2 Flashcards
Congenital adrenal hyperplasia (e-lytes)
Hypotension Hyponatremia Hyperkalemia
In case of DiGeorge syndrome, a _____ is crucial to identify cardiac abnormalities
Echocardiogram
MCC of primary hyperparathyroidism
Glandular adenoma
Ulcers due to chronic NSAIDs are located
Anywhere along the stomach (type V ulcers)
______ is pathognomonic for gallstone ileus
Pneumobilia
Tx of gallstone ileus
Enterotomy (proximal)
Benign liver tumor that has potential for malignant transformation
Liver cell adenoma
Thyroid tumor that cannot be diagnosed by FNA
Follicular thyroid carcinoma
Psamomma bodies
Papillary thyroid cancer (MC ca)
GIST locations
Stomach> small intestine > large intestines
GIST risk factors of malignancy:
Tumor>10cm
>5 mitoses/hpf
A ______ will make the surgeon refuse the offered organ for transplantation
Positive crossmatch (subsequent hyperacute rejection)
Early postoperative bowel obstruction MCC
Adhesions
Most common breast malignancy
Invasive ductal carcinoma
Hyperkalemia least effective Tx
Binding resins
Ovarian metastasis of adenocarcinima of the digestive tract
Krukenberg tumor
Most common cause of wound dehiscence
Infection
Most common inguinal hernia
Indirect
Murmur increases with valsalva
HCM MVP
Sodium glucose correction
+1.6Na for every 100 glucose above 100
Gram-positive rod
Listeria
Listeria - penicillin allergy
TMP-SMX
Indications for drainage of pleural effusions
Loculated
PH<7.2
Gluc<60
Frank pus
Bacteria on Gram stain or culture
Lights criteria
Effusion protein/serum p >0.5
Ef LDH/ S LDH > 0.6
Clinically suspected transudate with Light criteria positive for exudate ->
Protein gradient -> if >3.1g/dl ; Transudate
Cellulitis Tx
Beta-lactams: Cefazolin, Naficillin, Oxacillin, etc
Diamond-shape, holosystolic murmur, increases with valsalva
HOCM
Deafness and QT prolongation
Jervell-Lange-Nielsen syndrome
Tx: beta blockers
The 30 day postop mortality rates in pts with a preop albumin <2 is
30%
Main intracellular anions are
Phosphate and proteins
Main intracellular electrolyte
Potassium and Magnesium
Main extracellular electrolytes
Sodium
Femoral hernia is located _______ to the femoral vein
Medially
1st-generation antipsychotics that cause retinal pigmentation and possible vision loss
Chlorpromazine (reversible pigment, rare v loss)
Thioridazine (irreversible pigment, common v loss)
Supportive psychotherapy
Therapist is not neutral
Suicide tendency in schizophrenic pts
Often unpredictable
Suicide in schizophrenia
Attempts 20-50%
Death 5-6%
Medication of choice for delirium
Haloperidol
Isolated PT prolongation
Factor VII (7) deficiency
Main clinical features of heart failure
Dyspnea on exertion, orthopnea, nocturnal cough, paroxysmal nocturnal dyspnea, nocturia and *early satiety
Progressive PR interval prolongation until a dropped QRS
Mobitz type I
BUN/Cr > 20:1
FENa < 1%
Urine Na < 20
UOsm > 500
Pre-renal azotemia
MCC of death in RA
Ischemic heart disease
Massive hemoptysis def
> 150ml at once
400ml in 24h
Fidaxomicin advantage over vancomycin
Lowers C.dif recurrence rate
SAAG =/>1.1 & protein <2.5
Cirrhosis
SAAG =/> 1.1 (عالي)
Portal hypertension (عالي)
(Cardiac ascites, cirrhosis, Budd-Chiari)
Ascitic protein < 2.5 (low) - 2 cases
Cirrhosis (⬇️production) - SAAG>1.1
Nephrotic syndrome ( ⬆️secretion) - SAAG<1.1
Surgery of choice for Toxic megacolon
Subtotal colectomy with an ileostomy by an abdominal approach
FAP surgery of choice
Proctocolectomy with ileal pouch anal anastomosis
Tx of Infected pancreatic necrosis as a result of Acute pancreatitis
Carbapenems
Surgery for UC in case of high malignancy risk
Proctocolectomy (total. Resection of the colon and rectum)
CRC hepatic mts management
Hepatectomy
Surgery in fulminant Crohn’s colitis (failed conservative therapy)
Subtotal colectomy & ileostomy
Infection with: Hyponatremia, Thrombocytopenia and ⬆️aminotransferases
Rickettsia
Tx: Doxycycline
DOF for refractory Schizophrenia
Clozapine
HypeRcalciuria, kypokalemic metabolic alkalosis
BaRtteR syndrome
HypOcalcemia, hypokalemic metabolic alkalosis
Gitelman syndrome
Hypokalemia, hypernatremia, fluid retention, hypertension & metabolic alkalosis
Liddle syndrome (ENaC increased activity)
Not a typical hernia as there is no defect in the transversalis fascia
Diastasis recti
It is an Acquired thinning of the linea alba
OCD Tx
Behavioural therapy & pharmacotherapy (1st line SSRIs)
SSRIs e.g Fluvoxamine
Akathisia Tx
1st-L: Beta-blockers
Benzodiazepines & clonidine
Tx of Neuroleptic malignant syndrome includes
Dantrolene, Anti-Parkinson meds, Bromocriptine & Amantadine
Types of therapy for Borderline Personality Disorder
Dialectical behaviour therapy
Mentalization based treatment
Transference-focused psychotherapy
Clozapine side effects
Constipation, sialorrhea, agranulocytosis, leukopenia, dizziness, tachycardia, hypotension
Paliperidone (2nd-G APsych) side effects
Renal toxicity, sensitivity to temperature extremes, QT elongation,
Resperidone Side Effects
Weight gain, anxiety, nausea, vomiting, rhinitis, orgasmic and erectile dysfunction, increased pigmentation and HYPERPROLACTINEMIA
Brucellosis
Fever is associated with musculoskeletal symptoms in ~50% of pts
25% have Hepatosplenomegaly
10-20% have significant lymphadenopathy
Neurological involvement is Common
Lumbar/low thoracic osteomyelitis
Endocarditis
Drugs for Idiopathic lung fibrosis
Nintedanib &
Pirfenidone ( anti-fibrotic agents)
Hypercalcemia is corrected when albumin < 4.1
For every 1 below 4.1 -> Add 0.8 Ca+
Bisphosphonates side effects
Jaw necrosis
In HIV pts, seizures are __________ common with cerebral toxoplasmosis than with cryptococcus meningitis
More
MCC of meningitis in HIV
Cryptococcus ( CD4 < 100)
Tx: Amphotericin B and Flucytosine
In COPD exacerbation - steroids rout of administration
Systemic
Tx of Hypothyroidism in Elderly pts esp with heart disease
Lower doses are usually required - starting dose of Levothyroxine is 12.5-25 mcg/day
Hypothyroidism - usual dose of Levothyroxine
100-150 mcg
Bronchiectasis shows ________ pattern in PFTs
Obstructive
A combination of rheumatoid arthritis and pneumoconiosis (intrapulmonary nodules - well-defined and homogeneous on X-ray)
Caplan’s syndrome
RA associated valvular pathology
Mitral regurgitation
RA most common cause of death
Cardiovascular disease
Most common pathogen in peritonitis in pts who undergo peritoneal dialysis
Staph aureus
Churg-Strauss - Eosinophilic granulomatosis with polyangiitis Tx
Glucocorticoids
Cyclophosphamide if cardiac involvement
Mepolizumab (anti-IL6)
Antibiotics for variceal bleeding
Ceftriaxone
Hyperkalemia - calcium gluconate dose
10% calcium gluconate 10mL IV over 2-3mins - Repeated as needed
Physiologic gynecomastia mechanisms
Hormonal imbalance and increased IGF-1 levels
Vomiting, loss of appetite, upper abdominal discomfort, diarrhea, swelling due to protein loss, ascites.
On endoscopy: Enlarged gastric folds
Upper GI imaging: thickened folds
Hypertrophic Gastropathy
Tx of Hypertrophic Gastropathy
Hydration / supportive
N.meningitdes Prophylaxis
Priority is for close contact to oral secretions within a week
Ceftriaxone / Ciprofloxacin > rifampin
Infantile hemangioma requires additional testing when:
5 or more skin lesions-> liver US
Facial/Segmental hemangioma-> Echo and Cranial MRI (PHACE syndrome)
Cervicofacial - beard-like distribution-> Laryngoscopy
Lumbosacral -> Spinal US
Indications for Tx for infantile hemangioma with Beta-Blockers
- Extensive facial, segmental or enlarging lesions prone to ulceration and scarring
- periorbital lesions
- Liver associated cases
- Subglottic region involvement
Duchene Muscular Dystrophy is associated with
Dilated cardiomyopathy
Cardiogenic shock, bronchoconstriction, altered mental status, convulsions
Beta blocker overdose
Give atropine, glucagon and fluids
Tuberous sclerosis - Heart
Rhabdomyomas
mitral regurgitation
Congenital adrenal hyperplasia
Decreased aldosterone -> Salt wasting; hyponatremia, hypotension and hyperkalemia
HSP - involved systems
Gastrointestinal 80%
Musculoskeletal 75%
Renal 30%
Intussusception in HSP
Ileoileal
Liver tumors that have potential for malignant transformation - Hepatocellular carcinoma
Hepatic adenoma ( liver cell adenoma)
Malignant Phyllodes tumor - Indications for adjuvant radiation
Close or concerning margins
Fascia / chest wall involvement
> 5cm
Wide local excision only
Is regional lymph node dissection required with malignant Phyllodes tumor ?
No, it spreads Hematogenously
Colon cancer - cases where Neoadjuvant treatment is recommended
Low rectal tumor with local lymph node involvement
- clinically T3 and node-positive rectal cancers in close proximity of the sphincter in whom sphincter sparing is desired -
Hinchy classification - Diverticulitis
1a - confined pericolic inflammation or a phlegmon
1b - confined pericolic abscess
2 - distant abscess
3 - generalized purulent peritonitis
4 - fecal peritonitis
Hernia tension-free repair is
Mesh repair (lower recurrence rate)
Acute pancreatitis - Nutritional support
Enteral feeding preferred
Vascular thrombosis as a complication of acute pancreatitis
Most commonly in splenic vein -> splenomegaly, gastric varices and splenic vein occlusion
Pseudoaneurysm as a complication of acute pancreatitis
Most commonly in splenic artery -> spontaneous bleeding
Paget’s disease of the nipple
If imaging rules out suspicious breast findings, breast-conserving operation is acceptable *as long as Axillary lymph nodes are evaluated
Acute cholangitis - Reynold’s pentad
Fever, jaundice, RUQ pain (Charcot) + hypotension and altered mental status
MCC of early post-op bowel obstruction
Adhesions (90%)
Achalasia Dx test of choice
Manometry
Surgical site infection most common pathogen
Staph aureus
Inguinal Hernia repair - laparoscopic with mesh and open with mesh- recurrence rate
The SAME
Peritonitis- source of pain
Parietal peritoneum nerve endings
Contraindication to mesh in inguinal hernia repair
Strangulated hernias (necrotic) for which bowel resection is necessary - here tissue repair is necessary
Bariatric surgery that is solely Restrictive - No malabsorption
Gastric Band
Metastasis of gastric carcinoma to the ovary
Krukenberg tumor
A hernia that protrudes through the deep inguinal ring, traverses the inguinal canal and exits into the scrotum via the superficial inguinal ring - and is lateral to the inferior epigastric vessels
Indirect inguinal hernia
Hernia protruding medial to the inferior epigastric vessels and the deep inguinal ring - through Hesselbach’s triangle
Direct inguinal hernia
Indirect and femoral hernias occur more commonly on the ______ side
Right
Pelvic fracture immediate management is with
Pelvic binder/sheet
Acute Dystonia - a SE of antipsychotics (e.g Haloperidol) -> Tx
IV/IM Biperdin 2mg (anticholinergic) or
IV/IM Diphenhydramine
ADHD drug with No abuse potential
Atomoxetine (Starterra)
In major depressive disorder, acute phase medication trials should last ________ to allow for adequate time for meaningful symptom reduction
4-6 weeks
يعني إذا المريض بعده ماتحسنش خلال اقل من شهر، كمل العلاج للشهر وبعدها شوف
Initial dose of SSRI (Fluoxetine) for MDD
10 or 20mg PO daily
Brief psychotic disorder- duration
> 1day & <1 month
اكثر من يوم وأقل من شهر
Diarrhea, myoclonus, diaphoresis, hyperactive reflexes, tremors, disorientation, ataxia & mood lability
Serotonin syndrome
- as a result of co-administration of SSRIs with MAOI, L-tryptophan or Lithium-
Obsessive-Compulsive and related disorders - repetitive and intrusive thoughts-
OCD
Body dysmorphic disorder
Hoarding disorder
Trichotillomania
Excoriation disorder
Pick’s disease = Frontotemporal dementia
Early stage are characterized by personality and behavioural changes, with relative preservation of other cognitive functions (compared to dementia)
Akathisia - SE of antipsychotics - subjective feelings/objective signs of restlessness, jitteriness, pacing, inability to relax and stay still -> Tx
Propranolol (beta-blockers) as 1st line
2nd line- BDZ
Tourette disorder Dx depends on:
Multiple motor tics and at least one vocal tic
For PTSD - A type of trauma-focused cognitive behavioural therapy that focuses on re-experiencing the traumatic event through repeatedly engaging with the memories and everyday reminders:
Prolonged Exposure therapy
Schizophrenia- positive prognostic factors
Acute onset
Female
Living in a developed country
Dx of schizophreniform disorder
Duration 1 to <6 months
Negative symptoms
Acute mania - 1st line Monotherapy
Lithium, Divalproex, Olanzapine, Risperidone, Quetiapine, Aripiprazole, Ziprasidone, Asenapine, Paliperidone, Cariprazine
Exaggerated conceptions of one’s importance, power or identity
Grandiose/garndeur delusions
Supportive psychotherapy indications:
Pts contraindicated for classic or insight-oriented psychoanalytic psychotherapy
Pts in acute crisis or a temporary state of disorganisation & inability to cope
Fragile/deficient/depleted ego
Contraindications for Vaginal breech delivery
Fetal head is hyperextended
Footling presentation
Endometrial carcinoma - preferred modality for endometrial sampling
Hysteroscopy
Diagnostic workup for recurrent Miscarriages
Parental karyotyping (cytogenetics)
Anatomical exam; US, hysterosalpingogram, hysteroscopy
Midluteal progesterone level, TSH, prolactin, fasting insulin and glucose, GTT
Lupus anticoagulant, Anticardiolipin IgG/IgM
Thrombophilic disorders
Protective factors against myomas (fibroids)
SMOKING
Exercise
Multiparity
Late menarche / early menopause
OCPs
Klinefelter Infertility (azospermia) Tx
Sperm donation
Klinefelter - leydig cell dysfunction (hypoleydigism) Tx
Testosterone
Klinefelter - Gynecomastia Tx
There’s No effective treatment
Surgical removal if psychosocial symptoms
Gynaecologic procedures that does NOT require antibiotic prophylaxis
IUD insertion
Hysteroscopy (even with polyp excision)
Endometrial biopsy
Surgical abortion - prophylactic antibiotics
First trimester: Doxycycline before and after
Second trimester: IV cefazolin before
Caesarean section - antibiotic prophylaxis
IV Cefazolin 1-2g 30mins before
Hysterectomy (vaginal/abdominal) - AB prophylaxis
IV Cefazolin 1-2g 30mins before
A hormone that demonstrates a pattern similar to estrogen levels throughout the menstrual cycle
LH
HPV vaccine recommended age
11-12 years
Cervical cancer 1a1(only)- management
Fertility desired -> repeat conization
Not desired -> Simple hysterectomy (only stage where simple is acceptable)
What group of genetic diseases is screened for before pregnancy?
Autosomal Recessive disorders
Most vulnerable area for ureteral injury in abdominal hysterectomy is
The site where the ureter courses underneath the uterine artery in the cardinal ligament
Call-Exner bodies (Multiple small cavities containing eosinophilic fluid)
Coffee-bean (grooved) nuclei
Granulosa cell tumor
Ovarian tumor that causes precocious puberty in young girls
And adenomatous hyperplasia and vaginal bleeding in post menopausal women
Granulosa cell tumor (estrogen secretion)
B-Lynch Brace Suture
Uterine atony or
Placenta percreta
Twin pregnancy that unequivocally requires CS
Monochorionic Monoamnionic twins
Parental karyotype of most Down syndrome cases
Normal
Suspected late-IUGR without any alarming signs - management
Fetal kick count
Antepartum testing with BPP and UA Doppler once/twice a week
Amniotic fluid embolism is almost always associated with
Some form of coagulopathy
Ovarian hyperstimulation syndrome - effect on Sodium
Hyponatremia
Asymptomatic bacteruria in pregnancy - empiric antibiotics:
Sulfonamides, Nitrofurantoin, cephalosporins
Pre-implantation genetic diagnosis (PGD) Indications:
- High risk of transmitting an inherited condition
- monogenic disorder (AR, AD, X-linked)
- chromosomal structural abnormality / translocation (stable translocation) - Chromosome screening in IVF
A negative brucellosis serology test
Rules out the disease
Anemia, thrombocytosis, splenomegaly, 9;22 translocation
CML
Low leukocyte alkaline phosphatase score
Leukocytes > 50,000
Blast cells <5%
Basophilia
CML
CML Tx
Tyrosine kinase inhibitors: Imatinib, Dasatinib
Methymalonic acid is increased in
Vit B12 deficiency (vs folate deficiency where it’s normal)
Necrotizing fasciitis / Gas gangrene Tx
Clindamycin + penicillin
Non-oliguric AKI can occur with (drug) ________
Aminoglycosides (e.g Amikacin, Tobramycin, Neomycin, Gentamicin, Streptomycin)
What differentiates between DKA and HHS
In DKA there’s Increased Ketone levels and acidosis
Anticoagulants in pregnancy
LMWH (e.g Enoxaparin; Clexane)
Lobar pneumonia, Neurological signs and Diarrhea
Legionella pneumonia-> Tx with fluoroquinolones (Levofloxacin) or Macrolide
Infective Endocarditis - Indications for emergent (within 24h) surgery
- Cardiogenic shock/ pulmonary edema
- Acute AR causing premature mitral valve closure
- Abscess rupture into right heart
- Rupture into the pericardial sac
Fever, rash, peripheral eosinophilia and oliguric kidney injury
7-10 days after Tx with methicillin or another beta-lactam
Acute interstitial nephritis
Atypical acute interstitial nephritis
Occurs with NSAIDs - AKI with heavy proteinuria but fever,rash& eosinophilia are RARE
A clinical picture of STEMI without significant coronary artery disease that responds well to Nitroglycerin
Prinzmetal angina
Prinzmetal angina Tx
Nitrates and Calcium Channel Blockers
What’s elevated in Mitral stenosis
Left atrial pressure
In a pt with Sjogren syndrome; persistent parotid enlargement, purpura, leukopenia, cryoglobulinemia, low C4
Are signs of Lymphoma, which is known complication of Sjogren syndrome
In case of amiodarone-associated Hypothyroidism
Continue Amiodarone and Add Levothyroxine
First serological evidence of HBV infection
HBsAg
In HBV - what indicates ongoing viral replication, infectivity and inflammatory liver injury
HBeAg
HBV first-line Tx
Entecavir / Tenofovir (PO)
Tx of any inflammatory life-threatening or organ-threatening manifestation of SLE
Glucocorticoids + cytotoxic/immunosuppressive agents ( Cyclophosphamide or Mycophenolate mofetil)
Crohn’s disease - induction of remission
Corticosteroids, TNF-alpha inhibitors in severe dz (infliximab, adalimumab)
Crohn’s maintenance medications
Methotrexate, Azathioprine, Integrin inhibitors & others
CLL 5 year survival rate
Over 80%
Smudge cells, CD5+ cells
CLL
Contrast-induced nephropathy occurs ____ days after exposure
And resolves after ______
2 days
5-7days
Diabetic pts should stop ______ before contrast exposure (risk of contrast-induced neohropathy)
Metformin (24h prior to the procedure and for 48h after)
Cardiac tamponade - on physical exam
Pulsus paradoxus
High LDL despite high dose statin, add
Ezetimibe
Fibrates are for
Hypertriglyceridemia
Howell-Jolly bodies
Asplenia
What cancer is associated with polyarteritis nodosa?
Hairy-cell leukemia
If an SVT terminates after AV node block with vagal manoeuvres - it’s an indication of
AVNRT, AVRT or Adenosine-sensitive focal AT
Diarrhea - acid/base disturbance:
NON-anion gap metabolic acidosis (loss of bicarbonate)
When bicarbonate is lost either with diarrhea or Renal tubular abnormalities- acidosis is
Non anion gap
Indications for prophylactic ICD implantation
EF<35% : after 3 months of revascularization OR 40 days of MI
Cushing - e-lyte disturbance
Hypokalemic alkalosis
Is SBP more common in cirrhotic pts with esophageal varices compared to cirrhotic pts without varices?
Yes, SBP is more common in cirrhotic pts with esophageal varices
Some risk factors for developing active TB
(بالإضافة للأسباب الواضحة)
Recent infection <1yr
Fibrotic lesions (spontaneously healed)
Gastrectomy
Jejunoileal bypass
TNF-alpha inhibitors
Neuropathy in a pt being treated for TB
Caused by INH -> give vitB6
Active TB Tx
RIPE for 6 months
Latent TB Tx
Either Rifampin for 4months or
INH 6-9 months
TB pt with back pain, fever, parasthesia
Pott’s disease (the most common extrapulmonary manifestation)
Catheter-associated UTI - pathogens that necessitate catheter replacement
Pseudomonas aeruginosa
Candida spp
Repeated regurgitation of food, where the regurgitated food may be rechewed, re-swallowed or spit out, for a period of at least one month, following a period of normal functioning and may be precipitated by complex familial situations
Rumination disorder
Tx of Rumination disorder
Behavioural and supportive
SIMPLE febrile seizure
Generalized, tonic-clonic, associated with fever
Lasting max 15 mins
Not recurrent within 24h
Gaze deviation during a febrile seizure suggest -
Focal seizure; Complex
Major risk factors for Febrile seizures recurrence
Age < 1yr
Duration of fever < 24h
Seizure at a fever of 38-39C
Minor risk factors for febrile seizure recurrence
Male attends day care complex febrile seizure Hyponatremic with FHx of febrile seizures
Pts with long QT syndrome who fail beta-blocker therapy ->
Defibrillator implantation
Early teeth eruption in infants
Precocious puberty
Hyperthyroidism
Cleidocranial dysplasia causes _________ teeth eruption
Delayed
Newborn with a late volume of watery stool and a Hx of polyhydraminos
Microvillus inclusion disease.
Dx of microvillus inclusion disease
PAS and CD10 staining on light microscopy
Retropharyngeal abscess management
IV antibiotics with or without surgical drainage (in case of no response to AB or impending airway compromise)
Intubate only in case of deterioration vital signs
