05-27-2008, 09:13 AM
I got this material on some other forum and pasting it here that it migh help others
INJURIES TO ELBOW
1. Lateral Epicondylitis (tennis elbow). A very common inflammatory process of the extensor origin of the lateral epicondyle. May be secondary to overuse/repetitive use. Pain at the lateral epicondyle, with referred pain to the extensor surface of the forearm is typical. The pain is exacerbated by resisted extension of the wrist or fingers. Treatment includes avoiding exacerbating activities, NSAIDs, and placing a constrictive "tennis elbow" band just distal from the elbow. Occasionally immobilization of the wrist in a volar splint is required. Local steroid injection or orthopedic referral may be advised in recalcitrant cases.
2. Medial Epicondylitis. This results from repeated flexion activities of the wrist and fingers. Pain is at the medial epicondyle and exacerbated by resistant flexion of the fingers. Treatment is the same as that of lateral epicondylitis.
3. Radial Head Subluxation (nursemaid™s elbow).
a. The mechanism is a sudden pull on the extended pronated elbow of a child less than 4 years of age (for example, when one picks up a child by the forearm or swings the child). The child holds his arm in pronation and usually refuses to move it with pain on supination and palpation of the radial head.
b. Although radiographic findings are usually normal, one must be sure to rule out undisplaced supracondylar fracture. Frequently, the subluxation spontaneously reduces from x-*** positioning.
c. Treatment is firm supination of the forearm, flexing the elbow gently to 90 degrees with pressure over the radial head. Reduction is achieved with a palpable click over the radial head, and the pain is immediately relieved. The patient should resume full activity within several minutes of reduction although some are hesitant. It may take an hour or so to resume full activity.
4. Little Leaguer™s Elbow. Results from overuse of an adolescent™s pitching elbow. On exam there is tenderness over the medial humoral epicondyle with mild swelling. An acute syndrome with sudden onset also occurs from the avulsion of a fragment of bone from the medial humeral epicondyle. Treatment includes rest for 3-6 weeks followed by rehabilitation. Loose bodies and locking elbow require referral.
5. Olecranon Bursitis (note: the same treatment and diagnostic modalities hold true for prepatellar bursitis as well).
a. Clinically there is tenderness and swelling over the olecranon bursa. Olecranon bursitis may be secondary to trauma (e.g., lying on carpet with elbows propped up while watching TV) or may be infectious (Staphylococcal). Frequently, traumatic bursitis leads to infectious bursitis.
b. Diagnosis. Must differentiate infectious from sterile bursitis. Tap the bursa and evaluate gram stain, cell count, crystals, and culture.
c. Treatment consists of repeated aspiration until fluid no longer re- accumulates. Start antistaphylococcal antibiotics (e.g., amoxicillin/ clavulanate, nafcillin) if an infectious etiology is likely. May require admission for IV antibiotics the patient is toxic or there are comorbid conditions (e.g., immunosuppression, diabetes). If the etiology is not infectious, treat with NSAIDS, aspiration and compression dressings. Occasionally, an olecranon bursa must be opened surgically.
RED EYE
Clinical clue table suggesting the possibility of serious eye disease causing the "red eye", clinical features that may necessitate immediate ophthalmologist consultation
Clinical features:
Severe eye aching: Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus thrombosis (CST)
Prominent photophobia: Iritis, keratitis
Impaired vision: Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST
Cloudy cornea: Keratitis, acute angle-closure glaucoma
Corneal opacification: Keratitis - chemical or infectious
Circumcorneal conjunctival injection: Iritis, keratitis
Cloudy anterior chamber: Iritis
Pain on eyeball palpation: Scleritis (+++), orbital cellulitis, CST
Proptosis: Orbital cellulitis, CST, posterior scleritis
Impaired, or painful, extraocular eye movements: Orbital cellulitis
Fever, toxic appearance: Orbital cellulitis (+), CST (++)
Hyperpurulent discharge from an "angry" eye: Gonococcal conjunctivitis/endophthalmitis
Prominent nausea and vomiting: Acute angle-closure glaucoma
Small, irregular, poorly-reactive pupil: Iritis
Fixed mid-dilated pupil: Acute angle-closure glaucoma
Increased intra-ocular pressure: Acute angle-closure glaucoma, iritis (secondary complication)
History of connective tissue disease, or granulomatous disease: Iritis, scleritis
Recall:
23 yo runner developed fracture of the medial malleolus...next step:
a-posterior splinting
b-medial splinting
c-lateral splinting
d-orthopedic referral
The answer to this question is posterior splinting..The trick here is to know the intervention and the position of splinting..
Think of the ankle as a "ring" composed of medial malleolus, deltoid ligamnet, calcaneous, lateral ligamnet, lateral malleolus.
DISRUPTION OF THE RING AT ONE POINT ONLY OF THE RING results in a stable ankle that can be treated by CONSERVATIVE means (POSTERIOR splinting+non-weight bearing)
DISRUPTION OF THE RING AT TWO OR MORE POINTS OF THE RING makes the ankle unstable and the treatment is immobilization and emergent referral..
Difference b/w Raloxifene and Tamoxifen:
Tamoxifen:
Often used in women over 50 years of age and younger women with ER + tumors. ER + respond better than ER -. Treatment for 5 years seems to be optimal duration. Side effects include, nausea, menopausal symptoms, thromboembolism and and a small increase in uterine cancer (mandating work for any abnormal uterine bleeding). Ovarian ablation is only beneficial as hormonal treatment in premenopausal women.
* women at high risk for the development of breast cancer may reduce their risk by taking tamoxifen.
* Tamoxifen appears to be antiestrogenic at the level of the breast but proestrogenic at other levels.
It causes endometrial changes, including polyp formation, hyperplasia NOT ATROPHY, and frank invasive carcinoma. Thus, women on tamoxifen need to be followed carefully, and prompt evaluation of abnormal vaginal bleeding should be conducted.
Tamoxifen, like estrogen, has been shown to lower blood levels of LDL cholesterol
Women on tamoxifen appear to be at no greater risk, and may be at a lower risk, for the development of myocardial infarction .
Tamoxifen, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis .
Raloxifene:
Raloxifene appears to function like estrogen in bone, acting to maintain bone strength and increase bone density.
In addition, raloxifene also resembles estrogen in its ability to lower LDL cholesterol levels, thereby decreasing the risk of heart disease.
Although information on the long-term risks and benefits of raloxifene is limited compared to tamoxifen, preliminary evidence suggests that raloxifene may exert these beneficial effects on bones, heart, and blood vessels without increasing a woman's risk of developing cancer.
Even if the STAR trial confirms the effectiveness of raloxifene in reducing the risk of breast and uterine cancer, raloxifene is still not the perfect drug. It does not reduce the frequency of hot flashes associated with menopause and, like estrogen, it increases the risk of blood clots. Just as tamoxifen was an important milestone, if a single SERM like raloxifene is found to protect women against osteoporosis, heart disease, breast cancer, and uterine cancer, it will represent an important milestone in women's health. For the recall question raloxifene if h/o breast ca is there.
Asymptomatic hematuria:
1)>50, + Risk factors(tob, dye, etc) or is consistent with underlying causes straight cystoscopy.
2)<50 without RF, do Urine cx/AXR first. if all are wnl, then watch and wait, document that u informs pt pro and con of w/u.
Ureteral Colic:
First step: UA with sediment followed by AXR. Uric is lUcent others opaque. Urinary Ph can also distinguish different varieties. Minimal work up is crt, electrolytes, ca, phosphorus, cbc.
Next is helical/spiral CT abdomen (test of choice). Most would be seen, if still in doubt IVP (former gold standard BECAREFUL).
*** REMEMBER 6 is the KEY DIGIT for ureteral stones
Stones less than 6 mm pass spontaneously. Conservative observation with pain meds is sufficient for 6 weeks. After 6 weeks, 2 options, ureteroscopic stone extraction or extra shock wave lithotripsy (ESWL). Read the debate on p 919 CMDT. Women of childbearing age are best NOT treated with ESWL for a stone in LOWER URETER as impact upon ovary is unknown. Most stone fragments pass uneventfully w/n 2 weeks after ESWL, stones that persist need additional intervention. Also see 104 Bp med
Renal Stones: 919 CMDT
Asymptomatic------No management and F/u with AXR or U/S
Symptomatic less than 3 cms---------ESWL and F/u in 3 months by AXR
Symptomatic more than 3 cms and stones despite treatment with ESWL-----Percutaneous Nephrolithotomy + perioperative Abx coverage
Drugs causing Erythema Multiforme (Targetoid lesions i.e rash like lymes)
Barbiturates
Sulphonylurea anti-diabetic agents
Sulphonamides
Thiazide diuretics
Phenytoin
Captopril
Diltiazem
Gold
Non-steroidal anti-inflammatory drugs, particularly piroxicam, also aspirin
Statins
ORGAN DONATION:
The physician declares death using brain criteria (potential organ and tissue donor) or from cardio-pulmonary arrest (potential tissue donor).
According to Medicare Conditions of Participation, a hospital must notify its local organ procurement organization upon every death.
Recovery coordinator discusses organ and tissue donation with the family or next-of-kin.
In the case of a tissue donor, a recovery team is called to the hospital and a room is prepped for the donation.
All tissues are carefully removed, packed in sterile conditions, and transported to a tissue bank to be prepared for transplantation, research or therapy.
If the case of an organ donor, the process of identifying the recipient begins.
What is brain death?
Brain death occurs when the brain has permanently stopped working, as determined by the physician not related to transplantation. Artificial support systems (machines) may maintain functions such as heartbeat and breathing for a few days, but not permanently. Donor organs are usually taken from people who have been declared "brain dead".
What is cardiac death?
Cardiac death occurs when the heart has stopped beating completely. While a person dying by cardiac death cannot be an organ donor, they may still donate tissues.
When must organs be removed?
Organs must be recovered as soon as possible after the declaration of brain death, while circulation and respiration are being maintained artificially. Tissue may be removed within 12 to 24 hours after cardiac death.
How long before an organ or tissue must be transplanted into a recipient?
That varies from organ to organ and tissue to tissue. For example heart or lungs must be transplanted within 4 to 6 hours; for kidneys potentially up to 72 hours. Corneas must be transplanted within 5 to 7 days and other tissues may be preserved for 3 to 5 years.
Can donor families have contact with their loved one™s recipient?
Confidentiality is respected unless both the donor family and recipient agree individually to make contact and sign a release of confidentiality waiver. Either side may communicate through letters that are passed on by WRTC if they choose to do so.
FACT: Upon arrival at an accident scene or upon receiving you in the emergency room, emergency or critical care staff immediately spring into action to try and save your life. Physicians involved in a patient's care in an emergency or critical care setting by law may have nothing to do with transplant programs. The OPO (organ procurement organization) is not notified until all lifesaving efforts have failed and death has occurred. Death can be declared only by following strict medical and legal guidelines and usually with the input of more than one physician.
FACT: By the time your will is read, it will be too late to recover your organs. Telling your family that you want to be a donor is the best way to ensure your wishes are carried out because they will always be at the hospital and can relate your wishes. You may also sign an advance directive or driver™s license.
Organs that can be donated at the time of your death include your heart, lungs, two kidneys, liver, pancreas and intestines (although in the Washington, D.C. region there is no intestine transplant program).
A typical organ donor is someone who has died after suffering from a traumatic injury to the brain; for example, a stroke, an aneurysm, or a car accident. For death to be declared, a strict set of medical criteria must be met. Among the criteria is the complete absence of activity in either the brain or the brain stem (responsible for reflexes such as cough, gag, blinking, etc.). By law, only a doctor not connected to the transplantation process may declare brain death.
After death by neurological criteria is declared, the heart, as a muscle, can still circulate blood for a limited amount of time and keep the internal organs viable. It is during that short amount of time that organs may be recovered for transplantation.
WRTC Recovery staff are notified after death has been declared. If the patient is a potential donor, they will approach the patient's family and discuss organ and tissue donation. To find out how to be an organ and tissue donor, click here.
Tissue Donor
While officially considered life-enhancing and not life-saving, a tissue transplant is still a life-changing opportunity for the recipient. From someone who receives the gift of sight for the first time in a cornea transplant to someone who receives skin for burn treatments, tissue recipients are incredibly grateful to donors for having given them the opportunity of greatly improving their lives and the lives of those around them.
A tissue donor is different from an organ donor because someone can be a potential tissue donor if they died according to brain death criteria or if their heart has stopped (cardiac death). Tissues can be recovered up to 24 hours after the heart has stopped beating.
Tissues that can be donated at the time of your death include:
Bone: Facial reconstruction, limb salvage, birth defect correction, cancer treatment, spinal and oral surgery
Cartilage : Facial and other post-traumatic injury reconstruction
Corneas : Restoring eyesight
Fascia : In neurosurgery, to correct damage from trauma or tumor
Heart valves: For valve replacement where animal or artificial valves cannot be tolerated
Pericardium : Used in neurosurgery, especially in brain operations
Skin : Temporary covering for burn patients to reduce pain, scarring, fluid loss, infection
Tendons : Correcting joint injuries
Veins : Used in heart bypass surgery
ULCERS :
If you see the ulcer at the distal tip of the toes ==> Think ischemic ulcer
If you see the ulcer at the heel ==> Think diabetic ulcer
If you see the ulcer above the malleolus ==> Think in stasis ulcer
Diabetic ulcers typically develop at pressure points, and the heel is a favorite location. The patient has evidence of neuropathy, and the correlation with the trauma inflicted by the new shoes is classic
Ischemic ulcers, whether due to arteriosclerosis or embolization are typically seen at the tip of the toes, as far away from the heart as one can get.
Stasis ulcers are seen above the malleolus, surrounded by edematous, hyperpigmented skin.
RECALLS:
1.pregnant exposed to a lacy rashed boy
a.it wonot affect u
b.u will get mild disease
c.u are vaccinated to this,no harm
d.u may lose your fetus
A. no longer infectious once rash appears.
2.pt heavy smoker,lost 8 lbs lately and serum ca=11.5
what do u do next;
a.recheck ca
b.check cxr
CXR.
3.14 yrs old girl never been vaccinated for varicella and she exposed to 5 yrs old her sister with varicella
how would u tx 14 yr one
a.varicella immuno
b.varicella ig g and vaccine
c.var vaccine now
d.va vaccine now and month later
edo nothing.she already exposed
Answer D ref CDC guidelines
4.4 yr old almost near drowing was cpr for 45 mts to get pulse and circulation.in er pt is on dopamine and intubated.he pronouned brain dead and ready for organ donation.what is the best time for this.
a.now
b.after 48 hrs
c.after good b.p. control
Answer NOW
5.56 yr man came to pmd he is s/p CABG 10 yrs back and c/o sob with exertion and chest pain what is next step:
a.thallium stress test
b.dobutamine test
c.ekg
Next step EKG
6.Pt with carbamezapine toxicity what should u monitor
a.cardiac
b.renal
Cardiac
7.what is definitive diagnosis for mi
a.ekg
b.enzyme
c.physical exam
Enzyme
8.cocaine induced htn what will be tx
a.nitropru
b.beta blocer
c.phentolamnine
Phentolamine
9.cocaine induced mi
a.thrombolytic
b.angioplasty
Angioplasty
10.which is not a risk factor for osteoporosis
a.smoking
b.etoh
c.caffinated product
d.white race
e.obesity
Obesity
11. woman on contraceptive > >>> became amenorrheic
a.let her be ameno
b.modify estro(increase)
c.progesterone (lower)?
Likely B
12. A child goes to picnic has redness in arms and legs What the dx:
Poison Ivy
Atopic dermatitis
Irritant contact dermatitis: Just local inflammation of the skin following contact of the skin with a noxious substance. NO immunologic reaction eg; Industrial and household detergents
Allergic contact dermatitis: Delayed type of hypersensitivity..Occurs when an external agent sensitizes T-cells, Poison ivy, poison oak, some metals (nickel), various preservatives in medications, ingredients in rubber industry, agents in finishing process for clothing or other naturally occurring or industry produced chemicals. MKSAP p 16
Atopic dermatitis: Atopy in the skin. Type I hypersensitivity ..Part of generalized atopic reaction. The Ig-E mediated immunity occurs in many parts of the body including the skin.
Having understood the type of hypersensitivity in each dermatitis.., timing here is very important. If the child develops the reactions of erythema and pruritis 24-72 hrs after the return of the picnic, .Poison ivy /allergic contact dermatitis will be choice, If the child develops the symptoms immediately, atopic dermatitis is the choice.
HTN High yield facts
Hypertension Rx
¢ Trial of Lifestyle Change x6-12mos in Pt.'s w/ NO Co-morbid Dz.
““““““““““““““““““““““““““““““““““““““““““““““““““ “
*** 1st LINE DRUGS ***
¢ No Other Dz.
- Diuretic OR ß-blocker
- (Proven to Decr. Mortality)
¢ Hyperthyroidism
- ß-blocker
- (Decreases HyperT3 Sx, also)
¢ DM
- ACE Inh.
- (Proven to Decr Vasc & Kid Dz)
¢ Blacks
- Ca Channel Blocker
¢ Decr. Ejec. Frac.
- ACE Inh.
- (Proven to Decr. Mortality)
¢ MI
- ß-blocker AND ACE Inh.
- (Proven to Decr. Mortality)
¢ Atrial Fibrillation
- Diltiazem (Ca Chan. Blocker)
- (Controls Atrial Rate, also)
¢ Osteoporosis
- Thiazides
- (Decr. Ca Excretion)
¢ Prostatic Hypertrophy
- Alpha-blockers
(Ex.: PRAZOSINâ„¢, TERAZOSINâ„¢)
- (Treats HTN & BPH Concurrently)
HTN *** CONTRAINDICATIONS ***
¢ ß-blockers
- COPD
- due to Bronchospasm
¢ ß-blockers (Relative)
- DM
- due to alteration in insulin/glc homeostasis & blockade of
autonomic response to hypoglycemia
¢ ß-blockers
- Incr. K
- due to risk of Incr.'ing K even higher
¢ ACE Inh.
- Preg.
- due to Teratogenicity
¢ ACE Inh.
- Renal Artery Stenosis (B/l)
- due to precipitation of ARF
¢ ACE Inh.
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
¢ K Sparing Diuretics
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
¢ Diuretics
- Gout
- due to causation of Hyperuricemia
¢ Thiazides
- DM
- due to Hyperglycemia
See page 251 Katzung for uses and side effects of Diuretics.
Immunization Contraindications
No MMR:
¢ if PREG / IC Pt / EGG ALLERGY
¢ OK if HIV+ (Asymp)
No DPT:
¢ if SEIZ / Any NS Dz.
¢ if FEVER > 104° AFTER 1st DOSE
No OPV:
¢ if IC Pt
¢ (Use IPV, which is IV & Killed)
¢ UPDATE:
- Last Polio Inf. in 1979 w/ ~8 cases/yr due to OPV (Live-attenuated)
- As of Jan. 2000, No more OPV. (ie.: IPV is only given)
NB: Live Vaccines
- MMR
- OPV (Replaced w/ IPV)
- Varicella
Oral Contraception Pill (OCP) Contraindications
¢ PE, DVT
¢ Cerebral vascular disease
¢ Coronary artery disease
¢ CA of breast
¢ CA of endometrium
¢ Cholestatic Jaundice in Preg.
¢ Hepatic adenoma
¢ Impaired liver function
¢ Type II hyperlipidemia
¢ Factor V Leiden mutation
¢ Smoker (if > 35yo)
Varicella Vaccine
Live attenuate vaccine
- Given at 12 to 18 months in pt with no previous infection
*< 12 yo, only one injection is given
*>12 yo, two injection is given 1 to 2 months apart
Route of administration
-Subcutaneuosly
Complication:
-Erythema 20-25%
-Varicella < 1%.
WBC Shift
¢ LEFT SHIFT:
- Increased Seg.'d Neutrophils + Bands
- Bacterial
¢ RIGHT SHIFT:
- Increased Lymphocytes
- Viral
Labor Induction (Indications)
¢ Abruption
¢ Chorioamnitis
¢ IUFD
¢ PIH / Pre-eclampsia
¢ PROM
¢ Post-term (42 wks)
¢ Maternal Medical Conditions:
- Diabetes mellitus
- Renal disease
- Chronic pulmonary disease
- Chronic HTN
¢ Fetal Compromise:
- Severe IUGR
- Isoimmunization
Contraindictions to Labour Induction
¢ Vasa/Placenta previa
¢ Transverse fetal lie
¢ Umbilical cord prolapse
¢ Previous uterine surgery
DKA Treatment
**LABS**
¢ SMA-7 / Ketones / ABG / EKG
¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢
**TREATMENT**
1) FLUIDS -> 2L NS (500cc/hr x 4hr), then 250 cc/hr x 2hr
2) INSULIN -> Bolus 10U Reg, then run at 0.1U/kg/hr
¢ Make sure drip is running
3) K -> in 1/2 NS 20-40mEq/L after 1-2L NS
4) Check Glc q1hr (until ** < 250)
5) Once ** < 250, add Dextrose (D5NS) to Insulin drip
6) Turn off drip when HCO3 > 22
¢ ie.: Improvement of Anion Gap (AG)
¢ AG = Na - (HCO3 + Cl) = 140 - (24 + 100) = ~8-16
7) Start SQ Insulin 1-2 hr before stopping Insulin drip
Amenorrhea Work Up:
Remember the definition of Primary Amenorrhea is either 14yo without secondary Sex characteristics OR 16yo without menses yet. Secondary Amenorrhea is NO menses for 6 months OR 3 cycles.
Progesterone Challenge test is needed after Preg Test(neg) / TSH (normal) / Prolactin (normal). If she bleeds with the progesterone, then she's anovulatory (Tx-> Progesterone). If she does not bleed, then test with Estrogen & Progesterone (OCP). If no bleeding still she has scarring in the uterus (Asherman's synd or TB). If bleeding occurs, then do LH/FSH level. If LH/FSH is low then repeat Prolactin level and do a Coned down view of Sella Tursica. She probably has a Prolactinoma (Tx-> Bromocriptine (may breastfeed)). If LH/FSH is normal, then she has Polycystic Ovarian Syndrome (PCO) and treatment is OCP (or Clomiphene if she desires pregnancy now). Testosterone is also high in these patients. If LH/FSH is high, she either has Menopause, Ovarian Failure, Testicular Feminization (46XY) or Turner's Syndrome (XO).
For PCOD LH/FSH ratio is greater than 2:1
Cervical cancer guidelines
ASC-US
-Repeat PAP in 4 mos
-HPV with reapeat PAP
-If (+), then Colpo
ASC-H
-Colpo
AGC
-Colpo + Endocervical Curretings (ECC)
-If >35yo also do Endometrial Biopsy (EMBx)
-If Endometrial cells present, do Colpo + ECC + EMBx
LGSIL
-Colpo +/- ECC
HGSIL
-Colpo with Cervical Biopsy + ECC
Endometrial Cells present
- EMBx if Postmenopausal and NOT on HRT
FACTS:
* If dog and cats bite and escape, dont give prophylaxis until animal acted strangely or there is rabies prevalent in that area
* If wild animals like bat, skunk, foxes, racooons bites and escapes give prophylaxis and vaccine
* If captured or killed animal has rabies or negri bodies give vaccine and prophylaxis
* If kid is bitten by neighbour dog who had all his vaccination just reassure the parents and clean the wound with soap and water and observe the wound..this is my exam q
* If spider bite gives u sloughing, necrosis and burning pain then its brown recluse spider...u have to give tetanus, and if swelling is not down after few h give steroid like dexamethasone
* If spider bites gives u like abdominal cramps and edema then its black widow u need to give calcium gluconate to the pt
* Enteric fever is a reportable disease give cipro for 10 days and check all family members stool for salmonella typhi
* Nodulo cystic acne best is isotrentione, but first check preg test and pt should be on contraceptive when she is on this drug
* To decrease the cong anomalies in babies born to mother with diabetes tight glucose control 01 month before the conception and throughout preg.(.my exam qs)
* Pt udergoing cabg, u see during transfusion...that blood is coming from all punctures or iv site , this is most likely to transfusion reaction and this is the only thing plus hypotenton is present when pt is under anesthesia to give u a clue that pt is having reaction from transfusion...
* U will c many qs ...in which u have to give iv f and mannitol in transfusion reaction,in crush injuries with rhabdo like pics...so think of compartment syndrome and faciotomy.....in all those cases where s/s r persent in mva cases
* Just remember supra condylar fx is a surgical emergency u have to do orif asap...
* Adult fall on outstretched hand is colles fx ...close reduction and long arm cast
* Kids fall on outstretched hand radial head subluxation.....
* Decelration injuries...aortic rupture c/o tamponade
* Fall from height on ur feet is calcaneus fx and spinal fx
* Ct scan with contrast for all type of kidney stones and rcc
if stone is more than .5 cm and at pelvic ureteral junction removed with basket through cystoscopy
no eswl when there is infection going on with kidney stone in that cases urology asap for nephrostomy tube and stent placement
* Mom interfere with lp and u think u need it to make sure that kid has meningitis do it bcz its a medcial emergecy dont fall for her choice ethic commetee, court order, talk to attending ,talk to risk management ist...(this was also my exam q)
* Stop both heparin and warfarin in HIT SYNDROME..use liprudine...u must d/c heparin if platelets r less than 50% from base line
* Dyslipidimia and hypertention in a pt he needs alpha antagonist like pt with bph
* Pt has psa of 10 or more go for transrectal biopsy..
* Kid or 50 yr with painles hematuria or microscopic ist thingis always ua...
* If Fna is eqvivocal go for open biopsy
* Any cystic or fluctuant mass except with ocp need fna...ocp is due to estrogen content it will regress after u d/c the pills
* Any mental retarded pt needed contraception ans is iud,or norplant
* The most common side effect after depoprovera norplant(my exam q)...is intermittant spotting..d/c if its not going away after 3-4 wks..
* The most common side effect from estrogen pill is nausea/wt gain
* Chf and pul embolism, asthma, mitral stenosis, asthma, pul edema increase dlco....intestitial lung dec and emphesema dec dlco like sarcoidosis, bronchitis is with normal dlco...
* D/c asp 1 wk bfore surgery
* D/c coumadin 48 h b4 surgery
* D/c heparin 4 h b4 surgery
* D/c antidepressent after 9month of depression free pd..some book say s 6 months
* D/c...antiepileptic after 2 yr of seizure free period..
* Rolaxifen is best choice if women has h/o breast ca ....but it can not protect endometrial ca....
* The most cc of death from ca is lung
* The most cc of disorder in future kids with adhd..is conduct /antisocial disorder
Recalls:
If you are asked about the management of the spine metastaisis ==> The emergent treatment should be dexamethasone i.v. This is followed by spine radiation. The same thing also applies for brain metastasis.
This is an old recall...
If you are asked about the treatment of a cancer ==> Know which cancer is chemo- or radio-sensitive.
For example, solitary nodule of small cell carcinoma of the lung is treated with chemotherapy as the small cell carcinoma is chemo-sensitive.
Squamous cell carcinoma is radio-resistant. So, chemotherapy is the choice...and so on. (All these are old recalls).
Nerve block doesn't solve the whole problem..it will only relieves the pain but will not relieves the compression.
Here is another old recall..
70 patient with skin squamous cell carcinoma on his forearm. Refused surgicaL excision. The alternative treatment is:
a-Chemo
b-Radio
c-Laser
70 patient with irresectable laryngeal carcinoma.
Management:
a-Chemo
b-Radio
c-Surgery
d-Combination of chemo/radio
Q: Young patient with signs and symptoms of appendicitis
most unfavorible sign is rebound tenderness or diffuse guarding?
Answer is diffuse guarding for peritonitis, rebound tenderness for localized
Q: Any association with Breast implant and CTS
Answer yes 40%
CSS: DKA
1st step:
do PE
2nd step:
O2 inhalation, pulse ox stat/cont, iv access, floey's if unconcious, NS bolus, NS coninous drip, stat finger glucose, ser alcolhol, serum acetaminophen, serum amylase/lipase, bHCG, U/a, urine toxicology screen, ABG stat. EKG
3rd step :
serum osmolality
serum electrolytes
serum ketones
" mg/ph
Insulin bolus 15 units regular
reg insulin infusion 8 to 10 units
abg
shift to icu:
NPO
strict input /out put control
cardiac monitor
BMP Q 4 hrs, Q 8 HRS, Q day
ABG Q 2hrs * 2
after 4 hrs change fluid to 1/2 NS
add K 20 to 30 meq
check stat glucose if betwene 250 to 300 change the fluid to D5/w continous
shift to floor
if infection suspected give iv antibiotics
send cultures for urine and blood and sputum
cxr etc.
fasting lipid profile
Discharge :
d/c iv insulin
start SQ insulin
diabetic diet
diabetic counciling
foot care
opthalmology consult
strict home glucose monitoring
family and patient education
stop smoking/alcohol
safe sex
seat belts
regular exercise
low fat diet
discharge with follow up in 2 wkz
CSS: Narcotic Overdose
Most of the pts are in respiratory distress or unconcious...so we'll go with basics of trauma
A: airway suction, o2 inhalation, pulse ox stat n continous
B: intubate if po2 is less than 55 or pco2 is more than 50 , or pt is unconcious
C: iv access, foleys. cardiac monitor, stat glucose
D: Iv thiamine, 50% dextrose, nalaxone...one time boluses
PE focused
Diag evaluation:
Ekg, cxr, serum alcohol, serum acetaminophen, urine analysis, urine toxicology, abg, stat glucose, lft, pt /ptt, serum ck
Initial management:
NG tube gastric lavage ( within 1hr)
charcoal
IV nalaxone continous ( do not give if the pt is opiod dependent )
review hx n physical
Shift to ICU:
NPO
D/c intubation
D/c nalaxone
D/c NG tube
Continue cardaic monitr n pulse ox for 24 hrs
Serum electrolytes
Educate family n patient:
Psych consult
d/c IV access
D/c foleys
shift to psych ward
give antidepresants if needed
suicidal evaluation n councilin
regular diet
exercise prog
stop amokin/alcohol
safe sex
seat belts
discharge
CSS TIA
routine physical
evaluation :
cbc, bmp, ekg, CT scan
ct is usually -ive within 24 hrs
admit to ward:
vitals every 12 hrs
continue home medications
ambulation
diabetic diet if hx suggest
doppler echocardiogram
tele monitoring
accu checks bid
carotid doppler
oral aspirin continue
MRI/A of brain and neck DWI
results:
if > 70 % stenosis
take surgical consult for elective CEA
other wise manage on medical basis ...aspirin is the drug
discharge with advices:
stop smoking/limit alcohol
BP control ( diet exercise meds)
diabetes control ( do )
pt education for drug compliance
safe sex, seat belt, injury prevention, regular exercise, low fate diet
fasting lipids
follow up after 4 wkz
OB-GYN FACTS:
If it is only spotting____________________ reassure
if it is heavy < 35 years __________________________increase estrogen
if it is heavy > 35 years_____________Biopsy
you can add the following
acne + OCP _______ decrease progesterone
depression+ OCP _______ give SSRI
amenorhea+ OCP
urine pregnancy test if -ve
1) reassure
2) if she wants menstruation_____________ increase estrogen.
COMMON SIDE-EFFECTS of medications....
1. T****done= priapism
2. verapamil= constipation
3. ACEIs= angio edema, rash, Dry Cough
4. Clopidogrol-- HUS,TTP
6. Indinavir -- Renal Stone
7. AZT -- Bone Marrow Supp
8. Heparin - Thrombocytopenia
9. INH - Prepheral Neuropathy
10. Hydralazine- Lupus Like Syndrome(also Procainamide)
11. Ethambutol- loss of red green visual acuity
12. Pyrazinamide- Liver toxicity
13. Carbamazapine- SIADH
14. Lithium- Hypothyroidism,wt gain, Flair up of Psoriasis, Tremor, Acne,DI
15. Demiclocycline-DI
16. Aminoglycosides- Ototoxicity and nephrotoxicity
17. Bleomycin- Pulmonary fibrosis
18. Doxorubicin and Daunorubicin-Cardiotoxicity
19. Cyclophosphamide- Hemorrhagic cystitis
20. Vincristine-Peripheral neuropathy
21. Metronidazole-Disufiram like reaction and peripheral neuropathy
22. Niacin- flushing and abnorman LFT's
23. HMG coa (statins- myositis HIGH AST ALT( check lft's often )
24. Thiazide diuretics- hypercalcemia .. can cause GOUT
25. metformin- anorexia wt loss and lactic acidosis
26. imepenem- seizures
27. rifampicin= color change urine tears skin orange color
28. NSAIDs- gastritis, nephrotoxicity, can increase BP
29. B-Blocker- Cover Hypoglycemia Symptoms,
30. Clozapine- Bone Marrow Supp
31. Amitriptyline- Convultion, Cardiac arrythmia,Coma
32. steroids- avascular necrosis, edema. osteoporosis, poor wound healing
33. aspirin.... ototoxicity and resp alkalosis/ metabolic acidosis
34. Quinidine- diarrhea, thromocytopenia
35. Acarbose- flatuence
36.methimazole- agranlocytosis, aplastic anemia
37)Prazocin-- First Dose Syncope(give the first dose in your office)
38)Amilodarone -- Pul Fibrosis
39)Chlorpropamide -- SIADH
40)Colchicine -- DI
41)Nitrate Drugs+ Viagra(sildenafil)---> Sudden Death
42)Ethosuximide -- GI upset
43)Tolcapone --- Hepatotoxicity
44)Thioridazine --- Retinal Deposits, Torsade
45)Vancomycin --- "Red Man" Syndrome
46)Chloramphenicol--- "Gray Baby" Syndrome
47)Cimetidine--- Genycomastia
48)Ketoconazole-- Gynecomastia
49)Protease Inhibitors(in General)-- Hyperglycemia, Hyperlipidemia
50)Cisapride---Torsade
51)Methotrexate(long Term)--- Liver Fibrosis
52)Asparaginase--- Pancreatitis
53)Cyclosporine--- Nephrotoxicity
Bites quick points (Cat bites > humans > dogs) Also look CMDT 1255
* If stray dog bites to some one give both Ig and vaccine....make sure 1/2 of Ig is sprinkled over the wound and half in the buttocks in kids and in adult in deltoid muscle...and make sure Ig and vaccine should be on separate sites of injection...
* If neighbours dog bites which has all his vaccination upto date then just reassure the victim and clean with soap and water....nothing to worry about
* If human bites to another human (Recall) a man comes with a bite wound that result in swelling of his whole forearm...and on qustioning he admitted that his wife bit him.. what u will do....since human bites r worse than all other because of aerobic and anaerobic bacteria in one™s mouth need special attention and since it was such an extensive lesion so we have to admit him and give him iv antibiotic....augmentin is good as out pt and inpatient u can give ampicillin, iv and clindamycin.
* If cat bites, ... if extensive wound then give ampicillin or augmentin
* If dog bites same augmentin or amp...(domestic)
* Scorpion bites ..... brown recluse ...will cause stinging sensation, sloughing necrosis need dexamethasone and tetanus....
* If black widow bites then u will have abdominal cramps and rigidity u have to give calcium gluconate ...
* A mom is worried that baby is so lethargic not taking bottle and she is not having any fever just dilated pupil on exam....and ans was did u give him honey lately
Pointers
Three vaccine can induce anaphylactic reactions in egg-allergic people: INFLUENZA, YELLOW-FEVER and MMR.
The MMR and yellow fever still can be given in egg allergic people.
Varicella zoster vaccine is given at age of 1 year! (with the MMR).
Influenza vaccine ==> all people > 50 YEARLY
Penumococcal vaccine ==> for adults above 65 with chronic diseases/immunocompromised
MALE HOMOSEXUAL..What vaccines you give beside Hepatitis B? Hepatitis A !!! (becuase hepatitis A transmits through the faeces like feco-oral or feco-mucosal route...Male homosexual are thus subject to Hepatitis A).
60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows hyperplastic polyp..next step:
a-colonoscopy
b-do nothing
The answer is do nothing..Itis hyperplastic polyp..
60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows tubular adenoma polyp..next step:
a-colonoscopy
b-do nothing
The answer is colonoscopy...It is tubular adenoma..It has risk of malignancy. So, you have to make sure that there are no more tubular adenoma polyps..sigmoidoscopy screens the descending colon only and doesn't reach the rest of the colon..so, colonoscopy should be the next step.
PAP shows ASCUS ==> Repeat test in 4-6 months
LGSIL/HGSIL on PAP ==> colposcopy and followed by cervical biopsy.
ITP ==> steroids are the first line. IVIG is the second line.
TTP/Gullian Barre ==> plasmapheresis
When the patient is in severe depression/suicidal tendency, he is not compotent:
30 year old man found on the floor with empty bottle of valium. A suicidal note was found saying that he wants to die peacefully and doesnot want any heroic procedures to save his life. Next step:
a-Flumazine i.v
b-Intubate and move to the ICU.
Choose B
For any drug overdose, do not choose the option of the anti-dote/the antagonist..remove the drug first by charcot/gastric lavage unless contraindicated.
Acetaminophin overdose..next step:
a-N-acetylcystiene iv
b-gastric lavage
Choose B
Don't afraid to give morphine for the pain management in patients with terminal stage of their cancers:
..but it should be under monitoring to prevent respiratory depression!!
75 patient with pacreatic cancer and severe back pain ..next step:
a-morphine intrathecal
b-morphine i.v every 3 hours
c-morphine i.v on needed basis
d-morphine i.v in a monitored bed.
Jump to D
Emancipated minor is the minor who lives alone/married/works
Pregnant minors are not emancipated but have the excetion of signing the consents!
A 16 year pregnant girl need Cesearan section for delivery ..who signs the consent?
a-In most states, she is emancipated minor.
b-In most states, she can sign the consent
Point your arrow to B
Jehovah's witness refuses blood transfuion..His Bp is 50/0..next step:
a-do nothing
b-iv fluids
Respect the autonomy but tries to do any supportive measure outside the conflict!! so jump to B
Do not respect the patient's wishes in organ donation if they parents refuse the donation even if he has the organ donation card! This is the only exception for the patient's autonomy after his brain death.
The spouse is the next after the patient (not his parents or siblings). Ask the wife for any consents if there is no guardian or advance directive!!
Treat keloid by intralesional steroids. The same thing for alopecia aerata (NOT topical!!)
Emergent reversal for warafin overdose is FFP (not Vit K) while emergent reversal of heparin is protamine sulphate (not FFP!!..The FFP is c.i.)
If the Q is clueless..choose the most common
70 yo patient with weight loss...next step; CXR (to exclude lung cancer which is the most common malignancy)
70 yo patient with fatigue...CBC (to detect iron deificency anemia..followed by colonoscopy becuase lower GI bleeding is the most common cause of iron deficiency in the US..NOT NUTRITIONAL CAUSE!)
EFFECTs of OCP:
HDL LDL Glucose TG
a low high high high
b high low high normal
c high high normal normal
d normal normal normal normal
e normal normal high high and high total cholesterol
The answer is E why?
Remember that estrogen increases HDL but decreases LDL
Progetreone decreases HDL and increases LDL
Their combined effects is nill!!keeping the levels of LDL and HDL normal
TG is elevated and impaired glucose tolerance!!
Patients with adenomyosis/endometriosis/leiomyomata uteri (refused surgery)..What is the medical treat? OCP. Remember all these cases are caused by state of hyperestrogenism..but you still have to give OCP..not progestrone only.
Patient with rheumatoid arithritis...refused to take steroids..The alternative drug should be: METHOTREXATE
Patient with SLE...refused to take steroids..The alternative drug should be: CYLCOPHOSMAIDE
Patient with Crohn's disease..The first line is s-ASA with metronidazole or cirpofloxacin...Steroids are SECOND LINE..AZATHIOPRINE or ^-Mercaptopurine are THIRD line. INFLXIMAB is the last line OR for the treatment of FISTULAS!!
Treatment of IBS (Irritable bowel syndrome)?? FIBER+ ANTICHOLINERGIC DRUGS like hyoscine
GERD ==> First line is therapeutic trial of H2 blockers , followed by Proton-pump inhibitors. If fails, go to 24-hr esophageal PH monitoring. Don't forget the life style modification before any pharmacologic therapy.
The following vaccinations should not be given during pregnancy becuase they are live attenuated virus vaccines:
1-Mumps/Measles/Rubella
2-Yellow fever
3-Varicella
REMEMBER>>>
A prgenant in her 2nd trimester exposed to a child with Varicella one day age. You checked her serum for varicella antibodies titre and it was negative..Give VZV ig (not vaccine) ..It should be given within 96 hours of exposure.
The mother ask you: Does the VZIG protect my fetus againts infection? NO. VZIG is given to prevent MATERNAL NOT CONGENITAL/FETAL infection!. The congenital varicella syndrome results from exposure during the first 16 weeks of pregnancy.
These vaccines can be safely given and their indications are not aletred by pregnancy:
1-Pneumococcus (polysaccharide)
2-Meningococcus (polysaccharide)
3-Rabies (killed virus)
4-Influenza (inactivated virus)
5-Hepatitis B (purified surface antigen)
6-Hepatitis A
7-Tetanus-Diphtheria (toxoid)
Pictures
pic of a kid with arm and mouth vesicular lesion i put cockscakie virus A....bcz it was hand mouth fooot diease kind of pic...
kid with the xray chest with pnumo one side and bowel other..cong diaphragmatic h
man with apple core lesion..colorectal ca
a fib ...ekg
3rd degree heart block
inf mi...st elevation in typical leads
pic of scabies
pic of pudohyphe
pic of shingles with eye involvement
pic of nodular cystic acne
ct of head with lenticualr mass .....epiduarl hematomaa.
achlasia....pic
Hematology Pointers
1) THE main DIFFIRENCE between TTP and HUS is lack of Neurological involvement in HUS....otherwise same as both have inc BUN/CRETINE both have INC LDH both ha THROMBOCYTOPENIA both have MICROANGIOPATHIC HEMOLYTIC anemia......both have SHISTOCYTES on periphral bloood smear...v imp for exammmm REMMBER BOTH HAVE NORMAL COAG AND NORMAL OTHER CELL LINES...
2)INC PTT IN CLASSIC HEMOPHILIA AND ITS XLINKED...TREAT WITH FACTOR 8 AND IF IT DOESNT CORRECT PTT THEN IT MEANS THAT PT HAVE ANTIBODIES AGAINST FACTOR 8 WHICH CAN OCCUR IN 10% OF TH E CASES AND TEST THIS WITH MIXING STUDY MEANING WHEN U WILL MIX PTS BLOOOD WITH FFP OR NORMAL BLOOOD NOTHING WILL CORRECT PTT IT WILL STILL INC ...TRETAMENT OF THIS WILL B CYCLOPHOSPHAMDIE ALONG WITH PREDNISONE
3)MOST COMMON CONGENITAL BLEEDING PROB IS WITH VON VILLIBRAND DIASES ITS AUTOSOAML DOMINENT...AND IT WILL INC BLEEDING TIME..INMILD CASES U CAN GIVE PT DESPOPRESSIN ,,,AND IN SEVER CASES CRYO WILL HELP...DONT GIVE DESMO IN SEVER CASES IT WILL MAKE IT WORSE..
4)DESMOPRESSINIS ALSO GOOOD FOR MILD CLASSIC HEMOPHILIA A...
5)IN ITP THERE WILL B MEGAKARYOCYTES ONPERIPHRAL BLOOOD SMEAR BCZ THERE IS INC RATE OF DISTRUCTION OF PLATELETS AND DEC FORMATION OF PLATELETS DUE TO AUTOIMMUNE PHENOMENON, ANTPLATELET IgG ANTOBODIES DESTRY ALL PLATESLETS SO THESE PTS R MORE PRONE TO HAV EMUCOSAL BLEEDING LIKE THEY WILL HAV E MENORHAGIA,OR EPISTAXIS.....FORTREATMENT IST TRY WITH PREDNISONE IT HELPS ALOT BY INC THE PLATELETS itworks by dec the affinity of platelets to activated macrophagesin th e spleen and steroid also dec the binding of autoantobodies toplatelets....tretament always start with low dose of platelets it will inc th eplatelets numb but if u hav eto keep thept on prednisoneor u hav eto inc the dose then do splenectomyis the definate treatmentofitp if they ask u in step 3,,,,but make sure that u give pnumovac and h influenza vac 2 wk prior to splenectomy,other drugs that use when platelets r low and causing bleeding or if pt is going for urgent surgery is ivig..its v expensive so only reserve for life thretening bleeders and its always given slow and never in ppl who have igA defiency bc zthey will die from anaphylaxis...another imp point is that when pt cant go for splenectomy or cantbon prednisone or cant afford 5 k dollerivig give him danazol,or rh gam its helpful tooo...som e tried inflaximab group its helpful but infectionis the side efefct....so watch for that...if u c ccs in exam which most of u willl..... just treta as an out pt with prednisone and call pt in 2 wks and when platelets above 50 taper prednisone and advise for no contact sport..and pt teaching about diease ...v imp...
6)dic is dif from sub acute dic in thatpttis normal and fibrinogenis normal...and remmber in dic treat the underlying cause...
never give aminocaproic acid in dic without heparin bc zit cause severe thrombosis...
7)liver disease have both prolong pt and ptt but fibrinogen level is normal...ff will correct th ebleeding..
8)the dif bet the vitamin k deficiency and dic is noraml platelets and normal fibrinogen vit k will help....
9)if platelet r 10 k still u can perform splenectomy so never ever give platelets in itp when its in exam..bcz it will b destryed by the antibodies...
10)inmy exam they ask that baby had circumcison and lost lots of bloood on lab hisptt was 100 an his bleedint time was 12....and mom said his uncle has sam e prob he bled in suregry and after surgery...whatu will do u will check factor 8and 9...its dic,its ttp,its itpand blabla...
11)remmber factor x11 deficiney u wont have bleeding just inc ptt they canhave surgery without any prob its also callled hadgman factor deficiency..
12) ifpt is having factor 13 deficiency.u will hav e normal coag but still u will hav e bleeding....so remmebr these clues they will help u to exclude wrong choices in exam...
13)lupus anticoagulant antibodies is v imp subjects so u have to read about it.....its igG or igM antobodies taht produce aprolonged pttby binding to phospholipids,its present in 10% pt of sle and is characterized by recurrent abortion,and thrombosis .there is no bleeding unless second ry factor is presenttaht cause bleeding,the prolonged ptt will failed to correct with mixing study so that is a clue for diag....the russell viper venum isgood and senstive assey and is diag of lupus anticoagulant...antiphpjolipid and lupus anticoagulant will cause the false positive vdrl...u can suspect lupus anticoagulant when inc ptt but no bleeding and vdrl is in and anticardiolipid and natiphospholipid positive...predison is th ebest treatment and give heparin if thrombosis is suspected....
14)autologous bloood can b given to pt for surgery and it can b stored for upto 35 days...it dec the chance of infection and reaction..
15)i pack of rbc pack can raise the hct by 3-4%and prbc is used to raise hct ...not the whole blood that is reserved for sever hypovolemic pt...
16) dont transfuse awake juhuwa witness against his will but for a kid go ahead and transfuse if urgent or in nonurgent situation just tak e court oreder...ifkid belongs to juhuwa witness
17)always remmber when ever kid is in the womb mom will give consent for every thing evenif she is competent and refusing for csection and endangering her baby thats fine u just listen to her an d respect her wish..but as soon as she deliver she has no longer authority if child lif eis in danger....but for non urgent cases we stilll need her consent even if she is in jail or drug addict .....
18)febrile bloood transusion reaction pt need leukopooor bloood
19)for graft verses host reaction u need to give iiridiated bloood next time..
20)HIT need that u d/d heparin and coumadin both and start with leupridine...inc risk of thrombosis with the HIT...plez read more from wash manual ....21)...in cases of hemoglobuburia weather its due to rhabdoor bloodo transfusion reaction give vigrous hydration with n/s and mannito or lasix...so hemoglonuria will not damage kidney tubule....bcz atn will cause rf sooon..if will not go aggressive hydration v imp for exam....
21)ist day jaundance is always due to abo imcompatibility
22) if husband is onegative and wife is tooo no prob baby will b normal..(.cam e in my exam..)..case senario was that a gal is pregnantand her rh is negative and her b fd is rh positive and they tell s u in sep setting that this babyis not my b fd but my ex and he is rh negative what u will tell her....
23)delayed transfusion reaction is due to duffy,kell and c,e loci of rh system..they cause delayed reaction after 8 to10 days of transfusion..
.
24)i unit of platelet will inc 5 k of platelets usually we giv e 6 pack..
25)fever chillsl and sever backach eis due to heamolytic reaction,stop transfusion and give ns bolus and lasix..flush th ekid so no damage to tubule and no renal failure other prob is dic....
26)kid if they have dirrhea due to slmonella sheggella or due to e coli they will most like ly have hus so keep that inmind in exam they ask that akid ate hamburger while his father was stilll barb qing...an dkid has now fever and dec inc bun/cretinine .. and thrombocytopenia and in c ldh itS HUS
27)WALDSTROME MACROGLOBUNEMAI IS DUE TOMONOCLONAL IGm paraprotein and in MM ITS DUE TO IgG
THE MAIN DIFIS THAT NO LYTIC BONE LESION IN THE WALDSTROME ...the cause of death in mm is due to infection from streptp pnumoni and h infuenza...
28)hairy cell leukia is having pancytopenia,splenomegalyand hairy celll on p blood smear and bm biopsy
Isolation from School/Day Care :
1) Chicken pox: until all lesions have dried and crusted
2) Scarlet fever: until atleast 24 hrs after appropriate antibiotics
3) Rubella: 7 days after onset of rash
4) Measles: until 4 days after onset of rash
5) Mumps: return to school 9 days after appearance of parotitis
6) Strep pharyngitis: until 24hrs after appropriate antibiotics
7) Parvovirus B19 (5th disease): until appearance of rash [pregnant pt should be evaluated]
Rota virus: until stool is contained by diapers or toilet use
Factitious Hyperthyroidism:
Pt is a nurse with symptoms of hyperthyroidism - Graves Dz vs. Factitious hyperthyroidism distinguished via :
a. TSH
b. FT4 concentration
c. T3 resin uptake
d. TSI (thyroid peroxidase antibody)
Discussion: In factitious hyperthyroidism following labs are seen:
-Thyroglobulin level is low or undetectable
-RAIU decrease
-Low TSH
-T3 and T4 increase.
If only T4 is ingested....Serum T4 could be low. (low TSH)
But in graves there is Antibody.......In factitious No
Recalls:
Q: Infants begin to differentiate their mom™s face and voice at
A. 1 WEEK OF AGE
B. 8 week of age
C. 12 weeks of age
D. 7 months of age
Ans: 1 week of age
Q: Prognostic Sign in Bell™s Palsy is
A. Lack of Parotid gland swelling
B. The presence of incomplete paralysis after 5 days
C. The presence of only a few herpetic vesicles.
D. A lack of motor involvement of tongue
Ans: The presence of incomplete paralysis after 5 days
Q: A patient recovering from Meperidine addiction sustains traumatic injury. What therapeutic modality is appropriate:
A. Accupunture and cold packs
B. Adequate dose of morphine
C. Trans-cutaneous electrical stimulation
D. NSAID
Ans: Adequate dose of morphine
Q: Which vaccine is contraindicated in a 4 year old child receiving immunosuppressive therapy?
a)HAV
b)Acellular pertussis
c)IPV
d)varicella vaccine
Ans: Varicella vaccine
Q: A patient with chronic malabsorption presented with absent tendon reflexes, ataxia, loss of pain sensation, ophthalmoplagia, and anemia. He is suffering from which of the followin vitamin deficiency?
a) vit. A
b) vit. B12
c) vit. C
d) vit. D
e) vit. E
Ans: Vit E
Neurologic findings follow a pattern of progression that can be divided into early and late stages.
Early findings include hyporeflexia, decreased proprioception, decreased vibratory sense, distal muscle weakness, nyctalopia (night blindness), and normal cognition.
With continued deficiency, neurologic symptoms progress and patients can develop truncal and limb ataxia and diffuse muscle weakness. Further eye problems may develop, including limited upward-gaze nystagmus and dissociated nystagmus.
Late manifestations include areflexia, loss of proprioception and vibratory sense, dysphagia and dysarthria, cardiac arrhythmias, ophthalmoplegia, and possible blindness. Cognition may be affected in later stages, and dementia can occur.
Q: Which one of the following vitamin deficiency causes squamous metaplasia of the airway, pulmonary infection, renal stones, immunodeficiency, and it is used as a supplemental treatment in some patients with measles?
a) vit. A
b)vit. B
c)vit. C
d)vit. D
Ans: Vit A
Q: 70 yr old male experiencing attacks of "whirling sensations", nausea, diplopia, dysarthria and tingling of lops. Episodes occur several times a day and are so severe,he collapses and becomes immobile.
A. Panic attacks.
B. Benign positional vertigo.
C. Vertebro-basilar insufficiency
D. Cataplexy
Ans: Vertebro-basilar insufficiency
Q: Alcohol dependent on Disulfiram reports recurrent craving.
Which medication is suitable?.
A. Paroxitine
B. Carbamazepine
C. Naltrexone
D. Propanolol
Ans: Naltrexone
Q: Late stage of HIV infection, the most common neurologic complication.
A. Cytomegalovirus encephalitis
B. HIV polyneuritis
C. AIDS dementia complex.
D. Cryptococcal menigitis
Ans: AIDS dementia complex
Q: 21 yr old female with lethargy, restlesness, confusion, diaphoresis, tremors and myoclonic jerks. She is receiving trearment for depression and does not know the name of pill. What is it?
A. Tyramine reaction.
B. Anticholenergic reaction.
C. Serotonin syndrome.
D. Neuroleptic malignant syndrome.
Ans: Serotonin syndrome
Q: Evidence is accumulated that ADHD is connected to:
a) Dopamine
b) serotonin
c) melanin
d) estrogen
Ans: Dopamine
Q: Cause of death in hospitalized elderly:
a) UTI
b) Pneumonia
Ans: Pneumonia. Most common infection is UTI
Q: A 29-year-old woman presents with an exacerbation of her asthma. She is 11 weeks pregnant. She has mild intermittent asthma and usually takes a b-agonist as needed. She has one 4-year-old child who is in day care and has had a recent upper respiratory tract infection. She has a dry cough, clear nasal discharge, myalgias, and fatigue.
On physical examination, she is talking in full sentences and has normal tympanic membranes, mildly erythematous oropharynx without exudates, no adenopathy; she has positive wheezing bilaterally. The peak flow is 300 mL; her usual result is 390 mL. Pulse oximetry is 93% on room air.
Which of the following is indicated in the management of this patient?
(A) Amoxicillin
(B) Theophylline
© Prednisone
(D) Montelukast
(E) Flunisolide
A: Answer: E Flunisolide
Manage asthma in a pregnant patient
Treatment principles for asthma in the nonpregnant patient apply also to the pregnant patient. She has mild intermittent asthma with an exacerbation, for which therapy with an inhaled glucocorticoid is an appropriate choice. Use of inhaled glucocorticoids is safe in pregnancy.
Q: What is drug of choice pt with HTN and DM II but no proteinuria
A: Inhibition of the renin“angiotensin system with an ACE inhibitor or angiotensin II“receptor antagonist is warranted to decrease both blood pressure and albuminuria; the dose should be titrated upward to the moderate or high range, as tolerated, to achieve a systolic pressure below 130 mm Hg and a diastolic pressure below 80 mm Hg. Although data from clinical trials provide stronger support for the use of angiotensin II“receptor antagonists than for the use of other agents in patients with type 2 diabetes and microalbuminuria or macroalbuminuria, in the absence of a direct comparison of the two strategies, we consider either of these classes of medication to be a reasonable first choice. Serum potassium and creatinine should be checked in all patients seven days after the initiation of treatment with drugs that block the renin“angiotensin system and after any increase in the dose of such drugs. A beta-blocker or diuretic ” or if these agents are inadequate, a nondihydropyridine calcium-channel blocker ” should be added if ACE inhibitors or angiotensin II“receptor antagonists are insufficient to maintain blood pressure in the desired range . We consider adding dihydropyridine calcium-channel blockers or alpha-blockers only when the target for blood pressure is not met with the use of these other approaches
-review article from NEJM
Q: Q:
ileojejunum bypass, diarrhea, what kind of fluid you give?
A: choice is TPN, BUT normal saline+calcium and magnasium replacement
Q:
75 y/o male constipation, no other abnormalities, what is most likely cause
A:
Constipation is seen in 30% of elderly.
It's usually due:
-Declined or impaired general health status
-Drugs: Verapamil
- diminished mobility and physical activity
Treatment: Bowel training, exercise, high fiber diet and increase fluid intake
Pharmacologic treatment: Bulk laxative, emolient laxatives, hyperosmalar laxatives
Renal
Q:
post mva suspect bladder trauma, most sensitive exam
a ct
b u/s
c peritoneal lavage
d kub
A:
Preferred Examination: Retrograde cystogram, performed after urethrogram, was considered the criterion standard for evaluation of bladder trauma. However, in recent years, enthusiasm has grown for CT cystography for proper diagnosis. Initial studies were not indicative of CT reliability when retrograde contrast was not used. However, contemporary studies have overwhelmingly demonstrated both sensitivity and accuracy, provided that adequate bladder distention with contrast material is achieved prior to performing the study with at least 300-400 mL of contrast.
Ultrasound has never been sensitive or specific enough to be useful for evaluation of bladder rupture.
Even in this article it is CT Cystography. So I think rather than choosing CT, cystography is a better choice
Other said: also emed. Most patients have multiple injuries and require abdominal or pelvic CT scans as part of their trauma evaluation. This does not preclude obtaining a separate contrast cystogram, since a CT scan of the pelvis using intravenous contrast alone is an unreliable study for bladder rupture.
A properly performed cystogram consists of an initial kidney-ureter-bladder (KUB), followed by anteroposterior (AP) and oblique views of the bladder filled with contrast, plus another AP film obtained after drainage. The following procedure is recommended:
So kub first, if cystogram then it is the answer, ct will not be the intial as pt will be too sick and pelvic # need more er management first.
Q: Nausea, vomiting taking digoxin, stable, k+6.0
a) give ca gluconate
b) digiband
c) take digoxin levels
A: Digiband see CMDT 1574
Q: Q:
A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
1.Increase the warfarin dose to bring the INR into therapeutic range
2.Switch to dicumarol
3.Interrupt the inferior vena cava with a filter
4.Discontinue warfarin and begin heparin at a therapeutic dose
5.Discontinue warfarin and begin thrombolytic therapy
Explanation
Answer: 4
This 50 year old man has suffered a recurrent venous thrombosis, most likely from suboptimal prophylactic anticoagulation. The target INR for warfarin anticoagulation to prevent recurrent thromboembolism is 2.0-3.0. When a new thrombosis is diagnosed, therapeutic doses of heparin must be initiated. Simply increasing the warfarin dose to bring the INR into therapeutic range is inadequate, because warfarin is used for prophylaxis only, rather than for the treatment of acute thrombosis. For the same reason, switching to a different anticoagulant like dicumarol would be ineffective. After starting up heparin he should be restarted at a higher dose of warfarin.
Interruption of the inferior vena cava with a filter is primarily indicated only for patients in whom anticoagulation is contraindicated or in whom thrombosis has recurred despite adequate prophylactic anticoagulation. Neither of these considerations applies to this patient.
Thrombolytic therapy is not necessary in most case of DVT of the leg. This mode of therapy can be considered in patients with extensive venous thrombosis, particularly involving extension into the inferior vena cava, in order to prevent long-term postphlebetic complications.
Q:
The method of choice for initial evaluation of bone involvement in patients with multiple myeloma is.
A - Technetium-99m bone scanning
B - Conventional roentgenograms
C - CT-scanning
D - MRI of the skeleton
E - None of the above
A: Skeletal series
Perform a complete skeletal series at diagnosis, including the skull (a very common site of bone lesions in multiple myeloma), the long bones (looking for impending fractures), and the spine.
Diffuse osteopenia may suggest myelomatous involvement before discrete lytic lesions are apparent.
The findings on this evaluation may be used to identify impending pathologic fractures, allowing physicians the opportunity to repair debilities and prevent further morbidity.
Do not use bone scans to evaluate myeloma. Cytokines secreted by myeloma cells suppress osteoblast activity; therefore, no increased uptake is observed.
MRI scan
Findings on MRI scans of the vertebrae ofte
INJURIES TO ELBOW
1. Lateral Epicondylitis (tennis elbow). A very common inflammatory process of the extensor origin of the lateral epicondyle. May be secondary to overuse/repetitive use. Pain at the lateral epicondyle, with referred pain to the extensor surface of the forearm is typical. The pain is exacerbated by resisted extension of the wrist or fingers. Treatment includes avoiding exacerbating activities, NSAIDs, and placing a constrictive "tennis elbow" band just distal from the elbow. Occasionally immobilization of the wrist in a volar splint is required. Local steroid injection or orthopedic referral may be advised in recalcitrant cases.
2. Medial Epicondylitis. This results from repeated flexion activities of the wrist and fingers. Pain is at the medial epicondyle and exacerbated by resistant flexion of the fingers. Treatment is the same as that of lateral epicondylitis.
3. Radial Head Subluxation (nursemaid™s elbow).
a. The mechanism is a sudden pull on the extended pronated elbow of a child less than 4 years of age (for example, when one picks up a child by the forearm or swings the child). The child holds his arm in pronation and usually refuses to move it with pain on supination and palpation of the radial head.
b. Although radiographic findings are usually normal, one must be sure to rule out undisplaced supracondylar fracture. Frequently, the subluxation spontaneously reduces from x-*** positioning.
c. Treatment is firm supination of the forearm, flexing the elbow gently to 90 degrees with pressure over the radial head. Reduction is achieved with a palpable click over the radial head, and the pain is immediately relieved. The patient should resume full activity within several minutes of reduction although some are hesitant. It may take an hour or so to resume full activity.
4. Little Leaguer™s Elbow. Results from overuse of an adolescent™s pitching elbow. On exam there is tenderness over the medial humoral epicondyle with mild swelling. An acute syndrome with sudden onset also occurs from the avulsion of a fragment of bone from the medial humeral epicondyle. Treatment includes rest for 3-6 weeks followed by rehabilitation. Loose bodies and locking elbow require referral.
5. Olecranon Bursitis (note: the same treatment and diagnostic modalities hold true for prepatellar bursitis as well).
a. Clinically there is tenderness and swelling over the olecranon bursa. Olecranon bursitis may be secondary to trauma (e.g., lying on carpet with elbows propped up while watching TV) or may be infectious (Staphylococcal). Frequently, traumatic bursitis leads to infectious bursitis.
b. Diagnosis. Must differentiate infectious from sterile bursitis. Tap the bursa and evaluate gram stain, cell count, crystals, and culture.
c. Treatment consists of repeated aspiration until fluid no longer re- accumulates. Start antistaphylococcal antibiotics (e.g., amoxicillin/ clavulanate, nafcillin) if an infectious etiology is likely. May require admission for IV antibiotics the patient is toxic or there are comorbid conditions (e.g., immunosuppression, diabetes). If the etiology is not infectious, treat with NSAIDS, aspiration and compression dressings. Occasionally, an olecranon bursa must be opened surgically.
RED EYE
Clinical clue table suggesting the possibility of serious eye disease causing the "red eye", clinical features that may necessitate immediate ophthalmologist consultation
Clinical features:
Severe eye aching: Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus thrombosis (CST)
Prominent photophobia: Iritis, keratitis
Impaired vision: Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST
Cloudy cornea: Keratitis, acute angle-closure glaucoma
Corneal opacification: Keratitis - chemical or infectious
Circumcorneal conjunctival injection: Iritis, keratitis
Cloudy anterior chamber: Iritis
Pain on eyeball palpation: Scleritis (+++), orbital cellulitis, CST
Proptosis: Orbital cellulitis, CST, posterior scleritis
Impaired, or painful, extraocular eye movements: Orbital cellulitis
Fever, toxic appearance: Orbital cellulitis (+), CST (++)
Hyperpurulent discharge from an "angry" eye: Gonococcal conjunctivitis/endophthalmitis
Prominent nausea and vomiting: Acute angle-closure glaucoma
Small, irregular, poorly-reactive pupil: Iritis
Fixed mid-dilated pupil: Acute angle-closure glaucoma
Increased intra-ocular pressure: Acute angle-closure glaucoma, iritis (secondary complication)
History of connective tissue disease, or granulomatous disease: Iritis, scleritis
Recall:
23 yo runner developed fracture of the medial malleolus...next step:
a-posterior splinting
b-medial splinting
c-lateral splinting
d-orthopedic referral
The answer to this question is posterior splinting..The trick here is to know the intervention and the position of splinting..
Think of the ankle as a "ring" composed of medial malleolus, deltoid ligamnet, calcaneous, lateral ligamnet, lateral malleolus.
DISRUPTION OF THE RING AT ONE POINT ONLY OF THE RING results in a stable ankle that can be treated by CONSERVATIVE means (POSTERIOR splinting+non-weight bearing)
DISRUPTION OF THE RING AT TWO OR MORE POINTS OF THE RING makes the ankle unstable and the treatment is immobilization and emergent referral..
Difference b/w Raloxifene and Tamoxifen:
Tamoxifen:
Often used in women over 50 years of age and younger women with ER + tumors. ER + respond better than ER -. Treatment for 5 years seems to be optimal duration. Side effects include, nausea, menopausal symptoms, thromboembolism and and a small increase in uterine cancer (mandating work for any abnormal uterine bleeding). Ovarian ablation is only beneficial as hormonal treatment in premenopausal women.
* women at high risk for the development of breast cancer may reduce their risk by taking tamoxifen.
* Tamoxifen appears to be antiestrogenic at the level of the breast but proestrogenic at other levels.
It causes endometrial changes, including polyp formation, hyperplasia NOT ATROPHY, and frank invasive carcinoma. Thus, women on tamoxifen need to be followed carefully, and prompt evaluation of abnormal vaginal bleeding should be conducted.
Tamoxifen, like estrogen, has been shown to lower blood levels of LDL cholesterol
Women on tamoxifen appear to be at no greater risk, and may be at a lower risk, for the development of myocardial infarction .
Tamoxifen, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis .
Raloxifene:
Raloxifene appears to function like estrogen in bone, acting to maintain bone strength and increase bone density.
In addition, raloxifene also resembles estrogen in its ability to lower LDL cholesterol levels, thereby decreasing the risk of heart disease.
Although information on the long-term risks and benefits of raloxifene is limited compared to tamoxifen, preliminary evidence suggests that raloxifene may exert these beneficial effects on bones, heart, and blood vessels without increasing a woman's risk of developing cancer.
Even if the STAR trial confirms the effectiveness of raloxifene in reducing the risk of breast and uterine cancer, raloxifene is still not the perfect drug. It does not reduce the frequency of hot flashes associated with menopause and, like estrogen, it increases the risk of blood clots. Just as tamoxifen was an important milestone, if a single SERM like raloxifene is found to protect women against osteoporosis, heart disease, breast cancer, and uterine cancer, it will represent an important milestone in women's health. For the recall question raloxifene if h/o breast ca is there.
Asymptomatic hematuria:
1)>50, + Risk factors(tob, dye, etc) or is consistent with underlying causes straight cystoscopy.
2)<50 without RF, do Urine cx/AXR first. if all are wnl, then watch and wait, document that u informs pt pro and con of w/u.
Ureteral Colic:
First step: UA with sediment followed by AXR. Uric is lUcent others opaque. Urinary Ph can also distinguish different varieties. Minimal work up is crt, electrolytes, ca, phosphorus, cbc.
Next is helical/spiral CT abdomen (test of choice). Most would be seen, if still in doubt IVP (former gold standard BECAREFUL).
*** REMEMBER 6 is the KEY DIGIT for ureteral stones
Stones less than 6 mm pass spontaneously. Conservative observation with pain meds is sufficient for 6 weeks. After 6 weeks, 2 options, ureteroscopic stone extraction or extra shock wave lithotripsy (ESWL). Read the debate on p 919 CMDT. Women of childbearing age are best NOT treated with ESWL for a stone in LOWER URETER as impact upon ovary is unknown. Most stone fragments pass uneventfully w/n 2 weeks after ESWL, stones that persist need additional intervention. Also see 104 Bp med
Renal Stones: 919 CMDT
Asymptomatic------No management and F/u with AXR or U/S
Symptomatic less than 3 cms---------ESWL and F/u in 3 months by AXR
Symptomatic more than 3 cms and stones despite treatment with ESWL-----Percutaneous Nephrolithotomy + perioperative Abx coverage
Drugs causing Erythema Multiforme (Targetoid lesions i.e rash like lymes)
Barbiturates
Sulphonylurea anti-diabetic agents
Sulphonamides
Thiazide diuretics
Phenytoin
Captopril
Diltiazem
Gold
Non-steroidal anti-inflammatory drugs, particularly piroxicam, also aspirin
Statins
ORGAN DONATION:
The physician declares death using brain criteria (potential organ and tissue donor) or from cardio-pulmonary arrest (potential tissue donor).
According to Medicare Conditions of Participation, a hospital must notify its local organ procurement organization upon every death.
Recovery coordinator discusses organ and tissue donation with the family or next-of-kin.
In the case of a tissue donor, a recovery team is called to the hospital and a room is prepped for the donation.
All tissues are carefully removed, packed in sterile conditions, and transported to a tissue bank to be prepared for transplantation, research or therapy.
If the case of an organ donor, the process of identifying the recipient begins.
What is brain death?
Brain death occurs when the brain has permanently stopped working, as determined by the physician not related to transplantation. Artificial support systems (machines) may maintain functions such as heartbeat and breathing for a few days, but not permanently. Donor organs are usually taken from people who have been declared "brain dead".
What is cardiac death?
Cardiac death occurs when the heart has stopped beating completely. While a person dying by cardiac death cannot be an organ donor, they may still donate tissues.
When must organs be removed?
Organs must be recovered as soon as possible after the declaration of brain death, while circulation and respiration are being maintained artificially. Tissue may be removed within 12 to 24 hours after cardiac death.
How long before an organ or tissue must be transplanted into a recipient?
That varies from organ to organ and tissue to tissue. For example heart or lungs must be transplanted within 4 to 6 hours; for kidneys potentially up to 72 hours. Corneas must be transplanted within 5 to 7 days and other tissues may be preserved for 3 to 5 years.
Can donor families have contact with their loved one™s recipient?
Confidentiality is respected unless both the donor family and recipient agree individually to make contact and sign a release of confidentiality waiver. Either side may communicate through letters that are passed on by WRTC if they choose to do so.
FACT: Upon arrival at an accident scene or upon receiving you in the emergency room, emergency or critical care staff immediately spring into action to try and save your life. Physicians involved in a patient's care in an emergency or critical care setting by law may have nothing to do with transplant programs. The OPO (organ procurement organization) is not notified until all lifesaving efforts have failed and death has occurred. Death can be declared only by following strict medical and legal guidelines and usually with the input of more than one physician.
FACT: By the time your will is read, it will be too late to recover your organs. Telling your family that you want to be a donor is the best way to ensure your wishes are carried out because they will always be at the hospital and can relate your wishes. You may also sign an advance directive or driver™s license.
Organs that can be donated at the time of your death include your heart, lungs, two kidneys, liver, pancreas and intestines (although in the Washington, D.C. region there is no intestine transplant program).
A typical organ donor is someone who has died after suffering from a traumatic injury to the brain; for example, a stroke, an aneurysm, or a car accident. For death to be declared, a strict set of medical criteria must be met. Among the criteria is the complete absence of activity in either the brain or the brain stem (responsible for reflexes such as cough, gag, blinking, etc.). By law, only a doctor not connected to the transplantation process may declare brain death.
After death by neurological criteria is declared, the heart, as a muscle, can still circulate blood for a limited amount of time and keep the internal organs viable. It is during that short amount of time that organs may be recovered for transplantation.
WRTC Recovery staff are notified after death has been declared. If the patient is a potential donor, they will approach the patient's family and discuss organ and tissue donation. To find out how to be an organ and tissue donor, click here.
Tissue Donor
While officially considered life-enhancing and not life-saving, a tissue transplant is still a life-changing opportunity for the recipient. From someone who receives the gift of sight for the first time in a cornea transplant to someone who receives skin for burn treatments, tissue recipients are incredibly grateful to donors for having given them the opportunity of greatly improving their lives and the lives of those around them.
A tissue donor is different from an organ donor because someone can be a potential tissue donor if they died according to brain death criteria or if their heart has stopped (cardiac death). Tissues can be recovered up to 24 hours after the heart has stopped beating.
Tissues that can be donated at the time of your death include:
Bone: Facial reconstruction, limb salvage, birth defect correction, cancer treatment, spinal and oral surgery
Cartilage : Facial and other post-traumatic injury reconstruction
Corneas : Restoring eyesight
Fascia : In neurosurgery, to correct damage from trauma or tumor
Heart valves: For valve replacement where animal or artificial valves cannot be tolerated
Pericardium : Used in neurosurgery, especially in brain operations
Skin : Temporary covering for burn patients to reduce pain, scarring, fluid loss, infection
Tendons : Correcting joint injuries
Veins : Used in heart bypass surgery
ULCERS :
If you see the ulcer at the distal tip of the toes ==> Think ischemic ulcer
If you see the ulcer at the heel ==> Think diabetic ulcer
If you see the ulcer above the malleolus ==> Think in stasis ulcer
Diabetic ulcers typically develop at pressure points, and the heel is a favorite location. The patient has evidence of neuropathy, and the correlation with the trauma inflicted by the new shoes is classic
Ischemic ulcers, whether due to arteriosclerosis or embolization are typically seen at the tip of the toes, as far away from the heart as one can get.
Stasis ulcers are seen above the malleolus, surrounded by edematous, hyperpigmented skin.
RECALLS:
1.pregnant exposed to a lacy rashed boy
a.it wonot affect u
b.u will get mild disease
c.u are vaccinated to this,no harm
d.u may lose your fetus
A. no longer infectious once rash appears.
2.pt heavy smoker,lost 8 lbs lately and serum ca=11.5
what do u do next;
a.recheck ca
b.check cxr
CXR.
3.14 yrs old girl never been vaccinated for varicella and she exposed to 5 yrs old her sister with varicella
how would u tx 14 yr one
a.varicella immuno
b.varicella ig g and vaccine
c.var vaccine now
d.va vaccine now and month later
edo nothing.she already exposed
Answer D ref CDC guidelines
4.4 yr old almost near drowing was cpr for 45 mts to get pulse and circulation.in er pt is on dopamine and intubated.he pronouned brain dead and ready for organ donation.what is the best time for this.
a.now
b.after 48 hrs
c.after good b.p. control
Answer NOW
5.56 yr man came to pmd he is s/p CABG 10 yrs back and c/o sob with exertion and chest pain what is next step:
a.thallium stress test
b.dobutamine test
c.ekg
Next step EKG
6.Pt with carbamezapine toxicity what should u monitor
a.cardiac
b.renal
Cardiac
7.what is definitive diagnosis for mi
a.ekg
b.enzyme
c.physical exam
Enzyme
8.cocaine induced htn what will be tx
a.nitropru
b.beta blocer
c.phentolamnine
Phentolamine
9.cocaine induced mi
a.thrombolytic
b.angioplasty
Angioplasty
10.which is not a risk factor for osteoporosis
a.smoking
b.etoh
c.caffinated product
d.white race
e.obesity
Obesity
11. woman on contraceptive > >>> became amenorrheic
a.let her be ameno
b.modify estro(increase)
c.progesterone (lower)?
Likely B
12. A child goes to picnic has redness in arms and legs What the dx:
Poison Ivy
Atopic dermatitis
Irritant contact dermatitis: Just local inflammation of the skin following contact of the skin with a noxious substance. NO immunologic reaction eg; Industrial and household detergents
Allergic contact dermatitis: Delayed type of hypersensitivity..Occurs when an external agent sensitizes T-cells, Poison ivy, poison oak, some metals (nickel), various preservatives in medications, ingredients in rubber industry, agents in finishing process for clothing or other naturally occurring or industry produced chemicals. MKSAP p 16
Atopic dermatitis: Atopy in the skin. Type I hypersensitivity ..Part of generalized atopic reaction. The Ig-E mediated immunity occurs in many parts of the body including the skin.
Having understood the type of hypersensitivity in each dermatitis.., timing here is very important. If the child develops the reactions of erythema and pruritis 24-72 hrs after the return of the picnic, .Poison ivy /allergic contact dermatitis will be choice, If the child develops the symptoms immediately, atopic dermatitis is the choice.
HTN High yield facts
Hypertension Rx
¢ Trial of Lifestyle Change x6-12mos in Pt.'s w/ NO Co-morbid Dz.
““““““““““““““““““““““““““““““““““““““““““““““““““ “
*** 1st LINE DRUGS ***
¢ No Other Dz.
- Diuretic OR ß-blocker
- (Proven to Decr. Mortality)
¢ Hyperthyroidism
- ß-blocker
- (Decreases HyperT3 Sx, also)
¢ DM
- ACE Inh.
- (Proven to Decr Vasc & Kid Dz)
¢ Blacks
- Ca Channel Blocker
¢ Decr. Ejec. Frac.
- ACE Inh.
- (Proven to Decr. Mortality)
¢ MI
- ß-blocker AND ACE Inh.
- (Proven to Decr. Mortality)
¢ Atrial Fibrillation
- Diltiazem (Ca Chan. Blocker)
- (Controls Atrial Rate, also)
¢ Osteoporosis
- Thiazides
- (Decr. Ca Excretion)
¢ Prostatic Hypertrophy
- Alpha-blockers
(Ex.: PRAZOSINâ„¢, TERAZOSINâ„¢)
- (Treats HTN & BPH Concurrently)
HTN *** CONTRAINDICATIONS ***
¢ ß-blockers
- COPD
- due to Bronchospasm
¢ ß-blockers (Relative)
- DM
- due to alteration in insulin/glc homeostasis & blockade of
autonomic response to hypoglycemia
¢ ß-blockers
- Incr. K
- due to risk of Incr.'ing K even higher
¢ ACE Inh.
- Preg.
- due to Teratogenicity
¢ ACE Inh.
- Renal Artery Stenosis (B/l)
- due to precipitation of ARF
¢ ACE Inh.
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
¢ K Sparing Diuretics
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
¢ Diuretics
- Gout
- due to causation of Hyperuricemia
¢ Thiazides
- DM
- due to Hyperglycemia
See page 251 Katzung for uses and side effects of Diuretics.
Immunization Contraindications
No MMR:
¢ if PREG / IC Pt / EGG ALLERGY
¢ OK if HIV+ (Asymp)
No DPT:
¢ if SEIZ / Any NS Dz.
¢ if FEVER > 104° AFTER 1st DOSE
No OPV:
¢ if IC Pt
¢ (Use IPV, which is IV & Killed)
¢ UPDATE:
- Last Polio Inf. in 1979 w/ ~8 cases/yr due to OPV (Live-attenuated)
- As of Jan. 2000, No more OPV. (ie.: IPV is only given)
NB: Live Vaccines
- MMR
- OPV (Replaced w/ IPV)
- Varicella
Oral Contraception Pill (OCP) Contraindications
¢ PE, DVT
¢ Cerebral vascular disease
¢ Coronary artery disease
¢ CA of breast
¢ CA of endometrium
¢ Cholestatic Jaundice in Preg.
¢ Hepatic adenoma
¢ Impaired liver function
¢ Type II hyperlipidemia
¢ Factor V Leiden mutation
¢ Smoker (if > 35yo)
Varicella Vaccine
Live attenuate vaccine
- Given at 12 to 18 months in pt with no previous infection
*< 12 yo, only one injection is given
*>12 yo, two injection is given 1 to 2 months apart
Route of administration
-Subcutaneuosly
Complication:
-Erythema 20-25%
-Varicella < 1%.
WBC Shift
¢ LEFT SHIFT:
- Increased Seg.'d Neutrophils + Bands
- Bacterial
¢ RIGHT SHIFT:
- Increased Lymphocytes
- Viral
Labor Induction (Indications)
¢ Abruption
¢ Chorioamnitis
¢ IUFD
¢ PIH / Pre-eclampsia
¢ PROM
¢ Post-term (42 wks)
¢ Maternal Medical Conditions:
- Diabetes mellitus
- Renal disease
- Chronic pulmonary disease
- Chronic HTN
¢ Fetal Compromise:
- Severe IUGR
- Isoimmunization
Contraindictions to Labour Induction
¢ Vasa/Placenta previa
¢ Transverse fetal lie
¢ Umbilical cord prolapse
¢ Previous uterine surgery
DKA Treatment
**LABS**
¢ SMA-7 / Ketones / ABG / EKG
¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢
**TREATMENT**
1) FLUIDS -> 2L NS (500cc/hr x 4hr), then 250 cc/hr x 2hr
2) INSULIN -> Bolus 10U Reg, then run at 0.1U/kg/hr
¢ Make sure drip is running
3) K -> in 1/2 NS 20-40mEq/L after 1-2L NS
4) Check Glc q1hr (until ** < 250)
5) Once ** < 250, add Dextrose (D5NS) to Insulin drip
6) Turn off drip when HCO3 > 22
¢ ie.: Improvement of Anion Gap (AG)
¢ AG = Na - (HCO3 + Cl) = 140 - (24 + 100) = ~8-16
7) Start SQ Insulin 1-2 hr before stopping Insulin drip
Amenorrhea Work Up:
Remember the definition of Primary Amenorrhea is either 14yo without secondary Sex characteristics OR 16yo without menses yet. Secondary Amenorrhea is NO menses for 6 months OR 3 cycles.
Progesterone Challenge test is needed after Preg Test(neg) / TSH (normal) / Prolactin (normal). If she bleeds with the progesterone, then she's anovulatory (Tx-> Progesterone). If she does not bleed, then test with Estrogen & Progesterone (OCP). If no bleeding still she has scarring in the uterus (Asherman's synd or TB). If bleeding occurs, then do LH/FSH level. If LH/FSH is low then repeat Prolactin level and do a Coned down view of Sella Tursica. She probably has a Prolactinoma (Tx-> Bromocriptine (may breastfeed)). If LH/FSH is normal, then she has Polycystic Ovarian Syndrome (PCO) and treatment is OCP (or Clomiphene if she desires pregnancy now). Testosterone is also high in these patients. If LH/FSH is high, she either has Menopause, Ovarian Failure, Testicular Feminization (46XY) or Turner's Syndrome (XO).
For PCOD LH/FSH ratio is greater than 2:1
Cervical cancer guidelines
ASC-US
-Repeat PAP in 4 mos
-HPV with reapeat PAP
-If (+), then Colpo
ASC-H
-Colpo
AGC
-Colpo + Endocervical Curretings (ECC)
-If >35yo also do Endometrial Biopsy (EMBx)
-If Endometrial cells present, do Colpo + ECC + EMBx
LGSIL
-Colpo +/- ECC
HGSIL
-Colpo with Cervical Biopsy + ECC
Endometrial Cells present
- EMBx if Postmenopausal and NOT on HRT
FACTS:
* If dog and cats bite and escape, dont give prophylaxis until animal acted strangely or there is rabies prevalent in that area
* If wild animals like bat, skunk, foxes, racooons bites and escapes give prophylaxis and vaccine
* If captured or killed animal has rabies or negri bodies give vaccine and prophylaxis
* If kid is bitten by neighbour dog who had all his vaccination just reassure the parents and clean the wound with soap and water and observe the wound..this is my exam q
* If spider bite gives u sloughing, necrosis and burning pain then its brown recluse spider...u have to give tetanus, and if swelling is not down after few h give steroid like dexamethasone
* If spider bites gives u like abdominal cramps and edema then its black widow u need to give calcium gluconate to the pt
* Enteric fever is a reportable disease give cipro for 10 days and check all family members stool for salmonella typhi
* Nodulo cystic acne best is isotrentione, but first check preg test and pt should be on contraceptive when she is on this drug
* To decrease the cong anomalies in babies born to mother with diabetes tight glucose control 01 month before the conception and throughout preg.(.my exam qs)
* Pt udergoing cabg, u see during transfusion...that blood is coming from all punctures or iv site , this is most likely to transfusion reaction and this is the only thing plus hypotenton is present when pt is under anesthesia to give u a clue that pt is having reaction from transfusion...
* U will c many qs ...in which u have to give iv f and mannitol in transfusion reaction,in crush injuries with rhabdo like pics...so think of compartment syndrome and faciotomy.....in all those cases where s/s r persent in mva cases
* Just remember supra condylar fx is a surgical emergency u have to do orif asap...
* Adult fall on outstretched hand is colles fx ...close reduction and long arm cast
* Kids fall on outstretched hand radial head subluxation.....
* Decelration injuries...aortic rupture c/o tamponade
* Fall from height on ur feet is calcaneus fx and spinal fx
* Ct scan with contrast for all type of kidney stones and rcc
if stone is more than .5 cm and at pelvic ureteral junction removed with basket through cystoscopy
no eswl when there is infection going on with kidney stone in that cases urology asap for nephrostomy tube and stent placement
* Mom interfere with lp and u think u need it to make sure that kid has meningitis do it bcz its a medcial emergecy dont fall for her choice ethic commetee, court order, talk to attending ,talk to risk management ist...(this was also my exam q)
* Stop both heparin and warfarin in HIT SYNDROME..use liprudine...u must d/c heparin if platelets r less than 50% from base line
* Dyslipidimia and hypertention in a pt he needs alpha antagonist like pt with bph
* Pt has psa of 10 or more go for transrectal biopsy..
* Kid or 50 yr with painles hematuria or microscopic ist thingis always ua...
* If Fna is eqvivocal go for open biopsy
* Any cystic or fluctuant mass except with ocp need fna...ocp is due to estrogen content it will regress after u d/c the pills
* Any mental retarded pt needed contraception ans is iud,or norplant
* The most common side effect after depoprovera norplant(my exam q)...is intermittant spotting..d/c if its not going away after 3-4 wks..
* The most common side effect from estrogen pill is nausea/wt gain
* Chf and pul embolism, asthma, mitral stenosis, asthma, pul edema increase dlco....intestitial lung dec and emphesema dec dlco like sarcoidosis, bronchitis is with normal dlco...
* D/c asp 1 wk bfore surgery
* D/c coumadin 48 h b4 surgery
* D/c heparin 4 h b4 surgery
* D/c antidepressent after 9month of depression free pd..some book say s 6 months
* D/c...antiepileptic after 2 yr of seizure free period..
* Rolaxifen is best choice if women has h/o breast ca ....but it can not protect endometrial ca....
* The most cc of death from ca is lung
* The most cc of disorder in future kids with adhd..is conduct /antisocial disorder
Recalls:
If you are asked about the management of the spine metastaisis ==> The emergent treatment should be dexamethasone i.v. This is followed by spine radiation. The same thing also applies for brain metastasis.
This is an old recall...
If you are asked about the treatment of a cancer ==> Know which cancer is chemo- or radio-sensitive.
For example, solitary nodule of small cell carcinoma of the lung is treated with chemotherapy as the small cell carcinoma is chemo-sensitive.
Squamous cell carcinoma is radio-resistant. So, chemotherapy is the choice...and so on. (All these are old recalls).
Nerve block doesn't solve the whole problem..it will only relieves the pain but will not relieves the compression.
Here is another old recall..
70 patient with skin squamous cell carcinoma on his forearm. Refused surgicaL excision. The alternative treatment is:
a-Chemo
b-Radio
c-Laser
70 patient with irresectable laryngeal carcinoma.
Management:
a-Chemo
b-Radio
c-Surgery
d-Combination of chemo/radio
Q: Young patient with signs and symptoms of appendicitis
most unfavorible sign is rebound tenderness or diffuse guarding?
Answer is diffuse guarding for peritonitis, rebound tenderness for localized
Q: Any association with Breast implant and CTS
Answer yes 40%
CSS: DKA
1st step:
do PE
2nd step:
O2 inhalation, pulse ox stat/cont, iv access, floey's if unconcious, NS bolus, NS coninous drip, stat finger glucose, ser alcolhol, serum acetaminophen, serum amylase/lipase, bHCG, U/a, urine toxicology screen, ABG stat. EKG
3rd step :
serum osmolality
serum electrolytes
serum ketones
" mg/ph
Insulin bolus 15 units regular
reg insulin infusion 8 to 10 units
abg
shift to icu:
NPO
strict input /out put control
cardiac monitor
BMP Q 4 hrs, Q 8 HRS, Q day
ABG Q 2hrs * 2
after 4 hrs change fluid to 1/2 NS
add K 20 to 30 meq
check stat glucose if betwene 250 to 300 change the fluid to D5/w continous
shift to floor
if infection suspected give iv antibiotics
send cultures for urine and blood and sputum
cxr etc.
fasting lipid profile
Discharge :
d/c iv insulin
start SQ insulin
diabetic diet
diabetic counciling
foot care
opthalmology consult
strict home glucose monitoring
family and patient education
stop smoking/alcohol
safe sex
seat belts
regular exercise
low fat diet
discharge with follow up in 2 wkz
CSS: Narcotic Overdose
Most of the pts are in respiratory distress or unconcious...so we'll go with basics of trauma
A: airway suction, o2 inhalation, pulse ox stat n continous
B: intubate if po2 is less than 55 or pco2 is more than 50 , or pt is unconcious
C: iv access, foleys. cardiac monitor, stat glucose
D: Iv thiamine, 50% dextrose, nalaxone...one time boluses
PE focused
Diag evaluation:
Ekg, cxr, serum alcohol, serum acetaminophen, urine analysis, urine toxicology, abg, stat glucose, lft, pt /ptt, serum ck
Initial management:
NG tube gastric lavage ( within 1hr)
charcoal
IV nalaxone continous ( do not give if the pt is opiod dependent )
review hx n physical
Shift to ICU:
NPO
D/c intubation
D/c nalaxone
D/c NG tube
Continue cardaic monitr n pulse ox for 24 hrs
Serum electrolytes
Educate family n patient:
Psych consult
d/c IV access
D/c foleys
shift to psych ward
give antidepresants if needed
suicidal evaluation n councilin
regular diet
exercise prog
stop amokin/alcohol
safe sex
seat belts
discharge
CSS TIA
routine physical
evaluation :
cbc, bmp, ekg, CT scan
ct is usually -ive within 24 hrs
admit to ward:
vitals every 12 hrs
continue home medications
ambulation
diabetic diet if hx suggest
doppler echocardiogram
tele monitoring
accu checks bid
carotid doppler
oral aspirin continue
MRI/A of brain and neck DWI
results:
if > 70 % stenosis
take surgical consult for elective CEA
other wise manage on medical basis ...aspirin is the drug
discharge with advices:
stop smoking/limit alcohol
BP control ( diet exercise meds)
diabetes control ( do )
pt education for drug compliance
safe sex, seat belt, injury prevention, regular exercise, low fate diet
fasting lipids
follow up after 4 wkz
OB-GYN FACTS:
If it is only spotting____________________ reassure
if it is heavy < 35 years __________________________increase estrogen
if it is heavy > 35 years_____________Biopsy
you can add the following
acne + OCP _______ decrease progesterone
depression+ OCP _______ give SSRI
amenorhea+ OCP
urine pregnancy test if -ve
1) reassure
2) if she wants menstruation_____________ increase estrogen.
COMMON SIDE-EFFECTS of medications....
1. T****done= priapism
2. verapamil= constipation
3. ACEIs= angio edema, rash, Dry Cough
4. Clopidogrol-- HUS,TTP
6. Indinavir -- Renal Stone
7. AZT -- Bone Marrow Supp
8. Heparin - Thrombocytopenia
9. INH - Prepheral Neuropathy
10. Hydralazine- Lupus Like Syndrome(also Procainamide)
11. Ethambutol- loss of red green visual acuity
12. Pyrazinamide- Liver toxicity
13. Carbamazapine- SIADH
14. Lithium- Hypothyroidism,wt gain, Flair up of Psoriasis, Tremor, Acne,DI
15. Demiclocycline-DI
16. Aminoglycosides- Ototoxicity and nephrotoxicity
17. Bleomycin- Pulmonary fibrosis
18. Doxorubicin and Daunorubicin-Cardiotoxicity
19. Cyclophosphamide- Hemorrhagic cystitis
20. Vincristine-Peripheral neuropathy
21. Metronidazole-Disufiram like reaction and peripheral neuropathy
22. Niacin- flushing and abnorman LFT's
23. HMG coa (statins- myositis HIGH AST ALT( check lft's often )
24. Thiazide diuretics- hypercalcemia .. can cause GOUT
25. metformin- anorexia wt loss and lactic acidosis
26. imepenem- seizures
27. rifampicin= color change urine tears skin orange color
28. NSAIDs- gastritis, nephrotoxicity, can increase BP
29. B-Blocker- Cover Hypoglycemia Symptoms,
30. Clozapine- Bone Marrow Supp
31. Amitriptyline- Convultion, Cardiac arrythmia,Coma
32. steroids- avascular necrosis, edema. osteoporosis, poor wound healing
33. aspirin.... ototoxicity and resp alkalosis/ metabolic acidosis
34. Quinidine- diarrhea, thromocytopenia
35. Acarbose- flatuence
36.methimazole- agranlocytosis, aplastic anemia
37)Prazocin-- First Dose Syncope(give the first dose in your office)
38)Amilodarone -- Pul Fibrosis
39)Chlorpropamide -- SIADH
40)Colchicine -- DI
41)Nitrate Drugs+ Viagra(sildenafil)---> Sudden Death
42)Ethosuximide -- GI upset
43)Tolcapone --- Hepatotoxicity
44)Thioridazine --- Retinal Deposits, Torsade
45)Vancomycin --- "Red Man" Syndrome
46)Chloramphenicol--- "Gray Baby" Syndrome
47)Cimetidine--- Genycomastia
48)Ketoconazole-- Gynecomastia
49)Protease Inhibitors(in General)-- Hyperglycemia, Hyperlipidemia
50)Cisapride---Torsade
51)Methotrexate(long Term)--- Liver Fibrosis
52)Asparaginase--- Pancreatitis
53)Cyclosporine--- Nephrotoxicity
Bites quick points (Cat bites > humans > dogs) Also look CMDT 1255
* If stray dog bites to some one give both Ig and vaccine....make sure 1/2 of Ig is sprinkled over the wound and half in the buttocks in kids and in adult in deltoid muscle...and make sure Ig and vaccine should be on separate sites of injection...
* If neighbours dog bites which has all his vaccination upto date then just reassure the victim and clean with soap and water....nothing to worry about
* If human bites to another human (Recall) a man comes with a bite wound that result in swelling of his whole forearm...and on qustioning he admitted that his wife bit him.. what u will do....since human bites r worse than all other because of aerobic and anaerobic bacteria in one™s mouth need special attention and since it was such an extensive lesion so we have to admit him and give him iv antibiotic....augmentin is good as out pt and inpatient u can give ampicillin, iv and clindamycin.
* If cat bites, ... if extensive wound then give ampicillin or augmentin
* If dog bites same augmentin or amp...(domestic)
* Scorpion bites ..... brown recluse ...will cause stinging sensation, sloughing necrosis need dexamethasone and tetanus....
* If black widow bites then u will have abdominal cramps and rigidity u have to give calcium gluconate ...
* A mom is worried that baby is so lethargic not taking bottle and she is not having any fever just dilated pupil on exam....and ans was did u give him honey lately
Pointers
Three vaccine can induce anaphylactic reactions in egg-allergic people: INFLUENZA, YELLOW-FEVER and MMR.
The MMR and yellow fever still can be given in egg allergic people.
Varicella zoster vaccine is given at age of 1 year! (with the MMR).
Influenza vaccine ==> all people > 50 YEARLY
Penumococcal vaccine ==> for adults above 65 with chronic diseases/immunocompromised
MALE HOMOSEXUAL..What vaccines you give beside Hepatitis B? Hepatitis A !!! (becuase hepatitis A transmits through the faeces like feco-oral or feco-mucosal route...Male homosexual are thus subject to Hepatitis A).
60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows hyperplastic polyp..next step:
a-colonoscopy
b-do nothing
The answer is do nothing..Itis hyperplastic polyp..
60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows tubular adenoma polyp..next step:
a-colonoscopy
b-do nothing
The answer is colonoscopy...It is tubular adenoma..It has risk of malignancy. So, you have to make sure that there are no more tubular adenoma polyps..sigmoidoscopy screens the descending colon only and doesn't reach the rest of the colon..so, colonoscopy should be the next step.
PAP shows ASCUS ==> Repeat test in 4-6 months
LGSIL/HGSIL on PAP ==> colposcopy and followed by cervical biopsy.
ITP ==> steroids are the first line. IVIG is the second line.
TTP/Gullian Barre ==> plasmapheresis
When the patient is in severe depression/suicidal tendency, he is not compotent:
30 year old man found on the floor with empty bottle of valium. A suicidal note was found saying that he wants to die peacefully and doesnot want any heroic procedures to save his life. Next step:
a-Flumazine i.v
b-Intubate and move to the ICU.
Choose B
For any drug overdose, do not choose the option of the anti-dote/the antagonist..remove the drug first by charcot/gastric lavage unless contraindicated.
Acetaminophin overdose..next step:
a-N-acetylcystiene iv
b-gastric lavage
Choose B
Don't afraid to give morphine for the pain management in patients with terminal stage of their cancers:
..but it should be under monitoring to prevent respiratory depression!!
75 patient with pacreatic cancer and severe back pain ..next step:
a-morphine intrathecal
b-morphine i.v every 3 hours
c-morphine i.v on needed basis
d-morphine i.v in a monitored bed.
Jump to D
Emancipated minor is the minor who lives alone/married/works
Pregnant minors are not emancipated but have the excetion of signing the consents!
A 16 year pregnant girl need Cesearan section for delivery ..who signs the consent?
a-In most states, she is emancipated minor.
b-In most states, she can sign the consent
Point your arrow to B
Jehovah's witness refuses blood transfuion..His Bp is 50/0..next step:
a-do nothing
b-iv fluids
Respect the autonomy but tries to do any supportive measure outside the conflict!! so jump to B
Do not respect the patient's wishes in organ donation if they parents refuse the donation even if he has the organ donation card! This is the only exception for the patient's autonomy after his brain death.
The spouse is the next after the patient (not his parents or siblings). Ask the wife for any consents if there is no guardian or advance directive!!
Treat keloid by intralesional steroids. The same thing for alopecia aerata (NOT topical!!)
Emergent reversal for warafin overdose is FFP (not Vit K) while emergent reversal of heparin is protamine sulphate (not FFP!!..The FFP is c.i.)
If the Q is clueless..choose the most common
70 yo patient with weight loss...next step; CXR (to exclude lung cancer which is the most common malignancy)
70 yo patient with fatigue...CBC (to detect iron deificency anemia..followed by colonoscopy becuase lower GI bleeding is the most common cause of iron deficiency in the US..NOT NUTRITIONAL CAUSE!)
EFFECTs of OCP:
HDL LDL Glucose TG
a low high high high
b high low high normal
c high high normal normal
d normal normal normal normal
e normal normal high high and high total cholesterol
The answer is E why?
Remember that estrogen increases HDL but decreases LDL
Progetreone decreases HDL and increases LDL
Their combined effects is nill!!keeping the levels of LDL and HDL normal
TG is elevated and impaired glucose tolerance!!
Patients with adenomyosis/endometriosis/leiomyomata uteri (refused surgery)..What is the medical treat? OCP. Remember all these cases are caused by state of hyperestrogenism..but you still have to give OCP..not progestrone only.
Patient with rheumatoid arithritis...refused to take steroids..The alternative drug should be: METHOTREXATE
Patient with SLE...refused to take steroids..The alternative drug should be: CYLCOPHOSMAIDE
Patient with Crohn's disease..The first line is s-ASA with metronidazole or cirpofloxacin...Steroids are SECOND LINE..AZATHIOPRINE or ^-Mercaptopurine are THIRD line. INFLXIMAB is the last line OR for the treatment of FISTULAS!!
Treatment of IBS (Irritable bowel syndrome)?? FIBER+ ANTICHOLINERGIC DRUGS like hyoscine
GERD ==> First line is therapeutic trial of H2 blockers , followed by Proton-pump inhibitors. If fails, go to 24-hr esophageal PH monitoring. Don't forget the life style modification before any pharmacologic therapy.
The following vaccinations should not be given during pregnancy becuase they are live attenuated virus vaccines:
1-Mumps/Measles/Rubella
2-Yellow fever
3-Varicella
REMEMBER>>>
A prgenant in her 2nd trimester exposed to a child with Varicella one day age. You checked her serum for varicella antibodies titre and it was negative..Give VZV ig (not vaccine) ..It should be given within 96 hours of exposure.
The mother ask you: Does the VZIG protect my fetus againts infection? NO. VZIG is given to prevent MATERNAL NOT CONGENITAL/FETAL infection!. The congenital varicella syndrome results from exposure during the first 16 weeks of pregnancy.
These vaccines can be safely given and their indications are not aletred by pregnancy:
1-Pneumococcus (polysaccharide)
2-Meningococcus (polysaccharide)
3-Rabies (killed virus)
4-Influenza (inactivated virus)
5-Hepatitis B (purified surface antigen)
6-Hepatitis A
7-Tetanus-Diphtheria (toxoid)
Pictures
pic of a kid with arm and mouth vesicular lesion i put cockscakie virus A....bcz it was hand mouth fooot diease kind of pic...
kid with the xray chest with pnumo one side and bowel other..cong diaphragmatic h
man with apple core lesion..colorectal ca
a fib ...ekg
3rd degree heart block
inf mi...st elevation in typical leads
pic of scabies
pic of pudohyphe
pic of shingles with eye involvement
pic of nodular cystic acne
ct of head with lenticualr mass .....epiduarl hematomaa.
achlasia....pic
Hematology Pointers
1) THE main DIFFIRENCE between TTP and HUS is lack of Neurological involvement in HUS....otherwise same as both have inc BUN/CRETINE both have INC LDH both ha THROMBOCYTOPENIA both have MICROANGIOPATHIC HEMOLYTIC anemia......both have SHISTOCYTES on periphral bloood smear...v imp for exammmm REMMBER BOTH HAVE NORMAL COAG AND NORMAL OTHER CELL LINES...
2)INC PTT IN CLASSIC HEMOPHILIA AND ITS XLINKED...TREAT WITH FACTOR 8 AND IF IT DOESNT CORRECT PTT THEN IT MEANS THAT PT HAVE ANTIBODIES AGAINST FACTOR 8 WHICH CAN OCCUR IN 10% OF TH E CASES AND TEST THIS WITH MIXING STUDY MEANING WHEN U WILL MIX PTS BLOOOD WITH FFP OR NORMAL BLOOOD NOTHING WILL CORRECT PTT IT WILL STILL INC ...TRETAMENT OF THIS WILL B CYCLOPHOSPHAMDIE ALONG WITH PREDNISONE
3)MOST COMMON CONGENITAL BLEEDING PROB IS WITH VON VILLIBRAND DIASES ITS AUTOSOAML DOMINENT...AND IT WILL INC BLEEDING TIME..INMILD CASES U CAN GIVE PT DESPOPRESSIN ,,,AND IN SEVER CASES CRYO WILL HELP...DONT GIVE DESMO IN SEVER CASES IT WILL MAKE IT WORSE..
4)DESMOPRESSINIS ALSO GOOOD FOR MILD CLASSIC HEMOPHILIA A...
5)IN ITP THERE WILL B MEGAKARYOCYTES ONPERIPHRAL BLOOOD SMEAR BCZ THERE IS INC RATE OF DISTRUCTION OF PLATELETS AND DEC FORMATION OF PLATELETS DUE TO AUTOIMMUNE PHENOMENON, ANTPLATELET IgG ANTOBODIES DESTRY ALL PLATESLETS SO THESE PTS R MORE PRONE TO HAV EMUCOSAL BLEEDING LIKE THEY WILL HAV E MENORHAGIA,OR EPISTAXIS.....FORTREATMENT IST TRY WITH PREDNISONE IT HELPS ALOT BY INC THE PLATELETS itworks by dec the affinity of platelets to activated macrophagesin th e spleen and steroid also dec the binding of autoantobodies toplatelets....tretament always start with low dose of platelets it will inc th eplatelets numb but if u hav eto keep thept on prednisoneor u hav eto inc the dose then do splenectomyis the definate treatmentofitp if they ask u in step 3,,,,but make sure that u give pnumovac and h influenza vac 2 wk prior to splenectomy,other drugs that use when platelets r low and causing bleeding or if pt is going for urgent surgery is ivig..its v expensive so only reserve for life thretening bleeders and its always given slow and never in ppl who have igA defiency bc zthey will die from anaphylaxis...another imp point is that when pt cant go for splenectomy or cantbon prednisone or cant afford 5 k dollerivig give him danazol,or rh gam its helpful tooo...som e tried inflaximab group its helpful but infectionis the side efefct....so watch for that...if u c ccs in exam which most of u willl..... just treta as an out pt with prednisone and call pt in 2 wks and when platelets above 50 taper prednisone and advise for no contact sport..and pt teaching about diease ...v imp...
6)dic is dif from sub acute dic in thatpttis normal and fibrinogenis normal...and remmber in dic treat the underlying cause...
never give aminocaproic acid in dic without heparin bc zit cause severe thrombosis...
7)liver disease have both prolong pt and ptt but fibrinogen level is normal...ff will correct th ebleeding..
8)the dif bet the vitamin k deficiency and dic is noraml platelets and normal fibrinogen vit k will help....
9)if platelet r 10 k still u can perform splenectomy so never ever give platelets in itp when its in exam..bcz it will b destryed by the antibodies...
10)inmy exam they ask that baby had circumcison and lost lots of bloood on lab hisptt was 100 an his bleedint time was 12....and mom said his uncle has sam e prob he bled in suregry and after surgery...whatu will do u will check factor 8and 9...its dic,its ttp,its itpand blabla...
11)remmber factor x11 deficiney u wont have bleeding just inc ptt they canhave surgery without any prob its also callled hadgman factor deficiency..
12) ifpt is having factor 13 deficiency.u will hav e normal coag but still u will hav e bleeding....so remmebr these clues they will help u to exclude wrong choices in exam...
13)lupus anticoagulant antibodies is v imp subjects so u have to read about it.....its igG or igM antobodies taht produce aprolonged pttby binding to phospholipids,its present in 10% pt of sle and is characterized by recurrent abortion,and thrombosis .there is no bleeding unless second ry factor is presenttaht cause bleeding,the prolonged ptt will failed to correct with mixing study so that is a clue for diag....the russell viper venum isgood and senstive assey and is diag of lupus anticoagulant...antiphpjolipid and lupus anticoagulant will cause the false positive vdrl...u can suspect lupus anticoagulant when inc ptt but no bleeding and vdrl is in and anticardiolipid and natiphospholipid positive...predison is th ebest treatment and give heparin if thrombosis is suspected....
14)autologous bloood can b given to pt for surgery and it can b stored for upto 35 days...it dec the chance of infection and reaction..
15)i pack of rbc pack can raise the hct by 3-4%and prbc is used to raise hct ...not the whole blood that is reserved for sever hypovolemic pt...
16) dont transfuse awake juhuwa witness against his will but for a kid go ahead and transfuse if urgent or in nonurgent situation just tak e court oreder...ifkid belongs to juhuwa witness
17)always remmber when ever kid is in the womb mom will give consent for every thing evenif she is competent and refusing for csection and endangering her baby thats fine u just listen to her an d respect her wish..but as soon as she deliver she has no longer authority if child lif eis in danger....but for non urgent cases we stilll need her consent even if she is in jail or drug addict .....
18)febrile bloood transusion reaction pt need leukopooor bloood
19)for graft verses host reaction u need to give iiridiated bloood next time..
20)HIT need that u d/d heparin and coumadin both and start with leupridine...inc risk of thrombosis with the HIT...plez read more from wash manual ....21)...in cases of hemoglobuburia weather its due to rhabdoor bloodo transfusion reaction give vigrous hydration with n/s and mannito or lasix...so hemoglonuria will not damage kidney tubule....bcz atn will cause rf sooon..if will not go aggressive hydration v imp for exam....
21)ist day jaundance is always due to abo imcompatibility
22) if husband is onegative and wife is tooo no prob baby will b normal..(.cam e in my exam..)..case senario was that a gal is pregnantand her rh is negative and her b fd is rh positive and they tell s u in sep setting that this babyis not my b fd but my ex and he is rh negative what u will tell her....
23)delayed transfusion reaction is due to duffy,kell and c,e loci of rh system..they cause delayed reaction after 8 to10 days of transfusion..
.
24)i unit of platelet will inc 5 k of platelets usually we giv e 6 pack..
25)fever chillsl and sever backach eis due to heamolytic reaction,stop transfusion and give ns bolus and lasix..flush th ekid so no damage to tubule and no renal failure other prob is dic....
26)kid if they have dirrhea due to slmonella sheggella or due to e coli they will most like ly have hus so keep that inmind in exam they ask that akid ate hamburger while his father was stilll barb qing...an dkid has now fever and dec inc bun/cretinine .. and thrombocytopenia and in c ldh itS HUS
27)WALDSTROME MACROGLOBUNEMAI IS DUE TOMONOCLONAL IGm paraprotein and in MM ITS DUE TO IgG
THE MAIN DIFIS THAT NO LYTIC BONE LESION IN THE WALDSTROME ...the cause of death in mm is due to infection from streptp pnumoni and h infuenza...
28)hairy cell leukia is having pancytopenia,splenomegalyand hairy celll on p blood smear and bm biopsy
Isolation from School/Day Care :
1) Chicken pox: until all lesions have dried and crusted
2) Scarlet fever: until atleast 24 hrs after appropriate antibiotics
3) Rubella: 7 days after onset of rash
4) Measles: until 4 days after onset of rash
5) Mumps: return to school 9 days after appearance of parotitis
6) Strep pharyngitis: until 24hrs after appropriate antibiotics
7) Parvovirus B19 (5th disease): until appearance of rash [pregnant pt should be evaluated]
Rota virus: until stool is contained by diapers or toilet use
Factitious Hyperthyroidism:
Pt is a nurse with symptoms of hyperthyroidism - Graves Dz vs. Factitious hyperthyroidism distinguished via :
a. TSH
b. FT4 concentration
c. T3 resin uptake
d. TSI (thyroid peroxidase antibody)
Discussion: In factitious hyperthyroidism following labs are seen:
-Thyroglobulin level is low or undetectable
-RAIU decrease
-Low TSH
-T3 and T4 increase.
If only T4 is ingested....Serum T4 could be low. (low TSH)
But in graves there is Antibody.......In factitious No
Recalls:
Q: Infants begin to differentiate their mom™s face and voice at
A. 1 WEEK OF AGE
B. 8 week of age
C. 12 weeks of age
D. 7 months of age
Ans: 1 week of age
Q: Prognostic Sign in Bell™s Palsy is
A. Lack of Parotid gland swelling
B. The presence of incomplete paralysis after 5 days
C. The presence of only a few herpetic vesicles.
D. A lack of motor involvement of tongue
Ans: The presence of incomplete paralysis after 5 days
Q: A patient recovering from Meperidine addiction sustains traumatic injury. What therapeutic modality is appropriate:
A. Accupunture and cold packs
B. Adequate dose of morphine
C. Trans-cutaneous electrical stimulation
D. NSAID
Ans: Adequate dose of morphine
Q: Which vaccine is contraindicated in a 4 year old child receiving immunosuppressive therapy?
a)HAV
b)Acellular pertussis
c)IPV
d)varicella vaccine
Ans: Varicella vaccine
Q: A patient with chronic malabsorption presented with absent tendon reflexes, ataxia, loss of pain sensation, ophthalmoplagia, and anemia. He is suffering from which of the followin vitamin deficiency?
a) vit. A
b) vit. B12
c) vit. C
d) vit. D
e) vit. E
Ans: Vit E
Neurologic findings follow a pattern of progression that can be divided into early and late stages.
Early findings include hyporeflexia, decreased proprioception, decreased vibratory sense, distal muscle weakness, nyctalopia (night blindness), and normal cognition.
With continued deficiency, neurologic symptoms progress and patients can develop truncal and limb ataxia and diffuse muscle weakness. Further eye problems may develop, including limited upward-gaze nystagmus and dissociated nystagmus.
Late manifestations include areflexia, loss of proprioception and vibratory sense, dysphagia and dysarthria, cardiac arrhythmias, ophthalmoplegia, and possible blindness. Cognition may be affected in later stages, and dementia can occur.
Q: Which one of the following vitamin deficiency causes squamous metaplasia of the airway, pulmonary infection, renal stones, immunodeficiency, and it is used as a supplemental treatment in some patients with measles?
a) vit. A
b)vit. B
c)vit. C
d)vit. D
Ans: Vit A
Q: 70 yr old male experiencing attacks of "whirling sensations", nausea, diplopia, dysarthria and tingling of lops. Episodes occur several times a day and are so severe,he collapses and becomes immobile.
A. Panic attacks.
B. Benign positional vertigo.
C. Vertebro-basilar insufficiency
D. Cataplexy
Ans: Vertebro-basilar insufficiency
Q: Alcohol dependent on Disulfiram reports recurrent craving.
Which medication is suitable?.
A. Paroxitine
B. Carbamazepine
C. Naltrexone
D. Propanolol
Ans: Naltrexone
Q: Late stage of HIV infection, the most common neurologic complication.
A. Cytomegalovirus encephalitis
B. HIV polyneuritis
C. AIDS dementia complex.
D. Cryptococcal menigitis
Ans: AIDS dementia complex
Q: 21 yr old female with lethargy, restlesness, confusion, diaphoresis, tremors and myoclonic jerks. She is receiving trearment for depression and does not know the name of pill. What is it?
A. Tyramine reaction.
B. Anticholenergic reaction.
C. Serotonin syndrome.
D. Neuroleptic malignant syndrome.
Ans: Serotonin syndrome
Q: Evidence is accumulated that ADHD is connected to:
a) Dopamine
b) serotonin
c) melanin
d) estrogen
Ans: Dopamine
Q: Cause of death in hospitalized elderly:
a) UTI
b) Pneumonia
Ans: Pneumonia. Most common infection is UTI
Q: A 29-year-old woman presents with an exacerbation of her asthma. She is 11 weeks pregnant. She has mild intermittent asthma and usually takes a b-agonist as needed. She has one 4-year-old child who is in day care and has had a recent upper respiratory tract infection. She has a dry cough, clear nasal discharge, myalgias, and fatigue.
On physical examination, she is talking in full sentences and has normal tympanic membranes, mildly erythematous oropharynx without exudates, no adenopathy; she has positive wheezing bilaterally. The peak flow is 300 mL; her usual result is 390 mL. Pulse oximetry is 93% on room air.
Which of the following is indicated in the management of this patient?
(A) Amoxicillin
(B) Theophylline
© Prednisone
(D) Montelukast
(E) Flunisolide
A: Answer: E Flunisolide
Manage asthma in a pregnant patient
Treatment principles for asthma in the nonpregnant patient apply also to the pregnant patient. She has mild intermittent asthma with an exacerbation, for which therapy with an inhaled glucocorticoid is an appropriate choice. Use of inhaled glucocorticoids is safe in pregnancy.
Q: What is drug of choice pt with HTN and DM II but no proteinuria
A: Inhibition of the renin“angiotensin system with an ACE inhibitor or angiotensin II“receptor antagonist is warranted to decrease both blood pressure and albuminuria; the dose should be titrated upward to the moderate or high range, as tolerated, to achieve a systolic pressure below 130 mm Hg and a diastolic pressure below 80 mm Hg. Although data from clinical trials provide stronger support for the use of angiotensin II“receptor antagonists than for the use of other agents in patients with type 2 diabetes and microalbuminuria or macroalbuminuria, in the absence of a direct comparison of the two strategies, we consider either of these classes of medication to be a reasonable first choice. Serum potassium and creatinine should be checked in all patients seven days after the initiation of treatment with drugs that block the renin“angiotensin system and after any increase in the dose of such drugs. A beta-blocker or diuretic ” or if these agents are inadequate, a nondihydropyridine calcium-channel blocker ” should be added if ACE inhibitors or angiotensin II“receptor antagonists are insufficient to maintain blood pressure in the desired range . We consider adding dihydropyridine calcium-channel blockers or alpha-blockers only when the target for blood pressure is not met with the use of these other approaches
-review article from NEJM
Q: Q:
ileojejunum bypass, diarrhea, what kind of fluid you give?
A: choice is TPN, BUT normal saline+calcium and magnasium replacement
Q:
75 y/o male constipation, no other abnormalities, what is most likely cause
A:
Constipation is seen in 30% of elderly.
It's usually due:
-Declined or impaired general health status
-Drugs: Verapamil
- diminished mobility and physical activity
Treatment: Bowel training, exercise, high fiber diet and increase fluid intake
Pharmacologic treatment: Bulk laxative, emolient laxatives, hyperosmalar laxatives
Renal
Q:
post mva suspect bladder trauma, most sensitive exam
a ct
b u/s
c peritoneal lavage
d kub
A:
Preferred Examination: Retrograde cystogram, performed after urethrogram, was considered the criterion standard for evaluation of bladder trauma. However, in recent years, enthusiasm has grown for CT cystography for proper diagnosis. Initial studies were not indicative of CT reliability when retrograde contrast was not used. However, contemporary studies have overwhelmingly demonstrated both sensitivity and accuracy, provided that adequate bladder distention with contrast material is achieved prior to performing the study with at least 300-400 mL of contrast.
Ultrasound has never been sensitive or specific enough to be useful for evaluation of bladder rupture.
Even in this article it is CT Cystography. So I think rather than choosing CT, cystography is a better choice
Other said: also emed. Most patients have multiple injuries and require abdominal or pelvic CT scans as part of their trauma evaluation. This does not preclude obtaining a separate contrast cystogram, since a CT scan of the pelvis using intravenous contrast alone is an unreliable study for bladder rupture.
A properly performed cystogram consists of an initial kidney-ureter-bladder (KUB), followed by anteroposterior (AP) and oblique views of the bladder filled with contrast, plus another AP film obtained after drainage. The following procedure is recommended:
So kub first, if cystogram then it is the answer, ct will not be the intial as pt will be too sick and pelvic # need more er management first.
Q: Nausea, vomiting taking digoxin, stable, k+6.0
a) give ca gluconate
b) digiband
c) take digoxin levels
A: Digiband see CMDT 1574
Q: Q:
A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
1.Increase the warfarin dose to bring the INR into therapeutic range
2.Switch to dicumarol
3.Interrupt the inferior vena cava with a filter
4.Discontinue warfarin and begin heparin at a therapeutic dose
5.Discontinue warfarin and begin thrombolytic therapy
Explanation
Answer: 4
This 50 year old man has suffered a recurrent venous thrombosis, most likely from suboptimal prophylactic anticoagulation. The target INR for warfarin anticoagulation to prevent recurrent thromboembolism is 2.0-3.0. When a new thrombosis is diagnosed, therapeutic doses of heparin must be initiated. Simply increasing the warfarin dose to bring the INR into therapeutic range is inadequate, because warfarin is used for prophylaxis only, rather than for the treatment of acute thrombosis. For the same reason, switching to a different anticoagulant like dicumarol would be ineffective. After starting up heparin he should be restarted at a higher dose of warfarin.
Interruption of the inferior vena cava with a filter is primarily indicated only for patients in whom anticoagulation is contraindicated or in whom thrombosis has recurred despite adequate prophylactic anticoagulation. Neither of these considerations applies to this patient.
Thrombolytic therapy is not necessary in most case of DVT of the leg. This mode of therapy can be considered in patients with extensive venous thrombosis, particularly involving extension into the inferior vena cava, in order to prevent long-term postphlebetic complications.
Q:
The method of choice for initial evaluation of bone involvement in patients with multiple myeloma is.
A - Technetium-99m bone scanning
B - Conventional roentgenograms
C - CT-scanning
D - MRI of the skeleton
E - None of the above
A: Skeletal series
Perform a complete skeletal series at diagnosis, including the skull (a very common site of bone lesions in multiple myeloma), the long bones (looking for impending fractures), and the spine.
Diffuse osteopenia may suggest myelomatous involvement before discrete lytic lesions are apparent.
The findings on this evaluation may be used to identify impending pathologic fractures, allowing physicians the opportunity to repair debilities and prevent further morbidity.
Do not use bone scans to evaluate myeloma. Cytokines secreted by myeloma cells suppress osteoblast activity; therefore, no increased uptake is observed.
MRI scan
Findings on MRI scans of the vertebrae ofte