SMLE study revision Flashcards
post antibiotic C diff infection antibiotic?
oral vancomycin (or oral metronidazole) severe infection with C difficle: creatinine \>1.5 or WBC \>15000 \>\> oral fidaxomicin (preferred)
scoring system for pneumonia?
CURB-65 sscore
C: confusion
U: urea >7 mmol/L
R: respiratory rate >30/min
B: blood pressure <90/60
Age >65
0-1: home treatment
2: admit
3-5: ICU
what is growing pain?
Growing pains most commonly occur in children 3–12 years old and manifest with episodic, bilateral pain that predominantly affects the lower extremities (shins, calves, thighs, popliteal fossa). The cramping pain most commonly occurs at the end of the day or during the night, ranges from mild to severe, and can awaken the child from sleep. Symptoms typically resolve by the morning and are not present during the day or during periods of activity. Growing pains is a clinical diagnosis because physical examination and diagnostic imaging show no abnormalities. Management consists of analgesics and massages, and reassuring patients and their parents of the condition’s benign nature.
urine electrolyte changes after 1-3 days of vomiting?
high urine sodium
high urine potassium
low urine Cl
alkaluria
urine electrolyte changes after vomiting for > 3 days
low urine Na
low urine K
low urine Cl
aciduria
vomiting leads to dehydration which will secrete ADH to reabsorb water and aldosterone to reabsorb sodium and secrete potassium and hydrogen ions
so urine will be low in sodium and high potassium and aciduria
earliest sign of rheumatoid arthritis on plain x ray?
juxta articular osteopenia
causing the classical hitch - hiker’s deformity
target INR for Afib, aortic and mitral valve replacement, VTE
Important target International Normalised Ratios (INRs) to remember include:
For patients with atrial fibrillation: 2-3
For patients with metallic valve replacements: 2-3 (aortic valve) 2.5-3.5 (mitral valve)
Following venous thromboembolism (VTE): 2-3
Note that for patients with a recurrent VTE whilst on Warfarin, the target INR should be increased from 2-3 to 3-4.
when to administer Anti-D
Anti-D prophylaxis should be administered during the 28th week of gestation and within 72 hours following the birth of an Rh-positive baby.
screening on celiac disease in patients with type 1 diabetes?
on diagnosis and every 2 years in asymptomatic patients
investigations of DIC:
Thrombocytopenia
Increased prothrombin time
Increased fibrin degradation products (such as D-dimer)
Decreased fibrinogen
treatment of giant cell arteritis:
Uncomplicated disease: oral glucocorticoids, e.g., prednisolone
Ischemic organ damage (e.g., impaired vision): Consider initial pulse therapy with IV glucocorticoids before oral glucocorticoids.
Pulse therapy with methylprednisolone
Oral glucocorticoids (initially, or following pulse therapy), e.g., prednisolone
types of rapid acting insulin:
aspart, lispro, glulisine
onset: 5-15 min
peak: 1 hour
duration: 3-4 hours
Types of short acting insulin and characteristics:
regular insulin
onset: 30 min
duration of action: 4-6 hours
standard insulin option for lowering blood glucose during hyperglycemic crisis
the only insulin given IV
types and characteristics of intermediate acting insulin:
NPH insulin
onset: 1-2 hours
duration: 10-16 hours
used for glucocorticoid induced hyperglycemia
Long acting insulin types and characteristics:
Glargine, detemir, degludec
onset 1-4 hours
duration 24 hours
When to give long term oxygen therapy in COPD patients:
- PaO2 ≤ 55 mm Hg or SaO2 ≤ 88% at rest despite optimal medication
- OR PaO2 55–60 mm Hg or SaO2 <90% in patients with pulmonary hypertension, CHF, or polycythemia
Target oxygen saturation: > 90%
Recommended duration: continuous oxygen therapy for ≥ 15 hours/day
Reevaluate after 60–90 days (with ABG or pulse oximetry).
Wolff-Parkinson-White syndrome
Aetiology
Wolff-Parkinson-White (WPW) is caused by a congenital accessory electrical pathway which connects the atria to the ventricles bypassing the AV node.
This accessory pathway leads to the potential for re-entrant circuits to form leading to supraventricular tachycardia
- Features on ECG in WPW
Delta waves (slurred upstroke in the QRS)
Short PR interval (<120ms)
Broad QRS
If a re-entrant circuit has developed the ECG will show a narrow complex tachycardia
-Management of WPW
Radiofrequency ablation of the accessory pathway
Drug treatment (such as amiodarone or sotalol) to avoid further tachyarrhthmias. These are contraindicate din structural heart disease.
Surgical (open heart) ablation - rarely done and only used in complex cases
-Unstable pateints > cardioversion
-In patients with an orthodromic AV reciprocating tachycardia (narrow QRS complex with short PR interval) management is with vagal manoeuvres (carotid sinus massage or Valsalva manoeuvre) in the first instance. If this fails IV adenosine should be administered.
-Contraindications in WPW
Digoxin and NDP-CCBs (e.g. verapamil) are contraindicated for long term use because they may precipitate ventricular fibrillation.
which autoantibodies are associated with systemic sclerosis?
- Anti-centromere antibodies are specific for limited cutaneous systemic sclerosis
- Anti-Scl-70 antibodies are specific for diffuse systemic sclerosis
- Anti RNA polymerase
Poor prognostic factor for pneumonia
Community-acquired pneumonia severity index (PSI) for adults
One point per year Age 62 pints
Pleural effusion (10 points)
Non for CBC or DM
A number of risk factors for mortality have been identified. Having two or three of the following variables have been associated with high risk in several studies:
Blood urea nitrogen> 20 mg/dL
Diastolic blood pressure less than 60 mmHg, and/or
RR 30 per minute.
plus
Confusion and
Age greater than 65 years constitute the CURB-65 score
Increasing age, presence of COPD and malignancy as comorbidities, hypothermia, tachypnea, PaO2/FiO2 ratio ≤250 mmHg, low Alb level, high BUN level and mechanical ventilatory support predict a worse prognosis;
Combination therapy should be considered for CAP
Common side effects of bupropion
Bupropion Common side effects
Headache, weight loss, dry mouth, trouble sleeping (insomnia), nausea, dizziness, constipation, fast heartbeat, and sore throat.
Diaphoresis (5% to 22%)
Constipation (8% to 26%),
Blurred vision (≤15%)
management of status epilepticus
-ABCDE approach
-Oxygen
-Ensure IV access
-Arterial Blood gas
-Bloods for glucose, FBC/UE/CRP,Calcium/Phosphate/Magnesium, drug levels if the patient is on anti-epileptic medications
-Anaesthetic review to ensure the airway is managed
-IV lorazepam 4mg
A second dose of lorazepam should be given if no response
-In the absence of IV access, PR diazepam or buccal midazolam can be administered.
-If the initial benzodiazepine fails, further anti-convulsants can be used:
Leviteracetam
Phenytoin
Valproate
-If seizures continue to persist, intubation and general anaesthesia is necessary.
most common causative agent of infective endocarditis
staph aureus
stept viridans post dental procedure
staph epidermidis infected peripheral venous catheter
smoking cessation management options
1- nicotine replacement therapy
gum, lozingens, patches, nasal spray, inhaler
Increases smoking cessation 1.5 times more than control.
Avoid with recent MI, arrhythmia, and unstable angina.
2- Bupropion
Increases smoking cessation rates about 2 times more than control.
*Avoid with seizure disorder and eating disorder. May be associated with suicidal ideation.
Safety in pregnancy is unclear.
3-Varenicline
Increases smoking cessation rates about 3.5 times more than control and almost 2 times more than bupropion.
SIRS diagnostic criteria
SIRS is diagnosed if ≥ 2 of the following 4 criteria are fulfilled:
- Temperature: > 38°C or < 36°C
- Heart rate: > 90/min
- Respiratory rate: > 20/min or PaCO2 < 32 mm Hg
- White blood cell count: > 12,000/mm3, < 4000/mm3, and/or > 10% band cells-
management of spontaneous bacterial peritonitis
Indications (presence of any of the following in a patient with cirrhosis and ascites):
- Abdominal pain and/or tenderness
- Fever > 37.8°C (100°F)
- Ascitic fluid neutrophil count ≥ 250/mm3
Most common isolates: Escherichia coli, Streptococcus spp., Staphylococcus spp., and Klebsiella
Managemnet:
community acquired infection with no beta lactam antibiotic exposure: IV 3rd generation cephalosporin (cefotaxime)
hospital acquired infection: pipracillin tazobacam monotherapy
Autoimmune hepatitis serology
Patients present with the following signs and symptoms:
Jaundice
Fatigue
Loss of appetite
Hepatomegaly
Splenomegaly
Abdominal pain
Liver function test results
Liver function tests are usually deranged and indicate a hepatic pattern of disease such as Raised ALT and bilirubin with normal/mildly raised ALP.
Patients may have an IgG predominant hypergammaglobulinemia.
Type 1 - The commonest type. These patients have raised levels of anti-smooth muscle antibodies (80%), and antinuclear antibodies may also be positive (10%).
Type II - Less common but often more severe; anti liver/kidney microsomal antibodies type 1 tend to be positive.
Type III - Also less common, and often positive for anti-soluble liver antigen.
risk factors for recurrence of febrile seizure
Initial complex febrile seizure
Family history of febrile seizures
Initial febrile seizure with temperature < 40°C
Age of onset < 18 months [5]
Structural brain lesions, cerebral palsy
treatment of shoulder dystocia
1- McRobert manuver
Or all four position
2- traction with
-Wood’s screw manuver
-Robin manuver 2
3-Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)
4-Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section
causes of polyhydramnios
Excess production can be due to increased foetal urination:
Maternal diabetes mellitus
Foetal renal disorders
Foetal anaemia
Twin-to-twin transfusion syndrome
Insufficient removal can be due to reduced foetal swallowing:
Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
What is mullerian agenesis?
Both of the Müllerian ducts fail to develop, leading to the absent or hypoplastic uterus, absent cervix, and vaginal agenesis (but functional ovaries)
Develop normal secondary sexual characteristics
Presentes with primary amenorrhea
Normal female karyotype
Investigation: testostrone.
at what age do you diagnose primary amenorrhea?
no spontanous uterine bleeding has occured by the age of 16 years or if patient hasnt menstruated after 2 years of thelarche
no evidence of breast development by age 14
primary amenorrhea
BREAT PRESENT, UTERUS PRESENT:
1- imperforated hymen >> monthly dysmenorrhea but absent bleed >> hematocolpus on ultrasound >> hymenectomy
2- vaginal septum >> MRI >> surgical correction
3-anorexia nervosa >> hypogonadotropic hypogonadism
BREAT PRESNET, UTERUS ABSENT:
1- Mullerian agenesis: (mayer rokitansky kvester hauser syndrome)
karyotypically female 46XX
absent fallopian tube, uterus, cervix, upper vagina.
patient developes secondary sexual characteristics, normal pubic and axillary hair.
2-Androgen insensitivity:
karyotypically male 46 XY
lack of androgen receptor function >> wolffian duct structure atrophy >> patients grow up as females
female secondary sexual characteristics are present (testes secrete estrogen)
normal male level of testostrone
no pubic or axillary hair
Tx: testes removal at age of 20
BREAST ABSENT, UTERUS PRESENT:
1- gonadal dysgenesis: Turner syndrome 45X >> streak gonads
2- hypothalamic pituitary failure: severe weight loss, excessive exercise, low body fat
Abnormal uterine bleeding normal parameters
frequency: 24-38
cycle to cycle variation: +/- 2/20 days
duration of flow: 4.5-8 days
volume: 5-80mL
Management of abnormal uterine bleeding:
ACUTE
1- Hospitalize if Hb <7g/dL, hemodynamically unstable
stabiliaze pateints who are hemodynamically unstable.
2- High dose progestrone only therapy is first line for heavy acute bleeding
3- IV conjugated equine estrogen:
4- Combined oral contraceptives
5- Oral progestrone
6- Tranesxamic acid
If there is no respose within 12-24 hours consider surgical managemnet
7- Dilation and currettage:
8- Balloon tamponade
9- Selevtive embolization
10- hysterectomy
CHRONIC: (>6 months)
1- NSAID: to normalize prostaglandin
2- Anti fibrinolytic therapy (Tranexamic acid)
3- Coordinate endometrial sloughing *best for anovulation* (oral medroxy progestrone acetate pr norethindrone)
4-Endometrial supression: (Levonorgesrel intrauterine system)
when is the anomaly scan normally performed for OBGYN?
18-20+6
Signs of placental separation and imminent placental delivery in third stage of labor?
Gush of blood
Lengthening of the umbilical cord
Ascension of the uterus in the abdomen
causes of oligohydramnios:
Uteroplacental insufficiency leading to intrauterine growth restriction. This may be due to maternal disease such hypertension or pre-eclampsia, maternal smoking and placental abruption.
Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). Examples include renal agenesis, polycystic kidneys or urethral obstruction.
Premature rupture of membranes
Post-term gestation
Chromosomal anomalies
Maternal use of certain drugs (prostaglandin inhibitors, ACE-inhibitors)
side effects of progestin only hormone injection: Medroxyprogesterone acetate
- Irregular breathing
- Bone loss (gained back after stopping medication)
- Doesnt cause weight gain.
Absolute contraindication to the combined estrogen and progesterone contraception:
- Hypertension 140-159/90-99mmHg
- Pregnancy
- Acute liver disease
- History of vascular disease: DVT, CVA, SLE,
- Hormonally dependent cancer
- Smoker age >35
- Migraine with aura
- Diabetes mellitus iwth vascular disease
- Thrombophilia
Contraception during breastfeeding?
Depo provera injections/ progestrone only pills
what is the mode of action for emergency contraception? what are the medications used?
prevent ovulation
oral ulipristal acetate and levonorgestrel
screening for gestational diabetes: when to screen early?
-Second trimester (at 24–28 weeks): Recommended in all pregnancies
-Early screening (prior to 24 weeks) is recommended in women with risk factors
Gestational diabetes prior to pregnancy
Recurrent pregnancy loss
At least one birth of a child diagnosed with fetal macrosomia
Initial screening: 50-g, one-hour oral glucose challenge test
Blood glucose level should be < 135 mg/dl
If positive, patients are given the 100-g oral glucose challenge test as confirmation
Confirmation test: 100-g, three-hour oral glucose tolerance test (oGTT) ≥ 140 mg/dl–
Polycystic ovarian syndrome: clinical feature, Investigation:
Pathology:
1- Chronic anovulation: >> infertility, irrigular bleeding, endometrial hyperplasia and endometrial cancer
2- increase testrone >> increase LH, hirsutism
3- ovarian enlargement on ultrasound
CLINICAL FEATURE:
- Menstrual irrigularities: anovulation and infertility, amenorrhea
- Obesity >> sleep apnea
- Non alcaholic fatty liver disease
- Acanthosis negricans
- Hirsutism
INVESTIGATIONS:
1- Hormonal profile:
- LH to FSH ratio high
-Progestrone low
-Androgen high
-Testostrone high
-Sex hormone binding capacity is high
- Estrol high
-Estradiol high
2- Ultrasound:
peripheral small fibers, necklace apperance, 3-10ml, dense stroma
TREATMENT:
1- Irregular bleeding: OCP
2- Hirsutism: OCP or spironolactone
3- Infertility: clomiphene citrate for ovulation induction or human menopausal gonadotropin or Letrozole. metformin can increase ovultaion
folic acid quantity for a healthy lady wants to conceive and with no prior disease or disorder
1mg
for average risk women supplements with 400micrograms per day/ 0.4mg
women at increase risk of NTDs (either due to prior pregnancy with NTD or seizure disorders) >> 4mg of folic acid daily
treatment of hyperemesis gravidarum
1- Pyridoxine (vitamin B6) and/or doxylamine
2- For refractory symptoms, add one of the following:
Diphenhydramine
Dimenhydrinate
Prochlorperazine
Promethazine
3- For refractory symptoms despite combination therapy above, add one of the following:
Metoclopramide
Ondansetron
Promethazine
4- Last resort: Add chlorpromazine or methylprednisolone.
Thiamine repletion (in patients with severe recurrent vomiting)
How to diagnose an Anembryonic pregnancy:
presentation: could be asymptomatic, loss of pregnancy symptoms, falling B-HCG
investigation:
- Gestational sac measuring >25mm and no visible embryo
- No visible embryo during a follow-up endovaginal ultrasound ≥ 11 days after confirming the presence of a gestational sac with a yolk sac
- No visible embryo during a follow-up endovaginal ultrasound ≥ 2 weeks after confirming the presence of a gestational sac without an embryo or a yolk sac
Treatment of abortion (inevitable, incomplete, missed abortion)
1- Expectant management (option for women < 14 weeks gestation): Surgical evacuation is usually recommended if evacuation does not occur after 4 weeks.
2- Medical evacuation
Misoprostol is used to induce cervical ripening and expulsion of the products of conception.
When available, pretreatment with mifepristone 24 hours prior is recommended.
3- Surgical evacuation (dilation and curettage)
Preferred method in septic abortion or if there is heavy bleeding or significant maternal disease, unstable patinets
Complications include uterine perforation, hemorrhage, endometritis, and/or intrauterine adhesions [2]
Rh(D)-negative women should receive Rh(D)-immune globulin in all cases of vaginal bleeding during pregnancy.
Name the 3 types of placenta accreta:
Placenta accreta occurs where adherence of the placenta directly to superficial myometrium but does not penetrate the thickness of the muscle.
Placenta increta occurs where the villi invade into but not through the myometrium
Placenta percreta occurs when the villi invade through the full thickness of the myometrium to the serosa. There is increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.
contraindication to methotrexate treatment in ectopic pregnancy:
indications to treat surgically:
- Hemodynamically unstable
- MTX sensitivity
- Renal, liver or hematologic dysfunction
- Active pulmonary disease
- Active peptic ulcer
- Breastfeeding
- B-HCG 6000-15,000
- Gestational sac >3.5
- Embryonic cardiac motion seen
indications to treat surgically:
- Hemodynamically unstable
- Contraindications to MTX
- Ruptured ectopic pregnancy or signs or intraperitoneal bleeding
- Failed medical management
surgical options:
1- laparoscopic salpingectomy: removal of the affected fallopian tube.
2- laparoscopic salpinsotomy: removal of the ectopic pregnancy.
3- laparotomy if hemodynamically unstable, ruptured ectopic pregnancy, large amount of intraperitoneal bleed.
risk of ectopic pregnancy following one previous ectopic and following two previous ectopic pregnancies?
following one ectopic pregnancy is 10% and following 2 ectopic pregnancy is 25%
secondary prophylaxis or rheumatic fever - Duration of therapy:
penicillin
1- Rheumatic fever with carditis + residual heart disease:
10 years or until the age of 40 (which ever is longer)
2- Rheumatic fever with carditis but no residual heart disease:
10 years or until the age of 21 (whichever is longer)
3- Rheumatic fever without carditis:
5 years or until the age of 21 (whichever is longer)
treatment of neutropenic fever
monotherapy with an antipsudomonal beta lactam agent: cefepime, meropenem, imipenem, piperacillin tazobactam, ceftazidime
results of Down syndrome in chromosomal study performed during:
11-13+6
- AFP low
- PAPPA low
- Eostriol low
- thickened nuchal translucency
- B-HCG high
indications for cervical cerclage: and management:
Clinical diagnosis typically before 24 weeks’ (may be up to 28 weeks’) gestation;
OR
History of ≥ 2 previous midtrimester pregnancy losses or ≥ 3 preterm births not explained by any other cause, and a transvaginal ultrasound cervical length < 25 mm before 24 weeks’ gestation (short cervical length)
Management:
In women with risk factors (i.e. previous preterm birth), serial cervical ultrasound monitoring between 16–24 weeks’ gestation
-Cervical cerclage placed at 13-14 weeks
Definition: placement of a supportive suture in the cervicovaginal junction to prevent early pregnancy loss or preterm birth
Indications: only in singleton pregnancies
Progesterone supplementation (vaginal or intramuscular): indicated for a short cervical length at < 24 weeks’ gestation
prevention of preeclampsia?
low dose asprin initiated between 12-28 weeks gestation and until delivery
treatment of magnesium sulfate toxicity?
monitory reflexes for respratory depression
treated with calcium gluconate
when is nuchal translucency performed and what does it indicate?
performed as part of the first trimester combined screening at 10-13 weeks
A thickened nuchal translucency increases the likelihood of aneuploidy and cardiac disease
treatment of giardiasis?
metronidazole or tinidazole
what is bronchiolitis?
generally affects < 2 years old
Most common cause is RSV or parainfluenza virus
presents with rhinorrhea, low-grade fever, cough, poor feeding followed by respiratory distress
on auscultation wheeze and crackles
1- Supportive treatment
-Adequate hydration
-Relief of nasal congestion/obstruction
-Monitoring
2- Indications for hospitalization
Toxic appearance, poor feeding, dehydration, lethargy
Marked respiratory distress
Age < 12 weeks and/or history of prematurity (< 34 weeks)
Pre-existing heart, lung, or neurological conditions
Immunodeficiency
3- Treatment in severe
-Bronchodilators, epinephrine and corticosteroids
treatment of hypertensive emergency and hypertensive urgency
HYPERTENSIVE URGENCY:
>180/120 without signs of end organ damage
treatment:
- outpatient management
-consider a rapid-acting oral antihypertensive agent: clonidine, captopril, labetalol, prazosin
HYPERTENSIVE EMERGENCY:
-ICU admission
-reduce blood pressure max 25% within the first hour to prevent coronary insufficiency and to ensure adequate cerebral perfusion pressure.
-reduce blood pressure to 160/100-110mmhg over the next 2-6 hours
-reduce BP to baseline over 24-48 hours
-medications given IV
1- calcium channel blocker: Nicardipine, Clevidipine
2- Nitric oxide dependent vasodiltaor: sodium nitroprusside and nitroglycerine
3- Direct arterial vasocilators: hydralazine
4- antiadrenergic drugs: esmmolol, labetalol
RECOMMENDATION BASED ON ASSOCIATED CONDITION:
1- aortic disseection: Esmolol, labetalol
2- pulmonary edema: clevidipine, sodium nitroprusside, nitroglycerine
3- acute coronary syndrome: Nitroglycerine, esmolo, labetalol, nicardipine
4- acute renal failure: clevidipine, nicardipine, fenoldopam
what is ischemic hepatitis?
acute diffuse liver injury due to hypoperfusion
2% of patients admitted to the ICU develop ischemic hepatitis.
ETIOLOGY:
- impaired perfusion due to heart failure, severe hypotension, shock, thromboembolism, cardiac tamponade.
- hypoxemia: respiratory failure.
- septic shock, burns, surgery.
INVESTIGATION:
1-Medical history and physical examination: cardiopulmonary disease, hypotension
2- Laboratory studies
-Severely elevated AST levels (> 1000 U/L)
Serum levels peak 1–3 days
Values return to normal within 7–10 days, once hepatic perfusion is restored.
-Elevated bilirubin levels
-Elevated LDH levels
-ALT:LDH ratio of < 1.5
-Elevated serum creatinine and BUN levels
-Normal alkaline phosphatase levels
-Coagulation studies: prothrombin time may be prolonged
if a child develop high fever and rash after a vaccine what should be done?
give prophylactic paracetamol and give antihistamine if develop rash
if the patient develop severe symptoms come back to ER.
what would happen if a female received Rubella vaccine and got pregnant before 2 months?
live attenuated vaccines should not be given to women for 1 month before planned pregnancy.
however if pregnancy occurs within 4 weeks from live vaccine then its safe to proceed the pregnancy and no reported cases of fetal damage from live vaccine
the risk of damage to fetus is hypothetical
first-trimester vaccine in pregnancy
influenza vaccine
which vaccine is contraindicated in immunodeficiency
live attenuated vaccine:
MMR
Varicella
Zoster
Yellow fever
Rotavirus
Influenza (intranasal)
Smallpox
Adenovirus
Typhoid (oral, Ty21a)
which vaccines are contraindicated in HIV patients?
oral polio and BCG
HIV patient can receive live vaccine if
1- asymptomatic
2- CD4 percentage is more than 15% in children less than 5 years
3- if CD4 count is more than 200 cell/micro in children above 5 years
contraindications to DTP vaccine?
- encephalopathy within 7 days of previous vaccine
- unstable CNS condition
- anaphylactic reaction to previous dose
- High fever or severe acute illness (delay till the child is doing well)
Precautions to DTaP vaccine
- Febrile seizure after DTap
- Hisrory of crying or high fever or febrile seizure from previous vaccine
- History of gullian barre syndrome within 6 weeks of previous DTap
varicella vaccine contraindications
live attenuated vaccine
in children less than 7 year: give 2 doses with 3 month apart
in children above 7 years: give 2 doses with 4 weeks apart.
-Primary immunization
The CDC recommends two doses of the vaccine: first dose at 12–15 months of age ; second dose at 4–6 years of age (may be given earlier, but must be at least three months after the first dose)
A combined measles, mumps, rubella, varicella (MMRV) vaccine is available.
-Catch-up vaccination
Two doses of varicella vaccine recommended for all children without evidence of immunity between the ages of 7–18
After 18 years of age:
Individuals in close contact to individuals at high risk of infection (e.g., caretakers of immunocompromised patients)
Individuals at high-risk of exposure to infected individuals (e.g., childcare employees)
Before patients undergo immunosuppressive therapy or organ transplantation
Seronegative women of child-bearing age
Individuals with severe neurodermatitis
patients who have an allergy to egg, chicken protein or gelatin which vaccine is contraindicated?
yellow fever vaccine
if a pregnant is taking a biological agent during pregnancy which vaccines are affected?
affect the immune response against live vaccine
live vaccine should be given at 6 months or ideally at 12 months
in chronic granulomatous disease which vaccine is contraindicated?
live vaccine
BCG
yellow fever
plague
MMR and varicella vaccine contraindications
neomycin and gelatin are contraindications to MMR and varicella
which vaccine is contraindicated in patients with siblings who are immunocompromised?
oral polio is contraindicated as it is transmitted feco orally
what can happen years after measles vaccine?
subacute sclerosing panencephalitis
initial symptoms between 8-11 years of age Clinical presentation: characterized by four clinical stages
Stage I: dementia, personality changes
Stage II: epilepsy, myoclonus, autonomic dysfunction
Stage III: decerebration, spasticity, extrapyramidal symptoms
Stage IV: vegetative state, autonomic failure
when should a live vaccine be given after stopping steroid or chemotherapy?
4 weeks after stopping steroids
oral steroid cause immunosuppression only if given more than 2 weeks with a dose 2mg/kg per day
12 weeks after stopping chemotherapy
no live or killed vaccine after rituximab for 6 months
brucelosis
zoonotic disease from animal (from raw meat or unpasturized milk)
affect CNS, heart (aortic valve endocarditis)
General
Flu-like symptoms (undulating fever)
Night sweats
High, potentially undulant fever
Painful lymphadenopathy
Localized infection
Arthralgias, low back pain → osteoarticular infection (e.g., osteomyelitis, spondylitis)
Epididymal and testicular tenderness, flank pain → genitourinary infection (e.g., epididymo-orchitis, pyelonephritis)
Murmurs, friction rubs, tachycardia → cardiac infection (e.g., endocarditis, myocarditis)
investigation:
serum agglutination test
treatment
<8 yeras: TMP/SMX and rifampicin
>8 years: doxycyclin and rifampicin
duration of treatment:
- 6 weeks if no CNS, CVS or back involvement
- >3-6 months
non pregnant adults: doxycyclin + steptomycin or gentamycin
pregnant female: TMP/SMX + rifampin
adult or child >8 years: brucellosis + spondylitis >> doxycyclin + rifampin
what is milwaukee shoulder syndrome:
subtype of BCP-associated osteoarthritis characterized by noninflammatory osteoclast-mediated destructive arthritis of the shoulder joint
clinical feature:
typically affect shoulder
causing joint pain, swelling, restricted range of motion, crepitus with joint movement
diagnostics:
- synovial fluid analysis: few WBC, many RBC, CPP crystals, alizarin red S stain
- Calcium hydroxyapatite
Acute rheumatic fever:
delayed inflammatory complication of group A beta-hemolytic streptococcal (streptococcus pyogenes) pharyngitis that occur within 2-4 weeks of acute infection.
post-acute tonsilitis or pharyngitis
COMPLICATION:
- acute pancarditis
- chronic cardiac valvular changes
CLINICAL FEATURE:
JONES criteria:
-constitutional symptoms: fever, malaise, fatigue
-migratory polyarthritis
-Heart: pancarditis, valvular lesion (mitral valve most common)
-CNS: Sydenham chorea: involuntary, nonrepetitive movement of the limbs, neck, head, face. occur 1-8 months after infection.
-Skin: subcutaneous nodule, erythema marginatum
DIAGNOSTIC:
- ANtistreptolysin O titer
- Antistreptococcal DNAse B titer
MANAGEMENT:
-penicillin V (first line)
for symptomatic management:
1- NSAID, asprin, naproxen
2- glucocorticoids
PREVENTION:
Primary infection: treatment of GAS tonsilitis or pharyngitis with penicillin V
Secondary prevention:
patients with a history of ARF are at high risk for recurrence
IM penicillin G benzathine every 4 weeks
whichever of the following results in the longest treatment duration:
Possible ARF: 12 months
Rheumatic fever without carditis: 5 years or until the patient reaches 21 years of age
Rheumatic fever with carditis (with no residual heart disease): 10 years or until the patient reaches 21 years of age
Rheumatic fever with carditis and permanent valvular heart defects: 10 years or until the patient reaches 40 years of age
abruptio placentae
normally implanted placenta seperates from the uterine wall before delivery
TYPES: overt/external OR Concealed/internal
RISK FACTOR:
- previous abruptio
- hypertension
- maternal blunt trauma
- cocaine abuse
CLINICAL PRESENTATION:
- painful late trimester vaginal bleed
- uterine pain and tenderness
- in moderate abruptio: fetal monitoring shows tachycardia, decreased variability, mild late deceleration. in severe cases fetal monitoring will show bradycardia.
INVESTIGATON: ultrasound.
TREATMENT:
-emergency C-section
if >36 weeks and heavy bleed but controlled => vaginal delivery
-conservative if pregnancy is remote from term and both fetus and mother are stable.
COMPLICATION:
- DIC
- Acute tubular necrosis
treatment of dyspepsia if H pylori negative and if positive? how to confirm eradication
dyspepsia with h pylori negative?
PPI for 8 weeks
H.pylori positive
1- Triple therapy:
PPI + clarithromycin + amoxicillin (or metronidazole) for 10-14 days
2- Quadruple therapy:
PPI + bismuth + tetracyclin + metronidazole
CONFIRM ERADICATION:
4-6 weeks after completion of treatment regimen
-Urea breath test
-Stool antigen test
-Biopsy
echinococcosis infection
TRANSMISSION:
-hand to mouth
Echinococcus granulosus (cystic echinococcus): singular hydatid cyst; Echinococcus multilocularis (alveolar echinococcosis): infiltrative growth.
CLINICAL FEATURE:
-hydatid cyst: RUQ pain, N/V, hepatomegaly, lung involvement in 25% of cases
INVESTIGATION:
1-LAB: mild eosinophilia, abnormal liver function test
2- Serology: positive ELISA
3- Ultrasound: initial
4- CT scan: diagnostic
TREATMENT:
CYSTIC:
-medical therapy if <5cm –> albendazole
-Ultraosund or CT guided percutanous drianage: in combination to medical therapy if >5cm
-Surgery: if >10cm or complicated cyst.
ALVEOLAR:
1- curative resection followed by at least 2 years of albendazole.
Amebiasis:
Entamoeba histolytica
TRANSMISSION: feco oral
CLINICAL FEATURE:
1- Intestinal amebiasis:
-Incubation period: 1-4 weeks
- loose stool with mucus and bright res blood
-painful defcetation, tenesmus, abdominal pain, cramps, weight loss, anorexia
-fever only in 10-30%
-high risk of recurrence through self inoculation
ALWAYS CONSIDE IN PATIENTS THAT PRESENT WITH DIARRHEA AFTER TRAVELING TO TROPICAL OR SUBTROPCAL DESTINATION.
2- Extraintestinal amebiasis:
95% amebic liver abscess: usually solitary abscess in the right lobe: RUQ pain, fever
INVESTIGATION:
1- stool analysis: (BEST INITIAL) identification of cyst or trophozoit in fresh stool, trophozoit often contain ingested erythrocyte
2- colonoscopy with biopsy: flask shaped ulcer
3- serology (PCR or ELISA) the best diagnostic
Extra intestinal amebia
1- serology antibody
2- aspiration of abscess
3- ultrasound: hypoechoic solitary lesion
4-CT or MRI: well defined round lesion with contrast enhancing wall
TREATMENT:
-asymptomatic: no treatment
-Symptomatic intestinal and extraintestinal: metronidazole or tinidazole followed by luminal agent (paromomycin) to eradicate cyst (if liver abscess followed by Diloxanide furate)
oral metronidazole for 7-10 days
oral imidazole for 5 days
IV is not superior to oral
- Aspiration vua ultrasound or Ct guided if complicated liver abscesses:
Indications:
Localized in the left lobe
Pyogenic abscess
Multiple abscesses
Failure to respond to pharmacotherapy
-Surgical drainage: should generally be avoided
COMPLICATION: ameboma: a tumor like mass caused by granulomatous reaction in the intestine in amebiasis which result in a large local lesion of the bowel
empiric antibiotic treatment for community acquired pneumonia in outpatient setting
1- previously healthy patient without comorbidities or risk factor for resistant pathogen:
Monotherapy with one of the following:
Amoxicillin
Doxycycline
A macrolide (only in areas with a pneumococcal macrolide resistance < 25%): Azithromycin, Clarithromycin
2- patients with comorbidites or risk factor for resistant pathogen:
- Combination therapy
An antipneumococcal β-lactam:
Amoxicillin-clavulanate
Cefuroxime
Cefpodoxime
PLUS one of the following:
A macrolide
Azithromycin
Clarithromycin
Doxycycline
- Monotherapy: with a respiratory fluoroquinolone
Gemifloxacin
Moxifloxacin
Levofloxacin
DURATION OF TREATMENT:
5 days are usually sufficient
treatment of hepatocellular carcinoma
1- very early stage HCC: (<2cm)
First line
Minimal concomitant liver disease: surgical resection
Significant concomitant liver disease: liver transplantation if Milan criteria are met
Alternative: ablative therapy e.g. radiofrequency ablation
2- intermediate stage (>3 tumors or >3cm)
Locoregional therapy with:
Transcatheter arterial chemoembolization
Transarterial radioembolization
3- Advanced HCC: (portal vein invasion/ nodal or extrahepatic metastesis)
Systemic chemotherapy
First line: targeted treatment e.g., with atezolizumab/bevacizumab
Alternatives
Nontargeted chemotherapy
Hepatic arterial infusion chemotherapy
4- End stage HCC:
typically supportive care only
How to read a CTG?
1- fetal heart rate
- normal range 110-160 beats/min
Tachycardia causes: terbutaline, atropine, scopolamine (beta adrenergic agonist), fever, thyrotoxicosis
Bradycardia: beta adrenergic blockers, local anesthesia, fetal congenital heart block
2- baseline variability:
- absent
- minimal: <5beats/min
- moderate: 6-25 beats/min
- marked variability: >25
3- accelerations:
- if >32 weeks gestation: acceleration is >15 beats/min above baseline for >15 seconds but <2 min
- If <32 weeks gestation: acceleration has a peak of 10beats/min above baseline for >10 seconds but <2 min
4- deceleration
-Early deceleration: the peak of the deceleration occurs at the same time as the peak of contraction
Associated with uterine contraction
-Late deceleration:
The deceleration is delayed in timing, the deceleration occur after the peak of contraction
Associated with placental insufficiency
-variable decelerations:
Associated with umbilical cord compression
-sinusoidal pattern: smooth sine wave like undulating pattern
Indicated fetal anemia and vasa previa
Fetal heart rate categories:
Category 1: Normal
- baseline 110-160
- baseline FHR variability moderate
- late or variable deceleration: absent
- early deceleration present or absent
- acceleration: present or absent
Category 2: intermediate
Treatment: fetal resuscitation if no improvement > c section
Category 3: abnormal
-recurrent late deceleration
-recurrent variable deceleration
-bradycardia
-sinusoidal pattern
Treatment: prepare for delivery + fetal resuscitation >> no improvement immediate C-section
Intrauterine resuscitation
1- decrease uterine contraction: turn off IV oxytocin
2- argument IV fluid volume
3- high flow oxygen administration 8-10L of oxygen by face mask
4- amino infusion:
5- change position to lateral position to decrease pressure on inferior vena cava
6- vaginal examination to rule out prolapse
7- scalp stimulation
Abnormal first stage of labor
NORMAL FIRST STAGE
1-Latent phase: onset of labor till 6cm cervical dilation
2- active phase: from 6cm to 10cm dilation
ABNORMAL FIRST STAGE
1- prolonged latent phase
In nulliparis women >20 hours
In multiparis women >14 hours
Management:
Supportive care
Unless rupture of membranes >> argumentation with oxytocin
2- prolonged active phase
-No change in cervical dilation after 6hours of inadequate contraction
-No change in cervical dilation after 4 hours of adequate contraction.
Management:
-argument with oxytocin
-aminotomy
3-ARREST of active phase
>6cm dilation
->4 hours of adequate contraction
->6hours of i adequate contraction despite oxytocin
Management: c-section
Abnormal second stage of labor
DEFINITION:
Arrest of fetal descent
>3 hours in nulliparis women
>2 hours in multiparis women
(One hour extra if epidural is given)
Management:
- instrumental delivery (if head is engaged at +2 station and beyond)
- C- section (if 3 attempts of instrumental delivery failed)
Oxytocin side effect
- uterine tachysystole >> can lead to abruptio placenta or uterine rupture
- category 2 or 3 FHR
Effect of medications of fetal heart rate pattern intrapartum
1- Mg sulfate
2- Epidural analgesic
3- Oxytocin
1- Mg sulfate: decrease in short term variability,
2- Epidural analgesia: late or prolonged deceleration (maternal hypotension >> uteroplacental insufficiency
3- oxytocin: late or prolonged deceleration + uterine hyper stimulation
Contraindications to external cephalic version
Should be offered >37 weeks
ABSOLUTE CONTRAINDICATION:
- Previous classical C section
- previous uterine surgery (myomectomy)
- placenta previa
- non reassuring fetal heart rate
- multiple pregnancy
- mechanical obstruction to vaginal birth (pelvic fracture, large fibroid, fetal hydrocephalus)
- uterine rupture
- macrosomia
- unexplained APH
RELATIVE CONTRAINDICATIONS
- early delivery
- oligohydramnios or rupture membrane
- known nuchal cord
- structural uterine abnormality
- fetal growth restriction
- prior abeuptio or it’s risk
Management of post term pregnancy
If patient is 41 weeks gestation > fetal surveillance
If patient is 42 weeks gestation > induction of labor
If complications develop > induction of labor
If gestational age is uncertain > induce labor by 41 weeks gestation.
When is the quadruple test performed and what is it used for
Performed at 15-20 weeks gestation
FOR DOWN SYNDROME
- MS-AFP and estriol >> decreased
- B-HCG and inhibin A >> increased
FOR TRISOMY 18
All four markers are decreased
Vaccines given intramuscularly
DTP/DTaP
Hepatitis B
IPV
Hib
PCV-7
Intradermal vaccine
BCG
Subcutaneous vaccine
Measles and yellow fever vaccine
Tocolysis options for preterm labor
FIRST LINE:
1- indomethacin if patient 24-32 weeks gestation
2- Nifedipine if 32-34 weeks gestation
SECOND LINE
1- Nifedipine if 24-32 weeks gestation
2- terbutaline if 32 to 34 weeks gestation
terbutaline tocolysis side effect:
MOTHER SIDE EFFECT:
management of premature rupture of membrane
Unstable patients
Prompt delivery in:
Patients with signs of intraamniotic infection, abruptio placentae, cord prolapse
Signs of fetal distress (nonreassuring fetal heart rate)
Additionally, collect cervical cultures and commence empiric antibiotic therapy ampicillin and gentamicin.
Stable patients
Gestational age: ≥ 37 0/7 weeks (term)
Delivery by induction of labor is generally recommended.
Expectant management for up to 12–24 hours is reasonable in otherwise uncomplicated pregnancies and in the absence of infection.
Gestational age: 34 0/7–36 6/7 weeks (late-preterm)
Expectant management and induction of labor are both reasonable options.
Expectant management
Bed rest, pelvic rest
Induction of fetal lung maturity: single-course of antenatal corticosteroids if not previously given if there is no evidence of chorioamnionitis and delivery is anticipated in > 24 hours and < 7 days
Gestational age: 24 0/7–33 6/7 weeks
Expectant management
Bed rest, pelvic rest
Prophylactic antibiotics to reduce the risk of infection and delay delivery
Ampicillin IV PLUS erythromycin IV followed by amoxicillin PO PLUS erythromycin PO
OR
Ampicillin IV PLUS azithromycin IV followed by amoxicillin PO PLUS azithromycin PO
Single-course of antenatal corticosteroids (betamethasone or dexamethasone)
Tocolysis can be used to delay delivery for up to 48 hours so that antenatal corticosteroids can be administered. [14]
Magnesium sulfate if preterm delivery < 32 weeks gestation is anticipated [15]
Gestational age < 23–24 weeks
Fetal outcome is generally poor in PPROM before or at the limit of viability.
The choice of management depends on patient-specific factors and preference.
Expectant management
Not recommended before viability
Same approach as for pregnant women at 24 0/7–33 6/7 weeks
management of post partum hemorrhage
C_SECTION >> B lynch suture >> artery embolisation (if hemodynamically stable) laparotomy and artery ligatioon (if hemodynamically unstable) >> hysterectomy
VAGINAL DELIVERY >> Bakri balloon >> artery embolisation (if hemodynamically stable) laparotomy and artery ligatioon (if hemodynamically unstable) >> hysterectomy
1- oxytocin 10-40 units in 500-1000mL of normal saline
2- 0.2mg of ergonavine or methylergonavine IM (contraindicated in preeclampsia or hypertension)
3-prostaglandin F2a IM
4- Carboprost (Hemabate) IM (contraindicated in asthma)
5- misoprostol per rectum or subinguinal
6- uterine compression suture (B-Lynch suture)
7- bimanual compression and massage of uterine corpus
8-packing (large volume balloon cather)
9-percutanous catheter into the uterine arteries for injection of thrombogenic material to control blood flow and hemorrhage
10- hysterectomy
indications to evacuate a vaginal hematoma after episiotomy
- >5cm
- Expanding
- Painful
what ultrasound findings suggest a malignant adnexal mass?
- Mass size graeter than 10cm
- Irrigular
- High flow on color doppler
- Pappilary or solid (hypoechoid) mass
- Presence of ascitis
patient with complement deficiency which vaccine can he be given?
all the vaccines
measles vaccine schedule:
should be given at 9, 12, 18 and then again at 4-6 years
Live vaccine MMR
patient with dog bite (rabies) what should you do?
If the wound is MAJOR with major scratches or involving mucus membrane or bleeding
1- give immunoglobulin
2- vaccinate
-if not previously vaccinated >> give on days 0,3,7, and 28
-if previously vaccinated >> give on days 0 and 3
if the wound is MINOR with only minor scratch without bleeding:
-no need for immunoglobulin
-Give vaccination
if not previously immunized on days 0,3 and 28
if previously immunized on day 0 and 3
which vaccine is contraindicated to patients with previous history of intussusception?
Rota virus vaccine
contraindicates to live attenuated vaccines
- immunodeficiency
- history of recet blood transfusion, blood products or immunoglobulin
- steroids for more than 2 week more than 2mg/kg per day
- should be delayed 3-11 months after IVIG
- should be delayed after 6 months of PRBC
- should be delayed after 7 month of givening FFP or platlet
- immediatly after packed RBC products
- Live attenuated vaccines should be delayed after 3 months or before 2 weeks of chemotherapy.
- Pregnancy
- if received another live vaccine 4 weeks ago
- anaphylaxis to the vaccine
- Allergy to neomycin or geeatin are contraindications to MMR and varicella
which vaccine is contraindicated in eczema patients?
smallpox vaccine
influenza vaccine indications
INDICATIONS:
- all infants >6 months given annually
- all children exposed to or living with healthcare workers, chronic illness or immunodeificnexy
Gullian barre syndrome etiology
it usually follows a gastroentestinal infection by 1-4 weeks
- Campylobacter jeujeni
- CMV (most common virus)
- Influenza vaccine
patients with chronic respiratory disorders should receive which vaccines?
1- Influenza
2- Pneumococcal vaccine
women presents with recurrent still births which vaccine should be given and when
rubella is teratogenic and should be givem 1 month before getting pregnant or immediately after deliver.
Hard signs of vascular injury
- Severe or uncontrolled hemorrhage
- Large, expanding or pulsatile hematoma
- Thrills or bruits
- Shock unresponsive to IV fluid resuscitation
- Abset or diminished radial pulse
- Neurologic deficit (hemiplegia) consistent with cerebral ischemia
- Air bubbling from a wound
- Massive hemoptysis or hematemesis
- Respiratoy distres
most common cause of infective endocarditis in pediatric patients
what is the treatment of staph epidermides
in general staph aureus
- for patients with underlying congenital herat disease: strept virdans >>> vancomycin
- for patients with normal heart: staph aureus >>> vancomycin
- for patients with prosthesis: staph epidermis >>>> treated with vancomycin, rifampicin and gentamycin
Measles (Rubeola) infection features
clinical feature:
- Fever and conjunctivitis, coryza, cough and pathognomonic koplik spots on the buccal mucosa
- Sudden development of a high fever, malaise and exantham (erythematous maculopapular rash) start on the face and spreads down
- usually in children older than 5
- no hands and foot changes
- no strawberry tongue
treatment
- supportive
- vitamin A
DVT management
MI ECG
prophylactic treatment for patients previous history of TIA
antiplatelet: either aspirin or clopidogrel
long term secondary prevention of ischemic stroke
for long-term prevention of ischemic stroke
recommend treatment with an antiplatelet agent using either aspirin, clopidogrel, or aspirin-extended-release dipyridamole.
asprin is first line
how to differentiate between organic and functional pain?
how to differentiate between hirschsprung and functional constipation
management of hirshprung disease is colostomy initially then followed by definitive surgical treatment by modified duchamel procedure, swenson procedure or pull through surgery (Suave procedure)
how to differentiate between marasmus and kwashirkor?
Marasus is deficiency in all major nutrients
Kwashirkor is deficiency in protients primerily
treatment for pelvic inflammatory disease
Treatment of PID consists of broad antimicrobial coverage against the likely pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, and the gram-negative and gram-positive organisms that comprise the cervical and vaginal flora, including anaerobic organisms
Indications for hospitalization –
- Severe clinical illness (eg, high fever, nausea/vomiting preventing oral intake, severe abdominal pain)
- Suspected pelvic abscess
- Pregnancy
- A possible alternative diagnosis that could warrant surgery (eg, appendicitis)
managment of penetrating neck injury:
acetaminophen toxicity treatment
Give activated charcoal (AC) 50 g to all adult patients presenting within 4 hours of ingestion, unless contraindicated; AC may be useful for coingestants beyond 4 hoursTreat with N-acetylcysteine (NAC) if:Serum APAP concentration drawn at 4 hours or more after a single acute ingestion is above the “treatment” line of the treatment nomogram for APAP poisoning
- <4 hours >> activated charcoal wait till 4 hours then plot the APAP
- 4-24 >> plot the APAP >> if level are high enough NAC
- >24 hours >> give NAC if patient is symptomatic
treatment of premenstrual syndrome
asthma management in patients <5 years old
classification of PPD reaction
pediatric age specific cause of pneumonia and treatment of pneumonia
admit patient:
- not tolerate oral antibiotic
- severe hypoxia <92%
- severe tachypnea >50 per minutes in infants and more than 70 per minutes in children older than 1 year
- toxic appearance
- patient with underlying medical condition
- pneumonia complicated by effusion or empyema
Treatment:
Outpatient: Amoxicillin
Inpatient: ceftriaxone + macrolide
most common cause of pneumonia according to pediatric age and management
renal tubular acidosis
Type 4 RTA: related to defect in aldosterone or renal obstruction
- congenital adrenal hyperplasia
- hyporaldosteronism
- obstructive uropathy
- spironolactone or amiloride
what is fanconi anemia
from birth
high MCV, high HbF and high ADA
autosomal recessive
absent thumb
short stature
microcephaly
blood transfusion dependent
features of fetal alcohol syndrome
- Dysmorphic features [11]
- Thin upper lip
- Smooth hypoplastic philtrum
- Down-slanting, short palpebral fissures
- Hypertelorism
- Microcephaly
- Epicanthal folds
- Receding chin
- Features of specific systemic defects
- Heart defects (mainly ventricular septal defect)
- Heart-lung fistulas
- Skeletal anomalies (limb dislocations, joint contractures, pectus excavatum/pectus carinatum)
- Renal anomalies (aplastic/dysplastic kidneys) leading to hypertension
- Prenatal or postnatal growth retardation → short stature
- Holoprosencephaly: a developmental field defect in which the forebrain fails to divide into two hemispheres, resulting in fusion of ventricles (leading to the formation of monoventricle) and other bilateral cerebral structures, e.g., basal ganglia [12]
- Most commonly occurs during the 3rd–4th week of pregnancy [13]
- Potential genetic causes include:
- Mutations in SHH gene coding for sonic hedgehog protein
- Trisomy 13
- Associated clinical features
- Craniofacial abnormalities (cyclopia, cleft lip/palate, hypotelorism, and/or proboscis)
- Endocrine disorders related to pituitary dysfunction (e.g., diabetes insipidus)
- Seizures and epilepsy
how to differentiate between TTP, ITP, and DIC
indications for lymph node biopsy in patients with lymphadenopathy
Indications of CT head in childhood head injury
How to differentiate between simple febrile and complex febrile seizure:
Fragile X syndrome
Spinal muscular atrophy: High Yield
Autosomal recessive
genetic disorder where nerve cells in the spinal cord die prematurely (degeneration of anterior horn cells) >> muscle atrophy
Spinal muscle atrophy type 1:
- hypotonia but alert
- severe progressive disorder
- diminished fetal movement during pregnancy
- arthrogryposis (position deformity of the limb with contracture of at least two joints)
- fasiculation of the tongue
- symmetrical flaccid paralysis
- absent deep tendon reflex
- intercostal recession
- weakness of bulbar muscle, weak cry, poor suck with pooling of secretion
- never sit unaided
- die of respiratory failure
Spinal muscular atrophy type2:
- infants are normal at birth
- develop progressive weakness worse proximally
- weak sucking, chewing, and swallowing (aspiration)
- weakness in chest wall and diaphragm
- can sit but never walk
investigation
1- Genetic testing: best and initial
2- creatine kinase is elevated
3- EMG spontaneous large amplitude, low frequency
4- muscle biopsy atrophy of groups of motor units
transiet synovitis
- most common cause of acute hip pain in children 2-12 years
- often follows or accompanied by viral infection
- sudden onset hip pain or limp
- no pain at rest
- there is decrease range of motion particularly internal rotation
- no fever
- at risk of the development of perthes disease ( avascular necrosis of the capital femoral epiphysis of the femoral head)
- ultrasound may show effusion
most coomon cardic anomaly in turner syndrome
most common finding
Elongated transverse aortc arch
Bicuspid aortic valve
coarcitation of aorta
most common finding: fold skin at the nape of the neck
faetures of marfan syndrome
most common cardiac deformity in marfan syndrome
most common congenital heart anomaly: motral valve prolapse
murmurs
features of Edwards syndrome
Prince Edward turned 18
- Prominent occiput
- Rocker bottom feet
- Intellectual
- Nondisjunction (in meiosis)
- clenched fist
- low set ears
- chromose 18
Trisomy 13 features:
Patau syndrome
- Microcephaly, holoprosencephaly
- cleft lip and palate
- low set ears
- micropthalmia
- polydactyly
- congenital heart defect
- ricker bottom feet
- aplasia cutis congenita
- omphalocele
prader willi syndrome
- muscular hypotonia
- hyperphagia and obesity
- hypogonadism
- almond shaped ears
- intellectual disability
- behavioral problems
treatment of ulcerative colitis
when does moro reflex disappear, palmer grasp, plantar grasp, rooting, stepping reflex, parachute reflex
differential diagnosis of vulvuvaginitis
features of infectious mononucleosis
signs of severe asthma exacerbation
interstinal protozoa
Indications for cholecystectomy in gallbladder polyps:
- >10mm - <3 polyps - increase in size >2mm - age >50 - symptomatic - associated with gallstones -Associated with primary sclerosis cholangitis with cirrhosis Otherwise continue ultrasound evaluation for 3-6 months.
Treatment of asthma
Indication for operative treatment after chest thoracostomy
How to differentiate between an endometrial polyp and sub mucus fibroid
Endometrial polyp is usually a solitary homogenous and echo genie lesion
Primary biliary cholangitis
Woman in 40-50 Fatigue and itching Normal bilirubin with an elevated alkaline phosphatase Xanthelasma/xanthoma Osteoporosis -Antimitochondrial antibody -Liver biopsy is definitive Treated with urodeoxycholid acid or obeticholic acid
Erythema toxicum neonatorum
Erythema toxicum neonatorum (ETN) presents with multiple erythematous macules and papules (1 to 3 mm in diameter) that rapidly progress to pustules on an erythematous base. The lesions are distributed over the trunk and proximal extremities, sparing the palms and soles. They may be present at birth but typically appear within 24 to 48 hours. The rash usually resolves in five to seven days, although it may wax and wane before complete resolution. Biopsy will show eosinophils
Transient neonatal pustular Melanosis
Biopsy will show neutrophils
