| * My_CK_notes
** Depressed CO + elevated PCWP+elevated SVR=> left ventricular failure. Cardio shock
Hypovolemia shock=> decreased PCWP + decreased CO
Pulmon shock => normal or lower PCWP,
** ST elevation in II, III, and aVF =>acute inferior wall myocardial infarction. occlusion of either the right coronary artery or the left circumflex artery. Left anterior descending artery occlusion causes anterior wall myocardial infarction.
# Pericarditis will have diffuse ST elevation in all leads
# Atrial fibrillation is a common complication of hyperthyroidism. Tx: beta-blocker like propranolol.
# early complications of an acute anterior wall Ml: Papillary muscle dysfunction=> Sudden onset of shortness of breath (SOB), bibasilar rales, an apical pansystolic murmur (PSM) radiating to the axilla(mitral regurgitation ). Ventricular septal rupture has similar features but the murmur is heard at the left sternal border and would not radiate to the axilla.
Pericardial tamponade-- not have any murmurs
# late complication of an acute anterior wall MI: Left ventricular aneurysm=>Precordia double apical beat, additional S3 or S4 and sometimes a murmur of mitral regurgitation is present due to papillary muscle dysfunction. Chest x-ray usually shows a characteristic prominence of the left border of the heart. The EKG shows persistent ST elevation.
# Free-wall rupture is an early mechanical complication of Ml. It does not produce a murmur and it presents with cardiogenic shock.
# Rupture of chordae tendinae is not a complication of Ml and it usually occurs secondary to trauma or infective endocarditis
# sick sinus node syndrome -- the best treatment is placement of a permanent pacemaker.
sick sinus syndrome refers to a clinical syndrome in which sinus node dysfunction produces symptomatic bradyarrhythmias, including sinus bradycardia, sinoatrial block and sinus arrest either singly or in combination. Symptoms may range from syncope, dizziness, confusion, and congestive heart failure.
# malignant hypertension-- high blood pressure (>/= 200/140 mmHg) + papilledema.
The pathologic change responsible for end-organ damage in malignant hypertension is fibrinoid necrosis of small arterioles.
# Amiodarone is a class 3 anti-arrhythmic agent, which has now been shown to be very effective in terminating both atrial and ventricular arrhythmias. However, administration of this drug has been known to cause lipoid accumulation in lung parenchyma lead to fibrosis. In a patient with compromised lung function, use of amiodarone can potentiate the lung injury and its use should be with held.
# Atrial fibrillation due to macro re entry circuits-- characterized by irregular undulation base line, No discrete P wave and QRS irregularly spaced.
Tx: hemodynamically unstabl-- electrical cardioversion
Stable w acute process -- either cardioversion or rate control
Stable w chronic process -- rate control along with anticoagulation
Electrical cardioversion should not be performed without 3-4 weeks of anticoagulation in chronic atrial fibrillation (>48hours), as the risk of embolization is high. Cardioversion can be either electrical or chemical. chemical cardioversion the best drugs would be class III agents (amiodarone, sotalol, ibutilide etc.)
For rate control -- either IV diltiazem or beta-blockers (IV metoprolol). Digoxin is a good agent for patients with heart failure (systolic dysfunction)
# recurrent VT, first thing to do after stabilizing the patient is to search for underlying cause, eg: Measure serum electrolytes if pt use digoxin, furosemide decreased K
# third degree AV block-- atria and ventricles beat independently. Tx: permanent pacemaker
# Electromechanical dissociation is typical for pulmonary thromboembolism and pericardial tamponade.
# Increased automaticity is a frequent cause of arrhythmia in patients with glycoside intoxication.
# Reentrant ventricular arrhythmia (ventricular fibrillation) is the most common cause of
death in acute myocardial infarction.
# exertional angina + hypertension -- ST depression. best initial treatment-- beta-block, Calcium antagonists if beta-blockers are contraindicated or poorly tolerated.
# vasovagal syncope= neurocardiogenic syncope=> prodrome (lightheadedness, weakness, and blurred vision), provocation by an emotional situation, and rapid recovery of consciousness. frequently recurrent. Diag: upright tilt table testing
# The most common cause of aortic dissection is systemic HTN. – sudden excruciating chest pain radiates to back. an early diastolic decrescendo murmur at the right or left sternal border. Chest x-ray -- a widened superior mediastinum. normal EKG. Diag: Transesophageal echocardiography
# Renal artery stenosis is a common cause of resistant hypertension in a patient with advanced atherosclerosis.
# diagnosis and follow-up of abdominal aortic aneurysms is an abdominal ultrasound
# The primary mechanism responsible for the effect of nitroglycerin in patients with anginal pain is dilation of veins (capacitance vessels). Increased venous capacitance and venous pooling of the blood lead to significant decrease in ventricular preload and decrease in heart size. As the result of these changes, oxygen requirement of the heart greatly reduces.
# aortic stenosis and hypertrophic cardiomyopathy produce a midsystolic (ejection systolic murmurs) murmur;
For aortic stenosis -- murmur at right second intercostal space, radiates to the carotids, Valsalva maneuver attenuates murmur
For HCM-- murmur at the lower left sternal border and it does not radiate to carotids, Valsalva maneuver accentuates murmur
# Myxomatous valvular degeneration is the most frequent cause of mitral valve prolapse
# Elderly patients are particularly sensitive to fluid loss, and even mild hypovolemia may predispose them to orthostatic syncope, especially upon getting up in the morning. BUN/creatinine ratio is a useful indicator of dehydration.
# Aortic regurgitation-- high-pitched, blowing, early diastolic decrescendo murmur heard best in the left third intercostal space. collapsing (water-hammer) pulse
Pulmonary regurgitation-- early diastolic, decrescendo, high-pitched, blowing, best heard along the left sternal border
The murmur of mitral stenosis is a mid-diastolic rumble and it is best heard at the apex.
The murmur of tricuspid stenosis is a mid-diastolic rumble and is best heard along the left lower sternal border.
The murmur of the aortic stenosis is ejection systolic and best heard at right 2nd intercostal space.
The murmur of tricuspid regurgiation is pansystolic
#Elevated liver enzymes and myopathy are well-known side effects of statins, the popular lipid-lowering drugs. They inhibit HMG-CoA reductase, a rate-limiting enzyme in the synthesis of cholesterol that converts HMG-CoA to mevalonate. It is important to know that mevalonate is used not only for the synthesis of cholesterol, but also for the production of several other products including dolichol and CoQ10. Reduced CoQ10 production has been implicated in the pathogenesis of statin-induced myopathy
# right ventricular infarction Decreased compliance of right ventricle right ventricle dilated tricuspid regurgitation(pansystolic murmur at the left lower sternal border) , Diastolic dysfunction of R ventricle R heart failure(jugular venous distension, KussmaulDs sign, hepatomegaly, and hypotension in the presence of clear lung fields)
# The hallmark finding mitral stenosis is elevated left atrioventricular pressure gradient that ultimately leads to left atrial enlargement.
# evaluate aortic stenosis – Echocardiography
# Aspirin, beta-blockers, ACE inhibitors and spiranolactone improve survival in patients with heart failure, while digoxin and loop diuretics does not provide any survival benefit.
# It is better to keep Bp < 130/80 mmHg to slow end-organ damage in patients with diabetes and chronic renal failure.
# Amiodarone is an excellent drug for stable ventricular tachycardia and maintaining normal sinus rhythm following a ventricular arrhythmia
# Torsades de pointes—caused by 1st – Quinidine, then procainamide, tricyclics and disopyramide. EKG -- varying QRS morphology with prolonged QT
Torsades can caused by hypokalemia, hypomagnesemia and hypocalcemia, acute ischemia and bradycardia. mitral valve prolapse, amyloidosis and acute myocarditis.
# Jervell-Lange-Nielson syndrome=> congenital QT prolongation syndromes + congenital deafness. autosomal recessive. Cause torsades de pointes syncopal episodes and sudden death. Tx: beta-blocker like propranolol.
# Restrictive cardiomyopathy is characterized by severe diastolic dysfunction due to a stiff ventricular wall. Chest x-ray shows only mild enlargement of the cardiac silhouette. Echocardiography usually shows a symmetrically thickened ventricle wall, normal or slightly reduced left ventricle size and normal or near normal systolic function.
# Dilated cardiomyopathy is characterized by impaired systolic function of left and right ventricle leading to progressive cardiac enlargement. Chest x-ray shows marked or moderate enlargement of cardiac silhouette. Echocardiography shows systolic dysfunction and left ventricular dilatation with normal thickness of the ventricular wall.
# Hypertrophic cardiomyopathy is characterized by asymmetric left ventricular hypertrophy. In HCM, a harsh systolic murmur best heard at the left sternal border is also present. Chest x-ray shows mild enlargement of cardiac silhouette. Echocardiography shows vigorous systolic function, asymmetric septal hypertrophy and in some cases systolic anterior motion of the mitral valve. Due to the hypertrophy of the left ventricular wall, there is diastolic dysfunction.
# Dipyridamole and adenosine are coronary vasodilators. Infusion of these substances in patients without coronary artery disease, increases coronary blood flow three to five times above the baseline levels. However, in patients with coronary artery disease, the diseased vessels distal to the obstruction are already maximally dilated, and their ability to increase myocardial perfusion is limited; therefore, redistribution of coronary blood flow to non-diseased areas occurs, and the perfusion of diseased segments diminishes. This phenomenon demonstrated by dipyridamole is called coronary steal and is used to diagnose ischemic heart disease. Dipyridamole can be used during myocardial perfusion scanning to reveal the areas of restricted myocardial perfusion.
# prevention of recurrent attacks of rheumatic fever with antibiotic prophylaxis may slow down the progression of mitral stenosis in adolescents.
# The drugs that slow the AV conduction (digoxin and verapamil) are contraindicated in patients with atrial fibrillation and Wolff-Parkinson-White syndrome because they can increase the conduction of impulses through the accessory pathway, thus leading to malignant arrhythmias and hypotension.
# Procainamide or disopyramide are for Atrial fibrillation in the context of WPW syndrome.
# chemical cardioversion for atrial flutter is ibutilide
Either calcium channel blockers (verapamil or diltiazem) or beta-blockers can be used for rate control in acute/chronic atrial flutter
Atrial flutter with unstable hemodynamics is best treated with cardioversion
# ST segment depression, T wave inversion and first degree AV block can occur at therapeutic levels of digoxin. Atrial tachycardia along with variable degree of AV block is the most important EKG finding of digitalis toxicity
# In a post-MI hypertensive patient, beta-blockers and ACE inhibitors are preferred over diuretics and calcium channel blockers. Beta blockers decrease myocardial oxygen demand by reducing heart rate and contractility. ACE inhibitors improve prognosis in post-MI patients with subnormal EF by decreasing ventricular remodeling,
# Any patient who presents with sudden onset of chest pain, SOB, and has evidence of hypoxia and the new onset right bundle branch block should be considered as having a pulmonary embolism
# Marfan’s syndrome-- aneurysms of the ascending aorta
In aldut, Atherosclerosis-- aneurysm of the descending aorta
In yang, of blunt injuries to the chest-- aneurysm of the descending aorta
CT scans or angiograms are diagnostic
# high risk to develop infective endocarditis include: 1. All prosthetic heart valves. 2. Any history of previous bacterial endocarditis. 3. Complex cyanotic congenital heart disease and surgically- constructed systemic pulmonary shunts.
Patients with artificial pacemakers and defibrillators do not require prophylaxis for infective endocarditis.
# Absolute indications for dialysis
1. Fluid overload not responsive to medical treatment.
2. Hyperkalemia not responsive to medical management.
3. Uremic pericarditis.
4. Refractory metabolic acidosis.
1. Debilitating chronic disease.
2. Severe irreversible dementia.
# isolated systolic hypertension—1st low-dose thiazide diuretic
# Antihypertensive management should be the first step in patients with aortic dissection with hypertension, then Transesophageal echocardiogram
# a difference of more than 30 mmHg in the blood pressure readings between two arms-- aortic dissection
# Cutaneous flushing and intensive generalized pruritis are well-known side effects of high-dose niacin therapy caused by drug-induced release of histamine and prostaglandins=> peripheral vasodilatation. can be reduced by low-dose aspirin
# Age-dependant idiopathic sclerocalcific changes are the most frequent cause of isolated aortic stenosis in elderly patients. Cause Exertional syncope.
# In a patient with an Ml who develops a cold leg, one has to get an ECHO to rule out a
thrombus in the left ventricle.
# A detailed medical history and physical examination is the most effective way to screen a low risk population for the presence of underlying cardiac disease.
# alcoholism-- thrombocytopenia, macrocytosis, and elevated transaminases, dilated cardiomyopathy—heart failure.
# Mobitztype 2 block is characterized by a fixed PR interval with an occasional dropped beat in a 2:1,3:1,4:1 pattern. The QRS is usually wide. Tx: permanent pacemaker
# Type I Mobitz or Wenckebach AV block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped
# Stress testing with imaging is indicated when the patient has complete left bundle branch block, an idioventricular rhythm, Wolff-Parkinson-White syndrome, and ST depression of greater than 1 mm at rest.
Dobutamine stress echo is indicated in patients who can’t do sufficient exercise,
Coronary angiogram is indicated in patients who have abnormal stress testing
exercise EKG testing should be the initial test of choice for stable angina when there is an intermediate pretest probability of coronary heart disease that is based on patient’s age, sex and symptoms.
# Sepsis is the most common cause adult ARDS
# hypertrophic obstructive cardiomyopathy -- systolic anterior motion of mitral valve leaflet that causes mitral regurgitation.
# Mitral annulus calcification due to aging occurs in elderly, is a degenerative process and it may lead to severe mitral regurgitation.
# Mitral valve prolapse is the most common cause for isolated mitral regurgitation in North America.
# An atrial premature beat results from the premature activation of the atria that originates from a site other than the SA node. EKG shows an early P wave. Tobacco and alcohol are reversible risk factors for the development of atrial premature beats.
# Think of cocaine intoxication in a young patient presenting with chest pain/myocardial infarction or stroke. Features of cocaine intoxication are cocaine bugs, agitation, decreased appetite, dilated pupils, elevated or decreased blood pressure, tachycardia or bradycardia, and sweating.
# The earliest EKG finding in acute Ml is peaked (hyperacute) T waves, followed by ST elevation, followed by the inversion of T waves, followed by the appearance of Q waves.
Peaked T ST elevation inversion T Q waves
# Nitrates are contraindicated when a patient is continuously or intermittently taking sildenafil. It is recommended not to use nitrates within 24 hours of the last dose of sildenafil. The reason for the dangerous interaction between nitrates and sildenafil is that both induce nitric oxide mediated vasodilatation. In such settings nitrates may cause syncope, Ml, or sudden death when a patient has an acute coronary syndrome.
# ventricular tachycardia – widen QRS. The best treatment w no hemodynamic compromise either lidocaine or amiodarone. Unstable cardioversion
# Carotid massage is useful for supraventricular tachycardia
# Dressler’s syndrome, an autoimmune pericarditis, is a late complication of acute Ml that usually develops between the second and tenth weeks post Ml.
# Norepinephrine is a powerful vasoconstrictor and can lead to decreased blood supply to both the lower and upper extremity cause Bluish discoloration and cool fingers
# septic shock both right atrial pressures and pulmonary capillary wedge pressure are low.
# Treatment with IV heparin, aspirin, beta-blocker, and nitroglycerin is indicated unstable angina and non-Q wave infarcts
# thrombolytic therapy indicate 1) MI w ST elevation greater than 1 mm in two contiguous leads after sublingual nitroglycerin administration to rule out coronary vasospasm. 2) new left bundle branch block
# Thrombolytic therapy, with tissue plasminogen activator, requires co-administration of heparin and aspirin for additional benefit. Streptokinase do not need co-administration of heparin because it may produce allergy.
Thiazide diuretics are the initial antihypertensive of choice in patients with osteoporosis. Thiazide diuretics decrease urinary calcium excretion
# Chaga’s disease caused by Trypanosoma cruzi. megacolon or mega-esophagus, cardiomegaly -- >cardiomyopathy, conduction abnormalities
** Decreased tolerance to glucose is a well-known side effect of thiazide diuretic therapy hyperglycemia. Also increased LDL cholesterol & triglycerides. hyponatremia, hypokalemia and hypercalcemia
# Presence of hypotension, pulsus paradoxus, and pulseless electrical activity in a
patient with a recent acute Ml should make you think of free ventricular wall rupture acute cardiac tamponade
Free wall rupture usually occurs in the first week after Ml. Risk factors include advanced age, large Q wave infarct, a history of HTN, and no prior history of angina pectoris.
# Papillary muscle rupture -- occurs in the first week after an acute Ml. lead to acute mitral regurgitation and a pansystolic murmur
# Premature atrial beats never require any treatment and are completely benign
# Digoxin is particularly used in patients with heart failure (systolic dysfunction) and atrial fibrillation/flutter. It increases the AV nodal refractoriness and thereby slows the ventricular rate in atrial fibrillation and flutter.
# In all ST elevation Ml, reperfusion therapy with thrombolytics or PTCA(Percutaneous Coronary Interventions (previously called Angioplasty, Percutaneous Transluminal Coronary [PTCA], or Balloon Angioplasty) with or without stenting must be performed as soon as possible.
PCI is the reperfusion therapy of choice as it has a better outcome than thrombolysis.
Contraindications to thrombolytics include active bleeding, history of a hemorrhagic stroke anytime or a cerebrovascular accident within the last year, drug allergy or systolic BP greater than 175 mmHg.
Concurrent administration of glycoprotein llb/llla inhibitors has shown promising results with improved coronary reperfusion, early ST segment resolution, and reduction of the incidence of recurrent ischemia and infarction. The role of GP llb/llla inhibitors in primary PCI(PTCA) is not certain. At some centers it is used routinely while at others, it is given under special circumstances like the finding of residual thrombus.
# Constrictive pericarditis-- decreased cardiac output (fatigue, muscle wasting etc) and /or signs and symptoms of venous overload like elevated JVP, dyspnea, ascites, positive Kussmaul's sign, pedal edema, tender hepatomegaly etc. Sharp 'x' and y descent on central venous tracing is characteristic of constrictive pericarditis as is the presence of pericardial knock. Tuberculosis is the most common cause of constrictive pericarditis
# Calcium channel blockers are the drugs of choice for Variant angina rest chest pain w transient ST elevation during the episode of chest pain which usually returns to baseline as the pain resolves. Cardiac enzymes are usually negative. Caused by coronary vasospasm
# situational syncope related to micturition caused by autonomic dysregulation
# The EKG findings in pericardial tamponade include sinus tachycardia, low voltage QRS complexes, and electrical alternans. Electrical alternans is characterized by alternating amplitudes of QRS complexes
# Mobitz type I heart block is characterized by a narrow QRS, progressive increase in PR interval until a ventricular beat is dropped,. In type II block -- dropped QRS complex with normal PR interval. In third degree AV block -- atria and ventricles beat independently
# Even though IV beta-blockers improve mortality in acute Ml, they are contraindicated in the presence of pulmonary edema. Other absolute contraindications to their use include asthma, hypotension, severe bradycardia and heart block greater than first degree.
# CK-MB fraction has a high specificity for an acute Ml (slightly lower than cardiac troponins). It begins to rise within 4-6 hours after Ml and returns to baseline within 48-72 hours. It’s high specificity and rapid return to the baseline makes it the biomarker of choice for the diagnosis of a recurrent Ml.
# Cardiac troponins T and cardiac troponins I are proteins that control the interaction of actin and myosin. They are more specific than all the other biomarkers of cardiac injury being used for the diagnosis of Ml. They begin to rise 4-6 hours after an Ml, and remain elevated for 10 days. They have now become the primary biochemical tests used for the diagnosis of acute Ml. They have also replaced LDH for the retrospective diagnosis of Ml.
# Acute transmural infarct => Q-waves + ST elevation
# The diagnosis of ventricular septal rupture (The diagnosis of ventricular septal rupture can be made if there is evidence of left to right shunting on Swan-Ganz catheter readings )can be made if there is evidence of left to right shunting on Swan-Ganz catheter readings
# Aspirin, ACE inhibitors, and beta-blockers have been shown to reduce mortality in
the setting of acute Ml.
# Alpha-blockers(Doxazosin) are preferred in patients with BPH and an unfavorable metabolic profile (dyslipidemia, glucose intolerance).
# Mitral valve prolapse is the most common cause of mitral regurgitation in USA. papillary muscle dysfunction or infarction as the next most common cause
#Beta blockers are used to treat chest pain, palpitations, and autonomic symptoms of MVP.
# The first line medication for HTN in the general population is either a thiazide diuretic or beta-blocker. Non-selective beta-blockers are contraindicated in asthmatics especially if they are steroid dependent or on continuous albuterol.
# ACE inhibitors, like enalapril, are the 1st line drugs for diabetics with hypertension. These are usually 2nd line drugs for the general population.
# Generally, we can say that prophylaxis is recommended for high-risk conditions and is optional for moderate risk conditions.
Conditions put a patient at high risk to develop infective endocarditis include:
1. All prosthetic heart valves.
2. Any history of previous bacterial endocarditis.
3. Complex cyanotic congenital heart disease and surgically constructed systemic pulmonary shunts.
Conditions, which put a patient at moderate risk to develop infective endocarditis includes:
1. Congenital cardiac malformations not falling into the high or negligible risk categories (such as PDA, VSD, ostium primum ASD, bicuspid aortic valve and coarctation).
2. Acquired valvular heart disease (such as rheumatic heart disease, valvular stenosis and regurgitation).
3. MVP with regurgitation and/or myxomatous leaflets.
4. Hypertrophic cardiomyopathy.
a moderate-risk cardiac condition and now the decision about the need and choice of antibiotic regimen will depend on the type of procedure.
For dental procedures with bleeding, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For dental procedures which are unlikely to cause bleeding, prophylaxis is not recommended.
For respiratory procedures like rigid bronchoscopy and operations involving mucosa, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For flexible bronchoscopy, prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients. For endotracheal intubation, prophylaxis is not recommended
For gastrointestinal procedures like sclerotherapy of varices, gastrointestinal surgery involving mucosa, biliary tract surgery, esophageal stricture dilatation and ERCP in the presence of obstruction, antibiotic prophylaxis is recommended in high-risk patients and optional in moderate risk patients. For endoscopy and TEE, prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients
For genitourinary tract procedures like prostatic surgery, cystoscopy and urethral dilatation, antibiotic prophylaxis is recommended both in high-risk and moderate-risk patients. For urethral catheterization, uterine D&C, therapeutic abortion, sterilization or insertion or removal of IUD, prophylaxis is recommended only when an infection is present. For vaginal delivery and vaginal hysterectomy, prophylaxis is optional in the high-risk patient. For cesarian section, prophylaxis is not recommended.
# supraventricular tachycardia-- HR of >140/min, regular, loss of P waves and narrow QRS complex. Tx: unstable cardioversion. Stable vagal maneuvers initially, If these fail -- > IV adenosine push
# Prolonged, tachysystolic atrial fibrillation causes significant left ventricular (LV) dilation and a depressed ejection fraction. Tx: Controlling the rhythm or rate
# Hyperkalemia and pregnancy are contraindications to the use of ACE inhibitors
# Beta-blockers can worsen severe peripheral vascular disease while helping for blood pressure.
# Jugular venous distention (JVD) and RBBB indicate right heart strain
# Think of PE in a postoperative patient with JVD and new onset RBBB
# Hypertrophic cardiomyopathy has an autosomal dominant mode of inheritance.
# Screening should be done in all first-degree relatives of the patients of hypertrophic cardiomyopathy and the most effective way of screening these people is echocardiography. Detailed history and examination is the screening method used for young athletes
# Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using transthoracic Doppler echocardiography. Midsystolic soft murmurs (grade l-ll/IV) in an asymptomatic young patient are usually benign and need no further work-up.
# Hyperkalemia present in this patient may be due to the combination of enalapril, digoxin, and spironolactone. Furosemide causes hypokalemia.
# Hyponatremia is a bad prognostic factor in patients with heart failure. It indicates the presence of severe heart failure and a high level of neurohumoral activation
# The early third heart sound, that is also called pericardial knock and the inspiratory increase in the jugular venous pressure (KussmaulDs sign), are important physical findings of constrictive pericarditis. KussmaulDs sign is also present in right sided heart failure, severe tricuspid regurgitation, right ventricular infarction and cardiac tamponade.
# Water hammer or collapsing pulse and pistol shot femoral pulses are diagnostic clues to aortic regurgitation
Tapping apex beat and malar flush are important physical findings of mitral stenosis. Pulsus paradoxus is defined as greater than 10-mmHg fall of the systolic blood pressure during inspiration
# Pulsus paradoxus and hypotension point toward the diagnosis of pericardial tamponade
# A pansystolic murmur at the left sternal border is usually seen in tricuspid regurgitation
# Calcium channel blockers have good peripheral vasodilating properties that can help to diminish the symptoms of intermittent claudication. They are also metabolically neutral, not affecting plasma lipid profile.
# Infective endocarditis prophylaxis and repeated regular follow-ups are recommended for all patients of aortic stenosis even if they are asymptomatic.
# Isolated premature ventricular arrhythmias generally do not require any medical
treatment; observation is usually the treatment of choice
# Transmural infarcts-- ST segment elevation followed by the development of Q waves and elevation of cardiac enzymes
# Subendocardial infarcts are characterized by ST segment depressions that are not followed by the development of Q waves and elevation of cardiac enzymes.
# All patients with unstable angina(either ST depression, T wave inversion, or many times no changes) should be hospitalized and treated with aspirin, IV heparin, and IV nitroglycerin. Once the patient is free of chest pain, an angiography can be performed non-emergently.
# Chronic oral contraceptive use is a common cause of secondary hypertension caused by an estrogen-mediated increase in the synthesis of angiotensinogen in the liver
# Coxsackie-B virus is a common cause of acute pericarditis.
# A history of recent upper respiratory tract infection followed by sudden onset of cardiac failure in an otherwise healthy patient is suggestive of dilated cardiomyopathy, most likely secondary to acute viral myocarditis(Coxsackie B infection). The diagnosis is made by echocardiogram, which typically shows dilated ventricles with diffuse hypokinesia resulting in low ejection fraction (systolic dysfunction). Viral myocarditis can cause dilated cardiomyopathy by direct viral damage, as well as sequel of humoral or cellular immune responses to persistent viral infection.
Concentric hypertrophy of the heart is seen following chronic pressure overload, as in valvular aortic stenosis or untreated hypertension
Eccentric hypertrophy of the heart is seen following chronic volume overload, as seen in valvular regurgitation
# Isolated systolic hypertension (ISH) is important cause of hypertension in elderly patients caused by decreased elasticity of the arterial wall. Tx: Always treat isolated systolic hypertension. – Hydrochlorothiazide
# Diuretics, nitrates, ACEi and digitalis be avoided in HCM especially when an outflow gradient is present. hypertrophic cardiomyopathy Beta-blockers are usually the first line of medication.
# Dressier syndrome typically occurs two-to-four weeks after an Ml and presents with a low-grade fever, malaise and pleuritic chest pain. ECG will reveal 'non specific1 ST elevations and there may be a pericardial effusion. NSAIDs are the agents of choice.
# Lidocaine increased risk of asystole
# Valsalva maneuver and standing after squatting are two maneuvers that decrease left ventricle volume thus increasing the gradient and intensifying the associated systolic murmur. handgrip increases the systemic arterial resistance and thus decreases the gradient and associated systolic murmur. Phenylephrine also decreases the murmur by increasing systemic arterial pressure. Leg elevation increases the left ventricular volume and thus decreases the gradient and the associated murmur.
# Whenever a patient of chronic aortic regurgitation develops symptoms of LV dysfunction, he should undergo aortic valve replacement after his congestive symptoms are relieved by intense medical treatment with digoxin, diuretics, and vasodilators (ACE inhibitors).
Acute aortic regurgitation is an emergency and requires emergent surgery. Sodium nitroprusside or inotropes like dopamine or dobutamine are used to stabilize this condition before emergent surgery can take place.
#I.V atropine is the drug of first choice in patients with symptomatic bradycardia (Choice B). Transcutaneous pacing is the next step after atropine. If the patient has severe bradycardia with hypotension then epinephrine is the drug of choice
Adenosine is used for supraventricular tachycardia
# If average alcohol intake is greater than 2 drinks/day, risk of development of hypertension increases by 1.5-2 times compared to the general population and the risk increases substantially if the average alcohol intake is greater than 5 drinks/day. On the other hand moderation of alcohol intake to 1-2 drinks per days also has been shown to have a cardioprotective effect decrease blood pressure
# Thrombolytic therapy is indicated when the chest pain is suggestive of Ml and there is ST segment elevation greater than 1 mm in two contiguous leads after sublingual nitroglycerin administration to rule out coronary vasospasm. Another indication for thrombolytic therapy is a new or presumably new left bundle branch block. Thrombolytic therapy is not indicated for an Ml with ST segment depression and it is also not indicated for unstable angina.
Thrombolytic therapy with tissue plasminogen activator requires co-administration of heparin and aspirin for greater benefit. Tissue plasminogen activator is slightly more effective than streptokinase but it has a slightly more risk of intracranial bleeding. For streptokinase, co-administration of heparin is not required.
# Treatment with IV heparin, aspirin, and IV nitroglycerin is indicated in cases of unstable angina and non-Q wave infarcts
# Manage a patient with ST segment elevation Ml with immediate angiography and PTCA when thrombolytic are contraindicated. Even if the patient has no contraindications forthrombolytic therapy and a catheterization laboratory is available in the hospital, or within 30 min of the hospital, PTCA with stent placement has been shown to have better outcomes than thrombolytic therapy in acute ST elevation Ml.
# Severe systolic dysfunction and increased left ventricle size are features of dilated cardiomyopathy.
Supernormal ejection fraction is present in hypertrophic cardiomyopathy as is dynamic outflow obstruction. Diastolic dysfunction is present in HCM, due to the stiff, hypertrophied ventricle wall.
# ejection fraction (EF) normal = 55-65%
# Digoxin slows the ventricular response rate in atrial fibrillation by slowing down AV conduction and thus increasing the diastolic filling. It also has a beneficial effect in patients of systolic dysfunction due to its positive inotropic effect. Thus any patient who has atrial fibrillation and heart failure will benefit from digoxin; it should be considered over before beta-blockers or calcium channel blockers.
# Beta-blockers are preferred over the digoxin or calcium channel blockers in patients with coronary artery disease. Calcium channel blockers are not the best drugs for patients with heart failure due to their negative inotropic effect.
# IV dobutamine is used when a patient is in cardiogenic shock.
# Mitral valve prolapse-- systolic click, The click occurs earlier with standing and Valsalva maneuver and it disappears with squatting and handgrip
#Cutaneous flushing and intensive generalized pruritis are well-known side effects of high-dose niacin therapy (high dose is required to treat lipid abnormalities). These effects are explained by niacin-induced peripheral vasodilatation. The mechanism involved in this reaction is believed to be drug-induced release of histamine and prostaglandins. can be reduced by low-dose aspirin
# In a patient with an Ml who develops a cold leg, one has to get an ECHO to rule out a
thrombus in the left ventricle.
# exercise EKG testing should be the initial test of choice for stable angina
# Presence of complete RBBB (or) ST depression at rest of less than 1 mm are not contraindications to perform stress testing. Stress testing with imaging is indicated when the patient has complete left bundle branch block, an idioventricular rhythm, Wolff-Parkinson-White syndrome, and ST depression of greater than 1 mm at rest.
# Dobutamine stress echo is indicated in patients who canDt do sufficient exercise.
# in hypertrophic cardiomyopathy it is the systolic anterior motion of mitral valve leaflet that causes mitral regurgitation Coronary angiogram is indicated in patients who have abnormal stress testing
# Aortic stenosis may present with syncope, angina, or dyspnea (SAD) on exertion
4 allergic rhinitis -- pale bluish mucosa, dark, puffy eyelids
5 Otitis externa is always painful and tender; pain without tenderness suggests middle rather than an external infection
6 Juvenile angiofibroma-- triad of nasal obstruction, nasopharyngeal mass, and recurrent epistaxis. headache, conductive hearing loss, and diplopia secondary to erosion into cranial cavity and pressure on optic chiasm. CTscan of the head and the face is confirmatory
7 nasal polyps are recurrent episodes of rhinitis, chronic nasal obstruction, altered taste sensation, diminished sense of smell and persistent postnasal drip
8 Manner -- recurrent episodes of rotational vertigo, sensorineural hearing loss and tinnitus.
9 Serous otitis media—aids pt with hearing difficulty, dull tympanic membrane which is sluggish to air insufflation and presence of air fluid levels in the middle ear. Caused by auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas
10 Peritonsillar abscess presents with unilateral sore throat, neck pain, referred
earache, dysphagia, swollen tonsils, drooling, and trismus -- Streptococcus pyogenes
1 Furosemide, a loop diuretic can cause ototoxicity—hearing loss, tinnitus and dysequilibrium
2 Cavernous Sinus Thrombosis is the most common, late complication of infection of the central face or para nasal sinuses.-- dysfunction of the CN III, IV, V, and VI are present. Lateral gaze palsy (CN VI dysfunction), ptosis, mydriasis (CN III dysfunction), absent corneal reflex (CN V dysfunction), CT is the definitive procedure for diagnosis. The mainstay of treatment is early and aggressive antibiotic administration. Anticoagulants and corticosteroids may also be used as adjunctive therapy, Patients present with severe headache, followed by fever and periorbital edemea.
3 Viral rhinitis-- Nasal examination shows an erythematous mucosa, Allergic rhinitis-- clear nasal discharge and nasal mucosa is pale or bluish.
4 Juvenile angiofibroma is a vascular tumor -- the most common benign tumor of nasopharynx The triad of nasal obstruction, nasopharyngeal mass, and recurrent epistaxis in a young male is highly suggestive of juvenile angiofibroma. Juvenile angiofibroma can be managed with medical or surgical therapy depending on the stage of tumor, examination there is a grayish-red mass in the posterior nasopharynx.
5 Typical symptoms of nasal polyps are recurrent episodes of rhinitis, chronic nasal obstruction, altered taste sensation, diminished sense of smell and persistent postnasal drip
6 meniere’s syndrom-- recurrent episodes of rotational vertigo, sensorineural hearing loss and tinnitus. Benign positional vertigo-- not usually associated with hearing loss or tinnitus. Acute labyrinthitis-- follows a viral infection or mumps, ear ache, vertigo
7 Serous otitis media is the most common middle ear pathology in acquired immuno deficiency syndrome. It presents with hearing difficulty, dull tympanic membrane which is sluggish to air insufflation and presence of air fluid levels in the middle ear. It is due to the auditory tube dysfunction arising from HIV lymphadenopathy or obstructing lymphomas.
8 Chronic otitis media usually presents with purulent aural discharge. Tympanic membrane appears thickened with calcific patches and perforation
9 Otosclerosis is an osseous dyscrasia limited to the temporal bone. It causes symptomatic hearing loss + tinnitus tinnitus by third decade of life. Otoscopic examination --usually normal, 10% of patients demonstrate a Schwartz sign, characterized by a reddish-blue hue over promontory and oval window niche areas, secondary to rich vascular supply associated with immature and audiometry shows conductive hearing loss and loss of stapedial reflex, It is inherited in an autosomal dominant pattern with incomplete penetrance. Treatment consists of oral sodium fiuoride
10 peritonsillar abscess -- unilateral sore throat, neck pain, referred earache, and dysphagia, trismus, pooling of saliva, and a muffled voice. associated with prominent cervical lymphadenitis and deviation of uvula. tonsils are swollen-- Streptococcus pyogenes is the most commonly associated organism-- Treatment consists of Iv antibiotics and needle aspiration of the abscess. Failure to obtain pus is an indication for surgical incision and more formal exploration
Retropharyngeal abscess also presents with neck pain, sore throat, and dysphagia. These patients have posterior pharyngeal edema, nuchal rigidity, cervical adenopathy, fever, and drooling of saliva. Tonsils are normal
11 Presbyopia is the loss of accommodative capacity that occurs with ageing. Usually patients notice inability to focus objects at normal reading distance and complain of having to hold books at arms length to read. It is corrected with convex lenses In Hyperopia light rays fall behind the retina, Myopia or shortsightedness -- light rays are focused in front of the retina. It is corrected using concave lenses
12 quinine is being used for treating cramps in dialysis patients. Vancomycin can cause nephrotoxicity and the red man syndrome (due to histamine release from mast cells)
13 Tinnitus can sometimes occur in patients taking aspirin, quinine, and even in patients who are depressed -- It can cause disruption of sleep, concentration and depression. Tricyclic anti¬depressants have been found to be effective for this condition.
14 Glomus tumor arises in the middle ear or in the jugular bulb. They present with pulsatile tinnitus and hearing loss
15 Presbyacusis-- high frequency hearing loss in both ears associated with difficulty in speech discrimination
16 Petrous apicitis presents with a triad of retro orbital pain, lateral rectus palsy, and otorrhea.
17 Orbital cellulitis is manifested by abrupt onset of fever, proptosis, restriction of extra
ocular movements, and swollen red eyelids. – cause Staphylococcus aureus, Streptococcus pneumoniae, and Hemophilus influenza
18 Malignant otitis externa is an infection of external ear -- caused by pseudomonas aeruginosa and occurs in patients who suffer from coexisting diseases such as diabetes mellitus, malnutrition, leukemia, and other debilitating diseases. foul smelling discharge, deep otalgia, granulations in ear canal and involvement of cranial nerves VII, IX-XII. X-rays should be done in all cases of suspected malignant otitis externa to look for the degree of damage to the body tissues X-rays should be done in all cases of suspected malignant otitis externa to look for the degree of damage to the body tissues
19 Cholesteatoma is an epithelial cyst that contains desquamated keratin-- repeated infections or progressive conductive hearing loss, drainage and granulation tissue that are unresponsive to antibiotic treatment, characterized by marginal tympanic membrane perforation or sometimes it may present as ear canal filled with mucous, pus and granulation tissue. Cholesteatomas destroy bones and therefore, any bony structure in or around the middle ear and mastoid cavity can be eroded –CT. Therapy consists of surgical removal Therapy consists of surgical removal
20 Tympanic sclerosis is common sequelae of chronic otitis media. It presents as thickening and calcification of the tympanic membrane. Hearing loss is rare Tympanic sclerosis is common sequelae of chronic otitis media. It presents as thickening and calcification of the tympanic membrane. Hearing loss is rare
21 Central Retinal Vein Occlusion (CRVO) presents with sudden, painless, unilateral loss of vision. disk swelling, venous dilation and tortuosity, retinal hemorrhages and cotton wool spots. -> emergent ophthalmologist referral emergent ophthalmologist referral
22 Acute angle closure glaucoma is characterized by sudden onset of symptoms such as blurred vision, severe eye pain, nausea and vomiting. Examination reveals a red eye with hazy cornea and a fixed dilated pupil
23 Optic neuritis also presents with sudden unilateral loss of vision but is associated with severe pain. Fundoscopy may reveal swollen optic disc and central scotoma. They will also have pupillary abnormalities pallor of the optic disc, cherry red fovea and boxcar segmentation of blood in the retinal veins.
24 Central retinal artery occlusion is also characterized by sudden painless loss of vision in one eye.-- pallor of the optic disc, cherry red fovea and boxcar segmentation of blood in the retinal veins.
25 In patients with asthma and nasal polyps, aspirin is contraindicated as it may lead to severe bronchospasm (aspirin triad or SamterDs triad).
26 Eustachian tube dysfunction is a common cause of conductive hearing loss in children. Symptoms follow the onset of upper respiratory tract infection or allergic rhinitis - aural fullness, popping noise while swallowing or yawning, intermittent ear pain, and hearing loss. Otoscopy reveals retraction and decreased mobility of the tympanic membrane. Hallmark of eustachian tube dysfunction is a middle ear effusion. treated with auto insufflations and oral and nasal decongestants
27 Leukoplakia -- whitish patch or plaque, granular appearance ->hard to remove caused by chronic irritation to the oral mucosa due to smoking, alcohol, or ill-fitting dentures and Vitamin A and B deficiencies and syphilis. risk of transformation into squamous cell carcinoma. incisional biopsy or exfoliative cytologic examination should always be done.
28 Hairy leukoplakia is a white, painless lesion - found in AIDS patient on the lateral aspect of tongue. It is caused by Epstein Barr Virus (EBV).
29 Lichen planus is characterized by polygonal, violaceous, papular eruption covered by fine scales. These lesions when involving oral mucosa have higher incidence of malignant transformation.
30 Keith-Wagener classification -- stages of hypertensive retinopathy
Slight AV nicking – grade 1
Copper wiring, AV depression with humping ends –g 2 G2g
Silver wiring, flame shaped hemorrhages, exudates –g3 333
Flame shaped hemorrhages, exudates and papilledema – g 4
31 Mastoiditis is the most common complication of the otitis media, pain behind the ear, and fever. Examination reveals erythema, edema, and tenderness over mastoid area( behind ear ). protruded auricle. CT imaging may be used to confirm the clinical diagnosis. It demonstrates fluid filled middle ear and demineralization of mastoid trabeculae. Intravenous antibiotics are the immediate treatment of choice
32 Treatment of choice for streptococcal pharyngitis is single injection of IM Benzathine penicillin G
33 IV crystalline penicillin G is used in cases of bacterial meningitis, endocarditis, and neurosyphilis
34 Bullous myringitis presents with painful vesicles on the tympanic membrane. It is associated with mycoplasma or viral respiratory Infection
35 Diabetic Retinopathy -- micro aneurysms, hemorrhages, exudates, and retinal edema. pre proliferative retinopathy with cotton wool spots. malignant retinopathy-- proliferative retinopathy consisting newly formed vessels -> leading cause of blindness in USA.
Tx- Argon Laser photocoagulation
36 Retinal detachment - retina hanging in the vitreous.
37 Open angle glaucoma-- gradual loss of peripheral vision resulting in tunnel vision. cupping of optic disc
38 Cigarette smoking increases the risk of macular degeneration
39 H. Influenzae and Group A Streptococcus are the most common causes of
40 Gonococcal conjunctivitis - copious purulent eye discharge with swollen eyelids and chemosis, occurs 2-3 days after birth. Tx ->A single intramuscular dose of ceftriaxone
41 Neonatal chlamydial conjunctivitis presents with mild hyperemia with scant mucoid eye discharge not purulent. It occurs about 5-14 days after birth
42 Chemical conjunctivitis is the most common cause of conjunctivitis occurring within the first 24 hours after birth. A history of silver nitrate eye drops instillation is usually present
43 Sialolithiasis presents as post-prandial pain and swelling. calculus formation within the ductal system of salivary gland is most common in submandibular gland followed by sublingual and parotid gland. x-ray of the involved salivary gland is diagnostic. Treatment consists of dilation and incision of the involved duetto remove the calculus.
1 Membranoproliferative glomerulonephritis, type 2 -- Dense intramembranous deposits that stain for C3, caused by IgG antibodies (termed C3 nephritic factor) directed against C3 convertase of the alternative complement pathway. These antibodies reacting with C3 convertase lead to persistent complement activation and kidney damage
2 immune complex-mediated glomerulopathies that include SLE, post-streptococcal glomerulonephritis
3 anti-GMB antibody – good pasture ‘ syndrom. idiopathic crescentic glomerulonephritis.-- Cell-mediated injury
4 collapsing focal and segmental glomerulosclerosis is the most common form of
glomerulopathy associated with HIV. Typical presentation includes nephritic range proteinuria, azotemia, and normal sized kidneys
5 HIV + hepatitis B -> membranous glomerulonephritis
6 Cardiovascular disease is the most common cause of death in dialysis patients and in renal transplant patients
7 interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDDs, Rifampin, phenytoin, and allopurinol. Discontinuing the offending drug is the treatment of drug-induced interstitial nephritis
Clinical features include fever, rash and arthralgias. Other features are peripheral eosinophilia, hematuria, sterile pyuria and eosinophiluria. WBC casts may be present in the urine
8 sickle cell trait in a young black male - > painless episode hematuria. Caused by apillar ischemia. Papillar necrosis can occur with massive hematuria
9 analgesic nephropathy – headache + painless hematuria. results from papillary ischemia induced by analgesic-mediated vasoconstriction of medullary blood vessels (vasa recta). ->Papillary necrosis
10 several years of analgesic abuse induce pailess hematuria characterized by chronic tubuiointerstitial damage
11 Any patient with recurrent sinusitis, cavitary lung lesions, pulmonary hemorrhages and
glomerulonephritis will most likely have WegenerDs glomerulonephritis. Both hematuria and hemoptysis are seen in cases of GoodpastureDs syndrome and WegenerD s granulomatosis. In WegenerDs granulomatosis
12 hepatitis B infection-- membranous glomerulonephritis, but HBsAg carriers-- membranoproliferative glomerulonephritis
13 Child or adolescent presenting with priapism suspect sickle cell disease and leukemia
14 Fluoxetine does lead to sexual dysfunction, resulting in impotence, decreased libido and ejaculatory problems,
15 Priapism with Trazadone.
16 All patients with chronic renal failure and hematocrit < 30% (or hemoglobin <10g/dl_) are candidates for recombinant erythropoietin therapy after iron deficiency has been ruled out. Erythropoietin is also indicated in all the hemodialysis patients who have symptoms attributed in part to anemia
most common side effects of erythropoietin therapy are:
a. Worsening of hypertension or induced hypertension – Tx: fluid removal (by dialysis) and use of anti¬hypertensive drugs (beta blockers and vasodilators are preferred).
c. Flu like syndrome
d. red cell aplasia
17 recurrent renal stones need 24hr urine is collected to find any underlying metabolic disorder. A detailed metabolic evaluation is not needed when a patient presents with their first renal stone
18 Finasteride acts on epithelium. alpha-1 blockers act on smooth muscles of
prostate and bladder base
19 Finasteride is 5-alpha reductase inhibitor and it inhibits the conversion of testosterone to dihydrotestosterone. It acts on the epithelial components of the prostate gland and produces improvement of symptoms as well as reduction in the size of the gland. BPH w collagen predominance respond neither to finasteride nor to alpha-1 blockers
19 epididymitis characterized by fever, painful enlargement of testes, and irritative voiding symptoms usually w UTI, in younger patients is usually caused by sexually transmitted organisms such as C. trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is caused by gram-negative rods
20 Peritoneal dialysis is an alternative to hemodialysis when vascular access is not possible; when there is bleeding tendency; when there is hemodynamic instability; or when a patient is having hypothermia
21 Indications for dialysis includes uremic symptoms such as pericarditis, encephalopathy, coagulopathy, and fluid overload unresponsive to diuresis, hyperkalemia not amenable to standard therapy, and pH less than 7.20 (acidosis
22 All patients with irritative or obstructive voiding symptoms should have their urinalysis and serum creatinine done. Patients with elevated serum creatinine levels should have ultrasound of kidney, ureter and bladder done
23 Glomerular hyperfiltration is believed to be the earliest renal abnormality present in patients with diabetes mellitus. It creates intraglomerular hypertension leading to progressive glomerular damage and renal function loss. diabetic nephropathy =>Thickening of the glomerular basement membrane is the first change that can be quantitated -> mesangial expansion -> Nodular sclerosis
24 acyclovir- Nephrotoxicity.= > Crystalluria with renal tubular obstruction & acute renal failure
25 Fibromuscular dysplasia can present with diastolic hypertension in children. Bruit or venous hum may be heard at the costovertebral angle. Angiogram will reveal "string of beads" sign
26 Alport’s syndrome -recurrent episodes of hematuria with proteinuria
sensorineural deafness and family history of renal failure. Electron microscopy --thinned and thickened capillary loops with splitting of GBM
27 In a patient with flank pain, fevers, chills and white blood cells in the urine, think
pyelonephritis. Urine and blood cultures should be obtained prior to obtaining
28 medullary cystic kidney- in adults with recurrent UTI or renal stones ( x-ray shows nephrocalcinosis and contrast filled cysts demonstrated by IVP. AD. is not associated with renal failure or hypertension. whereas the juvenile form also known as nephronophthisis is autosomal recessive.
29 Alpha-blockers are used for the treatment of benign prostatic hyperplasia. Phenoxybenzamine is a non- selective alpha-blocker. Prazosin, Terazosin and Doxazosin are all selective alpha-1 blockers recommended for the treatment of BPH. They produce side effects like orthostatic hypotension, headache, dizziness, retrograde ejaculation and rhinitis
30 Tamsulosin is a new drug and it blocks only alpha-1 receptors that are present in prostate and bladder base used for the treatment of benign prostatic hyperplasia
31 Cystinuria is an inherited disease causing recurrent renal stone formation. impaired amino acid transport by the brush borders of renal tubular and intestinal epithelial cells. Urinalysis - hexagonal crystals. Urinary cyanide nitroprusside test, detects elevated cystine level, helps to confirm the diagnosis
32 cryoglobulinemia includes palpable purpura, glomerulonephritis(proteinuria and hematuria) along with high titers of rheumatoid factor, non-specific systemic symptoms, arthralgias, hepatosplenomegaly, peripheral neuropathy, and hypocomplementemia. Most of these patients have evidence of Hepatitis C.
33 nephrotic syndrome- proteinuria in excess of 3.5g/day, hypoalbuminemia and edema, -1. Accelerated atherogenesis may occur due to increased levels of LDL. 2. Microcytic hypochromic anemia may be due to loss of transferring. 3 immunoglobulins may be lost in urine resulting in hypogammaglobulinemia. 4 cholecalciferol-binding protein may be lost in urine with resulting deficiency of vitamin D and hypocalcemia. Hypocalcemia may result in secondary hyperparathyroidism
***Patients with nephrotic syndrome are at increased risk for developing
hypercholesterolemia, hypertriglyceridemia, and hypercoagulable state
34 In hyperkalemia, removal of K+ from the body can be achieved with dialysis, cation
exchange resins or diuretics. Kayexalate or sodium polystyrene sulfonate is a cation-exchange resin, which acts in Gl tract by promoting the exchange of Na+ for K+, and thereby increasing the excretion of K+.
35 Sodium bicarbonate, insulin plus glucose drip and beta agonist decrease the extra cellular concentration of potassium by driving the potassium into the cell, however they do not remove potassium from the body.
36 prostatodynia are afebrile and have irritative voiding symptoms urinary hesitancy and interruption of flow, increased urinary frequency and urgency ). Physical examination is unremarkable and urinalysis is normal
37 chronic diarrhea may develop renal stones composed of calcium oxalate. Fat malabsorption result in increased absorption of oxalic acid. This is because unabsorbed fatty acids chelates calcium and thus oxalic acid is free for absorption
38 Calcium phosphate stones are common in primary hyperparathyroidism and renal tubular acidosis (RTA)
39 Struvite stones are formed when urine is alkaline because of infection with urease producing bacteria like Proteus
40 dysuria, urinary frequency, suprapubic discomfort along with urinary findings of bacteriuria and pyuria establish the diagnosis of acute cystitis. Oral trimethoprim-sulfamethoxazole is the preferred empiric treatment for acute uncomplicated cystitis
41 Uric acid stones are radiolucent; however, they are seen on USG and CT scan. Treatment of uric acid stones includes hydration, alkalinization of urine, and use of low purine diet with/without allopurinol if hyperuricosuria is present. alkali nization of urine to pH > 6.5 with oral sodium bicarbonate or sodium citrate is indicated.
42 Hydrochlorothiazide decreases urinary calcium excretion and is used in management of recurrent hypercalciuric renal stones
43 Renal vein thrombosis is an important complication of nephrotic syndrome, most common with membranous glomerulonephritis
44 amyloidosis are renal amyloid deposits that show apple-green birefringence under polarized light after staining with Congo red. history of rheumatoid arthritis (that predisposes to amyloidosis), enlarged kidneys w proteinuria, and hepatomegaly Crescent formation revealed on light microscopy is characteristic for rapidly progressive glomerulonephritis
45. Linear immunoglobulin deposits on immunofluorescence microscopy are typical for anti-glomerular basement membrane disease (e.g., GoodpastureDs syndrome)
46 Granular immunoglobulin deposits revealed on immunofluorescence microscopy -- usually present during immune complex glomerulonephritis (e.g., lupus nephritis or poststreptococcal glomerulonephritis).
47 The two initial tests, which are recommended in all the patients with possible benign
prostatic hyperplasia, are serum creatinine and urinalysis.
48 Transient proteinuria is a common cause of isolated proteinuria and can occur during stress or any febrile illness
49 When an old patient comes with irritative voiding symptoms and cultures are negative, nonbacterial prostatitis ->bladder cancer must be ruled out by urinary cytology and cystoscopy. Oral erythromycin is used to treat nonbacterial prostatitis, as it may be caused by Mycoplasma or Ureaplasma. Oral trimethoprim-sulfamethoxazole is used to treat chronic bacterial prostatitis
49 Hypertensive nephrosclerosis-- Arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts -> Nephrosclerosis is characterized by hypertrophy and intimal medial fibrosis of renal arterioles; whereas, glomerulosclerosis is characterized by progressive loss of glomerular capillary surface area with glomerular and peritubular fibrosis. The kidneys are generally small and microscopic hematuria and proteinuria occurs due to glomerular lesions.
50 diabetes mellitus
1. Within first year of diabetes mellitus - Glomerular hyperperfusion and renal hypertrophy with increase in glomerular filtration rate.
2. First five years of diabetes mellitus - Glomerular basement membrane thickening, glomerular hypertrophy, and mesangial volume expansion with glomerular filtration rate returning to normal.
3. Within 5-10 years of diabetes mellitus- Microalbuminuria, which later progresses to overt nephropathy.
51 Analgesic abuse nephropathy is primarily a tubulointerstitial disease characterized by focal glomerulosclerosis.
52 hematuria with irritative or voiding symptoms, suprapubic pain should alarm the physician for the possibility of bladder cancer
53 a patient with acute pyelonephritis does not respond to 72 hr treatment with appropriate antibiotics, urological imaging with CT scan or ultrasound must be performed to exclude obstruction, renal, perirenal abscess, or some other complication
54 Calcium gluconate is the treatment of choice for hyperkalemic patients with significant EKG abnormalities
55 Kayexalate is a cation exchange resin used in case of chronic hyperkalemia
56 The duration of diabetes should be longer (10-15 years) to cause nephropathy. Hypercalcemia is usually not caused by HTN related renal failure
57 Any elderly patient with bone pain, renal failure, and hypercalcemia has multiple myeloma until proven otherwise
58 Papillary necrosis and chronic tubulointerstitial nephritis is the most common pathology seen in analgesic nephropathy. Patients with chronic analgesic abuse are more likely to develop premature aging, atherosclerotic vascular disease, and urinary tract cancer
59 BPH -weak urinary stream, urgency, frequency, and sensation of
incomplete voiding, it starts in the center of prostrate. treatment with alpha-blockers is usually the first choice
60 uremic coagulopathy -- platelet dysfunction. desmopressin (DDAVP), cryoprecipitate, and conjugated estrogens has been used to correct the coagulopathy in uremic patients.
61 nafcillin cause acute allergic interstitial nephritis -> a Type 4 hypersensitivity reaction. The triad of fever, petechial rash, and peripheral eosinophilia in an azotemic patient is highly suggestive of allergic interstitial nephritis. eosinophiluria (positive Hansel stain).
62 Acute tubular necrosis-- Muddy brown granular casts are characteristic
63 The nephrotic syndrome is a hypercoagulable condition, which manifests as venous or arterial thrombosis and even pulmonary embolism. Renal vein thrombosis is the most frequent manifestation. Other complications of nephrotic syndrome include: protein malnutrition, iron-resistant microcytic hypochromic anemia, increased susceptibility to infection, and vitamin D deficiency.
64 Imaging studies should be performed in all children under the age of 10 years with UTI, in all male children with UTI, and in all prepubertal non-sexually active females with UTI. Imaging studies are performed to find any underlying structural abnormality predisposing to UTI. The most common one in this age group is vesico-ureteral reflux. Voiding cystoureterogram is usually done for this purpose but it is performed only after the acute illness is over
65 Struvite stones almost always occur in the presence of alkaline urine that is
persistently infected with urease producing bacteria
**66 Cholesterol embolization, usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low complement level should make you think of cholesterol embolism
67 1)WBC casts are definite evidence that urinary WBCs originate in the kidney and are seen in cases of interstitial nephritis, pyelonephritis, etc.
2)RBC casts are indicative of glomerular disease or vasculitis.
3) Hyaline casts are composed almost entirely of protein and they pass unchanged along the urinary tract. They may be seen in asymptomatic individuals and in patients with pre-renal azotemia.
4) Fatty casts are seen in conditions causing nephrotic syndrome.
5) Broad casts arise in the dilated tubules of enlarged nephrons that have undergone compensatory hypertrophy in response to reduced renal mass; thus, they are seen in chronic renal failure (CRF). Also, waxy cast, which is shiny and translucent, is generally seen in chronic renal disease.
68resence of urinary eosinophils (remember the positive Hansel stain) often indicates either allergic interstitial nephritis or cholesterol embolization
**69 Muddy brown granular cast- Acute tubular necrosis
RBC casts - Glomerulonephritis
WBC casts - Interstitial nephritis and pyelonephritis
Fatty casts - Nephrotic syndrome
Broad and waxy casts - Chronic renal failure
70 WegenerDs granulomatosis is treated with a combination of cyclophosphamide and steroids
71 A high protein diet is associated with increased predisposition for stone formation, mainly calcium stones. Hence, patients with an established diagnosis of nephrolithiasis should restrict protein in their diet.
72 Dietary calcium restriction is no longer recommended in patients with renal calculi, as it is associated with an enhanced tendency to stone formation. Instead, these patients should be encouraged to include calcium in their diet.
***Dietary recommendations for patients with renal calculi are:
1. Decreased dietary protein and oxalate
2. Decreased sodium intake
3. Increased fluid intake
4 Increased dietary calcium
73 Mega doses of Vitamin C lead to increased formation of oxalate stones, especially in patients with renal failure.
**74 In young patients, renal artery stenosis is caused by fibromuscular dysplasia. In older patients, the cause is usually an atheromatous plaque- reatment of choice for fibromuscular dysplasia is percutaneous angioplasty with stent placement.
75 Factors that improve the prognosis in a patient with chronic renal failure are protein restriction and use of ACE inhibitors. However, ACE inhibitors are likely to worsen renal failure when serum creatinine levels are greater than 3-3.5 mg/dl
In general, membranous nephropathy is the most common nephropathy associated with carcinoma
**76 The most common cause of nephrotic syndrome in patients with HodgkinDs lymphoma is minimal change disease
77 Leucocyte esterase in urine is indicative of significant pyuria whereas nitrites signify the presence of Enterobacteriaceae
78 hypercalciuria (24 hour urinary calcium excretion > 300 mg in males and >250 mg in females; > 4 mg/kg in both males and females. Idiopathic hypercalciuria (hypercalciuria with normal serum calcium and in absence of metabolic disease - most common form of hypercalciuria Treatment for a first uncomplicated calcium stone is hydration and observation.
79 Varicoceles typically fail to empty when the patient is recumbent. - always raise suspicion for a renal cell carcinoma w Increased erythropoietin by kidney mass can produce polycythemia and thrombocytosis. CT scan of the abdomen is most sensitive and specific for diagnosing the renal cell carcinoma
** 80 Cyclosporine and tacrolimus have the same mechanism of action. Major side effects of cyclosporine include nephrotoxicity, hyperkalemia, hypophosphatemia, hypomagnesemia, hypertension, gum hypertrophy, hirsutism, and tremor. Tacrolimus has similar toxicity except for hirsutism and gum hypertrophy. Major toxicity of azathioprine is dose related diarrhea, leukopenia, and hepatotoxicity. Major toxicity of mycophenolate is bone marrow suppression.
81 DM--Autonomic neuropathy may lead to a denervated bladder, resulting in overflow
incontinence due to detrusor weakness
82 Alcoholism is the most frequent cause of rhabdomyolysis
83 Focal segmental glomerulosclerosis (FSGS) is the most common cause of nephrotic syndrome in African American adults. It also occurs in patients with HIV and IV drug abuse
84 Rifampin causes red to orange discoloration of body fluids
85 classic signs of dehydration (dry mucosa, marginally high values for hematocrit and serum electrolytes, BUN/creatinine ratio > 20
Hemto & onco
**1 Surgical resection is the preferred management of solitary brain metastasis. Multiple brain metastases are best treated with palliative whole brain radiation.
2 not reported (almost never metastasize) to have metastasized to brain
1. Non-melanomatous skin cancer
2. Oropharyngeal cancer
3. Esophageal carcinoma
4. Prostate cancer
2 Thymoma is associated with pure red cell aplasia
3 Migratory thrombophlebitis, known as Trousseau's syndrome. an occult tumor (pancreatic carcinoma, lung carcinoma, prostate cancer, …)
4 increase in serum levels of both insulin and C-peptide is diagnostic of insulinoma.
5 basal cell carcinoma: Basal cell carcinoma is the most common form of skin cancer in the US. cancer usually remains local and almost never spreads. Tx - surgical removal, including microscopic shaving (Mohs1 surgery) i.e. excision with 1-2 mm of clear margins
1. Open Sore that bleeds, oozes, or crusts and remains open for three or more weeks.
2. A Reddish Patch or irritated area
3. A Shiny Bump or nodule, that is pearly or translucent and is often pink, red, or white.
4. A Pink Growth with a slightly elevated rolled border and a crusted indentation in the center.
5. A Scar-like Area, which is white, yellow or waxy, and often has poorly defined borders.
6 The incidence of stomach cancer has dramatically declined universally, the reasons for which are still not known
7 solitary pulmonary nodule" defined as a 2cm or less coin-shaped lesion. Popcorn" calcification is a hamartoma while "bulls eye" is a granuloma
8 warfarin therapy alone may increase the risk of venous limb gangrene in patients with deep vein thrombosis
9 Thrombocytopenia is a well-recognized serious complication of heparin therapy. There are two types of heparin-induced thrombocytopenia (HIT). HIT II usually occurs within 4 to 10 days after heparin treatment has started. HIT II is an autoimmune disorder characterized by the formation of antibodies against the heparin-platelet factor 4 complex. The other type, HIT I, occurs within the first two days after heparin therapy. The mechanism is non-immune and is possibly due to a direct affect of heparin on platelet activation.
The first step in a patient with HIT should be immediate cessation of all exposure to heparin including LMW heparin since it may cross react with the heparin-induced antibodies and may induce heparin-dependent IgG antibody formation. However, cessation of heparin alone is often not sufficient, since these patients remain at risk for thrombosis. There are two recommended alternatives to heparin in patients who developed HIT and requires ongoing anticoagulation (e.g mechanical heart valve): danaparoid and a direct thrombin inhibitor such as lepirudin orargatroban.
10 hypercalcemic crisis -- vomiting, oliguria, and anuria as well as somnolence and coma. Tx - normal saline followed by furosemide to maintain urine output at 200cc/hr. If the patient does not show improvement -> hemodialysis against a calcium-free dialysate
11 Leukocyte depletion techniques, like cell washing, decrease the probability of febrile, nonhemolytic transfusion reaction
12 osteosarcoma -- Codman’s triangle and sunburst appearance are the two classic radiologic features. Symptom- pain, ->swelling and limitation of motion, limping
13 Ewings sarcoma --onion skinning
14 Giant cell tumor has characteristic "soap bubble appearance" on the radiograph
15 Acute vasoocclusive crisis is an important complication of sickle cell anemia and may cause stroke, priapism or intractable pain -> Tx: Exchange transfusion
16 Hydroxyurea is a cytotoxic agent and is used in a patient of sickle cell anemia when his life is disrupted by frequent painful episodes.
17 Tumor burden, based on TNM staging, is considered the single most important prognostic consideration in treating patient with breast cancer
ER + and PR + are good prognostic features. Over expression of Her-2/new oncogene is related to worse prognosis
18 Fecal occult blood testing (FOBT) is the most commonly used screening test for
colon cancer. Patients with positive FOBT test should be followed up with colonoscopy
19 hairy cell leukemia- B Lymphocyte, bone marrow may become fibrotic, tartrate resistant acid phosphatase (TRAP) stain. TX – Cladribine, SR: neurological and kidney damage.
20 Presence of partial ptosis, and miosis (HornerDs syndrome) in a known smoker should alert you to think of lung cancer until proven otherwise. Simple chest x-ray should be the first test in patients with suspected lung cancer.
21 acute cord compression with cauda equina, most likely secondary to metastasis of prostrate cancer. Management : Intravenous dexamethasone. Then do MRI, Once the diagnosis of metastatic cord compression is confirmed => radiotherapy
22 Helicobacter pylori infection => gastric mucosa-associated lymphoid tissue (MALT) lymphoma, Tx: eradication of H. pylori w omeprazole, clarithromycin, and amoxicillin if fail to respond to eradication of H. Pylori. Therapeutic regimens usually include CHOP (cyclophosphamide, Adriamycin, vincristine, and prednisone) or CHOP-Bleomycin
23 Folate deficiency is the most common cause of megaloblastic anemia in chronic alcoholics.
24- Any patient who has long history of scar, and develops a non-healing, painless, bleeding ulcer should be considered for carcinoma most likely squamous cell. Diag: Punch biopsy
25 - Turcot's syndrome =brain tumors (primarily medulloblastomas and gliomas) and FAP (Familial Adenomatous polyposis) or HNPCC (Hereditary nonpolyposis colorectal cancer).- autosomal recessive
26 Gardner's syndrome is autosomal dominant where colonic polyps are seen with prominent extraintestinal lesions. These include desmoid tumors, sebaceous or epidermoid cysts, lipomas, osteomas (especially of the mandible), supernumerary teeth, gastric polyps, and juvenile nasopharyngeal angiofibromas.
27 Peutz-Jeghers syndrome is an autosomal dominant inherited disorder characterized by intestinal hamartomatous polyps in association with mucocutaneous melanocytic macules
28 Multiple hamartoma syndrome (Cowden syndrome) is association of Gl-tract hamartomas with breast Ca, thyroid Ca, and nodular gingival hyperplasia.
29 Cronkhite-Canada syndrome is association of juvenile-type polyps and ectodermal abnormalities like alopecia, hyperpigmentation, and nail loss (onycholysis).
30 The patient has squamous cell carcinoma of mucosa of head and neck. These are
very common in people who smoke and drink a lot of alcohol. The first manifestation
of such a tumor may be a palpable cervical lymph node. The best test for such
patients is panendoscopy (triple endoscopy= esophagoscopy, bronchoscopy, and
laryngoscopy) to detect primary tumor, or in most case, tumors. After the primary
tumor/s is detected, we should biopsy it to confirm diagnosis. CT scan may be
repeated later to have a close look at its extent. Open dissection of the lymph node at
this stage is always discouraged because it makes the task of surgeon difficult later
as it obscures the surgical approach to the cancer
31 Acanthosis nigricans -- dark, thick areas on the skin, most common in the armpits and other body folds associated with being overweight. And various tumors like gastric carcinoma ** Acanthosis nigricans might be a manifestation of occult gastrointestinal malignancy
32 patients with ulcerative colitis who have pancolitis should begin colonoscopy after eight years of disease Four biopsies should be obtained every 10cm from the cecum to the rectum. Colonoscopy should be repeated every one to three years
33 Paroxysmal nocturnal hemoglobinuria (PNH ) -- intra-vascular Hemolysis w low serum haptoglobin and elevated serum LDH, pancytopenia, splenomegaly. Flow cytometry confirms the diagnosis of PNH by showing absence of CD59.
34 Whenever a person is having chronic ITP, the bone marrow examination must be performed to rule out primary hematological disorder. Patient must also be screened for SLE by antinuclear anti-body testing, as isolated thrombocytopenia may be a presenting feature of SLE especially if the patient is a young female.
If a patient, with diagnosis of chronic ITP, shows abnormal findings like hepatosplenomegaly, lymphadenopathy or atypical lymphocytosis, secondary causes of autoimmune thrombocytopenia like infection with CMV, HIV, hepatitis viruses and toxoplasma should be considered. The patient presented in this vignette does not have any such abnormality; therefore, she does not need to be screened for HIV by ELISA or EBV by Monospot test.
35 hereditary spherocytosis --autosomal dominant, defect spectrin, spherocytosis and polychromatophilia. Usually the MCV is normal but the mean corpuscular hemoglobin concentration is elevated.-> may develop cholelithiasis and present with cholecystitis & Chronic leg ulcers,
episodes of aplastic crisis caused by parvovirus infection. all patients should be prescribed folic acid supplementation Usually splenectomy should be delayed four to five years to prevent post splenectomy sepsis. All patients prior to splenectomy should receive vaccinations against encapsulated organisms such as Haemophilus, Pneumococci, and meningococci
36 Tamoxifen is an anti-estrogen drug used to treat breast cancer. it reduces the risk of recurrence of the original cancer and also reduces the risk of developing new cancer in the other breast. Increases the risk endometrial cancer and uterine sarcoma,
37 Hypercalcemia results in increased gastrin release
38 Glucagonoma is characterized by hyperglycemia, dermatitis, weight loss, and anemia.
39 leukocyte alkaline phosphatase score is high in leukemoid reactions and
usually low in chronic myeloid leukemia
A leukemoid reaction is a marked increase in leucocytes by a severe infection or inflammation. Chronic myeloid leukemia (CML) and a leukemoid reaction are indistinguishable on a peripheral blood film. The sudden elevation in the total leukocyte count and marked increase (to the left) of granulocyte precursors suggests a serious infection with or without an underlying leukemic state. The Leukocyte Alkaline Phosphatase (LAP) test is of diagnostic importance in distinguishing between CML and a leukemoid reaction. In CML, LAP score is decreased. However, an increased LAP score may be encountered in CML because of subsequent secondary infections. So, the presence of Philadelphia chromosome is more diagnostic for CML and should be obtained in suspected cases.
40 Polycythemia Vera (PCV)-- remarkable increase in RBC mass and total blood volume Symptoms such as headache, dizziness, and paresthesias are frequently related to hyperviscosity. Both thrombosis and bleeding can occur due to elevated platelet count and impaired platelet function Reversible moderate hypertension frequently occurs as a result of expanded blood volume. They also have granulocytosis and thrombocytosis on peripheral blood smear, and splenomegaly. Bone marrow is virtually always hypercellular. There is an elevated leukocyte alkaline phosphatase, normal oxygen saturation, and low erythropoetin level. A urinary erythropoetin assay reveals the absence of measurable erythropoetin in the urine. ESR will be very low
41 intra vascular hemolytic anemia -- elevated reticulocyte count, increased LDH levels, and decreased haptoglobin
**42 Iron deficiency is the most common cause of anemia in elderly patients. Inflammatory
joint disease, and not degenerative joint disease, causes the anemia of chronic disease.
43 Gardner syndrome refers to an association between colonic polyps and the presence of prominent extra-intestinal lesions. These include desmoid tumors, sebaceous or epidermoid cysts, lipomas, osteomas (especially of the mandible), supernumerary teeth, gastric polyps, and juvenile nasopharyngeal angiofibromas
44 low leukocyte alkaline phosphatase with leukocytosis is classic for chronic
45 Elevated Leukocyte Alkaline Phosphatase -- Leukemoid Reaction, Polycythemia Vera
46 Supplementation with folic acid is recommended in all cases of sickle cell anemia to prevent the occurrence of aplastic crisis. Hydroxyurea is used in sickle cell anemia when painful episodes occur very frequently
47 Acute lymphoblastic leukemia-- periodic acid schiff positive staining in diagnosis
48 Waldenstrom macroglobulinemia – Excess IgM in the blood causes hyperviscosity-- Increased size of the spleen, liver, and some lymph nodes, Various visual problems
49 Aminoglycosides are contraindicated in patients receiving cisplatin chemotherapy because of the potential for significant nephrotoxicity
50 Febrile neutropenia is a medical emergency, Gram negatives, particularly P. aeruginosa infection.. Empiric treatment with ceftazidime/cefepime is the first step
51 Bite cells on peripheral smear is also characteristic of G-6-P-D deficiency.-> X-linked
52 Sickle cells -- sickle cells or Howell Jolly bodies
53 Thrombotic thrombocytopenic purpura (TTP) is a serious disorder, which presents
with the following classical pentad:
1 .Severe thrombocytopenia
2.Microangiopathic hemolytic anemia (RBC fragments)
3.Fluctuating neurological signs
Hemolytic uremic syndrome (HUS) and TTP come under a spectrum of diseases. If the patient has more neurologic symptoms and less of renal failure, it is considered TTP. On the other hand if the patient has significant renal failure and less neurologic symptoms it is considered HUS. However, both conditions are very serious and require emergent plasmapheresis.
54 chronic lymhpocytic leukemia (CLL) -- often asymptomatic, may develop hypogammaglobulinemia. Smudge cells are highly characteristic. Lymph node biopsy not bone marrow biopsy confirms the diagnosis, lymphocytosis, presence of thrombocytopenia is a poor prognostic factor
55 Elderly patient with anemia, renal failure, and hypercalcemic should make you think of
56 Radiation therapy would be most appropriate for management of progressive pain in a patient with prostate cancer metastatic to bone after androgen ablation (orchiectomy).
**57 Recognize HUS in a child who has recently recovered from a diarrheal illness and presents with acute renal failure, microangiopathic hemolytic anemia, fever, thrombocytopenia and characteristic peripheral smear finding of schistocytes
**58 Sideroblastic anemia usually manifests as microcytic/hypochromic anemia, elevated serum iron level and increased TIBS caused by vitamin B6 deficiency (alcoholism, drugs), Tx : pyridoxine
59 giant cell tumor of bone -- soap-bubble appearance in the epiphysis
60 Hyperglycemia, necrolytic migratory erythema and diarrhea, weight loss should make you think about glucagonoma. Glucagonoma is usually malignant and metastasis to the liver may occur
61 After the diagnosis of a solid testicular mass has been made, (a painless hard mass in testicle + suggestive ultrasound), the initial management is removal of the testis and its associated cord. FNAC, or transscrotal biopsy, is contraindicated because of the risk of spillage of cancer cells, which can potentially spread through lymphatics and blood vessels
62 The bisphosphonates are the drugs of choice for mild to moderate hypercalcemia; they are relatively nontoxic and are more potent than intravenous saline. There is increasing evidence that bisphosphonates may prevent skeletal complications (reduce bone pain, fracture risk) and perhaps improve survival in patients with multiple myeloma or breast cancer. in all women with metastatic breast cancer and radiographic lytic bone disease who are receiving either hormone therapy or chemotherapy, intravenous pamidronate is recommended.
63 IV fluids and furosemide are the treatment of hypercalcemic crisis. The bisphosphonates are the drugs of choice for mild to moderate hypercalcemia pamidronate
64 bone marrow iron stain is the most definite way to diagnose an iron deficiency.
65 Screening Prostate cancer
Men age 40-50, do yearly rectal exam PSA-> n = 1-4pg/dl
Men age > 50, do yearly digital rectal plus PSA (Prostate Specific Antigen)
If either the rectal examination is suggestive or PSA is greater than 4 ng/dl (n= 0-4) or the age specific normal values, a transrectal ultrasonogram is usually the next best step, followed by needle biopsy and then staging. For staging of prostate cancer do the bone scan to see the bone metastasis.
66 hereditary Nonpolyposis Colorectal Cancer HNPCC Lynch syndrome (known as the Amsterdam Criteria I):
1. At least three relatives with colorectal cancer, one of whom must be a first degree relative of the other two
2. Involvement of two or more generations
3. At least one case diagnosed before age 50
4. Familial adenomatous polyposis has been excluded
67 Lynch syndrome II – high risk endometrial carcinoma
68 hemochromatosis diagnosed diabetes, hepatomegaly, and arthropathy. autosomal recessive disorder. intestinal iron absorption is abnormally increased leading to iron deposition in the tissue. damages the organs especially liver, pancreas, heart, and pituitary.Clinically it presents with hepatomegaly, hyperpigmentation, diabetes (bronze diabetes), arthropathy, restrictive heart failure, and hypogonadism. The first logical step in the diagnosis of this disease is serum iron studies. Increased serum iron, ferritin, and transferrin saturation correlates with hemochromatosis. Liver biopsy confirms the diagnosis.
69 polycythemia vera increased RBC mass, mild granulocytosis, and low erythropoetin level.. plethoric face and splenomegaly. Hypertension. Can myelofibrosis (teardrop shaped RBCs) Tx: phlebotomy to keep HCT < 45%.
70 cancer-associated anorexia: Tx :Megestrol acetate
**71 The most common cause of folic acid deficiency is nutritional due to poor diet and/or alcoholism. Folic acid deficiency can be caused by some drugs; these drugs can impair the absorption of folic acid (e.g., phenytoin) or antagonize its physiologic effects (e.g., methotrexate, trimethoprim)
72 Antiphospholipid antibody syndrome is characterized by recurrent arterial or venous thrombosis or recurrent fetal losses in the presence of antiphospholipid antibodies. Antiphospholipid antibodies are of three types. The first is responsible for false-positive syphilis serology. The second is lupus anticoagulant, which falsely elevates APTT. The third is anticardiolipin antibody. Antiphospholipid antibody syndrome is either primary or may be associated with other autoimmune disorders like SLE.
arterial or venous thrombosis or fetal losses due to Antiphospholipid antibody syndrome, he or she must be started on anticoagulant therapy. Acute thrombosis is treated with heparin and factor anti-X-a activity is measured, as APTT is not reliable in such cases. Subsequently such patient is anticoagulated with warfarin
Women with fetal losses due to Antiphospholipid antibody syndrome are managed during pregnancy with heparin and aspirin. Warfarin is not used due to its teratogenicity
PT n= 8.2-10.3s. aPTT n= 21-32s
73 microcytic hypochromic anemia- decreased MCV and MCH. Normal MCHC
MCV n=80-100 MCH n= MCHC n=
74 Hairy cell leukemia is a type of B-Lymphocytic derived chronic leukemia. enlarged spleen. bone marrow fibrotic, tartrate resistant acid phosphatase (TRAP) stain. CD11c marker is relatively specific for hairy cell leukemia.
75 Familial Colonic Polyposis is autosomal dominant disease caused by mutations in the adenomatous polyposis coli (APC) gene. 100% risk of cancer. require a proctocolectomy, before the age of 20
76 AFP is never produced in seminoma. It usually indicates embryonal cell carcinoma. AFP is not specific; it may also elevate in cancers of GIT and lungs
Seminoma: PLAP - Placental Alkaline phosphate
Embryonal Carcinoma: AFP + beta-hCG (50%)
77 tumor lysis syndrome -- hyperphosphatemia, hypocalcemia, hyperkalemia, and hyperuricemia
78 Vitamin K is an important cofactor in post translational modification of several
coagulation factors: factors II, VII, IX, and X as well as proteins C and S.
79 cystic fibrosis. exocrine deficiency of the pancreatic Fat malabsorption vitK defici
80 acute monocytic- M5gingival hyperplasia. Alpha-naphthyl esterase positive
81 acute myeloblasts leukemia with maturation (M2) myeloblast predominate on the peripheral blood film. Acute promyelocytic leukemia (M3) has a lot of promyelocytes, which may be hyergranular, microgranular or hypogranular. DIC is also some times seen with this type
82 Strict vegetarian diet can cause B12 deficiency. Usually the total body vitamin B12 stores are available for three to four years
83 PagetDs disease presents as a persistent dermatitis of the nipple. There is a red, oozing, crusted lesion, which is often unresponsive to topical steroid and antibiotics. Biopsy shows malignant cells that invade the epidermis and have abundant pale staining cytoplasm surrounding a hyper-chromatic nucleus, with prominent nucleoli. large cells, surrounded by halo-like area, invading the epidermis
84 Palliative radiation, along with anti-androgen therapy, is the treatment of choice for metastatic prostate cancer. Anti-androgen therapy consists of Leuprolide (LHRH analogue). Flutamide is considered inferior to LHRH analogues
85 Inadequate dietary intake, intestinal malabsorption, and loss of storage sites due to hepatocellular disease are the three major causes of vitamin-K deficiency. A 30-day store of vitamin K is stored in a normal liver; however, an acutely sick person can become vitamin-K deficient in 7-10 days.
86 Myasthenia Gravis-- diagnosis is confirmed by EMG and acetylcholine receptor antibody test. After the diagnosis is confirmed, it is important to look for evidence of thymoma, especially in patients younger than age 60
87 Bernard-Soulier syndrome-- Giant platelets. major defect is of membrane glycoprotein lb. This defective platelet membrane lacks the receptor site for vWF so the platelets canDt adhere to vascular subendothelium. Platelets from these patients do not aggregate in the presence of normal vWF and ristocetin Mild thrombocytopenia.
88 GlazmannDs Thrombasthenia is a qualitative platelet defect with normal platelet count but prolonged bleeding time and abnormal aggregation test with ADP
89 Platelet transfusion is indicated only if the patient is actively bleeding and the platelet count is less than 20,000 to 30,000/mm3
90 The most significant risk factor for breast carcinoma is increased age. Early menarche, nulliparity, conjugated estrogens, and alcohol ingestion are all associated with slight increased risk of breast cancer
91 When ITP fails to respond to high-dose prednisolone therapy (2 weeks after diagnosis), splenectomy. When fails to respond to glucocorticoids and splenectomy, then treated with danazol or cytotoxic agents like cyclophosphamide
92 Hypercalcemia is usually associated with Squamous Cell Carcinoma of Lungs (Remember sCa++mous) not Oat Cell Carcinoma. Sarcoidosis does cause hypercalcemia but usually patients have bilateral hilar adenopathy, evidence of erythema nodosum. Adenocarcinoma of lung is usually a peripheral lesion and usually not associated with hypercalcemia.
93 Tamoxifen reduces the risk of breast cancer in patients who are at an increased risk of developing breast cancer. there is no evidence that tamoxifen is beneficial for women who do not have an increased risk of developing breast cancer. The decision to take tamoxifen is an individual one since risks associated with tamoxifen ( endometric ca. )
94 Water restriction is the first step in managing hyponatremia in patients with syndrome of inappropriate antidiuretic hormone secretion If the serum sodium is below 120 or if the patient is seizing, emergency treatment is administration of 3% sodium chloride solution to raise the serum sodium to 125 If the patient has evidence of fluid overloading, a history of CHF, or is resistant to treatment, loop diuretics may be added as well. Chronic treatment may involve administration of lithium or demeclocycline, which inhibit ADH action
95 Monoclonal gammopathy of undetermined significance (MGUS)-- the absence of symptoms; M component (IgA, or IgG, or IgM) <3000mg/dl. best treated with reassurance and regular followup
96 Cryptorchidism -- Treatment is delayed until 12 month of age to give the testicle a chance to come down on its own. if 3 month premature, wait until they are 15 month. child has increased risk of testicular carcinoma even if it is fixed by surgery.
97 Adenocarcinoma of lung has the least association with smoking. usually located peripherally. present as a solitary nodule. consists of columnar cells growing along the septa
98 fibrocystic disease. Aspiration of the cyst got a clear fluid. The best approach wait for 4-6wk mass goes away and does not come back. If the mass recurs, or it doesn’t go away a biopsy is indicated
99 Ondansetron, a 5-HT3 receptor antagonist is the drug of choice for chemotherapy-induced emesis
100 angiofibroma—epistaxis, localized mass with bony erosion on the back of the nose. Recurrence of the tumor after surgical resection is common. In some cases, no treatment is necessary
101 imatinib (Gleevec).a tyrosine kinase inhibitor. First line Tx CML. SR mild nausea, diarrhea, leg aches/cramps, swelling of the face and around the eyes, itchy rash, and temporary reduction in the production of blood cells by the bone marrow. Cladribine is the drug of choice for hairy cell leukemia
101 CML—crisis phase: visual blurring and altered mental status.
102 Splenomegaly is associated with extra-vascular hemolysis while decreased levels of serum haptoglobin are caused by intra-vascular hemolysis
103 Glazmann’s Thrombasthenia-- autosomal recessive, deficient glycoproteins llb-llla complex so fibrinogen will not cross-connect. Epinephrine, collagen and thrombin fail to induce aggregation. Platelet aggregation studies with ADP Abnormal
104 he bleeding time (BT) is a measure of the interaction of platelets with the blood vessel wall
105 Spironolactone is the diuretic of choice for managements of ascites
106 Paroxysmal Nocturnal Hemoglobinuria (PNH). A red cell membrane defect causes increased binding of complement to the red cell leading to increased intravascular hemolysis. These cells are more susceptible to lysis in an acidic environment. Due to relative hypoventilation at night, there is mild acidosis. So the hemolysis is more at night and hemosiderinuria is common in the first morning urine. Thrombosis of major venous structures especially the hepatic vein is the common cause of death in these patients. Test specific to PNH are sugar-water test and the acidified-hemolysis (Ham) test, Decay Activating Factor (DAF) is diminished in PNH.
107 Heparin-lnduced Thrombocytopenia, increase aPTT
# Whipple’s disease multi systemic illness. Extra intestinal manifestations include migratory polyarthropathy, chronic cough, and myocardial or valvular involvement leading to congestive failure or valvular regurgitation. Later stages characterized with dementia
,supranuclear ophthalmoplegia and myoclonus. Intermittent low-grade fever, pigmentation and lymphadenopathy. PAS-positive materials in lamina propria with villous atrophy
# Clostridium difficle diarrhea Dx: Cytotoxin essay in the stool. Tx: oral/IV metronidazole
# All patients suspected of having Zollinger-Ellison syndrome and having a nondiagnostic fasting serum gastrin levels, should have secretin stimulation test done -- Serum gastrin concentrations do not rise in patients with other causes of hypergastrinemia as secretin stimulates the release of gastrin by gastrinoma cells whereas normal gastric G cells are inhibited by secretin. Measurement of gastric pH on a single specimen is important to exclude secondary hypergastrinemia due to achlorhydria.
# Toxic megacolon from ulcerative colitis Tx: IV corticosteroids
# Crohn’s disease skip lesions. Linear ulcers with a cobblestone pattern
# In chronic pancreatitis when the duct is dilated and the patient has pain, the best
procedure is to perform anastomosis between the jejunum and the pancreatic duct.
# The common drugs (important for USMLE) cause pancreatitis are:
1. diuretics furosemide, thiazides.
1. Patient with inflammatory bowel disease sulphasalazine, 5-ASA.
2. Patient on immunosuppressive agents azathioprine, L-asparaginase.
3. Patient with history of seizures or bipolar disorder valproic acid.
4. AIDS patient think about didanosine, pentamidine.
5. Patient on antibiotics metronidazole, tetracycline
# The most common cause of pancreatitis is alcohol, followed by gallstones. Abdominal pain is the most common symptom. Diagnosis serum amylase and lipase. CT scan is diagnostic for pancreatitis--will show diffuse or focal parenchymal changes, edema, necrosis or liquefaction. Treatment supportive care with fluids and electrolyte replacement
# Ultrasound can be used to assess gallstone pancreatitis and common bile duct obstruction.
# CTscan is the best test for the diagnosis of diverticulitis in acute setting.
# VIPomas are cancerous tumors that affect cells in the pancreas that produce vasoactive intestinal peptide (VIP). VIPomas cause diarrhea, hypokalemia resulting in leg cramps, and a decrease acid in the stomach.
# Glucagonoma presents with narcotizing dermatitis, weight loss, anemia, and persistent hyperglycemia
# Esophagoscopy is indicated when GERD fails to respond to empiric treatment or when patient has features of complicated disease.
# Esophageal pH monitoring is done when empirical therapy fails to control symptoms of GERD and endoscopy is negative. It is also performed when atypical symptoms are present
# Achalasia dysphagia to both solids and liquids, x-ray shows a dilated esophagus with an air fluid level. Barium swallow will reveal a large dilated esophagus with a bird’s beak tapering at the distal end. This is not diagnostic of achalasia because a tumor or stricture of the esophagus may also look very similar. Diagnosis made by manometry-> absence of peristaltic contractions in the upper esophagus, distal lower esophageal sphincter is normal with failure to relax
# Multiple myeloma The combination of back pain, anemia, renal dysfunction, and elevated ESR, hypercalcemia
# Giardia lamblia trophozoites adhere to the mucosal surface by adhesive disks and produce a malabsorption.
# quantitative estimation of stool fat is the gold standard for diagnosis of steatorrhea. Excretion of more than 7g of fat per day (normal is less than 6 g) is diagnostic of malabsorption,
# D-xylose test is a test for carbohydrate malabsorption
# Abdominal CTscan is the next diagnostic test when abdominal ultrasound does not
explain cholestatic jaundice.
# HIDA scan is used for the diagnosis of acute cholecystitis
# Hypercalcemia may manifest as severe constipation, anorexia, weakness, increased urination, or neurologic abnormalities (like confusion or lethargy).
# Increased intragastric pressure during vomiting could cause tears in the mucosa of
the cardia and sometimes of the distal esophagus- called Mallory-Weiss tears.
# There are two watershed zones in the colon. (1) The splenic flexure supplied by narrow terminal branches of the superior mesenteric artery, and (2) the recto-sigmoid junction supplied by narrow terminal branches of the inferior mesenteric artery. These two watershed areas are most vulnerable to ischemia during systemic hypotension.
# Presence of 5-HIAA in the urine is indicative of a carcinoid tumor. Even though carcinoids are most commonly found on the appendix, when they present with carcinoid syndrome, they are usually located in the small bowel # Ulcerative colitis nearly always involves the rectal mucosa and it usually produces bloody diarrhea. Hepatic enzymes could be elevated in Crohn’ disease. # Dyspepsia is defined as pain or discomfort centered in the upper abdomen. Noninvasive tests for H. pylori should be the first step in the management of patients
with dyspepsia under 45 years of age who do not have alarm symptoms. # An empiric trial of antisecretory therapy, like H2 blocker or proton pump inhibitor; or a prokinetic agent for one month is recommended in young patients without alarm symptoms who are H. pylori negative
# The major risk factors of squamous cell cancer of esophagus are smoking, alcohol, dietary deficiency of beta carotene, vitamin Bl.
# Hypotension, hyponatremia, azotemia, and oliguria with normal urinalysis in a patient with severe liver disease are suggestive of hepato-renal syndrome. No treatment is available. Measures are taken to withhold all possible precipitating factors and initial management includes careful volume load.
# The first sign of colorectal cancer in individuals of less than 40 years of age is rectal bleeding.
# Neuromas and marfanoid status are characteristic for MEN2B
** Treatment of both acute and chronic anal fissures starts with dietary modification (high-fiber diet and large amount of fluids) along with a stool softener and local anesthetics.
# Chronic pancreatitis alone does not cause elevation of alkaline phosphatase.
# Painless obstructive jaundice is more likely to be due to malignancy. Adenocarcinoma of the head of pancreas causes obstruction of extra hepatic bile duct leading to elevation of direct bilirubin and marked icterus. It may be associated with weight loss, dull back pain, and anorexia. There is astronomical elevation of alkaline phosphatase.
# Cryptosporidium parvum is a major cause of chronic diarrhea in HIV-infected patients with a CD4 count less than 180 cells/mm3. The modified acid-fast stain showing oocysts. Self-limiting illness in HIV-infected patients with a more preserved CD4 count.
# Celiac disease is a malabosorbtion syndrome associated with skin condition called dermatitis herpetiformis chronic, intensely burning, and pruritic vesicular skin disease, characterized by granular IgA deposits in the upper dermis. Presence of pruritic papulovesicular rash in association with symptoms of malabosorbtion is highly suggestive of dermatitis herpetiformis
# Diffuse esophageal spasm intermittent episodes of chest pain and dysphagia. Barium swallow may reveal a Dcorkscrew’ esophagus. Manometric studies demonstrate high amplitude peristaltic contractions. In contrast to achalasia, the lower esophageal sphincter usually has a normal relaxation response. Since the esophageal spasms occur in episodes, manometric findings may be intermittent, making the diagnosis difficult. it is associated with emotional factors and functional gastrointestinal disorders. Treatment includes
antispasmodics, dietary modulation and psychiatric counseling
** In achalasia, the lower esophageal sphincter does not relax (high tone).
** Scleroderma is a collagen vascular disorder loss of distal peristalsis of the esophagus. There is fibrosis and complete atrophy of the esophageal smooth muscle. The lower esophageal sphincter becomes incompetent (low tone) with time, leading to reflux esophagitis and a stricture.
# Polyps can be classified as follows
1. Hyperplastic polyps: These are the most common non-neoplastic polyps in the colon and arise from a hyperplastic mucosal proliferation. No further work¬up is needed.
2. Hamartomatous polyp: This includes juvenile polyp (a non-malignant lesion, generally removed due to the risk of bleeding) and Peutz Jeghers Polyp (generally non-malignant).
3. Adenoma: This is the most common type of polyp found in colon, These polyps are potentially premalignant, however <1% of such polyps become malignant. Most of the polyps are asymptomatic; less than 5 % of patients have positive occult stool blood tests.
Cancer is seen more commonly in sessile polyps. The risk of malignancy: villous > tubulovillous > tubular *** The risk factors for a polyp progressing into malignancy are villous adenoma, sessile adenoma, and size >2.5 cm. Also, remember hyperplastic polyps do not require further work-up.
# Plummer-Vinson syndrome is characterized by atrophic glossitis, stomatitis, and upper esophageal webs associated with iron-deficiency anemia. Usually these webs don’t regress and require dilatation.
# Non-caseating granulomas are pathognomonic of Crohn’s disease. Crypt abscess are characteristic of CD; however, they are not pathognomonic of CD. Crypt abscess following cryptitis may also be seen in UC.
# The classic triad of flushing, valvular heart disease, and diarrhea indicates that this patient has carcinoid syndrome. Carcinoid syndrome is associated with carcinod tumors with hepatic metastasis. Isolated tumors without metastasis do not produce carcinoid syndrome. These tumors secrete serotonin and various other products. Elevated serotonin and its metabolites 5-hydroxy indole acetiic acid (5-HIAA) are present in the blood and urine of most patients with this syndrome. 5-hydroxy tryptophan is degraded in the liver to functionally inactive 5HIAA. That’s the reason that these syndromes are common in the setting of hepatic metastasis. Tryptophan is the precursor of serotonin and use for synthesis of niacin. So Carcinoid syndrome Niacin deficiency.
# Zollinger-Ellison syndrome increased production of stomach acid inactivates pancreatic enzymes impaired fat absorption
# Fulminant colitis is a serious complication of ulcerative colitis and plain radiography shows distended colon. Proctosigmoidoscopy with biopsy establishes the diagnosis of ulcerative colitis and it can be performed in acute settings.
# Side-to-side porto-caval shunt will improve the ascites but may worsen the encephalopathy. Peritoneo-jugular shunt is designed for treatment of ascites only. Peritonitis, sepsis, and disseminated intravascular coagulation are its major drawbacks. Slow tapping of ascitic fluid balanced with infusion of albumin per liter tapped, is the final conservative measure for the treatment of acsites secondary to cirrhosis that has to be attempted before surgery.
# Office-based anoscopy/proctoscopy is the first procedure to be done in patients less than 50 years old who present with minimal bright red blood per rectum and do not have any risk factors for colon cancer. Blood intermixed with stool is not considered in this category.
# The initial evaluation of the patient with upper Gl bleeding involves an assessment of hemodynamic stability and the necessity for fluid resuscitation. Endoscopy is the procedure of choice for the diagnosis and treatment of active upper Gl bleeding and also for the prevention of re bleeding. Somatostatin or its long-acting analogue octreotide acts by reducing splanchnic blood flow, inhibiting gastric acid secretion, and exerting gastric cytoprotective effects. Somatostatin or octreotide can thus be used when endoscopy is unsuccessful, contraindicated, or unavailable, or as an adjunctive before endoscopy.
# Migratory thrombophlebitis and atypical venous thromboses are suggestive of chronic DIC, most probably due to cancer.
# Bacterial overgrowth is a malabsorption syndrome, which can be associated with a
history of abdominal surgery. Physical examination may reveal abdominal distention with identifiable succussion spiash due to palpable soft, fluid-filled loops of bowel.
# Worsening postprandial pain that leads to avoidance of food is characteristic of chronic occlusion of visceral arteries (abdominal angina).
# Interferon, plus ribavirin, is used to treat chronic HCV infection and may be used to prevent recurrent HCV infection after liver transplantation.
# Hepatitis B virus immune globulin plus lamivudine treatment is the most effective treatment to prevent recurrent HBV infection after liver transplantation.
# Esophageal cancer may mimic achalasia. Focal involvement of lower esophageal sphincter by malignancy is difficult to differentiate from achalasia on manometric and radiographic studies. Rapid weight loss and inability of esophagoscope to pass through the lower esophageal sphincter point towards the diagnosis of esophageal cancer.
# A CT scan is a standard diagnostic tool employed in patients with newly diagnosed gastric cancer to evaluate the extent of the disease. In most of the patients, surgery is the treatment of choice
# Laxative abuse is characterized by high frequency watery and nocturnal diarrhea and characteristic dark brown discoloration of the colon with lymph follicles shining through as pale patches confirms the diagnosis.
# Zenker’s diverticulumBarium esophagogram is for confirmation.
# D-xylose Its absorption requires an intact mucosa only. WhippleDs disease damages small intestinal mucosa, thus impairing D-xylose absorption. In bacterial overgrowth there will be both impaired fat absorption due to bacterial de-conjugation of bile salts as well as decreased excretion of xylose due to bacterial consumption of the simple sugar.
D-xylose absorption is abnormal both in bacterial overgrowth and WhippleDs disease.
# An elevated level of serum bilirubin and alkaline phosphatase is suggestive of compression of the intrapancreatic portion of the bile duct by edema, fibrosis, or pancreatic cancer.
# Abdominal ultra sonogram is the initial investigation of choice in patients with jaundice. However, CT scan has higher sensitivity for suspected pancreatic cancer. ERCP is most useful for patients in whom chronic pancreatitis is a strong suspicion or in cases where CT or USG fails to reveal a mass lesion within the pancreas. MRI is the investigation of choice in patients in whom ERCP is not possible due to pancreatic duct obstruction.
# In acute appendicitis, initial peri umbilical pain is a referred pain and visceral in nature, however pain shifts to right lower quadrant with involvement of parietal peritoneum and become somatic in nature.
# Asymptomatic diverticulosis needs only dietary modifications
# Metronidazole is the drug of choice for pseudomembrane colitis. Oral vancomycin is effective for the treatment of pseudomembrane colitis but it is used as an alternative to metronidazole when there is intolerance to the latter
# Diagnosis of Whipple’s disease can be confirmed with upper gastrointestinal
endoscopy with biopsy of the small intestine. PAS staining of small intestinal biopsies PAS-positive material in the lamina propria and villous atrophy.
# Pain that radiates to the arms is strongly suggestive of Ml. If you have a high index of suspicion for Ml, you should obtain EKG/serum enzymes immediately- you must rule out Ml before further Gl work-up.
# Diagnosis of Tropical sprue is made by small intestinal mucosal biopsy, which shows blunting of villi with infiltration of chronic inflammatory cells including lymphocytes, plasma cells and eosinophils.
# The most common cause of lower Gl bleed in elderly is diverticulosis. The second is vascular ectasia or angiodysplasia. Angiodysplasia typically presents in an elderly patient with painless bleeding. There has been a well-defined association of aortic stenosis and angiodysplasia. The other well recognized association is renal failure. Even though these ectasias can present throughout the colon, most often the bleeding originates from the cecum or ascending colon.
# Angiodysplasia is seen as a cherry red fern-like pattern of blood vessels that appear to radiate from a central feeding vessel
# . Lactose intolerance manifests as osmotic diarrhea after ingestion of dairy products, accompanied by abdominal cramps, bloating and flatulence. Lactase is a brush border enzyme that hydrolyses lactose. Lactase deficiency is characterized by a positive Clinitest of stool for reducing substances. Lactose intolerance is characterized by a positive hydrogen breath test, positive Clinitest of stool for reducing substances and increased stool osmotic gap. # Hemorrhage is the most common complication of peptic ulcer disease.
# Various predisposing factors for cholesterol gallstones are:
1. More common in western population than the Asian population
2. Obesity or rapid weight loss
3. Female sex hormones and oral contraceptive pills (OCP).
4. Hypomotility of gall bladder as in pregnancy, old age, fasting, octreotide or prolonged TPN.
5. Malabsorption of bile acids as in ileal disease or resection.
6. Clofibrate therapy.
#Risk factors for pigment gallstone are:
1. Chronic hemolysis
2. Chronic biliary tract infection or parasites
3. Increasing age.
80% of gallstones are radiolucent so an abdominal x-ray is not a sensitive tool for diagnosis of gall stone disease. Cholesterol and mixed stones together comprise 80% of all gallstones
Gallstones are common in Fat Fertile Female of Forty. Pregnancy is a risk factor of gallstone disease due to gallbladder hypomotility and stasis thus leading to formation of sludge
# Acute acalculous cholecystitis is an acute inflammation of the gallbladder in the absence of gallstones, most commonly seen in hospitalized in the following conditions and severely ill patients.
1 Extensive burns
1. Severe trauma
2. Prolonged TPN.
3. Prolonged fasting
4. Mechanical ventilation.
Involved pathophysiology is localized or generalized ischemia, biliary stasis, infection, or external compression of the cystic duct. It generally presents with right upper quadrant abdominal pain with fever, leucocytosis, and abnormal liver function tests. It can lead to complications like gangrene, perforation, and emphysematous cholecystitis. The initial investigation of choice is an ultrasonogram, which shows signs of acute cholecystitis and no gallstones; however, CT scan and HIDA scans are more sensitive and specific for the diagnosis. It is important to have a high degree of suspicion in high-risk patients in order to correctly identify this problem.
Three major types of gallstones:
1. Cholesterol stones.
2. Pigment stones composed of chiefly calcium bilirubinate (20 %).
3. Mixed stones.
# chronic cholecystitis generally show a small fibrosed gall bladder on the ultrasonogram.
# The first step in the treatment of acute variceal bleeding is to get vascular access with
two large bore intravenous needles followed by fluid resuscitation. The second step control the bleeding itself. Perform an endoscopic band ligation of varices. The medical control of bleeding ->vasoconstrictors like octreotide and somatostatin, but re bleeding is very common
# Acute onset of severe epigastric pain radiating to the back associated with leucocytosis in an alcoholic is highly suggestive of acute pancreatitis
# Anti HBcAg and HBsAg is the best screening of the acute hepatitis. IgM anti HBcAg is present in the window period (when both HBsAg and Anti HBsAg are undetectable)
HbeAg active viral replication, high degree of infectivity.
Anti HBeAg cessation of active viral replication and low infectivity. # Caroli’s syndrome is a rare congenital disorder characterized by intrahepatic dilatation of biliary tree and is associated with adult polycystic kidney disease. Risk w Cholangiocarcinoma. Symptom a. Intermittent abdominal pain due to bile stasis or intermittent passage of stone. b. Cholangitis leading to fever and right upper quadrant abdominal pain. C. Portal hypertension leading to hematemesis and melena. d. Renal complaints due to APKD. Tx : ursodeoxycholic acid to decrease the complication from stone and surgical treatment in patients with recurrent or refractory cholangitis. # Primary sclerosing cholangitis associated w ulcerative colitis # Abdominal ultrasound is the best initial investigation for gallbladder pathology. HIDA scan is a very specific tool for confirmation of suspected acute cholecystitis. #Gallstone disease is common in Fat, Fertile, and Female of Forty. OCP also predisposes to gall stones. Patients generally complain of bloating and dyspepsia after eating fatty foods with occasional right upper abdominal pain. # porcelain gall bladderX-ray: gall bladder appears large and dilated outlined by a line of calcium (calcium salt deposits into the wall of a chronically inflamed gall bladder). associated with gall bladder carcinom
# Choledochal cysts are congenital abnormalities of the biliary tree characterized by dilatation of the intra and/or extra hepatic biliary ducts. In children it causes abdominal pain, jaundice, and attacks of recurrent pancreatitis. can degenerate into cholangiocarcinoma., initial investigation of choice is an ultrasonogram followed by CT scan or magnetic resonance imaging (MRI) as needed.
# Primary biliary cirrhosis, which is a chronic progressive cholestatic liver disease commonly presenting with fatigue, intense pruritus, and jaundice; characterized by markedly elevated alkaline phosphatase and cholesterol levels, positive anti mitochondrial antibodies. Ursodeoxycholic acid is the most commonly used drug for primary biliary cirrhosis (PBC )as it relieves symptoms and improves the transplant free survival time. Cholestyramine can be used to control the severe pruritus and hypercholesterolemia in patients with PBC, but it does not improve the survival rates. It is a second choice, mainly used to control severe symptoms. Liver transplantation is the only ultimate cure of progressive PBC, but it is indicated in patients with progressive primary biliary cirrhosis with severe liver damage or cirrhosis. Steroids, methotrexate, and other immunosuppressant drugs, have been used in cases of severe primary biliary cirrhosis with very severe symptoms not controlled by other drugs and when liver transplantation is not an option.
# Normal physiological changes in liver enzymes in pregnancy include mild elevation of alkaline phosphatase due to placental secretion but normal bilirubin, aminotransferase, and GGT.
# Intrahepatic cholestasis of pregnancy is a functional disorder of bile formation, characterized by intense pruritus & markedly elevated serum bile acid levels. Variable elevation in bilirubin, alkaline phosphatase, GGT, mild elevation of amino transferase, It resolves on its own and has no hepatic sequelae. Treatment options include cholestyramine with or without phenobarbital or ursodeoxycholate.
# Acute fatty liver of pregnancy is a complication of the third trimester of pregnancy. association of pre-eclampsia. characterized by microvesicular fat deposition in the hepatocytes.
# Persistently elevated hematocrit with organomegaly Polycythemia rubra Vera which is risk of hepatic vein occlusion (Budd Chiari syndrome), characterized by tender congestive hepatomegaly with ascites. Hepatic venogram or a liver biopsy is the diagnostic test Constrictive pericarditis could also cause tender congestive hepatomegaly and would be characterized by a pericardial knock and elevated jugular venous pressure.
# In the evaluation of tender congestive hepatomegaly, the first step is to rule out right-sided heart failure and constrictive pericarditis, then the next best step in the diagnosis would be to do a hepatic venogram or a liver biopsy. #Hepatitis B and C can both be transmitted by blood transfusions Persons who received blood transfusions before 1992 should be screened for Hepatitis C and those with blood transfusions before 1986 should also be screened for
hepatitis B. # Panlobular emphysema and cirrhosis in non-alcoholic, non-smoker young adults are highly suggestive of alpha-1 antitrypsin deficiency. The hepatocytes contain granules w PAS positive and diastase resistant. Risk hepatocellular carcinoma. #Primary sclerosing cholangitis is caused by inflammatory destruction of both the intrahepatic and extrahepatic biliary channels. It is often associated with ulcerative colitis w jaundice, pruritus, RUQ abdominal pain and very high alkaline phosphatase with mild elevation of transaminases. May have Hypergammaglobulinemia, Increased serum IgM, Atypical perinuclear antineutrophil cytoplasmic antibodies (P-ANCA), A number of other autoantibodies (ANA, Anti SMA, anticardiolipin, thyroperoxidase, and rheumatoid factor) may also be present, but they have uncertain clinical significance. Diag: ERCP Cholangiography shows characteristic beading due to strictures and dilation of intra and extra-hepatic ducts. Treatment is directed toward the relief of obstruction and treatment of the infectious complications. Liver transplantation is indicated in deteriorating PSC.
#Newborns of mothers with active hepatitis B should be passively immunized at birth with hepatitis B immunoglobulin followed by active immunization with recombinant HBV vaccine.
# Most of the first line anti tubercular drugs are hepatotoxic except for streptomycin. Many second line anti tubercular drugs can be used in patients who develop significant
hepatotoxicity with the first line drugs. Glucocorticoids would have been indicated in the case of severe miliary tuberculosis # About 10% of patients on isoniazid develop a mild elevation of aminotransferases within first few weeks of the treatment. However, it returns to
normal despite continued use of isoniazid in most of the patients.
# Cigarette smoking is the most consistent reversible risk factor for pancreatic
cancer. Not risk factors Alcohol, Gall stones, Coffee intake
# interferon + lamivudine treat hepatitis B
# All chronic hepatitis C patients with elevated ALT, detectable HCV RNA and histologic evidence of chronic hepatitis of at least moderate grade are candidates
for antiviral therapy with interferon and ribavirin.
# PT is considered the single most important test to assess the function of liver as almost all of the clotting factors except factor VIII are synthesized in the liver.
Tests to assess the functions of liver PT, Albumin, Cholesterol, Bilirubin
Tests to assess the structural integrity and cellular damag Transaminases, Gamma glutaryl transferase, Alkaline phosphatase
A marked increase in the transaminase is indicative of active ongoing tissue destruction. A progressive decrease in transaminase levels can represent either recovery from liver injury or that there is very little tissue left from destruction.
# Rotors syndrome causes predominantly conjugated hyperbilirubinemia
# Non-selective B blockers are used in primary and secondary prevention (recurrent bleeds )of variceal bleeding in cirrhotic patients who have portal hypertension with varices. Endoscopic interventions should be used as the first line to control the acute variceal bleed, Octreotide is used medical management of acute variceal bleeding
# Hyperestronism in cirrhosis leads to gynecomastia, testicular atrophy, decrease bodily hair, spider nevi and palmar erythema.
# Endoscopic retrograde cholangiopancreatography is the investigation of choice for
patients with recurrent pancreatitis with no obvious cause.
# Pseudopancreatic cysts are collections of amylase rich fluid, debris, and tissue in the lesser sac of peritoneum (or bursa omentalis minor). can resolve on their own over 6 weeks. Therefore all the uncomplicated pseudopancreatic cysts smaller than 5cm should be observed for 6 weeks before any therapeutic intervention is done. Serious complications and should be treated with either percutaneous drainage or a gastrostomy
# Chronic hepatitis C who show persistently normal liver enzymes on multiple occasions have minimal histological abnormalities, do not need to be treated, in this case antiviral treatment can lead to liver injury.
# Gallstones and alcoholism are the two most common causes of acute pancreatitis. Ultrasonogram (USG) of the abdomen would provide the best information on the presence/ absence of gallstones. CT scan is better than USG to identify pancreatic edema, necrosis, and cysts but is relatively insensitive for gallstones. Acute pancreatitis is a clinical diagnosis (history and biochemical) and usually does not require CT abdomen to diagnose. CT abdomen is indicated in patients with a white count of >20,000 and when the suspicion for necrotizing pancreatitis/infection is very high.
# HIDA scan is a very sensitive diagnosis of acute calculous or acalculous cholecystitis, but not for acute pancreatitis. ERCP is a very good diagnostic and therapeutic intervention for common bile duct (CBD) stones and chronic pancreatitis # Ursodeoxycholic acid (UDCA) is the medical treatment of small radiolucent gallstones in patients with normal functioning gall bladder who are poor surgical candidates, however it is very costly and has high recurrence rates.
# Hepatic adenoma is a benign tumor seen in middle age females taking oral contraceptive pills. Intra-tumor hemorrhage is the major complication. Biopsy confirms the diagnosis by finding mildly atypical to normal hepatocytes with glycogen deposits. Superficial and big adenomas can be resected, whereas the smaller, asymptomatic ones are managed by imaging surveillance.
# OCP can cause an increase in liver enzyme but it does not cause the liver cell necrosis
# Tuberculous hepatitis granulomas on biopsy
# Cholestasis CPZ, Nitrofurantoin, Erythromycin, Anabolic steroids
Fatty liver Tetracycline, Valproate, Anti-retrovirals
Hepatitis. Halothane, Phenytoin, Isoniazid, Alpha methyldopa
Toxic or fulminant liver failureCarbon tetrachloride, Acetaminophen
# Isoniazid causes idiosyncratic liver injury with histology similar to viral hepatitis.
# chronic hepatitis B persistence of HBsAg in the serum for more than six months
# Liver biopsy is the most reliable way to distinguish chronic active from chronic
# Risk factors for non alcoholic hepatic steatosis are obesity, diabetes mellitus, hyperlipidemia, total parental nutrition and bypass surgery for obesity.
# Autoimmune hepatitis is characterized by presence of anti smooth muscle antibodies and hypergammaglobulinemia.
# Non-alcoholic hepatic steatosis biopsy shows steatosis, polymorphonuclear cellular infiltrates, and necrosis.
# Patients with cirrhosis should have an endoscopy to screen for varices
# The degree of elevation of serum ALT is important in deciding the treatment since it is one of the most important predictors of response to both interferon and lamivudine. Treatment with alpha interferon or lamivudine is unlikely to be effective in patients with normal serum ALT
# Hepatitis E no chronic carrier state, has a very high rate of progression to fulminant hepatitis in pregnant women.
# Orthotopic liver transplantation remains the only effective mode of treatment of fulminant hepatic failure. Liver transplantation is contraindicated if cerebral edema has already ensued.
# Indications for screening for HCV are:
1 IV drug users
2. Persons who received blood transfusions or organ transplantation before July 1992.
3. Hemodialysis patients
4. Persons with chronic elevation of ALT levels.
5. Children born to HCV positive mothers.
6. Health care workers after a needle stick injury or mucosal exposure to HCV positive blood.
7. Patients who received blood transfusions from a donor who later on became seropositive for HCV.
# Chronic hepatitis C is associated with number of extra hepatic
1. Cryoglobulinemia.-- glomerulonephritis
2. B cell lymphomas.
4. Autoimmune diseases like SjDDnDs syndrome and thyroiditis.
5. Lichen planus.
6. Porphyria cutanea tarda.
7. Idiopathic thrombocytopenic purpura.
complications of chronic hepatitis C. Membranous glomerulonephritis is an important one.
# Endoscopic cholangiopancreatography can lead to iatrogenic biliary enteric fistula
causing gas in the biliary tree.
# pain management with chronic pancreatitis endoscopic retrograde
cholangiopancreatography with removal of the stone and stent insertion. # Celiac plexus nerve block can be used to relieve pain in chronic pancreatitis patients with non-dilated
# Acute cholecystitis usually presents with acute onset of fever and right upper quadrant abdominal pain radiating to the right scapula, generally after a meal and associated with leukocytosis. The triad of sudden onset right upper abdominal pain, fever, and leukocytosis is highly suggestive of acute cholecystitis. Impaction of a gallstone in the cystic duct.
# The development of a palpable mass in epigastrium 4 weeks after the onset of acute pancreatitis is highly suggestive of Pseudocyst formation. USG is the investigation of choice.
# spontaneous bacterial peritonitis (SBP) in cirrhotic patients with fever and ascites. treated with empirical cefotaxime or an ampicillin with an aminoglycoside
# Presence of bilirubin in urine is indicative of conjugated hyperbilirubinemia.
# ERCP with sphincterotomy is the treatment of choice for sphincter of oddi dysfunction.
# Females are more susceptible than males to liver injury from alcohol.
# hallmark of alcoholic hepatitis is hepatic cell injury evidenced by the presence of ballooning degeneration, PMN cellular infiltration, and necrosis in the peri-sinusoidal space
# HCV RNA is the single most sensitive serological marker to screen for HCV infection.
# Acute bleeding in patients with liver failure is best treated with fresh frozen plasma. liver synthesizes all the clotting factors except factor VIII.
# Alcoholism is the most common cause of cirrhosis in United States
# Post cholecystectomy pain occurs most commonly because of a common bile duct stone, sphincter of Oddi dysfunction, or functional causes. having normal liver function tests and no dilatation of biliary tree, then sphincter of Oddi dysfunction and CBD stone can be ruled out
# Choreiform movements copper deposition in basal ganglia
# Hypertriglyceridemia > 1000mg/dl can cause acute pancreatitis.
# Spironolactone is the diuretic of choice in the treatment of cirrhotic ascites.
# : Halothane hepatotoxicity can be of two types: Type 1 is mild elevation of liver enzymes without jaundice and Type 2 is characterized by acute liver failure. Acute liver failure will have elevated prothrombin time, decrease in serum albumin levels
# Benign intrahepatic cholestasis can develop after a major surgery in which hypotension, extensive blood loss into tissues and massive blood replacement are notable. Syptem: jaundice by second or third postoperative day, alkaline phosphatase levels can be markedly elevated, the AST and ALT levels are only mildly elevated
# Transjugular intrahepatic portosystemic shunt (TIPS)
1. Refractory cirrhotic hydrothorax.
2. Refractory ascites (defined as diuretic resistant or diuretic refractory ascites).
3. Recurrent variceal bleed not controlled by other minimal invasive means.
4. Patients waiting for liver transplantation and needing portocaval shunts.
# Emphysematous cholecystitis is a common acute complication in elderly diabetic males due to infection of the gallbladder with gas forming bacteria. X-ray showing air fluid levels in the gallbladder and the ultrasonogram showing the curvilinear gas shadows in the gallbladder.
# Protein free diet, lactulose, and neomycin are used for the treatment of acute hepatic
1. During acute attack all the dietary protein should be withheld. Later on patient should be started on low protein diet of 20 g/day.
2. Give oral or rectal lactulose. Bacterial action on lactulose results in acidification of the colon contents, which converts the absorbable ammonia into nonabsorbable ammonium ion (ammonia trap).
3. Oral neomycin a nonabsorbable antibacterial agent kills the colonic bacteria producing ammonia.
# Hepatocellular carcinoma is characterized by minimal elevations of alkaline phosphatase and marked elevation of AFP.
# Acute liver failure is defined as development of liver failure within 8 weeks of onset of hepatocellular injury. Fulminant hepatic failure is defined as acute liver failure with hepatic encephalopathy. most commonly due to acetaminophen toxicity.
# Balloon degeneration with polymorphic cellular infiltrates acute alcoholic hepatitis
# Panlobular mononuclear infiltration with hepatic cell necrosis acute viral hepatitis.
# Portal necrosis including piecemeal necrosis and/or bridging fibrosis chronic hepatitis.
# Inflammatory destruction of small intrahepatic biliary ducts primary biliary cirrhosis
# Reye’s syndrome or acute fatty liver with encephalopathy(hepatic mitochondrial injury) can lead to fulminant hepatic failure in children. it is characterized by extensive fatty vacuolization of the liver. markedly elevated serum aminotransferases, ammonia levels, PT prolongation, hypoglycemia and metabolic acidosis. treatment consists of administration of glucose with FFP and mannitol to decrease the cerebral edema.
# The treatment of acute cholangitis is to give supportive care, broad-spectrum antibiotics, and biliary drainage with an endoscopic retrograde cholangiopancreatography.
# Primary biliary cirrhosis usually presents in middle age and 90 percent of patients are females. Pruritus is generally the first symptom and is very severe, especially at night. It is characterized by markedly elevated serum cholesterol levels, alkaline phosphatase, IgM, and minimally elevated aminotransferases. Jaundice and osteopenia occur in later stages of disease. associated with SjDDnDs disease, RA, and CREST syndrome. Liver biopsy granulomatous destruction of bile ducts in portal triad. The presence of anti mitochondrial antibodies. Ursodeoxycholic acid decreases the pruritus and slows the rate of progression. The definitive treatment is liver transplant
# In the evaluation of asymptomatic elevation of aminotransferases, the first step is to rule out alcohol, drug use The next step in the evaluation should be to repeat the liver function tests after stopping the drugs and alcohol. If only AST is elevated then ALT should be checked to rule out extrahepatic causes of AST elevation, because ALT is more specific for liver injury than AST.
# Hydatid cysts in the liver are due to infection with Echinococcus granulosus. Most of the patients asymptomatic and generally diagnosed on screening for some other problem. CT well-defined cyst will egg shell calcifications
# Cysticercosis secondary to infection with tenia solium and generally results in cysts in the brain or in muscle.
#HAV vaccine or serum immune globulin should be given to all non-immunized travelers to endemic region. The vaccine might take at least one month for the immunity to become effective. So traveling in a month serum immune globulin
# ERCP is a good evaluation tool in case of suspected chronic pancreatitis to look for abnormalities of the pancreatic and biliary ducts.
# Hemochromatosis is an autosomal recessive disorder characterized by increased skin pigmentation, diabetes, cirrhosis and arthralgia.
# The presence of cirrhosis in a young patient with choreiform movements and the finding of a Kayser Fleischer ring (yellow brown pigmentation of the cornea) are highly suggestive of Wilson’s disease
# Amebic abscess is characterized by an Danchovy paste’ collection in the liver.
Treatment is with oral metronidazole.
# Principles of conservative treatment for acute pancreatitis are as follows:
1. Give analgesics for pain.
2. Intravenous fluids to maintain intravascular volume.
3. No oral alimentation.
4. Nasogastric suction to decrease gastrin release from the stomach and prevent gastric contents from entering the duodenum. Recent studies have shown that nasogastric suction must be considered elective rather than mandatory.
#The pathogenic factors involved in the development of hepaticencephalopathy are:
1. Accumulation of ammonia in blood.
2. Production of false neurotransmitters.
3. Increased sensitivity of the CHS to inhibitory neurotransmitters like GABA.
4. Zinc deficiency.
# Gallbladder carcinoma is a rare tumor found in patients with chronic choledocholithiasis and usually diagnosed intra or post operatively after a cholecystectomy.
# Acyclovir --prophylaxis or treatment of herpes simplex infection in transplant patients. Ganciclovir --prophylaxis or treatment of cytomegalovirus infection in transplant patients. Oral Trimethoprim-sulfamethoxazole is effective in preventing Pneumocystis carinii in transplant patients.
# Trimethoprim -sulfamethoxazole is used for prophylaxis of Toxoplasmosis, while sulfadiazine and pyrimethamine is for treatment
# Esophagitis occurs with HIV CD4 counts less than 50/microL caused by Candida, Herpes simplex virus (HSV), or Cytomegalovirus (CMV). Tx: first started on fluconazole directed against candidiasis. If fail to respond to 3-5 days, The next step is to perform esophagoscopy with cytology, biopsy and culture to find out the specific etiology.
# Streptococci viridians species (S. mutans - most commonly) are the most commonly causes
endocarditis following dental procedures. S. epidermidis is cause of prosthetic valve endocarditis; Group B streptococcal endocarditis include diabetes mellitus, carcinoma, alcoholism, hepatic failure, elective abortion, and intravenous drug use.
# S. Bovis is a normal inhabitant of the Gl tract, and is associated with colon cancer. Colonoscopy should be performed when this organism is isolated from blood cultures
# All the allogenic bone marrow recipients are at risk for CMV pneumonitis, however, CMV pneumonitis is not seen in immediate post transplant period, about 2 weeks after. X_ray diffuse patchy infiltrates. high-resolution chest CT ground glass attenuation and innumerable small nodules, parenchymal opacification
# VDRL is a useful screening test and FTA-ABS is a confirmatory test for syphilis.
# Intermittent catheterization is an effective measure to reduce the risk of UTI in patients with neurogenic bladder.
# Diarrhea due to Vibrio parahemolyticus -- ingestion of seafood
# Pseudomonas aeruginosa is the most frequent cause for malignant otitis externa
# The patients with uncomplicated pyelonephritis can be usually switched to an oral antibiotic after 48-72 hours of parenteral therapy. The average duration of antibiotic therapy during uncomplicated pyelonephritis is two weeks
#Albendazole or mebendazole is the first line of treatment for E. vermicularis infection( nao cong in child ). Pyrantel palmate is an alternative.
# Intravenous cefotetan, ampicillin/sulbactam, or the combination of clindamycin and a fluoroquinolone is the appropriate empirical treatment for limb-threatening infections. In diabetics, whereas mild, or non-limb-threatening, infections can be treated with oral antibiotics like cephalosporin, clindamycin, amoxicillin/clavulanate and fluoroquinolones. Infections that do not improve after forty-eight hours of antibiotic therapy require the addition of antimicrobial therapy to treat methiciHin-resistantS. aureus (e.g., vancomycin) and Pseudomonas aeruginosa (Ticarcillin).
# Gonorrhea is a common infection and is characterized by cervicitis and urethral discharge and pharyngeal inflammation cause by oral sex
# Mucormycosis(Rhizopus infection) requires aggressive surgical debridement plus early systemic chemotherapy with amphotericin B. which is the only effective drug against this fungus.
# Whenever a health care worker is exposed to HIV, baseline HIV testing should be performed immediately and postexposure prophylaxis with combination of two or three anti retroviral drugs should be started without any delay.
# Babesiosis is a tick borne illness Long island, splenectomized, hemolytic anemia associated with jaundice. Tx: quinine-clindamycin and atovaquone-azithromycin. # Rocky Mountain spotted fever Ehrlichiosis, include fever, malaise, headache, nausea or vomiting. Labs show
leukopenia and thrombocytopenia.
# In a HIV patient, bilateral interstitial pneumonia(fluffy infiltrates) is most likley due to Pneumocystis carinii infection occurs with CD4 counts less than 200/microL. Tx: Trimethoprim-sulfamethoxazole. IV pentamidine is an alternative when patients cannot tolerate trimethoprim-sulfamethoxazole. Inhaled pentamidine is used for prophylaxis. For moderate to severe Pneumocystis carinii in individuals with AIDS, the use of adjunctive corticosteroids has decreased mortality. Prednisolone is used in combination w trimethoprim-sulfamethoxazole when Pa02 is less than 70 mmHg
# IV cefuroxime is used to treat bacterial pneumonias. Bacterial pneumonia in HIV-infected patients usually occurs with CD4 counts above 200, onset is abrupt and patient is usually productive of sputum with chest pain and high fever.
# Nocardia is a gram-positive filamentous branching rod with weak acid fast staining. Lung is the most frequently involved organ and it may produce suppurative, granulomatous or mixed disease. It may cause nodules, lung abscess, cavity, reticulonodular, or diffuse pulmonary infiltrates.
# The organism most likely responsible for endocarditis in native valves, following dental procedures, is Streptococci viridians. Four types of S. viridans cause IE, they are S. mitis, S. sanguis, S. mutans, and Streptococcus saiivarius. S. mutans is the most commonly involved organism in dental caries.
# Intravenous ceftriaxone or cefotaxime are indicated for early disseminated and late Lyme disease. In pregnant and lactating women and in children-- amoxicillin.
#Strep viridans is the most frequent cause of infective Subacute endocarditis with damaged heart valves. Staph aureus is major cause of acute infective endocarditis in IV drug abusers. Staph. Epidermidis is the most frequent cause of infective endocarditis with prosthetic valves. Staph. Saprophyticus usually causes urinary tract infections.
# Prophylaxis against Mycobacterium Avium Complex (MAC) in HIV-infected patients is indicated when CD4 cell count falls below 50/micro-L Azithromycin or clarithromycin
# Blastomycosis is big-based budding yeast. Skin - crusted, heaped up and warty with violaceous hue w sharp border , maybe surrounded by micro abscesses
# In case of suspected osteomyelitis, blood cultures and x-rays should be taken and the patient should be started on intravenous antibiotics. If the x-rays are negative three-phase technetium bone scan should be considered. Needle biopsy can be done to identify the organism if the blood cultures are negative.
# In both infants and children, Staphylococcus aureus is the most common organism responsible for osteomyelitis. S. Epidermidis is a frequent cause of osteomyelitis associated with prosthetic devices. Salmonella is a frequent cause of osteomyelitis in patients of sickle cell anemia. Gram-negative rods like Klebsiella or Pseudomonas cause osteomyelitis when patients have a history of urinary tract infection (UTI) or urinary instrumentation.
# Empiric antibiotic therapy with either ceftazidime or cefepime should be started in febrile neutropenic patients.
# Pig farmers are at high risk for neurocysticercosis
#The majority of human infections with E. granulosus are asymptomatic. Hydatid cysts can be found in almost any part of the body but liver (MC) is involved in two-thirds of patients and the lungs are involved in 25 percent of patients. It is most commonly seen in areas where sheep are raised—Echinococcosis
# Urethral cultures have higher yield than synovial or blood culture in cases of suspected gonococcal purulent arthritis.
# Hematological abnormalities seen in infectious mononucleosis include autoimmune hemolytic anemia, thrombocytopenia, disseminated intravascular coagulation. (DIC) and thrombotic thrombocytopenic purpura / hemolytic uremic syndrome (TTP/HUS).
* infectious mononucleosis cause autoimmune hemolytic anemia
# Abrupt onset of nausea and vomiting is mot likely due to intake preformed toxin, Staphylococcus aureus toxin is present in foods like dairy, salad, meat and eggs and symptoms usually begin within one to six hours after ingestion.
toxin of Bacillus cereus is present in rice.
# Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae and primarily affects the peripheral nerves and skin. In the early part of the disorder, it may present as a hypopigmented patch, which is insensate. With progressive peripheral nerve damage, muscle atrophy is common causing crippling deformities of the hands. diagnosis is made by demonstration of acid-fast bacilli in skin biopsies
# Drug of choice for early syphilis is benzathine penicillin G and a single IM injection is required. For those patients who are allergic to penicillin, doxycycline or tetracycline is given for 14 days. For patients with neurosyphilis, IV aqueous crystalline penicillin is the treatment of choice and IM procaine penicillin is a good alternative.
# Ciprofloxacin is contraindicated in children as it may cause cartilage destruction and growth retardation.
# Whenever there is a severe acute exacerbation of pulmonary infection in a patient with cystic fibrosis, a combination of an aminoglycoside with anti-pseudomonal penicillin is the preferred therapy. ceftazidime or cefepime and aminoglycoside, In adult patients, a fluoroquinolone like ciprofloxacin may be used as an alternative to aminoglycosides
# Treatment of disseminated Histoplasmosis in HIV patients is IV amphotericin B followed by lifelong treatment with itraconazole. Initial treatment with IV amphotericin B decreases the fungal load and lifelong treatment with itraconazole prevents relapse.
** Immunocomplex disease is primarily responsible for glomerulonephritis, Roth spots and OslerDs nodes. Janeway(macular, blanching, nonpainful, erythematous lesions on the palms and soles) lesions result from septic embolism.
# Cervicofacial actinomycosis classically presents as slowly progressive, non-tender, indurated mass, which evolves into multiple abscesses, fistulae, and draining sinus tracts with sulfur granules, which appear yellow. The treatment of actinomycosis is high dose penicillin or erythromycin for 6-12 weeks.
# Granuloma inguinale (Gl) caused by Donovania granuiomatis. the ulcer and lymphadenopathy of granuloma inguinale present at the same time. Moreover, the ulcer of Granuloma inguinale has irregular borders and is characterized by a beefy red granular base.
# Untreated Lymphogranuloma venereum caused by Chlamydia trachomatis may progress to a severe and chronic disease causing ulceration, proctocolitis, rectal stricture, rectovaginal fistulas and elephantiasis.
#The herpes simplex virus (HSV) esophagitis ulcers are usually multiple, well circumscribed and have a "volcano" (small and deep) like appearance, whereas the ulcers seen in CMV infection tend to be large, shallow and superficial w A biopsy -- intracellular inclusions
Esophagitis caused by CMV, tx: iv Ganciclovir
# Skin induration of greater than 5 mm with PPD testing in HIV patients requires prophylaxis with isoniazid for 9 months.
# Heterophil antibody test is sensitive and specific for diagnosis of IM. EBV specific antibody test is used in patients with high suspicion for IM and have negative heterophil antibody test.
# Herpes simplex virus (HSV) encephalitis-- affects temporal area, bizarre behavior and gustatory hallucinations, in onset and fever is present along with impaired mental status. CSF tested by PCR for herpes simplex virus DNA is now the diagnostic test of choice, IV acyclovir should be started without delay.
# arterial insufficiency and peripheral neuropathy account for the susceptibility of diabetic patients to foot ulcer. The infection can spread from the soft tissues to the bone. Such contiguous spread is the most likely pathogenic mechanism of contiguous osteomyelitis in patients with arterial insufficiency (mostly diabetic patients).
** Streptococcus pneumoniae is the most common pathogen causing pneumonia in nursing home patients.
# Condylomata acuminata caused by are skin colored or pink, verrucous and papilliform skin lesions present around the anus. Tx: podophyllin
# Ganciclovir prophylaxis is given when CD4 count is less than 50/cu.mm and serum CMV IgG is positive or there is a positive biopsy for CMV.
# H. Influenza and Moraxella catarrhalis are the common causes of bacterial sinusitis.
# Mucor mycosis of the nose and maxillary sinus caused by Rhizopus. Poorly controlled DM is a predisposing factor for this disease. Low-grade fever, bloody nasal discharge, nasal congestion, involvement of the eye with chemosis, proptosis and diplopia are important features. Involved turbinates usually become necrotic.
# Streptococcus bovis endocarditis is associated with colorectal cancer and colonoscopy is advisable in such patients.
# Erysipelas is a specific type of cellulitis in which there is inflammation of the superficial epidermis producing prominent swelling. The characteristic finding of erysipelas is a sharply demarcated, erythematous, edematous tender skin lesion with raised borders. most frequently caused by group A- beta-hemolytic streptococci.
# IV amphotericin-B plus oral flucytosine is the initial treatment of choice for central nervous system cryptococcal infection(positive India ink staining) in AIDS patients. oral fluconazole is started with the discontinuation of amphotericin and flucytosine.
# Ehrlichiosis-- tick bite, systemic symptoms along with leukopenia and thrombocytopenia, Usually there is no rash. Tx: Doxycycline
# Tick bite is not treated prophylactically even in high-risk patients. Amoxicillin prophylaxis is given in pregnant patients who have history of tick bite and have anxiety about acquiring disease.
# Kaposi sarcoma -- trunk, face and the extremities. papules that later on become plaques or nodules. The color from light brown to pink to dark violet.
Pneumocystis carinii may cause nodular and papular cutaneous lesions of external auditory meatus in immunocompromised HIV patients
Bacillary angiomatosis is caused by Bartonella species, a gram-negative bacillus. Cutaneous lesions are round reddish papules or nodules, vascular and are associated with fever, malaise and headaches.
# Salmonella species are the most common organisms (upto 70% of cases) causing osteomyelitis in patients with sickle cell disease; Staph aureus accounts for less than 25% of cases. In general population, Staphylococci aureus is the most common organism causing osteomyelitis
# the treatment of RMSF needs to be initiated on clinical suspicion. doxycycline (oral or intravenous) for adults and children
# Three phase technetium scan is the test of choice for acute osteomyelitis. MRI is usually performed for suspected osteomyelitis of the spine and some times foot. CT scan is not very sensitive in detecting osteomyelitis. Plain x-ray films are usually normal in first two to 3 weeks of acute osteomyelitis
# Pseudomonas aeruginosa is a frequent cause of osteomyelitis in adults with nail puncture wound. A bone scan is extremely sensitive, and is recommended for diagnosis early in the disease course. Treatment is with oral or parenteral quinolones and aggressive surgical debridement.
#Histoplasmosis – Missouri, mucous membrane ulcers, hepatosplenomegaly and pancytopenia, x-ray are consistent with interstitial pneumonitis
# Coccidioidomycosis is endemic in Arizona, New Mexico, Texas, Central and South USA. Primary pulmonary infection has non- specific features like fever, fatigue, dry cough, weight loss and pleuritic chest pain. Cutaneous findings like erythema multiforme and erythema nodosum as well as arthralgias are immunologically mediated.
# Aspergillosis-- occurs in immunocompromised, Chestx-ray may show cavitary lesion. CT scan shows pulmonary nodules with halo sign or lesions with air crescent. Aspergillus is ubiquitous in its geographic distribution.
# Cat-scratch disease is an infectious disease caused by B. henselae, transmitted by a cat scratch or bite, vesicular, erythematous and popular. Tx: Five days of azithromycin
# Stool examination should be done first in all HIV-infected patients with diarrhea for bacterial culture, ova and parasites. Colonoscopy and biopsy of the ulcers is reserved for those with persistent diarrhea and negative stool examination.
# History of rheumatic fever, presence of murmur and hematuria suggest the diagnosis of infective endocarditis. Hematuria in bacterial endocarditis is usually the result of glomerular injury caused by deposition of immune complexes.
# Trichinosis has two phases. The initial phase is manifested by gastrointestinal complaints, such as abdominal pain, nausea, vomiting and diarrhea. It is followed by, features like subungual splinter hemorrhages, conjunctival and retinal hemorrhages, periorbital edema and chemosis. As larvae enter skeletal muscles, muscle pain, tenderness, swelling and weakness occur.
# Orchitis is one of the most frequent complication of mumps. Tx: Steroids
# ELISA is the preferred test to screen for HIV infection, Western blot is a confirmatory test for HIV infection
# Cysticercosis is a parasitic disease caused by the larval stage of Tenia solium, also known as pork tapeworm. The most prominent clinical manifestation includes neurocysticercosis (NCC), which is characterized by multiple small (<1 cm usually, but can be larger) fluid-filled cysts in the brain parenchyma. Humans develop NCC from ingestion ofT. solium eggs, which are shed by infected animals and not from ingestion of infected pork. Thus, people who do not eat pork can also have NCC
# Condyloma Lata(exophytic formations which develop abundantly on the anogenital region or upper thighs, and ulcerate subsequently) and bilaterally symmetrical maculopapular rash involving the entire trunk and extremities are characteristic of second stage of syphilis. Remember the rash is present on palms and soles. Serological tests are positive in secondary syphilis.
# The three most frequent causes of community-acquired meningitis are Pneumococcus, Hemophilus influenzae and Meningococcus. Listeria monocytogenes is a frequent cause of meningitis in patients older than 55.
empiric antibiotic regimen—vancomycin+ ceftriaxone+ ampicillin
# Itch, redness and fissuring in swimmers is typical of athlete’s foot. treated with antifungal creams such as tolnaftate.
# Amoxicillin-clavulanate --prophylaxis infections caused by human bite.
# The cutaneous lesions of Kaposi sarcoma are asymptomatic, elliptical, arranged linearly on areas such as legs, face, oral cavity and genitalia. They are initially papules and later develop into plaques or nodules and their color changes from light brown to violet. There is no necrosis of skin or underlying structures.
# All of the patients who are diagnosed with HIV infection should have the following evaluations:
1. A detailed history and physical examination.
2. A routine chemistry and hematology.
3. Two plasma HIV RNA levels.
4. A CD4 T lymphocyte count.
5. A VDRL test for syphilis.
6. A PPD skin test.
7. An anti-Toxoplasma antibody titer.
8. A Mini Mental Status Examination.
9. A pneumococcal polysaccharide vaccine, unless the CD4 count is less than 200/cmm.
10. Hepatitis A and B serology.
11. Hepatitis A and B vaccine if seronegative.
12. HIV counseling.
13. Extend help and information to those who might have been infecteded by the subject.
The following studies are indicated before starting anti retroviral
1. A complete history and physical examination.
2. A CBC, complete blood chemistry, serum transaminases, and lipid profile.
3. A CD4 T lymphocyte count.
4. A plasma HIV RNA titer.
Trimethoprim-sulphamethoxazole prophylaxis against P. Carinii is indicated in HIV-positive patients whose CD4 count is less than 200/cmm.
# Mitral regurgitation is the most common valvular abnormality observed in patients
with infective endocarditis not related to IV drug abuse.
# Proteus is the most likely cause of urinary tract infection in patients with alkaline urine. Proteus produce a urease which makes the urine alkaline.
# Sporotrichosis-- papule at the site of inoculation and followed by ulceration and lymphadenopathy. It is classically seen in gardeners.
# Cutaneous larva migrans or creeping eruption-- sandy beach and sand boxes contact, erythematous papule followed by characteristic severely pruritic elevated, serpiginous, reddish brown lesions
# Lyme disease-- The infectious spirochetes (Borrelia burgdorferi) are transmitted to humans through bites of the tick, Ixodes
# hemochromatosis are vulnerable to listeria monocytogenes infections. Iron overload is also a risk factor for infection with Yersinia enterocolitica and septicemia from Vibrio vulnificus both of which are iron-loving bacteria.
# The presence of gram-negative bacilli in sputum of an intubated intensive care unit (ICU) patient with fever and leukocytosis is highly suggestive of nosocomial pseudomonas infection. Pseudomonas aeruginosa is a common cause of gram-negative nosocomial pneumonia
#Any HIV-positive patient with bloody diarrhea and normal stool examination should have a colonoscopy and biopsy done to look for CMV colitis. CMV colitis is characterized by bloody diarrhea with abdominal pain, multiple ulcers and mucosal erosions on colonoscopy; biopsy shows characteristic cytomegalic cells with inclusion bodies-- large cells with eosinophilic intranuclear and basophilic intracytoplasmic inclusions (OwlDs eye effect).
# infective endocarditis in iv drug abuse. Tx: vancomycin and gentamycin
# Pneumococcal vaccine is recommended in all HIV infected patients whose CD4
count is above 200 cells/mi cro-L.
** Steroids have been shown to decrease the mortality in patients with severe PCP infection. Indication of steroid use in PCP includes:
1. PaO2<70mmHg. 2 . A-a gradient > 35;
# For chemoprophylaxis of malaria, chloroquine is the drug of choice. However, Southeast Asian countries like India, Pakistan and Bangladesh -- chloroquine resistant malaria is present in these areas. mefloquine should be given instead of chloroquine
# Blood smear with atypical lymphocytes should make you rank Cytomegalovirus
(CMV) higher on the list in a patient with mononucleosis Iike symptoms.
#Nocardiosis is diagnosed by the presence of crooked, branching, beaded, gram-positive, and weakly acid-fast positive filaments on microscopy. The combination of sulfamethoxazole and trimethoprim is the treatment of choice-- pulmonary nocardiosis nodule with cavity
# Glucocorticoids are indicated in a case of infectious mononucleosis complicated by upper airway obstruction, autoimmune hemolytic anemia, and thrombocytopenia.
# Facial nerve palsy and classical Erythema migrans (EM) indicate Lyme disease, Lyme disease may cause palsy of any cranial nerve with facial nerve palsy being the most common.
# a positive PPD >10 mm. all patients with positive PPD should undergo a chest x-ray. If the lesion is present and the patient is asymptomatic, she should start INH and pyridoxine as prophylaxis. If the chest x-ray is negative, no workup is necessary. If the patient is symptomatic she should be treated with combination drugs
# hyperthyroidism is very well tolerated by pregnant women. Graves disease is the most common cause of hyperthyroidism in pregnancy
# Sudden onset atrial fibrillation in pregnant women should alert the physician to look for hyperthyroidism. Diagnosis is best made with serum TSH and free T4 ieveis. However, the best screening test would be TSH oniy.
# selective mutism in a child who is verbal and talkative at home, but does not speak in select places such as school and other social events. Social phobia in childhood may occur due to learning and communication disorders # Testicular feminization syndrome present with amenorrhea, developed breasts, absent pubic and axillary hair, absent internal reproductive organs, and a 46 XY karyotype. defect or absence of androgen receptors resulting in androgen resistance of peripheral tissues. The Mullerian Inhibiting Factor (MIF) is produced by the gonads, so the uterus, tubes and vagina are absent. Breasts develop because of peripheral production of estrogen
# Placenta previa presents commonly with bright red and painless vaginal bleeding in the third trimester. Diag ultrasonography
# Vasa previa fetal blood vessels traverse the fetal membranes across the lower segment of the uterus between the fetus and the internal cervical os. a painless antepartum hemorrhage, associated with rapid deterioration of the fetal heart tracing.
# Abruptio placenta- Painful third trimester vaginal bleeding with normal ultrasound
# Alpha-Feto-protein (AFP) is produced by the yolk sac and fetal liver. Increased levels are seen in the presence of neural tube defects, abdominal wall defects (Gastroschisis, Omphalocele), as well as false positive causes such as fetal demise, multiple gestation, and inaccurate gestational age. However, the most common cause of abnormal AFP is a gestational age error. In the case of an increase in MSAFP levels, the physician should first perform an ultrasonography to rule out the false positive causes, and to detect the presence of any anomaly that may be seen by ultrasound. Amniocentesis has to be ordered afterwards for confirmation by measuring amniotic levels of AFP and Acetylcholinesterase (AChE). AChE is a protein that is increased only in neural tube defects. Low levels of MSAFP are frequently associated with chromosomal anomalies, especially Down’s syndrome Triple test: A combination of a decreased MSAFP, increased beta-hCG and decreased UE3 levels is typical of Down’s syndrome. in trisomy 18, all three parameters are decreased
# pelvic inflammatory disease hospitalization is usually needed especially for women who are severly infected (i.e. with temperature > 39 C, nausea and vomiting or signs of ileus), adolescents, nulliparous (such as in this case), women with low socioeconomic status and women who fail to respond to oral antibiotic therapy. ; in hospitalized patients, used regimens include Cefoxitin/Doxycycline, Cefotetan/Doxycycline and Clindamycin/gentamycin. In non-hospitalized patients, Cefoxitin/probenecid or Ceftriaxone/Doxycycline are used. The patient's partner should also be treated. # Ovulatory abnormalities may initially be screened for by basal body temperature and midluteal level of progesterone; the former assesses the duration of the luteal function and the latter the level of the luteal function. #Diabetes screening is performed between 24 and 28-weeks of gestation. The screening test is the 1-hour 50 g oral glucose tolerance test(>140 mg/dL). Confirmation is done by the 3-hour 150 g OGTT.
# In mild peeclampsia bed rest, salt-reduced diet, and close observation. Hypertensive therapy is used in patients with BP >160/110 mmHg, and patients with CNS symptoms regardless of the BP.
# Pregnancy leuteoma usually appears as bilateral, multinodular, solid masses on both ovaries. It is characterized by replacement of the normal ovarian parenchyma by solid proliferation of luteinized stromal cells under the influence of human chorionic gonadotropin (HCG). It is a benign self-limited condition and requires no treatment.
# Radiation levels used for diagnostic exams are not assocaited with teratogenicity. Doses inferior to 5 cGy are not associated with fetal abnormalities Termination of pregnancy should be considered and even mandated when the mother is exposed to doses between 5 and 10 cGy.
# Beta-2 agonists may worsen the edema by decresaed water clearance, tachycardia and increased myocardial workload. It increase gluconeogenesis in the liver and muscle resulting in hyperglycemia, which increases insulin requirements in diabetic patients. The mean arterial pressure do not change with beta-agonist treatment, since the rise in systolic pressure is compensated by decrease in diastolic pressure.
# Abdominal circumference is the most effective parameter for estimation of fetal weight in cases of suspected IUGR. IUGR may be symmetrical and asymmetrical. In symmetrical growth restriction, the insult to the fetus begins before 28 weeks gestation and growth of both the head and the body is deficient. It is usually caused by congenital infections, congenital anomalies and vascular diseases of the mother. Asymmetrical IUGR is a result of a late exposition to the insult past 28 weeks and is characterized by a normal or almost normal head size and a reduced height and weight.
3 Grave's disease and migraine headaches improve in pregnancy. Beta-blockers should be avoided as they may decrease placental blood flow and cause growth retardation.
# In a patient with primary amenorrhoea and no breasts Estrogen is low. Need to measure FSH, if it is decreased, GnRH stimulation test is the next step; if it is increased, karyotype is the next step. If karyotype is normal, diagnosis of ovarian agenesis or dysgenesis is established. Measurement of LH has no diagnostic value.
# BUN, serum creatinine, and hematocrit are often decreased in pregnant patients, and it is due to a dilutional affect.
# Combination of thrombocytopenia, microangiopathic hemolytic anemia and increased liver enzymes in a patient with preeclampsia is defined as HELLP syndrome.
# the first step in the workup of male infertility is the sperm count. If the sperm count is abnormal, an endocrine evaluation is carried out; it includes (1) thyroid function tests, since like in the female, increase in TSH inhibits GnRH production and consequently decreases FSH production; (2) testosterone levels to indicate the presence or not of hypogonadism; (3) gonadotropin levels to determine whether the hypogonadism is central or testicular; and (4) prolactin levels.
# Prolactin is responsible for milk synthesis whereas oxytocin for contraction of the gland’s ducts and acini and thus excretion of milk.
# for lactation suppression Tight fitting bra and ice packs
# Premature rupture of membranes When the patient is not in labor, and whether the pregnancy is at term or not, the hand of the examiner should not be inserted into the vagina because of the increased risk of infection, and the examination should be performed with a sterile speculum.
# phenytoin and other hydantoins in utero Neuroblastomas.
# cocaine abuse & Folate deficiency can cause Abruptio placenta. Once the diagnosis is made, a large-bore IV line, as well as a Foley catheter must be placed. Blood products should always be available. Patients with placental abruption in labor have to be managed aggressively to insure a rapid vaginal delivery, since this will remove the inciting cause of DIC and hemorrhage
# Ritodrine is beta 2 agonist and is contraindicated in hypertension.
# benign edema of pregnancy Cramps and mild leg edema
# the earliest sign of magnesium sulfate toxicity depressed deep tendon reflexes. The second sign of toxicity is respiratory depression, then coma, the cardiac arrest and death. The treatment of MgS04 toxicity is to immediately stop the infusion then to administer calcium gluconate
# Danazol is an androgen derivative that has a gonadotropin inhibitory effect. It is indicated in endometriosis, fibroids and fibrocystic breast disease
#A defect in the luteal phase refers to a relatively low progesterone secretion by the corpus luteum. Progesterone is important for embryo implantation and maintenance of pregnancy, so a defect in its secretion may cause infertility even if ovulation takes place. The defect may affect the level or duration of production of progesterone. Luteal phase defect is suggested by short cycles, history of spontaneous abortion, abnormal basal body temperature (BBT) or low levels of midluteal progesterone. The diagnosis is confirmed by endometrial biopsy, which demonstrates a lag in endometrial maturation of 2 days or more as compared with normal states.
Luteal phase defect is treated with progesterone vaginal suppositories. Clomiphene citrate or human menopausal gonadotropin (hMG) may be used if progesterone suppositories give no results; they increase serum FSH level and thus correct follicular maturation and oocyte expulsion
# Labor progresses through four stages:
1 The first stage extends from the onset of labor until full dilation of the cervix, and includes two phases: a latent phase, during which dilation progresses at a slow rate until reaching 2-3cm, followed by an active phase, during which the dilation is more rapid. The length of the latent phase is highly variable but is considered prolonged when it exceeds 20 hours in the primiparous and 14 hours in the multiparous. The progression of the active phase is evaluated by the rate of cervical dilation. At this phase, the cervix normally dilates at a rate of at least 1cm/hr in the primiparous and 1.2cm/hr in the multiparous.
2 The second stage of labor extends from complete dilation of the cervix to delivery of the baby. It usually lasts 30 min to 3 hours in the primiparous, and 5 to 30 minutes in the multiparous.
3 The third stage of labor starts with the delivery of the baby, and ends with the delivery of the placenta.
4 The fourth stage extends from delivery of the placenta until 6 hours postpartum. The mother should be closely observed during this stage because of the risk of postpartum hemorrhage.
Prolonged latent phase can be caused by hypertonic uterine contractions( Tx: rest with morphine sulphate), hypotonic contractions(treated with a diluted infusion of oxytocin), or premature or excessive use of anesthesia or sedation.
Anesthesia may reduce uterine activity if administered in the latent phase
# Prolactin production is inhibited by dopamine and stimulated by serotonin and TRH. Hypothyroidism may result in amenorrhea and galactorrhea
# trichotillomania in patients with uncontrollable urges to pull out their hair, resulting in alopecic patches.
# Syphilis by the spirochete Treponema Pallidum.
1.The chancre-- primary stage: painless, indurated ulceration with a punched-out base and
rolled edges w painless inguinal adenopathies. heals spontaneously in 3 to 9 weeks.
Serologic testing is not reliable at this stage and includes a high rate of false-negatives, so
diagnosis in the first stage is made via spirochete identification on dark field microscopy
2.The Condylomata Lata z(anogenital region or upper thigh)--second stage: malaise,
headaches, anorexia and a generalized maculopapular rash and/or moist papules on the
skin or mucous membranes.
3. Tertiary syphilis-- gummas of the skin and bones, aortitis, meningovascular disease,
paresis and tabes dorsalis. Gummas are nodular formations that ulcerate and become
necrotic, leaving large defects in the structure
# The ulcer in chancroid is very painful, has a gray base and is foul smelling. inguinal nodes are painful with subsequent bubo formation and suppuration
# The ulcer of granuloma inguinale starts as a nodule or papule, rapidly ulcerates. painless, irregular borders and a beefy red granular base.
# Metronidazole for Trichomonas vaginitis(thin, bubbly and grayish vaginal discharge accompanied with erythema and swelling of the vulva and vaginal mucosa. strawberry cervix) to both the patient and the partner. Clotrimazole cream is preferably used in pregnancy because of the risk of teratogenicity of metronidazole
# Midplevis contraction which is indicated by prominent ischial spines is an important
cause of arrest disorder of dilation. Tx: C-section.
# Anesthesia may cause a decrease in the strength of uterine contractions if it is administered in the latent phase.
# Asymmetrical IUGR is a result of a late exposition to the insult past 28-weeks and is characterized by a normal or almost normal head size and a reduced abdominal circumference. It is usually caused by maternal factors such as hypertension, preeclampsia and chronic renal disease.
# Polycystic ovarian syndrome(irregular periods, acne, hirsutism)
is an risk factor for type-2 diabetes mellitus in women
# The benefits of metformin use in polycystic ovarian syndrome are as follows:
1. It helps prevent type 2 diabetes mellitus.
2. Helps losing weight by causing anorexia (most of the patients with polycystic ovarian syndrome are obese).
3. In conjugation with clomiphene citrate, it helps to induce ovulation in infertile polycystic ovarian syndrome patients with anovulation; however, it is not FDA approved to be used for this purpose.
4. It has modest effect in suppressing androgen production and, thus, helps correct hirsutism to some extent.
5. Metformin can be used as an alternative to oral contraceptive pills for restoring ovulatory menses in polycystic ovarian syndrome patients who refuse or are contraindicated to use oral contraceptive pills.
# Before 37-weeks of gestation, fetuses in breech presentation need no intervention as they may convert to vertex automatically
# Pseudocyesis( jia yu) is a rare condition in which a woman presents nearly all symptoms and signs of pregnancy; however, ultrasound reveals a normal endometrial stripe.
# The major source of estrogen in menopausal women is from the peripheral conversion of adrenal androgens by fat tissue.
During childbearing years, estrogens are mainly formed through the conversion of androgens by the action of the enzyme aromatase present in granulosa cells. The major sources of androgens in the female are the adrenal glands and the ovaries, and the most abundant androgen is androstenedione. Peripheral fat tissue also contains the enzyme aromatase, which converts androstenedione therein, into estrone.
# The increase in blood pressure that appears before 20-weeks gestation is either chronic hypertension or hydatiform mole.
# The high incidence of UTI in females is primarily due to the shorter length of the urethra in females.
# For gross lesions, biopsy is needed and Pap smear is no longer appropriate
# Conization is indicated in any situation wherein the results of the tests (i.e. Pap smear, endocervical curettage, biopsy) are equivocal or unsatisfactory, or when the result of endocervical curettage is abnormal, Pap smear suggests carcinoma in situ, or biopsy indicates severe dysplasia or microinvasion.
# emergency contraception is a combination of ethinyl estradiol (estrogen) and norgestrol (progestin): 2 tablets taken within 72-hours of intercourse, and 2 others 12-hours later.
# Presence of dysmenorrhea, heavy menses, and enlarge uterus is almost diagnostic of either adenomyosis or fibroid uterus. They are estrogen-dependant tumors, and therefore, increase in size with oral contraceptive pills (OCPs) or pregnancy, and often regress after menopause.
# Pelvic congestion presents as a dull ill-defined pelvic ache usually worse premenstrually, relieved by menses and often with a history of sexual problems.
# The diagnosis of major depression requires presence of symptoms for at least six months.
# In posttraumatic stress disorder (PTSD), the traumatic event is persistently re-experienced in the form of recurrent nightmares and flashbacks of the event. The patient tries to avoid places, people or activities that remind him/her of the trauma.
# adjustment disorder is the development of emotional or behavioral symptoms in response to an identifiable stressor, with the presence of marked distress, The symptoms occur within three months of the onset of the stressor and rarely last beyond six months of the termination of the stressor.
# Polycystic ovarian disease amenorrhea, hirsutism, infertility and obesity. androgen excess and a LH to FSH ratio greater than 2:1. ACTH stimulation test exaggerated increased DHEA because of increased sensitivity of the adrenal gland to ACTH.
# Lichen sclerosis is characterized by epithelial thinning, inflammation and dryness of the skin. severe itch and vaginal soreness, vulva is red and appears dry with scaly patches. Tx: topical steroids. may progress to vulvar cancer routine biopsies.
# Eclampsia results from cerebral vasospasm and the resultant cerebral hypoxemia
# Severe preeclampsia: BP >=160/110 and /or have one or more of
1. Oliguria (< 500ml_/24hr)
2. Altered consciousness, headache, scotoma or blurred vision
3. Pulmonary edema or cyanosis
4. Epigastric or right upper quadrant pain
5. Significant thrombocytopenia
6. Microangiopathic hemolysis
7. Altered liver function test
8. Elevated serum creatinine level
9. IUGR, or oligohydramnios
# Premature ovarian failure refers to a failure of estrogen production by the ovaries that occur in women less than 35 years. associated with Hashimoto's thyroiditis, Addison's disease, type I diabetes mellitus and pernicious anemia. Diagnosis is confirmed by increased FSH serum levels. Infertility in premature ovarian failure is treated with egg donation.
# One of the side effects of epidural anesthesia is urinary retention caused by bladder denervation. This incontinence is only transient and lasts until the effect of the anesthetic wears off and the bladder regains normal function. Tx: intermittent catheterization
# Oxybutynin has antocholinergic properties. used for urge incontinence.
# Urethropexy is indicated in stress incontinence(pelvic floor weakness)
# follicular cells secrete estrogen & inhibin (inhibition of FSH only ). Testosterone is produced by stromal cells of ovary
# Menopause results in increased LDL, decreased HDL, osteoporosis, and high risk of heart disease due to lack of effect of estrogen on cholesterol balance, and also due to altered vascular endothelium reactivity due to decreased estrogen.
# Mittelschmerz is mid cycle abdominal pain and typically presents in young females.
# ABO antigens are strongly antigenic. antibodies to ABO antigens belong to the IgM that do not cross the placenta.Anti-D antibodies that are responsible for Rh alloimmunization belong to the IgG class and cross the placenta easily.
# There are three types of breech presentation: 1/Frank breech-- fetal legs stretched in front of the fetal trunk; 2/Complete breech-- both thighs and knees are flexed, the presenting parts are the feet and the buttocks; 3/Footling or incomplete breech, one or both of the hips are not flexed in way that the foot or knee lies below the buttocks. frank or complete breech can be virginal delivery.
# All patients with pseudocyesis need psychiatric evaluation
# Active phase arrest dilation fails to progress in the active phase >= two hours. In the primigravida, cervical dilatation in the active phase progresses at a speed of 1.2 cm/hr.
# Pap smear – dysplasia, next do Colposcopy ( ying duao jing ). If it reveals an inflammatory atypia, repeat after 4 to 6 months. If negative do conization
# Vulvar papillomatosis, or condylomata acuminata, are genital lesions caused by human papilloma virus (HPV) serotypes 6 and 11. Condylomas present as exophytic lesions with a raised papillomatous or spiked surface and may grow into large and cauliflower-like formations. Biopsy inflammation, Koilocytes and hyperplasia.
# Alpha-Feto-Protein (AFP)Increased levels are seen in the presence of neural tube defects, abdominal wall defects (Gastroschisis, Omphalocel) and false positive. Low levels of MSAFP are frequently associated with chromosomal anomalies, If maternal serum Alpha-Feto-Protein levels are found to be abnormal in a pregnant patient, the next step is
# chorioamnionitis Tx Ampicillin and gentamicin, Labor
#Toxoplasmosis should be suspected in any patient with mononucleosis syndrome. Infection is demonstrated by detection of IgM to Toxoplasma. During the first two trimesters, the presence of fetal infection may require elective termination of pregnancy. If the mother chooses to continue gestation, spiramycin is the agent of choice as pyrimethamine is contraindicated in the first trimester. In the third trimester, interruption of pregnancy is no longer possible and pyrimethamine and sulfadiazine should be administered to reduce the severity of fetal disease as well as to decrease the risk of transmission.
In pregnant lady with Toxoplasmosis (recognize contact with cats), Spiramycin for first trimester, pyrimethamine and sulfadiazine is preferred in second and third trimester. Elective termination of pregnancy is an option in first trimester of pregnancy
# Zavanelli maneuver is used as a last resort in case of shoulder dystocia. It consists of pushing back the baby into the uterine cavity followed by a cesarea section.
# Metronidazole is associated with disulfiram like reactions. Like disulfiram, it inhibits aldehyde dehydrogenase in the metabolic pathway of alcohol, causing accumulation of Acetaldehyde in the blood stream and consequently symptoms such as flushing, nausea, vomiting and hypotension. For this reason, all patients who take metronidazole should abstain from drinking alcohol.
# all oral antidiabetic medications & ACE inhibitors are contraindicated in pregnancy. Use insulin only. For hypertension, short acting drugs that can be used safely in pregnancy are hydralazine and labetolol. As for long acting drugs, the most widely used agent is methyldopa.
# Penicillin desensitization is considered to be the treatment of choice for the pregnant patients with syphilis and having penicillin allergy
# In false labor, progressive cervical changes are absent and all such patients need reassurance
# Magnesium sulfate is the drug of choice for tocolytic therapy
# premature labor (28 weeks) Bed rest, cervical cultures, antibiotics, steroids, I.V. magnesium sulfate
# Estroge used for atrophic vaginitis. Testosterone cream and progesterone cream are effective for 2nd line treatment of lichen sclerosus
# Hypertrophic dystrophy of the vulva may be seen in women of reproductive age but occurs most commonly in postmenopausal women. Patients often present for vulvar pruritus. On examination, lesions are thickened and hyperkeratotic with evidence of chronic rubbing and scratching. They may be multiple, distributed symmetrically but are frequently localized and discreet. Hyperplastic dystrophy cannot be distinguished clinically from cancer of the vulva and biopsy is therefore required every time the diagnosis is suspected. Treatment consists of local application of 1% corticosteroid ointment three times a day for 6 weeks.
# Preeclampsia caused by uteroplacental ischemia
# A significant granulocytic leukocytosis may be seen in immediate postpartum period
# Hypotension is a common side effect of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling caused by sympathetic fiber block that results in vasodilatation of the lower extremity vessels
# The ulcer of lymphogranuloma venereum is also painless but is shallow and associated with nonspecific systemic symptoms. Moreover, the inguinal adenopathy is inflammatory and does not appear at the same time as the ulcer.
# ulcer in chancroid is very painful, has a gray base and is foul smelling, inguinal nodes are painful with subsequent bubo formation and suppuration.
# The ulcer of lymphogranuloma venereum --painless , shallow and associated with nonspecific systemic symptoms. the inguinal adenopathy is inflammatory and does not appear at the same time as the ulcer.
# Granuloma inguinale-- caused by the bacterium Donovania granulomatis, painless ulcer w irregular borders and a beefy-red granular base, inguinal lymphadenopathy. Giemsa or Wright’s stain-- reddish, encapsulated, bipolar staining bacteria found within monocytes.. Tx: tetracycline for 10-21d.
# Septic abortion is managed with cervical and blood sampling, IV antibiotics and gentle suction curettage.
# Treatment for vaginismus relaxation, Kegel exercises (to relax the vaginal muscles), and individual and partner involvement in a series of at-home exercises. These should include repeated practice with insertion (dilation) training.
#Human Chorionic Gonadotropin (hCG) is a hormone secreted by the syncytiotrophoblast and is composed of two subunits: alpha and beta. The alpha subunit is common to hCG, TSH, LH, and FSH; whereas, the beta subunit is specific to hCG. hCG is responsible for maintenance of progesterone secretion by preservation of the corpus luteum until the placenta starts producing progesterone on its own
# Management of dysfunctional uterine bleeding If the patient is older than 35 years, obese, diabetic or with chronic hypertension, do Endometrial biopsy. If biopsy is negative for hyperplasia or carcinoma, treated with cyclic progestins. Endometrial ablation or hysterectomy are indicated only if hormonal therapy fails.
# Although hydralazine is indicated to control HTN in pregnancy, it is ineffective as a monotherapy and does not prevent proteinuria or diabetic nephropathy. It can, however, be used to treat HTN in combination with methyl-dopa. Labetalol as an alpha and beta blocker has become the drug of choice to control HTN in pregnancy, and it has also been shown to be very effective in preventing proteinuria and diabetic nephropathy. Thiazides and calcium channel blockers should not be used in pregnancy
# Prolactin production is inhibited by dopamine and stimulated by serotonin and TRH. In the case of amenorrhea-hyperprolactinemia, first rule out hypothyroidism by measuring serum TSH.
# Idiopathic precocious puberty presence of similar cases in the family and a normal sequence of secondary sexual characteristics apparition. should be treated with GnRH agonist therapy in order to inhibit secretion of estrogens, preventing premature epiphyseal plate fusion.
# Low back pain is a very common complaint in the third trimester of pregnancy. It is believed to be caused by the increase in lumbar lordosis and the relaxation of the ligaments supporting the joints of the pelvic girdle.
# Preeclampsia rarely presents before the 20 weeks of pregnancy
# premenstrual syndrome Symptoms usually disappear near menses and symptom free until her next ovulation. Psychological symptoms may include anxiety, mood swings, difficulty concentrating, decreased libido and irritability. A menstrual diary for at least 3 cycles is a useful aid for confirming the diagnosis
# Levothyroxine does not cross the placenta. In many women with Grave's disease, the circulating levels of thyroid stimulating immunoglobulin (TSI) remains as high as 500 times the normal value for several months, even after surgery. These antibodies cross the placenta and can cause thyrotoxicosis in the fetus and the neonate.
# Turner syndrome is characterized by primary ovarian failure, amenorrhea, multiple congenital anomalies, short stature and bilateral streaked ovaries. FSH elevation, greater than LH elevation
# Mild PID is often treated as an outpatient with single dose IM/IV ceftriaxone and PO doxycycline or azithromycin severe PID includes cefotetan (2 g IV every 12 hours) or cefoxitin (2 g IV every 6 hours) plus doxycycline (100 mg PO or IV every 12 hours).
# A young woman who presents with a breast lump can be asked to return after her menstrual period for reexamination if no obvious signs of malignancy are present. If the mass decreases in size after the menstrual period, the probability of a benign disease is very high. Otherwise, it is advisable to proceed with ultrasonography, fine needle aspiration biopsy and/or excisional biopsy. Mammography is usually not helpful in interpreting the mass because the density of breast tissue is high in young women.
# Etiologies of precocious puberty in females can be subdivided into (1)true isosexual precocious puberty, which is secondary to activation of the hypothalamic-pituitary-ovarian axis, and (2) pseudoisosexual precocious puberty, in which the increase in female steroid hormones and the resultant apparition of secondary sexual characteristics occurs without activation of the hypothalamic-pituitary axis, mostly from ovarian tumors, but also adrenal tumors, exogenous estrogen exposure, advanced hypothyroidism and McCune-Albright syndrome.
In GnRH stimulation test, 100 micrograms are administered as an I.V. bolus: A significant release of LH indicates an activation of the pituitary gland; therefore, true isosexual precocious puberty.
# Pelvic congestion presents as a dull ill-defined pelvic ache, usually worse premenstrually, relieved by menses, and often associated with a history of sexual problems.
# Primary dysmenorrhea caused by higher level of prostaglandins. Tx : NSAIDs. oral cntraceptive pills inhibit ovulation and are also effective.
# Classic endometriosis is associated with premenstrual and postmenstrual pain, deep dyspareunia, tender pelvic nodes, and a fixed retroverted uterus.
# Pelvic congestion presents as a dull ill-defined pelvic ache, usually worse premenstrually, relieved by menses, and often associated with a history of sexual problems.
# RhoGAM is indicated in previously unsensitized(antibody titers <1:6 ) negative women at 28 weeks gestation, and within 72 hours after any procedure or incident (e.g. abortion, ectopic pregnancy), and delivery
# Raloxifene is a mixed agonist/antagonist of estrogen receptors. In breast tissue and vaginal tissue, it is an antagonist, whereas in bone tissue, it is an agonist and may be used to treat osteoporosis. It increases the risk of thrombo-embolism.
# Long-term bethanechol and alpha-blockers are used for overflow incontinence.
Long-term oxybutin therapy is used for motor urge incontinence.
# Stress incontinence -- Kegel exercises should be advised in all patients to restore pelvic floor strength. the most beneficial treatment is restoration of urethrovesical angle by urethropexy.
# Triad of renal failure, microangiopathic hemolytic anemia and thrombocytopenia occurs in hemolytic uremic syndrome.
# DiethylstiIbestroI-- increased risk of developing clear cell adenocarcinoma of the vagina and cervix, as well as cervical anomalies and uterine malformations.
# BehDDs disease is a rare multisystem disorder with an autoimmune etiology and manifests with recurrent ulceration in the mouth and genital area associated with uveitis. Oral lesions are aphtha-like, whereas genital ones are more destructive, ultimately leading to a completely scared and fenestrated vulva
# Anticoagulants are not used for superficial thrombophlebitis unless the disease is rapidly progressing or it extends the deep vein system.
Anti staphylococcal antibiotics are indicated when there is an evidence of septic phlebitis.
Local heat, bed rest and NSAIDs are the mainstay of treatment of superficial thrombophlebitis.
# Ligation and division of the saphenous vein at saphenofemoral junction is indicated when thrombophlebitis is extensive or is in close proximity to the saphenofemoral junction. This will prevent clot extension into the deep vein system.
# In cases of intrauterine growth retardation, presence of oligohydraminos is an indication for delivery
#In cases of post-term pregnancy (42-43 weeks), the non-stress test and biophysical profile should be performed twice weekly and if there is oligohydramnios or if spontaneous decelerations are noted, delivery has to be accomplished. If the pregnancy is more than 43 weeks, delivery is mandated. If the pregnancy is more than 42 weeks, the cervix is favorable and fetal head is into the pelvis labor should be induced.
# Detrusor instability, bladder irritation from a neoplasm, and interstitial cystitis result in urge incontinence, Diabetic neuropathy causes overflow incontinence
#Savage's syndrome, or ovarian resistance syndrome, is a congenital condition characterized by a failure of the ovaries to respond to FSH and LH, secondary to a receptor defect. Patients present with primary amenorrhea and absent secondary sexual characteristics
# Mayer-Rokitansky-KDDr-Hauser syndrome congenital condition secondary to mullerian agenesis, and characterized by either a complete vaginal agenesis and absent uterus, or partial vaginal agenesis and presence of a rudimentary uterus. Patients have a normal pubertal development and typically present with primary amenorrhea. Ovaries are visualized on ultrasound and chromosomal study reveals a 46, XX karyotype. Treatment is achieved either by reconstructive surgery or serial dilation of the perineal body by the patient.
# Oral contraceptive pills are first line agents in the treatment of endometriosis in young women desiring future fertility. Danazol is used when patients cannot tolerate or fail to respond to birth control pills. It is an androgen derivative that causes a pseudomenopause state. It is used as a second line agent because of its side effects (acne, hirsutism, deepening of the voice) and cost. GnRH agonists have an inhibitory action on the secretion of FSH and LH when given continuously and thus, produce a temporary castration. They are also considered as second line agents.
** Antiphospholipid antibodies (such as Lupus anticoagulant and anticardiolipin antibodies), which are present in some patients of SLE, predispose to recurrent mid trimester fetal loss. These antibodies cause placental infarction leading to fetal growth restriction or death. These antibodies are also associated with thromboembolic disease.
# Atrophic vaginitis(vulvar irritation and a mild clear or yellow vaginal discharge, dyspareunia, urinary frequency, urgency, nocturia or even stress incontinence, the vulva is diffusely erythematous, epithelium is pale with erythematous patches and visible vessels, basal epithelial cells instead of superficial cells)is treated with estrogen; this latter should be balanced with medroxyprogesterone if the uterus is still present. If the patient is not willing to use oral hormones, Premarin(estrogen) cream twice daily may be used.
# Pregnancy is associated with increased prostaglandins, which are protective of the gastric mucosal barrier, thus resulting in improvement of peptic ulcer in pregnancy. with multiple sclerosis have a significant decrease in the incidence of relapses during the 3rd trimester, followed by an increase in the postpartum period.
# Heavy unremitting endometrial hemorrhage through the menarche and perimenopuase requires high dose conjugated estrogens to suppress bleeding, and to ensure cardiovascular stability. Once cardiovascular stability is achieved, D&C should be performed. The most common cause of dysfunctional uterine bleeding (DUB) in adolescent women is anovulation. So, endometrial biopsy is not required in these patients. Once the bleeding is stopped, advise the patient to: take 25 mg of oral conjugated estrogen daily for 25 days; add 10 mg of medroxyprogesterone for the last 10 to 15 days of treatment; then allow 5-7 days for withdrawal bleeding. All this in order is to mimic the menstrual cycle.
# Bed rest and hydration are the first step in stopping uterine contractions in early stages of preterm labor and if these measures fail, tocolytics are indicated. Hydration has a negative feedback on the secretion of ADH as well as oxytocin
# Chorionic villus sampling is the best test for detection of fetal chromosomal abnormalities in the first trimester of pregnancy. ( 10-12 w). Amniocentesis is done between 16th and 18th week of gestation. early amniocentesis can be performed before 15 weeks’ gestation when CVS cannot be performed. MSAFP is routinely performed during the second trimester. screen for neural tube and abdominal wall defects
# Tubo-ovarian abcesses are usually managed with triple antibiotic therapy(gentamycin plus clindamycin plus ampicillin). Drainage(ultrasound guided aspiration) is indicated if there is no response to antibiotic therapy after 24 to 48-hours.
# Diagnosis of luteal phase defect is confirmed by endometrial biopsy. which demonstrates a lag in endometrial maturation of 2 days or more as compared with normal states.
# Pick disease Personality and language changes are often more prominent than other cognitive symptoms.
# Creutzfeldt-Jakob disease is caused by a slow virus (prion). Diagnostic features are
a rapidly progressive dementia, myoclonus and classic EEG findings-- sharp, triphasic, synchronous discharges
# In the presence of decreased fetal movements, fetal compromise should be suspected, best next step -- non-stress test (NST).
NST is usually performed in 1)high risk pregnancies starting at 32-34 weeks’ gestation, 2) when there is a decrease in fetal movements, anytime in both high risk and low risk pregnancies. It is carried out by recording fetal heart rate while the mother is resting on her left lateral side. A test is considered reactive (good), if in 20 minutes, 2 accelerations of fetal heart rate of at least 15 beats per minute above the baseline, lasting at least 15 seconds each. If less than 2 accelerations are noted in 20 min, the test is said to be non-reactive (bad).The most common cause of non reactive NST is sleeping baby; so vibroacoustic stimulation to wake the baby up. If acceleration (>15 bpmfor>15 sec) is noted after exposure to the stimulus, the test is considered positive, and reassuring. If the NST is abnormal BPP is the next step. It includes the NST in addition to four parameters assessed by ultrasonography: 1/ Fetal tone; 2/fetal movements (3 per 10 min); 3/fetal breathing (30 per 10 min); 4/amniotic fluid index (5-20). Each of these five variables is given a score of two when present, and a score of zero when absent or abnormal. A total score of 8-10 is considered normal. should only be repeated once or twice weekly until term for high risk pregnancies. If the score is 6 without oligohydramnios, contraction stress test should be ordered. If this latter gives non-reassuring results, delivery is usually indicated; if it gives suspicious results, repeat the next day. If the score is 4 without oligohydramnios and fetal lungs are mature, delivery should be considered. If fetal lungs have not yet reached their maturity, steroids injection should be administered and BPP assessed within 24 hours.
If the score is <4, the fetus should be delivered. In the presence of oligohydramnios (AFI <5) delivery is to be considered since it can result in umbilical cord compression and therefore fetal compromise Contraction stress test is indicated when the BPP score is 6, in the absence of oligohydramnios.
# The risk factors for osteoporoses include: Thin body habitus, smoking, alcohol intake, steroid use, menopause, malnutrition, family history of osteoporosis, and Asian or Caucasian race. Dark, green leafy vegetables (such as broccoli, collard greens, and spinach) are good sources of calcium; moreover, the patient may benefit from foods fortified with calcium (such as orange juice, cereals, and breads). So, a vegetarian diet is not a risk factor for osteoporosis.
# Premenopausal women with simple or complex hyperplasia without atypia usually respond to therapy with cyclic progestins. Need repeat biopsy after 3-6 months of treatment If a premenopausal woman is diagnosed with complex hyperplasia with atypia and does not want to preserve fertility, total hysterectomy is the treatment of choice. If she wants to preserve fertility, you can give cyclic progestins, even though the response rates are lower. biopsy should be repeated after 3-6 months.
# Total abdominal hysterectomy is the treatment of choice for uterine rupture. Debridement and closure of the site of rupture can be considered in women with low parity or who desire more children.
# Tzanck smear-- Identification of a multinucleated giant cell is characteristic of herpes genitalis. Wright’s stain is a combination of eosin and methylene blue. It is useful to demonstrate Donovan bodies for diagnosis of granuloma inguinale
# The causes of female infertility fall into one of the four following categories: peritoneal factor, ovulatory factor, cervical factor, and tubo-uterine factor. The peritoneal factor is the most common and includes endometriosis and peritoneal adhesions. Laparoscopy is the procedure of choice for diagnosis and treatment of such conditions. Mild forms of endometriosis usually respond to medical treatment with agents such as GnRH agonists, Danazol and Medroxyprogesterone.
The ovulatory factor involves defects in the hypothalamo-pituitary-ovarian axis and related infertility may be due to impairment of follicular maturation, ovulation, or endometrial development. Ovulatory abnormalities may initially be screened by basal body temperature and midluteal level of progesterone; the former assesses the duration of the luteal function and the latter the level of the luteal function.
# Pelvic thrombophlebitis is a diagnosis of exclusion. It should be suspected in any postpartum patient with persistent spiking fever for 7-10 days despite adequate antibiotic therapy. When it is clinically suspected heparin should be instituted. Rapid response will be noted.
# diagnosis of ectopic pregnancy is entirely made by rapid beta HCG and tranasvaginal ultrasonogram
# Danazol is an androgen derivative that has a gonadotropin inhibitory effect. It is indicated in endometriosis, fibroids and fibrocystic breast disease
# Bromocriptine is a dopamine analogue that suppresses prolactin secretion. It is used for treatment of prolactin secreting microadenomas, for ovulation induction in patients with amenorrhea-hyperprolactinemia, and in the postpartum to suppress milk production.
# Clomiphene citrate is an antiestrogen that acts by competitively blocking estrogen receptors of the hypothalamus; inhibiting thus the negative feedback estrogen has on GnRH production and consequently increasing FSH and LH secretion, and improving ovulation. Along with hMG and hCG it is indicated in cases of chronic anovulation associated with PCOD and mild hypothalamic insufficiency secondary to obesity, emotional stress, intensive exercise, and psychological disorders. Side effects include ovarian enlargement, hot flashes, abdominal-pelvic bloating, breast discomfort and abnormal uterine bleeding. Major complications include ovarian hyperstimulation syndrome (OHSS) and multiple gestation.
# PCOD is characterized by an unbalanced estrogen secretion that may result in endometrial hyperplasia.risk endometrial cancer Patients are treated with combined oral contraceptive pills or cyclic progestins.
# The first step in a patient with secondary amenorrhea is to rule out common situations; that is, pregnancy, then hyperprolactinemia, and hypothyroidism. The subsequent step should be the determination of the patient's estrogen status. The usual method serving this purpose is the progestin challenge test; however, this method is progressively abandoned, as it relies on the patient's compliance and may not result in withdrawal bleeding, despite the presence of adequate endogenous estrogen. Because of such limitations, clinical methods such as assessment of cervical mucus, vaginal epithelial cell maturation, and endometrial thickness, are more and more employed. If the patient has an adequate estrogen production and a history of intrauterine instrumentation, then Asherman's syndrome should be suspected. Patients with no such history are virtually all anovulatory or oligo-ovulatory. If estrogen production is inadequate, FSH levels should be ordered to determine the gonadal or central origin of the disorder.
# Early decelerations are due to fetal head compression, decrease in fetal heart rate by 15 beats/sec from baseline for at least 15 seconds, occuring at the same time as the uterine contraction. Fetal cord compression presents with variable decelerations
# Kallmann's syndrome consists of a congenital absence of GnRH secretion associated with anosmia and a normal karyotype. patients have hypogonadotropic hypogonadism, and present with amenorrhea, anosmia and absent secondary sexual characteristics, although, internal reproductive organs are present. Abnormal development of the olfactory bulbs and tracts result in the hyposmia or anosmia (decreased sense of smell).
#Adenomyosis defined as the presence of endometrial glands in the uterinemuscle occurs most frequently in women above 40 and typically presents with severe dysmenorrhea and menorrhagia, an enlarged and generally symmetrical soft uterus.
#Vasa previa or fetal vessel rupture necessitates immediate C. section. A ruptured fetal vessel presents typically as an antepartum hemorrhage with fetal heart deterioration, progressing from tachycardia, to bradycardia, to a sinusoidal pattern
# Bacterial vaginosis caused by Gardnerella vaginalis manifests with a profuse ivory to gray malodorous discharge with a pH of 5 to 6.5. When adding potassium hydroxide, the discharge gives a characteristic amine or "fishy" odor. Itching and burning are not usual, Identifying "clue cells" on a wet-mount makes the diagnosis. Clue cells are characteristic epithelial cells diffusely coated with the organism. Tx: oral metronidazole. If pregnancy intravaginal cream or metronidazole cream
# Lichen sclerosis tx: 'superpotent topical corticosteroids' such as clobetasol or halobetasol.
# CA-125 levels are used in ovarian carcinoma for follow-up after treatment. Patients with PCOD are not at risk for ovarian carcinoma
# Patients with polycystic ovarian disease are at risk of developing type II diabetes
# Hypertension and diabetes are risk factors for endometrial cancer.
# Late childbirth and pauciparity are risk factors for breast cancer
Risk factors of cervical cancer include young age at first coitus (<20), young age at marriage and at first pregnancy, high parity, multiple sexual partners, , smoking, and low socioeconomic status.
# The most common cause of mucopurulent cervicitis is Chlamydia trachomatis. Besides that, cervical ectopy created by oral contraceptives may preferentially predispose to colonization with C trachomatis.
# Candida vaginitis is not considered a sexually transmitted disease and occurs in presence of risk factors such as diabetes mellitus, oral contraceptive pills, pregnancy and immunosuppressive therapy.
# Excessive use of oxytocin may cause water retention, hyponatremia and seizures
*** Estrogen replacement therapy increases the requirement for L-thyroxine in patients
receiving estrogen replacement therapy. The potential causes may include induction of liver enzymes, increased level of TBG, and an increased volume of the distribution of thyroid hormones. In pregnancy, also, thyroid hormone requirements will be increased, and the patient should be monitored every 4-6 weeks for dose adjustments.
# Endometritis caused by mostly Anaerobes. Tx: clindamycin with either aminoglycoside or ampicillin.
# Asymptomatic bacteriuria increases the risk of cystitis and pyelonephritis in pregnancy Treatment : a 7 to 10-day course of nitrofurantoin, ampicillin or first generation cephalosporin.
# ovarian hyperstimulation syndrome -- It develops in 5 to 7 days after hMG or hCG administration and refers to an acute increase in vascular permeability of enlarged ovaries. Symptoms and signs include abdominal pain, abdominal distension, nausea, vomiting, diarrhea, weight gain, hypotension and pleural effusion. Ovaries are enlarged on Ultrasound and serum electrolytes and hematocrit are elevated. OHSS may be complicated with ovarian torsion, ovarian rupture, thrombophlebitis and renal insufficiency. Symptoms generally resolve in 1 to 2 weeks, but may be more severe and persist longer if pregnancy is successful. Treatment is supportive.
# Laparoscopy is the gold standard of diagnosis of endometriosis
# OCPs have been shown to decrease the risk of ovarian and endometrial carcinoma. may worsen diabetes they do not precipitate diabetes in a nondiabetic patient. OCP are steroid compounds, cause sodium and water retentionworsening of hypertension. OCPs expose to other complications such as thromboembolism, cerebrovascular disease, Ml, gallblader disease and benign hepatic tumors.
# Tamoxifen-- mixed agonist-antagonist action on estrogen receptors. It acts as an agonist on the endometrium, increasing the risk of endometrial carcinoma; however, this risk is small (1.1%) and is seen only in postmenopausal women. With tamoxifen therapy, the overall mortality is decreased from breast cancer, Tamoxifen has a great adjuvant role, not only in preventing recurrences, but also in preventing development of carcinoma in the opposite breast. Its agonist effect on bone tissue protects from osteoporosis. Because of its antiestrogenic effects, patients usually develop hot flashes and vaginal dryness.
# Diabetes screening is also mandated in all pregnant women between 24 and 28 weeks gestation.
# Benign glycosuria is a very common finding in pregnant women because of decreased renal threshold1st step Obtain fasting urine sample rule out other causes. Then screen gestational diabetes
# The major cause of death in eclampsia is hemorrhagic stroke.
# In the ovulatory phase, cervical mucus is profuse, clear and thin
# All patients with primary amenorrhea and high FSH levels need to have a karyotype
# Labor should be induced immediately in patients with intrauterine fetal demise who develop coagulations abnormalities.
**High estrogen levels accompanying pregnancy result in an increase in thyroid binding globulin (TBG). production of total T3 and T4 is increased (but not serum free T4 and T3), possibly by the TSH action of hCG. This increase, however, does not result in clinical symptoms, because the excess of T3 and T4 is bound to the excess of TBG. Normal TSH
**In Chlamydial infection, empiric treatment of gonorrhea is not recommended. But in Gonococcal infections empiric treatment of Chlamydia is recommended since is it difficult to identify Chlamydia on smears. Tx: Single dose Azithromycin plus single dose IM Ceftriaxone
# Screening cultures for group B streptococcus should be performed at 36-37 weeks gestation, and positive cases should be treated with penicillin G during labor
# hyperemesis gravidarum 1st HCG measurement, 2nd Ultrasound
# Treatment for overflow incontinence(detrusor hypotonia) include cholinergic agents and intermittent self-catheterization.
# Lithium is associated with the congenital anomalies, classically Ebstein's anomaly. When a woman is treated with isotretinoin, she should be under strict contraception. Inhaled steroids are ok in pregnancy.
# Clotrimazole cream is an effective treatment for Candidal vaginitis, and partners need not be treated.
# Mastitis-- Staphylococcus aureus, Tx: penicillinase-resistant antibiotic such as oral dicloxacillin
# Missed abortion involves a dead fetus that is still retained in the uterus
# Delivery is definitive treatment of HELLP syndrome in women beyond 34 weeks gestation
#21-hydroxylase deficiency is the most common form of CAH. It presents with virilism(ambiguous genitalia at birth), salt wasting, and increased 17-alpha-hydroxyprogesterone levels. Diagnosis is suggested by increased levels of 17-alpha-hydroxyprogesterone and confirmed with ACTH stimulation test.
11-alpha-hydroxylase deficiency, which results in androgen and mineralocorticoid excess
# Cephalohematoma is a subperiostal hemorrhage. presents few hours after birth limited to the surface of one cranial bone.
Cput succedaneum is a diffuse, sometimes ecchymotic, swelling of the scalp. across the midline and across suture line
# Craniopharyngiomas derived from epithelial remnants of Rathke’s pouch. cause bi-temporal hemianopia by pressing optic chiasma. There may also give signs and symptoms of Diabetes Insipidus. X-ray: calcified lesion above the sell
# Arthrocentesis and empiric treatment with IV nafcillin are the most appropriate
measures for the management of suspected septic arthritis in a child.
# Always consider antibiotic prophylaxis and vaccination against Pneumococci and H. influenza in patients with splenectomy or functional asplenia. The most common cause of bacteremia or sepsis in sickle cell disease is Pneumococcus.
# Diffuse thickening of glomerular basement membrane and subepithelial spikes are characteristic for membranous glomerulonephritis
# Minimal change disease Light microscopy and immunofluorescence does not usually reveal any change in kidney architecture. Electron microscopy shows
diffuse effacement of foot processes of podocytes.
# Iron supplementation in the form of iron-fortified milk formula or medicinal iron, should be started at 6 weeks in all premature and low birth weight babies
# Marfan’s features + mental retardation + thromboembolic events + downward dislocation of the lens = Homocystinuria. It is an autosomal recessive disease caused by cystathionine synthase deficiency. Treatment mainly involves administration of high doses of Vit B6. Restriction of methionine along with supplementation of cysteine is used for patients not responsive to Vitamin B6 therapy.
# Krabbe's is a sphingolipidosis due to a deficiency in beta-galactosidase. total absence of myelin. Clinical features include mental retardation, blindness, deafness, paralysis, peripheral motor sensory neuropathy and seizures.
#Fabry's disease is also a sphingolipidosis --deficiency of alpha-galactosidase. Classic clinical features include angiokeratomas, peripheral neuropathy, and asymptomatic corneal dystrophy. They may also develop kidney and heart failure, and thromboembolic events
# Clubfoot is initially managed with stretching and manipulation of the foot, followed by serial plaster casts, malleable splints, or taping. Surgical treatment is indicated if conservative management gives unsatisfactory results, and is preferably performed between 3 and 6 months.
# Beckwith-Wiedemann syndrome macrosomia, macroglossia, visceromegaly and omphalocele, hypoglycemia and hyperinsulinemia, microcephaly, prominent eyes, prominent occiput, ear creases and hyperplasia of the pancreas. increased risk of neoplasms such as Wilms1 tumor, hepatoblastoma, and gonadoblastoma.
# The common congenital problems in an infant of diabetic mother are:
1. Caudal regression syndrome.
2. Transposition of great vessels.
3. Duodenal atresia and small left colon.
4. Anencephaly and neural tube defects.
# WAGR syndrome consists of Wilms’ tumor, Aniridia, genitourinary anomaly and mental retardation. deletion in chromosome 11.
# Denys-Drash syndrome male pseudohermaphrodism and early onset renal failure characterized by mesangial sclerosis with increased risk of Wilms’ tumor
# Von-Gierkes deficiency of glucose-6-phosphatase. Hypoglycemia caused by failure to release glucose from the liver into the circulation.
# The first step in the management of an infant with suspected congenital diaphragmatic hernia is the placement of an orogastric tube.
# Mongolian spot a flat, well-demarcated, and gray-pigmented lesion over the sacral area. usually disappear by the first few years of life.
# Salmon patch is a flat salmon-colored lesion commonly seen over glabellas, eyelids, and neck. It is a flat vascular lesion and usually disappears in early childhood.
# A leukocoria is a retinoblastoma until proven otherwise. Diagnosis is made by clinical findings in the presence of calcifications on US or CT scan. a highly malignant tumor, if untreated, leads almost invariably to death because of liver and brain metastases. It results from inactivation of the Rb suppressor gene
# Metanephros is at the origin of Wilms’ tumor
# Neuroblastoma is the third most common cancer in the pediatric population (after
leukemia and CNS tumors). It arises from neural crest cells which secondarily
populate sympathetic ganglia and adrenal medulla.
# Spondylolisthesis is a developmental disorder characterized by a forward slip of
vertebrae (usually L5 over S1) that usually manifests in preadolescent children. In the
typical clinical scenario, back pain, neurologic dysfunction (urinary incontinence),
and a palpable "step-off" at the lumbosacral area present if the disease is severe.
# DiGeorge syndrome results from microdeletion of 22q11
# strabismus -- most common cause of amblyopia. Tx: Continuous covering of the normal eye
# Presence of inflamed tympanic membrane and diminished movement of the membrane with insufflation are the hallmarks of otitis media.
# Group B streptococcus is the most common cause of neonatal sepsis. It is part of the normal vaginal flora of women and is transmitted to infants during their passage through the birth canal. Escherichia coli—2nd, Listeria is the third
# myotonic muscular dystrophy—AD, Patients are usually normal at birth. Muscle abnormalities begin in childhood and continue slowly into adulthood and include weakness and progressive muscle wasting, especially in the distal muscles of the hands, posterior forearm muscles, and anterior compartment of the lower legs. Myotonia-- represents as delayed relaxation of the affected muscles after contraction. inability to release the handshake. associated with multiple endocrinopathies(testicular atrophy, diabetes mellitus, frontal baldness, and hypothyroidism), immunologic deficiencies, cataract, neurologic abnormalities, intellectual impairment and dysmorphic facies.
# Pyloric stenosis is a surgical condition. surgery should be undertaken only after the infant has been resuscitated and electrolytes replaced.
# ARDS-- Hyaline membrane disease, x-ray: fine reticular granularity of the lung parenchyma, treatment :echanical ventilation and surfactant.
# ASD is the only congenital heart disorder, does not develop endocarditis.
# Urinalysis is a fundamental test that should be performed in all urologic patients.
# Hand-foot syndrome, or dactylitis, occurs in children ages 6 months to 2 years. It is the earliest manifestation of vaso-occlusion in sickle cell anemia. Hence, a workup for sickle cell anemia should be done in these patients. Dactylitis presents with the acute onset of pain and swelling, symmetrically involving the hands and feet.
# Granulosa cell tumors produce excessive amounts of estrogen, and can present with precocious puberty in younger children and postmenopausal bleeding in elderly patients.
# Childhood disintegrative disorder is a rare pervasive developmental disorder, which occurs more commonly in males. It is characterized by a period of normal development for at least two years. This is followed by a loss of previously acquired skills in at least two of the following areas: expressive or receptive language, social skills, bowel or bladder control, play and motor skills.
# Oppositional defiant disorder is a childhood behavioral disorder. -- defiant and hostile behavior. disobedient, easily annoyed, spiteful and argumentative, deliberately annoy others, and often blame others for their mistakes.
# Asperger disorder is characterized by a qualitative impairment in social interaction and restricted, repetitive and stereotyped patterns of behavior. have normal cognitive and language development.
# Voiding after intercourse has been shown to decrease the risk of UTI in sexually-active females.
# The incidence of vertical transmission of HIV can be reduced from 25% to 8% by administrating ZDV to pregnant women and their offspring. ZDV is administered orally during pregnancy after the first trimester, intravenously during labor and delivery, and orally to the neonate for the first 6 weeks of life.
# Retinal hemorrhage is considered to be an extremely ominous sign of preeclampsia
# McCune-Albright syndrome precocious puberty, cafe au lait spots and multiple bone defects (polyostotic fibrous dysplasia—fractures). Associated with other endocrine disorders, such as hyperthyroidism, prolactin or GH-secreting pituitary adenomas and adrenal hypercortisolism. Caused by defect in the G-protein cAMP-kinase
# Peutz-Jeghers syndrome is characterized by gastrointestinal tract polyposis and mucocutaneous pigmentation. It may also involve an estrogen-secreting tumor, leading to precocious puberty.
# Sturge-Weber-- mental retardation, seizures, visual impairment and a characteristic port-wine stain over the territory of the trigeminal nerve, may also be hemianopia, hemiparesis, hemisensory disturbance, and ipsilateral glaucoma. Skull X-rays, reveal gyriform intracranial calcifications that resemble a tramline. Treatment is aimed at controlling seizures and reducing intraocular pressure. Argon laser therapy is successful in removing the skin lesions.
# Language development:
Social smile: 2 months
Babbles: 6 months
2 words, obeys 1-step command: 1 year
2-3 word phrases, obeys 2-step command: 2 years
Gross motor development:
Holds head: 3 months
Rolls back to front and front to back: 4 months
Sits well unsupported: 6 months
Walks alone: 12 months
Walks up and down stairs without help: 24 months
Fine motor development:
Raking grasp: 6 months
Throws object: 12 months
Builds tower of 2 blocks: 15 months
Builds tower of 6 blocks/turn pages of books: 24 months
Recognizes parents: 2 months
Recognizes strangers (stranger anxiety): 6 months
Imitates action/comes when called: 12 months
Plays with other children: 18 months
Parallel play: 24 months
# Klumpke paralysis—Klumpke’s paralysis is a brachial palsy that occurs in newborns following excessive traction on the arm. It consists of hand paralysis and ipsilateral Horner’s syndrome (ptosis and miosis), and is secondary to injury to seventh and eighth cervical nerves and first thoracic nerve.
# Erb-Duchenne palsy -- brachial palsy, fifth and sixth cervical nerves. absent Moro reflex and intact grasp reflex of the affected arm. with a characteristic position adduction and internal rotation of the arm with pronation of the forearm.
# Children with a parental history of elevated total cholesterol levels (>240 mg/dL), or risk factors for coronary artery disease should get a screening test for total cholesterol level.
# Midgut volvulus usually presents in a child less than one month with bilious vomiting, abdominal distension and bloodstained stools.
# Meningitis may be complicated by regression of developmental milestones.
# Increased gastric residues in a preterm neonate is highly suspicious for necrotizing enterocolitis.
# Pinealoma develops in the dorsal aspect of the midbrain. Symptoms consist of endocrine syndrome, intracranial hypertension, Parinaud's sign (paralysis of vertical gaze), and Collier's sign (retraction of the eyelid).
# Craniopharyngiomas arise in the sella turcica, and symptoms usually include visual field defects and endocrine syndrome. It is characterized by a cystic structure with presence of calcifications
# In the pediatric population, infratentorial tumors are more common than supratentonal tumors, and benign astrocytomas are the most common histologic type in both group.
# Vitamin A reduce morbidity and mortality of measles
# Immnunoprophylaxis with VZIG may not prevent infection, but does effectively reduce disease severity. Postexposure prophylaxis for chicken pox is provided with VZIG (Varicella Zoster Immune globulin) or acyclovir. Postexposure prophylaxis with VZIG is preferred and indicated in susceptible high-risk persons exposed to varicella within 96 hours (preferably 72 hours) of exposure.
# Thyroid dysgenesis is the most common cause of congenital hypothyroidism in
# Iodine deficiency or endemic goiter is the most common cause of congenital hypothyroidism worldwide but essentially not seen in the United States.
# In a young child of 2-5 years age with a localized abdominal mass and hematuria, one has to think of Wilms tumor, does not cross the midline, associated with Beckwith-Wiedemann and Denys-Drash syndromes. If the child age is less than 1 year think of neuroblastoma-- usually crosses the midline and diagnosis is made by urinary metabolites of catecholamine.
# Diagnosis of anemia of prematurity:
1. Peripheral smear shows normocytic and normochromic anemia. No other abnormal forms are seen.
2. The reticulocyte count is low, and red blood cell precursors in the bone marrow are decreased.
3. Normal WBC and platelet counts.
4. Normal total bilirubin level.
The treatment involves iron supplementation, periodic hemoglobin checking and blood transfusion if needed. Erythropoietin is not routinely used.
# erythema toxicum eosinophils in the skin lesions
Milia are small pearly white cysts
** Transposition of great vessels is the most common cyanotic heart disease which presents with cyanosis in the first 24 hours of life. It is commonly seen in infants of diabetic mothers and in males w tachypnea, subcostal retractions, a normal S1, single and loud S2, and no murmur. Maintaining the patency of the ductus arteriosus is important for survival. Surgical treatment is definitive.
# A simple-partial seizure causes either motor, sensory, autonomic or psychic symptoms without alteration in consciousness.
# Complex-partial seizures present with an aura, and subsequently with behavioral arrest accompanied by involuntary automatism; there is a postictal confusion or aphasia.
# The 24-hour esophageal pH monitoring is the gold standard for the diagnosis of
gastroesophageal reflux disease. Infant w this disease posturing of Sandifer’s syndrome -- during the vomiting episodes, the child assumes a position with his head tilted to the left side and his back arched
# Tricuspid atresia is a cyanotic congenital heart disease characterized clinically by cyanosis that appears early in life and left axis deviation. Most cases (90%) are associated with ventricular septal defect, and 30% are associated with transpositioned great arteries. Both tetralogy of Fallot and tricuspid atresia have normal heart size and decreased vascular marking on chest x-ray. However, in tetralogy of Fallot, EKG demonstrates right atrium dilation and right ventricle hypertrophy.
# Ebstein’s anomaly extreme cardiomegaly with marked right atrial enlargement.
# an upper respiratory tract infection and later develops a rash after exposure to ampicillin or amoxicillin infectious mononucleosis caused by Epstein-Barr virus
** Aseptic necrosis of the femoral head is a common complication of sickle cell disease. It involves occlusion of end arteries supplying the femoral head, bone necrosis, and eventually collapse of the periarticular bone and cartilage. non-traumatic causes of avascular necrosis of the femoral head include chronic corticosteroid therapy, SLE, alcoholism, and Gaucher's disease .
# Surgery used for primary coarctation. Recoarctation can present years later with upper extremity hypertension and diminished lower extremity pulses. treatment is balloon angioplasty.
# hemophilia--factor VIII assay is diagnostic. Prolonged PTT, normal prothrombin time, normal bleeding time, normal fibrinogen level and low serum factor VIII activity .The standard treatment for hemophilia is to replace the factor VIII. mild hemophilia may be treated with desmopressin (DDAVP), which causes release of factor VIII from the endothelial cells.
# Parainfluenza virus is the most common agent responsible for croup in children. Staphylococcus aureus and anaerobes are common causes of chronic sinusitis
#Streptococcus pneumonia is the most common cause of acute sinusitis in childhood, followed by Haemophilus influenzae and Moraxella catarrhalis. Same as otittis media
# Attention deficit hyperactivity disorder--short attention span, impulsivity, and hyperactive, excessive talking for more than 6 months & than one setting (school and home).
# Oppositional defiant disorder usually presents in adolescence with negativistic, hostile, and defiant behavior towards adults. Arguments, temper outbursts, and deliberate annoyance
# Conduct disorder-- aggression, property destruction, theft, and deceitfulness
# Silver nitrate is administered to all neonates at birth to prevent Gonococcal conjunctivitis. It may cause mild conjunctival irritation and tearing that resolve generally within 24 hours. Gonococcal conjunctivitis is the most destructive to the eye; it presents as a hyperacute and highly purulent conjunctivitis that appears 2 to 5 days after birth and may result in corneal perforation and permanent loss of vision if left untreated. Tx: ceftriaxone.
# Neonatal chlamydial conjunctivitis is treated with systemic erythromycin because of the risk of pneumonia.
# Moderate to severe degree of slipped capital femoral epiphysis requires surgery. failure of the growth plate between the femoral neck and femoral head, resulting in displacement. limitation on internal rotation, range of external rotation is normal.
SCFE has three degrees of severity:
Mild - approximately 30% of the femoral head slips off of the metaphysis.
Moderate - approximately 30-60% of the femoral head slips off of the metaphysis
Severe - more than 60% of the femoral head slips off of the metaphysic
Mild SCFE may be treated conservatively by regular use of crutches to keep weight off the affected hip.
** cyanosis, aggravated by feeding and relieved by crying choanal atresia. Diagnosis is made by the failure to pass a catheter through the nose 3-4 cm into the oropharynx. CT scan with intranasal contrast, which shows a narrowing at the level of the pterygoid plate. The first step in management consists of placing an oral airway and lavage feeding. Definitive treatment consists of repairing the obstruction with surgery or endoscopy
# Edwards' syndrome--closed fists with the index finger overlapping the 3rd digit and the 5th digit overlapping the 4th, narrow hips with limited abduction, short sternum, rocker-bottom feet, microcephaly, prominent occiput, micrognathia, cardiac and renal malformations
# Trisomy 13, or Patau's syndrome, presents with cleft lip, flexed fingers with Polydactyly, ocular hypotelorism, bulbous nose, low-set malformed ears, small abnormal skull, cerebral malformation, microphthalmia, cardiac malformations, scalp defects, hypoplastic or absent ribs, visceral and genital anomalies.
# Epiglottitis is seen in children 3-7 years of age. They appear very toxic, have stridor and high-grade fever, and will often be droolingTx: Endotracheal intubation with a set up for tracheostomy
# Nebulized Racemic epinephrine and oral dexamethasone are the management options for Croup
# The infantile form of botulism is different from the adult form:
Infant the Clostridium botulinum gains entry through the food, especially in
honey and produces the toxin in the intestinal tract
Adult the toxin ingested produces the symptoms
# Werdnig Hoffmann's disease Degeneration of the anterior horn and cranial nerve motor nuclei
# Gaucher’s disease-- deficient activity of the lysosomal enzyme acid beta-glucosidase, bone pain, pathological fractures. Erlenmeyer flask deformity of the distal femur, and characteristic Gaucher cells with their wrinkled paper appearance in bone marrow
# Niemann-picks-- deficient sphingomyelinase. failure to thrive, hepatosplenomegaly, and a rapidly progressive neurodegenerative, cherry red macula, protruding abdomen, lymphadenopathy, and regression of developmental milestones.
# GM1 gangliosidosis results from the deficient beta-galactosidase-- hepatosplenomegaly along with skeletal abnormalities including anterior beaking of the vertebrae, enlargement of the sella turcica, and thickening of the calvarium.
# GM2 gangliosidoses include Tay-Sachs and Sandhoff's -- deficiency of
Hexosaminidase, cherry-red spot in retina and neurologic symptoms
** The growth of axillary hair results from androgen secretion by the adrenal glands (adrenarche). Premature adrenarche, or the isolated appearance of axillary hair before the age of six years, is generally benign and has no clinical significance.
# Positive anti-Smith antibodies and/or anti-double stranded DNA antibodies is
specific and confirmatory for the diagnosis of systemic lupus erythematosus.
#Kartagener’s syndrome -- situs inversus, recurrent sinusitis, and bronchiectasis. on x-ray--dextrocardia (the apex of the heart is in the right chest). Autosomal recessive, aberrant production or attachment of dynein arms-- in impaired cilial function
# Acute severe exacerbation in patients with cystic fibrosis caused by **pseudomonas aeruginosa, S. aureus, and H. Gram-positive rods D Listeria, Bacillus Gram-negative rods D Pseudomonas, Hemophilus, Klebsiella, Legionella
# Gram-positive rods D Listeria, Bacillus
Gram-negative rods D Pseudomonas, Hemophilus, Klebsiella, Legionella
The common organisms cause pneumonia in cystic fibrosis are: Hemophilus.
# Asperger syndrome-- language development is normal.
# Kawasaki disease or mucocutaneous lymph node syndrome is one of the most common causes of generalized vasculitis in children. echocardiography performed within 7 days of the disease onset, then repeated 6 to 8 weeks later. Tx: hospitalized with intravenous immune globulin (IVIG) and high-dose aspirin. Aspirin is useful for fever and arthritis. IVIG has been shown to reduce the incidence of coronary artery aneurysms and other complications. Influenza vaccination is recommended in patients with Kawasaki's disease taking life long aspirin therapy
# Bedwetting is a normal phenomenon until the age of 5.
# Trachoma, caused by Chlamydia trachomatis is the most common cause of blindness in the world. The diagnosis made by lymphoid follicles on the conjunctiva, scarring and limbal follicles.
# Pyloric stenosis presents with non-bilious vomiting in a 4 to 8-week-old child, and abdominal ultrasound confirms the diagnosis.
# Clavicular fracture-- Generally, no specific treatment is required. Rarely, immobilization may be required using a figure-of-eight strap
# Milk protein intolerance may present with vomiting and bloody diarrhea. Stools may show RBCs and eosinophils
# Galactosemia-- Galactose-1-phosphate uridyl transferase deficiency: jaundice, hepatomegaly, vomiting, hypoglycemia, convulsions, poor weight gain, aminoaciduria, cataract, hepatic cirrhosis, or mental retardation. increased risk for Escherichia coli neonatal sepsis.
** Remember, failure to thrive, bilateral cataract, jaundice and hypoglycemia for galactosemia.
# Iron poisoning --Tx Deferoxamine, an iron chelator, is used IV in moderate to severe intoxications
# Gastroschisis is diagnosed at birth by protrusion of bright red intestines to the right side of the umbilicus. There is no covering of the intestines and umbilicus is normal. It is a surgical emergency.
# Topical mupirocin or oral erythromycin is the treatment of choice for local impetigo. Impetigo is a superficial skin infection with multiple vesiculopustules on the exposed areas of face and extremities, which rupture giving a thick adherent crust with characteristic golden yellow appearance
# Surgery is advised in umbilical hernia if the hernia persists to the age of 3-4 years, exceeds 2 cm in diameter, causes symptoms, becomes strangulated, or if it enlarges progressively after the age of 1 to 2 years.
# An omphalocele is a herniation or protrusion of abdominal contents into the base of the umbilical cord, the sac is covered with peritoneum without overlying skin. Immediate surgical repair
# Acute post streptococcal glomerulonephritis-- C3 and CH50 levels are low resolve in 8 to 12 weeks. Hematuria may persist for up to 6 months. renal function returns to normal in 1 - 2 weeks
# Meckel's diverticulum usually presents at 2 years of age with painless rectal bleeding.
# Intussusception, the most common cause of intestinal obstruction in the first two years of life, presents with intestinal obstruction and red currant jelly stools containing blood and mucus. sausage-like mass palpable
# Obesity is a risk factor for uterine cancer, type 2 diabetes later in life
# Laryngomalacia or congenital flaccid larynx is the most common cause of chronic inspiratory noise in infants, laryngoscopy-- finding of an epiglottis rolling in from side to side is diagnostic, virtually all infants the symptoms disappear by two years of age. Need hold the child in an upright position for half an hour after feeding, and to never feed the child when he is lying down.
# Septic joint is a true surgical emergency in pediatric orthopedics and needs immediate surgical drainage as delay of even 4-6 hours can lead to avascular necrosis of the femoral head, Intravenous antibiotics are required along with surgical drainage
# Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which
may be complicated by Volkmann’s ischemic contracture.
# Hyper-IgM syndrome (HIM) is characterized by high levels of IgM with deficiency of IgG, IgA and poor specific antibody responses to immunizations. HIM presents with recurrent sinopulmonary infections and Pneumocystis carinii pneumonia.
# X-linked agammaglobulinemia (XLA) is characterized by four findings:
1 . recurrent bacterial infections in the first 5 years of life,
2.Serum IgG, IgM and IgA values at least 2 SD (standard deviation) below the normal for age,
3.Absent isohemagglutinins or poor response to vaccines,
4.Less than 2% CD19+ B cells in the peripheral circulation.
#Common variable immunodeficiency (CVID) is a heterogeneous syndrome, presenting with low IgG levels, IgM and IgA levels. The serum immunoglobulins and antibody deficiencies in CVID may be as profound as in XLA but with normal numbers of circulating immunoglobulin-bearing B-lymphocytes
# Wiskott-Aldrich syndrome-- eczema, thrombocytopenia, and recurrent infections with encapsulated germs in a young boy. low IgM, high IgA and IgE
# Fetal alcohol syndrome is characterized by midfacial abnormalities (short palpebral fissures, epicanthal folds, long philtrum, thin upper lip), cardiac defects (atrial or ventricular septal defect, persistence of arterial canal), multiple joint anomalies, prematurity, growth retardation and mental retardation.
# lithium—Ebstein’s anomaly
# Self-mutilation in the presence of dystonia is characteristic of Lesch-Nyhan syndrome. It is an X-linked recessive disorder-- deficiency in hypoxanthine-guanine phosphoribosyl transferase (HRPT), neurologic features including mental retardation, dystonia, choreoathetosis and spasticity. Gout is usually seen in patients of above 50 years of age. If you see a boy with gout, suspect this.
# Friedreich ataxia-- autosomal recessive, an excessive number of trinucleotide repeat sequences, resulting in an abnormality of a tocopherol transfer protein. gait ataxia, frequent falling, and dysarthria. Neurological manifestations result from degeneration of spinal tracts (spinocerebellar tracts, posterior columns, pyramidal tract). also associated with necrosis and degeneration of cardiac muscle fibers leading to myocarditis, myocardial fibrosis and hypertrophic cardiomyopathy, diabetes, and skeletal deformities, like scoliosis and hammer toes. The most common causes of deaths are cardiomyopathy and respiratory complications Remember the combination of neurologic (ataxia, dysarthria), skeletal (scoliosis, feet deformities) and cardiac (concentric hypertrophic cardiomyopathy) manifestations of the disease.
# Zellweger's syndrome is a disorder due to a defect in peroxisomes. Features of diagnostic importance are the typical facial appearances of high forehead, up-slanting palpebral fissures, hypoplastic supraorbital ridges, epicanthal folds, and redundant skin fold of the neck. Severe weakness and hypotonia, neonatal seizures, wide-open sutures and eye abnormalities such as a cloudy cornea, cataract, or glaucoma are also frequently found in the neonatal period. Infants with Zellweger's syndrome rarely live more than a few months.
# Turner's syndrome with 46 XY ( usually 45XO )karyotype is associated with a higher incidence of gonadoblastoma, and hence, prophylactic bilateral gonadectomy is indicated.
# neonatal adrenoleukodystrophy-- Enlarged liver and impaired liver function, pigmentary degeneration of the retina, severely impaired hearing
X-linked ALD is a genetically determined disorder associated with the accumulation of saturated very long chain fatty acids and a progressive dysfunction of the adrenal cortex and nervous system white matter. Symptoms are generally first noted between the ages of 4 and 8 years. The most common initial manifestations are hyperactivity, disturbances of vision, ataxia, poor handwriting, seizures, and strabismus
# Refsum disease-- gait abnormalities, sensorineural hearing loss, and pigmentary degeneration of the retina(impaired vision)
# treatment of Bordetella pertussis infection is erythromycin for 14 days.
# A positive Coombs' test points towards autoimmune hemolytic anemia, and a
positive osmotic fragility test points towards hereditary spherocytosis.
# Maternal HIV infection is an absolute contraindication to breast-feeding.
# Hydroxyurea is indicated in patients with frequent, acute, painful episodes, as it tends to increase Hb F levels.
# Reye's syndrome – After treated with salicylates for a viral infection, vomiting, agitation, and irrational behavior, progressing to lethargy, stupor, restlessness, and
convulsions. Lab findings include hyperammonemia, normal or slightly elevated bilirubin and alkaline phosphatase, prolonged prothrombin time, hypoglycemia, and moderate to severe elevations in AST, ALT, and lactate dehydrogenase. Tissue histopathology demonstrates microvesicular steatosis of the liver, kidneys, and brain. Treatment for Reye's syndrome is supportive.
# Glucose-6-phosphatase deficiency-- Von-Gierkes: hepatomegaly w hypoglycemic seizures, fat cheeks, relatively thin extremities, short stature, and a protuberant abdomen. kidneys enlarged, whereas the spleen and heart are normal. The hallmarks of the disease are hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia.
# Pompes1 disease -- deficiency acid maltase. floppy baby, macroglossia,
Hepatomegaly, hypertrophic cardiomyopathy
# Type III glycogen storage disease -- deficiency of glycogen debranching enzyme. hepatomegaly, hypoglycemia, hyperlipidemia growth retardation. Splenomegaly may be present, but kidneys are not enlarged. elevation of liver transaminases level and fasting ketosis are prominent, but blood lactate and uric acid concentrations are usually normal.
# Deficiency of branching enzyme -- type IV glycogen storage disease or amylopectinosis.
# Infection by respiratory syncytial virus may increase the risk of asthma in later life.
** The adverse reactions to the DTaP vaccine are usually attributed to the pertussis component of the vaccine. So Administer the diphtheria and tetanus toxoids, avoid the pertussis component. If An immediate anaphylactic reaction, an encephalopathy, or any CNS complication within 7 days of administration of the vaccine is a contraindication for further administration of DTaP
** Mammary gland enlargement and non-purulent vaginal discharge are common findings in newborn infants. They represent benign and transitory events that are explained by target-organ response to transplacental^ acquired maternal hormones (estrogens). No work-up is necessary, and routine care should be provided to the infant.
# The cerebral lesions in Sturge-Weber syndrome are histologically similar to the facial lesions.diagnosis as well as the follow-up is CT scan of the head
# the highest morbidity and mortality after HUS is the kidneys damage.
** DNA studies are used to confirm the diagnosis of Duchenne muscular dystrophy, not Muscle biopsy
# Painless gross hematuria is the most common presentation of sickle cell trait
# Frequent UTI is found to occur in pregnant individuals with sickle cell trait. Dactylitis, otherwise known as hand-foot syndrome, is common in patients with sickle cell anemia. It presents as painful swelling of feet and hands, symmetrically.
# 3 years- copies a cross and circle, 4 years- copies a square and rectangle, 5 years- copies a triangle, 6 years- copies a diamond
# Tx: ITP when pt < 30000/mm3 w corticosteroids
# supracondylar fractures of humer Brachial artery injury
# Rib notching, caused by the dilatation of the collateral chest wall vessels, is specific for coarctation.
# Howell Jolly bodies are characteristic findings seen in the peripheral smear (PS) of patients with functional asplenia due to sickle cell disease. Howell-Jolly bodies are the nuclear remnant within the RBC, which are generally removed by functional spleen, thus their presence in peripheral smear suggests splenectomy or functional asplenia
# Heinz bodies -- aggregates of denatured hemoglobin, common see in G6PD deficiency and thalassemia. When phagocytes extract this rigid precipitate, they form the characteristic Bite cells
# Helmet cells are fragmented RBC, suggestive of traumatic hemolysis, seen in DIC, HUS and TTP.
# measles (rubeola)—
# Rubella-- posterior cervical lymphadenopathy, The rash is fine, pink, maculopapular, and occurs in rapid progression (3 days) from face to trunk, giving it the name of 3-day measles. Leukopenia
# American Academy of Pediatrics advises against the use of cow's milk in the first year of life. Infants should receive breast milk or iron fortified formulas for the first year of life, and iron-fortified cereal should be added at the age of 4-6 months.
# Persistent oral thrush, lymphadenopathy, chronic diarrhea and hepatosplenomegaly may be the presenting symptoms of AIDS in infants.
# Classic phenylketonuria -- deficiency phenylalanine hydroxylase accumulation of phenylalanine in body fluids. blonde with fair skin and blue eyes, unpleasant odor of phenylacetic acid(musty or mousy), may have a seborrheic or eczematoid rash. in early infancy with vomiting, failure to thrive, developmental delay, and metabolic acidosis. The criteria for diagnosis of classic PKU are:
1. A plasma phenylalanine level above 20mg/dl_,
2. A normal plasma tyrosine level,
3. Increased urinary levels of metabolites of
phenylalanine (phenylpyruvic and ohydroxyphenylacetic acids),
4. A normal concentration of the cofactortetrahydrobiopterin.
# Alcaptonuria-- deficiency of homogentisic acid oxidase, a darkening of the urine to almost a black color on standing. ochronosis and arthritis
# Neonatal necrotizing enterocolitis-- x-ray: pneumatosis intestinalis
# Lateral epicondylitis, or "Tennis elbow," is caused by repetitive contraction of the extensor muscles at their origin on the lateral epicondyle. Tenderness is elicited over the lateral epicondyle, and pain is felt with passive wrist flexion and resisted wrist extension.
# Nursemaid's elbow-- radial head subluxation. 1-5 years caused by lifted or pulled by the hand or arm
# For pertussis prevention, all close contacts should be given erythromycin for 14 days, regardless of age, immunizations, or symptoms.
# In a young child who presents with recurrent upper respiratory tract infections and
bilateral nasal polyps, cystic fibrosis must be ruled out.
# Recurrent self-limiting episodes of vomiting and nausea in children, in the absence of any apparent cause, suggest the diagnosis of cyclical vomiting. treatment consists of anti-emetics and reassurance of the parents
**A white reflex (also called cat's-eye reflex) means that the patient has leukocoria, or white pupils. The most common cause of leukocoria is congenital cataract, and the most dreaded cause is retinoblastoma. The causes of cataract include familial, congenital infections, metabolic conditions (e.g. diabetes mellitus, galactosemia), genetic disorders (e.g. Down's syndrome, Turner's syndrome), and long-term/high-dose glucocorticoid use.
# Empiric steroid therapy is indicated in young patients presenting with nephrotic syndrome. Renal biopsy is commonly used in adult patients presenting with nephrotic syndrome
# Tuberous sclerosis (TSC) --- often presents during the first year of life with clusters of brief symmetrical contractions of the neck, trunk, and extremities, known as infantile spasms. EEG hypsarrhythmia, which consists of chaotic, high-voltage, bilateral, asynchronous, slow-wave activity. hypopigmented lesions (ASH leaf spots), cortical tubers on head CT. risk renal angiomyolipomas and cardiac rhabdomyosarcomas
The best drug for infantile spasms is intramuscular ACTH
# asthma accompanied by other allergic disorders like allergic rhinitis and eczema, mast cell stabilizers are the agents of choice-- Inhaled sodium cromolyn
Fluticasone severe chronic asthma not controlled with steroids like beclomethasone or triamcinolone. It is four times more potent than beclomethasone.
Oral corticosteroids when inhalation corticosteroids do not provide adequate control of asthma symptoms.
Oral theophylline ->control of nocturnal symptoms of asthma
# Parinaud's syndrome-- paralysis of vertical gaze, may be associated with pupillary disturbances and eyelid retraction (Collier’s sign). It results from lesion of the rostral midbrain at the level of the superior colliculus and CN III. most commonly caused by germinomas and pinealomas
# In 90% of cases, Medulloblastoma arises from the cerebellar vermis
# Nodular swellings in the irises of patients with neurofibromatosis are hamartomas
Neurofibromatosis—AD, risk for optic gliomas(pale optic discs and decreased visual acuity
# Always give a trial of epinephrine in cases of croup before intubation
# congenital toxoplasmosis- chorioretinitis, hydrocephalus, and intracranial
Congenital rubella-> sensorineural deafness, cataracts, and cardiac defects.
congenital syphilis-> intermittent fever, osteitis and osteochondritis,
mucocutaneous lesions, lymphadenopathy, hepatomegaly
and persistent rhinitis
# Fragile X syndrome profound to normal IQ with learning disabilities, generalized language disability, hyperactivity, short attention span, autism, large head, prominent jaw, large low set ears and macroorchidism. increased number of CGG trinucleotide repeats, mutation in the FMR1 gene
Fetal hydantoin syndromeis hypoplastic nails, cleft palate, and vitamin K deficiency
#Werdnig-Hoffman syndrome is an autosomal recessive disorder that involves degeneration of the anterior horn cells and cranial nerve motor nuclei. It is a cause of "floppy baby" syndrome along with infant botulism
# Myotonic congenital myopathy is an autosomal dominant disorder characterized by muscle weakness and atrophy most predominant in distal muscles of the upper and lower extremities, myotonia, testicular atrophy, and baldness.
# Congenital hypothyroidism hypotonia, large tongue, sluggish movement, abdominal bloating, and umbilical hernia. most common cause is thyroid dysgenesis
# Fanconi's anemia is an autosomal recessive, progressive pancytopenia and macrocytosis, Associated deformities include cafe-au-lait spots, microcephaly, microphthalmia, short stature, horseshoe kidneys and absent thumbs
# Diamond-Blackfan anemia -- also called congenital hypoplastic anemia. an intrinsic defect of erythroid progenitor cells which results in increased apoptosis (programmed cell death). macrocytic pure red aplasia associated with several congenital anomalies including short stature, webbed neck, cleft lip, shielded chest and triphalangeal thumbs.
# arteriovenous malformation is the most common of the subarachnoid hemorrhage in children. The history of seizures and migraine-like headaches is characteristic.
# Upper gastrointestinal endoscopy is the diagnostic study of choice when a patient presents with acute alkali ingestion
# Acute UTI in children is most commonly due to vesicoureteral reflux. Diagnosis is made with voiding cystourethrogram (VCUG) followed by renal imaging.
# Unilateral flank mass in a child more than 3 years is most likely due to WilmDs tumor arises from the metanephros.
# Ventricular septal defects are common in patients with Edward ‘s syndrome
# Conotruncal abnormalities (Truncus arteriosus, Tetralogy of Fallot, interrupted aortic arch) are associated with CATCH D22 syndromes, including DiGeorge and velocardiofacial syndromes.
# The current recommendations by the American Association of Pediatrics suggest that for children <6 years of age, the diagnosis of acute bacterial sinusitis be based on clinical criteria rather than radiographic criteria. The treatment uncomplicated sinusitis --amoxicillin 45-50 mg/kg/day.
# Bruton’s agammaglobulinemia (XLA) is anX-linked recessive disorder with defect in the gene product tyrosine kinase in B cells. marked reduction in the number of B cells in the peripheral circulation.
# Common variable immunodeficiency (CVID) also known as "acquired" hypogammaglobulinemia-- normal numbers of circulating immunoglobulin-bearing B-lymphocytes.
# transient hypogammaglobulinemia of infancy-- low levels of IgG and normal levels of IgA with variable levels of IgM.
# Selective IgA deficiency-- respiratory, gastrointestinal, and urogenital tracts infection.
# Prader-Willi syndrome-- deletion in the long arm of chromosome 15, genomic imprinting. diamond-shaped eyes, short stature, hypogonadism, obesity, hypotonia, mental retardation and dysmorphic craniofacial features.
# Impaired leukocyte adhesion-- Delayed separation of the umbilical cord, recurrent bacterial infections, and necrotic periodontal infections
# opsonization defect --asplenia. Infections with encapsulated bacteria (like S. pneumoniae) are typical
** osteogenesis imperfecta-- Mutations in type 1 collagen, multiple recurrent fractures, blue sclera, hearing loss, joint laxity, short stature, and scoliosis.
# Marfan syndrome-- mutation fibrillin-1 gene, autosomal dominant, ectopia lentis, and aortic root dilatation. Skeletal manifestations include arachnodactyly and hypermobility of joints
# Still’s disease-- juvenile rheumatoid arthritis. high-grade fever, fleeting maculopapular rashes, hepatosplenomegaly, lymphadenopathy, pleuroperi carditis and myocarditis, joint is swollen and erythematous but has a normal range of motion, leukocytosis, thrombocytosis and elevated ESR. The mainstay of treatment is NSAIDs. Liver enzymes need to be monitored. Corticosteroids are used if the patient do not respond to NSAIDs, or in the presence of myocarditis or anterior uveitis.
# Wolf-Hirschhorn syndrome-- Deletion of chromosome 4p. Greek helmet facies with ocular hypertelorism, prominent glabella and frontal bossing, microcephaly, dolichocephaly, hypoplasia of the eye socket, ptosis, strabismus,
# pyloric stenosis-- abdominal ultrasound to establish the diagnosis
# TTP-- microangiopathic hemolytic anemia, neurologic disturbances, renal dysfunction and fever.
# Chronic granulomatous disease (CGD) is a defect of phagocytic cells with dysfunction of the NADPH oxidase enzyme complex, leading to recurrent and uncontrolled infections with catalase-positive organisms, such as S. aureus, S. marcescens, B. cepacia, and Aspergillus sp. Most common clinical findings are lymphadenopathy, hypergammaglobulinemia, hepatomegaly, splenomegaly, anemia of chronic disease, underweight, chronic diarrhea, short stature, gingivitis, and dermatitis. Diagnosis is made by nitroblue tetrazolium (NBT) slide test, flow cytometry, or cytochrome C reduction. Treatment includes prevention of infection with daily trimethoprim-sulfamethoxazole and gamma-interferon three times a week; bone marrow transplantation is experimental but curative.
#Chak-Higashi syndrome is characterized by decreased degranulation, chemotaxis and granulopoiesis. It is a multisystem disorder with clinical characteristics of mild coagulopathy, peripheral and cranial neuropathy, hepatosplenomegaly, pancytopenia, partial oculocutaneous albinism, frequent bacterial infections (usually S. aureus), and progressive lymphoproliferative syndrome. Diagnosis is made by neutropenia, and the detection of giant lysosomes in neutrophils, and treatment includes prevention of infection with daily trimethoprim-sulfamethoxazole and daily ascorbic acid
# Hyper-lgE (JobDs) syndrome is characterized by chronic pruritic dermatitis, recurrent staphylococcal infections (skin and respiratory tract), markedly elevated serum IgE, eosinophilia and coarse facial features. Recurrent staphylococcal infections involving the skin, lungs and joints, with other features such as distinctive facial appearance, dental abnormalities and bone fractures are essential for the diagnosis.
# Guillain-Barr’yndrome-- involves mainly motor nerves, but sensory and autonomic nerves may also be affected. demyelinization of the peripheral nerves
# Guthrie test is a qualitative (coloration) test --detect the presence of metabolic products of phenylalanine in the urine.
# Todd’s paralysis-- Postictal paralysis followed by generalized as well as focal seizures. Sudden loss of consciousness with following disorientation and slow gain of consciousness, restoration of motor function within 24 hours
** severe tricyclic antidepressant intoxication -- seizure, hypotension, and QRS complex prolongation on ECG. Tx: Sodium bicarbonate
#21-hydroxylase deficiency—late on set in boy, an excess of sex steroids severe cystic acne, significant growth acceleration, enlarged testicles and penis, and coarse pubic and axillary hair
# Chronic pyelonephritis is characterized by focal parenchymal scarring and blunting of calices on IVP.
# Dandy-Walker anomaly -- cystic expansion of the fourth ventricle
Chiari malformation is a condition in which the structures of the posterior fossa protrude through the foramen magnum. Along with Dandy-Walker anomaly, it causes non-communicating hydrocephalus.
# scarlet fever-- Group A streptococcus that produce erythrogenic exotoxins. sandpaper-like rashes. throat is erythematous with gray-white exudates, tender lymphadenopathy. Tx: Penicillin V is the drug of choice.
# Antibiotics like penicillin or metronidazole are used for the treatment of wound botulism. They should not be employed to treat infant botulism, unless there is some secondary infection like pneumonia or UTI, as they may cause lysis of intestinal C. botulinum, and consequently release of their neurotoxin. Supportive care is the mainstay of treatment in cases of infant botulism
# Girl infants less than 3 months of age sometimes develop vaginal spotting or bleeding. This is caused by maternal estrogens, which crosses the placenta and enters the fetal blood stream before birth.
# posterior vermis syndrome (Truncal dystaxia)—medulloblastomas
# Chlamydia is the most common causative agent of infectious neonatal conjunctivitis. Chlamydial pneumonia can also develop in infected infants.
# The drug of choice for persistent nocturnal enuresis is DDAVP. The second line medication is imipramine.
# Diamond-Blackfan anemia (DBA)-- congenital pure red cell aplasia
# A CT scan of the head is a very rapid and accurate means to confirm increased intracranial pressure and should be performed before an LP if signs of increased ICP are present, however, this should not delay the antibiotic administration.
# Rubella is characterized by low-grade fever, lymphadenopathy (sub-occipital and posterior auricular) and rash. The rash is erythematous, maculopapular and classically begins on the face, spreading subsequently down the body.
# Heroin withdrawal usually presents within the first 48 hours of life, with tremors and
hyperirritability as the most prominent symptoms.
# Stranger anxiety starts anywhere between 6-8 months, and peaks at 12-15 months.
# In Henoch-Schin purpura (HSP), there maybe manifestations of palpable purpura, scrotal swelling, hematuria and abdominal pain. These children are susceptible to intussusception.
Newborns Group B streptococcus, L. monocytogenes , S. pneumoniae,
one month through two years S. pneumoniae, N. meningitides, group B
age 2 through 18 years N. meningitides, S. pneumoniae, H. influenzae
age 18 and above S. pneumoniae 60-70 percent of cases
# pediatric Migraine—tx: acetaminophen orNSAIDs
# Cystic fibrosis may presents with meconium ileus, which is characterized by bilious vomiting, failure to pass meconium at birth, and ground glass appearance on abdominal X-rays.
# Noninvasive positive pressure ventilation is an excellent option for patients with COPD exacerbation. It should be tried before intubation and mechanical ventilation. NIPPV is recommended in a patient of respiratory distress with a pH<7.35 or PaC02 >45mmHg or respiratory rate >25 per min. There is better alveolar ventilation and less fatigue of respiratory muscles by using NIPPV. However, in septic, hypotensive, or dysrhythmic patients, NIPPV is contraindicated
# The patient has multifocal atrial tachycardia, which is associated with the exacerbation of chronic obstructive pulmonary disease (COPD). theophylline and beta agonists may actually worsen the arrhythmia.
# Indicators of a severe asthma attack include normal to increased Pco2 values,
speech difficulty, diaphoresis, altered sensorium, cyanosis, and silent lungs. # multifocal atrial tachycardia associated with the exacerbation of chronic obstructive pulmonary disease (COPD), theophylline and beta agonists worsen the arrhythmia. beta agonists also have the tendency to lower the potassium levels, which have further arrhythmic effects. # Theophylline toxicity usually manifests as CNS stimulation (headache, insomnia), gastrointestinal disturbances (nausea, vomiting), and cardiac toxicity (arrhythmia). The mechanisms responsible for the toxicity may include phosphodiesterase inhibition, adenosine antagonism, and stimulation of epinephrine release. ciprofloxacin and erythromycin decreases Theophylline clearance serum theophylline increased. # Anterior mediastinal mass along with elevated AFP and HCG indicates Nonseminomatous tumor, AFP and HCG are used to monitor response to therapy # Rigid bronchoscopy is indicated in patients with massive hemoptysis as it allows rapid visualization of the bleeding site and to control bleeding through cauterization or other means# Sarcoid can present in a black female with bilateral hilar adenopathy. association with erythema nodosum. Biopsy typically shows non-caseating granulomas. Serum Ca and ACE levels are elevated. Steroids are the treatment of choice in symptomatic patients. Once mediastinal adenopathy is seen on a chest x-ray, the next step is to perform a mediastinal bronchoscopy and obtain tissue for biopsy. **Glucocorticoids cause neutrophilia by increasing the bone marrow release and mobilizing the marginated neutrophil pool. Eosinophils and lymphocytes are decreased. ** Suspect cystic fibrosis in patients with bronchiectasis and symptoms suggestive of intestinal malabsorption due to pancreatic insufficiency. # Anticholinergic drugs (Ipratropium bromide) are the first line medications in COPD. Beta-2 agonists like albuterol are used as second-line drugs Aminophylline or oral Theophylline is used after beta-2 agonists and anticholinergic agents, as 3rd or 4th line agent. Systemic steroids are the first line therapy of the acute exacerbation of COPD. Two modalities that can decrease mortality in patients with COPD are home oxygen therapy and smoking cessation. # Adverse effects of low-dose inhaled corticosteroids are limited to topical problems like dysphonia and thrush. # High doses of inhaled corticosteroids can lead to increased systemic absorption and can produce adrenal suppression, cataract formation, decreased growth in children, interference with bone metabolism and purpura. However, these systemic effects are dose-dependent and occur in patients who are on high-dose inhaled steroids for prolonged period of time. # The diagnosis of pulmonary embolism based on a chest x-ray is virtually impossible. The most common presentation of a patient with a pulmonary embolism will be a normal chest x-ray. When the x-ray is normal and suspicion is still high, the next step is to obtain a V/Q scan. If the V/Q scan is of low probability with a normal x-ray, one can exclude the diagnosis of PE. When a pulmonary embolus occurs, it may occlude one or few branches of the pulmonary artery and present on an x-ray as a cone shaped area of opacification representing an area of atelectasis or infraction. This sign is seen in only a few patients. # Acute bronchopulmonary aspergillosis is characterized by: worsening asthma; fleeting pulmonary infiltrates; increased serum IgE; peripheral eosinophilia; immediate skin hypersensitivity reaction to aspergillus antigen; and precipitating antibodies against aspergillus in serum. Oral prednisolone is the treatment of choice for the treatment of acute bronchopulmonary aspergillosis, which is a hypersensitivity reaction to inhaled aspergillus antigens. Oral itraconazole reduces steroid requirement in patients with acute bronchopulmonary aspergillosis and improves pulmonary function but the mainstay of treatment is oral prednisolone. Nebulised albuterol is used for acute exacerbation of asthma.
Inhaled beclomethasone is the first-line treatment for persistent asthma.
# P. Carinii pneumonia is characterized by dyspnea, fever, and a nonproductive cough. Physical examination would show tachypnea, tachycardia, and cyanosis with minimal chest findings. Bilateral diffuse interstitial infiltrates beginning in the peri hilar region is a characteristic finding on chest x-ray # Aspergillosis can also be seen in immunocompromised patients; however, the chest x-ray typically shows a solid mass surrounded by a radiolucent crescent (crescent sign, Monod's sign).
# Candida is an extremely rare organism to cause pneumonia in any patient.
# the three major complications of too high a PEEP: Alveolar damage, Tension
pneumothorax and Ventricular failure.
# Both mesothelioma and bronchogenic carcinomas are associated with the asbestos exposure( plumber ) but bronchogenic carcinoma is far more common and occurs more frequently after asbestos exposure. Cigarette smoking acts synergistically with asbestos exposure in increasing the risk for bronchogenic carcinoma. Both pleural mesothelioma and peritoneal mesothelioma can occur after asbestos exposure. Chest X-ray shows multiple pleural plaques bilaterally; a mass on the periphery of the lung * Pleural involvement is a hallmark of asbestos exposure # Extrinsic allergic alveolitis or hypersensitivity pneumonitis results from exposure to organic dusts like fungal spores, thermophilic actinomycetes etc. Patients have antibodies to the offending antigen in their serum and this disease is mediated thru a type III hypersensitivity reaction. Farmer’s lung and bird breeder’s lung are two typical examples. Taking a careful history is critical for the diagnosis. Clinical features include fever, malaise, dyspnea and non-productive cough. Chest-X ray shows interstitial infiltrates. Chest-X ray reveals diffuse ill-defined patchy infiltrates. Pulmonary function tests may show a restrictive pattern. The most effective treatment is avoidance of offending antigens or haptens.
# Alveolar proteinosis is characterized by accumulation of phospholipid rich material in the alveoli probably due to impaired clearance. Its cause is unknown and it presents with dyspnea and dry cough. Chest-X ray shows bilateral alveolar infiIterates and pulmonary function tests shows restrictive lung disease. Lung biopsy will confirm the diagnosis by showing PAS positive material. Total lung bronchoalveolar lavage is effective treatment of this disorder. Corticosteroids are of no benefit in this disease.
** Chronic dry cough is a very common side effect of the therapy with ACE inhibitors like enalapnl. # All patients with suspected bacterial pneumonia should have a chest x-ray done as the first step, and antibiotics should be administered as soon as possible without waiting for sputum gram stain or cultures.
# Factor V Leiden is the most common inherited disorder causing hypercoagulability
and predisposition to thromboses, especially DVT of lower extremities. A point mutation in a gene coding for the coagulation factor V Factor V becomes resistant to inactivation by protein C # corticosteroids are the most important intervention in patients with moderate persistent asthma. Inhaled corticosteroids reduce the inflammation, and hyper-responsiveness of the bronchial mucosa. More importantly, they lack the systemic toxicity of oral corticosteroids. Beta-2 agonists and oral theophylline are very useful to control symptoms but do not make any difference in the long term out come of the disease. Use of prophylactic inhaled corticosteroids is beneficial in the long term out come of chronic persistent asthma.
# ARDS results from diffuse inflammatory injury to the alveoli of lungs. Inflammatory mediators are released as a result of local or distant tissue injury. Neutrophils recruited to the lungs become activated and release proteases and free oxygen radicals which damage alveolar endothelial and epithelial cells. Alveolar capillary permeability increases and protein is released into alveoli increasing osmotic pressure in alveoli and as a result, free water is also dragged into the alveoli. Accumulation of protein rich fluid in alveoli as a result of diffuse alveolar damage makes the lungs stiff and they become less distensible or compliant. Alveolar-arterial P02 difference is widened in cases of ARDS and hypoxemia occurs as a result. It occurs largely due to ventilation-perfusion mismatch. Pulmonary hypertension is very common in ARDS and it occurs as a result of hypoxemic vasoconstriction of pulmonary vasculature. **Pulmonary capillary wedge pressure is normal in ARDS and it is the most important differentiating point between ARDS and cardiogenic pulmonary edema. It is usually less than 15 mmHg in ARDS while it is greater than 18 mmHg in cardiogenic pulmonary edema. # When an acute pulmonary embolus occurs with hemodynamic compromise, the best treatment is fibrinolytic therapy. But, if the patient has contraindications to the use of fibrinolytic therapy( eg, in a fresh postoperative patient, especially after trauma. It may cause diffuse bleeding) , an embolectomy is the treatment of choice. A pulmonary embolectomy can be performed either surgically or percutaneously. Even after an embolectomy, the patient may require warfarin (Coumadin) for a few months.
# Remember pneumonia, hyponatremia and diarrhea are almost classic for Legionella. Legionella is a gram-negative bacteria known to cause community acquired and hospital acquired pneumonia. They are usually associated with contamination of water sources like air conditioners. Patients usually are chronic alcoholics and smokers. Other risk factors include cancer, AIDS, transplantation and long term steroid therapy. Patients usually complain of fatigue, malaise, confusion, and fever with chills, productive cough, chest pain, non-bloody diarrhea and abdominal pain. Physical exam may show tachypnea, tachycardia, hypotension, decreased breath sounds with dullness on percussion. Labs may reveal proteinuria, hyponatremia and hematuria. Legionella usually cannot be seen under ordinary gram staining. Sputum analysis will reveal neutrophils. Chest x-ray usually shows patchy interstitial inflammation and unilateral lower lobe involvement, which may progress to areas of consolidation over a few days. Erythromycin is the treatment of choice.
# Infective Endocarditis in IV drug abusers is usually right-sided and mostly caused by staph aureus. The cardiac examination usually reveals involvement of the tricuspid valve. The holosystolic murmur, which intensifies with inspiration, is most probably due to tricuspid regurgitation. Vegetations over the tricuspid valve can embolise to remote organs. Hemoptysis with fever are most probably due to septic pulmonary emboli. #Right-sided valvular lesions are common in carcinoid syndrome owing to degradation of serotonin metabolites by the lung. Carcinoid syndrome refers to a classic triad of flushing, valvular heart disease and diarrhea. It is usually caused by carcinoid tumors with hepatic metastasis.
# Lung abscess X-rays : thickened wall cavities with air fluid levels w fever and foul- smelling productive cough. Amphoric breath sounds on lung examination
# All COPD patients with Pa02 < 55 mmHg or Sa02 < 88% are candidates for long-term home oxygen treatment. Patient with signs of pulmonary hypertension or hematocrit > 55% should be started on home oxygen when the Pa02 < 60 mmHg. # When PEEP is increased, its major drawback is a decrease in cardiac output. Patients who are maintained on PEEP, CO should be monitored with a Swan-Ganz catheter. PEEP increases the intrathoracic pressure which results in a decrease in preload and thus a decrease in cardiac output, and slightly increase the central venous pressure. To counteract the effects of PEEP on cardiac output, some physicians may elect to use inotropic agents or more fluids.
# N-acetylcysteine is used to treat patients who have very viscous secretions. The agent reduces the viscosity and prevents airway plugging.
# Idiopathic pulmonary fibrosis is a diagnosis of exclusion. It is also known as cryptogenic fibrosing alveolitis. present with fatigue, anorexia, arthralgias, weight loss, cyanosis and clubbing. x-ray shows a diffuse bilateral reticulonodular pattern bilateral interstitial involvement. Almost always a biopsy is done to rule out sarcoid. The treatment is steroids.
# The most common cause of superior vena cava obstruction(venous congestion of his face and arms, angioplasty with stenting is the standard of care) bronchogenic cancer. # Mycoplasma pneumonia -- x-ray usually shows peribronchial pneumonia pattern. # Wegener’s granulomatosis vasculitis of the small vessels and necrotizing granulomatous lesions affecting both upper and lower respiratory tract and glomerulonephritis. Chest x-ray reveals infiltrates, nodules, masses, and cavities. anti neutrophil cytoplasmic antibodies confirms this diagnosis. The cytoplasmic pattern (C-ANCA) is highly specific for WegenerDs granulomatosis.
# TMP+SMX is the drug of choice for Pneumocystis carinii pneumonia. Ampicillin and gentamycin is almost never used for pneumonia
# In patients with fever and cough after upper Gl endoscopy suspect anaerobic lung infection. Clindamycin and ampicillin plus metronidazole are the commonly used agents
** Undiagnosed pleural effusion is best evaluated with thoracentesis, except in patients with clear-cut evidence of congestive heart failure. When pleural effusion is suspected or diagnosed, the first step is to determine the cause of pleural effusion, and management starts with determining whether the fluid is transudate or exudate. Diagnostic thoracentesis is the preliminary investigation of choice in the management of pleural effusion, If a diagnostic thoracentesis shows exudative pleural fluid, further diagnostic investigations are indicated. (transudative fluid would rule out malignant effusion). Bronchoscopy will be the next step if the pleural fluid cytology is non-diagnostic and the patient has lung mass. If the pleural fluid cytology is positive for lung cancer, then the patient does not require a bronchoscopy.
# In a postoperative patient who presents with dyspnea and tachypnea, one has to exclude Ml, PE, pneumonia and ARDS(bilateral fluffy infiltrates on a chest x-ray w hypoxemia persists, difficult to oxygenate the patient)
# Postoperative atelectasis is a major cause of fever.
# Therapeutic INR for most clinical indications of warfarin is 2.0 to 3.0. A higher INR of 3.0 to 4.5 is required in prosthetic heart valves.
# Histoplasma capsulatum is a common and usually asymptomatic infection(asymptomatic pulmonary nodule) in endemic areas like Mississippi and Ohio River valleys and Central America. # Pulmonary Function Tests (PFTs) are the most useful tool to determine if a patient can benefit from the lung resection surgery. Predicted postoperative FEV1 is very helpful for this purpose. It can be derived from preoperative value and the fractional function of the lung tissue to be resected.
# A chest x-ray is normal in almost all asthmatic patients, except when they have acute exacerbations where you can see hyperinflation. Even in COPD patients, chest x-ray findings are delayed for a long period of time until the significant air trapping occurs. All patients with suspected COPD should have pulmonary function tests done as soon as possible, regardless of the chest x-ray findings. A bronchodilator response test is used to demonstrate reversibility of airway obstruction. It helps to differentiate between COPD and asthma,
tests can help you most in differentiating asthma from emphysema . FEV1 measurement with and without a bronchodilator
# In ARDS, the one treatment that can improve oxygenation is the addition of PEEP. it is also best to keep the patient on the dry side and avoid fluid overload
# Any patient with fever, night sweats and copious foul smelling sputum has any one of these three condition: 1. Bronchiectasis 2. Lung abscess 3. Anaerobic pneumonia.
# bronchiectasis CXR: increased vascular markings, ring shadows and peribronchial thickening (tram track appearance). High resolution CTscan of the lung is the diagnostic modality of choice for bronchiectasis
# pulmonary embolism right axis deviation on ECG
# transudation ( shen chu yie ) coused by increased hydrostatic pressure or hypoalbuminemia
# Exudate is formed as the result of local factors like inflammation. Pleural fluid
a. protein/serum protein ratio > 0.5.
b. Pleural fluid LDH/serum LDH ratio > 0.6
c. Pleural fluid LDH more than two-thirds of the upper limit of normal serum LDH
Normal pleural fluid pH is approximately 7.64. Pleural fluid pH< 7.3 indicates pleural inflammation. pH of 7.35 is consistent with transudative pleural effusion. PH < 7.2 requires a chest tube aspiration to prevent empyema. # Pleural fluid Glucose level < 60 mg/dL favors the diagnosis of parapneumonic effusion, tuberculosis, or rheumatoid arthritis # Klebsiella is a capsulated gram-negative bacillus, grows as mucoid colonies. and can cause pneumonia in subjects with debilitating conditions, especially alcoholics. Friedler’s pneumonia generally affects the upper lobe and is characterized by current jelly-like sputum.
# Beta agonists and mast cell stabilizers both play an important role in the management of exercise-induced asthma.
# The most serious complication of bronchiectasis is hemoptysis.
# Aspergillosis is an opportunistic infection, characterized by coarse fragmented septae. Hyphae are typically seen. The chest x-ray may demonstrate a crescent radiolucency next to a rounded mass. Cavitary lesions may form because of destruction of the underlying pulmonary parenchyma, and debris and hyphae may coalesce and form a fungus ball, which lies free in the cavity and moves around with position change.
# Histoplasmosis Calcified nodes in the lung, mediastinum, spleen, and liver may occur. The chest x-ray may demonstrate central or target calcification. A solitary nodule may be seen sometimes.
# The most common cause of pulmonary complications in patients with systemic sclerosis is interstitial fibrosis.
# 24-hour pH employed in patients with chest pain or chronic cough when esophagoscopy is negative.
# Patients with suspected pulmonary embolism should have a chest-x ray and arterial blood gases, followed by EKG and V/Q scan.
# A-a gradient = PA02- Pa02 (Normal gradient is 5-15).
PA02 = FiO2(760-47)-PaCO2/0.8 =0.21*
# Shunt should be suspected if there is no response to 100% 02.
Shunt can result from any of the following causes:
2.Intraalveolar filling (pulmonary edema)
3.Intra cardiac shunt (Right-Left) due to VSD, ASD etc.
4.Vascular shunt within the lungs
# COPD, in general, is characterized by reduced FEV1 and rapid decline FEV1 FEV1/FVC is decreased. two main types of COPD are emphysema and chronic bronchitis. Patients with COPD are generally smokers with a history of 1 pack per day for at least 20 years. # Chronic bronchitis chronic productive cough, prominent bronchovascular marking, mild flattening of the diaphragm, and normal DLCO. # Emphysema Pink puffers, hyperinflation of the chest, decreased vascular markings, decreased DLCO (due to destruction of alveoli),and moderate oxygen desaturation. #Restrictive lung disease is characterized by an equal decrease in FEV1 and FVC and, thus, a normal ratio of FEV1/FVC. # When an individual with asthma presents with subcutaneous emphysema, the first thing one wants to rule out is a pneumothorax. do CXR first. if no pneumothorax is seen, the patient can be observed. Subcutaneous emphysema does not require any formal treatment, save for observation # Presence of bilateral hilar lymphadenopathy and non-caseating granulomas is diagnostic for sarcoidosis. # Coccidioidomycosis Cutaneous findings like erythema multiforme and erythema nodosum as well as arthralgias. # obstructive ventilatory defects (such as asthma and COPD), restrictive ventilatory defects (such as interstitial fibrosis and chest wall deformities). a low DLCO can be seen in both emphysema and interstitial fibrosis. DLco is normal in asthma. # Dysphagia first step: barium. Then endoscopy. Then motility #Alcohol precipitate cluster headache. # Haloperidol cause dystonia # hill sign & de musset sign aortic regurgitation. # Large a wave tricuspid regurgitation.
# Corticosteroid lead to more difficult glucose control in DM
# Esophgeal spasm precipitated by cold, hot water
# Multiple air_fluid level in the small intestine intestine obstruction. First step Tx: nasogastric tube
# Trimethoprim/Sulfamethoxazole for prophylaxis Toxoplasmosis.
Pyrimethamine and sulfadiazine for treating Toxoplasmosis.
# Disordered thought associations and affective flattening is main point to diag schizophrenia
# First line empiric Tx hospitalized pt w pneumococcus fluoroquinolone (levofloxacin) or beta-lactam + macorlide
# cryptococcal India ink, but antigen assay in CSF more sensitivity and specificity.
Tx: Amphotericin B + flucytosine
# ALLERGIC BRONCHO PULMONARY ASPERGILLOSIS--1 .Asthma like symptoms
2.Elevated IgE 3.Hypereosinophilia 4.Central bronchiectasis 5.Positive Aspergillus Skin test # community-acquired pneumonia (CAP). CAP can be caused by a host of bacteria and viruses; and, in many cases, it is not possible to isolate the causative organism. Hence, most of the time, treatment is empirical. Newer antipneumococcal quinolones, like levofloxacin or gatifloxacin, are the drugs of first choice for in-patient treatment of community-acquired pneumonia. For out¬patient therapy, either azithromycin or doxycycline can be used.
#Primary pulmonary hypertension can be seen in middle-aged patients, and it presents with exertional breathlessness. Lungs will be clear to auscultation. Chest x-ray would show enlargement of the pulmonary arteries with rapid tapering of the distal vessels (pruning) and enlargement of the right ventricle.
# Diabetic Cardiomyopathy cause left ventricular hypertrophy and diastolic dysfunction which ejection fraction is normal.
# steroid indicated when Po2<70mmHg
#Obstructive sleep apnea Tx: weight loss & nasal continuous positive pressure ventilation. # Tx: central sleep apnea acetazolamide, progesterone.
# Pt >60y w meningitis, empiric Tx: ampicillin(listeria G+ rod)+vancomycin+ceftriaxone. # screen gestation DM start at 24-28 w
#Tx neurocystocercosisalbendezole & dexamethasone
#Tx systolic hypertesion Ca channel block.
# bronchoalveolar lavage is > 90% effective in diagnosing Pneumocystis carini
pneumonia in HIV positive patients, especially when CD4 count is less than 200.
# Steatorrhea in newborn caused by bile acid deficiency. Tx : substitute medium chain TG for long-chain TG.
# Direct inguinal hernias lateral aspect of Dr’s finger placed on external inguinal ring. Indirect inguinal hernia feel hernia on the tip of finger.
#Tx necrotizing enterocolitis w perferation surgery, reanastomosis after 6 weeks.
# Frotteurismrubbing genital against women. Fetishism use certain inanimate objects to accomplish sex arousal
# Gabapetin use for treating DM neuropathy, neuropathic pain.
# In Parapneumonic effusions, if Glucose of less than 60mg/dL is an indication for tube thoracostomy.
# Any person from Wisconsin, Mississippi river belt or Ohio River Belt presenting with chronic respiratory symptoms should be suspected of having Blastomycosis triad of lung(lobe cavitation), skin(sharply demarcated papules) and bone lesions(a lytic lesion)
# Patients with DVT in whom anticoagulation is contraindicated require placement of
inferior vena cava filter for the prevention of pulmonary embolism.
# A pulmonary angiogram is the gold standard to diagnose a pulmonary embolism.
# The most typical findings of a pulmonary embolism on arterial blood gas sampling
are hypoxemia and hypocarbia. A-a gradient & D-dimers usually increased.
# Hamartomas are the most common benign lung masses and contain abundant cartilage. The best treatment for a patent with a confirmed hamartoma is observation. ** Proximal (above knee veins-> iliac, femoral and popliteal.)
deep vein thrombosis of lower extremities is the most frequent source of
pulmonary embolism # Acute bronchopulmonary aspergillosis (ABPA) is characterized by transient recurrent pulmonary infiltrates, peripheral eosinophilia, asthma and immediate wheal and flare reaction to Aspergillus fumigatus and presence of antibodies in the serum against Aspergillus fumigatus. Other important features include history of brownish plugs in the sputum and high IgE levels. Sometime bronchiectasis is also present in this disorder, and is due to immune complex deposition. Glucocorticoids are used to treat this disorder. skin testing with A. antigen is the first diagnostic step. If the test is positive, serum precipitins against Aspergillus fumigatus and IgE level are checked. ABPA is excluded if IgE levels are less than 1000ng/ml or if serum precipitins against Aspergillus fumigatus are absent.
# Job Syndrome is characterized by recurrent bacterial infections and markedly elevated IgE levels. skin is the most frequent site, Neutrophils impaired chemotaxis
# Wiskott-Aldrich syndrome—X-link, . IgE and IgA levels are high while IgM levels are low. Lymphoreticular malignancies are common in such patients.
# Increased ventilatory rate in patients on mechanical ventilation leads to auto PEEP(condition starts to deteriorate.)and it can be corrected by reducing the ventilatory rate.
# Excessive alcohol intake can lead to aspiration pneumonia(. Foul-smelling sputum and the right, lower lobe pneumonia ) # Suspected deep vein thrombosis (DVT) do compression ultrasonography first. Impedence plethysmography is the study of choice for recurrent DVT. Venography is considered to be the gold standard for the diagnosis of DVT, but not initial step. It is used only when the noninvasive testing is not possible or the results obtained by noninvasive testing are equivocal.
# Pancoast tumor grow in the apex of the lung (superior sulcus) and tend to invade the upper chest wall, ribs, sympathetic chain and lower brachial plexus.
TCAs toxicity prolongation QRS interval
# For small cell lung Cancer, primary Tx is Chemotherapy. Other lung Ca Tx: surgery.
#Sildenafil contraindicate w nitrates since it cause severe hypotension
# Symptom of high K muscles cramping, weakness, ascending paralysis, arrhythmia. Peak T, widen QRS, loss P.
# low K flattened T & prominent U.
# Osler-Weber-Rundu syndromMultiple angiondysplasias on mucuous membrances.
# Adrenal insufficiency decreased Na, Cl, hypotension, low glucose, High K, hyperpigmentation on skin. ACIH increased. Tx primary adrenal insufficiency prednison + fludrocortisone. For secondary, do not need fludrocortisone.
# Granulomatous disease like sarcoidosis and lymphoma cause high Ca via increased 1,25 D3 ( calcitriol ).
# HIV w CD4 < 50 CMV infection
# Roughly, every 3mEq/L increaded Na represent 1L water deficit.
# Risperidone cause increased prolactin amenorrhea
# Thrombolytic Tx for ST elevated MI or new onset left bundle branch block.
# Hypertrophic obstructive cardiomyopathybrisk upstroke carotid pulse, systolic murmur increased w standing ( aortic stenosis murmur decreaded w standing )
# Excessive alcohol intake can lead to aspiration pneumonia_. Foul-smelling sputum and the right, lower lobe pneumonia
# Suspect choriocarcinoma in any postpartum women who presents with shortness of breath and hemoptysis. The next step is chest x-ray, pelvic exam, and beta-hCG.
# If ventilation/perfusion scan is inconclusive in patients undergoing diagnostic work-up for pulmonary thromboembolism, order venous ultrasonography to reveal DVT or CT angiogram. Pulmonary angiography is an invasive procedure and should be employed only if venous ultrasonography or CT angiogram is negative.
# When pneumonia fails to heal after two weeks of appropriate antibiotics, a CT scan of the chest followed by bronchoscopy is indicated to ensure that the bronchus is not blocked and there is no lung abscess.
#An enlarged left atrium in mitral stenosis can cause a persistent cough and elevation
of the left main stem bronchus.
# A sudden drop in oxygen saturation, restlessness, and agitation in a patient on mechanical ventilation in IPPV(Intermittent Positive Pressure Ventilation) mode is suggestive of barotrauma. Chest-x ray should be the next step.
# Fluvoxamine Tx obesive-compulsive disorder.
# Beta-2 transferrinCSF marker
# Most frenquent cause skin infection in injecting drug is staphylo. If using black tar heroin Clostridium spp.
# Coronary artery pypass use for 3 vessels disease or left main coronary disease.
Percutaneous-transluminal-coronary angioplasty w stent insertion use for 2 vessels disease.
# Serum-ascites albumin gradient >1:1 caused by portal hypertention. <1:1 by non portal hypertensive etiology.
# Amyloid nephropathy w increased size of kidney associated w injecting drug abuse
Heroin nephropathy small kidney w hypertention.
# Rheumatoid arthritis can cause keratoconjunctivitis( dry eye, foreign-body sensation, photophobia) Tx: artificial tears.
# Ziprasidone Wt neutral.
# Echocardiography is best initial test for CHF. MUGA ( multigated acquisition ) is accurate test.
# Ipuprofen can cause epistaxis
# Obstructive sleep apnea is a common condition among obese population w Habitual nighttime snoring Daytime somnolence and Hypertension. Investigation of choice is Nocturnal Polysomnography. Multiple Sleep Latency Test is used only when the diagnosis is not clear after nocturnal polysomnography. It is usually done the day after an inconclusive Polysomnography
# The most common locations of post aspiration lung abscess in recumbent position
are apical segment of right lower lobe and posterior segment of right upper lobe.
# diffuse bilateral interstitial infiltrates are typical of Pneumocystitis carinii pneumonia (PCP). PCP occurs with CD4 counts less than 200/microL
# Tuberculosis occurs early in the course of HIV when the CD 4 counts are greater than
200/microL. Upper lobe consolidation and/or cavitation is the typical X-ray finding.
** Aspirin is a cyclooxygenase (COX-1 and COX-2) inhibitor. Aspirin sensitivity syndrome is believed to be a pseudo-allergic reaction. It results from aspirin-induced prostaglandin/leukotriene misbalance that triggers characteristic reactions (bronchoconstriction, polyp formation) in susceptible individuals. Treatment includes avoidance of NSAIDs and the use of leukotriene receptor antagonists
# All beta-2 agonists reduce serum potassium levels because they drive potassium into cells. any patient receiving beta-2 agonists and complains of muscle weakness, hypokalemia should be ruled out. Beta 2 agonists also produce fine resting tremor of fingers, tachycardia, and peripheral edema.
# A non-productive caused by ACE inhibitors: an accumulation of kinins, and possibly by the activation of the arachidonic acid pathway.
# Any emphysema in a non-smoker, emphysema presenting in the 3-rd decade or any emphysematous changes in the lower lobes should strongly raise the suspicion of alpha-1 anti-trypsin deficiency. diagnosis can be made by serum alpha-1 anti-trypsin levels. High resolution CT scan should be considered only after the assessment of alpha-1 anti-trypsin levels.
# Churg Strauss syndrome (CSS)-- allergic granulomatosis is a multisystem vasculitic disorder of unknown etiologythat affects the skin, kidney, nervous system, lungs, gastrointestinal tract and heart. It is characterized by allergic rhinitis, asthma and prominent peripheral blood eosinophilia. A CSS-like syndrome has been noted in patients who have been successfully treated for chronic steroid dependent asthma with the leukotriene receptor antagonists. Up to 75% of the patients with CSS have evidence of peripheral neuropathy. The treatment with glucocorticoids and sometimes with immunosuppressants. remember that leukotreine antagnoists cause CSS.
# Loeffler’s syndrome
# Acute bronchopulmonary aspergillosis (ABPA) is characterized by eosinophilic pulmonary infiltrates, peripheral eosinophilia, asthma, an immediate wheal and flare reaction to Aspergillus fumigatus (type 1 hypersensitivity) and the presence of antibodies in the serum against Aspergillus fumigatus. Sometime bronchiectasis is also present in this disorder, which is due to immune complex deposition (type III hypersensitivity). Glucocorticoids are used to treat this disorder.
# Salbutamol at bedtime would be a good treatment for mild nocturnal asthma.
# Patients with impaired consciousness, advanced dementia, and other neurologic
disorders are predisposed to aspiration pneumonia due to impaired epiglottic function.
# Erythema multiforme( target shaped skin lesions) is one of the extra pulmonary manifestations of mycoplasma pneumonia.
# Acute exacerbation of COPD is treated with a combination of inhaled/nebulized
bronchodilators (ipratropium and albuterol nebulization )and systemic steroids
# Hypertrophic osteoarthropathy is associated with chronic proliferative periostitis of the long bones, clubbing, and synovitis. associated with squamous cell carcinomas and adenocarcinoma of the lungs.
# If you suspect a pulmonary embolism clinically, and chest X ray, ABG and EKG results rule out other differential diagnoses then you should begin treatment with heparin without waiting for a V/Q scan to confirm your diagnosis. Spiral CT will be the answer instead of V/Q scan if the baseline chest-x ray is abnormal, eg. Destroyed lung.
# Silicosis is a type of pneumoconiosis caused by exposure to crystalline silica. There are three patterns of this disease that include acute, accelerated and chronic silicosis. High-risk professions include glass making, pottery working, underground mining abrasive working etc. Small nodules with predominance in the upper lung lobes are important radiographic findings in cases of chronic silicosis.
# Alveolar proteinosis is characterized by accumulation of phospholipid rich material in the alveoli probably due to impaired clearance. Its cause is unknown and it presents with dyspnea and dry cough. Chest X-ray shows bilateral alveolar infiltrates and pulmonary function tests shows restrictive lung disease. Lung biopsy will confirm the diagnosis by showing PAS positive material. Bronchoalveolar lavage is effective treatment of this disorder. Corticosteroids are of no benefit in this disorder.
# Asbestosis is a type of pneumoconiosis caused by inhalation of asbestos fibers and is characterized by slowly progressive pulmonary fibrosis. Other disorders produced by asbestos exposure are pleural disease and mesothelioma. High-risk professions include shipbuilding, plumbing, working with textiles, cement and insulation. Exertional dyspnea is the usual clinical presentation. Examination shows bilateral end-inspiratory crackles. A radiographic finding of pleural plaques is the hallmark of asbestos exposure. Bilateral irregular opacities of reticulonodular or reticular pattern most prominent in lower lung lobes. Lung function tests show a restrictive pattern. There is no effective treatment of this disorder.
#Anserine bursitis-- pain over the medial tibial plateau just below the joint line, history of trauma.
#Prepatellar bursitis presents with pain and swelling over the anterior aspect of knee. Examination shows cystic swelling over the patella with variable signs of inflammation.
# Lumbar spinal stenosis-- neurogenic claudication radiates back to the buttocks, upper or lower legs; it becomes better with sitting or leaning forward due to flexion of the lumbar spine or hips and gets worsened by extension of the lumbar spine. Wide gait (walking like a drunken sailor) and positive Romberg sign are specific but not sensitive for lumbar spinal stenosis. spaghetti legs
#Herniated disc syndrome – Pain worsened with sitting and lumbar flexion #The cauda equina syndrome -- compression of lumbosacral nerve roots by infection or tumor. Usual w urinary retention or overflow incontinence. saddle anesthesia around the anus or perineum and decreased tone of anal sphincter.
# Leriche syndrome caused by atherosclerotic vascular disease, impotence and intermittent claudication # Progressive low back pain not relieved by rest and worse at night suggests vertebral body metastasis, Technetium 99 scinti scanning is the most effective method to assess bone metastasis. # Total knee replacement is indicated in patients with severe restriction of walking and nocturnal and rest pain # Hydroxychloroquine-- cause serious eye disease including macular degeneration. Eye examinations at 6 months to 1 year intervals should be performed # osteoarthritis-- narrowing of joint space, osteophyte formation, sharpened articular margins, and thickened subchondral bone. #Punched out erosion with a rim of cortical bone gouty arthritis. # Narrowing of joint space and juxta articular erosions rheumatoid arthritis--an erosive arthritis. Symmetrical synovitis of the Metacarpophalangeal (MCP) and the proximal interphalangeal (PIP) joints, Joint stiffness lasts for more than 30 minutes. ESR is always elevated. # Marginal bony erosions and irregular joint destruction psoriatic arthritis-- Sausage-shaped digits, asymmetric oligoarticular arthritis # arthritis, urethritis and uveitis characterizes Reiter’s syndrome # Corticosteroid-induced avascular necrosis of the femoral head usually presents as progressive hip or groin pain without restriction of motion range and normal radiograph on early stages. MRI is gold standard for the diagnosis of avascular necrosis of hip.
# diseases modifying anti-rheumatic drugs(slow down the progression of bony erosions and cartilage loss) -- methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, etanercept, infliximab and azathioprine. Methotrexate is the initial drug. Leflunomide used when contraindications to methotrexate( caused pulmonary fibrosis ). Etanercept and infliximab are the new generation TNF inhibitors, highly effective w refractory disease with methotrexate. They are very expensive and are not indicated as first line of treatment. Erosive joint disease in rheumatoid arthritis is a clear-cut indication for the use of diseases modifying anti-rheumatic drugs
# rotator cuff tear -- shoulder pain aggravated by movements like pushing, pulling and positioning the arm above the shoulder. limitation of mid arc abduction and external rotation that does not improve after lidocaine injection. Definitive diagnosis-- MRI or arthrography.
# Reflex sympathetic dystrophy-- pain and swelling associated with vasomotor instability. discolored limb with atrophy. X-ray -- osteopenia, bone scan shows increased uptake. Physical therapy is done to restore function. Prednisone is indicated in resistant cases. Stellate ganglion block is also very effective.
# fibromyalgia—Tx: either amitriptyline or cyclobenzaprine are the initial drugs. Selective serotonin reuptake inhibitors (SSRIs) are added when disease is refractory to the above medicine. they are usually given in low doses at nighttime. To relieve the pain, non-narcotic analgesics like acetaminophen can be given during the daytime. excessive muscular tenderness in 9 or more tenderpoints.
# Neisseria gonorrhea -- asymmetric migratory polyarthralgia followed by monoarticular arthritis, multiple necrotic pustules over palm and soles. Tx; ceftriaxone
# Chlamydia causes Reiter’s syndrome characterized by urethritis, conjunctivitis, mucocutaneous lesions, and arthritis.
# Polymyositis-- proximal muscle weakness w difficulty climbing the stairs or rising from the chair, increasing creatine kinase and aldolase & ESR.
Dermatomyositis—Polymyositis + Skin w Heliotrope rash around the eyes associated with periorbital edema, and Gottron's papules, which are red scaly patches over the metacarpophalangeal joints. (Periorbital edema with a purplish suffusion is called the heliotrope rash) .Diag: muscle biopsy. Tx: prednisone. cannot tolerate corticosteroid, immunosuppressive agents such as methotrexate may be effective.
# Baker’s cyst is a complication of rheumatoid arthritis
# major criteria of rheumatic fever -- carditis, polyarthritis(migratory), chorea, erythema marginatum and subcutaneous nodules. Minor criteria include fever, arthralgias and previous history of rheumatic fever or rheumatic heart disease. Diagnosis of rheumatic fever is made when two major criteria or one major and two minor criteria,
# Adult Parvovirus infection – symmetrical joint pain w morning stiffness < 15 min. Hands, wrists, knees and feet are the most frequently involved. No joint redness & swelling, no rash. Anti-B19 IgG antibodies appear a few days after Anti-B19 IgM antibody persist for life. Diag: Anti-B19 IgM.
# Polymyalgia rheumatica—pain & stiffness of the shoulder and pelvic girdle(muscles of the neck, shoulders, lower back, hips and thighs), pain caused by the swelling of blood vessels in the muscles. It does not affect the bones, or the joints. no muscles weakness, seen over the age of 50. associated with giant cell arteritis. Tx : low-dose prednisolone
# Giant cell arteritis-- >50y, headache, visual problems and polymyalgia rheumatica. ESR highly increased , may elevated platelet counts. Tx: high dose glucocorticoids immediately once clinical diagnosis made. Confirm diag: temporal artery biopsy
# Subacromial bursitis characterized by shoulder pain, which is absent at rest but present on overhead activity. Range of active shoulder movements are limited by pain. Neer’s impingement sign (pain on passive internal rotation and forward flexion at shoulder) is present. Ultrasonogram or MRI generally confirms the diagnosis. Treatment is conservative with NSAIDs, physical therapy and activity modification
# Rupture of long head of biceps commonly occurs in bicipital groove and would lead to a bulging muscle mass in the middle arm.
# Tennis elbow is epicondylitis-- point tenderness over lateral epicondyle of the humerus and exacerbation of pain by extension of wrist against resistance.
** Cessation of alcohol and staying on a low purine diet are important measures in the prevention of future attacks in patients with acute gouty arthritis.
# CREST-- do not develop interstitial lung disease or renal failure, however, scleroderma does. In CREST syndrome hardening of the skin is limited to the face and hands whereas in the diffuse form of scleroderma it extends to involve the trunk and proximalextremities.
# sarcoidosis-- Asymptomatic sarcoidosis does not require treatment. Systemic steroids symptomatic sarcoidosis (anterior uveitis, bilateral nodular lung infiltrates, peri carinal, mediastinal, and hilar lymphadenopathy. noncaseating granulomas, mild eosinophilia, hypercalcemia)
# Thoracic outlet syndrome refers to compression of the neurovascular structures supplying the upper extremity. Paresthesias aggravated at night. weakness and muscle atrophy. elevated arm stress tes used for screening purposes.
# Lofgren’s syndrome -- acute form of sarcoidosis w triad of arthritis (of ankles, knees, wrists or elbows), erythema nodosum and bilateral hilar adenopathy. Lung involvement is very rare in this acute form. false positive rheumatoid factor, and antinuclear antibodies.
# Heerfordt-Waldenstrom syndrome is another rare from of acute sarcoidosis consists of fever, parotid enlargement, anterior uveitis, and facial nerve palsy.
# cervical spondylosis-- Osteophytes
# kidney damage in SLE patients is immune complex-mediated.
# Frozen shoulder-- stiffness of glenohumeral joint, restricted both on active and passive movement in all cardinal movements. This is a result of peri capsulitis. Arthroscopy establishes the diagnosis by showing decreased joint space volume, and loss of normal axillary pouch. The treatment involves NSAIDs, corticosteroids injection into the joint space, and physical therapy.
# Rotator cuff tear or rotator cuff tendinitis presents with severe pain and weakness of the shoulder abduction. Movements of shoulder like positioning the arm above the shoulder aggravate pain. Range of motion is limited only on active movement but is normal on passive flexion. A positive drop arm sign, with inability to actively maintain 90 degree of passive abduction, may be present in large tears. Rotator cuff tendinitis can be distinguished from rotator cuff tear by injecting lidocaine that will result in improvement in range of motion in cases of rotator cuff tendinitis but no effect in range of motion in cases of rotator cuff tear.
# Suprascapular nerve supplies supraspinatus and infraspinatus muscles. Suprascapular neuropathy is characterized by weakness on abduction and external rotation
# Anti-Scl-70 antibodies are positive in scleroderma
# Pseudogout is characterized by acute onset of pain and swelling of large joints. It is more commonly associated with aging, trauma, hyperparathyroidism, hemochromatosis, hypomagnesemia, hypophosphatemia and hypothyroidism. rhomboid shaped, calcium pyrophosphate crystals with positive birefringence
# Coffin lid shaped crystals represent struvite crystals seen in nephrolithiasis.
# Regular exercise has been shown to halt the progression of ankylosing spondylitis. Sulfasalazine is effective for symptom control
# SLE—migratory, asymmetrical joints pain.
# renal injury in patients of SLE is immune mediated glomerular injury that can be divided into six sub-groups. Type I is normal. Remaining five are as follows: Mesangial, focal proliferative, diffuse proliferative, membranous and sclerosing.-- Diffuse proliferative glomerulonephritis is the severest form
# Epicondylitis about the origin of flexors of forearm is also called golfer’s elbow, exacerbated by flexion at wrist against resistance, point tenderness over the medial epicondyle
# Interosseous nerve is most commonly entrapped at the proximal edge of the supinator. It results in significant extensor weakness leading to loss of digital extension.
# Rupture of long head of biceps commonly occurs in bicipital groove and would lead to a bulging muscle mass in the middle arm.
# Radial tunnel syndrome can be confused with lateral epicondylitis as both the conditions can coexist. It is a compression neuropathy of radial nerve in radial tunnel characterized by tenderness over mobile muscle mass distal to the radial head. Also, the pain is reproduced by simultaneously extending the wrist and fingers while the long finger is passively flexed by the examiner and also by resisted forearm supination.
# Prophylactic allopurinol is the most effective method to prevent gout in patients at risk for tumor lysis syndrome.
# Anti phospholipid antibody syndrome is characterized by recurrent arterial or venous thrombosis or recurrent fetal losses in the presence of anti phospholipid antibodies. Anti phospholipid antibodies are of three types. The first is responsible for false-positive syphilis serology. The second is lupus anticoagulant, which falsely elevates APTT. The third is anticardiolipin antibody. Antiphospholipid antibody syndrome is either primary or may be associated with other autoimmune disorders like SLE.
# Mixed Connective Tissue Disease-- SLE, polymyositis and systemic sclerosis are present simultaneously w positive anti-RNP.
# Buerger’s Disease-- an episodic, segmental inflammatory process of small and medium sized arteries (thromboangiitis obliterans) characterized by occlusive disease of the arteries, migratory superficial thrombophlebitis, and RaynaudDs phenomenon w history of smoking. Berger’s Disease= IgA nephropathy
# Oral contraceptive pills use in SLE is considered safe if the patient is in remission. increased risk of thrombosis. In patients with active nephritis, oral contraceptive pills shouldn’t be used as it can aggravate renal disease. Barriers method is used instead.
# For fibromyalgia, Initial evaluation should include a Complete blood count, ESR, Thyroid function tests (TFTs) and enzymes (CK)-- Always consider thyroid abnormalities and fibromyalgia in a patient with diffuse muscle aches and excessive fatigue with non-restorative sleep
# Phalen’s sign -- flexion of both wrists to 90 degrees with the dorsal aspect of hands held in opposition for 60 seconds leads to pain or paresthesia along the median nerve--positive This test has a good specificity but lower sensitivity.
Tinel’s sign is elicited by tapping over the median nerve. This causes a tingling sensation along the median nerve distribution. It has very low sensitivity and specificity. Carpal compression test-- more sensitive than Tinel’s and Phalen’s signs but not diagnostic.
• Nerve conduction studies very useful in diagnosing the carpal tunnel syndrome
# erythema nodosum(EN)-- pink to reddish painful, subcutaneous, nodules that usually develop in a pretibial location. . Histologically, this is a panniculitis involving inflammation of septa in the subcutaneous fat tissue. associated with recent streptococcal infections, sarcoidosis, tuberculosis, inflammatory bowel disease.
Sarcoidosis often presents with EN as an initial symptom. So, initial step - Chest X-ray
# ankylosing spondylitis-- back pain with morning stiffness, improves with exercise, insidious onset, presence of symptoms for more than three months, reduced range of forward flexion of the lumber spine on Schober testing and reduced chest expansion. evidence of sacroiliitis is essential for the diagnosis. plain X-ray of the sacroiliac joint is the next step.If X-ray are negative or equivocal, CT scan is next.
# Paget’s disease is characterized by excessive bone resorption and repair, Bone remodeling is constant. Both osteoclasts and osteoblasts are involved in the process and by itself is not a cause of pain. Its features are normal serum calcium and an elevated alkaline phosphatase. A small number of patients will develop osteosarcoma or sarcomatous changes over 10 years -- present as a new lytic lesion and a sudden increase in alkaline phosphatase.
# De Quervain’s tenosynovitis-- tendonitis of abductor pollicis longus and extensor pollicis brevis as they pass beneath the retinacular pulley. diagnosis can be made by positive Finkelstein maneuver (passive stretching of the thumb tendons over the radial styloid in thumb flexion aggravates pain). Treatment is best with local injection of long-acting steroids. pain over the lateral side of wrist, severe when lifts the infant from the crib.
# scaphoid fracture-- history of trauma and point tenderness over the snuffbox.
# Flexor carpi radialis tenosynovitis is characterized by pain with wrist motion like active wrist flexion or passive wrist dorsiflexion.
# Reactive arthritis is a form of seronegative spondyloarthropathy w Enthesopathy(pain and sausage digits) is quite specific for it. The treatment of choice for reactive arthritis or ReiterDs syndrome is with NSAIDs
# HCV infection is associated with 80% cases of mixed essential cryoglobulinemia.
#In patients with frequent attacks of acute gouty arthritis not controlled by colchicine, a 24-hour uric acid levels in urine is determined. This evaluates whether hyperuricemia is due to over production or under secretion of uric acid. A value of less than 800 mg/day suggests under secretion. A value of more than 800 mg/day suggests over production. Hence accordingly a uricosuric agent or a xanthine oxidase inhibitor is added to the patientDs medication. The goal is to maintain serum uric acid levels to less than 6 mg/dL
Uricosuric agent is indicated for cases of under secretion of uric acid. Xanthine for over production.
# Thoracic aortic aneurysm is a serious complication of giant cell arteritis
# The single most common cause of asymptomatic isolated elevation of alkaline phosphatase in an elderly patient is Paget’s disease.
# Sjogren’s syndrome-- chronic dysfunction of the exocrine glands, dryness of mouth, eyes, and other mucosal areas. dental caries due to salivary insufficiency. leukopenia, eosinophilia, and elevated ESR. Lip biopsy is the only specific diagnostic. biopsy shows lymphoid foci in accessory salivary glands. Schirmertest measures the quantity of tears secreted
# Reiter’s syndrome—onset of arthritis after infection with Chlamydia, Salmonella, Shigella, Yersinia and Campylobacter. seronegative spondyloarthropathy and such patients have negative rheumatoid factor.
# Anti-DsDNA antibodies are primarily involved in the pathogenesis of lupus nephritis.
# Erosion of bone and cartilage is the hallmark feature of rheumatoid arthritis w symmetrical and non-migratory
SLE-- Nonerosive arthritis, migratory and asymmetrical. Presence of rheumatoid nodules in SLE is associated with active disease.
# disk herniation-- back pain without significant neurologic deficit, conservative approach is preferred for a period of 4-6 weeks. This includes early mobilization, muscle relaxants, and NSAIDs. Bed rest and physical therapy has not been shown to be helpful.
# Absent ankle reflex can be seen in elderly patients as part of the normal aging process.
# Adult still’s disease-- a variant of rheumatoid arthritis. high spiking fevers w evanescent salmon colored maculopapular or macular rash that involves trunk and extremities, arthritis or arthralgias and significant leukocytosis. To make the diagnosis of adult still’s disease, conditions like systemic lupus erythematosus (SLE), rheumatoid arthritis, malignancy, infectious mononucleosis and Parvovirus infection should not be present. Rheumatoid factor and ANA are usually negative.
# polychondritis—recurrent inflammation of cartilaginous structures and other internal organs. pain, redness, swelling, and tenderness in one or both ears, the nose, throat, joints and/or eyes. the pathogenesis is autoimmune. Tx: High-dose steroids
# Churg Strauss syndrome is a multisystem vasculitis-- affects skin, kidney, nervous system, lungs, gastrointestinal tract and heart. history of asthma followed by fever and marked eosinophilia. tissue sample showing a blood vessel with eosinophils around it Tx: glucocorticoids
# Polyarteritis nodosa-- necrotizing inflammation of small- and medium-sized arteries without glomerulonephritis or vasculitis in arterioles, capillaries, or venules. multiple systems, including renal, musculoskeletal, nervous, gastrointestinal, integumentary, cardiac, and genitourinary. However, the lungs are usually spared. Renal failure is the most common cause of dealth.
# When kidney is involved, a SLE renal biopsy is needed, Corticosteroids are the mainstay of treatment; usually IV methylprednisolone is used
# atheromatous embolism—painful cyanotic toe w intact pulses
# livedo reticularis-- blood vessels are constricted, or narrowed results in mottled discoloring on large areas of the legs or arms.( blue-reddish skin discoloration)
# Erythema nodosum, arthralgias, diarrhea, and positive P-ANCA in a young patient are highly suggestive of inflammatory bowel disease.
# Muscle biopsy is the best diagnostic study for polymyositis.
# Typical skin lesion of Reiter’s syndrome is Keratoderma blennorrhagicum found on palms and soles -- clear vesicles on red bases and later on develop into macules or papules. Other skin lesions are circinate balanitis -- painless shallow ulcers present on the glans penis or urethral meatus.
# Dupuytren’s contracture occurs due to fibrosis of palmar fascia-- thickening and contracture of the fibrous bands on the palmar surfaces of the hand and fingers., associated with cigarette smoking, alcohol, diabetes mellitus, epilepsy and tuberculosis. Tx: surgery.
# Disseminated gonococcal infection is a syndrome of rash, tenosynovitis and polyarthralgia. Rash is pustular or vesiculopustular and is usually present on trunk and extensor surfaces of the distal extremities and it may become hemorrhagic. Tenosynovitis of multiple tendons at wrist, hands and ankles may occur. Arthralgia is migratory. Skin and joint manifestation are thought to be immune-mediated caused by immune-complex formation from gonococcemia. Women are at more likely to develop disseminated gonococcal infection especially during menses and pregnancy.
#Acetaminophen is the initial therapy to relieve pain in patients of osteoarthritis. If analgesics, like acetaminophen, fail to control pain NSAIDs, like indomethacin, are indicated. Cyclooxygenase-2 (COX-2) inhibitors, like celecoxib, are indicated for the treatment of osteoarthritis when patient is at risk for upper Gl bleed and has failed to respond to analgesics
# Bladder carcinoma is a recognized complication of long-term use of cyclophosphamide.
# Psoriatic arthritis --pitting nails and onychodystrophy, pencil cup deformity of fingers, fluffy periostitis, and bilateral asymmetrical fusiform soft tissue
# Trigger finger presents with pain on flexion of the involved digit followed by inability to extend.swelling. asymmetrical and oligo-articular, Distal interphalangeal (DIP) joint involvement
# Behcet’s syndrome-- recurrent oral ulcers, recurrent genital ulcers, anterior uveitis, erythema nodosum
The international criteria for diagnosis includes: Recurrent oral ulcers plus two of the following features - recurrent genital ulcers; eye lesions, including anterior uveitis and posterior uveitis; retinal vascularization; skin lesions including erythema nodosum, acneiform nodules and papulopustular lesions; and a positive pathergy test. Corticosteroids offer relief from most of the symptoms but do not protect from progression to dementia or blindness.
# Ganglion cyst presents as small nodule that is mobile and tender to touch and is usually located over the metacarpophalangeal joint.
Polycystic ovarian disease LH increased, normal or low FSH levels. initially present with infertility w obesity and insulin resistance. androgen excess hirsutism. an irregular or no menstrual cycle
Premature Ovarian FailureFSH increased > 40. an irregular or no menstrual cycle, infertility.
Serum sickness can also be caused by several drugs, notably penicillin based medicines The classic clinical manifestations consist of fever, arthralgia, lymphadenopathy, and skin eruption(urticaria, Maculopapular or purpuric lesions)
# CT scan diagnosis intraabdominal abscess.
# In an unstable patient with suspected intraabdominal bleeding the best diagnostic intervention is diagnostic peritoneal lavage.Ultrasonogram used in emergency room by trauma team is actually the best option. CT scan of abdomen is a better option in stable patient but not in unstable patient. Exploratory laparotomy would have been the first step in trauma patient with signs of abdominal irritation or penetrating injuries to abdomen. So USG or DPL are the procedures of choice to diagnose intra abdominal bleeding in an unstable trauma patient.
# Body surface involved in burn injury is calculated with the help of Rule of Nines:
Each arm: 9 %
Each lower extremity: 18 % (9 % anterior and 9% posterior)
Anterior torso: 18%
Posterior torso: 18%
For children: Head: 18% (9 % anterior and posterior each), Lower extremities: 27% total
Rule of Palm The size of the patient’s hand is roughly equal to 1 % of the body surface area.
# a gangrenous, ruptured, retrocecal appendix Right hemicolectomy with ileotransverse anastomosis # E. coli and S. aureus, are the most commonly found organisms in nosocomial infections. A urinary tract infection is the most common type of nosocomial infection. Surgical site infections second. Nosocomial pneumonia is the third most common cause of nosocomial infections. Atelectasis is the most common cause of fever in the first postoperative day.
# Major determinant for decision of surgical v/s non-surgical management of splenic rupture are : 1. Vital signs and hemodynamic stability.2. Change in hematocrit overtime. 3. Need for blood transfusion.
# Slipped capital femoral epiphysis typically occurs in an obese adolescent and presents with a painful limp. Radiography shows displaced femoral epiphysis.
# Osgood Schlatter disease involves tibial tuberosity resulting in tenderness over it. It occurs between the ages of 10-16yrs. Radiography shows irregularities of the tubercle contour
# Legg-calve-perthes disease occurs between the ages of 2-12 year old with the mean age of 7 years. Pain is absent or mild. Gait is antalgic and range of motion of the hip is limited on internal rotation, flexion and abduction. The patient may have abnormal limb length. AP and lateral films of the pelvis show widening of the joint space and collapse of the femoral head
# Duodenal injuries are best diagnosed with CT scan of the abdomen with oral contrast or an upper Gl study with gastrograffin, followed by barium, if necessary. # Green stick fracture is an incomplete fracture in which one cortex is broken, while the opposite cortex and periosteum is intact. Physeal fracture is a fracture across the growth plate of bone. Torus fracture is an impaction injury in which the cortex of long bone buckles with no loss of cortical continuity. Plastic deformation is an injury exclusively of children in which bones simply bend without any break in either cortex.
# Boerhaave’s syndrome is esophageal perforation due to severe vomiting and it produces pneumomediastinum. Mallory Weiss tear is an incomplete esophageal tear, usually seen in patients with recurrent vomiting. However, complete perforation is not a feature, so you wont see pneumomediastinum.
# After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a mass in the left lower chest, one should suspect a diaphragmatic perforation. A barium swallow will be diagnostic. All diaphragmatic ruptures require treatment. Surgery is best done via the abdomen in acute conditions and via the chest in chronic cases
# Open fractures should not be closed primarily because of the associated increased risk of infection and subsequent osteomyelitis. Stabilization and delayed primary closure is the optimal therapy Dressing of the wound and plaster cast.
# Beck's triad of hyotension, elevated JVP, and muffled heart sounds confirms the diagnosis of pericardial tamponade.
# Hemothorax is most commonly managed by a tube thoracotomy in lower part of chest. Surgery is seldom necessary. It is indicated when there is more than 1500 ml of blood recovered on inserting the chest tube or when there is more than 600 ml of blood loss over 6 hours after inserting the chest tube.
# Central cord syndrome may result from hyperextension injuries and is characterized by weakness that is more pronounced in the upper extremities than in the lower extremities. # McMurray sign popping sound on passive flexion/extension of the joint, specific for meniscal injury. Arthroscopy or MRI to confirm diagnosis. Rest and NSAIDs are used as an initial conservative therapy for acute meniscal injury. Surgery (arthroscopic or open) is often necessary to correct the problem.
# History of a traumatic event and presence of crunching are compatible with fracture of metatarsal.
# Retrograde cystogram with post void films is used for diagnosis of bladder injury
# Retrograde urethrogram should be the first step in management of suspected posterior urethral injury(inability to void, blood at urethral meatus and scrotal hematoma. high riding prostrate) Immediate surgical repair is done in case of anterior urethral injury; the posterior urethral injury should have a supra pubic catheterization and delayed repair.
# Scaphoid fractures a fall on an outstretched hand. pain with wrist movement, tenderness in the anatomical snuffbox. Radiologically evident fractures may not be visible for up to two weeks. Treatment with long arm cast. Open reduction and internal fixation is required if initial X ray shows fracture displacement.
# The recommended treatment in isolated diaphyseal humeral fracture is closed reduction followed by hanging cast or a coaptation splint # Hypoventilation is a frequent occurrence after abdominal hernia repair and early physiotherapy and respiratory exercises are mandatory.
# Dumping syndrome is a common postgastrectomy complication. The symptoms usually diminish overtime and dietary changes are helpful to control the symptoms. In resistant cases, octreotide should be tried. Reconstructive surgery is reserved for intractable cases.
# Early manifestations of carbon monoxide poisoning headache and respiratory distress followed by acute confusion and agitation. treated with 100% oxygen via a facemask.
# Bolus 50% dextrose and thiamine is indicated in any unconscious patient as an emergency measure
# Intravenous morphine in emergency setting is indicated for acute pulmonary edema.
# Inhalation injury is common in burns patients and may take several days to manifest.
Diagnosis is best done with a bronchoscopy. Beta agonists along with steroids, endotracheal intubation, pulmonary toilet and antibiotic have all been used in patients with inhalation injury.
# Barlow’s maneuver: Used to determine if a hip is dislocatable. Ortolani’s maneuver: to see if the dislocated hip is reducible. USG is the most sensitive investigation for the diagnosis of Developmental dysplasia of the hip(uneven gluteal folds, subluxatable and dislocatable proximal femur and acetabulum, examination the hip can be easily displaced posteriorly and can be brought back to normal position with a click sound.) for infants less than 6 months of age.
# An airway is needed in all unconscious patients. In the field the best option would be a needle cricothyroidectomy. In emergency room an orotracheal intubation with pulse oxymetry monitoring is the best option. Restoring circulation in emergency is best done by rapid infusion of isotonic fluids rather than packed red blood cells
# Cystic lesion involving the pancreas on CT scan in the setting of acute pancreatitis with systemic toxicity must be considered an abscess and should be treated with external drainage
# Protamine is antagonist of heparin. Warfarin treated patients should be given fresh frozen plasma instead of vitamin K(Vitamin K therapy and cessation of warfarin will have effect in 1 or 2 days)when emergency surgical procedure is to be performed.
# Glasgow coma scale is used to assess the severity of head injury but it does not indicate the presence or absence of increased intracranial pressure.
# Clinical signs of increased intracranial pressure (ICP) include:1. bilaterally dilated pupils, anisocoria or non-reactivity of one or both pupils. 2.Flaccidity or decerebrate or decorticate motor posturing, or progressive neurological deterioration not attributable to other causes 3.Papilledema.
# Treatment of acute subdural hematoma is essentially conservative if no midline shift is present on CTscan.(semi lenticular hematoma) Treatment is centered on prevention of intracranial hypertension by head elevation, hyperventilation and if needed, use of acetazolamide or mannitol.Craniotomy is indicated in acute subdural hematoma with midline shift of structures on CT scan but is associated with grave prognosis.
# Mesenteric thrombosisSevere abdominal pain out of proportion to the physical findings along with bloody diarrhea
# Intermittent claudication is best treated with aspirin and an exercise program.
# Absent bowel sounds with gaseous distention of both small and large bowels indicate paralytic ileus.
# Uric acid stones, which are radiolucent, have to be evaluated by either CT of the
abdomen or intravenous pyelography.
# An exploratory laparotomy is needed in all the patients with blunt trauma to abdomen with signs of peritoneal irritation. CT scan of abdomen to diagnose intra abdominal bleed should only be done in stable patient and not in unstable patient.
# Transient submandibular gland swelling may occur during feeding due to partial obstruction of its duct and further evaluation is required if swelling is persistent or
recurrent. # Necrotized surgical infection is characterized by intensive pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. Early surgical exploration is essential. usually caused by mixed gram-positive and gram-negative flora.
# When clavicle injuries occur and a bruit is present, an arterial injury must be ruled out with an angiogram. Proximal and middle third clavicle injuries can be treated with closed reduction with figure of eight brace or sling for one-to-two weeks. Early range of motion and strengthening are recommended. Distal third clavicle injuries are usually unstable and may require open reduction and internal fixation.
# pain on passive extension of fingers is the most sensitive marker of compartment syndrome
# Pulmonary contusion is not uncommon after high-speed car accidents. The symptoms usually develop in the first 24 hours and a patchy alveolar infiltrate on chest x-ray is typical.
# Patients who present more than five days after the onset of symptoms of appendicitis, and have localized right lower quadrant findings, should be treated with IV hydration, antibiotics and bowel rest. Antibiotics should cover enteric gram-negative organisms and anaerobes. A second/third generation cephalosporin or a fluoroquinolone plus metronidazole are usually used. # Acalculous cholecystitis occurs in critically ill patients and imaging studies show diagnostic findings of thickening of the gall bladder wall and presence of pericholecystic fluid. The treatment is cholecystectomy.
# Acute blood loss in excess of 1500 ml requires blood transfusion. Crystalloid resuscitation is adequate for blood loss that is less than 25% of the patient’s blood volume. Unexplained acidosis, in anemic patients, may indicate blood transfusion.
# In cases of bleeding esophageal varices need for 5 or more units of blood transfusion in a period of 24 hours is considered an indication for surgery and transjugular intrahepatic portosystemic shunt is the best choice in emergency. Hepatic encephalopathy is the main risk after this procedure. if the patient had required less than 5 units of blood transfusion Continue the pharmacotherapy and leave the tube for another 24 hrs
# Legg Calve Perthes disease is serious but self-limiting disease in children of 4-10 years, characterized by avascular necrosis of head of femur. with painless limp and pain if present is mild and may be referred to knee or thigh. atrophy of thigh, limitation of internal rotation and abduction at the hip joint. Children less than 5 years of age generally do not need treatment. Children above 5 year of age or those with severe disease may require abduction bracing or surgical corrections.
# Slipped capitis femoral epiphysis is seen in adolescent obese boys and antalgic gait is characteristic.
# Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound below the 4th intercostal space (level of nipple) is considered to involve the abdomen.
# Unless strangulation or perforation is suspected, bowel obstruction is treated conservatively with fluids, nasogastric suction and enemas.
# CT, with contrast, will visualize both kidney and spleen. In stable patients with abdominal trauma, CT scan is the single best study to evaluate solid organ damage.
# Pneumomediastinum associated with tension pneumothorax usually responds to chest tube drainage and it does not usually require surgical decompression. Pneumomediastinum associated with mediastinitis would need surgical drainage of the mediastinum.
# Pseudomembranous colitis usually develops 2-3wks after the onset of the antibiotic treatment
# bowel ischemia and infarction as an early complication of operation on the abdominal aorta.
# The presence of deep Q waves without ST/T wave change indicates old transmural infarction
# Monteggia(isolated fracture of proximal third of ulna, with anterior dislocation of radial head )& Galeazzi (isolated radial shaft fracture, associated with disruption of distal radio ulnar joint )fractures in adults are treated with open reduction and internal fixation. Closed reduction and casting are optimal for treatment of Monteggia fracture in children
# Anterior cord syndrome is commonly associated with burst fracture of the vertebra and is characterized by total loss of motor function below the level of lesion with loss of pain and temperature on both sides below the lesion with intact proprioception.
# Central cord syndrome is characterized by burning pain and paralysis in upper extremities with relative sparing of lower extremities. It is commonly seen in elderly secondary to forced hyperextension type of injury to the neck.
# Brown Sard syndrome is acute hemisection of cord and is characterized by ipsilateral motor and proprioception loss and contra lateral pain loss below the level of lesion.
# Cauda equine syndrome is characterized by paraplegia, variable sensory loss, urinary and fecal incontinence.
# Increased oxalate can also occur in people who drink large amounts of tea, coffee, beer, chocolate and ethylene glycol overdose. excessive Gl absorption of oxalate. Hyperoxaluria occurs in patients with small bowel resection, inflammatory bowel disease and other malabsorptive states. The increased intestinal fat binds dietary calcium, which is then unavailable to bind oxalate as usual. Therefore, increased oxalate absorption in large bowel (unabsorbed bile salts may aid this) occurs and precipitates in the kidney
# Non-communicating hydrocele disappears spontaneously by 12 months of age and it
is therefore managed expectantly. In communicating hydrocele, the upper limit can’t be reached and it is treated surgically
# Zone 1 (lower zone) extends from clavicle to cricoid cartilage.
Zone 2(middle zone) extends from cricoid cartilage to angle of mandible.
Zone 3(upperzone) extends from angle of mandible to base of skull
All gun shot injury in middle zone of neck should be surgically explored. stab wound injury to middle zone in asymptomatic patient can be safely observed.Gunshot wound in lower zone (zone 1) and not upper zone (zone 3) needs esophagogram and bronchoscopy. Expanding or large neck hematomas need surgical intervention
# CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages
with blurring of grey-white interface caused by traumatic deceleration injury and results in vegetative state
# Mesenteric thrombosis (arterial or venous) or non-occlusive ischemia can lead to massive fluid sequestration in the bowels Hypovolemic shock( cvp = 0 ) and hemoconcentration usually ensue. The extreme elevation of CK suggesting massive ischemia is characteristic. The intensive abdominal pain out of proportion to the physical findings and the diarrhea, which may contain occult blood, further support this diagnosis. The poor neurologic condition in this patient is probably due to brain hypoperfusion as a consequence of shock.
# hyperextension of the knee Anterior cruciate ligament injury. Lachman's test is a very sensitive physical test for acute anterior cruciate ligament tear
# McMurray's test is used for diagnosis of meniscus injury
# Cardiac contusion can be associated with various arrhythmias and is best monitored by continuous ECG monitoring.
# Intestinal obstruction with metabolic acidosis and shock indicates serious disease and it requires laparotomy.
#Bladder rupture can be classified into the following types:
Type 1: Bladder contusion.
Type 2: Extra peritoneal rupture is more common than intra peritoneal rupture and usually occurs at lateral border or base.
Type 3: Intraperitoneal rupture is less common but is commonly seen in patients with full bladder at accident due to rupture of dome of bladder
Type 4: Combined intra and extra peritoneal rupture: it accounts for 10% of bladder injury.
gross hematuria. Suprapubic pain and high riding prostrate
# Isolated duodenal hematoma is treated conservatively with nasogastric tube and parenteral nutrition. Surgery in needed only if there are other associated injuries or if the hematoma does not resolve within 2 - 3 weeks with nasogastric tube and parenteral nutrition.
# Arterial insufficiency usually presents with symptoms of claudication and worsened by leg elevation. The pulses are weak or absent, and the ulcers are deep and located usually in the distal parts of the leg where the blood supply is least. There is no swelling with arterial insufficiency; but hair loss and muscle atrophy may be visible.
#The most common symptoms from varicose veins are fatigue, tiredness in the leg, aching, swelling, and occasional cramps at night. The symptoms are generally worsened by standing or after prolonged periods of sitting. The swelling and aching rapidly decrease after leg elevation and rest. The edema associated with varicose veins is due to incompetent perforators. The hypertension in the varicose veins leads to a leakage of red cells in the surrounding tissues, which is responsible for the discoloration. Ulceration occurs from the prolonged venous hypertension, and is usually located on the medial aspect of the leg and is superficial. In patients who develop deep vein thrombosis (DVT), follow-up studies reveal ulcers and incompetent veins
# gun shot injury in anteromedial portion of the upper thigh, Even though the peripheral pulses are present, a femoral arteriogram to rule out femoral vessel injury is required
# Patients with increased ICP should be treated with hyperventilation, head elevation, and intravenous mannitol and diuretics. Hyperventilation works by causing vasoconstriction and decreasing the intracranial pressure by decreasing the cerebral blood volume
# Fat embolism characterized by severe respiratory distress, petechial rash, subconjuctival hemorrhage, tachycardia, tachypnea, and fever. Diagnosis can be confirmed by presence of fat droplets in urine or presence of intra-arterial fat globules on fundoscopy. # Anaphylactic shock should be promptly treated with subcutaneous epinephrine.
# Amount of fluid required in the first 24 hours = 4 ml / kg / % of body surface area involved in the burns. Half of this is given in the first 8 hours and half in the next 16 hours.
# basilar skull fracture are rhinorrhea, raccoon eyes (black eyes), ecchymosis behind the ears and otorrhea. Expectant therapy is a rule for all patients with uncomplicated basilar skull fracture. Craniotomy may be required for patients with leak that continue for more than 2 weeks
# Crush injuries are associated with rhabdomyolysis. It is manifested as myoglobinemia, myoglobinuria and eventual renal failure w Hyperkalemia. The best diagnostic test is serum creatine kinase levels. The best initial treatment for rhabdomyolysis is osmotic diuretics and bicarbonate (to alkalinize the urine) to prevent renal failure
# emoral artery aneurysmA pulsatile groin mass below the inguinal ligament is characteristic
# First-degree burns or superficial burnsThe injury is confined to the epidermis with minimal skin damage. The skin is mildly erythematous and pain is the chief complaint. It heals without scaring. Sunburn is a classical example.
Second-degree burns or partial thicknessIt involves the entire epidermis and various layers of the dermis. The skin is painful, red, edematous and blistered. Spontaneous healing may occur depending on the dermal involvement and viability of dermal appendages. They can be further classified as superficial and deep depending on the depth of dermal involvement.
Third-degree burns or full thickness burnnessThe epidermis and dermis is completely destroyed and no dermal appendages remain. They are not painful and have leathery, waxy and charred appearance. Debridement and skin grafting is required, as spontaneous healing does not occur. An example would be flame burn.
# Superficial and erythematous burns while painful do not require any special wound care. Topical or oral analgesics agents can be prescribed. Early excision therapy is indicated for extensive partial-thickness and full-thickness burns, as they do not heal spontaneously. Also, it allows for early skin grafting and lesser complications. The topical anti bacterial agent most commonly used is silver sulphadiazine. Mafenide sulphate is only used if deep penetration is required in case of wound with eschar. Mafenide sulfate is associated with severe pain and acidosis. # Clear fluid discharge from nose after a facial or head injury is suggestive of cerebrospinal fluid rhinorrhea secondary to fracture of base of skull. Nasoethmoidal fractures may be associated with injuries to ethmoidal roof, lacrimal system, medial canthal tendons, cribriform plate and vasculature of nose. Associated injuries of these structures can give rise to cerebrospinal fluid rhinorrhea, epistaxis, anosmia, epiphoria or telecanthus.
# tension pneumothorax hypotension, shortness of breath, jugular venous distension and decreased breath sounds.
# Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the dead muscle has been replaced with fibrous tissue
# After rhinoplasty, if there is a whistling noise during respirationnasal septal perforation
# The usual sequence of management of injury to bone, artery and nerve is to stabilize the bone followed by repair of vasculature followed by the nerve repair.
# Torus palatinus is a benign bony mass located on the hard palate. No medical or surgical therapy is required.
# Nasopharyngeal cancer usually presents initially as a painless neck mass. Associated w Ebstein-Barr virus infection # Gentle traction to attempt alignment of the fragments of a fractured long bone is important to prevent further vascular and neurological damage and it should be attempted immediately.
# Pelvic X ray should be routinely done in all patients with trauma to screen for pelvic injury. CT scan of pelvis is an excellent method to access the pelvic fracture. However, it is not suitable as an initial means in a hemodynamically unstable patient.
# Ulcers on the medial aspect of the leg indurated with irregular margins are generally from venous disease. Venous hypertension may be due to vein varicosities and incompetent perforators. Ulcers from arterial insufficiency (peripheral vascular disease) are usually located on the lateral aspect of the foot and are well circumscribed. The individual is a smoker and his peripheral pulses may be absent. # Muffled heart sounds are common in severe hypovolemia and do not necessarily indicate pericardial fluid. Moreover, cardiac tamponade is unlikely without distention of the neck veins. Whenever a patient is in decompensated hemorrhagic shock most probably from ruptured abdominal organ bleeding, next step is diagnostic peritoneal lavage or abdominal ultrasound once the resuscitative efforts are begun.
# Stress fracture or March fracture or insufficiency fracture is commonly seen in young active adults involved in vigorous and excessive exercises. Bones most commonly involved in stress fractures are metatarsal, navicular, neck of femur and tibia.
# The characteristic finding of tear of patellar tendon is proximal displacement of patella.
# Osgood Schlatter disease is an epiphysitis of the tibial tubercle and is characterized by pain over tibial tubercle, which is exacerbated by contraction of quadriceps muscle. This is almost exclusively seen in young men and women of less than 19 years age whose growth centers are still active. The typical patient is a 13 -14 year old boy or 11-12 year old girl who has had recent rapid growth spurt.
# Intubation with mechanical ventilation and administration of intravenous fluids, analgesics and sedatives should be done in all the patients with severe head trauma as indicated by Glasgow coma scale.
# Slipped femoral capitis Loss of abduction and internal rotation. external rotation of thigh when hip is flexed. Tx: external screws
# ulcers on the soles of the foot, neuropathic ulcers from diabetes should be suspected.
# Abdominal rigidity and muscle cramps are seen with black widow spider bite. treated with calcium gluconate and muscle relaxants.
# Brown recluse spider bite causes deep necrotic ulcer at the bite site. Local excision is the treatment of choice and skin grafting should be considered in severe cases.
# Most of the fractures of shaft of femur can be managed with closed intramedullary
fixation of fracture. # Posterior urethra consists of the prostatic urethra and membranous urethra. Posterior urethral injury is associated with pelvic fractures and presents with blood at meatus, high riding prostrate, scrotal hematoma and inability to void in spite of sensation to void.
# Anterior urethral injury due to injury to urethra anterior to the perineal membrane. most commonly due to blunt trauma to the perineum (straddle injuries), and many have delayed manifestation.
History of Tetanus immunization Clean wounds Dirty looking wounds
< 3 doses of tetanus toxoid in past. TT:Yes TIG: No TT:Yes TIG: Yes
More than or equal to 3 doses of tetanus toxoid in past. TT: Yes if last dose >10 years ago TIG: No TT: Yes if last dose > 5
# Mediastinitis needs thoracotomy for debridement, drainage, and antibiotic therapy
# Garden classification for femoral neck fracture is as follows:
Type 1: Valgus impaction of femoral head commonly seen with stress fractures.
Type 2: Complete but non-displaced femoral neck fractures
Type 3: Complete fracture with displacement < 50 %.
Type 4: Complete fracture with displacement > 50%.
Type 1 or stress fractures can be managed with toe touch weightbearing until there is radiological evidence of complete healing. Type3 &4 Primary arthroplasty. Internal fixation can be used for type 2 or 3 fracture in young patients. type 2,3 and 4 are called unstable fractures and need open reduction and internal fixation or a primary arthroplasty as soon as the patient is stabilized.
# When blunt chest trauma occurs with a widened mediastinum on chest x-ray, aortic injury must be suspected. Either a CT( stable) scan or ECHO(unstable) will be diagnostic.
# Galactogram guided resection is the treatment of choice for intraductal papilloma which presents with serous or bloody nipple discharge. Mammogram is not useful for young women, since their breast tissue is dense.
# Thus compression fracture of vertebra should always be ruled out in patients with calcaneus fracture secondary to fall from a height
# acute adrenal insufficiency Acute onset of nausea, vomiting, abdominal pain, hypoglycemia, and hypotension after a stressful event (e.g., surgical procedure) in a patient who is steroid-dependent(preoperative steroid use)
# Neutralization of gastric pH should be considered for severely ill patients to prevent gastric stress erosions.
# Compartment syndrome Nerve palsy is not very common
# Patient with cirrhosis may have upper Gl bleeding due to: erosive gastritis, varices, peptic ulcer disease (PUD), and Mallory-Weiss tears.
# Breast mass that produces non-bloody aspirate and disappears completely on aspiration does not need any further evaluation other than observation # Cysts that disappear completely, the content of which is non-bloody as well as possess a characteristic diffuse nodularity, are most likely due to fibrocystic disease. Careful observation for recurrence of the mass is the standard follow-up. Mammogram would be indicated if the mass didn’t disappear completely or if its content was bloody. If the normal breast tissue is dense, as in young women, a mass may not be seen on mammogram. In such a case, ultrasound would be indicated. Ultrasound is useful also for evaluation of cystic lesions, but this cyst is already drained.
# breast coarse calcifications are more characteristic of benign lesions, whereas microcalcifications are more characteristic of malignancy.
Fat necrosis shows coarse calcification on mammography and biopsy reveals fat globules. Fat necrosis is not a premalignant lesion. No treatment is needed.
# Angiography would not be informative after the barium enema because the colon is already filled with contrast. Labeled erythrocyte scintigraphy could be helpful to define the site of bleeding
# Osgood Schlatter disease caused by overuse, pain and swelling around the tibial tubercle. Pain increases on contraction of quadriceps muscle. Radiographs may show characteristic fragmentation on lateral view of upper tibia. Treatment is symptomatic with rest, NSAIDs and brief casting.
# Diverticulosis is the most common cause of bleeding in an elderly patient. Chronic constipation is the single most predisposing factor to develop diverticulosis.
# Nonunion and avascular necrosis are common complications seen in scaphoid fracture.
# Ludwig’s angina is infection of the submaxillary and sublingual glands. The source of the infection is from an infected tooth. Treatment is intravenous penicillin with coverage for anaerobes.
# Complications after central line placement pneumothorax, hemothorax, sepsis and tamponade. Radiologic confirmation of the position of the catheter is a standard step in protocols after insertion of central lines. A cardinal rule for the prevention of myocardial perforation is radiologic confirmation that the catheter tip is proximal to the cardiac silhouette. Prior to use of any newly placed central lines, the chest x-ray must be reviewed to ensure the absence of pneumothorax, hemothorax and good positioning of the catheter tip.
# MRI is choice for ligamentous injuries of the knee with an accuracy rate of 95%. Surgery is rarely necessary for MCL tear.
# Upright abdominal x-ray is the first diagnostic test when intestinal perforation is suspected. If it is negative US, CT and diagnostic peritoneal lavage may be indicated.
# Surgical exploration is the treatment of choice for fracture of penis, but it should always be preceded by a retrograde urethrogram to rule out a urethral injury which is very common with penile fracture.
# Aortic rupture should be ruled out in all the chest trauma patients with hypotension. Screening for aortic trauma can best be done with a chest x-ray. Confirmatory test is angiography or spiral CT scan. Tx: Immediate surgical intervention
# Intravenous pyelography is the best investigation to look for stones or tumors
# Careful observation with follow-up in patients with mild curve (< 20 degree). Scoliosis tends to progress till the skeletal growth is achieved so careful follow-up to assess the rate of progression of scoliosis is needed. Bracing is needed if the initial curve at diagnosis is more than 30 degree or it shows more than 5 degrees of progression in follow-up studies of mild scoliosis. For patients with curve between 20-30 degrees, the choice between observation and bracing should be made based on the presence of rotational deformity and positive family history in which case a more aggressive approach is recommended. Surgery is generally needed for curves more than 40 degrees at initial diagnosis.
# Medial meniscus injury Initial treatment in acute injury is conservative with immobilization and bracing. Recurrent or persistent locking needs arthroscopic assessment and treatment.
# Angiograms are done following neck trauma to rule out carotid artery injury. Angiograms are usually done for penetrating injury. The angiograms will evaluate the aortic arch and its branches. In the above patient, there is an intimal flap. Despite the patient being neurologically intact, exploration is mandatory, to prevent a stroke. The intimal flap may progress to complete obstruction of the vessel or may lead to emboli and stroke.
# Percutaneous drainage is the standard treatment approach for pelvic abscess. Laparotomy, debridement and drainage are indicated if the percutaneous drainage fails.
# Colles fracture is the most common fracture of distal radius characterized by dorsal
displacement and dorsal angulation giving a dinner fork deformity. Tx: closed reduction and casting
# Galeazzi fracture is isolated fracture anywhere along the length of radius with associated injury to the distal radio ulnar joint.
# Saphenous vein cut down or percutaneous femoral vein catheterization are alternatives to have an intravenous access in trauma patients with collapsed veins.
# HIV-infected patients are at high risk for the development of tuberculosis, which may
cause collapse of the vertebral bodies and intervertebral disk.
# Clavicle fractured is not commonly associated with neurovascular damage, treated with figure of eight bandage.
#Osteogenic sarcoma usually presents with painful swelling around the knee. ESR is normal and serum alkaline phosphatase is elevated. X-ray shows osteolytic lesion with periosteal reaction Systemic manifestations are rare. Ewing’s sarcoma is another frequent tumor of adolescent population (usually <10yr age group). Local findings are similar to those of osteogenic sarcoma but systemic features like fever, malaise, and weight loss are marked. X-ray shows osteolytic lesion with onionskin appearance Giant cell tumor or Osteoclastoma is a tumor of adults and it involves the epiphysis of the distal femur or proximal tibia. Radiology characteristically shows a soap-bubble appearance.
# Once an esophageal perforation has been diagnosed, primary repair of the esophagus should be done immediately.
# Retrograde cystogram with post void film is the investigation of choice for patients with suspected bladder trauma.
#When hemorrhage occurs, the pulse pressure is the first physiological change.
# Pain relief should be the prime objective in management of rib fracture in elderly.
# After an abdominal aortic aneurysm repair, diarrhea with blood in the stools should raise the suspicion of
ischemic colitis. If the CTscan is inconclusive a sigmoidoscopy/colonoscopy is
# Glasgow coma scale: Points
# iatrogenic esophageal perforation. Contrast study would best demonstrate it. If perforation is present, primary closure of esophagus, and drainage of mediastinum must be attempted within 6 hours to prevent the development of mediastinitis. # Internal fixation with sliding
#screw and plate and early mobilization is the treatment of choice for intertrochanteric fractures.
# Technetium pertechnetate scintigraphy is the best diagnostic test for Meckel's diverticulum.
#There are two malignant tumors of the eye for which enucleation would be done: retinoblastoma and melanoma. Only melanoma would have this weird timetable, in which 20-some years may elapse between primary tumor and metastatic manifestations. metastasize to liver.
#Sarcomas metastasize via the blood stream, rare in organs that drain via the portal system. Thus, they favor the lungs as the metastatic site.
#suggests a skin cancerThe edge of the lesion offers the best information for the pathologist. Diag: Full thickness biopsy of the edge of the lesion
# the appropriate course of action when coagulopathy develops in Surgery is to empirically provide fresh frozen plasma and platelet packs. However, when hypothermia complicates the picture, the abdomen also has to be closed immediately albeit temporarily in the most expeditious manner. The bleeding surfaces have to be packed, waiting for a more propitious time in which to attempt hemostasis, once coagulation function and body temperature have improved.
#herniated lumbar discdiag:MRI. Tx: bed rest
#squamous cell carcinoma of the lower lip. Basal cell carcinoma favors the upper part of the face
#The most sensitive test to detect early bone metastasis is the radionuclide scan.
#A high spinal anesthetic can produce vasomotor shock by inducing widespread vasodilation. Vasoconstrictors are the appropriate therapy, but since the capacity of the vascular tree is also increased under these circumstances, filling it up with additional volume is also helpful
#Follicular cancers(Tx: Total thyroidectomy plus postoperative radioactive iodine) can metastasize by way of the blood stream to the liver, lung, brain, or bones. Because the tumor has rudimentary functional capability, it can be traced with and ablated by radioactive iodine; however, the tumor cannot compete successfully with normal thyroid tissue for the capture of iodine. After removal of the entire gland, the tumor becomes the most effective iodine trapper in the body.
#prostatic metastases to bone are blastic rather than lytic, Lung and brease to bone is lytic.
#antireflux operationlaparoscopic Nissen fundoplication
#Heller myotomy is used for achalasia. Transhiatal total esophagectomy is the most commonly used operation for esophageal cancer.
#The diagnostic study of choice to confirm the presence of gallstones is a sonogram.
#Examination of the animal's brain for signs of rabies will determine whether the painful and risky process of rabies passive and active immunization is required.
#most penetrating wounds of the chest that produce hemothorax require no surgery
#Colles fracturedorsally displaced, dorsally angulated fracture of the distal radius. dinner fork. Tx: Closed reduction and long arm cast
#A newly developed white pupil in a child raises the possibility of retinoblastoma
#the diagnosis of the pheochromocytoma can best be confirmed by MRI of the adrenals
#Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is prolonged hypotension. the expected mortality is 50%-90%
#Obstructive jaundice is evident by the high alkaline phosphatase and the dilated biliary ducts. Malignancy is suggested by the dilated, thin-walled gallbladder without stones. If there is a cancer of the head of the pancreas, CT has a good chance of showing it in a noninvasive manner. Endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiogram (PTC) would be the next step if the CT scan were negative.
# Plantar fasciitis
#A chest tube high in the pleural space is for a pneumothorax. Air goes to the top, and blood goes to the bottom. For hemothorax, Insertion of a chest tube at the base
#In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration.
# Cystosarcoma phyllodes occurs in young women, grows to huge size over many years, and yet spares the skin, the nodes, and the underlying chest wall.
# The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman, except for two restrictions: no chemotherapy during the first trimester, and no radiation therapy during the pregnancy.
#Any gunshot wound below the nipples involves the abdomen
# Urinary stones Stone >3mm Extracorporeal shock wave lithotripsy. Stone >3cmOpen surgical removal
# A rough guideline to quantify water loss is that every 3 mEq/L that the serum sodium concentration is above normal, represents about 1 L of water deficit.
#mitral valve prolapseMitral valve annuloplasty, mitral valve replacement iwhen repair of the native valve cannot be done.
#Rubber band ligation internal hemorrhoids
#anal fissure Tx: Forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections
#Pelvic fractures External fixation
#causalgia, also known as reflex sympathetic dystrophy
thanks a lot.
Is this Uw notes or ur total preparation( uw+ some other notes..)? Why i am asking this is if it's purely uw notes.. first i want to do usmle world q bank afterward i'll go through it..if it not i'll do in otherway plz give me some input.
||I just cannot imagine such a nice gift just 5 days before my exam. You are amazing sundna!!!! trust me I pray from the core of my heart for your success. May you keep on growing and glowing in this life.