosis ! #oncotic prssure (#albumin synthesis) + "hydrostatic pressure (portalhypertension) ! ascites.

- Pitting edema in the legs can be caused by #oncotic pressure (cirrhosis) or "hydrostatic pressure (RHF).

- Lymphedema: post radical mastectomy (#1), Wuchereria Bancrofti, inflammatory carcinoma of the breast, lymphogranuloma venereum (Chlamydia Trachomatis).

lymphangiosarcoma is a complication of chronic lymphedema.

- Osmolality is mainly determined by Na (doubled, one for Cl), glucose and BUN.

- Diffusion: high ! low, osmosis: low ! high.

- Hyponatremia ! osmosis (ICF)! brain edema ! mental status abnormality

Hypernatremia ! osmosis (ECF) ! brain contract ! mental status abnormality

- Glucose is an EC molecule (the IC one is phosphosylated).

Hyperglycemia ! osmosis from ICF to ECF ! [Na] # (dilutional hyponatremia)

- Urea is permeable so it can go through the compartments to establish equilibrium.

- Isotonic loss of fluid (EC loss, no osmotic gradient): hemorrhage, adult diarrhea.

Isotonic gain of fluid (EC gain, no osmotic gradient): isotonic saline.

Hypertonic loss of fluid (ECF ! ICF because of hyponatremia): diuretics.

Hypotonic loss of fluid: sweat, baby diarrhea (you give back hypotonic solution).

Hypotonic gain of fluid (ECF+ICF expanded): SIADH (treatment: restrict water).

- Serum Na < 120mmol " ALWAYS SIADH (at least on boards…)

- 1st generation oral sulphonylureas (chlorpropamide; insulin secretagogues for DM-II):

SIADH as a side effect in 30% of cases.

- Pitting edema (RHF, cirrhosis): gain of both Na and water (but more water). Treatmentwill be both Na and water restriction, diuretics.

- Glucose or Mannitol in urine ! hypertonic loss in the urine.

- Glucose has to be in the solution with Na, because of the gut Na-Glc transporter.

- Normal saline (0.9%) is plasma without the proteins, it stays in the ECF.

- CO# ! renal blood flow# ! peritubular hydrostatic pressure# ! peritubular oncotic

pressure" ! reabsorption" (isotonic solution).

- Dry tongue (dehydration) ! hyponatremia, skin indentations ! hypernatremia

Normal skin turgor ! normal Na concentrations (except in elderly)

- Diabetes Insipidus CANNOT produce shock (only water loss from ICF, NOT hypovolemic). No dehydration signs (no salt loss). Treatment: 5% dextrose+water

- Tilt test: Lying down (no effective gravity) ! normal BP + pulse,

Sat up (imposing gravity) ! BP!, pulse# (catecholamine release from BP#) ! sign of

volume depletion. Treatment: normal saline (0.45% saline after BP stable)

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- DKA ! hypovolemia ! give normal saline (around 6-8 liters until BP stable).

- After BP stabilization, you give what you lose!! (hypo ! hypo, iso ! iso…)

- Loss of salt ! Hypovolemic shock (CO#, cold skin, TPR", MVOC#, BP#, pulse",LVEDP#)

MI ! cardiogenic shock (everything like hypovolemic except LVEDP")

E. coli (urinary catheter) ! septic shock (CO", warm skin, TPR#, MVOC")

- Poiseuille law: Q = ' (Pi-Po) (r$)$ 8%L => TPR (diastolic BP) = % (r$)$

- Endotoxins ! activate complement ! C3a, C5a (anaphylatoxins) ! mast cells !

histamine ! vasodilation of arterioles.

Endotoxins ! damage endothelieal cells ! NO, PGI2 release ! vasodilation.

- Mixed venous oxygen content can be measured in the right atrium and it is the best

test for tissue hypoxia. It is high in septic shock (lots of blood but oxygen cannot be extracted because blood is going to fast), Low in hypovolemic shock.

- Kidney medulla suffers the most from shock (BUN + creatinin" ! sugar" ! ATN !renal tubular casts blocks urine ! oliguria). Treatment: "RBF.

- Sickle cell trait can cause micro infarction in kidney medulla ! micro hematuria.

- Chronic respiratory alkalosis in high altitude is the only case where pH goes

completely back to normal.

- Barbiturates, CNS injury ! damages resp. center in medulla ! resp. acidosis.

- Anxiety, pregnancy ! respiratory alkalosis ! tetany (ionized Ca#) – signs:

Tourseau sign (compression of the forearm produces spasm in the hand and wrist)

Chvostek's sign (contraction of the muscles of the eye, mouth or nose, elicited by tapping along the course of the facial nerve).

- Estrogen and progesterone over stimulate the respiratory system, cause spider angioma on the skin (normal in pregnancy) and AV fistula in the lung.

- Endotoxins, Salicylate ! respiratory alkalosis+metabolic acidosis. Normal pH.

- 6 year child with inspiratory stridor ! acute epiglotitis (H. influenza)

3 month baby with inspiratory stridor ! croup (parainfluenza virus):

tracheal obstruction, stipple sign on X-ray.

- ALS, Guillain-Barr, Polio ! paralysis of inspiration muscles ! resp. acidosis.

- COPD ! resp. acidosis.

Restrictive lung disease ! resp. alkalosis.

- High altitude: atmospheric pressure decrease ! pCO2" ! pO2# ! hyperventilation

! pCO2# ! resp alkalosis.

- Caisson’s disease = the bends = decompression sickness:

Headache, pain in the arms, legs, joints, and epigastrium, itching of the skin, vertigo,

dyspnea, coughing, choking, vomiting, weakness and sometimes paralysis, and severe peripheral circulatory collapse.

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Nutrition:

- Anorexia nervosa: #GnRh, #FSH, #LH, #estrogen, amenorrhea, osteoporosis.

Usually die of cardiac disease, HF.

- First step of treatment for DM-II and hypertension is diet!

- Bulimia nervosa: teeth erosion of enamel ! dentin showing (brown)

Metabolic alkalosis ! resp. acidosis as compensation ! hypoxia ! PVC !VF.

Mallory-Weis syndrome (tear in the cardia)

Boerhaave syndrome (rupture) ! air and fluid in the pleural cavity, mediastinal

emphysema.

- BMI: Kg (height in meters) % => Obesity > 30, morbid obesity > 40.

- Obesity: main complication is HT ! LVH ! HF (most common cause of death). Other complications: 1. Gall bladder diseases. 2. "adipose ! aromatase ! "estrogen !

endometrial adenocarcinoma, breast cancer, colon cancer.

- Marasmus: total calorie deprivation, muscle wasting, good survival chance.

- Kwashiorkor: normal calorie intake, protein deprivation, anemia, cellular immunity

problems, edema, ascites, fatty liver, dermatitis, more likely to die.

- Lipid soluble vit. have greater chance of toxicity (water soluble can be peed out).

- Water soluble vit. are all co-factors of biochemical reactions.

- Vit. A: Bone and muscle growth, prevents squamus metaplasia.

- Vit. A deficiency: FTT, follicular hyperkeratosis, night blindness, white spots,corneomalacia, squamus metaplasia ! bronchogenic carcinoma.

- Vit A toxicity (bear hunters): liver toxicity, cerebral edema ! headache.

- Blindness: DM, trachoma, vit. A def.

- Vit D: mostly from sunlight, not food (hardly in breast milk).

- PTH is responsible for the synthesis of 1-(-hydroxylase, which is in the PT.

- ACE is synthesized in endothelial cells and pulmonary capillaries.

- Erythropoietin is synthesized in endothelial cells and peritubular capillaries.

- Hypercalcemia is a potential side effect of thiazide (used in stones).

- Only calcitonin has a receptor on osteoclasts.

PTH receptor is on osteoblasts ! release IL-1 (osteoclast activating factor) ! break down bone and increase serum Ca.

Estrogen + testosterone puts an inhibitory effect on IL-1 release.

Lack of estrogen ! osteoporosis.

Vit D mineralizes bone and cartilage ("absorption of both P + Ca)

- lack of sunshine, poor diet, liver disease, renal disease (DM) ! Vit D deficiency:

Children: Rickets - craniotabes (soft skull), rachitic rosary (excess osteoids in costochondral junctions), rest like in adult.

Type 1: 1-(-hydroxylase deficiency, Type 2: missing the Vit D receptor.

Adults: osteomalacia - soft bones, pathologic fractures.

Vit D toxicity: hypercalcemia ! stones.

- Oral Vit D still has to go through the steps of hydroxylation to work.

1-(-hydroxy-vit D is a prescription drug (can be dangerous).

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- Phenetoin, alcohol, barbiturate, rifampin ! induce CYP450 ! sER hyperplasia:

1. ! metabolize drugs and other things like 25-(-hydroxy-vit D ! #Vit D.

2. ! metabolize of estrogen and progesterone in OC ! not significant enough levels to prevent pregnancy.

3. ! )GT"

- Vit E: prevent lipid peroxidation of cell membrane (protect from PLA).

Neutralize oxidized LDL (also Vit C).

- Vit E deficiency is mostly seen in CF because of malabsorption, which will cause the deficiency of all DEKA vitamins. Cause: Hemolytic anemia, neurological diseases

(posterior column disease, spinal cerebellar diseases, related to myelin).

- Vit E toxicity: prevent the synthesis of the Vit K dependent coagulation factor:

2, 7, 9, 10, C, S ! synergistic with warfarin (after MI) ! INR" ! anticoagulant.

- Vit K: mostly from colonic anaerobe bacteria, less from food (danger in day 3-5 of newborn, between the end of the mother’s contribution and the beginning of bacteria growth in colon ! can lead to hemorrhage).

- Bacteria make inactive Vit K (K2), converted to K1 by epoxide reductase (inhibited by warfarin). Function: )-carboxylation of Vit K dependant factors

! activates them ! allows Ca to bound ! help formation of the clot.

- Broad spectrum antibiotics (most common cause in hospital), poor diet, newborn,malabsorption ! Vit K deficieny: hemorrhagic diathesis ! bleed to brain, skin.

- Treatment of rat poisoning (=warfarin) is intramuscular Vit K.

- Vit C deficiency (scurvy): blood vessel unstable ! gums bleed, hemoarthrosis (related also to Hemophilia A), ring hemorrhage around hair follicles, pig tail hair, glossitis (smooth tongue).

- Vit C toxicity: renal stones (mainly uric acid).

- Vit C is used as a treatment for MetHb (reducing agent)

- Vit C is a co-factor in making NE from dopamine (def. in pheochromocytoma).

- Thiamin (B1): co-factor of transketolase in PPP, pyruvate DHG (to acetyl CoA, which together with oxaloacetate, givers citrate, part of TCA cycle), (-keto-glutarate DHG, (-keto-acid DHG.

- Thiamin is mostly deficient in alcoholics, main problem is ATP depletion:

Dry Beri Beri: peripheral neuropathy (ATP is needed for myelination) ! foot drop

(peroneal nerve palsy), wrist drop (radial nerve), clawed hand (ulnar nerve).

Wernicke encephalopathy: confusion, ataxia, nystagmus, eye weakness.

Korsakoff psychosis: can’t remember new and old things.

Wet beri beri: left + right HF, congestive cardiomyopathy ! pitting edema, pulmonary

edema.

- Intravenous thiamin can sometimes reverse this entirely

- Glc treatment in the hospital can drive a subclinical thiamin deficiency into acute

Wernicke encephalopathy, because: glc ! pyruvate ! acetyl CoA needs thiamin.

- Comatose/semi-comatose patient, give: glc, nalaxone (for overdose), thiamin.

- Niacin (B3): co-factor for NAD, NADP reaction.

- Niacin deficiency (pellagra): dermatitis (hyper-pigmentaion in sun exposed areas,

Casal's necklace around the neck), dementia, diarrhea.

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- Tryptophan can be used to make serotonin and niacin (not main source)

- Least expensive lipid lowering drug is nicotinic acid, used in familial combined

hyperlipidemia. Side effect is flushing (aspirin makes it disappear).

- Riboflavin (B2): co-factor of FAD, FMN reaction, glutathione reductase.

- Pyridoxine (B6): co-factor of ALA synthase (first enzyme of heme synthesis),

transaminase reactions: alanin ! pyruvate (ALT), aspartate ! oxaloacetate (AST),

neurotransmitter synthesis.

- Pyridoxine deficiency: mainly caused by isoniazid. Causes convulsions, neurological

problems, hemolytic (sideroblastic) anemia.

- Biotin: co-factor of pyruvate carboxylase (to form oxaloacetate).

Biotin deficiency: baldness, rash, hypoglycemia, lactate acidosis.

- Chromium: glucose tolerance factor (helps glucose do its job), good for DM-II.

- Copper: co-factor of lysil oxidase (cross bridges of collagen fibers, elastic tissue),

Copper deficiency: dissecting aortic aneurysm (weak collagen and elastic tissue).

Also, a co-factor of cytochrome aa3 amd tyrosinase.

- Fluoride: prevent dental carries.

Flouride toxicity: white chalky teeth, calcification of ligaments that go into bone,

subject to rupture.

- Selenium: co-factor of glutathione peroxidase (anti-oxidant, given with Vit E).

- Zinc: co-factor of metaloprotease like collagenase (type 3 ! 1).

Zinc deficiency: taste and smell deficiency, rash on face, poor wound healing.

Diabetics are all zinc deficient (except those who take supplements).

- Fiber (oat meal) can lower cholesterol (mostly soluble fiber)

Suck up water into it and whatever is inside like lipocholic acid (carcinogenic !colon cancer)give stool more often

eliminates estrogen which is recycled and not necessarily needed ! decrease risk of breast, ovarian and uterine cancer.

- Protein restriction in renal failure ("urea) and cirrhosis (no urea cycle):

Most ammonia comes from bacteria that have urease that breaks urea ! hepatic encephalopathy ! mental status abnormalities, asterixis (jerking movements).

Octopamine, amino benzoic acid, false neurotransmitters also cause those.

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Neoplasm:

- Invasive mole is benign tumor that can metastasize to the lung and go away.

- Basal cell carcinoma is a benign tumor that can invade but not metastasize.

- Most common benign tumor in women is in the uterus (leiomyoma).

There is no transformation to leiomyosarcoma

- Most common benign tumor in men is lipoma.

- Tubular adenoma (strawberry on a stick) is precursor to colon cancer.

- Melanocytes: Malignant - melanoma, first line of treatment is excision, most rapidly growing tumor in the US. Benign - nevus.

- S-100 antigen stains APUD tumors (melanoma, small cc, carcinoid, neuroblastoma in adrenal medulla), neurosecretory granules on EM.

- Embryonal rhabdomyosarcoma (vaginal, penis) - desmin positive.

- Mixed tumor, most common salivary gland (parotid) tumor, mostly benign. From same cell layer, unlike teratoma derived from all 3 cell layers (teeth, bone, hair).

- Sudden onset of RLQ pain: Cystic teratoma of the ovary (calcification in pelvic area on

X-ray due to teeth, bone), appendicitis, Crohn’s disease, ectopic pregnancy, follicular cyst.

- Teratoma (AKA germ cell tumor) have a tendency to stay in the midline.

- Auer rod (myeloblast) ! leukemia (can metastasize out of BM, HSM)

Hypersegmented neutrophil ! B12/folate deficiency.

- Leukemia originate from BM (can metastasize out, to lymph nodes ! generalized lymphadenopathy, hepatosplenomegaly).

- Malignant lymphoma originate from lymph nodes (can metastasize out, to BM)

- Most common sites of a lymphoma developing outside lymph node are:

#1: stomach (related to H. pylori), #2: Peyer’s patches (terminal ileum).

- Most common lymphoma: follicular B cell lymphoma (apoptosis inactivation).

- Trophoblastic tumors seen in pregnancy. In men they are non-gestational.

Hydatidiform mole appear in first trimester with signs of pre-eclampsia (HT,proteinurea, edema), looks like a bunch of grapes. Uterus too large for gestational age in US.

Complete mole has the highest tendency of becoming choriocarcinoma.

- Umbilical vein is the vessel with the highest oxygenation in the fetus.

- Syncytiotrophoblast produce &-hCG, hPL

- Choriocarcinoma metastasize to the lung, respond very well to chemotherapy.

- Non neoplastic: Hemartoma is an over growth of tissue normally present in that area

(bronchial hemartoma, PJS, hypertrophied polyp).

Choristoma = Heterotopic rest: Meckel’s diverticulum (gastric mucosa in the small bowel), benign pancreatic tissue in stomach.

- Atypical mitotic spindle (and not increased mitotic rate) is the cause of cancer.

- 30 doubling times (cell cycles): clinically detectible tumor (1cm)

- Malignancy: lack adhesion, anaerobic metabolism, protease, collagenase.

- Carcinoma usually spread to lymph nodes first (but later through them to blood).

Exceptions (hematogeous spread): follicular carcinoma of thyroid, renal

adenocarcinoma, HCC.

Sarcoma usually spread hematogenously (usually does not go to lymph node).

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- Subcapsular sinus of a lymph node is the part that gets replaced by tumors.

- Pouch of Douglas: unclotted blood, ruptured ectopic pregnancy, endometrial implants

(endometriosis), seeding of ovarian cancer.

- Seeding: ovarian carcinoma to omentum, peripheraly located lung cancer to pleural

cavity, glioblastoma multiforme & medulloblastoma to spinal fluid & cord.

- In most cases, metastases is the most common cancer of an organ.

Exception: renal adenocarcinoma.

Most common cancer of lung and bone (vertebral column, head of femur) is breast metastasis.

Most common cancer of liver, brain and adrenal gland is lung metastases.

2nd most common cancer of liver is colon metastases.

Most common metastases of testicular cancer (e.g. seminoma) is the para-aorticlymph nodes (and not inguinal, since the testes are originated in the abdomen)

Most common metastases of left supra-clavicular node (Virchow’s) is the stomach.

- MM is osteolytic (plasma cells release IL-1), can cause hypercalcemia.

- Prostate cancer is osteoblastic (lumbar vertebrae), release ALP. Do a rectal exam because prostate is palpable in stage 4.

- X-ray: lucency is seen in osteolytic, entities are seen in osteoblastic.

- Multiple (growth) lesions are always metastases (at least in the borads…)

- Most carcinoma have carotene in them.

- Histiocytosis X, Letterer-Siwe disease, Hand-Schuller-Christian disease:

CD-1, Birbeck granules under EM

- Oncogenesis: initiation – mutation, promotion – multiple copies of that mutation,progression – different cancer cells have different function (invasion, resistance).

- sis - growth factor.

erb-2 (breast), ret (MEN1,2) - receptors.

ras, abl - messengers (phosphorylation, tyrosine kinase).

n-myc (neuroblastoma), c-myc (burkitt’s lymphoma) - transcription factors.

- Mechanism of mutation: point mutations - p-53, ras (all suppressor genes)

Amplification (multiple copies) - erb-2

Translocation (irreversible) - t(9,22) in CML (Philadelphia chr.), t(8,14) in Burkitt’s lymphoma (EBV related, CD-21 ! turns B-cells into plasma cells), t(14,18) in B-cell lymphoma, t(15, 17) in acute promyelocytic leukemia (AML-3, can be treated with retinoic acid ! matures the blasts).

- Suppressor genes knock out: FAP, neurofibromatosis, Wilm’s tumor, BRCA-1,2(chr.13, chr.17 respectively).

- BRCA 2 is only related to breast cancer, BRCA 1 also to ovarian and others.

- Most breast cancers are NOT genetic (only 15% are).

- Initiators: chemical (smoking), viruses, radiation. Chemical are 80%.

- Smoking related cancers: 1° reason – lung, mouth, larynx, pancreas, bladder 2° reason - cervical, colon, leukemia.

- Viral related cancers: Kaposi sarcoma - HHV-8.

HCC - HBV, HCV, aflatoxin (Asia).

1° CNS lymphoma - HIV.

nasopharyngeal carcinoma (China), burkitt’s &other malignant lymphomas - EBV.

SCC of vagina, cervix, vulva, anus (in homosexuals) - HPV.

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- Radiation related cancers: CML (and other leukemia), metastatic papillary carcinoma of the thyroid, osteogenic sarcoma, basal cell carcinoma (non-ionizing from UVB, also causes SCC and melanoma), actinic keratosis (sun, pearly-gray).

- Transitional cell carcinoma carcinogens: smoking, aniline dye, cyclophosphamide.

- Arsenic related cancers: SCC of the skin, angiosarcoma of the liver, lung cancer.

Arsenic is abundant in Bangladesh.

- Wide eye reflex: #1: congenital cataract (CMV, rubella, corticosteroids) #2: Rb.

- Genetic related cancers: xeroderma pigmentosum (DNA repair enzymes)

predispose to ALL, skin cancers.

- Chromosome instability syndromes: Wiskott-Aldrich syndrome, Bloom syndrome,

ataxia telangiectasia, Fanconi’s ayndrome.

- In most cases: Upper lip - basal cell carcinoma, lower lip - SCC.

- Constant irritation is a risk factor for SCC of the skin.

Scars in the lung are usually related to adenocarcinoma.

- H. pylori is a risk factor for gastric adenocarcinoma and low grade malignant lymphoma.

- Keratin pearls are an histological picture of SCC.

- Tumor > 2cm, generally has a chance of metastasize.

- Significance in prognosis: M > N > T.

- Tc cells are the most important host defense system (also MP, NK, Ab).

- Cachexia is caused by TNF-( (catabolic state, irreversible)

- The most common cause of anemia in malignancy is anemia of chronic disease.

Other reasons: right sided colon cancer bleed (iron def.), bone metastases that penetrates BM, chemotherapy drugs, autoimmune mechanisms.

- Most patients with disseminated cancer are thrombocytosis, hyper-coagulable.

Trousseau sign (superficial migratory thrombophlebitis) in carcinoma of the head of the pancreas.

- Most common cause of fever and death in malignancy is gram negative infection.

- Most common para-neoplastic syndrome is hypercalcemia because of a PTH producing cancer like renal or bronchial carcinoma. Another reason for hypercalcemia could be bone metastases (NOT para-neoplastic).

- Acanthosis nigricans: marker for gastric adeno cc, insulin receptor def., MEN.

Leser-Trélat sign (eruption of multiple seborrheic keratosis over night) is another marker for gastric adenocarcinoma.

- Hypertrophic osteoarthropathy produces clubbing which can be seen in lung cancer,bronchiectasis, IBD.

- Dermatomyositis (elevated serum CK, raccoon eyes, Gottron’s patches over the knuckles) is related to leukemia, lymphoma and lung cancer.

- Marantic endocarditis: vegetation over mitral valve in mucus producing cancer like colon cancer which can embolize.

- Small cell carcinoma (APUD, S-100 antigen), produce ADH, ACTH and can cause hyponatremia and cushing syndrome.

- Renal adenocarcinoma can produce PTH-like hormone, erythropoietin and can cause hypercalcemia and/or 2° polycythemia.

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- HCC produces insulin-like factor, erythropoietin and can cause hypoglycemia and/or 2° polycythemia.

- Medullary carcinoma of the thyroid, produces calcitonin (tumor marker that can be

converted to amyloid) and can cause hypocalcemia and/or cushing’s syndrome.

- Tumor markers: (FP - increased in: testicular cancer (yolk sac = endodermal sinus tumor, also hCG"), HCC, neural tube defect (give mom folate in pregnancy to prevent). decreased in: down syndrome.

- Bence-Jones protein (light chain, monoclonal spike) - MM

- PSA - prostate cancer and hyperplasia (sensitive, not specific). Not effected by rectal exam, unlike prostatic acid phosphatase.

- CA-125: ovarian cancer.

- CEA: colon cancer, breast cancer, small cell. CEA-anti CEA immune complex can be deposited in the kidney and cause nephritic syndrome (diffuse membranous glumerolunephritis)

- &-hCG: trophoblastic tumor or a mole.

- Most common primary tumor of the brain is cerebellar cystic astrocytoma.

- Most common primary cancer of the brain is meningioblastoma (also cerebellar).

- Childhood tumors: #1: ALL (and other leukemia), #2: CNS tumors,

#3: neuroblastoma (adrenal medulla), burkitt’s lymphoma, Ewing sarcoma (onion skin calcification, t(11,22), small blue cells), embryonal rhabdomyosarcoma.

- Cancer incidence: women - #1: breast, #2: lung, #3: colon

men - #1: prostate, #2: lung, #3: colon.

- Cancer death: women - #1: lung, #2: breast, #3: colon.

men - #1: lung, #2: prostate, #3: colon.

- 2nd most common cancer incidence & death in men and women combined is colon.

- Most common GYN cancers are: #1:endometrial. #2: ovarian, #3: cervical.

- Most common GYN cancer killers are: #1: ovarian. #2: cervical, #3: endometrial.

- Only known tumor vaccine is HBV vaccine (HBV is the most common infection transmitted by accidental needle stick in hospital).

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Hematology:

- Microcytic anemia (MCV < 80): iron deficiency, chronic disease, thalassemia,

sideroblastic anemia.

- Macrocytic anemia (MCV > 100): B12/folate deficiency (folate in alcoholics)

- Normocytic anemia - low reticulocyte count (BM problem): aplastic anemia, renal

disease. high reticulocyte count (takes 5-7 days): hemolytic anemia, sickle cell,

spherocytosis, G6PD, autoimmune hemolytic anemia, microangiopathy.

- Correct reticulocyte count: Ht 45 x reticulocyte count > 3% is increased.

- In reticulocytes, we can see RNA filaments under LM with methylene blue.

- Polychromesia (younger RBC, take 2-3 days to become mature, still have basophilia),

if present in peripheral blood (normally not) ! strong BM response, pushes younger

RBC out (we would prefer the reticulocyte, that need only 24 hours to mature). In

order to factor them out from the correct reticulocyte count, we divide by 2 ! if now

it’s below 3, then the actual BM response is not good.

- Hb x 3 ~ Ht

- For every unit of transfusion of packed RBC " "Hb by 1%, "Ht by 3%.

Patient with Hb=5 that gets 3 units, should have Hb=8, Ht=24, if it is not, we should think about GI bleed.

- Most common anemia is iron deficiency and the most common cause is GI bleed.

- MCV gives an average size, so in di-morphic (microcytic and macrocytic together, like in Celiac) RBC population, MCV will be normal.

- Iron - duodenum, folate - jejunum, B12 - ileum.

- RDW - are the RBC uniformly micro/normo/macro? Can detect size change.

- Since iron deficiency anemia doesn’t develop over night, some cells will be small, and some will still normal. This could be detected by high RDW.

- Target cells are “obese” cells, because excess membrane bulges ! more Hb can collect there ! markers for alcoholics and hemoglobinopathy (thalassemia, HbC).

- Microcytic anemia (#Hb synth) ! less red, pale, greater central area of power.

Spherocyte has no central area of power, all red.

- Physical signs of anemia: spoon nails = koilonychia (iron def., riboflavin def).

Pallor of conjunctiva (6g or less Hb), pale palmar creases (iron def.), lead line (gum margin discoloration), neurological symptoms (proprioception abnormalities, decrease vibratory sensation, babinski sign) in B12 def.

- Serum iron = 100, ferritin (iron storage), TIBC = 300 (= transferrin).

- #iron " "transferrin, #TIBC, ferittin!.

- Iron TIBC = normal % saturation = 33%.

- #Hb ! "RBC mitosis in BM ! dividing cells are smaller ! microcytic anemia.

- HbA = 2(2& (95-96%), HbA2 = 2(2* (1-2%), HbF = 2(2) (1%)

- Iron is usually stored in MP in the BM. In inflammation (chr. disease), our body responds as if it’s an infection ! we don’t want bacteria reaching our iron (because it increases their reproduction), so we keep it away from the bacteria, but also keep it away from the RBC. Serum iron!, even though we have a lot of stored iron ! not enough to make heme. TIBC!, ferittin#.

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- Heme synthesis: mitochondria ! cytosol ! mitochondria (GNG, TCA also both).

- Tetanus toxin inhibits glycine ! constant contractions.

- ALA synthase (pyridoxine co-factor) is the rate limiting step of heme synthesis.

- Ferrochelatase combines iron together with protoporphyrin

- Alcohol related anemia: #1: of chronic disease, #2: folate def.

- Sideroblastic anemia (least common), iron overload disease, "ferittin, TIBC#:

3 causes: #1: alcohol: uncoupler ! every reaction in the mitochondria is dysfunctional, incl. heme synthesis ! iron that enters RBC, some stored in ferritin,most enter mitochondria where it cannot escape. Mitochondria is around the nucleas of RBC ! ring sideroblast (seen in BM stained with Prussian blue).

#2: B6 deficiency (isoniazid treatment) ! no ALA synthase reaction.

#3: lead poisoning: denature protein, mostly ferrochelatase, also ALA dehydrase.

Lead denature ribonuclease ! ribosome persist ! coarse basophilic stippling.

Lead can deposit in the epiphysis (seen on x-ray) ! growth retardation, wristdrop.

Symptoms: severe abdominal colic, cerebral edema ("vessel permeability ! ALA accumulate, neurotoxic), convulsions, diarrhea, FTT, anemia.

Causes of lead poisoning: automobile factory (batteries), pottery painter, moon shine(make alcohol), kid eating paint or plaster.

- &-thalassemia: Blacks (like G6PD, sickle), Asians.

4 genes responsible for making (-globin chains:

one deletion - no anemia

two deletions - mild anemia (globin# ! microcytic),

three deletions- bad anemia with hemolytic component (##globin) ! form HbH (can diagnose with electrophorsis).

four deletions - spontaneous abortion, can’t live. 4) hemoglobin ! hemoglobin barts(show up on electrophoresis, but doesn’t matter…).

- Far east: high tendency of abortion due to (-thalassemia ! "choriocarcinoma.

- '-thalassemia: Blacks, Italians, Greeks. &: normal, &+: #&, &°: no &.Severe (Cooley’s anemia) - stop codon. Constant transfusion, death before 30 (from iron overload or transfusion related viruses).

Mild - splicing defect. #& ! HbA# ! "HbA2, "HbF (show on electrophoresis).

- We do not treat the mild thalassemias ((&&). Don’t give iron ! iron etc. - normal.

- &*-thalassemia: hereditary persistent HbF disease, "HbF. No symptoms.

- Iron deficiency reasons: prematurity (give iron supplements), bleeding Meckel’s

diverticulum in a newborn.

Women: under 50: mainly menorrhagia. Under 20: anovulatory cycles.

20-40: ovualotry cycles with irregular shedding, inadequate luteal phase, pregnancy

related bleed, endometrial polyp bleed.

Men: peptic (duodenal) ulcer disease

Over 50: colon cancer.

- undigested iron tablets in a baby (mom with menorrhagia) can be seen on X-ray.

- B12/folate deficiency ! dTMP deficiency ! immature nucleas ! big cells.

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- Circulating form of folate is methyl-THF.

- Purpose of cobalamine: taking off the methyl group of methyl-THF !

methylcobalamine ! gives the methyl group to homocystein ! methionine (needed for 1C transfer reactions).

- Folate (less B12) def. ! "homocystein ! produce thrombosis including MI.

- MTX, trimethoprim inhibit DHF reductase (DHF ! THF).

- B12 is a co-factor for this reaction: methylmalonyl CoA ! succinyl CoA.

Excess propionyl CoA, methamalonic acid (specific, sensitive test for B12 def.)

Demyelination ! dementia, proprioception and vibratory problems, spasticity, babinski

sign).

- B12 deficiency can present as a neurological disease without anemia.

- Dementia: check B12 and TSH (hypothyroidism), both reversible causes.

- Pure vegan (no dairy or meat) need B12 supplements.

- Crohn’s disease in terminal ileum: #B12, #bile salts ! malabsorption

- Pernicious anemia ! atrophic gastritis of body and fundus ! achlorhydia !

predisposing factor of gastric adenocarcinoma.

- Chr. pancreatitis (alcoholics) ! cant cleave off the R-factor ! #B12

- Diphyllobothrium latum (fish tape-worm) “eating” B12-IF complexes

- Bacterial overgrowth (peristaltic problem, diverticular pouches) ! B12-IF and bile salt deficiency.

- Folate is eaten in a poly-glutamate form which cannot be absorbed in the jejunum, and has to be transformed into mono-glutamate form by intestinal conjuagase (blocked by phenetoin).

- OC and alcohol prevent absorption of mono-glutamate form of folate.

- B12 stores last 6-9 years, folate stores last 3-4 months.

- Hypersegmented nuclei (> 5 lobes), arrive before the anemia developes.

- Romberg test: patient stands with eyes open and then closed; if closing the eyes

increases the unsteadiness ! loss of proprioception (posterior column disease).

- Weber test for hearing can also be used to detect vibratory problems.

- B12/folate deficiency can lead to pancytopenia (cells are too big, can’t get out to circulation).

- Positive Schilling’s test with IF ! pernicious anemia.

Positive Schilling’s test with correction by antibiotics or pancreatitc extract !

bacterial overgrowth or chr. pancreatitis

Negative Schilling’s test ! crohn’s, worm, etc…

Normocytic anemia with corrected reticulocyte count < 2% :

- EARLY iron deficiency, anemia or chronic disease. check ferittin, it is first to decrease.

All iron studies# before any anemia present.

- Aplastic anemia: have to do BM, everything is decreased. Idiopathic mostly. Drugs:chloramphenicol (RMSF), indomethacin (gout), phenylbutazone (arthritis), thyroid related drugs.

Infections: HCV (parvovirus destroys only RBC)

Radiation.

- chronic renal failure ! #erythropoetin (give orally)

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- Blood loss of less then a week.

- Malignancy.

Normocytic anemia with corrected reticulocyte count > 3% :

- Hemolytic anemia - extravascular: IgG, C3B on the surface (autoimmune), abnormal

shape (sphere, sickle - removed by MP, don’t leave spleen).

End product of phagocytizing an RBC ! unconjugated bilirubin in the MP ! leaves

MP, bind albumin, go to liver (doesn’t get to urine) and get conjugated.

Clinical finding of extravascular hemolytic anemia is jaundice.

Intravascular: smash into something (calcified valve, IgM mediated).

Hb is released (! hemoglobinurea), haptoglobin binds it (! #haptoglobin).

Usually no jaundice.

- Extrisinsic: problem not related to RBC - smash into valve and so on.

- Intrinsic: Membrane defect (spherocytosis, PNH), Abnormal Hb (sickle cell), Deficient

enzyme (G6PD):

- Spherocytosis (AD): spectrin defect, no central area of power. Removed extravasculary (spleen), jaundice, splenomegaly, gall bladder disease (unconjugated bili" ! conjugated bili" ! supersaturation of bile !

Ca-bilirubinate stone). Diagnosis: "osmotic fragility. Treatment: splenectomy.

- PNH: defect in decay accelerating factor. Acidosis at night ! complement activation! attach to all blood cells, protected by decay accelerating factor.

Pee Hb in the morning, pancytopenia.

- Sickle cell (AR): Trait - no anemia, no sickle cells in peripheral blood (could have in renal medulla peritubular capillaries).

Black, normal CBC, normal physical, microscopic hematuria ! sickle cell screen.

Disease - over 60% HbS ! can spontaneously sickle. Oxygen tension can inducesickling. Hemolytic anemia (can be severe, requires transfusion). Occlusion of small blood vessels ! veso-occlusive crisis ! ischemia of lung, liver, spleen, BM. In children - dactylitis (digit inflammation) of hands and feet ! pain. Splenomegaly, followed later by autosplenectomy (~age 20).

Howel-Jolly body in peripheral blood - spleen not working (if it was, the MP would have removed them) ! Strep. Pneumoniae sepsis (most common cause of death).

Pneumovacc. can only be given at age 2.

Veso-occlusive crisis: HbF inhibits sickling, but when HbS increase (6-9 months) !first crisis.

Susceptible to osteomyelitis by salmonella (which is normally destroyed by MP).

Hydroxyurea: decrease incidence of veso-occlusive crisis by increasing HbF synthesis

(has to be taken with a chemotherapy agent).

- Lesch-Nyan syndrome (X-linked recessive): purin metabolism defect, "uric acid,HGPRT deficient. Mentally retarded, self mutilation.

- G6PD deficiency (X-linked recessive): Black, Greek, Italian.

Peroxide (made by every cell) can be neutralized by catalase or glutathione. Peroxide is increased in infections or when taking sulfa or nitro drugs (chloraquine for malaria,dapson for leprosy) or eating fava beans.

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Cause Hb clumping, damges membrane ! Heinz Bodies (= bite cells). Mainly intravascular hemolysis, but also extravascular.

Diagnosis: during episode - normal enzyme essay, special stain to identify Heinz bodies. When hemolytic episode is over, you confirm diagnosis by enzyme essay.

- Family with autoimmune disease, best screening test is HLA.

- Autoimmune hemolytic anemia: warm - IgG, cold - IgM. Most common is warm. IgG,C3b on RBC, removed by MP (extravascular).

IgG C3b on RBC surface can be checked by direct Coombs test (like this case).

Ab in the serum can be checked by Indirect Coombs.

- Most common causes of autoimmune hemolytic anemia: #1: SLE, #2: Drug induced:

penicillin, methyldopa (anti HT) - H-S type 2, IgG, extravascular.

Quinidine - H-S type 3 (innocent bystander), IgM, intravascular.

- Methyldopa and hydralazine can both be used in pregnancy. Hydralazine can precipitate drug induced lupus, 2nd to procainamide.

- Schistocyte (fragmented RBC): most common cause is aortic stenosis, followed by DIC, TTP, HUS. Intravascular hemolysis (because its chronic ! iron loss ! can be accompanied by iron deficiency anemia).

Also called runners anemia (from hitting the pavement) ! hemoglobinurea.

- Aortic stenosis: systolic ejection murmur, right 2nd intercostal space, radiating to

carotid, S4 sound, increase intensity on expiration.

- Malaria: hemolytic anemia. Quotidian (anytime) fever correlate to cells rupture.

- Leukomoid reaction: can involve any of the cell lines. Caused by serious infections

(TB, sepsis). Mainly in kids (otitis media). Neutrophils > 30,000.

Pertusis: (mature, typical) lymphocytosis > 60,000 (looks like ALL).

- Atypical (T) lymphocyte (= Downey cells, antigen stimulated lymphocyte, grows bigger): mononucleosis (EBV), CMV, toxoplasmosis, hepatitis, phenetoin.

- Mononucleosis: viremia, generalized painful lymphadenopathy, exudative tonsillitis,hepatitis without jaundice (ALT, AST > 2000). Spleen with tendency to rupture (not auto) - do not do contact sport for 6-8 weeks.

Diagnostic test: mono spot = heterophilic Ab - anti-horse RBC Ab (unique to mono),anti-sheep RBC Ab.

Once you have mono, you always have it. 3-4 recurrences in a lifetime.

- Monocytosis (chronic): rheumatoid arthritis, IBD, SLE, malignancy.

- Eosinophilia: hay-fever, penicillin rash, Strongyloides, Trichuris.

Amebiasis, Malaria, Enterobius (pinworm), Ascaris do not cause it. Only invasive helminthes do.

- Creatinin", urea normal ! oral creatine.

- Relative polycythemia: Most common cause of polycythemia

Decreased plasma volume ! normal RBC mass, "RBC count, normal O2 sat.

- Absolute polycythemia: "RBC mass.

Appropriate - tissue hypoxia: COPD, high altitude.

Inapprorpriate - no hypoxia: polycythemia rubra vera, tumor (e.g. renal adenocarcinoma) or cyst with excess production of erythropoietin.

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- Meloproliferative disease: Stem cell disease (neoplastic) with stem cell that lost all regulation (no inhibition) - Polycythemia rubra vera, CML, agnogenic myeloid metaplasia (myelofibrosis), essential thrombocythaemia (least common),myelodysplastic syndrome (pre-leukemia).

- Polycythemia rubra vera: "RBC mass, "plasma volume, normal O2 saturation,

#erythropoietin.

Hyper viscosity ! "resistance, thrombosis (Budd-chiari, dural sinuses, coronary artery,SMV) as the leading cause of death.

Phlebotomy: reduce viscosity, reduce iron (slowing down RBC synthesis)

Hyper volemia: PRV is the only polycythemia where "volume matches "RBC mass,both can be measured by radioactive techniques.

Histaminemia (mast cells, basophils increase): itching after temperature change, red looking face, migranes.

Generlized itching: Bile salt deposition (obstructive jaundice), mast cell degranulation.

Hyperuricemia: "nucleated hematopoetic cells ! when die, purin metabolism gives uric acid. Give allopurinol to prevent renal failure due urate nephropathy (also from dying cancer cells in chemotherapy - tumor lysis syndrome).

- COPD, Tetralogy of Fallot, high altitude: "RBC mass, normal plasma volume, !O2 saturation, "erythropoietin.

- Renal adenocarcinoma, hydronephrosis, Wilm’s tumor: "RBC mass, normal plasma volume, normal O2 saturation, "erythropoietin (ectopic production).

- Leukemia: malignancy of stem cells in BM that can metastasize anywhere.

Generalized lymphadenopathy, HSM.

Abnormal cells in peripheral blood = blasts.

Crowded BM ! anemia (usually normocytic), thrombocytopenia, "WBC.

- BM ! count blasts: if < 30% ! chronic, if > 30% ! acute.

- Age: 0-14: ALL, 15-39: AML (Auer rods), 40-59: AML, CML, 60+: CLL.

- CLL is the most common leukemia regardless of age. Most common cause of generalized non tender lymphadenopathy (metastases) in patients over 60.

- Neutrophil alkaline phosphatase score: overlay stain for AP on smear, check which

neutrophils take up the stain ! mature neutrophils all have AP, neoplastic ones do not

take it. Take 100 cells, grade each cell’s intensity with 1-4 score ! CML: low or 0

score. Another study is Philadelphia chromosome.

- Agnogenic meloid metaplasia: extramedullary hematopoiesis (e.g. spleen, which is

huge). Megakaryocyte cause BM fibrosis. RBC which stay in the fibrotic BM, in order to get out to the sinusoids, have to go through fibrotic tissue, that damages its membrane = tear drop (marker).

- ALL is the most common cancer in kids. CALLA CD-10 positive B cell leukemia.

- CLL: smudge cells, hypo-)-globulinemia (neoplastic cells do not change into plasma cells ! most common cause of death is infection).

- TRAP stain - hairy cell leukemia (cells with projections of the cytoplasm).

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- AML: Auer rods (abnormal lysosomes),

Acute monocytic leukemia (M5) likes to invade gums.

Acute promyelocytic anemia (M3): t(15,17). Always have DIC. Treat with retinoic acid.

- Painful lymphadenopathy is never malignant ! inflammatory condition, but not necessarily infection, could be SLE for example.

Painless: #1: metastases, #2: 1° lymphoma (follicular).

Generalized = systemic disease

- Bruton’s agammaglobulinemia: germinal follicle (B-cells) will be absent Di-george: para trabecular (T-cells) area will be absent.

Histioctosis X: CD1 positive, sinus is absent.

SCID (ALA deaminase def.): combined B+T def., histiocytes are present.

- Follicular lymphoma (B-Cells) is the most common Non-Hodgkin’s lymphoma.

t(14,18) ! apoptosis knocked off.

- Cartilage and elastic tissue are the two tissue resistant to invasion of cancer cells.

- Burkitt’s lymphoma: EBV, t(8.14), transfer of myc oncogene. Stary sky appearance

(stars = normal benign MP). 3rd most common cancer in kids. Most common abdominal lymphoma in kids in the US (peyer’s patches, para-aortic lymph nodes,even testes). Burkitt’s in the jaw is frequent in Africa.

- Mycosis fungoides: neoplastic cells are Th cells. Plaque like lesion. Involves skin,

lymph nodes. When the malignant Th cells get to the peripheral blood it is called Sezary syndrome.

- Malignant histiocytic disease: monomorphic CD-1 positive empiric cells with Birbeck granule (tennis racquet) under EM.

- Clostridium tetany spore also looks like a tennis racquet.

- Fever, night sweats, weight loss have TB until proven otherwise.

- Hodgkin’s disease: Reid-Sternberg cell (owl eyes, so is CMV, giardia, Aschoff’snodule of RF) is the neoplastic cell. Less RS cells ! better prognosis.

Most common one is nodular sclerosis (more common in women, unlike other 3).

Typical presentation: women, lymph nodes involvement in 2 places, one of which in the anterior mediastinum (presents as a mass), 2nd one is somewhere above the diaphragm (e.g. neck).

- Serum protein electrophoresis: albumin migrates the furthest,)

-globulin stays put.

Albumin ! (1 ! (2 ! & ! ).

- Polyclonal gammapathy: multiple clones of plasma cells which produce GAMMA

globulin = IgG - most abudant, IgA, IgM - least. IgE, IgD very little). In electrophoresis,

in the )-globulin region, the peak is increase in IgG (RA, IBD), seen as big diffuse elevation. Benign, chronic inflammation.

- Monoclonal: one clone of plasma cells, the others are suppressed by immunological mechanism. Malignancy of plasma cells (mostly MM), mostly IgG ! light chains get into the urine ! Bence-Jones protein.

- MM is incurable unless you have a BM transplantation. Usually > 50 years (a bit more common in women). Most common type is of Ig kappa. Plasma cells release IL-1(osteoclastic) ! nice neat round, sharp bordered, lytic lesion in the bone (Paget’s disease - fuzzy looking) ! pathologic fracture (cough can fracture a rib).

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- Amyloidosis: systemic disease. Pre-albumin, calcitonin, light chains can be converted into amyloid. Chr. 21 codes for &-amyloid protein, so Down’s syndrome are more common to develop it. &-amyloid is toxic to neurons ! senile plaques in frontal +

temporal lobes, atrophy in the brain. All Down patients will develop Alzheimer’s if they live to age of 35-40 (in childhood they usually die of the endocardial cushion defect in their hearts).

- Gaucher’s disease (AR): wrinkled cytoplasm appearance of MP, lysosomes filled with glucocerebrosides (glucocerebrosidase deficiency).

- Niemann-Pick disease: bubbly cytoplasm, severe mental retardation, sphyngomyelin accumulation (sphyngomyelinase deficiency).

- Pompe’s disease is the only glycogen storage disease with lysosomal glycogen storage (lysosomal )-1,4-glucosidase deficiency, can’t break it). Excess deposition of glycogen in the heart is the main cause of death.

- Heparin (GAG) prevents clots by enhancing AT3 (which can only inhibit serine proteases - XII, XI, X, VII, II, prothromin). Evaluate it with PTT which is prolonged (PT is less good, but also prolonged)

- PGI2 prevents platelet activation

- Protein C, S inactivate factors V, VIII (not serine proteases)

- TPA activates plasminogen.

- OC increase synthesis of V, VIII, fibrin and inhibit AT3 ! heparin antagonist.

OC + smoking (damage endothelial cells) ! thrombosis.

- Bleeding time is used to estimate platelet aggregation, function (nothing to do with coagulation factors). Check when bleeding stops (7-9 min).

- Small vessel bleed: Tissue thromboplastin released whenever a tissue is damaged! activate extrinsic pathway.

Exposed collagen in that wound ! activation of factor XII.

Endothelial cells and megakaryocyte produce adhesion molecules - vWF.

When platelet stick, with the help of vWF, they release chemicals (“release reaction”),

the most important of which is ADP which is an aggregating factor.

Platelets also need TXA2 (vasoconstrictor, bronchoconstrictor, platelet aggregator)

which they make themselves (only cell that has TXA synthase).

- Prolonged bleeding time: thrombocytopenia < 90,000 or vW disease AD)

- Aspirin inhibit the platelet COX, 9 times stronger than the endothelial COX.

- Aspirin is an irreversible inhibitor of COX, other NSAID inhibit it for 48 hours.

- Platelet problem: bleeding time", bleeding from superficial scrathes/cuts (no temporary hemostatic plug), petechia, pin point hemorrhage, nose bleed (most common) ecchymosis/purpora - none of which occur in coagulation deficiency.

- Coagulation problem: bleeding time normal. Massive amount of delayed bleed,because there is only temporary hemostatic blood held together by fibrinogen (not fibrin). e.g. wisdom tooth removed or surgical procedures with bleeding problem.

Menorrhagia, hemoathrosis, GI bleeds and bleeding into closed spaces.

- Ristocetin cofactor is the most sensitive test to diagnose vW disease. In vW disease it cannot cause platelet to clump.

- Donor platelets (platelet pack transfusion) can work in a bleeding patient with platelet problems (NSAID), even though the patients own cannot.

- PT: evaluation of extrinsic pathway = INR. PTT: evaluation of intrinsic pathway.

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- Most common factor deficiency: #1: vW disease, #2: Hemophilia A

- Warfarin blocks epoxide reductase ! prevent )-carboxylation of II, VII, IX, X. we evaluate warfarin with PT which is prolonged (only factor which we’re not evaluating is IX). PTT is also prolonged, yet PT is better.

- Fibrin degradation products (D-dimers) is the best screening test for DIC. Proves that

there was a clot (coronary artery platelet thrombosis, held together by fibrin).

- PE: D-dimes and ventialation/perfusion scan are the best test.

- Fibrin stabilizing factor (factor XIII) links fibrin (cross bridge), makes it stronger.

- Vascular diseases: Scurvy.

Senile purpura on the back of the hand (place that hits things) because of vessel instability and subcutaneous tissue thinning. Age dependant, all will have it.

Osler-Weber-Rendu disease = hereditary telangiectasia (most common genetic vascular disease): chr. iron def. anemia related to GI bleed, telangiectasia (little red spots) on fingers, lips, tongue, entire GI.

- Petechia, when you press on it doesn’t go away, spider angioma (AV fistula) does.

- ITP: platelet very low, IgG against platelet (H-S type 2), MP in the spleen removing the platelet. If very symptomatic - corticosteroids, if not - nothing. Mainly in kids. ITP can

be part of SLE (women usually).

- TTP, HUS: PTT, PT are normal, bleeding time prolonged. Something in the plasma damages small vessels throughout the body ! stick, aggregate, clot ! thrombocytopenia ! bleeding. RBC smashed into the thrombi ! schistocytes !

micro angiopathic anemia. Fever, renal failure.

HUS is caused by either 0157:H7 E. coli toxin or shigella toxin.

One of the most common cause of renal failure in children is HUS.

- Hemophilia A Vs. vW disease: in vW disease we see all the symptoms of platelets problem but on top of that they have a mild factor 8 def. that cause a coagulation defect ! combined symptoms.

Factor VIII molecule: VIII coagulant, vWF, VIII antigen (carrier protein).

Classical vW disease is AD, hemophilia A is X linked and appear in men.

Hemophilia A - !VIII coagulant, vW disease - all 3 are decreased.

ddADP (desmopressin) can cause synthesis of all 3 compononent, help to treat MILD hemophilia A and it’s the choice treatment for vW disease.

Estrogen (OC) increases the synthesis of all 3 components, so girls stop bleed.

Sensitivity of PTT and bleeding time being abnormal is vW disease is 50%.

- Anti PL syndrome: lupus anticoagulant (seen in SLE, HIV), anti-cardiolipin Ab

(produce false positive syphilis serology, check FTA-ABS to make sure), both cause vessel thrombosis.

A women with a biological false positive syphilis serology should first of all get a serum anti-nuclear Ab test for SLE.

- DIC: problem in laboratory diagnosis, easy clinically. Clot forming throughout the body

in small vessels ! fibrinogen, V, VIII, prothrombin and platelet are consumed !

bleeding from every orifice (mouth, anus, penis, venus punctures). In a “clot tube”,

which has serum on top, serum will be missing all those factors, so only serum is circulating without the plasma.

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Septic shock (E. coli), snake bite (rattle snake), ARDS, amniotic fluid emolism (contain thromboplastin) can cause it.

PT, PTT prolonged, platelet count decrease, D-dimers positive (most important).

- Hereditary thrombosis: young person with DVT. Leyden factor V (protein C cannot break it), AT3 deficiency (if you give heparin and PTT remains normal).

- Aspirin treatment: platelet normal, "bleeding time, PT-PTT normal.

ITP: #platelet, "bleeding time, PT-PTT normal

HUS, TTP: #platelet, "bleeding time, PT-PTT normal

Hemophilia A: platelet, bleeding time and PT - normal, PTT prolonged.

vW disease: platelet normal, "bleeding time, PT-PTT normal.

Warfarin, heparin: platelet and bleeding time normal, "PT-PTT.

- O: anti A IgM, anti B IgM, anti AB IgG. Universal donor.

A: anti B IgM

B: anti A IgM

AB: no antibodies. Universal recipient.

Newborns: no antibodies (don’t begin synthesizing IgM before they’re born, IgG is

only produced after 2-3 motnhs).

Elderly: antibodies level very low.

- Relations: gastric cancer - A, duodenal ulcer - O.

- Duffy Ag - missing in the black population (less likely to get malaria from Vivax, they

need it to get into the RBC). Thalassemia, sickle cell, G6PD protect against malaria from Flaciparum, because their life span is short.

- Major cross match: serum of patient getting blood + RBC from donor. Looking if there’s anything in the patient serum that will attack the donor’s RBC.

- Every unit of blood increases the risk of developing Ab which may attack later transfusions.

- Ab against CMV is the most common Ab in the US.

CMV is the most common infection transmitted by blood transfusion

- HCV is the most common hepatitis related virus transmission.

- HIV screening: gp120 is measured by ELISA, western blot looks for 3-4 different Ab(very specific).

- Any blood that a new born gets is being radiated to kill all lymphocytes. CMV lives inside lymphocytes.

- If you stick you finger with a needle of HIV patient (most common way of medical personal of accidentally getting HIV), there’s a 1:300 of getting it. You start triple therapy for 6 months as if you got infected.

- Don’t transfuse an ASYMPTOMATIC patient.

- Never use FFP to expand a patient’s plasma volume (use saline…).

Use FFP for multiple coagulation disease like DIC, bleeding due to liver cirrhosis or bleeding due to warfarin over anticoagulation (not intramuscular vit. K which takes 6-8 hours to work).

- Bleeding due to heparin over anticoagulation is treated with protamine sulfate which works immediately.

- Transfusion reactions: allergic (treat with benedril and antihistamines), febrile (due to anti-HLA Ab against the donor’s WBC, release pyrogens).

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- If I never got a blood transfusion, I will NOT have any anti-HLA Ab.

Every women who was pregnant (also abortion), has anti-HLA Ab developing against her baby’s WBC. More pregnancies ! more risk. This is H-S type 2.

- Hemolytic transfusion reactions: “clerical error” (giving wrong blood) or patient has an Ab against RBC Ag (some Ab are not present but we have memory B-cells, from past experience to produce them) which can be immediate (hours) or delayed (after days week,

you get jaundice and a drop of Hb ! check with Coomb’s test).

- ABO incompatibility can be a problem in the first pregnancy ! anti AB IgG Ab against baby’s RBC, destroyed by MP in baby’s spleen ! anemia, unconjugated bili derived from that MP is handled by mom’s liver in utero. When baby is born they will develop jaundice and mild anemia (liver conjugation system isn’t as good) ! put them under

UV light (converts bili in skin to dipyerol - water soluble, peed). Coomb’s test on baby’s RBC (covered by IgG Ab) will be positive.

- The most common cause of jaundice in a newborn in the first 24 hours is ABC incompatibility. Physiological jaundice of a new born starts on day 3.

- Rh incompatibility (mom negative, baby positive): First pregnancy - feto-maternal bleed ! baby’s O+ cells cause mom to develop anti D Ab against ! sensitized !

2nd pregnancy - IgG Ab cross placenta, attach D Ag ! baby - more severe anemia !

exchange transfusion (all blood out) at birth.

Prevention: Ab screen negative. Around 28 week, give Rh Ig as prophylaxis (anti D,doesn’t cross placenta) incase of feto-maternal bleed before birth. With a special test(stain mom blood to identify fetal RBC), we can decide how many Rh Ig to give mom to protect her further (for about 3 months, while anti D lasts).

- ABO and Rh incompatibility: Not a problem in most cases, mom destroys RBC so fast.

ABO incompatibility actually protects against Rh sensitization. Still give Rh Ig,just incase.

- Erythroblastosis fetalis (Rh incompatibility): death of high output heart failure (severe anemia decreases viscosity of blood), left first, later right. Huge liver (extramedullaryhemopoiesis).

- Orange color in a baby’s brain ! Kern icterus.

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Cardiovascular:

- Jugulo-venous pulse (checked on right side): A wave - atrial contraction of late diastole (last contraction cause some backflow into venous pulse)

C wave - systole (blood hits tricuspid valve into atrium, S1)

X wave - blood through pulm. artery creates negative pressure, sucks valve down.

V wave - filling of right atrium (beginning of diastole, S2)

Y wave - tricuspid valve opens, blood goes to ventricle.

- Mitral stenosis ! atrial fibrillation ! A wave disappears (S4, if was present, will disappear).

Tricuspid stenosis ! atrium contracts harder against close valve ! giant A wave.

Tricuspid regurgitation ! in systole, blood goes to right atrium + pulm. artery ! giant CV wave.

- Turbid plasma is only due to triglyceride.

- In order to get the real triglyceride level (excluding chylomicrons), you must fast.

For cholesterol, fasting is not necessary because chylomicrons have only 3% cholesterol. We measure HDL, LDL, cholesterol.

- In a simple tube, in 4°c, over night: chylomicron floats (supernate), VLDL is the pinkish turbidity (infranate) below it (more dense, have proteins).

- Turbid infranate with no chylomicrons ! type 4 hyperlipoproteinemia.

- "chylomicron, no VLDL ! patient probably didn’t fast (type 1, less likely).

- Xanthelasma (yellow islet): due to cholesterol (not TAG), get a lipid profile.

- Achilles tendon xanthelasma is pathognomonic for familiar hypercholestemia (death by coronary artery disease by age 20, no LDL receptors).

- Atherosclerosis: “reaction to injury” theory - injury of endothelial cells of muscular and elastic arteries (smoking, oxidized LDL, viruses, Chlamydia Pneumonia,homocystein) ! platelet stick ! GF released into artery ! SM cells in media proliferate ! migrate from media to sub-intima (below endothel).

Monocytes have access because of injury, also release GF.

MP and SM cells phagocytize oxidized LDL ! fatty streak.

Fibroblast develop over time ! fibrofatty plaque ! complicated by dystrophic calcification, fissuring or thrombosis.

Tc cells are involved by making cytokine.

- Hyaline arteriolosclerosis - HT (force proteins through basement mem.), diabetes (non enzymatic glycosylation of AA ! basement mem. permeable to proteins).

- Hyperplastic arteriolosclerosis (onion skin look) - malignant HT.

- Hb A1C is an example of glycosylation. It should be under 6% in diabetics.

- HT kidney - cobble stone appearance, shrunken ! fibrosis and atrophy. Lacunar strokes in internal capsule (tiny areas of infarction).

- Aneurysm: out-pouching of vessel wall due to weakening (ATH). All aneurysm will rupture, it’s just a matter of time. Aorta below the renal artery is the most common location (no vasa vasorum there, getting less oxygen and nutriens).

29 Rupture triad: sudden onset of left flank pain (retroperitoneal bleed), hypotension,pulsatile mass on physical exam.

- Tertiary syphilis: painless chancre = little arterioles surrounded by plasma cells(vasculitis) ! lumen is shut ! ischemic necrosis.

Aortic arch aneurysm: syphilis attack the vasa vasorum ! endarteritis obliterans !

ischemia ! weakening ! pouching under systolic pressure ! aortic valve ringstretch ! murmur with or without valvular damage (aortic regurgitation) ! "stroke

volume + EF (more blood in the LV) ! pulsating, hoarseness (recurrent laryngeal n.

goes around the aorta and get stretched), rupture (most common complication).

- EF: 80ml out 120ml in the ventricle = 0.66.

- Elastic tissue fragmentation, cystic medial necrosis ! weakening.

Weakening + HT ! rupture. If it’s in the pericardial sack attachment ! tamponade

(proximal dissection, most common).

- Dissecting aortic aneurysm: tearing pain in retrosternal pain radiating to back. Pulse on the left in diminished compared to the right.

MI: sub-sternal pain radiating to arm and jaw.

Chest X-ray: diameter of proximal aorta is widened (85% sensitive, test of choice).

Confirm by trans esophageal US or angiography.

- Diseases predisposing to DAA: Marfan’s syndrome (AD, chr. 15, fibrillin defect).

More common cause of death is mitral/tricuspid valve prolapse ! sudden death (conduction defect).

Ehlers-danlos syndrome (collagen defect): DAA is most common cause of death.

Pregnancy: DAA is most common catastrophic disease of the aorta (twice the plasma volume, 2:1 volume/RBC ! #Hb concentration (11.5 as anemia cut off in pregnancy,normally it’s 12.5).

- Retinal vein engorgement (blurry vision), head ache, overall congestion ! SVC syndrome (1° lung cancer as the main cause ! radiation treatment).

- Sturge-Weber syndrome: vascular malformation of face (“port-wine stain”, trigeminal nerve distribution) and AV malformation of brain (meningeal angiomatosis, on same side) with predisposing to bleeding. Mental retardation.

- Capillary hemangioma: red lesion on face. Leave it alone! (gone by age 8)

- Bacillary angiomatosis: Bartonella Henselae (also cause of cat scratch disease),silver stain it, treat it with sulfa drug. Only seen in AIDS, looks like Kaposi.

- Causes of angiosarcoma of the liver: vinyl chloride (plastic, rubber), arsenic(pesticides, contaminated water), thorotrast.

- Vasculitis: small vessel (H-S type 3) ! fibrinoid necrosis ! palpable purpura (not a platelet problem, where it’s hemorrhagic and not palpable).

Muscular artery - Polyarthritis nodusa, Wegener granulomatosis, Kawasaki (coronaryartery vasculitis) ! thrombosis ! infarction

Elastic artery - Takayasu arteritis ! pulsless disease, strokes, “aortic arch synd.”.

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- Temporal arteritis: granulomatous vasculitis of temporal artery. If involves the ophthalmic branch, can cause blindess. Sedimentation rate is elevated (in arteritis, it should be elevated). Put them on corticosteroids to prevent blindness. Polymylagia rheumatica (no CK elevation unlike polymyositis).

- Buerger's disease = thromboangiitis obliterans = smoker’s disease: digital vessel thrombosis ! auto-infarction of fingers + toes.

- Henoch-Schonlein purpura (anti IgA immune complex): most common vasculitis in children, associated with acute upper respiratory infection. Polyarthritis, hematuria(RBC casts ! glumerolunephritis), palpable purpura of buttocks and lower extremities.

- Berger disease = (focal) IgA glomerulonephritis.

- Wegener’s granulomatosis: c-ANCA. Saddle nose deformity (also congenital syphilis),upper respiratory (sinuses) + lungs problems (nodular masses), glumerular disease.

Treatment: cyclophosphamide - side effects: hemorrhagic cystitis (prevented by mesna), bladder cancer.

- Polyarthritis nodusa: muscular arteries, p-ANCA. Young adult men. Association with HBs Ag. Usually affects the GI tract and the kidney (albumin/hematuria).

- RMSF: Rickettsia Rickettsii, tic vector (also Lyme’s). Petechia which starts on extremities and spreads to trunk UNLIKE other rickettsia: truck ! extremities.

- Mucor mycosis: cerebral abscesses, association with DKA.

- Reynaud’s phenomena: cold reacting Ab - IgM cold agglutinin disease,

cryoglobulinemia (old men with HCV),

Vasculitis of digits - scleroderma/CREST (Cyanosis, Centromere Ab, Reynaud’s,Esophageal dysmotility, Sclerodactylia, Telangiectasia).

Vasoconstriction - ergot derivatives (for migraines), Buerger’s disease.

- Causes of death in hypertension: #1: MI, #2: stroke, #3: renal failure.

- Multifactorial/polygenic inheritance: essential HT (blacks), CAD, gout, DM-II,congenital pyloric stenosis.

- Essential HT: retaining of salt ! ECF" ! SV" (systolic HT), !renin.

Salt goes into SM cells (peripheral resistance arterioles) ! open Ca channels !

muscles contract ! TPR" (diastolic HT).

Treatment of choice in blacks and elderly - hydrochlorothiazide (get rid of salt + water),can’t use it with hyperlipidemia.

- Most hypertensive bleed in the brain occur in the globus pallidus, putamen area(lenticulostriate branches of the middle cerebral artery are under increased risk for aneurysm = Charcot-Bouchard aneurysm, which rupture).

- Hyaline arteriolosclerosis of the kidney ! ischemia ! tubular atrophy, glomerular destruction, kidney shrink ! renal failure.

- Most common overall abnormality of HT is LV hypertrophy ("afterload) ! HF.

- Concentric hypertrophy: "afterload (TPR", stenotic aortic valve, HT)

Dilatation + hypertrophy: "preload (volume overload)

- S1 Systole - mitral/tricuspid valve close (mitral first)

S2 Diastole - aortic/pulmonary valve close (inspiration ! pulmonary close later)

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S3 Early diastole - volume overloaded chamber, turbulence (left or right heart failure ! left or right S3). Can be normal until age 35, above - pathologic.

S4 Late diastole - compliance problem (filling ability) of hypertrophied ventricle or if it’s already filled up (has to put more blood in already overfilled heart)

- Hypertension/hypertrophy - S4, volume overload - S3, S4 (gallop rhythm).

Rules:

- Right sided heart murmurs and S3, S4 increase in intensity on inspiration.

Left sided heart murmurs and S3, S4 increase in intensity on expiration.

- Stenosis murmurs - opening problem - opening murmur.

Regurgitation murmurs - closing problem - closing murmur.

- Aortic - right 2nd intercostal space

Pulmonary - left 2nd intercostals space

Tricuspid - left parasternal border

Mitral - apex

- Aortic stenosis: systole, diamond shape configuration (crescendo-decresendo) =ejection murmur, radiate to carotid. S4.

- Mitral stenosis: diastole. Opening snap followed by rumbling sound.

Atrium hypertrophy + dilation ! atrial fibrillation, stasis, thrombosis, underfilling of ventricle.

- Mitral regurgitation: pansystolic. Volume overloaded atrium. S3, S4

- Aortic regurgitation: diastole, right after S2. Volume overloaded ventricle. S3, S4.

- Austin Flint murmur: occur in aortic regurgitation due to the vibration of the anteriorleaflet of the mitral valve because it receives both the outflow tract into the aorta and

blood from the left atrium ! surgery to replace valve.

- The best non-pharmacological treatment for heart failure is restriction of fluids and

salts. The best pharmacological treatment is ACE inhibitor (#preload, #afterload). If you add spironolactone, you improve prognosis substantially.

- High output failure: endotoxic shock ! vasodilation of peripheral resistant arterioles

! HF.thiamine deficiency ! ATP depletion ! arteriolar vasodilation! HF.

Hyperthyroidism (Grave’s disease) ! thyroid increase synthesis of & receptor in the heart ! increase forct of contraction ! HF.

AV fistulae ! blood coming back faster to heart due to bypass. Brenham sign:

pressure on artery proximal to fistula causes swelling to diminish, thrill and bruit to cease, and pulse to fall.

- IVC ! RA ! foramen ovale ! LA ! LV ! aorta

SVC ! RA ! RV ! pulmonary artery ! ductus arteriosus (kept open by placental PGE2) ! aorta.

- Breath ! oxygen levels" ! pulmonary vessel open ! blood goes through them.

- Umbilical arteries have the least amount of oxygen, umbilical vein has the most.

- Left to right shunt ! "oxygen saturation - step up

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Right to left shunt ! #oxygen saturation - step down

- Oxygen saturation on right side (entering) is 75%, on the left side (exiting) 90%.

- VSD: left to right shunt ! RV, PA step up ! over time, if not corrected, pulmonary hypertension ! RV "contraction, could become stronger than the left ! shunt

reversal (Eisenmenger syndrome, cyanosis tardii). Most close spontaneously, some need to be patched.

- ASD: left to right shunt ! RA, RV, PA step up ! Eisenmenger syndrome, paradoxical embolization.

Fetal alcohol syndrome: most common teratogen producing disease with ASD.

- PDA: left to right shunt ! PA step up. Machinery murmur between the shoulder blades. Volume overload right side ! pulmonary hypertension ! DA empty distal to subclavian artery ! pink on top, blue on bottom (differential cyanosis).

Congenital rubella is the teratogen associated with PDA.

Indomethacin (potent NSAID) inhibits PGE2 ! constriction, PDA closes.

- Teratology of Fallot: overriding aorta, membranous septal defect, pulmonary stenosis below the valve, right ventricular hypertrophy. Right to left shunt.

The degree of pulmonary stenosis will determine whether you develop cyanosis.

PDA and ASD are cardio-protective in TOF patients.

- Right to left shunting : polycythemia, "risk of infective endocarditis

- Transposition of great vessels (Kartagener syndrome is not a transposition):

Right ventricle emptied by the aorta, left ventricle emptied by the pulmonary artery !

incompatible with life unless you have shunts (usually all 3). RV step up.

- Coarctation of the aorta: preductal - occur in Turner’s syndrome. Systolic murmur between shoulder blades. BP in upper extremities > lower extremities.

Potential for sub-arachnoid bleeding, strech aortic valve ring ! aortic aneurysm,dissecting aortic aneurysm.

Postductal - don’t present at birth, happens in adulthood. Surgically correctable cause of HT. Claudication, BP different between lower and upper extremities, renal artery BF# ! RAS activation ! HT with "renin.

Collaterals - superficial epigastric artery-internal mammary artery, intercostals (seen on X-ray as rib notching).

- In all people - the junction where the communicating branches connect to the main branch of the cerebral vessels is a weak area (no internal elastic lamina or smooth muscles) ! berry aneurysm risk, exacerbated by HT.

- CAD risk factors: age is the most important risk factor - men > 45, women > 55

(estrogen is protective, when you reach menopause, HDL decrease to men’s range!

"risk), family history of CAD/stroke, any smoking, HT, diabetes, HDL < 35 (if HDL >60, you can subtract another risk factor, like age).

- IHD: angina, acute MI, sudden cardiac death, chronic ischemic heart disease :

Sudden death (25%): death within one hour. No thrombosis, but severe coronary

artery disease (ATH). Ischemia ! PVC ! R on T phenomenon ! VF ! death.

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Chronic ischemic heart disease: little infarcts (subendocardial) ! muscle get replaced by fibrotic tissue, #contractility ! EF = 0.2 ! HF.

Angina: Classical - chest pain when you exerting, goes away after 5-10 min of resting. ST depression (subendocardial) of 1-2mm ! coronary angiogram.

Prinzmetal - usually occur in morning, due to vassal spasm (TXA2), not ATH.

ST elevation (transmural).

Unstable - while resting, initially classical that got worse ! hospitalized, angiogram,angioplasty. No treadmill.

CABG - use Saphenous vein (get arterialized within 10 years due to the pressures !

high tendency of fibrosing after 10 years

Internal mammilary artery (no fibrosis, remain patent, but we only have one…).

Acute MI: thrombosis of platelet held by fibrin, TPA breaks it easily (venous clot is harder to break) ! reperfusion injury but no further extension.

Pale infarct - 24 hours. Coagulation necrosis - 4-6 hours (visible under LM).

EF is the best prognostic factor for how well you’ll do after infarct.

Complications of MI: thrombosis -

LAD supplies entire anterior part and 2/3 of septum (most conduction bundles).

RCA supplies entire posterior part, posterior 1/3 of septum, entire RV. AV node is almost exclusively supplied by it (SA is 50%). Complications - mitral regurgitation during MI (posterio-medial papillary muscle dysfunction or ruptured, supplied by the

RCA, new S4), sinus bradycardia, atypical (epigastric) chest pain.

Rupture - most are anterior (LAD thrombosis) ! hemopericardium (chest pain,

muffled heart sound, neck vein distended).

Septum rupture gives left to right shunt, most are LAD thrombosis related.

Mural thrombosis - mixed clot, prevented by giving aspirin (against platelet aggregation) + warfarin/heparin (for coagulation factors). Can embolize.

Fibrinous pericarditis - occur two times - first week (friction rub, chest pain relieved by leaning forward) and 6 weeks later - Dressler syndrome (autoimmune pericarditis, 3 component friction rub). Treat with NSAID.

Ventricular aneurysm - late manifestation. Systolic bulge of precordium: blood collecting in the aneurysm ! makes the chest bulge out. It does not rupture because it is lined by scar tissue. Die of HF because aneurysm covers the ventricle.

Diagnosis: Gold standard - CK-MB: appears after 6 hours, peaks at 24, last for 3 days (re-appearance after 3 days means re-infarction). Troponin - appears after 4hours, peaks at 24, lasts 7 days.

Normally LDH2 is higher than LDH1. In MI ! LDH flip - LDH1 becomes higher,appears after 18 hours, peaks at 3 days, lasts 7 days.

- Mitral valve prolapse: “too much” valve, parachute look, blood underneath pushes the valve into the LA ! click murmur - #preload (lying) ! closer to S2 (takes longer toget blood out), !preload (standing, anxiety) ! closer to S1.

Excess of dermatan sulfate (made from GAG) on the valve ! redundant valve.

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- Aortic stenosis: most common valvular cause of syncope/angina with exercise, mostcommon cause of microangiopathic hemolytic anemia.

"preload ! "intensity of murmur (distinguish it from hypertrophic cardiomyopathy)

- Rheumatic fever is the most common cause of mitral stenosis (most common valveinvolved). Caused by group A, & Strep. Pyogenes (ASO titer elevated).

Post pharyngitis (and not a skin infection). M protein is the pathogenic factor ! Ab against those, attack heart, joints, brain (basal ganglia) - mimicry. Sterile vegetation,no embolization, erythema marginatum (nodules, immunological) ! Sydenham

chorea is a complication of that (months after). Jones criteria.

- Most common valvular lesion of acute rheumatic fever is mitral regurgitation murmur(the stenosis takes at least 10 years to evolve).

- Polyarthritis - juvenile rheumatoid arthritis, HSP, rubella, acute rheumatic fever.

- Mitral stenosis - fish mouth appearance of the valve

Most posterior located chamber of the heart is the LA.

In mitral stenosis, the LA presses esophagus ! dysphagia only for solid, presses recurrent laryngeal nerve ! hoarseness (Ortner’s syndrome)Irregular-regular pulse ! atrial fibrillation ! thrombosis from LA embolize.

- Mitral valve prolapse is usually asymptomatic, can have palpitation. A rare complication is tear of the chordae tendinae ! mitral insufficiency ! death.

Most common genetic related to it are Marfan and Ehlers-Danlos syndromes.

- IV drug abusers ! infective endocarditis (Staph. Aureus) ! #1: tricuspid regurgitation,

#2: aortic regurgitation.

- Carcinoid syndrome (with liver metastases) ! serotonin produces a fibrous tissue response of the valves ! TIPS (tricuspid insufficiency, pulmonary stenosis)

- Most common organisms to cause infective endocarditis: #1: Strep. Viridans (mouth flora) on damaged valves, #2: Staph. Aureus on both normal and damaged valves.

Most common valves involved: #1: mitral, #2: aortic.

Strep. Bovis cause infective endocarditis associated with UC or colon cancer.

- Membranous portion of the septum has a close relationship with the aortic valve !

vegetation on aortic valve due to VSD ("risk for infective endocarditis).

- Splinter hemorrhage (fingers): painful - Osler nodes, painless - Janeway lesions.

Koplik spot in the eye (red with white center) in measles.

All of these + glomerulonephritis are seen in infective endocarditis (type 3 H-S)

- Most common lesions of the heart in SLE (positive ANA): #1: pericarditis. Libman-Sacks endocarditis (vegetation all over the valve). Fibrinoid necrosis.

- Marantic vegetation is a paraneoplstic syndrome of mucus secreting colon cancer.

Looks exactly like acute rheumatic fever (with the appropriate history) - vegetation along the margins of the valve.

- If you get an infection question with Coxsackie virus as an answer, mark it.

It’s the most common cause of: myocarditis, pericaridits, viral meningitis, hand-foot

disease, herpangina. Do a biopsy of myocardium ! lymphocytic infiltrate.

- Congestive (=dilated) cardiomyopathy: big LV+RV (huge heart), dyspnea.

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Causes: post partum (6 weeks), Coxsackie (myocarditis complication), doxorubicin,tricyclics, thiamin deficiency.

Most common reason for cardiac transplant in adults.

- Hypertrophic cardiomyopathy is the most common cause of sudden death in young athletes (conduction defect in an asymmetrical hypertrophied septum).

""Thickness of septum, "contraction ! obstruction due to narrowing below the aortic valve (negative pressure behind blood flow sucks anterior leaflet).

"preload ! #amount of obstruction (#systolic murmur intensity).

Do not give digitalis. & blocker or Ca channel blocker are good.

- Restrictive cardiomyopathy: filling problem of the ventricle.

Endocardial fibroelastosis most common disease producing it in children and most common reason for a child to get a heart translation (will die otherwise).

Other reasons: Pompe’s disease, iron overload, amyloid (from RA for example).

- Cardiac myxoma: 85% in LA, 15% in RA. Benign, moveable (can block mitral valve orifice ! syncope), can embolize. Cause fever, neurological deficits.

Most common benign cardiac tumor in adults. Diagnosis by TEUS of LA.

- Most common benign cardiac tumor in kids in rhabdomyoma (associated with tuberous sclerosis).

- Pericardial effusion: water bottle configuration on X-ray. Beck’s triad: muffled heart sounds, on inspiration - neck vein distension (Kussmaul sign, normally collapse), pulse magnitude decreases (pulsus paradoxus), BP fall by 10mmHg. Diagnosis: echocardiogram. Most commonly due to pericarditis.

- Any young women with unexplained pleural and pericardial effusion has SLE untilproven otherwise.

- Constrivctive pericarditis: most common due to TB (3rd world countries), previous cardiac surgery (USA). Thick pericardium (no fluid) ! on inspiration, heart fills up !hit the wall and make a pericardial knock. Dystrophic calcification on X-ray.

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Respiratory:

- Ventilation is better on apex, perfusion is better on lower lobes.

Most infarcts are on the lower lobes, re-activation TB is in the apex.

- Aa gradient ~ 5mmHg, increase as we get older but not much.

Aa gradient > 30mmHg ! positive predictive value (must have a problem)

Increased in 1° lung disease (ventilation defects, perfusion defects, diffusion defects,PE). Extrapulmonary hypoxic diseases (respiratory center depression, upper airway obstruction, diaphragm paralysis) do not increase the gradient.

- Alveolar oxygen = 150 - pCO2/0.8 = 100, in normal situations.

- Nasal polyps: allergic (not in kids), or triad asthma (aspirin sensitive asthma.

Presented as a women with fibromyalgia or chronic headaches, because she’s taking a lot of NSAID for the pain).

- Allergic kids with a nasal polyp, do not have allergic polyp, they probably have CF !

perform a sweat test as first step of management.

- False vocal cords (upper) are covered by squamous epithelium, true vocal cords

(lower) are covered by ciliated pseudostartified columnar epithelium.

- Most common causes of laryngeal carcinoma: #1: smoking. #2: alcohol. Synergism effect - if use both, there’s a much greater risk to develop any SCC of the esophagus,larynx and mouth. Most common symptom is hoarseness.

- Epiglottitis with inspiratory stridor is most commonly caused by H. influenza.

Tracheal inflammation with inspiratory stridor ! Croup (parainfluenza virus)Both produce upper airway obstruction.

- Hyaline membrane disease (IRDS): surfactant deficiency ! massive atelectasis.

Massive ventilation defect (massive intrapulmonary shunt), perfusion is intact.

Causes: pre-maturity (before 32 weeks), mom’s diabetes (hyperglycemia of baby !

insulin release ! #synthesis of surfactant), C-section (stress is missing ! #ACTH +cortisol on the way out).

Mom with diabetes - macrosomia of the baby due to insulin which "adipose + musclemass. Also hypoglycemia at birth.

Glucocorticoids (give mom), thyroxin, prolactin - stimulate surfactant synthesis.

Commonly have PDA because of hypoxemia ! Machinery murmur.

PEEP therapy (positive end expiratory pressure) + surfactant treatment.

- Surfactant is produced in the lamellar bodies of type 2 pneumocytes.

- ARDS: septic shock is the most common cause ! 24 hours - dyspnea due to ARDS! 48 hours - bleeding from every orifice due to DIC.

Neutrophils get into the lund and destroy all the cells ! #surfactant ! collapse.

Neutrophils cause a leaky (pulmonary) capillary syndrome ! protein, fibrinogen gets into ! hyaline membrane.

- Pneumothorax: spontaneous - most commonly due to ruptured sub-pleural bleb.

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Lung collapse ! diaphragm goes up on that side, tracheal deviation to the same side of collapse. Tall thin patients. Scuba divers can get it from going up too fast.

Tension - most commonly due to knife injury/GSW to lung. Tear produced (not a hole)

! air goes into pleural cavity (flap open on inspiration) and stays there (flap close on

expiration). Increase in pleural pressure pushes the mediastinum (including SVC, RV,

RA) and lung to the other side ! compression atelectasis, compromise blood return

to the heart and breathing, diaphragm goes down.

- Pneumonia: community acquired - typical: sudden onset, Strep. Pneumoniae.

Pus in alveoli ! consolidation, micro abscesses, productive cough.

Consolidation signs - #percussion, "tectile fremitus, E to A sign - egophony (patients

says E, you hear A with stethoscope), whispering pectoriloquy (patients whisper, you

hear it very loud with stethoscope). Treatment - Penicillin G.

Atypical: slow and insidious onset, #1: Mycoplasma Pneumoniae, #2: Chlamydia

Pneumoniae. Interstitial pneumonia, no pus in alveoli, no signs of consolidation.

Relatively no productive cough, not high fever.

Nosocomial - E. Coli, Pseudomonas Aeruginosa, Staph. Aureus.

- Pleural effusion - only "percussion.

Viruses + bacteria:

- Rhinovirus is the most common cause for the common cold.

- RS is the most common cause for bronchiolitis ! whizzing. Most common cause of pneumonia in children.

- Influenza: antigenic shift - change completely, NA or hemagglutinin change (need new

vaccine). Antigenic drift - minor mutation. Vaccine is against influenza A.

- Chlamydia Psittaci - people who works with birds, parrots, turkey.

- Chlamydia trachomatis - whizzing a week after birth, "A-P diameter, no fever,conjunctivitis, staccato cough. Caused by infective cervix of the mom.

- Most common cause of conjunctivitis on the 2nd week is C. Trachomatis Most common overall cause of conjunctivitis is erythromycin drops.

- Pseudomonas - water loving bacteria (respirators), productive cough with green cod discoloration.

- Klebsiella Pneumoniae - common in alcoholics, high spiking fever, productive cough of mucoid appearing sputum. Can cause cavitations in upper lobe.

- Legionella - atypical pneumonia, unproductive cough, very sick. Water loving bacteria(water cooler, mists in grocery stores/restaurants).

Hyponatremia (interstitial nephritis, damages JGA ! #renin, # aldosterone).

Fungus:

- Candida - from indwelling catheters (subclavian) ! candida sepsis.

- Midwest (Ohio) - Histoplasmosis (tiny yeast - starlings, bats, cave explorers)NY - Cryptococcus (pigeons)Southeast - Blastomycosis (large yeast - skin, lung infections)

Southwest - Coccidioides mycosis (spherule with endospore - in dust, caves).

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- Actinomycin is the treatment for both Histoplasmosis and Cryptococcus (both related to bridges which have both pigeons and starlings)

- Histoplasmosis is the only systemic fungus that have yeast form in MP.

- Blastomycosis - broad based buds

- Aspergillus - likes to inhabit TB cavity (fungus ball = aspergilloma, common cause of massive hemoptysis), vessel invader (! thrombosis, infarction), allergy to the molds(instrinsic asthma). Corona, septated, budding, narrow angles.

- Mucor mycosis - nonseptated, wide angles.

- Pneumocystis - most common AIDS defining lesion (CD count < 200).

Prophylaxis with trimethoprim/sulfamethoxazole. “Ping pong ball” look under silverstain. Foamy bubbly alveolar infiltrate, dyspnea. Not just lungs, lymph nodes and more.

- Silver stain is used for - Bordetella, Legionella, Pneumocystis.

- Toxoplasmosis - most common cause of space occupying lesion (brain) in AIDS.

Described as “ring enhancing lesion”. Same treatment as for Pneumocystic.

- 1° TB - upper part of lower lobe, lower part of upper lobe. Ghon focus/complex.

Reactivation - apex, cavitary lesion.

Diagnosis of TB : acid fast staining which stains mycolic acid.

- Cavitation of upper lobe: Histoplasmosis, SCC of the lung, Klebsiella.

- Foreign body: standing - posterior basal segment of the right lower lobe Lying on the back - superior segment of right lower lobe.

Lying on right side - middle lobe or posterior segment of right upper lobe Lying on left side - lingula.

- Most common cause of an abscess (aerobes + anaerobes) in the lung is aspiration of oropharyngeal material. Common in homeless. Fluid cavity on X-ray.

Also from pneumonia (Staph. Aureus, Klebsiella), but less common.

- PE: can be little ones (! wedge shaped hemorrhagic infarction if you have underlying lung disease) or huge one (saddle embolus ! knocks off orifices of the pulmonary arteries, if it blocks 3 out of 5 ! immediate death).

Most originate from femoral vein.

Screening test of choice: ventilation-perfusion scan (have ventilation, no perfusion),and confirm it with pulmonary angiogram.

- Deep veins of lower legs are the most common site of thrombosis but not emboli.

- Restrictive lung disease: restriction in filling up the lung with air (fibrosis).

#compliance (filling term), "elasticity (expiration term), all volumes#

#FEV1 (normal is 4 liters, here 3), #FVC (normally 5, here 3), "FEV1/FVC(normally 0.8, here 1).

- Pneumoconiosis: coal worker’s - anthracotic pigment which sets off a fibrotic reaction in the lung. Increase incident of TB, not cancer.

Silicosis - sand, rock, dust related. Big nodules, hard as rock (looks like metastases).

Increase incident of TB, not cancer.

Caplan’s syndrome - rheumatoid nodules of rheumatoid arthritis (like on the arm) in the lung + pneumoconiosis.

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Asbestos - roofer, shipyard. ferruginous body = asbestos body (iron coated fiber).

Most common pulmonary lesion associated with it is fibrous plaque of the pleura.

The most common cancer associated with it is: #1: 1° lung cancer,

#2: mesothelioma. If you also smoke, there’s a incredibly higher chance of getting 1°

lung cancer. There is no equivalent relationship with mesothelioma.

- Sarcoidosis: non-caseating granulomatous disease that has no connection to infection.

No known cause. Lung always involved (interstitial fibrosis).

More common in blacks. Bilateral hilar node enlargement. Face + neck involvement:

uveitis (uveal tract ! blurry vision), salivary or lacrimal gland enlargement. Diagnosis of exclusion (TB, histo). Steroid treatment.

ACE is very high (granulomas have it), hypercalcemia (epitheloid cells synthesize 1-(-

hydroxylase ! hyper Vit D). Most common non-infectious cause of granulomatous

hepatitis (2nd - pneumoconiosis).

- Hypersensitivity pneumonitis: Farmer’s lung - Thermophilic Actinomycetes.

Sitophilus disease - also in farmers. Fermented into NO2 ! wheezing, dyspnea.

Byssinosis - textile industry. Sick all week, better on weekends.

- Good pasture - starts in lungs (restrictive, hemoptysis), ends in kidneys.

- COPD: no problem getting air in, problem getting air out. Elastic tissue support is

destroyed. Can’t get all the air out ! "Residual volume, "TLC ! diaphragm

depressed, increased A-P diameter ! #tidal volume, #vital capacity.

##FEV1 (1 liter), #FVC (3 liters), !#!FEV1/FVC (0.33).

- Chronic bronchitis: clinical diagnosis - patient has cough 3 months out of a year for 2

consecutive years. Disease of terminal bronchioles (also for asthma, bronchiolitis),

proximal to that - mucus gland hypertrophy.

Ventilation-perfusion mismatch ! can’t get rid of CO2 due to mucus plugs in the

terminal bronchioles ! Blue Bloaters (cyanotic).

- Trapped air on X-ray - can be due to bronchiolitis in little kids (RSV) or new born with

Chlamydia Trachomatis or emphysema.

- Emphysema: respiratory unit disease (where you can exchange gas, you can’t exchange in the terminal bronchioles). Also destroy the vasculature associated with it! even loss of ventilation + perfusion! no CO2 retention ! pink puffers.

Centrolobular - most associated with smoking. Upper lobe emphysema. Primary portion of the respiratory unit that gets ruined is the respiratory bronchioles.

High amount of neutrophils (smoking is chemotactic to neutrophils), not enough (-1-antitrypsin (acquired deficiency, smoking denature it).

Panacinar - entire respiratory unit is destroyed. Lower lobe emphysema.

No (-1-antitrypsin at all (AR, liver doesn’t make it).

Smokers can get cetrolobular emphysema on upper lobe and panacinar emphysema on the lower lobe.

- Bronchiectasis: bronchi extending to the pleura (further than the hyaline). Infection !destruction of elastic tissue support ! dilatation of airways ! fill up with pus.

Productive cough, “cup full” of pus.

CF is the most common cause in the US. In 3rd world countries it’s TB.

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- Immotile cilia syndrome = Kartagener syndrome (absent dynein arm ! all places with cilia are effected ! sinusitis, bronchiectasis, infertility (fallopian tube needs cilia to carry the egg, sperm needs cilia for tail), organs being located on the other side(dextrocardia) or organ shifts.

- Asthma: extrinsic (type 1 H-S), intrinsic (chemical involvement like NSAID - triad asthma, exertional asthma, cold temperature). Inflammation of terminal bronchioles

due to LTC/D/E4 + PG ! narrowing ! wheezing.

- Cancers: centrally (highest association with smoking) - SCC, small CC.

Peripherally - adenocarcinoma (most common): 4 types, 1 has smoking relation, the

rest don’t (bronchiolo-alveolar carcinoma, large CC).

- PAP smear (for cytological specimens) - stains carotene bright red ! SCC.

- Small CC: looks like lymphocytes, most malignant, no surgery, only chemo.

Neurosecetory granules (S100 antigen), produce ADH, ACTH.

- Bronchio-carcinoid: low grade malignancy, can metastasize, can produce carcinoid

syndrome if make enough serotonin (no need to metastasize).

- Most common cancer of the lung is metastases. Most commonly from breast.

- Pancoast tumor: posterior upper lobe, usually SCC. Invade the lower parts of the brachial plexus and superior cervical ganglion ! Horner’s syndrome (sup. sulcus

syndrome): lid lag (ptosis), no sweating (anhidrosis), pupil contraction (miosis).

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GI

- Plummer-Vinson syndrome: iron deficiency anemia, dysphagia, koilonychia,

esophageal web, and atrophic glossitis. Premalignant (SCC of the cricopharyngealregion).

- Dysphagia - Solid: obstruction (PVS, cancer).

Both: peristalsis (myesthesia gravis in upper one third of esophagus or sclerodermapSS)/CREST/achalsia in lower esophagus).

- Achalsia: vomit when they go to bed at night.

- Candida esophagitis is the most common cause of odynophagia in AIDS patients (It’s

AIDS defining when it’s in the esophagus).

- Tracheo-esophageal fistulae (proximal is blind end, distal from trachea) or duodenal

atresia of the baby cause Polyhydramnios for the mom.

- VATER association: Vertebral anomalies, Anal malformations, Tracheo-Esophageal

fistulae/atresia, Radial and Renal anomalies.

- Achlasia: ganglion cells are destroyed ! damages movement (peristalsis) of LES +

reduce VIP levels (VIP relaxes the LES) ! constant constriction of the LES.

- Chagas disease (Reduviid bug = kissing bug): AQUIRED achalasia (megaesophagus)

and AQUIRED Hirschsprung (megacolon).

Other clinical features: Romana sign, myocarditis, CHF, DCM.

- Distal esophagus = Adenocarcinoma, middle esophagus = SCC.

- Left gastric vein (branch of portal vein) drains distal esophagus and proximal stomach! responsible for esophageal varices in portal hypertension.

- Mallory-Weiss syndrome: tear in the lower esophagus or cardia from prolonged

vomiting.

Boerhaave's syndrome: spontaneous rupture/puncture of a non-diseased esophagus

from vigorous vomiting. Respiratory symptoms.

Both usually caused by Bulimia or alcoholic patient with retching (vomiting without vomit)

- Congenital pyloric stenosis: non bile stained vomit a few weeks after birth,

hyperperistalsis, and right upper quadrant mass. Pyloroplasty treatment.

- Duodenal atresia: “Double bubble” sign - one in stomach, one in proximal duodenum(air trapped bubble). Bile stained vomit at birth.

- H. pylori (comma shaped): produces urease (makes ammonia) and cytokines.

Serology is good for first diagnosis but doesn’t help for recurrent episodes.

Cause atrophic gastritis in the pylorus and antrum.

- Most gastric cancers are along the lesser curvature of the pylorus and antrum (like

gastric ulcers). Most common cause is H. Pylori (also cause gastric lymphoma)

- Pernicious anemia (parietal cells) is in the Body and Fundus.

-Duodenal ulcer is never malignant (never biopsy). Gastric ulcer may be.

- Melena: upper GI bleed, black stool due to conversation of Hb to hematin.

- Stress ulcer (usually duodenal): severe epigastric pain radiates to left shoulder (same

dermatome, referred pain) from irritated diaphragm, because of air coming out from perforated ulcer. Can see air under diaphragm.

- Dermatitis Herpetiformis has a 100% association with Celiac Disease.

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- Foamy macrophages in the lamina propria ! Whipple Disease.

In an HIV patient, we should suspect Mycobacterium Avium-Intracellulare which

produces a whipple LIKE syndrome.

- Alcoholics have malabsorption for two reasons: chr. pancreatitis (lipase def.) and/or

cirrhosis (bile salt def.).

- Fecal smear for leukocytes ! positive for neutrophils ! take a culture to identify

micro organism ! suggest invasive diarrhea (low volume diarrhea) and not secretory

or osmotic (high volume diarrhea).

- Lactase def. = disaccharidase enzyme def. = brush border enzyme def.

- Traveler’s Diarrhea = ETEC

- Fluid replacement for Cholera patients must include glucose (for the Na-Glc

co- transporter)

- ETEC & Cholera are NON invasive (bowel biopsy is normal, no inflammation), just a toxin stimulating a pump.



- Camplyobacter Jejuni is the #1 cause of diarrhea (coma shape).



- Giardia lamblia is the #1 parasitic cause of chr. diarrhea (metronidazole treatment).



- Cryptosporidium parvum is the most common organism associated with AIDS diarrhea



(partially acid fast).



- Shigella, C. jejuni, C. difficille can all produce a pseudomembrane.



- #1: Ampicillin, #2: Clyndamicin cause pseudomembranous colitis (diagnosis: toxin



assay of stool, treatment: metronidazole, used to be vancomycin).



- Colicky pain (with pain free intervals) = TOTAL obstruction of the small bowel.



- Obstipation (complete intestinal obstruction) = constipation + not passing gas.



- Down syndrome, GI related: duodenal atresia and Hirschsprung disease (no stool in



rectal ampulla)



- Adhesion (from previous surgery) and indirect inguinal hernia (no history of surgery)



are the two major reasons for colicky pain (obstruction).



- Intussusception (terminal ileum goes into the cecum): bloody stool, colicky pain, young



child, Dance sign (mass in right upper quadrant)



- Gallstone Ileus: fistulae (between gallbladder and small bowel), colicky pain, ileuocecal



(usually) obstruction, older people, air in billiary tree.



- Cystic fibrosis: meconium ileus.



- Small bowel (single blood supply) infarcts (diffuse abdominal pain) are more



common than the large bowel (double blood supply) infarct (localized pain).



- Ischemic colitis = localized pain (e.g splenic flexure) + bloody diarrhea.



- Most common cause of hematochezia (bloody stool): #1: diverticulosis,



#2: angiodysplsia (related to aortic stenosis & Von Willebrand disease).



- Meckel’s diverticulum is persistence of the vitelline duct. 2 feet from ileuocecal



junction, 2 inches long, 2% of population.



Most common complication of is bleeding (! hematemsis, hematochezia).



Also: right lower quadrant pain, diverticulitis.



- Sigmoid colon is the most common location for GI cancer, hemartoma, polyps (into the



lumen) and diverticuli (out of the lumen).



- Most common complication of diverticulosis is diverticulitis (“left sided appendicitis”:



pain, fever, neutrophilic leukocytosis, rebound).



- Most common fistulae are the colo-vesical fistulae (causes pneumaturia).



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- Fistulae can rupture and cause peritonitis.



- Crohn’s disease involves terminal ileum 80% of times. It doesn’t cause hematemesis.



Produces fistulae in anus. Transmural. Skip lesions, segmental. Colicky right lower



quadrant pain with diarrhea in a young person (TB in 3rd world country). Cobble stone



(fissuring) appearance, linear ulcers. Non caseating granuloma.



- UC mainly in rectum (always begin there). Produces bloody diarrhea. Mucosa + sub



mucosa. No Skip lesions. Pseudopolyps (residual inflamed bloody mucus). High



association with cancer. Most common cause of primary sclerosing cholangitis



(around common bile duct) ! obstructive jaundice, cholengial carcinoma.



- Tubular adenoma (precursor lesion of colon cancer) = “strawberry on a stick”.



- Mass coming out of the butt: in children – juvenile polyp (hemartoma, not precancerous),



in adult – prolapsed internal hemorrhoids.



- Internal hemorrhoids bleed, not painful, prolapse.



External hemorrhoids thrombosis and painful.



- Villous adenoma have the greatest malignant potential (50% chance), secretes



mucus, seen on stool. Tubular adenoma are precursors also, dangerous over 2 cm.



- Familial polyposis is characterized by over a 100 polyps. Autosomal dominant, APC



involved. Always get cancer (age 35-40), prophylactic removal of bowel.



- Autosomal dominant diseases are characterized by late manifestations, penetrance,



and variable expressivity.



- Turcot's syndrome = polyposis coli + brain tumors (autosomal recessive).



- Gardner’s syndrome = polyposis coli + soft tissue and bony tumors.



- All carcinoid tumors are malignant but have low grade potential (depend on size !



greater than 2 cm ! metastasize).



Most common location that cause carcinoid syndrome is terminal ileum (>2cm).



Most common location that doesnt cause it is tip of the appendix (yellow, <2cm).



- Carcinoid tumors produce serotonin (metabolized by liver). Hepatic metastasis !



Escapes metabolism ! #1: flushing, #2: diarrhea.



Also: tricuspid insufficiency, pulmonary stenosis (TIPS). Tryptophan def. (use it to



make serotonin) ! niacin def. ! pellagra (diarrhea, dermatitis, and dementia).



- Colon caner: left side obstructs (! constipation, diarrhea), right side bleeds (! iron



def.).



- CEA used to follow for recurrence of colon cancer, not for diagnosis.



- Pathogenesis of acute diverticulitis and acute appendicitis (fecolith) and acute



cholecystitis (stone) are the same: pressure ! ischemia ! E. coli invasion !



inflammation.



- Most common cause of acute appendicitis in children is measles or adenovirus.



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Liver:



- Urobillin (oxidized urobilinogen) gives the color to both urine and feces.



- Unconjugated hyperbilirubinemia (<20% conjugated), hepatitis (20-50%), conjugated



hyperbilirubinemia (>50%, obstruction, light stool + dark urine).



- Gilbert’s disease: autosomal dominant, uptake failure and/or conjugation failure.



Jaundice appears only after 24 hour fasting (bilirubin doubles in blood).



- Most common cause of Jaundice: #1: Hepatitis A, #2: Gilbert.



- Dubin-Johnson (black color pigment in liver), Rotor: Autosomal recessive. Defective



excretion of conjugated bilirubin.



- ALT (more specific), AST (also RBC, muscle) elevated, PT elevated, albumin



decreased in diffuse liver necrosis.



- Alcoholic liver disease: AST (mitochondria) > ALT (cytosol), (GT#



Viral hepatitis: ALT > AST.



- Obstruction: alkaline phosphates (also bone, placenta), )GT (synthesized in sER), 5



nucleatidase (less important) elevated. ALT, AST elevated but to lesser degree.



- Hepatitis A, B, C, D, E – common at that order (A - most common, so forth).



- Hepatitis A can never become chronic (E only chronic in pregnancy).



- Anti HAV IgM - have it, anti HAV IgG - had it, protective.



Anti HCV IgG - have it, anti HDV IgG - have it.



Protective - anti HAV IgG, anti HBV surface antibody, anti HEV IgG.



- Hepatitis B markers by order of appearance: 1. S antigen (asymptomatic, last to



disappear), 2. E antigen + HBV DNA (both: only infective ones, disappear first), 3.



Core antibody IgM (only marker during window period: not infective, had it, during



recovery. Becomes IgG later on), 4. Surface antibody (about a month after surface



antigen is gone).



- Acute Hepatitis B: S antigen, E antigen, HBV DNA, core antibody IgM.



- Vaccination = only surface antibody



- Recovered from disease = surface antibody, core IgG



- Chronic hepatitis = Surface antigen over 6 months.



- Infective = S antigen, E antigen, HBV DNA.



- Healthy carrier = surface antigen, core IgM.



- (IFN therapy for infective patients (good chance of full recovery), NEVER give



corticosteroids for viral hepatitis.



- Entamoeba histolytica: resistant to acid, ex cyst in cecum (alkaline), produce chemical



that drills holes in mucosa ! ulcer, bloody diarrhea, can penetrate liver and cause



abscess (also in lung, brain). Trophozoites contain RBC. Metronidazole treatment.



- Echinicoccus multi/unilocularis (Ship herder’s disease): Definitive host (dog) – has



sexually active worms, can lay eggs (develop to larvae). Intermediate host (sheep,



human) – only larvae (end stage in intermediate, can become adult in definite). If cyst



rupture and fluid gets to abdominal cavity ! anaphylactic shock.



- Taenia Solium: 1. Larvae in pig (intermediate host), eaten by human (definite host),



develops to adult. 2. Eggs eaten by human (intermediate host) develop into larvae =



cysticerci ! cysticercosis (eye, brain cyst which calcify ! seizures).



- Most common complication of corticosteroid treatment is cataract.



- Nutmeg liver (big & congested) is a consequence of right sided HF



45



- Portal vein thrombosis ! portal hypertension, ascites, varices, NO nutmeg liver (since



it’s a pre hepatic).



- Budd Chiari syndrome (heptic vein thrombosis): #1: polycythemia vera, #2: oral



contraceptives. Can cause Nutmeg liver (post hepatic), death with no surgery.



- Fatty change (alcohol) is reversible. Alcohol hepatitis results in death if consumption is



not stopped. Mallory bodies appear in both.



- Acetaldehyde-protein complex stimulate Ito cells (normally stores Vitamin A) to make



collagen ! cirrhosis.



- Cholestasis: deep green liver (from bile backflow), light stool, dark yellow urine (from



conjugated bili), hypercholesteremia, itching (bile salt deposit), AP", )GT".



- Primary biliary cirrhosis cause late jaundice because of triad reserve.



Anti mitochondrial antibody for diagnosis.



(Hashimoto thiroiditis – anti microsomal antibody for diagnosis)



- OC + anabolic steroids have same effect on liver - intrahepatic cholestasis (!



jaundice), hepatic adenoma (may rupture ! intraperitoneal hemorrhage).



- Pregnancy jaundice (due to estrogen effect) disappears after pregnancy.



- Intraperitoneal hemorrhage during pregnancy can be caused by ruptured ectopic



pregnancy or ruptured hepatic adenoma (caused by OC taken before pregnany).



46



GYN:



- Hirsutism - excess of hair in normal hair bearing areas.



Virilization - hirsutism + male2nd sex charectristics (acne, deeper voice, cliteromegaly).



Spironolactone can treat hirsutism, can cause gynecomastia.



Most testosterone in a women is from the ovary. DHT-sulfate (androgen) is mostly



from the adrenal. If we check both levels, we can determine the hirsutism origin: "



DHT-sulfate ! andreno-genital sysdrome, cushing. "Testosterone ! polycystic



ovarian syndrome, ovarian stromal hyperplasia, ovarian tumor.



- PCOS: FSH suppressed ! "LH ! 17-keto-steroids synthsis (DHEA,



androstenedione) around the developing follicle ! converted into testosterone !



goes into granulosa cells where aromatase is presented ! estradiol ! hirsutism.



Aromatase also present in adipose ! obese women produce estrogen there.



"estrogen ! risk of andometrial hyperplasia and carcinoma ! #FSH, "LH.



Can break this cycle with OC since it has progesterone to inhibit LH.



!FSH, "aromatase activity ! follicle degenerate, cystic space where it used to be.



Can be felt sometimes by rectal exam or seen with US.



- Dysmenorrhea: primary - due to "PGF ! "uterine contraction.



Secondary - due to endometriosis.



- Dysfunctional uterine bleeding: not related to organic or anatomical cause



(endometrial polyp or cancer). Hormone imbalance.



3 causes: anovulatory cycles (most common in women from menarche to 20 years.



Due to "estrogen, #progesterone ! endometrial hyperplasia ! sloughed off !



bleeding), inadequate luteal phase, irregular shedding of the endometrium.



Amenorrhea: primary, secondary. Hypothalamus-pituitary problem, ovarian problem,



end organ problem (menses is fine, anatomical reason - no vagina, hymen not



perforated, cervical stenosis + stenosis - Asherman’s syndrome, from injury). First



step of diagnosis of amenorrhea is pregnancy test.



FSH, LH levels: high - hypothalamus-pituitary, low - ovarian, normal - end organ.



- Turner’s syndrome (XO): diagnosis at birth by physical exam - defects in lymphatics !



sweeling of hands and feet in newborn female (lymphedema).



4th metacarpal has a dimple, instead of a knuckle when you make a fist (“knuckle,



knuckle, dimple, knuckle” sign). Cystic hygroma - dilated lymphatics in neck area !



strech the skin ! webbing of the neck skin. Preductal coarctaion, no mental



retardation, all their ovarian follicles are gone by age 2 (“streak gonad”, susceptible to



dysgerminoma), amenorrhea. If mosaic, can be fertile.



- Knuckle, knuckle, dimple, dimple (K-K-D-D) - pseudohypoparathyroidism.



- Adenomyosis - glands and stroma in the myometrium. Cause of dysmenorrhea,



dyspareunia, menorrhagia. Hysterectomy because uterus is very big.



- Endometriosis - functioning gland and stroma outside the uterus. Most common



location is ovary ! bleeding (“chocolate cyst”). Other: fallopian tube, Douglas pouch.



Pain in defecation while having period, gone when period gone.



47



Theories: reverse menses (endometrial tissue while being sloughed off, reverse



through fallopian tubes and spread), surface epithelium in peritoneum metaplasticly



make endometrial mucosa, hematogenous-lymphatic spread.



- Endometrial hyperplasia - unopposed estrogen (PCOS, early menarche, late



menopause, obesity). Most common cause of endomaterial cancer.



- Pouch of Douglas: painful defecation in endometriosis, collect seeding in ovarian



cancer, collect pus in PID, collect clotted blood in ruptured ectopic pregnancy.



- Obesity (associated with DM-II): "risk of breast, ovarian, endometrial cancer.



- Age: 45 - cervical, 55 (post menopausal) - endometrial, 65 - ovarian.



- Any women whose been in menopause for over a year and has bleeding, has



endometrial cancer until proven otherwise. Do endometrial biopsy.



- Any women over 55 with palpable ovaries, have cancer until proven otherwise.



- Leiomyoma is not a precursor of leiomyosarcoma.



- Ectopic pregnancy - sudden onset of lower abdominal pain. Do pregnancy test.



- Ovarian masses: surface derived tumors (lining of the ovary) - serous cystadenoma,



serous cystadenocarcinoma - most common benign and malignant tumors of ovary



respectively, most common bilateral tumors. Adenocarcinoma has psammoma bodies



(apoptosis replaced by dystrophic calcification).



germ cells tumors (like in men) - cystic teratoma is the most common germ cell tumor



(usually benign).



sex cords stromal tumors - granulosa cell tumor (low grade malignancy) produce



estrogen (! hyperestronism ! bleeding), sertoli-leydig cell tumor produce androgens,



fibroma (Meig’s syndrome - fibromyoma, ascites, right sided pleural effusion).



- Men have mainly germ cell tumors.



- Most common cause of ovarian mass in young women is follicular cyst (palpable



mass). Cause sudden onset of pain, can rupture ! peritonitis.



- DD of sudden onset of right lower abdominal pain - ruptured ectopic, appendicits, PID,



ruptured follicular cyst. Do an US, &-hCG.



- Psamomma bodies: papillary carcinoma of the thyroid, meningioma, serous



adenocarcinoma of the ovary.



- Signet ring cells in the ovary ! metastases from the stomach (Krukenberg tumor).



- Syncytiotrophoblast (chorionic villi outer layer) produces &-hCG, HPL.



- Hydatidiform moles: complete (46 XX, both X from dad), partial (69, can have fetus



present). Benign tumors of chorionic villi.



- Causes of choriocarcinoma: 50% - complete mole, 25% - spontaneous abortion, 25%



- normal pregnancy. Malignancy of the trophoblastic tissue (no villi). Metastases to



lung, responds wonderfully to chemotherphy.



- Nipple ! Paget’s disease.



Lactiferous ducts ! intraductal papilloma (most common cause of bloody nipple



discharge in women under 50).



Major ducts ! most breast cancer (invasive ductal, medually, mucinous)



Terminal lobules ! lobular cancer (bilateral), not picked up by mammograpy.



- Most common cause of a breast mass in a women under 50 is fibrocystic change.



48



Most common cause of a breast mass in a women over 50 is cancer (infiltrating



ductal carcinoma ! late diagnosis).



Most common cause of a moveable breast mass in a women under 35 is



fibroadenoma (cycle progression).



- Fibrocystic change: lumpy bumpy feel, painful (estrogen sensitive, worst as the cycle



goes on), ductal hyperplasia (estrogen sensitive epithelial cells), sclerosing adenosis



in terminal lobules.



- Fibroadenoma: neoplastic component is the stroma. Very common. Still perform



needle biopsy ! if positive, take it out.



- Invasive cancer: nipple sucked down, very hard. When cancer invades stroma !



fibro+elastic tissue response ! makes it palpable mass, painless.



Stellate appearing whitish mass, density on mammograpy, calcification.



- Painful, under 50 - inflammatory lesion (fat necrosis)



- Outer quadrant is the most common location (most breast tissue is there).



2nd most common is around the aerola.



- First step in management of a palpable mass in the breast is FNA (gives diagnosis



and can tell whether it’s solid or cystic. US only gives the latter).



First step in management of a cold nodule in the thyroid is FNA.



- Comido carcinoma (zit like): when you cut across, caseous necrosis comes out. erb2



oncogene, aggressive cancer, invasive.



- Indian filing - invasive lobular cancer, infiltrating ductal cancer (more common).



- Paget’s disease - rash on the nipple, cancer of the duct underneath that spread to the



skin.



- Inflammatory carcinoma: worst. Dimpled skin because the lymphatics are plugged



with cancer ! leaks out ! peau d’orange.



- Winged scapula (cutting the long thoracic nerve) is the most common complication



of modified mastectomy. Lumpectomy - removing underlining tumor with a border and



take nodes for staging, then do radiation (same prognosis as modified mastectomy but



saving the breast, good if fits the criteria).



- Estrogen/progesterone receptor essay: young women have ERA, PRA negative



because estrogen levels are high and there’s down regulation of receptor.



Tumor responding to estrogen (older women, ERA positive) ! give tamoxifen (weak



estrogen) hooks into the receptor, so estrogen can’t. Side effects: menopausal type



symptoms, "risk of endometrial cancer, prevent osteoporosis.



49



Endocrinology:



- Most reasons for over activity, cannot be suppressed. Exceptions: prolactinoma



(bromocryptin - dopamine analogue, suppresses it), pituitary cushing (high dose



dexamethasone suppresses it).



- #cortisol, which is not increased by ACTH (checked by 17-hydroxycorticoids in the



urine) ! Addison’s disease. If does increase ! hypopituitarism.



- Hypopituitarism: most common causes in adults are #1: pituitary adenoma,



#2: post partum couagulation necrosis (ischemia due to hypotensive episode during



delievery) = Sheehan’s syndrome. Sudden breast milk stops.



In children, craniopharyngioma is the most common cause. It is suprasellar, goes



forward and damages the optic chiasm ! bitemporal hemianopsia (visual defects)



- Decrease of hormones is in specific succession: gonadotropins (amenorrhea,



impotence) ! GH (adult - muscle mass loss, fasting hypoglycemia, child - dwarfism)



! TSH (hypothyroidism) ! ACTH (hypocortisolism - fatigue, fasting hypoglycemia) !



prolactin (in non pregnant - you won’t notice)



- GH is mostly released aroung 5AM, so sleep is the best stimulation test (check IGF-1).



Arginine, lysine stimulate GH.



- Diabetes insipidus: polyurea, polydipsia. Central - lacking ADH (car accident, sever



your stalk ! initially only DI, later complete hypopituitarism).



Nephrogenic - have ADH, doesn’t work.



Restrict water - normal: plasma osmolality goes up to 290, urine - 750.



abnormal: plasma ~ 315 (hypernatremia), urine ~ 100. To differ we give ADH,



if increase over 50% ! central, if not ! nephrogenic.



- Cheapest way to screen acromegaly is through an old picture.



Gigantism - "GH, "IGF ! linear growth (death of cardiomyopathy).



Acromegaly - epiphysis closed so only wide growth (frontal lobe, hands, feet)



- Causes for galactorrhea (only women) - OC, hydralazine, Ca channel blockers,



psychotropic drugs, 1° hypothyroidism ("TRH ! stimulates prolactin, used as a test).



Prolcatin > 200 ! prolactinoma. Nipple stimulation (bra!) can cause it.



2° Amenorrhea, because prolactin inhibits GnRH (temporary birth control…)



- Thyroid: TSH is the most important screening.



Estrogen increases TBG (thyroid), transcortin (cortisol) ! "T4, normal TSH (free



hormone levels are normal), "cortisol, normal ACTH (normal free cortisol levels).



Anabolic steroids (need AA supplements for it to work) decrease TBG ! #T4, normal



TSH.



- I-131 uptake test: hyperthyroidism (Grave’s) ! increase uptake.



Excess oral thyroid hormone to lose weight ! decrease uptake (gland atrophy).



- Midline cyst - thyroglossal cyst, antero-lateral neck - brachial cleft cyst.



50



- Grave’s disease: exophtalmus (pathognemonic) apathetic, atrial fibrillation (any



patient with AF, you must take a TSH level). Heat intolerance, sinus tachycardia,



diarrhea, systolic HT, hypercalcemia ("bone turnover) - all symptoms are



catecholamine related (thyrosin !!! NE). Initial treatment: &-blockers (stops all



symptom except sweating). Later: propylthiouracil. T4", TSH#, I-131 uptake".



IgG Ab against TSH receptor ! continued stimulation (in hashimoto, the IgG Ab



inhibits the gland).



Excess of GAG deposition - periorbital edema, horse throat, pretibial mixedema (also



in hashimoto).



- Mitral valve prolapse is another disease related to GAG excess.



Lysosomal storage diseases are related to GAG decrease.



- Hypothyroidism: muscle weakness ("CK), brittle hair, periorbital edema, coarse skin,



mental slowness, delayed Achilles reflex, constipation, diastolic HT.



#T4, "TSH, #I-131 uptake (usually not done in hypo)



- Thyroid hormone is responsible for brain development after birth (year+).



- Most common cause of goiter is idodine deficiency.



Treatment of choice for goiter is thyroxine.



Sudden increase in size is a hemorrhage from within a cyst/nodule in the goiter.



- Hot nodule: taking up I-131 (black dot in the nodule location, nothing else).



- Cold nodule: not taking up I-131(the nodule is an area of lucensy).



In a women - 15-20% is malignant. Most are cyst, some are adenoma.



In men and children, it’s malignant until proven otherwise.



Any person who was exposed to radiation to neck area with cold nodule ! papillary



carcinoma of the thryroid - psammoma bodies, cervical lymph node metastases, good



prognosis.



- Follicular carcinoma: hematogenous to bone and lungs (not to lymph nodes)



- Medullary carcinoma - sporadic or AD (MEN syndrome). ret associated with it,



calcitonin tumor marker is converted into amyloid. Worst prognosis.



- Calcium metabolism: Most common cause of hypocalcemia is hypoalbuminemia.



Alkalosis ! #H ! more COO+ groups on albumin ! binds more Ca ! total body Ca



normal but ionized Ca is decreased ! #threshold for activating the nerve of the



muscle ! easier to activate the muscle ! tetany (Trouseau sign)



- #Ca, #PTH ! 1° hypoparathyroidism (previous thyroid surgery)



Newborn, cyanosis, irritable ! Di George syndrome.



!Ca, "PTH ! 2° hyperparathyroidism (renal failure)



"Ca, #PTH ! 1° hyperparathyroidism !#P. Mostly asymptomatic, if symptomatic -



usually stones. Most common in women, almost always > 50.



#Ca, #PTH ! all other reason for hypercalcemia, usually malignancy (renal



adenocarcinoma, SCC of lung, MM, bone metastases - lytic, sarcoidosis).



51



- Cushing’s: purple striae, central obesity, thin extremities.



Most common cause is long term steroid therapy (renal transplant, SLE), when that’s



excluded: pituitary, adrenal (lowest ACTH), ectopic (highest ACTH).



Screening test: 24 hour urine for free cortisol (not attached to any protein), will differ



cushing’s (high) from cushingoid.



Dexamethasone (cortisol analogue) suppression test: high dose dexamethasone



suppress ACTH release from pituitary cushing’s (not for other 2 types).



Cortisol is GNGenic, need AA from muscle (thin arms, legs), "glucose ! "insulin !



"fat storage (moon face, buffalo hump, trunkal obesity). Sterch marks due to the



obesity, purple because cortisol decreases collagen synthesis.



- Hyperaldosteronism (Cohn’s syndrome): HT, hypernatremia, hypokalemia, alkalosis,



tetany.



- Adrenal medulla tumors: pheochromocytoma (adults, benign), neuroblastoma (kids,



malignant), both cause HT. Both are neural crest origin.



Unstable HT, anxious, lots of sweat ! check 24 hour urine metanephrin & VMA.



Pheochromocytoma: associated with MEN2A, MEN2B, neurofibromatosis.



- Waterhouse-Friderichsen syndrome: caused by Neisseria Menigitidis (most common



cause of meningitis in 1month-18 years, only meningitis with petechial lesions).



Hypotensive shock (hemorrhagic adrenals ! no cortisol + aldosterone)



- Most common cause of chronic hypocortisolism is Addison’s diseae, which is most



commonly due to autoimmune disease (used to be miliary TB).



Addison’s disease destroys all the adrenal cortex ! "ACTH ! "melanin !



hyperpigmentaion, especially in the mouth.



#Aldosterone ! salt losing ! hyperkalemia ! peak T waves, metabolic acidosis.



- Ambiguous genitalia: first step in management is chromosome analysis to find out



genetic sex. Adrenogenital syndrome usually due 21-hydroxylase deficiency.



- 17-keto-corticoids: androstendione, DHEA (weak androgens)



17-hydroxy-corticoids: 11-deoxy cortisol, cortisol



- 21 hydroxylase deficiency: #mineralcorticoids, #17-hydroxy, "17-keto !



salt losing, hyperpigmentation, girl - ambiguous genitalia.



- 11 hydroxylase deficiency: #cortisol, #corticosterone, #aldosterone, "11-deoxy



corticosterone, "11-deoxy-cortisol, "17-keto ! girl - ambiguous genitalia,



boy - precocious puberty, salt retainer ! HT.



- 17 hydroxylae deficiency: #17-keto, "17-hydroxy, "mineralocorticoids ! HT, boy -



no testetosterone ! female external genitalia, girl - underdeveloped.



- Islet cell tumors: ZES - "gastrin ! peptic ulcers. Insulinoma - C-peptide is increased.



If you inject insulin ! "insulin, #glucose, C-peptide is suppressed.



52



- Diabetes: type 1 - absolute insulin deficiency, Ab against islet cells (insulitis),



ketoacidosis, HLA relationship (means there’s a predisposition to develop under the



right trigger - coxsackie, mumps, EBV), always have to use insulin.



Type 2 - family history, obesity, hyperosmolar nonketotic coma, amyloid in the islet



cells, eventually when get resistant to sulfonylurea - use insulin.



Mechanisms: osmotic damage in tissues with aldose reductase - sorbitol sucks water



into the lens, pericytes in retinal vessels become weak ! microaneurysms !



blindness, schwan cells ! peripheral neuropathy.



Non enzymatic glycosilation ! basement membrane permeable to proteins !hyaline



arteriolosclerosis, diabetic nephropathy, Hb A1C.



Fasting glucose > 126mg/dl on two seperate occasions ! diabetes (used to be 140,



so now it’s increased sensitivity).



- Gestational diabetes - mom didn’t have diabetes before pregnancy, now she does.



It is a risk factor for baby to get - RDS, premature delievery. Mom is in increased risk



to develop diabetes further on in life.



53



Musculoskeletal & skin:



- Crystals in synovial fluids can be seen in: gout - needle shape (mono-Na urate).



pseudogout - 2 crystals types, rhomboid & needle shape. " joint space, no erosion.



Get a sample of synovial fluid, put a red filter into it which makes the background red,



and the crystals blue (east-west direction, parallel to analyzer) ! pseudogout or



yellow (north-south direction, parallel to analyzer, mono-sodium urate) ! gout.



- Arthritis - Oteoarthritis (most common): wearing down of articular cartilage.



Osteophyte is a reaction to injury from that constant wearing down ! Heberden’s



node (DIP joints), Bouchard’s node (PIP joints). Worse as day progresses.



Rheumatoid arthritis: involves the MCP, PIP joints. Inflammatory joint disease



caused by rheumatoid factor (IgM Ab against IgG) in the synovial fluid ! activate



complement, neutrophils come in ! damage the joint ! synovitis ! synovial



hyperplasia ! synovial tissue grows over the surface of the articular cartilage



(pannus) ! fibrosis and destruction of cartilage ! ankylosed, fixed joints. Usually



symmetric. Rheumatoid nodules (also in rheumatic fever).



Treatment: MTX (treat early, less severe damage in the long run).



- Sjogren syndrome: rheumatoid arthritis + autoimmune destruction of lacrimal glands



! keratoconjunctivitis sicca (dry eyes), dry mouth (swallowing problems).



Biopsy of the lower lip (confirmatory test), loking for inflammtoary reaction in the



salivary glands. Anti-SSa (Ro), SSb (La).



- Caplan’s syndrome: rheumatoid nodules in the lung + pneumoconiosis.



- Felty syndrome: splenomegaly, neutropenia and rheumatoid arthritis.



- Gout: big toe (“podagra”) is the first joint to be involved, mostly happens at night.



Precipitation of mono-Na urate crystals (gout defining) ! neutrophils phagocytize it



! release their enzymes ! inflammatory reaction. "uric acid.



Initial treatment (to control inflammation): anti inflammatory like indomethacin (used to



be colchicine). Treatment of cause: allopurinol (blocks xanthine oxidase) for



overproduction, probenecid or sulfinpyrazole for under excretion (90%).



- Chronic gout: tophus filled with crystalline material, multinucleated giant cells.



It is a mono-Na urate in soft tissues, seen in feet, hand, ear. Erodes joints. Treatment



from here on is only allopurinol.



- Multi factorial inheritance (HLA B27 positive) - Do not eat red meat, red wine, alcohol



(! metabolic acidosis ! more lactic + &-hydroxybutyric acid excretion, less uric acid



excretion).



- Sacro-iliac joint (severe lower back pain in the morning, feel better as the day



progresses), eventually also vertebral column (“bamboo spine”).



Restrict movements of chest cavity (due to hunched back) ! blood gas abnormalities.



Aortitis, aortic regurgitation. Uveitis, iridocyclitis ! blindness.



- Alcaptonuria (AR): degenrative arthritis in vertebral column, cartilage in between



vertebrae is black color, urine exposed to light becomes black.



54



Homogentisate oxidase deficiency ! "homogentisic acid ! black on exposing to



light. Destroy cartilage.



- Non specific urethritis Chlamydia: sterile pyurea, dysurea, "frequency. few weeks



after treatment ! sterile conjunctivitis, pain in Achilles tendon (pathognomonic)!



Reiter’s syndrome (multifactorial, HLA B27 positive), triggered by Chlamydia, (could



also be UC, psoriasis, shigella, y. enterocolitica) ! ankylosing spondylitis.



- Disseminated gonococcemia: STD (Synovitis, Tenosynovitis, Dermatitis).



Disseminate for sure if C5-C9 missing (need it to phagocytize N. Gonorrhea).



- Most common cause of septic arthritis in the US is gonorrhea.



- Lyme’s disease (Borrelia Burgdorferi): erythema chronicum migrans (Pathognomonic)



at the site of the bite (Ixodes tick). Treat with tetracycline, if not ! chronic:



myocarditis, bilateral bell’s pulsy (facial paresis pathognomonic. Herpes - unilateral).



Hemolytic anemia due to an intra erythrocytic parasite transmitted by the same tick



from whitetail deers, causing babesiosis (eastern seaboard, 1 week incubation).



Treatment for chronic disease is ceftriaxone.



- Osteogenesis imperfecta: defect in synthsis of type 1 collagen, bluish discoloration of



the sclera (reflection of the choroidal veins underneath).



- Osteopetrosis (brittle bone disease): defect in osteoclasts ! no BM ! severe anemia,



different nerves get caught inside.



- Osteoporosis: Breaking > building bone, because there’s not enough estrogen to



inhibit IL-1. Both mineral + organic loss of bone mass. Collapsing of vertebral column



! height loss, kyphosis. Fractures of distal radius, Dowager’s hump.



Swimming is not good (water taking off the stress, we need stress to build bone).



Walking and weight training is good (put stress on it).



Should: excercise, get 1500mg of Ca every day, 400-800 units of Vit D, iron.



Being in space causes osteoporosis.



- Osteomalacia: only mineralization problem, the organic part is normal (cartilage,



osteoid).



- Most common bone tumor is osteochondroma (neoplasm of cartilage capped by bone



on the surface). Ollier’s disease - have enchondromas all over the body ! "risk to



develop chondrosarcoma (most common malignant tumor).



- Osteogenic sarcoma - distal femur, proximal tibia (knee area pain), early 20s.



Develops in the metaphysis of bone, invades muscle + periosteom (lifting on it,



Codman’s trianlge on X-ray), “sunburst” appearance. Rb, chr. 13.



- Duchenne muscular dystrophy (X-linked): absence of dystrophin. "CK, "LDH.



Gowers' maneuver in children (when trying to stand, begins with both hands and feet



on the floor, then works his way up the legs with his hands).



Pseudohypertrophy of the sural region (enlarged, weak calves).



- Becker’s muscular dystrophy (X-linked): make abnormal dystrophin.



- Most common cause of HCC in children is (-1-antitrypsin deficiency.



- Myotonic dystrophy (AD, chr. 19): most common adult muscle dystrophy.



Trinucleotide repeat (like Huntington, Fragile-X, Friedreich’s ataxia) - anticipation



55



(becomes worse with every generation). Can’t relax their muscle grip, diabetes,



cardiac abnormality, hanging jaw, cataract, dementia, baldness.



- Fragile X: mental retardation, macroorchidism, mitral valve prolapse.



- Myasthenia gravis: IgG Ab against Ach receptor ! progressive muscle weakness !



lid lag, eye muscles (double vision), dysphagia to liquids + solids. Feel good in the



morning, get worse as the day goes on. Treatment: Ach esterase inhibitors, but



eventually when there are no receptors ! death, unless:



Thymoma (20%) or germinal follicles in the thymus (B-cells !! which makes the auto



Ab) are responsible ! Thymectomy (third - complete cure, third - partial).



- SLE: first - positive ANA (99% sensitivity), then anti-Sm (100% specificity) and anti



double stranded DNA (98% specificity & indicate kidney disease) to confirm.



Butterfly distribution (mallar) rash on the face, morning stiffness, pericarditis.



LE cell - anti DNA Ab react against DNA and phagocytized by neutrophils.



Anti Ro (also present) can cross placenta and attack baby’s conduction system.



- PSS/CREST: if the kidney is involved, it’s PSS.



- Dermatomyositis: raccoon eyes, "CK, rash over the proximal phalangeal joint



(Gottron's patches). Highest association with underlying cancer.



- Psosriasis: most common location is scalp, involves pressure points (elbow). Reddish,



silvery-plaque rash.



- Allergic diathesis: atopic dermatitis (type 1 H-S), kids.



- Contact dermatitis: type 4 H-S (like positive PPD).



- Seborrheic dermatitis (Malassezia Furfura - fungi): adult disease. Disseminted disease



suggest an immunocompromised patient (pre-AIDS defining).



- Tinea capitis (superficial dermatophytis): used to be by Microsporum Canis fungi, now



it’s Trichophyton tonsurans). Under UV-A, it fluorescents.



Workup: scrape the outside and do KOH preparation ! can see yeast form.



- All other superficial dermatophytis are by Trichophyton rubrum.



- Molluscum contagiosum (Pox virus): common in children. Volacano look (like BCC),



sandy like material, kids pick on it, can get it over and over again.



- Pityriasis rosea: non preuritic rash on the truck (mostly), red on outside, pale on



inside. “Christmas tree” distribution rash = Herald rash, in the lines of Langer, usually



precedes. Topical steroids do not help (it’s not a fingi).



- Dysplastic nevi syndrome: over 100 nevi, have to check it every year, could be a



precursor lesion to melanoma. Very common.



- First step of management of different variation of melanoma is excision.



Superficial spreading melanoma is the most common one.



Lentigo melanoma: older people, always on face (sun exposed area), least likely to



metastases out of all the melanomas.



Acrolentiginous melanoma: worst kind, most aggressive. Even blacks (which don’t



get the other types) can get it. Primary disease under nails, palms, soles.



Nodular melanoma: aggressive, no radial growth, arises on normal skin.



Depth of invasion is the key to prognosis. Less than 0.76mm ! no metastases.



56



- Black widow spider: neurotoxin ! muscle spasm in upper thigh & abdomen.



- Brown Recluse = Violin spider: necrotoxin ! skin ulcer, not painful.



- Sebaceous glands have androngen receptors ! men get more acne.



CNS:



- CSF derived from choroids plexus (ventricles), ultra filtrated plasma - !protein, no



cells, #glucose (if high - bacteria, fungus, cancer), ""chloride.



- Block of the aqueduct of sylvius is the most common cause for hydrocephalus in



children.



- Epidural hematoma: blood clot between the bone and the dura. Have to fracture the



bone ! arterial (middle meningeal) rupture ! dura separation.



When you reach 50 ml of blood (6 hours ) ! uncal herniation ! death.



- Subdural hematoma: rupture the bridging veins between the dura and arachnoid !



fluctuating consciousness, dementia (if untreated).



- CT for diagnosis of both types of hematoma and hemorrhagic stroke.



- 70% of tumors in adults are supratentorial (cerebral cortex).



70% of tumors is children are infratentorial (cerebellar cystic astrocytoma,



medulloblastoma).



- Hydrocephalus: communicating - CSF in the ventricle with the subarachnoid space.



Causes: benign tumor of the choroid plexus (! "ultrafiltrate ! "CSF ! "P),



subarachnoid bleed or meningitis (no draining).



Non communicating (more common) - prevention of CSF to reach subarachnoid



space. Causes: stenosis of the aqueduct, ependymoma (4th ventricle, most common),



meningitis (TB) at the base (! scar tissue which blocks the foramens).



- Normo pressure hydrocephalus, like with aqueduct stenosis (started as high pressure)



! dilatation of the ventricle ! dementia, ataxia, urinary incontinence.



- Arnold-Chiari syndrome: herniation of cerebellum & medulla into spinal canal.



- Dandy-Walker syndrome: cerbellar vermis & 4th ventricle did not develop.



57



- Tuberous sclerosis (AD): proliferation of astrocytes ! tubercles (hamartomas) bulging



into ventricles, angiomyolipoma (hamartoma) in the kidney, facial angiofibromata



(adenoma sebaceum), mental retardation, cardiac rhabdomyoma, shagreen patch



(hypopigmentation) which shine under wood’s light.



- Tonsillar edema: tonsils herniate into the foramen magnum



- Uncal (tentorial) herniation: uncus herniates through the tentorium cerebelli, pressing



against the mid brain ! Duret hemorrhages, compression of CN-III ! opthalmoplegia



of 4 eye muscles (not lateral rectus - VI, sup. oblique - IV) ! ocular nerve pulsy -



down and out.



First sign of uncal herniation is mydriasis (dilated pupils) on the side of the herniation.



Posterior cerebral artery compressed ! occipital lobe infarction.



- Trocheal nerve palsy - down and in.



- Papilledema is a sign of "intracranial pressure. Vit A toxicity or lead poisoning (due to



"vessel permeability) can cause it.



- NTD: "(FP. Have to be on folate before pregnancy to prevent it.



Anenchepahly - absent brain.



Spinia bifida occulta - vertebral arch don’t fuse with each other. If meninges come



out - meningocele, if both the cord+meninges - myelomeningocele.



- Neurofibromatosis (AD): café au lait spots, axillary freckles (brown pigmentation),



neurofibromas, plexiform neurofibroma (diffuse soft tissue or nerve enlargement



following the course of a nerve, involve skin, subcutaneous tissue, cause distortion of



bone growth ! “elephant man”), Lisch nodules.



AD characteristics: Late manifestation, penetrance (not in this case), variable



experivity (expressing in different severities in the same family).



Relation to pheochromocytoma ! HT ! 24 hour urine for metanephrines, VMA.



Related tumors: NF2 - acoustic neuroma (benign tumor of schwan cells of CN-VIII),



optic nerve glioma (most common), NF1 - meningioma.



- Albright syndrome: café au lait, precocious puberty, short stature, shortened 4th + 5th



metacarpals (K-K-D-D), polyostotic fibrous dysplasia (“whorls” of CT).



- Syringomyelia: cavitation in the central segments of the spinal cord (cervical, mainly).



Loss of musculature in the intenal intrinsic muscle of the hand (like in ALS), loss of



pain and temperature sensation in a cape like distribution along arms and shoulders,



bladder problems.



- ALS: pure motor loss (both upper and lower motor loss)



- Meningitis: nuchal rigidity, cerebral abscess, pus at base of the brain ! obstructive



hydrochepalus. Treatment: steroids (prevent scar tissue formation complication) and



antibiotics. Deafness is one of the most common complications.



Most common causes in first month is: #1: Strep Agalactiae (also of sepsis), #2: E.



Coli, #3: Listeria Monocytogenes (don’t eat soft cheese).



Most common cause from 1 month to 18 years is Neisseria Meningitidis.



58



Most common cause above 18 years is Strep. Pneumoniae.



"protein, "neutrophils, #glucose.



- Cryptococcus: narrow based buds on India ink (broad = Blastomycosis).



Most common cause of meningitis in AIDS patients.



- Encephalitis: sleepy, drowsy, mental status abnormality.



- Rabies: most common cause in the US is skunks. Raccoons (NJ), foxes (SF), coyotes



(Texas). Dogs are the leading cause in 3rd world countries.



Negri bodies (pathognomonic inclusion bodies in nerve cells with rabies virus).



- Congenital CMV: periventricular calcifications, encephalitis. Urine culture is best for



diagnosis.



- Tumbling motility: Trichomonas Vaginalis, Listeria Monocytogenes.



- Mucor mycosis in the frontal lobe is common with diabetics in ketoacidosis.



- Toxoplasma: multiple space occupying lesions in the brain. AIDS, CD < 50.



- Cysticercosis (Pigs): focal epileptic (grand mal) seizures (dilantin therapy), multiple



cystic calcified lesion in the brain.



- Creutzfeldt-Jakob disease (prions): neuropathologist, neurosurgeons mostly get it.



Undercooked beef, lettuce from Arizona (use cow manure for fertilization).



- Most (atherosclerotic) strokes are pale liquefactive infarcts.



- Emboli from the heart almost always go to the middle cerebral artery ! hemorrhagic



infarct.



- HT ! intracerebral bleed ! clot in the putamen, basal ganglion.



HT ! lacunar infarcts ! can casue pure motor stroke or pure sensory stroke.



- Subarachnoid hemorrhage: ruptured congenital berry aneurysm, most commonly in



the junction of the anterior communicating branch &the anterior cerebral artery.



- MS is the most common demyelinating disease in the US.



Auto Ab against the myelin sheath. "proteins, normal glucose, "lymphocytes.



Nystagmus, ataxia, optic neuritis with blurry vision, internuclear ophthalmoplegia



(pathognomonic, demyelination of both sides of medial longitudinal fasiculus).



Charcot triad: nystagmus, intention tremor and scanning apeech.



Changes confined to CNS, no peripheral involvement.



- Morbili virus (measles, SSPE), papova (polyoma JC) virus (PMLE), HPV ! infect



oligodendrocytes ! demyelination.

- Guillian Barre syndrome: acute inflammatory demyelinating disease primarily involving

the PNS. Autoimmune etiology, often preceded by viral infection (URI), immunization

or allergic reaction. """protein, "cell count.

Ascending muscle weakness and paralysis beginning in the lower part of the lower

extremities. Death due to respiratory failure. Most patients recover.

- Alzheimer’s: hydrocephalus ex vacuo (due to loss or atrophy of brain tissue), senile

plaque (congo red will show ' amyloid inside ! neurotoxic), dementia, neurofibrillary

tangles (any kind of dementia show that, Huntington’s), hirano bodies, generalized

atropy with moderate neuron loss (frontal, hippocampus).

It’s a presumable clinical diagnosis. only way to confirm it is an autopsy.

59

- & amyloid gene is on chromose 21, so all Down’s patients has alzheimer’s.

- Pick disease: pronounced brain atrophy, temporal and frontal lobe. Ballooned

neurons (pick cells), cytoplasmic inclusions (pick bodies). Slowly progressive

dementia, language disturbances, behavioral changes, even mutism.

- Huntington (AD): CAG nucleotide repeat, chr. 4. Paternal transmission results in

increased number of repeats ! earlier onset in next generations (usually 30-40).

Progressive degeneration and atrophy of the caudate nucleus, putamen and frontal

cortex with neuronal depletion and gliosis.

- Parkinson: usually over age 50. Depigmentaion of substantia nigra and locus

ceruleus, damaged cells contain Lewy bodies (eosinophilic inclusions) ! dopamine

depletion. Therapy: L-dopa.

Pill rolling tremor, expressionless face, slow movements, muscular rigidity.

- ALS: degeneration of upper and lower motor neurons ! atrophy of lateral

corticospinal tracts and anterior motor neurons ! hyperrefliexia, spasticity.

Clinical onset in middle age with death in 1-6 years.

TOP SECRET Notes

1. Gastroparesis (DM) Rx = metoclopramide, erythromycin; symptoms: post-prandial fullness, hypoglycemia, sweating, dizziness, constipation

2. Drugs that lead to hypercalcemia = thiazides, lithium

3. Calcium greater than 12 or symptoms = NSS IV 3-6 l in 24 h, furosemide if necessary

4. Hungry bones syndrome = hypocalcemia post op removal of parathyroid adenoma

5. Sarcoidosis = increase in vit D levels

6. Familial hypocalciuric hypercalcemia = low 24 h urine calcium

7. Chronic thyroiditis (Hashimoto) = antimicrosomal antibodies

8. Drugs that lead to hypothyroidism = lithium, ASA

9. Large nodule (cold) in multinodular goiter (hot) = FNA; if follicular elements = excision

10. Psammoma bodies = papillary carcinoma of thyroid = MC type of thyroid cancer, RF radiation exposure, lymphatic spread

11. Thyroid cancer types = papillary, follicular (hematogenic spread), anaplastic, medullary (MEN); painful, low uptake, increased ESR

12. Graves disease Rx = bring the patient to euthyroid stae, then: radioactive iodine, steroids for ophtalmopathy

13. Plummer disease = long-standing multinodular goiters that become thyrotoxic later

14. Thyroiditis = low 24 h radioactive iodine uptake

15. Graves disease Dx = increased thyroid, "hot", proptosis, positive TSH Ig

16. Nitroblue tetrazolium test = chronic granulomatous disease; tets phagocyte fuction, oxidative burst

17. Cellular deficiency disease = fatal infections after receiving live viral vaccines (MMR, varicella)

18. Ab deficiency disease = encapsulated organisms, sino=pulmonary bacterian infections, sepsis

19. Phagocytic deficiency disease = recurrent abcesses, lymphadenitis, periodontal infections, Gram negatives, catalase positives, e.g. CGD, Chédiak-Higashi

20. Complement deficiency dis = C2-C4: autoimmune dis; terminal: Neisseria; C3: encapsulated, unusual strains

21. Severe combined immunodeficiency = first year of life, decrease in T and B cells

22. Ig A deficiency = MC primary immune deficiency, major anaphylatic reaction to blood products

23. X-linked hypogammaglobulinemia Rx = IV Ig; defect in tyrosine kinase

24. X-linked lymphoproliferative disease = catastrophic after EBV infection

25. Chronic granulomatous disease = decreased intracelular and fungal killing; S. aureus, Aspergillus; Rx: prophylatic antibiotics (TMP/SMX, doxycycline), interferon gamma; vaccinate: Haemophilus, Pneumoccocus, Neisseria, viral vaccines

26. T-cell deficiency Rx = bone marrow transplant

27. Transfusion in cellular deficient patient = irradiated, leukodepleted, virus free product

28. C3 deficiency = increased number of pyogenic infections

29. Properidin and C5 deficiency = increased Neisseria infections

30. C1 inhibitor deficiency = hereditary angioedema

31. Decay accelerating factor deficiency = paroxysmal nocturnal hemoglobinuria

32. Clomiphene citrate use = ovulation induction (for patients with good estrogen production, such as in OPCD)

33. Pregnancy = increase in alkaline phosphatase does not indicate disease necessarily, may be normal finding

34. Primary hypothyroidism = may lead to increase in pituitary, amenorrhea, galactorrhea

35. Meconium ileus suspicion = barium enema

36. Cystic fibrosis tests = sweat test, nasal potential testing

37. Hepatitis B mother = breastfeed is OK!

38. Graves in pregnancy Rx = propylthiouracil

39. Cocaine use in pregnancy = placental abruption

40. Clue cells = bacterial vaginosis; Rx = metronidazole - counsel not to drink alcohol because of disulfiram-like reaction

41. Pruritic urticarial papules and plaques of pregnancy = third trimester

42. RF for ectopic pregnancy = age, PID, salpingitis, more than 3 pregnancies

43. Testicular feminization = dysfunction or absence of testosterone receptors; patient is XY, normal breast development, scant pubic and axilar hair, blind vagina, undescendent testicles, may be felt on the groin.

44. fever greater than 38 C in less than 4 m.o. = admission, IV antibiotics, full evaluation, multiple cultures

45. Pyloric stenosis = non-bilious emesis, midepigastric olive: Dx = USG; RF = erythromycin use

46. MCC of jaundice in pregnancy = viral hepatitis

47. Symptomatic biliary stones = pregnancy Rx = laparoscopic cholecystectomy

48. Asymptomatic biliary stones Rx = none

49. N. gonorrhea = Gram negative diplococci; Rx = ceftriaxone + azithromycin (to cover Chlamydia, which generally is there too); notify publc health authorities

50. Trichomonas vaginalis = motile flagellated microorganisms in vaginal wet mount

51. Low grade squamous intraepithelial lesion (cervix) = CIN I; Rx = rescreen in 4-6 months

52. Abnormal vaginal bleeding in woman older than 35 yo next step = office endometrial pipelle biopsy

53. Small subchorionic henorrhage Rx = clinical and USG observation

54. Menorrhagis, anovulatory bleeding = order a TSH!

55. Group B strep prophylaxis = penicillin or ampicillin to mother during active labor, CBC and blood culture on the newborn

56. Low plasma bicarbonate causes = diarthea, renal tubular acidosis

57. Erythema infectiosum = not contagiuos during the rash (slapped face, lacy), only before it

58. Bleeding in pregnancy = order bood type, Rh, atypical antibodies

59. Bilious vomiting in infant = think malrotation with volvulus; if no peritoneal signs, flexible sigmoidoscopy is diagnostic and treatment at the same time

60. Bilious vomiting in newborn = remember the 3 Ds: duodenal atresia, double bubble on abd XR, greater incidence in Down\\\\\\\'s syndrome

61. Side effects of MgSo4 use for the NB: meconium plug syndrome; in this case, contrast enema is both diagnostic and curative

62. Polythelia = accessory nipple

63. Polymastia = extraglandular breast tissue

64. Hugh grade intraepithelial lesion (cervix) management = colposcopy + endocervical curetage + biopsy

65. Following a molar pregnancy = contraceptives for 1 year, monitor beta HCG, if it goes up, it could be choriocarcinoma

66. Fetal alcohol syndrome = cardiac malformation (VSD), CNS abnormalities, face deformities

67. Tuboovarian abscess Rx = IV atbtcs; surgery only if necessary - it\\\\\\\'s one of the few cases of abscess that are cured without incision!

68. Prostate cancer Dx = USG guided needle biopsy with 6-12 specimens

69. Metastatic prostate cancer Rx = GnRh agonists (flutamide), orchiectomy + chemo

70. Staging for testicular cancer = serum LDH, AFP, beta HCG, CT chest/abd/pelvis; Rx = radical inguinal orchiectomy + spermatic cord ligation

71. MC sites of melanoma = trunk for men, legs for women

72. Basophilic palisiding cells, pearl apperance, upper 1/3 of the face = basal cell ca (the MC skin ca)

73. Moh's micrographic surgery = for squamous cell ca (lower 1/3 of the face), makes 1-2 mm margins

74. MCC of encephalitis in adults = HSV; meningeal signs + focal neurological signs, temporal lobe changes on CT; Rx = IV Acyclovir 14-21 days

75. Listeria monocytogenes meningitis Rx = ampicillin; NB, elderly

76. Chronic sinusitis = longer than 3 months; clinical Dx, but if something is going to be ordered = CT sinus; Rx = amoxicillin +/- clavulanate +/- clindamycin for 21 days, nasal steroid sprays, endoscopic surgery if necessary

77. Otitis media, ac. sinusitis Rx = TMP/SMX or amoxicillin +/- clavulanate

78. Otitis externa Rx = topical ofloxacin with steroids; remember to clean the ear before applying the Rx; Pseudomonas, swimmers

79. Chr carriers of group A strep Rx = clindamycin

80. Smoker with pneumonia, diarrhea, increased LDH = think Legionella; Dx = urine Ag; Rx = doxycycline

81. Cystic fibrosis pneumonia Rx = IV ceftazidime + IV levofloxacine = IV aminoglycoside; MCC = Pseudomonas

82. Aspiration pneumonia Rx = IV ceftriaxone + IV azythromycin + IV clindamycin; chronic, not presentiated, RF positive

83. Aspiration pneumonitis = acute event, presentiated by somebody, no need for atbtcs

84. PCP pneumonia Dx = silver stain of sputum, bronchial lavage; Rx = IV TMP/SMX or inhaled pentamidine, add prednisone if: PaO2 less than 70 or A-a gradient more than 35

85. TB Rx = RIPE for 8 w., then INH + rifampin for 16 w. more

86. Add vit. B6 for INH

87. Keep an eye on uric acid for Pyrazinamide

88. Order ophtalmologic avaliation for Ethambutol

89. Latent TB Rx = nine months of INH (+ B6)

90. TB + HIV = use Rifabutin instead of Rifampin because of possible drug interaction

91. Ac. prostatitis Rx = TMP/SMX or fluoroquinolone for 14 d

92. Chr prostatitis Rx = fluoroquinolone 1 m. or TMP/SMX 3 m.

93. Primary/secondary syphilis Rx = Penicillin G 2.4 million U IM; if disease present for more than 1 year = three doses with 1 w. intervals; notify health department

94. Neurosyphilis Rx = Penicillin G IV for 14 days

95. DM Dx = random glucose test >200 + symptoms OR twice fasting glucose > 126 OR 75 GTT > 200 at 2 h. OR 50 g GTT > 146 at 2 h

96. Annual influenza vaccine = patients older than 50 yo, healthcare workers

97. OCPs = decrease risk for gonococcal PID

98. Osteoporosis Rx with drugs, not only calcium is indicated when = T-score < 1.5 OR < 2.5 + RF

99. Dual X-ray absorptiometry (DEXA) T-score = compared to young adults

100. DEXA z-score = compared to age and race matched population

101. Elderly + fall = do a home safety evaluation, avoid narcotics

102. Woman sexually active, younger than 25 yo or with RF = screen for Chlamydia

103. HTN Dx = 3 separate readings with increased BP

104. Post exposure TB prophylaxis = 2 drugs chosen according to bug susceptibility

105. Smallpox Rx = Cidofovir

106. Anthrax Rx and prophylaxis = ciprofloxacin (adults), penicillin (children)

107. Household with children = water heater < 120-130 F

108. Pneumococcal vaccine = q5 y for >50 yo with chr disease

109. Td vaccine = q10 y or once at age 50 yo

110. woman with relative with breast ca = mammogram 10 y before the affected person age + self breast examination

111. Men with relative with prostate cancer = annual PSA + DRE after 40 yo

112. Bipolar I = Hx of mania; major depression + or -

113. Bipolar II = Hx of hypomania + major depression; NO mania

114. Autism suspicion = order a hearing test before saying it is!

115. Gingko biloba + warfarin = increased risk of bleeding

116. 1 yo vaccines = Hib, MMR, varicella, PCV

117. Adopted foreign child = serology hep B, C, HIV, syphilis, PPD, stool tests

118. HIV + CD4 , 200 = TMP/SMX prophylatic for PCP pneumonia

119. Pediculosis, scabies Rx = permethrin lotion; in scabies: treat all household members

120. Necrotizing infection + DM Rx = X-ray, OR for debridement, amputation if needed

121. Infection in CRF + indwelling catheter Rx = vancomycin + gentamycin

122. Tinea versicolor Rx = topical ketoconazole

123. Waterhouse-Friderichsen syndrome = adrenal infarction after/during meningococcal meningits, decreased cortisol level

124. Postherpetic neuralgia Rx = amitriptiline

125. Mononucleosis = leukopenia with atypical lymphocytes, heterophile Abs

126. Bacteremia in a baby Rx = ampicillin + cefotaxime; covering group B strep, Listeria, E. coli

127. Hep. B window period = surface Ag and Ab negative (they cancel each other), Dx may be made through core Ag IgM Ab +

128. Rat bite fever Rx = penicillin G or tetracycline

129. HUS = ac. renal failure + anemia + thrombocytopenia; E. coli 0157:H7, raw meat

130. Tinea pedis Rx = topical antifungal for 2-3 w, if not gone = oral griseofulvin 6-8 w

131. Invasive aspergillosis = multiple bilateral lung nodules with surrounding hemorrhages

132. Post chemo fever Rx = hospitalize, broad spectrum atbtcs, antifungal if no response

133. HPV infection Dx when lesions not apparent = apply vinegar to the region

134. Cat scratch disease Dx = lymph node biopsy; treat only if = bact superinfection (S. aureus), encephalitis

135. Ac. post-infectious cerebellar ataxia = post varicella infection or vaccine; differential = poisoning

136. Fever + neutropenia Rx = antipseudomonal third generation cephalosporin OR antipseudomonal penicillin + aminoglycoside

137. First generation cephalosporin = cefadroxil, cefalexin, cefalotin, cefazolin

138. Second generation = cefaclor, cefuroxime; antianaerobe: cefotetan, cefoxitin

139. Thrid generation = cefixime, cefotaxime; antipseudomonal: cefoperazone, ceftazidime

140. Herpes zoster Rx = acyclovir

141. Crush injuries Rx = copious alkalinized IV crystaloid (for renal protection)

142. Exertional heat stroke = may lead to DIC and rhabdomyolysis; Rx = ice water, cold wet sheets + fan

143. Ecstasy intoxication = may lead to rhabdomyolisis

144. Ac. ethanol withdrawal Rx = chlordiazepoxide

145. Edrophonium = acetylcholinesterase inhibitor

146. Organophosphate poisoning Rx = atropine, pralidomide

147. Ac. tubular necrosis due to contrast prophylaxis = hidration, acetylcysteine

148. Avoid/suspend metformin use before tests with IV contrast (for renal protection)

149. Opioid intoxication = miosis, resp. depression, coma, hypotension, bradycardia; Rx = naloxone

150. Severe dehydration in elderly = may lead to ac. suppurative parotitis by S. aureus; Rx = IV hidration, sialogogues, atbtcs; surgical drainage if not better in 12 h

151. Intoxicated patient = impossible to clear cervical spine because you need to have patient communicating symptoms to do it

152. Priapism causes = TPN, sickle cell disease, crack/cocaine, trauma, spinal or general anesthesia, trazodone, leukemia

153. Alcohol withdrawal = happens in hours to 10 days

154. Urinary retention causes = BPH, prostate ca, prostatitis, urethral stricture, meds, blood clots

155. Cyanide toxicity (nitroprusside) Rx = sodium thiosulfate

156. Gallbladder rupture suspicion = exploratory laparotomy

157. Compartment syndrome signs = most sensitive is loss of DTRs, most ominous is loss of pulse; 6 Ps = pallor, pain, paralysis, paresthesia, pulselessness, poikilothermia

158. Hyperkalemia + EKG changes Rx = calcium gluconate

159. Motor vehicle accident with seat belt in place = may cause pancreatic fracture = order a CT scan with IV contrast

160. Carboxy hemoglobin level > 40% (>15% in pregnancy) Rx = hyperbaric O2 therapy

161. Methylene chloride (paint remover) intox. = carbon monoxide poisoning; use co-oxymeter

162. Methemoglobinemia Rx = Methylene blue

163. IV epinephrine = Rx of pulseless VT or VF (post eletric cardioversion try), not for hypovolemia

164. PCP intoxication = aggression, ac. psychosis, ataxia, violence, nystagmus, suicide, fever, hypersalivation, hyperacusis

165. QRS amplitude alternance = cardiac tamponade

166. ERCP complications = ac. pancreatitis, infected pancreatic pseudocyst formation, cholangitis, perforation

167. Disrupted/transected urethra suspicion next step = retrograde urethrogram; blood at meatus + high riding prostate

168. Leaking CSF (ears) = cribiform fracture = blind nasogastric or nasal intubations are contraindicated!

169. Femoral canal = NAVEL from lat. to medial

170. Radial head fracture (outstretched hand, Cole's fracture) Rx = sling 2-3 days, early exercises

171. Wound dehiscence = new onset serous discharge

172. CXR in pneumothorax = at maximal expiration

173. Compartment syndrome suspicion = measure compartment pressures, emergent fasciotomy if confirmed

174. In burn patients, succinylcholine use is contraindicated due to the risk of hyperkalemia

175. Thioridazine S. E. = prolonged QT

176. Diuretic for sulfa alergic patients = etacrinic acid

177. Anabolic steroids S. E. testicular atrophy, liver disease, gynecomastia, impotence

178. Concussion = head trauma + transient LOC + short amnesia, may have not serious late symptoms up to 6 m. later

179. Increased ICP first steps in management = intubation + hyperventilation

180. Lumbar puncture headache = positional, within 24 h.

181. Anterior spinal arterial occlusion = decreased motor function, decreased sensation, decreased pinprick, preserved proprioception

182. AST = less specific for liver than ALT; increased in alcoholic liver injury

183. Ketorolac = NSAID, IV, used in testicular torsion; S.E. = gastric ulceration, GI bleeding

184. Human bite Rx = ampicillin-sulbactam OR TMP/SMX + clindamycin; if HIV involved = don't worry, it doesn't get transmitted by bite (yet!)

185. Methanol toxicity = vision changes; order: ABG, electrolytes, osmolality; Rx = IV ethanol, dyalisis

186. Amytriptiline S.E. = constipation, ac. glaucoma, urinary retention, dry mouth, paralytic ileus; but the worst event in intoxication = cardiac arrhythmias

187. Electromyography = checks nerve and muscle integrity

188. Evoked potential studies = monitor transmission of motor impulses in the anterior columns of spinal cord

189. JC virus + HIV Rx = HAART

190. JC virus causes = progressive multifocal leukoencephalopathy

191. Epididimoorchitis Rx = Doxycycline 100 mg PO bid for 10 d + ceftriaxone 250 mg IM

192. HTN + BPH Rx = terazosin, doxazosin

193. Increase in AFP = embryonal, yolk sac elements (nonseminomas)

194. Increase in HCG = seminomas and nonseminomas

195. Hydrocele = Dx with USG, no Rx required

196. Metastatic prostate ca Rx = leuprolide, goserelin OR bilateral orchiectomy

197. Priapism etiology = idiopathic (60%), leukemia, sickle cell dis, pelvic tu and infections

198. PSA > 4 next step = prostate biopsy

199. Chancroid = Haemophilus ducreyi, painful, unilateral lymphadenopathy, lesion with purulent base; Rx = ceftriaxone, azithromycin

200. Granuloma inguinale = C. granulomatis, painless, beefy-red lesion; Rx = TMP/SMX

201. Lymphogranuloma venereum = Chlamydia trachomatis, herpetiform vesicle with erosion, bilateral suppurative lymphadenopathy; Rx = doxycycline

202. Syphillis = Treponema pallidum, painless papula with clear, clean base, nontender, nonsuppurative lymphademopathy; Dx = RPR, VDRL, dark field mycroscopy; Rx = penicillin, doxycycline, erythromycin; notify health authorities

203. Hematospermia with normal PE and labs = observation and reassurance

204. Tertiary syphilis = not contagious

205. HAART indications = symptomatic HIV, CD4 < 200, pregnancy

206. CD4 < 200 = PCP prophylaxis = TMP/SMX, dapsone or atovaquone

207. CD4 < 50 = MAI prophylaxis = azithromycin weekly

208. Toxo Ig G + and CD4 < 100 = TMP/SMX OR dapsone + pyrimethamine + leucovorin

209. TB contact OR PPD > 5 mm + HIV = INH + vit B6 for 9 m.

210. HIV Dx = vaccines to be given = pneumococcal q 5 y., influenza q 1 y., hepatitis B

211. Mefloquine S.E. = bradycardia, neuropsychiatric symptoms, prolonged QT

212. NB of woman with SLE may have = congenital CHB

213. Chronic fatigue syndrome = fatigue + cognitive changes for 1 y. or more; infectious basis: virus, Chlamydia pneumoniae

214. Fibromyalgia = pain, tender points (11 of 18), sleep changes, psychological distress, allodynia, more than 3 m., realated to SLE, RA

215. Allodynia = even gentle touch is unpleasant

216. Avascular necrosis of femoral head causes = pancreatitis, alcoholism, fat embolus, sickle cell anemia, air emboli, steroids; Dx =MRI, SPECT

217. Idiopathic AVN = Legg-Calve-Perthes disease

218. AVN Rx = avoidance of activity, taper steroid

219. Pyogenic granuloma Rx = shave, electrodesiccate base, send it to pathology evaluation

220. Amelanotic melanoma = It can resemble pyogenic granuloma clinically

221. Temporomandibular joint disease = orofacial pain, noisy joint, restricted jaw function; Dx = MRI

222. Complication of hand/wrist trauma = AVN of scaphoid (navicular) bone

223. Osler-Weber-Wendu = hereditary hemorrhagic telangiectasia = epistaxis, GI bleeding, polycystic kydneys

224. Von-Hippel-Lindau dis.= cavernous hemangiomas, hemangioblastomas in CNS, retina, renal cell ca

225. Sturge Weber syndrome = facial port wine stain, seizure, ocular changes

226. Caplan syndrome = rheumatoid nodules in the lings

227. Felty syndrome = splenomegaly + neutropenia in severe R.A.

228. Tuberous sclerosis = ash leaf macules (hypopigmented), calcified intracranial nodules, epilepsy, low inteligence, adenoma sebaceum

229. Leser-Trelat sign = multiple pruritic seborrheic keratosis associated with internal malignancy

230. Polymyalgia rheumatica = very high ESR; Rx = low dose corticoids; keep an eye open for possible temporal arteritis

231. Vitiligo Rx = topical sterois, phototherapy

232. Porphyria cutanea tarda = blistering in a sun exposed area + milia; Dx = urine prophirin level + hepatitis panel

233. Dermatitis herpetiformis = chr. pruritic papulovesicular lesions on extensor surfaces, post. hairline; Rx = dapsone

234. Pemphigus vulgaris Rx = immediate high dose corticosteroids

235. Hypertensive urgency = the goal is to decrease the diastolic BP to about 100-105 mmHg within a period of 2-6 hours

236. Avoid nitroprusside infusion for more than 48 h (it may lead to cyanide toxicity)

237. Hypert. urg. in pregnancy Rx = hydralazine, labetalol

238. In pheochromocytoma, serotonin syndrome, cocaine use = IV phentolamine

239. In aortic dissection = nitroprusside + labetalol/metoprolol

240. Joint replacement in osteoarthritis indications = refractory pain, functional limit, inability for ADLs

241. Alendronate (Fosamax) S.E. = esophageal irritation, ulceration and it has to be taken with an empty stomach, so always counsel the patient to take it in the morning and sit or stand upright for 30 minutes

242. Achantosis nigricans = DM, hypothyroidism, Cushing's, Addison's, malignancy

243. Kaposi's sarcoma = vascular tu, purplish lesions, extravasation of erythrocytes

244. MCC of alergic contact dermatitis = nickel

245. Methotrexate, azathioprine, chloroquine, etanercept, infliximab = disease modifying antirheumatic drugs

246. Lumbar stenosis = pseudoclaudication, worse with hyperextending movements, better with leaning forward, normal ankle-brachial index; Dx = MRI of the lumbar spine

247. Knee ligament injury Dx = MRI

248. PNH = GPI anchor prot defic. = hemolytic anemia + pancytopenia + venous thrombosis (e.g. hepatic)

249. PNH Dx = flow cytometry, HAM test

250. PNH labs = increased LDH, reticulocyte, decreased or negative haptoglobin, hemosiderinuria, hemoglobinuria

251. PNH Rx = iron, folic acid, transfusion, corticoids, eculizumab

252. Erythema nodosum Rx = NSAIDs

253. Back pain MRI indications = spinal stenosis, osteomyelitis, epidural abscess, post trauma

254. Down syndrome = should NOt participate in contact sports

255. Fracture on landing on feet = calcaneum, spine, acetabulum, post. hip dislocation

256. Melanoma suspicion = excisional biopsy

257. Osgood-Schlatter dis. = apophysitis of tibial tuberosity; Rx = decrease physical activity

258. Rotator cuff tear = weakness, instability; Dx = MRI; Rx = arthroscopic repair

259. Slipped capital femoral epiphysis = Dx = X-ray; Rx = fixation of epiphysis with long screws

260. Iliotibial band syndr. = pain in lat. aspect of knee

261. Axillary adenopathy in woman = mammography

262. Supraclavicular lymph node = lymph node biopsy

263. Miliaria = heat rash

264. Erythema multiforme minor = bull's-eye on palms, herpes simplex; Rx = long-term use acyclovir

265. Pustular psoriasis = sterile, post steroids, fever, malaise, arthralgia, diarrhea; Rx = cyclosporine

266. Seborrheic keratitis = "stuck=on", waxy grease scale

267. Dermatomyositis = often is paraneoplasic

268. Hypercalciuria (renal stones) Rx = hctz orally

269. Dye S.E. = ac. tubular necrosis = muddy granular casts

270. ATN = BUN/Cr < 20:1; cisplatin is one of the causes

271. Ac. interstitial nephritis (drugs) = rash, fever, hematuria, white cell casts, eosinophiluria

272. Increase in eosinophils = tumors, parasitic infectious, autoimmune diseases

273. Renal calculi = Abd XR, if - = CT scan of abdomen (shows all types of stones) - actually this information is conflicting between some sources, so one should do some research about it

274. Indinavir (HIV drug) S.E. = renal stone

275. Struvite stones = Mg ammonium phosphate, pH>7.2, presence of urea splitting bugs (Proteus, Pseudommonas, Klebsiella; Rx = removal

276. Uric acid stones = radiotranslucent

277. Asymptomatic bacteriuria in non-pregnant, healthy patient = no Rx is indicated

278. Doxorubicin (Adriamycin) S.E. = cardiac toxicity, myelosuppression

279. Vincristine S.E. = motor, sensory and autonomic neuropathy

280. Bleomycin S.E. = pulmonary fibrosis

281. Myelosuppressant drugs = methotrexate, vinblastine, doxorubicin

282. Polycystic kidney dis = colonic diverticular dis (with increased risk for perfuration), it may evolute to end stage renal dis, 10-15% of the patients have intracranial aneurysm

283. Chrug-Strauss dis = nephritic syndr + eosinophilia + asthma, p-anca +; Rx = steroids, cyclophosphamide, azathioprine

284. Goodpasture syndr = nephritic syndr + pulmonary hemorrhage; Abs to glomerular basement membrane

285. Wegener granulomatosis = nephritis + nasal/sinus problems, c-anca +; Rx = same as Chrug-Strauss

286. Berger\'s syndr = IgA nephropathy, no latent period post infection, nephrotic syndr

287. DMSA renal scan = radionucleotide study for renal function

288. IV pyelogram = C.I. in renal insufficiency

289. Kegel exercises = benefits within 6 weeks

290. Dribbling + dyspareunia + dysuria in woman = urethral diverticulum; Dx = urethroscopy or voiding cystourethrography

291. Nephrotic syndr = increased susceptibility to bact. infections, hyperlipidemia, mildly hypercoagulable state, hypovolemia

292. Renal cell ca suspicion = radical nephrectomy; Bx only for metastatic cases (when Sx is not indicated)

292. Rapidly progressive GN Rx = high dose IV methylprednisolone

293. Alport syndr = hematuria +/- blindness +/- deafness; type IV collagen of GMB in abnormal

294. Membranous glomerulonephropathy = MCC of nephrotic syndr in adults; Rx = ACEi

295. Membranoprolipherative GN = nephrotic sundr; renal dis + decreased complement, realted to hepatitis C virus

296. Painless hematuria = CT urogram or IVP (check ureteres)

297. Pyelonephritis suspicion = blood + urine cultures, urinalysis

298. Immunotherapy = for asthmatics patients with a single allergen

299. Interstitial fibrosis = decerased FVC, FEV1, RV, TLC, diffusion; increased FEV1/FVC; no response to bronchodilator

300. Immunisuppressed pat + pulm. aspergilosis Rx = IV amphotericin B

301. Primary pulm. HTN Rx = inhaled nitrous oxide, Calcium channel blockers

302. ARDS Rx = limit tidal volume to 6 cc/kg or less

303. Lung nodule on X-ray = thorax CT scan with contrast

304. Appropriate tube placement = colorimetric detection of end-tidal carbon dioxide

305. Sarcoidosis Dx = skin, transbronchial lung biopsy

306. To decrease aspiration risk during entubation = cricoid pressure

307. After pulm HTN Dx = vasodilator response testing

308. Albuterol usage > twice a week = add triamcinolone MDI

309. Ipratropium bromide = takes about 45 minutes to make effect

310. Non-massive hemoptysis = CXR, then bronchoscopy, then high resolution CT scan to Dx; not all tests necessary every time, though

311. Croup (laryngotracheobronchitis) = subglotic swelling, steeple sign on XR, parainfluenza, barking cough; Rx = mist tent, racemic epinephrine, IV corticosteroid, diphenhydramine

312. TB confirmatory Dx test = sputum acid-fast stain

313. Ciprofloxacin = does NOT cover streptococcus

314. Community acquired pneumonia Rx = azithromycin, levofloxacin

315. Sup. vena cava syndr due to ca Rx = radiation therapy

316. Penicillin alergy = cephalosporin use is OK if penicillin skin test is -

317. Heparin = given with warfarin untill 2 days after INR reaches desired level

318. Foreign body aspiration in children = rigid bronchoscopy, methylprednisolone, cefazolin

319. Gout Rx = for overproducers = allopurinol; for underexcreters = probenecid

320. Cauda equina syndr. suspicion = MRI; it's an emergency!

321. Gian cell arteritis Rx = Prednisone 40-60 md daily for 1-2 m., then taper down; if there is suspicion, treat immediately, even before biopsy, to avoid blindness as a complication!

322. Fight bite bug: Eikenella

323. Thompson test = pressure on gastrocnemius does not cause foot flexion, + in Achilles tendon rupture

324. Fibromyalgia symptoms with less than 11 trigger points = myofascial pain syndr.

325. Gottron's paules = happen in dermatomyositis

326. Polymyosistis Dx = increased creatinine, aldolase, CPK; EMG; muscle Bx; Rx = high dose corticosteroids

327. Urobilinogen = increased in hemolysis, hepatocelular dis.; decreased in biliary obstruction

328. Lithium S.E. = nephrogenic diabetes insipidus, hypothyroidism

329. Symptomatic hyponatremia Rx = 3% hypertonic saline to increase PNa by 3-5 mEq in 6 h, but no more than 12 mEq per day, because of the risk of central pontine myelinolisis

330. Central pontine myelinolisis = flacid paralysis, dysarthria, dysphagia

331. Osmotic diuresis = Uosm/Posm>0.7

332. Diabetes insipidus = Uosm/Posm 13.5 Rx = hydration + furosemide, then biphosphonate or calcitonin; hemodyalisis if necessary

335. Hypercalcemia has no specific signs and symptoms, only hypocalcemia has them (Chvostek, carpal pedal spasm)!

336. Intraductal papilloma = bloody nipple discharge

337. Duct ectasia = fever, greenish cheesy discharge, pain, tenderness

338. Breast ca = single, hard, immobile, irregular borders, >2cm

339. Triple Dx = PE + mammogram + FNA citology/Bx

340. Around 15% of breast cancers have a false negative mammogram

341. Breast lump in woman younger than 35 yo = if cystic = FNA = if nonbloody liquid = reassurance, if bloody = citology; if not = US and core Bx or excisional biopsy

342. MC sequelae of meningitis = hearing loss; rememeber to order audiometry in ccs once the meningitis is cured

343. Meningococcal meningitis prophylaxis = rifanpim or cipro for close contacts

344. Measles = high fever for 3 days, then Koplik, then 1 day after head-to-toe rash; pneumonia; O.M.; encephalitis (ac.), subac. sclerosing panencephalitis (even after years)

345. Roseola infantum (exanthema subitum) = high fever for 4 days, stop, then rash on trunk; human herpes virus 6

346. Erythema infectiosum (fifth disease) = slapped cheek rash; parvovirus B19; when the rash is there, it's not contagious anymore

347. Varicella Ig = for immunodebilitated, NB, within 4 days of exposure

348. Scarlet fever = sand paper rash, circumoral pallor, strawberry tongue; Rx = penicillin to prevent RF

349. Kawasaki syndr Rx = aspirin + IV Ig; f/u with echo

350. Rocky mountain spotted fever Rx = tetracycline + chloranfenicol OR doxycycline; it may cause DIC, delirium

351. Epiglottitis Rx = entubate ot tracheostomy, third generation cephalosporin; "thumb sign" on XR, child 2-5 yo, H. influenzae, S. aureus

352. RSV/bronchiolitis Rx = O2, mist tent, bronchodilators, IV fluids, ribavirin if severe, child

353. Diphteria = grayish pseudomembranous + myocarditis; Rx = atbtc + antitoxin

354. Pertussis = paroxysmal coughing + whooping inspiratory noise; Rx = atbtc

355. Post-streptococcal GN = NOT prevented by atbtc

356. Congenital toxoplasmosis = IC calcifications, chorioretinitis

357. Congenital varicella-zoster = limb hypoplasia, scarring of the skin

358. Congenital CMV = deafness, cerebral calcifications, microphtalmia

359. Conjunctivitis in the first day of life = chemical reaction

360. Gonorrhea conjunctivitis Rx = erythromycin ointment for 2-5 days

361. Chlamydial conjunctivitis Rx = topical + oral erythromycin for 5-14 days; the intention is to avoid that it becomes a Chlamydial pneumonia

362. NB cataracts = TORCH, inherited metabolic dis (e.g. galactosemia)

363. Orbital cellulitis = ophtalmoplegia, ptosis, severe pain, decreased acuity, it's an emergency!; Rx = blood culture, inpatient IV atbtc

364. Uveitis in juvenile RA = Dx = slit-lamp exam; Rx = steroid drops

365. Orchiopexy = correction of cryptorchidism after 1 yo; does NOT affect risk of testicular ca, wich is increased in these cases

366. PDA = congenital rubella, high altitudes

367. T4F = VSD + RV hypertrophy + pulm. stenosis + overriding Ao

368. "Tet" spells = squatting after exertion; increases venous return and peripheric resistance, keeping more blood in lungs and improving oxygenation; very common in T4F, although not patognomonic

369. Coarctation of Ao = Turner syndr; mid upper back systolic murmur, BP difference between arms and legs

370. VSD = MC congenital cardiac defect; muscular type is the one that has the greater cahnce of closing by itself before 2 yo, but rarely after 4 yo; fetal alcohol syndr, TORCH, Down syndr

371. Necrotizing enterocolitis = premature, fever, rectal bleeding, air in bowel wall; Rx = NPO, gastric tube, IV fluids, atbtcs

372. Cystic fibrosis = meconium ileus, rectal prolapse

373. Kernicterus = increased unconjugated bilirubin, depoists into the basal ganglia, poor feeding, seizures, flaccidity, opisthotonus, apnea

374. Breast milk jaundice = peak at 2-3 w; Rx = temporary bottle feeding

375. Increased unconjugated bilirubin = Criggler-Najar dis., Gilbert dis.

376. Increased conjugated bilirubin = Rotor, Dubin-Johnson dis.

377. Sulfa in neonates = displace bilirubin from albumin, leads to kernicterus

378. Exchange transfusion = unconjugated bilirubin >20 mg/dl + failed phototherapy

379. MC primary immunodeficiency = Ig A deficiency: respiratory and GI infections; avoid giving Ig (anti IgA antibodies)

380. Bruton agammaglobulinemia = 6 mo, lung + sinus infections; Streptococcus, Haemophilus

381. Wiskott-Aldrich defic. + boy, eczema + thrombocytopenia + resp. infections

382. Chediak-Higashi syndr. = giant granules in neutrophils + oculocutaneous albinism

383. Complement defic. (C5-9) = recurrent Neisserial infections

384. Chr. mucocutaneous candidiasis = often associated with hypothyroidism

385. Osteosarcoma = 10-20 yo, about the knee, "sunburst" on X-ray

386. Job-Buckley syndr = intense increase in IgE, recurrent Staph infections; fair skin, red hair, eczema

387. Unicameral bone cyst = expansile, lytic, prox. portion of humerus

388. Bitot spots(debris in conjunctiva) = vit A deficiency

389. Vit A toxicity = pseudotu cerebri, bone thickening, teratogenicity

390. Vit. E defic. = anemia, peripheral neuropathy, ataxia

391. Give vit. A for = patients with measles

392. Give vit. E for = Alzheimer\'s patients

393. Give vit C for = iron deficiency anemia (increases absorption of Fe; calcium decreases it)

394. Vit E toxicity = necrotizing enterocolitis in infants

395. Vit K toxicity = hemolysis (kernicterus)

396. Vit. B6 defic. and toxicity both manifest as = peripheral neuropathy

397. Vit. B12 (cobalamin) defic. = megaloblastic anemia + neurologic symptoms

398. Folic acid defic. = megaloblastic anemia

399. Bone pain in vit C defic = periosteal hemorrhages

400. Wernicke/Korsakoff syndr = vit B1 deficiency (thiamine); never give glucose before thiamine for an alcoholic in the ER

401. Manganese toxicity = "manganese madness\"in miners of ore

402. Chromium deficiency = impaired glucose tolerance

403. Removal of the ileum, tapeworm Diphylobothrium latum = B12 defic.

404. MCC of vit. B12 defic. = pernicious anemia

405. Pernitious anemia association = vitiligo, hypothyroidism, hypoadrenalism

406. Liver failure + increase in PT Rx = fresh frozen plasma

407. Rubella vaccine = NOT for immunocompromised patients (except for HIV), if given to a woman and she gets pregnant in the first three months after, abortion is NOT indicated, chances are nothing bad will happen to the fetus

408. Mean = average value

409. Median = middle value

410. Mode = MC value

411. Brain death with confounding medical dis. = needs additional confirmatory test

412. Tardive dyskinesia Rx = switch anitipsychotic to clozapine

413. Ac. dystonia, parkinsonism as S.E. Rx = diphenhydramine, trihexyphenidyl, benztropine

414. Akathisia Rx = betablockers

415. Neuroleptic malignant syndrome, malignant hyperthermia Rx = dantrolene

416. Thioridazine S.E. = retinal pigment deposits

417. Chlorpromazine S.E. = jaundice, photosensitivity

418. P. aeruginosa bacteremia Rx = tobramycin or amikacin + piperacillin OR ceftazidime OR cefepime

419. Ecthyma gangrenosum Rx = IV atbtc (not debridement)

420. Cryptococcal meningitis Dx = + india ink preparation; Rx = amphotericin B + flucytosine 10-14 d, then fluconasole prophylaxis forever (for HIV); may require repeated lumbar punctures to decrease the pressure

421. Phenytoin toxicity = nystagmus on far lateral gaze, neurotoxicity; remember that it decreases the OCP levels in the blood

422. Catheter-related syst. infection = removal + vancomycin + gentamycin

423. Vertebral osteomyelitis Dx = MRI is the most accurate, bone Bx is the gold standard

424. Meningococcal meningitis prophylaxis = oral rifampin OR S.D. oral ciprofloxacin OR S.D. IM veftriaxone

425. IV pentamidine S.E. = metabolic disturbances, such as hypoglycemia (always check in case of seizure)

426. Herpes zoster Rx = acyclovir within 48 h of onset of rash

427. Candida ophtalmitis with vitreal involvement Rx = vitrectomy + systemic antifungal

428. Hypothermia or shock post blood transfusion = think hypocalcemia!

429. HIV prophylaxis post exposure = zidovudine + lamivudine for 4 w

430. Lungs + sinuses infections post bone marrow transplant = invasive aspergillosis

431. Rhinocerebral mucormicosis Rx = surgical debridement + IV amphotericin B

432. MCC of FUO = infection (30-40%)

433. Progressive multifocal leucoencephalopathy (JC) = multiple focal neuro symptoms in HIV patient

434. Shoulder dystocia Rx = stop pushing, suprapubic pressure, McRobert's maneuver

435. McRobert's maneuver = two assistants flexing thighs back against abd.

436. Zavanelli maneuver = replace fetal head back into the pelvis, but then you have only 7 minutes to perform the c-section

437. ARDS = clear lungs + diffuse bilat. infiltrates on CXR; Rx = PEEP around 9, high O2 concentration, low tidal volume ( 30 mmHg; Rx = emergent fasciotomy

445. Mental status change in the elderly = meds, infection, metabolic, thyroid dis.

446. Metastasis prostate ca Rx = leuprolide (LHRH agonist) + flutamide (antiandrogen)

447. Octreotide = somatostin analog, for bleeding esophageal varices

448. Active lower GI bledding = STAT colonoscopy or radionuclide scan

449. Ac. hemolytic transfusion reaction Rx = stop it and hydrate!

450. Metronidazole = contraindicated for breastfeeding women

451. Postpartum endometritis Rx = clindamycin + gentamicin

452. Infant botulism Rx = supportive care, human derived botulin antitoxin; expect 1-3 m of hospitalization and full recovery

453. Febrile transfusion reaction avoidance = washed cells

454. Pre-angiography = discontinue metformin to avoid renal complications and acidosis

455. Hypocalcemia = hyperactive DTRs

456. Hypermagnesemia = loss of DTRs

457. Condyloma acuminata = vaginal delivery is OK!

458. Transurethral resection of the prostate S.E. = hyponatremia = twitching, seizures

459. Stress ulcer prevention = oral PPI suspension

460. Erb's palsy association = diaphragmatic paralysis

461. Torsades de points with instability = unsynchronized cardioversion, then, IV magnesium sulfate, then temporary transvenous overdrive pacemaker (in this orden, according to necessity)

462. MCC of CAH = 21-hydrolase enzyme defic. (increased 17-alpha-hydroxyprogesterone)

463. 11-hydroxilase defic. = HTN, hypernatremia, hypokalemia, due to the increase in 11-deoxycorticosterone, which is a mineralocorticoid

464. Classic dashboard injury (car accident) = post. cruciate ligament lesion

465. Mechanical valves INR goal = 2.5-3.5

466. Cimetidine, trimethoprim S.E. = decrease clearance of creatinine

467. ITP in adults Rx = corticosteroids, then IV Ig, then splenectomy (rarely needed)

468. Hyperhomocysteinemia Rx = folic acid

469. Borderline personality dis. Rx = dialectical behaviour therapy

470. RSV Dx = detection of RSV Ag in nasal/pulm secretions by ELISA

471. Sudden hyperglycemia + total parenteral nutrition = sepsis

472. Hashimoto's thyroiditis association = thyroid lymphoma

473. Chr. recurrent pancreatitis complication = isolated gastric varices

474. Doxorubicin use = serial radionuclide ventriculography or MUGA is used to evaluate cardiotoxicity

475. Hospice care = life expectancy < 6 m

476. DM screening = 45 yo, q3y if no risk factor

477. Chlordiazepoxide = Rx of alcohol withdrawal

478. Ceftriaxone S.E. = increase in both types of bilirubin

479. CIN 1 = repeat pap smear in 6 m

480. Wernicke's encephalopathy = confusion + ataxia + nystagmus (ophtalmoplegia)

481. Korsakoff's psychosis = may happen as a consequence of giving glucose before thiamine; confabulation (creating a story to fill the gap in memory); mamilory bodies changes

482. Multiple sclerosis suspicion = MRI brain and spine; Rx (acutely) = steroids; to prevent relapsing = interferon OR glatiramer (remember they are both teratogenic); repeat MRI in 3 months

483. Increased bleeding time Rx = IV desmopressin (e.g. renal failure)

484. Isotretinoin, minocycline S.E. = pseudotu cerebri

485. MC scaphoid fracture complication = nonunion

486. Orthostatic hypotension = decrease by 20 mmHg in syst BP OR 10 mmHg in dyast BP

487. Thiazides, amiodarone, sulfa S.E. = photosensitivity

488. Increase in fibrinogen happens with use of = lovastatin, atorvastatin, pravastatin, simvastatin

489. Ac. Ao dissection HTN Rx = IV betablockers + nitroprussiate

490. Dipyridamole, adenosyne = C.I. in asthma or COPD

491. Antenatal corticosteroid therapy = 24-34 w = IM bethametasone, dexamethasone

492. 50 mg oral glucose challenge >140 = do a 100 mg OGTT with 3 h measurement

493. Glucose in pregnancy goals = fasting 60-90, postprandial < 120

494. TMP-SMX = NOT in first and third trimester

495. Pyelonephritis + pregnancy Rx = IV ceftriaxone OR ampicillin + gentamycin

496. Condyloma acuminata in mucosa or pregnancy Rx = trichloroacetic acid

497. Severe PID Rx = IV cefoxitin/ceftriaxone + IV doxycycline

498. Next day pill = levonorgestrel (up to 120 h after)

499. Cystic fibrosis infertility = 95% for men, 20% for women

500. Hyperthyroidism + pregnancy Dx = free T4, total T4, TSH

501. Pap smear screening = 3 y after first intercourse or 18 yo

502. Hypothyroidism in pregnincy = dose of L-thyroxine needs to be increased (increased thyroglobulin)

503. Pessaries (+ vaginal estrogen) = structures to support the vagina walls

504. ASCUS Dx next step = HPV DNA testing, then colposcopy if necessary

505. RA with poor response to methotrexate = infliximab OR etanercept; do a PPD first!

506. PCP intoxication Rx (if patient not extremely agitated) = low-sensory enviroment; haloperidol, diazepam if necessary

507. Metoclopramide S.E. = extrapyramidal symptoms

508. Influenza Rx = zanamivir, rimantadine or amantadine within first 30-48 h of symptoms

509. Sup. vena cava syndr = CT of neck + chest wcontrast

510. MCC of Guillain-Barre syndr = C. jejunii infection; Rx = IV Ig or plasmapheresis, respiratory support if necessary, keep an eye on the patient, with bedside pulmonary function tests!

511. Ac. stress disorder = < 4 w post event

512. Post-traumatic stress disorder = > 4w post event, even years

513. Hyperviscosity syndr = Waldenstrom's macroglobulinemia (increased Ig M), multiple myeloma

514. PE suspicion = V/Q scan, then venous USG, then CT angiogram of the chest (in this order, if necessary)

515. Chlamydia infection + HLA-B27+ = Reiter's syndr; Rx = atbtc, exercise, sulfasalazine, methotrexate

516. Ethylene glycol = severe anion gap acidosis, Kussmaul's respiration

517. Ethylene glycol, methanol intox. Rx = fomepizole infusion (ADH competitive inhibitor)

518. Klinefelter\'s syndr = risk factor for male breast cancer

519. Doxycycline S.E. = photosensitivity

520. Isotretinoin S.E. = hypertriglyceridemia, may lead to pancreatitis

521. Pulm. contusion Rx = admission for 24-48 h, pulm. toilet, O2, pain control, fluid management

522. Renal cell ca = renal mass + polycythemia + flank pain + smoking

523. Amiodarone S.E. = thyroid dysfunction, corneal deposits, skin discoloration, pulm. fibrosis, liver toxicity

524. Metformin S.E. = metabolic acidosis, weight loss

525. Glyburide = metabolized by kydneys; glitazones = metabolized by liver

526. indirect inguinal hernia Rx = elective repair ASAP

527. TSS Rx = clindamycin +/- naficillin + IV fluids (up to 20 L!)

528. Metformin C.I. = CHF, alcoholism, renal failure

529. Glitazones C.I. = CHF NYHA classes III, IV

530. C. difficile infection is caused by = clindamycin, ampicillin, amoxacillin, cephalosporins

531. After 2 cystitis in 6 months = prophylaxis for 6-12 m

532. Decreased TSH, but normal T3, T4 = repeat TSH after 6-8 w

533. Anorexia nervosa with 20% plasma cells), skeletal suvey, whole body XR

554. Cleft lip surgical correction = 10 pounds, 10 weeks, 10 g of Hb

555. Marfan's syndr = corrective Sx when Ao root = 45 mm

556. Asymptomatic alfa 1 antitrypsin defic. = spirometry q3 m

557. Opioid withdrawal + HTN Rx = clonidine

558. Meningoencefalitis + pneumonia + splenomegaly = Chlamydia psittaci pneumonia (birds contact); Rx = doxycycline 100 mg q12h for 21 days

559. Lyme dis. with Bell\'s palsy = order CSF analysis!

560. Asymptomatic increase in TSH = order anti-TPO!

561. Any bite Rx = ampicillin-sulbactam

562. Exposure to active TB = immediate PPD, if - repeat in 3 m

563. Early stress fracture Dx = MRI, triple phase bone scans with tecnitium; Rx = rest for 4-6 w, pain control, gradual return to activity

564. Spinal epidural abscess Dx = gadolinium-enhanced MRI or CT with myelography; Rx = early surgical decompression + drainage in the first 24 h

565. Lactose intolerance = yogurt is recommended

566. Ureteral stones < 5 mm = usually pass by themselves; if not = shockwave lithotripsy

567. Ureteral stones > 8-10 mm = flexible ureteroscopy + laser lithotripsy

568. Cervical cerclage = done at 13-17 w, removed at 36 w

569. Scrotal trauma with abnormal PE = surgical exploration

570. Risk factor for prostate cancer = start screening (PSA + DRE) at 45 yo

571. Alopecia areata Rx = topical or intralesional corticosteroids

572. Hypokalemia + paralytic ileus = correct hypokalemia immediately!

573. Marfan\'s syndr = dural ectasia (MC), ectopia lentis, Ao dilatation, MVP

574. Pineal tu = Parinaud\'s syndr = loss of pupillary reaction, vertical gaze, optokinetic nystagmus, ataxia, can secrete HCG

575. MC symptom of sickle cell dis = dactylitis; second = splenic sequestration

576. Cough due to forced expiration = asthma

577. Common migraine = no aura; classic migraine = aura +

578. Chlamydia in pregnancy Rx = erythromycin

579. DM retinal, vitreous hemorrhages Rx = laser photocoagulation

580. Sydehams chorea Rx = oral penicillin 10 d, then prophylaxis

581. HAART Rx for asymptomatic HIV = CD4 < 350, viral load > 55000, check q 3 m

582. Paget's dis of the bone Rx = biphosphonates (alendronate)

583. First generation relative with colon ca = start screening at 40 yo

584. Asymptomatic bacterial vaginosis in pregnancy = NO Rx!; if high risk for preterm labor or symptomatic = oral metronidazole or clyndamycin

585. Anaphylaxis with pulm/cardiovascular symptoms = epinephrine IV

586. Hemochromatosis Rx = therapeutic phlebotomy

587. Penicillamine = promotes excretion of copper

588. Post communicating art aneurysm = CN III palsy

589. Inoperable head and neck ca = chemo + radiotherapy

590. P. carinii pneumnia Dx = fiberoptic bronchoscopy with bronchoalveolar lavage; Rx if mod/severe = admission + IV TMP/SMX, add corticosteroids if A-a gradient >35 or pO2 220, dyast > 120

600. Rhabdomyolisis causes = cocaine, acohol, trauma, exertion. hypothermia, hypothyroidism

601. Drugs that cause pancreatitis = diuretics, valproic acid, metronidazole, tetracycline

602. Peripheral vasc dis Rx = cilostazol (platelet inhibitor and art vasodilator)

603. Rocky mountain spotted fever Rx = doxycycline

604. New onset of severe seborrheic dermatitis = order an HIV test!

605. Necrotizing fasciitis due to group A strep Rx = surgical debridement + IV clyndamycin

606. Pill-induced thyrotoxicosis = undetectable thyroglobulin

607. Graves dis. Rx = bring the patient to a normal thyroid state with beta=blockers, PTU, methimazole, then radiodine ablation + glucocorticoids (for ophtalmopathy)

608. Thyroid storm Rx = PTU or methimazole + glucocorticoids

609. Cushing\'s triad (increased ICP) = bradycardia, HTN, respiratory depression

610. Postherpetic neuralgia Rx = desimipramine, amitriptyline, capsaicin, gabapentin, topical long acting oxycodone

611. Diabetic neuropathy Dx = nerve conduction studies

612. Amaurosis fugax = carotid doppler evaluation

613. TCA induced VT Rx = lidocaine

614. Watching out for scleroderma renal involvement = monthly BP measurement

615. Constructional, dressing apraxia = nondominant parietal lobe lesion

616. Aphasia = dominant temporal lobe lesion

617. Porphyria cutanea tarda = painless blisters + hyperthricosis + hyperpigmentation, associated with hepatitis C

618. Lyme arthritis Dx = synovial fluid ELISA or western blott; Rx = 30 d of amoxicillin or ceftriaxone or doxycycline or erythromycin; 90% of cure in 1 y

619. Pheochromocytoma Rx = alpha blockade 10-14 d pre-op + CT/MRI

620. Neonate opiate withdrawal Rx = paregoric or tincture of opium

621. Amyotrophic lateral sclerosis Rx = riluzole

622. Neurogenic syncope = vasovagal, common faint

623. Autonomic neuropathy = leads to postural hypotension

624. Restless legs syndr Rx = pramipexole, ropinirole (dopamine agonists)

625. Pick's dis = slowly progressive frontal and/or temporal lobe dementia = not only cognitive, but behavioral changes

626. Varicocele complication = testicular atrophy

627. Obesity surgery indication = BMI > 40 kg/m2

628. Ao stenosis association = angiodysplasia in colon

629. CO poisoning = several people in the same household with throbbing headache, nausea, malaise, dizziness

630. Ovaries = 2-3 cm in young women, non palpable after menopause

631. Venous sinus thrombosis Rx = heparin, even with hemorrhagic infarction

632. Ac. variceal bleeding = give fluoroquine 7-10 d for infection prophylaxis, it improves the outcome

633. Infant botulism symptoms = decreased gag reflex, constipation, lethargy, poor sucking

634. Ac. gout Dx = arthrocentesis; Rx = ibuprofen, indomethacin, colchicine, glucocorticoids

635. Giardia = no eosinophilia

636. Down syndr screening = AFP, HCG, unconjugated estriol, dimeric inhibin-A

637. Severe pneumonia Rx = hospitalization + ceftriaxone + azithromycin

638. Delayed puberty = no increase in testicle size by 14 yo, diameter < 2.5 cm; Dx = bone age determination (XR)

639. HTN + scleroderma renal crisis Rx = ACEi

640. Scombroid = fish bad conservation; 10-30 minutes after ingestion, patient has histamine realted symptoms; self-limited

641. Ac. dystonic reaction (e.g. metoclopramide) Rx = IV diphenhidramine

642. Urine toxicology = urine immunoassay screen (results in 1 hour)

643. Achalasia = dysphagia for both solids and liquids

644. Fasting blood glucose 100-126 = increased risk for CAD; metformin may be given, specially if metabolic syndr present

645. Sjogren's syndr Dx = minor salivary glan Bx is gold standard

646. Celiac dis. Dx = anti-endomisial, anti-tissue transglutaminase Ab levels

647. SAH = xantochromia in CSF is found only after 4 h of symptoms

648. COPD prognosis = FEV1

649. Cosyntropin stimulation test indication = adrenal failure

650. RA = clinical Dx; if RF - order anti-CCP Ab; if erosive joint dis = treat with methotrexate and other DMARDs

651. Mother with DM type I = 3% risk, father = 6% risk the child will have it too

652. Transverse myelitis = rapidly progressive weakness post URI + sensory loss + urinary retention

653. Nonbacterial prostatitis Rx = sitz baths + NSAIDs

654. Mesenteric ischemia = metabolic acidosis

655. HIV teratogenic drugs = efavirenz, delavirdine

656. Dextrose + insulin = decrease tryglycerides

657. Extrapyramidal symptoms + dementia = subcortical dementia

658. Carpal tunnel syndr initial Rx = continuous wrist splint

659. Cutaneous cryptococcosis suspicion = bx of skin lesions

670. Trichomoniasis in breastfeeding mother = no breastfeeding for 24 h after SD of metronidazole, discard pumped milk

671. Erysipela = group A strep

672. Papillary thyrois ca Rx = near total thyroidectomy; no need to stage before it

673. Onychomicosis Rx = oral terbinafine or itraconazole

674. Disseminated gonococcal infection Dx = cultures = joint fluid, mucosal surfaces

675. Lead blood level > 44 = chelation therapy; intoxication = > 10

676. Vit B12 replacement = check K closely for 48 h (it may decrease quickly)

677. Dumping syndr Rx = high prot, low carbohydrate diet

678. Initial screening for infertility = semen analysis

679. Excess iodine contrast S.E. = thyrotoxicosis

680. CD4 < 200 = TMP/SMX (P. carinii)

681. CD4 20 = FFP, IV vit K; between 5 and 20 = oral vit K; 20, order imaging studies

701. Tinea versicolor Rx = topical terbinafine

702. Bacterial overgrowth Dx = quantitative jejunal cultures

703. Ultrarapid acting insulin = lispro, aspart

704. Hydrocortisone = low-potency steroid

705. Betamethasone = high-potency steroid

706. Barret's esophagus without dyspalsia = endoscopy + Bx q 1-3 y

707. Premenstrual syndr Rx = SSRIs; no improvement = alprazolam

708. Retrosternal goiter with compressive symptoms = surgery

709. Drugs that decrease sexual drive = bupropion, mirtazapine

710. Valproic acid S.E. = urinary frequency and incontinence

711. Renal art. stenosis Dx = MR angiography

712. Primary pulm. HTN Rx = anticoagulation (INR = 2) + oral vasodilator

713. CoAo Dx = MRI of chest

714. Undescended tests = wait until 6 mo

715. Initial smoking cessation aid = high dose nicotine patch (but patient needs to be commited, because smoking using the patch may lead to coronary spasm and even MI!); bupropion later

716. Initial sleep apnea investigation = medical workup (investigate hypothyroidism too)

717. Rare event study = meta-analysis (incerase sample size, therefore increase power); limitation = heterogeneous studies put together

718. Mass in the hepatic duct Rx = ERCP + stent placement; if it fails = percutaneous transhepatic cholangiography + stent

719. Borderline personality = splitting, e.g. primitive idealization; Rx = dialectical behavour therapy

720. Falling on an outstretched hand = scaphoid fracture; Dx = CT scan of the hand, bone scan; complication = nonunion

721. Epidural spinal cord compression (metastasis) = thoracic radicular pain, neuro symptoms; Rx = high dose corticosteroids, MRI, radiation

722. Hemochromatosis Rx = phlebotomy

723. Penicillamine = promotes copper excretion (Wilson\\\\\\\'s dis)

724. Extremely ominous sign of preeclampsia/eclampsia = retinal hemorrhages

725. Ac. adrenal insuf. Rx = dexamethasone + cosyntropin stimulation test

726. Symptomatic rectocele Rx = surgery or pessary + estrogen cream

727. HIV and RPR + = CSF examination; if nl = benzathine penicillin weekly x 3, warn about possible Jarisch-Herxheimer reaction

728. Painless low GI bleeding = colonoscopy or radionuclide scan with technitium-99

729. IgM HIV Ab assay = low sensitivity, do NOT use!

730. Indeterminate HIV ELISA = order HIV RNA PCR assay or p24 Ag

731. HIV with or without Rx = monitor CD4 count and HIV load q 3-4 m

732. Survival analysis = accounts for number of events AND timing of events

733. Blepharospasm = focal dystonia; Rx = botulin toxin injection

724. Prerenal azotemia = decrease fractional excretion of sodium

725. Drug-induced allergic interstitial nephritis = happens after 3-5 d of causal agent; eosinophils in urine

726. Most benefitial step to decrease osteoporosis risk = quit smoking

727. Ankylosing spodilitis suspition = X-ray sacroiliac joint, repeat q 3 m + ESR

728. Chr. Foley catheter + candida on urine culture = no Rx if asymptomatic

729. Viral meningitis in chidren = enterovirus, arbovirus; in adults = HSV

730. Drugs with thrombocytopenia as S.E. = clopidogrel, heparin

731. Ideal blood culture = 1 h before fever

732. Chr. non-remiting cluster headache Rx = verapimil, lithium; ac. crisis = 100% oxygen inhalation

733. Condyloma acuminata in pregnancy = do NOT use podophilin, use trichloroacetic acid instead

734. Chr. hepatitis C Rx = interferon alpha-2b (+/- ribavirin)

735. Hormone replacement therapy cessation = do not do it abruptly, taper it down instead!

736. Confidence interval includes 1.0 = not sattistically significant

737. Latent TB infection = PPD + and CXR WNL; Rx = isoniazid + B6 for 6-12 m

738. ARDS causes = sepsis, pneumonia, severe trauma, burns, drowning, pancreatitis; clear lungs on PE + diffuse, bilat infiltrates on CXR; Rx = PEEP around 9 cmH2O, high O2 concentration, low tidal volume (6 ml/kg)

739. Emergency contraception after 120 h = copper IUD

740. DM + C-section prep = normal insulin the night before; insulin drip + D5 1/2 NS + KCl during the day, keep glucose

741. Single most important predictor for CV risk = DM

742. Diet for diarrhea = normal, age appropriate with low fat and low sugar

743. Sedative and hypnotic drugs for the elderly = increased risk for falls, so risk x benefits have to be carefully evaluated

744. BZD withdrawal = tremolousness, seizure, psychosis, increased HR, BP, body temperature, anxiety, restlessness, confusion, disorientation; Rx = IV lorazepam, diazepam

745. Anemia of chr. dis. = RA, SLE, vasculitis; if severe, with normal erythropoietin levels = red cell transfusion

746. Sjogren\'s syndr Dx = anti-Ro, anti-L2 in salivary gland; gold standard = labial minor salivary gland Bx = focal collections of lymphocytes; associated with non-Hodgkin\'s lymphoma (B-cell lymphoma)

747. MEN 1 = hyperparathyroidism, pancreatic tu, pituitary tu

748. MEN 2A = medullary thyroid ca, pheochromocytoma, hyperparathyroidism

749. MEN 2B = medullary thyroid ca, pheochromocytoma, mucosal neuromas, marfanoid habitus

750. Vertebrae osteomyelitis and diabetic foot = most accurate test = MRI; gold standadrd = bone Bx; culture = deep curetage tissue

751. Addison\'s dis = decreased Na, increased K, hyperchloremic metabolic acidosis; Dx = ACTH stimulation test, early mornong cortisol

752. IV pentamidine S.E. = increased or decreased K, decreased Ca, hyper or hypoglycemia

753. Obesity surgery indications = BMI > 40, coexisting diseases, decreased quality of life

754. Erb's palsy prognosis = 80% chance near full recovery in 1 y

755. NF 1 = cafe-au-lait spots, cutaneous neurofibromas, axillary freckling, unilat. acoustic neuroma

756. NF 2 = hypopigmented spots, family history of bilat. deafness (bilat. acoustic neuromas)

757. Tuberous sclerosis = congenital ash-leaf spots, glial prolipheration, organ hamartomas/cysts

758. Sturge-Weber syndr = facial port-wine stain, leptomeningeal angiomatosis

759. Osler-Rendu-Weber syndr = vascular lesions of the CNS, multiple telangiectasias

760. Diaper rash Rx = topical zinc oxyde paste, petrolatun, keep area dry; if it fails = low-potency corticosteroids ointment, but keep an eye open for fungal infections!

761. Situations with increased amylase = pancreatitis, ac. parotiditis, intestinal dis., renal failure, cholecystitis, fallopian tube dis.

762. Mild ac. pancreatitis Rx = IV fluids + pain control + NPO + NG tube aspiration; atbtcs if severe necrotizing pancreatitis, fever, evidence of infection (imipenem, third gen. cephalosporin, piperacillin, fluoroquinolone, metronidazole); if it fails = CT-guided aspiration of tissue, culture and sensitivity

763. Infant, children with TB meningitis Rx = 12 m of anti-TB drugs + corticosteroids; if resistant = 18-24 m

764. LDL goal is < 100 in = coronary dis. peripheral and cerebral vascular dis., DM

765. Hypophosphatemia = respiratory weakness, hemolysis, decreased release of O2 from Hb

766. Postpartum endometritis + breastfeeding Rx = clindamycin + gentamycin; main risk factor = C-section

767. Sarcoidosis = hypercalciuria, hypercalcemia, thrombocytopenia, increased serum ACE, hypergammaglobulinemia

768. Herpes gestationis = paules, plaques, vesicles around umbilicus; Rx = topical steroids, oral antihistamins (it has nothing to do with the virus)

769. Inflammatory myositis Rx = high-dose glucocorticoids (prednisone 1 mg/kg), immunosuppressants

770. Depot medroxyprogesterone indicated as contraceptive = menorrhagia, PID, fibrosis, heavy smoking; decrease the incidence of endometrial ca

771. Shuffling gait = decreased speed and amplitude of leg movements; Parkinson\'s

772. Spastic paraparesis = patient drags legs forward, no bending of the knees

773. Cerebellar ataxia = "drunken sailor", zigzag, jergy gait

774. Senile gait = "walking on ice"

775. Neonatal polycythemia = Htc > 65%, apnea, hypoglycemia, increased bilirubin, cardiac and respiratory compromise; Rx = adequate hydration + partial exchange transfusion

776. C. botulinum soil spores = California, Pennsylvania, Utah

777. Neuropathic ca pain Rx = sharp = carbamazepine; dull = desipramine

778. Organophosphate poisoning Rx = atropine + pralidoxime

779. Meralgia paresthetica = entrapment of lat. femoral cutaneous nerve

780. Higher specificity = higher PPV; higher sensitivity = higher NPV

781. Emphysematous pyelonephritis (DM) Rx = IV atbtcs + immediate nephrectomy

782. Pregnancy + epilepsy with no seizures for 2-5 y = try to taper down and withdrawal the drug

783. No adequate response to osteoporosis Rx = investigate multiple myeloma!

784. Pseudomembranous colitis = repeat immunoassay if - but strong suspition, repeat Rx with metronidazole if no response on first try

785. Diabetic mononeuropathy prognosis = very good, improvement in a few weeks

786. Metoclopramide = many S.E., tachyphylaxis

787. Single small pedunculated polyp = colonoscopy q 3 y

788. Seizures post stroke Rx = phenytoin, carbamazepine

789. Glucocorticoids for < 3 weeks = no need to taper it down

790. Increased anion gap metabolic acidosis = renal failure, ketoacidosis, lactic acidosis, metformin, intoxications = aspirin, ethylene glycol, methanol

791. CCS - Rupture of AAA case = order monitors, oxygen, IV access BEFORE PE

792. CCS - DKA = order calcium, phosphate, amylase, lipase, serum osmolality, ketones

793. CCS - COPD with pneumonia = monitor peak flow and FEV1

794. CCS - Anaphylaxis case = give epinephrine BEFORE PE

795. CCS - Paracentesis needed = order analysis of the fluid = ceel count, diff., prot, glucose, cytology; depending on the case = Gran stain, culture, AFB staining, amylase, bilirubin

796. CCS - Domestic abuse = urine toxicology, skeletal survey, support group, social worker

797. CCS - SLE = ESR, serum ANA, UA, CXR, total complement, anti-ds DNA, DEXA, prednisone, NSAIDs, rheumato consult, nephro consult, sunblock use

798. CCS - Croup = cool mist tent, decadron, racemic epinephrine, observe for 4 h

799. CCS - Turner's syndr = GH, oxandrolone, estrogen + progestin, vit. D

800. CCS - When ordering corticosteroids in high doses or prolonged use intended = H2 blockers, vit. D, calcium, DEXA scan, exercise, sometimes even biphosphonate

Gulf war syndrome

Veterans of Persian Gulf War (8/90-6/91)

25,000 troops with unexplained symptoms post exposure

Etiology

Thought to be related to Neurotoxin exposure

Ammunition detonated in March 1991

Ammunition dump contained Sarin

Likely 100,000 troops exposed

Symptoms

Fatigue

Headache

Joint pain

Stiffness

Muscle pain

Hair loss

General weakness

Nasal and sinus congestion

Diarrhea

Excessive Flatulence

Abdominal pain

Memory problems

Impaired concentration

Word finding

Insomnia

No decrease in fertility in Gulf war veterans and no increase in teratogenicity.

DKA

blood electrolyte value,ABG and serum osmolality

Use of sodium bicarbonate has some unwanted effect on DKA, if PH is 7.0 or less or HCO3 is below 9meq then NaHCO3 should be given once ph reach 7.1 d/c bicarb.

if potssium < 5 then give potassium( pt.should have good urine out put)

if phosphate is < 3 -add phosphate replacement

if

Is glucose < 250- add dextrose AZT-side effects

Lactic acidosis one of seriuos complication.

myositis is most common best predictor of good htn control is preserved target organ dammage.

difinitive symptom of left heart failure is dyspnea and Sign is s3,

Bactrim and Cipro both increase Warfarin\'s concen ,interferes with

the mechanism of warfarin redultant increae bleding tendencies

Tetracycline is not interact with warfarin, but not good choice for UTI.

emergent oral contraceptives.- high dose estrogen, high dose progestin

High dose ehtinyl estradiol for 5days (estro)

or

high dose Levonorgestrel bid (progestro)single dose

or

Ovral 2 tab Bid (high estro + high progestro)

All have start within 72 hrs

or

mifepristone within 120hrs

or

IUD within 5days.

Emergency contraception (also known as the morning-after pill) is a high dosage of the birth control pill. It is recommended to be used after sexual intercourse, over a period of 72 hours, to achieve the goal of preventing or ending pregnancy. There are three different ways birth control pills are currently being promoted for this use: progesterone alone, estrogen alone, or both of these artificial steroids together. These are the same steroids found in the typical birth control pill.

UTI

ADENOCARCINOMA IN WOMEN IN FIFTIES

DOUDENAL ATRESIA

LEAD POISINING IN 18 MO OLD

PERICARDITIS

PERICARDIAL EFFUSION

DUB

UNCONSCIOUS MAN IN 40 WITH R/R 8

there was also a question set on Gulf war syndrome 4 qustions, mostly how would u responde to his qustions

sign of rotator cuff injury

pain with abduction at shoulder joint

acalculous cholycystitis laperoscopic cholecystectomy

ac choly in first trimester-conservative, u operate in sec trimester

Surgery in 2nd trimester,

Only concern about acalculous cholecystitis is prognosis is gaurded without surgery.

pedigree thalassemia

Rx of Elderly insomnia

Type of DM with grand pa thyroid and father parathyriod ca

chronic metal exposer with crystal in perepheral smear

Pt with dig subendocardial MI next step asa and heparin

Leukocoria (white pupillary reflex or cat\'s eye reflex) is the most common presenting sign in retinoblastoma.

Best treat for WPWS is procanamide

Adenosine used to temporarily treat CMTs

But Procainamide blocks the accessory Pathway.

stable--procainamide, unstable--cardioversion

ASA\" IS BEST for post MI, for Mortality Reduction

primary and secondary syphilis both r transmissible

quinolone Decreases excretion oh thyephyline

quinolone +coumadin=Incr risk of bleeding,causesincr

Tension headache typically occur daily, begin later in the day.

Cluster headaches are different from tension headaches.

Waking up at night charac of cluster headaches.

morning after pills.maost common side effects nausea and vomitting

Scombroid: allergic-like symptoms due to histamine ,begin within 15-90 min.Nausea, omitting,diarrhea, flushing, itching

chinese restaurant syndrome? It is due to oversensivity of people to monosodium glutamate.

Cigutera:(fish)

1-6 hrs after ingestion, victims develop GI sx accompanied by a variety of neurologic sx.

Scombroid:(fish)

Allergic-like SXs usually begin within 15-90 mins also with GI Sx.

Bacilus cereus:

The incubation period is 1-6 hrs.

!)most cc of hypothyroidism is hashimotos..

2) most cc of dizziness in elderly is their medciation

3)most cc of impotency is antihypertensive medciation and ssris..

4)tumor marker for melignant melanoma is s-100

5)if family history of ovarian ca is positive then yrly pelvic exam and ultrasound is screening test...

6)no bone scan for melignany melonoma bcz these r lytic bone lesion not osteoblastic...

7)dontjust give ca for steoporosis or jut s vitD both along with alendronate

8)if pt on alendronate or any of these easophagitis is the most common risk so ask pt that take medcine with galss of water and sit up for 30 minutes after take medciation

9)griseofulvin is beetr absorb if taken with fatty foood..not for kids just liek cipro u cant give pt less tahn 10(cipro)

10)if pt is having meliganncy or some bed ridden condition he or she needs anti coag for life

11) d/c ocp i month b4 surgery and restart i month after

12 )d/c coumadin at least 48 h b4 surgery

13) d/c asp 10 days b4

14)d/c heparin 4 h b4 going to or...half life for heparin is 90 minutes

15) if heparin reversal is reqguired then reverse 100 unit ofheparin with 1 mg of protamine sulfate and thats how u calculate the dose...

16)b4 giving all protein inhibiters plez check all th ept medciation bcz of lots of inter action

17) if ptis on pis..then no rifampine but rifabutin

18)if ca is high recheck ist

19)if recheck ca is still high then check pth

20) if pth is low and ca is high then think of sarcoidosis

21)if pt is hypovolemic and has ccf always put central line so u can measure cvp....but remmber ccfis not a contraindication forivfluids if can always give lasix

22)if ca is low always check albuminist

23) never ever pick hypertonic soulutionin exam unless pt is not seizing or na is less than 115...always restrict fluids..

24)in siadh urin eosmolaity will b higher than th e serum..

25)in melig ca is high bcz it s produced by pth like protein which is also produced by granuloma in sarcoidosiss...and for melignancy hypercalcemia steroid will b best forothers ist try ns and lasix then iv palmidronate...

28)mallet fx close reduction is goood

29)collls fx close reduction withlong arm cast

30) supracondylar fx in a kid is a surgical emergency ...orif is th e ans and asap...but of nerve palsy risk...

31)smith fx...fx of distal radius withventral displacement due to fall when forearm is supinated and hand is extended...

32)scaphoid fx..risk of avascular necrosis,dont do xray its is neagtive until 2 wks...

33)fall on feet calcanious fx...orif is req

34)dont give flumazenil if mix drug over dose bcz it dec threshold for seizure and dont ever give in tricyclic od...

35)plez read dif bet tricuspid atresia and transposition of great v..both cause cyanosis on ist day...but dif is on t e xtay in vascularity of pul v ..i dont recall rt now bcz its middleof th enite i dont wana put anything which i am not sure about...but its vvvimp...

36)if 6 wks of abx is not able to bring fever down in acut e bec endocarditis....call cardiology asap...

37)any kid wit fever ifless tahn 3 month admit her or him to r/o sepsis

38)suction rectal biopsy is best to diag hursprung

diease butist will b kub

39) plez remmber ist test for stess incontinence or heamturia or enuresis will b ua

40)cobble stone aaprence is in crohnand appple core lesion is in colorectal ca

41)central incisor dental carries r due to nocturnal bottle feeding...

42)last but not th eleast just remmber where u c xray ,ultrasound,excercise behaviour therapy,diet ,reassurance,smoking cessation,alcohal abstinence ,nsaid thatis most likely the ans..

fasinopril is best medicine for hypertention due to conn syndrome...

for perioperative control of htn bb is always prefered

ace inhibiter is goood only if uni lat renal artery stenosis in bilateral its contraindicated

in exam dont order tft just order tsh ist its cost efective and best way to know about hypo or hyperthyrodism..

after treatmentof hyperthyroidism f/u with free thyroxine level not tsh...

dont give rai to a preg lady...no pregancy 6 m b4 or after use of rai...cause hypothyrodism....and teratogenic for baby..

if u want prescrive isotrention bcz its best drug for nodular cystic acne do preg test ist...

no pnumovac b4 2 yrs of age its not effective and no imunoglobulin with in 11 month with mmr other vaccination pd is 3-6 m but for mmr its 11 months...

if some body have reaction after gettingimunoglobulin then they r IGA DEFIENCT...

NSALINE IS BEST FOR MVA...WHY BCZ NO LR IN TRUMAA BCZ OF RHABDO ORPOSSIBLE HISTORY OF RENAL PROB SO NS...ONLY

NS IS ALSO GOOOD FOR RENAL FAILURE PT AND NEURO SURGERY PT BCZ LESS K..AND WILL NOT CAUSE HARMFUL EFEFCT...

NO SUCCINYCHOLINE FOR A BURN PT BCZ OF INC CHANCE OF HYPERKALEMIA BCZ THEY HAVE EXTRA POTASSIUM RECEPTERS..

MORPHINE I/V B4 DRESSING CHANGE IN THE BURN PT

NO INHALATIONAL AGENT AND SUCCINYLCHOLINE IF HISTORY OF MELIGNANAT HYPERTHERMIAA....GIVE DENTROLINE..MUSCLE WEAKNESS IS CHEIF SIDE EFFECT OF DENTROLIN ITS IS ALSO BEST FOR NEUROMELIGNANT SYNDROME WHICH IS DUE TO INC CA RELEASED FROM SARCOPLASMIC RETICULAUM AND CAUSE FEVER AND RIGIDITY

IF PT HAS PARKISNISM DONT GIVE REGLON FOR VOMITTING BCZ IT IS HIBITER OF DOPAMINE HE NEEDS DOPAMINE ..

IF CYSTIC BREAT SNODULE DO FNA WITHOUT MAMO IF PT IS LESS THAN 35

IF NONPALPABLE MASS BUT SUSPICIOUS CALFICATIONON MAMO THEN DO NEEDLE DIRECTED BIOPSY..

the dif bet primary and secondry addison diease is primiry start with p and p is for pigmentation so in c pigmentation due to inc acth in primary addison diease and secondry no pigmentaion due to dec acth..

in diabtes kidney will b double in size remmber d for diabetes and d for double.....but in htn its shrinked...see the dif..

TBG WILLL INC IF TOTAL T4 WILL INC BUT FREE T4 WILL B NORMAL...

IF THYROID MASS AND TSH IS NORMAL DO FNA

IF INC TSH DO THYROID SCAN

IF PT HAS AAA AND ANY CARDIAC DIEASE TERAT CARDIAC IST LIKE DO CABG BCZ MOST CC OF DEATH FROM ALL MAJOT VASCULAR DIEASE LEIKE CAROTID ENDARTERCTOMYOR AAA REPAIR IS AMI..SO FIX HEART IST IF NOT URGET...

IF BPIS MORE THAN 180/85 AND PT SAID IT WAS HIGH IN MALLL TOOO TREAT IT BCZ THATS WH THEY GIVE U THIS SENARIO...OTHERWISE RECHECK I MORE TIME....AND THEN EXCERCISE AND DIET IST AND IF FAIL THEN START WITH DIURETIC AND BB..

epidural hematoma is lenticular in shape on ct head while subdural hematoma is cresent shape..

do physical ist and report child abuse later bcz u have to have som e solid evidence ist...on physical exam to report otherwise its worthless even though if u r just suspicious and u report falsely u will not b panished...

plez plez plez move pt before last 5 minute on ccs cases bcz u will not b bale to go back and do any thing even u cant see the lab result...just u can write new order do councliing and delete som eorders...so plez dont forget otherwise no marks on that most impstep of ccs..

pertussis and bronchiolitis both can b diag by nashophrangeal wash ingor culture

catthral phase of the pertusis is mos contageous and

abx erythromycine act best if given early not efeective if given late in sec phase

pertussis is the only diease which if mom had will not provide immunity through antibody frommom u have to protect the baby tooo

the most comom cause ofinfection with pertusis in incomplete vaccinationagaisnt pertusis...7-10% cases still occurs even after child is immunized

erythromycine to close contact is imp to save them from this contagious diease..

pertusis is reportable disease

isolate the child dont send to day care or schoool until cough is not gone...

sever cases need steroid and mild need humidified oxygenand erythro...

if gcs is less than 7 must intubate

if in nutropenic fever pipercillin is not helping and fever is more athn 7 days addd ampho b bcz fungal infection is also cause this

after every transplant cmv infection r most common

to differentiate bet the inc bun/creatinin weather its due to transplant rejection orcyclosporin..do ultrasound...and see if the transplant site is tender and pt has fever if both r present then its rejectionand if both r negative its due to cyclosporin,never d/c cyclosporin just dec the dose..and recheck bun/creatinine

the idea behind giving lactulose in heaptic encephalopathy is toconvert nh3 to nh4 ion so ph of th e stool should b inc and we give neomycin to stablize the bowel...so both go hand in hand

if sclerotherapy or banding didnt help to stop bleed and pt dont want surgery or not stable for surgery then do TIPS...

eevn though they say do medical management always calll consult when u think its neccessary.....but plez dont calll surgery for chest tube..if u r er doc...imeanif pt comes in e r...but definatel;y call if pt r/i for mi or bect endocarditis or aortic stenosis or a fib ,som etimes we forget in exam we think its normal....but it gives u negative marking...andits not goood for ur over all score...

a)scoliosis..they will ask u ist test..that is a/p xray dont chooose multiple view just single i s enough...

they will ask if angle is less than 20 regular check up and f/u every 3-6 month

they will say if angle is bet 20 -40 then milwakie brace , u hav e wear day and nite and for three to 4 yrs if pt is growing like in 13-15 yrs of age

most prognostic factor is age of puberty tooo

more than 40 need orthopedic referal....suregery is only if they hav ecardio pulmonary compromise...

b)atopic dematitis..... v imp they will ask any thing so b prepared

c)poison ivy....is contact dermatitis....linear lesion is typical.... they will ask u u will c...steroid iv or other forms is the ans..

diaper rash .....is irritant contact dermatitis.... the will ask u

Guest

THE END.