发信人: Oldray (oldray), 信区: MedicalCareer
标 题: zt: uw ck notes
发信站: BBS 未名空间站 (Fri Nov 16 23:47:45 2007)

from usmleforum, a guy's note from uw ck. enjoy.

propranolol=drug of choice for HTN+beningn essential tremor

)Reccurent chalazion=> do histopathologic examination because of risk of
Squamous cellular carcinoma (SCC)

)PH=7.23, HCO3=16, PCO2=40-what is it?
=mixed metabolic+respiratory acidosis, because if it were simple metabolic
acidosis, then PCO2 would have been=1.5*HCO3+8=1.5*16+8=32mmHg and in this
case it is 40mmHg, so there is also a respiratory acidosis

Know the formula for calculating the compensation in acidosis: PC02=1.5*HCO3
+8
Ex.: a diabetic suffering from COPD treated with metformin may have mixed
acidosis, metabolic from metformin, respiratory from COPD.

)NSAID can give SIADH (innapropriate secreation of ADH)

)Quinsy=peritonssilar abcess

)Tamsulosin=blocks alpha1-receptors only in prostate and bladder=>no side
effects like hypoTN, headache, rhinitis as other alpha 1 blockers

)Sideroblastic anemia-high Fe, high TIBS, may be hypocromic and normocromic
anemia in the same time=HIGH YIELD

)Streptoccocus bovis endocarditis-asoc. with colorectal cancer=>do
colonoscopy

)Treatment of MG crisis=intubation+withdrawl of anticholinesterasic drugs
for many days, then do plasmapheresis and iv IG

)Foreign body in the eye=>first pen light exam=>fluoresceine exam, if still
(-)=>CT or US, never MRI (it can dislocate the foreign body)

)patient with XYY karyotype=severe acne, but not precocious puberty
21-hydroxylase deficiency=precocious pseudo-puberty, independent of the
hypotalamic-hypophyseal-gonadal axe

)Black widow spider bite=>treat with narcotics, muscle relaxants and Ca
gluconate

)Women with CIN (cervical intraepithelial neoplasia):
a) imunocpmpromized
b) in utero exposure to DES
c) hystory of CIN II/III
will have annual PAP smear done, regardless the normal previous ones.

)In severly depressed patient, even suffering from terminal illness with
suicidal thoughts=>start antidepressant therapy

)Systemic steroids=drug of choice in sarcoidosis with disabling symptoms, if
not responding=>cyclosporine
if asymptomatic sarcoidosis=>no treatment

)Lachman test is more sensitive than anterior drawer test in ACL rupture (
anterior cruciate ligament)

)Primary polydipsia=increased thrist first, can be given by antipsyhotic
medication (phenotiazines) because they give a dry mouth. Look for a patient
in the psychiatric ward on antipsychotics who gets diarhhea, polyuria and
thrist
Insipid diabetes=increased polyuria first

)HTN+peripheral vascular disease=>give Ca channel blocker

)BCC (basal cell carcinoma)=most common tumor of the eyelid
=pearly, indurated
=>treat by chemosurgery of frozen section control excision

)Respiratory alkalosis-in liver insufficiency because of increased levels of
progesterone (not metabolized anymore)

)Hashimoto thyroiditis-can be eu/hypo/hyper thyroid
-anti preoxidase Antibodies are diagnostic
-risk (6 times) of thyroid lymphoma
)Nasopharingeal carcinoma-appears in all age groups

)Colonic villous adenoma, sessile adenoma or size>2.5 cm=> increased risk of
malignancy=HIGH YIELD
No further work-up for hyperplastic polyps

)US of KUB (kidney, ureter, bladder)=first step in evaluating BPH (benign
proastate hypertrophy) with elevated Creatinine and normal urinalysis

)MALT gastric lymphoma and no metastasis=>eradicate H.pylori infection, if
this fails, then give chemotherapy (CHOP)

)Athlete's foot (in swimmers too)=fungal infection, treat with tolnaftate

)Excessive bleeding (like abruptio placenta) in pregnant woman Rh (-)=>give
higher dose of anti-D globulin

)If HDL>60mg%=>it removes one risk factor for CV disease

)Alcohol withdrawl=>first-line give chlordiazepoxide (librium), then
lorazepam=second-line

)Sjogen syndrome=>diagnosis confirmed by lip biopsy (lymphoid foci in
accessory salivary glands)=most specific

)Allergic contact dermatitis=erythema, edema, pruritus, tiny vesicles, weepy
&crusted lesions 24-48h after contact with the allergen-cell mediated
hypersensitivity

)Psammoma bodies=thyroid papillary cancer
Invasion of tumor capsule and blood vessels=folicular cancer
Hurtle cells-appears in both the above types (rarely)

)Carcinoid syndrome=>develop deficiency of niacine (dermatitis, diarhea
dementia) because Trp is mainly converted to serotonine and 5HIAA
Hyper Ca crisis=vomiting, oliguria/anuria, dizziness, coma

)Invasive aspergillosis="halo sign" on CT scan of lung
=in imunocompromized people
=on CXR-cavitary nodule

)Miastenia gravis=>thymectomy if:
-between age of puberty and 60
-if <12 years of age=>frecquent spontaneous remissions
-if>60 years of age=>give corticosteroids
-if only ocular disease=>no thymectomy

)Defect in Le adhesion=reccurent bacterial infections
-characteristic are: delayed separation of umbilical stump
necrotic periodontal infections

)Defect in opsonisation=asplenia (infections with S. Pneumoniae are frecq)

)Acute ingestion of masssive alcohol=> reduces the toxic effect of
acetaminophen by inhibiting CYP2E1 like in suicide attemps with alcohol and
acetaminophen together, but
Chronic ingestion of alcohol reduces glutathion=>increases the toxicity of
acetaminophen like in an alcoholic patient with some kind of fever due to
common cold

)Egg allergy=>contraindication to influenza vaccine and Q fever vaccine, and
relative c.i. to MMR (which is however still recommended)-HIGH YIELD

)ACE inhibitors=>increase renin and kinin derivates=>cough

)Dermatomiositis=Gottron's sign=scaly patches on MCP and IP joints
=heliotrop rash (periorbital edema+purplish suffusion)
=proximal muscle weakness
)Vertebral osteomyelitis-lumber area frecq.=>back pain
- low fever, high ESR, local tenderness, spasm
Do MRI=of choice for diagnosis
-Complications=epidural abcess, spinal cord compression
)Pale lesions, velvet-pink or whitish that do not tan and are not scaly=
tinea versicolor (Malassezia furfur)
-thick budding spores, large blunt hyphae="spaghetti and meatballs"
-treat=>Se sulfid shampoo and ketoconazole

)Loss of gastric fluid by NG suction in intestinal obstruction=>metabolic
alkalosis (contraction alkalosis) even if initially it was a metabolic
acidosis from the obstruction
)Hypophosphatemic rickets-only P is low, the rest are normal (PTH, Ca)
)Migratory trombophlebitis-due to cancer=> do CT of chest abdomen and pelvis
; can be pancreatic, lung, prostate, stomach cancer

)Acyclovir=nephrotoxic=>renal tubular obstruction, gives crystalluria
)Deficiency of Iron=most common anemia in the elderly=HIGH YIELD
)Anemia of chronic disease is given by inflamatory joint disease not
degenerative joint disease

)Pseudomonas osteomyelitis (punctures through snikers in the foot)=>give
quinolones+surgical debridement
) Anemia of prematurity-normocitic, normochromic, low reticulocytes, few
precursors of red line, normal WBC, T, normal Bilirubin, , no other
abnormalities

)Isoniazide=>lowers the levels of GABA in the brain=>seizures in 1h after
administration, treat by Vit. B6
)For screening use=total cholesterole+HDL
For treament use=LDL+Risk assessment

)Undiagnosed pleural effusion=best evaluated by thoracocentesis, except in
CHF (here give diretics and see what happens-it will disappear)-HIGH YIELD
Varicose veins with incompetent perforating veins- can give:
-non-pitting edema
-medial leg ulcer
-fatigue
-brown discoloration of the ankles

)Warfarin induces skin necrosis=>mostly in patients with deficiencies of
prot C or S or when it is started in high doses without prior heparin
coverage (like in Atrial fibrillation)

)Larger Confidence interval (CI)=wider range of possible effects for a
tested drug (efficient drug in some patients, non efficient in others)
If CI of 2 groups overlap=>no statistical significance
If they don't overlap=> statistical significant differences

)Niacine treatment=> raises HDL, but gives pruritus and flushing (release of
Prostaglandines)=>prevent this by giving aspirin 30 min. prior to taking
niacine

)Pulmonary embolism (PE)-post surgery in pacients with JVD and new RBBB;
also dilated pupils=ominous sign

)Post-ictal (after seizures) lactic acidosis is transient=> no treatment, it
resolves by itself in 60-90 min.
HCO3 is given in acidosis only if PH<7.2

)In primary hyper aldosteronism, there's no edema, but hyper Na

)Retinal vein occlusion=disk swelling, venous dilation and tortuosity,
retinal hemorrhages, cottol-wool spots
)Retinal artery occlusion=pale disk, cherry-red fovea, boxcar segmentation
of blood in the retinal veins

)Celiac disease-diarrhea, pallor (anemia), bone pain (osteomalacia), easy
buising (low vit.K), hyperkeratosis (low vit. A), Ig A Antib. to gliadine,
to endomissium and to tissue transglutaminase
=malabsortion+Iron def. anemia

)Overflow incontinence-can be given by: TCA, antichol., antipsychotics,
sedative-hypnotics

)Spinal cord compression=>first give STEROIDS, then do MRI of the spine, if
not available do=>CT myelogram=> give radiotherapy for malignancies=HIGH
YIELD

) Diagnosis of Bartonella Henselae is clinical, confirm by Warthin-Starry
stain of tissue specimen or Antib.
treat by azytromycin for 5 days and only in regional lymphadenopathy or
systemic symptoms (also can give claritromycin, rifampin, TMP/SMX, cipro or
Doxi)

)Shy-Dragger syndrome=Parkinson +autonomic instability (HypoTN...)
-can have bulbar dysfunction or laringeal stridor
-treat by iv expansion (fludrocortisone), salt, alpha agonists
Riley-Day Syndrome-AR disease, in Askenazi Jews
=autonomic dysfunction +severe hypoTN

)Prepubertal vulvo-vaginitis=>pruritus mainly in the night=>do scotch tape
test to detect pinworm (do not answer stool examination)
)Treatment for low HDL=>Choice=fibrates, the niacine
)Treatment of choice for anorexia=hospitalisation

)Subcutaneous emphysema in patients on 100% O2 on mask=> do first CXR to
rule out pneumotorax; if (-) this is a benign condition=>no furthet
treatment

)Thoracic outlet syndrome-after MVA, playing with musicalinstruments,
chronic illnesses, cervical ribs, congenital muscle band...=has signs of
neuro-muscular bundle compression
-do EAST test for screening (elevated arm stress test), and CXR, MRI or
angiography for confirming the diagnosis

)Medial meniscus tear-C shaped meniscus (the lateral is O-shaped)
by twisting the leg, effusion forms in 24h and is not as bloody as in ACL
tear, tenderness on the medial part on the knee
=characteristic=bucket handle tear and locking of the knee joint in
extension
(+)McMurray sigh=snapping felt with tibial torsion, knee flexed at 90
degrees
-trea by immobilization+bracing

ACL tear=hystory of hyperextension
(+) Lachman test, ant. drawer test, pivot shift test

)CI=1.02-2.15
RR=1.6 What does it mean? Well, the CI does not include value of where RR=1,
then it means that the result is statistical significant
RR=1=> no effect or association

)Low cardiac output + high PCWP+high SVR=left ventricular failure (
cardiogenic shock)=HIGH YIELD, I got some similar questions on actual exam,
know this type of Q for cardilogy very well!!!

)Eczema herpeticum=HSV infection associated with atopic dermatitis, there
are vesicles over the areas of atopic dermatitis
treat by acyclovir in infants

)Causes of altered mental status in the elderly patients:
low+high Na, Ca, low Mg, low P, low glucose, stroke, cardaic events,
infections
-risk of dehydration by:WATER ACCESS IS DENIED=main mechanism in:
a)nursing homes
b)post-surgery
c)intubation in ICU

)To slow down the progression of Diabetic nephropathy=>restrict proteins and
give ACE inhibitors (even if normal TN, but not if Clearance of Creatinine>
2)

) Treat of both acute and chronic anal fissures=> starts with dietary
modifications+stool softner+local anesthetics; in refractory cases do
lateral sphincterotomy or gradual dilatation=>risk of incontinence and
disruption of sphincter

)Paroxismal nocturnal hemoglobinuria-may cause pancitopenia
-like hemolytic anemia (High reticulocytes)
-intravascular process (high LDH, total billirubin, low haptoglobin)
-splenomegaly, Cooms (-)
-loss of iron in the urine=>microcytes, hyprocromia
-bone marrow=hypocellular
-flow cytometry=absence of CD59 -used for confirmation of disease

)Screen for hepatitis C if blood transfusion was before 1992 and for hep. B
is before 1986

)To supress lactation=>tight-feeting bra+ice packs, no longer bromcriptine

)First step in organo-phosphoric poisoning=remove clothes and wash patient,
then atropine
)Use CA-125+vaginal US for screening the intermediate risk of ovarian cancer
in women with family hystory of ovarian cancer (not other type of cancer);
otherwise, there's no screening done for ovarian cancer

)Avascular hip necrosis-given by steroids, scikle cell disease, alcoholism,
SLE, Gaucher's disease
=hip pain with normal range of motion and normal X-rays. Do MRI=GOLD
STANDARD for diagnosis
)Intraperitoneal rupture of bladder in MVA=previous full baldder in a
patient who drank water (2l) and didn't urinated for 8h
Extraperitoneal rupture=more common

)Treat Ig A deficeincy:-prophilactic TMP/SMX, donor erytrocytes washed five
times or bloodfrom other IgA def.patients

)HTA+osteoporosis=first choice are THIAZIDIC DIURETICS

)Vitiligo=pale macules with pigmented borders-acral or peri-orificial areas,
autoimmune distrcution of melanocytes
Piebaldism=absence pf melanocyes, obvious from birth
Infection with M. Leprae=areas of hypopigmentation+anesthesia

)Metabolic alkalosis:
a) Cl sensitive (Urinary Cl<20mEq/l)-causes;vomiting,diurectics...=ECF
contraction; treatable by NaCl infusion
b) Cl resistant (U Cl>20mEq/l)=ECF expansion, not correctede by Na Cl
infusion; causes:persistent mineralocorticoid stimulation

)Nerve IX neuralgia-associated with Multiple Sclerosis (MS)

)Nephrotic syndrome-associated with arterial+venous thrombosis (freq. renal
vein thrombosis and even PE
-anemia microcytes, hypocromia, resistant to iron therapy (loss of
transferine)
-vit D deficiency, low Thyroxine levels

)Angiofibroma in the nose-can give bony erosions
Chondroma of nasal cartillage-is very rare in young patients

)Lyme disease in pregnancy and in children<9 years of age=>give AMOXI, not
Doxi; also can give Azytromycin or cefuroxime

)Sympathetic ophtalmia-ant. uveitis, panuveitis, papillary edema, blindness
-by uncovering of "hidden antigens" (auto-Antib, cell-mediated reaction)

)Diphenilhydramine toxicity-seizures+cholinergic effects
Mercury overdose=vomitting, abdom. pains, bloddy diarrhea, renal
insufficiency

)Best prevention of osteoporosis=HRT, c.i. if hystory of endometrial/breast
cancer, but not if only family hystory

)Pulmonary nodule with cartillage in it=hamartoma=>observe
Radiotherapy-use it emergently in Superior Cava Vein syndrome

)Dupuytren contracture-associated with alcoholism, epilepsy, DM, TB,
Peyronnie disease, Riedel thyroiditis; over 50 years of age

)Perforated retro-cecal appendix, edematous cecum, pus behind the ascending
colon=>do right hemicolectomy+ileo-transverse anastomosis=best post-surgical
results

)Excruciating pain from femur fracture=>give iv. Morphine (even in patients
with hystory of drug abuse), then give PCA (patient controlled analgezia)
Give methadone in chronic severe pain syndromes

) If a test is (-)=> probability of the disease is =1-NPV

)HCO3 if given in lactic acidosis can depress the myocardium and increase
the production of lactic acid by stimulating the phosphofructokinase enzyme

)Most common location of ischemic colitis is splenic flexure, than recto-
sigmoid area

)MCC of bleeding in patients with renal failure is platelet dysfunction;
treat by DDAVP

)Bacterial meningitis-treat empirically with ceftriaxone+vancomycine
Give iv dexamethasone in intracranial HTN and bacterial meningitis in
infants

)The decision of using N-acetyl-cysteine for acetaminophen overdose is based
on the drug levels taken at 4h post-ingestion. But if taken>7.5g
acetaminophen or levels are not available at 8h of ingestion=>start
treatment

)COPD exacerbation with: ph=7.32, pco2=52, po2=60=> give NIPPV (non-invasive
positive pressure ventilation)-the indications are:
ph<7.35
pc02>45mmHg
Resp. rate>25/min.

)Adult Still's disease-variant of RA
-at 20-30 years of age
-high spiking fever
-salmon colored rash along with thye fever
-arthralgias, lymphadenopathy, high Le

)Any gunshot under the 4th i.c. space=>do laparotomy of the abdomen

)Latex allergy-associated with spina bifida
-gives anaphilactic reaction to "sex and surgery" (because of condoms and
surgical gloves)

)Selection bias=loss of follow-up in a prospective study

)Reccurent myocardial infarction-detect by serial CK-MB levels

)RTA 1-assoc. with Sjogren syndrome
-urine ph>5.5
low HCO3
low K+

RTA 2-osteomalacia
-urinary ph<5.5
low HCO3 levels
-low K+

)Corrected Ca=measured Ca+0.8 (4.5-measured albumin)
For each 1g of lost albumin, Ca goes down by 0.8-1mg%

)Cavernous sinus thrombosis-like orbital cellulitis but with cranial nerves
involvement (III,IV,V, VI) and bilateral
-treat by Antibiotics, then anticoagulation and corticosteroids

)Acute pancreatitis and non-alcoholic=>suspect gall-stones=>do US=first step
; do CT only if Le>20000/ml and suspect necrotising pancreatitis

)DM foot ulcer-treat by cephalosporine, ampi/sulbactam, clidamycine+
fluoroquinolone

)Syringomyelia=areflexic weakness + dissociated anesthesia in a "cape"
distribution in the upper extremities

)Emergent contraception=estradiol+norgestrol, 2 tb taken in no later than
72h, 12h apart

)HIV individuals-give Td vaccine

)Aspirin sensitivity syndrome=pseudo-allergic reaction; treat with
leukotriene inhibitors=drug of choice

)To confirm Ankilosing spondilitis=>do X-ray of the sacro-iliac joint, if
not conclusive=>do CT
)Splenic rupture- the need of surgery determined by:
a)vital sighns+hemodynamic stability
b)change in hematocrit over time
c)need for blood transfusion

)NTG-dilates the capacity vessels not the resistance vessels=>reduces
preload


)Molluscum contagiosum-poxvirus
-diseminated in HIV patients
-central umbilicated, dome shaped
resolves spontaneous in 1 year

)Bullous myringitis-painful vesicles on the timpanic membrane
-mycoplasma or viral infection

)Drug-induced pancreatitis: valproic acid, diuretics (loop and thiazidic), 5
-ASA, sulfasalazine, imunosuppressive (L-asparaginase, azathioprine), AIDS-
patient (didanosine, pentamidine), metronidazole, tetracycline

)Cystinuria-reccurent stones since childhood
-family hystory
-hexagonal crystals, hard stones which are radio-opaque
-screening test=urinary cyanide nitroprusside test

)Antiphospholipid syndrome-reccurent fetal losses, reccurent artery+vein
thrombosis
-types-I has false (+) VDRL
-II has lupic anticoagulant=>false + APTT
-III-has anticardiolipin antibody
treat in pregnancy by: heparin+aspirin and measure factor X activity and not
APTT for treatment

)Gilbert syndrome-associated with fasting, alcohol, stress, complete
reversal with phenobarbital
Crygler Naijar 1-billirubin=8-30mg%, kernicterus, no response to
phenobarbital
Crygler Naijar 2-billirubin<20mg%, no kernicterus, 25% response to
phenobarbital

)In gonochoccal arthritis=>do urethral culture to identify the gonococcus

)Common variable imunodeficiency=15-35 years of age
-normal B and T cells
-frecq. sino-pulmonary infections
-low IgG, Ig M, Ig A
Wiskot-Aldrigh=has low IgM, but high Ig A, IgE

)Acute appendicitis-can perforate and give pelvic abcess with diarrhea,
fever, tender mass on rectal exam, low abdom pain and not the usual sighns
of appendicitis

)PTCA=has better outocme than thrombolysis

)NPV is high and PPV is low if the pre-test probability of the disease is
low

)Microalbuminuria in DM=>start ACE inihibitors even if no HTN

)Motility disorder of the oesophagus=>do contrast study=>then oesophagoscopy
to exclude mecanic causes (strictures,cancer)=>only then manometry

)Chronic headaches+painless hematuria=>think analgesic nephropathy due to
papillary necrosis

)Terminal patients with severe pain=>give short-acting morphine, then long-
acting narcotics

)Campylobacter jejuni-MCC of diarrhea
-in undercooked poultry
-diarrhea is watery or hemorrhagic

)Craniopharingiomas-bimodal distribution:
-children (gives growth problems)
-55-65 age group (gives sexual dysfunction, bitemporal hemianopsia-think of
a truck driver who has to turn his head all over when looking sideways

)Chlamydia screening-do it in all women under 25 years of age if sexually
active

)Nonseminomatous tumor-may give ant.mediastinal mass, high AFP, HCG; treat
by cysplatinum for 6 weeks; use the above two markers to monitor the therapy

)Signs of high ICP: dilated pupils, anisocoria
flaccidity, decerebrate or decorticate posturing
papilledema
NOT Glasgow coma scale=it assesses the severity of head injury only

)Matching=tool that makes cases and controls have similar distribution of
some important confounding variables; it's an efficient mean to control
confounding

)Warfarin induced skin necrosis-pain, bullae, skin necrosis; use heparin
until they heal

)Furosemid-is ototoxic

)SLE-has-low T supressor cells, high T helper cells>B-cell hyperactivity>
high serum Antib and Ig G auto-anitbodies which form the immune complexes

)Hyperlipidemia 1 and 5=associated with pancreatitis

)In PCP in HIV patients give steroids, besides TMP/SMX if:
-Pa O2<70mmHg
-A-a gradient>35=150-(1.25*PCO2)-PO2
sat O2<75%

)Amantadine-dual drug=anti-viral+anti-Parkinson

)Granulosa cell tumors-precocious puberty
-postmenopausal bleeding

)Trachoma-given by chlamydia trachomatis (A-C)
-cause of blindness by neovascularisation=pannus
-follicular conjunctivitis
-treat by oral erytro or tetracycline

)Anserine bursitis-medial knww pain below the joint line, hystory of trauma
-valgus stess test is (-), it's (+) in medial collateral ligament strain
-X-ray of tibia is normal

Patellofemural syndrome-in females <45 years
-ant. knee pain aggravated by flexion
-retropatellar tenderness and crepitation

)A narrower CI=>the study is more precise

)If DM type II is not controlled by one hypoglicemic agent, add another one
from another class; give insulin only if BUN and Cr are abnormal

)In acute bacterial prostatitis=>get urnie sample for culture before
starting empirical antibiotics

)Acute variceal bleeding-give octreotid; beta-blockers are for prophylaxis

)Mucormicosis-treat by surgical debridement and amphotericin B

)Labetalol=drug of choice in pregnancy if HTN+DM nephropathy

)Open-angle gluacoma-cupping of optic disk
-loss of peripheral vision=tunnel vision
-more frecq. in African-Americans
Macular degeneration=central vision loss

)Give MMR to all HIV patients (except those severly compromized)

)Patients with impaired consciousness, advanced dementia=>predisposed to
aspiration pnemonia due to impaired epiglotic function


)In patients with frecq. attacks of gout=>first step is to measure 24h
urinary uric acid level
-<800mg/day=>under-secretion (probenecid)
->800mg/day=>over-production (allopurinol)

)Ulnar nerve syndrome=MC site of entrapment is: medial epicondilar groove;
think of counter clerks who sit with their elbows on the table all day

)In CHF-improved survival by: aspirin, beta-blockers, ACE inhib.,
spironolactone
-don't improve survibal: digoxin and loop diuretics

)What acid-base disorder is this?
ph=7.53
pco2=30mmHg
HCO3=24
Cl=85
Na=138
Well, tough one: we have alkalosis and is respiratory because Pco2 is low;
AG=Na-(Cl+HCO3)=29=>metabolic acidosis;
But a change in the AG (increase) is accompanied by a similar change in the
levels of HCO3 (decrease). Here HCO3 is normal=> metabolic alkalosis.
Scenario (all three together): pneumonia=>respiratory alkalosis
vomiting=>metabolic alkalosis
DKA (from ketones)=>metabolic acidosis

)Any patient with bone pains, renal failure and hypercalcemia has Multiple
Mieloma until proven otherwise

)Sudden RUQ pain+rise in hematocrit levels with hepatomegaly, splenomegaly
and ascites=>think Budd-Chiari syndrome (from polycitemia vera)=>first step=
hepatic venogram or liver biopsy

)Carotid stenosis of >60%-99%=> do CEA even if asymptomatic; complete
occlusion=c.i. to surgery

)Lichenus sclerosis-dryness, severe itch, vaginal soreness
-may give vaginal cancer
-do biopsy to rule out cancer
-treat by topical steroids

)Retinal artery occlusion-treat with occular massage+high flow O2
-give thrombolytics within 4-6 hours of visual loss

)TCA- cardiotoxic potential=>because they inhibit fast Na channels
-to asses the severity of the toxicity=>get QRS duration

)Pneumovax-has capsular polysacharrides and gives T-cell independent B cell
response; live vaccines give T-cell dependent......

)All uncouncious patients, even those breathing need airway established by:
-intubation in the ICU
-cricothyroidectomy in the field

)In unstable angina=> no thrombolytics; give aspirin, heparin, NTG, beta-
blockers

)In MI, give thrombolytics after sublingual NTG to rule out vasospasm.

)VF=is a reentrant ventricular arrythmia

)Superficial spreading melanoma=MC
-increased intraepithelial atypical melanocytes
Acral lentiginous melanoma-on palms, soles, beneath nail plate
Lentigo melanoma-head, neck, arms of fair skinned older people

)Diuretic use (also thiazidic)=>gives metabolic alkalosis

)Euthyroid sick syndrome: low T3, Normal T4, normal TSH; in severe disease:
low T4+T3, normal TSH


)Cholesterol embolism-follows surgical or intervention on arterial tree
-livedo reticularis, gangrene, ulcer or mottling of toes
-systemic eosinophilia, low complement levels
-renal failure (eosinophiluria)

)If an ulcer is seen on colonoscopy=>do biopsy to rule out cancer

)Subconjunctival hemorrhage-benign condition, observe only; think of a
person with a red eye on awakening in the morning

)Parvovirus infection=>arthralgias of small joints with 5-10 min morning
stiffness, normal ESR, no signs of inflamation locally
-joint involvement is symmetrical+-rash

)Intermitent claudication-give aspirin and exercise program
-do angiogram only pre-op,otherwise do duplex arterial study if you want
imaging

)Acantosis nigricans-insulin resistance (DM)-in young people
-gastro-intestinal malignancy in the older
-symmetrical, hyperpigmented, velvety palques in axilla, groin, neck

)Drug-induced acute allergic interstitial nephropathy:
a)antibiotics (meticilline, cephalosporine, sulfonamides...)
b)NSAID
c)thiazides
d)phenytoin
e)allopurinol

)Epiglotitis-given MC by H.influenzae type B and strep. group A

)Food droolong out of the mouth and nose during meals=Zenker diverticulum=>
can give aspiration pneumonia
-diagnose by oesopphagography

)Chronic diarrhea=>oxalate stones (due to malabs. of fatty acids, they bind
Ca and oxalate is free for absortion)

)Gardner syndrome:colonic polyps+lipoma, nasal angiofibroma, gastric polyps,
osteomas, epidermoid cysts, more teeth

)Amebic hepatic abcess-"anchovy paste" in the liver
-treat by oral metronidazole (not percutaneous drainage)
-in the tropics acquired

)Cluster headache=>treat by 100%O2 and s.c. sumatriptan; prophilaxis:
verapamil, Li, ergotamine

)Vaginal delivery in breech:
-frank or complete breech
->36 weeks of gestation
-weight:2500-3800g
-adequate maternal pelvis
External cephalic version-converts breech into cephalic presentation=>use
over 37 weeks until the onset of labor
Internal podalic version-in twin delivery (from transverse/oblique to breech)

)Friedrich ataxia-ataxia, dysarthria, skeletal deformities (scoliosis,
hammer toes, pes cavus), cardiomyopathy; three words: neurologic, cardiac
and skeletal problems

)Pseudogout-can be triggered by surgery or trauma
-may have 100000 Le/ml in joint fluid

)Nosocomial infections-UTI
-surgical wound infection
-pneumonia

)Know the X-ray appearance of descented aorta aneurysm-well circumscribed
lesion=>due to aterosclerosis

)For acute aortic dissection=>use first TEE or CT(only if hemodynamically
stable)

)Herpetic withlow-HSV 1 and 2
-in health care workers
-pain in the finger pulp with vesicles and systemic symptoms
-treat by acyclovir+topical bacitracin (to prevent secondary infection)
Felon-appears in tailors
-from needle injuries
-it's a bacterial abcess (tense abcess)=>do drainage+cephalosporine

)Urinary diversion procedure (ureter implanted in the ileum for example)=>
gives Hyper Cl metabolic acidosis because the colon absorbs NH4+ derived
from ureea under the action of intestinal bacteria
-also the pum Cl/HCO3 functions like this: absorbs Cl, lets HCO3 go!

)Tinitus-by aspirin, quinine
-also in Meniere disease, acoustic neuroma and ...depressed patients=>give
TCA

)Chronic myelogenous leukemia=>give IMATINIB (Gleevec)=Tyrosine kinase
inhibitor; side effects are: nausea, diarrhea, cramps, rash, face swelling,
temporary reduction in blood cell production

)Post-herpetic neuralgia=>give acyclovir
-follows acute herpetic-zoster infection

)Intra-uterine fetal demise (IUFD)-death in utero>20weeks
-Beta-HCG remaind eleveted
-confirm with US
-first do a coagulation profile to assess the risk of DIC
<=>between 13-28 weeks, no DIC=>watchful expectancy
<=>between 13-28 weeks, with DIC=>induction of labor with PG suppositories
<=>after 28weeks, with/out DIC=>induction of labor with oxytocin and
laminaria tents
-can use vaginal delivery
So, in case of DIC=>deliver immediately by induction of labor

)Acute retinal necrosis in HIV patients
-pain, keratitis, uveitis
-peripheral pale lesions+central retinal necrosis
-given by HSV or VZV
CMV retinitis=hemorrhages+granular lesions around the retinal vessels

)Pneumonia after upper GI endoscopy=>suspect anaerobic bacteria=> give
clindamycine or ampi+metronidazole
Ampi+genta=used almost NEVER for pneumonia, they are used for abdominal
infections+-metronidazole

)Cyclophosphamide=> can give bladder cancer
-prevent by lots of fluids and mesna

)Stress fracture (March fracture) or insufficiency fracture:
-young adults who exercise a lot
-X-ray=normal, dignose it with CT or MRI
-dull pain increased by exercise
-point tenderness
-at metatarsal, navicular, neck of femur/tibia

)Hypothyroidism-consider in patients with unexplained high CK levels

)Bicuspid aortic valves=>can give aortic stenosis later in life (4-5th
decade)=MCC of aortic stenosis in middle-aged adults

)Seborrheic keratosis-in the elderly
-0.3-2cm large
-slow enlargement
-greasy surface, stuck on appearance-HIGH YIELD these words
-varies in color
-anywhere on the body, except palms and soles
-can itch or rub
-do shave biopsy (DON'T DO IT FOR MELANOMA)
)Aspirin toxicity-gives metabolic acidosis and respiratory alkalosis (not
normal compensation, but two distinct processes)

)Gastroparesis-treat in order by: metoclopramide, bethanecol, erythromycine;
also cysapride-but it gives cardiac arrythmias
-confirm study=Nuclear Medicine Scintigraphy

)To determine the type of jaundice (conjugated or unconjugated) do:
-check urnary excretion of billirubin
-Van der Bergh test

)Lyme disease prophylaxis-do it only in pregnant women with hystory of tick
bite in order to RELIEVE ANXIETY by Amoxi
-give vaccine to people living in moderate/high risk areas
-to the rest of the population=NO PROPHYLAXIS

)MCC of SAH (subarahnoid hemorrhage) syndrome in children is AVM rupture
-may have a case with hystory of seizures and migraine-like headaches

)Screen patients for lipid abnormalities:
-men>35 years
-women>45 years, if in good health or
between 20-35 (M) and 20-45 (W) if they suffer from:
a)DM
b)family hystory of hyperlipidemia
c)personal risks of CAD
d)family hystory of cardiac disease<50 years (M) or <60 years (W)

)Gout attacks-give:
-low-purine diet
-no alcohol=>metabolises to lactic acid=>impairs renal excretion of uric
acid by acidifying the ph
-avoid diuretics, pyrazinamide=>they compete with uric acid for renal
excretion

)Penile fracture=emergency
-penis deviated to one side due to the rupture of albugineea of a cavernous
body
-first do retrograde urethrogram, then surgical exploration of the penis

)Hypercarotinemia-in anorexia, DM, hypothyroidism

)A confounder (ex.smoking), to be considered so, needs to be linked to the:
-exposure (ex.people who drink alcohol are more likely to smoke)
-outcome (ex. smoking is associated with oral cavity cancer)
So smoking can be a confounder if a study concludes that alcohol alone is
responsable for oral or oesophageal cancer!!!

)Effect modification=the effect of exposure (ex.drugs) on outcome (a disease
) is modified by another variable (ex.family hystory). This effect is not
BIAS!!!

)Amiodarone=> don't give it if low BP
)Lesion suspicious of melanoma=>do excisional biopsy with narrow margins

)Radioactive iodine=treat of choice for Grave's disease
Antithyroid drugs-give in pregnancy+Grave's
-pre-op for surgery on Grave's
Iodinated contrast agents=>treat thyrotoxicosis
-give them if intolerant to anthytiroid drugs
Surgery-if:
-very large goiters
-antithyroid drugs do not control thyrotoxicosis in pregnancy
-increased risk of malignancy
-if next year scheduled pregnancy

)Petrous apicitis-triad=retro-orbital pain, paralysia of lateral rectus,
otorrhea

)Anoscopy/proctoscopy=first step for blood per rectum in patients <50 years
of age, without risk factors for colon cancer (here's not included blood
mixed with stool=this is a risk factor)

)Sickle cell disease-aplastic crisis-prevent by folic acid administartion
and NOT by vaccination against parvovirus (which is a nother cause)

)Exercise level in pregnancy=keep it at the same level as before preganancy

)Phenothiazine-gives hypothermia, inhibit shivering-think of a schizo
wandering in the streets in winter and is found lying in a park

)If someone exposed to HBV is vaccinated already and HAS a documented
response to HBV (by prior adequate titer of antibodies)=>do nothingm, just
reassure!!!

)If in 2 weeks from the beginning of a pneumonia, the CXR is still
pathologic=> do bronchoscopy and CT scan to rule out abcess or tumor and to
take cultures, to drain...

)A reliable test gives similar results on repeat measurements
A valid (accurate) test gives results that can be compared with a gold
standard test!!!

)Graft versus host disease=> affects skin (rash), intestin (blood+diarrhea),
liver (abnormal LFT)
-by activation of donor T-cells, so it's cell-mediated immune response
)In DKA there's a paradoxycal hyper K+ from acisosis, because the reserves
of K+ are actually depleted=> so give K+ in your treatment plan

)FIRST sign of colo-rectal cancer under 40 years of age=Rectal Bleeding

)Removal of K+ from the body=cation-exchange resin (kayexalate), diuretics,
dialysis; NOT Ca gluconate, NOT insulin (these create only a shift
intracellularly)

)Roth spots and Osler nodulesm in IE are from immune complex deposition (
immune vasculitis)
Janeway lesions=septic embolism

)Optic neuritis=rapid vision decrease
-marked changes in color perception
-pain on eye movements
-central scotoma
-afferent pupillary defect
-swollen disk

)Myotonic muscular dystrophy
-begins in childhood (~13 years)
-AD disease
-muscle weakness, wasting in distal hands, post. forearms, ant. compartment
of legs
-myotonia=delayed relaxation
-associated with testicular atrophy, DM, frontal balldness, hypothyroidism

)Matitis-in nursing
-treat by anti-Staph penicillin
-continue nursing to decrease breast engorgement and observe
-drainage only if there'sa fluctuating mass (=abcess)

)Atracurium-metabolized in plasma, by serum esterases
-use it safe in renal and liver dysfunctions
Pancuronium+mivacuronium=>not good in renal disease
Rocuronium=>not good in liver disease
Succinylcholine-in renal disease gives Hyper K+ and apneea

)Randomization=similarities in the baseline characteristics of patients in
both placebo and treated groups. It controls known/unknown confounders!!!

)Mild acne=>topical retinoids; if reactivation occurs, give topical
antibiotics
Moderate to severe acne (papular or inflamatory acne)=>oral antibiotics
Nodulocystic, scarring acne=>oral isotretinoin

)IMPORTANT!!!
In any metabolic acidosis=>first step=get AG (Na-Cl-HCO3); normal is 6-12 (
or 8-14 depends on the author)
a)Normal AG metabolic acidosis-usually hyper Cl-2 causes:
-renal loss of HCO3 by RTA, moderate renal failure (GFR>20ml/min), carbonic
anhidrase inhibitors
-GI loss of HCO3 by diarrhea, pancreatic fistula, ureterosigmoidostomy
To differentiate between them, get next step=urine AG(Na+K-Cl); normal is
from -50 to 0.
If (+)=> defective urine acidification, lower urinary Cl, like RTA 1,2 and 4
If (-)=> higher urinary Cl=>adecquate NH4+ production=> GI causes
Then, urine PH differentiates different types of RENAL causes of acidosis!!!
b)High AG metabolic acidosis:
-lactic acidosis
-ketoacids (DM, starvation, alcohol ingestion)
-methanol ingestion
-ethjylen glycol ingestion
salycilate poisoning
uremia (GFR<20ml/min)
Here, next step is to calculate the osmolar gap (especially if toxicity is
suspected)

)Paget disease=disordered skeletal remodelling
Osteoporosis=low bone mass with normal mineralization
Rickets=defective mineralization of bone and cartillage of the growth plate

)Malignant otitis externa-by pseudomonas (in DM, imunocompromized)
-granulations of the ear canal
-involvement of CN VII, IX to XII
-erosion of bone
-foul smelling discharge
-deep otalgia
Rhizopus+Aspergillus are fungal infections that give external otitis, (not
malignant), but don't make granulations

)Suspect Zollinger-Elisson syndrome if refractory ulcers are associated with
renal stones and there's a + family hystory of PUD

)HIGH-YIELD:
Erythopoietin in dialysed patients-side effects:
-raises BP, even HTN encephalopathy
-headaches
-flu-like syndromes
-red-cell aplasia (rare)
Start treatment at Hematocrit<30% or Hb<10g%

)Gall-bladder pathology-First use US
HIDA scan-for diagnosis of acalculous cholecystitis or suspected on US

)Trichinosis-2 phases:
a)GI upsets:pain, nausea, vomit, diarrhea
b)splinter hemorrhages, retinal&conjunctival hemorrhages, periorbital edema,
chemosis, muscle pain, tenderness, swelling, weakness

)Eato-Lamber syndrome-earliest manifestation is hip-girdle weakness, later
shoulder girdle involvement

)Thioridazine toxicity-cardiac arrythmias, prolonged QRS, low BP, tahicardia
; treat by NaHCO3

)Sputum gram stain of pneumonia-purulent specimen if >25 neutrophils and <10
epithelial cells/field

)Respondent bias=when outcome is obtained by patient's response (ex.migraine
) and not by objective means of diagnosis (ex.biopsy)

)Tinea corporis infection-itching
-ring-shaped scaly patches with centralclearing and distinct borders
-caused most frecq. by Trichophyton rubrum
-treat by topical terbinafine
-use griseofulvine if only extensive disease (this drug is usually not used
today)


)Salivary glands inflamation-from drugs such as: tioureea, iodine,
cholinergic drugs

)Hepatitis B-associated with membranous GN
Carrierrs of Hep. B virus-associated with membrano-proliferative GN

)Vit.K deficiency:
-NPO patient
-receiving antibiotics
-high PT, then high PTT (prolongation of PT>> prolongation of PTT)

)Primary sclerosing cholangitis-in Ulcerative Colitis
-complication of it is cholangiocarcinoma=contraindication to transplant
So any severe stricture of the biliary tree MUST BE BIOPSIED!!!

)Mitral regurgitation=MC valvular abnormality in patients with IE

)Hollenhorst bodies=cholesterol particles, signs of impending stroke

)Benzodiazepines-can cause paradoxycal agitation in the elderly

)Congenital cataract=MCC of white reflex in pediatric population

)Any nocturnal, newly diagnosed asthma in middle-aged patients=>suspicion of
GERD if associated laryngitis; to differentiate between asthma and GERD
give a trial of proton pump inhibitors which can be both dignostic anf
therapeutic

)CREST syndrome-may have pulmonary HTN (loud P2 sound)
)Mechanical symptoms in patients with meniscal problems=>evaluate by
arthroscopy or MRI, then correct by surgery (arthroscopic or open)

)Latent period-in chronic disease epidemiology; is NOT BIAS
=extended time of continuous exposure is needed to affect the outcome (ex. 2
years of continuous multivitamins administration is needed to give a
protective effect against cancer)

)Nitrates are c.i. for at least 24h after taking sildenafil (viagra)

)SCC-scaly plaque, central ulceration, 1.5cm, on the forearm
-polygonal cells, atypical nuclei at all levels of epidermis, zones of
keratinization; sometimes is difficult to tell it apart from BCC

)Hypo K+ metabolic alkalosis:
-vomiting=>low urine Cl
-S. Bartter
-S. Gitelmann
-diuretic abuse; all three have high urine Cl

)Otosclerosis-AD disease
-Women>>men
-more in Caucasian race
-treat by NaF

)Lactose intolerance-diagnose with Lactose Breath H+ Test or (+) Clinitest
for stool reducing substances
-high osmotic stool gap=290-2(stool Na+stool K)>50mosm/kg

)Goodpasture's syndrome-give emergent plamapheresis!!!

)Metastatic bleeding brain mass=> FIRST think MELANOMA
Tumors that don't metastisize to the brain are:
a) non-melanomatous skin cancer
b) oropharingeal cancer
c) oesophageal cancer
d) prostate cancer


)Parkinson's tremor=>gibe benztropine
Choreea Huntington=>give haloperidol

)Vitreous hemorrhage-sudden, acute loss of vision
-sudden onset of floaters
-fundus is hard to visualize, floating debris, dark red glow
-treat conservatively-sleep in upright position

)Prematurity-cause of intraventricular hemorrhage

)Mamography-do it annually between 50-75 years
FOBT-anually; 50-80 years
sigmoidoscopy-every 5 years between 50-80 years
Pap smear-until the age of 65 years, not after
Lipid screening-men>35y
-women>45y
-not >75y
-??unknown recommendations between 65-75y

)Alpha-1 antitrypsine deficiency in non-smoker, 3rd decade of life, lower
lobe emphysema, neonatal jaundice in hystory

)Relapsing polychondritis
-recurrent inflamation of cartillaginous structures: ear=MC,spares the
lobules; eye (conjunctivitis, episcleritis); joints (diffuse joint pains);
skin; CNS.

)Fracture of calcaneum due to fall=> evaluate for other potetial fractures
by X-ray of head, chest, abdomen, lumber area and pelvis
It's a very painful fracture and prior taken narcotics may alter pain
perception
-so give morphine in severe pain, but after investigating for potential
injuries (head and neck first)!!!

)Li-can cause seizures, opisthotonus, hyperreflexia, coma

)Attributable risk percent (ARP)=risk in exposed-risk in unexposed/risk in
exposed=1-risk in unexposed/risk in exposed=1-1/RR=RR-1/RR
-it's the excess risk in the exposed population attributable to the risk
factor!!!

)Impaired NH4+ excretion=main mechanism of metabolic acidosis in renal
failure

)Hypo K+ periodic paralysis-by stress or medication
-sudden drop in K+ levels
-renin=normal, BP=normal
-familial condition or thyrotoxicosis

)Bartter syndrome=hypoK+ metabolic alkalosis
-impaired Na absortion in Henle ascending loop=hypovolemia=>activate RAA
syste
-polyuria, polydipsia, growth abnormalities
-high urine Cl

)Serous otitis media=>air bubbles seen in the middle ear
Cholesteatoma-marginal tympanic membrane perforation, ear canal filled with
mucus, pus, granulation tissue, destroys bone; remove surgically

)All patients suspencted of Zollinger-Elisson syndrome should have checked:
-first: serum gastrin levels (if>1000pg/ml are diagnostic); if not
diagnostic,
-then:secretin stimulation test, if (-),
-then: Ca infusion study
Also measure gastric PH once to exclude hypergastrinemia from achlorhydria

)Chlamydial urethritis-dysuria, urinary frecquency
-mucopurulent urethral discharge
-sexual hystory of multiple partners
-pyuria+absence of bacteria on urialysis (colonies<100/ml)
In gonochoccal, the discharge is purulent!!!

)Differentiate CML from leukemoid reaction by measuring Leukocyte Alkaline
Phosphatase (LAP); low in CML, high in leukemoid reaction!!!

)Lewy body dementia-fluctuating cognitive impairement
-reccurent visual halucinations
-motor features of Parkinson

Pick's disease-fronto-temporal
-personality changes (euphoria, dezinhibition,apathy)
compulsive behaviour
-peculiar eating habits, hyperorality
-impaired memory
-visuo-spatial function=intact

)Transient synovitis of the hip:
-X-ray=normal
-2 weeks after URI
-high ESR
-pain of joint movements
-treat by bed rest and hip joint in the position of comfort

)Beta-blockers intoxication-treat by:
-atropine, if fails
-isoproterenol, if fails
-glucagon

)Gold standard for osteoporosis is DEXA scan

)Increased ventilatory rates onmechanical ventilation=>can lead to auto-PEEP
=>lowers BP
-treat by decreasing the ventilator rate

)Erythema nodosum-may be the first sign of sarcoidosis
-goes with flare-ups of IBD
-appears in TB too

)Osgood-Schaltter disease-treat with rest, NSAID, brief casting

)Beta-blockers-selective beta 1 are agents of choice for perioperative MI
risk decrease

)Cocaine abuse-young, venous trace marks, EKC with ischemia (ST depression),
tahicardia, HTN
-treat-first line: Benzodiazepine, then nitrates, aspirin
-do catheterisation only if MI is obvious!!!

)Use aspirin in children only in:
a)Kawasaki disease
b)Juvenile rheumatoid arthritis

)Patients on both Mg(OH)2 and Kayexalate can get metabolic alkalosis due to
the fact that Kayexalate bind Mg, so HCO3 remains in access and can be
reabsorbed from GI tract!!!

)Treatment of hypo Na (SIADH):
-mild, asymptomatic, Na=120-130: fluid restriction
-moderate, asymptomatic, Na=110-120: normal saline+loop diuretic
-severe, symptomatic: hypertonic saline (3%)+loop diuretic

)Laxative abuse-10-20 evacuations/day and night,cramps=cause of factitious
diarrhea
-on colonoscopy you see melanosis coli, because of the use of anthraquinone-
laxatives (bisacodyl) and is dark-brown discoloration of the colon with
shining limph follicles as pale patches

)Cyclosporine side effects=HIGH YIELD:
a)nephrotoxicity, high K+
b)HTN-tret with Ca channel blocker
c)neurotoxicity-tremors
d)glucose intolerance
e)infections
f)malignancy
g)gingival hypertrophy, hirsutism
h)GI complaints
Tacrolimus-same side effects except no gingival hypertr. and no hirsut.
Mycophenolate=>bone marrow suppression
Azathioprine=>bone marrow suppression,hapatotoxicity, diarrhea, leukopenia

)Pernicious anemia=>has high levels of LDH

)Nosocomial pneumonia in intubated patients=>think Pseudomonas=>give
cefepime or ceftazidime (4th generation)

)A definite diagnosis for Alzheimer's disease can be made only post-mortem
by brain biopsy!!!

)Chronic fatigue syndrome-like fibromialgia,but no trigger-points+symptoms
of at least 6 months duration

)Barton's fracture-intraarticular, carp+distal margi of radius
Chauffeur's fracture-of radial styloid
Galeazzi's fracture-anywhere on the radius+radio-ulnar junction
Smith's fracture-reverse Colles fracture

)Null-hypothesis for cross-sectional study:
There's no association between elevated ESR level and colon cancer!
Null-hypothesis for cohort study:
The risk of colon cancer is the same for the subjects with and without
elevated ESR level

)Descending aortic aneurysm in a young male is frecq. due to blunt trauma to
the chest!!!
HIGH-YIELD:

)Bullous penphigoid=IgG+C3 deposits at the dermal-epidermal junction
-no oral lesions
-tense blisters in flexural areas
->60 years of age
-pruritus precipitated by UV, NSAID, antibiotics

Pemphigus vulgaris-intraepidermal blistering disease with auto-antibodies to
adhesion molecules
-Ig G deposits intracellularly in the epidermis

Cicatricial pemphigoid-affectsmucous membrames
-Ig G deposits in linear band at the deromo-epidermal junction

Herpes gestationis-2nd trimester
-sub-epidermal blisters
-deposits of C3 at the basement membrane zone

)Amphotericine=>can give hypoK+

)Hshimoto thyroiditis:
-low TSH, high T4, T3, high T3 resin uptake
-low radioactive iodine uptake
-high thyroglobilin level
-non-tender goiter
-dry mouth&eyes

)Leukoplakia:
-increased risk of SCC
-from tabacco, vit. A, B deficiencies, syphilis
-do incisional biopsy or exfoliative citology examination!!!

)Soemtimes UC can involve the terminal ileum=>backwash ileitis

)Adult PKD complications:
-hepatic cysts
-valvualr heart disease (MVP, AR)
-colonic diverticula
-abdominal wall and inguinal hernia

)Thrombastenia Glanzmann-RA disease
-defect in GP IIb-IIIa
-increased BT
-trombocytes=normal, vWF=normal
-clot retraction is decreased
-epinephrine, colagen, thrombin and ADP fails to induce aggrgation
-normal response to ristocetin test
Bernar-Soulier syndrome-giant trombocytes, bleeding tendencies
-lack of aggrgation to vWF and ristocetin
-normal responde to ADP
-abnormality in GP Ib

)Acalculous cholecytitis:
-extensive burns
-severe trauma
-prolonged TPN
-prolonged fasting
-mechanical ventilation

)HIV patients with esophagitis-give fluconazole against Candida; if it
donesn't cure, then and only then do esophagoscopy, cytology, biopsy,
culture!!!

)In alkali ingestion(ex. lye)=>do contrast study with gastrografin+endoscopy
as easrly as possible
-don't give charcoal=ineffective!!!

)Bupropion-can be given with nicotin patches, monitor BP=>risk of HTN
-causes weight loss
-risk of seizures=>don't give to anorexic patients as antidepressant

)In tumor lysis syndrome=>give allopurinol+hydration!!! If on allopurinol,
give only 25% of purine antagonists (mercaptopurine, azathioprine)!

)In heat stroke=>rapid cooling with evaporating cooling=choice,then gastrci
lavage or imersion in cold water

)Dermatitis herpetiformis=>dapsone

)In metab acidosis=>look for compensation (PaCo2)=>look at AG=>look at
variation of AG and HCO3; one goes up and the other should go down, if this
is the only acid-base problem, so the divisation of their variations is
equal to 1!!!

)Prevalence high=>high PPV, low NPV

)Nickel jewelry, poison ivy=allergic contact dermatitis (type IV reaction)

)Do thyroid function tests if:
-hyperlipidemia
-unexplained low Na
-high CK levels

)Treat strep.pharingitis with one shot of benzatin-penicilline G i.m.

)MC complication of PUD=hemorrhage

)MC drug causing priapism=prazosin

)Asymptomatic lymphocytosis in older=>suspect CLL=> lymphadenopathy=>
hypogamaglobulinemia=infections!
-Smudge cells are characteristic
-lymph node biopsy is not required for diagnosis, but it confirms it!

)In primary billiary cirrhosis-give ursodeoxycolic acid=first line, second-
line=cholestiramine; ultimate cure=liver transplant



)Actinomycosis-anaerobic gram (+) branching bacteria
-draining infection, indurated area
-sulfur granules
-treat by high dose penicilline or erythromycine 6-12 weeks!!!
Another cause of draining face/neck infection=scrofula!

)Scoliosis-Cobb's angle
-mild curve<20degrees=>careful follow-up to assess the rate of progression
-20-30 degrees=>choice between observation and bracing is made on the
presence of rotational deformity and + family hystory
->30 degrees=>bracing
->40degrees=> surgery

)Unacceptability bias=participants' response with desirable answers which
leads to underestimation of the risk factors-ex. medical students are asked
to complete a survey about whether they smoke or not...some may say that
they don't smoke just because they know that smoke is bad for health!!!

)Hystory of normal skin at birth+gradual progression to dry scaly skin=
ichthyosis
-dry skin with horny plates over the extensor surfaces of the limbs
-worsens in winter due to increased dryness=lizard skin!

)Markers of adrenal tissue: DHEA, DHEA-Sulfate
Testosterone+androstendione coem equally from ovaries and adrenal glands

)Symple renal cyst on CT=>reassurance (know the CT appearance), but
investigate if:
-multilocular mass
-thcikened irregular walls and septae within the mass
-contrast enhancement

)In mononucleosis, patients can play sports only when physical exam is
normal (no splenomegaly)

)TIA-give anticoagulation if embolic
-in the rest, give aspirin; if fails, give clopidogrel, if fails, give
ticlopidine
-aspirine+dipiridamole-if there's a hystory of TIA on aspirin alone

)Zellweger's syndrome-defect in peroxisomes
-neonatal seizures
-facial dysmorphism
-hypotonia, wide open sutures, cloudy cornea, glaucoma
-they live only a few months

Neonatal adrenoleukodystrophy-no dysmorphic features
-enlarged liver, abnormal LFT, pigmentary degeneration of retina, impaired
hearing

X-linked adrenoleukodystrophy
-accumulation of fatty acids (log chain ones)=>pregressive adrenal cortex
dysfunction and CNS white matter

Infantile Refsum disease
-gait problems, hearing loss, pigmentary degen. of retina, dysmorphic
features

Classic Refsum disease-young adulthood
-visual problems (night blindness), ataxia, cardiac arrythmia, ichthyosis,
peripheral neuropathy

)Osteoporosis-acute backpain with noobvious preceding trauma in the elderly
women=compression fractures of the vertebrae

)More than 5 days of symptoms of appendicitis with RLQ findings=>give iv.
hydration, antibiotics (cover gram (-)), bowel rest

)Chronic therapy with Vit. D=>hyper Ca
-stop vit.D, low Ca diet, acidify urine, give corticosteroids!



)To control confounding-means:
-matching
-randomization
-restriction
Selection bias=>controlled by selecting a representative sample of the
population for the study+high rates of follow-up
Ascertainment bias=>avoided by a strict protocol of case ascertainment
Observer's bias=>controlloed by blinding

)Patients with dyspepsia and <45 years of age without alarm symptoms (
bleeding, anemia, dysphagia, weight loss)=>first step=Non-invasive test for
H.pylori (breath test or serologic test)
-if +=>eradication therapy of H.pylori
-if -=>empirical trial of H2 blockers or PPI or prokinetics
If >45 years or with alarming symptoms=>do endospcopy+H.pylori testing

)Hematuria+irritative or voiding symptoms=>suspect bladder cancer, even in a
patient with large, firm prostate
-associated factors: cigarette smoking, suprapubic pain, long hystory of
analgezic use

)Chronic ITP-can be a feature of SLE; that's why in chronic cases of ITP=>
do BM biopsy

)In conjugated hyper bilirubinemia=> first do LFT, then US of CT scan

)Dubin-Jonhsons+Rotor syndromes=> have normal ALP

)Hawthorne effect=tendency of the studied population to affect the outcome
due to the fact that they are being studied!!!
Sample distorsion bias=when the sample is not representative for the whole
population in "exposure" and "outcome"
Information bias=imperfect assessment of association between exposure and
outcome as a result of errors in the measurement of exposure and outcome-it'
s minimized by standard techniques for surveillance and measurement+trained
observers

)HIGH-YIELD:
Left ventricle dysfunction: high RA and PCWP pressure
Septic shock: low PCWP and RA pressure, low SVR, high debit
In pericarditis, tamponade=>RA pressure=PCWP and both are high
RV infarct=> low PCWP, low BP

)Post-prandial worsening pain+avoidance of food+risk factors for
atherosclerosis=abdominal angina

)Hydatid cysts-Echinococcus granulosus
-asymptomatic
-mostly in the liver, but also lung
-comes from sheep
=fluid-filled cyst with numerous secondary daughter cysts
Pig farmers=> get neurocysticercosis
Commercial sex-worker=>can get perihepatitis from STD (gonorrhea)

)Congenital adrenal hyperplasia-hirsutism, virilization+very high levels of
17-HO-progesteron, normal Testosteron and DHEA
Idiopatic hirsutism-from excessive peripheral conversion of testosteron=>
dihidro-testosteron

)If bleeding >25-30% of blood volume (or 1500ml)=>give blood transfusion
In trauma, usually give 2l of crystalloid solution in 10 min=>if still
hypovolemic=>give blood
Give blood also if:
-Ht<25%
-Ht<30%+ COPD, Ischemic Heart, chronic renal failure
-unexplained acidosis in anemic patients

)Epiglotitis=>first do fiberoptic laryngoscopy to establish a diagnosis,
then do nasotraheal intubation (alternative=traheostomy)

)HIGH-YIEDL-Know this thouroughly!!!
low PCWP, normal MV02 (mixed venous O2 concentration)=>is septic shock; also
: low RA pressure, high debit, low SVR
low PCWP, low MVO2=>is volume depletion or neurogenic shock
)Atopic dermatitis-infants<6 months
-pruritus
-symmetrical-scalp, cheeks, trunk, extensor areas
-unknowun etiology
-in acute attacks give low-moderate potency corticosteroids
-spares diaper area (contact dermatitis does not)

Exfoliative dermatitis-over 40 years of age
-prior dermatological condition, systemic illness, new medication

)Dehydration in diabetes insipidus=>give normal saline; once the volume
deficit is replaced, can switch to 0.45% saline to restore water deficit

)HIGH-YIELD
CT scan=>use it to evaluate the extent of newly diagnosed gastric cancer;
treat by surgery

)In dialysis-persist or worsen the followings: anemia, HTN, bone disease,
autonomic neuropathy

)Intrahepatic cholestasis of pregnancy
-3rd trimester with jaundice
-marked pruritus, high AST, ALT(<200), very high bile acid levels, ALP<200,
PT=normal

)If suspect IUFD=>GET US, then coagulation profile

)Spontaneous hemarthrosis=>think hemophilia

)Osteogenesis imperfecta=>get type 1 collagen assay

)If one parent gives consent for the treatment of a minor is sufficient
9even if the other one disagrees)=>go ahead with the treatment!!!
If both parents refuse treatment=>get a court order if the situation is not
emergent!!! If it's emergent=>treat as you see fit; you are protected by the
law that you act in the best interest of the child!!!

)Inhaled steroids=> can give dysphonia, thrush

)In a ureteral colic, one can have intestinal ileus=>do CT scan or IVP;
treat by ureterolithiasis
Enteroclysis=used to diagnose small bowel tumors or other pathology which
cause intestinal obstruction

)In case-control studies, if prevalence of the disease is low=>odd ratio=~RR
(this is rare disease assumption). They love these questions, try to
understand them, though they are difficult!!!

)Study of choice for abdominal aortic aneurysm=abdominal US

)Malignant melanoma-MC as a changing mole
-hystory of sun exposure
3 major crteria:
change in-color
-shape
-size
4 minor criteria:
inflamation
bleeding/crusting
>7mm
sensory changes

)In metabolic alkalosis from vomitting=> give K, not Ca which is normal in
total, only ionized is decreased

)In acute respiratory alkalosis=>PH raisis the afinity of Ca for albumin=>
decreased ionized Ca, increased albumin-bound Ca, normal total Ca and normal
Ca bound to inorganic anions

)Chronic pancreatitits with central duct>1cm and severe pain=>do lateral
pancreatico-jejunostomy

)Alcoholism=>can cause rhabdomyolysis (drunk man lying in a park)=> urine
dipstick is + for blood but (-) for RBC=>from myoglobinuria

)IE of drug users: give vanco+genta because of high incidence of meticillin-
resistant Staph
-if not drug abuser=>give naph+genta

)Acarbose (alpha glucosidase inhibitor)=> don't allow carbohydrate breakdown
in the intestin=>high carbohydrates in the stool!
-indicated in late onset type II DM

)Dysphagia to both solids&liquids=>achalasia=>domanometry, but alsoendoscopy
to rule out cancer

)Acute monicitic leukemia- M5A in young (~16 years)
- M5B-middle age(~49 years)
-(+) alpha-naftyl esterase
-numerous promonocytes and monocytes
M3 leukemia-assoc. with DIC

)Post-op benign intrahepatic cholestasis
-after major sugery
-low BP
-extensive blood loss
-or after massive blood replacement

Halothane toxicity-type 1-mild elevation of LFT, no jaundice
-type 2-acute liver failure

)Kaposi sarcoma-on the trunk, face, extremities
-papules>plaques/nodules
Bacillary angiomatosis-like Kaposi sarcoma, but with systemic signs (malaise
, headaches, fever)

)Prolactin is (+) by TRH, serotonin and (-) by dopamine
Hyperprolactinemia=>(-)GnRH=>amenorrhea
=>galactorrhea
Both of them appear in hypothyroidism due to high TRH

)Idiopathic pulmonary fobrosis-treat by steroids; lung transplant is not an
option since it must be bilateral and there's a shortage a donors!

)In fibromyalgia=>check thyroid tests and CK levels
Diffuse axonal injuries-from deceleration
-at the gray-white matter junction
-looses consciousness on the spot=>then persistent vegetative state
MRI is more sensitive than CT for detecting the axonal injuries

)Lumbosacral strain-pain after exertion
-absence of radiation
-(+) paravertebral tenderness
-(-) straight-leg raising test
-normal neurologic exam

)Situational syncope: middle-aged, old male, losses counsciousness
immediately after urination or during coughing fits

)Hypocalcemia-after major surgery, extensive transfusions
-due to volume expansion, hypoalbuminemia
Mypo Mg-alcoholism
-diarrhea, diuretic abuse
-prolonged NG suction
)Management of DM foot ulcer from mild to severe forms:
-off-loading
-debridement
-wound dressing
-antibiotics
-revascularization
-amputation


)In refractory ascites=>do tapping of up to 2l/day+give 10g albumin/liter
taped as a last resort before any surgical procedure you may think!!!
Spleno-renal shunt-will worsen ascites
Side to side porto-caval shunt-improves ascites, worsens encephalopathy
Peritoneo-jugular shunt-for the treatment of ascites only; risks:DIC, sepsis
, peritonitis
iv furosemide therapy=>worsens encephalopathy, precipitates hepato-renal
syndrome

)Treat Ca-oxalate stone lithiasis by:
a)increased fluid intake>3l
b)normal or increased Ca intake-yes!!! you read fine!!! (1000mg)
c)low Na diet
d)low oxalate diet (no chocolate, vit C)
e) low dietary proteins (meat, eggs)

)Soap-bubble appearance in the distal femur on x-ray with knee pain, some
mass, in 20-40 years old=>think giant-cell tumor of the bone=>refer to
orthopedic surgeon; don't do bone scan=this is for solid tumor metastasis
identification

)Choledocal cyst=congenital anomaly of the biliary tree
-dilatation of the intra/extra hepatic ducts
-jaundice, acholic stools
-reccurent attacks of pancreatitis
-can degenerate into cholangiocarcinoma
-First do US, then CT or MRI
Caroli'ssyndrome=congenital
-intrahepatic dilation of bile ducts

)In transplant patients=> give TMP/SMX to prevent PCP pneumonia;
alternatives:dapsone or aerosolized pentamidine

)Lumbar pain in the 3rd trimester=> due to lumbar lordosis and relaxation of
the ligaments of the sacro-iliac joints

)Dystonia-treat by benztropine or diphenilhydramine

)90% of PE come from emboli in the ileo-femoral veins

)Pseudogout under 50 years=>think any of:
hypo Mg, hypo P, hyper PTH, hypothyroidism, hemochromatosis

)Treat fractures of the humeral shaft by: closed reduction and
immobilization of the arm in a hanging cast

)Cystic fibrosis-may develop Cl sensitive metabolic alkalosis
Barter'syndrome-Cl resistant metab. alkalosis

)In GERD=> give empirical treatm. with PPI or H2 blockers=>if it fails or
there are features of complicated disease=>esophagoscopy=>if (-)=>PH
monitoring

)HIGH-YIELD
Acute tubular necrosis-muddy-brown cast
GN-RBC cast
Pyelonephritis, interstitial nephritis-WBC cast
Nephrotic syndrome-fatty cast
Chronic renal failure-broad, waxy cast

)Febrile reaction to transfusion=>prevent it by Le depletion with cell
washing

)Chronic Hep C with normal enzymes=>follow yearsly with LFT, not biopsy!!!

)Biophysical profile (BPP); N=8-10
-if AFI<5=>deliver because of possible cord compression
-if BPP=6 and no oligohydramnios=>do CST, if non-responsive=>deliver; if
suspicious=>repeat CST in 24h
-if BPP=4, no oligohydramnios and fetal lungs are mature=>deliver; if not
mature=>give steroids and do BPP in 24h
-if BPP=2=>deliver no matter what!!!

)Cyclical vomiting-in children with parents with headaches
-no obvious cause

)Contraindications to exercise stress test are:
LBBB
ST>1MM
WPW Syndrome
idioventricular rythm
**but NOT: RBBB, ST depression at rest<1mm

)Ehylene glycol poisoning-has Ca-oxalate rectangular, envelope shaped
crystals
-high AG=>SO WHAT DO YOU DO???
-Osmolar Gap=observed osm-calculated osm
calculated osm=2Na+Glu/18+BUN/2.8

)Chronic painful DM neuropathy: give TCA, NSAID or GABAPENTIN=CHOICE

)Constipation with back pain, renal dysfunction, high ESR,anemia=>what is it
?????
Multiple myeloma, where the constipation is from hyper Ca; also polyuria,
anorexia.
Similar scenario from metastatic bone cancer=>think Hyper Ca as a cause for
constipation!!!! HIGH-YIELD

)Still HIGH-YIELD
MC nephrotic syndrome in Hodgkin disease=minimal change disease
In general membranous GN is associated with carcinoma

)Disseminated hystoplasmosis-in imunosupressed people
-low fever, wieght loss
-hepatosplenomegaly, mucous membrane ulcers
-pancytopenia, pneumonia

)Lichen sclerosis-post-menop
-treat by superpotent topical corticosteroids
Any itchy spot on vulva post-menop=>needs biopsy!!!

)To diagnose polymiositis=muscle biopsy

)Blunt abdominal trauma with negative US and CT scan=> do DPL to detect
small lacerations; if also (-
)=>observation is next!!!

)In DM goals are BP<130/80mmHg

)Carpal tunnel syndrome-associated with hypothyroidism

)Toxic epidermal necrolysis-mucocutaneous
-(+)Nikolsky sign
-painful skin lesions
-idiosyncratic reaction to sulfonamides, barbiturates, phenitoin
KNOW THE PICTURE!!!
Steven-Jonhson's syndrome=target lesions on >2 of mucosal surfaces; also
from sulfonamides, NSAID, phenitoin

)Cirrhotic with fever, abdom. pain, ascites=spontaneous bacterial pneumonia!
!!
-do paracentesis to confirm: Le>250/ul, protein>2.5g/l, specific gravity>
1016, serum/ascitic protein<1.1

)Metastatic breast cancer with solitary metastase=>do surgery (resect it)
Pulmonary metastasectomy-do it if:
a)primary tumor is out
b)no other sites exist
clow operative risk
d)complete resection is possible
In widespread disease=>hormone or chemotherapy!!!

)Pseudopancreatic cyst<5mm, usually resolves on its own in 6 weeks

)Cystic fibrosis with pneumonia=>think Pseudomonas
-treat by: pipracillin+genta/cipro (cipro not in children) or cephalosporine
(4th gen.)+aminoglycoside


)Pregnancy-high total T3 adn T4, nornal free T4, T3, TSH=normal
-due to increased TBG

)Intermitent explosive disorder-episodes of aggersive impulses with
assaultive acts or destruction of property
-degree of aggressiveness is disproportionate with any stressor
-treat by symptoms-if manic:Li, if depressive:SSRI

)Tricuspide valve endocariditis=>can give pulmonary infarct or abcess
-on CXR=well circumscribed elsion with cavitation
-look for this if there's a drug user!!!

)Gonorrhea=>migratory asymmetric polyarthralgias,then a monoarticular
arthritis
-skin lesions: multiple necrotic pustules over palmes and soles

)Zn deficiency:prolonged TPN, diarrhea
-alopecia, diarrhea, oligospermia, dysgeusia, rash around the mouth+eyes,
mental changes,impaired wound healing
Selenium def.:-cardiomyopathies,skeletal dysfunction
Copper def.:kinky hair syndrome, dissecting aortic aneurysm
Essential fatty acid def.: low thrombocytes, eczematous rash

)Erysipelas-raised sharply demarcated advancing marigins lesion
-on the face
-regional lymphadenopathy
-hystory of trauma or pharingitis

)Subacute lymphocitic thyroiditis-painless
-small goiter
-no ophtalmopathy
-after receiving amiodarone, INF-alpha, IL2

)HIGH-YIELD
Giardiasis-from a developing country
-Rockies
-adhesive disks and malabsortion
-fatty stools, foul smelling, bloating

)Membranous-proliferative GN-caused by Ig antib (C3 nephritic factor)
against C3 convertase of the alternative C pathway=>persistent C activation!
!!

)In HIV patients-treat histoplasmosis by amphtericin B and then life-long
itraconazole

)Dejerine-Roussy syndrome (thalamic stroke): severe dysesthesia, athetosis,
transient hemiparesis

)Imipenem+cilastin=second line drugs for Pseudomonas, first line=
cephalosporines

)MC lipid anomaly in hypothyroidism=hypercholesterolemia, then
hypercholesterol+hyper TG

)D-xylose absortion test is abnormalin bacterial overgrowth and Whipple
disease; if you want to tell them apart give antibiotics; they will cure the
overgrowth and normalize the test!!!

)First sigh of renal involvement in DM=hyperfiltration
First change that can be quantitated in renal DM=thickening of BM

)HCV-RNA=most sensitive test for diag. HCV infection=gold standard
Anti-HCV antib (ELISA)=very specific

)E.coli urinary infection does not change ph; Proteus DOES=>alkalin

)In brain dead people-deep tendon reflexes can be present due to spinal
activity

)High AFP=neural tube defects (NTD), GI defects=>get acetylcholinesterase
level-it''s increased only in NTD


)MSAFP -screening
Down's syndrome: high beta-HCG, low AFP and UE3
Trisomy 18 (Eduard's syndrome): low beta-HCG, low AFP and UE3

)Guillan-Barre syndrome-treat by human IG and plasmapheresis

)Share information about a patient disease only after he/she signed
an official consent to release information!!!
Only if the diagnosis is a risk for the co-workers=>breech confidentiality!!!

)Severe asthma attack: normal/high PaCo2, speech difficulty, diaphoresis,
altered sensorium, cyanosis, silent lungs, paradoxycal diafragmatic
movements
)RV infarction-elevation of ST in DII, DIII, aVF, V4R, V6R, also elevation
in DIII>than in DII
-loss of diatolic function gives rise to RV infarction sysmptoms!!!

)Leydig cell tumors=>high estrogen, testosteron
Yolk-sac tumors=>high AFP
Choriocarcinoma=>high beta-HCG
Seminoma-normal markers usually; also in teratoma!!!

)Hystory of hepatitis+objective hapatomegaly now+weight loss, mild abnormal
LFT=>think Hepatocellular Carcinoma=> get CT scan

)Mononucleosis like symptoms with atypical lymphocytes=CMV infection
)MC site of obstruction of emboli is lateral striate arteries=arteries of
stroke

)Missed abortion in the I trimester:
-arrest of uterine growth
-beta-HCG level lower than normal
-cervix closed
-no fetal heart tones
-disappearance of nausea and vomitting
Before 16 weeks do D&C,after that induce labor or wait forit to come if
there is no DIC!

Threaten abortion-rest and do US 1 week later
Complete abortion-follow with serial HCG to see if it returns to 0

)Laringomalacia-"epiglotitis rolling in from side to side"
-self-limiting
-subsides by 18 months of age!
-noisy breathing when cries or supine, improves in prone position
-feed him/her in upright position

)Unstable trauma patient, no bleeding source identifyable=>do DPL or US of
abdomen; CT only when stable!!!
If there are signs of abdominal irritation (peritoneal signs) or penetrating
injuries=> first=exploratory laparotomy!!!

)Male hypogonadism=>first check testosteron level
If low=>check FSH, LH
High FSH, LH=primary hypogodism>stimulates testosteron aromatase=>high
estradio levels
Low FSH, LH=seconday hypogonadism=>think pituitary tumor=> check prolactin
level (even if no gynecomastia)

)Metastatic cancers+x-rays lytic lesions=>give pamidronate=choice for mild/
moderate hyper Ca!!!

)If a woman gets pregnant<3months from Rubella vaccine=>treat by reassurance
!!!

)Pseudotumor cerebri-risk factors:OCP, corticosteroids, trauma, weight gain,
high doses of vit. A
-first exclude space occupying lesions
-treat by lumbar punctures

)In PCOS- levels of DHEA may be high, ACTH=normal, but ACTH stimulation test
gives an exaggerated response due to a very high sensitivity of the adrenal
glands to ACTH!!!

Adrenal tumors=very high DHEA unaffected by ACTH test!


)Eibstein anomaly-from Li
=atrialisation of RV=> reduced size of RV

)Sleep apnea=> dopolysomnography test; if inconclusive, do multiple sleep-
latency test
Lateral cephalometry or MRI-do prior to surgery of the pharinx!

)Pain in the big toe, discoloration, cyanotic,tender, COLD, intact pulses,
livedo reticularis bilaterally, high ESR, low C,eosinophilia-what is it???
Blue-Toe Syndrome=cholesterol embolization syndrome!!! HIGH-YIELD
Erythromelalgia=dilation of peripheral vessels with bilateral burning, pain
on palms and soles=>to an entire extremity
Reflex sympathetic dystrophy=burning pain in an area with hystory of trauma!
!!

)Wounds that fail to heal=>suspect malignancy; SCC on burn wounds (Marjolin'
s ulcers)

)VT and stable=>give lidocaine or amiodarone=CHOICE

)In DKA give NaCO3 if:
-ph<7.1 (or 7.2 according to others
-severe hyper K
-HCO3 level<5mEq/l

)In toxic megacolon of IBD=>Corticosteroids=CHOICE or emergent surgery:
subtotal colectomy with end-ileostomy

)Pericarditis in any renal failure patient (even post-strep nephrtic
syndrome)=indication of dialysis

)Cryptorhidism-delay surgery until 1 year of age
-in prematures, add the months of prematurity (born at 6 months, do
operation at 3+12=15 months)

)In Budd-Chiari syndrome, investigation of choice=Duplex doppler imaging!!!

)Gonorrhea-can give a sore throat!

)Maternal of fetal deterioaration, regardlessof gestational age=> immediate
delivery (vaginally if possible)!!!

)In severe preeclampsia=> first stabilize the patient-bde rest, low salt
diet, antihypertensive drugs
-when stable decide:-if at term, fetal lungs mature=>deliver; if remote from
term=>wait until 34 weeks for fetal lung maturity

)HIGH-YIELD
Incidence of mania:
-general population=1%
-dyzigotic twins or one parent with bipolar disorder=20%
-both parents with bipolar disorder=60%
-monozygotic twin=70%
So incidence of familial occurence for mania=20%

)Gout attacks in:
-diurectics, niacin, alcohol
-psoriasis
-chronic renal failure
-hemoglobinopathies
-myeloproliferative disorders

)Mild head injuries-low risk=>send home if somebody can look after them
-moderate risk (loss of counsciousness)=>get CT scan and discharge if norma
with a "head sheet" list for symptoms that warrant return to the hospital
Moderate to severe head injuries-admit the patient and monitor neurologic
signs every2-4h+get CT scan too

)To screen for HCM in all first-degree relatives=>do echocardiography, not
by hystory or physical examination=use thisin athletes




)MCC of bleeding in the elderly=diverticulosis;
Second-most common=angiodysplasia/vascular ectasia-painless bledding
-association bet: angiodysplasia and renal failure and also with aortic
stenosis
-colonsocopy:cherry-red fern-like pattern of blood vessels that radiate from
a central feeding vessel

Ischemic colitis=abdominal pain!!!

)Mixed cryoglobulinemia=palpable purpura, GN, arthralgia, systemic symptoms,
hepatosplenomegaly, peripheral neuropathy, low C
-in hep. C infection

)Primary biliary cirrhosis-90% are women
-pruritus=first symptom
-very high cholesterole, ALP, IgM
-mild elevation of AST/ALT
-presence of anti-mitocondrial antibodies

)Tick borne paralysis-rapidly progressive ascending paralysis- over hours to
days, no fever, no sensory loss, normal CSF
-treat by searching the tick and remove it!!!

)In Down' s syndrome-on US there's increased nuchal thickness

)Informed consent can be revokwed any time by the patient=>withhold the
procedure!!!

)Frozen shoulder-restricted range of motions in all directions, both apssive
and active due to pericapsulitis
-treat by NSAID, intraartic. corticosteroids, physical therapy

Rotator cuff tendinitis or tear-tell them apart by lidocaine injection; it
will clear the pain in tendinitis

Supracapsular neuropathy-weakness on abduction and external rotation
-atrophy of the supra/infraspinous muscles

)DM symmetrical neuropathy=>earliest finding=loss of viratory sense
MC CN involved=III
MC peripheral nerve involved=median

)If pyelonephritis does not respond to antibiotics in 3 days (still feverish
)=>get renal US to rule out obstruction/abcess/complications

)To all newly diagnosed HIV patients this should be done:
-routine chemistry and hematology
-2 plasma HIV-RNA titers
-CD4 count
-VDRL
-PPD skin test
-anti-toxoplasma antib. titer
-mini mental status examination
-hep.A, B serology
-hepA, B vaccine if serology is (-)
-pneumococcal vaccine if CD4>200/ul

Before starting anti-retroviral treat, do:
-hystory+physical exam
-CBC, chemstry, LFT, lipid profile
-CD34 count
-a plasma HIV-RNA titer

)Hyeprdense areas on CT=Hemorrhage
Hypodens areas=infarcts

)HIGH-YIELD
Pregnancy protects against PUD and multiple sclerosis (MS)

)PEEP complications=tension pneumotorax, alveolar damage, ventricular
failure

)Cellulitis-diffuse infection of deep skin layers
-fever, inflam. signs, no crepitus or bullae
-lymphangitis
-overlying skin necrosis
-toe web tinea pedis=gate for cellulitis

Necrotizing fasciitis-deep cellulitis
-overlying skin necrosis, bullae, crepitus, fever
-anesthesia due to nerve damage

Sclerosing panniculitis-acute tender lesion over the medial meleolus
-in venous stasis of the limb
Erysipeloid-purplish plaque with central clearing
-no fever, not very painful
-on hands of fishermen and meat handlers

)Osteomalacia-x-ray: symetrical looser zones, pseudofractures bilaterally
with blurring of the spine=characteristic
-low Ca, P, high PTH

)Genralized resistance to thyroid hormons=>hypothyroid features despite high
T4, T3, high to normal TSH
)Fibromuscular dysplasia of renal artery-children, women<50 years
-on angiogram: "string of beads"
-diastolic HTN

)Mass in the epigastrium 4 weeks after acute pancreatitis=>think pseudocyst;
drain if over 6 weeks and >5cm large

)Leprosy-affects peripheral nerves, skin
-hypopigmented patch of insensate skin
-muscle atrophy due to nerve damage (patchy and segmental)
-diagnose by skin biopsy
-patient came from Asia

) Hyperthofic osteoarthropathy=chronic proliferating periostitis of long
bones, clubbing of fingers, synovitis
-associated with SCC and adenocarcinoma of the lung
REMEMBER!!!Any chronic smoker with this disease should have a CXR done to
rule out lung cancer!!!

)Atrial flutter-unstable=>cardiovertion 50-100J
-stable-either cardioversion with ibutilide (in acute cases) or rate control
with beta and Ca channel blockers (in chronic cases)

)Turocut's syndrome-brain tumors+fam. adenomatous polyposis or HNPCC
Multiple mamartoma syndrome (Cowden's syndrome)=GI tract hamartoma+breast
cancer, thyroid cancer, nodular gingival hyperplasia
Cronkite-Canada syndrome=juvenile-type polyps+alopecia, hyperpigmentation,
nail loss

)In stroke-treat HTN if only>220/130mmHg
-reduce it gradually over several hours
-use nicardipine or ACE inhibitors

Use iv. steroids-in trauma (head injury)
-in tumor induced cerebral edema
-use tPa in 3h after the onset of stroke

)Beta-2 agonists-give higher systolic and lower diastolic pressure,
tahicardia, fluid retention, hyperglicemia (stimulates gluconeogenesis)=>
increases insulin requirements in DM patients
-gives low K
-edema, increased myocardial work

)Berylliosis=granulomatous lung disease
-high teck industry (aerospace, ceramics,electronics)

)In MVA patients=>rule out cervical injury by X-ray of the neck or CT or
head+neck


)Barrter's syndrome-normal BP
-low K, metabolic alkalosis
-high renin, high aldo
-high urinary Cl

)BPH-treat with alpha-blockers or finasteride
Finasteride-effective in BPH with epithelial predominance
Alpha-blockers-for muscle predominance
Collagen predominance-doesn't respond to either of them

)Megaloblastic anemia-high MCV, MCH, normal=MCHC
)If asymptomatic elevation of AST/ALT in anti-TB treatment=>continue
treatment because they return to normal later in most patients
)Antibodies to Borellia burgdorferi=>cross-react with Treponema pallidum

)Vaginismus-treat by relaxation, Kegel exercises, gradual dilatation
-refer to sex-therapist only in case of hypoactive-sexual desire

)MCC of death in order:
-before 1 month of age: -cong.anomalies
-low birth weight
-SIDS
-between 1month-1year of age:-SIDS
-congenital anomalies

)In panick attacks, next step in treatment=benzodiazepine; then for long-
term=SSRI

)Pneumonia+diarrhea+hypo Na=>think Legionella

)Scleroderma-anti SCL70, ANA
Sjogren syndrome-anti SS-A, anti SS-B
Polymyositis/dermatomyositis-ANA, anti Jo 1
SLE-ANA, RF, anti-Smith,...

)MVP-gives IE prophylaxis if murmur heard
-give beta-blockers for palpitations, chest pain...

)Hyperthyroid=>higher systolic BP
Hypothyroid=>higher diastolic BP

)To see if thre's statistical association between HRT therapy and CRP levels
=>use Chi-square test; it compares proportions of categorized outcome. The
expected values are compaired with the observed values; if there's no
difference=> no statistical significance

)Angioedema=non-inflamatory edema of face, limbs, genitalia, laryngeal,
bowels; high levels of C2B and bradikinin

)Hepatic encephalopathy-due to NH3=>metabolic alkalosis

)MCC of death in dialysed patients=from CV disease; the same in renal
transplanted patients

)In hepatic failure-if active bleeding=>give FFP
if only high PT and PTT=>give vit.K 3 days

)Hydatid cyst-do not aspire (risk of anaphilaxis); treat by surgery with
metronidazole cover

)Bacterial vaginosis in pregnancy-give clindamycin cream or metronidazole
cream, not oral metro because of teratogenity in Ist trimester

)Iron poisoning-GI upsets, resp alkalosis+metab. acidosis, hypoTN, X-ray:
tablets in the stomach
-treat-asymptomatic: ipeca
-moderate-severe intox.:deferoxamine; NOT Charcoal

)PTSD-associated with substance abuse=>avoid benzodiazepine in these
patients
-treat by SSRI+exposure therapy

)Reiter syndrome-due to Chlamydia, but also from diarrhea from Salmo, Shige,
Campilo
-entesopathy(heel pain+saussage digits)
-polyarthralgias
-treat by NSAID +tetracycline

)Dissection of thoracic aorta with high BP(>200/115mmHg)=>give Nitroprusside
+short acting beta-blocker

)Generalizability=external validity of a test-answers the question how
generalizable are the results of a study on a certain population (middle-
aged males) to the rest of the population

)Hahimoto's thyroiditis-anti-peroxidase antibodies

)In acute ulcerative colitis (even toxic megacolon)=>can do
proctosigmoidoscopy with biopsy for the diagnosis
-NOT CT

)Fibromuscular dysplasia-treat by angioplasty=CHOICE

)In women with high risk of breast cancer=>give prophylactic tamoxifen

)Porcelain gall-bladder-diagnose it entirely on X-ray of abdomen=>resect it
because of risk of carcinoma

)CT scan in Alzheimer: diffuse cortical&subcortical atrophy

)Premenop.women with intermitent menstrual bleeding, heavy menses=>
endometrial biopsy
-if complex hyperplasia without atypia=>give cyclic progestins and repeat
biopsy 3-6 months later
-if complex with atypia=>cyclic progestins (if she wants fertility)+3-6
months biopsy; if no fertility desired=>hysterectomy

)Neonatal tetanus-generalized, born from unimmunized mothers, infection of
umbilical stump in poor obstetrics

)Systemic sclerosis=>gives interstitial fibrosis (40%) and pulmonary HTN (10
%)

)Arthritis=late manif. of Lyme disease
-intermitent attacks are typical (months after exposure)

)Ant. dislocation of shoulder=>injury to the axillary nerve

)HIGH YIELD Syncope from arrythmia:
-heart disease
-ectopic beats
-hydrochlorothiazide

)Pulmonary edema in infero-lateral MI=>give diuretics, NOT beta-blockers

)Parkinson disease-(+) Meyerson sign
-associated with seborrheic dermatitis-this is associated with HIV too or
acutely ill patients!!!!

)MC acid-base disorder in U.S hospitals=metabolic alkalosis

)In DKA-monitor recovery by PH and serum AG

)HIV and heroin addicts=>associated with focal segmental glomerulosclerosis

)Acute vaso-oclussive crisis(priapism,stroke, severe pain) in HbSS=>exchange
transfusion

)Caroli's syndrome-associated with adult PKD
-risk of 100 times of cholangiocarcinoma

)Stable angina+HTN=>gibe beta blockers; if c.i. give Ca channe blockers
)In children, aspirin toxicity gives metab acidosis+resp. compensation
In adults, it gives primary metab.acidosis+primary resp.alkalosis

)MC side effect of radioactive thrapy for Graves is hypothyroidism!!! HIGH
YIELD; also exacerbates ophtalmopathy

)Acute interstitial nephritis-fever, rash and peripheral eosinophilia in an
azotemic patient
-(+) Hansel stain-for eosinophiluria
-type 4 hypersensitivity reaction

)If suspect SCC=>do punch biopsy
-treat by surgery with wide excision; alsoradiotherapy could reduce its size

)Cryptococcal meningitis-by India Ink
-treat by: iv amphotericin B +oral flucytosine; then when improves give oral
fluconazole-give it from the beginning if asymptomatic

)PID-treat by: cefotetan/cefoxitin+doxi or clinda+genta

)Asthma+allergic rhinitis or eczema=>drug of choice=mast cell stabilizers (
chromolyn)

)Subacromial bursitis-from impingement syndrome by prolonged overhead
activity (tennis, golf, swimming)
-shoulder pain on overhead activity, absent on rest
-Neer's sign of impingement=pain on passive internal rotation and forward
flexion at shoulder
-confirm by US or MRI, X-ray is normal
-treat by NSAID, physical therapy

)Urethral injury-triad:
-blood at the meatus
-inability to void
-destended bladder

High riding prostate+scrotal hematoma=post. urethral injury

)Heat stroke-may progress to DIC
-is due to failure of the thermoreglatory center
-t>105F, CNS symptoms

Uncontrolled Ca release=malignant hyperthermia
Fever-by citokine activation

)Miliaria-in people living in moist and hot climates
=heatr rash

)Addison's disease=low Aldo=>non-anion gap metab. acidosis

)Primary adrenal insufficiency=>high ACTH=>hyperpigmentation
Secondary............................=>low ACTH=>nohyperpigmentation

)In BPH=> first do urinalysis+serum creatinine, only after US or IVP in case
of complications (hematuria, UTI...)

)Human bites-prophylaxis with Amoxi-Clavulanate

)Lacunar infarcts-from HTN-remember dysarthria-clumsy hand syndrome
-limited neurologic deficit

)Whipple disease-diarrhea,arthralgias, weight loss, fever, chills,
hyperpigmentation, valvular regurgitation, migratory lymphadenopathy
-PAS (+) deposits in the lamina propria+villous atrophy

IBD-has migratory polyarthritis, erythema nodosum,(+) p-ANCA

)Galactogram guided resection=treatment of choice for intraductal papilloma!
!!

)Mutations-severe: frameshift or nonsense mutation
-milder: missense or splice-site mutaion
-silent: same sense mutation
)Thiazide effects: low Na, low K, high Ca, hyperglicemia, high TG, high LDL

)Ibuprofen raisis Li levels, so if a patient is on both medications=>can
worsen psoriasis beacuse of high Li levels

)Screen for DM: fasting blood glucose
-in getationalm DM-use 50 g glucose tolerance test for screening and 100g
for confirmation
-use 75 g for confirmating non-gestastional DM

)Steatorrhea-gold standard=3-5 days of fecal fat collection

)Non -alcoholic hepatic steatosis-risk factors:
-obezity
-DM
-TPN
-hyperlipidemia
-amiodarone
-bypass surgery for obezity
On biopsy, it looks like alcoholic steathosis
-treat by ursodeoxycolic acid

)Complex partial seizures-brief episodem of impaired consciuosness,
automatisms (lip-smaking, swallowing, picking with hands...), followed by
post-ictal state, EEG=normal; hyperventilation does not produce a seizure

Juvenile myoclonic epilepsy-starts in adolescents
-unilat/bilat. myoclonic jerks
-appear in the morning, precipitated by sleep deprivation

Atypical absence seizure-last longer than typical and EEG shows slow-spike
and wave activity<2.5Hz

)Male infertility=>do sperm count=>endocrine evaluation (testosteron, FSH,
LH, prolactin)

)Marfan's features+thromboembolic events=>think of classic homocystinuria
-RA disease
-normal at birth
-in infancy=failure to thrive
-ectopia lentis (downwards here, as compared to upwards in Marfan's syndrome
), cataract
-fair skin, hair, blue eyes=>like in PKU
-high homocysteine, high Met confirm the diagnosis
-treat by high doses of Vit B6; can give also cysteine

Fabry disease=deficiency of alpha-galactosidase
-angiokeratoma, peripheral neurophathy
-asymptomatic cornea dystrophy
-thromboembolic events

)Aortic regurgitation-rapidly raising carotid pulse+sudden collapse=Water-
Hammer pulse
-3rd intercostal space diastolic murmur, intensified by Valsalva!!!

)Parathyroid adenoma, even asymptomatic=> do parathyroidectomy

)Metastatic osteolysis-normal P, high ALP

)Amebic abcess-hystory of travel (Mexico), followed by bloody diarrhea, then
RUQ pain because of cyst in the liver
-treat by metronidazole

)Ulcerative esophagitis in HIV patients-due to CMV
-large, shallow superficial ulceration+intracellular inclusions
HSV esophagitis-multiple, well circumscribed, small deep ulcers (like
volcanos)
Aphtous ulcer-giant ulcer on the esophag, treat by prednisolone

)If on MAO inhibitors=> don't give SSRI, meperidine, pseudoephedrine

)If swalloed battery in the esophagus=>remove immediately (not by emesis)
)Post-op pulmonary edema=>think overhydration
-high central venous pressure (CVP)
-S3 gallop
-high diuresis >2.5l/day
-high BP
Must rule out MI first!!!
)MC thyroid nodule=hyperplastic colloid nodule=>followed by follicular
adenoma

)Bilroth II=> can be followed by bacterial overgrowth with malabsortion

)Young black male with painless hematuria=sickle-cell trait

)Complications of chronic hep. C:
-cryoglobulinemia, GN
-B-cell lymphoma
-plasmocytomas
-autoimmune disease (Sjogren, thyroiditis)
-lichen planus
-ITP
-porphiria cutanea tarda

)Testicular feminization syndrome
-testicles produce MIF (Mullerian inhibiting factor)=>no uterus, vagina,
tubes
-breasts develop because of peripheral production of estrogens
-no pubic/axillary hair

)Galactose-1P-urydil transferase deficiency=>shock, low IQ, vomiting,
diarrhea, hepatomegaly, cataract, hyperglicemia

Galactokinase deficiency-milder form, only cataract if untreated

)ECT-indications:
-severe depression/mania, also in pregnancy
-neuroleptic malignant syndrome
-catatonia
Side effects: apnea, amnesia, seizures, muscle soreness, headaches, status
epilepticus, skin burns, delirium

)Cystic fibrosis-brochiectasis (upper lobes)-tram track lines on CXR
Gold standard=sweat chloride test, prefered over DNA mutation indetification

)Hemodialysis on citrate=>metabolic alkalosis
-also from infusion of more than 8 units of banked blood

)Cat-scratch disease-B. Henselae
developsin 3-10 days after scratch or bite
-papular/vesicular lesion+proximal adenopathy

Pasteurella Multocida- cat/dog bite
-intense inflamatory reaction in 24 h
-purulent discharge

)Ant. cerebral artery stroke=>controlat. sensory/motor paresis more
prominent in the lower limbs, urinary incontinence, gait apraxia, abulia,
primitive reflexes

)Purpura Henoch-Schonlein=> can cause intussusception (ileo-ileal=>get
surgery to resolve it)

)Introjection=absorbing aspect of another person into one's own self-image;
ex. a victim of abuse absorbs her father's iamge about her as "stupid" and
defends his father's need to abuse her!!!

)If suspect PE, do X-ray, EKC, ABG to rule out other diseases=>then give
heparin without waiting for V/Q scan to confirm it; you'll do it finally,
but treatment is more important first!!!

)ARDS-has:
-PaO2/FiO2<200
-PCWP<18mmHg
-diffuse alveolar infiltrates, prominent air bronhograms

)DM cystopathy (overflow incontinence)-treat by:
-strict voluntary urinary scheduling+oral bethanecol
-intermitent catheterisations in advanced cases
-internal sphincter resection at the bladder neck in severe cases
)Esopahgeal cancer-may looklike achalasia,but:
-duration of sysmptoms is short (months)
-wieght loss is profound
-elderly, smoking hystory
-inability to pass a tube through LES

)Amyloidosis-hystory of RA
-enlarged kidneys and liver
-biopsy of kidney: apple-green birefringence under polarized light after
staining with Congo red

)Asymptomatic gall-stones=>do not treat

)Lymphogranuloma venereum-if untreated can give proctocolitis, rectal
stricture, recto-vaginal fistulas, elephantiasis

)Toxoplasmosis-in pregnancy:
-Ist trimester=>give spiramycin or elective terminationof prenancy
-IInd or IIIrd trimester=>give perimetamine+sulfadiazine; also give folic
acid

)Aspergillosis-in worsening asthma, coughing brownish mucous plugs,
reccurent infiltrates, peripheral eosinophilia

)Mediastinitis-post CABG complication
-systemic signs, wide mediastinum on CXR
-treat by thoracotomy for debridement, drainage and antibiotic therapy

Post-pericardiotomy syndrome-systemic inflamatory signs, small amount of
pericardial fluid that does not cause a wide mediastinum

)High risk IE: -prosthetic valves
-hystory of IE
-cyanotic heart disease of surgically constructed systemic-pulmonary shunts
Moderate risk IE:-PDA, VSD,osteum primum ASD, coarctation, aortic bicuspidy,
MVP with regurgitation, HCM

If one of these patients get an upper GI endoscopy (low risk procedure)=>
prophylaxis is optional in high risk group and not recommended in the rest
of the population
Generally give prophylaxis for bleeding procedures (but not cesarian or
vaginal delivery) in both groups!!!

)Unexplained HTN+low K levels=>measure Aldo+renine levels, then do Aldo
suppression test to confirm primary Aldosteronism=>CT scan of the adrenal to
locate the tumor=>if no mass on CT, do adrenal vein sampling

)Reye's syndrome=extensive fatty vacuolization of the liver
Alcoholic hepatitis=balloon degeneration with PMN infiltrates

)If travelling to SE Asia (zone with highly resistant to chloroquine malaria
)=>give mefloquine for prophylaxis
Use Fansidar=>only for treatment after the occurence of symptoms
Use Primaquine for P. vivax and ovale

)Slipped-capital femoral epiphysis-X-ray of choice for diagnosis is frog-leg
lateral view
-treat by surgery (external fixation the joint with screws)

)Pericardial cyst-in the middle mediastinum
-aspirate fluid for treatment (not surgery)

)Impaired ADH secretion=>occurs in alomost all patients with Sheehan's
syndrome=>differentiate from lymphocytic thyroiditis HIGH-YIELD

)To prevent hep. B infection after liver transplant in a chronic hep. B
patient=>give Hep.B IG+lamivudine

)Analgezic nephropathy-papillary necrosis or tubulo-interstitial nephritis
-polyuria+sterile pyuria=early manifestations

)In refractory cirrhotic hydrotorax=> do TIPS=CHOICE
Use pleurodesisw in refractory effusions from malignancies, not cirrhosis


)Ovarian hyperstimulation syndrome
-5-7 days after hCG or hMG administration
-abdom. pain, distension, dullness to percusion, weight gain, pleural
effusions, low BP
-complications: ovarian torsion, multiple gestation, ovarian rupture,
trombophlebitis

)<3 tetanus immunizations:
-clean wound=>give Tetanus toxoid (TT)
-dirty wound=>give TT+ TIG
>3immunizations:
-clean wound=>give TT if last immunization>10years ago
-dirty wound=>give TT if ..........................>5 years ago

)Prolonged central venous lines for TPN=> can give subclavian vein
thrombosis

)Diastolic dysfunction of LV secondary to hypertrophic cardiomyopathy from
HTN=>give Beta-blockers=CHOICE, if fail add Ca channel blockers

)Prolactinoma-asymptomatic=>follow with MRI and serum prolactin
-symptomatic microadenoma (amenorrhea, galactorrhea)=>give dopamine agonists
(bromocritine or cabergoline); also add estrogens because of risk of
osteoporosis due to hypoestrogenism
-if not responding to drugs or impaired vision=>do surgery
-use radiotherapy for aggressive tumors that do not respond to surgery

)Reccurent pancreatitis with no obvious cause (no alcohol, no gall-stones)=>
do ERCP to look for microlithiasis, choledocal cyst, pancreatic divisum

)IE-no arthralgias (this would be rheumatic fever)
-can have microscopic hematuria
-do blood cultures and give antibiotics immediately
-then do TEE to confirm it

)Impaired consciousness, even following a first seizure=>do CT scan without
contrast
-not EEG

)Pneumonia that does not respond to beta-lactamines=>suspect Legionella
-diagnose by urinary Legionella antigen (ELISA)

)Rotator cuff injury-diagnose by MRI
-does not respond to lidocaine injection as tendinitis does

)Ant. urethral injury=>immediate surgical repair
Post. urethral injury=> voiding cystourethrogram

)Hep. C-moderate: IFN+ribavirin
-mild: IFN

)Raloxifene=>increases risk of thromboembolism
-c.i. in DVT

)Tardive diskynesia: 4 months-4 years
-switch to clozapine

)HIGH-YIELD
In asthma, after iv glucocorticoids can give neutrophilia by mobilizing the
neutrophile pool; also lower Eo and lymphocytes

)Fibromyalgia=>give TCA for treatment or cyclobenzaprine
-trigger point injections

)Pericardial tamponade=>has electrical alternans (alternating amplitudes of
QRS)

)When suspect Addison' s disease=> do ACTH (cosytropin) stimulation test to
make the diagnosis
-get plasma ACTH to distinguish between primary or secondary Addison, oce
the diagnose is made!!!

)Patients with cirrhosis shouldhave endoscopy to be screened for esophageal
varices=>prophylactic beta-blockers
)Ehrlichiosis=called spotless RMSF
-no rash
-incubation=1-3 weeks
-anemia, low Le, low T
-increase in AST/ALT
-treat by Doxi or Chloramfenicol

)Lung cancer=>think of paraneoplstic syndrome=>muslce strengh diminuished
bilaterally, more proximal than distal
-normal reflexes
-increase in CK, (+) EMG
-pathology is located in the muscle membrane!!! Strange this topic, I don't
know why either, but this is what they say!!!

)Foreign body aspiration=sudden onset of resp. distress, afebrile,
interstitial retractions
-do direct laryngoscopy+rigid brochoscopy
-one lung is hyperinflated, the other is hypoinflated
)Bronchiectasis=>can have life-threatening hemoptysis
Disseminated gonococcal infection-rash, tenosynovitis, polyarthralgia (
migratory)
-mediated by immune complexes from gonococcemia!!!

)Venous ulcers=>medial aspect of foot
Arterial ulcers=>lateral........................

)If isolated proteinuria detected=>repeat distick testing at least twice
more; then if still (-)=>reassurance; if (+)=>check 24h urinary proteins,
BUN, Cr

)Salmonella=MCCof osteomyelitis in HbSS disease (not Staph as many say)---
there's much controversy about this issue!!!

)Dipyridamole=>gives coronary steal when used in heart stress tolerance
testing

)Asymptomatic Paget disease=>no treatment
-symptomatic (lytic lesions or skullinvolvement)=>biphosphonates=CHOICE

)Iron def. anemia in males or post-menop.female is MC from GI blood loss!!!

)Pneumonia post bone marrow transplant=>think CMV
-not immediate, comes in about 2 weeks to 2 years post-transplant

)Cerebral wasting syndrome=>in patients with SAH because of innapropriate
secretion of ADH, increased secretion of BNP=>low Na+water retention
-it clears in 1-2 weeks

)Marfan's syndrome=>AD disease, mutation of fibrillin-1 gene
-also has iridodonesis, ectasia of dura

)To detect the benefit of lung resection=>do PFT, especially FEV1

)Brown recluse spider-deep bite, ulcer with a necrotic center and
erythematous halo, treat by local excision
Black widow spider=>abdominal rigidity, muscle cramps, nausea, vomitting, no
local ulcer
-treat by Ca gluconate, muscle relaxants

)In pheocromocitoma=>if use beta-blockers first, before alpha=>rapidrise in
BP, so first use alpha, than beta blockers!!!

)Screening for prostate cancer:
->40 years=yearly rectal exam
->50 years=PSA=rectal exam
-if abnormal=>transrectal US, then niddle biopsy, then bone scan for staging

)Status epilepticus=> treat by general anesthesia+intubation!!!
)In epiglotitis=>endotraheal intubation+preparations for a traheostomy, then
antibiotics (ceftriaxone)


)Intelectualization=transforming an unpleasant event into a purely
intellectual problem
Rationalization=offering rational explanations in an attempt to justify
undesirable attitudes, impulses, beliefs-ex. a guy is rejected from getting
jobs at various interviews says that he saved money because the commute was
paid by his interogators...

)Choriocarcinoma:post-partum, women with dyspnea, hemoptysis
-CXR: multiple infiltrates, high Le, anemia
-enlarged uterus, vaginal bleeding
-so pulmonary and genital symptoms present
-do quantitative beta hCG first to confirm the diagnosis!!!

)Solid testicular mass, painless+suggestive US=>first do inguinal orhiectomy
In testicular caner, first we kill the tumor, then we investigate. NEVER DO
BIOPSY=>risk of metastasis

)If uncomplicated pyelonephritis responds to iv. antibiotics=>can switch to
oral ones in 48-72h based on antibiogram

)Internuclear ophtalmoplegia=demyelinization of medial longit. fasciculus
-sign of MS

)Cervical spondylosis-chronic neck pain, limited rotation and lateral
bending of head
-sensory deficit due to osteophyte-induced radiculopathy

)Atrial myxoma=>systemic signs, dyspnea, like mitral stenosis, but no
opening snap, murmur changes with position=>high risk of embolization

)Low Ca, high P, high PTH=secondary hyperPTH due to renal failure
-lung cancer: high PTH-related peptide, high Ca, low P
-primary hyper PTH: high Ca, low P, high PTH
-multiple mieloma: high Ca, low to normal PTH

)Hairy-cell leukemia: B-cell leukemia
-tartrate resistant acid phosphatase
-give cladribine for treatment!!!

)HIV patient pneumonia-MC is still pneumococcus
In PCPpneumonia=>no pleural effusions

)Eaton-Lamber Syndrome=>auto-antib. against gated Ca channels
-small-celllung cancer
-treat by plasmapheresis+immunossupressive therapy

)To diagnose lutheal phase defect=>endometrial biopsy which shows loss of
endometrial maturation by more than 2 days as compared to normal

)MVP=MCC of mitral insufficiency in the U.S.

)CD<50/ul=> do prophylaxis for mIcobacterium intracellulare with azytromycin
or claritromycin; alternative: rifabutin

)In cerebellar hemorrhage=>do emergent cerebellar decompresion

)Schizoaffective disorder=>schizofrenia is present even in the absence of
modd disorders, but not visa-versa!!!

)To improve oxygenation in ARDS=>give PEEP

)In SLE, the most severe form of GN is also the MC= diffuse prolipherative

)To diagnose inhalation injury=> do brochoscopy and Xe retention studies for
the terminal respiratory tree

)Risk factors in order for DM foot ulcers:
a)neuropathy
b)peripheral vascular disease
c)glicemic control
d)abnormal structure of the foot
e)other:smoking, male sex, DM with a duration>10 years

)Solitary brain metastasis=>surgical resection, followed by whole brain
irradiation
Multiple brain metastasis=>palliative brain irradiation

)Acute livwer failure-appears within 8 weeks from the start of the injury
Fulminant hepatitis=acute liver failure+hepatic encephalopathy
)In neurofibromatosis type 2, when suspect acoustic neuroma=> first do MRI
with gadolinium=best test, then surgery to remove the tumor

)Kallmann's syndrome-46,XX
-anosmia
-hypogonadotropic hypogonadism
-absent pubic, axillary hair
-absent breasts
-amenorrhea

)Displaced ant. fad pad=X-ray sign of supracondylar fracture which may be
complicated by Volkmann's ischemic contracture

)Patient of IPPV who deteriorates=>do CXR to rule out barotrauma

)In SLE=> non-erosive arthritis
In RA=erosive arthritis

)Afetr abdom. aortic aneurysm repair and blood in the stool=>suspect
ischemic colitis=> do sigmoidoscopy/colonoscopy to assess coloniv viability,
if CT scan is inconclusive, BUT NOT Barium enema=>can cause perforation

)Metabolic X Syndrome: central-type obesity
-insulin resistance

)OCP in chronic users=>cholestatic liver disease

)Malaria-P.vivax-fever every 48h
P.ovale-fever every 72h
P. falciparum=>no periodicity
-starts with intens chills, then the hot phase, then 2-6h later-vomitting,
low BP, tahicardia
-anemia, splenomegaly
-hystory of past similar complaints when in Africa

)Babesiosis-RBC cell parasite
-from ticks
-varies frrom asymptomatic to severe anemia, jaundice and renal failure
-seen in splenectomised patients or with HbSS diseases

)Polyneuropathy in DM=best diagnostic tests are: EMG+conduction studies, not
evoked potentials!!!

)If pregnant minor doesn't want ot tell her parents about the preganancy=>
encourage her not to tell!!! (patient's right to confidentiality)

)TB can appear in HIV patients even with CD4>200/ul
-no need of hystory of close contacts

)CHF due to aortic regurgitation=>give diuretics, ACE inhibitors, digoxin,
NOT Beta-blockers-which prolong the diastole=>increased regurgitation

)Gall-stones-mostly of cholesterol
-in obese patients
-in pregnancy
-clorfibrate therapy
-more in Western than in Asian populations

)Diarrhea in HIV patients=> first do stool examination to determine the
bacteria responsable for this
-usually is determined by bacteria rather than by previous antibiotics
intake, son don't stop TMP/SMX, Claritromycin...


)In amenorrhea=> determine estrogen status (endogenous estrogen production)
by a challange test; however this has been lately abandonned and replaced by:
-cervical mucus analysis
-vaginal epithelial maturation
-endometrial thickness

)Asthma not controlled by medication with a silent chest, even with a 90% O2
saturation=>intubate+mechanical ventilation
-DON'T GIVE thophiline in status asmaticus

)Dressler's syndrome-2-4 weeks post-MI
-pericardial effusion, diffuse ST elevation
-treat by NSAID, or if they fail, give steroids

)DM with erectile dysfunction=>first choice is Sildenafil (Viagra) and NOT:
-local PG (alprostadil)
-tighter glicemic control
If combined with an alpha-blocker=>give them at least 4h apart to prevent
hypotension

)PCP pneumonia in HIV patients-bilat. interstitial pneumonia
-think of it even if the patient is on steroids, even there's no fever, even
if there's blood in the sputum and asymetry of infiltrates; second choice=
TB

)Pseudotumor cerebri-medical treatment: acetazolamide=first line, then
steroids or repeated lumbar punctures
-surgical treatment: optic sheath decompression+lumboperitoneal shunting

)HIGH-YIELD
Osteogenesis imperfecta-mutations of collagen type 1 gene
-blue sclerae, reccurent fractures
-hearing loss

)Rib fractures=>prime priority=appropriate analgesia
-mechanical stability=>not required with a single rib fracture, only in
flail chest

)HIGH-YIELD
Insipidus diabetes-polyuria, polydipsia, patients prefer cold beverages
because they quench their thrist better
-Serum Osm>Urine Osm
Primary polydipsia, low both serum and urinary Osm
Osmotic diuresis-Urinary Osm>Serum Osm
SIADH-low serum Na, Urine Osm>Serum Osm

)Think of sphincter ODDI dysfinction post-cholecystectomy=>do ERCP with
sphincterotomy

)Lutheal phase defect-treat with progesterone vaginal suppositories; first
confirm with endometrial biopsy
-if suppositories don't work, try clomiphene or hMG

)In taking antidepressants=> monitor therapy at least 4-6 weeks before
changing to another one

)When suspect DVT=>do compression US, then give anticoagulation; this is not
a clinical diagnosis and you need a confirmatory test. If there was a
similar question about pulmonary embolism (PE), you would have started
anticoagulation first, followed later by V/Q scan!!!!! REMEMBER THIS!!!
Use impedance pletismography=>for recurent DVT

)Total knee replacement-do it in patients with severe restriction of walking
or nocturnal and rest pain

)In trauma patients with collapsed veins in order to give iv. fluids=> do
saphenous vein cutdown or percutaneous femoral vein catheterisation
-DON'T USE subclavian or jugular veins!!!
In children <4 years of age=> do interosseous canullation

)Ca channel blockers=> can give peripheral edema

)CT scan-is not diagnostic of pheocromocitoma, but hormone levels are!!!

)Ursodeoxycolic acid=>disolve radioluscent stones<1cm in 50% of patients in
6-12 months of therapy
)Hystory of iv. drug abuse+high fever+bony point tenderness, redness, pain,
swelling=>suspect osteomyelitis=>get Tc scan, MRI=>good for vertebral
osteomyelitis

)In pseudodementia-CT is normal
-dexamethasone suppression test in abnormal in 50% of patients
-there's a trigger event
Tourette's disorder-associated with ADHD(60%) and OCD (27%) HIGH YIELD -I
got many questions on my actual exam!!!!!

)Acute inflamatory arthritis superimposed on osteoarthritis=>septic
arthritis
)Intimal flap injury of the carotid artery=>do surgery to repair it, because
it can lead to vessel occlusion

)Myocarditis-MCC=Coxsackie's B virus
-dilated cardiomyopathy, after a "flu" 4 weeks earlier
-raise in CK, CK-MB

)To detect microalbuminuria in DM=> do urine collection over 24h or more
convenient check random albumin/creatinine ratio. If =30-300mg albumin/mg
creatinine=>microalbuminuria
Protein dipstick is (+) only for >300mg/day proteinuria

)Essential tremor=>give beta-blockers=first line; also primidone, BUT
PRIMIDONE converts into feniletilmalonamide+phenobarbital=> can give acute
intermitent porphiria-diagnose it by urinary porphobillinogen

)In Candida infections=> do not treat partners

)Stranger anxiety: 12-15 months of age
Separation anxiety: older child

)Narcolepsy-treat by day-time scheduled naps, psychostimulants+
antidepressants (if cataplexy present)

)Extrinsic allergic alveolitis-Farmer's lung, bird breader's lung
-type III reaction
-CXR: bilat.interstitial infiltrates, PFT: restrictive pattern
-treat by avoiding exposure

Alveolar proteinosis-phospholipid-rich material in the alveoli due to
impaired clearance
-restrcitive pattern
-bilat. interstitial infiltrates
-lung biopsy: PAS(+) material
-treat by broncho-alveolar lavage

)Post-cholecystectomy pain-causes:
-sphincter Oddi dysfunction
-CBD stone
-functional pain-think of this only if LFT are normal, no biliary tree
dilation
If biliary tree is dilated and high ALP=>check to rule out stone
and if no stone=> do biliary manometry to detect sphincter Oddi dysfunction

)Nocardiosis-pulmonary disease
-in imunocompromized patients
-CNS manifestations
-cutaneous manifestations
-onset is subacute (days to weeks)
-abcess formation in the lung
-crooked branching beaded gram (+) filaments, weakly acid-fast (+)
-treat by TMP/SMX or Minocycline
-prophylaxis: TMP/SMX

)Guillane-barre syndrome-causes:
-Campilobacter
-herpes viruses
-mycoplasma
-H. influenzae
-recent HIV infection
-recent immunisation
)If suspicious of PR=> do V/Q scan; if inconclusive do limb venous US or CT
angiogramof the chest; if both are (-)=> do pulmonary angiography

)In SLE, anti-Ds DNA antibodies=> correlate with disease activity of
nephritis
Anti-Ro-associated with neonatal lupus, cong. heart block, interstitial lung
disease, fotosensitivity

)Nasopharingeal cancer-MC presenting symptom is painless neck mass!!!

)OCP-potential cause of HTN=>first measure is to discontinue them, if still
HTN=> do lifestyle modifications, then try low dose thiazidic is these fail

)Metastatic solid tumors=>hyper Ca by citokines (IL-1, TNF)
Hodgkin's disease-hyper Ca by calcitriol production
Non-metastatic solid tumors-hyper a by PTH-related Peptide

)Complications of ERCP:
-pancreatitis
-biliary enteric fistula after sphincterotomy
-biliary peritonitis
-sepsis
-hemorrhage
Note: AIR in the billiary tree after ERCP is NOT normal!!!

)Sumatriptan-c.i. in:
-uncontrolled HTN
-basillar migraine
-CAD
-Prinzmetal angina
-ischemic stroke
-pregnancy
-familial hemiplegic migraine

)Vesico-ureteral reflux in children can lead to renal scarring!!!

)Malignancy of a solitary nodule:->3cm
-irregular borders
-eccentric calcifications

)MCCof asymptomatic elevation of ALP in the elderly is
Paget disease
Simvastatin-increases AST/ALT and not ALP

)Ligament injury=>get MRI of the knee, if inconclusive do arthroscopy

)In aortic dissection with HTN=> first give anti-HTN medication, then do TEE

)Infectious mononucleosis-heterophile antibody test is very specific, so a (
-) test does not exclude the disease!!!

)Ascites-management:
-first: diagnostic paracentesis
-then: salt restrction diet (0.8-1g/day)
-then: spironolactone=directic of CHOICE in ascites
-then if still uncontrolled: add thiazides or loop diuretics
-if refractory: do TIPS

)Strep. pneumoniae=MCC of pneumonia in nursing home patients=HIGH YIELD

)Herpes encephalitis-CSF:lymphocytosis, high erytrocytes too, high protein,
normal glucose, high opening pressure
-acute onset<1 week
-focal neurological findings (seizures...)-temporal lobe
-CT scan ca be normal in 50% of patients (SO THINK OF THIS DISEASE EVEN IF
CT IS (-))
-fever
In Cryptococcal meningitis, there's low glucose, but the rest can look the
same as in herpes


)In utero exposure to phenitoin=>risk of neuroblastoma
Hydantoin syndrome: nail hypoplasia, microcephaly, cleft-lip, hypoplasia of
the distalphalanx, cardiac problems

)Type I Collagen storage disease (von Gierke)
-deficiency of G-6P phosphatase
-hepatomegaly, enlarged kidneys, hypoglicemic seizures
-doll-like face with fat cheeks
-short stature, protuberant abdomen
-low glucose, high TG, high lactic acid, high total cholesterol, high uric
acid, normal AST/ALT
Type II-Pompe-def. of glycogen storage enzyme=maltase
-first weeks of life with floppy baby, macroglosia, hepatomegaly, heart
failure, HCM
Type III-def. of glycogen debraching enzyme:
-high AST/ALT, fasting ketosis
-normal uric acid, lactic acid
Type IV-def. of bracnhing enzyme:
-progressive cirrhosis of the liver
-hepatoslenomegaly in the first 18 months of life

)Gouty arthritis=punch out erosions with a rim of cortical bone
RA=narrowing of joint space+juxta articullar erosions
Gonococcal arthritis=normal joint space+soft tissue swelling
Psoriatic arthritis=marginal bony erosions+irregular joint destruction
Osteoarthritis=narrowing of joint space+osteophytes

)After placement of a central venous line=> do X-ray to check proper line
placement

)In patients with family history of MEN IIa=> do DNA TESTING to identify the
mutation on cromozome 10; if (+)=> do total thyroidectomy because of high
risk of medullary carcinoma

)Chemotherapy for metastatic prostate cancer-with anti-androgen (leuprolide
in monotherapy)+radiation

)Pseudocyesis=imaginary pregnancy because of a strong desire to become
pregnant; has hormonal changes like in pregnancy, morning sickness, weight
gain, changes of uterus and cervix, sensation of fetal movements, even a (+)
home pregnancy test
BUT:on US-vacant uterus, pregnancy test is (-)
-treat by psychiatric evaluation

)Pertusis prevention=>give all contacts erytromycine for 14 days regardless
the status of immunisation

)In exercise-induced asthma: beta-blockers+mast-cell stabilizers

)Blastomycosis south¢ral USA
-immunocompetent people
-pulmonary infection is asymptomatic or with flu-like symptoms
-cutaneous disease: verucous or ulcerative papulopustular initially, then
crusted heaped-up and warthy with violaceous hue lesions, sharp borders

)Klumpke's paralysis-hand paralysis+ipsilateral Horner's syndrome
-injury of C7,C8,T1 nerves

Erb-Duchenne palsy-injury of C5, C6
-absent Moro reflex
-intact grasp reflex
-waiter's tip

Phrenic nerve injury
-injury at C3, C4, C5
-diaphragmatic+upper brahial palsy
)Acute bronchopulmonary aspergillosis
-transient pulmonary infiltrates
-peripheral Eo
-asthma
-immediate wheal and flare reaction to Aspergillus fumigatus
-brownish mucus plugs in the sputum
-high Ig E
Job syndrome-skin infections frecq. with Staph
-neutrophiles impaired chemotaxis
-very high Ig E
-treat with intermitent/continuous antibiotics

Chronic eosinophilic pneumonia-systemic signs for weeks to months
-hystory of asthma or allergic rhinitis may be present
-peripheral infiltrates negative of pulmonary edema=patognomonic
-BAL->40% Eo
-treat by steroids

Churg-Strauss syndrome-hystory of asthma treated with Zafirlukast
-fever, high Eo, with asthma becoming better
-affects: skin, kidneys, CNS, lungs, GI tract, heart
-treat by steroids+-imunosupressants

)Sinus sick syndrome-treat by ventricular pacemaker for controlling
ventricular rate and type 1 antiarrythmic for atrial tachyarrythmias

)DON'T GIVE BCG TO HIV PATIENTS!!!

)In a manic patient with symptoms despite therapy=> first step check
compliance with detecting Li levels...
-also get urine toxicology screen for cocaine/amphetamines

)In severe head injury (GCS=7)=>give mechanical intubation, fluid
resuscitation (isotonic), sedatives and analgesics!!!

)Lidocaine-NOT used for prophylaxis of VT
-lowers the risk of VF
-increases the risk of asystole

)Patient with lung cancer and joint pains=hypertrophic osteoarthropathy

)If suspect RMSF=>start treatment, because antibodies will be (+) in
convalescence

)Acute stress disroder-onset within 4 weeks from the event
-resolves in 4 weeks from onset

)If suspect intraabdominal abcess=>get CT scan of the abdomen

)In any ant-wall MI=+give heparin+3 months of warfarin due to high risk of
embolism

)Because pneumococcus is resistant to penicillin/cephalosporine=> give also
vancomycin
-add ampiciline (for Listeria)-in elderly and immunocompromized
-in children, give cefotaxime+ampiciline
-in hospitalized patients:ceftazidime (covers Pseudomonas)+vacomycine

)Amiotrophic lateral sclerosis=> treat by riluzole

)Metronidazole-may give disulfiram-like reactions, so avoid alcohol

)Treatment of bulimia=>antidepressants+cognitive therapy+interpersonal
therapy, family therapy, group therapy

)Symptoms of GERD and (-) endoscopy=>do 24h ph monitoring

)GCA-associated with thoracic aortic aneurysm

)In trauma patient to rule out pelvic injury=> do X-ray of pelvis!!! not
other complicated procedure!!!

)In drug users-Staph aureus=MCC of IE
In prosthetic valves-Staph epidermidis

)If FOBT is (+)=> do colonoscopy

)Hemochromatosis-high risk of infection wioth Listeria, but also Yersinia
and vibrio vulnificus
)To diagnose MG do anti-acetylcholine antibody test, also tensillon test,
but the first is currently recommended

)Kartagener's syndrome: situs inversus, sinusitis, brochiectasis

)Prinzmetal angina-avoid beta-blockers and aspirin because they increase the
vasospasm

)Macrovascular hemolysis-from severly calcified aortic valves or prosthetic
valves

)In HIV patient-pulmonary cavity formation from:
-TB (not if PPD<5mm)
-atypical mycobacterium
-Nocardia
-gram (-) rods
-anaerobes
-cocidioides (in SW USA)

)MS-painfull optic neuritis, central visual defect

)Treat of CHOiCE for social phobia=assertive training +SSRI
-second-lie=MAOi
-beta-blockers may help with symptoms
In adjustment disorder=>use supportive psychotherapy

)Empiema-treat by tube placement if: ph<7.2 and glucose<60mg%

)Constrcitive pericarditis-characteristic are sharp X and Y descent on
central venous tracing
-in immigrant population, TB is the MCC for this disease

)Multiple fluid-filled cysts in the brain parenchyma=neurocysticercosis

)In migraines, first try NSAID, if don'twork, give triptans or ergotamine
Avoid ergotamine in:
-CAD
-HTN
-peripheral vascular disease
-liver, renal disease
-complicated migraine

)In precoucious puberty-differentiate between:
-true isosexual puberty-from activationj of the axis
-pseudo-isosexual puberty-from tumors, exogenous estrogens, severe
hypothyroidism, Mc Cune-Albright
BY:GnRH stimulation test-if LH rises=>true isosexual puberty

)Congenital rubella-"blueberry muffin spots"

)Think of ruptured duodenum if free retroperitoneal air after bycicle fall

)Hypo Na(<137mEq/l)=bad prognostic factor in CHF
-it means a high level a neurohormonalo activation
-do not give high Na diet, but restrict water intake
-do not give digoxin because of reduced renal function

)Drug of CHOICE in cancer induced anorexia=Megestrol acetate

)Meningitis from Neisseria=> can go to Waterhouse-Fiedericksen syndrome and
DIC

)If pregnancy is>43 weeks=> deliver; MCC of post-term dates=meconium
aspiration

)Infection with resp syncitial virus=>risk of asthma later in life

)Think of PE if: new onset RBBB, FA or P pulmonale on EKG
)Folic acid deficiency:
-poor diet, alcoholism
-phenitoin-impairs absortion
-TMP/SMX, metotrexate-antagonists of dihydrofolate-reductase
)Progressive multifocal leukoencephalopathy-in HIV patients
=multiple non-enhancing lesions without mass effect in the white matter+
focal neurological deficits
Primary CNS lymphoma=solitary, weakly enhancing, periventricular
-presence of DNA-EBV in the CSF is very specific
=second MCC of mass lesion in HIV patients
Toxoplasmosis-unlikely if on TMP/SMX
=ring enhancing mass lesions in the basal ganglia
-a(+) antibody titer for toxoplasma is normal in USA in normal people

)Iron supplementation-start at 6 weeks of age in all premature babies

)Quetiapine=>gives cataract
Clorpromazine=>jaundice

)Histoplasmosis-in Mississippi&Ohi river valleys
-<5% are asymptomatic
-gives an asymptomatic pulmoanry nodule

)HIGH-YIELD
Amiodarone- side effects:
-pulmonary toxicity
-thyrioid dysfunction-hypo (85%), hyper (15%)
-hepatotoxicity-raises AST/ALT transiently, but stop the drug if levels are>
2 times normal
-corneal depostis
skin reactions: bluish-slate gray

)Most important factor for breast cancer is incresing age, then family
hystory

)Glioblastoma multiforme-classic butterfly appearance with central necrosis

)Li maintenance therapy-life-long if >3 relapses
-for a simple manic episode-maintain it forat least 1 year

)A bronchodilator response test=> to differentiate COPD from asthma,
although in some COPD there's reversibility too!!!

)If a primary siphilis is confirmed by dark-field microscopy=>no need for
VDRL or FTA-ABS, but SCREEN for HIV antiboides by ELISA

)Ramsay-Hunt ataxia-generalized myoclonus, cerebellar ataxia, epileptic
seizures

)Risk factors for osteoporosis: thin body habitus, smoking, alcohol, steroid
use, malnutrition, family hystory, Asian or Caucasian race

)Vitamin A=>reduces morbidity/mortality of measles

)Mycoplasma=>can give erythema multiforme
-does not have a waal=>does not stain or Gram coloration
-infiltrates the lower lungs lobes

)OCP-are safe in SLE
-avoid if active renal disease present (type III in SLE)
-avoid in anti-phopholipidic syndrome
-avoid in nephrotic syndrome

)Open fractures of the foot=> don't close primarly, because of high risk of
osteomyelitis
-do wound dressing+plaster cast
-do open reduction only if displaced towards planta pedis, but NOT if mildly
angulated






)Waldenstrom Macroglobulinemia-hyperviscosity from very high Ig M levels
-NO RENAL PROBLEMS
-hepatosplenomegaly
-lymphadenopathy
-anemia
-low T, bleeds easily
-night sweats
-headaches,dizziness
-visual problems
-demyelinating sensory-motor neuropathy

Heavy-chain disease-like abdom. lymphoma (high Ig A)
Multiple myeloma-high Ig G or Ig A, but NOT hyperviscosity

)In mononucleosis=> get heterophileantibody test; if(-)=> do EBV specific
antibody test

)Pleural PH-normal is 7.64
-empiema-<7.2
-inflamation of pleura-<7.3
-transudate due to CHF=7.35

)Buerger's disease-triad of occlusive disease of the arteries, migratory
superficial trombophlebitis, Raynaud's phenomenon in a smoking young male

)Orthostatic hypoTN-in elderly:
-tolerate poorly even a mild loss of fluid (diarrhea)
-syncope after bed rest at night
-highBUN/Cr ratio

)Heparin-induced trombocytopenia=>stop heparin, DON'T GIVE LMWheparin or
warfarin in exchange
-if ongoing anticoagulation is required (like in prosthetic valves)=>can
give danaparoid+direct thrombin inhibitor (lepirudin or argatroban)

)Pneumovax-give in HIV patients with CD4>200/ul
-give also Hep A vaccine if they have hep B or C

Give meningococcal vaccine for splenectomized or travel exposure, not
routinely

)High risk of candida in: DM, pregnancy, OCP use, immunosupression; but NOT
IUD

)Dilation of ventricular system+subarahnoid space=comunicationg
hydrocephalus where intraventricular hemorrhage caused subarahnoidian
hemorrhage in premature babies

Dandy-Walker=cystic expansion of the 4th ventricle
Chiary malformation=pst-fossas through foramen magnum. These two are non-
comunicationg hydrocephalus!!!

)Denial-a person that does not accept reality-ex.: she is told that she has
breast cancer=> she goes to another doctor for a second opinion
Repression=unconcious, involuntary separation of a painful thought
ex.: she is aware of breast cancer, but she is not conciously aware ot it!
Supression-like repression, but it's a concious separation...
Dissociation=blocking emotions or thoughts from consciousness-ex.: she cries
when she finds out of her breast cancer, but later she denies any memory of
the event!!!

)Psoriatic arthritis-oligo-articular, asymetrical
-pitting nails
-skin rash
-arthritis mutilans
-spondiloarthropathy (sacroielitis)

)In cirrhosis, GI bleeding due to: erosive gastritis, varices, PUD, Mallory-
Weis tear
-do sclerotherapy for varices only after first bleeding, NOT
prophylactically
-if bleeding PUD and stopped bleeding=>conservative management; if fails=>
surgery


)Fever in neutropenic patient-one reading >38.3
-or persistent readings>38 for 1h
-neutropenia<500/ul
-give empiric treatment against Pseudomonas: cefepime or ceftazidime or anti
-pseudomonal penicillin+aminoglycoside
-if fever persists=>think of fungi=> add amphotericin B
-if severe mucisitis of low BP, or hystory of infection with S. aureus or
Pnumococcus=> add vancomycin

)Phenitoin and carbamazepine=>can cause Steven-Johnson's syndrome or toxic
epidermal necrolysis

)PKU-criteria: -Phe>20mg%
-Tyr=normal
-high urinary fenilpiruvic acid and HO-fenil-acetic acid
-normal tetrahidrobiopterin
-musty odor
fair skin, blue eyes
-eczema

)Lumbar stenosis=neurogenic claudication
-better with sitting or leaning forward
-worse with spine extension
-aggravated by walking or standing
-pain radiates to the buttocks, lower legs
-straight leg test is (-)
-degenerative changes in the vertebrae

)Treatment of acute subdural hematoma is conservative if no midline shift;
otherwise do craniotomy!!!

)Epidural anesthesia=> gives hypoTN due to blood venous pooling

)Down's syndrome-Brushfield spots (speckled iris)
-hypoplasia of 5th finger middle phalanx

)Cutaneous larva migrans-dog or cat hookworm (Ancylostoma braziliense)
-by skin contact, SANDY BEACH=REMEMBER!!!
-erythematous papule that progresses with a few mm/day

)LV aneurysm-double apical beat, persistent ST elevation

)Tumor lysis syndrome-low Ca, high P, K, uric acid=HIGH YIELD

)Niemann-Pick's disease-def.of sphingomyelinase
-hypotonia,hepatosplenomegaly, cervical lymphadenopathy
-protruding abdomen
-cherry-red spot on macula

Tay-Sachs disease-def. of hexozaminidase
-hyperacusis, low IQ, no lymphadenopathy, no hepatosplenomegaly
-cherry-red spot on macula
-seizures

Gaucher's disease-def. of glucocerebrosidase
-hapatosplenomegaly, anemia, low Le, low T
-NOT involved macula

Krabbe's disease-def. of galactocerebrosidase
-hyperacusis, seizures, irritability

Mucopolysaccharidoses-course facial features, hydrocephalus, umbilical
hernia

)LOW ALP-in CML, Paroxistic noct. hemoglobinuria, hypophosphatemia
Auer rods-in AML

)Rapid meningitis+skin rash=meningococcus
RMSF-does not give meningitis
)Iris nodules in neurofibromatosis are hamartomas!!!

)Aspergiloma-gives fungus ball that moves around with position change=>
intermitent hemoptysis
Histoplasmosis of lung=-has calcified nodules

)To detect Meckel diverticulum: do Tc pertechnatate scintigraphy
Do angiography-for bleeding>0.5ml/min.

)Murmur of HCM-increases with Valsalva, standing, amyl nitrit, digoxin
-decreases with hand grip, leg elevation, phenilephrine

)Vit.l B12 stores of the body are available for 3-4 years, so if on
vegetarian diet for only 1 year=>think of pernicious anemia as a cause for
megaloblastic anemia and not low B12 levels!!!

)Epidural anesthesia=>can give urinary retention, treat it by intermitent
catheterisation
-it's a transient overflow incontinence

)Chronic bronhitis-markers: prominent vascular markings, mild flattening of
the diaphragm, normal DLCO, low FEV1/CV
Emphysema-has low DLCO, decreased vascular markings

)Severe pancreatitis=>give antacids to prevent stress-gastritis

)PNH-it's a RBC membrane defect=>increased binding of C=>intravascular
helolysis

)Enterobius vermicularis=>treat with Albendazole or Mebendazole; second-line
=Pyrantel pamoate

)Adjustment disorder-stress factor in the last 3 months, lasts reraly over 6
months from the event
-treat by psychodynamic psychoterapy
-also SSRI as adjuvant

)Catatonia-treat by Lorazepam or ECT

)Simvastatin-inhibitsHMGCoA reductase
-reduces also CoQ10=>myopathy

)Mononucleosis-can have hemolytic anemia, low T, DIC, TTP/HUS

)In a patient with renal symptoms (oliguria, high BUN, Cr)=>first do
urinalysis

)Fragile X syndrome-low/normal IQ
-autism
-large head, jaw, testes, low set ears

)If parents refuse a therapy for their children=> agree with them if there's
no significant harm from withholding therapy-ex. a parent can refuse
vaccinations for the sons if she/he wants so!!!

)Bleeding (small) not seen on Ba enema or sigmoidoscopy=> do labeled
erythrocyte scintigraphy
-NOT colonoscopy in active bleeding; if it stops, can do it!
-NOT angiography after Ba enema=>cannot see anything

)In all new diagnosed MG=> do CT scan of the chest to look for thymoma!!!

)PROM-under 34 weeks
-give steroids, no tocolysis
-deliver when fetal lungs are mature
)In parents refuse refuse treatment for their child=> go ahead with
treatment or tests if it is an immediate life-threatening situation (like
Hirschprung disease)
-if not life-threatening=> get court order
-consult ethics commitee only in case of dillema

)HIGH-YIELD
Theophyline toxicity-CNS stimulation (insomnia, headaches), GI problems,
arrythmia
-inhibits phosphodiesterase, adenozine antagonism, stimulate epinephrine
release
-if given with ciprofloxacin or eritromycin=>potential toxic effects due to
higher theophyline levels!!!

)Diafragmatic hernia-after blunt abdominal trauma
-X-ray: elevation of left diaphragm, breath sounds decreased on the left
side

)FA-cardiovert if unstable (100-200J); needs anticoagulation 3-4 weeks prior
to that in chronic
FA-acute-cardiovert with medication (classe III antiarrythmics) or control
rythm
-chronic(over 2 weeks)-control rythm beta-blockers or Ca channel blockers
-if CHF present=>use digoxin

)In PE with hemodynamic compromise and embolus in the main pulmonary artery=
> do embolectomy
-DO NOT USE fibrinolitics post-op or after trauma and PE in 5 days from the
event!!!

)Pulmonary contusion-after trauma
-appears in <24h
-decreased breath sounds
-hypoxemia
-CXR: patchy irregualr alveolar infiltrate, unilateral!!!

ARDS-after 24-48h from trauma and is bilateral

)Migratory trombophlebitis (Trousseau sign)=> do CT scan of the abdomen to
identify the malignancy
-most patients have pancreatic carcinoma, lung, prostate, stomach, acute
leukemia or colon cancers!!!
Use spiral chest CT-for PE

)PID-hospitalize if:
-fever>39
-present nausea, vomitting
-adolescents
-nulliparous
-low socio-economic status
-fail to respond to antibiotics
-pregnancy

Treat by: cefotetan+Doxi or
cefoxitin+Doxi or
clinda+genta (in pregnancy)
Outpatient give:
-ceftraxone+doxi or
-cefoxitin+probenecid

)A hystory of epilepsy or seizures is an absolute CONTRAINDICATION to
Bupropion!!!

)Blastomycosis-Wisconsin, Mississippi, Ohio rivers
-chronic resp. symptoms
-fever, night sweats, weight loss
-triad: lung (cavitation), skin (papules), bone (lytic lesions)

)In age-reproductive period, if abnormal bleeding=>first do endometrial
sampling and NOT GIVE estrogens!!!
-if (-) on biopsy=> can start cyclic progestins=>if fail to cont
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