Dr. Jiggy's Facts... Quick Review Of Step 2

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CARDIOLOGY:

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1. Stable angina

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chest discomfort, can be felt in back, arms, jaw, abdomen, and occurs with stress and emotion, relieved with rest, diagnosed with stress test.

Treatment with nitrates, beta blockers, Calcium-channel blockers (Cabs), heparin, aspirin,

if 3 vessels or left main artery do CABG.

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2. Unstable angina

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unpredictable at rest or abruptly worsening pattern of angina, prolonged duration (>20)

diagnosed with ECG (ST depression, T inversion) or catheterization shows coronary artery disease, but negative cardiac markers

treatment with nitrates, cabs, beta blockers, heparin.

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3. Variant or Prinzmetal Angina

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chest pain at rest, ST elevation (note the 3 causes of ST elevation are MI (inferior left diagonal artery is II, III AVF; lateral circumflex artery is I, AVL, V5, V6; anterior is V1-V4), Pericarditis (diffuse, meaning every lead has it), and Variant Angina with negative markers. Treat with Calcium-channel blockers (Cabs) or nitrates.

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4. Acute MI

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chest discomfort, crushing pain without warning (females and diabetics get atypical chest pain, with abdominal pain, fatigue, neck pain or weakness), prolonged duration (hours), ECG may be abnormal (ST elevation or depression), increased markers, treatment with MONA, ACE inhibitors, heparin, beta blockers, TPAs if < 12 hrs after onset of pain, complications include MR, VSD, cardiac rupture and ventricular aneurysm.

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5. CAD risk factors

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smoking, HTN, male >45, female >55, family history of premature CAD (<55 in male, <65 in female), HDL <40, LDL >100. (If HDL >60, subtract one). >2 risk factors. Treatment: diet if >160, drugs if >190. In case of 2 or more risk factors: diet if >130, drugs if >160, Patient has CHD: diet if >100, drugs if >130.

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6. Causes of High Output Heart Failure

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severe anemia, thyrotoxicosis, acute beriberi, Paget’s disease, large AV fistula.

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7. Acute Pulmonary Edema Treatment

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1st upright position and O2, 2nd loops, nitrates, morphine, and 3rd intubate if severe.

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8. HOCM Treatment

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1st avoid dehydration, 2nd strenuous activity prohibited, 3rd beta blockers, 4th Cab’s, 5th surgical myectomy. Best diagnosed with history (screen family) and physical, then ECHO.

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9. Restrictive Cardiomyopathy

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JVD, edema and ascites, diagnosed with echo, treatment 1st diuretics and decrease salt.

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10. Myocarditis

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history of upper respiratory infection (coxsackie), then fever, dyspnea, compression, edema, tachycardia.

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11. Acute Pericarditis

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positional compression, treatment with NSAIDS.

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12. Pericardial Effusion

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pericardial friction rub, treatment with pericardiocentesis.

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13. Tamponade

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becks triad (JVD, muffled heart sounds, pulsus paradoxicus with hypotension), treatment with pericardiocentesis.

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14. Constrictive Pericarditis

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pericardial knock, Kussmaul breathing, CXR shows pericardial calcification, treatment with diuretics.

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15. Acute Rheumatic Fever

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PECCS (polyarthritis, erythema marginatum, carditis, chorea, subcutaneous nodules). In kids 5-15 years old it is due to group A strep. Treatment is antibiotics, bed rest, salicylates, sedatives for chorea, and steroids for carditis.

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16. Mitral Stenosis

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most associated with rheumatic heart disease, LA enlargement, hoarseness and dysphagia, and AFib, diastolic rumble at LV apex, treatment with diuretics, and coumadin for AFib, endocarditis prophylaxis, balloon valvoplasty.

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17. Mitral Regurgitation

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associated with Marfan’s, rheumatic heart disease, myxomatous change, high-pitched holosystolic murmur at left sternal border, treatment with diuretics, dilators, endocarditis prophylaxis, mitral valve replacement or repair.

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18. Aortic Regurgitation

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congenital, Marfan’s, trauma, aortitis, high-pitched decrescendo diastolic murmur at left sternal border and/or apex and wide pulse pressure, treatment with diuretics, valve dilators, endocarditis prophylaxis, valve replacement (as a last step).

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19. Aortic Stenosis

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calcification in elderly, bicuspid in congenital aortic stenosis, angina, dyspnea, syncope, mid to late systolic murmur at base radiating to carotids, treatment with replacement (as a 1st step).

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20. Endocarditis

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if dental procedure, give amoxicillin (clindamycin if allergic to amoxicillin). If GI/GU procedure give amoxicillin with gentamycin, (vancomycin with gentamycin if allergic to amoxicillin).

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21. Ventricular Septal Defect

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membranous septum, harsh systolic murmur at left sternal border, spontaneous closure in 30 - 50%. Treatment – for small ventricular septal defect observe. For large ventricular septal defect and significant shunt, surgical repair and endocarditis prophylaxis.

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22. ASD

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wide, fixed splitting S2. Treatment – if small observe, if large do surgery.

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23. PDA

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machinery murmur, wide systemic pulse pressure, treatment with indomethacin, then surgery.

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24. Aortic Coarctation

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Upper limbs HTN with lower limbs hypotension, rib notching, lower limbs claudication, Headache, diagnosed with MRA or contrast aortography, treatment is surgery (best at 4-8 years old).

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25. Tetralogy of Fallot

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PROVe (Pulmonary HTN, RVH, Overriding aorta, VSD), kid squats to increase systemic resistance, thus decreased R to L shunt, cyanosis in kid >1 year old, CXR with boot shaped heart, confirm diagnosed with cath, treatment is surgery, endo prophylaxis.

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26. Transposition of great vessels

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most common cause of cyanosis in 24hrs of birth, treatment with surgery.

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27. Initial Treatment of CHF

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thiazide, beta blockers, ACE inhibitors, aldosterone receptor blockers, aldosterone antagonist

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28. Hyperaldosteronism

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hypokalemic metabolic alkalosis, PRA ratio, captopril-suppression test, high aldosterone level, 24hr urinary aldosterone, salt loading test.

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29. Pheochromocytoma

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24 hrs urine collection for VMA, MRI to visualize adrenal tumors, MIBG if chemistries positive but CT and MRI are negative.

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30. Renal artery stenosis

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renal ULTRASONOGRAM with Doppler, captopril scanning, CT, MRA, high renin, ACE inhibitors contraindicated if bilateral.

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31. Urgent versus Emergent HTN

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Urgent is just one high reading. Give nitroprusside or labetalol, wait till BP goes down and discharge to home. Emergent is when there are signs of end-organ damage (must admit and do workup).

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32. PAD

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claudication, rest pain, ulceration at medial ankle, diagnosed with ankle-brachial index before and after exercise, angiography, most common cause is atherosclerosis, treatment with medications (pentoxifylline, cilostazol, cab’s), angioplasty, stenting, avoid constricting drugs (beta blockers).

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33. Temporal Arteritis

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>55 year old Patient with headache, scalp tenderness, visual signs & symptoms, next step is low-dose steroids (before temporal a biopsy or getting ESR).

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34. Polyarteritis

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HTN, abdominal pain, numbness in legs, skin findings, CNS signs and symptoms, diagnosed with biopsy, treatment with steroids.

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35. AV Fistula

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thrill and bruit over fistula (buzzing sound), diagnosed with angiography, treatment with surgical excision, if congenital do conservative management instead.

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36. Varicose Veins

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pain, pigmentation, superficial ulcer, treatment with elastic stockings.

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37. Superficial Thrombophlebitis

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pain, erythema, and embolism is rare, treatment with warm compression, limb elevation and NSAIDs.

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38. Deep Vein Thrombophlebitis

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pain, swelling, fever, + Homans sign and physical examination is risk, so must do plethysmography or Doppler, treatment with heparin and warfarin, put IVF filter if recurrent.

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39. Dissecting Aortic Aneurysm

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sharp chest pain radiating to back, diagnosed with CT, TEE or MRI, treatment – 1st decrease BP (nitroprusside), 2nd - If ascending aorta (up to aortic arch) do surgery, if descending aorta use medications.

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40. Abdominal Aortic Aneurysm

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bruit, diagnosed with ultrasonogram, see abdominal notes.

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41. Aneurysm of Thoracic Aorta (Non Dissecting)

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may compress adjacent structures causing compression, dysphagia, hoarseness, diagnosed with aortography, Atherosclerosis is most common cause. Also due to cystic medial necrosis. Treatment with surgical graft replacement.

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SKIN:

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42. HSV

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type 1 at mouth, type 2 in genitalia. Recurrent erythema nodosum is characteristic. Diagnosed with Tzanck, treatment with acyclovir.

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43. Herpes Zoster (Shingles)

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dermatomal, reactivated at dorsal nerve root, treatment with acyclovir.

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44. Varicella (Chickenpox)

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lesions in all stages of development, treatment with Benadryl. In 1st trimester causes microcephaly, chorioretinitis, IUGR and cataracts. Treat neonates with varicella zoster immunoglobulin if mom contracted varicella within 5 days of delivery.

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45. Impetigo

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honey-crusted lesions. S aureus and beta hemolytic strep. Treatment with mupirocin.

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46. Rubella

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3 days of cervical, suboccipital, postauricular node enlargement, and prevention best with immunization before 1st trimester to prevent triad: visual (cataracts), hearing loss, heart (PDA) defects.

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47. Measles (Rubeola)

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looks like spilled red paint over your head (rash spread behind ears and over forehead to neck to trunk and extremities), prevent with immunization.

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48. Roseola

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3 - 5 days of fever, and THEN rash after (never together). No Treatment.

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49. Erythema Infectiosum

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5th disease– slapped cheek appearance, parvo B19, causes aplastic crisis in sickle cell patients, no Treatment.

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50. Rocky Mountain Spotted Fever

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fever, rash on wrists then palms and soles, diagnosed with Weil-Felix test, treatment with tetracycline (chloramphenicol if pregnant).

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51. Lyme Disease

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erythema chronicum migrans with central clearing, treatment is doxycycline (amoxicillin if pregnant and children <9 years old).

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52. Scabies

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burrows in hands, axillae, genitalia, highly contagious, treatment with permethrin to the whole family.

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53. Allergic contact dermatitis

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type 4 (cell-mediated) hypersensitivity like poison ivy.

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54. Psoriasis

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a T-cell mediated epidermal hyperproliferation, scaling plaques on knees, elbows, associated with clubbing of fingers, worsened by antimalarial drugs, lithium, beta blockers, treatment with steroids, calcipotriene.

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55. Seborrheic Dermatitis

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on scalp is dandruff, on kids is cradle cap. Treatment with ketoconazole (Patient on chronic azoles need to have LFTs monitored). If generalized, rule out histiocytosis X; if severe, rule out AIDS.

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56. Bullous Pemphigoid

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>60 years old, large tense blisters, - Nikolsky, IgG, C3 at dermal-epidermal junction. Treatment with prednisone, tetracycline, azathioprine (remember BCDE – Bullous pemphigoid, C3 at Dermal Epidermal junction).

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57. Pemphigus Vulgaris

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40-60 years old, multiple flaccid bullae, + Nikolsky, biopsy shows acantholysis, antibodies to epidermal antigen, treatment is prednisone, fluids, and tetracycline.

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58. Dermatitis herpetiformis

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itchy papulovesicular eruption usually on shins, - Nikolsky, associated with celiac sprue, treatment with gluten-free diet and dapsone (rule out G6PD first).

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59. Factitial Dermatitis

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no rash in non-reachable areas (mid back, butterfly sign).

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60. Acne Vulgaris

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common acne. 1st line treatment with benzoyl peroxide, 2nd line with topical or oral antibiotics, 3rd line with topical retinoids, 4th line with isotretinoin (rule out pregnancy first).

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61. Hereditary Angioedema

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autosomal dominant, C1 esterase inhibitor deficiency, subcutaneous or mucosal edema.

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62. Pilonidal Cyst

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swelling, tender sacral mass, treatment with antibiotics, incision & drainage.

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63. Epidermoid Cyst

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contains keratin, asymptomatic, if infected (incision & drainage, antibiotics), if not infected then excise.

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64. Capillary Hemangioma

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strawberry nevus, reddish-purple hemangioma, treatment with pulse dye laser therapy.

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65. Cavernous Hemangioma

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purplish vascular anomaly, treatment with reassurance, compression.

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66. Seborrheic Keratosis

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benign skin tumor in elderly, brown flat macule that appears “stuck-on”. Observe unless eruption is multiple then do shave excision and curettage, cryotherapy.

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67. Port-Wine Stain

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associated with Sturge-Weber syndrome, brain calcifications, and seizures.

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68. Actinic Keratosis

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precursor to SQUAMOUS CELL CARCINOMA, sun induced hyperkeratotic coarse lesions that are hard to remove. Treatment with cryosurgery, 5-FU, excision.

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69. Squamous Cell Carcinoma

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generally from the lower lip down. Ulcer that won’t heal. Treatment with surgery or radiation.

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70. Basal Cell Carcinoma

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generally from upper lip up. Pearly nodule with rolled border. Surgical removal has high cure rate.

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71. Melanoma

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ABCD (asymmetry, borders irregular, color variation, diameter >6mm), Most common is superficial spreading type, diagnosed with total excision, loves to metastasize.

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72. Behcet’s Syndrome

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aphthous ulcers, genital ulcers and uveitis, treatment with chlorambucil after discontinuing antibiotics.

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73. Dermatomyositis

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difficulty rising from chair, proximal weakness, Gottron’s sign (purple papules on knees and knuckles), diagnosed with muscle biopsy, treatment with prednisone.

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74. Lofgren Syndrome

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fever, erythema nodosum (LE nodules), and sarcoidosis.

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75. Amyloidosis

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macroglossia, waxy papules on face, Congo red stain on biopsy.

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76. Scleroderma

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Raynaud’s, dysphagia, masklike face, and tight skin. Diagnosed with skin biopsy. Treatment symptomatically or with D-Penicillamine. Associated with CREST syndrome.

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77. Tuberous Sclerosis

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retinal phakoma, seizures, mental retardation, sebaceous adenomas, and ash-leaf hypopigmented macules. Treatment with seizure control.

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78. Porphyria Cutanea Tarda

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no abdominal pain, but +ve red urine and vesicles on back of hand after having alcohol, drugs, estrogens, associated with Hepatitis C, treatment with 1st stop EtOH then phlebotomy.

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79. Acute intermittent Porphyria

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abdomen pain, weakness in shoulders, arms, change in behavior. Blocks porphobilinogen deaminase, high ALA in the stool.

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80. Acanthosis Nigricans

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black axillary and neck patches, associated with PCOS, DM, obesity and abdominal adenocarcinoma. Next step is get fasting glucose to rule out insulin resistance.

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81. TTP

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fever, thrombocytopenia (causing petechia, purpura), MAHA, renal problems (hematuria) and CNS symptoms (depression, headache, psychosis).

Treatment with plasmapheresis.

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82. Disseminated Intravascular Coagulation

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all labs messed up (BT, PT, PTT, fibrinogen, fibrin split products) causing cutaneous hemorrhage and ecchymosis. Treatment – 1st treat primary cause, 2nd heparin.

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ENDOCRINE:

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83. Thyroid nodule

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1st do TSH, then do FNA (preferred) or scan to see if it’s hot or cold (cold is malignant. if hot, observe – do not biopsy). Most common benign is follicular adenoma, most common malignant is papillary (psammoma bodies), must if history of radiation, worse if Patient is male, >40 or young, distant metastasis If results turn out that it’s a cyst, aspirate it and follow-up, if cancer, surgery with radioiodine (if papillary or follicular).

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84. Goiter

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high or low iodine uptake, lithium, amiodarone use, familial, treatment with levothyroxine. Do not discontinue drug, just continue the drug and add levothyroxine.

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85. De Quervain’s (subacute) thyroiditis

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painful thyroid, treatment is NSAIDs.

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86. Sick Euthyroid Syndrome

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low T4, T3 and normal TSH. No signs & symptoms, just a goiter. Treatment - nothing.

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87. Riedel’s

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tracheal compression due to sclerosing fibrosis (rare).

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88. Hashimoto’s

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antimicrosomal antibody, treatment with levothyroxine.

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89. Congenital hypothyroidism (cretinism)

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jaundice, lethargy, umbilical hernia, low T4, high TSH, treatment with Synthroid (levothyroxine).

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90. Adult hypothyroidism

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fatigue, myxedema, cold intolerant, weight gain, eyebrow thinning, high TSH, low T4, most common cause is Hashimoto’s, but also due to prior graves Treatment, Sheehan’s, amiodarone, lithium, treatment with Synthroid (Levothyroxine Sodium).

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91. Graves

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low TSH, high T4, tachycardia, palpitations, weight loss, ophthalmopathy, smooth goiter, A. fib, treatment with beta blockers (tremor and tachy), PTU, methimazole, radioactive iodine or subtotal thyroidectomy.

In pregnancy, PTU can be used, as well as surgery if appropriate.

Patient <25 year old get surgery, Patient >40 year old get radioactive iodine.

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92. Toxic Nodule

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high radioactive iodine uptake, no eye signs & symptoms, nodular goiter, on scan there is ONE area of increased uptake, whereas the rest its decreased (in toxic multinodular goiter (Plummer’s disease), there are several areas of increased uptake and in Graves the entire gland has increased uptake).

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93. Thyroid storm

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very high fever, delirium, nausea & vomiting, abdomen pain, high t4, low TSH, treatment with supportive care first (decrease temperature, arrhythmia, BP), beta blockers, glucocorticoids.

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94. Type 1 DM

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polyuria, polydipsia, hyperphagia, islet cell antibodies, HLA DR3, 4, low C-peptide, treatment with insulin.

If having surgery, give 10 units insulin in AM, and then 0.1U, kg/hr infusion.

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95. Type 2 DM

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polyuria, polydipsia. Fasting glucose >126, random >200 on 2 visits. Treatment first with diet, weight changes (decrease calories and carbs), oral agents, insulin. HBA1c to monitor glucose over 2-3 months. For retinal neovascularization, give laser photocoagulation therapy. For nephropathy, check for microalbuminuria (1st sign) and give ACE INHIBITORS. For neuropathy, give foot care and analgesia.

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96. DKA

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lethargy, nausea & vomiting, polyuria, abdomen pain, confusion, Kussmaul breathing, fruity breath, glucose 400-600, and anion gap met acidosis. Treatment isotonic fluids with insulin, replace K+ if needed (prevent cerebral edema).

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97. Hyperosmolar coma

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dehydration, lethargy, confusion, coma, high glucose without ketones, treatment with fluids, insulin and electrolyte replacement.

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98. Lactic Acidosis

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coma, confusion, hyperventilation, no ketones, and anion gap metabolic acidosis, rare associated with metformin, treatment etiology (starvation).

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99. Patient with high blood glucose in the morning?

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Get 4 AM blood glucose. If it’s high (Dawn effect), then increase morning NPH, if it’s low (Somogyi effect) then decrease night-time NPH.

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100. Insulinoma

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lethargy, diplopia, headache, glucose <40, high proinsulin, high c-peptide (low c-peptide if exogenous insulin used). Treatment with surgery, if emergency then first give 50mL of 50% dextrose IV.

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101. Primary Hyperparathyroidism

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kidney stones, osteitis fibrosa cystica, muscle weakness, high calcium, low phosphate, high PTH, associated with MEN. Treatment with surgery if adenoma, but if Patient has severe hypercalcemia, 1st treatment with saline, then furosemide, calcitonin and, or pamidronate.

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102. Hypoparathyroidism

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low calcium (Chvostek’s sign, trousseau’s sign, tetany), high phosphate, normal renal function. Treatment with vitamin D and calcium.

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103. Diabetes Insipidus

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water loss, polyuria, nocturia, thirst, craving for ice, low urine osmolarity (< 250), and high serum osmolarity. Diagnosed – Give vasopressin, if corrected its central, if still getting worse its nephrogenic (can be due to demeclocycline or lithium), if no change in urine osmolarity its primary polydipsia. Treatment – if central give vasopressin (DDAVP), if nephrogenic give diuretic (thiazides, amiloride).

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104. SIADH

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low Na, low serum osmolarity, high urine osmolarity, associated with small cell carcinoma, morphine, chlorpropamide, oxytocin, treatment with 1st fluid restriction, 2nd demeclocycline or hypertonic saline if Na is really low. Do not treat too rapidly to avoid central pontine myelinosis.

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105. Acromegaly

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enlarging hands, feet, coarse features, deep voice, large tongue, hat, wedding ring doesn’t fit anymore (hat don’t fit anymore can be Paget’s), due to high GH, diagnosed with glucose suppression test, then IGF-1, then MRI to confirm adenoma, treatment with surgery (transsphenoidal), or radiation, medications (bromocriptine, octreotide) if surgery doesn’t work.

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106. Acute adrenocortical insufficiency

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shock, fever, abdomen pain, low sugar, diagnosed with cosyntropin testing, treatment with hydrocortisone sodium succinate.

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107. Chronic adrenocortical insufficiency (Addison’s)

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most common cause in US is autoimmune; most common cause in world is TB. Lethargy, skin pigmentation, hypotension, low Na, high K+, low cortisol, high ACTH is primary, normal, low ACTH is secondary. Diagnosed with ACTH stimulation test (cortisol should increase, but remains low in Addison’s). Treatment with hydrocortisone (glucocorticoid) and fludrocortisone (mineralocorticoid).

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108. Cushing’s syndrome

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obesity, purple striae, HTN, hirsutism, buffalo hump, weakness, osteoporosis, diagnosed with 1st 24hrs urine free cortisol, then dexamethasone suppression test (if suppressed that means its pituitary caused (Cushing disease), if not its adrenal or ectopic ACTH like small cell carcinoma or carcinoid). Treatment – if iatrogenic use smallest effective steroid dose possible, if Cushing’s disease do surgery, radiation of pituitary adenoma.

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109. Adrenogenital syndrome

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hirsutism, amenorrhea, high urinary 17-OH, most common cause is 21-OH deficiency in kids, most common cause in adults is PCOS or adrenal disease. Treatment is surgery if ambiguous genitalia in girls), then estrogen spironolactone, metformin (if PCOS), gluco, mineralocorticoid if CAH.

Front 113

110. Conn’s Syndrome

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high aldosterone, low K+, high Na, High BP, low renin, treatment is adrenalectomy with spironolactone preop.

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111. Secondary Hyperaldosteronism

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most common cause is renal artery stenosis – high Na, low K, high rennin, renal bruit. Diagnosed with Aldosterone: Renin ratio, then CT Abdomen.

Front 115

112. Prolactinoma

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milky discharge from breast, if prolactin level 20-100 then rule out dopamine antagonist drugs (haloperidol, metoclopramide) and rule out hypothyroidism, if prolactin level >100, then do MRI of brain. Treatment – if CNS Signs & Symptoms (bitemporal hemianopsia) do surgery, if not give bromocriptine.

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113. Pheochromocytoma

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sudden episodes of flushing, HTN, headache, sweating, feeling of doom, associated with MEN II, III, diagnosed with urinary VMA or catecholamines, then if + do CT of abdomen and treatment with give phenoxybenzamine (then beta blockers) followed by surgery.

Front 117

114. PCOS and Premature ovarian failure

Back 117

see OB gyn notes.

Front 118

115. Hemochromatosis

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AR, hepatomegaly, bronze skin, cardiomegaly, DM, diagnosed with liver biopsy, treatment with phlebotomy 1st, then deferoxamine (if needed).

Front 119

116. Gestational DM

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measured at 26-28 weeks, glucose checked 1 hour after 50g load, if abnormal, check 3 hours after 100g load (fasting should be <95, 1hr <180, 2hr <155, 3hr <140). Treatment with diabetic diet and insulin if needed.

Front 120

117. Carcinoid syndrome

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diarrhea, flushing, bronchospasm, low BP, R heart valve lesions, diagnosed with urinary 5HIAA, treatment with surgery. Most common is at appendix, but if symptomatic, most common is at small bowel.

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GI:

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Front 122

118. Upper GI bleed

Back 122

hematemeses, diagnosed with EGD, treatment (in order) – If bleeding ulcer: PPI, transfuse, urgent endoscopy when possible, epinephrine into vessel, surgery if needed. If esophageal varices: Octreotide, banding, sclerotherapy, ET intubation, TIPS (for esophageal varices, prevent next bleed with beta blockers).

Front 123

119. Lower GI bleed

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most common cause of BRBPR is diverticulosis, then angiodysplasia. Diagnosed with colonoscopy if bleeding stops, blood scan if bleeding continues and if +, angiography. Treatment – replace blood, vasopressin at site.

Front 124

120. What is the cutoff between upper and lower GI bleeding?

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Ligament of Treitz.

Front 125

121. Crohn’s

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all GI tract (usually rectal sparing), fistula, skipped lesions, all layers of bowel (transmural), fistula, abscess, non caseating granuloma, gallstones, calcium oxalate kidney stones, extraintestinal manifestations, diagnosed with colonoscopy and biopsy. Treatment using infliximab (must do PPD before starting it), sulfasalazine, metronidazole, prednisone.

Front 126

122. Ulcerative Colitis

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rectum mainly (unless backwashing present), continuous, just mucosa, submucosa, crypt abscesses, toxic megacolon, small, frequent bloody diarrhea with tenesmus. Treatment with Azulfidine, sulfasalazine.

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123. Toxic Megacolon

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emergency, associated with UC, Treatment: NPO, NGT, IVF, DISCONTINUE medications, Antibiotics, surgery only if + perforation (free air on AXR).

Front 128

124. Peptic Ulcer

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Duodenal decreases with food, Gastric increases with food, gastric is more associated with cancer and duodenal is more associated with H. pylori. Diagnosed 1st with H. pylori testing, then endoscopy with biopsy to rule out cancer. Risks for NSAIDS: >70, history of prior PUD, only available treatment is misoprostol. H. pylori: breath test, gastric biopsy, urease. Diagnosed for PUD: 1st Upper GI endoscopy, then biopsy for gastric ulcers to rule out cancer. Treatment with amoxicillin, clarithromycin and omeprazole. Follow-up with urea breath tests after 1 month of Treatment. Complications: hemorrhage (MC), perforation – do AXR to see free air in a Patient with peritoneal Signs & Symptoms and treatment with antibiotics and laparotomy. After surgery (antrectomy, vagotomy, Billroth I and II), watch out for Dumping Syndrome (weakness, nausea & vomiting after eating), Afferent loop syndrome (bilious vomiting relieves abdomen pain after meal), Iron, B12 deficiency.

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125. Zollinger Ellison syndrome

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Severe, non-healing ulcers. Get gastric levels and rule out carcinoma (MEN).

Front 130

126. Oropharyngeal dysphagia

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swallowing impaired due to lack of neuromuscular control from prior CVA, Parkinson’s, Alzheimer’s. Diagnosed with barium swallow. Treatment underlying disease.

Front 131

127. Achalasia

Back 131

aperistalsis, incomplete LES relaxation with high LES pressure, dysphagia for solids and liquids, no regurgitation, diagnosed with barium (dilated distal 2/3rd) then manometry (bird beak), then endoscopy to rule out cancer. Treatment with pneumatic dilatation, then Botox, then surgical Nissen’s fundoplication.

Front 132

128. Chagas Disease

Back 132

achalasia, cardiomegaly, hepatomegaly in a South American.

Front 133

129. GERD

Back 133

heartburn, chest pain, epigastric pain, older guy, most common cause of nocturnal cough. Diagnosed with 24hr pH, upper GI endoscopy to rule out Barrett’s or ulcers.

If you suspect it, treat it without doing any diagnostics. Treatment with lifestyle changes, PPI, H2 blockers.

If Patient still has symptoms then do 24hr pH.

If Patient says drugs used to work but don’t work anymore, do EGD to rule out cancer.

Front 134

Initial Treatment of Post-MI

Back 134

beta blockers, ACE inhibitors, aldosterone antagonist

Front 135

Initial Treatment of recurrent strokes

Back 135

thiazide, ACE inhibitors.

Front 136

Initial Treatment of Diabetes Mellitus

Back 136

ACE inhibitors, beta blockers, thiazide, aldosterone receptor blocker

Front 137

130. Zenker’s Diverticulum

Back 137

a motility disorder, causing halitosis, diagnosed with barium, treatment with section.

Front 138

131. Esophagitis

Back 138

painful swallowing (odynophagia), Candida so start with fluconazole.

Front 139

132. Diffuse Esophageal Spasm (Nutcracker)

Back 139

Chest pain due to strong intermittent contractions. Diagnosed with barium (corkscrew pattern) first, then manometry (shows non peristaltic uncoordinated contractions), treatment with calcium channel blockers or nitrates.

Front 140

133. Scleroderma Esophagus

Back 140

younger guy with GERD symptoms, Raynaud’s, heartburn, dysphagia for solids and liquids, diagnosed with manometry (low LES pressure unlike achalasia which is high), absent contractions in the smooth muscle esophagus, normal peristalsis in the striated muscle, normal UES). Treatment with same things as GERD.

Front 141

134. Schatzki Ring

Back 141

young Patient with episodic difficulty (not pain) swallowing. Diagnosed with barium, treatment with pneumatic dilatation of LES.

Front 142

135. Plummer Vinson Syndrome

Back 142

hypopharyngeal web with iron deficiency. Risk of SQUAMOUS CELL CARCINOMA. Middle-aged female with dysphagia immediately after meals. Diagnosed with barium, treatment with surgery.

Front 143

136. Barrett’s Esophagus

Back 143

5yrs of dysphagia, weight loss, no reflux, Signs & Symptoms visible on EGD so do biopsy. If biopsy shows no dysplasia then repeat in 2-5yrs, if biopsy shows low dysplasia, repeat in 3-6 months, if biopsy shows high grade dysplasia – resection.

Front 144

137. Esophageal CA

Back 144

progressive dysphagia for solids and eventually liquids, weight loss, chest pain, hypercalcemia (SQUAMOUS CELL CARCINOMA), diagnosed with barium, then confirm with EGD and biopsy. Treatment with surgery, chemotherapy (cisplatin, 5-FU) and radiation.

Front 145

138. Gastroparesis

Back 145

delayed gastric emptying causing nausea & vomiting, bloating and upper abdomen discomfort, common in DM, treatment with metoclopramide.

Front 146

139. When you suspect GI perforation, use ___, when you suspect aspiration, use ___.

Back 146

When you suspect GI perforation, use gastrografin (not barium), when you suspect aspiration, use barium (not gastrografin).

Front 147

140. Diarrhea

Back 147

see ID notes.

Front 148

141. Irritable Bowel Syndrome

Back 148

alternating constipation, diarrhea and pain relieved with defecation. Treatment with increased fiber in diet.

Front 149

142. Diverticulosis

Back 149

due to low fiber, high fat diet. LLQ pain, fever, tenderness. Diagnosed with colonoscopy. Treatment with increased fiber.

Front 150

143. Diverticulitis

Back 150

peritonitis, fever due to micro, macro-perforations, do CT scan. Treatment with NPO, IVF and antibiotics (Ciprofloxacin, metro or cefoxitin or ampicillin, sulbactam).

Front 151

144. Pseudomembranous Colitis

Back 151

C. Difficile overpopulation due to prior use of Antibiotics weeks ago, diagnosed with C. Difficile in stool. Colonoscopy shows yellow adherent plaques on mucosa. Treatment: discontinue drug, start metronidazole, if still +, vancomycin.

Front 152

145. Colorectal CA

Back 152

2nd MCCOD due to cancer, rectal bleeding, change in BM, weight loss, sometimes asymptomatic (found incidentally on colonoscopy). Diagnosis: FOBT yearly after age 50, flexible sigmoidoscopy every 4 years, colonoscopy at 50 then 53 then every 5 years, but start 10 years earlier than the age of which family relative was diagnosed with it. Treatment – surgical resection of primary tumor.

Front 153

146. Chronic Liver Disease

Back 153

causes include autoimmune hepatitis, hemochromatosis, chronic alcohol use, fatty liver disease(non-alcoholic steatohepatitis), Wilson’s disease, viral (HBV, HCV), Signs & Symptoms include fatigue, increased abdomen girth, jaundice, spider angiomas, palmar erythema, HSM, gynecomastia, testicular atrophy, labs with high AST, ALT, PT, INR, thrombocytopenia, hyponatremia, hypoalbuminemia.

Front 154

147. Autoimmune hepatitis

Back 154

20-40 year old female with +ANA, +anti-smooth muscle Antibody, everything else normal. Treatment with steroids.

Front 155

148. Wilson’s disease

Back 155

young guy with parkinsonism due to hepatolenticular degeneration, Kayser-Fleischer ring, hemolytic anemia, diagnosed with low serum ceruloplasmin, low total copper (not free), high urine copper. CT shows hypodense regions in the basal ganglia. Confirm diagnosed with liver biopsy. Treatment with D-penicillamine.

Front 156

149. Ascites

Back 156

ULTRASONOGRAM, CT and then paracentesis. Treatment with Na, fluid restriction, diuretics, then furosemide, then large-volume paracentesis, then TIPS.

Front 157

150. Spontaneous bacterial peritonitis

Back 157

>250 polys in 3 bedside cultures, treatment with cefotaxime.

Front 158

151. Encephalopathy

Back 158

treatment with protein restriction and lactulose.

Front 159

152. HAV

Back 159

shellfish, fecal-oral, diagnosed with + anti-HAV IgM (IgG shows previous infection).

Front 160

153. HBV

Back 160

HBsAg is earliest marker, >6 months is chronic, if vaccinated = +HBs AB, -Hbc AB, if exposed in the past = +HBs AB, +Hbc AB. Window period has anti-HBc IgM only. Prevent with vaccine + HEPATITIS B IMMUNOGLOBULIN. Treat with Interferon alpha and lamivudine. Give vaccine at 0-2mo, 4-6mo, 13-18 months. If mom has +HBsAg, give baby vaccine + HEPATITIS B IMMUNOGLOBULIN within 12 hours of birth.

Front 161

154. HCV

Back 161

diagnosed with anti-HCV Antibody, IgG, IgM and HCV RNA by PCR. Treatment – Interferon-A with ribavirin.

Front 162

155. Drug-induced

Back 162

Tylenol, isoniazid, halothane, carbon tetrachloride and tetracycline. Diagnosed with very high AST, ALT levels. Treatment – DISCONTINUE med.

Front 163

156. Acute fatty liver of pregnancy

Back 163

develops in 3rd TM. Treatment – immediate surgery.

Front 164

157. Primary Biliary Cirrhosis

Back 164

antimitochondrial Antibody in serum, pruritus, fatigue, hepatomegaly, high alkaline phosphatase, destruction of intrahepatic and extrahepatic ducts. Treatment with ursodeoxycholic acid, cholestyramine.

Front 165

158. Primary Sclerosing Cholangitis

Back 165

young man with IBD (UC), destruction on extrahepatic ducts only (shows beading effect due to fibrosis).

Front 166

159. Gallstones

Back 166

female, fat, 40, fertile, RUQ or epigastric pain, worsened with food, radiates to mid scapular area. Diagnosed with ultrasonogram, then HIDA scan if negative. Treatment with lap chole. ERCP if Patient still has symptoms after (stone is in CBD).

Front 167

160. Mesenteric Ischemia

Back 167

severe abdomen pain, tenderness with paucity of clinical findings. Patient will usually have extensive ischemic history (MI, DM, etc.), diagnosed with angiography, treatment with prompt laparotomy to reestablish arterial flow.

Front 168

161. Acute Pancreatitis

Back 168

most common cause is gallstones, then alcohol. Epigastric pain radiating to mid back, alleviated with sitting up, jaundice sometimes fever. High amylase, lipase. Diagnosed with CT. Treatment with NPO, NGT, analgesia, and then begin to consider ERCP and surgery if perforated, bleeding, abscess, pseudocyst or peritonitis.

Front 169

162. Pancreatic Pseudocyst versus Abscess

Back 169

worsening of pain, nausea & vomiting, fever high WBC and positive blood culture after initial improvement. Diagnosed with CT. Treatment with Antibiotics, then surgical drainage of abscess. Pseudocyst is generally asymptomatic.

Front 170

163. Pancreatic CA

Back 170

vague abdomen pain (doesn’t have to radiate to the back anymore), anorexia and weight loss with jaundice, nausea & vomiting. Diagnosed with CT. If negative do ERCP. Check CA 19-9. Treatment: If only at pancreatic head with no spread, try resection. If not, do Whipple (pancreaticoduodenectomy) procedure.

Front 171

164. Malabsorption

Back 171

Steatorrhea (diagnosed with Sudan stain – 1st test). Then diagnosed with D-xylose, if abnormal, suggests small bowel disease. Normal value suggests focus on pancreatic disease: CT of abdomen, serum amylase, AST, ALT. If overgrowth considered, note response to malabsorption to Antibiotics. Celiac sprue panel: antiendomysial, antigliadin Antibody, tissue transglutaminase, total serum IgA, antigliadin Antibody IgA and IgG; at least 3 biopsy specimens from distal duodenum is gold standard.

Front 172

165. Whipple’s

Back 172

malabsorption, arthralgia and CNS symptoms (dementia). Diagnosed with small bowel biopsy (shows foamy macrophages on PAS stain). Treatment with TMP-SMX.

Front 173

PEDS GI:

Back 173

0

Front 174

NAME AGE VOMITUS FINDINGS.

Pyloric Stenosis

Back 174

0-2 months non bilious, projectile M>F, olive-shaped mass, low K.

Front 175

NAME AGE VOMITUS FINDINGS.

Intestinal Atresia

Back 175

0-1 week Bilious, projectile Double bubble sign, associated with Downs.

Front 176

NAME AGE VOMITUS FINDINGS.

TE Fistula

Back 176

0-2 week Food regurgitation Respiratory problems with feeding, aspiration pneumonia, diagnosed via not being able to pass NGT.

Front 177

NAME AGE VOMITUS FINDINGS.

Hirschsprung

Back 177

0-1 year Feculent Distention, obstipation, no ganglia on biopsy.

Front 178

NAME AGE VOMITUS FINDINGS.

Anal Atresia

Back 178

0-1 week late, feculent Seen on initial exam in nursery.

Front 179

NAME AGE VOMITUS FINDINGS.

Choanal Atresia

Back 179

0-1 week - Cyanosis with feeding, relieved with crying, CHARGE syndrome, and can’t pass NGT.

Front 180

NAME AGE VOMITUS FINDINGS.

Intussusception

Back 180

4 months to 2 year old bilious currant jelly stool, palpable abdomen mass, kid draws up legs, diagnosed with barium enema.

Front 181

NAME AGE VOMITUS FINDINGS.

Necrotizing Enterocolitis

Back 181

0-2 months bilious Preemies, fever, rectal bleeding, air in bowel wall, treatment with NPO, IVF.

Front 182

NAME AGE VOMITUS FINDINGS.

Meconium Ileus

Back 182

0-2 week feculent, late cystic fibrosis.

Front 183

NAME AGE VOMITUS FINDINGS.

Midgut Volvulus

Back 183

0 - 2 years Bilious Due to malrotation, sudden pain, nausea and vomiting. Diagnosed with upper GI, treatment with section.

Front 184

NAME AGE VOMITUS FINDINGS.

Meckel’s Diverticulum

Back 184

0-2 years old, GI ulcer, bleed, diagnosed with Meckel’s (Technetium) scan, treatment with section.

Front 185

NAME AGE VOMITUS FINDINGS.

Strangulated Hernia

Back 185

Any Bilious Bowel loops in inguinal canal

Front 186

ONCOLOGY:

Back 186

0

Front 187

166. Tumor markers

Back 187

B hCG – testicular cancer, choriocarcinoma, mole; AFP – hepatocellular carcinoma testicular ca; CEA – GI cancers; PSA – prostate ca; CA-125 – Ovarian ca; CA 19-9 – colorectal, GI, pancreatic cancer.

Front 188

167. Sigmoidoscopy - >50 year old every 3-5 yrs; FOBT >50 annually; DRE - >40 annually; PSA - >50 annually in normal risk, >40 annually in high risk; Pap smear

Back 188

onset of sexual activity or 18 year old annually for 3 consecutive years then however often; Pelvic exam – 18-40 year old every 1-3 yr, >40 annually; Endometrial biopsy – menopause, high risk annually; Self breast exam - >20 monthly; Clinical breast exam – 20-40 every 3 years, >40 annually; Mammogram – 40-49 every 1-2 yrs, >50 annually.

Front 189

168. Cancerous Occupation Hazards

Back 189

aromatic amines with bladder ca, arsenic with lung, skin, liver ca, asbestos with mesothelioma (bronchogenic MC), benzene with leukemia, mustard gas with lung, larynx, sinus cancer, vinyl chloride with liver cancer.

Front 190

169. Hodgkin’s

Back 190

fever, night sweats, chills, weight loss (like TB), and painless cervical adenopathy. Diagnosed with CT chest, abdomen and then lymphangiography and then biopsy (for treatment purposes). Reed-sternberg cells. Treatment – If no B Signs & Symptoms (fever, weight loss, sweats) give radiation alone. If B Signs & Symptoms give chemotherapy (MOPP or ABVD).

Front 191

170. Non-Hodgkin’s

Back 191

variable nodes, monoclonal B, T-cell proliferation, diagnosed with CT chest, abdomen, pelvis then other stuff like BM biopsy, PET scan, gallium scan. Treatment with radiation and chemo (CHOP) with Rituximab (CD20 Antibody).

Front 192

171. Acute Lymphocytic Leukemia

Back 192

kids, blasts, treatment with intrathecal chemo (MTX).

Front 193

172. Acute Myelogenous Leukemia

Back 193

M3 causes DIC, Auer rods, blasts, add All-trans retinoic acid (Vit. A) to Treatment.

Front 194

173. CML

Back 194

high WBCs, high PMNs, splenomegaly, LUQ pain, fullness and early satiety, decreased LAP, diagnosed with Philadelphia chromosome (t9;22 of brc:abl) in BM, treatment with Imatinib (Gleevec).

Front 195

174. CLL

Back 195

elderly, high WBCs, high lymphocytes, splenomegaly, diagnosed with smudge cells, no treatment if no lymphocytosis, if + lymphocytosis give fludarabine or chlorambucil.

Front 196

175. Hairy Cell Leukemia

Back 196

CD10+ and TRAP+ (tartrate-resistant acid phosphatase), treatment with cladribine.

Front 197

176. Mycosis fungoides

Back 197

cutaneous T-cell lymphoma (look at 1st aid picture), lion-like facies, treatment with PUVA chemotherapy. If affecting peripheral blood, its Sezary syndrome.

Front 198

177. Multiple Myeloma

Back 198

high calcium, high OAF, high uric acid. Best initial test is X ray if bone pain or electrophoresis if high protein. Most accurate test is >10% plasma cells. Treatment: <70 year old get stem cell transplant, >70 year old get Melphalan or Thalidomide.

Front 199

178. Aplastic Anemia

Back 199

low RBC, WBC, platelet, drugs (chloramphenicol), parvo-B19 (sickle cell), Treatment: <50 year old get BMT, >50 year old get cyclosporine + anti-thymocyte globulin.

Front 200

179. If Patient has neck + pelvic mass after chemo the mass gets smaller, wheat test checks content of the lymph node?

Back 200

PET scan. So in a nutshell, a lymphoma gets excisional biopsy of the node, then PET scan, and chemo if they have B symptoms.

Front 201

180. Adverse effects of chemo

Back 201

Vincristine, blastin – peripheral neuropathy, cyclophosphamide – hemorrhagic cystitis, Busulfan, Bleomycin – Irreversible Pulmonary Fibrosis (that’s why Lance Armstrong refused it), Cisplatin – renal disease, ototoxicity, anemia. Overall most common adverse effect with chemo drugs is sterility.

Front 202

181. Lung cancer

Back 202

chronic cough (most common signs & symptoms), weight loss, smoker, hemoptysis. Diagnosis: 1st CXR, then biopsy. Treatment: Small cell get chemo only, Non-small cell – chemo with radiation. Horner’s syndrome – unilateral ptosis, meiosis, anhidrosis due to compression of ipsilateral superior cervical ganglion by lung tumor, particularly squamous cell carcinoma. SVC syndrome – obstruction of SVC causes facial swelling, plethora, dyspnea, cough, JVD. Pancoast syndrome – tumor of the superior sulcus causes brachial plexus signs & symptoms. Small cell causes Cushings syndrome (ACTH) and SIADH, squamous cell carcinoma causes hypercalcemia (PTH-like peptide).

Front 203

182. Solitary nodule

Back 203

1st step is to get old x-ray. If present and same size, it’s benign (send home), if increase in size it’s probably cancer. If it wasn’t there, assess risk (high is smoker and >35, low risk is nonsmoker and <35). If low risk follow up later, if high risk do biopsy.

Front 204

183. Breast Cancer

Back 204

biopsy everyone with palpable mass >35 except if B, L, lumpy and Signs & Symptoms only occur with menses. If <35 it’s probably fibroadenoma (rubbery moveable mass, observe pt). After biopsy, get mammogram if >35 year old. If mammogram was already done, get FNA. If after biopsy, mass goes away, send Patient home. Treatment: tamoxifen, mastectomy, radiation, axillary dissection, chemotherapy (c platinum) if + nodes.

Front 205

184. Prostate cancer

Back 205

Signs & Symptoms of BPH with hematuria, high PSA (only to screen, monitor, not for Diagnosis), irregular, boggy, back pain. Treatment with surgery. If +ve metastasis, then do orchiectomy, leuprolide, flutamide, DES, but no chemo. Only do TURP and radiation of metastasis is local (bone).

Front 206

185. Colon cancer

Back 206

R sided bleeds (bloody stools), L sided obstructs (constipation), weight loss. Diagnosed with colonoscopy. Treatment with surgery and 5-FU and then follow up CEA levels. If metastasis (most common is liver) to liver do surgery, but anywhere else do chemo.

Front 207

186. Pancreatic cancer

Back 207

40-80 year old male smoker with jaundice, weight loss and vague abdomen pain. May have migratory thromboplebitis (Trousseau’s syndrome) or palpable, nontender gallbladder (Courvoisier’s sign). Diagnosed with CT, then FNA. Treatment with whipples.

Front 208

HEMATOLOGY:

Back 208

0

Front 209

187. Microcytic (MCV <80)

Back 209

Iron deficiency, Thalassemia, Anemia of Chronic disease, Sideroblastic Anemia (lead poising, isoniazid, alcohol-induced).

Front 210

188. Normocytic (MCV 80-100)

Back 210

Check Reticulocyte count (should be <2% with anemia, otherwise marrow isn’t responding properly), <2% is acute blood loss (<5-7days), early iron deficiency, aplastic anemia, early AOCD, renal disease. >3% is due to either Intrinsic RBC defect (MAD: Membrane defects (Spherocytosis, PNH), Abnormal hemoglobins (Sickle cell), Deficient enzymes (G6PD, pyruvate kinase deficiency)) or Extrinsic RBC defect (Autoimmune hemolytic anemia, MAHA, blood loss >1 week).

Front 211

189. Macrocytic (MCV >100)

Back 211

B12 def., folate def., Myelodysplastic syndrome, drug-induced, hepatic dysfunction (due to alcohol), reticulocytoses.

Front 212

190. Red Cell Morphologies

Back 212

Rouleaux (myeloma), Burr cells (uremia), Tear drops and nucleated red cells (myelofibrosis), hypochromic, microcytic (iron def.), target cells (HALT: Hemoglobinopathies, Asplenia, Liver disease(obstructive jaundice), Thalassemia), Oval macrocytes (B12, Folate def.), basophilic stippling (Lead, B12 def.), spherocytes (HS), Schistocytes (MAHA, AIHA, DIC), bite cells and Heinz bodies(G6PD), Howell-Jolly bodes (Asplenia like SCD).

Front 213

191. Iron deficiency

Back 213

low MCV, high TIBC, low ferritin, low iron (<60), high RDW (why? Because some are normocytic and some are microcytic so the range of width will be high), pica kid who eats sand and ice, Plummer-Vinson (web, low iron, glossitis), cow milk before age 1, exclusive breast-feeding, pregnancy. Treatment – 1st is to find the source of iron loss and fix that (before you give iron!), 2nd transfusion (if needed fast) or oral iron supplements for 6-12 months.

Front 214

192. Anemia of Chronic Disease

Back 214

(how does this work? The body knows diseases (RA, TB, SLE, cancer) love iron, so it will hide iron away in stores (high ferritin) but keep it out of the serum (low serum iron and high TIBC)) if anemia is associated with chronic renal disease, look for Burr cells.

Front 215

193. Thalassemia

Back 215

normal iron (so don’t give iron), target cells, nucleated RBC, x-ray shows crew-cut appearance of skull, diagnosed with Hb electrophoresis, no treatment for traits. Thal major gets transfusion 1st and deferoxamine to prevent iron overload, splenectomy (now give Pneumovax, penicillin prophylaxis, folate supplement).

Front 216

194. Lead Poisoning

Back 216

pica kids who have ABCD (Anemia, Ataxia, Abdomen pain, Basophilic stippling, Behavioral changes, Constipation, Drops (foot, wrist), Death), high free erythrocyte protoporphyrin. Diagnosed with blood lead level and x-ray (lead visible in bones). Treatment with EDTA or dimercaprol.

Front 217

195. B12 Deficiency

Back 217

most common cause is pernicious anemia (anti IF, parietal Antibody), also due to gastrectomy, terminal ileus resection, vegetarian, chronic pancreatitis and diphyllobothrium latum infection. Look for CNS Signs & Symptoms (symmetric paresthesia in feet, fingers, disturbed proprioception and vibratory sense, irritability, somnolence, abnormal taste, smell, central scotomas, positive Babinski) and achlorhydria (no stomach acid secretion so pH in stomach is high). Check serum B12. Schilling test (never used in real world). Hypersegmented PMN. High methylmalonic acid level. Treatment with cobalamin. Folate may worsen the CNS signs & symptoms.

Front 218

196. Folate

Back 218

usually due to dietary lack (green vegetables, liver, kidney, yeast, mushrooms), alcoholism, pregnancy, celiac sprue, phenytoin, Bactrim, MTX, 5-FU, OCPs. Treatment with folate supplements.

Front 219

197. Autoimmune Hemolytic Anemia

Back 219

Antibody, complement binds to RBC membrane. Two types IgM (agglutination at colder temperature like Mycoplasma) and IgG (warm agglutination like SLE, penicillin, methyldopa). Diagnosed with direct Coombs’ positive. If hemolysis is mild, observe, if hemolysis is severe, give glucocorticoids. If recurrent, do splenectomy.

Front 220

198. Paroxysmal Nocturnal Hemoglobinuria

Back 220

Hypoventilate at night, so acidosis causes RBC burst due to low DAF, therefore complement comes right off (CD 55, 59). May die in 10 yrs due to thrombosis. Best test is Sugar water test or Ham’s test (Acidic sounds like Hasidic, Hasidic don’t like Ham). Signs & Symptoms include Hemoglobinuria in the morning time (not at night, that would be a prostate problem), increase risk of AML. Give steroids.

Front 221

199. G6PD Deficiency

Back 221

most common cause is infection (they usually won’t say Greek, primaquine, fava beans, Dapsone). Hemolysis, jaundice Abdomen, back pain 1-3 days after exposure. Heinz bodes, bite cells. Best treatment with avoiding offending agents.

Front 222

200. Spherocytosis

Back 222

increased osmotic fragility, AD, low spectrin, splenomegaly. Diagnosed with osmotic fragility test, treatment with splenectomy (defer until 6 years old), pneumonia vaccine and folate.

Front 223

201. Sickle Cell Disease

Back 223

African descent, AR, Signs & Symptoms >6 months due to hemoglobin F, if trait only gets UTI, best initial test is smear, most accurate test is Hb electrophoresis, for crisis 1st give fluids, pain management, if fever (due to autosplenectomy) give Antibiotics (Ceftriaxone), if eye, CNS, chest, Priapism give exchange transfusion, to prevent next aplastic crisis give folate, to prevent next vasoocclusive pain crisis (they will just say “crisis”) give hydroxyurea, if Hct drops suspect Aplastic anemia due to Parvovirus. Give prophylactic penicillin, Pneumococcal, Haemophilus influenza vaccine @ childhood.

Front 224

202. Aplastic Anemia

Back 224

low rbc, wbc, platelets, chloramphenicol, parvovirus, benzene, acute leukemia, AZT, zidovudine. Treatment with 1st stop drug, then give antithymocyte globulin.

Front 225

203. Myelophthisic anemia (Myelofibrosis)

Back 225

malignant invasion of BM, anisocytosis (aniso = any size), poikilocytosis (shape), teardrop-shaped RBC, diagnosed with BM biopsy showing no cells (dry tap).

Front 226

204. Transfusions

Back 226

Whole blood (poisoning, TTP), Packed RBC (post-surgery, trauma transfusion or instead of whole blood), washed RBC (IgA deficiency), Platelets (>10,000), granulocytes (post chemo), FFP (bleeding diathesis like DIC, warfarin poisoning, liver failure), cryoprecipitate (vWD and DIC).

Most common cause of transfusion reaction is lab error. If it occurs, 1st step is stop transfusion.

Front 227

205. Platelet problems =

Back 227

skin, gums, nose, gingival (ALL SUPERFICIAL), GI, CNS and vaginal bleeding; Factor problems; bleeding into join and muscles (DEEP), GI, CNS.

Front 228

206. von Willebrand Disease

Back 228

high PTT, normal PT, high BT, normal platelet, RBC count, AD (look for family history) (a platelet type of bleeding with a normal platelet count).

Best initial test is bleeding time, then ristocetin level.

Best treatment with desmopressin (DDAVP).

Front 229

207. Hemophilia A, B

Back 229

really high PPT, normal PT, normal BT, platelet, RBC, looking for delayed hemarthrosis in males only (A is factor 8, B is factor 9).

Front 230

208. DIC

Back 230

high PT, PTT, BT, low platelet, low RBC, low factor 8.

Front 231

209. Liver failure

Back 231

high PT, normal, high PTT, normal BT, normal, low platelet, RBC, jaundice, normal factor 8, do not give vitamin K (ineffective), give FFP’s.

Front 232

210. Heparin

Back 232

high PTT, thrombocytopenia. Treatment with discontinue drug.

Front 233

211. Warfarin

Back 233

high PT, vit. K antagonist (2, 7, 9, 10), treatment with FFP (fast) or vit. K (slow), skin necrosis.

Front 234

212. ITP

Back 234

low platelets, high BT, history of URI

next step is steroids (just treat it), auto-platelet Antibody

if platelets fall <7000 give IVIG or RhoGAM.

Front 235

213. TTP

Back 235

high BT, low platelet, low RBC, hemolysis, CNS, renal, fever, thrombocytopenia (petechia, purpura). Treatment with plasmapheresis.

Front 236

214. HUS

Back 236

like TTP but no renal failure or CNS signs & symptoms, history of infection, E. coli 015H7.

Front 237

215. Scurvy

Back 237

all studies normal. Fingernail, gum, bone, perifollicular hemorrhage, poor diet (only eats hot dogs and soda or tea and toast). Treatment with vitamin C.

Front 238

216. Neutropenia

Back 238

PMN <2.0 x 10_9. Diagnosed with bone marrow aspirate, biopsy. Treatment: 1st determine the cause, 2nd Antibiotics, 3rd steroids, 4th GM-CSF.

Front 239

217. Polycythemia Rubra Vera

Back 239

4 H’s (Hypervolemia, Hyperviscosity (thrombosis is MCCOD), Hyperuricemia, Histaminemia (itch all over after a hot shower)). Treatment with phlebotomy.

Front 240

Infectious Disease:

Back 240

0

Front 241

218. Toxic Shock Syndrome

Back 241

preformed toxin, prolonged tampon placement, hypotension, fever, desquamated rash (peeling of palms & soles), S. aureus.

Front 242

219. Conjunctivitis

Back 242

1st 24 hours is chemical, 2-5 days is Neisseria and 4+ is Chlamydia. If they say painful conjunctivitis, that’s viral (HSV) so treat with acyclovir.

Front 243

220. External Otitis

Back 243

pain, drainage, itchy swimmer’s ear, Pseudomonas.

Front 244

221. Otitis Media

Back 244

40% S. pneumoniae, 30% H. Influenza and 30% M. Catarrhalis, Diagnosis: 1st step is pneumatic otoscopy showing immobility of tympanic membrane, 2nd step is tympanocentesis, treatment with amoxicillin.

Front 245

223. Meningitis

Back 245

0-1 month– GBS, E. coli, Listeria

2 mo-2 year old – S. pneumoniae

2-18 year old – Neisseria

18+ - S. pneumoniae

Kernig’s, Brudzinski sign, lethargy, fever, bulging fontanelle, photophobia, nuchal rigidity, nausea & vomiting

diagnosed with LP (bacteria: low glucose, high protein, PMN’s; viral: normal glucose, slightly high protein, low WBC, lymphocytes).

Front 246

222. Sinusitis

Back 246

same % as above. Yellow green discharge, sinus tenderness, best initial step – empiric antibiotics (amoxicillin + decongestant), then X-ray, then Sinus biopsy (most accurate).

Front 247

Meningitis - Management

Back 247

If bacterial, give ceftriaxone, vancomycin or steroids.

Give ampicillin (listeria) if immunocompromised.

If neisseria suspected (2-18 year old with rash) next step is respiratory isolation and treatment him and family members with rifampin.

If >100 lymphocytes: Cryptococcus (rule out HIV, best initial test is India ink, most accurate test is Cryptococcus antigen, treatment with Amp B), Viral (no specific test), TB (Pulmonary signs & symptoms, high CSF protein, give RIPE + steroids), Lyme Disease (serology, history of bite, target rash, doxycycline, or if CNS Signs & Symptoms like cranial nerve 7 effects, give Ceftriaxone), RMSF (serology, rash on wrists, ankles moving centrally, history of camping or hiking, treatment with Doxycycline, chloramphenicol if pregnant).

The most common sequela is hearing loss.

Front 248

224. Encephalitis

Back 248

look for acute febrile confusion (if they say confusion, its encephalitis not meningitis), most common cause is herpes (blood in CSF), best initial test is CT (temporal lope), if negative do PCR (most accurate).

Treatment with acyclovir, then foscarnet if resistant.

Front 249

225. Brain Abscess

Back 249

look for focal neurologic findings with ring, contrast enhancing lesions. If HIV (-), do biopsy, if HIV +, start sulfadiazine-pyrimethamine treatment for Toxo and repeat CT.

Front 250

226. Spinal Abscess

Back 250

local severe back pain that becomes radicular pain, then weakness with fever. Next step is CT, then surgical drainage with antibiotics.

Front 251

227. Tetanus

Back 251

rictus sardonicus (facial sneer), tonic muscle spasms (jaw, trismus), clostridium tetani, treatment with tetanus IG and penicillin G.

Front 252

228. Diptheria

Back 252

gray pharyngeal pseudomembrane with sore throat, treatment with diphtheria antitoxin (DAT) and penicillin or erythromycin.

Front 253

229. Croup

Back 253

aka acute laryngotracheitis – barking cough in a 1-2 year old. Parainfluenza virus. Frontal neck x-ray shows steeple sign. Treatment with racemic epinephrine.

Front 254

230. Epiglottitis

Back 254

2-5 year old kid unimmunized (H. influenza) with rapid progression of high fever, drooling and respiratory distress with no coughing. X ray shows thumb sign. Do not examine throat or irritate the kid (worsen airway obstruction). Treatment with airway assessment, then cephalosporins.

Front 255

231. Bronchiolitis

Back 255

0-18month old kid in the fall, winter gets expiratory wheezing due to RSV. Treatment with ribavirin. (In a nutshell, 0-2 year old with wheezing is bronchiolitis, 1-2 year old with barking cough is croup, 2-5 year old with drooling is epiglottitis).

Front 256

232. Pertussis

Back 256

whooping inspiratory wheeze.

Front 257

233. Lung abscess

Back 257

fever for weeks, bad teeth, alcoholic, aspiration, stroke pt, intubated pt, next step is CXR, best way to prevent it is to remove all teeth, how do you differentiate from TB? The smell (very bad in abscess), most accurate test is biopsy, treatment with clindamycin.

Front 258

234. Bronchitis

Back 258

mild cough with sputum, negative CXR, treatment with azithromycin, Levaquin or doxycycline.

Front 259

235. Pharyngitis

Back 259

sore throat, exudes, lymph nodes, no cough, no hoarseness, best test is rapid strep test, treatment with penicillin.

Front 260

236. Influenza

Back 260

aches, pains, tired, cough, headache, no fever. Best treatment is oseltamivir or zanamivir (note the “Ivir” (for Influenza), not “Ovir” like acyclovir, famciclovir for HSV or “Avir” like ritonavir, nelfinavir for AIDS).

Front 261

237. Pneumonia

Back 261

outpatient treatment is same as bronchitis (azithromycin, Levaquin, doxycycline), inpatient treatment include ceftriaxone. In young healthy pt, think mycoplasma (get serologies) or if inpatient, think S. pneumoniae. If CNS and GI symptoms, pick Legionella. If AIDS with CD <200 pick PCP (TMP-SMX Treatment). If exposed to sheep placenta, pick Coxiella burnetii. If lobar pneumonia (S. pneumonia is most common) then stain and culture next. When do you give steroids? PO2 <75, A-a gradient <35. When do you admit and give Pneumovax? Hypoxia, >65, splenectomy, hypotensive with high pulse, comorbidities, confusion, low Na (SIADH).

Front 262

238. TB

Back 262

homeless, alcoholic, immigrant, HIV, health care worker, prisoner, fever, cough, sputum, weight loss, night sweats, first thing to do is CXR (NOT PPD – when do you choose PPD first? Screens asymptomatic pts!), 2nd step is AFP and then give RIPE with isolation for 2 months, then isoniazid and rifampin for another 4 months (6 months total). Adverse effects are Isoniazid is neurotoxic (less with B6), Rifampin with red urine, pyrazinamide with high uric acid (do not treat it, it will pass) and ethambutol with eye problems.

Front 263

239. PPD –Positive if

Back 263

>5mm in HIV, steroid users, close contacts; >10mm in immigrants, health care workers (me!), >15 in Patient with no risk facts. If PPD is positive, proceed to CXR, if (-) take INH for 9 months, if + get sputum AFB. If PPD is negative, repeat it in 1-2 weeks to rule out false negatives. If Patient had PPD in the past that was +, don’t do PPD again (it will always be positive), go right to CXR.

Front 264

240. Endocarditis

Back 264

fever and a murmur is key, history of IV drugs, Staph aureus at tricuspid valve, #1 diagnostic test is blood culture (not ECHO) and #2 diagnostic test is ECHO (TTE type, not TEE). For dental procedures (must be dental procedure with blood, can’t be dental fillings) give amoxicillin or clindamycin if allergic, for GI, GU (strep bovis) procedure give amoxicillin + gentamycin, or vancomycin + gentamycin if allergic. Strongest indication for surgery is ruptured valve. So, 1st step is blood culture, 2nd step is start antibiotics while waiting for results.

Front 265

241. Thrush

Back 265

oral candida, removable white mouth patches (Candida CAN come off, hairy leukoplakia cant). Treatment with nystatin mouth rinse.

Front 266

242. Lyme Disease

Back 266

problems in joints, CNS (bilateral Bell’s palsy), heart (3 degree AV block).

If it’s just a tick bite and no signs & symptoms, do nothing. If it’s a bite with Lyme rash give amoxicillin (pregnant or kids) or doxycycline (not serology).

If patient has bilateral bell’s palsy get serology. If AV block with CNS signs & symptoms (except Bell’s palsy) give ceftriaxone next.

Front 267

243. HIV

Back 267

1st ELISA, 2nd western blot (in kids, 1st is PCR). Peripheral neuropathy with stavudine, didanosine, anemia with zidovudine, rash with trimethoprim, sulfamethoxazole (start dapsone), nephrolithiasis with indinavir. Most common overall adverse effect is increase lipids and glucose levels. Prophylaxis: <200 for PCP (trimethoprim, sulfamethoxazole), <50 MIA (azithromycin). What if Patient finds out she has HIV during pregnancy? Continue all medications except efavirenz. When do you only continue with AZT? If she has high CD count, give it in end of pregnancy and to newborn for 6 weeks. If Patient gets stuck with needs, start 2 nucleosides and 1 PI or 2 nucleosides with efavirenz. Must you start treatment if patient got splashed in eyes? Yes. Kissing? No.

Front 268

244. If Patient is stuck with HBV needle, now has +HBsAg, what do you do?

Back 268

If vaccinated, do nothing. If not vaccinated, give IVIG + vaccine. If Patient got stuck with HCV needle do nothing.

Front 269

245. How can you tell urethritis from cystitis?

Back 269

Urethritis has discharge. For both conditions, 1st step is swab, then stain, then DNA probe then Treatment. For urethritis treatment GC (Ceftriaxone), for cervicitis, treatment for Chlamydia (Azithromycin or Doxy).

Front 270

246. Genital ulcers and + Lymph could be

Back 270

syphilis, LGV or chancroid.

Front 271

247. Syphilis

Back 271

painless genital ulcer, skin rash (lata), CNS, aortitis. 1st step is Darkfield microscopy (not RPR, vdrl). DOC is penicillin. If allergic give doxycyline. If allergic and pregnant, desensitize with penicillin. If Patient gets immediate allergic reaction to penicillin, give aspirin.

Front 272

248. LGV

Back 272

painless ulcer with painful nodes. 1st step is serology (Chlamydia is culture negative), treatment with doxycycline.

Front 273

249. Chancroid

Back 273

painful ulcer, 1st step is culture, treatment with azithromycin.

Front 274

250. Genital vesicles, next step is

Back 274

acyclovir (not Tzanck because you already have Diagnosis), if resistant give foscarnet.

When do you choose PCR? HSV in the brain.

Front 275

251. If they show or describe a vesicle (but don’t say vesicle), then do

Back 275

Tzanck test

Front 276

252. If they describe or show warts, next step is

Back 276

remove (no tests needed)

Front 277

253. Septic Arthritis

Back 277

1st step is arthrocentesis (>50,000 WBC). If you suspect gonorrhea (look for tenosynovitis, rash or migratory polyarthritis), next step is culture pharynx, rectum, cervix, etc.

Front 278

254. Osteomyelitis

Back 278

1st step is x-ray (periosteal elevation), 2nd is MRI, 3rd is biopsy. When do you choose bone scan? If you can’t do MRI (metal, pacemaker, hearing tubes, etc.). After biopsy you can make Diagnosis: S. aureus (nafcillin), MRSA (vancomycin, linezolid), E. coli (quinolones for bones) and then follow up ESR. When do you choose culture or sinus drainage? Never!

Front 279

RHEUMATOLOGY:

Back 279

0

Front 280

255. Osteoarthritis

Back 280

stiff, not red, not hot. DIP (Heberden’s node), PIP (Bouchard’s), worse in PM (not in AM like RA).

X-ray shows osteophytes and joint narrowing.

Treatment with weight loss 1st, then NSAIDS.

Front 281

256. Rheumatoid Arthritis

Back 281

red, hot, swollen, fever, subcutaneous nodules, +RF, pericarditis, pleural effusion, uveitis, long morning stiffness, swan neck, PIP, MCP (not DIP). X-ray shows pannus.

Treatment with NSAIDS (1st if mild), methotrexate (1st if severe), 2nd is TNF (infliximab – rule out TB 1st), then steroids.

Front 282

257. Gout

Back 282

podagra, tophi (subcutaneous uric acid deposits with punched-out bone lesions), (-) birefringent crystals, associated with alcohol, aspirin and HCTZ use.

Treatment: Acute: 1st with NSAIDS (Indomethacin), then colchicine’s, then steroids (1st if renal disease).

Chronic: If over secretor give allopurinol (allo for people who make a lot), under secretors get Probenecid.

Front 283

258. Pseudogout

Back 283

calcium rhomboid shaped crystals, + birefringence, chondrocalcinosis, associated with 4 H’s (hemochromatosis, hyperparathyroidism, hypophosphatemia, hypomagnesemia). Most common @ knees, elbows.

Front 284

259. Psoriasis

Back 284

scaly skin lesions, finger clubbing, RF negative.

Treatment with NSAIDS, MTX.

Front 285

260. Ankylosing spondylitis

Back 285

HLA-B27 (not diagnostic), family history, back pain, bent over (bamboo spine), worse with rest (key), better with exercise, diagnosed with 1st Sacral X-ray (sacroiliitis).

Treatment with exercise and NSAIDS.

Front 286

261. Reiter’s Syndrome

Back 286

HLA-B27, can’t see (conjunctivitis), pee (uveitis) and climb a tree (arthritis).

Treatment with NSAIDS, eye drops, STD treatment.

Front 287

262. Behcet’s syndrome

Back 287

20-40 year old with painful oral, genital ulcers and arthritis.

Treatment with steroids.

Front 288

263. Kawasaki’s

Back 288

(FEEL My Conjunctiva – Fever >5days, Edema, Erythema, Lymphadenopathy, Myositis, Conjunctivitis). Next step is ECHO (rule out coronary aneurysms).

Treatment with Aspirin + IVIG.

Front 289

264. Takayasu arteritis

Back 289

Chinese 30-50 year old female with pulselessness on 1 side. Diagnosed with angiogram of aortic arch (coronaries to rule out stroke).

Treatment with steroids, cyclophosphamide.

Front 290

265. Wegener’s

Back 290

nasal (sinusitis), lung (hemoptysis, dyspnea), kidney (hematuria), c-ANCA

treatment with cyclophosphamide.

Front 291

266. Fibromyalgia

Back 291

young female with pain all over, multiple points of tenderness, irregular sleep pattern, anxiety, exams all normal.

Treatment with antidepressant, NSAIDS.

Front 292

267. Polymyalgia Rheumatic

Back 292

old female with pectoral, pelvic pain, stiffness, elevated ESR, normal biopsy, associated with temporal arteritis.

Treatment with steroids.

Front 293

268. Polymyositis

Back 293

40-60 year old female with proximal muscle weakness, elevated ESR, CPK, abnormal muscle biopsy, diagnosed with 1st muscle biopsy, then EMG.

Treatment with steroids.

Front 294

269. Dermatomyositis

Back 294

same as above, but with rash (heliotrope rash around eyelid).

Front 295

270. Paget’s disease

Back 295

>40 year old male with pelvic, skull damage, hats don’t fit anymore, deafness, paraplegia, bone pain, very high alkaline phosphatase, normal calcium, phos, increased risk of osteosarcoma.

X-ray shows thickened bones.

Treatment with NSAIDS, bisphosphonates (Etidronate) and calcitonin.

Front 296

271. Herniated disk

Back 296

most at L4-5 (weak big toe), and L5-S1 (reduced Achilles reflex), positive straight leg test.

Front 297

272. Carpal Tunnels

Back 297

median nerve compression (thumb, pointer, middle finger), Tinel’s sign (tapping wrist causes numbing), Phalen’s sign (flexing wrist), treatment with rest, splint, workplace modifications and then NSAIDS.

Front 298

273. Osgood-Schlatter

Back 298

inflammation of tibial tubercle in boys. Treatment with rest and immobilization.

Front 299

274. Slipped Capital Femoral Epiphysis

Back 299

Obese kid with painful limp.

Diagnosed with x-ray. Treatment with surgical pinning >5 year old.

Front 300

275. Legg-Calve-Perthes

Back 300

non-obese kid with a limp (due to avascular necrosis @ hip).

Treatment with observation and pain relief, 2nd is bracing, 3rd is surgery.

Front 301

276. Osteoporosis

Back 301

risks include early menopause, alcohol, Caucasian, thin body, tobacco.

Diagnosed with DEXA >-2.5 (-1 to -2.5 is osteopenia).

Treatment 1st weight-bearing exercise, 2nd lifestyle (smoking, alcohol cessation), 3rd calcium, vit. D, bisphosphonates, etc.

Front 302

277. Patellar tendonitis

Back 302

an NBME 3 test question, aka jumper’s knee, patellar tenderness due to overuse and jumping sports resulting in quadriceps contraction.

Treatment with rest, NSAIDs, quadriceps stretching.

Front 303

278. Osteosarcoma

Back 303

10-25 year old with knee pain, mass, limping, high alkaline phosphatase. X-ray with sunburst appearance. Treatment with surgery and chemotherapy.

Front 304

279. Osteoid Osteoma

Back 304

bone pain worse at night and relieved with NSAIDS. Treatment with NSAIDs.

Front 305

280. Osteochondroma

Back 305

bone pain, x-ray shows pedunculated metaphyseal tumor at distal femur. Treatment with surgery.

Front 306

281. Ewing sarcoma

Back 306

fever, pelvic, femur bone pain, swelling, xray shows onion skinning. Treatment with radiation, chemo, surgery.

Front 307

282. Reflex Sympathetic Dystrophy

Back 307

burning pain, skin changes (color, temperature), edema in a Patient who had prior injury to that area. Treatment with pain management (hard to do).

Front 308

283. Nursemaids Elbow

Back 308

from pulling your child’s arm, he develops severe pain at elbow and will not use that arm. Treatment with pushing back the head of the radius while the arm is supinated and flexed. Kid will feel much better immediately.

Front 309

NEUROLOGY:

Back 309

0

Front 310

284. Migraine headache

Back 310

70% unilateral, throbbing, aura, photophobia, family history, possible risk of stroke, worse with OCPs, EtOH, chocolate. Treatment with NSAIDS, triptans (contraindicated in heart disease), ergots. Prevent with beta blockers 1st, cab’s 2nd, sodium valproate, SSRI, TCAs.

Front 311

285. Cluster headache

Back 311

same time every month, year, males mostly, tearing, redness, pain, rhinorrhea, feels like an icepick is shoved in your eye (old question). Treatment with 100% oxygen 1st, steroids 2nd.

Front 312

286. Temporal Arteritis

Back 312

>50 year old with unilateral temporal headache, scalp tenderness, vision changes, high ESR. 1st step is give steroids, 2nd step temporal artery biopsy.

Front 313

287. Pseudotumor Cerebri

Back 313

aka Benign Intracranial HTN – increased ICP, headache, visual changes, obese female, papilledema, no focal CNS findings, associated with vitamin A toxicity. Diagnosed with MRI 1st then LP 2nd, treatment with acetazolamide.

Front 314

288. Trigeminal Neuralgia

Back 314

pain whenever you touch your face @ 5th cranial nerve distribution. Treatment with carbamazepine. Definitive treatment with surgical rhizotomy.

Front 315

289. Essential Tremor

Back 315

at rest and motion. Treatment with propranolol. (Tremor at rest only is Parkinson’s or hyperthyroidism, tremor with motion only is cerebellar dysfunction).

Front 316

290. Nystagmus, Vertigo

Back 316

if + focal deficits, the problem is central (vertical nystagmus): cerebellum (CT, MRI), M. Gravis (MRI), Stroke (MRI, CT), phenytoin without a hearing loss or tinnitus. If no focal deficits, the problem is peripheral (in the ears), so Patient will have hearing loss and tinnitus. If Patient only has vertigo, its benign positional vertigo. If Patient has hearing loss and tinnitus with it: Meniere’s disease (chronic disease), Acoustic Neuroma (look for ataxia), Labyrinthitis (acute viral infection).

Front 317

291. Epilepsy (as per Kaplan on what is important)

Back 317

do not treat 1st time seizures unless there is a family history, EEG is positive or Patient has status epilepticus.

Front 318

292. Status Epilepticus

Back 318

Diagnosis: 1st sodium, 2nd glucose, 3rd calcium, 4th hypoxia, toxicology, CT-head, EEG (last!). Treatment: 1st Benzo (Lorazepam IV), 2nd Phenytoin, 3rd Barbiturate, 4th Anesthesia (succinylcholine, propofol – these will just stop the shaking, won’t stop the seizure).

Front 319

293. Absence seizures

Back 319

kid stares into space, doing poorly in school, eye blinking, lip smacking, EEG with 3, sec spike and wave pattern. Treatment with ethosuximide.

Front 320

294. TIA

Back 320

focal, abrupt onset lasting less than 1 hour, symptoms resolve after 1 day. Risk of stroke in days to weeks. Amaurosis fugax (curtain over an eye due to retinal dysfunction) needs Doppler ULTRASONOGRAM of carotids or MRA. Give heparin acutely (if no contraindications), then long term aspirin. If stenosis >70%, amaurosis fugax, TIA or small, non-disabling stroke do CEA (carotid endarterectomy) and give aspirin. If stenosis <70%, severely disabling stroke, or TIA, stroke in evolution give daily aspirin alone.

Front 321

295. CVA

Back 321

1st test is CT without contrast (although, if ischemic, it will show negative), 2nd is MRI. Heparin is not given until hemorrhagic stroke is ruled out. If ischemic, give TPAs if less than 3 hours of onset. If hemorrhagic, control BP and ICP.

Front 322

296. Ischemic Stroke Locations: MCA

Back 322

contralateral hemiplegia, hemianopsia, Broca’s (nonfluent, babbling), Wernicke’s (fluent but doesn’t make sense) aphasia. ACA – contralateral leg paralysis, sphincter incontinence (they can’t kick you, so they pee on you); Posterior – cortical blindness, hemianopsia; Vertebrobasilar – ataxia, horizontal gaze, nystagmus; Cerebellar – ataxia and dizziness; As for hemorrhagic, remember that in the thalamus its only sensory loss, in the pontine, internal capsule, putamen its only motor loss.

Front 323

297. Multiple Sclerosis

Back 323

insidious onset of CNS Signs & Symptoms in a woman aged 20-40 with exacerbations and remissions of numbness, parasthesia, weakness, optic neuritis, gait disturbance, incontinence and emotional, mental status changes. Look for classic bilateral internuclear ophthalmoplegia (lesion @ MLF so you cannot adduct in horizontal gaze) and scanning speech. Babinski may be positive. Entirely CNS (Myasthenia Gravis and G-Barre are entirely PNS). 1st step is MRI, 2nd test is LP (oligoclonal bands). Treatment acute exacerbation with steroids. Prevent next attack with ABC (Avonex (Inf-B), Betaseron (Inf-B) and Copaxone (Glatiramer acetate)). If stuck in 1 position all day, give baclofen or Tizanidine. If incontinent give oxybutynin or bethanecol.

Front 324

298. Guillain-Barre Syndrome

Back 324

history of URI of GI infection (campylobacter jejuni) or immunization 1 week before develops onset of symmetric, ascending progressive weakness or paralysis and loss of DTRs.

1st step is PFTs (MCCOD is respiratory dysfunction due to paralysis, so monitor the patient’s NIF (negative inspiratory force) and if it keeps decreasing, consider intubation).

Most accurate test is EMG.

When do you choose LP? Last (shows elevated CSF protein).

Treatment with IVIG or plasmapheresis (not steroids!).

Front 325

299. Myasthenia Gravis

Back 325

Antibody against Acetylcholine receptors in women 20-40 year old. Look for ptosis, diplopia, difficulty swallowing and weakness with repetition (at the end of the day they are exhausted).

Best initial test is Acetylcholine Antibody (NOT edrophonium test, which is 2nd or if they already mention the Acetylcholine Antibody). Most accurate test is EMG.

Treatment for Myasthenia crisis (breathing problems) with DISCONTINUE anticholinergics and give IVIG and Plasmapheresis (NOT steroids).

Treatment for chronic disease: <60 gets thymectomy (do CXR, Chest CT), >60 gets neostigmine and steroids, then azathioprine, cyclosporine, tacrolimus.

What antibiotics is contraindicated? Aminoglycosides.

Front 326

300. Eaton-Lambert

Back 326

Antibody against presynaptic calcium channels causing limb weakness that gets stronger with repetitive stimulation (opposite of gravis), no loss of DTRs or extraocular manifestations, associated with small cell lung cancer, treatment with guanidine. (CABs are contraindicated).

Front 327

301. Neurosyphilis

Back 327

tertiary Treponema pallidium disease. Treat with high dose penicillin.

After giving penicillin, Patient may develop hypotension, fever, headache, chills and tachycardia within 24 hours of treatment due to treponemal products (Jarisch-Herxheimer reaction, this is not a penicillin reaction).

Treatment with aspirin.

Front 328

302. Myotonic Dystrophy

Back 328

20-30 year old guy grabs something and can’t let go (impaired relaxation) due to mutations in chloride channel.

Treatment with phenytoin.

Front 329

303. Duchenne Muscular Dystrophy

Back 329

XLR, boys 3-7 have muscle weakness, very high CK, calf pseudohypertrophy, Gower’s sign (kid climbs his legs to stand, look at it in Google videos. It’s so sad). Kid is in wheelchair by teenager and dead by 20. Diagnosed with muscle biopsy.

Front 330

304. Mitochondrial Myopathy

Back 330

aka Leber’s hereditary optic atrophy – every mom gives to all offspring (no male transmission).

Look for ragged red fibers on biopsy.

Front 331

305. Botulism

Back 331

infant ingests honey and develops floppy baby syndrome. 1st step is intubate if needed, 2nd step is antitoxin.

Spontaneous recovery in 1 week.

Front 332

306. Amyotrophic lateral Sclerosis

Back 332

aka Lou Gehrig’s disease– 55 year old male upper (spasticity, hyperreflexia, Babinski) and lower motor neuron (fasciculations, atrophy, flaccidity) problem.

Only motor problems, no sensory, sexual, bowel problems.

Treatment with Riluzole.

Front 333

307. Huntington’s disease

Back 333

AD (father had it, you have it at a younger age) with CAG repeats, chorea, personality change, psychiatric syndromes, progressive dementia.

Diagnosed with CT, MRI showing caudate nucleus and cerebral cortex atrophy, causing decreased Acetylcholine and GABA (thus causing increased dopamine).

Treatment with antipsychotics (haloperidol). When you see a movement disorder, dementia and emotional problems, think of Huntington’s. When you see dementia and emotional problems (no chorea), pick Pick’s disease.

Front 334

308. Parkinson’s

Back 334

60 year old with extrapyramidal movement disorder (pill-rolling resting tremor, cogwheel rigidity, shuffling gait, bradykinesia and masked facies).

Caused by loss of dopaminergic neurons in substantia nigra.

Treatment: Mild Signs & Symptoms (can still take care of themselves): <60 year old with Anticholinergic (cabergoline, benztropine, trihexyphenidyl), >60 year old with amantadine. If Severe signs & symptoms: 1st Levo, Carbidopa, 2nd is DA agonist (pramipexole, ropinirole, pergolide), 3rd COMT-inhibitors (tolcapone), 4th MAOI (selegiline). Some antipsychotics (haloperidol, risperidone, MPTP) can cause Parkinson-like symptoms, treatment with anticholinergics (benztropine, trihexyphenidyl and cabergoline). Young guy with Parkinsonism, but not on medications, think of Wilson’s disease.

Front 335

309. Alzheimer’s

Back 335

progressive dementia (memory, language, visuospatial, mood, hallucinations, personality, behavior) in mid-late life.

Associated with Down’s syndrome (amyloid precursor protein).

Diagnosed with MRI showing cortical atrophy, senile plaques and neurofibrillary tangles.

Treatment with donepezil, rivastigmine and galantamine to increase Acetylcholine just in brain.

Front 336

310. Pick’s

Back 336

early aged (40) personality change, dementia. CT, MRI shows frontotemporal atrophy, argyrophilic neuronal (Pick) bodies in frontal and temporal lobe, sparing superior temporal gyrus (generally no memory problems).

Front 337

311. Multi-infarct Dementia

Back 337

stepwise dementia in a Patient with bad medical history (HTN, DM, etc.). They will describe the Patient as progressively getting worse, little-by-little. Diagnosed with PET, SPECT scan showing multifocal decreases in cerebral blood flow. Treatment with aspirin.

Front 338

312. Normal Pressure Hydrocephalus

Back 338

“wet, wacky, wobbly” (incontinent, dementia, ataxia).

Diagnosed with CT scan, treatment with ventriculoperitoneal shunt.

Front 339

313. Creutzfeldt-Jakob

Back 339

young guy with rapidly progressive dementia, myoclonus due to abnormal isoform of prion protein. Diagnosed with biopsy (nothing else). No treatment.

Front 340

314. Narcolepsy

Back 340

daytime sleep attacks with cataplexy, hypnogogic (going to sleep), hypnopompic (waking up) hallucinations, sleep paralysis. Rapid onset of REM sleep. Treatment with amphetamines for sleepiness, clomipramine for cataplexy.

Front 341

315. Obstructive sleep apnea

Back 341

overweight, HTN, arrhythmia, gasping for air. Diagnosed with polysomnography. Treatment with CPAP.

Front 342

316. Central sleep apnea

Back 342

old, non-obese Patient with loss of respiratory drive. Treatment with acetazolamides.

Front 343

317. Epidural Hematoma

Back 343

+ head trauma + headache + LOC, lucid intervals after brief LOC followed by increasing obtundation, middle meningeal artery.

Diagnosed with CT without contrast showing convex hematoma.

Treatment with 1st hyperventilate and elevate head, 2nd evacuate, 3rd mannitol.

Front 344

318. Subdural Hematoma

Back 344

+ head trauma, + headache, + LOC, bridging veins injured, can be acute (CT showing concave or crescent-shaped hematoma), days (MRI), or gradual deterioration (MRI).

Treatment with same as above.

Front 345

319. Subarachnoid Hemorrhage

Back 345

+headache, + LOC, no head trauma, spontaneous, sudden onset of meningitis (stiff neck, photophobia, Kernig’s, Brudzinski), worst headache of my life, associated with polycystic kidney disease, CSF with blood.

Best initial test is Head CT, most accurate test is LP.

Treatment supportively (bed rest, analgesia).

Front 346

320. Concussion

Back 346

+ head trauma, + LOC, no focal CNS deficits. Treatment – go home.

Front 347

321. Contusion

Back 347

+ head trauma, + LOC, blood, bruise on head. Treatment – go home.

Front 348

322. Neuroleptic malignant syndrome

Back 348

high temperature, muscular rigidity, confusion, high CPK, high K+, no sweating, treatment with IV dantrolene or bromocriptine.

Front 349

323. Malignant hyperthermia

Back 349

high temperature, confusion, high CPK, high K+, no sweating, history of anesthesia (halothane). Treatment with IV dantrolene.

Front 350

324. Heat Stroke

Back 350

high temperature, confusion, no sweating, normal CPK, normal K. Treatment with fanning them (don’t overcool them) and water.

Front 351

325. Closed-angle Glaucoma

Back 351

sudden eye pain, nausea & vomiting, vision loss. Treatment with surgical iridectomy.

Front 352

326. Open-angle Glaucoma

Back 352

progressive peripheral vision loss, disc cupping, no pain. Treat with beta blockers (timolol), acetazolamide, eye drops and prostaglandins (latanoprost).

Front 353

Growth, Development, Preventative Medicine:

Back 353

0

Front 354

327. Gestational Age

Back 354

fundus at pubic symphysis @ 8 weeks, above symphysis @ 14 weeks, umbilicus @ 20 weeks, xiphoid @ 38 weeks.

Front 355

328. Naegeli’s rule

Back 355

assuming 28 day cycle, subtract three months, add 7 days (if more than 28 days, add the remaining days to the 7).

Front 356

329. Infant size

Back 356

gains back birth weight by 2 weeks of age, double weight by 6 months, triples weight by 1 year.

Front 357

330. Lactation

Back 357

estrogen makes mammary duct tissue grow, progesterone stimulates alveolar glands. Postpartum, they both drop, prolactin increases (inhibiting ovulation) and oxytocin, via nipple stimulation, allows milk letdown. Contraindicated with HIV, CMV or certain medications.

Front 358

331. Newborn care

Back 358

“Caput succedaneum” is a hematoma across the suture line, cephalohematoma is a hematoma that does not cross the suture line. Mongolian spot is a bluish discoloration at the sacrum, always benign (do not assume abuse). Check for red eye reflex (rule out retinoblastoma and congenital cataracts), Ortolani, Barlow maneuver (rule out DDH), abdomen masses (ARPKD, Wilms’ tumor, neuroblastoma, umbilical hernia (rule out hypothyroidism)).

Front 359

332. Development

Back 359

1 month – head lag, social smile;

3 months – lifts head,

6 months – rolls over, sits up alone, stranger anxiety,

9 months – crawls, takes steps if hands held,

12 months – walks if you hold one hand, speaks three words;

15 months – walks alone, separation anxiety, two-block tower;

2 year old – six cube tower, poison-proof home.

Front 360

333. At 4 years old, must get ???

Back 360

objective hearing and visual exam

Front 361

334. Puberty

Back 361

Females sequence (estrogen): ovary growth, breast bud, growth spurt and then pubic hair. Male sequence (testosterone): testicular growth, growth spurt and then pubic hair.

Front 362

335. When to keep child-physician confidentiality?

Back 362

Drugs, EtOH, OCP, STD prevention.

Front 363

336. OCP

Back 363

Barrier Method (condoms help prevent STDs, diaphragms might be annoying to prepare, thus inhibiting use), hormonal contraceptives (combined estrogen, progesterone (safe, effective), minipill (more pregnancy, bleeding), or injectable and implanted progestins), vaginal spermicides, IUD, surgical sterilization.

Front 364

337. #1 stressor is ???, # 2 is ???.

Back 364

#1 stressor is death of a spouse, # 2 is divorce.

Front 365

338. Normal Aging

Back 365

cardiac (decreased CO), musculoskeletal (decreased bone mass), pulmonary (decreased strength and compliance), immunity (thymus involution), senses (decreased visual, auditory, tactile and taste), endocrine (decreased insulin-secreting cells, glucose intolerance), mental (decreased memory, learning ability and calculation speed).

Front 366

339. Exceptions to informed consent

Back 366

emergency, incompetent patient, minors.

Front 367

340. Influenza

Back 367

>50 years old, high risk (COPD, cardiovascular, renal), women who WILL become pregnant in winter, household contacts of high-risk Patient (to protect the high-risk pt).

Pneumococcal - >65, comorbidities.

Front 368

341. Stat Formulas

Back 368

[A = True Positive; B = False positive; with = False negative; D = True Negative] (positives always on top)

Sensitivity = TP, TP+FN;

Specificity = TN, TN+FP;

PPV = TP, TP+FP;

NPV = TN, TN+FN;

Attributable risk (attributable = subtract) = (a, a+b) – (c, c+d);

Relative risk (only for prospective studies like cohort study)= (a, a+b) , (c, c+d);

Odds ratio (only for retrospective studies like case-control) = ad, bc; attack rate (how many people get attacked with disease) = a+c, b+d.

Front 369

342. Power =

Back 369

rejecting the null when it’s false (a good thing, like saying Viagra does not treat constipation, which it doesn’t do). However, sometimes FDA may not always make the right choice and end up approving something that doesn’t work, or not approving something that works.

Type 1 error rejecting the null when it’s true (saying Viagra does not treat erectile dysfunction).

Type 2 error = acceptance of the null hypothesis when it is false (saying Viagra treats constipation).

Generally, the only way to increase power is to increase the sample size.

Front 370

343. Mean = ???; Median = ??? #, Mode = ??? #.

Back 370

Mean = average; Median = middle #, Mode = MC #.

Front 371

344. Confidence Interval =

Back 371

[mean +, - Z score x standard error of mean]

where Z is the standard score (If confidence interval is 95%, Z is 2, if CI is 99%, Z is 2.5) and standard error of mean is (S, square root of N), where S is the standard deviation and N is the sample size.

For example, old TQ said the mean was 67%, standard deviation was 8% in a sample size of 16, calculate a 95% CI: (67 +, - 2 (8, square root of 16) = (67 +, - 2 (8, 4)) = 64 +, - 4. The answer was 63-71.

Front 372

345. When they give you a chart with different confidence intervals,

Back 372

just look for the one that has 1 within the range (ie. 0.89-2.3, not 1.12-2.25 or 0.56-0.93). That one is NOT statistically significant, meaning the risk is the same. If 1 is not within the range, is statistically significant. If it was over 1 (1.12-2.25 used above), there is an increased risk. If it was under 1 (0.56-0.93 used above), there is a decreased risk.

Front 373

346. When given statistical scales and asked for the statistical test

Back 373

Nominal is categorical (how many you can split into groups, like genders, ethnicities, etc.), Interval is a measurement (height, wt, BP, etc.). Pearson correlation = 2 intervals; Chi-square = 2 nominal; t-test = 1 nominal + 1 interval. For example, if you want to find out if men do better than women on step 2. Men versus women are nominal, Step 2 is an interval, and therefore one of each makes it a t-test.

Front 374

347. If given the following data

Back 374

After surgery: 90% survive 1year, 75% survive 2years, 50% survive 3years, and 40% survive 40%, and asked: what is the life expectancy after surgery? Always pick closest to 50%, so the answer would be 3 years. If asked, if a Patient survives 2 years, what is the chance of surviving 3 years? Always put the # ending on top, # starting on bottom, so it will be 50, 75, or 67%.

Front 375

348. Cohort study (think

Back 375

Cohort to Go Forth) – a prospective study where people are followed for a period of time. Advantages are that incidence (# of new cases) can be determined, there is an accurate relative risk (remember RR with cohort), and less control group bias. Disadvantages are that it takes too long, expensive, the sample size can get too large, and you might run into an ethical problem.

Front 376

349. Case-control study

Back 376

a retrospective study where you start with an outcome and then check backwards to evaluate the risk or cause. Advantages are that it’s cheap and easy, small sample size and minimal ethical risk is involved. Disadvantages are that incidence (new cases) are not determined, RR is just approximated (not exact, just taking odds, remember OR with case-control) and that there is some control group bias. Kaplan says, if you have no idea which type of study it is, pick this one.

Front 377

350. Confounding bias

Back 377

when hidden factors affect the results. For example, an experimenter measures the # of ashtrays owned and incidence of lung cancer and finds that people with lung cancer have more ashtrays. He or she then concludes that ashtrays cause lung cancer. Smoking is the confounding bias here, because it increases both ashtrays and lung cancer. So how can you prevent this? Do multiple studies.

Front 378

351. Lead-time bias

Back 378

when you confuse the facts that early screening will increase life expectancy. Look for false estimates of survival rates. For example, if I diagnosed you with cancer at 18 and you lived until 30, you will think I treated you for 22 years. However if I didn’t diagnose you until 25 and didn’t treat you after, and then you lived until 30, you will think that you only survived 5 years. The difference is not that my drug treats you better, but that I am diagnosing you earlier, thus getting a good lead on time. The solution here is to measure the “back-end” survival (ie. Getting the age 30 as the age that they both die at, whether they were treated or not).

Front 379

352. Recall bias

Back 379

subjects can’t remember past events. Solution is to make them confirm information with other sources.

Front 380

353. Late-look bias

Back 380

subjects die before the end of the survey, so your information gets distorted. For example, a survey finds that AIDS pts only get mild symptoms. This is wrong because they die before the really bad symptoms occur. Solution here is to stratify the disease by severity.

Front 381

354. Experimenter, Interviewer bias

Back 381

aka Pygmalion effect - when the experimenter’s expectations are inadvertently communicated to subjects, who then produce the desired effect. Solution is to make the study a double-blind one.

Front 382

355. Selection bias

Back 382

aka sampling bias – when the sample selected is not a representative of the population. For example, taking the people from a health club and doing a survey on the lungs in the general population. Another cause is when a study uses hospital records to estimate population prevalence (Bergson’s bias). For example, a doctor says all the people in NY are sick because all day he works with sick patients in NY.

Front 383

356. Measurement bias

Back 383

aka Hawthorne effect – when being observed makes you change how you answer to questions. Also, when the way the information is presented makes you answer in a certain way. For example, asking a Patient “you don’t like your doctor, do you?” The Patient is likely to say no because of the way the question was presented. In the law world, it’s termed “leading.” Prevent this by having a control, placebo group.

Front 384

OB:

Back 384

0

Front 385

357. Numbers to note

Back 385

How many weeks in each trimester? 13; what is so special about 37 weeks? Lungs are mature because lethicin-sphingomyelin ratio is 2:1; what is the risk of having Down’s if mom is 35? 1, 350; risk @ 40? 1, 100; risk @ 45? 1, 50, so you absolutely must recommend amniocentesis. Pregnancy weight gain is about 25 pounds (5 pounds in first 20 weeks, and 1 pound every week after that). Uterine height: 8 weeks @ iliac, 14 weeks @ pubic symphysis, 20 weeks @ umbilicus, 38 weeks @ xiphoid process.

Front 386

358. Dates to note:

Back 386

6-8 weeks is prenatal workup. 15-18 weeks is triple screen. 18 weeks is ultrasound. 26 weeks is glucose challenge test for DM. 35 weeks is GBS culture.

Front 387

359. Diagnostics

Back 387

Ultrasound (noninvasive, no adverse effects, done at 18-20 weeks), Chorionic villus sampling (“CVS,” invasive, done at 9-12 weeks, best for early gestation so mom has the chance to choose an abortion, may be fatal, follow up with triple screen after), Amniocentesis (done at 15-20 weeks for genetic purposes or high risk patients, done at 24 weeks for Rh isoimmunization, done at 34 weeks for gestation age, pregnancy loss about 0.5%).

Front 388

360. Diabetes workup

Back 388

Done at 24-28 weeks in normal patient. Done with prenatal workup (6-8 weeks) if Patient is obese or has history of macrosomic baby, history of DM or family history of DM. The Patient will come to your office fasting for 1 hour, her blood sugar should be >140. If <140, get her fasting glucose (should be <90) and proceed to a 3 hour 100g glucose tolerance test: 1hr <180, 2hr <155, 3hr <140.

Front 389

361. Embryology

Back 389

Week 1 – implantation, week 2 – 2 layers formed (epiblast and hypoblast) and b-hCG is produced by syncytiotrophoblast, week 3 – 3 layers formed, week 4 – major organs formed. Note that week’s 3-8 are the period of greatest teratogenicity.

Front 390

362. Teratogens

Back 390

Infections (TORCH), Radiation (>20 rads), Chemotherapy (In first TM, can’t give MTX, Adriamycin), Environmental (smoking causes IUGR, alcohol causes microcephaly, flat philtrum, thin upper lip), Recreational drugs (cocaine causes placental abruption and intraventricular hemorrhage, marijuana causes prematurity), Medications (DES (vaginal, cervical cell CA), Dilantin (gingival hyperplasia, nystagmus, craniofacial dysmorphism), Warfarin (Stippled epiphysis), Isotretinoin (deafness, CNS), Lithium (Ebstein anomaly), Streptomycin (CN 8), Tetracycline (black teeth), Thalidomide (small limbs), Valproic acid (spina bifida)).

Front 391

363. B-hCG 3 purposes

Back 391

maintains corpus luteum (which keeps making progesterone) until placenta takes over at 9th week, regulates steroid production, stimulates testosterone production in fetal male testes. Levels may be too high (incorrect dates (MC), twins, hydatidiform mole, choriocarcinoma, embryonal CA) or too low (incorrect dates (MC), ectopic, threatened, missed abortions). If levels are high or low, next step is to recheck the dates.

Front 392

364. Human Placental lactogen (HPL)

Back 392

chemically similar to GH and prolactin, thus antagonizing insulin which will contribute to gestational diabetes if too high.

Front 393

365. Estrogens

Back 393

Estradiol (non-pregnant reproductive years, made from granulose cell from testosterone via aromatase), estriol (pregnancy, made from DHEA via sulfatase in the placenta), estrone (menopause, made from adrenal androstenedione in adipose).

Front 394

366. Changes in pregnancy

Back 394

Skin (striae gravidarum (stretch marks), Chadwick’s sign (bluish cervix), linea nigra and chloasma. Note the only cancer that increases with pregnancy is melanoma), CVERSUS (decreased BP in 1st TM, highest CO in L lateral decubitus position, systolic ejection murmur is normal, diastolic murmur is abnormal), GI (progesterone causes increased salivation, gum hyperplasia, GERD, aspirations, decreased gastric motility, constipation), pulmonary (generally, most increase except tidal volume causing respiratory alkalosis), renal (increased GFR, decreased BUN, Cr, decreased uric acid, glycosuria is normal, proteinuria is not), pituitary (size increases, contributing to possible Sheehan’s syndrome), thyroid (increase in TBG and total T3, T4, not free T3, T4 thus not causing Signs & Symptoms of hyperthyroidism, blood (increase RBC, WBC, normal platelets. Note low platelets with HELLP syndrome due to preeclampsia, most common cause of anemia is iron deficiency, then folate deficiency).

Front 395

367. Prenatal workup

Back 395

done at 6-8 weeks. Check CBC, UA (rule out asymptomatic bacteruria where >1000 E. coli will be found, treat with ampicillin or nitrofurantoin if allergic), Rubella (worst at 1st TM), RPR, HBV, Rh blood typing, sickle cell prep (if (+), proceed to Hb electrophoresis). If Patient is a teenager, do Chlamydia and gonorrhea cultures.

Front 396

368. Triple Screen

Back 396

AFP, hCG, estriol (currently inhibin-A makes for quad screen). If AFP is low, think of Down’s, Edwards synd. If AFP is high think of NTDs, gastrocele, omphalocele. Again, if AFP is high, low, next step is to get vaginal ultrasonogram to check dates. If dates are correct and ULTRASONOGRAM is non-explanatory (did not show nuchal fold thickening of Down’s), get amniocentesis for karyotype, amniotic fluid-AFP and acetylcholinesterase activity (both high in NTD). Down’s syndrome – high hCG, low AFP, low estriol. Edwards’s syndrome – all 3 are low.

Front 397

369. Mom says she doesn’t feel the baby move anymore.

Back 397

Next step is ULTRASONOGRAM. If it shows fetal cardiac activity, get non-stress test. If it doesn’t show fetal cardiac activity, this is fetal demise and the next step is D&E AT 12-16 week (not D&C (<12 week), not C, S, induce labor <16 week) followed by cervix, placental culture, autopsy, karyotyping and total body x-ray (rule out osteochondroplasia). Non-stress test (done in high risk, or if Patient says she doesn’t feel the baby move anymore): reactive is good (2 accelerations in 20 minutes), nonreactive is bad (<2 accelerations, 20 minutes).

Front 398

370. Nonstress test (NST)

Back 398

if reactive baby is ok (monitor). If non-reactive, baby may be sleeping or in danger, so do vibroacoustic stimulation (VAS) and repeat NST. If NST is now reactive, baby was sleeping and is now ok (monitor). If still non-reactive, get a Biophysical profile (BPP) with ULTRASONOGRAM. If BPP is 8-10, baby is ok (repeat in 4 days); if BPP is 6-4, do a stress test (check for decelerations). If BPP is 0-2, deliver immediately.

Front 399

371. BPP: measures 5 components (each worth 2)

Back 399

NST, amniotic fluid volume (normal is 5-15, <5 is oligohydramnios, >15 is polyhydramnios), fetal gross body movements, fetal extremity tone, fetal breathing movements.

Front 400

372. Stress test

Back 400

checks for decelerations. Go in order (head, then cord, then placenta). Early deceleration means head compression, Variable deceleration means cord compression, Late deceleration means utero-placental insufficiency. Treatment for decelerations in a stress test: 1st DISCONTINUE oxytocin, 2nd Give oxygen and fluids, 3nd position her to L lateral decubitus position, 4th get scalp pH (normal 7.25 – 7.4, if <7.2 go right to Cesarean section).

Front 401

373. Group B Strep (GBS)

Back 401

not a disease or pathogen to the mother, but if transmitted to the newborn during delivery can cause pneumonia, sepsis or meningitis. Prophylaxis with IV penicillin G (if allergic, give clindamycin, erythromycin of cefazolin) is given for +GBS culture @ 37 weeks, history of previous child with infection, preterm gestation (even if culture negative), PROM >18 hours (must give enough time for penicillin to reach fetus), or maternal fever.

Front 402

374. Toxoplasma gondii

Back 402

cat feces, raw goat milk, undercooked meat. Worst in 2, 3rd TM. In neonate it can cause seizures, in fetus look for intracranial calcifications. Treatment with pyrimethamine-sulfadiazine.

Front 403

375. Varicella

Back 403

kid with “zigzag” lesions (due to nerve distribution), cataracts and chorioretinitis. Worst if mom has the pruritic vesicles 5 days’ antepartum-2 days postpartum. Prevent with VZIG 96 hours prior to birth. Treatment with acyclovir.

Front 404

376. Rubella

Back 404

worst in 1st TM. Prevent 3 months before conceiving. Look for triad: deafness, cataracts and PDA. Sometimes “blue-berry muffin” rash. No treatment.

Front 405

377. CMV

Back 405

look for cerebral calcifications, deafness and microphthalmia. Blood shows intranuclear inclusions. Treatment with ganciclovir, or foscarnet if resistant.

Front 406

378. Syphilis

Back 406

Diagnosed with darkfield microscopy (RPR, VDRL may be negative until secondary disease). Child will have Hutchinson’s teeth, saber shins, saddle nose and 8th cranial nerve deafness. Treatment with Penicillin, if allergic then desensitize penicillin.

Front 407

379. HSV

Back 407

if vesicular lesions are present in vulvar area at time of delivery, do C, S. If lesions are only on legs, none of vulva, labia, cover with towel and proceed with vaginal delivery (never done in real world). If history of lesions of culture 1 week before delivery, do C, S.

Front 408

380. Hepatitis B

Back 408

worst in 3rd TM. If mom has +HBsAg, next step is to get LFT’s (if high, she has active disease, if normal she may just be a carrier). Upon delivery, give baby vaccine and Hepatitis B immunoglobulin within 12 hours of birth. Give mom Interferon-A with lamivudine.

Front 409

381. HIV

Back 409

ELISA then western blot. If (+), get viral load and CD-4 count. If viral load >1000 or CD <500, give all the drugs except efavirenz. If CD>500, only give AZT throughout pregnancy (starting at 14 weeks) and 6 weeks postpartum. After 6 weeks, diagnosed HIV with PCR (can’t use ELISA yet). Mom must avoid breastfeeding.

Front 410

382. 4 big causes of 1st TM bleeding

Back 410

Incomplete, Complete abortion, Threatened abortion, Ectopic pregnancy, Mole. Use APT test to make sure blood is from fetus, not from mom.

Front 411

383. 1st TM bleeding

Back 411

1st step is speculum exam. If cervical os is open, Patient had an incomplete, complete (depending how much products of conception passed), next step is D&C. If cervical os is closed, next step is vaginal ULTRASONOGRAM with HCG. If vaginal ULTRASONOGRAM shows an intrauterine pregnancy, Patient had a threatened abortion, next step is bed rest. If vaginal ULTRASONOGRAM shows no intrauterine sac and HCG >1500, Patient has an ectopic pregnancy and the next step salpingostomy or MTX treatment followed by serial hCG levels until zero. If vaginal ULTRASONOGRAM shows a snowstorm appearance, Patient has a mole and the next step is D&C followed by serial hCG levels to zero (also put Patient on OCP’s to prevent birth, which would increase hCG and not be able to allow you to monitor hCG appropriately).

Front 412

384. Ectopic

Back 412

amenorrhea, vaginal bleeding, abdomen pain, HCG >1500, no IUP on vaginal ULTRASONOGRAM. If unstable with peritonitis, do laparoscopic salpingectomy. If stable and does not want surgery, give methotrexate and follow-up hCG levels until zero.

Front 413

385. Mole

Back 413

preeclampsia before 3rdTM, very high HCG, in 1st TM you will see expulsion of grapes and a uterine size that’s too big for gestation age. Vaginal ULTRASONOGRAM shows snow-storm appearance. Complete (46XX, all from dad) have no fetal tissue, incomplete does. Treatment with D&C and follow up hCG while Patient is on OCP’s. If HCG still doesn’t fall, Patient has choriocarcinoma and needs MTX and actinomycin.

Front 414

386. 3rd TM bleeding

Back 414

1st step is ultrasound (absolutely not pelvic exam). Possible choices are placenta previa, vasa previa, abruption placenta, uterine rupture.

Front 415

387. Placenta previa

Back 415

painless bleeding with ultrasound showing placental implantation over the lower uterine segment. Patient may say she woke up in a pool of blood. Treatment: If preterm gestation, Patient is stable and bleeding stops: 1st admit, then bedrest, get vital signs, labs, transfuse if needed and put on steroids (for lung maturity) with magnesium sulfate. If Patient is >37 weeks, do C-section (whether she is still bleeding or not).

Front 416

388. Vasa previa --- look for triad

Back 416

rupture of membranes (gush of fluid), bright red painless vaginal bleeding and fetal bradycardia. Next step is C-section.

Front 417

389. Abruptio placenta

Back 417

painful vaginal bleeding (if bleeding stops, it may be collecting in retroperitoneal area), uterine tenderness and increased uterine tone with hyperactive contraction pattern. May even cause DIC. If mild to moderate, give fluids and deliver vaginally. If severe, Patient will have acute abdomen (rock hard) with profound hypotension, next step is immediate C-section.

Front 418

390. Uterine rupture

Back 418

sudden abdomen pain with profuse vaginal bleeding and abnormal fetal heart rate. Treat with immediate C-section and then uterine repair if mom wants kids in future, or hysterectomy if she doesn’t.

Front 419

391. Rh Isoimmunization

Back 419

mom is Rh (-), dad is Rh (+), second baby is affected with erythroblastosis fetalis. Prevent with RhoGAM at 28 weeks and 72 hours of delivery, D&C or CVS. If mom already has Rh antibodies, RhoGAM is useless (only for prevention) and so the next step is to get Rh titers. If >1:8, do amniotic fluid spectrophotometry to assess severity of hemolysis.

Front 420

392. Premature rupture of membranes

Back 420

sudden gush of fluid. Next step is fern test, Nitrazine test. Risk of chorioamnionitis (maternal fever, uterine tenderness, PROM, culture, gram stain amniotic fluid, treat with ampicillin while awaiting results and if (+), deliver). Management: if infection present, deliver. If no infection present and fetus is <24 weeks, outcome is dismal (induce labor with bedrest at home). If baby is 24-35 weeks with no fever, hospitalize, IM betamethasone, culture, Antibiotics. If baby is >36 weeks, prompt vaginal delivery.

Front 421

393. Preterm Labor

Back 421

must have cervical change >2cm (if none, Patient has false (Braxton-hicks) contractions and send her home). Most common risk factor is previous preterm labor. Diagnosed with fetal fibronectin (if +, tocolytics and steroids, if (-), send home). Management: 1st L lateral decubitus position, bed rest, O2 and IVF. 2nd Start tocolytics (useless >4cm dilatation, rule out contraindications first), get cervical, urine culture before giving IV Pen G (for GBS), IM betamethasone and send home.

Front 422

394. Tocolytics

Back 422

1st Mg Sulfate (calcium blocker that may cause respiratory depression, loss of DTRs and pulmonary edema. If so, give IV calcium gluconate). 2nd Ritodrine, Terbutaline (B-adrenergic agonists that may cause hypotension and tachycardia so don’t give in Patient with heart disease or DM). 3rd Nifedipine (calcium blocker that may cause hypotension). 4th Misoprostol (prostaglandin inhibitor that may cause in utero ductus arteriosus closure, so don’t give if gestation age >32 weeks). Some contraindications to tocolytics include (conditions where you may need to deliver) abruption placenta, ROM, chorioamnionitis, fetal demise, late decelerations, eclampsia, severe eclampsia and cervical dilatation >4cm.

Front 423

395. Post-date pregnancy (>40 week)

Back 423

complications include increased perinatal mortality, macrosomia, need for C-section, dysmaturity syndrome (mother’s support runs out). 1st step is to check dates (if dates still unsure, continue with conservative treatment and biweekly NSTs), 2nd step is induction of labor. If cervix is favorable (soft), begin aggressive treatment with oxytocin and artificial ROM. If cervix is unfavorable (hard), give prostaglandins with oxytocin and wait for spontaneous delivery.

Front 424

396. Transient HTN

Back 424

unsustained high BP without proteinuria or edema. No Treatment.

Front 425

397. Chronic HTN

Back 425

high BP before 20 weeks gestation. Treatment with methyldopa, hydralazine.

Front 426

398. Mild preeclampsia

Back 426

mild HTN (140, 90), petal edema, 2+ proteinuria after 24 weeks gestation. Management: <36 weeks – conservative (no medications). >36 weeks – deliver.

Front 427

399. Severe preeclampsia

Back 427

sustained BP >160, 110, >3+ proteinuria, edema, epigastric pain, headache, blurred vision, thrombocytopenia (rule out HELLP syndrome). Treatment: prompt vaginal delivery with oxytocin, MgSO4 (to prevent convulsions) and IV hydralazine, labetalol.

Front 428

400. Eclampsia

Back 428

HTN, proteinuria, edema, seizures. Treatment: 1st ABC’s, 2nd MgSO4 to stop seizure (do not deliver 1st, you can never attempt delivery if Patient is seizing), 3rd aggressive prompt vaginal delivery with oxytocin and hydralazine to decrease BP.

Front 429

401. HELLP syndrome

Back 429

hemolysis (schistocytes), elevated LFTs, low platelets. No CNS or renal problems (rule out TTP), no history of URI, GI infection (rule out HUS). Treatment with steroids and prompt delivery.

Front 430

402. Never recommend termination of pregnancy, unless

Back 430

1 – pulmonary HTN in mom,
2 – Marfan’s syndrome with an aortic aneurysm >4cm,
3 – Eisenmenger’s syndrome (Pulmonary HTN with bidirectional shunt,
4 – peripartum cardiomyopathy.

Front 431

403. If they ask about rheumatic heart disease in the context of pregnancy,

Back 431

know about mitral valve stenosis management (diuretics 1st, vasodilators and then balloon valvoplasty). Management of cardiac disease in pregnancy is bed rest, decreased physical activity, decrease weight, correct anemia, analgesics and vacuum delivery.

Front 432

404. Management of hyperthyroid disease in pregnancy

Back 432

is to stay on PTU to prevent thyroid storm, but warn mom that baby might be mentally retarded or have IUGR.

Front 433

405. DM in pregnancy

Back 433

associated with fetal NTD (most common fetal anomaly), hypoglycemia (due to maternal insulin, treatment with IV glucose), hypocalcemia (failure of PTH synthesis after birth), polycythemia (due to increased erythropoietin from intrauterine hypoxia), respiratory distress (to check lung maturity, phosphatidylglycerol is a better choice than L:C ratio), hyperbilirubinemia.

Front 434

406. Prolonged latent phase

Back 434

cervical dilatation <3cm (>20hrs in primipara, >14rhs in multipara). Most common cause is analgesia, so treatment is bedrest and sedations.

Front 435

407. Prolonged active phase

Back 435

cervical dilatation >3cm, but slow, no rate (<1.2cm, hr in primipara, <1.5cm, hr in multipara). Causes include the 3 P’s (passenger (macrosomia), pelvis (cephalopelvic disproportion) or power insufficiency). Treatment: If contractions are hypotonic (<200MVU in 2hrs), give oxytocin. If contractions are hypertonic, give morphine and consider C-section.

Front 436

408. Prolonged 2nd stage

Back 436

failure to deliver head (1hr in primi, 2hrs in multi). Causes are the same as above (3 P’s). If head is engaged, vacuum deliver. If head is not engaged, do C-section.

Front 437

409. Prolonged 3rd stage

Back 437

failure to deliver placenta within 30 minutes. Causes include placenta accreta (A for A, accreta adheres to uterine wall, most common cause is placenta previa), placenta increta (In for In, increta goes into uterine wall), placenta percreta (invades uterine wall). Treatment with 1st manual placental removal, 2nd curettage in the OR and 3rd hysterectomy.

Front 438

410. Prolonged 4th stage

Back 438

Postpartum hemorrhage: >500 in vaginal delivery, >1000 in C-section. Most common cause is uterine atony (Treatment: 1st massage uterus, 2nd Pitocin, 3rd PGE, 4th Methergine, 5th hysterectomy), then lacerations, retained placenta (treatment with sedation, then ex-lap for bilateral uterine and hypogastric artery ligation and hysterectomy), DIC, uterine inversion (from pulling).

Front 439

411. Prolapsed umbilical cord

Back 439

emergency due to cord compression. Do not hold the cord or attempt to reinsert it into the uterus. 1st step is place Patient in knee-chest position, 2nd elevate the presenting cord (avoid palpating), 3rd emergency C-section.

Front 440

412. Shoulder Dystocia

Back 440

most common cause is macrosomia (DM). 1st step is McRobert’s maneuver (maternal thigh flexion with suprapubic (not fundal) pressure). 2nd C-section.

Front 441

413. Postpartum Fever

Back 441

Day 0 is atelectasis (due to anesthesia), Day 1-2 is UTI, Day 2-3 is Endometritis (this is what they will ask, causes include C-sections, prolonged PROM, prolonged labor. Treatment with ampicillin, gentamycin, metronidazole). Day 4-5 is wound infection, Day 5-6 is pelvic abscess & septic thrombophlebitis (they will say, Patient still spikes fever despite antibiotics. 1st step is CT scan, if there is an abscess drain it, if there is no abscess, Patient has thrombophlebitis, treatment with heparin). It is normal to have discharge (first red, then white lochia) up to 10 days postpartum. If there is a bad smell, fever or tenderness, suspect endometritis.

Front 442

414. Mastitis

Back 442

fever, unilateral breast tenderness, erythema and edema due to lactational nipple trauma. Treat with oral cloxacillin and continued breast feeding from that breast. If the same symptoms occur, but the woman was not lactating, think of cancer.

Front 443

415. If woman does not want to breast feed, tell her

Back 443

to wear tight-fitted bras with ice-packs and analgesia. If that is not enough, give bromocriptine or estrogens.

Front 444

416. In a pregnant female with antiphospholipid syndrome and recurrent abortions, treatment with

Back 444

aspirin (otherwise, avoid aspirin in pregnancy).

Front 445

417. Cholestasis with pregnancy

Back 445

jaundice, itchiness, increase LFT’s, treatment with deliver baby. Acute Fatty liver of Pregnancy is more serious because it can progress to hepatic coma. Treatment AFLP with fluids, IV glucose and FFPs.

Front 446

418. Amniotic Fluid Embolism

Back 446

postpartum female with dyspnea, tachypnea, chest pain, hypotension and, or DIC.

Front 447

GYN:

Back 447

0

Front 448

419. Cervical Dysplasia

Back 448

firstly, note the word dysplasia (it’s not cancer, its precancer that has not yet invaded the basement membrane or affected lymphatics) asymptomatic or lesions on cervix. Most common cause is HPV 16, 18 (6+11 are benign). Risk factors are early aged intercourse, smoking, multiple partners and immunosuppression. Screening with Pap smear (shows dysplasia at transformation zone). Start pap smears annually at 18 year old or age of sexual activity onset for 3 consecutive years, and then every 3 years thereafter. If Patient has risk factors, pap smear annually. In order: 1st Pap, 2nd colposcopy (abnormal findings include mosaicism and white epithelium; colposcopy tells you where the disease is, so if a Patient comes to you with a lesion on her cervix, you can skip pap smear and skip this phase because you already know where the lesion is and go right to stage 3), 3rd Ectocervical biopsy and Endocervical curettage (ECC should not be done on pregnant pts), 4th Cone biopsy and treat with cryotherapy (mild CIN) or LEEP (loop electro diathermy excision procedure for moderate CIN). Remember, it’s not cancer, do not choose chemo, surgery or radiation for dysplasia.

Front 449

420. ASCUS

Back 449

Pap smear may show atypical squamous cells of undetermined significance, which is basically the step right before HPV (so you would not yet find koilocytosis). The next step would be HPV, DNA testing. If the smear returns with HPV 6 or 11, proceed with colposcopy and biopsy, ECC. If the smear returns (-) HPV 11, 16, then just repeat Pap smear in 1 year.

Front 450

421. Invasive Cervical cancer

Back 450

now it has penetrated the BM. Look for postcoital vaginal bleeding. Diagnosed with cervical biopsy 1st (don’t pick pap or colposcopy). Only a pelvic exam and IVP can be used to stage cervical cancer. Treatment: Stage Ia1 (<3mm invasion) do TAH (total abdominal hysterectomy). Stage Ia2 (3-5mm invasion) do modified radical hysterectomy. Stage Ib (>5mm) or IIa (upper 2, 3 vagina) do radical hysterectomy, para-aortic lymphadenectomy and radiation. All patients with cervical cancer should be followed-up with pap smears every 3 months for 2 years after Treatment, then every 6 months thereafter. Most common site of metastasis is liver. MCCOD is uremia due to ureteral obstruction.

Front 451

422. Cervical cancer in pregnancy

Back 451

colposcopy and biopsy, but no ECC. If CIN (no invasion), pap every 3 months then repeat colposcopy and pap 2 months postpartum. If microinvasion (3-5mm), do cone biopsy (rule out frank invasion) and if (+), treatment with LEEP and cryotherapy 2 months later. If invasive cancer, 1st punch biopsy, 2nd if <24 week give radiation with radical hysterectomy; if >24 weeks do C, S at 37 weeks then hysterectomy.

Front 452

423. Uterine, Endometrial Cancer

Back 452

postmenopausal bleeding. Diagnosed with endometrial biopsy. If it comes back negative, Patient is assumed to have bled from atrophy and is treated with HRT (estrogen AND progesterone, not estrogen alone). If it shows cancer, do TAH, SBO. If prognosis is poor (nodes affected, metastasis past the cervix into the uterus and beyond) give radiation and chemotherapy as well.

Front 453

424. Leiomyoma uterine

Back 453

submucosal fibroids cause menometrorrhagia, pain, infertility, visceral obstruction (causing urinary retention and constipation). Treat with leuprolide (GnRH analog therapy), then myomectomy (if Patient wants fertility) or hysterectomy (if Patient is anemic or does not want to be fertile anymore). Leiomyomas are asymmetrical and bumpy.

Front 454

425. Adenomyosis

Back 454

endometrial glands and stroma located in the myometrium. Enlarged, symmetrical, tender uterus in the absence of pregnancy. Only definitive diagnosed is histological sampling confirmation. Treatment with hysterectomy.

Front 455

426. Ovarian Cancer

Back 455

look for adnexal mass, abdomen pain and ascites in a postmenopausal woman. Prevent with OCPs. Screen with bimanual pelvic exams. Diagnosed (generally hard to Diagnosis) with ULTRASONOGRAM first, then CA-125. In kids, suspect germ cell tumors (teratoma, choriocarcinoma), in adults suspect epithelial tumor (mucinous, serious, clear cell). Treatment with debulking (TAH, BSO, omentectomy) and chemotherapy (carboplatin and Taxol).

Front 456

427. Vulvar cancer

Back 456

vulvar itching in a 65 year old. Diagnosed with biopsy. Treatment with surgery.

Front 457

428. Germ Cell Tumors

Back 457

Teratoma, Dermatoid cyst (skin, hair, teeth and pelvic calcifications on X-ray), Sertoli-Leydig cell tumor (high testosterone causing virilization), Granulose-theca cell tumor (high estrogen causing feminization and precocious puberty), Meigs’ syndrome (ovarian fibroma, ascites and R hydrothorax) and Krukenberg tumor (stomach cancer with metastasis to ovaries).

Front 458

429. Gestational Trophoblastic Neoplasia

Back 458

signs & symptoms: very high hCG, large uterus, pregnancy with bleed, no fetal heart tones, high BP in 1st TM, hyperemesis, hyperthyroidism (must to TSH in a Patient with GTN), snowstorm ultrasonogram. Can be benign (mole) or malignant (choriocarcinoma). Complete mole is an empty egg fertilized with single X-sperm (46XX so sperm duplicated), no fetus, uterus filled with grape-like vesicles (same description as sarcoma botryoides in young girls). Incomplete mole is a normal egg with 2 sperm (causing 69XXX), + fetus, cord, but fetus dies. For either mole, treatment is D&C, follow up HCG, start OCPs. If choriocarcinoma, 1st step is CT head, chest, abdomen, pelvis to rule out METASTASIS If poor prognosis (HCG >40,000, brain, liver metastasis, >6 months of D&C) do radiation and chemotherapy (MAC: MTX, Adenomycin, Cytotoxin). If good prognosis, give MTX only and follow up HCG every week for 3 months while on OCPs.

Front 459

430. Uterine prolapse

Back 459

loss of uterine support due to cardinal ligament dysfunction. Most common cause is childbirth. Best treatment is vaginal hysterectomy with ant, post repair (yes, first!), but if Patient refuses surgery, do Kegel exercises, estrogen HRT and pessaries.

Front 460

431. Stress Incontinence

Back 460

weak pelvic floor causes you to urinate whenever you sneeze, cough, none at night. Diagnosed with Q-tip test. Treatment with Kegel exercises, then surgery (Marshall-Marcheli-Krantz procedure).

Front 461

432. Urge Incontinence

Back 461

involuntary detrusor contractions causing spurts of urine to fall at any time. Diagnosed with cystometric studies. Treatment with anticholinergics (Ditropan).

Front 462

433. Overflow Incontinence

Back 462

denervated bladder (DM, MS, CVA) causes bladder to keep filling up, thus high residual volume even after urination. Treatment with cholinergics (bethanecol).

Front 463

434. Endometriosis

Back 463

dysmenorrhea, dyspareunia, infertility, uterosacral ligament nodularity in the cul-de-sac, chocolate cysts. Diagnosed with laparoscopy. Treatment: 1st OCP, 2nd Danazol and Leuprolide (best Treatment, but not 1st because of side-effects), 3rd surgical resection, 4th pregnancy (however hard, due to infertility), 5th TAH, SBO. If endometriosis is present, and Patient has no signs & symptoms, do nothing.

Front 464

435. Chancroid

Back 464

painful chancre (H. ducreyi – you cry with ducreyi) with ragged, rolled edges. Treatment with Azithromycin.

Front 465

436. LGV

Back 465

painless ulcer that heals and then forms painful nodes. Treatment with erythromycin.

Front 466

437. Granuloma inguinale

Back 466

painless, beefy-red ulcer. Diagnosed with Donovan-bodies on smear. Treatment with Azithromycin.

Front 467

438. Chlamydia

Back 467

most common bacterial STD, can be asymptomatic or mild mucopurulent cervical discharge with or without cervical motion tenderness (CMT), (+) Culture, Antibody test, (-) stain. Treatment with azithromycin (1 dose) or oral doxycycline (7 days).

Front 468

439. Gonorrhea

Back 468

Lower GU causes discharge, itching, burning, dysuria;
Upper GU causes abdomen, pelvic pain.
Disseminated when there is dermatitis, polyarthritis or tenosynovitis.

Patient has vulvovaginitis with mucopurulent discharge with CMT on bimanual exam.
Diagnosed with chocolate agar, Gram (-) diplococci on stain.
Treatment (for GC and Chlamydia) Ceftriaxone + Doxycycline.

Front 469

440. PID

Back 469

lower abdominal pain, adnexal tenderness, CMT and fever 1 week after menses in a sexually active female. Cervicitis (only vaginal DISCHARGE, no pain – treatment G, C), Salpingo-oophoritis (bilateral lower abdomen, pelvic pain with CVA tenderness – treatment G, C), Tubo-ovarian abscess (Patient will look septic, severe pain, nausea & vomiting, dyschezia, fever – treatment with Ampicillin, Gentamycin and Flagyl. If ruptured, ex-lap is done). Treatment for G, C in these cases are: outpatient: ceftriaxone + doxycycline, inpatient: clindamycin + gentamycin.

Front 470

441. Gardnerella Vaginosis

Back 470

fishy odor on whiff test, pH 6, clue cells, treatment with metronidazole (clindamycin if pregnant in 1st TM).

Front 471

442. Trichomonas vaginalis

Back 471

frothy, green smelly discharge with strawberry cervix, pH 5. Treatment with metronidazole for Patient and partner (if Patient pregnant, treatment with vaginal betadine).

Front 472

443. Candida yeast infection

Back 472

itchy, burning, dyspareunia, cottage-cheese discharge, that sticks to the vaginal wall, pseudohyphae, pH 4, treatment with nystatin or Amp B.

Front 473

444. Contraception

Back 473

remember effects of estrogen (increases BP, cholelithiasis, LFTs, HDL, art, venous thrombosis and decreases LDL) and progesterone (affects mood, increase weight, acne, increase LDL and decrease HDL). Absolute CI: pregnancy (causes VACTERL), liver disease, vascular disease (DVT, SLE and CVA) and hormonally-dependent cancers like breast). Benefits include decreased risk of ovarian, endometrial cancer, decreased dysmenorrhea, DUB, PID, ectopics.

Front 474

445. IUD

Back 474

put it in 1 week after menses and follow up in 1 week. Does not affect risk of STDs. Absolute contraindications include pregnancy, pelvic cancer, salpingitis, steroid use (Patient on Crohn’s, asthma), history of PID. Increased risk of ectopics and PID when placed.

Front 475

446. Abnormal vaginal bleeding

Back 475

Pre-menarchal (<12 year old - foreign body, trauma, sarcoma botryoides, precocious puberty), reproductive (13-52 year old - pregnancy, fibroids, adenomyosis, DUB), postmenopausal (>52 year old - endometrial cancer). A neonate with vaginal bleeding is normal due to maternal estrogen, thus reassure mom.

Front 476

447. Precocious Puberty

Back 476

normally: breast development @ 9 years old, pubic, axillary hair @ 10 years old, growth @ 11 years old, menarche @ 12 years old. If only 1 stage occurs early, this is incomplete isosexual precocious puberty; next step is CT brain, abdomen, and pelvis. If all stages occur early, this is complete isosexual precocious puberty; next step is treatment with constant GnRH stimulation (to decrease estrogen). If Patient has bone lesions and café-au-lait spots, Patient has McCune-Albright Syndrome. If Patient has high estrogen with a pelvic mass, they have a granulose-theca cell tumor, treatment with surgery.

Front 477

448. Dysfunctional Uterine Bleeding

Back 477

most common cause is anovulation due to unopposed estrogen, so no secretory phase (due to lack of progesterone) with unstable endometrial thickening. Patient will have history of irregular, unpredictable menstrual bleeding without cramps. Next step is endometrial biopsy to rule out cancer. Treatment with NSAIDS if she desires children, cyclic progestin therapy or daily combined OCPs if she doesn’t desire children or has menorrhagia.

Front 478

449. Primary Amenorrhea

Back 478

1st step is pregnancy test (whether she says she is sexually active or doesn’t), 2nd step is physical exam: (+) breasts and (+) uterus ->check prolactin, if normal rule out imperforate hymen (cyclic menstrual pain with bulging hymen, predisposition to endometriosis, treatment with surgery) and treatment with progesterone. (+) breasts and (-) uterus ->get karyotype, if 46 XY, Patient has Androgen Insensitivity Syndrome (Testicular Feminization, no pubic hair, next step is remove testes from abdomen), if 46XX, Patient has Rokitansky-Hausen syndrome (she will have pubic hair). (-) breast and (+) uterus ->gonadal dysgenesis, so next step is get karyotype to rule out Turners syndrome (45XO, webbed neck, far spaced nipples, streak ovaries, premature ovarian failure, needs estrogen).

Front 479

450. Secondary Amenorrhea

Back 479

1st step is rule out pregnancy, 2nd rule out prolactinoma (if prolactin level is high, next step is MRI of head. If abnormal, Patient has pituitary tumor, if normal, Patient has drug-induced prolactinoma) and hypothyroidism, 3rd progesterone challenge test. If Patient bleeds after 2 weeks (estrogen is adequate), check LH. If elevated patient has PCOS, if normal, low check TSH, prolactin again. If Patient does not bleed after 2 weeks (inadequate estrogen) check FSH, if high Patient has premature ovarian failure (next step is karyotype to rule out Turners versus Ovarian failure due to congenital adrenal hyperplasia), if normal, low Patient has craniopharyngioma, next step is MRI. If MRI is insufficient, Patient has Asherman’s syndrome (scarring due to prior D&C, D&E. Treatment by surgically removing scarred tissue then giving high-dose estrogen for 1 month to regenerate lining). Again, if LH, FSH are high, next step is karyotype. If XO, Patient has turners, if XX Patient has ovarian failure (now rule out autoimmune disease versus CAH). If LH, FSH is normal or low, next step is MRI of head. If abnormal Patient has pituitary tumor, destruction or hypothalamic disease (may be associated with Kallmann’s syndrome (anosmia, amenorrhea), anorexia, exercise, treatment with estrogen). If normal, Patient has Asherman’s syndrome.

Front 480

451. Breast mass in a female <35 year old

Back 480

Fibrocystic Disease (bilateral, tender especially with menses, multiple, treatment with reassurance and follow up later), Fibroadenoma (painless, rubbery, mobile, treatment with observe but try not to stare too long), Mastitis, Abscess (lactating, painful, red, treatment with cloxacillin, if still there, INCISION & DRAINAGE), Fat Necrosis (history of trauma, treatment with observation). Avoid mammogram in women <35 year old (tissue too dense) and if suspicious of cancer go right to biopsy.

Front 481

452. Breast mass in a female >35 year old

Back 481

Fibrocystic Disease (same as above, but this time you must aspirate it and do a mammogram.
If mass resolves, observe.
If FNA shows blood or if cyst recurs quickly, do biopsy), Fibroadenoma (mobile, get mammogram.

If Patient is low risk, observe, if high risk get biopsy.

If Patient is postmenopausal and has a mass, go right to biopsy.

Front 482

453. If bloody discharge from the nipple ->

Back 482

intraductal papilloma. Next step is galactogram-guided excision.

Front 483

454. Polycystic Ovarian Syndrome

Back 483

female, hirsutism, amenorrhea, infertility (most common cause of infertility in women <30 year old with abnormal menses, while PID is most common cause if normal menses) and insulin resistance (DM). Next step is ULTRASONOGRAM to show multiple cysts, then LH and FSH (ration should be 2:1), then testosterone and DHEA levels. Unopposed estrogen will increase risk of endometrial cancer. Treatment with OCP’s, cyclic progestins, Metformin, Spironolactone and clomiphene if she wants kids.

Front 484

455. Congenital Adrenal Hyperplasia

Back 484

overproduction of androgens causing virilization and amenorrhea. Young girls get clitoromegaly. 90% is 21-OH deficiency (salt-wasting, high K, low BP, high urinary 12-hydroxyprogesterone). Treatment with steroids + IVF (to prevent death). Must do karyotype to figure out gender.

Front 485

456. Review of hirsutism (excessive sexual hair) versus virilization (excess androgen, thus acne, balding, deep voice, clitoromegaly, amenorrhea):

Back 485

Hirsutism with high testosterone, normal DHEAS, CT shows enlarged ovaries is PCOS.

Virilization with normal testosterone, high DHEAS, CT shows enlarged adrenals is Adrenal Tumor (CAH, treatment with DEXAMETHASONE suppression).

Virilization with high testosterone, normal DHEAS, CT shows enlarged ovaries is ovarian tumor (treatment with OCPs, GnRH analogs and surgery).

Hirsutism with normal testosterone, normal DHEA, normal CT is familial hirsutism (associated with 5-alpha reductase deficiency, treatment with spironolactone, flutamide).

Front 486

457. Menopause

Back 486

high LH, FSH, low estrogen, progesterone. Hot flashes, osteoporosis, atrophic vaginitis, abnormal lipid profile, atherosclerosis, CAD.

Treatment with HRT for <5years and then calcium, exercise, and lubricants for sexual activity. HRT increases risk of CAD, invasive breast cancer, memory loss, stroke, PE. Decreased osteoporosis and colon cancer.

Contraindicated in breast and endometrial cancer (must do endometrial biopsy before giving it), acute liver disease, active thrombosis, vaginal bleeding. If contraindicated, give SERMS (Tamoxifen, Raloxifene, which still increase risk of endometrial cancer).

Front 487

458. Infertility:

Back 487

1st step is semen analysis (treatment with sperm injection), 2nd step is ovulation analysis (basal body temperature, endometrial biopsy, serum estrogen level to rule out anovulation. Treatment with clomiphene), 3rd step is hysterosalpingogram for tubal blockage, 4th step is laparoscopy.

Front 488

CONGENITAL ANOMALIES, PERINATAL MEDICINE:

Back 488

0

Front 489

459. Down’s Syndrome

Back 489

trisomy 21, 1, 700 births (1, 350 if >35yo), MR, endocardial cushion defect, ASD, VSD, duodenal atresia, simian crease, Alzheimer’s @ 40yo, epicanthal folds. Prenatal Diagnosis: high hCG, low AFP, low estriol, increased maternal age, amniocentesis, ultrasonogram shows thickened nuchal folds, CVERSUS @ 9-12 week. Neonatal: 1st step is echo, then genetic counseling.

Front 490

460. Edwards Syndrome

Back 490

trisomy 18, IUGR, rocker-bottom feet, clenched hands, PDA, VSD.

Front 491

461. Patau’s Syndrome

Back 491

trisomy 13 (P for P: cleft liP, cleft Palate), holoprosencephaly, renal and ocular malformations.

Front 492

462. Cri du Chat Syndrome

Back 492

Chrom 5p deletion, cat-like cry, MR so treatment with special schooling.

Front 493

463. Turners Syndrome

Back 493

Gonadal dysgenesis 45XO, 1, 2000 newborn girls, short webbed neck, horseshoe kidney, coarctation of aorta, primary amenorrhea. Estrogen replacement.

Front 494

464. Klinefelter’s Syndrome

Back 494

seminiferous tubule dysgenesis 47XXY, hypogonadism, gynecomastia, tall stature, infertility, give testosterone replacement starting at 12 year old.

Front 495

465. Fragile X Syndrome

Back 495

macro-orchidism, MR.

Front 496

466. Achondroplasia

Back 496

AD, short limbs and hydrocephalus (must monitor closely).

Front 497

467. Xeroderma Pigmentosa

Back 497

sunlight sensitivity from 1st exposure, conjunctivitis leading to blindness, diagnosed with skin biopsy and treatment with strict sun avoidance (they will say kid only comes out at night).

Front 498

468. Fetal Alcohol Syndrome

Back 498

MR, flat philtrum, thin upper lip, worst in 1st TM.

Front 499

469. Tobacco in pregnancy

Back 499

IUGR.

Front 500

470. Cocaine in pregnancy

Back 500

CNS damage, placental abruption.

Front 501

471. Fetal Warfarin Syndrome

Back 501

epiphyseal stippling, CNS malformations, MR.

Front 502

472. Thalidomide

Back 502

Phocomelia (absence of long bones in extremities).

Front 503

473. Syphilis

Back 503

Treponema pallidium, snuffles, palm, sole rash, anemia, hepatosplenomegaly, periostitis, Hutchinson’s teeth and saber shins, saddle nose, treatment with penicillin.

Front 504

474. Toxoplasmosis

Back 504

oocytes from cat litter and meat, hydrocephalus, chorioretinitis, scattered CNS calcifications, Treatment: 1st avoidance, 2nd pyrimethamine, 3rd shunt for hydrocephalus.

Front 505

475. Rubella

Back 505

blueberry muffin rash, PDA, deafness, cataracts.

Front 506

476. CMV

Back 506

deafness, Preventricular CNS calcifications, microcephaly.

Front 507

477. Herpes

Back 507

acquired at birth (prevent with Cesarean section), seizures (temporal lobe), encephalitis, vesicles, overwhelming sepsis, hepatitis, treatment with acyclovir.

Front 508

478. HIV

Back 508

all medications (except efavirenz) if CD <500, AZT only if CD>500 in 2nd, 3rd TM and 6 weeks postpartum. Diagnosed in kid with PCR (not ELISA).

Front 509

479. Hypospadias

Back 509

pee on your feet (ventral urethral opening), hooded prepuce, chordee (ventral curving of penis), and treatment with 1st avoid circumcision to save foreskin for reconstruction, 2nd surgery at 1 year old.

Front 510

480. Omphalocele, Gastrocele

Back 510

absence of anterior wall (gastrocele has no sac, omphalocele does). Treatment: 1st cover with plastic wrap, 2nd surgery within 24 hours.

Front 511

481. Posterior urethral valves

Back 511

cause of UTI in young boys, associated with potter’s syndrome, diagnosed with VCUG.

Front 512

482. Undescended testicle

Back 512

cryptorchidism, rarely descent after 1yo, must differentiate from retractable testis, Treatment: if testes is palpable – wait for descent and do orchiopexy after 1 year. If testes are not palpable – consider hCG trial if b, l. 2nd – Orchiectomy for atrophied testis due to risk of malignancy and infertility for other testis.

Front 513

483. Congenital Adrenal Hyperplasia

Back 513

adrenogenital syndrome, no steroidogeneses due to 21-OH deficiency, ambiguous genitalia, clitoromegaly, salt-wasting, hyperkalemia. Treatment: 1st fluids for low BP, 2nd treat hyperkalemia (calcium, alkalinization, insulin, glucose, Kayexalate).

Front 514

484. Choanal atresia

Back 514

respiratory distress, cyanosis relieved by crying, associated with CHARGE Syndrome (Colobomas of eye, Heart defect, Atresia of choanae, Retardation, Genital hypoplasia, Ear anomalies). Treatment with respiratory support.

Front 515

485. Laryngomalacia

Back 515

flexible larynx collapses causing obstruction on inspiration. Diagnosed with fluoroscopy or direct laryngoscopy. Airway support if needed, otherwise self-limited.

Front 516

486. Diaphragmatic Hernia

Back 516

either at foramen of Bochdalek (left sided (b, c R side has liver), severe newborn respiratory distress, scaphoid abdomen, mediastinal shift, pulmonary hypoplasia) or at foramen of Morgagni (presents later with bowel obstruction). Treatment with 1st aggressive resuscitation, 2nd extracorporeal membrane oxygenation (ECMO), 3rd surgery.

Front 517

487. Tetralogy of Fallot

Back 517

PROVe (Pulmonary HTN due to RV outflow obstruction, RVH, Overriding aorta, VSD), most common cyanotic CHD, presents >1yo, TET spells, boot-shaped heart.

Front 518

488. Transposition of great vessels

Back 518

cyanosis in 1st 24hrs, aorta from RV, Pulmonary artery from LV, egg on a string heart, treatment with balloon atrial septostomy, then arterial switch.

Front 519

489. Total anomalous Pulmonary venous return

Back 519

pulmonary veins drain into systemic venous circulation (partial or total), snowman heart. 1st medications, 2nd surgery.

Front 520

490. Truncus arteriosus

Back 520

single great artery is origin of aorta and Pulmonary artery and coronary artery, listen for truncal valve click. Treatment: 1st treat CHF, 2nd surgery.

Front 521

491. VENTRICULAR SEPTAL DEFECT

Back 521

most common CHD, holosystolic murmur at 1-2 months, treatment with subacute bacterial endocarditis prophylaxis.

Front 522

492. ASD

Back 522

pulmonary ejection murmur plus wide, fixed split S2, no SBE prophylaxis, usually presents after infancy.

Front 523

493. Coarctation of aorta

Back 523

HTN in UE, low BP in LE, poor femoral pulses, Turners syndrome, rib notching on CXR, treatment with balloon angioplasty.

Front 524

494. PDA

Back 524

premature babies, congenital rubella, continuous machinery murmur with wide pulse pressure.

Front 525

495. Hypoplastic left heart

Back 525

underdeveloped LV and aorta, vascular collapse in 1st week of life, ductus dependent, Treatment: 1st prostaglandin E, 2nd Norwood or transplant.

Front 526

496. Hydrocephalus

Back 526

communicating (obstruction of arachnoid villi) or noncommunicating (Aqueduct of Sylvius stenosis, Chiari malformation at cerebellar tonsils or Dandy-walker cyst of 4th ventricle). Baby with rapid increase in head circumference, split sutures, bulging anterior fontanelle, setting-sun sign (of eyes), 6th nerve palsy, papilledema, diagnosed with CT scan (do not do LP in risk of herniation). Treatment: 1st hyperventilate and elevate head, 2nd mannitol, 3rd ventriculoperitoneal shunt.

Front 527

497. Congenital cataracts

Back 527

rubella, CMV, toxo, galactosemia, treatment with surgery right away to prevent permanent visual impairment.

Front 528

498. Congenital glaucoma

Back 528

tearing, corneal clouding, photophobia, Sturge-Weber Syndrome (facial port-wine stain, seizures, CNS calcifications), neurofibromatosis, rubella, treatment with surgery.

Front 529

499. Congenital deafness

Back 529

Alport’s (nephritis with deafness), CMV, rubella, maternal drugs.

Front 530

500. Osteogenesis Imperfecta

Back 530

brittle bones cause multiple fractures in a kid, blue sclera, osteoporosis, family history, type I collagen disorder, teeth deformities.

Front 531

501. Developmental Dysplasia of the Hip

Back 531

subluxation of femoral head from the acetabulum, causing asymmetric thigh creases, clicking sound, + Ortolani sign (hip reducibility), + Barlow sign (hip dislocatability), diagnosed with ultrasound. Treatment with harness, then closed reduction, then open reduction (>6 months age) if closed reduction failed.

Front 532

502. Talipes Equinovarus

Back 532

toes face medially, forefoot adduction. Treatment with manipulative casting, then surgery if needed.

Front 533

503. Transesophageal Fistula

Back 533

diagnosed with failure to pass nasal catheter to stomach, AXR shows air-distended proximal esophagus. Treatment: 1st NGT, 2nd surgery.

Front 534

504. Duodenal atresia

Back 534

bilious projectile emesis, associated with Downs syndrome, abdominal distention, double bubble on AXR (air-distended stomach and proximal duodenum). Treatment: 1st correct fluids, electrolytes, 2nd surgery.

Front 535

505. Pyloric stenosis

Back 535

non bilious projectile emesis, olive-shaped RUQ mass, dehydration with hypochloremic alkalosis. Treatment: 1st fluid, electrolyte correction, 2nd pyloromyotomy.

Front 536

506. Meckel’s Diverticulum

Back 536

2 year old with painless rectal bleeding and abdomen pain. Diagnosed with technetium-labeled nuclear scan (Meckel’s scan), Treatment: 1st correct life-threatening anemia, 2nd surgical excision.

Front 537

507. Hirschsprung’s Disease

Back 537

congenital megacolon causing obstruction, absence of Auerbach’s and Meissner’s plexus, failure to pass meconium in 1st week, diagnosed with 1st barium enema (shows transitional zone) rectal biopsy (aganglionosis). Treatment: 1st fluid, electrolyte correction, 2nd Antibiotics if enterocolitis suspected, 3rd surgical excision of ganglionic segment.

Front 538

508. Hyaline membrane Disease

Back 538

RSD, surfactant insufficiency, early onset (hours after birth) baby has tachypnea, grunting, nasal flaring and retractions. Early problems include breathing difficulty, metabolic disturbances and infection. Late problems include bronchopulmonary dysplasia. Risk factors include prematurity, maternal DM and multiple pregnancies. Diagnosis: 1st CXR (shows fine reticular granularity in bilateral lungs), 2nd L:S ratio (should be >2:1) and phosphatidylglycerol. Treatment: Prevention is the best treatment (prevent prematurity, give maternal steroids 48-72 hours antepartum if <33 weeks to women who do not have toxemia, DM or renal disease), 2nd – correction of hypoxia, acidosis, hypercapnia, hypotension, hypothermia and anemia. 3rd neonatal surfactants (via ETT) at delivery but avoid unnecessary pulmonary barotraumas or oxygen toxicity.

Front 539

509. Chlamydia

Back 539

conjunctivitis 4-7 days after birth, staccato cough, treatment with erythromycin.

Front 540

510. Gonorrhea

Back 540

conjunctivitis 3-5 days after birth, disseminated infection, chocolate agar, Thayer-martin media and treatment with parenteral antibiotics.

Front 541

511. GBS

Back 541

early onset (<3days old) has respiratory distress, pneumonia, meningitis; late onset (7days-3mo) has meningitis, osteomyelitis, septic arthritis and occult bacteremia. Prevent with culture at 35-37 week and penicillin at birth. Neonates given antibiotics if febrile.

Front 542

PSYCHIATRY.

Back 542

0

Front 543

512. If you see a question about the best next test

Back 543

and one of the answers is “mini-mental exam,” pick that one.

Front 544

513. Autism

Back 544

starts by 3 year old. Impaired social interactions (unaware of surroundings), impaired verbal, nonverbal communication (if verbal is okay, diagnosed is Asperger’s syndrome), and restrictive activities and interest (head banging, strange movements). Linked to congenital rubella. Treatment with 1st structured classroom training, behavioral modifications, family support, 2nd haloperidol, risperidone, SSRI’s. If child has normal development and then deteriorates into this condition or worse, that is Rett’s syndrome.

Front 545

514. Learning disorder

Back 545

impairment in reading (80%), math, language, written expression with no mental retardation or lifestyle anomalies. Treatment with educational intervention.

Front 546

515. ADHD

Back 546

diagnosed <7 year old. Boy is hyperactive, impulsive and has a short memory span, but is not cruel. Treatment: 1st individual, family therapy and behavioral modifications, 2nd methylphenidate (Ritalin) or dextroamphetamine, both of which may cause insomnia, abdomen pain, headache, anorexia, exacerbations of tics, weight loss or growth suppression. Treatment with 1st atomoxetine (but must be given every day, so if mom says kid only has Signs & Symptoms Monday thru Friday, then you cannot give this, give treatment #2), 2nd Methylphenidate or amphetamine.

Front 547

516. Conduct Disorder

Back 547

violates society norms, pediatric form of antisocial disorder. Look for fire setting (if only this, diagnosed is pyromania), cruelty to animals, lying, stealing, fighting. Must have this disorder in order to make diagnosis of antisocial disorder as adult. Treatment: 1st evaluate suicide, violence potential, 2nd containment by parents, schools, legal system or hospital, 3rd treatment aggression with SSRI or haloperidol, 4th individual, group, family therapy.

Front 548

517. Oppositional Defiant Disorder

Back 548

negative, hostile and defiant behavior towards authority figure. Note the difference between this and conduct disorder is that here the kid is just bad to adults but behaves with peers and is not a cruel, lying criminal. Treatment with individual, family therapy.

Front 549

518. Separation anxiety Disorder

Back 549

look for a kid who refuses to go to school or sleep alone or away from home by claiming sickness, stomachache, headache or temper tantrums. Must be >6 months old (might ask about 8 months baby who cries when he sees grandma for 1st time = separation anxiety, but if kid was under 6mo, its normal) School refusal is a psychiatric emergency and needs prompt evaluation and treatment involving parents, school and peers.

Front 550

519. Tourette’s Disorder

Back 550

(only 10-30% curse), look for males with motor tics (blinking, grunting, throat clearing, grimacing, barking, shrugging) that are exacerbated by stress and remit with activity or sleep. Linked to ADHD and OCD. Treatment: 1st Haloperidol (improves 80% but watch for EPS, mental dulling and tardive dyskinesia). 2nd Pimozide or Clonidine.

Front 551

520. Encopresis

Back 551

>4 year old with passage of feces into inappropriate places (clothing, floor). Rule out Hirschsprung’s disease. Treatment with behavioral techniques, individual therapy.

Front 552

521. Enuresis - >5 year old with inappropriate voiding of urine. Treatment:

Back 552

1st behavioral techniques (bell, buzzer, bed time fluid restriction), 2nd Imipramine (last resort).

Front 553

522. Dementia versus Delirium:

Back 553

Delirium (rapid onset, fluctuating consciousness, often reversible, perceptual disturbances, incoherent speech). Dementia (insidious onset, clear consciousness (until late in course), irreversible).

Front 554

523. Alzheimer’s versus Vascular (Multi-Infarct) Dementia:

Back 554

Alzheimer’s dementia (women, older, chrom 21, linear, progressive, no focal deficits (key), supportive Treatment). Vascular dementia (men, younger than Alzheimer’s, HTN, stepwise, patchy pattern, (+) focal deficits (key), treatment underlying condition).

Front 555

524. Alcohol

Back 555

intoxication includes slurred speech, ataxia, disinhibition, impaired judgment, coma and blackouts. Withdrawal includes tremor, agitation, irritability, nausea & vomiting, fever, seizures, delirium tremens (onset of delirium, vivid auditory, tactile, visual hallucinations, paranoid delusions 2-3 days post cessation of long-term heavy use). Treatment intoxication supportively. Treatment withdrawal with vital sign, electrolytes, Mg, thiamine, vit. B12, folate, glucose monitoring. 2nd Hydration with thiamine before glucose (prevent Wernicke), 3rd benzodiazepine (chlordiazepoxide). Treatment dependence with confrontation of denial and rehab (AA). Specific managements: Alcohol hallucinations (chlordiazepoxide, IVF, haloperidol), Wernicke’s encephalopathy (sudden ataxia, confusion, nystagmus, lateral rectus palsy from thiamine deficiency. Treatment with thiamine) Korsakoff’s syndrome (severe anterograde, retrograde amnesia, confabulations and polyneuritis from thiamine deficiency).

Front 556

525. Opioids

Back 556

intoxication includes euphoria, analgesia, hypoactivity, anorexia, drowsiness, nausea & vomiting, constipation, pin-point pupils, hypotension and bradycardia. Overdose includes CNS, respiratory depression, pinpoint pupils, pulmonary edema, seizure, coma and death. Withdrawal includes (not deadly) rhinorrhea, yawning, diarrhea, sweating, dilated pupils, tachycardia and HTN. Treatment overdose with naloxone. Treatment dependence with abstinence through methadone titration.

Front 557

526. Stimulants

Back 557

amphetamines, cocaine, rapid dependence of tolerance, IVDA risks, paranoid psychosis. Intoxication includes euphoria, alertness, increased energy, anxiety, talkativeness, mydriasis, tactile hallucinations (crawling bugs), HTN and tachycardia. Withdrawal includes (non-deadly) fatigue, hypersomnia, anxiety, dysphoria, suicidal ideation and craving. Treatment intoxication symptomatically (antiarrhythmic, benzo for agitation, haloperidol). Treatment withdrawal supportively (observe for suicidality). Treatment dependence with rehabilitation.

Front 558

527. Sedatives

Back 558

benzo, barbiturates – intoxication causes slurred speech, drowsiness, impaired attention, and disinhibition. (Flumetrazepam is the date-rape drug). Overdose with barbiturates for suicide, (not so much benzo because of high therapeutic index, unless taken with another drug or alcohol). Both cause respiratory depression, coma and death. Withdrawal causes anxiety and insomnia. Severe withdrawal is a medical emergency (nausea & vomiting, autonomic hyperactivity, photophobia, tremor, hyperthermia, delirium, seizures, death) most severe with short-acting drugs. Overdose benzo with flumazenil (does not reverse respiratory depression), barbiturates with charcoal, gastric lavage. Treatment barbiturate withdrawal with pentobarbital challenge test to get daily dose, and taper off. Treatment benzo withdrawal with long-acting benzo (diazepam, clonazepam) and gradually withdraw.

Front 559

528. Nicotine

Back 559

acetylcholine (nicotinic) agonist. Withdrawal causes irritability, weight gain, and difficulty with concentration. Treatment: 1st obtain specific date to stop, 2nd educate, counsel.

Front 560

529. PCP

Back 560

paranoia, assaultive, impulsiveness, vertical and, or horizontal nystagmus (dead give-away), diaphoresis, respiratory depression, seizures, normal size pupils. Treatment symptomatically.

Front 561

530. Hallucinogens

Back 561

LSD, Ecstasy – sympathomimetic effects (mydriasis, tachycardia, sweating, diarrhea, urination), panic reactions, illusions, paranoia. Later on, Patient may not be using drug anymore and re-experience intoxication (flashback).

Front 562

531. Cannabinoids

Back 562

Marijuana, THC – intoxication has euphoria, bad judgment, slowed reactions, dry mouth, and conjunctival injection (dead give-away). Chronic use causes amotivational syndrome and memory impairment.

Front 563

532. Hallucination

Back 563

is a disturbed sensory perception (visual, tactile, auditory). Delusion is a fixed, false belief (even if people prove to you otherwise). Psychosis is inability to judge boundary between real and unreal.

Front 564

533. Schizophrenia

Back 564

presence of >2 Signs & Symptoms of the following for >6 months: delusions, hallucinations (generally auditory, link visual with alcohol withdrawal), disorganized speech, behavior, negative Signs & Symptoms (flat affect, no speech, no motivation, anhedonia). Better prognosis (NBME 3 question) if acute, late onset, good social, occupation history, positive signs & symptoms, medication compliance, married, female gender. Symptoms due to altered dopamine activity (newer antipsychotics affect serotonin also). Negative Signs & Symptoms have enlargement of cerebral ventricles and hypoactive frontal lobe. Treatment: 1st assess if Patient needs hospitalization (protect self, others), 2nd Antipsychotics (Risperidone), 3rd Psychosocial Treatment. [Timeline: <1 month = brief psychotic d, o, 1-6 months = schizophreniform, >6 months= schizophrenia].

Front 565

534. Delusional (Paranoid) Disorder

Back 565

persistent, non-bizarre, well-systematized delusion. Erotomania (on is loved by a famous other, NBME 3 TQ), grandiose (one possesses great talent), jealous (conviction that lover is unfaithful), persecutory (one is conspired against, MC), somatic (one has a physical abnormality like odor). Treatment: 1st hospitalization for inability to control suicidal, homicidal impulses or danger associated with delusions, 2nd psychotherapy, 3rd antipsychotics and antidepressants.

Front 566

535. Schizophreniform

Back 566

schizophrenia < 6 months. Good prognosis with acute onset, confusion, and disorientation, full affect treatment with antipsychotics for at least 6 months.

Front 567

536. Brief Psychotic Disorder

Back 567

sudden onset of psychotic Signs & Symptoms with emotional turmoil and confusion, often following obvious stressor, duration <1month. Suicide risk, thus treatment 1st hospitalization as needed, 2nd antipsychotics, antianxiety agent, 3rd psychotherapy.

Front 568

537. Schizoaffective

Back 568

schizophrenia with depression or mania for at least 2 weeks.

Front 569

538. Shared Psychotic disorder

Back 569

submissive, dependent isolated relationship with person with established delusion. Suicide, homicide pacts. Treatment: 1st separate the 2 people, 2nd antipsychotics.

Front 570

539. Mania

Back 570

>1 week of elevated, expansive, irritable mood with grandiosity, no sleep, talkativeness, impulsivity (shopping sprees, gambling, promiscuity) , racing thoughts, distractibility, agitation. Hypomania is less severe and lasts >4 days.

Front 571

540. Major depression disorder (MDD)

Back 571

2 of SIGECAPS in >2 weeks– sleep changes (delayed sleep onset, decreased REM. Note the difference: Anxiety has increased REM latency, depression and narcolepsy have decreased REM latency), interest loss, guilt, energy loss, concentration decreased, appetite (up or down), psychomotor (retardation or agitation), suicidality. Decreased serotonergic activity associated with violence and suicide. Treatment: Hospitalize if suicide risk, 2nd Antidepressant (SSRI 1st) for 6-12 months (not that it takes 4-6 weeks to start effects), 3rd ECT (rapid response in pregnancy, elderly, medically ill), 4th psychotherapy, 5th antipsychotic + antidepressant for psychotic pts, 5th Phototherapy if depression is seasonal, 6th treat comorbid psychopathology (anxiety, substance abuse, personality d, o, ADHD).

Front 572

541. Depression versus Bereavement

Back 572

Depression (mood pervasive, unremitting, constant low self-esteem, worthlessness, suicidal, sustained psychotic signs & symptoms, no improvement with treatment, social withdrawal). Bereavement (mood fluctuates, self-reproach regarding deceased, not suicidal, transient visual, auditory hallucinations or deceased, Signs & Symptoms improve with time and usually gone by 6 months, often welcomes social support). It is normal to have an illusion or hallucination about the deceased, but a normal grieving person knows that it is an illusion or hallucination, while an MDD Patient thinks it’s real. Other clues to MDD that are not normal are feeling of worthlessness, suicidality and psychomotor retardation.

Front 573

542. Bipolar Disorders

Back 573

Type I is full-blown mania with MDD. Type II is hypomania with MDD. Treatment: 1st assess risk of suicide, assaultive, dangerous poor judgment. 2nd For acute mania give mood stabilizer (lithium). For depression – mood stabilizer with or without antidepressant if necessary.

Front 574

543. Cyclothymia

Back 574

numerous hypomanic episodes with depressive episodes for >2 yrs. (Cyclo is a psycho, while dysthymia is just depression for >2 yrs).

Front 575

544. Panic Disorder

Back 575

minutes to hours of unexpected, sudden intense anxiety, dyspnea, parasthesia, chest pain, fear of dying. Associated with agoraphobia (fear of places where escape is difficult such as bridges, public transportation, large crowds, traveling). Treatment: 1st If acute, emergent case, give reassurance and benzo (alprazolam, clonazepam). 2nd Rule out MI, PE, CVA, hypoglycemia, 3rd Antidepressants (SSRI is treatment of choice for long-term management), 4th Cognitive-behavioral therapy (CBT) for agoraphobia.

Front 576

545. Obsessive-Compulsive Disorder

Back 576

recurrent intrusive images, impulses, thoughts (obsessions) and ritualistic behaviors (compulsions) that produce anxiety and affect way of life. Associated with Tourette syndrome. Abnormality is serotonin system. Treatment with SSRIs (fluvoxamine), but if you only see TCA’s pick clomipramine.

Front 577

546. Specific Phobia

Back 577

irrational, excessive fear and avoidance of a specific object or situation. Treatment: Systemic desensitization.

Front 578

547. Social Phobia

Back 578

fear of embarrassment, scrutiny of others (public speaking, eating in public, public bathrooms). Treatment: 1st CBT, 2nd beta blockers (propranolol) for stage fright, 3rd Antidepressants (not TCAs) and high-potency benzodiazepines.

Front 579

548. Posttraumatic Stress Disorder

Back 579

>1 month, must have 3: re-experiencing (flashbacks), emotional numbing (avoidance), autonomic arousal (insomnia, irritability). Treatment: 1st hospitalize for acute suicide, violence risk. 2nd CBT, 3rd Antidepressants.

Front 580

549. Acute Stress Disorder

Back 580

<1month of the same 3 symptoms. Treatment with psychotherapy.

Front 581

550. Generalized Anxiety Disorder

Back 581

unrealistic, persistent anxiety for >6 months. Muscle tension, restlessness, poor concentration, fatiguability, irritability, loss of sleep. Treatment: 1st psychotherapy, 2nd Antidepressants (Buspirone).

Front 582

551. Somatoform Disorders

Back 582

unlike factitious disorder and malingering, the symptoms are not intentionally produced but are strongly linked to psychological factors. Examples include somatization disorder (multiple somatic complaints, treatment with regularly scheduled visits with PMD), conversion disorder (neurologic signs & symptoms), pain disorder (pain in absence of adequate physical findings, treatment with psychotherapy), hypochondriasis (fear of specific disease, treatment with regular medical visits), and body dysmorphic disorder (preoccupation with defect in appearance, treatment with psychotherapy and SSRI’s after you assess suicide risk).

Front 583

552. Factitious disorder

Back 583

“Munchausen syndrome.” Intentional production of Signs & Symptoms for unconscious psychological reasons (need to assume sick role) usually in someone in medical occupation or with history of illness. If Signs & Symptoms produced by parent, this is Munchausen’s by proxy. Treatment with psychiatric consult, confrontation may be helpful.

Front 584

553. Malingering

Back 584

intentional production of symptoms for a recognized gain (money, drugs, avoid work, military, prison).

Front 585

554. Dissociative Identity disorder

Back 585

multiple personalities, which take over life and Patient may or may not be aware of each other. Treatment with intensive psychotherapy.

Front 586

555. Amnestic Disorder

Back 586

2 types: psychogenic fugue (sudden, unexpected travel with amnesia of old identity and assumption of new identity that lasts hours to months, Patient is unaware of loss) and psychogenic amnesia (sudden inability to recall important personal information of a traumatic or stressful event, but aware of loss). Recovery usually returns spontaneously. If not, try hypnosis, amobarbital or psychotherapy.

Front 587

556. Depersonalization disorder

Back 587

recurrent feeling of detachment from one’s body or self (feel like you’re in an outside world).

Front 588

557. Anorexia Nervosa

Back 588

must have 3: amenorrhea, minimal normal body weight, fear of gaining weight. Treatment: 1st hospitalize for dehydration, starvation, hypotension, electrolyte, hypothermia, suicide risk. 2nd treatment contract for weight gain, 3rd CBT.

Front 589

558. Bulimia Nervosa

Back 589

binge eating, normal weight, over concerned with wt, diet, exercise, self-induced vomiting, laxatives, diuretics, associated with kleptomania. Treatment: 1st hospitalize for ECG (hypokalemia-induced arrhythmia is MCCOD), electrolytes, amylase, LFTs, esophageal, gastric rupture, suicide risk. 2nd psychotherapy, nutritional counseling, SSRI for binging (do not give bupropion for risk of seizures).

Front 590

559. Old, classic USMLE TQ: Mom finds her son having sex with another boy, is this normal or homosexuality?

Back 590

Normal (unless they say he enjoys it). Another TQ is a man, who knows he is a man and likes women, dresses up like a woman and acts like a woman, what is his sexual orientation? Heterosexual (b, c he likes women).

Front 591

560. Projection

Back 591

attributing your own wishes to someone else. Associated with paranoid personality disorder (p for p – paranoia with projection).

Front 592

561. Denial

Back 592

if they deny having a disease, next step is doing nothing! (Because it usually does not interfere with treatment, but if it does, next step is confront the pt).

Front 593

562. Splitting

Back 593

all is good or bad. Associated with borderline d, o. If they only say all is good, its idealization. If they only say all is bad, its devaluation. Splitting must have both.

Front 594

563. Regression

Back 594

look for history of bedwetting in a kid >5 year old (<5 year old is normal).

Front 595

564. Reaction formation versus Undoing

Back 595

reaction formation is a thought, undoing is an action. Both are classically associated with obsessive compulsive d, o, where reaction formation is the obsession, and undoing is the compulsion.

Front 596

565. Reaction formation versus sublimation

Back 596

sublimation does something good for mankind.

Front 597

566. Primary insomnia

Back 597

disturbance in initiating, maintaining or feeling rested after sleep. Treatment: 1st hygiene treatment: regularize sleep hours, use of bed only for sex, sleep, if not asleep in 30 minutes then leave bed and return only when drowsy, no napping, regular exercise but not immediately prior to bedtime, reduce, eliminate alcohol, caffeine, smoking, relaxation exercise. 2nd sedative-hypnotics (benzo, zolpidem) for short-term relief.

Front 598

567. Narcolepsy

Back 598

daytime drowsiness, irresistible sleep attacks with hypnagogic, hypnopompic hallucinations, sleep paralysis, cataplexy (loss of muscle control with strong emotions). Treatment with short daytime naps, 2nd stimulants for sleep attacks and TCAs for cataplexy.

Front 599

568. Sleep apnea

Back 599

obstructive type due to occlusion of upper airway during sleep in an obese pt. Central type is due to reduced nocturnal respiratory drive). Diagnosed with polysomnography. Treatment: 1st weight reduction, 2nd CPAP for obstructive type, Acetazolamide or protriptyline for central type.

Front 600

569. Restless Legs Syndrome

Back 600

agonizing, deep creeping sensations in leg, arm muscles relieved by moving or massage. Patient has trouble falling asleep at night because of it. Treatment with benzo diazepam.

Front 601

570. Intermittent Explosive

Back 601

discreet episodes of loss control of aggressive impulses, but otherwise not aggressive. Treatment with benzo (causes disinhibition) and CBT.

Front 602

571. Kleptomania

Back 602

failure to resist stealing unnecessary and unneeded things. Associated with Bulimia.

Front 603

572. Pyromania

Back 603

deliberate fire setting and fascination with fire, usually in kids. Make sure the guy is not getting paid to do it and that it is completely for self-satisfaction.

Front 604

573. Trichotillomania

Back 604

recurrent pulling out of one’s own hair. Treatment with psychotherapy, SSRI.

Front 605

574. Adjustment Disorder

Back 605

excessive emotional, behavioral responses that occur within 3 months of a stressor that is within range of normal experience (unlike PTSD), such as school problems, marital discord, job loss or illness.

Does not persist after 6 months of stressor.
Lacks sufficient evidence to make for other diagnosis (MDD).

Treatment: 1st evaluate suicide risk. 2nd psychotherapy, antianxiety, antidepressants, 3rd stress reduction.

Front 606

575. Personality Disorders

Back 606

Cluster A (Weird: Paranoid, Schizoid (Patient wants to be alone), Schizotypal (peculiar ideations, appearance, behavior magical thinking)), Cluster B (Wild: Antisocial (exploitative, destructive, impulsive behavior with no remorse. Childhood history of conduct disorder essential for Diagnosis. Treatment with SSRI), Borderline (instability of self-image, identity, relationships and mood. Does crazy things and still feels empty inside. History of child abuse. Treatment with psychotherapy (long-term), SSRI for mood stability and impulsivity, haloperidol for psychosis. Avoid benzo), Histrionic (attention seeking, hits on the doctor, needs praise and reassurance), Narcissistic (grandiose, mad if humiliated, lack of empathy). Cluster with (Worried: Obsessive-compulsive (treatment with fluvoxamine), Dependent, Avoidant (does not want to be alone (unlike schizoid), but fears rejection).

Front 607

576. Antipsychotics (Neuroleptics)

Back 607

Low-doses (thioridazine, chlorpromazine), high-doses, long-acting (haloperidol, fluphenazine. Highest risk of EPS, NMS), atypical (clozapine, risperidone, olanzapine, quetiapine, ziprasidone). Typicals block dopamine (D2) receptors, thus used for positive symptoms only and have many side-effects, while Atypicals block serotonin (5-HT), D2 and D4, thus can be used for positive and negative symptoms and have fever side-effects. Adverse-effects: Hours-Days: Dystonia (spasms), Torticollis and oculogyric crisis (eyes stay looking up). Treatment with benztropine, diphenhydramine or trihexylphenidate. Weeks: Akathisia (restlessness). Treatment with lowering drug-dose, benzo, beta blockers, or switch to atypical (best). Months: Tardive dyskinesia (lip-smacking). Treatment with switching to atypical. Neuroleptic malignant syndrome: most common with high-potency drugs, increased risk if used with lithium, fever, rigidity, autonomic instability, very high CPK levels, high K+, treatment with IV dantrolene or bromocriptine. Clozapine causes agranulocytosis (must do weekly CBC if taking), thioridazine causes retinal pigment deposits and chlorpromazine causes jaundice and photosensitivity.

Front 608

577. Newer Atypicals Adverse Effects

Back 608

Risperidone (less sedative, but increases prolactin, increase risk of movement d, o), Olanzapine (love to ask about. weight gain (MC), risk of DM), Ziprasidone (prolonged QT), Quetiapine (risk of movement d, o).

Front 609

578. Antidepressants

Back 609

block NE, 5-HT, Dopamine. MAOIs (bad because of Tyramine food reaction (cheese, red wine, chocolates, sausages). Must stop MAOI at least 2 weeks before starting TCAs or SSRI. Treatment of choice for atypical depression (increased sleep, weight, appetite or Leaden paralysis)). TCAs (best ones are nortriptyline and desipramine, worst is amitriptyline. Causes hypotension, anti-cholinergic signs & symptoms, conduction defect (MCCOD, most common is sinus tachy, but USMLE loves widened QRS, treatment with bicarbonate), sexual problems, changes in wt, sedation). SSRI (1st choice for MDD (fluoxetine, sertraline, paroxetine, citalopram, escitalopram), Anxiety (fluoxetine, sertraline, paroxetine) and OCD (fluvoxamine only). Causes headache (MC), GI upset, sedation, agitation, sexual dysfunction (worst signs & symptoms) and weight gain). Others include Venlafaxine (MDD, anxiety), Duloxetine (MDD, pain d, o), Bupropion (MDD, smoking cessation), Mirtazapine (weight good (good for anorexia), sedation) and Trazodone (priapism). In a nutshell, always answer SSRI unless: 1- Patient with MDD and neuroleptic (spinal) pain, give duloxetine; 2 – Patient with MDD and has sexual changes, weight gain, give bupropion (not buspirone for GAD).

Front 610

579. Mood stabilizers

Back 610

Depressed Patient (lithium or lamotrigine) or Mixed, Manic (Lithium, valproic acid, antipsychotics). Either way, lithium is 1st line. It causes tremors, GI upset, hypothyroidism, nephrotoxic, teratogenic, acne, weight gain, leukocytosis, ataxia, and seizures. Must get weekly blood levels and must get TSH, BUN, Cr, hCG before starting it. If renal disease, pick valproic acid, if very acute mania pick haloperidol, otherwise always go with lithium first. Never discontinue lithium abruptly and levels >3.0 is a medical emergency that needs IV saline or hemodialysis.

Front 611

580. Electroconvulsive therapy

Back 611

increases serotonin for conditions like MDD, mania and schizophrenia. No absolute contraindications. Only relative CI is high intracranial pressure (brain tumors). Who gets it? Suicidal Patient (treatment of choice), those who don’t respond to medications, pregnancy, history of benefit with ECT, medication complications. Most common adverse effect is memory loss.

Front 612

581. Benzodiazepines

Back 612

all work on CP450 exams OTL (Oxazepam, Temazepam, Lorazepam), so remember OTL for Outside The Liver.

Front 613

582. Suicide

Back 613

if Patient mentions it, next step is to ask more questions (attempt, ideations), then admit. Risks: history of attempt (best indicator of eventual success), hopelessness, psychiatric, physical illness, drug abuse, elderly, social isolation (living alone is worse than single, they are not the same thing!), low job satisfaction. Most common method in males are guns, females are guns. Most common attempt in males are guns, females are pills.

Front 614

PULMONARY:

Back 614

0

Front 615

583. When to intubate?

Back 615

pO2 < 50, pCO2 >50, pH < 7.3 @ room air. Remember if Patient becomes fatigued, this is a bad sign, don’t assume he’s just tired, and intubate him.

Front 616

584. Common cold

Back 616

rhinitis, sneezing, headache, malaise and cough (no fever). Rhinovirus is most common cause (also adenovirus, RSV, influenza). Treatment: keep well hydrated, NSAIDS for fever, warm salt water gargles for pharyngitis (fever, dry and sore throat) and laryngitis, pseudoephedrine, phenylephrine for nasal congestion, avoid aspirin in children.

Front 617

585. Pharyngitis (strep throat)

Back 617

although viruses can be a common cause, rule out bacterial infection (group A strep, aka strep pyogenes) with rapid strep test. Clues to strep throat include cervical lymphadenopathy, fever, pharyngeal and tonsillar exudates and the absence of cough. Treatment with penicillin, erythromycin is given to prevent complications (peritonsillar, retropharyngeal abscess, meningitis, endocarditis, acute RF and glomerulonephritis). If viral etiology, supportive care only.

Front 618

586. Peritonsillar abscess

Back 618

dysphagia, fever, pain and trismus (hard to open mouth). Uvula displaced by swelling, treatment with surgical drainage and antibiotics.

Front 619

587. Thrush

Back 619

candidal infection that has removable white patches in the mouth (remember, candida CAN come off, hairy leukoplakia can’t). Treatment with nystatin, fluconazole.

Front 620

588. Sinusitis

Back 620

facial pain, pressure, fever, greenish purulent rhinitis. If suspected, go ahead and begin treatment with amoxicillin, then get x-ray, then CT-scan of sinus. Only maxillary and ethmoid sinuses are present in children. Ethmoid sinusitis is more frequent in children. Cavernous sinus thrombosis is a complication that includes facial edema, meningitis and ophthalmoplegia.

Front 621

589. Allergic rhinitis

Back 621

sneezing, itchy, water eyes, nose blocked and, or runny. Treatment with corticosteroids and cromolyn sodium, antihistamines, decongestants, allergy shots.

Front 622

590. Nasal polyps

Back 622

swollen mucosa, submucosa polypoid tissue causing obstruction of nasal cavity. Associated with allergic rhinitis, cystic fibrosis and aspirin intolerance.

Front 623

591. Croup

Back 623

(laryngotracheobronchitis) an acute viral illness in young kids who get cold Signs & Symptoms at onset, then barking cough, slight fever and inspiratory, expiratory stridor. X-ray shows steeple sign. Treatment with humidified air then racemic epinephrine.

Front 624

592. Epiglottitis

Back 624

kid with drooling, high fever, respiratory obstruction, dyspnea, dysphagia, inspiratory stridor, lateral x-ray shows thumb sign. Do not irritate the kid or maneuver epiglottis as that would worsen obstruction. Most common cause is H. influenza type B. Treatment with cephalosporins and intubation if needed.

Front 625

593. Pertussis

Back 625

3 stages: catarrhal (coryza for 1-2 week), paroxysmal (whooping cough, 2-4 week), convalescent stage weeks later. Treatment with erythromycin in catarrhal stage, otherwise supportive care.

Front 626

594. Acute Bronchitis

Back 626

large airway inflammation, productive cough, fever, mild dyspnea, CXR is clear (if there was an infiltrate, then its pneumonia). Treatment with antibiotics, hydration, expectorants, bronchodilators.

Front 627

595. Bronchiolitis

Back 627

small airway inflammation, tachypnea, wheezing, fever, cough in a child <2 year old. Caused by RSV. Treatment with ribavirin and oxygen.

Front 628

596. Pulmonary Nodule

Back 628

1st step is get old x-ray. 2nd step if lesion was present and is the same size, its benign (hamartoma, discharge home). If the lesion was there and has gotten bigger, assume cancer. However, if the lesion was not in the old-x-ray, then classify his risk. If he is low risk (<40 yo, non-smoker) then it’s probably benign (hamartoma, CXR every 3 months for 2 yrs). If he is high-risk (>50, smoker), assume cancer (do open-lung biopsy).

Front 629

597. Pneumonia

Back 629

Typical (<2 days prodrome, fever >102, >40 year old, one lobe involved) is due to strep pneumonia (gram + diplococci, treatment with Levaquin, prevent with vaccine in >65 year old and Patient with comorbidities, treatment with 3rd generation cephalosporins). Atypical (>3days, headache, aches, dry cough, <40yo, multiple lobes, diffuse) in a young, otherwise healthy adult with atypical pneumonia is Mycoplasma, H. Influenza, Chlamydia and treatment with Azithromycin. College student with dry cough, think of Mycoplasma (cold agglutinins) or Chlamydia. An elderly Patient with COPD likely has bacterial pneumonia or if in the winter, possible influenza. An AIDS Patient with low CD4 and subacute illness has PCP (treatment with Bactrim (if allergic, give dapsone) or prophylaxis when CD<200). A Patient whose mentation is altered (postop from anesthesia, demented, intoxicated) or who have swallowing dysfunction (CVA) has aspiration pneumonia. An alcoholic will likely have Klebsiella. If you see CNS (headache), GI (diarrhea) and pneumonia, it’s Legionella so give erythromycin (1st test is urine legionella Ag test, most accurate test is direct fluorescent antibody from sputum). If cystic fibrosis or hospitalized for a long time, think pseudomonas (though S. aureus is still a big one here) and treatment with piperacillin, tazobactam or ceftazidime. If Patient is a farmer (cattle, sheep, and goats) or veterinarian, think of Coxiella burnetii (treatment with doxycyline) or chlamydia psittaci (bird-exposure, treatment with doxycycline). (Pediatric Wheezing: <1 year old is RSV, 2-5 year old is Croup (barking) or epiglottitis (drooling), >6 year old is Asthma).

Front 630

598. Influenza

Back 630

fever, chills, cough, sore throat with positive throat, nasal swabs in the winter-time. For prophylaxis, give Amantadine (influenza A only) or vaccine (>50 year old or high-risk pt). If discovered <2 days, give Oseltamivir. If >2 days, rest, fluids, and symptomatic treatment with analgesics and antipyretics.

Front 631

599. Pneumococcal vaccine

Back 631

everyone >65yo, anyone (>2yo) with COPD, DM, alcoholism, immunocompromised (HIV, AIDS, cancer, steroid-use, chemotherapy), post-splenectomy.

Front 632

600. Influenza vaccine

Back 632

children 6-23 months, >65 (Dr. Fisher says >50 year olds) with chronic medical conditions, residents of nursing homes, health care workers with patient contact, children (2-18) with chronic aspirin use (Kawasaki’s), caregivers of kids <6 months.

Front 633

601. TB

Back 633

caseating granulomas, transmission by aerosolized droplets (overcrowded areas, poor ventilation, health-care workers, immunocompromised, homeless), fever, productive cough, night sweats, chills, weight loss. If symptomatic, next step is CXR then AFB. If asymptomatic, next step is PPD (refer to ID notes for Mantoux reaction margins), then CXR then AFB. Treatment with RIPE until culture sensitive.

Front 634

602. Histoplasma

Back 634

Ohio, Mississippi river bird, bat droppings in soil grow spores, which are inhaled. If mild, no Treatment. If more ill give ketoconazole or amphotericin B. If disseminated (AIDS pt) then 1st step is blood, bone marrow culture, 2nd Amphotericin B.

Front 635

603. Coccidiomycosis

Back 635

flulike signs & symptoms, arthralgia, erythema nodosum, multiforme rash. If mild, no Treatment. If severe, give Amphotericin B.

Front 636

604. Cryptococcus

Back 636

AIDS or steroid-use Patient gets infected with encapsulated yeast found in soil, pigeon droppings in NY area causing Signs & Symptoms in the lungs and CNS (meningitis). Treatment with Amphotericin B + flucytosine for severe disease.

Front 637

605. Lung Abscess

Back 637

purulent, putrid sputum, cough, chest pain, fever, Patient with poor dentition and aspiration, CXR shows cavities and air-fluid level. Treatment with IV penicillin G.

Front 638

606. A-a gradient: 150

Back 638

(1.25 x PCO2) – PaO2. (NL = 5-15, high with all hypoxemia causes except hypoventilation and high altitude).

Front 639

607. Obstructive

Back 639

low FEV1, low FVC, low FEV1, FVC, low DLCO in emphysema, normal DLCO in Chronic bronchitis, Asthma. FEV1 determines severity of disease (60-70% is normal-moderate COPD, <50% is severe COPD). Decreased lung flow.

Front 640

608. Restrictive

Back 640

FEV1, FVC both decreased, but FEV1, FVC is normal. TLC is reduced. Decreased lung volume.

Front 641

609. COPD

Back 641

what are the only things that decrease mortality? Home O2 (when PaO2 <60mmHg) and smoking cessation. If treatment is not sufficient with bronchodilators, give theophylline (decreased clearance if also given with erythromycin, ciprofloxacin and cimetidine). Treatment 1st Anticholinergics (ipratropium bromide MDI), 2nd Albuterol, 3rd Theophylline. What is the best predictor of survival? FEV1. Vaccines? Influenza annually and pneumococcus every 5 years.

Front 642

610. Chronic Bronchitis

Back 642

blue bloaters (due to cyanosis), productive cough, recurrent pulmonary infections.

Front 643

611. Emphysema

Back 643

pink puffer, progressive dyspnea, low DLCO, less cough, cachetic, barrel chest, sits in tripod position, hyperresonant lungs, distant heart sounds, CXR shows huge lungs with bullae,. If in a young Patient with no smoking history, pick alpha-1-antitripsyn (AAT) deficiency, treatment with purified human AAT.

Front 644

612. Asthma

Back 644

for attacks: 1st give oxygen, 2nd peek flow, 3rd Albuterol, 4th Steroids for 14 days (no antibiotics). What if Patient has attack secondary to beta blockers? Give anticholinergics (ipratropium bromide). For exercise-induced asthma, give cromolyn and albuterol before exercising. Chronic Treatment: daily inhaled steroids, albuterol as needed (other drugs depend on type of asthma). For acute evaluation get ABG (respiratory alkalosis, if it gets normal that’s bad), Pulse ox, CXR. For chronic evaluation, get PFTs, methacholine challenge, bronchodilator (test reversibility). Treatment of choice for nocturnal cough is long acting B-agonist (Salmeterol).

Front 645

613. Bronchiectasis

Back 645

Cupfuls of purulent, malodorous productive cough, weight loss, hemoptysis, clubbing, associated with cystic fibrosis and Kartagener’s syndrome (immotile cilia). Diagnosed with CXR 1st then CT (best, but not 1st). For acute management, treatment for pseudomonas (ticarcillin, piperacillin, quinolones, ceftazidime). For chronic Treatment, give bronchodilators, postural drainage, rotate antibiotics (prevent resistance), surgery and vaccines.

Front 646

614. Pulmonary Fibrosis

Back 646

interstitial inflammation, exertional dyspnea (most common signs & symptoms), crackles, clubbing, cor pulmonale. Diagnosis: 1st CXR (shows ground-glass appearance), 2nd CT, 3rd Lung biopsy (gold standard). Treatment with steroids for 6 months, then transplant if needed and follow up PFTs.

Front 647

615. Allergic Bronchopulmonary Aspergillosis (ABPA)

Back 647

must have 6 of the following 7: history of asthma, peripheral eosinophilia, pulmonary infiltrates, + skin test to Aspergillus, high serum IgE, +IgE, IgG for Aspergillus, central bronchiectasis. Treatment with prednisone.

Front 648

616. Atelectasis

Back 648

most common cause of postop fever after 1-2 days. Treatment: 1st incentive spirometry, 2nd Deep breathing exercises, 3rd out of bed, 4th chest physical therapy, 5th CPAP, 6th Bronchoscopy (if atelectasis is severe and spontaneous-due to mucus plug).

Front 649

617. Hemothorax

Back 649

blood in pleural space. Dyspnea with massive shock. Treatment: if very small, observe. All others need a chest tube. Some need thoracotomy (bleeding >200mL, hr).

Front 650

618. Asbestosis

Back 650

exposure to removal sites, pipe maintenance, etc. Takes >20 years to develop mesothelioma, but much less to develop bronchogenic CA (esp. if smoking). Diagnosed with lung biopsy showing ferruginous bodies (not CXR or CT). No Treatment.

Front 651

619. Silicosis

Back 651

increased risk of TB (must do annual PPD). Upper lob nodules with eggshell hilar node calcification.

Front 652

620. Caplan Syndrome

Back 652

rheumatoid nodules in lung periphery with coal-workers pneumoconiosis.

Front 653

621. Sarcoidosis

Back 653

blacks, females, biopsy shows non-caseating granulomas (most accurate), fever, dyspnea, skin (erythema nodosum), eye (iritis), CNS (nerve palsy), cardiac (arrhythmia) signs & symptoms. CXR shows bilateral enlarged hilar adenopathy, diagnosed with biopsy, elevated ACE, high calcium. Treatment with steroids.

Front 654

622. Acute Respiratory Distress Syndrome (ARDS)

Back 654

acute lung damage from increased pulmonary (alveolar) permeability. Patient with dyspnea, tachypnea, tachycardia, no improvement with oxygen, arterial hypoxemia (PaO2, FiO2 ratio <300), hypercapnia, CXR shows bilateral whited out lungs. History of infection, aspiration, near-drowning, drugs, shock, burns, and pancreatitis. Treatment with PEEP.

Front 655

623. Pulmonary Embolism

Back 655

venous stasis, thrombosis, hypercoagulable state (pregnancy, SLE, cancer, protein C and S deficiency, OCP, antithrombin III deficiency, Factor V leidin). Sudden onset of dyspnea, pleuritic CP, hemoptysis, syncope, split S2 sound. Clear CXR. EKG shows sinus tachycardia or S1Q3T3. ABG shows respiratory alkalosis with hypoxia and increased A-a gradient. Mostly from deep leg vein thrombi (above knee is not possible, must be below knee). Diagnosed with spiral CT or V, Q scan (esp. if pregnant). Definitive diagnosed with pulmonary angiography. Treatment with 1st anticoagulation with heparin (LMW-heparin if pregnant) with O2 if stable, 2nd thrombolytics (TPA) if unstable, 3rd embolectomy (if severe like a saddle embolism), 4th filter (if recurrent or if anticoagulation is contraindicated).

Front 656

624. Pulmonary HTN

Back 656

Chest pain, dyspnea, lethargy, shortened S2 split with louder P2, weak peripheral pulses, cold hands. Treatment with oxygen and vasodilators.

Front 657

625. Goodpasture’s

Back 657

renal with Pulmonary so Patient with hemoptysis and hematuria, anti-GBM antibody, Treatment: 1st prednisone, 2nd cyclophosphamide, 3rd plasmapheresis.

Front 658

626. Wegener’s

Back 658

Upper airway, pulmonary, renal so Patient with sinusitis, hemoptysis, hematuria, c-ANCA. Treatment: 1st cyclophosphamide, 2nd prednisone.

Front 659

627. Pleural Effusion

Back 659

once you see it on CXR, next step is tap (thoracentesis) to see if it is transudative (CHF, PE, nephrotic syndrome, atelectasis) or exudate (parapneumonic, cancer, PE, chylothorax, esophageal rupture, rheumatoid arthritis). For it to be exudates: Pleural fluid to serum protein ratio >0.5, Pleural fluid to serum lactate dehydrogenase (LDH) ratio >0.6, Pleural fluid LDH more than 2, 3 of the upper limits of normal serum value. What if they don’t give you the serum levels? Then exudates is when pleural fluid cholesterol >45 mg, dl and pleural fluid protein >2.9. If you think it is malignancy (old guy, weight loss, smoker, etc.) then look for LDH >1000, glucose 30-50, and lymphocytes 50-70%. However, if you worry about parapneumonic effusion, look for LDH >1000, glucose >30, pH <7.2, next step is chest tube drainage.

Front 660

628. Lung Cancer

Back 660

no available screening test. Squamous cell (central cavitation, associated with hypercalcemia due to PTH-like peptide, diagnosed with bronchoscopy), Small cell (central cavitation, associated with SIADH, Eaton-Lambert and Cushings syndrome, diagnosed with bronchoscopy), Adenocarcinoma (peripheral lesion, most common is bronchoalveolar CA, increased hyaluronidase levels, diagnosed with FNA then thoracotomy with pleural biopsy). When is it unresectable? Hoarseness, METS, weight loss >10%, CNS signs & symptoms, SVC syndrome (JVD with facial discoloration due to squamous cell carcinoma) or tumor at the trachea, esophageal, pericardium. For small cell carcinoma, treatment with chemotherapy (VP16-etoposide and platinum). For non-small cell CA give radiation and chemo (CAP – Cyclophosphamide, Adriamycin and Platinum).

Front 661

RENAL, UROLOGY:

Back 661

0

Front 662

629. Prostatitis

Back 662

dysuria, chills, fever, low back pain, perineal pain and frequency, prostate may feel boggy and large but is always tender. E. coli. Treatment with levaquin and hydrate.

Front 663

630. Epididymitis

Back 663

tender (relieved with scrotal elevation, opposite of torsion), enlarged testicle, fever, scrotal thickening. Caused by neisseria, E. coli and chlamydia. Treatment with antibiotics (tetracycline, levaquin), NSAIDs, scrotal support.

Front 664

631. Orchitis

Back 664

fever, increase testicular size, scrotal pain, erythema, associated with mumps and TB. Treatment with same as above.

Front 665

632. Urethritis

Back 665

urethral discharge, dysuria. Next step is culture, gram stain (rule out STD). Treatment with antibiotics.

Front 666

633. Testicular torsion

Back 666

most common cause of scrotal swelling in kids, causing severe pain (especially when scrotum is lifted, opposite of epididymitis), abdomen pain (sometimes this is their only signs & symptoms, so must check scrotum), vomiting. Urologic emergency for blood supply must be regained within 6 hrs to prevent loss of testicle.

Front 667

634. Cryptorchidism

Back 667

no signs & symptoms. Diagnosed with CT. Treatment: Orchiopexy at age 1 to prevent cancer.

Front 668

635. Any testicular mass needs to have cancer ruled out,

Back 668

so excise and biopsy it.

Front 669

636. Benign Prostatic Hypertrophy

Back 669

enlargement of prostate gland causing obstruction (hesitancy, dribbling, weak, low stream), urgency, nocturia and frequency. Diagnosis: 1st DRE, 2nd ULTRASONOGRAM. Treatment: 1st a-blocker (terazosin, remember tamsulosin (Flomax) has the least adverse effects), 2rd 5-a-reductase inhibitors (finasteride), 3th Surgery (TURP). However, if Patient is in ER in pain, 1st Foley (if it won’t pass, do suprapubic tap), 2nd TURP (skip medications).

Front 670

637. Hypospadia

Back 670

meatus below penis tip, so you pee on your feet. Patient may have chordee (ventral penile curve causing penis to curve 90degrees). Treatment: 1st line is to observe until 1 year old (do not circumcise), 2nd line is surgery.

Front 671

638. Hydrocele

Back 671

fluid around the testis due to patent processus vaginalis. Diagnosed with + transillumination. Treatment with observation.

Front 672

639. Varicocele

Back 672

pampiniform plexus vein dilation due to inefficient pampiniform valves. Disappears in supine position (no venous pooling). Diagnosed with (-) transillumination. Treatment with surgery.

Front 673

640. Cystitis

Back 673

bladder infection causing dysuria, frequency, nocturia, urgency. Diagnosed with UA, Urine culture, Urine dipstick. Most common cause is E. coli. Treatment: 1st antibiotics, 2nd IVP, cystoscopy (if recurrent).

Front 674

641. UTI

Back 674

urgency, dysuria, low back pain, low fever. Diagnosed with midstream urine culture to show high nitrates and leukocytes. Treatment with TRIMETHOPRIM, SULFAMETHOXAZOLE, amoxicillin, nitrofurantoin, Levaquin. Any kid <6 year old with UTI needs VCUG (most common cause is vesicoureteral reflux and posterior urethral valves).

Front 675

642. Nephrolithiasis

Back 675

severe flank pain radiating to the groin with hematuria. Diagnosis: 1st X-ray (uric acid stones not visibile), 2nd CT scan abdomen, pelvis without contrast. Treatment: 1st Hydration with analgesia, 2nd (remember, ureter is 8mm wide, so a small stone (<5mm) will pass with supportive measures, but larger stones may completely obstruct) extracorporeal lithotripsy if upper GU tract, or ureteroscopy if lower GU tract.

Front 676

643. Anytime you suspect urethral injury (high riding prostate or blood at urethral meatus), next step is

Back 676

retrograde urethrogram (not Foley!).

Front 677

644. We give cyclosporine for graft rejection, but cyclosporine itself is nephrotoxic. How do you differentiate renal graft rejection from cyclosporine toxicity?

Back 677

Do percutaneous needle biopsy.

Also, if situation occurs, trying increasing cyclosporine: if kidney function worsens, its nephrotoxicity. If kidney function improves, its graft rejection (however try percutaneous needle biopsy first in risk of worsening kidney).

Front 678

645. Incontinence

Back 678

discussed in Gyn notes. Functional, Overflow (nerve dysfunction, DM, MS, high voiding residual volume, treatment with self-catheterization if Patient cannot empty or anticholinergics if Patient cannot store), Stress (weak pelvic floor, aggravated by coughing, sneezing, laughing, treatment with Kegel exercises, then surgical MMK procedure), Urge (detrusor hyperreflexia causing spontaneous contractions, treatment with anticholinergics).

Front 679

646. Hydronephrosis

Back 679

kidney, ureter damage from ureter obstruction (in men, think BPH) causing flank, back pain and oliguria. Diagnosed with ultrasound. Treatment with 1st Foley catheter to relieve distal obstruction, 2nd cystoscopy and ablation of stones.

Front 680

647. Pyelonephritis

Back 680

ascending infection into kidney causing fever, chills, nausea & vomiting, flank pain and anorexia. If Patient is not seriously ill, treatment with antibiotics. If Patient has severe nausea & vomiting and appears ill (dehydration, hypotension) give IV hydration and antibiotics for 2 weeks.

Front 681

648. Glomerulonephritis

Back 681

hematuria, proteinuria, HTN, edema. If acute, give bed rest, anti-HTN. Causes include HIV, HBV, poststreptococcal, SLE, Goodpasture’s, Wegener’s, RA, Polyarteritis nodosa, penicillamine, hydralazine, allopurinol and rifampin. If rapid progression give steroids, cytotoxics, plasmapheresis.

Front 682

649. Berger’s Disease

Back 682

IgA nephropathy, gross hematuria after viral URI. Diagnosed with biopsy (immune deposits of IgA in glomeruli). No Treatment. (Don’t confuse with Buerger’s disease, which is a problem of the fingers in smokers).

Front 683

650. Diabetic Nephropathy

Back 683

microvascular glomerular damage (thickened GBM) and Kimmelstiel-Wilson lesions (nodular deposits in glomeruli). Best treatment is prevention.

Front 684

651. Acute Renal Failure

Back 684

rales, JVD, hyponatremia. Causes include prerenal, renal and postrenal. See below.

Front 685

652. Prerenal Failure

Back 685

hypovolemia (dehydration) BUN, Cr >15:1, Treatment with IVF. Causes include sepsis, CHF (treatment with diuretic), Liver Failure (Hepatorenal Syndrome, which has no Treatment).

Front 686

653. Renal Failure

Back 686

most common cause is ATN (muddy-brown casts) due to: IV contrast (avoid in DM, renal disease, asthma, shellfish allergy), Rhabdo, Myoglobinuria (high CPK, treatment with IVF and diuretics), SLE, Chronic NSAID use (papillary necrosis), aminoglycosides, cyclosporine, Goodpasture’s (anti-GBM Antibody, linear on biopsy, treatment with steroids and cyclophosphamide), Wegener’s (treatment with cyclophosphamide). ATN usually resolves in 6 weeks so just try to keep them alive (dialysis) until then. 2nd most common cause is AIN (acute interstitial nephritis – look for wbc casts and eosinophilia. due to drugs (B-lactam), calcium crystals, oxalate (antifreeze), chemo treatment (uric acid), treatment with d, c stressor). 3rd most common cause is Glomerulonephritis (RBC casts, diagnosed with biopsy immediately) and 4th most common cause is vasculitis (HUS< TTP, Multiple Cholesterol Emboli Syndrome (s, p cardiac cath Patient gets blue feet, HTN and eosinophilia).

Front 687

654. Postrenal Failure

Back 687

Anuria (no urine output with >25cc residual volume). Diagnosed with renal ultrasonogram (shows hydronephrosis). Most common cause is BPH (then bilateral renal stones). Treatment with catheterization, then TURP.

Front 688

655. Minimal Change Disease

Back 688

kids, glomerulus looks normal, but may have fusion of podocytes. Diagnosed with 24hr urine protein (no need for biopsy). Treatment with steroids.

Front 689

656. Membranous Glomerulonephritis

Back 689

elderly Caucasian with amyloidosis. No need to do biopsy for diagnosis.

Front 690

657. Focal Segmental Glomerulonephritis

Back 690

history of IVDA, 50% get ESRD, diagnosed with biopsy.

Front 691

658. Membranoproliferative Glomerulonephritis

Back 691

associated with hepatitis with (give ribavirin) and endocarditis, diagnosed with biopsy.

Front 692

659. When do you choose dialysis?

Back 692

Acidosis <7.25, Uremic encephalopathy (1st give DDAVP, then dialysis), Increased K+ and creatinine, pericarditis, heart failure.

Front 693

660. Polycystic Kidney Disease

Back 693

family history, HTN, hematuria, palpable flank mass, Diagnosed with CT of abdomen (shows multiple cysts).

Front 694

661. Chronic Renal Failure

Back 694

azotemia (high BUN, Cr), metabolic acidosis, high K, hypervolemia (HTN, CHF, edema), low calcium, high phosphate. Treatment with dialysis 1st, then water-soluble vitamins (lost in dialysis), calcium, EPO and anti-HTN medications.

Front 695

662. Hyponatremia

Back 695

3 types: Hypovolemic Hyponatremia (treatment with saline), Hypervolemic Hyponatremia (Patient with cardiomyopathy and edema, treatment with correcting underlying cause), and Euvolemic Hyponatremia (Hypothyroidism (treatment with thyroxine), SIADH (high urine osmolarity, treatment with fluid restriction), Psychogenic polydipsia (low urine osmolarity, treat with fluid restriction)).

Front 696

663. Never give IV Potassium unless

Back 696

1. Potassium <2.8, 2. Patient on digoxin, 3. arrhythmia.

Front 697

664. Only 2 conditions in Anion-gap acidosis (MUDPILES) where you do NOT give bicarbonate:

Back 697

DKA and Lactic acidosis.

Front 698

665. Vomiting versus Conn’s Syndrome

Back 698

in vomiting (lose potassium and chloride, thus chloride is low) you treat with saline. In Conn’s Syndrome (lose K, not Chloride, thus Chloride is normal) treatment with Spironolactone and ACE INHIBITORS.

Front 699

666. Renal Artery Stenosis

Back 699

high rennin HTN. 1st test is captopril imaging, 2nd test is Angiogram. Treatment with angioplasty.