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Question 1

Rando

Abrupta Placenta - 4

Answer 1

Pt presents with vaginal bleeding, ABDOMINAL PAIN, and uterine tenderness. The absence of hemorrhage DOES NOT rule out this Dx. DDX:Placenta Previa, absence of bleeding RULES OUT this dx.Risk factors are:1-HT and preecclampsia, 2-Placental abruption in previous pregnancy, 3-trauma, 4-short umbilical cord, 6-COCAINE abuse. AP is the mcc of DIC in pregnancy, which results from a release of activated thromboplastin from the decidual hematoma in to maternal circulation.Risk factors are smoking and,Folate def. It can progress rapidly so careful monitoring is mandatory. Once dx is made, large-bore IV , as well as Foley cathater is inserted. Pts with AP in LABOR should be managed aggressively to insure rapid vaginal delivery, since this will remove the inciting cause of DIC and hemorrhage. Now if pt is stable tocolysis with MgSO4 is considered, but remmeber Ritordin is CI in pt with HT. ***Again, once we dx the next step is Vaginal delivery with augmentation of labor if necessary. Now if mother and baby are not stable or if there is CI, then Emergency C-section is indicated. Now if there is Dystocia ( narrowing of the birth passage) then forceps can be used. Continue to monitor DIC labs as it may alter after few hours.

Question 2

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ABCD of Homeostasis: ~

Answer 2

1-AIRWAY: An airway is needed for all unconscious pts, in the ER best method is Orotrachial intubation and in the field its needle cricothyroidectomy. For consciouns pt the best airway is chin lift with face mask. Nasal tubes are CI in people with facial injury. In patients with rheumatoid arthritis, vertebral subluxation is possible so be careful. 2-BREATHING: Cervical spine injury should be analyzed but the first step is to establish ABC. 3-CIRCULATION: It needs control of bleeding and restoring the BP. In most external injuries pressure is enough to stop bleeding but in case of scalp laceration suturing is needed. Also all pts with hypotension should receive rapid infusion of isotonic fluid like ringer lactate to prevent life threatening hypotension. If IV line is not good for adults do saphaneous vein cut down and for children intraosseous membrane cannulation.

Question 3

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Absence seizures - 3

Answer 3

~Ethosuximide is tx. Now remmeber that Phenytoin and Carbamazapine are first line drug used for primary generalized tonic clonic sezure or partial seizures, both work by blocking Na channels voltage dependent, Phenytoin is a second drug line for myoclonic and tonic clonic seizure, its available in both IV and oral forms, SE is gingivial hypertrophy, lymphadenopathy, hirsutism and rash, Both Phenytoina & Carbamazepine can cause Steven Johnson synd and Toxic Epidermal Necrolysis.*****Tx is Ethusuxamide or VALPROATE. Classic EEG is symetric 3mhtz spike and wave .

Question 4

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Acarbose SE

Answer 4

~It blocks carbohydrate break down in the intestinal tract. The most significant SE is GI disturbance due to increased undifested CHO in the stool.

Question 5

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ACE inhibitor SE, Respira, 6/2 ~

Answer 5

CAPTOPRIL (Cough, Angioedema, Pregnancy, Taste change, hypOtention, Proteinuria,Rash, Increase renin, Lower AII) and HyperKalemia. Cough is caused by accumulation of Kinins possibly by activation of arachadonic acid pathway. Kinins are degraded by ACE, when there is noACE they increase.*****Angioedema that is seen in ER. Pt presents with non-inflamatory subcutaneous edema and laryngeal edema due to bradykinin stimulation.

Question 6

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Acetaminophen toxicity - 2~

Answer 6

Acute alcoholic intake can reduce the risk of hepatic injury by Acetaminophen because it competes with CYP2E1, so there is less production of toxic metabolites. Chronic alcohol intake increases risk of hepatic injury by stimulating P450 system and decreasing the amount of Glutathione (used for metabolism of acetaminophen). Management process: 1-4-hr post ingestion AA levels are determined to decide whether the pt will benefit from NAC or not. 2-On the other hand if the pt has ingested >7.5 gm AA and levels will not be available w/i 8 hours of ingestion, he should be given the antidote.

Question 7

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Acetazolamide Toxicity

Answer 7

Causes normal anion gap metabolic accidosis due to renal loss of bicarbonate. Anion Gap is 140-(114+116)=10 which is normal anionic gap metabolic acidosis.

Question 8

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Achalasia - 3 ~

Answer 8

Dx 1-Barium studies, 2-Esopgaguscopy 3-Manometry. ** the CONFIRMATION test is Manometry. We also need to do Endoscopy to rule out malignancy.

Question 9

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ACL Injury ~

Answer 9

It prevents gliding of tibia under femur. Injury is seen after Hyperextension. A poping sensation is felt at time of injury. Commonly associated with Medial Meniscus and Medial Colateral Ligament (TRIAD). Lachman test is a test for ACL tear. Flex and pull tibia. Drawer sign also test ACL but its less sensitive. Posterior Drawer sign tests PCL. Mc murry’s sign tests Meniscus injury. Valgus test is for MCL.

Question 10

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Acne - 2 ~

Answer 10

1-Comedons (black/white heads): cuase minimal inflamation and tx is topical retinoids. If reactivation occur add topical Erythromycin or Benzoyl peroxide. 2-Papular and inflamatory acne: with moderate-severe inflamation: Oral Doxycycline. 3-Nodular or scaring acne: Oral Isotretinoin.

Question 11

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Actinomycosis ~

Answer 11

Cervicofacial actinomycosis presents as slowly progressing , non tender, indurated mass, which evolves into multiple abscesses, fistula, and draining sinus tracts with sulfur granules, which appear yellow. Actinomyces israelii is the agent, Tx is high dose IV peniciline for 6-12 weeks. Surgical debrement comes after penicillin therapy.

Question 12

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Acute adrenal insufficiency: ~

Answer 12

Acute onset of naseau, vomiting, abdominal pain and hypoglycemia and hypotension after a stressful event (surgery) in a pt sho is steroid dependant is typical. A clue is preoperative steroid use. Exogenous steroids depress pit-adrenal axis and a stressful situation can precipitate AAI. DDX: insulin induced hypoglycemia does not cause naseau and vomit and abdominal pain and hypotension.

Question 13

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Acute Alkali ingestion ~

Answer 13

When a pt takes Lye (alkali substance for suicide), upper GI contrast studies should be performed as eary as possible, to assess the damage and posible perforation of esophagus. Normal x-ray does not rule out a perforation. Once you know there is no perforation then you can do Diagnostic peritoneal lavage if necessary. But the first thing is to rule out perforation.

Question 14

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Acute Appendicitis - 3 ~

Answer 14

Pt who comes to hospital after 5 days of initial symptoms must be hospitalized with IV hydration and IV Cefotetan. If threre is abcess with CT, percutaneous drainage is an option.Most pelvic abscesses are due to perforation of AA. Pt might have a 24 hour RUQ pain that resoves spontaneously and then later on in a few days he might come with anal abscess symptoms. Drainage of the abscess is tx of choice.Experiecne has shown that right hemiclectomy with ileo-transvers anatomosis has best postoperative results when resection of part of ascending is requires. And that is when pt has shown gangrenous rupture of appendix with questionable necrotized colon.

Question 15

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Acute Bacterial Proctatitis: ~

Answer 15

MCC in young is Chlamydia and Gonococcus, in old E. Coli. To diagnose do culture of mid-stream urine sample and start empiric therapy. Prostatic massage is contraindicated due to septecemia chance.

Question 16

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Acute GI bleeding ~

Answer 16

There are three causes: 1-Diverticulosis (Painless. can be ruled out with Barium Enema), 2-Angiodysplasia (Painless. maybe seen as cherry-red sopts that maybe coagulated, dx with labeled erythrocyte scintigraphy). 3-PUD (Painfull. Dx with endoscopy, if there is Hematochezia, red bright blood,due to lower GI bleed, then there is no need for endoscopy, the blood is from lower UGI bleeding).

Question 17

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Acute renal transplant rejection ~

Answer 17

Renal transplant rejection in the early post-operative stage can be expained by, ureteral obstruction, Acute rejection, Cyclosporine tox, vascular obstruction and ATN. To determine the cause we do US, MRI and Biopsy. If biopsy shows infiltration of lymphocytes and vasular swelling and there is increase Crt and Bun and oliguria, then the cause is Acute Rejection. Tx is high dose IV steriods.

Question 18

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Acute Tubular Necrosis

Answer 18

Prolonged hypotention due to any reason (Hypovolemic shock) can lead to ATN. Hallmark finding on urin analysis is Muddy brown granular cast. DDX1:RBC cast, GN. DDX2:WBC cast, Interstitial Nephritis and Pyelonephritis. DDX3:Fatty cast, NephrOtic Synd. DDX4:Broad and Waxy cast:Chronic renal failure.

Question 19

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Acyclovir Toxicity

Answer 19

Can cause crystalluria with renal tubular obstruction during high dose parenteral therapy, especially in inadequately hydrated pts.

Question 20

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Addison’s Disease - 2

Answer 20

MM-101. Aldosterone def leads to non-anion gap hyperkalemic, hyponatremic metabolic acidosis. 80% of pt have primary adrenal deficiency due to Autoimmune adrenalitis. These pts also present with autoimmune involvement of other glands as well, like thyroid,parathyroid, ovaries. 70% of the Causes of Primary Adrenal Insufficiency autoimmune, mostly in developed countries. In underdeveloped countries TUBERCULOSIS, Fungal infection and CMV infection are the mcc, TB is the MCC in undeveloped countries. Adrenal Calcification is a typical feature of TB PAI. Pt presents with no rise in serum cortisol following injection of Cosyntropin (ACTH analog), CT shows calcification of adrenal glands. Tx of TB does not result in normalization of adrenal gland. PAI in HIV pt is common, mcc is CMV. Sometimes Ketoconazole can cause it. PAI is very rare with adrenal tumor metastasis, even then calcification is not seen.

Question 21

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Adenomyosis

Answer 21

Is defined as presence of Endometrial glands in the uterine muscle. MF in women above 49, , presents with severe dysmenorrhea, and menorrhagia. The typica lexam reveals enlarged sysmetrical uterus. If Adenomyosis is in one side of uterus then enlargment is asymetrical. DDX includes Myomatous Uterus , Leomyoma, Endometrial carcioma. For women above 35, its mandatory to perform an Endometrial curetage or even hysterectomyto rule out endometrial cancer. DDX1:Endometriosis is a benign condition, where foci of endometrial glands are found OUTSIDE of endometrium. They increase in size throgh out menstrual cycle. Associated with Adenomyosis occurs in 15% of cases. DDX2:Leomyomas, are difficult to ddx from Adenomyosis, except that consistency of Uterus is softer in Adenomyosis. DDX3:Endometrial Carcinoma, occurs in women after menopause . DDX4:Endometritis manifest with fever, and enlarged and tender uterus, associated with vaginal discharge . It usually occurs after a septic abortion, and the mc oranism responsible is Strep.

Question 22

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ADHD

Answer 22

Short attention span, impulsivity, hyperactivity for >6mo. Tx is Methylphenidate, se is decreased appetite.

Question 23

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Adjustment Disorder - 2

Answer 23

Emotional or behavioral symptoms that develop w/I three months of exposure to an identifiable streesor and raely lasts more than 6 months after the stressor.The tx choice is Conginitve or Psychotherapy, not drugs. DDX is GAD where pt worries about many things , AD pt worry about one thing. DDX PTSD is when pt relives the trauma that she experienced, nightmare, flashbacks. FOR >1 month. DDX Acute Stress Disorder is PTSD but FOR <1 month

Question 24

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Adrenal insufficiency, 2ary

Answer 24

Is caused by Pituitary tumor. There is Hypothalamic-Pit failure. There is Glucocorticoid def (weakness, fatigue, depresion,irritability,hypotention, lymphocytosis,eosinophilia), and Hypothyroidism(cold intolerance,constipation, dryskin), while Normal K level indicated Aldosterone production is not impaired, and absence of Hyperpigmentation(characteristic of Primary adrenal insuff), all suggest 2ary adrenal insufficiency. Other causes of Primary adrenal insuff are:Autoimmune destruction,adrenal CMV, adrenal TB and adrenoleukodystrophy.

Question 25

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Adrenal insufficiency, Acute

Answer 25

Pt presents with nasea and vomitting, abdominla pain , hypoglycemia and hypotension. Preoperative steriod use is the main cause.

Question 26

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Adrenal Tuberculosis: Endo, 6/2

Answer 26

Adrenal insufficiency plus adrenal calcifications. It’s the primary cause of Primary Adrenal insuff in developing countries. In contrast autoimmune adrenalitis is the mcc of Primary Adrenal insufficiency in developed countries.

Question 27

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Airway assess

Answer 27

An airway is always patent(SECURE) when a pt is conscious and able to speak. If he is tachypnea and noisy respiration he needs chin lift and face mask. An airway is needed in ALL UNCONSIOUS pts. In the FIELD best option is needle Crricothyroidectomy. In ER best option is Orotrachial intubation. Nasotracheal is time consuming. Surgical cricothyroidectomy is a good choice for Apneac pts with head and spine injury.

Question 28

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Alcohol withdrawl

Answer 28

It might occur after surgey when pt has not had drinnk for a few days. Prestns with fever, HA, N&V and TREMORS. Tx is Chlordiazepoxide.

Question 29

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Alcoholic Gastritis

Answer 29

Pt presents with epigastic pain, vomitting dark brown blood after alcohol binge, and has a hx of PUD. A BUN level >40 in a presence of normal creatine is highly suggestive of upper GI bleed, its due to bacterial break down of Hb in the GIT and the resulting absorption of urea. Another place that causes increase BUN w/o Crt is in administration of steriods.

Question 30

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Alcoholic liver disease - 2

Answer 30

T9Q9. The three major pathological findgins of ALD are: 1-Fatty liver (steatosis). 2-Alcoholic Hepatitis. 3-Alcoholic Fibrosis/Cirrhosis. Fatty liver is the result of short term alcohol ingestion, where as Hepatitis and Cirrhosis require long,sustain alcohol use. Alcohol Hepatitis is manifested by Mallory bodies, infiltration by neutrophils, liver cell necrosis, and a perivenular distribution of inflamation. Fatty liver, Alcohol Hepatitis and even early fibrosis can be potentially reversible if the pt stops alcohol consumption. Females are more suseptable to ALD. The most characteristic manifestation is ALT/AST > 2 . ALT & AST are almost always 500 this raises the probability of injury from drugs. Fatty liver exist in 80% of alcoholics but only 15-20% develop alcoholic hepatitis, and only 50% of pts w alchoic hepatitis develop Cirrhosis. Malory bodies are NEITHER specific NOR required for dx of Alcoholc Hepatitis. Pts with Alcoholic Cirrhosis should have Esophagoscopy to prevent varices.

Question 31

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ALL - 2

Answer 31

Presence of more than 25% lymphoblast in BM and the Positive Periodic Acid Shiff reaction (PAS) makes the Dx. **First symptoms are non specific, fatigue, palor, fever, anorexia, petechia and lymphadenopathy. Dx is suggested by thrombocytopenia and blast cells, but confirmed with BM bioposy. DDX1: Hodgkins, presents with painless, firm cervial adenopathy, sign and symptms are similar to ALL but LYMPHOBLASTS make ddx of ALL. DDX2: AML, occurs in adults, main dx is >25% MYELOblasts in BM biopsy. DDX3: Aplastic Anemia, can present lilke ALL BUT lab shows decrease in ALL cell lines including WBC. DDX4: ITP, children with ITP present with sudden onset of bruising,petechia and occasional Epistaxis. The only cells that are very low are Platelets and their size is LARGE. DDX5: Infectious mononucleosis, presnts with lymphadenopahty, fever and pharyngitis, due to EBV. ATYPICAL lymphocyte are seens on peripheral blood smear and MONOSPOT test is positive. ***** If parents refusing treatment, obtain court order for chemotherapy. **TX meds.

Question 32

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Allergic Bronchopulmonar Aspergillosis

Answer 32

ABPA is characterized by transient recurrent pulmonary infiltrates, peripheral eosinophilia, asthma and immediate wheel and flair reaction to Aspergilus fumigatus and presence of antibodies in serum against AF. Other characteristics are Hx of Brownish plug in the sputum and high IgE levels. Glucocorticoids are used to tx this dis. Whenever an Asthmatic pt is suspected of having ABPA, skin testing with Aspergillos antibody is first dx step, if its negative ABPA is tuled out. If positive serum precipitants agianst Aspergilos and IgE levels are checked. ABPA is excluded if IgE is 40% is suggestive of this dis. Tx is Glococorticoid. DDX4: Churg-Strauss is a multisystem vasulitic disorder of unknown etiology hat affects skin,kidney, CNS, lungs, GI and heart. There is asthma, , fever, marked Eosinophilia. Tx is glucocorticoids.

Question 33

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Allergic Conjunctivitis:

Answer 33

Is an acute hypersensitivity reaction that is caused by environmental exposure to allergens. Characterized by intense itching hyperemia, tearing, conjunctivla edema and eyelid edema.

Question 34

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Allergic Contact Dermatitis -3

Answer 34

Caused by Nickel and poison IV. Type VI hypersensitivity reaction. It mostly occurs in adults. DDX1: Atopic Dermatitis, presents as pruritic lesions in infants <6mo. Prevention is the mainstay of tx. Everywhere is involved but diaper area apears spared. Give infant warm bath and moisterizers. Acute attack maybe helped with low dose corticosteriods.

Question 35

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Allergic Interestitial Nephritis

Answer 35

Its secondary to Nafciline use. It’s a type IV hypersensivity reaction. Nephrotoxic agents are antibiotics (pencilline,cephalosporine, sulanamide, rifampine, cipro), thiazides, omeprazole, NSAID. Triad of fever,petechial rash and peripherla eosinophilia in an azotemic (Increased Urea) pt is highly suggestive. DDX: Acute Tubal Necrosis is mostly seen in ischemic or nephrotoxic renal failure. MUDDY brown casts are characteristic.

Question 36

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Allergic Rhinitis - 2

Answer 36

Dark puffy eyelids is called allergic shiners. The red crease over the nose causes constant rubbing, called allergic salute. Tx is avoidance and decongestants. **If rhinitis is not clear if its allergic or infectious, then next step is Nasal cytology. Demonstration of neutrophils in nasal secretions suggests infectious cause. Predominant of Eosinophils suggest allergic cause. Other cause of nasal eosinophilia include Nasal Polyposis (Aspirin sensitivity).

Question 37

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Allergy, Drug

Answer 37

for mild reactions just use antihistamines. For systemic reactions, like anaphylactic use Adrenalin or Steriods

Question 38

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Alpha Feto Protein

Answer 38

The mcc of its deficiency is gestational age error. HIGH levels are seen in Gastrochisis and omphalocele, as well as ‘false positive’ causes like fetal demise, multiple gestation, inacurate gestational age. In case of increased MSAFP should first do US to rule out false positive causes and to detect presence of any anomaly. Afterwards, Amniocenthesis must be ordered for confirmation by measuring amniotic level AFP and AchE. AchE is a protein that increased only in neural tube defects. LOW levels of MSAFP are seen in chromosomal abnormality especially Down’s synd. The screening is more acurate when MSAFP is coupled with b-hCG and Unconjugated Etridiol (UE3) levels, Its called TRIPLE TEST. Combnation of Decreased MSAFP + Increased b-hCG + Decreased UE3 is typical for Down’s. In trisomy 18, ALL three are decreased. Likewise, US has to be perfomed to rule out inacurate dates and fetal demise, then amniocenthesis to confirm the Dx. MSAFP and triple test should be performed by 16-18 week of gestation. **AFP is produced by Yok sac and fetal liver, some passes to maternal circulation. Other procedures: CVS- is indicated in women who are known to have genetic abnormality or previous affected children. Its done 10-12 weeks and offers advantage of 1st trimester testing.

Question 39

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Alpha-1 Antitrypsin Deficiency

Answer 39

It’s a protease inhibitor synthesized in liver. Pts w homozygous def are at risk of Panlobular Emphysema in adult life. The mc manifestation in adults is Asymptomatic cirrhosis, and maybe complicated by Hepatocellular Carcinoma. Hepatocytes contain granules that are PAS positive and Diastase resistant. DDX1: Whipple’s, which is PAS positive but doesnt cause cirrhosis.

Question 40

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Alport Synd

Answer 40

Recurent episodes of Hematuria, sensoryneural deafness and a family hx of renal disease. Alternating areas of thinned and thickened capilary loops with spliting of GBM.

Question 41

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Alprazolam:

Answer 41

Abrupt cessation is associated with significant withdrawl symptoms like generalized seizure and confusion.

Question 42

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ALS - 2

Answer 42

Tx is Riluzole (glutamate inhibitor. Side effects are dizziness, nasea, weight loss, elevated liver enzymes and skeletal weakness.) Both upper (spasticity, bulbar symptoms, hyperreflexia) and lower motor neuron (Fasciculation) damage. Muscle wasting of all body muscles. “Tuesdays with Morrie” Jack Lemon.

Question 43

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Altered Mental status in elderly

Answer 43

Major causes include: 1-Hypo/Hyper natremia. 2-Hypo/Hypercalcemia. 3-Hypomagnesemia. 4-Hypophosphatemia. 5-Hypoglycemia. 6-Stroke. 7-cardiac events. 8-infections.

Question 44

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Alturism

Answer 44

Alturism is minimizing internal fears by helping other who have same problem (Alcoholic volunteering in AA). DDX: Sublimation, turning unacceptable behavior to a more acceptable ones.

Question 45

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Alzheimer’s Disease - 4

Answer 45

Diffused cortical atrophy. Tx is Donezapin, Tacrine, rivastigmine, galantamine. ** Elderly gradual memory decline with Apraxia (Loosing the ability to do routine acts), Aphasia and Agnosia (not recognizing familiar objects). ***DDx it from Picks by MMSE, which is decreased in AD. In picks you need to see more than just one indication of behavior changes(urinating is not enought).

Question 46

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Amaurosis Fugax

Answer 46

Amorosis Foo-Gacs: Visual loss that is monocular, transient “dropping of the curtain”. Opthalmoscopy reveals zones of whitend, edematous retina, following retinal artery distribution. Seen in pt with atherosclerosis and CV disesae. Its caused by retinal emboli from ipsilateral carotid artery. It last about 15 minutes. Tx of atherosclerosis is important to reduce the risk of stroke. Dx is with Duplex of the carotid.

Question 47

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Amebic (liver) abscess - 2

Answer 47

More common in tropical males. After intestinal infection with Entameba Histolytica. Transmission by water or food. Dx of liver abscess is by CT. When aspirated has “Anchovi-paste” appearance, Tx is Metroniddazole, orally, given one to two weeks. **Hx of travel to endemic areas followed by dysentry and RUQ pain with a single Cyst in right lobe of liver is indicative of ALA. Primary infection is i the colon, but then it goes to portal vein and liver. Dx is made by stool examination of trophozoit serology and liver imaging. Tx is Metronidazole. DDX:Hydatid Cyst, caused by Echinococcus acquired by contact with dogs

Question 48

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Amenorrhea - 3

Answer 48

1-Secondary Amenorrhea: the first step is to rule out pregnany, then hyperprolactinoma, then hypothyroidism. The 2nd step should be determination of pt’s estrogen status with progestine challenge test. A- If pt has adequate estrogen and a history of intrauterine instrumentation then suspect Asherman’s synd (intrauterine adhesions. A hysterosalpingogram can show). Pts with no such hx are all anovulatory or oligo-ovulatory. B- If estrogen is inadequate, FSH should be ordered to determine gonadal or central origin.Prolactin production is inhibited by Dopamine and stimulated by serotonin and TRH. An increase in TSH and TRH may lead to Hypothyroidism. Hyperprolactinoma may also affect GnRh and gonadotropin secretion and thus result in ammenorrhea. Other causes are dopamine antagonist (antipsychotics,TCA), hypothalamic and pituitary tumors. In the case of ammenorrhea-hyperprolactinoma , first rule out hypothyroidism by measuring serum TSH.2ary Ammenorhhea in athletes is due to Estrogen deficiency because menstruation happens because of Estrogen.***Check out Table in Q41, Exam 12 0r 13.

Question 49

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Amiodarone tox - 2

Answer 49

1-Pulmonary, 2-Hepatotox, 3-corneal deposits, 4-skin reactions. *** If a pt needs rate control but has Restrictive lung disease Amiodarone is CI.

Question 50

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Amlodipine side effect

Answer 50

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Question 51

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Amphetamine intox

Answer 51

pt might act like schizo but HT is not normal. Cocaine is the same as Amphetamine. DDX is Manic episode that has the mnemonic DIGFAST (Distractbility,Insomina,Grandiosity,Flight of idea, Activity increase,Speech talkative,Thoughtlessnes risky actions.).And Herion Tox: Triad of altered consciousness,respiratory depression and pinpoint pupils. Herion Withdrawl: muscel and joint pain , N&V, diarrhea,abdominal cramps, rihnorea,lacrimation,sweating. Amphetamine Withdrwal:depression, increased appetite ,fatig , irritability.

Question 52

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Amphotericine Toxicity

Answer 52

Hypokalemia.

Question 53

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Amyloidosis:

Answer 53

In heart is the end stage and next step is Transplantation.

Question 54

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Anal Fisure

Answer 54

They are most comonly caused by passage of hard, large constipated stool. The mc symptoms are severe pain and bright red rectal bleeding during defecation. Tx of both acute and chronic fisures starts with dietry modification (high fiber diet and lots of fluids) along with stool softner and local anesthetics.

Question 55

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Analgesic Nephropathy - 2

Answer 55

Clinical senario describes a woman with chronic HA, almost everyday, who presents for Hematuria. Several years of abuse leads to chronic tubointerstitial damage. Hematuria is due to Papilary Necrosis** It’s the mc form of drug induced chronic renal failure. Most commonly in femlaes . Papilary Necrosis and Tubulointerestitial nephritis are the mc pathologies seen. Polyuroa and sterile Pyuria with WBC casts are early manifestations. In advanved cases you see Proteinuria and hematuria.

Question 56

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Anaphylactic shock

Answer 56

One HOUR After bee sting in ER the first thing to do is SC Epi, not removing the sting. If after oneminute then first remove the sting.

Question 57

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Anemia of Prematurity

Answer 57

is the mc anemia in premature and low birth weight infants. Pathology involves a diminished RBC production, shortened RBC life span. And blood loss. Iron supplementation doesn’t help falling Hb levels and iron def is not the cause of prematurity.

Question 58

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Aneurysms

Answer 58

Causes are: 1-TARUMA:Aneurism in a young pt who presents with Desending Aortic aneurism. Pathophy is acceleration trauma. It might show in Cxr by wide midiastinum, 10% will have normal cxr so if you suspect it do CT or MRI. Tx is surgery to prevent rupture. 2-ATHEROSCLEROSIS:Is the mcc of Descending Aorta aneurism. Pts are older, smokers. They are generaly asymptomatic and are seen on Cxr. Majority of pts also have significant CAD. 3-MARFAN:nomonic is ‘m.A.AR.f.A.n”. Pts present with Ascending aneurism of Aorta. Associated findings are Aortic regurgitation Surgery is required to replace both aortic valve and entire ascending aorta. They also have a higher chance of Aortic Dissection than genral population. 4-MYCOTIC:result from localized infection , Its mc in Femoral artery and 2mc in Ascending aorta. The mc pathogen is S. Aureus and 2mc is Salmonela. 5-SYPHLYTIC:Occur in Ascending Aorta. Pt presens with fever,chills, spliner hemorrhages. CT is dx.

Question 59

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Angina, Prinzmetal or Variant - 2

Answer 59

Classis picture is a pt with absence of risk factors of CAD, night pain waking her up, transient ST elevation, absence of Q waves and negative cardiac enzymes. The disease results from coronary vasospasm of the artery that causes “Transmural Ischemia” and hence ST elevation on EKG. Other things to know is: “Subendocardial ischemia” in Angina pectoris causes ST Depression. “Transmual Infarct” causes ST elevation followed by development of Q waves and increased cardiac enzymes. “Subendocardial infarcts” cause ST Depression that are not followed by Q waves and elevation of cardiac enzymes. Summary: TM-IS=Elevate ST-Q-Enz. TM-IN=Elevate ST+Q+Enz. SE-IS=Suppresed ST-Q-Enz.and SE-IN=Suppresed ST+Q+Enz. *** Propranalol and Aspirin are CI in these pts. The initial tx is with Nitrates and Calcium channel blockers. Second drug is only added when there is no response to the first drug. DOC for initial mgmt is Calcium channel bloker, Diltiazam.

Question 60

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Angina, Stable - 4

Answer 60

EKG stress test is the initial test for dx. Rbbb is not a CI. But when a pt has Lbbb,WPW, ST depression >1mm at rest then stress testing with imaging is done. Dobutamine stress test is for those pt who cant exercise sufficiently. Coronary Angiogram is done if stress test fails. Myocardial Perfusion is for those who are at risk of develoing complications with excercise or Dobutamine. **Medications that has to be withheld prior to EKG Exercise test are Anti ischemic mdeciation, Digoxin and medications that slow the heart (B-Blockers, Atenolol).*In pts with stable angina and HT, B-blocker is tx of choice. CCB(Verapamil) is indicated if BBs are CI or dont work. They both have BOTH anti HT and anti anginal effect. Enalapril has ONLY anti HT effect. **Stress EKG or an Excercise Echo should be done for risk stratification in pts with stable angina. Pharmocological stress testing is an alternative if pt cant do excercise. Coronary angiography is done when pt is refractory to medical tx or when excercise tesidentifies pt as high risk.

Question 61

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Angina, Unstable - 2 Ishcemic chest pain only partially releived by Nitroglycerin, T wave inversion, and negative cardiac enzymes. Tx for unstable angina and NON-Q wave infarction is with IV heparin, aspirin, B-blobker and nitroglycerin is indicated. Thrombolytic tx is associated with mortality in these pts. Thrombolytic therpay is indicated in MI with ST elevation after sublingual Nitro rules out coronary vasospasm. Another indication for Thrombolytics is LBBB. **Give CLOPIDOGREL not Ticlopidine for platelet de aggregtion.

Answer 61

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Question 62

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Angiodysplasia or Vascular Ectasia

Answer 62

The two mc causes for pianles GI bleeding are diverticulosis and Angiodysplasia. DDX is that Angiodysplasia is associated w Aortic Stenosis. Other associated is renal failure. Also Sigmoidoscopy reveal Diverticulosis and not Angiodysplasia. MERK:Angiodysplasia is an acquired submucosal AVM, which may cause lower GI bleeding in elderly patients. When the bleeding is massive, it is usually from either angiodysplasia or diverticulosis. Typical angiodysplastic lesions are 0.5 to 1.0 cm, bright red, flat or slightly raised, and covered by very thin epithelium (see Plate 22-3). Treatment is indicated for angiodysplasia that has bled because of its tendency to cause chronic recurrent hemorrhage. Active, severe bleeding may be controlled quickly by intra arterial or IV administration of vasopressin when the patient is stabilized, but results are variable. The lesions then may be treated more definitively by endoscopic coagulation or surgery. The most difficult aspect of treatment is to eliminate other potential causes for the GI bleeding and to locate all of the angiodysplastic lesions. If the lesions are not large or numerous, endoscopic coagulation with hot biopsy forceps or laser photocoagulation is preferred. The usual surgical treatment is a right hemicolectomy because of the propensity for angiodysplasia to involve the right colon.

Question 63

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Angioedema - 2

Answer 63

ACE inhibitors are notorius for producing Angioedema in ER. Pt presents with non-inflamatory edema and laryngeal edema that could be life threatening. Angioedema occurs due to proinflamatory action of substance.P which is stimulated by Bradykinin. Bradykinin can be broken down by angiotensinogen converting enzyme. When an ACE inhibitor blocks this enzyme, the levels of brady kinin increases leading to angioedema. Tx is Anti histamine.

Question 64

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Angiofibroma - 3

Answer 64

A benign vascular tumor found in adulescent male. Present with frequent epistaxis(Epistaxis is the major symptom), nasal obstruction, HA & conductive hearing loss. In PE hay greyish-red mass in the posterior nasopharynx. CT is Dx, TX is medical and surgery, depending on stage. **Any adulescent boy with epistaxis and has localized mass with bony erosions on the back of the nose has an Angiofibroma unless proven otherwise.

Question 65

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Anion Gap Metabolic Acidosis 3

Answer 65

T9Q3. First see pH< 7.20)****AG formula is (Na)-(Cl+HCO3), normal is 6-12.

Question 66

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Ankylosing Spondolytis - 3

Answer 66

Associated with IBD.**regular exercise is the only tx that halts progression of the disease. Pt is young, presents with insidious onset of back pain for more than 3 months, positive family hx, reduced back motion and chest expantion, also HLA-B27. Xray shows scoliosis. NSAID is for pain control. Sulfasalazine is for peripheral joint involvment. Surgey is recommended when dis is sever and refractory to medical tx. **Dx cant be made unless there is evisence of sacrolitis. So when pt has symptoms of AS, the next step is to do Xray of the sacro iliac joint. If Xray is inconclusive then MRI is done.

Question 67

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Anorexa Nervosa - 2

Answer 67

Elevated carotene gives the skin a yellow color. Carotene is also elevated in DM and Hypothyroidism. Pregnant women with current or previous AN are at risk for Miscarriage, intrauterine growth retardation, hyperemeis gravidarum, premature birth, cesarean delivery, & post-partum depression. Osteoporosis is a common finding in women pregnant or not. Also elevated cholesterol and carotene levels, euthyroid sick syndrome, cardiac arrythmias (prolonged QT). The FIRST step of MGMT is Hospitalization. There Ammenorrhea and body weight is below normal. In bulemia weight is normal.Once the dx is made the first step in managementis hospitalization.

Question 68

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Anserine Bursitis

Answer 68

Pain over medial tibial plateu, hx is associated with trauma and cxr is normal.

Question 69

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Anterior Cord Synd

Answer 69

Usually occurs due to motor vehicle accident injury. There is Paralysis and analgesia below the level of injury and preservation of posterior column function like position,touch and vibratory. Pts trearted with High-dose Methyl prednisone w.I 8 hrs of injury have significant neuorologiccal improvement. All trauma pt do 2 things, 1-Immobalize, 2-ABC.*****Associated with burst fracture of the vertebra, characgterized by total loss of motor function (Paraplegia) below the lesion, with loss of pain and temperature on both sides below the lesion. MRI is the best initial Dx procedure.

Question 70

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Anti Psychotc drugs

Answer 70

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Question 71

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Work by blocking Dopaminergic receptors. Typical ones are Haloperidol, Chlorpromazine, Fluphenazine. Atypical ones , add Serotonin blocks as well, so block EPS SE. Atypical is Clozapine, Risperidone. **Dystonia, an extrapyramidal SE of Haloperidol is treated with Benztropine or Diphenhydramine.

Answer 71

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Question 72

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Anti-D Ig

Answer 72

After events that are associated with maternal-feto hemorrhage (placenta abruption) the failure to correct the dose of Anti D can result in maternal Alloimmunization (T22Q39).

Question 73

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Anti-depressants - 2

Answer 73

Are SSRI, MAO inhbx,TCA. SSRI causes sexual dysfunction. If it does, discontinue and give Bupriopoin (inhibit Nepi, and dopamine reuptake) it doesn’t cause impotence. TCA also causes sex dysfunction. Trazodone is good for antidepressant in those with Insomnia, but it too causes sex dysfunction. *****In pts with terminal dis, when severly depressd with active suicidal thoughts antidepressnt should be given immediately, not lectures about accepting the fact and the feeling being normal and .blahblahlah…

Question 74

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Antiphospholipid Antibody Synd

Answer 74

Recurrent arerial or venous thrombosis or recurent fetal loses in the presnece of Antiphopholipid antibodies. There are 3 types of APLA, first one is responsible for false VDRL, Second is LUPUS and falsly elevates APTT, the Third is Anticardiolipin. The tx is Heparin+Aspirin.

Question 75

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Antisocal Personality

Answer 75

Is dx in those older than 18 yo who engage in illegal activites and abuse others. They show CONDUCT disorder when they are minors.

Question 76

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Aortic Aneurysm

Answer 76

MCC is ascending aorta and cuase is cystic medial necrosis. Descending aorta is associated with atherosclerosis.

Question 77

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Aortic Aneurysm, Abdominal -3

Answer 77

After AAA repair (surgery) , diarrhea and blood in stool should raise the question of Ischemic Colitis. . If CT is inclusive, a sigmoidoscopy/Colonoscopy is recommended. DDX is Pseudomembraneous Colitis due to antibiotics will present with same symptoms but not the ischemic changes in the colon. CT shows ruptured aorta and blood around aorta, tx is exploring the abdomen.The study choice of Dx and folow up is abdominal USG. ****When pt presents with pulsatile mass and hypotension , a presunptive dx must be entertianed. and pt should be taken directly ro surgery, NO USG OR CT.spinal cord ischemia with lower spastic paraplegia is a rare complication of AAA. Its due to loss of blood during the operation.***When there is ruptured AA confirmed with CT, then the next step is Explore abdomen not Laparoscopy (not used in acute conditions).

Question 78

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Aortic dissection - 6 Htn and BP difference in two arms. First thing to do is admit to ICU, IV Nitropruside(reduce BP), Beta blocker(Esmolol,reduce heart rate). Any delay maybe fatal, don’t even give pain killer first, just do the above. So first tx is antihypertensive agent, before CT,MRI,TEE or Cxr. Intense retrosternal pain that radiated to subscapular area, also check for Aortic regurgitation (decresendo diastolic murmur in the left sternal border, also Hypertension. Dx w TEE. **The mCC of AD is HT, if given no info pick this as the cause.Acute AD is a risk factor in Marfan pts. Tearing pain and raddiation to the back and a difference BP of 30mmhg b/w two arms are impotant clinical clues. TEE or CT ar the dx studies of choice.

Answer 78

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Question 79

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Aortic Regurgitation

Answer 79

Presents with Water hammer or collapsing heart and pistol shot femoral pulses. These occur due to hyperdynamic circulation and early diastolic runn off of aortic insufficincy.**Tx is Diuretics+ACE inhibitors+Digoxin, are given first to releive congestive sysmtoms for LV dysfuntion and then we need to change valve is indicated. Pt must undergo Echo for diagnosis.

Question 80

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Aortic Anreurysm Rupture

Answer 80

Aortic rupture should be rulled out in ALL trauma pts with Severe chest trauma, pulsatile mass and hypotention. Its best done with Cxr. The signs are:1-widening of mediastinum>8cm, 2-Depresion of L main bronchus >140degrees, 3-Deviation of nasotracheal tube, 4-Fracture of 1st&2ns rib,sternum,scapula, 5-L apical hematoma. Immediate surgery is very important but do confirmatory CT or angiogram. BUT REMEMBER if question gives you option b/w Surgery and CT go with surgery.

Question 81

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Aortic Coarcation:

Answer 81

the tx for RECURRENT AC is Baloon Angiography.

Question 82

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Aortic Stenosis - 4

Answer 82

Age dependant idiopathic sclero-calcific changes are the mfc of isolated AS in elderly. Pt presents with exersional syncope. PE shows increased intensity of point of maximal impulse. Auscultation reveals ejction-type systolic murmur. With radiation to carotid arteries. NOTE:Bacterial endocarditis may lead to Aortic insufficiency not aortic stenosis. Pt presents with Anginal chest pain, dyspnea or syncope (The classic triad of symptoms is syncope, angina, and dyspnea on exertion.). Pain is ischemic in origin and occurs due to increased O2 demand 2ary to LV hypertrophy. ECHO is the study of choice to Dx AS. Its also used in follow upsKey to Dx is Harsh systolic murmur over the right sternal edge, know that only left sided murmurs increase on exspiration. S4 results from forceful atrial contraction against the thick non-compliant ventricle. The classic indication for surgery in pt with AS is SAD (Syncope, Angina, Dyspnea). Dyspnea results from CHF. Presentation of either indicates valve replacment surgery. The indications for Aortic valve replacment are:1-All Symptomatic pts, 2-Pt with severe AS undergoing CABG. 3-Asymptomatic pt with severe AS either poor LV systolic function , LV hypertrophy > 15mm.**In ALL AS pt who are SYMPTOMATIC, IE prophylaxis and repeated regular follow ups are recommended.

Question 83

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Aplastic Anemia, Acquried

Answer 83

Injury to the bone marrow by drugs, radiation, toxins or insecticide. Pedaitrics disese. Pallor,fatigue, loss of appetite, easy bruising, petechia, mucosal hemorrhage and fever. Lab shows, anemia, leukopenia, thrombocytopenia. BM biopsy is essential for Dx and shows hypocellular BM and fatty infiltration. MERCK:Tx: Equine antithymocyte globulin (ATG) has become the treatment of choice for older patients or those without a compatible donor. Combined ATG and cyclosporine is also effective.. Bone marrow transplantation from an identical twin or an HLA-compatible sibling is a proven treatment for severe aplastic anemia, particularly in patients aged < 30.. DDX:Fanconi syndrome, familial, pancytpenia, brown pigmentation, cafe au lait, short stature, upper limb abnormality, skeletal abnormality, it starts w thrombocytopenia then neutropenia and then anemia. DDX2 Diamond-Blackfan Anemia, or congenital RBC aplasia presents in the first three months of life w pallor and poor feeding. WBC and platelet counts are normal.

Question 84

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Appendicitis:

Answer 84

If a 62 yo on WARFARIN comes in with appendicits and requires emergent surgery, first step is to reverse the effect of Warfarin not by Vitamin K infusion (takes 1-2 days for effect), but with infusion of FFP. Then proceed with the surgery. Acute Appendicits may be complicated by pelvic abscess that presents with lower abdominal pain, malaise, low grade fever, and tender pelvic mass on rectal exam. Most of pelvic abscesses are due to perforation of appendix. Pt could have had appendicits that resolved with rupture and abscess formation. The diarrhea is reactive due to irritation. Drainage of the abscess is the tx in these cases. **Experiecne has shown that right hemicolectomy with ileotransverse anastomosis has best postoperative results, when resection of part of ascending colon is required, when hay appendicits with cecum inflammation and pus.**Complicated appendicitis is when the pain is ignored for days and pt presents with high fever and localized pain to RLQ. Tx is with IV hydration, Antibiotics and bed rest. Non-operative management is curative, CT may reveal abscess that can be drained percutaneously Antibiotics should cover Gram negative and Anaerobics, Cipro+Vancomycin.

Question 85

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ARDS - 4

Answer 85

Could happen secondary to Acute pancreatitis. Dx:PaO2/FiO2 must be <200 (PaO2=55, Receiving O2 by mask

Question 86

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is 60%) in the setting of absence elevation of left atrial pressure (PCWP

Answer 86

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Question 87

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Arm Fractures

Answer 87

1-Colles, outstreched hands in elderly. 2-Smith, my injury, 3-Bartion, intraarticular fraction of distal radius. 4-Chauffer’s, fracture of radial styloid process in drivers. 5-Galazzi, isolated fracture anywherea long radius with associated injury to the distal radial joint.

Question 88

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Arrest Disorder - 2

Answer 88

Midpelvic contraction which is indicated by prominent ischial spines is an important cause of Arrest disorder or dialation. DDX:Inlet Dystocia, Descent of the presenting part at +1 indicates that fetus is engaged, so ID is unlikely.**Arrest in dilation more than 2 hours, and arrest in descent more than 1hour is the definition. Can be caused by hypotonic contraction, anesthesia, cephalopelvic malproportion or malpresentation. If arrest is in midpelvic contraction, indicated by prominent ishcial spines, then the next step is to do a C-section. Forcetps cant be used until cervix is fully dialated (10cm). Oxytocin might cause uterine rupture due to pelvic prevention of birth. Now in case of Shoulder Dystonia, a last resort tx is ‘Zavanelli’ maneuver (pushing back the fetus in uterus & doing a C-section.

Question 89

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Arthritis, Reactive

Answer 89

It’s a form of seronegative spondyloarthropahty. Enthesopathy(A disease process occurring at the site of insertion of muscle tendons and ligaments into bones or joint capsules ) causes heel pain and sausage digits. Enthesopathy is quite specific to spondyloarthropathy. Tx of choice for Reactive Arthritis and Reiter’s is NSAIDS. Tetracycline is added if UTI with Chlamydia is suspected and IM Ceftriaxone if Gonoccocal is suspected (but NIsseria does not cause RA).

Question 90

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Asbestosis

Answer 90

The hx of shipyard worker with cxr with pleural plaques is dx. DDX1:Sillicosis, hx of glass and pottery making. DDX2:Berylliosis, hx of high tech industries.

Question 91

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Ascending Cholangitis

Answer 91

Characterized by Triad of RUQ pain, Fever and Jaundice (charcot triad). Its an infection of the CBD, generaly 2ndary to obstruction of CBD with a stone leading to dilatation of CBD. Broad spectrum antibiotics should be started immediately, however, its very important to decompress the billiary duct and provide their drainage. ERCP (Endoscopic Retrograde CholangioPancreatography) is the method of choice. ERCP can be used to do a sphingtrectomy with the stone removal and drain the bile via the sphingter or by placement of a stent. Early drainge can significantly reduce mortality and morbidity.

Question 92

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Ascites - 3

Answer 92

Management starts wirh sodium, water and protein restriction, spironolactone, furesamide. If given a choice for only one drug tx b/w spironolactone and Furesamide, pick spironolactone. If that didn’t help then slow tapping of up to 2L of ascites fluid a day balanced with infusion of 10gr albumin per liter tapped. If that didn’t work then do surgery. The vascular shunts are indicated after first bleeding. Distal spleno-renal shunt will not improve and it might worsen it. Side to side porto-caval shunt might improve the ascites but worsen encephalopathy. Peritoneum-Jugular shunt is designed for tx of Ascites only. *If pt ‘s ascites is so much that is compromising other systems, the next step is Paracentesis which is both therapeutic and diagnostic. **Spironolactone is the DOC in tx of Cirrhotic Ascites. Tx of ascites in Cirrhotic pts should be as followes: 1-All the pt shold have Dx paracentesis done. 2-Salt Restrcited Diet is the coner stone of the therapy, in 10-20% of pt thats all you need to do. 3-Pts not controlled with SRD, Spironolactone is next. Its an Aldosterone antagonist, and it works because Ascites is only due to 2ary Hyperaldosteronism. 4-Recalcitrant (difficult to manage) ascites should be tx with TIPS. 5-Very severe ascites should be tx with paracentesis initially.

Question 93

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Aspergilosis - 3

Answer 93

An opportunistic infection in South East USA. A mobile cavitary mass in the lung, which prestns with occasional hemoptysis. DDX1:Lung abcess, due to anerobic organism, with an AIR FLUID level on Cxr. Medical mgmnt is antibiotics, postural drainage and bronchoscopy. DDX2:PE, from lower legs, presents with Dyspnea,Tachpnea, Chest pain and collapse. ECG may demonstrate RV Hypertrophy, RBBB, Right Axis and T inversionin antreior leads. Cxy may show decreased pulmonary vascular markings. DDX3:Histoplasmosis:The mc fungal infection in US. Acquired by inhalatin. “Calcified Nodes” in lung , mediastenum or spleen. Cxr shows central or target calcification. Ocasionaly causes mediastinal lymph node enlargment.Allergic Broncho Pulmonary Aspergillosis (ABPA), finding of central bronchiectasis on the cxr and elevated AgE and Eosinophilia is characteristic. Next do a skin test for Aspergilosis antibody and you ahve your Dx. Tx is Prednisone oral. Itraconazole may reduce the need for steriod but its not the main therapy.*It occurs in immunocompromised pt (those taking cyclosporine, chemotherapy). Pt prestns with fever, cough, hemoptosis, and dyspnea. Cxr may show cavity lesion. CT shows pulmonary nodule with a ‘halo’ sign. Aspergiloma is the “fungus ball” in preexisting cavities, mc presentation is hemoptysis, TX is Lobectomy.4 types of infection: 1-ABPA (tx is Prednisone), 2-Aspergious Colonization, 3-Aspergiloma (surgery), 4-Invasive Aspergilosis (tx ix IV Amphotericine)

Question 94

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Aspirin intoxication - 3

Answer 94

!-ADULTS: Initially increased respiration leads to respiratory alkolosis and then uncouples oxidative phosphorylation and leads to met acidosis. So they have mixed metabolic acidosis and respiratory alkalosis. 2-CHILDREN: Initially causes Metabolic Acidosis and then compensatory Respiratory Alkolosis. Aspirin can cause acute erosive gastritis and upper GI bleeding. , alcohol can aggrevate this effect.

Question 95

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Aspirin Sensitivity Synd

Answer 95

Pathogenesis is ‘Pseudo-allergic reaction’. Accumulation of leukotriens and changed leukotrien/progtaglandin balance triggers bronchoconstriction, nasal polyps in suseptible individuals. Tx are Leukotrien receptor inhibitors(DOC), topical steriods and aspirin desensitization therapy.

Question 96

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Asthma - 9

Answer 96

before and after administration of a bronchodialator (Beta-2 agonist). Significant improvement in FEV1 after bronchodialator indicates reversibility of destruction, which is more consistant with Asthma. Mast cell stabalizers (Sodium Cromolyn) are doc for pts who have other allergic disorders, so give this to a boy who started to have night time cough and wheeze with hx of allergic rhinitis. Exercise induces Asthma (not to be confused with post excercise asthma) presnts with chest discomfort, wheezing cough, breathlessness, fatigue and abdominal discomfort. Beta Agonist and Mast cell stabalizers (Sodium Cromolyn) are the best tx for these pts. ** When an asthmatic pt presents with Subcutaneous Emphysema, which is face becomes all swollen and palpation reveals crepitans all over face and neck, then the first thing to do is to do Cxr to rule out Penumothorax. Once that is rules out just observe the pt, it needs no tx.Inhaled corticosteriods are indicartd in pt with persistant asthma symptoms. The agents are beclomethasone. In adults SE of low-dose drug are limited to are Dysphonia and Thrush. In high-dose systemic toxicity may occur. **Its a common illness in childhood. 10% of children come ro ED with un-remitting asthma (continues wheezing despite tx with neubelizers and een steriods). This is called Acute Status Asthmaticus. Of these pts 10% require MECHANICAL VENTILATION, however hospitalization is mandatory. If on auscultation there is no air entry bilateraly, the child has ‘silent chest’ or absent air entry and continues to desaturate despite Prednisone therapy, therefor the best option is mechanical ventilation and hospitalization.For pt who have asthma accompanied with other allergic disorders, mast cell stabilizers like Sodium Cromolyn are the agent of choice. **1st neubelizers, 2nd IV steroids, 3rd mech ventilax.Normal PCO2 is one of the indicators of a severe attack. During an attack, pt is tachpneac so he hyperventilates which should cause decrease in PCO2. So if PCO2 seems to be normal that means the obstruction is getting worst or respiratory muscel are getting too tired. Other signs of severity are broken speech, diaphoresis, cyanosis, altered sensorium and “silent lung”. Inhaled corticosteriods improve long term quality of life in Asthmatics. Initial hypertensive therapy for pt with asthma is Hydrochlorothiazide.*To differentiate b/w Asthma and COPD (Emphysema) the best test is a bronchodialator response test. , its conducted by measuring FEV1

Question 97

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Astrocytoma

Answer 97

Occurs in Parietal lobe, supratentorial. It’s the mc tumor in both infra and supra tentorial. Medulablastomais the 2nd mc tumor in posterior fossa, 90% occur in vermis. Craniopharyngioma arise in sella torsica, visual field defect, Its characterized with cystic structure with calcification.

Question 98

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Asymptomatic actriuria of pregnancy:

Answer 98

When everything is normal but a routin clean catch urine culture grows 100000 colonies of E choli. Untreated pt have increased risk for cystitis and acute pyelonephritis. So they should be treated with 100mg Nitrofurantoin or Ampicillin for 7-10 days.

Question 99

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Atelectasis

Answer 99

its common after surgery in smokers. Bronchoscopy needs to be done to remove mucus Plug.Pt prestns with tachycardia, tachypnea, low grade fever. Once Bronchopscopy is done, cxr is repeatd and coughing is encouraged.

Question 100

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AtheroEmbolic Disease

Answer 100

It immitates Gout, but does not say red toe but its Blue toe. DON’T FALL FOR GOUT TRICK. Pt has cyanosis and circulation problems like pain in calf, pulses are fine.

Question 101

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Athlete foot

Answer 101

Pt presents with sever itching, fissure, thickness of the nail in a swimmer. Best tx is antigungal medicine, Tolnaftate.

Question 102

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Atpoic Dermatitis:

Answer 102

Edema and erythema of the skin. Skin is Itchy. Tx is Pimecrolimus, like Tacrolimus, its MOA is through inhibition of T cell activation.

Question 103

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Atracurium:

Answer 103

Is the neuromuscular blocking agent of choice for pt with renal and hepatic problems, because its metabolized in plasma.

Question 104

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Atrial Fibrillation - 4

Answer 104

Control rate and rhythm.** AF along with WPW tx of choice is Procainamide or Disopyramide. Drugs that slow AV conduction (Dixogin, Verapamil) are CI in these pts, they may lead to malignant arrythmais. Lidocaine might also worsen the situation. Cardioversion is used in pts that are HemoDynamicalt unstable (very rapid vent rates with hypotension).***When AF (absent P waves and irregular heart rate) is associatedciated with HemoDynamic compromise, tx is only Cardioversion. If AF is not associated with hemodynamic compromise, Amiodarone is used. Amiodarone causes hypotension so its CI with HD compromise (hypotention already in pt), but once cardioversion stabalizes pt then Amiodarone is an excellent choice to maintain the pt. Calcium channel blockers are also ONLY excellent choices for AF when there is no HD compromise.

Question 105

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Atrial Flutter

Answer 105

shows with saw tooth EKG. Unstable AF is best tx with cardioversion. ACUte AF with stable hemodynamics is tx with cardioversion or rate control. Chronic stable AF is best tx with rate control with Ca Chanel blocker(VerapamiL) or Betablocker.

Question 106

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Aut Dom Polycystic Kidney Dis

Answer 106

5-7% associated w. Berry aneurysm. Routine screening is not recommended.

Question 107

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Autism - 3

Answer 107

Mainstay of tx is special education and behavioral modification techiques. Have special interests.Usuallt starts before age 3. DDX:Childhood Disintegrative Disorder, is a rare pervasive developmental disorder, mc in males. Chracterized by a period of NORAML development for atleast 2 yrs, followed by a lost of already acquired skills. They have autism symptoms. Prognosis is poor and they are disabled for life.***Rett Synd: characterized by an initial period normal development until 6mo, followed by loss of hand coordination and sterotype hand movments. Almost exclusively in Females.

Question 108

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Autoimmune Hemoytic Anemia

Answer 108

Types: warm antibody & cold antibody. In the warm antibody type, the autoantibodies attach to and destroy red blood cells at temperatures equal to or in excess of normal body temperature. In the cold antibody type, the autoantibodies become most active and attack red blood cells only at temperatures well below normal body temperature. Rx: prednisone, azathioprine, cyclophosphamide

Question 109

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SEE Spherocytosis

Answer 109

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Question 110

Rando

Avascular Necrosis of femur

Answer 110

The well known causes of non-traumatic avascular (aseptic) necrosis are chronic corticosteriod therapy, alcoholism. Pt presents with progressive hip pain w/o restriction of motion and normal Xray. MRI is the gold standard. High degree of suspicion is desired. MRI may not show changes initially.

Question 111

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Avoidant personality:

Answer 111

Shyness and feeling of inferiority, and desire to make friends.

Question 112

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B12 Deficincy, Hem&Onco, 6/2

Answer 112

DDx b/w Anemia and vegeterian diet is the duration. We store 3-4 years of B12 in the body, so if you’re a vegeterian 4 years then we do Abody test for intrinsic factor.**DDX b/w Folate and B12 is increase in Methylmalonic level. Folate will cure anemia but neurological problems will progress.

Question 113

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Bacillary Angiomatosis:

Answer 113

is caused by Bartonella species, gram negative bacilli. Cutaneous lesions are round papules or nodules, vascular and associated with fever malaise and headache. It occurs in HIV pts.

Question 114

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Bacterial Meningitis

Answer 114

CSF : elevated protein, decreased glucose, and elevated WBC. Plus skin lesions of Purpura and petechia.**Acute Bacterial Meningitis:the 3 mf causes in communit acquired ABM are S. Pneumonia, H. Inf and Meningococcus. Pneumococci have become resistant to penicillin and cephalos, so empirical therapy in adults and children include Vancomycin in addition to Ceftriaxone. Listeria Monocytogenes is a fc in pt older than 55, so we add Ampiccilin for these pts. Other pts at risk for LM are immunocompromised and lymphoma pts. In children >3 yo, LM is a risk so empiric regimen inclused Ampicillin in addition to Cerotaxime. Now S. Aureus and pseudomona are agents in meningitis in hospitalized pts, so empiric therapy is with Vancomysin (for aureus) and Ceftazidime (pseudomona).

Question 115

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Bartter Synd - 2

Answer 115

The DDX of normotensive pt with hypokelemia and metabolic alkolosis include: 1-Diuretic abuse, 2-Surrepticous vomitting, 3-Bartter synd, 4-Gitelman synd. Classis Barter usualy presnts early in life, as polyuria,polydupsia,growth and mental retardation. However this can occur later. The underlying pathology is defective sodium and chloride reabsorption. in the ascendign loop, thereby resulting hypovolemia and consequent activation of renin-angiotensinogen aldosteron system. This then causes increase in K & H ion secretionleagin to hypokalemia and alkolosis. DDX:Primary hyperaldosteronism and Renin secreting tumors are charcterized by HT, Met Alk and Hypokalemia. Measurment of Plasma renin activity and aldosterone is used for DDX b/w the two. in Primary hypoer Aldosteronism, PRA is suppresed and aldosteron is elevated, but in renin tumors, both PRA and Aldosterone are elevated. Now remember the mcc of Hypokalemia in clinical practice is Diuretics, which is hard to ddx with Barter.

Question 116

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Basal Cell Carcinoma - 2

Answer 116

Is the mc malignant tumor of the eyelid. Lesions are slow growing, pearly and indurated. Invasive clusters of spindle cells surrounded by palisaded basal cells. It rarely might appear on upper lip but NEVER on the lower lip. The mc location is the lower eyelid. They rarely metastasize. Squamous CC is much less commn and faster growing, It presents as plaque nodule or inverted wart, its ddx is Actinic Keratosis.**sun is Bad for Basal cell carcinoma. Five warning signs are 1-Open sore tht bleeds, oozes and remain open for >3weeks. 2-Redish patch,3-Shiny bump, scar like area, 5-Pink growth with rolled border. BCC is the mcc of skin in US. Never metastasis. Its removed using by 1-Cauterization(burning), 2-Surgical (excision with 1-2mm margin). 3-Cryosurgery(freez) and 5-radiation.

Question 117

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Basilar skull fracture

Answer 117

Signs are rhinorrhea, raccoon eyes (black eye), ecchymosis behined the ear. A way to see if hay CSF mixed w blood is to drop a drop on a cleansing tissue, if hay csf there would be a yellowish spreading on the paper. In this pt head fracture has to be ruled out w CT of head and spine. Expectant therapy for all uncomplicated cases. Anterior packing is not necessary to control CFS loss. If CSF leak continues for >4 days, spinal drainage and acetazolamide is used to reduce CSF production and reduce ICP.

Question 118

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Bechet - 2

Answer 118

Is a rare multisystem disorder that affects males <20yo, in mediteranean area and east asia. An AUTOIMMUNE mechanism is suspected. It manifest with Ulcers in mouth and genital area and associated with Uveitis. Oral lesions are Aphtha like but genital lesions are more destructive leading to fenesterated vulva. No specific tx yet. ***Its a Multisystemic Inflammatory condition with recurrent oral and genital ulcers, skin lesions, mc in Turkey, Asian and middle east.Corticosteriods offer releif but dont prevent progression to Dementia and Blindness.

Question 119

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Beckwith-Wiedemann synd

Answer 119

Infant with macrosomia, macroglossia, visceromegally, omphalocele, hypoglycemia & hyperinsulinemia. iT might be associated with duplication of CH 11p, this region has the gene for IGF-2, which may explain macrosomia. DDX1:congenital hypothyroidism has umbilical hernia instead of omphalocele, and there is no hypoglycemia and hyperinsulinemia. DDX2:Macrosommia due to maternal diabetes, however these infants dont have the dysmorphic features of omphalocele, prominant occiput and macroglossia. The common congenital problems in these infants are Caudal progression synd, Transposition of great vessles, Duodenal atresia and small left colon, Anencephay and neural tube defects. DDX3:WAGR synd, Wilms tumor, Aniridia, Genitourinary anomaly, and mental Retardation. Its related to deletion of CH11involving the gene WT1.

Question 120

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Bells palsy

Answer 120

Is the PERIPHERAL seventh nerve palsy, Its dx with absence of forehead furrows and thus ruling out the CENTRAL Facial Paresis. Pts with Central lesion still have furrows because contralateral motor inervation of forehead rremians intact.

Question 121

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Benign Intrahepatic Cholestasis

Answer 121

It can develop after a major surgery in which hypotension, extensive blood loss in tissues, and massive blood replacement are noted. Jundice develop due to pigment load from transfusion. Jaundice becomes evident 2nd day post operative. Alkaline phosphatase is markedly elevated but ALT & AST are only mildly elevated. DDX1:Acute hepatic failure, has increased PT, low albumin and neurologic signs due to hepatoencephalopathy. DDX2:Hepatitis, presents with marked elevation of ALT & AST. DDX3:Halothane Hepatotoxicity, type-1 has mild elevation of liver enzymes and NO jaundice, type-2 is characterized by Acute Liver failure.

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Bernard_SoulierSynd

Answer 122

The hallmark is GIANT platelets.Its auto recessive. There is mild thrombocytopenia but the major defect is of membrane glycoprotein Ib. This defective membrane lacks the receptor for VW atachment so platelet cant adhear to endohtelium. Plateles don’t aggregate in presence of normal VWF and Ristocetin. Vigniet prsents a 16 yo girl who’s periods last 6-10 days and her brother also had bleeding problems.

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Beta blocker Toxicity

Answer 123

Overdose causes hypotension and bradycardia. Sever overdose may result in cardiogenic shock. If bradycardia or AV abnormallity is found Atropine is indicated to oppose unopposed vagal tone. Isoproterenol is given if Atropine fails and if both of them fails then Glucagon is the DOC. If medication fails then a temp pacemaker is indicated.

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BIASES: SEE STEP UP book

Answer 124

1-Selection: loss of people to follow

Question 125

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2-Observers and Ascertainment: result in misclassification of the outcome due to flaw of the design of the study.

Answer 125

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Question 126

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3-Recall: Misclassification of the exposure status, its potential problem for case-control.

Answer 126

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Question 127

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4-Confounding:

Answer 127

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Question 128

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5-Generalizability: when th epopulation you study does not include all the population where the topic of the research is covering. Like studying just men when ALL people are targeted.

Answer 128

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Question 129

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6-Reliability:

Answer 129

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Question 130

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7-Validity.

Answer 130

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Question 131

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8-Leadtime: Its prolongation of apparent survival in pts whom this test was applied, w/o changing the prognosis.

Answer 131

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Question 132

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Bicuspid Aortic Valve

Answer 132

Is the mcc of aortic stenosis in middle age adult. Both AS and HCM produce a midsystolic (Ejection systolic murmur) murmur, however murmur of HCM is best heard at left lower sternal border and it doesn’t radiate to carotids. Valsalva Attenuates AS murmur but Accenuates HCM murmur. Murmur of AS is best heard right second intercostal space and radiates to the carotids. Slow rising puls is seen in HCM.

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Billiay Cholic:

Answer 133

Is symptomatic for CheledoCholelithiasis. If there are no signs of acute cholecystitis (Murphy sing, elevated WBC and fever) then there is no need for hydration, antibiotics or emergent chlecystectomy. There could be Emphesematous cholecystitis that presents with gas in gall bladder. DM pts are at increased risk. For an uncomplicated billiary cholic just do spasmolytic and analgesic therapy and elective surgery is done at a later time.

Question 134

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BioPhysical Profile

Answer 134

BPPis a scoring system to evaluate baby’s well being. Its indicated when there is Decreased movement or a non-reactive NST. It includes NST in addition to 4 things, 1-Fetal tone, 2-Movment, 3-Breathing(30/10min), 4-Amniotic fluid inxed(5-20). Each has a score of 2, when present and 0 when absent. 8-10 is normal, and should be repeated once or twice weekly, until term.In presence of OlygoHydramnions (AFI<4, deliver now.

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Black widow spider:

Answer 135

Presents with Acute abdomen and best treated with calcium Gluconate and muscle relaxant. Brown Recluse spider causes skin necrosis localized, resembles pyoderma gangreosum. Deep skin ulcer develops. Local excision is tx of choice for the ulcer. Dapsone is used for pts with G6PD def.

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Bladder cancer - 2

Answer 136

Up to 80% of pts who go through a urinary diversion procedure, specially an ileal conduit, can develop hyperchloremic metabolic acidosis due to exchange of Cl for HCO3 in the intestinal mucosa, leading to loss of HCO3 and increase Chloride

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Bladder Rupture - 2

Answer 137

Hematuria, suprapubic tenderness, non palbable bladder and lower abdominal and perineal edema. The best Dx method is retrograde cystogram

Question 138

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Bladder Rupture - 2

Answer 138

Hematuria, suprapubic tenderness, non palbable bladder and lower abdominal and perineal edema. The best Dx method is retrograde cystogram with voiding films. Remember for Urethral injury we do Retrograde urethrogram. **Intraperitoneal rupture is more common in pts in trauma accidents.

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Blastomycosis - 2

Answer 139

Anyone in Wisconsin, Ohio, Mississippi with chronic respiratory problem is suspected. Another dx triad is Skin,Lung Cavity and Bone Lytic lesions.

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Blood Transfussion

Answer 140

Femur fracture can acct for 1L blood loss, if Pelvic is also fractured the blood loss could be several liters. General guidelines are start iv crystalloids initially, 2L in 10 min, if pt continues sign of hypovolumia then Blood transfusion is started. So the best indicator for transfussion is blood loss of >1500ml.**Washing of RBC washes off antigens associated with transfusion. Its used for IgA def pts. Leukoreduced RBC reduces the risk of allosensitization

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Blunt Chest Trauma:

Answer 141

When it happens with wide mediastinumon CXR, aortic injury must be suspected. Either a CT scan or Echo is Dx.

Question 142

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Body Dysmorphic Disorder

Answer 142

Woman thinks her nose is ‘enormous’.

Question 143

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Boerhaave’s Syndrome

Answer 143

Complete tear of distal esophagus that leads to pneumomediastinum, vs incomplete tear in Malory Weiss and no Pneumomediastinum. Xray shows subcutaneous emphysema. Dx w barium swallow. Tx give antibiotics and thoracotomy and repair of esophagus immediately.

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Borderline Personality

Answer 144

Spliting characteristic. You are the best and the other doctor was terrible.

Question 145

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Bordetella Pertusis:

Answer 145

For preventin, all close contacts (houshold and daycare) get 14 day Erythromycin, regardless of age, immunization or symptoms.

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Botulism - 2

Answer 146

we have two types: 1-Infantile type, organism gains entry through the food and prduces toxin in the intestinal tract. It’s a protease that blocks Ach release. 2-Adult type the toxin is ingested pesay, produces the effect.**Infntile botulism, tx is supportive only. BUT if Children get it then administer equine derived botulism anti toxin right away.

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Bowel Ischemia

Answer 147

Always consider it as an early complication of operation on the abdominal aorta . Pt presents with bloody diarrhea and abdominal pain. Its due to infarction of Inferior Mesenteric artery, 1-2 daya post surgery. DDX:Pseudomembraneous colitis, takes 2-3 weeks after drug therapy. **** Unrecognized bowel ischemia is one of the mc causes of lactic acidosis with severe atherosclerotic disease. Pt complains of abdominal pain after meals.

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Bowel Obstruction

Answer 148

if a pt comes with constipation and no flatulus, even then, unless strangulation or perforation is suspected, bowel obstruction is treated conservatively. So dotn do surgery first. 1st thing to do afyer IV is nasogastric suction and barium enema.

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Bowel resection:

Answer 149

In pt who goes under bowel resection the mc type of kidney stone is Oxalatedue to excessive absorption of Oxalate from GI tract. Increased intestinal fat binds calcium which is then unavailable bind oxalate. Therefore increased absorption of oxalate occurs in GI and precipitates in kidney.

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BP criteria

Answer 150

BP should be kept below 140/90. But BP in DM and chronic renal pts should be kept under 130/80 to prevent end-organ damage.

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BPH - 7

Answer 151

Starts in the center of the prostate. Cancer starts in periphery. The mcc of overflow incontinence in elderly male. Finasteride acts on epihtelium and alpha-1blocker acts on smooth muscles of prostate. Alpha blockers (Doxazocin) are prefered in pt with BPH and dyslipidemia and glucose-intolerance. If Creatinine is elevated do US of kidney, bladder and ureter to check for damages. * Tamsulosin, an Alpha-1 receptor blocker has the least SE of all alpha one blockers used for Tx of BPH.The two initial tests that are recommended in ALL possible bph pts are serum creatinin and urine analysis. Urine analysis rules out infection and creatinin rules out kidney problems.*****US of the kidney, ureter and bladder should be done in pts whose creatinin level is elevated.

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Brain Abscess

Answer 152

A pt with acute onset of HA and focal neurological symptoms (cant walk right) after an episode of acute otitis media or sinusitis most likely has brain abscess. CT and MRI show ring enhaning lesion. Fever pesents with only 50% of cases so its not a reliable sign.

Question 153

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Braindeath

Answer 153

is defined as irreversible cessation of brain activities. It’s a clinical dx. The characteristic findings are absent cortical and brain stem functions. The spinal cord may still be functioning, therefore DEEP TENDON REFLEX are intact. EEG can confirm but is not necessary. In brain dead people, pupilary reaction & oculovestibular reaction are absent, Atrpine doesnt accelerate heart since vagal is gone, and there is no spontaneous respiration.

Question 154

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Brainstem Infarction

Answer 154

1-Medial Medulary Syndrome:Occlusion of vertebral A. Contralateral paralysis of limbs, contralateral loss of tactile, vabratory and position. Tongue deviated to affected side. 2-Lateral mid-pontine synd:A lesion in Lateral Pons. Impaired sensory and motor function of CN V (trogeminal) and limb ataxia. 3-Medial midpontine Synd:A lesion in Medial Pons. ipsilateral limb ataxia, and contralateral eye deviation and paralysis of the face,arm and leg. 4-Wallenberg synd: A lesion of laterla Medula. ipsilateral horner synd, loss od pain and temperature of the face, weakness of the palate, pharynx and vocal cords, and cerebellar ataxia. Also loss of pain and temperaturein cotralateral side of the body.

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Breaking Bad News Protocol

Answer 155

1-Comfortable environment, 2-Ask pt how much he knows about his symptoms, 3- Ask pt how much he wants to know, 4- Give him a warning shot ( ie its worst that we thought, do you want someone with you), 5-Break the news if he wants that. 6- Tell him of prognosis but also of the option to make hi slife as comfy as possible, 7- Try to explain everything clearly and simple as possible.

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Breast Carcinoma - 4

Answer 156

Inflamatory beast cancer: Erythema and edema of non lactating breast could be due to locally advanced cancer, biopsy should be done first to rule out that dx. Tx is 2-3 weeks of combination chemotherapy to shrink the tumor allowing sybsequent extended resection. *Metastatic Breast Cancer has a poor prognosis. with little chance of cure. Its importnat to choose Local (Surgery) vs Systemic (Systemic Chemotherapy) tx in pt with metastatic breast cancer. **Tumor burden, based on TNM staging, is considered the single most important prognostic consideration in treating pts with breast cancer. ER+ and PR+ are good prognostic factors. Over expression of Her2/Neu oncogene is worst progosis. **Breast cancer is the leading cause of metastatic skin disease in women. These lesions are erythematous that present as erosions covered by necrotic skin. Tx is palliative radiation therapy with aggressive wound care. **Two proibitions when hay breast cancer in pregos: No chemo in 1st trimester, and no Radiotherapy anytime in pregnancy. Also Lumpectomy is not a good choice for 1st trimester cuase it needs Radiation afterwards. So the only Tx for 1st trimester is Modified Radical Mastectomy.

Question 157

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Breech presentation - 2, 6/24/06

Answer 157

If prior to 37 must be left alone. After that External cephalic version may be attempted PRIOR TO onset of labor, given no CI (Hypertension).

Question 158

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Bronchiectasis - 2

Answer 158

An irrevesible widening of medium size airways in the lung. Characterized by destruction of bronchial walls and chronic bacterial infection. They migh thave life threating Hemoptysis. Bronchiectasis is due to formation of large collateral vessels, which have a very fragile wall. Hemoptysis could be very extensive and ALL pt should be admited. **Any pt with fever, night weats, copious foul smelling sputum has one of the following: 1-Bronchiectasis, 2-Lung Abscess, 3-Anerobic Pneumonia. “Copious foul smelling” sputum is the KEY word. Cxr shows characteristic “Tram Track Appearance” (increased vascular markings) ring shadows, peribeonchial thickening. CT is the confirmatory investigation, it has REPLACED Bronchography. After that Sputum for AFB is done.

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Bronchiolitis:

Answer 159

Is defined as the first episode of wheezing associated with an URT infection. The infection is usually caused by CMV and is common in winter. In affects 50% of children in the first two years of life especially those prone to airway reactivity, and there is an increased inidence for Asthma later in life. WBC in nl and Cxr shows air trapping or atelectais. Tx is supportive care and humidified oxygen and bronchodilators.

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Bronchogenic Carcinoma. Pulm. 6/3

Answer 160

BGC is the mc lung cancer associated with asbestos exposure, while Malignant Mesothelioma is almost exclusively associated with asbestos exposure but its not the mc malignancy after asbestos exposure. Pleural involvment is HALLMARK of asbestos exposure. Cigarete smoking acts synergicaly with asbestos exposure in increasing risk factor for BGC.

Question 161

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Brown Sequard synd

Answer 161

Associated with damage to lateral spinohtalamic tract, causing contralateral loss of pain and temperature beginning TWO LEVELS BELOW the lesion. Therefore, a lesion of right sided Laterla SPT at T10 will result in left sided loss of pain and temperature at beginng at T12.

Question 162

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Bruton’s Agamaglubinemia

Answer 162

T9Q14. X-linked. MERCK: Panhypogammaglobulinemia of male infants characterized by levels of IgG < 100 mg/dL and other Ig levels low or absent, low or absent B cells. onset of infections sometime after age 6 mo. These infants have recurrent pyogenic infections of the lungs, sinuses, and bones with such organisms as pneumococcus, haemophilus, and streptococcus. A defect of the Btk (Bruton’s tyrosine kinase) gene at Xq22 prevents differentiation of pre-B cells to B cells. Lifelong IG given IM or IV in the lowest dose that prevents recurrent infection is essential.

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Bud Chiari Syndrome

Answer 163

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Question 164

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Buergers disease

Answer 164

Triad of occlusive dis of arteries, migratory superficial thrombophlebitis[Thrombi+Phlebe(vein)+Itis(inflamation)], and Reynaud phenomenon in a smoke male. DDX w atherosclerotic disease is that in those Pulses are normal.

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Bulimia Nervosa - 2

Answer 165

Outpatient tx include: SSRI antidepressant, cognitive therapy, interpersonal pshychotherapy, family and group therapy. If pt failed this and/or has metabolic problems or is suicidal then Hospitalize. *Pt bing eat and then feel guilty. They might even feel sad about their situation. But they maintian their BMI and are NOT Amenorrheic. They bing eat at least TWICE per WEEK. If they dont do that, they are dx as “Eating disorder, not otherwise specified”.

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Bullous Pemphigoid- Dermo, 6/3

Answer 166

Is characterized by tense blisters in the flexural areas. Commonly in elderly (>60). The precipitating factors are ultra violet rays, NSAIDS, antibiotics. Autoantibodies are formed against basement membrane. Immunofloresence microscopy reveals diagnostic findings of IgG & C3 at the epidermal-dermal junction and Prednisones are tx of choice. In Pemphigus vulgaris IgG deposits are intercellulary in the dermis. In Herpes there is C3 at the basement membrane zone.

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Bupropion - 2

Answer 167

Its used for Major depression, ADHD, cigaret craving. It ma be used in conjunction with Nicotin patches, but such combination requires frequent BP monitering. It reduces weigh gain that comes with cigarett smoking. Although it might cause seizure, you dont stop the drug due to this rare SE, unless pt has a Hx of seizures. ***Pt has hx of epilespy and wants Bupropion, Dont give him Bupropion its CI for his Hx of epilepsy, give SSRI

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Burns

Answer 168

Tx of superficial and deep burns. * For inhalation injury which may take a few days to manifest, Dx is best done with bronchoscopy. For calculations only consider 2nd and 3rd degree burns. Kids: head=18, lower ext 27. **when circumferencial full thickness burns involving extremities or chest is present, Escharectomy maybe the best option.Parkland formula for ressecitation is 4ml/kg/ % of body burned, half in 8hrs and rest in 16hrs. ****Early excision therapy is indicated for extensive partial thickness and full thickness burns.mcc of death in burn pts in hospital is infection.Inhalation injury is commonin burn pts and may take several days to manifest. Dx is best done with a bronchoscopy. Beta agonists along with steroids, endotrachial intubation and antibiotics have all been used in pt with inhalation injury.**1st degree: confined to epidermis, erythomatous skin. Heals w/o scarring. Example is sun burn. 2nd degree:Involves entire epidermis, red and blisters. Its partial thickness burn. 3rd degree: is full thick ness burn, epidermis and ermis completey destroyed. Not painful. Debridment and grafting is required.

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Calcanium Fracture: Surgery 6/2

Answer 169

If due to fall, evaluate for other injury, plain film of head, neck, abdominal, lumbar & pelvic. Its associated with compression fracture of thoracic spine.

Question 170

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Cancer Drugs

Answer 170

1-Anorexia: doc for anorexia associated w cancer is Megesterol Acetate. 2-Nausea&Vomit: Metoclopropamide and ondansentron

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Carcinoid syndrome -3, 6/3

Answer 171

Triad of flushing, diarrhea and valvular heart disease. Its associated with carcinoid tumors and hepatic metastasis. Isolated tumors w/o metastasis do not produce carcinoid syndrome. These tumors produce serotonin. Elevated serotonin and its metabolite (5HIAA) are in plasma and urine. Tryptophan is the precursor of Serotonin . Tryptophan is the aa used in synthesis of Niacin. Pts of Carcinoid synd are at risk of Niacin deficiency due to increased formation of serotonin from tryptophan. As a result supply of tryptophan is decreased and 3 Ds of Niacin def (Diarhhea, dementia, dermatitis) of Pellagra develops. *Carcinoid tumor when symptomatic is in Small bowel, when asymptomatic its in Appendice.Triad of flushing,diarrhea and wheezing.

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Cardiac Contusion

Answer 172

Is associated with arrythmias, so the first thing to do if you suspect it, is Continues ECG NOT Echo.

Question 173

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Cardiac Temponade - 2

Answer 173

Characterized by 1-hypotension, 2-Sinus tachycardia. 3-Pulsus paradoxus. 4-Prominent JVD with ‘Y’ descent. US shows blood in pericardial sac. DDX is Medicastinal hemorrhage, which is the same as CT except that US shows no blood in pericardium and the blood is in mediastinum. It could happen in pts who are taking warfarin and cause coagulation abnormality.

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Cardiomyopathy, Dialated - 3

Answer 174

Characterized by 1-Impaired systolic function of left and right ventricle leading to progressive cardiac enlargement. 2-Cxr shows marked or moderate enlagemnt of cardiac silouette. 3-Echo shows systolic dysfunction and left ventricle dilatation with Normal wall thickness. Pt should refrain from drinking alcohol. Viral infection is the mcc of myocarditis that results in DCM, and the mc virus is Coxsackie virus. .**DCM is the end result of myocardial damage produced by toxic, infectious, or metabolic agents. Viral or idiopathic cause is mc by Coxsackie virus. The dx is by Echo, shows dilated ventrilces with diffuse hypokinesia resulting in low EF (systolic dysfunction and CHF). Concentric Hypertrophy is seen in Aortic stenosis. Eccentric in Valvular regurgitation. Hypokinesia is due to MI inferior wall. MS has Left atrial hypertrophy. HCM shows Asymetric vent septum hypertrophy.

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Cardiomyopathy, Hyper - 5

Answer 175

Characterized by 1-Asymetric left ventricular hypertrophy. 2-Harsh systolic Diamond shape murmur best heard at the left sternal border. 3-Cxr shows mild enlargement of cardiac silouette. 4-Echo shows vigorous systolic function, Asymetric septal hypertrophy and Systlic anterior motion of the mitral valve. 5-Due to hypertrophy of left ventricul there is Diastolic dysfunction. * Beta blockers are the tx of choice for isolated ventricular diastolic dysfunction. MERCK:Systolic murmurs are usually present, but patients with apical and symmetric hypertrophic cardiomyopathy may have no murmur. Most common is a crescendo-diminuendo ejection-type murmur that does not radiate to the neck; it is best heard at the left sternal edge in the 3rd or 4th intercostal space. This murmur is caused by obstruction of left ventricular ejection (produced in systole when the hypertrophied interventricular septum and the anterior leaflet of the mitral valve approach each other). A mitral regurgitation murmur due to distortion of the mitral apparatus is heard in some patients. It has a characteristic blowing quality and is best heard at the apex, radiating toward the left axilla. Rarely, early or midsystolic clicks are heard. In some patients with right ventricular outflow tract narrowing, a systolic ejection murmur is heard in the second interspace at the left sternal border. An S4, almost always present, indicates a forceful atrial contraction against a poorly compliant left ventricle in late diastole. Mitral regurgitation is as a result of anterior motion of the mitral valve leaflet. Mitral regurgitation in “Infective endocarditis” or “trauma” is caused by rupture of chordae tendinae. Mitral degeneration in “elderly women” can be caused by mitral annulus calcification. Mitral valve prolapse is the mcc for “isolated mitral trgurgitaion” in north america. * Echo is dx of choice, shows asymetrical ventricle septal hypertrophy. in 25% of HCM pt there is obstruction of LV ourflow tract (echo shows anterior motion of mitral valve) , becauseof this filling preffure is furthur elevated and out is compromised. This outflow gradient is incresed by manuvers that reduce cavity size of left ventricle. Valsava and standing after squatting, decrease LV Vol thus increasing the gradient and intensify the murmur. But Handgrip, increases systemic arterial resistence and so decreases gradient and the murmur. Leg elevation also decreases the murmur.because it increases LV vol. *To screen young athlets for HCM Echo is non sensitive. Do detailed personal,family Hx and PE.Tx for HCM is Beta blockers.**HCM is Auto DOMINANT. Pt is young, dyspnea on exertion, harsh diamond shape systolic murmur at the left lower sternal border.Echo shows Asymetrical septal hypertrophy.

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Cardiomyopathy, Restrictive - 4

Answer 176

Characterized by 1-Severe Diastolic dysfunction due to a stiff ventricular wall. 2-Echo shows symetrical thickening of the ventricular wall. 3-Kussmal sign. 4-Apical impluse palpable. DDX: Constrictive pericarditis no no 4, cxr shows calcification, and normal thickness of ventricular wall. Tx of most causes of RCM is useless except Hemochromatosis, Phlebotomy and Iron chelation with subcunatous defroxamine may result in substantial improvement.Since heart cant relax filling is compromised so both Liver and Lung are congested.***Xray shows mild cardiac slouette. Echo shows symetricly thickened vent wall and near normal systolic function. “Speckled Pattern” is specific for Amyliodosis .

Question 177

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Caroli Syndrome

Answer 177

Is a rare congetnital disorder characterized by intrahepatic dialatation of billiary tree, associated wi APKD.

Question 178

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Carotid Artery Stenosis & Endarterectomy

Answer 178

Asymp pt with 66-99% are considered for surgery, 100% is CI for surgery.

Question 179

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Carpal tunnel syndrome - 2

Answer 179

most likely location of pathologic process is the wrist. Pt presents with pain and burning sensation of the first three fingres and atrophy of thenar eminence, poor 2-point discrimination over the thumb, and they keep dropping things. Its seen in associated with RA, Myxedema, Sarcoidosis, amyloidosis and Leukemia. Most specific test is Nerve conduction study. Tinel test (tapping on Median nerve) Phalen test (90 degree flextion of both wrist and pushing them together dorsally), Carpel compression test (applying pressure over carpal tunnel) are not specific.

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Cat Bite - 2

Answer 180

Should be tx prophylacticaly with Amoxicillin/Calvulanate for 5 days, due to fear from Pasturela Multicoida.**1-Pasturella Multicoida, occurs after cat or dog bite, and there is an intense inflamatory reaction w/I 24 hrs of the bite. Pain, swelling, purulent discharge are features. 2-Bartonella Hensalae, occurs after cat scratch or bites. Clinical features occur after 3-10 DAYS. . They include papular or vesicular lesion, at the site of injury and proximal Lymphadenpathy.

Question 181

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Cat Scratch Disease

Answer 181

By Bartenella Hensalea. It most commonly presents with localized cutanous and lymph node disorder near the site of inioculation. A local skin lesion evolves through vesicular erythematous and papular phases, but can be postular or papular. Dx is by clinically and antibody to B. Hensale or a positive Warthin-Stary stain on the tissue specimen.Most people resolve gradualy w/o therapy. However, tender lymphadenopathy and systemic symptoms require five days of Azithromycin.

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Cataract congenital -2

Answer 182

Its due to progresively thickening of the lens. In “Congenital cataract” the retina CAN’T be visulized properly, exam reveals bilateral white reflex, the mcc of white reflex in the pediatric population is Congenital Cataract. Tx is extraction of the lens.

Question 183

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Caustic Poisoing - 2

Answer 183

Upper GI Endoscopy is the dx study of choice when a person comes in with ingestion of Alkali (oven cleaner) in the first 24 hr to assess the damage.

Question 184

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Cavernous sinus thrombosis

Answer 184

Presents with severe headache, followed by fever and periorbital edema. Also CN involvements in the form of opthalmoplegia, lateral gaze palsy, ptosis and dilated pupils. Nasal discharge and blood should be cultured. CT scans of the cavernous and air sinuses, orbit, and brain should be performed. Treatment with high-dose IV antibiotics, nafcillin or cefuroxime should be started, pending culture results. Surgical drainage of the infected air sinus may be indicated, especially if there is no response to the antibiotics in 24 h. The prognosis is grave; the mortality rate remains about 30%, despite antibiotic therapy. DDX:Orbital Cellulitis:Its unilateral, and more common in children. Presents w abrupt onset of fever, proptosis, restriction of extraocular movements and swollen red eyelids. there is NO CN dysfunction or visual disturbances in the early stages unless it spreads to cavernous sinus.Treatment with antibiotics, cephalexin should be started, pending culture results. Incision and drainage are indicated if suppuration is suspected or if the infection does not respond to antibiotics.

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Celiac dis - 2

Answer 185

Pt present swith malabsorption, loss of muscle or subcutanous fat, pallor due to iron def anemia, bone pain due to osteomalasia, easy bruising due to vitK def and Hyperkeratosis due to VitA def. Hay fatigue and weight loss. Dx is with ELISA for IgA antibodies to gliadin and immunoflorescence for IgA antibodies to endosomysium. ALso antibodies against rtansglutaminase. But CONFIRMATION is small intestine biopsy. **A 15mo old girl with dermatitis herpitiformis (erythematous vesicles symetrically distributed over the extensor surfaces of elbows and knees.) and chronic non-bloddy diarrhea with malabsorption (foul smelling stool) and distended stomach, is suggestive of CD.

Question 186

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Cellulitis - 2

Answer 186

Is an inflamation of skin that could extend into deeper tissues. In majority of pt is caused by Strep hemolytic or Staph aureus. Clinical symptoms can be Systemic as well as Local. Local findings are swelling, erythema, warm and tender and less well demarcated than Erysipela. The systemic signs are high grade fever chills and rigors, malise and confusion. When systemic signs are present IV Nafcilin or Cefazolin is preffered. ** The senario is usually a lady with painful leg DDX are:1-Cellulitis, high fever and chills. 2-DVT, cellulitis of calf is the one when there is high fever and no risk of DVT. 3-Necrotizing facitis is a deep seated cellulitis, suspect it in pt with bulla or crepitus. 4-Erysipelas, is a superficial cellulitis, it usually attacks cheeks, area is erythematous, painful and raised, with vesicles or bullae. No lymphangitis. 5-Erysipeloid is an edematous, purplish plaque with central clearing. Its caused by Erysipelothrix incidiosa. Usually at hands of fishermen and meat heandlers, its not as painful as cellulitis and there is no fever.

Question 187

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Central Cord Syndrome:

Answer 187

Characterized by burning pain and paralysis in the upper extremities with relative sparing of lower extremities. It is commonly seen in elderly 2ndary to forced hyperextension of the neck.

Question 188

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Central line complication:

Answer 188

Include pneumothorax, sesis and temponade occurs in 1-5% of pts. Cxy confirms that the tip is proximal to cardiac silhouette.

Question 189

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Central retinal Artery occulsion

Answer 189

Sudden painless loss of vision in one eye, however opthalmoscopy reveals pallor of the optic disk, cherry red fovea, cotton woolspots, retinal hemorrhages.

Question 190

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Central retinal Vein occulsion 2-

Answer 190

Sudden painless loss of vision in one eye, however opthalmoscopy reveals disk swelling venous dilation, tortuosity, retinal hemorrhage and cotton wool spots.

Question 191

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Cephalohematoma

Answer 191

Is a benign bleeding of newborn’s scalp. It’s a sub-periosteal hemorrhage. It shows like a swelling. No tx is necessary. DDX:Caput succedaneum is a diffuse and ecchymotic swelling of the scalp. It may extend across the midline

Question 192

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Cerebral Hemorrhage

Answer 192

If its due to excess warfarin (PT is icreased) then FFP reverses the effect.Pt on anticoagulants should be on INR measure check. So if 1-INR 9 DO stop warfarin and give oral VitK. Pts with serious intracranial bleeding cant wait for VitK, give them FFP right away to bring INR<1.5. Now to reverse Heparin give Protamine sulfate.

Question 193

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Cerebral infarction

Answer 193

Hypodense on CT ( white area over the cerebral surface).

Question 194

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Cervical cancer - 2.OBGYN 6.2

Answer 194

Risk factors: Young age at first coitus (<20). Young age at marriage and first pregnany. High parity, multiple sex partners, smoking, and low socioeconomic status. **If pap is dysplasia, perform colposcopy. If it shows inflamatory Atypia then repeat after 4-6 weeks. **If pt comes in with spotting, and you see the cervix having a gross lesion that bleeds by touching, dont even bother for PAP, go straight to Punch biopsy to rule out cancer. ** Once pt had the cancer check for cytology every year not every 2 year for normal people.

Question 195

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Cervical Spondylosis

Answer 195

It affects 10% of people >50. Hx of neck pain is typical. Osteophytes are the mc findings in cervical radiography in pt with CS. Bony spurs are the mc findings.

Question 196

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CGD

Answer 196

A defect of phagocytic cells Due to NADPH oxidase def. Leading to recurrent infection with catalase positive organism, Aureus, seratia, Klebsiela, Aspergillosis. Not suseptible to catalase neg (strep, influenza, Pyogenes). The MC clinical findings are lymphadenopathy, hypergamaglobolenemia, hepato and splenomegaly, anemia of chronic causse, short, gingavitis and dermatitis. NitroBlueTetrazolin is dx. Tx is prevention with trimeta-sulfa and Gamma interferone 3 times a week. BMT is curative. DDX1:Wiskot aldrich:Eczema,thrombocytopenia,recurent infection with encapsulted organism. Manifest at birth, petechia, bruises, circumcision bleeding, bloody stools. DDX2:Chediak Higashi, decreased granulation,chemotaxis and granulopoesis.Finding of neutropenia, ginat Lysosome in neutrophil will confirm Dx. Tx includes prevention with Trimeta-Slfa and daily ascorbic acid. DDX3:Jobs syn (Hyper IgE), chronic pruritic dermatitis, recurent staph infection, marked elevated IgE, eosinophilia and coarse facial features.

Question 197

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Chaga’s dis

Answer 197

Caused by insect borne Trypanosoma Cruzi which is a common form of carditis in Centerl and South America. Pt presetns with Cardiomegally, conduction anomalies. Almost all pts have a hx of Megacolon or Megaesophagus.

Question 198

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Chalazion

Answer 198

a small swelling(NODULE) of the eyelid. It results from obstruction of the glands in the eyelid. First try to cure it by putting hot compress on it if it comes back again and again then do histopathology. It often requires surgery. Recurrent chalazion requires histopathologic exam because there is a risk of underlying Squamous cell carcinoma. DDX Hordeulom(Stye). Occurs at the edge of the eyelid(pretty red)

Question 199

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CHD risk factors:

Answer 199

Age (men>45, Women>55. Family Hx of premature CAD (<35. HDL up to or equal to 60 negates one risk factor.

Question 200

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Risk factor LDL goal LSM Meds

Answer 200

CHD or Equiv =100 >=130

Question 201

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> or =2 =130 >=160

Answer 201

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Question 202

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0 or 1 =160 >=190

Answer 202

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Question 203

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Chediack Higashi:

Answer 203

Is a storage granulocyte abnormality resulting in hepatosplenomegaly, lymphadenopathy, anemia, thrombocytopenia, and susceptibility to infection in childood.

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CHF - 6

Answer 204

CHF is a common cause of Pleural Effusion. Pleural analysis is consistant with transudate effusion. The effusion caused as a result of systemic factors (CHF) is Transudate. The effusions caused as a result of local factors is Exudate effusion. Existence of at least one of the following indicates exudate, if non exist its a transudate. 1-Pleural/Serum Protein is >0.5, 2-Pleural/Serum LDH is >0.6. The determination of pH is important in parapneumonic effusion in which a value of 100 is dx for CHF. BNP is like ANP but BNP is released from Ventricles vs ANP from Atria.Also remember in CHF pt sodium is reabsorped in kidneys in response to renin-angiotensinogen -Aldosterone system, therefre sodium in urine would be low .**ACE inhibitors increase survival rate in CHF pts, so cosider it in a pt with E<40%. Also out of all diuretics, Spironolactone is the only one that improves survival. *** Drugs that improve survival are B-blocers, Spironolactone, ACE inhibitors (Captopril and Losartan), and Aspirin. Digoxin helps the situation but NOT survival.

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Choanal Atresia

Answer 205

Suspect it in a infant who presnts with cyanosis that is aggrevated by feeding and releived by crying. Failure to pass a cathater through the nose is sugestive of dx. Dx is confirmed by CT with intranasal contrast. The first step in mgmnt consist of placing an oral airway and lavage feeding. Definite tx is repairing the obstruction with surgery.

Question 206

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Cholecystitis, Acute - 3

Answer 206

MM-402. Dx stages: 1-USG(initial workup), 2-HIDA (very specific, for confirmation. Its particulary useful in dx of Acalculus cholecystitis). Triad of acute RUQ pain, fever and leukocytosis. Pain radiates to scapula. Billirubin is normal and Murphy (pain on deep inspiration) exist. Its most commnly 2ary to gallstones. , in these pts it mc due to impaction of stones in a cystic duct. The inflamatory response results from any of the following, 1-Mechanical(increased intraluminal pressure), 2-Chemical(release of tissue factors) 3-Bacteria(2ary to stasis), this occurs in 50-70% of cases. REMEMBER although in 50-70 of cases there is infection due to bactreia, but the cause for AC is mc due to impaction of the stone in cystic duct. If pt still has pain after cholecystectomy, and ERCP shows sphincter of Oddi dysfucntion, then ERCP with sphincterectomy is the procedure of choice.** After ERCP and shingterectomy, if pt has normal LFT and no dilation of biliary tree with US, then Oddi and CBD can be ruled out and pt is having FUNCTIONAL PAIN. Give analgesics and reassurance.** Acalculus Cholecystitis occurs in CRITICALLY ill pts and imagin studies show thickening of gall blader wall and presence of pericholesistic fluid. Etiology might be stasis of bile ducts and ISCHEMIA of the gall bladder (after accident with loss of blood).

Question 207

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Cholecystectomy: Hepatology, 6/2

Answer 207

Post cholecystectomy pain most commonly is due to either Common bile duct stone, Sphincter of oddi or Functional pain. If LFT is normal and no dilatation of biliary tree then its functional pain, tx is symptomatically with analgesics and assurance. If pt has abnormal Alkaline phosphatase and dialation of billiary tree on US, then we do ERCP to confirm and treat, by stone removal or sphincterectomy.

Question 208

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Choledochal Cyst

Answer 208

congenital abnormalities of the billiary tree characterized by dialation of intra and extra hepatic billiary ducts. Presentation vary with age. An infant presents with jaundice and passage of acholic stools. In children it causes abdominla pain, jaundice and attakcs of recurrent pancreatitis, which maybe evident by increase inamylase and lipase. Adults present with vague epigastric or RUQ pain or Cholangitis. Choledochal cyst could degenerate into cholangiocarcinoma. Initial investigation of choice is US followed by CT or MRI. DDX1:Caroli’s Synd, congenital disorder of intrahepatic dialation of bile ducts. DDX2:Biliary Atresia presents in infancy with marked obstructive jaundice and acholic stool.

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Cholelithiasis - 3

Answer 209

Tx: 1-Asymptomatic pt, leave it alone. 2-Symptomatic pt, if ok with surgery choice is Laparoscopic Cholesystectomy, if surgery is CI or pt declines surgery then Ursodeoxycholic acid 10 mg/kg/day reduces biliary secretion of cholesterol and decreases the cholesterol saturation of bile, resulting in gradual dissolution of cholesterol-containing stones in 30 to 40% of patients.**There are 3 types: 1-Cholestrol, 2-Pigment stones(mostly calcium bilirubinate, 20%) and 3-Mixed stones. Water insoluble cholestrol is secreted in bile where its converted into soluble miscles by bile acids and phospholipids. If too much cholestrol and too little bile then cholestrol crystals precipitate. Predisposing factors are Fat,Femlae,Forty,Fertile(OCP), cloFibrate. Remember 80% of stones are radiolucent so xray cant see them.

Question 210

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Cholesteatoma, ENT 6/2

Answer 210

Causes acquired conducting hearing loss in CHILDREN .Its not a tumor. Its an Epithelial Cyst that contain desqumated Keratin. It could be acquired secondary to Otitis media or Eustachian tube dysfunction. Infection is usally due to Pseudomona. Pt presnts with recurrent infection. MC sign is drainage and granulation tissue and debris unresponsive to antibiotics & marginal tympanic perforation. They destroy bone. CT can detect defected bone. Tx is surgical removal. DDX Chronic Otitis media where there is no debris and granulation.

Question 211

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Cholesterol embolizarion

Answer 211

Or Atheroembolic disease, follows surgical or manipulation of arterial tree ( ie Angiography), due to showering of cholesterol from aorta or other major arteries. Its mc seen in elderly pt with evidence of diffused Atherosclerotic dis.. Renal failure, Livedo reticularis, sstemic eosinophilia, and low complement levels, should ake you think of this. Tx is conservative, antocoags should be stoppedsince it may prevent healing of the ruptures Plaque. Physical exam shows painless, redish blue mottling of the skin of the extremities.

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Cholesterol lipid profile - 3

Answer 212

For CHILDREN the recommendation is: A child with a parental hx of elavated total cholesterol (>240mg/dl) or a chld with risk factors for CAD should be screened for total cholesterol level. If its >200mg/dl then we do a fasting lipid profile test. For screening we use HDL and Total Cholesterol. For Tx guidelines we use LDL levels.

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Cholestyramine:

Answer 213

A bile acid sequesterant that lowers LDL and mostly increase HDL when combined with statin. In addition to binding bile acids in gut it also binds other drugs and reduces their bioavailibility so the pt needs higher doses ( ex hypothyrism )

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Chorioamnionitis

Answer 214

Pts present with fever >38, uterine tenderness, irritability, elevated WBC and fetal tachycardia.Its associated with preterm or prolonged rupture of membrane. Fetal tachy could also be caused by Beta-2 agonist for tocolysis. Elevation of WBC could also be caused by steriods admin. Amniotic fluid cultures are gold for Dx (Nitrazine paper test). Once Dx is established samples are taken for culture and then Ampicciline and Gentamcin are given. Labor should be induced. If cervix is unfavorable C-section is done.

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Choriocarcinoma

Answer 215

It’s a malignant tumor of the trophoblastic tissue. Clasically prestns w Hemoptosis, but it could also present with shortness of breath and chest pain. In any postpartum female you should suspect Choriocanrinoma. Quantitative Beta HCG is important in Dx. So once you have postpartum woman with hemoptosis chest pain and shortness of breath then we need to do Cxr, pelvic exam and BetaHCG.

Question 216

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Chronic Liver Disease

Answer 216

Do Merck. Associated with respiratory alkolosis.

Question 217

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Chronic Mesenteric Ischemia

Answer 217

suspect it in pt with chronic abdominal crampy pain, weight loss and people who don’t eat food because of pain and other malabsorptive symptoms. Evidence of Atherosclerotic dis is present. Abdominla exam might reveal bruit in 50% of pts. Dx needs angiography and Doppler US.

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Chronic renal failure - 2

Answer 218

Secondary hyperparathyroidism with resultant renal osteodystrophy (loose calcium and retain phosphate) is almost universal in CRF.**Normochromic normocytic anemia due to eryhtropoetin def is a very common I pt with End Stage Renal Failure. Recombinant Eryhtropoetin is the tx of choice, however, Iron supplemnt should be given BEFORE erythropeitin. All Chronic Renal Failre pts hct3-3.5 mg/dl.

Question 219

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Churg Strauss

Answer 219

A20. MERCK:Its one of the group of diseases of known or unknown etiology characterized by eosinophilic pulmonary infiltrates and, commonly, peripheral blood eosinophilia.allergic granulomatosis (Churg-Strauss syndrome), a variant of polyarteritis nodosa with a predilection for the lungs.

Question 220

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Circumstantiality

Answer 220

is a thought disorder that answers in un-necassary details that deviate form the topic but eventually goes back to the topic. DDX is Tangentiality which is an abrupt permanent deviation from the topic. DDX2:Loose associated which there is no associated b/w sentences.

Question 221

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Cirrhosis - 3

Answer 221

Could happen 2ary to alcoholism. Pt has ascites, and esophageal varices 2ary to portal hypertension. Prophylactic tx of pt wth large varices who have never bled with propranolol significantly decrese the risk of futur bleeding. In a pt with refractory ascites , refractory hydrothorax, and recurrent variceal bleeding, TIPS (Transjugular Intrahepatic Portosystemic Shunt). is used.Alcoholism is the mcc of cirrhosis in US. 33% alcoholics, 10% HBV, 20-30% HCV(the mcc of liver transplant in US).*Pts with cirrhosismay have upper GI bleding due to : Erosve gastritis, PUD, Mallory-Weiss tear. Sclerotherapy isindicated for first varices, but not prophylactically. For PUD do consertavie mngmnt, if that didnt work then we do surgey, Excision of ulcer and vagotomy and pyloroplasty.

Question 222

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Clavicle Fracture

Answer 222

In bew borns it presents with irregularity,crepitus and fulness over the fracture site and decreased movemnt of the arm. Predisposing factors ar shoulder dystonia, traumatic delivery, large infant. No tx is needed.*For Adults do a figure of 8 bandage. **Clavicle fractures that are displaced can damage subclavian artery, Artriogram is needed to rule out injury. Next step would be nerve donduction studies to rule out Brachial plxes injury. If fracture is in distal third then may require open reduction and internal fixation. Proximal and middle third are treated with closed reduction and figure of eight brace.

Question 223

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CLL (Chronic Lymphocytic Leukemia - 3

Answer 223

MC Leukemia in Western countries. In older pts. Mostly asymptomatic and discovered accidentaly. Smudge cells. In general don’t need to do lympb node biopsy to confirm dx, but if you want to a highly specific biospy is available to confirm dx. DDX:CML, presents with LEUKOcytosis with left shift Imyelocytes, neutrophils) not LYMPHOcytosis.Smodge cells (leukocytes that break down because of theri greater fragility) are charcteristic. Staging is directly related to prognosis, stage 0= Lymphocytosis only, Good; StageI=Lymphocytosis+Adenopathy, Fair; StageII=Splenomegally present, Fair; StageIII=Anemia present, Intermediate; StageIV=Thrombocytopenia,Poor. Mean survival is 8-10 years.*****To CONFIRM dx do lymph node biopsy.

Question 224

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Clomiphene Citrate

Answer 224

Is an antiestrogen acts by competitive blocking of receptors of hypothalamous, inhibiting the negative feedback that estrogenhas on GnRH and consequently insreasing Lh & FSH and improving ovulation. Along with hMg and hCG itsindicated for chronic ovulation. SE are hot flashes, breast discomfort, spotting. DANAZOL is an androgen derivative that has gonadotropin inhibitory effect . Its indicated in Endometriosis, Fibroids and Fibrocystic breast disease.

Question 225

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Clonazepam toxicity

Answer 225

Clonazepam is used for insomnia. In elderly pt it could cause memory disruption. The next step in mngmt is to discountinue it.

Question 226

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Clozapine se

Answer 226

Agranulocytsis.

Question 227

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Club foot

Answer 227

Or Talipus Equinovarus. Calcaneum and talus are in equines and varus position. Initial mgmnt involves non-surgical methods (stretching and manipulation of the foot, followed by serial plaster casts, splint or taping). Surgical tx is indicated if that didn’t work , its performed b/w 3 and 6 month of age.

Question 228

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Cluster headache - 2

Answer 228

Tx for acute attack is 100% oxygen & subcutaneous Sumatriptan. *Presents with acute , sever retroorbital pain that wakes pt up at night. Maybe accompanied with redness of ipsilateral eye, tearing , runny nose, and Ispilateral HORNER synd (Ptosis, Myosis, Anhydrosis). Prophylaxis is key to mgmt, with verapamil, lithium and ergotamine.

Question 229

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CML

Answer 229

There is increased mature granulocytes like segmented neutrophils and band forms. BM shows hypercellularity with prominent granlocyte hyperplasia. When pt is in Crisis phase, IMATINIB is DOC. It’s a tyrosine kinase inhibitor that block signals w/I cancer cells. SE are mild naseau, diarrhea, leg cramps and swelling of the face and itchy rash. It has chenged the prognosis with CML.

Question 230

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CMV Pneumonitis

Answer 230

Is seen in 15-20% of Bone Marrow Transplants with case fertality of 84-88%. Pt presents with dypnea, cough and fever. Cxr shows multifocal diffused pathy infiltrates, and ground glass attenuation, parenchymal opacification or multiple small nodules on high res CT. BAL is dx in most cases. IT IS NOT SEEN IN IMMEDAITE post transplant period, wich is DDX with bacterial and fungus pneumonitis. PCP is also seen in immediate post transplant but its occurance has decreased dramatically due to routine prophylactic use of tri.sulfa in pre-transplant period.

Question 231

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Coarcation of Aorta

Answer 231

Present with rib notching (the 3 sign). HA is a presenting sign. Hay HT in upper extremity. Cxr shows dilatated ascending aorta and subvlavian artery. Indentation of aorta at site of coarcation and pre and post stenting dilation is called the ‘3’ sign.

Question 232

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Cocaine Tox - 3

Answer 232

Pt presents with EKG abnormality of st depresion (ischemia and infarction), HT and excrutiating chest pain. Tx is Benzodiazepine, Nitrate and aspirine.If pt has MI then first line is Cathaterization. **Fetuses exposed to cocain abuse exhibit intracranial hemorhage., nerotizing enterocolitis and cardaic defets and GU malformations. **Could cause MI due to causing vasospasm, threre is blood in narises and dilated pupils . He has no risk for MI and is only 27.

Question 233

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Coccidiomycosis

Answer 233

Is endemic in California Arizona and new mexico and texas. Primary Pulmonary infection has non-specific features life fever, fatigue, dry cough weight loss. Cutaneous Erythem multiform and erythema nodosum anf arthralgias might be. Blastomycosis cutaneous dis is verrucous or ulcerative.

Question 234

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Colon Cancer

Answer 234

FOBT is the mc used screening test for colon cancer. Pts should be followed with colonoscopy.

Question 235

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Colorectal Cancer

Answer 235

MC presenting symptom is bleeding!

Question 236

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Communicable dis

Answer 236

If pt’s dis could harm others he should be tx against his will. Senario is a man with Meningitidis and fever 104 for 2 days who wants to be tx at home. Answer is treat him in hospital agains his will since he will be harmful to others at home.

Question 237

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Compartment Synd Dx is made clinically with pallor, pain, pulselesness, paralysis and paresthesia. PAIN on passive extension of fingers is the most sensitive marker of CS. Pain is persistant,progressive, unrelieved with imobilization and out of proportion to initial injury. CS is cused by increased pressure w/i an anatomical space.

Answer 237

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Question 238

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Complex Patial Seizure

Answer 238

Breif episodes of impared consiousness, failure to respond to varius stimuli, staring spells, AUTOMATISM( Lip smacking, swollowing), and post-ictal confusion. EEG is usually normal. DDX1,Typical Absence seizure might have lip smalcking but they have n post-ictal confusion.

Question 239

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Conduct disorder

Answer 239

Charcterized by disruptive behavior that violate basic social norms for at least one year in pt <18 yo. Like stealing, setting fire, fighting, animla abuse. DDX is Antisocial disorder is when these boys become adults.

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Congenital Adrenal Hyperplasia- 2

Answer 240

Hyponatremia, HyperKalemia, Hypoglycemia, and metabolic acidosis. Its due to 21-Hydroxylase deficiency. Its auto recessive. Deficiency of both glucocorticoids and mineralocorticoids. Male infants will NOT have ambigous external genitalia unlike female infants, thats why male infants go on un-noticed until 2-4 weeks when they present with salt wasting. Treatment of 21-hydroxylase deficiency is with glucocorticoid replacement. *****Adolescent onset of hirsutism and virilism with normal mensturationand elevated 17-OH Progesterone.

Question 241

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Congenital Diaphragmetic Hernia:

Answer 241

In all emergency cases remember TX supercedes Diagnosis. The 1st step if oyu suspect CDH is to place orogastric tube and connecting it to a continues suction in order to prevent bowel distension and further lung compression. Bag-and-mask is to be avoided because this can cuase the stomach and intestine to become distended with air, further compromising lung funx.

Question 242

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Congenital heart defects

Answer 242

1-TOF: VSD. 2-Down: Endocardial cushing defect. Also ASD ( L to R shunt). 3-Turner synd:Coasrcation of aorta. 4-Congenital rubella: PDA.

Question 243

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Congenital Hypothyroidism:

Answer 243

The mcc is thyroid dysgenesis, 85% of cases. Infant has apathy, , weakness, hypotonia, constipated, sleeps a lot, large tongue, umbilical hernia. Screening is by T4 and TSH levels, Tx is Levothyroxine

Question 244

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Congenital Rubella;

Answer 244

Triad of sensorineural deafness + Cardiac malformation (PDA & ASD) + Cataracts. There could also be thrombocytopenia and purpule skin lesions ( Blueberry muffin spots). If transmission occurs in first 4 week of pregnancy the risk of developing CR is 50%, it drops to 1% in third trimester. The child might show symptoms when he is 2 years old.

Question 245

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Congenital Toxoplasmosis:

Answer 245

Triad of Chrioretintis + Hydrocephalus + Intracranial calcification. Look for pet in the picture somewhere.

Question 246

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Conjunctivitis, Neonatal - 2

Answer 246

Hay 3 causes for NC in US. 1-Chemical is the mc of the red eye presents at 1st 24hr of life. About 80% who receive prophylaxis w silver nitrate (to prevent gonococcal) experience mild conjuncitivis and tearing that resolves w/I 24 hrs. 2-Gonococcal: is acquired through contact with infected vaginal secretions, it occurs 2-5 days after birth, it presents as Copious purulent eye discharge with swellen eyelids & Chemosis(conjunctival edema), dx is by obtaining a smear and culture of the discharge, tx is a single intramuscular dose of ceftriaxone. 3-Chlamydia:Trachoma,presents with mild hyperemia and scant mucoid eye discharge and pannus (neovascularization) formation, it occurs b/w 5-14 after birth. TX is Systemic Erythromycin to decrease risk for Chlamydial pneumonia.

Question 247

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Constrictive Pericarditis. - 2

Answer 247

Associated with TB in immigrants.Etiology could be early TB in life. The early third hear sound, called Pericardial knock and the respiratory increase in JVD (Kussmal sign) are important findings. Kusmaul is also present in right side hear failure, sever tricuspic regurgitation ,RV infarction and cardiac temponade. **CP will lead to inability of ventricles to fill during diastole and would furthur cause the signs of decreased cardiac output (fatigue) and signs of venous overload like JVD, dyspnea, ascites, Kussmaul, pedal edema tender hepatomegaly. Sharp ‘x’ and ‘y’ descent on central venous tracing is the sign of CP as is Pericardial Knock (early sound after S2).

Question 248

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Contraception

Answer 248

Lactation is a contraceptive methid in itself because prolactin inhibits GnRH thus preventing ovulation. However, it is not a reliable methis. If a woman wants contraception right after giving birth, give her Minipill (Progestin only pills), Don’t give her Combined OCP because Estrogen may cause decrease in milk production.

Question 249

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Conversion disorder - 2

Answer 249

Tx is psychotherapy. Pt looses eye site in stressful situation. *** If pt comes with bilateral leg paresis, give him Sodium Amytal and he will dramatically improves.

Question 250

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COPD - 8

Answer 250

If pt is not crashing, the first line of tx is non-invasive positive pressure ventilation before intubation. All pt with PaO255 should be started with home therapy if PaO2 falls <90%.* chronic pt comes in with severe sypnea and confusion and profuse sweating. Cxr shows complete collpase of L lung, possibly by a mucus plug (atelectasis is the same after surgery). Tx is emergency Bronchopscopt to remove the plug. And that will improve PaO2.***Non Invasive Positive Pressure Ventillation is the best option for pts with COPD exacerbation. It should be tried before intubation and mechanical ventilation in COPD pts with CO2 retention.

Question 251

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Core Pulmonale

Answer 251

Combination of Elevated JVP, Hepatomegaly,ascites, and lower extremity edema w/o evidence of pulmonary congestion is suggestive of isolated right heart failure. If there are no RALES it means there is no pulmonary congestion. The mcc of Right side heart failure is Pulmonary disease, and its known as Core Pulmonale. CP is most likely caused by COPD(Smoker) , lees common causes are pneumoconiosis, pulmonary fibrosis.

Question 252

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Court order T9Q38

Answer 252

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Question 253

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Craniopharyngioma - 2

Answer 253

Althought mc in children, they are bimodal and could happen in adults too. In children retarded growth is the mc presentation. In adults hyposexuality. Bitemporal blindness is a classic sign. Dx is MRI or CT. Tx is surgery or radiothreapy.**A young boy with symptoms of increased ICP (HA,Vomit) , Bitemporal anopsia and a calcified lesion above sella has Craniopharygioma until proven otherwise. Presense of a Cystic Calcified parasellar lesion on MRI is almost Dx. DDX is Pituitary Adenoma, where its more frequent in women and Prolactinoma is an important part of it, and there is no CALCIFICATION of the gland.

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CREST Synd - 2

Answer 254

Anticentromere antibody is Dx.*****Calcinosis, Reynauds, Esophageal dysfunction, Sclerodactyly and Telangiectasia. It has a better prognosis than diffused Scleroderma.

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Creutzfeldt-Jacob - 2

Answer 255

Pt is b/w 50-70, with rapidly progresive dementia, myoclonic and periodic synchronous bi or triphasic sharp wave complex on EEG.Brain biopsy shows cortical spongiform changes. CSF is normal, Death w/I 12 months, NO TX. Spongiform encephalopathy is caused by prion.

Question 256

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Crohn’s disease - 2

Answer 256

DDX with UC is non-caseating granulomas.

Question 257

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Croup

Answer 257

Also known as Laryngotrachiatis or LaryngoTrachioBronchitis, is characterized by laryngeal inflammation that results in hoarseness, a barking cough and respiratory distress. Typical pt is <3 and the mcc is Parainfluenza virus. Dx is clinical and lateral xray shows subglotial narrowing. Always give Epinephrine before any invasive tx like intubation. This is ONLY for croup not Epigolitis. Tx is 1st O2, 2nd Epi, 3rd intubate in ER.

Question 258

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Cushing’s Syndrme - 3

Answer 258

Due to ectopic ACTH.***Pt with lung cancer and ectopic ACTH production can have Cushing’s. **Dx procedure.

Question 259

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Cutaneous Larava Migrans

Answer 259

Is a cc of dermatological disease in tropical travelers. Its caused while “Sand box handling” and its characterized by serpiginous lesion in the skin. Tx is Applying thiabendazole or mebendazole

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CVA

Answer 260

Occurs in middle and late years of life. Could be either Ishcemic (85%) or Hemorrhagic (15%). Ischemic CVA orignates from aortic arch, carotid bifurcation, and obstruct arteries. Clinically atherothrombotic stroke occurs at rest and have a gradual onset. Pt experiecne successive strokes. Babinsky indicates UMN due to major cerebral artery obstruction. Ischemic CVA could also be caused by thrombi from left heartIts associated with sudden onset and preexisting cardiac disease. EKG is characteristic. The mc site islaterl astriae arteries (arteries of stroke) which are branches of MCA, they supplt internal capsule,putamen. So if a pt has normal EKG and cardiac enzyme, this kind of stroke is unlikely.

Question 261

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Cyclical vomitting

Answer 261

recurrent self-limiting episodes of vomitting and nausea in children. Tx is antiemetis and reassurance.

Question 262

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Cyclosporine side effects

Answer 262

1-Nephrotoxicity:the mc and serious side effect. It manifest as acute azothemia or irreversible progressive renal disease. 2-Hypertension:due to vasoconstriction and sodium retension. Ca chanel blokers are doc. 3-Neurotoxicity:Often reversible. Tremor, headache, nasea, seizure, visual problems. 4-Glucose intolerance. 5-Infection: 40% of pt get infection chronically. 6-Malignany: Risk of squamous cell carcinoma. 7- Gingival hypertrophy and hirsutism. 8-GI, mild. Tacrolimus has the same se except hirsutism and gum hypertrophy. Azothioprine se is dose related diarrhea, leukopenia,hepatotoxicity. Mycophenolate se is Marrow suppression.

Question 263

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Cyclphosphamide SE

Answer 263

Bladder carcinoma is a SE. Also alopecia, sterlity, amenorrhea, acute hemorrhagic cystitis.

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Cystic Fibrosis - 8

Answer 264

Bronchiectasis due to pseudomona and infertility and recurrent respiratory infections. Cxr showing “Tram Track pattern” and opacities is dx for Bronchiectasis. CF is due to abnormal chloride transportation in all exocrine glands. Sweat chloride concentration >60 is DX. Since there is fat malabsorption, fat soluble vitamins are deficient. So vit K is deficient and since vit K is a cofactor for the enzyme gama-glutamil carboxylase which adds carboxyl group to glutamate residue of factor II,VII,IX & X, and protein C & S, those coagulation factors will be also deficient.A routine influenza vaccine is indicated in all CF pts, but not Pneumococcus vaccine. There is associated b/w Pseudomona pneumonia and CF, use Gentamycin+Pipercilline. **Tx of an acute severe exacerbation of lung dis in CF is IV Pen/Cephalo+Gentamycin. **Aut rececive, we need to know both parents DNA status to determine child’s possibility of having CF. **The mc mutation is a DELETION of a three base pair coding for Phenylalanine (DjO8) in the CFTR gene in CH7.Pts with CF present with Meconium Ileus characterized by bilious vomiting, failure to pass meconium at birth, and ground glass apperance on abdominla xray.***Suspect it in a pt with Bronchiectasis(cough productive of sputum for 3 months) and Malabsorption (foulsmelling stool) due to pancreatic insufficeny. One clue if the pt starts to show in his 20s is a hx of Meconium Ilueus (intestinal obstruction) as a neonate. Whenever hay acute exacerbation of pulmonary infection in a pt with CF, think Pseudomona and treat it with Pipercillin + Gentamycin.

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Cystinuria:

Answer 265

An inherited disease causing recurrent renal stone formation. Look for positive family history and stones since childhood. Stones are radiopaque and Hexagonal. The urinary cyanide nitropruside test is a screening procedure.

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Cystitis - 2

Answer 266

Most commonly caused by Ascending infection. Pt presents with UTI symptoms and suprapubic tenderness.** In an Uncomplicated Cystitis, where pt presents with suprapubic discomfort and signs of UTI, then there is NO need to do culture. Just give Oral Trimeta-Sulfa. If there is resistance to it then give Cipro or Nitrofurantoin.

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Dacryocyctitis

Answer 267

Inflamatory changes in medial canthal region. Staph aureus and Strep are common causes. Acute dacryocystitis is treated by frequent application of hot compresses; cephalexin or cefazolin; and incision and drainage if an abscess has formed. Chronic dacryocystitis may be treated by dilating the nasolacrimal duct

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De Quervains Tendonitis

Answer 268

abductor or extensor tendons of the thumb) is usually diagnosed by localized tenderness, if not mild swelling, along the course of the tendon .Sharp pain is elicited or accentuated when the ipsilateral thumb is flexed across the palm, enclosed by the fingers, and the wrist is deviated ulnarly to stretch the tendons and surrounding sheath (Finkelstein’s sign in stenosing tenosynovitis). Symptomatic relief is provided by rest or immobilization (splint or cast) of the tendon, application of heat for chronic inflammation or cold for acute inflammation (whichever benefits the patient should be used),and NSAIDs.Surgery for release of fibro-osseous tunnels.

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Dehydration - 2

Answer 269

Mainstay of tx is IV sodium containing crystaloids (0.9% NaCl=Normal Saline)***Elderly pts are sensitive to dehydraion and even mild Hypovolemia can lead to orthostatic syncope, especially upon getting up in the morning. INCREASED BUN/Creatinin is a good indicator of dehydration.

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Delirium Tremors

Answer 270

Tx is Chlordiazepoxide.

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Delirium vs Dementia

Answer 271

Delirium has:Acutenes, impaired conciousness, fluctuating course, reversible symptoms and global memory impairment. In the absence of any focal neurological signs, even if there is evidence of carotic bruit (Vascular Dementia) Delirium is the most like Dx.

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Delusional Grandiosity

Answer 272

Pt thinks she has special powers, extraordinary accomplishments, or specila relationship with God. There are three types of Delusion: 1-Grandiose (religious in nature) 2-Paranoid 3-Somatic.

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Dependant personality

Answer 273

When ot is so agreeing and depends on whatever the doctor suggests.

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Dermatitis Herpetiformis-3. Dermo. 6/3

Answer 274

Pruritic papules, vesicles over the knee, elbow, buttocks. Immunofloresence shows granular IgA desposits along dermal papillae. Associated w Celiac sprue. Tx is Dapsone. Suspect DH in a pt with Malabeosrtion and pruritic papules and vesicels over the extensor surfaces. Anti-Endomysial anribodies are charcteristic. Pt also suffers from Gluten sensitive enteropathy or Celiac Sprue. Tx:Strict adherence to a gluten-free diet for prolonged periods (eg, 6 to 12 mo) may control the disease in some patients, or Dapsone.

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Dermatomyocytis:

Answer 275

Is an autoimmune disorder involving muscles and the skin. Skin eruption is dusty red in color. Edema around the eye and the helitrope rash of the eyelid are more specific. Gottron’s sign is highly suggestive of this disorder in which skin over the back of knuckles show non-scaly violacious erythomatous eruption.

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DES toxicity

Answer 276

If given to pregnant women causesClear cell ADENOCARCINOMA of vagina in their duaghters. In the old days it was the best tx for threatened abortion. With erly dx and tx survival is 80%.

Question 277

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Development Dysplasia of Hip

Answer 277

DDH is characterized by subluxatable and dislocatable proximal femur and acetabulum. Early dx and tx is important because failure will result in sigificant morbidity. On inspection uneven gloteal fold are seen. Its mc in femlae cockasian females. Dx is confirmed by USG in infants <6mo. Positive Barlow and ortolani are highly suggestive. Tx is surgical reduction.

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Developmental Milstones

Answer 278

1-LANGUAGE:Social smile=2mo, Bables=6mo, 2words and obey one step command=12mo, 2-3Phrase& 2 step command=2yr. 2-GROSS MOTOR: Hold head=3mo, Rolls back to front=4mo, sits unsuported=6mo, walks alone=12mo, walks staris=2y. 3-FINE MOTOR: Raking Grasp=6mo, Throw objest=12mo, Build tower of 2 block=15mo, build 6 blocks=2yr. 4-SOCIAL: Recognize parents=2mo. Recognize strangers=6mo, Imitates/comes when called=12mo, play with other kids=18mo, Pararel play=2yr.

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Dextrometorphan- Poisenining 6/3

Answer 279

A cough medicine. has drung toxicity with MAO inhibiors, causes hyperthermia

Question 280

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Diagnostic Peritoneal Lavage

Answer 280

Is the best dx procedure for intraperitoneal organ laceration. Like a guy being hit in the stomach. Angiography is never done.

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Diabetes Incipidus - 3

Answer 281

Presents with polyuria and polydypsia, due to ADH def or resistance. Pt prefer cold beverages and their urine osmolarity is < serum osmolarity. Pts pass excessive amounts of diluted urine. Normal saline is the initial fluid of choice in hypotensive pt and later on Hypotonic fluids. DDX1:Primary hyperaldosteronism (aldosterone=saves sodium and loses K), Hypernatremia is rarely symptomatic, other features are hypertension & hypoKalemia. DDX2:Osmotic Diuresis(increase renal excretion of water relative to sodium), occurs in cases of hyperglycemia and manitol intake. Urine osmolarity is > serum osm. DDX3:SIADH, results in hyponatremia, low serum osmolarity and inapropriately high urine osmolarity. sually seen in pt with lung cancer and abnormal brain pathology like trauma or stroke. DDX4:Primary polydypsia, is a disorder where pt drinks fluid in excess of 5L/day and both plasma and urine osmolarity are low (diluted).**Administration of DDAVP (desmopressin) ddx b/w CDI and NDI. Pt with CDI will have increase of urine osmolarity following admin of AVP (arginin Vaso Pressin, or DDAVP), but NDI pt wont have that increase. Tx for CDI is intranasal Desmopresin.

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Diabetis Melitus - 34

Answer 282

1-Normal anion gap metabolic acidosis in a diabetic pt with Gastroenteritis could be either due to loss of bicarbonate due to diarrhea, or defective NH4 sunthesis due to nephropathy. So next we need to calculate urine anion gap. [Urinary (Na+K) - Urinary Cl]. If its positive value problem is Nephropahy, if its a negative value its due to Gastroenteritis. 2-Diabetic Osteomyelitis (due to arterial insufficiency) that involves bone adjasent to the foot ulcers is explained by contigous spread of infection. 3-Acanthosis nigrans is a complication of DM. Although its associatedciated with both DM and Addison’s disease insulin resistance is the mcc in young population, and its associated with malignany in older individuals. 4-Somogi effect. 5-Diabetic neuropathy tx is Gabapentin and TCA (imipramine). 6-Diabetic Cystpathy tx is Bethanechol. 7-Diabetic retinopathy. 8-Infection in diabetes. 9- Diabetic Nephropathy, detection of microalbunemia is the best detection. Fasting blodd glucose is now test of choice for screening high risk individual for DM. When fasting G is 126 or greater, repeat it, and if its still elevated the Dx is made. Dx could also be made if pt is SYMPTOMATIC and G after 75gr tolerance test its 200 or greater. Ketones responsible for DKA are Acetone, acetoacetate and beta hydroxy butyrate. Diabetic Neuropathy leads to denervation of bladder resulting in urinary retention, Overflow incontinence day and night, aside from strict glucose control tx includes intermittent cathaterizarion and Bethanechol, avoiding alcohol maybe helpful. ** Antibiotics dont cure ulcers, do a debriment of the wound. **Glomerular Hyperfiltration is the earliest renal abnormality seen, as early as several days w/i dx of DM. Its the major pathophysiologic mechanism of glomerular injury in these pts. Thickening of the glomerular basement membrane is the first change that can be quantified. Effectiveness of ACE inhibitors is related to their ability to reduce intraglomerular hypertension and decrease glomerular dam

Question 283

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Diabetis Melitus - 34

Answer 283

1-Normal anion gap metabolic acidosis in a diabetic pt with Gastroenteritis could be either due to loss of bicarbonate due to diarrhea, or defective NH4 sunthesis due to nephropathy. So next we need to calculate urine anion gap. [Urinary (Na+K) - Urinary Cl]. If its positive value problem is Nephropahy, if its a negative value its due to Gastroenteritis. 2-Diabetic Osteomyelitis (due to arterial insufficiency) that involves bone adjasent to the foot ulcers is explained by contigous spread of infection. 3-Acanthosis nigrans is a complication of DM. Although its associatedciated with both DM and Addison’s disease insulin resistance is the mcc in young population, and its associated with malignany in older individuals. 4-Somogi effect. 5-Diabetic neuropathy tx is Gabapentin and TCA (imipramine). 6-Diabetic Cystpathy tx is Bethanechol. 7-Diabetic retinopathy. 8-Infection in diabetes. 9- Diabetic Nephropathy, detection of microalbunemia is the best detection. Fasting blodd glucose is now test of choice for screening high risk individual for DM. When fasting G is 126 or greater, repeat it, and if its still elevated the Dx is made. Dx could also be made if pt is SYMPTOMATIC and G after 75gr tolerance test its 200 or greater. Ketones responsible for DKA are Acetone, acetoacetate and beta hydroxy butyrate. Diabetic Neuropathy leads to denervation of bladder resulting in urinary retention, Overflow incontinence day and night, aside from strict glucose control tx includes intermittent cathaterizarion and Bethanechol, avoiding alcohol maybe helpful. ** Antibiotics dont cure ulcers, do a debriment of the wound. **Glomerular Hyperfiltration is the earliest renal abnormality seen, as early as several days w/i dx of DM. Its the major pathophysiologic mechanism of glomerular injury in these pts. Thickening of the glomerular basement membrane is the first change that can be quantified. Effectiveness of ACE inhibitors is related to their ability to reduce intraglomerular hypertension and decrease glomerular damage. ** In pt with Diabetic Nephropathy add ACE inhiitor even if BP is under control, it slows progression of nephropathy and keeps glomerualar bp reduced. **Glycosylated Hemoglobin (HbA 1-c) is the best way to monitor DM control. HbA1c is fomred by non-enzymatic glycation of Hb. Its reflective of the average glucose blood levels w/i the precedding 2-3 months, which corresponds tothe life of RBC. Every 1% increase in HbA1c correspodes to 35mg increase in glucose. Remember measurement of C-peptide is done to determine if the insulin use is internal or external. DIABETIC KETOACIDOSIS:Anion Gap Metabolic Acidosis observed during DK is accompanied by HyperKalemia, its called paradoxial because body K reserves are actually depleted. Hay hyperKalemia for 2 reasons: 1-extracellular shift of K in exchange for H with resultant intracellular K depletion. 2-Impaired insulin-dependant K entry. So in Tx for DKA, after insulin and diuresis administer K. **Suspect it if pt presents with rapid breathing, hx of weight loss, polydipsia nd polyuria.END OF KA. **Fasting bloog glucose measurement is now the screening of choice. A FBG of 126 or more on two occasiona is Dx. FBG b/w 100-125 is categorized as impaired FBG or pre-DM. If pt has symptoms, poluuria, polydyspsia, and obesity FBG of >200 may confirm the dx but its not appropriate for screening. The 50gr glocose tolerance test is used for screening gestational DM, while 100gr is used to confirm it.DM Neuropathy seen in 50% of pts. Pt manifest with poplyneuopathy,mononeuropathy or Autonomic Neuropathy. AN is related to the duration of disease and glycemic control. Any part of GIT can be affected. Involvement of small intestine causes diarrhea, and Colon causes constipation, and stomach causes gastroparesis which presents as nausea, vomit, bloating, anorexia, and early satiety. Due to delayes gastric emptying, glucose control is difficult to achieve. Pt have post meal hypoglycemia after insulin injection. Nuclear Medicine Scintigraphy after ingestion of radio-labeled food is the best method to document Delayed gastric Emptying. Management includes:1-improved glycemic control, 2-small,frequent meals, 3-Dopamine agonist(Metachlopromide,domperidone) before meals, 4-Bthanechol, 5-Erythromycin (reaction with Motilin promotes emptying), 6-Cisapride. **The most beneficial therapy to reduce progrssion of DN in presence of renal insufficiency is to control HT. Nonketotic Hyperosmolar synd occurs in DM2 pt because level of insulin in these pt is enough to prevent ketoacidosis but not hyperglycemia. Hyperglycemia occurs, with hyperglycosurea and dehydration. They will present with semicomatose state. So first thing you do is to check blood glucose.Diabetes screening in pregnant women is performed b/2 24-28 weeks of gestation. If urine dipstick reveals glycosuria then the next step is Fasting Urine samples if its positive then do a 1hr-50g oral glucose tolerant test. If its 140, 3hr-100gr OGTT is used for confimation.Diabetic Neuropathy can present with ulcer in the foot. Risk factors for development of diabetic foot ulcer are: Diabetic Neuropathy, peripheral vascular dis, poor glycemic control, bony abnormalities of the foot, male sex, smoking, chronic DM (>10ys), and a hx of previous ulcer or amputation. Neuropathy is found in 80% of diabetics with foot ulcer.Symetrical distal sensorimotor polyneuropathy is the mc type of diabetic neuropathy. Characterized by “stocking glove” pattern or sensory loss. DM is a risk factor for Non alcoholic fatty stetosis.Hyperglycemic, hyperosmolar, non-ketioc coma is characterized by very high blood glucose, plasma hyperosmolarity, normal aion gap and negative serum ketones. DDX KA is sugested by 1-blood glucose >250, 2-pH<15-20,4-Plasma ketones.DDX2:Alcoholic Ketoacidosis is ketoacidosis with increased anion gap BUT near normal glucose levels. Always consider candida albicans as a casue of infection in a pt with uncontrolled DM.Diabetic mothers babies are often born with clavicle fracture that heals spontaneouly w/o any tx.The Dx procedure of choice for Diabetic Polyneuropathy is Electromyography and conduction studies. **Poorly controled pt with low grade fever,bloody nasal discharge,nasal congestion,involvement of the eye and chemosis ,proptosis and diplopia is more likely suffering from Mucor Mycosis and maxillary sinus due to Rhizopus. Involved turbinates usually become necrotic. DDX is Pseudomona which causes Malignant Otitis Externa, it my also cause black necrotic lesions. DDX also H.inf and Moraxella are the mcc of bacteria sinusitis, they dont cause NECROTIC infections*Non-ketoic Hyperosmolar coma presents with gllucose 1000, and normal pH. Tx is normal saline initially and then replaces with 0.45% saline. Once glucose is down to 250, then we give 5% dextrose that prevents cerebral edema. ** Diabetic Cystopathy usually secondary to diabetic autonomic neuropathy. It begins with inability to sense s full bladder & failure to void completely. With time bladder size increase leading to signs of BPH & recurrent UTI. Dx is made with Cystometry and Urodynamic studies. Initial mgmnt is strict voluntary urinary scheduling couplded with Bethanechol. If there is no response intermittent catheterization is recommended. **Emphysematous Pyelonephritis: is a life threatening condition caused by E. Coli. Dx is confirmed by CT. TX is IV antibiotics and possible Emergency Nephrectomy.

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Diamond Blackfan Anemia:

Answer 284

Also called “congenital hypoplastic anemia”. Suspect it in a child with macrocytic anemia, low reticulocyte count and congenital anomalies. Primary path is an intrinsic defect of erythroid progenitor cells which results in increased apaptosis. Over 90% are dx w/I the first year of life. Macrocytic anemia is distinct from megaloblastic anemia because hay no hypersegmentation of the nucleus in neutrophils. Pt presents with anemia, short stature, webbed neck, shielded chest, triphalangial thumbs. Tx is mainly corticosteriods, if unresponsive then transfusion therapy.

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Diaphragmatic Herniation

Answer 285

Occurs in accidents and Cxr sign of elevated left diaphragm could be the only sign.*****One dx often missed in er is traumatic rupture of the diaphragm. Usually on the left side. Pt comes back months later with breathing difficulty. Cxr shows deviated mediastinum with a mass in the left lower chest. Barium Swallow is dx. In acute cases surgery is done via abdomen and in chronic cases via chest.

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Diarhhea - 6

Answer 286

Campylobacer Jejuni is the mcc of bloody diarrhea in US. Its from undercoocked pulteryVibria Parahemolyticus:by ingestion of sea food. Bloody diarrhea,abdomnal cramps,nasea and feve. Incubation 12-24hrs. Shigela diarrhea occurs in day care and institutional settings. Yersinia diarrhea is by eating undercooked pork. Campylobacter is the mcc of diarrhea in US due to uncooked infected poultry. could be watery or hemorrhagic. **Staph causes toxin induced gastroenteritis mostly emetic type that starts w/i 6 hours.Salad,meat and egg.Travelers diarrhea, due to E Coli, is the cause of diarrhea w/i blood,mucus,explosive,rice watery diarrhea even in Mexico travelers. DDX Giardia is endemic in Nepal. MCC of diarrhea in children is Roto virus that causes acute gastroenteritis.Most causes are self limiting but maintain hydration Ther is now a vacine for it but it was withdrawn due to risk of IntussusseptionTypes of diarrhea are: 1-Inflamatory, where ESR is elevated and there is anemia and blood positive stool. 2-Osmotic, caused by meds or hormonal disturbance. 3-Motor, exemplified by Hyperthyroidism. 4-Factitial, is psychologic.

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DIC:

Answer 287

Tx is FFP if pt is bleeding only. If pt is not bleeding and has sepsis (high T and low BP) first step is IV antibiotics plus Activated Protein C.

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Diffuse Esophageal Spasm - 2

Answer 288

Manifest with chest pain and dysphagia. Etiology in unknown but its related to emotional stress. Unlike Achalasia LES has a normal relaxation response. Esophagogram might show Corkscrew. Tx is with antispasmic drugs, dietry modulation and psychiatric counselling. for USMLE know 1-pathophys, 2-present or absence of perstalsis, 3-LES tone. MERCK:A generalized neurogenic disorder of esophageal motility in which phasic nonpropulsive contractions replace normal peristalsis and, in some cases, lower esophageal sphincter malfunctions occur. Esophageal manometry shows: contractions are usually simultaneous, prolonged or multiphasic, and possibly of very high amplitude.*****Esophagography may not show the corkscrew, so do Manumetry, if revealed “repetitive,nonpeistoltis,high amplitude contraction either spontaneoud or after Ergonovin stimulation then its Dx.

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Di-George synd:

Answer 289

Infants have cyanotic heart dis, cranofacial anomalies, thymic dysplasia, cognitive impairment and hypoparathyroidism. Associated with Ch 22/11 deletion. In Surgery keep an eye on Ca levels.

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Digitalis Toxicity - 2

Answer 290

Some of the toxicities occur in therapeutic range (AV block, ST depression, T inversion) and there is no need to discountinue the drug. Some occur in Toxic serum levels (Atrial Tachycardia and AV heart block) and we need to discountinue the drug. Digoxin also causes Nasea and Anorexia.

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Diphenhydramine Toxicity

Answer 291

Prduces seizure as well as anti-cholinergic effects.

Question 292

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Dipyridamole

Answer 292

used during myocardial perfusion scaning to reveal areas of restricted myocardial perfussion. It shows “Coronary steal phenom”

Question 293

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Disk Herniation

Answer 293

Once you know its DH and straight leg is positive, then NSAID and early mobilization s the tx of choice.

Question 294

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Displacement - 2

Answer 294

An immature defense mechanism, in which individual displaces negative feelings associated with unacceptable situation onto a safer one.

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Disseminated GonoCoc infx

Answer 295

Persents in menturating women with tampon, many partners, occasional condom, presents with high fever, rash, tenosynovitis and migratory arthralgia. DDX with TSS which presents with Fever, macular erythema of palms and soles,, vomit and diarrhea nad hypotension.

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Dissociative Fugue

Answer 296

Pt get lost in another city.

Question 297

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Diverticulitis - 2

Answer 297

the dx test to evaluate the abdomen during an acute episode of diverticulitis is a CT scan. Colonoscopy and Sigmoidoscopy can cause perforation.*****Acute diverticulitis complication may be bowel perforation where xray shows air under diaphragm and rigidity and guarding. Next step is Laparotomy with surgical resection of perforated bowel and proximal colostomy.

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Diverticulosis

Answer 298

Pseudodiverticulum can erod a penetratinf atrery. This leads to perfuse arterial bleeding of bright red blood. Diverticulosis is the mcc of bleeding in elderly pt. Chronic constipation is the single most predisposing factor to develop Diverticulosis. Normal xray does not rule out diverticulosis if its negative. You need xray with contrast ( Barium ) to be able ro see it. DDX1: Colon Cancer, presetns with chronic,occult bleeding NOT BRIGHT RED. DDX2:Ischemic Colitis, Associated with Abdominla pain, feverand vomit and atherosclerosis, xray shows thickening of colon wall. DDX3:Mesenteric Thrombosis, Pain out of proportion is a classical symptom, Bloddy diarrhea rather than bright red blood is charcteristic, Bowel sounds are diminished.

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Down Synd in Pregnancy

Answer 299

T14Q12 explains how to test for DS in older women. Decreased MSAFP and Estriol and Increased B-HCG is the best test. SEE FIRASR AID.. Know heart defect, and also that they have Duedenal atresia. Learn this.** Hay ASD and endocardial cushin defects. **Duodenal Atresia is the mc anomaly associated with Down, in xray you see a double bubble sign. Other anomalies are Hirshsprung, Esophageal atresia, Pyloric stenosis, malrotation. Congenital heart disease is the mcc of death in childhood, like endocardial cushin defect, VSD, PDA.

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Dressler Syndrome:

Answer 300

It’s a post MI Pericarditis. Non specific ST elevation. NSAID is tx of choice.

Question 301

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Drug induced Pancreatitis

Answer 301

1-Diuretics, furesamide and thiazide. 2-IBD, Sulphasalazine and 5-ASA. 3-Immunosupresants, azathioprine. 4-Seizures, Valprioc acid. 5-AIDS, Didanosine, Pentamidine. 6-Antibiotics, Metronidaole, tetracycline. CT is dx with inflamed pancrease. Tx supportive.

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Drug induces Interest Nephritis - 2

Answer 302

Caused by Cephalosporins, Penicillins, Sulfa drugs, NSAID, Rifampin, Phenytoin and Allopurinole. Pt presents with Acute renal failure+Arthralgia+rash.*** 70% of cases are induced by drugs, discountinue the drug and it will be OK. Pt present with fever, and urine analysis shows RBC, WBC and white cell casts, eosinophelia and proteinuria.

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Drugs CI

Answer 303

1-Beta blockers: peripheral vascular dis (pt presents with worsening intermittant claudication), asthma, copd, Raynaus. 2-ACE inhibitors: Hyperkalemia, pregnancy. 3-Calcium channel blockers:Second&thrid degree heart block and CHF.

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Dubin-Johnson

Answer 304

…

Question 305

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A familial disorder of hepatic bile secretion. Leads to conjugated Hyperbilirubinemia. May be aggrevated by women taking OCP. Liver biopsy reveals cells with DARK granular pigments. DDX1:Rotor, like DJ but no DARK granule pigments.

Answer 305

…

Question 306

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Duchenes MD

Answer 306

Muscle biopsy will reveal dx.

Question 307

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Dumping Synd

Answer 307

Is a common post-gasterectomy complication. Pt with recent Gasterectomy presents with postprandial abdominal cramps, lightheadedness, diaphoresis. First thing to do is to Modify diet, small frequent meals and avoid simple CHO. Dx is made clinically but occasionaly Contrast xray (barium swallow) is used.

Question 308

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Duedenal Atresia:

Answer 308

Bilous vomiyying few hous after the FIRST eating, usually associated with congenital anomalites and Down’s Synd.

Question 309

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Duodenal Hematoma, isolated

Answer 309

If pt is hemodynamically stable, she needs nasogastric succion and parenteral nutrition (food ) not IV fluid.

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Duedenal Injury:

Answer 310

Isolated duodenal injury is easily missed. They occurin accidents due to the belt or steering wheel. Present with epigastric or RUQ pain. Retroperitoneal air or obliteration of right psoas margin on xray is very suggestive. Best dx with CT scan of the abdomen with oral contrast or an upper GI study with gastrograffin, followed by barium if necessary.

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DVT - 3

Answer 311

OCP is a well known risk factor for DVT. TX steps:Anticoag therapy has serious Ses so accurate dx must be made before anticoag is started. Test of choice for DVT is Compression US. Impedence Plethysmography is for recurrent DVT. Venography is the Gold standard for dx of DVT, but it causes discomfort so its not the initial test for suspected DVT. Its only done when other tests are impossible or inclusive.Surgical pts can be categorized according to their risk of DVT. 1-Low risk, Minor surgery in a pt 40, one or more addiiotnal risk, minor/non-minor surgery, risk is 2-10%. 3-Hihg risk, pt is >40, additional risk factors, major operation, risk of DVT is 10-20%. In Low risk pt, prophylaxis other than early mobilization is not recommended. In Moderate risk pt, LMWHeparin or Unfractionted Heparin is recommended. Pts in whom bleeding risk are unacceptable (intracranial.spinal cord injury) should receive intermittant pneumatic compression. In High risk pt, undergoing general surgery can be given LMWH, those pts going under Orthopedic surgery of lower extremity (knee replacemnt) LMWH or Oral Warfarin.INR (International Normalized ratio) is used to monitor tx response to Warfarin. Therapeutic Range of INR for most pts is 2-3, which is for venous thromboembolism, valvular heart dis. 3-4.5 is for Proshtetic valves.*****The besr DVT prophylaxis for high risk surgery ptgoing under orthopedic surgery includes either warfarin or LMWH.

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Dysfuncx Uterine Bleeding- 2

Answer 312

Heavy unremiting endometrial hemorhage throught menarche and perimenopause requires Estrogen (conjugated) to supress the bleeding to ensure CV stability. Once that is achieved D&C should be performed. The MCC of DUB in adulescent is anovulation. Therefore endometrial biopsy is not required in these pts. Once bleeding is stopped , advise pt to take the following: conjugated estrogen for 25 days , then add methoxyprogestrone for the last 10-15 days and then allow 5-7 days for withdrawl bleeding to mimic menstural cycle.**In which pts with CUB do you perform endometrail biopsy to rule out endometrial carcinoma? When a pt is >35, obese, DM or has chronic HT.

Question 313

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Dysthymia

Answer 313

Depressed mode for more than twoyears.

Question 314

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Dystonia

Answer 314

from antipsychotics, tx is Benztopine or Diphenhydramine.

Question 315

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Eaten Lambert

Answer 315

Is associated with small cell carcinoma. And antibodies against the voltage gated calcium channels in presynaptic motor nerve terminal. It is presynaptic, resulting from impaired release of acetylcholine from nerve terminals.The diagnosis is confirmed by finding an incremental response to repetitive nerve stimulation: Amplitude of the compound muscle action potential increases > 200% at rates > 10 Hz. Treatment is first directed at the underlying malignancy and sometimes induces remission. Guanidine facilitates acetylcholine release.

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Eating disorder not otherwise sp

Answer 316

If the senario shares features of both bulemia and anorexia, its this disorder.

Question 317

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Echinococcus

Answer 317

Due to close cntct with SHEEP. Pt presents with hepatomegally, forms hydatid cyst in liver after US. Hydatid cyst has an inner germinal layer and an outer acellular laminated membrane. DDX is Neurocysticercosis, due to PIG farming. With cysts in Brain, kills fast.

Question 318

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Eczema Herpeticum

Answer 318

T9Q23. A form of Herpes simplex that is associated with atopic dermatitis. Numeric umbilicated vesicles around The healing area is typical. In infants tis could be life threating, start acyclovir asap.

Question 319

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Edward synd - 2

Answer 319

Microcephaly, prominent occiput, micrognathia, closed fists, index finger overlaping 3-4-5 bilaterllay, rocker bottom feet. 95% die by first year.*** Pts have hear mumur due to VSD. This is trisomy-18 (E-lection age)

Question 320

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EKG abnormalities

Answer 320

1-T wave inversion, in ischemia of myocardium. 2-ST depression, subendocardial infarcts and unstable angina. 3-Ptoonged PR, first degree heart block. 4-Delta waves, WPW. 5-New RBBB, seen in PE. 6-Electrical Alterns, seen in pericardial Temponade.

Question 321

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Embolus, limb

Answer 321

If pt presents with cold hand due to embolus, immediate antocoag with heparin and surgcal intervention is indicated.

Question 322

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Emphysema

Answer 322

In a non smoker should raise the suspicion to Alpha-1 anti trypsin def. Its also associated with Neonatal Jaundice in the hx of the pt. Dx is made by estimating alpha-1 trypsin levels.

Question 323

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Emphysematous Cholecystitis:

Answer 323

is a common form of acute Cholecystitis in elderly diabetic males. It arises due to infection of the gallbladder wall with gas forming bacteria. Dx is confirmed with abdominal xray showing air-fluid level in the gall bladder or US showing gas line. Lab shows moderate unconjugated hyperbillirubinemia or small elevation of aminotransferases. Tx includes early fluid resuscitation, early cholecystectomy, and parenteral antibiotic therapy effective aginast gram positive Anaerobic Clostridium sp. (Ampicillin- Sulbactam, or combination of aminoglycoside or quinolone with clindamycin or metronidazole.

Question 324

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Empyema

Answer 324

Can occur from parapneumonic effusions(In parapneumonic effusions, the visceral pleura overlying a pneumonia becomes inflamed; often, an outpouring of serous exudative fluid accompanies acute pleurisy. The fluid contains many neutrophils and may contain bacteria. Parapneumonic effusions are usually caused by bacteria. If the body’s defenses do not control infection in a patient with pneumonia and parapneumonic effusion, the number of neutrophils and bacteria increases, and the fluid takes on the gross appearance of pus. The result is empyema of the thorax (purulent exudate in the pleural space). Fluids with > 100,000 neutrophils/µL, bacteria seen on Gram stain, and pH < 7.2 may be presumed to be empyema). Pt presents with low gade fever, dyspnea and chest pain. Dx with CT. When its localized, complex and has a thick rim best tx is surgery to remove the clotted blood.

Question 325

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Endometria hyperplasia

Answer 325

A28. Printed out

Question 326

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Endometriosis - 4

Answer 326

Pt presnts with painful periods. Bimanual exam shown a few firm nodularities in pouch of douglas.The first line of tx is OCP. They cause a state of pseudopregnancy and causing an “exhaustion atrohpy” of the endometriomas. If OCP fails or not tolerated then we give Danazole, its an androgen deivative that causes Pseudomenopause state. SE are acne,hirsutism deep voice.GnRh agonists have an inhibitory action of LH & FSHwhen given continuslywhich produces temporary castration. Its also a 2nd line of choice. Typically pt prestns with Dysmenorrhea, Dysparunea(when endometriomas is in cule-de-sac), Dyschezia(Pain on defecation), hematochezia, hematuira, and pre post menstrual spotting. Laparoscopy is GOLD standard which shows powder burns. The hemorrhage of endometriomas into the ovaries results in formation of cystic cavity filled with blood with dark color, hence the name ‘Chocolate cyst’. **The ‘3Ds’ are Dyspareunia, Dysmenorrhea and Dyschezia (defecation pain). Tx is OCP. DDX1:Vaginismus, use Vaginal dialators. DDX2:Pain disorder, pain in one or more anatomical sitetxis pain managment training. DDX3:Somatization disorder, tx is follow up visitsregularly scheduled. ***Endometriosis is the location of tissue outside uterine cavity so hysterosalpingogram cant see it.

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Endometritis:

Answer 327

It usually occurs on 2nd-3rd day postpartum. Predisposing risk factors are prolonged labor, prolonged and premature rupture of the membrane, manual removal of placenta, and repeated pelvic exam. Clinically it presents with fever, uterine tenderness and foul smelling luchia. Antibiotic start asap to conver both aerobic and anaerobic. Clindamycin with aminoglycoside or ampicillin. MC pathogen is anaerobics.

Question 328

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End stage lung dis:

Answer 328

PFT is the best test to to determine if the pt can benefit from lung resection surgery. Predicted postoperative FEV1 is very useful for this. Blood tests don’t reveal any good info in this regard, they’re more useful in determining the level of respiratory compromise and appropriate ventilator settings for pts undergoing lung resection surgery. Results of split function quantitative lung scans and exercise testing are useful in pts in whom the potential benefit is doubtful even after determining the results of the predicted postoperative FEV1.

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Enterobius Vermicularis

Answer 329

Or Pin worm is the MC helminthic infection in US. Most commonly seeb in school children 5-10. Larva goes to perineal area to lay eggs, which gives characteristic Nocturnal perianal pruritis. Dx is made by “Scotch tape test”. Albendazole or Mebendazol is the first line of tx. Pyrantel Palmate is an alternative.

Question 330

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Enuresis - 2

Answer 330

Tx is low doses of Imipraimne or desmopressin.***It should go away begore school age. The first step is reassurance. Then wet alarms and walking the child to bath room is tried. If persiss, then Desmopressin (ADH) is first line, Imipramine is the 2ns line tx. **Its important to rule out treatable causes like UTI. The initial evaluation is urine analysis.

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Epididymitis, Acute

Answer 331

…

Question 332

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Epidemiology:

Answer 332

Mean is average, Mode is the number repeated mostly, Median is the number in the middle given by vigniette, don’t put them in order treat it as is. Reliable test is one that gives similar results repeatedly. Accurate is when the results are on the target.** Sensitivity curve movements and its effect on PPV.

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Epiglotitis - 3

Answer 333

MC by H. inf and 2nd mc by Strep. Tx is antibiotics, antipyretic, racemic epinephrine, steriods and immediate intubation. Dx is by Fiberoptic Laryngoscopy in the operating room, once its made then nasotracheal intubation secures the airway. If intubation is CI then Emergency Tracheostomy is performd.. *****you dont need epinephine before intubation, intubation is the first thing to do here.

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Erectile Dysfunction

Answer 334

Types are 1-Neurogenic:A pelvic fracture with an urethral injury is usually accompanied with ED. The cause is nerve injury and altered blood supply. 2-Venogenic:After penile fracture and disruption of tunica albuginea. 3-Endocrinologic:Prolactinoma. 4-Systemic M can cause Ed through many systems (neuro, vascular). 5-Situational:Psychogenic, where night and morning eection is preserved.**If pt is taking Nitrate drugs, Sildenafil is CI so the next step is Penile prosthesis devices or Vaccum devices.

Question 335

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Erysipelas

Answer 335

Is a specific type of cellulitis in which there is superficial inflamation of epidermis producing prominent swelling. The characteristic finding is a sharply demarcaded , erythomatous, edematous tender skin lesion with raised borders. Onset is abrupt with systemic signs. Group A strep is the mcc. Penicillin V or erythromycin 500 mg po qid should be given for >= 2 wk. See pic on desktop.

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Erythema Multiform. Dermo. 6/3

Answer 336

Onset is usually sudden, with erythematous macules, papules, wheals, vesicles, and sometimes bullae appearing mainly on the distal portion of the extremities (palms, soles) and on the face. The skin lesions (target or iris lesions) are symmetric in distribution and often annular. Stevens-Johnson syndrome is a severe form. EM Usually folows infection with Herpes Simplex. Erythema multiforme associatedciated with mycoplasmal pneumonia should be treated with tetracycline. If frequent or severe erythema multiforme is preceded by herpes simplex, acyclovir

Question 337

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Erythema Nodosum Pink to redish painful subcuataneous nodules that usually develop in pretibial region. Most often in woman 15-40. Lesion resolve w/o scaring w/I 2-6 weeks. Histologically there is paniculitis involving inflamation of septa in the subcutaneous fat tissue. There are other conditions that could cause EN, like TB and Sarcoidosis. So the initial work up is include Antistreptolysin O (ASO) titer, a TB test and chest CXr. Its also associated with IBD. Sarcoidosis pt often presents with EN as an initial symptom, cxr will show bilateral hilar adenopathy. An inflammatory disease of the deep dermis and subcutaneous fat (panniculitis) characterized by tender red nodules, predominantly in the pretibial region but occasionally involving the arms or other areas. Bed rest helps to relieve painful nodules. If an underlying streptococcal infection is suspected, antibiotic therapy is beneficial (eg, penicillin for >= 1 yr).

Answer 337

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Question 338

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Erythema Toxicum

Answer 338

Is a benign self imited condition in newbors characterized by rash with red haloes, and eosinophils in sin lesions. Neonate presents with No fever, no infectious risk factoe, looks healthy, with erythematous papules and vesicles surrounded by pathes of erythema.

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Esophageal Atresia:

Answer 339

It’s the mc esophageal anomaly w esophagotracheal fistula. It leads to gastric distention. It results in drooling and regurgitation due to incomplete esophagus. In addition food gets into trachea and lungs and cuses aspiration pneumonia. Inability to pass tube is suggestive.

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Esophageal cancer - 2

Answer 340

It mimics Achalasia. Short hx , rapid weight loss, and inability to pass esophaguscope isindicative of cancer. The next step is biopsy. Ofcourse BS followed by endoscopy should be done first.

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Esophageal Varices, Acute - 2

Answer 341

Variceal bleeding is a life threatning emergency. FIRST step is fluid replacement with two large bore IV needles followed by fluid resucitation. SECOND step is control of bleeding medically with vasoconstrictors (Octreotide, somatostatin) THIRd step is Endoscopic Sclerotherapy or Band Ligation (which is better due to less SE). If endoscopic therapy is not available then Baloon temponade with S-B tube is done. If all this fails then surgery is indicated (TIPS). In case of EV, need for 5 or more units os blood transfusion in a period of 24 hours is considered an indication for surgery and Transjugular Intrahepatic Portosystemic Shunt. Remember both ligation andmeso-caval shunt have high mortality rate in ER setting, TIPS has less mortality rate.*Varices are submucosal veins dilated due to portal HT.

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Estrogen Replacement Therapy:

Answer 342

Affects metabolism of thyroid hormones. The requirement for L-Thyroxine increases, although the exact mechanism not known it could be due to induction of liver enzymes, increased level of TBG. In pregnancy also thyroid hormon requirement will be increased and the pt should be monitored for dose adjustment.

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Essential Tremors - 3

Answer 343

DOC is Beta blockers.Another drug is Primidone, Its SE is Acute Intermittent Porphyria (Abdominal pain, neurologic and psychologic abnormalities, it can be dx by urine prophobillinogen. ****Propranalol is the DOC for pts with benign essential tremors + HT.*Its famililal, its worse with action and resolved at rest. Rule out Thyroid problem before starting therapy.

Question 344

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Ethyline alcohol poisening

Answer 344

Presents with anion gap metabolic acidosis with Rectangular envlope shaped crystals (calcium oxalat).

Question 345

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Eustachian tube dysfunction

Answer 345

Is a common cause of conducting hearing loss in children. Aurul fulness, pop when swallow, hearing loss, intermittant ear pain. Usually following URT infection or allergic rhinitis. Retraction and decreased mobility of tympanic membrane. Hallmark is a middle ear effusion. “Acute Otitis media”: Otalgia, hearing loss, fever and dysequilibrium, bulging membrane. “Serous otitis media”: Due to prolonged blockage of auditory tube, common in children, membrane is hypomobile and dull, air bubbles in the middle ear. “Otitis externa”: Purulent dischatge, common in swimmers, pain with tenderness is the hallmark. “Foreign body in children”: Foul-smelling discharge and signs of infection.

Question 346

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Ewing sarcoma

Answer 346

Highly malignant tumor of lower exremities in children. With early metastasis. Presentation is pain and swelling for weeks. Oftern confused with Osteomyelitis due to intermittent fever, leukocytosis, anemia, elevated ESR. CXr shows “ONION SKINING” peroosteal retraction. Lesion is Lytic and central. Onion skin is followedby ‘moth eaten’ appearance. Tx includes surgery , radiation, and multiple drug chemo. DDX is Osteomyelitis:Pt presnts with feve, malaise, local pain in joints and swelling. Xray in chronic osteomyelitis shows Lytic bone defect with surounding sclerosis termed as “Brodie’s Abscess”.

Question 347

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ExtraPyramidal Synd (EPS)

Answer 347

Is seen as SE of antipsychotics (Risperidone). 1-Tardive dyskinesia, lip smacking, tongue protrusions, chewing,biting. It occurs b/w 4mo-4ys. Tx is discontinue Risperidone and give Clozapine. 2-Akathesia is the feeling of restlessness, beta blocker gives some releif. 3-Dystonia, occurs b/w 4h-4d, there is muscle spasm, stiffness, twisting, opisthotonus. Antihistamine (diphenhydramine) or Anticholinergic (Benztropine) releif.

Question 348

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Factitious diarrhea

Answer 348

Laxative abuse, profuse diarrhea. 10-20 times a day. DDX with IBS diarrhea is that IBS does not happen nocturnaly but factitious does. FD is usually done by women of high socioeconomic status and Nurses. There is also characteristic dark brown discoloration of the colon with lymph folicles shining through as pale patches that confirms the dx.

Question 349

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False Labor

Answer 349

Characterized by painless and irregular contractions for 5hrs or more. In the last month these contractino may become rhythmic occuring every 10-20 minutes mimicking contraction of real labor. The main characteristic is however they are not accompanied with progressive cervical changes, so cervix is closed shut. All the pt needs is reassurance.

Question 350

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Familial Colonic Polyposis

Answer 350

Pt hace 100% risk of colon caner, so when they are dx (colonoscopy reveals 100s polyps), then then next step is elective proctocolectomy.

Question 351

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Fanconi’s Anemia:

Answer 351

An auto recessive dis, progressive pancytopenia and macrocytosis. Deformities include, café au lait spots, microcephaly, micropthalmia, short staure, horseshoe kidneys and ABSENT thumb. Dx agerage age is 8 YO

Question 352

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Fantacy Defense Mechanism

Answer 352

An immature defense mechanism, that does not exist in the real world, like an angel telling you things are gonna be OK.

Question 353

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Fat embolism

Answer 353

Dyspnea, confusion and petechia in the upper part of the body, After multiple fractures of long bones. Tx should include prompt respiratory support. Use of heparin, steriods is controversial.

Question 354

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Fat Necrosis

Answer 354

Biopsy shows foamy macrophages and fat globules. Coarse calcification is indicative of benign, and microcalcification indication of malignant tumors. FN is associated with hx of surgery or trauma and it mimics breast cancer.Exisional biopsy is dx and no tx is needed and standard follow up and mamogram is sufficient.

Question 355

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Febrile Neuropenia - 2

Answer 355

A neutropenic pt with sustained fever of >100.4 for one hour. Its an emergency, admit to hospital and obtain blood cultures and IV Cefepime, or Ceftazidime, or Imipenem. Vancomycin is added IF pt is hypotensive, evidence of skin or line infection, Hx of resistant to S. Aureus or pneumococcus, or recent prophylaxis with flouroquinolones.

Question 356

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Femor Shaft fractures

Answer 356

Most can be managed with closed intra medulary fixation of the shaft. This allows for early mobilization improved hip and knee function and less hospital cost. I this technique, closed reduction of fracture segment is followed by inrta medullary nail insertion through small skin insertion over the greater trochaner.Closed nailing is preferedover OPEN nailing due to reduce risk of infection. Internal fixation with plates and screws are used in NECK fractures of femur.*****Interochanteric fracture of the femur is mostly an extracapsular fracture in elderly. Occurs along the line b/w greater and lesser trochanter, Extremity is shortended and internally or externally rotated. Dx is xray. Operative tx is indicared asa pt is stabilized. Do internal fixation with sliding screw with plate and early mobilization.

Question 357

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Femoral Neck Fractures

Answer 357

They are seen in Elderly. The limb is shortended and rotated and painful with limited motion. Unstable fractures (complete neck fractures), need Open reductionb and internal fxation or Primary Athroplasty(surgical reconstruction of the joint) as soon as pt is stabalized. If surgery is CI the pt should be mobilized asap and eventual malunion can be dealt with later.

Question 358

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Fetal Alcohol Synd - 2

Answer 358

irritability, mild to moderate mental retardation, hpoplastic maxilla, lng philtrum, thin upper lip border and microcephaly, and epicanthal folds.

Question 359

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Fetal Demise - 6/24/06

Answer 359

if pt comes to you due to not feeling any mvemnt and you cant hear any beats with Doppler, then the first thing to do is to do a Real Time Sonogram.. It’s the most appropriate test to confirm fetal demise. BhCG might be lower but it doesn’t make it a dx tool.

Question 360

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Fetal Distress (Repetative Late Decelerations

Answer 360

Is an indication for C-section. Remember Tocolysis means not delivering.

Question 361

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Fetal Hydantoin Synd. - 2

Answer 361

Caused by using Phenytoin in pregnancy due to seizure. Infants presents with small size, microcephaly, hypoplasia of distal phalanx of fingers and toes, nail hypoplasia, low nasal bridge, cleft rib and rib abnormality and cardiac mmurmur. Its also associated with Neuroblastoma. Karytype and TORCH should be measured.***Diphenylhydantoin (phenytoin) is metabolized to Epoxide Metabolite, which is eliminated inturn by enzyme Epoxide Hydroxylase. The genetic expression of EH is different from one subject to other and its substrate EMis the agent incriminated in the syndrome.

Question 362

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Fever, Post operative:

Answer 362

Fever after the first day is due to Atelectasis. Pt might have pain at the incision and not take deep breaths causing atelectasis. Fever 3-5 days post surgery is due to UTI. Fever 3-7 days post surgery may be due to Pulmonary Embolism. Pt is Tachypnea,tachycardia and Hypoxia. Dx requires Duplex US to look for clots in extremities. Eventhough pt are given anticoags, 200,000/y die of PE. Fever one to two months post durgery is due to post spleenectomy sepsis. All pt are given Pneumococcal vaccine after surgery to prevent this. Fever due to Pneumonia can occur 3-6 days post surgery. Pts are most likely, smokers,obese, elderly and fail to ambulate. Pt will have sputum and leukocytosis. Fever due to wound infection is 4-7 days post surgery. Redness, pain and induration.

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Fibroadenoma:

Answer 363

1x1 cm firm rubbery freely mobile round mass in a 35 yo women w/o axillary nodes palpable. Best initial step is Mamogram.

Question 364

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Fibrocystic Dis of Breast

Answer 364

A 4x5x6 cm moveable rubbery mass that will go away after poking the needle and secretion of clear discharges. The best approach after aspiration of fuid is to wait 4-6 weks . In FCD the mass goes away and doesn’t come back. It it recure or doesn’t go away, then a biopsy is indicated. If the fluid (initially) was bloody or foul smelling, cytology is needed at that stage.

Question 365

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Fibroid uterus

Answer 365

Presents with Dysmenorrhea, heavy menses, and enlarge uterus is almost dx of either Adenomyosis or FU. Submucosal fibroids often imterefre with rmbryonal implantation and infertility. Fibroids are the mc benign uterin tmors in women and the mc indication for hysterectmy. Tey are estrogen-dependent tumors, therefore they increase in csize with OCP and pregnancy. and often regress after menopause. DDX is Endometriosis which presents with Amenorrhea. Make sure you can DDx the above conditions with Adenomyosis.

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Fibromuscular Dysplasia - 2

Answer 366

Is the mcc of 2ary HT in childern. It responsible for 20% of the cases of renal HT. Its also seen in premenopausal women. PE shows a hum or bruit (soft to-and-fro bruit) in the right costovertebral angle due to well developed collaterals. The right renal artery is more affected than the left. Angiography shows ‘string of beads ‘ pattern in the renal artery**Pt presents with Occipital HA, HT and renal bruit, suggestive of renovasculat HT due to Renal Artery Stenosis. The usual cause in youner pt (30) is FMD. In older pt its atheroslcerotic plaques. Goal of tx is decrease BP and restore perfusion to kidneys. Interventanl therapy is better than medical mgmnt alone, so Angioplasty with stent replacemnt is best tx. If it fails then Surgery is indicated. Ace inhibitors are reserved for Elderly pts who are not good candidate for surgery. Remmber Ace inbitors are CI in bilateral renal stenosis.

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Fibromyalgia- 4. Rheumo 6/3

Answer 367

Occurs mainly in females and may be induced or intensified by physical or mental stress, poor sleep, trauma, or exposure to dampness or cold .Pt presents with diffuse musculoskeletal pain, multiple tender points, with no joint swelling/pain. Initial work up is 1-CBC, 2-ESR, 3-TFT, and 4-CK enzyme. Normal spine movement makes “Ankylosing Spodylitis” unlikely. Normal ESR with pain rather than stiffness makes “Polymyalgia Rheumatica” unlikely. “Polymyocytis”, usually presents with weakness rather than diffuse pain and increased CK. Characterized by muskuloskeletal PAIN and presents of 11-18 tender points. Pt prsents with recurrent HA, IBS, Reynauds, The most importnat ddx of this diseases is masked depression and somatoform disorder. Tx is excercise & Antidepresssants.DDX1:Chronic Fatigue Synd: pt prestns with extremem fatigue and not body aches. It must be there for 6mo. DDX2:Polymyalgia Rehumatica:Pain and stiffness of shoulder and pelvic. Very unlikely in pt <50yo. ESR is elevated. Complain of stiffness rather than weakness or pain. Associated with fever,weight loss and HA. DD3:Polymyositis:Proximal weakness of muscle in upper and lower extremity. Pt complains of difficulty raising from chair position or climbing stairs. No pain just weakness** Fibromyalgia is not an inflmatory disease so NSAISs like Naproxen & steroids are not helpful. Tricyclic antidepressant like Amitriptine are tx at bedtime. For daytime pain use acetaminophen. You can also use Cyclobenzaprine. So the initial tx is either Amitriptalin or cyclobenzaprine. If refractory to the above medicine then SSRI are added. When pt feels better then exercise is initialed. Other refractory tx is trigger point injections

Question 368

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First degree heart block

Answer 368

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Question 369

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Fluphenazine SE:

Answer 369

Hypothermia by causing vasodialation and inhibition of shivering.

Question 370

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Focal segmental GN

Answer 370

Associated with HIV.

Question 371

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Fragil X syndrome - 2

Answer 371

Pt can be tought to take care of himself with and perfor simple task with close observation, like down’s. *** Low to normal IQ, with learning disability. , general language disability, short attention span, autism, Mutation of FMR-1 gene caused by increased number of CGG trinucleotide repearts. Large head, prominent jaw and large low set ears.

Question 372

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Friedrisk Ataxia

Answer 372

Auto rec. excessive number of trinucleotide repeats resulting in abnormalilty of topopheral transfer protein. Poor ptognosis. Tell the parent to seek genetic counseling for future pergnancy. MRI of the brain and spinal cord shows marked atrophy of cervical spinal cord and minimal cereberal atrophy. *****Auto rec dis. Begins before 22 years of age. Neurological manifesration gait ataxia, falling, dysarthria) result from degeneration of spinal tracts (spinocerebellar, posterior tract, pyramidal tracts). Non neuro symptoms include concentric HCM, DM and skeletal abnormality (scoliosis annd Hammer toes). Median survivial is 20 years. Mcc of death is CV, 90%.

Question 373

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Frost bite injury

Answer 373

Warm up the body with warm water is the tx.

Question 374

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Frozen Shoulder

Answer 374

There is stiffnes and limited motion due to glenohumeral joint stifness. In PE range of motion in all directions is limited whether passive or active movement. This is as a result of Pericapsulitis. Majority are idiopathic. Arthroscopy establishes the dx by showing decreased joint space volume and loss of normal axillary pouch. Tx involves NSAIDa, steriods injection in the joint and physical therapy. Rotator Cuff Tear or Rotator Cuff Tendinitis presents with severe pain and weakness of shoulder abduction. Positionng arm above shoulder aggrevates the pain. Range of motion is only limited in active movement but is normal in passive flextion. A positive drop arm sign, with inability to actively maintain 90 degree of passive abduction maybe present in large tears. Tendinitis can be ddx from Tear by injecting Lidocain that would result in improvment in motion in Tendinitis but not in Tear.

Question 375

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Furosemide Tox:

Answer 375

Causes oto-toxicity. Aminoglycosides, vancomycin, quinine, and chloroquin also cause oto-tox. Aspirin causes Tinnitus.

Question 376

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Galactosemia

Answer 376

In a newborn or young infant with failure to thrive, bilateral cataracts, jaundice and hypoglycemia. Early dx and tx by removing galactose from diet are mandatory. It’s a metabolic disrorder causd by Galactose-1Phosphate Uridyl Transferace def. That leads to increse level of Galactose. DDX: galactokinase def, only have cataratct and otherwise asymptomatic.

Question 377

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Gallblader Carcinoma

Answer 377

It’s a rare tumor, found in pts with chronic Choledocholithiasis usually diagnosed intra or post operatively after cholecystectomy.*****Chronic Cholecystitis predisposes to carcinoma, in xray we can see Porceline gall bladder, due to calcium deposition in gall bladder.

Question 378

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Gastric Carcinoma

Answer 378

Pt might present with blood vomiting and Acanthosis Nigrans. Don’t be fooled into thinking that its Aspirin tox, becaseu aspirin tox doesn’t cause AN. AN is a diease that causes dark,thick areas on the skin. MC in arm pits and other folds. Its associatedciated with being over weight and other tumors like GASTRIC carcinoma. so pt needs complete work up like endoscopy and bioposy.

Question 379

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Gastric MALT

Answer 379

H. Pylori has an important role in parhogenesis of Gastric Mucosa-Associated Lymphoid Tissue Lymphoma. These Lymphomas may regress after eradication of H. Pylori, IF THERE IS NO METASTASIS. If Pylori eradication fails then Chemotherapy is the choice (CHOP). In the old days they used to do radical gasterectomy. Tx Pylori with Omeprazole+Clarithromycin+Amoxicilline.

Question 380

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Gastroschisis:

Answer 380

Bowel protrudes through a defect. Bowel not covered with protective membrane. First thing is to cover the exposed bowel with sterile wrapping, then iv access for nutrition and then iv antibiotics, then surgery to fix the defect. Omphalocele: Bowel protrudes through unbilicla ring. Bowel covered with amnioperitoneal membrane. Associated with other congenital abnormalities. Management is first wrapping, then orogastric tube to decompress stomach. If <2cm repair with primary closure if bigger Silastic Silo.

Question 381

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Gaucher’s Dis:

Answer 381

Sphingolipidosis due to deficiency of glucocerebosidase. Characterized by Hepatomegaly, anemia, leukopenia, and thrombocytopenia, but NOT chery red macula.

Question 382

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General Anxiety Disorder

Answer 382

First line of tx is Buspirone, because it does not show the dependence and withdrawl symptoms associated with Benzodiazepines. If sexual performance is a problem use Nefazodone.

Question 383

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Gentamycin

Answer 383

causes nephrotoc and Ototoxicity, vestibular toxicity that causes the pt to feel dizzy w/I a couple of weeks of use.

Question 384

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GERD - 6

Answer 384

In neonates is regurgitation after eating and failure to thrive. The child assumes the position of tilted head and arched back. Dx is 24hr pH monitoring of esophagus. When its unclear whether the pt has nocturnal asthma or GERD, a trial of proton pump inhibitor (Omeprazole) before breakfast is both Dx and therpeutic. ** Esophagoscopy is indicated when a pt fails to respond to antibiotics and or theye are signs of implications (weight loss in cancer).Dx Process: once pt presents with cough, and the vigniette says esophagoscopy is normal, the next thing is 24 hour pH monitoring. Then Manometry will confirm dx.GERD can happen due to hiatal hernia. Chronic GERD can lead to metaplastic change in lower esophagus called Barret esophagus and is a risk for Adenocarcinoma of esophagus.When pt comes in with symptoms of GERD you need to differenciate b.w Barrets,PUD,Gastritis, or tumor. Endoscopy is the most informative procedure for all these. Now if the vingette says “he has no Dysphagia” then you can skip the normal Barium test that precedes endoscopy and go straight to endoscopy.***Indications to endoscopy are: 1-Nausea/vomiting, 2-weight loss, anemia or melena, 3-Long duration of symptoms (>1-2 yr), 4-Failre to responde to PPI. So here is the order, if there if Dysphagia first do BS, then EC then Manometry. If no dysphagia, first EC and then Manometry, you can skip BS.

Question 385

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Giant cell arteritis - 3

Answer 385

Don’t wait for biposy start high dose Prednisone right away.***Lab may show elevated ESR and normochromic normocytic anemia. Thoracic aortic aneurysm is a complication of this dis, maybe due to disruption of collagen and elastin.

Question 386

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Giardiasis

Answer 386

Adheres to mucosal surfaces by adhesive disk and cause malabsorption, may lead to weight loss. The MC symptom is foul smelling sttol, fatty stool, bloating and flatulence, nausea, malaise, abdominla cramps. Empiric tx should be given w a course of Metronidazole.

Question 387

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Gilbert synd

Answer 387

Partial absecnce of enzyme leads to : 1-mild uncongugated hyperbilirubinemia, 2-More elevated values happen with stress, fasting, alcohol abuse. 3-normal cbc, 4-normal liver enzyme, 5-complete reversal of hyperbilirubinemia. DDX1:Crigler-Najar-I: cgaracterized by 1-Unconj.Hyperbilirubinmeia 8-30, 2-Normal liver enzymes, 3-High rates od Kernicterus, 4-No response to Phenobarbital. DDX2:C-N-2: characterized by 1-Unconj HyperB, 2-Normal liver enz, 3-No Kernicterus, 4-25% decrease of Bilirubin with Phenobarbital. DDX3:Rotor synd: Conjugated Hyperbilirubinemia.

Question 388

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Glascow coma scale - 2

Answer 388

EYE opening:Spontanous 4, to verbal command 3, to pain 2, none 1. VERBAL response:Oriented 5, confused 4, Inappropriate 3, Incomprehensive 2, non 1. MOTOR respopnse:Obeys 6, localization 5, Flexion 4, abnormal felxtion 3, extenstion 2, none 1. Total 15. Minor injury is GCS of >14. Moderate 9. Severe <8. **Pt with GCS of 7 in an accident is having a severe head injury. All pts with sever head injury should be intubated, with mechanical ventilation,and admin of IV fluids,analgesics and sedatives.

Question 389

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Glaucoma

Answer 389

it’s the leading cause of blindness in North America. Its characterized by elevated ICP. Symptoms are sudden onset of photophonia., eye pain, HA nasea. Eye is hard to touch. A non reactive mid dialated pupil suggest Acute Glaucoma.The best Dx is Tonometry. OPEN angle glaucoma: has incidious onsert with gradual loss of peripheral vision and consequence tunnel vision. Intraoclar pressures are high. Opthalmoscopic exam shows cupping of the optic disk.*****once you suspect it do MAPPING VISUAL FIELDS to find out defects.

Question 390

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Glaucoma, Acute closure angle 2

Answer 390

Age 55-70, Acute onset of severe pain and blurred vision, nausea and vomiting. Anterior chamber is shallow with inflammatory changes. Tonometry reveals increased IOP. IV Acetozolamide, Manitol, Pilocarpin with subseq oral. Permanent cure is laser peripheral iridotomy. Avoid Atropine.

Question 391

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Glaucoma, Acute Open angle:

Answer 391

Its more common in blacks. Gradual loss of peripheral vision, tunnel vision. IOP is high. There is cupping of the optic disk with loss of peripheral vision. Beta blockers, Timilol are effective in initial mngmnt. Later on Trabeculoplasty. Its associated with Diabetes.

Question 392

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Glioblastoma Multiform

Answer 392

GBM or HIGH grade astrocytoma. CT shows butterfly appearnce in the frontal lobe of alesion (surrounded by white calcification, looks like cyst membrane but not round). DDX is Brain Metastasis, pt will have a duration of symptoms of <2months, the site is grey-white juunction or watershed zones, they are multifocal and round. DDX2:Lowgrade astrocytoma, prestns with seisure and longer duration os symptoms.

Question 393

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Glucagonoma

Answer 393

Triad of Hyperglycemia, necrotizing Dermatitis, and weight loss. It’s a tumor of islet cells in Pancrease . The excess glucagon causes symptoms like glucose intolerance, and hyperglycemia. It also causes a distint skin lesion called ‘Necrolytic migratory erythema’. Dx is confirmed by fasting glucose elevation, elevated glucagon, and pancreatic tumor by CT. Surgery is the prefered tx. It doesnt respond to Chemotherapy.

Question 394

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Glucose 6 Phosphatase deficiency:

Answer 394

Also glycogen storage type 1 or Von Gierke Dis. Presents with hypoglycemia, lacic acidosis, hyperuricemia, & hyperlipidemia. Hypoglycemic seizure occurs. Hay hepato and renal megally. Doll face, fat cheeks, thin legs, and a protuberant abdomen.

Question 395

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Glucocorticoud SE

Answer 395

Long term use in asthmatic pt can lead to Neutrophilia by increasing BM release and mobilization of marginated neutrophil pool. Eosinophils and lymphocytes are decreased.

Question 396

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Glycogen storage diseases

Answer 396

1-Von Gierke, 2-Pompe, type 3 and type 4. Read on them.

Question 397

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Gonococcal arthritis

Answer 397

Urethral cultures have the highest yeled than synovial or blood or urine cultures in cases of suspected purulent gonococcal arhtritis.

Question 398

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Gonorrhea - 2

Answer 398

Commonly causes cervisitis, urethral discharge. It also causes Pharyngitis. *It also causes GA(arthritis), which is asymetric migratory polyarthralgia, followed by monoarticular arthritis and rash, palms and soles have multiple necrotic pustules.

Question 399

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Goodpasteur’s synd - 3

Answer 399

Involves lung and kidney. There is lower respiratory problems (hemoptosis) and proteinuria (renal failure), there is antibodies against glomerular basement membrane. Sputum shows iron in form of hemosiderin . There is anemia and RBC cast in urine. DDX1:Idiopathic pulmonary Hemosiderosis: Like GP, but there is more copious hemoptasis and its for children. DDX2: Wegner’s, involves Upper (rhinorrhea) and Lower (hemoptasis) and Kidney problems. And Granular granulomatosis. Cresent formation.*Caused by circulating antiglomerular basement membrane antibodies. Early removal is imperative in order to minimize the damage tokidney. Emergency Plasmaphoresis is indicated.Pt presents with massive hemoptosis, weightloss, hematuria and proteinuria. To confirm measure anti glumerulat basement membrane antibodies.

Question 400

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Goughers Dis

Answer 400

Is due to deficient activity of the lysosomal enz, acid beta glucosidase. The typical pt is Ashkani Jew adulescent with chronic fatigue, easy bruisability, bone pain and pathological fractures. The dx is conformed with radiologic (Erlenmeyer flask deformity of the distal femur) and bone marrow studies (Gaucher cells with wrinkled paper appearance).

Question 401

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GOUT- 2

Answer 401

Fluid joint aspiration for dx.*****In pt with frequent attacksof gout not controlled by Colchicine, a 24hr uric acid level in urine is determined. This evaluates whether hyperuricemia id due to over production or under secretion. A value of 800 indicates over production, so add a xanthin oxidase inhibitor (Allopurinol).

Question 402

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Gouty arthritis - 2

Answer 402

Very painful, mostly in toe but could happen in long term RA pt in the hands. Alcohol is metabolized to Lactate which competes with Urate for renal excretion leading to accumulation of urate in the body and gout.Cessation of alcohol is important. Acute attack give oral indomethacin, colchicine or steriods. Chronic Cholcicine.

Question 403

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Graft Vs Host Disease

Answer 403

By activated donor T lymphocytes. Targeted at Skin (maculopapular rash in palm,sole and face), Intestine (bloody diarrhea, Liver.

Question 404

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Granuloma Inguinale

Answer 404

Is an STD caused by Donovane granulomatis. Its uncommon in US and is mc in Balck population. It starts with a papule that rapidly develops into a painless ulcer characterized by irregular border and red beefy granular base. Inguinal lymphadenopathy occurs w/o Buboes. Advnced stage has scaring, depigmentation and keloids. Fibrosis may lead to vaginitis and elephantitis. Dx is by identifying Donovan bodies, visulized by giemsa or wright stain of tissue smears, and appear reddish, encapsulated bipolar bacteria found within Monocytes. Tx is tetracycline, 500mg, every 6hr, 10-21 days. DDX1:Ulcer of primary syphlis has roled edges and punched out base. DDX2:Ulcer in Chancroid is very painful and foul smelling, buboes form and are painful. DDX3:in Genital herpes many vesicles appear before they turn into ulcers. DDx4 Ulcer in Lymphogranuloma Veneruem is also painless but its shallow and associated w non-specific systemic symptoms, also lymphadenopathy is inflamatory and does not appear at the same time as ulcers.*****The first thing to do is stop Heparin. However, most pt need anticoag so two options are offered: -Danaparoid and a direct thrombin inhibitor such as Lepirudin or Argatruban.

Question 405

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Granulosa Cell Tumor

Answer 405

Are SOLID tumors. Bimodal distribution. If occur before puberty , Precociouspuberty is presented. It produces excess estrogen and causes pubic hair, hpertrophy of brest and hyperplasia of uterus. Usually removal of tumor reverses the problem. If its in postmenopausal women it causes bleedingand uterus shows myohyperplasia. DDX1 ysgerminoma, in young women and children, unilateral and go under torsion. It doesnt produce any hormones. DDX2:Sertoli-Leydig,produces androgen and DEFEMINIZATION, followed by masculinization in childbearing years. DDX3:Mature teratoma or Dermoid cysts, benign and dont produce any hormones. DDX4;Serous cystadenomas, are the mc CYSTIC ovarian neoplasm. 25% are malignant,half cases are bilateral. They dont produce any hormones. Ovarian mass and abdominla pain are presenting features.

Question 406

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Grave’s Disease - 3

Answer 406

Tx is radioactive iodine. Might cause hypothyroidism *** Sudden onset of Atrial Fibrilation (irregularly irregulat rhythm with tachycardia) in pregnant women should alert the doctor to look for Hyperthyroidism, GRAVES is the MCC of hyperthyroidism in pregnancy. Remember Dx is made by TSH, T3 & T4, BUT the best SCREENING is just TSH. So next step is ordering TSH. Now the vigniette may not even indicate other signs of Graves, but you must recognize it as well. DDX is Hydatiform Mole, but sonogram will easily show it.

Question 407

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Green stick fracture

Answer 407

Commonly seen in children because the bone is less brittle. Also see torus fracture and plastic deformation.

Question 408

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Growing Pain

Answer 408

Common in children from 2-12. Mostly at night, awakens the pt, responds to massage and NSAIDs. Obs/Reasur.

Question 409

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Guillain Barre - 4

Answer 409

The best way to monitor respiratory function is to measure serial bedside vital capacity, to make sure it stays above 15ml/kg.**DDX is Tick borne paralysis charcterized by rapidly progresive ascending paralysis, absence of feve , absence of sensory abnormality and normal CSF. ****Campylobacter Jejuni is the most frequent precipitant in GB. **GB is characterized by Ascending paralysis , previous hx of infection, CSF shows albumino-cytologic dissociation(Elevated protein despite normal cell count). Tx is IVIG and plasmophoresis. DDX is Botulism which presents with desceing paralysis, tx is antitoxin.

Question 410

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Gun Shot wound:

Answer 410

If its below 4thrib, level of nipples, then exploratory laparatomy is done.

Question 411

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Hairy Cell Leukemia - 2

Answer 411

It’s a type of B-lymphocytic derived chronic leukemia. Tartrate resistant acid phosphatase stain is Dx.**Picture looks like hairy projections of large cells. BM may become fibrotic so BM aspirate are frequently unsuccessful (Dry Tap). Tx DOC is a purine analog, Cladribine.Its toxic to BM, it causes neurological and kidney damage. Remember CHOP is for Nonhodgkins, Chlorambucil+Prednisone are for CLL.

Question 412

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Hashimoto Thyroiditis - 2

Answer 412

Transient thyrotoxicosis can occur in initial stages due to thyroid-stimulating antibodies. Positive anti-thyroperoxidase antibodies with an enlarged rubbery goiter are virtually diagnostic. The risk of thyroid Lymphoma is 60times greater in these pts. CT shows elragemnt of thyroid around trachea, “Doughnut sign”. US shows “psudocycst pattern”. RAIU is decreased. Since FNA might miss dx, Core biopsy is prefered. * Anti Thyroid Peroxidase Antibodies are present in >90% of pts.

Question 413

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HCV

Answer 413

If pt is + but no sign and symptoms, just follow up w yearly tests. No Tx.

Question 414

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Head trauma - 2

Answer 414

always do spine xray in pt with falls or accidents leading to head trauma. ** Pt with increased ICP should be treated with hyperventilation , head elevation, and IV Manitol and diuretics. Hyperventilation works by causing vasoconstriction and decreasing the ICP by decreasing cerebral blood flow volume.

Question 415

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Heart Block - 2

Answer 415

1-First Degree: prolonged but constant PR >0.2s . No tx is neede. 2-Mobitz Type-1: or Wenkeback, narrow QRS and progressive increase in PR until a ventricular beat is dropped. It may occur with Digoxin, or Inferior MI. If pt is symptomatic Atropine is gven. 3-Mobitz Type-2: Fixed PR with occasional drop . QRS is wide. Its seen after MI. Its dangerous and all pts have to be monitored in ICU. It can progress to complete heart block and needs Pace maker. Atropine must be by bed side at all times until a permanant pacemaker is inserted. *****Third degree heart block, no atrail impulses will travel to ventricles. , Atrail rate is 80 and Vent is 30. Pts are at risk of suden cardiac death and they should be transmitted to ICU and PERMANENT pacemaker should be placed. Always have Atropine by bed side. B-blocker WILL KILL HIM IMMEDIATELY.

Question 416

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Heat Exhaustion

Answer 416

Characterized by volume depletion under the conditions of heat stress. DDX:Heat Stroke, has CNS symptoms and T>40. DDX2:Heat Syncope:breif syncope after exposire to heat. DDX3:Heat cramps: painful muscle cramps due to depletion of salt in muscles.

Question 417

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Heat stroke

Answer 417

Characterized by body T of >40.5, due to filaure of thermoregulatory center. Rapid Evaporation cooling is the tx of choice. Immersion in ice water is also useful but makes it difficult to monitor the pt.

Question 418

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HELLP Syndrome

Answer 418

Hemolysis & Hypertension (preeclampsia), Elevated Liver enzyme, Low platele(thrombocytopenia). DDX are DIC, Preeclampsia, TTp, HUS, and Acute Fatty Liver of Pregnancy. In AFLP tx is supportive with early dx and rapiddelivery, there is incresed PT & PTT. In HUS, thrombosis of the glomerular arteries, happens in children. Often preceeded by infection. . TTP is wide spread of HUS and it occurs in Adults and Associated with NEUROlogical symptoms. Tx is exchange transfusion or plasmaphoresis with FFP**Delivery is definitive tx for HELLP in women beyond 34 weeks, give Mg SO4 to reduce BP & VAGINAL deliver.

Question 419

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Hematochezia, scant

Answer 419

Pt see fresh blood on toilet paper. Most common causes are hemorhhoids, fistulas or even cancer. If pt is <50 chance for cancer very low. Do Anoscopy first and then if still nnot clea do sigmoidoscopy or colonoscopy is done.

Question 420

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Hemi Neglect Synd

Answer 420

Involves the Right (Non dominant ) parietal lobe.

Question 421

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Hemochromatosis - 3

Answer 421

Genetic disorder of iron absorption, increased aborption from intestine . Liver, pancrease, heart and joints are mc affected. Pt prsents with weakness, loss ob libido, skin pigmentation, weight loss, abdominal pain and symptoms of DM (polyuria& polydypsia). Trensferin saturation (>=50%) and Ferritin (>1000) is a simple reliable sreen test. Hepatoma(Hepatocellular Carcinoma) is the most serious complications. Hay increased Fe and Feritin. Its Auto Recessive causing increased iron absorp and deposition in skin (pigmentation), Testes(decreased libido), pancrease (Diabetes), Joints (Arthralgia), and liver (cirrhosis). Pts are at increased risk for Listeria Monocytogenes, maybe due to impaired phagocytosis. Iron overload is also a risk for Yersenia Enterocolitica and sepsis from Vibria Vulnificus which are iron loving bacteria.*** IF pt presents with Joint pain and Hepatomegally and no other sysmptoms suspect it and FIRST thing you do is CBC to check Fe level. It presents with hepatomegaly,hyperpigmentation,diabetes (BRONZE diabetes), arthropathy, heart failure and hypogonadism.

Question 422

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Hemolytic Uremic Synd - 4

Answer 422

When you get Thrombocytopenia (decreased platelet 56000), a MicroAngiopathic Hemolytic Anemia(MAHA) (Increasesd bilirubin, and schitzocytes and RBC fragments and abnormal renal function) in a pregnant woman DDX include HEELP(Hemolysis, Elevated Liver enzymes, Low platelet count), HUS, TTP, DIC, preecclampsia and Acute Fatty Liver of Pregnancy (AFLP). Oliguric renal failure+MAHA+Thrombocytopenia points to HUS. Its characterized by thrombosis of the glomerular arterioles and capilaries. It occurs more frequesntly in childhood and presents with fever, thrombocytopenia, MAHA, HT and renal failure. Usually preceded with viral infection and associated with E. Coli. TTP is a variant of HUS, the thrombosis is systemic and it obstructs microvascular of several organs. It presents with fever, altred level of consciousness, focal neurologic signs, renal failure, MAHA and thrombocytopenia. tx is exchange transfusion, or plasmophoresis with FFP. HELLP is a variant of preeclampsia, in women older than 25, multipara, before 36 weks gestation. DIC is a comsumptive coagulopathy, Presents with elevated PT, PTT, fibrin degradation product and decreased fibrin. Occurs in young children. Preceeded by a diarrheal disease. Hallmark is Microcangiopathic hemolytic anemia. Other features are renal filure, fever, oliguria, thrombocytopenia. GI bleeing is common. Purpura and HT. Schizocytes, which represent frabmented RBC. Also Giant Platelets. Intravasculat hemolysis results in elevated LDH, indirect bilirubin and reticulocyte count. BUN andCrt are markedly elevated. . Urine contains, Hb, Hemosiderin, albumin, RBC,WBC and casts.Its caused by E.coli released toxin, it injures kidney epithelium. Pt prsents with abdomnal pain, young pt, decreased Hb,Hct and Platelets. , bloody diarhea and swollen face. When kidney is damaged mortality is 5-10%.*****Its caused by toxin released by E.Coli, it destroys epithelial lining and causes bloody diarrhea. Subsequesnt activation of coagulation system and red cell hemolysis causes Jaundice. Its mc in children adn initial presentation is abdomnal pain and diarrhea. The classis TRIAD is Uremia(Renal Failure), Thrombocytopenia, and Hemolytic Anemia. Tx is generally suportive and involves Plasmaphoresis and Dialysis if necessary and steriods. DDX it with Campylobacter jejuni, althought it causes bloody diarrhea, there is no Thrombocytopenia.

Question 423

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Hemophilia

Answer 423

Bruising since child hood, excessive bleeding in a tooth extration procedure and uncle having the same problem. In these pts recurrent Hemarterosis ma lead to injury called ‘hemophilic arthropathy’. Iron (HEMOSIDERINE) deposition and synovial thickening with fibrosis is characteristic. ***** Its X-linked. PTT is elevated and PT & BT are normal.

Question 424

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Hemothorax

Answer 424

Collectin of blood in pleural cavity. Tachypnea,tahcycardia,hypotention, deviated trachea , dullness to percusion, elevated JVP, fluic in pleural cavity(seen in Cxr) and collapsed lung. . Lung is the usual bleeding source 2ary to rib fracture. Its very important to evacuate the blood in order to stop bleeding, which stops on its own. Best initial interventon is to insert a low anterior chest tube to remove blood. Surgical Thoracotomy is indicated when more than 1500ml blood recovered when tube is inserted, or if more than 600ml blood loss after 6 hour post tube insertion.

Question 425

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Henoch-Schonlein Purpura

Answer 425

A common vasculitic of childhood, its commonly seed after URT infection and is more common in males. Classis findings are palpable Purpura in buttucks and lower extrmity. Peripheral edema nd scrotal swelling. Renal finding are Hematuria dn proteinuria. Tx includes steriod and monitoring renal function. When pt prestns with Abdominla pain two pathologies should be rules out emergently, GI bleeding and Intussuseption. Intus is characerized by sudden onet of abdominlapain with large amount of blood in stool. This is a surgical emergency and is tx with Air/barium enema.*****HSP is an IgA mediated vasculitis of small vessels, which results in rashes, arthralgias, abdominal pain and renal disease. Immuno florescence microscopy reveals IgA deposition in the kidney.

Question 426

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HepA

Answer 426

Acute disease associated w travelling. If travel 4 weeks give vaccine.

Question 427

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Heparin induced thrombocytopenia - 3

Answer 427

Its seen in 5-15% of of pt taking Heparin with onseet b/t 3-15 days and resolution in 4-5 days of discontinuation. While PTT is a therapeutic effect of heparin, the thrombocytopenia is an adverse effect. So PTT is increased and Platelets are decreased.**Hospitalized pt who develop DVT after a period of bed rest are standardly treated with Heparin. An adverse effect is Thrombocytopenia, along with thrombosis (causes stroke sysmptoms). The combination os Arterial/Vnous thrombosis and thrombocytopenia in pts receiving Heparin is suggestive of HIT. Antibodies against Heparin-Platelet factor 4 complex are responsible for this. The antibodies activete platelets which will cause their removal form circulation.

Question 428

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Hepatic Adenoma

Answer 428

Is a benign tumor seen in mieedle age females taking OCP . Intra tumor hemorhhage is a major comlication. Dx is by bipsy, atypical hepatocytes with glycogen deposits. Tx Superficial and large adenomas are resected. But smaller and asymptomatic onces are under surveilance with imaging.

Question 429

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Hepatic Encephalopathy - 3. Hepatology. 6/3

Answer 429

Characterized by reversal of sleep cycle, asterixis, porgreive coma, and Delta waves in EEG. It’s a CNS complication of liver failure secondary to accumulation of ammonia in blood becuase of inability of live to detoxify ammonia (that comes from intestine) into urea. Eliminating toxic enteric products is the other main therapy: (1) The bowels should be cleared with enemas. (2) Dietary protein should be eliminated, and oral or IV carbohydrate should be given. (3) Oral lactulose should be given. (4) Oral neomycin.**Pt with hepatic failure should be given vit K to correct PT and if they are bleeding in this setting, or he needs immediate surgey, then FFP is indicated.Platelet transfusion is only indicated if it falls below 20,000-30,000. Cryoprecipitate is requied for coag factor def like factor VIII. Packed RBC is indicated when RBC is <10 in symptomatic pt.

Question 430

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Hepatitis B -8. GIT. 6/3

Answer 430

Hepatitis B virus Ig + Lamivudine is used to prevent recurrent HBV after liver transplant.For HepB Interferon+Lamuvidine. Vaccination criteria: if someone is exposed and has Documented response there is no need for furthur action. If vaccined but no response to vaccine must be vaccined again. If vaccined many times and still no response, give HBIG on exposure. If exposed to virus and never been vaccinated before, give HBIG w/i 24 hrs and start HBV vaccination. Best screening test to dx acute HepB is AntiHBcAg and HBsAg. ** HepB vaccine is a recombinant vaccine containing HBsAg, which stimulated Anti HBsAg, person who receives it will have immunity and thus be positive for Anti HBsAg and negative for HBsAg. Person with ACUTE HBV will have HBsAg, HBeAg and IgM Anti HBcAg. Chronic HBV will have HBsAg only, for >6months. Person with recovery phase HBV will have AntiHBsAg, HBsAg, Anti HBeAg and ABSENT HBeAg. **If seroogy shows HBsAg, HBeAg positive and high titers of HBV DNA, he has Chronic HEpB. The 2 drugs approved are Inerferone and Lamuvidine. Either one is indicated for pt with positive HBsAg,HBeAg,HBV DNA and persistantly elevated ALT. Degree os elevation of ALT is important in deciding the Tx. Serum ALT of mor than two times the upper limit requires need for Lamuvidinr or alpha interferone. If less than that its not useful. Generally Lamuvidine has less SE and easier to administer (ORAL). Inteferone is not successful in young children and immunocompromised pts. NOW, if the pt has just been exposed to virus, POSTEXPOSURE and has never had response to vaccine, we give vaccine+Ig, and if did have response and has antibodies then we just give Ig. **Of all acute Hep B cases 90% recover, minority go to chronic, out of those 1% goes to Fulminant hepatic failure, defined as hepatic encephalopathy that develops w/I 8 weeks of the onset of acute liver failure and evidence by marked increase in ALT. and signs of Hepatic encephalopathy. Liver transplantation is the only effective method for tx, so initial step in tx at this point is to put her name on the list**Newborn of mothers with active HebB should be passivly at birth with HepB immunoglobin followed by Vaccination. **Transmission from mother w chronic dis & +HBs antigen and Hbe antigen to the fetus is 90%.*If given choice b/w Interferon and Lamuvidine in a depressed pt, pick Lamuvidine cause interferone is CI in Psych pts..

Question 431

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Hepatitis C - 4

Answer 431

Risk factors for rapid progression of liver fibrosis in chronic HepC are: 1-Male sex, 2-Acquire infection after age of 40, 3-Co-infection with HepB or HIV, 4-Alcohol intake. Complications of Chronic HepC: 1-Cryoglobulinemia (causes Membraneous glomerulonephritis), 2-B-cell Lymphomas, 3-Plasmocytosis, 4-Autoimmune dis like Sjogren and thyroiditis, 5-Lichen Planus, 6-Porphyrea cutanea tarda, 7-ITP. Management: All pt with mild Hep C(alevated ALT,HCVRNA, moderate bridgenecrosis) should get Interferone+Ribavirin. Liver transplantation is the last step and its done when Pt and Albumin levels are very affected. ** HCV RNA is the single most sensitive serological marker to screen HepC, HCV RNA antibody takes months to show up dont do that one. ** All pts with chronic HepC, including Pregnant women, should be tested for HepA and HepB and if not immuned should be vaccinated which is safe for pregnancy. Ribavirin & Interferone are teratogenic.Transmission risk could be a steady sex partner but the chances are low.

Question 432

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Hepatitis E

Answer 432

Associated with pregnant women.Ocurs in India,Asia, Africa and central USA.Ther is no vaccin or Ig avaible for HepE.

Question 433

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Hepatocellular carcinoma- 2

Answer 433

Most are palpable mass. It accts for 80-90% of liver cancers. Occurs more often in men. Cause is unknown but contributing factors are Chronic liver disease, HepB & HepC, hemochromatosis. Dx is by abdominal CT. ***High serum AFP (>500) in an adult with liver disw/o an obvious GI malignany is HCC. Pt has a hx ox Chronic HepC. Dx is confirmed by biopsy, Tx is surgical resection.

Question 434

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Hepato-Renal Synd

Answer 434

…

Question 435

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Hypotension, Hyponatremia, Azothemia and oliguria with normal urine analysis with sever liver disease. No tx is available. Pathogenesis is not clear. Initial mgmt is careful volume loading and withholding of Spironolactone and Furesamide.

Answer 435

…

Question 436

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Hereditary Spherocytosis - 3

Answer 436

Osmotic fragility test is dx.An auto RECESSIVE dis. Folic acid is encouraged in ALL pts. MCV is normal or Elevated. They rarely require transfusion unless they have Aplastic crisis. Splenectomy is usually curative.*The tx for most pt involves Folic acid oral and blood transfusion. during periods of extrmem anemia. Splenectomy is considered if htey are refractory to medication. The most feared long term complication is overwhelming sepsis with encapsulated bacteria Strep Pneumonia. The risk is present for up to 30 years and even longer after splencetomy. Current recommendations state that pt shuld receive anti-penumococcal,Haemophilus and Meningococci Vaccinces several weeks before the operation and daily oral Penicilline prophylaxis for 3-5 years following splenectomy.

Question 437

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Herion Withdrawl

Answer 437

Signs are muscle spasm, abdominla pain, rhinorrhea , lacriation, sweating. Dilated pupils. These are oppsit signs when pt is toxicated, pin point pupil, constipated, depressed respiration and bp. DDX is Cocain withdrawl:irritable, fatigue, HUNGRY(opped to anorexic when toxicated).

Question 438

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Hernia

Answer 438

Respiration and hemodynamics are altered after repair of large hernias. Because large hernia content is displaced inside the peritoneal cavity, the pressure inside the cavity increases. The diaphram is pushed upwards and this impaires respiration, causing hypoventillation. At least a week is needed for the pt to accomudate to its new state. Early physiotherapy and respiratory excercises (blowing against resistance) are mandatory to prevent , Atelectasis, mucus pluggung and possible subsequent penumonia development.

Question 439

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Herpes Simplex Encephalitis -2

Answer 439

Mainly affects the Temporal lobe, bizare behavior and gustatory hallucination. CSF show Lymphocytosis, low glucose, and elevated proteins. HSV PCR is the gold standard. Tx Acyclovir.

Question 440

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Herpes Simplex Keratitis or Herpetic Keratitis due to HSV-1

Answer 440

Simplex More common in young pt. Zoster is mc in old pt. DX is with Slit lamp. Common in health workers.

Question 441

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Herpes Zoster Ophthalmicus

Answer 441

DDX with Herpes simplex keratitis is addition of vesicular rash in Varicella-Zoster. “Bacterial keratitis” occurs w contact lenses.

Question 442

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Herpetic Whitlow

Answer 442

Is the mc viral infection of the hand. The appearance of vesicles on the volar or dorsal distal phalanx is diagnostic. Caused by type I or II herpes simplex and its self limiting. Dentist are at increased risk.

Question 443

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Hirshsprung dis - 2

Answer 443

Pts with Down, are more likely to present with Duedenal atresia, Hirshsprung, endocardial cushin defect and acute leukimia. Typically there is a “double buble sign” is seen in abdominla radioraph.**This is an emerrgency, so if the infant has it and mother refuses tx, then go ahead and treat the infant because court order will take a while.

Question 444

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Hirsutism

Answer 444

Women produce androgens. DHEA-s and Testosterone in adrenals and ovaries. DHEA-S is only in adrenals by adrenal tumors. See T2-Q16. ACTH increase in pts w hirsutism is seen with ectopic or pituitary dependant Cushings dis. ACTH increases the production of cortisol as well as angrogens from the adrenal glands, however, the adrenal glands show diffuse hyperplasia rather than a discrete adenoma.

Question 445

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Histoplasmosis - 3

Answer 445

Is a common and asymptomatic infection in endemic areas of Mississippi & Ohio. Found in bird or bat dropings. ***** It’s the mf endemic fungal infectinin USA. Disseminated histoplasmosis occurs in immuncompromised pts. Presnece of mucous membrane ulcers, hepatospleenomegally and pancytopenia are clues to Dx. ** Tx is IV amphotericine followed by lifelong Itraconazole. Histoplasmosis happens to HIV pt in OHIO.

Question 446

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HIV- 30

Answer 446

TB occurs in the course of HIV when the CD4 counts are >200. Uper lobe consolidation and cavitation is typical Xray fiding. Associated with Hairy Leukoplakia (white painless lesion that appears hairy, found on the tounge, caused by EBV). All HIV pt should have the following done: 1-Hx & PE, 2-routine chemistry and hematology, 3-two plasma hivRNA levels, 4-CD4 count. 5-VDRL for syphlis. 6-PPD test. 7-Anti Toxoplasma antibody titer. 8-MMSE. 9-Pneumococcal vaccine, unles CD4 is 5mm in HIV pt then Prophylactic theapy with Isoniazide + Pyridoxine is indicated for 9months. ** in a pt with bilateral interestitial pneumoni, the agent is PCP. Tx is Trimeta-Sulfa, in pt with moderate to severe infection adding corticosteriods has reduced mortlity. Indication for steriod is 1-PaO235. * Best screening test is Eliza, then confirmatory with Western bloting. *** Multiple ring enhancing lesionson on CT in aids pt, is tx w Sulfadiazine and Pyrimethamine which is both diagnostic and therapeutic. Remember trimeta-sulfa is for prophylaxis. If health worker is infected, right away get blood for serology and start him on 3 drug therapy while waiting for results. Blood serology should be repeated in 6 weeks, 3 and 6 moths. ** HIV pts are at increased risk of TB which may cause collapse of vertebral bodies and intervertbral disk. DDX of Diarrhea in HIV pt with CD4=80. 1-Cryptosporidium :Modified Acid fast stain shows Oocytes in stool. It becomes persistent in CD200. *** PML (by JC virus) presents in HIV pt with CD490% effective in dignosinfg PCP in HIV pt, especially when CD50% have encephalitis. Necrosis of inner retina as white flyffy lesions. 3-Herpes Simples Keratitis, pain, photophobia and decreased vision. Dendritic ulcer is the mc presentation. 4-Herpes Zoster Ophtalmicus, mostly in elderly, or HIV pt. Presents with fever, malaise, itching and burning around the eye. Vesicular rash following trigeminal nerve. If eye is involved hay conjunctivitis and dendriform corneal ulcers. 5-HIV Retinopathy, presents as benign cotton wool spots in retina which remits spontaneously. **Tx for Condylomata Acuminata is Podophyline. ***Cryptococcal Meningitis infection in AIDS pts, tx ia iv Amphotericin+Flucytosine.

Question 447

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Hodgkin’s :

Answer 447

Tx is ABVD. Adriamycin SE is cardiomyopathy. Bleomycin SE is pulmonary. Dacabrazine is Ematogenic. Vinblastin SE is Neuropathy leading to constipation.

Question 448

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Homocystinuria

Answer 448

Marfan features+mental retardation+thromboembolic events+downward dislocation of the lens is suggestive. Tx is high dose Vit B6.

Question 449

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Hordeolum ( Stye)

Answer 449

a common staph abscess of the eyelid. Tx is warm compresses. Incision and drainage is performed if resolution does not begin in the next 48 hours.

Question 450

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Hormone Replacement Therapy:

Answer 450

According to 2005 studies HRP increases the risk for Cerebrovascular accident, CV disease, Breast Cancer and DVT. It Decreases the risk of Hip fracture, Colorectal cancer and vulvovaginal atrophy.

Question 451

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Human Bites

Answer 451

Tx of choice is Amoxicilline/Clavulanic.

Question 452

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Humeral Fractures

Answer 452

Tx of choice is closed reduction and hanging cast. In cases of Segmented fragtures, or open fracture in trauma, pathologic fracture and vascular structures, open reduction and internal fixation is done.

Question 453

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Huntington - 2

Answer 453

Atrophy of caudate nucleous is characteristic. Mood disturbance, Dementia, Chorea and family history.

Question 454

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Hyaline membrane dis

Answer 454

should be suspected in preerm infacnts. With respirtory distress and hypoxia, NOT responding to oxygen therapy. The characterisric cxy shows fine reticuar granularity of the lung parenchyma. Tx includes early ventillation and surfactant.

Question 455

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Hydatid Cyst of Liver

Answer 455

Is due to infection with Echinococcus ganulosis. Can be contacted from dogs. It can cause Cyst in lung,muscle,bone,liver. In most pts its asymptomatic. “Eggshel calcification” of a hepatic cyst on CT is highly suggestive. Aspiration is NOT indicated due to chance of anaphylactic shock. Tx is surgical resection under the cover of Albendazole.

Question 456

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Hydrocele

Answer 456

1-Non Communicating Hydrocele is refered to a fluid containing sac which is a remnant of processus vaginalis. The upper limits of the mass is easily identified. Most cases of NCHC will dispear spontanously by the age of 12 months. 2-Communicating Hydrocele, the upper limit cant be reached and it treated with surgery.

Question 457

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Hydrocephalus

Answer 457

Happens in infants. CT scan , dialation of entire ventricular system with distinct enlargment of subarachnoid space ofer the cerebral cortex), is very suggestive of non-communicating or commuicating hydrocephalus.Accumulation of blood in subarachoid space may destry Arachnoid villi and whose job is to absorb CSF and lead to hydrocephalus. SAH is the mcc od communicating hydrocephalus. Its very common in PREMATURE infants. Non-Communicating hydrocephalus examples are Dandy-Walker and Arnorld-Chiari. DW shows a cyctic exapansion of fourth ventricle, and AC will rreveal posterior protrusion of posterior fossa through foramen magnun.

Question 458

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Hydroxychloroquine

Answer 458

is the safest drug for SLE but rarely it may cause serious eye dis including Macular degeneration, so eye exam at 6mo to 1yr intervals should be performed. Remember the mc SE is Alegic skin reaction. Also CI is G6PD Def.

Question 459

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Hyperandrogenism

Answer 459

A female prsetns with virilization, balding and clitonegaly. What to do next? Rapidly developing hyperandrogenism with virilization is indicative of androgen-secreting neoplasm of OVARY or ADRENAL. So next measure serum Testosterone and DHEAS to determine the site of tumor. Elevated Testosteone level with noraml DHEAS indicate ovarian source, but Elevated DHEAS with normal Testtosterone indicate Adrenal source. Now dont try to measure 17-HO, because that is for Congenital Adrenal Hyperplasia and happen very early inlife.

Question 460

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Hypercalcemia - 8

Answer 460

Hypercalcemia due to metastatic tumor (Breast) cancer. In all womem w metastaic breast cancer and radiographic lytic bone disease who are receiving either hormone therapy or chemotherapy (Tamoxifen), IV Pamidronate (Biphosphonate) is recommended. * In acute severe hypercalcemia, its importnant to FIRST give IV 0.9% Saline before giving Furesamide. Its complicated read MERCKs. * Constipation is the mc GI presentation in pt. The important renal manifestation is neprolithiasis. Chronic therapy with vitD is a major cause for Hypercalcemia. Tx is stopping vitD tx and low calcium diet, keeping urin acidic and give corticosteriods. **Hypercalcemia is the mc Paraneoplastic syndrom that is associated with Squamous CC lung cancer. Hypercalcemia production is due to ectopic PTH related petide (PTHrP) production.Immobilization can lead to HyperCa. Prolonged bed rest can lead to accelerated bone resorption, OsteoClastic activation in increased bone turn over is established. Biphosphonate therapy is helpful. DDX:Rhabdomyolysis, HypOcalcemia (not HyperCa) is seen, normaly du eto increased binding of Ca to Phosphorous that was released by muscle. DDX2:Hypercalcemia due to Malignancy, Causes include local osteolytic metastasis, secretion of PTHrPand increased 1-25VitD. DDX3:Hypoalbuminemia, Any change in albumin levels will affect total serum Ca levels w/o affecting the ionized fraction. In pt with decreased albumin total serum ca is decreased.Malignancy is a frequent casue, lilke Breast cancer. There are various mechanism by which cancer causes hypercalcemia. 1-Procuction of Cytokins:Tumors that are metastatic to bones cause local osteolysis by production of Cytokins like IL-1 and TNF. The mf tumors that produce hyperalcemi byt his method are lung and breast cancer. .2-PTHrH (related hormones):Themcc of Hypercalcemia in pt with non-metastatic solid tumors is production of PTHrH. in these pt PTH is low. 3-Calcitriol:Hypercalcemia in case of Hodgkins is due to Calcitrol 4-Ectopic PTH:Its very rare and has been reported in ovarian cancer, lung cancer and neuroectodermal tumurs.Hypercalcemia 2ary to malignancy is dueto multiple reasons, including osteolytic metastasis, secretion os PTHrP, increased formation of 1,25-dihydroxyVitD, increased interleukins-6. Generaly, hypercalcemia due to malignancy(2ary HCa) is higher than primary HCa. *****Pt with Squamous cell carcinoma will have Hypercalcemia, now if he vomits, he will be at risk for Acute Hypercalcemic Crisis. Tx is first normal saline for hydration and 2nd Furesamide to maintian urine output at 200cc/hr. Biphosphonate Pamidronate would work too, but by givng saline you both take careof hypercalcemia and hydrate to prevent Azothemia (renal failure) in the pt.

Question 461

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Hyperemesis Gravidarum:

Answer 461

In a pregnant female in her first trimester, who presents with severe and persistant vomiting think of HG. It is severe enough that requires admission. Cause is unknown but related to elevated HCG, which maybe indicative of Hydatiform mole. Order HCG to confirm that levels are consistant with the stage of pregnancy.

Question 462

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HyperKalemia - 4

Answer 462

MC due to Rhabdomyolysis. Ekg shows Tall T waves. Calcium Gluconate is given first and then Insulin, glucose and Kayexalate. Insulin drives K in to the cell, its given with glucose to prevent hypoglycemia, and Kayexalate exchanges Na for K in GI and excretes K. * Caused by either Medication (K sparing diuretis, ACE inhibitors, NSAID) or PseudohyperKalemia (the lab sample is hemolysed), decreased renal K excretion, transcellular shift, increased K intake. The most serious SE is cardiac toxicity, so do an EKG in ALL pts. It shows peaked T waves, prolong PR and QRS, progressive widening of QRS leads to Ventricular Fibrillation or Asystole. The approach to Tx depends on EKG and degree of HyperKalemia. Immediate tx is needed if there is cardiac toxicity, muscular paralysis, or K>6.5. For these pts 10ml of 10% calcium gloconate stabalizes cardiac membrane. To lower K level , insulin or B2 agonist is used since they drive K into cells. Sodium Bicarbonate can also drive K into cells. Slower acting tx is loop or thiazide diuretics which excrete K. Dialysis is reseved for pts with renal failure and those with lilfe threating hyperlalemia wich wont respond to medication. So…If the pt is Asymptomatic and just non malignant hyperkalemia, just discontinue Amiloride ( to get rid of K ) for a weak and recheck. If the pt has evidence of cardiac tox or K is >6.5, then give Calcium Gloconate and IV Dextrose plus Insulin. ** best drug to excrete K from body is Kayaxelate.

Question 463

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Hyperparathyroidism - 3

Answer 463

Increaed Calcium, decreased phosphate, increased PTH. Could be Asymptomatic. While all pt with symptomatic HPTshould have parathyroidectomy, not all Asymptomatic pt need this surgery. Criteria is as follows: 1-Serum Ca level at least 1mg/dl above upper normal lilmit, 2-24hr urinary Ca above 400mg, 3-Young age< T-2.5 at any site, 5-difficulty in follow up if the pt. Hyperparathyroidism s associated with Pseudogout, Joint fluid aspiration reveals rhomboid shape calcium pyrophosphate crystals with positive bifringent. Tx is Colchicine, Indomethacin often stops acute attacks promptly.Primary HPT is the mcc of hypecalcemia in ambulatory pts. Its associated with elevated PTH and decreased phsphorous. Now CRF can lead to SECONDARY HPT, PTH levels are higher in 2ary than Primary HPT, Ca levels are normal to low in 2ary HPT because cause of elevated PTH level is hypocalcemia.Now in Sarcoidosis there is increased conversion of 25-hydroxy VitD to 1,25 hydroxy VitD. thereby increased absorption of calcium from GIT and hypercalcemia, PTH is supressed.**Asympomatic Primary Hyperpara: HyperCa, HypoPO4, Elevated PTH. Its common in female >60, identified during routin lab work. While Parathyroidectomy is needed for all symptomatic pts, not all Asymptomatic pts need surgery. Criteria includes: 1-Serum Ca level at least 1mg/dL above the upper limit of normal. 2- 24hr urinary Ca level >400mg. 3-Young age <50. 4-Bone Mineral Density lower than T-2.5 . 5-Difficulty to follow up pt.

Question 464

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Hypertension - 7

Answer 464

In elderly HT leads to Benign Nephrosclerosis. HT is the 2nd mcc of renal dis in US. The process of kidney damage evolves from Nephrosclerosis to Glomerulosclerosis. Nephrosclerosis is characterized by hypertrophy and intimal medial fibrosis of renal arteries, whereas, GlomeruloSclerosis is progressive loss of glomerular capilary surface area and glomerular and peritubular fibrosis. Microscopic Hematuria and proteinuria occurs due t glomeriular lesions. So pt presents with Anemia (decreased Hb). DDX iabetic Nephropathy, is the leading cause of end stage renal disease in US. Increased extracellular metrix, , basement membrane thickening, mesangial expansion and fibrosis characterize DN. Isolated SYSTOLIC HT, is an importnat cause of HT in Elderly.Pathophys is decreased elasticity of arterial wall, leading to increased SYSTOLIC bp, w/o diastolic bp leading to wide pulse pressure.Hydrochlorothiazide is the DOC. DDX:Aortic Insufficiency can cause the same systems, Echo will differentiate.Tx of choice for Pt with Intermittant claudication due to atherosclerosis and HT is Ca chanle blocker. OCPs are common causes of 2ary HT caused by Estrogen mediated increase in in teh synthesis of Angiotensinogen in the liver. So stop taking the OCP and HT should go back to normal. If it didnt then its Essential HT and life style modification can be tried. If that didnt work either, then the next step is Thiazides.Alcohol is a risk factor for HT, Smoking is not.***The tx of choice for Isolated Systolic HT (150/70,160/78) is Thiazides low dose. **Lifestyle modification should ALWAYS be a part of mngmnt. All pts should be encouraged to lose WEIGHT , reduce SALT, avoid excess ALCOHOL (3bottle a week is excess). and stop SMOKING. This is more important than DRUG MODIFICATION. REMEMBER.

Question 465

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Hypertensive Retinopathy -2

Answer 465

Don’t show any symptoms associateds with visual loss. Initially hay focal spasm of arteriols followed by progressive sclerosis and narrowing. Fundoscopy may reveal AV nicking, coper or silver wiring, exudates and hemorrhages.*****Grade1=slight AV nicking. Grade2=Copper wiring, AV depression with humping heads. Grade3=Silver wiring, flame shaped hemorrhages, exudates. Grade4=Flame shape hemorrhages, exudates and papil edema.

Question 466

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Hyperthyroidism - 5

Answer 466

Hyperchlosterolemia (increased LDL) is the most frequent lipid abnormality in pts. High estrogedn levels in pregnancy result in increase TIBG production by liver. So production of T4 nd T3 is increased (but not Free ones) . This increase however does not result in clinical symptoms because excess T3&T4 are bound to excess TIBG. And since Free T3&T4 are the same TSH will be normal.Atrial Fibrilation is a common complication in hyperthyroidism, Graves disease. In pts with Hyperthyroidism related tachysystolic Atrial Fibrilation a beta blocker,propranolol, is the doc. ** Antithyroid drugs, PropylThioUracil and Methimazole are associated with Agranulocytosis. Immune destruction of granulocytes starts w/i 90 days post therapy. Fever and sore throat are indicative of Agranulocytosis. Monitering in ineffetive. Stop othe drug immediately.**Palpitation should make you think of it. Thne the 1st test is TSH, almost all pt have low TSH (only exception is TSH secreting pituitary Adenoma). If TSH is low then measure Free T4, if its elevated Dx is established. Then do 24-hr thyroid radioiodine uptake to ddx Graves form the rest. Propranolol is initially used for symptoms until definitive cause is known. Radioactive iodine is tx of choice for ALL Grave’s pts, however, Propranalol is STILL best initial choice. PTU can be used but hyperthyroidism can recur w/i 6 months. So PTU is only used when Iodine tx is CI, like in Pregnancy. Subtotal Thyroidectomy is also curative but its not the INITIAL tx of choice.

Question 467

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Hypertrophic Osteoarthropathy

Answer 467

Characterized by chronic proliferative periostitis of long bones , clubing of fingers and synovitis, Its associated with Squamou cell carcnimoa and Adenocarcinoma of the lung.

Question 468

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HypoCalcemia

Answer 468

Plasma calcium exists in three forms: ionized calium (45%), ALBUMIN-BOUND (40%), and calcium bound to organic and inorganic anions. Homeostasis of these forms is significantly influenced by the extracellularpH level. An increased pH level causes an increase in the affinity of serum albumin to calcium, thereby increasing the level of albumin-bound calicium, and consequently decreasing the levels of ionized calcium. Ionic calcium is the only physio logically active form, which means the decreased levels of this form can result in clinical manifestations of hypocalemia (crampy pain, paresthesias and carpopedal spasm). Increased extracellular pH levels (Respiratory Alkolosis) can cause an increase in the affinity of serum albumin to calcium, thereby increasing the levels of albumin-bound calcium, and consequently decreasing the levels of ionized calcium leading to hypocalcemia. **Hay increased DTR. **Hypocalcemia can occur during or right after SURGEY, especially if transfusion is involves. First manifestation is increased DTR. HypoMg manifest with Decreased DTR.

Question 469

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Hypochondiasis

Answer 469

Symptoms occur durng periods of stress (med student worried about intracranial hemorrhage), pt shoudlbe asked about current emotional stresses and then referd for a breif psychotherpay.

Question 470

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Hypogonadism

Answer 470

T9Q4. Re-read Merck highlights.

Question 471

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HypoKalemia - 2

Answer 471

A35. All Beta-2 agonist reduce serum K by driving it in to cells. In occasional pt they cause HypoKalemia. So any pt taking B2 and complaining of muscle weakness Hypokalemia must be rules out. PEFR (peek expiratory flow rate) and Cxr are not of any use. We need to do Serum Electrolyte panel. and EKG to see “U” waves. Beta-2 also produces a more common SE of Fine resting tremor of fingers and peripherla edema.

Question 472

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Hyponatremia

Answer 472

Is a bad prognostic factor for pt with heart disease.

Question 473

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Hypothermia

Answer 473

Fluphenazine causes hypothermia by causing vasodialation and inhibition of shivering. Hyperthermia is common in drug abusers.

Question 474

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Hypothyroidism - 5

Answer 474

Generalized resistance to thyroid hormones.Its associated with wide spectrum of musle involvement ranging from astmptomatic elevation of CK to Myalgia, muscle hypertrophy, myopathy. So suspect it if hay elevated CK and Myopathy. It’s the most common SE of radiation therapy for Graves. * Associated with Hyperlipidemia. So unexplained hyponatremia, hyperlipidemia ane elevated serum muscle enzymes are indication for thyroid function tests.Always rule out Hypothyroidims in a pt with Major Deppresive Disorder.If this option, “ordering blood test” for TSH was offered pick it over other options. ***** Thyroid dysgenesis is the mcc of congenital hypothyroidism in US.

Question 475

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Iatrogenic Esophag perforax

Answer 475

Pt comes back w/I hours with problems. Do contrast study of esophagus, if perforation is present , priary closureof esophagus, , and drainge of mediastinum must be done w/I 6 hours to prevent development of Mediastiitis.

Question 476

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Ichthyosis Vulgaris(Lizard Skin)

Answer 476

Dry and rough skin with horny plates over the surfaces of the limb. Tx is minimizing bathing, Oral retinoids (CI in pregnant women)

Question 477

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Idiopathic Pulmonary Fibrosis

Answer 477

Presents in 4-5 decade of life, fatigue,anorexia,weightloss, rthralgia, cyanosis and clubbing. Xr shows bilateral interstitial involvement. Biopsy is done to rule out sarcoid. Tx is Steriods. Mean survival is 2-5 yr after dx. Pleurodesis (where visceral and parietal pleura are fused, is used to treat recurrent pneunomothorax and effusion) is not used here.

Question 478

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Iga Deficiency, Misc 6/2

Answer 478

Recurrent sinopulmonary and GI infections (diarrhea), and anaphylactic transfusion reaction. Dx is made if IgA serum concentration is t cause anaphylactic reaction.

Question 479

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IgA Nephropathy

Answer 479

Is the mcc of glomerulonephritis in adults. Pt have recurrent episodes of gross hematurea, beginning 1-3 days after upper respiratory infection. Serum complement levels are normal.

Question 480

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Immune Thrombocytopenia

Answer 480

Occurs in children 2/6 yo. Pathogenesis involves antibodies that bind to platelets and subsequent destruction of these complexes in spleen. Its preceded with viral infection, and presents with petechia,purpura,hematuroa,or GI bleeding. No adenopathy. Lab shows no abnormality ecept thrmbocytopenia (60000). The course is felf limited. It requires no TX. If thrombocytopenia is <30000corticosteriods are DOC.

Question 481

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Impetigo Bullous - 2 . Dermo. 6/3

Answer 481

Tx: Mupirocin ointment is choice for local impetigo. If no respose then treat systmicallly. Because most cases are caused by penicillinase-producing staphylococci, Cloxacillin or a 1st-generation cephalosporin is the drug of choice in severe cases. Penicillin-allergic patients should receive cefadroxil or cephalexin rather than erythromyc.

Question 482

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Incontinence - 4

Answer 482

1-STRESS incintinence: Occurs when there is a sudden increase in abdominla muscle. Pelvic muscle exercise (Kegel exercise) Urethropexy are rcommended tx. It’s a CC of incontinence in older women, HIGH PARITY is a major risk factor. A high number of vaginal deliveries may lead to pelvic floor weakness over a period of time. Urethra relapses outside the pelvic so whenrver there is increase intraabdominal pressure (cough,sneez,laugh) urine ensues. Aggrevating factors are Obesity, pregnancy, COPD and Smoking. Postvoid cystometry is normal. Tx include Kegel excercise, esterogen in post menopasusal women. Surgical tx is Burch and Sling procedures. 2-URGE Incontinence etruser instability, blader irritation form neoplasm, and interestitial cyctitis result in UI, which causes sudden and frequesnt loss of moderate to large amount of urine. Often accomodated with Nocturia. 3-OVERFLOW: Diabetic Nephropathy causes OI. Characterized by loss of small amount of urine from an over extended bladder and a markedly increased residual volume. There is hx of DM which is not controlled. CC are certain medications (Ibuprofen), Diabetic nephropathy, MS and spinal cord injury. NSAIDs have an inhibitory action on the detruser, so the first step is to stop NSAID. Then cholinergic drug (Bethanechol) should be added afterwards to improve detruser action . Intermittent self catheterization can be used.One of effects of epidural anesthesia is urinary retension due to denervation of bladder. When bladder presure is > sphingter pt urianates until balace is achieved again. This incontinence is transient. PE may show distended blader. Postvoidal vol is high. Tx is by Intermittant cathaterization until control is regained. Oxybutyrin is used for Urge incontinence. Urethroplexy is for stress incontinence.

Question 483

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Infantile SAH:

Answer 483

CT scan shows dilation of entire ventricular system with distinct enlargment of subarachnoid space over the cerebral cortex, is suggestive of nonobstructive or communicating hydrocephalus secondary to SAH. SAH is the mcc of communicating hydrocephalus. Accumulation of blood in subarachnoid space may lead to destruction of arachnoid villi and cisterns (that absorb CSF), SAH is caused by intracranial hemorrhage common in premies. DDX Arnord Chiari, non-communicating, protrusion of structures through foramen magnum. DDX Dandy -Walker, NC, cystic expantion of 4th ventricle.

Question 484

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Infectious Diarrhea

Answer 484

Classified into 2 types, bloody or non bloodt. Bloody is caused by E.coli O157:H7 most commonly, also by Shigella, salmonella, Campylobacter, E. Histolytica and Yersinia and C. difficile.

Question 485

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Infectious Mononucleosis - 7

Answer 485

Heterophil antibody test is sensitive and specif. If its negative and you’re still suspitious, do EBV specific antibody test. Splenic rupture is a serious complication. So pts with splenomegally are advised bed rest and avoidance of contact sports until no more spleenomegally. Glucocorticoids are indicated if IM is complicated by upper airway obstruction, autoimmune hemolytic anemia, and thrombocytopenia( and resultant petechia). IM is caused by Ebstein Bar virus. Sometimes it is detected only after pt develops a characteristic polymorphic rash after taking Ampicilline for an apparant upper respiratory track infection. ** Is associated with Autoimmune Hemolytic Anemia.Blood smear with Atypical Lymphocytes ( Large basophilic Lymphocytes) should make oyu tink of it. It might also be in Toxoplasmosis by CMV is the mc organism.***A negative Heterophile antibodies dont exclude IM, because sometimes they appear later in the course.

Question 486

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Infective Endocarditis - 14, Infx 6/2

Answer 486

Generally if the procedure involves bleeding, prophylaxis is recommended. For procedures that is low risk like, GI endoscopy, there is no need for prophylaxis. Tx inclludes: 1-For IV drug user is IV Vancomycin+ IV gentamycin, since the incidence of MRSA is increased in IV users Vancomycin is better than Nafcilline). 2-For non IV users IV Nafcilline+ IV gentamycin. If IE is due to Strep Bovis, he is at risk for Colon cancer, colocoscopy is recommended. Chordinae tendinea rupture occurs as a complication if IE. ** Pathophysiological consequesnces and clinical manisfestation od IE can be explained by:1-Cytokine production, responsible for fever. 2-Embolization of veg fragments that leads to Pulm and Spleen infarction. 3-Hematogenous infection of sites. 4-Tissue injury due to Immune complex and immune responses to the deposited bacterial antigens. ROTH spots, are due to immune vasculitis. They are oval retinal hemorrhages with pale centers, they have been noticed in pts with collagen vasculat dis and hemorrhagic disorders. OLSER NODES, violacious nodules founf at the pulp of the fingers and toes, due to immune complex deposition. Immune complex is also responsible for GN and Rehumatolic manifestation of IE. JANEWAY LESIONS, macular,blanching, non painful erythomatous lesions on the palms and soles, they are due to SEPTIC EMBOLI, revealing subcutanous abcesses.Tricuspid Endocarditis is associated with IV drug abusers. S.aureus is the mc organism. Tricuspid murmurs are accentuated by inspiration and neck vein distention. Echo is the dx choice. Cxr shows peripheral Welll circumsribed lesion with cavitation, Surgery is required in majority of pts. Valve repair or replacement is therapeutic.Pt with IE who goes inder GU instrumentation for evaluation of microscopic hematuria could have an exacerbation post procedure with murmur and other symptoms of IE.Subacute bacterial infective endocarditis (SABIE) is seen n pts with damaged valves. Strep Viridens is the mcc. Acute BIE is caused by S.Aureus in IV drug users. S.Epidermitis is seen in pt with Prosthetic valves. *Strep Viridans (S. Mutans) are the mc responsible for endocarditis after dental work.Decision to give prophylactic antibiotis depends on risk due to condition of the pt and also depends on the procedure being done. Risk classication are:1-HIGH risk pt are Prosthertic valves, previous hx of IE, Cyanotic pts. 2-MODERATE risk pt are congenial cadiac abonormmalies Acquired valve dis, MVP and regurgitation, and HCM. Now conditions that DONT REQUIRE prophylaxis are MVP w/o regorgitation, innocent murmurs, Pacemakers and defibrilators. **IE in IV drug users is in right heart and caused by staph aureus with involvemtn of Tricuspid valve. The holosystolic mumur that intensifies with inspiration is Tricuspid Regurgitation. Vegetations can emboli to remote organs, so if pt have fever and hemoptysis this would be SEPTIC EMBOLI. DDX with Bronchiectasis is that there s a hx of CHRONIC productive cough. DDX of Abscess is foul smell and cavity in Cxr.Prophylaxis medication guides: 1-Amoxicilline is the DOC in Dental, and Respiratory procedures. In pt with penicilline allergy, Cefazolin, Clindamycin or Clarithromycin is used. 2-In Genitourinary and GI procedures, other than esophageal, the doc is Ampicillin plus Gentamycin. If pt is allergic to penicillin Vancomycin Plus Gentamycin is usedOnce you suspect it the next step is to give IV biotics after you draw blood. TEE comes afterwards. Positive blood cultures and vegetatin on the valve seen in TEE confirms dx.Always suspect IE when a pt is febrile , hx of Rheumatic fever and hematuria. Hematuria in Bacterial Endocarditis is due to glomerlar injury caused by deposition of immune complex. ****If pt has FUNGAL endocarditis then the next step is surgery because they are very aggressive in the valves.

Question 487

Rando

Infertility - 4, OBGYN, 6/2

Answer 487

The first step in WOMEN is to check Basal Body Temperature and mid luteal PROGESTERONE. The ovulatory factor involves defects in the hypo-thalamic pituitary ovarian axis, and related infertility maybe due to impairment of follicular maturation ovulation or endometrial development. BBT assess the DURATION luteal finction and MLP asseses LEVEL of lutal function. Endometrial biposy is done to confirm luteal phase defect. rather than initial evaluation. MALES: Male coital factor is responsible for 40% of all cases infertility, common conditions include varicocele, genital tract trauma or surgerydisruption of hypothalamic-pic axis, or Iatrogenic causes like smoking and occupational exposure. The first step in MALE evaluation is sperm count. if its normal then an endocrine hormonal evaluation is carried out. It includes: 1-TFT (since increaed TSH inhibits GnRH and then decrease FSH. 2-Testosterone levels to indicate the presene or not of Gonadism. 3-Gonadotropin to determine whether hypogonadism is central or testicular and 4-Prolactin lelevs. **Causes of infertility in femlaes falls in 4 factors: 1-Peritoneal factor. 2-Ovulatory. 3-Cervical. 4-tubo-uterine. Peritoneal is the mc type and includes Endometriosis and peritoneal adhesions. Laparoscopy is the procedure of choice. for dx and tx. Mild forms of endometriosis usually respond to meds like GnRH agonists, Danazol and Medroxyprogesterone. 2-Ovulatory factor involves hypothalamus-pit-ovary axis. and infertility might be due to impairment of follicular maturation, ovulation,or endometrial development. ovulatory abnormality may initially be screened by Basal body temp and midluteal phase level of progesterone, the former asseses DURAtion and later LEVEL of luteal function. If luteal phase shows low progesterone, hence infertility, then tx is suppository progesterone deposition. 3-Tubo0uterine is seldom a cause. It onvolves Fibroids, endometrial polyps, tubal occlusion(2ary to IUD or endometriosis). Investigation is ainlt hysterosalpingography or laparoscopy. 4-Cervial involves cervial structure abnormalities and abnormal mucus production. In 5-10% infertility remains unidentified. Intrauterine insemination is the tx. ***Clomiphene Citrate is an antiesterogen that acts by competitively inhibiting esterogen receptors at hypo-thalamus, thus inhibiting the negative feed back esterogen has on GnRH production and consequesntly increasing LH & FSH secretion and improving ovulation. Along with HCG and HMC its indicated for chronic anovulaation. Side effects include large ovaries, hot flashes, abdominal bloating, breast discomfort and abnormal uterine bleeding. Major complications include Ovarian Hyperstimulation Synd and multiple gestations. Danazol is an androgen derivative having a gonadotropin inhibitory effect, indicated in endometriosis, fibroids and fibrocystic breast disease.

Question 488

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Inflamatory Bowel Disease - 2

Answer 488

Erythema nodosum, arthralgias, diarrhea, and positive PANCA ( 60-80% in UC and 10-25% in Crohn) in a young pt are highly suggestive of IBD. ***Any young pt with with bloody diarrhea should make you think of IBD. DDX would be infectious diarrhea, mostly Campylobacter. If pt presents with rectal tenderness and mucus and distended abdomen he might have UC with a fulminant course and Toxic megacolon. Fulminant colitis is a serious comlication, xray shows it. Proctosigmoidoscopy with biopsy establishes Dx.

Question 489

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Influenza

Answer 489

Presnts with, cough,coryza,fever,chills,malaise,sorethroat, muscle pain. Dx is made clinicaly, however a rapid lab test for Influenza antigens srom nasal swap is available. The infection is self limiting b/w 1-7 days. Treat with bed rest and acetaminophen. Two calsses of drugs for prvention and tx are 1-Amantidine (influ-A), 2-Oseltamivir for both A & B.

Question 490

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Influenza Vaccine:

Answer 490

Is recommended in annual basis for all adults over 65 and adults of any age at risk of developing influenza (1-Chronic dis like CV or COPD. 2-Immunocompromised. 3-Nersing home residents. 4-Pregos in 2nd trimeseter in influenza season). This is NOT Influenza B vaccine.

Question 491

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Insulinoma - 2

Answer 491

Pancreatic B-cell tumor. Whipple’s triad of attack occurs in fasting, there is hypoglycemia and ingestion of CHO releives the symptom. Tx is surgery. 80-90% are single benign tumor. !0% is malignant.DDX with Sulfunyluria(The sulfonylureas lower plasma glucose primarily by stimulating insulin secretion. SE is hypoglycemia and increased Cpeptide and increased plasma sulfunyluria) and DDX2 is Exogenous insulin admin (normal Cpeptide).

Question 492

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Intellectualization

Answer 492

Helps the pt to be emotinaly detached from the wrong doing (murder) or unacceptable fact (cancer). DDX:Rationalization is a logical reasoning for an upsetting event rather than the true reason (students says they failed me).

Question 493

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Interestitial Lung Diseases

Answer 493

1-Extrinsic Allergic Alveolitis or Hypersensitivity Pneumonitis, due to exposure to organic dust like fungal sporres or actinomyces, Farmer’s Lung and Bird Breeders are two examples. Features are fever, sypnea and non productive cough. Cxr shows interstitial infiltrates. PFT shows restrictive pattern (Reduces total lung volume). The best tx is aviodance. 2-Alveolar Proteinosis, accumulation of phospholipid rich material in alveoli. It presents with dyspnea and cough. Cxr shows Bilateral alveolar infiltrate and PFT shows restrictive pattern. Dx is lung bipsy and PAS positive material. Tx is total lung Bronchoalveolar lavage. 3-Acute Interestitial Pneumonia, an acute fatal disorder that rapidly progress to pulmonary fibrosis. It presents in >40 people, fever, breathlessness and cough. Pt has hypoxia and requires ventilation. Cxr shows diffused bilateral alveolar infiltrate. 4-Asbestosis, Its initial presentation may be Obstructive. Presents with Pleural Fibrosis. Its exposed to IN organic dusts.

Question 494

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Intermittant explosive disorde

Answer 494

Is an impulse control disorder. Characterized by multiple episodes of assault resulting from aggressive impulses, out of proportion to any stressor. Its associated with abnormality in serotonergic pathway of limbic system.

Question 495

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Internal carotid a. occlusion

Answer 495

most commonly manifest in ocular disturbances and ischemia in middle cerebral artery territory.

Question 496

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Interossseous access

Answer 496

whenever pediatric iv line cant be found, this is the best place for it.

Question 497

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Intestinal Obstruction:

Answer 497

If hay simple mechanical obstruction then both Barium enema and Naslgastric tube+IV fluids+NPO would be appropriate. But if hay obstruction with metabolic acidosis and shock, then laparotomy is the only way to go and Laparoscopy is CI due to shock & acidosis.

Question 498

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Intestinal perforation:

Answer 498

Best test is standing abdominal xray. Used for PUD rupture. If negative then US, Ctand DPL is indicated.

Question 499

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Intra abdominal bleeding

Answer 499

Once you know the pt is bleeding into the abdomen the next thing to do is either US or Diagnostic Peritoneal Lavage to find out the location of bleeding and then exploratory laparotomy.

Question 500

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Intracranial Pressure:

Answer 500

Increased ICP is indicated by 1-Bilat dilated pupils. 2-Anisocoria, pupils are non reactive to light. 3-Flacidity or decerbrate motor posturing. 4-Papiledema. Glascow is not anindication for increased ICP.