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684 Cards in this Set

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signs of pneumothorax
absent breath sounds
hyperresonance to percussion
decreased fremitus
transmitted voice sounds
pleural effusion signs
dullness to percussion
decreased breath sounds
decreased fremitus
decreased transmitted voice sounds
hepatic hydrothorax
transudate pleural effusion in cirrhotic patient in the right side
1st choice is salt restriction and diuretics
if refractory --> TIPS (transjugular intrahepatic portosystemic shunt)
mechanical ventilation mechanics
end inspiratory hold --> compliance/elastic pressure
end expiratory hold --> PEEP
resistive pressure --> tube resistance + ventilator resistance + airway resistance

peak airway pressure = elastic pressure + resistive pressure + PEEP
V/Q scan findings in PE
perfussion defect without ventilation defect
PCWP is indicator of what
left atrial pressure
aspirin exacerbated respiratory disease
asthma
chronic rhinosinusitis
nasal polyps
bronchospasm following aspirin
pulmonary embolism treatment
start heparin and warfarin
stop heparin in 5-6 days and continue warfarin in 6 months
new clubbing in COPD
lung cancer
hypoxemia
PaO2 < 80
normal A-a gradient
< 15 in young
< 30 in old
hypoxemia differential
increased PaCO2 + normal A-a --> hypoventilation
normal PaCO2 + normal A-a --> decreased inspired O2
normal PaCO2 + increased A-a that does not correct with O2 --> shunt
normal PaCO2 + increased A-a that corrects with O2 --> V/Q mismatch
pulmonary shunt causes
pulmonary edema
pneumonia
vascular shunt
hyperventilation causes
repiratory depression
anesthesia
V/Q mismatch causes
asthma exacerbation
pulmonary embolism
criteria for O2 in COPD
prolongs survival
PaO2 < 55
SaO2 < 88
hematocrit > 55
evidence of cor pulmonale
symptomatic relief in COPD
antimuscarinic ipatropium and short acting beta agonist
cor pulmonale
signs of right heart failure
increased JVD
hepatomegaly
ascites
lower extremity edema w/o evidence of pulmonary congestion
most common findings in PE
hypoxemia and hypercabia
non-cardiogenic Vs. cardiogenic pulmonary edema
if PCWP > 18 --> cardiogenic
if PCWP < 18 --> ARDS
non-cardiogenic pulmonary edema causes
ARDS is caused by sepsis, bleeding, pneumonia, toxicity, burns
ARDS criteria
acute respiratory distress
inciting condition
bilateral infiltrates
PCWP < 18
PAO2/FiO2 < 200
diagnosis of PE
most used is CT
gold standard is angiography
V/Q scan also used
tension pneumothorax
sudden shortness of breath
hypotension
tachycardia
contralateral tracheal deviation
ipsilateral absence of breath sounds
ipsilateral hyperresonance to percussion
complications of PEEP
tension pneumothorax
alveolar damage
hypotension
spirometry algorhythm
low FEV1/FVC --> obstructive --> bronchodilator challenge -->
if FEV1 increases --> asthma
no change in FEV1 --> COPD

high FEV1/FVC --> DLCO -->
if normal --> chest wall weakness
if decreased --> interstitial lung disease
aspiration pneumonia
systemic signs + foul-smelling sputum
due to anaerobics
treat with clindamycin (anaerobic coverage)

predisposed by -->
alcohol intoxication
dysphagia
dementia from impaired epiglottic reflex
sedation
altered consciousness
outpatient community-acquired pneumonia treatment
macrolide
if resistance add doxycycline
management of DVTs
first heparin
then warfarin till INR = 2
compression stockings

if this fails --> IVC filter
MCC of pneumonia in HIV
pneumococcus
smoker with Horner
do CXR for lung cancer
exudative Vs. transudative pleural effusion
for exudative 1 or more -->
fluid protein/serum protein > 0.5
fluid LDH/serum LDH > 0.6
fluid LDH > 2/3 upper serum limit
if adenosine deaminase --> TB

for transudative requires all criteria reversed
recurrent pneumonia at same anatomic site
obstruction until proven otherwise
think CA
do CT
indications for thoracostomy
effusion pH < 7.2
effusion glucose < 60
effusion gram stain is positive
pus in effusion
glucose levels in pleural effusion
effusion glucose levels are low in -->
RA
TB
empyema
malignancy
solitary neck mass in smoker
probable SCC metastasis from lung
cirrhotic pleural effusion
usually on right
primary pulmonary HTN
exertional dyspnea
prominent pulmonary arteries
right heart enlargement
clear auscultation
COPD exacerbation management
O2
inhaled beta agonist and ipatropium
broad spectrum antibiotics
2 weeks of steroids
CMV pneumonia
post-transplant patients with pneumonitis and colitis
bronchiectasis diagnosis
high-res CT showing cystic dilation of bronchi
Eaton-Lambert
SCC paraneoplastic syndrome due to antibodies against pre-synaptic Ca channels
proximal muscle weakness due to decreased Ach release
diagnosis with electromyography
treatment is plasmapheresis and immunosuppression
CO2 narcosis
from COPD exacerbation
confusion, somnolence, seizures, coma
avoid sedatives
inhaled O2 theraphy in COPD criteria
SaO2 < 88%
PaO2 < 55mmHg
hematocrit > 55%
nocturnal hypoxia
low-probability solitary pulmonary nodules
serial CTs every 3 months for 1 year then every 6 months for 1 year
do this also if no previous CXR found
meniere
sensation of ear fullness
vertigo
nausea
inner ear disease
initial work-up of delirium
confusional state due to organic illness often superimposed on dementia
need to do electrolytes and urinalysis first
myasthenia crisis
often due to excess anticholinesterases
intubate and stop anticholinesterases if respiratory function is compromised
functional impairment in dementia
differentiates it from normal aging
lacunar stroke pathology
microatheromas and lypohyalinosis cause obstruction of small vessels
Lewy body dementia
cognitive impairment
parkinsonism
hallucinations
Dejerine-Rousy syndrome
VPL stroke at thalamus
transient hemiparesis
athetosis
dysestesia
thalamic pain
hemihypoesthesia
brain death
absent corneal reflex
absent gag reflex
absent oculovestibular reflex
pupils fixed and dilated
must be confirmed by 2 physicians
new-onset seizures initial test
CT
craniopharyngioma
hypopituitarism, headache, bitemporal blindness, benign
diagnosis --> CT or MRI
treat --> surgery
lacunar stroke syndromes
pure motor hemiparesis -->
posterior limb of internal capsule; hemiparesis, mild dysarthria, no sensory or visual loss

pure sensory stroke -->
VPL nucleus; hemiparesthesia only

ataxic- hemiparesis -->
posterior limb of internal capsule; weakness more prominent in lower limb with ipsilateral arm and leg incoordination

dysarthria-clumsy hand -->
basis pons; hand weakness, mild motor aphasia, no sensory loss
complex partial seizure Vs. absence seizure
complex partial has post-ictal state ans usually normal EEG
absence has 3Hz spike-and-wave EEG
reversible causes of confusion
wernicke encepahlopathy --> thiamine
hypoglycemia --> dextrose
opiates --> naloxone
hypoxia --> oxygen
brain death
clinical diagnosis
cortical and brainstem function is lost
aura in seizures
indicates partial seizure with secondary generalization
neurofibromatosis
type 1 --> café-au-lait spots, Lisch iris nodules, neurofibromas
type 2 --> bilateral acoustic neuromas
Sturge-Weber
port-wine stain on V1 distribution
angiomas
seizures
contralateral hemiparesis
tuberous sclerosis
hypopigmented spots
rhabdomyoma
kidney angioleiomyoma
retardation
seizures
lumbar pain differential
metastasis --> constant, at night, subacute or chronic
lumbar strain --> acute, relieved by rest, no point tenderness
spinal stenosis --> subacute, relieved by rest
compression --> history of osteoporosis or trauma
disk herniation --> radiates to butt or leg, in a dermatone, positive leg raise
hypertensive encephalopathy
headache
nausea/vomit
visual disturbance
seizures
if in the setting of preeclampsia --> eclampsia
first step in seizure management
respiratory rescucitation and secure airway
then anticonvulsants
hypertensive intraparenchymal hemorrhage
HTN is most important risk factor

most common sites:
1) putamen
2) cerebellum
3) pons

focal neurological deficits are sudden and progress in minutes to hours (different from subarachnoid)
cerebellar hypertensive hemorrhage
2nd most common site
ataxia
vomiting
occipital headache
gaze palsy
focal weakness
coma
no hemiparesis
pontine hemorrhage
3rd most common site
deep coma
paraplegia
abrupt onset
pinpoint reactive pupils
decerebrate rigidity
no horizontal eye movements
subarachnoid hemorrhage
suddenly abrupt headache without focal deficits due to aneurysm rupture
brain solitary metastasis management
1) surgery
2) radiotherapy
if multiple --> whole brain radiation
intracraneal hypertension
headaches
nausea/vomit
blurry vision
papilledema
cranial nerve deficits
somnolence
confusion
Cushing reflex --> hypertension and bradycardia
seen in obese women and isotretinoin intoxication

do CT or MRI
lumbar spinal stenosis
MCC is degenerative disk disease
low back pain and leg pain
pain is worse with extension and relieved by lumbar flexion
neuroexam and straight leg raise is normal
diagnose with MRI
multiple system atrophy
AKA Shy-Drager
internuclear opthalmoplegia
demyelination of MLF in MS
conjugate gaze palsy
nystagmus
cerebellar signs
ataxia
broad-based gait
dysmetria
intention tremor
difficulty with rapid alternating movements
nystagmus
dystonia
sustained muscle contracture
twisting
repetitive movements
abnormal postures
due to typical antipsychotics, metoclopramide, prochlorperazine or primary
pseudotumor cerebri work-up
diagnosis of exclusion
do MRI first to exclude mass
LP for increased ICP
all else is normal
metastatic cord compression algorhythm
1) neuroexam
2) steroids
3) MRI
4) consider radiotherapy
tick paralysis
ascending paralysis
arreflexia
normal sensation
no fever

remove tick
resting Vs. essential Vs. cerebellar tremor
resting does not involve the head
cerebellar may have nystagmus and gait imbalance
essential involves the head
wernicke encephalopathy
altered mental status
gait instability
nystagmus
conjugate gaze palsy
clinical diagnosis
give thiamine
cavernous sinus thrombosis
periorbital edema with headache
exopthalmus
chemosis
papilledema
dilated tortous retinal veins
usually bilateral with involvement of CN3, 4, 6 and early visual loss
from skin, nose infections, sinusitis

do contrast CT or MRI
treat with IV antibiotics
CNS lymphoma in HIV
altered mental status
EBV DNA in CSF
ring-enhancing lesion
periventricular mass on MRI
pellagra
diarrhea
dermatitis
dementia
acute intermittent porphyria
abdominal and neurologic signs without rash
monitor respiratory function in GBS
with bedside measurement of vital capacity
carotid endarterectomy indication
obstruction > 60-70% except complete occlusion
acute back pain management
if no neurologic deficits --> early mobilization and NSAIDs
if pain persists --> MRI
conservative management for 4-6 weeks
MRI in multi-infarct dementia
multiple hyperintesities in T-2 in periventricular areas
MS treatment
acute attacks --> steroids
decrease exacerbations with B-interferon
ascites management
1) Na and H2O restriction
2) spironolactone
3) loop diuretic < 1L diuresis/day
4) frequent paracentesis 2-4L/day
HCV with normal transaminases
no treatment necessary
HCV recommendations
all shouldreceive HBV or HCV vaccines if not already immune including in pregnancy
SAAG
difference > 1.1 is transudate; else exudate
fulminant hepatitis B
acute liver failure + encephalopathy
needs transplant
post-exposure prophylaxis for HBV
to patients with unknown immunity
give HBIG + HBV vaccine
hepatic encephalopathy precipitating factors
high protein diet
alkalosis
diuretics
GI bleed
sedatives
narcotics
amoinium-containing medications
infections
portocaval shunt
PTT and PT normal values
PTT --> 25-40s
PT --> 25-40s
inherited hyperbilirubinemia
Gilbert --> mild unconjugated
Crigler-Nager 1 --> unconjugated > 20 with kernicterus, doesn't respond to phenobarbital
Crigler-Nager 2 --> unconjugated < 20, no kernicterus, responds to phenobarbital
Rotor --> mixed mild hyperbilirubinemia
Dubin-Johnson -->
HBV and HCV screening
blood transfusions before 1986 for HCV and 1992 for HBV
liver in preeclampsia
centrilobular necrosis, hematoma and thrombi
causes distention of liver capsule and RUQ pain
acute fatty liver of pregnancy
mild elevation of liver enzymes with increased PT and PTT
acute hepatic failure
hepatic adenoma
solitary mass with cells that contain lipids and glycogen
hepatomegaly
jaundice
increased AP and GGT
can progress to hepatocellular CA
treat with resection
withdraw contraceptives
focal nodular hyperplasia of liver
mass due to hyperperfusion
sinusoids and Kupfer cells
hydatid cyst of liver
echinococus
hepatomegaly
RUQ pain
nausea/vomit
calcified cysts with fluid and budding cells
causes of ductopenia
PBC
failed liver transplant
Hodgkin
graft Vs. host disease
acetaminophen toxicity pathology
centrilobular or diffuse liver necrosis
alcoholic hepatitis pathology
steatosis reverses with alcohol cessation
hepatocyte swelling and necrosis
mallory bodies and neutrophil infiltrate
hepatitis B chronic pathology
hepatocellular injury
reactive sinusoidal changes
liver function tests
PT for function
transaminases for destruction of tissue
liver metastasis
firm hepatomegaly
RUQ pain
increased liver enzymes is mild
MCC is colon CA
conjugated hyperbilirubinemia
conjugated is filtered by kidney and causes coluria
due to Rotor
cirrhosis pathology
regenerative nodules
choledocal cyst
congenital anomaly of billiary ducts
jaundice
light-colored stools
recurrent pancreatitis
do ultrasound followed by CT or MRI
HEV infection
similar to HAV
can progress to fulminant hepatitis in pregnant women
no chronic progression
non-alcoholic fatty liver
insulin resistance leads to increased fat deposition in hepatocytes by increasing lypolysis -->
pro-inflammatory cytokines -->
liver inflammation

diagnose with biopsy
chronic hepatitis C
intermittent arthrlagias with waxing and waning transaminase levels
hydatid cyst of liver
cyst with calcifications from contact with dogs due to echinococud
do not aspirate
do surgery
hepatomegaly causes
portal HTN
CHF
alcoholic liver
nonalcoholic steatohepatitis
angiofibroma
epistaxis
localized mass
bony erosion of bone
reiter
non-gonococcal urethritis
asymetric arthritis
conjunctivitis
treat with NSAIDs
osteosarcoma
periosteal elevation and sunburst appearance
psoriatic arthritis
DIP involvement
morning stiffness
defmornity and nail involvement
IBD arthritis
lower extremities and sacroiliac joints
waxes and wanes with bowel symptoms
GIT symptoms
sarcoidosis arthritis
ankles and knees with cutaneous and pulmonary manifestations
migratory thrombophlebitis
occults maliganancy can be pancreas, lung, stomach or prostate
dermatomyositis complications
internal organ malignancy
pulmonary fibrosis
hyperthyroid myopathy
proximal muscle weakness with conserved reflexes
eye muscles are affected
additional hyperthyroid signs
polymyositis
progressice proximal muscle weakness with spared muscles of face or eyelids
avascular necrosis
excessive alcohol and chronic steroids account for 90%
do MRI
disseminated gonococcus
polyarthrlagia
tenosynovitis
vesiculopustular lesions on skin
baker cyst
inflamed synovium with tender mass in popliteal fossa in RA
Charcot's joint
complication of neuropathy
deformity, degenerative joints, osteophytes and pain
myopathies
drug-induced
hypothyroid myopathy
muscular dystrophy
myositis
myasthenia
Paget disease of bone
osteoclast hyperfunction
bone pain and lesions
skeletal defomities
hearing loss
increased AP
first line in disease-modifying agents for RA
methotraxate
lupus pancytopenia cause
autoimmune
puncture osteomyelitis
pseudomonas
RA patient is at risk of
osteoporosis and osteopenia
complication of temporal arteritis
aortic aneurysm
do serial x-rays
increased AP in asymptomatic elderly
Paget disease of bone
amyloidosis Vs. sarcoidosis
amyloidosis usually has liver and kidney involvement
sarcoidosis has lung involvement and erythema nodosum
varicocele fails to empty in recumbent position
think renal cell carcinoma obstructing gonadal vein where it enters left renal vein
may also have thrombocytosis and polycythemia due to increased EPO
corrected calcium
correction is needed if there's hypoalbuminemia
corrected calcium = 0.8 (normal albumin - measured albumin) + Ca++
testicular cancer markers
seminoma --> PLAT
embryonal --> AFP
chorio --> b-hCG
abdominal bruit
renal artery stenosis has systolic/diastolic bruit
AAA has systolic bruit
hypokalemia and digoxin
increases toxicity
types of solution
crystalloid --> NaCl
colloid --> albumin
HIV glomerulonephritis
focal segmental glomerulosclerosis
nephrolithiasis recommendations
decrease intake of proteins, oxalate, Na, calcium
increase intake of water
alcoholic refractory hypokalemia
due to hypomagnasemia
most common glomerulonephritis
IgA nephropathy
radiolucent stone
uric acid
alkalinize the urine with K citrate
most effective non-drug intervention for HTN
weight loss then physical acitivty
salt restriction
moderation of alcohol
reduce progression of diabetic nephropathy
tight BP control < 130/80
urine dipstick
detect nitrites and leukocyte esterase
UTI with alkaline urine
proteus
MC complication of mumps
orchitis
treatment of hypercalcemia
saline
furosemide
acute renal transplant rejection treatment
steroids
MCCOD in dyalisis
1) cardiac (sudden death and MI)
2) infections
severe symptomatic hyponatremia
hypertonic saline
watch out for central pontine myelinolysis
painless hematuria
kidney, urether or bladder malignancy
do contrast CT or pyelogram for upper urinary tract
endoscopy for bladder and urether
hepatorenal syndrome
decreased GFR in absence of shock
proteinuria
fails to respond to saline bolus
cirrhotic patient

deadly and requires liver transplant
mixed acid-base disorders
inapropriately normal lab values
DI Vs. primary polydipsia
DI has dilute urine in prescence of increased serum osmolarity
primary polydipsia has diluted plasma and urine
IV fluid solutions use
mild hypovolemic hypernatremia --> dextrose 0.45% saline
severe hypovelemic hypernatremia --> 0.9% saline
euvolemic and hypervolemic hypernatremia --> D5W
asymptomatic hypervolemic hypernatremia --> oral free water
IV free water --> never due to osmotic RBC damage
anion gap metabolic acidosis causes
lactic acidosis
ketoacidosis
methanol/formic
ethylene/oxallic
salicylates
uremia
lupus nephritis
need to do kidney biopsy because treatment changes
microalbuminuria
measured in spot urine
calculate microalbumin/creatinine ratio
simple renal cyst
asymptomatic, benign
contrast CT to rule-out multilocular mass, irregular walls, septae (shows enhancement)
Hep B + nephrotic syndrome
membranous glomerulonephritis
secondary hyperparathyroidism from CRF
PTH is high but calcium is low
prerenal failure findings
increased creatinine + decreased urine sodium
shift potassium intracellularly
insulin + glucose
sodium bicarbonate
B2 agonists
urinalysis casts
RBCs --> GN
WBCs --> interstitial nephritis or pyelonephritis
muddy brown casts --> ATN
fatty casts --> nephrotic syndrome
broad --> chronic renal failure
acute tubular necrosis
BUN/Cr < 20:1
urine osm 300-350
urine Na > 20
fractional Na 2%
most effective lifestyle modification for HTN
alcohol cessation
also salt restriction, weight loss, exercise
mixed alkalosis and acidosis
aspirin toxicity
Witer's formula
PaCO2 = 1.5 (HCO3) + 8
acid base disturbance from vomiting
hypochloremic hypokalemic metabolic alkalosis from H and Cl loss
EPO side effects
worsening HTN
headaches
flu-like syndrome
red cell aplasia
interstitial cystitis
urgency, frequency, chronic pelvic pain in absence of other pathology
relieved by voiding
idiopathic hypercalciuria stones
treat with increased fluids
dietary sodium restriction
thiazides
cystinuria
recurrent stones since childhood
postitive family history
radiopaque stones with hexagonal crytals
urinary cyanide nitroprusside test (+)
hyposthenuria
inability to concentrate urine --> nocturia in sickle cell and trait
hypercalcemia in inmobilized patients
treat with biphosphonates whoch decreases osteoclast activation
hyperkalemia management
membrane stabilization with calcium gluconate, insulin/glucose, resins, dyalisis
renal complication of Hodgkin lymphoma
minimal change disease
benign prostatic hyperplasia initial tests
creatinine for kidney function and urinalysis to rule out infection
MCC of HTN in children
fibromuscular dysplasia
bruit at CVA and string of beads on angiography
MEN IIa
medullary thyroid CA
pheochromocytoma
parathyroid hyperplasia
due to ret protopncogene mutation
MEN IIb
medullary thyroid CA
pheochromocytoma
neuromas
marfanoid habitus
due to ret protooncogene mutation
osteomalacia
low-normal serum calcium
low phosphate
increased PTH
defective mineralization of bone
from vitamin D deficiency (IBD, ADEK malabsorption)
thyroid lymphoma
hashimoto predisposes
follicular CA Vs. follicular adenoma
need invasion of tumor capsule and blood vessels for CA
glucagonoma
hyperglycemia
necrolytic migratory erythema
diarrhea
MEN IIa screening
genetic analysis for ret protoncogene mutation
if (+) --> total thyroidectomy
hypercalcemia mechanisms in metastasis
cytokines IL-1, TNF --> metastatic solid tumor
calcitriol --> Hodgkin
PTH-like --> non metastatic solid tumors
atypical CAH
21OH deficiency with virilization in early adulthood and no salt wasting
cosyntropin stimulation test
to rule out Addison's
increase in serum cortisol above 20 1 hour after consyntropin injection rules our Addison's
somogyi effect
nocturnal hypoglycemia from NPH insulin leads to epinephrine and glucagon release with early morning hyperglycemia
vitamin D toxicity
hypercalcemia
constipation
abdominal pain
weight loss
polyuria
polydypsia
indecations for parathyroidectomy
calcium > 1 above upper limit
24h urine calcium > 400
<50 yo
bone mineral density < T-2..5
reduced renal function
hypogonadotropic hypogonadism
low FSH, LH
complications are amenorrhea, weak muscle bulk, osteoporosis, infertility
causes --> excessive exercise, anorexia, marihuana, starvation, depression, chronic illness
thyrotoxicosis with low radioactive iodine uptake
lymphocytic subacute thyroiditis
subacute granulomatous
iodine-induced thyrotoxicosis
levothyroxine overdose
struma ovarii (teratoma)
low T3 syndrome
any patient with acute severe illness
decreased peripheral conversion
sick euthyroid syndrome
metabolic syndrome
abdominal obesity
insulin resistance
hypertension
hypertriglyceridemia
decreased HDL
MEN I
pituitary
parathyroid
pancreas tumors
weight gain from OCPs?
no weight gain
congenital aromatase deficiency
no conversion of androgens to estrogen by ovaries
maternal and fetal virilization
then delayed puberty, osteoporosis, decreased estrogens, increased LH/FSH, polycystic ovaries
leydig cell tumor
high testosterone and estradiol --> low LH and FSH --> gynecomastia in males
VDRL (+) in pregnancy
treat with penicillin
if allergic --> confirm allergy with skin test then penicillin desensitization
fetal demise diagnosis
ultrasound then if no heart sounds --> real time U/S for fetal movement and heart activity
do autopsy for cause
emergency contraception
plan B levonogestrel up to 120 hours after unprotected sex
asymptomatic chlamydia infection
treat with single-dose azythromycin
nipple discharge
can be any color in galactorrhea
alarm signs are lump on breast, guaiac(+), discharge and unilateral secretions
types and causes of decelerations
early --> fetal head compression
variable --> cord compression
late --> uteroplacental insufficiency
active herpes in delivery
inmediate c-section
lactating mother contraceptive
progestin only
uterine atony
bimanual uterine massage
fluid rescucitation
oxytocin
blood transfusion if needed
Lyme in pregnant treatment
amoxicillin
breast engorgement
24-72 hours post-partum secondary to milk accumulation
breast tenderness, fullness and warmth
cool compresses, acetaminophen and NSAIDs
mastitis Vs. plugged ducts
mastitis has fever
treat mastitis with antistaph drugs
ABO antibodies Vs. Rh antibodies
ABO --> are IgM and don’t cross the placenta
Rh --> are IgG and cross the placenta
post CIN procedure
pap + colposcopy every 3 months until 3 negative consecutively
then normal pap every year
RhoGam administration
give at 28 weeks of uncomplicated pregnancy
if there's abruption then do rossette test and if positive -->
need to correct dose of RhoGam
variable decelerations
due to umbilical cord compression
administer O2 and change mother's position
if persistance --> trendelenburg +- amnioinfusion
chorioamnionitis
PROM + fever + tachycardia
also leukocytosis > 15,000
uterine tenderness
foul-smelling amniotic fluid

treat with broad spectrum antibiotics and expedite delivery
PROM and GBS status unknown
GBS prophylaxis with penicillin
Rh antibody testing
at first prenatal visit
if unsensitized or Rh status of partner unknown --> repeat testing at 24-28 weeks
endometriosis diagnosis
laparoscopy is gold standard
uterine rupture Vs. abruptio placenta
UR has intense abdominal pain
hypovolemia
palpability of fetal extremities on abdominal exam
post-partum endometritis
fever
uterine tenderness
foul-smelling lochia
in the presence of PROM
due to prolonged labor or operative labor
polymicrobial infection treat with clinda + genta
eclampsia drugs
labetalol or hydralazine for hypertension
magnesium sulfate to prevent further seizures
causes of prolonged latent phase
hypotonic contractions
uncoordinated contractions
fetopelvic disproportion
premature or excessive anesthesia
GBS screening
at 35-37 weeks
if positive or previous culture or previous GBS infection --> prophylactic penicillin at delivery
breech presentation
vertex at fundus
usually corrects by week 37
if not --> external cephalic version
contraindications --> placental abnormalities, fetopelvic disproportion, hyperextended fetal head
vaginismus
contraction of perineal muscles
psychological
dyspareunia
treat with Kegel exercises
fetal growth retardation
fundus less than dates
do ultrasound for abdominal circumference because it is affected in symetrical and asymetrical
sudden hirsutism in pregnancy
PE + sonogram --> if no ovarian mass --> abdominal CT for adrenal mass

bilateral cystic --> theca/lutein cysts
bilateral solid --> benign pregnancy luteoma
unilateral solid --> laparotomy or laparoscopic biopsy for malignancy
increased MS-AFP causes
MCC is gestational age error
also NTDs, abdominal wall defects, multiple gestation
do ultrasound +- amniocentesis
spontaneous abortion diagnosis
ultrasound
hyperemesis gravidarum
severe vomiting causes electrolyte disturbance
there is ketonuria and mild increase in amylase, lipase, transaminases and AP
sheehan
post-partum necrosis of anterior pituitary
tamoxifen
increases risk of endometrial cancer and DVT
uterine fibroids
dysmenorrhea
heavy menses
enlarged uterus
adenomyosis
symetrically enlarged tender uterus
menorrhagia
dysmenorrhea

if > 35yo --> endometrial curetage to rule out endometrial CA
cervical dysplasia algorhythm
adolescents --> repeat pap in 1 year
premenopausal --> colposcopy
postmenopausal --> HPV DNA --> colposcopy
false labor
no cervical changes
contractions are irregular and relieved by sedation
corionic vilus sampling
can be done earlier than amniocentesis at 10-12 weeks in women over 35 with abnormal ultrasound

earlier gestational age has risk of limb reduction defects
biophysical profile
BPP 8-10 --> reasurance and repeat BPP
BPP 6 --> contraction test; if non-reasuring --> delivery
BPP 4 --> lung maturation and delivery
if oligohydramnios --> consider delivery
PID management
if high fever
or failure to respond to antibiotics
or inability to take oral medications due to nausea
or risk of noncompliance -->
hospitalization and empiric cefoxitin/doxy or cefotetan/doxy
cervical insuficiency diagnosis
transvaginal sonogram for short cervix
phenytoin toxicity
horizontal nystagmus
ataxia
confusion
mucus in ovulatory phase
profuse clear and thin
stretches 6cm vertically
fern (+)
evaluate in infertility
PID screening tests to perform
HIV
syphilis
HBV
pap
HCV if IV drug use
risks and benefits of OCPs
risks -->
venous thromboembolism
CV events and stroke
hypertriglyceridemia
cholecystitis
DM
HTN

protection benefits -->
ovarian cysts and cancer
endometrial cancer
benign breast disease
dysmenorrhea
asymptomatic bacteriuria in pregnancy treatment
nitrofurnatoin
1st gen ceph
or amoxicillin for 7 days
pseudocyesis
all signs of pregnancy but no ultrasound evidence
form of conversion disorder requires psychiatric consultation
cervicitis treatment
may have gonococus and chlamydia coinfection
ceftriaxone + azithro or doxycyline
abnormal MS-AFP
do ultrasound to confirm gestational age
amniocentesis Vs. corionic vilus sampling
CVS at 10-12 weeks
while AC is 16-20 weeks
primary amenorrhea work-up
1) determine if central or peripheral with FSH levels
2) if decreased FSH --> do GnRH
3) if increased FSH --> karyotype
mallory weiss tear
tears in the mucosa of the cardias and sometimes distal esophagus from vomiting
billroth II gastrojejunostomy side effects
bacterial overgrowth leads to abdominal pain, watery diarrhea, weight loss and sucussion splash; may also have ADEK deficiency
manometry in achalasia
decreased esophageal peristalsis and poor relaxation of LES
HIV esophagitis
first fluconazole
if failure to respond --> endoscopy
toxic megacolon
mostly due to ulcerative colitis
emergency steroids, decompression and fluids
esophageal varices treatment
1) large IV lines
2) octeotride
3) endoscopic sclerotherapy if obscured field of vision but may also use band ligation
zenker diverticulum
posterior outpouching above upper esophageal sphincter due to motor dysfunction
surgical excision
causes of constipation
hyercalcemia
obstruction
anti-cholinergics
hypothyroidism
colonic angiodysplasia
intermittent occult bleeding with anemia can be missed by colonoscopy
esophageal dysmotility in scleroderma
absent peristaltic waves of lower esophagus and weak LES tone in manometry
laxative abuse factitious diarrhea
frequent watery nocturnal diarrhea
biopsy shows melanosis coli (dark diiscoloration of colon with lymph follicles)
strep bovis endocarditis
do colonoscopy due to occult colon cancer
splenectomy risk for sepsis
>30 years after
vaccinations are antipneumococcal, haemophilus, meningococcal
splenectomy mechanism for sepsis
impaired antibody-mediated opsonization in phagocytosis
B cells in spleen normally produce the antibodies
leukoplakia
localized plaque, witish with granular appearance and hard to remove
premalignant, associated with smoking
do biopsy
GERD Vs. MI
GERD has no shortness of breath nor diaphoresis
virchow's node
enlarged left supraclavicular node may be the presentation of gastric cancer
gastric cancer types
intestinal type --> intestinal metaplasia of gastric mucosal cells; due to diet with nitrites and salt low in vegetables, H. pylori and chronic gastritis
diffuse type --> poorly differentiated; unlnown origin; signet cells
krukenberg tumor
gastric adenocarcinoma metastasis to ovary
acute PUD management
rule out bleeding with serial hematocrit, rectal exam and Guaiac and NG lavage
IV hydration and medications
if perforation --> surgery
complications of PUD
hemorrhage --> posterior ulcers erode gastroduodenal artery
gastric outlet obstruction
perforation --> anterior ulcers
intractable pain
clostridium difficile diarrhea complication
toxic megacolon
entamoeba diarrhea complications
perforation if steroid use
amebic liver cyst
campylobacter treatment
erythromycin
salmonella treatment
oral quinolone or TMP-SMX
shigella complications
febrile seizures in infants
severe dehydration
chronic dirrhea with normal osmotic gap and normal stool weight
irritable bowel syndrome
factitious dirrhea
chronic dirrhea with normal osmotic gap and increased stool weight
secretory
laxative abuse
chronic dirrhea with increased osmotic gap and fecal fat
malabsoprtion syndrome
bacterial overgrowth
chronic pancreatitis
chronic diarrhea with increased osmotic gap and normal fecal fat
lactose intolerance
sorbitol
lactulose
laxative abuse
treatment of chronic diarrhea
treat underlying cause
loperamide
opiods
octeotride
cholestyramine
causes of malabsorption
pancreatic insufficiency
celiac
whipple's
tropical sprue
bile salt deficiency --> bacterial overgrowth, ileal disease
short bowel syndrome
diagnosis of lactose intolerance
increased breath hydrogen
small bowel obstruction presentation
cramping abdominal pain in intervals
vomiting
flatus in partial, obstipation in complete
high pitched bowel sounds and peristaltic rushes
if rebound and guarding --> peritonitis
leukocytosis if ischemia or necrosis
dehydrationand metabolic alkalosis from vomit
air-fluid levels in AXRif radiopaque material in cecum --> gallstone ileus
small bowel obstruction treatment
partial --> NPO, NG suction, hydration, electrolytes
complete, necrosis or >3 days --> surgery
ileus
causes --> surgery, severe illness, hypokalemia, hypothyroidism, anticholinergics, opioids
presentation --> abdominal discomfort, nasusea, absence of flatus or bowel sounds
treat --> discontinue meds, NG suction, parenteral feed
ogilvie's syndrome
large bowel pseudo-obstruction
most malignant polyp
villous sessile
HIDA scan
for acute cholecystitis if ultrasound is equivocal
dye is injected and uptaken by liver then secreted to common bile duct
nonvisualization of gallbladder is diagnostic
treatment of ascending cholangitis
ERCP for diagnosis and biliary decompression
if ERCP contraindicated --> percutaneous transhepatic drainage or open decompression
primary sclerosing cholangitis associated disease
ulcerative colitis
spontaneous bacterial peritonitis
fever
abdominal pain
altered mental status
>250 PMN or >500 WBCs
ransons criteria
on admission -->
glucose > 200
age > 55
LDH > 350
AST > 250
WBC > 16000

48 hours -->
Ca < 8
Hct decreased 10%
PaO2 < 60
BUN incresaed 5
metoclopramide side effects
it’s a dopamine antagonist and produces agitation, loose stools and extrapyramidal symptoms
criteria for metastasis surgery
1) primary tumor is controlled
2) no other sites of disease exist
3) no significant co-morbidity
4) complete resection is possible
warfarin bleed management
fresh frozen plasma
aspirin pseudo allergy
prostaglandin/leukotriene imbalance
avoid NSAIDs and leukotriene antagonists
amiodarone side effects
pulmonary fibrosis
hypothyroidism
hepatotoxicity
corneal deposits
bluish discoloration of skin
cyclosporine side effects
nephrotoxicity
HTN
neurotoxicity
hyperglycemia
gingival hypertrophy
hirustism
tacrolimus side effects
nephro and neurotoxicity
HTN
hyperglycemia
no gingival hypertrophy
no hirsutism
azathioprine side effects
diarrhea
leukopenia
mycophenolate side effects
bone marrow supression
breaking bad news
1) quiet comfortable environment
2) ask how much he knows
3) ask how much he wants to know
4) warning shot
5) break the news if he wants to
6) give prognosis
7) explain as clear as possible
heparin-induced thrombocytopenia
antibodies activate platelets with consequent removal
thrombocytopenia and thrombosis
hydroxycloroquine side effects
retinopathy or corneal damage
need eye exams every 6 months
influenza vaccine
adults 0-59 with close contact with children
claridibine
for hairy cell leukemia
SE --> tobone marrow and kidney damage
digoxin interactions and side effects
anorexia
nausea/vomit
bidirectinal ventricular tachycardia
accelerated junctional rhythms
verapamil --> decreases renal clearance
lead poisoning
basophilic stipling and microcytic hypochroanemia
warfarin interactions
decrease INR --> dark green vegetables rich in vitamin K
increase INR --> alcohol, vit E, gingko, ginseng, St. Johns
alcohol withdrawal
hypertension
tremors
tachycardia
treat with benzodiazepine chlordiazepoxide
TCA overdose management
first ABCs
then sodium bicarbonate to improve BP, shorten QRS and prevent arrhythmia
influenza vaccine in pregnancy
all women should be vaccinated
succinylcholine
life threatening hyperkalemia

not used in -->
crush injuries
demyelinating diseases (GBS)
tumor lysis syndrome

use veraconium or rocuronium
niacin side effects
flushing
pruritus
due to increased prostaglandins
treat with aspirin
vaccinations in HIV
influenza
HBV
HepA if sex with men
tetanus and diptheria boosters
diseases associated with carpal tunnel syndrome
RA
sarcoidosis
amyloidosis
diseases associated with aortic stenosis
Behecet
takayasu
temporal arteritis
ankylosing spondylitis
RA
psoriasis
reiter
decubitus ulcer pathogenesis
continuous pressure > 2 hours in individuals with decreased sensation causes ischemic necrosis
catheterism complications
blue toe syndrome is atheroembolism from aorta to toes
presents with cyanosis, pain and intact pulses
TCA intoxication
EKG + sodium bicarbonate
mycobacterium avium prophylaxis
CD4 < 50 --> azythro or clarythro
acyclovir side effect
crystalline nephropathy prevented by hydration
opioid intoxication
miosis
respiratory depression
somnolence
bradycardia
hypotension
decreased bowel sounds
pneumococcal vaccine
23 valent polysacchride
T-cell independent B-cell response
types of shock
cardiogenic
septic
hemorrhagic
neurogenic
heat
ciprofloxacin coverage
gram (-) but not anaerobes or gram (+)
ampicillin + genta coverage
gram (-) anaerobes
when does eclampsia occur
25% before labor
50% during labor
25% following delivery
lipid screening
age 35 in men w/o risk factors
if risk factors --> age 20
side effects of beta 2 agonists
tremor
hypokalemia
headache
palpitations
warfarin side effects
skin necrosis
bleeding
hematomas
retroperitoneal hematoma
vaccines in immunosupressed
pneumococcal with booster in 5 years
influenza yearly
vipoma
severe diarrhea
hypokalemia
leg cramps
decreased gastric acid

pancreatic cholera
fluphenazine side effects
hypothermia
also other antipsychotics
methanol poisoning
anion gap metabolic acidosis
optic hyperemia
vision loss
coma
methotrexate side effects
antimetabolite is dihydrofolate reductase inhibitor
causes megaloblastic anemia
give folic acid
transplant patient opportunistic prevention
TMP-SMX for PCP
ganciclovyr for CMV
influenza, pneumococcus and HBV vaccines
contraindications of triptans
hemiplegic migraine
uncontrolled HTN
CAD
prinzemetal
pregnancy
ischemic stroke
basilar migraine
antithyroid drug side effects
agranulocytosis
if fever, sore throat and WBC < 1000 --> stop drug
thrombosis of subclavian line
from parenteral nutrition in a couple of weeks
remove catheter
pica
apetite for paper, ice and clay
indicates iron deficiency
intial step in management of ARF
foley catheter
specially in post-operative obstructive ARF
glomerulopathy in HIV
focal segmental glomerulosclerosis
acute pyelonephritis routine cultures
urine and blood before antibiotics
metformin contraindications
renal failure
hepatic failure
sepsis
due to increased risk of lactic acidosis
uncomplicated acute cystitis
routine urine culture not indicated
give oral TMP-SMX
nephropathy after URI
IgA nephropathy
kidney lesion in hypertension
arteriosclerotic lesions of efferent and afferent arterioles
glomerular capillary tufts
sclerosis
intimal thickening
kidney lesion in diabetic nephropathy
increased extracellular matrix
basement membrane thickening
mesangial expansion
fibrosis
focal segmental (most characteristic) or diffuse (most common) glomerusclerosis
test of choice for hydronephrosis
do ultrasound in severe benign prostatic hyperplasia
chlamydial Vs. gonococcal urethritis
chlamydia --> mucopurulent discharge, absent bacteria
gonococcal --> purulent discharge, positive gram stain
focal segmental glomerulosclerosis associations
african americans
obesity
heroin users
HIV
contrast nephropathy prevention in renal insuficiency
non-ionic contrast agent
IV hydration
acetylcysteine
children with nephrotic syndrome and HBeAg(+)
membranous glomerulonephritis
aortic stenosis Vs. hypertrophic cardiomyopathy murmur
AS radiates to carotids and is in upper right sternal border
HC is in lower left sternal border and does not radiate to carotids and increases with maneuvers that increase preload
right ventricular MI management
fluid rescusitation and avoid nitrates
septic shock management
IV antibiotics + normal saline
pulsatile abdominal mass
AAA
heart pressures
right atrium --> 4-6
pulmonary artery --> 25/15
PCWP --> 6-12
premature ventricular beats post-MI
wide bizarre QRS
no treatment necessary unles symptomatic
pulsus paradoxus
due to increased return to right heart with dilation of intervetricular septum into left ventricle
ventricular aneurysm
persistent ST elevation and may have CHF, arrhythmias, mural thrombus and mitral regurgitation
late complication of MI
test of choice for abdominal aortic aneurysm
ultrasound has 100% sensitivity and specificity
S3
ken-tuc-KY
GERD Vs. MI
GERD has no shortness of breath nor diaphoresis
S4
stiff ventricle can be from diastolic dysfunction in MI
paroxysmal supravertricular tachycardia pathophysiology
due to re-entry into AV node
vagal maneuvers decrease conduction through AV node
vagal maneuvers
valsalva
carotid sinus masage
inversion in cold water
strongest risk factor for abdominal aortic aneurysm enlargement
smoking
erectile dysfunction from trauma
when there is pelvic fracture with urethral damage the cause is nerve damage
lidocaine in acute coronary syndrome
decreases ventricular premature beats and risks of v-fib but prognosis is unafected and there's incresed risk of aystole

not used prophylactically in MI
pulsus paradoxus
difference in blood pressure > 12 during inspiration due to tamponade, tension pneumothorax and severe asthma
target INR for DVT and a-fib
2 to 3
heat shock Vs. heat exhaustion
in heat shock the termoregulatory mechanisms fail and there's increased temperature
heart failure prognostic factor
hyponatrmemia
associated with high renin-aldosterone-vasopresin-norepinephrine
exercise stress test medications to withdraw
anti-ischemics
digoxin
beta-blockers
CCBs
ST findings in unstable angina Vs. prinzemetal
unstable angina --> ST depression
prinzemetal --> transiet ST elevation
medications in prinzemetal
use CCBs or nitro
avoid beta blockers and aspirin
electrical alternans
QRS complexes with varying amplitudes in pericardial efusion
vagal/neurocardiogenic syncope
nausea
diaphoresis
tachycardia
pallor
syncope
non-drug user infective endocarditis most common valvulopathy
mitral regurgitation is the cause
anti-arrhythmic in WPW
procainamide
constrictive pericarditis
thick pericardium due to cardiac surgery, viral pericarditis and radiation

hepatomegaly
ascites
increased JVP
premature atrial beats
normal QRS
an abnormal P wave resets the rhythm
benign and no treatment necessary
MI with cold leg
do echo to rule out mural thrombus
orthostatic hypotension in elderly
due to decreased baroreceptor sensitivity
torsades de pointes
patients with hypogonadism (alcoholics)
tricyclics
moxifloxacin
fluconazole

treatment is cessation of offending agents and magnesium sulfate
ventricular tachycardia in the hemodynamically stable
amidarone or lidocaine
electrical pulseless activity
discernible rhythm such as Afib --> CPR
not a shockable rhythm
epi, atropine, CPR
lone Afib
no risk factors and asymptomatic
anticoagulation with aspirin alone
coronary steal
during myocardial perfusion scanning in work-up of angina
dypiridamole vasodilates coronaries except diseased vessels and then blood is redistributed to healthy vessels which helps diagnosis
left ventricular function in Afib
improved by rate and rhythm control
bradyarrhythmia Vs. tachyarrhythmia
increased QRS --> bundle brach block --> bradyarrhythmia
increased QT --> torsades --> tachy --> hypomagnesemia
mitral prolapse progression
mitral regurgitation
Afib
MCC of mitral regurgitation
MV prolapse
septic shock
increased cardiac output
decreased SVR
decreased atrial pressure
decreased PCWP
normal mixed venous O2
paroxysmal nocturnal hemoglobinuria
pancytopenia + hemolytic anemia + thrombosis at unusual sites such as portal or hepatic veins
antibody in multiple myeloma
IgG causes M-spike in electrophoresis
autoinmune hemolytic anemia
associated to non-Hodgkin lymphoma
treat with steroids
schistocytes
microangiopathic hemolytic anemias (TTP, HUS, DIC) and prosthetic heart valves
decreased haptoglobin, increased LDH and bilirubin
tartrate-resistant acid-phosphatase stain (+)
hairy-cell leukemia
Hodgkin secondary malignancy
from radio and chemo up to 20 years later
febrile neutropenia treatment
monotherapy --> ceftazidine, imipenem, cefepime, meropenem
combo --> genta + antipseudomonal
hairy cell leukemia
lymphocytes with hairy-like projections and tartrate-resistant acid phosphatase stain
treat with claridibine
megaloblastic anemia increased substances
increased homocysteine
decreased methionine
increased methylmalonic acid only in B12 deficiency
acute homolytic transfusion reaction
donor RBCs destroyed by recipient antibodies due to ABO mismatch
fever
chills
flank pain
hemoglobinuria
direct Coombs (+)

complications --> DIC, ARF
treatment --> supportive
non-hemolytic transfusion reaction
fever
chills
due to cytokines
prevented by leuko-reduced products and washed RBCs
delayed hemolytic transfusion reaction
low-grade hemolysis 2-10 days after transfusion due to anamnesic antibody response to RBCs
cryoprecipitate
rich in factor VIII, fibrinogen and vonWillenbrand
vaso-oclusive crisis
stroke
priapism
intractactable pain
indication for exchange transfusion
G6PDH deficiency
hemolysis after sulfa
x-linked
G6PD levels often normal
polycythemia vera
all cell lines can be increased
gout
hypertension
splenomegaly
ulcers from histamine release
pruritus after hot bath from histamine release

treat with phlebotomy
multiple myeloma
CRAB

hypercalcemia
renal failure
anemia
bone lesions and pain
infections from decreased antibodies
increased total proteins with normal albumin
senile purpura
echymotic lesion due to perivascular tissue atrophy
no action required
inherited coagulation disorders
factor V leiden - MCC
protein C/S deficiency
antithrombin III deficiency
antiphospholipid syndrome in pregnancy
use heparin and aspirin
acute leukemias pathology
acute monocyttic --> increased blasts + alpha-napthyril
acute myeloblastic --> increased myeloblasts in M2
promyelocytic --> hypergranular promyelocyted, Auer rods
lymphoblastic --> lymphoblasts are PAS+
erythroleukemia --> erythroblasts
prevention of aplastic crisis
folic acid
waldestrom macroglobulinemia Vs. multiple myeloma
waldestrom has IgM spike
MM has IgG spike
IgM increases blood viscosity
micrcytosis and target cells
thalasemia minor
no transfusion needed
reassurance
MCC of anemia in elderly
iron-deficiency
MC due to GI bleed
do colonoscopy
epiglotitis
fever
odynophagia
sore throat
drooling
airway obstruction
MCC is haemophilus and strep pyogenes
erythema nodosum
painful subcutaneous pretibial nodules signifies more serioud disease such as sarcoidosis, TB, histoplasmosis, strep infection, IBD
do appropriate tests
shingles
rash and pain in dermatomal distribution in immunosuppressed
Lyme in pregnant treatment
amoxicillin
heterophile antibodies
may be negative early in the disease
work-up of initial HIV infection
VDRL
PPD
hepatitis A and B serology and vaccine if seronegative
antibodies for toxoplasma
routine chem and hematology
CD4 count
HIV RNA levels
cat scratch disease
bartonella
treat with azythromycin
toxoplasmosis in AIDS
empirical sulfadiazine + pyrimethanine is diagnostic and therapeutic
primary HIV infection
mononucleosis-like
fever
night sweats
lymphadenopathy
arthralgias
diarrhea
histoplasmosis
mississippi, ohio, carolinas
attacks hystiocytes and reticuloendothelial system
lymphadenopathy
hepatosplenomegaly
pancytopenia
blastomycosis
multiple lung nodules and consolidation
skin lesions
lesions of mucous membranes
osteolytic bone lesions
prostate involvement
coccidioides
southwestern deserts
pulmonary infiltrates
hilar adenopathy
maculopapular lesions
bone lesions
sporotrichosis
subcutaneous infection
papules along lymphatic tract
rubella Vs measles
measles --> koplik spots
rubella --> posterior cervical lymphadenopathy and arthralgias
legionella
typical pneumonia + GI symptoms
confusion
fever > 39
no organisms in gram stain
treat with azythro or levofloxacin
babesiosis
parasite from tick in northeastern US
invades RBCs and causes hemolysis
fever
night sweats
treat with quinine/clinda or atrovaquone/azythro
erlichiosis
fever
malaise
headache
nausea/vomit
leukopenia
thrombocytopenia
from tick
tick removal
ASAP with tweezers
enterobious infection
anal pruritus
positive scotch-tape test
treat with albendazole or mebendazole
bacillary angiomatosis
bartonella in immunosupressed
cutaneous and visceral angioma-like blood vessel growth
treat with antibiotics
mononucleosis-like
CMV
monospot (-)
atypical large vacuolated lymphocytes
no sore throat or lymphadenopathy
cryptococal meningitis treatment
ampB + flucytosine
community acquired pneumonia management
outpatient --> azythro or doxycyline
inpatient --> levofloxacin
nocardiosis
gram-positive branching rods partially acid-fast
pulmonary disease in immunosupressed
treat with TMP-SMX
staph pneumonia
complication of influenza pneumonia
pneumocystis pneumonia treatment
TMP-SMX and steroids if PaO2 < 70 or A-a > 35
mucormycosis
nasal turbinate necrosis
chemosis
proptosis
plus systemic signs

treat with surgical debridment + IV ampB
MCC of conductive hearing loss
otosclerosis
cholesteatoma
in children
new-onset hearing loss
chronic ear drainage despite antibiotics
granulation and skin debris with intact timpanic membrane
inverted nasal papyloma
tumor causes unilateral nasal obstruction +- epistaxis
acute otitis media
ear discharge
decreased hearing
ear pain
fever

otoscopy shows erythema, retraction and decreased motility of tympanic membrane
frostbite
rapid re-warming with water
no debridment
serous otitis media
middle ear effusion without signs of infection
otoscopy shows dull tympanic membrane
pneumatic otoscopy shows hypomobile tympanic membrane
temporomandibular joint dysfunction
refererd pain to ear worsened by chewing and nocturnal teeth grinding
retropharyngeal abscess
throat pain
dysphagia
xialorrhea
worst complication is acute necrotizing mediastinitis
peritonsillar abscess
complication of tonsilitis
muffled voice
uvula deviation
unilateral tender lymphadenopathy
trerat with IV antibiotics and peritonsilar needle aspiration
orbital cellulitis Vs preseptal cellulitis
preseptal is superficial and involves eyelid without proptosis or decreased visual acuity
presbycusis
sensorineural hearing loss of aging
symetrical
high-frequency sound loss
otosclerosis
chronic conductive hearing loss due to bony outgrowth of stapes
loss of low frequency sounds
denys-drash syndrome
increased risk of Wilm's tumor
male pseudohermaphrodite
renal failure
galactosemia
liver failure
renal failure
acidosis
emesis
failure to thrive
bilateral cataracts
jaundice
hypoglycemia
von-Gierke
glucose phosphatase deficiency
liver and kidney problems with severe fasting hypoglycemia
intussusception treatment
air contrast enema
nursemaid's elbow
subluxed radial head
supination with pressure over radial head and click sound restores to normal
no deformity (difference with elbow dislocation)
kawasaki
need 4 or more -->
fever > 5 days
bulbar conjunctivitis
desquamation of fingers
erythema and crusting of lips
strawberry tongue
oropharynx injection
morbilliform rash
cervical lymphadenopathy

treat with aspirin and IVIG
DTaP vaccine side effects
anaphylaxis
enecephalopathy or any CNS complication
avoid pertussis component and give DT
RSV virus and asthma
RSV infections increase risk of suffering from asthma
transient synovitis
limping and externally rotated hip with hip pain
difference with septic arthritis --> WBC > 12000, fever, ESR > 40)
do x-ray to exlcude Legg-Calve-Perthers
treat with NSAIDs
neonatal abstinence syndorme
irritability
high-pitched cry
poor sleep
tremors
seizures
sneezing
vomit
diarrhea
MCC of primary amenorrhea
Turner
aplastic sickle cell crisis
severe acute anemia without reticulocytes in peripheral blood
tricuspid atresia
early cyanosis
left axis deviation
hypoplastic right ventricle
ASD, VSD, PDA needed for survival
McCune-Albright
precocious puberty
café-au-lait spots
bone defects
endocrine disorders (hypothyroidism, hypocortisolism)
Peutz-Jeghers
polyposis and hyperpigmented spots +- precocious puberty
Sturge-Weber
retardation
seizures
port-wine stain in V1
neonatal chlamydia conjunctivitis treatment
oral erhythromycin to decrease risk of pneumonia
rubella
low fever
suboccipital and posterior auricular lymphadenopathy
rash
infectious rashes
scarlet fever --> sandpaper, erythematous
chickenpox --> vesicles and crusts by day 6
fifth disease --> slapped cheek
roseola --> maculopapular, high fever stops with rash
rubella --> low fever, maculopapular rash, posterior lymphadenopathy
rubeola --> koplik spots
Beckwith-Wiedeman
macrosomia
macroglosia
visceromegaly
omphalocele
hypoglycemia
hyperinsulinemia
microcephaly
infants of diabetic mothers problems
caudal regression
transposition of great vesels
duodenal atresia
anencephaly
NTDs
separation anxiety disorder Vs. stranger anxiety
separation --> older children
stranger --> toddlers
vaginal foreign body
if it is seen then try iriigation with warm fluid
if unsuccessful --> sedation, anesthesia and manual removal
SCID
confirmed by absent thymus
absent lymph nodes and tonsils
lymphopenia
decreased B and T cells
bacterial and viral infections
Bruton's agammaglobulinemia
x-linked
no B cells
no Igs
bacterial infections after 6 months
CGD
recurrent catalase (+) infections
normal lymphocytes
decreased NADPH oxidase
otitis media most specific sign
immobile tympanic membrane with insuflation
congenital adrenal hyperplasia
can be early or late onset
spondylolisthesis
palpable "step-off" at lumbosacral area
neurologic dysfunction
back pain
MCC of congenital hypothyroidism
thyroid dysgenesis
undetected hearing impairment
can be confused with autism
inatentivity
refusal to listen
poor eye contact
low language abilities
low social skills
acute unilateral cervical lymphadenitis
staph
subarachnoid hemorrhage in children
AVM is MCC
history of seizures and migraines
foreign body aspiration diagnosis and treatment
rigid bronchoscopy
mamary gland enlargement and vaginal discharge in newborn
physiologic
subcutaneous emphysema from cough
do chest x-ray for pneumothorax
guthre test
phenylketonuria screening
severe asthma attack unresponsive to treatment
mechanical ventilation
posterior urethral valve
MC congenital urethral obstruction
distended palpable bladder + oliguria
meduloblastoma
trunk dystaxia + increased ICP signs
tumor arises from cerebellar vermis 90%
ineffective potty training
stop for a few months then re-start
acute sinusitis
clinical diagnosis
treat with amoxicillin
posturing of sandifier syndrome
GERD in toddler makes him arch back to left
diagnose with 24 hour pH monitoring
metatarsus adductus
physiologic
septic arthritis in child
surgical emergency requires inmediate drainage
supracondylar fracture
can damage brachial artery
check radial pulse
pompe disease
acid maltase deficiency
floppy baby
macroglosia
heart failure
Osgood-Schlatter
traction apophysitis of tibial tubercle
diaphragmatic hernia first step
orogastric tube
night terrors
during non-REM sleep
fear
crying
screaming
amnesia of the event
epinephrine use in respiratory distress
used in croup before intubation
in asthma intubation is done first
cyanosis in heart disease
transposition in 1st 24 hours
TOF in first couple of years
pertussis treatment
macrolide
vitamin A in measles
reduces morbidity and mortality
leukocyte adhesion deficiency
delayed umbilical cord separation and recurrent bacterial infections
nocturnal enuresis treatment
desmopresin or imipramine
club foot
do stretching, manipulation and serial casts first
if not --> surgery by 3 months
rotavirus vaccine
between 2 and 8 months
do not give later
eye exam in children
screening recommended before 5 years of age
osteogenesis imperfecta
blue sclera
hearing loss
joint hypermobility
dentinogenesis imperfecta
lyme disease treatment
if > 9 years --> doxycycline
if < 9 years --> amoxi
hemophilic arthropathy
recurrent hemarthrosis leads to hemosiderin deposition, fibrosis, arthritis
MC risk for acute sinusitis
viral URI
pertussis prevention
erythromycin for 2 weeks to all close contacts regardless of age
breastfeeding jaundice
exageration of physiologic in babies without enough breastfeeding
unconjugated
child with meningitis + increased ICP
first empiric ceph then CT then LP
intraventricular hemorrhage in neonate
due to prematurity
infantile colic
inconsolable crying > 3h per day
resolves by 4 months
infantile Vs. adult botulism
infantile --> C botulinum in intestine
adult --> toxin ingestion
cannot establish peripheral IV line in child
get intraosseous access
vesiculouretheral reflux
recurrent pyelonephritis
do voiding cystourethrogram
complication is renal scarring
impetigo treatment
topical mupirocin
Todd's palsy
postictal hemiparesis improves after 24 hours
lead screening
first fingerstick lead levels
if positive --> serum lead levels to confirm
acquired torticolis
obtain cervical x-ray to rule out fracture or dislocation
PT Vs. PTT
PT --> warfarin, vitamin K, indirect, 2, 7, 9, 10
PTT --> heparin direct, 8
infantile spasms treatment
ACTH
myotonic muscular dystrophy
autosomal dominant
delayed relaxation of muscles with sustained hand-shake
hydroxyurea
increases HbF
nocturnal enuresis work-up
urinalysis
behavioral modification
desmopressin or imipramine
chest x-ray in infant
large thymic shadow with sail sign
homocystinuria
Marfan features
mental retardation
thromboembolic events
dislocation of lens
cysththione synthase deficiency
treat with B6 and low methionine diet
Henoch-Schonlein purpura
palpable purpura
scrotal swelling
hematuria
abdominal pain
possible intuscuception
late-onset GBS neonatal sepsis
often meningitis
Blackfan-Diamond
congenital hypoplastic anemia
pure red cell macrocytic aplasia
congenital anomalies
chronic pyelonephritis
focal parenchymal scarring and blunting of calices on intravenous pyelography
complication of vesicoureteral reflux
rickets
cranitabes (pin pong ball on occiput)
rachitic rosary (costochondral junction enlargement)
thickened bones
defective mineralization of osteoid
sickle cell trait
HbS 35-40%
painless gross hematuria is MC presentation
breath-holding spells
episodes of apnea from crying with LOC
normal
reasurance
trachoma
due to chlamydia
follicular conjunctivitis and neovascularization pannus in cornea
Dx --> giemsa stain
Tx --> topical tetracycline or oral azythro
postop endopthalmitis
within 6 weeks of eye surgery
decreased visual acuity
swollen eyelids and conjunctiva
hypopion
corneal edema

do gram stain and culture of vitreous
give intravitreal antibiotic injection
uveitis
pain
conjunctival injection
miosis
hypopion
keratic precipitates
associated with HLA-B27
cavernous sinus thrombosis
proptosis
opthalmoplegia
chemosis
visual loss
dacryocistitis
infection of lacrimal sac with pain and redness of medial canthal region
use systemic antistaph drugs
chalazion
chronic granulomatous inflamation of meibomian gland
hard painless lid nodule
episcleritis
infection between conjunctiva and sclera with photophobia and watery discharge
optic neuritis
acute decreased acuity
color perception deficitis
afferent pupillary defect
central scotoma
presbyopia
age-related decrease in lens elastivity
macular degeneration
distortion of straight lines
drunsen in the macula
neurofibromatosis eye lesion
optic glioma
tuberous sclerosis eye lesion
retinal hamartoma
multiple sclerosis eye lesion
optic neuritis
herpes retinitis
in HIV
keratitis
eye pain
visual loss
peripheral retinal lesions
central necrosis of retina
CMV retinitis
MC complication in HIV eye
painless fluffy granular retinal lesions
no keratitis or conjunctivitis
measles supplement
vitamin A
xanthelasma
soft yellow plaques on medial aspect of eyelids
lipid filled macrophages
seen in OBC but also idiopathic
recurrent chalazion
do histopathology for mebomian cancer or basal cell carcinoma
preseptal Vs. orbital cellulitis
eyelid discoloration --> preseptal
orbital has systemic signs, proptosis, decreased eye movements and decreased acuity
types of hypersensitivity reactions
type I --> IgE mediated, atopy, urticaria, anaphylaxis
type II --> antibody mediated, inmune hemolytic anemia
type III --> inmune complex mediated, serum sickness, arthus reaction
type IV --> cell-mediated, contact dermatitis, nickel jewerly
herpetic whitlow
viral infection of hand by type 1 or 2 HSV
dentists and sex workers at risk
strawberry Vs cherry hemangioma
strawberry --> children
berry --> adults
tinea corporis lesion
pruritic
erythematous
scaly
red ring with central necrosis
photo-protection
avoidance of sun between 10am and 4pm is best
sunscreen should be applied 15-60 minutes before sun exposure
dermatitis herpetiformis treatment
dapsone
tinea versicolor
pale velvety pink or whitish hypopigmented macules that do not tan and don’t appear scaly but scale on scrapping

treat with selenium sulfide
pitiriasis rosea
oral fawn-colored plaques in a christmas tree pattern
eczema herpeticum
HSV infection associated with atopic dermatitis
umbilicated vesicles
treat with acyclovir
ichthyosis
dry, rough skin with horny plates over extensor surfaces of limbs
rosacea
telangiectasias over cheeks, nose, chin and flushing
treat with metronidazole
perforated appendix management
if well loculated abscess and patient not septic --> percutaneous drainage
murphy's sign
halt of inspiration upon deep palpation of RUQ
intestinal adhesions diagnosis
more than 6 air-fluid levels on x-ray in patient with signs of bowel obstruction
abnormal location appendicitis
in elderly and pregnant and in those with retrocecal or pelvic appendix
carotid endarterectomy
symptomatic patients with >50% stenosis or assymptomatic in >60% do it within 2 weeks of TIA
posterior urethral injury sign
blood in meatus
high-riding prostate
lack of palpable prostate
pelvic gracture with hemodynamic instability
never explore due to pelvic or retroperitoneal hematoma
do serial hematocrits and fluid rescusitation + external fixation
mesenteric ischemia management
IV fluids
heparin
antibiotics
emergency laparotomy for nonviable bowel resection
HIDA scan
test to use in cholecystitis if U/S equivocal
imidoacetic acid is secreted to bile ducts and gallbladder won't be visualized
tracheobronchial rupture
blunt trauma
can have subcutaneous emphysema or pneumothorax
diagnose with bronchoscopy
uncomplicated diverticulitis treatment
outpatient clear liquid diet and morxifloxacin or amoxi/clavulanic
partial small bowel obstruction management
in-hospital nasogastric suction to decompress proximal bowel
NPO
fluid correction
sliding hiatal hernia
heartburn worst on recumbency
wheezing
dysphagia
diagnose with barium swallow
osteomyelitis in trauma patient
due to staph
coliform bacili and pseudomonas
treat with nafcillin and gentamycin
extraperitoneal bladder rupture
contrast extravasation confined to perivesical space, thighs, penis, perineum
if more severe into abdominal wall
no reabsorption of urine into blood
intraperitoneal bladder rupture
direct blow to distended bladder causes increase in intravesical pressure with horizontal tear at peritoneal portion of bladder
there's reabsorption of leaked urine from peritoneum into blood with hyperkalemia, uremia, acidosis
there's contrast extravasation into peritoneal cavity
MC complication of sigmoid diverticulitis
abscess
zone II penetrating injury
exploration if platysma is penetrated, if there's subcutaneous air or expanding hematoma
small bowel obstruction in kids
due to encarcerated hernia (MC inguinal)
chandelier sign
pain with cervical motion in PID
lead pipe appearance x-ray
ulcerative colitits
step ladder appearance x-ray
small bowel obstruction
air-fluid levels on x-ray
small bowel obstruction
pneumobilia
air in biliary tree in gallstone ileus
MCC of lower GI bleed
1) diverticulosis
2) cancer/polyps
3) angiodysplasia
peritoneal signs in small bowel obstruction
laparotomy
ogilvie's syndrome
colonic pseudo-obstruction
no evidence of obstruction but colon is dilated and can perforate
seen in elderly and trauma patients
hip dislocation complications
posterior --> avascular necrosis
anterior --> femoral artery, nerve and vein damage
indications of AAA repair
1) symptomatic
2) >5.5cm
3) increase in size >0.5cm in 6 months
if 4-5.4cm --> U/S or CT every 6-12 months
melanoma adjuvant treatment
(+) nodes without evidence of mets
give interferon alfa after surgery
complication of ERCP
acute pancreatitis
hot thyroid nodule
almost never cancerous and should not be biopsied but followed clinically
MOHS surgery
microsurgery is best choice for SCC at high risk of recurrence
ranson criteria on admission
glucose >200
age > 55
LDH > 350
AST > 250
WBC > 16,000
bloody diarrhea w/fever
e. coli
types of melanoma
acral lentiginous --> on palms, soles, nailbeds or mucous membranes
superficial spreading --> most comon on sun-exposed areas
lentigo maligna --> rarest, in sun-exposed area from premalignant lession
informed consent components
BRAIN
Benefits
Risks
Alternatives
Indications
Nature
parietal cell highly selective vagotomy
for refractory ulcers
trendelenburg sign
drooping of contralateral hemipelvis below horizontal line in nonpedal stance
due to paralysis of gluteal muscles innervated by superior gluteal nerve
complications of central line placement
arterial puncture
pneumothorax
hemothorax
thrombosis
air embolism
myocardial perforation
central line catheter placement
proximal to cardiac silhouette or proximal to angle of trachea and right stem bronchus
in the superior vena cava
do chest x-ray to confirm
drop arm sign
arm is abducted to >90 degrees and patient is asked to lower it slowly --> the arm drops when it reaches 90 degrees
means complete rotator cuff tear
rotator cuff
from tendons of
supraspinatous
infraspinatous
teres minor
subscapularis
klumpke palsy
damages lower trunks C8-T1 from sudden upward pull of arm
damages ulnar nerve with weakness and atrophy of hypothenar and interosseous and claw hand
varicocele
dilation of pampiniform plexus of veins surrounding spermatic cord and testis
often in left side
feels like bag of worms and is worsened with valsalva
hydrocele
fluid in tunica vaginalis transilluminates
observation in newborns for 12 months, else surgery
spermatocele
cystic dilation of efferent ductules above testis and transilluminates
urethral injuries
anterior --> from urethral intrumentation or blunt perineum trauma; prostate is normal; blood at meatus; perineal tenderness/hematoma; no problem urinating

posterior --> from pelvic fracture; pain, inability to void, blood at meatus, high-riding prostate; scrotal hematoma
necrotizing wound infection
laparotomy
best test for abdominal abscess
CT
intraductal papilloma
intermittent bloody nipple discharge; benign
best way to establish airway in apneic
orotracheal intubation or surgical cricothyroidectomy
blunt splenic rupture management
IV fluids
if it responds --> CT then laparotomy
if unresponsive --> laparotomy
Ludwig angina
submaxillary and sublingual glands
infection from teeth microbes
MCC of death is asphyxia
osteosarcoma Vs. Ewing
osteosarcoma --> normal ESR; increased AP; lytic lesion with periosteal elevation
Ewing --> systemic signs fever, malaise, wight loss; lytic lesion with onion skin appearance
best study for blunt trauma in stable patients
CT with contrast to evaluate solid organ damage
goal of rib fracture management
control pain to avoid hypoventilation --> atelectasis --> pneumonia
use opiods, NSAIDS or nerve block
Legg-Calve-Pethers Vs. SCFE
LCP --> kids < 10; femoral head out of acetabulum
SCFE --> overweight teenagers; femoral head in acetabulum
medial meniscus tear
palpable or audible snap while extending the leg and applying tibial torsion
there's tenderness and locking
ligament Vs. meniscal tear
ligament tear --> swollen inmediately
meniscal tear --> popping sound; swollen 12-24 hours after
diaphragn rupture
in blunt or penetrating trauma
elevated left hemidiaphragm
respiratory distress
deviated mediastinum +- atelectasis

do CXR
worst complication is herniation of bowels and strangulation
post-op atelectasis pathogenesis
1) shallow rapid breathing
2) narcotics decrease respiration
3) decreased mucocilliary clearing
4) more common in obese
5) supine position

all factors contribute to decreased vital capacity and decreased functional respiratory capacity
first-line prevention is moving from supine to sitting which decreases pressure on diaphragms
pilonidal cyst
acute pain and swelling of midline sacrococcygeal skin
due to infection of hair follicles --> abscess --> rupture --> pilonidal sinus tract --> recurrent infections
spetic arthritis management
antibiotics + surgical wash out of joint
humeral shaft fracture management
attempt to realign humerus
if unsuccessful --> surgery
first step in diagnosis of peropheral artery disease
ankle-brachial pressure index --> systolic pressure of posterior tibial and dorsalis pedis by Doppler divided by systolic pressure in brachial artery

1-1.3 --> normal
< 0.9 --> occlusion of major vessel

follow with images
Leriche syndrome
occlusion of aorta at bifurcation of illiacs (aortoiliac)

1) bilateral hip, buttock and leg claudication
2) impotence
3) symmetric atrophy of lower limbs

most commonly due to atherosclerosis
ileus Vs. small bowel obstruction
ileus --> decreased bowel sounds
small bowel obstruction --> hyperactive high pitched bowel sounds
tetanus prophylaxis in trauma
< 3 doses of TT + clean wound --> TT
< 3 doses of TT + dirty wound --> TT + TIG
>=3 doses of TT + clean wound --> TT if last dose >10y
>=3 doses of TT + dirty wound --> TT if last dose >5y
tibial nerve
motor supply to posterior thigh, posterior leg, plantar muscles
flexes knee, plantar foot and toes
sensation to leg except medial side, and plantar foot
obturator nerve
motor supply to medial thigh and controls adduction
sensation over medial thigh
common peroneal nerve
deep and superficial branches give motor and sensory supply to anterolateral leg and dorsom of foot
femoral nerve
motor supply to anterior thigh
knee extension and hip flexion
sensation to anterior thigh and medial leg via saphenous branch
massive atraumatic hemoptysis management
bronchoscopy
acalculous cholecystitis
seen in ICU patients with multiorgan failure, severe trauma, surgery, burns
presents with vague RUQ signs and gallbladder distention
thickening of gallbladder and pericholecystic fluid
torus palatinus
bony mass in hard palate
no treatment required unless symptomatic
developmental dysplasia diagnosis
<4 months --> U/S
> 4 months --> x-ray
fat necrosis of breast
similar to breast cancer with mass, nipple retraction and calcifications
biopsy shows fat globules and foamy macrophages
self-limited, no treatment necessary
esophageal perforation diagnosis
gastrofin contrast esophagram
pancreatic blunt trauma
may be missed by CT in first 6 hours following trauma
if untreated --> retroperitoneal abscess or pseudocyst
intra and retroperitoneal bleed diagnosis
intra --> FAST or peritoneal lavage
retro --> angiogram
need to rule out both
acute blood loss
first 2L of crystalloids
if doesn't respond --> blood transfusion
usually need transfusion if loss >1500ml
mid femur shaft fracture treatment
closed intramedullary fixation
closed reduction and nailing to skin
tibial stress fracture diagnosis
x-ray normal
do contrast CT
volkman ischemic contracture
final sequel of compartment syndrome with fibrous replacement of dead muscle
referred pain to shoulder
from irritation of diaphragm by bile, pancreatic secretions, blood or urine that spills into peritoneum (bladder dome is intraperitoneal)
post op fever after transfusion
from preformed antibodies
transtentorial uncal herniation
compression of cerebral peduncle can be contralateral --> ipsilateral hemiparesis
compression of ipsilateral CNIII --> ipsilateral mydriasis, ptosis, down and out gaze
compression of ipsilateral PCA --> contralateral homonymous hemianopsia
compression of reticular formation --> coma
rupture of duodenum
retroperitoneal air is seen on x-ray
do abdominal CT with oral contrast
has subtle epigastric signs