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Old 11-26-2004, 12:52 AM
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Asclepius1 Asclepius1 is offline
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Join Date: Feb 2006
Posts: 125
Moon's Pearls
Posted: Mon Mar 15, 2004 9:42 pm Post subject: Moon's Pearls
--------------------------------------------------------------------------------
fasinopril is best medicine for hypertention due to conn syndrome...
for perioperative control of htn bb is always prefered
ace inhibiter is goood only if uni lat renal artery stenosis in bilateral its contraindicated
in exam dont order tft just order tsh ist its cost efective and best way to know about hypo or hyperthyrodism..
after treatmentof hyperthyroidism f/u with free thyroxine level not tsh...
dont give rai to a preg lady...no pregancy 6 m b4 or after use of rai...cause hypothyrodism....and teratogenic for baby..
if u want prescrive isotrention bcz its best drug for nodular cystic acne do preg test ist...
no pnumovac b4 2 yrs of age its not effective and no imunoglobulin with in 11 month with mmr other vaccination pd is 3-6 m but for mmr its 11 months...
if some body have reaction after gettingimunoglobulin then they r IGA DEFIENCT...
NSALINE IS BEST FOR MVA...WHY BCZ NO LR IN TRUMAA BCZ OF RHABDO ORPOSSIBLE HISTORY OF RENAL PROB SO NS...ONLY
NS IS ALSO GOOOD FOR RENAL FAILURE PT AND NEURO SURGERY PT BCZ LESS K..AND WILL NOT CAUSE HARMFUL EFEFCT...
NO SUCCINYCHOLINE FOR A BURN PT BCZ OF INC CHANCE OF HYPERKALEMIA BCZ THEY HAVE EXTRA POTASSIUM RECEPTERS..
MORPHINE I/V B4 DRESSING CHANGE IN THE BURN PT
NO INHALATIONAL AGENT AND SUCCINYLCHOLINE IF HISTORY OF MELIGNANAT HYPERTHERMIAA....GIVE DENTROLINE..MUSCLE WEAKNESS IS CHEIF SIDE EFFECT OF DENTROLIN ITS IS
ALSO BEST FOR NEUROMELIGNANT SYNDROME WHICH IS DUE TO INC CA RELEASED FROM SARCOPLASMIC RETICULAUM AND CAUSE FEVER AND RIGIDITY
IF PT HAS PARKISNISM DONT GIVE REGLON FOR VOMITTING BCZ IT IS HIBITER OF DOPAMINE HE NEEDS DOPAMINE ..
IF CYSTIC BREAT SNODULE DO FNA WITHOUT MAMO IF PT IS LESS THAN 35
IF NONPALPABLE MASS BUT SUSPICIOUS CALFICATIONON MAMO THEN DO NEEDLE DIRECTED BIOPSY..
the dif bet primary and secondry addison diease is primiry start with p and p is for pigmentation so in c pigmentation due to inc acth in primary addison
diease and secondry no pigmentaion due to dec acth..
in diabtes kidney will b double in size remmber d for diabetes and d for double.....but in htn its shrinked...see the dif..
TBG WILLL INC IF TOTAL T4 WILL INC BUT FREE T4 WILL B NORMAL...
IF THYROID MASS AND TSH IS NORMAL DO FNA
IF INC TSH DO THYROID SCAN
IF PT HAS AAA AND ANY CARDIAC DIEASE TERAT CARDIAC IST LIKE DO CABG BCZ MOST CC OF DEATH FROM ALL MAJOT VASCULAR DIEASE LEIKE CAROTID ENDARTERCTOMYOR AAA
REPAIR IS AMI..SO FIX HEART IST IF NOT URGET...
IF BPIS MORE THAN 180/85 AND PT SAID IT WAS HIGH IN MALLL TOOO TREAT IT BCZ THATS WH THEY GIVE U THIS SENARIO...OTHERWISE RECHECK I MORE TIME....AND THEN
EXCERCISE AND DIET IST AND IF FAIL THEN START WITH DIURETIC AND BB..
TOOO SLEEPY MORE LATER ..GOOOD LUCK DOCS.....UR DAY IS COMING ...ALLUR HARD WORK WILL PAID OFFF SO KEEP ON DOING TH EGREAT WORK...GN
-----------------------------------------------------------------------------
!)most cc of hypothyroidism is hashimotos..
2) most cc of dizziness in elderly is their medciation
3)most cc of impotency is antihypertensive medciation and ssris..
4)tumor marker for melignant melanoma is s-100
5)if family history of ovarian ca is positive then yrly pelvic exam and ultrasound is screening test...
6)no bone scan for melignany melonoma bcz these r lytic bone lesion not osteoblastic...
7)dontjust give ca for steoporosis or jut s vitD both along with alendronate
8)if pt on alendronate or any of these easophagitis is the most common risk so ask pt that take medcine with galss of water and sit up for 30 minutes after
take medciation
9)griseofulvin is beetr absorb if taken with fatty foood..not for kids just liek cipro u cant give pt less tahn 10(cipro)
10)if pt is having meliganncy or some bed ridden condition he or she needs anti coag for life
11) d/c ocp i month b4 surgery and restart i month after
12 )d/c coumadin at least 48 h b4 surgery
13) d/c asp 10 days b4
14)d/c heparin 4 h b4 going to or...half life for heparin is 90 minutes
15) if heparin reversal is reqguired then reverse 100 unit ofheparin with 1 mg of protamine sulfate and thats how u calculate the dose...
16)b4 giving all protein inhibiters plez check all th ept medciation bcz of lots of inter action
17) if ptis on pis..then no rifampine but rifabutin
18)if ca is high recheck ist
19)if recheck ca is still high then check pth
20) if pth is low and ca is high then think of sarcoidosis
21)if pt is hypovolemic and has ccf always put central line so u can measure cvp....but remmber ccfis not a contraindication forivfluids if can always give
lasix
22)if ca is low always check albuminist
23) never ever pick hypertonic soulutionin exam unless pt is not seizing or na is less than 115...always restrict fluids..
24)in siadh urin eosmolaity will b higher than th e serum..
25)in melig ca is high bcz it s produced by pth like protein which is also produced by granuloma in sarcoidosiss...and for melignancy hypercalcemia steroid
will b best forothers ist try ns and lasix then iv palmidronate...
28)mallet fx close reduction is goood
29)collls fx close reduction withlong arm cast
30) supracondylar fx in a kid is a surgical emergency ...orif is th e ans and asap...but of nerve palsy risk...
31)smith fx...fx of distal radius withventral displacement due to fall when forearm is supinated and hand is extended...
32)scaphoid fx..risk of avascular necrosis,dont do xray its is neagtive until 2 wks...
33)fall on feet calcanious fx...orif is req
34)dont give flumazenil if mix drug over dose bcz it dec threshold for seizure and dont ever give in tricyclic od...
35)plez read dif bet tricuspid atresia and transposition of great v..both cause cyanosis on ist day...but dif is on t e xtay in vascularity of pul v ..i dont
recall rt now bcz its middleof th enite i dont wana put anything which i am not sure about...but its vvvimp...
36)if 6 wks of abx is not able to bring fever down in acut e bec endocarditis....call cardiology asap...
37)any kid wit fever ifless tahn 3 month admit her or him to r/o sepsis
38)suction rectal biopsy is best to diag hursprung
diease butist will b kub
39) plez remmber ist test for stess incontinence or heamturia or enuresis will b ua
40)cobble stone aaprence is in crohnand appple core lesion is in colorectal ca
41)central incisor dental carries r due to nocturnal bottle feeding...
42)last but not th eleast just remmber where u c xray ,ultrasound,excercise behaviour therapy,diet ,reassurance,smoking cessation,alcohal abstinence ,nsaid
thatis most likely the ans..
if u dont get any ans then go for th elongest choice do thatin ur practice test and u will c
always go forur ist intusion..dont change ur ans its 80-90% correct
relax b4 exam....24 b4 just listen to music..watch movie...dont go out to eat u might get sick eat light dinner sleep early and uwill b fresh when u wil wake
up and do som e revisionin th emorning from ur notes only.....so u can have som e memory of what ever is imp.....
dont read any new materail in last 2 wks
practice practice practice ob usmle cd....its worth....it......bye guys and gooodluck....jerry ,gulabooo,hbnorhbs sorry i cant recall ur name atthis time
ofnight but best of luck to naz natisha and alll others ...and welcome to new commers just stick to this great site..and pray for waheed and his family...i
do...;-)whothought of such great site....for alll of ius..thanks doc.waheed!!!
************************************************** ***********************
Methyldopa (Aldomet) -- Centrally acting antihypertensive agent widely considered the first-line agent for treatment of hypertension during pregnancy.
Studies have revealed no adverse effects on cognitive development up to the age of 7.5 y among children with in utero exposure to methyldopa.
Hydralazine (Apresoline) -- Intravenous form is useful when treating severe hypertension due to preeclampsia/eclampsia.
///////////////////
Lead poisoning case
I. complete physical exam
II. cbc,sma7 blood lead level, lft, glucose,
peripherial blood smear, serrum ferritin
III. <25 environmental intervention
25-44 environmental and oral dimercaprol
44-69 IM or IV edetate disodium
>70 IM or IV dimercaprol
IV. Plan to admit or d/c home
V. console: Inspect home for lead paint
remove child from lead hazard
//////////////Meniere¡¯s disease. Triad. ---1-Vertigo 2.Hearing loss 3.Tinnitus
//////////////////////
Sarcoidosis patient gets affection of eye.---uveitis and. Glaucoma
/////////////////////
This case clearly indicated the PD pt presented psychiatic s/s, not depression.. So, the management step by step is (MKSAP, in Neurology, parkinson's dis,
Table, 39):
Hallucinations, delusions TX: (step by step):
1). Discontinue non-levodopa drugs, if failed..
2)/. Reduce dose of carbidopa/levodopa (to the minimum theraputic dose), if failed...
3). Clozapine, quetiapine, donepezil, respiridone, olanzapine
For the depression in PD pt:
MKSAP: SSRIs.
Swanson: TCAs
/////////////////
HIV is a major no no for breast feeding, pretty much anything else, except meds like (antipsychotics, lithium), drug abuse, etc, you can encourage breast
feeding. even with jaundice, you can usually keep breast feeding. The AAP does not recommed very much not to breast feed.
//////////////////////
PMR : --No muscle tenderness, but muscle ache..
-- Weakness: yes, it is main s/s of PMR
polymyositis -- weakness and muscle pain and tenderness..
FM is almost always dx in a <40yo and ESR=NL. PM and PMR are dx in the same age range, but PM has proximal muscle weakness and muscle bx is=AbNL. PMR= no
proximal muscle weakness and muscle bx=NL
///////////////////////
polymyositis has specific weakness which always demonstrated by something like cannot raise from chair or cannot climb stair because of their severe proximal
muscle weakness. Polymyositis pt does not complaint pain that much although they have tenderness in PE. the diagnostic for polymyositis is EMG, biopsy and CK
etc. Fibromyalgia is a very vague similar to chronic fatigue syndrom. those pt complaint everything but find nothing conclusive (alway negative on labs etc,
unless coexist with other dis).
/////////////////////////Which one of the following treatment strategies has been shown to decrease mortality in adult patients with ARDS?
C. Mechanical ventilation that delivers lower tidal volumes and limits plateau pressure.
A patient is found to have prostate cancer metastasis in the spine. Which one of the following is the initial treatment of choice ?
B. Dexamethasone i.v if the presence of spinal cord compression otherwise
E. Leuprolide (or LHRH antagonist, or orchiectomy)
A patient is found to have lactose-intolerance. What food you advise him to take?
D. Yogurt with live activated cultures.
Which one of the following is the mainstay of treatment for pemphigus vulgaris?
B.Prednisone
A mother brought her 5-year boy because of “bed-wetting? She told you that she found on the internet that alarms are more effective than the mediciation.
What's the best choice?
C. Data reflect that alarms are most useful when augmented by other behavioral approaches.
////////////////////////
Valproic acid (dapakote)is generally regarded the drug of first choice in primary generalized epilepsy, particularly in patients with more than one seizure
type, because of its broad spectrum of activity. Lamotrigine and topiramate also have a broad spectrum of activity and show promise in the management of
these patients. Phenytoin, carbamazepine, and phenobarbital are effective in primary generalized tonic-clonic seizures but are ineffective against
generalized absence and myoclonic seizures. Felbamate is effective in primary generalized seizures but is relegated to the refractory population because of
its potential for toxicity
///////////
BLL <10 mcg/dL: No action is required.
BLL 10-14 mcg/dL: Obtain a confirmatory venous lead level within 1 month. If the BLL is still within this range, patient education about lead exposure is
needed, and the BLL test should be repeated in 3 months.
BLL 15-19 mcg/dL: Same as #2, but repeat the BLL in 2 months.
BLL 20-44 mcg/dL: Obtain a confirmatory venous BLL in 1 week. If the BLL is still within this range, assess complete medical, nutritional, and environmental
hazards. Environmental evaluation by the local health department is also needed. A 2001 large-scale study reported no improvement in neurologic and
behavioral test scores after succimer chelation of children with BLL in this range.
BLL 45-69 mcg/dL: Obtain a confirmatory BLL within 2 days. If still within this range, undergo complete evaluation as in #4. At this level, chelation therapy
is recommended. Treatment should be in a lead-free environment. If this is not possible, hospitalization is necessary. Chelation can be started with oral
succimer, or, if the patient is hospitalized, calcium disodium edetate (calcium EDTA) can be used. These agents have potential toxicities, and monitoring of
the CBC, electrolytes, and LFTs is necessary.
BLL >70 mcg/dL: Hospitalize, obtain a confirmatory venous BLL, and initiate chelation with dimercaprol and calcium EDTA. Because calcium EDTA does not cross
the blood-brain barrier, its use as the only agent in this situation is not recommended because of the possibility of lead redistribution from the soft
tissues to the CNS. Pretreatment with dimercaprol (which crosses the blood-brain barrier) is recommended.
////////////////The measles (rubeola) vaccine recommended for use in this country is a live attenuated vaccine. It is recommended for use at 15 months of
age, but whenever there is likely exposure to natural measles, infants as young as 6 months should be vaccinated and then revaccinated at 15 months to ensure
protection. Exposure to measles is not a contraindication to vaccination, and if the vaccination is given within 72 hours of exposure, it may provide
protection. Studies indicate that measles vaccine, by protecting against measles, significantly reduces an individual's chances of developing SSPE, a "slow
virus" infection of the central nervous system associated with a measles-like virus.
///////////////
Eye movement and pupil size, such as miosis in opioid, organophos intox and barbiturate coma, or pontine lesion etc and mydriasis in TCA, amphetamin/cocaine,
higher level herniation, brain hemorrhage etc. And that bilaterally dilated and fixed pupils are due to inadequate cerebral perfusion.
nystagmus: Vertical -damage to the brain stem; horizontal more related to drug.
Cushing's triad, which includes bradycardia, hypertension, and a change in respiratory pattern, is seen in head injuries with increased intracranial pressure
(ICP).
Head injuries rarely cause hypotension therefore, if it does, other causes of hypotension must be sought.
if pt injested TCA, neither serum or urine give you any good information, because the level does not correlate with symptoms, EKG is key in TCA
////////////////////////
wilson diease-diagnostic test is --Inability to incorporate a copper isotope into ceruloplasmin
/////////////////
Raloxifene is FDA approved for osteoporosis and is anti estrogenic. Its however not approved for chemoprevention like Tamoxifen, the latter is more superior
than raloxifene as a chemopreventor and is FDA approved for chemoprevention.
Tamoxifen complication- hypercalcemic crisis, both predispose to thromboembolic complications.
INDICATIONS FOR CARDIOVERSION///CHF August 19 2003, 1:23 PM
DC VERSION SHOULD BE DONE IN THE PRESENCE OF
1.SYS. BP <90
2.MENTAL STATUS CHANGES
3.CHF
4. CHEST PAIN
////////////////////its LR--- dont give renal pt lactate ringer bcz they r already having hyperkalemia. neverin neurosurgical pts also
////////////////////////
ranson's criteria include
wbc>16000
age>55yrs
ldh>350 units
glucose>200mg/dl
AST>250units/lt.
////////////////////
AVOID DIGOXIN AND VERAPAMIL in WPW syndrome
////////////////////mn
Polyarteritis nodosa
Fever, abd pain, weight loss, renal disturbances.
Labs: elevated ESR, leukocytosis, anemia, hematuria, proteinuria.
Dx: Biopsy
DO NOT MISS HEPATITIS B!!!!!
////////////////////////////////
Tourette's associations:
Attention-Deficit/Hyperactivity Disorder (ADHD)
Difficulties with Impulse Control (disinhibition)
Obsessive-Compulsive Disorder (OCD)highest prevalance
Various Learning Disabilities (such as dyslexia)
Various Sleep Disorders
Remember, Tourette's is an Axis I disorder in DSM IV.
/////////////////
purigo gravidarum
it says that 3rd trimester pruritic rash after jaundice for a couple of weeks...i dunno how jaundice occurs...resolves after delivery.....recurs in future
pregnancies...may also recur with OCP use if happened once/////////////////////
cerebellar ataxia
25% after 1to2 months of varicella inf
5% after vaccination
resolves over weeks to months
/////////////////////////
prostate ca with bony mets and pain
this is acute conditioin
we have to stop testosterone
bilateral orchiectomy...castrate testo levels achieved in 3 hrs
ketoconazole...in pts who cannot undergo surgery...it blocks cytochrome 450 system and thus stops adrenal and gonadal tetsto..castrate levels achieved in 8
hrs
LHRH...its increases the FSH and LH in the begining by the flare phenomenon and thus is not good for acute setting..castrate levels in 30 days
if there is spinal cord compression due to bone metastasis...give steroids also...it will decrease edema and testosterone
/////////////////////////
In an unconscious pt with an intact brain stem, the fast component of the nystagmus disappears ,so that the eyes deviate toward the irrigated side for 2-3
minutes before returning to their original position.
With impairment of brain stem function,the response becomes peverted and finally disappears.
Ref CMDT
I think if the pt. is UNCONCIOUS the nystagmus disappears and eyes are tonically deviated to the side of applied irrigation for 2/3 min. If in this case
nystagmus is present, that means pt. is concious.
//////////////////
long acting biphosphnates,pamidronate or zolendronate r the drug ofchoice for the treatment of hypercalcemia
//////////////////GIVE testosterone TO MAINTAIN ERRECTION.
///////////////
STARRING INTO THE SKY=GENERALISED COMPLEX SZ.TEMP. LOBE EPILEPSY= DEPAKOTE
//////////////
aida /needle stick/GIVE POST EXPO PROPX FOR 28DAYS
3 DRUGS
DDI+AZT +ANY NRTI
/////////////////////
CMDT says renal osteodystrophy confirms the diagnosis of CRF
///////////
both DI and polydipsia has low urin osmolarity; however; when you do water deprivation test, the urin osmolarity does not change in DI, but increases in
polydipsia.
so for discussion to differentiat causes of DI;
what is the best initial diagnostic test? water deprivation test. it will differentiate btw polydipsia and the other two.
what is the most accurate test:--- vassopressing stimulation test. it wii differentiate btw central vs nephrogenic DI
////////
Mohs surgery for skin cancer.
///////////
No I/m laoding dose of phenoytin-- erratic absorption/SLOW ABSORPTION
/////////////////
NSAID/ methotrexate: parenteral steroid is not used for psoriasis,
//////////
viral pericarditis---pericardial tamponade, ---Pulsus Paradoxsus,
///////// LEGS FOR ERYTHEMA NODOSUM, it's associated with Chrohn's disease
//////////////Ceftriaxone displaces bilirubin in albumin thus affecting conjugation.
It is generally avoided in neonates less than 1 month old for fear of exacerbating jaundice!
After 1 month of age, it is safe to use Ceftriaxone already!
///////////////////
PID---IV Cefotetan or IV Cefoxitin plus IV Doxycycline is generally use for inpatient treatment of PID.
IM Ceftriaxone x 1 plus oral Doxycyline x 14 days is the outpatient treatment of PID.
You will shift IV antibiotics to PO antibiotics after patient has been AFEBRILE for at least 24 hours and there are clinical signs of improvement!
order wet mount + Koh ( associated STD infection ), RPR , HIV Eliza, HBAgn, vaccination ( HB vaccine if she does not have the infection)
/////////////////////////
Cause of increased erythropoiten - the renal cell carcinoma.
////pt on penicilin and developed autoimmune hemol--do direct coomb test
////SBP_
cefotaxime,if sever
ceftriaxon also we ,treating E-coli, gram +'s,,polys>250 absolute neutrophil count.
//////////Tourette's disorder is a neuropsychiatric disorder characterised clinically by motor and vocal tics, which may be associated to conductual
disorders such as obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD). Although the neurochemistry of Tourette's disorder
is not well known, there are some effective therapies for tics, OCD and ADHD. However, these are not devoid of adverse effects. Tics only require treatment
when they interfere with the functioning of the patient. If therapy is needed, monotherapy at the minimal effective dose is desirable, but some patients may
require two or more drugs. The most frequently used drugs for tics are antipsychotics (mainly pimozide and haloperidol) and clonidine ..The drugs of choice
for OCD in patients with Tourette's disorder are the selective serotonin reuptake inhibitors (SSRIs), although the tricyclic antidepressant clomiplamine,
which inhibits both serotonin and noradrenaline uptake, has also been found to be useful. ADHD can be treated with some psychostimulants, mainly
methylphenidate, although these drugs must be used with caution. Other potentially useful drugs for the treatment of ADHD in patients with Tourette's
disorder are clonidine, guanfacine, selegiline, some tricyclic antidepressants, sertraline, pimozide and clonazepam. Finally, the potential value of some
nonpharmacological therapies (hypnotherapy, biofeedback, conductual therapies, electroconvulsive therapy, acupuncture and surgery) is briefly reviewed.
///////
Saw palmetto is utilized throughout the world mainly for its effects on BPH. (B9 prostatic hyper) saw palmetto led to an increase in flow rate in men with
BPH....It will increase your urine stream.
///////////////////////
Ipecac, an over-the-counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated
with serious cardiac toxicity.
/////////////
-----------------------------------------------------------------------------
Treatment of spasticity in post stroke patient
Answer is beclofen
///////////////Treatment of influenza. Indications and limitation of AMANTADINE
Answer is
influ. A amantidine within 48-72 hrs
////////////////
male constipation, no other abnormalities, -------Functional causes.
//////////////////////
ileojejunum bypass, diarrhea, what kind of fluid you give?
Total parental nutrition ,BUT normal saline+calcium and magnasium replacement
//////////////////shoulder dystocia.first step tell mom not to push…then ******* manouver then c- section…breaking of clavicle is the last resort
/////////////////
primigravida 28 weeks, rh negative ,husband positive
anti ***** antibody positive what next
1)give anti rhd2)
dont give anti rhd3)
do amniocentesis,
answer,,,, DON’T DO ANYTHING
////////////
During a flu. Season, a pt who did got get flu. Shot and had a flu.s/s for 4 days came in for treatment. You provide for him:
1. amantadine 2. zanamivir 3. only symptomatic support including (Tyleno)
Symptomatic treatment ( amantadine or zanamivir is given within 72 hours of influnza… ZANAMIVIR is the best treatment it covers both A and B)
//////////////////// 4 month-old-boy who is diagnosed as having OM without fever yesterday is brought by his mother for his regular vaccination scheduled. At
this time, as his PMD, you: 1. give the boy vaccines scheduled 2. Wait after he recovered from his disease 3. others.
Answer is give vaccination ( ever is not a contraindication )
////////////////
Most common parasitic infection in usa
Answer is PINWORM (Entrobius vermicularis)
///////////////////////
A boy (5 may 8 yrs old) was brought by his mother with c/o right hip pain for 3 days. The boy had upper respiratory infection prior this hip pain. After
working up, it is dx as septic arthritis.
1. what is the cause ? a. strep. Pneumo. B. staph. A. c. other bacteria (no surgical intervention)
2. what antibiotics ? a. methicillin b. penicillin c. vancomycin d others
3. 2 days after antbx, now there are a few small maculae (2-3 mm in diameter) without itching or redness. What do you do ? a. d/c antx b. continue the
treatment c change to another antx. D others
Answers…………………..1) staph aureus 2) methicillin 3) change the antibiotics
Q)23 yrs old women with a vaginal presure symptoms and on pe has a 5 cm cystic mass,use diaphram for contraception, pregnancy test negative
next step
1.u/s
2.observation for 6-8 weeks
3.birth control pills
4.laprotomy
ultrasound
///////////////
Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV
No beta blockers like propranolol
////////////////
Q)29 yo M c severe diarrhea
o/e listless but responsive
vitals stable
Na 118,K 2.9, hco3 12,,urine na <10
R
a IV hypetonic saline
b hypotonic
c isotonic
d fluid restriction
e hco3
answer is isotonic solution
//////////////////A 3-month-old child was exposed to an adult with active pulmonary tuberculosis. ..........
Administer a TST, perform a CXR, administer INH, and reevaluate in 3 months.
////////////////////////////
the kid should be given INH prophylaxis even if CXR/PPD are negative. You have to reevaluate in 3 months with a skin test:
. if the test is negative :- to D/C INH
. if the test is positive :- to coninue INH for another 6 months (total 9 months )
/////////////
?????????you want give quinolon to a pt. whuch drug of the following should you worn him from:
2- theophyllin
////////////////////
A diabetic man with sexual dysfunction,,comes in for evalutaion of depression,, he is found to be depress..what is the best treatment
a)paroxitine (paxil)
b)fluoxetine (prozac)
c)sertraline (zoloft)
d)citalopram (celexa)
e) bupriopram (wellbutrin)
Answer is E.
wellbutrin and serzone are the only antidepressant that have least effect on sextual function.
///////////////////////
Painless gross and microscopic hematuira: THESE ARE THE STEPS>>>>U/A > IVP > CT..
Q)Painful gross or microscopic hematuira (s/s -> kidney stone):these are the steps >>>> U/A > KUB > IVP > CT ??
/////////////////
thyroid disorders,
early menopause
or somethign else???
answer is osteoprosis and early menopause AND STRESS FRACTURES
/////////////////////////
paNIC DISORDER---DEPRESSION
/////
Atropine should not be used to treat Mobitz type II block associated with BBB
Hemodynamically unstable pts should be treated initially temporary transvenous pacemaker insertion followed by permanent pacemaker implantation.
///////////////
Infection of which valve is most likely to be associated with the development of heartblock.
Mitral valve
///////////////
Q1) how do u check the progression of multiple sclerosis?
Q2) how to u follow Multiple sclerosis?
Q3) Diagnostic test of Multiple sclerosis
Q4) Effect of pregnancy on multiple sclerosis?
Answers to above question
1) Progression based on clinic
2) F/U depend on clinical course
3) Dx MRI
4) Pregnancy? Pregnancy exacerbate MS symptom.
/////////////////////
person with symptoms of Obstructive sleep apnea...what is the first/next step?
a) sleep study
b)medical workup
c)CPAP treatment
Answer is Medical w/u as below
1.r/o hypothyrid.ent exam
2.polysomnogram
3.treat-weight reduction(doenot work) >>>cpap
/////////////////////////////////
A mother is concern about obese child 3 y. what is the reason child is obese
mother behaviour problem
child neglect
genetic
eating disorder
ANSWER IS MOTHERS behavioral problems excessive eating may lead to childs excessive eating
///////////////////
--------------------------------------------------------------------------------
drugs which cause exacerbations of psoriasis
lithium
inderal( beta blockers)
anti malarials (chloroquin)
, beta-blockers, aspirin).
....//////////////
Which of the following drugs is the least sedating and anticholinergic, which can be prescribed safely to elderly patients with depression?
a.fluoxetine
b.MAOI
c.Imipramine
d.Sertraline
e.Trazodone
/////////////////////
Amantadine. ----is class of chemotherapy
///////////////
metronidazole taking mother---- not to feed for 24 hours
///////////////
LYME disease /pregnant
amoxicillin or cefta if CNS involved NO tetracycline because she is pregnant
If this patient was not pregnant then tetracycline is doc ten day therapy is usually reserved for isolalated erythema migrans....if systemic or severe
symptoms therapy is recommended for 21 days.
any one of the following
tetracycline 250 po qid
doxycycline 100 mg po bid
amoxicillin 500 po tid
/////////////////////
minimum age is 2 years.. both nephritic and sickle cele will nedd vaccine
//////////////////////
45 years old woman with history of DM and mild Hypertension with occational history of seizure for last 6 month came to your office with 6 hours h/o headach
right sided partial ptosis,pain in lower half of face and neck rigidity.what would be the cause?
a)Trigeminal neuralgia
b)SAH of Post communicating artery
c)SAH of PICA
d)Brainstem glioma
e)Lacunar stroke
Answer is C…..Ipselateral facial pain sensetion,ipselateral horner's syndrom
and involvement of V11 nerve (bells palsy).
/////////////////////
incontinence with no urinary symptoms.side effect of---Phenytoin therapy
////////////// lchen planus-- on biopsy it is hyperkeratosis
////////////////////
ACETAMINPHEN--------acute hepatic necrosis
/////////////////
best test for confirming rupture of membrane -- nitrazine test
//////////////
girl with DM1 now reach puberty,---- increase insulin.
///////////////////
HOW to follow Multiple sclerosis -- f/u with MRI……
INITIAL diagnosis made by MRI
/////////
baseball pichter with shoulder injury,xray with compound fracture of clavicle --- open reduction internal fixation
he can play the game after 2-3 months
///////////////
TCA toxicity ---alkalinize urine with Nacho3
/////////////////
histoplasmosis in moist cave and cocci in dry caves,,,
//////////////
Current recommendations are to initiate treatment for HIV-infected patients with CD4 cells < 350/µL
or viral load > 30,000 copies/mL by branched-chain DNA or
55,000 copies/mL by PCR testing.
/////////////////////
complications of meniscus injury ?
tear of medial meniscus is more common than lateral.
Cmplication
Hemarthrosis
Locked knee
Locked knee should be reduced in 24 hrs, because beyond this period, effusion cause loss of elasticity of the meniscus, preventing it to snap back into its
normal position.
///////////////////
girl 13 yr left shoulder/scapula is higher 4 cm than right. (no degree info. provided). You recommend:
ref to ortho. surgeon
greater then 2 cm needs referral to ortho.
There are three basic options for the treatment of scoliosis. These include observation, bracing, or surgery. Alternative treatments, although currently
popular, have no proven benefit in the current orthopedic scientific literature. Observation is the preferred management choice for curves at low risk of
further progression, and where the natural history is favorable. This would include curves less than 20o, or curves under 40o after the child has reached
skeletal maturity. Bracing is preferred for curves in which there is documented progression of the curve and where the child has not reached skeletal
maturity. These curves are at risk for progression, and the goal of the bracing is to stop this progression. The final option for scoliosis is surgical
treatment. This is generally reserved for curves which are out of balance or those in excess of 50o. Curves of this magnitude tend to progress after the
onset of skeletal maturity and ultimately cause significant functional compromise.
according to this the patient shoud be followe for 6 months & if any progression is found then suggest a brace !!
///////////////////////////
family history of breast cancer cancer is not a contraindication of HRT
//////////////////
Levothyroxine to a pregnant pt --- increased dose
because …. Pt. who are pregnant, on HRT, or infection have increases in TBG
///////////////////////
1 wk baby turn blue when feeding but when cry is pinkish??
Answer is choanol atresia
/////////////
pt.need immunoglobulins you give develop severe anaphylaxis.
chronic granulomatous dz,regular allergic reaction,Iga def.
Answer is IGA deficiency Patients with IgA deficiency may develop antibodies to IgA, and can have severe reactions (including anaphylaxis, a potentially
life-threatening allergic reaction) to transfusions of blood and blood products. If transfusions are necessary, they should ideally come from another
IgA-deficient individual.
--------------------------------------------------------------------------------
1) THE main DIFFIRENCE between TTP and HUS is lack of Neurological involvement in HUS....otherwise same as both have inc BUN/CRETINE both have INC LDH both
ha THROMBOCYTOPENIA both have MICROANGIOPATHIC HEMOLYTIC anemia......both have SHISTOCYTES on periphral bloood smear...v imp for exammmm REMMBER BOTH HAVE
NORMAL COAG AND NORMAL OTHER CELL LINES...
2)INC PTT IN CLASSIC HEMOPHILIA AND ITS XLINKED...TREAT WITH FACTOR 8 AND IF IT DOESNT CORRECT PTT THEN IT MEANS THAT PT HAVE ANTIBODIES AGAINST FACTOR 8
WHICH CAN OCCUR IN 10% OF TH E CASES AND TEST THIS WITH MIXING STUDY MEANING WHEN U WILL MIX PTS BLOOOD WITH FFP OR NORMAL BLOOOD NOTHING WILL CORRECT PTT IT
WILL STILL INC ...TRETAMENT OF THIS WILL B CYCLOPHOSPHAMDIE ALONG WITH PREDNISONE
3)MOST COMMON CONGENITAL BLEEDING PROB IS WITH VON VILLIBRAND DIASES ITS AUTOSOAML DOMINENT...AND IT WILL INC BLEEDING TIME..INMILD CASES U CAN GIVE PT
DESPOPRESSIN ,,,AND IN SEVER CASES CRYO WILL HELP...DONT GIVE DESMO IN SEVER CASES IT WILL MAKE IT WORSE..
4)DESMOPRESSINIS ALSO GOOOD FOR MILD CLASSIC HEMOPHILIA A...
5)IN ITP THERE WILL B MEGAKARYOCYTES ONPERIPHRAL BLOOOD SMEAR BCZ THERE IS INC RATE OF DISTRUCTION OF PLATELETS AND DEC FORMATION OF PLATELETS DUE TO
AUTOIMMUNE PHENOMENON, ANTPLATELET IgG ANTOBODIES DESTRY ALL PLATESLETS SO THESE PTS R MORE PRONE TO HAV EMUCOSAL BLEEDING LIKE THEY WILL HAV E MENORHAGIA,OR
EPISTAXIS.....FORTREATMENT IST TRY WITH PREDNISONE IT HELPS ALOT BY INC THE PLATELETS itworks by dec the affinity of platelets to activated macrophagesin th
e spleen and steroid also dec the binding of autoantobodies toplatelets....tretament always start with low dose of platelets it will inc th eplatelets numb
but if u hav eto keep thept on prednisoneor u hav eto inc the dose then do splenectomyis the definate treatmentofitp if they ask u in step 3,,,,but make sure
that u give pnumovac and h influenza vac 2 wk prior to splenectomy,other drugs that use when platelets r low and causing bleeding or if pt is going for
urgent surgery is ivig..its v expensive so only reserve for life thretening bleeders and its always given slow and never in ppl who have igA defiency bc
zthey will die from anaphylaxis...another imp point is that when pt cant go for splenectomy or cantbon prednisone or cant afford 5 k dollerivig give him
danazol,or rh gam its helpful tooo...som e tried inflaximab group its helpful but infectionis the side efefct....so watch for that...if u c ccs in exam which
most of u willl..... just treta as an out pt with prednisone and call pt in 2 wks and when platelets above 50 taper prednisone and advise for no contact
sport..and pt teaching about diease ...v imp...
6)dic is dif from sub acute dic in thatpttis normal and fibrinogenis normal...and remmber in dic treat the underlying cause...
never give aminocaproic acid in dic without heparin bc zit cause severe thrombosis...
7)liver disease have both prolong pt and ptt but fibrinogen level is normal...ff will correct th ebleeding..
8)the dif bet the vitamin k deficiency and dic is noraml platelets and normal fibrinogen vit k will help....
9)if platelet r 10 k still u can perform splenectomy so never ever give platelets in itp when its in exam..bcz it will b destryed by the antibodies...
10)inmy exam they ask that baby had circumcison and lost lots of bloood on lab hisptt was 100 an his bleedint time was 12....and mom said his uncle has sam e
prob he bled in suregry and after surgery...whatu will do u will check factor 8and 9...its dic,its ttp,its itpand blabla...
11)remmber factor x11 deficiney u wont have bleeding just inc ptt they canhave surgery without any prob its also callled hadgman factor deficiency..
12) ifpt is having factor 13 deficiency.u will hav e normal coag but still u will hav e bleeding....so remmebr these clues they will help u to exclude wrong
choices in exam...
13)lupus anticoagulant antibodies is v imp subjects so u have to read about it.....its igG or igM antobodies taht produce aprolonged pttby binding to
phospholipids,its present in 10% pt of sle and is characterized by recurrent abortion,and thrombosis .there is no bleeding unless second ry factor is
presenttaht cause bleeding,the prolonged ptt will failed to correct with mixing study so that is a clue for diag....the russell viper venum isgood and
senstive assey and is diag of lupus anticoagulant...antiphpjolipid and lupus anticoagulant will cause the false positive vdrl...u can suspect lupus
anticoagulant when inc ptt but no bleeding and vdrl is in and anticardiolipid and natiphospholipid positive...predison is th ebest treatment and give heparin
if thrombosis is suspected....
14)autologous bloood can b given to pt for surgery and it can b stored for upto 35 days...it dec the chance of infection and reaction..
15)i pack of rbc pack can raise the hct by 3-4%and prbc is used to raise hct ...not the whole blood that is reserved for sever hypovolemic pt...
16) dont transfuse awake juhuwa witness against his will but for a kid go ahead and transfuse if urgent or in nonurgent situation just tak e court
oreder...ifkid belongs to juhuwa witness
17)always remmber when ever kid is in the womb mom will give consent for every thing evenif she is competent and refusing for csection and endangering her
baby thats fine u just listen to her an d respect her wish..but as soon as she deliver she has no longer authority if child lif eis in danger....but for non
urgent cases we stilll need her consent even if she is in jail or drug addict .....
18)febrile bloood transusion reaction pt need leukopooor bloood
19)for graft verses host reaction u need to give iiridiated bloood next time..
20)HIT need that u d/d heparin and coumadin both and start with leupridine...inc risk of thrombosis with the HIT...plez read more from wash manual
....21)...in cases of hemoglobuburia weather its due to rhabdoor bloodo transfusion reaction give vigrous hydration with n/s and mannito or lasix...so
hemoglonuria will not damage kidney tubule....bcz atn will cause rf sooon..if will not go aggressive hydration v imp for exam....
21)ist day jaundance is always due to abo imcompatibility
22) if husband is onegative and wife is tooo no prob baby will b normal..(.cam e in my exam..)..case senario was that a gal is pregnantand her rh is negative
and her b fd is rh positive and they tell s u in sep setting that this babyis not my b fd but my ex and he is rh negative what u will tell her....
23)delayed transfusion reaction is due to duffy,kell and c,e loci of rh system..they cause delayed reaction after 8 to10 days of transfusion..
.
24)i unit of platelet will inc 5 k of platelets usually we giv e 6 pack..
25)fever chillsl and sever backach eis due to heamolytic reaction,stop transfusion and give ns bolus and lasix..flush th ekid so no damage to tubule and no
renal failure other prob is dic....
26)kid if they have dirrhea due to slmonella sheggella or due to e coli they will most like ly have hus so keep that inmind in exam they ask that akid ate
hamburger while his father was stilll barb qing...an dkid has now fever and dec inc bun/cretinine .. and thrombocytopenia and in c ldh itS HUS
27)WALDSTROME MACROGLOBUNEMAI IS DUE TOMONOCLONAL IGm paraprotein and in MM ITS DUE TO IgG
THE MAIN DIFIS THAT NO LYTIC BONE LESION IN THE WALDSTROME ...the cause of death in mm is due to infection from streptp pnumoni and h infuenza...
28)hairy cell leukia is having pancytopenia,splenomegalyand hairy celll on p blood smear and bm biopsy
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Old 11-26-2004, 12:50 AM
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Boston File
Posted: Sat Mar 13, 2004 6:57 pm Post subject: Boston File
--------------------------------------------------------------------------------
INJURIES TO ELBOW
1. Lateral Epicondylitis (tennis elbow). A very common inflammatory process of the extensor origin of the lateral epicondyle. May be secondary to
overuse/repetitive use. Pain at the lateral epicondyle, with referred pain to the extensor surface of the forearm is typical. The pain is exacerbated by
resisted extension of the wrist or fingers. Treatment includes avoiding exacerbating activities, NSAIDs, and placing a constrictive "tennis elbow" band just
distal from the elbow. Occasionally immobilization of the wrist in a volar splint is required. Local steroid injection or orthopedic referral may be advised
in recalcitrant cases.
2. Medial Epicondylitis. This results from repeated flexion activities of the wrist and fingers. Pain is at the medial epicondyle and exacerbated by
resistant flexion of the fingers. Treatment is the same as that of lateral epicondylitis.
3. Radial Head Subluxation (nursemaid’s elbow).
a. The mechanism is a sudden pull on the extended pronated elbow of a child less than 4 years of age (for example, when one picks up a child by the forearm
or swings the child). The child holds his arm in pronation and usually refuses to move it with pain on supination and palpation of the radial head.
b. Although radiographic findings are usually normal, one must be sure to rule out undisplaced supracondylar fracture. Frequently, the subluxation
spontaneously reduces from x-*** positioning.
c. Treatment is firm supination of the forearm, flexing the elbow gently to 90 degrees with pressure over the radial head. Reduction is achieved with a
palpable click over the radial head, and the pain is immediately relieved. The patient should resume full activity within several minutes of reduction
although some are hesitant. It may take an hour or so to resume full activity.
4. Little Leaguer’s Elbow. Results from overuse of an adolescent’s pitching elbow. On exam there is tenderness over the medial humoral epicondyle with mild
swelling. An acute syndrome with sudden onset also occurs from the avulsion of a fragment of bone from the medial humeral epicondyle. Treatment includes rest
for 3-6 weeks followed by rehabilitation. Loose bodies and locking elbow require referral.
5. Olecranon Bursitis (note: the same treatment and diagnostic modalities hold true for prepatellar bursitis as well).
a. Clinically there is tenderness and swelling over the olecranon bursa. Olecranon bursitis may be secondary to trauma (e.g., lying on carpet with elbows
propped up while watching TV) or may be infectious (Staphylococcal). Frequently, traumatic bursitis leads to infectious bursitis.
b. Diagnosis. Must differentiate infectious from sterile bursitis. Tap the bursa and evaluate gram stain, cell count, crystals, and culture.
c. Treatment consists of repeated aspiration until fluid no longer re- accumulates. Start antistaphylococcal antibiotics (e.g., amoxicillin/ clavulanate,
nafcillin) if an infectious etiology is likely. May require admission for IV antibiotics the patient is toxic or there are comorbid conditions (e.g.,
immunosuppression, diabetes). If the etiology is not infectious, treat with NSAIDS, aspiration and compression dressings. Occasionally, an olecranon bursa
must be opened surgically.
RED EYE
Clinical clue table suggesting the possibility of serious eye disease causing the "red eye", clinical features that may necessitate immediate ophthalmologist
consultation
Clinical features:
Severe eye aching: Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus thrombosis (CST)
Prominent photophobia: Iritis, keratitis
Impaired vision: Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST
Cloudy cornea: Keratitis, acute angle-closure glaucoma
Corneal opacification: Keratitis - chemical or infectious
Circumcorneal conjunctival injection: Iritis, keratitis
Cloudy anterior chamber: Iritis
Pain on eyeball palpation: Scleritis (+++), orbital cellulitis, CST
Proptosis: Orbital cellulitis, CST, posterior scleritis
Impaired, or painful, extraocular eye movements: Orbital cellulitis
Fever, toxic appearance: Orbital cellulitis (+), CST (++)
Hyperpurulent discharge from an "angry" eye: Gonococcal conjunctivitis/endophthalmitis
Prominent nausea and vomiting: Acute angle-closure glaucoma
Small, irregular, poorly-reactive pupil: Iritis
Fixed mid-dilated pupil: Acute angle-closure glaucoma
Increased intra-ocular pressure: Acute angle-closure glaucoma, iritis (secondary complication)
History of connective tissue disease, or granulomatous disease: Iritis, scleritis
Recall:
23 yo runner developed fracture of the medial malleolus...next step:
a-posterior splinting
b-medial splinting
c-lateral splinting
d-orthopedic referral
The answer to this question is posterior splinting..The trick here is to know the intervention and the position of splinting..
Think of the ankle as a "ring" composed of medial malleolus, deltoid ligamnet, calcaneous, lateral ligamnet, lateral malleolus.
DISRUPTION OF THE RING AT ONE POINT ONLY OF THE RING results in a stable ankle that can be treated by CONSERVATIVE means (POSTERIOR splinting+non-weight
bearing)
DISRUPTION OF THE RING AT TWO OR MORE POINTS OF THE RING makes the ankle unstable and the treatment is immobilization and emergent referral..
Difference b/w Raloxifene and Tamoxifen:
Tamoxifen:
Often used in women over 50 years of age and younger women with ER + tumors. ER + respond better than ER -. Treatment for 5 years seems to be optimal
duration. Side effects include, nausea, menopausal symptoms, thromboembolism and and a small increase in uterine cancer (mandating work for any abnormal
uterine bleeding). Ovarian ablation is only beneficial as hormonal treatment in premenopausal women.
* women at high risk for the development of breast cancer may reduce their risk by taking tamoxifen.
* Tamoxifen appears to be antiestrogenic at the level of the breast but proestrogenic at other levels.
It causes endometrial changes, including polyp formation, hyperplasia NOT ATROPHY, and frank invasive carcinoma. Thus, women on tamoxifen need to be followed
carefully, and prompt evaluation of abnormal vaginal bleeding should be conducted.
Tamoxifen, like estrogen, has been shown to lower blood levels of LDL cholesterol
Women on tamoxifen appear to be at no greater risk, and may be at a lower risk, for the development of myocardial infarction .
Tamoxifen, like estrogen, has been shown to increase bone density and to reduce the likelihood of development of osteoporosis .
Raloxifene:
Raloxifene appears to function like estrogen in bone, acting to maintain bone strength and increase bone density.
In addition, raloxifene also resembles estrogen in its ability to lower LDL cholesterol levels, thereby decreasing the risk of heart disease.
Although information on the long-term risks and benefits of raloxifene is limited compared to tamoxifen, preliminary evidence suggests that raloxifene may
exert these beneficial effects on bones, heart, and blood vessels without increasing a woman's risk of developing cancer.
Even if the STAR trial confirms the effectiveness of raloxifene in reducing the risk of breast and uterine cancer, raloxifene is still not the perfect drug.
It does not reduce the frequency of hot flashes associated with menopause and, like estrogen, it increases the risk of blood clots. Just as tamoxifen was an
important milestone, if a single SERM like raloxifene is found to protect women against osteoporosis, heart disease, breast cancer, and uterine cancer, it
will represent an important milestone in women's health. For the recall question raloxifene if h/o breast ca is there.
Asymptomatic hematuria:
1)>50, + Risk factors(tob, dye, etc) or is consistent with underlying causes straight cystoscopy.
2)<50 without RF, do Urine cx/AXR first. if all are wnl, then watch and wait, document that u informs pt pro and con of w/u.
Ureteral Colic:
First step: UA with sediment followed by AXR. Uric is lUcent others opaque. Urinary Ph can also distinguish different varieties. Minimal work up is crt,
electrolytes, ca, phosphorus, cbc.
Next is helical/spiral CT abdomen (test of choice). Most would be seen, if still in doubt IVP (former gold standard BECAREFUL).
*** REMEMBER 6 is the KEY DIGIT for ureteral stones
Stones less than 6 mm pass spontaneously. Conservative observation with pain meds is sufficient for 6 weeks. After 6 weeks, 2 options, ureteroscopic stone
extraction or extra shock wave lithotripsy (ESWL). Read the debate on p 919 CMDT. Women of childbearing age are best NOT treated with ESWL for a stone in
LOWER URETER as impact upon ovary is unknown. Most stone fragments pass uneventfully w/n 2 weeks after ESWL, stones that persist need additional
intervention. Also see 104 Bp med
Renal Stones: 919 CMDT
Asymptomatic------No management and F/u with AXR or U/S
Symptomatic less than 3 cms---------ESWL and F/u in 3 months by AXR
Symptomatic more than 3 cms and stones despite treatment with ESWL-----Percutaneous Nephrolithotomy + perioperative Abx coverage
Drugs causing Erythema Multiforme (Targetoid lesions i.e rash like lymes)
Barbiturates
Sulphonylurea anti-diabetic agents
Sulphonamides
Thiazide diuretics
Phenytoin
Captopril
Diltiazem
Gold
Non-steroidal anti-inflammatory drugs, particularly piroxicam, also aspirin
Statins
ORGAN DONATION:
The physician declares death using brain criteria (potential organ and tissue donor) or from cardio-pulmonary arrest (potential tissue donor).
According to Medicare Conditions of Participation, a hospital must notify its local organ procurement organization upon every death.
Recovery coordinator discusses organ and tissue donation with the family or next-of-kin.
In the case of a tissue donor, a recovery team is called to the hospital and a room is prepped for the donation.
All tissues are carefully removed, packed in sterile conditions, and transported to a tissue bank to be prepared for transplantation, research or therapy.
If the case of an organ donor, the process of identifying the recipient begins.
What is brain death?
Brain death occurs when the brain has permanently stopped working, as determined by the physician not related to transplantation. Artificial support systems
(machines) may maintain functions such as heartbeat and breathing for a few days, but not permanently. Donor organs are usually taken from people who have
been declared "brain dead".
What is cardiac death?
Cardiac death occurs when the heart has stopped beating completely. While a person dying by cardiac death cannot be an organ donor, they may still donate
tissues.
When must organs be removed?
Organs must be recovered as soon as possible after the declaration of brain death, while circulation and respiration are being maintained artificially.
Tissue may be removed within 12 to 24 hours after cardiac death.
How long before an organ or tissue must be transplanted into a recipient?
That varies from organ to organ and tissue to tissue. For example heart or lungs must be transplanted within 4 to 6 hours; for kidneys potentially up to 72
hours. Corneas must be transplanted within 5 to 7 days and other tissues may be preserved for 3 to 5 years.
Can donor families have contact with their loved one’s recipient?
Confidentiality is respected unless both the donor family and recipient agree individually to make contact and sign a release of confidentiality waiver.
Either side may communicate through letters that are passed on by WRTC if they choose to do so.
FACT: Upon arrival at an accident scene or upon receiving you in the emergency room, emergency or critical care staff immediately spring into action to try
and save your life. Physicians involved in a patient's care in an emergency or critical care setting by law may have nothing to do with transplant programs.
The OPO (organ procurement organization) is not notified until all lifesaving efforts have failed and death has occurred. Death can be declared only by
following strict medical and legal guidelines and usually with the input of more than one physician.
FACT: By the time your will is read, it will be too late to recover your organs. Telling your family that you want to be a donor is the best way to ensure
your wishes are carried out because they will always be at the hospital and can relate your wishes. You may also sign an advance directive or driver’s
license.
Organs that can be donated at the time of your death include your heart, lungs, two kidneys, liver, pancreas and intestines (although in the Washington, D.C.
region there is no intestine transplant program).
A typical organ donor is someone who has died after suffering from a traumatic injury to the brain; for example, a stroke, an aneurysm, or a car accident.
For death to be declared, a strict set of medical criteria must be met. Among the criteria is the complete absence of activity in either the brain or the
brain stem (responsible for reflexes such as cough, gag, blinking, etc.). By law, only a doctor not connected to the transplantation process may declare
brain death.
After death by neurological criteria is declared, the heart, as a muscle, can still circulate blood for a limited amount of time and keep the internal organs
viable. It is during that short amount of time that organs may be recovered for transplantation.
WRTC Recovery staff are notified after death has been declared. If the patient is a potential donor, they will approach the patient's family and discuss
organ and tissue donation. To find out how to be an organ and tissue donor, click here.
Tissue Donor
While officially considered life-enhancing and not life-saving, a tissue transplant is still a life-changing opportunity for the recipient. From someone who
receives the gift of sight for the first time in a cornea transplant to someone who receives skin for burn treatments, tissue recipients are incredibly
grateful to donors for having given them the opportunity of greatly improving their lives and the lives of those around them.
A tissue donor is different from an organ donor because someone can be a potential tissue donor if they died according to brain death criteria or if their
heart has stopped (cardiac death). Tissues can be recovered up to 24 hours after the heart has stopped beating.
Tissues that can be donated at the time of your death include:
Bone: Facial reconstruction, limb salvage, birth defect correction, cancer treatment, spinal and oral surgery
Cartilage : Facial and other post-traumatic injury reconstruction
Corneas : Restoring eyesight
Fascia : In neurosurgery, to correct damage from trauma or tumor
Heart valves: For valve replacement where animal or artificial valves cannot be tolerated
Pericardium : Used in neurosurgery, especially in brain operations
Skin : Temporary covering for burn patients to reduce pain, scarring, fluid loss, infection
Tendons : Correcting joint injuries
Veins : Used in heart bypass surgery
ULCERS :
If you see the ulcer at the distal tip of the toes ==> Think ischemic ulcer
If you see the ulcer at the heel ==> Think diabetic ulcer
If you see the ulcer above the malleolus ==> Think in stasis ulcer
Diabetic ulcers typically develop at pressure points, and the heel is a favorite location. The patient has evidence of neuropathy, and the correlation with
the trauma inflicted by the new shoes is classic
Ischemic ulcers, whether due to arteriosclerosis or embolization are typically seen at the tip of the toes, as far away from the heart as one can get.
Stasis ulcers are seen above the malleolus, surrounded by edematous, hyperpigmented skin.
RECALLS:
1.pregnant exposed to a lacy rashed boy
a.it wonot affect u
b.u will get mild disease
c.u are vaccinated to this,no harm
d.u may lose your fetus
A. no longer infectious once rash appears.
2.pt heavy smoker,lost 8 lbs lately and serum ca=11.5
what do u do next;
a.recheck ca
b.check cxr
CXR.
3.14 yrs old girl never been vaccinated for varicella and she exposed to 5 yrs old her sister with varicella
how would u tx 14 yr one
a.varicella immuno
b.varicella ig g and vaccine
c.var vaccine now
d.va vaccine now and month later
edo nothing.she already exposed
Answer D ref CDC guidelines
4.4 yr old almost near drowing was cpr for 45 mts to get pulse and circulation.in er pt is on dopamine and intubated.he pronouned brain dead and ready for
organ donation.what is the best time for this.
a.now
b.after 48 hrs
c.after good b.p. control
Answer NOW
5.56 yr man came to pmd he is s/p CABG 10 yrs back and c/o sob with exertion and chest pain what is next step:
a.thallium stress test
b.dobutamine test
c.ekg
Next step EKG
6.Pt with carbamezapine toxicity what should u monitor
a.cardiac
b.renal
Cardiac
7.what is definitive diagnosis for mi
a.ekg
b.enzyme
c.physical exam
Enzyme
8.cocaine induced htn what will be tx
a.nitropru
b.beta blocer
c.phentolamnine
Phentolamine
9.cocaine induced mi
a.thrombolytic
b.angioplasty
Angioplasty
10.which is not a risk factor for osteoporosis
a.smoking
b.etoh
c.caffinated product
d.white race
e.obesity
Obesity
11. woman on contraceptive > >>> became amenorrheic
a.let her be ameno
b.modify estro(increase)
c.progesterone (lower)?
Likely B
12. A child goes to picnic has redness in arms and legs What the dx:
Poison Ivy
Atopic dermatitis
Irritant contact dermatitis: Just local inflammation of the skin following contact of the skin with a noxious substance. NO immunologic reaction eg;
Industrial and household detergents
Allergic contact dermatitis: Delayed type of hypersensitivity..Occurs when an external agent sensitizes T-cells, Poison ivy, poison oak, some metals
(nickel), various preservatives in medications, ingredients in rubber industry, agents in finishing process for clothing or other naturally occurring or
industry produced chemicals. MKSAP p 16
Atopic dermatitis: Atopy in the skin. Type I hypersensitivity ..Part of generalized atopic reaction. The Ig-E mediated immunity occurs in many parts of the
body including the skin.
Having understood the type of hypersensitivity in each dermatitis.., timing here is very important. If the child develops the reactions of erythema and
pruritis 24-72 hrs after the return of the picnic, .Poison ivy /allergic contact dermatitis will be choice, If the child develops the symptoms immediately,
atopic dermatitis is the choice.
HTN High yield facts
Hypertension Rx
• Trial of Lifestyle Change x6-12mos in Pt.'s w/ NO Co-morbid Dz.
–––––––––––––––––––––––––––––––––––––––––––––––––– –
*** 1st LINE DRUGS ***
• No Other Dz.
- Diuretic OR ß-blocker
- (Proven to Decr. Mortality)
• Hyperthyroidism
- ß-blocker
- (Decreases HyperT3 Sx, also)
• DM
- ACE Inh.
- (Proven to Decr Vasc & Kid Dz)
• Blacks
- Ca Channel Blocker
• Decr. Ejec. Frac.
- ACE Inh.
- (Proven to Decr. Mortality)
• MI
- ß-blocker AND ACE Inh.
- (Proven to Decr. Mortality)
• Atrial Fibrillation
- Diltiazem (Ca Chan. Blocker)
- (Controls Atrial Rate, also)
• Osteoporosis
- Thiazides
- (Decr. Ca Excretion)
• Prostatic Hypertrophy
- Alpha-blockers
(Ex.: PRAZOSIN™, TERAZOSIN™)
- (Treats HTN & BPH Concurrently)
HTN *** CONTRAINDICATIONS ***
• ß-blockers
- COPD
- due to Bronchospasm
• ß-blockers (Relative)
- DM
- due to alteration in insulin/glc homeostasis & blockade of
autonomic response to hypoglycemia
• ß-blockers
- Incr. K
- due to risk of Incr.'ing K even higher
• ACE Inh.
- Preg.
- due to Teratogenicity
• ACE Inh.
- Renal Artery Stenosis (B/l)
- due to precipitation of ARF
• ACE Inh.
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
• K Sparing Diuretics
- Renal Failure (Cr. > 1.5)
- due to Incr. K Morbidity
• Diuretics
- Gout
- due to causation of Hyperuricemia
• Thiazides
- DM
- due to Hyperglycemia
See page 251 Katzung for uses and side effects of Diuretics.
Immunization Contraindications
No MMR:
• if PREG / IC Pt / EGG ALLERGY
• OK if HIV+ (Asymp)
No DPT:
• if SEIZ / Any NS Dz.
• if FEVER > 104° AFTER 1st DOSE
No OPV:
• if IC Pt
• (Use IPV, which is IV & Killed)
• UPDATE:
- Last Polio Inf. in 1979 w/ ~8 cases/yr due to OPV (Live-attenuated)
- As of Jan. 2000, No more OPV. (ie.: IPV is only given)
NB: Live Vaccines
- MMR
- OPV (Replaced w/ IPV)
- Varicella
Oral Contraception Pill (OCP) Contraindications
• PE, DVT
• Cerebral vascular disease
• Coronary artery disease
• CA of breast
• CA of endometrium
• Cholestatic Jaundice in Preg.
• Hepatic adenoma
• Impaired liver function
• Type II hyperlipidemia
• Factor V Leiden mutation
• Smoker (if > 35yo)
Varicella Vaccine
Live attenuate vaccine
- Given at 12 to 18 months in pt with no previous infection
*< 12 yo, only one injection is given
*>12 yo, two injection is given 1 to 2 months apart
Route of administration
-Subcutaneuosly
Complication:
-Erythema 20-25%
-Varicella < 1%.
WBC Shift
• LEFT SHIFT:
- Increased Seg.'d Neutrophils + Bands
- Bacterial
• RIGHT SHIFT:
- Increased Lymphocytes
- Viral
Labor Induction (Indications)
• Abruption
• Chorioamnitis
• IUFD
• PIH / Pre-eclampsia
• PROM
• Post-term (42 wks)
• Maternal Medical Conditions:
- Diabetes mellitus
- Renal disease
- Chronic pulmonary disease
- Chronic HTN
• Fetal Compromise:
- Severe IUGR
- Isoimmunization
Contraindictions to Labour Induction
• Vasa/Placenta previa
• Transverse fetal lie
• Umbilical cord prolapse
• Previous uterine surgery
DKA Treatment
**LABS**
• SMA-7 / Ketones / ABG / EKG
• • • • • • • •
**TREATMENT**
1) FLUIDS -> 2L NS (500cc/hr x 4hr), then 250 cc/hr x 2hr
2) INSULIN -> Bolus 10U Reg, then run at 0.1U/kg/hr
• Make sure drip is running
3) K -> in 1/2 NS 20-40mEq/L after 1-2L NS
4) Check Glc q1hr (until
< 250)
5) Once
< 250, add Dextrose (D5NS) to Insulin drip
6) Turn off drip when HCO3 > 22
• ie.: Improvement of Anion Gap (AG)
• AG = Na - (HCO3 + Cl) = 140 - (24 + 100) = ~8-16
7) Start SQ Insulin 1-2 hr before stopping Insulin drip
Amenorrhea Work Up:
Remember the definition of Primary Amenorrhea is either 14yo without secondary Sex characteristics OR 16yo without menses yet. Secondary Amenorrhea is NO
menses for 6 months OR 3 cycles.
Progesterone Challenge test is needed after Preg Test(neg) / TSH (normal) / Prolactin (normal). If she bleeds with the progesterone, then she's anovulatory
(Tx-> Progesterone). If she does not bleed, then test with Estrogen & Progesterone (OCP). If no bleeding still she has scarring in the uterus (Asherman's
synd or TB). If bleeding occurs, then do LH/FSH level. If LH/FSH is low then repeat Prolactin level and do a Coned down view of Sella Tursica. She probably
has a Prolactinoma (Tx-> Bromocriptine (may breastfeed)). If LH/FSH is normal, then she has Polycystic Ovarian Syndrome (PCO) and treatment is OCP (or
Clomiphene if she desires pregnancy now). Testosterone is also high in these patients. If LH/FSH is high, she either has Menopause, Ovarian Failure,
Testicular Feminization (46XY) or Turner's Syndrome (XO).
For PCOD LH/FSH ratio is greater than 2:1
Cervical cancer guidelines
ASC-US
-Repeat PAP in 4 mos
-HPV with reapeat PAP
-If (+), then Colpo
ASC-H
-Colpo
AGC
-Colpo + Endocervical Curretings (ECC)
-If >35yo also do Endometrial Biopsy (EMBx)
-If Endometrial cells present, do Colpo + ECC + EMBx
LGSIL
-Colpo +/- ECC
HGSIL
-Colpo with Cervical Biopsy + ECC
Endometrial Cells present
- EMBx if Postmenopausal and NOT on HRT
FACTS:
* If dog and cats bite and escape, dont give prophylaxis until animal acted strangely or there is rabies prevalent in that area
* If wild animals like bat, skunk, foxes, racooons bites and escapes give prophylaxis and vaccine
* If captured or killed animal has rabies or negri bodies give vaccine and prophylaxis
* If kid is bitten by neighbour dog who had all his vaccination just reassure the parents and clean the wound with soap and water and observe the wound..this
is my exam q
* If spider bite gives u sloughing, necrosis and burning pain then its brown recluse spider...u have to give tetanus, and if swelling is not down after few h
give steroid like dexamethasone
* If spider bites gives u like abdominal cramps and edema then its black widow u need to give calcium gluconate to the pt
* Enteric fever is a reportable disease give cipro for 10 days and check all family members stool for salmonella typhi
* Nodulo cystic acne best is isotrentione, but first check preg test and pt should be on contraceptive when she is on this drug
* To decrease the cong anomalies in babies born to mother with diabetes tight glucose control 01 month before the conception and throughout preg.(.my exam
qs)
* Pt udergoing cabg, u see during transfusion...that blood is coming from all punctures or iv site , this is most likely to transfusion reaction and this is
the only thing plus hypotenton is present when pt is under anesthesia to give u a clue that pt is having reaction from transfusion...
* U will c many qs ...in which u have to give iv f and mannitol in transfusion reaction,in crush injuries with rhabdo like pics...so think of compartment
syndrome and faciotomy.....in all those cases where s/s r persent in mva cases
* Just remember supra condylar fx is a surgical emergency u have to do orif asap...
* Adult fall on outstretched hand is colles fx ...close reduction and long arm cast
* Kids fall on outstretched hand radial head subluxation.....
* Decelration injuries...aortic rupture c/o tamponade
* Fall from height on ur feet is calcaneus fx and spinal fx
* Ct scan with contrast for all type of kidney stones and rcc
if stone is more than .5 cm and at pelvic ureteral junction removed with basket through cystoscopy
no eswl when there is infection going on with kidney stone in that cases urology asap for nephrostomy tube and stent placement
* Mom interfere with lp and u think u need it to make sure that kid has meningitis do it bcz its a medcial emergecy dont fall for her choice ethic commetee,
court order, talk to attending ,talk to risk management ist...(this was also my exam q)
* Stop both heparin and warfarin in HIT SYNDROME..use liprudine...u must d/c heparin if platelets r less than 50% from base line
* Dyslipidimia and hypertention in a pt he needs alpha antagonist like pt with bph
* Pt has psa of 10 or more go for transrectal biopsy..
* Kid or 50 yr with painles hematuria or microscopic ist thingis always ua...
* If Fna is eqvivocal go for open biopsy
* Any cystic or fluctuant mass except with ocp need fna...ocp is due to estrogen content it will regress after u d/c the pills
* Any mental retarded pt needed contraception ans is iud,or norplant
* The most common side effect after depoprovera norplant(my exam q)...is intermittant spotting..d/c if its not going away after 3-4 wks..
* The most common side effect from estrogen pill is nausea/wt gain
* Chf and pul embolism, asthma, mitral stenosis, asthma, pul edema increase dlco....intestitial lung dec and emphesema dec dlco like sarcoidosis, bronchitis
is with normal dlco...
* D/c asp 1 wk bfore surgery
* D/c coumadin 48 h b4 surgery
* D/c heparin 4 h b4 surgery
* D/c antidepressent after 9month of depression free pd..some book say s 6 months
* D/c...antiepileptic after 2 yr of seizure free period..
* Rolaxifen is best choice if women has h/o breast ca ....but it can not protect endometrial ca....
* The most cc of death from ca is lung
* The most cc of disorder in future kids with adhd..is conduct /antisocial disorder
Recalls:
If you are asked about the management of the spine metastaisis ==> The emergent treatment should be dexamethasone i.v. This is followed by spine radiation.
The same thing also applies for brain metastasis.
This is an old recall...
If you are asked about the treatment of a cancer ==> Know which cancer is chemo- or radio-sensitive.
For example, solitary nodule of small cell carcinoma of the lung is treated with chemotherapy as the small cell carcinoma is chemo-sensitive.
Squamous cell carcinoma is radio-resistant. So, chemotherapy is the choice...and so on. (All these are old recalls).
Nerve block doesn't solve the whole problem..it will only relieves the pain but will not relieves the compression.
Here is another old recall..
70 patient with skin squamous cell carcinoma on his forearm. Refused surgicaL excision. The alternative treatment is:
a-Chemo
b-Radio
c-Laser
70 patient with irresectable laryngeal carcinoma.
Management:
a-Chemo
b-Radio
c-Surgery
d-Combination of chemo/radio
Q: Young patient with signs and symptoms of appendicitis
most unfavorible sign is rebound tenderness or diffuse guarding?
Answer is diffuse guarding for peritonitis, rebound tenderness for localized
Q: Any association with Breast implant and CTS
Answer yes 40%
CSS: DKA
1st step:
do PE
2nd step:
O2 inhalation, pulse ox stat/cont, iv access, floey's if unconcious, NS bolus, NS coninous drip, stat finger glucose, ser alcolhol, serum acetaminophen,
serum amylase/lipase, bHCG, U/a, urine toxicology screen, ABG stat. EKG
3rd step :
serum osmolality
serum electrolytes
serum ketones
" mg/ph
Insulin bolus 15 units regular
reg insulin infusion 8 to 10 units
abg
shift to icu:
NPO
strict input /out put control
cardiac monitor
BMP Q 4 hrs, Q 8 HRS, Q day
ABG Q 2hrs * 2
after 4 hrs change fluid to 1/2 NS
add K 20 to 30 meq
check stat glucose if betwene 250 to 300 change the fluid to D5/w continous
shift to floor
if infection suspected give iv antibiotics
send cultures for urine and blood and sputum
cxr etc.
fasting lipid profile
Discharge :
d/c iv insulin
start SQ insulin
diabetic diet
diabetic counciling
foot care
opthalmology consult
strict home glucose monitoring
family and patient education
stop smoking/alcohol
safe sex
seat belts
regular exercise
low fat diet
discharge with follow up in 2 wkz
CSS: Narcotic Overdose
Most of the pts are in respiratory distress or unconcious...so we'll go with basics of trauma
A: airway suction, o2 inhalation, pulse ox stat n continous
B: intubate if po2 is less than 55 or pco2 is more than 50 , or pt is unconcious
C: iv access, foleys. cardiac monitor, stat glucose
D: Iv thiamine, 50% dextrose, nalaxone...one time boluses
PE focused
Diag evaluation:
Ekg, cxr, serum alcohol, serum acetaminophen, urine analysis, urine toxicology, abg, stat glucose, lft, pt /ptt, serum ck
Initial management:
NG tube gastric lavage ( within 1hr)
charcoal
IV nalaxone continous ( do not give if the pt is opiod dependent )
review hx n physical
Shift to ICU:
NPO
D/c intubation
D/c nalaxone
D/c NG tube
Continue cardaic monitr n pulse ox for 24 hrs
Serum electrolytes
Educate family n patient:
Psych consult
d/c IV access
D/c foleys
shift to psych ward
give antidepresants if needed
suicidal evaluation n councilin
regular diet
exercise prog
stop amokin/alcohol
safe sex
seat belts
discharge
CSS TIA
routine physical
evaluation :
cbc, bmp, ekg, CT scan
ct is usually -ive within 24 hrs
admit to ward:
vitals every 12 hrs
continue home medications
ambulation
diabetic diet if hx suggest
doppler echocardiogram
tele monitoring
accu checks bid
carotid doppler
oral aspirin continue
MRI/A of brain and neck DWI
results:
if > 70 % stenosis
take surgical consult for elective CEA
other wise manage on medical basis ...aspirin is the drug
discharge with advices:
stop smoking/limit alcohol
BP control ( diet exercise meds)
diabetes control ( do )
pt education for drug compliance
safe sex, seat belt, injury prevention, regular exercise, low fate diet
fasting lipids
follow up after 4 wkz
OB-GYN FACTS:
If it is only spotting____________________ reassure
if it is heavy < 35 years __________________________increase estrogen
if it is heavy > 35 years_____________Biopsy
you can add the following
acne + OCP _______ decrease progesterone
depression+ OCP _______ give SSRI
amenorhea+ OCP
urine pregnancy test if -ve
1) reassure
2) if she wants menstruation_____________ increase estrogen.
COMMON SIDE-EFFECTS of medications....
1. T****done= priapism
2. verapamil= constipation
3. ACEIs= angio edema, rash, Dry Cough
4. Clopidogrol-- HUS,TTP
6. Indinavir -- Renal Stone
7. AZT -- Bone Marrow Supp
8. Heparin - Thrombocytopenia
9. INH - Prepheral Neuropathy
10. Hydralazine- Lupus Like Syndrome(also Procainamide)
11. Ethambutol- loss of red green visual acuity
12. Pyrazinamide- Liver toxicity
13. Carbamazapine- SIADH
14. Lithium- Hypothyroidism,wt gain, Flair up of Psoriasis, Tremor, Acne,DI
15. Demiclocycline-DI
16. Aminoglycosides- Ototoxicity and nephrotoxicity
17. Bleomycin- Pulmonary fibrosis
18. Doxorubicin and Daunorubicin-Cardiotoxicity
19. Cyclophosphamide- Hemorrhagic cystitis
20. Vincristine-Peripheral neuropathy
21. Metronidazole-Disufiram like reaction and peripheral neuropathy
22. Niacin- flushing and abnorman LFT's
23. HMG coa (statins- myositis HIGH AST ALT( check lft's often )
24. Thiazide diuretics- hypercalcemia .. can cause GOUT
25. metformin- anorexia wt loss and lactic acidosis
26. imepenem- seizures
27. rifampicin= color change urine tears skin orange color
28. NSAIDs- gastritis, nephrotoxicity, can increase BP
29. B-Blocker- Cover Hypoglycemia Symptoms,
30. Clozapine- Bone Marrow Supp
31. Amitriptyline- Convultion, Cardiac arrythmia,Coma
32. steroids- avascular necrosis, edema. osteoporosis, poor wound healing
33. aspirin.... ototoxicity and resp alkalosis/ metabolic acidosis
34. Quinidine- diarrhea, thromocytopenia
35. Acarbose- flatuence
36.methimazole- agranlocytosis, aplastic anemia
37)Prazocin-- First Dose Syncope(give the first dose in your office)
38)Amilodarone -- Pul Fibrosis
39)Chlorpropamide -- SIADH
40)Colchicine -- DI
41)Nitrate Drugs+ Viagra(sildenafil)---> Sudden Death
42)Ethosuximide -- GI upset
43)Tolcapone --- Hepatotoxicity
44)Thioridazine --- Retinal Deposits, Torsade
45)Vancomycin --- "Red Man" Syndrome
46)Chloramphenicol--- "Gray Baby" Syndrome
47)Cimetidine--- Genycomastia
48)Ketoconazole-- Gynecomastia
49)Protease Inhibitors(in General)-- Hyperglycemia, Hyperlipidemia
50)Cisapride---Torsade
51)Methotrexate(long Term)--- Liver Fibrosis
52)Asparaginase--- Pancreatitis
53)Cyclosporine--- Nephrotoxicity
Bites quick points (Cat bites > humans > dogs) Also look CMDT 1255
* If stray dog bites to some one give both Ig and vaccine....make sure 1/2 of Ig is sprinkled over the wound and half in the buttocks in kids and in adult in
deltoid muscle...and make sure Ig and vaccine should be on separate sites of injection...
* If neighbours dog bites which has all his vaccination upto date then just reassure the victim and clean with soap and water....nothing to worry about
* If human bites to another human (Recall) a man comes with a bite wound that result in swelling of his whole forearm...and on qustioning he admitted that
his wife bit him.. what u will do....since human bites r worse than all other because of aerobic and anaerobic bacteria in one’s mouth need special attention
and since it was such an extensive lesion so we have to admit him and give him iv antibiotic....augmentin is good as out pt and inpatient u can give
ampicillin, iv and clindamycin.
* If cat bites, ... if extensive wound then give ampicillin or augmentin
* If dog bites same augmentin or amp...(domestic)
* Scorpion bites ..... brown recluse ...will cause stinging sensation, sloughing necrosis need dexamethasone and tetanus....
* If black widow bites then u will have abdominal cramps and rigidity u have to give calcium gluconate ...
* A mom is worried that baby is so lethargic not taking bottle and she is not having any fever just dilated pupil on exam....and ans was did u give him honey
lately
Pointers
Three vaccine can induce anaphylactic reactions in egg-allergic people: INFLUENZA, YELLOW-FEVER and MMR.
The MMR and yellow fever still can be given in egg allergic people.
Varicella zoster vaccine is given at age of 1 year! (with the MMR).
Influenza vaccine ==> all people > 50 YEARLY
Penumococcal vaccine ==> for adults above 65 with chronic diseases/immunocompromised
MALE HOMOSEXUAL..What vaccines you give beside Hepatitis B? Hepatitis A !!! (becuase hepatitis A transmits through the faeces like feco-oral or feco-mucosal
route...Male homosexual are thus subject to Hepatitis A).
60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows hyperplastic polyp..next step:
a-colonoscopy
b-do nothing
The answer is do nothing..Itis hyperplastic polyp..
60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows tubular adenoma polyp..next step:
a-colonoscopy
b-do nothing
The answer is colonoscopy...It is tubular adenoma..It has risk of malignancy. So, you have to make sure that there are no more tubular adenoma
polyps..sigmoidoscopy screens the descending colon only and doesn't reach the rest of the colon..so, colonoscopy should be the next step.
PAP shows ASCUS ==> Repeat test in 4-6 months
LGSIL/HGSIL on PAP ==> colposcopy and followed by cervical biopsy.
ITP ==> steroids are the first line. IVIG is the second line.
TTP/Gullian Barre ==> plasmapheresis
When the patient is in severe depression/suicidal tendency, he is not compotent:
30 year old man found on the floor with empty bottle of valium. A suicidal note was found saying that he wants to die peacefully and doesnot want any heroic
procedures to save his life. Next step:
a-Flumazine i.v
b-Intubate and move to the ICU.
Choose B
For any drug overdose, do not choose the option of the anti-dote/the antagonist..remove the drug first by charcot/gastric lavage unless contraindicated.
Acetaminophin overdose..next step:
a-N-acetylcystiene iv
b-gastric lavage
Choose B
Don't afraid to give morphine for the pain management in patients with terminal stage of their cancers:
..but it should be under monitoring to prevent respiratory depression!!
75 patient with pacreatic cancer and severe back pain ..next step:
a-morphine intrathecal
b-morphine i.v every 3 hours
c-morphine i.v on needed basis
d-morphine i.v in a monitored bed.
Jump to D
Emancipated minor is the minor who lives alone/married/works
Pregnant minors are not emancipated but have the excetion of signing the consents!
A 16 year pregnant girl need Cesearan section for delivery ..who signs the consent?
a-In most states, she is emancipated minor.
b-In most states, she can sign the consent
Point your arrow to B
Jehovah's witness refuses blood transfuion..His Bp is 50/0..next step:
a-do nothing
b-iv fluids
Respect the autonomy but tries to do any supportive measure outside the conflict!! so jump to B
Do not respect the patient's wishes in organ donation if they parents refuse the donation even if he has the organ donation card! This is the only exception
for the patient's autonomy after his brain death.
The spouse is the next after the patient (not his parents or siblings). Ask the wife for any consents if there is no guardian or advance directive!!
Treat keloid by intralesional steroids. The same thing for alopecia aerata (NOT topical!!)
Emergent reversal for warafin overdose is FFP (not Vit K) while emergent reversal of heparin is protamine sulphate (not FFP!!..The FFP is c.i.)
If the Q is clueless..choose the most common
70 yo patient with weight loss...next step; CXR (to exclude lung cancer which is the most common malignancy)
70 yo patient with fatigue...CBC (to detect iron deificency anemia..followed by colonoscopy becuase lower GI bleeding is the most common cause of iron
deficiency in the US..NOT NUTRITIONAL CAUSE!)
EFFECTs of OCP:
HDL LDL Glucose TG
a low high high high
b high low high normal
c high high normal normal
d normal normal normal normal
e normal normal high high and high total cholesterol
The answer is E why?
Remember that estrogen increases HDL but decreases LDL
Progetreone decreases HDL and increases LDL
Their combined effects is nill!!keeping the levels of LDL and HDL normal
TG is elevated and impaired glucose tolerance!!
Patients with adenomyosis/endometriosis/leiomyomata uteri (refused surgery)..What is the medical treat? OCP. Remember all these cases are caused by state of
hyperestrogenism..but you still have to give OCP..not progestrone only.
Patient with rheumatoid arithritis...refused to take steroids..The alternative drug should be: METHOTREXATE
Patient with SLE...refused to take steroids..The alternative drug should be: CYLCOPHOSMAIDE
Patient with Crohn's disease..The first line is s-ASA with metronidazole or cirpofloxacin...Steroids are SECOND LINE..AZATHIOPRINE or ^-Mercaptopurine are
THIRD line. INFLXIMAB is the last line OR for the treatment of FISTULAS!!
Treatment of IBS (Irritable bowel syndrome)?? FIBER+ ANTICHOLINERGIC DRUGS like hyoscine
GERD ==> First line is therapeutic trial of H2 blockers , followed by Proton-pump inhibitors. If fails, go to 24-hr esophageal PH monitoring. Don't forget
the life style modification before any pharmacologic therapy.
The following vaccinations should not be given during pregnancy becuase they are live attenuated virus vaccines:
1-Mumps/Measles/Rubella
2-Yellow fever
3-Varicella
REMEMBER>>>
A prgenant in her 2nd trimester exposed to a child with Varicella one day age. You checked her serum for varicella antibodies titre and it was negative..Give
VZV ig (not vaccine) ..It should be given within 96 hours of exposure.
The mother ask you: Does the VZIG protect my fetus againts infection? NO. VZIG is given to prevent MATERNAL NOT CONGENITAL/FETAL infection!. The congenital
varicella syndrome results from exposure during the first 16 weeks of pregnancy.
These vaccines can be safely given and their indications are not aletred by pregnancy:
1-Pneumococcus (polysaccharide)
2-Meningococcus (polysaccharide)
3-Rabies (killed virus)
4-Influenza (inactivated virus)
5-Hepatitis B (purified surface antigen)
6-Hepatitis A
7-Tetanus-Diphtheria (toxoid)
Pictures
pic of a kid with arm and mouth vesicular lesion i put cockscakie virus A....bcz it was hand mouth fooot diease kind of pic...
kid with the xray chest with pnumo one side and bowel other..cong diaphragmatic h
man with apple core lesion..colorectal ca
a fib ...ekg
3rd degree heart block
inf mi...st elevation in typical leads
pic of scabies
pic of pudohyphe
pic of shingles with eye involvement
pic of nodular cystic acne
ct of head with lenticualr mass .....epiduarl hematomaa.
achlasia....pic
Hematology Pointers
1) THE main DIFFIRENCE between TTP and HUS is lack of Neurological involvement in HUS....otherwise same as both have inc BUN/CRETINE both have INC LDH both
ha THROMBOCYTOPENIA both have MICROANGIOPATHIC HEMOLYTIC anemia......both have SHISTOCYTES on periphral bloood smear...v imp for exammmm REMMBER BOTH HAVE
NORMAL COAG AND NORMAL OTHER CELL LINES...
2)INC PTT IN CLASSIC HEMOPHILIA AND ITS XLINKED...TREAT WITH FACTOR 8 AND IF IT DOESNT CORRECT PTT THEN IT MEANS THAT PT HAVE ANTIBODIES AGAINST FACTOR 8
WHICH CAN OCCUR IN 10% OF TH E CASES AND TEST THIS WITH MIXING STUDY MEANING WHEN U WILL MIX PTS BLOOOD WITH FFP OR NORMAL BLOOOD NOTHING WILL CORRECT PTT IT
WILL STILL INC ...TRETAMENT OF THIS WILL B CYCLOPHOSPHAMDIE ALONG WITH PREDNISONE
3)MOST COMMON CONGENITAL BLEEDING PROB IS WITH VON VILLIBRAND DIASES ITS AUTOSOAML DOMINENT...AND IT WILL INC BLEEDING TIME..INMILD CASES U CAN GIVE PT
DESPOPRESSIN ,,,AND IN SEVER CASES CRYO WILL HELP...DONT GIVE DESMO IN SEVER CASES IT WILL MAKE IT WORSE..
4)DESMOPRESSINIS ALSO GOOOD FOR MILD CLASSIC HEMOPHILIA A...
5)IN ITP THERE WILL B MEGAKARYOCYTES ONPERIPHRAL BLOOOD SMEAR BCZ THERE IS INC RATE OF DISTRUCTION OF PLATELETS AND DEC FORMATION OF PLATELETS DUE TO
AUTOIMMUNE PHENOMENON, ANTPLATELET IgG ANTOBODIES DESTRY ALL PLATESLETS SO THESE PTS R MORE PRONE TO HAV EMUCOSAL BLEEDING LIKE THEY WILL HAV E MENORHAGIA,OR
EPISTAXIS.....FORTREATMENT IST TRY WITH PREDNISONE IT HELPS ALOT BY INC THE PLATELETS itworks by dec the affinity of platelets to activated macrophagesin th
e spleen and steroid also dec the binding of autoantobodies toplatelets....tretament always start with low dose of platelets it will inc th eplatelets numb
but if u hav eto keep thept on prednisoneor u hav eto inc the dose then do splenectomyis the definate treatmentofitp if they ask u in step 3,,,,but make sure
that u give pnumovac and h influenza vac 2 wk prior to splenectomy,other drugs that use when platelets r low and causing bleeding or if pt is going for
urgent surgery is ivig..its v expensive so only reserve for life thretening bleeders and its always given slow and never in ppl who have igA defiency bc
zthey will die from anaphylaxis...another imp point is that when pt cant go for splenectomy or cantbon prednisone or cant afford 5 k dollerivig give him
danazol,or rh gam its helpful tooo...som e tried inflaximab group its helpful but infectionis the side efefct....so watch for that...if u c ccs in exam which
most of u willl..... just treta as an out pt with prednisone and call pt in 2 wks and when platelets above 50 taper prednisone and advise for no contact
sport..and pt teaching about diease ...v imp...
6)dic is dif from sub acute dic in thatpttis normal and fibrinogenis normal...and remmber in dic treat the underlying cause...
never give aminocaproic acid in dic without heparin bc zit cause severe thrombosis...
7)liver disease have both prolong pt and ptt but fibrinogen level is normal...ff will correct th ebleeding..
8)the dif bet the vitamin k deficiency and dic is noraml platelets and normal fibrinogen vit k will help....
9)if platelet r 10 k still u can perform splenectomy so never ever give platelets in itp when its in exam..bcz it will b destryed by the antibodies...
10)inmy exam they ask that baby had circumcison and lost lots of bloood on lab hisptt was 100 an his bleedint time was 12....and mom said his uncle has sam e
prob he bled in suregry and after surgery...whatu will do u will check factor 8and 9...its dic,its ttp,its itpand blabla...
11)remmber factor x11 deficiney u wont have bleeding just inc ptt they canhave surgery without any prob its also callled hadgman factor deficiency..
12) ifpt is having factor 13 deficiency.u will hav e normal coag but still u will hav e bleeding....so remmebr these clues they will help u to exclude wrong
choices in exam...
13)lupus anticoagulant antibodies is v imp subjects so u have to read about it.....its igG or igM antobodies taht produce aprolonged pttby binding to
phospholipids,its present in 10% pt of sle and is characterized by recurrent abortion,and thrombosis .there is no bleeding unless second ry factor is
presenttaht cause bleeding,the prolonged ptt will failed to correct with mixing study so that is a clue for diag....the russell viper venum isgood and
senstive assey and is diag of lupus anticoagulant...antiphpjolipid and lupus anticoagulant will cause the false positive vdrl...u can suspect lupus
anticoagulant when inc ptt but no bleeding and vdrl is in and anticardiolipid and natiphospholipid positive...predison is th ebest treatment and give heparin
if thrombosis is suspected....
14)autologous bloood can b given to pt for surgery and it can b stored for upto 35 days...it dec the chance of infection and reaction..
15)i pack of rbc pack can raise the hct by 3-4%and prbc is used to raise hct ...not the whole blood that is reserved for sever hypovolemic pt...
16) dont transfuse awake juhuwa witness against his will but for a kid go ahead and transfuse if urgent or in nonurgent situation just tak e court
oreder...ifkid belongs to juhuwa witness
17)always remmber when ever kid is in the womb mom will give consent for every thing evenif she is competent and refusing for csection and endangering her
baby thats fine u just listen to her an d respect her wish..but as soon as she deliver she has no longer authority if child lif eis in danger....but for non
urgent cases we stilll need her consent even if she is in jail or drug addict .....
18)febrile bloood transusion reaction pt need leukopooor bloood
19)for graft verses host reaction u need to give iiridiated bloood next time..
20)HIT need that u d/d heparin and coumadin both and start with leupridine...inc risk of thrombosis with the HIT...plez read more from wash manual
....21)...in cases of hemoglobuburia weather its due to rhabdoor bloodo transfusion reaction give vigrous hydration with n/s and mannito or lasix...so
hemoglonuria will not damage kidney tubule....bcz atn will cause rf sooon..if will not go aggressive hydration v imp for exam....
21)ist day jaundance is always due to abo imcompatibility
22) if husband is onegative and wife is tooo no prob baby will b normal..(.cam e in my exam..)..case senario was that a gal is pregnantand her rh is negative
and her b fd is rh positive and they tell s u in sep setting that this babyis not my b fd but my ex and he is rh negative what u will tell her....
23)delayed transfusion reaction is due to duffy,kell and c,e loci of rh system..they cause delayed reaction after 8 to10 days of transfusion..
.
24)i unit of platelet will inc 5 k of platelets usually we giv e 6 pack..
25)fever chillsl and sever backach eis due to heamolytic reaction,stop transfusion and give ns bolus and lasix..flush th ekid so no damage to tubule and no
renal failure other prob is dic....
26)kid if they have dirrhea due to slmonella sheggella or due to e coli they will most like ly have hus so keep that inmind in exam they ask that akid ate
hamburger while his father was stilll barb qing...an dkid has now fever and dec inc bun/cretinine .. and thrombocytopenia and in c ldh itS HUS
27)WALDSTROME MACROGLOBUNEMAI IS DUE TOMONOCLONAL IGm paraprotein and in MM ITS DUE TO IgG
THE MAIN DIFIS THAT NO LYTIC BONE LESION IN THE WALDSTROME ...the cause of death in mm is due to infection from streptp pnumoni and h infuenza...
28)hairy cell leukia is having pancytopenia,splenomegalyand hairy celll on p blood smear and bm biopsy
Isolation from School/Day Care :
1) Chicken pox: until all lesions have dried and crusted
2) Scarlet fever: until atleast 24 hrs after appropriate antibiotics
3) Rubella: 7 days after onset of rash
4) Measles: until 4 days after onset of rash
5) Mumps: return to school 9 days after appearance of parotitis
6) Strep pharyngitis: until 24hrs after appropriate antibiotics
7) Parvovirus B19 (5th disease): until appearance of rash [pregnant pt should be evaluated]
Rota virus: until stool is contained by diapers or toilet use
Factitious Hyperthyroidism:
Pt is a nurse with symptoms of hyperthyroidism - Graves Dz vs. Factitious hyperthyroidism distinguished via :
a. TSH
b. FT4 concentration
c. T3 resin uptake
d. TSI (thyroid peroxidase antibody)
Discussion: In factitious hyperthyroidism following labs are seen:
-Thyroglobulin level is low or undetectable
-RAIU decrease
-Low TSH
-T3 and T4 increase.
If only T4 is ingested....Serum T4 could be low. (low TSH)
But in graves there is Antibody.......In factitious No
Recalls:
Q: Infants begin to differentiate their mom’s face and voice at
A. 1 WEEK OF AGE
B. 8 week of age
C. 12 weeks of age
D. 7 months of age
Ans: 1 week of age
Q: Prognostic Sign in Bell’s Palsy is
A. Lack of Parotid gland swelling
B. The presence of incomplete paralysis after 5 days
C. The presence of only a few herpetic vesicles.
D. A lack of motor involvement of tongue
Ans: The presence of incomplete paralysis after 5 days
Q: A patient recovering from Meperidine addiction sustains traumatic injury. What therapeutic modality is appropriate:
A. Accupunture and cold packs
B. Adequate dose of morphine
C. Trans-cutaneous electrical stimulation
D. NSAID
Ans: Adequate dose of morphine
Q: Which vaccine is contraindicated in a 4 year old child receiving immunosuppressive therapy?
a)HAV
b)Acellular pertussis
c)IPV
d)varicella vaccine
Ans: Varicella vaccine
Q: A patient with chronic malabsorption presented with absent tendon reflexes, ataxia, loss of pain sensation, ophthalmoplagia, and anemia. He is suffering
from which of the followin vitamin deficiency?
a) vit. A
b) vit. B12
c) vit. C
d) vit. D
e) vit. E
Ans: Vit E
Neurologic findings follow a pattern of progression that can be divided into early and late stages.
Early findings include hyporeflexia, decreased proprioception, decreased vibratory sense, distal muscle weakness, nyctalopia (night blindness), and normal
cognition.
With continued deficiency, neurologic symptoms progress and patients can develop truncal and limb ataxia and diffuse muscle weakness. Further eye problems
may develop, including limited upward-gaze nystagmus and dissociated nystagmus.
Late manifestations include areflexia, loss of proprioception and vibratory sense, dysphagia and dysarthria, cardiac arrhythmias, ophthalmoplegia, and
possible blindness. Cognition may be affected in later stages, and dementia can occur.
Q: Which one of the following vitamin deficiency causes squamous metaplasia of the airway, pulmonary infection, renal stones, immunodeficiency, and it is
used as a supplemental treatment in some patients with measles?
a) vit. A
b)vit. B
c)vit. C
d)vit. D
Ans: Vit A
Q: 70 yr old male experiencing attacks of "whirling sensations", nausea, diplopia, dysarthria and tingling of lops. Episodes occur several times a day and
are so severe,he collapses and becomes immobile.
A. Panic attacks.
B. Benign positional vertigo.
C. Vertebro-basilar insufficiency
D. Cataplexy
Ans: Vertebro-basilar insufficiency
Q: Alcohol dependent on Disulfiram reports recurrent craving.
Which medication is suitable?.
A. Paroxitine
B. Carbamazepine
C. Naltrexone
D. Propanolol
Ans: Naltrexone
Q: Late stage of HIV infection, the most common neurologic complication.
A. Cytomegalovirus encephalitis
B. HIV polyneuritis
C. AIDS dementia complex.
D. Cryptococcal menigitis
Ans: AIDS dementia complex
Q: 21 yr old female with lethargy, restlesness, confusion, diaphoresis, tremors and myoclonic jerks. She is receiving trearment for depression and does not
know the name of pill. What is it?
A. Tyramine reaction.
B. Anticholenergic reaction.
C. Serotonin syndrome.
D. Neuroleptic malignant syndrome.
Ans: Serotonin syndrome
Q: Evidence is accumulated that ADHD is connected to:
a) Dopamine
b) serotonin
c) melanin
d) estrogen
Ans: Dopamine
Q: Cause of death in hospitalized elderly:
a) UTI
b) Pneumonia
Ans: Pneumonia. Most common infection is UTI
Q: A 29-year-old woman presents with an exacerbation of her asthma. She is 11 weeks pregnant. She has mild intermittent asthma and usually takes a b-agonist
as needed. She has one 4-year-old child who is in day care and has had a recent upper respiratory tract infection. She has a dry cough, clear nasal
discharge, myalgias, and fatigue.
On physical examination, she is talking in full sentences and has normal tympanic membranes, mildly erythematous oropharynx without exudates, no adenopathy;
she has positive wheezing bilaterally. The peak flow is 300 mL; her usual result is 390 mL. Pulse oximetry is 93% on room air.
Which of the following is indicated in the management of this patient?
(A) Amoxicillin
(B) Theophylline
(C) Prednisone
(D) Montelukast
(E) Flunisolide
A: Answer: E Flunisolide
Manage asthma in a pregnant patient
Treatment principles for asthma in the nonpregnant patient apply also to the pregnant patient. She has mild intermittent asthma with an exacerbation, for
which therapy with an inhaled glucocorticoid is an appropriate choice. Use of inhaled glucocorticoids is safe in pregnancy.
Q: What is drug of choice pt with HTN and DM II but no proteinuria
A: Inhibition of the renin–angiotensin system with an ACE inhibitor or angiotensin II–receptor antagonist is warranted to decrease both blood pressure and
albuminuria; the dose should be titrated upward to the moderate or high range, as tolerated, to achieve a systolic pressure below 130 mm Hg and a diastolic
pressure below 80 mm Hg. Although data from clinical trials provide stronger support for the use of angiotensin II–receptor antagonists than for the use of
other agents in patients with type 2 diabetes and microalbuminuria or macroalbuminuria, in the absence of a direct comparison of the two strategies, we
consider either of these classes of medication to be a reasonable first choice. Serum potassium and creatinine should be checked in all patients seven days
after the initiation of treatment with drugs that block the renin–angiotensin system and after any increase in the dose of such drugs. A beta-blocker or
diuretic — or if these agents are inadequate, a nondihydropyridine calcium-channel blocker — should be added if ACE inhibitors or angiotensin II–receptor
antagonists are insufficient to maintain blood pressure in the desired range . We consider adding dihydropyridine calcium-channel blockers or alpha-blockers
only when the target for blood pressure is not met with the use of these other approaches
-review article from NEJM
Q: Q:
ileojejunum bypass, diarrhea, what kind of fluid you give?
A: choice is TPN, BUT normal saline+calcium and magnasium replacement
Q:
75 y/o male constipation, no other abnormalities, what is most likely cause
A:
Constipation is seen in 30% of elderly.
It's usually due:
-Declined or impaired general health status
-Drugs: Verapamil
- diminished mobility and physical activity
Treatment: Bowel training, exercise, high fiber diet and increase fluid intake
Pharmacologic treatment: Bulk laxative, emolient laxatives, hyperosmalar laxatives
Renal
Q:
post mva suspect bladder trauma, most sensitive exam
a ct
b u/s
c peritoneal lavage
d kub
A:
Preferred Examination: Retrograde cystogram, performed after urethrogram, was considered the criterion standard for evaluation of bladder trauma. However, in
recent years, enthusiasm has grown for CT cystography for proper diagnosis. Initial studies were not indicative of CT reliability when retrograde contrast
was not used. However, contemporary studies have overwhelmingly demonstrated both sensitivity and accuracy, provided that adequate bladder distention with
contrast material is achieved prior to performing the study with at least 300-400 mL of contrast.
Ultrasound has never been sensitive or specific enough to be useful for evaluation of bladder rupture.
Even in this article it is CT Cystography. So I think rather than choosing CT, cystography is a better choice
Other said: also emed. Most patients have multiple injuries and require abdominal or pelvic CT scans as part of their trauma evaluation. This does not
preclude obtaining a separate contrast cystogram, since a CT scan of the pelvis using intravenous contrast alone is an unreliable study for bladder rupture.
A properly performed cystogram consists of an initial kidney-ureter-bladder (KUB), followed by anteroposterior (AP) and oblique views of the bladder filled
with contrast, plus another AP film obtained after drainage. The following procedure is recommended:
So kub first, if cystogram then it is the answer, ct will not be the intial as pt will be too sick and pelvic # need more er management first.
Q: Nausea, vomiting taking digoxin, stable, k+6.0
a) give ca gluconate
b) digiband
c) take digoxin levels
A: Digiband see CMDT 1574
Q: Q:
A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being
treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents
recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
1.Increase the warfarin dose to bring the INR into therapeutic range
2.Switch to dicumarol
3.Interrupt the inferior vena cava with a filter
4.Discontinue warfarin and begin heparin at a therapeutic dose
5.Discontinue warfarin and begin thrombolytic therapy
Explanation
Answer: 4
This 50 year old man has suffered a recurrent venous thrombosis, most likely from suboptimal prophylactic anticoagulation. The target INR for warfarin
anticoagulation to prevent recurrent thromboembolism is 2.0-3.0. When a new thrombosis is diagnosed, therapeutic doses of heparin must be initiated. Simply
increasing the warfarin dose to bring the INR into therapeutic range is inadequate, because warfarin is used for prophylaxis only, rather than for the
treatment of acute thrombosis. For the same reason, switching to a different anticoagulant like dicumarol would be ineffective. After starting up heparin he
should be restarted at a higher dose of warfarin.
\Interruption of the inferior vena cava with a filter is primarily indicated only for patients in whom anticoagulation is contraindicated or in whom
thrombosis has recurred despite adequate prophylactic anticoagulation. Neither of these considerations applies to this patient.
Thrombolytic therapy is not necessary in most case of DVT of the leg. This mode of therapy can be considered in patients with extensive venous thrombosis,
particularly involving extension into the inferior vena cava, in order to prevent long-term postphlebetic complications.
Q:
The method of choice for initial evaluation of bone involvement in patients with multiple myeloma is.
A - Technetium-99m bone scanning
B - Conventional roentgenograms
C - CT-scanning
D - MRI of the skeleton
E - None of the above
A: Skeletal series
Perform a complete skeletal series at diagnosis, including the skull (a very common site of bone lesions in multiple myeloma), the long bones (looking for
impending fractures), and the spine.
Diffuse osteopenia may suggest myelomatous involvement before discrete lytic lesions are apparent.
The findings on this evaluation may be used to identify impending pathologic fractures, allowing physicians the opportunity to repair debilities and prevent
further morbidity.
Do not use bone scans to evaluate myeloma. Cytokines secreted by myeloma cells suppress osteoblast activity; therefore, no increased uptake is observed.
MRI scan
Findings on MRI scans of the vertebrae often are positive when plain radiographs are not.
For this reason, evaluate symptomatic patients with an MRI scan to obtain a clear view of the spinal column and to assess the integrity of the spinal cord.
( Ref: emedicine)
bone scan is unreliable in multiple myeloma because the lytic process of MM doesn't take up radioisotope.
MR is no specific for bont lesions of MM,could use if to see extramarrow hematopoietic sites.
End of the session on this question.
Endocrine
OBGYN
Q:
pregant pt c urinary stone, next exam
a u/s
b. ivp
c ct
A: u/s, ct is contraindicated also ivp(contrast terato)
Q:
Estrogen replacement therapy has risks, which one is not
a. gallbladder dx
b. breast ca
c. uterine ca
d. pacreatitis
e. thromboembolic dx
Q:
A 37 y/o F G2P1, at term gestation has been in the 2nd
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Old 11-26-2004, 12:48 AM
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Asclepius1 Asclepius1 is offline
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Ghost Files
Posted: Wed Sep 17, 2003 12:07 pm Post subject: Ghost Files
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(these files are also available to download for free in word format from valuemd's free download area)
All solved File #1
Q)You are the resident on duty. A pt. under XYZ(attending physician) dies. What do you do next?
Don't recall choices. Probably
A. Communicate the news of the death to the relatives
B.Communicate the news to the attending physician.
C.certify death.
ANSWER IS CERTIFY DEATH
Q) 24 year old male with three day history of testicular swelling progressive, no nausea vomitting,mild fever, dull pain, no radiation. Pain does not
diminish on lifting the testis up but aggravates from 6/10 to 7/10.No risk factors for std.
what s your diagnosis
a. torsion
b. epididymitis
Answer is epididymitis (three days of onset)…most likely answer
Q) Mother comes with 12 year old child. child is blond with blue eyes.
she ask which is the best way to prevent malign melanoma there is no family history
spf15
spf16
forbid out door activities in sun
tell her to wear protective clothing
Answer is tell her to wear protective clothing
Q) Elderly pt with hx of high bp, controled well, suddenly increase bp what's the cause?
Answer is Most likely non compliance with meds is the answer
Q )Pt c Parkinson disease, tx c L-dopa, had agitation, tx c haloperidal, getting worse, next:
a. increase haloperidal
b. decrease halo...
increase l-dopa
Answer is change it to other antipsychotic… Clozapine .. if that not in the choice answer is Decrease / dc haldol.
Q)14 y/o girl pregnant is there increased chance of congenital malformations or not?
ANSwer is ……No clear increase risk with young age
Q) black male with HTN + DM .what HTsive med do u give?
Answer is …..Ace inhibitor….*htn plus diabetes*
Q) “BILATERAL”renal a. stenosis with HTN, what med do you use to tx HTN…
Answer is calcium channel blocker…. If it was unilateral stenosis then ACE inhibitors. Ace inhibitors are contraindicated in Bilateral stenosis
Q) Estrogen replacement therapy has risks, which one is not
a. gallbladder dx
b. breast ca
c. uterine ca
d. pancreatitis
e. thromboembolic dx no clear answers? I THINK THE Answer is pancreatitis.
Q) A kid with Down syndrome has one parent with down sy. the mother asking about another baby but she scared will have down syndrome, what should tell her?
100% chance
50%
25%
0%
Answer is 50 %
Q) A 5 y/o kid with turner syndrome his mother is pregnant and she is asking what % chance will have this coming baby with TURNER SYNDROME?
ANSWER Is ….Somewhat increase chances.. if one previous baby is with turner… no clear numbers.
Q) Parents have a kid with Cystic Fibrosis, what is the chance to have another kid with same disease?
Answer is 25 percent chances
Q) Mallory Weiss, next
a) chest x-***
b) surge consults
c) prepare for urgent endoscopy
Answer is C endoscopy
Q)nausea vomitting taking digoxin, stable, k+6.0
a) give ca gluconate
b) digiband
c) take digoxin levels
d) stop digoxin
Answer is stop digoxin. If this is not in the choice in exam calcium gluconate….read the qs carefully.. if its next step then stop digoxin and treatment is
calcium gluconate.
Q) 50 yr annual office visit common finding at this age
1.htn
2.cad
3.cancer
is it HTN or CAD. I think it is HTN.
Q) organ donation in a pt who had a ishemic death
1 but which organ you will take and
2 the time ........]
Brain death…. U can take any organ out… if its cariac death or ischemic death ..take superficial organs only..skin cornea , fascia and bone…. Not other
organs like heart lung kidney liver.
Q) Tanning and skin cancer relation with –UVA /UVB
which is more malignant
UVA is the answer… Both causes cancerr… UVA is causes melagnany melanoma.
Q) pt was bit by an animal (not high risk for rabies) in the zoo. What is the most important question to ask:
1- how long.
2- any disease present in the zoo.
3- from where the animal.
4- any symptoms happened to the patient right after the biting.
ANSWER IS ENQUIRE WHERE THE ANIMAL IS FROM
Q) A child allergic to neighbor’s cat what you do
a ask pt to avoid cat
b antihistamine
c. steroid
d isolate cat
Answer is A
Q) A male pt with thumb base pain what is dxa.
De querene tensovitis is the answer… treatment is nsaid and intrathecal steroids.
Q) 12 month child with mouth candida what do you do
Nystatin and treat mom with topical anti fungal cream on breast
Q)neonate c thrush what do you do
obs
antifungal
Answer is anti fungal
Q)a pregnant rh- do not know father what is next?
a give rh antibody 28 w
b test rh titer now
c. no need rh antibody
Answer the B
Q)post mva, pt can not extend knee, decreased low leg medial sensation, which n injury?
a femor n
b tibia n
c. fabula n
answer is A femoral nerve
Q)post mva suspect bladder trauma, most sensitive exam
a ct
b u/s
c peritoneal lavage
d kub
Answer CT
Q)75 y/o male constipation, no other abnormalities, what is most likely cause
Functional causes. Is the answer
Q)pt with s/s of aortic dissection, what is next exam
1 ct
2.TEE
3.U/S
4.cxr
Answer is TEE……..or Ct with contrast… now becareful how the qs is phrases… if it is next step then X *** is a possible answer but if it is diagnostic then
TEE…. So read carefully.
Q)ileojejunum bypass, diarrhea, what kind of fluid you give?
Total parental nutrition ,BUT normal saline+calcium and magnasium replacement
Q)which of followings is most likely to distinguish pk from major depression
a mask face
b tremor
c rigidity
d imbalance
e brady
Answer is ANSWER IS RIGIDITY,,,,,
Q) pregant pt c urinary stone, next exam
a u/s
b. ivp
c ct
Answer is U/S
Q)subarachnoid hemorrhage in pt taking coumadin:
1- ffp.
2- vit K 3- whole blood.
4- stop coumadin and do nothing.
5- cont coumadin
fresh frozen plasma
Q) A kid with chicken pox, when could he return to school?
Q)shoulder dystocia
next step,
a) mcroberts manover
b)call your collegue
c)tell mother not to push
d)call anesthesia
answer….first step tell mom not to push…then ******* manouver then c section…breaking of clavicle is the last resort
Q)which is not a risk factor of osteoporosis
a) smoking
b)alcohol
c)caffieneted products
d) white race
e) obesity
f)there were 2/3 more but not convincing
answer is obesity ( qs is NOT a risk Factor…ok)
Q)there was a picture of breast focussed on the nipple area a 43 year old women coming with pruritus,I thaught it must be pagets disease,the question waas
what is the next step, mamography normal
a) biopsy
b) steroidd cream call after 7 days
c) sfecesing the lesion
d) i dont ???remember but wasnt so convincing
answer is Biopsy
Q)most common risk factor of PID
1) multiple sexual partner
2) women with intrauterine contraceptive deivice
answer is multiple sexual partners
Q) primigravida 28 weeks, rh negative ,husband positive anti ***** antibody positive what next
1)give anti rhd2)
dont give anti rhd3)
do amniocentesis,
answer,,,, DON’T DO ANYTHING….
Q)early post partum hemmorage,iv access done,resuccitated,bleeding present
next step
a) do pelic examin
b) uterine massage
Answer is pelvic exam… this is how u gonna find out about atony uterus….treatment is uterine massage
During a flu. Season, a pt who did got get flu. Shot and had a flu.s/s for 4 days came in for treatment. You provide for him:
1. amantadine 2. zanamivir 3. only symptomatic support including (Tyleno)
Symptomatic treatment ( amantadine or zanamivir is given within 72 hours of influnza… ZANAMIVIR is the best treatment it covers both A and B)
Q)A 4 month-old-boy who is diagnosed as having OM without fever yesterday is brought by his mother for his regular vaccination scheduled. At this time, as
his PMD, you: 1. give the boy vaccines scheduled 2. Wait after he recovered from his disease 3. others.
Answer is give vaccination ( ever is not a contraindication )
Q)Most common parasitic infection in usa
Answer is PINWORM (Entrobius vermicularis)
(3 peds questions)
A boy (5 may 8 yrs old) was brought by his mother with c/o right hip pain for 3 days. The boy had upper respiratory infection prior this hip pain. After
working up, it is dx as septic arthritis.
1. what is the cause ? a. strep. Pneumo. B. staph. A. c. other bacteria (no surgical intervention)
2. what antibiotics ? a. methicillin b. penicillin c. vancomycin d others
3. 2 days after antbx, now there are a few small maculae (2-3 mm in diameter) without itching or redness. What do you do ? a. d/c antx b. continue the
treatment c change to another antx. D others
Answers…………………..1) staph aureus 2) methicillin 3) change the antibiotics
Q)23 yrs old women with a vaginal presure symptoms and on pe has a 5 cm cystic mass,use diaphram for contraception, pregnancy test negative
next step
1.u/s
2.observation for 6-8 weeks
3.birth control pills
4.laprotomy
ultrasound
Q)What is the best method to diagnose CHF
a. Echo
b. PE and symptomes
c ECG
d Serum levels of B-type natriuretic peptide
e CXR
Q)Would anyone post the exact inetrvals for pap smear (cervical cancer screening), breast cancer screeing, prostate cancer screening and colorectal cancer??
This is very important topic as I had many Q in this topic
Q)How do you treat Cocaine abuser with 210/115 BP?
Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV
No beta blockers like propranolol
Q)which is the not a sign of ovulatory bleeding,
1)Infrequent heavy bleeding
2)Presence of premenstrual symptoms
3)Dysmenorrhea
4)Breast tenderness
5)Change in cervical mucus
6)Mittleschmertz answer is 1…
Q) which is maximum risk for preoperative assesment of cardiac function
1)Suspected critical aortic stenosis
2)Myocardial infarction within six months with age >70
3)Poor general medical status and emergency operation
4th was easy to be removed
Answer is 1 read below
this was totally confusing as i did not read this topic nicely now i know the answer please try to discuss , lots of questions
Risk
Age older than 70 years 5
Myocardial infarction within six months 10
Myocardial infarction after six months 5
Canadian Cardiovascular Society Angina Classification*
Class III 10
Class IV 20
Unstable angina within six months 10
Alveolar pulmonary edema
Within one week 10
Ever 5
Suspected critical aortic stenosis 20
Arrhythmia
Rhythm other than sinus or sinus plus atrial premature beats 5
More than five premature ventricular beats 5
Emergency operation 10
Poor general medical status† 5
SOURCE IS AAFP ALSO AMERICAN HEART INEX
Q)a 8 month old kid cant turn over…what is the next exam
neuroreflex
check teeth
????
Answer Is neuroexam.neuro reflex
Q)29 yo M c severe diarrhea
o/e listless but responsive
vitals stable
Na 118,K 2.9, hco3 12,,urine na <10
R
a IV hypetonic saline
b hypotonic
c isotonic
d fluid restriction
e hco3
answer is isotonic solution
Q)prom with 34 weeks,
next step
1)take culture
2)start oxytocin
answer is take culture first
what next,bp,smac,cbc.normal
ct with contrast
mri
ivp
do we have to save money by doing ctscan or be more perfect doning mri, i was confused, Kaplan says mri, so i clicked mri.but what are your opinions
answer CT mri requires sedation
Q)A 3-month-old child was exposed to an adult with active pulmonary tuberculosis. What is the recommended approach to this problem?
A. Administer a TST and reevaluate in 3 months.
B. Administer a TST, perform a CXR, and reevaluate in 3 months.
C. Administer a TST, perform a CXR, administer INH, and reevaluate in 3 months.
D. Reevaluate after 3 months.
E. None of the above.
ans: C
the kid should be given INH prophylaxis even if CXR/PPD are negative. You have to reevaluate in 3 months with a skin test:
. if the test is negative :- to D/C INH
. if the test is positive :- to coninue INH for another 6 months (total 9 months )
Q)A pt on warfarin and heparin develops thrombocytopenia and petechias, what is next ?
a. d/c heparin only
b. d/c warfarin only
c continue both
d d/c both
Answer is dc both seems to be the answer
Q)25 yr old male routine visit with his father diag with colon cancer, what will you ask him next
age of onset
family h/o
diet pattern
sign and sym
answer is family history
Q)pt has been treated with lithium and developed hypothyroidism. after stopping lithium, when do you do tsh:
1- 3ds
2- 1w.
3- 2w.
4- 1m.
5- 3m
answer is 4-6 weeks
Q)pt has been treated with 0.075 mg thyroxin for possible hypothyroidism. you want to stop the drug and test the patient to see if he really has hypo-, when:
same options like the previous.
note: the amount is real.
An initial dose of thyroxine of 0.05 to 0.075 mg per day is usually sufficient to normalize the serum thyrotropin level.Patients with coronary artery disease
should receive lower initial doses (e.g., 0.0125 to 0.025 mg daily). Serum thyrotropin levels should be measured four to six weeks after therapy is begun,
after any change in the dose, and then annually once the levels become stable. Thyroxine requirements may increase over time if there is progressive thyroid
failure.
NEJM
Q)pt with history of cancer. dnr. developed stroke at home what do you do.
leave him home
give him drug for pain.
admit
admit the pt. Seems to be the answer
Q)DMI glucose 160 wants to sport:
1- insulin before match.
2- glucose before match.
3-nothing…..GLUSOCE BEFORE MATCH OR NOTHING ????
Q))you want give quinolon to a pt. whuch drug of the following should you worn him from:
1- coumadin
2- theophyllin
3- propanolol
answer is theophyliine
Q)50 y.o.w with multiple problems told you she is gonna get married from somebody she has met 2 weeks ago and asking you to attend:
1- congrat.. so nice of you to ask me but i am sorry i cant.
2- no my proffesional cant let me
3-you have so many problems it will affect on you negatively.
4-arent you too old to get married
5-is too soon to get married after two weeks only of knowing him
answer is A
Q)stroke family want dnr. you dont have previllage in that hospital and the doc wount give the familly dnr. the familly now calling you to support them
having dnr for their pt:
1- tell them to take the pt to a hosp where he has previllage.
2- ask attorny.
tell me about the pt situation
answer si tell me more about the patient
pictures of fundoscopy ( glaucoma, DM, and cmv)
skin (herpes zoster)
ecg (1st degree block) preop.
Q)pregnant exposed to a lacy rashed boy:
1- it will not affect you.
2- you get mild disease.
3- you are vaccinated to this. no harm
4- your may loose your fetus
Q)pt haevy smoker, loss 8bl lately, surem Ca++ 11.5,
what do you do next?
a.recheck Ca++ level
b.check CXR
answer is chest x ***
Q)pt has unilateral hearing loss, tinnus. also has lung Ca
what is most likely her symptom?
ANSWER IS MAYBE METASTASIS
Q)A diabetic pt with non healing ulcer..next step
Debribment
Antibiotic
Answer si debribe first
Q)A diabetic man with sexual dysfunction,,comes in for evalutaion of depression,, he is found to be depress..what is the best treatment
a)paroxitine (paxil)
b)fluoxetine (prozac)
c)sertraline (zoloft)
d)citalopram (celexa)
e) bupriopram (wellbutrin)
Answer is E.
wellbutrin and serzone are the only antidepressant that I know have least effect on sextual function.
I have checked it out this is not a guess.
Q)Most important risk factor for breast cancer?
a)involment of upper outer quadrent
b)breast cancer in mother
c)breast cancer in sister
d)use of OCP
e) early onset of breast cancer in family
Answer e
Q)karotype of complested hydatidiform mole is?
a) 46 xy
B)45 xy
c)46xx
d)69xxx
e) or somethign else..please specify?
Types
Complete Mole
Total hydatidiform change
Marked proliferation of trophoblastic cells
No evidence of fetal vessels
Karyotype: 46XX
Derived from haploid 23X sperm
Sperm duplicates chromosomes without cell division
Higher risk for malignant change
Partial Mole
Associated with a fetus (may be only vessels)
Moderate trophoblastic proliferation
Karyotype: Triploid (69XXX or 69XXY)
Fertilization by more than one sperm
Malignant change less likely than in complete mole
Q) Painless gross and microscopic hematuira: THESE ARE THE STEPS>>>>U/A > IVP > CT..
Q)Painful gross or microscopic hematuira (s/s -> kidney stone):these are the steps >>>> U/A > KUB > IVP > CT ??
Q)thyroid disorders,
early menopause
or somethign else???
answer is osteoprosis and early menopause AND STRESS FRACTURES
Q)What IS the most common associated finding in patient with paNIC DISORDER?
a)aLCOHOLISM
B)OCD
C)DEPRESSION
D) SUBSTANCE ABUSE DISORDER
Answer is depression
Q) A WOMAN IS TAKING OCP NOW PREGNANT ?effect of OCP ON FETUS
what will u do or say??
a) Sono..if boy consider abortion
b)sono if girl Do abortion
c) tell her no adverse effect on fetus
answer is C. I have cheked this out. No harm to baby
Q)A man with 5x5 cm mass in left lobe of thyroid which is found to be papillary carcinoma..The man has develop HOARSENESS. the right lobe of thyroid is
irregular on exam.. what is the best treatment
a)radiation
b)partial thyroidectomy plus radiation
c)total thyroidectomy with left neck dissection
d) total thyroidectomy with removal of enlarged nodes
answer is B or C ?? one of them
Q)2 yo child, mother reports he is pulling his LEFT ear, no fever vomiting, appetite good exam reveals cooperative kid,tympanic membrane red, no fluid on
tympanogram..
what will u do?
a)PO amoxillin
b)gentamycin ear drops
c)refer to ENT
d)tylenol only
E) reassurance
Answer is possibly E reassurance.. I guess
DON’T KNOW THE ANSWER
Q)woman with symptomatic Tachycardia, otherwise stable, positive for signs of hyperthyroidism,,,what is the IMMEDIATE way to treat her symptoms?
a)PTU
b)RAI
c)surgery
d)propranolol
answer is D
Q)pt with heart rate of 45/min, BP 90/50, PR constant.Every third wave without QRS complex?
management?
A) atropine IV push
b)observation
c)external pacemaker
d)transvenous pacemaker
Answer is C.
Atropine should not be used to treat Mobitz type II block associated with BBB
Hemodynamically unstable pts should be treated initially temporary transvenous pacemaker insertion followed by permanent pacemaker implantation.
Q) picture of a 7-8 yo boy with ulceration in AXILLA and lateral chest only...what is the most likely diagnosis?
A)impetigo
b)subepidermal bullous dermatosis
c)herpes
d)bullous pehphigoid
Answer is impetigo
Q)most effective contraceptive????
a)condoms
b)IUD
c)ethynyl estradiol +levonorgestrol orally
d)medroxypregestrone acetate IM (depot)
ANSWER IS OCP (COMINED )
Q)CGlucagon is least likely to be used for severe hypoglycemia in
1) Type II DM
2) Malnourished patient
3) Infant overdose of injected insulin
4) Obese patient > 65yrs
answer is B
Q)Can a boy with Type I Diabetes compete in competitive sports? If yes what precautions to be taken, regarding insulin dose?
decrease insuline (and take a snack ?) exercise=insulin so need less insulin prior to exercise.
Q)Infection of which valve is most likely to be associated with the development of heartblock.
a. tricuspid
b. Pulmonic
c. Tricuspic and pulmonic
d. Aortic
e. Mitral
Answer is E
MULTIPLE SCLEROSIS
Q1) how do u check the progression of multiple sclerosis?
Q2) how to u follow Multiple sclerosis?
Q3) Diagnostic test of Multiple sclerosis
Q4) Effect of pregnancy on multiple sclerosis?
Answers to above question
1) Progression based on clinic
2) F/U depend on clinical course
3) Dx MRI
4) Pregnancy? Pregnancy exacerbate MS symptom. Agree with rest of info.
Q)person with symptoms of Obstructive sleep apnea...what is the first/next step?
a)sleep study
b)medical workup
c)CPAP treatment
Answer is Medical w/u as below
1.r/o hypothyrid.ent exam
2.polysomnogram
3.treat-weight reduction(doenot work) >>>cpap
Q)Most common site of pancreatic cancer?
Answer is adeno carcinoma (type) head of the pancreas(site)
Q)A mother is concerned about obese child 3 y. what is the reason child is obese
mother behaviour problem
-child neglect
-genetic
-eating disorder
-ANSWER IS MOTHERS behavioral problems excessive eating may lead to childs excessive eating
Q)OLD lady with hemoptysis,Sob,questionable murmur.X *** chest HTN with Left artial enlargement, EKG a fib,Both artial enlagement AND rt vent hyperthrophy?
what is the diagnosis?
Answer is mitral stenosis
Q)A41 yr old women with a 2 month history of abdominal pain and reports constipation and altered calibre of stool with a history of weight loss of 9 pounds.
What is the likely possibilty?
-Inflammatory bowel disease
-Irritable bowel disease
-Colon cancer
-Tropical sprue
-celiac disease
Answer is colon cancer.
Q)A 4 yo comes to ER with muscle weakness, miosis, salivation, diarrhea, heart rate slowing down. You will give;
A. naloxone
B. atropine and pralidoxime
C. flumazenil
D. N-acetylcysteine
E. Pyridoxine
B. atropine and pralidoxime
Q) A 14 year old boy with acne lesions on face and back on benzoic peroxide and topical tretenoin with only partial response. What will you do next
-Oral tretenoin
-Corticosteroids
-Oral tetracycline
-topical erythromycin
Answer is oral antibiotic ( tetra)
Q) Treatment of spasticity in post stroke patient
Answer is beclofen
Q)Pt came with chest pain. No EKG is done yet...after oxygen,,,next step?
a)aspirin
b)captopril
c)heparin
d)metoprolol
e)streptokinase
Answer is aspirin
Q) Treatment of influenza. Indications and limitation of AMANTADINE
Answer is
influ. A amantidine within 48-72 hrs
************************************************** ************************************************** ***
1. labetaolo 2. hydralazine, 3 methyldopa
first, look at the medication she is taking for essential hypertension, if that is ace, change it.
for pregnant patient, good control of BP is very important.
*maintaince of BP can be done with methlydopa tid. If controlled well, keep close monitoring and continue methlydopa.
beta blockers can be safely used and if the patient's hypertension is well controlled on a Beta blocker there is no need to change.
Labetalol and hydralazine can be used for acute control of BP readings.
*for pregnacy+chronic THN
*Labetalol for pre-eclampsia
***********************
the most likely disease that one can get from in discriminate sexual activity:
gonorrhea
chlamydia
HIV
HBV
I had a worse question.
which of the following is not sexually transmitted from a prostitute.
a. Hep B
b. treponema pallidum
c. HPV
d. tricomonas
e. neisseria gonarrhea
I thought of all of those, hepatitis requires blood conatct, but it is just a guess. The rest are pretty much impossible to choose. What about Treponema? I
think syphilis is very contageous. What do you think, Raavii?
if it is HEP C, sure pick it.....
Among these....I do not know, can go with HEP B....then..
any suggestions....anyone....
**************************
a young female came with acne you prescribed topical isotretinoin later after few weeks she came with complaint of its itching of amole under her breast
which has become itchy after the usage, your response is.
1.isotretinoin causes itching some times
2.itching may be an indication for the removal of the mole.
3.other choices dont remember
sounds like you have to biopsy the mole.. any thoughts?
looks like the mole started to have itch after the medcine topical isotretinoin was started and the Q is asking.....
if it is from the medicine or not?????
so 2 is the answer?
or isotretinoin causes itching some times???
I have no idea.....
***************************
1. Female comes for treatment of recurrent herpes.
Do you tell her to send her sex partner for examination?( That was on the choices.)
2. Female with increased pigmented lines on neck and axilla. Most likely diagnosis.
a. Cushing¡¯s
b. Conn¡¯s syndrome
c. Addison¡¯s disease
d. DM
e. PCOS
is it c or d?????
acanthosis nigrans... DM
foll is some info from emedicine:
ACANTHOSIS NIGRICANS: The definitive cause for AN has not yet been ascertained, although several possibilities have been suggested. Eight types of AN have
been described.
Obesity-associated AN, once labeled pseudoacanthosis nigricans, is the most common type of AN.
Lesions may appear at any age but are more common in adulthood.
The dermatosis is weight dependent, and lesions may completely regress with weight reduction.
Insulin resistance is often present in these patients; however, it is not universal.
Syndromic AN is the name given to AN that is associated with a syndrome. In addition to the widely recognized association of AN with insulin resistance, AN
has been associated with numerous syndromes (see Picture 2). The type A syndrome and type B syndrome are special examples.
The type A syndrome also is termed the hyperandrogenemia, insulin resistance, and acanthosis nigricans syndrome (HAIR-AN syndrome). This syndrome is often
familial, affecting primarily young women (especially black women). It is associated with polycystic ovaries or signs of virilization (eg, hirsutism,
clitoral hypertrophy). High plasma testosterone levels are common. The lesions of AN may arise during infancy and progress rapidly during puberty.
The type B syndrome generally occurs in women who have uncontrolled diabetes mellitus, ovarian hyperandrogenism, or an autoimmune disease such as systemic
lupus erythematosus, scleroderma, Sjögren syndrome, or Hashimoto thyroiditis. Circulating antibodies to the insulin receptor may be present. In these
patients, the lesions of AN are of varying severity.
Acral AN (acral acanthotic anomaly) occurs in patients who are in otherwise good health.
Acral AN is most common in dark-skinned individuals, especially those of African American descent.
The hyperkeratotic velvety lesions are most prominent over the dorsal aspects of the hands and feet.
Unilateral AN, sometimes referred to as nevoid AN, is believed to be inherited as an autosomal dominant trait.
Lesions are unilateral in distribution and may become evident during infancy, childhood, or adulthood.
Lesions tend to enlarge gradually before stabilizing or regressing.
Familial AN is a rare genodermatosis that seems to be transmitted in an autosomal dominant fashion with variable phenotypic penetrance.
The lesions typically begin during early childhood but may manifest at any age.
The condition often progresses until puberty, at which time it stabilizes or regresses.
Drug-induced AN, although uncommon, may be induced by several medications, including nicotinic acid, insulin, pituitary extract, systemic corticosteroids,
and diethylstilbestrol.
Rarely, triazinate, oral contraceptives, fusidic acid, and methyltestosterone also have been associated with AN.
The lesions of AN may regress following the discontinuation of the offending medication.
Malignant AN, which is associated with internal malignancy, is the most worrisome of the variants of AN because the underlying neoplasm is often an
aggressive cancer.
AN has been reported with many kinds of cancer (see Picture 3), but, by far, the most common underlying malignancy is an adenocarcinoma of gastrointestinal
origin, usually a gastric adenocarcinoma. In an early study of 191 patients with malignant AN, 92% had an underlying abdominal cancer, of which 69% were
gastric. Another study reported 94 cases of malignant AN, of which 61% were secondary to a gastric neoplasm.
In 25-50% of cases of malignant AN, the oral cavity is involved. The tongue and the lips most commonly are affected with elongation of the filiform papillae
on the dorsal and lateral surfaces of the tongue and multiple papillary lesions appearing on the commissures of the lips. Oral lesions of AN seldom are
pigmented.
Malignant AN is clinically indistinguishable from the benign forms; however, one must be more suspicious if the lesions arise rapidly, are more extensive,
are symptomatic, or are in atypical locations.
Regression of AN has been seen with treatment of the underlying malignancy, and reappearance may suggest recurrence or metastasis of the primary tumor.
Mixed-type AN refers to those situations in which a patient with one of the above types of AN develops new lesions of a different etiology. An example of
this would be an overweight patient with obesity-associated AN who subsequently develops malignant AN.
In the light of the above more than one choice in this qs is possible ...any comments welcome.
thanks
*******************
Elderly woman with Alzheimer's becomes agitated. What will you give?
a.tacrolimus
b.trazodone
c.amitriptyline
no mention of haldol or benzodiazepine
recently posted recall...........
Tacrolimus is just a distractor
Trazodone is a good sedating agent with short onset and half life.
Amitryptaline is sedating too but will cause orthostasis and anticholinergic effects in elderly.
Among the above given, choice would to to Trazodone to calm the patient and sedate.
************************
Presentation of ankle sprain with tenderness and swelling. Dx:
* MRI ankle
* XRY foot
* XRY anteropost view of ankle
* XRY lateral view of ankle
Raaviio2, Iknow this q is confusing. Probably the recall is not complete. I think previously either **** frank or somebody mentioned xray is the first step
if imaging is required. In certain cases according Ottawa rule no xray is needed.
Ankle sprains involves posible injuries of the anterior talofibular ligament (most prevalent type) and frcture bone. Most sprain injuries to the ankle can be
successfully treated conservatively. The ability to bear weight after an ankle injury is an important consideration in deciding whether x-rays are needed. If
a patient is unable to bear weight, or if there is significant tenderness at the posterior aspect of the lateral or medial malleolus, then x-rays are needed
to rule out a fracture. If there is no evidence of fracture, or one less than 3 mm. of displacement, then conservative care is generally appropriate. I know
you concern about the ligament injury, which MRI may better than Xray. However, for initial and general practice ankle X-*** is first.
Hope this help.
Agree, under most circumstances, acute ankle sprain does not need an image. If the presence of inability to walk, then X-*** (AP) will provide more
information.
*********************
Long, long time ago, there was a posting that a patient after 16 yrs of renal transplantation (on azithioprine), had severe immunosuppressive. The questions
ask what's the reason and what is the outcome of his immunosuppression.
I asked one nephrology fellow at Mayo, he told me that in such a patient, azithioprine use is the reason for his immunosuppression, and this drug could be
stopped and the immunosuppression will get better. The reason that azithioprine can be stopped is because of 16 yrs history of renal transplantation without
rejection
Hope this will help.
renal transplant patient transplant done 16 yrs ago and pt maintained on chronic azathioprine and prednisone. renal status is perfect and it is not only
anemia but pancytpenia now with severe myelosuppression
what next step?
-decrese pred dose
-stop azathioprine
-start erythropoeitin
-start GCSF
-start fluconazole
next question
what wud be prognosis for this patient's myelosuppr
-improve
-worsen
-worsen then improve
-wax and wane
-unpredictable
*********************
Two kids. Older one eats chipped wall-paint and younger one eats newspaper!!
Older brother is having learning problems. Younger one is asymptomatic.
RBC protoporphyrin in older brother is 200
Younger brother 140
( Normal values given.)
What next?
Ans for elder brother is ........
Admit and BAL and EDTA.
2. Choices for younger brother
a. Await See Lead Level
b. Ca EDTA mobilization of lead for 8 hrs.
c. Do nothing.
I will wait and see lead level-ans A
The younger kid has PICA and so may have anemia but we have to check his lead level because he has a risk factor for lead poisoning(being exposure to lead
since older brother has lead poisoning) but he is asymptomatic and we have to make a definitive diagnosis before treating.
I don't have any references but I know the standard care for supposed lead exposure without symptoms is determination of blood lead levels.
you know, I know that FEP (free erythrocyte protoporpyrin) is more sensitive than lead level and I know there is a conversion value for FEP to Lead which can
tell you what the lead level is, but O don't have much experience with this. At this time, we still go by lead level. One interesting thought that did come
up is that patients with anemia (like sicklers) have artificially low serum lead level, because they have artifically low amount of hemoglobin, and this is
why the go by protoporphyrin. This is new stuff, and I don't think it will be tested on the boards. Go with lead levels for therpay..
**********************
an old lady with pain in the shoulder and back, and complains of weakness, and limitation in range of motion and physical exam shows upper extremity
weakness, what next, and then they give you choice of
-NSAID,
-excercise program,
-bone densitometry,
-EMG
-ESR.
coz PMR is one of the main concerns but then the vignette will have more to it like stiffness of joints,etc
I will go with ESR to rule out any connective tissue disease, especially giant cell arteritis. However, if there is CPK, I probably will go with it if the
history suggests polymyolitis. EMG can be used for confirmation of polymyolitis, but at this stage,you need a screening test
***********************
16 year old high school drop out did not have periods for last 3 months. She is sexually active with one patner for 1 year. Does not use contracptives. Preg.
test positive.
The reason that this adolescent's failure to use contraceptive
A. Concern about weight gain
B. Cost of Contraception
C. Patner's opposition to contraception (hard to predict, but I will choose this one)
D.Concern about confidentiality
E.Desire to become pregnant
If you live in bif city like LA or NY, you see it all the time. case closed.
*****************************
PDR could you pl. do our favor? short lecture about baby fluid supplement
3% dehydration, what should give
what % dehydration consider severe or moderate, what should order?
thank you in advance
Aslo 15 % dehydration Rx? Thanks!
dehydration.
based on age group:
babies:
mild - 3%
moderate - 6%
severe - 9% or greater
children:
mild - 5%
moderate - 10%
severe - 15%
how do you know how dehydrated a child is? actually, the best way is looking at weight. If weighed 10 kg last week, and weighs 9 kg today, then 10%
dehydrated.
- most common cause of dehydration in peds: vomiting, then, diarrhea.
assessing dehydration. first things that you see is thirst, and dry lips. then you see tachycardia, decrease urine output, and urine osmolarity is still
normal, and you are still mild dehydration. treatment always should start with oral rehydration using something like pedialyte or an oral rehydration
solution. If child is not tolerating p.o., this is reason for admission, and IV fluids. Don't forget to correct underlying illness. IV fluids could include
NS bolous for rapid correction, (where you correct only 10% of deficit. If total deficit is 1 liter, then 200cc NS will correct 100C deficit and 100C for
current need. Then you correct the rest of deficit with isotonic sugar containing solution (in babies D5 0.225, and in bigger kids D5 045NS over 24 hours.
half in the first 8 hours, and second half in next 16 hours. It is the same with moderate and severe dehydration, except severe dehydration (9% in babies,
15% in older kids) you must look at electrolytes. Still, no matter what, don't give hypotonic solution or free water no matter what.
**********************
Q) 16 year old high school drop out did not have periods for last 3 months. She is sexually active with one patner for 1 year. Does not use contracptives.
Preg. test positive.
The reason that this adolescent's failure to use contraceptive
A. Concern about weight gain
B. Cost of Contraception
C. Patner's opposition to contraception
D.Concern about confidentiality
E.Desire to become pregnant
Most teenagers think contraceptives cause weight gain
Some contraceptives has wt gain as a RF - OCPS, DMPA, other forms do not. She could use barrier form of contraception, the fact that she is not using
anything might indicate that she desires to become pregnant also, b/c is is a drop out.
comments
...but any reference regarding that;
i thought it could be regarding her confidentiality matters.,etc.
it's C. that was what I just to do with my ex-girlfriends a few years ago.. .no more.
All of these choices are possible, however, in this particular case, the most likely reason, I think, is the pressure or the opposition from the partner. A
drop out teenage usually has low self-esteem, and like to please her partner, if he does not like any contraceptive, then she won't use it.
All the options are possible. But WT gain is the most common concern among teenage girl.
Agree with Julia,most common concern is wt. gain amoung teenagers.In such questions where both partners can make a difference as to whether something is done
or not, we need to watch the wording of the Ques.Here the ques said what are her reason for not using contr. and this tells you that the decision is hers not
her partner's because no info. about the partner is given.
The answer could be E too but I chose A because a teenage drop-out will not desire pregnancy unless there is some info. in the ques. that points to that and
surveys have proved ans A.Sorry, can't remember any refs.
Zaslau s book.There the answer is :
-Why she doesnt use condom --> Because she doesnt know how to use.
-why didnt she use any contraceptive--->because she didnt think that she gets pregnant in first intercourse.
-why she doesnt want any OCP --> Because she thinks she gains weight
she desires to get pregant.. saw two like that Friday night in the ER
If you live in big cities in America, you will see it. Partner's opposition is not enough for most girls to risk getting pregnant. If she did not want to get
pregnant, then she would show up at an adolescent clinic and ask for a Depo shot. See that all the time too. Case closed. Hope I don't see this case again...
********************
Q)67 yrs old with lower extermities BP 180/90. upper extremities 150/85 what is Dx?
a. essential HTN
b. renal artery stenosis
c. pheochromocytoma
d. malignant HTN
e. Stenosis of ascending aorta
Can you tell me why this is your answer. I think something is wrong with the Q.
a person came to ER complaining of generalised abdominal pain first started as periumbilic
pain the most appropriate to diagnose the problem is --guarding and rigidity are present on examination
1.chest xray
2.abdominal xray
3.endoscopy
4.upper GI series
6118
a person came to ER complaining of generalised abdominal pain first started as periumbilic pain the most appropriate to diagnose the problem is --guarding
and rigidity are present on examination
1.chest xray
2.abdominal xray
3.endoscopy
4.upper GI series
*********************
treatment of meinere dz?
1 hctz
2.meclizine
meclizine for acute vertigo and hctz for long term prophylaxis and treatment
**************************
patient with IDDM 18 yr old. everything was perfect in her mgmt /OC pills, insulin, diet,exercise
what change ?
........"confused till the end on following choices" (good fellow )..........
-recommend depo
-no change
I think the none of the forum members should be confused with this one again.....
18 yr old patient with IDDM. everything is well for the pt. meds include OCPs, insulin, diet,exercise
IS THERE any need of a change in mgt?
the confusion was b/w
1. every think ok
2. d/c OCP and give depo progestrone..
In short will insulin affect OCPs???????? is my thought....
use low dose ocp's
inc. insulin
ocp's cause glucose intl
but not c/i in iddm
************************************
kid has, enterovirus infection, diarrehea. should stay home or go to day care?
Only if diapers are not able to contain stools, he should stay at home???????????
I am not sure what the USMLE wants here
enterovirus diarrhea is highly contagious, and diaper changing can..
cause transmission in day care setting. Daycare workers probably don't wash their hands properly between diaper changes. My best guess, and my answer on the
test is to keep baby from daycare until diarrhea resolved.
***********************
a infant is allergy to cow milk,
is the infant also allergy to soy bean?
how to RX?
usually
unfortunately....that is what they ask,
Home made meat based formula is the remedy.avoid cow's milk and soya.Meet with dietacian.
********************
14 y/o boy has asthma attack with RR 38.
-mask o2
-rebreath mask o2
-intubation
-others
If so, intubate. he should be alkalotic. We usually try albuterol first, but if any sings of respiratory tiredness, like decrease RR, or pCO2 that is not
low, we jump on the ETT.
then hit with albuterol nebs and steroid p.o. or IV, but if he keeps getting worse and works harder to breath and too tired to breath so fast, then
intubate... If any blood work shows PH less than like 7.45 (needs to be alkalotic because he is hyperventilating) then you worry. Also, remember, stress and
steroids cause serum glucose elevation, so don't trip if you see blood glucose is 230 or something.
********************
18 month old with diarrohe, day 3 in hospital , now stable, u are about to dc the pt.. u recived stool culture report positive for salmonella what is the
next:
1)ampicillin x 14 days
2)chloremphenicol x 14 days
3)no treatment
4)amp +chlornphencol
no treatment
************************
clinical features of measles, then the child is ataxic, what will you advize the parents
ans) it is one of the complication of measles and it will resolve-
His ans was posted as above.....check out guys>>>>>>>>> was the advise from the great fellow!!!!
What do you think PDR??
is it measles though? are we talking SSPE
pt with clinical features of measles, then the child is ataxic, what will you advize will you give to the parents?
the recaller selected ...the statement below as ans
...it is one of the complication of measles and it will resolve
TO ME...it looks like measles might have progressed to SSPE (I am not sure???) and in short the Q is asking prognosis.....
this is what the CDC says about measles infection in brief
Measles (rubeola) is often a severe disease, frequently complicated by middle ear infection or bronchopneumonia. Encephalitis occurs in approximately 1 of
every 2,000 reported cases; survivors often have permanent brain damage and mental retardation. Death, predominantly from respiratory and neurologic causes,
occurs in 1 of every 3,000 reported measles cases. The risk of death is known to be greater for infants and adults than for children and adolescents.
Does this help with the answer?
*************************************
ACNE Mx >>>>>>Is this sequence right???
ACNE Mx
>Benzoyl Peroxide>Topical Tretinoin >Topical Antibiotics> Systemic Antibiotic >Systemic Isotretinoin
Start with topical benzoyl peroxide then try (tt) topical clinda, oral tetra and oral erythro.
Next step topical tretinoin.
Last Oral Isotretinoin (teratogenic)
Source : Crush' Page 172.
SO Basically,
Benzoyl Peroxide >Topical Antibiotics> Systemic Antibiotic >Topical Tretinoin > Systemic Isotretinoin
*********************
Two 6 yrs old playing together & one kid bite other kid's hand. how to treat?
a.culture
b.pcn
c.hand xray
d.tetra
e.admit& iv antibiotics
human bites need to be admitted to hospital and iv therapy with ceftriaxone.also culture the wound as bacteriology is variable.---CMDT p1251
"HUMAN BITES". Antibiotics should be given prophylactically for all human bites:
amoxicillin/clavulanate 20 to 40 mg/kg/day divided TID;
cefixime is an alternative.
Consider IV antibiotics if infection has already occurred, especially on the hand.
If a joint may be involved (e.g., MP joint after an altercation), surgical exploration is indicated.
*******************
Q) There is a patient with a picture of retina with cotton wool type lesions. What the underlying diagnosis?
a. Patient with BP 210/112
b. Uncontrolled DM
c. Patient with BP 169/89
d. Eye pigment dz
May see cotton wool spots in HTN, DM, AIDS, but in this question b is the best choice.
*******************************
Q) A 56 y/o man came to PMD, he is s/p CABG 10 yeas back, c/o SOB with exertion and chest pain. He is relived with rest. What is next step?
a. EST
b. thalliun stress test
c. dobutamine test
d. 12 leads EKG
was closed as thallium but......
later on doing MCQs I found that the right ans was EST ...... in that exp as ...........exercise stree test is much cheaper and easier test to do that a nuc
med thallium scan for screening.
any comments......
Thalliun stress test also give you the functional status of heart. Especially if the patient previously had MI, the interpretation of EKG in this case will
be very difficult
sounds ok here,he doesnt have a pacemaker,all he had done was cabg,12 lead ekg and cardiac enzymes for starters,rest all later....what one want to know is
whether he has new ischemia/infarction...
***********************
Q) A 59 y/o lady had seizure came to ER, neurological deficit present. CT scan of the head showed ring enhancing lesion in brain. What is probable organism?
a. cryptococus
b. grm positve micro coccobacilli
c. strepto cocci
Q A 45 y/o man with lung ca came with pain at thoracic region at the back, what is next step?
-CT
- Pain meds
Q A 65 y old patient , died of congestive cardiomyopathy. What organ can be donated?
Q)38. A 35 y/o female patient c/o facial pain and current like sensation. What is next step?
a. amytriptyline
b. carbamazipine
c. steroid
crypto, pain meds, kidneys, carbamazepine
Ring enhanced lesion on Ct-scan - abscess, tumor, TOXO, tumor (Kaplan)
organs to be donated skin & bones
facial pain - carbamazipine
*******
crypto coccus,
for tigeminal nueralgia- carbamazepine best -- mksap
***
A. cryptococus
Pain meds
Skin, bone, and cornea
b. carbamazipine
**************************
1.At what age do you advise moms to start potty training? At 1 yr is it too early?How about 18 months. I know there's no fixed time but for USMLE purposes
what should you take?
2.baby around 8 months . Gets up middle of the night and drinks milk. What advise to mom?
-Give water instead of milk.
-Pat and cuddle and put to sleep.
-Ignore crying.
-delay the response to crying.
My baby's pediatrician asked me to do both 1 & 2 when my baby had the problem.But at the exam what is the choice?This was a real exam Q.
The first question is 24 months or 2 years. Just last month, the AAP (American Academy of Pediatrics) started advising a delay to 27 months, becaue rushing
the process sometimes makes things worse. For USMLE, the answer is 2 years.
the other question, I think there was more to it. Wasen't it about infant colic? the baby who drank milk and cried a lot? what to do about the crying? right?
colic is self limiting after 3 months of life. treatment is position change, supportive, and decrease the carbohydrates (I guess milk), but I am not sure if
I go as far as giving baby water instead of milk. Theoretically this means less milk, but it is not standard.
it was simply the baby wakes up in the night crying for milk.After giving milk he goes to sleep.The resposes were the ones i gave. One other was to give a
stomach full of milk just before bedtime.which can't be the answer.
This question appears many time and with diff explaination. My own experiance is to delay the response to cry. The important lesson is NOT PICK THE BABY up
so easily and often in these benign situation. In other words, don't feed him and don't curdel him.
I found the following mess from web and hope we can close this with consensus:
The First Year - Babies 8 to 9 Months
Crying During the Night
Some babies make a game of calling out for you or dropping toys out of the crib for you to pick up. Other babies cry after you put them to bed. Check on your
baby, but keep the lights dim and don't pick him up. If baby is ok, put him on his tummy, pat his back for a minute or two, and leave.
If you try this for a few weeks and baby still wakes up and cries during the night, you may try letting them cry. Here is a way that works for many parents.
Pick a weekend night. When baby cries, check on him and rub or pat baby's back, then tell him you'll be back in 10 minutes. Check on baby every 10 minutes
even if he is not still crying, until he falls back to sleep. It probably won't take more than a night or two to end the habit for good.
Letting baby cry like this can be hard on you. Be sure you're up to it. Baby may cry for hours. If you give in after an hour, you could be training him to
cry for longer periods. The goal is to help baby learn to sleep on his own.
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Ghost
Guest
Posted: Wed Sep 17, 2003 12:10 pm Post subject: Ghost File #2
--------------------------------------------------------------------------------
ALL solved file #2
Q)Pregnant women in third trimester had Placenta abrutio due to MVA had aburtio placenta due to wearing seat belt(lap and shoulder ) question ask what would
you recommend pregnant in third trimester?
1. don't wear seat belt
2. wear only shoulder strap seat belt
3. wear only Lap strap seat belt
4. wear the regular shoulder and lap seat belt.
Answer 4 wear both seat belts
Q) A kid had fx. clavicle question than ask what is next management?
1. ?sling
2. ?cast
3. ?sugery
Answer is Sling and immobilize.
Q) 16 year old high school drop out did not have periods for last 3 months. She is sexually active with one patner for 1 year. Does not use contracptives.
Preg. test positive.
The reason that this adolescent's failure to use contraceptive
A. Concern about weight gain
B. Cost of Contraception
C. Patner's opposition to contraception
D.Concern about confidentiality
E.Desire to become pregnant
Surprisingly answer is desire to become pregnant?
Q) Which of the following drugs is the least sedating and anticholinergic, which can be prescribed safely to elderly patients with depression?
a.fluoxetine
b.MAOI
c.Imipramine
d.Sertraline
e.Trazodone
*****************************
Q1)
4 year old boy has swallowed a coin...x *** showed coin in lower 1/3 of esophagus..
a.ask the parents to check for coin in stool
b.do and endoscopy
c.give syrup ipecac
d.give a laxative
Q2
a 3 year old boy swallowed a coin and it is in the duodenum...same choices as above...
Answer 1—do endoscopy 2- watch in stool
*******************************
Q) A healthy young pt with ppd test 15 mm induration next step?
Answer is chest x ***
Q)
First child of this lady has Duchenne's. What are the chances that she will again have a baby with Duchenne's?
-25 % overall,
-50 % if it is a boy,
-O% if it is a girl ( assumption is that mother is a carrier and father is healthy)
this is sex-linked recessive disorder. Affected child is boy. The mother must be carrier. So, the chance of her next child to be affected will be 50% among
her sons or 25% among all of her children.
Q) A pt has flu and was treated with Amantadine. Now the Q ask the drug is belonged to:
1.chemotherapy
2.antibiotics
Answer is chemotherapy
Q) A 24 y/o woman came to your office with frothy vaginal discharge and rash on her cervix. You diagnosed her with Trichomoniasis vaginitis. You gave her RX
for metronidazole. She remined you that she is breastfeeding. What should you do now?
Answer is give metronidazole and ask her not to feed for 24 hours
Q) a patient with tibial osteomylelitis, cultures taken , xray done,antibiotics started which is the next best step leading to diagnosis presents on second
day of osteomyleitis
a)mri
b)bone scan ANSWER: MRI
Q) A man with 5x5 cm mass in left lobe of thyroid which is found to be papillary carcinoma..The man has develop HOARSENESS. the right lobe of thyroid is
irregular on exam.. what is the best treatment
a)radiation
b)partial thyroidectomy plus radiation
c)total thyroidectomy with left neck dissection
d)total thyroidectomy with removal of enlarged nodes
Answer is C
Q)
Kid with meningitis,but family don't want tx. what to do?
-respect their wish
-court order
-go ahead and treat.
GO ahead and treat….. is the answer.
Q)8wks pregnant women returing from vacationing in conneticult discover a tick on skin, 1 wk later noticed a lesion ask for treatment.?
LYME disease is the scenerio here …
Answer is
-amoxicillin or cefta, if CNS involved -
-NO tetracycline because she is pregnant
-If this patient was not pregnant then tetracycline is doc ten day therapy is usually reserved for isolalated erythema migrans....if systemic or severe
symptoms therapy is recommended for 21 days.
any one of the following
tetracycline 250 po qid
doxycycline 100 mg po bid
amoxicillin 500 po tid
Q)a parent has asthma since childhood now is pregnant she ask what the chances baby has asthma.
-none
-25
-50
-100
25% if one parent involved 50 % if both have asthma
Q)Stroke pt was treated and vital signs are stable. Now the pt has blood vomiting. Dx:
-1.diffuse gastritis
-2.gastric ulcer
-3.others..
A-nswer is diffuse gastritis
Q) Low back pain with lower extremity neurological s/s and bladder problem. Dx ?
1.spinal stenosis
2.disc hernia
Spinal stenosis is the answer..
Q)Organ donation. Father and sister agree. But mother did not agree. What do you do ?
Point about organ donation.. DO not take organs from the body until FAMILY agrees.. in this situation,,, try to resolve the conflict… let them have family
meeting educate them etc etc..
If in the end family is not agreeing with the donation..DO NOT Take organs..
Q)Pneumococcal vaccine is indicated for which one of the following?
A-15-year-old with recurrent sinusitis and URI
b- 8-year-old with recurrent tonslitis
c 3-year-old with nephrotic syndrome
d- 6-month-old with sickle-cell disease
e- 3-month-old whose mother has active human immunodeficiency virus (HIV) infection
Answer is C.. minimum age is 2 years.. both nephritic and sickle cele will nedd vaccine
Q)Which one of the following is the most appropriate management?
1-Perform serial L/S ratios until greater than 3.0, followed by prompt delivery
2-Induce labor, with careful fetal monitoring
3-Perform an immediate cesarean section
4-Follow the mother weekly with serial ultrasounds
5-Follow the mother weekly with nonstress tests
Answer is 2…. Induce labour and monitor fetus
Q)A 22-year-old white female who works in the newborn nursery of a hospital consults you regarding her exposure yesterday to an infant with congenital
rubella. Today she has a positive pregnancy test and is 8 weeks pregnant by dates and examination. Her rubella immunization status is unknown.
Your immediate recommendation is
A) a therapeutic abortion
b) intramuscular gamma globulin
c) oral amantadine (Symmetrel)
d) a rubella antibody test
e) an MMR vaccination
Answer is D…. rubella antibody test
Q) In a woman with preeclampsia, the impending onset of eclampsia is most likely to be indicated by
A) urinary protein excretion >300 mg/dL/24 hr
b) facial edema
c) increased serum uric acid
d) headache and visual disturbancesAnswer is D…… headache and visual disturbances
Q)35 yrs male iv drug abusers with a history of haemorrhagic shock 6 month ago came with weakness, P/E enlarged liver 3cm ALT 400 and rest of the liver
function test normal. which one of the following investigations is the most important to diagnose the case?
a)HbS Ag + HbcIgM
b)HBV PCR DNA
C)HCV Ab
d)Liver biopsy
e)HbSAg+ HbcIgM + HDV Ab
Answer is C hepC AB
Q) 45 years old woman with history of DM and mild Hypertension with occational history of seizure for last 6 month came to your office with 6 hours h/o
headach right sided partial ptosis,pain in lower half of face and neck rigidity.what would be the cause?
a)Trigeminal neuralgia
b)SAH of Post communicating artery
c)SAH of PICA
d)Brainstem glioma
e)Lacunar stroke
Answer is C…..Ipsilateral facial pain sensetion,ipselateral horner's syndrom
and involvement of V11 nerve (bells palsy).
Q) 60 years old female h/o chronic diabetes & Hypertension with a left sided stroke came in ER 3 month ago with repeated attack of seizure there she was
given some anti-seizure medication for Chronic control but last two months she developed incontinence with no urinary symptoms.The most likely cause
a)UTI
b)Phenytoin therapy
c)Carbamazapine
d)Valproic acid
e)BHP
Answer is B PHENYTOIN therapy
Q)which of the following anomalies is the major concern with chronic lead intoxication?
a. Abnormal bone growth
b. Hyperurecemia and gout
c. Microcytic anemia
d. lower I.Q. scores
Answer is D lowe IQ score
Q) A 6-year-old Hispanic female develops watery diarrhea, with at least twelve episodes over a 48-hour period. She is taking fluids orally without nausea and
vomiting, is afebrile, and has an unremarkable physical examination except for hyperactive bowel sounds. There are no signs of dehydration.
According to current practice guidelines, which one of the following is the most appropriate recommendation?
-Age-appropriate diet without milk products
-Age-appropriate diet
-Clear liquid diet alone
-Clear liquid diet (juices, soft drinks) and loperamide (Lomotil) orally
Answer is B age appropriate diet
Q) what is the most common associated finding in patients with panic disorder?
a. Alcoholism
b. OCD
c. Depression
d. Any substance abuse
Answer is C depression
Q) Which is the most accurate method for detecting Down's syndrome
a. amniocentesis
b. CVS sampling
c. ultrasound
d. MRI
Answer is karotyping BY amniocentesis
Q) what is the single most important risk factor for the development of postpartum depression:
a- history of depression
b- history of bipolar disorder
c- a greater than average postpartum drop in serum progesterone
d- a recent stressful life event
e- the mother's experience as a child in her family of origin
Answer A.. history of depression
Q) A patient with Few pounds weight loss. He has been unable to eat due to pain with swallowing either liquid or solids. He smokes one pack of cigarettes per
day. On PE, he is a thin man with diffuse cervical and axillary lymphadenopathy . His T- 101,4. There is no oral thrush and his lung have fine bronchi at
right base. What is most appropriate diagnostic test?
A) Barium esophagram
b) endoscopy with biopsy
C) empiric trial of antifungal with ketocanazole
d) empiric treatment with ganciclovir
E) give him a prednisone
Answer is B…. barium is the initial/first test… Endoscopy/biopsy is the diagnostic
Q) 60 yrs old lady moved to a new residential center a year ago and came for annual exam. She has no specific complain and just mentioned that she only slept
for 5 hrs a day. She functions well. Physic examination is WNR. What do you do for short sleep time of this lady.
1. It is normal for old lady
2. Prozac
3. Benzodiazepem
4. lifestyle change with more exersize
Answer is 4. lifestyle change with exercise….it could be normal not sure yet
Q) A 45 year old man comes to the doctors office and complains of "the worst headache in his life".
He is awake and oriented. He refuses to have a CT.
A lumbar puncture yields lightly blood tinged sample with rbc count 300,000
wbc count 55000(90% polyps), protein-88,glucose-20
gram stain is negative.
Most appropriate treatment is
a) E aminocaproic acid
b) angiography
c) ceftriaxone
d) heparin
Answer is B….. SAH diagnosis is angiography….after LP and CT… tx is surgical Clipping
Q)A 40 yr old man with a history of DM and sexual dysfunction comes to you with a history of insomnia, loss of apetite, fatigue,feeling of worthlessness, and
guilt, diminished ability to concentrate and depressed mood for 4 months. Which of the following would be the most appropriate treatment for this patient
a. Paroxetine
b. fluoxetine
c. sertraline
d. citalopam
e. bupropion
Answer is E…… Bupriopion
Q)Which of the following is most characteristic of a patient who has vitamin C deficiency?
(A) Diarrhea and delusions
(B) Ocular muscle palsy and dementia
(C) Cheilosis and beefy red tongue
(D) Perifollicular hemorrhages and hyperkeratosis
(E) Paresthesias and ataxia
Answer is D.
Q) What you will see in a biopsy of lchen planus ?
Answer is hyperkeratosis
Q)Orbital cellulitis
Next step
a) ct scan
b) iv antibiotics
Answer is Iv antibiotics first then investigations
Q) which is the best dx choice of pituitary tumor ?
a. CT
b. MRI
c others
Answer is A… MRI is the best
Q)which of the following causes acute hepatic necrosis?
A INH,
B.acetaminophen
C.halothen,
D.methydopa Answer is A…. ACETAMINPHEN
Q)A DM type II pt is under glipizide. His current glucose level is 270. what is the next:
A..add insulin
B.add metformin
C.add pioglitazone
D.add glyburide
Answer is B .. add metformin………if sulfonylurea failed to control it then add metformin and if both fail to control then add a thiazolidinedone
and if they fail to improve give insulin
Q) a man loss of vision in 24hrs c/o curtain in eyes.,no pain
A)ret.detachment
B)retinal artery obst.
C)retinal vein obt.
Answer is A retinal detachment
) which is the best test for confirming rupture of membrane ?
a. pool test
b. nitrazine test
c. fern test
d. U/S
Answer is B.
Q) In gallbladder sludge by u/s and pt is sym with pain fever and has diabetic,next step
-ct abdomen
-start antibiotic
-ercp
-observation
Answer is CT ( acalcolus cholecystitis )
Q) Which of the following drugs is the least sedating and anticholinergic, which can be prescribed safely to elderly patients with depression?
a.fluoxetine
b.MAOI
c.Imipramine
d.Sertraline
e.Trazodone
Q) 45 y/o guy who was 5' 5'' tall and weighed 280 pounds and is on HTZ for HTN and Metformin for DM and HbA1c is 6%....and BP is
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Aster's USMLE Step 3 Notes
Posted: Sat May 24, 2003 10:31 pm Post subject: Aster's USMLE Step3 Notes
--------------------------------------------------------------------------------
USMLE Step3 Notes
May 19, 2003
Aster's USMLE Step3 Notes
Recommended Study Material for Step3
Textbooks
1.Crush the Boards [5 days]
2.Swanson's Family Practice [15-20 days]
3.Ethics in Medicine (U of W site) [1 day]
4.Biostatistics [2 days]
5.BluePrints in OBG [2 days]
6.BluePrints in Peds [2 days]
7.Compass Surgery & Trauma Notes [1 day]
CCS
1.USMLE 2003 CD (Software Tutorial + Sample Cases)
2.Kaplan CCS TUTORIAL
MCQs
1.Swanson's Family Practice
2.USMLE 2003 CD – sample MCQs
3.Kaplan Step3 CD – 200 sample MCQs
4.NMS Review – 750 questions
5.Kaplan QBank for Step3
6.familypractice.com
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Guest
Posted: Sat May 24, 2003 10:33 pm Post subject: Aster's note-page-2
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Critical aortic stenosis: virtually zero chance of successful CPR.
Gout with h/o peptic ulcer disease: Rx of choice – colchicine (not indomethacin)
pseudocyst
<6w: external rainage >6w: internal drainage
St. John's Wort: is a herbal medication with some efficacy in treatment of depression
(no FDA Approval)
Vaginal d/c pH < 4.5 : Consider Candida
ph > 4.5 : Consider Bacterial Vaginosis
Maternal Smoking / Alcohol: Symm IUGR
Maternal HTN: Symm IUGR
Physiological Jaundice / Exaggerated Physio / Breast Milk Jaundice: no risk of
Kernicterus
Kernicterus occurs @ 1% x Birth Wt. (in grams) [Bilirubin Level]
PKU screen can be negative at 48hrs of life
(requires a repeat screen after 48 hrs. to confirm)
Maternal SLE: Congenital Lupus & 3rd degree Ht. Block (Anti-Ro)
Respi Failure: <60 mmHg O2 >60mHg CO2
Maternal Solvent Abuse: assoc. with nail hypoplasia
PDA closure achieved by Indomethacin
NEC: Pneumatosis Intestinalis
Neonatal CMV: confirm by isolation of virus from urine
Transplacental spread is highest in primary HSV,
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Guest
Posted: Sat May 24, 2003 10:34 pm Post subject: Aster's -page3
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Aster's USMLE Step3 Notes May 2003
very low in recurrent HSV
Breast Milk (cf. Cow's Milk)
high carboydrate
low protein
low iron, but more bioavailable
inadequate Vit. D, Vit. K
supplement Iron @ > 6 m in exclusively breast fed
Infants of Diabetic Mothers with proteinuria, hematuria:
? Renal Vein Thrombosis (gluteal. with maternal DM)
Transfusion Reactions:
Febrile Reaction: WBCs in Donor Blood (Acetaminophen)
Anaphylaxis: Proteins in donor blood (Antihistaminics, SQ Epinephrine)
Hemolysis: Mismatch (Hydration & Diuresis)
Infantile Colic: (Wessel Criteria)
3 m child; 3 hrs/day; >3 days/week; > 3 wks. duration
ADHD:
1.Methylphenidate / Dextroamph / Mg Pemoline
2.TCA / SRI (second line)
3.Don't use Benzodiazepines
4.consider “drug holiday” on weekends
ACEIs contraindicated in preg.
HyperTG Rx: Gemfibrozil
Hypercholesterolemia (Drug Rx):
>190: 0-1 risk factors
>160: >= 2 risk factors
>130: CAD equivalent / CAD
if > 15% reduction reqd: “statins”
if < 15% reduction reqd: (Low HDL) Niacin
(normal HDL) Cholestyramine
Obesity in Children Triceps Skin Fold Thickness
OCP induced hepatic adenomas : tendency to rupture
(Surgical resection)
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Guest
Posted: Sat May 24, 2003 10:35 pm Post subject: Aster's -page4
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Aster's USMLE Step3 Notes-May 2003
ELISA â-hCG (Urine) is (+) 14 d post conception
RIA â-hCG (Serum) is (+) 14 d post conception
Symptomatic Gallstones: Lap Cholecstectomy
Ca. Tail of Pancreas: Poorest Prognosis
Lobular Ca in situ is not premalignant
Digitalis Toxicity is enhanced by:
HYPERcalcemia, HYPOkalemia, HYPOmagnesemia
Infant of HIV + mother (steps to derease transmission)
1.Intrapartum I/V AZT
2.LSCS delivery
3.AZT prophylaxis to child x 6 m
4.No breastfeeding
5.HIV test at 6m - 12 m
Finkelstein Test: Chr. Stenosing Tenosynovitis (deQuervain's Disease)
Rx for Chlamydial Ophthalmia: ORAL Erythromycin
(to prevent chlamydial pneumonia)
Commonest Hernia: Indirect Inguinal Hernia
T4 / RTU / FT4-I move up or down together unless there is a derangement in TBG
CPK-MM is increased in hypothyroidism (proximal myopathy)
Fetal Weight Determination:
HC, BPD, AC, FL
Fetal Age Determination:
Transcerebellar Diameter
RA: associated with atlanto-axial subluxation
(“drop” attacks)
PTE: (A-a) O2 gradient is always abnormal
even if PaO2 is normal [highly sensitive]
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Guest
Posted: Sat May 24, 2003 10:35 pm Post subject: Aster's-Page 5
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Aster's USMLE Step3 Notes-May 2003
Fever 24-48 hrs. Postop: #1 Atelectasis
Pneumococcal Vaccination is required in CSF Leak
Nephrotic Syndrome: Fatty Casts
Pyelonephritis: WBC Casts
Cystitis: WBCs
GN (PSGN): RBC Casts
CRF: Broad Casts
Cold Antibody: IgM - Inravascualr Hemolysis
Warm Antibody: IgG - Extravascular Hemolysis
Addison's: ACTH Simulation Test
Cushing's: Dexamethasone Suppresion Test
Conn's: Salt Loading Response
Diabetes Insipidus: Water Deprivation Test
Hemophilia A: aPTT increased, BT normal
vWD: aPTT increased; BT increased
(Ristocetin Cofactor Assay)
Factor VII def.: PT increased, BT normal
Aspirin: prolonged BT, no effect on CT
spiking fever despite antibiotics, 1 wk. postLSCS
?Septic Pelvic Thrombophlebitis (Mx: i/v Heparin)
Mx of Myesthenia Gravis: PYRIDOSTIGMINE
(not PHYSOSTIGMINE cuz of CNS effects)
vWD & Aortic Stenosis: gluteal. with Angiodysplasia
Alcoholic Cirrhosis: â-gamma bridge
d-xylose test: abnormal in small bowel malabsorption, normal in pancreatic disease
screening for malabsorption: 24 hour fecal fat
? Penicillamine increases survival in Scleroderma
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Guest
Posted: Sat May 24, 2003 10:36 pm Post subject: Aster's- page6
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Aster's USMLE Step3 Notes- May 2003
Congenital Syphilis may be associated with severe osteochondritis. Child may refuse to
move limbs (Pseudoparalysis of PARROT)
Abciximab: decreases restenosis rates post-PTCA
PTCA: no effect on morbidity or mortality
Diabetes Mellitus : assocation with hyperTG
First line management of newly diagnosed diabetic: DIET (not drugs)
DM+HTN: ACEIs
Hypercalcemia: I/V Hydration + Loop Diuretics
Obesity: BMI>27g/m2 or 120% of ideal body weight
Caloric Intake increase:
300 Cal (Pregnancy); 50 Cal (Lactation)
Pulmonary Embolism: i/v Heparin
COPD excacerbation: H.flu, Pneumo., Moraxella
Long term stabilization of exercise induced asthma: Salmetrol & Zafirlukast
Severe acute asthma: < 50% best PEFR
Moderate acute attack: 60-80% best PEFR
Mild acute attack: >80% best PEFR
#1 community acq. pneumonia: S. pneumoniae
Ideal sputum sample: <10 epi./HPF & many PMNs
GERD: Transient relaxation of LES
Always perform an EKG for any adult with chest pain (esp. with risk factors for CAD)
Esophageal Ca.: most common type is AdenoCa. (Barrett's Esophagus)
Sulfasalazine:
effective in UC & Crohn's colitis / ileocolitis
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Guest
Posted: Sat May 24, 2003 10:36 pm Post subject: Aster's- page7
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Aster's USMLE Step3 Notes- May 2003
Celiac Sprue:
villous atrophy & reactive crypt hyperplasia
Dermatitis Herpetiformis (Mx: Dapsone)
H. pylori association:
DUODENAL > GASTRIC
.Serology (Past or Present Infection)
.Fecal Antigen Detection (False [-] with PPI)
.Urease Breath Test (False [-] with PPI)
Triple Therapy, esp. for non-NSAID ***. ulcers
1st episode of PUD: emperical therapy (H2 -> PPI)
Recurrent PUD: H. pylori eradication
Infectious mononucleosis
EBV, Sore Throat, LN, Splenomegaly
Atypical Lymphocytes (also in CMV)
Monospot (+): positivity wanes with time
Serology: increased Anti-EA; increased Anti-VCA IgM
â blockers decrease variceal bleed in portal HTN
Ascites: Salt Restriction, Diuretic: Spironolactone
narcotic analgesic switching
use 1/5 equianalgesic dose
Graves': Rx – Radioactive Iodine
children & pregnant: Propylthiouracil
WHO analgesic stepladder
1st LINE
Aspirin, Acetaminophen, NSAIDs
2nd LINE
Hydrocodone, Codeine
3rd LINE
Morphine Sulfate, Hydromorphone, Fentanyl, Methadone
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Guest
Posted: Sat May 24, 2003 10:37 pm Post subject: Aster's-page8
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Aster's USMLE Step3 Notes- May 2003
Ca. ***. cachexia & anorexia: Prednisone, Magestrol
Agitated Depression Rx: sedating TCA (not SSRI)
Rx of choice for narcotic induced costipation: Lactulose
Nephropathy Incidence: IDDM (40%) > NIDDM (20%)
but #1 cause of Diab. Nephropathy is NIDDM
('cuz NIDDM prevalence is much higher than IDDM)
Prevalence Inreases: PPV of test increases
(NPV of negative test decreases)
Screening for GDM
Oral 50g Glucose: Bl. Glu. @ 1 hr. > 140mg% (+)
F/U with Oral 100g Glu. 3 hour GTT
values > 105 (0h) / 190 (1h) / 165 (2h) / 145 (3h)
Obese Diabetic: Diet/Wt.Loss -> Metformin
(***. With Lactic Acidosis)
Insulin in DM
Initial dose: 15-20 U
2/3 of total : AM dose (2/3 regular, 1/3 intermediate)
1/3 of total : PM dose (2/3 regular, 1/3 intermediate)
Conn's syndrome Mx
Adenoma: Sx resection
B/L hyperplasia: Spironolactone
"cold nodules" on thyroid scan: ? Malignant
#1 Thyroid Study: Serum TSH (yields max. info.)
Multiple Sclerosis:
2 attacks more than 24 hours apart
> 1 area of damage (Oligodendrocyte damage)
m/c variant: relapsing-remitting type
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Guest
Posted: Sun May 25, 2003 4:29 pm Post subject: Aster's -pag9
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Step3 Notes- May 2003
CSF mononuclear pleocytosis, CSF IgG increase
Oligoclonal Banding of CSF IgG
Myelin Breakdown Metabolites
Headache on stopping NSAIDs:
Analgesic withdrawl headache
Jaw Claudication & Scalp Tenderness: GCA
ESR increased
Visual Loss
Start Glucocorticoids without waiting for Bx results
Aspirin in febrile children: Reye's Syndrome
Continue anticonvulsants till seizure free for 4 years
Menorrhagia with hemodynamic compromise:
i/v conjugated estrogen
normal Hb in women: 12.0
normal Hb in pregnancy: 11.0 (1st & 3rd trimester)
10.5 (2nd trimester)
m/c variant of Hodgkin's : Nodular Sclerosis
Hodgkin's: Supraclav. node
NHL: epitrochlear node / likely to be extranodal
Osteoarthritis
Joint space narrowing
sclerosis
subchonral cysts
osteophytes (mere osteophytes are not OA)
OA: Isometric exercizes are better than isotonic
CFS: T cell activation -> CNS effect of cytokines
nonREM sleep anomaly
(also seen in Fibromyalgia)
Gout prophylaxis: required for recurrent attacks
(not indicated after first attack)
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Guest
Posted: Sun May 25, 2003 4:29 pm Post subject: Aster's page10
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Aster's USMLE Step3 Notes- May 2003
Strep Sore Throat Rx: can prevent Rh. Fever
NOT PSGN!!!
Potassium sparing diuretics can cause severe
hyperkalemia in CRF
SULINDAC: NSAID with no nephrotoxicity
Asymp. Bacteruria in Pregnancy : Treat with antibiotics [Amoxycillin is safe] (high risk of
pyelonephritis)
Give Chlamydia Rx in Gonorrhea
-> i/m Ceftriaxone + PO Doxycycline
Biophysical Profile : TBMAN
Tone, Body Movements, Breathing, AFI, NST
Early Deceleration: Head Compression
Variable Deceleration: Cord Compression
Late Deceleration: Uteoplacental insufficiency
GU+NGU: 1 g Azithromycin stat
ACNE Mx
.Benzoyl Peroxide
.Topical Tretinoin
.Topical Antibiotics
.Systemic Antibiotics
.Systemic Isotretinoin
Acne Rosacea Mx
Topical Metronidazole -> Systemic Antibiotic
[Benzoyl peroxide & Tretinoin can aggravate rosacea]
Female Infertility (Hormonal)
Hyper-estrogenic: CLOMIPHENE CITRATE
Hyper-PRL: Bromocriptine (PIH)
Narcotic Dependence: Methadone replacement
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Guest
Posted: Sun May 25, 2003 4:30 pm Post subject: Aster's-page11
--------------------------------------------------------------------------------
Aster's USMLE Step3 Notes- May 2003
External Hemorrhoids: Excision with elliptical incision
Internal Hemorrhoids: Banding
2nd trimester eclampsia: Molar pregnancy
Molar pregnancy: hyperemesis gravidarum
Most important obstetric measurement:
Diagonal Conjugate (at least 11.5 cm)
Amniotomy: perform after enagement of fetal head
Rx of HTN in preg.: á-methyldopa, hydralazine
BP reduction goal in pre-eclampsia:
Lower diastolic to 90-100 mmHg (lowering to 80mmHg could jeopardize placental perfusion)
#1 maternal disease causing IUGR: Maternal HTN
#1 cause for 1st tri. abortions: Chromosomal ab(n)
Postpartum Blues: < 2 weeks
Postpartum Depression: > 2 weeks
Major Depression: >= 5 symptoms for > 2 weeks
Mania: >= 3 symptoms for > 1 week
Primary Type 1 Osteoporosis: # vertebrae
Primary Type 2 Osteoporosis: # neck femur
HRT
Progesterone required only if uterus is present
Estrogen: dec. LDL, inc. HDL
Progesterone: inc. LDL, dec. HDL
Estrogen's cardioprotective effects of estrogen are not mediated through cholesterol.
Estrogen promotes EDRF synth. In vascular endothelium
Repeat Pap: if reqd., no sooner than 6 weeks
Hormonal contraception if h/o DVT/PE (+):
Norplant & DMPA (Progesterone based), not OCPs
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Guest
Posted: Sun May 25, 2003 4:31 pm Post subject: Aster's- page12
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Aster's USMLE Step3 Notes- May 2003
Jarisch Herxheimer reaction: Syphilis Rx (chills)
HPV: condyloma acuminata
HPV 18: fastest progression to Ca. Cx
Acute Epididymitis:
#1 cause: Chlamydia trachomatis
#1 bacterial cause: E. coli (m/c in >40 y age)
Depression: Cognitive Psychotherapy + SSRI
Drug Rx of Bipolar Disorder:
Li, Carbamazepine, Valproate,
Gabapentin, Lamotrigine (***. With SJS)
Lithium: Hypothyroidism, NDI
Atypical Antipsychotics are especially useful for negative symptoms of Schizophrenia
Drug Dependence: WITHDRAWL & TOLERANCE
Mx of DTs
.Intermediate acting BZDs (Diazepam)
.IV saline (no glucose containing fluids)
.IV thiamine
BZD in Hepatic Enceph.: Oxazepam
Fluid Deficit in Burns
= 4mL/kg x %BSA (Parkland Formula)
1st degree:
2nd degree: clean, sulfadizine, nonadhesive dressing
3rd degree: refer to plastic surgeon for escharotomy
Heat Cramps: ORS
Heat Exhaustion: IV Fluids
Heat Stroke: neurological dysfunction & absence of sweating (may not be dehydrated), Temp. >104
Mx- cooling fan/blank, check CPK
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Guest
Posted: Sun May 25, 2003 4:31 pm Post subject: Aster's- page13
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Hypothemia: Osborne (J) wave on EKG
Mild: (32-35 C) Passive External Rewarming
Moderate: (27-32 C) Active External Rewarming
Severe: (< 27C) Active Core Rewarming
Depression: Cognitive Psychotherapy
Anxiety Dsorders: Behavioral Psychotherapy
Adjustment Disorder: Supportive Psychotherapy
Social phobia: bea blockers & assertive training
Specific phobia: systematic desensitization
Panic: SSRI & Alprazolam (short T1/2)
.Na Lactate can mimic a panic attack
.use alprazolam for panic, not GAD
.may be associated with rebound anxiety
OCD: (associated with anxiety) SSRI
OC PD: insight-oriented psychotherapy
Somatization Disorder:
4 Pain, 2 GI, 1 sexual symptoms
(associated with abuse in childhood)
Depression: SSRI + Cognitive Psychotherapy
“Atypical” depression: MAOIs are first-line
Generalized Anxiety: Buspirone (selective anxiolytic)
Sexual Dysfunction
Young Males: Premature Ejaculation
(Mx: start and stop penile stimulation, not SSRIs)
Older Males: #1 Erectile Dysfunction
Females: #1 Hypoactive Sexual Desire
Young males with sexual dysfunction: Psychogenic
Older males with sexual dysfunction: Organic
The PATIENT is the head of the healthcare team
ADHD associated with:
Conduct Disorder and Oppositional Defiant Disorder
(also with Tourette's Syndrome)
ADHD with (+) h/o or F/H tics
DO NOT USE STIMULANTS
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Guest
Posted: Sun May 25, 2003 4:32 pm Post subject: Aster's- page14
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Phototherapy isomerizes bilirubin to a state that can be excreted in urine & bileunchanged. (does not enhance conjugation)
Water Supply > 1 ppm fluoride: No supplementation
Retrocecal Appendicitis: poorly localized pain
Appendicitis
#1 cause : lymphoid hyperplasia
Mx: Surgery
Yersnia enterocolitis can mimic appendicitis
Painkillers & antibiotics can alter presentation
Preg. With appendicitis: atypical location of pain
Elderly: higher chances of perforation
Appendiceal abscess: Delay surgical intervention
If on lap., some other cause is found – do an appendectomy anyway, to prevent confusion in future
Oral Dissolution of Gallstones URSODIOL
single floating cholesterol stones in functioning g.b.
Asymp. Gallstones: DO NOTHING
Symptomatic Gallstones: Lap. Cholecystectomy
#1 complication of Lap Chole: Bile Duct Injury
Choledocholithiasis: ERCP with sphincterotomy
idications of ERCP:
.small stones
.dilated CBD
.palpable stones in CBD
.jaundice
Plantar Warts: Cryosurgery
Venereal Warts: Podophyllin (not in pregnancy)
Cullen's Sign: periumbilical discoloration
Grey Turner Sign: flank discoloration
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Posted: Sun May 25, 2003 4:33 pm Post subject: Ast-page15
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Aster's USMLE Step3 Notes- 2003
Grey Turner Sign: flank discoloration
#1 radiological signs in pancreatic disease
acute pancreatitis: sentinel bowel loop
chronic pancreatitis: pancreatic calcification
Crucifer intake reduces Colon Ca.
Ca. risk of polyps is dependent on villous content
#1 risk factor for pancreatic ca. : smoking
#1 cause for chronic low back pain: idiopathic
.bed rest has no role
.no need for imaging (X-*** / CT / MRI)
.prescribe an exercize program (can temporarily excacerbate symptoms)
Acetohydroxamic acid: urease inhibitor
(acidifies urine in patients with struvite stones)
HTN with BPH: Terazocin (á blocker)
Vestibular Neuronitis: NO hearing loss
Meniere's Diseass: Tinnitus, Vertigo, Hearing Loss
Ac. Labrynthitis: Ac Hearing Loss, Nystagmus, Vertigo
Acute Bacterial Sinusitis:
Pneumococcus
no role of imaging (Dx by h/o & PE)
? antibiotics – PO Amox x 7-10 days
Antidep. of choice in depresion in elderly: TCA (Nortryptaline) - minimal side effects cf.
other TCAs
Alzheimer's Rx: DONEPEZIL (OD) & Tacrine Cholinesterase Inhibitors
Polymyalgia Rheumatica: Oral Steroids
GCA: I/V Seroids
Elderly black HTN: CCB & Thiazide Diuretics
Parkinson's with Tremor has a better prognosis than pts. with symptoms of Postural Instability & Gait Disturbance
Perform Postvoid Residual Urine measurement on every elderly patient with Urinary
incontinence to r/o Urinary Retention
Alzheimer's & Parkinson's cause Detrusor Hyperreflexia : URGE INCONTINENCE
@ high risk for pressure ulcers: reposition q2h
low-risk patients: reposition q6h
USPSTF
.prenatal ultrasound not mandatory
.? role of PSA & DRE in screening of asymptomatic individuals
Hyperlipidemia screening:
NONFASTING SERUM CHOLESTEROL
if elevated: do a FASTING LIPID PROFILE
á-FP estimation at 5-17 weeks to r/o NTD
.increased: ultrasound (can detect 80% anomalies)
.decreased: does not necessarily indicate Downs'
QUIT SMOKING before starting Nicotine replacement
Transdermal Nicotine Replacement:
21mg -> 14mg -> 7mg
[Pts. with CAD, start with 14 mg.]
[Nicotine is vasoconstrictor, risk of MI]
Pesticide exposure has been linked to Prostate Cancer
HTN increases the risk of stoke > CAD
2% reduction in CAD for every 1% decrease in serum cholesterol
Cancer mortality is increasing
stroke/CAD mortality is decreasing
HAART drug interactions
“statins”, Antihistaminics, Ergot alkaloids
AIDS in infants: better prognosis cf. adults
d/o/c for malaria prophylaxis: MEFLOQUIN
once-a-week (1 w before travel & 6 weeks after)
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Old 11-20-2004, 01:13 PM
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Aster's USMLE Step3 Notes
Posted: Sun May 25, 2003 4:33 pm Post subject: Ast-page16
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Aster's USMLE Step3 Notes- May 2003
Influenze A: adults
Influenza B: children
Influenza epidemics: Influenza A
Influenza vaccine: A & B
Amantidine protects only against “A”
(Rimantidine preferred in patients with renal failure)
Oseltamivir (Tamiflu®) protects against both “A” & “B”
Annual influenza vaccination for age > 65 y
#1 cause of traveler's diarrhea: ETEC
Cardiac Arrest: 1st step – initiate 911 call
Cardiac Arrest in Children: Assess, 1 min. on CPR
Initiate 911 call
Mx of Respiratory Acidosis: Increase Ventilation
(Use of NaHCO3 is not wise to Mx Respi. Acidosis)
1-person CPR: 15:2
2-person CPR: 15:2
symptom to treatment time: <60 minutes
ED to needle time: <30 minutes
A. Fib.: (Unstable): Sync. Cardioversion
V. Fib.: Async. Defib. [200 -> 300 -> 360 mJ]
SVT: Vagal Maneuvres -> Adenosine
V.Tac.: Lidocaine, Procainamide, Bretylium
V.Tac.: (Unstable): Cardiovert
V. Fib:
Defibrillate,
Epinephrine
Defibriallate again
Lidocaine
2nd line antiarrhythmic
Asystole:
Immediate transcutaneous pacing
Epinephrine -> Atropine -> Consider Bicarbonate
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Posted: Sun May 25, 2003 4:34 pm Post subject: Ast-page17
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Aster's USMLE Step3 Notes- 2003
Use intra-osseous route in age < 6 years
DKA
Insulin 0.1U/kg/hr + NS
Add K+
when Blood Glucose approaches 250, shift to D5NS
m/c cause of abdo. Pain in elderly: CONSTIPATION
Use activated charcoal with 70% sorbitol in poisonings
Cuffed ETT for age > 7yrs
#1 Poisoning: OTC Analgesics
Naloxone: Short acting
Naltrexone: Long acting
(used in rehab programs, not acute overdose)
Urticaria: Subcutaneous edema
Angioedema: Mucosal edema
Colles' #: Dinner Fork abnormality
(Splint in Neutral position)
Suspected Scaphoid # & X-*** (-)
APPLY THUMB SPICA CAST anyway
Ankle Inversion Injury
- Lateral Ligament Sprain
- Anterior Talofibular Ligament
McMurray Test:
.Meniscal Tear
.Joint Line Tenderness
Lachman Test:
Anterior Cruciate Ligament Injury
Dislocation of Shoulder:
.Anterior
.associated with axiallry artery injury
NBT (-) : CGD (SXR) -> IFN-gamma
Prostatic Mets.: BONE SCAN > SKELETAL SURVEY
MYELOMA: SKELETAL SURVEY
(Bone Scan is useless, does not detect lytic lesions)
#1 cause of death in myeloma: Pulmonary or UTI
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Posted: Sun May 25, 2003 4:35 pm Post subject: Ast- pagwe18
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Duration of Maintenance Pharmacotherapy for depression (even for single episode)
should be at least 6-9 months.
Desert Rheumatism: C immitis
Mx – Conservative
Rx required only for dissemination / lung lesions
#1 Kidney stones: Calcium Oxalate (radiopaque)
[Square Crystals]
URIC ACID stones are radiolucent
CYSTINE crystals in urine are always pathological
Crohn's: associated with gallstones & kidney stones
[increased absorption of oxalates from the gut]
#1 complicatin of chickenpox: 2º skin infection
Postop Fever @ 24 hours: atelectasis
Postop Fever @ 5-10 days: wound infection
(early wound infection: clostridia / pesudomonas)
Neonatal Meningitis: S. agalactiae (Gp B Strep)
C1 esterase inhibitor deficiency:
.hereditary angiodema
.depleted C4 levels
.Mx: FFP/e-ACA/Stanozolol
.Maintain: ANDROGENS (inc. synthesis)
Suspect endometrial cancer:
gynecological referral for enometrial biopsy
Pap misses 60% of endometrial Ca.
Cryoprecipitate: replaces Fibrinogen & Factor VIII
FFP: replaces all coagulation factors
Reversal of warfarin action: FFP (chronic: Vit. K)
Reversal of heparin action: Protamine
sterile subdural effusions: H. influenzae meningitis
pneumonia with effusion / empyema: Staph. aureus
Lipase is more sensitive and specific than amylase
Serum amylase elevated for 2-4 days
Urinary amylase elevated for 7-10 days
#1 cause of sensorineural hearing loss:
PRESBYACUSIS
#1 cause of conductive hearing loss: OTOSCLEROSIS
osteomyelitis after foot puncture wound:
Pseudomonas
Acromegaly
.Inability to supress glucose
.no stimulation of GH with levodopa
.paradoxical increase of GH with TRH
#1 intracranial mass lesion: METASTASIS
#1 brain malignancy (adult): Glioblastoma multiforme
#1 brain malignancy (child): Astrocytoma
adult: supratentorial
children: infratentorial (#1 supratentorial in children is craniopharyngoma)
SVC Syndrome: Think Bronchogenic Ca.
AML with DIC: M3 variant of AML
AML with gum chloromas: M5 variant of AML
Hairy Cell Leukemia: TRAP+ (Rx: Cladribine)
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Posted: Mon May 26, 2003 10:38 am Post subject: Aster pg 19
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Aster's USMLE Step3 Notes
Port Wine Stain: Sturge Weber Syndrome
CSF has a higher Cl- content compared to plasma
Rocky Mountain Spotted Fever:
Dx – Indirect IF
Rx – DOXYCYCLINE (< 8y: Chloramphenicol)
Neurofibromatosis:
> 6 cafe au lait spots [or 1 spot > 5cm]
Tuberous Sclerosis:
Cardiac Rhabdomyomas
Angiomyolipoma of Kidney
Subungal Fibromas
Decreased Haptoglobin:
Intravascular Hemolysis
Very Severe Extravascular Hemolysis
OSTEOPOROSIS: Serum Ca++ & PO4
3- are normal
Testicular Torsion: affected testis lies horizontally
Mx – Surgical Fixation of BOTH Testes
Torsion of Testicular Appendix: BLUE DOT
Mx – Exploration of other scrotum not required
m/c Thyroid Malignancy: Papillary Ca. Thyroid
MEN Syndrome: Medullary Syndrome
Hematogenous Spread: Follicular Ca.
Patella dislocates laterally
Mx PTSD with Group Psychotherapy
(not BZD : high risk of BZD abuse)
Fever without Focus:
#1 cause: Occult Bacteremia
due to Pneumococcus
due to Otitis Media
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Posted: Mon May 26, 2003 10:39 am Post subject: Aster pg 20
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Aster's USMLE Step3 Notes
Signs of Occult Bacteremia:
Temp > 40C
WBC < 5000 or WBC > 15000
Acute Otitis Media: Strep. pneumoniae (Amoxicillin)
#1 Pediatric Gastroenteritis: Rotavirus
#1 Pediatric (Bacterial) Gastroenteritis: C. jejuni
Recurrent Otitis Media:
–definition: >3 in 6 months or >4 in 1 year
–Amox prophylaxis -> Myringotomy & Tubes
Indications of Tonsillectomy:
–1 episode of Quinsy (Peritonsillar abscess)
–> 7 proven streptococcal pharyngitis
–airway obstruction
decreases recurrent sore throat, not URI
Suspected Strep Sore Throat:
Sore throat, fever, cervical LN, tonsillar exudates
Only 15% of sore throats are streptococcal
Rapid Strep. Test (HIGH SPECIFICITY)
even If (-), start treatment & perform a throat swab
Simple Diarrhea
No role of Stool Culture:
Stool Culture indicated only if:
–bloody diarrhea
–persistent diarrhea
–(+) tenesmus
–h/o foreign travel
Mx: Oral Rehydration Solution
(not juices or carbonated beverages)
Children with no dehydration – age-appropriate diet
Gp A â-hemolytic Streptococci are usually susceptible to Penicillin (this is not the case
with Staphylococci)
Strep viridans sensitive to Ampicillin + Gentamycin
German Measles (Rubella)
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Posted: Mon May 26, 2003 10:40 am Post subject: Aster pg 21
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Aster's USMLE Step3 Notes
Measles (Rubeola)
Roseola infantum (Exanthem subitum) HHV 6
high fever, rash appears after fever subsides
Lead levels > 10 : environmental abatement
start chelation therapy @ higher levels (? > 25)
single umbilical artery associated with renal ab(n)
Caput crosses midline; cephalhematoma does not
HbS Disease: Prophylactic Penicillin till 5y age
Stranger Anxiety: 6-9m
Separation Anxiety: 12-15m
Encopresis: >4 y
Enuresis: >5 y
Simple Febrile Seizures:
–Single Seizure
–Nonfocal
–< 15 minutes durations
–associated with high fever
–Rx: antipyretics (NOT ANTICONVULSANTS)
–F/H (+)
–Can recur
Meningococcal Contacts: Rifamp/Cipro prophylaxis
(#1 cause) Seasonal Allergic Rhinitis-Ragweed
(#1 cause) Perennial Allergic Rhinitis-House Dust Mite
Choanal Atresia
–cyanosis with feeding
–relieved by crying
Dog & Cat Bite: P multocida (Rx: Amox-Clav)
Cat scratch disease: Bartonella henselae
Cushing's Syndrome: #1 Iatrogenic
Cushing's Disease: #1 Pituitary Microadenoma
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Posted: Mon May 26, 2003 10:41 am Post subject: Aster pg 24
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Aster's USMLE Step3 Notes
Dx: 24 hour urinary free cortisol
to diff. Pituitary & adrenal cause: Overnight DST
Pick's Disease:
Dementia / atrophy of frontal & anterior temporal lobes
[early psychiatric manifestations]
Dementia with Lewy bodies:
(Alzheimer's + Parkinsonism features)
DO NOT USE ANTIPSYCHOTICS
[they can excecerbate parkinsonism features]
Dialysis Dysequilibrium Syndrome:
associated with rapid correction of uremia
HTN in elderly African Americans: CCB + Diuretics
HTN in young African Americans: Diuretics
Paget's Disease of the bone:
extent is delineated by Tc 99 scan
Wounds < 12 hours old, clean: primary closure
Wounds > 12 hours old, contaminated: debridement and secondary closure
concomitant use of I/v heparin with thrombolysis:
Ac. anterior MI & Left Venticular Thrombus
Pts. with non-Q wave MI & previous CABG do not benefit considerably from
thrombolysis
High risk features post-MI
1. Post MI angina
2. Non Q Wave MI
3. CHF
4. LVEF < 40%
5. > 10 PVCs / min
e/o Significant Ischemia on Exercize Stress Test:
1.ST segment depression
2.< 6 METS work
3.@ < 70% predicted maximum heart rate
4.Hypotensive Response
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Posted: Mon May 26, 2003 10:41 am Post subject: Aster pg 25
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Aster's USMLE Step3 Notes
LDL is the most important “lipid” risk factor for CAD
Cholesterol: < 200, 200-240, > 240
LDL: < 130, 130-160, > 160
treatment of choice for hypercholesterolemia: DIET
Basilar & Hemiplegic Migraine
DO NOT use SUMATRIPTAN
(also c.i. in IHD/MI, Pts on SSRI/MAOI/Li)
Acute A. Fib.:
(Stable) â-blockers & CCB
(Unstable) Sync. Cardioversion
Obesity is a risk factor for Endometrial Ca.
Surgical intervention for obesity : BMI > 40 kg/m2
Heparin: keep PTT 1.5-2.0 x control
Warfarin: keep PT 1.5-1.8 x control
Enoxaparin (LMWH): No PTT monitoring required
COPD : smooth muscle hyperplasia (as in asthma), but Methacholine challenge test is
negative
REID INDEX: ratio of thickness of bronchial glands to bronchial wall thickness
(increased in chronic bronchitis)
Nicotine enhances growth of H. flu
Most effective long term pharmacotherapy for COPD: Ipratropim bromide
COPD excecacerbations: H. flu, Pneumococcus, Moraxella
LONG TERM HOME OXYGEN THERAPY
Only Rx in COPD that enhances survival
indications:
–Resting PaO2 < 55 mmHg
–Resting PaO2 < 60 mmHg with tissue hypoxia
(cor pulmonale / polycythemia)
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Posted: Mon May 26, 2003 10:42 am Post subject: Aster pg 26
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Aster's USMLE Step3 Notes
Acute Bronchitis in healthy non-smoker:
no Investigations, no treatment (no antibiotics)
Early phase of asthma: primary mediators
Late phase of asthma: secondary mediators
Prophylaxis of exercize induced asthma: Albuterol
Long term stabilization of exercize induced asthma: Salmetrol (long acting) +
Zafirlukast
Mycoplasma pneumonia:
–minimum physical findings
–B/L lower lobe infiltrates
–Cough (+)
–Mx: Macrolide
Cold Agglutinins (IgM) Inravascular hemolysis
Pnenumonia in elderly debilitated alcoholic:
Lower Lobe: Strep pneumoniae
Upper lobe: Klebsiella
(currant jelly sputum, hemoptysis, cavitatory lesion)
Normal Semen analysis
vol. 2-5 mL
sperm conc. > 20 million / mL
morph > 30% normal
motile > 50% motile
#1 cause of dysphagia: lower esophageal ring
(in the absence of risk factors for esophageal cancer)
Systemic Sclerosis associated with severe GERD
UC (Dx): Colonoscopy
Crohn's (Dx) : air contrast barium enema
Alcoholic Hepatitis: AST >> ALT (ratio > 2.0)
Malignant Neuropathic Pain
Sharp Stabbing: Rx anticonvulsants (Carbamazepine)
Dull Aching: Rx TCA (Desipramine)
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Posted: Mon May 26, 2003 10:43 am Post subject: Aster pg 27
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Aster's USMLE Step3 Notes
Mx of Chemotherapy induced Emesis: ONDANSETRON
Pain control : round-the-clock dosing > cf. PRN
TPN: no mortality/morbidity benefit in cancer pts.
Vestibular Nausea Rx: Cyclizine
Radiotherapy assoc. diarrhea: Loperamide / Codeine
Narcotic induced constipation: LACTULOSE
#1 symptom in avanced cancer is weakness (ASTHENIA)
SSRIs can make agitated depression worse
(Use sedating TCA & Anxiolytic PRN)
#1 metabolic derangement with advanced malignancy:
–hyperCa++ (long PR, decreased QT, wide T waves)
Type 1 DM is HLA DR3/DR4 associated
Type 2 DM - Obesity & Family History
OHAs
–Biguanides
decrease Glucose production & increase peripheral utilization (Metformin)
–Sulfonylureas
stimulate Insulin release (Glibenclamide)
–Glitazones
DECREASE INSULIN RESISTANCE
(Troglitazone)
–á-glucosidase inhibitors
decrease carbohydrate absorption (Acarbose)
MODY
–pts. are normal to underweight
–< 40 years age
–AD inheritance
–F/H (+) in 50%Dx of DM
Diagnosis of Diabetes Mellitus
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Posted: Mon May 26, 2003 10:44 am Post subject: Aster pg 28
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Aster's USMLE Step3 Notes
–FBS (2 values) > 126 mg%
–RBS (1 value) > 200 mg%
–GTT (100g oral glucose): 2 hour value > 200 mg%
Li induced NDI : stop Li -> start Carbamazepine
#1 feature of Cushing's: Truncal Obesity (90%)
Pathophysiology of Migraine:
CNS Platelet aggregation with Serotonin release
Very Severe Migraine (abortive): SUMATRIPTAN
Moderately severe Migraine (abortive): DHE
Status migrainous: migraine lasting > 72 hours
Cluster Headaches: Sumatriptan / O2 inhalation
New onset seizure
< 40 y age: #1 Idiopathic
> 40 y age: #1 Brain Tumor
Discontinue anticonvulsants after seizure-free for 4y
(confirmed by absence of epileptiform activity on EEG)
Grand mal: Phenytoin
Petit mal: Ethosuximide
Thrombotic Stroke: slow and continuing (m/c variety)
Embolic Stroke: sudden
#1 risk factor for CVA: HTN
CEA for Symptomatic Carotid Artery stenosis > 70%
Fe deficiency anemia (most sensitive Ix): S. Ferritin
#1 inherited bleeding disorder: vWD
Inherited hypercoagulable state
Factor V Leyden (most common)
Prot C def. / Prot. S def.
Anti-thrombin III deficiency
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Posted: Mon May 26, 2003 10:44 am Post subject: Aster pg 29
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Aster's USMLE Step3 Notes
Anti-PL antibodies: can cause arterial thrombosis
TTP: do NOT give platelet transfusion
vWD: Factor VIII (cryoppt.)
DIC: FFP
COX-2 (Celecoxib): less GI side effects cf. NSAIDs
Exercize program in OA
Graded, Active Exercize, Isometric
Fibromyalgia
–tenderness in 11 of 18 defined points
–r/o comorbid depression
–ass. with sleep disorder
(á-nonREM sleep anomaly) -> also in CFS
Mx of Chronic Fatigue Syndrome:
–NSAIDs
–nonsedating TCAs
Both FIBROMYALGIA & CHRONIC FAIGUE SYNDROME have á-nonREM sleep
anomaly
GOUT prophylaxis: only for recurrent attacks
(> 2-3 attacks) [not after first atack]
#1 cause of Chr. Renal Failure: DM
Mx of uncomplicated UTI: 3 days of TMP-SMX
Artificial Donor Insemination
–Store semen for 6 months
–Check donor for HIV @ 6 m
–If still (-), proceed with insemination
#1 step in Obstructive Sleep Apnea: Weight Reduction
BZD can worsen Obstructive Sleep Apnea
Narcolepsy Mx:
–Methylphenidate
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Posted: Mon May 26, 2003 10:45 am Post subject: Aster pg 30
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Aster's USMLE Step3 Notes
–Dextroamphetamine
–Mazindol (TCA)
Long T1/2 BZD are associated with lower incidence of rebound anxiety (e.g.
Flurazepam)
Bisphosphonates
Oral - to be taken in the morning on empty stomach with 8 oz of water (to prevent
esophagitis)
Alendronate (FDA approved)
Etidronate (less efficacious)
Pamidronate (I/V infusion)
SERMs (Raloxfene):
–Estrogenic on Bone / Lipids
–Anti-estrogenic on Uterus & Breats
Marjolin Ulcers: squamous cell ca. in old scars
Immunosuppression is a risk facor for Sq Cell Ca.
PRCA (Pure red cell aplasia) may be associated with thymoma
Aplastic Anemia causes <3% fall in Hct / week
[>3% fall in Hct / week: Hemolysis / Hemorrhage]
Hereditary Spherocytosis:
–AD
–Spectrin
–Microcytosis
–increased MCHC, increased Osmotic Fragility
–Lifelong FOLATE supplementation
–Rx: SPLENECTOMY
PNH:
–acquired defect in DAF
–Dx: Sugar Water Test
–prone to hepatic & mesenteric vein thrombosis
–may progress to Aplastic Anemia / AML
Blody Nipple d/c: DUCT EXCISION
(no role of ductography)
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Posted: Mon May 26, 2003 10:46 am Post subject: Aster pg 31
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Aster's USMLE Step3 Notes
G6PD def.: older RBCs are deficient in enzyme, hemolysis is self-limited
G6PD def. (Mediterranean Variant): all cells are deficient - severe and chronic
hemolysis
MYELOFIBROSIS:
–poikilocytosis
–giant abnormal platelets
–dry bone marrow tap
“Clustered Polymorphic Microcalcification” on Mammography is s/o Breast Cancer
Mammography is never a substitute for BIOPSY. Mammo is for detection of other
lesions and screening the contralateral bereast. It does not rule-in or rule-out cancer
HbSC disease:
–increased incidence of Proliferative Retinopathy
–decreased vaso-occlusive and pain crisis
Fever in Neutropenia: consider infectious
Rx of acute promyelocytic leukemia: RETINOIC ACID
Serum LDH is a prognostic marker in Lymphomas
multiple myelomas with no paraprotein : 1%
(very aggressive)
TTP & HUS: normal coagulation studies (cf. DIC)
Uremia is asscoaited with qualitative platelet defect
Hemophilia with low platelet count:
??? HIV associated immune-thrombocytopenia
Hemophilia with no improvement with Factor VIII infusion: ??? suspect Factor VIII
Inhibitor activity
[Serum Mixing Test]
Mx: Steroids or Cyclophosphamide
Vit. K dep. factors:
Factor II, VII, IX, X
(Vit. K def.: corrected by Vit. K administration)
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Posted: Mon May 26, 2003 10:47 am Post subject: Aster pg 32
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Aster's USMLE Step3 Notes
Liver Disease:
decreased vit. K dependent factors & Factor V
(coagulopathynot corrected by Vit. K administration)
1 Unit of Packed Red Cells
300 mL volume = 200 mL of Red Cells
raises Hc by 4%
When Typo “O” blood is being used (universal donor): use packed red cells, not
whole blood
Constipation
<50y: increase fiber or osmotic laxatives
>50y: FOBT
If (+), Colonoscopy (Sigmoido/Ba enema)
Mayonnaise/Salad Dressing: S. aureus food poisoning
Small Bowel Diarrhea: Voluminous, Bloating
Large Bowel Diarrhea: small volume, LLQ Cramps
Methylene Blue stain of stool detects Fecal Leukocytes
Follow-up Rx of DKA with ANION GAP
(not serum Ketones)
–ketone estimation detects only acetate and acetoacetate
–the predominant ketone in DKA is b-HAP
–as DKA Rx progresses, b-HAP converts to acetoacetate and estimation of serum
ketones might suggest "paradoxical" worsening ketonemia
Osmotic Diarrhea: decreases with fasting
Fecal Fat > 10g/24hours : s/o Malabsorption
UGIH
#1 Peptic Ulcer
#2 Variceal Bleed (#1 cause of death from UGIH)
LGIH
#1 (>50y) Diverticulosis (#2: Angiodyslasia)
LGIH Dx
<50y: Anoscopy or Sigmoidoscopy
>50y: Colonoscopy (Sigmoido/Ba enema)
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Old 11-20-2004, 01:14 PM
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Aster's USMLE Step3 Notes
Posted: Mon May 26, 2003 10:52 am Post subject: Aster pg 33
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Aster's USMLE Step3 Notes
Ascitic Flluid: SAAG > 1.1 [Portal HTN]
Spontaneous Bacterial Peritonitis
–> 500 cells / ìL
–> 250 PMNs / ìL
–Total Protein < 1g / dL
–Mx: i/v Ceftriaxone (no anaerobic cover required)
–prophylactic FLUOROQUINOLONES to
prevent recurrences
Familial Mediterranean Fever:
–Turks, Armenians, Arabians
–recurrent abdominal pain (resembles acute surgical abdomen)
–attacks resolve in 24-48 hours
–associated with serositis & pleuritis
–recurrent attacks cause secondary amyloidosis
–Rx: COLCHICINE
Uncomplicated GERD: H2 blockers (1st line) -> PPI
Complicated GERD: PPI (1st line)
Preferred procedure for portal decompression is TIPS (Transvenous Inrahepatic
Portosystemic Shunt)
–associated with maximum decrease in rebleeding rate (> banding, sclerotherapy, âblockers)
Non-invasive tests for H. pylori
–serology (past & present infection)
–fecal antigen detection
–urea breath testing
PPI can cause False (-) fecal antigen & breath test
Duodenal ulcers heal faster than gastric ulcers
Long term PPI Rx not required in PUD
Long term PPI Rx required in GERD
H. pylori eradication: PPI / Amox / Clarithromycine
50% of H pylori isolates are Metronidazole-resistant
•10-14 days of H. pylori eradication followed by 4-8 weeks of PPI for Rx of PUD
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Posted: Mon May 26, 2003 10:53 am Post subject: Aster pg 34
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Aster's USMLE Step3 Notes
Rx of Whipple's Disease: TMP-SMX for 1 year
Giardiasis can cause Lactase deficiency
Ogilvie's: acute colonic pseudo-obstruction
Gastric malignancy
#1 Gastric adenocarcinoma
#2 B-cell lymphoma
Celiac Sprue
increased incidence of intestinal T-cell lymphomas
Carcinoid Syndrome: small bowel carcinoid with hepatic metastasis (increased urinary
5-HIAA)
•increased right sided valvular lesions
Abdominal Pain relieved by defecation: IBS
Cl. difficile: watery diarrhea (Dx: Toxin Assay)
Budesonide:
high potency steroid
low systemic side efects
(due to high first pass metabolism)
useful in nflammatory bowel disease
When UC/CD diff. is difficult
UC: pANCA (+)
CD: ASCA (antbodies to s. cerevisiae)
UC: assoc. with PSC (PSC is an independent risk factor for colonic malignancy in UC)
APC Gene:
–AD
–Polyps -> Adenomatous Polyps -> Ca
–small bowel polyps (low malignant potential) & gastric polyps (no malignant potential)
may also be found
FPC: begin screening colonoscopy @ 12-20 y age
Peutz Jeghers:
–colonic polyps have no malignant potential
–increased extraintestinal malignancies
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Guest
Posted: Mon May 26, 2003 10:54 am Post subject: Aster pg 35
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Aster's USMLE Step3 Notes
(Breast, Gonads, Pancreas)
HPNCC:
–Colorectal Ca (+)
(few, flat, fast-progressing adenomas)
–40% lifetime risk of endometrial cancer
Right sided Colon Ca: Bleeding
Left sided Colon Ca: Obstruction
Hep D superinfection is more severe than co-infection
HAV infection: may have relapses
Acute Hepatic Failure: Encephalpathy in < 8w
Subacute Hepatic Failure: Enceph. in 8w - 6m
Chr. Hepatitis: > 6m
Anti-HCV: EIA -> if (-) -> confirmatory test RIBA
Chronic HBV: IFN-á or LAMIVUDINE
Chronic HCV: IFN-á or RIBAVARIN
Chronic HCV infection:
gluteal. with cryoglobulinemia and Type2 DM (NIDDM)
Individuals with Hemachromatosis are susceptible to V. vulnificus, Listeria, Y
enterocolitica infections
Dx of Budd Chiari syndrome: Duplex Doppler U/S
Left Heart Failure:
increased liver enzymes (ischemic injury)
Right Heart Failure:
increased Bilirubin & Ascites (>> periph. edema)
Gastric Varices without Esophageal Varices: Splenic Vein Thrombosis
Mx: Splenectomy
#1 organism causing pyogenic liver abscess: E. coli
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Posted: Mon May 26, 2003 10:55 am Post subject: Aster pg 36
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Aster's USMLE Step3 Notes
OCP associated Liver Adenoma
(Mx: RESECTION even for asymptomatic cases)
Meperidine: least Sphincter of Oddi spasm
UC with pruritus: consider PSC
S. amylase can be increased in MUMPS ue to salivary gland involvement without
involvement of pancreatic gland [but S. Lipase would be normal in cases of
extrapancreatic elevation of amylase]
Antibiotic of Choice in Pancreatic Infections: IMIPENEM
Tamoxifen:
decreases Breast Ca. / increases Endometrial Ca.
SERMs (Raloxifene):
decreases Breast Ca. / decreases Endometrial Ca.
Medical Adrenalectomy
Aminoglutethemide + Corticosteroids
HRT after Breast Ca. -> Raloxifene
IgE is not involved in anapylactoid reactions
(e.g. radiocontrast allergy)
CD3 : pan B cell marker
CD19: pan T cell marker
Dx of CREST syndrome is clinical
(not based on anti-centromere antibody)
Of all HLAs - HLA-DR compatibility is essential for long term graft survival
Cyclosporin:
decreases CMI & decreases IL-2 (T-cell activation)
Steroids: decrease CMI
Cyclophosphamide: decreases CM as well as HMI
IFN-á: HCL, HepB & C, Kaposi's, CML
IFN-â: Multiple Scerosis
IFN-ã: CGD
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Posted: Mon May 26, 2003 10:56 am Post subject: Aster pg 37
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Aster's USMLE Step3 Notes
Acidosis due to Organic Acids is not assoc. with HyperK+ (cuz they freely permeate the
cell membrane)
Renal Glycosuria, Hyphosphatemia, Hypouricemia: FANCONI's
Commonest TA: Type IV RTA
(Hyperchloremic Hyperkalemic metabolic acidosis)
Thyroid Scan: I-123
Thyroid Ablation: I-131
Prerenal Azotemia: BUN/Cr > 20.0
L4: Knee Jerk & Sensory on Medial Calf
S1: Akle Jerk & Lateral Foot
PIVD L5 compression:
DORSIFLEXION of foot affected
PIVD S1 compression:
PLANTAR FLEXION of foot affected
[Ca][PO4] > 64 : predictive of metastatic calcification
Mx of Myedema Coma:
300-500 microg bolus of i/v thyroid hormone
followed by 50 microgram daily
Panhypoptuitarism presenting with Myxedema coma:
–first give HYDROCORTISONE
–then THYROID REPLACEMENT
(to prevent Adrenal Crisis)
Allopurinol potentiates the action of Azathioprine: if used together, reduce
Azathioprine dose by 75%
Routine PIVD: MRI not indicated
(conservative Mx – resolve in 1-4 weeks)
PIVD with neurological deficits: MRI
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Posted: Mon May 26, 2003 10:56 am Post subject: Aster pg 38
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Aster's USMLE Step3 Notes
Lumbar Spinal Stenosis:
–Discomfort in Thighs on walking / standing
–pedal pulses preserved (PSEUDOCLAUDICATION)
–Ix: MRI
Phaeochromocytoma
Urinary Catecholamines: sensitive
Urinary Metanephrine: specific
Urinary VMA: least useful
Mx of Fibromyalgia: TCA (NSAIDs are ineffective)
#1 functional pituitary adenoma: PROLACTINOMA
Pain in sole of foot after getting up in he morning: Plantar Fascitis (Mx: Arch Support /
NSAIDs)
SLE
ANA- sensitive
Anti-Sm: specific
Ant-dsDNA: correlates with disease activity
#1 vitamin deficiency: Vit. D
Polymyositis associated dysphagia:
oropharyngeal (striated muscle)
Scleroerma associated dysphagia:
esophageal (smooth muscle)
Muscle Biopsy findings in Dermatomyositis:
lymphoid infiltrate AROUND muscle fascicles
Muscle Biopsy findings in Polymyositis:
lymphoid infiltrate INSIDE muscle fascicles
Ix of choice: Muscle Biopsy (not EMG/NCV)
Woman with Joint Pains and Dental Caries : Sjogren's syndrome
GCA: associated with increased incidence of
Thoracic Aortic Aneurysms
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Posted: Mon May 26, 2003 10:57 am Post subject: Aster pg 39
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Aster's USMLE Step3 Notes
Ank. Spond. vs. SI joint involvement in Psoriasis:
lack of calcification in Psoriasis
Prompt Rx of NGU:
associated with decreased indcidence of REITER's
Whipple's: Joint symptoms precede GI symptoms
Synovial Fluid WBC count
< 200 normal
< 2000 noninflammatory (OA)
2000-50000 Rheumatoid Arthritis
50000-100000 Septic / Gout
> 100000 Septic
#1 Septic Arthritis: N gonorrheae
#1 non-gonococcal arthritis: S. aureus
#1 with IVDU/arthroscopy/prosthesis: S epidermidis
Recurrent Gonococcal Arthritis:
? C5-C8 deficiency
#1 cause of Osteomyelitis: S. aureus
#1 renal involvement after URI:
IgA nephropathy (1-2 days after URI)
PSGN occurs 1-3 weeks after Strep. infection
Nephrotic Syndrome:
#1 (Children): MCD
#1 (Adults): MGN
Dialysis :acquired renal cysts (? malignant pot.)
Enthesopathy:
inflammation of Ligaments / Tendons
(Ankylosng spondylosis / Reactive Athritis)
Polycystic Kidney Disease:
associated with Berry aneurysms in circle of Willis
(SAH)
Multile Myeloma & Kidney:
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Posted: Mon May 26, 2003 10:57 am Post subject: Aster pg 40
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Aster's USMLE Step3 Notes
Myeloma Kidney - LIGHT CHAIN Renal Toxicity
(light chains are not detected by urine protein dipstick)
Renal Amyloidosis - Heavy Chains excreted
(heavy chains are detected by urine protein dipstick)
Aging: decreasd GFR but S. Cr. remains constant ('cuz Lean Body Muslce Mass
decreases too)
Initial Hematospermia: Prostate
Terminal Hematospermia: Seminal Vesicle
RBCs: Hematuria
WBCs: Cystitis
RBC Cast: GN
WBC Cast: APN, Pyelonephritis
Acute Bacterial Prostatitis:
NO Prostatic Massage or Catheterization
Chronic Bacterial Prostatitis:
Prostatic massage -> C/S of expressed secretions
(Mx: TMP-SMX)
Ureteral Stones < 6mm:
Conservative Mx for 6 weeks
Asymptomatic Renal Stones: Conservative
F/U with serial X-Rays
Symptomatic Renal stones (Fever/Pain/UTI):
–< 3cm: ESWL
–> 3cm: PCNL
Urinary Incontinence:
Total: Sx
Stress: Sx is curative (Kegel/Pessary/Estrogen)
Urge: Antispasmodic / Anti-Ach / TCA
Overflow: Catheterize
Sildenafil (Viagra) c.i. in patients on Nitroglycerine
Right Ventricular Infarction:
Nitroglycerine precipitates HYPOTENSION
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Posted: Mon May 26, 2003 12:26 pm Post subject: Aster pg 41
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Aster's USMLE Step3 Notes
Mx: I/V Fluids
70y old man with urinary obstruction and backache:
? Prostatic Ca with mets
Prostatic Biopsy: U/S guided biopsy > finger-guided
Prostatic Ca: Transrectal U/S = MRI for staging
(CT has no role)
Prostatic Mets: Radionuclide Bone Scan > X-***
Ix for suspected Bladder Ca.: CYSTOSCOPY
MEN II: hyperparathyroidism is due to HYPERPLASIA, not PARATHYROID
ADENOMA
Testicular Neoplastic Mass:
Children: Embryonal Cell Ca.
Adult: Seminoma
> 50y: Lymphoma
Intracranial H'age (< 48h. duration):
CT without contrast is superior to MRI
Cerebellar Vermis:
Axial ataxia
Cerebellar Hemisphere:
“IPSILATERAL” Appendicular Ataxia
Frontal Lobe Lesions:
Personality Changes
Temporal Lobe Lesions:
Hallucinations/ deja vu / emotional changes
Parietal Lobe Lesions:
cortical sensory loss (astereognosis)
Occipital Lobe Lesions:
macular sparing field defects &
UNFORMED VISUAL HALLUCINATIONS
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Posted: Mon May 26, 2003 12:28 pm Post subject: Aster pg 42
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Aster's USMLE Step3 Notes
Acoustic Neuroma:
first symptom is IPSILATERAL hearing loss
To measure severity of ASTHMA attack:
Peak Expiratory Flow Rate [PEFR] (not ABG)
Alcohol can temporarily decrease symptoms in BENIGN ESSENTIAL TREMOR
(intention tremor)
Myerson's Sign:
2 per second tap on nose -> sustained blinking
(seen in Parkinsonism)
Shy-Drager:
Parkinsonism + Autonomic Insufficiency + Neurological Deficits
Progressive Bulbar Palsy (CN Motor nuclei): TONGUE WASTED
Pseudobulbar Palsy (UMN):
TONGUE SPARED
ALS : UMN + LMN
Peripheral Neuropathy:
AXONAL (NCV normal)
DEMYELINATION (NCV decreased)
TT Leprosy: Neuropathy in area of skin lesions
LL Leprosy: Neuropathy > Skin Lesions
Tarsal Tunnel Syndrome
Pain, Paraeshesiae on bottom of foot
(Sparing of the HEEL)
Cervical Rib:
–Thenar Wasting
–Pain & Numbness on medial 2 fingers
(ulnar side of forearm)
Myotonic Dystrophy:
–AD
–stiffness
–cataracts
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Posted: Mon May 26, 2003 12:29 pm Post subject: Aster pg 43
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Aster's USMLE Step3 Notes
–baldness
Mx - Quinine, Phenytoin, Procainamide
Neuropathy: DISTAL ± Sensory Loss
NM Junction: Fluctuating Deficits
Myopathy: PROXIMAL weakness (NO sensory loss)
non-enhancing white matter lesions without mass effect (in AIDS): PML
Ix of Valvular Ht. Disease:
ECHO foll. by Catheterization (definitive Dx)
ILD
–Non-productive Cough
–Exertional Dysnea
–Fine Expiratory Crackles
–decreased DLCO
–increased A-a gradient
–gold standard for diagnosis: LUNG BIOPSY
Dx of Malignant Mesothelioma: Pleural Biopsy
100% of small cell ca. occur in smokers
Complicated Parapneumonic Effusions
–Gross Pus
–Gram Stain (+)
–Glucose < 50 mg%
–Pleural Fluid pH < 7.0
Severe Hyperkalemia Mx: Calcium Gluconate
Mx of Mg toxicity: Calcium Gluconate
1st test in asymptomatic hematuria:
URINE CULTURE -> IVP
1st test in suspected pneumonia:
CXR -> Sputum C/S
Currant jelly sputum: Klebsiella
Rusty sputum: Pneumococcus
Smokers / COPD: H. influenzae
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Posted: Mon May 26, 2003 12:30 pm Post subject: Aster pg 44
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Aster's USMLE Step3 Notes
Interstitial infiltrates: Mycoplasma
Empyema / Rapidly progressive: Staph. aureus
Pneumonia Rx:
Community acquired: Macrolide
> 60y or COPD/smoker: 2nd gen cephalosporin
Nosocomial: 2nd / 3rd gen cephalosporin
ICU (severe): Macrolide + Antipseudomonadal
Uncomplicated UTI: 3 day course of TMP-SMX
Native Valve Endocarditis - S. viridans
[â-lactam + aminoglycoside]
Prosthetic Valve Endocarditis (Early) - S. epidermidis [Vancomycin + Aminoglycoside]
Prosthetic Valve Endocarditis (Late) - S. viridans [Vancomycin + Aminoglycoside]
IVDU - S. epidermidis / S. aureus
[Vancomycin + Aminoglycoside]
IE prophylaxis:
- Amox 2g 1 hr. before Dental / GI / GU procedures
- penicillin allergy -> Clarithromycin
Don't delay antibiotics in Meningococcal meningitis
(even if LP is not done)
HAART: AZT+3TC & Indinavir
AIDS - avoid all live vaccines except MMR
Abdo. Pain: 1st investigation - AXR
UC: Pseudopolyps, Crypt Abscesses
CD: Skip Lesions, Fistulae
ddI can cause Pancreatitis
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Posted: Mon May 26, 2003 12:31 pm Post subject: Aster pg 45
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Aster's USMLE Step3 Notes
RA: PIP involvement (DIP sparing)
OA: DIP involvement
Ix of choice in Osteoporosis: DEXA scan
Vaginal Candidiasis:
Topical Miconazole / Systemic Fluconazole (recurrent)
(Oral agents eliminate rectal reservoir of yeast)
Trichomoniasis:
PO Metronidazole 2g stat (Rx male partner also)
Bacterial Vaginosis:
PO Metronidazole 250-500mg x 7 days
(cf. single dose in Trichomoniasis)
Pap shows LGSIL (F/U reliable):
repeat Pap 4-6 months later
Women Smokers should always have annual Pap
Primary Dysmenorrhea: within 2 years of menarche
–inreased Prostaglandins
–arteriolar spasm
–uterine hypoxia
–Mx: (sexually active): OCP's
–Mx (sexually inactive / OCP c.i.): NSAIDs
#1 cause of DUB: Anovulatory Cycles
Mx: Hormonal Therapy===>Endometrial Ablation
Severe acute DUN with orthostatic hypotension
I/V Conjugated Estrogen
#1 STD: Chlamydia trachomatis
Ectopic (hemodynamically stable / no rupture):
Methotrexate
Ectopic (Unstable / rupture):
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Posted: Mon May 26, 2003 12:31 pm Post subject: Aster pg 46
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Aster's USMLE Step3 Notes
Salpingectomy or Salpingotomy
OCPs:
decrease Gonococcal STD
may increase Chlamydial STD (cervical ectropion)
Vaginal Spermicides:
decrease Gonococcal & Chlamydial STD
(no effect on HIV transmission)
Breastfeeding & OCPs: can use. Use low-dose OCPs
('cuz of effect on milk production, not because of infant safety consideration. Estrogens
do pass into milk in small quantity, but they are safe)
Hormonal Contraception for h/o DVT/PE:
Norplant & Depo-Provera [no OCP's]
PID
in-patient:
I/V Cefoxitin or Cefotetan + Doxycycline
out-patient:
I/M Ceftriaxone + PO Probenecid + PO Doxycycline
Depression: Cognitive Psychotherapy
Adjustment Disorder: Supportive Psychotherapy
Anxiety Disorder: Behavioral Psychotherapy
Antidepressant Ladder:
–SSRI
–another antidepressant (except MAOIs)
–best tolerated agent + LiCO3
–MAOIs
–ECT
Lab Test for Cocaine:
Urine Benzoylecgonine (Cocaine metabolite)
Genital Herpes transmission occurs even in asymptomatic state
(Acyclovir decreases freq. of recurrences)
H'agic crust on "molluscum" like lesions in HIV pts. : Cutaneous Cryptococcosis
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Posted: Mon May 26, 2003 12:32 pm Post subject: Aster pg 47
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Aster's USMLE Step3 Notes
HPV (Genital Warts)
Heaperd up lesions flesh colored lesions on penis
female partner has increased risk of Ca. Cx
Leprosy with painful red patches on extremities that become nectrotic and ulcerate:
LUCIO REACTION (seen in unreated leprosy, responds to Steroids)
Excessive use of Aluminium containin laxatives:
risk factor for postmenopausal osteoporosis
KOH Prep "meatball-and-spaghetti" appearance: Tinea versicolor
binge eating and purging behavior
(even without depression) : SSRI
Factitious Disorder : assoc. with child abuse
Somatoform Pain Disorder:
limit analgesic use
best managed in a multi-disciplinary pain clinic
Rx of choice for Panic Disorder: PAROXETINE [dependence might develop with
Alprazolam]
Mx of Social Phobia:
â-blockers + ASSERTIVE TRAINING
Mx of OCD: SSRI [Fluvoxamine]
Clomipramne is no longer the first line drug
Mx of PTSD: >1m; assoc. with life-threatening event
Group Psychotherapy
Anorexia nervosa:
75% have Depression, 25% have OCD
Buckman's 6 steps of Breaking Bad News
1. Getting started
2. find out how much the pt. knows
3. find out how much the pt. wants to know
4. share the info. a) Give Warning Shot
5. respond to pt.'s feelings
6. Plan F/U - give hope
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Aster's USMLE Step3 Notes
Posted: Mon May 26, 2003 12:33 pm Post subject: Aster pg 48
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Aster's USMLE Step3 Notes
Skew: depends on direction of tail (not hump)
± 1 SD 68%
± 2 SD 95%
± 3 SD 99.7%
To increase power of a test: inrease sample size
Nominal or Ordinal Data:
Non-parametric Tests [Chi Square]
Interval or Ratio Data:
Parametric Tests [T-test, Z-test, F-test]
Correlation coefficient
Ordinal Data: Spearman Rank Order
Interval or Ratio Data: Pearson product-moment
r=correlation coeeficient
r2 (square)=coefficient of determination
(proportion of variation in one variable explained by variation in other)
Causality is only proven by properly conducted experimental studies
A test can only be 100% sensitive and specific if there is no overlap between
measurements in normal and diseased states
Higher the prevalence of a disease:
Higher the PPV of a (+) test
Lower the NPV of a (-) test
Untreated apendicitis in young female can cause infertility (peritoneal adhesions)
Appendiceal abscess: delay
Sx till inflammation has subsided
[the acute process has been walled off]
Cholangitis (gluteal. with CBD stones):
ERCP with Sphincterotomy + Lap Chole.
Skin Suture: cutting needle
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Posted: Mon May 26, 2003 12:33 pm Post subject: Aster pg 49
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Aster's USMLE Step3 Notes
Deeper Layer Suture: Taper Needle
Ingrown Toe Nail
first episode:
antibiotics, elevation of edge -> wedge resection
recurrent:
Nail Removal
Anal Fissure: Local Steroid Cream / Sitz Bath
Anaesthetic of choice for skin lesion removal: Lidocaine + Adrenaline
(No Adrenaline for fingers and nails)
#1 type of breast Ca.: Infiltrating Ductal Ca. (80%)
Mx of Fibrocystic Disease: Low Dose OCP
Mx of Fibroadenoma: Biopsy (Excisional)
Danger Signs in Chronic Low Back Pain
- Bowel or Bladder dysfunction
- Impotence
- Ankle clonus
- NIGHT PAIN
- Weight Loss
- Lymph Node enlargement
- Buttock claudication
- New Onset in age > 50 y
No imaging for routine chronic low back pain
Mx of Chronic LBP:
TCA's have the best cost/benefit ratio
[Muscle relaxants and NSAIDs have low effectiveness]
Dx of Childhood PCKD: > 2 cysts in EITHER Kidney
Dx of Adult PCKD: > 5 cysts in EACH Kidney
C/I to thrombolysis
- Sx < 2 weeks
- Unconrolled HTN
- Aortic Dissection
- h/o CVA / 'aic stroke / CNS tumor / AVM
- prolonged traumatic CPR
- allergy to thrombolytic agents
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Posted: Mon May 26, 2003 12:34 pm Post subject: Aster pg 50
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Aster's USMLE Step3 Notes
- pregnancy
Risk Stratification in Unstable Angina
(Outpt.) Low - Onset < 2 weeks
(Telemetry) Medium - Onset < 2 weeks, Pain > 20 minutes but resolved @ present
(CCU) High - Rest Pain > 20 minutes and not resolved @ present
(CHF / Pulm. Edema / ST changes / Mitral Regurg.)
1st episode of syncope / low risk of heart disease:
NO FURTHER EVALUATION
Emperical Rx for IE:
Nafcillin + Ampi + Genta
(add Rifampin for Prosthetic Valve)
IE prophylaxis not reqd. for:
1. small ASD of secundum type
2.MVP without Mitral Regurg.
Acute Asthma:
Give Albuterol, O2, steroids -> assess response (PEFR, O2 sat.)
Good Response
PEFR > 80% of best (discharge with â-agonist)
Moderate Response
PEFR 60-80% of best
(hospitalize and continue medications, O2)
Poor Response
PEFR < 50% of best
(ICU admission)
(prepare for Intubation if silent chest, altered sensorium, respiratory failure)
Chronic Asthma
Mild Intermittent:
<2/week, nocturnal symp. < 2/month
(Inh â2-agonist)
Mild Persistent:
>2/week, nocturnal symp. >2/month
(Inh â2-agonist + Anti-LT)
Moderate Persistent:
Daily, PF 60-80%
(Inh â2-agonist + Inh. Steroids/Inh. long acting â2-agonist)
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Posted: Mon May 26, 2003 2:37 pm Post subject: Aster pg 51
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Aster's USMLE Step3 Notes
Severe Persistent:
Continuous, PF<60%
(Inh â2-agonist + Inh. Steroids + Inh. long acting â2 / Anti LT)
SPN: Conservative Mx
Age < 45, nonsmoker, no inrease in size, size < 4cm
Psoriasis:
Pustular: ACITRETIN
Plaques:
–Emollients / Keratolytics / Corticosteroids
–Tar / Calcipotriol / Anthracin
–UVB
–PUVA
–Methotraxeate / Cyclosporin
–Hydroxyurea
Rx of Onychomycosis: PO Terbinafine
Acute Mastoiditis develops 2-3 w after acute otitis
Mx: Ceftriaxone / Sx drainage
Acute Bacterial Sinusitis: Pneumococcus
Chronic Bacterial Sinusitis: S. aureus
most serious form of sinusitis: FRONTAL sinusitis
d/o/c for Alzheimer's :
DONEPEZIL (OD dosing, no liver toxicity)
Upper Lips: BCC > SCC
Lower Lips: SCC > BCC
RCA stenosis: Saphenous grafts
Anterior Duodenal Ulcers: Perforation
Posterior Duodenal Ulcers: Bleeding
Acute Meseteric Ischemia: Embolization
Chronic Mesenteric Ischemia: Atherosclerosis
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Posted: Mon May 26, 2003 2:37 pm Post subject: Aster pg 52
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Aster's USMLE Step3 Notes
Carcioid: Appendix > Ileal
(Ileal have higher chances of metastasis)
#1 GI malignancy: HCC (not colorectal Ca.)
#1 Liver neoplasm: Cavernous hemangioma
#1 Breast Lesion: Fibrocystic Disease
#1 Breast Malig.: Infiltrating Ductal Ca.
Indications for Hormonal Therapy for Breast Ca.
- Postmenopausal
- Nodes -
- ER +
Aortic Aneurysms
Thoracic:
Type A: Sx
Type B: Sx if > 6 cm
Abdominal:
Sx if > 5cm
#1 Congenital Heart Disease: VSD
#1 Cyanotic Heart Disease: TOF
ASD: Fixed Splitting of S2
Biliary Atresia:
Jaundice @ 2 wks of life, dark urine & acholic stools
Rx: Surgery (Roux-en-y portoenterostomy)
Neck Injuries:
Zone I : Arteriography -> Sx
Zone II : Sx
Zone III : Arteriography -> Sx
Mortality in Burns = Age + % BSA
1st degree: Leave Open
2nd degree: Clean,Sulfadiazine,nonadhesive dressing
3rd degree: Escharotomy + Skin Grafting
Sprain: Ligament Pull
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Posted: Mon May 26, 2003 2:38 pm Post subject: Aster pg 53
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Aster's USMLE Step3 Notes
Strain: Muscle Pull
# Neck Humerus: Axillary Nerve Damage
# Shaft Humerus: Radial Nerve Damage
Quick Neuro Exam
AVPU:
Alert
Responds to Verbal Stimulus
Responds to Pain
Unresponsive
Rescusitation:
O2, 2 large bore IV lines, IV fluids, EKG
- 100 mg Thiamine
- 1 amp 50% Dextrose
- 0.4 mg Naloxone
C/I to Foley's Catheter: (do retrograde urethrogram)
1. Blood at tip of urethral meatus
2. Perineal Eccymoses
Abdo. Trauma
#1 Injury in Blunt Trauma: Spleen
#1 Injury in Penetrating Trauma: Small Bowel
Indications for Exploratory Laparatomy in Abdo. trauma
1. Shock with Abdo. Injury
2. Pneumoperitoneum
3. Gunshot
4. (+) DPL
- Blood
- RBC > 100,000/mL
- WBC > 500/mL
- Food
- Bile
- Bacteria
Referral for Burns
- 3rd degree burns > 10% BSA, < 10 y, > 50 y
- 2nd degree burns > 20% BSA
- Electrical burns / Chemical burns
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Posted: Mon May 26, 2003 2:38 pm Post subject: Aster pg 54
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Aster's USMLE Step3 Notes
- Inhalation Injury
- Perineal burns
- Radiation burns
#1 symptom of Parkinsonism: Tremor (Resting)
Benign Essential Tremor
–Intention Tremor
–Familial
–Head Nodding
–temporary decrease with alcohol intake
S. pneumoniae: Rx - Macrolide or newer Quinolone (Levofloxacin / Gatifloxacin)
Majority of elderly patients with sepsis:
URINARY TRACT is the culprit
#1 cause of death in hospitalized elderly: UTI
#1 cause of death in institutionalized pts.: Bacterial Pneumonia
#1 cause of Urinary Incontinence: Urge Incontinence
Clean pressure ulcers with Normal Saline
(avoid Povidone-Iodine, Hydrogen Peroxide etc.)
Unimmunized with infected wounds
3 TT + 1 ATS
Stroke mortality is higher in WHITES than in BLACKS
indications for pneumococcal vaccine
1. Splenectomy
2. Sickle Cell
3. > 65 y
4. Chr. Cardio / Pulmonary / Renal Disease
4. Hodgkin's Disease
Continued Gastric Lavage for : PCP overdose
#1 Foods causing angioedema: Nuts / Seafood
#1 Drug causing allergy: Aspirin
Electronic Fetal Monitoring & Intermittent Auscultation of Fetal Heart have similar
outcomes
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Posted: Mon May 26, 2003 2:39 pm Post subject: Aster pg 55
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Aster's USMLE Step3 Notes
NST (Non-stress Test)
> 2 accelerations (in 20 minutes)
15 bpm lasting > 15 sec
CST
>= 3 consecutive late decelerations in 10 minutes
< 20w. POG with HTN: Essential HTN
(not PIH or pre-eclampsia)
Pre-eclampsia:
Bed Rest / (L) lateral position /
pharmacotherapy [á-methyldopa / labetalol]
#1 indicator of perinatal outcome in IUGR is:
presence of vertical pocket of Amniotic Fl > 3 cm
0-8 weeks : Embryo
8w-term : Fetus
0-14 weeks: 1st Trimester [Routine Ix]
14-28 weeks: 2nd Trimester [GDM Screen]
28-40 weeks: 3rd Trimester [GBS Culture]
<24 weeks: Previable
24-27 weeks: Preterm
37-42 weeks: Term
> 42 weeks: Post-term
Cervical Incompetence:
- Cerclage @ 12-14 weeks, till 36-38 weeks POG
Bishop Score:
<= 5: Prime (with Prostaglandins)
> 8: Induce Labor
#1 cause of PPH: Uterine Atony
Preterm ROM: @ < 37 weeks POG
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Posted: Mon May 26, 2003 2:39 pm Post subject: Aster pg 56
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Aster's USMLE Step3 Notes
Premature ROM: > 1 hr before onset of labor
Prolonged ROM: > 18 hours before onset of Labor (Mx: Antibiotics)
Mastitis in breasftfeeding:
continue breastfeeding, Cloxacillin
Early Breast Milk Jaundice
–Exaggerated Physiological Jaundice
–Onset < 4 days of life
Late Breast Milk Jaundice
–Breast Milk Jaundice
–Onset 4-14 days
–competitive inhibition of glucuronyl ransferase by nonesterified long chain fatty acids in
reast milk
–Mx: Stop breastfeeding for 2-3 days /
Give Formula Milk [Jaundice comes down quickly] -> Resume Breastfeeding
Any jaundice @ Birth is PATHOLOGICAL
Success of Contraceptives
Norplant > OCPs > Barrier
Norplant: quick return to fertility
DMPA: 18 months for fertility to return
Complete Mole:
Diploid; 46, XX; has higher malignant potential
Kernicterus never occurs with:
–physiological jaundice
–exaggerated physiological jaundice
–breast milk jaundice
Features of Pathological Jaundice:
–present @ birth
–increase in bili. > 5 mg/dL/day on first day
–Bili. >12 mg/dL [term] or Bili. >14mg/dL [preterm]
–persists > 1 week of life
–Conjugated Bili. > 1 mg/dL @ any time
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Posted: Mon May 26, 2003 2:40 pm Post subject: Aster pg 57
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Aster's USMLE Step3 Notes
Wessel Criteria for Infantile Colic
Unexplained Crying:
–> 3 hr/day,> 3 d/week, > 3 weeks, 3 m old child
–Do Urinanalysis
–Reassure
–No treatment necessary
–Bottle-fed infants have higher incidence
–Dicyclomine: risk of apnea
After a feed, allow "burping" and lay the child on
(R) side of abdomen
Introduce Solid Foods @ 6 months age
Vaginal pH < 4.5: Candida
Vaginal pH > 4.5: Bacterial Vaginosis
Transfusion Reactions
Fever: Leukoagglutination (donor WBCs)
Mx: acetaminophen
Anaphylaxis (donor proteins,severe in IgA-deficiency)
Mx: Epinephrine, Steroids
Hemolysis (ABO mismatch)
Mx: stop transfusion, hydration & diuresis
Familial Short Stature: NORMAL BONE AGE
Constitutional Delay: DELAYED BONE AGE
Short Stature with Webbed Neck is seen both in Turner's (XO) & Noonan's (normal
Sex chromosomes)
Budesonide has proven to be beneficial in Croup (along with racemized epinephrine)
Rx of choice for AOM in primary practice:
Amox ===> Cefaclor (if no response to Amox)
Transmission of Common Cold:
Indirect Spread is more important than Aerosol spread
Absolutely no antibiotics in common cold
(even if patient demands it!)
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Posted: Mon May 26, 2003 2:40 pm Post subject: Aster pg 58
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Aster's USMLE Step3 Notes
Erysipelas: Gp. A â-hemolytic Srep.
Impetigo: Staph. or Strep. [Bullous - Staph.]
Coxsackie A16: Hand Foot Mouth Disease
Pitryasis rosea: Herald Patch
PNEUMONIA
2 wks: GBS
2 wks - 4 m: Chlamydia trachomatis
#1 Bacterial: Strep. pneumoniae
4 months - 4 years: Mycoplasma pneumoniae
#1 Bacterial: Strep. pneumoniae
> 4 years: VIRAL
#1 bacterial: Strep. pneumoniae
Antibiotic Rx of Occult Bacteremia
does not decrease the occurence of meningitis
Yersenia entercolitica: can mimic acute appendicitis (no Rx necessary - self limiting)
ROTAVIRUS G/E is preceded by URI symptoms
Rec. Abdo. Pain Syndrome
- 10% prevalence
- school phobia
- no organic signs
- no Rx necessary
Growing Pains
- B/L deep pains
- can awaken child from sleep
Mx: exercize program
SCFE
–overweight and sedentary "teenage" BOY
–Groin Pain/ Knee Pain
Dx: X-***
Mx: Surgical fixation
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Posted: Mon May 26, 2003 2:41 pm Post subject: Aster pg 59
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Aster's USMLE Step3 Notes
LCP
–Avascular necrosis of femoral head
–LIMP
–hip pain or referred knee pain
(knee is NOT TENDER to palpation)
Osgood Schlatter
–tenderness over tibial tubercle
–aggraveated by activity
–occurs in pysically actve males around puberty
Mx: Limit activity, NSAIDs;
(if severe) Knee immobilization splint
Teenager with knee pain aggravated by climbing stairs: Patellofemoral Syndrome
Child with Limp / Hip Pain
- preceded by URI
- Fever (+)
- normal ESR
TOXIC SYNOVITIS [Sterile Hip Effusion]
Mx: Rest / NSAIDs (NO ANTIBIOTICS)
Foot dorsiflexes easily
banana shaped sole: Congenital calcaneovalgus
kidney bean shaped sole: Metatarsus adductus
Intoeing
patella points forward: Internal Tibial Torsion
patella points medially: Excessive Femoral Anteversion (#1 cause of intoeing in
children)
CTEV: inability to dorsiflex
Mx: progressive serial casts,
posteromedial release of heel cord
#1 substance of abuse: Alcohol
Nocturnal Enuresis
–> 4 years
–majority of children do NOT have any physical or psychiatric disorder
–Mx: Behavioral modification
Bell / Buzzer system
d/o/c: dDAVP (no longer IMIPRAMINE)
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Posted: Mon May 26, 2003 2:41 pm Post subject: Aster pg 60
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Aster's USMLE Step3 Notes
Encopresis: > 4 y.
Enuresis: > 5 y.
Allergic Rhinitis:
–Hyperemic Nasal Mucosa
–Clear Discharge
–Bluish-purple rings around eyes (SHINERS)
–Ix: Nasal smear for Eosinophils
–Mx: elimination / inra-nasal corticosteroids
Child with rash on introduction of "whole milk":
Atopic Dermatitis
Mx: Cow Milk ----> Formula Milk ----> Soy Milk
(Cow milk allergic might show allergy to soy milk, too)
Diaper Rash
–Candidal: Satellite lesions
–Seborrheic
–Primary Irritant Dermatitis:
maceration with sparing of henitocrural folds
(Mx: frequent changing, washing,
no occlusive plastic pants, ZINC OXIDE,
NO ANTIBIOTICS)
Innocent Murmur in Children
–prevalence: 50%
–accentuated by sitting, anxiety, fever, tachycardia
–mid to low sternal border
–systolic
–no thrill
–vibratory or musical in quality
[Still's Murmur]
Common Cold: Steam Inhalation provides superior relief of nasal congestion cf.
antihistaminics
•Decongestants (sympathomimetics) :
can cause CNS overstimulation
•Cough Suppressants (Dextromethorphan) :
can cause respiratory depression in children
#1 complication of sickle cell disease
Painless Hematuria (Paillary Necrosis)
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Posted: Mon May 26, 2003 2:42 pm Post subject: Aster pg 61
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Aster's USMLE Step3 Notes
Priapism in Sickle Cell Disease
> 6 hrs. : Hospitalize
no effect on future erectile function
may respond to Nifedipine / NTG
Complications of Sickle Cell Disease
- Hemolytic Crisis
- Vaso-occlusive crisis
- Aplastic Crisis
- Splenic sequestration crisis
- CVA
- Renal Papillary Necrosis
- LOwer extremity skin ulcers
- Proliferative retinopathy
Mx of HbS disease
–Oxygenation
–Pneumococcal vaccination
–FOLATE supplementation
–Prophylactic antibiotics (Penicillin till age 5)
–Narcotic analgesia for pain crisis
–CVA: Exchange transfusion
–Painless Massive Hematuria: e-ACA
–HydroxyUrea for frequent vaso-occlusive crisis
–Bone Marrow Transplantation
(Age < 16, availability of Bone Marrow Donor)
STROKE / TIA in Sickle cell disease is an indication for exchange transfusion to keep
the HbS < 50%
HbS disease 'per se' can lead to restrictive lung disease -> hypoxemia -> increased
sickling tendency
Avoid use of MEPERIDINE in severe chronic pain (short T1/2)
Malignant Hyperthermia:
Mx-Dantrolene
Symp. AORTIC STENOSIS: high perioperative risk
In preop pts. with A. Fib. : achieve rate control
In preop pts. on Diuretics : Get Electrolyte Levels
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Posted: Mon May 26, 2003 2:43 pm Post subject: Aster pg 62
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Aster's USMLE Step3 Notes
Avoid elective surgery in patients with
significant hepatic dysfunction
Indications for Intra-op Insulin
- IDDM : any surgical procedure
- NIDDM on Insulin : any surgical procedure
- NIDDM on OHA : major surgical procedure
Prophylactic preop antibiotics only decrease the incidence of wound infection
(no effect on postop pneumonia, UTI, sepsis) : CEFAZOLIN is a good choice
elderly with repeated falls with dementia / seizures:
look for chronic SDH
stool impaction can cause urinary incontinence
Breast Cancer with BRCA1 gene: Better prognosis
Breast Cancer with HER2/neu gene: POOR prognosis
Kaposi's: HHV8 (Male Homosexuals)
Cyclophosphamide: Mesna
Methotrexate: Leucovorin
Cisplatin: Amifostine
Doxorubicin: Dexrazoxane
Mx of chemotherapy induced dry mouth:
Pilocarpine Hcl 5-10 mg PO TDS
Assessment of Doxorubicin toxicity: MUGA scan
Neutropenia:
requires antibiotic prophylaxis for G(-) / fungus
Competent individuals @ the end of life have right to refuse nutrition and hydration
Cutaneous absorption of drugs is 3 times more in children than in adults
Topical drugs c/i in pregnancy
1. Podophyllin
2. Isotretinoin
3. Lindane
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Aster's USMLE Step3 Notes
Posted: Mon May 26, 2003 2:43 pm Post subject: Aster pg 63
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Aster's USMLE Step3 Notes
most appropriate initial investigation in â-Thalassemia: CBC with red cell indices
SLE: decreased C3/C4
Dumping Syndrome post-Bilroth II
- Dietary modification
- Octrotide
- (fails) Bilroth I conversion
75%-95% of AAAs are infra-renal
- Dx: U/S abdo.
Food poisoning: < 6 hrs. after food intake
- S. aureus (mayonnaise / salad dressing)
- B. cereus (fried rice)
> 16 hours / poultry consumption: C. jejuni
Carbamazepine intoxication
- QRS prolongation : predisposes to
- QT lengthening
Defib. followed by pulseless electrical activity
- Hypovolemia
- Hypoxia
- cardiac tamponade
- pneumothorax
- massive pulmonary embolism
- drug toxicity
- hyperkalemia
- acidosis
- massive MI
Coarctation of aorta is associated with
Bicuspid aortic valve in 70% cases
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Posted: Mon May 26, 2003 2:46 pm Post subject: Aster pg 64
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Aster's USMLE Step3 Notes
#1 cause of GI h'age following AAA repair is:
Colonic Ischemia (not stress gastritis)
Early onset wound infections: Strep / Clostridium
Dementia:
Visuospatial: Alzheimer's
Gait disturbance / Urinary Incontinence: NPH
Delayed DTR: Hypothyroidism
Myoclonus: CJD (Creutzfeld Jacob Disease)
Alzheimer's with agitation: use HALOPERIDOL
(not BZDs -> they can aggravte agitation)
Testicular tumors
–#1 seminoma
–increased incidence in cryptorchidism
–metastatize to retroperitoneal nodes
–inguinal nodes involved only with scrotal spread
–Children: Embyonal Cell Ca.
–Adults: Seminoma
–> 50 y: Lymphoma
–Dx: Testicular Ultrasound (no BIOPSY)
Mx: Inguinal exploration & cross clamping of cord
& Orchiectomy
Pregnancy:
–increased tidal volume
–decreased BP (decreased TPR – progesterone)
–Hb decreases (dilutional effect)
TV U/S > sensitive cf. Abdo. Scan for ectopic preg.
Fat Embolism: associated with Eosinophilia & Lipiduria
Shoulder Pain
Rotator Cuff Injury:
best elicited by positioning of the reater tubercle of humerus beneath acromion
Subacromion bursitis:
elicited by palpation over deltoid
Biceps tendinitis:
aggravated by flexion or supination of elbow
Acromioclavicular arthritis:
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Posted: Mon May 26, 2003 2:46 pm Post subject: Aster pg 65
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Aster's USMLE Step3 Notes
elicited by crossed arm adduction against resistance
RANSON CRITERIA
at admn. @ 48 hours
Age > 55 Fall in Hct > 10%
WBC > 16000 Fluid deficit > 6L
Bl. Glu > 200 S. Ca++ < 8.0
LDH > 350 PaO2 < 60 mmHg
AST > 250 BUN increase > 5 mg/dL
Base deficit > 4 mEq/L
Rx of sigmoid volvulus: Sigmoidoscopy
(Sx required if s'copy fails)
Hemodialysis in CRF
–Uremia
–Pericarditis
–Acidosis
–Hyperkalemia
–Unresponsive Volume Overload
AIDS Chemoprophylaxis
CD4 < 200: PCP
CD4 < 100: Cryptococcus
CD4 < 50: MAIC
Cryptococcal Meningitis: very high CSF pressure
(serial lumbar punctures may be warranted)
#1 cause of inracranial mass lesions:
Metastasis (not primary brain tumor)
#1 benign liver neoplasm:
HEMANGIOMA (not Hepatic Adenoma)
Propylthiouracil: can cause agranulocytosis
smoking is a relative c.i. to OCPs - not absolute
#1 cause for osteomyelitis: S. aureus
Bed Rest has no proven benefit in chronic low back pain & threatened abortion
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Posted: Mon May 26, 2003 2:47 pm Post subject: Aster pg 66
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Aster's USMLE Step3 Notes
Significant Hematuria: > RBCs/HPF
Significant Pyuria: > 10 WBCs/HPF
increased PEEP causing hypotension/hypoxemia -> consider pneumothorax
Confirm erythema nodosum by SKIN BIOPSY (Conservative Mx) -> Steroids for
persistent Pain
Change in Antipsychotics should be done
within 2-4 weeks, if no desired effect
Ice should not be applied on snake bite site ->
can delay efflux of venom by causing vasoconstriction
Severity of AS: late peaking murmur & delayed and weak carotid upstroke
Hymenoptera anivenom is not available
Even after treating anaphylaxis with S/Q Epinephrine -> monitor patient in ED
(patient is not risk-free, complications can develop)
#1 cause of fever in AIDS, without overt symptoms: MAC (Rx Ethambutol +
Clarithromycin)
#1 cause of Seizures in AIDS: TOXOPLASMOSIS
#1 cause of dysphagia in AIDS:
Candidal Esophagitis
Suspected child abuse:
inform child protective services
(Hospitalize only if child's conition requires it)
ITP : improvement with splenectomy but platelet counts falls again (Ix:
radionuclide spleen scan for splenic remnant)
HSP: usually remits in 1 week (Mx is conservative) - Leukocytoclastic vasculitis
#1 cause of hematuria after URI: IgA nephropathy
ABI < 0.4 - sever vaso-occlusive disease
Mx: surgical revascularization
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Posted: Mon May 26, 2003 2:47 pm Post subject: Aster pg 67
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Aster's USMLE Step3 Notes
Oliguria in hospitalized pt. -> assess pulmonary wedge pressure (to diff. hypovolemia
and ATN)
Fibrinogen is the most abundant acute phase reactant (responsible for increased ESR)
Age, Myeloma, Macroglobulinemia, Hypoalbuminemia increase ESR
Number-needed-to-screen is reciprocal of absolute risk reduction
Celiac Sprue: dermatitis herpetiformis Mx: Dapsone
Localization of extra-adrenal phaeo: MIBG scan
suspected phaeo
1.catecholamine levels
2.if levels elevated, Imaging
(imaging, done first, will lead to detection of incidental adrenal masses – high
prevalence)
Preop prep in Phaeo
full á blockade followed by â blockade (not vice versa)
Antidote for Mg toxicity is Calcium Gluconate
Mild pre-eclampsia: Bed Rest and Monitoring
Severe pre-eclampsia: Hospitalization,
Control of HTN, MgSO4 infusion
Dx of Hemachromatosis (Gold Standard):
Hepatic Iron Index (not HFE Gene analysis)
#1 cause of TEN : Adverse Drug Reaction
Rapid Correction on HypoNa: CPM
Frozen shoulder = adhesive capsulitis
takes months to regain full function
(steroid injections can hasten recovery)
Orchiopexy in Cryptorchidism @ 1 year age
Orchiopexy deceases the proportion of seminomatous malignancies - but total risk of
malignancy stays the same
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Posted: Mon May 26, 2003 2:49 pm Post subject: Aster pg 68
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Aster's USMLE Step3 Notes
Urine dipstick only detects albumin,
24 urinary protein assessment detecs all proteins
(Myeloma light chains will not be detected by dipstick)
Bone scan has no role in lytic lesions of myeloma
Hypotension in Meningococcemia:
Waterhouse-Frederrikson syndrome
Macrolide antibiotics prolong QT interval:
V.Tac.->Syncope
Kartagener's:
Sinusitis / Bronchiectasis / Infertility / Situs inversus
Disulfiram : slow excretion from the ody. Adverse reactions can occur even 1-2 weeks
after cessation of therapy. Disulfiram is not an option for long term alcohol abstinence
Statin therapy: monitor LFTs regularly
(CPK only if rhabdmyolysis is suspected)
Intravascular Catheter related infection :
Staph. epidermidis / S. aureus
(use Vancomycin, cultures pending)
Arterial Clots: Anti-PL antibody
Venous Clots: #1 inh. cause: Factor V Leyden
Postcoital contraception: is not 100% effective
(Progestin-only Pills are safer than OCPs)
HIRUDIN: is a direct thrombin inhibitor approved for use in pts. with Heparin-induced
Thrombocytopenia
Pulmonary Embolism: CXR is usally NORMAL
#1 finding on EKG: Sinus Tachycardia
- Hampton's Hump: seen in Pulmonary Infarction
- Westermark's Sign: sign of Pulmonary Oligemia
Meningococcemia: seen in C5-C8 deficiency
Meningococcal vaccine: Polysaccharide vaccine (A,C,Y,W135)
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Posted: Mon May 26, 2003 2:50 pm Post subject: Aster pg 69
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Aster's USMLE Step3 Notes
Neutropenia with Fever: (Neutropenia = < 500/mcL)
suspect Pseudomonas
Piperacillin/Tazobactam & Gentamycin
(or Ceftazidime)
if central line is present: Add Vancomycin
[Continue antibiotics even if cultures are negative]
Indomethacin: can decrease amniotic fluid production
Indications for CONIZATION
1. non-visualization of transformation zone
2. "pap" worse than bopsy
3. AdenoCa.
4. (+) endocervical cuerettage
5. Microinvasion on Bx
(+) F/H is not a risk factor for Ca. Cx
Neuroblastoma metastasis:
can cause periorbital ecchymosis / proptosis
- increased urinary VMA
- N-myc gene
PEPTO-BISMOL: affects platelet function
(can prolong bleeding time)
"popcorn" calcification in SPN : Hamartoma
Mx of SIADH: Fluid Restriction
Mx of malignant SIADH: Demeclocycline
"pop" or snap in knee : ACL tear
[Knee Immobilization / Crutches]
post-URI abdo pain / vomiting / RUQ mass in a child: ? Intussusception [Barium Enema
- Rx & Dx]
Legitimate Vanco. use :
â-Lactam resistant Staph. epidermidis
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Posted: Mon May 26, 2003 2:51 pm Post subject: Aster pg 70
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Aster's USMLE Step3 Notes
Vit. A toxicity can cause Hypercalcemia
Gatsric ulcers: located on lesser curvature
within 1cm of gastric antrum
Adrenal Mass > 4cm & High Hounsfiled Values:
high chance of being malignant
Most ensitive test for Cushing's:
24 hour urinary cortisol
(levels are subject to diurnal variation)
Bilroth II:
Afferent Loop Syndrome (Pain after meal ingeston) Mx: Bilroth I conversion, roux-en-y
gastrojejunostomy
Blind Loop syndrome (bacerial overgrowth, malabs.) Mx: antibiotics
â-Thalassemia major: HbF increased
â-Thalassemia trait: HbA2 increased
Risk of Postop DVT
#1 Elective Knee Arthroplasty
#2 Elective Hip Arthroplasty
3 Hip Repair
highest risk with ELECTIVE KNEE ARTHROPLASTY
Cocaine use assoc. MI:
combination of spasm and plaque rupture
(don't assume spasm is the cause, do angiography)
Pappenheimer's Bodies: Iron inclusions in RBCs
Rhabdomyolysis:
Hypocalcemia, Hyperkalemia, Hyperphosphatemia
Diverticulosis: #1 complication - BLEEDING
85% bleeds stop spontaneously
(#1 complication is not Diverticultis)
DIVERTICULITIS:
–Polymicrobial
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Posted: Mon May 26, 2003 2:52 pm Post subject: Aster pg 71
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Aster's USMLE Step3 Notes
–Broad spectrum antibiotics
–no barium enema / colonoscopy
h/o Malig. Hyperthermia with succinylcholine:
use NITROUS OXIDE in future anesthesia
Chronic Fatigue with normal physical exam: DEPRESSION INVENTORY -> Thyroid
studies
IE -> Mycotic Aneurysm -> Bleeding -> SAH
[embolization of bacteria to the brain)
IFN-â: decreases relapse frequency in MS
First Episode of DVT:
Heparinize -> Warfarin for 3-6m (INR 2.0-3.0)
Recurrent DVT:
Lifelong "Warfarin"
[if Warfarin is not tolerated : ENOXAPARIN]
Fever / Sore Throat / Atypical Lymphocytes
(without LN / Splenomegaly / MonoSpot) : CMV
Colles' #: splinting in NEUTRAL postion
(not in FLEXED position)
PSA levels in Prostatic Ca. correlate with lymphatic spread
Antibiotics in postpartum endometritis:
I/V Imipenem / Cilastatin
Vaginal Delivery in Breech
1. FRANK BREECH
2. Fetal Weight between 2000-3000g
3. Gynecoid Pelvis
Rx of Catatonia: Lorazepam
Incisions done for pre-existing infections and abscesses are considered INFECTED
WOUNDS
Severe Depression with Psychosis: Mx with ECT
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Posted: Mon May 26, 2003 2:52 pm Post subject: Aster pg 72
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Aster's USMLE Step3 Notes
Hypertensive Heart Disease: S4 Gallup (LVH)
Depo-provera: - associated with Irregular bleeding
(use conjugated estrogen x 7 days to control bleeding)
Peak CPK levels:
give idea about size of an infarct
(no prognostic value)
Nephrolithiasis with increased Creatinine:
IVP can not be done
(No I/V CONTRAST in the setting of renal dysfn.)
Renal and Bladder Ultrasound Scan, instead
HTN in Graves' disease: Rx with â-blockers
Anti-Ro: associated with neonatal Lupus
(resolves in 6 months) and Congenital Heart Block
Lupus anticoagulant
–anti-PL
–recrrent abortions
–thrombotic state (arterial + venous)
–"in vitro" increased PTT
(doesn't correct with mixing)
–Russel Viper Venom Time
Doxepin (a TCA) is useful in chronic urticaria
suspected ADHD: get psychometric tests
Misleading Low Sodium is caused by Hyperglycemia
Mx of acute mountain sickness: acetazolamide
Dx of Sarcoidosis:
–Biopsy
–Kveim test is obsolete
–ACE levels are elevated in 50% pts.
Rx of Brown Recluse Spider Bite: DAPSONE
Middle Ear Effusion persisting for 4-6 months following an adequate course of
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Posted: Mon May 26, 2003 2:53 pm Post subject: Aster pg 73
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Aster's USMLE Step3 Notes
antibiotics, with significant hearing loss (especially bilateral), is an indication for
myringotomy and insertion of tympanostomy tubes.
Chlamydial Ophthalmia:
Rx with SYSTEMIC ERYTHROMYCIN
(to prevent chlamydial pneumonia)
Appropriate Initial Test for suspected B12 def:
Serum B12 levels
(many patients have normal CBC and normal indices)
fruity breath odor: ketosis
prolonged latent phase of labor :
–therapeutic rest & sedation (usually morphine).
–No Oxytocin / No Amniotomy
DtaP contra-indications:
1.previous febrile reaction: fever > 105 F
2.h/o seizures
(F/H of seizures is not a contra-indication)
Rx of choice for SVC syndrome:
Radiation
First HiB vaccine @ 2 months age
Female > 40y with abnormal vaginal bleeding Endometrial Bx to r/o Endo. malig.
Atrial Flutteris not a serious arrhythmia, but cardioversion should be attempted in the
presence of CHF.
Atrial Flutter due to Digitalis toxicity:
PACEMAKER
Anorexia nervosa:
BUN increase
Low Platelet Count
Leukopenia with relative lymphocytosis
elevated serum carotene levels
Legionaire's disease:
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Posted: Mon May 26, 2003 2:54 pm Post subject: Aster pg 74
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Aster's USMLE Step3 Notes
Person-to-person spread has not been documented
Childhood obesity is not a predictor for adult obesity
long-term Rx of obesity in children : usually fails
Thoracic outlet syndrome:
appearance on numbness and paraesthesiae
with arm abducted to 90 degrees and externally rotated
(not defined by the disappearance of radial pulse)
Postmenopausal with stress incontinence:
Kegel exercizes, pessary, estrogen replacement
Retractile Testes:
–exaggerated cremasteric reflex
–temporary
–resolves in adolescence
–no increased risk of malignancy
Flail Chest: Intubation & Assisted ventilation
(Strapping of Chest may lead to hypoxia & atelectasis)
Vaginismus is involuntary contraction
Behcet's: cutaneous hypersensitivity
60-70% will develop a sterile pustule within 48 hours of any aseptic injection
epidydimitis -> check age of pt.
< 35: Chlamydia, Gonococcus
> 35: E.coli
Gold stadard for diagnosis of melanoma:
BIOPSY
Treatment of alcoholism in wife-batterers does not treat battering behavior
Pt. with hemoptysis and normal chest film:
Fibre-optic bronchoscopy
(PPD is not indicated)
F/U COPD progression with FEV1
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Posted: Mon May 26, 2003 2:55 pm Post subject: Aster pg 75
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Aster's USMLE Step3 Notes
Tick paralysis (neuro-toxin mediated): 10% mortality
prompt resolution if tick is identified and removed
Let children attend funerals, if they want to. They should be accompanied by adults who
can provide comfort and support
Hyperparathyroidism: inc. incidence of Pseudogout
NIACIN: can be associated with hepatotoxicity
rear-facing infant seats should be on the back seat.
< 12 y children: ride secured on car backseat
Headache onset with exertion, such as weight-lifting:
serios sign (look for CNS malformations & vascular malformations)
Minocycline: has anti-inflammatory action
(has been used in Rheumatoid Arthritis)
Gynecomastia in adolescence: Observation
Long standing Gynecomastia: SURGERY
HCM: EKG is abnormal (LVH, WPW, abnormal Q wves)
Ticlopidine: has been associated with neutropenia
Immediate gastric lavage is ot indicated in strychnine poisoning
Continuous gastric lavage: PCP overdose
Not all persons with anaphylaxis will have a repeat
reaction when exposed again to the agent. Repeat reactions are usually less severe.
Head, Neck, Face sutures:
leave in place for 3-5 days (rapid healing)
Eclampsia: MgSO4
(no role of anticonvulsants)
Clonidine withdrawl: Hypertensive Crisis
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Posted: Mon May 26, 2003 2:55 pm Post subject: Aster pg 76
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Aster's USMLE Step3 Notes
The woman's need for physical intimacy often increases during pregnancy.
Abstention from intercourse in the last month of normal pregnancy is not necessary
Valsalva maneuver decreases the venous return to the heart, thereby decreasing
cardiac output. This decreases murmurs due to AS, MR, PS, but increases the
murmur due to HCM
FOBT testing does not decrease the mortality from colorectal carcinoma
#1 symptom in vaulvar carcinoma: Pruritus
Of the anticonvulsant, VAPROATE has the least effect on hepatic enzymes and
therefore has the least impact on decreasing the efficacy of OCP's
Gilbert's syndrome: lower levels of unconjugated bilirubin cf. Crigler Najjar (6-45 mg/dL)
Menopause: Serum FSH increased
Estradiol decreases, and Estone becomes predominant estrogen.
Infiltration of local anesthetic agents (less pain):
–warm solution
–small needles
–slow infiltration
–addition of bicarbonate to the mixure
Mg-containing antacids in CRF:
can cause magnesium toxicity
Postherpetic neuralgia: higher incidence in older pts.
ANA titre < 1:160 is common in healthy older people
Orthostatic hypotension:
Drop in Systolic > 20 mmHg
Drop in Diastolic > 10 mmHg
Mx: discontinue any drugs that might be responsible
-> arise slowly -> elastic stockings -> Fludrocortisone
B pertussis is being recognized as a cause of
persistent cough in adults. (associated with dysnea, tingling sensation in throat)
d/o/c for Giardiasis in children: Furazolidone
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Posted: Mon May 26, 2003 2:56 pm Post subject: Aster pg 77
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Aster's USMLE Step3 Notes
Tinea capitis: Oral Griseofulvin
poor response to topical medication
Males with impotence, decreased libido & decreased testosterone: order a prolactin
level
(r/o pituitary adenoma)
Pre-term infants: normal response to immunization
(although they have relative immunodeficiency)
Drug indiced LE: anti-histone antibodies
[ANA (+), Anti-dsDNA absent]
–hydralazine, isoniazid, procainamide, penicillamine
–Mx: discontinue medication + short-course of glucocorticoids
–disease lasts < 6 months
–ANA may remain (+)
–most lupus inducing drugs can be safely used in SLE, if no alternative exists
HCM: sudden death in athletes
Dx: Echo Rx: â-BLOCKERS
Valsalva maneuver increases murmur
ITP: low platelet, BM aspiration shows numerous megakaryocytes
Risk of suicide: Female Physicians > general females
Physicians' risk of suicide
Psychiatrists > Ophthalmologist > Anesthesiologist
Anaphylaxis: Epinephrine
Juvenile Rheumatoid Arthritis:
very few patients are left with disabilty / deformity. At least 50% remit fully and majority
regain normal function
Urticaria > 48 h :
Skin Biopsy to r/o Urticarial Vasculitis
Mobitz Type II Heart Block: Mx is PACEMAKER
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Old 11-20-2004, 01:18 PM
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Aster's USMLE Step3 Notes
Posted: Mon May 26, 2003 2:57 pm Post subject: Aster pg 78
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Aster's USMLE Step3 Notes
Stage IA Hodgkin's: Radiotherapy alone is effective
Total Hip replaement:
–immediate relief
–perioperative anticoagulation
–successful (no need for revision in 90%)
–bone resorption is a major concern for long-term stability of implant
Pressure Ulcers:
Stage I: Nonblanching Erythema
Stage II: Broken Skin with partial thickness skin loss
Stage III: Full tickness skin loss (extension into subcutaneous fat)
Stage IV: Extension into Muscle or Bone
"kennel cough" is produced by a canine Bordetella
Risk factor for domestic abuse: female gender
Trochanteric bursitis
–presents with a deep, dull, aching pain
–burning & tingling in lateral upper thigh
–worse with activity
–excacerbated by sitting cross-legged with affected leg
The mortality rate for pneumococcal pneumonia is same for the past 50 years
SKIN SWELLING with Bee sting: local reaction
[not anaphylaxis]
Rx of Restless Leg Syndrome: Clonazepam
Alendronate: Pill-induced esophagitis
TCA withdrawl symptoms (cholinergic symptoms) : best managed with Benzotropine
(Anti-Ach)
Aspartame is c.i. in children with PKU
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Posted: Mon May 26, 2003 2:57 pm Post subject: Aster pg 79
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Aster's USMLE Step3 Notes
Diaphragm & spermicidal jelly:
insert upto 2 hrs before intercourse
and leave in place for 6 hrs after intercourse
(for repeated intercourse, re-apply jelly)
Asthmatics who require â2-agonists > once/day; can be prescribed inhaled
glucocorticoids
Psoriasis in infancy: begins n diaper area (the area of greatest trauma)
Labia minora adhesions:
–not present @ birth
–acquired condition
–no urinary retention
–not assoc. with other anomalies
–surgical correction has a 100% recurrence rate
–estrogen cream can lyse the adhesions
Carbidopa/Levodopa do not alter the progression of Parkinson's disease
Chronic Choleystitis with Cholelithiasis is frequently non-visualized on ultrasound.
Umbilical hernia in a child < 6m
Mx: Conservative [Strapping is ineffective]
(usually disappear by 1 year of age)
Surgery for strangulated hernia; persisting beyond 4y
Increased Postop Cardiac Death
–S3 Gallop
–h/o MI in the past 6 months
–Frequent PVCs
–Aortic Stenosis
Supression of lactation: breast inder & cold pack
[Bromocriptine is not approved for this purpose]
Cardiac Pacemaker: does not warrant IE prophylaxis
Pubertal development in an adolescent girl:
Thelarche, Pubic Hair, Growth spurt, Menarche
(Growth spurt precedes Menarche)
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Posted: Mon May 26, 2003 2:58 pm Post subject: Aster pg 80
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Aster's USMLE Step3 Notes
Most sensitive and specific means of diagnosing appendicitis is history and physical
exam.
(not CT or U/S)
In stroke, overzealous antihypertensive medications can reduce cerebral perfusion and
increase tissue damage.
Scabies in young children:
Permethrin
[Lindane not approved]
Wheezing in children may also be due to GERD
A single sexual encounter with a person with genital warts carries a 60% chance of
transmission. Transmission occurs in asymptomatic state too.
Hydrocephalic children:
–increased developmental disabilities
–lower IQ
–learning deficits
–defective verbal abilities
–memory and visual problems
Chlamydial infections:
Azithromycine & Doxycycline have equal efficacy
#1 cause of hematemesis in healthy newborn:
comiting of swallowed maternal blood
Clinical privileges to physicians are granted by the GOVERNING BODY of the hospital
New onset LBBB may be an indication for thrombolysis even in the absence of
characteristic ST elevation of MI
Dexfenfluramine: 1º Pulmonary Hypertension
Transdermal NTG Patches: Rapid Tolerance
Oropharyngeal dysphagia in elderly:
? early Parkinson's
Paget's disease of bone:
–Head Enlargement
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Posted: Mon May 26, 2003 4:01 pm Post subject: Aster pg 81
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Aster's USMLE Step3 Notes
–Deafness
–Nerve compression
–increased urinary hydroxyproline
–increased alkaline phosphatase
HIDA scan: Cholecystitis (+)
–nonvisualization of the GB
–visualization of CBD & Bowel
Leading cause fo mental retardation in US:
Fetal Alcohol Syndrome
Rotavirus G/E: decreased incidence in breast fed infants. None of the antibodies that
develop after the first attack are protective
Grade 1 Vesico ureteral reflux:
prophylactic antibiotics and double voiding of urine
Sodium Nitroprusside infusion:
may increase Thiocyanate levels to toxic range (delirium, tinnitus, blurred vision)
Allergic bronchopulmonary aspergillosis is treated by corticosteroids (not
ANTIFUNGALS)
Childhood autism:
Echolalia, minimal eye contact, repetitive behavior
serum digoxin levels elevation can be seen in pts. treated with oral verapamil
Recurrent Zoster is rare
Cocaine > Coronary Spasm
(free basing can lead to loss of eyebrows/eyelashes)
Measles vaccine significantly reduces the chances of developing SSPE
Influenza A is usually sensitive to Amantidine
(resistance occasionally seen in institutionalized pts.)
Synovial Fluid in OA : High Viscosity
Children with diarrhea who are not dehydrated should be give age appropriate diet
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Posted: Mon May 26, 2003 4:01 pm Post subject: Aster pg 82
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Aster's USMLE Step3 Notes
Loperamide: contra-indicated in children
Secondary Amenorrhea: give Progestin Challenge
Rapidly Progressive Periodonitis (with good dental hygiene) might be suggestive of
HIV / AIDS
Hyperosmolar nonketotic coma:
–require less insuin for correction (cf. DKA)
–Fluid deficit is larger (cf. DKA) (10 L)
–patients are older
–can also occur in Type 1 DM
The hypochondriac believes that his fears about disease are totally realistic. He also
believes that physicians are not acting in his best interests by disputing the reality of
these fears.
Hypochondriacs:
poor response to antidepressants
Old age:
Vital Capacity decreases
Functional Residual Capacity increases
Arterial Oxygen Tension slowly declines with age
Pasturella multocida:
Rx Amox-Clav
(Pn allergy: Doxycycline) [NOT ERYTHROMYCIN]
Place PPD on all individuals being admitted to a nursing home. Persons with doubtful
reactions should be tested a second time within 1-2 weeks (boosted reaction). This
second reading should be taken as the baseline reading for that person.
Tennis Elbow : Lateral Epicondylitis
(usually acquired occupationally)
Obesity lowers aminoglycoside volume of distribution necessitating decrease in
dosage
Primary indication of joint replacement in OA:
Severe Pain
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Posted: Mon May 26, 2003 4:02 pm Post subject: Aster pg 83
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Aster's USMLE Step3 Notes
Postcoital test : best done in midcycle
Adhesive bands are now the most common cause of intestinal obstruction for all age
groups
(strangulated hernias are the m/c cause in children)
Rx for ANUG (acute necrotizing ulcerative gingivitis) PENICILLIN
Vasoldilators of choice for CHF
ACEIs
Use of TCAs in patients with glaucoma can precipitate acute angle-closure attacks (antcholinergic
properties)
The only absolute contra-indication to breast feeding is
GALACTOSEMIA
Major abdominal trauma in 3rd trimester pregnancy:
evaluate for placental abruption & preterm labor
[electronic fetal monitoring: obtain reactive NST]
Transient cortical blindness due to mild head traums usually recovers (benign outcome)
Pneumococcal vaccine: not before 2 years of age
#1 cause of microscopic hematuria in elderly is BPH
Polychlorinated Biphenyls: skin rash called Chloracne
Ludwig's angina: infection of the deep fascial space of the submandibular space (early
airway compromise)
Mx: Intravenous steroid cover
Wilson's disease confirmed by inability to incorp. a copper isotope into Ceruloplasmin
Patients with procaine allergy usually tolerate Lidocaine (amide group) well
Always inject insulin in skin of non-exercized areas (to prevent exercize-induced
hypoglycemia). If the lefg is used as injection site, insulin absorption will be enhanced
with running leading to hypoglycemia.
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Posted: Mon May 26, 2003 4:02 pm Post subject: Aster pg 84
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Aster's USMLE Step3 Notes
Celecoxib: not to be used in patients with SULFA allergy
Passengers with stable medical conditions requiring low-flow oxygen cannot bring their
own oxygen on aircrafts according to Federal Air Regulations concerning hazardous
cargo. Most air carriers will provide O2 for a fee
Do not fly within 3 weeks of a MI
No air travel with term pregnancy
OCD
–SSRI
–Response prevention & in vitro exposure
Don't give OPV to a child whose sibling is immunodeficient
Post MI Risk Stratification is done with an Exercize Stress Test (for patients who can
exercize). For patients who can not exercize, a Pharmacological stress testing or
Dobutamie Echo is indicated (both are less sensitive than Exercize Stress Testing)
Continue ASPIRIN in the post-MI period
Antiplatelet agent Post-stent placement:
Clopidogrel (ADP receptor inhibitor)
Abciximab (anti-IIb/IIIa)
(decrease restenosis rates)
The choice of agents in asthma therapy is determined by frequency of asthma
symptoms
The presentation & management of acute cholecystitis in pregnant patients is the same
as in non-pregnant population (Lap Cholecystectomy). Fetal otcome is the best in 2nd
trimester
Hyperactive children: hypoperfusion in frontal lobes
NPH: order CT scan head to r/o ICSOL
(confirm NPH by documentation of improvement in symptoms with serial lumber
punctures)
Severe pre-eclampsia:
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Posted: Mon May 26, 2003 4:03 pm Post subject: Aster pg 85
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Aster's USMLE Step3 Notes
–delivery @ term
–MgSO4 for seizure prophylaxis
–antihypertensives for BP control
–MgSO4 is not an antihypertensive.
–Control of BP alone does not obviate the need for seizure prophylaxis
Suspected PCP in AIDS: Obtain a Chest X-***
Migraine prophylaxis: â-blockers
Migraine treatment: Sumatriptan
Somatization disorders: 1st step in Mx
avoid un-necessary Ix & medical/surgical treatment
Community acquired pneumonia: S pneumoniae
Rx: Macrolide (Clarithromycin)
Patient presents to the office with unstable angina:
1st step: Chew & Swallow Aspirin
Vaginal douching > 3-4 times / month:
associated with alteration of vaginal flora and increased incidence of PID
Prolonged survival in CHF: ACEI's
A fecal gram stain is always positive for bacteria and is not indicative of any pathology.
Inflammatory Bowel Disease: Fecal Leukocytes(+)
Gold standard for Dx of IBD: COLONOSCOPY
Critical Aortic Stenosis: Valve Repair Surgery
(Valvuloplasty in high risk due to other co-morbidity)
Spinal metastasis: Emergent Radiotherapy
COPD patient who still smokes:
#1 step is smoking cessation
(immediate effect on declining lung function)
COPD patients should receive annual influenza vaccine (not HiB vaccine, it is only
given to children)
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Posted: Mon May 26, 2003 4:03 pm Post subject: Aster pg 86
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Aster's USMLE Step3 Notes
Dx of Adenomyosis: MRI (most accurate)
(U/S has lower sensitivity and specificity)
Abnormal Vaginal Bleeding:
Periodic, abnormal flow: Anatomic cause
Irregularly Irregular: Endocrine cause
Routine screening of asymptomatic population for dyslipidemia:
NONFASTING SPOT CHOLESTEROL
Screening of population with CAD/risk factors:
FASTING LIPID PROFILE
(non fasting random spot cholesterol not indicated)
Patient must have quite smoking 15 years ago
for it to not count as a risk factor for CAD
Digoxin with or without a nodal blocking agent (beta-blocker) is effective in
achieving rate control in Atrial Fibrillation
Chronic A.Fib.:
associated with enlarged Left atrium
Medical emergency in a physician's office:
1st step is to initiate call to “911”
beta-blockers improve outcome in patients at cardiac risk undergoing noncardiaovascular
surgery
Mx of HTN in patients with migraine: â-blockers
Renal Failure: is associated with calcium wasting & secondary
hyperparathyroidism (Calcium supplementation is beneficial)
Patient with syphilis & penicillin allergy:
Do a penicillin skin test to confirm & perform desensitization if necessary
uncomplicated UTI:
–perform urinalysis
–Oral TMP-SMX (3 days)
–no need for urine cultures
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Posted: Mon May 26, 2003 4:04 pm Post subject: Aster pg 87
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Aster's USMLE Step3 Notes
The occurrence of PVCs post-MI is associated with increased mortality &
morbidity. Treatment of asymptomatic PVC's with anti-arrhythmics is not
indicated. (Such treatment is itself associated with increased mortality)
No role of prophylactic anti-arrhythmics post-MI
Initiate Calcium supplementation even in cases of prolonged secondary
amenorrhea
Exercize-induced amenorrhea
–low adipose tissue
–estrogen biosynthesis shifts to 2-hydroxylation with increased synthesis of catechol
estrogens
–catechol estrogens compete with catecholamines for COMT
–results in inreased dopamine
–dopamine decreases GnRH release
–results in secondary amenorrhea
–whatever the age, OCPs (for HRT) & calcium supplementation are required to prevent
bone loss
Mx of psychotic depression: ECT
Post-void urinary volume estimation:
Straight Urinary Catheterization
(U/S is inaccurate in estimating bladder volumes)
All GDM patients should be tested @ 6w post-partum with 2-hr (75g Glucose) Oral
GTT
GDM is a risk for DM unrelated to pregnancy (regardless of glycemic control in
GDM)
Klebsiella penumonia
–necrotizing pnemonia
–hospitalized patients / aspiration / post-stroke & alcoholics
–currant-jelly sputum (bloody)
Staph aureus: causes cavitatory pneumonia
(associated with rapidly progressive effusions & empyema)
Colon Cancer screening:
–FOBT annually
–Colonoscopy q10y
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Posted: Mon May 26, 2003 4:05 pm Post subject: Aster pg 88
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Aster's USMLE Step3 Notes
–Sigmoidoscopy q5y
PSA estimation is not recommended for Prostatic cancer screening (if at all one test has
to be done, it should be Digital Rectal Examination)
Chronic Uterine prolapse:
–first fit a pessary
–prescribe estrogen cream
–later proceed to surgery (surgical failure rate is high when performed in the presence
of dry atrophic mucosa)
In any patient with pain of cardiac origin: EKG
(to differentiate between Ischemia & Infarction)
Inhaled corticosteroids:
long-term stabilization of severe asthma
(beta-agonists provide only symptomatic relief)
Hypotensive response to NTG drip in patients with inferior ischemia: Right Ventricular
Failure
(Mx: Stop NTG, Start I/V crystalloids)
suspected anemia: 1st Ix – CBC
suspected Fe deficiency anemia: Serum Ferritin levels
Normocytic anemia: 1st Ix – Reticulocyte count
h/o GI bleeds with DVT: not a candidate for anticoagulation
Alcohol induced dilated cardiomyopathy:
#1 step – stop alchol intake to halt progression
Polycythemia vera: increased risk of stroke
Valsalva maneuvre: decreases pre-load
Jedrassik maneuvre: decreases after-load
Valsalva decreases HCM murmur,
Jedrassik increases HCM murmur
Ankle – Brachial Index:
< 0.5 suggests severe ischemia
(surgical revascularization required)
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Posted: Mon May 26, 2003 4:05 pm Post subject: Aster pg 89
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Aster's USMLE Step3 Notes
MVP without MR: no IE prophylaxis required
[absence of MR to be documented by Echo]
Pilonidal Cyst: infection of hair follicles in sacrococcygeal area. Mx: removal of hair /
I&D
Elderly with Knee “locking”: Medial Meniscal Tear
“pop” in he knee: ACL tear
pain in lateral knee, athlete: Iliotibial Band Syndrome
COPD @ any stage, smoking cessation in beneficial
Painless Testicular Enlargement
–? Malignancy [Embryonal/Seminoma/Lymphoma]
–Ultrasound, no Biopsy
–spreads to retroperitoneal nodes, if inguinal nodes (+), suspect scrotal invasion
–Sx: Inguinal approach, not Scrotal (Orchiectomy)
Evaluation of lung malignancy: CECT (IV contrast)
Dermatomyositis: search for occult malignancy
Most testicular varicoceles are on the left side
Neomycine allergy: 5% of population (Treat with Steroids). It is a Type IV
hypersensitivity reaction
SCC Lip Risk factor: Smoking > Sunlight exposure
Hydrocele: typically idiopathic (No Rx required).
Persistent hydrocele: Refer to Urology for Sx
Tuberous Sclerosis: Skull X-*** to look for intracranial calcifications
AFP increase: NSGCT
b-hCG increase: Seminoma & NSGCT
Li-induced hypothyroidism: Mx – levothyroxine
(not discontinuation of Lithium)
Latest recommendation advise Influenza vaccination for >50y instead of >65y
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Posted: Mon May 26, 2003 4:06 pm Post subject: Aster pg 90
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Aster's USMLE Step3 Notes
suspected Pseudotumor cerebri:
LP (inc. CSF pressure)
complex partial seizure:
aura, behavioral arrest, automatisms
Myesthenia gravis: CT Chest to r/o Thymoma
Propranolol is associated with depression
Fluoxetine takes 6-8 weeks to act !
Asplenia: PneumoVax / HiB / Influenza vaccine
Headache excacerbated by position & exertion:
increased ICT (? mass lesion)
Mitral Regurgitation
1.Transthoracic Echocardiography
2.If quantification reqd.: TEE
3.Gold Standard for any valvular disease:
Cardiac Catheterization
Suspected Anemia: next step – CBC
MICROCYTIC ANEMIA, to Dx Fe.-def anemia:
SERUM FERRITIN (Gold. Std.: Bone Marrow Bx)
NORMOCYTIC ANEMIA, next step:
RETICULOCYTE COUNT
GI side effects are common with oral FeSO4. They are not an indication for
discontinuing therapy. Always assess response (% Retics) after Iron Therapy.
OCPs can prevent anemia, they do not treat established Iron deficiency anemia. (Rx:
Iron)
ABI < 0.5: s/o significant PVD (Sx revascularization)
Steroid Rx in suspected GCA: start without waiting for ESR / Temporal Artery Bx results
Excessive Cow's Milk Intake: Fe. Def. Anemia
Pericarditis: Diffuse ST elevation
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Posted: Mon May 26, 2003 4:06 pm Post subject: Aster pg 91
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Aster's USMLE Step3 Notes
Factor V Leyden: Lifelong Warfarin Prophylaxis
beta-blockers in stable CHF: decrease mortality
DVT with h/o UGIH: no prophylaxis (?IVC Filter)
Critical Aortic Stenosis: Mx – Valve Repair (Valvulopalsty only for high risk cases)
Esophageal Varices: BANDING
TIPS is for portal decompression before Transplant. Not used as a primary procedure
only for Eso. Varices
Chronic Malabsorption in Pancreatitis: Mx – non-enteric coated Pancreatic enzyme with
H2 blockers
Child < 2 years with symp. Inguinal Hernia:
Contralateral Exploration indicated
GERD:
–non-pharmacological measures
–emperical pharmacological measures (H2 / PPI)
–if fail, do Esophageal 24 hr. pH monitoring
probe kept 5 cm proximal to LES
pH<4 for >5 minutes or >9% of total time
–followed by UGIE & Surgical Mx if needed
Irritable Bowel Syndrome is a Dx of exclusion
12 weeks of GI symp. In preceding 12 months
Gilbert's: jaundice may only be noticed in the times of stress / infection or fasting
(Unconj.)
Anal Fissure: Steroid Cream & Sitz Bath
Stress is a trigger of IBS, not cause
Biliary colic: RUQ pain following meals
Cholecystitis: RUQ Pain / Murphy's / Fever / Leuko.
Cholangitis: RUQ Pain / Fever / Jaundice
False (+) Guaiac stools: meats & vegetables containing peroxidases (Inorganic Iron
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Posted: Mon May 26, 2003 4:07 pm Post subject: Aster pg 92
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Aster's USMLE Step3 Notes
does NOT cause False (+))
F/H Duodenal Ulcers with Hypercalcemia:
MEN I
HNPCC: Mx – subtotal colectomy with TAHBSO
Child with Constipation: Mx prune / pear juice (sorbitol)
Rectum devoid of stool: Hirschsprung's
Rectum full of hard stool: Fecal Impaction
Graves': Cigarette smoking increases ophthalmic involvement (advise patients to quit
smoking)
Smoking Cessation:
1.success usually takes 5-6 attempts
2.associated with weight gain
3.counsel patients at each visit
4.pharmacotherapy should be offered to all
5.relapse rates decrease after 6m of abstinence
suspected Phaeo: first step is alpha-blockade with phenoxybenzamine (before Bx /
FNAC)
#1 side effect of radioactive Iodine: hypothyroidism
Glitazones – asociated with liver toxicity (LFT's)
Hypothyroidism with macrocytosis & hyperlipidemia:
1st step is THYROID hormone replacement
(might correct macrocytic anemia & decrease lipid levels)
Infection in suppressed adrenal axis due to chronic use of exogenous steroids
(refractory hypotension) :
administer stress dose of i/v steroids
Cholesteatoma: CT scan of temporal bone (Mx: Sx)
CN III palsy with pupillary involvement: MRI
Child attending day care with viral conjunctivitis:
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Old 11-20-2004, 01:20 PM
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Aster's USMLE Step3 Notes
Posted: Mon May 26, 2003 4:07 pm Post subject: Aster pg 93
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Aster's USMLE Step3 Notes
remove from daycare till symptoms subside
Fifth Disease: child is infectious before onset of rash
Mx of epistaxis: pressure, no need to tilt head upwards
Alk. Phosphatase is norally increased in pregnancy
Med. Mx of Ectopic: MTX
(b-hCG sample on Day 4 & 7, 15% decrease in level)
LGSIL = CIN I (most lesions resolve spontaneously)
Newborns can lose upto 10% of their weight in 1st wk
Breast – Cystic Mass
clear : discard
bloody : send for cytology
Delayed age at 1st preg: increased risk of Ca. Breast
Polycystic Ovaries: 1st step: OCP's
Churg-Strauss: (+) pANCA
#1 extra-renal manifestation of adult PCKD:
Colonic Diverticular Disease
(not Intracranial Berry Aneurysms: seen in 15%)
Nephrotic Syndrome in adult with recurrent hematuria:
IgA nephropathy
HSP: self limiting. Do urinanalysis (r/o kidney involv.)
Cisplatin: nephrotoxic
Never prescribe prescription drugs over the phone, especially if the patient is “new”
(call for evaluation)
F/H (+) of HTN: ? Adult PCKD
Biopsy has no role for Diagnosis of RCC. If suspected, refer for Sx management (Bx
only if e/o metastasis present)
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Posted: Mon May 26, 2003 4:08 pm Post subject: Aster pg 94
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Aster's USMLE Step3 Notes
Nephrotic Syndrome with HTN: start ACEI's
(no role of high-protein diet in nephrotic syndrome)
DEXA:
T-score: cf. Normal healthy young population
Z-score: cf. Age matched conrols
Osteoporosis is defined by the T-score
Rx (HRT + Bisphosphonates) indicated if:
–T < 2.5 or
–T < 1.5 with presence of risk factors
Smallpox Rx: Cidofovir
Smoking cessation: Mortality reduced to ½ in first year and smoking caeses to be a risk
factor 15 years after quitting
Infants: always rear facing on backseat
< 12y: always on rear seat
Fertility returns as early as 1-2 weeks after cessation of OCP use.
Tinea capitis: KOH prep (Ix)
not Wood's lamp, all species don't show fluorescence
Postherpectic neuralgia: Mx – TCA
(Acyclovir decreases PHN when given prophylactically)
Toxic megacolon in U/C:
–high mortality rate
–Ix: AXR
–Mx: NPO/NG/Rectal Tube/Antibiotics
–Sx if doesn't resolve in 2-5 days
Peptic Ulcer disease with Gout: acute Rx – colchicine
(NSAIDs can not be used)
Necrobiosis Lipoidal Diabeticorum: DM
plaques with depressed atrophy on anterolateral leg
Parkinson's patients hould be referred to neurologist
Anosmia: r/o neoplasm/#/sinusitis (CT/MRI)
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Posted: Mon May 26, 2003 4:08 pm Post subject: Aster pg 95
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Aster's USMLE Step3 Notes
Endometriosis:
–abdominal pain
–dyspareunia
–painful defecation
–dysuria
–GI upset with periods
–Ix: Laparoscopy
Influenza vaccine is indicated in healthcare workers @ any age
alpha-1-AT def.: avoid smoking & alcohol
(to prevent emphysema & cirrhosis)
PUPPP:
Pruritic Urticarial Papules & Plaques of Pregnancy
–no umbilical involvement
–Mx: conservative
Impetigo herpetiformes:
rare form of pustular psoriasis
–acute onset
–febrile
–erythematous plaques surrounded by sterile pustules
Herpes Gestationis:
–autoimmune
–2nd or 3rd trimester onset
–involves umbilicus
–recurs in subsequent pregnancies
Routine rectal examination does not lead to elevation of PSA (levels can be done on the
same visit as DRE)
Uncomplicated varicella in preg., Conservative Mx
Hematuria without UTI: next step – contrast study
LiCO3 can excacerbate psoriasis
TT in past 5y: No Rx reqd.
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Posted: Mon May 26, 2003 4:09 pm Post subject: Aster pg 96
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Aster's USMLE Step3 Notes
TT in past 5-10y:
prone wound: T toxoid
clean wound: No Rx
TT > 10y ago
prone wound: T toxoid
clean wound: No Rx
Post-PE: maintain INR between 2.0 & 3.0
If > 3.0 (no e/o ICH):
admit / give Vit. K (heparinize if INR falls to 2.0)
If e/o ICH: give FFP to replenish clotting factors
Thioridazine: prolongation of QT interval
PPD(+): obtain CXR to r/o active infection before starting INH prophylaxis
Chronic Steroid Use:
–osteopenia
–Avascular Necrosis of Femoral Head (not due to osteopenia) avoid trauma, slow taper
of steroids
Relapsing Polychondritis
–Ear (Painful external ear)
–Nose
–Larngeal Inflammation (focal narrowing) with airway obstruction
–can be associated with aortic aneurysms
–Mx: STEROIDS
Avascular Necrosis of Scaphoid: Sx Pinning
(X-Ray: sclerosis)
#1 cause of U/L vocal cord paralysis: Lung Ca.
Prostatic Mets.: respond to andrigen deprivation for the first 2-3 years and then
become resistant
>6m with exclusive b.f. : Iron Supple.
Breast Feeding (Hormonal Contra.): Progestin-only
minimal effect on milk quality & quantity
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Posted: Mon May 26, 2003 4:09 pm Post subject: Aster pg 97
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Aster's USMLE Step3 Notes
Uterus & Cx reach normal size:
6 wks post-partum (IUCD & Diaphragm can be used)
If one FBS > 126, send another sample (Dx of DM)
MMR immunization is assoc. with simple febrile reaction. Can be associated with
seizures too.
Gingko biloba used with warfarin:
severe bleeding tendency
Give MMR to children with egg allergy (contains cross-reacting egg protein but in
very small quantity)
Varicella vaccine @ 12 months
suspected Giardiasis: send stool for ova/parasite before starting treatment
Shell fish intake: associated with Hep. A
Rx of Clostridial infection: Penicillin & Clindamycin
Neonatal Sepsis: Ampicillin + Cefotaxime
Meningococcal disease with persistent hypotension: Give I/V hydrocortisone
(Waterhouse-*********son)
SBP prophylaxis: Levofloxacin
Acute post-infectious cerebellar ataxia:
–ataxia / nystagmus
–post varicella infection (1m later)
–acute onset, resolves
–Mx: conservative
Pulmonary Coccidiomycosis:
Pap smear of fresh expectorate is diagostic
Meningococcal prophylaxis:
Rifampin/Ceftriaxone/Ciprofloxacin
Immunosuppressed: increased risk of fungal sinusitis
(high mortality rate, intracranial compli., Ampho-B)
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Posted: Mon May 26, 2003 4:10 pm Post subject: Aster pg 98
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Aster's USMLE Step3 Notes
After toilet, wipe front to back (decreases UTI inci.)
Candida Diaper Rash: Topical Nystatin
Primary Irritant Dermatitis: Zinc Oxide
Rx of viral pericarditis: NSAIDs
Rotavirus vaccine is no longer FDA approved (due to incidence of intussusception in
recipients)
Ant-HCV is (+) 18 weeks after infection
Newborn with (+) TB contact should be given
INH prophylaxis for 3 months irrespective of CXR/PPD status.
If at 3 months PPD(+), continue for 6 more months (else stop INH)
Pruritus ani: E.vermicularis (Mebendazole)
Mandatory seat belt laws decrease MVA mortality
Smoking cessation counseling should be provided to all patients regardless of age,
duration, previous attemps. (decreases cardiovascular mortality)
HSV transmission may not be prevented by condoms: skin-to-skin transmission occurs
too.
G(-) diplococci in Otitis: Moraxella
(usually Penicillin resistant, use penicillinase resistant antibiotics)
MMR is not contra-indicated in AIDS
Dog Bite infection
Rx with Amox-clav for puncture wounds or bites on hand (for non-infected wounds: local
care)
Home air humidifiers favor growth of house dust mite
Post GA Sx hoarseness of voice:
evaluate by ENT
Mx aspiration pneumonia:
Clindamycin (anaerobic cover)
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Posted: Mon May 26, 2003 4:11 pm Post subject: Aster pg 99
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Aster's USMLE Step3 Notes
Breastfeeding mother with Trichomoniasis:
Give MNZ one dose stat, discard milk for 24 hours
Air Travel: decreased cabin pressure
–decreased pO2 can cause hypoxemia, CAD patients have increased risk of MI
–decreased pressure leads to expansion of gases. (problematic for patients with
volvulus, GI surgery, recent intestinal obstruction)
Female patients with CF may be infertile (plugging of fallopian tubes)
Inpatient Rx for community acquired pneumonia:
Malignancy, AIDS, cardiopulmonary/renal/liver disease
PSA is not present in ejaculate. Butejaculation can increase PSA levels transiently for
48 hours
Hemoptysis workup:
–Chest X-***
–Bronchoscopy
–HRCT
Chlamydial/Gono. Epidydimitis can be treated with a 10 day course of Ofloxacin
PSA > 4.0ng/mL: required prostatic biopsy
(esp. with F/H prostatic Ca.; 30% risk of Prostatic Ca. When PSA levels are >
4.0ng/mL). But no evidence that screening with PSA is beneficial
suspected esophageal perf.:
esophagoscopy with water soluble contrast
Anabolic Steroids:
Acne/Testicular Atrophy/Liver Dyfn./Depression
IV contrast is contra-indicated in renal dysfn.
Contrast nephropathy can be prevented by prior administration of N-acetylcysteine
Dx of Sarcoidosis: Skin / Transbronchial Bx
[Kveim is obsolete, Ca/ACE levels unreliable]
Postop Sensory loss: EMG (Ix)
Physiotherapy has role in motor weakness only
Occupational Vitiligo: affects persons who work in rubber clothes, rubber gloves or
handle phenolic or antioxidant chemicals
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Posted: Mon May 26, 2003 4:11 pm Post subject: Aster pg 100
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Aster's USMLE Step3 Notes
Seborrheic Keratosis: Stuck-on appearance
100's of Seborrheic keratoses (Leser-Trelat sign)
search for internal malignancy
BZD in OLD patients: Oxazepam (hepatic excretion)
BZD in Liver Disease: Lorazepam (renal excretion)
Severe pain in OA is indication for joint replacement
Hyperpigmented lesions with velvety appearance on nape & axillae: Acanthosis
nigricans
[associated with DM, obesity, Cushing's]
Nursemaid's elbow: Mx – supination of forearm with elbow flexed (No cast
necessary)
Acne
Blackheads: open comedones
Whiteheads: closed comedones
Supraclavicular node: BIOPSY
Axillary node in female: Mammography -> Bx
3-10% of patients with spina bifida are hypersensitive to latex (also to foods like
banana, chestnut, avocado, kiwi): SPINA BIFIDA – LATEX ALLERGY
Osler Weber Rendu: epistaxis, GI bleed
(lesions on lips/nose/tongue/palatepalm/sole)
(chronic blood loss anemia)
Chronic plaque psoriasis: Scale Bx
Mx of autoimmune vitiligo: Steroids+Phototherapy
Time released oxycodone: can be abused by drug-seekers (snorting or injecting
crushed pill)
prevention of recurrent erythema multiforme minor:
ACYCLOVIR
Bullae / Papules on Hand with Naproxen intake:
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Posted: Mon May 26, 2003 4:12 pm Post subject: Aster pg 101
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Aster's USMLE Step3 Notes
r/o Porphyria cutanea tarda / pseudo-porphyria
(order urine porphyrin & hepatic panel)
Kyphosis with thoracic vertebrae wedging:
Scheurmann's Kyphosis
Tracheal deviation with impinging neck mass:
consult thoracic surgery for securing airway
Agitation in Delirium: d/o/c low dose Haloperidol
When giving i/v high-dose Haloperidol, add Benzotropine to prevent Parkinson's
symptoms
Benzotropine is c.i. In Malignant Neurolept Syndrome
(anticholinergic, leads to worsening of hyperthermia)
If a child is to be given long-term salicylates, prior Influenza vaccination is
recommended
(to prevent Reye's syndrome)
Post-MI: chest pain (aggravated by supine posture, relieved by sitting and leaning
forward): Dressler's
(Pericarditis)
Emergent Pericardial Drainage: V5 EKG guided
Postpartum psychosis: increased risk of infanticide
Pt. with A.Fib.:
require anticoagulation before cardioversion
(if anticoag. c.i.: TEE to r/o mural thrombus)
AIDS: primary CNS lymphoma
CSF EBV PCR estimation is highll sensitive & specific
If patient with altered sensorium has no DPAHC:
do not use relatives for consent
Post-SAH deterioration: mediated by vasospasm
(prevent by NIMODIPINE)
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Posted: Mon May 26, 2003 4:12 pm Post subject: Aster pg 102
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Aster's USMLE Step3 Notes
diffuse osteoporosis despite HRT / inc. infections
??? Myeloma
MVA with Quadriplegia with h/o recent Sx:
DVT prophylaxis required but anticoag. c.i.
(use IVC Filter)
Post-MI:
absolute bedrest required only for 12 hours.
Patients can begin graded activity after 12 hours.
Submaximal EST @ discharge
Maximal EST @ 2-4 weeks
Sexual activity after 2-4 weeks
#1 complication of vascular Sx: MI
No Verapamil / Diltiazem in WPW gluteal. SVT
(sync. Cardioversion)
tPA use in stroke: monitor neuro. Q1h
(high risk of intracranial h'age)
suspected Conn's in 2º HTN: 1st step – CT abdo.
(not Renal Vein Renin Levels), CT yields more info.
Definitive Mx of Hepatorenal Synd.: Liver Transplant
Diverticulitis with Pneumaturia: Mx – Sx
(Colovesical Fistula)
<50y Diverticulitis: Sx after 1st episode
> 50y Diverticulitis: Sx after 3rd episode
UGIH: i/v Octreotide (Splanchnic vaso-constriction)
Malignant Otitis Externa: CT scan of temporal bone
(Mx: i/v antibiotics)
Rapid Rx of DKA: risk of cerebral edema
Radio. Dx of Pleural Effusion: X-*** in decubitus view
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Posted: Mon May 26, 2003 4:13 pm Post subject: Aster pg 103
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Aster's USMLE Step3 Notes
Elderly with Bloody Diarrhea & patchy mucosal depigmentation (with other e/o
atherosclerosis):
Ischemic colitis (Mx - Bowel Rest & Hydration)
Dural Venous Sinus Thrombosis (headache/seizure):
Ix: CT Mx: Anticoag.
Infants of GBS (+) mothers who received <2 doses of ampicillin: Take CBC/Bl.Culture &
observe for 48hrs.
Nephrolithiasis with Hydronephrosis with Urosepsis:
#1 step is DECOMPRESSION
Percutaneous Nephrostomy Tube Insetion
(Antibiotics alone will not help)
Mx of Neonatal UTI:
i/v Ampi + Genta
Neonatal Adrenal H'ages (B/L):
sign of birth trauma (F/U with rpt. U/S in 1-2 weeks)
Urinary retention with Renal Dysfn.: Catheterize (Decompress tract)
Competent pregnant female may refuse diagnostic or surgical procedure that may be
therapeutic, even life-saving, for the fetus (Patient autonomy)
Previous abortion & OCP use are not risk factors for ectopic pregnancy
Breast engorgement: Continue breast feeding
(Use warm compresses) – antibiotics not needed
An intact pulse distal to injury DOES NOT R/O compartment syndrome
Ix – measure compartment pressure
Mx – fasciotomy
Lap Chole in Pregnancy: best results in 2nd trimester
discoloration of synovial fluid indicates infection
Acute onset of renal dysfn. - look at BUN/C
next step: estimate electrolytes
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Posted: Mon May 26, 2003 4:13 pm Post subject: Aster pg 104
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Aster's USMLE Step3 Notes
Children, with delayed passage of meconium, born to mothers who recv'd MgSO4
prepartum:
MECONIUM PLUG SYNDROME
“bubbly” appearance on radiographs
(not synonymous with meconium ileus)
Ix & Mx: Water-soluble contrast
Biliary vomiting in infant: VOLVULUS until proved otherwise (Mx – Sx)
Muddy Brown Casts in urine: ATN
(Contrast nephropathy is a common cause, prevent by prior administration of Nacetylcysteine)
#1 Sensitive test for proper intubation:
End-tidal colume CO2 detection (colorimetric)
1st step after insertion of ETT (>7y):
inflate cuff, auscultate (or check end-tidal CO2)
Any anatomical defect in airway, get thoracic surgery consult before securing airway
Ix for Latent TB: PPD
Ix for Active TB: Sputum AFB Stain
RA+Splenomegaly = Felty's
severe disease, might require immunosuppressive agents like cyclophosphamide /
azathiprine for Rx
Patient on ventilator:
acidosis & hypercarbia: increase Tidal Volume
hypoxic respi.failure (ARDS, cardiogenic pulmonary edema): increase PEEP
Apiration penumonia:
Right Lower Lobe, foul smelling, anaerobic cover reqd.
Selective pulmonary vasodilator: NO (Nitric Oxide)
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Posted: Mon May 26, 2003 4:14 pm Post subject: Aster pg 105
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Aster's USMLE Step3 Notes
Evaluation of TMJ: MRI
Heliox: mixture of Helium + Oxygen
(used for oxygen delivery in severe bronchoconstriction, it has better laminar flow)
Cystic Fibrosis with pneumonia:
Aggressive chest physiotherapy to clear secretions
Steroid acne: papules & pustules
–steroid induced
–atypical site
–Mx: Tretinoin (no need to stop steroids)
–also with: anabolic steroids, Iodide, Bromides, Li
If unable to intubate after repeated attempts:
Surgical Airway Access (No Resusci. without airway)
Increased survival with ARDS:
ventilator setting of TV < 6cc/kg bdy weight
Alkali ingestion:
–UGI study with water soluble contrast
–if (-) can be repeated with Barium
–Early endoscopy (endoscopy in acute ingestion might cause perforation)
post-AAA repair, loss of sensation but intact proprioception: Anterior Spinal Artery
occlusion
(posterior cord spared)
Catheter associated sepsis:
Remove catheter, start broad spectrum antibiotics
if still spiking fever (add fungal cover)
Post-heart transplant chest pain / dysnea / fever
? Mediastinitis (Mx: broad-spectrum antibiotics)
Post-thyroidectomy STRIDOR:
? Arterial bleed (call vascular surgeon, will open neck @ bedside – do ot attempt to
open neck yourself)
Post-thyroidectomy hoarseness of voice:
Recurrent Laryngeal Nerve injury
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Posted: Mon May 26, 2003 4:14 pm Post subject: Aster pg 106
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Aster's USMLE Step3 Notes
IJV line: associated with Carotid Bleed (if bleed occurs, and neck is tense, call vascular
surgeon)
Subclavian Line: associated with pneumothorax
Guide wire loss while inserting central line:
#1 complication – arrhythmia (call interventional cardiologist or radiologist for guide wire
removal)
post-GI Sx, ileus, LLQ mass, localized tenderness with some air under diaphragm
(Pelvic Abscess)
–some air under diaphragm post-op may be normal, does not necessarily indicate
perforated viscus
TURP syndrome: associated with hyonatremia
(aborption of irrigating fluid)
Alcohol withdrawl: Day 3
Fat Embolism: shortly after Long Bone #
DVT: risk increases with duration of immobilization
Nitroprusside : CN toxicity (Mx-Na thiocyanate)
Mx of MethHb: Methylene Blue
Rib #: shallow rapid respiration (due to chest pain): associated with higher incidence
of atelectasis
Patients receiving epidural narcotics should not receive I/V narcotics till epidural
narcotics have stopped
#1 cause of wound dehiscence: poor surgical closure
DPL may not reveal retroperitoneal processes
LGV: suppurative inuinal adenitis
(1º lesion: herpetiform vesicle or erosion on glans)
Chancroid: Painful punched out lesion
–Syphilitic chancre can appear after appearance of chancroid 'cuz the incubation period
of syphilis is longer than chancroid
–Mx: Ceftriaxone / Azithromycin
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Posted: Mon May 26, 2003 4:15 pm Post subject: Aster pg 107
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Aster's USMLE Step3 Notes
Granuloma inguinale:
–seprenginous ulceration of groin/genitalia/anus
–granulomatous tissue
–beefy red / bleeds easily
Acute suppurative parotitis:
–S aureus
–high mortality rate
–seen in post-op patients with poor oral hygiene
–fever with preauricular swelling
Fastest way to achieve androgen deprivation (for prostatic mets.) is B/L orchiectomy
(castrate level testosterone in 3 hours) – Leuprolide can take 30 days to achieve
castrate level testosterone
INR > 3.0, dysnea, no fever/leuko, increased Dlco:
Dx is Pulmonary Hemorrhage
AIDS with PML: start HAART (improves survival)
–no Rx for PML (caused by JC virus)
Post-LP: c/o postural headache
–Post-LP headache
–Mx: remain horizontal
Broca's aphasia: broken speech, comprehension intact
Wernicke's: “word salad”
1st episode of vasovagal syncope: reassure (get EKG)
recurrent vasovagal syncope: TILT TABLE TEST
Neuro. deficits in hypoglycemia: give I/V Dextrose
SAH: Early CT can be normal, if CT does not agree with clinical suspicion – do CSF
analysis
TIA: 1st step – auscultate carotid
If bruit (+): do Duplex U/S
If Stenosis > 70% - CEA
TCA overdose: admit to ICU
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Old 11-20-2004, 01:22 PM
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Posts: 125
Aster's USMLE Step3 Notes
Posted: Mon May 26, 2003 4:15 pm Post subject: Aster pg 108
--------------------------------------------------------------------------------
Aster's USMLE Step3 Notes
(high risk of arrhythmia)
Bell's palsy: Mx ?Conserv. / Acyclovir & Prednisone
Li levels > 4.0mEq/L – urgent hemodialysis
Bifrontal headache, OK when supine, worse on getting up : Intracranial Hypotension (?
Dural tear – exertion)
Meningitis with Papilledema: No LP
Pt. with A.Fib
on warfarin with increased INR with stroke:
CT Head : if non-h'agic – tPA
CT Head : h'agic – administer FFP & Vit.K
Acute arterial occlusion:
start i/v heparin + prepare for Sx embolectomy
Pt. in ED with asystole: Transcutaneous pacing
severe CAD & brady alternating with tachy:
Sick Sinus Syndrome
Pt. with uncontrolled HTN with chest pain & unequal blood pressure in R & L arm:
Acute Aortic Dissection (Dx: CT)
Mx - 1st step – lower systolic to < 100-120 mmHg
HbS disease with fever: ADMIT (high risk of sepsis)
CT can detect pericardial effusion, only ECHO can detect cardiac tamponade
Dx of IE: isolation of organism from 2 separate sites
FFP transfusion is also blood group matched
anemia, t'penia, fever, renal dysfn., neuro ab(n):
TTP (Mx: Plasmapheresis)
Sigmoid volvulus: forms an omega loop
can be reduced with sigmoidoscopy
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Posted: Mon May 26, 2003 4:16 pm Post subject: Aster pg 109
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Aster's USMLE Step3 Notes
Abdo exam: 1st step is AUSCULTATION
eavluation of any acute abdomen: check hernial sites
DM with hearing loss / pain / granulation in external auditory canal: Malignant
Otitis Externa
(Pseudomonas) Mx – I/V Antibiotics
Frontal sinusitis: can lead to a subperiosteal abscess (Pott's puffy tumor)
Adult PCKD: cysts are found in kidneys, aso in liver
PID with severe pain / guarding / mass:
TOA ? Ruptured
Child < 1 m with fever > 100F
send Blood / Stool / CSF to r/o Sepsis
Epiglottitis: Intubate (in OR by Anesthetist)
Avoid NSAID use in renal insufficiency
Acute Gout with PUD / recent Bleed:
Colchicine
Acute Gout with Renal Failure
(NSAIDs and Colchicine are both unsafe)
Intra-articular steroids
HZ Ophthalmicus: ORAL Acyclovir
Rx human bites with antibiotics
Rx rat bites with Penicillin (rat bite fever)
Pain remover: absorbed by skin, metabolized to CO in liver, can lead to CO poisoning
100% O2 vs Hyperbaric Oxygen therapy
Indications for Hyperbaric O2 therapy in
Carbon Monoxide poisoning
–CarboxyHb > 40%
–CarboxyHb > 25% with neuro. symptoms
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Posted: Mon May 26, 2003 4:16 pm Post subject: Aster pg 110
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Aster's USMLE Step3 Notes
CarboxyHb > 15% in pregnancy (HbF has a high affinity for CO and fetal CO levels are
10-15% higher than maternal levels)
to detect small pneumothoarx: end-expiratory CXR
Radial Head #: heals faster with early mobilization
Clearing Cx Spine: X-Rays and Examination
Clearing involves response from patient. Therefore, a patient in altered sensorium with
suspected Cx spine injury can not have hi Cx spine cleared !!!
Antibiotics improve outcome in COPD flare
A Living Will with DNR orders needs to be verified by the hospital's legal / social work
dept.
Penile chordee: CONGENITAL, fibrosis of tunica albuginea – increased curvature of
penis
Peyronie's disease: ACQUIRED, fibrosis of tunica albuginea – increased curvature &
palpable plaques
evaluation of rotator cuff injuries:
MRI
Diabetic Foot Ulcer: X-*** to detect air
Mx: Debridement
DVT/PE: start i/v heparin & warfarin. Stop heparin 2 days after attaining therapeutic
INR
Pemphigus: acantholysis, Nikolsky sign (+)
In patients @ high-risk for aspiration, apply cricoid pressure while intubating
Fall from height & landing on feet:
increased incidence of calcaneal & vertebral #'s
Mx of acute prostatitis: Fluoroquinolones / TMP-SMX
–no prostatic massage / no catheteriACLS Mnemonics
V-Fib & Pulseless V-Tach
ZAP-ZAP-ZAP ELB: Zaps represent initial defibrillations. ELB = the order of medications to be given
1. Epinephrine
2. Lidocaine
3. Bretylium
Asystole
HAD2: Represents the causes & what to do 1st:
H = Hypovolemia, Hypoxia, Hyperkalemia, Hypothermia
A = Acidosis
D = Drug overdose
2 = reminds you to check for asystole in 2 leads to confirm
The word "asystole" gives you a clue as to the drugs to use to reverse asystole:
A = Atropine
E = Epinephrine
But to reverse asystole you need to reverse the word too, so:
E is 1st so epi is used 1st
A is last so use atropine 2nd
PEA
ITCH PAD : represents possible causes of PEA:
I = Infarction (myocardial)
T = Tension Pneumo Thorax
C = Cardiac Tamponade
H = Hypovolemia, Hypoxia, Hyperkalemia, Hypothermia (4-H club)
P = Pulmonary Embolism
A = Acidosis
D = Drug Overdose (tricyclics, digitalis, beta blockers, calcium channel blockers)
The acronym itself tells you how to treat:
P = treat underlying PROBLEM 1st
E = Epi 1 mg IV push q3 - 5 minutes
A = Atropine 1 mg IV push q 3 - 5 minutes
Bradycardia
AD in bradycardia
A = Atropine
D = Dopamine
The starting dose of atropine in bradycardia is half that of what is
used in asystole; remember this since bradycardia is only half as bad
as asystole.
Tachycardia (with a pulse)
Wide complex tach without serious signs & symptoms calls for the Wide sisters:
Lida, Pro & The Brat = Lidocaine; Procainamide; Bretylium
Wide complex tach of unk. cause
The 1st Wide sister calls her cousin:
Lida calls Addie (Lidocaine 1st drug used, then if needed, adenosine)
If this fails then call the rest of the sisters: Pro & The Brat
Drugs that can go down the ETT
2 NAVEL:
N = Nitroglycerine
A = Atropine
V = Valium
E = Epinephrine
L = Lidocaine
2 = reminds you to double the dose for ETT administration
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Old 08-07-2007, 11:45 AM
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Posted: Mon May 26, 2003 4:21 pm Post subject: Aster pg 111
--------------------------------------------------------------------------------
Aster's USMLE Step3 Notes
e-mail additions / revisions / suggestions to:
astereognosis@yahoo.com
==========================================
Many thanks to Aster for these wonderful notes and thanks to all the ppl who have helped contribute by distributing these files for free. Also thanks to
ValueMD for allowing us to use their site to post and share this information. For anyone who prefers to download these files in pdf format (Adobe Acrobat
Reader required) can download the complete file in the ValueMD free download area, just remember to always share . Best of luck to all in your studies!
==========================================
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Closed Thread
«
---------------------------------------------------------
I have received numerous requests to email this collection that I am unable to comply. I could not prepare fro the exam myself by just attaching and emailing
this thing...
If only you guys showed this much activity when one of our friends asked for your help to participate in the making of this great collection now we would
have all the recalls from this forum, not only a few months' work. Not to mention that collecting it, is more educational than just reading the whole thing
at once, you retain a lot more!
Anyway, thanks to him, we can all enjoy it now:
Neurology
Q1
What is the best drug to treat depression in a pt. with Parkinson's?
Answer: prevalence of depression is 31% for all PD patients. The clinical manifestations of PD depression include apathy, psychomotor retardation, memory
impairment, pessimism, irrationality, and suicidal ideation without suicidal behavior. PD depression is effectively treated with a variety of
antidepressants, most commonly at present the selective serotonin reuptake inhibitors. Anecdotal evidence supports the use of sertraline to treat PD
depression.
The first choice is selective serotonin reuptake inhibitors (sertraline 50-200 mg/day; pa
http://bmj.com/cgi/content/full/320/7245/1287
Actually, because of the following question in USMLE Line CD, I was wondering whether whether or not SSRIs would be the right choice:
This is a 75-year-old male with Parkinson's disorder and depression. For 4 years, he was put on Paxil, that caused him to be delirious and didn't help much.
He has decreased energy, but sleeps well and has a good appetite. The Anti Depressant of choice would be:
A. Prozac
B. Wellbutrin (Bupropion)
C. Increase the dose of Paxil
D. Nardil (MAO inhibitor)
E. Serzone
A18. The answer is B. Bupropion (Wellbutrin). It is supposed to have the least anticholinergic effects and thus would reduce the tremor and rigidity the
patient is facing with Paxil.
Nardil is an MAO inhibitor and thus for the sheer reason of its interactions - almost never prescribe it in an elderly person
But from all references it appears that this SE of SSRIs is very rare. Hence, for the timebeing, it is best to start with SSRIs ( either sertraline or
Paroxetine.) And if SE occur, change to Bupropion.
Q2
1 Metabolic or medical coma is usually characterized by
a. Bilaterally reactive pupils symmetrical in size
b. Pinpoint pupils
c. Dilated, unreactive pupils
d. Unilateral dilated, unreactive pupil
2. The type of coma with the best prognosis is
a. Hypoxic-ischemic coma
b. Metabolic coma
c. Coma caused by head injury
d. Coma caused by subarachnoid hemorrhage
Answer: A & B
Pinpoint pupils: Pontine lesions disrupt sympathetic pathways and cause "pinpoint pupils," A patient presenting in coma with pinpoint pupils should be
suspected of having a pontine hemorrhage, large brainstem or pontine infarction or opoid poisoning.
Dilated, unreactive pupils: Brain Death.
Unilateral dilated, unreactive pupil :
sign of herniation of the uncus (part of the temporal lobe) and represents a neurosurgical emergency. Pressure on the third nerve after its exit from the
midbrain results in failure of parasympathetic innervation to the eye. This pressure on the third nerve can arise from a herniating uncus or an expanding
posterior communicating artery aneurysm.
Metabolic or medical coma
http://www.postgradmed.com/issues/2002/02_02/*****.htm
Patients with this type of coma generally have reactive pupils, an absence of focal neurologic signs, and no evidence of increased intracranial pressure.
There are some exceptions to these general rules. For example, patients with acute hepatic encephalopathy and hyperammonemia often have increased
intracranial pressure, which can lead to death. Ayus and associates (3) have reported on increased intracranial pressure that has led to herniation and death
in menstruant women with iatrogenic acute hyponatremia. Patients with hyperosmolar states (nonketotic hyperglycemia) may present with focal neurologic signs,
especially focal seizures, as may hypoglycemic patients.
Prognostic factors
Metabolic causes of coma carry the best prognosis, whereas coma associated with structural damage, such as cerebrovascular disease or subarachnoid
hemorrhage, tends to have the poorest prognosis. Hypoxic-ischemic injury has a poor prognosis also. As a general rule, patients with a nontraumatic cause of
coma usually do not regain consciousness if they have been comatose or in a vegetative state for more than a month.
Q3
pt has unilateral hearing loss, tinnus. also has lung Ca
what is most likely her symptom? Q was ask what is most likely Dx, not manage
Answer: any pt with known cancer first r/o mets whether its for treatment planning or medicolegal point of view.In any case pt will have an MRI.I recall one
question about possible brain abscess in a pt with breast CA.The correct answer was biopsy of the lesion to r/o mets.
Ans is metastetic lung Ca.. Most common source of intracranial metastesis is ca of the lung, other primary site is breast, kidney and GI tract.
Pt. with any primary ca with cns and related s/s
1st have to r/o metastesis
Q4
Alzhiemer's dx with insomnia?
Answer: Short acting benzo for insomnia but for agitation /insomnia.. Rx is Risperidon,
Read below for more information..in alzhimer's
topcs
http://www.aafp.org/afp/algorithm/#41
Q5
an 80 yr male with no other problem health wise has difficulty sleeping,he does 30 mts of brisk walk every morning..increase exercise or give some medication
to sleep..
(in my country 80+ didn't see a doc about things like sleep).
Answer: Prescribe an exercise schedule in the evening
Avoid daytime naps
Avoid evening coffee
Sleep only when sleepy, rather than getting into bed early and tossing around, trying to f all asleep
Q
Which one of the following decreases pain from infiltration of local anesthetics?
Using a cool solution
Using a 22 gauge needle rather than a 30 gauge needle
Infiltrating quickly
Infiltrating through surrounding intact skin
Adding sodium bicarbonate to the mixture
A: using a cooling solution
it itself is a type of anaesthesia
when there is sensitivity to local anesthetics
it can used
. Q:
71 yo m with mild HT,high cholesterol comes with vertigo not positional lasting for 2-4hrs ,buzzing ,deafness.R/
a diazepam
b HZT
c Meclizine
d scopalamine
cell crisis
A: the aptient has meneire's disease..the classic symptoms are recurrent episodes of vertigo,fluctuating sensorineural hearing loss,tinnitus( ringing or
buzzing in the ears) and aural fullness in the affected ear....
classically the veritigo "LASTING for HOURS" not minutes or days.
these 2 symptoms are must to diagnose
vertigo lasting for hours
sensorineural hearing loss
one of these additional symptom also needed to make the diagnosis
-low frequency hearing loss
aural fullness
buzzing tinnitus
treatment is:
diuretics
antiemetics for acute attacks
Guy2: Diuretics decrease endolymph fluid pressure and help prevent acute attack, But do not help once an attack has been triggered.
Vestibulosuppressants decrease symptoms by dulling the brain response to inner ear signals.
So do we conclude that acute attacks resolve best with vestibuolsuppressants such as antiemetics and antivertigo meds?
Guy1: I guess so...either one of these ...answer depends upon question but agree in acute episode meclizine, reccurent episode HCTZ
Q:
pt c pk, tx c L-dopa, had agitation, tx c haloperidal, getting worse, next:
a. increase haloperidal
b. decrease halo...
increase l-dopa
A: Halo should not be given in the first place. It is D2 agonist and parkinsonism (EPS ) is one of the side effect of antipsychotics.
L-dopa can cause agitation and restlesness, when it happen it needs adjustment of dose of L-dopa.
Risperidone has less EPS.------need check ref with this
Q:
which of followings is most likely to distinguish pk from major depression
a mask face
b tremor
c rigidity
d imbalance
e brady
A: Rigidity....
Elderly depressed Pt. might have balance problem, tremor, mask face but not rigidity.
Q:
what is the Tx for PTSD
Paxil
imipramine
or others
A: ssri?
Pulmonary
Q1
recall-most reliable sign of PE on a plain film- pyramid type consolidation
or effusion?
Answer: pyramid type consolidation not effusion
Q2
female patient comes with acute SOB,cough and bilateral chest infiltrate, she also have multiple sexual partners. You suspect PCP..
What is the method for diagnosis, 1)do you do brochoscopy?
q2)DO you admit the patient q
q3)When do you give steroid??
Answer: Bronchoscopy and bronchoalveolar lavage for direct identification of organism is specific diagonostic test But if this pt.is HIV +iv, chest X-***
show bilateral infiltret and has +iv S/S , low CD4 count then Rx of PCP can be started before confirmation of DX, Admit Pt >>I/V abx.
Steriod is indicated in severe case when PO2is <70 or A-a gradiant >35.
thank you so i/v trimethoprin-sulfamethezole
admit and Steriod is indicated in severe case when PO2is <70
or A-a gradiant >35.
Q3
pt haevy smoker, loss 8bl lately, surem Ca++ 11.5,
what do you do next?
a.recheck Ca++ level
b.check CXR
Answer: Check X-***.. answer is carcinoma of lung. smoker, old age, wt loss and increase calcium...could be small cell carcinoma of lungs or metastasis of
lung cancer
Q:
what is the most appropriate management of a solitary pulmonary nodule on CXR in a pt who is a known smoker 20 pack years?
HRCT
Bronchoscopy with needle biopsy
resection of the mass
VATS
serial cxr's
A:
1.One of the first things done to clinically evaluate an SPN is to compare the most recent chest x-*** with older x-rays, if any are available. This is
extremely important because the growth rate of a nodule is a more reliable indicator of malignancy than a one-time x-*** or CT scan.
Chest radiographs can provide information regarding nodule size, growth rate, margin characteristics, and calcification pattern, which can aid in the
assessment of benign versus malignant lesions.
best thing to do is compare with an old cxr if patint has one if not, then next step is to do a ct scan of the chest, since patient
is risk for ca then one would approach with broncoscopy and bx.
Q:
A guy with his arm showing the ppd reaction.NO size was emntioned in the q....based on looking at his arm...I had to choose the choices..
( YOu are supposed to look at teh formarm and make out if its positive or not.
There was a light red lesion covering the whole forearm.
There was another darker central circle like a target where the actual injection was given.)
1.give INH only
2.GIve all 3 drugs etc...
A: This q probably test the point for positive PPD, how treat, ans. is INH ?
I agree with IN-1 but once postive ppd oone need to go for the cxr to role out the active TB. If only ppd positive and no othr findings of TB i think the
answer is INH
Q:
What¡¯s the treatment choice for a lung cancer pt with Horner¡¯s syndrome ?
1.surgery
2.chemo.
3.radiation
4.observation¡.
A: Horner syndrome or SVC syndrome does not mean that CA is inoperable. However extention to parietal pleura, horsness of voice means pt is inoperable.
I remember it is Squamous Cell Ca. I seleted Surgery, but not sure if it is right ?
Radiation! you can't decide any Tx option on Horner symptom per se! Combine with other things! Why?
Patients with Horner's syndrome have a worse prognosis, but this is not a contraindication to surgery
The following criteria usually signal a poor prognosis and generally indicate an unresectable lesion: tumor invasion of the subclavian vessels [12]-- most
commonly the subclavian artery because of it's location; phrenic or recurrent laryngeal nerve paralysis; mediastinal lymph node involvement [12]; invasion of
the vertebral bodies [12], trachea, or esophagus; invasion of the soft tissues at the base of the neck [13]; and distant metastases [11]. Resection of the
lower cords of the brachial plexus (if involved) may be necessary, but extensive involvement usually renders the patient inoperable.
Q:
best diag of sarcoidios
1. transbronchial biopsy of LN
2. skin biposy of nodule
A: guy1---- Transbronchial Biopsy
Guy2--- answer is skin nodule biposy for nonceaseting granuloma. cheep and noninvasive
Guy1: I agree with you pk that skin biopsy is cheap and noninvasive. But how was the question put in the exam is it the best test to diagnose or wordings
were something else. Because in this exam they play around with words and chances of your messing up are always there if you don't read what exactly they are
asking.
thanks for posting the questions. Good Job
Guy4: agree biopsy of skin lesion, palpable lymph node or salivary gland..read below
TISSUE BIOSPY is a must to rule out other diseases..ie.brucelossis and TB and to diagnose sarcodoisis
tansbronchial biopsy MAYBE reqd if no other S/S of disease present
PROGNOSIS of disease
best for ONLY hilar node involvement.
parenchymal involvement of lung is associated with worst prognosis
NOTE>.>>.erythema nodosum indicates good outcome.
Q:
what is the best indicator of sarcoidosis ? elevation of Ca, hilar LN enlargment and other labs. Forgot exact choice.
A: Friends, many all choice you given are all work up for sarcoidosis but the best would be b/l hilar nodes, since many entity can cause increase in ca,
sarcoidosis is very characteristics for b/l hilar aka "potato nodes"
Q & A
Friends, someone posted question earlier regarding the treatment of anaphylaxis from cookies, and what would you give and dosage? The answer is epinephrine
.o1mg/kg(1:1,000 dilution) and not 1:10,000 dilution this is very important because the latter is used to treat cardiac arrest. Please memorize these dosage
because it is very critical. suggestions welcome.
Dose depends on route of administration and severity of anaphylaxis...
EPI o.3- o.5 ml of 1:1000 S/C
o.5 ml of 1:1000 S/L
3-5 ml of 1:10000 I/V
3-5 ml of 1:10000 via endotracheal tube
Re .. Washington Manual
Q:
Case. Pt with high clinical suspicion of PE on Hx and clinical exam.
there are 3 qs.
1. whai is initila step in this case. ( make sure its asked initil step , not diagnostic or not the test )
2. What is best intial diagnostic test in this case.
3. What is the first test in evaluation of this pateint. ( here its not asked best diag test but initial test )
chices
1. EKG
2. ABG
3. Iv heparin
4. V/Q scan.
5. oxygen .
hope will help to all.
A: My opinion of order. What is the confirmed true order.
Order of preference:
O2
IV Heparin If you suspect DVT or PE, immediate
emperic anticoagulation is mandatory.
Diagnostic investigations should not
delay IV Heparin.
EKG
ABG
CXR
V/Q or spiral CT
pulmonary angiogram
Q:
lung cancer with horners syndrome
1)surgery
2)radiation
A: radiation
Q:
Which of followings suggests a benign cause for lung lesion?
a Calcification located eccentrically in a nodule
b Unilateral adenopathy
c A hard nodule in a anterior cervical chain
d Hoarseness
e Calcification scattered in a nodule in a " popcorn"
fashion
A: friends, the answer is E. "popcorn" calcification are almost always benign aka hamartoma. source from NMSR review step 3.
Q:
Patients who are Young and in good health-PPD 15mm induration or more...next step?
A:
CXR---you have to find out if its latent or active tb...if latent inh prophylaxis...if active you have to treat with att regime. i am sure you all know this,
just posting to refresh memory.
Q:
A 29-year-old woman presents with an exacerbation of her asthma. She is 11 weeks pregnant. She has mild intermittent asthma and usually takes a b-agonist as
needed. She has one 4-year-old child who is in day care and has had a recent upper respiratory tract infection. She has a dry cough, clear nasal discharge,
myalgias, and fatigue.
On physical examination, she is talking in full sentences and has normal tympanic membranes, mildly erythematous oropharynx without exudates, no adenopathy;
she has positive wheezing bilaterally. The peak flow is 300 mL; her usual result is 390 mL. Pulse oximetry is 93% on room air.
Which of the following is indicated in the management of this patient?
(A) Amoxicillin
(B) Theophylline
(C) Prednisone
(D) Montelukast
(E) Flunisolide
A: Answer: E Flunisolide
Q:
Manage asthma in a pregnant patient
Treatment principles for asthma in the nonpregnant patient apply also to the pregnant patient. She has mild intermittent asthma with an exacerbation, for
which therapy with an inhaled glucocorticoid is an appropriate choice. Use of inhaled glucocorticoids is safe in pregnancy.
Cardiovascular
Q1
recall-ekg of svt, hypotension palpitationand
treatment
1.adenosin
2cardioversion
no vagal massage
Answer: hemodynamically unstable patient, immediate cardioversion. in stable patient with svt: adenosin6-12 mg iv fast, flush it with nss.
Q2
recall- 50 yr annual office visit common finding at this age
1.htn
2.cad
3.cancer
4.?
CAD is usu the one which goes undiagnosed
Q3
is there a target LDL level for diabetics with no other medical problems?
I know for CAD & PVD it is <100
Answer: ....The Desirable LDL for those with CAD or CAD equivalent is <100mg/dl(<2.6 mmol/L. O.K, What is CAD equivalent? Here we go:
- DM
- Symptomatic Carotid Artery Disease
- Abdominal Aortic Aneurism
- Peripheral Arterial Disease
Trust me,Buddy
Ref: either CMDT or Kaplan?
Q4
What are the HTN meds used with dialysis pt.
Is it atenolol
Lisinopril
Lasix
Answer: Ref: E-Medicine.com
Medical care in HTN and Renal Failure
...Use of ACE inhibitors as tolerated, with close monitoring for renal deterioration and for hyperkalemia (avoid in advanced renal failure, bilateral renal
artery stenosis [RAS], RAS in a solitary kidney)
atenolol.(i think)
not an ACE inhib-to avoid hyperkalemia
not lasix to avoid hypotension which is common side effect during dialysis
Q5
What is the most specific s/s of right heart failure?
Is it hepato-jugular reflux?
Since, hepatojugular reflex is the test that is usually done to test incepient heart failure. I would go for HJR!
Q6
definitive symptom of sign of left heart failure ?
low co
decreased lvef
dyspnea
Answer: < EF... is the sign of LHF
Dyspnea is the symtom of LHF
Q7
# 1 risk factor for heart disease?
HTN/
OBES/
DM/
fam hx/
high cholest
Answer: HTN is for overall cardiovascular event, But family history is for CHD/IHD.
http://www.nhlbi.nih.gov/health/publ...r/chdfacts.htm
Who is at risk for CHD?
Controllable:
High blood pressure
High blood cholesterol
Smoking
Obesity
Physical inactivity
Diabetes
Stress
Uncontrollable
Gender
Heredity (family history of CHD)
Age
Q8
heart block is most likely associated with which valve infections?
aortic
pulmonary
tricuspid
mitral
Answer: I thought mitral?
http://www.merck.com/pubs/mmanual/se...er207/207b.htm
Q9
is c/s is indication of Endocarditis prophylaxix in high risk cardiac conditions. pt is otherwise healthy.
Answer: Not recommended... In
1)C.section, hysterectomy, DE&C and abortion
2) cardiac cath and PTCA
3)circumcision
4)TEE, Endotracheal intubation,Fexible bronchoscopy(Except in high risk Pt.),Endoscopy
5)Tympanostomy tube insertion
6)filling of dental cavity (not root canal)
7)Fluoride treatment
Intracanal endodontic treatment.
NEJM
Q10
patient new onset HTN middle aged , BP recording 168/96
1 step
1 diet and execise only with salt restriction
2 pharmaco therapy with lifestle modifications indicated
Answer: How long pt had HTN? new ans is not always exe first , depend on TOD and DM......
Q11
b/l renal a. stenosis with HTN, what med do you use to tx HTN
Answer:
Q12
cardiac cathetrization ..?
Answer: Cardiac cath should be done in patients with unstable angina refractory to medical management or with any of the following-
1. Prior revascularization
2. Depressed LV function (LV EF <50%)
3. Life threatening ventricular arrythmias
4. Persistent or recurrent angina
5. Inducible myocardial ischemia provoked by exercise, dobutamine etc.
Q13
A 45-year-old male suddenly loses consciousness and falls to the ground. He has been previously healthy and has been on no medications. There is no obvious
evidence of trauma. An electrocardiogram reveals wide complex tachycardia at a rate of 300 beats per minute. Which of the following is the most appropriate
intervention?
A. Obtain vital signs
B. Administer a bolus of intravenous lidocaine
C. Administer a thrombolytic agent
D. Perform asynchronous cardioversion
E. Perform synchronous cardioversion
anotjer mcq
An 82-year-old with COPD, hypertension, and coronary artery disease is brought to the emergency department by his daughter who reported that for the last 30
minutes her father has been becoming progressively confused and complaining of chest pain and shortness of breath. His temperature is 38.0 C (100.7 F),
systolic blood pressure is 60 mm Hg, pulse is 133/min and irregular, and respiratory rate is 24/min. His pulse oximetry reveals 92%. Physical examination
shows a confused elderly male in moderate respiratory distress. He has bilateral rales and a tachycardic irregularly irregular heart beat. Peripheral pulses
are very weak. An electrocardiogram shows atrial fibrillation with a rate of 180. No ST elevations are noted. The most appropriate next step in this
patient's management is to
A. administer adenosine, intravenously
B. admit him to the cardiac intensive care unit
C. begin a diltiazem drip with heparin
D. perform electrical cardioversion[synchronised]
E. transport him to the cardiac catheterization laboratory
Answer: IF patient is STABLE treat with medications initially.
IF unstable.......always use cardioversion FIRST
what are the creteria for being unstable
answer is///////
1---LOW BLOOD PRESSURE (SYSTOLIC BP less then 90)
2--- Shortness of breat (sob)
3---chest pain
4--- confusion secondary to hemodynamic instability(low perfusion of cns)
ALL cardioversions are SYNCHORNIZED.....Forget the word unsynchornized as a treatment option in any patient.
Q14
organ donation in a pt who had a ishemic death
Answer: hypertension not a contraindication of ctp
Contraindications: Heart transplant is not covered for patients with ANY of the following contraindications:
Presence of systemic diseases (e.g., autoimmune, vascular, amyloidosis, sarcoidosis)
Presence of irreversible end-organ diseases (e.g., renal, hepatic, pulmonary)
Presence of severe pulmonary hypertension with irreversibly high pulmonary vascular resistance
Presence of intracranial cerebrovascular disease
Presence of bleeding peptic ulcer
Presence of hepatitis B antigen
Presence of diverticulitis
Presence of neuromuscular disorders
Presence of HIV/AIDS with profound immunosuppression (CD4 counts of < 200 cells/mm3)
Q15
b/l renal a. stenosis with HTN, what med do you use to tx HTN
Answer: only ace i and ccb have renoprotective effects,
source jama
Only recently have long-term clinical trials assessed the renoprotective effects of CCBs. Although few, the available studies suggest that CCBs may be
beneficial in stabilizing renal failure.70 Some studies using CCBs in hypertensive patients with renal insufficiency have demonstrated an increase in
glomerular filtration rate or preservation of renal function; however, other trials have not.66, 71 Although there is not enough current evidence to consider
CCBs as renoprotective beyond their antihypertensive effect, these agents can be effective antihypertensive agents in patients with renal insufficiency
especially in bilateral renal artery stenosis in which Ace i are contraindicated.
good job, I agree. I choiced CCB
Q16
universal SCREENING is not recommended
1.child > 2 yrs and has a a parent with total cholestrol>240---- do random cholestrol, if <170- rpt in 5 yrs
if > 200, do flp
2.children> 2yrs with a + family h/o of premature CAD in parents or grandparents do FLP.
RECALL- MOTHER HAD A HIGH CHOLESTROL BROUGHT A CHILD 18 MONTHS AND CONCERN ABOUT THE BABY, WHAT DO YOU DO NEXT- 1.DIET RESTRICTION
2.CHECK FLP
3.TOTAL CHOLESTROL
4.NOTHYING
Answer: Agree.. Need to come back after 2 for FLP, this is one of USMLE release Q
Q: if a patient with cystic fibrsis female is concern about
having a baby
is there any % or decrese fertility in CF disease.my friend got this q.
A: The incidence of cholecystitis and gallstones is higher in patients with CF than in other individuals. Delayed puberty and reduced fertility are other
complications; most males are azoospermic because of agenesis of the vas deferens. Female fertility is probably only mildly impaired, and many successful
pregnancies have been reported in women with CF.
Reference :
http://www.emedicine.com/ped/topic535.htm
The fertility % for men is very low. 1%. Not so bad with women.Don't know exact %. Anyone??
Q:
What's the effect of oral OCP [ combo pills ] on LDL/HDL/TG/Total chl/glucose
What's the effect of ocp patch [ skin patch ] on LDL/HDL/TG/Total chl/glucose
Is there any difference guys ?
A: estro incr hdl , decre ldl, and incr tg, incr vldl
Q:
hypothermic patient with 70/palp, rr-6,40 pulse with some ectopic
what is the next step
1.lidocaine
2.atropine
3.breytilium
4.iv fluids
5.oxygen
A: in hypothermic patients, bretylium is infact given on site, even before pt comes to ER as any arrhythmia can rapidly progress to vfib.
In hypothermic pts. vfib is commonest cause of death.
Extreme bradydysrhythmias may provide sufficient cardiac output to meet the patient's depressed metabolic demands. Indeed, apparent cardiovascular collapse
may be an illusion because the cold myocardium is extremely irritable and some sources feel that iatrogenic VF and bradyarrythmias is easily precipitated
with closed-chest compressions. The patient should be intubated and initial warming begun. patient should be adequately preoxygenated. Wet clothing should be
removed and blankets utilized (aluminum-coated foils are more efficient than woolen rescue blankets). Active rewarming should be limited to the truncal area
(near the core) using chemical packs or hot water bottles in the ambulance if available. 1
Q: How do you treat Cocaine abuser with 210/115 BP?
A:
Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV
Q:
Q21. A 16-year-old boy is diagnosed with acute rheumatic fever (RF) based upon the presence of antecedent group A beta-hemolytic streptococcal pharyngitis
infection, erythema marginatum, and subcutaneous nodules. An electrocardiogram demonstrates first-degree atrioventricular heart block, and an echocardiogram
reveals a large pericardial effusion. Both his heart block and pericardial effusion resolve by his first follow-up visit. Which of the following statements
is true concerning long-term (secondary) prophylaxis against recurrent attacks of RF in this patient?
A. Long-term prophylaxis is not needed for this patient since he does not have evidence of rheumatic heart valve disease.
B. This patient should receive prophylaxis until aged 21 years.
C. This patient should receive prophylaxis for 10 years or well into adulthood, whichever is longer.
D. This patient should receive prophylaxis for 10 years since his last episode and at least until aged 40 years.
E. Lifelong prophylaxis is recommended for this patient.
A: Below 18 years without any complications ,prophylaxis for a couple of years and stop.
If his heart block had persisted,he would require life long prophylaxis. So C is the answer
. Ideally, continue prophylaxis indefinitely, because recurrent GAS(group A beta-hemolytic streptococcal ) infection and RF can occur at any age; however,
the American Heart Association currently recommends that patients with
**RF without carditis:- receive prophylactic antibiotics for 5 years or until aged 21 years, whichever is longer.
**Patients with RF with carditis but no valve disease should receive prophylactic antibiotics for 10 years or well into adulthood, whichever is longer.
Finally, patients with RF with carditis and valve disease should receive antibiotics at least 10 years or until aged 40 years.
source AHA
Q:
which is maximum risk for preoperative assesment of cardiac function
1)Suspected critical aortic stenosis
2)Myocardial infarction within six months with age >70
3)Poor general medical status and emergency operation
4th was easy to be removed
this was totally confusing as i did not read this topic nicely now i know the answer please try to discuss , lots of questions
A: No.1
age >70 + MI wirhin 6 month = risk point 5 + 10 = 15
Suspected critical aortic stenosis = risk point 20
CMDT.
Risk
Age older than 70 years 5
Myocardial infarction within six months 10
Myocardial infarction after six months 5
Canadian Cardiovascular Society Angina Classification*
Class III 10
Class IV 20
Unstable angina within six months 10
Alveolar pulmonary edema
Within one week 10
Ever 5
Suspected critical aortic stenosis 20
Arrhythmia
Rhythm other than sinus or sinus plus atrial premature beats 5
More than five premature ventricular beats 5
Emergency operation 10
Poor general medical status† 5
SOURCE IS AAFP ALSO AMERICAN HEART INEX
Q: screen?
bp check every 2 years from birth,
lipids, usptsf every 5 reccomends males 35, females 45, but the necp recommends at 20 every 5 years
Blood glucose screening (Am. Diabetes Soc.)
all people at or over 45 years old, FPG, if normal, Q 3 yrs interval.
High risk people should start younger than 45 years old.
Q:
Q61. While examining a patient you hear what sounds like a gunshot, followed seconds later by a second shot. You dash across the hall to discover that a
disgruntled patient has shot your partner in the chest with a small-caliber pistol, then placed the gun in his own mouth and pulled the trigger again. He is
obviously dead, but your partner is alive. He is pale and cyanotic and gasping for breath.
After ripping open his shirt you see a wound just to the left of the sternum. His pulse is weak and thready at 140 beats/min. You hear breath sounds
bilaterally but his heart sounds appear to be decreased. His neck veins are distended. His blood pressure is barely palpable at 60 mm Hg. Assuming the
necessary equipment is at hand, which one of the following should you do immediately?
a. Administer oxygen at 12 L/min
b. Administer epinephrine, 1 mg subcutaneously
c. Perform pericardiocentesis
d. Insert a #16 needle into the left lung
e. Begin lactated Ringer's solution at 500 cc/hr
A:
The answer is C. All the measures listed are reasonable, but only pericardiocentesis is likely to save the wounded physician's life. He exhibits the classic
triad of cardiac tamponade: elevated venous pressure, decreased arterial pressure, and muffled heart tones. Removal of as little as 15 to 20 cc of blood by
pericardiocentesis should result in immediate hemodynamic improvement. The presence of breath sounds rules out tension pneumothorax and massive hemothorax as
the cause of his shock.
Q:
1st risk factor?
A: the #1 RISK FACTORS-
1.CAD- HTN
2.HTN- SMOKING
3.OBESITY- FAMILIAL
4.HYPERLIPEDEMIA- FAMILIAL
5.DIABETIC(TYPE2)- OBESITY
6.MELANOMA-FAMILIAL
8.OSTEOPOROSIS- AGE
9.BREAST,COLON,PROSTATE CANCER- FAMILIAL
10.LUNG CA-SMOKING
11CERVICAL- HPV
12.PANCRATIC- ALCOHOL
13.THYROD- RADIATION
14.ESOPHAGEAL- ?
15.GASTRIC- H.PYLORI
for stroke its htn
pancreatic-smoking,
Q:
26 yo female came to office with intermittent PALPITATIOns. Exam reveals mid systolic click and late low grade systolic murmur... Echo confirms ur
disgnosis...THe next best step is?
A) Discuss options regarding valve replacement
b) Suggest Treatment with beta blockers
C)observation with Antibiotic prophylaxis for dental Procedures.
d)Advice abstinence from exercise and stressful activities
WHAT IS THE DISGNOSIS AND MANAGEMENT OF THIS DISORDER????
A: First, I thought is B, but this pt also has late low systolic murmur. Pts who have only a mid systolic click usu. have no sequelae, but pts with a late or
pansystolic murmur may develop significant mitral reguitation. Male or age > 60 yrs of those pts require valve replacement, otherwise just need observation
with antibiotic prophylaxis for endocarditis,
CMDT, p366
Mirtal valve prolape is the disgnosis.......
MVP without MURMUR requires no prophylaxis
MVP with murmur requires endocarditis prophylaxis
IN terms of treatment most MVP are asymptomatic...requires no treatment even when they have audible murmur....just observation and prophylaxis if murmur
positive.
IN terms of ENDOCARDITIS prophylaxis,,,,,, ONLY ASD with ostium secundum type defect and MITRAL VALUE PROLAPSE wihout murmur requires NO PROPHYLAXIS...
every thing else requires prophylaxis..i.e VALVULAR disease///congenetial diseases///prosthethic valve disease.
Q:
A pt who developed DVT after a surgery was under anticoagulation therapy (heparin + warfarin) (did not mention INR or PTT). Now the pt develops typical PE
symptoms and is stable, next:
1 continue current anticoagulation therapy
2 TPA
3 filter
4 ¡.
A:
Q:
pt with dig subendocardial MI next step
1. thrombolytic
2. heparin
3. ASA
4. ??
A: answer is Heparin, not tpa b/c its non q wave Mi
Q:
best treat for WPWS
1. adenosine
2, digoxin
.3. amiodraone
4. pracanamide
A: Friends, depending on what source you read both adenosine and procainamide are treatment, but according the the acls guild line procainamid is the DOC
also quinidine is effective, but must avoid digoxin and verapamil.
Treatment depends on whether the patient is having atrial fibrillation or CMTs. This can be decided by looking at the QRS regularity. If irregular, atrial
fib: Give Procainamide. Procainamide increases the refractoriness of the atria.
If regular,then it is CMT. treat with Adenosine as in any other PSVT.
Definitive treatment is ablation of the abberrant pathway.
Q:
# 1 drug decreasing MR in post MI
1. ASA
2. B blocker
3. ACE I
A: asa better thanb/b sourche Washington
should be b-blocker
Is it ACEinhibtor?
WM: agents that decrease afterload,particularly ACEinhi,may limit infarct expansion and ventricular dilatation after MI
Need to check which is better, but in real life, first thing you go ASA chew, right? then 325mg keep going, right? ACE- and B/B both reduce MR----so need to
check
Q:
Does teeth cleaning in pt with prosthetic volve need enodcarditis prophylaxis
A:
Endocarditis prophylaxis recommended*
Dental extractions
Periodontal procedures, including surgery, scaling, root planing, probing and recall maintenance
Dental implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Subgingival placement of antibiotic fibers or strips
Initial placement of orthodontic bands (but not brackets)
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants, where bleeding is anticipated
Endocarditis prophylaxis not recommended
Restorative dentistry (operative and prosthodontic), † with or without retraction cord ‡
Local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment (post-placement and build-up)
Placement of rubber dams
Postoperative suture removal
Placement of removable prosthodontic or orthodontic appliances
Oral impressions
Fluoride treatments
Oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth
One guy said: Yes, in such condition prophylaxis should be given,
preferably with amoxacillin 1gm one hour before and after the procedure
Friends, a 54 y/0 AAF with history of copd,cad,and b/l osteoarthritis of knee in need of stress test. Best choices is.
1.treadmill
2.persantine
3.dobutamine.
A: .dobutamine
Q:
what is the best initioal RX of Mitral stenosis with pregnancy. Pt is symptmatic and other q is pt is asymptomatic.
A: in general asymptomatic patient should be reated with bed rest,salt restriction,treatment of concurrent infections and judicial use of diuretics use to
lower preload without compromising the placental blood volume..given these steps they usually tolerate pregnancy and vaginal delivery well
symptomatic patients. requires earlier measure with hemodynamic monitoring during labour and delivery. pt who develops heart failure despite these measure
can be considered for ballon valvuloplasty or even mitral valve repair. pt who develops atrial fibrlillation should be rate controlled with a beta blocker or
calcium blocker prior to prompt cardioversion
Mitral stenosis with pregnency.. February 17 2003, 4:25 PM
Asymtomatic > restriction of activityavoidence of stress( echocardigraphy to measure the valve orifice for future risk prediction )Diuretics is not
recommendedSymtomatic > In less activity ( class 3) and at rest(class 4) Digoxin is recommended, alternative therapy is beta blocker.If fibrilation develop
anticoagulate with heparin.In failure of medical therapy > valvuloplastyCorrect me if I am wrongRE.....Manual of obstratics
Q:
pt with s/s of aortic dissection, what is next exam
1 ct
2.TEE
3.U/S
4.cxr
A: CXR: wide mediasterium first, then TEE need cardiaology consult
If very acute, unstable, echo TTE bed side(not need cardiologist)
Aortogram if need
Q:
50 yr annual office visit common finding at this age
1.htn
2.cad
3.cancer
4.?
is it HTN or CAD. I think it is HTN.......
suggestions welcome
Answer: HTN, case closed
Q:
black male with HTN + DM .what HTsive med do u give
A:
common
1.htn in a black- diuretic
2.htn + dm in any- aci
3.htn +osteo- diuretic
4.htn+ bil ras- ccb
Q:
What is drug of choice pt with HTN and DM II but no proteinuria
A:
Inhibition of the renin–angiotensin system with an ACE inhibitor or angiotensin II–receptor antagonist is warranted to decrease both blood pressure and
albuminuria; the dose should be titrated upward to the moderate or high range, as tolerated, to achieve a systolic pressure below 130 mm Hg and a diastolic
pressure below 80 mm Hg. Although data from clinical trials provide stronger support for the use of angiotensin II–receptor antagonists than for the use of
other agents in patients with type 2 diabetes and microalbuminuria or macroalbuminuria, in the absence of a direct comparison of the two strategies, we
consider either of these classes of medication to be a reasonable first choice. Serum potassium and creatinine should be checked in all patients seven days
after the initiation of treatment with drugs that block the renin–angiotensin system and after any increase in the dose of such drugs. A beta-blocker or
diuretic — or if these agents are inadequate, a nondihydropyridine calcium-channel blocker — should be added if ACE inhibitors or angiotensin II–receptor
antagonists are insufficient to maintain blood pressure in the desired range . We consider adding dihydropyridine calcium-channel blockers or alpha-blockers
only when the target for blood pressure is not met with the use of these other approaches
-review article from NEJM
Gastrointestinal
Q1
jewish lady with diarrha and costipation for 3-4 months
and abd pain. what next
1.sigmiodoscopy
2.sool leukocyte
3.reassusranse and regular vist
4. barium enema
Answer: To make the IBS Dx, You have to exclude other possibility first We don't have her Age? Jews are prone to IBD too.So I think it's not that easy to
tell it's IBS.You got to do Barum enema or Colonoscopy.Am I right?
begin with BE-spastic colon etc
Q2
Q: SCREENING FOR COLON CANSER?
A: 1)Annual digital exam starting at age 40 years
2)anual hemoccult testing of stool(FOBT) starting at 50.
3)Colonoscopy every 3-5 yrs36 has been recently recommended for screening ASYMPTOMATIC patients starting at age 50 and found to be more sensitive then
sigmoidoscopy and barium enema.....
REFERENCE:
Kaplan notes..and .....N ENDLAND JOURNAL OF MEDICINE
Q1:
what is the best/next diagnostic step in a antibiotic induced diarrhoe
stoo toxin
stool for c.difficle
elisa
endoscopy
A:
Stool assay for C difficile toxins (mostly toxin B)
This test requires 2 days. It is considered positive when cultured cells undergo cytopathic changes when exposed to stool, and the result then is confirmed
by neutralizing these toxins with specific antitoxins.
This is the criterion standard test (sensitivity is 95% in patients with antibiotic-induced diarrhea, and sensitivity increases with the severity of the
colitis); however, results are negative in 5-10% of patients with endoscopic evidence of pseudomembranous colitis
Q:
29 yo M c severe diarrhea
o/e listless but responsive
vitals stable
Na 118,K 2.9, hco3 12,,urine na <10
R
a IV hypetonic saline
b hypotonic
c isotonic
d fluid restriction
e hco3
A: c, never choose hypertonic if pt. is not symptomatic go with isostonic 99% of time.(Crush Step #)
Other guy: isotonic...unless serum Na is less than 110, then you give hypertonic saline. have to be extremely careful with hypertonic saline!!
This pt. has hypotonic, hypovolemic hyponatremia. Does not have altered mental status or seizures. Therefore giving isotonic saline will address his problem
of hyponatremia and hypovolemia.
Correct at the rate of 0.3 mmol/lit/hr. Should not exceed 8mmol/lit over the first 24 hrs.
Correction of serum sodium that is too rapid can precipitate severe neurologic complications, such as central pontine myelinosis, which can produce spastic
quadriparesis, swallowing dysfunction, pseudobulbar palsy, and mutism.
Q:
25 yr old male routine visit with his father diag with colon cancer, what will you ask him next
age of onset
family h/o
diet pattern
sign and sym
A:
To find out if Pt. have h/o familial adeno.polyposis.
Polyps occur mean age of 16 years.
If there is f/h, Screening sigmoidoscopy begin at
10 - 12 years and repeat every 1-2 years.
RE..CMDT.
Q:
In gallbladder sludge by u/s and pt is sym with pain fever
and has diabetic,next step
ct abdomen
start antibiotic
ercp
observation
Q:
An inpatient on the medical service, a60 year of female is hospitalized for diverticulosis. the bleeding that is associated with this conditionis due to
which of the following?
A.rupture of the diverticulum
B.Infection of the diverticulum
C.venous bleeding
D.erosion of an artery
E. pancreatic calcifications
A: erosion of an artery--------no ref.
Q:
Which is the most specific symptom of esophageal herpes infection?
A: The most common symptoms are odynophagia and dysphagia. Substernal chest pain occurs in some patients. Patients with candidal esophagitis are sometimes
asymptomatic. Oral thrush is present in only 75% of patients with candidal esophagitis and 25–50% of patients with viral esophagitis and is therefore an
unreliable indicator of the cause of esophageal infection. Patients with esophageal CMV infection may have infection at other sites such as the colon and
retina. Oral ulcers (herpes labialis) are often associated with herpes simplex esophagitis.
Q:
What is the initial management for GERD?
A: life motification?
Q:
Do we to refer patient to surgery if the he just had colon polyp ca, confined only to the polyp not to the mucosa?
A: one guy: I think just remove the polyp is enough then repeat colonoscopy in 3-6 months
Need ref.
Q:
ileojejunum bypass, diarrhea, what kind of fluid you give?
A: choice is TPN, BUT normal saline+calcium and magnasium replacement
Q:
75 y/o male constipation, no other abnormalities, what is most likely cause
A:
Constipation is seen in 30% of elderly.
It's usually due:
-Declined or impaired general health status
-Drugs: Verapamil
- diminished mobility and physical activity
Treatment: Bowel training, exercise, high fiber diet and increase fluid intake
Pharmacologic treatment: Bulk laxative, emolient laxatives, hyperosmalar laxatives
Renal
A pt with gross hematuria, what is next ?
1. KUB
2. U/A
3. U/S
4. CT
5. IVP
Answer: Simple, non-invasive.
If RBC casts or distorted RBCs present, it points to a glomerular lesion
There may be a calculus, you will see calculi
Presence or absence of protein
If no RBCs seen, it points to myoglobinuria or hemoglobinuria.
That's a lot of information to guide further studies.
Q:
59 yr male with increased PSA, aymmtamatic what next
rpt psa in 6 month
biopsy
observation
A:
Depends on the value and age of patient...usually a PSA of more than 6.5 is taken as significant in a 60 year old and followed by biopsy. Also depends on the
examination of the patient
Q:
what is the most common complication after prostectomy???
A:
retrograde ejection from TURP, no ref.
Q:
A 35-year-old white man is brought to the ED after being involved in a motor vehicle accident. On examination, he is found to have multiple pelvic fractures.
Prostate examination findings are normal. No blood is observed at the meatus, but he has gross hematuria. What is the major cause of the hematuria?
A. Renal trauma
B. Bladder injury
C. Anterior urethral trauma
D. Ureteral disruption
E. Posterior urethral trauma
A: multiple pelvic fractures--- Bladder injury? No ref.
Q:
A 75-year-old man is diagnosed with metastatic prostate cancer as a result of a diagnostic work-up of back pain. He has no evidence of spinal cord
compression or impending bone fractures, but he has diffuse skeletal metastases.
What course of therapy would you recommend?
(A) Single-agent diethylstilbestrol
(B) A single luteinizing hormone–releasing hormone (LHRH) analogue
(C) A single nonsteroidal antiandrogen such as flutamide
(D) An LHRH analogue plus flutamide (complete androgen blockade)
(E) An LHRH analogue plus chemotherapy (mitoxantrone
A: D, LHRH agonists + Flutamide
As components of combined androgen blockade (CAB), controlled studies have shown survival benefits of flutamide plus a luteinising hormone-releasing hormone
analogue (LHRH-A) over LHRH-A alone, and for nilutamide plus orchiectomy over orchiectomy alone. Other studies have failed to show such survival benefits,
including those comparing flutamide plus orchiectomy with orchiectomy alone, and nilutamide plus LHRH-A with LHRH-A alone. In a direct comparative study,
bicalutamide (50 mg, once daily) was compared with flutamide (250 mg, three times daily), each in combination with an LHRH-A. Both therapies were well
tolerated, although more patients could not tolerate flutamide therapy: 25 flutamide plus LHRH-A and 2 bicalutamide plus LHRH-A patients withdrew from
therapy due to diarrhoea. There were no statistically significant differences for time to progression or survival between the two antiandrogens. This
clinical trial of bicalutamide confirms the prediction from preclinical studies that a 50 mg dose of bicalutamide would be appropriate for use in patients
with advanced prostate cancer, and demonstrates that this bicalutamide dose is clinically effective when administered as part of CAB.
Q:
Is voiding cystography and retrograde cystography same ?
What are their indications ?
voiding cystogram
Reflux is evaluated by a voiding cystogram and this generally requires a catheter passed into the bladder to fill it with an imaging substance. The catheters
used are very small (usually the same size used for newborn babies). Nonetheless, for a "first-timer" this procedure is threatening and requires some
preparation and reassurance. We give the patient a short course of antibiotics to cover this procedure if none are otherwise being taken. A contrast voiding
cystourethrogram (VCUG), will also image the entire urethra to rule out valves or other problems. Minimal x-*** exposure is involved and the testicles are
protected in boys. A nuclear voiding cystogram does not offer urethral visualization but involves almost negligible radiation. The bladder is instilled with
a tiny amount of radioactive material and the ureters and kidneys are scanned with a special camera during filling and voiding. The radioactive substance has
a very short life and is passed directly out of the urinary tract without absorption into the body. This test is more sensitive than the x-*** VCUG although
not quite as specific in showing the degree of reflux.
Reflux is classified into five grades -- grade I is the least and grade V is the most severe.
retrograde cystogram
A retrograde cystogram is performed to evaluate the structure of the bladder and identify bladder disorders, such as tumors, or recurrent urinary tract
infections. The presence of urine reflux (backward flow) into the ureters may also be visualized with this x-*** study.
tubelike instrument called a catheter through the patient's urethra and into the bladder. The contrast medium is then injected through the catheter into the
bladder. X-*** pictures are taken at various stages of filling, from various angles, to visualize the bladder. Additional films are taken after drainage of
the dye. The procedure takes approximately one to one and one-half hours and the patient may be asked to wait while films are developed.
Alternately, instead of a contrast dye and x-*** pictures, the test can be done with a radioactive tracer and a different camera. This is known as a
"radionuclide" retrograde cystogram.
Abnormal results may indicate:
stones
blood clots
tumors
reflex (urine passing backward from the bladder into the ureters)
Essentially both are the SAME.
Read above.
Q:
A man with painless mass in testis
a.Give him antibiotics
b.do a ct pelvis
c.examine him after 6 weeks
d.send for urology consult!
A: I agree the answer should be d among these choices.Urologist do the BX or whatever necessary in this pt as this is likely to ba testicular tumor
Don't mislead others. Never bx a testiculat tumor.
Q:
a 65-yo old pt with prostate cancer (probably at stage B1, forgot exact..). After discussing with pt about the treatment option, he emphasizes that he wants
to have a treatment which will not affect his sexual function. So, you recommend him for the following treatment:
1.radiation
2.surgery (prostectomy)
3.Hornone
4.chemotherapy
I¡¯m sure there is no ¡°watchful ¡¡± in the choice
A: i will select radiation here. The side effects are milder than prostectomy.
radiation alone is needed for stage b 1.
chemo has no role in treatment at this stage.
Need ref. Here
Q:
pian less hematuria in lady with no menses, next
1. cysto
2. ua
3. us
4. ??
A: UA is the first step..it tells u a lot
infectious cause, renal glomerular cause, stones,bladder cause etc etc
the above mentioned causes are the most common ...
so UA is the first step then after that u go for other test to rule in /out other diagnosis
UA for infection, ketones, protien, crystals RBC WBC etc etc
Q:
post mva suspect bladder trauma, most sensitive exam
a ct
b u/s
c peritoneal lavage
d kub
A:
Preferred Examination: Retrograde cystogram, performed after urethrogram, was considered the criterion standard for evaluation of bladder trauma. However, in
recent years, enthusiasm has grown for CT cystography for proper diagnosis. Initial studies were not indicative of CT reliability when retrograde contrast
was not used. However, contemporary studies have overwhelmingly demonstrated both sensitivity and accuracy, provided that adequate bladder distention with
contrast material is achieved prior to performing the study with at least 300-400 mL of contrast.
Ultrasound has never been sensitive or specific enough to be useful for evaluation of bladder rupture.
Even in this article it is CT Cystography. So I think rather than choosing CT, cystography is a better choice
Other said: also emed. Most patients have multiple injuries and require abdominal or pelvic CT scans as part of their trauma evaluation. This does not
preclude obtaining a separate contrast cystogram, since a CT scan of the pelvis using intravenous contrast alone is an unreliable study for bladder rupture.
A properly performed cystogram consists of an initial kidney-ureter-bladder (KUB), followed by anteroposterior (AP) and oblique views of the bladder filled
with contrast, plus another AP film obtained after drainage. The following procedure is recommended:
So kub first, if cystogram then it is the answer, ct will not be the intial as pt will be too sick and pelvic # need more er management first.
Q:
nausea vomitting taking digoxin, stable, k+6.0
a) give ca gluconate
b) digiband
c) take digoxin levels
A: Because the patient is not that toxic, I do not think Digibind is a good choice. well, if there is choice of discontinue digoxin, that would be the first
step.
Digibind is for severe toxicity
For stable patient, no need of digibind. Discontinuing digoxin is enough
Blood
Q1
woman on HRT gets DVT-next step:stop HRT? begin anticoagulants?
Answer:
http://www.2womenshealth.co.uk/27-22.htm noneed to stop HRT, can give anticoagulants.......
if stop hrt & start anticoag.
is an option i will go with it..........
Was that there?
Koosti read somewhere, if HRT already start long time( > 9? mons), then do not need to stop HRT, if HRT just started for short time, better stop. After all
stop HRT or not did not show too much diff (ref. May from uptodate)
Q2
A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being
treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents
recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
1.Increase the warfarin dose to bring the INR into therapeutic range
2.Switch to dicumarol
3.Interrupt the inferior vena cava with a filter
4.Discontinue warfarin and begin heparin at a therapeutic dose
5.Discontinue warfarin and begin thrombolytic therapy
Answer: the correct ans is dicontinue warfarin & start on heparin as pt's inr was not on therpeutic range which resulted in 2nd dvt.start pt again on
warfarin at higher dose than before & when inr is therapeutic d/c heparin after 48 hrs.
Q3
subarachnoid hemorrhage in pt taking coumadin:
1- ffp.
2- vit K
3- whole blood.
4- stop coumadin and do nothing.
5- cont coumadin
Answer: Agree fresh frozen plasma ..reason immediate action..VIT. K takes several hours..
Q4
A 1 year old returns for follow-up for a recent admission to the hospital for symptomatic treatment of painful, swollen hands and feet. with peripheral
picture of sickle cell anemia
1. What is the most likely hemoglobin electrophoresis pattern found on his original newborn sample?
a. Hemoglobins F, A, andS
b. Hemoglobins F and S
c. Hemoglobins F, S, andC
d. Hemoglobin F only
2. What is the most important drug to prescribe at this visit?
a. codeine
b. hydroxyurea
c. penicillin
d. iron
Answer: This baby is homozygote, because heterozygotes are normal and do not experience hemolysis, painful crises or thrombotic complication.
In AS (hetero)Hb electrophoresis will show Hb A and Hb S But in SS ( Homozygotes ) there will be only
Hb S with variable amount of Hb F and no Hb A.
penicillin should be choice for 2nd Q.
prophylactic antibiotics and pneumococcal vaccine are in general for sickle cell Pt. Penicilline prophylaxis with continous oral therapy (begening at age 4
month ) have reduced mortality, particularly during childhood.
Hydroxyurea is indicated in patients whose quality of lief is disrupted by frequent pain crises ( so one painful crises would not be the indication of
Hydroxyurea in next visit )
Q:
A pt on warfarin and heparin develops thrombocytopenia and petechias, what is next ?
a. d/c heparin only
b. d/c warfarin only
c continue both
d d/c both
A:
D/C both...
Warfarin has been associated with worsening venous thrombosis, venous limb gangrene, and/or skin necrosis when used alone or in combination with ancrod in
acute HIT. However, warfarin is appropriate for longer term anticoagulation in patients with HIT and thrombosis. Warfarin should be delayed until therapeutic
anticoagulation with danaparoid, lepirudin or argatroban is achieved, and ideally, until there is substantial resolution of the thrombocytopenia.
Warfarin-induced thrombotic complications have been described in patients in whom the alternative anticoagulant was stopped prior to resolution of
thrombocytopenia. The optimal duration of anticoagulation in patients with HIT and thrombosis is not known.
Q
A 25 year old postpartum female, develops oliguria, dark urine,and petechiae on lower limb.Labs: normal INR, decreased platelet count, decreased Hemoglobin,
normal U/A.The most likely dg is:
a) HUS
b) DIC
c) ITP
d) renal artery throbosis
A: should be A, It is common in postpartum state, anemia, renal failure with normal coagulation profile.
Q:
warfarin and heparin!!!!!!
why should we give heparin before warfarin for eg in PE
can we give it alone?
A: warfarin takes time to get thereputic effect
what about skin necrosis thing?
if protein c deficencicy present giving wafa will cause this
need ref here!!!
Q:
A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being
treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents
recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
1.Increase the warfarin dose to bring the INR into therapeutic range
2.Switch to dicumarol
3.Interrupt the inferior vena cava with a filter
4.Discontinue warfarin and begin heparin at a therapeutic dose
5.Discontinue warfarin and begin thrombolytic therapy
Explanation
Answer: 4
This 50 year old man has suffered a recurrent venous thrombosis, most likely from suboptimal prophylactic anticoagulation. The target INR for warfarin
anticoagulation to prevent recurrent thromboembolism is 2.0-3.0. When a new thrombosis is diagnosed, therapeutic doses of heparin must be initiated. Simply
increasing the warfarin dose to bring the INR into therapeutic range is inadequate, because warfarin is used for prophylaxis only, rather than for the
treatment of acute thrombosis. For the same reason, switching to a different anticoagulant like dicumarol would be ineffective. After starting up heparin he
should be restarted at a higher dose of warfarin.
\Interruption of the inferior vena cava with a filter is primarily indicated only for patients in whom anticoagulation is contraindicated or in whom
thrombosis has recurred despite adequate prophylactic anticoagulation. Neither of these considerations applies to this patient.
Thrombolytic therapy is not necessary in most case of DVT of the leg. This mode of therapy can be considered in patients with extensive venous thrombosis,
particularly involving extension into the inferior vena cava, in order to prevent long-term postphlebetic complications.
Q:
The method of choice for initial evaluation of bone involvement in patients with multiple myeloma is.
A - Technetium-99m bone scanning
B - Conventional roentgenograms
C - CT-scanning
D - MRI of the skeleton
E - None of the above
A: Skeletal series
Perform a complete skeletal series at diagnosis, including the skull (a very common site of bone lesions in multiple myeloma), the long bones (looking for
impending fractures), and the spine.
Diffuse osteopenia may suggest myelomatous involvement before discrete lytic lesions are apparent.
The findings on this evaluation may be used to identify impending pathologic fractures, allowing physicians the opportunity to repair debilities and prevent
further morbidity.
Do not use bone scans to evaluate myeloma. Cytokines secreted by myeloma cells suppress osteoblast activity; therefore, no increased uptake is observed.
MRI scan
Findings on MRI scans of the vertebrae often are positive when plain radiographs are not.
For this reason, evaluate symptomatic patients with an MRI scan to obtain a clear view of the spinal column and to assess the integrity of the spinal cord.
( Ref: emedicine)
bone scan is unreliable in multiple myeloma because the lytic process of MM doesn't take up radioisotope.
MR is no specific for bont lesions of MM,could use if to see extramarrow hematopoietic sites.
End of the session on this question.
Endocrine
Q1
32 years old hypothyriod pt. got pregnent, what you will advise regurding medication,
1.have to stop medication because of teratogenicity.
2 have to decrease dose
3 have to increase dose
4 dont have do to anything
same pt. came 5 month after delivery wants to start OCP for contraception. your advise.
1. can't take OCP
2 have to increase the dose of levothyroxine
3.have to decrease the dose of levo'
4 need higher dose OCP
Answer: Increased in both situations(well for OCP is another choice!) ....Finally, pregnancy is associated with significantly increased levothyroxine
requirements and many hypothyroid pregnant women will require a 30% or higher increase in their dose....
....Estrogen therapy increases the protein that binds thyroxine in the blood. It is possible that some patients who start treatment with estrogen hormones
(for example, Premarin or oral contraceptives) may require an adjustment in their levothyroxine dose. It is prudent to check a TSH a few months after
starting an estrogen containing medication to be sure that the dose requirements have not changed...
Q2
thyroid storm and myexedema In these two cases, do you start trating empirically or wait for the labs to confirm the diagnosis. t4 takes 7hours and the
others two days!!
Answer: Final Comment Family physicians should be alert for myxedema coma, particularly in elderly women with mental status changes who present during the
winter months. An accurate diagnosis generally follows a careful history, physical examination and laboratory evaluation. The most important elements in
treatment of myxedema coma are early recognition, "presumptive thyroid hormone replacement", hydrocortisone and appropriate supportive care. While myxedema
coma carries a significant mortality rate even with appropriate testing and treatment, an early diagnosis of hypothyroidism may well save a patient's life.
one correction ; Pt should be covered with regular blanket because warm blanket will cause vesodilatation.
RE;American family Physician Journal
dec.1,2000
Q3
DM unhealing ulcer, do you do debriment first? or Abx first?
Answer: debridement then Abx
Q4
DMI glucose 160 wants to sport:
1- insulin before match.
2- glucose before match.
3-nothing
Answer: 3-nothing
Q5
pt has been treated with lithium and developed hypothyroidism. after stopping lithium, when do you do tsh:
1- 3ds
2- 1w.
3- 2w.
4- 1m.
5- 3m
Answer: TSH levels take time to normalize, so 1 month seems like a good bet. Could not find any ref.though.
Anant's ref. for the above ques. could apply for this one too.
Q6
pt has been treated with 0.075 mg thyroxin for possible hypothyroidism. you want to stop the drug and test the patient to see if he really has hypo-, when:
same options like the previous.
note: the amount is real.
Answer: 3 ie 4-6 wks after starting treatment for hypothyroidism An initial dose of thyroxine of 0.05 to 0.075 mg per day is usually sufficient to normalize
the serum thyro
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