Aster's notes for USMLE step 3 is a collection of about 100 pages of useful information that has a lot of information. We made the whole notes available online for your benefit on residentscafe.com. Recommended Study Material for Step3 Textbooks 1.Crush the Boards 5 days 2.Swansons Family Practice 15-20 days 3.Ethics in Medicine (U of W site) 1 day 4.Biostatistics 2 days 5.Blueprints in OBG 2 days 6.Blueprints in Peds 2 days 7.Compass Surgery & Trauma Notes 1 day CCS
1.USMLE 2003 CD (Software Tutorial + Sample Cases) 2.KAPLAN CCS TUTORIAL 3.VETANS LIST OF CCS CASES 4.list of recent cases MCQs 1.Swansons Family Practice 2.USMLE 2003 CD – sample MCQs 3.Kaplan Step3 CD – 200 sample MCQs 4.NMS Review – 750 questions 5.Kaplan Qbank for Step3 6.www.familypractice.com. to be continued Asters Notes 2 of 111 -------------------------------------------------------------------------------- Critical aortic stenosis : virtually zero chance of successful CPR. Gout with h/o peptic ulcer disease: Rx of choice – colchicine (not indomethacin) pseudocyst <6w: external rainage >6w: internal drainage St. Johns Wort is a herbal medication with some efficacy in treatment of depression (no FDA Approval) Vaginal d/c pH < 4.5 : Consider Candida ph > 4.5 : Consider Bacterial Vaginosis Maternal Smoking / Alcohol: Symm IUGR Maternal HTN: Symm IUGR Physiological Jaundice / Exaggerated Physio / Breast Milk Jaundice: no risk of Kernicterus Kernicterus occurs @ 1% x Birth Wt. (in grams)Bilirubin Level PKU screen can be negative at 48hrs of life (requires a repeat screen after 48 hrs. to confirm) Maternal SLE: Congenital Lupus & 3rd degree Ht. Block (Anti-Ro) Respiratory Failure: <60 mmHg O2 >60mHg CO2 Maternal Solvent Abuse: assoc. with nail hypoplasia PDA closure achieved by Indomethacin NEC: Pneumatosis Intestinalis Neonatal CMV: confirm by isolation of virus from urine Transplacental spread is highest in primary HSV,. Asters Notes 4 of 111 -------------------------------------------------------------------------------- ELISA â-hCG (Urine) is (+) 14 d post conception RIA â-hCG (Serum) is (+) 14 d post conception Symptomatic Gallstones: Lap Cholecstectomy Ca. Tail of Pancreas: Poorest Prognosis Lobular Ca in situ is not premalignant Digitalis Toxicity is enhanced by: HYPERcalcemia, HYPOkalemia, HYPOmagnesemia Infant of HIV + mother (steps to derease transmission) 1.Intrapartum I/V AZT 2.LSCS delivery 3.AZT prophylaxis to child x 6 m 4.No breastfeeding 5.HIV test at 6m - 12 m Finkelstein Test: Chr. Stenosing Tenosynovitis (deQuervains Disease) Rx for Chlamydial Ophthalmia: ORAL Erythromycin (to prevent chlamydial pneumonia) Commonest Hernia: Indirect Inguinal Hernia T4 / RTU / FT4-I move up or down together unless there is a derangement in TBG CPK-MM is increased in hypothyroidism (proximal myopathy) Fetal Weight Determination: HC, BPD, AC, FL Fetal Age Determination: Transcerebellar Diameter RA: associated with atlanto-axial subluxation (“drop” attacks) PTE: (A-a) O2 gradient is always abnormal even if PaO2 is normalhighly sensitive. Asters Notes 5 of 111 -------------------------------------------------------------------------------- Fever 24-48 hrs. Postop: #1 Atelectasis (D)EH / (B)CP / BR Pneumococcal Vaccination is required in CSF Leak Nephrotic Syndrome: Fatty Casts Pyelonephritis: WBC Casts Cystitis: WBCs GN (PSGN): RBC Casts CRF: Broad Casts Cold Antibody: IgM - Inravascualr Hemolysis Warm Antibody: IgG - Extravascular Hemolysis Addisons: ACTH Simulation Test Cushings: Dexamethasone Suppresion Test Conns: Salt Loading Response Diabetes Insipidus: Water Deprivation Test Hemophilia A: aPTT increased, BT normal vWD: aPTT increased; BT increased (Ristocetin Cofactor Assay) Factor VII def.: PT increased, BT normal Aspirin: prolonged BT, no effect on CT spiking fever despite antibiotics, 1 wk. postLSCS ?Septic Pelvic Thrombophlebitis (Mx: i/v Heparin) Mx of Myesthenia Gravis: PYRIDOSTIGMINE (not PHYSOSTIGMINE cuz of CNS effects) vWD & Aortic Stenosis: ass. with Angiodysplasia Alcoholic Cirrhosis: â-gamma bridge d-xylose test: abnormal in small bowel malabsorption, normal in pancreatic disease screening for malabsorption: 24 hour fecal fat ? Penicillamine increases survival in Scleroderma. Asters Notes 6 of 111 -------------------------------------------------------------------------------- Congenital Syphilis may be associated with severe osteochondritis. Child may refuse to move limbs (Pseudoparalysis of PARROT) Abciximab: decreases restenosis rates post-PTCA PTCA: no effect on morbidity or mortality Diabetes Mellitus : assocation with hyperTG First line management of newly diagnosed diabetic: DIET (not drugs) DM+HTN: ACEIs Hypercalcemia: I/V Hydration + Loop Diuretics Obesity: BMI>27g/m2 or 120% of ideal body weight Caloric Intake increase: 300 kCal (Pregnancy); 550 kCal (Lactation) Pulmonary Embolism: i/v Heparin mandatory, fibrinolysis COPD excacerbation: H.flu, Pneumo., Moraxella Long term stabilization of exercize induced asthma: Salmetriol & Zafirlukast Severe acute asthma: < 50% best PEFR Moderate acute attack: 60-80% best PEFR Mild acute attack: >80% best PEFR No 1 community acq. pneumonia: S. pneumoniae Ideal sputum sample: <10 epi./HPF & many PMNs GERD: Transient relaxation of LES Always perform an EKG for any adult with chest pain (esp. with risk factors for CAD) Esophageal Ca.: most common type is AdenoCa. (Barretts Esophagus) Sulfasalazine: effective in UC & Crohns colitis / ileocolitis. Asters Notes 7 of 111 -------------------------------------------------------------------------------- (not small-bowel Crohns) Celiac Sprue: villous atrophy & reactive crypt hyperplasia Dermatitis Herpetiformis (Mx: Dapsone) H. pylori association: DUODENAL > GASTRIC Serology (Past or Present Infection) Fecal Antigen Detection (False- with PPI) Urease Breath Test (False- with PPI) Triple Therapy, esp. for non-NSAID ass. ulcers 1 st episode of PUD: emperical therapy (H2 -> PPI) Recurrent PUD: H. pylori eradication Infectious mononucleosis EBV, Sore Throat, LN, Splenomegaly Atypical Lymphocytes (also in CMV) Monospot (+): positivity wanes with time Serology: increased Anti-EA; increased Anti-VCA IgM â blockers decrease variceal bleed in portal HTN Ascites: Salt Restriction, Diuretic: Spironolactone narcotic analgesic switching use 1/5 equianalgesic dose Graves: Rx – Radioactive Iodine children & pregnant: Propylthiouracil WHO analgesic stepladder 1 st LINE Aspirin, Acetaminophen, NSAIDs 2 nd LINE Hydrocodone Codeine 3 rd LINE. Asters Notes 8 of 111 -------------------------------------------------------------------------------- Morphine Sulfate Hydromorphone Fentanyl Methadone Ca. ass. cachexia & anorexia: Prednisone, Magestrol Agitated Depression Rx: sedating TCA (not SSRI) Rx of choice for narcotic induced costipation: Lactulose Nephropathy Incidence: IDDM (40%) > NIDDM (20%) but #1 cause of Diab. Nephropathy is NIDDM (cuz NIDDM prevalence is much higher than IDDM) Prevalence Inreases: PPV of test increases (NPV of negative test decreases) Screening for GDM Oral 50g Glucose: Bl. Glu. @ 1 hr. > 140mg% (+) F/U with Oral 100g Glu. 3 hour GTT values > 105 (0h) / 190 (1h) / 165 (2h) / 145 (3h) guide lines have changed to= Screen with 50-gram glucose challenge test: 1-hour plasma glucose >140 mg/dL positive; >120 mg/dL suspected F/U with 100gm oral GTT, 100 gram oral glucose tolerance test after 8 to 10 hours overnight fast: Fasting plasma venous Glucose >95 mg/dL, 1 hour >180 mg/dL, 2 hour >155 mg/dL, 3 hour >140 mg/dL; two abnormal values required for diagnosis; if one abnormal, consider self-monitored blood glucose for 7 days; if average fasting blood glucose >95 mg/dL or average 2-hour post-meal >120 mg/dL, re-evaluate for gestational diabetes mellitus. Obese Diabetic: Diet/Wt.Loss -> Metformin (ass. With Lactic Acidosis) Insulin in DM Initial dose: 15-20 U 2/3 of total : AM dose (2/3 regular, 1/3 intermediate) 1/3 of total : PM dose (2/3 regular, 1/3 intermediate) Conns syndrome Mx Adenoma: Sx resection B/L hyperplasia: Spironolactone "cold nodules]] on thyroid scan: ? Malignant 1 Thyroid Study: Serum TSH (yields max. info.) Multiple Sclerosis: 2 attacks more than 24 hours apart > 1 area of damage (Oligodendrocyte damage) m/c variant: relapsing-remitting type. Asters Notes 9 of 111 -------------------------------------------------------------------------------- CSF mononuclear pleocytosis, CSF IgG increase Oligoclonal Banding of CSF IgG Myelin Breakdown Metabolites Headache on stopping NSAIDs: Analgesic withdrawl headache Jaw Claudication & Scalp Tenderness: GCA ESR increased Visual Loss Start Glucocorticoids without waiting for Bx results Aspirin in febrile children: Reyes Syndrome Continue anticonvulsants till seizure free for 4 years Menorrhagia with hemodynamic compromise: i/v conjugated estrogen normal Hb in women: 12.0 normal Hb in pregnancy: 11.0 (1 st & 3 rd trimester) 10.5 (2 nd trimester) m/c variant of Hodgkins : Nodular Sclerosis Hodgkins: Supraclav. node NHL: epitrochlear node / likely to be extranodal Osteoarthritis Joint space narrowing sclerosis subchonral cysts osteophytes (mere osteophytes are not OA) OA: Isometric exercizes are better than isotonic Chronic Fatigue Syndrome : T cell activation -> CNS effect of cytokines nonREM sleep anomaly (also seen in Fibromyalgia) Gout prophylaxis: required for recurrent attacks (not indicated after first attack). Asters Notes 10 of 111 -------------------------------------------------------------------------------- Strep Sore Throat Rx: can prevent Rh. Fever NOT PSGN!!! [ PSGN is caused by both pyoderma and sorethroat streptococcal strains , so the preceding statement is not valid. Yes there is no need for antistreptococcal prophylaxis in children with history of PSGN] Potassium sparing diuretics can cause severe hyperkalemia in CRF SULINDAC: NSAID with no nephrotoxicity Asymp. Bacteruria in Pregnancy : Treat with antibioticsAmoxycillin is safe (high risk of pyelonephritis) Give Chlamydia Rx in Gonorrhea -> i/m Ceftriaxone + PO Doxycycline Biophysical Profile : TBMAN Tone, Body Movements, Breathing, AFI, NST Early Deceleration: Head Compression Variable Deceleration: Cord Compression Late Deceleration: Uteoplacental insufficiency GU+NGU: 1 g Azithromycin stat ACNE Mx Benzoyl Peroxide Topical Tretinoin Topical Antibiotics Systemic Antibiotics Systemic Isotretinoin Acne Rosacea Mx Topical Metronidazole -> Systemic Antibiotic [Benzoyl peroxide & Tretinoin can aggravate rosacea] Female Infertility (Hormonal) Hyper-estrogenic: CLOMIPHENE CITRATE Hyper-PRL: Bromocriptine (PIH) Narcotic Dependence: Methadone replacement. Asters Notes 11 of 111 -------------------------------------------------------------------------------- External Hemorrhoids: Excision with elliptical incision Internal Hemorrhoids: Banding 2 nd trimester eclampsia: Molar pregnancy Molar pregnancy: hyperemesis gravidarum Most important obstetric measurement: Diagonal Conjugate (at least 11.5 cm) Amniotomy: perform after enagement of fetal head Rx of HTN in preg.: á-methyldopa, hydralazine BP reduction goal in pre-eclampsia: Lower diastolic to 90-100 mmHg (lowering to 80mmHg could jeopardize placental perfusion) 1 maternal disease causing IUGR: Maternal HTN 1 cause for 1 st tri. abortions: Chromosomal ab(n) Postpartum Blues: < 2 weeks Postpartum Depression: > 2 weeks Major Depression: >= 5 symptoms for > 2 weeks Mania: >= 3 symptoms for > 1 week Primary Type 1 Osteoporosis: # vertebrae Primary Type 2 Osteoporosis: # neck femur HRT Progesterone required only if uterus is present Estrogen: dec. LDL, inc. HDL Progesterone: inc. LDL, dec. HDL Estrogens cardioprotective effects of estrogen are not mediated through cholesterol. Estrogen promotes EDRF synth. In vascular endothelium Repeat Pap: if reqd., no sooner than 6 weeks Hormonal contraception if h/o DVT/PE (+): Norplant & DMPA (Progesterone based), not OCPs. Asters Notes 12 of 111 -------------------------------------------------------------------------------- Jarisch Herxheimer reaction: Syphilis Rx (chills) HPV: condyloma acuminata HPV 18: fastest progression to Ca. Cx Acute Epididymitis: 1 cause: Chlamydia trachomatis 1 bacterial cause: E. coli (m/c in >40 y age) Depression: Cognitive Psychotherapy + SSRI Drug Rx of Bipolar Disorder: Li, Carbamazepine, Valproate, Gabapentin, Lamotrigine (ass. With SJS) Lithium: Hypothyroidism, NDI Atypical Antipsychotics are especially useful for negative symptoms of Schizophrenia Drug Dependence: WITHDRAWL & TOLERANCE Mx of DTs Intermediate acting BZDs (Diazepam) IV saline (no glucose containing fluids) IV thiamine BZD in Hepatic Enceph.: Oxazepam Fluid Deficit in Burns = 4mL/kg x %BSA (Parkland Formula) 1 st degree: 2 nd degree: clean, sulfadizine, nonadhesive dressing 3 rd degree: refer to plastic surgeon for escharotomy Heat Cramps: ORS Heat Exhaustion: IV Fluids Heat Stroke: neurological dysfunction & absence of sweating (may not be dehydrated) Hypothemia: Osborne (J) wave on EKG Mild: (32-35 C) Passive External Rewarming. Asters Notes 13 of 111 -------------------------------------------------------------------------------- Moderate: (27-32 C) Active External Rewarming Severe: (< 27C) Active Core Rewarming Depression: Cognitive Psychotherapy Anxiety Dsorders: Behavioral Psychotherapy Adjustment Disorder: Supportive Psychotherapy Social phobia: bea blockers & assertive training Specific phobia: systematic desensitization Panic: SSRI & Alprazolam (short T1/2) Na Lactate can mimic a panic attack use alprazolam for panic, not GAD may be associated with rebound anxiety OCD: (associated with anxiety) SSRI OC PD: insight-oriented psychotherapy Somatization Disorder: 4 Pain, 2 GI, 1 sexual symptoms (associated with abuse in childhood) Depression: SSRI + Cognitive Psychotherapy Atypical depression: MAOIs are first-line Generalized Anxiety: Buspirone (selective anxiolytic) Sexual Dysfunction Young Males: Premature Ejaculation (Mx: start and stop penile stimulation, not SSRIs) Older Males: #1 Erectile Dysfunction Females: #1 Hypoactive Sexual Desire Young males with sexual dysfunction: Psychogenic Older males with sexual dysfunction: Organic The PATIENT is the head of the healthcare team ADHD associated with: Conduct Disorder and Oppositional Defiant Disorder (also with Tourettes Syndrome). Asters Notes 14 of 111 -------------------------------------------------------------------------------- ADHD with (+) h/o or F/H tics DO NOT USE STIMULANTS Phototherapy isomerizes bilirubin to a state that can be excreted in urine & bile unchanged. (does not enhance conjugation) Water Supply > 1 ppm fluoride: No supplementation Retrocecal Appendicitis: poorly localized pain Appendicitis 1 cause : lymphoid hyperplasia Mx: Surgery Yersnia enterocolitis can mimic appendicitis Painkillers & antibiotics can alter presentation Preg. With appendicitis: atypical location of pain Elderly: higher chances of perforation Appendiceal abscess: Delay surgical intervention If on lap., some other cause is found – do an appendectomy anyway, to prevent confusion in future Oral Dissolution of Gallstones URSODIOL single floating cholesterol stones in functioning g.b. Asymp. Gallstones: DO NOTHING Symptomatic Gallstones: Lap. Cholecystectomy 1 complication of Lap Chole: Bile Duct Injury Choledocholithiasis: ERCP with sphincterotomy idications of ERCP: small stones dilated CBD palpable stones in CBD jaundice Plantar Warts: Cryosurgery Venereal Warts: Podophyllin (not in pregnancy) Cullens Sign: periumbilical discoloration Grey Turner Sign: flank discoloration. Asters Notes 15 of 111 -------------------------------------------------------------------------------- 1 radiological signs in pancreatic disease acute pancreatitis: sentinel bowel loop chronic pancreatitis: pancreatic calcification Crucifer intake reduces Colon Ca. Ca. risk of polyps is dependent on villous content 1 risk factor for pancreatic ca. : smoking 1 cause for chronic low back pain: idiopathic bed rest has no role no need for imaging (X-Ray / CT / MRI) prescribe an exercize program (can temporarily excacerbate symptoms) Acetohydroxamic acid: urease inhibitor (acidifies urine in patients with struvite stones) HTN with BPH: Terazocin (á blocker) Vestibular Neuronitis: NO hearing loss Menieres Diseass: Tinnitus, Vertigo, Hearing Loss Ac. Labrynthitis: Ac Hearing Loss, Nystagmus, Vertigo Acute Bacterial Sinusitis: Pneumococcus no role of imaging (Dx by h/o & PE) ? antibiotics – PO Amox x 7-10 days Antidep. of choice in depresion in elderly: TCA (Nortryptaline) - minimal side effects cf. other TCAs Alzheimers Rx: DONEPEZIL (OD) & Tacrine Cholinesterase Inhibitors Polymyalgia Rheumatica: Oral Steroids Giant Cell Arthritis : I/V Seroids Elderly black HTN: CCB & Thiazide Diuretics Parkinsons with Tremor has a better prognosis than pts. with symptoms of Postural Instability & Gait Disturbance. Asters Notes 32 of 111 -------------------------------------------------------------------------------- Liver Disease: decreased vit. K dependent factors & Factor V (coagulopathynot corrected by Vit. K administration) 1 Unit of Packed Red Cells 300 mL volume = 200 mL of Red Cells raises Hc by 4% When Typo “O” blood is being used (universal donor): use packed red cells, not whole blood Constipation <50y: increase fiber or osmotic laxatives >50y: FOBT If (+), Colonoscopy (Sigmoido/Ba enema) Mayonnaise/Salad Dressing: S. aureus food poisoning Small Bowel Diarrhea: Voluminous, Bloating Large Bowel Diarrhea: small volume, LLQ Cramps Methylene Blue stain of stool detects Fecal Leukocytes, so basically presence of fecal leukocytes in a stool sample of a diahorrhea victim means presence of an invasive organism like shigella, salmonella, eiec, camp jejuni, yersinia enterocolitica etc] Follow-up Rx of DKA with ANION GAP not serum Ketones) ketone estimation detects only acetate and acetoacetate the predominant ketone in DKA is b-HAP [ beta hydroxy butyrate] as DKA Rx progresses, b-HAP converts to acetoacetate and estimation of serum ketones might suggest paradoxical worsening ketonemia Osmotic Diarrhea: decreases with fasting Fecal Fat > 10g/24hours : s/o Malabsorption UGIH 1 Peptic Ulcer 2 Variceal Bleed (#1 cause of death from UGIH) LGIH 1 (>50y) Diverticulosis (#2: Angiodyslasia) LGIH Dx <50y: Anoscopy or Sigmoidoscopy >50y: Colonoscopy (Sigmoido/Ba enema). Asters Notes 33 of 111 -------------------------------------------------------------------------------- Ascitic Flluid: SAAG > 1.1Portal HTN Spontaneous Bacterial Peritonitis > 500 cells / ìL > 250 PMNs / ìL Total Protein < 1g / dL Mx: i/v Ceftriaxone (no anaerobic cover required) prophylactic FLUOROQUINOLONES to prevent recurrences Familial Mediterranean Fever: Turks, Armenians, Arabians recurrent abdominal pain (resembles acute surgical abdomen) attacks resolve in 24-48 hours associated with serositis & pleuritis recurrent attacks cause secondary amyloidosis Rx: COLCHICINE Uncomplicated GERD: H2 blockers (1 st line) -> PPI Complicated GERD: PPI (1 st line) Preferred procedure for portal decompression is TIPS (Transvenous Inrahepatic Portosystemic Shunt) associated with maximum decrease in rebleeding rate (> banding, sclerotherapy, â-blockers) Non-invasive tests for H. pylori serology (past & present infection) fecal antigen detection urea breath testing PPI can cause False (-) fecal antigen & breath test Duodenal ulcers heal faster than gastric ulcers Long term PPI Rx not required in PUD Long term PPI Rx required in GERD H. pylori eradication: PPI / Amox / Clarithromycine 50% of H pylori isolates are Metronidazole-resistant 10-14 days of H. pylori eradication followed by 4-8 weeks of PPI for Rx of PUD. Asters Notes 34 of 111 -------------------------------------------------------------------------------- Rx of Whipples Disease: TMP-SMX for 1 year Giardiasis can cause Lactase deficiency Ogilvies: acute colonic pseudo-obstruction Gastric malignancy 1 Gastric adenocarcinoma 2 B-cell lymphoma Celiac Sprue increased incidence of intestinal T-cell lymphomas Carcinoid Syndrome: small bowel carcinoid with hepatic metastasis (increased urinary 5-HIAA) £increased right sided valvular lesions Abdominal Pain relieved by defecation: IBS Cl. difficile: watery diarrhea (Dx: Toxin Assay) Budesonide: high potency steroid low systemic side efects (due to high first pass metabolism) useful in nflammatory bowel disease When UC/CD diff. is difficult UC: pANCA (+) CD: ASCA (antbodies to s. cerevisiae) UC: assoc. with PSC (PSC is an independent risk factor for colonic malignancy in UC) APC Gene: AD Polyps -> Adenomatous Polyps -> Ca small bowel polyps (low malignant potential) & gastric polyps (no malignant potential) may also be found FPC: begin screening colonoscopy @ 12-20 y age Peutz Jeghers: colonic polyps have no malignant potential increased extraintestinal malignancies. Asters Notes 35 of 111 -------------------------------------------------------------------------------- (Breast, Gonads, Pancreas) HPNCC: Colorectal Ca (+) (few, flat, fast-progressing adenomas) 40% lifetime risk of endometrial cancer Right sided Colon Ca: Bleeding Left sided Colon Ca: Obstruction Hep D superinfection is more severe than co-infection HAV infection: may have relapses Acute Hepatic Failure: Encephalpathy in < 8w Subacute Hepatic Failure: Enceph. in 8w - 6m Chr. Hepatitis: > 6m Anti-HCV: EIA -> if (-) -> confirmatory test RIBA Chronic HBV: IFN-á or LAMIVUDINE Chronic HCV: IFN-á with RIBAVARIN Chronic HCV infection: ass. with cryoglobulinemia and Type2 DM (NIDDM) Individuals with Hemachromatosis are susceptible to V. vulnificus, Listeria, Y enterocolitica infections Dx of Budd Chiari syndrome: Duplex Doppler U/S Left Heart Failure: increased liver enzymes (ischemic injury) Right Heart Failure: increased Bilirubin & Ascites (>> periph. edema) Gastric Varices without Esophageal Varices: Splenic Vein Thrombosis Mx: Splenectomy 1 organism causing pyogenic liver abscess: E. coli. Asters Notes 36 of 111 -------------------------------------------------------------------------------- OCP associated Liver Adenoma (Mx: RESECTION even for asymptomatic cases) Meperidine: least Sphincter of Oddi spasm UC with pruritus: consider PSC S. amylase can be increased in MUMPS ue to salivary gland involvement without involvement of pancreatic gland[[but S. Lipase would be normal in cases of extrapancreatic elevation of amylase]] Antibiotic of Choice in Pancreatic Infections: IMIPENEM Tamoxifen: decreases Breast Ca. / increases Endometrial Ca. SERMs (Raloxifene): decreases Breast Ca. / decreases Endometrial Ca. Medical Adrenalectomy Aminoglutethemide + Corticosteroids HRT after Breast Ca. -> Raloxifene IgE is not involved in anapylactoid reactions (e.g. radiocontrast allergy) CD3 : pan B cell marker CD19: pan T cell marker Dx of CREST syndrome is clinical (not based on anti-centromere antibody) Of all HLAs - HLA-DR compatibility is essential for long term graft survival Cyclosporin: decreases CMI & decreases IL-2 (T-cell activation) Steroids: decrease CMI Cyclophosphamide: decreases CM as well as HMI IFN-á: HCL, HepB & C, Kaposis, CML IFN-â: Multiple Scerosis IFN-ã: CGD. Asters Notes 37 of 111 -------------------------------------------------------------------------------- Acidosis due to Organic Acids is not assoc. with HyperK + (cuz they freely permeate the cell membrane) Renal Glycosuria, Hyphosphatemia, Hypouricemia: FANCONIs Commonest TA: Type IV RTA (Hyperchloremic Hyperkalemic metabolic acidosis) Thyroid Scan: I-123 Thyroid Ablation: I-131 Prerenal Azotemia: BUN/Cr > 20.0 L4: Knee Jerk & Sensory on Medial Calf S1: Akle Jerk & Lateral Foot PIVD L5 compression: DORSIFLEXION of foot affected PIVD S1 compression: PLANTAR FLEXION of foot affected [Ca]][PO4]] > 64 : predictive of metastatic calcification Mx of Myedema Coma: 300-500 microg bolus of i/v thyroid hormone followed by 50 microgram daily Panhypoptuitarism presenting with Myxedema coma: first give HYDROCORTISONE then THYROID REPLACEMENT (to prevent Adrenal Crisis) Allopurinol potentiates the action of Azathioprine: if used together, reduce Azathioprine dose by 75% Routine PIVD: MRI not indicated (conservative Mx – resolve in 1-4 weeks) PIVD with neurological deficits: MRI. Asters Notes 38 of 111 -------------------------------------------------------------------------------- Lumbar Spinal Stenosis: Discomfort in Thighs on walking / standing pedal pulses preserved (PSEUDOCLAUDICATION) Ix: MRI Phaeochromocytoma Urinary Catecholamines: sensitive Urinary Metanephrine: specific Urinary VMA: least useful Mx of Fibromyalgia: TCA (NSAIDs are ineffective) 1 functional pituitary adenoma: PROLACTINOMA Pain in sole of foot after getting up in he morning: Plantar Fascitis (Mx: Arch Support / NSAIDs) SLE ANA- sensitive Anti-Sm: specific Ant-dsDNA: correlates with disease activity 1 vitamin deficiency: Vit. D Polymyositis associated dysphagia: oropharyngeal (striated muscle) Scleroerma associated dysphagia: esophageal (smooth muscle) Muscle Biopsy findings in Dermatomyositis: lymphoid infiltrate AROUND muscle fascicles Muscle Biopsy findings in Polymyositis: lymphoid infiltrate INSIDE muscle fascicles Ix of choice: Muscle Biopsy (not EMG/NCV) Woman with Joint Pains and Dental Caries : Sjogrens syndrome GCA: associated with increased incidence of Thoracic Aortic Aneurysms. Asters Notes 39 of 111 -------------------------------------------------------------------------------- Ank. Spond. vs. SI joint involvement in Psoriasis: lack of calcification in Psoriasis Prompt Rx of NGU: associated with decreased indcidence of REITERs Whipples: Joint symptoms precede GI symptoms Synovial Fluid WBC count < 200 normal < 2000 noninflammatory (OA) 2000-50000 Rheumatoid Arthritis 50000-100000 Septic / Gout > 100000 Septic 1 Septic Arthritis: N gonorrheae 1 non-gonococcal arthritis: S. aureus 1 with IVDU/arthroscopy/prosthesis: S epidermidis Recurrent Gonococcal Arthritis: ? C5-C8 deficiency 1 cause of Osteomyelitis: S. aureus 1 renal involvement after URI: IgA nephropathy (1-2 days after URI) PSGN occurs 1-3 weeks after Strep. infection Nephrotic Syndrome: 1 (Children): MCD 1 (Adults): MGN Dialysis :acquired renal cysts (? malignant pot.) Enthesopathy: inflammation of Ligaments / Tendons (Ankylosng spondylosis / Reactive Athritis) Polycystic Kidney Disease: associated with Berry aneurysms in circle of Willis (SAH) Multile Myeloma & Kidney:. Asters Notes 40 of 111 -------------------------------------------------------------------------------- Myeloma Kidney - LIGHT CHAIN Renal Toxicity (light chains are not detected by urine protein dipstick) Renal Amyloidosis - Heavy Chains excreted (heavy chains are detected by urine protein dipstick) Aging: decreasd GFR but S. Cr. remains constant (cuz Lean Body Muslce Mass decreases too) Initial Hematospermia: Prostate Terminal Hematospermia: Seminal Vesicle RBCs: Hematuria WBCs: Cystitis RBC Cast: GN WBC Cast: APN, Pyelonephritis Acute Bacterial Prostatitis: NO Prostatic Massage or Catheterization Chronic Bacterial Prostatitis: Prostatic massage -> C/S of expressed secretions (Mx: TMP-SMX) Ureteral Stones < 6mm: Conservative Mx for 6 weeks Asymptomatic Renal Stones: Conservative F/U with serial X-Rays Symptomatic Renal stones (Fever/Pain/UTI): < 3cm: ESWL > 3cm: PCNL Urinary Incontinence: Total: Sx Stress: Sx is curative (Kegel/Pessary/Estrogen) Urge: Antispasmodic / Anti-Ach / TCA Overflow: Catheterize Sildenafil (Viagra) c.i. in patients on Nitroglycerine Right Ventricular Infarction: Nitroglycerine p Asters Notes 41 of 111 -------------------------------------------------------------------------------- Mx: I/V Fluids 70y old man with urinary obstruction and backache: ? Prostatic Ca with mets Prostatic Biopsy: U/S guided biopsy > finger-guided Prostatic Ca: Transrectal U/S = MRI for staging (CT has no role) Prostatic Mets: Radionuclide Bone Scan > X-Ray Ix for suspected Bladder Ca.: CYSTOSCOPY MEN II: hyperparathyroidism is due to HYPERPLASIA, not PARATHYROID ADENOMA Testicular Neoplastic Mass: Children: Embryonal Cell Ca. Adult: Seminoma > 50y: Lymphoma Intracranial Hage (< 48h. duration): CT without contrast is superior to MRI Cerebellar Vermis: Axial ataxia Cerebellar Hemisphere: “IPSILATERAL” Appendicular Ataxia Frontal Lobe Lesions: Personality Changes Temporal Lobe Lesions: Hallucinations/ deja vu / emotional changes Parietal Lobe Lesions: cortical sensory loss (astereognosis) Occipital Lobe Lesions: macular sparing field defects & UNFORMED VISUAL HALLUCINATIONS. Asters Notes 42 of 111 -------------------------------------------------------------------------------- Acoustic Neuroma: first symptom is IPSILATERAL hearing loss To measure severity of ASTHMA attack: Peak Expiratory Flow RatePEFR (not ABG) Alcohol can temporarily decrease symptoms in BENIGN ESSENTIAL TREMOR (intention tremor) Myersons Sign: 2 per second tap on nose -> sustained blinking (seen in Parkinsonism) Shy-Drager: Parkinsonism + Autonomic Insufficiency + Neurological Deficits Progressive Bulbar Palsy (CN Motor nuclei): TONGUE WASTED Pseudobulbar Palsy (UMN): TONGUE SPARED ALS : UMN + LMN Peripheral Neuropathy: AXONAL (NCV normal) DEMYELINATION (NCV decreased) TT Leprosy: Neuropathy in area of skin lesions LL Leprosy: Neuropathy > Skin Lesions Tarsal Tunnel Syndrome Pain, Paraeshesiae on bottom of foot (Sparing of the HEEL) Cervical Rib: Thenar Wasting Pain & Numbness on medial 2 fingers (ulnar side of forearm) Myotonic Dystrophy: AD stiffness cataracts. Asters Notes 43 of 111 -------------------------------------------------------------------------------- baldness Mx - Quinine, Phenytoin, Procainamide Neuropathy: DISTAL ± Sensory Loss NM Junction: Fluctuating Deficits Myopathy: PROXIMAL weakness (NO sensory loss) non-enhancing white matter lesions without mass effect (in AIDS): PML Ix of Valvular Ht. Disease: ECHO foll. by Catheterization (definitive Dx) ILD Non-productive Cough Exertional Dysnea Fine Expiratory Crackles decreased DL CO increased A-a gradient gold standard for diagnosis: LUNG BIOPSY Dx of Malignant Mesothelioma: Pleural Biopsy 100% of small cell ca. occur in smokers Complicated Parapneumonic Effusions Gross Pus Gram Stain (+) Glucose < 50 mg% Pleural Fluid pH < 7.0 Severe Hyperkalemia Mx: Calcium Gluconate Mx of Mg toxicity: Calcium Gluconate 1 st test in asymptomatic hematuria: URINE CULTURE -> IVP 1 st test in suspected pneumonia: CXR -> Sputum C/S Currant jelly sputum: Klebsiella Rusty sputum: Pneumococcus Smokers / COPD: H. influenzae. Asters Notes 44 of 111 -------------------------------------------------------------------------------- Interstitial infiltrates: Mycoplasma Empyema / Rapidly progressive: Staph. aureus Pneumonia Rx: Community acquired: Macrolide > 60y or COPD/smoker: 2 nd gen cephalosporin Nosocomial: 2 nd / 3 rd gen cephalosporin ICU (severe): Macrolide + Antipseudomonadal Uncomplicated UTI: 3 day course of TMP-SMX Native Valve Endocarditis - S. viridans [â-lactam + aminoglycoside]] Prosthetic Valve Endocarditis (Early) - S. epidermidis[[Vancomycin + Aminoglycoside]] Prosthetic Valve Endocarditis (Late) - S. viridans[[Vancomycin + Aminoglycoside]] IVDU - S. epidermidis / S. aureus [Vancomycin + Aminoglycoside]] IE prophylaxis: - Amox 2g 1 hr. before Dental / GI / GU procedures - penicillin allergy -> Clarithromycin Dont delay antibiotics in Meningococcal meningitis (even if LP is not done) HAART: AZT+3TC & Indinavir AIDS - avoid all live vaccines except MMR Abdo. Pain: 1 st investigation - AXR UC: Pseudopolyps, Crypt Abscesses CD: Skip Lesions, Fistulae ddI can cause Pancreatitis. Asters Notes 45 of 111 -------------------------------------------------------------------------------- RA: PIP involvement (DIP sparing) OA: DIP involvement Ix of choice in Osteoporosis: DEXA scan Vaginal Candidiasis: Topical Miconazole / Systemic Fluconazole (recurrent) (Oral agents eliminate rectal reservoir of yeast) Trichomoniasis: PO Metronidazole 2g stat (Rx male partner also) Bacterial Vaginosis: PO Metronidazole 250-500mg x 7 days (cf. single dose in Trichomoniasis) Pap shows LGSIL (F/U reliable): repeat Pap 4-6 months later Women Smokers should always have annual Pap Primary Dysmenorrhea: within 2 years of menarche inreased Prostaglandins arteriolar spasm uterine hypoxia Mx: (sexually active): OCPs Mx (sexually inactive / OCP c.i.): NSAIDs 1 cause of DUB: Anovulatory Cycles Mx: Hormonal Therapy===>Endometrial Ablation Severe acute DUN with orthostatic hypotension I/V Conjugated Estrogen 1 STD: Chlamydia trachomatis Ectopic (hemodynamically stable / no rupture): Methotrexate Ectopic (Unstable / rupture):. Asters Notes 46 of 111 -------------------------------------------------------------------------------- Salpingectomy or Salpingotomy OCPs: decrease Gonococcal STD may increase Chlamydial STD (cervical ectropion) Vaginal Spermicides: decrease Gonococcal & Chlamydial STD (no effect on HIV transmission) Breastfeeding & OCPs: can use. Use low-dose OCPs (cuz of effect on milk production, not because of infant safety consideration. Estrogens do pass into milk in small quantity, but they are safe) Hormonal Contraception for h/o DVT/PE: Norplant & Depo-Proverano OCPs PID in-patient: I/V Cefoxitin or Cefotetan + Doxycycline out-patient: I/M Ceftriaxone + PO Probenecid + PO Doxycycline Depression: Cognitive Psychotherapy Adjustment Disorder: Supportive Psychotherapy Anxiety Disorder: Behavioral Psychotherapy Antidepressant Ladder: SSRI
another antidepressant (except MAOIs)
best tolerated agent + LiCO 3
MAOIs
ECT
Lab Test for Cocaine: Urine Benzoylecgonine (Cocaine metabolite) Genital Herpes transmission occurs even in asymptomatic state (Acyclovir decreases freq. of recurrences) Hagic crust on molluscum like lesions in HIV pts. : Cutaneous Cryptococcosis. Asters Notes 47 of 111 -------------------------------------------------------------------------------- HPV (Genital Warts) Heaperd up lesions flesh colored lesions on penis female partner has increased risk of Ca. Cx Leprosy with painful red patches on extremities that become nectrotic and ulcerate: LUCIO REACTION (seen in unreated leprosy, responds to Steroids) Excessive use of Aluminium containin laxatives: risk factor for postmenopausal osteoporosis KOH Prep meatball-and-spaghetti appearance: Tinea versicolor binge eating and purging behavior (even without depression) : SSRI Factitious Disorder : assoc. with child abuse Somatoform Pain Disorder : limit analgesic use best managed in a multi-disciplinary pain clinic Rx of choice for Panic Disorder: PAROXETINE dependence might develop with Alprazolam Mx of Social Phobia: â-blockers + ASSERTIVE TRAINING Mx of OCD: SSRIFluvoxamine Clomipramne is no longer the first line drug Mx of PTSD: >1m; assoc. with life-threatening event Group Psychotherapy Anorexia nervosa: 75% have Depression, 25% have OCD -------
Continued in Asters Notes II