| Original Message |
Anonymous (no login)
Posted Jun 17, 2008 9:57 PM
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 d1. Treatment of BV in Premature CONTRACTIONS (note not Premature labor!) - pt 29 wks pregnant, with mild uterine contractions, irregular, cervix dilated at 2cm, BV Symptoms, on exam, you find clue cells:
a. Tocolytic MgSo4
b. Po hydration and metronidazole
(clindamycin was not in the choice)
2. s/p renal transplant patient presenting with HTN– I think the question was about the possible etiology of HTN in this patient : RAS
3. vulvar discharge and urethritis in women – chlamydia - TREATMENT? Doxycycline (no ceftriaxone in choice or in combo with doxy)
4. Down Syndrome in baby presenting with VSD and turning blue on feeding: 1. Further evaluation? ECHOCARDIOGRAM and 2. LONG TERM Px – will develop what? ACUTE LEUKEMIA
5. Breast tenderness /swelling /weight gain / acne : change to OCP? Decrease Estrogen in OCP
6. Scoliosis 30 degrees/3cm on Xray – next step?
a. Follow up in 9 months
b. Refer to ortho
7. Trichomonas Vaginitis – Treat patient and partner
8. Pt DNR, wife supports, children disagree, patient has advance directive to terminate life support:
a. Terminate life support
b. Discuss with family members
9. Teenager with multiple partners requesting OCP
a. Prescribe it to her and encourage condoms
b. Contact parents before prescribing
10. Parkinson’s Disease patient on Levodopa/Carbidopa with visual hallucinations and difficulty sleeping at night –
a. Haloperidol
b. Carbamazapine
c. Risperidone
11. MVA - multiple rib fractures with hypertension and tachycardia – most likely etiology of presentation : Flial chest? Pneumothorax? Mycocardial contusion?
12. JVD, hypotension, absent breath sounds – Diagnosis? Pneumothorax Next step? Chest tube placement
13. Questions about Ventilator settings for patients in the ICU – Patient with bad asthma , intubated, now in the ICU, ABG showing poor oxygenation – next step? Increase PEEP, Increase FiO2, Decrease minute ventilation – now the patient is getting better with improving ABG and a CXR shows Pneumomediastinum – next step? Decrease inspiratory pressure, decrease PEEP, insert mediastinal tube, B/L chest tubes, Decrease ventilatory rate….
14. Capillary hemangioma picture– Prognosis? Most likely to disappear within one year
15. Homosexual patient presents with fever, cough, tachypnea and rusty sputum, XRAY (showing RML infiltrate) and GRAM STAIN (showing gram positive cocci in chains) – diagnosis? The choices included :
a. PCP
b. Strep Pneumonia
c. Legionella
d. mycoplasma
16. Patient with risk factors for Hepatitis C and diagnosed with Hep C: what’s the prognosis for this patient:
a. patient will recover completely with treatment
b. will develop Hepatocellular Carcinoma
c. Patient will acquire Hepatitis B as well
17. Statistics : NNT (number needed to treat)? Given that incidence for some disease decreases from 8/1000 to 6/ 1000 (25% RR reduction)with some treatment, the number of people you would need to treat to prevent one case from occurring ? -
a. 250
b. 1000
c. 2000
d. 800
e. I don’t remember the other numbers
18. Stats – Increase Sensitivity (60% to 90% of cases being detected) – would also affect what? :
a. Increases false positive rates
b. Inc ppv
c. Inc npv
d. Inc true positives
19. RR reduction of cardiac sudden death with low dose HCTZ (25mg) vs. (100mg) of HCTZ given in the question as RR reduction = 0.3 with no 1 in CI (therefore making it significant) –interpret this :
a. Decreases risk by 70%
b. Decreases risk by 30%
c. Not a significant result
20. Patient presents with Schizophrenia with paranoid symptoms. Dx? Schizophrenia, paranoid type
21. EBV 19 yr old patient – next step to diagnosis?
a. Monospot test
b. EBV titres
c. Strep RAD test
d. Culture /swab
22. Patient presents with peripheral edema with no hx of CHF or kidney disease Patient on a few drugs one of which was diltiazem : etiology of this patient’s presentation:
a. Diltiazem
b. Other drugs that the patient was on : none that specifically caused peripheral edema as a side effect
23. Pt on nitrates and Ipratropium Bromide presents with orthostatic hypotension, history of really bad COPD and CAD (might be stable angina?) : next step? D/c nitrates? D/c Ipratropium?
24. hyperlipidemia treatment: 35 yo female with an LDL > 198 with Family history of hyperlipidemia – diet and exercise? Start treatment with statins?
25. man with BPH/ HTN/ and urinary incontinence : Best treatment for this man’s hypertension :
a. Thiazides
b. Propranolol
c. Furosemide
d. Terazosin
26. In January, members of the family having URTI symptoms and one year old patient presents with what sounds like a viral infection and mild periods of apnea : what is the most likely etiology?
a. RSV Bronchiolitis
b. Strep Pneumonia
c. EBV
d. Croup
27. A four month old child with pneumonia like presentation with rhinorrhea and CXR showing peribronchial thickening, the most important question to ask to aid with differential diagnosis:
a. Vaccination history
b. Conjunctivitis as a new born
28. HIV + man doesn’t want to tell his wife and will not stop relationship with her – the most appropriate statement to this man is:
a. I really am in a difficult situation here – can we work together to find the right solution
b. I will inform Public health authorities and they will then inform her
c. The other choices were really inappropriate – don’t remember what they were
29. hepatits C man comes in – newly diagnosed – admits to having sexual relationship with multiple partners – what will you do next?
a. Give him Hepatitis A and Hepatitis B vaccines
b. Treat him with Interferon (?)
30. SBP in a patient with history of Cirrhosis – next step in management? Admit and start IV ABX
31. Salmonella Osteomyelitis in a 1 yo boy, suggestion of mild anemia in the question(?)– next step? Hgb Electrophoresis
32. RECURRENT Maxillary Sinusitis in a girl whose parents both smoke with opacification of both sinuses – Parents should be told that:
a. Smoking associated with her disease
b. She’s using cocaine
33. She’s coughing and smells of smoke and has dirty nails (or something like that) on the next visit – the best explanation for this is? She started smoking too
34. 25 yo pt wants Norplant injection – no contraindications given– ans: r/o contraindications and give Norplant
35. PID (classic presentation) - patient’s condition most likely caused by: gonorrhea (chlamydia not given as choice)
36. Atopic Dermatitis (blisters) : Prognosis?
a. Will disappear and never recur because the patient would develop antibodies
b. Rash will most likely be gone in 10 days
37. Before starting patient on chronic corticosteroids – what is the most appropriate test? DO a bone densitometry (??)
38. Radial fracture – management :
a. Cast 3 wks
b. Sling
c. Cast 6 wks
d. ORIF
e. Observe
39. Spousal abuse, poor family, having trouble making ends meet, both patient and husband are not educated, patient is not willing to leave husband who uses alcohol frequently and was arrested for DUI. The next step in management in this patient is:
a. Report to Protective agency
b. Remove patient from home and admit
c. Tell her that you will help in whatever way you can, give her shelter phone number and to go to emergency whenever needed
40. the second part– The degree of danger in this situation is correlated with
a. substance use ( alcohol)
b. arrest for DUI
c. Financial instability of family
d. Poor education level of both parents
41. Growth Chart ( case cluster) : wgt dropping , hgt stable, otherwise nl growth chart and unremarkable medical history in a 5 month old baby :most likely explanation for the growth chart? :
a. nutritional deficiency (deprivation)
b. major medical illness
42. Anemia in a patient with Chronic disease found on regular check up and no hx of cancer – immediate Tx?
a. Transfuse
b. Fe supplements
43. In the above – next best step in the evaluation of anemia? Reticulocyte count
44. Beta thalassemia- Dxed - blood transfusion done : risk for long term hemochromatosis:
a. Chronic Oral Fe supplements
b. Chronic blood transfusion
c. Anemia
45. Hypothyroidism 2ndry to lithium tx – management?
a. Add levothyroxine
b. d/c lithium
46. 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)
47. Pt on chronic steroid treatment, Xray of hips – possible avascular necrosis – the best management : B/L hip replacement? ORIF? Cast ?
48. In a clinic setting, there was TB exposure to all employees : next step?
a. Start tx with all 4 drugs
b. Tx all with INH for 6 months
c. Do PPD on all those exposed to the active TB person
49. Pt (HIV -, no other comorbidities) with PPD + (> 15mm), CXR neg – Txed with INH for 6 months – F/u?
a. PPD Qyr
b. CXR annually(?)
c. PPD Q5yrs
d. Tx with INH for another 3months
e. Tx with INH for another 6 mths
50. Pt is a chronic smoker, wants to quit, has tried to quit in the past with patch (?) but didn’t work, really wants to quit now – next best step is to prescribe?
a. Bupropion
b. Low dose nicotine patch
c. Do nothing
d. Nicotine gum
51. To confirm the diagnosis of Parkinson’s Disease in a patient presenting with a hx consistent with PD –
a. CT scan of the head
b. Nothing further
c. LP
52. An elderly pt in hospital – with hx of dementia presents with psychosis and visual hallucinations , agitated, I think the pt had a hx of alcohol use – most likely cause for presentation:
a. Delirium
b. Don’t remember the other choices
53. PMS associated with :
a. Depression
b. Mania
c. Antisocial personality disorder
54. Human Bite on forearm (note that it is not on the hand which would have a high chance of infection and therefore admission with iv abx would be the choice of management) - the right ABX for prophylaxis is :
a. Amoxicillin-clavulunate
b. PCN
c. Ampicillin
d. Nothing
e. Isolate patient
55. Hx of cat scratch on face/cheek – papule on cheek – abscess like structure with cervical lymphadenopathy – sounded like cat scratch disease - Tx for this pt:
a. I & D
b. Self-limited
c. ABX tx
56. DM in pt with malignant otitis externa – pseudomonas – tx?:
a. Topical abx
b. Po amoxicillin
c. Acetic acid drops
d. Draining of external canal
e. Admit to hospital and tx with iv abx
57. Electric Burn on fingers only – painful – after hydration, next step?
a. ABX therapy
b. Tetanus toxoid
c. Nothing
58. 8 yr old child with dirty wound after a fight at school – Parents immigrated from Russia recently and mom doesn’t speak English, sister translates, say that the pt has received one injection since birth – in this patient, you would give :
a. Td, Tig and hepatitis B vaccine
b. Dtap, Hib and MMR
c. Nothing
59. picture – cottonwool exudates in diabetic retinopathy – poorly controlled Diabetic patient - , next step –
a. refer to ophthalmologist
b. do nothing
c. Inc glyburide dosage
60. DM in a boy wanting to play a sport after school – how would you adjust his insulin?
a. Dec Insulin dose before starting exercise program
b. D/c insulin
c. Increase insulin since his requirement would increase
61. EKG given, dx? 1st degree hrt block
62. Elderly gentle man with terminal illness, now presents with acute Stroke - has a DNR order, comes to the ER with family - next step:
a. Send home on pain meds
b. Admit and start tx for stroke
63. Chronic Renal Failure and HTN. Best tx?
a. ACEInhibitors
64. GERD in a middle age women refractory to medical treatment(has been on all drugs with no relief) – next step:
a. Refer to surgeon (nissen fundoplication)
b. Start a different drug
65. CI interpretation: RR with CI given, which of the following is significant?
a. 0.3 (0.2 –0.56)
b. 0.7 ( 0.5 –1.5)
c. 0.95 (0.9 –1.9)
66. Brst tenderness, nausea, headache on OCP :
a. dec estrogen
b. Dec estrogen, inc progestin
67. Pt s/p suicide attempt which she denies, and says she wants to see you everyday of the week for a few hrs and that it’s the only thing that would be of help to her because you’re the only one who understands her , and seductive behavior – m.likely has:
a. Schizophrenia
b. Depression
c. Psychosis
d. Borderline Personality Disorder
68. Episodes of deterioration and multiple neurologic deficits, demented pt with new onset urinary incontinence – dx?
a. Multi-infarct dementia
b. Alzheimer’s
c. CJD
69. Hypervolemic Hyponatremia with a Una 72, Sna 120, Sosm 240 in a male presenting to you with confusion and history of smoking, CXR showing a mass around the hilar area, pt also on chlorpromazine. M. likely cause of findings:
a. Chlorpromazine toxicity
b. SIADH
70. Know Peds developmental milestones – mom and child come to you for office visit – Child is 2 and only saying mama and dada – mom asks you if child is developing normally?
a. Reassure
b. Send for hearing test
c. Perform further evaluation
71. Cervical spine evaluation in a trauma pt – get all of the following except:
a. AP
b. Odontoid
c. Lateral
d. Oblique
e. Flexion and Extension
72. Trauma pt comes in with absent breathing. The first step in this pt is :
a. Assess the airway (remember ABCs!!)
73. Pt in ICU setting – ARDS – on ventilator. An ABG was given -- FiO2 was 70- asked something like next step in management:
a. Inc fio2
b. Add peep
c. Dec fio2
74. A 35 yo asymptomatic women with Family history of Brst Cancer in mom and sis in their 60s comes for office visit and is concerned about family hx, wants to be evlauated – best management?
a. Baseline mammo now and Q2yrs after 40
b. Baseline mammo now and Qyr after 50
c. She’s at no risk, therefore, she need not be worried
75. 33 yo women presents with Bvaginosis and a pap smear done at this visit shows ASCUS (no CA risk factors). You treated her for BV and the next step as a follow up for Pap smear is:
a. Colposcopy next visit
b. Cone Bx
c. Pap smear in one yr
d. LEEP
76. LGSIL (Pt is reliable, long-term pt of yours with no risk factors and previously nl pap smear) - next step: F/U pap smear in 6 months
77. Asthma exacerbation, poor oxygenation with hx of previous intubation now coming in with severe SOB- next step?
a. Admit and start iv corticosteroids
b. Intubate
c. D/c on albuterol and Po steroids
78. Pregnant women and radiation from computer – you would recommend that
a. No inc risk as long as she limits exposure to 2hrs/day
b. Limit exposure to 20 hrs/wk but no greater than this
c. No known risk in pregnancy to the baby from radiation from computers
79. Smoking cessation – another question – pt motivated to quit and has tried to quit many times in the past without success. Pt says that starts shaking and other symptoms on quitting smoking are unbearable for her. You should:
a. Prescribe low-dose nicotine patch
b. Prescribe Bupropion
c. Prescribe nicotine gum
d. Advice to quit smoking
e. Congratulate pt on her decision
80. pt presents with dysphagia, drooling, fever, now very lethargic and confused , hx of family going camping and spending lots of time in caves:
Most likely dx:
a. RABIES
b. Tetanus
c. Pertussis
d. Epiglottitis
Most appropriate statement about this patient’s condition at this point is :
a. Very poor prognosis
b. Pt will recover completely with treatment
c. This will worsen in the next 24 hrs then begin improving
81. Prostate CA with mets to the back – pt comes in with severe pain, already on narcotic analgesic, no symptoms of Spinal Cord compression. You would:
a. Immediate radiation tx
b. Start high dose hormone suppression treatment
c. Start steroids
d. Consult urology immediately
82. colonic polyp and screening following resection (one colonic polyp – which showed ½ adenocarcinoma, the other half is free of cancer – no family hx) :
a. annual colonoscopy
b. Elective Sigmoid resection
c. Hemicolectomy
83. Large Bowel obstruction – next step in management?
a. Stat surgery consultation
b. Supportive treatment
c. D/c home and f/u in clinic
84. Chinese American mom asks for female circumcision for her 1 yo girl as suggested by her grand father who is visiting from China. Your response:
a. If you want it you should go outside the USA
b. Sorry, I don’t do things like that
c. Have you or any other female member of your family had this done?
85. lots on ethics – what would be your next statement to this patient?
CCS
Torsion of the ovary in a 23 yo female
Viral Pneumonia in a 6 yo African American boy
Nephrolithiasis in a truck driver – passing stone with UTI on UA
Sigmoid diverticulitis with pericolic abscess and free air in the peritoneal cavity in a 46 yo obese, sedentary, caucasian women
New-onset DM in a 17 yo girl with UTI
Community acquired pneumonia in a 45 yo women
Splenic hematoma in a middle-age Asian American man
Pulmonary Embolism in a man who was in a long flight from Australia – pt with hx of CHF and HTN
PID in an 18 yo pt that didn’t meet criteria for admission (tx with one time dose of ceftriaxone and azithromycin and f/u in 24hrs)
Know these:
-choosing the right method of contraception for patients in different age groups and different histories
-human, cat, dog bites and rabies, tetanus shots
-Pictures of glaucoma, DM, man with herpes zoster, capillary hemangioma
-immunizations in immigrants, travelers and all kids
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I am in this form sometimes....but i feel that i should not just see this forum and leave , take print out and go..
I will try to paste as much as notes i have for step3 and recalls from this forum ....
I have not taken the exam yet.... i don't know if i going to be successful or not....but i want to give back to this forum much more than it gave me.....
Thank you again..
Bull
!!! bites notes!!! September 28 2003, 4:52 AM
a)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 inthe buttocks if kids and in adult in deltoid muscle...and make sure igand vaccine should b on sep sites of injection...
if neighbours dog bites which has all his vaccination upto date then just reassure the victom and clean with soap and water....nothing to worry about
if human bites to another human in my exam they gave a q that a man comes with a bite wound that result in swelllingof his whole forearm...and on qustioninghe admiited that his wife bit him... what u will do....since human bites r worse tahn all other bc zof aerobic and anaerobic becteria in one s mouth need sp attention and treta mentin this man case since it was such an extensive lesion so we have to admit him and give him iv antibiotic....augumentin is goood as out pt and inpt u can give ampicilline.ivand clindamycine
if cat bites if kid is asymptomatic do nothing just clean with soap and water ... if extensive wound then give ampicillin or augumentin
if dog bites same augumentin or amp...(domestic)
scorpion bites ..... brown reclouse ...will cause stinging sensation,sloughing ,necrosis need dexamethasoneand tetanus....
if black widow bites then u will have abdominal cramps and rigidity u hav eto give calcium gluconate ...about snake bites i dont remmber much but its imp tooo..so read it.. they will also ask about botulism ......
in y exam they ask a mom is worried that babyis so lethargic not takingbotttle and she is not having any fever just dialted pupil on exam....and ans was did u give him honey lately.....other choices i dont recalll... lucine...u ask v goood q.....its v imp atleast 5-6 qs..on bites ..goodluck dear!!!blaze and gulabooo plez read it tooo...its usually on sec day
BROWN RECLUCE SPIDER September 28 2003, 11:33 PM
Add DAPSONE to the treatment ( familypractice.com)
and always remmber ppl who have allergy to sulfa or who r deficient in g6pd they dont need bactrim or dapsone if they have hiv or aids they need atovaquin...another exam q
================
Xray,Ekg and Pics in exam
pic of a kid with arm and mouth vesicular lesion i put cocksake 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.
achalasia....pic
pic of pudohyphe, I have this in my EXAM yesterday
kid with the xray chest with pnumo one side and bowel other..cong diaphragmatic.
It is a newborn and left diaphrama hernia asking which is the most commen complication??
======
Most sensitive/specific clinical parameters:
1)'pinna displaced inferiorly and laterally' =mastoiditis
2)'cervical motion tenderness' = PID
3)'tenderness of sinuses' = sinusitis
4)'fixed and immobile TM' = OM
5)'tender tragus or pain on traction of pinna' = Otitis externa
6) 'temp, chills, RUQ pain' = cholangitis
7)'palpable painless abdominal mass[typically, noticed by mom while bathing the kid] with hypertension' = Wilms tumor
8)'Rash that begins at hairline+ face with retroauricular/post cervical/post occipital LN' = Rubella
9)'high fever followed by rash in infants' =roseaola infantum
10)'growth failure assoc with cough & vomiting'= fistula or reflux
11)'muffled, hot potato voice' =quincy
12)'mid-dilated, fixed pupil with headache & red eye'=glaucoma
13)''orientation of long axis of oval macules &papules along lines of skin cleavage' pityriasis rosea
14)maculopapular rash that blanches with pressure, begins in groin,neck and axilla' = scarlet fever
15)'dark wavy lines that end in a pearly bleb' =scabies
16)h/o change in mental status+ pulmonary inf = FB aspiration
17)h/0 psoriasis + sore throat/inf = guttate psoriasis
18)'tenosynovitis' = gonococcal arthritis
19)'sandpaper like rash + strawberry tongue' = scarlet fever
The following sources are the best:
alll pic come in exam from crush so pay attention:
ekg all ist degree sec degree third degree blocks,and wpw,a fib,a flutter,they ask with dif senario what u will give for treatment...
like for svt which includeafib and a flutter if thereis no conraindication then bb is best
if they giv e history of chf then digitalis
never give verapamil in kids less than i yr for arrythmia
child< 1 year with umbilical hernia_______ Do nothing. ( do you agree) ?
a child< 1 year with hydrocele_______ Do nothing. do you agree)?
a child < 1 year with indiredt inguinal hernia ????
observe or interfere?
a man with incisional reducible hernia______ Do nothing
a man with reducible direct or indirect hernia ________ what should we do?
Faram
Agree with no treatment for hydrocele in a child < 1 yr
Addition...
Empty scrotum in a child < 1 year ==> observation and follow-up. Wait till the child is 1 yr.
Empty scrotum in a child > 1 yr ==> surgical removal of the abdominal/pelvic testis with orchiopexy.
Cryptorchidism in an adult ==> surgical removal without orchiopexy
==========
Anthrax - a guide for doctors and patients
Introduction:
Anthrax is a bacterial disease. It is caused by a bacteria that belongs to the same family as E. coli. called Enterobacteraciae. It is not a virus. Unfortunately, it has become a recent threat as it can be used for biological warfare.
The bacteria:
It is a rod shaped bacteria with rounded edges. It cannot be seen by the naked eye. Labs need a microscope to see it.
When doctors check or screen for bacteria, they stain the specimens commonly with a simple technique called gram staining. There are very few bacteria that are rod shaped and test positive on this test. Fortunately - for diagnostic purposes, anthrax bacteria test positive. This immediately raises a flag.
Modes of spread:
It is spread by its spores that can survive harsh natural conditions for years.
It may be transmitted by infected or contaminated animals and animal products, insect bites, inhalation or ingestion.
Spread of anthrax usually does not take place from person to person except where the patient has skin lesions. It could however take place by handling contaminated articles.
In the Florida cases, it seemed to be transmitted by exposure from spores that were sitting on the computer keyboard (I am looking at my own keyboard as I type this).
I do not want people to panic because Florida is currently one of the most prepared states in the United States to tackle this problem. In my own office, we have at least a hundred doses of medicines that tackle anthrax. I am sure other doctors are prepared too.
Types of disease:
It is seen in three main forms.
Skin (cutaneous), intestinal (gastrointestinal), and its most dangerous form - lung infection or pneumonia (pulmonary).
Cutaneous anthrax is the most common manifestation of infection with B. anthracis. Inhalation (pulmonary) anthrax occurs in persons working in certain occupations where spores may be forced into the air from contaminated animal products, such as animal hair processing. Occupational risk groups include those coming into contact with livestock or products from livestock, e.g., veterinarians, animal handlers, abattoir workers, and laboratorians.
A patient with this form of anthrax may present with a blister with central denting and surrounding swelling that cannot be indented.
This is full of the antrax bacteria, making it highly infective as it sheds a lot of bacteria.
The intestinal form shows up as diarrhea and fever. Fortunately the commonest family of drugs used to treat this type of illness even in the non-anthrax condition treats anthrax as well.
The lung form of the disease begins abruptly with high fever and chest pain. It quickly turns into a bleeding type of illness and is frequently fatal. These cases are not highly infective.
If untreated, anthrax in all forms can lead to the bacteria entering the bloodstream and quickly - death. Early treatment of cutaneous (skin) anthrax is usually curative, and early treatment of all forms is important for recovery. 25% to 75%. of patients with gastrointestinal (intestinal) anthrax will die. Almost 90 - 100% of those with lung anthrax will die.
Preventing disease and its spread:
Anthrax in the veterinary world commonly affects herbivorous animals. Human immunity against anthrax is higher than the herbivores. This does not mean that vegetarians are any less immune to the bacteria than non-vegetarians.
We must identify what common things that come in contact with many hands in a day's time and be cautious about their safety. I am going to list a few here.
Currency notes and coins, Paper files and inter office mail envelopes, Card swiping areas, e.g. time card machines and credit card machines, Support bars into a bus, Door knobs, Water fountains, Gas station vending handles, Vending machines, Public telephones, Perfume testers in a mall, Coins and tokens for a slot machine, Buttons at traffic signals used by pedestrians to get access, Library computers, books and video tapes, Rented video tapes, etc, Objects in churches that many people touch, etc.
Please wash your hands before you touch your mouth or nose after you touch something that may be contaminated. Avoid opening letters if you have a wound on your hands.
Treatment:
Early treatment is vital. Therefore you do not need to hoard a full course of the antibiotics that are effective but just the first dose alone.
Many good antibiotics are available that are approximately equally useful but Once symptoms of the lung form appear, fatality is high inspite of treatment.
Levaquin, Cipro, Tequin, avelox are good medicines that could be used.
Penicillin too is useful as are many other antibiotics.
Most commonly, the skin form comes along and one can treat that very effectively.
What should your doctor do?
Having been a licensed practitioner for over 10 years, practice of reasonable and economical medicine has now become second nature to me. I am not trying to say that what is outlined here is perfect but these guidelines will certainly help those who have not put in a lot of thought into this. If other doctors also put in thought into this, they will come out with similar answers.
If a patient wants to keep antibiotics at home for him and his family, he should only be offered dosing for 24 hours.
This means 2 tablets of Ciprofloxacin (Cipro) or 1 tablet of Levaquin or Avelox or Tequin. He should be told that this should be given if suspicion is high and the patient should be examined by a doctor soon.
Giving out long courses are going to create a shortage and thus further panic in the community.
If the doctor has a suspicion of anthrax in the patient, he should immediately draw and keep blood from the patient and then administer the first dose of the antibiotic immediately.
If it is a skin lesion that the doctor sees, he should take a scraping from the skin lesion and send part of it for a Gram stain and another part for culture. Antibiotic of course should be given immediately.
Doctors also should try to avoid use of these antibiotics in conditions where other antibiotics are equally effective.
What does it mean that the cases are due to genetically un-altered bacterial strains?
Since the cases had the above type of strain, it is unlikely that these are from terrorists. It is more likely that someone who has animals got that strain and now has mailed the stuff to different people across the country. One should look through veterinary records and match up people who owned animals that died of anthrax in the Tampa-bay area. I could certainly be wrong but I rarely am.
How concerned should we be about the future:
Not very. I am not an astrologer nor a psychic but seeing that these cases have been from unaltered bacteria, I feel that these are not well prepared terrorists left around. Had this attack come from well prepared terrorists, we would have seen very communicable, genetically altered anthrax strains. They would have used their biowarfare material already within this one month. Regardless, almost all doctor's offices are well prepared with antibiotics.
Vaccine:
In the civilian world, the health departments are most likely going to be the first to recieve vaccine supplies. I think that many of us doctors should volunteer and offer to give out the vaccines if that is decided by the government. Our clinic has already registered with the health department for this purpose.
===============
it is easier to remember the nonreportable diseases...
this would be
Herpes[pt is already crying with pain,so u dont have to bother to report it!thats the way i remember it]
HIV +ve status
Chlamydia[but in ur list,i see that it is nonreportable?]
------------------------------------------------------------------------------------------------------------------------------
Reportable diseases:
A single case of a disease of known or unknown etiology that may be a danger to the public health.
Unusual manifestation(s) of a communicable disease.
An outbreak of a disease of known or unknown etiology is reportable immediately by telephone.
Acquired immunodeficiency
syndrome (AIDS)
Amebiasis
ƒÏAnimal bites
ƒÏAnthrax
ƒÏBotulism
Brucellosis
Chancroid
chlamydia
ƒÏCholera
ƒÏDiphtheria
Encephalitis
Gonococcal infection
ƒÏHaemophilus influenzae type b
invasive disease
Hepatitis, viral (AƒÏ, B, C, all other
types and undetermined)
Kawasaki syndrome
Legionellosis
Leprosy
Leptospirosis
Lyme disease
Malaria
ƒÏMeasles (rubeola)
Meningitis (viral, bacterial,
parasitic, and fungal)
ƒÏMeningococcal disease
Mumps (infectious parotitis)
Mycobacteriosis, other than
tuberculosis and leprosy
ƒÏPertussis
Pertussis vaccine
adverse reactions
ƒÏPlague
ƒÏPoliomyeltis
Psittacosis
ƒÏRabies
Rocky Mountain spotted fever
ƒÏRubella (German measles) and
Congenital rubella syndrome
Salmonellosis
Septicemia in newborns
Shigellosis
Syphilis
Tetanus
Trichinosis
Tuberculosis
ƒÏƒnTularemia
ƒÏƒnTyphoid fever (case or carrier)
Acquired immunodeficiency syndrome (AIDS)
Anthrax
Botulism
Brucellosis
Chancroid
Chlamydia trachomatis, genital infection
Cholera
Coccidioidomycosis
Cryptosporidiosis
Cyclosporiasis
Diphtheria
Ehrlichiosis, human granulocytic
Ehrlichiosis, human monocytic
Ehrlichiosis, human, other or unspecified agent
Encephalitis, California serogroup viral
Encephalitis, eastern equine
Encephalitis, St. Louis
Encephalitis, western equine
Escherichia coli: enterohemorrhagic (EHEC), O157:H7
Gonorrhea
Haemophilus influenzae, invasive disease
Hansen disease (leprosy)
Hantavirus pulmonary syndrome
Hemolytic uremic syndrome, postdiarrheal
Hepatitis A, acute
Hepatitis B, acute
Hepatitis B, perinatal
Hepatitis C; non-A, non-B
Human immunodeficiency virus (HIV) infection, adult
HIV infection, pediatric (<13 yrs)
Legionellosis
Listeriosis
Lyme disease
Malaria
Measles
Meningococcal disease
Mumps
Pertussis
Plague
Poliomyelitis, paralytic
Psittacosis
Q fever
Rabies, animal
Rabies, human
Rocky Mountain spotted fever
Rubella
Rubella, congenital syndrome
Salmonellosis
Shigellosis
Streptococcal disease, invasive, group A
Streptococcal toxic-shock syndrome
Streptococcus pneumoniae,invasive, drug-resistant
Streptococcus pneumoniae,invasive, <5 yrs
Syphilis
Syphilis, congenital
Tetanus
Toxic-shock syndrome
Trichinosis
Tuberculosis
Tularemia
Typhoid fever
Varicella (chickenpox)*
Varicella deaths
Yellow fever
==========
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 excetion for the patient's autonomy after hhis 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
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.
A patient presents with heartburn and regurgitation..
First step..Life style modifications..
Failed..
The patient can be tried on H2 blockers/anatcids/promotility drugs..
Doesnot respond..
Trial of omeprazole..
No response..
24-hour esopaheal PH monitoring/ Esophageal acid infusion test (Bernstein test)
Proton pump inhibitors are indicated for use in severe GERD or if it is resistent to other treatments.
Fundoplication is the last resort.
Question examples::::
45 year old obese patient came to you with epigastric pain..first step:
a-EKG
b-CXR
c-Zantac
EKG first...Epigastric pain can be cardiogenic!!!
Next step:
a-Lansoprazole
b-Zantac
c-Counselling the patient about losing wieght, bed head elevation..
The answer is of course C
Came to your office 4 weeks later and the heartburn persists:
next step
Zantac or Tagamet (H2 blockers) for 8 weeks
Came back with no response..next step:
a-Omperazole
b-Increase the dose of Zantac
c-Fundoplication
Choose A
The patient's pain is improved. The patient came to you after five years..next step:
Endoscopy
To rule out Barett esophagus!!!!!!1 The most common LONG-TERM complication of GERD!!!!
well in IBS, the anticholinergics are not given routinely. Only if it is IBS-diarrheal predominant. ANd also when the urge occurs acutely after the meals( In which case loperamide is given).
=========
Immunization & Pregnancy..
The following vaccinations should not be given during pregnancy becuase they are live attenuated virus vaccines:
1-Mumps/Measles/Rubellla
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)
LEAVE STATISTICS ALONE IF UWILL B MASTRE U WILLL NEVER GET WHAT THEY WILL GIVE U INEXAM SO FORGET ABOUT IT ITWONT B MORE THAN 6-7 QS MAX..
READ PEADS.....ALOT GYNE AND SURGERY JUST IMP STUFFF....DO ALOT OF CDS FINISH THEM ALLL 3 TIMES ...LIKE QBANK,ALERT ,ACE THE BOARD,IST PASS,CCS CDS,U WILL MAKE IT
IF UWONTCLLL CONSULT OR IF U CANT FIGUREOUT WHAT S THE DIAG THEY WILL FORGIVE U BUT IF UORDER CT DIRECT INSTEAD OF XRAY THEY WILL CHEW U....THEY SAID THAT IN THEIRORIENTATION LECTURE IN CD...SO THINK LIKE PT...HOW U WOULD FEEL IF U GET THIS MUCH BILLL ..SO COSTEFFECTIVENESS IST
Metastatic prostate cancer
Spine metastasis is urgency...Radiation first to reduce the compression.
To relieve the spine compression:
Dexamethason i.v (systemic intravenous NOT intrathecal....A real Q!!)
Followed or accompanied by spine radiation
Laminectomy is the last resort
Total orchiectomy is the Rx for metastatic prostate cancer in general.
==========
isolation from school/daycare
1)chicken pox:until all lesions have dried and crusted
2)scarlet fever: until atleast 24hrs after appropriate antibiotics
3)rubella:7days 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 pharyngitisL:until 24hrs after appropriate antibiotics
7)parvovirus B19 (5th disease): until appearance of rash [pregnant pt should be evaluated]
8)rota virus: until stool is contained by diapers or toilet use
=========
=>Alendronate(or/& other Mx) in postmenopausal
-women with low impact trauma
-T score< 2.5
-T score <1.5 with risk factors
-women with loss of bone mass despite preventive intervention
=>Bipolar disorder(rapid cycling)
-valproic acid
-thyroid supplements
-[rapid cycling: >4 discreet mood episodes within one calender yr]
=>=>CAD with depression
-DOC: paroxetine (anti-platelet action)
proven to decrease mortality
=>=>ARDS
-Treatment: PEEP(>10cmH02) with TV < 6cc/Kg & PIP<35cmH02
[lower tidal volume and limit plateau pressure]
=>=>Poorly controlled Asthma:
1)Albuterol rescue treatment> 2 x week
2)Nighttime waking >2 x month
3)Albuterol canisters >2 x month
=>=>Orbital fracture:
-Inferior rectus injury-> restriction of upward gaze
=>=>Fetal distress-> CST-> positive(50% FP)-> BPP-> <6 -> Delivery
HIV/AIDS
-Azt/zidovudine: S.E-macrocytic anemia
-all D's (DDI/didanosine, DDC/zalcitabine, D4T/Stavudine): S.E-pancreatitis, neuropathy
-3TC/lamivudine: used to treat hep B
Protease I
-Indinavir: renal stones
-ritonavir:both hyperlipedemia, hyperglycemia
=>needle stick injury prophylaxis
-2nucleoside+ 1 protease I x 1month
=>pregnant HIV+ve with CD4<350 and viral load >55k
-2nucleoside +1 protease =immediately thru preg
=>neonate born to HIV
-AZT x 6 weeks
=>HIV +ve guy
-doctor shud tell g/f(tarasoff 1)[emember:there is legal protection to BUT NOT legal requirement for partner notification]
-written/informed consent req for testing
=>NONE of antiretroviral drugs are TERATOGENIC
=>chance of transmission of HIV
-female to male= 1/3000
-male to female=1/1000(women are exposed for longer time to semen)
-needle= 1/300
-anal receptive=1/100
=>PCP
-if suspected do CXR(almost never normal), LDH, ABG(remember criteria for steroid!!)[PCP cannot be culture]
=>Routine 28 week prenatal visit
-check 2 things:1) GTT
2)Blood type
=>Breast feed
-AAP recommends breat feeding until 12 months
-After 6 months, iron-enriched foods or supplements should be added to prevent IDA
=>HBV & breast feeding
-not a CI to breast feeding, baby needs Ig and vaccine asap after birth
=>Temporary teeth
-1st tooth:L central inscissors, 6-7mon
-2nd tooth:U central inscissors, 6-7mon
-All teeth formed by 20-30mon
-All teeth lost by 10-11yr
Vs
Permanent teeth
-1st tooth:lower 1st molar, 6yrs
-All teeth by 11-12yr
=>Eczema/ Atopic dematitis:
-generalized xerosis, tend to worsen in winter
-Sites of predeliction: antecubital fossa, poplitial fossa, face & neck
-other findings: keratosis pilaris, accentuated palmar creases, lichenification, cataracts, & allergic shiners
(infraorbital discoloration)
atopic dermatitis: allergy to environmental, food, animals, sometimes maybe assoc with hay fever or asthma..Histology: Acute - spongiosis of epidermis; chronic - hyperkeratosis and acanthosis
=>Mulluscum Contagiosum
-pox virus
-pearly umbilicated papules & white, curd-like core may be easily expressed
-generally asymptomatic
=>=>Drug eruption:
-generalized morbilliform erythematous plaques begining on trunk and extend peripherally
=>=>Head Lice
-cause by pediculosis humanis capitis
-spread by direct contact with hair if infected person, hat, combs & hairbrushes
-treatment: permethrin
-NO isolation from school required; NO prophylaxis for family members, bedmates should be treated
==========
=>Unilateral vision changes without an acute history of trauma:
1)Optic neuritis:
young female, vision changes & pain with eye movement), afferent pupil
2)Retinal detachment:
ocular trauma, surgery
flashing lights or sparks, floaters, 'dark curtain', afferent pupil
3)Macular degeneration:
'Metamorphopsia'(distortion of shape of objects in view) usually slowly progressive
4)Amaurosis Fugax:
h/o intravascular procedures.
5)CRVO: prognosis variable; H/O of HTN, AS, Glaucoma
painless loss of vision, classic "blood and thunder" fundus.
6)CRAO: profound visual loss
=>CRVO......2 types 1)ischemic,which is painful
2)non-ischemic ,which is painless..more common.the second type is relatively more common than the first
7)Vitreous h'aghe:
Trauma, conditions causing neovascularization[DM,RVO], SAH
clue: if red reflex cannot be seen but the lens appears clear.
8)Ac. Glaucoma:
Increased cup:disc ratio, fixed mid-dilated pupil, hazy cornea, hard tender eye
9)Ischemic Optic neuritis:
>50yrs, painless, afferent pupil, swelling of disc, assoc with GCA
=>=>And ALWAYS get a right sided EKG in inferior infarction patterns:
-To look for posterior (RV) extension of the infarct, which occurs in 50% of inf MI and 14%-84%
of all LV infarctions
-RV infarct:clinical triad of hypotension, elevated jugular veins, and clear lung fields.
=>Mobitz type 1 rhytm: Inferior wall MI[block within AVnode due to increased vagal tone or
ischemia of AV junction]
Mobitz type 2 rhytm: Anterior wall MI[AV junc or bundle of his damage]
=>=>CDC criteria for hospital admission of pt's with PID
1)noncomplaint pts
2)pregnant pts with PID
3)pts with severe nausea & vomiting precluding outpatient management
4)pts with abscess or peritonitis
5)immunodeficient pts with PID
6)and all those who fail outpatient therapy
=>Indications for Tonsillectomy:
1)Obstructive tonsils (sleep apnea, dysphagia, speech defects, failure to cry)
2)Recurrent sore throat(relative):
->[7 episodes/yr or >5 in each of 2 yrs or >3 x 3yrs ] assoc with T>100.4 or increased Cx LN or
exudate or +ve strep c/s
=>=>Poorly controlled Asthma:
1)Albuterol rescue treatment> 2 x week
2)Nighttime waking >2 x month
3)Albuterol canisters >2x month
=>=>Orbital fracture:
-Inferior rectus injury-> restriction of upward gaze
=>=>Air travel in pregnancy:
-In healthy women:safe upto 36 wks ; C.I >36 wks
-C.I : h/o PIH
Preterm delivery
poorly controlled DM
Sickle cell anemia
=>=> Necrotizing Fascitis:
-group A streptococci account for about 60% of these cases(also staph, bacteroids, anaerobic strep &
Vibrio[shell fish & sea food exposure]
-gram stain may not show the classic textbook images of streptococci in "chains"
-Surgery is required for both diagnosis and therapy
rq 36: a ACLS case. V-tach/v fib, after failed convert, patient is now in asystoly. What to do next? give epi.
rq37: mostly likely org in 4 yo bacterial meningitis?
rq38: mostly likely org causing skin infection after surgery?
rq39: 50 man urinary retention big smooth prostate, Foley or suprapubic empty bladder.
rq40: several growth chart related quesitons.
Thallium stress test was mentioned several times in the answers. So pay attentions to the inplication of the stress test.
//
rq30: old patient second day after TURP, agitated with intermittent COMBATIVE and WITHDRAWAL. I thought delirium so ordered Lyte study. the next quesiton ask what to treat: haldol or restraint?
rq31: Bald area in man's head, ask treatment: tramcinolone injection.
rq32: About a dozen raised lesions on the back of a black teenage girl, with h/o acne. ask for the treamtnet: surgery removal of every lesion, steroid injection.
rq33: 6 y AA boy came in with malaize and some clue of leukemia. Ask what will change. I chose leukocyte number. dont remember other choice.
rq34: picture of hand xray of a man who just caught a baseball. ask what is the damage to the hand. I have no idea and picked ligment damage.
rq35: A young man got a bee sting 10 min ago, has wheezing and some sort skin reaction. He works with bee for more than 5 years and never has this before. Then the history said only in his early career that he was sting MILDLY. what you give to prvent future event? I chose Epipen.
rq26: 1 yo with flat feet, what to do: observation or correct shoe?
Spontaneous correction is usually expected within one year of walking. No treatment is indicated for painless flexible flat foot. Trauma, occult infection, a foreign body, tarsal coalition, bone tumors or osteochondrosis of the tarsal navicular bone may cause a stiff and painful flat foot. Where referral to ortho would be indicated
rq27: Your patient asks you to her wedding:
thank you, but I may not have time to go.
Thank you, but my professional standard would not permit to go.
re28: 15 yo boy malaize with a node in the left neck about 3cm. 3 wk later, symptoms improves but the node only slightly smaller. What do you do: biopsy or observe?
rq29: man runing 5 miles x3/wk, now has right leg pain. what will you find? bone scan and MRI not in the choice and stress fracture not mentioned. I chose normal xray finding.
rq30: 30 yo female now has ammenorrhea, FSH and LH increased. what is the cause? ovarian failure, PCOS etc
===========
rq21: adenovirus eye infection -conjucvitis in child.
rq22: EKG picture, AV block, I mistakenly chose A-flutter. So rest is much important before the exam day.
rq23: 60 male with atypical chest pain last 5 min usually. Did not remember has history of CAD or not. Pt now has 3 times chest during the last week and each lasts 20 min. EKG is normal. ask you
admit? (chosen this one)
thallium stress?
no choice for regular treadmill.
rq24: 50 yo GERD symptoms, related to food, sometimes NTG also help. ask work uP
upper endo
echo
rq25: skin leions ask causes among: simvasta, b-blocker, or levothyroxin
q23. atypical cp, it depends on RFs and his symp.
q24, gerd, betwn egd adn echo, I will with egd. but upper gi series is better initial test if it is on the list.
q25. skin lesion from meds: synthroid does not cause sl. other two(statin and bb) cause sl but rare, need more info to close.
rq16: Xray Picture of pt's knee pretty bad. ask treatment. I chose total knee replace over meds.
rq17: New born baby picture, one leg is significantly shorter than the other. observe, treat in one year, ortho immediately?
rq18: recalled last week or so. ICU nurse gave Tylenol to pt who allergic to tylenol. what do you do?
tell patient
wait, don't tell if no symptom.
rq19: gauze in the abdomen after surgery (old recall). you should
consult patient?
call lawyer?
hospital comitte
rq20: topic of rotavirus infection in small baby.
on that rq 10, the 13 wk preg, a following qusteioin ask what do you f/u pt with? US (chosen) or aminiocentisis.
rq11: another rq many time twisted, on my it read this: preg girl Rh-, previous baby Rh-, current husband Rh-. Do you give RhoGam?
She cried and said she did not know who the current baby's father is. what do you do?
rq12: skin lesion after wood cut. recalled before.
rq13: samll body with superficial redish skin lesion (picture) under the right armpit. ask tX? antibiotic, soap and wash. etc. Because no infor about the temp and symptoms so I chose soap wash. did not remember about steroid etc.
rq14: 70 yo male's back, a lot black dot (stuck on?) picture, not a very good picture. I chose the common one with the stuck on appearance.
rq15: 9 month old can he say mama and dada, or can he say 2-3 words?
rq6: HIV positive pt with no sign of TB but PPD 6. what do you treat? inh +B6; or 3 TB med (no PZA), others less likely for me.
rq7: Hispanic nurse newly PPD 10, cxr given which I thought is normal. and no symptoms. ask treamtent option. forgot choice. just topic. quite a few TB related questions with boardline information to confuse.
rq8: 70 yo female picture has uterocele. diagnosis.
rq9: 70 yo vaginal bleeding, SMALL uterus, ask waht to do. endo sample or hesterectomy?
rq10:13 wk preg woman exposed to varicella. pt has MILD chicken pox as child. what to do? I chose do NOTHING.
this one discussed before many times. a lot qs are repeated with a twister. i put several unrelated q together for easiness.
recalls 1: You got call from MEXICO, where the family is vacationing. The 5 yo son got bite by a stray dog. The boy has ALL vac in US (did not mention specifically, I assume all regular). Father asked you what to do after the basic treatment. choose immune ig and vac.
rq2: this q is a exact usmle sample q. the Italian man, a mechanic does his job. His friend refer him to see you for paranoid disorder. you should treat him in detail but professional manner. not over do it.
rq3: pedegree, muscle problem with mitochondrial. woman patient in first generation with a normal husband gave diseases to all their children (f and male). a man in second generation married a normal woman, ask about the chance of their daughter having the disease? not remember exactly, so read the topic. does anyone know this kind?
rq4: 14 yo girl with bluish lesion on skin. She wants to be treated for acne. THe mom said it is not acne and ask you to confirm. You said not acne. what is the girl's disorder? Conversion or dysmorphic etc. I chose the later among all the choices.
re5: fascarnet AIDS patient meds causing seizure. recalled manytimes.
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
========
Know different problems faced by health care workers who are either carriers or get exposed to different Bacteria/viruses.
Explanation
The discussion will focus on HIV & HBV exposure, Meningococcal exposure, Needlestick injury, MRSA & VRE carrier states.
All of us should be immunized against Hepatitis B.
HIV does not preclude a doctor or nurse to discontinue their job.
A needlestick injury must be carefully evaluated. If a needle contaminated with a patient,s body fluid enters a healthcare worker, the employer is responsible for all the expenses. Anti HIV medications MUST be offered within 4 hours. SOLID needles (eg lance for accucheck) have not been shown to transmit HIV. At least 2 anti HIV drugs should be offered. If the source patient has been on Zidovudine, the victim should also be offered a 3rd anti HIV drug as well. These should be taken for 1 month & victim to be sexually protective for 6 months. The source & patient needs to be checked immediately and in 6 weeks, 12 wks & 6 mo- and the source patient has no right to refuse but we generally get a consent form signed.
There was recently a question on the risk of HIV transmission - it is 1 in 200 encounters. The risk of Hepatitis B on the other hand is 1 in 20 encounters. This is also called the transmission rate.
Meningococcal prophylaxis must be given to close contacts of the patient with meningococcal meningitis. The drug of choice is Rifampin for 2 days. A good alternative is Ciprofloxacin - single dose but this cannot be given to patients under the age of 17.
MRSA & VRE carriage states are no longer of any isolation benefit. Mupirocin cream is good for MRSA eradication from the nostril.
Recognize the manifestations of carpal tunnel syndrome.
Explanation:
Pain, tingling and numbness in the median nerve distribution (lateral 3 and a half fingers) but may go up as high as the shoulder.
Worst after sleep because of abnormal positioning as one sleeps. Tinel's(tingling on tapping over course of median nerve at the wrist) and Phalen's(tingling on keeping the wrist hyper-flexed for a minute or two) signs may be elicited.
Diagnosis is clinical but Nerve Conduction Study confirms the diagnosis.
First line therapy is wrist splints during sleep.
If not effective then try hydrocortisone injection under carpal tunnel
If Motor signs are present at any time- confirm diagnosis and operate for release of carpal tunnel.(minor surgery).
FOR AA October 2 2003, 11:27 AM
I have this real exam question. Presentation is CTS carpal tunnel syndrome + atrophy of the affected hand =
Treatment? splint, steroid, surgery.thenar muscle wasting is an indication for surgery--kaplan
Recognize the complications of Aminoglycosides
Explanation
Aminoglycoside antibiotics are extremely useful in serious infections. Unfortunately they have a very narrow therapeutic index. The most important question asked on them is the adjustment of the dose amount and dose interval based on the Trough and peak levels.
There are 2 levels measured - the peak and the trough. The peak level is measured 1 hour after the 3rd dose is given and the trough is measured just before the next dose (4th dose) is given.
Higher the amount in each dose, higher will be the peak. The efficacy is related to its peak level. If it is found to be lower than the recommended value, please increase the dose of each shot to ensure that the person gets the most benefit from the drug (It also improves the post antibiotic effect of Aminoglycosides).
The toxicities of Aminoglycosides are related to its trough level. This is related to the time interval between doses (Shorter the interval, higher the troughs & higher the chances of toxicity therefore if troughs are too high, please increase the interval between the doses to decrease the trough and its related toxicities).
The toxicities of Aminoglycosides are:
Renal failure - due to tubular necrosis that can be reduced in the presence of antipseudomonal penicillins.
Muscle weakness: Direct Neuro muscular junction blockade therefore cautioned in Myasthenia.
Deafness due to cochlear toxicity
Vertigo - vestibular toxicity
Complications can be prevented by good hydration and monitoring the trough levels.
Sensitivity/specificity
Sensitivity = I am going to explain the sensitivity of a radio. There are 10 stations in the air. If it can only pick up 7 of them, it is 70% sensitive. Therefore if there are 10 cases of a disease in a population, and only 7 can be picked up by the test, it is 70% sensitive.
Specificity = Of all that are free of the disease, how many actually test negative. Now we think of a machine which opens oysters that have pearls inside. We feed it 20 oysters. It opens 8 of them. 2 out of the 8 did not have pearls. We then went on to open all those that it did not open and found 3 pearls but 9 were without pearls. Therefore the specificity is 9/11 - i.e. of the total without the pearls (11), it correctly identified 9.
DNR ¹ DNRx
DNR holds a meaning only in the code situation. When a patient has either cardiac or respiratory ARREST, we will not start CPR. That is what it means. It does not hold you back from a treatment that addresses a different issue. For example, if a patient who is DNR goes into VT where he has a pulse, you are allowed to cardiovert. If he goes into VF or pulseless VT, on the other hand, the situation constitutes cardiac arrest and you should not enter the ACLS protocol.
When a patient is DNR (do not resuscitate), many doctors hold off on vasopressors and strong antibiotics or interventions such as pacemaker or even ventilators for respiratory distress. This is incorrect. This is the kind of situation that exams like to test on.
If you think it is not appropriate to use pressors or cardioversion or antibiotics because you deem them futile, you have to address each one separately and specify on the consent form.
GENERAL INTERNAL MEDICINE
Understand the initial treatment of acute hyperkalemia if the ECG shows features of high potassium.
Explanation:
When presented with a patient with high potassium and Electrocardiographic abnormality- Calcium chloride is the drug of choice because its specific action is cardio protection. This fact is asked so commonly that you should not mix this up with the treatments given below. Calcium chloride is more readily available than Calcium gluconate.
Thereafter or in a non emergency situation one can use Insulin/Glucose combination or Sodium Bicarbonate or Albuterol (Salbutamol). These push potassium into the cells therefore reducing serum potassium.
The Potassium binding resin (Sodium polystyrene sulfonate) should be given to everyone as this is the primary medicine to REMOVE and not just cause a trans-cellular shift of potassium.
If medical measures fail - Dialyze (hemofilter if dialysis not available)
Recognize the clinical manifestations and appropriate treatment of otitis externa and malignant external otitis
Explanation:
Otitis externa is a common problem and is usually treated topically but its rarer counterpart: malignant otitis externa needs parenteral antibiotics aimed at Pseudomonas.
Otitis externa is associated with the tragus sign where -if you push or pull the external ear gently - you elicit pain.
As the skin and cartilage of the external ear are so tightly held together - the swelling tries to rip these two apart and thus is responsible for the pain associated with the condition.
Pain relief along with swelling relief is key to treatment-commonly used preparations include combo of hydrocortisone with neomycin/polymyxin..
If the inflammation becomes obvious on the pinna and is no longer restricted to the ear canal - 2 diagnoses should come to mind
1. Malignant otitis externa(MOE) or
2. Relapsing polychondritis (RP).
MOE will be suggested by the presence of Immunosuppression/Diabetes/malignancy - all of which predispose to MOE. Findings include unbearable pain and pus discharge ( If there is pus but no pain - think otitis media with ruptured tympanic membrane).
MOE is treated IN HOSPITAL with IV antipseudomonal antibiotics (Ciprofloxacin/Ceftazidime/Antipseudomonal penicillins-Ticarcillin)and usually requires surgical debridement too (unless it is very early) .
RP on the other hand is suggested by another cartilage being affected or prior history of the problem. This could be the nasal or laryngeal cartilages and is treated with steroids. These patients can go into laryngeal stridor but need not be admitted if there is no suggestion of it.
i got these cases:
MVA with 3rd degree heart block
Down syndrome with duodenal atresia
ovarian torsion
cardiomyopathy
DUB
lead poisoning
SAH
colon carcinoma
last case was of an african american , may be of gastritis, i couls not reach the diagnosis...will write the details later...
CCS in sep 24/25
subacute thyroiditis
niddm
spouse abuse
turner syndrme
as
urosepsis
TCA overdose
meningitis 9month old baby
sigmoid diverticulitis
1- Exacerbation of asthma
2-G 6 PD deficiency with sulfa allergy
3-UTI with pregnancy
4-Ovarian cancer
5-MI with high blood sugar
6-erforated peptic ulcer
7- DKA
8-Colon cancer
9- Normal Physical exam with HTN in young male
http://cyberdev.ucsd.edu/curricular_resources/MED/im-quiz/quiz1.htm
==========
CCS TURP
do ABC
pulse oximetery
o2
heparinized ivline
look for hypertautremia if not s/s atart ringer or ns
pt stable move to pe and look for any sing sum of sepsis, menigit, chest sin for pe, aspiration, cardiad anomaly
cbc, bmp, ecg, cxr.
abg
do another pe and check the test reslts
anything abnormal go for it and try to find the reason.
i continue with admit to ICU if BP not stable or confusion cardiac problem.
other wise to ward
npo,
o2
bed rest
int/ouput control
weight monitor
vital q 1 h
ask for results
if all neg and hypo tension gone
it could be hypovolimia and anethesia fever
if something wrong follow it
--------------------------------------------------
You asked a very important Q a bout a patient with indwelling catheter and developed UTI..next step:
a-ABS.
b-Remove the catheter.
Also this is a real CCS..A patient who had TUR of his prostate and developed a fever postoperatively..He had indwelling catheter
------------------------
on MVA accident, patient on vent, pinpoint pupil reactive to light, decerebrate posturing, no advance directive, friend says patient wants to live life the fullest.... what will you do?
pull out vent?
give steroids?
order MRI?
etc?
etc?
Ethical issue is respecting the patient's wishes in doing whatever possible to prolong his life
Understanding neurology!!
DECEREBRATE POSTURE indicates a brain ijury at the level of the brain stem (compare this with decorticate level which results from corticospinal tracts injury)
Corticosteroid will not add significant effect!
May be doing MRI will be help to identify any lesion at the level of the brain sten and manage the patient accordingly..(MRI is the diagnostic study)
I will go with MRI unless better options are there!
------------------------------------
21 yr old male dead after MVA had a organ donation card which family did not know about and they refuse to allow donation so what do you do now
go ahead donate
do not donate
ethics commitee
-Patient has advance directives saying to go all the way, has been on life support for 10 days now with neurology saying no hop, family wants the vent off, what do you do
pull the vent off
cont with the vent
ethics comitee
eeg
For the first ethics Q,
Do not donate. For organ donation, family wishes are respected. This is the only excetion to override patient's wishes!. Discussed before on this forum.
For the second ethic Q,
The advance directive say go all the way..
The family says wean the patient from the ventilator..
The neurologist says no hope...
How to solve the Q?
Since the patient has advance directives ==> immediately ignore patient's family wishes and respect the decision of the advance directives.
But if you continue the ventilatory support according to advance directive wishes, the ventilation is "futile"...This means it produces no benefit to the patient. THE PHYSICIAN RESPECTS THE AUTONOMY OF THE PATIIENT IN THE WISHES WHICH ARE CONSISTENT WITH THE PROFESSIONAL STANDARD OF CARE.
If the physycian agrees that the interventions in question would be futile, the goal should be to withdraw or withhold these interventions.
So the answer is withdraw it.
No need to refer the issue to the ethics committee as the ethic principle here is clear.
----------------------------------------
read kaplan ethics and digest every single word..
-------------------------------
ccs-Coccydynia-Diagnosis-I do not remember the choices I put rectal exam
Pain in the area of the coccyx (tailbone) is called coccydynia or coccygodynia (or sometimes a variety of other spellings). Coccydynia can be anything from discomfort to acute pain, varying between people and varying with time in any individual. The name describes a pattern of symptoms (pain brought on or aggravated by sitting), so it is really a collection of conditions which can have different causes and need different treatments.
The links on the right cover all the causes of pain on sitting that I have found in the medical literature or that people have emailed me about.
Coccydynia can follow after falls, childbirth, repetitive strain or surgery. In some cases the cause is unknown. The pain can disappear by itself or with treatment, or it can continue for years, and may get worse. It is five times more common in women than men, probably because the female pelvis leaves the coccyx more exposed. It appears that in most cases the pain is caused by an unstable coccyx, which causes chronic inflammation.
Medical trials have shown that coccydynia can be cured eventually in the great majority of cases, given the right treatment. However, finding a doctor who can do a proper diagnosis of the condition and supply effective treatments is difficult, and many people suffer years of pain.
Causes of coccydynia
The coccyx is the very bottom portion of the spine. It represents a vestigial tail (hence the common term "tailbone") and consists of four or more very small bones fused together. The coccyx articulates with the sacrum through a vestigial disc, and is also connected to the sacrum with ligaments (see Figure 1).
It is not clearly understood which portions of the anatomy can cause coccyx pain. Either the ligaments or the vestigial disc may be a cause of pain and, rarely, a primary bone tumor or soft tissue tumor can cause pain.
It is thought that the condition is more common in women because:
In women the coccyx is rotated and faces backward, which makes it more susceptible to trauma.
Women have a broader pelvis, which means that sitting places pressure not only on their ischial tuberosities ("butt bone") but also on the coccyx. (Men tend to sit only on their ischial tuberosities without a lot of pressure applied to the coccyx.)
Childbirth is a common cause of the condition
The two most common causes of coccydynia are:
Local trauma. A fall on the tailbone can inflame the ligaments or injure the coccygeal attachment to the sacrum
Childbirth. During delivery, the baby’s head rides over the top of the coccyx and can injure Causes of pain
Unstable coccyx
Spur on coccyx
Misaligned, rigid, or long coccyx
Muscle spasm or tightness
Pilonoidal cyst
Tarlov/meningeal cyst
Pudendal neuropathy
Cancer
Referred pain
Neuropathic pain
Idiopathic coccydynia
Imaginary pain
Diagnosis
A health professional diagnoses coccydynia by taking a thorough medical history and completing a physical examination. Diagnostic tests, such as x-*** or MRI, are also commonly performed in order to rule out other potential causes of the pain.
A thorough physical examination should include:
Pelvic and rectal exam to check for a mass or tumor that could be a cause of the pain
Palpation to check for local tenderness.
The most striking finding on examination is usually the local tenderness upon palpation of the coccyx. If the coccyx is not tender to palpation, then the pain in the region is referred from another structure, such as a lumbosacral disc herniation or degenerative disc disease.
Diagnostic studies that should be done include:
X-rays of the sacrum and coccyx should be done to rule out the unlikely event that either an obvious fracture or a large tumor is the cause of the discomfort.
An MRI scan is useful to rule out infection or tumor as a cause of pain
Bone scans and CT scans add very little information and are generally not done. Typically, all imaging studies will be
Conservative treatments for coccydynia
Treatments for coccydynia are usually conservative and local. The first line of treatment typically includes:
Non-steroidal anti-inflammatory drugs NSAID’s. NSAID’s (such as ibuprofen, naproxen, COX-2 inhibitors) help reduce the inflammation that can cause pain.
A donut-shaped pillow to help take pressure off the coccyx when sitting
Patience is also very important, since it often takes many weeks, or even months, for the pain to subside.
If the pain is persistent or severe, additional conservative treatments may include:
A local injection of a numbing agent (lidocaine) and steroid (to decrease inflammation in the area) can provide some relief.
Some practitioners treat the condition with manipulations.
Stretching the ligaments attached to the coccyx can be helpful.
Physical therapy with ultrasound can also be helpful.
Provided that infection and tumor has been ruled out as a cause of pain (through exam, x-***, and MRI scan), then prolonged conservative treatment is a reasonable option.
Surgical treatments for coccydynia
For people who have persistent pain that is not alleviated or well-controlled with conservative treatment, surgical removal of the coccyx (coccygectomy) is an option.
This surgery is rarely performed, and the procedure is not even included in most spine surgery textbooks. It is, however, a relatively simple operation.
Surgical approach
A one to two-inch incision is made right over the top of the coccyx, which is located directly under the skin and subcutaneous fat tissue. There are no muscles to dissect away.
The covering over the bone (the periosteum) is then dissected away from the bone starting on the back and carried around the front. Staying in this plane of tissue is very safe, and allows the coccyx to be dissected free and then separated from the sacrum.
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vBulletin® v3.7.1, Copyright ©2000-2008, Jelsoft Enterprises Ltd.
Search Engine Optimization by vBSEO 3.2.0 RC7 ©2008, Crawlability, Inc.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.
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
///////////////////
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.
/////////////
///toddlers, under the age of 5, are treated differently from children 5 years and older.
According to www.eMedicine.com, infants and toddlers are susceptible to Streptococcus pneumoniae, H. influenzae type B, and Staphylococcus aureus, so they should be treated with cephalosporins, such as ceftriaxone, cefotaxime, or cefuroxime, or a penicillin such as ampicillin.
Children of 5 years, ready to start school, are susceptible to Mycoplasma pneumoniae, so they should be treated with macrolides, such as azythromycin, clarithromycin, or erythromycin
///DM is the most important risk factor for CAD.
///Q 1) Rx of DHB after Premarine > I will choose Low and low ( because her endometrium is stable by premarine)so try low/low , if pt. have spotting with it then high esro or med estro with low progesterone.
If was not treated with premarine try high estro and low progesterone.
Q2) In turner - before fusion > Conjugate estrogen 0.3 q.d 21 days. Add DMPA 5mg q.d from 15 - 25th day of cycle to induce period.
Can use OCP also ( not my choice) should be low and low.
After fusion - estrogen 0.625mg ( can use higher according to tolerance )add progestreone as above
OCP try high estro and med progesterone.
///False elevation of PSA.. March 26 2003, 1:23 AM
1)* PSA levels have been demonstrated to be elevated in acute prostatitis, subclinical or chronic prostatitis, and urinary retention.
2)* An increase in PSA levels has been reported following ejaculation. In 67% of the men older than 50 years who were tested, a 41% mean increase (0.8 ng/mL) in PSA occurred 1 hour after ejaculation.
3)* Performing a prostate needle biopsy increases PSA by a median of 7.9 ng/mL or 6.5 times baseline values within 5 minutes following the biopsy, and this level persists for 24 hours
4) * vigorous prostate massage
***No significant change occurs in the PSA level following a DRE . Cystoscopy, urethral catheterization, and transrectal prostate ultrasonography do not tend to elevate the PSA.
///Only nocardia is weakly acid fast other than Mycobacteria.
In nocardia thre will be mainly pulmonary involvment, begins with malaise, weight loss, fever night sweats and cough, dont know about hepatoslenomegaly.
Choice of Abx is TMP/SMZ
///Legionnaire's disease is caused by L.Pneumophilia followed by L micdadie
Sputum examination on Gram stain show..
Typically, many leukocytes and a paucity of organisms are observed.
If visible, the organisms are small, faintly staining, gram-negative bacillii. Erythromycin was considered the drug of choice for L pneumophila, but the newer macrolides and quinolones have begun to replace erythromycin.Fluoroquinolones, primarily levofloxacin, sparfloxacin, and trovafloxacin, as well as newer macrolides (eg, azithromycin)are now used for treating it.
///Sturge Weber Syndrome?
Laser for capillary angioma...
opthalmology referal
anti convulcent med when needed
///ASCUS and LGSIL - atypia /mild dysplasia - CIN 1
HGSIL -moderate CIN II
severe dysplasia - CIN III
* If your Pap test is normal, you will continue routine screening.
* If your Pap test is atypical ( ASCUS, not able to be categorized as normal or abnormal), you will repeat the test in 4 months.( if Pt is compliant otherwise do colpo )
* If the repeat test is abnormal, your doctor will do a colposcopy.
.
If there are abnormal cells on the cervix, the doctor will perform a biopsy.
* If your test is abnormal and suggestive of cancer, you will have a colposcopy, ECC and biopsy.
In a biopsy your doctor will take a small sample of the tissue of your cervix to see if cancer cells are present.
A biopsy is the only way to tell for certain if you have precancer, true cancer, or neither.
.
Sometimes, the biopsy itself is used to treat a precancer or a very early cancer.
If the biopsy is normal and you have a normal Pap test, the Pap test will be performed again in 4 months.
If the biopsy is normal but a Pap test is abnormal, your doctor will repeat the colposcopy and biopsy.
If the biopsy is abnormal and suggestive of cervical intraepithelial neoplasia (CIN) or cancer, you will be treated for cervical cancer.
///"Is there any benefit to giving varicella vaccine to a child who's been exposed to the disease and who hasn't been previously immunized?"
IVIG is not generally recommended for everybody whoever exposed to chickenpox(large quantity of imunoglobuline is needed to modify the disease)
IT is only recommended in :
1. pregnent women after exposure
2. newborne whose mother developed chickenpox 5 days before or 2-5 days after delivery.
3 Exposed leukemic pt. any imunodeficient state, svere debilitating illness(after exposure)
Varivax can be offered within 3 days of exposure who is more than 12 month old in epidemics.
Because of benign nature of disease in healthy children vaccine is not rutine after exposure.
Yes, you immunize exposed child if prev unimmunized. March 25 2003, 2:01 AM
Will post-exposure use of the vaccine prevent or modify varicella?
Yes, the vaccine may prevent or modify illness when administered within 3 to 5 days after exposure. The ACIP now recommends vaccination of susceptible persons who are eligible for vaccination as soon as possible after exposure--ideally within 3 days but possibly up to 5 days of an exposure--to prevent illness or modify disease severity. If a person has already been infected, and the vaccine is given soon enough, disease may be modified or prevented. If the person was infected >5 days prior to vaccination, there is unlikely to be any benefit from vaccination but vaccination is not known to be harmful. Finally, exposure even in a household setting does not result in transmission 100% of the time. So, if the exposed person has not been infected, vaccination will confer protection against subsequent exposures.
///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.
///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)
///TMP-SMX is considered to be the initial drug of choice for mild, moderate, or severe PCP infection. Alternative therapies for mild-to-moderate PCP include oral therapy with dapsone/trimethoprim, clindamycin/primaquine, and atovaquone. Alternative therapies for patients with moderate-to-severe PCP include intravenous (IV) trimetrexate, IV pentamidine, and IV clindamycin with oral primaquine. In addition, corticosteroids are indicated for patients infected with HIV who have severe PCP and hypoxemia.
///if someone is on carbamezapine with measure CBC periodically. serum conc. to be done for monitoring.
In the event of toxicity..do EKG
beccause in acute toxicity it can cause bradycardia and cardiovascular collapse,Also has cns symtom (Ataxia, nystagmus, stupor convulsion and coma)in acute toxicity.
* can cause aplastic anemia and agrnulocytosis, should f/u CBC
* cause liver damage and seriuos hepatotoxicty f/u liver funtion.
///Coronary artery disease and hypertension are the leading causes of heart failure
/// heart block is most likely associated with mitral valve infections
///Ticlopidine can be used in patients intolerant to Aspirin but they should be monitored for the development of neutropenia or agranulocytosis That's why clopidogrel is preferred over ticlopidine
///DOWN SYNDROME
Affected individuals rarely reproduce. Between 15-30% of females with trisomy 21 are fertile and they have 50% risk of having an affected child. There is no evidence of an affected male fathering a child.
So far there is no known case of a "MALE" down syndrome patient fathering a child
In female's About 70% are infertile, and the risk to child getting down is 50% if the mother has down syndrome,
Few facts about down syndrome,,,,
most common disease associated with down
mental retardation ,congenital heart disease,(endocardial cushion defect most common then VSD and asd, tof, pda)
leukemia, GI defect, hearing loss, cataract.
single best test to perform on a down patient,, is ECHOcardiogram,,, even the patient is asymptomatic,
most death's in down are related to heart diease
///In pregnancy and with OCP there will be increase thyriod binding globuline, that will bind with thyroxine and will decrease free thyroxine available for work, but total T4 will be normal so in hypothyroid pt ,u have to increase the thyroxine dose
///DMII in case with hepatic failure give Insulin -all other anidiabetics are cotraindicated
/// Child asthma/maintenance therapy if symp>2times a wk and nighttime symp>2/mth
You can start inhaled steroids or montelukast
///For insomnia in alzheimer's
For long term use - it is trazodone
short term use is ativan (lorazepam)
///CF /A.Recessive
.( in hetero + hetero) 25% affected (1 in 4), 50% carrier ( should be 1in 2 ) and 25% (1 in 4) normal
Thus two- thirds (3 in 4 ) of all clinically unaffected offspring are carriers.
A healthy older brother of cystic fibrosis ask what is the chance that he could be carrier- it's - 3 in 4
///Diuretics use should be carefully monitor to avoid
volume deplation. Loop diurectics e.g furosemide is the drug of choce. (Effective even when renal function is markedly reduced)
////Diuretics use should be carefully monitor to avoid
volume deplation. Loop diurectics e.g furosemide is the drug of choce. (Effective even when renal function is markedly reduced)
///As s3 indicate impaird ventricular compliance, so I peak s3. Though s3 is very signufican in CHF, s4 is happen to be significant in angina and MI.
this is from Merck manual.
The fourth heart sound (S4) is produced by the augmented diastolic ventricular filling near the end of diastole caused by atrial contraction
It is absent in atrial fibrillation but almost always present during active myocardial ischemia or early after MI.
The third heart sound (S3), or pericardial knock, occurs in early diastole, when the ventricle is dilated and noncompliant (hear Audio 197-8). It occurs during passive diastolic ventricular filling and indicates serious ventricular dysfunction, except in children, in whom it can be normal
http://www.merck.com/pubs/mmanual/section16/chapter197/197c.htm
Fourth heart sound is common in Angina
http://www.merck.com/pubs/mmanual/section16/chapter202/202c.htm
///Hypotension and tachycardia are often late findings of shock in young athletes.
///A diabetic with poor glucose control on maximum dose of glyburide?
add metformin
///.AAM teen ager boy with snycope come with mother and Ekg classic for wpw asked for imediate management(procainamide) and next q how do u treat permanently(radio ablation)
/// Campylobactor -common bloody diorrhea in neonate
///E coli and shigella-positive systemic symptoms.
/// Genetics of following disorder.( tansmission in off spring, if one sibling has this chances for the next one, if parent is diseased etc etc )
Turner syndrome
down syndrome
cystic fibrosis
sickle cell disease
questions like....ABOve mentioned patients wants to become pregnant.... what advice. chances of prganacy , complications of pregnancy.. et cetc
///
Down syndrom can be confirm by amnio- by Kariotype and culture of fetal cell.
///PCP -Vivid hallucination
Insects crawling on body common in cocaine.
///aspirin. displace thyroxine from biding site so in Hyperthyroid crisis or thyroid storm Like hyperthermia, atrial fibrillation, confusion the easpirin is ABSOLUTELY contraindicated.
/// Heparin induced thrombocytopenia.
Warfarin should be avoided in acute HIT unless it is used in combination with therapeutic-dose danaparoid, lepirudin, or argatroban. 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
///A 75-year-old man , metastatic prostate ,,no 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
/// 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.
///In an adult pt with dehydration and volume contraction, some of the signs/symptoms are hypotension and tachycardia, and the management is to expand the intravascular volume, regardless of [Na+] level, with normal saline solution. We've all seen nursing home pt's with [Na+] > 150, hypotensive, tachycardic, dry mucosa, skin tenting, etc., and the first thing we do is infuse normal saline for volume expansion, and correct hypernatremia after the pt is hemodynamically stable.
///1/4 NS or 1/2 NS March 21 2003, 9:43 PM
depends on the weight of the infant. It could be 1/2 NS or 1/4 NS
Saline guide (Rough):
Weight <28 kg: D5 1/4NS (38 meq/L)
Weight >28 kg: D5 1/2NS (77 meq/L)
Summary: 35 kg Child with isotonic dehydration
First 8 hours: D5 1/2NS with 20 KCl at 250 cc/hour
Next 16 hours: D5 1/2NS with 20 KCl at 163 cc/hour
///NG losses usually replaced with D5 1/2NS with 20 mEq/L of KCl.
Diarrhea usually replaced with D5 1/4NS with 40 mEq/L of KCl.
General principles in treating dehydration.
///COMPLICATION OF TURP
IMMEDIATE COMPLICATION.
* Most immediate and serious complication is hyponatremia >>nausia, vomiting, confusion , hypertension,bradycardia, visual disturbance, skin changes, coma.(TUR syndrom)
*Hemorrhage
*perforation of prostate capsule with extravesion.
LATE COMPLICATION
*Tertrograde Ejaculation and Impotence
* Urethral stricture and bladder neck contacture
*Urinery incontinence >> Urge. stress,Total
///Using reference ranges of 0-2.5 for men aged 40-49 years, 0-3.5 for men aged 50-59 years, 0-4.5 for men aged 60-69 years, and 0-6.5 for men aged 70-79 years, they reported an overall specificity of 95%.
/// 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 HUS
///The risk of a diagnosis of breast cancer is slightly increased during OC use but diminishes after discontinuance and is not increased among former OC users who have discontinued OCs for >= 10 yr.
Several epidemiologic studies show that the incidence of cervical neoplasia, particularly adenocarcinoma of the cervix, is increased in OC users, particularly those who have used OCs for > 5 yr. A causal relationship has not been established, but OC users should have a Papanicolaou test at least annually.
A number of studies have shown that OC use decreases the risk of lethal endometrial and ovarian cancers by about 50%; this reduced risk persists for at least 10 to 15 yr after discontinuance. Other documented benefits of OC use include decreased incidence of abnormal uterine bleeding (including menorrhagia), dysmenorrhea, premenstrual tension, iron-deficiency anemia, benign breast disease, and functional ovarian cysts; the reduced incidence of ectopic pregnancy and of salpingitis associated with OC use should decrease infertility
If breakthrough bleeding persists, the woman should be given a combination with a higher dose of estrogen (ie, a more estrogenic formulation).
**If amenorrhea develops, the progestin component should be decreased.
Gulf war syndrome
Veterans of Persian Gulf War (8/90-6/91)
25,000 troops with unexplained symptoms post exposure
Etiology
Thought to be related to Neurotoxin exposure
Ammunition detonated in March 1991
Ammunition dump contained Sarin
Likely 100,000 troops exposed
Symptoms
Fatigue
Headache
Joint pain
Stiffness
Muscle pain
Hair loss
General weakness
Nasal and sinus congestion
Diarrhea
Excessive Flatulence
Abdominal pain
Memory problems
Impaired concentration
Word finding
Insomnia
No decrease in fertility in Gulf war veterans and no increase in teratogenicity.
///DKA
blood electrolyte value,ABG and serum osmolality
Use of sodium bicarbonate has some unwanted effect on DKA, if PH is 7.0 or less or HCO3 is below 9meq then NaHCO3 should be given once ph reach 7.1 d/c bicarb.
if potssium < 5 then give potassium( pt.should have good urine out put)
if phosphate is < 3 -add phosphate replacement
if
Is glucose < 250- add dextrose
///AZT-side effects
Lactic acidosis one of seriuos complication.
myositis is most common
///best predictor of good htn control is preserved target organ dammage.
///difinitive symptom of left heart failure is dyspnea and Sign is s3,
///Bactrim and Cipro both increase Warfarin's concen ,interferes witht he mechanism of warfarin redultant increae bleding tendencies
Tetracycline is not interact with warfarin, but not good choice for UTI.
///emergent oral contraceptives.- high dose estrogen, high dose progestin
High dose ehtinyl estradiol for 5days (estro)
or
high dose Levonorgestrel bid (progestro)single dose
or
Ovral 2 tab Bid (high estro + high progestro)
All have start within 72 hrs
or
mifepristone within 120hrs
or
IUD within 5days.
Emergency contraception (also known as the morning-after pill) is a high dosage of the birth control pill. It is recommended to be used after sexual intercourse, over a period of 72 hours, to achieve the goal of preventing or ending pregnancy. There are three different ways birth control pills are currently being promoted for this use: progesterone alone, estrogen alone, or both of these artificial steroids together. These are the same steroids found in the typical birth control pill.
ccs case.
my ccs were
UTI
ADENOCARCINOMA IN WOMEN IN FIFTIES
DOUDENAL ATRESIA
LEAD POISINING IN 18 MO OLD
PERICARDITIS
PERICARDIAL EFFUSION
DUB
UNCONSCIOUS MAN IN 40 WITH R/R 8
there was also a question set on Gulf war syndrome 4 qustions, mostly how would u responde to his qustions
/// sign of rotator cuff injury
pain with abduction at shoulder joint
///acalculous cholycystitis laperoscopic cholecystectomy
///ac choly in first trimester-conservative, u operate in sec trimester
Surgery in 2nd trimester,
Only concern about acalculous cholecystitis is prognosis is gaurded without surgery.
/// pedigree thalassemia
Rx of Elderly insomnia
Type of DM with grand pa thyroid and father parathyriod ca
chronic metal exposer with crystal in perepheral smear
///Pt with dig subendocardial MI next step asa and heparin
///Leukocoria (white pupillary reflex or cat's eye reflex) is the most common presenting sign in retinoblastoma.
////Best treat for WPWS is procanamide
Adenosine used to temporarily treat CMTs
But Procainamide blocks the accessory Pathway.
stable--procainamide, unstable--cardioversion
////ASA" IS BEST for post MI, for Mortality Reduction
////primary and secondary syphilis both r transmissible
///quinolone Decreases excretion oh thyephyline
quinolone +coumadin=Incr risk of bleeding,causesincr
///Tension headache typically occur daily, begin later in the day.
Cluster headaches are different from tension headaches.
Waking up at night charac of cluster headaches.
///morning after pills.maost common side effects nausea and vomitting
///Scombroid: allergic-like symptoms due to histamine ,begin within 15-90 min.Nausea, omitting,diarrhea, flushing, itching
chinese restaurant syndrome? It is due to oversensivity of people to monosodium glutamate.
Cigutera:(fish)
1-6 hrs after ingestion, victims develop GI sx accompanied by a variety of neurologic sx.
Scombroid:(fish)
Allergic-like SXs usually begin within 15-90 mins also with GI Sx.
Bacilus cereus:
The incubation period is 1-6 hrs.
BZ_BEE PEARLS:
!)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!!!
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
epidural hematoma is lenticular in shape on ct head while subdural hematoma is cresent shape..
do physical ist and report child abuse later bcz u have to have som e solid evidence ist...on physical exam to report otherwise its worthless even though if u r just suspicious and u report falsely u will not b panished...
plez plez plez move pt before last 5 minute on ccs cases bcz u will not b bale to go back and do any thing even u cant see the lab result...just u can write new order do councliing and delete som eorders...so plez dont forget otherwise no marks on that most impstep of ccs..
pertussis and bronchiolitis both can b diag by nashophrangeal wash ingor culture
catthral phase of the pertusis is mos contageous and
abx erythromycine act best if given early not efeective if given late in sec phase
pertussis is the only diease which if mom had will not provide immunity through antibody frommom u have to protect the baby tooo
the most comom cause ofinfection with pertusis in incomplete vaccinationagaisnt pertusis...7-10% cases still occurs even after child is immunized
erythromycine to close contact is imp to save them from this contagious diease..
pertusis is reportable disease
isolate the child dont send to day care or schoool until cough is not gone...
sever cases need steroid and mild need humidified oxygenand erythro...
if gcs is less than 7 must intubate
if in nutropenic fever pipercillin is not helping and fever is more athn 7 days addd ampho b bcz fungal infection is also cause this
after every transplant cmv infection r most common
to differentiate bet the inc bun/creatinin weather its due to transplant rejection orcyclosporin..do ultrasound...and see if the transplant site is tender and pt has fever if both r present then its rejectionand if both r negative its due to cyclosporin,never d/c cyclosporin just dec the dose..and recheck bun/creatinine
the idea behind giving lactulose in heaptic encephalopathy is toconvert nh3 to nh4 ion so ph of th e stool should b inc and we give neomycin to stablize the bowel...so both go hand in hand
if sclerotherapy or banding didnt help to stop bleed and pt dont want surgery or not stable for surgery then do TIPS...
eevn though they say do medical management always calll consult when u think its neccessary.....but plez dont calll surgery for chest tube..if u r er doc...imeanif pt comes in e r...but definatel;y call if pt r/i for mi or bect endocarditis or aortic stenosis or a fib ,som etimes we forget in exam we think its normal....but it gives u negative marking...andits not goood for ur over all score...
some body ask if they ask u u wana stop clock or not...stoping clock will help u gret adeal if u forgot som eimp thing to order suppose ifptis unconscious and u didnt order head ct yest just stop clock and order it and then farward clock by clicking on clock.cz just farwarding clock will not do any goood only thing will happpen that soft wear willl sense it wrong and 5minute sign will come if u dont belive me do it on practice cd and c yrself...bcz its writtenin direction..that when u did every thing and u hav e any else left then just move clock farward so soft wear will end ur case...when i failed i was just farwarding clock in exam and i was wondering why case is ending in just 15 minutes instead of 25......that was the cause and all those pppl who finish at 230 or 3 on sec day that is the most common cause..so stop the clock when u need it to b stopped...usually u should stop it when nurse message u like pt is asking for edciation or pt is till pale or still dizzy it means u r just farwarding the clock u should calm down and give her some basic treatment like medciations morphine or demerol or tylenol...so alll these nursing messages there for a reason...some one just ask that how we will know that we did goood in ccs or bad...my friened u will com eto know rt away..bcz if u r doing rt thing for the pt....things will change messages will b telling u pt is not drwosyanymore,pt is hungry wants foood...or kids with meningitis will accept bottleand playing with mom...so that mean u did goood...
like in my persoanl case ...in nortryptaline od..i did every thing ato z corerct and pt was stable abg wise and vital sign and ekg wise but was still unconstious.and i was looking at vitals and was thinking i did goood...but b4 i callled psych consult message appeared taht pych will coming shortly as sooon as pt will bgetting constiousness..and i said dammm i didnt do ct head bcz he was found in garage..so i order ct and as soon as i orderd ct it showed hematomaa ..i callled nuro consult and soon after they say pt isgotten better after heamtomaa evacuation....so plez pay attention to every single message...that isto put u in rt path...butthat will only b happeneing if u did otehr stufff rt...
ike my case with 9 mont old kid brought bymom that he is throwingup and irritable and not taking feederfever was 102.5 i send everything ua,blood culture.started abtibiotic,did lp send to lab csf was turbid..i was happy that i was on the rt path...ceftrioxne and vanco...iv was working...kid temp cam edown and he was taking bottle againand i was happy ...and suuudenlywhen i move him to icu message came mom is still saying my kid is still pale....i recheck bili it was normal i thought 9 month old will iron deficient so i should give iron syp...but stupid 5minutes showed up and i only checked the g6passey in rbc...couldnt c the result bcz in those 65 minutes u cant go back..to labs results but i guess my approac was corrects so i passed...i will post more pearls later...this is just bcz jerry has exam in 2 wks.....and my dear fd gulaboooo in 3 days..so i guess this will help them..and others...c we can learn alot from pthers mistakes....;-)best of luck every body!!!
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Search Engine Optimization by vBSEO 3.2.0 RC7 ©2008, Crawlability, Inc.Fig 1: Second-degree AV block, type 1 (Mobitz 1, Wenckebach): RR almost always irregular, progressively longer PR intervals with dropped QRS complexes (some P waves do not conduct).
Fig 2: Second-degree AV block, type 2 (Mobitz 2): RR may be regular or irregular. Classical 2:1 block will have regular RR intervals; with variable conduction ratios, RR intervals will vary. Beats that conduct have fixed PR intervals, some P waves do not conduct.
Fig 3: Complete Heart Block: Atrial rhythm and ventricular rhythm usually regular, variable PR intervals random lengths (P waves are unrelated to QRS's) more P's than QRS complexes.
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Hepatitis C: the new king of chronic hepatitis (causes 2/3 of cases); usually transmitted through shared IV needles (rarely if ever transmitted sexually, donated blood now screened). Like hep B, can also progress to chronic hepatitis (roughly 75% of cases), cirrhosis, and cancer. Serology: antibody to hepatitis C virus shows evidence of prior exposure, but not immunity, as most have chronic, active infection. A test for HCV RNA detects virus directly and allows better determination of infection status / prognosis.
Most common cause of post-transfusion hepatitis (1/3300 chance).
Common in alcoholic liver dz (25-60%).
RNA: flavivirus
ELISA immunoassay test + in 2-6 wks. RIBA is confirmatory test along with PCR.
Sources: Crush the Boards, Brochet, page 43 and Kaplan notes
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Ankle injuries are the most common injuries incurred during sports and recreational activities. They are particularly common during soccer, basketball, and volleyball.
Pathophysiology: Most ankle sprains are due to inversion during extension of the ankle. Thus, approximately 85% of injuries involve the 3 distinct lateral ligaments: anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). Of sprains due to inversion, 65% are isolated to the ATFL. In some patients, the subtalar complex may also be injured. The CFL is rarely injured in isolation.
Isolated injury to the medial (deltoid) ligament is rare and usually involves malleolar fractures. Distal tibiofibular syndesmotic rupture is very rare and is associated with dorsiflexion and external rotation. Recovery from this injury is significantly prolonged, unlike isolated lateral ligament sprains.
Rupture of the superior peroneal retinaculum results in subluxation or dislocation of the peroneal tendons. The mechanism of injury is usually forced dorsiflexion with reflex contraction of the peroneal muscles. Patients complain of pain and a snapping sensation over the posterolateral ankle with weakness of eversion.
Ankle sprains are classified into 3 grades, as follows:
Grade I injuries involve a stretch of the ligament with microscopic but not macroscopic tearing. Generally, little swelling is present, with little or no functional loss and no joint instability.
Grade II injuries stretch the ligament with partial tearing, moderate-to-severe swelling, ecchymosis, moderate functional loss, and mild-to-moderate joint instability.
Grade III injuries involve the complete rupture of the ligament with immediate and severe swelling, ecchymosis, an inability to bear weight, and moderate-to-severe instability of the joint.
Frequency:
In the US: Inversion injuries occur at a rate of 1 per 10,000 people per day, which is about 27,000 injuries per day in the United States. Injury to the dominant ankle is 2-3 times more likely than injury to the nondominant ankle. Ankle sprains are twice as likely in intercollegiate athletes when compared with interscholastic athletes.
Mortality/Morbidity:
Ankle sprains can cause significant morbidity. As many as 73% of athletes with an ankle sprain suffer recurrent sprains, and 59% have significant disability and impairment of athletic performance.
Up to 50% of people who incur an ankle sprain have some type of chronic sequelae. These conditions include functional instability, mechanical instability, chronic pain, stiffness, and recurrent chronic swelling.
Eversion injuries are more likely to result in persistent pain or chronic instability.
Sex: Women athletes are 25% more likely to sustain ankle injuries than male athletes.
Age: Ankle injuries primarily involve young people because they participate more often in physically demanding recreational activities and sports. Fractures and tendon ruptures occur more often in older adults.
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Anonymous10-12-2003, 12:13 AM
CLINICAL
History:
Assessment of all orthopedic injuries should include the following:
Mechanism of injury
Previous ankle injuries
Presence of immediate or delayed pain, swelling, and ability or inability to bear weight
Presence or absence of any popping-type sensations or actual noise at the time of injury
Physical:
Observe for edema, ecchymosis, or deformity.
Palpate for tenderness, crepitant, or deformity.
Assess active and passive range of motion as well as weight-bearing ability.
Perform talar tilt test.
Place the foot in 20-30° of plantar flexion, and apply slight adduction and gentle inversion stress to the calcaneal midfoot.
If both the anterior talofibular and the calcaneofibular ligaments are ruptured, the examiner will detect talar tilt (ie, movement of the talus in the mortise).
Perform anterior drawer test.
Place foot in 10-15° of plantar flexion and apply gentle forward traction to the heel.
With anterior talofibular ligament rupture, the deltoid ligament becomes the center of rotation, and a dimple may appear just anterior to the lateral malleolus. Forward motion of the talus is detected by the examiner.
For this test, 3 mm of movement may be significant; 1 cm of movement is certainly significant.
Perform and document a neurovascular examination, including checks of the dorsalis pedis and posterior tibial pulses.
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Anonymous10-12-2003, 12:14 AM
DIFFERENTIALS
Fractures, Ankle
Tendonitis
Tenosynovitis
Other Problems to be Considered:
Achilles tendon rupture
Peroneal tendon subluxation
Septic joint
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Anonymous10-12-2003, 12:15 AM
WORKUP
Imaging Studies:
Radiographic studies of the ankle should include the following films:
An anteroposterior (AP) film with the ankle in 5-15° of adduction
A true lateral film
A 45° oblique film with the ankle in dorsiflexion (ie, Mortise view)
The Ottawa rules are a prospectively validated clinical decision tree for radiograph ordering in adults. By following these rules, emergency physicians can eliminate 30% of radiographs without missing clinically significant fractures. Criteria for foregoing radiography are as follows:
Younger than 55 years
Able to walk 4 steps at the time of injury and at the time of evaluation
No tenderness over the posterior edge (distal 6 cm) or tip of either malleolus
Other Tests:
Stress radiographs or arthrographies are not mandatory in the ED, but they may be requested by an orthopedic consultant
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Anonymous10-12-2003, 12:15 AM
TREATMENT
Prehospital Care: For patient comfort, splint all ankle injuries prior to transport to the ED.
Emergency Department Care:
First-degree sprains or mild second-degree sprains
Rest, ice, and elevation
Compression dressing or commercially available air stirrup splint
Possible cessation of weight bearing initially
Early range of motion exercises
Wobble board training after recovery in order to reduce the number of recurrent injuries and prevent functional instability
Severe second- or third-degree sprains or possible fractures
Rest, ice, and elevation
Plaster or fiberglass posterior splint
Orthopedic or sports physician referral
Consultations:
Obtain orthopedic consultation for severe sprains, suspected peroneal tendon subluxation, or associated fractures.
Emergent orthopedic evaluation rarely is required. Office follow-up in a week usually suffices.
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Anonymous10-12-2003, 12:17 AM
MEDICATION
The goals of therapy are to reduce pain and prevent complications.
Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs) -- With analgesic and anti-inflammatory properties, NSAIDs are the ideal agents for treating ankle injuries. Acetaminophen with or without an opiate analgesic may be added to NSAID therapy (or used as a substitute).Drug Name
Ibuprofen (Ibuprin, Advil, Motrin) -- Usually the DOC for treatment of mild to moderate pain, if there are no contraindications.
Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclo-oxygenase, resulting in the inhibition of prostaglandin synthesis.
Adult Dose 200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose 6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Contraindications Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Drug Name
Ketoprofen (Oruvail, Orudis, Actron) -- Used for the relief of mild to moderate pain and inflammation.
Administer small doses initially to patients with small body size, the elderly, and those with renal or liver disease.
Doses higher than 75 mg do not increase its therapeutic effects. Administer high doses with caution and closely observe patients for response.
Adult Dose 25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose 3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Drug Name
Flurbiprofen (Ansaid) -- Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclo-oxygenase enzyme, causing the inhibition of prostaglandin biosynthesis that may in turn result in analgesic and anti-inflammatory activities.
Adult Dose 200-300 mg/d PO divided bid/qid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Drug Name
Naproxen (Anaprox, Naprelan, Naprosyn) -- For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose 500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric Dose <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Drug Category: Analgesics -- Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens. Many analgesics have sedating properties that are beneficial for patients who have sustained injuries.Drug Name
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin) -- DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult Dose 325-650 mg PO q4-6h or 1,000 mg tid/qid; not to exceed 4 g/d
Pediatric Dose <12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Contraindications Documented hypersensitivity; known G-6-PD deficiency
Interactions Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Drug Name
Acetaminophen and codeine (Tylenol #3) -- Drug combination indicated for the treatment of mild to moderate pain.
Adult Dose 30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tab/d
Pediatric Dose 0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d acetaminophen
Contraindications Documented hypersensitivity
Interactions Toxicity of codeine increases with CNS depressants, tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Drug Name
Hydrocodone bitartrate and acetaminophen (Vicodin ES) -- Drug combination indicated for moderate to severe pain.
Adult Dose 1-2 tab PO q4-6h prn pain
Pediatric Dose <12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d; single dose should not exceed 10 mg of hydrocodone bitartrate
Contraindications Documented hypersensitivity; high-altitude cerebral edema (HACE); elevated intracranial pressure (ICP)
Interactions Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
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Anonymous10-12-2003, 12:18 AM
FOLLOW-UP
Further Outpatient Care:
Patients with grade I or mild grade II lateral sprains should have a follow-up visit with their primary care physician in 1-2 weeks.
Consult orthopedics or sports medicine for all other injuries.
Complications:
Functional and/or mechanical instability
Chronic pain, stiffness, and/or edema
Prognosis:
With appropriate initial treatment, referral, and physical therapy, the majority of patients have a favorable outcome.
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Anonymous10-12-2003, 12:18 AM
MISCELLANEOUS
Medical/Legal Pitfalls:
Failure to diagnose
Failure to obtain a radiograph
Misinterpretation of a radiograph
Failure to recognize ankle instability
Failure to treat injury appropriately
Failure to immobilize unstable injuries
Failure to refer significant injuries to the appropriate specialist
Special Concerns:
Elderly patients may require home health visits to assess mobility and ability to perform activities of daily living (ADL).
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Anonymous10-12-2003, 12:21 AM
REFERENCE
eMedicine Journal, September 25 2003, Volume 4, Number 9
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Search Engine Optimization by vBSEO 3.2.0 RC7 ©2008, Crawlability, Inc.A 27-year-old man complains of cervical radicular pain radiating into his left thumb and mild neck and headache pain. His clinical examination and diagnostic studies suggest a C5-C6 disc protrusion compressing the left C6 nerve. Despite conservative care, his pain persists, and he is limited functionally. Which therapeutic injection can be considered?
A: Cervical epidural steroid injection
B: Cervical occipital nerve block injection
C: Cervical intra-articular facet injection
D: Cervical stellate ganglion blockade injection
E: Cervical translaminar epidural nerve block injection
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AnonymousA 5-week-old infant is brought to the clinic for a 4-week history of noisy breathing that has not improved. She has otherwise been healthy except for a current upper respiratory infection for the past 4 days, which according to the parents, has worsened the noisy breathing. On examination, she has inspiratory stridor. The noisy breathing improves when the infant is asleep. Which of the following is the most likely diagnosis?
A. Bronchoalveolar carcinoma
B. Foreign object obstruction
C. Laryngomalacia
D. Bacterial pneumonia
E. Tuberculosis
Explanation:
The correct answer is BELOW
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Seborrheic keratosis "Stuck-on" appearance, symmetric, often multiple
Traumatized or irritated nevus Returns to normal appearance within 7 to 14 days
Pigmented basal cell carcinoma Waxy appearance, telangiectasias
Lentigo Prevalent in sun-exposed skin, evenly pigmented, symmetric
Blue nevus Darkly pigmented from dermal melanocytes, no history of change
Angiokeratoma Vascular tumors, difficult to distinguish from melanoma
Traumatic hematoma May mimic melanoma but resolves in 7 to 14 days
Venous lake Blue, compressible, found on ears and lips
Hemangioma Compressible, stable
Dermatofibroma Firm growths of fibrous histiocytes, "button-hole" when pinched
Pigmented actinic keratosis Sandpapery feel; sun-exposed area
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ec 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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