04-06-2006, 01:02 AM
Nasis notes---------
1.The typical presentation of a thrombosed external hemorrhoid is an acute onset of very severe perianal pain, particularly when walking and sitting.
2. You know that external hemorrhoid is below the dentate line. internal hemorrhoids arise above the dentate line.
3. thrombosed external hemorrhoid requires immediate incision and evacuation of the clot to provide symptomatic relief. Pressure by compression is usually all that is needed to control the bleeding.
4..Sitz baths, applying a topical steroid cream, and increasing fiber intake are the usual treatment for symptomatic external hemorrhoids that are not thrombosed.
5..as a rule alwayes remember that external hemorrhoid s hurts but do not bleeding(opossit internal hemorrhoids)
6.typical picture of pyloric stenosis.,Projectile non-bilious vomiting is seen in virtually all patients. Patients also often develop a hypokalemic, hypochloremic metabolic alkalosis from the persistent vomiting. remeber if they give a child with intermittent spitting up think about pyloric stenosis.
7.abrupt onset of colicky abdominal pain in childeren <2 years ,think about intussusception! what's the etiology? The exact cause is unknown. However, it is associated with Meckel's diverticulum, cystic fibrosis, polyps, and Henoch-Schonlein purpura.
remeber A barium enema or air enema is both diagnostic and therapeutic.
8.Remember In any patient with dysphagia that is progressive for only solids, it suggests a growing and obstructive lesion. The history of cigarette and alcohol use, puts person at a much higher risk of carcinoma. The two ways to diagnose this are a barium swallow study, which will show the mucosal mass, or an upper endoscopy study to directly visualize and biopsy the lesion.
9.Remember Esophageal manometry is used to evaluate dysphagia caused by motility disorders. These typically present with dysphagia for solids and liquids and may or may not be progressive.
10.Incarcerated or strangulated hernias in an elderly patient can cause acute abdomen, dehydration, and altered mental status.
11.. Frequent, greasy, malodorous stools are a result of steatorrhea from chronic pancreatitis. This happens from the lack of pancreatic enzymes. Non-enteric coated pancreatic enzyme supplements with concurrent H2 blockers will deliver active enzymes to the proximal small bowel and help reduce malabsorption and steatorrhea.
12.. Acute acalculous cholecystitis is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder. BUT
biliary colic, which is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound.
13.Acute cholangitis is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad).
14.The hallmark of mesenteric ischemia is pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely in a patient with known vascular disease and a history of cigarette smoking. The next diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most often compromised vessel.
15. Patients with ulcerative colitis are at high risk for toxic megacolon, which is also associated with Clostridium difficile colitis
16.. Toxic megacolon presents clinically as abdominal distension and bowel motility disturbances. The next step in evaluation is an abdominal radiograph which will demonstrate a distended large bowel.
17.spontaneous bacterial peritonitis. This diagnosis should be first on your list in any patient with ascites who presents with fevers, abdominal pain, change in mental status, or with other non-specific complaints. These patients need to have a paracentesis. This fluid is then sent to the lab for a cell count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a positive peritoneal fluid culture. Patients with SBP need to be started on a third-generation cephalosporin
18.. Lead levels over 10 mg/dL are considered abnormal.
19.Remeber Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects.
20.congenital diaphragmatic hernia, which is when the abdominal contents herniate into the left hemithorax through a congenital defect in the left hemidiaphragm. This causes displacement of the heart into the right hemithorax and pulmonary hypoplasia.
21 key finding for Esophageal atresia with distal tracheoesophageal fistula usually presents with a history of polyhydramnios, cyanosis with feeding, and increased oropharyngeal secretions.
22.Remember in a traumatic lumbar puncture even though the CSF is initially red, the supernatant of the centrifuged cerebrospinal fluid is clear. This means that the red blood cells have not yet had a chance to lyse and release their intracellular contents into the cerebrospinal fluid.
BUT in subarachnoid hemorrhage there would be blood in the CSF, the supernatant of the centrifuged fluid would be xanthochromatic (yellow) due to the lysis of red blood cells and the release of their intracellular contents into the cerebrospinal fluid.
23.The symptoms of crampy abdominal pain and watery, explosive, secretory diarrhea are consistent with enterotoxic E. coli. the cause of traveler's diarrhea ,treatment ciprofloxacin if symptoms persistent.
24.The symptoms of Giardiasis, which usually occur about a week after exposure, include flatus, loose stools, diarrhea, abdominal pain, bloating, and vomiting. The usual scenario for a healthy person that develops this infection is the onset of these symptoms after a camping trip. tx:metronidazole
25.infectious mononucleosis typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur.
26.Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor.
27.Remember sudden onset of right upper quadrant pain associated with nausea and vomiting and history right upper quadrant and epigastric pain before, associated with food intake. These symptoms are classical for a perforated peptic ulcer. In a perforated peptic ulcer, a patient can still have right upper quadrant localized tenderness, a thickened gallbladder wall, and pericholecystic fluid from the perforated ulcer. Hence, with any abdominal pain associated with signs, abdominal x-rays both erect and supine are very essential in the initial evaluation to rule out any free air.
28.The first line in treatment of panic disorder is selective serotonin reuptake inhibitors (SSRIs), a group of medications including sertraline, paroxetine, fluoxetine, and citalopram. .
29.Remember Surveillance colonoscopies are generally recommended every 6 months for 2 years beginning after 8 to 10 years duration of ulcerative colitis.
30.The presence of endocervical cells on a Pap test is regarded as evidence of adequate sampling of the transformation zone during cytologic screening of the cervix. When these cells are absent, it indicates that this area may not have been sampled. This is considered a satisfactory, but limited smear. In patients with no known risk factors (i.e., prior abnormal Pap test, multiple sexual partners, smoking) the American College of Obstetricians and Gynecologists recommends that the physician may defer to repeating the Pap test in 12 months even if the sample is not adequ
31.in superior vena cava syndrome (SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS.
32.Remember in patients with known lung cancer, a biopsy of the mass causing the SVCS is usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis).
33.Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women.
34.Acneiform eruptions is characterized by papules and pustules resembling acne lesions. The eruptions are distinguished by their sudden onset.
Oral medications such as iodides, bromides, testosterone, cyclosporine, antiepileptic medications, lithium, and systemic corticosteroids are common agents that can lead to acneiform eruption. When medium or high doses of corticosteroids are taken for as short a time as 3-5 days, a distinctive eruption may occur, known as steroid acne. It is a sudden out-cropping of inflamed papules, most numerous on the upper trunk and arms, but also seen on the face. The lesions typically present as papules rather than comedones. Tretinoin cream applied once or twice daily may clear the lesions within 1-3 months, despite the continuation of high doses of corticosteroid.
35.The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma.
36. Remeber anterior uveitis is associated with sarcoidosis. Anterior uveitis is usually marked by the abrupt onset of pain and photophobia. Specifically anterior uveitis causes iritis and iridocyclitis. Constriction of the pupil causes increased pain. Slit-lamp examination is diagnostic, showing inflammatory cells in the aqueous humor or deposited along the corneal endothelium.
37.Many diseases are associated with anterior uveitis, including sarcoidosis and the seronegative spondyloarthropathies, including ankylosing spondylitis, psoriasis, inflammatory bowel disease, and Behçet's disease. Infectious disease may also cause uveitis. Some of the associated infections include herpesviruses, tuberculosis, onchocerciasis, and leprosy. In the majority of cases, uveitis is idiopathic. Treatment should include topical corticosteroids to decrease inflammation and mydriatics because dilation of the pupil decreases pain and the formation of synechiae.
38. hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.(tingling sensation in the fingertips.)
39.Remember treatment of CMV retinitis in HIV if Gancyvlovier dosen't work is FOSCARNET(can cuase renal toxicity).
40.Asperger disorder
it's characterized by defecits in interpersonal development,restricted patterns of interest&behaivior,and normal cognitive and speech development.
41.Spondylolysis is a defect seen in the pars interarticularis portion of the lamina.Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level.Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point(with hyperextension maneuvers)
42.Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific.
43..Remember The sudden onset of tachycardia and hypotension in a patient who is being mechanically ventilated with positive pressure, is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax,
44.young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis.
45.Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations.
46.Still disease is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis.
47.whenever the terms "coin-shaped" or "discoid" are used to describe a patient's skin lesions in a question you should think about nummular dermatitis.
48.Remeber symptoms of congestive heart failure and possible atrial fibrillation, as demonstrated by irregularly irregular heartbeat in question(they never mention stright forward A.F). In addition, are at high risk for the development of an embolic occlusion of the superior mesenteric artery. These patients will present with severe pain out of proportion to their objective physical findings. The diagnosis should be suspected clinically, and immediate superior mesenteric arteriogram should be performed. If evidence of ischemia is confirmed, the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia and possible gangrenous bowel.
49.BUT Ischemic colitis will usually present as diarrhea, often bloody, in elderly patients with known atherosclerotic heart disease.
50.malignant external otitis, This form is specifically caused by Pseudomonas aeruginosa, and tends to affect elderly diabetics and AIDS patients, causing the findings in the severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor.
51.Headache of sudden onset ("thunderclap" headache), rapid deterioration of mental status and blood in the CSF are virtually diagnostic of ruptured berry aneurysms. Note the characteristic hyperdensity on CT of the supra s e l l a r cistern, indicating blood in the subarachnoid space. Rupture of a berry aneurysm is the most common cause of subarachnoid bleeding.
52.PBC is due to an autoimmune destruction of intrahepatic bile ductules, and the diagnosis is made by liver biopsy. The serology that should be checked is the antimitochondrial antibody. Primary biliary cirrhosis is often seen in individuals with other autoimmune diseases, such as Sjِgren syndrome, pernicious anemia, and Hashimoto thyroiditis.
53.Myasthenia gravis is an autoimmune disease in which antibodies directed against the acetylcholine receptor of the muscle side of the neuromuscular junction block the ability of the receptor to bind to acetylcholine. Remember insulin resistance is also produced by a similar mechanism, i.e. antibodies to insulin receptors block the receptors' ability to bind to insulin
54.The first step in the approach to a patient with a community-acquired pneumonia is to categorize condition according to the American Thoracic Society guidelines (1993), which are based on severity of illness, age, comorbidities, and the need for hospitalization. the criteria for hospitalization (one of the following is needed: respiratory rate > 30 breaths/min, room air PaO2< 60 mm Hg, O2 saturation less than 90% on room air, or bilateral or multiple lobes involved), and older than 60 years.
55.normal value for the anion gap is 12 ± 4 mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes mellitus, alcoholism, starvation), renal failure with retained sulfate and phosphate, drugs or metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of protein anions, and dehydration (hemoconcentration).
56.Remember Subcutaneous unfractionated heparin is used for prevention of DVT in immobile patients or in hospitalized patients unable to ambulate. However, after orthopedic surgery, especially after joint procedures, its efficacy is very poor, given the increased venous stasis ,you should use warfarin.
57.Remember Both chronic laxative use and chronic diuretic use can produce hypokalemia. Severe hypokalemia, with plasma potassium <3 mEq/L, can markedly affect skeletal, smooth, and cardiac muscles. Skeletal muscle effects can include weakness, cramping, fasciculations, paralysis (with risk of respiratory failure), tetany, and rhabdomyolysis. Smooth muscle effects include hypotension and paralytic ileus. Cardiac muscle effects include premature ventricular and atrial contractions, tachyarrhythmias, and AV block. Additional ECG changes can include ST segment depression, increased U wave amplitude, and T wave amplitude less than U wave.
58.Basal cell carcinoma affects sun-exposed areas, particularly the mid and upper face, in patients lacking protective pigmentation. One of its morphologic forms is that of a raised, waxy, pale lesion that grows very slowly and doesn't metastasize to lymph nodes.
59.Key for Keratoacanthoma : grows very rapidly in a matter of weeks and has a scaly, rough appearance, with a core of keratin. If untreated, it eventually sloughs off.
60.Squamous cell carcinoma is usually an ulcer, rather than a nodule. In the face, it favors the lower lip. If present for several years, lymph node metastasis can sometimes occur.
61.euthyroid sick syndrome, which occurs in many seriously ill patients who do not have clinical hypothyroidism. especially in ICU
61. The TSH level is usually most helpful in distinguishing euthyroid sick syndrome from true hypothyroidism, as it often above 30 mU/mL in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick syndrome. Disproportionately decreased T3 is also typical of euthyroid sick syndrome, and T4 may be normal or decreased.
62.Remember hepatorenal syndrome occurs during the end stages of cirrhosis and is characterized by diminished urine output and low urinary sodium. In the setting of end-stage liver disease, renal vaso const-riction occurs, and the distal convoluted tubule responds by conserving sodium. Unless the renal function is allowed to deteriorate further, liver transplantation will reverse this vaso constriction and kidney function will return to normal.
then when ever you have cirrhosis with reanal faiuler the most appropriate treatment is LIVER TRANSPALNTION!
63.In beta thalassemia, a reduced production of beta chains occurs with normal amounts of alpha production
64.A shock-like pain upon percussion on the volar aspect of the wrist (Tinel sign) is a characteristic sign of Carpal tunnel syndrome ,,is most often idiopathic, but may represent a manifestation of underlying disorders such as rheumatoid arthritis, sarcoidosis, amyloidosis, acromegaly, and leukemia.
65.Fibrositis , also known as fibromyalgia, refers to a poorly understood syndrome of widespread musculoskeletal pain associated with tenderness in multiple trigger points. Fatigue, headache, and numbness are also common. Women between 20 and 50 years of age are most commonly affected. Neck, shoulders, low back and hips are usually involved.
66.Reflex sympathetic dystrophy describes a syndrome of pain and swelling of one extremity (most commonly a hand), associated with skin atrophy. It is thought to be secondary to vasomotor instability. Sometimes, it follows injuries to the shoulder (shoulder-hand variant).
67.Femoral pseudoaneurysms represent an important vascular complication of cardiac catheterization. The combination of a pulsatile mass, femoral bruit, and compromised distal pulses make this diagnosis likely. The diagnosis can be confirmed by ultrasound of the groin.(it was exam question of one of my friend).
68.Cholesterol emboli syndrome is also an important complication to recognize in the post-catheterization patient. It usually presents, however, with skin findings in the distal extremities of livedo reticularis, ischemic ulcerations, cyanosis, gangrene, or subcutaneous nodules.
69.Remember Another important complication of cardiac catheterization via the femoral artery is a retroperitoneal bleed . This complication presents, however, as either new back pain, an unexplained drop in the hematocrit, or purpura over the flanks.
70.what is piriformis syndrome??
As you may recall from your anatomy, the piriformis is the small muscle that crosses the greater sciatic foramen, cutting it into two spaces as the muscle passes from the edge of the sacrum to the greater trochanter. The sciatic nerve comes out of the greater sciatic foramen below the piriformis, and is liable to compression by the muscle. Symptoms are as described above; bicycle riding and running may also set off the symptoms, which may take the form of chronic nagging ache, pain, tingling, or numbness. Treatment is usually to teach the patient to avoid maneuvers that set off the symptoms. Some patients have been helped by corticosteroid injection near the site where the piriformis muscle crosses the sciatic nerve; this therapy is thought to work by reducing the fat around the muscle and thereby increasing the available space in the area.
71.in Adison disease Laboratory findings include hyponatremia (due to aldosterone deficiency), hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement.
72.HIV encephalitis, clinically known as AIDS dementia complex, . The pathologic substrate is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS.
73. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion. MRI studies and CSF analysis are useful in excluding other CNS diseases .
74.HIV myelopathy manifests mainly with spastic paraparesis. It is a complication similar in pathologic substrate to vitamin B12 deficiency, i.e., vacuolar degeneration of the posterior and lateral columns of the spinal cord.
75.Progressive multifocal leukoencephalopathy consists of multifocal areas of myelin destruction. These changes would be visible on MRI. This complication is due to JC virus, a papovavirus that causes asymptomatic infections in immunocompetent individuals.
76.Patients with longstanding extensive ulcerative colitis for at least 10 years' duration are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia
77.Individuals with herpes zoster are contagious and can spread the VZV virus.
78.Decreased esophageal peristalsis and decreased LES pressure :SCLERODERMA , These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's esophagus.
79.Patients with this erythema infectiosum (Fifth disease) are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death.
80.If a pergnant woman was in contact with a patient with fifth disease during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy.
81.Most authorities think that it is appropriate to initiate a progestin-only method of contraception immediately postpartum. It has no impact on lactation or the quality of breast milk.
82.The triad of miosis, respiratory depression, and coma is suggestive of opioid intoxication
83.Phenelzine is an antidepressant monoamine oxidase inhibitor (MAOI) that causes hypertensive crises and the serotonin syndrome (hypertension, tachycardia, fever, coma, and possibly death) when combined with tyramine-containing food (cheese) and serotonin-altering drugs.Pseudoephedrine and other nasal decongestants, bronchodilators, amphetamines can cause severe hypertension when monoamine oxidase is inhibited and should be avoid.
84.the classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles.
85.Fiberoptic bronchoscopy is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation.
then remeber if you have a patient with hemoptysis with past history of smoking ,your first step is CXR even if he/she is normal right now!but!!!!!!!Keep in mind that a chest x-ray is not part of a routine physical examination of an asymptomatic smoker.
86.Complications of ovarian torsion include infection, peritonitis, sepsis, adhesions, chronic pelvic pain, and infertility due to the loss of the viability of the torsed ovary.
87.Remember One of the most important considerations in evaluating patients with conjunctivitis is to rule out any vision-threatening conditions such as iritis, keratitis, glaucoma, or a corneal ulceration. Symptoms such as marked photophobia, decreased visual acuity, or globe pain suggest that ocular structures other than the conjunctiva are involved and should trigger immediate ophthalmologic evaluation.
88.The pathophysiology of ITP:
involves antibody (IgG or IgM) binding to platelets. These antibody- coated platelets are subsequently destroyed in the spleen.
89.Remember an extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients.
90.Multifocal glioblastoma multiforme (GBM) , the most frequent malignant primary brain neoplasm, manifests as an ill-defined mass in the white matter.
91.Wernicke encephalopathy is characterized by nystagmus progressing to ophthalmoplegia, truncal ataxia and confusion.
92.Korsakoff syndrome refers to alcohol-related amnesia and confabulation. Wernicke-Korsakoff syndrome is due to vitamin B1 deficiency, which is often seen in chronic alcoholics. This deficiency results in degeneration of periaqueductal gray matter.
93.Remember Huntington disease autosomal dominant condition is caused by an unstable expansion of a CAG trinucleotide repeat and MRI examination of the brain reveals hyperintensity in the region of the caudate on T2-weighted images.
94.The pathologic substrate of this condition(Huntington disease ) is degeneration of the striatal neurons, especially those in the caudate nucleus.
95.the pathogenesis of stress-induced gastritis
iffuse gastric mucosal vaso constriction
96.Right-sided endocardial fibrosis, with pulmonary stenosis and tricuspid regurgitation, is common in carcinoid patients and is the result of toxic damage to the heart
97.Ondansetron, a 5-hydroxytryptamine3 antagonist, is the most potent antiemetic available for chemotherapy-induced vomiting.It has side effects only infrequently, the most common being constipation.
98.Copper deficiency can present with anemia and neutropenia, Zinc deficeincy will present with alopecia, impaired wound healing , dermaititis, selenium def will present with dilated cardiomyopathy
99.Bernard-Soulier syndrome is an autosomal recessive disease of platelet adhesion which causes prolonged bleeding times in the presence of normal platelet counts. These patients' platelets cannot bind to subendothelial collagen properly because of a deficiency or dysfunction of the glycoprotein Ib-IX complex. Clinically the patients have impaired hemostasis and recurrent severe mucosal hemorrhage. The only treatment for an acute episode is a transfusion of normal platelets. This patient has a slightly decreased hemoglobin due to blood loss.
100.Von Willebrand's disease causes increased bleeding times with normal platelet counts. It is the most common inherited bleeding disorder, caused by a defect in von Willebrand factor, which aids the binding of platelets to collagen. Even though the platelets themselves are normal, binding is impaired, thus a platelet transfusion would not correct the problem. Cryoprecipitate, a plasma fraction rich in von Willebrand factor, would help in the case of von Willebrand's disease, but would not help with Bernard-Soulier syndrome.
Coarctations account for approximately 7% of congenital cardiac abnormalities, occur more frequently (2x) in men than in women, and are associated with gonadal dysgenesis and bicuspid aortic valves. Adults will present with hypertension, manifestations of hypertension in the upper body (headache, epistaxis), or leg claudication. Physical examination reveals diminished and/or delayed lower extremity pulses, enlarged collateral vessels in the upper body, or reduced development of the lower extremities.
101..Lymphoma is well known to develop specifically in the late stage of Sjِgren's syndrome. Common manifestations of this malignant condition include persistent parotid gland enlargement, purpura, leukopenia, cryoglobulinemia, and low C4 complement levels.
102.if they give you a farmer patient presents with acute-onset pulmonary symptoms, including wheezing, with no other medical problems and was recently handling hay.think about farmer's lung, a hypersensitivity pneumonitis caused by Actinomyces. In this disorder moldy hay with spores of actinomycetes are inhaled and produce a hypersensitivity pneumonitis. The disorder is seen most commonly in rainy periods, when the spores multiply. Patients present generally 4 to 8 h after exposure with fever, cough, and shortness of breath without wheezing. Chest radiograms often show patchy bilateral, often upper lobe infiltrates. The exposure history will differentiate this disorder from other types of pneumonia.
103.The Women's Health Initiative (WHI) demonstrated that estrogen-progestin therapy in Postmenopausal can reduce the risk of hip fractures by 34%. However, the WHI also demonstrated that estrogens are associated with a 30% increase in myocardial infarction, a 40% increase in stroke, a 100% increase in venous thromboembolism, and a 25% increase in breast cancer. In the WHI study there was no overall effect of estrogen-progestin therapy on mortality, probably because of the balance between the detrimental cardiovascular effects and the beneficial effects (in addition to fractures, there was a beneficial effect on the development of colon cancer).harrison new eddition!
104. Remember Pain, loss of function (without clear-cut sensory or motor deficits), and a localized autonomic impairment are called reflex sympathetic dystrophy (also known as shoulder-hand syndrome or causalgia). Precipitating events in this unusual syndrome include myocardial infarction, shoulder trauma, and limb paralysis. In addition to the neuropathic-type pain, autonomic dysfunction, possibly resulting from neuroadrenergic and cholinergic hypersensitivity, produces localized sweating, changes in blood flow, and abnormal hair and nail growth as well as edema or atrophy of the affected limb. Treatment is difficult; however, anticonvulsants such as phenytoin and carbamazepine may be effective, as they are in other conditions in which neuropathic pain is a major problem.
101. Remember when a patient has acute attacke with Renal faiuler the best drug for treatment would be either oral prednisone or steroids injected into the joint. He should not receive NSAIDs because he has renal insufficiency. Rofecoxib, a COX-2 inhibitor, can also be detrimental to renal function and should not be used in this setting.
102.remember Typical radiographic findings in osteoarthritis include joint space narrowing, subchondral bone sclerosis, subchondral cysts, and osteophytes (bony spurs). In the small interphalangeal joints of the fingers, central erosions may be seen within the joint space
105.HTN+Glocuma treatment?B blocker
106.Remember Addiction has identifiable risk factors, including genetic factors. The most well-established risk factors for addiction are family history and male sex. 105 in cocain toxi serum and urine tests are useful when they are positive, but they are of limited utility when they are negative because of the short duration of detectability of cocaine (6 to 8 hours) and cocaine metabolites (2 to 4 days). Cocaine does not produce compensatory adaptations in brain regions that control somatic functions and therefore does not produce dependence. Dependence and, therefore, withdrawal are not produced by highly addictive compounds such as cocaine.
107.The benzodiazepines (e.g., chlordiazepoxide, diazepam, lorazepam, and oxazepam) are the safest and most effective medications for treatment of alcohol withdrawal
108.glucagonoma and gastric adeno ca are associated with acanthosis nigric
109.nasopharyngeal ca also
burkitts lymphoma t8:14
are associated with EBV
110.Findings in Von Recklinghausen's disease: ... cafپEau-lait spots, neural tumors, Lisch nodules (pigmented iris hamartomas), skeletal disorders (scoliosis), and increased tumor susceptibility
111.Findings of Cri-du-chat syndrome: ... microcephaly, severe MR, high pitched crying/mewing -(Cri-du-chat is French for cry of the cat), cardiac abnormalities
112.Pathogenesis of Cystic Fibrosis: ... defective Cl- channel --> secretion of abnormally thick mucus that plugs lungs, pancreas, and liver --> recurrent pulmonary infections (Pseudomonas species and Staph aureus), chronic bronchitis, bronchiectasis, pancreatic insufficiency (malabsorption and steatorrhea), meconium ileus in newborns.
113.Which gene is affected in Fragile X? ... methylation and expression of the FMR 1 gene is affected in this X-linked disorder
114.2 skin conditions in AIDS patients one is a bacterial infection and another viral cause both look similar?
kaposi's sarcoma-HHV 8 AND BACILLARY ANGIOMATOSIS-caused by bartonella henselea
115.urticaria you get subcutaneous edema and angioedema you get mucosal edema
116.Genetic anticipation of Fragile X syndrome may be shown by what?
Triplet repeat (CGG)n
117.Huntington gene involved and triplet repeat CAG ,chromosome 4p
118.: Kidney cancer is a neoplastic condition that can initially appear with many different paraneoplastic manifestations. The initial presentation may include hypertension, flank mass, gross or microscopic hematuria, hypercalcemia, fever, weight loss, and/or polycythemia. This polycythemia is the presenting sign in 3% of cases of kidney cancer. In kidney cancer, polycythemia is secondary to a hypersecretion of tumor cytokines, including renin. The patient's erythropoietin level is usually high. Surgical removal of the cancer resolves the polycythemia.
, full evaluation is important in patients presenting with polycythemia and hematuria. Kidney cancer is an important differential diagnosis of secondary polycythemia.
119.Remember esophagitis in HIV often presents with belly or epigastric pain that could be caused by CMV or herpes simplex, but Candida most common (80%-90%); treat empirically with fluconazole 100 to 200 mg/day
120.Cryptococcal meningitis in HIV minority of patients have meningeal signs; most have only fever and headache; obtain head CT and lumbar puncture (LP); elevated opening pressure most common abnormality; cerebrospinal fluid (CSF)”can be normal; most have normal glucose; only 50% of patients have elevated protein; minority of patients have white blood cells in CSF; india ink simple test that detects 75% of cases; cryptococcal antigen >90% sensitive, but results take 1 to 2 days at most institutions
how do you treat?Treatment: treat with amphotericin B; flucytosine added in patients with severely elevated pressures; fluconazole as maintenance for rest of life
121.Remember LDH: nonspecific test; appears to be consistently greatly elevated in PCP; PCP unlikely if LDH normal (in HIV )
122.Remember Pneumocystis carinii pneumonia (PCP) less common now because many patients receiving medical care get prophylaxis for this organism; P carinii now considered closer to fungi than to protozoa; bacterial pneumonia now more common than PCP
123.Antiretroviral treatment for HIV: no consensus on when to start; indications include acute HIV infection, symptomatic HIV infection, CD4 count <350 cells/µL, high viral load (ie, >55,000 copies/mL
124.Kaposi™s sarcoma: reddish/purplish lesions can be located anywhere (internal or external); characteristic appearance of sharp demarcation (HSV8)
Hairy leukoplakia: tends to occur on side of tongue; cannot be scraped off like thrush; related to Epstein-Barr virus
125.What 2 neoplasms are associated with AIDS? ... 1. Aggressive malignant lymphomas (non-Hodgkins) 2. Kaposi's sarcoma
126.What 2 neoplasms are associated with Tuberous sclerosis (facial angiofibroma, seizures, and mental retardation)? ... 1. Astrocytoma 2. Cardiac rhabdomyoma
127.What are a common histopathological finding of meningiomas? ... Psammoma bodies. These are spindle cells concentrically arranged in a whorled pattern
128.What are ependymomas? ... Ependymal cell tumors most commonly found in the 4th ventricle. May cause hydrocephalus
129.Reason why Pregnant women get more chances of UTI: Increase in ventilation rate causes respiratory alkalosis: This causes renal compensation for and causes alkaline urine. This provides a good growth media
130. Remember the normal values of Non pregnant women does not apply to pregnant women. In pregnant women, the upper limts of BUN and Serum creatinine should be 10 and 0.5 respectively. If a pregnant woman has a serum creatinine of 1.5, then it can only mean 2 things: Either she has a kidney disease or it could be due to hyper coagulation which is seen only in Preeclampsia
131: What constitutes a positive SLR sign to diagnose radiculopathy?
SLR is positive if the maneuver REPRODUCES THE PATIENT'S USUAL PAIN .The patient may describe pain in the low back,buttocks, post. thigh or lower leg. But the key feature is reproduction of the patient's usual pain.
Other factors such as muscle stiffness can mimic radicular pain.
SLR is used to detect lesions of L5 and S1 roots and sciatic nerve.
Reverse SLR (passive extension of leg with patient standing)-for L2-L4 roots and femoral nerve
Crossed SLR-Performance of maneuver on one leg produces pain in the opposite leg or buttocks-The nerve or nerve root lesion is always on the side of the pain.
For all these tests, the key feature is REPRODUCTION OF PATIENT'S ORIGINAL PAIN.
(source: Harrison')
132.How do you manage a patient with non massive9less than 100 cc in 24 hour) hemoptysis?
The work-up begins with history and physical examination. A chest x-ray and laboratory studies should be ordered initially.
If the chest x-ray is normal and the patient has risk factors for cancer, like smoking a bronchoscopy should be ordered to localize the bleeding site and look for an endobronchial mass. If none is found, a high resolution CT scan should be considered. If a mass is found on a study, referral to a thoracic surgeon is necessary.
133.Remember Once a biopsy diagnosis of cervical intraepithelial neoplasm has been made, an appropriate treatment option is a loop electrosurgical excision procedure, and the most common complication being postoperative bleeding.
134.Remember Patients with dural sinus and cerebral venous thrombosis can present with headaches, stroke-like symptoms, and/or seizures. There are multiple etiologies including dehydration, sepsis, and trauma. In addition, hypercoagulable states such as sickle cell disease, leukemia, and pregnancy are also predisposing factors. Because the symptomatology of a dural sinus thrombosis is nonspecific, imaging studies play a critical role in the diagnosis. On non-contrast enhanced head CT, a cord sign or tubular hyperdensity may be seen in the acute setting along with cortical and subcortical hemorrhage due to venous stasis and infarction. The treatment of choice during pregnancy is intravenous heparin. Unfractionated heparin and low molecular weight heparin (LMWH) do not cross the placenta and are considered safe for the fetus, but must be administered parenterally.
135.alwayes remember Children with sickle cell disease, despite splenomegaly, have reduced function of the reticuloendothelial system, (functional asplenia). Therefore, in a sickle cell patient with a fever, it is important that broad spectrum antibiotics are instituted as soon as possible to protect against septicemia from encapsulated organisms such as H. influenzae, Pneumococcus, and Neisseria.
136.Heat stroke can occur in athletes who exert themselves in conditions of high humidity and temperatures. Clinical signs of this condition include a core body temperature of >40.5 C (or 105 F), profuse sweating, and mental status changes. Patients with exertional heat stroke are at risk for disseminated intravascular coagulation and rhabdomyolysis
137.Treatment for rhabdomyolysis involves intravenous saline infusions to maintain a high urine output and alkalization of urine with a target pH of 7-8 to prevent myoglobin deposition.
138.remember aortic dissecting aneurysm caused by degeneration of tunica media-cystic medial necrosis
139.Remember cardiac rupture most common 4-7 days post MI. ventricular free wall rupture leads to cardiac tamponade
140.Remember New onset serous discharge from a laparotomy wound should raise the suspicion of wound dehiscence.
141.Remember acute angle-closure glaucoma, which is an ocular emergency that requires immediate treatment to prevent blindness:
Immediate treatment includes mannitol (to reduce vitreous volume), acetazolamide and topical beta-blockers, such as timolol (to block aqueous production), and pilocarpine (to facilitate aqueous outflow). Ophthalmologic consultation should also be sought as soon as possible. A peripheral laser iridectomy is the definitive procedure and is usually performed after the IOP is controlled.
142.treatment of Acne rosacea,avoiidng exogenouse factor,topical metronidazole ,no response give tetracycline
143.Risk factors for TOA include IUD use, multiple sexual partners, and previous episodes of pelvic inflammatory disease.ntravenous cefoxitin is used because it is an antimicrobial agent that is active against Gram-negative and anaerobic organisms, the predominant bacteria found in these abscesses
what wwill you see in sono?trasonography of the pelvis demonstrates a complex, cystic mass containing multiple septations and internal echoes in the left adnexa.
144.A tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way valve mechanism and compromises the contralateral lung and the venous return to the chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the pressure
145.A pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion scan.
in trension pneumothorax The ventilation perfusion scan demonstrates lack of ventilation and perfusion .
146.how do you manage a syncopal episode in a yaoung healthy adult?
when a young, healthy, athletic patient had a syncopal episode, which can be cardiogenic or neurogenic in origin. After the history and physical, blood work is usually sent to rule out anemia, infections, hypocalcemia, or hypomagnesemia and an EKG must be performed. An EKG may show evidence of cardiac abnormalities such as Wolf-Parkinson-White syndrome (r wave slurring), idiopathic hypertrophic subaortic stenosis, or congenital prolonged QT syndrome.
147. Remember,Higher prevalence enhances positive predictive value. Simply put, if more people actually have the disease, then a positive test result has a higher probability of being true. Note that for the reasons described here, diagnostic tests always have a higher positive predictive value than screening tests.
148.Remember The definition of chronic sinusitis is a sinus infection greater than 3 months. The most common etiology is infectious and the organisms most responsible are rhinovirus, H. influenza, S. pneumoniae, and influenza. The hallmark of acute sinusitis compared with sinus inflammation is total ostial obstruction. Once obstructed, fluid accumulates and becomes infected. The diagnosis is suggested by clinical signs and symptoms although certain imaging studies are very useful. The only imaging study to consider is a sinus CT. If positive, the maxillary or ethmoid sinuses will be opacified.
149.Remember Women who have very low body fat and/or participate in intense exercise are known to have a decrease in gonadotropin releasing hormone (GnRH), which in turn results in a diminished release of follicle stimulating hormone (FSH) and leuteinizing hormone (LH). Ovulatory dysfunction is responsible for approximately 20-25% of infertility cases.
151.Decreased CI, increased SVR, and normal PAWP is an example of cardiogenic shock. This is common with cardiac tamponade or myocardial infarction. It should be thought of as pump failure. The cardiac index is low because the heart is not pumping well. The SVR is increased in an effort to maintain blood pressure. The PAWP is normal in these patients since volume is typically not the primary problem
152.Hypovolemic shock is demonstrated by a low cardiac index, an increased SVR, and a decreased PAWP. Simply, CI and PAWP are low because there isn't enough blood volume to be pumped by the heart (low volume = low pre-load). SVR is elevated to attempt to increase blood pressure.
153.Obstructive shock, characterized decreased CI and normal SVR and PAWP , is typically caused by massive pulmonary embolus. Supportive care with IV fluids and vaso constrictors along with possible embolectomy is indicated. Note: The only indication for embolectomy is hemodynamic instability.
154.Remember the presentation of painless jaundice is highly suspicious for a pancreatic head mass and in particular adenocarcinoma of the pancreas. Adenocarcinoma of the pancreas accounts for more than 90% of pancreatic malignancies and jaundice is present in about 65% of patients. Risk factors for pancreatic adenocarcinoma include smoking and diabetes. The best initial evaluation for pancreatic masses is by CT of the abdomen and pelvis.
155.Remember Lorazepam is a short acting benzodiazepine with no active metabolites. Lorazepam is metabolized to the glucuronide form and excreted by the kidneys. The drug is tapered over 4-6 days for detoxification purposes. It is safe in patients with severe liver damage, and it won't compromise respiration in severe COPD
156.Chlordiazepoxide is a long-acting benzodiazepine that is used for detoxification from alcohol in uncomplicated cases. It has several metabolites that are long acting, thus making it difficult to efficiently manage the detoxification without risking the accumulation of drug and its metabolites because of impaired liver metabolism. In patients with severe COPD, it can compromise respiration secondary to sedative effects.
157.Remember renal vein thrombosis. Most commonly occurs in Membranous glomerulonephritis.
158. Excessive friction between the iliotibial band and the lateral femoral condyle can lead to iliotibial band tendonitis. This overuse syndrome commonly occurs in runners and cyclists, although it may develop in any person subsequent to activity involving repetitive knee flexion. Tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial torsion are predisposing factors.
159.The patient with iliotibial band tendonitis reports pain at the lateral aspect of the knee joint. The pain is aggravated by activity, particularly running downhill and climbing stairs. On physical examination, tenderness is present at the lateral epicondyle of the femur, approximately 3 cm proximal to the joint line. Soft tissue swelling and crepitus also may be present, but there is no joint effusion. Radiographs are not indicated.
160.Remember he two live vaccines, MMR and the varicella vaccine, are not recommended for use before the first birthday, but should be given the first time the child sees the doctor after 12 months of age.
161.Remember The findings of diffuse osteoporosis in a patient on hormone replacement therapy are suspicious for a multiple myeloma.
161. Laboratory data for multiple myeloma includes anemia, an elevated creatinine from secondary renal dysfunction, and elevated IgA and IgG levels and hypercalcemia.
162.alwyes remember bone scan has a low sensitivity for myeloma lesions and has no role in its workup. Do not confuse a bone survey which is a series of x-rays evaluating all of the bones with a bone scan which is a nuclear medicine scan.
NO!NO!NO!NO BONE SCANE FOR MULTIPLE MYELOMA!!!!!!!!!!!!!!!!!!!!!!
163. a postoperative pelvic abscess: This condition may occur after abdominal surgery, and presentation usually occurs after postoperative day 7. Diarrhea is frequently the earliest manifestation of abscess formation. . A fluctuant mass is a common finding on physical exam, and a rectal exam should be performed on all postoperative patients who are at risk for developing an abscess. A postoperative abscess will frequently cause an ileus, as manifested by vomiting, abdominal distention, decreased bowel sounds, and radiographic findings. Although the clinical grounds may provide you with the diagnosis of abscess, imaging studies should be undertaken to localize the fluid collection and aid in drainage. A CT scan probably has the highest yield compared to the other imaging modalities. Besides localizing the abscess, a CT scan will aid in the drainage of the fluid collection.
164.APGAR is a named after Virginia Apgar, M.D. who came up with a rating system for neonates at delivery. One helpful mnemonic is A: appearance, P: pulse, G: grimace or response to catheter in nostril, A: activity or tone, and R: respiratory effort. Each category is rated from 0-2.
165.Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections.
166.After a myocardial infarction, normal sexual activity can typically be resumed 2-4 weeks after discharge from the hospital.
167.some of the most common anomalies associated with congenital rubella are intrauterine growth retardation, microcephaly, microphthalmia, cataracts, glaucoma, retinopathy, patent ductus arteriosus, hepatomegaly, jaundice, thrombocytopenia, metaphyseal lucency, and a purpuric rash also known as a "blueberry muffin" rash. Infants may be asymptomatic at birth, but the earlier in pregnancy the mother is infected with the rubella virus, the more likely the baby is to have defects. For example, if a mother is infected in the first 8 weeks of pregnancy, the baby has an 85% chance of having a defect.
168.Remember Toxoplasma gondii is another organism that can cause congenital infection, but 70-90% of infants with congenital infection are asymptomatic at birth. It is important to note that a large percentage of the infants that are asymptomatic at birth will develop visual impairment, learning disabilities, or mental retardation months to years later. Signs of congenital toxoplasmosis include: hydrocephalus, microcephaly, cerebrospinal fluid abnormalities, intracranial calcifications, chorioretinitis, hepatosplenomegaly, generalized lymphadenopathy, and a maculopapular rash.
169.Varicella-zoster infection in a mother causes different syndromes in a baby depending on the time of the infection. If the mother is infected in the first trimester or early in the second trimester, the baby may develop varicella embryopathy which is characterized by microphthalmia, cataracts, chorioretinitis, cutaneous and bony aplasia/atrophy, and scarring of the skin of the extremity. If the mother is infected during the second 20 weeks of pregnancy, the baby may show no clinical manifestations of varicella, but may develop zoster later in life without ever having extrauterine infection. If the mother develops varicella from 5 days before delivery until 2 days after delivery, the child may develop severe infection, which may lead to death.
170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%.
The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%.
171.Remember when ever you use niacin you should monitor liver function and plasma glucose carefully.
when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL
172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.
173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.
170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%.
The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%.
171.Remember when ever you use niacin you should monitor liver function and plasma glucose carefully.
when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL
172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.
173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.
174. Remember white cells generally indicate active inflammation. The presence of leukocytes in a stool sample would be highly suggestive of IBD.
175.The treatment of unstable atrial fibrillation (atrial fibrillation associated with hypotension, myocardial ischemia, congestive failure, etc.) is immediate synchronous cardioversion, in an attempt to immediately restore sinus rhythm.
176.Churg-Strauss vasculitis: Prednisone should be started at a moderate dose, along with a bisphosphonate to prevent osteoporotic fractures,in initial therapy no cyclophosphamid,...
177.Remember Major depression need not present as classic dysphoria or sadness.It may present as irritability particularly in children and adolescent.
178.know pictures of fundoscopy ( glaucoma, DM, and cmv)
skin (herpes zoster)
ecg (1st degree block) preop.
179.IN DM with sports this is what we doپEcheck ketone.. if positive ,, he cant participate until ketones are goneپEin DM insulin is decreased with snacks during breakپEcheck glucose before and after sports is also a recoomendation
180.black male with HTN + DM .what HTsive med do u give?
پE.Ace inhibitorپE*htn plus diabetes
181.œBILATERALrenal a. stenosis with HTN, what med do you use to tx HTNپElt;br>Answer is calcium channel blockerپE If it was unilateral stenosis then ACE inhibitors
182.A male pt with thumb base pain what is dxa.
De querene tensovitis is the answerپEtreatment is nsaid and intrathecal steroids.
183.a pregnant rh- do not know father what is next?
test rh titer now
184.primigravida 28 weeks, rh negative ,husband positive anti lewis antibody positive what next
1)give anti rhd
2.dont give anti rhd
3.do amniocentesis,
answer,,,, DON™T DO ANYTHINGپElt;br>185.During a flu. Season, a pt who did got get flu. Shot and had a flu.s/s for 4 days came in for treatment. You provide for him:
1. amantadine 2. zanamivir 3. only symptomatic support including (Tyleno)
Symptomatic treatment ( amantadine or zanamivir is given within 72 hours of influnzaپEZANAMIVIR is the best treatment it covers both A and B)
186.Know exact inetrvals for pap smear (cervical cancer screening), breast cancer screeing, prostate cancer screening and colorectal cancer.
This is very important topic many Q in this topic
187.How do you treat Cocaine abuser with 210/115 BP?
Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV
No beta blockers like propranolol
188. Remember Bilious vomiting in an infant means that there is a malrotation with volvulus until proven otherwise. The radiographic findings of the cecum in the left upper quadrant confirms this clinical diagnosis. An upper gastrointestinal series would likely show a bird-beak deformity of the midgut where there is volvulus of the gut around a mesenteric "Ladd" band.
189.Remember about 20% of malrotation with volvulus is associated with duodenal atresia, annular pancreas, or a duodenal diaphragm. About 33% of cases present in the first week of life and 85% present in the first year of life. The hallmark of malrotation is ischemia of the midgut as the superior mesenteric vein and the superior mesenteric artery are occluded by the twisting mesentery. Immediate surgery is necessary to prevent death or the loss of much of the bowel.
190.Intussusception typically presents in infants from 4 months to 2 years of age, with alternating lethargy and irritability, colicky abdominal pain, and currant jelly stools. In addition, there is usually a right lower quadrant mass on abdominal x-ray.
191. The presence of tamponade is suggested by the presence of diminished heart sounds and pulsus alternans (a beat to beat variability in the QRS amplitude) on EKG.
192.It 's useful to note that the shock typically associated with sepsis, anaphylaxis, and neurogenic shock is associated with vasodilation, and hence, with warm extremities.
193.complication of polycytemia vera:
1.Hyperuricemia due to increased rbc turnover is common in patients with polycythemia vera, and these patients are at increased risk of gout.
2.Both arterial and venous thrombosis are common in polycythemia vera. The Hct is directly related to the risk of thrombosis. This association between Hct and risk of thrombosis forms the basis for the treatment recommendation to keep the Hct less than 46%. The platelets are derived from the neoplastic clone and may not function normally
3.Approximately 15-20% of patients with Polycythemia vera eventually develop myeloid metaplasia. Myeloid metaplasia is characterized by gradual replacement of the marrow space with fibrosis, and movement of hematopoiesis into the spleen and liver. The spleen and liver become massively enlarged, and the patient becomes progressively pancytopenic
194. Polycythemia vera :Neoplastic hematopoietic stem cell,CBC in Polycythemia vera: Hct and often WBC and platelets are increased ,reatment: Phlebotomy or hydroxyurea or 32P to keep Hct below 46% ,Decreased or low normal erhtropoitine
195. Secondary Polycythemia: disorder Due to tissue hypoxia causing an appropriate increase in Epo production, or to renal or hepatic disease causing an inappropriate increase in Epo production ,Only Hct is increased ,Treatment is usually not required,Normal or increased erhtropoithine
196.Hyperuricemia: An elevated uric acid level can result from gout, renal failure or an increased production of uric acid secondary to high rates of cell turn over such as in patients with hematologic malignancies. it may also be seen during treatment of these malignancies with chemotherapy when the rapid destruction of cells releases large amounts of uric acid into the blood, so called "tumor lysis."
197.Whenever u see an HIV positive patient on pentamidine with seizure think ((pentamidine induced hypoglycemia..and check bld glc!!))
198. Efavirenz contraindicated in pregnancy
199.Hypocalcemia, hypomagnesemia, hyperphosphatemia. Renal impairment progressing to renal failure. side effect of foscarnet also remember other drugs like Other drugs that affect the kidneys like amphotericin B and pentamidine should be avoided.
200.). The CT scan can be normal in 5% of patients with a subarachnoid hemorrhage within the first 12 hours of headache onset. Between 24 and 72 hours from onset of headache, up to 25% of CT scans can be normal. Therefore, if one suspects a subarachnoid hemorrhage from the patient's history, it is imperative to perform a lumbar puncture to evaluate the CSF for xanthochromia and red blood cells. Xanthochromia is not seen in a traumatic tap and may be more specific than RBC analysis.
201.the age of 18 months, most children will have developed a specific set of skills which can be divided into: social, self-help, gross motor, fine motor, and language. Social skills at this age include greeting people by saying "hi" or something similar, giving hugs and kisses, and playing patty-cake. Self-help involves drinking from a cup and feeding self with a spoon. Gross motor skills include walking without help and beginning to run. Fine motor skills would include scribbling with a crayon and stacking 2 blocks. Language skills should encompass talking in single words, asking for food or drink with words, and following simple instruction
1.The typical presentation of a thrombosed external hemorrhoid is an acute onset of very severe perianal pain, particularly when walking and sitting.
2. You know that external hemorrhoid is below the dentate line. internal hemorrhoids arise above the dentate line.
3. thrombosed external hemorrhoid requires immediate incision and evacuation of the clot to provide symptomatic relief. Pressure by compression is usually all that is needed to control the bleeding.
4..Sitz baths, applying a topical steroid cream, and increasing fiber intake are the usual treatment for symptomatic external hemorrhoids that are not thrombosed.
5..as a rule alwayes remember that external hemorrhoid s hurts but do not bleeding(opossit internal hemorrhoids)
6.typical picture of pyloric stenosis.,Projectile non-bilious vomiting is seen in virtually all patients. Patients also often develop a hypokalemic, hypochloremic metabolic alkalosis from the persistent vomiting. remeber if they give a child with intermittent spitting up think about pyloric stenosis.
7.abrupt onset of colicky abdominal pain in childeren <2 years ,think about intussusception! what's the etiology? The exact cause is unknown. However, it is associated with Meckel's diverticulum, cystic fibrosis, polyps, and Henoch-Schonlein purpura.
remeber A barium enema or air enema is both diagnostic and therapeutic.
8.Remember In any patient with dysphagia that is progressive for only solids, it suggests a growing and obstructive lesion. The history of cigarette and alcohol use, puts person at a much higher risk of carcinoma. The two ways to diagnose this are a barium swallow study, which will show the mucosal mass, or an upper endoscopy study to directly visualize and biopsy the lesion.
9.Remember Esophageal manometry is used to evaluate dysphagia caused by motility disorders. These typically present with dysphagia for solids and liquids and may or may not be progressive.
10.Incarcerated or strangulated hernias in an elderly patient can cause acute abdomen, dehydration, and altered mental status.
11.. Frequent, greasy, malodorous stools are a result of steatorrhea from chronic pancreatitis. This happens from the lack of pancreatic enzymes. Non-enteric coated pancreatic enzyme supplements with concurrent H2 blockers will deliver active enzymes to the proximal small bowel and help reduce malabsorption and steatorrhea.
12.. Acute acalculous cholecystitis is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder. BUT
biliary colic, which is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound.
13.Acute cholangitis is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad).
14.The hallmark of mesenteric ischemia is pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely in a patient with known vascular disease and a history of cigarette smoking. The next diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most often compromised vessel.
15. Patients with ulcerative colitis are at high risk for toxic megacolon, which is also associated with Clostridium difficile colitis
16.. Toxic megacolon presents clinically as abdominal distension and bowel motility disturbances. The next step in evaluation is an abdominal radiograph which will demonstrate a distended large bowel.
17.spontaneous bacterial peritonitis. This diagnosis should be first on your list in any patient with ascites who presents with fevers, abdominal pain, change in mental status, or with other non-specific complaints. These patients need to have a paracentesis. This fluid is then sent to the lab for a cell count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a positive peritoneal fluid culture. Patients with SBP need to be started on a third-generation cephalosporin
18.. Lead levels over 10 mg/dL are considered abnormal.
19.Remeber Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects.
20.congenital diaphragmatic hernia, which is when the abdominal contents herniate into the left hemithorax through a congenital defect in the left hemidiaphragm. This causes displacement of the heart into the right hemithorax and pulmonary hypoplasia.
21 key finding for Esophageal atresia with distal tracheoesophageal fistula usually presents with a history of polyhydramnios, cyanosis with feeding, and increased oropharyngeal secretions.
22.Remember in a traumatic lumbar puncture even though the CSF is initially red, the supernatant of the centrifuged cerebrospinal fluid is clear. This means that the red blood cells have not yet had a chance to lyse and release their intracellular contents into the cerebrospinal fluid.
BUT in subarachnoid hemorrhage there would be blood in the CSF, the supernatant of the centrifuged fluid would be xanthochromatic (yellow) due to the lysis of red blood cells and the release of their intracellular contents into the cerebrospinal fluid.
23.The symptoms of crampy abdominal pain and watery, explosive, secretory diarrhea are consistent with enterotoxic E. coli. the cause of traveler's diarrhea ,treatment ciprofloxacin if symptoms persistent.
24.The symptoms of Giardiasis, which usually occur about a week after exposure, include flatus, loose stools, diarrhea, abdominal pain, bloating, and vomiting. The usual scenario for a healthy person that develops this infection is the onset of these symptoms after a camping trip. tx:metronidazole
25.infectious mononucleosis typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur.
26.Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor.
27.Remember sudden onset of right upper quadrant pain associated with nausea and vomiting and history right upper quadrant and epigastric pain before, associated with food intake. These symptoms are classical for a perforated peptic ulcer. In a perforated peptic ulcer, a patient can still have right upper quadrant localized tenderness, a thickened gallbladder wall, and pericholecystic fluid from the perforated ulcer. Hence, with any abdominal pain associated with signs, abdominal x-rays both erect and supine are very essential in the initial evaluation to rule out any free air.
28.The first line in treatment of panic disorder is selective serotonin reuptake inhibitors (SSRIs), a group of medications including sertraline, paroxetine, fluoxetine, and citalopram. .
29.Remember Surveillance colonoscopies are generally recommended every 6 months for 2 years beginning after 8 to 10 years duration of ulcerative colitis.
30.The presence of endocervical cells on a Pap test is regarded as evidence of adequate sampling of the transformation zone during cytologic screening of the cervix. When these cells are absent, it indicates that this area may not have been sampled. This is considered a satisfactory, but limited smear. In patients with no known risk factors (i.e., prior abnormal Pap test, multiple sexual partners, smoking) the American College of Obstetricians and Gynecologists recommends that the physician may defer to repeating the Pap test in 12 months even if the sample is not adequ
31.in superior vena cava syndrome (SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS.
32.Remember in patients with known lung cancer, a biopsy of the mass causing the SVCS is usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis).
33.Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women.
34.Acneiform eruptions is characterized by papules and pustules resembling acne lesions. The eruptions are distinguished by their sudden onset.
Oral medications such as iodides, bromides, testosterone, cyclosporine, antiepileptic medications, lithium, and systemic corticosteroids are common agents that can lead to acneiform eruption. When medium or high doses of corticosteroids are taken for as short a time as 3-5 days, a distinctive eruption may occur, known as steroid acne. It is a sudden out-cropping of inflamed papules, most numerous on the upper trunk and arms, but also seen on the face. The lesions typically present as papules rather than comedones. Tretinoin cream applied once or twice daily may clear the lesions within 1-3 months, despite the continuation of high doses of corticosteroid.
35.The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma.
36. Remeber anterior uveitis is associated with sarcoidosis. Anterior uveitis is usually marked by the abrupt onset of pain and photophobia. Specifically anterior uveitis causes iritis and iridocyclitis. Constriction of the pupil causes increased pain. Slit-lamp examination is diagnostic, showing inflammatory cells in the aqueous humor or deposited along the corneal endothelium.
37.Many diseases are associated with anterior uveitis, including sarcoidosis and the seronegative spondyloarthropathies, including ankylosing spondylitis, psoriasis, inflammatory bowel disease, and Behçet's disease. Infectious disease may also cause uveitis. Some of the associated infections include herpesviruses, tuberculosis, onchocerciasis, and leprosy. In the majority of cases, uveitis is idiopathic. Treatment should include topical corticosteroids to decrease inflammation and mydriatics because dilation of the pupil decreases pain and the formation of synechiae.
38. hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.(tingling sensation in the fingertips.)
39.Remember treatment of CMV retinitis in HIV if Gancyvlovier dosen't work is FOSCARNET(can cuase renal toxicity).
40.Asperger disorder
it's characterized by defecits in interpersonal development,restricted patterns of interest&behaivior,and normal cognitive and speech development.
41.Spondylolysis is a defect seen in the pars interarticularis portion of the lamina.Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level.Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point(with hyperextension maneuvers)
42.Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific.
43..Remember The sudden onset of tachycardia and hypotension in a patient who is being mechanically ventilated with positive pressure, is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax,
44.young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis.
45.Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations.
46.Still disease is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis.
47.whenever the terms "coin-shaped" or "discoid" are used to describe a patient's skin lesions in a question you should think about nummular dermatitis.
48.Remeber symptoms of congestive heart failure and possible atrial fibrillation, as demonstrated by irregularly irregular heartbeat in question(they never mention stright forward A.F). In addition, are at high risk for the development of an embolic occlusion of the superior mesenteric artery. These patients will present with severe pain out of proportion to their objective physical findings. The diagnosis should be suspected clinically, and immediate superior mesenteric arteriogram should be performed. If evidence of ischemia is confirmed, the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia and possible gangrenous bowel.
49.BUT Ischemic colitis will usually present as diarrhea, often bloody, in elderly patients with known atherosclerotic heart disease.
50.malignant external otitis, This form is specifically caused by Pseudomonas aeruginosa, and tends to affect elderly diabetics and AIDS patients, causing the findings in the severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor.
51.Headache of sudden onset ("thunderclap" headache), rapid deterioration of mental status and blood in the CSF are virtually diagnostic of ruptured berry aneurysms. Note the characteristic hyperdensity on CT of the supra s e l l a r cistern, indicating blood in the subarachnoid space. Rupture of a berry aneurysm is the most common cause of subarachnoid bleeding.
52.PBC is due to an autoimmune destruction of intrahepatic bile ductules, and the diagnosis is made by liver biopsy. The serology that should be checked is the antimitochondrial antibody. Primary biliary cirrhosis is often seen in individuals with other autoimmune diseases, such as Sjِgren syndrome, pernicious anemia, and Hashimoto thyroiditis.
53.Myasthenia gravis is an autoimmune disease in which antibodies directed against the acetylcholine receptor of the muscle side of the neuromuscular junction block the ability of the receptor to bind to acetylcholine. Remember insulin resistance is also produced by a similar mechanism, i.e. antibodies to insulin receptors block the receptors' ability to bind to insulin
54.The first step in the approach to a patient with a community-acquired pneumonia is to categorize condition according to the American Thoracic Society guidelines (1993), which are based on severity of illness, age, comorbidities, and the need for hospitalization. the criteria for hospitalization (one of the following is needed: respiratory rate > 30 breaths/min, room air PaO2< 60 mm Hg, O2 saturation less than 90% on room air, or bilateral or multiple lobes involved), and older than 60 years.
55.normal value for the anion gap is 12 ± 4 mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes mellitus, alcoholism, starvation), renal failure with retained sulfate and phosphate, drugs or metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of protein anions, and dehydration (hemoconcentration).
56.Remember Subcutaneous unfractionated heparin is used for prevention of DVT in immobile patients or in hospitalized patients unable to ambulate. However, after orthopedic surgery, especially after joint procedures, its efficacy is very poor, given the increased venous stasis ,you should use warfarin.
57.Remember Both chronic laxative use and chronic diuretic use can produce hypokalemia. Severe hypokalemia, with plasma potassium <3 mEq/L, can markedly affect skeletal, smooth, and cardiac muscles. Skeletal muscle effects can include weakness, cramping, fasciculations, paralysis (with risk of respiratory failure), tetany, and rhabdomyolysis. Smooth muscle effects include hypotension and paralytic ileus. Cardiac muscle effects include premature ventricular and atrial contractions, tachyarrhythmias, and AV block. Additional ECG changes can include ST segment depression, increased U wave amplitude, and T wave amplitude less than U wave.
58.Basal cell carcinoma affects sun-exposed areas, particularly the mid and upper face, in patients lacking protective pigmentation. One of its morphologic forms is that of a raised, waxy, pale lesion that grows very slowly and doesn't metastasize to lymph nodes.
59.Key for Keratoacanthoma : grows very rapidly in a matter of weeks and has a scaly, rough appearance, with a core of keratin. If untreated, it eventually sloughs off.
60.Squamous cell carcinoma is usually an ulcer, rather than a nodule. In the face, it favors the lower lip. If present for several years, lymph node metastasis can sometimes occur.
61.euthyroid sick syndrome, which occurs in many seriously ill patients who do not have clinical hypothyroidism. especially in ICU
61. The TSH level is usually most helpful in distinguishing euthyroid sick syndrome from true hypothyroidism, as it often above 30 mU/mL in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick syndrome. Disproportionately decreased T3 is also typical of euthyroid sick syndrome, and T4 may be normal or decreased.
62.Remember hepatorenal syndrome occurs during the end stages of cirrhosis and is characterized by diminished urine output and low urinary sodium. In the setting of end-stage liver disease, renal vaso const-riction occurs, and the distal convoluted tubule responds by conserving sodium. Unless the renal function is allowed to deteriorate further, liver transplantation will reverse this vaso constriction and kidney function will return to normal.
then when ever you have cirrhosis with reanal faiuler the most appropriate treatment is LIVER TRANSPALNTION!
63.In beta thalassemia, a reduced production of beta chains occurs with normal amounts of alpha production
64.A shock-like pain upon percussion on the volar aspect of the wrist (Tinel sign) is a characteristic sign of Carpal tunnel syndrome ,,is most often idiopathic, but may represent a manifestation of underlying disorders such as rheumatoid arthritis, sarcoidosis, amyloidosis, acromegaly, and leukemia.
65.Fibrositis , also known as fibromyalgia, refers to a poorly understood syndrome of widespread musculoskeletal pain associated with tenderness in multiple trigger points. Fatigue, headache, and numbness are also common. Women between 20 and 50 years of age are most commonly affected. Neck, shoulders, low back and hips are usually involved.
66.Reflex sympathetic dystrophy describes a syndrome of pain and swelling of one extremity (most commonly a hand), associated with skin atrophy. It is thought to be secondary to vasomotor instability. Sometimes, it follows injuries to the shoulder (shoulder-hand variant).
67.Femoral pseudoaneurysms represent an important vascular complication of cardiac catheterization. The combination of a pulsatile mass, femoral bruit, and compromised distal pulses make this diagnosis likely. The diagnosis can be confirmed by ultrasound of the groin.(it was exam question of one of my friend).
68.Cholesterol emboli syndrome is also an important complication to recognize in the post-catheterization patient. It usually presents, however, with skin findings in the distal extremities of livedo reticularis, ischemic ulcerations, cyanosis, gangrene, or subcutaneous nodules.
69.Remember Another important complication of cardiac catheterization via the femoral artery is a retroperitoneal bleed . This complication presents, however, as either new back pain, an unexplained drop in the hematocrit, or purpura over the flanks.
70.what is piriformis syndrome??
As you may recall from your anatomy, the piriformis is the small muscle that crosses the greater sciatic foramen, cutting it into two spaces as the muscle passes from the edge of the sacrum to the greater trochanter. The sciatic nerve comes out of the greater sciatic foramen below the piriformis, and is liable to compression by the muscle. Symptoms are as described above; bicycle riding and running may also set off the symptoms, which may take the form of chronic nagging ache, pain, tingling, or numbness. Treatment is usually to teach the patient to avoid maneuvers that set off the symptoms. Some patients have been helped by corticosteroid injection near the site where the piriformis muscle crosses the sciatic nerve; this therapy is thought to work by reducing the fat around the muscle and thereby increasing the available space in the area.
71.in Adison disease Laboratory findings include hyponatremia (due to aldosterone deficiency), hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement.
72.HIV encephalitis, clinically known as AIDS dementia complex, . The pathologic substrate is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS.
73. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion. MRI studies and CSF analysis are useful in excluding other CNS diseases .
74.HIV myelopathy manifests mainly with spastic paraparesis. It is a complication similar in pathologic substrate to vitamin B12 deficiency, i.e., vacuolar degeneration of the posterior and lateral columns of the spinal cord.
75.Progressive multifocal leukoencephalopathy consists of multifocal areas of myelin destruction. These changes would be visible on MRI. This complication is due to JC virus, a papovavirus that causes asymptomatic infections in immunocompetent individuals.
76.Patients with longstanding extensive ulcerative colitis for at least 10 years' duration are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia
77.Individuals with herpes zoster are contagious and can spread the VZV virus.
78.Decreased esophageal peristalsis and decreased LES pressure :SCLERODERMA , These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's esophagus.
79.Patients with this erythema infectiosum (Fifth disease) are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death.
80.If a pergnant woman was in contact with a patient with fifth disease during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy.
81.Most authorities think that it is appropriate to initiate a progestin-only method of contraception immediately postpartum. It has no impact on lactation or the quality of breast milk.
82.The triad of miosis, respiratory depression, and coma is suggestive of opioid intoxication
83.Phenelzine is an antidepressant monoamine oxidase inhibitor (MAOI) that causes hypertensive crises and the serotonin syndrome (hypertension, tachycardia, fever, coma, and possibly death) when combined with tyramine-containing food (cheese) and serotonin-altering drugs.Pseudoephedrine and other nasal decongestants, bronchodilators, amphetamines can cause severe hypertension when monoamine oxidase is inhibited and should be avoid.
84.the classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles.
85.Fiberoptic bronchoscopy is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation.
then remeber if you have a patient with hemoptysis with past history of smoking ,your first step is CXR even if he/she is normal right now!but!!!!!!!Keep in mind that a chest x-ray is not part of a routine physical examination of an asymptomatic smoker.
86.Complications of ovarian torsion include infection, peritonitis, sepsis, adhesions, chronic pelvic pain, and infertility due to the loss of the viability of the torsed ovary.
87.Remember One of the most important considerations in evaluating patients with conjunctivitis is to rule out any vision-threatening conditions such as iritis, keratitis, glaucoma, or a corneal ulceration. Symptoms such as marked photophobia, decreased visual acuity, or globe pain suggest that ocular structures other than the conjunctiva are involved and should trigger immediate ophthalmologic evaluation.
88.The pathophysiology of ITP:
involves antibody (IgG or IgM) binding to platelets. These antibody- coated platelets are subsequently destroyed in the spleen.
89.Remember an extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients.
90.Multifocal glioblastoma multiforme (GBM) , the most frequent malignant primary brain neoplasm, manifests as an ill-defined mass in the white matter.
91.Wernicke encephalopathy is characterized by nystagmus progressing to ophthalmoplegia, truncal ataxia and confusion.
92.Korsakoff syndrome refers to alcohol-related amnesia and confabulation. Wernicke-Korsakoff syndrome is due to vitamin B1 deficiency, which is often seen in chronic alcoholics. This deficiency results in degeneration of periaqueductal gray matter.
93.Remember Huntington disease autosomal dominant condition is caused by an unstable expansion of a CAG trinucleotide repeat and MRI examination of the brain reveals hyperintensity in the region of the caudate on T2-weighted images.
94.The pathologic substrate of this condition(Huntington disease ) is degeneration of the striatal neurons, especially those in the caudate nucleus.
95.the pathogenesis of stress-induced gastritis
iffuse gastric mucosal vaso constriction 96.Right-sided endocardial fibrosis, with pulmonary stenosis and tricuspid regurgitation, is common in carcinoid patients and is the result of toxic damage to the heart
97.Ondansetron, a 5-hydroxytryptamine3 antagonist, is the most potent antiemetic available for chemotherapy-induced vomiting.It has side effects only infrequently, the most common being constipation.
98.Copper deficiency can present with anemia and neutropenia, Zinc deficeincy will present with alopecia, impaired wound healing , dermaititis, selenium def will present with dilated cardiomyopathy
99.Bernard-Soulier syndrome is an autosomal recessive disease of platelet adhesion which causes prolonged bleeding times in the presence of normal platelet counts. These patients' platelets cannot bind to subendothelial collagen properly because of a deficiency or dysfunction of the glycoprotein Ib-IX complex. Clinically the patients have impaired hemostasis and recurrent severe mucosal hemorrhage. The only treatment for an acute episode is a transfusion of normal platelets. This patient has a slightly decreased hemoglobin due to blood loss.
100.Von Willebrand's disease causes increased bleeding times with normal platelet counts. It is the most common inherited bleeding disorder, caused by a defect in von Willebrand factor, which aids the binding of platelets to collagen. Even though the platelets themselves are normal, binding is impaired, thus a platelet transfusion would not correct the problem. Cryoprecipitate, a plasma fraction rich in von Willebrand factor, would help in the case of von Willebrand's disease, but would not help with Bernard-Soulier syndrome.
Coarctations account for approximately 7% of congenital cardiac abnormalities, occur more frequently (2x) in men than in women, and are associated with gonadal dysgenesis and bicuspid aortic valves. Adults will present with hypertension, manifestations of hypertension in the upper body (headache, epistaxis), or leg claudication. Physical examination reveals diminished and/or delayed lower extremity pulses, enlarged collateral vessels in the upper body, or reduced development of the lower extremities.
101..Lymphoma is well known to develop specifically in the late stage of Sjِgren's syndrome. Common manifestations of this malignant condition include persistent parotid gland enlargement, purpura, leukopenia, cryoglobulinemia, and low C4 complement levels.
102.if they give you a farmer patient presents with acute-onset pulmonary symptoms, including wheezing, with no other medical problems and was recently handling hay.think about farmer's lung, a hypersensitivity pneumonitis caused by Actinomyces. In this disorder moldy hay with spores of actinomycetes are inhaled and produce a hypersensitivity pneumonitis. The disorder is seen most commonly in rainy periods, when the spores multiply. Patients present generally 4 to 8 h after exposure with fever, cough, and shortness of breath without wheezing. Chest radiograms often show patchy bilateral, often upper lobe infiltrates. The exposure history will differentiate this disorder from other types of pneumonia.
103.The Women's Health Initiative (WHI) demonstrated that estrogen-progestin therapy in Postmenopausal can reduce the risk of hip fractures by 34%. However, the WHI also demonstrated that estrogens are associated with a 30% increase in myocardial infarction, a 40% increase in stroke, a 100% increase in venous thromboembolism, and a 25% increase in breast cancer. In the WHI study there was no overall effect of estrogen-progestin therapy on mortality, probably because of the balance between the detrimental cardiovascular effects and the beneficial effects (in addition to fractures, there was a beneficial effect on the development of colon cancer).harrison new eddition!
104. Remember Pain, loss of function (without clear-cut sensory or motor deficits), and a localized autonomic impairment are called reflex sympathetic dystrophy (also known as shoulder-hand syndrome or causalgia). Precipitating events in this unusual syndrome include myocardial infarction, shoulder trauma, and limb paralysis. In addition to the neuropathic-type pain, autonomic dysfunction, possibly resulting from neuroadrenergic and cholinergic hypersensitivity, produces localized sweating, changes in blood flow, and abnormal hair and nail growth as well as edema or atrophy of the affected limb. Treatment is difficult; however, anticonvulsants such as phenytoin and carbamazepine may be effective, as they are in other conditions in which neuropathic pain is a major problem.
101. Remember when a patient has acute attacke with Renal faiuler the best drug for treatment would be either oral prednisone or steroids injected into the joint. He should not receive NSAIDs because he has renal insufficiency. Rofecoxib, a COX-2 inhibitor, can also be detrimental to renal function and should not be used in this setting.
102.remember Typical radiographic findings in osteoarthritis include joint space narrowing, subchondral bone sclerosis, subchondral cysts, and osteophytes (bony spurs). In the small interphalangeal joints of the fingers, central erosions may be seen within the joint space
105.HTN+Glocuma treatment?B blocker
106.Remember Addiction has identifiable risk factors, including genetic factors. The most well-established risk factors for addiction are family history and male sex. 105 in cocain toxi serum and urine tests are useful when they are positive, but they are of limited utility when they are negative because of the short duration of detectability of cocaine (6 to 8 hours) and cocaine metabolites (2 to 4 days). Cocaine does not produce compensatory adaptations in brain regions that control somatic functions and therefore does not produce dependence. Dependence and, therefore, withdrawal are not produced by highly addictive compounds such as cocaine.
107.The benzodiazepines (e.g., chlordiazepoxide, diazepam, lorazepam, and oxazepam) are the safest and most effective medications for treatment of alcohol withdrawal
108.glucagonoma and gastric adeno ca are associated with acanthosis nigric
109.nasopharyngeal ca also
burkitts lymphoma t8:14
are associated with EBV
110.Findings in Von Recklinghausen's disease: ... cafپEau-lait spots, neural tumors, Lisch nodules (pigmented iris hamartomas), skeletal disorders (scoliosis), and increased tumor susceptibility
111.Findings of Cri-du-chat syndrome: ... microcephaly, severe MR, high pitched crying/mewing -(Cri-du-chat is French for cry of the cat), cardiac abnormalities
112.Pathogenesis of Cystic Fibrosis: ... defective Cl- channel --> secretion of abnormally thick mucus that plugs lungs, pancreas, and liver --> recurrent pulmonary infections (Pseudomonas species and Staph aureus), chronic bronchitis, bronchiectasis, pancreatic insufficiency (malabsorption and steatorrhea), meconium ileus in newborns.
113.Which gene is affected in Fragile X? ... methylation and expression of the FMR 1 gene is affected in this X-linked disorder
114.2 skin conditions in AIDS patients one is a bacterial infection and another viral cause both look similar?
kaposi's sarcoma-HHV 8 AND BACILLARY ANGIOMATOSIS-caused by bartonella henselea
115.urticaria you get subcutaneous edema and angioedema you get mucosal edema
116.Genetic anticipation of Fragile X syndrome may be shown by what?
Triplet repeat (CGG)n
117.Huntington gene involved and triplet repeat CAG ,chromosome 4p
118.: Kidney cancer is a neoplastic condition that can initially appear with many different paraneoplastic manifestations. The initial presentation may include hypertension, flank mass, gross or microscopic hematuria, hypercalcemia, fever, weight loss, and/or polycythemia. This polycythemia is the presenting sign in 3% of cases of kidney cancer. In kidney cancer, polycythemia is secondary to a hypersecretion of tumor cytokines, including renin. The patient's erythropoietin level is usually high. Surgical removal of the cancer resolves the polycythemia.
, full evaluation is important in patients presenting with polycythemia and hematuria. Kidney cancer is an important differential diagnosis of secondary polycythemia.
119.Remember esophagitis in HIV often presents with belly or epigastric pain that could be caused by CMV or herpes simplex, but Candida most common (80%-90%); treat empirically with fluconazole 100 to 200 mg/day
120.Cryptococcal meningitis in HIV minority of patients have meningeal signs; most have only fever and headache; obtain head CT and lumbar puncture (LP); elevated opening pressure most common abnormality; cerebrospinal fluid (CSF)”can be normal; most have normal glucose; only 50% of patients have elevated protein; minority of patients have white blood cells in CSF; india ink simple test that detects 75% of cases; cryptococcal antigen >90% sensitive, but results take 1 to 2 days at most institutions
how do you treat?Treatment: treat with amphotericin B; flucytosine added in patients with severely elevated pressures; fluconazole as maintenance for rest of life
121.Remember LDH: nonspecific test; appears to be consistently greatly elevated in PCP; PCP unlikely if LDH normal (in HIV )
122.Remember Pneumocystis carinii pneumonia (PCP) less common now because many patients receiving medical care get prophylaxis for this organism; P carinii now considered closer to fungi than to protozoa; bacterial pneumonia now more common than PCP
123.Antiretroviral treatment for HIV: no consensus on when to start; indications include acute HIV infection, symptomatic HIV infection, CD4 count <350 cells/µL, high viral load (ie, >55,000 copies/mL
124.Kaposi™s sarcoma: reddish/purplish lesions can be located anywhere (internal or external); characteristic appearance of sharp demarcation (HSV8)
Hairy leukoplakia: tends to occur on side of tongue; cannot be scraped off like thrush; related to Epstein-Barr virus
125.What 2 neoplasms are associated with AIDS? ... 1. Aggressive malignant lymphomas (non-Hodgkins) 2. Kaposi's sarcoma
126.What 2 neoplasms are associated with Tuberous sclerosis (facial angiofibroma, seizures, and mental retardation)? ... 1. Astrocytoma 2. Cardiac rhabdomyoma
127.What are a common histopathological finding of meningiomas? ... Psammoma bodies. These are spindle cells concentrically arranged in a whorled pattern
128.What are ependymomas? ... Ependymal cell tumors most commonly found in the 4th ventricle. May cause hydrocephalus
129.Reason why Pregnant women get more chances of UTI: Increase in ventilation rate causes respiratory alkalosis: This causes renal compensation for and causes alkaline urine. This provides a good growth media
130. Remember the normal values of Non pregnant women does not apply to pregnant women. In pregnant women, the upper limts of BUN and Serum creatinine should be 10 and 0.5 respectively. If a pregnant woman has a serum creatinine of 1.5, then it can only mean 2 things: Either she has a kidney disease or it could be due to hyper coagulation which is seen only in Preeclampsia
131: What constitutes a positive SLR sign to diagnose radiculopathy?
SLR is positive if the maneuver REPRODUCES THE PATIENT'S USUAL PAIN .The patient may describe pain in the low back,buttocks, post. thigh or lower leg. But the key feature is reproduction of the patient's usual pain.
Other factors such as muscle stiffness can mimic radicular pain.
SLR is used to detect lesions of L5 and S1 roots and sciatic nerve.
Reverse SLR (passive extension of leg with patient standing)-for L2-L4 roots and femoral nerve
Crossed SLR-Performance of maneuver on one leg produces pain in the opposite leg or buttocks-The nerve or nerve root lesion is always on the side of the pain.
For all these tests, the key feature is REPRODUCTION OF PATIENT'S ORIGINAL PAIN.
(source: Harrison')
132.How do you manage a patient with non massive9less than 100 cc in 24 hour) hemoptysis?
The work-up begins with history and physical examination. A chest x-ray and laboratory studies should be ordered initially.
If the chest x-ray is normal and the patient has risk factors for cancer, like smoking a bronchoscopy should be ordered to localize the bleeding site and look for an endobronchial mass. If none is found, a high resolution CT scan should be considered. If a mass is found on a study, referral to a thoracic surgeon is necessary.
133.Remember Once a biopsy diagnosis of cervical intraepithelial neoplasm has been made, an appropriate treatment option is a loop electrosurgical excision procedure, and the most common complication being postoperative bleeding.
134.Remember Patients with dural sinus and cerebral venous thrombosis can present with headaches, stroke-like symptoms, and/or seizures. There are multiple etiologies including dehydration, sepsis, and trauma. In addition, hypercoagulable states such as sickle cell disease, leukemia, and pregnancy are also predisposing factors. Because the symptomatology of a dural sinus thrombosis is nonspecific, imaging studies play a critical role in the diagnosis. On non-contrast enhanced head CT, a cord sign or tubular hyperdensity may be seen in the acute setting along with cortical and subcortical hemorrhage due to venous stasis and infarction. The treatment of choice during pregnancy is intravenous heparin. Unfractionated heparin and low molecular weight heparin (LMWH) do not cross the placenta and are considered safe for the fetus, but must be administered parenterally.
135.alwayes remember Children with sickle cell disease, despite splenomegaly, have reduced function of the reticuloendothelial system, (functional asplenia). Therefore, in a sickle cell patient with a fever, it is important that broad spectrum antibiotics are instituted as soon as possible to protect against septicemia from encapsulated organisms such as H. influenzae, Pneumococcus, and Neisseria.
136.Heat stroke can occur in athletes who exert themselves in conditions of high humidity and temperatures. Clinical signs of this condition include a core body temperature of >40.5 C (or 105 F), profuse sweating, and mental status changes. Patients with exertional heat stroke are at risk for disseminated intravascular coagulation and rhabdomyolysis
137.Treatment for rhabdomyolysis involves intravenous saline infusions to maintain a high urine output and alkalization of urine with a target pH of 7-8 to prevent myoglobin deposition.
138.remember aortic dissecting aneurysm caused by degeneration of tunica media-cystic medial necrosis
139.Remember cardiac rupture most common 4-7 days post MI. ventricular free wall rupture leads to cardiac tamponade
140.Remember New onset serous discharge from a laparotomy wound should raise the suspicion of wound dehiscence.
141.Remember acute angle-closure glaucoma, which is an ocular emergency that requires immediate treatment to prevent blindness:
Immediate treatment includes mannitol (to reduce vitreous volume), acetazolamide and topical beta-blockers, such as timolol (to block aqueous production), and pilocarpine (to facilitate aqueous outflow). Ophthalmologic consultation should also be sought as soon as possible. A peripheral laser iridectomy is the definitive procedure and is usually performed after the IOP is controlled.
142.treatment of Acne rosacea,avoiidng exogenouse factor,topical metronidazole ,no response give tetracycline
143.Risk factors for TOA include IUD use, multiple sexual partners, and previous episodes of pelvic inflammatory disease.ntravenous cefoxitin is used because it is an antimicrobial agent that is active against Gram-negative and anaerobic organisms, the predominant bacteria found in these abscesses
what wwill you see in sono?trasonography of the pelvis demonstrates a complex, cystic mass containing multiple septations and internal echoes in the left adnexa.
144.A tension pneumothorax is a unilateral pneumothorax that becomes loculated by a one-way valve mechanism and compromises the contralateral lung and the venous return to the chest. Diagnosis is made by the lack of ipsilateral lung sounds due to cardiopulmonary collapse or chest radiograph. Treatment is immediate chest tube insertion to relieve the pressure
145.A pulmonary embolus creates ventilation perfusion mismatches on the ventilation perfusion scan.
in trension pneumothorax The ventilation perfusion scan demonstrates lack of ventilation and perfusion .
146.how do you manage a syncopal episode in a yaoung healthy adult?
when a young, healthy, athletic patient had a syncopal episode, which can be cardiogenic or neurogenic in origin. After the history and physical, blood work is usually sent to rule out anemia, infections, hypocalcemia, or hypomagnesemia and an EKG must be performed. An EKG may show evidence of cardiac abnormalities such as Wolf-Parkinson-White syndrome (r wave slurring), idiopathic hypertrophic subaortic stenosis, or congenital prolonged QT syndrome.
147. Remember,Higher prevalence enhances positive predictive value. Simply put, if more people actually have the disease, then a positive test result has a higher probability of being true. Note that for the reasons described here, diagnostic tests always have a higher positive predictive value than screening tests.
148.Remember The definition of chronic sinusitis is a sinus infection greater than 3 months. The most common etiology is infectious and the organisms most responsible are rhinovirus, H. influenza, S. pneumoniae, and influenza. The hallmark of acute sinusitis compared with sinus inflammation is total ostial obstruction. Once obstructed, fluid accumulates and becomes infected. The diagnosis is suggested by clinical signs and symptoms although certain imaging studies are very useful. The only imaging study to consider is a sinus CT. If positive, the maxillary or ethmoid sinuses will be opacified.
149.Remember Women who have very low body fat and/or participate in intense exercise are known to have a decrease in gonadotropin releasing hormone (GnRH), which in turn results in a diminished release of follicle stimulating hormone (FSH) and leuteinizing hormone (LH). Ovulatory dysfunction is responsible for approximately 20-25% of infertility cases.
151.Decreased CI, increased SVR, and normal PAWP is an example of cardiogenic shock. This is common with cardiac tamponade or myocardial infarction. It should be thought of as pump failure. The cardiac index is low because the heart is not pumping well. The SVR is increased in an effort to maintain blood pressure. The PAWP is normal in these patients since volume is typically not the primary problem
152.Hypovolemic shock is demonstrated by a low cardiac index, an increased SVR, and a decreased PAWP. Simply, CI and PAWP are low because there isn't enough blood volume to be pumped by the heart (low volume = low pre-load). SVR is elevated to attempt to increase blood pressure.
153.Obstructive shock, characterized decreased CI and normal SVR and PAWP , is typically caused by massive pulmonary embolus. Supportive care with IV fluids and vaso constrictors along with possible embolectomy is indicated. Note: The only indication for embolectomy is hemodynamic instability.
154.Remember the presentation of painless jaundice is highly suspicious for a pancreatic head mass and in particular adenocarcinoma of the pancreas. Adenocarcinoma of the pancreas accounts for more than 90% of pancreatic malignancies and jaundice is present in about 65% of patients. Risk factors for pancreatic adenocarcinoma include smoking and diabetes. The best initial evaluation for pancreatic masses is by CT of the abdomen and pelvis.
155.Remember Lorazepam is a short acting benzodiazepine with no active metabolites. Lorazepam is metabolized to the glucuronide form and excreted by the kidneys. The drug is tapered over 4-6 days for detoxification purposes. It is safe in patients with severe liver damage, and it won't compromise respiration in severe COPD
156.Chlordiazepoxide is a long-acting benzodiazepine that is used for detoxification from alcohol in uncomplicated cases. It has several metabolites that are long acting, thus making it difficult to efficiently manage the detoxification without risking the accumulation of drug and its metabolites because of impaired liver metabolism. In patients with severe COPD, it can compromise respiration secondary to sedative effects.
157.Remember renal vein thrombosis. Most commonly occurs in Membranous glomerulonephritis.
158. Excessive friction between the iliotibial band and the lateral femoral condyle can lead to iliotibial band tendonitis. This overuse syndrome commonly occurs in runners and cyclists, although it may develop in any person subsequent to activity involving repetitive knee flexion. Tightness of the iliotibial band, excessive foot pronation, genu varum, and tibial torsion are predisposing factors.
159.The patient with iliotibial band tendonitis reports pain at the lateral aspect of the knee joint. The pain is aggravated by activity, particularly running downhill and climbing stairs. On physical examination, tenderness is present at the lateral epicondyle of the femur, approximately 3 cm proximal to the joint line. Soft tissue swelling and crepitus also may be present, but there is no joint effusion. Radiographs are not indicated.
160.Remember he two live vaccines, MMR and the varicella vaccine, are not recommended for use before the first birthday, but should be given the first time the child sees the doctor after 12 months of age.
161.Remember The findings of diffuse osteoporosis in a patient on hormone replacement therapy are suspicious for a multiple myeloma.
161. Laboratory data for multiple myeloma includes anemia, an elevated creatinine from secondary renal dysfunction, and elevated IgA and IgG levels and hypercalcemia.
162.alwyes remember bone scan has a low sensitivity for myeloma lesions and has no role in its workup. Do not confuse a bone survey which is a series of x-rays evaluating all of the bones with a bone scan which is a nuclear medicine scan.
NO!NO!NO!NO BONE SCANE FOR MULTIPLE MYELOMA!!!!!!!!!!!!!!!!!!!!!!
163. a postoperative pelvic abscess: This condition may occur after abdominal surgery, and presentation usually occurs after postoperative day 7. Diarrhea is frequently the earliest manifestation of abscess formation. . A fluctuant mass is a common finding on physical exam, and a rectal exam should be performed on all postoperative patients who are at risk for developing an abscess. A postoperative abscess will frequently cause an ileus, as manifested by vomiting, abdominal distention, decreased bowel sounds, and radiographic findings. Although the clinical grounds may provide you with the diagnosis of abscess, imaging studies should be undertaken to localize the fluid collection and aid in drainage. A CT scan probably has the highest yield compared to the other imaging modalities. Besides localizing the abscess, a CT scan will aid in the drainage of the fluid collection.
164.APGAR is a named after Virginia Apgar, M.D. who came up with a rating system for neonates at delivery. One helpful mnemonic is A: appearance, P: pulse, G: grimace or response to catheter in nostril, A: activity or tone, and R: respiratory effort. Each category is rated from 0-2.
165.Cystic fibrosis is a pulmonary/gastric disorder caused by mutation in a protein responsible for maintaining salt and water gradients across cell membranes. The clinical manifestations of the disease stem from the presence of thick, copious secretions in the airways and ducts of the pancreas. The pulmonary manifestations are frequent infection such as pneumonia and eventually bronchiectasis. In addition to antibiotics, aggressive chest physiotherapy to loosen and remove impacted secretions is critical to clearing hyper-acute infections.
166.After a myocardial infarction, normal sexual activity can typically be resumed 2-4 weeks after discharge from the hospital.
167.some of the most common anomalies associated with congenital rubella are intrauterine growth retardation, microcephaly, microphthalmia, cataracts, glaucoma, retinopathy, patent ductus arteriosus, hepatomegaly, jaundice, thrombocytopenia, metaphyseal lucency, and a purpuric rash also known as a "blueberry muffin" rash. Infants may be asymptomatic at birth, but the earlier in pregnancy the mother is infected with the rubella virus, the more likely the baby is to have defects. For example, if a mother is infected in the first 8 weeks of pregnancy, the baby has an 85% chance of having a defect.
168.Remember Toxoplasma gondii is another organism that can cause congenital infection, but 70-90% of infants with congenital infection are asymptomatic at birth. It is important to note that a large percentage of the infants that are asymptomatic at birth will develop visual impairment, learning disabilities, or mental retardation months to years later. Signs of congenital toxoplasmosis include: hydrocephalus, microcephaly, cerebrospinal fluid abnormalities, intracranial calcifications, chorioretinitis, hepatosplenomegaly, generalized lymphadenopathy, and a maculopapular rash.
169.Varicella-zoster infection in a mother causes different syndromes in a baby depending on the time of the infection. If the mother is infected in the first trimester or early in the second trimester, the baby may develop varicella embryopathy which is characterized by microphthalmia, cataracts, chorioretinitis, cutaneous and bony aplasia/atrophy, and scarring of the skin of the extremity. If the mother is infected during the second 20 weeks of pregnancy, the baby may show no clinical manifestations of varicella, but may develop zoster later in life without ever having extrauterine infection. If the mother develops varicella from 5 days before delivery until 2 days after delivery, the child may develop severe infection, which may lead to death.
170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%.
The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%.
171.Remember when ever you use niacin you should monitor liver function and plasma glucose carefully.
when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL
172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.
173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.
170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%.
The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%.
171.Remember when ever you use niacin you should monitor liver function and plasma glucose carefully.
when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL
172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.
173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest.
174. Remember white cells generally indicate active inflammation. The presence of leukocytes in a stool sample would be highly suggestive of IBD.
175.The treatment of unstable atrial fibrillation (atrial fibrillation associated with hypotension, myocardial ischemia, congestive failure, etc.) is immediate synchronous cardioversion, in an attempt to immediately restore sinus rhythm.
176.Churg-Strauss vasculitis: Prednisone should be started at a moderate dose, along with a bisphosphonate to prevent osteoporotic fractures,in initial therapy no cyclophosphamid,...
177.Remember Major depression need not present as classic dysphoria or sadness.It may present as irritability particularly in children and adolescent.
178.know pictures of fundoscopy ( glaucoma, DM, and cmv)
skin (herpes zoster)
ecg (1st degree block) preop.
179.IN DM with sports this is what we doپEcheck ketone.. if positive ,, he cant participate until ketones are goneپEin DM insulin is decreased with snacks during breakپEcheck glucose before and after sports is also a recoomendation
180.black male with HTN + DM .what HTsive med do u give?
پE.Ace inhibitorپE*htn plus diabetes
181.œBILATERALrenal a. stenosis with HTN, what med do you use to tx HTNپElt;br>Answer is calcium channel blockerپE If it was unilateral stenosis then ACE inhibitors
182.A male pt with thumb base pain what is dxa.
De querene tensovitis is the answerپEtreatment is nsaid and intrathecal steroids.
183.a pregnant rh- do not know father what is next?
test rh titer now
184.primigravida 28 weeks, rh negative ,husband positive anti lewis antibody positive what next
1)give anti rhd
2.dont give anti rhd
3.do amniocentesis,
answer,,,, DON™T DO ANYTHINGپElt;br>185.During a flu. Season, a pt who did got get flu. Shot and had a flu.s/s for 4 days came in for treatment. You provide for him:
1. amantadine 2. zanamivir 3. only symptomatic support including (Tyleno)
Symptomatic treatment ( amantadine or zanamivir is given within 72 hours of influnzaپEZANAMIVIR is the best treatment it covers both A and B)
186.Know exact inetrvals for pap smear (cervical cancer screening), breast cancer screeing, prostate cancer screening and colorectal cancer.
This is very important topic many Q in this topic
187.How do you treat Cocaine abuser with 210/115 BP?
Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV
No beta blockers like propranolol
188. Remember Bilious vomiting in an infant means that there is a malrotation with volvulus until proven otherwise. The radiographic findings of the cecum in the left upper quadrant confirms this clinical diagnosis. An upper gastrointestinal series would likely show a bird-beak deformity of the midgut where there is volvulus of the gut around a mesenteric "Ladd" band.
189.Remember about 20% of malrotation with volvulus is associated with duodenal atresia, annular pancreas, or a duodenal diaphragm. About 33% of cases present in the first week of life and 85% present in the first year of life. The hallmark of malrotation is ischemia of the midgut as the superior mesenteric vein and the superior mesenteric artery are occluded by the twisting mesentery. Immediate surgery is necessary to prevent death or the loss of much of the bowel.
190.Intussusception typically presents in infants from 4 months to 2 years of age, with alternating lethargy and irritability, colicky abdominal pain, and currant jelly stools. In addition, there is usually a right lower quadrant mass on abdominal x-ray.
191. The presence of tamponade is suggested by the presence of diminished heart sounds and pulsus alternans (a beat to beat variability in the QRS amplitude) on EKG.
192.It 's useful to note that the shock typically associated with sepsis, anaphylaxis, and neurogenic shock is associated with vasodilation, and hence, with warm extremities.
193.complication of polycytemia vera:
1.Hyperuricemia due to increased rbc turnover is common in patients with polycythemia vera, and these patients are at increased risk of gout.
2.Both arterial and venous thrombosis are common in polycythemia vera. The Hct is directly related to the risk of thrombosis. This association between Hct and risk of thrombosis forms the basis for the treatment recommendation to keep the Hct less than 46%. The platelets are derived from the neoplastic clone and may not function normally
3.Approximately 15-20% of patients with Polycythemia vera eventually develop myeloid metaplasia. Myeloid metaplasia is characterized by gradual replacement of the marrow space with fibrosis, and movement of hematopoiesis into the spleen and liver. The spleen and liver become massively enlarged, and the patient becomes progressively pancytopenic
194. Polycythemia vera :Neoplastic hematopoietic stem cell,CBC in Polycythemia vera: Hct and often WBC and platelets are increased ,reatment: Phlebotomy or hydroxyurea or 32P to keep Hct below 46% ,Decreased or low normal erhtropoitine
195. Secondary Polycythemia: disorder Due to tissue hypoxia causing an appropriate increase in Epo production, or to renal or hepatic disease causing an inappropriate increase in Epo production ,Only Hct is increased ,Treatment is usually not required,Normal or increased erhtropoithine
196.Hyperuricemia: An elevated uric acid level can result from gout, renal failure or an increased production of uric acid secondary to high rates of cell turn over such as in patients with hematologic malignancies. it may also be seen during treatment of these malignancies with chemotherapy when the rapid destruction of cells releases large amounts of uric acid into the blood, so called "tumor lysis."
197.Whenever u see an HIV positive patient on pentamidine with seizure think ((pentamidine induced hypoglycemia..and check bld glc!!))
198. Efavirenz contraindicated in pregnancy
199.Hypocalcemia, hypomagnesemia, hyperphosphatemia. Renal impairment progressing to renal failure. side effect of foscarnet also remember other drugs like Other drugs that affect the kidneys like amphotericin B and pentamidine should be avoided.
200.). The CT scan can be normal in 5% of patients with a subarachnoid hemorrhage within the first 12 hours of headache onset. Between 24 and 72 hours from onset of headache, up to 25% of CT scans can be normal. Therefore, if one suspects a subarachnoid hemorrhage from the patient's history, it is imperative to perform a lumbar puncture to evaluate the CSF for xanthochromia and red blood cells. Xanthochromia is not seen in a traumatic tap and may be more specific than RBC analysis.
201.the age of 18 months, most children will have developed a specific set of skills which can be divided into: social, self-help, gross motor, fine motor, and language. Social skills at this age include greeting people by saying "hi" or something similar, giving hugs and kisses, and playing patty-cake. Self-help involves drinking from a cup and feeding self with a spoon. Gross motor skills include walking without help and beginning to run. Fine motor skills would include scribbling with a crayon and stacking 2 blocks. Language skills should encompass talking in single words, asking for food or drink with words, and following simple instruction