Aster's Notes for USMLE step 3
Part II Aster's Notes for USMLE step 3
Cont. from part I
Aster's Notes - Part II
Aster's Notes 48 of 111
-------------------------------------------------------------------------------- Skew: depends on direction of tail (not hump) ± 1 SD 68% ± 2 SD 95% ± 3 SD 99.7% To increase power of a test: inrease sample size Nominal or Ordinal Data: Non-parametric Tests [Chi Square] Interval or Ratio Data: Parametric Tests [T-test, Z-test, F-test] Correlation coefficient Ordinal Data: Spearman Rank Order Interval or Ratio Data: Pearson product-moment r=correlation coeeficient r 2 (square)=coefficient of determination (proportion of variation in one variable explained by variation in other) Causality is only proven by properly conducted experimental studies A test can only be 100% sensitive and specific if there is no overlap between measurements in normal and diseased states Higher the prevalence of a disease: Higher the PPV of a (+) test Lower the NPV of a (-) test Untreated apendicitis in young female can cause infertility (peritoneal adhesions) Appendiceal abscess: delay Sx till inflammation has subsided [the acute process has been walled off] Cholangitis (ass. with CBD stones): ERCP with Sphincterotomy + Lap Chole. Skin Suture: cutting needle. Aster's Notes 49 of 111 -------------------------------------------------------------------------------- Deeper Layer Suture: Taper Needle Ingrown Toe Nail first episode: antibiotics, elevation of edge -> wedge resection recurrent: Nail Removal Anal Fissure: Local Steroid Cream / Sitz Bath Anaesthetic of choice for skin lesion removal: Lidocaine + Adrenaline (No Adrenaline for fingers and nails) 1 type of breast Ca.: Infiltrating Ductal Ca. (80%)
Mx of Fibrocystic Disease: Low Dose OCP Mx of Fibroadenoma: Biopsy (Excisional) Danger Signs in Chronic Low Back Pain - Bowel or Bladder dysfunction - Impotence - Ankle clonus - NIGHT PAIN - Weight Loss - Lymph Node enlargement - Buttock claudication - New Onset in age > 50 y No imaging for routine chronic low back pain Mx of Chronic LBP: TCA's have the best cost/benefit ratio [Muscle relaxants and NSAIDs have low effectiveness] Dx of Childhood PCKD: > 2 cysts in EITHER Kidney Dx of Adult PCKD: > 5 cysts in EACH Kidney C/I to thrombolysis - Sx < 2 weeks - Unconrolled HTN - Aortic Dissection - h/o CVA / 'aic stroke / CNS tumor / AVM - prolonged traumatic CPR - allergy to thrombolytic agents. Aster's Notes 50 of 111 -------------------------------------------------------------------------------- - pregnancy Risk Stratification in Unstable Angina (Outpt.) Low - Onset < 2 weeks (Telemetry) Medium - Onset < 2 weeks, Pain > 20 minutes but resolved @ present (CCU) High - Rest Pain > 20 minutes and not resolved @ present (CHF / Pulm. Edema / ST changes / Mitral Regurg.) 1 st episode of syncope / low risk of heart disease: NO FURTHER EVALUATION Emperical Rx for IE: Nafcillin + Ampi + Genta (add Rifampin for Prosthetic Valve) IE prophylaxis not reqd. for: 1. small ASD of secundum type 2.MVP without Mitral Regurg. Acute Asthma: Give Albuterol, O2, steroids -> assess response (PEFR, O2 sat.) Good Response PEFR > 80% of best (discharge with â-agonist) Moderate Response PEFR 60-80% of best (hospitalize and continue medications, O2) Poor Response PEFR < 50% of best (ICU admission) (prepare for Intubation if silent chest, altered sensorium, respiratory failure) Chronic Asthma Mild Intermittent: <2/week, nocturnal symp. < 2/month (Inh â 2 -agonist) Mild Persistent: >2/week, nocturnal symp. >2/month (Inh â 2 -agonist + Anti-LT) Moderate Persistent: Daily, PF 60-80% (Inh â 2 -agonist + Inh. Steroids/Inh. long acting â 2 -agonist).Aster's USMLE Step3 Notes Aster's Notes 51 of 111 -------------------------------------------------------------------------------- Severe Persistent: Continuous, PF<60% (Inh â 2 -agonist + Inh. Steroids + Inh. long acting â 2 / Anti LT) SPN: Conservative Mx Age < 45, nonsmoker, no inrease in size, size < 4cm Psoriasis: Pustular: ACITRETIN Plaques: ŒEmollients / Keratolytics / Corticosteroids ŒTar / Calcipotriol / Anthracin ŒUVB ŒPUVA ŒMethotraxeate / Cyclosporin ŒHydroxyurea Rx of Onychomycosis: PO Terbinafine Acute Mastoiditis develops 2-3 w after acute otitis Mx: Ceftriaxone / Sx drainage Acute Bacterial Sinusitis: Pneumococcus Chronic Bacterial Sinusitis: S. aureus most serious form of sinusitis: FRONTAL sinusitis d/o/c for Alzheimer's : DONEPEZIL (OD dosing, no liver toxicity) Upper Lips: BCC > SCC Lower Lips: SCC > BCC RCA stenosis: Saphenous grafts Anterior Duodenal Ulcers: Perforation Posterior Duodenal Ulcers: Bleeding Acute Meseteric Ischemia: Embolization Chronic Mesenteric Ischemia: Atherosclerosis. Aster's Notes 52 of 111 -------------------------------------------------------------------------------- Carcioid: Appendix > Ileal (Ileal have higher chances of metastasis) 1 GI malignancy: HCC (not colorectal Ca.)
1 Liver neoplasm: Cavernous hemangioma
1 Breast Lesion: Fibrocystic Disease
1 Breast Malig.: Infiltrating Ductal Ca.
Indications for Hormonal Therapy for Breast Ca. - Postmenopausal - Nodes -- ER + Aortic Aneurysms Thoracic: Type A: Sx Type B: Sx if > 6 cm Abdominal: Sx if > 5cm 1 Congenital Heart Disease: VSD
1 Cyanotic Heart Disease: TOF
ASD: Fixed Splitting of S2 Biliary Atresia: Jaundice @ 2 wks of life, dark urine & acholic stools Rx: Surgery (Roux-en-y portoenterostomy) Neck Injuries: Zone I : Arteriography -> Sx Zone II : Sx Zone III : Arteriography -> Sx Mortality in Burns = Age + % BSA 1 st degree: Leave Open 2 nd degree: Clean,Sulfadiazine,nonadhesive dressing 3 rd degree: Escharotomy + Skin Grafting Sprain: Ligament Pull. Aster's Notes 53 of 111 -------------------------------------------------------------------------------- Strain: Muscle Pull Neck Humerus: Axillary Nerve Damage
Shaft Humerus: Radial Nerve Damage
Quick Neuro Exam AVPU: Alert Responds to Verbal Stimulus Responds to Pain Unresponsive Rescusitation: O 2 , 2 large bore IV lines, IV fluids, EKG - 100 mg Thiamine - 1 amp 50% Dextrose - 0.4 mg Naloxone C/I to Foley's Catheter: (do retrograde urethrogram) 1. Blood at tip of urethral meatus 2. Perineal Eccymoses Abdo. Trauma 1 Injury in Blunt Trauma: Spleen
1 Injury in Penetrating Trauma: Small Bowel
Indications for Exploratory Laparatomy in Abdo. trauma 1. Shock with Abdo. Injury 2. Pneumoperitoneum 3. Gunshot 4. (+) DPL - Blood - RBC > 100,000/mL - WBC > 500/mL - Food - Bile - Bacteria Referral for Burns - 3 rd degree burns > 10% BSA, < 10 y, > 50 y - 2 nd degree burns > 20% BSA - Electrical burns / Chemical burns. Aster's Notes 54 of 111 -------------------------------------------------------------------------------- - Inhalation Injury - Perineal burns - Radiation burns 1 symptom of Parkinsonism: Tremor (Resting)
Benign Essential Tremor ŒIntention Tremor ŒFamilial ŒHead Nodding Œtemporary decrease with alcohol intake S. pneumoniae: Rx - Macrolide or newer Quinolone (Levofloxacin / Gatifloxacin) Majority of elderly patients with sepsis: URINARY TRACT is the culprit 1 cause of death in hospitalized elderly: UTI
1 cause of death in institutionalized pts.: Bacterial Pneumonia
1 cause of Urinary Incontinence: Urge Incontinence
Clean pressure ulcers with Normal Saline (avoid Povidone-Iodine, Hydrogen Peroxide etc.) Unimmunized with infected wounds 3 TT + 1 ATS Stroke mortality is higher in WHITES than in BLACKS indications for pneumococcal vaccine 1. Splenectomy 2. Sickle Cell 3. > 65 y 4. Chr. Cardio / Pulmonary / Renal Disease 4. Hodgkin's Disease Continued Gastric Lavage for : PCP overdose 1 Foods causing angioedema: Nuts / Seafood
1 Drug causing allergy: Aspirin
Electronic Fetal Monitoring & Intermittent Auscultation of Fetal Heart have similar outcomes. Aster's Notes 55 of 111 -------------------------------------------------------------------------------- NST (Non-stress Test) > 2 accelerations (in 20 minutes) 15 bpm lasting > 15 sec CST >= 3 consecutive late decelerations in 10 minutes < 20w. POG with HTN: Essential HTN (not PIH or pre-eclampsia) Pre-eclampsia: Bed Rest / (L) lateral position / pharmacotherapy [á-methyldopa / labetalol] 1 indicator of perinatal outcome in IUGR is:
presence of vertical pocket of Amniotic Fl > 3 cm 0-8 weeks : Embryo 8w-term : Fetus 0-14 weeks: 1 st Trimester [Routine Ix] 14-28 weeks: 2 nd Trimester [GDM Screen] 28-40 weeks: 3 rd Trimester [GBS Culture] <24 weeks: Previable 24-27 weeks: Preterm 37-42 weeks: Term > 42 weeks: Post-term Cervical Incompetence: - Cerclage @ 12-14 weeks, till 36-38 weeks POG Bishop Score: <= 5: Prime (with Prostaglandins) > 8: Induce Labor 1 cause of PPH: Uterine Atony
Preterm ROM: @ < 37 weeks POG. Aster's Notes 56 of 111 -------------------------------------------------------------------------------- Premature ROM: > 1 hr before onset of labor Prolonged ROM: > 18 hours before onset of Labor (Mx: Antibiotics) Mastitis in breasftfeeding: continue breastfeeding, Cloxacillin Early Breast Milk Jaundice ŒExaggerated Physiological Jaundice ŒOnset < 4 days of life Late Breast Milk Jaundice ŒBreast Milk Jaundice ŒOnset 4-14 days Œcompetitive inhibition of glucuronyl ransferase by nonesterified long chain fatty acids in reast milk ŒMx: Stop breastfeeding for 2-3 days / Give Formula Milk [Jaundice comes down quickly] -> Resume Breastfeeding Any jaundice @ Birth is PATHOLOGICAL Success of Contraceptives Norplant > OCPs > Barrier Norplant: quick return to fertility DMPA: 18 months for fertility to return Complete Mole: Diploid; 46, XX; has higher malignant potential Kernicterus never occurs with: Œphysiological jaundice Œexaggerated physiological jaundice Œbreast milk jaundice Features of Pathological Jaundice: Œpresent @ birth Œincrease in bili. > 5 mg/dL/day on first day ŒBili. >12 mg/dL [term] or Bili. >14mg/dL [preterm] Œpersists > 1 week of life ŒConjugated Bili. > 1 mg/dL @ any time. Aster's Notes 57 of 111 -------------------------------------------------------------------------------- Wessel Criteria for Infantile Colic Unexplained Crying: Œ> 3 hr/day,> 3 d/week, > 3 weeks, 3 m old child ŒDo Urinanalysis ŒReassure ŒNo treatment necessary ŒBottle-fed infants have higher incidence ŒDicyclomine: risk of apnea After a feed, allow "burping" and lay the child on (R) side of abdomen Introduce Solid Foods @ 6 months age Vaginal pH < 4.5: Candida Vaginal pH > 4.5: Bacterial Vaginosis Transfusion Reactions Fever: Leukoagglutination (donor WBCs) Mx: acetaminophen Anaphylaxis (donor proteins,severe in IgA-deficiency) Mx: Epinephrine, Steroids Hemolysis (ABO mismatch) Mx: stop transfusion, hydration & diuresis Familial Short Stature: NORMAL BONE AGE Constitutional Delay: DELAYED BONE AGE Short Stature with Webbed Neck is seen both in Turner's (XO) & Noonan's (normal Sex chromosomes) Budesonide has proven to be beneficial in Croup (along with racemized epinephrine) Rx of choice for AOM in primary practice: Amox ===> Cefaclor (if no response to Amox) Transmission of Common Cold: Indirect Spread is more important than Aerosol spread Absolutely no antibiotics in common cold (even if patient demands it!). Aster's Notes 58 of 111 -------------------------------------------------------------------------------- Erysipelas: Gp. A â-hemolytic Srep. Impetigo: Staph. or Strep. [Bullous - Staph.] Coxsackie A16: Hand Foot Mouth Disease Pitryasis rosea: Herald Patch PNEUMONIA 2 wks: GBS 2 wks - 4 m: Chlamydia trachomatis 1 Bacterial: Strep. pneumoniae
4 months - 4 years: Mycoplasma pneumoniae 1 Bacterial: Strep. pneumoniae
> 4 years: VIRAL 1 bacterial: Strep. pneumoniae
Antibiotic Rx of Occult Bacteremia does not decrease the occurence of meningitis Yersenia entercolitica: can mimic acute appendicitis (no Rx necessary - self limiting) ROTAVIRUS G/E is preceded by URI symptoms Rec. Abdo. Pain Syndrome - 10% prevalence - school phobia - no organic signs - no Rx necessary Growing Pains - B/L deep pains - can awaken child from sleep Mx: exercize program SCFE Œoverweight and sedentary "teenage" BOY ŒGroin Pain/ Knee Pain Dx: X-Ray Mx: Surgical fixation. Aster's Notes 59 of 111 -------------------------------------------------------------------------------- LCP ŒAvascular necrosis of femoral head ŒLIMP Œhip pain or referred knee pain (knee is NOT TENDER to palpation) Osgood Schlatter Œtenderness over tibial tubercle Œaggraveated by activity Œoccurs in pysically actve males around puberty Mx: Limit activity, NSAIDs; (if severe) Knee immobilization splint Teenager with knee pain aggravated by climbing stairs: Patellofemoral Syndrome Child with Limp / Hip Pain - preceded by URI - Fever (+) - normal ESR TOXIC SYNOVITIS [Sterile Hip Effusion] Mx: Rest / NSAIDs (NO ANTIBIOTICS) Foot dorsiflexes easily banana shaped sole: Congenital calcaneovalgus kidney bean shaped sole: Metatarsus adductus Intoeing patella points forward: Internal Tibial Torsion patella points medially: Excessive Femoral Anteversion (#1 cause of intoeing in children) CTEV: inability to dorsiflex Mx: progressive serial casts, posteromedial release of heel cord 1 substance of abuse: Alcohol
Nocturnal Enuresis Œ> 4 years Œmajority of children do NOT have any physical or psychiatric disorder ŒMx: Behavioral modification Bell / Buzzer system d/o/c: dDAVP (no longer IMIPRAMINE). Aster's Notes 60 of 111 -------------------------------------------------------------------------------- Encopresis: > 4 y. Enuresis: > 5 y. Allergic Rhinitis: ŒHyperemic Nasal Mucosa ŒClear Discharge ŒBluish-purple rings around eyes (SHINERS) ŒIx: Nasal smear for Eosinophils ŒMx: elimination / inra-nasal corticosteroids Child with rash on introduction of "whole milk": Atopic Dermatitis Mx: Cow Milk ----> Formula Milk ----> Soy Milk (Cow milk allergic might show allergy to soy milk, too) Diaper Rash ŒCandidal: Satellite lesions ŒSeborrheic ŒPrimary Irritant Dermatitis: maceration with sparing of henitocrural folds (Mx: frequent changing, washing, no occlusive plastic pants, ZINC OXIDE, NO ANTIBIOTICS) Innocent Murmur in Children Œprevalence: 50% Œaccentuated by sitting, anxiety, fever, tachycardia Œmid to low sternal border Œsystolic Œno thrill Œvibratory or musical in quality [Still's Murmur] Common Cold: Steam Inhalation provides superior relief of nasal congestion cf. antihistaminics £Decongestants (sympathomimetics) : can cause CNS overstimulation £Cough Suppressants (Dextromethorphan) : can cause respiratory depression in children 1 complication of sickle cell disease
Painless Hematuria (Paillary Necrosis). Aster's Notes 61 of 111 -------------------------------------------------------------------------------- Priapism in Sickle Cell Disease > 6 hrs. : Hospitalize no effect on future erectile function may respond to Nifedipine / NTG Complications of Sickle Cell Disease - Hemolytic Crisis - Vaso-occlusive crisis - Aplastic Crisis - Splenic sequestration crisis - CVA - Renal Papillary Necrosis - LOwer extremity skin ulcers - Proliferative retinopathy Mx of HbS disease ŒOxygenation ŒPneumococcal vaccination ŒFOLATE supplementation ŒProphylactic antibiotics (Penicillin till age 5) ŒNarcotic analgesia for pain crisis ŒCVA: Exchange transfusion ŒPainless Massive Hematuria: e-ACA ŒHydroxyUrea for frequent vaso-occlusive crisis ŒBone Marrow Transplantation (Age < 16, availability of Bone Marrow Donor) STROKE / TIA in Sickle cell disease is an indication for exchange transfusion to keep the HbS < 50% HbS disease 'per se' can lead to restrictive lung disease -> hypoxemia -> increased sickling tendency Avoid use of MEPERIDINE in severe chronic pain (short T1/2) Malignant Hyperthermia: Mx-Dantrolene Symp. AORTIC STENOSIS: high perioperative risk In preop pts. with A. Fib. : achieve rate control In preop pts. on Diuretics : Get Electrolyte Levels. Aster's Notes 62 of 111 -------------------------------------------------------------------------------- Avoid elective surgery in patients with significant hepatic dysfunction Indications for Intra-op Insulin - IDDM : any surgical procedure - NIDDM on Insulin : any surgical procedure - NIDDM on OHA : major surgical procedure Prophylactic preop antibiotics only decrease the incidence of wound infection (no effect on postop pneumonia, UTI, sepsis) : CEFAZOLIN is a good choice elderly with repeated falls with dementia / seizures: look for chronic SDH stool impaction can cause urinary incontinence Breast Cancer with BRCA1 gene: Better prognosis Breast Cancer with HER2/neu gene: POOR prognosis Kaposi's: HHV8 (Male Homosexuals) Cyclophosphamide: Mesna Methotrexate: Leucovorin Cisplatin: Amifostine Doxorubicin: Dexrazoxane Mx of chemotherapy induced dry mouth: Pilocarpine Hcl 5-10 mg PO TDS Assessment of Doxorubicin toxicity: MUGA scan Neutropenia: requires antibiotic prophylaxis for G(-) / fungus Competent individuals @ the end of life have right to refuse nutrition and hydration Cutaneous absorption of drugs is 3 times more in children than in adults Topical drugs c/i in pregnancy 1. Podophyllin 2. Isotretinoin 3. Lindane. Aster's Notes 63 of 111 -------------------------------------------------------------------------------- most appropriate initial investigation in â-Thalassemia: CBC with red cell indices SLE: decreased C3/C4 Dumping Syndrome post-Bilroth II - Dietary modification - Octrotide - (fails) Bilroth I conversion 75%-95% of AAAs are infra-renal - Dx: U/S abdo. Food poisoning: < 6 hrs. after food intake - S. aureus (mayonnaise / salad dressing) - B. cereus (fried rice) > 16 hours / poultry consumption: C. jejuni Carbamazepine intoxication - QRS prolongation : predisposes to - QT lengthening Defib. followed by pulseless electrical activity - Hypovolemia - Hypoxia - cardiac tamponade - pneumothorax - massive pulmonary embolism - drug toxicity - hyperkalemia - acidosis - massive MI Coarctation of aorta is associated with Bicuspid aortic valve in 70% cases. Aster's Notes 64 of 111 -------------------------------------------------------------------------------- 1 cause of GI h'age following AAA repair is:
Colonic Ischemia (not stress gastritis) Early onset wound infections: Strep / Clostridium Dementia: Visuospatial: Alzheimer's Gait disturbance / Urinary Incontinence: NPH Delayed DTR: Hypothyroidism Myoclonus: CJD (Creutzfeld Jacob Disease) Alzheimer's with agitation: use HALOPERIDOL (not BZDs -> they can aggravte agitation) Testicular tumors Œ#1 seminoma Œincreased incidence in cryptorchidism Œmetastatize to retroperitoneal nodes Œinguinal nodes involved only with scrotal spread ŒChildren: Embyonal Cell Ca. ŒAdults: Seminoma Œ> 50 y: Lymphoma ŒDx: Testicular Ultrasound (no BIOPSY) Mx: Inguinal exploration & cross clamping of cord & Orchiectomy Pregnancy: Œincreased tidal volume Œdecreased BP (decreased TPR – progesterone) ŒHb decreases (dilutional effect) TV U/S > sensitive cf. Abdo. Scan for ectopic preg. Fat Embolism: associated with Eosinophilia & Lipiduria Shoulder Pain Rotator Cuff Injury: best elicited by positioning of the reater tubercle of humerus beneath acromion Subacromion bursitis: elicited by palpation over deltoid Biceps tendinitis: aggravated by flexion or supination of elbow Acromioclavicular arthritis:. Aster's Notes 65 of 111 -------------------------------------------------------------------------------- elicited by crossed arm adduction against resistance RANSON CRITERIA at admn. @ 48 hours Age > 55 Fall in Hct > 10% WBC > 16000 Fluid deficit > 6L Bl. Glu > 200 S. Ca ++ < 8.0 LDH > 350 PaO 2 < 60 mmHg AST > 250 BUN increase > 5 mg/dL Base deficit > 4 mEq/L Rx of sigmoid volvulus: Sigmoidoscopy (Sx required if s'copy fails) Hemodialysis in CRF ŒUremia ŒPericarditis ŒAcidosis ŒHyperkalemia ŒUnresponsive Volume Overload AIDS Chemoprophylaxis CD4 < 200: PCP CD4 < 100: Cryptococcus CD4 < 50: MAIC Cryptococcal Meningitis: very high CSF pressure (serial lumbar punctures may be warranted) 1 cause of inracranial mass lesions:
Metastasis (not primary brain tumor) 1 benign liver neoplasm:
HEMANGIOMA (not Hepatic Adenoma) Propylthiouracil: can cause agranulocytosis smoking is a relative c.i. to OCPs - not absolute 1 cause for osteomyelitis: S. aureus
Bed Rest has no proven benefit in chronic low back pain & threatened abortion. Aster's Notes 66 of 111 -------------------------------------------------------------------------------- Significant Hematuria: > RBCs/HPF Significant Pyuria: > 10 WBCs/HPF increased PEEP causing hypotension/hypoxemia -> consider pneumothorax Confirm erythema nodosum by SKIN BIOPSY (Conservative Mx) -> Steroids for persistent Pain Change in Antipsychotics should be done within 2-4 weeks, if no desired effect Ice should not be applied on snake bite site -> can delay efflux of venom by causing vasoconstriction Severity of AS: late peaking murmur & delayed and weak carotid upstroke Hymenoptera anivenom is not available Even after treating anaphylaxis with S/Q Epinephrine -> monitor patient in ED (patient is not risk-free, complications can develop) 1 cause of fever in AIDS, without overt symptoms: MAC (Rx Ethambutol +
Clarithromycin) 1 cause of Seizures in AIDS: TOXOPLASMOSIS
1 cause of dysphagia in AIDS:
Candidal Esophagitis Suspected child abuse: inform child protective services (Hospitalize only if child's conition requires it) ITP : improvement with splenectomy but platelet counts falls again (Ix: radionuclide spleen scan for splenic remnant) HSP: usually remits in 1 week (Mx is conservative) - Leukocytoclastic vasculitis 1 cause of hematuria after URI: IgA nephropathy
ABI < 0.4 - sever vaso-occlusive disease Mx: surgical revascularization. Aster's Notes 67 of 111 -------------------------------------------------------------------------------- Oliguria in hospitalized pt. -> assess pulmonary wedge pressure (to diff. hypovolemia and ATN) Fibrinogen is the most abundant acute phase reactant (responsible for increased ESR) Age, Myeloma, Macroglobulinemia, Hypoalbuminemia increase ESR Number-needed-to-screen is reciprocal of absolute risk reduction Celiac Sprue: dermatitis herpetiformis Mx: Dapsone Localization of extra-adrenal phaeo: MIBG scan suspected phaeo 1.catecholamine levels 2.if levels elevated, Imaging (imaging, done first, will lead to detection of incidental adrenal masses – high prevalence) Preop prep in Phaeo full á blockade followed by â blockade (not vice versa) Antidote for Mg toxicity is Calcium Gluconate Mild pre-eclampsia: Bed Rest and Monitoring Severe pre-eclampsia: Hospitalization, Control of HTN, MgSO4 infusion Dx of Hemachromatosis (Gold Standard): Hepatic Iron Index (not HFE Gene analysis) 1 cause of TEN : Adverse Drug Reaction
Rapid Correction on HypoNa: CPM Frozen shoulder = adhesive capsulitis takes months to regain full function (steroid injections can hasten recovery) Orchiopexy in Cryptorchidism @ 1 year age Orchiopexy deceases the proportion of seminomatous malignancies - but total risk of malignancy stays the same. Aster's Notes 68 of 111 -------------------------------------------------------------------------------- Urine dipstick only detects albumin, 24 urinary protein assessment detecs all proteins (Myeloma light chains will not be detected by dipstick) Bone scan has no role in lytic lesions of myeloma Hypotension in Meningococcemia: Waterhouse-Frederrikson syndrome Macrolide antibiotics prolong QT interval: V.Tac.->Syncope Kartagener's: Sinusitis / Bronchiectasis / Infertility / Situs inversus Disulfiram : slow excretion from the ody. Adverse reactions can occur even 1-2 weeks after cessation of therapy. Disulfiram is not an option for long term alcohol abstinence Statin therapy: monitor LFTs regularly (CPK only if rhabdmyolysis is suspected) Intravascular Catheter related infection : Staph. epidermidis / S. aureus (use Vancomycin, cultures pending) Arterial Clots: Anti-PL antibody Venous Clots: #1 inh. cause: Factor V Leyden Postcoital contraception: is not 100% effective (Progestin-only Pills are safer than OCPs) HIRUDIN: is a direct thrombin inhibitor approved for use in pts. with Heparin-induced Thrombocytopenia Pulmonary Embolism: CXR is usally NORMAL 1 finding on EKG: Sinus Tachycardia
- Hampton's Hump: seen in Pulmonary Infarction - Westermark's Sign: sign of Pulmonary Oligemia Meningococcemia: seen in C5-C8 deficiency Meningococcal vaccine: Polysaccharide vaccine (A,C,Y,W135).Aster's USMLE Step3 Notes Aster's Notes 69 of 111 -------------------------------------------------------------------------------- Neutropenia with Fever: (Neutropenia = < 500/mcL) suspect Pseudomonas Piperacillin/Tazobactam & Gentamycin (or Ceftazidime) if central line is present: Add Vancomycin [Continue antibiotics even if cultures are negative] Indomethacin: can decrease amniotic fluid production Indications for CONIZATION 1. non-visualization of transformation zone 2. "pap" worse than bopsy 3. AdenoCa. 4. (+) endocervical cuerettage 5. Microinvasion on Bx (+) F/H is not a risk factor for Ca. Cx Neuroblastoma metastasis: can cause periorbital ecchymosis / proptosis - increased urinary VMA - N-myc gene PEPTO-BISMOL: affects platelet function (can prolong bleeding time) "popcorn" calcification in SPN : Hamartoma Mx of SIADH: Fluid Restriction Mx of malignant SIADH: Demeclocycline "pop" or snap in knee : ACL tear [Knee Immobilization / Crutches] post-URI abdo pain / vomiting / RUQ mass in a child: ? Intussusception [Barium Enema - Rx & Dx] Legitimate Vanco. use : â-Lactam resistant Staph. epidermidis. Aster's Notes 70 of 111 -------------------------------------------------------------------------------- Vit. A toxicity can cause Hypercalcemia Gatsric ulcers: located on lesser curvature within 1cm of gastric antrum Adrenal Mass > 4cm & High Hounsfiled Values: high chance of being malignant Most ensitive test for Cushing's: 24 hour urinary cortisol (levels are subject to diurnal variation) Bilroth II: Afferent Loop Syndrome (Pain after meal ingeston) Mx: Bilroth I conversion, roux-en-y gastrojejunostomy Blind Loop syndrome (bacerial overgrowth, malabs.) Mx: antibiotics â-Thalassemia major: HbF increased â-Thalassemia trait: HbA2 increased Risk of Postop DVT 1 Elective Knee Arthroplasty
2 Elective Hip Arthroplasty
3 Hip # Repair
highest risk with ELECTIVE KNEE ARTHROPLASTY Cocaine use assoc. MI: combination of spasm and plaque rupture (don't assume spasm is the cause, do angiography) Pappenheimer's Bodies: Iron inclusions in RBCs Rhabdomyolysis: Hypocalcemia, Hyperkalemia, Hyperphosphatemia Diverticulosis: #1 complication - BLEEDING 85% bleeds stop spontaneously (#1 complication is not Diverticultis) DIVERTICULITIS: ŒPolymicrobial. Aster's Notes 71 of 111 -------------------------------------------------------------------------------- ŒBroad spectrum antibiotics Œno barium enema / colonoscopy h/o Malig. Hyperthermia with succinylcholine: use NITROUS OXIDE in future anesthesia Chronic Fatigue with normal physical exam: DEPRESSION INVENTORY -> Thyroid studies IE -> Mycotic Aneurysm -> Bleeding -> SAH [embolization of bacteria to the brain) IFN-â: decreases relapse frequency in MS First Episode of DVT: Heparinize -> Warfarin for 3-6m (INR 2.0-3.0) Recurrent DVT: Lifelong "Warfarin" [if Warfarin is not tolerated : ENOXAPARIN] Fever / Sore Throat / Atypical Lymphocytes (without LN / Splenomegaly / MonoSpot) : CMV Colles' #: splinting in NEUTRAL postion (not in FLEXED position) PSA levels in Prostatic Ca. correlate with lymphatic spread Antibiotics in postpartum endometritis: I/V Imipenem / Cilastatin Vaginal Delivery in Breech 1. FRANK BREECH 2. Fetal Weight between 2000-3000g 3. Gynecoid Pelvis Rx of Catatonia: Lorazepam Incisions done for pre-existing infections and abscesses are considered INFECTED WOUNDS Severe Depression with Psychosis: Mx with ECT. Aster's Notes 72 of 111 -------------------------------------------------------------------------------- Hypertensive Heart Disease: S4 Gallup (LVH) Depo-provera: - associated with Irregular bleeding (use conjugated estrogen x 7 days to control bleeding) Peak CPK levels: give idea about size of an infarct (no prognostic value) Nephrolithiasis with increased Creatinine: IVP can not be done (No I/V CONTRAST in the setting of renal dysfn.) Renal and Bladder Ultrasound Scan, instead HTN in Graves' disease: Rx with â-blockers Anti-Ro: associated with neonatal Lupus (resolves in 6 months) and Congenital Heart Block Lupus anticoagulant Œanti-PL Œrecrrent abortions Œthrombotic state (arterial + venous) Œ"in vitro" increased PTT (doesn't correct with mixing) ŒRussel Viper Venom Time Doxepin (a TCA) is useful in chronic urticaria suspected ADHD: get psychometric tests Misleading Low Sodium is caused by Hyperglycemia Mx of acute mountain sickness: acetazolamide Dx of Sarcoidosis: ŒBiopsy ŒKveim test is obsolete ŒACE levels are elevated in 50% pts. Rx of Brown Recluse Spider Bite: DAPSONE Middle Ear Effusion persisting for 4-6 months following an adequate course of. Aster's Notes 73 of 111 -------------------------------------------------------------------------------- antibiotics, with significant hearing loss (especially bilateral), is an indication for myringotomy and insertion of tympanostomy tubes. Chlamydial Ophthalmia: Rx with SYSTEMIC ERYTHROMYCIN (to prevent chlamydial pneumonia) Appropriate Initial Test for suspected B12 def: Serum B12 levels (many patients have normal CBC and normal indices) fruity breath odor: ketosis prolonged latent phase of labor : Œtherapeutic rest & sedation (usually morphine). ŒNo Oxytocin / No Amniotomy DtaP contra-indications: 1.previous febrile reaction: fever > 105 F 2.h/o seizures (F/H of seizures is not a contra-indication) Rx of choice for SVC syndrome: Radiation First HiB vaccine @ 2 months age Female > 40y with abnormal vaginal bleeding Endometrial Bx to r/o Endo. malig. Atrial Flutteris not a serious arrhythmia, but cardioversion should be attempted in the presence of CHF. Atrial Flutter due to Digitalis toxicity: PACEMAKER Anorexia nervosa: BUN increase Low Platelet Count Leukopenia with relative lymphocytosis elevated serum carotene levels Legionaire's disease:. Aster's Notes 74 of 111 -------------------------------------------------------------------------------- Person-to-person spread has not been documented Childhood obesity is not a predictor for adult obesity long-term Rx of obesity in children : usually fails Thoracic outlet syndrome: appearance on numbness and paraesthesiae with arm abducted to 90 degrees and externally rotated (not defined by the disappearance of radial pulse) Postmenopausal with stress incontinence: Kegel exercizes, pessary, estrogen replacement Retractile Testes: Œexaggerated cremasteric reflex Œtemporary Œresolves in adolescence Œno increased risk of malignancy Flail Chest: Intubation & Assisted ventilation (Strapping of Chest may lead to hypoxia & atelectasis) Vaginismus is involuntary contraction Behcet's: cutaneous hypersensitivity 60-70% will develop a sterile pustule within 48 hours of any aseptic injection epidydimitis -> check age of pt. < 35: Chlamydia, Gonococcus > 35: E.coli Gold stadard for diagnosis of melanoma: BIOPSY Treatment of alcoholism in wife-batterers does not treat battering behavior Pt. with hemoptysis and normal chest film: Fibre-optic bronchoscopy (PPD is not indicated) F/U COPD progression with FEV1. Aster's Notes 75 of 111 -------------------------------------------------------------------------------- Tick paralysis (neuro-toxin mediated): 10% mortality prompt resolution if tick is identified and removed Let children attend funerals, if they want to. They should be accompanied by adults who can provide comfort and support Hyperparathyroidism: inc. incidence of Pseudogout NIACIN: can be associated with hepatotoxicity rear-facing infant seats should be on the back seat. < 12 y children: ride secured on car backseat Headache onset with exertion, such as weight-lifting: serios sign (look for CNS malformations & vascular malformations) Minocycline: has anti-inflammatory action (has been used in Rheumatoid Arthritis) Gynecomastia in adolescence: Observation Long standing Gynecomastia: SURGERY HCM: EKG is abnormal (LVH, WPW, abnormal Q wves) Ticlopidine: has been associated with neutropenia Immediate gastric lavage is ot indicated in strychnine poisoning Continuous gastric lavage: PCP overdose Not all persons with anaphylaxis will have a repeat reaction when exposed again to the agent. Repeat reactions are usually less severe. Head, Neck, Face sutures: leave in place for 3-5 days (rapid healing) Eclampsia: MgSO4 (no role of anticonvulsants) Clonidine withdrawl: Hypertensive Crisis. Aster's Notes 76 of 111 -------------------------------------------------------------------------------- The woman's need for physical intimacy often increases during pregnancy. Abstention from intercourse in the last month of normal pregnancy is not necessary Valsalva maneuver decreases the venous return to the heart, thereby decreasing cardiac output. This decreases murmurs due to AS, MR, PS, but increases the murmur due to HCM FOBT testing does not decrease the mortality from colorectal carcinoma 1 symptom in vaulvar carcinoma: Pruritus
Of the anticonvulsant, VAPROATE has the least effect on hepatic enzymes and therefore has the least impact on decreasing the efficacy of OCP's Gilbert's syndrome: lower levels of unconjugated bilirubin cf. Crigler Najjar (6-45 mg/dL) Menopause: Serum FSH increased Estradiol decreases, and Estone becomes predominant estrogen. Infiltration of local anesthetic agents (less pain): Œwarm solution Œsmall needles Œslow infiltration Œaddition of bicarbonate to the mixure Mg-containing antacids in CRF: can cause magnesium toxicity Postherpetic neuralgia: higher incidence in older pts. ANA titre < 1:160 is common in healthy older people Orthostatic hypotension: Drop in Systolic > 20 mmHg Drop in Diastolic > 10 mmHg Mx: discontinue any drugs that might be responsible -> arise slowly -> elastic stockings -> Fludrocortisone B pertussis is being recognized as a cause of persistent cough in adults. (associated with dysnea, tingling sensation in throat) d/o/c for Giardiasis in children: Furazolidone. Aster's Notes 77 of 111 -------------------------------------------------------------------------------- Tinea capitis: Oral Griseofulvin poor response to topical medication Males with impotence, decreased libido & decreased testosterone: order a prolactin level (r/o pituitary adenoma) Pre-term infants: normal response to immunization (although they have relative immunodeficiency) Drug indiced LE: anti-histone antibodies [ANA (+), Anti-dsDNA absent] Œhydralazine, isoniazid, procainamide, penicillamine ŒMx: discontinue medication + short-course of glucocorticoids Œdisease lasts < 6 months ŒANA may remain (+) Œmost lupus inducing drugs can be safely used in SLE, if no alternative exists HCM: sudden death in athletes Dx: Echo Rx: â-BLOCKERS Valsalva maneuver increases murmur ITP: low platelet, BM aspiration shows numerous megakaryocytes Risk of suicide: Female Physicians > general females Physicians' risk of suicide Psychiatrists > Ophthalmologist > Anesthesiologist Anaphylaxis: Epinephrine Juvenile Rheumatoid Arthritis: very few patients are left with disabilty / deformity. At least 50% remit fully and majority regain normal function Urticaria > 48 h : Skin Biopsy to r/o Urticarial Vasculitis Mobitz Type II Heart Block: Mx is PACEMAKER. Aster's Notes 78 of 111 -------------------------------------------------------------------------------- Stage IA Hodgkin's: Radiotherapy alone is effective Total Hip replaement: Œimmediate relief Œperioperative anticoagulation Œsuccessful (no need for revision in 90%) Œbone resorption is a major concern for long-term stability of implant Pressure Ulcers: Stage I: Nonblanching Erythema Stage II: Broken Skin with partial thickness skin loss Stage III: Full tickness skin loss (extension into subcutaneous fat) Stage IV: Extension into Muscle or Bone "kennel cough" is produced by a canine Bordetella Risk factor for domestic abuse: female gender Trochanteric bursitis Œpresents with a deep, dull, aching pain Œburning & tingling in lateral upper thigh Œworse with activity Œexcacerbated by sitting cross-legged with affected leg The mortality rate for pneumococcal pneumonia is same for the past 50 years SKIN SWELLING with Bee sting: local reaction [not anaphylaxis] Rx of Restless Leg Syndrome: Clonazepam Alendronate: Pill-induced esophagitis TCA withdrawl symptoms (cholinergic symptoms) : best managed with Benzotropine (Anti-Ach) Aspartame is c.i. in children with PKU. Aster's Notes 79 of 111 -------------------------------------------------------------------------------- Diaphragm & spermicidal jelly: insert upto 2 hrs before intercourse and leave in place for 6 hrs after intercourse (for repeated intercourse, re-apply jelly) Asthmatics who require â2-agonists > once/day; can be prescribed inhaled glucocorticoids Psoriasis in infancy: begins n diaper area (the area of greatest trauma) Labia minora adhesions: Œnot present @ birth Œacquired condition Œno urinary retention Œnot assoc. with other anomalies Œsurgical correction has a 100% recurrence rate Œestrogen cream can lyse the adhesions Carbidopa/Levodopa do not alter the progression of Parkinson's disease Chronic Choleystitis with Cholelithiasis is frequently non-visualized on ultrasound. Umbilical hernia in a child < 6m Mx: Conservative [Strapping is ineffective] (usually disappear by 1 year of age) Surgery for strangulated hernia; persisting beyond 4y Increased Postop Cardiac Death ŒS3 Gallop Œh/o MI in the past 6 months ŒFrequent PVCs ŒAortic Stenosis Supression of lactation: breast inder & cold pack [Bromocriptine is not approved for this purpose] Cardiac Pacemaker: does not warrant IE prophylaxis Pubertal development in an adolescent girl: Thelarche, Pubic Hair, Growth spurt, Menarche (Growth spurt precedes Menarche). Aster's Notes 80 of 111 -------------------------------------------------------------------------------- Most sensitive and specific means of diagnosing appendicitis is history and physical exam. (not CT or U/S) In stroke, overzealous antihypertensive medications can reduce cerebral perfusion and increase tissue damage. Scabies in young children: Permethrin [Lindane not approved] Wheezing in children may also be due to GERD A single sexual encounter with a person with genital warts carries a 60% chance of transmission. Transmission occurs in asymptomatic state too. Hydrocephalic children: Œincreased developmental disabilities Œlower IQ Œlearning deficits Œdefective verbal abilities Œmemory and visual problems Chlamydial infections: Azithromycine & Doxycycline have equal efficacy 1 cause of hematemesis in healthy newborn:
comiting of swallowed maternal blood Clinical privileges to physicians are granted by the GOVERNING BODY of the hospital New onset LBBB may be an indication for thrombolysis even in the absence of characteristic ST elevation of MI Dexfenfluramine: 1º Pulmonary Hypertension Transdermal NTG Patches: Rapid Tolerance Oropharyngeal dysphagia in elderly: ? early Parkinson's ====[[Aster's Notest's disease of bone: ŒHead Enlargement. Aster's Notes 81 of 111 -------------------------------------------------------------------------------- ŒDeafness ŒNerve compression Œincreased urinary hydroxyproline Œincreased alkaline phosphatase HIDA scan: Cholecystitis (+) Œnonvisualization of the GB Œvisualization of CBD & Bowel Leading cause fo mental retardation in US: Fetal Alcohol Syndrome Rotavirus G/E: decreased incidence in breast fed infants. None of the antibodies that develop after the first attack are protective Grade 1 Vesico ureteral reflux: prophylactic antibiotics and double voiding of urine Sodium Nitroprusside infusion: may increase Thiocyanate levels to toxic range (delirium, tinnitus, blurred vision) Allergic bronchopulmonary aspergillosis is treated by corticosteroids (not ANTIFUNGALS) Childhood autism: Echolalia, minimal eye contact, repetitive behavior serum digoxin levels elevation can be seen in pts. treated with oral verapamil Recurrent Zoster is rare Cocaine > Coronary Spasm (free basing can lead to loss of eyebrows/eyelashes) Measles vaccine significantly reduces the chances of developing SSPE Influenza A is usually sensitive to Amantidine (resistance occasionally seen in institutionalized pts.) Synovial Fluid in OA : High Viscosity Children with diarrhea who are not dehydrated should be give age appropriate diet. Aster's Notes 82 of 111 -------------------------------------------------------------------------------- Loperamide: contra-indicated in children Secondary Amenorrhea: give Progestin Challenge Rapidly Progressive Periodonitis (with good dental hygiene) might be suggestive of HIV / AIDS Hyperosmolar nonketotic coma: Œrequire less insuin for correction (cf. DKA) ŒFluid deficit is larger (cf. DKA) (10 L) Œpatients are older Œcan also occur in Type 1 DM The hypochondriac believes that his fears about disease are totally realistic. He also believes that physicians are not acting in his best interests by disputing the reality of these fears. Hypochondriacs: poor response to antidepressants Old age: Vital Capacity decreases Functional Residual Capacity increases Arterial Oxygen Tension slowly declines with age Pasturella multocida: Rx Amox-Clav (Pn allergy: Doxycycline) [NOT ERYTHROMYCIN] Place PPD on all individuals being admitted to a nursing home. Persons with doubtful reactions should be tested a second time within 1-2 weeks (boosted reaction). This second reading should be taken as the baseline reading for that person. Tennis Elbow : Lateral Epicondylitis (usually acquired occupationally) Obesity lowers aminoglycoside volume of distribution necessitating decrease in dosage Primary indication of joint replacement in OA: Severe Pain. Aster's Notes 83 of 111 -------------------------------------------------------------------------------- Postcoital test : best done in midcycle Adhesive bands are now the most common cause of intestinal obstruction for all age groups (strangulated hernias are the m/c cause in children) Rx for ANUG (acute necrotizing ulcerative gingivitis) PENICILLIN Vasoldilators of choice for CHF ACEIs Use of TCAs in patients with glaucoma can precipitate acute angle-closure attacks (ant-cholinergic properties) The only absolute contra-indication to breast feeding is GALACTOSEMIA Major abdominal trauma in 3 rd trimester pregnancy: evaluate for placental abruption & preterm labor [electronic fetal monitoring: obtain reactive NST] Transient cortical blindness due to mild head traums usually recovers (benign outcome) Pneumococcal vaccine: not before 2 years of age 1 cause of microscopic hematuria in elderly is BPH
Polychlorinated Biphenyls: skin rash called Chloracne Ludwig's angina: infection of the deep fascial space of the submandibular space (early airway compromise) Mx: Intravenous steroid cover Wilson's disease confirmed by inability to incorp. a copper isotope into Ceruloplasmin Patients with procaine allergy usually tolerate Lidocaine (amide group) well Always inject insulin in skin of non-exercized areas (to prevent exercize-induced hypoglycemia). If the lefg is used as injection site, insulin absorption will be enhanced with running leading to hypoglycemia.. Aster's Notes 84 of 111 -------------------------------------------------------------------------------- Celecoxib: not to be used in patients with SULFA allergy Passengers with stable medical conditions requiring low-flow oxygen cannot bring their own oxygen on aircrafts according to Federal Air Regulations concerning hazardous cargo. Most air carriers will provide O2 for a fee Do not fly within 3 weeks of a MI No air travel with term pregnancy OCD ŒSSRI ŒResponse prevention & in vitro exposure Don't give OPV to a child whose sibling is immunodeficient Post MI Risk Stratification is done with an Exercize Stress Test (for patients who can exercize). For patients who can not exercize, a Pharmacological stress testing or Dobutamie Echo is indicated (both are less sensitive than Exercize Stress Testing) Continue ASPIRIN in the post-MI period Antiplatelet agent Post-stent placement: Clopidogrel (ADP receptor inhibitor) Abciximab (anti-IIb/IIIa) (decrease restenosis rates) The choice of agents in asthma therapy is determined by frequency of asthma symptoms The presentation & management of acute cholecystitis in pregnant patients is the same as in non-pregnant population (Lap Cholecystectomy). Fetal otcome is the best in 2 nd trimester Hyperactive children: hypoperfusion in frontal lobes NPH: order CT scan head to r/o ICSOL (confirm NPH by documentation of improvement in symptoms with serial lumber punctures) Severe pre-eclampsia:. Aster's Notes 85 of 111 -------------------------------------------------------------------------------- Œdelivery @ term ŒMgSO4 for seizure prophylaxis Œantihypertensives for BP control ŒMgSO4 is not an antihypertensive. ŒControl of BP alone does not obviate the need for seizure prophylaxis Suspected PCP in AIDS: Obtain a Chest X-Ray Migraine prophylaxis: â-blockers Migraine treatment: Sumatriptan Somatization disorders: 1 st step in Mx avoid un-necessary Ix & medical/surgical treatment Community acquired pneumonia: S pneumoniae Rx: Macrolide (Clarithromycin) Patient presents to the office with unstable angina: 1 st step: Chew & Swallow Aspirin Vaginal douching > 3-4 times / month: associated with alteration of vaginal flora and increased incidence of PID Prolonged survival in CHF: ACEI's A fecal gram stain is always positive for bacteria and is not indicative of any pathology. Inflammatory Bowel Disease: Fecal Leukocytes(+) Gold standard for Dx of IBD: COLONOSCOPY Critical Aortic Stenosis: Valve Repair Surgery (Valvuloplasty in high risk due to other co-morbidity) Spinal metastasis: Emergent Radiotherapy COPD patient who still smokes: 1 step is smoking cessation
(immediate effect on declining lung function) COPD patients should receive annual influenza vaccine (not HiB vaccine, it is only given to children). Aster's Notes 86 of 111 -------------------------------------------------------------------------------- Dx of Adenomyosis: MRI (most accurate) (U/S has lower sensitivity and specificity) Abnormal Vaginal Bleeding: Periodic, abnormal flow: Anatomic cause Irregularly Irregular: Endocrine cause Routine screening of asymptomatic population for dyslipidemia: NONFASTING SPOT CHOLESTEROL Screening of population with CAD/risk factors: FASTING LIPID PROFILE (non fasting random spot cholesterol not indicated) Patient must have quite smoking 15 years ago for it to not count as a risk factor for CAD Digoxin with or without a nodal blocking agent (beta-blocker) is effective in achieving rate control in Atrial Fibrillation Chronic A.Fib.: associated with enlarged Left atrium Medical emergency in a physician's office: 1 st step is to initiate call to “911” beta-blockers improve outcome in patients at cardiac risk undergoing non-cardiaovascular surgery Mx of HTN in patients with migraine: â-blockers Renal Failure: is associated with calcium wasting & secondary hyperparathyroidism (Calcium supplementation is beneficial) Patient with syphilis & penicillin allergy: Do a penicillin skin test to confirm & perform desensitization if necessary uncomplicated UTI: Œperform urinalysis ŒOral TMP-SMX (3 days) Œno need for urine cultures. Aster's Notes 87 of 111 -------------------------------------------------------------------------------- The occurrence of PVCs post-MI is associated with increased mortality & morbidity. Treatment of asymptomatic PVC's with anti-arrhythmics is not indicated. (Such treatment is itself associated with increased mortality) No role of prophylactic anti-arrhythmics post-MI Initiate Calcium supplementation even in cases of prolonged secondary amenorrhea Exercize-induced amenorrhea Œlow adipose tissue Œestrogen biosynthesis shifts to 2-hydroxylation with increased synthesis of catechol estrogens Œcatechol estrogens compete with catecholamines for COMT Œresults in inreased dopamine Œdopamine decreases GnRH release Œresults in secondary amenorrhea Œwhatever the age, OCPs (for HRT) & calcium supplementation are required to prevent bone loss Mx of psychotic depression: ECT Post-void urinary volume estimation: Straight Urinary Catheterization (U/S is inaccurate in estimating bladder volumes) All GDM patients should be tested @ 6w post-partum with 2-hr (75g Glucose) Oral GTT GDM is a risk for DM unrelated to pregnancy (regardless of glycemic control in GDM) Klebsiella penumonia Œnecrotizing pnemonia Œhospitalized patients / aspiration / post-stroke & alcoholics Œcurrant-jelly sputum (bloody) Staph aureus: causes cavitatory pneumonia (associated with rapidly progressive effusions & empyema) Colon Cancer screening: ŒFOBT annually ŒColonoscopy q10y. Aster's Notes 88 of 111 -------------------------------------------------------------------------------- ŒSigmoidoscopy q5y PSA estimation is not recommended for Prostatic cancer screening (if at all one test has to be done, it should be Digital Rectal Examination) Chronic Uterine prolapse: Œfirst fit a pessary Œprescribe estrogen cream Œlater proceed to surgery (surgical failure rate is high when performed in the presence of dry atrophic mucosa) In any patient with pain of cardiac origin: EKG (to differentiate between Ischemia & Infarction) Inhaled corticosteroids: long-term stabilization of severe asthma (beta-agonists provide only symptomatic relief) Hypotensive response to NTG drip in patients with inferior ischemia: Right Ventricular Failure (Mx: Stop NTG, Start I/V crystalloids) suspected anemia: 1 st Ix – CBC suspected Fe deficiency anemia: Serum Ferritin levels Normocytic anemia: 1 st Ix – Reticulocyte count h/o GI bleeds with DVT: not a candidate for anticoagulation Alcohol induced dilated cardiomyopathy: 1 step – stop alchol intake to halt progression
Polycythemia vera: increased risk of stroke Valsalva maneuvre: decreases pre-load Jedrassik maneuvre: decreases after-load Valsalva decreases HCM murmur, Jedrassik increases HCM murmur Ankle – Brachial Index: < 0.5 suggests severe ischemia (surgical revascularization required). Aster's Notes 89 of 111 -------------------------------------------------------------------------------- MVP without MR: no IE prophylaxis required [absence of MR to be documented by Echo] Pilonidal Cyst: infection of hair follicles in sacrococcygeal area. Mx: removal of hair / I&D Elderly with Knee “locking”: Medial Meniscal Tear “pop” in he knee: ACL tear pain in lateral knee, athlete: Iliotibial Band Syndrome COPD @ any stage, smoking cessation in beneficial Painless Testicular Enlargement Œ? Malignancy [Embryonal/Seminoma/Lymphoma] ŒUltrasound, no Biopsy Œspreads to retroperitoneal nodes, if inguinal nodes (+), suspect scrotal invasion ŒSx: Inguinal approach, not Scrotal (Orchiectomy) Evaluation of lung malignancy: CECT (IV contrast) Dermatomyositis: search for occult malignancy Most testicular varicoceles are on the left side Neomycine allergy: 5% of population (Treat with Steroids). It is a Type IV hypersensitivity reaction SCC Lip Risk factor: Smoking > Sunlight exposure Hydrocele: typically idiopathic (No Rx required). Persistent hydrocele: Refer to Urology for Sx Tuberous Sclerosis: Skull X-Ray to look for intracranial calcifications AFP increase: NSGCT b-hCG increase: Seminoma & NSGCT Li-induced hypothyroidism: Mx – levothyroxine (not discontinuation of Lithium) Latest recommendation advise Influenza vaccination for >50y instead of >65y. Aster's Notes 90 of 111 -------------------------------------------------------------------------------- suspected Pseudotumor cerebri: LP (inc. CSF pressure) complex partial seizure: aura, behavioral arrest, automatisms Myesthenia gravis: CT Chest to r/o Thymoma Propranolol is associated with depression Fluoxetine takes 6-8 weeks to act ! Asplenia: PneumoVax / HiB / Influenza vaccine Headache excacerbated by position & exertion: increased ICT (? mass lesion) Mitral Regurgitation 1.Transthoracic Echocardiography 2.If quantification reqd.: TEE 3.Gold Standard for any valvular disease: Cardiac Catheterization Suspected Anemia: next step – CBC MICROCYTIC ANEMIA, to Dx Fe.-def anemia: SERUM FERRITIN (Gold. Std.: Bone Marrow Bx) NORMOCYTIC ANEMIA, next step: RETICULOCYTE COUNT GI side effects are common with oral FeSO4. They are not an indication for discontinuing therapy. Always assess response (% Retics) after Iron Therapy. OCPs can prevent anemia, they do not treat established Iron deficiency anemia. (Rx: Iron) ABI < 0.5: s/o significant PVD (Sx revascularization) Steroid Rx in suspected GCA: start without waiting for ESR / Temporal Artery Bx results Excessive Cow's Milk Intake: Fe. Def. Anemia Pericarditis: Diffuse ST elevation.
Cont. in part III
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