SMLE mix Flashcards
Acetaminophen heptotoxicity stages
Stage 1:
- 0.5-24 hours after ingestion.
- Patients may be asymptomatic or report anorexia, nausea or vomiting, and malaise.
- Physical examination may reveal pallor, diaphoresis, malaise, and fatigue.
Stage 2 :
- 18-72 h after ingestion
- Patients develop right upper quadrant abdominal pain, anorexia, nausea, and vomiting.
- Right upper quadrant tenderness may be present.
- Tachycardia and hypotension may indicate volume losses.
- Some patients may report decreased urinary output (oliguria)
Stage 3: Hepatic phase
- 72-96 h after ingestion
- Patients have continued nausea and vomiting, abdominal pain, and a tender hepatic edge
- Hepatic necrosis and dysfunction may manifest as jaundice, coagulopathy, hypoglycemia, and hepatic encephalopathy
- Acute kidney injury develops in some critically ill patients
- Death from multiorgan failure may occur.
Stage 4:Recovery phase
- 4 d to 3 wk after ingestion
- Patients who survive critical illness in phase 3 have complete resolution of symptoms and complete resolution of organ failure
What is the Minimum toxic doses of acetaminophen for a single ingestion, posing significant risk of severe hepatotoxicity ?
In :
- Adults: 7.5-10 g
- Children: 150 mg/kg; 200 mg/kg in healthy children aged 1-6 years
How to treat acetaminophen toxicity ?
- ABCs
- Gastric decontamination with Oral Activated charcoal (AC) if the patient has a stable mental and clinical status, patent airway, and presents to the emergency department within 1 hour of ingestion.
- N-acetylcysteine (NAC) : 100% hepatoprotective when it is given within 8 hours after an acute acetaminophen ingestion or if pt is pregnant. (even if it exceeded 8 hrs you should still give it).
- Psychosocial, psychological and/or psychiatric evaluation is indicated if the patient intent to do self harm
What are the criteria for liver transplantation in patients with acetaminophen toxicity ?
- Metabolic acidosis, unresponsive to resuscitaton
- Renal failure
- Coagulopathy
- Encephalopathy
Stepwise Pharmacological therapy in Asthma
- SABA
- low dose ICS
Alternatives: Cromolyn/Leukotriene receptor antagonist (LTRA)/Theophylline. - low dose ICS + LABA OR medium-dose ICS
Alternatives: low-dose ICS + either an LTRA or theophylline. - medium-dose ICS + LABA
Alternatives: medium-dose ICS + either LTRA or theophylline. - high-dose ICS + LABA
- High-dose ICS + LABA + oral corticosteroid.
*SABA: Albuterol (Ventolin)
*LABA: Salmeterol
* Symbicort: ICS + LABA
* ICS : Budesonide (Pulmicort)
What are the tests used to confirm the diagnosis of asthma ?
- Spirometry
- Peak airflow
- FeNO tests (exhaled nitric oxide)
- Provocation tests
At which age does colorectal cancer screening is recommended ?
50 years old
What are the screening options of colorectal cancer screening ?
Tests that detect adenomatous polyps and cancer:
- Flexible sigmoidoscopy every 5 years
- Colonoscopy every 10 years
- Double-contrast barium enema every 5 years
- Computed tomographic (CT) colonography every 5 years.
Tests that primarily detect cancer:
- Annual guaiac-based fecal occult blood test (FOBT) with high test sensitivity for cancer.
- Annual fecal immunochemical test (FIT) with high test sensitivity for cancer.
- Stool DNA test with high sensitivity for cancer, interval uncertain
What are the 4 typical features of tetralogy of Fallot ?
- Right ventricular (RV) outflow tract obstruction (RVOTO (infundibular stenosis).
2.Ventricular septal defect (VSD).
3.Aorta dextroposition (overriding aorta).
4.Right ventricular hypertrophy.
What is the screening age of osteoporosis?
Women 65 years or older without previous known fractures or secondary causes of osteoporosis.
What are the Treatment Options of Neurobrucellosis ?
Antimicrobial drugs like Rifampicin, doxycycline, ceftriaxone, or co-trimoxazole for a duration of 3–6 months or until normalization of CSF.
What is the antibiotic of choice for Campylobacter infections?
Azithromycin therapy would be a primary antibiotic choice for Campylobacter infections, when indicated (see Medical Care), with a typical regimen of 500 mg/d for 3 days. If the patient is bacteremic, treatment can be extended to two weeks.
However, erythromycin is the classic antibiotic of choice. Its resistance remains low, [32] and it can be used in pregnant women and children.
In which conditions does schistocytes occur ?
Characteristic feature of : microangiopathic hemolytic anemia(MAHA).[5] The causes of MAHA:
can be:
- Disseminated intravascular coagulation
- Thrombotic thrombocytopenic purpura
- Hemolytic-uremic syndrome
- HELLP syndrome: hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome.
- Malfunctioning cardiac valves
What is Disseminated intravascular coagulation (DIC)?
Systemic activation of blood coagulation, which results in generation and deposition of fibrin, leading to microvascular thrombi in various organs and contributing to multiple organ dysfunction syndrome (MODS).
Consumption of clotting factors and platelets in DIC can result in life-threatening hemorrhage.
How does the lab values usually be in DIC patients?
- Prolonged coagulation times.
- Thrombocytopenia.
- High levels of fibrin degradation products (FDPs).
- Elevated D-dimer levels.
- Microangiopathic pathology (schistocytes) on peripheral smears.
How to appraoch Contrast Medium Reactions ?
- ABCs
- Vital signs
- Immediately discontinue ICM administration.
- Oxygen administration.
- IV Epinephrine (Adrenaline)
- H1 antihistamines, such as diphenhydramine, and H2-receptor blockers, such as cimetidine, do not have a major role in the treatment of respiratory reactions, but they may be administered after epinephrine.
- Vital signs monitoring
- If pt is hypotensice: intravenous iso-osmolar fluid (ie, normal saline, Ringer lactate solution) in large volumes. Vasopressors should be considered if hypotension is resistence.
The most specifically effective vasopressor is dopamine; at infusion rates of 2-10 mcg/kg/min.
Name the muscles of the eye, thier actions and thier nerve supply.
- Lateral rectus - Moves eye laterally - Abducens VI
- Medial rectus - Moves eye medially - Oculomotor III
- Superior rectus- Elevate eye + medially - Oculomotor III
- Inferior rectus- depresses eye + medially + Oculomotor III
- Inferior oblique - elevates eye+ laterally - Oculomotor III
- Superior oblique - depressess eye + laterally - Trochlear IV.
What is the management of ascities ?
Sodium restriction and diuretic therapy constitute the standard medical management for ascites:
- Start with spironolactone at 100 mg/d (aldosterone antagonists)
- loop diuretics may be necessary in some cases to increase the natriuretic effect.
- If no response occurs after 4-5 days, the dosage may be increased stepwise up to spironolactone at 400 mg/d plus furosemide at 160 mg/d.
- Therapeutic paracentesis
- Supplementing 5 g of albumin per each liter over 5 L of ascitic fluid removed decreases complications of paracentesis, such as electrolyte imbalances and increases in serum creatinine levels secondary to large shifts of intravascular volume.
- The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional radiologic technique that reduces portal pressure and may be the most effective treatment for patients with diuretic-resistant ascites.
What is Lewy Body Dementia?
Signs and symptoms ?
management ?
It is a progressive, degenerative dementia of unknown etiology. Affected patients generally present with dementia preceding motor signs, particularly with visual hallucinations and episodes of reduced responsiveness..
Signs and symptoms:
- varying levels of alertness and attention.
- Visual hallucinations
- Parkinsonian motor features
- Anterograde memory loss
- Nonvisual hallucinations
- Delusions
- Unexplained syncope
- Rapid eye movement sleep disorder
- Neuroleptic sensitivity
Management:
- Cholinesterase inhibitors (eg, donepezil, rivastigmine, rivastigmine patch, galantamine)
- 2nd-generation antipsychotics (eg, clozapine, quetiapine, aripiprazole)
- Antidepressants (eg, venlafaxine, paroxetine, sertraline, fluoxetine)
- Benzodiazepines (eg, clonazepam)
- Dopamine precursors (eg, levodopa and carbidopa)
What is Malaria?
Parasitic disease caused by infection with Plasmodium protozoa transmitted by an infective female Anopheles mosquito.
Plasmodium falciparum infection carries a poor prognosis with a high mortality if untreated.
What are the Signs and symptoms of malaria?
- Headache
- Cough
- Fatigue
- Malaise
- Shaking chills
- Arthralgia
- Myalgia
- Paroxysm of fever, shaking chills, and sweats (every 48 or 72 hours, depending on species)
Less common symptoms include the following:
- Anorexia and lethargy
- Nausea and vomiting
- Diarrhea
- Jaundice
- Cerebral malaria (sometimes with coma)
- Severe anemia
- Respiratory abnormalities: Include metabolic acidosis, associated respiratory distress, and pulmonary edema; signs of malarial hyperpneic syndrome include alar flaring, chest retraction, use of accessory muscles for respiration, and abnormally deep breathing
- Renal failure (typically reversible)
What is the treatment of malaria ?
Quinine-based therapy is with quinine (or quinidine) sulfate plus doxycycline or clindamycin or pyrimethamine-sulfadoxine;
What is the classic triad of bacterial meningitis ?
- Fever
- Headache
- Neck stiffness
Name the medications in which can be used as meningitis prophylaxis ?
Rifampin, quinolones, and ceftriaxone are the antimicrobials that are used to eradicate meningococci from the nasopharynx.
Malaria Chemoprophylaxis?
- Atovaquone/proguanil (Malarone)
50/100 mg per day one to two days before travel through seven days after return. - Doxycycline:
100 mg per day one to two days before travel through four weeks after return. - Mefloquine:
250 mg per week one week before travel through four weeks after return - Chloroquine (Aralen):
500 mg per week one to two weeks before travel through four weeks after return
How to manage pulmonary embolism ?
- Anticoagulation:
- LMWH or fondaparinux.
- If concerns regarding subcutaneous absorption arise, severe renal failure exists, or if thrombolytic therapy is being considered, IV UFH is the recommended form of initial anticoagulation.
- Three months of treatment with anticoagulation
- Thrombolytic therapy:
- In patients with acute PE associated with hypotension (systolic BP< 90 mm HG) who do not have a high bleeding risk.
Thrombolytic therapy is not recommended for most patients with acute PE not associated with hypotension.
- In patients with acute PE associated with hypotension (systolic BP< 90 mm HG) who do not have a high bleeding risk.
- Direct thrombin inhibitors and factor Xa inhibitors:
- Apixaban, dabigatran, rivaroxaban, and edoxaban are alternatives to warfarin for prophylaxis and treatment of PE.
- Warfarin therapy:
- A vitamin K antagonist such as warfarin should be started on the same day as anticoagulant therapy in patients with acute PE. [5] Parenteral anticoagulation and warfarin should be continued together for a minimum of at least five days and until the INR is 2.0.
- The recommended therapeutic range for venous thromboembolism is an INR of 2-3. This level of anticoagulation markedly reduces the risk of bleeding without the loss of effectiveness. Initially, INR measurements are performed on a daily basis; once the patient is stabilized on a specific dose of warfarin, the INR determinations may be performed every 1-2 weeks or at longer intervals.
- A patient with a first thromboembolic event occurring in the setting of reversible risk factors, such as immobilization, surgery, or trauma, should receive warfarin therapy for at least 3 months.
How to approach a pregnant patient with high suspicion of PE?
D-dimer if -ve but still high suspicion -> bilateral leg Doppler assessment.
If the results are positive, the patient should be treated for pulmonary embolism. If the results are negative, CT pulmonary angiography is the next step.
Pregnant patients diagnosed with DVT or pulmonary embolism may be treated with LMWH throughout their pregnancy. Warfarin is contraindicated, because it crosses the placental barrier and can cause fetal malformations
What is pheochromocytoma ?
It is a rare, catecholamine-secreting tumor derived from chromaffin cells.
What are the syndromes that are associated with pheochromocytoma?
- Von Hippel-Lindau (VHL) syndrome.
- Multiple endocrine neoplasia type 2 (MEN 2)
- Neurofibromatosis type 1 (NF1)
What are the precintage of malignant pheochromocytoma?
10% of pheochromocytomas and 35% of extra-adrenal pheochromocytomas are malignant.
What are the common metastatic sites of malignant pheochromocytoma ?
Bone
Liver
Lymph nodes.
What is the classic presentation and what are the other clinical signs associated with pheochromocytomas ?
Classically:
- Headaches
- Palpitations
- Diaphoresis
- Severe hypertension
Other:
- Tremor
- Nausea
- Weakness
- Anxiety, sense of doom
- Epigastric pain
- Flank pain
- Constipation
- Hypertension: Paroxysmal in 50% of cases
- Postural hypotension: From volume contraction
- Hypertensive retinopathy
- Weight loss
- Pallor
- Fever
- Tremor
- Neurofibromas
- Tachyarrhythmias
- Pulmonary edema
- Cardiomyopathy
- Ileus
- Café au lait spots
How to Diagnose pheochromocytoma and what are the tests used ?
- Plasma metanephrine testing:
In patients at high risk (ie, those with predisposing genetic syndromes or a family or personal history of pheochromocytoma) - 24-hour urinary collection for catecholamines and metanephrines:
- In patients at lower risk.
Imaging studies should be performed only after biochemical studies have confirmed the diagnosis of pheochromocytoma:
- Abdominal CT scanning.
- MRI: Preferred over CT scanning in children and pregnant or lactating women.
- Scintigraphy: Reserved for biochemically confirmed cases in which CT scanning or MRI does not show a tumor.
- PET scanning.
Additional studies to rule out a familial syndrome:
- Serum intact parathyroid hormone level and a simultaneous serum calcium level to rule out primary hyperparathyroidism (which occurs in MEN 2A).
- Screening for mutations in the ret proto-oncogene (which give rise to MEN 2A and 2B).
- Genetic testing for mutations causing the MEN 2A and 2B syndromes.
- Consultation with an ophthalmologist to rule out retinal angiomas (VHL disease)
How to manage pheochromocytoma ?
Surgical resection of the tumor is the treatment of choice.
Careful preoperative treatment with alpha and beta blockers is required to control blood pressure and prevent intraoperative hypertensive crises:
- Start alpha blockade with phenoxybenzamine 7-10 days preoperatively.
- Provide volume expansion with isotonic sodium chloride solution.
- Encourage liberal salt intake
- Initiate a beta blocker only after adequate alpha blockade, to avoid precipitating a hypertensive crisis from unopposed alpha stimulation.
- Administer the last doses of oral alpha and beta blockers on the morning of surgery.
What is Uncomplicated Cystitis ?
usually occur in which type of patients?
what are the Sx ?
Uncomplicated cystitis occurs in patients who have a
- Normal, u
- Unobstructed genitourinary tract.
- who have no history of recent instrumentation
- whose symptoms are confined to the lower urinary tract.
Uncomplicated cystitis is most common in:
- young
- sexually active women.
Patients usually present with:
- dysuria
- urinary frequency
- urinary urgency
- suprapubic pain
What is the management of uncomplicated Cystitis in Nonpregnant Patients ?
First-line therapy:
- Trimethoprim/sulfamethoxazole 160 mg/800 mg (Bactrim DS, Septra DS) 1 tablet PO BID for 3d or
- Nitrofurantoin monohydrate/macrocrystals (Macrobid) 100 mg PO BID for 5-7d or
-Nitrofurantoin macrocrystals (Macrodantin) 50-100 mg PO QID for 7d or - Fosfomycin (Monurol) 3 g PO as a single dose with 3-4 oz of water.
Second-line therapy:
- Ciprofloxacin (Cipro) 250 mg PO BID for 3d or
- Ciprofloxacin extended release (Cipro XR) 500 mg PO daily for 3d or
-Levofloxacin (Levaquin) 250 mg PO q24h for 3d or
- Ofloxacin 200 mg PO q12h for 3d
Alternative therapy:
- Amoxicillin-clavulanate (Augmentin) 500 mg/125 mg PO BID for 3-7d or
- Amoxicillin-clavulanate (Augmentin) 250 mg/125 mg PO TID for 3-7d or
- cefdinir 300 mg PO BID for 7d or
- cefaclor 500 mg PO TID for 7d or
- cefpodoxime 100 mg PO BID for 7d or
- cefuroxime 250 mg PO BID for 7-10d
How to manage Complicated Cystitis in Nonpregnant Women ?
First-line therapy
Oral:
- Ciprofloxacin (Cipro) 500 mg PO BID for 7-14d or
- Ciprofloxacin extended release (Cipro XR) 1 g PO daily for 7-14d or
- levofloxacin (Levaquin) 750 mg PO daily for 5d
Parenteral:
- Ciprofloxacin (Cipro) 400 mg IV q12h for 7-14d or
- Levofloxacin (Levaquin) 750 mg IV daily for 5d or
- Ampicillin 1-2 g IV q6h + gentamicin 2 mg/kg/dose q8h for 7-14d or
- piperacillin-tazobactam (Zosyn) 3.375 g IV q6h or
- Doripenem 500 mg (Doribax) IV q8h for 10d or
- Imipenem-cilastatin (Primaxin) 500 mg IV q6h for 7-14d or
- Meropenem (Merrem) 1 g IV q8h for 7-14d
Second-line therapy
- cefepime (Maxipime) 2 g IV q12h for 10d or
- ceftazidime (Fortaz, Tazicef) 500 mg IV or IM q8-12h for 7-14d
- Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized.
- Parenteral therapy can be switched to oral therapy once clinical improvement is observed.
How to manage Urinary Tract Infections in Pregnancy ?
- In pregnancy, treating asymptomatic and symptomatic bacteriuria is important.
- Behavioral methods include the following:
- Avoid baths
- Wipe front-to-back after urinating or defecating
- Wash hands before using the toilet
- Use washcloths to clean the perineum
- Use liquid soap to prevent colonization from bar soap
- Clean the urethral meatus first when bathing.
- Tx in asymptomatic bacteruria during pregnancy + symptomatic:
- Nitrofurantoin monohydrate/macrocrystals 100 mg orally twice daily for 5-7 days or
- Amoxicillin 875 mg orally twice daily (alternative: 500 mg orally three times daily) for 5-7 days or
- Amoxicillin-clavulanate 500/125 mg orally three times daily for 5-7 days (alternative: 875/125 mg orally two times daily for 5-7 days) or
- Cephalexin 500 mg orally four times daily for 5-7 days or
- Fosfomycin 3 g orally as a single dose with 3-4 oz. of water
What are the side effects of Angiotensin-converting enzyme (ACE) inhibitors ?
- Dry cough
- Hyperkalemia
- Fatigue
- Dizziness from blood pressure going too low
- Headaches
- Loss of taste
What is the chance of transmission of the following virusis, in needle stick injury :
- HCV
- HIV
- HBV ?
- HCV : 3%
- HIV: 0.3 %
- HBV: 30%
What is Cardiac Tamponade Treatment ?
- Pericardiocentesis.
- Patients should be monitored in an intensive care unit.
- Oxygen
- Volume expansion with blood, plasma, dextran, or isotonic sodium chloride solution.
- Bed rest with leg elevation.
What is the classification of pulmonary hypertension ?
- Group 1 - Pulmonary arterial hypertension (PAH)
- Group 2 - Pulmonary hypertension due to left-sided heart disease
- Group 3 - Pulmonary hypertension due to lung diseases and/or hypoxia
- Group 4 - Chronic thromboembolic pulmonary hypertension (CTEPH)
- Group 5 - Pulmonary hypertension with unclear or multifactorial etiologies,
Guillain-Barre Syndrome effective treatment ?
Intravenous immunoglobulin (IVIG) and plasma exchange have proved equally effective.
Status Epilepticus diagnostic workup ?
- Check ABCs
- Insert IV
- STAT labs:
- Electrolytes, Ca, Mg.
- CBC
- LFT + renal function tests.
- Toxicology screen
- Anticonvulsant level
- ABG
- Insert urinary catheter.
- Urinanalysis + urine toxicology
- Cardiac O2 saturation + monitors
- Consider:
- Trauma
- Stroke
- Infection
- Drug ingestion
- Do As indicated:
- CXR
- CT scan / MRI
- Lumbar puncture
- Blood cultures
- Blood toxicology screen
- Treat underlying cause
- Admit to hospital.
Status Epilepticus treatment?
- Start IV line
- Administer a 50 mL bolus of 50% dextrose IV + 100mg Thiamine. (Add Naloxone 0.4 - 2 mgIV to dextrose bag if OD is suspected).
- Start anticonvulsant:
- Diazepam 0.15 mg/Kg OR Lorazepam 0.1mg/kg IV over 5 mins OR IM midazolam.
- Followed by: Fosphyntoin 15-20mg (not to exceed 150mg PE/min. OR phenytoin 18-20 mg/kg (not to exceed 50mg/min)
- Never mix Phenytoin with 5% dextrose solution, put it in normal saline.
- Intubate if indicated
- Control hyperthermia
- If seizure continued after 20 mins give additional Fosphyntoin 10mg PE/Kg IV. OR Phenytoin 10mg/Kg IV.
- If seizure continued after 20 mins, give Phenobarbital 15mg/Kg IV
- If seizure continued consider general anesthesia.
*PE = phenytoin equivalents
What are the types of urinary Incontinence ?
- Stress:
Urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder - Urge:
An occasional sudden need to urinate with large volume urine loss; can also exist without incontinence.
May be associated with pregnancy, childbirth, menopause, pelvic trauma, and neurologic diseases such as Parkinson’s disease and multiple sclerosis. - Mixed:
Combination of stress and urge incontinence. - Overflow:
A frequent dribble of urine due to inefficient bladder emptying; symptoms are similar to stress incontinence.
Many causes, such as spinal cord injury, diabetes, neurological damage, Parkinson’s disease, multiple sclerosis, or an enlarged prostate - Functional:
Urine loss not associated with any pathology or problem in the urinary system.
Associated with physical or cognitive impairment such as immobility, Alzheimer’s disease, or head injury. - Reflex:
Reflex (spastic bladder) incontinence happens when the bladder fills with urine and an involuntary reflex causes it to contract in an effort to empty.
Usually occurs when the spinal cord is injured above the area medically labeled as the “T12” level.
What is Celiac disease ?
also known as celiac sprue or gluten-sensitive enteropathy, is a chronic disorder of the digestive tract that results in an inability to tolerate gliadin, the alcohol-soluble fraction of gluten. Gluten is a protein commonly found in wheat, rye, and barley.
When patients with celiac disease ingest gliadin, an immunologically mediated inflammatory response occurs that damages the mucosa of their intestines, resulting in maldigestion and malabsorption of food nutrients.
What is the best first test for suspected celiac disease, ?
Antibody testing, especially immunoglobulin :
Anti-tissue transglutaminase antibody (IgA TTG). although biopsies are needed for confirmation
How to investigate in acromegaly ?
- Oral glucose tolerance test is the definitive test for the diagnosis of acromegaly; a positive result is the failure of GH to decrease to < 1 mcg/L after ingesting 50-100 g of glucose.
- Serum insulinlike growth factor 1 (IGF-1) level is the best endocrinologic test for acromegaly. IGF-1 reflects GH concentration in the last 24 hours.
- Thyrotrophin-releasing hormone (TRH), 200 mcg, can be given to increase the test’s accuracy. A GH level > 5 mcg/L suggests acromegaly.
How to investigate in Cushing disease and Cushing syndrome ?
- Dexamethasone suppression test: The physiological basis of this test is a decrease in adrenocorticotropic hormone (ACTH) secretion by the pituitary because of exogenous glucocorticoid administration. One mg of dexamethasone is administered. Serum cortisol level is measured the next morning; it should be < 138 nmol/L (ie, < 5 mcg/dL).
- Standard low-dose dexamethasone:
The patient is then given 4 doses of 0.5 mg of dexamethasone at 6-hour intervals. Normal suppression is a serum cortisol level of < 138 nmol/L or a urine level of less than 55 nmol/L. - High-dose dexamethasone suppression confirms diagnosis of a pituitary adenoma. It suppresses the pituitary gland even in the presence of an adenoma. If cortisol levels remain unchanged, the cause of increased cortisol is not a pituitary adenoma.
What are the types of pleural effusion ?
- Transudative pleural effusion: is caused by fluid leaking into the pleural space. This is from increased pressure in the blood vessels or a low blood protein count. Heart failure is the most common cause.
- Exudative effusion: is caused by blocked blood vessels or lymph vessels, inflammation, infection, lung injury, and tumors.
Light’s criteria ?
These criteria classify an effusion as exudate if one or more of the following are present:
- (1) the ratio of pleural fluid protein to serum protein is greater than 0.5,
- (2) the ratio of pleural fluid lactate dehydrogenase (LDH) to serum LDH is greater than 0.6, or
- (3) the pleural fluid LDH level is greater than two thirds of the upper limit of normal for serum LDH.
What are the main indications for splenectomy in SCD?
1) acute splenic sequestration crisis
2) hypersplenism
3) splenic abscess.
What is the mainstay of treatment for patients with primary melanoma ?
Wide local excision with completion lymph node dissection (CLND) in patients with positive sentinel lymph node biopsy results is considered the mainstay of treatment for patients with primary melanoma.
Is surgery appropriate in melanoma in patients with solitary or acutely symptomatic brain metastases ?
Surgical management may alleviate symptoms and provide local control of disease.
What are the guidelines recommendation regarding adjuvant treatment in melanoma ?
In patients with no BRAF mutation:
- Single-agent immunotherapy with the programmed cell death–1 (PD-1) inhibitor pembrolizumab or
- Nivolumab or
- Combination therapy with nivolumab plus ipilimumab.
For patients with a BRAF mutation:
- Targeted combination therapy with dabrafenib/trametinib or
- Vemurafenib/cobimetinib.
**Targeted therapy is preferred if clinically needed for early response. Current targeted therapies can slow tumor growth (eg, BRAF inhibition) or release the brakes on the immune response, resulting in tumor lysis (eg, PD-1 inhibition).
What is Nitrous oxide (N2O)?
what are the indications ?
What are the contra-indications ?
It is known as laughing gas or happy gas used as anesthetics in both dental and medical applications.
Indications:
- General anesthesia, in combination with other anesthetics.
- In Dentistry:
to decrease the pain and anxiety associated with procedures. It is commonly delivered by a nasal mask in combination with oxygen.
Indications in adult dental patients include anxiety, low pain tolerance, underlying psychiatric disorders, and mental retardation.
In prolonged dental procedures + in patients with hyperresponsive gag reflexes.
Contraindications :
- Significant respiratory compromise.
- Nitrous oxide can leave the bloodstream and enter air-filled cavities 34 times faster than nitrogen. As a result, nitrous is contraindicated in patients in whom expansion of these air-filled cavities could compromise patient safety. This includes patients with pneumothorax, pulmonary blebs, air embolism, bowel obstruction, and those undergoing surgery of the middle ear.
- Nitrous oxide is absolutely contraindicated in patients who have had eye surgery that uses an intraocular gas.
Positive seatbelt sign indicates which type of injuries ?
A positive seatbelt sign, in combination with abdominal pain or tenderness, results in a higher likelihood of intra-abdominal injuries, in particular bowel/mesenteric injury
How to treat Echinococcosis Hydatid Cyst ?
- Albendazole alone (if < 5 cm in diameter).
- Percutaneous treatment in association with medical therapy (if cysts are 5-10 cm in diameter).
- For cysts larger than 10 cm, continuous catheterization may be a viable option.
- Percutaneous treatment:
The puncture of echinococcal cysts has long been discouraged because of risks of anaphylactic shock and spillage of the fluid.
What are the most common malignancies associated with HCV ?
- Hepatocellular carcinoma (HCC).
- Non-Hodgkin lymphoma.
How to manage Mallory-Weiss Tear ?
- Resuscitative measures as appropriate, performing endoscopy promptly, and triaging patients to intensive care, hospital inpatient, or outpatient management, depending on the severity of bleeding, comorbidities, and risk of rebleeding and complications.
- Monitor the patient’s vital signs.
- Obtain serial hemoglobin and hematocrit values (q6h initially).
- Watch for clinical signs of rebleeding.
- Correct coagulopathy, and maintain hemodynamic support with fluid and blood replacement.
- Control or eliminate precipitating factors, such as nausea and vomiting.
- Acid suppression (eg, omeprazole) and antiemetic drug therapy (eg, prochlorperazine).
- Transfuse, generally, for hemoglobin levels less than 8 g/dL (< 10 g/dL for patients with cardiopulmonary disease).
- Endoscopic Mx:
- contact thermal modality.
- Epinephrine injection.
- Sclerosant injection.
- Argon plasma coagulation.
- Band ligation
- Hemoclip placement
- Balloon tamponade
- Angiotherapy with either selective vasopressin infusion or embolization of the left gastric artery.
- Outpatient Monitoring:
- Watch for recurrent symptoms or signs of rebleeding.
- Acid suppressant (eg, proton pump inhibitor; omeprazole, 20 mg PO qd) or a mucosal protectant (eg, sucralfate, 1 g PO qid) for 1-2 weeks to accelerate healing by reducing injurious factors, such as acid, pepsin, or bile, that impair the healing of the mucosal tear.
- An antiemetic (eg, prochlorperazine) is useful for controlling nausea and vomiting, common precipitating factors for Mallory-Weiss tears.
What is the medullary thyroid carcinoma management?
Total thyroidectomy
What are the contents of the jugular foramen?
- Ascending pharyngeal and occipital arteries enter the jugular foramen.
- The glossopharyngeal, vagus, and accessory nerves pass through the jugular foramen on the medial side of the jugular bulb.
What is the presentation of jugular foramen injury ?
- Vagus: Vagal compression initially causes paralysis of the laryngeal muscles leading to hoarseness and a nasal pitch. If the nerve gets compressed further, it results in unilateral paralysis of the soft palate and deviation of the uvula to the normal side.
- Glossopharyngeal nerve leads to the following:
- Loss of sensation to the posterior ipsilateral aspect of the tongue.
- Reduced secretions from the ipsilateral parotid gland.
*Loss of the ipsilateral gag reflex.
- Accessory nerve: This manifests as drooping of the shoulder, difficulties in abducting the ipsilateral arm and rotating the head contralaterally due to weakness of sternocleidomastoid and trapezius muscles.
- Obstruction of the traversing venous sinuses and veins: Headache and papilledema due to intracranial venous congestion leading to cerebral edema and raised intracranial pressure.
What is a Phyllodes tumor?
cystosarcoma phyllodes is a rare, predominantly benign tumor that occurs almost exclusively in the female breast.
What are the characteristics of a malignant phyllodes tumor ?
- Recurrent malignant tumors seem to be more aggressive than the original tumor.
- The lungs are the most common metastatic site, followed by the skeleton, heart, and liver.
- Symptoms of metastatic involvement can arise from as early as a few months to as late as 12 years after the initial therapy.
- Most patients with metastases die within 3 years of the initial treatment.
- No cures for systemic metastases exist
Roughly 30% of patients with malignant phyllodes tumors die of the disease.
What is the definitive methods for diagnosing phyllodes tumors?
+ how to manage ?
Open excisional breast biopsy for smaller lesions and incisional biopsy for large lesions are the definitive methods for diagnosing phyllodes tumors.
No absolute rules regarding margin size have been established. [25] However, a 2-cm margin for small (< 5 cm) tumors and a 5-cm margin for large (>5 cm) tumors have been advocated.
If the tumor-to-breast ratio is sufficiently high to preclude a satisfactory cosmetic result with segmental excision, total mastectomy, with or without reconstruction, is an alternative.
Axillary lymph node dissection should be performed only for clinically suspicious nodes.
There is no proven role for adjuvant chemotherapy or radiation therapy in the treatment of phyllodes tumors.
What is the commonest cause of acute abdomen in pregnancy ?
The commonest cause of acute abdomen in pregnancy is acute appendicitis followed by acute cholecystitis.
Which area does the pudendal nerve supplies?
- Sensation to external genitalia of both sexes.
- Skin around the anus, anal canal and perineum through its branches.
rectum innervation ?
The rectum receives sensory and autonomic innervation.
- Sympathetic nervous supply to the rectum is from the lumbar splanchnic nerves and superior and inferior hypogastric plexuses.
- Parasympathetic supply is from S2-4 via the pelvic splanchnic nerves and inferior hypogastric plexuses. Visceral afferent (sensory) fibres follow the parasympathetic supply.
What are the indications for initiation of long- term O2 therapy ?
- Room air arterial partial pressure of O2 =/< 55 mmHg, OR 56-59 mmHg with cor pulmonate or signs of tissue hypoxia.
- Room air O2 saturation =/< 88%, OR =/< 89% with cor pulmonate or signs of tissue hypoxia.
- Nocturnal SpO2 =/< 88% (use O2 only at night).
- Exercise hypoxemia with arterial partial pressure of O2 =/< 55mmHg or SpO2 =/< 88% (use O2 only with exercise).
Ophthalmology screening guidelines in DM ?
- DM1 ——> 5 years after diagnosis, then Q 1 year.
- DM2 —–> Q1 year
What is Turner syndrome and what is the clinical manifestation of the syndrome?
It is caused by the absence of one set of genes from the short arm of one X chromosome.
- Swollen hands and feet because of lymphedema.
- Dysplastic or hypoplastic nails and lymphedema gives a characteristic sausage-like appearance to the fingers and toes.
- Higher incidence of congenital hip dislocation.
- Short stature.
- Adrenarche, the beginning of pubic hair growth, occurs at a normal age.
- Breast development is absent when ovarian failure occurs before puberty.
- Primary or secondary amenorrhea occurs with ovarian failure.
- High arched palate.
- Webbed neck.
- Short fourth and fifth metacarpals and metatarsals.
- Shield chest: The chest appears to be broad with widely spaced nipples.
- Ears: Serous otitis media is more common [4] ; the auricles may be posteriorly rotated or low set; hearing loss due to otosclerosis is common in adults.
- GI bleeding: due to intestinal vascular malformations, + high incidence of Crohn disease and ulcerative colitis.
- Scoliosis.
- Hypertension.
- Coarctation of the aorta.
- Renal anomalies.
- Cardiac murmurs
- Hypoplastic left heart
- Coarctation of the aorta.
- Bicuspid aortic valve.
- Aortic dissection in adulthood
- Thyroid: Hypothyroidism +/- thyroid enlargement
What is the antidote to acetaminophen overdose ?
N-acetylcysteine (NAC).
baby’s reflex smile at which age ?
2 months
What is the causitive agent of viral and bacterial gastroenteritis ?
Viral :
- Group A rotavirus.
- Calicivirus
Bacterial :
- Salmonella,
- Shigella, and
- Campylobacter species
are the top three leading causes of bacterial diarrhea worldwide, followed closely by Aeromonas species
Minimum daily exercise for children ?
180 minutes (three hours) a day.
CDC : 60 mins
What is the name of the medication that can be given in iron toxicity ?
Deferoxamine.
used to chelate iron
What is the classic Sx of measles ?
- High fever
- Cough
- Runny nose
- Watery eyes.
Measles rash appears 3 to 5 days after the first symptoms.
What is Transient tachypnea of the newborn (TTN) ?
It is a benign, self-limited condition that can present in infants of any gestational age, shortly after birth. It is caused due to delay in clearance of fetal lung fluid after birth which leads to ineffective gas exchange, respiratory distress, and tachypnea.
What is the causitive agent of Syphilis ?
And how does the transmission occur ?
Spirochete Treponema pallidum.
Transmissible by
- Sexual contact with infectious lesions.
- From mother to fetus in utero.
- Via blood product transfusion.
- Occasionally through breaks in the skin that come into contact with infectious lesions.
If untreated, it progresses through 4 stages: primary, secondary, latent, and tertiary.
What are the indications of Cesarean delivery ?
- Previous cesarean delivery.
- Breech presentation
- Dystocia.
- Fetal distress.
- Repeat cesarean delivery
- Obstructive lesions in the lower genital tract.
- Pelvic abnormalities that preclude engagement or interfere with descent of the fetal presentation in labor.
- Malpresentations (eg, preterm breech presentations, non-frank breech term fetuses)
- Certain congenital malformations or skeletal disorders.
- Infection.
- Prolonged acidemia.
- Abnormal placentation (eg, placenta previa, placenta accreta).
- Abnormal labor due to cephalopelvic disproportion
Abruptio Placentae Clinical Presentation ?
Triad: bleeding, uterine contractions, and fetal distress.
- Vaginal bleeding - 80%
- Abdominal or back pain and uterine tenderness - 70%
- Fetal distress - 60%
- Abnormal uterine contractions (eg, hypertonic, high frequency) - 35%
- Idiopathic premature labor - 25%
- Fetal death - 15%
What is a Cystocele?
- Simply: It is a protrusion of the bladder into the vagina due to defects in pelvic support.
- Radiographic definition of a cystocele is descent of the bladder base below the inferior margin of the symphysis pubis.
How to diagnose cystocele ?
- Physical examination.
- Upright resting and straining cystogram.
During fluorourodynamic studies to evaluate incontinence, the type and degree of cystocele also can be assessed.
What is the clinical presentation of cystocele ?
- Stress urinary incontinence during activity.
- Difficulty emptying the bladder.
- The presence of pelvic prolapse creates a feeling of incomplete bladder emptying or fullness.
What is the most common types of vulvar cancer?
Vulvar squamous cell carcinoma.
What is the treatment of mastitis in routine casess (outpatient) ?
- Amoxicillin-clavulanate 875 mg PO BID for 10-14 days or
- Dicloxacillin 500 mg PO QID for 10-14 days or
- Flucloxacillin 250-500 mg PO QID for 5-7 days
If penicillin intolerance (not allergy):
- Cephalexin 500 mg PO QID for 10-14 days
If beta-lactam allergy:
- Clarithromycin 500 mg PO BID for 10-14 days
If suspected community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection:
- Clindamycin 300 mg PO TID for 10-14 days or
- Trimethoprim-sulfamethoxazole 1 DS tablet PO BID for 10-14 days [4] (caution if nursing preterm infant or child with known or suspected glucose-6-phosphate dehydrogenase [G6PD] deficiency) or
- Doxycycline 100 mg PO BID for 10-14 days ( do not use in pregnancy or if breastfeeding ) or
- Ciprofloxacin 500 mg PO BID for 10-14 days (use caution if pregnant or breastfeeding).
What is the guidlines for Cervical Cancer Screening?
- Recommended in women aged 21 to 65 years.
21- 29 :
Every 3 years with cervical cytology alone.
30 - 65:
- Every 3 years with cervical cytology alone OR
- Every 5 years with high-risk human papillomavirus (hrHPV) testing alone OR
- Every 5 years with hrHPV testing in combination with cytology (cotesting).
Definition of Gestational hypertension ?
Having a blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart, without the presence of protein in the urine and diagnosed after 20 weeks of gestation(Pre-eclampsia)..
What is endometriosis ?
Endometriosis is defined as the presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity.
What is the definitive method of diagnosis of endometriosis ?
Gross visualization of endometrial implants remains the definitive method of diagnosis:
- laparoscopy is the procedure of choice.
- Laparotomy can be another method of diagnosis. This is usually performed when another cause of patient pain is suspected.
What is the most common ectopic site of ectopic pregnncy ?
- Fallopian tube (96% of cases): ampulla»_space; isthmus > fimbriae > interstitial pregnancy.
- Ovary (3% of cases).
- Abdomen (1% of cases).
- Cervix (very rare).
What is the initial test for ectopic pregnancy ?
β-hCG test + Transvaginal ultrasound (TVUS).
What are the risk factors of ectopic pregnancy ?
Anatomic alteration of the fallopian tubes is the main cause of ectopic pregnancy. It may be due to:
- A history of PID
- Previous ectopic pregnancy
- Past surgeries involving the fallopian tubes
- Endometriosis
- Exposure to DES (diethylstilbestrol) in utero
- Bicornuate uterus
Non‑anatomical risk factors
- Intrauterine device (IUD)
- History of infertility
- Hormone therapy
What is the clinical presentation of ectopic pregnancy ?
- Lower abdominal pain and guarding.
- Vaginal bleeding.
- Signs of pregnancy: amenorrhea, nausea, breast tenderness, frequent urination.
- Tenderness in the area of the ectopic pregnancy.
- Cervical motion tenderness, closed cervix.
- Enlarged uterus.
- Interstitial pregnancies tend to present late, at 7–12 weeks of gestation, because of myometrial distensibility.
How frequent we should measure β-hCG if we’re suspecting ectopic pregnancy ?
Every 48 hours,
What are the findings of Transvaginal ultrasound (TVUS) in ectopic pregnancy ?
- Empty uterine cavity in combination with a thickened endometrial lining.
- Possible free fluid within the pouch of Douglas.
- Possible extraovarian adnexal mass.
- Tubal ring sign (blob sign) : an echogenic ring that surrounds an unruptured ectopic pregnancy .
- Interstitial line sign: an echogenic line that extends from the gestational sac into the upper uterus (thought to be the echogenic appearance of the interstitial portion of the tube).
- A thin myometrial layer (< 5 mm) surrounding the gestational sac [17]
What are te indications of Exploratory laparoscopy in ectopic pregnancy ?
- Unstable patients suspected of having an ectopic pregnancy.
- In pregnancy of unknown location if the location is still uncertain after 7–10 days.
Consider earlier laparoscopic exploration for high-risk patients (e.g., previous ectopic pregnancy).
What is the medical treatment of ectopic pregnancy + it mechanism of action + its indication + contraindications ?
The treatment of choice is methotrexate (MTX).
Mechanism of action: inhibits folate-dependent steps in DNA synthesis to terminate the rapidly dividing ectopic pregnancy.
Indications:
- Uncomplicated ectopic pregnancies.
- Hemodynamically stable patients
- Unruptured mass
- β-hCG ≤ 2,000 mlU/mL .
- Mass size < 3.5 cm .
- No fetal heartbeat
Absolute contraindications
- Pulmonary , renal , hepatic , or hematologic disease
- Breastfeeding
- Methotrexate sensitivity
- Immunodeficiency
- Peptic ulcer disease
- Ruptured ectopic pregnancy
What are the contraindications of External cephalic version ?
Absolute CI :
- Previous scar on the uterus.
- Placenta praaevia
- Unexplained APH (Antipartum hemorrhage)
- APH within last 7 days.
- Pre-eclampsia
- Multiple pregnancy.
- If C-section is required
- Abnormal cardiotocography
- Major uterine anamoly
- Ruptured membranes
Relative CI:
- Rhesus isoimmunisation
- Elderly primigravida.
- IUGR
- Oligohydramnios
- Polyhydramnios
- Protienuric pre-eclampsia
- Major fetal anomalies
- Unstable lie
What is the classification of perineal tear ?
- First-degree tear: Injury to perineal skin and/or vaginal mucosa.
- Second-degree tear: Injury to perineum involving perineal muscles but not involving the anal sphincter.
- Third-degree tear: Injury to perineum involving the anal sphincter complex:
- Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
- Grade 3b tear: More than 50% of EAS thickness torn.
*Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.
- Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa.
What is the most common ovarian mass in young women?
Follicular cyst of the ovary.
Patients with PCOS has an increase risk of which cancer ?
Endometrial cancer.
What are the clinical features of PCOS ?
- Onset typically during adolescence.
- Menstrual irregularities (primary or secondary amenorrhea, oligomenorrhea).
- Difficulties conceiving or infertility
- Obesity and possibly other signs of metabolic syndrome
- Hirsutism
- Androgenic alopecia
- Acne vulgaris and oily skin
- Acanthosis nigricans: hyperpigmented, velvety plaques (axilla, neck)
- Premature adrenarche
How is the Blood hormone levels in PCOS ?
- ↑ Testosterone (both total and free) or free androgen index
- ↑ LH (LH:FSH ratio > 2:1)
- Estrogen is normal or slightly elevated
How to treat PCOS ?
The therapeutic approach in PCOS is broadly based on whether or not the patient is seeking treatment for infertility.
If treatment for infertility is not sought:
- Therapy aimed at controlling menstrual, metabolic, and hormonal irregularities.
- If the patient is overweight (BMI ≥ 25 kg/m2):
* First-line: weight loss via lifestyle changes (e.g., dietary modifications, exercise).
* Second-line (as an adjunct): combined oral contraceptive therapy.
- If the patient is not overweight: combined oral contraceptive therapy
If seeking treatment for infertility
- First-line
* Ovulation induction with clomiphene citrate or letrozole
Clomiphene inhibits hypothalamic estrogen receptors, thereby blocking the normal negative feedback effect of estrogen → increased pulsatile secretion of GnRH → increased FSH and LH, which stimulates ovulation.
If the patient is overweight: advise weight loss.
* Second-line: ovulation induction with exogenous gonadotropins or laparoscopic ovarian drilling
HTN Tx in pregnancy in acute + nonemergent ?
- Acute HTN : Hydralazine
- HTN in pregnancy : Nifedipine (CCB).
- Nonemergent HTN in pregnancy: Methyldopa.
Hypertensive Moms Need Love :
Hydralazine
Methyldopa
Nifedipine
Labetalol
Hyperthyroidism Tx in pregnancy ?
- First trimester : Propylthiouracil
- After first trimester: Switch to Methimazole for the rest of the pregnancy.
What are the types of Breech Presentation ?
- Complete (flexed) breech – both legs are flexed at the hips and knees (fetus appears to be sitting ‘crossed-legged’).
- Frank (extended) breech – both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation.
- Footling breech – one or both legs extended at the hip, so that the foot is the presenting part.
When it is recommended to screen for DM in pregnant women ?
After 24 weeks of pregnancy.
What is Kartagener syndrome (KS) ?
It is an autosomal recessive syndrome, presents with the following triad:
1. Situs inversus
2. Chronic sinusitis
3. Bronchiectasis
Fanconi anemia mode of inheritance ?
Autosomal recessive pattern.
What are the causes of essential tremors ?
Positive family history (50–70%; autosomal dominant inheritance) or sporadic; benign form.
What is the clinical features of Essential tremor ?
- Localization: hands (about 90%), head (about 30%; “yes-yes” or “no-no” motion), voice (about 15%)
- Mostly bilateral postural tremor with a frequency of 5–10 Hz
- Slowly progressive
- Worse with voluntary movement , stress, fatigue, and caffeine
- Resolves at rest
- Improves with alcohol consumption
What is the treatment of Essential tremor ?
- Drugs of choice: propranolol or primidone
Alternatives (if propanolol and primidone are unresponsive or contraindicated)
- Other beta blockers (e.g., atenolol, sotalol)
- Other anticonvulsants (e.g., gabapentin, topiramate) including certain benzodiazepines (e.g., alprazolam, clonazepam)
In drug-resistant cases
- Deep brain stimulation (DBS)
- Thalamotomy
What is Medullary sponge kidney ?
It is a benign congenital disorder characterized by dilatation of collecting tubules in one or more renal papillae, affecting one or both kidneys.
Usually is not diagnosed until the second or third decade of life or later
Interpret ankle - brachial index (ABI).
> 1.3 —> Calcified.
<0.9 —> Significant arterial disease.
0.4 - 0.9 —> Claudication
<0.4 —> critical limb ischemia.
What is the auscultation features of aortic regurgitation?
- Site: Aortic area
- Timing: Early diastolic
- Radiates to the lower left sternal edge
- Character: Decrescendo
- Manoevres: Expiration , pt leaning forward.
What is the auscultation features of aortic stenosis ?
- Site: Aortic area
- Timing: Systolic
- Radiates to the carotids
- Character: ejection
- Manoevres: Expiration
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 2 weeks old?
- Gross motor: Moves head side to side.
- Personal - social : regards face
- Language: alerts to bell.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 2 months old?
- Gross motor: Lift shoulder while prone.
- Fine motor adaptive : Tracks past midline.
- Personal - social : smiles responsively.
- Language : cooing and searches for sound with eyes.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 4 months old?
- Gross motor: Lifts up on hands, rolls front to back, If pulled to sit from supine there is no head lag.
- Fine motor adaptive : Reaches for object, raking grasp.
- Personal - social: Looks at hand, begins to work toward toys.
- Language: laughs and squeals
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 6 months old?
- Gross motor : sits alone
- Fine motor adaptive: Transfers object hand to hand.
- Personal - social: feeds self, hold bottle.
- Language: babbles.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 9 months old?
- Gross motor: pulls to stand, gets into sitting position.
- Fine motor adaptive: starts to pincer grasp, bangs 2 blocks togather.
- Personal - social : waves bye-bye , plays pat a cack.
- Language : Says dada and mama but nonspecific, 2 syllable sounds.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 12 months old?
- Gross motor: Walks, stoops and stands
- Fine motor adaptive: Puts block in cup.
- Personal - social: drink from a cup, imitates others.
- Language : Says mama and dada specific, and says to other words.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 15 months old?
- Gross motor: walks backward
- Fine motor adaptive: scribbles, stacks 2 blocks.
- Personal - social: Uses spoon and fork, helps in housework
- Language: 3 -6 words , follows command.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 18 months old?
- Gross motor: Runs.
- Fine motor adaptive : stacks 4 blocks, kicks a ball.
- Personal - social: Removes clothes, feeds doll.
- Language : says at least 6 words.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 2 years old?
- Gross motor: walks up and down stairs, throws overhand.
- Fine motor adaptive: stacks 6 blocks, copies line
- Personal - social : washes and dries hand, brushes teeth, puts on clothes.
- Language: puts 2 words togather, points to pics, knows body parts.
+ understands the concept of today.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 3 years old?
- Gross motor: walks steps alternating feets, broad jump.
- Fine motor adaptive : Stacks 8 blocks , wiggles thumb
- Personal - social: uses spoon well, put on T-shirt
- Language: names pics, speech understandable to stranger 75%, says 3 words sentence.
+ understands the concept of tomorrow and yesterday
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 4 years old?
- Gross motor: Balances well on each foot, hops on one foot
- Fine motor adaptive: copies O + draws a person with 3 parts.
- Personal - social : brushes teeth without help, dresses without help.
- Language : name colors and understand adjectives.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 5 years old?
- Gross motor : skips, heels to toe walks
- Fine motor adaptive: copies a square.
- Language : counts , understands opposites.
What is the
- Gross motor
- Fine motor adaptive
- Personal - social
- Language
developemental milestones in a 6 years old?
- Gross motor: balance on each foot 6 sec
- Fine motor adaptive: Copies a trangle
- Language : define words
+ begins to understand left and right
What are the stages of change for smoking cessation?
- Precontemplation “ما قبل التأمل”:
current smoker not planning to quit in the next 6 months. - Contemplation “the action of looking thoughtfully at something for a long time”:
Current smoker, planning on quitting in next 6 months but never tried to quit during last year. - Preparation:
current smoker who is definitely planning to quit within next 30 days and have made a quit attempt in the past year. - Action:
not currently a smoker and have stopped within the past 6 months. - Maintenance:
Not currently a smoker, and stopped more than 6 months but less than 5 years.
What is the Canadian Cardiovascular Society grading scale for the classification of angina pectoris severity?
- Class I - Angina only during strenuous or prolonged physical activity.
- Class II - Slight limitation, with angina only during vigorous physical activity.
- Class III - Symptoms with everyday living activities, ie, moderate limitation.
- Class IV - Inability to perform any activity without angina or angina at rest, ie, severe limitation
Define Unstable angina.
Unstable angina is defined as new-onset angina (ie, within 2 mo of initial presentation) of at least class III severity, significant recent increase in frequency and severity of angina, or angina at rest.
Define Benign prostatic hyperplasia (BPH).
Benign prostatic hyperplasia (BPH): benign glandular and stromal hyperplasia of the transitional zone of the prostate.
What are the clinical features of Benign prostatic hyperplasia (BPH)?
Irritative symptoms of BPH:
- Urinary frequency
- Urinary urgency and urge incontinence
- Nocturia
- Occasionally dysuria
Obstructive symptoms of BPH
- Hesitancy
- Straining to urinate
- Poor and/or intermittent stream (not continuous)
- Prolonged terminal dribbling
- Sensation of incomplete voiding
Often gross hematuria
Digital rectal examination (DRE) findings: symmetrically enlarged, smooth (no nodules), firm, nontender prostate with rubbery or elastic texture .
*** To remember the symptoms of BPH, think “FUNWISE”: Frequency, Urgency, Nocturia, Weak stream /hesitancy, Intermittent stream, Straining to urinate, and Emptying (not emptying completely, terminal dribbling).
How to confirm the diagnosis of Benign prostatic hyperplasia (BPH)?
Diagnosis can be confirmed on abdominal ultrasound which demonstrates an enlarged prostate and increased post-void residual urine in the bladder
How to treat Benign prostatic hyperplasia (BPH)?
- Conservative management:
- Restrict fluid intake before bedtime or before going out.
- Avoid/reduce caffeine and alcohol intake .
- Ensure complete bladder. - Medical therapy:
- Alpha-blockers (first-line):
Examples: tamsulosin, doxazosin, terazosin, alfuzosin
- 5-alpha-reductase inhibitors:
Examples: finasteride, dutasteride - Parasympatholytics/anticholinergics:
Examples: oxybutynin, darifenacin - Phosphodiesterase type 5 inhibitors:
Example: tadalafil.
What is the mechanism of action of Alpha-blockers in the Tx of Benign prostatic hyperplasia (BPH)?
Mechanism of action: α1 receptors (α1A receptors) inhibition of the bladder neck and the prostatic urethra → relaxation of the smooth muscle of the bladder neck and the urethra → decreased resistance to urinary outflow → symptomatic improvement.
What is the mechanism of action of 5-alpha-reductase inhibitors in the Tx of Benign prostatic hyperplasia (BPH)?
Mechanism of action: ↓ conversion of testosterone to DHT (Dihydrotestosterone) → lower intraprostatic DHT levels → decreased prostatic growth and increased prostatic apoptosis and involution → improvement of LUTS (Lower urinary tract symptoms).
Male patient with androgenetic alopecia + Benign prostatic hyperplasia (BPH), which medication is appropriate to use ?
5-alpha-reductase inhibitors:
Examples: finasteride, dutasteride
What are the side effects of 5-alpha-reductase inhibitors (e.g finasteride, dutasteride) ?
Adverse effects:
- sexual dysfunction (erectile dysfunction, Decreased libido, Ejaculatory dysfunction)
- Gynecomastia
What are the surgical interventions used in Benign prostatic hyperplasia (BPH) ?
- Transurethral resection of the prostate (TURP):
Procedure: resection of the hyperplastic prostatic tissue under cystoscopic guidance, using a cautery resectoscope. - Transurethral incision of the prostate (TUIP):
(used in pt with small prostates with obstructive symptoms or those at high risk for surgical complications). - Open/laparoscopic/robotic prostatectomy.
HBV Postexposure Prophylaxis ?
Hepatitis B immune globulin is recommended in addition to vaccine for added protection.
How to treat infective endocarditis ?
- Native valve endocarditis:
penicillin G + gentamicin for coverage of streptococci. - History of IV drugs:
Nafcillin + gentamicin. - History of prosthetic valves:
Vancomycin + gentamicin + refampin
How to diagnose Subacute thyroiditis ?
Thyroid function tests
- Thyrotoxic phase: ↑ T3 and T4 , ↑ thyroglobulin, ↓ TSH
- Hypothyroid phase: ↓ T3 and T4, ↑ TSH
Confirmatory test
- ↑ ESR
Radioiodine uptake study : ↓ iodine uptake (< 5%)
Ultrasound: thyroid with poorly defined hypoechoic regions and decreased vascularity, giving rise to a cobblestone appearance
Histologic features :
Subacute granulomatous thyroiditis: granulomatous inflammation, multinucleated giant cells
Subacute lymphocytic thyroiditis: lymphocytic infiltration, sparse germinal centers
What is Familial Mediterranean fever ?
Familial Mediterranean fever (FMF), also known as recurrent polyserositis, is an autosomal recessive autoinflammatory disorder characterized mainly by brief recurrent episodes of peritonitis, pleuritis, and arthritis, usually with accompanying fever.
What are the absolute and relative contraindications for fibrinolytic use in ST-segment elevation myocardial infarction (STEMI)?
Absolute contraindications for fibrinolytic use in STEMI include the following:
- Prior intracranial hemorrhage (ICH).
- Known structural cerebral vascular lesion.
- Known malignant intracranial neoplasm.
- Ischemic stroke within 3 months.
- Suspected aortic dissection.
- Active bleeding or bleeding diathesis (excluding menses).
- Significant closed head trauma or facial trauma within 3 months.
- Intracranial or intraspinal surgery within 2 months.
- Severe uncontrolled hypertension (unresponsive to emergency therapy).
- For streptokinase, prior treatment within the previous 6 months.
Relative contraindications (not absolute) to fibrinolytic therapy include:
- Uncontrolled hypertension (BP > 180/110), either currently or in the past.
- Intracranial abnormality not listed as absolute contraindication (i.e. benign intracranial tumor).
- Ischemic stroke more than 3 months prior.
- Bleeding within 2 to 4 weeks (excluding menses).
- Traumatic or prolonged cardiopulmonary resuscitation
- Major surgery within 3 weeks.
- Pregnancy
- Current use of anticoagulants
- Non-compressible vascular puncture
- Dementia
What is the precipitating cause of rheumatic fever ?
Group A streptococcus (GAS) infections of the pharynx .
How to confirm rheumatic fever caused by Group A streptococcus (GAS) infection ?
By throat culture or rapid antigen detection test (RADT).
What is the treatment of rheumatic fever ( Group A streptococcus GAS pharyngitis) ?
- Intramuscular penicillin G benzathine
- oral penicillin V potassium
- oral amoxicillin.
For patients with Penicillin allergy:
- Narrow-spectrum cephalosporin (cephalexin [Keflex], cefadroxil [formerly Duricef]).
- Azithromycin (Zithromax)
- Clarithromycin (Biaxin)
- Clindamycin (Cleocin)
** Patients are no longer considered contagious after 24 hours of antibiotic therapy.
What is the Duration of Secondary Prophylaxis for Rheumatic Fever ?
- Rheumatic fever with carditis and residual heart disease (persistent valvular disease†):
10 years or until age 40 years (whichever is longer); lifetime prophylaxis may be needed. - Rheumatic fever with carditis but no residual heart disease (no valvular disease†):
10 years or until age 21 years (whichever is longer). - Rheumatic fever without carditis:
5 years or until age 21 years (whichever is longer).
What is Dengue fever ?
- Dengue is a viral disease caused by dengue virus (Serotype: DENV 1–4).
- RNA virus of the genus Flavivirus
- Transmission route: vector-borne: mosquitoes most commonly from the species Aedes aegypti .
What is the Clinical features of dengue fever ?
- Incubation period: 2–14 days.
- Children are usually asymptomatic.
- Starts with fever and malaise that lasts ∼ 1 week.
- Severe arthralgia and myalgia (often referred to as “break-bone fever”).
- Severe headache and retro-orbital pain.
- Maculopapular, measles-like exanthem (typically appears 2–5 days following fever).
- Generalized lymphadenopathy.
**If symptoms appear more than 2 weeks after returning from a dengue-endemic region, it is very unlikely that dengue is the cause!
What is Dengue hemorrhagic fever (DHF) ?
- Occurs in 1–2% of cases.
- Generally develops as the initial fever subsides (∼ 1 week after onset).
Clinical manifestations:
- Temperature change: ranges from hypothermia to a second spike in fever.
- Abdominal pain, vomiting.
- Changes in mental status (e.g., confusion).
- Hemorrhagic manifestations (e.g., petechiae, epistaxis, gingival bleeding) .
- Positive capillary fragility test [7]
- Increased vascular permeability → signs of pleural effusion and/or ascites.
** Dengue shock syndrome (DSS): DHF + shock.
** Dengue hemorrhagic fever is more frequent in individuals who experience a repeat infection with a second serotype, especially serotype 2!
How to diagnose dengue fever ?
Laboratory tests
- Leukopenia
- Thrombocytopenia
- ↑ AST
- Hct elevated ≥ 20% of normal values if vascular permeability (in DHF)
Best test for confirming infection: serology (IgM, IgG)
Alternatives
- PCR
- Molecular methods (ELISA): detection of viral antigen
What is the treatmnet of dengue fever ?
SUPPORTIVE MANAGEMENT :
Symptomatic treatment
- Fluid administration to avoid dehydration
- Acetaminophen
Dengue hemorrhagic fever
- Blood transfusions in case of significant internal bleeding (e.g., epistaxis, gastrointestinal bleeding, or menorrhagia)
- IV fluids
What is the treatment of chronic HBV ?
Antiviral treatment:
- Indication: chronic active hepatitis B with evidence of liver inflammation (ALT ≥ 2 times upper limit) or cirrhosis.
Goals:
- Reduce HBV DNA below detectable levels
- Seroconversion of HBeAg to anti‑HBe
- Reverse liver disease
A.Nucleoside/nucleotide analogs : indicated for patients with both decompensated and compensated liver disease and nonresponders to interferon treatment:
* Tenofovir is commonly the drug of choice * Entecavir
B. Pegylated interferon alfa (PEG-IFN-a) :
- Especially in younger patients with compensated liver disease.
- Regimen is shorter than nucleoside/nucleotide analogs
Contraindications:
* Decompensated cirrhosis
* Psychiatric conditions
* Pregnancy
* Autoimmune conditions
* Leukopenia or thrombocytopenia
* Coinfection with HDV is best treated with PEG-IFN-a.
Surgical treatment:
- Liver transplantation
* In cases of end-stage liver disease due to HBV
* In cases of fulminant hepatic failure (emergent transplantation).
What is Hypochondriasis or hypochondria ?
It is a condition in which a person is excessively and unduly worried about having a serious illness.
What is the treatment of toxoplasmosis ?
Pyrimethamine and sulfadiazine, plus folinic acid.
Anorexia nervosa definition ?
It is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.
Site of thoracentesis ?
- The visceral and parietal pleura are thin layers of connective tissue, and the space between the two linings is the pleural space. The pleural space extends inferiorly to level of approximately the 10th intercostal space. The intercostal vascular bundles are located along the inferior aspect of the ribs which is an important consideration during needle insertion due to the potential risk of injury to this bundle.
- The intercostal neurovascular bundle is located along the lower edge of each rib. Therefore, the needle must be placed over the upper edge of the rib to avoid damage to the neurovascular bundle.
- The liver and spleen rise during exhalation and can go as high as the 5th intercostal space on the right (liver) and 9th intercostal space on the left (spleen).
What is Bulimia nervosa ?
It is a serious eating disorder, you eat large amounts of food (binge eating) and then purge to get rid of extra calorie.
What are indications for methacholine challenge testing?
It is used diagnose asthma, confirm a diagnosis of asthma, document the severity of hyperresponsiveness, and follow changes in hyperresponsiveness.
What is the DDx of microcytic anemia ?
Defective heme synthesis:
- Iron deficiency anemia (the most common)
- Lead poisoning
- Anemia of chronic disease (late phase)
- Sideroblastic anemia
Defective globin chain
- Thalassemia
***The causes of microcytic anemia can be remembered with IRON LAST: IRON deficiency, Lead poisoning, Anemia of chronic disease, Sideroblastic anemia, Thalassemia.
What is the DDx of Normocytic anemia ?
Hemolytic anemia:
A. Intrinsic defects
- Hemoglobinopathies
* Sickle cell anemia
* HbC disease
- Enzyme deficiencies
* Pyruvate kinase deficiency
* G6PD deficiency
- Membrane defects
* Paroxysmal nocturnal hemoglobinuria
* Hereditary spherocytosis
B. Extrinsic defects
- Autoimmune hemolytic anemia
- Microangiopathic hemolytic anemia
- Macroangiopathic hemolytic anemia
- Infections
- Mechanical destruction
Nonhemolytic anemia:
- Blood loss
- Aplastic anemia
- Anemia of chronic kidney disease
- Iron deficiency anemia (early phase)
- Anemia of chronic disease (early phase)
What is the DDx of Macrocytic anemia ?
Megaloblastic anemia: impaired DNA synthesis and/or repair with hypersegmented neutrophils
- Vitamin B12 deficiency
- Folate deficiency
- Medications
- Phenytoin
- Sulfa drugs
- Trimethoprim
- Hydroxyurea
- MTX
- 6-mercaptopurine
- Fanconi anemia
- Orotic aciduria
Nonmegaloblastic anemia: normal DNA synthesis without hypersegmented neutrophils
- Liver disease
- Alcohol use
- Diamond-Blackfan anemia
- Myelodysplastic syndrome
- Multiple myeloma
- Hypothyroidism
Tennis elbow site of injury ?
name of test ?
Lateral epicondylitis
Mill’s test + Cozen’s test
Golfer’s elbow site of injury ?
Medial epicondylitis
What is the most common humerus fractures ?
Proximal humerus fractures.
What is the classification of humerus fractures ?
- Proximal humerus fracture (common in the elderly):
- The proximal humerus has four major segments: the anatomical neck, the humeral shaft, the greater tuberosity, and the lesser tuberosity (the surgical neck is distal to the lesser and greater tuberosity).
- Commonly used classification (Neer) is based on whether one or more of these four segments have been displaced. - Humeral shaft fracture
Classified according to location: proximal third, middle third (most common location), distal third.
Or according to comminution: type A (no comminution), type B (butterfly fragment), and type C (comminution is present). - Distal humerus fracture
Classification according to anatomical site
- Lateral/medial fractures
- Supracondylar fractures (supracondylar fractures are the most common pediatric elbow fracture )
Which nerve is at risk in fractures of the middle third (midshaft) of the humerus ?
The radial nerve runs through the radial sulcus of the upper arm and is especially at risk in fractures of the middle third (midshaft) of the humerus!
How to treat Humerus fractures ?
A.Conservative therapy:
- Indication: nondisplaced, closed fractures
- Procedures:
* Hanging-arm cast or coaptation splint and sling for approx. one to two weeks; subsequent follow‑up X‑ray and brace.
* Early physical therapy to restore function.
B.Surgical treatment
- Indication: open fractures, displaced fractures that cannot be reduced, associated injuries (nerves, blood vessels), floating elbow (simultaneous humerus and forearm fracture), pseudarthrosis.
- Procedures:
* Internal fixation using plates and screws, or intramedullary implants (especially supracondylar fractures).
* External fixation (e.g., open fracture, polytrauma)
* Arthroplasty of humeral head or elbow (complex fractures or poor quality bone), especially in elderly patients.
In carpal tunnel syndrome which muscles will be paralyzed ?
The first and second lumbricals are supplied by the median nerve .
What is the motor function of the radial nerve ?
The radial nerve innervates the muscles located in the posterior arm and posterior forearm.
- In the arm, it innervates the three heads of the triceps brachii, which acts to extend the arm at the elbow.
- The radial nerve also gives rise to branches that supply the brachioradialis and extensor carpi radialis longus (muscles of the posterior forearm).
- As a generalisation, these muscles act to extend at the wrist and finger joints, and supinate the forearm.
Which nerve innervates the medial aspect of the lower leg and the medial foot as far as the first metatarsal phalangeal joint ?
The saphenous nerve.
What are the Steps of nonoperative management in appendiceal mass ?
- Empiric parenteral antibiotic therapy for 2–3 days.
- Supportive care:
- Bowel rest (NPO)
- Intravenous fluids.
- Electrolyte repletion as needed
- IV analgesics (see pain management).
- IV antiemetics as needed
- Antipyretic therapy
- Periappendiceal abscess > 4 cm: image-guided percutaneous drainage; send aspirate for cultures
- Monitor vitals and serial abdominal examinations every 6–12 hours.
- Insignificant improvement/worsening of symptoms: urgent surgical intervention.
- Symptomatic improvement within 24–48 hours
- Slow introduction of enteral nutrition.
- Switch to oral antibiotics for 7-day course.
- Schedule interval colonoscopy in patients > 40 years of age following NOM of acute appendicitis to rule out early colonic malignancy.
Medscape :
- Patients with a phlegmon or a small abscess: After intravenous (IV) antibiotic therapy, an interval appendectomy can be performed 4-6 weeks later.
- Patients with a larger well-defined abscess: After percutaneous drainage with IV antibiotics is performed, the patient can be discharged with the catheter in place. Interval appendectomy can be performed after the fistula is closed.
- Patients with a multicompartmental abscess: These patients require early surgical drainage.
What is Amebiasis ?
Pathogen + route of transmission ?
It is an infectious disease caused by the anaerobic protozoan Entamoeba histolytica.
Transmission
- Fecal-oral
- Amebic cysts are excreted in stool and can contaminate drinking water or food.
- Transmission may also occur through sexual contact.
What is the clinical features of Amebiasis ?
A. Intestinal amebiasis (Amebic dysentery)
- Loose stools with mucus and bright red blood.
- Painful defecation, tenesmus, abdominal pain, cramps, weight loss, and anorexia.
- Fever in 10–30% of cases and possible systemic symptoms (e.g., fatigue).
- High risk of recurrence, e.g., through self-inoculation (hand to mouth).
- A chronic form is also possible, which is clinically similar to inflammatory bowel disease.
B.Extraintestinal amebiasis
- In 95% of cases: amebic liver abscess, usually a solitary abscess in the right lobe
- Fever in 85–90% of cases (compared to amebic dysentery)
- RUQ pain or pressure sensation
- Chest pain, pleuralgia
- Diarrhea precedes only a third of all cases of amebic liver abscesses.
- In 5% of cases: abscesses in other organs (e.g., especially the lungs; in rare cases, the brain), with accompanying organ-specific symptoms.
How to treat Amebiasis ?
A.Medical therapy
Asymptomatic intestinal amebiasis
- No treatment in endemic areas
- In nonendemic areas:
- Luminal agents such as paromomycin, diloxanide, or iodoquinol
- Goal: To prevent the development of invasive disease and the shedding of cysts.
Symptomatic intestinal amebiasis and invasive extraintestinal amebiasis:
- Initial treatment with a nitroimidazole derivative such as metronidazole or tinidazole to eradicate invasive trophozoites.
- Followed by a luminal agent (e.g., paromomycin, diloxanide, or iodoquinol) to eradicate intestinal cysts and prevent relapse
B. Invasive procedures
Aspiration: ultrasound or CT-guided puncture of
complicated liver abscesses at risk for perforation
Indications:
* Localized in the left lobe
* Pyogenic abscess
* Multiple abscesses
* Failure to respond to pharmacotherapy
Surgical drainage: should generally be avoided, but may be indicated for inaccessible abscesses or ruptured abscesses in combination with peritonitis
***To ensure successful treatment, the patient’s stool must be analyzed regularly!
How to manage asymptomatic umbilical hernia in pediatrics ?
The literature does suggest that expectant management of asymptomatic hernias until age 4-5years, regardless of size of hernia defect, is both safe and the standard practice of many pediatric hospitals.
Where to insert the needle in tension pneumothorax ?
Treatment of tension pneumothorax is immediate needle decompression by inserting a large-bore (eg, 14- or 16-gauge) needle into the 2nd intercostal space in the midclavicular line.
Chest Tube Thoracostomy Anatomical Placement ?
5th intercostal space at the midaxillary line (note: in most patients this is lateral to the nipple at the point of the midaxillary line).
What is the management of Hepatocellular adenoma ?
- Discontinue oral contraceptives.
- Women with symptoms or tumor > 5 cm: indication for surgical resection because of increased risk of rupture, bleeding, or malignant transformation.
- Men with hepatocellular adenoma: indication for surgical resection irrespective of the size of the lesion because of an increased risk of malignant transformation.
What is the treatment of varicose veins ?
A. Conservative measures
- Indications
* Superficial disease with no correctable cause of reflux.
* Postoperative period.
- Measures
* Compression therapy with compression stockings
* Frequent elevation of the legs
* Physical therapy, manual lymphatic drainage
* Avoid long periods of standing and sitting (with bent legs) and heat
B. Definite treatment:
- Indications:
* Symptomatic venous disease with correctable cause of reflux
* In case of complications such as bleeding, ulcers, or recurrent superficial thrombophlebitis.
- Technique: vein ablation therapies
- Interventional:
**First-line: endovenous thermal ablation (laser and radiofrequency).
** Alternative: chemical ablation (sclerotherapy) - Open surgery with partial or complete removal of a vein: only for veins that are not accessible by interventional techniques .
- Interventional:
How to classify Clinical signs of vascular injury ?
Hard signs:
- active hemorrhage,
- rapidly expanding hematomas,
- absent pulses,
- pallor,
- paresthesia,
- pain,
- paralyses,
- poikilothermia,
- palpable thrill or audible bruit.
Soft signs:
- history of arterial bleeding at the scene of injury,
- diminished distal unilateral pulse,
- small hematoma,
- neurological deficit,
- abnormal flow velocity wave on Doppler examination,
- abnormal ankle-brachial pressure index (ABI, <0.9).
***The presence or not of hard clinical signs may decide whether the patient needs an immediate operation, can undergo further investigation, or may only need continuous observation.
What are the recommendations of breast cancer screening ?
- Women who are 50 to 74 years old and are at average risk for breast cancer get a mammogram every two years.
***Women who are 40 to 49 years old should talk to their doctor or other health care professional about when to start and how often to get a mammogram. Women should weigh the benefits and risks of screening tests when deciding whether to begin getting mammograms before age 50.
- What is the definition of Pancreatic pseudocysts?
- How to diagnose it ?
- How to treat it ?
- What are the complicaitons ?
- It is an encapsulated collection of pancreatic fluid that develops 4 weeks after an acute attack of pancreatitis; can occur in both acute and chronic pancreatitis.
- Diagnostics: abdominal ultrasound/CT/MRI → extrapancreatic fluid collection within well-defined wall/capsule; no solid cyst components detectable.
- Treatment : surgical/endoscopic cystogastrostomy/cystoduodenostomy/cystojejunostomy ; ultrasound/CT-guided percutaneous drainage.
- Complications
- Infection → fever, abdominal pain, sepsis
- Rupture → pancreatic ascites/pancreaticopleural fistula
- Erosion into an abdominal vessel with hemorrhage into the cyst → sudden abdominal pain, signs of hemorrhagic shock .
- What is the definition of achalasia ?
- Clinical features ?
- initial work up ?
- Confirmation test ?
- Achalasia is a failure of the lower esophageal sphincter (LES) to relax that is caused by the degeneration of inhibitory neurons within the esophageal wall.
- Dysphagia to solids and liquids; can be progressive or paradoxical
- Regurgitation
- Retrosternal pain and cramps
- Weight loss.
- upper endoscopy and/or esophageal barium swallow;.
- Esophageal manometry.
What are the findings of the following studies in patients with achalasia :
- Chest x-ray.
- Esophageal barium swallow.
- Upper endoscopy.
- Esophageal manometry. ?
- Esophageal barium swallow: supportive and/or confirmatory test:
* Bird-beak sign: dilation of the proximal esophagus with stenosis of the gastroesophageal junction
* Delayed barium emptying or barium retention - Upper endoscopy: to rule out pseudoachalasia
* Usually normal.
* May show retained food in esophagus or increased resistance of LES during passage with endoscope.
* If malignancy is suspected, biopsy and endoscopic ultrasound are indicated. - Esophageal manometry: confirmatory test of choice
* Peristalsis is absent or uncoordinated in the lower two-thirds of the esophagus.
* Incomplete or absent LES relaxation
* High LES resting pressure
* No evidence of mechanical obstruction - Chest x-ray
* Widened mediastinum
* Air-fluid level on lateral view
* Possible absence of gastric air bubble
What is the treatment of achalasia ?
If a low surgical risk:
- Pneumatic dilation:
Endoscope-guided graded dilation of the LES that tears the surrounding muscle fibers with the help of a balloon
- LES myotomy (Heller myotomy) (2nd choice).
If a high surgical risk:
Botulinum toxin injection in the LES
If other measures are unsuccessful:
- nitrates or calcium channel blockers.
What is the rare form of Down syndrome ?
Mosaic Down syndrome, or mosaicism.
- What is Osgood-Schlatter disease ?
- Clinical features ?
- Dx ?
- Tx ?
- It is an avascular necrosis thought to arise from overuse of the quadriceps muscle during periods of growth.
- Progressive anterior knee pain that is worse with activity and is reproducible with extension against resistance.
- Proximal tibial swelling.
- X-ray:
*Anterior soft tissue swelling.
*Lifting of tubercle from the shaft
*Irregularity or fragmentation of the tubercle - Ultrasound: soft tissue swelling.
- X-ray:
4.
- Mostly conservative (rest, ice, NSAIDs ).
- Strengthening and stretching of the quadriceps muscle
- Generally resolves once full bone maturity is reached
- Surgical excision of intratendinous ossicles in severe cases.
- What is Iliotibial band syndrome (runner’s knee) ?
- Clinical features ?
- Tx ?
- Common overuse injury of the distal portion of the iliotibial band (over the lateral femoral epicondyle)
Etiology: repetitive flexion and extension of the knee (e.g., during running). - Pain in the lateral knee (due to friction of iliotibial band against femoral epicondyle)
- Sharp pain when the foot strikes the ground
- Dull, constant pain at rest
- Noble test: patient lies on their side and the examiner passively flexes the patient’s leg while exerting constant pressure on the lateral femoral epicondyle with his thumb → test is positive if pain is elicited.
- Conservative treatment:
- Rest
- Cooling/ice for the first 24–48 hours
- Topical/oral NSAIDs
- Physiotherapy: stretching and strength training once the pain has subsided
- Orthotic braces and bands
- Conservative treatment:
- Corticosteroid and lidocaine injections:
- Only considered if conservative treatment has failed
- Short-term relief (no long-term benefit).
- Injection into surrounding tissue, not directly into tendons.
- Surgery :
- Indicated in patients with persistent symptoms despite 6 months of conservative treatment.
- Excision of abnormal tendon tissue.
- Longitudinal incisions (tenotomies) to release scarred and fibrotic areas
***Corticosteroid injections are generally avoided in insertional tendinopathy since they may cause tendon rupture!
What are the common caustive agent of bronchiolitis?
- RSV: Respiratory syncytial virus
- rhinovirus,
- human metapneumovirus (hMPV),
- parainfluenza virus,
- adenovirus,
- coronavirus,
- influenza virus
- human bocavirus
What is the
1. transmission route
2. Clinical features
3. Tx
4. Complications
of Salmonella enterica ?
- Transmission: foodborne (poultry, raw eggs, and milk.
- Clinical features
- Duration: 3–7 days
- Fever (usually resolves within 2 days), chills, headaches, myalgia
- Severe vomiting and inflammatory (watery-bloody) diarrhea. - Treatment (antibiotic therapy in severe cases):
- Fluoroquinolones (e.g., ciprofloxacin)
- Alternative: TMP-SMX or cephalosporins (e.g., ceftriaxone), depending on the antimicrobial susceptibility test.
- Antibiotic treatment prolongs fecal excretion of the pathogen; only indicated for systemic manifestations or diarrhea > 9/day. - Complications: (especially in immunocompromised patients, e.g., HIV):
- Bacteremia
- Reactive arthritis
- Systemic disease: osteomyelitis, meningitis, myocarditis
What is the
1. transmission route
2. Clinical features
3. Tx
4. Complications
of Shigellosis ?
- Transmission:
- Fecal-oral (especially a concern in areas with poor sanitation)
- Oral-anal sexual contact
- Foodborne (unpasteurized milk products and raw, unwashed vegetables)
- Contaminated water. - Clinical features:
- Duration: 2–7 days
- High fever
- Tenesmus, abdominal cramps
- Profuse inflammatory, mucoid-bloody diarrhea. - Treatment: in severe cases, antibiotic therapy with fluoroquinolones or 3rd generation cephalosporins.
- Complications:
- HUS
- Intestinal complications (e.g., toxic megacolon, colonic perforation, intestinal obstruction, proctitis, rectal prolapse) .
- Febrile seizures
- Reactive arthritis
What is the definition of short stature ?
It is a height that is at least two standard deviations (SDs) below the mean for children of the same age and sex.
How to differentiate between Familial short stature, Constitutional growth delay and Idiopathic short stature ?
Familial short stature:
- Hereditary short stature
- Most common cause of proportionate short stature.
- Normal development
- Skeletal age consistent with chronological age.
Constitutional growth delay :
- Inherited type of developmental delay
- Second most common cause of short stature
- Normal adult height
- Delayed skeletal age
- Delayed onset of puberty
Idiopathic short stature:
-Diagnosis of exclusion in the absence of an underlying condition
What is the peak incidence of Intussusception ?
3–12 months; otherwise commonly occurs in children 5 months to 6 years of age.
What are the casues of Intussusception ?
Mostly idiopathic (usually in children 3 months to 5 years of age)
∼ 75% of cases have no identifiable lead point
Disorganized peristalsis with enlarged Peyer’s patches may underlie idiopathic cases.
Pathological lead points: more likely the underlying cause in patients with recurrent episodes of intussusception; more common in children < 3 months or > 5 years of age.
- Meckel’s diverticulum (most common)
- Intestinal polyps or other tumors (2nd most common)
- Bowel wall thickening in Henoch-Schönlein purpura
- Recent rotavirus immunization
- Cystic fibrosis
How to classify Intussusception (according to site) ?
- Ileocecal invagination (most common).
- Ileoileal invagination
- Ileocolic invagination
- Colosigmoidal invagination
- Appendicocecal invagination (very rare)
What are the clinical features of Intussusception ?
** Less than 15% of patients with intussusception present with the classic triad of abdominal pain, a palpable sausage-shaped abdominal mass, and blood per rectum!
- Child typically looks healthy.
- Acute cyclical colicky abdominal pain (sudden screaming or crying spells), often with legs drawn up, with asymptomatic intervals.
- Acute attacks occur approx. every 15–30 min.
- Vomiting (initially nonbilious)
- Lethargy , pallor, and other symptoms of shock or altered mental status may be present.
- Abdominal tenderness, palpable sausage-shaped mass in the RUQ , and an “emptiness” or retraction in the right lower quadrant (Dance sign) during palpation.
- High-pitched bowel sounds on auscultation
- “Currant jelly stool” (usually a late sign) may be noticed in passed stool or during digital rectal examination .
What is the best initial test for Dx Intussusception ?
Abdominal ultrasound (best initial test): often sufficient to confirm diagnosis :
- Target sign (transverse view): The invaginated portion of bowel appears as rings on a target in transverse view on ultrasound.
- Pseudokidney sign (longitudinal view): the lead point of the invagination in the distal loop of bowel resembles a kidney. This “pseudokidney” is made up of longitudinal layers of bowel wall.
- Possible pendulous peristalsis
What is the best confirmatory test for Intussusception ?
Contrast or pneumatic enema using ultrasound or fluoroscopy (best confirmatory test).
Interruption of contrast or air at the site of invagination.
How to Tx Intussusception ?
Initial steps: nasogastric decompression and fluid resuscitation.
Nonsurgical management (performed under continuous ultrasound or fluoroscopic guidance):
- Air (pneumatic) enema: treatment of choice
- Hydrostatic reduction: normal saline (or water-soluble contrast enema)
- Observe for 24 hours post-reduction, as there is a small risk of perforation and recurrence is common during this period.
Surgical reduction
- Indications:
* When a pathological lead point is suspected
* Failed conservative management
* Suspected gangrenous or perforated bowel
* Critically ill patient (e.g., shock)
- Open or laparoscopic method:
* Hutchinson maneuver: manual proximal bowel compression and reduction of intussusception.
* For necrotic bowel segments: Resection and end-to-end anastomosis.
How to calculate incidence ?
New cases devided by total population at risk x 100
How to calculate Prevalence
New cases + old cases devided by total population at risk x 100
- What is the definition of Lactose intolerance ?
- What are the clinical features of Lactose intolerance ?
- Lactose intolerance is the inability to absorb lactose, caused by lactase deficiency.
- Clinical features:
- Symptoms occur about an hour to several hours following consumption of milk products. The intensity of symptoms correlates with the amount of lactose consumed.
- Diarrhea (often watery, bulky, and frothy)
- Cramping abdominal pain (often periumbilical or in the lower abdomen)
- Abdominal bloating
- Flatulence
- Nausea
What are the causes of Lactose intolerance ?
- Primary (lactase non‑persistence): most common type of lactose intolerance; a decrease in lactase activity is primarily observed during childhood or adolescence.
- Secondary (acquired): due to underlying disorders of the small intestine that result in mucosal damage (e.g., gluten‑sensitive enteropathy following gastroenteritis).
- Developmental: occurs in children born prematurely, as lactase activity develops late during pregnancy.
- Congenital: autosomal recessive gene defect (extremely rare).
Where does the lactose digestion occur ?
In the small intestine (particularly the jejunum).
How to Dx Lactose intolerance ?
How to Tx Lactose intolerance ? ?
- Stool analysis: ↑ stool osmotic gap , stool pH < 6.
- Hydrogen breath test:
The amount of hydrogen in the expired air increases after administering lactose in the fasting state.
Measurement at baseline and at 30‑minute intervals over 3 hours following the ingestion of 50 g of lactose (children: 2 g/kg lactose (max. amount 25 g)). - Lactose tolerance test: Following the administration of lactose, the normal rise in blood glucose levels is pathologically reduced and symptoms appear → rarely used, as the test has low sensitivity and specificity.
- Trial lactose‑free diet: to see if symptoms resolve.
- Biopsy of the small intestine: qualitative and quantitative assessment of lactase via an endoscopic tissue biopsy (conclusive, although rarely used). Histologic analysis shows normal intestinal architecture.
Tx:
Either by avoidance or Oral lactase supplements.
Name the most common viable numerical chromosomal aberrations.
Autosomal chromosomal aberrations:
- Trisomy 13 (Patau syndrome)
- Trisomy 18 (Edwards syndrome)
- Trisomy 21 (Down syndrome)
Gonosomal chromosomal aberrations
- Klinefelter syndrome
- Turner syndrome
What are the clinical features of Trisomy 13 (Patau syndrome) ?
Dx and Prognosis ?
- Microcephaly, holoprosencephaly
- Characteristic facial anomalies:
- Cleft lip and palate
- Low-set, malformed ears
- Bulbous nose
- Small chin
- Eyes: microphthalmia (small orbits, which may be unilateral or bilateral), possibly coloboma , ocular hypotelorism.
- Polydactyly, primarily hexadactyly, flexed fingers
- Congenital heart defects (particularly ventricular septal defect, patent ductus arteriosis)
- Rocker-bottom feet
- Visceral and genital anomalies, especially of the kidneys and ureters (e.g., polycystic kidney disease)
- Aplasia cutis congenita: congenital absence of skin; most commonly scalp lesions with a punched-out appearance that may extend to the bone or the dura.
- Omphalocele
- Capillary hemangioma
Diagnosis :
- Usually detected during first trimester screening with combined ultrasound and maternal serum testing (↓↓ PAPP-A, ↑ nuchal translucency).
Prognosis:
Infants usually die before the age of 1, only approx. 11% of infants survive past 12 months of age.
What are the clinical features of Trisomy 18 (Edwards syndrome)?
Dx and Prognosis ?
- Characteristic facial anomalies:
- Prominent occiput
- Microcephaly
- Broad nose
- Low-set ears (malformed auricle)
- Micrognathia (congenital mandibular hypoplasia)
- Cleft lip and palate, high palate
- Clenched fists with flexion contractures and overlapping fingers
- Rocker-bottom feet: convex deformity of the plantar side of the foot, with a vertical talus, and prominent calcaneus
- Congenital heart defects (particularly VSD, ASD, tetralogy of Fallot)
- Malformations of internal organs: diaphragmatic hernia, ureter, and kidneys (horseshoe kidneys).
- Myelomeningocele
- Omphalocele
- Severe intellectual disability
Diagnosis
- Quadruple test in the second trimester shows
* ↓ free estriol,
* ↓ AFP,
* ↓ Inhibin A
* ↓ β-HCG
Prognosis:
Only approx.13% of patients survive past 12 months of age.
What is the most common pathogen of Pelvic inflammatory disease (PID) ?
- Chlamydia trachomatis
- Neisseria gonorrhoeae
***Less common (consider coinfections):
- E. coli
- Ureaplasma
- Mycoplasma
- other anaerobes
What are the risk factors of Pelvic inflammatory disease (PID) ?
- Multiple sexual partners, unprotected sex
- History of prior STIs and/or adnexitis
- Intrauterine devices.
- Vaginal dysbiosis (bacterial vaginosis).
- Risk is lower during pregnancy; PID development during pregnancy increases the risk of maternal morbidity and preterm births.
What are the clinical features of Pelvic inflammatory disease (PID) ?
- Lower abdominal pain (generally bilateral), which may progress to acute abdomen.
- Nausea, vomiting
- Fever
- Dysuria, urinary urgency
- Menorrhagia, metrorrhagia
- Dyspareunia
- Abnormal vaginal discharge
What are the investigations ordered in Pelvic inflammatory disease (PID) ?
- History:
- Most often a sexually active young woman.
- Lower abdominal pain.
- PEx: Vaginal examination:
- Cervical motion tenderness: severe cervical pain elicited by pelvic examination.
- Uterine and/or adnexal tenderness
- Purulent, bloody cervical and/or vaginal discharge.
- Blood tests: elevated ESR, leukocytosis.
- Pregnancy test: to rule out an (ectopic) pregnancy
- Cervical and urethral swab:
- Gonococcal and chlamydial DNA (PCR) and cultures.
- Giemsa stain of discharge can show cytoplasmic inclusions in C. trachomatis infections, but not in N. gonorrhoeae infection.
- Imaging
- Ultrasound: free fluid, abscesses, pyosalpinx/hydrosalpinx
- Exploratory laparoscopy:
Indicated in ambiguous cases and if patient does not respond to treatment.
Characteristic findings include tubal edema, erythema, and purulent exudate. - Endometrial biopsy: to confirm the presence of endometritis.
- Culdocentesis: aspiration of intraperitoneal fluid from the pouch of Douglas(no longer a routine procedure ,replaced by ultrasound).
What is the Tx of Pelvic inflammatory disease (PID) ?
Outpatient regimen:
- One single dose of IM ceftriaxone and oral therapy with doxycycline.
- If signs of vaginitis or recent gynecological instrumentation add oral metronidazole.
Inpatient regimen (parenteral antibiotics):
- Indications:
* No response to or inability to take outpatient oral regimen
* Non-compliance concerns (e.g., teenagers)
*High fever
- Possible combinations (should be administered for 14 days)
- Cefoxitin or cefotetan plus doxycycline.
- Clindamycin plus gentamicin
- Switch to oral therapy with doxycycline after clinical improvement.
What are the complications of Pelvic inflammatory disease (PID) ?
Short-term complications:
- Pelvic peritonitis
- Fitz-Hugh-Curtis syndrome (perihepatitis):
* Inflammation of the liver capsule
*Characterized by violin-string-like adhesions extending from the peritoneum to the liver
- Tubo-ovarian abscess.
* A confined pus collection of the uterine adnexa
* May spread to adjacent organs (e.g., bladder, bowel)
Long-term complications:
- Infertility: caused by adnexitis, adhesions of the fallopian tubes and ovaries, and tubal scarring, which result in impaired ciliary function and tubal occlusion
- Ectopic pregnancy
- Chronic pelvic pain
- Hydrosalpinx/pyosalpinx: accumulation of fluid/puss in the fallopian tubes due to chronic inflammation and consequent stenosis.
- Chronic salpingitis
Hirschsprung’s disease (congenital aganglionic megacolon) common site?
rectosigmoid region.
What is the Pathophysiology of Hirschsprung’s disease (congenital aganglionic megacolon) ?
-It is caused by defective caudal migration of parasympathetic neuroblasts (precursors of ganglion cells) from the neural crest to the distal colon.
- Affected segments are histologically characterized by the absence of the Meissner plexus and Auerbach plexus (submucosal and myenteric plexus ganglion) beginning at the anorectal line, leading to::
- Inability of the myenteric plexus to control the intestinal wall muscles → uncoordinated peristalsis and slowed motility.
- Spastic contraction of intestinal muscles → stenosis
- Expansion of the colon segment proximal to the aganglionic section (possible megacolon).
What are the clinical features of Hirschsprung’s disease (congenital aganglionic megacolon) ?
Early presentation:
- Delayed passage of meconium.
- Distal intestinal obstruction: abdominal distention and bilious vomiting.
- Tight anal sphincter with explosive release of stools and air upon removal of the finger.
- Failure to thrive/poor feeding.
- Palpation of feces via the abdominal wall.
Late presentation
- Chronic constipation with possible inability to pass gas
What is the gold standard confirmatory test for Hirschsprung’s disease (congenital aganglionic megacolon) ?
rectal biopsy is the gold standard for confirming the diagnosis
What is the initial test for Hirschsprung’s disease (congenital aganglionic megacolon) ?
Abdominal x-ray.
What are the diagnostic test and thier findings of Hirschsprung’s disease (congenital aganglionic megacolon) ?
Abdominal x-ray
- Best initial test
- Findings:
* Decreased or absent air in rectum.
* Dilated colon segment immediately proximal to aganglionic region.
* Distal intestinal obstruction.
Barium enema
- Indication: Usually performed in addition to x-ray, to localize and determine the length of the aganglionic segment prior to surgery.
- Findings:
* Change in caliber along the affected intestinal segment .
* Retention of barium for 24–48 hours.
Anorectal manometry
- Findings:
* Absent relaxation reflex of the internal sphincter after stretching of the rectum (paradoxical increase in pressure).
* Typical ‘mass contractions’: lack of physiological, propulsive waves.
Rectal biopsy
- Confirmatory test
- Procedure:
* Full-thickness biopsy under general anesthesia
* Bedside suction biopsy
- Findings
* Absence of ganglion cells in an adequate tissue sample.
* Elevated acetylcholinesterase activity
* Hyperplasia of the parasympathetic nerve fibers
* Absent calretinin immunostained fibers.
What is the treatment of Hirschsprung’s disease (congenital aganglionic megacolon) ?
Surgical treatment is usually performed in two stages:
- First stage: diverting colostomy to relieve the dilated bowel .
- Second stage:
* Resection of the aganglionic segment
* Anastomoses of the normal ganglionic colon segment to either the distal modified rectum or normal (unmodified) distal rectum.
* Preservation of internal anal sphincter function is of the atmost importance.
Preterm labor definition ?
Preterm labor: Regular uterine contractions with cervical effacement, dilation, or both before 37 weeks gestation.
What are the risk factors of preterm labor ?
High risk factors:
- History of preterm birth
- Cervical insufficiency
- Multiple gestation
Low risk factors:
- Maternal and fetal medical conditions:
* Infections
* Polyhydramnios
* Malaria
* Hypertensive pregnancy disorders
* Diabetes mellitus, gestational diabetes
* Uterine anomalies (e.g., anomalies of Mullerian duct fusion, uterine fibroids)
* Placenta previa
* Placental abruption
* Congenital abnormalities of the fetus
- Lifestyle and environmental factors:
- Smoking
- Substance use (e.g., alcohol or drugs)
- Maternal or fetal stress
- Maternal age (≤ 18 years, > 35 years)
- Low maternal pre-pregnancy weight
- African-american race
What are the clinical features of preterm labor ?
- Regular uterine contractions and associated symptoms of labor .
- Cervical dilation ≥ 3 cm, effacement, or both.
- Premature rupture of membranes.
How to Dx preterm labor ?
- Clinical diagnosis based on preterm contractions and cervical changes.
- Supportive tests:
- Transvaginal cervical ultrasound: for diagnosis of short cervix
- Cervicovaginal fetal fibronectin detection test: a positive test supports the diagnosis of preterm labor
How to Tx preterm labor ?
- Single course of antenatal steroids (IM betamethasone or IM dexamethasone ):
- Indication: 24–34 weeks gestation with a risk of delivery within the next 7 days .
- Improves fetal lung maturity and surfactant production.
- Repeat the course if the last dose of corticosteroids was > 14 days previously.
2.Tocolysis: administration of tocolytics to inhibit uterine contractions and prolong pregnancy:
- Recommended for up to 48 hours to enable administration of antenatal corticosteroids in preterm labor .
- First-line: beta-adrenergic agonists, NSAIDs, or calcium-channel blockers.
- Second-line: Magnesium sulfate
- Contraindications:
* Maternal drug contraindications
* Nonreassuring fetal CTG
* Intrauterine fetal demise
* Chorioamnionitis
* Antepartum hemorrhage with hemodynamic instability
* Severe pre-eclampsia or eclampsia
* Lethal fetal anomaly
- Fetal neuroprotection: Magnesium sulfate
Indication: if birth < 32 weeks is anticipated.
*** Antibiotics for group B streptococcus (GBS) prophylaxis is recommended in preterm labor, preterm premature rupture of membranes and when GBS infection is evident.
What are the complications of preterm labor ?
- Neonatal respiratory distress syndrome (RDS)
- Bronchopulmonary dysplasia (BPD)
- Patent ductus arteriosus (PDA)
- Retinopathy of prematurity (ROP)
- Necrotizing enterocolitis (NEC)
- Periventricular leukomalacia (PVL).
- Neurological disorders (e.g., cerebral palsy, learning disabilities, developmental delays, ADHD).
- Problems of homeostasis: apnea, bradycardia, hypothermia.
- Infection and sepsis (e.g., pneumonia) .
- Anemia of prematurity: impaired ability to produce adequate erythropoietin (EPO).
- Intraventricular hemorrhage (IVH) .
What are the risk factors of Premature rupture of membranes (PROM) ?
- Ascending infection (common)
- Cigarette smoking
- Multiple pregnancy
- Previous preterm delivery
- Previous PROM
What are the complications of Premature rupture of membranes (PROM) ?
- Umbilical cord prolapse
- Placental abruption
- Chorioamnionitis
When to perform Cervical cerclage in Cervical insufficiency ?
< 24 weeks gestation; most commonly performed at 13–16 weeks gestation
What is the quadruple test?
Second trimester quadruple test (15–18 weeks) to Dx down syndrome :
- ↓ Free estriol
- ↓ Alpha-fetoprotein (AFP)
- ↑ Inhibin A
- ↑ β-hCG
Can a HIV infected mother breastfeed her baby ?
to prevent HIV transmission, HIV-infected mothers should not breastfeed their infants. HIV is a virus that attacks the body’s immune system and is spread through certain body fluids, including breast milk. Mother-to-child transmission can occur during pregnancy, birth, or breastfeeding.
The crown-rump length (CRL) is a measurement of the embryo, usually identified at which weeks of gestation ?
7 and 13 weeks’ gestation.
Head circumference is measured at which weeks of gestation ?
13–25 completed weeks
Femur length is measured at which weeks of gestation ?
13–25 completed weeks
How to calculate the expected date of delivery ?
- First, determine the first day of your last menstrual period.
- Next, count back 3 calendar months from that date.
- Lastly, add 1 year and 7 days to that date.
When does Vitamin K deficiency bleeding of the newborn (VKDB) usually occur ?
- Early-onset (within 24 hours after birth).
- Classic (within 4 weeks).
- Late-onset (between 2–8 months).
Lab results in patints with Vitamin K deficiency bleeding of the newborn (VKDB)
Coagulation studies:
- ↑ Prothrombin time (PT)
- Normal or ↑ activated partial thromboplastin time (PTT)
- Normal bleeding time
- ↓ Factors II, VII, IX, and X
What is the treatment of Vitamin K deficiency bleeding of the newborn (VKDB ?
- Transfusions as necessary
- Administration of vitamin K
How to estimate a child’s adult height ?
- Add the mother’s height and the father’s height in either inches or centimeters.
- Add 5 inches (13 centimeters) for boys or subtract 5 inches (13 centimeters) for girls.
- Divide by two.
What is Wiskott-Aldrich Syndrome ?
It is an X-linked disorder characterized by the clinical triad of microthrombocytopenia, eczema, and recurrent infections.
What is Kawasaki disease ?
It is an acute, necrotizing vasculitis of unknown etiology.Usually occur in patient who are 5 years of age or younger.
What is the clinical features of Kawasaki disease ?
Clinical diagnosis requires fever for at least 5 days and one of the following:
* ≥ 4 other specific symptoms
* < 4 specific symptoms and involvement of the coronary arteries.
- Specific symptoms include:
- Erythema and edema of hands and feet, including the palms and soles (the first week).
- Possible desquamation of fingertips and toes after 2–3 weeks.
- Polymorphous rash, originating on the trunk
- Painless bilateral “injected” conjunctivitis without exudate.
- Oropharyngeal mucositis:
- Erythema and swelling of the tongue (strawberry tongue).
- Cracked and red lips.- Cervical lymphadenopathy (mostly unilateral).
- Erythema and swelling of the tongue (strawberry tongue).
- Nonspecific symptoms may precede the onset of Kawasaki disease (e.g., diarrhea, fatigue, abdominal pain)
What labs and other investigation used to evlauate Kawasaki disease and how are the results ?
- Laboratory findings
- ↑ ESR and CRP
- Leukocytosis
- Thrombocytosis
- Echocardiography:
- For evaluating coronary artery aneurysms
- Minimal evaluation: should be performed at diagnosis, at 2 weeks, and at 6–8 weeks after onset .
How to treat Kawasaki disease ?
- IV immunoglobulin (IVIG)
- High single-dose to reduce the risk of coronary artery aneurysms.
- Most effective if given within the first 10 days following disease onset.
- High-dose oral aspirin
- IV glucocorticoids: may be considered in addition to standard treatment, esp. in cases of treatment-refractory disease, as they lower the risk of coronary involvement
*** To avoid the risk of Reye syndrome, children should not be treated with aspirin, especially if a viral infection is suspected. Kawasaki disease is an exception to this rule.
What are the clinical features of Meckel diverticulum ?
Asymptomatic (∼ 96%).
Symptomatic (2–4%):
- Painless lower gastrointestinal bleeding (most common presentation)
- Hematochezia
- Tarry stools
- Currant jelly stools
How to Dx Meckel diverticulum ?
- Same protocol as that for lower gastrointestinal bleeding and/or acute abdomen +
- Meckel scintigraphy scan (Meckel scan): a noninvasive nuclear medicine imaging technique using radiolabelled technetium (99mTc), which is preferentially absorbed by the gastric mucosa and can identify ectopic gastric mucosa.
- CT angiography: may demonstrate the vitelline artery or even contrast extravasation from a bleeding Meckel diverticulum.
- Double balloon enteroscopy: A long endoscope is advanced, either through the mouth or the rectum, into the small intestine. The sequential inflation and deflation of the two balloons helps advance the scope into the intestine by pleating the bowel onto the scope.
- Capsule endoscopy: The patient is asked to swallow a small, encapsulated camera, which takes multiple images of the bowel as it passes through the gastrointestinal tract.
- Diagnostic laparoscopy
What is the Tx of Meckel diverticulum ?
Asymptomatic Meckel diverticulum:
- Incidentally detected on imaging studies: no treatment necessary
- Incidentally detected on laparotomy/laparoscopy:
* Children or young adults: surgical resection of all incidentally detected Meckel diverticuli.
* Adults < 50 years: surgical resection only for Meckel diverticuli that have a high risk of developing complications.
* Adults > 50 years: no treatment necessary.
- Symptomatic or complicated Meckel diverticulum:
- Initial stabilization of the patient
- Surgical resection of all symptomatic/complicated Meckel diverticuli
- Surgical procedures:
- Segmental resection : Indicated for a Meckel diverticulum that is bleeding, has a broad base, or a palpable abnormality.
- Diverticulectomy: Meckel diverticulum is resected at the base.
What are the major classes of antihypertensive agents?
- Diuretics
- Beta- blockers
- ACEIs (Angiotensin-converting-enzyme inhibitors)
- ARBs (Angiotensin II receptor blockers)
- CCBs (Calcium channel Blockers)
- Vasodilators
- Alpha 1 adrenergic blockers
- Centrally acting adrenergic agonist.
What are the
1. Types
2. Mechanism of action.
3. Side effects.
Of diuretics ?
- Thiazide - loop (Furosemide) - K sparing (spironolactone).
- Decreases extracellular fluid volume and thereby decreases vascular resistance.
- Hypokalemia (not with K sparing) - hyperglycemia - hyperlipidemia- hyperurecemia - azotemia.
What are the
1. Types
2. Mechanism of action.
3. Side effects.
Of beta- blockers ?
- Propranolol - Metoprolol - Nadolol- Carvedilol
- Decrease cardiac contractility and renin release
- Bronchospasm in asthma - bradycardia - CHF exacerbation - impotence - fatigue - depression.
What are the
1. Types
2. Mechanism of action.
3. Side effects.
Of ACEIs ?
- Captopril - Enalopril - Benazepril
- Block aldosterone formation , decreases peripheral resistance and salt/water retention
- Cough - Rash - leukopenia - hyperkalemia
What are the
1. Types
2. Mechanism of action.
3. Side effects.
Of ARBs ?
- Losartan - Valsartan
- Block aldosterone effect, decreases peripheral resistance and salt/water retention
- Rash - leukopenia - hyperkalemia
What are the
1. Types
2. Mechanism of action.
3. Side effects.
Of CCBs ?
- Dihydropyridines ( Nifedipine- Felodipine- Amlodipine) Nondigydropyridines ( Diltiazem - verapmil).
- Decreases smooth muscle tone => vasodilation , decreases cardiac output.
- Dihydropyridines: headache, flushing, peripheral edema.
Nondigydropyridines: decreases contractility.
What are the
1. Types
2. Mechanism of action.
3. Side effects.
Of Vasodilators ?
- Hydralazine - Minoxidil
- Decreases peripheral resistance by dilating arteries/ arterioles
- Hydralazine : headache - lupus like syndrome.
Monoxidil: orthostasis - hirsutiam
Which tendon makes patient unable to stand on his toe if ruptured?
Achilles / Calcaneal tendon
What is galactosemia and what is the type of inheritance ?
Galactosemia, which means “galactose in the blood,” refers to a group of inherited disorders that impair the body’s ability to process and produce energy from a sugar called galactose. When people with galactosemia injest foods or liquids containing galactose, undigested sugars build up in the blood.
Type of inheritance: Autosomal recessive
What is pheochromocytoma ? And what is the management?
Its a catecholamine secreting tumor that causes life threatening HTN.
Mx:
- Alpha blockers (Phenoxybenzamine)
- Beta blockers
- surgical removal.
Name the cranial nerves that arise from the jugular foramen ?
IX Glossopharyngeal nerve
X Vagus nerve
XI Accessory nerve
What are the side effects of Haloperidol?
- involuntary movement: Akathisia, dystonia , Parkinsonism
- wight gain
- erectile dysfunction
- Amenorrhea
What are the muscles supplied by tibial nerve ?
2 T, 2 P, 2 F
- Triceps Surae
- Tibialis posterior
- Plantaris
- Popliteus
- Flexor digitorum longus
- Flexor hallicus longus
What is Pericardial tamponade (Becks Triad) ?
- Distant (Muffled) heart sound
- Decreased arterial BP
- Distended jugular veins.
Can mothers with HCV and HBV breastfeed ?
Yes
What is the equation of sensitivity?
True Positive/ True positive + False negative.
( have disease)
What is the equation of Specificity ?
True Negative/ True negative + False positive
(Don’t have disease)
What are the vaccines that are contraindicated in pregnancy?
- Measles
- Mumps
- Rubella
- Zoster
- Varicella
- Typhoid
- Influenza “Live attenuated)
- BCG: Bacille calmette- Guerin
- smallpox (pre-exposure)
Total body surface area rule of 9s?
- Head and neck 9%
- Anterior Trunk 18%
- posterior trunk 18%
- Arm 9%
- leg 18%
- Genitalia 1%
Parkland formula in burns ?
Total fluid requirements in 24 hours:
4 mL x TBSA (%) x body weight (Kg).
- 50 % given in first 8 hours
- 50 % given in next 16 hours.
How to diagnose bacterial vaginosis?
By Amsel criteria ( 3/4):
- Demonstration of clue cells on a saline smear.
- A pH > 4.5
- Thin, grey and homogeneous discharge
- Positive whiff test ( add potassium hydroxide to a slide that contains vaginal discharge, positive when fishy odor occurs).
What is the treatment of bacterial vaginosis ?
Metronidazole or Clindamycin
How to diagnose subclinical hypothyroidism by labs and what is the management?
TSH : high
T4 or Free Thyroxine Index FTI : Normal
Start levothyroxine 75-125 ug if TSH > 10 uU
What are the signs and symptoms of myxedema coma ?
- Altered mental status
- hypothermia
- Bradycardia
- Hyponatremia
- Hypercarbia
- cardiomegaly, pericardial effusion, cardiogenic shock
- Ascites
How to diagnose hypothyroidism by labs ?
TSH : high
T4: low
Free thyroxine index FTI : low
When to screen for Thyroid function ?
- Pregnancy
- Female > 60 years old
- DM type 1
- any autoimmune disease
- History of neck radiation
Name the medications that needs serum TSH re-assessment when started ?
- Estrogen
- Androgen
- Tyrosine Kinase Inhibitors
- Phenobarbitals
- Phenytoin
- Carbamazepine
- Rifampin
- Sertraline
How to treat myxedema coma ?
- IV levothyroxine 200 - 250 ug bolus
- after 24 hours —> levothyroxine 100 ug IV
- then 50 ug /day IV
- Give stress dose of IV glucocorticoids
How to calculate pediatric fluid maintenance ?
- 1st 10 kg : 100
- 2nd 10 Kg: 50
- rest 10 kg : 25
Divid total by 24 hours to get per hour
Labs in tumor lysis syndrome
High :
- Urea
- K
- P
Low : Calcium
+ Acute Kidney Injury
Reiter’s syndrome / Reactive arthritis classic triad ?
- Conjunctivitis
- Urethritis
- Arthritis
Usually occur after infection ( urogenital / GI infections)
What are the relative indications for surgery in primary hyperparathyroidism ?
- Age < 50 years
- Marked decrease in bone mass
3.Nephrolithiasis , renal insufficiency - Markedly elevated serum Ca or episodes of severe hypercalcemia
- Urine Ca > 400 mg in 24 hours
What are the common triggers of C.difficile infection?
- Abx: Clindamycin- Cephalosporins
- Gastric acid suppression: PPIs
How to differentiate between Nephrotic syndrome and Nephritic syndrome?
Nephrotic:
- Proteinuria > 3.5 g / 24 hours
- Hypoalbuminemia ( serum Albumin < / = 30 g/L
- Edema
- hyperlipidemia
Nephritic syndrome:
- Hematuria
- Red cell casts
-Proteinuria “small amount”
- HTN
- Oliguria
How to diagnose HTN in pediatrics ?
When BP in 3 separate visits is > 95th percentile
What are most common area of metastasis in prostate cancer ?
- Lymph nodes
- Bone
What is the management of medullary thyroid cancer ?
Total thyroidectomy and lymph node dissection
What is the mode of inheritance in Neurofibromas?
Autosomal dominant
What are the most common pathogens in meningitis according to age ?
0-6 months : GBS , E.coli , Listeria
6 months - 6 years : S.pneumonia , N.meningitidis , H.influenza
6 - 60 years: N.meningitidis, S.pneumonia , enterovirus, HSV
> 60 years : S.pneumonia , listeria , N.meningitidis.
What is the treatment of Toxoplasmosis in HIV patients?
Cotrimoxazole for 6 months
Alternative: Dapsone + Pyrimethamine
When to perform sweat chloride test for cystic fibrosis ?
If:
- siblings or parents have CF
- A family member is a known carrier of CF gene
- your partner is a carrier.
DKA biochemically ?
- Serum ketones > 5 meq/ L
- blood sugar > 250 mg/dl
- Arterial pH < 7.3
- Serum HCO3 =< 18
- Increased anion gap
- increased serum osmolarity
- Increased uric acid
What are the signs of poor prognosis in DKA ?
- Deep coma
- Oliguria
- Hypothermia
What are the most common causes of mortality in DKA?
- Cerebral edema (results from rapid intracellular fluid shifts + most common).
- Severe hypokalemia
- Adult respiratory distress syndrome
- Comorbid states
What are the complications associated with DKA ?
- Sepsis
- Diffuse ischemic process
- MI
- DVT
- acute gastric dilation
- Erosive gastritis
- Late hypoglycemia
- Respiratory distress
- Infections
- hypophosphatemia
- CVA
How does the labs in DKA patients should be scheduled?
Glucose : Q 1-2 hours until stable, then Q4-6 hours
Serum electrolytes: Q1-2 hours until stable, then Q 4-6 hours
In DKA , which ketone is detected in urine dipstick ?
Acetoacetate
Which ketone in predominant in severe untreated DKA ?
Beta - hydroxybutyrate
What is the plasma osmolarity equation ?
Plasma osmolarity = 2 (Na + K ) + BUN/3 + Glucose/18
What is the action of Insulin ?
- Suppresses hepatic glucose output.
- Enhamces glucose uptake by peripheral tissue.
- Suppresses ketogenesis and lipolysis.
- Stimulates proper use of glucose by the cells.
- Reduces blood sugar levels.
What are the side effects of Corticosteroids?
- Osteoprosis.
- Cataract, Glucoma, and visual blurring.
- Cushinoid appearence.
- Truncal obesity.
- Hirsutism
- Acne
- Impaired wound healing.
- Striae
- Easy brusing and capillary refill.
- Immunosuppression
- HTN
- Glucose intolerance
- Electrolytes disturbence
- Fluid retention
- Peripheral edema
- Increases appetite.
- Gastrointestinal bleeding.
- Avascular necrosis.
- Growth retardation.
- Steroid myopathy.
- Pneumocystis jiroveci pneumonia (PJP).
- Tremor.
- Behavioral changes.
- Insomnia
- Cerebral atrophy.
What is the normal endometrial thickening in postmenopause females?
< 5 mm.
What is the most common HCV genotype in SA ?
HCV-4.
What are the symptoms of Maple syrup urine disease MSUD ? and what’s the Tx?
- Burnt maple sugar smell in diapers after urine has dried.
- Fussiness
- Lethargy
- Decreased feeding
- Poor weight gain
- Hypo/hyper tonia
- High pitched cry
- seizures
Tx:
Dietry restriction of branched - chain amino acids BCAAs.
In which age group does Maple syrup urine disease MSUD occurs in ? and whats the complications if not treated ?
Maple syrup urine disease occur in neonates aged 3-7 days, if untreated could lead to encephalopahty and progressive neurodegeneration.
What is Olanzapine and what its one of his improtant side effects?
Olanzapine it is an antipsychotic
S/E: weight gain
What is the role of ACEI in nephrotic syndrome ?
protect the kidneys
What are the side effects of the following Anti-TB meds ?
- Isoniazid
- Rifampicin
- Pyrazinamide
- Ethambutol
- Streptomycin
- Isoniazid:
- Heptotoxicity
- Peripheral neuritis
- Drug induced lupus
- Psychotic changes - Rifampicin:
- Hepatotoxicity
- Autoimmune reactions
- Thromocytopenia
- Respiratory shock syndrome
- Acute hemolytic anemia - Pyrazinamide:
- Heptotoxicity
- Arthralgia
- Hyper-uricemia - Ethambutol:
- Optic neuritis
- color blindness
- Hyperuricemia - Streptomycin :
- Vestibular dysfunction
- Nephrotoxicity
- Deafness
- Peripheral neuritis
Which of the following in air-borne transmitted and which is droplets ?
- Meningococal
- Measles
- TB
- RSV
- Varicella
- Influenza
- Smallpox
Airborne:
- Measles
- Varicella
- Smallpox
- TB
Droplets:
- RSV
- Influenza
- Meningococal
What is FELTY syndrome and what are its components ?
It is a rare condition that involves RA, decreased WBC and swollen spleen.
its components:
“SANTA “:
Splenomegaly
Anemia
Neutropenia
Thrombocytopenia
Arthritis (RA)
Contraindications of liver transplantation ?
- Alcoholism
- Extrahepatic malignancy
- Severe and uncontrolled extrahepatic infection
- Compensated cirrhosis
- Advanced cardiopulmonary disease
- Multisystem organ failure
- Active substance abuse.
plantar fasciitis clinical presentation ?
It is the most commin casue of heel pain:
It is an intense, sharp heel pain with the first couple of steps in the morning.
Pain decreses with walking or athletic warm up, but then increases throughout the day as activity increases.
In severe cases patient complain of pain after prolonged sitting.
What is the differnece between Radical, modified and simple mastectomy ?
- Radical mastectomy :
Removes all breast tissue + skin + axillary lymph nodes + pectoralis muscle - Modified mastectomy:
Removes all breast tissue + skin+ axillary lymph nodes. - Simple mastectomy:
Removes all breast tissue + skin.
What is a brachial cyst ? and how to treat it ?
Smooth and painless neck mass, appears after URTI.
Surgical removal , but if it was infected start with Abx first.
What are the 2 most common tumors in HIV positive patients ?
- Kaposi sarcoma (skin and oral mucosa)
- Non-hodgkin lymphoma (chest and abdomen).
Burkitt’s lymphoma :
- B cell lymphoma
- C myc gene dysregulation
- Starry sky pattern on microscope
- Associated with EBV infection.
What are the indications of surgical excision of a thyroid nodule?
- FNA suspicion
- > 3-4 cm in size (even if FNA is normal).
- Increasing in size on serial US
- Hyperthyroidism unmanageable with radio-iodine therapy.
- Malignancy other anaplastic CA or thyroid lymphoma.
What is the gold standard study for diagnosing intussusception ?
Barium enema
Meckel’s diverticulum investigations?
Abdominal x-ray
Tc 99m
- What is Hirschsprung ?
- gold standard for Dx ?
- AXR findings?
- Tx ?
- Migration defect of neurocrest cells “aganglionic”. Failure to pass meconium/distal bowel obstruction/abdominal distention.
- Rectal biopsy is gold standard : aganglionosis and neuronal hypertrophy in muscularis externa.
- AXR: narrow rectum
4: Surgical resection of aganglionic part “anal pull through”
What is the medication that can treat small renal stones ?
Urodeoxycholic acid
Pancreatic cancer tumor marker ?
CA 19- 9
Digeorge syndrome ?
- 22q11.2 deletion syndrome
- Syndrome is caused by deletion of small segment of chromosome 22
- Congenital heart problems
- Specific facial features
- Frequent infections
- Developmental delay and learning problems
- Cleft palate
Defenition of pyrexia of unknown origin?
- Temp. > 38.3 on several occasions
- > 3 weeks duration of illness
- Failure to reach a diagnosis despite 1 week of inpatient investigations.
Which type of cancer is associated with hashimoto’s thyroiditis ?
Papillary thyroid cancer
What is the most common cancer in childhood ?
Leukemia
Obturator nerve trauma may cause paralysis to which muscles ?
- Adductor longus
- Adductor brevis
- Gracilis
