SMLE study revision

Question 1

post antibiotic C diff infection antibiotic?

Answer 1

oral vancomycin (or oral metronidazole)
severe infection with C difficle: creatinine \>1.5 or WBC \>15000 \>\> oral fidaxomicin (preferred)

Question 2

scoring system for pneumonia?

Answer 2

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

Question 3

what is growing pain?

Answer 3

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.

Question 4

urine electrolyte changes after 1-3 days of vomiting?

Answer 4

high urine sodium
high urine potassium
low urine Cl
alkaluria

Question 5

urine electrolyte changes after vomiting for > 3 days

Answer 5

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

Question 6

earliest sign of rheumatoid arthritis on plain x ray?

Answer 6

juxta articular osteopenia
causing the classical hitch - hiker’s deformity

Question 7

target INR for Afib, aortic and mitral valve replacement, VTE

Answer 7

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.

Question 8

when to administer Anti-D

Answer 8

Anti-D prophylaxis should be administered during the 28th week of gestation and within 72 hours following the birth of an Rh-positive baby.

Question 9

screening on celiac disease in patients with type 1 diabetes?

Answer 9

on diagnosis and every 2 years in asymptomatic patients

Question 10

investigations of DIC:

Answer 10

Thrombocytopenia
Increased prothrombin time
Increased fibrin degradation products (such as D-dimer)
Decreased fibrinogen

Question 11

treatment of giant cell arteritis:

Answer 11

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

Question 12

types of rapid acting insulin:

Answer 12

aspart, lispro, glulisine

onset: 5-15 min
peak: 1 hour
duration: 3-4 hours

Question 13

Types of short acting insulin and characteristics:

Answer 13

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

Question 14

types and characteristics of intermediate acting insulin:

Answer 14

NPH insulin
onset: 1-2 hours
duration: 10-16 hours
used for glucocorticoid induced hyperglycemia

Question 15

Long acting insulin types and characteristics:

Answer 15

Glargine, detemir, degludec
onset 1-4 hours
duration 24 hours

Question 16

When to give long term oxygen therapy in COPD patients:

Answer 16

• 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).

Question 17

Wolff-Parkinson-White syndrome

Answer 17

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.

Question 18

which autoantibodies are associated with systemic sclerosis?

Answer 18

• Anti-centromere antibodies are specific for limited cutaneous systemic sclerosis
• Anti-Scl-70 antibodies are specific for diffuse systemic sclerosis
• Anti RNA polymerase

Question 19

Poor prognostic factor for pneumonia

Answer 19

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

Question 20

Common side effects of bupropion

Answer 20

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%)

Question 21

management of status epilepticus

Answer 21

-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.

Question 22

most common causative agent of infective endocarditis

Answer 22

staph aureus

stept viridans post dental procedure
staph epidermidis infected peripheral venous catheter

Question 23

smoking cessation management options

Answer 23

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.

Question 24

SIRS diagnostic criteria

Answer 24

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-

Question 25

management of spontaneous bacterial peritonitis

Answer 25

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

Question 26

Autoimmune hepatitis serology

Answer 26

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.

Question 27

risk factors for recurrence of febrile seizure

Answer 27

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

Question 28

treatment of shoulder dystocia

Answer 28

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

Question 29

causes of polyhydramnios

Answer 29

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

Question 30

What is mullerian agenesis?

Answer 30

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.

Question 31

at what age do you diagnose primary amenorrhea?

Answer 31

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

Question 32

primary amenorrhea

Answer 32

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

Question 33

Abnormal uterine bleeding normal parameters

Answer 33

frequency: 24-38
cycle to cycle variation: +/- 2/20 days
duration of flow: 4.5-8 days
volume: 5-80mL

Question 34

Management of abnormal uterine bleeding:

Answer 34

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)

Question 35

when is the anomaly scan normally performed for OBGYN?

Answer 35

18-20+6

Question 36

Signs of placental separation and imminent placental delivery in third stage of labor?

Answer 36

Gush of blood

Lengthening of the umbilical cord

Ascension of the uterus in the abdomen

Question 37

causes of oligohydramnios:

Answer 37

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)

Question 38

side effects of progestin only hormone injection: Medroxyprogesterone acetate

Answer 38

• Irregular breathing
• Bone loss (gained back after stopping medication)
• Doesnt cause weight gain.

Question 39

Absolute contraindication to the combined estrogen and progesterone contraception:

Answer 39

• 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

Question 40

Contraception during breastfeeding?

Answer 40

Depo provera injections/ progestrone only pills

Question 41

what is the mode of action for emergency contraception? what are the medications used?

Answer 41

prevent ovulation
oral ulipristal acetate and levonorgestrel

Question 42

screening for gestational diabetes: when to screen early?

Answer 42

-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–

Question 43

Polycystic ovarian syndrome: clinical feature, Investigation:

Answer 43

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

Question 44

folic acid quantity for a healthy lady wants to conceive and with no prior disease or disorder

Answer 44

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

Question 45

treatment of hyperemesis gravidarum

Answer 45

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)

Question 46

How to diagnose an Anembryonic pregnancy:

Answer 46

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

Question 47

Treatment of abortion (inevitable, incomplete, missed abortion)

Answer 47

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.

Question 48

Name the 3 types of placenta accreta:

Answer 48

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.

Question 49

contraindication to methotrexate treatment in ectopic pregnancy:
indications to treat surgically:

Answer 49

• 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.

Question 50

risk of ectopic pregnancy following one previous ectopic and following two previous ectopic pregnancies?

Answer 50

following one ectopic pregnancy is 10% and following 2 ectopic pregnancy is 25%

Question 51

secondary prophylaxis or rheumatic fever - Duration of therapy:

Answer 51

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)

Question 52

treatment of neutropenic fever

Answer 52

monotherapy with an antipsudomonal beta lactam agent: cefepime, meropenem, imipenem, piperacillin tazobactam, ceftazidime

Question 53

results of Down syndrome in chromosomal study performed during:

Answer 53

11-13+6

• AFP low
• PAPPA low
• Eostriol low
• thickened nuchal translucency
• B-HCG high

Question 54

indications for cervical cerclage: and management:

Answer 54

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

Question 55

prevention of preeclampsia?

Answer 55

low dose asprin initiated between 12-28 weeks gestation and until delivery

Question 56

treatment of magnesium sulfate toxicity?

Answer 56

monitory reflexes for respratory depression
treated with calcium gluconate

Question 57

when is nuchal translucency performed and what does it indicate?

Answer 57

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

Question 58

treatment of giardiasis?

Answer 58

metronidazole or tinidazole

Question 59

what is bronchiolitis?

Answer 59

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

Question 60

treatment of hypertensive emergency and hypertensive urgency

Answer 60

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

Question 61

what is ischemic hepatitis?

Answer 61

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

Question 62

if a child develop high fever and rash after a vaccine what should be done?

Answer 62

give prophylactic paracetamol and give antihistamine if develop rash

if the patient develop severe symptoms come back to ER.

Question 63

what would happen if a female received Rubella vaccine and got pregnant before 2 months?

Answer 63

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

Question 64

first-trimester vaccine in pregnancy

Answer 64

influenza vaccine

Question 65

which vaccine is contraindicated in immunodeficiency

Answer 65

live attenuated vaccine:
MMR
Varicella
Zoster
Yellow fever
Rotavirus
Influenza (intranasal)
Smallpox
Adenovirus
Typhoid (oral, Ty21a)

Question 66

which vaccines are contraindicated in HIV patients?

Answer 66

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

Question 67

contraindications to DTP vaccine?

Answer 67

• 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

Question 68

varicella vaccine contraindications

Answer 68

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

Question 69

patients who have an allergy to egg, chicken protein or gelatin which vaccine is contraindicated?

Answer 69

yellow fever vaccine

Question 70

if a pregnant is taking a biological agent during pregnancy which vaccines are affected?

Answer 70

affect the immune response against live vaccine
live vaccine should be given at 6 months or ideally at 12 months

Question 71

in chronic granulomatous disease which vaccine is contraindicated?

Answer 71

live vaccine
BCG
yellow fever
plague

Question 72

MMR and varicella vaccine contraindications

Answer 72

neomycin and gelatin are contraindications to MMR and varicella

Question 73

which vaccine is contraindicated in patients with siblings who are immunocompromised?

Answer 73

oral polio is contraindicated as it is transmitted feco orally

Question 74

what can happen years after measles vaccine?

Answer 74

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

Question 75

when should a live vaccine be given after stopping steroid or chemotherapy?

Answer 75

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

Question 76

brucelosis

Answer 76

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

Question 77

what is milwaukee shoulder syndrome:

Answer 77

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

Question 78

Acute rheumatic fever:

Answer 78

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

Question 79

abruptio placentae

Answer 79

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

Question 80

treatment of dyspepsia if H pylori negative and if positive? how to confirm eradication

Answer 80

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

Question 81

echinococcosis infection

Answer 81

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.

Question 82

Amebiasis:

Answer 82

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

Question 83

empiric antibiotic treatment for community acquired pneumonia in outpatient setting

Answer 83

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

Question 84

treatment of hepatocellular carcinoma

Answer 84

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

Question 85

How to read a CTG?

Answer 85

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

Question 86

Fetal heart rate categories:

Answer 86

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

Question 87

Intrauterine resuscitation

Answer 87

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

Question 88

Abnormal first stage of labor

Answer 88

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

Question 89

Abnormal second stage of labor

Answer 89

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)

Question 90

Oxytocin side effect

Answer 90

• uterine tachysystole >> can lead to abruptio placenta or uterine rupture
• category 2 or 3 FHR

Question 91

Effect of medications of fetal heart rate pattern intrapartum
1- Mg sulfate
2- Epidural analgesic
3- Oxytocin

Answer 91

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

Question 92

Contraindications to external cephalic version

Answer 92

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

Question 93

Management of post term pregnancy

Answer 93

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.

Question 94

When is the quadruple test performed and what is it used for

Answer 94

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

Question 95

Vaccines given intramuscularly

Answer 95

DTP/DTaP
Hepatitis B
IPV
Hib
PCV-7

Question 96

Intradermal vaccine

Answer 96

BCG

Question 97

Subcutaneous vaccine

Answer 97

Measles and yellow fever vaccine

Question 98

Tocolysis options for preterm labor

Answer 98

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

Question 99

terbutaline tocolysis side effect:

Answer 99

MOTHER SIDE EFFECT:

Question 100

management of premature rupture of membrane

Answer 100

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

Question 101

management of post partum hemorrhage

Answer 101

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

Question 102

indications to evacuate a vaginal hematoma after episiotomy

Answer 102

• >5cm
• Expanding
• Painful

Question 103

what ultrasound findings suggest a malignant adnexal mass?

Answer 103

• Mass size graeter than 10cm
• Irrigular
• High flow on color doppler
• Pappilary or solid (hypoechoid) mass
• Presence of ascitis

Question 104

patient with complement deficiency which vaccine can he be given?

Answer 104

all the vaccines

Question 105

measles vaccine schedule:

Answer 105

should be given at 9, 12, 18 and then again at 4-6 years
Live vaccine MMR

Question 106

patient with dog bite (rabies) what should you do?

Answer 106

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

Question 107

which vaccine is contraindicated to patients with previous history of intussusception?

Answer 107

Rota virus vaccine

Question 108

contraindicates to live attenuated vaccines

Answer 108

• 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

Question 109

which vaccine is contraindicated in eczema patients?

Answer 109

smallpox vaccine

Question 110

influenza vaccine indications

Answer 110

INDICATIONS:

• all infants >6 months given annually
• all children exposed to or living with healthcare workers, chronic illness or immunodeificnexy

Question 111

Gullian barre syndrome etiology

Answer 111

it usually follows a gastroentestinal infection by 1-4 weeks

• Campylobacter jeujeni
• CMV (most common virus)
• Influenza vaccine

Question 112

patients with chronic respiratory disorders should receive which vaccines?

Answer 112

1- Influenza
2- Pneumococcal vaccine

Question 113

women presents with recurrent still births which vaccine should be given and when

Answer 113

rubella is teratogenic and should be givem 1 month before getting pregnant or immediately after deliver.

Question 114

Hard signs of vascular injury

Answer 114

• 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

Question 115

most common cause of infective endocarditis in pediatric patients
what is the treatment of staph epidermides

Answer 115

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

Question 116

Measles (Rubeola) infection features

Answer 116

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

Question 117

etiology of otitis media

Answer 117

most common ause below 2 years:

• Streptcoccus pneumonia
• Hemophilis influenza
• Moraxella catarahlis

most common in children above 2 years:

• psudomona arguinosa
• Staph aureus

Question 118

intususseption: High yield notes.

Answer 118

proximal part invaginates into the distal part leading to mechanical obstruction.
AGE: 6-18 months
ETIOLOGY: 75% idiopathic. Meckle’s diverticulum, enlarged payers patch,
MOST COMMON SITE: ileocecal invagination.
CLINICAL FEATURES:
-abdominal pain, abdominal distension, vomiting, constipation
-palpable sausage shaped mass in RUQ
-high pitched sounds
-current jelly stool
INVESTIGATION:
-Abdominal x ray: bowel obstruction sign
-Ultrasound is best initial” target sign, donut sign, psudo kidney sign
-Contrast or pneumatic ENEMA using ultrasound or fluoroscopy is best confirmatory
TREATMENT:
IV fluids, keep NPO, NG tube
-NON surgical: air enema (hydrostatic reduction with normal saline or water soluble contrast enema) under ultrasound or fluscopy guidance
Contraindicated in secondary intussuception, <3m, peritonitis, necrosis
can be done for 3 trials
recurrence after enema is 10%
-SURGICAL: indicated when
pathological lead point is suspected
failed conservated management
suspected gangrenous or perforated bowel or peritonitis
critically ill
recurrence after surgery is 1%

Question 119

Pyloric stenosis: high yield notes

Answer 119

aquired pyloric circler muscle hypertrophy resulting in gastric outlet obstruction
AGE: 2 weeks to 2 months
more common in males
ETIOLOGY: smoking during pregnancy, first male boy, young maternal age, bottle feeding, macrolide antibiotics (erythromycin)
CLINICAL FEATURE: repeated episodes of projectile non billious vomiting after meals, palpable olive mass, peristalitic waves, hungry after vomiting, electrolyte disturbance
INVESTIGATION:
-Ultrasound (initial) elongated >16mm and thickened >4mm pylorus
-Barium study: narrow pyloric orifice, string sign, beak sign, double railroad tract sign
TREATMNET:
IV fluid, NPO, NG tube, correct electrolyte,
Ramstad pyloromyotomy

Question 120

incubation period od food poisoning

• Staph aureus
• Vibro cholera
• Closteridium perfringens
• salmonella
• Ecoli
• Cambylobacter
• Cyclospora

Answer 120

staph aureus 30min to 8 hours

vibrio cholera 2 hours to 48 hours

clostridium perfringens 6-48 hours

Salmonella, Ecoli, Cambylobacter 2-5 days

Cyclospora and listeria 1-4 weeks

Question 121

treatment od dermatitis herpetiforms

Answer 121

characterized by eruption of burning and intensly puritic papules and vesicle
associated with celiac disease
treatment: Gluten free diet, Dapsone

Question 122

when to strat antibiotic in patients with gastroenteritis

Answer 122

shigella
Clostridum difficile
sever dehydration
prolonged illness (more than one week)
immunosuppressed

antibiotic treatment in shiga toxin Ecoli can lead to HUS
however in shigella doesn’t increase risk of HUS

Question 123

what is the gallbladder ghost triade

Answer 123

• small gallbladder less than 1.9cm
• thin gallbladder wall
• irregular contour

this triad is 97% sensitive and 100% specific for biliary atresia
which is discontinuity of the extrahepatic biliary system
treated with kasai hepatoportoenterostomy by age of 2 months

Question 124

which organism that can cause seizure after gastroenteritis

Answer 124

shigella can cause febrile seizures
either due to electrolyte disturbance
or affect the CNS directly leading to encephalopathy (Ekiri syndrome)

Question 125

eosinophilic esophagitis

Answer 125

allergic inflammatory condition of the esophagus that involves eosinophils

eosinophel migrates to the esophagus in large numbers, then precipitate an allergic reaction when a trigger food is eaten

Clinical feature: excessive chewing
associated with atopy
best diagnostic: endoscopy and biopsy

Question 126

indications for IV antibiotics in pediatric UTI

Answer 126

• Age <2 months
• Clinical urosepsis (toxic apperance, hypotension, poor capillary refill)
• Immune compromise
• Vomiting or inability to tolerate oral medication
• Lack of adequate outpatient follow up
• Failure to respond to outpatient therapy

Question 127

DVT management

Answer 127

Question 128

MI ECG

Answer 128

Question 129

prophylactic treatment for patients previous history of TIA

Answer 129

antiplatelet: either aspirin or clopidogrel

Question 130

long term secondary prevention of ischemic stroke

Answer 130

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

Question 131

motion sickness treatment:

Answer 131

scopolamine first line

diphenhydramine

Question 132

side effects of methotrexate

Answer 132

Gastrointestinal problems, such as nausea, stomach upset, and loose stools

●Stomatitis or soreness of the mouth

●Abnormal liver chemistries, which are typically mild elevations in hepatic transaminases (hepatotoxicity)

●A macular punctate cutaneous eruption, which usually occurs on the extremities, often affecting the elbows and knees, but sparing the trunk

●Central nervous system symptoms, including headache, fatigue, malaise, or impaired ability to concentrate

●Alopecia

●Fever, which is drug-related, although fever can also occur due to infection

●Hematologic abnormalities, particularly macrocytosis, in addition to infrequent but severe myelosuppression (see ‘Myelosuppression’ below)

Question 133

how to differentiate between organic and functional pain?

Answer 133

Question 134

giardia high yield points

Answer 134

Etiology:

waterbone from drinking recreational water, child care setting, travelers, swimmers hhhth

feco oral route

clinical feature

• foul smelling, volumonious, frothy and fatty stool (not bloody)
• excessive gas, abdominal pain and cramps
• fatigue
• nausea and vomiting
• anorexia

diagnostic: stool analysis (3 samples in different days)

best diagnostic: stool antigen or PCR

treatment: 7-10 days of metronidazole or tinidazole

Question 135

wilson disease

Answer 135

autosomal recessive

impaired copper excretion

clinical features:

• hepatosplenomegaly, portal hypertension, abdominal pain, jaundie, ascitis, hepatic encephalopathy
• kayser fleischer ring
• parkinsonsim, dysarthria, dystonia, drooling, tremor
• renal fanconi syndrome

diagnostic

1- best initial: 24 hour urine collection for copper, low serum ceruloplasim

2- best test: lover biopsy or genetic (chromosome 13

treatment:

D penicillamine or trienitine hydrochloride

Question 136

COPD exacerbation management

Answer 136

-Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed

Short-acting muscarinic antagonist (anticholinergic agent): Ipratropium 500 micrograms (can be combined with albuterol) in 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 to 3 doses

Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours)

Antibiotic therapy*: Appropriate for majority of severe COPD exacerbations; select antibiotic based on likelihood of particular pathogens (eg, Pseudomonas risk factors^¶, prior sputum cultures, local patterns of resistance)

• No Pseudomonas risk factor(s)^¶: Ceftriaxone 1 to 2 grams IV, or cefotaxime 1 to 2 grams IV, or levofloxacin 500 mg IV or orally, or moxifloxacin 400 mg IV or orally
• Pseudomonas risk factor(s)^¶: Piperacillin-tazobactam 4.5 grams IV, or cefepime 2 grams IV, or ceftazidime 2 grams IV

Antiviral therapy (influenza suspected)*: Oseltamivir 75 mg orally every 12 hours or peramivir 600 mg IV once (for patients unable to take oral medication)

Question 137

hyperparathyroidism indications for surgery

Answer 137

• Symptomatic patients
• Asymptomatic patients who meet at least one of the following criteria:
  
  • Age < 50 years
  • Serum calcium level more than 1 mg/dL higher than the normal upper limit
  • Impaired renal function (eGFR < 60 mL/min)
  • Increased calcium excretion (> 400 mg/day) in combination with an increased risk for nephrolithiasis
  • Evidence of nephrolithiasis or nephrocalcinosis via imaging
  • Reduced bone mineral density (T-score < -2.5 at lumbar spine, total hip, femoral neck, or distal third of the radius, or preexisting asymptomatic vertebral fracture)

Question 138

isoniazid adverse reaction

Answer 138

• peripheral neuropathy, ataxia, paresthesia (neurologic side effects can be reduced by concomitant administration of pyridoxine “vitamin B6”)
• hepatotoxicity

Question 139

organophosphates High Yield Points

Answer 139

an organophosphate compound and irreversible acetylcholinesterase inhibitor

clinical feature:

• Acute cholinergic crisis and paralysis
  
  • Parathion has a garlic-like or petrol-like odor
  • Sarin is odorless and tasteless
  • Parathion may cause blue-colored saliva and mucosa
  • Cardiovascular symptoms: bradycardia, hypotension
  • Gastrointestinal symptoms: diarrhea, vomiting, abdominal pain
  • Uncontrolled urination
  • ↑ Sweating, ↑ salivation
  • Respiratory symptoms: bronchospasm, bronchorrhea
  • CNS-related symptoms: lethargy, seizures, tremor, possibly coma
  • Musculoskeletal symptoms: fasciculations, weakness, spasms, paralysis → peripheral neuromuscular respiratory failure
  • Ocular symptoms: miosis, lacrimation
• Chronic low-dose exposure: chronic organophosphate-induced neuropsychiatric disorder characterized by fatigue, depression, impaired memory, extrapyramidal symptoms, peripheral neuropathy, and autonomic dysfunction

management

1-decontaminate (wash skin, remove clothes)

2- measure erthrocyte chilinesterase activity

3- atropine

Question 140

how to differentiate between hirschsprung and functional constipation

Answer 140

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)

Question 141

how to differentiate between marasmus and kwashirkor?

Answer 141

Marasus is deficiency in all major nutrients

Kwashirkor is deficiency in protients primerily

Question 142

when is endoscopy indicated in a child with foreign body ingestion

Answer 142

• sharp opjects
• long objects (more than 5cm)
• round batteries
• super magnetic object
• patient is symptomatic: fever or pain
• object not passed and still in stomach for 4 weeks

Question 143

diagnostic test of gastrinoma

Answer 143

assumed to arise fro endocrine cells of the gut (mostly the duodenum) or pancreas

best initial test: esophagogastroduodenoscopy to rule out H.pylori and malignant ulcers

confirmatory: increase serum gastrin if non conclusive secretin stimulation test

Question 144

Tracheomalacia

Answer 144

softening trachea cartilage

clinical presentation:

• upper airway: stridor and barking cough
• lower airway: monophonic wheeze

Classification

1. type 1: congenital, sometimes associated with tracheoesophageal fistula or esophageal atresia
2. type 2: extrinsic compression sometimes due to vascular rings
3. type 3: acquired due to chronic infection or prolonged intubation or inflammatory condition like relapsing poluchondritis

management:

if mild and isolated usually resolve by 2 years

if severe then requires surgical intervention

Question 145

when is diagnostic study required in patients with laryngomalacia

Answer 145

a flexible fibrooptic scope is required when

• severe episode of distress
• cyanotic spell
• growth failure
• feeding difficulty
• suspicious of other cause in larynx

Question 146

treatment for pelvic inflammatory disease

Answer 146

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)

Question 147

managment of penetrating neck injury:

Answer 147

Question 148

treatment of thrombotic thrombocytopenic purpura

Answer 148

ADAMTS113 deficiency

clinical feature:

• Fever
• Neurological signs and symptoms
  
  • Altered mental status, delirium
  • Seizure, focal defects, stroke
  • Headache, dizziness
• Low platelet count (i.e. thrombocytopenia)
  
  • Petechiae, purpura
  • Mucosal bleeding
  • Prolonged bleeding after minor cuts
• Microangiopathic hemolytic anemia
  
  • Fatigue, dyspnea, and pallor
  • Jaundice
• Impaired renal function
  
  • Hematuria, proteinuria
  • Oliguria, anuria (uncommon)

Prompt initiation of plasma exchange therapy (PEX)

• High-dose glucocorticoids
  
  • Prednisone
  • OR methylprednisolone
• Patients with a high pretest probability of TTP (based on clinical judgment)
  
  • Consider early caplacizumab.
  • Consider rituximab.

Question 149

what is a follicular cyst, a theca luteal cyst and corpus luteal cyst

Answer 149

• Follicular cyst of the ovary (most common ovarian mass in young women)
  
  • Develops when a Graafian follicle does not rupture and release the egg (ovulation) but continues to grow
  • Eventually develops into a large cyst (∼ 7 cm) lined with granulosa cells
  • Associated with hyperestrogenism and endometrial hyperplasia
• Corpus luteum cyst
  
  • Enlargement and buildup of fluid in the corpus luteum after failed regression following the release of an ovum
  • Produces progesterone, which may delay menses
  • Associated with progesterone-only contraceptive pills and ovulation-inducing medication
  • Common during pregnancy
• Theca lutein cysts
  
  • Often multiple cysts that typically develop bilaterally
  • Result from exaggerated stimulation of the theca interna cells of the ovarian follicles due to excessive amounts of circulating gonadotropins such as β-hCG
  • Strongly associated with gestational trophoblastic disease and multiple gestations
  • Usually resolve once β-hCG levels have normalized

Question 150

acetaminophen toxicity treatment

Answer 150

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

Question 151

treatment of premenstrual syndrome

Answer 151

Question 152

asthma management in patients <5 years old

Answer 152

Question 153

classification of PPD reaction

Answer 153

Question 154

types of respiratory failure

Answer 154

Type 1: Hpoxemic: PO2 <60mmHg on room air: pneumonia, pulmonary edema, pulmonary embolism

Type 2: hypercapnic/ventilatory: PCO2>50mmHg: COPD, asthma, neurological

Type 3: peri-opeartive (a subset of type1)

Type4: shock secondary to cardiovascular instability

Question 155

most common cause of pneumonia in cystic fibrosis patients age younger than 5 years and older than 5 years?

Answer 155

in children below 5 years: Staph aureus

in children above 5 years: pseudomonas aeruginosa

Question 156

pediatric age specific cause of pneumonia and treatment of pneumonia

Answer 156

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

Question 157

most common cause of pneumonia according to pediatric age and management

Answer 157

Question 158

indication of hospitalization in pediatric pneumonia patients

Answer 158

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

Question 159

electrolyte changes in diarrhea

Answer 159

in diarrhea there will be metabolic acidosis because of loss of bicarbonate in stool

Question 160

diabetes insipidus

Answer 160

Etiology:

1- Central diabetes insipidus: absent synthesis or secretion of ADH from posterior pituitary

• Primary idiopathic
• secondary to brain tumor, neurosurgery, traumatic brain injury, pituitary ischemia, infection

2- Nephrogenic diabetes insipidus: defect in ADH receptors in the distal tubules and collecting duct

clinical features:

• Polyuria
• Nocturia
• Polydipsia
• in severe cases of dehydration, altered mental status, lethargy, seizure, coma and hypotension

investigation:

• Sodium: mild hypernatremia
• ADH levels: decreased
• plasma osmolality: high-normal or slightly elevated
• urine osmolality: low
• Water deprivation test: plasma osmolality rises but urine osmolality remains low
• Desmopressin test:if central DI > urine osmolality rises BUT in nephrogenic osmolality remains low (due to resistance)

Treatment:

1- Central diabetes insipidus: Desmopressin

2- Nephrogenic diabetes insipidus: Thiazide diuretic, NSAID, Amiloride

Question 161

when to investigate nocturnal enuresis and what is the treatment

Answer 161

investigate nocturnal enuresis when

1- secondary enuresis: previous dryness was achieved for more than 6 months

2- growth failure

3- symptoms of UTI, weak stream urine, daytime incontinence, polyuria

4- daytime enuresis

Management:

treatment should be started for patients older than 8 year old

initial treatment: behavior and modification therapy

if not responding then Alarm or desmopressin should be started

Question 162

renal tubular acidosis

Answer 162

Type 4 RTA: related to defect in aldosterone or renal obstruction

• congenital adrenal hyperplasia
• hyporaldosteronism
• obstructive uropathy
• spironolactone or amiloride

Question 163

what are the indications for voiding cystourethrogram in pediatric patients

and when is ultrasound performed

and how to diagnose renal scarring after UTI

Answer 163

Indications:

children below 6 months:

• Recurrent UTI (2 pyelonephritis or 3 cystitis Or 2 cystitis and 1 pyelonephritis in 12 months)
• Atypical UTI
• UTI and renal ultrasound showed hydronephrosis

from 6 months to 3 years:

• Atypical UTI
• Renal ultrasound showed hydronephrosis

what is Atypical UTI:

• no response to antibiotic after 48 hours
• presence of hypertension
• presence of renal failure
• UTI caused by organism other than E coli
• presence of abdominal mass
• poor urine stream

Ultrasound is performed after first febrile UTI

DMSA scan is performed 6-12 months after UTI to detect scarring

Question 164

indications for surgical intervention for vesicoureteral reflux

Answer 164

• Grade 5 reflux
• if patients reached 5 years old and still has reflux
• hypertension
• renal scar
• renal failure
• failure of medical treatment

Question 165

treatment of UTI in pediatrics

Answer 165

oral antibiotic is the first line treatment in upper and lower UTI

• oral cephalosporins
• augmentin
• TMP/SMX
• nitrofurantoin

indication to use IV antibiotic:

• in neonates
• severely ill
• immunosuppressed patients
• patients with underlying renal disease

duration of treatment:

for cystitis only 3-5 days

• trimethoprim/sulfamethoxazole
• nitrofurantoin
• augmentin
• second generation cephalosporins

for pyelonephritis 7-10 days

• oral second generation cephalosporins
• amoxicillin and clavulanic acid
• IV ceftriaxone

Question 166

what is the definition of steroid resistant nephrotic syndrome

Answer 166

not responding to oral steroid for 4 weeks and additional 3 doses of IV methylprednisolone

most common cause of steroid resistant nephrotic is focal segmental glomerulosclerosis in pediatric

treatment of steroid resistant nephrotic syndrome:

• cyclosporine
• diuretic if needed
• ACE

Question 167

indications for renal biopsy in nephrotic syndrome

Answer 167

• age less than 1 year or more than 10 years
• gross hematuria
• hypertension
• renal failure
• low serum complement
• steroid resistance

Question 168

Tumor lysis syndrome electrolyte changes

what is the treatment of TLS

Answer 168

• hyperkalemia
• hyperuricemia
• hyperphosphatemia
• hypocalcemia

Management:

1- hydration

2- Hyperkalemia: cardiac monitoring and standard therapy for hyperkalemia if K⁺ ≥ 6 mEq/L, e.g., glucose and insulin (rapid action)

3- Hyperphosphatemia: hydration and possibly oral phosphate binders, e.g., sevelamer

4- Hypocalcemia: Treat only if symptomatic and give the lowest calcium dose to relieve symptoms (see “Hypocalcemia”)

5- Hyperuricemia

• Allopurinol
  
  • Indicated as prophylaxis in patients at low to intermediate risk
• Rasburicase: recombinant uricase that catalyzes the breakdown of uric acid to allantoin
  
  • Indications
    
    • Treatment of established TLS
    • Prophylaxis for intermediate to high-risk patients

Question 168

Henoch Schonlein Purpura

Answer 168

Etiology:

• Up to 90% of cases preceded by viral or bacterial infection 1–3 weeks prior ^[3]
• Most commonly an upper respiratory tract infection caused by group A Streptococcus

Clinical feature:

1- Skin: (100% of the cases): symmetrically distributed palpable purpura (most commonly in the lower extremities)

2- Joints: (75% of the cases): arthritis and arthralgia (mmost commonly ankle and knee

3- GI: colicky abdominal pain, can cause intussusception, bloody stool, nausea and vomiting

4- Kidney: Nephritic syndrome symptoms

Investigation:

• clinical diagnosis
• Biopsy is indicated in patients with unusual skin presentation or severe renal involvement. (skin leukocytoclastic vasculitis with IgA and C3 immune complex deposition. Kidney mesangial IgA deposition)

Management:

1- General management: adequate oral hydration, bed rest, and symptomatic relief of joint and abdominal pain.

2- Treatment of joint and abdominal pain: NSAID

3- Severe refractory abdominal pain: (failed to respond NSAID, interfere with oral intake): systemic glucocorticoid

Question 169

when should the screening for anemia in pediatric age should be done?

Answer 169

all children should be screened for anemia by doing CBC from 9-12 months

in patients with underlying medical condition repeat screening should be done again at 15-18 months

Question 169

Lead poisoning

Answer 169

Clinical features:

• CNS: poor concentration, abnormal behavior, lethargy, seizure
• GIT: abdominal pain
• renal failure
• ABCDEFGH: Anemia, Basophilic stippling, Constipation, Demyelination, Encephalopathy, Foot drop, Gum deposition/Growth retardation/Gout, Hyperuricemia/Hypertension

when to treat:

asymptomatic child with lead level more than 3.38mmol/l or 70mcg/dl

symptomatic children but no encephalopathy with level >2.16mmol/l or 45mcg/dl

• Treatment ^[20]
  
  • Decrease exposure: professional lead paint abatement, dust reduction, minimization of contact with bare soil
  • Nutrition: calcium, iron, zinc, vitamin C, and vitamin D-rich diet ^[21]
  • Chelation therapy indications: ^[22]
    
    • Oral succimer with/without intravenous or intramuscular Calcium EDTA (calcium disodium ethylenediamine tetraacetic acid) ^[23]
      
      • Children with BLL ≥ 45 μg/dl ^[24]
      • Asymptomatic adults with BLL ≥ 80 μg/dl
      • Symptomatic adults with BLL ≥ 50 μg/dl
    • IM dimercaprol
      
      • Patients with lead encephalopathy

Question 170

what is fanconi anemia

Answer 170

from birth

high MCV, high HbF and high ADA

autosomal recessive

absent thumb

short stature

microcephaly

blood transfusion dependent

Question 170

indication for simple blood tansfusion in sickle cell patients

Answer 170

• hemoglobin dropped by >2g/l from baseline
• patient is symptomatic (respiratory or hemodynamic instability)
• hyperhemolytic crisis
• aplastic crisis
• mild acute chest syndrome
• before major surgery

Question 171

what is diamond blackfan anemia

Answer 171

autosomal dominant

• Additional clinical features: physical abnormalities manifest in ∼50% of affected individuals
  
  • Fatigue, poor feeding
  • Short stature, webbed neck
  • Upper extremity malformations (e.g., triphalangeal thumbs)
  • Microcephaly, micrognathia
  • Hypertelorism, flat nasal bridge, cleft palate
  • Congenital cataracts or glaucoma
  • Atrial and ventricular septal defects
• Diagnostics
  
  • Electrophoresis
    
    • Elevated HbF levels
    • Low total Hb levels
  • Specific laboratory findings
    
    • Elevated erythrocyte adenosine deaminase levels (eADA)
    • Increased expression of i antigen in RBCs
• Treatment ^[31]
  
  • Corticosteroids (first-line treatment)
  • Chronic red cell transfusions: individuals who do not respond to corticosteroids
  • Hematopoietic stem cell transplantation
• Complications
  
  • Increased risk of malignancy: acute myelogenous leukemia, myelodysplastic syndrome, solid tumors (e.g., colon cancer, osteogenic sarcoma)
  • Treatment-associated complications: iron overload due to repeated transfusions, corticosteroid-induced hyperglycemia
  • Endocrine dysfunction: adrenal insufficiency, hypogonadism, vitamin D deficiency

Question 171

indication for exchange transfusion in sickle cell patients

Answer 171

• severe acue chest syndrome
• stroke
• silent stroke
• multiorgan failure

Question 172

investigation of hereditary spherocytosis and what is the treatment

Answer 172

• low MCV
• high MCHC
• high RDW
• high unconjugated bilirubin
• low haptoglobin
• high LDH
• positive osmotic fragility test (initial)
• Eosin-5-maleimide binding test (diagnostic)

treated with splenectomy (sole definitive treatment)

Question 173

features of fetal alcohol syndrome

Answer 173

• 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 3^rd–4^th 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

Question 176

Familial Mediterranean fever

Answer 176

The diagnosis of FMF should be suspected in individuals with recurrent febrile episodes accompanied by peritonitis, synovitis or pleuritis, recurrent erysipelas-like erythema, repeated laparotomies for an acute abdomen with no identifiable underlying pathology, a first-degree relative with FMF, and/or membership in an at-risk ethnic group. The diagnosis of FMF is made based on clinical symptoms and supported by ethnic origin and family history. Genetic testing is used to further confirm the diagnosis of FMF and to exclude other autoinflammatory syndromes mimicking FMF. In individuals who meet clinical criteria for FMF but in whom genetic testing is not diagnostic (only one or no pathogenic MEFV mutation), the diagnosis of FMF is supported by a six-month trial of colchicine therapy, which results in a relief of attacks and recurrence after cessation of treatment.

side effect of clochicine: abdominal pain and diarrhea, muscle weakness especially when taking statin, acrolide, verapamil

Question 177

what is hemorrhagic disease of newborn

Answer 177

usually happen in babies delivered at home because they did not receive vitamin L

vitamin K deficient factors: 10,9,7,2

both PTT and PT will be prolonged

Question 178

how to differentiate between TTP, ITP, and DIC

Answer 178

Question 179

indications for lymph node biopsy in patients with lymphadenopathy

Answer 179

Question 180

what is a benign ronaldic epilepsy

Answer 180

benign epilepsy with centrotemporal spikes

Clinical features

• Usually occurs during sleep
• Facial twitching or numbness, hypersalivation, and speech arrest (during and frequently even after the event)
• Involvement of an arm/entire side of the body is possible, as is secondary generalization.

Diagnostics: EEG shows centrotemporal spikes or sharp wave

Question 181

Indications of CT head in childhood head injury

Answer 181

Question 182

How to differentiate between simple febrile and complex febrile seizure:

Answer 182

Question 183

infantile spasm

Answer 183

• 3–7 months
• Sex: ♂ > ♀
• Perinatal infections
• Hypoxic-ischemic injury
• PKU
• Tuberous sclerosis complex
• Idiopathic
• Sudden symmetric, synchronous spasms, usually in clusters of 5–10
• Jerking flexion (jackknife movement) or extension of the neck, torso, and extremities
• Followed by a tonic phase
• Hypsarrhythmia: characteristic finding in interictal EEG; high-voltage delta waves with irregular multifocal spikes and slow waves
• Ictal EEG: very heterogeneous
• First-line treatment: ACTH, prednisone, or vigabatrin

Question 184

when to screen for asymptomatic bacteriuria in pregnant patient?

management of asymptomatic bacteriuria?

Answer 184

screening all pregnan women at least once performed at 12-16 weeks

treatment options include beta lactam, nitrofurantoin (for 5-7 days) and fosfomycin

if pyelonephritis is suspected nitrofurantoin and fosfomycin should not be used as it doesn’t reach the kidney

Question 185

How to diagnose Neurofibromatosis

Answer 185

Autodomal Dominant

1-Six or more café-au-lait spots or hyperpigmented macules =5 mm in diameter in
prepubertal chil-dren and 15 mm postpubertal
2-Axillary or inguinal freckles (>2 freckles)
3- Two or more typical neurofibromas or one plexiform neurofibroma

4- Optic nerve glioma
5-Two or more iris hamartomas (Lisch nodules), often identified only through slit- lamp examination by an ophthalmologist
6- Sphenoid dysplasia or typical long-bone abnormalities such as pseudarthrosis
7-Positive genete in allele for NF1 from WBC

Question 186

tuberous sclerosis

Answer 186

Autosomal dominant

TSC1 and TSC2 gene mutation

Clinical features:

• Ash leaf macules
• cafe au lait spots
• Peiungual fibroma
• Angiomyolipoma of renal artery
• cardiac rhabdomyoma
• polycystic kidney disease
• adenoma sebacioum
• shagren batch

Question 187

Fragile X syndrome

Answer 187

Question 188

Spinal muscular atrophy: High Yield

Answer 188

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

Question 189

juvenile dermatomyositis

Answer 189

• autoimmune myopathy
• symmetrical proximal muscle weakness (most important clinical feature)
• heliotrope rash (reddish purple rash on the upper eyelid often accompanied by swelling of the eyelid)
• Gottron’s papules (erythematous, papulosquamous eruption over the dorsal surfaces of the knuckles) (characteristic)
• nailfold capillary changes, skin ulcerations, calcinosis (soft tissue calcification), nonerosive arthralgia and arthritis, lipodystrophy, and insulin resistance

investigation:

• serum creatinine kinase is best initial
• muscle biopsy is diagnostic

Treatment

• Ultraviolate protection
• physiotherapy
• steroid
• biological agent

Question 190

transiet synovitis

Answer 190

• 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

Question 191

most coomon cardic anomaly in turner syndrome

most common finding

Answer 191

Elongated transverse aortc arch

Bicuspid aortic valve

coarcitation of aorta

most common finding: fold skin at the nape of the neck

Question 192

fatures of congenital rubella syndrome

Answer 192

Triade of congenital rubella syndrome

• Cardiac defect: most common (PDA, pulmonary, pulmonary artery stenosis)
• Cataract: (other eye manifestations may occur later in life like glaucoma, salt and pepper retinopathy)
• cochlear defect: bilateral sensorineural hearing loss
• blueberry muffin rash

Question 193

faetures of marfan syndrome

most common cardiac deformity in marfan syndrome

Answer 193

most common congenital heart anomaly: motral valve prolapse

Question 194

features of inncoent murmur

Answer 194

• short
• soft
• healthy child
• no radiation
• change with posture
• no thrill (grade 1 to 2)

known as still’s murmur

Question 195

prophylactic measures for patients with congenital heart disease

Answer 195

• high calorie diet (150 kcal/kg)
• high dense calorie formula
• immunization like influenza
• RSV immunoglobulin prophylaxis

Question 196

murmurs

Answer 196

Question 197

indications for VSD closure surgically

Answer 197

VSD usually close spontanously if small (less than 5mm)

muscular VSD more likely to close than peirmembrenaous

Indications for surgical closure:

• heart failure not responding to medications
• large pulmonary blood flow with a ratio to systemic blood flow 2:1
• early pulmonary hypertension

Method of closure: surgical

Question 198

management of Trtralogy of fallot

Answer 198

• Oxygen
• Sodium bicarbonate
• Alpha agonist (phenylephrine)
• Morphine
• Adrenergic antagonist (beta blocker)
• Hydration

Question 199

infective endocarditis diagnostic criteria

treatment for infective endocarditis

surgery is indicated in?

Answer 199

modified jones criteria

• two positive blood culture out of 3 for typical organism (street viridans, staph aureus, HACEK)
• ECHO findings like vegetation, abscess or dehiscence of prosthetic valve
• new valvular regurgitation
• fever
• predisposing factors like IV drug abuse or congenital heart disease
• immune phenomena like: roth spot, osler node, glomerulonephritis
• vascular phenomena like janeway lesion, mycotic aneurysm, conjunctival hemorrhage, septic emboli
• blood culture result don’t meet the major criteria

treatment: IV vancomycin for 6 weeks

surgery indicated in:

• fungal endocarditis
• severe valve regurgitation
• dehiscence of prosthetic valve
• myocardial abscess
• mycotic aneurysm

Question 200

treatment of neonatal sepsis

Answer 200

Causes of neonatal sepsis:

• Group B strept
• Ecoli
• Listeria mnocytogene

Treatment of early: ampicillin + gentamycin

Treatment of late: ampicillin + gentamycin + cefotaxime

Question 201

when to worry about vaginal discharge in newborns?

Answer 201

• if persist more than 2 weeks
• if it became yellow in color
• if foul smelling
• if mixed with blood

Question 202

differential of prolonged QT syndrome

Answer 202

Congenital:

1. Jervell Lange syndrome: deafness, syncopal attacks and sudden death
2. Romano Ward syndrome: autosomal dominant, most common inherited long T syndrome, syncope and sudden death.

Acquired:

• During sleep
• hypocalcemia
• acute myocarditis
• acute MI
• hypothermia
• HOCM
• cerebral injury
• advanced AV block

Question 203

approach to pediatric UTI

Answer 203

Treatment:

Indications for hospitalization:

• age <2 months
• clinical urosepsis
• immunocompromised
• vomiting and unable to tolerate oral
• lack of outpatient follow up
• failure to respond to outpatient therapy

Emperic antibiotic therapy:

• children without genitourinary abnormality: Cephalosporin (if enterococcal infection is suspected add amoxicillin or ampicillin)
• pyelonephritis: second generation cephalosporin (cefuroxime) or third generation (cefixime, cefdinir)

Duration of treatment:

• Afebrile children are treated for 3-5 days
• Febrile children are treated for 10 days

Imaging:

• First febrile UTI in children younger than 2 >> renal bladder ultrasound
• recurrent febrile UTI >> ultrasound
• voiding cystourethrogram to diagnose vesicoureteral reflux if

1. any age with >2 febrile UTI
2. any anomaly on renal ultrasound
3. temp >39c and a pathogen other than E coli
4. poor growth or hypertension
5. children less than 6 months + atypical UTI, recurrent UTI, hydronephrosis in US
6. in children above 6 months: atypical UTI, hydronephrosis in rental US

Question 204

triad of wiskott aldrich syndrome:

Answer 204

X linked recessive

• pupura
• eczema
• recurrent opportunistic infection with encapsulated organism (eg otitis media)
• thrombocytopenia

Serum IgM is low

serum IgG is normal

Serum IgA and IgE are elevated

Question 205

chronic granulomatosis disease

Answer 205

deficiency of superoxide production by neutrophils and macrophage

Etiology: X linked recessive or autosomal recessive

Clinical feature:

• recurrent severe infection (chronic skin, lymph node, respiratory , Gi, urinary tract infection) with catalase positive organism (S.aureus, E.coli, candida, klebsiella, psudomonas, aspergillus)
• Lymphadenopathy
• Granulomas
  *

Question 206

Chediak Higashi syndrome

Answer 206

defect in neutrophil chemotaxis and microtubule polymerization dysfunction

Autosomal recessive

Clinical feature:

• recurrent pyogenic infection (s. pyogenes, s.aureus, psudomonas)
• partial albinism
• progressive degeneration of neurons and peripheral neuropathy

Question 207

features of Edwards syndrome

Answer 207

Prince Edward turned 18

• Prominent occiput
• Rocker bottom feet
• Intellectual
• Nondisjunction (in meiosis)
• clenched fist
• low set ears
• chromose 18

Question 208

Trisomy 13 features:

Answer 208

Patau syndrome

• Microcephaly, holoprosencephaly
• cleft lip and palate
• low set ears
• micropthalmia
• polydactyly
• congenital heart defect
• ricker bottom feet
• aplasia cutis congenita
• omphalocele

Question 209

prader willi syndrome

Answer 209

• muscular hypotonia
• hyperphagia and obesity
• hypogonadism
• almond shaped ears
• intellectual disability
• behavioral problems

Question 210

Trisomy 21 characteristics

Answer 210

• upward slanting palpebral fissure
• epicanthal fold
• brushfield spots
• apperanc of protroduing tongue
• broad and flat nasal bridge
• transevere palmer crease
• sndal gap
• clindodactyly
• short stature
• atlantoaxial instability
• Congenital heart defect: Atrioventricular septal defect (endocardial cushion defect)
• GI: duodenal atresia, hirshprung disease, annular pancreas
• autoimmune: DM type 1, celiac disease, hypothyroid
• most common malignancy: leukemia
• CNS: mental retardation, central hypotonia (most common feature), seizure
• recurrent otitis media and deafness

Question 211

prune belly syndrome

Answer 211

• partial absence of abdominal wall muscle (prune like or wrinkled appearance)
• bilateral cryptochrisim
• urinary tract malformation (obstructed bladder neck: bladder distension)

Question 212

symptoms of galactosemia disorder:

Answer 212

• jaundice
• seizure
• metabolic acidosis
• cataract
• recurrent e coli infection
• urinary positive for glucose, amino acid and phosphate

Question 213

caustive organisms for reactive arthritis:

what is the characteristic triad of reactive arthritis

Answer 213

• shigella
• yersinia
• salmonella
• campylobacter
• chlamydia

arthritis

conjunctivitis

urethritis

Question 214

Post exposure prophylaxis for meningococcal meningitis

Answer 214

Rifampin Ceftriaxone (preferred during pregnancy) Ciprofloxacin (avoid during pregnancy and if patient <18 of age)

Question 215

treatment of hydatid cyst

Answer 215

a hydatid cyst is caused by echinococcosis is a parasitic disease caused by small tapeworm

fecal contaminated food or water

definitive foxes, dogs, cats

treatment:

• single cyst + <5cm ==> albendazole
• single cyst + > 5cm ==> percutanous drainage (puncture, aspiration, injection, reaspiration)
• daughter cells ==> surgical deroofing + albendazole
• ultiseperated (rossete like or honeycoming) ==> surgical deroofing or albendazole

Question 216

Herpangina

Answer 216

acute infection that manifests with fever, sore throat, herpes-like lesion on the posterior oropharynx and tonsils

Etiology: Coxsackie A virus infection

Clinical feature:

• high grade fever
• sore throat
• herpes like oral lesion: multiple 1mm vesicles located on the posterior oropharynx and tonsils
• pharyngeal and tonsillar redness

Treatment:

• supportive care

Question 217

management of increased intracranial pressure

Answer 217

1. elevate head of the bed 30 degree
2. sedation and analgesia
3. maintain normothermia
4. target euvolemia and avoid serum hypoosmolarity (serum sodium >135)
5. seizure control: prophylaxis for patients with high risk seizure
6. IV mannitol
7. Dexamethasone if ICP is caused by CNS infection or neoplasm
8. SURGICAL therapy

• CSF drainage: External ventricular drain, lumbar drain, cerebral shunt
• decompressive crainectomy:

Question 218

pertussis

Answer 218

typically affect age <1 year

Stages:

1- catarrhal stage: (1-2 weeks) mild cough, rhinorrhea, low-grade fever

2- paroxysmal stage (2-6 weeks): paroxysmal cough often at night, high pitched whooping cough, posttussive vomiting.

3- convalescent stage: coughing may persist for several weeks before resolving.

Diagnosis:

clinical diagnosis

culture or PCR from deep nasopharyngeal aspiration or posterior nasopharyngeal swab (gold standard)

Treatment:

MAcrolide: azithromycin, clarithromycin

post exposure prophylaxis:

all household contact of pertussis (regardless of their vaccine status) should receive macrolide

Question 219

treatment of thyroid storm:

Answer 219

1. beta blocker to control symptoms
2. thionamide (block new hormone synthesis): propythiouracil or methimazole
3. iodine solution (block release of thyroid hormone)
4. iodinated radiocontrast
5. glucocorticoids (reduce conversion of T4 to T3)

Question 220

first line treatment for sarcoidosis:

Answer 220

glucocorticoids

Question 221

treatment of ulcerative colitis

Answer 221

Question 222

Empyema

Answer 222

accumulation of pus in the pleural cavity

Etiology: pneumonia

Clinical feature: fever, cough, chest discomfort

Diagnostic:

• CT ches: split pleural sign
• pleural fluid analysis: low pH, low glucose, increase LDH, purulent

Question 223

autoimmune hepatitis antibodies

Answer 223

• Type 1 AIH (80% of cases): characteristic autoantibodies include antinuclear antibodies (ANAs), anti-smooth muscle antibodies (ASMAs), anti-soluble liver antigen/liver pancreas antibodies (anti-SLA/LP)
• Type 2 AIH: characteristic autoantibodies include anti-liver-kidney microsomal-1 antibodies (anti-LKM-1), anti-liver cytosol antibodies-1 (ALC-1)

Question 224

when does moro reflex disappear, palmer grasp, plantar grasp, rooting, stepping reflex, parachute reflex

Answer 224

Question 225

indications of laparotomy after injury

Answer 225

Unexplained signs of blood loss or hypotension in a patient who cannot be stabilized and in whom intra-abdominal injury is strongly suspected

●Clear and persistent signs of peritoneal irritation

●Radiologic evidence of pneumoperitoneum consistent with a viscus rupture

●Evidence of a diaphragmatic rupture

●Persistent, significant gastrointestinal bleeding seen in nasogastric drainage or vomitus

Question 226

vascular dementia

Answer 226

gradual cognitive decline caused by small or large vessel disease.

Risk factors:

• Age
• history of stroke
• HTN
• hyperglycemia
• hypercholesterolemia and hypertriglyceridemia
• obesity

Investigation:

• Brain MRI: multiple cortical infract, subcortical infract *lacunar)
• CT brain: microangiopathy lesion located in white matter, multiple lacunar lesion in subcortical brain

Question 227

differential diagnosis of vulvuvaginitis

Answer 227

Question 228

what is the treatment of SLE

Answer 228

depends on disease activity which is determined by

• CBC
• anti DsDNA
• ESR
• CRP
• C3 and C4
• GFR

Question 229

what are the medications of SLE that are contraindicated during pregnancy?

Answer 229

• clyclophosphomide
• methotrexate
• mycophenalate
• leflunamide

Question 230

features of infectious mononucleosis

Answer 230

Question 231

signs of severe asthma exacerbation

Answer 231

Question 232

Scarlet fever

Answer 232

Etiology Group A streptococcal infection Most common in children aged 5-12 years Clinical feature: Fever Headache Tonsillitis Sandpaper like maculopapular rash with flushed cheeks perioral sparing Tongue is white and coated and may be sore or swollen Treatment Penicillin V Erythromycin

Question 233

Blood transfusion electrolyte disturbance

Answer 233

Hyperkalemia Hypocalcemia Hypoglycemia Citrate toxicity

Question 234

Appendiceal carcinoid tumor management

Answer 234

Appendectomy is adequate treatment unless Lymph node involved visibly Tumor more than 2cm Mucinous element present in tumor Mesoappendix or base of cecum is invaded In these cases right hemicolectomy is recommended

Question 235

Treatment of lupus

Answer 235

Neuropsychiatric lupus: IV cyclophosphamide + corticosteroids Nephrotic and cardiac lupus: Mycophenalate + corticosteroids Systemic Hydroxycholochen + NSAID > steroid > methotrexate

Question 236

antiphospholipid syndrome treatment

Answer 236

Acute management

• SC low molecular weight heparin or UF heparin
• severe cases: high dose glucocorticods, plasmaphoresis, immunoglobulin

secondary prophylasxis:

1- Low risk: low dose asprin

2- High risk:

• wishes to get pregnant: LMWH + asprin
• doesn’t wish to conceive long term treatment with oral warfarin

Question 237

indications for endocsopic removal of foreign bodies

Answer 237

• sharp objects
• long objects >5cm
• round batteries
• magnetic objects
• not passed in stool for 4 weeks
• symptomatic: pain or fever

emergent removal

·When the patient shows signs of airway compromise

·When there is evidence of near-complete esophageal obstruction (eg, patient cannot swallow secretions)

·When the ingested object is sharp, long (>5 cm), or a superabsorbent polymer and is in the esophagus or stomach

·When the ingested object is a high-powered magnet or magnets

·When a disk battery is in the esophagus (and, in some cases, in the stomach)

·When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)

Question 238

interstinal protozoa

Answer 238

Question 239

Erb palsy

Answer 239

Brachilal plexus injury

injury to the upper trunk of brachial plexus (c5-c6)

Clinical feature

• waiter tip posture = flexed wrist with an extended forearm and internally rotated and abducted
• bicep brachii
• weak infraspinatus and supraspinatus
• weak deltoid and supraspinatus
• weak wrist extensor
• asymmetric more reflex in infants

Question 240

indications for surgery in a patent with upper GI bleed?

Answer 240

• failure of endoscopy therapy after 2 trials
• persistent hemodynamic instability despite aggressive resuscitation
• cardiovascular disease with predictive poor response to hypotension
• hemorrhagic shock
• excluding esophageal varices
• after transfusion of 6 units of blood

Question 241

indications for craniotomy in subdural hematoma

Answer 241

• open skull fracture
• midline shift >5mm

Question 242

electrolyte changes in refeeding syndrome

Answer 242

• hypokalemia
• hypophosphatemia
• hypomagnesemia
• hyperglycemia

Question 243

when is it safe to operate on an MI patient?

Answer 243

after 6 weeks

Question 244

Signs that an ovarian cyst is suspicious for malignancy?

Answer 244

• size >10cm Papillary Solid component Irrigularity Presence of ascitis High color Doppler flow

Question 245

Indications for cholecystectomy in gallbladder polyps:

Answer 245

• >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.

Question 246

What 3 things improve the survival of COPD patients?

Answer 246

• Smoking cessation - Vaccination (influenza and pneumococcal) - Home oxygen therapy

Question 247

Treatment of parapneumotic effusion

Answer 247

Pleural drain + pipracillin tazobatam

Question 248

Treatment of asthma

Answer 248

Question 249

What are the causative organisms of reactive arthritis

Answer 249

Chlamydia, ureaplasma urealyticum Shigella, yersinia, salmonella, campylobacter

Question 250

First line treatment for febrile neutropenia

Answer 250

Cefepime Meropenem Impeneum Pipracillin-tazobactam

Question 251

Electrolyte disturbances during re feeding syndrome

Answer 251

Hypophosphatemia -Hypokalemia - Congestive heart failure -Peripheral edema -Rhabdomyolysis -Seizures- Hemolysis -Respiratory insufficiency Hypophosphatemia is the hallmark of the syndrome and predominant cause of the refeeding syndrome

Question 252

Treatment of endometrial polyps?

Answer 252

Initial => D&C biopsy or hysteroscopy sampling Definitive => laparoscopic hysterectomy Indications for malignancy -old age >55, or post menopausal -endometrial thickening >20mm -abnormal uterine bleed

Question 253

Indication for operative treatment after chest thoracostomy

Answer 253

Question 254

Contraindications to IUD

Answer 254

Both copper and progesterone -suspected pregnancy -Undiagnosed genital tract bleeding - Acute or chronic PID -Lifestyle risk for STI -Known distorted uterine cavity -Immediatly post septic abortion Copper IUD -known allergy to copper Not contraindicated but increases blood loss and duration of menses and dysmenorrhea

Question 255

What is WAGR syndrome

Answer 255

Wilms tumor Anirdia Genitourinary anomalies Retarded mentally

Question 256

How to differentiate between an endometrial polyp and sub mucus fibroid

Answer 256

Endometrial polyp is usually a solitary homogenous and echo genie lesion

Question 257

Rules for resuscitation on previable fetus

Answer 257

22 => no resuscitation 22-25 =:> discuses risk and benefit with parents >25 => resuscitation is always initiated

Question 258

Complications after esophageal atresia correction

Answer 258

Anastomitic leak Esophageal stricture Recurrent fistula GERS

Question 259

When should children be screened for iron deficiency anemia

Answer 259

9-12 months

Question 260

Treatment of aspergillus pneumonia

Answer 260

Voriconazole

Question 261

Primary biliary cholangitis

Answer 261

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

Question 262

Acute otitis media: Etiology and treatment

Answer 262

Etiology: Streptococcus pneumonia H.influenza Moraxella catarrhalis Treatment Amoxicillin Amoxicillin-Calvulanate

Question 263

Erythema toxicum neonatorum

Answer 263

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

Question 264

Transient neonatal pustular Melanosis

Answer 264

Biopsy will show neutrophils

Question 265

Indications for cholecystectomy in patients with acalculous cholecystitis

Answer 265

Gallbladder necrosis Emphysematous cholecystitis Gallbladder perforation Patients without indications for emergency cholecystectomy, who are critically ill or in poor health, or unfit for general anesthesia should be treated with gallbladder drainage

Question 266

Vaccination that is safe during pregnancy

Answer 266

Influenza given in first or second trimester DTaP given third trimester between 27-36 weeks

Question 267

Steroid sensitive age

Answer 267

24-96 months (2 years to 8 years)

Question 268

Indications for gallbladder polyp cholecystectomy

Answer 268

Size >10mm <3 polyps Symptomatic Age >50 Associated with gallstones

Question 269

Management of neuroendocrine appendix tumor

Answer 269

1cm —> appendectomy <2cm —> if on the tip of the appendix —> appendectomy. If at the base of the appendix —> right hemicolectomy. >2cm —> right hemicolectomy

Question 270

Pregnancy outcome in sickle cell disease

Answer 270

Fetal growth restriction Perinatal mortality Low birth weight Preeclampsia Maternal mortality Eclampsia

Question 271

Characteristics of innocent murmur

Answer 271

Grade <2 intensity Softer intensity when the patient is sitting compared to when he is supine Short systolic duration Minimal radiation Musical or vibratory quality

Question 272

B-HCG follow up after molar pregnancy

Answer 272

The initial B-hCG level is obtained within 48 hours after evacuation. (baseline) - Then weekly until undetectable. - Once B-hCG is undetectable(for three consecutive weeks), this is confirmed with monthly for another 6 months

Question 273

The risk of GERD post gastric sleeve

Answer 273

Between 10-50% Go with 30%

Question 274

Splenic trauma indications for surgery

Answer 274

Symptoms: LUQ pain Shoulder pain (kehr’s signs) LUQ mass (balance sign) Gastric bubble displacement Unstable patient >> FAST scan Stable patient >> CT scan Indication for non operative management: Hemodynamically stable <2 units transfusion No increasing hematoma size when followed by ultrasound Stable Hb Indications for splenectomy Grade 5 traumatic injury

Question 275

Malaria prophylaxis

Answer 275

Atovaquone proguanil

Question 276

Papillary thyroid cancer management

Answer 276

If <1cm —> lobectomy If >1cm —> near total or total thyroidectomy

Question 277

Treatment of pancreatic pseudo cyst

Answer 277

Usually wait until maturation of cyst 6 weeks If infected —> percutanous drainage If not infected —> endoscopic drainage

Question 278

Most common location for eczema

Answer 278

In infants below 6 months: face and scalp • Between 6 months to 2 years: extensor surfaces of elbows and knees • Between 2-5 years: extensor in elbows and knees, wrist and hands, around mouth and eyes • Above 5 years: flexor surfaces

Question 279

Contraindications to MMR vaccine

Answer 279

Severe life threatening allergy Pregnant Weak immune system or on radiation, immunotherapy, steroids, or chemotherapy Has parent or siblings with history of immune system problem Bleeds or bruise easily Recent blood transfusion (wait 3 months0 Has TB Has gotten any other vaccine within 4 weeks ago Moderate to severe illness

Question 280

Side effects of Amitriptyline?

Answer 280

Absolute side effect: constipation Most common side effect: weight gain

Question 281

Nerve injury after breast surgery

Answer 281

Long thoracic nerve: wining of scapula Thoracodorsal nerve: cant push up + weak adduction Medial and lateral pectoral nerve: weakness of the muscle Intercostobrachial nerve:anesthesia in the inner arm

Question 282

Indications for diyalisis in kidney injury

Answer 282

Refractory fluid overload ●Severe hyperkalemia (plasma potassium concentration >6.5 mEq/L) or rapidly rising potassium levels ●Signs of uremia, such as pericarditis, encephalopathy, or an otherwise unexplained decline in mental status ●Severe metabolic acidosis (pH <7.1) ●Certain alcohol and drug intoxications

Question 283

Shigella antibiotic treatment

Answer 283

Azithromycin and third generation cephalosporine (cefixime or ceftriaxone)

trimethoprime-sulfamethoxasole and ampicilin are also susciptible

Question 284

Molluscum contagiosum

Answer 284

Common localized skin infection caused by molluscum contagiosum On trunk, face, and genitalia Sexually transmitted Lesion appear smooth, dome shaped papilledma with central umbilication Self limited and heals spontaneously Could persist in immunocompromised individual treated with cryotherapy with liquified nitrogen If in the genital region it should be treated

Question 285

Signs of severe pancreatitis

Answer 285

Important predictors of severity 8 • Age > 55 • Gastrointestinal bleeding • Fall in Hct within 48 hours • Hypocalcemia and/or hyperglycemia • Inflammatory markers: ↑↑ CRP, ↑ IL-6, ↑ IL-8 • Evidence of shock and/or organ failure o ↑ AST, ↑ ALT o ↑ BUN, creatinine o ↑ LDH pO2 < 60 mm Hg, metabolic acidosis with a base deficit > 4 mmol/L

Question 286

Contraindications to nitrofurantoin

Answer 286

nitrofurantoin contraindications Children < 1 month of age Breastfeeding women Women at 38–42 weeks’ gestation or during delivery Hepatic dysfunction [70] Renal dysfunction with a creatinine clearance < 60 mL/min

Question 287

Laparoscopic repair indications and contraindications in hernia

Answer 287

laparoscopic repair indications: A- Recurrent B- Bilateral C- Needs less time for recovery. D- Femoral hernia (UTD) E- Female patient (UTD) laparoscopic repair contraindications: A-Inability to tolerate general anesthesia B-Prior pelvic surgery in the preperitoneal space C-Incarcerated inguinal hernia D-Strangulated inguinal hernia E-Large scrotal hernia F-Ascites G-Active infection

Question 288

Elderly vaccines

Answer 288

Influenza vaccine Pneumococcal vaccine Herpes zoster vaccine And Tdap one time if not immunized after age 65

Question 289

Pertussis secondary prophylactic for close contact

Answer 289

children > 1 month and adults: any macrolide; If macrolides are not tolerated, use trimethroprim-sulfamethoxazole. Infants < 1 month: azithromycin

Question 290

Treatment of uncomplicated cystitis

Answer 290

Cephalosporins as first Line oral agent Trimethoprime-sulphamethoxasole Nitrofurantoin Amoxicillin-clav