ABRUPTIO PLACENTA- 4 vaginal bleeding, ABDOMINAL PAIN, and uterine tenderness and the absence of hemorrhage. DOES NOT rule out this Dx DDx: Placenta Previa, absence of bleeding RULES OUT PP. ****Risk factors: 1-HTN and PRE-ECLAMPSIA, 2-Placental abruption in previous pregnancy, 3-trauma, 4-short umbilical cord, 6-COCAINE abuse. AP MCC of DIC in pregnancy, which results from a release of activated thromboplastin from the decidual hematoma in to maternal circulation. ****Risk Factors: Smoking and Folate def. It can progress rapidly so careful monitoring is mandatory. Once dx is made, large-bore IV and Foley catheter. Pts with AP in LABOR -- managed aggressively to insure rapid vaginal delivery, this will remove the inciting cause of DIC and hemorrhage. ***If stable: Tocolysis with MgSO4 is considered, but remember Ritordin is C/I in pt with HTN. *** Once we dx the next step: Vaginal delivery with augmentation of labor if necessary. Now if mother and baby are not stable or if there is C/I à EMERGENT C-SECTION. If there is Dystocia (narrowing birth passage) then Forceps can be used.

ABCD of HOMEOSTASIS 1-AIRWAY: An airway is needed for all unconscious pts *** ER = OROTRACHIAL INTUBATION (Best method) *** In the field = NEEDLE CRICOTHYOIDECTOMY *** Conscious pt = CHIN LIFT w/FACE MASK 2-BREATHING: Cervical spine injury should be analyzed but 1st step is to establish ABC. 3-CIRCULATION: Needs control of bleeding and restoring the BP. ***Most External Injuries -- PRESSURE is enough to stop bleeding ***Scalp Laceration -- SUTURING is needed. All pts with HYPOTENSION receives rapid infusion of isotonic fluid (e.g. RINGERS LACTATE) to prevent life-threatening hypotension. If IV line is not good for ADULTS do saphaneous vein cut down and CHILDREN -- intraosseous membrane cannulation.

ABSENCE SEIZURES - 3 Tx: Ethosuxamide or VALPROATE. Classic EEG: Symmetric 3 MHz spike and wave ***Phenytoin and Carbamazapine are 1st line for primary generalized tonic clonic seizure or partial seizures, both work by blocking Na channels voltage dependent ***Phenytoin is a 2nd line for myoclonic and tonic clonic seizure, FORMS: IV and oral SE: Gingival hypertrophy, lymphadenopathy, hirsutism and rash, Both Phenytoin & Carbamazepine can cause Steven-Johnson and Toxic Epidermal Necrolysis.

ACARBOSE SE Blocks carbohydrate breakdown in the intestinal tract. Most significant SE: GI disturbance d/t increased undigested CHO in the stool.

ACE INHIBITORS SE Resp, 6/2 CAPTOPRIL (Cough, Angioedema, Pregnancy, Taste change, hypOtension, Proteinuria, Rash, Increase renin, Lower AII) and HyperK. Cough is caused by accumulation of Kinins possibly by activation of arachadonic acid PW. Kinins are degraded by ACE, when there is no ACE they increase. *****Angioedema that is seen in ER. Pt presents with non-inflammatory subcutaneous edema and laryngeal edema due to bradykinin stimulation.

ACETAMINOPHEN TOXICITY - 2 ***Acute alcoholic intake: Can reduce the risk of hepatic injury by Acetaminophen b/c it competes w/CYP2E1, so there is less production of toxic metabolites. ***Chronic alcohol intake increases risk of hepatic injury by stimulating P450 system and decreasing the amount of Glutathione (used for metabolism of acetaminophen). Management: 1) 4-hr post ingestion Acetaminophen levels are determined to decide whether the pt will benefit from NAC or not. 2) If ingested >7.5 g and levels will not be available w/in 8 hrs of ingestion, the antidote should be given

ACETAZOLAMIDE TOXICITY Causes normal anion gap metabolic acidosis due to renal loss of bicarbonate. Anion Gap is 140-(114+116) =10 which is normal anionic gap metabolic acidosis.

ACHALASIA - 3 Dx 1-Barium studies 2- Esophagoscopy 3-Manometry. **CONFIRMATION is Manometry; also need to do Endoscopy to rule out malignancy.

ACL INJURY It prevents gliding of tibia under femur. Injury is seen after Hyperextension. A popping sensation is felt at time of injury. Commonly assoc w/ Medial Meniscus and Medial Collateral Ligament (TRIAD). Lachman test --- for ACL tear. Flex and pull tibia. Drawer sign also tests ACL but it’s less sensitive. Posterior Drawer sign tests PCL. McMurry's sign tests Meniscus injury. Valgus test is for MCL.

ACNE - 2 1-Comedones (black/white heads): minimal inflammation and tx is topical retinoids. If reactivation occurs add topical Erythromycin or Benzoyl peroxide 2-Papular and inflammatory: w/ moderate-severe inflammation: Oral Doxycycline. 3-Nodular or scaring: Oral Isotretinoin.

ACROMEGALY

ACTINOMYCOSIS Cervicofacial actinomycosis presents as slowly progressing, non-tender, indurated mass, which evolves into multiple abscesses, fistula, and draining sinus tracts with sulfur granules, which appear yellow. Actinomyces israelii is the agent Tx: High dose IV penicillin x 6-12 weeks. Surgical debridement after penicillin therapy.

ACUTE ADRENAL INSUFFICIENCY Acute onset of nausea, vomiting, abd pain and hypoglycemia and hypotension after a stressful event (surgery) in a pt is steroid dependant is typical. ***CLUE: Pre-Operative steroid use. Exogenous steroids depress pit-adrenal axis and a stressful situation can precipitate AAI. DDx: Insulin-induced hypoglycemia r/o b/c doesn’t cause N and V, abdominal pain and hypotension.

ACUTE ALKALI INGESTION When a pt takes Lye (alkali substance for suicide), UPPER GI CONTRAST STUDIES--ASAP to assess the damage and possible perforation of esophagus. Normal XR doesn’t R/O a perforation. Once you know there is no perforation then do DIAGNOSTIC PERONEAL LAVAGE if necessary. But 1st rule out perforation.

ACUTE APPENDICITIS - 3 Pt who comes to hospital after 5 days of initial symptoms must be hospitalized w/IV hydration and IV CEFOTETAN. If there is abscess w/CTà PERCUTANEOUS DRAINAGE is an option ****Most pelvic abscesses are due to perforation of AA. Pt might have a 24 hr RUQ pain that resolves spontaneously and then in a few days he may come with anal abscess symptoms. Tx of choice: Drainage of the abscess **** When resection of part of ascending colon is required (e.g. right hemicolectomy w/ileo-transverse anastomosis has best postoperative results); and that is when pt has shown gangrenous rupture of appendix with questionable necrotized colon.

ACUTE BACTERIAL PROCTATITIS MCC in young is Chlamydia and Gonococcus, in elderly = E. Coli. Dx: Culture of mid-stream urine sample & start empiric therapy. Prostate massage is C/I due to septicemia chance.

ACUTE GI BLEEDING There are 3 causes: 1-Diverticulosis (Painless. can be r/o with Barium Enema), 2-Angiodysplasia (Painless. maybe seen as cherry-red spots that maybe coagulated, Dx: Labeled erythrocyte scintigraphy). 3-PUD (Painful) Dx: Endoscopy, if there is Hematochezia, bright red blood, d/t lower GI bleed, no need for endoscopy, the blood is from lower UGI bleeding).

ACUTE RENAL TRANSPLANT REJECTION Renal transplant rejection in the early post-op stage can be explained by urethral obstruction, acute rejection, Cyclosporine toxicity, vascular obstruction and ATN. To determine the cause do U/S, MRI and Bx. If Bx shows infiltration of lymphocytes & vascular swelling and increased CR and BUN and oliguria, then the cause is Acute Rejection. Tx: High dose IV steroids.

ACUTE TUBULAR NECROSIS Prolonged hypotention due to any reason (Hypovolemic shock) can lead to ATN. Hallmark on U/A is Muddy brown granular cast. DDx1: RBC cast, GN DDx2: WBC cast, Interstitial Nephritis & Pyelonephritis DDx3: Fatty cast, NephrOtic Syndrome DDx4: Broad and Waxy cast: Chronic renal failure

ACYCLOVIR TOXICITY Can cause crystalluria with renal tubular obstruction during high dose parenteral therapy, especially in inadequately hydrated pts.

ADDISON’S DISEASE - 2 MM-101. Aldosterone deficiency: non-anion gap hyperK+, hypoNa+, metabolic acidosis. ***80% of pt have primary adrenal deficiency due to Autoimmune adrenalitis. These pts also present with autoimmune involvement of other glands as well, like thyroid, parathyroid, ovaries. *** 70% of Causes of Primary Adrenal Insufficiency is autoimmune, mostly in developed countries. In underdeveloped countries MCC: TB, Fungal infection and CMV infection. Adrenal Calcification is a typical feature of TB PAI. Presents w/NO RISE IN SERUM CORTISOL AFTER COSYNTROPIN (ACTH analog); CT shows calcification of adrenal glands. Tx of TB does not result in normalization of adrenal gland. PAI in HIV is common, MCC is CMV. Sometimes Ketoconazole can cause it. PAI is very rare with adrenal tumor metastasis; even then calcification is not seen.

ADENOMYOSIS Presence of endometrial glands in uterine muscle. MF in women > 49, presents w/severe dysmenorrhea, and menorrhagia. The typical exam reveals enlarged symmetrical uterus. If Adenomyosis is in one side of uterus then enlargement is ASSYMMETRICAL & SOFTER consistency DDx: Myomatous Uterus, Leomyoma, Endometrial carcinoma. Women age> 35, MANDATORY to perform Endometrial curettage or even hysterectomy to rule out endometrial cancer. DDx1: Endometriosis: a benign condition, where foci of endometrial glands are found OUTSIDE of endometrium. They increase in size throughout menstrual cycle. Assoc w/Adenomyosis occurs in 15% of cases. DDx2: Leomyomas: are difficult to distinguish from Adenomyosis, except consistency of Uterus is softer in Adenomyosis. DDx3: Endometrial Carcinoma : occurs in women after menopause. DDx4: Endometritis: fever, and enlarged and tender uterus, assoc with vaginal discharge. It usually occurs after a septic abortion, and the MCC is Strep.

ADHD Short attention span, impulsivity, hyperactivity >6mo. Tx: Methylphenidate or Pimoline, SE: Decreased appetite

ADJUSTMENT DISORDER: - 2 Emotional or behavioral symptoms that develop w/in 3 months of exposure to an identifiable stressor and rarely lasts more than 6 months after the stressor. Tx choice is Cognitive or Psychotherapy, not drugs. DDx: GAD where pt worries about many things, AD pt worries about 1 thing. DDx PTSD pt re-lives the trauma that she experienced, nightmare, flashbacks >1 month. DDx: Acute Stress Disorder is PTSD but FOR <1 month

ADRENAL INSUFFICIENCY, SECONDARY Caused by Pituitary tumor = Hypothalamus-Pit failure. Glucocorticoid deficiency (weakness, fatigue, depression, irritability, hypotension, lymphocytosis, eosinophilia), and Hypothyroidism (cold intolerance, constipation, dry skin), while Normal K+ level indicated Aldosterone production is not impaired, and absence of Hyperpigmentation (characteristic of Primary Adrenal Insuff), all suggest 2ary adrenal insufficiency. Other causes of Primary adrenal insufficiency: Autoimmune destruction, adrenal CMV, adrenal TB and adrenoleukodystrophy.

ADRENAL INSUFFICIENCY, ACUTE Pt presents with N & V, abdomen pain, hypoglycemia and hypotension. Pre- operative steroid use is the main cause.

ADRENAL TUBERCULOSIS Endo, 6/2 Adrenal insufficiency plus adrenal calcifications. It’s the primary cause of Primary Adrenal Insufficiency in developing countries. In autoimmune adrenalitis is the MCC of Primary Adrenal insufficiency in developed countries.

AIRWAY ACCESS An airway is always patent (SECURE) when a pt is conscious and able to speak. **Tachypnea & noisy respiration -- CHIN LIFT & FACE MASK AIRWAY needed in ALL UNCONSIOUS pts. **In the FIELD -- NEEDLE CRICOTHYROIDECTOMY (best option). **ER -- OROTRACHIAL intubation (best option). Nasotracheal is time consuming. **Apneic pts w/head and spine injury -- Surgical CRICOTHYROIDECTOMY.

ALCOHOL WITHDRAWL It might occur after surgery when pt has not had drink for a few days. Presents: Fever, HA, N&V and TREMORS. Tx: Chlordiazepoxide.

ALCOHOLIC GASTRlTIS Epigastic pain, vomiting dark brown blood after alcohol binge, and hx of PUD. BUN > 40 in a presence of normal creatinine = UPPER GI BLEED (highly suggestive), d/t bacterial breakdown of Hb in GIT and the resulting absorption of urea, also seen in administration of steroids (increase BUN w/o Cr). ALCOHOLIC LIVER DISEASE - 2 The 3 major pathological findings of ALD are: 1-Fatty liver (steatosis) the result of short-term alcohol ingestion. Fatty liver exists in 80% of alcoholics but only 15- 20% develop alcoholic hepatitis. 2-Alcoholic Hepatitis: requires long, sustain alcohol use (Mallory bodies, infiltration by neuts, liver cell necrosis, and a perivenular distribution of inflammation). Alcohol Hepatitis and even early fibrosis can be potentially reversible if the pt stops alcohol consumption. Only 50% of pts w/alcoholic hepatitis develop cirrhosis. 3-Alcoholic Fibrosis/Cirrhosis: requires long, sustain alcohol use. ***Females are more susceptible to ALD. Most characteristic manifestation is ALT/AST > 2. ALT & AST are almost always <500, if >500 raises the probability of injury from drugs. Mallory bodies are NEITHER specific NOR required for dx of Alcoholic Hepatitis. ****If (+) Alcoholic Cirrhosis should have Esophagoscopy to prevent varices.

ALL - 2 Presence of more than 25% lymphoblast in BM & Positive PAS makes the Dx. ***1st symptoms: non-specific, fatigue, pallor, fever, anorexia, petechiae and lymphadenopathy. Dx is suggested by THROMBOCYTOPENIA & BLAST CELLS, but confirmed with BM biopsy. DDx1: Hodgkin’s: presents with painless, firm cervical adenopathy, sign and symptoms are similar to ALL but LYMPHOBLASTS make DDx of ALL. DDx2: AML, occurs in adults, main dx is >25% MYELOblasts in BM biopsy. DDx3: Aplastic Anemia: can present like ALL BUT lab shows decrease in ALL cell lines including WBC. DDx4: ITP, children w/ITP present w/sudden onset of bruising, petechiae & occasional Epistaxis. The only cells that are very low are Platelets & their size is LARGE. DDx5: Infectious Mononucleosis: Lymphadenopathy, fever and pharyngitis, due to EBV. ATYPICAL lymphocytes are seen on peripheral blood smear and MONOSPOT test is positive. ***** If parents refusing treatment, obtain court order for chemotherapy. ****Tx meds.

ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS ABPA is characterized by transient recurrent pulmonary infiltrates, peripheral eosinophilia, asthma and immediate wheal and flair rxn to Aspergillosis fumigatus and presence of Abs in serum against AF. Other characteristics: Hx of Brownish plug in the sputum & high IgE levels. Tx: Glucocorticoid If Asthmatic pt is suspected of having ABPA, 1st step in dx – SKIN TESTING w/Aspergillosis Antibodies If negative à ABPA is r/o. If positive serum precipitants against Aspergillosis and IgE levels are checked. ABPA is excluded if IgE is <1000, or if serum precipitants against Aspergillus are absent. DDx1: Job Syndrome: A recurrent bacterial infection and markedly elevated IgE. Infections are due to Staph and are SKIN infections. Neuts exhibit impaired chemotaxis. Other features are eczema, asthma, allergic rhinitis. Tx: Abx DDx2: Wiskott Aldrich: (XR) Triad: eczema, thrombocytopenia, recurrent pyogenic infections. IgA & IgE are high while IgM is low DDx3: Chronic Eosinophilic Pneumonia: is MC eosinophilic pneumonia in US. Pts presents w/ systemic signs: fever, malaise, anorexia, weight loss. Eosinophils >40% is suggestive of this dx. Tx: Glucocorticoid. DDx4: Churg-Strauss: A multi-system vasculitic disorder of unknown etiology that affects skin, kidney, CNS, lungs, GI & heart. There is asthma, fever, marked Eosinophilia. Tx is Glucocorticoid.

ALLERGIC CONJUNCTIVITIS Is an acute hypersensitivity reaction that is caused by environmental exposure to allergens. Intense itching hyperemia, tearing, conjunctiva edema and eyelid edema.

ALLERGIC CONTACT DERMATITIS -3 Caused by Nickel and poison IV. Type VI hypersensitivity reaction. It mostly occurs in adults. DDx1: Atopic Dermatitis presents as pruritic lesions in infants <6mo. Prevention is the mainstay of tx. Everywhere is involved but diaper area spared. Tx: infant warm bath and moisturizers. Acute attack -- low dose corticosteriods.

ALLERGIC INTERSTITIAL NEPHRITIS It’s 2ndary to Nafcillin use. It’s a type IV hypersensivity reaction. Nephrotoxic agents are antibiotics (penicillin, cephalosporin, sulfonamide, rifampin, cipro), thiazides, omeprazole, NSAID. Triad: FEVER, PETECHIAL RASH & PERIPHERAL EOSINOPHILIA in an azotemic (Increased Urea) is highly suggestive. DDx: Acute Tubular Necrosis Mostly seen in ischemic or nephrotoxic renal failure. MUDDY brown casts

ALLERGIC RHINITIS - 2 Dark puffy eyelids is called allergic shiners. The red crease over the nose causes constant rubbing, called allergic salute. Tx is avoidance and decongestants. ****If cause of rhinitis is not clear allergic or infectious, then next step is Nasal cytology. Demonstration of neuts in nasal secretions suggests infectious cause. Predominant of Eosinophils suggest allergic cause. Other cause of nasal eosinophilia include Nasal Polyposis (ASA sensitivity)

ALLERGY, DRUG Mild reactions à just use antihistamines. Systemic reactions, like anaphylactic à Adrenalin or Steroids

ALPHA FETO PROTEN MCC of deficiency is gestational age error. HIGH levels à GASTROCHISIS & OMPHALOCELE as well as 'false positive' causes: FETAL DEMISE, MULTIPLE GESTATION, inaccurate gestational age. If increased MSAFP: 1st do U/S to rule out false positive causes and to detect presence of any anomaly. Afterwards, ORDER AMNIOCENTESIS for confirmation by amniotic level AFP and AchE. AchE à increased only in NTD. LOW levels of MSAFP in chromosomal abnormality especially Down's. Screening is more accurate when MSAFP w/ b-hCG and Unconjugated Estradiol (UE3) levels, a.k.a TRIPLE TEST. Decreased MSAFP + Increased b-hCG + Decreased UE3 = Down's. Trisomy 18 = ALL three are decreased. Likewise, U/S has to be performed to r/o inaccurate dates and fetal demise, then amniocentesis to confirm the Dx. MSAFP and Triple Test should performed by 16-18 week of gestation. ****AFP is produced by Yolk sac and fetal liver, some passes to maternal circulation. Other procedures: CVS - indicated in women w/known genetic abnormality or previous affected children. Do between 10- 12 weeks and offers advantage of 1st trimester testing.

ALPHA-1 ANTITRYPSIN DEFICIENCY A protease inhibitor synthesized in liver. Pts w/homozygous deficiency are at risk of Panlobular Emphysema in adult life. The MC manifestation in adults -- Asymptomatic Cirrhosis, and maybe complicated by Hepatocellular Carcinoma. Hepatocytes contain granules that are PAS positive and Diastase resistant. DDx1: Whipple's: PAS positive but doesn’t cause cirrhosis.

ALPORT SYNDROME Recurrent episodes of Hematuria, sensorineural deafness & family hx of renal dz. Bx: Alternating areas of thinned & thickened capillary loops w/splitting of GBM.

ALPRAZOLAM Abrupt cessation is assoc w/significant withdrawal symptoms like generalized seizure & confusion.

ALS - 2 Tx is Riluzole (glutamate inhibitor. SE: Dizziness, nausea, weight loss, elevated liver enzymes and skeletal weakness) Both UMN (spasticity, bulbar symptoms, hyperreflexia) & LMN (Fasciculation) damage. Muscle wasting of all body muscles.

ALTERED MENTAL STATUS in ELDERLY Major causes: 1-Hypo/Hyper Na+. 2-Hypo/HyperCa++. 3-HypoMg+. 4- Hypophosphatemia, 5-Hypoglycemia. 6-Stroke. 7-cardiac events. 8- Infections.

ALTRUISM Altruism is minimizing internal fears by helping others who have same problem (Alcoholic volunteering in AA). DDx: Sublimation: Turning unacceptable behavior to more acceptable ones.

ALZHEIMER’S DZ - 4 Diffuse cortical atrophy. Tx is Donezapin, Tacrine, rivastigmine, galantamine. **** Elderly gradual memory decline with Apraxia (Losing the ability to do routine acts), Aphasia and Agnosia (not recognizing familiar objects). *****DDx it from Picks by MMSE, which is decreased in AD. In Pick’s; need to see more than just one indication of behavior changes (urinating is not enough). AMAUROSIS FUGAX Visual loss that is MONOCULOAR & TRANSIENT (15 mins) "dropping of the curtain". Opthalmoscopy reveals zones of WHITENENED, EDEMATOUS RETINA, which follows retinal artery distribution. Seen in pt with arteriosclerosis and CV disease. Caused by retinal emboli from ipsilateral carotid artery. Tx of arteriosclerosis is important to reduce the risk of stroke. Dx: Duplex of the carotid.

AMEBIC (liver) ABSCESS - 2 MC in tropical males. After intestinal infection w/Entameba Histolytica. Transmission by water or food. Dx: LIVER ABSCESS by CT. When aspirated has "Anchovy- paste" appearance. Tx: Metronidazole, oral 1-2 wks ****Hx of travel to endemic areas followed by dysentery and RUQ pain with a single Cyst in right lobe of liver is indicative of ALA. Primary infection is in the colon, but then goes to portal vein and liver. Dx: STOOL EXAMINATION of TROPHOZOITE SEROLOGY & LIVER IMAGING. Tx is Metronidazole. DDx: Hydatid Cyst: caused by Echinococcus acquired by contact w/dogs

AMENORRHEA - 3 1-Secondary Amenorrhea: 1st step: r/o pregnancy, then hyperprolactinoma, then hypothyroidism. The 2nd step: Determination of pt's estrogen status with progestin challenge test. A- If pt has adequate estrogen & hx intrauterine instrumentation suspect Asherman's syndrome (hysterosalpingogram can show intrauterine adhesions). Pts w/ no such hx are all anovulatory or oligo-ovulatory. 2- If estrogen is inadequate, FSH should be ordered to determine gonadal or central origin. ****Prolactin production is inhibited by Dopamine and stimulated by serotonin and TRH. An increase in TSH and TRH may lead to Hypothyroidism. Hyperprolactinoma may also affect GnRH and gonadotropin secretion therefore results in amenorrhea. Other causes: Dopamine antagonist (antipsychotics, TCA), Hypothalamic & Pituitary Tumors. In the case of Amenorrhea-Hyperprolactinoma, 1st r/o HYPOTHROIDISM by measuring serum TSH. ***2ary Amenorrhea in athletes is due to Estrogen deficiency because menstruation happens because of Estrogen. ******Check out Table in Q41, Exam 12 0r 13.

AMIODARONE TOXICITY- 2 1-Pulmonary Fibrosis, 2-Hepatotox, 3-Corneal deposits, 4-Skin reactions. *** If a pt needs rate control but has Restrictive lung disease Amiodarone is C/I.

AMLODIPINE SE

AMPHETAMINE INTOXICATION Pt might act like schizo but HTN is not normal. Cocaine is the same as Amphetamine. DDx: Manic episode that has the mnemonic DIGFAST (Distractibility, Insomnia, Grandiosity, Flight of idea, Activity increase, Speech talkative, Thoughtlessness risky actions) Heroin Toxicity : Triad: ALTERED CONSCIOUSNESS, RESPERATORY DEPRESSION & PINPOINT PUPILS. Heroin Withdrawal: MUSCLE & JOINT PAIN N/V/D, ABD CRAMPS, RHINORRHEA, LACRIMATION, SWEATING. Amphetamine Withdrawl: Depression, increased appetite, fatigue, irritability.

AMPHOTERICIN TOXICITY HypoK+

AMYLOIDOSIS In heart is the end stage and next step is Transplantation.

ANAL FISSURE MCC: Passage of hard, large constipated stool. MC symptoms: SEVERE PAIN & BRIGHT RED RECTAL BLEEDING during defecation. Tx: Both acute and chronic fissures starts with dietary modification (high fiber diet and lots of fluids) w/stool softener and local anesthetics

ANALGESIC NEPHROPATHY - 2 Clinical scenario describes a woman with chronic HA (almost everyday), who presents with Hematuria. Several years of abuse leads to chronic tubointerstitial damage. Hematuria is due to Papillary Necrosis **** MCC form of drug-induced chronic renal failure. MC in females. Papillary Necrosis and Tubulointerestitial nephritis are the MC pathologies seen. Early Manifestations Polyuria and sterile Pyuria w/ WBC casts. In advanced cases you see Proteinuria and hematuria.

ANAPHYLACTIC SHOCK Bee Sting >After 1 HOUR in ER; 1st give: SC EPI, not removing the sting. If after 1 min then 1st remove the sting.

ANEMIA of PREMATURITY MC anemia in premature and LBW infants. Pathology: Diminished RBC production, shortened RBC life span & blood loss. Iron supplementation doesn’t help falling Hb levels and iron deficiency is not the cause of prematurity.

ANEURYSMS Causes are: 1-TRAUMA: Aneurysms in a young pt presents w/Descending Aortic aneurysm. Pathophy: Acceleration Trauma. CXR +/- wide mediastinum, 10% will have normal CXR. So if you suspect it do CT or MRI. Tx: Surgery to PREVENT RUPTURE. 2-ATHEROSCLEROSIS: MCC of Descending Aorta aneurysm. Pts = OLDER, SMOKERS. They are generally asymptomatic and are seen on CXR. Majority of pts also have significant CAD. 3-MARFAN: Mnemonic is “m.A.AR.f.A.n”. Pts present with Ascending aneurysm of Aorta. Assoc findings: Aortic Regurgitation Surgery is required to replace both aortic valve and entire ascending aorta. They also have a higher chance of Aortic Dissection than general population. 4-MYCOTIC: result from localized infection, MC in Femoral art. & 2nd MC in Ascending aorta. MCC: S. aureus & 2 MCC Salmonella. 5-SYPHLYTIC: Occur in Ascending Aorta. Presents: fever, chills, splinter hemorrhages. CT is dx.

ANGINA, PRINZMETAL or VARIANT - 2 Classic pic: A pt with absence of risk factors of CAD, night pain waking her up, transient ST elevation, absence of Q waves and negative cardiac enzymes. The dz results from coronary vasospasm of the artery that causes "Transmural Ischemia" and hence ST elevation on EKG. Other things to know is: "Subendocardial ischemia" in Angina pectoris causes ST Depression. "Transmural Infarct" causes ST elevation followed by development of Q waves and increased cardiac enzymes. "Subendocardial infarcts" cause ST Depression that are not followed by Q waves and elevation of cardiac enzymes. Summary: TM-IS=Elevate ST-Q-Enz. TM- IN=Elevate ST+Q+Enz. SE-IS=Suppressed ST-Q-Enz. and SE-IN=Suppressed ST+Q+Enz. *** Propranalol and ASA are C/I in these pts. Initial Tx: Nitrates and CCB 2nd drug is only added when there is no response to the 1st drug. DOC Diltiazam.

ANGINA, STABLE - 4 EKG stress test (INITIAL TEST to dx). RBBB is not C/I. C/I: LBBB, WPW, ST depression >1mm at rest then stress testing with imaging is done. Dobutamine stress test -- pt that can’t exercise sufficiently. If stress test fails à Do Coronary Angiogram. MYOCARDIAL PERFUSION: Those at risk of developing complications w/Exercise or Dobutamine. *****Withheld prior to EKG Exercise test: Anti ischemic meds, Digoxin & BBs, Atenolol (slow the heart). ****In pts w/stable angina HTN, BB (DOC). CCB (Verapamil) is indicated if BBs are C/I or don’t work. Both have BOTH anti HTN & anti-anginal effect. Enalapril à ONLY anti HTN effect. ****Stress EKG or Exercise ECHO àfor risk stratification in pts with stable angina. Pharmacological stress testing is an alternative if pt can’t do exercise. Coronary angiography when refractory to med tx or when exercise test identifies pt as high risk.

ANGINA, UNSTABLE - 2 Sharp chest pain only partially relieved by NTG, T wave inversion, and negative cardiac enzymes. Tx: Unstable angina and NON-Q wave infarct à IV heparin, ASA, BB and NTG is indicated. Thrombolytic tx is assoc with mortality in these pts. Thrombolytic therapy is indicated for STEMI after sublingual Nitro r/o coronary vasospasm & LBBB. ****Give CLOPIDOGREL not Ticlopidine for platelet de aggregation.

ANGIODYSPLASIA or VASCULAR ECTASIA 2nd MCC: Painless GI bleeding are diverticulosis and Angiodysplasia. DDx: Angiodysplasia is assoc w/Aortic Stenosis. Other assoc is renal failure. Also Sigmoidoscopy reveals Diverticulosis and not Angiodysplasia. MERCK: Angiodysplasia: Acquired submucosal AVM, which may cause lower GI bleeding in elderly patients. When the bleeding is massive, it’s usually either angiodysplasia or diverticulosis. Typical angiodysplastic lesions are 0.5 to 1.0 cm, bright red, flat or slightly raised, and covered by very thin epithelium (see Plate 22-3). Treatment is indicated for angiodysplasia that has bled because of its tendency to cause chronic recurrent hemorrhage. Tx: Active, severe bleeding: may be controlled quickly by intra arterial or IV vasopressin when the patient is stabilized, but results are variable; then lesions treat by ENDOSCOPIC COAGULATION or SURGERY. Most difficult aspect of Tx à Eliminate potential causes of GI bleeding & locate all of the angiodysplastic lesions. If the lesions (not large or numerous),à endoscopic coagulation w/ hot biopsy forceps or laser photocoagulation (preferred) Usual surgical tx à RIGHT HEMICOLECTOMY b/c of the propensity of angiodysplasia for the right colon.

ANGIOENDEMA - 2 ACE inhibitors are notorious for producing Angioedema in ER. Pt presents with non- inflammatory edema and laryngeal edema that could be life-threatening. Angioedema occurs due to pro-inflammatory action of substance P is stimulated by Bradykinin. Bradykinin can be broken down by angiotensinogen converting enzyme. When an ACE inhibitor blocks this enzyme, the levels of bradykinin increase leading to angioedema. Tx: Antihistamine

ANGIOFIBROMA - 3 A benign vascular tumor found in adolescent male. Present with frequent epistaxis (Epistaxis is the major symptom), nasal obstruction, HA & conductive hearing loss. PE: grayish-red mass in the posterior nasopharynx. CT is Dx. Tx is medical and surgical, depending on stage. ****Any adolescent boy w/epistaxis and localized mass with bony erosions on the back of the nose has an Angiofibroma unless proven otherwise.

ANION GAP METABOLIC ACIDOSIS - 3 First look @ pH<7.4, then see HCO3<24 then we know its MA. To calculate compensation use Winter's Formula PaCO2 = 1.5 (HCO3) + 8, this is what CO2 would be after compensation. Normal AG is b/w 6-12. MERCK: When metabolic acidosis results from inorganic acids (i.e., hyperchloremic or normal anion gap acidosis), HCO3 is required to treat the acid-base disturbance. However, when acidosis results from organic acid accumulation (i.e. increased anion gap acidosis), e.g. Lactic Acidosis, ketoacidosis, most experts still recommend judicious use of IV sodium bicarbonate in the treatment of severe metabolic acidosis (pH < 7.20)******AG formula is (Na+) - (Cl-+HCO3), normal is 6-12.

ANKLYLOSING SPONDOLYTIS - 3 Assoc with IBD ****Regular exercise is the only tx that halts progression of the disease. Pt is young, presents with insidious onset of back pain for more than 3 months, positive family hx, reduced back motion and chest expansion, also HLA-B27. XR: Scoliosis. NSAID is for pain control. Sulfasalazine is for peripheral joint involvement. Surgery is recommended if severe & refractory to medical tx. ****Dx can’t be made unless there is evidence of sacrolitis. When pt is AS symptoms à Do XR of sacroiliac joint. If XR is inconclusive then àMRI

ANOREXIA NERVOSA - 2 Elevated carotene gives the skin a yellow color. Carotene is also elevated in DM & Hypothyroidism. Pregnant women w/current or previous AN are at risk for Miscarriage, intrauterine growth retardation, hyperemesis gravidarum, premature birth, cesarean delivery, & post-partum depression. Osteoporosis is a common finding in women pregnant or not. Also elevated cholesterol and carotene levels, euthyroid sick syndrome, cardiac arrhythmias (prolonged QT). The FIRST step of MGMT is Hospitalization. ****There Amenorrhea and body weight is below normal. In bulimia weight is normal ****Once the dx is made the first step in management is hospitalization.

ANSERINE BURSITIS Pain over MEDIAL TIBIAL PLATEAU, hx is assoc with trauma and CXR is normal.

ANETERIOR CORD SYNDROME Usually occurs due to MVA injury. PARALYSIS & ANALGESIA below level of injury & preservation: position, touch and vibratory (posterior column). Tx: High-dose Methylprednisone w/in 8 hrs of injury = significant neurological improvement. All trauma pt do 2 things, 1- Immobilize, 2-ABC. *****Assoc w/ burst fracture of the vertebra, characterized by total loss of motor function (Paraplegia) below the lesion, w/ loss of pain and temperature Bilaterally, below the lesion. Best initial test: MRI

ANTI-PSYCHOTIC DRUGS Work by blocking Dopaminergic receptors. Typicals: Haloperidol, Chlorpromazine, Fluphenazine. Atypicals: Clozapine, Risperidone à Add Serotonin, blocks EPS SE. ****Dystonia: an extrapyramidal SE of Haloperidol is treated with Benztropine or Diphenhydramine.

ANTI-D Ig After events that are assoc with maternal-feto hemorrhage (placenta abruption) the failure to correct the dose of Anti D can result in maternal Alloimmunization

ANTI-DEPRESSANTS - 2 Are SSRI, MAO-I, TCA, SSRI causes sexual dysfunction. If it does, discontinue and give Bupropion (inhibits NE and dopamine reuptake), doesn’t cause impotence. Trazodone is good for antidepressant in those with Insomnia, but also causes sex dysfunction. *****In pts with terminal dz, when severely depressed with active suicidal thoughts antidepressant should be given immediately, not lectures about accepting the fact and the feeling being normal

ANTIPHOSPHOLIPID ANTIBODY SYNDROME Recurrent arterial or venous thrombosis or recurrent fetal loses in the presence of Antiphopholipid antibodies. There are 3 types of APLA: 1 st type : Is responsible for false VDRL, 2 nd type : LUPUS and falsely elevates, 3 rd type : Anticardiolipin. Tx: Heparin + ASA

ANTISOCIAL PERSONALITY Is dx in those Age>18 yo who engage in illegal activities and abuse others. They show CONDUCT disorder when they are minors.

AORTIC ANEURYSM MCC is ascending aorta and cause is cystic medial necrosis. Descending aorta is assoc with arteriosclerosis.

AORTIC ANEURYSM, ABDOMINAL -3 After AAA repair (surgery), diarrhea and blood in stool should raise the question of Ischemic Colitis. If CT is inclusive, a sigmoidoscopy/Colonoscopy is recommended. DDx1: Pseudomembraneous Colitis: Due to antibiotics will present with same symptoms but not the ischemic changes in the colon. ***CT shows ruptured aorta and blood around aorta, tx is exploring the abdomen. ***Abd USG (study choice of Dx & follow up). ****When pt presents: pulsatile mass & hypotension, a presumptive dx must be entertained. GO DIRECTLY TO SURGERY (NO USG or CT). *****Spinal cord ischemia with lower spastic paraplegia is a rare complication of AAA. It’s due to loss of blood during the operation. *****When ruptured AA confirmed w/CT, next step à Explore abdomen not Laparoscopy (not used in acute conditions).

AORTIC DISSECTION - 6 HTN and BP difference in two arms. 1ST à Admit to ICU, IV Nitroprusside (reduce BP), BB (Esmolol, reduce HR). Any delay maybe fatal, don’t even give painkiller first; just do the above. 1ST tx is anti-HTN agent, before CT, MRI, TEE or CXR. Intense retrosternal pain that radiated to subscapular area, also check for Aortic regurgitation (decrescendo diastolic murmur in the left sternal border, also HTN Dx TEE. ******The MCC of AD is HTN, if given no info pick this as the cause ****Acute AD is a risk factor in Marfan pts. Tearing pain and radiation to the back and a difference BP of 30 mmHg b/w two arms are important clinical clues. Dx of Choice: TEE or CT

AORTIC REGURGITATION Presents with Water-Hammer or collapsing heart and pistol shot femoral pulses. Occurs d/t hyperdynamic circulation and early diastolic run off of aortic insufficiency. ****Tx: Diuretics + ACE inhibitors + Digoxin (relieve congestive symptoms for LV dysfxn) and then change valve is indicated. Pt must undergo ECHO for dx

AORTIC ANEURYSM RUPTURE Aortic rupture should be r/o in ALL trauma pts w/Severe chest trauma, pulsatile mass and hypotention. Best testà CXR. The signs: 1-widening mediastinum > 8cm, 2-Depression of L main bronchus >140degrees, 3-Deviation of Nasotracheal tube, 4-Fracture of 1st & 2nd rib, sternum, scapula, 5- L apical hematoma. Immediate surgery is very important but do confirmatory CT or Angiogram. BUT REMEMBER if question gives you option b/w Surgery and CT PICK surgery. AORTIC COARCTATION Tx for RECURRENT AC is Balloon Angiography.

AORTIC STENOSIS - 4 Age dependant idiopathic sclero-calcific changes are the mfc of isolated AS in elderly. Pt presents with exertional syncope. PE: increased intensity of PMI, Auscultation reveals ejection-type systolic murmur with radiation to carotid arteries. NOTE: Bacterial endocarditis may lead to Aortic insufficiency not aortic stenosis. ****Presents: Anginal chest pain, dyspnea or syncope (Triad: Syncope, angina, and dyspnea on exertion). Pain is ischemic in origin and occurs due to increased O2 demand 2ary to LV hypertrophy. ECHO (study of choice to Dx). It’s also used in follow ups ****Key to Dx: Harsh systolic murmur over the right sternal edge; know that only left-sided murmurs increase on expiration. S4 results from forceful atrial contraction against the thick non-compliant ventricle. Classic indication for surgery in AS is SAD (Syncope, Angina, Dyspnea). Dyspnea results from CHF. Presentation of either indicates valve replacement surgery. Indications for AV replacement: 1-All Symptomatic pts, 2-Pt with severe AS undergoing CABG. 3-Asymptomatic pt with severe AS either poor LV systolic function, LV hypertrophy > 15mm. ****In ALL SYMPTOMATIC AS pt à IE prophylaxis & repeated regular follow-ups are recommended.

APLASTIC ANEMIA, ACQUIRED Injury to the bone marrow by drugs, radiation, toxins or insecticide. Pediatrics dz: Pallor, fatigue, loss of appetite, easy bruising, petechiae, mucosal hemorrhage and fever. Lab shows: anemia, leukopenia, thrombocytopenia. BM bx is essential for Dx and shows hypocellular BM and fatty infiltration. MERCK: Tx: Equine anti-thymocyte globulin (ATG) has become the tx of choice for older patients or those without a compatible donor. Combined ATG and cyclosporine is also effective. BM transplantation from an identical twin or an HLA- compatible sibling is a proven treatment for severe aplastic anemia, particularly age < 30. DDx1: Fanconi syndrome: familial, pancytpenia, brown pigmentation, cafe au lait, short stature, upper limb abnormality, skeletal abnormality, it starts w/ thrombocytopenia then neutropenia and then anemia. DDx2: Diamond-Blackfan Anemia: or congenital RBC aplasia presents in the first 3 months of life w/pallor and poor feeding; WBC & platelet are normal.

APPENDICITIS If a 62 yo on WARFARIN comes in with appendicitis and requires emergent surgery: 1 st step : Reverse the effect of Warfarinà infusion of FFP, not by Vit K infusion (1-2 days for effect), then proceed with the surgery. ****Acute Appendicitis may be complicated by pelvic abscess (lower abdominal pain, malaise, low-grade fever, and tender pelvic mass on rectal exam). Most of pelvic abscesses are due to perforation of appendix. Pt could have had appendicitis that resolved with rupture and abscess formation. The diarrhea is reactive due to irritation. Drainage of the abscess is the tx. ****Experience has shown that right hemicolectomy with ileotransverse anastomosis has best post-op results, when resection of part of ascending colon is required, when there’s appendicitis w/cecum inflammation and pus. *****Complicated Appendicitis: When the pain is ignored for days & pt presents w/high fever & localized RLQ pain. Tx: IV hydration, Antibiotics and bed rest. Non-operative management is curative, CT may reveal abscess that can be drained percutaneously Antibiotics should cover Gram negative and Anaerobes, Cipro+Vancomycin.

ARDS - 4 Could happen 2ndary Acute pancreatitis. Dx: PaO2/FiO2 must be <200 (PaO2=55, Receiving O2 by mask is 60%) in the setting of absence elevation of LA pressure (PCWP<19mmHg). Sepsis is the MCC ARDS. Other causes: Heroin, acute pancreatitis, severe burn and near drowning. ****Goal of mechanical ventilation is to improve oxygenation and is best done with increased PEEP. PEEP keeps the alveoli at end expiration and keeps them open for a longer duration to improve oxygenation. PEEP is the major factor in improving oxygenation in ARDS. **In a pt post-op w/ dyspnea and tachypnea must exclude MI, PE, Pneumonia and ARDS. If presents with CXR: Bilateral fluffy infiltrates & hypoxia with difficulty with oxygenation (most probably ARDS). It’s not Atelectasis so there is NO FEVER.

ARM FRACTURES 1-Colles -- outstretched hands in elderly. 2-Smith – REVERSE of Colles-fall on dorsum (knuckles) 3-Bartion -- intra-articular fx of distal radius. 4- Chauffer's -- fx of radial styloid process in drivers. 5-Galazzi -- isolated fx anywhere a long radius w/assoc injury to the distal radial joint.

ARREST DISORDER - 2 MIDPELVIC CONTRACTION: indicated by PROMINENT ISCHIAL SPINES = an important cause of ARREST DISORDER or DIALATION. DDx: Inlet Dystocia: Descent of the presenting part at +1 indicates that fetus is engaged, so ID is unlikely. ****ARREST IN DILATION> 2 hrs, & ARREST IN DESCENT >1hour (definition). Can be caused by: HYPOTONIC CONTRACTIONS, ANESTHESIA, CEPHALOPELVIC MALPROPORTION or MALPRESENTATION. If arrest is in midpelvic contraction, indicated by prominent ischial spines, the next step is C-section. Forceps can’t be used until cervix is fully dilated (10cm). Oxytocin might cause uterine rupture due to pelvic prevention of birth. In case of Shoulder Dystocia (a last resort tx) is 'Zavanelli' maneuver (pushing back the fetus in uterus & doing a C-section).

ARTHRITIS, REACTIVE It’s a form of seronegative spondyloarthropathy. Enthesopathy (A dz process at site of insertion of muscle tendons and ligaments into bones or joint capsules- causes heel pain and sausage digits. Enthesopathy is quite specific to spondyloarthropathy. DOC for Reactive Arthritis and Reiter's is NSAIDS. Tetracycline is added if UTI with Chlamydia is suspected and IM Ceftriaxone if Gonococcus is suspected (but Neisseria doesn’t cause Reactive Arthritis).

ASBESTOSIS The hx of shipyard worker with CXR: Dx: Pleural plaques. DDx1: Silicosis: hx of glass and pottery making. DDx2: Berylliosis: hx of high tech industries.

ASCENDING CHOLANGITIS Charcot Triad: RUQ pain, Fever and Jaundice. An infection of the CBD, generally 2ndary to obstruction of CBD with a stone leading to dilatation of CBD. Broad spectrum antibiotics should be started ASAP, however, very important to decompress the biliary duct and provide their drainage. ERCP (Endoscopic Retrograde CholangioPancreatography) is the method of choice. ERCP can be used to do a sphingtrectomy w/the stone removal and drain the bile via the sphincter or by placement of a stent. Early drainage can significantly reduce mortality and morbidity.

ASCITES- 3 Management starts with sodium, water and protein restriction, spironolactone, furosemide. If given a choice for only one drug tx b/w spironolactone and Furosemide, pick spironolactone. If that didn’t help then slow tapping of up to 2L of ascites fluid/day balanced w/infusion of 10g albumin per L tapped. If that didn’t work then do surgery. The vascular shunts are indicated after first bleeding. Distal spleno-renal shunt will not improve and it might worsen it. Side to side porto-caval shunt might improve the ascites but worsen encephalopathy. Peritoneum-Jugular shunt is designed for tx of Ascites only. *If pt’s ascites is so much that is compromising other systems, the next step is Paracentesis is both therapeutic and diagnostic. ****Spironolactone is the DOC in tx of Cirrhotic Ascites. Tx of ascites in Cirrhotic pts: 1-All the pt should have diagnostic paracentesis done. 2-Salt Restricted Diet is the cornerstone of the therapy, in 10-20% of pt that's all you need to do. 3-Pts not controlled with SRD, Spironolactone is next (Aldosterone antagonist, and it works because Ascites is only due to 2ary hyperaldosteronism. 4-Recalcitrant (difficult to manage) ascites should be tx with TIPS. 5-Very severe ascites should be tx with paracentesis initially.

ASPERGILOSIS - 3 An opportunistic infection in South East USA. A mobile cavitary mass in the lung, which presents with occasional hemoptysis. DDx1: Lung abscess: due to anaerobic organism, with CXR: AIR FLUID level. Medical Mgmnt: Abx, postural drainage and bronchoscopy. DDx2: PE: from lower legs, presents: Dyspnea, Tachypnea, Chest pain and collapse. ECG may demonstrate RV Hypertrophy, RBBB, Right Axis and T inversion in ant. leads. CXR: Decreased pulmonary vascular markings. DDx3: Histoplasmosis: The MC fungal infection in USA. Acquired by inhalation. "Calcified Nodes" in lung, mediastinum or spleen. CXR: Central or target calcification. Occasionally causes mediastinal LN enlargement. ***Allergic Broncho Pulmonary Aspergillosis (ABPA), finding of central bronchiectasis (CXR) & elevated IgE and Eosinophilia is characteristic. Next do a skin test for Aspergillosis antibody to get Dx. Tx: Prednisone oral. Itraconazole may reduce the need for steroid but it’s not the main therapy. ****It occurs in immunocompromised pt (those taking cyclosporine, chemotherapy). Pt presents: Fever, cough, hemoptysis, and dyspnea. CXR: may show cavitary lesion. CT: Pulmonary nodule with a 'halo' sign. ****Aspergilloma: A “fungus ball” in preexisting cavities, MC presentation is hemoptysis, Tx: Lobectomy ****4 types of infection: 1-ABPA (Tx: Prednisone), 2-Aspergious Colonization, 3- Aspergiloma (surgery), 4-Invasive Aspergillosis (Tx: IV Amphotericin)

ASPIRIN INTOXICATION - 3 1-ADULTS: Initially increased respiration leads to respiratory alkalosis & then uncouples oxidative phosphorylation and leads to metabolic acidosis. They have mixed metabolic acidosis and respiratory alkalosis. 2-CHILDREN: Initially causes Metabolic Acidosis and then compensatory Respiratory Alkalosis. ASA can cause acute erosive gastritis and upper GI bleeding. Alcohol can aggravate this effect.

ASPIRIN INSENSITIVITY SYNDROME Pathogenesis is 'Pseudo-allergic reaction'. Accumulation of LTs and changed LT/PG balance triggers bronchoconstriction, nasal polyps in susceptible individuals. Tx: LT receptor inhibitors (DOC), topical steroids and ASA desensitization therapy.

ASTHMA - 9 Before and after administration of a bronchodilator (Beta-2 agonist). Significant improvement in FEV1 after bronchodilator indicates reversibility of destruction, which is more consistent with Asthma. **** Pts who have other allergic disorders, so give to a boy who started to have night time cough and wheeze with hx of allergic rhinitis—DOC: Mast cell stabilizers (Sodium Cromolyn) **** Exercise-induced Asthma (not to be confused w/post exercise asthma) presents w/chest discomfort, wheezing, cough, breathlessness, fatigue and abdominal discomfort. Best Tx: Beta Agonist & Mast cell stabilizers (Sodium Cromolyn). **** When asthmatic pt presents w/Subcutaneous Emphysema, which is face becomes all swollen & palpation reveals crepitus all over face and neck, 1st step management: CXR (to r/o Penumothorax). Once that is r/o just observe the pt, no tx indicated ***Pt w/persistent asthma symptomsà BECLOMETHASONE (Inhaled corticosteroids). In adults SE of low-dose drug: Dysphonia and Thrush. In high-dose systemic toxicity may occur. ****It’s a common illness in childhood. 10% of children come to ED with un-remitting asthma (continues wheezing despite tx w/nebulizers and steroids) a.k.a. Acute Status Asthmaticus. 10% of these pts require MECHANICAL VENTILATION, however hospitalization is mandatory. If no air entry bilaterally on auscultation à the child has 'silent chest' or absent air entry & continues to desaturate despite Prednisone therapy, therefore the best option is1) Mechanical ventilation and hospitalize, 2) IV steroids, 3) Mech ventilation. Normal PCO2 is one of the indicators of a severe attack. During an attack, pt is tachypneic, so he hyperventilates. *****Pt w/asthma and other allergic disorders, DOC: SODIUM CROMOLYN (Mast cell stabilizers) *****1st nebulizers which should cause ↓PCO2. So if PCO2 seems to be normal that means the obstruction is getting worst or respiratory muscle are getting too tired. Other signs of severity: Broken speech, diaphoresis, cyanosis, altered sensorium and "silent lung". Inhaled corticosteroids improve long-term quality of life of asthmatics. Initial HTN therapy for pt with asthma is HCTZ. ***To differentiate b/w Asthma and COPD (Emphysema) the best test is a bronchodilator response test. It’s conducted by measuring FEV1

ASTROCYTOMA PARIETAL LOBE, SUPRATENTORIAL (MC tumor in both infra- and supra-tentorial). MEDULLABLASTOMAS (2nd MC tumor in POSTERIOR FOSSA) - 90% occur in VERMIS. CRANIOPHARYNGIOMA arise in SELLA TURCICA, visual field defect, w/cystic structure w/calcification.

ASYMPTOMATIC BACTRIURIA of PREGNANCY When everything is normal but a routine clean catch urine culture grows 100000 colonies of E coli. If untreated à increased risk for CYSTITIS & ACUTE PYELONEPHRITIS. Should be treated w/100mg Nitrofurantoin or Ampicillin x 7- 10 days.

ATELECTASIS it’s common after surgery in smokers. Bronchoscopy needs to be done to remove mucus plug. Presents w/tachycardia, tachypnea, low-grade fever. Once Bronchoscopy is done, repeated CXR, and coughing is encouraged.

ATHEROEMBOLIC DISEASE Imitates Gout, but does not say red toe but IT’S A BLUE TOE. DON’T FALL FOR GOUT TRICK. S/S: cyanosis & circulation problems like calf pain, normal pulses

ATHLETIC FOOT Pt presents w/SEVERE ITCHING & FISSURES, thickness of the nail in a swimmer. Best Tx: TOLNAFTATE (antifungal medicine)

ATOPIC DERMATITIS: Edema and erythema of the skin. Skin is Itchy. Tx is PIMECROLIMUS like Tacrolimus; MOA: Inhibition of T cell activation.

ATRACURIUM The neuromuscular blocking agent of choice for pt w/renal & hepatic problems, b/c metabolized in plasma.

ATRIAL FIBRILLATION - 4 AF (absent P waves & irregular heart rate) Control RATE & RHYTHM **** AF w/ WPW: PROCAINAMIDE or DISOPYRAMIDE. Drugs that slow AV conduction (DIXOGIN, VERAPAMIL) are C/I in these pts; they may lead to malignant arrhythmias. Lidocaine may also worsen the situation. **** Hemodynamically UNSTABLE pts (very rapid ventricular rates w/hypotension) àTx: Only CARDIOVERSION ****Hemodynamically STABLEàAMIODARONE is used. Amiodarone causes hypotension so it’s C/I with HD UNSTABLE (hypotension already in pt), but once cardioversion stabilizes pt then Amiodarone is an excellent choice to maintain the pt. CCBs are also ONLY excellent choices for AF when there is no HD compromise.

ATRIAL FLUTTER SAW TOOTH EKG. Unstable AF tx à CARDIOVERSION (BEST Tx). Acute AF w/stable hemodynamics tx à CARDIOVERSION or RATE CONTROL. Chronic stable AF tx à RATE CONTROL (BEST Tx) w/CCB (Verapamil) or BB

AD POLYCYSTIC KIDNEY DISEASE 5-7% assoc w/Berry aneurysm. Routine screening is not recommended.

AUTISM - 3 Main Tx: Special education & behavioral modification techniques. *Have special interests. Usually starts before age 3. DDx: Childhood Disintegrative Disorder: a rare pervasive developmental disorder, MC in males. Characterized by a period of NORMAL development for at least 2 yrs, followed by a lost of already acquired skills with autism symptoms. Prognosis: Poor and they are disabled for life. ****Rett Synd: characterized by an initial period normal development until 6mo, followed by loss of hand coordination and stereotypical hand movements. Almost exclusively in Females.

AUTOIMMUNE HEMOLYTIC ANEMIA SEE Spherocytosis

AVN of FEMUR Well-known causes of non-traumatic avascular (aseptic) necrosis are chronic steroid therapy, alcoholism. Presents w/progressive hip pain w/o restriction of motion and normal XR. MRI (gold standard)

AVOIDANT PERSONALITY: Shyness and feeling of inferiority, and desire to make friends.

B12 DEFICIENCY, Himont, 6/2 DDx b/w Anemia and vegetarian diet is the duration. We store 3-4 years of B12 in the body, so if you’re a vegetarian <3 years can get B12 deficiency, due to Pernicious Anemia not vegetarian diet. If >4 years then do Antibody test CORTICOSTEROIDS for intrinsic factor. ***DDx b/w Folate and B12 is increased in Methylmalonic level. Folate will cure anemia but neurological problems will progress. BACILLARY ANGIOMATOSIS: Is caused by Bartonella species, gram-negative bacilli. Cutaneous lesions: round papules or nodules, vascular and assoc with fever malaise and HA. It occurs in HIV pts.

BACTERIAL MENINGITIS CSF: Elevated protein, decreased glucose, elevated WBC+ Skin Lesions: Purpura and petechiae. ****Acute Bacterial Meningitis: the 3 mf causes in community acquired ABM are S. Pneumonia, H. Inf and Meningococcus. Pneumococci have become resistant to penicillin and cephs, so empirical therapy in adults & children: Vancomycin & Ceftriaxone . Listeria is fc in AGE> 55, so add AMPICILLIN. Other pts at risk for Listeria are immunocompromised and lymphoma pts. Children >3 yo: LM is a risk so empiric regimen included Ampicillin w/CEFOTAXIME. Now S. Aureus and pseudomonas à meningitis in hospitalized pts, so empiric Vanco (for aureus) & Ceftazidime (pseudomonas).

BARTTER SYNDROME - 2 The DDx of normotensive pt with hypoK+ and metabolic alkalosis include: 1-Diuretic abuse 2-Surreptitious vomiting 3-Bartter Syndrome (LOW Cl-) 4-Gitelman synd. Classic Bartter usually presents: Early in life, as polyuria, polydipsia, growth and MR. However this can occur later. The underlying pathology is defective sodium and chloride reabsorption in the ascending loop, thereby resulting hypovolemia and consequent activation of renin-angiotensinogen aldosterone system. This causes increase in K+ & H+ ion secretion leading to hypoK+ and metabolic alkalosis. DDx: Primary Hyperaldosteronism and Renin secreting tumors are characterized by HTN, Met Alk and HypoK+. Measurement of Plasma renin activity and aldosterone is used for DDx b/w the two. ***Primary HyperAldosteronism à PRA is suppressed & aldosterone is elevated, but in ***Renin tumors àBOTH PRA and Aldosterone are elevated. ***MCC of HypoK+ in clinical practice is Diuretics, which is hard to DDx with Bartter.

BASAL CELL CARCINOMA - 2 MC Malignant tumor of eyelid. Lesions are slow growing, pearly and indurated. Invasive clusters of spindle cells surrounded by palisaded basal cells. It rarely might appear on upper lip but NEVER on the lower lip. MC location is lower eyelid. Rarely metastasize. Squamous CC is much less common and faster growing, Presents plaque nodule or inverted wart, its DDx is Actinic Keratosis. ****The sun is Bad for Basal cell carcinoma. 5 warning signs: 1- Open sore that bleeds, oozes and remains open for >3weeks. 2- Reddish patch, 3-Shiny bump, scar like area, 5-Pink growth with rolled border. BCC MCC of skin in US. Never metastasis. It’s removed using by 1- Cauterization (burning), 2-Surgical (excision with 1-2mm margin). 3- Cryosurgery (freeze) and 5-Radiation.

BASILAR SKULL FRACTURE Signs: Rhinorrhea, raccoon eyes (black eye), ecchymosis behind the ear. A way to see if there is CSF mixed w/blood is to drop a drop on a cleansing tissue, if there is CSF it would be a yellowish spreading on the paper. Pt head fracture has to be r/o with CT of head and spine. Expectant therapy for all uncomplicated cases. Anterior packing is not necessary to control CFS loss. **If CSF leak >4 days à SPINAL DRAINAGE & ACETAZOLAMIDE (REDUCES CSF production & reduce ICP).

BECHET - 2 A rare multi-system disorder: MALES <20yo, in Mediterranean area and east Asia. An AUTOIMMUNE mechanism is suspected. It manifest w/MOUTH ULCERS (APHTHA-like) & GENITAL AREA (more destructive leading to fenestrated vulva), assoc w/UVEITIS. No specific tx yet. ***It’s a Multi-systemic Inflammatory condition with recurrent oral and genital ulcers, skin lesions, MC in Turkey, Asian and Middle East. Corticosteriods offer relief but don’t prevent progression to Dementia and Blindness.

BECKWITH-WIEDEMANN SYNDROME Infant w/macrosomia, macroglossia, visceromegaly, omphalocele, hypoglycemia & hyperinsulinemia. It may be assoc w/duplication of CH 11p; this region has the gene for IGF-2, which may explain macrosomia. DDx1: Congenital Hypothyroidism: Umbilical hernia instead of omphalocele, there is no hypoglycemia and hyperinsulinemia. DDx2: Macrosomia d/t Maternal DM: however these infants don’t have dysmorphic features of omphalocele, prominent occiput and macroglossia. The common congenital problems in these infants are Caudal progression Syndrome, Transposition of Great Vessels, Duodenal Atresia and Small Left Colon, Anencephaly and neural tube defects. DDx3: WAGR syndrome: Wilms tumor, Aniridia, GU anomaly, and MR. Its related to deletion of CH11 involving the gene WT1.

BELL’S PALSY Is the PERIPHERAL 7th nerve palsy, It’s dx w/absence of forehead furrows and thus ruling out CENTRAL Facial Paresis. Pts with Central lesion still have furrows because contralateral motor innervation of forehead remains intact.

BENIGN INTRAHEPATIC CHOLESTASIS Can develop after a major surgery in which hypotension, extensive blood loss in tissues, and massive blood replacement are noted. Jaundice develops due to pigment load from transfusion. Jaundice becomes evident 2nd day post- operative. Alkaline phosphatase is markedly elevated but ALT & AST are only mildly elevated. DDx1: Acute Hepatic Failure: PT, low albumin and neurologic signs d/t hepatoencephalopathy. DDx2: Hepatitis: presents w/marked elevation of ALT & AST DDx3: Halothane Hepatotoxicity: type-1 Mild elevation of liver enzymes and NO jaundice, type-2 Characterized by Acute Liver failure.

BERNARD SOULIER SYNDROME The hallmark is GIANT platelets. (AR). There is mild thrombocytopenia but the major defect is of membrane glycoprotein Ib. This defective membrane lacks the receptor for VW attachment so platelet can’t adhere to endothelium. Platelets don’t aggregate in presence of normal VWF and Ristocetin. Vignette: presents a 16 yo girl’s periods last 6-10 days and her brother also had bleeding problems.

BETA-BLOCKER TOXICITY Overdose: HYPOTENSION & BRADYCARDIA. Severe overdose may result in cardiogenic shock. If bradycardia or AV abnormality is found, Atropine is indicated to oppose unopposed vagal tone. Isoproterenol is given if Atropine fails and if both of them fail then Glucagon is DOC. If medication fails then a temporary pacemaker is indicated.

BIASES: SEE STEP UP book 1-Selection: loss of people to follow up in prospective studies. 2-Observers and Ascertainment: result in misclassification of the outcome due to flaw of the design of the study. 3-Recall: Misclassification of the exposure status, its potential problem for case- control. 4-Confounding: 5-Generalizability: when the population you study does not include all the population where the topic of the research is covering. Like studying just men when ALL people are targeted. 6-Reliability: 7-Validity: 8-Lead-time: Prolongation of apparent survival in pts whom this test was applied, w/o changing the prognosis.

BICUSPID AORTIC VALVE MCC aortic stenosis in middle-age adult. Both AS and HCM produce a midsystolic (Ejection systolic murmur) murmur, however murmur of HCM is best heard at left lower sternal border and doesn’t radiate to carotids. Valsalva attenuates AS murmur but Accentuates HCM murmur. Murmur of AS: Best heard right 2nd intercostal space and radiates to the carotids. Slow rising pulse is seen in HCM.

BILIARY CHOLIC Is symptomatic for choledocholithiasis. If there are no signs of acute cholecystitis (Murphy sign, elevated WBC and fever) there is no need for hydration, antibiotics or emergent cholecystectomy. There could be emphysematous cholecystitis that presents w/gas in gallbladder. DM pts are at increased risk. For uncomplicated biliary cholic: Do spasmolytic and analgesic therapy; elective surgery at a later time.

BIOPHYSICAL PROFILE BPP: A scoring system to evaluate baby's well being. INDICATIONS: Decreased movement or a non-reactive NST. It includes NST in addition to 4 things, 1-Fetal tone, 2-Movement, 3-Breathing (30/10min), 4-Amniotic Fluid Index (5-20). Each has a score of 2, when present and 0 when absent. Normal: 8-10, and should be repeated 1x or 2x weekly, until term. In presence of oligohydramnios (AFI<5) delivery is considered. If score is 6 w/o oligohydramnios à Order Contraction stress test. If CST gives non-reassuring results then DELIVER, if it gives suspicious results then repeat the next day. If its 4 w/o oligohydramnios and fetal lung are mature, Delivery is considered. If lungs are not mature, steroids given and BPP accessed w/in 24 hrs. If score is <4, deliver now.

BLACK WIDOW SPIDER Presents w/Acute abdomen and best treated w/Calcium Gluconate and muscle relaxant. Brown Recluse spider: causes localized skin necrosis, resembles pyoderma gangrenosum (purplish nodules and pustules which tend to coalesce and form ulcers). Deep skin ulcer developsàTx: Local excision Dapsone is used for pts with G6PD def.

BLADDER CANCER - 2 Up to 80% of pts who go through a urinary diversion procedure, especially an ileal conduit, can develop hyperchloremic metabolic acidosis due to exchange of Cl- for HCO3 in the intestinal mucosa, leading to loss of HCO3 and increase Chloride

BLADDER RUPTURE - 2 Hematuria, suprapubic tenderness, non-palpable bladder and lower abd & perineal edema. Best Dx method is retrograde cystogram w/voiding films. Remember for Urethral injury àdo Retrograde urethrogram. ****Intraperitoneal rupture is more common in pts in trauma accidents.

BLASTOMYCOSIS - 2 Wisconsin, Ohio, Mississippi with chronic respiratory problem is suspected. Another Dx Triad: Skin, Lung Cavity and Bone Lytic lesions.

BLOOD TRANSFUSION Femur fracture can acct for 1L blood loss, if Pelvis is also fractured the blood loss could be several liters. General guidelines: Start IV crystalloids. Initially, 2L in 10 min, if pt continues sign of hypovolemia then Blood transfusion is started. Best indicator for transfusion is blood loss of >1500ml. ****Washing of RBC washes off antigens assoc w/transfusion. It’s used for IgA deficiency: pts. Leukocytes reduced, RBC reduces the risk of allosensitization BLUNT CHEST TRAUMA: When it happens CXR: Wide mediastinum aortic injury must be suspected. Dx: Either a CT scan or ECHO

BODY DYSMORPHIC DISORDER Woman thinks her nose is 'enormous'.

BOERHAAVE’S SYNDROME Complete tear of distal esophagus that leads to pneumomediastinum, vs. incomplete tear in Mallory Weiss and no Pneumomediastinum. XR shows subcutaneous emphysema. Dx w/barium swallow. Tx: Give antibiotics and Thoracotomy and repair of esophagus immediately.

BORDERLINE PERSONALITY Splitting characteristic. You are the best and the other doctor was terrible.

BORDETELLA PERTUSSIS For prevention, all close contacts (household and daycare) Erythromycin x 14 days, regardless of age, immunization or symptoms.

BOTULISM - 2 2 types: 1-Infantile type: Organism gains entry through the food and produces toxin in the intestinal tract. It’s a protease that blocks Ach release. 2-Adult type: the toxin is ingested, produces the effect. ****Infantile botulism, tx is supportive only. BUT if Children get it then administer equine derived botulism anti toxin right away.

BOWEL ISCHEMIA Always consider it as an early complication of operation on the abdominal aorta. Presents w/bloody diarrhea and abdominal pain. It’s d/t infarction of Inferior Mesenteric artery, 1-2 days post surgery. DDx: Pseudomembraneous colitis: Takes 2-3 weeks after drug therapy. **** Unrecognized bowel ischemic is one of the MCCs of lactic acidosis w/severe atheroslcerotic disease. Pt c/o of abdominal pain after meals.

BOWEL OBSTRUCTION If a pt comes with constipation and no flatus, even then, unless strangulation or perforation is suspected, bowel obstruction is treated conservatively. So don’t do surgery first. 1st thing to do after IV is nasogastric suction and barium enema.

BOWEL RESECTION Pt goes under bowel resection the MC type of kidney stone is Oxalate d/t excessive absorption of Oxalate from GI tract. Increased intestinal fat binds Ca++ that is then unavailable bind oxalate. Therefore increased absorption of oxalate occurs in GI and precipitates in kidney.

BP CRITERIA BP should be kept below 140/90. But BP in DM and chronic renal pts should be kept under 130/80 to prevent end-organ damage.

BPH - 7 Starts in the center of the prostate. Cancer starts in periphery. MCC of overflow incontinence in elderly male. Finasteride acts on epithelium and alpha-1blocker acts on smooth muscles of prostate. Alpha-blockers (Doxazosin) are preferred in pt with BPH and dyslipidemia and glucose-intolerance. If CR is elevated do U/S of kidney, bladder and ureter to check for damage. ***** Tamsulosin, Alpha-1 receptor blocker has the least SE of all alpha-1 blockers used for Tx of BPH. ****The 2 initial tests recommended in ALL possible BPH pts: serum CREATININE & U/A. U/A rules out infection and creatinine r/o kidney problems. *****U/S of the kidney, ureter and bladder should be done when CR level is elevated.

BRAIN ABSCESS A pt w/acute onset of HA and focal neurological symptoms (cant walk right) after an episode of acute otitis media or sinusitis most likely has brain abscess. CT and MRI show ring-enhancing lesion. Fever presents with only 50% of cases so it’s not a reliable sign.

BRAIN DEATH Irreversible cessation of brain activities à a clinical dx. Characteristic findings: Absent cortical and brain stem functions. The spinal cord may still be functioning, therefore DEEP TENDON REFLEX are intact. EEG can confirm but is not necessary. In brain dead people, pupillary reaction & oculovestibular reaction are absent, Atropine doesn’t accelerate heart since vagal is gone, and there is no spontaneous respiration.

BRAINSTEM INFARCTION 1-Medial Medullary Syndrome: Occlusion of VERTEBRAL A. Contralateral paralysis of limbs, contralateral loss of tactile, vibratory and position. Tongue deviated to affected side. 2-Lateral Mid-Pontine Synd: A lesion in LATERAL PONS. Impaired sensory and motor function of CN V (trigeminal) and limb ataxia. 3-Medial Midpontine Synd: A lesion in Medial Pons. IPSILATERAL limb ataxia, & CONTRALATERAL eye deviation and paralysis of the face, arm and leg. 4-Wallenberg Syndrome: A lesion of LATERAL MEDULLA. IPSILATERAL Horner’s Syndrome, loss of pain and temperature of the face, weakness of the palate, pharynx and vocal cords, and cerebellar ataxia. Also loss of pain & temperature in contralateral side of the body.

BREAKING BAD NEWS PROTOCOL 1-Comfortable environment, 2-Ask pt how much he knows about his symptoms, 3- Ask pt how much he wants to know, 4- Give him a warning shot (i.e. its worst that we thought, do you want someone with you), 5-Break the news if he wants that. 6- Tell him of prognosis but also of the option to make his life as comfy as possible, 7- Try to explain everything clearly and simple as possible. BREAST CARCINOMA - 4 Inflammatory Breast Cancer: Erythema and edema of non-lactating breast could be due to locally advanced cancer, Bx should be done 1ST to r/o that dx. Tx: 2-3 wks of combination chemotherapy to shrink the tumor allowing subsequent extended resection. ****Metastatic Breast Cancer has a poor prognosis with little chance of cure. It’s important to choose Local (Surgery) vs. Systemic (Systemic Chemotherapy) tx in pt with metastatic breast cancer. ****Tumor burden, based on TNM staging, is considered the single most important prognostic consideration in treating pts with breast cancer. ER+ and PR+ are good prognostic factors. Over expression of Her2/Neu oncogene is worst prognosis. ****Breast cancer is the leading cause of metastatic skin disease in women. These lesions are erythematous that present as erosions covered by necrotic skin. Tx is palliative radiation therapy with aggressive wound care. *****Two prohibitions w/breast cancer in pregnancy: No chemo in 1st trimester, and no Radiotherapy anytime in pregnancy. Also Lumpectomy is not a good choice for 1st trimester because it needs Radiation afterwards. Only Tx for 1st trimester is Modified Radical Mastectomy.

BREECH PRESENTATION - 2, 6/24/06 If prior to 37 must be left alone. After 37 wks, EXTERNAL CEPHALIC VERSION may be attempted PRIOR to onset of labor, given no C/I (HTN).

BRONCHIECTASIS - 2 An irreversible widening of medium size airways in the lung. Characterized by destruction of bronchial walls and chronic bacterial infection. They might have life- threatening HEMOPTYSIS. Bronchiectasis is due to formation of large collateral vessels, which have a very fragile wall. Hemoptysis could be very extensive and ALL pt should be admitted. ****Any pt with fever, night sweats, copious foul smelling sputum has one of the following: 1-Bronchiectasis, 2-Lung Abscess, 3-Anerobic Pneumonia. "Copious foul smelling" sputum is the KEY word. CXR: "Tram Track Appearance" (increased vascular markings) ring shadows, peribronchial thickening. CT is the confirmatory, it has REPLACED Bronchography. After that Sputum for AFB is done.

BRONCHIOLITIS Definition: The first episode of wheezing assoc w/an URT infection. The infection is usually caused by CMV and is common in winter. In affects 50% of children in the 1st two years of life especially those prone to airway reactivity, and there is an increased incidence for Asthma later in life. WBC - WNL & CXR: Shows air trapping or atelectasis. Tx: Supportive Care, Humidified Oxygen and Bronchodilators.

BRONCHOGENIC CARCINOMA Pulm. 6/3 BGC is the MC lung cancer assoc w/asbestos exposure, while Malignant Mesothelioma is almost exclusively assoc w/asbestos exposure but it’s NOT the MC malignancy after asbestos exposure. HALLMARK: Pleural involvement of asbestos exposure. Cigarette smoking acts synergically w/asbestos exposure, increasing risk factor for BGC. BROWN SEQUARD SYNDROME Assoc w/Damage to LATERAL SPlNOTHALAMIC tract, causing CONTRALATERAL loss of pain and temperature beginning 2 LEVELS BELOW the lesion. Therefore, a lesion of right-sided Lateral SPT at T10 will result in left sided loss of pain and temperature at beginning at T12.

BRUTON’S AGAMMAGLOBINEMIA T9Q14. X-linked. MERCK: Panhypogammaglobulinemia of male infants characterized by IgG < 100 mg/dL and other Ig levels low or absent, low or absent B cells. Onset of infections sometime after age 6 mo. These infants have recurrent pyogenic infections of the lungs, sinuses, and bones w/ organisms as Pneumococcus, Haemophilus, and Streptococcus. Defect of the Btk (Bruton's tyrosine kinase) gene at Xq22 prevents differentiation of pre-B cells to B cells. Life- long IG given IM or IV in the lowest dose that prevents recurrent infection is essential.

BUDD-CHIARI SYNDROME Obstruction of hepatic venous flow at any level above the venule. Obstruction can result from various conditions, particularly prothrombotic states. Triad: Abdominal pain, Ascites, Hepatomegaly Causes: Hepatic vein thrombosis, compression of Hepatic v by tumor, pregnancy, OCP, infection (Tb), PNH, Polycythemia vera

BUERGERS DISEASE Triad: Occlusive disease of arteries, migratory superficial thrombophlebitis [Thrombi+Phlebe (vein) + -Itis (inflammation)], and Raynaud’s phenomenon in a male smoker. DDx w/atherosclerotic disease in those w/Pulses WNL.

BULIMA NERVOSA - 2 Outpatient Tx: SSRI, cognitive therapy, interpersonal psychotherapy, family and group therapy. If pt failed this and/or has metabolic problems or is suicidal then hospitalization. *Pt binge eat and then feels guilty. They might even feel sad about their situation. But they maintain their BMI and are NOT Amenorrheic. They binge eat at least TWICE per WEEK. If they don’t do that, they are dx as "Eating disorder, NOS.

BULLOUS PEMPHIGOID- Derm 6/3 Is characterized by tense blisters in the flexural areas. Commonly in elderly (age > 60); the precipitating factors are UV rays, NSAIDS, antibiotics. Autoantibodies are formed against BM. Immunoflorescence microscopy reveals diagnostic findings of IgG & C3 at the epidermal-dermal junction. Tx of choice: Prednisone. PEMPHIGUS VULGARIS: Intracellular IgG deposits in the dermis. Herpes there is C3 at the basement membrane zone.

BUPROPION - 2 Uses: Major Depression, ADHD, cigarette craving. May be used w/Nicotine patches, but such combination requires frequent BP monitoring. It reduces weigh gain that comes w/cigarette smoking. Although it might cause seizure, you don’t stop the drug due to this rare SE, unless pt has a Hx of seizures. ***Pt has hx of epilepsy and wants Bupropion, Don’t give him Bupropion it’s C/I, b/c his Hx of epilepsy, give SSRI

BURNS Tx of superficial and deep burns. * For inhalation injury that may take a few days to manifest, BRONCHOSCOPY is best to Dx. *****For calculations only consider 2nd and 3rd degree burns. Kids: head=18, lower extremities=27. *****When circumferential full thickness burns involving extremities or chest is present, ECHARECTOMY maybe the best option. *****Parkland formula for Resuscitation: 4ml/kg/ % of body burned, half in 8hrs and rest in 16hrs. ****Early excision therapy is indicated for extensive partial thickness & full thickness burns. *****MCC of death in burn pts in hospital is infection. *****Inhalation injury is common in burn pts and may take several days to manifest. Dx is best done with a bronchoscopy. Beta agonists along w/steroids, endotrachial intubation and antibiotics have all been used in pt with inhalation injury. *****1st degree: Confined to epidermis, erythematous skin. Heals w/o scarring. e.g. sunburn. 2nd degree: Entire epidermis, red and blisters. Its partial thickness burn. 3rd degree: Full thickness burn, epidermis and dermis completely destroyed. Not painful. Debridement and grafting is required.

CALCANIUM FRACTURE Surgery 6/2 If due to fall, evaluate for other injury, plain film of head, neck, abdominal, lumbar & pelvic. Assoc w/ compression fracture of thoracic spine.

CANCER DRUGS 1-Anorexia: DOC for anorexia assoc w/cancer is MEGESTEROL ACETATE. 2-Nausea &Vomit: METACLOPROPAMIDE and ODANSETRON

CARCINOID SYNDROME 3, 6/3 Triad: Flushing, diarrhea and valvular heart disease. Its assoc w/carcinoid tumors and hepatic metastasis. Isolated tumors w/o metastasis do not produce carcinoid syndrome. These tumors produce serotonin. Elevated serotonin and its metabolite (5HIAA) are in plasma and urine. Tryptophan is the precursor of Serotonin. Tryptophan is used in synthesis of Niacin. Pts of Carcinoid syndrome are at risk of Niacin deficiency due to increased formation of serotonin from tryptophan. As a result supply of tryptophan is decreased and 3 Ds of Niacin def (Diarrhea, dementia, dermatitis) of Pellagra develops. ****Carcinoid tumor when symptomatic is in SMALL BOWEL, when asymptomatic it’s in Appendix***Triad: Flushing, diarrhea and wheezing.

CARDIAC CONTUSION Assoc w/arrhythmias, so 1ST do if you suspect arrhythmia and it continues ECG NOT ECHO.

CARDIAC TAMPANADE - 2 Characterized by 1-Hypotension, 2-Sinus tachycardia. 3-Pulsus paradoxus. 4- Prominent JVD with 'Y' descent. U/S: Blood in pericardial sac. DDx: Mediastinal Hemorrhage (MH), which is the same as CT except that U/S shows no blood in pericardium and the blood, is in mediastinum. MH could happen in pts who are taking Warfarin and cause coagulation abnormality.

CARDIOMYOPATHY, DILATED (DMC) - 3 Characterized by 1-Impaired systolic function of LV and RV leading to progressive cardiac enlargement. 2-CXR: Marked/Moderate enlargement of cardiac silhouette. 3-ECHO: shows SYSTOLIC DYSFXN & LV dilatation w/ Normal wall thickness. Pt should refrain from drinking alcohol. MCC of myocarditis à Viral infection that results in DCM, and MC virus is Coxsackie. ****DCM is the end result of myocardial damage produced by toxic, infectious, or metabolic agents. Viral or idiopathic cause is MCC by Coxsackie virus. Dx: ECHO shows dilated ventricles w/diffuse hypokinesia resulting in low EF (systolic dysfunction and CHF). Concentric Hypertrophy is seen in Aortic Stenosis. Eccentric in Valvular regurgitation. Hypokinesia is due to MI inferior wall. MS has LA hypertrophy. HCM shows Asymmetric INTRAventricular septum hypertrophy.

CARDIOMYOPATHY, HYPERTROPHIC - 5 Characterized by 1- Asymmetric LV hypertrophy. 2-Harsh systolic Diamond shape murmur best heard at the LEFT STERNAL BORDER. 3-CXR: Mild enlargement of cardiac silhouette. 4-ECHO: Shows vigorous systolic function, Asymmetric septal hypertrophy and Systolic ANTERIOR MOTION of MITRAL VALVE. 5-Due to LVH there is Diastolic dysfunction. * BETA BLOCKER (tx of choice) for isolated ventricular diastolic dysfunction. MERCK: Systolic murmurs are usually present, but patients with apical and symmetric hypertrophic cardiomyopathy may have no murmur. MC murmur: Crescendo-diminuendo ejection-type murmur that DOESN’T radiate to the neck; best heard at the left sternal edge in the 3rd or 4th intercostal space. This murmur is caused by obstruction of left ventricular ejection (produced in systole when the hypertrophied interventricular septum and the anterior leaflet of the mitral valve approach each other). A mitral regurgitation murmur due to distortion of the mitral apparatus is heard in some patients. It has a characteristic blowing quality and is best heard at the apex, radiating toward the left axilla. Rarely, early or midsystolic clicks are heard. In some patients with RV outflow tract narrowing, a systolic ejection murmur is heard in the second interspace at the left sternal border. An S4, almost always present, indicates a forceful atrial contraction against a poorly compliant left ventricle in late diastole. Mitral regurgitation is a result of anterior motion of the mitral valve leaflet. ***Mitral Regurgitation in "Infective endocarditis" or "trauma" is caused by rupture of chordae tendineae. ***Mitral degeneration in "elderly women" can be caused by mitral annulus calcification. ***Mitral valve prolapse: MCC for "isolated mitral regurgitation" in North America. *ECHO (dx of choice) shows asymmetrical ventricle septal hypertrophy. *In 25% of HCM pt there is obstruction of LV outflow tract (ECHO shows anterior motion of mitral valve), because of this filling pressure is further elevated and out is compromised. This outflow gradient is increased by maneuvers that reduce cavity size of LV: Valsalva and Standing after squatting (decreases LV volume thus increasing the gradient & intensify the murmur). Decreases gradient: Handgrip, Leg elevation (increases LV volume). Increases systemic arterial resistance and so decreases gradient and the murmur. *****To screen young athletes for HCM ECHO is not sensitive. Do detailed personal, family Hx and PE. ****Tx for HCM is Beta-blockers. ***HCM (AD) Pt is young, dyspnea on exertion, harsh diamond shape systolic murmur at the left lower sternal border. ECHO shows Asymmetrical septal hypertrophy.

CARDIOMYOPATHY, RESTRICTIVE - 4 Characterized by 1-Severe DIASTOLIC DYSFXN (a stiff ventricular wall). 2- ECHO: Symmetrical thickening of the ventricular wall. 3-Kussmaul sign. 4-Palpable Apical impulse. ****Tx of most causes of RCM is useless except Hemochromatosis; Phlebotomy and Iron chelation with subcutaneous Deferoxamine may result in substantial improvement. *****Since heart can’t relax filling is compromised so both Liver and Lung are congested. ****XR shows mild cardiac silhouette. ECHO: Symmetrically thickened ventricular wall and near normal systolic function. "Speckled Pattern" is specific for Amyloidosis ***DDx: CONSTRICTIVE PERICARDITIS no 4, CXR shows calcification, and normal thickness of ventricular wall. ****Tx of most causes of RCM is useless except Hemochromatosis; Phlebotomy and Iron chelation with subcutaneous Deferoxamine may result in substantial improvement.

CAROLI SYNDROME A rare CONGENITAL disorder characterized by intrahepatic dilation of biliary tree, assoc w/APKD.

CAROTID ARTERY STENOSIS & ENDARTERECTOMY Asymptomatic pt with 66-99% are considered for surgery, 100% is C/I for surgery.

CARPAL TUNNEL SYNDROME - 2 Most likely location of pathologic process is the wrist. Presents w/pain and burning sensation of the first three fingers and atrophy of thenar eminence, poor 2-point discrimination over the thumb, and they keep dropping things. Seen in assoc w/RA, Myxedema, Sarcoidosis, amyloidosis and Leukemia. Most specific test: Nerve Conduction Study. Tinel test (tapping on Median nerve) Phalen test (90 degree flexion of both wrist and pushing them together dorsally), Carpel compression test (applying pressure over carpal tunnel) are not specific.

CAT BITE - 2 Pasturella Multocida: Should Tx prophylactically w/Amoxicillin/Calvulanate x 5 days. ****1-Pasturella Multocida, occurs after cat or dog bite, and there is an intense inflammatory rxn w/in 24 hrs of the bite. Pain, swelling, purulent discharge 2-Bartonella Hensalae: Occurs after cat scratch or bites. Clinical features occur after 3-10 DAYS. They include papular or vesicular lesion at the site of injury and proximal lymphadenopathy.

CAT SCRATCH DISEASE Bartonella Henselae MC presents w/localized cutaneous and LN disorder near the site of inoculation. A local skin lesion evolves through vesicular erythematous and papular phases, but can be pustular or papular. Dx: Clinical and antibody to B. Henselae or positive Warthin-Starry stain on the tissue specimen. Most people resolve gradually w/o therapy. However, tender lymphadenopathy and systemic symptoms require 5 days of Azithromycin.

CATERACT, CONGENITAL -2 It’s due to progressively thickening of the lens. In "Congenital cataract" the retina CAN’T be visualized properly, exam reveals bilateral white reflex, the MCC white reflex in the pediatric population is Congenital Cataract. Tx is extraction of the lens.

CAUSTIC POISONING - 2 Upper GI Endoscopy is the dx of choice when a person comes in with ingestion of Alkali (oven cleaner) in the first 24 hr to assess the damage.

CAVERNOUS SINUS THROMBOSIS Presents w/severe HA, followed by fever and periorbital edema. CN involvement: Opthalmoplegia, lateral gaze palsy, ptosis and dilated pupils. Nasal discharge and blood should be cultured. CT scan: Cavernous and air sinuses, orbit, and brain should be performed. Tx: High-dose IV antibiotics, NAFCILLIN or CEFUROXIME should be started, pending culture results. Surgical Drainage: Infected air sinus may be indicated, especially if there is no response to the antibiotics in 24 h. The prognosis is grave; the mortality rate remains about 30%, despite antibiotic therapy. DDx: Orbital Cellulitis: UNILATERAL, and more common in children. Presents w/ abrupt onset of fever, proptosis, restriction of extraocular movements and swollen red eyelids. NO CN dysfxn or visual disturbances in the early stages unless it spreads to cavernous sinus. Treatment: Antibiotics, cephalexin should be started, pending culture results. Incision and drainage are indicated if suppuration is suspected or if the infection does not respond to antibiotics.

CELIAC DISEASE - 2 Presents w/MALABSORPTION, loss of muscle or subcutaneous fat, pallor due to iron def anemia, bone pain due to osteomalacia, easy bruising (vit K defic) and Hyperkeratosis due to (Vit A defic). Fatigue and weight loss. Dx: ELISA for IgA antibodies to gliadin and immunoflorescence for IgA antibodies to endosomysium. Also antibodies against transglutaminase. CONFIRMATION: Small Intestine Bx. ****A 15 mo old girl with dermatitis herpetiformis (erythematous vesicles symmetrically distributed over the extensor surfaces of elbows and knees.) and chronic non-bloody diarrhea with malabsorption (foul-smelling stool) and distended stomach, is suggestive of CD.

CELLULITIS - 2 An inflammation of skin that could extend into deeper tissues. In majority of pt is caused by Strep hemolytic or Staph aureus. Clinical symptoms can be Systemic as well as Local. Local findings: swelling, erythema, warm and tender and less well demarcated than erysipelas. The systemic signs are high-grade fever chills and rigors, malaise and confusion. When systemic signs are present -->IV Nafcilin or Cefazolin is preferred. **** The scenario is usually a lady with painful leg DDx: 1-Cellulitis: High fever and chills. 2-DVT: Cellulitis of calf is the one when there is high fever and no risk of DVT. 3-Necrotizing Fasciitis: A deep-seated Cellulitis, suspect it in pt with bulla or crepitus. 4-Erysipelas: A superficial cellulitis, it usually attacks cheeks; area is erythematous, painful and raised, with vesicles or bullae. No lymphangitis. 5-Erysipeloid: An edematous, purplish plaque with central clearing. Cause: Erysipelothrix incidiosa. Usually at hands of fishermen and meat handlers, not as painful as cellulitis and no fever.

CENTRAL CORD SYNDROME Characterized by burning pain and paralysis in the upper extremities with relative sparing of lower extremities. Commonly seen in elderly 2ndary to forced hyperextension of the neck.

CENTRAL LINE COMPLICATION Include pneumothorax, sepsis and tamponade occurs in 1-5% of pts. CXR: Confirms that the tip is proximal to cardiac silhouette.

CENTRAL RETINAL ARTERY OCCULSION: Sudden painless loss of vision in one eye, however opthalmoscopy reveals pallor of the optic disk, cherry red fovea, cotton wool spots, retinal hemorrhages.

CENTRAL RETINAL VEIN OCCLUSION - 2 Sudden painless loss of vision in one eye, however opthalmoscopy reveals disk swelling venous dilation, tortuosity, retinal hemorrhage and cotton wool spots.

CEPHALOHEMATOMA A benign bleeding of newborn's scalp. SUB-PERIOSTEAL HEMORRHAGE It shows like a swelling. Doesn’t CROSS MID-LINE. No tx is necessary. DDx: Caput Succedaneum: A diffuse and ecchymotic swelling of the scalp. It may extend across the midline

CEREBRAL HEMORRHAGE If due to excess warfarin (PT is increased) then FFP reverses the effect. Pt on anticoagulants should be on INR measure check. 1- INR <5, no significant bleeding DO omit next warfarin dose. 2 - INR is 5-9 and no significant bleeding DO stop warfarin temporarily. 3- INR >9 DO stop warfarin and give oral Vit K. Pt w/serious intracranial bleeding cant wait for Vit K, give FFP right away to bring INR<1.5. Now to reverse Heparin give Protamine sulfate.

CEREBRAL INFARCTION Hypodense on CT (white area over the cerebral surface).

CERVICAL CANCER – 2 OBGYN 6.2 Risk factors: Young age at first coitus (<20). Young age at marriage and first pregnancy. High parity, multiple sex partners, smoking, and low socioeconomic status. ****If PAP is DYSPLASIA à Do COLPOSCOPY If it shows inflammatory Atypia à repeat after 4-6wks ****If pt with SPOTTING and a gross lesion that bleeds by touching à straight to PUNCH BX to r/o cancer. (Don’t even bother w/PAP)**** Once pt has the cancer check for cytology every year not every 2 year for normal people.

CERVICAL SPONDYLOSIS It affects 10% of people >50. Hx of neck pain is typical. CERVICAL RADIOGRAPHY: MC findings: Osteophytes. MC FINDINGS: Bony spurs

CGD Defect of Phagocytic cells à NADPH oxidase deific. Leads to recurrent infection with catalase positive organism: Aureus, Serratia, Klebsiella, Aspergillosis. Not susceptible to catalase neg (strep, influenza, pyogenes). MC clinical findings: Lymphadenopathy, hypergammaglobinemia, hepatosplenomegaly, anemia of chronic cause, short, gingivitis and dermatitis. Dx: NitroBlueTetrazolin. Tx: Prevention w/TMP-SMX & Gamma-Interferon x 3/wk. BMT is curative. DDx1: Wiskott-Aldrich: Eczema, thrombocytopenia, recurrent infection w/encapsulated organism. Manifest at birth, petechiae, bruises, circumcision bleeding, bloody stools. DDx2: Chediak-Higashi: decreased granulation, chemotaxis and granulopoesis, neutropenia, Confirmatory: Giant lysosome in neutrophil. Tx Prevention w/TMP- SMX and daily ascorbic acid. DDx3: Jobs Syndrome: (Hyper IgE), chronic pruritic dermatitis, recurrent stash infection, marked elevated IgE, eosinophilia and coarse facial features.

CHAGA’S DISEASE Insect borne: Trypanosome Cruz, common form of cordites in Central & South America. Presents w/ Cardiomegaly, conduction anomalies. Almost all pts have a hx of Megacolon or Megaesophagus.

CHALAZOIN A small swelling (NODULE) of the eyelid. Results from obstruction of the glands in the eyelid. Management: First à HOT COMPRESS; if it returns repeatedly then do histopathology. It often requires surgery. Recurrent chalazoin requires histopathologic exam because of risk of underlying Squamous cell carcinoma. DDx: Hordeulom (Stye). Occurs at the edge of the eyelid (pretty red)

CHD, RISK FACTORS AGE: (M>45, W>55) Family Hx of premature CAD (<55 in first degree male parent, <65 in females relatives). HTN up to or equal to 140/90 even controlled w/medication. Cigarette smoking. DM. HDL <35. HDL up to or equal to 60 negates one risk factor.

Risk factor LDL goal LSM Meds CHD or Equiv <100 ≥100 ≥130 > or =2 <130 ≥130 ≥160 0 or 1 <160 ≥160 ≥190

CHEDIAK HIGASHI Is a storage granulocyte abnormality resulting in hepatosplenomegaly, lymphadenopathy, anemia, thrombocytopenia, and susceptibility to infection in childhood.

CHF - 6 CHF is a common cause of Pleural Effusion. Pleural analysis is consistent w/transudate effusion. The effusion caused as a result of systemic factors (CHF) is Transudate. Effusions due to local factors is exudate effusion. EXUDATE CRITERIA: At least one of the following, if none exists therefore it’s a transudate. 1-Pleural/Serum Protein is >0.5 2-Pleural/Serum LDH is >0.6. The determination of pH is important in parapneumonic effusion, a value of <7.2 requires a chest tube aspiration to prevent empyema. Pleural fluid pH<7.3 indicates pleural inflammation. **** If CHF is exacerbated due to development of AF then tx of choice à Add Digoxin. ******Measurement of serum B-type Natriuretic Peptide (BNP) can help DDx CHF from other causes of Dyspnea (COPD). If BNP >100 is dx for CHF. BNP is like ANP but BNP is released from Ventricles vs. ANP from Atria. ***Remember in CHF pt: Na+ is reabsorbed in kidneys in response to renin- angiotensinogen-Aldosterone system; therefore sodium in urine would be low. ****ACE inhibitors increase survival rate in CHF pts, so consider it in a pt with EF<40%. Of all diuretics, SPIRONOLACTONE, the only one that improves survival. *** Drugs that improve survival are B-blockers, Spironolactone, ACE-I (Captopril and Losartan), and ASA. Digoxin helps the situation but NOT survival.

CHILD ABUSE STEPS A19-

CHOANAL ATRESIA Suspect it in an infant who presents with cyanosis that is aggravated by feeding and relieved by crying. Failure to pass a catheter through the nose is suggestive of dx. Dx: Confirmed by CT with intranasal contrast. Management: First step: Place an oral airway and lavage feeding. Definite tx: Surgical repair of obstruction

CHOLESTASIS, ACUTE - 3 MM-402. Dx stages: 1-USG (initial workup) 2-HIDA (very specific, for confirmation; particularly useful in dx of Acalculus cholecystitis). ***Triad: Acute RUQ pain: fever and leukocytosis. Pain radiates to scapula. Bilirubin is normal and positive Murphy (pain on deep inspiration). MC 2ary to gallstones, in these pts MC due to impaction of stones in a cystic duct. The inflammatory response results from any of the following: 1-Mechanical (increased intra-luminal pressure), 2-Chemical (release of tissue factors) 3-Bacteria (2ary to stasis), this occurs in 50-70% of cases. REMEMBER although in 50-70 of cases there is infection due to bacteria, MCC for AC: Impaction of the stone in cystic duct. *** If pt still has pain after cholecystectomy, and ERCP shows sphincter of Oddi dysfunction, then ERCP with sphincterectomy is the procedure of choice. **** After ERCP and sphincterectomy, if pt has normal LFT and no dilation of biliary tree with U/S, then Oddi and CBD can be r/o and pt is having FUNCTIONAL PAIN. Give analgesics and reassurance. **** Acalculus Cholecystitis (thickening of GB wall and presence of pericholecystic fluid) occurs in CRITICALLY ill pts. Etiology might be stasis of bile ducts and ISCHEMIA of the gall bladder (after accident with loss of blood).

CHOLECYSTECTOMY: Hepatology, 6/2 Post cholecystectomy pain MC due to either Stone in Common bile duct or Sphincter of Oddi or Fxnal pain. If LFT is normal and no dilatation of biliary tree then it's fxnal pain. Tx: Symptomatically w/analgesics and assurance. If pt has abnormal Alkaline phosphatase and dilatation of biliary tree on U/S, then do ERCP to confirm and treat, by stone removal or sphincterectomy.

CHOLEDOCHAL CYST Congenital abnormalities of the biliary tree characterized by dilatation of intra and extra hepatic biliary ducts. Presentation varies with age. Infant presents: Jaundice and passage of acholic stools. Children causes: Abdominal pain, jaundice and attacks of recurrent pancreatitis, maybe evident by increased: amylase and lipase. Adults present: Vague epigastric or RUQ pain or Cholangitis. Choledochal cyst could degenerate into cholangiocarcinoma. Initial Test of Choice: U/S followed by CT or MRI. DDx1: Caroli’s Synd: Congenital disorder of intrahepatic dilatation of bile ducts. DDx2: Biliary Atresia presents in infancy w/marked obstructive jaundice and acholic stool. CHOLELITHIASIS - 3 Tx: 1-Asymptomatic pt: Leave alone. 2-Symptomatic pt: if ok w/surgery choice is Laparoscopic Cholecystectomy, if surgery is C/I or pt declines surgery then Ursodeoxycholic acid 10 mg/kg/day reduces biliary secretion of cholesterol and decreases the cholesterol saturation of bile, resulting in gradual dissolution of cholesterol-containing stones in 30 to 40% of patients. **** 3 types: 1-Cholestrol, 2-Pigment stones (mostly calcium bilirubinate, 20%) and 3-Mixed stones. Water insoluble cholesterol is secreted in bile where it’s converted into soluble muscles by bile acids and phospholipids. If too much cholesterol and too little bile then cholesterol crystals precipitate. Predisposing factors are Fat, Female, Forty, Fertile (OCP), cloFibrate. Remember 80% of stones are radiolucent so XR can’t see them.

CHOLESTEATOMA, ENT 6/2 Causes: Acquired conducting hearing loss in CHILDREN. It’s not a tumor. It’s an Epithelial Cyst that contains desquamated Keratin. It could be acquired secondary to Otitis media or Eustachian tube dysfunction. Infection is usually due to Pseudomonas. Presents with recurrent infection. MC sign: Drainage and granulation tissue and debris unresponsive to antibiotics & marginal tympanic perforation. They destroy bone. CT can detect defected bone. Tx: Surgical removal. DDx: Chronic Otitis Media: There is no debris and granulation.

CHOLESTEROL EMBOLIZATION Or Atheroembolic dz, follows surgical or manipulation of arterial tree (i.e. Angiography), due to showering of cholesterol from aorta or other major arteries. It’s MC seen in elderly pt w/evidence of diffused Atherosclerotic dz, Renal failure, Livedo reticularis, Systemic eosinophilia, and Low complement levels, should make you think of this. Tx: Conservative, STOP ANTICOAGS (it may prevent healing of the ruptured Plaque). PE: Painless, reddish blue mottling of the skin of the extremities.

CHOLESTEROL LIPID PROFILE - 3 CHILDREN recommendation: A child with a parental hx of elevated total cholesterol (>240mg/dl) or a child with risk factors for CAD should be screened for total cholesterol level. If total cholesterol >200mg/dl then do a fasting lipid profile test. For Screening: use HDL and Total Cholesterol. Tx guidelines -- Use LDL levels.

CHOLESTYRAMINE A bile acid sequestrant that lowers LDL and mostly increases HDL when combined with statin. In addition to binding bile acids in gut it also binds other drugs and reduces their bioavailability so the pt needs higher doses (ex hypothyroidism)

CHORIOAMNIONITIS Presents with fever >38, uterine tenderness, irritability, elevated WBC and fetal tachycardia. Its assoc with preterm or prolonged rupture of membrane. Fetal tachycardia could also be caused by Beta-2 agonist for tocolysis. Elevation of WBC could also be caused by steroids administration. Gold Standard Dx: Amniotic fluid cultures (Nitrazine paper test). Once Dx is established samples are taken for culture and then give Ampicillin and Gentamicin. Labor should be induced. If cervix is unfavorable C-section is done.

CHORIOCARCINOMA A malignant tumor of the trophoblastic tissue. Classically presents: hemoptysis, but it could also present with SOB and chest pain. In any postpartum female you should suspect Choriocarcinoma. Quantitative Beta HCG is important in Dx. So once you have postpartum woman with hemoptysis chest pain and SOB then to do CXR, pelvic exam and Beta HCG.

CHRONIC LIVER DISEASE Do Merck. Assoc with respiratory alkalosis.

CHRONIC MESENTERIC ISCHEMIA suspect it in pt with chronic abdominal crampy pain, weight loss and people who don’t eat food because of pain and other malabsorptive symptoms. Evidence of Atherosclerotic dz is present. Abdominal exam might reveal bruit in 50% of pts. Dx needs angiography and Doppler US.

CHRONIC RENAL FAILURE - 2 Secondary hyperPTHism with resultant renal osteodystrophy (lose calcium and retain phosphate) is almost universal in CRF. ****Normochromic normocytic anemia due to Erythropoietin deficiency is a very common in End Stage Renal Failure. Tx of choice: Recombinant Erythropoietin, however, Iron supplement should be given BEFORE Erythropoietin. All Chronic Renal Failure pts Hct<30, Hb<10 are candidates for Erythropoietin after Iron def has been ruled out. Erythropoietin SE: 1- Worsening HTN (~ 30% of pts) SC route less common than IV route). Tx: Removing fluid with Dialysis and B-blockers. 2-HA, 3-Flulike symptoms, 4-Red cell aplasia. ****Factors that improve prognosis in CRF: Protein restriction and ACE-I. ACE-I are more likely to worsen RF if serum Creatinine are >3-3.5 mg/dl.

CHURG STRAUSS A20. MERCK: It’s one of the group of diseases of known or unknown etiology characterized by eosinophilic pulmonary infiltrates commonly, peripheral blood eosinophilia, allergic granulomatosis (Churg-Strauss syndrome), a variant of polyarteritis nodosa w/a predilection for the lungs.

CIRCUMSTANTIALITY A thought disorder that answers in unnecessary details that deviate from the topic but eventually goes back to the topic. DDx1: Tangentiality: An abrupt permanent deviation from the topic. DDx2: Loose Associations: There is no association between sentences.

CIRRHOSIS - 3 Could occur 2ary to alcoholism. Pt has ascites, and esophageal varices 2ary to portal hypertension. Tx w/Large Varices but never bled: Prophylactic Propranalol significantly decrease the risk of future bleeding. ***A pt with refractory ascites, refractory hydrothorax, and recurrent variceal bleeding à TIPS (Transjugular Intrahepatic Portosystemic Shunt). is used. ***Alcoholism is the MCC of cirrhosis in US. 33% alcoholics, 10% HBV, 20-30% HCV (the MCC of liver transplant in US). ****Pts with cirrhosis may have upper GI bleeding due to: Erosive gastritis, PUD, Mallory-Weiss tear. Sclerotherapy is indicated for first varices, but not prophylactically. For PUD do conservative management, if that didn’t work then we do surgery, Excision of ulcer and vagotomy and pyloroplasty.

CLAVICLE FRACTURE In newborns presents w/ irregularity, crepitus and fullness over the fracture site and decreased movement of the arm. Predisposing factors: Shoulder dystonia, traumatic delivery, large infant. No tx is needed. ****For Adults do a figure-8 bandage. *****Clavicle fractures that are displaced can damage subclavian artery; Arteriogram is needed to r/o injury. Next step: Nerve conduction studies to r/o Brachial plexus injury. ***Fracture in distal 1/3: May require OPEN REDUCTION and INTERNAL FIXATION. ***Proximal and middle 1/3: Treated with CLOSED REDUCTION & FIGURE of 8 brace.

CLL (Chronic Lymphocytic Leukemia) - 3 MC Leukemia in Western countries. In ELDERLY: Mostly asymptomatic and discovered accidentally. Smudge cells. In general don’t need to do LN biopsy to confirm dx, but if you want to a highly specific biopsy is available to confirm dx. ***DDX: CML: presents w/LEUKOcytosis with left shift myelocytes, neutrophils not LYMPHOcytosis. ****Smudge cells (leukocytes that break down because of their greater fragility) are characteristic. Staging is directly related to prognosis: stage 0= Lymphocytosis only - Good Stage I = Lymphocytosis+Adenopathy - Fair Stage II = Splenomegaly present - Fair Stage III = Anemia present - Intermediate Stage IV = Thrombocytopenia, Poor. Mean survival is 8-10 years. *****To CONFIRM dx do LN biopsy.

CLOMIPHENE CITRATE An Anti-estrogen: Competitive blocking of receptors of hypothalamus, inhibiting the negative feedback that estrogen on GnRH and consequently INCREASING LH & FSH and improving ovulation. Along with hMg and hCG is indicated for chronic ovulation. SE: Hot flashes, breast discomfort, spotting. DANAZOL: An androgen derivative that has gonadotropin inhibitory effect. Indications: Endometriosis, Fibroids and Fibrocystic Breast Disease. CLONAZEPAM TOXICIY Use: Insomnia. Elderly possible could cause memory disruption. Next step à Discontinue it.

CLOZAPINE SE Agranulocytosis.

CLUB FOOT Or TALIPUS EQUINOVARUS. Calcaneum and talus are in equines and varus position. Initial management: (non-surgical) stretching and manipulation of the foot, followed by serial plaster casts, splint or taping). Surgical tx is indicated if that didn’t work, performed b/w 3 and 6 month of age.

CLUSTER HEADACHE - 2 Tx: Acute attack: 100% oxygen & subcutaneous Sumatriptan. *Presents with acute, sever retro-orbital pain that wakes pt up at night. =/-redness of ipsilateral eye, tearing, runny nose, and Ispilateral HORNER syndrome (Ptosis, Myosis, Anhydrosis). Prophylaxis is key to mgmt: Verapamil, lithium and ergotamine.

CML There is increased mature granulocytes like segmented neutrophils and band forms. BM shows hypercellularity with prominent granulocyte hyperplasia. Pt is in Crisis phase à IMATINIB (DOC). It’s a tyrosine kinase inhibitor that block signals WITHIN cancer cells. SE: Mild nausea, diarrhea, leg cramps and swelling of the face and itchy rash. It has changed the prognosis of CML.

CMV PNEUMONITIS Seen in 15-20% of BM transplants w/ case fatality of 84-88%. Presents with: Dyspnea, cough and fever. CXR: Multifocal diffused patchy infiltrates, and ground glass attenuation, parenchymal opacification or multiple small nodules on high res CT. BAL is dx in most cases. IT IS NOT SEEN IN IMMEDAITE post-transplant period, which is DDx: Bacterial and fungus pneumonitis. PCP is also seen in immediate post-transplant but occurrence has decreased dramatically due to routine prophylactic use of TMP-SMX in pre-transplant period.

COARCTATION of AORTA Presents w/rib notching (the 3 sign). HA is a presenting sign. Upper extremity: HTN. CXR: shows dilated ascending aorta and subclavian artery. Indentation of aorta at site of coarctation and pre and post stenting dilation is called the '3' sign.

COCAINE TOXICITY - 3 Presents with EKG abnormality: ST depression (ischemia and infarction), HTN and excruciating chest pain. There is blood in nares and dilated pupils. Tx: Benzodiazepine, Nitrate and ASA. If pt has MI then 1ST line is Catheterization. ****Fetuses exposed to cocaine abuse exhibit: INTRACRANIAL HEMORRHAGE, NECROTIZING ENTERCOLITIS, CARDIAC DEFECTS, G-U MALFORMATIONS. ****Could cause MI due to causing vasospasm. He has no risk for MI and is only 27. COCCIDIOMYCOSIS Endemic in California Arizona and New Mexico and Texas. Primary Pulmonary infection -- non-specific feature: Fever, fatigue, dry cough weight loss. Cutaneous Erythema multiform and erythema nodosum and arthralgias possible. ***Blastomycosis: Cutaneous disease is verrucous (warts or wart-like projections) or ulcerative.

COLON CANCER: MC Screening test: FOBT. Pts should be followed with colonoscopy.

COLORECTAL CANCER MC presenting symptom is bleeding

COMMUNICABLE DISEASE If pt's disease could harm others à Tx against his will. Scenario: A man with meningitis & fever 104 X 2 days who wants to be tx at home. Answer: Treat in hospital against his will since he will be harmful to others at home.

COMPARTMENT SYNDROME CLINICAL Dx: Pallor, pain, pulselessness, paralysis and paresthesias (numbness, tingling). PAIN on passive extension of fingers (most sensitive marker of CS). Pain is persistent, progressive, unrelieved with immobilization & pain out of proportion to initial injury. CS is caused by increased pressure within an anatomical space.

COMPLEX PARTIAL SEIZURE Brief episodes of impaired consciousness, failure to respond to various stimuli, staring spells, AUTOMATISM (Lip smacking, swallowing), and postictal confusion. EEG is usually normal. DDx1: Typical Absence seizure might have lip smacking but without postictal confusion.

CONDUCT DISORDER Characterized by disruptive behavior that violate basic social norms for at least one year in pt <18 yo. Like stealing, setting fire, fighting, animal abuse. DDx: Antisocial disorder is when these boys become adults (Age>18yo).

CONGENITAL ADRENAL HYPERPLASIA- 2

HypoNa, HyperK, Hypoglycemia, and metabolic acidosis. It’s due to 21-Hydroxylase deficiency. Its Autosomal Recessive. Deficiency: both glucocorticoids and mineralocorticoids. Male infants will NOT have ambiguous external genitalia unlike female infants, that’s why male infants go on unnoticed until 2-4 weeks when they present with salt wasting; Tx: Glucocorticoid replacement *****Adolescent onset of hirsutism and virilism with normal menstruation & elevated 17-OH Progesterone. CONGENITAL DIAPHRAGMATIC HERNIA: All emergency cases à remember: Tx supersedes Diagnosis. 1st step if you suspect CDH: OROGASTRIC tube and connecting it to a continuous suction in order to prevent bowel distension and further lung compression. AVOID: Bag-and-mask b/c can cause the stomach and intestine to become distended with air, further compromising lung fxn.

CONGENITAL HEART DEFECTS 1-TOF: VSD. 2-Down: Endocardial Cushion Defect. Also ASD (L to R shunt). 3- Turner Synd: Coarctation of aorta. 4-Congenital rubella: PDA.

CONGENITAL HYPOTHROIDISM MCC: Thyroid dysgenesis, 85% of cases. Infant has apathy, weakness, hypotonia, constipated, sleeps a lot, large tongue, umbilical hernia. Screening: T4 and TSH levels. Tx: Levothyroxine

CONGENITAL RUBELLA Triad: Sensorineural deafness, Cardiac malformation (PDA & ASD) + Cataracts. And possible: thrombocytopenia and purple skin lesions (Blueberry muffin spots). If transmission occurs in first 4 week of pregnancy the risk of developing CR is 50%, it drops to 1% in 3rd trimester. The child might show symptoms at 2 years old.

CONGENITAL TOXOPLASMOSIS Triad: Chorioretinitis + Hydrocephalus + Intracranial calcification. Look for pet in the scenario somewhere.

CONJUNCTIVITIS, NEONATAL - 2 There 3 causes for NC in USA. CHEMICAL GONOCOCCAL 1st 24hr of life Occurs 2-5 days after birth Occurs b/w 5-14 days (MCC of the red eye) after birth Copious purulent eye TRACHOMAS presents Mild conjunctivitis discharge with swollen w/mild hyperemia and and tearing eyelids & Chemosis scant mucoid eye (conjunctival edema) discharge and pannus (neovascularization) formation About 80% from Acquired through contact prophylaxis w/ silver w/infected vaginal secretions nitrate (to prevent at birth gonococcal) Dx: A smear and culture of Tx: Systemic Erythromycin Resolves within 24 hrs the discharge to decrease risk for Tx: Ceftriaxone a single IM Chlamydial pneumonia dose

CONSTRICTIVE PERCARDITIS - 2 Assoc with TB in immigrants. ****Etiology could be early TB in life. The early 3RD heart sound, called PERICARDIAL KNOCK and the respiratory increase in JVD (Kussmaul sign) are important findings. Kussmaul is also present in right side heart failure, severe tricuspid regurgitation, RV infarction and cardiac tamponade. ******CP will lead to inability of ventricles to fill during diastole and would further cause the signs of decreased cardiac output (fatigue) and signs of venous overload like JVD, dyspnea, ascites, Kussmaul, pedal edema tender hepatomegaly. Sharp ‘x’ and ‘y’ descent on central venous tracing is the sign of CP as is Pericardial Knock (early sound after S2).

CONTRACEPTION Lactation is a contraceptive method in itself because prolactin inhibits GnRH thus preventing ovulation. However, it is not a reliable method If a woman wants contraception right after giving birth, give her Minipill (Progestin only pills), Don’t give Combined OCP because Estrogen may cause decrease in milk production.

CONVERSION DISORDER - 2 Tx: Psychotherapy. Pt loses eyesight in stressful situation. *** If pt comes with bilateral leg paresis, give Sodium Amytal and he will dramatically improves.

COPD - 8 If pt is NOT CRASHING: 1st line of tx: Non-invasive positive pressure ventilation before intubation. All pt with PaO2<55 and SaO2<88 are candidates for long term home oxygen therapy. Pt with pulmonary HTN and Hct >55 start w/ home therapy if PaO2 falls <60mmhg. Smoking cessation and home oxygen therapy are 2 modalities that can reduce mortality in pt. ****Acute Exacerbation of COPD: Tx: Combo: Inhaled/nebulized bronchodilators and systemic steroids (Methylprednisone). *****If w/multi-focal atrial tachycardia due to exacerbated COPD: Theophylline and Beta Agonist (Albuterol) (Remember beta agonists decrease K+ & worsen arrhythmia) will WORSEN tachycardia à Give Oxygen to stop the arrhythmia. ****COPD comprises lung OBSTRUCTIVE diseases: Chronic Bronchitis and Emphysema. The airflow obstruction is irreversible. A chronic smoker with a productive cough and dyspnea on exertion, with decreased FEV1/FVC is suggestive of COPD. Chronic Bronchitis EMPHYSEMA Def. Chronic cough: Least 3 mo for 2 Destruction of alveolar wall consecutive years CB: Chronic productive cough, Pink Puffer (emPhysema), hyperinflation prominent bronchovascular of the chest, Decreased vascular markings, mild flattening of diaphragm, markings and normal DLCO. These are called Decreased DLCO (due to destruction of Blue Bloaters (for Bronchitis), they have alveoli) & moderate O2 saturation heart failure signs & profound O2 desaturation Remember RESTRICTIVE lung diseases: Sarcoidosis, Silicosis, Asbestosis, Scleroderma and RA lung all characterized by NORMAL FEV1/FVC. ****The most impact on COPD pt is by Oxygen home Tx. O2 HOME Tx guideline: PaO2<55 and O2 saturation <90%. *** Chronic pt à Severe dyspnea and confusion and profuse sweating. CXR: Complete collapse of L lung, possibly by a mucus plug (atelectasis is the same after surgery). Tx: Emergent Bronchoscopy to remove the plug that will improve PaO2. ***** Best option for COPD exacerbation: Non-Invasive Positive Pressure Ventilation. It should be tried before intubation and mechanical ventilation in COPD pts with CO2 retention.

COR PULMONALE Combination of Elevated JVP, Hepatomegaly, ascites, and lower extremity edema w/o evidence of pulmonary congestion is suggestive of isolated right heart failure. If there are no RALES means there is no pulmonary congestion. MCC: Right side heart failure is Pulmonary Dz and known as Cor Pulmonale. CP is most likely caused by COPD (Smoker); less common causes are pneumoconiosis, pulmonary fibrosis.

COURT ORDER T9Q38

CRANIOPHARYNGIOMA - 2 Although MC in children, they are bi-modal and could happen in adults too. Children: Retarded growth (MC presentation). Adults: Hyposexuality, Bitemporal blindness (classic sign). Dx: MRI or CT. Tx is surgery or radiotherapy. ****A young boy with symptoms of increased ICP (HA, Vomit), Bitemporal anopsia and a calcified lesion above sella has Craniopharyngioma until proven otherwise. Almost Dx: a Cystic Calcified parasellar lesion on MRI is. DDx: Pituitary Adenoma: More frequent in women and Prolactinoma is an important part of it, and there is no CALCIFICATION of the gland.

CREST SYNDROME - 2 Anti-Centromere antibody is Dx. *****Calcinosis, Raynaud's, Esophageal dysfunction, Sclerodactyly and Telangiectasia. It has a better prognosis than diffused Scleroderma.

CREUTZFELDT-JACOB - 2 Age: b/w 50-70, with rapidly progressive dementia, myoclonic and periodic synchronous bi- or triphasic sharp wave complex on EEG. Brain Bx: Cortical spongiform changes. CSF is normal, Death within 12 months, NO Tx. Spongiform encephalopathy is caused by prion.

CROHN’S DISEASE: - 2 DDx with UC is non-caseating granulomas. CROUP Also known as LARYNGOTRACHEITIS or LaryngoTrachioBronchitis, is characterized by laryngeal inflammation that results in hoarseness, a barking cough and respiratory distress. Typical Age <3 and the MCC is Parainfluenza virus. Dx: Clinical and lateral XR: subglottal narrowing. Always give Epinephrine before any invasive tx like intubation. This is ONLY for croup not Epiglottis. Tx: 1st OXYGEN, 2nd EPI, 3rd intubate in ER.

CUSHING’S SYNDROME - 3 Due to ectopic ACTH. ***Pt with lung cancer and ectopic ACTH production can have Cushing's. ****Dx procedure.

CUTANEOUS LARVA MIGRANS Is a CC of dermatological disease in tropical travelers. It’s caused while "Sand box handling" and it’s characterized by serpiginous lesion in the skin. Tx: Thiabendazole or Mebendazole

CVA Occurs in middle and late years of life. Could be either Ischemic (85%) or Hemorrhagic (15%). Ischemic CVA: Originates from aortic arch, carotid bifurcation, and obstruct arteries. Clinically atherothrombotic stroke occurs at rest and have a gradual onset. Pt experience successive strokes. (+) Babinski Sign indicates UMN due to major cerebral artery obstruction. ***Ischemic CVA can also be caused by thrombi from left heart. It’s associated with sudden onset and preexisting cardiac disease. EKG is characteristic. MC site: Lateral STRIAE arteries (arteries of stroke) which are branches of MCA, supply: INTERNAL CAPSULE, PUTAMEN. So if a pt has normal EKG and cardiac enzyme, this kind of stroke is unlikely.

CYCLICAL VOMITING Recurrent self-limiting episodes of vomiting and nausea in children. Tx: Antiemetics and reassurance.

CYCLOSPORINE SE 1-Nephrotoxicity: the MC and serious SE. Manifest as acute azotemia or irreversible progressive renal disease. 2-HTN: due to vasoconstriction and sodium retention. DOC: CCB 3-Neurotoxicity: Often reversible. Tremor, HA, nausea, seizure, visual problems. 4-Glucose Intolerance 5-Infection: 40% of pt get chronic infection. 6-Malignacy: Risk of squamous cell carcinoma. 7- Gingival Hypertrophy and Hirsutism. 8-GI: Mild Tacrolimus has the same SE except hirsutism and gum hypertrophy. Azothioprine SE: Dose-related diarrhea, leukopenia, hepatotoxicity. Mycophenolate SE: Marrow suppression. CYCLOPHOSPHAMIDE SE SE: Bladder carcinoma. Also alopecia, sterility, amenorrhea, acute hemorrhagic cystitis.

CYCLOTHYMIC DISORDER Depressed mood > than two years.

CYSTIC FIBROSIS: - 8 Bronchiectasis due to Pseudomonas, infertility, and recurrent respiratory infections. CXR: "Tram Track pattern" and opacities is dx for Bronchiectasis. PATHOPHYS: Abnormal chloride transportation in all exocrine glands. Dx: Sweat chloride concentration >60. Since there is fat malabsorption, fat-soluble vitamins are deficient. So vit K is deficient and since vit K is a cofactor for the enzyme gamma-glut amyl carboxyl’s which adds carboxyl group to glutamate residue of factor II, VII, IX & X, and protein C & S, those coagulation factors will be also deficient. *****A routine influenza vaccine is indicated in all CF pts, but not Pneumococcus vaccine. There is assoc b/w Pseudomonas pneumonia and CF use Gentamicin & Pipercillin *****Tx of acute severe exacerbation of lung disease in CF: IV Pen/Cephalo+Gentamicin. *****Autosomal Recessive, need to know both parents DNA status to determine child's possibility of having CF. *****MC mutation: DELETION of a 3 base pair coding for Phenylalanine (D F5O8) in the CFTR gene in Chromosome 7. ****Pts with CF present with Meconium Ileus characterized by bilious vomiting, failure to pass meconium at birth, and Abd XR: Ground-glass appearance *****Suspect it in a pt with: Bronchiectasis (productive cough for 3 months) and Malabsorption (foul-smelling stool) due to pancreatic insufficiency. ***One clue if the pt starts to show in his 20s is a hx of Meconium Ileus (intestinal obstruction) as a neonate. Whenever there is acute exacerbation of pulmonary infection in a pt with CF, think Pseudomonas and treat it with Pipercillin + Gentamicin.

CYSTINURIA An inherited dz causing recurrent renal stone formation. Look for positive family history and stones since childhood. Stones are radiopaque and hexagonal. Screening test: Urinary Cyanide Nitroprusside test

CYSTITIS - 2 Most commonly caused by Ascending infection. Presents: UTI symptoms and suprapubic tenderness. ****Uncomplicated Cystitis: Presents with suprapubic discomfort and signs of UTI, then there is NO need to do culture. Tx: Oral TMP-SMX. If there is resistance give Cipro or Nitrofurantoin.

DACRYOCYSTITIS Inflammatory changes in MEDIAL CANTHAL, MCC Staph aureus and Strep. Acute Dacryocystitis: Tx: Frequent hot compresses; cephalexin or Cefazolin; an abscess has formed incision and drainage. Chronic Dacryocystitis: Tx: Dilating the nasolacrimal duct

De QUERVAIN’S TENDONITIS (Abductor or extensor tendons of the thumb) is usually diagnosed by localized tenderness, if not mild swelling along the course of the tendon. Sharp pain is elicited or accentuated when the ipsilateral thumb is flexed across the palm, enclosed by the fingers, and the wrist is deviated ulnarly to stretch the tendons and surrounding sheath (Finkelstein's sign in stenosing tenosynovitis). Symptomatic relief: Rest or immobilization (splint or cast) of the tendon, application of heat for chronic inflammation or cold for acute inflammation (whichever benefits the patient should be used), and NSAIDs. Surgery for release of fibro- osseous tunnels.

DEHYDRATION: - 2 Mainstay of Tx: IV sodium containing crystalloids (0.9% NaCl=Normal Saline) ***Elderly pts are sensitive to dehydration and even mild Hypovolemia can lead to orthostatic syncope, especially upon getting up in the morning. INCREASED BUN/Creatinine is a good indicator of dehydration.

DELIRIUM TREMORS Tx: Chlordiazepoxide.

DELIRIUM vs. DEMENTIA Delirium: Acuteness, impaired consciousness, fluctuating course, reversible symptoms and global memory impairment. In the absence of any focal neurological signs, even if there is evidence of carotid bruit (Vascular Dementia) Delirium is the most likely Dx.

DELUSIONAL GRANDIOSITY Pt thinks has special powers, extraordinary accomplishments, or special relationship w/God. There are three types of Delusion: 1-Grandiose (religious in nature) 2- Paranoid 3-Somatic.

DEPENDENT PERSONALITY Pt is so agreeable and depends on whatever the doctor suggests.

DERMATITIS HERPETIFORMIS-3. Derm 6/3 Pruritic papules, vesicles over the knee, elbow, buttocks. Immunoflorescence: Granular IgA deposits along dermal papillae. Assoc w Celiac Sprue. Tx: Dapsone. Suspect DH in a pt with Malabsorption and pruritic papules and vesicles over the extensor surfaces. Anti-Endomysial antibodies are characteristic. Pt also suffers from Gluten sensitive enteropathy or Celiac Sprue. Tx: Strict adherence to a gluten-free diet for prolonged periods (e.g. 6 to 12 mo) may control the dz in some patients or Dapsone.

DERMATOMYOSITIS: Is an autoimmune disorder involving muscles and the skin. Skin eruption is dusty red in color. Edema around the eye and the heliotrope rash of the eyelid are more specific. Gottron’s sign: Skin over the back of knuckles show non-scaly violaceous erythematous eruption (highly suggestive of this disorder).

DES TOXICITY If given to pregnant women causes Clear cell ADENOCARCINOMA of vagina in their daughters. In the old days it was the best tx for threatened abortion. With early dx and tx survival is 80%.

DEVELOPEMENTAL DYSPLASIA of HIP DDH is characterized by subluxatable and dislocatable proximal femur and acetabulum. Early dx and tx is important because failure will result in sigificant morbidity. On inspection uneven gluteal fold are seen. MC in white female. Dx is confirmed: USG in infants <6mo. (+) Barlow and Ortolani are highly suggestive. Tx: Surgical REDUCTION

DEVELOPMENTAL MILESTONES:

Language Gross Motor Fine Motor Age: Age: Age: Age:

2 mo Social smile 3 mo Holds head 2 mo Recognize parents 4 mo Rolls back to 6 mo Recognize strangers 6 mo 2 words, obey front 12 mo Imitates, comes 1 word 6 mo 6 mo Raking grasp when called commands Sits unsupported 18 mo 12 mo 12 mo 12 mo Throw object 2 yr Play w/ other kids 2 yrs 2 yr 15 mo 2 block tower Parallel play Walk alone 2 yr 6 block tower 2-3 phrases, Walk stairs 2 step command

1-LANGUAGE: 2 mo: Social Smile, Babies = 6mo: 2 words and obey 1-step command = 12mo; 2yr: 2-3Phrase& 2 step command 2-GROSS MOTOR: Hold head=3mo, Rolls back to front=4mo, sits unsupported = 6mo, walks alone=12mo, walks stairs=2yr. 3-FINE MOTOR: Raking Grasp=6mo, Throw object=12mo, Build tower of 2 block=15mo, build 6 blocks=2yr. 4-SOCIAL: Recognize parents=2mo. Recognize strangers=6mo, Imitates/comes when called=12mo, play with other kids=18mo, Parallel play=2yr.

DEXTROMETHORPHAN - Poisoning 6/3 A cough medicine. has drug toxicity with MAO inhibitors, causes hyperthermia DIAGNOSITIC PERITONEAL LAVAGE The best dx procedure for intraperitoneal organ laceration. Like a guy being hit in the stomach. Angiography is never done.

DIABETES INSIPIDUS- 3 Presents with polyuria and polydypsia, due to ADH defic or resistance. Pt prefer cold beverages and their urine osmolarity < serum osmolarity. Pts pass excessive amount of dilute urine. Initial fluid of choice in hypotensive pt: Normal saline then later Hypotonic fluids. DDx1: Primary Hyperaldosteronism: (aldosterone = saves Na+ and loses K+), HyperNa+ is rarely symptomatic, other features are HTN & HypoK+ DDx2: Osmotic Diuresis: (increase renal excretion of water relative to Na+), occurs in cases of hyperglycemia and Mannitol intake. Urine osmolarity > serum osm. DDx3: SIADH: results in HypoNa+, low serum osmolarity & inappropriately high urine osmolarity. Usually seen in pt with lung cancer and abnormal brain pathology like trauma or stroke. DDx4: Primary Polydypsia: A disorder where pt drinks fluid in excess of 5L/day and both plasma and urine osmolarity are low (diluted). ****Administration of DDAVP (desmopressin) ddx b/w CDI and NDI. CDI: INCREASED URINE OSM after administration of AVP (arginine Vasopressin, or DDAVP), Tx for CDI is intranasal Desmopressin. NDI No INCREASE IN URINE OSM.

DIABETES MELITUS - 34 1-Normal anion gap metabolic acidosis in DM pt with Gastroenteritis: could be either due to loss of bicarbonate due to diarrhea, or defective NH4 synthesis due to nephropathy. Next need to calculate urine anion gap. [Urinary (Na+ + K+) - Urinary Cl-]. If its positive value problem is Nephropathy, if it’s a negative value = Gastroenteritis. 2-Diabetic Osteomyelitis (due to arterial insufficiency) that involves bone adjacent to the foot ulcers is explained by contiguous spread of infection. 3- Acanthosis Nigricans: A complication of DM. Although it’s associated with both DM and Addison's disease; insulin resistance is the MCC in young population, and its assoc with malignancy in older individuals. 4-Somogi Effect: “rebound hyperglycemia” (low blood glucose values of less than 70) followed by hyperglycemia (high blood glucose levels of more than 200). 5-Diabetic Neuropathy: Tx: Gabapentin and TCA (Imipramine). 6-Diabetic Cystopathy (OVERFLOW INCONTINENCE) Tx is Bethanechol. 7-Diabetic Retinopathy 8-Infection in diabetes 9- Diabetic Nephropathy, detection of microalbuminemia is the best detection. Fasting blood glucose is now test of choice for screening high-risk person for DM. Fasting glucose 126 or greater, repeat it, and if it’s still elevated the Dx is made. Dx could also be made if pt is SYMPTOMATIC and glucose after 75g tolerance test is 200 or greater. Add ACE inhibitor even if BP is under control, it slows progression of nephropathy and keeps glomerular BP reduced Ketones responsible for DKA are Acetone, acetoacetate and beta hydroxybutyrate. Diabetic Neuropathy leads to denervation of bladder resulting in urinary retention, Overflow incontinence day and night, aside from strict glucose control tx includes intermittent catheterization and Bethanechol, avoiding alcohol maybe helpful. **** If Antibiotics don’t cure ulcers, DEBRIDE the wound. ****Glomerular Hyperfiltration is the earliest renal abnormality seen, as early as several days within dx of DM. It’s the major pathophysiologic MOA of glomerular injury in these pts. 1ST change that can be quantified: Thickening of the glomerular BM (1ST change). Effectiveness of ACE-I is related to their ability to reduce intra- glomerular HTN & decrease glomerular damage **** HbA 1-c = Best way to monitor DM control. HbA1c is formed by non- enzymatic glycosylation of Hb. It reflects the average glucose blood levels within the preceding 2-3 months that corresponds to RBC life. Every 1% increase in HbA1c corresponds to 35mg increase in glucose. Measurement of C-peptide is done to determine if the insulin use is internal or external. Every 1% increase in HbA1c corresponds to 35mg increase in glucose. Measurement of C-peptide is done to determine if the insulin use is internal or external.

DIABETIC KETOACIDOSIS Anion Gap Metabolic Acidosis observed during DK is accompanied by HyperK+, it’s called paradoxical because body K+ reserves are actually depleted. There is hyperK+ for 2 reasons: 1-Extracellular shift of K+ in exchange for H+ with resultant intracellular K+ depletion. 2-Impaired insulin-dependant K+ entry.

So in Tx for DKA, after insulin and diuresis administer K. ***Suspect it if pt presents with rapid breathing, hx of weight loss, polydipsia polyuria. END OF KA. ****Fasting blood glucose measurement is now the screening of choice. Dx: A FBG of 126 or more on 2 occasions. Impaired FBG/pre-DM: FBG 100-125. A pt w/symptoms: polyuria, polydypsia, & obesity FBG of >200 may confirm the dx but it’s not appropriate for screening. The 50g glucose tolerance test is used for screening gestational DM, while 100g used to confirm it. ***DM Neuropathy seen in 50% of pts. Presents: polyneuropathy, mononeuropathy or Autonomic Neuropathy. AN: Related to the duration of disease and glycemic control; Any part of GIT can be affected: Small Intestine: Diarrhea Colon: Constipation Stomach causes gastroparesis which presents as nausea, vomit, bloating, anorexia, and early satiety. Due to delays gastric emptying, glucose control is difficult to achieve. Pt has post-meal hypoglycemia after insulin injection. Nuclear Medicine Scintigraphy after ingestion of radio-labeled food à Best method to document Delayed gastric Emptying. Management includes: 1-Improved glycemic control, 2-Small, frequent meals, 3- Dopamine agonist (Metoclopramide, Domperidone) before meals, 4-Bethanechol, 5- Erythromycin (rxn w/Motilin promotes emptying), 6-Cisapride. ****Most beneficial therapy to reduce progression of DN in presence of renal insufficiency is control HTN. *****Nonketotic Hyperosmolar syndrome occurs in DM2 because insulin level is sufficient to prevent DKA but not hyperglycemia. Hyperglycemia occurs with hyperglycosurea and dehydration. Will present w/semi-comatose state. 1ST do: Check blood glucose. *****Diabetes screening in pregnant women is performed: 24-28 weeks of gestation. If urine dipstick reveals glycosuria then, Next step: Fasting Urine samples if (+) à Do a 1hr-50g oral glucose tolerance test. If glu <140, DM is ruled out. If glu >140, 3hr-100gr OGTT is used for confirmation. ****Diabetic Neuropathy can present with ulcer in the foot. Risk factors for DM foot ulcer: Diabetic Neuropathy, peripheral vascular dz, poor glycemic control, bony abnormalities of the foot, male sex, smoking, chronic DM (>10ys), a hx of previous ulcer or amputation. Neuropathy is found in 80% of diabetics with foot ulcer. **** MC type of diabetic neuropathy: Symmetrical distal sensorimotor polyneuropathy ("stocking glove" pattern or sensory loss). ****DM is a risk factor for Non-alcoholic fatty steatosis. *****Hyperglycemic, Hyperosmolar, Non-Ketotic Coma: Very high blood glucose, plasma hyperosmolarity, normal anion gap and negative serum ketones. DDx KA is suggested by 1-blood glucose >250, 2-pH<7.3, 3-Bicarbonate<15-20, 4-Plasma ketones. DDx2: Alcoholic Ketoacidosis: Ketoacidosis w/increased anion gap BUT near normal glucose levels. ****Always consider Candida albicans as a cause of infection in a pt with uncontrolled DM. ****DM mothers’ babies - Often born w/Clavicle fracture that heals spontaneously w/o tx. ***The Dx test of choice for Diabetic Polyneuropathy is Electromyography & Conduction studies. **** Mucor Mycosis and maxillary sinus due to Rhizopus: Poorly controlled pt with low-grade fever, bloody nasal discharge, nasal congestion, involvement of the eye and chemosis, proptosis and diplopia. Involved turbinates usually become necrotic. DDx: Pseudomonas causes Malignant Otitis Externa; it may also cause black necrotic lesions. DDx also H. inf and Moraxella are MCC Bacteria Sinusitis, don’t cause NECROTIC infections*****Non-Ketotic Hyperosmolar Coma presents: Glucose 1000, and normal pH. Tx: 1st Normal Saline then replaces with 0.45% saline. Once glucose is down to 250, then give 5% dextrose that prevents cerebral edema. **** Diabetic Cystopathy usually secondary to diabetic autonomic neuropathy. Begins w/inability to sense a full bladder & failure to void completely. With time bladder size increase leading to signs of BPH & recurrent UTI. Dx: Cystometry and Urodynamic studies. Initial mgmnt: Strict voluntary urinary scheduling with Bethanechol, If no response intermittent catheterization is recommended. ****Emphysematous Pyelonephritis: A life-threatening condition caused by E. Coli. Dx is confirmed by CT. Tx: IV antibiotics and possible Emergency Nephrectomy

DIAMOND BLACKFAN ANEMIA Also called CONGENITAL HYPOPLASTIC ANEMIA. Suspect in a child with macrocytic anemia, low reticulocyte count and congenital anomalies. Primary pathophys: An intrinsic defect of erythroid progenitor cells which results in increased apoptosis. Dx within the 1st year of life (> 90%). Macrocytic anemia is distinct from megaloblastic anemia because no hypersegmentation of the nucleus in neutrophils. Presents with: Anemia, Short Stature, Webbed neck, Shielded Chest, Triphalangial Thumbs. Tx: Corticosteroids (mainly), if unresponsive then Transfusion therapy.

DIAPHRAGMATIC HERNIATION Occurs in accidents and CXR: Elevated left diaphragm could be the only sign. ****One Dx often missed in ER is TRAUMATIC RUPTURE of DIAPHRAGM. Usually on the LEFT SIDE. Pt returns months later: Breathing difficulty. CXR: Deviated mediastinum w/a mass in the left lower chest. Dx: Barium Swallow. Acute cases: SURGERY via ABDOMEN and Chronic cases via CHEST.

DIARRHEA, INFLAMMATORY- 6 MCC bloody diarrhea in USA: Campylobacter Jejuni. undercooked poultry; can be watery or hemorrhagic. ***Vibrio Parahemolyticus: Seafood. Bloody diarrhea, abdominal cramps, nausea, fever; Incubation 12-24hrs. Shigella: Daycare and institutional settings. Yersinia: Undercooked pork. ***Staph causes toxin-induced gastroenteritis mostly emetic type that starts within 6 hours. Salad, meat and egg. ***Traveler’s diarrhea, due to E Coli, is the cause of diarrhea w/o blood, mucus, explosive, rice watery diarrhea even in Mexico travelers. DDx: Giardia is endemic in Nepal. ***MCC of diarrhea in children is Rotavirus that causes acute gastroenteritis. Most cases: self limiting but maintain hydration There is now a vaccine, but was withdrawn due to risk of Intussusception *****Types of diarrhea: 1-Inflammatory: ESR is elevated, anemia and blood positive stool. 2-Osmotic: Caused by meds or hormonal disturbance. 3-Motor: exemplified by Hyperthyroidism. 4-Factitious: is psychological.

DIARRHEA Laxative abuse, profuse diarrhea. 10-20 times a day. DDx: BS diarrhea: IBS does not happen nocturnally but factitious does. FD is usually done by women of high socioeconomic status and Nurses. There is also characteristic dark brown discoloration of the colon with lymph follicles shining through as pale patches that confirm the dx.

DIC Tx: FFP if pt is bleeding only. If pt is not bleeding and has sepsis (high Temp and low BP) 1st step: IV antibiotics plus Activated Protein C.

DIFFUSE ESOPHAGEAL SPASM - 2 Manifest with chest pain and dysphagia. Etiology in unknown but related to emotional stress. LES has a normal relaxation response. Esophagogram might show Corkscrew. Tx: Antispasmodic drugs, dietary modulation and psychiatric counseling. ***For USMLE know 1-pathophys, 2-present or absence of peristalsis, 3-LES tone. MERCK: A generalized neurogenic disorder of esophageal motility in which phasic non-propulsive contractions replace normal peristalsis and, in some cases, lower esophageal sphincter malfunctions occur. Esophageal Manometry shows: Contractions are usually simultaneous, prolonged or multiphasic, and possibly of very high amplitude. ****Esophagography may not show the corkscrew, so do Manometry, if revealed "repetitive, non-peristaltic, high amplitude contraction either spontaneously or after Ergonovine stimulation then it’s Dx.

DI-GEORGE SYNDROME Infants: cyanotic heart dz, craniofacial anomalies, thymic dysplasia, cognitive impairment and hypoPTH. Assoc with Ch 22/11 deletion. In Surgery keep an eye on Ca++ levels.

DIGITALIS TOXICITY - 2 Some of the toxicities occur in therapeutic range (AV block, ST depression, T inversion) and there is no need to discontinue the drug. Some occur in Toxic serum levels (Atrial Tachycardia and AV heart block), Need to discontinue the drug. Digoxin also causes Nausea and Anorexia.

DIPHENHYDRAMINE TOXICITY Produces seizure as well as anti-cholinergic effects.

DIPYRIDAMOLE Used during myocardial perfusion scanning to reveal areas of restricted myocardial perfusion. It shows "Coronary steal phenomena"

DISK HERNIATION Once you know its DH and straight leg is positive, then NSAID and early mobilization is the tx of choice.

DISPLACEMENT - 2 An immature defense mechanism, in which individual displaces negative feelings assoc with unacceptable situation onto a safer one.

DISSEMINATED GONOCOCCAL INFECTION Presents in menstruating women with tampon, many partners, occasional condom, presents with high fever, rash, tenosynovitis and migratory arthralgia. DDx: TSS presents with fever, macular erythema of palms and soles, vomit and diarrhea and hypotension.

DISSOCIATIVE FUGUE Pt gets lost in another city.

DIVERTICULITIS - 2 Dx test: CT (to evaluate the abdomen during an acute episode). Colonoscopy and Sigmoidoscopy can cause perforation. *****Acute Diverticulitis complication may be bowel perforation where XR: Air under diaphragm and rigidity and guarding. Next step: Laparotomy with surgical resection of perforated bowel and proximal colostomy.

DIVERTICULOSIS Pseudodiverticulum can erode a penetrating artery. This leads to perfuse arterial bleeding of bright red blood. Diverticulosis is the MCC of bleeding in elderly. Chronic constipation is the single most predisposing factor to develop Diverticulosis. Normal XR does not r/o diverticulosis if it’s negative. Need XR with contrast (Barium) to be able to see it. DDx1: Colon Cancer: Presents with chronic, occult bleeding NOT BRIGHT RED. DDx2: Ischemic Colitis: Assoc with Abdominal pain, fever and vomit and atherosclerosis; XR: shows thickening of colon wall. DDx3: Mesenteric Thrombosis: Pain out of proportion is a classical symptom; Bloody diarrhea rather than bright red blood is characteristic, Diminished Bowel sounds.

DOWN’S SYNDROME in PREGNANCY T14Q12 explains how to test for DS in older women. Decreased MSAFP and Estriol and Increased B-HCG is the best test. SEE FA. Know heart defect, and also that they have Duodenal Atresia. Learn this. ***** ASD and Endocardial Cushion Defects. *****Duodenal Atresia (MC anomaly assoc with Down’s), XR: Double Bubble Sign. Other anomalies: Hirshsprung, Esophageal atresia, Pyloric stenosis, Malrotation. Congenital heart disease is the MCC of death in childhood, like endocardial cushion defect, VSD, PDA.

DRESSLER’S SYNDROME: Post-MI Pericarditis. Non-specific ST elevation. NSAID is tx of choice.

DRUG-INDUCED PANCREATITIS 1-Diuretics: Furosemide and Thiazide. 2-IBD: Sulphasalazine and 5-ASA. 3- Immunosuppressants: Azathioprine. 4-Seizures, Valproic Acid. 5-AIDS, Didanosine, Pentamidine. 6-Antibiotics, Metronidazole, Tetracycline. CT is dx with inflamed pancreas. Tx supportive.

DRUG-INDUCED INTERSTITIAL NEPHRITIS - 2 Caused by Cephalosporins, Penicillins, Sulfa drugs, NSAID, Rifampin, Phenytoin and Allopurinol. Pt presents with Acute renal failure+Arthralgia+rash. *** 70% of cases are drug-induced, discontinue the drug and it will be OK. Pt present with fever; urine analysis shows: RBC, WBC and white cell casts, eosinophilia and proteinuria.

DRUGS, C/I 1-Beta Blockers: Peripheral Vascular Dz (pt presents with worsening intermittent claudication), asthma, COPD, Raynaud’s. 2-ACE inhibitors: HyperK+, pregnancy (birth defects). 3-Calcium Channel Blockers: Second & third degree heart block and CHF.

DUBIN-JOHNSON A familial disorder of hepatic bile secretion. Leads to conjugated Hyperbilirubinemia. May be aggravated by women taking OCP. Liver Bx: reveals cells with DARK granular pigments. DDx1: Rotor: like DJ but no DARK granule pigments.

DUCHENNE’S MD Muscle biopsy will reveal dx.

DUMPING SYNDROME A common post-gasterectomy complication. Pt with recent Gasterectomy presents with postprandial abdominal cramps, lightheadedness, diaphoresis. 1st thing: Modify diet, small frequent meals and avoid simple CHO. Dx is made clinically but occasionally Contrast XR (barium swallow) is used.

DUODENAL ATRESIA Bilious vomiting few hrs after the 1st feeding, usually assoc with congenital anomalies and Down’s Syndrome.

DUODENAL HEMATOMA, ISOLATED If hemodynamically stable, needs nasogastric suction and parenteral nutrition (food) not IV fluid.

DUODENAL INJURY Isolated duodenal injury is easily missed. They occur in accidents due to the seatbelt or steering wheel. Present with epigastric or RUQ pain. Retroperitoneal air or obliteration of right psoas margin on XR is very suggestive. Best Dx: Abd CT scan w/oral contrast or an upper GI study w/ gastrografin, followed by barium if necessary.

DVT - 3 OCP is a well-known risk factor for DVT. Tx steps: Anticoagulation therapy has serious SEs, so accurate dx must be made before anticoagulation is started. Test of choice for DVT is Compression U/S. Impedance Plethysmography is for recurrent DVT. Venography is the Gold standard for dx of DVT, but it causes discomfort so it’s not the initial test for suspected DVT. It’s only done when other tests are impossible or inclusive. ***Surgical pts can be categorized according to their risk of DVT.

LOW risk MODERATE risk HIGH risk Minor surgery Age Pt>40, 1 or more Pt >40, additional risk <40 with no additional risk, factors, major operation, risk additional risk minor/non-minor surgery, of DVT is 10-20%. factors. w/o risk is 2-10%. **General Surgery can be prophylaxis risk for given LMWH; **Orthopedic DVT is <2%. surgery of lower extremity (knee replacement) LMWH or Oral Warfarin.. w/o prophylaxis risk for DVT is <2%.

**Prophylaxis other ** LMWH or *****The best DVT than early Unfractionated Heparin is prophylaxis for high-risk mobilization is not recommended surgery pt going under recommended orthopedic surgery includes either warfarin or LMWH.

**Pts w/unacceptable ***INR used to monitor tx bleeding risk: response to Warfarin intracranial, spinal cord injury should receive ***Therapeutic Range of INR intermittent pneumatic for most pts is 2-3, for compression venous thromboembolism, Valvular heart dz 3-4.5 for Prosthetic valves.

Therapeutic Range of INR for most pts is 2-3, for venous thromboembolism, Valvular heart dz 3-4.5 is for Prosthetic valves. *****The best DVT prophylaxis for high-risk surgery pt going under orthopedic surgery includes either warfarin or LMWH.

DYSFUNCTIONAL UTERINE BLEEDING - 2 Heavy unremitting endometrial hemorrhage through menarche and perimenopause requires conjugated Estrogen to suppress the bleeding to ensure CV stability. Once that is achieved D&C should be performed. MCC of DUB in adolescent is anovulation; therefore endometrial biopsy is not required in these pts. Once bleeding is stopped, advise pt to take: Conjugated estrogen for 25 days, then add Medroxyprogesterone for the last 10-15 days and then allow 5-7 days for withdrawl bleeding to mimic menstrual cycle. ****In which pts w/DUB do you perform endometrial biopsy to r/o endometrial carcinoma? Pt is >35, obese, DM or has chronic HTN

DYSTONIA Def: involuntary contractions of muscles. These contractions result in twisting and repetitive movements. Sometimes they are painful. from antipsychotics. Tx: Benztropine or Diphenhydramine.

EATON LAMBERT Assoc with small cell carcinoma. Voltage-gated calcium channels antibodies in presynaptic motor nerve terminal. It is presynaptic, resulting from impaired release of acetylcholine from nerve terminals. Dx: is confirmed by finding an incremental response to repetitive nerve stimulation: Amplitude of the compound muscle action potential increases > 200% at rates > 10 Hz. Treatment: 1st treat underlying malignancy and sometimes induces remission. Guanidine facilitates acetylcholine release.

EATING DISORDER, NOT OTHERWISE SPECIFIED (NOS) if the scenario shares features of both bulimia and anorexia, it’s this disorder.

ECHINOCOCCUS Due to close contact with SHEEP. Pt presents with hepatomegaly, forms hydatid cyst in liver after U/S. Hydatid cyst has an inner germinal layer and an outer acellular laminated membrane. DDx: Neurocysticercosis, due to PIG farming. With cysts in Brain, kills fast.

ECZEMA HERPETICUM T9Q23. A form of Herpes simplex that is assoc with atopic dermatitis. Numerus umbilicated vesicles around the healing area are typical. In infants could be life threatening, start acyclovir ASAP.

EDWARD'S SYNDROME - 2 Microcephaly, prominent occiput, micrognathia, closed fists, index finger overlapping 3-4-5 bilaterally, rocker bottom feet. 95% die by first year. *** Pts have murmur due to VSD. This is trisomy-18 (E-lection age)

EKG abnormalities 1-T wave inversion: Ischemia of myocardium. 2-ST depression: Subendocardial infarcts and unstable angina. 3-Prolonged PR: first degree heart block. 4-Delta waves: WPW. 5-New RBBB: seen in PE. 6- Electrical Alternans: in cardiac tamponade

EMBOLUS, LIMB If pt presents with cold hand due to embolusà immediate HEPARIN (anticoagulation) and surgical intervention is indicated.

EMPHYSEMA In a non-smoker should raise the suspicion to Alpha-1 anti-trypsin def; Also associated w/Neonatal Jaundice in the hx of the pt. Dx: by estimating alpha-1 trypsin levels.

EMPHYSEMATOUS CHOLECYSTITIS Is a common form of acute Cholecystitis in elderly diabetic males. Due to infection of the gallbladder wall with gas forming bacteria. Dx: Abdominal XR showing air-fluid level in the gallbladder or U/S showing gas line. Lab: Moderate unconjugated hyperbilirubinemia or small elevation of aminotransferases. Tx: Early fluid resuscitation, early cholecystectomy, and parenteral antibiotic therapy effective against GP Anaerobic Clostridium sp. (Ampicillin- Sulbactam, or combination of Aminoglycoside or Quinolone with Clindamycin or Metronidazole.

EMPYEMA Def: A collection of pus in the space between the lung and the inside of the chest wall (pleural space). Symptoms: chest pain that worsens w/inspiration, dry cough, excessive sweating, especially night sweats, fever and chills, general discomfort, uneasiness, malaise, SOB, unintentional weight loss Can occur from parapneumonic effusions: (In parapneumonic effusions, the visceral pleura overlying a pneumonia become inflamed; often, an outpouring of serous exudative fluid accompanies acute pleurisy. The fluid contains many neutrophils and may contain bacteria. Parapneumonic effusions are usually caused by bacteria. If the body's defenses do not control infection in a patient with pneumonia and parapneumonic effusion, the number of neutrophils and bacteria increases, and the fluid takes on the gross appearance of pus. The result is empyema of the thorax (purulent exudate in the pleural space). (Fluids > 100,000 neutrophils/µL, bacteria seen on Gram stain, and pH < 7.2 may be presumed to be empyema). Presents with low-grade fever, dyspnea and chest pain. Dx: with CT. When it’s localized, complex w/a thick rim best tx is surgery to remove the clotted blood.

ENDOMETRIAL HYPERPLASIA A28. Printed out

ENDOMETRIOSIS - 4 Presents with painful periods. Bimanual exam: a few firm nodularities in pouch of Douglas. Tx: OCP (1ST line). They cause a state of pseudopregnancy and causing an "exhaustion atrophy" of the endometriomas. If OCP fails or not tolerated à Danazole (androgen derivativeà causes Pseudo-Menopause state. SE: acne, hirsutism deep voice, GnRH agonists: have an inhibitory action of LH & FSH when given continuously produces temporary castration. It’s also a 2nd line of choice. ****Typically pt presents with '3Ds': Dysmenorrhea, Dyspareunia (when endometriomas is in cul-de-sac), Dyschezia (Pain on defecation), Hematochezia, Hematuria, and pre-postmenstrual spotting. Laparoscopy shows powder burns (GOLD standard). The hemorrhage of endometriomas into the ovaries results in formation of cystic cavity filled with blood with dark color, hence the name 'Chocolate cyst'. DDx1: Vaginismus: use vaginal dilators. DDX2: Pain disorder: pain in 1 or more anatomical sites is pain management training. DDx3: Somatization Disorder: Tx is follow-up visits regularly scheduled. *****Endometriosis is the location of tissue outside uterine cavity so hysterosalpingogram can’t see it.

ENDOMETRITIS: It usually occurs on 2nd-3rd day postpartum. Predisposing risk factors: Prolonged labor, prolonged and premature rupture of the membrane, manual removal of placenta, and repeated pelvic exam. Clinically presents: Fever, uterine tenderness and foul-smelling lochia. Start ASAP Antibiotic to cover both aerobic and anaerobic. Clindamycin with aminoglycoside or Ampicillin. MCC: Anaerobics.

END STAGE LUNG PFT is the best test to determine if the pt can benefit from lung resection surgery. Predicted postoperative FEV1 is very useful for this. Blood tests are more useful in determining the level of respiratory compromise and appropriate ventilator settings for pts undergoing lung resection surgery (don't reveal any good info in this regard). Results of split function quantitative lung scans and exercise testing are useful in pts in whom the potential benefit is doubtful even after determining the results of the predicted postoperative FEV1.

ENTERBIUS VERMICULARIS Or Pinworm is the MC helminthic infection in USA. Most commonly see in school children 5-10. Larva goes to perineal area to lay eggs, which gives characteristic Nocturnal perianal pruritus. Dx: "Scotch tape test" Tx: Albendazole or Mebendazole (1st line). Pyrantel Palmate is an alternative.

ENURESIS - 2 Tx: Low dose Imipramine or Desmopressin. ***It should go away before school age. 1st step: Reassurance. 2 nd step : Wet alarms and walking the child to bathroom is tried. If persists, then Desmopressin (1ST first line), Imipramine (2ND line). ****Its important to r/o treatable causes like UTI. The initial evaluation is urine analysis.

EPIDIDYMITIS, ACUTE Pain begins in Abd/flank/groin, scrotal pain & swelling (2-3x norm) within 3-4hrs, dysuria, urethral discharge (esp age<35yo), fever, chills, nausea CDC EVALUATION GUIDELINES: should include 1 of the following: ***Gram stain of urethral secretions demonstrating ≥5 WBC. Gram stain is preferred rapid diagnostic test for evaluating urethritis. It is highly sensitive and specific for documenting both urethritis and the presence or absence of gonococcal infection. Gonococcal infection is established by documenting the presence of WBC containing intracellular gram-negative diplococci on urethral Gram stain. ***Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine sediment demonstrating ≥10 WBC per high-power field. Testis U/S: Enlarged and predominantly hypoechoic epididymis with a reactive hydrocele CDC treatment guidelines for epididymitis: ***For acute epididymitis most likely gonococcal or chlamydial infection (STD): Ceftriaxone 250 mg IM, a single dose + doxycycline 100 mg orally BID x 10 days. ***For acute epididymitis most likely enteric organisms or allergic to cephalosporins and/or tetracyclines: Ofloxacin 300 mg orally BID x 10 days OR levofloxacin 500 mg orally once daily x 10 days. DDx: Acute Scrotal Pain: Testicular torsion, and testicular tumors. In prepubertal boys and men > 35 yo, the dz is most frequently caused by Escherichia coli or Proteus mirabilis.

EPIDEMIOLOGY Mean is average, Mode is the number repeated mostly, Median is the number in the middle given by vignette, don’t put them in order treat it as is. Reliable test à gives similar results repeatedly Accurate à results are on target. **** Sensitivity curve movements and its effect on PPV.

EPIGLOTITIS - 3 MCC: H. inf & 2nd MCC Strep. Tx: Antibiotics, antipyretic, racemic EPI, steroids and immediate intubation. Dx: Fiberoptic Laryngoscopy in the OR, once its made then Nasotracheal intubation secures the airway. If intubation is C/I then Emergency Tracheostomy is performed. ***** DON’T need EPI before intubation; intubation is the 1st thing to do.

ERECTILE DYSFUNCTION Types 1-Neurogenic: A pelvic fracture with an urethral injury is usually accompanied with ED. The cause is nerve injury and altered blood supply. 2-Venogenic: After penile fracture and disruption of tunica albuginea. 3-Endocrinologic: Prolactinoma. 4-Systemic DM can cause ED through many systems (neuro, vascular). 5-Situational: Psychogenic, where night and morning erection is preserved. ****If pt is taking Nitrate drugs, Sildenafil is C/I so the next step is Penile prosthesis devices or Vacuum devices.

ERYSIPELAS A specific type of cellulitis: Superficial inflammation of epidermis producing prominent swelling. Characteristic finding: A sharply demarcated, erythematous, edematous tender skin lesion with raised borders. Abrupt Onset with systemic signs. MCC: Group A strep Tx: Penicillin V or erythromycin 500 mg p.o. qid should be given for ≥ 2 wk. See pic on desktop.

ERYTHEMA MULTIFORME Derm6/3 Onset: Usually sudden, with erythematous macules, papules, wheals, vesicles, and sometimes bullae appearing mainly on the distal portion of the extremities (palms, soles) and on the face. The skin lesions (target or iris lesions) are symmetric in distribution and often annular. Stevens-Johnson syndrome is a severe form. EM usually follows infection with Herpes Simplex. Erythema Multiforme associated w/ Mycoplasma pneumonia àTreat with tetracycline. If frequent or severe erythema multiforme is preceded by HSVà Acyclovir

ERYTHEMA NODOSUM Pink to reddish painful subcutaneous nodules that usually develop in pre- tibial region. Most often in woman 15-40. Lesion resolves w/o scaring w/in 2- 6 weeks. Histologically: Panniculitis involving inflammation of septa in the subcutaneous fat tissue. Other conditions that could cause EN, like TB and Sarcoidosis. Initial work up: includes Antistreptolysin O (ASO) titer, TB test and CXR. EN: also assoc with IBD; Sarcoidosis often presents with EN as an initial symptom, CXR: Show bilateral hilar adenopathy. An inflammatory disease of the deep dermis and subcutaneous fat (panniculitis) characterized by tender red nodules, predominantly in the pretibial region but occasionally involving the arms or other areas. Bed rest helps to relieve painful nodules. If underlying streptococcal infection is suspected, antibiotic therapy is beneficial (e.g. Penicillin for ≥ 1 yr).

ERYTHEMA TOXICUM Is a benign self-limited condition in newborns characterized by rash with red halos, and eosinophils in skin lesions. Neonate presents: No fever, no infectious risk factor, looks healthy, with erythematous papules and vesicles surrounded by patches of erythema.

ESOPHAGEAL ATRESIA MCC: esophageal anomaly w/esophagotracheal fistula. It leads to gastric distention. It results in drooling and regurgitation due to incomplete esophagus; In addition food gets into trachea and lungs and causes aspiration pneumonia. Inability to pass tube is suggestive.

ESOPHAGEAL CANCER - 2 It mimics Achalasia: Short hx, rapid weight loss, and inability to pass esophagoscope is indicative of cancer. Next step is biopsy. Of course BS followed by endoscopy should be done first.

ESOPHAGEAL VARICES, Acute - 2 Variceal bleeding is a life threatening emergency. 1 ST step : is fluid replacement with 2 large bore IV needles followed by fluid resuscitation. 2 ND step : Control of bleeding medically with vasoconstrictors (Octreotide, Somatostatin) 3 RD step : Endoscopic Sclerotherapy or Band Ligation (better due to less SE). If endoscopic therapy is not available then Balloon tamponade with S-B tube. If all this fails then surgery is indicated (TIPS). ****In case of EV, need for 5 or more units of blood transfusion in a period of 24 hrs is considered an indication for surgery and Transjugular Intrahepatic Portosystemic Shunt. Remember both ligation and meso-caval shunt have high mortality rate in ER setting, TIPS has less mortality rate. *****Varices are submucosal veins dilated due to portal HTN.

ESTROGEN REPLACEMENT THERAPY Affects metabolism of thyroid hormones. The requirement for L-Thyroxine increases, although the exact mechanism not known it could be due to induction of liver enzymes, increased level of TBG. In pregnancy also thyroid hormone requirement will be increased and the pt should be monitored for dose adjustment.

ESSENTIAL TREMOR - 3 DOC: Beta blockers. ***Another drug is PRIMIDONE: SE is Acute Intermittent Porphyria (Abdominal pain, neurologic & psychological abnormalities); it can be dx by urine porphobilinogen. ****Propranalol DOC for benign essential tremors + HTN **** Familial, gets worse with action & resolved at rest; rule out: Thyroid problem before starting therapy.

ETHYLENE ALCOHOL POISONING Presents with anion gap metabolic acidosis w/ Rectangular envelope shaped crystals (calcium oxalate).

EUSTACHIAN TUBE DYSFUNCTION A common cause of conducting hearing loss in children. Aural fullness, pop when swallow, hearing loss, intermittent ear pain; usually following URI or allergic rhinitis. Retraction and decreased mobility of tympanic membrane. Hallmark: a middle ear effusion. "Acute Otitis Media": Otalgia, hearing loss, fever and disequilibrium, bulging membrane. "Serous Otitis Media": Due to prolonged blockage of auditory tube, common in children, membrane is hypomobile and dull, air bubbles in the middle ear. "Otitis Externa": Purulent discharge, common in swimmers, pain with tenderness is the hallmark. "Foreign body:” (children) Foul-smelling discharge and signs of infection.

EWING SARCOMA Highly malignant tumor of lower extremities in children, with early metastasis. Presentation: Pain and swelling for weeks. Often confused with Osteomyelitis due to intermittent fever, leukocytosis, anemia, elevated ESR. CXR: "ONION SKINING" periosteal retraction. Lesion: Lytic & central. Onion skinning is followed by 'moth eaten' appearance. Tx: Surgery, radiation, multiple drug chemo. DDx: Osteomyelitis: Presents with persistent fever, malaise, local pain in joints and swelling. Chronic Osteomyelitis XR: Lytic bone defect with surrounding sclerosis termed as "Brodie's Abscess".

EXTRAPYRAMIDAL SYNDROME (EPS) SE of antipsychotics (Risperidone). 1-Tardive Dyskinesia: Lip smacking, tongue protrusions, chewing, biting. It occurs b/w 4mo-4yrs. Tx: Discontinue Risperidone and give Clozapine. 2-Akathesia The feeling of restlessness, beta-blocker gives some relief. 3-Dystonia: occurs b/w 4h-4d, there is muscle spasm, stiffness, twisting, opisthotonus (severe hyperextension and spasticity in which an individual's head, neck and spinal column enter into a complete "bridging" or "arching" position) . Antihistamine (diphenhydramine) or Anticholinergic (Benztropine) relief FALSE LABOR Characterized by painless and irregular contractions for 5hrs or more. In the last month these contraction may become rhythmic occurring every 10-20 minutes mimicking contraction of real labor. The main characteristic is however they are not accompanied with progressive cervical changes, so cervix is closed shut. All the pt needs is reassurance.

FAMILIAL COLONIC POLYPOSIS 100% risk of colon cancer, so when they are dx (colonoscopy reveals 100s polyps), then next step is elective proctocolectomy.

FANCONI’S ANEMIA An autosomal recessive dz, progressive pancytopenia and macrocytosis. Deformities: Cafe au lait spots, Microcephaly, Micropthalmia, short stature, horseshoe kidneys and ABSENT thumb. Dx average age is 8 yo

FANTASY DEFENSE MECHANISM An immature defense mechanism, that does not exist in the real world, like an angel telling you things are going to be OK.

FAT EMBOLISM Dyspnea, confusion and petechiae in the upper part of the body; after multiple fractures of long bones. Supportive Tx : Prompt maintenance of adequate oxygenation & ventilation, stable hemodynamics, blood products as clinically indicated, hydration, prophylaxis of DVT and stress-related GIT bleeding, and nutrition. Use of heparin, steroids is controversial.

FAT NECROSIS Biopsy: Foamy macrophages and fat globules. Coarse calcification is indicative of benign, and microcalcification indication of malignant tumors. FN is assoc with hx of surgery or trauma and it mimics breast cancer. Dx: Excisional biopsy and no tx is needed. Standard follow up and mammogram is sufficient.

FEBRILE NEUTROPENIA - 2 A neutropenic pt with sustained fever >100.4 for 1 hr. An EMERGENCY: Admit to hospital and get blood cultures & IV Cefepime, or Ceftazidime, or Imipenem. Vancomycin is added IF pt is hypotensive, evidence of skin or line infection, Hx of resistant to S. aureus or Pneumococcus, or recent prophylaxis with quinolones.

FEMORAL SHAFT FRACTURES Most can be managed: CLOSED INTRA-MEDULLARY FIXATION of the SHAFT. Allows for early mobilization improved hip and knee function and less hospital cost. In this technique, closed reduction of fracture segment is followed by intra- medullary nail insertion through small skin insertion over the greater trochanter. Closed nailing is preferred over OPEN nailing due to reduce risk of infection. Internal fixation with plates and screws are used in NECK fractures of femur. *****Intero-trochantic fracture of the femur is mostly an extracapsular fracture in elderly. Occurs along the line b/w greater and lesser trochanter, Extremity is short-ended and internally or externally rotated. Dx is XR. Operative tx is indicated as soon as pt. is stabilized. Do internal fixation with sliding screw with plate and early mobilization.

FEMORAL NECK FRACTURES They are seen in ELDERLY. The limb is short-ended and rotated and painful with limited motion. Unstable fractures (complete neck fractures): Need OPEN REDUCTION & INTERNAL FIXATION or PRIMARY ARTHROPLASTY (surgical reconstruction of the joint) as soon as pt is stabilized. If surgery is C/I the pt should be mobilized ASAP and eventual mal-union can be dealt with later.

FETAL ALCOHOL SYNDROME - 2 Irritability, mild to moderate MR, Hypoplastic maxilla, long philtrum, thin upper lip border and microcephaly, and epicanthal folds.

FETAL DEMISE 6/24/06 if pt comes to you do not feeling any movement & you can’t hear any beats with Doppler: 1 ST thing : Do Real Time Sonogram. Most appropriate test to confirm fetal demise. BhCG might be lower but it doesn't make it a dx tool.

FETAL DISTRESS (REPETITIVE LATE DECELERATIONS) Is an indication for C-section. Remember Tocolysis means not delivering.

FETAL HYDANTOIN SYNDROME - 2 Caused by using Phenytoin in pregnancy due to seizure. Infants present: Small size, microcephaly, hypoplasia of distal phalanx of fingers and toes & nail, low nasal bridge, cleft rib and rib abnormality and cardiac murmur. It’s also assoc with Neuroblastoma. Karyotype and TORCH should be measured. ***Diphenylhydantoin (phenytoin) is metabolized to Epoxide Metabolite, which is eliminated in turn by enzyme Epoxide Hydroxylase. The genetic expression of EH is different from one subject to other and its substrate EM is the agent incriminated in the syndrome.

FEVER, POST OPERATIVE Day 1: ATELECTASIS. Pt might have pain at the incision and not take deep breaths causing atelectasis. Days 3-5: UTI Days 3-6: if fever is due to pneumonia Day 3-7: may be due to PE. Tachypnea, tachycardia and Hypoxia. Dx: Duplex U/S to look for clots in extremities. Even if given anticoags, 200,000/yr die of PE. Days 4-7: wound infection. Redness, pain and induration. 1-2 Mo: is due to post-splenectomy sepsis. All pts given Pneumococcal vaccine after surgery to prevent this. Pts are most likely, smokers, obese, elderly and fail to ambulate. Pt will have sputum and leukocytosis. FIBROADENOMA 1x1 cm firm rubbery freely mobile round mass in a 35 yo women w/o axillary nodes palpable. Best initial step is Mammogram.

FIBROCYSTIC DZ of BREAST A 4x5x6 cm moveable rubbery mass that will go away after aspiration w/needle & secretion of clear discharge. The best approach after aspiration of fluid is to wait 4-6 wks. In FCD the mass goes away and doesn't come back. IF it recurs or doesn't go away, then a biopsy is indicated. If the fluid (initially) was bloody or foul smelling, cytology is needed at that stage.

FIBROID UTERUS Presents with Dysmenorrhea, heavy menses, and enlarged uterus is almost dx of either Adenomyosis or FU. Submucosal fibroids often INTERFERE w/ embryonal implantation and infertility. Fibroids MCC benign uterine tumors & MC indication for hysterectomy. They are estrogen-dependent tumors; therefore they increase in size with OCP and pregnancy; and often regress after menopause. DDx: Endometriosis which presents with Amenorrhea. Make sure you can DDx the above conditions with Adenomyosis.

FIBROMUSCULAR DYSPLASIA - 2 MCC of 2ary HTN in children. Is responsible for 20% of the cases of renal HTN. Also seen in pre-menopausal women. PE: a hum or bruit (soft to-and-fro bruit) in the right costovertebral angle due to well-developed collaterals. The right renal artery > affected than the left. Angiography shows 'string of beads ' pattern in the renal artery ****Presents with Occipital HA, HTN and renal bruit, suggestive of renovascular HTN due to Renal Artery Stenosis. The usual cause in younger pt (Age: 30) is FMD. In older pt its atheroslcerotic plaques. Goal of Tx: decrease BP and restore perfusion to kidneys. Interventricular therapy is better than medical management alone, so Angioplasty with stent replacement is best tx. If it fails then Surgery is indicated. ACE-I are reserved for Elderly pts who are not good candidate for surgery. Remember ACE-I are C/I in bilateral renal stenosis.

FIBROMYALGIA- 4. Rheum 6/3 Occurs mainly in females and may be induced or intensified by physical or mental stress, poor sleep, trauma, or exposure to dampness or cold .Pt presents with diffuse musculoskeletal pain, multiple tender points, with no joint swelling/pain. Initial Work Up: 1-CBC, 2-ESR, 3-TFT, and 4-CK enzyme. Normal spine movement makes "Ankylosing Spondylitis" unlikely. Normal ESR with pain rather than stiffness makes "Polymyalgia Rheumatica" unlikely. “Poliomyelitis ", usually presents with weakness rather than diffuse pain and increased CK. *Characterized by musculoskeletal PAIN and presents of 11-18 tender points. Presents w/recurrent HA, IBS, Raynaud’s. The most important DDx of these dz: Masked depression and somatoform disorder. Tx: Exercise & Antidepressants. **DDx1: Chronic Fatigue Syndrome: Present w/extreme fatigue and not body aches. It must be for 6 mo. DDx2: Polymyalgia Rheumatica : Pain and stiffness of shoulder and pelvic. Very unlikely in pt <50yo. ESR is elevated. Complain of stiffness rather than weakness or pain. Assoc with fever, weight loss and HA. DDx3: Polymyositis: Proximal Weakness: Muscle in upper and lower extremity. Pt complains of difficulty raising from chair position or climbing stairs. No pain just weakness***** Fibromyalgia is non-inflammatory dz so NSAIDS like Naproxen & steroids are not helpful. Tx: TCAs Amitriptine at bedtime. For daytime pain use acetaminophen. You can also use Cyclobenzaprine. Initial tx: Either Amitriptyline or cyclobenzaprine. If refractory to the above medicine then SSRI are added. When pt feels better then exercise is initialed. Other refractory tx is trigger-point injections

FIRST DEGREE HEART BLOCK

FLUPHENAZINE SE Hypothermia by causing vasodilatation and inhibition of shivering.

FOCAL SEGMENTAL GN Assoc with HIV.

FRAGILE X SYNDROME - 2 Pt can be taught to take care of himself with and perform simple task with close observation, like Down's. *** Low to normal IQ, with learning disability, general language disability, short attention span, autism, Mutation of FMR-1 gene caused by increased number of CGG tri-nucleotide repeats. Large head, prominent jaw and large low set ears.

FREDRICK’S ATAXIA: Autosomal Recessive excessive number of tri-nucleotide repeats (AGG), chromosome 9; resulting in abnormality of tocopherol transfer protein. Poor prognosis. Tell the parent to seek genetic counseling for future pregnancy. MRI of the brain and spinal cord shows marked atrophy of cervical spinal cord and minimal cerebral atrophy. ***** Begins before 22 years of age. Neurological manifestation: Gait ataxia, falling, dysarthria) result from degeneration of spinal tracts (spinocerebellar, posterior tract, pyramidal tracts). Non-Neuro symptoms: Concentric HCM, DM and skeletal abnormality (scoliosis and Hammer toes). Median survival is 20 years. MCC of death is CV, 90%.

FROSTBITE INJURY Warm up the body with warm water is the tx.

FROZEN SHOULDER There is stiffness and limited motion due to glenohumeral joint stiffness. PE: range of motion is limited in all directions whether passive or active movement. This is as a result of Pericapsulitis. Majority is idiopathic. Dx: Arthroscopy decreased joint space volume and loss of normal axillary pouch. Tx: NSAIDs, steroids injection in the joint and physical therapy. Rotator Cuff Tear or Rotator Cuff Tendonitis: presents with severe pain and weakness of shoulder abduction. Positioning arm above shoulder aggravates the pain. Range of motion is only limited in active movement but is normal in passive flexion. LARGE TEARS: positive drop arm sign, with inability to actively maintain 90 degree of passive abduction. DDx: TENDONITIS from Tear: by injecting Lidocaine that results in improvement in motion in Tendonitis but not in Tear.

FUROSEMIDE TOXICITY Causes OTOTOXICITY. Aminoglycosides, vancomycin, quinine, and chloroquine also cause ototoxicity. ASA causes TINNITUS

GALACTOSEMIA In a newborn or young infant with FTT, bilateral cataracts, jaundice and hypoglycemia. Early dx and tx: Remove galactose from diet - mandatory. A metabolic disorder caused by Galactose-1-Phosphate Uridyl Transferase deficiency. That leads to increase level of Galactose. DDx: Galactokinase deficiency: Cataracts ONLY and otherwise asymptomatic.

GALLBLADDER CARCINOMA It's a rare tumor, found in pts with chronic Choledocholithiasis usually diagnosed intra- or post-operatively after cholecystectomy. *****Chronic Cholecystitis predisposes to carcinoma; XR: Porcelain gallbladder, due to Ca++ deposition in gallbladder.

GASTRIC CARCINOMA Pt might present with bloody vomiting and Acanthosis Nigricans. Don't be fooled into thinking that its ASA toxicity, because ASA toxicity doesn't cause AN. AN is a dz that causes dark, thick areas on the skin. MC in armpits and other folds. It’s associated with being over weight and other tumors like GASTRIC carcinoma. Needs complete work up: like ENDOSCOPY & Bx.

GASTRIC MALT H. Pylori has an important role in pathogenesis of Gastric Mucosa-Assoc Lymphoid Tissue Lymphoma. These Lymphomas may regress after eradication of H. Pylori, IF THERE IS NO METASTASIS. If H. Pylori eradication fails then Chemotherapy is the choice (CHOP). In the old days they used to do radical gasterectomy. Tx: Pylori with Omeprazole+Clarithromycin+Amoxicillin.

GASTROSCHISIS Bowel protrudes through a defect. Bowel not covered with protective membrane. 1ST thing: Cover the exposed bowel with sterile wrapping; then IV access for nutrition and then IV antibiotics, then surgery to fix the defect. Omphalocele: Bowel protrudes through umbilical ring. Bowel covered with amnioperitoneal membrane. Assoc with other congenital abnormalities. Management: 1ST wrapping, then orogastric tube to decompress stomach. If <2cm repair with PRIMARY CLOSURE; if > 2cm à SILASTIC SILO.

GAUCHER’S DZ Sphingolipidosis due to deficiency of GLUCOCEREBROSIDASE. Characterized by Hepatomegaly, anemia, leukopenia, and thrombocytopenia, but NOT cherry red macula.

GENERALIZED ANXIETY DISORDER Tx: Buspirone (1ST line), because it does not show the dependence and withdrawl symptoms assoc with Benzodiazepines. If sexual performance is a problem use Nefazodone.

GENTAMICIN Causes NEPHROTIC and OTOTOXICITY, VESTIBULAR toxicity that causes the pt to feel dizzy within a couple of weeks of use.

GERD - 6 Neonates: is REGURGITATION after eating and FTT. The child assumes the position of tilted head and arched back. Dx: 24hr pH monitoring of esophagus. *****If unclear whether the pt has nocturnal asthma or GERD give, à A trial of PPI (Omeprazole) before breakfast is both Dx and therapeutic. ***** Esophagoscopy is indicated when a pt fails to respond to antibiotics or they are signs of implications (weight loss in cancer). ****Dx Process: once pt presents with COUGH, and the vignette says Esophagoscopy is normal, the next step à 24 hour pH monitoring; thenà MANOMETRY (confirms dx). ****GERD can happen due to hiatal hernia. Chronic GERD can lead to metaplastic change in lower esophagus called Barrett's esophagus and is a risk for Aden carcinoma of esophagus. ****When pt comes in with symptoms of GERD: Need to differentiate b/w Barrett's, PUD, Gastritis, or tumor. Endoscopy, most informative procedure for all these. If the vignette says: "He has no Dysphagia" then can skip the normal Barium test that precedes endoscopy and go straight to endoscopy. *****Indications to endoscopy are: 1-Nausea/vomiting, 2-weight loss, anemia or melena, 3-Long duration of symptoms (>1-2 yr), 4-Failure to respond to PPI. So here is the order, if there if Dysphagia 1ST do BS, then EC then Manometry. If no dysphagia, first EC and then Manometry can skip BS.

GIANT CELL ARTERITIS - 3 Don't wait for Bx; start high dose Prednisone right away. ***Lab may show elevated ESR and normochromic normocytic anemia. Thoracic aortic aneurysm is a complication of this dz, maybe due to disruption of collagen and elastin.

GIARDIASIS Adheres to mucosal surfaces by adhesive disk and cause malabsorption, may lead to weight loss. The MC symptom is foul-smelling stool, fatty stool, bloating and flatulence, nausea, malaise, abdominal cramps. Empiric tx Metronidazole. GILBERT'S SYNDROME Partial absence of enzyme leads to: 1-mild uncongugated hyperbilirubinemia, 2- More elevated values happen with stress, fasting, alcohol abuse. 3-normal CBC, 4- normal liver enzyme, 5-complete reversal of hyperbilirubinemia. DDx1 Crigler-Najar-I: characterized by 1-Unconj.Hyperbilirubinmeia 8-30, 2-Normal liver enzymes, 3-High rates of Kernicterus, 4-No response to Phenobarbital. DDx2: C-N-2: characterized by 1-Unconj Hyperbilirubinemia, 2-Normal liver enzyme, 3-No Kernicterus, 4-25% decrease of Bilirubin with Phenobarbital. DDx3: Rotor syndrome: Conjugated Hyperbilirubinemia.

GLASCOW COMA SCALE - 2 EYE opening: Spontaneous 4, to verbal command 3, to pain 2, none 1. VERBAL response: Oriented 5, confused 4, Inappropriate 3, Incomprehensive 2, none 1. MOTOR response: Obeys 6, localization 5, Flexion 4, abnormal flexion 3, extension 2, none 1. Total 15. Minor injury: GCS >14. Moderate <13 and >9. Severe <8. ****Pt with GCS of 7 in an accident is having a severe head injury. All pts w/severe head injury should be intubated, w/mechanical ventilation, and admin of IV fluids, analgesics and sedatives.

GLAUCOMA it’s the leading cause of blindness in North America. Characterized by: elevated ICP; Symptoms: sudden onset of photophobia, eye pain, HA, nausea. Eye is hard to touch. A non-reactive mid dilated pupil suggests Acute Glaucoma. Best dx is Tonometry. OPEN-angle glaucoma: Insidious onset with gradual loss of peripheral vision and consequence tunnel vision. intraocular pressures are high. Opthalmoscopic exam: Cupping of the optic disk. *****Once you suspect it Do MAPPING VISUAL FIELDS to find out defects.

GLAUCOMA, ACUTE CLOSURE ANGLE 2 Age 55-70, Acute onset: severe pain and blurred vision, nausea and vomiting. Anterior chamber is shallow with inflammatory changes. Tonometry reveals increased IOP. Management: IV Acetazolamide, Mannitol, Pilocarpine with subsequent oral. Permanent cure is laser peripheral IRIDOTOMY. Avoid Atropine.

GLAUCOMA, ACUTE OPEN ANGLE: MC in Blacks. Gradual loss of peripheral vision, tunnel vision. ICP is high. There is cupping of the optic disk with loss of peripheral vision. Beta-blockers (Timolol) are effective in initial management. Later on Trabeculoplasty. It’s assoc with Diabetes.

GLIOBLASTOMA MULTIFORME GBM or HIGH-grade astrocytoma. CT: Butterfly appearance in the frontal lobe of lesion (surrounded by white calcification, looks like cyst membrane but not round). DDx: Brain Metastasis; Duration of symptoms of <2months, Site is GREY-WHITE junction or watershed zones, multifocal and round. DDx2: Low-grade astrocytoma: presents with seizure and (longer duration of) symptoms > 2mo.

GLUCAGONOMA Triad: Hyperglycemia, Necrotizing Dermatitis, and weight loss. It’s a tumor of islet cells in Pancreas. The excess glucagon causes symptoms like glucose intolerance, and hyperglycemia. It also causes a distinct skin lesion called 'Necrolytic Migratory Erythema'. Dx is confirmed by fasting glucose elevation, elevated glucagon, and pancreatic tumor by CT. Surgery is the preferred tx. It doesn’t respond to Chemotherapy.

GLUCOSE 6 PHOSPHATASE DEFICIENCY: Also glycogen storage type 1 or Von Gierke Dz. Presents with hypoglycemia, lactic acidosis, hyperuricemia, & hyperlipidemia. Hypoglycemic seizure occurs. There is hepatorenomegaly. Doll face, fat cheeks, thin legs, and a protuberant abdomen.

GLUCOCORTICOID SE Long-term use in asthmatic pt can lead to Neutrophilia by increasing BM release and mobilization of marginated neutrophil pool. Eosinophils and lymphocytes are decreased.

GLYCOGEN STORAGE DISEASES 1-Von Gierke, 2-Pompe, type 3 and type 4. Read on them.

GONOCOCCAL ARTHRITIS Urethral cultures have the highest yield than synovial or blood or urine cultures in cases of suspected purulent gonococcal arthritis.

GONORRHEA - 2 Commonly causes cervicitis, urethral discharge. It also causes Pharyngitis. *It also causes GA (arthritis): which is asymmetric migratory polyarthralgia, followed by monoarticular arthritis and rash, palms and soles have multiple necrotic pustules.

GOODPASTURE'S SYNDROME - 3 Involves lung and kidney. There is lower respiratory problems (hemoptysis) and proteinuria (renal failure); there are antibodies against glomerular BM. Sputum shows iron in form of hemosiderin. There is anemia and RBC cast in urine. DDx1:Idiopathic pulmonary Hemosiderosis: Similar to GP, but there is more copious hemoptysis and it’s for children. DDx2: Wegner's involves URI (rhinorrhea) and LRI (hemoptysis) and Kidney problems, and Granular granulomatosis. Crescent formation. ****Caused by circulating anti-glomerular BM antibodies. Early removal is imperative in order to minimize the damage to kidney. Emergency Plasmaphoresis is indicated. ***Pt presents with massive hemoptysis, weight loss, hematuria and proteinuria. To confirm: Measure anti glumerular BM antibodies.

GAUCHER’S DZ Is due to deficient activity of the lysosomal enzyme, acid beta glucosidase. Typical pt is Ashkenazi Jew adolescent with chronic fatigue, easy bruisability, bone pain and pathological fractures. The dx is confirmed with radiologic (Erlenmeyer flask deformity of the distal femur) and BM studies (Gaucher cells with wrinkled paper appearance).

GOUT- 2 Dx: Fluid joint aspiration ***** In pt with frequent attacks of gout not controlled by Colchicine, a 24hr uric acid level in urine is determined. This evaluates whether hyperuricemia id due to over production or under secretion. A value of uric acid < 800 indicates under secretion, so use a Uricosuric agent (Probenecid) is needed. If uric acid >800 indicates overproduction, so add a xanthine oxidase inhibitor (Allopurinol).

GOUTY ARTHRITIS - 2 Very painful, mostly in toe but could happen in long-term RA pt in the hands. Alcohol is metabolized to Lactate that competes with Urate for renal excretion leading to accumulation of urate in the body and gout. Cessation of alcohol is important. Acute attack: oral indomethacin, colchicine or steroids. Chronic Colchicine.

GRAFT vs. HOST DISEASE By activated DONOR T LYMPHOCYTES. Targeted at Skin: (maculopapular rash in palm, sole and face), Intestine (bloody diarrhea, Liver).

GRANULOMA INGUINALE Is an STD caused by Donovan granulomatis. Uncommon in USA and MC in Black population. Starts with: A papule that rapidly develops into a painless ulcer (irregular border and red beefy granular base). Inguinal lymphadenopathy occurs w/o Buboes. Advanced stage: Scarring, depigmentation and keloids. Fibrosis may lead to vaginitis and elephantitis. Dx: Donovan Bodies, visualized by Giemsa or Wright stain of tissue smears, à Reddish, encapsulated bipolar bacteria found within monocytes. Tx: TETRACYCLINE, 500mg, every 6hr, 10-21 days. DDx1: Ulcer of Primary Syphilis: Rolled edges and punched out base. DDx2: Ulcer in Chancroid: Very painful and foul smelling, buboes form and are painful. DDx3: Genital Herpes: Many vesicles appear before they turn into ulcers; painless but is shallow and assoc w/ non-specific systemic symptoms DDx4: Ulcer in Lymphogranuloma Venereum : is also, also lymphadenopathy is inflammatory and doesn’t appear at the same time as ulcers. *****The 1ST thing: Stop Heparin. However, most pt need anticoag so 2 options are offered: - Danaparoid and Lepirudin or Argatroban (direct thrombin inhibitor).

GRANULOSA CELL TUMOR Are SOLID tumors. Bimodal distribution. If occur before puberty à presentation: Precocious puberty (excess estrogen: pubic hair, hypertrophy of breast and hyperplasia of uterus). Usually removal of tumor reverses the problem. If occurs in postmenopausal women à Bleeding and uterus shows myohyperplasia. DDx1: Dysgerminoma: in young women and children, unilateral and undergo torsion. Doesn’t produce any hormones. DDx2: Sertoli-Leydig: produces androgen and DEFEMINIZATION, followed by masculinization in childbearing years. DDX3: Mature Teratoma or Dermoid cysts: Benign and don’t produce any hormones. DDx4: Serous Cystadenomas: MC: CYSTIC ovarian neoplasm. 25% are malignant, ½ cases are bilateral. Don’t produce any hormones. Ovarian mass & abdominal pain are presenting features.

GRAVE’S DISEASE - 3 Tx: RADIOACTIVE IODINE. Might cause hypothyroidism *** Sudden onset of Atrial Fibrillation (irregularly irregular w/tachycardia) in pregnant women should alert the doctor to look for Hyperthyroidism; GRAVES is the MCC of hyperthyroidism in pregnancy. Remember Dx is made by TSH, T3 & T4, BUT the best SCREENING is just TSH. So next step is ordering TSH. Now the vignette may not even indicate other signs of Graves, but you must recognize it as well. DDx: Hydatiform Mole: but sonogram will easily show it.

GREEN STICK FRACTURE Commonly seen in children because the bone is less brittle. Also see torus fracture and plastic deformation.

GROWING PAINS Common in children from 2-12 yo. Mostly at night, awakens the pt, responds to massage and NSAIDs. Observe/Reassurance

GUILLAN BARRE - 4 Best way to monitor respiratory function is to measure serial bedside vital capacity, to make sure it stays above 15ml/kg. ***DDx: Tick-Borne Paralysis characterized by rapidly progressive ascending paralysis, absence of level, absence of sensory abnormality and normal CSF. ****Campylobacter Jejuni is the most frequent precipitant in GB. ***Characterized by: Ascending paralysis, previous hx of infection, CSF shows albumino-cytologic dissociation (Elevated protein despite normal cell count). Tx: IVIG and plasmophoresis. DDx: Botulism: which presents with descending paralysis, tx is antitoxin.

GUN SHOT WOUND: If below 4th rib, level of nipples, then exploratory laparatomy is done.

HAIRY CELL LEUKEMIA - 2 It’s a type of B-lymphocytic derived chronic leukemia. Dx: Tartrate resistant acid phosphatase stain ****Picture looks like hairy projections of large cells. BM may become fibrotic so BM aspirate are frequently unsuccessful (Dry Tap). Tx DOC: CLADRlBINE (purine analog) SE: Toxic to BM, causes neurological & kidney damage. **Remember CHOP is for Non-Hodgkin’s, Chlorambucil+Prednisone are for CLL. HASHIMOTO THYROIDITIS - 2 Transient thyrotoxicosis can occur in initial stages due to thyroid-stimulating antibodies. Positive anti-thyroperoxidase antibodies with an enlarged rubbery goiter are virtually diagnostic. The risk of thyroid Lymphoma is 60x greater in these pts. CT shows enlargement of thyroid around trachea, "Doughnut sign". U/S shows "pseudocyst pattern". RAIU is decreased. Since FNA might miss dx, Core biopsy is preferred. *Anti Thyroid Peroxidase Antibodies in >90% of pts.

HCV If pt is (+) but no sign and symptoms; just follow up w yearly tests. No Tx.

HEAD TRAUMA- 2 Always à Do spine XR in pt with falls or accidents leading to head trauma. **** Pt with increased ICP: treat with hyperventilation, head elevation, and IV Mannitol and diuretics. Hyperventilation causes vasoconstriction & decreasing the ICP by decreasing cerebral BF volume.

HEART BLOCK - 2 1-First Degree: prolonged but constant PR >0.2s. No tx is needed. 2-Mobitz Type-1: (Wenckebach), narrow QRS & progressive increase in PR until a ventricular beat is dropped. It may occur with Digoxin or Inferior MI. If pt is symptomatic à GIVE Atropine. 3-Mobitz Type-2: Fixed PR with occasional drop. WIDE QRS. Seen after MI. It’s dangerous and all pts must monitor in ICU. It can progress to complete heart block and needs pacemaker. Atropine must be by bedside at all times until a permanent pacemaker is inserted. *****Third degree heart block: No atrial impulses will travel to ventricles, Atrial rate is 80 and Vent is 30. Pts are at risk of sudden cardiac death and they should be transmitted to ICU and PERMANENT pacemaker should be placed. Always have Atropine by bedside. B-blocker WILL KILL HIM IMMEDIATELY.

HEAT EXHAUSTION Characterized by volume depletion under the conditions of heat stress DDx: Heat Stroke: CNS symptoms and T>40. DDx2: Heat Syncope: Brief syncope after exposure to heat. DDx3: Heat cramps: painful muscle cramps due to depletion of salt in muscles.

HEAT STROKE Characterized: Body T of >40.5, due to failure of thermoregulatory center. Tx of choice: Rapid Evaporation cooling. Immersion in ice water is also useful but makes it difficult to monitor the pt.

HELLP SYNDROME Hemolysis & HTN (preeclampsia), Elevated Liver enzyme, Low platelets (thrombocytopenia). DDx: DIC, Preeclampsia, TTP, HUS, and Acute Fatty Liver of Pregnancy. In AFLP tx is supportive with early dx and rapid delivery; there is increased PT & PTT. In HUS: Thrombosis of the glomerular arteries; happens in children. Often proceeded by infection. TTP is widespread of HUS and it occurs in Adults and associated w/ NEUROlogical symptoms. Tx: Exchange transfusion or plasmaphoresis w/FFP ****Delivery is definitive tx for HELLP in women beyond 34 weeks; give Mg SO4 to reduce BP & VAGINAL delivery.

HEMATOCHEZIA, SCANT Pt sees fresh blood on toilet paper. Most common causes are hemorrhoids, fistulas or even cancer. If pt is <50 chance for cancer very low. 1st do Anoscopy and then if still not clear do sigmoidoscopy or colonoscopy is done.

LEFT HEMI-NEGLECT SYNDROME Involves the Right (Non dominant) parietal lobe.

HEMOCHROMATOSIS - 3 Genetic disorder of iron absorption, increased absorption from intestine, liver, pancreas, heart and joints are MC affected. Presents: Weakness, loss of libido, skin pigmentation, weight loss, abdominal pain and symptoms of DM (polyuria & polydypsia). Transferrin saturation (≥50%) & Ferritin (>1000) is a simple reliable screen test. Hepatoma (Hepatocellular Carcinoma) is the most serious complications. ***There’s increased Fe and Ferritin. It’s Autosomal Recessive causing increased iron absorption and deposition in skin (pigmentation), Testes (decreased libido), pancreas (Diabetes), Joints (Arthralgia), and liver (cirrhosis). *** Pts are at increased risk for Listeria Monocytogenes, maybe due to impaired phagocytosis. Iron overload is also a risk for Yersinia Enterocolitica and sepsis from Vibrio Vulnificus, which are iron-loving bacteria. *** IF pt presents with Joint pain and Hepatomegaly and no other symptoms suspect it and 1st thing to do à is CBC to check Fe level. It presents with hepatomegaly, hyperpigmentation, diabetes (BRONZE diabetes), arthropathy, heart failure and hypogonadism.

HEMOLYTIC UREMIA SYNDROME - 4 When you get Thrombocytopenia (decreased platelet 56000), a MicroAngiopathic Hemolytic Anemia (MAHA) (Increased bilirubin, and schistocytes and RBC fragments and abnormal renal function) in a pregnant woman DDx include HEELP (Hemolysis, Elevated Liver enzymes, Low platelet count), HUS, TTP, DIC, PREECLAMPSIA and Acute Fatty Liver of Pregnancy (AFLP). HUS: Oliguric renal failure+MAHA+Thrombocytopenia. Characterized by thrombosis of the glomerular arterioles and capillaries. It occurs more frequently in childhood and presents with fever, thrombocytopenia, MAHA, HTN and renal failure. Usually proceeded by viral infection and assoc with E. Coli. TTP is a variant of HUS, the thrombosis is systemic and it obstructs microvascular of several organs. It presents with fever, altered level of consciousness, focal neurologic signs, renal failure, MAHA and thrombocytopenia. Tx is exchange transfusion, or plasmophoresis with FFP. HELLP is a variant of preeclampsia, in women older than 25, multipara, before 36 wks gestation. DIC: a consumptive coagulopathy, Presents with elevated PT, PTT, fibrin degradation product and decreased fibrin. ****Occurs in young children. Preceded by a diarrheal dz. Hallmark is Microcangiopathic hemolytic anemia. Other features: Renal failure, fever, oliguria, thrombocytopenia. GI bleeding is common. Purpura and HTN. Schistocytes, which represent fragmented RBC and Giant Platelets. Intravascular Hemolysis results: elevated LDH, indirect bilirubin and reticulocyte count. BUN and Cr are markedly elevated. Urine contains: Hb, Hemosiderin, albumin, RBC, WBC and casts. ****Its caused by E. coli released toxin à injures kidney epithelium. Presents: Abdominal pain, young pt, decreased Hb, Hct and Platelets, bloody diarrhea and swollen face. When kidney is damaged mortality is 5-10%. *****It’s caused by toxin released by E. Coli, it destroys epithelial lining and causes bloody diarrhea. Subsequent activation of coagulation system and red cell hemolysis causes Jaundice. It’s MC in children and initial presentation: Abdominal pain and diarrhea. Classic TRIAD: Uremia (Renal Failure), Thrombocytopenia, and Hemolytic Anemia. Tx is generally supportive and involves Plasmaphoresis and Dialysis if necessary and steroids. DDx: Campylobacter jejuni, although it causes bloody diarrhea, there is no Thrombocytopenia. Hemophilia Bruising since childhood, excessive bleeding in a tooth extraction procedure and uncle having the same problem. In these pts recurrent hemarthrosis may lead to injury called 'hemophilic arthropathy'. Iron (HEMOSIDERIN) deposition and synovial thickening with fibrosis is characteristic. ***** It’s X-linked. PTT is elevated and PT & BT are normal.

HEMOTHORAX Collecting of blood in pleural cavity. Tachypnea, tachycardia, hypotention, deviated trachea, dullness to percussion, elevated JVP, fluid in pleural cavity (seen in CXR) and collapsed lung. Lung is the usual bleeding source 2ary to rib fracture. It’s very important to evacuate the blood in order to stop bleeding, which stops on its own. Best initial intervention: Insert a low anterior chest tube to remove blood. Surgical Thoracotomy is indicated when more than 1500ml blood recovered when tube is inserted, or if more than 600ml blood loss after 6 hour post tube insertion.

HENOCH-SCHONLEIN PURPURA A common vasculitis of childhood, it's commonly seen after URI infection, and is more common in males. Classic findings: Palpable Purpura in buttocks and lower extremity, peripheral edema and scrotal swelling. Renal finding are Hematuria and proteinuria. Tx includes steroid and monitoring renal function. When pt presents with Abdominal pain 2 pathologies should be ruled out emergently: GI bleeding & Intussusception. Intussusception: Sudden onset of abdominal pain w/large amt of blood in stool. This is a surgical emergency and is tx: Air/barium enema. *****HSP is an IgA mediated vasculitis of small vessels, which results in rashes, arthralgias, abdominal pain and renal disease. Immunoflorescence microscopy reveals IgA deposition in the kidney.

HEPATITIS A Acute disease associated w/travel. If travel <4 weeks give Ig. If >4 weeks give vaccine.

HEPARIN INDUCED THROMBOCYTOPENIA - 3 Its seen in 5-15% of pt taking Heparin with onset b/w 3-15 days and resolution in 4-5 days of discontinuation. While PTT is a therapeutic effect of heparin, the thrombocytopenia is an adverse effect. So PTT is increased and Platelets are decreased. ****Hospitalized pt who develops DVT after a period of bed rest are standardly treated with Heparin. An adverse effect is Thrombocytopenia, along with thrombosis (causes stroke symptoms). The combination of Arterial/Venous thrombosis and thrombocytopenia in pts receiving Heparin is suggestive of HIT. Antibodies against Heparin-Platelet factor 4 complex are responsible for this. The antibodies activate platelets which will cause their removal form circulation.

HEPATIC ADENOMA Is a benign tumor seen in middle age females taking OCP. Intra-tumor hemorrhage is a major complication. Dx is biopsy (atypical hepatocytes with glycogen deposits). Tx: Superficial and large adenomas are resected, but smaller and asymptomatic ones à Surveillance with imaging.

HEPATIC ENCEPHALOPATHY 3 Hepatology 6/3 Characterized by: Reversal of sleep cycle, asterixis, progressive coma, and Delta waves in EEG. It’s a CNS complication of liver failure secondary to accumulation of ammonia in blood because of inability of live to detoxify ammonia (that comes from intestine) into urea. Eliminating toxic enteric products is the other main therapy: (1) The bowels should be cleared with enemas. (2) Dietary protein should be eliminated, and oral or IV carbohydrate should be given. (3) Oral lactulose should be given. (4) Oral neomycin. ****Pt with hepatic failure à Give vit K to correct PT and if they are bleeding in this setting, or he needs immediate surgery, then FFP is indicated. Platelet transfusion is only indicated if it falls below 20,000-30,000. Cryoprecipitate is required for coag factor def like factor VIII. Packed RBC is indicated when RBC is <8 in asymptomatic pt or <10 in symptomatic pt.

HEPATITIS B GIT 6/3 HBV Ig + Lamivudine à To prevent recurrent HBV after liver transplant. For HepB: Interferon+Lamivudine. Vaccination criteria: if someone is exposed w/Documented response à No need for further action. If vaccinated but no response to vaccine must be vaccinated again. ***If vaccinated many times and still no response, give HBIG on exposure. ***If exposed to virus and never been vaccinated before, give HBIG within 24 hrs and start HBV vaccination. ***Best screening test to dx acute HepB is AntiHBcAg and HBsAg. ***HepB vaccine is a recombinant vaccine containing HBsAg, which stimulated Anti HBsAg, person who receives it will have immunity and thus be positive for Anti HBsAg and negative for HBsAg. ACUTE HBV: will have HBsAg, HBeAg and IgM Anti HBcAg. CHRONIC HBV will have HBsAg only, for >6months. Person with recovery phase HBV will have AntiHBsAg, HBsAg, Anti-HBeAg and ABSENT HBeAg. ****If serology shows HBsAg, HBeAg positive and high titers of HBV DNA, à Chronic HepB. The 2 drugs approved are Interferon and Lamivudine. Either 1 is indicated for pt with positive HBsAg, HBeAg, HBV DNA and persistently elevated ALT. Degree of elevation of ALT is important in deciding the Tx. Serum ALT > 2x the upper limit requires need for Lamivudine or alpha interferon. If less than that it’s not useful. Generally Lamivudine has less SE and easier to administer (ORAL). Interferon is not successful in young children and immunocompromised pts. NOW, if the pt has just been exposed to virus, POSTEXPOSURE and has never had response to vaccine, give vaccine + Ig, and if did have response and has antibodies then we just give Ig. ****Of all acute Hep B cases 90% recover, minority go to chronic, out of those 1% goes to Fulminant hepatic failure, defined as hepatic encephalopathy that develops within 8 weeks of the onset of acute liver failure and evidence by marked increase in ALT. and signs of Hepatic encephalopathy. Liver transplantation is the only effective method for tx, so initial step in tx at this point is to put her name on the list****Newborn of mothers with active HepB should be passively at birth with HepB immunoglobulin followed by Vaccination. *****Transmission from mother w chronic dz & + HBs antigen and HBe antigen to the fetus is 90%. ****If given choice b/w Interferon and Lamivudine in a depressed pt, pick Lamivudine b/c interferon is C/I in Psych pts.

HEPATITIS C - 4 Risk factors for rapid progression of liver fibrosis in chronic HepC are: 1-Male sex, 2-Acquire infection after age of 40, 3-Co-infection with HepB or HIV, 4-Alcohol intake. Complications of Chronic HepC 1- Cryoglobulinemia (causes Membranous GN) 2- B- cell Lymphomas 3- Plasmocytosis 4-Autoimmune Dz: Sjogren and Thyroiditis, 5- Lichen Planus 6 - Porphyria Cutanea Tarda 7- ITP. Management: All pt with mild Hep C (elevated ALT, HCVRNA, moderate bridge necrosis) should get Interferon+Ribavirin. Liver transplantation is the last step and it’s done when Pt and Albumin levels are very affected. **** HCV RNA is the single most sensitive serological marker to screen Hep C, HCV RNA antibody takes months to show up don’t do that one. **** All pts with chronic Hep C, including Pregnant women, should be tested for HepA and HepB and if not immune should be vaccinated which is safe for pregnancy. Ribavirin & Interferon are teratogenic. ****Transmission risk could be a steady sex partner but the chances are low.

HEPATITIS E Assoc w/ pregnancy; Occurs in India, Asia, Africa and central USA. No vaccine or Ig available for Hep E.

HEPATOCELLULAR CARCINOMA - 2 Most are palpable masses. It accts for 80-90% of liver cancers. Occurs more often in men. Cause is unknown but contributing factors are Chronic liver disease, Hep B & Hep C, hemochromatosis. Dx: Abdominal CT. ***High serum AFP (>500) in an adult with liver dz w/o an obvious GI malignancy is HCC. Pt has hx of Chronic Hep C. Dx is confirmed by biopsy, Tx: Surgical resection.

HEPATO-RENAL SYNDROME Hypotension, HypoNa+, Azotemia and oliguria with normal urine analysis with severe liver disease. No tx is available. Pathogenesis is not clear. Initial mgmt: Careful volume loading and withholding of Spironolactone and Furosemide.

HEREDITARY SPHEROCYTOSIS - 3 Osmotic fragility test is dx. ***An AUTOSOMAL RECESSIVE dz. Folic acid is encouraged in ALL pts. MCV is normal or elevated. They rarely require transfusion unless they have Aplastic crisis. Splenectomy is usually curative. ****The tx for most pt involves Folic acid oral and blood transfusion; during periods of extreme anemia. Splenectomy is considered if refractory to medication. The most feared long-term complication: Overwhelming sepsis with encapsulated bacteria Strep Pneumonia. The risk is present for up to 30 years and even longer after splenectomy. Current recommendations: VACCINES: Anti-pneumococcal, Haemophilus and Meningococcus several weeks before the operation & daily oral Penicillin prophylaxis x 3-5 years post- splenectomy.

HEROIN WITHDRAWL Signs: Muscle spasm, Abdominal pain, rhinorrhea, lacrimation, sweating, dilated pupils. These are opposite signs when pt is intoxicated: Pinpoint pupil, constipated, depressed respiration and BP. DDx: Cocaine Withdrawl: Irritable, fatigue, HUNGRY (opposite to anorexic when intoxicated).

HERNIA Respiration and homodynamic are altered after repair of large hernias; b/c large hernia content is displaced inside the peritoneal cavity, the pressure inside the cavity increases. The diaphragm is pushed upwards and this impairs respiration, causing hypoventilation. At least a week is needed for the pt to accommodate to its new state. Early physiotherapy and respiratory exercises (blowing against resistance) are mandatory to prevent: Atelectasis, mucus plugging and possible subsequent pneumonia development.

HERPES SIMPLEX ENCEPHALITIS -2 Mainly affects: TEMPORAL LOBE, bizarre behavior and gustatory hallucination. CSF: Lymphocytosis, low glucose, and elevated proteins. HSV PCR (gold standard). Tx Acyclovir

HERPES SIMPLEX KERATITIS or HERPETIC KERATITIS d/t to HSV-1 More common in young pt. Zoster is MC in elderly. Dx: Slit Lamp. Common in health workers.

HERPES ZOSTER OPHTHALMICUS DDx: Herpes Simplex Keratitis is addition of vesicular rash in Varicella-Zoster. "Bacterial Keratitis" occurs w/contact lenses.

HERPETIC WHITLOW MC viral infection of the HAND. The appearance of VESICLES on the VOLAR or DORSAL DISTAL PHALANX is diagnostic. Caused by type I or II herpes simplex and self-limiting. Dentists are at increased risk.

HIRSHSPRUNG DZ - 2 Pts with Down's, are more likely to present with Duodenal Atresia, Hirshsprung, Endocardial Cushion defect and ALL. Typically is a "double bubble sign" on abdominal XR **** An emergency, so if infant has it and mother refuses tx, then go ahead and treat the infant because court order will take a while.

HIRSUTISM Women produce androgens: DHEA-S and Testosterone in adrenals and ovaries. DHEA-S is only in adrenals by adrenal tumors. See T2-Q16. ACTH increase in pts w/ hirsutism is seen with ectopic or pituitary dependant Cushing’s dz. ACTH increases the production of cortisol as well as androgens from the adrenal glands, however, the adrenal glands show diffuse hyperplasia rather than a discrete adenoma.

HISTOPLASMOSIS - 3 Is a common and asymptomatic infection in endemic areas of Mississippi & Ohio. Found in bird or bat droppings. ***** The MF endemic fungal infection in USA. Disseminated histoplasmosis occurs in immunocompromised pts. Presence of mucous membrane ulcers, hepatosplenomegaly and pancytopenia are clues to Dx. **** Tx: Amphotericin IV followed by lifelong Itraconazole. Histoplasmosis happens to HIV pt in OHIO

HIV- 30 All HIV pt should have the following done: 1-Hx & PE, 2- Routine chemistry and Hematology, 3- 2 Plasma HIV-RNA levels, 4-CD4 count. 5-VDRL for syphilis. 6-PPD test. 7-Anti-Toxoplasma antibody titer. 8-MMSE. 9-Pneumococcal vaccine, unless CD4 is <200. 10-Hep A&B serology. 11-HepA&B vaccine (if seronegative) 12- Counselling. 13-Help for those who have been infected by the subject.

CD 4 > 200: TB à XR finding: Upper lobe consolidation and cavitation; Assoc w/ Hairy Leukoplakia (white painless lesion that appears hairy, found on the tongue, caused by EBV). *** Pneumococcal vaccine is recommended in pts with CD4>200.

CD 4 < 50: ***MAC (Mycobacterium Avium Complex) presents with (Unexplained fever and cough), Azithromycin, now MAC Tx: Clarithromycin w/ Ethambutol **** Breast-feeding is C/I in HIV. *** PCP Prophylaxis in HIV: DOC: Azithromycin or Clarithromycin (bilateral interstitial pneumonia) Tx: TMP-SMX IV in pt with moderate to severe infection adding corticosteriods has reduced mortality. Indications for PREDNISONE is 1- PaO2<70 & 2 - A-a gradient >35. ***** PCP tx is TMP-SMX IV. Inhaled Pentamidine is for prophylaxis. Prednisone is used in combo with TMP-SMX when PaO2 is <70mm/Hg. **** BAL (Broncho Alveolar Lavage) is >90% effective in diagnosing PCP in HIV pt, especially when CD 4 <200 *** Best screening test is ELISA, then confirmatory w/Western blotting. *** CMV Prophylaxis; DOC: Gancyclovir ****CMV Colitis is suspected à CD4<50, (Bloody diarrhea and abdominal pain multiple ulcers and biopsy shows basophilic intracytoplasmic inclusions or owl eye effect) Tx: Gancyclovir or if intolerance, Foscarnet. **** 1-CMV Retinitis, occurs in HIV pt w CD4<50, presents with yellowish-white patches of retinal opacification & retinal hemorrhages. Tx is Gancyclovir or Foscarnet

***HIV pt is at risk of 3 types of Esophagitis: MC is Candida, so 1st give Oral Fluconazole. If pt responded within 3-4 days, then we do esophagoscopy to check for Herpes or CMV causes.

CD 4<100: *** Histoplasmosis Prophylaxis ITRACONAZOLE, in endemic areas. *** PML (JC virus) presents. CT: Multiple NON-ENHANCING lesions with no mass effect. DDx1:Toxoplasmosis: MCC: RING enhancing mass lesion in HIV. MRI: Multiple spherical lesions in basal ganglia. Just b/c antibody is positive doesn’t mean pt has it. DDx2: CNS Lymphoma: 2ND MCC mass lesion in HIV pt. It also presents with RING- enhancing lesion on MRI but its usually SOLITARY & periventricular. Presence of EBV DNA in CSF is Dx. DDx: Molluscum Contagiosum: It resolves spontaneously in one year. Tx options are excision and cryotherapy.

M. TB Once PPD is >5mm in HIV pt then Prophylactic therapy with Isoniazid + Pyridoxine is indicated x 9 mo. *** If health worker is infected, right away get blood for serology and start him on 3-drug therapy while waiting for results. Blood serology should be repeated in 6 wks, 3 and 6 mo. ***** HIV pts are at increased risk of TB that may cause collapse of vertebral bodies and intervertbral disk. *** Role of BCG is not proven in HIV pts so don’t give it to them.

*** DDx: Diarrhea in HIV pt with CD4 = 80. 1-Cryptosporidium: Modified Acid-fast stain = Oocytes in stool. It becomes persistent @ CD4 <180, but self-limited. 2-Isospora: Dx similar to Cryptosporidiosis but not as common. 3-Microsporidia: Assoc with severe malabsorption and persistent diarrhea in pt with HIV (immunoINcompetent). STOOL: SPORES not Oocytes *****Since diarrhea in HIV pt could be caused by a number of organisms, the first step is Stool exam and not Empiric antibiotics ****HIV pt with fever, HA, CSF India ink shows encapsulated yeast = Cryptococcus Meningitis, Tx: Fluconazole IV + Flucytosine IV.

***** Kaposi Sarcoma: Elliptical, arranged linearly on legs arms, face, oral cavity and genitalia. Initially papules and later develop into plaques or nodules, and color changes from brown to violet. No necrosis of the skin. DDx: Bacillary Angiomatosis Bartonella (GNR); cured with antibiotics. They are red papules nodules assoc with fever, chills, malaise, HA and anorexia. They are highly vascular, initially and smooth. Later on eroded and encrusted.

**** DDx of cough in HIV pt: 1-Pneumococcus Pneumonia: presents with acute, high-grade fever, and pleuritic effusion. MCC pneumonia HIV pt. 2-TB: presents with Chronic cough, night sweat and weight loss. 3-Coccidiomycosis: presents with CXR: Miliary pattern or nodular infiltrate, in SW USA. 4-PCP: Presents with DRY cough, and dyspnea, NO EFFUSIONS. **** When HIV IV drug user with dry cough, regardless of having, diarrhea, IVDA and other things, the MCC is PCP. If he is allergic to sulfa, then pentamidine (DOC).

*** HIV pt with CAVITATION: possibilities are **TB **NOCARDIA: So if pt presents: night sweats, fever and cough and has PPD of 3mm, and partial acid-fast filaments branching rods, it’s Nocardia. Tx: TMP-SMX.

***Lymphoma in HIV pt presents with EBV DNA, SOLITARY ring enhancing mass in periventricular with MRI. DDx1: Toxoplasmosis: MRI shows MULTIPLE ring-enhanced lesion in basal ganglia. A positive toxoplasma serology is common in USA so it’s not specific. Also if pt is taking TMP-SMX, this etiology in unlikely. DDx2: Progressive Multifocal Leukoencephalopathy lesions are NON-Enhancing and don’t produce mass effect.

****Condylomata acuminata (anogenital warts) are skin-colored or pink, verrucous or papilliform skin lesions present around the anus; A tx option: Podophyline (anti-mitotic agent). C/I in pregnancy. DDx: Condylomata Lata: flat or velvety: Due to 2ndary Syphilis, Tx: Penicillin

**** HIV EYE problems: 1-CMV Retinitis: occurs in HIV pt w CD4<50, presents with yellowish-white patches of retinal opacification & retinal hemorrhages. Tx is Gancyclovir or Foscarnet. 2-Ocular Toxoplasmosis: severe retinal choroiditis (uveitis), >50% have encephalitis. Necrosis of inner retina as white fluffy lesions. 3-Herpes Simples Keratitis: pain, photophobia and decreased vision. MC Presentation: Dendritic ulcer. 4-Herpes Zoster Ophthalmicus: mostly in elderly, or HIV pt. Presents with fever, malaise, itching and burning around the eye. Vesicular rash following trigeminal nerve. If eye is involved there’s conjunctivitis and dendriform corneal ulcers. 5-HIV Retinopathy: presents as benign cotton wool spots in retina that remits spontaneously. *****Cryptococcal Meningitis infection in AIDS pts, Tx: Amphotericin IV+Flucytosine.

HODGKIN’S Tx is ABVD. Adriamycin SE: Cardiomyopathy. Bleomycin SE: Pulmonary. Dacarbazine SE: Emetogenic. Vinblastine SE is Neuropathy leading to constipation.

HOMOCYSTINURIA Marfan features+MR+thromboembolic events+ downward dislocation of the lens is suggestive. Tx: High dose Vit B6.

HORDEOLUM: (Stye) a common staph abscess of the eyelid. Tx: Warm compresses. Incision and drainage: if resolution does not begin in the next 48 hours.

HORMONE REPLACEMENT THERAPY According to 2005 studies HRP increases the risk: CVA, CV dz, Breast Cancer and DVT. Decreases the risk of Hip fracture, Colorectal cancer and vulvovaginal atrophy.

HUMAN BITES Tx of choice is Amoxicillin/Clavulanic acid

HUMERAL FRACTURES Tx of choice is closed reduction and hanging cast. For Segmented fractures or open fracture in trauma, pathologic fracture and vascular structures, OPEN REDUCTION & INTERNAL FIXATION is done.

HUNTINGTON - 2 Atrophy of caudate nucleus is characteristic. Mood disturbance, Dementia, Chorea and family history.

HYALINE MEMBRANE DZ should be suspected in pre-term infants. With respiratory distress and hypoxia, NOT responding to oxygen therapy. The characteristic CXR shows fine reticular granularity of the lung parenchyma. Tx includes early ventilation and surfactant.

HYDATID CYSTS of LIVER Is due to infection with Echinococcus granulosus Can be contacted from dogs. It can cause Cyst in lung, muscle, bone, liver. Most asymptomatic. "Eggshell calcification" of a hepatic cyst on CT is highly suggestive. Aspiration is NOT indicated due to chance of anaphylactic shock. Tx: Surgical resection under the cover of Albendazole.

HYDROCELE 1-Non Communicating Hydrocele: Referred to a fluid-containing sac that is a remnant of processus vaginalis. The upper limits of the mass is easily identified. Most cases of NCHC will disappear spontaneously by the age of 12 months. 2- Communicating Hydrocele: the upper limit can’t be reached and it treated with surgery.

HYDROCEPHALUS Happens in infants. CT scan: Dilation of entire ventricular system with distinct enlargement of subarachnoid space offer the cerebral cortex), is very suggestive of non-communicating or communicating hydrocephalus. Accumulation of blood in subarachnoid space may destroy Arachnoid villi and whose job is to absorb CSF and lead to hydrocephalus. SAH is the MCC of communicating hydrocephalus. It’s very common in PREMATURE infants. Non-Communicating hydrocephalus: Dandy-Walker and Arnold-Chiari. DW: a cystic expansion of fourth ventricle, and AC: will reveal posterior protrusion of posterior fossa through foramen magnum.

HYDROXYCHLOROQUINE The safest drug for SLE but rarely it may cause serious eye dz: Macular degeneration, so eye exam @ 6mo to 1yr intervals should be performed. Remember the MC SE is Allergic skin reaction. Also CI is G6PD Def.

HYPERANDROGENISM A female presents with virilization, balding and clitomegaly. What to do next? Rapidly developing hyperandrogenism with virilization is indicative of androgen- secreting neoplasm of OVARY or ADRENAL. So next measure serum Testosterone and DHEAS to determine the site of tumor. Elevated Testosterone level with normal DHEAS indicate ovarian source, but Elevated DHEAS with normal Testosterone indicate Adrenal source. Now don’t try to measure 17-HO, because that is for Congenital Adrenal Hyperplasia and happen very early inline.

HYPERCALCEMIA - 8 Hypercalcemia due to metastatic tumor (Breast) cancer. In all women w/metastatic breast cancer and radiographic lytic bone disease who are receiving either hormone therapy or chemotherapy (Tamoxifen), IV Pamidronate (Biphosphonate) is recommended. * In acute severe hypercalcemia, it’s important to FIRST give IV 0.9% Saline before giving Furosemide. It’s complicated read Merck’s. *** Constipation is the mc GI presentation in pt. The important renal manifestation is nephrolithiasis. Chronic therapy with vit D is a major cause for HyperCa. Tx: Stop vit D tx and low Ca diet, keeping urine acidic and give corticosteriods. ****Hypercalcemia is MCC Paraneoplastic syndrome that is assoc with Squamous CC lung cancer. HyperCa production is due to ectopic PTH related peptide (PTHrP) production. *****Immobilization can lead to HyperCa. Prolonged bed rest can lead to accelerated bone resorption; OsteoClastic activation in increased bone turnover is established. Biphosphonate therapy is helpful. DDx: Rhabdomyolysis: HypOcalcemia (not HyperCa) is seen, normally due to increased binding of Ca++ to Phosphorous that was released by muscle. DDx2: Hypercalcemia due to Malignancy; Causes: Local osteolytic metastasis, secretion of PTHrP & increased 1-25Vit D. DDx3: Hypoalbuminemia: Any change in albumin levels will affect total serum Ca levels w/o affecting the ionized fraction. In pt with decreased albumin total serum Ca++ is decreased. ****Malignancy is a frequent cause, like Breast cancer. MOAs Cancer causes HYPERCa++: 1- Production of Cytokines: Tumors that are metastatic to bones cause local osteolysis by production of Cytokines like IL-1 and TNF. The MF tumors that produce hyperCa++ by this MOA LUNG & BREAST cancer. 2- PTHrH (related hormones): The MCC of Hypercalcemia in pt with NON- METASTATIC SOLID TUMORS is production of PTHrH à PTH is low. 3- Calcitriol: HyperCa++ in case of Hodgkin’s is due to Calcitriol 4- ECTOPIC PTH: Very rare and has been reported in OVARIAN cancer, LUNG cancer and NEUROECTODERMAL tumors. *** HyperCa ++ 2ary to malignancy is due to multiple reasons including: Osteolytic metastasis, secretion of PTHrP, increased formation of 1,25-dihydroxyVit D, increased interleukins-6. Generally, hyperCa++ due to malignancy (2ary HYPERCa++) is higher than primary HyperCa++. *****Pt with Squamous cell carcinoma will have Hypercalcemia, now if he vomits, he will be at risk for Acute Hypercalcemic Crisis. **Tx: 1st Normal saline for HYDRATION 2nd Furosemide to maintain urine output at 200 cc/hr. Biphosphonate Pamidronate would work too, but by giving saline takes care of both hypercalcemia and hydrate to prevent Azotemia (renal failure)

HYPEREMESIS GRAVIDARUM: In a pregnant female in her 1ST trimester: Severe and persistent vomiting think of HG. It’s severe enough that requires admission. Cause is unknown but related to elevated HCG, which maybe indicative of Hydatiform mole. Order HCG to confirm that levels are consistent with the stage of pregnancy.

HYPERKALEMIA - 4 MCC: Rhabdomyolysis. EKG: Tall/peaked T waves; prolong PR and QRS, progressive widening of QRS leads to Ventricular Fibrillation or Asystole. The approach to Tx depends on EKG and degree of HyperKalemia: Immediate Tx: Needed if there is cardiac toxicity, muscular paralysis, or K+>6.5. For these pts 10ml of 10% calcium gluconate stabilizes cardiac membrane. Tx: 1ST Calcium Gluconate (stabilizes membrane) then Insulin, (drives K+ into the cell) Glucose, (prevents hypoglycemia) ** Caused by either Medication (K+ sparing diuretics, ACE-I, NSAID) or PseudohyperKalemia (the lab sample is hemolyzed), decreased renal K+ excretion, transcellular shift, increased K+ intake.

***The most serious SE: Cardiac toxicity, so do an EKG in ALL pts. To lower K level: Insulin or B2 agonist, Sodium Bicarbonate: Drives K into cells. Loop or Thiazide diuretics (Slower acting tx) which excrete K+. Dialysis is reserved for pts with renal failure and those with life threatening hyperK+ which won't respond to medication. So...If the pt is Asymptomatic and just non-malignant hyperK+ just discontinue Amiloride (to get rid of K+) for a weak and recheck. If the pt has evidence of cardiac toxicity or K+ is >6.5, then give Calcium Gluconate and IV Dextrose & Insulin. **** Best drug to excrete K+ from body is Kayaxelate.

HYPERPARATHYOIDISM - 3 Increased Calcium, decreased phosphate, increased PTH. Could be Asymptomatic. While all pt with symptomatic HPT: should have parathyroidectomy, not all Asymptomatic pt need this surgery. Criteria: 1-Serum Ca++ level at least 1mg/dl above upper normal limit, 2 -24hr urinary Ca++ above 400mg, 3-Young age<50 4-Bone Mineral Density < T-2.5 at any site, 5-difficulty in follow up if the pt. ****Hyperparathyroidism is assoc with Pseudogout, Joint fluid aspiration: rhomboid shape calcium pyrophosphate crystals with positive birefringent. Tx is Colchicine, Indomethacin (Stops acute attacks promptly). ****Primary HPT is the MCC: HyperCa++ in ambulatory pts. It’s assoc w/elevated PTH and decreased phosphorous. Now CRF can lead to SECONDARY HPT, PTH levels are higher in secondary HyperPTH > Primary HPT, Ca++ levels are normal to low in 2ary HPT because cause of elevated PTH level is hypocalcemia. ***Sarcoidosis there is increased conversion of 25-hydroxy VitD to 1,25 hydroxy- VitD. thereby increased absorption of calcium from GIT and hypercalcemia, PTH is suppressed. ****Asymptomatic Primary HyperPTH: HyperCa++, HypoPO4, Elevated PTH. Common in female >60, identified during routine lab work. While Parathyroidectomy is needed for all symptomatic pts, not all Asymptomatic pts need surgery. Criteria includes: 1-Serum Ca++ level at least 1mg/dL above the upper limit of normal. 2- 24hr urinary Ca++ level >400mg. 3-Young age <50. 4-Bone Mineral Density < T-2.5. 5-Difficulty to follow up pt.

HYPERTENSION - 7 In elderly HTN leads to Benign Nephrosclerosis. HTN: The 2ND MCC of renal dz in USA. MOA kidney damage: Evolves from Nephrosclerosis to Glomerulosclerosis. Nephrosclerosis is characterized by hypertrophy and intimal medial fibrosis of renal arteries, whereas, GlomeruloSclerosis: A progressive loss of glomerular capillary surface area and glomerular and peritubular fibrosis è Microscopic Hematuria and proteinuria due to glomerular lesions. ***So pt presents with Anemia (decreased Hb): DDx: Diabetic Nephropathy: the leading cause of end stage renal dz in USA. DN: Increased extracellular matrix, BM thickening, mesangial expansion and fibrosis. ***Isolated SYSTOLIC HTN: An important cause of HTN in Elderly. Pathophys: Decreased elasticity of arterial wall, leading to increased SYSTOLIC BP, w/o increasing diastolic BP = leading to wide pulse pressure (150/70,160/78). DOC: low dose HCTZ DDx: Aortic Insufficiency can cause the same symptoms, ECHO will differentiate b/w ISH & AI. ****Tx of choice for Pt with Intermittent claudication due to atherosclerosis and HTN à CCB ****OCPs are common causes of 2ary HTN caused by Estrogen-mediated increased synthesis of Angiotensinogen in the liver. So stop taking the OCP and HTN should go back to normal. If BP doesn’t normalize then it’s Essential HTN à Try life style modification can be tried. If that didn’t work either, then the next step is Thiazides. ****Alcohol is a risk factor for HTN, Smoking is not. ****Lifestyle modification should ALWAYS be a part of management. All pts should be encouraged: lose WEIGHT, reduce SALT, avoid excess ALCOHOL (3 bottle/wk is excess), and stop SMOKING. This is more important than DRUG MODIFICATION. REMEMBER.

HYPERTENSIVE RETINOPATHY -2 Don’t show any symptoms assoc with visual loss. Initially: Focal spasm of arterioles followed by progressive sclerosis and narrowing. Fundoscopy may reveal AV nicking, copper or silver wiring, exudates and hemorrhages. **Grade 1 = slight AV nicking. Grade 2 = Copper wiring, AV depression with humping heads. Grade 3 = Silver wiring, flame shaped hemorrhages, exudates. Grade 4 = Flame-shaped hemorrhages, exudates and papillary edema.

HYPERTHRYOIDISM - 5 Hypercholesterolemia (increased LDL) is the most frequent lipid abnormality in pts. *****High estrogen levels in pregnancy result in increase TIBG production by liver. So production of T4 and T3 is increased (but not Free ones). This increase however does not result in clinical symptoms because excess T3&T4 are bound to excess TIBG. And since Free T3 & T4 are the same TSH will be normal. ****Atrial Fibrillation is a common complication in hyperthyroidism, Grave’s disease. Pts with Hyperthyroidism related tachysystolic Atrial Fibrillation à DOC: Propranalol (BB). **** Antithyroid drugs, PropylThioUracil and Methimazole are assoc with Agranulocytosis (Fever and sore throat). Immune destruction of granulocytes starts within 90 days post-therapy. Monitoring in ineffective. Stop other drug immediately. ****Palpitations should make you think of it. Then the 1st test is TSH, almost all pt have low TSH (only exception is TSH secreting pituitary Adenoma). If TSH is low à Measure Free T4, if elevated à Dx is established. Thenà do 24-hr thyroid RADIOIODINE uptake to DDx Grave’s from the rest. Propranalol is initially used for symptoms until definitive cause is known. Radioactive iodine is tx of choice for ALL Grave's pts, however, Propranalol is STILL best initial choice. PTU can be used but hyperthyroidism can recur within 6 months. So PTU is only used when Iodine tx is C/I, like in Pregnancy. Subtotal Thyroidectomy is also curative but it’s not the INITIAL tx of choice.

HYPERTROPHIC OSTEOARTHROPATHY Characterized by chronic proliferative periostitis of long bones, clubbing of fingers and synovitis, It’s assoc with Squamous cell carcinoma and Adenocarcinoma of the lung.

HYPOCALCEMIA Plasma Ca++ exists in 3 forms: ionized calcium (45%), ALBUMIN-BOUND (40%), and Calcium bound to organic and inorganic anions. Homeostasis of these forms is significantly influenced by the extracellular pH level. An increased pH level causes an increase in the affinity of serum albumin to calcium, thereby increasing the level of albumin-bound Ca++, and consequently decreasing the levels of ionized Ca++. Ionic calcium is the only physiologically active form, which means the decreased levels of this form can result in clinical manifestations of hypocalemia (crampy pain, paresthesias and carpopedal spasm). Increased extracellular pH levels (Respiratory Alkalosis) can cause an increase in the affinity of serum albumin to Ca++, thereby increasing the levels of albumin-bound calcium, and consequently decreasing the levels of ionized Ca++ leading to hypocalcemia. *****There’s increased DTR. ****HypoCa++ can occur during or right after SURGERY, especially if transfusion is involves. 1st manifestation is increased DTR. HypoMg+ manifest w/ Decreased DTR.

HYPOCHONDRIASIS Symptoms occur during periods of stress (med student worried about intracranial hemorrhage), pt should be asked about current emotional stresses and then refer for a brief psychotherapy.

HYPOGONADISM T9Q4. Re-read Merck highlights.

HYPOKALEMIA - 2 A35. All Beta-2 agonist reduce serum K by driving it in to cells. In occasional pt they cause HypoKalemia. So any pt taking B2 and complaining of muscle weakness HypoKalemia must be rules out. PEFR (peak expiratory flow rate) and CXR are not of any use. We need to do Serum Electrolyte panel, and EKG to see "U" waves. Beta-2 also produces Fine resting tremor of fingers and peripheral edema (most common SE).

HYPONATREMIA A bad prognostic factor for pt with heart disease.

HYPOTHERMIA Fluphenazine causes hypothermia by causing vasodilatation and inhibition of shivering. Hyperthermia is common in drug abusers.

HYPOTHYROIDISM - 5 Generalized resistance to THs. ***It’s assoc with wide spectrum of muscle involvement ranging from symptomatic elevation of CK to Myalgia, muscle hypertrophy, myopathy. So suspect it if there’s elevated CK and Myopathy. *It’s the MC SE of radiation therapy for Graves. * Assoc with Hyperlipidemia; so unexplained, hyperlipidemia and elevated serum muscle enzymes are indication for thyroid function tests. ****Always rule out Hypothyroidism in a pt with Major Depressive Disorder. If this option, "ordering blood test" for TSH was offered pick it over other options. ***** Thyroid dysgenesis is the MCC Congenital hypothyroidism in USA IATROGENIC ESOPHAGEAL PERFORATION Pt returns within hrs w/problems. Do contrast study of esophagus, if perforation is present, primary closure of esophagus, and drainage of mediastinum must be done within 6 hours to prevent development of Mediastinitis.

ICHTHYOSIS VULGARIS (Lizard Skin) Dry and rough skin with horny plates over the surfaces of the limb. Tx is minimizing bathing, Oral RETINOIDS (C/I in pregnant women)

IDIOPATHIC PULMONARY FIBROSIS Presents in 4-5 decade of life, fatigue, anorexia, weight loss, arthralgia, cyanosis and clubbing. XR: BILATERAL INTERSTITIAL INVOLVEMENT. Biopsy to r/o SARCOIDOSIS. Tx is Steroids. Mean survival: 2-5 yr after dx. Pleurodesis (where visceral and parietal pleura are fused, is used to treat recurrent pneumothorax and effusion) is not used here.

IgA DEFICIENCY, Misc 6/2 Recurrent Sino-pulmonary and GI infections (diarrhea), and anaphylactic transfusion reaction. Dx is made if IgA serum concentration is <7mg/dl with normal IgG and IBM levels. Tx targets prophylaxis and prevention. Initially a 6-month course of daily prophylactic TMP-SMX or Amoxicillin, if fails needs IVIG with least amount of IgA. Don't confuse sinopulmonary recurrent infection with CF, CF doesn't cause anaphylactic rxn.

IgA NEPHROPATHY Is the MCC of glomerulonephritis in adults. Pt has recurrent episodes of gross hematuria, beginning 1-3 days after URI. Serum complement levels are normal.

IMMUNE THROMBOCYTOPENIA Occurs in children 2/6 yo. Pathogenesis involves antibodies that bind to platelets and subsequent destruction of these complexes in spleen. It’s preceded with viral infection, presents w/ petechiae, purpura, hematuria, or GI bleeding, No adenopathy. Lab shows no abnormality except thrombocytopenia (60000). The course is self-limited. It requires no Tx. If thrombocytopenia is <30000, corticosteriods are DOC.

IMPETIGO BULLOUS - 2 Derm 6/3 Tx: MUPIROCIN ointment is choice for local impetigo. If no response, then treat systemically. Because most cases are caused by penicillinase-producing staphylococci, Cloxacillin or a 1st-generation cephalosporin is DOC in severe cases. Penicillin-allergic patients should receive cefadroxil or cephalexin rather than erythromycin.

INCONTINENCE – 4 STRESS URGE: OVERFLOW a sudden increase in sudden and frequent Loss of small amount of abdominal muscle; loss of moderate to urine from an over extended (cough, sneeze, laugh) large amount of urine; bladder and a markedly urine ensues often w/Nocturia increased residual volume.

Tx: Pelvic muscle Tx: Oxybutyrin Tx: 1st step is to stop NSAID. exercise (Kegel Then cholinergic drug exercise), Urethropexy (Bethanechol) should be Surgical Tx: Burch and added afterwards to improve Sling procedures detrusor action. Intermittent self- catheterization can be used. a CC of incontinence in There is hx of DM that is not older women; HIGH controlled PARITY, a major risk CC: certain medications factor (Ibuprofen), Diabetic Post-void cystometry nephropathy, MS and spinal is normal cord injury. ***NSAIDs (inhibitory action on the detrusor) pelvic floor weakness; Detrusor instability, Urethra relapses bladder irritation from outside the pelvis; neoplasm, and interstitial whenever there is cystitis result in UTI increase intra- abdominal pressure (cough, sneeze, laugh) urine ensues.

Aggravating factors are Obesity, pregnancy, COPD and Smoking

****One of effects of epidural anesthesia is urinary retention due to denervation of bladder. When bladder pressure is > sphincter pt urinates until balance is achieved again. This incontinence is transient. PE may show distended bladder. Post-void volume is high. Tx: Intermittent catheterization until control is regained.

INFANTILE SAH: CT scan: Dilation of entire ventricular system with distinct enlargement of subarachnoid space over the cerebral cortex is suggestive of non-obstructive or communicating hydrocephalus 2ndary to SAH. SAH is the MCC of communicating hydrocephalus. Accumulation of blood in subarachnoid space may lead to destruction of arachnoid villi and cisterns (that absorb CSF); SAH is caused by intracranial hemorrhage common in premies. DDx: Arnold Chiari: non-communicating, protrusion of structures through foramen magnum. DDx: Dandy-Walker: NC, cystic expansion of 4th ventricle. INFECTIOUS DIARRHEA 2 Types: bloody or non-bloody. Bloody: E. coli O157:H7 (MC), Shield, Salmonella, Campylobacter, E. Histolytica and Yersinia and C. difficile.

INFECTIOUS MONONUCLEOSIS - 7 Heterophil antibody test is sensitive and specific. If heterophile negative and you're still suspicious, do EBV specific antibody test. Splenic rupture is a serious complication. So pts with splenomegaly are advised bed rest and avoidance of contact sports until no more splenomegaly. Glucocorticoids are indicated if IM is complicated by upper airway obstruction, autoimmune hemolytic anemia, and thrombocytopenia (and resultant petechiae). *Ebstein Bar virus causes IM. Sometimes it is detected only after pt develops a characteristic polymorphic rash after taking Ampicillin for an apparent upper respiratory track infection. **** Is assoc with Autoimmune Hemolytic Anemia. *****Blood smear with Atypical Lymphocytes (Large basophilic Lymphocytes). It might also be in Toxoplasmosis by CMV is the MC organism. *****A negative Heterophile antibodies don’t exclude IM, because sometimes they appear later in the course.

INFECTIVE ENDOCARDITIS 14, Infx 6/2 Generally if the procedure involves bleeding, prophylaxis is recommended. For LOW-RISK procedures like: GI endoscopy, there is no need for prophylaxis. Tx includes: 1-For IV drug user: Vancomycin IV + Gentamicin IV, since the incidence of MRSA is increased in IV users Vancomycin is better than Nafcilin). 2- For non-IV users: Nafcilin IV + Gentamicin IV. If IE is due to Strep Bovis; there is at risk for Colon cancer, colonoscopy is recommended. Chordae tendineae rupture occurs as a complication if IE. **** Pathophysiological consequences and clinical manifestations of IE can be explained by: 1-Cytokine production: responsible for fever. 2-Embolization of vegetation fragments: Leads to Pulm and Spleen infarction. 3-Hematogenous infection of sites. 4-Tissue injury due to Immune complex and immune responses to the deposited bacterial antigens: ROTH spots (oval retinal hemorrhages with pale centers,) are due to immune vasculitis. They have been noticed in pts with collagen vascular dz and hemorrhagic disorders. OLSER NODES: violaceous nodules found at the pulp of the fingers and toes, due to immune complex deposition. Immune complex is also responsible for GN and Rheumatoid manifestation of IE. JANEWAY LESIONS: Macular, blanching, non-painful erythematous lesions on the palms and soles, they are due to SEPTIC EMBOLI, revealing subcutaneous abscesses. ****Tricuspid Endocarditis is assoc with IVDA. S. aureus (MCC). Tricuspid murmurs are accentuated by inspiration and neck vein distention. ECHO is the dx choice. CXR: peripheral Well-circumscribed lesion with cavitation, Surgery is required in majority of pts. Valve repair or replacement is therapeutic. *****Pt with IE who goes under GU instrumentation for evaluation of microscopic hematuria could have an exacerbation post procedure with murmur and other symptoms of IE. ****Subacute bacterial infective endocarditis (SABIE) is seen in pts with damaged valves. Strep Viridans (MCC). Acute BIE is caused by S. aureus in IV drug users. S. Epidermidis is seen in pt with Prosthetic valves. ***Strep Viridans (S. Mutans) MC responsible for endocarditis after dental work. ****Decision to give prophylactic antibiotics depends on risk due to condition of the pt and also depends on the procedure being done. Risk classification: 1-HIGH risk: Prosthetic valves, previous hx of IE, Cyanotic pts. 2-MODERATE risk: Congenial cardiac abnormities Acquired valve dz, MVP and regurgitation, and HCM. Now conditions that DONT REQUIRE prophylaxis are MVP w/o regurgitation, innocent murmurs, Pacemakers and defibrillators. ****IE in IV drug users is in right heart and caused by S. aureus with involvement of Tricuspid valve. The holosystolic murmur that intensifies with inspiration is Tricuspid Regurgitation. Vegetations can emboli to remote organs, so if pt has fever and hemoptysis this would be SEPTIC EMBOLI. DDx: Bronchiectasis is there’s a hx of CHRONIC productive cough. DDx: Abscess is foul smelling and cavity in CXR. ****Prophylaxis medication guides: 1-Amoxicillin (DOC) in Dental, and Respiratory procedures. In pt with penicillin allergy: Cefazolin, Clindamycin or Clarithromycin is used. 2-In GU and GI procedures other than esophageal: Ampicillin plus Gentamicin (DOC). If allergic to penicillin Vancomycin + Gentamicin is used ****Once you suspect it, next stepà Give IV antibiotics after you draw blood. TEE comes afterwards. Positive blood cultures and vegetation on the valve seen in TEE confirms dx. ****Always suspect IE when a pt is febrile, hx of Rheumatic fever and hematuria. Hematuria in Bacterial Endocarditis is due to glomerular injury caused by deposition of immune complex. *****If FUNGAL endocarditis then next step is surgery because they are very aggressive in the valves.

INFERTILITY - 4, OBGYN, 6/2 The 1ST step in WOMEN: Check Basal Body Temperature (BBT) and mid luteal PROGESTERONE (MLP). The ovulatory factor involves defects in the hypothalamic pituitary ovarian axis, and related infertility maybe due to impairment of follicular maturation ovulation or endometrial development. BBT: assess the DURATION luteal function MLP assesses LEVEL of luteal function. Endometrial biopsy is done to confirm luteal phase defect, rather than initial evaluation. ****MALES: Male coital factor is responsible for 40% of all cases infertility; common conditions: Varicocele, genital tract trauma or surgery disruption of hypothalamic-pit axis, or smoking and occupational exposure (Iatrogenic causes). 1ST step MALE evaluation: Sperm count. If normal then an ENDOCRINE HORMONAL EVALUATION is carried out. It includes: 1-TFT (since increased TSH inhibits GnRH and then decrease FSH. 2-Testosterone levels to indicate the presence or not of Gonadism. 3-Gonadotropin to determine whether hypogonadism is central or testicular and 4-Prolactin levels. ****Causes of infertility in females falls into 4 factors: 1- Peritoneal factor. 2-Ovulatory. 3-Cervical. 4-tubo-uterine. Peritoneal is the MC type and includes Endometriosis and peritoneal adhesions. Laparoscopy is the procedure of choice (for dx and tx.) Mild forms of endometriosis usually respond to meds like GnRH agonists, Danazol and Medroxyprogesterone. 2-Ovulatory factor involves hypothalamus-pit-ovary axis; and infertility might be due to impairment of follicular maturation, ovulation, or endometrial development. Ovulatory abnormality may initially be screened by Basal body temp and mid-luteal phase level of progesterone, the former assess DURAtion and later LEVEL of luteal function. If luteal phase shows low progesterone, hence infertility, then tx is suppository progesterone deposition. 3-Tubo0uterine is seldom a cause. It involves Fibroids, endometrial polyps, tubal occlusion (2ary to IUD or endometriosis). Investigation is hysterosalpingography or laparoscopy. 4-Cervial involves cervical structure abnormalities and abnormal mucus production. In 5-10% infertility remains unidentified. Intrauterine insemination is the tx. *****Clomiphene Citrate is an anti-estrogen that acts by competitively inhibiting estrogen receptors at hypothalamus, thus inhibiting the negative feed back estrogen has on GnRH production and consequently increasing LH & FSH secretion and improving ovulation. Along with HCG and HMC it’s indicated for chronic anovulation. Side effects include large ovaries, hot flashes, abdominal bloating, breast discomfort and abnormal uterine bleeding. Major complications include: Ovarian Hyper stimulation Syndrome and multiple gestations. Danazol, an androgen derivative having a gonadotropin inhibitory effect, indicated in endometriosis, fibroids and fibrocystic breast disease.

INFLAMMATORY BOWEL DISEASE - 2 Erythema nodosum, arthralgias, diarrhea, and positive p-ANCA (60-80% in UC and 10-25% in Crohn) in a young pt are highly suggestive of IBD. ***Any young pt with bloody diarrhea should make you think of IBD. DDx: Infectious Diarrhea, mostly Campylobacter. If pt presents with rectal tenderness and mucus and distended abdomen he might have UC with a fulminant course and Toxic megacolon. Fulminant colitis is a serious complication, XR shows it. Proctosigmoidoscopy with biopsy establishes Dx.

INFLUENZA Presents with: cough, coryza, fever, chills, malaise, sore throat, muscle pain. Dx is made clinically, however a rapid lab test for Influenza antigens from nasal swap is available. The infection is self-limiting b/w 1-7 days. Treat with bed rest and acetaminophen. Two classes of drugs for prevention and tx are 1-Amantidine (Inf- A), 2-Oseltamivir for both A & B.

INFLUENZA VACCINE: Is recommended in annual basis for all adults over 65 and adults of any age at risk of developing influenza (1-Chronic dz like CV or COPD. 2-Immunocompromised. 3- Nersing home residents. 4-Pregos in 2nd trimester in influenza season). This is NOT Influenza B vaccine.

INSULINOMA - 2 Pancreatic B-cell tumor. Whipple's triad of attack occurs in fasting, there is hypoglycemia and ingestion of CHO relieves the symptom. Tx is surgery. 80-90% are single benign tumor. 10% is malignant. DDx: Sulfonylurea (The sulfonylureas lower plasma glucose primarily by stimulating insulin secretion. SE is hypoglycemia and increased C-peptide and increased plasma sulfonylurea) and DDx2: Exogenous insulin admin (normal C-peptide).

INTELECTUALIZATION Helps the pt to be emotionally detached from the wrong-doing (murder) or unacceptable fact (cancer). DDx: Rationalization is a logical reasoning for an upsetting event rather than the true reason (students says they failed me).

INTERSTITIAL LUNG DZ 1-Extrinsic Allergic Alveoli is or Hypersensitivity Pneumonitis, due to exposure to organic dust like fungal spores or Actinomyces, Farmer's Lung and Bird Breeders are two examples. Features are fever, dyspnea and non-productive cough. CXR: shows interstitial infiltrates. PFT shows restrictive pattern (Reduces total lung volume). The best tx is avoidance. 2-Alveolar Proteinosis: Accumulation of phospholipid rich material in alveoli. It presents with dyspnea and cough. CXR: Bilateral alveolar infiltrate and PFT shows restrictive pattern. Dx is lung biopsy and PAS positive material. Tx: Total lung Bronchoalveolar lavage. 3-Acute Interstitial Pneumonia: An acute fatal disorder that rapidly progress to pulmonary fibrosis. It presents in >40 people, fever, breathlessness and cough. Pt has hypoxia and requires ventilation. CXR: shows diffused bilateral alveolar infiltrate. 4-Asbestosis: It’s initial presentation may be Obstructive. Presents with Pleural Fibrosis. It’s exposed to IN organic dusts.

INTERMITTENT EXPLOSIVE DISORDER Is an impulse control disorder. Characterized by multiple episodes of assault resulting from aggressive impulses, out of proportion to any stressor. It's assoc with abnormality in serotonergic pathway of limbic system.

INTERNAL CAROTID A. OCCLUSION: MC manifest in OCULAR DISTURBANCES & ISCHEMIA in MIDDLE CEREBRAL ARTERY territory.

INTEROSSEOUS ACCESS whenever pediatric IV line cant be found, this is the best place for it.

INTESTINAL OBSTRUCTION: If there is simple mechanical obstruction then both Barium enema and Nasogastric tube + IV fluids + NPO would be appropriate. But if there’s obstruction w/ metabolic acidosis and shock, then laparatomy is the only way to go and Laparoscopy is C/I due to shock & acidosis.

INTESTINAL PERFORATION: Best test: STANDING abdominal XR. Used for PUD rupture. If negative then U/S, CT and DPL is indicated. INTRAABDOMINAL BLEEDING Once you know the pt is bleeding into the abdomen; next thing: Either U/S or Diagnostic Peritoneal Lavage to find out the location of bleeding and then exploratory laparotomy.

INTRACRANIAL PRESSURE: 1-Bilatateral dilated pupils indicate increased ICP. 2-Anisocoria: pupils are non reactive to light. 3- Flaccidity or decerbrate motor posturing. 4- Papilledema. Glascow is not an indication for increased ICP.

INTRADUCTAL PAPILOMA: A benign tumor of lactiferous ducts. Clinically manifest as serous bloody discharge. Mammogram won’t show it, too small. Resection has to be done to relief pain guided by galactogram.

INTRAPARENCHYMAL HEMORRHAGE -2 Due to HTN, think of Striae arteries that cause bleed in parenchymal in Basal Ganglia. **** HTN is the most important risk factor. 1-Cerebellar hemorhage: acts for 16% of cases. Pt presents with Ataxia, vomit, occipital HA, gaze palsy. NO HEMIPARESIS. Emergent decompression may be life saving. 2-The MC site of hypertensive hemorhage is Putamen, 35%. Internal capsule is always affected thereby leading to HEMIPARESIS. Other signs: Hemi-sensory loss, homonomous hemianopsia, stupor and coma. The eyes are deviated from paralytic side. 3-Pontine is accounted for 5-12%. Pt presents with DEEP COMA, and paraplegia developed within minutes; PINPOINT pupils are pinpoint and reactive to light. No horizontal eye movement.

INTRAHEPATIC CHOLESTASIS of PREGNANCY Jaundice in the 3RD trimester of pregnancy should be evaluated for hepatic disorders specific for pregnancy. Marked pruritus and elevation of bile acids should make you think of ICP. Tx: Cholestyramine with or w/o Phenobarbital or Ursodeoxycholate. Fetal monitoring is mandatory. DDx: Primary Biliary Cirrhosis: intense pruritus, markedly elevated Alk phosphatase and cholesterol levels. DDx: Primary Sclerosing Cholangitis: assoc with UC, presents with RUQ pain, Jaundice and pruritus.

INTRATROCHANTERIC FRACTURE Of the femur is mostly seen in ELDERLY FALL. The extremity: SHORTENED AND ROTATED. XR is Dx. Tx is INTERNAL FIXATION w/SLIDING SCREW and PLATE & EARLY mobilization.

INTRAUTERINE FETAL DEMISE DEATH of the FETUS in UTERO occurs after 20 weeks gestation and before the onset of labor. Its suspected when mother reports the disappearance of fetal movements, decrease or stagnation in the uterus size and no heart tones. REAL- TIME U/S to confirm, which will demonstrate the lack of movement and absence of fetal heart activity. After dx is established, coagulation profile has to be determined to detect an eventual DIC, which is a serious complication of IUFD early in the course.

INTRAVENTRICULAR HEMORRHAGE of the NEWBORN: Occurs in low birth weight infants; MC seen in premature infants. Pt presents: pallor, cyanosis, hypotension, seizures, focal neurologic signs, bulging or tense fontanels. So Transfontanel U/S is mandatory for all infants with risk factors.

INTUSSUSCEPTION 2-yr old child with abrupt onset of abdominal pain, nausea, vomit, red currant jelly stool containing blood and mucus. 75% of pts are younger than 1 yo; the MC is in Ileiocolic; Sausage-like abdominal mass and draws knees towards chest.

IRON DEFICIENCY ANEMIA (IDA) - 8 Hemo 6/3 normal: Fe 50-170. Decreased Fe, increased TIBC (460), MCV=68 and hypochromic microcytic anemia. Infants are at increased risk of this disease due to lack of Fe in milk. DDx1: Sideroblastic Anemia: A part of utilization anemia which is caused by inadequate or abnormal utilization of intracellular Iron for Hb synthesis despite increased amount of Iron, sometimes it help to give Pyridoxone (B6). IDA is the MCC of anemia, suspect it when a person is not eating well and lab shows microcytic hypochromic anemia. **** In elderly: blood loss from GI will lead to IRON DEF ANEMIA. Since fecal blood test is NOT sufficient we need to do Colonoscopy because in elderly pt w/o GI complain, the cause is probably cancer. ****It’s the MCC of anemia in children. The early introduction of COW MILK to INFANTS à assoc with iron def anemia, the larger the amount of milk consumed the higher the risk. Typical lab shows: Dx: Low MCV, low Hb, Low hematocrit, low reticulocyte count, microcytosis, hypochromia, low serum Iron, elevated TIBC. Low serum Ferritin. Infants yr 1: Should receive breast milk for the 1ST year or iron-fortified formulas. 1ST 6 mo: iron fortified cereal should be added. DDx1: Thalassemia: High Ferritin and signs of extramedullary hematopoiesis (hepato/splenomegaly and widened bones). *****Microcytic hypochromic anemia due to chronic blood loss (Iron def anemia) results in decreased serum Fe, Ferritin, Transferrin Saturation, and increased TIBC. DDx: Sideroblastic anemia has, Increased Fe, normal Ferritin, Increased TIBC, normal to increased Transferrin saturation. DDx2: Anemia of Chronic DISEASE will show decreased Fe, increased Ferritin, low TIBC and low Transferrin saturation. ***The MC type of anemia in elderly pts. This pt presents with Fatigue and pallor. Other causes: Chronic diseases like infections, inflammatory dz, and neoplasm. ****Bone Marrow Iron stain is the most definite way to Dx IDA. Low Ferritin increased TIBC and Low Iron are not as specific.

IRON POISONING Presents with N/V/D and abdominal pain, GI bleeding and metabolic acidosis. Fe accumulates in mitochondria and resulting in cellular damage. HTN then occurs due to increased vascular permeability and venodialation. Since Iron tablets are radiopaque they will be seen on XR. Dx: confirmed by serum Fe levels. Tx: IV Deferoxamine DDx: ASA Toxicity, presents: lethargy, fever, hyperpnea, vomit, tinnitus and metabolic acidosis. Abdomen XR is unremarkable.

ISCHEMIC COLITIS MC site is SPLENIC FLEXURE b/c it’s supplied by end arteries. It’s a 'watershed' area b/w Superior and Inferior Mesenteric aa. *****Ischemic colitis is due to construction of IMA. After AAA repair, diarrhea and blood in stool should raise suspicion. If CT is inconclusive a sigmoidoscopy is recommended. Angiogram is not recommended. Barium enema could cause perforation in case of IC. It’s a good technique for detection of colonic masses.

ISOLATED PROTEINURIA IP (w/o pyuria or Hematuria) can happen due to stress or any febrile illness. Evaluation should begin by testing the urine on at least 3 occasions (dipstick testing).

ISONIAZID TOXICITY Might cause elevation of AST ALT in the beginning, do nothing it will decline.

ITP - 2 Idiopathic Thrombocytopenic Purpura is an autoimmune disorder characterized by isolated thrombocytopenia absence of splenomegaly, absence of fever or other systemic signs normal BM with normal or increased Megakaryocytes. ITP is acute and self-limiting in children, but becomes chronic in adults. It presents with skin or mucosal bleeding. Coagulation studies are normal. Autoimmune destruction of platelets maybe primary or it may be 2ary to SLE or infection with CMV, Toxoplasma, HIV. Whenever pt is having Chronic ITP BM must examined to r/o primary hematological disorder. Pt must also be screened for SLE by anti nuclear antibody testing, as isolated Thrombocytopenia may be a presenting feature of SLE, especially in a young female. Now, if a pt shows hepatomegaly, lymphadenopathy, or atypical lymphocytes, 2ary causes of autoimmune thrombocytopenia like CMV, HIV, Hepatitis and Toxoplasma should be considered. ***The MC acquired bleeding disorder in children; that follows viral infection, with easy bruisability, and petechiae. Labs: Thrombocytopenia and normal PT & PTT. DDx: HUS: combination of Thrombocytopenia, Microangiopathic hemolytic anemia and acute renal failure.

IUGR - 2 Defined as: Birth weight below the 10% for a given gestational age, and refers to fetuses and neonates whose growth potential has been restricted by pathologic processes in utero. These fetuses are particularly prone to problems such as meconium aspiration, asphyxia, polycythemia, hypoglycemia and MR. IUGR maybe of maternal, fetal or placental origin.

MATERNAL FETAL PLACENTAL SYMMETRICAL ASYMMETRICAL CAUSES

Poor nutrition Fetal causes: Result in a FETAL insult FETAL insult (*ONLY abd TORCH, lack of < 28wk leads after 28 week circumference is congenital decidualization to damage to Only abd small) abnormities. of myoetrial both Head circumference Cigarette IUGR maybe aa resulting in and Body is small smoking Drug deficient abuse SYMMETRICAL: perfusion of Due to FETAL Due to Alcoholism FETAL insult < the fetus: FACTORS MATERNAL Cyanotic heart 28wk leads to HTN, DM, FACTORS DM, dz Pulm damage to CRF, and HTN, insufficiency both Head and Preeclampsia Preeclampsia & Antiphospholipid Body, only abd CRF; a better syndrome circumference prognosis is small

****The most effective parameter for estimation of fetal weight in cases of suspected IUGR is Abdominal circumference. ****Defined as birth weight below 10% for a given age. These fetuses are prone to Meconium aspiration, hypoglycemia, and MR. Once IUGR is dx fetal well-being has to be monitored, with NST and BPP 2x weekly. Mother can contribute to this monitoring by assessment of the kick count. Delivery is usually indicated at 34 weeks or when lung is matured. If there is Oligohydramnios, AFI of 4, DELIVERY SHOULD BE STRONGLY CONSIDERED. At birth, neonates with UGR are prone to hypothermia and hypoglycemia. RDS also frequently occurs. Bottom line: à even though gestational week is 28, go ahead and DELIVER VAGINALLY.

JAUNDICE DIAGNOSIS PROCEDURE Once the pt has jaundice (bilirubin>1), Next Step: Determine if it’s mostly conjugated or unconjugated. Direct bilirubin <10% of bilirubin Conjugated hyperbilirubinemia: Direct bilirubin >50% of total bilirubin Next step in Conjugated HBL: Study LIVER ENZYMES. Pts with dominant aminotransferase elevation è HEPATOCELLULAR DZ, whereas dominant Alkaline Phosphatase elevation èINTRA- or EXTRA-HEPATIC OBSTRUCTION CONJUGATED DIRECT HBL: ELEVATED ALKALINE PHOSPHATASE INTRAHEPATIC EXTRAHEPATIC CONGENTAL DEFECTS in OBSTRUCTION: OBSTRUCTION BILIARY EXCRETION: Viral or Autoimmune MUST r/o extrahepatic Dubin Johnson Hepatitis obstruction with U/S or Rotor Alcoholic Hepatitis abd CT If these fail to Drug reaction show extra hepatic biliary 3RD trimester pregnancy or dilatation then the next 2-Congenital defects in step would be ERCP or PTC biliary excretion (Dubin- Johnson and Rotor). b) Extrahepatic biliary obstruction.

Unconjugated Hyperbilirubinemia >90% of the total bilirubin.

JERVELL-LANGE-NEILSEN Or Congenital 'Q' syndrome. Syncopal episode w/o following disorientation, hearing impairment, normal PE, and family hx of sudden cardiac death is characteristic of this syndrome. Tx: Beta-blockers.

JUVENILE RA or STILL'S DZ. Child presents with systemic features, high fever, fleeting maculopapular rash (central clearing), hepatosplenomegaly, lymphadenopathy, pleuropericarditis, and myocarditis. Rheumatic factor is rarely positive. Tx: NSAID and monitoring of liver enzymes. Corticosteriods are used if pt does not respond to NSAID or if have myocarditis.

KALLMAN SYNDROME Consists of congenital absence of GnRH secretion assoc with Anosmia (can’t smell), Amenorrhea and absent 2ndary sexual characteristics; and a normal 46XX. Also amenorrhea and absent 2ary sexual characteristics.

KARTAGENER'S SYNDROME Baby with recurrent sinusitis, bronchiectasis, dextrocardia, infertility due to Dysmotile cilia (dynein aberrant).

KAWASAKI DISEASE – 2 Mucocutanous Lymph Node Syndrome Fever >5 days. Mucous membrane changes (fissured lips), extremity changes (edema, erythema), at least 1 cervical node >1.5cm and polymorphus rash. Coronary artery aneurysm or ectasia (widened) develops in 15-25% of children. MERCK: A syndrome occurring usually in infants and children < 5 yr, characterized by prolonged fever, exanthem, conjunctivitis, mucous membrane inflammation, cervical lymphadenopathy, and polyarteritis of variable severity. Therapy is started ASAP, optimally within the first 10 days of illness, with a combination of high-dose IGIV and oral high-dose ASA. MERCK END. ***Criteria are: 1-Fever>5 days. 2-4 of the following, Bulbar conjunctival injection, Desquamation of finger and toe tips, Erythema fissuring and crusting of the lips and strawberry tongue, Morbiliform truncal exanthem, Cervical lymphadenopathy. One of MCC of generalized vasculitis in children: Self-limited; BUT can be fatal due to thromboses leading to MI. TESTS: 2D ECHO is done to assess cardiac function. A baseline ECHO is done WITHIN 7 days then REPEATED 6-8 weeks later. Fever does not respond to Acetaminophen. All pts with Kawasaki should be hospitalized and treated with IV IG and High dose ASA. If untreated 25% will develop coronary artery aneurysm. DDx1: Scarlet Fever: POSITIVE Strep test and no LIP fissures. Latex Agglutination test ID a rapid Dx test. Tx: 10 day Penicillin, or Erythromycin for Pen allergy.

KLUMPKE'S PARALYSIS A brachial palsy in newborns following excessive traction of arms. It consists of hand paralysis, and ipsilateral Horner syndrome (ptosis & myosis) and it’s secondary to injury: C7, C8, T1.

KNEE INJURY: **MCL injury: Dx with MRI. As MCL resists valgus angulations at the knee, injury to this ligament leads to increased angulation of the affected knee in valgus maneuver. If MRI is inconclusive then à Do ARTHROSCOPY. Surgery is rarely necessary for MCL tear. ***ACL prevents leg from gliding anteriorly; it is damaged when KNEE HYPEREXTENDED. It’s assoc with MCL and medial meniscus. LACHMAN is the most sensitive test for Dx. Anterior drawer sign is also used for testing but it’s not as sensitive. McMURRAY test is for meniscus testing. VALGUS TEST: is used for MCL (Medial Collateral Ligament) testing. ****Meniscal injury result from twisting injury with the foot fixed. Bucket handle tear is MC. Tenderness along medial side. It results in LOCKING of the knee joint during the terminal extension. Initial tx: Conservative: immobilization and bracing.

KRABBE'S DISEASE: Sphingolipidoses due to deficiency in galactocerebrosidase. Characterized by hyperacusis, seizure and irritability.

LABOR - 2 Labor is defined as progressive cervical effacement, dilatation, or both resulting from uterine contractions, which occur at least every five minutes and last 30 to 60 seconds Labor progress through four stages:

First stage: ONSET of LABOR UNTIL FULL DILATATION of CERVIX; includes 2 phases: LATENT PHASE: Dilatation progresses in a slow rate until reaches 2-3 cm, followed by

Hypertrophic uterine Hypotonic contractions Premature or contractions excessive use of anesthesia or induction *Intense but Less painful; ineffective; *more characterized by easily painful and assoc with indentable uterus during increased uterine tone the contraction. * Hypertonic activity of the uterus usually Pts with hypocontractile responds to therapeutic dysfunction are best rest with Morphine treated with a diluted Sulfate. infusion of oxytocin.

Sometimes pts diagnosed with prolonged latent phase may actually still be in false labor. FALSE LABOR: Painless and sporadic contractions, but can be rhythmic, occurring every 10-20 minutes. Main characteristic NO cervical changes

ACTIVE PHASE: Dilatation is more rapid. The length of the latent phase is highly variable. Is considered PROLONGED when Active phase > 20hr in primiparous or Active phase > 14 in multiparous The progression of active phase is measured by the rate cervical dilation.

-- Primiparous: normal rate of cervical dilatation at least 1cm/hr

-- Multiparous 1.2cm/hr

SECOND STAGE: Extends from complete dilatation of the cervix to delivery of the baby. Usually lasts: --Primiparous: 30 min to 3 hours and --Multiparous: 5 to 30 minutes

THIRD STAGE: starts with delivery of the baby, and ends with the delivery of placenta.

FOURTH STAGE: starts with delivery of placenta to 6 hours postpartum. The mother should be closely observed because of high risk of postpartum hemorrhage.

*****EARLY DECELERATION: Fetal head compression is assoc with early deceleration, Uteroplacental insuff presents with late deceleration *****LATE DECELERATION: (decrease in fetal HR of 20 for a duration of 35 sec with absence of contraction) Fetal cord compression 1st step in Tx for FCC: is O2 admin and change in maternal position and elevating the presenting part

LACTATION SUPPRESSION: Tight fitting bra and ice packs. Bromocriptine is no longer used. LACTIC ACIDOSIS, POST-ICTERIC T9Q45. Its transient and it resolves in 60-90 minutes.

LACTOSE INTOLERANCE Characterized by a positive hydrogen breath test, positive Clinitest of stool for REDUCING substances and increased osmotic gap.

LACUNAR INFARCTION*** The principal cause is HTN There are 4 types, MEMORIZE THEM: 1-PURE MOTOR HEMIPARESIS: Lacunar infarction in POSTERIOR GENU of INTERNAL CAPSURE: unilateral motor deficit (face, arm and some leg); mild dysarthria (poorly articulated speech); NO sensory or visual dysfunction. 2-PURE SENSORY STROKE: VPL NUCLEUS of THALAMUS: Unilateral numbness, paresthesias, hemisensory deficit involving face, arm and leg and trunk. 3-ATAXIC HEMIPARESIS: Lacunar infarction in POSTERIOR LIMB of IC: weakness more prominent in lower extremity, and ispilateral arm and leg incoordination. 4-DYSARTHRIA: Clumsy Hand Syndrome: Lacunar stroke of BASIS PONTIS: Hand weakness, mild motor aphasia, NO sensory abnormality.

LARYNGOMALACIA: MCC: chronic inspiratory noise in infants. Laryngoscopy: flaccidity of the larynx, and collapses during inspiration; self-limiting mostly. Management: Baby in upright position for ½ hour after feeding and never to feed the child while lying down.

LATEX ALLERGY can manifest as an anaphylactic reaction during exposure to gloves or condoms. Pt is anaphylactic during surgery and sex.

LEAD POISONING Microcytic Hypochromic anemia and basophilic stippling, not normocytic normochromic.

LEG NERVES: 1-Femoral: thigh ext, hip flex. Sensory: Anterior thigh and medial leg through SAPHENOUS 2-Tibial: Flexion of knee and digits. Plantar flexion of foot; Sensation of leg (except medial) and plantar foot. 3-Obturator: adduction of thigh; Sensation of medial thigh. 4-Common Peroneal: muscles of anterior and lateral leg; Sensation: Anterolateral leg and Dorsum of the foot.

LEGG-CALVES-PERTHES - 3 Age: 2-12 yo. Pain: Absent or mild. ANGALGIC Gait and range of motion is limited to internal rotation, flexion and abduction. XR: (AP and lateral view) WIDENING of joint space and collapse of the femoral head. DDx: Osgood-Schlatter: Involves tibial tuberosity resulting in tenderness over it. Ages 10-16 yo. XR: Irregularity of tubercle contour DDx: Slipped Capital Femoral Epiphysis: (SCFE) occurs in obese MALE (MCC) kids, with painful limb, XR: displacement of femoral epiphysis. ****A serious but self- limiting dz, 4-10yo, characterized by AVN of head of femur on MRI & BONE SCAN; usually unilateral. Pt presents: painless limp or mild pain. There is severe limitation of internal rotation and abduction at the hip joint. Tx: AGE <5 no tx. Children >5 need abduction bracing or surgical correction. DDx1: Slipped Capitial Femoral Epiphysis: seen in adolescent obese boys with antalgic gait. DDx2: Septic Arthritis: systemic signs and leukocytosis. DDx3: Osteomyelitis of HIP: systemic signs and leukocytosis. DDx4: Developmental Dysplasia of the Hip, a congenital disorder. DDx5:Osgood-Schaltter (2 Qs) or Osteochondrosis of tibial tubercle: an apophysitis of tibial tubercle, caused by overuse commonly seen in teenagers. CC: Pain and swelling around tibial tubercle. Pain increases on contraction of quadriceps muscles. XR: fragmentation (lateral view) Symptomatic Tx: Rest, NSAIDs and brief casting.

LEGIONELLA T9Q39. Remember PhD (Pneumonia, Hyponatremia and Diarrhea) is almost always indicative of Legionella. Tx: Erythromycin

LEPROSY: A chronic granulomatous disease that primary affects peripheral nerves and skin. Dx: Acid-fast bacilli on skin biopsy. Pt is from Asia, lesion on arm, dry cough. Lesion has no sensory feeling and muscle atrophy. Next step: Skin biopsy for acid fast. Tx: Dapsone

LESCH-NYHAN SYNDROME Def of HGPRT. Self-mutilation and neurologic features, gouty arthritis (gout in men over 50, so if a BOY with gout suspect this syndrome). Tx is Allopurinol.

LEUKEMIA: 1-Acute Monocytic (FAB M5) Leukemia. CC: Onset: Dramatic HA and fever, also fatigue, weight loss, bleeding from mouth and nose, gingival hyperplasia. There is leukocytosis with high proportions of blast cells. Chemically they are 'Alpha- Naphthyl Esterase positive. DDx: Acute Myeloblastic Leuk with Maturation (M2) Myeloblasts predominant. DDx2: Acute Promyelocytic Leuk (M3) has lots of Promyelocytes. DIC sometimes seen with this type. DDx3: Acute Lymphoblastic Leuk: predominant cells are Lymphoblasts; mostly PAS positive DDx4: Acute Erythro Leuk (M6) characterized by erythroblasts.

LEUKEMIA: 1-ALL: 2-CML: Leukocytosis, Anemia, increased granular cells like segmented neutophils and bands. It’s mostly seen after 50 yo. Presents: fatigue, malaise, low-grade fever, anorexia, weight loss, and bone pains. Night sweats and fever assoc w/ increased metabolism due to granulocytic cell turnover. BONE Examination: Hypercellularity w/prominent granulocytic hyperplasia. The Leukocyte Alkaline Phosphate is low, the only other diseases that this may happen is Hypophosphatemia and PNH. Elevated Leukocyte Alkaline Phosphatase is characteristic of Leukemoid reaction. Presence of Philadelphia chromosome and LOW Leukocyte Alkaline Phosphatase makes CML more likely than Leukemoid reaction.

LEUKEMOID REACTION is a marked increase in leukocytes by a severe infection or inflammation. CML and LR are indistinguishable. Leukocyte Alkaline Phosphatase increase establishes DDx b/w CML and LR (increased LAP). In CML, LAP is decreased and there is Philadelphia chrom (t: 9,22). Left-shift; toxic granulation

Leukemoid CML WBC 10-100K 30-500K Eos/Bas rare increased LAP >100 (increased) < 10 Organomegaly none present

LEWY BODY DEMENTIA Characterized by: fluctuating cognitive impairment and bizarre, visual hallucination, parkinsonism also seen. The central feature required for dx: Progressive cognitive decline that interferes with normal social functions.

LICHEN SCLEROSIS: Is epithelial lining inflammation and dry skin. Usually occurs in postmenopausal women. MC presentation: A severe itch and vaginal soreness. It might progress to vaginal cancer. Once diagnosed start super potent steroid cream while awaiting biopsy results.

LITHIUM TOXICITY - 4 Presents with tremulousness, HA, confusion, GI disturbances, fatigue, seizure, coma, hyperreflexia and opisthotonus. Lithium exacerbates or precipitates Psoriasis. ***Lithium exposure in the 1st trimester of pregnancy = 20-fold increase in the risk of Ebstein anomaly, a CARDIAC malformation. It’s characterized by a malformed and inferiorly attached tricuspid valve that causes decrease in size of right ventricle. ****SE: Nephrogenic DI, Hypothyroidism, Ebstein anomaly in fetus à So test the pt for TFT, Creatinine, and pregnancy before prescribing. *****If a pt presents with refractory mania despite therapy with a mood stabilizer, a urine toxicology screen and mood stabilizer drug levels should be obtained in initial evaluation. LIVER CIRRHOSIS T6Q=30. Liver functions can be divided into the following categories: 1-Synthetic: Synthesis of clotting factors, cholesterol, proteins. 2-Metabolic: Metabolism of drugs and steroids including detoxification. 3-Excretion of bile Manifestations could include: A-Gynecomastia in (cirrhotic pt): Liver can’t metabolize estrogen. Other manifestations of hyperestrinism: testicular atrophy, decreased body hair in males, palmer erythema and Spider nevi (angioma). B-Caput medusa is due to portal HTN, w/ hematemesis and hemorrhoids. C-Ascites is a result of 1-Underfilling theory: Sequestration (accumulation) of fluid in splanchnic circulation due to portal HTN. 2-Overflow theory: Primary abnormality is inappropriate retention of salt and water by kidney. D-Asterixis is 2ary to hyperammonemia leading to hepatoencephalopathy. E-Pedal edema is due to hypoalbuminemia.

FUNCTIONS OF THE LIVER SYNTHESIS METABOLIC EXCRETION

Clotting factors Metabolism of drugs Excretion of (except VIII) and steroids including bile Cholesterol, detoxification proteins

LIVER DISEASE CRITERIA: Elevated TransAminases are indicative of liver cell damages since this intracellular enzyme leaks out of damaged cells. **A marked increase in TA is an indication of ongoing tissue destruction. **A progressive decrease in TA could mean either recovery from liver injury or there is little tissue is left (e.g. Fulminant hepatitis), so this interpretation is dependant on functional test like PT. If PT is OK then TA decrease means recovery, if PT is increased, TA decrease means fulminant hepatitis.

Lab Tests to Assess FUNCTION STRUCTURAL INTEGRITY & evaluate liver CELLULAR DAMAGE fxn PT (most imp. test) TRANSAMINASES ALBUMIN GAMMA GLUTAMYL TRANSFERASE CHOLESTEROL ALKALINE PHOSPHATASE BILIRUBIN

LIVER FAILURE COAGULOPATHY FFP is the tx of choice. Liver makes all clotting factors, except VIII. Among these are vit K-dependant factors, II, VII, IX and X. Proteins C, S. FFP has all clotting factors. Vit K can reverse the bleeding problem, if vit K def is the cause but if the cause is liver failure it is of no use to hepatocytes, also vit K takes a while to work.

LIVER FAILURE, ACUTE When PT is 20s = means hepatic failure. 1-ACUTE liver failure: development of liver failure within 8 weeks of onset of hepatocellular injury. 2- FULMINANT hepatic failure: means AHF+Encephalopathy. Acetaminophen toxicity is the MCC for both. AST will be very high (>3000), and there's 20% mortality rate. FHF has the most favorable prognosis. *****In EVALUATION of ASYMPTOMATIC ELEVATION of AMINOTRANSFERASES:

FIRST step: is to r/o Alcohol and drug abuse & risk factors for viral hepatitis by taking detailed hx. NEXT step: is LFT. If only AST is elevated then ALT should be checked to rule out extrahepatic causes of AST elevation, because ALT is more specific for liver injury than AST.

LIVER METASTASIS Metastasis is the MC neoplasm in the adult liver and is 20x MC than primary tumors. It’s the 2nd MC organ after LN that gets metastasis due to its big size and dual blood supply. Dx is by US, CT, MRI, however biopsy is confirmatory.

LIVER PATHOLOGY 1-Balloon degeneration w/ polymorphic cellular infiltrates: Acute Alcoholic Hepatitis. 2-Panlobular mononuclear infiltration w/hepatic cell necrosis: Acute Viral Hepatitis. 3-Portal necrosis including piecemeal necrosis and/or bridging fibrosis: Chronic Hepatitis. 4-Inflammatory destruction of small intra-hepatic biliary ducts: Primary Biliary Cirrhosis. 5-Extensive fatty vacuolization of the liver: Reye’s Syndrome (ASA toxicity in children).

LOWER EXTREMITY EDEMA The 2 important causes are 1-Liver dz (HepB favors it. Lower extremity edema, ascites, hepato- and splenomegaly. ) 2-Cardiac dz (Constrictive Pericarditis: TB favors it. Lower extremity edema, ascites, hepatomegaly, splenomegaly. Hepato- Jugular reflex is a useful tool is the DDx).

LOWER EXTREMITY NERVES: 1-Tibial 2-Obturator 3-Common Peroneal 4-Femoral

LUDWIG ANGINA An infection of submaxillary and sublingual glands and source of infection is an infected tooth. Pt presents with inflamed mouth, drooling and fever and dysphagia. Tx is IV penicillin with coverage of anaerobes.

LUMBOSACRAL STRAIN: MCC of back pain. Paravertebral tenderness; pain after physical exertion, negative straight leg sign. Tx: NSAID & early mobilization.

LUNG ADENOCARCINOMA t9q29. LEAST associated with smoking.

LUTEAL PHASE DEFECT - 2 A15. ***LPD is suggested by: SHORT CYCLES, hx of spontaneous abortion, abnormal Basal Body Temperature, or low levels of mid-luteal Progesterone. The Dx is confirmed by Endometrial biopsy that demonstrates a lag in endometrial maturation of 2 days or more. Tx: progesterone vaginal suppository FIRST, if that didn’t work then Clomiphene citrate or hMG (Human Menopausal Gonadotropin) is tried. They both increase serum FSH.

LYME DZ - 7, 6/2 Tx for Pregnant women is Oral Amoxicillin, EVEN if there is no reaction give prophylaxis for anxiety. *Facial nerve palsy and classical Erythema migrans indicate Lyme. DDx: Bell’s palsy: refers to idiopathic facial nerve palsy. *Lyme dz prophylaxis (Oral Amoxicillin) is given to pregnant women who have been exposed to the tick and are asymptomatic or have anxiety about getting the dz****Lyme arthritis is a late manifestation of Lyme infection; suspect it with a hx of travel to endemic areas, Rhode Island, NY, Connecticut, NJ, Wisconsin. DDx: Septic arthritis: sudden onset of acute MONOarticular arthritis in previously damaged joint, assoc with Chills and fever. DDx2: Reactive arthritis: occurs 2-4 weeks after GU or GI infection. Onset is acute, with malaise and fever; symmetric joint involvement. *****By Ixodes tick. Antibody cross-reacts with T. pallidium. ****Remember that dx of early dz is Clinical and there is no need for serology. So the 1st thing to do: Doxycycline for 28 days. **** Remember in children <9 yo, don’t give Doxy, give Amoxicillin.

LYMPHOGRANULOMA VENEREUM A STD caused by C.Trochomata, Serotype L1, L2, L3. Initially: HA and fever, then a papule appears that turns in to an ulcer typically in vulvovaginal region. Painless ulcer; disease may go unnoticed until inguinal adenitis develops a month after. If untreated at this stage LGV becomes chronic causing ulceration, PROCTATITIS, rectal stricture rectovaginal fistulas and elephantiasis. Tx is Doxycycline or erythromycin. DDx1: Granuloma Inguinale is caused by Donovania granulomatis, Unlike LGV the ulcer and lymphadenopathy present simultaneously. Also the ulcer w/irregular borders and beefy red granular base. Recommended Tx includes azithromycin, doxycycline, erythromycin.

LYNCH SYNDROME or HNPCC (Hereditary Non Polyposis Colorectal Cancer). Criteria include: 1-at least 3 relatives with CC, 2-involvement of 2 or more generations, 3-At least one case dx before 50, 4-FAP is rules out. Assoc with extra-colonic tumors, MC is Endometrial carcinoma.

MACULAR DEGENERATION Age related. Progressive loss of bilateral CENTRAL vision. Due to degeneration and atrophy of the outer retina, retinal pigment epithelium. Laser photo-coagulation is tx. DDx: Open Angle Glaucoma in which PERIPHERAL vision is lost.

MALABSORPTION SYNDROME One cause is bacterial overgrowth could be associated with stomach surgery (peptic ulcer or especially after Billroth II surgery). There could be A (night blindness) D (tetany due to hypocalcemia) Neuropathy (due to B12 def), dermatitis, arthritis and hepatic injury

MALARIA People traveling to India or Pakistan should get chemoprophylaxis against malaria. DOC is Chloroquine, but in case of chloroquine-resistant P. falciparum, Mefloquine is DOC. Tx with Primaquine is for Plasmodium vivax and ovale. ****The most sensitive test for Dx is Giemsa stain thick smear.

MALIGNANT HTN BP > 200/140. The most consistent sign is Papilledema. The pathological change responsible for end organ damage is Fibrinoid Necrosis of the small arteries.

MALIGNANT MELANOMA - 7 Always suspect it in a changing mole. DDx: Keratoacanthoma: the family of Squamous Cell carcinoma. Best protection is wearing protective clothing, because sunscreen with SPF 15-30 protects ONLY against non-malignant melanoma (Basal and Squamous) skin cancers. Excision biopsy with narrow margins is the preferred study for dx. If the depth is < .76mm the melanoma can be excised with a 1cm tumor free margin and they have 99% 5year survival rate. The MC subtype is "Superficial spreading melanoma, 70%), the least common is "Acral Lentiginous". ***Still the best way to protect fair skin individuals is avoidance of the sun in the middle of the day (10am-4pm). Better than lotion or clothing or what have you. ****The strongest risk factor for MM is recent change (color, size). ****It metastasizes YEARS later to the BRAIN.

MALINGERING Intentional production of false symptoms to get secondary gain (money or morphine) FACTITOUS: production of false symptoms to get the sick role, no secondary gain.

MALLORY-WEISS TEARS increased intragastric pressure during vomiting could cause tear in the mucosa of the cardia and distal esophagus. MANIA - 5 Manic episodes are characterized by DIGFAST. Distractibility, Insomnia, Flight of ideas, Activity increase, Speech (extremely talkative), Thoughtlessness (excessive gambling). **** Initial tx of choice: is antipsychotic, Haloperidol****For general population risk Bipolar dz is 1%, but for first-degree relatives its 10%. ****If pt shows signs of Mania, Bipolar is a good dx. CHRONIC Tx: Lithium (1ST line but not for a pt with renal problems). Valproate or Carbamazepine is better for those pts. Also remember that Haloperidol is the DOC for ACUTE management of initial agitation and aggressiveness. ****Lithium and Valproate (1ST line), 2ND line Carbamazepine. ****If pt has renal problem don't give him Lithium, give him Valproate for long-term treatment

MARFAN SYNDROME Assoc with Fibrillin-1 gene defect. It's AUTOSOMAL DOMINANT Aortic root dilatation. Lens dislocation.

MARIJUANA TOXICITY - 2 Impaired concentration and conjunctival injection are important features. *** A cannabis group causes dry mouth, tachycardia, increased appetite, and conjunctival injection.

MARCH FRACTURE or Stress fracture of METATARSAL: Is common among young active adults (female dancer) involved in vigorous and excessive exercise. Tibia is common. Management: Rest or possible cast

MARJOLI’S ULCER: Years after burn surgery pt presents with an ulcerating lesion from previous trauma that still hasn’t healed. Dx: Biopsy. It’s assoc w/SCC of the skin

MASSIVE HEMOPTYSIS > 600 ml of blood per 24h. It’s an Emergency. Initial intervention of choice is RIGID bronchoscopy, cause it gives better faster vision and has laser for control of bleeding. FLEXIBLE is not good for ER but its good for diagnosis.

MASTITIS Infection of breast with S. aureus. It must be DDx: with Breast Engorgement: (heavy, tender, firm and warm breasts bilaterally in women who not nursing). Management: Tight fitting bras, analgesics and ice pack, breast- feeding should be resumed). Mastitis Tx: oral Dicloxacillin. Breast-feeding should be suspended but milk has to be pumped until infection clears. If it involves abscess, incision and drainage is required.

MASTOIDITIS, ENT 6/2 It's very rare. It's a complication of AOM. Pt presents with fever, otalgia and tender mastitis. CT confirms: fluid filled middle ear & demineralization of mastoid. Tx: IV antibiotics immediately. MATERNAL HYPERTHROIDISM: Seen in 2/1000 pregnancies. MCC is Graves’s disease. Pt may present with sudden onset of Atrial Fibrillation (irregularly irregular rhythm and tachycardia). Dx: Best made with serum TSH and free T4. However the best screening test would be TSH only.

MATERNAL SUBSTANCE ABUSE 1-HEROIN ABUSE: Newborn will show tremors, increased weakness, frequent loose stool, high pitch cry, fist sucking, poor feeding and tachypnea, hyperirritability. Symptoms manifest within: 24/48 after birth, Exclude hypocalcaemia and hypoglycemia. 2-METHADONE WITHDRAWL: at the 2nd to 6th wk of life with seizure. 3-COCAINE: assoc w IUGR, intracranial hemorrhages, and premature labor or abruptio placenta. It’s not common. 4-ALCOHOL WITHDRAWL: presents with tremors, agitation, lethargy and seizures. It’s rare.

McCUNE-ALBRIGHT SYNDROME Rare, characterized by precocious puberty, café au lait spots (large and irregular borders) DDx: Von Recklinghausen & multiple bone defects (Polyostotic fibrous Dysplasia). It’s responsible for 5% of female precocious puberty. Its been related to defect in the G-protein cAMP-kinase in the affected tissue. Remember three P’s: Precocious puberty, Pigmentation (cafe), Polyostotic fibrous Dysplasia. Tx: Precocious puberty: a GnRH agonist (an analog of GnRH)--such as Hist-relin acetate, sc; or Nafa-relin acetate, intranasally; or Leuprolide acetate.

MEASLES: Vitamin A is known to reduce morbidity and mortality in pts with measles. *****Includes Koplik spots. It should be reported. DDx1: Fifth disease: or Erythema Infectiosum, by Parvovirus B19, rash is slapped cheek appearance. Fever is not present or is very mild. DDx2 Scarlet Fever: Pharyngitis, fever and sandpaper like erythematous rash; Strawberry tongue may be present.

MECONIUM ILEUS: Assoc w/CF. presents with failure to pass stool within 1st 24 hour of life.

MECKEL’S DIVERTICULUM - 2 Painless Melena (dark stool) in a 2-3 yo child is most likely MD. It results from the failure of vitelline duct to obliterate during fetal development. Dx is best made with 99m pertechnetate (is taken up by heterotropic gastric mucosa). MD is the MC anomaly in GIT. Heterotropic gastric tissue may be present in the diverticulum, which results in ulcerating and bleeding. ****In a pt with only abdominal pain and pale and hx of childhood Meckel’s, do Pertechnetate scintigraphy to dx it. Angiography can document bleeding at a rate of 0.5ml/min so its not helpful for this situation.

MEDIASTINITIS Hemorrhage and large pericardial effusion may acct for widening of mediastinum. Antibiotic alone is not sufficient for this SERIOUS dz. Mediastinitis needsThoracotomy for debridement, drainage, and antibiotic therapy. Remember widening of mediastinum is not because of that little pericardial fluid shows in ECHO that will resolve spontaneously, it’s because of effusion.

MEDULLOBLASTOMA The 2ND MC posterior fossa tumor in children after Cerebellar Astrocytoma. 90% occur in Vermis of cerebellum.

MEDULLARY CYSTIC DZ It’s not assoc with renal failure or HTN. Pt presents with stone formation or is found incidentally. IVP shows typical radial arrangement of contrast filled cyst. Adult form is Auto Dominant. There is no therapy to prevent progression of cysts. Stones are treated like regular stones, increase intake of water and salt. So suspect MCD in adults with recurrent UTI or renal stones and contrast filled cyst shown in IVP.

MEGALOBLASTIC ANEMIA - 3 Alcohol abuse is the MCC of Folate deficiency in chronic alcoholics in USA. ***

MEMBRANOPROLIFERATIVE GN Dense intramembranous deposits that stain for C3 (only, no Ig) is a characteristic finding for MPGN type 2 (also called dense deposit dz). It’s unique because cause it’s caused by IgG antibodies directed against C3 convertase of alternative C’ pathway.

MEMBRANOUS GN The most likely dx in pt with both HepB and Nephrotic syndrome. HepC is assoc with MPGN. MCD is assoc with Hodgkin’s. FSGN is assoc with HIV. DIFFUSE PROLIFERATIVE GN I severe form of GN seen in pt with SLE.

MEN I - 2 Type-I: Tumors of Parathyroid (hypercalcemia), Pituitary and Pancrease (Hypergastrinemia leads to recurrent peptic ulcers).

MEN IIA - 2 Total Thyroidectomy is recommended. Hyperparathyroidism + Thyroid Medullary Carcinoma + Pheochromocytoma. ***Thyroid C cell hyperplasia becomes Thyroid Medullary carcinoma. Following helps to Dx: Increased Ca, Increased Calcitonin, decreased Phosphorus, elevated urine metanephrine, increased Alk Phosphatase, elevated catecholamine, normal thyroid hormones, MRI of abdomen shows mass, Thyroid biopsy shows Medullary carcinoma, Adrenal biopsy shows Pheochromocytoma, Parathyroid biopsy shows tumor, PTH is increased.

MEN IIB Pheochromocytoma, Thyroid Medullary cancer, Neuroma.

MENIERE'S DISEASE Recurrent episodes of rotational vertigo, sensorineural hearing loss and tinnitus. Dx is clinically. Tx is not necessary or empiric. DDx: Acoustic Neuroma: Vertigo is CONTINUES, and may be assoc w/ataxia.

MENINGITIS 1-Meningococcemia: Suspect it in a neonate with signs of meningitis and petechial rash. Rash appears w/I 24 of sickness. 2-H. Inf: causes meningitis w/o rash, epiglotitis, rhinorrhea. 3-Listeria: meningitis w/o rash. 4-Strep group B: MCC of meningitis in infants, acquired from mother during childbirth. No rash. *****When a child presents with signs of ICP and meningitis, CT should be done before LP, HOWEVER start Cefotaxime 1st.

MENINGOCOCCAL VACCINE Recommended to people with Asplenia.

MENOPAUSE - 3 Peripheral FAT tissue has aromatase that converts Androesteodione (androgen) to Esterone (Estrogen), this process helps fat post menopausal women not to feel many of post menopausal symptoms like hot flashes, dryness of vagina, dyspareunia. ****Estrogen replacement therapy affects metabolism of thyroid hormones. The requirement for L-thyroxine increases, probably due to increase metabolism of hormones due to induction of P450. Rifampin, Carbamazepine and Phenytoin act the same way. Other causes might be increased TBG, increased volume of distribution. In pregnancy also, thyroid hormone requirement would be increased and pt should be monitored every 4-6 weeks for dose adjustment. ****Estrogen is responsible for 2ary sex characteristics, emotional and physical health. Progesterone, produced by corpus luteum at ovulation, prepares for implantation and maintaining pregnancy. Menopause occurs b/w 40-55, average is 51. Before MP there is period of transition, it last 2-4 years before complete cessation of menses. 1 st CC : Change of flow and duration. Afterwards, menses become more irregular, marking occurrence of anovulatory cycles, hot flashes, vaginal dryness. A woman considered menopausal when at least one year of no menses has occurred. Hot flashes there after may become more frequent vaginal dryness more prominent and may result in dyspareunia, infections vaginal, and UTI. Psychological problems may be less concentration, sleeping problems, mood swings.

MESENTERIC THROMBOSIS: It can lead to massive fluid sequestration in bowels, Hypovolemic shock ensues. Extreme elevation of CK suggests massive ischemia, characteristic. Abdominal pain and diarrhea with blood further supports Dx. Pt presents: BP 60/0, CVP of 0. DDX: MI (EKG abnormality). DDX2: AAA: This will show in U/S.

METABOLIC ACIDOSIS - 3 T10Q45. In case of MA, 1st step: Calculate anion gap. Normal anion gap is 6-12. Some of the CC of AG-MA are Lactic acidosis, Ketoacidosis, Methanol ingestion, ethylene glycol ingestion, Salicylate poisoning, Uremia (ESRD). A pt is said to have a normal anion gap MA if decreased HCO3, but a normal anion gap. This is also called Hyperchloremic metabolic acidosis. Some of the CC of normal anion gap MA: 1-renal loss of bicarbonate (RTA, Carbonic anhydrase inhibitors). 2-GI loss of bicarbonate (diarrhea). Urine anion gap tells if the loss is due GI or renal.

METABOLIC ALKALOSIS 10, 6/2 Hypochloremic Metabolic Alkalosis: vomiting causes loss of water, H, K, Na and Cl. Tx: IV normal saline and K. Also remember: there is MA in presence of uncompensated Cirrhosis. Also Diuretic use is one of the MCC of MA. i.e. Thiazides. ****NG tube placement may lead to loss of large amount of gastric acid leading to contraction metabolic alkalosis even in pt with preexisting metabolic acidosis. An example of MA after three days due to vomiting is pH=7.55, PCO2=50,HCO3=42. So CO2 is increased to neutralize alkalosis and make up for acid lost, and HCO3 is also increased because there is no acid to neutralize it. Metabolic Alkalosis can occur in Hemodialysis pt who receives Citrate. *****Met Alk can be divided into 2 broad category based on urinary chloride level:

Chloride-sensitive: Metabolic Alkalosis Chloride-resistant: Metabolic Alkalosis

(Urinary Cl <20) = suggestive of ECF (Urinary Cl>20) There is ECF expansion contraction Due to persistent mineralocorticoid Causes: the loss of gastric hydrochloric stimulation and HypoKalemia acid by suction or vomiting produces metabolic alkalosis that is perpetuated Characterized by HTN and so not by concomitant ECF volume contraction corrected with Saline infusion (NaCl loss in gastric juice) and development of K deficiency, due more Some causes: to secondary aldosteronism (i.e. renal K *Primary Hyperaldosteronism, *Cushing’s wasting) than to K loss in gastric juice. syndrome, *Barrett’s and Gitelman Syndromes (both *Thiazides or Loops are kidney syndromes). *Loss of gastric secretion: (Surreptitious Vomiting) *Acid ingestion CF Villus Adenoma

Correction: with saline infusion and is called Chloride sensitive Metabolic Alkalosis When we give Kayaxelate it causes Metabolic Alkalosis. *** Metabolic Alkalosis is the MC acid-base abnormality in hospitalized pts.

METARSUS ADDUCTUS Is a congenital foot deformity. 1ST born only. There are 3 types: 1-feet over correct both passively and actively into abduction. These correct spontaneously and no tx is needed. 2-foot that corrects to neutral position with passive and active movements. This is corrected with outhouses or corrective shoes and sometimes plaster cast. 3- foot is rigid and isn’t corrected. These are managed with serial cast. Now surgical tx may be required if there is significant residual metatarsus adductus in children by the age of 4.

METFORMIN Is added to DM pt who needs a better control of glucose. Make sure pt renal function is good, because it causes Lactic acidosis if otherwise. Also it helps to reduce weight in borderline obese pts. ****C/I in dye procedures and hospital stays. ****Most Serious but rare SE is Lactic Acidosis, MC SE: GI Distress.

METHANOL ALCHOHOL TOXICITY Blindness. Tx is Ethanol. Pt also has Anion Gap Met Acidosis. Is Assoc with renal failure and Crystalluria (rectangular)

METHYLPHENIDATE TOXICITY Use: ADHD. Its SE is nervousness, decreased appetite, weight loss, insomnia and abdominal pain.

MI - 24 T9Q21. T9Q43. RV infarction: Presents with JVD, Kussmaul sign, hepatomegaly and hypotension in presence of clear lung fields. Sometimes Tricuspid regurg is present. MOA of findings: RV becomes less compliant resulting in decreased filling and stroke volume with a resulting elevated CVP. RV also becomes dilated and tricuspid regurgitation may develop. Loss of LV diastolic function gives rise to the symptoms. MANAGEMENT OF STEMI: Immediate PTCA and angiography is sublingual thrombolytics are C/I (hemorrhagic stroke a < 1 yr ago).

Thrombolytic Indications: 1) ST elevation >1mm AFTER NTG rules out Coronary artery spasm (by persisting after NTG admin). 2) New LBBB. Thrombolytics not indicated for: ST depression or Unstable Angina. Absolute C/I: Internal bleeding Stroke within a year Intracranial neoplasm BP>180/110 Suspected Aortic Aneurysm. Thrombolytic therapy with t-PA requires co-admin of Heparin and ASA, with Streptokinase, heparin is not needed.

MI COMPLICATIONS:

VSD & Papillary Muscle Ventricular Ventricular LV ANTERIOR Wall Rupture Wall Septal Rupture Aneurysm MI Rupture within the 1st week 1st week Presents 4-day a late after MI, w/ cardiogenic post MI. post MI complication shock of MI, usually PM Rupture: It will lead to occurs after acute MR & audible anterior wall pansystolic murmur MI

Hypotension, low BP, JVD, either assoc w/ high risk Pulsus harsh pansystolic asymptomati of ART paradoxus, murmur at the c or with CHF thromboembolism, pulseless lower sternal need Heparin (full electrical border with wide dose) when activity radiation hospitalized, w/recent MI, follow w/ warfarin due to x 3mo Cardiac ***Post MI pt is tamponade on Heparin, emboli from heart can block supply to the leg and can present as Cold PULSELESS LEG. MUST do surgery for the leg, but MUST DO an ECHO to r/o thrombus in LV Dx: if there’s Precordial evidence of L-to- exam: **A pt develops a R shunt on Double apical cold leg after an Swan-Ganz beat, a MI episode should catheter, when murmur of be suspected of 2-D ECHO is not MR 2о an embolus. An available. papillary Angiography muscle should be done dysfxn, CXR: and Embolectomy prominent performed. left border-- heart, EKG: Persistent ST elevation. Post- MI Chest pain : Inferior wall MI friction rub, is either ST elevation: Acute Pericarditis or Leads II, III and Dressler's aVF

Acute Dressler's It results from Severe RVI Pericarditis: a LATE occlusion of could lead to a few days complicatio either RCA or cardiogenic after MI n occurs Left Circumflex shock, b/w 2-10 or artery; with a INITIAL TX 2-4wk post ratio of 5:1. Also acute RV MI if pt has infarction w/ 2-4 low- bradycardia & hypotension: grade hypotension Normal fever, poss involvemt Saline malaise, of SA node and (IMMEDIATE pleurtic CP right ventricle. vol. ECG: Non- ************** expansion) to specific ST If this pt later in increase RV elevation ER presents with filling and maybe low cardiac pressure. If pericardial output (cold fluid effusion. extremity and resuscitation Once you BP) & low alone is suspect it arterial pressure insufficient start MI has resulted then initiate NSAIDs, in RV infarction. inotropic and don’t need RVI leads to Chronotropic ECHO/CT or reduced filling stimulation XR. and so reduced with stroke volume of Dobutamine RV and then to reduced LV stroke volume and CO and reduced BP. So any med that reduces preload, like diuretics or nitrates should be avoided

****Pain that radiates to arm; Think of MI, need to r/o MI with ECHO. ***Reduce mortality in MI are BBs, ASA, ACE-I. Lidocaine is not given prophylactically to MI pts, although it might decrease the risk for VF, it may increase the risk for Asystole. In post-MI hypertensive pt: BB and ACE-I are preferred over diuretics and CBB. BB decrease myocardial oxygen demand by reducing HR & contractility. ACE-I are indicated when EF is decreased. ****In a pt with ACUTE HEART FAILURE, ACUTE INFERO-LATERAL MI, Pulmonary Edema (Bilateral crackles, edema, JVD) can set in even though BB decrease mortality in MI they are C/I in presence of Pulmonary Edema. Diuretics are DOC in this setting. The MC used in Furosemide. ***Reentrant Ventricular arrhythmia (VFIB) is MCC of death in acute MI. **** In STEMI, reperfusion therapy with PTCA (PCI) with or w/o Stent should be done ASAP. PTCA (PCI) is preferred over Thrombolytics (tPA). ****The earliest EKG finding: in MI: Peaked T waves, followed by ST elevation, followed by T inversion, followed by Q waves. ****All pt who had MI should receive 2ary prevention: shown to have mortality benefit: 1-ASA, 2-BB, 3-ACE-I, 4- Statins. Clopidogrel should be prescribed to all pt with unstable angina/NSTEMI, & who are post PCI (percutaneous Coronary Intervention). Clopidogrel is preferred over Ticlopidine due to less toxicity. Knowing Dressler's is a LATE complication of MI that occurs b/w 2-10 WEEK post MI, says this is Acute Pericarditis. Fever is not a must for the Dx. ****Drugs that improve survival in Acute MI: Thrombolytics, BB, ASA, ACE-I. CCB-- DONT. *****The most important enzyme for evaluation of RE-infarction (MI) is CK-MB.

MIGRAINE HA Tx Steps: 1ST start: NSAID, if that had a minor effect then use Acetaminophen, if that didn't work either then give Ergotamine (if attack last more than 48 hrs or recurs) . Ergotamine is C/I in pregnancy. Prophylaxis: Beta-blocker, if asthmatic à Amitriptyline.

MIGRATORY THROMBOPHLEBITIS - Inflammation of a vein caused by a blood clot - 2 Or Trousseau's Synd. Is indicative of chronic DIC, most probably due to cancer: Lung, pancreatic, stomach, prostate are the MCC. CT: Chest, Abdomen and Pelvic is indicated for complete work up of malignancy along with age appropriate cancer screening such as DRE, mammography and colonoscopy. ****Pt have occult tumor that is not always detected when they come in. The MC tumor is Adenocarcinoma. The thrombophlebitis of ATYPICAL sites like ARMS and CHEST are good clues. Tumors are 24% Pancreatic carcinoma, 20% lung, 13% prostate. 12% stomach.

MINIMAL CHANGE DISEASE - 2 In general, "membranous nephropathy" is the MC nephropathy assoc with carcinoma; however, nephrotic syndrome is a well-known complication of Hodgkin’s lymphoma and is usually caused by "MCD". *****In Children: Don't do biopsy, once we suspect it, start Prednisone. *****Light microscopy is normal but electron microscopy shows effacement of foot processes of podocytes.

MISSED ABORTION - 2 Once the dx is made, surgical evacuation (dilatation & curettage) of the uterus has to be performed to avoid complications (DIC and sepsis) to minimize hemorrhage. **** Missed abortion involves a dead fetus that is still retained in the e uterus. Dx: Suspected when there is disappearance of the N&V of early pregnancy and arrest of uterine growth. Urine pregnancy test would still be Positive. MITTELSCHMERZ It’s a mid-cycle (LMP was 2 weeks ago) abdominal pain that typically presents in young females. If there is no fever, it’s not PID. Abdominal pain in a young female in the middle of her cycle with a benign hx and clinical exam is most likely this.

MITRAL REGURGITATION - 4 Mitral Valve Prolapse is the MCC of isolated MR (soft S1 and a blowing high pitched pansystolic murmur that radiates to axilla.) Other causes of MR are: 1-RHD: accts for 1/3 of cases, M>F. 2-IE: by causing damage to leaflets or chordae tendinae; SUBCUTE IE: usually involves previously damaged heart valves 3-HCM: causes MR by systolic anterior motion of mitral valve 4-Mitral Annulus Calcification: due to aging in elderly 5-Ischemic Heart Dz: MI can cause it by papillary muscle. ****Papillary muscle rupture in the MI setting is the reason for MR a few days after MI. ***The MC predisposing factor to native valve endocarditis is MVP. Mitral valve is MC affected in endocarditis pts who are not IVDA, and MR is the MC valvular abnormality observed in these pts. ****Causes of MR: 1-MVP is MCC, Pt presents with DCM, Apical impulse is displaced. 2-Myocardial Ischemia: The 2ND MCC, ischemia leads to papillary muscle dysfunction or infarction. 3-Rheumatic Heart Fever: 4-IE: Presents with fever 5-Mitral Annular Calcification: usually in elderly.

MITRAL STENOSIS - 3 Hallmark: Elevated left atrioventricular pressure gradient that ultimately leads to LA enlargement. Exertional dyspnea and later pulmonary HTN and right heart failure. Very common AF is due to atrial dilatation. S&S: 1-RHD, 2-L&R side failure, 3- MidSystlic Rumble w/opening snap at apex, 4-AF, Pulm Rales, Increase intensity of S1, RV heave, 5-Tx: Diuretics, Anticoag, Digitalis, Balloon valvuloplasty. ****Tapping apex beat and malar rash are in MS.

MITRAL VALVE PROLAPSE - 2 Late systolic click, may or may not be followed by late systolic crescendo- decrescendo murmur. The click and murmur occur with maneuvers that decrease LV volume (Valsalva and standing). Both are delayed with squatting and exercise (increase LV volume). ****Beta-blockers are used to treat chest pain, palpitation, autonomic symptoms of MVP. If pt presents with TIA then ASA is given, if no response then Warfarin is given. MV repair is indicated when pt with MVP develops symptomatic or severe MR.

MIXED ACID-BASE DISORDERS - 2 MA disorders are defined as independently coexisting and not merely compensatory responses. In order to Dx them first look for pH to determine status. Second see if the change in PCO3 or PaCO2 can explain the change in pH. 3RD step to see the degree of compensation possible for the disorder and if the values are not matching with the observed values, pH=7.4, PaO2=51, PaCO2=32, HCO3=18. . Example DM pt with Metformin has pH=7.23, PaCO2=40, HCO3=16. OK first there is acidosis, then we see decreased HCO3 so its Metabolic Acidosis (Metformin induced), then use Winter's formula [1.5 x (16) + 8]=32, so Co2 must be 32 (compensated value) but its 40, so there is also a respiratory acidosis. Pt with Lobar pneumonia (Tachypnea leads to Res Alk, Alk pH and low PaCO2), with N&V (Met Alk, with Normal HCO3 of 24), and DKA (AG Met Acid). This pt will have Res Alk+Met Alk+AG Res Acidosis).

MIXED CRYOGLOBINEMIA - 2 80% of the cases are assoc with Hepatitis C. So always do HCV RNA assay. Suspect in a pt with palpable purpura, hematuria and proteinuria, non-specific systemic symptoms, peripheral neuropathy and hypocomplementemia. MERCK: Cryoglobulinemia: Characterized by the presence of immunoglobulins that precipitate when plasma is cooled (i.e. cryoglobulins) while flowing through the skin and subcutaneous tissues of the extremities. Monoclonal immunoglobulins formed in Waldenstrom's Macroglobulinemia or in multiple myeloma (see Ch. 140) occasionally behave as cryoglobulins, as may mixed IgM-IgG immune complexes formed in some chronic infectious diseases, MC in hepatitis C. Cryoglobulinemia can lead to small vessel damage and resultant purpura. Cryoglobulinemia can be recognized after clotting blood at 37° C (98.6° F), incubating the separated serum at 4° C (39.2° F) for 24 h, and examining the serum for a gel or precipitate. END MERCK

MIXED CT DZ Overlapping symptoms of SLE+Scleroderma+Myositis. Assoc with antibody to RiboNuclear Protein. Occurs in much younger generation. DDx: Dermatomyositis, Polymyositis

MOBITZ-I HEART BLOCK Mobitz-I or Wenckebach. Characterized by narrow QRS, progressive increase in PR until a ventricular beat is dropped. A benign arrhythmia and unless pt is asymptomatic, no tx is needed. If pt is symptomatic Atropine is needed, and rarely pacemaker. Mobitz-I is seen with Digitalis toxicity; increased vagal tone and inferior wall MI.

MOLUSCUM CONTAGIOSUM - 2 Pic. POXvirus family. Its assoc with AIDS when CD<100. It resolves spontaneously in one year. Tx options are excision and cryotherapy.

MONGOLIAN SPOTS - 2 it found in dark skinned population, presents at birth and usually disappears in several years. No tx is necessary. It’s caused by entrapment of melanocytes. The lesion is a bluish-gray, mostly located at lower back buttocks. The lesion does not fade in to surrounding skin. DDx: Salmon patch: a flat salmon-colored lesion commonly seen over the eyelids, and neck and glabella (forehead bone). A vascular lesion that disappears at early childhood.

MONTEGGIA & GALEAZZI FRACTURES: Monteggia: Isolated proximal third Ulna fracture with anterior dislocation of radial head. May be assoc with radial nerve injury, neurovascular exam is mandatory. Adults Tx: OPEN REDUCTION & INTERNAL FIXATION. Galleazzi: Isolated radial shaft fracture assoc w/ disruption of radial and ulna distal joint needs open reduction and internal fixation.

MONOCLONAL GAMMOPATHY MG of Undetermined Significance: There is only increased IgG. Plasma cell is <10% and no anemia or other signs of Multiple Myeloma. Tx is Assurance. MERCK: Low M- protein levels in serum, normal levels of other serum immunoglobulins, and no lytic bone lesions or Bence Jones proteinuria DDx: Multiple Myeloma

MUCOPURULENT CERVICITIS By C. Trochomatis is asymptomatic in 50% of pts. Presents with scant vaginal discharge, nontender abdomen, Yellow mucopurulent discharge is seen.

MUCORMYCOSIS Pts with DM are prone to it. Pt has fever, dull facial pain, bloody nasal discharge, diplopia, nasal turbinates are necrotic. Requires aggressive surgical debridement and early systemic chemotherapy with IV Amphotericin B

MULTI-INFARCT DEMENTIA: History of heart disease and HTN is suggesting, however, if there is no indication of focal neurologic defects, this dx is ruled out and AD is the more probable cause.

MULTIPLE MYELOMA - 5 A malignant proliferation of plasma cells mainly in the bone marrow. Characterized by marrow plasmacytomas (plasma cell tumors) and overproduction of an intact monoclonal immunoglobulin (IgG, IgA, IgD, or IgE) or Bence Jones protein (free monoclonal or light chains). MC presentation: Bone pain and old age, anemia, renal failure and hypercalcemia. Pathologic fractures may occur and vertebral collapse may lead to spinal cord compression. Bone lesions are osteolytic. Serum and urine electrophoresis is used to detect monoclonal protein. Skull XR reveal punched out lesions. Hypercalcemia is a characteristic of MM, it manifests as Constipation, anorexia, weakness, renal tubular dysfxn and neuro symptoms. DDx1:Osteoporosis: is reduction of bone density, Bone density scan (DEXA) is dx. DDx2: Paget’s disease: excessive resorption of bone mediated by osteoclast, followed by replacement of normal marrow by vascular fibrous connective tissue. Pt presents with elevated alkaline phosphatase, bone deformity, large skull and pain. Hearing loss and nerve palsy may occur. Sarcoma is a long-term complication. ***MM is caused by the proliferation of a single transformed plasma cell usually producing IgG. Following are the classic findings: 1-Lytic bone lesions, 2-Marrow Plasmacytosis, 3-Urine and serum monoclonal proteins. Complications: Renal failure, Hypercalcemia, hyperviscosity syndrome. Complete work up: CBC with differential and morphology, serum electrolyte, kidney and liver screening, skeletal survey and serum electrophoresis and BM biopsy that shows over production of plasma cells. BM DDx1: Essential Thrombocytopenia: increased marrow cellularity with megakaryocytic hyperplasia. DDx2: Aplastic Anemia: Hypoplastic fat-filled marrow with no abnormal cells. ****Any elderly with bone pain, renal failure and hypercalcemia has MM until proven otherwise. There is obstruction of distal and collecting tubules by large laminated cast containing Paraproteins (Bence Jones).

MULTIPLE SCLEROSIS - 9 *Acute symptoms: ONLY steroids (IV Methylprednisolone) are indicated. *Relapsing-remitting episodes: Interferon B or Glatiramar acetate. MS associations: Trigeminal neuralgia; Glossopharyngeal Neuralgia, sharp pain assoc with swallowing, chewing, talking and yawning; Assoc with MLF. * Dx of choice is MRI, which shows WHITE MATTER disease. ****Pt might present with patchy neurological problems (right upper extremity, right lower extremity, optic neuritis) which is characteristic of MS.****CSF: Oligoclonal bands but its not specific; however Plaques in periventricular regions on T2-Weighted MRI is Dx.

MUMPS Assoc with Orchitis.

MUNCHAUSEN SYNDROME by PROXY A family member receives satisfaction by making another member sick. Like the mother who gives her baby insulin to make her hypoglycemic.

MURMUR 1-Diastolic and loud systolic murmurs should always be investigated with TRANSTHORACIC DOPPLER ECHO. 2-Midsystolic soft murmurs in a young pt are benign and no further work up is needed.

MUTATIONS 1-Silent: does not effect the structure of protein. 2-Nonsense is very severe. 3- Missense is mild structural changes.4-Frameshift is also very severe.

MYASTHENIA GRAVIS - 8 Hallmark is decreased acetylcholine receptors due to antibodies. DDx: Botulism is that in MG pupils are spared. There are 3 Tx options for MG: 1- Anticholinesterase, 2-Immunosuppresive agents, 3-Thymectomy. Anticholinesterase, Pyridiostigmine (1st line), SE: abdominal cramps and fasciculations are treated with Atropine. Immunosuppressive agents, prednisone, azothioprine and Cyclosporine. Thymectomy is the best tx to induce remission and provide long-term benefit. *****Once the dx is established (EMG and antibody t acetylcholine receptor) the next step is to locate Thymoma (CHEST CT) especially in pt <60yo. It takes 3-4 years to notice the difference after thymectomy. ****The resolution of weakness with rest is the hallmark of MG. Pt presents with Dysarthria (speech difficulty), Dysphagia, ptosis, diplopia. ****Determination of level of antibodies to Ach receptors is Dx. TENSILON test is not used anymore. ****Myasthenia Crisis is a life-threatening situation. Characterized by weakness of respiratory and pharyngeal muscles. The tx includes endotrachial intubation and withdrawl from anticholinesterase for a few days. The most important cause is an infection, pt has high fever. ALL pts should have bedside PFT done. ****DDx: MG with TRICHINOSIS: which is GI complaints followed by muscle pain, swelling and weakness. Presence of subungual splinter hemorrhages, conjunctival and retinal hemorrhages, periorbital edema and Chemosis should think of Trichinosis. *****Level of lesion is in Neuromuscular junction.

MYELODYSPLASTIC SYNDROMES Are clonal stem cell disorders, which may progress to Acute Leukemias. They are characterized by Pancytopenia.

MYOSITIS, DERMATOMYOSITIS & POLYMYOSITIS - 3 Polymyositis and Dermatomyositis: Both inflammatory myopathies, characterized by proximal muscle WEAKNESS, and ultimately wasting. Dermatomyositis: Heliotrope rash around the eye assoc w/ periorbital edema, and Gottron's papules (red scaly papules over metacarpophalangeal joints). These conditions may occur alone or with cancers: breast, ovary, lung, prostate, colon. Unlike Myasthenia ocular muscle weakness is UNCOMMON. Unlike Scleroderma, which affects lower SMOOTH muscle, these affect STRAITED muscle of upper pharynx. Specific Dx is with muscle biopsy. They both respond to corticosteriods (Prednisone). If pt does not respond or C/I to it, then immunosuppressants (Methotrexate) is choice. *Polymyositis is not as generalized as SLE. Dermatomyositis, skin eruption is dusky red and may occur in the same proportion as SLE. DDx1: Mixed Connective Tissue Disease: Dx is made when Anti-RNP antibodies and clinical features of SLE, polymyositis and Systemic sclerosis are present simultaneously. These features include swollen hands, synovitis, myositis, and Raynaud’s. If 3 of these are present with anti-RNP antibodies the dx of MCTD is made. DDX2: SLE: has musculoskeletal, CV, hematological, skin, lungs, kidney and serous membrane. If 4 or more are present dx is made.

MYOTONIC MUSCULAR DYSTROPHY Is the 2nd MCC of muscular dystrophy, after Duchenne's. ALL muscle in body atrophy, lip looks like a “V”. It’s Autosomal Dominant. It’s defined as delayed muscle relaxation; characteristic is not being able to release the hand after handshake.

NARCOLEPSY Tx is Methyphenidate or Modafini (Psychostimulants)

NASAL POLYPS Are the MC nasal tumors, mostly malignant. Cause is either allergic or infectious. Usually a Hx of Asthma is present. Signs: recurrent rhinitis, nasal obstruction, postnasal drip, altered taste sensation and reduced sense of smell. Tx: Steroids or decongestants. If not sufficient then surgery is indicated. In pts with Asthma and Nasal Polyps, ASA is C/I, may lead to severe bronchospasm. DDx: Angiofibroma: localized mass that causes bony erosions and epistaxis.

NASOETHMOIDAL FRACTURE Surgery 6/2 Are very common in auto accidents and trauma to the face. There is swelling of soft tissue, ecchymosis, gross bleeding. Dx is made with suspicion, and CT (more sensitive than XR). Injuries are to ethmoidal roof, lacrimal system, cribriform plate and vasculature of nose. Nasal packings are C/I due to possible intracranial injury. Most of the injuries are managed by surgical reduction and fixation of unstable fragments. Remember Clear fluid discharge from the nose is due to CSF rhinorrhea 2ary to fracture of the base of the skull not ethmoid system.

NASOPHARYNGEAL CARCINOMA Higher incidence in Asians. Most frequent presentation is a painless neck mass. Other signs are Nasal blockage, epistaxis, hearing loss. They are benign and caused by EBV.

NECK SC CARCINOMA This is very common in people who smoke and drink a lot of alcohol. The first manifestation maybe a palpable cervical lymph node. Best test: PANENDOSCOPY (Triple Endoscopy= Esophago-, Broncho-, Laryngo-) to detect primary tumor or in most cases tumors. Then we do biopsy to confirm. Then we choose one of following: 1-radical neck dissection, 2-Tumor resection, 3-Platinum-based Chemotherapy, 4-Radiotherapy, 5-Palliative mgmnt.

NECK TRAUMA Zone 1(lower): from clavicle to cricoid cartilage. Zone 2 (middle): Cricoid to angle of mandible, this is an important zone, All GUNshot injury should be surgically explored, but stab wounds in asymptomatic pt can be safely observed. Zone 3 (higher): from mandible to base of skull. Cervical spine should be assessed in all pts with severe blunt trauma to the neck. *****Angiogram is done following neck trauma to rule out carotid a. damage. In case of an intimal flap finding, surgery has to be done to prevent strokes.

NECROTIZED SURIGICAL INFECTION: Is characterized by intensive pain in the wound, decreased sensitivity at the edges, cloudy-grey discharge & crepitus. Early surgical exploration is essential.

NECROTIZING ENTEROCOLITIS - 2 Should be suspected in any preterm or low birth weight infant with fever, vomiting, abdominal distension, and pneumatosis intestinalis (DDx: Malrotation of the gut). MERCK: The cause of NEC is not clear. It is believed that an ischemic insult damages the bowel lining so that mucus is not produced, leaving the bowel susceptible to bacterial invasion. Once feedings are begun, ample substrate is provided for proliferation of luminal bacteria, which can penetrate the bowel wall; there they produce hydrogen gas that collects, producing the characteristic appearance of pneumatosis intestinalis on XR. MERCK END. ****Newborn with abdominal distention, bloody diarrhea, and leukocytosis, usually after formula feeding. Radiologic finding of pneumatosis intestinalis (intramural air) in infants is Dx. Tx: Aggressive resuscitation is carried out w/o antibiotics. DDx: Duodenal Atresia, there is no abdominal distention; Classic radiologic sign is Double bubble sign (dilated stomach and duodenum). Assoc with Down and Polyhydramnios. ****Increased gastric residues in a pre-term neonate is highly suspicious.

NECROTIZING FASCIITIS Caused by Group A strep and/or Staph aureus. Sudden onset of pain and swelling after trauma or surgery. Systemic signs. CT identifies site involved and gas. Aggressive treatment and surgical debridement is the focus of tx. Suspect DM. Ampicillin & Sulbactam + Clindamycin.

NEONATAL CARE: Early neonatal care in an uncomplicated pregnancy include initial PE, removal of airway secretion, drying and keeping warm, Silver nitrate for gonococcal and vitamin K supplementation.

NEONATAL EYE INFECTIONS: Peds, 6/2

Organism/Cause Occurrence Characteristics Tx Chemical At birth Starting a few hours Resolves in 24h w/o conjunctivitis: after the drops have tx 2ndary to been placed in the eye, prophylactic drops of and lasts for only 24 to silver nitrite 36 hours Gonococcal 2-5 after May be prevented w/ Antibiotics (IV) conjunctivitis birth eye drops at birth. catheter (Neisseria Extremely purulent; Culture of the gonorrhea)-birth very red, with thick drainage from eye canal drainage and swelling of to look for Neisseria the eyelids gonorrhea Congenital Few days Conjunctivitis and Chlamydia infection to weeks respiratory problems. Culture of the (C. trachomatis) after birth Transmitted from the drainage from eye aka inclusion 5-12 days birth canal; Conjunctival to Chlamydia conjunctivitis edema and mucoid or trachomatis purulent; moderate Oral antibiotics. drainage from the eyes, redness of the eyes, swelling of the conjunctiva, and some swelling of the eyelids. MCC: Congenital neonatal conjunctivitis Congenital Rubella More serious, infection micropthamia, cataract, glaucoma and retinopathy Adenovirus infection Conjunctival secretion No tx aka childhood and respiratory conjunctivitis symptoms of URI Discharge is serous not mucoid or purulent; assoc w/mild itching. Pneumonia b/w 3-19 Symptoms: cough, Oral Erythromycin x weeks after tachypnea, rales, there 14d (not topical) birth is no fever and wheezing is rare (the last 2 features DDx from RSV bronchiolitis)

NEONATAL JAUNDICE Neonatal jaundice with conjugated hyperbilrubinemia is suggestive of neonatal cholestasis and warrants further evaluation. Hx of jaundice in assoc with light colored stool, hepatomegaly, and direct (conjugated) hyperbilirubinemia is indicative of neonatal cholestasis and impaired hepatic excretion of bilirubin, either by extrahepatic obstruction or liver cell injury. BILLIARY ATRESIA is the cause in this case. The purpose of the question was to keep in mind that conjugated hyperbilirubinemia >2mg/dl, is an indication for evaluating neonatal jaundice, even if the infant is otherwise normal.

NEPHROLITHIASIS - 8, 6/2

Calcium Uric acid Struvite/Triple Cysteine oxalate/phosphate Phosphate (1%) Idiopathic hypercalciuria 3 possibilities is not to if flat film of decrease the the abd Ca intake or (KUB) does increase not show excretion, stones in a pt because that with typical what causes signs: 1- the problem to Radiolucent begin with stone dz (excretion of (Uric acid too much Ca in stones) Urine). The 2-Ca stones way to Tx: To <1-3mm and increase 3-Non-stone absorption in causes Kidneys, by (obstruction increasing Ca by blood clot intake, or tumor). Thiazides The way to (which causes treat decrease urinary Ca excretion by inducing mild volume depletion which leads to compensatory rise in proximal reabsorption of Na and Ca) and prevent precipitation of calcium in urine.

Envelope-shaped 10% of pt, (10%): and seen under seen in pt alkaline urine, microscope with by Proteus unusually and Klebsiella low pH urine like 4.5 when normal is 5.6 Etiology: small the low pH bowel dz or could be due gastric resection to defect in or chronic renal diarrhea can lead ammonia to malabsorption secretion, of fatty acids and these are bile salts radiolucent but can be seen in USG & CT. predisposes to Tx includes formation of hydration calcium oxalate and stones (fat alkalinization malabsorption of urine and leads to increased a low purine absorption of diet, Since oxalic acid uric acid because the stones are unabsorbed fatty highly soluble acids chelate or in alkaline bond calcium and urine making oxalate alkalinization acid free for of urine to absorption). pH of >6.5 with oral sodium bicarbonate or sodium citrate is indicated).

Tx in the order of importance: 1-Increased fluid intake 3L/day, 2-normal or increased calcium intake 3-Dietary sodium restriction, 4-Oxalate restriction (dark roughage, chocolate, Vit C), 5-Decrease dietary protein (beef, fish, egg, poultry). *****Cystinuria is an inherited discasing recurrent dz. Look for personal hx of recurrent dz and family hx. Stones: hard, radiopaque, hexagonal crystals. Urinary cyanide Nitroprusside is positive. ****Management steps: 1-CT is choice for high specificity and sensitivity; Its advantage over plain XR (KUB) is detecting radiolucent stones. 2-Narcotics and NSAID, in pt with normal renal function NSAIDs are preferred because narcotics exacerbate N&V. 3-Size of stone, <5mm passes spontaneously, Tx: conservative w/fluid intake of greater than 2L/d. 4-Urology referral, urgent urological evaluation is warranted in pt with anuria, urosepsis and ARF. ***Oxalate stones are due to excessive GI absorption of oxalate. Hyperoxaluria occurs in pts with small bowel resection, like IBD. Increased dietary fat binds dietary calcium, which is then unavailable to bind oxalate. Therefore increased absorption of oxalate in large bowels occurs and precipitates in the kidney. Increased Oxalate can also occur in people with large consumption of tea, coffee, beer and chocolate. DDx1: Calcium phosphate is assoc with hypercalciuria: sarcoidosis, immobilization, Cushing and RTN. Tx includes Thiazide, Furosemide is C/I. DDx2: Struvite stones: infected w/Urea-splitting organisms. Conditions required for this are high urine pH, Mg, ammonium and carbonate levels. DDx3: Uric acid stones: occur in pt with Gout, diarrhea. Tx is fluid, alkalinization of urine and Allopurinol. DDx4: Cystine stones: a defect in transportation of cystine and excess excretion of Cystine. It starts in Childhood and are rare cause of Staghorn calculi. ****Nephrolithiasis during PREGNANCY: requires special consideration; don’t want to put baby at risk of radiation, USG procedure of choice. If USG is not informative, do Transvaginal USG to help locate stones. If this also is inconclusive, there are 2 options: 'LIMITED' IVP and Ureteroscopy. ****Diagnosis: Kidney stones pt urine analysis in normal, except hematuria and US shows dilated collecting system. Next step (Dx): IV pyelography; (not U/A in morning, it looks for protein), however Non- Contrast CT has replaced IVP.

NEPHROTIC SYNDROME - 4, GU 6/2 Hypercoaguable state. **** Pt presents with Proteinuria, Hypoalbumnemia, Edema, Hyperlipidemia and Lipiduria. Pt with Nephrotic syndrome: Increased risk of developing Hypercholesterolemia, Hypertriglyceridemia and Hypercoagulable state. **** Amyloidosis is a cause for NS. Pt has Hx of RA, enlarged kidneys, and hepatomegaly. Typical finding on renal biopsy are amyloid deposits that show apple green birefringence under polarized light after staining with Congo red. DDx1: Crescent formation under light microscopy is due to RPGN. DDx2: Linear immunoglobins on immunoflorescence are typical for anti-glomerular BM dz, (Goodpasture). DDx3: Granular deposits on immnofloresence microscopy are in SLE or PSGN. DDx4: Normal microscopy is due to MCD. ****FSGS: is the MCC of Nephrotic syndrome in blacks, HIV and IVDA and morbid Obese. MCD: MCC in children. Membranous Nephropathy may be 2NDARY to HBV, autoimmune dz or medication, like penicillamine.

IgA NEPHROPATHY Causes a nephritic syndrome with active urine sediments, usually follows URI. ****NS presents as high range proteinuria, hypoalbuminemia, and edema and is a well-known complication of Hodgkin’s Lymphoma. The MCC of NS in Lymphoma pts is MCD. NS resolves with treatment of Lymphoma. Glomerular disease is seen in pts with carcinomas of lung, stomach, breast and colon. In general glomerular nephropathy is the MC nephropathy associated with carcinoma. *****Nephrotic syndrome has many causes: MCD (MCC in kids and adolescent. It’s either idiopathic or post-URT infection. Assoc w/cancers), Membranous nephropathy (Could be primary or 2ndary to HBV, autoimmune or drugs like penicillamine and gold. Is MC in adults, FSGN (MC in BLACKS, it’s either idiopathic or 2ndary to IVDA), Amyloidosis (primary or 2ndary to inflammatory process) and Diabetic Nephropathy (increased extracellular matrix, BM thickening, mesangial expansion, fibrosis

NEUROBLASTOMA MC extra cranial solid tumor of children. Median age: 2 yo. It arises from Neural Crest cells, which are precursor of Adrenal medulla. The MC site: abdomen either from Adrenals or retroperitoneal ganglia. Mass is firm or nodular. XR or CT shows: Calcifications or hemorrhages. Up to 70% have metastatic dz to long bones, skull liver and skin. There’s increased serum HMA and VMA but w/o fainting spells, palpitations or HTN as in Pheochromocytoma.

NEUROCYSTICERCOSIS is the MC parasitic infection of the brain and highest prevalence seen in rural areas where pig farmers raise pigs in unsanitary conditions. Pt will develop HA and CNS symptoms and will die within wks.

NEUROFIBROMATOSIS - 5 Axillary freckling and cafe au lait spots. Assoc w/ Optic Glioma, nodular swellings are hamartomas. DDx1: Tuberous Sclerosis: Assoc w/Hamartoma. (Ash-leaf hypopigmentation, cardiac rhabdomyomas, kidney angioleiomyomas, MR). ** Autosomal Dominant ***Infant with Cafe au lait spots, FEEDING PROBLEM SINCE BIRTH, learning disability (can’t speak or walk). DDx2:Optic Neuritis is assoc with MS. *** Neurocutaneous Syndromes: 1-Neurofibromatosis: Type-1 presents w/cafe au lait, freckling, Lisch nodules (IRIS), neurofibromas and bony erosions. Type-2 presents with Bilateral Acoustic Neuromas. 2-Sturge-Weber Syndrome presents with port wine stains, angiomatous malformation of brain, seizures, hemiparesis.

NEUROFIBROMATOSIS type II - 2 Caused by Nonsense mutation. The mild variant, Gardner, results from missense or splice mutation. Silent or Same sense mutation does not change the protein. Suspect it in a young pt with acoustic neuroma and multiple cafe au lait spots. MRI with Gadolinium is the best method for dx. Tx is to remove the tumor. ****Bilateral acoustic Neuroma and Cataract.

NEUROLEPTIC MALIGNANT SYNDROME - 2 Characterized by marked hyperthermia, muscular rigidity and tremors, altered MS and diaphoresis. Tx: Bromocriptine (dopaminergic agonist) and Dantrolene (muscle relaxant) ****A SE of Haloperidol. Causes elevated CPK. Rhabdomyolysis followed by myoglobinuria can cause renal failure. TX: Discontinuation and supporting care (aggressive cooling, antipyretics, fluid and electrolytes, and alkaline diuresis in case of Rhabdomyolysis).

NIACIN SE Given to increase HDL level. It causes pruritus and flushing due to activation of PGs. That’s why we also give pt ASA to counteract. Flushing and pruritus improves within 2 weeks.

NIEMANN PICK’S: Is due to defic of sphingomyelinase. It‘s a fatal disease of infancy. Clinical manifestations: FTT, hepatosplenomegaly, and a rapidly neurodegenerative course and death by 2 yo. Pt presents with hypotonia, hepatosplenomegaly, cervical lymphadenopathy, protruding abdomen and cherry red spot.

NITRATES C/I Nitrates should not be given to a man within 24 hrs of using Sildenafil. NOCARDIA Pts at risk: Immunocompromised status, lymphoma, AIDS, Transplant. Pt presents after pneumonia, with cough, spectoration, fever, chills. Empyema in 1/3 of pts. 50% of pt have extra-pulmonary dissemination, mainly to brain. Histologically: An abscess that after acid fast shows Crooked, Branching, Beaded, G+ Filaments on the RED back ground. TMP-SMX is DOC.

NON-ALCOHOLIC HEPATIC STEATOSIS -2 Or Non-Alcoholic fatty liver disease. Looks like alcoholic steatosis but ALT/AST is not 2:1. Risk factors: Obesity, DM, hyperlipidemia, TPN and bypass surgery. Tx is aimed at the cause and Urodeoxycholic acid might help reduce Transaminase levels. *****Insulin resistance is the most likely mechanism. Insulin resistance leads to increased accumulation of fat in hepatocytes by increasing the rate of lipolysis and elevating circulating insulin levels. Intrahepatic fatty oxidation then leads to increase in oxidative stress thereby causing a local increase in the pro-inflammatory cytokines, TNF-Alpha, with consequent liver inflammation fibrosis and ultimately cirrhosis.

NOREPINEPHRINE Is a powerful vasoconstrictor, used for hypotension. Sometimes it will cause the hand to become cold & blue acutely. That's why it’s only used in ICU setting. Thrombosis of the forearm could cause bluish discoloration but not coldness and not in acute setting.

NORMAL PRESSURE HYDROCEPHALUS Triad: Gait disturbance, Dementia and Urinary incontinence. Memory impairment is very slow. CT or MRI: Dilated ventricles. CSF opening pressure is normal. If repeated spinal tap results in improvement then ventriculo-peritoneal shunt is definitive tx. DDx1: Multi infarct dementia: NO dilated ventricles. DDx2: Alzheimer’s: does not cause gait or urinary incontinence. DDx3: Pseudotumor Cerebri: young, obese female and presents with HA, NO memory impairment; and enlarged ventricles ARE NOT seen in MRI. Ventricles are shrunken. CSF pressure is increased, but the fluid is normal. Papilledema is present.

NORMAL PREGNANCY Respiratory alkalosis.

NOSOCOMIAL INFECTIONS MCC: E. Coli and Staph aureus. MC type NI: UTI. Risk factors: Female, not under antibiotics, prolonged catheterization and improper catheter care. Surgical site infection is the 2ND MC type. Nosocomal Pneumonia is the 3RD MCC. It’s the leading DEATH cause from NI. Seen in intubated pts. Mainly is Pseudomonas.

NURSEMAID ELBOW Occurs in 3-5 yo children. Its subluxation of head of radius @ elbow. Can be caused by swinging a child or pulling her hand in a hurry. Child: doesn’t want to move the arm, not distressed at presentation but will cry if you try moving it. Dx is clinical, b/c XR is normal Tx: Gentle passive elbow FLEXION and forearm SUPINATION

OBSTRUCTIVE JAUNDICE Obstructive or Cholestatic jaundice. Presents with elevated direct bilirubin and disproportionate elevation of serum alkaline phosphatase. It maybe due to gallstones or carcinoma of head of pancreas for which CT is the best initial test. CT is used when U/S can’t explain the Dx.

OBSTRUCTIVE SLEEP APNEA Is common among obese population. Pt presents with 1-Habitual nighttime snoring, 2-Day time Somnolence, 3-Hypertension. Usually obese, middle age man, Investigation of choice is Nocturnal polysomnography. Lateral Cephalometry is only indicated when pt is scheduled for surgery to relief obstruction. MRI is also used only in pre-surgery pts. Multiple Sleep Latency Test is used only if Nocturnal Polysomnography is not conclusive. ****HTN is a complication, weight loss helps, Apneic symptoms increase with age, cor pulmonale can develop, and Benzodiazepines are CI in these pts.

OCD - 3 Is assoc with Serotonin levels that regulates mood, aggression and impulsivity. SSRI (1st line), Clomipramine (2nd). ****Pts with Tourette who keep repeating the same gestures are at risk of developing OCD that makes them keep repeating the same habits.

OCP: Chronic OCP can cause HTN, discontinue it and problem goes away. *****SLE pts with increased risk of thrombosis (Antiphospholipid and nephritic syndrome) and pts with active renal involvement should avoid OCP. ****Pt with Migraine should avoid OCP due to increased risk for Stroke. Breast cancer has NO assoc with OCP. Endometrial and Ovarian cancers risk is decreased with use if OCP ****When you 1ST start taking it could cause irregular bleeding and that is the MCC of incompliance. Tell the pt to keep taking it and it will be OK.

OLANZAPINE SE An atypical antidepressant for Schizophrenia and Bipolar disorder alone or with mood stabilizers (Valproate). MC SE: Weight gain. Agranulocytosis is for Clozapine not Olanzapine.

OPEN FRACTURES Should not be closed primarily because of increased risk of infection and subsequent Osteomyelitis, therefore, dress the wound and plaster it.

OPIOD TOXICITY Hallmarks: Pinpoint pupils and respiratory depression. IV Naloxone (Tx of choice).

OPPOSITIONAL DEFIANT DISORDER Children that fight and argue with parents and other elderly.

OPTIC NEURITIS Central scotoma (an area of blindness or lowered vision involving the central area of the retina), afferent papillary affect, changes in color perception, and decreased visual acuity. Is assoc with MS. Usually occurs in adult women. Pain on eye movements.

ORBITAL CELLULITIS MC in children: characterized by abrupt onset of fever, proptosis, restriction of extra ocular movement and pain, swollen and red eyelids. Causative agents are S. aureus, S. Pneumonia and H. influenza. Tx: Immediate IV antibiotics.

OSGOOD SCHLATTER DZ Typical pt presents 10-17 yo male with knee pain at tibial tuberosity, is the site for insertion of quadriceps tendon. The exact cause is unknown but repeated stress and trauma is an important factor. It’s a self-limited condition **** AKA Osteochondrosis of tibial tubercle, seen in young teens due to overuse.

OSTEOARTHRITIS - 5, Rheumo 6/2 Obesity is a risk factor, so the single best step in the mgmnt: Lose weight. ****XR of hands: NARROW JOINT SPACE and SUBCHONDRAL CYST at DIP (distal interphalangeal joints). Heberden nodes are seen at DIP joints. Boucher nodes are at PIP joints. XR was not clear. I missed Dx. *****Once the pt has been given NSAID and even had arthroscopic shave of articular surface, if she still has severe restriction in walking and nocturnal and rest pain, the next step: Total Knee Replacement. Rehabilitation takes a long time but functional recovery is excellent. ***ALWAYS Acetaminophen (1ST line) for pain control. If they fail then NSAID, like Indomethacin is used. If at risk of upper GI bleeding or no respond to Analgesics then COX2 inhibitor like Celecoxib is used. ****XR: Narrowing of the joint space and osteophyte formation, RA shows narrowing of the space and juxta-articular erosions. DDx: Gouty arthritis: Punched-out erosion with a rim of cortical bone DDx: RA: Narrowing of the space and juxta-articular erosions. DDx: Infectious and Gonococcal arthritis: Normal joint space and tissue swelling. DDx: Psoriatic arthritis has marginal bony erosions and irregular joint destruction.

OSTEOGENESIS IMPERFECTA An inherited CT disorder caused by mutation in gene coding for Collagen type 1.

OSTEOGENIC SARCOMA Present with painful swelling around the knee. ESR is normal and Alk Phosphatase is elevated. XR: shows osteolytic lesion with periosteal reaction. There maybe a hx of trauma.

OSTEOMALACIA -2 Defective mineralization of BONE in adults. In children, Rickets is defective mineralization of BOTH bone and cartilage. In Osteogenesis imperfecta there is defective collagen formation (type 1). Low: Ca and phosphate, high PTH.

OSTEOMYELITIS - 6 Generally, S. aureus is the MCC. However in Sickle cell pt, Salmonella is MCC. MCC in children <1 yr is Group B strep. MCC in puncture wounds is Pseudomonas (Tx: Quinolone oral or parenteral & aggressive surgical debridement). Now Spinal OM: Lumbar area mostly affected, low fever and elevated ESR, paravertebral muscle spasm in PE. It’s important to Dx early because epidural abscess and spinal cord compression may develop. MRI is modality of choice for Dx. ***Is common in young children 2ary to hematogenous spread of organism MC from URI or partially treated distinct infection. It occurs in metaphysis of long bones. Infection in the bone lead to formation of dead tissue called sequestrum. Periosteum is elevated and forms a periosteum new bone called involucrum. Presents: pain tenderness and warmth over the involved bone, fever, swelling and elevated ESR. Clinical Dx, but bone scan can be done to localize. The XR is typically normal in the beginning. If XR is negative technetium bone scan is test of choice. Bone biopsy is the gold standard. If suspecting Osteomyelitis, blood cultures must be taken to ID the organism and IV antibiotics. If blood culture is negative, then needle biopsy is done. **** S. Epidermidis is a frequent cause assoc with prosthetic devices. ****Hx of IV drug user, high-grade fever, and bony point tenderness is always OM unless proven otherwise. Pt should receive antibiotics immediately after blood culture obtained. Three-phase TECHNITIUM SCAN is the test of choice for acute OM and it’s very sensitive. Plain XR is usually normal in first 2-3 weeks.

OSTEOPOROSIS - 4 Test to check for OP and Osteopenia is Dual Energy XR Absorptiometry (DEXA) of spine and pelvis. CT is most sensitive but not the test of choice. Risk factors include: 1-Thin body habitus, 2-smoking, 3-alcohol, 4-steriod use, 5-menopause, 6- malnutrition, 7-family history, 8- Asian or Caucasian. Numbers 1,7,8 are non- modifiable risk factors. Dx is by DEXA. Tx is 1000mg/d Calicium for 31-50yo. 1200mg for >50yo plus vitamin D. Pt should be encouraged to modify life style, like weight bearing exercise, smoking cessation and alcohol abstinence. *****DOC for osteoporosis pts with HTN is Thiazides; they are assoc with decrease in the urinary calcium excretion. ***** Compression Fracture of the vertebrae is a common complication of advanced OP. Local tenderness is present. Remember that Bilateral decreased ankle reflex has little significance for pt that are old due to normal aging process. Older pts on Glucocorticoid are at increased risk.

OSTEOSARCOMA Classic Codman triangle: (sclerotic lesion in distal femur with periosteum lifted) and SUNBURST appearance are the two radiographic features. The MC initial symptom is pain. Tx is Surgery.

OTITIS EXTERNA, MALIGNANT 4, ENT 6/2 Hallmark: pain on traction of pinna. By Pseudomonas, swimmers. Tx: Systemic Cipro is the most appropriate initial therapy. Malignant OE is seen in DM and immunocompromised pt, malodorous green discharge, granulation, CT should be done to seek damage; Tx is in-hospital admin of parenteral Cipro and possible surgical debridement. ****Fungal ones have while fibers in canal and Bacterial ones have nothing.

OTITIS MEDIA 2, ENT 6/2 Usually follows URT infection. Boggy nasal mucosa, postnasal drip. Pt present with earache, fever, decreased hearing. Inflammation of tympanic membrane and diminished movement of the membrane with air insufflation (blowing into) are hallmark of the disease. Amoxicillin is DOC. ***Acute Otitis Media: MCC Strep pneumonia (40%), 2nd is H. influenza (25-30%). and 3RD Moraxella (10-15%). Amoxicillin (1ST line). If it fails then Amox+Clavulininc acid. ***Chronic OM: presents as purulent discharge. Tympanic membrane: thicker w/ calcified patches but there is no exudation of debris or granulation tissue, ***Serous OM: results due to prolonged blockage. Tympanic membrane: dull and hypomobile. Air bubbles are seen in the middle ear; conductive hearing loss. *****The most specific for Dx is Immobile tympanic membrane.

OTOSCLEROSIS Autosomal dominant, osseous dyscrasia limited to temporal bone. It presents as hearing loss by 3rd decade of life. Audiometry shows hearing loss and loss of stapedial reflex. Tinnitus is also a sign. MC in women. Tx is oral sodium chloride.

OTOTOXICITY Furosemide, Aminoglycosides, vancomycin, quinine and chloroquine.

OVARIAN CANCER Screening for CA125 and vaginal U/S are good enough for pt at risk of OC. Although there is no evidence that U/S of abdomen can help decrease mortality from OC.

OVARIAN FAILURE, CHEMO-INDUCED Chemotherapy causes failure of follicular cells of the ovary resulting in decreased production of estrogen and inhibin. This result in loss of feedback inhibition of estrogen on FSH and LH, causing their high levels. Inhibin causes feedback inhibition of FSH only, so in the absence of inhibin, FSH levels are higher than LH that is pathognomonic of ovarian failure.

OVARIAN HYPERSTIMULATION SYNDROME Major complications of ovulation induction are multiple gestation and OHSS. OHSS occurs in 1-3% of pts. It develops 5-7 days after administration of hMG or hCG and refers to acute increase in vascular permeability of enlarged ovaries. Symptoms include abdominal pain, distension, N/V/D, weight gain, hypotension and pleural effusion. Ovaries are large in U/S. OHSS maybe complicated with: ovarian torsion, ovarian rupture, renal insufficiency. Symptoms resolve in 1-2 weeks, but may persist longer is pregnancy is successful. Tx is supportive.

PAIN MANAGEMENT: Pt with excruciating pain, even if in rehab for drug abuse, should be getting IV Morphine. Once the bolus morphine is given, the pt can be maintained on PCA (Pt Controlled Analgesics). The advantage is high quality analgesia, Pt and nurse satisfaction and freedom from painful injections. PCA can be used both at home and in the hospital by IV or SC. PCA is used mostly in postoperative conscious pt for initiation of parenteral opioid therapy, treatment of incidence pain (trauma) and short term home care intractable pain like cancer pain.

PAGET’S DZ of BONE - 3 Hx of hearing loss, increased hat size and occasional HA and elevation of Alkaline phosphatase. Pathophysiological is impaired bone remodeling. Initially increased osteoclastic activity is observed, with following osteoblasts and immature bone remodeling. Eventually, sclerotic bone is formed. Osteoporosis: Bone demineralization. Vit D deficiency: increased osteoid deposition. Primary HyperPTH: Fibrous replacement of the bone. Hypervitaminosis A: Abundant mineralization of the periosteum. **The MCC of Asymptomatic increase in Alkaline Phosphatase in an elderly is Paget’s, with normal Ca, Phosphorous, normal ALT and AST. *Indication for tx of pts are: 1-Bone pain, 2-Hypercalcemia, 3-Neurological defect, 4-High output cardiac failure, 5-Preparation for orthopedic surgery, 6-Involvement of weight bearing bones. Tx of Asymptomatic pts is not required. Biphosphonates are DOC for Paget's, they inhibit bone resorption (loss of bone tissue which is soaked up by blood), and last for years. Calcitonin also inhibits osteoclastic bone resorption, however its effect on osteoclasts is much weaker than Biphosphonates. Tx: Calcium and Vit D has no effect. ***PD is characterized by excessive Bone destruction and repair. It’s generally asymptomatic and may be suspected by elevated Alk Phosphatase. Serum Calcium is normal. Overtime 1/3 of pts may develop OSTEOSARCOMA or SACROMATOUS CHANGES. This will manifest as marked bone pain, Lytic lesions and a sudden increase in ALk Phosphate. Bone remodeling is constant in Paget's, both osteoclasts and osteoblasts are involved in process but BY ITSELF IS NOT A CAUSE OF PAIN.

PAGET’S DZ of BREAST Persistent dermatitis of nipple. Red, oozing crusted lesion non responsive to antibiotics or steroids. Biopsy reveals large cells surrounded by halo like area invading the epidermis. This disorder is a breast cancer and almost always there is an underlying breast carcinoma present. MC is an infiltrating Ductal cell carcinoma but occasionally Ductal carcinoma in situ.

PANCOAST TUMOR In a smoker with arm pain, cough and weight loss, mass in the lung apex is PT unless proven otherwise.

PANCREATIC CARCINOMA -5 Risk factors are: Family hx, Chronic pancreatitis, smoking, DM, Obesity and a diet high in fat. Alcohol is not a risk factor. *****Abdominal U/S is initial choice in pt with Jaundice. However they are usually not clear so the next step is CT has higher sensitivity for suspected pancreatic cancer. ****Anorexia, weight loss, painless jaundice in a smoker with increased Alkaline phosphatase and absence of gallstones is suggestive. CT of abdomen is the next best thing, it’s very sensitive for PT tumor. Then do ERCP to get biopsy or refer to a high volume surgery unit to do Whipple's procedure to remove tumor. Percutaneous Transhepatic Cholangiogram (PTC) is to assess biliary duct not PT. CA-19 is good for PT not for Dx of PT. Amylase is good for Pancreatitis no PT.

PANCREATITIS, ACUTE - 8 Hypertriglyceridemia > 1000 mg/dl can cause AP; If it’s due Acute cholecystitis, once the pt is stabilized perform cholecystectomy. Conservative Management: Pain med, IV fluid, NPO, Nasogastric suction. ****Development of palpable mass in epigastrium 4 weeks after the acute pancreatitis is Pseudopancreatic Cyst. They are not true cyst, they lack epithelial lining. Collection of fluids, tissue, and necrotic debris. Amylase rich fluid leaks out so Amylase is increased. USG is dx of choice. They should be drained ONLY if they persist after 6 weeks and are >5cm. ***** 1 st step confirm dx: Serum Lipase and Amylase (the most sensitive and specific test for AP), not ERCP (it’s used for CBD and Chronic pancreatitis). CT is used only if the pt is not responding to management and need to see if there are any complications. *****The 2nd MCC are Alcohol and gallstones. If pt isn’t alcoholic then cause is Gallstones. So the next step is U/S to look for stones. CT can’t help with Gallstones, but it’s good for necrosis and Cysts. CT is indicated if WBC>20000 & Necrotizing pancreatitis is suspected. HIDA is for calculus or acalculus Cholecystitis. ****Cyst+Fever = Abscess. In AP the abscess needs to be drained EXTERNALLY. Abscess needs to be drained, Pseudocyst can be managed conservatively. ****In severe pancreatitis and 2ary paralytic ileus: Neutralization of acidic pH with antacids should be considered, for severely ill pts, to prevent gastric stress erosions.

PANCREATITIS, CHRONIC - 5 Admit to hospital if pt has weight loss, pain, steatorrhea (malabsorption, best test to confirm it is 72hr fat in stool collection, if >7g/d is positive), malnutrition. Do CT to rule out pseudocysts and dilatation of the duct, when duct is dilated a cm the best Tx: Lateral pancreaticojejunostomy; this relieves the pain and improves nutrition. ****Pseudopancreatic Cysts: are untouched for 6 weeks if they are <5cm. If it doesn’t resolve then either do percutaneous drainage or gastrostomy. ****Surgical intervention in case of chronic pseudocyst and debilitating pain (due to compaction of stones in pancreatic duct). Tx: ERCP with removal of stone and stent insertion. Partial pancreatectomy is the last result, if ERCP didn’t work. **** Pt with recurrent pancreatitis after US is done should go under ERCP and BYPASS CT because CT is not good for pancreatic and biliary bile ducts and would miss microlithiasis. *****Lateral Pancreaticojejunostomy can provide relief for chronic pain.

PANIC DISORDER - 3 Women 20-40. Sense of IMPENDING DOOM. Acute Tx: Benzodiazepine, takes effect immediately. Long term tx: SSRI or TCA with cognitive or behavior therapy. ALSO according to Valia, Panic attack is assoc with Mitral Valve Prolapse. ***Of the 2 drugs for PA: Alprazolam has a Seizure attack due to withdrawl that happens in a few days of not taking the medication. But Diazepam, does not give you seizure that quickly. So if pt comes with Seizure and didn’t take panic drug for a few days Alprazolam is the drug. ****Pts suffering from Panic dz are at increased risk for DEPRESSION, agoraphobia, GAD and substance abuse.

PARANOID PERSONALITY: Cluster A (odd, eccentric), distrust and suspicious to others. Negatively interpret actions and words. Hold grudges for long time.

PARALYTIC ILLEUS Absent bowel sounds with gaseous distention of both small and large bowels are indicative.

PARANEOPLASTIC SYNDROMES (PNS) Hypercalcemia is the MCC of PNS (confusion, lethargy, fatigue, anorexia, constipation, polyuria) it is assoc with Squamous cell carcinoma of the lung . The classical pathophys responsible for hypercalcemia of the malignancy is the production of PTH-related peptide (PTHrP), which is homologous with PTH. Serum Ca is Increased and Phosphate is decreased *****Myopathy in assoc with PS: PS can manifest as muscular weakness. Proximal muscles are typically affected and strength is diminished symmetrically. Reflexes are normal and no sensation abnormality is detected. Elevated CK and myopathic EMG help to confirm Dx. Pathology in PS is in the muscle membrane, in MG is in Postsynaptic membrane, and in Lambert-Eaton is in the Presynaptic membrane.

PARENCHYMAL BRAIN HEMORRAGE Always suspect it when pt has hx of uncontrolled HTN and then presents to ER unconscious with focal neuro signs.

PARINAUD'S SYNDROME Consists of paralysis of vertical gaze that maybe assoc with pupillary disturbances and eyelid retraction (Collier sign). MCC by Pinealoma. Pt (10 yo) presents with facial hair and 2ary sex characteristics, plus vertical gaze and Collier sign. DDx: Craniopharyngioma that does not cause the Collier sign.

PARKINSON’S - 2 The most effective symptomatic therapy is L-Dopa. *** 1ST Drug for tremor and rigidity is Benztropine. *****assoc with Seborrhea dermatitis.

PAROXYSMAL SUPRAVENTRICAULAR TACHYCARDIA Test-1, Q-43. See picture. DOC is IV Adenosine

PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH)- 2 A red cell membrane defect causes increasing binding of complement to the red cell à increased intravascular hemolysis resulting marked anemia. Since RBC is more susceptible to hemolysis in acidic environment and serum is more acidic at night, lysis occurs at night and morning urine shows red urine. Thrombosis of Hepatic vein is a CC of death. Lab: Increased LDH, bilirubin and reticulocyte. Test specific to PNH is sugar-water test and the Acidified Hemolysis test (HAM test), which determines increased susceptibility to cell lysis by C’. DAF (Decay Activating Factor) is diminished in PNH. DDx1: RBC Enzyme Def (G6PD def): results in sudden hemolysis after drugs or infection. DDx2: Peripheral destruction of RBC is seen in Hereditary Spherocytosis. ****Is an acquired disorder that should be considered in ALL CONFUSING cases of hemolytic anemia. Hemolysis is intravascular with low serum haptoglobin, and elevated LDH. Urinary Loss of Iron may lead to iron def anemia. Congestive splenomegaly is a complication. BM maybe hypocellular. Flow cystometry is better choice for dx vs. Ham test, it shows absence of CD59. DDx1: Aplastic Anemia: BM is hypocellular, but peripheral blood smear does NOT show abnormal cells. RBC are normo- or macrocytic.There is NO hemolysis or Splenomegaly. SUGER test is for dx of PNH.

PARVOVIRUS INFECTION - 2 Parvovirus infection involves joint: symmetrical, hands, wrist, knee and feet are mostly affected. Rash may or may not present. Pt has Arthralgias or arthritis, MC in females. Pt presents with pain in small joints, arthralgia and arthritis. **** School teacher gets it. Anti-B19 IgM is the dx of choice.

PASSIVE AGGRESSIVE BEHAVIOR An immature defense which an individual expresses aggression toward other person with repeated, passive failure to meet the other person's demand. A secretary won’t let you talk to the doctor because she had an argument with you. DDx: Acting Out: A child throws a temper tantrum.

PATIENT CONSENT If pt needs transfusion and wife says it’s against his beliefs, go ahead with transfusion. Now if Pt himself is awake and tells you that he doesn’t want transfusion then you use other alternatives, Plasma.

PCP toxicity 3 Poison 6/3 Characterized by violence, vertical nystagmus, confusion, ataxia. DDx: Cocaine: causes tachycardia, HTN, sweating, mydriasis. ****LSD is like PCP but agitation and aggression is worse in PCP. Visual Hallucinations (Flashbacks) are hallmarks of LSD.

PEDIATRIC CNS TUMORS Infra-tentorial tumors are more common. MCC type: Benign astrocytomas. MC solid tumor: CNS tumors and are 2nd MC malignancy after Leukemias. 2nd MC tumor in posterior fossa: Medulloblastoma, 90% arise from Vermis.

PEDIATRIC IMMUNOLOGY: 1-Hyper IgM syndrome (HIM): Characterized by high levels of IgM, w/deficiency of IgG and IgA and poor specific response to immunization. HIM presents with recurrent sinopulmonary infections and PCP. The unique susceptibility to opportunistic infections and neutropenia DDx: it from XLA and other conditions. 2-Bruton’s X-linked Agammaglobinemia: characterized by 4 findings, a) Onset of recurrent bacterial infections in 1st 5 years of life, b) IgG, IgM and IgA are very low, c) Poor response to vaccination, d) <2% CD19+ B cells in peripheral circulation. 3-Common Variable ID: presents low IgG, IgM and IgA levels, but normal B cells. Clinically they present with recurrent sinopulmonary infections like XLA. Most pts don’t become symptomatic until 15-35 yo. 4-Selective IgA deficiency: MC well-defined ID disorder. Infections occurs predominantly in respiratory, GI and U-G tract. Serum concentrations of other Ig are normal. Dx is IgA <50 with no other immune defects. 5-Selective Subclass IgG Def: Recurrent infections despite normal IgG levels. 6-Severe Combined Immunodeficiency (SCID): is a life threatening synd. Presents w/recurrent sinopulmonary infection, oral candidiasis, persistent diarrhea, opportunistic and viral infections. Dx: Absent LNs and tonsils, lymphopenia, and abnormal B & T cells. CXR: Absent thymic shadow. 7-Wiskot Aldrich Syndrome: is an X-linked recessive, caused by a defective gene encoding for WAS protein. Classic presentation: young boy with eczema, thrombocytopenia, and recurrent infections w/ encapsulated bugs. Initial manifestation: At birth: petechiae, bruises, bleeding from circumcision, or bloody stools. Low IgM levels, high IgA and IgE levels reduced T cells and platelets. 8-Chronic Granulomatous Disease: a defect of phagocytic cells, due to dysfunction of NADPH oxidase enzyme complex, leading to recurrent and uncontrolled infections w/catalase positive organisms (Staph, Serratia, Klebsiella, Aspergillus) and not susceptible to catalase negative (Strep and H Influenza). MC infections: are lymphadenitis and abscesses of skin and viscera. Lymphocytes are normal. Dx is by Nitro Blue Tetrazolium test. Tx is prevention: DAILY TMP=SMX & Gamma Interferon 3x/wk BMT is Curative. 9-Transient Hypogammaglobinemia: Characterized by decreased IgG levels, normal IgA levels, and variable IgM levels. These Igs normalize by 6-11 month of age. 10-Di-George Syndrome: Typical of an infant with hypocalcemia seizures. Pathology is defect of 3 & 4th pharyngeal pouch leading to hypoplastic or aplastic thymus and parathyroid glands. 11-Chediak Higashi Syndrome: characterized by decreased granulation, chemotaxis. It’s a multi-system disorder: peripheral and central neuropathy, hepatosplenomegaly, pancytopenia, **partial albinism, infections w/aureus. Dx: finding neutropenia and giant lysosomes in neutrophils. Tx is prevention: DAILY TMP-SMX and daily ascorbic acid. 12-Leukocyte Adhesion Defect: result from failure of innate host defenses against bacteria, fungi due to adhesion targeting. Pt has hx of delayed separation of umbilical cord, recurrent bacterial infection, necrotic skin lesions, severe gingivitis. 13-Job’s Syndrome or Hyper IgE syndrome: Chronic pruritic dermatitis, recurrent Staph infections (resp and skin), markedly elevated IgE, eosinophilia and coarse facial features. PEDIATRIC JAUNDICE 1- 1 ST 24 hrs : requires immediate attention, maybe due to erythroblastosis fetalis, concealed hemorrhage, sepsis or infection. 2- 2 ND & 3 RD day : is usually physiologic. 3- 3 RD day to 1 week : suggests bacterial sepsis or UTI and requires prompt and aggressive attention. Sepsis in neonate rarely causes neck stiffness or boging frontal or shock. Clues: Poor feeding, lethargy, vomiting, or alteration of activity. MERCK: Diminished spontaneous activity, less vigorous sucking, apnea, bradycardia, and temperature instability (hypo- or hyperthermia) are particularly common. Fever is present in only 10 to 50% but, when sustained (e.g., > 1 h), generally indicates infection. Other symptoms and signs include respiratory distress, neurologic findings (e.g., seizures, jitteriness), jaundice (especially occurring within the 1st 24 h without Rh or ABO blood group incompatibility and with a higher than expected direct bilirubin concentration), vomiting, diarrhea, and abdominal distention. Anaerobic infection is often indicated by foul-smelling amniotic fluid at birth. The first step is to do a blood culture and a lumbar puncture.

PEDIATRIC MENIGITIS 1-Group B Strep: MCC meningitis in infants. Usually acquired from mother during childbirth; no rash and very unlikely for a 18mo child. 2-Meningococemia: Suspect it in a neonate with petechial rash: trunk, wrist, ankle (75%). 3-H. Influenza: 6-48mo, no rash involved. Antigen is in CSF. 4-Listeria: Meningitis in newborn vaginally, NO rash. Another mode of transmission is unpasteurized milk. MC in DM mothers. 5-Aseptic: Always viral cause. CSF shows: lymphocytosis, WBC<250, protein <150 and normal glucose. Typical pt: Alert and cooperative but uncomfortable and ill. **** 1-Newborns: Group B Strep(70%), then Listeria (20%) and S. Pneumonia (10%) 2-One month to 2 years: S. Pneumonia (50%), Neisseria (30%), Group B Strep (20%). 3-2-18 years: Neisseria (60%), S. Pneumonia (25%) and H Influenza (10%). 4-Adults >18yo S. Pneumonia (MCC) 60-70%.

PEDIATRIC RHEUMATIC FEVER Suspect in children with low grade fever, pericarditis, sore throat, arthritis, chorea, and subcutaneous nodules, erythema marginated, elevated ESR and prolonged PR. Caused by GA Strep. Dx: 2 major or 2 minor and 1 major Jones Criteria. 5 major criteria PECCS (Polyarthritis, Erythema marginatum, Carditis, Chorea, Subcutaneous nodules) and 3 minor FAR (Fever, Arthralgia and Previous RF). Tx: Benzathine Pen G. If (+) chorea, give antiepileptic, (+) Pericarditis give salicylates, and (+) Arthritis give codeine.

PEEP - 2 Positive End Expiratory Pressure: Development of positive pressure inside the thorax resulting in decreasing venous return. Decreased venous return leads to decreased cardiac output, which ultimately leads to hypotention. The increased ventilate rate causes development of auto PEEP by not allowing enough time for expiration. Thus, the ventilator delivers a tidal volume, in addition to that is still in the lung at the end of the expiration, which is already inside the lung. This produces positive pressure. ***The most appropriate step: when Hypotension happens is to decrease the respiratory rate, to allow the lung to deflate in b/w respirations. ****When PEEP is increased its major drawback is decreased CO. Pts who are maintained on PEEP should be monitored with Swan Ganz catheter. PEEP has no direct effect on Systolic BP or Systemic Vascular Resistance. ****If Tidal Volume is too high, 800, REDUCE Pressure support and INCREASE ventilation rate not to increase pCO2.

PERITONSILAR ABCESS - 2 Fever, sore throat, dysphagia, trismus (inability to normally open mouth CN V), pooling of saliva and muffled voice. Management: Needle drainage (in trendelenberg position) close monitoring and IV antibiotics.

PELLAGRA ***** MC corn diet, also Alcoholics people w/ Carcinoid tumor. Characterized by 4Ds: 1-Diarrhea, Dementia, Dermatitis, (skin rash in sun exposed areas) Death.

PELVIC ABSCESS Percutaneous drainage is the procedure of choice. If it fails then Laparotomy with debridement and drainage is indicated.

PELVIC TRAUMA: XR do for ALL pt w/trauma to pelvis to screen for pelvic injury. Not CT.

PEMPHIGUS VULGARIS Derm 6/3 Mucocutaneous blistering with flaccid bullae, with IgG deposits in intracellular in dermis. Autoantibodies against desmogelin. 1ST see in Oral mucosa. Easy separation of epidermis on superficial pressure (Positive Nikolsky sign) is characteristic. Tx: steroids. DDx: Bullous Pemphigoid: Tense blisters, IgG and C3 in dermal-epidermal junction.

PENILE FRACTURE: From women on top. Surgical exploration (tx of choice) but it should always preceded by retrograde urethrogram to r/o urethral injury

PEPTIC ULCER DZ - 3 If perforation occurs the 1 ST step : Upright abdominal XR. Now although the symptoms might suggest that pregnancy is a DDx, 1ST do XR to r/o the most dangerous possibility. ***** PUD can lead to gastric outlet obstruction, unceasing vomiting and dehydration resulting in Hypochloremic Met Alkalosis à Tx: 0.9%NaCl. This kind of Alkalosis is usually accompanied with HypoKalemia. K+ Supplementation is indicated whenever NG suction is done, Tx: Potassium Chloride. ****MC complication is Hemorrhage. ***PUD causes: Sudden onset of severe epigastric pain that spreads to the whole abdomen, and upright filmsà AIR UNDER DIAPHRAGM. DDx: Cholecystitis and Diverticulitis: NO sudden onset and short clinical course. DDx: Biliary Cholic: More localized pain w/o rebound.

PERICARDIAL CYST Diagnosed with CT. Located at the middle mediastinum and are benign. The fluid can be aspirated and the cyst will shrink. Surgery is NOT indicated. Other medial mediastinum masses are Bronchogenic cyst, lymphoma, and aortic aneurysm.

PERICARDIAL TAMPONADE (PT) Presents: Beck's triad: Hypotension, elevated JVD and muffled heart sounds. DDx: In case of hypotension due to BLEEDING, JVD will be decreased compare to PT or Tension Pneumothorax (TP). In TP mediastinum is deviated, but in PT its not. ****Pulsus paradoxus (NARROW PULSE PRESSURE) is a dx clue.

PERICARDITIS, ACUTE When combined with renal failure is Nephritic Syndrome that leads to Uremic pericarditis, which is an indication for Hemodialysis. If vascular access is not possible then do Peritoneal dialysis. *****Severe constant pain that localized to anterior chest, radiates to arm, back, shoulder, epigastrium, is intensified with respiration, relieved by sitting up or leaning forward. MCC by Coxsackie virus. A hx of current viral illness is common. EKG shows: 1-Diffuse ST elevation with concavity at "J" point, 2-PR elevation. Uremia can cause Pericarditis and this may represent an indication for dialysis. *****Uremic Pericarditis: chronic renal failure pts (10%). UP is an absolute indication for Dialysis. Pericardial fluid in UP is most often Hemorrhagic. Clinical features are same as Pericarditis, but BUN is >60 and anemia. Most pts respond rapidly to dialysis with resolution of chest pain, and decrease in size of pericardial effusion. *****Once you dx PC the next step: Start Hemodialysis not NSAIDS.

Indications of Dialysis:

INDICATIONS of ABSOLUTE RELATIVE C/I to dialysis Dialysis indications indications

1-Refractory *Fluid overload *GFR<10 *Debilitating HyperKalemia not responsive to *Serum CR <8 chronic dz 2-Volume overload & tx *severe uremic *Severe Pulmonary Edema * HyperK not symptoms (Seizure irreversible not responding to responsive to tx & coma are dementia diuretics. * Refractory indication of 3-Refractory metabolic acidosis immediate dialysis) metabolic acidosis (pH<7.2) 4-Uremic Pericarditis 5-Uremic Encephalopathy or neuropathy 6-Coagulopathy due to renal failure

Remember NSAID (sometimes corticosteriods) are 1st line tx for Pericarditis. Also for Pericardial Tamponade Pericardiocentesis is indicated.

PERIPHERAL ARTERY ANEURYSM: Manifests as a pulsatile mass that can compress adjacent structure (nerve, vein) and can result in thrombosis or ischemia. MC PAA: Popliteal and femoral aneurysms, frequently assoc with AAA. Pt has all the atherosclerotic risk factors.

PERIPHERAL ARTERY DZ Goal of therapy for occlusive arterial dz of lower extremity: Relieve pain, prevent limb loss & maintain gait. Most pts with Intermittent claudication remain stable with conservative management. Majority should be given exercise and ASA. Over 75% remain stable. Angiogram is not required if there’s no evidence of ischemia, infection, gangrene or loss of pulse. If surgery is not planned a duplex arterial study may suffice.

PERITONITIS, PRIMARY Abdominal pain with guarding and fever in a pt with ascites is suspect. Most likely peritonitis 2ND to paralytic ileus. If pt has signs of peritoneal fluid (shifting dullness) then diagnostic Paracentesis is the simplest test to perform. May reveal signs of Exudate: Turbid fluid >250 Leukocytes, Protein >2.5, Serum to Ascitic albumin gradient <1.1, and Specific gravity >1.016.

PERITONSILAR ABSCESS (QUINSY) Unilateral sore throat, neck pain, referred ear pain, dysphagia with swollen tonsils, Trismus is characteristic. *****It is a suppurative complication of Acute Tonsillitis. Scenario: a pt with sore throat, dysphagia, trismus, pooling of saliva and muffled voice. PE: Unilateral and cervical lymphadenitis and deviation of uvula. Management: Needle drainage (in Trendelberg position), close monitoring and IV antibiotics.

PERNICIOUS ANEMIA PA is the MC megaloblastic anemia. B12 def is caused by intrinsic factor deficiency 2nd to gastric atrophy. There is also basophilic stippling. Dx: Achlorhydria, decreased IF, decreased B12, extremely elevated LDH. ***DDx: Lead poisoning since they both have basophilic stippling. Lead poisoning presents like Iron deficiency anemia, MCV<80.

PESTICIDE POISONING 1ST step in mgmt: Remove the source of poison (if pt vomited the poison remove clothes to remove source of poison).

PHARYNGITIS, STREP A 7 yo with fever, erythema of pharynx has Pharyngitis, if Rapid dx test for Strep is positive the Next step: One IM dose of IM Benzathine Pen G, not IV aqueous crystalline Pen G or 10d oral Pen V. If allergy then Erythromycin is used.

PHENCYCLIDINE INTOXICATION Causes psychotic symptoms.

PHENELZINE C/I An MAO inhibitor and is use is C/I with SSRI (Paroxetine). Is called SEROTONIN SYNDROME: hyperthermia, rigidity and altered mental status. Is given to Depressed pts with SIGECAPS. Another SE: Hypertensive Crisis that occurs with wine and chocolate.

PHENYTOIN SE causes Folate deficiency. (megaloblastic anemia)

PHEOCHROMOCYTOMA - 2 Always 1ST give alpha blocker, followed by beta blocker. If you do it the wrong way you can precipitate a very dangerous increase in BP. ***Sudden attack of palpitation, HA, profuse sweating.

PHYSIOLOGIC JAUNDICE Seen in ALL newborns. Begins: 2-3 day and resolves within 1 st week . Pathophys: Increased bilirubin production, decreased bilirubin, clearance and increased enterohepatic circulation. DDx: Neonatal Sepsis: jaundice after the 5th day and within one week. DDx: Breast milk: jaundice that starts after the 1 st week . Tx: Cessation of breast milk and replacement with formula will reverse it. ***** Jaundice notices after the 1st week is Breast milk jaundice. Increased Jaundice at birth or within 24hrs is due to Erythroblastosis fetalis.

PICK’S DZ Fronto-Temporal dementia. Personality change (disinhibition, apathy, euphoria), compulsive behavior (peculiar eating habits, hyperorality) and impaired memory. May be positive family Hx. DDx1: LEWY BODY: fluctuating cognitive impairment. Bizarre visual hallucinations may occur. Parkinsonism may occur. DDx2: MULTI-INFARCT: cognitive dysfunction with motor and sensory dysfunction. DDx3: NEUROSYPHLIS: Pt maybe psychotic and personality change but NO family Hx.

PID - 2 Is suggested by Triad: abd pain, uterine & adnexal tenderness, & cervical motion tenderness. Other criteria: fever, cervical/vaginal mucopurulent discharge. Criteria for hospitalization: pregnancy, no response to outpatient treatment, noncompliance, severe illness and abscess. ***Severe PID: N +V and high fever 103F), admit pt. A common regimen for severe PID: Cefotetan (2g IV every 12hrs) or Ceftriaxone (2g IV q 6 hrs) AND Doxycycline (100mg PO or IV every 12hrs). ***Mild PID: single IM Ceftriaxone and 7 day PO Doxycycline or Azithromycin.

PKU Autosomal recessive. In fair skin, blue eye, rash, musty/mousy odor pts with vomiting in a month old neonate. Dx: Guthrie test, a qualitative test for color, shows metabolites of phenylalanine in the urine. Tx: no phenylalanine, low protein diet.

PLACENTA PREVIA - 2 PP presents with painless vaginal bleeding in the 3rd trimester. Dx: U/S accuracy of 90% transabdominally and 100% transvaginally. Pelvic exam is C/I. Risk factors: multi parity, advanced age, multiple gestation. If bleeding continues, C-section ASAP, even if pregnancy is not term yet. In cases of extended bleeding surgeon might discover Placenta Accreta. *****If the mother is stable and fetus is at term à Do scheduled C-section; until then monitor closely. If both mother and fetus are stable IM steroid are used to mature the lungs. Forceps are not used in complete PP. *** In any case Vaginal delivery is not an option for any kind of PP. *****If both mother and fetus are OK; there is no more bleeding and mother has access to close hospital then she can be sent home & monitored at home until 36wk, then schedule C-section is done. ***** Pt with complete PP, after bleeding is controlled & baby and mother are fine, Schedule Elective C-section.

PLEURAL EFFUSION When the lung is dull, CXR: ½ of lung is white due to effusion, too much fluid in pleural space causes collapse of partial lung. First step: Find the cause. Management starts: Is it exudate or transudate? àDiagnostic Thoracocenthesis (preliminary procedure of choice), EXCEPT in CHF pts-- diuretic is used. Thoracocenthesis is a bedside, minimal invasive. If it’s Exudate further procedure is followed. Learn what causes transudate vs. exudate. (i.e. Cancer=exudate). Bronchoscopy (an alternative), but it’s very invasive TC is done 1st, if inconclusive, next step is Bronchoscopy. *****MCC of PE is CHF. Transudate effusion. The important diagnostic criteria for separating pleural fluid into transudate and exudates: measurement of serum and pleural fluid protein & LDH levels. At least one must be present for exudates. If none is present, it’s transudate.

Exudate Criteria: Pleural Fluid Protein/ Serum is >0.5 PF LDH/S LDH >0.6 pH is important in parapneumatic effusions in which a value of <7.2 requires a chest tube aspiration to prevent empyema. Normal PF is 7.46 Pleural pH <7.3 is inflammation PH of 7.35 is transudate pleural effusion

PMS A menstrual diary for at least 3 months is a useful aid for confirming PMS. PMS is confirmed when one or severe particular symptoms occur repeatedly at the same cycle interval. (Anxiety, mood swing, bloating, decreased libido, difficulty concentrating) Tx depends on the pt and problems. Decrease caffeine may help with anxiety; SSRI (DOC for mood change)

PNEUMOMEDIASTINUM May accompany spontaneous pneumothorax: the air from ruptured alveoli or bulla dissects along the vessel into the hilum and mediastinum. Pneumomediastinum assoc w/spontaneous pneumothorax usually responds to chest tube drainage and doesn’t need surgical decompression, unless it’s very massive and causes cardiovascular compromise.

PNEUMOCOCCUS VACCINE Recommended for 1-Adults >65. 2-Chronic dz like CV and COPD. 3- Immunocompromised and DM. Chronic alcoholics. A one-time booster is given 5 years after primary vaccine in elderly. *****A T cell independent B cell response mechanism.

PNEUMONIA - 10 1- Community acquired (MCC Strep Pneumoniae in nursing homes). 2- Legionella: Any elderly pt w/pneumonia, abdominal pain, confusion and hypoNa+ should be suspected; also if beta-lactam antibiotics fail. Definite dx: ELISA and tx is high dose Erythromycin or Azithromycin. 3- Nosocomal: Pseudomonas is MC considered aerobic GNR in ddx of G- infections and is a CC of GN Nosocomal pneumonia. Seen in mechanically ventilated pt and intubated pts. Tx: IV 4th gen cephalos like Cefepime or Ceftazidime. ****In-patient Community Acquired Pneumonia: New generation Quinolones (Levofloxacin and gatifloxacin), for outpatient Azithromycin or Doxycycline are used. **** Alcoholic pneumonia: (3-4 ounces daily) Klebsiella, encapsulated GNR. Klebsiella grows in MUCOID colonies. ****Friedlander's pneumonia: affects UPPER lobe and presents with fever, productive cough and copious CURRANT jelly sputum. ****Pneumonia: present with fever, sweats and productive sputum, CXR: consolidation. Antibiotics are best given IV. 2 weeks after aggressive tx of a consolidation; have to ensure the pt that there is no bronchial obstruction by a tumor and that lung abscess has not developed. If pt has a tumor it might block the bronchus resulting in failure of antibiotic therapy. Thus if pt fails to resolve after 2 wk of antibiotics, Bronchoscopy is indicated; it will help: Obtain cultures, visualize the bronchus, and drainage. CT is indicated if a mass or abscess in lung is indicated and CT will help to see if an Empyema has set in. Empyema at early stages (tx: Antibiotics and drainage). Abscess requires antibiotics for 4-6 weeks. Do CT 1ST then Bronchoscopy. ***1-Mycoplasma: is common in teens; mostly it causes Pharyngitis or bronchitis only. In few cases there’s fever, cough, chills, sore throat, rhinorrhea. CXR: appears worst. Extra Pulmonary Signs: Erythema Multiforme, characterized by TARGET-shaped lesions. It does not stain because has no cell wall. ***2-Pneumococcus is rusty sputum. Gram stain reveals lancet shaped diplococci. ***3-H. Influenza occurs in children, vaccination prevents it. URT involvement is unlikely. It shows Gram negative staining. ***4-Legionella occurs in smokers and alcoholics, water source; may be diarrhea. Gram stain fails to reveal it. ****All pt suspected of bacterial pneumonia: 1st DO CXR. ****Parapneumonic effusions occur in pneumonia. The fluid maybe sterile in initial stages and resolve with antibiotic therapy, however in a few cases the pt will continue to have elevated temps, pleuritic chest pain and dyspnea. The lab test most helpful in placing tube in parapneumonic effusion is Pleural fluid pH CT will identify the fluid collection. The fluid may be aspirated to see if Empyema has set in. The fluid should be analyzed for: protein content, gram stain, cell count, cytology (r/o malignancy) and glucose level (low in: RA, TB, Empyema, malignancy, esophageal rupture). pH should be assessed. Low pH (<7.2) ALWAYS indicative of Empyema & indicates removal of fluid by THORACOSTOMY Glucose of <60 is ALWAYS indicative of Tube THORACOSTOMY. So the lab test most helpful in placing tube in parapneumonic effusion is Pleural fluid pH

PNEUMOTHORAX - 5 Pneumomediastinum may accompany Spontaneous Pneumothorax: the air from ruptured alveoli in the hila and mediastinum. Pt may present with facial subcutaneous emphysema, breath sounds are absent on the affected side and crushing sounds are heard over pericardium. It usually responds to chest tube drainage and doesn’t need surgical decompression. Now pneumomediastinum with Mediastinitis would need surgical drainage of mediastinum. **** TENSION Pneumothorax: This is an EMERGENCY, once you suspect it don’t even do CXR the 1ST thing: NEEDLE THORACOTOMY. It’s due to air in pleural space, it creates a one-way valve that allows only entry of the air and no exit. Pt presents: Severe chest pain, SOB, tachycardia, tachypnea, deviation of trachea, JVD, absence of breath sounds. TP is a clinical dx, don’t wait for CXR, needle it. ****Spontaneous Pneumothorax occurs when there is no provoking factor. a tall thin young male, almost always due to rupture of SUBPLEURAL BLEBS. Death is very rare. Dx: best made with CXR (shows deviation). ***Remember in Spontaneous P where the shifting of trachea, the main problem is: Oxygenation and Cardiovascular problem becomes secondary not like Tension P which CV is primary. ****Tension Penumothorax: after head-on accident and hemothorax. 1st thing is not oxygen mask (doesn’t help), It’s CHEST TUBE. **Tension P is a possible complication of mechanical ventilation when high PEEP is applied. The barotrauma causes rupture of the lung parenchyma and leaks air into pleural space. Rapid collapse of lung leads to RV filling failure, this results in Hypotension. **In Tension P. even if the Pt presents with severe hypotension (50, 0) the cause is still TP not Cardiac Tamponade. Remember Hypotension+SOB+JVD+Decreased breath sounds. And if you do thoracocenthesis and hypotension is resolved then it wasn’t Tamponade. ****DDx b/w TP & Hemothorax?

POLYCYSTIC OVARIAN DZ - 2 Insulin-resistant hyperinsulinemia is a common finding in patients with PCOD. PCOD is an important risk factor for development of DM-2 in women. About 10% of diabetes in premenstrual women is POS related. Thus a glucose tolerance test is needed in all POS pts. A 2-hr test with > 140 is Dx and needs further action: Lifestyle modification and Metformin is then indicated. Metformin helps by: 1- Prevents DM, 2-Causes anorexia and prevents obesity, 3-corrects hirsutism mildly, 4-menstural irregularity and infertility. Clomiphene Citrate induces ovulation and is used for infertility. *****POS should be suspected in any pt who has menstrual irregularities, and evidence of Hyper-androgenism (facial hair). Presence of these establishes the dx. 50% of pts are obese and are at risk of DM-II. The next step: Do Oral glucose tolerance test as mentioned above. *****Characterized by unbalanced Estrogen secretion resulting in Endometrial Hyperplasia.

POLYCYTHEMIA VERA - 3 A12-**** Persistently elevated Hct and HEPATOSPLENOMEGALY is highly suggestive of PCV. Pts are at risk of hepatic vein occlusion (Budd Chiari syndrome), which is characterized by tender congestive hepatomegaly with ascites (due to hypercoagulability). In cases of tender congestive hepatomegaly: 1 st step is to r/o right-sided heart failure. If RS heart failure and Constrictive pericarditis are ruled out; then NEXT BEST STEP: Do a HEPATIC VENOGRAM or Bx. ****Is distinguished from other kind of Myeloproliferative dz by the marked increase in RBC mass and total blood volume. A typical pt is an old plethoric male who complains of pruritus after bathing. Both thrombosis and bleeding can occur due to elevated platelet count and impaired platelet function. They have granulocytosis, thrombocytosis and splenomegaly. BM is always hypercellular. There is an elevated Leukocyte alkaline phosphatase, normal oxygen saturation and low EPO level. A urinary EPO assay: ABSENCE OF MEASURABLE ERYTHROPOETIN in urine. ESR will be low in PCV.

POLYMYALGIA RHEUMATICA Tx: Low dose prednisone. Pt has STIFFNESS rather than pain. Morning stiffness last >30minutes, Duration > month and include shoulder, hip, neck and torso. Pt says, "Doc my shoulder hip and neck are stiff". ESR is >40.

POLYMYOSITIS An inflammatory muscle dz of unknown etiology. Presents as proximal weakness, characterized by difficulty Ascending and Descending stairs, combing hair and kneeling down. There are no Skin rash or patches like Dermatomyositis. These pt has dysphagia due to weakness of striated muscle. Muscle biopsy is the best Dx study. It shows ENDOMYSIAL infiltration.

POLYPS Classified as 1-Hyperplastic: the MC non-neoplastic. No follow up is needed. 2- Hamartomatous: Include Juvenile polyp and Peutz Jeghers (non-malignant lesion). 3-Adenoma: MC polyp found in colon. Presents in 30-50% of elderly. Only >1% become malignant. Most are asymptomatic, <5% have positive occult stool test. Probability of adenoma becoming malignant is judged clinically according to size histology and appearance. An adenoma can be sessile or stalked (pedunculated). Cancer is usually in sessile. B-Histology: adenoma is villus, tubular and tubulovillus. Villus, which are sessile, are more likely to be malignant. 2nd is tubulovillus and 3rd is tubule.

PORCELAIN GALLBLADDER A13-

PORPHYRIA CUTANEA TARDA Painless blisters, Hypertrichosis and Hyperpigmentation, and increased skin fragility of hands. Assoc with HepC. It can be triggered by ingestion of OCP (Estrogen) or Ethanol. Elevated urinary porphyria confirms Dx. Phlebotomy or Hydroxychloroquine provides relief.

POST –EXPOSURE PROPHYLAXIS: For Chicken Pox can be provided with VZIG or acyclovir. VZIG is preferred and indicated in high-risk people exposed within 72 hours of exposure. If its longer it’s too late and the child will get it, warn the mother for the rash

POST TRAUMATIC STRESS DISORDER PTDS and Acute Stress Disorder are identical except that ASD cant last more than 4 weeks and PTDS lasts for months. ***AVOID Benzodiazepines in these pts since PTDS is assoc with substance abuse and Benzos are addictive, Best Tx: SSRI and exposure or cognitive therapy.

POST-TERM PREGNANCY - 2 Pregnancy age > 42 weeks resulting in macrosomia. Fetus has long nails, abundant hair and dry skin. Assoc syndromes are anencephaly and Trisomy 18. Mgmt depends on well being of the baby. Do biweekly with non-stress test and Biophysical profile, if baby is in danger (oligohydramnios or spontaneous deceleration) deliver. If not, labor should not be induced if cervix is not favorable. If the term is 34 weeks then delivery is mandated. If baby is >42 weeks and cervix is favorable then deliver. If all favorable delivery should not be induced until cervix is favorable, fetus is macrosomic. If pregnancy > 43 weeks then delivery is mandatory. If it’s more than 42 weeks, cervix is favorable and head is in pelvis labor should be induced

POSTOPERATIVE ENDOPHTHALMITIS MC endophthamitis. It occurs within 6 weeks of surgery. Pt has pain and decreased visual acuity, swollen conjunctiva & eyelids. Send Vitreous for culture, and based on severity intravitreal antibiotic injection or vitrectomy is performed.

POST STREP GN - 2 Seen 10-20 days after throat or skin infection. Features: periorbital swelling, hematuria and oliguria. Pt may show hematuria with RBC Cast and proteinuria. Serum C3 complement are low. DDx: Drug-induced interstitial Nephritis: Penicillins Cephs, Sulfas. Pt presents: fever, rash, arthralgia, eosinophilia, hematuria, pyuria, and eosinophiluria (WBC cast) but NO RBC cast. ****There is increased ASO titers, decreased C3 and CH50. Renal function returns to normal in 1-2 weeks. C3 returns to normal 8-12 weeks. ASO returns to normal 3-4 months.

PRADER-WILLI SYNDROME Deletion in arm of Ch15. It presents Genomic Imprinting where genetic disposition depends whether it’s inherited from mother or father. Narrow bifrontal diamond shaped eyes, down turned mouth, and he has to be restrained from eating so they are obese and hypogonadism.

PRECOCIOUS PUBARCHE: It’s important to ddx b/w Precocious Puberty (appearance of pubic hair <8yo- girls/9yo boys) that is caused by premature activation of the hypothalamic-Pit- Gonad axis and Precocious pseudopuberty that is caused by gonadotropin- independent process, typically an excess of sex steroids. Pseudopuberty: Severe acne and severe growth acceleration. It can be caused by LATE CAH. The axis PP is not so dramatic. The sequence is: testicular enlargement, penis enlargement, pubic hair growth, and then growth spur is absent.

PRECOCIOUS PUBERTY, IDIOPATHIC Represents 40% of cases of PP in females and results from premature activation of Pit-Hypothalamus-Ovarian axis. It characterizes by similar cases in family and a normal sequence of secondary characteristics. GnRH stimulation test may be performed to confirm the activation of axis, leads to release of LH. Pt should be tx with GnRH agonist in order to inhibit the secretion of estrogen, preventing premature epiphyseal plate fusion. Although parents need to know that this is benign, but they need to also know what action needs to be taken. ****DDx with precocious PUBArche, which is sign of severe androgen excess, caused by gonadotropin independent process like DDx: excess sex steroid due to 21-hydroxylase def.*****Etiology of PP can be divided into 1-True Isosexual PP 2ndary to activation of axis, 2-Pseudosexual PP: increase in steroid hormones and resultant 2ndary sex. Characteristics, mostly due to ovarian tumors, also adrenal tumors and exogenous estrogen exposure, hypothyroidism and McCune-Albright syn. In GnRH stimulation test, a significant release of LH indicates activation of pit gland, therefore true isosexual PP. PREDNISONE SE Insomnia, Nervousness, indigestion, hirsutism, DM, Arthralgias, Epistaxis and Osteoporosis. ***** Chronic use can cause Myopathy and pt presents with acidosis due to decreased pulmonary function, next step is PFT.

PREECLAMPSIA – 7 Def: new-onset HTN (BP≥ 140/90 mm Hg) + unexplained proteinuria ≥ 1+ (>2g/24hr on 2 occasions at least 4h apart) & assoc w/CR increase after 20 wk). **** Risk factors: 1ST conception, DM, renal failure and extreme age. ****Its important to ddx b/w PE and SLE in pregnancy because they respond to 2 different therapies. HTN in a pregnant woman in the setting of massive proteinuria, malar rash, and positive ANA titer is most likely due to SLE, which causes Glomerulonephritis. SLE very rarely STARTS in pregnancy, and it usually exists prior to pregnancy, so there is Chronic GN. ****The most effective tx for Preeclampsia and Eclampsia is delivery and evacuation of placenta. Most times it can’t be done because too far from delivery date. Guidelines: 1-MILD Preeclampsia: If at termà DELIVER, if not at term à BEDREST, SALT RESTRICTION and CLOSE OBSERVATION. Dexamethasone is given b/w 24-34 weeks and once the maturity is achieved baby is delivered. 2-SEVERE Preeclampsia: Stabilize pt & evaluate before making decisions. MANDITORY: Bed rest and salt reduction, if BP> 160/110 requires anti HTN meds. When the pt is stabilized, make decisions based on: The term, if Mature àDeliver; if not term à Wait till 34 wk and deliver. **If pt doesn’t responded to therapy or if mother or baby are at risk, prompt vaginal delivery is required after induction of labor, *** if vaginal is not possible then do C-section. HTN THERAPHY guidelines are: If NEAR TERM or already in LABORà Hydrazaline or Labetalol, short acting. If FAR FROM TERM à Oral Methydopa (DOC). CCB are (2nd line agent), and ACE-I is C/I. *****Nitroprusside is used when BP is extremely high, avoid before birth because causes cyanosis in fetus. For SEIZURE prophylaxis and Tx: Mg Sulfate (most effective agent). For prophylaxis its given IM to all severe preeclampsic pt from admission, and milder pts get it during labor and within 24hr of delivery. For Seizure tx, IV injection is used.

SEVERE PREECLAMPSIA: is defined as BP ≥ 190/110 or one or more of the following: 1-OLIGURIA, BLURRY VISION, EPIGASTRIC PAIN. Pts are at risk of ECLAMPSIA, PROTEINURIA>>300mg/24hr. It results from cerebral vasospasm and resultant cerebral hypoxemia. It’s a generalized Tonic-Clonic seizure that manifest like grand mal. It occurs 25% before labor, 50% DURING LABOR 25% after delivery. ****Depressed DTR = 1ST sign for Magnesium Sulfate toxicity which requires STOP & administer CALCIUM GLUCONATE. The 2ND sign: Respiratory Depression, then coma, then cardiac arrest and death. ** For SEIZURE prophylaxis: MAG SULFATE IM is started on admission, and carried out though out the period of evaluation and observation Milder pts get it during labor and within 24hr of delivery. For Seizure tx, IV injection is used.

MILD PREECLAMPSIA: For MILD PREECLAMPSIA prophylaxis à MAG SULFATE performed during labor, delivery and within 24 hrs after delivery.

**If pt is also taking Hydrazaline, need to stop Hydrazaline & C-section started if BP drops abruptly. *****If the HTN presents before 20week gestation it’s either Mole, or Chronic HTN. If U/S does not show "snow storm" then it’s Chronic HTN ***Transient HTN occurs in 2nd half of pregnancy during labor or delivery. Proteinuria may be present but doesn’t exceed >300mg/24hr, if it does then it is Preeclampsia. ****Seizure Txà IV injection Mg SULFATE ****MCC of death in ECLAMPTIC pt is Hemorrhagic stroke due to HTN and thrombocytopenia. **** For Seizure tx, IV injection is used.

PREGNANCY EARY DETECTIONS TEST DETECTS WKS DONE INDICATIONS Chorionic Villus chromosomal 10-12 weeks women >35 directly Sampling abnormalities after abnormal U/S

Amniocentesis 16-18 week

Cordocentesis or rapid karyotype Rhesus Percutaneous analysis isoimmunization is Umbilical Blood suspected Sampling (PUBS)

MSAFB Neural tubes and routinely 2nd abd wall defects trimester

PREGNANCY PROBLEMS – 12 1ST TRIMESTER 2nd TRIMESTER 3RD TRIMESTER wk 1-12 Hyperthyroid surgery 36-37wk GBS screen if (+) Pen G even w/o risks present during labor HTN before 20 wks, its either Mole or CHRONIC HTN HTN after 20 wks, its either Preeclampsia (Proteinuria, >300mg) or TRANSIENT HTN Low back pain- lumbar lordosis and relaxation of ligament to the joints

*** Both Graves Dz and Migraine will improve in Pregnancy. ***Excessive OXYTOCIN useà May cause H2O retention (acts like ADH), hypoNa and seizures (water intoxication). ****C/I in PREGNANCY: ACE inhibitors and Oral hypoglycemic agents (Glibenclamide). Stop them and give Insulin for DM, and Methyldopa (MC used), Hydralazine and Labetalol for HTN in pregnancy. ***Pregnancy has a protective effect on both MS and PUD. ****Pt 6 week gestation has positive FTA-ABS for syphilis, allergic to penicillin, Tx: Desensitize her to penicillin (best tx) is since Erythromycin can’t cure syphilis. ****In pregnancy both BUN and Creatinine are decreased to 1/2 of pre-pregnancy levels. Amoxicillin has no effect on them. ****Asymptomatic Bacteriuria of Pregnancy, increases risk of developing cystitis and pyelonephritis. E coli is the cause 70% of the times. Tx: 7-10 days of Nitrofurantoin, Ampicillin or 1st gen Cephs ****Neonates of pts with Graves dz treated with surgery are at risk for Thyrotoxicosis, because of the passage of thyroid stimulating immunoglobin across the placenta. ***** Epidural anesthesia: common SE: Hypotension. The cause of hypotension is blood redistribution to the lower extremities and venous pooling. ****In pregnancy, recommended to CONTINUE exercise just as you were doing before, like an aerobic instructor. *****Edema of lower extremities (Bilateral) in pregnancy is most commonly a benign problem. Pre-eclampsia should be suspected if the edema is associated with HTN or proteinuria, don’t need ECG or DVT (presents unilateral and fever). ***** Oxytocin is like ADH it causes water retention and Water toxicity due to decrease in Na concentration (123). It could cause seizure postpartum. ***** Screening cultures should be performed at week 36-37 and positive cases should be treated with IV penicillin therapy during labor to prevent the new born from getting infected. ***** If HTN before 20 weeks, its either Mole or CHRONIC HTN. If it sets in after 20 weeks, its either Preeclampsia (Proteinuria, >300mg) or TRANSIENT HTN (not accompanied by proteinuria, <300mg) *****Antibodies to ABO antigens belong to IgM antibody class so they don't cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies that are responsible for Rh Alloimmunization belong to IgG class and do cross placenta.

PREMATURE ADRENARCHE Isolated appearance of axillary hair before age of 6. Results from androgen secretion from Adrenal gland. It’s benign and has no clinical significance. But Premature Pubarche (pubic hair growth before 8) is in 50% of cases assoc with CNS disorder.

PREMATURE LABOR Premature labor must be managed aggressively, and tocolysis ASA à Mg Sulfate (DOC), but not FDA approved (but Ritordrine is); and need to administer steroid for speeding up lung maturity.

PREMATURE OVARIAN FAILURE A failure of estrogen production by the ovaries of a woman <35. MC idiopathic; But it could also be due to adhesions, Hashimoto’s, irradiation or chemo. Pt presents: few months of amenorrhea, atrophy of vagina, increased FSH, previously had a child. The only way to treat infertility is Egg Donation.

PREMATURE RUPTURE of MEMBRANES: Is a rupture that happens before labor at anytime of gestation. Premature PROM is a rupture that happens before term whether there is contraction or not. In PE: amniotic fluid in vagina, confirmed with Nitrazine paper. In case of PPROM, amniotic sampling to measure lung indices is mandatory also do U/S to measure AMNIOTIC volume & determine fetal anomalies. If fetal has congenital anomaly let vaginal delivery proceed. If fetus is viable then prolong pregnancy to mature lungs. REMEMBER if there is no contraction, no need to do tocolysis.

PREMATURE VENTRICULAR CONTRACTIONS Require no tx, just observation.

PRESBYCUSIS In older people, a high frequency hearing loss in both ears with difficulty in speech differentiation. Acoustic Neuroma is a unilateral hearing loss assoc with rotational vertigo

PRESBYOPIA Normal aging, loss of accommodative capacity.

PRETERM LABOR Defined as labor prior to 37 week and Dx 1-Occurrance of contractions, 2- Cervical change or effacement of 80% or dilatation of >2cm. Preterm birth: Delivery b/w 20-37 weeks. Low socioeconomic have higher incident. RDS is a common problem in premature births. If both mother and baby are stable: 1st thing to try bed rest and hydration, even IF there’s effacement and dilatation. It’s successful in 20% of times. Hydration is a negative feedback on the secretion of ADH and Oxytocin (post pituitary), which is responsible for induction of labor. If not successful, NEXT STEP: Initiate Mg sulfate (tocolytic). Pt should also be cultures for GBS and antibody considered. Dexamethasone IM is necessary for this stage of labor, when administered b/w 24-34 week they accelerate lung maturation. PREVENTATIVE MEDICINE 1-DRE and hemoccult (PSA option) >50 yo, annually. 2-Colonoscopy >50yrs every 10 years. 3-Pap is not needed for women who have had regular check up until 65 yo. 4-Mammogram should be done yearly from 50-75. 5-Routine Chlamydia infection screening for all sexually active women over 25 and younger. 6-If LDL Cholesterol is ≥100 for a DM risk factor then start life style modification. 7-Women who have had CIN II or III à Annual pap smear even if the result is negative 3 yr in a row. 8-Hormone replacement therapy à best therapy for osteoporosis in postmenopausal women. 9-Annual Influenza vaccine: All adults ≥65 yo & adults of any age at risk of Influenza. 10-MMR is highly recommended for all HIV infected pts who are asymptomatic and are not severely compromised. 11-HIV infected pt should receive Tetanus and Diphtheria immunization according to normal dosing schedule (meaning a booster every 15 years). DTP is only required for children since individuals >5years are highly unlikely to get Pertussis. 12-HepA vaccine is recommended for traveling to developing countries. 13-Yellow fever vaccination if necessary for Africa and South America travelers. 14- Menigococcial Meningitis is recommended for Hajj. ****Pneumococcus vaccine is given at age 65. ***Pap smear must be performed 3 years in a row before it could be left alone. *****If child develops seizure after DTP vaccine, it’s C/I, so next time, Don’t give Pertussis and just give DT.*****people with pancolitis and Ulcerative Colitis have in creased risk of colon cancer and should do colonoscopy 8 years after surgery and then every1-3 years after that to identify recurrent cancer in early stages.

PRIAPISM MC drug that causes it is Prazosin, but in boards Trazodone is mostly associated with it

PRIMARY BILIARY CIRRHOSIS - 3 Although no specific tx is indicated, Ursodeoxycholic Acid is recommended to reduce itching and slow progression of dz and intimately Liver transplant. ***Presents in middle age and 90% are female. Assoc with Sjogren, RA and CREST. Liver biopsy is pathognomonic with granulomatous destruction of bile ducts in portal triad. Def tx is liver transplant.

PRIMARY DYSMENORRHEA Pt present with hx of lower abdominal pain that radiated to upper thighs and back. The pain is colicky and starts a few hours prior to menses, lasting 3- 4 days. It usually appears 6-12 months after menarche. Tx: NSAID and OCPs. The pathology here is that menstrual fluid has higher levels of PGs.

PRIMARY HYPERALDOSTERONISM - 6 Parathyroidectomy is the only effective tx. Know how to ddx from Renovascular HTN based on low renin activity in PHA and high renin activity in RV-HTN. Characterized by HTN, HypoK+, and suppressed renin, The MCC is aldosterone producing adenoma (Adrenal Adenoma). ****The MCC of combination of HypoK+and HTN is PHA. *****The mineralocorticoid activity of Aldosterone results in increased salt & water retention, followed by Natriuresis (Aldosterone escape phenomenon). So there is MILD hypernatremia and NO EDEMA. ****Suspect it in a young pt with muscle weakness, numbness and HTN. The most specific lab value is high aldosterone / renin ratio.

PRIMARY HYPOPARATHYROIDISM - 2 A7 Hallmark: *Increased serum calcium + decreased serum phosphate + increased PTH. In PHPT, urinary calcium excretion is normal or elevated DDx: Familial Hypocalciuric Hypercalcemia. Ca++ excretion< 200 (decreased), and creatinine is normal.

PRIMARY OVARIAN FAILURE It could be caused by chemotherapy and will cause premature menopause. The diagnostic blood test is increased FSH levels. Chemo, especially of Alkaline agents, causes failure of follicular cells of the ovary resulting in decreased production of estrogen and inhibin. This results in loss of feedback inhibition of estrogen in LH & FSH, causing their high levels. Inhibin causes the feedback inhibition of FSH only, so in the absence of inhibin the absence of inhibin FSH levels are higher than LH levels, which is pathognomonic for ovarian failure. Clinically, pts have amenorrhea, hot flashes; +/- anxiety, depression and irritability. Loss of estrogen results in atrophy of breast, vagina, myometrium.

PRIMARY POLYDIPSIA Or Psychogenic Polydipsia: characterized by primary increase of water intake. In contrast with DI and DM, it’s the polyuria, which is the driving force of increased water intake. Seen mostly in anxious women young, Pt taking Phenothiazine have this problem because dry mouth d/t anticholinergic effect of drug. Other causes: Hypothalamic lesions affecting the thirst center.

PRIMARY SCLEROSING CHOLANGITIS Inflammatory destruction of both intra and extrahepatic bile ducts. Is assoc with IBD especially UC in 70% of cases. There is: jaundice, pruritus, RUQ pain, or acute cholangitis. May progress to complete obstruction, 2ary biliary cirrhosis, hepatic failure or portal HTN. ERCP is test of choice. Cholangiography: characteristic 'Beading' due to stricture and dilations of intra and extra hepatic ducts. (LFTs: Very high Alk Phosphatase, mild ALT & ALT, 4) is suggestive. Next step: Transrectal USG, followed by needle biopsy then staging. For staging, do bone scan to see metastasis. ***When the cancer is in late stages (metastasized) surgery is not performed unless needed for palliation. Tx of choice: Palliative radiation with anti-androgen therapy Leuprolide (LHRH analog) is DOC, Flutamide is not as good.

PROSTATITIS, ACUTE PROSTATITIS, PROSTATODYNIA BACTERIAL NON-BACTERIAL Younger pt: by STD 30-40 yo Older pt: E Coli. chills, fever, urge to afebrile, irritable voiding irritative voiding urinate pain in symptoms: frequency, symptoms urination, prostate is urgency and suprapubic tender and boggy. discomfort

1ST STEP: Get mid-stream U/A: normal. Expressed Expressed prostatic urine sample to culture prostatic secretion secretions: Normal FINDINGS: Leukocyte leukocytes, culture is 2ND STEP: Give antibiotics count > 10WBC/HPF negative for bacteria. empirically. Culture is negative. MUST No hx of UTI. r/o: Bladder cancer in all (DDx: Non-bacterial elderly pt with urinary prostatitis) cystology & cystoscopy.

PROSTATE CANCER - 4 Radiation is useful in managing bone pain with prostate cancer who have undergone orchiectomy. *Acute Cord Compression: Possible secondary to metastasis of cancer; a.k.a. called Cauda Equina. First symptom: Back Pain assoc w/tenderness@ site of the metastasis. Tx steps: Treatment: 3 steps 2-MRI of spine 3-If confirmed, then 1- Dexamethasone IV if MRI is C/I (Pacemaker) or radiotherapy CT myelogram Screening: - If either DRE or PSA If Late stage cancer -Men 40-50 , yearly DRE (>4) is suggestive the (metastasis): - Age>50 do yearly DRE next step is Surgery isn’t performed plus PSA Transrectal USG unless for palliation. Tx of - followed by needle bx choice: Palliative radiation then stagingàBone w/anti-androgen therapy. Scan to see metastasis DOC: Leuprolide (LHRH analog) Flutamide isn’t as good

PSEUDOCYESIS - 2 A woman presents with all symptoms of pregnancy, BUT, U/S: normal endometrial stripe. *** All pts need Psych evaluation.

PSEUDODEMENTIA - 2 Assoc with Depression, Pt preoccupied w/forgetfulness vs. Alzheimer’s pt doesn’t notice forgetfulness. *****Tx: SSRI

PSEUDOGOUT - 3 Positive birefringent crystals. *****Assoc with: Aging, Trauma, HyperPTH, Hemochromatosis. Pt complains of constipation, polyuria, fatigue and joint pain. Serum Ca++ HIGH & phosphate: LOW, (suggests hyperparathyroidism). Joint aspirate under light microscopy: Rhomboid shape, Ca++ pyrophosphate positive birefringent crystals. Gout has Needle-shaped negative birefringent. Nephrolithiasis: Struvite Crystals Coffin-lid shaped crystals.

PSEUDOMEBRANEOUS COLITIS 2, GI, 6/2 Tx: Stop offending drug and start Metro. ****Clostridium difficile is the cause. Suspect a pt with diarrhea who has been taking antibiotics for a while. Most sensitive test: Cytotoxin assay of stool. Tx of choice: Oral/IV Metronidazole or ORAL Vancomycin (NOT IV)

PSEUDOTUMOR CEREBRI – 4 (aka idiopathic intracranial HTN) Risk factors: Medication (steroids and OCP), ***Large dose Vit A (Isotretinoin acne). Trauma and increased weight. Initial sign: PULSATILE HA that awakens them from sleep; then increased ICP occurs (N, V, double vision, Papilledema), back pain, palsy. Management: 1) CT/MRI to rule out mass occupying lesion 2) Most have empty sella (CT); only then LP is indicated. 3) CSF: Increased P and normal cells. Sufficient CSF should be removed to lower P to 150mm/H2O. 4) If LP didn’t reduce the ICP, then 1st line: Acetazolamide (MOA: Choroid plexus CA Inhibitor) 5) Surgery is indicated if Acetazolamide fails, CNII sheath decompression or Lumboperitoneal Shunt

Diagnostic criteria: 1-Alert person w/ features 3-Normal CSF except increased opening of ICP (N,V, HA) pressure. 2-NO focal neuro signs 4-Absence of any ventricular abnormality except 6th CN palsy other than enlargement caused by ICP.

PSOAS ABCSESS: Presents with RUQ pain, fever, and positive psoas sign, he is also having furuncles (means infectious symptoms). The infection has lead to Psoas abscess. Next Best Step: Abdominal CT (to look for it). If suspicion is high and CT is negative; Next Step is Laparoscopy. Tx: Drainage and systemic antibiotics

PSORIASIS Lithium can precipitate it. ******Skin: Silvery scale.

PSORIATIC ARTHRITIS Is Asymmetric and oligo-articular. Pt has silvery scales on erythematous plaques on flexural surfaces. Think of PA w/hx of pitting nails. Other features: are spondyloarthropathy, DIP involvement. DDx1 OA: NON-INFLAMMATORY. DDX2: RA: RA is not DIP. PUERPERAL FEVER: Defined: T >38 more than 2 days within 10 days after delivery. Occurs in 6- 7% vaginally deliveries. MCC: Endometritis. In addition, genital tract infection may 2ndary evolve into pelvic Thrombophlebitis, abscess or shock. It suspected if: persistent spiking fever that won’t respond to antibiotic therapy. Add HEPARIN to antibiotics for 2-3 weeks. If a rapid response is not noted then suspect abscess.

PULMONARY CONTUSION Presents within 1ST 24 hrs of trauma, tachypnea, tachycardia, and hypoxia. PE: chest wall bruising, and decreased breath sounds. CXR: patchy irregular alveolar infiltrates. ABG: Hypoxia and, itself, is an indication to suspect PC in trauma pts.

PULMONARY EMBOLISM (Pulmonary Vascular Dz) - 14 There is NO PULMONARY EDEMA. Think of PE: Post-op pt with JVD and new onset RBBB. * PE occurs when there is a sudden dislodgment of blood clot from Deep Vein into the pulmonary artery. Risk factors: are prolonged bed rest, obesity, trauma, malignancy, inherited def of prothrombin-III, protein C+ S and use of Estrogen. Symptoms: Dyspnea, CP, cough, and hemoptysis, tachycardia, hypotension, and pain in the leg. The most typical feature of PE in seen in the ABG. Arterial Hypoxemia is ALWAYS present. Dx: V/Q mismatch or Venous Duplex U/S of the legs. PULMONARY ANGIOGRAM: is gold standard. Tx: Oxygenation and anticoagulant. LMWH, thrombolytic therapy, IVC filter may be required. **if ANTICOAGULATION is C/Ià Require of IVC filter placemt when diagnosed with DVT, for prevention of PE. *** A pt with PE and hx of recurrent unexplained DVT, FACTOR V LEIDEN is a common cause of it. Factor V Leiden: The result of a point mutation in a gene coding for the coag factor V, because of mutation factor V becomes resistant to inactivation by protein C, an important counter balance in hemostatic cascade. *Initial symptom: maybe sudden onset of hypoxia, tachycardia, and tachypnea, hypotensive. CXR maybe normal, if that is the case Pneumonia, Atelectasis and Pulmonary edema are ruled out; and NEXT STEP: Ventilation/Perfusion scan. *****A truck driver sitting all the time with tachypnea, tachycardia and dyspnea and right axis deviation has PE. NEXT STEP: Ventilation/Perfusion scan. You should expect large area of perfusion defect w/o ventilation defect.

PULMONARY EMBOLISM TX OPTIONS ****When the suspicion is established, V/Q is the next step, no need to r/o MI with CK-MB. if you suspect PE clinically, and CXR, Heparin w/o waiting for V/Q to confirm your ABG and EKG ruled out other ddx Dx then Embolectomy then hemodynamically compromised Heparin is a good choice but, doesn’t and the clot is situated in main dissolve the clot, so give heparin and take pulmonary artery; recent surg him to surgery hx (a few days ago); or Best Tx: Pulmonary Embolectomy C/I for thrombolytic use When an acute PE occurs, with Fibrinolytic therapy: Excellent choice but hemodynamic compromise w/o not in a post-op pt (may cause diffused recent surg. hx bleeding) BEST Tx for acute PE

In PE pt w/NORMAL CXR & Sudden Put the pt on O2 & bed rest. Heparin STAT onset SOB w/clear lung (CLUE) is x 10 days, if index of suspicion is high After CXR done, ABG and EKG then do V/Q to r/o PE. Gold standard: Angiogram (but rarely done) DVT: Doppler U/S (Test of choice) emboli is large and CXR is abnormal Spiral CT is done, in this case it’s better than V/Q hemodynamic instability or if after Thrombolytics IVC filter pt is worst placement of IVC filter should be C/I to prolonged anticoag therapy or has considered another embolization while in the hospital

Don’t mistake PE for "Pulmonary Septic Emboli: Is caused by release of emboli from right heart due to IE or IV drug users. ****When the suspicion is established, V/Q is the next step, no need to rule out MI by doing CK-MB. But if one of the options is Start coag tx, then that is the 1st step, then do V/Q.

PULMONARY HTN T13Q39. Defined as: Mean Pulmonary arterial pressure >25mmHg at rest and >30mmHg with exercise. Presents with: dyspnea on exertion, CXR: enlargement of pulmonary arteries, RV enlargement. EKG: right axis deviation. Untreated PHT leads to COR PULMONALE

PULMONARY REGURGITATION Early diastolic murmur, decrescendo, high pitched, blowing; best heard around the left sternal border & usually develops secondary to pulmonary HTN. More prominent with inspiration.

PYELONEPHRITIS - 7 Urine and blood cultures must be obtained prior to obtaining antibiotics. After 48-72 hours of IV Ceftriaxone (parenteral therapy) the pt can switched to oral agent (TMP-SMX). Dipstick is positive for both Nitrites (indicates Enterobacteriaciae) and Esterase (indicates Pyuria). It’s a risk factor in pregnant woman, so it’s important to treat UTI before it progresses to full disease. If there is no response to 72 hr therapy with antibiotics, U/S or CT is recommended to find out other pathology like obstruction or abscess. * Tx: Empiric IV antibiotics. ****CHRONIC Pyelonephritis is characterized by focal parenchymal scaring and blunting of calyces on IVP. PYLORIC STENOSIS - 2 ****4-8 week old infants suddenly started to vomit (non-bilious) after feeding for the past 2 days. It’s PS. Don’t be fooled by no mass being palpated. Must do U/S to dx (hypertrophied pylorus). Tx: 1st Correct hydration and electrolytes (give K+) then Surgery

QUINIDINE TOXICITY Tinnitus, Torsades de Pointes, prolonged QT, hemolytic anemia, diarrhea.

RA Pts with erosive joints need Disease Modifying Anti-Rheumatic Drugs (DMARD). Indomethacin or other NSAID may be used as ADJUNCT therapy. These drugs slow down progression of erosions and cartilage lost. If conservative mngt didn’t work then steroids are used. DMARDs: Methotrexate (DOC), Hydroxychloroquine, Sulfasalazine, Azathioprine. ****Methotrexate MOA: inhibits DHF reductase, so SE: Microcytic anemia. Hydroxychloroquine SE: GI distress, visual disturbances, and hemolysis in G6PD def. Prednisone may cause iatrogenic Cushing’s. Azathioprine may cause Pancreatitis, liver toxicity, and BM suppression. Cyclosporine is used in transplantation and may cause Nephrotoxicity.

RABIES Try to capture the dog to see if he has rabies, if the dog wasn’t captured assume he had rabies and tx is both active and passive immunization. If dog is captured, observe x 10 days, if suspicious, do brain autopsy. If confirmed then the post exposure prophylaxis (both passive and active immunity) is given.

RADIAL FRACTURE Fractures of shaft of humerus present with tender, swollen, crepitus and shortened arm. Dx: XR. Recommended tx for isolated diaphyseal humeral fx: Closed reduction followed by hanging cast

RALOXIFENE A Selective Estrogen Receptor Modulator (SERM) used for prevention of osteoporosis. Unlike Estrogen, it doesn’t increase risk of Endometrial cancer. It decreases risk of Breast cancer. It has no effect on Ovarian cancer. Most important SE increased risk of Pulmonary Thromboembolism & C/I in pt with a hx of DVT. It may worsen hot flashes and vaginal dryness.

RAMSAY-HUNT SYNDROME A facial nerve palsy, caused by Herpes Zoster. Pt presents with lesions of external ear +/- tympanic membrane involvement, vertigo, tinnitus, and deafness due to geniculate ganglion involvement.

RATIONALIZATION When a pt ignores a breast cancer and does not go to doctor, when asked why? Her rationalization is because there is no family hx of breast cancer in my family. DDx Denial: A pt dx with terminal dz but denies it. DDx: Intellectualization: allows someone to talk about his dz in a detached manner.

REACTION FORMATION When a women who hates foreigners volunteers to help them in a center. DDx: Altruism: A rape victim establishes a rape center to help other raped people, in order to help her own anxiety.

REFLEX SYMPATHETIC DYSTROPHY A syndrome of Pain and swelling assoc with vasomotor instability. Usually assoc with movemt restriction of shoulder. XR: Osteopenia. Physical therapy restores function. Prednisone for resistant cases.

REITER’S SYNDROME or REACTIVE ARTHRITIS Arthritis, Conjunctivitis and Urethritis. Typical skin lesion: Keratoderma Blenorrhagicum on palms and soles. Clear vesicles on red bases that later develop into macules and papules. Other lesion: Circinate Balanitis on penis, shallow painful ulcer. ****Grouped under "Seronegative Spondyloarthropathies" and these pts have NEGATIVE RF. HLA/B27 is found in ONLY 80% of white pts and 60% of blacks. *****It’s Arthritis reactive to G-U infection due to Chlamydia, might develop heel pain and sausage digits. Tx of choice: SAID, if dz is due Chlamydia add Tetracycline.

RELAPSING POLYCHONDRITIS an idiopathic disorder characterized by recurrent inflammation of cartilaginous structures and other internal organs

RENAL ARTERY STENOSIS In a pt with multiple risk factors for atherosclerosis (hypercholesterolemia, DM, smoking, HTN), RESISTANT HTN should think of RAS. Continuous murmur (Systolic and Diastolic) in the periumbilical area or in flanks is characteristic of RAS.

RENAL CALCULI Excessive use of Vit C in pt with renal insufficient can cause Oxalate stones (Radiopaque) (Gout stones are Radiolucent). MCC: renal stones are calcium, Dx procedure of choice: Abd CT of the abdomen w/o contrast. It can detect radiopaque (Ca++) and radiolucent (uric acid) stones, KUB or abd XR not the best test, the dietary recommendation: for pts with renal calculi is 1-Decreased dietary protein and oxalate, 2-decrease sodium intake, 3-increase fluid intake, 4-increase dietary calcium. *****Renal stones in pregnant require renal and pelvic U/S - procedure of choice - No radiation.

RENAL CELL CARCINOMA Classic triad (flank pan, hematuria, palpable mass) in uncommon, but when present means metastasis has occurred. No matter what the vignette says if it mentions VARICOCELE fails to empty in recumbent position, it is RCC. Next step: Abdominal CT.

RENAL LACERATION Presents with hematuria and retroperitoneal extravasation. CT with contrast will visualize both kidney and spleen. CT: Best study to evaluate solid organ damage in a stable pt.

RENAL TUBULAR ACIDOSIS RTA results in impaired ammonia excretion which is the principle mechanism of met acidosis in CRF.

RTA-1: 2-RTA: RTA-type 4 Distal tubular acidosis PCT acidosis Dx: urinary pH100,000 is dx. Empiric antibiotics STAT in Infants Nafcillin+3rdgen cephs, and for >5yo Nafcilin alone. A true surgical emergency and needs surgery and drainage immediately, a delay of 4-6 hrs can lead to AVN

Decreased distal tubular Hallmark: impaired PCT DM pt & HyperK+ H+ secretion and therefore HCO3 reabsorption inability to generate new leading to excretion of HCO3 excessive urinary HCO3.

AG MA and a urine pH>5.5. Pt has urinary pH100,000 is Serum K+ is classically low dx.

Causes are Sjogren, SLE, Empiric antibiotics STAT in Amphotericin Toxicity, Infants Nafcillin+3rd gen Wilson’s, Sickle cell, cephs, and for >5yo Nafcilin Fabry’s; assoc w/ alone. A true surgical Nephrolithiasis emergency: immediate Surgery and drainage, a delay of 4-6 hrs can lead to AVN

*RESPIRATORY ACIDOSIS presents with decreased pH, then looking at PaCO2 see increase and then HCO3 is a little elevated to compensate. Common causes are: 1-Pulmonary diseases. 2-Neuromuscular disease, any condition that weakens or paralysis respiratory muscles (MG, Polymyositis, MS and Kyphoscoliosis). 3-Primary CNS dysfunction like a brain lesion. ******RTA describes conditions in which normal AG metabolic acidosis occurs from decreased net renal acid secretion

RESPIRATORY ALKALOSIS - 4 Increased pH and decreased PCO2. Due to hyperventilation. Homeostasis of 3 forms of plasma Calcium is dependant on extracellular pH. An increased extracellular pH levels causes an increase in the affinity of serum albumin to calcium, thereby increasing the levels of albumin-bound calcium and consequently decreasing the levels of ionized calcium. Ionized calcium is the only physiologically active calcium, so decreased level lead to HypoCa++ (crampy pain, paresthesias and carpopedal spasm)

RESTRICTIVE LUNG DZ Do Merck. Increased A-a gradient in interstitial lung disease due to poor oxygenation. In restrictive lung dz: TLC, FRC, and RV are all reduced. But FEV1/FVC is either normal or increased.

RETINAL ARTERY OCCLUSION, CENTRAL Painless loss of monocular vision secondary to embolism. Embolism of retinal artery is the MCC of ocular stroke. Commonly assoc with Amaurosis Fugax before the occlusion. Fundoscopy: Ischemic retinal whitening and red cherry spots. It’s an ophthalmology emergency, delay in tx may result in blindness. Immediate intervention includes ocular massage (which moves the emboli) and high flow oxygen therapy.

RETINAL DETACHMENT Sudden onset & mostly unilateral of photophobia and floaters, the most classic description is "a curtain coming down over my eyes”. Tx: Laser and cryotherapy.

RETINAL NECROSIS, ACUTE MC by HSV and VZV in HIV pts. Assoc with pain, keratitis, uveitis and peripheral pale lesions. In CMV retinitis is painless, not assoc with keratitis and conjunctivitis, but Fundoscopy shows hemorrhages and fluffy or granular lesions around retinal vessels.

RETINAL, CMV T9Q13. Occurs in HIV pts when CD4 falls below 50. It presents as yellowish- white patches of retinal opacification and retinal hemorrhages. Tx: Gancyclovir or Foscarnet.

RETINOBLASTOMA Highly malignant tumor and failure to dx and tx early may lead to death from liver and brain metastasis. MC intraocular tumor of the childhood. Every case of LeukoCoria (white reflex) is considered retinoblastoma until proven otherwise, although the MCC is congenital cataract. So these pts should be refered to Ophthalmologist. Other signs: are strabismus, decreased vision, ocular inflammation, eye pain, glaucoma. ***** RETROPHARYNGEAL ABSCESS Fever and cervical adenopathy, POSTERIOR pharyngeal edema and nuchal rigidity. Tx: IV broad spectrum antibiotics or drainage

RHABDOMYOLYSIS - 2 Characterized by breakdown of muscles. MCC is alcoholism. Risk factors: Crush injuries, strenuous exercise and seizures. Dipstick testing: Hematuria, but microscopic analysis of urine does not show RBC. Serum creatinine is disproportionately elevated compare to BUN. ATN can occur due to ischemia or toxins. Hb or Myoglobin is endo- or exogenous nephrotoxic substances that can accumulate in the kidney due to breakdown of muscles, and leading to ATN. Tx: Aggressive IV hydration, and alkalinization of urine. In some cases, forced diuresis with Mannitol may be required. ***Crush injuries Tx: IV fluids, osmotic diuretics and Sodium Bicarbonate (to alkalinize urine). After crush injury in accidents, it might show with myoglobinemia, myoglobinuria and eventual renal failure, urine dipstick test: positive for hematuria. HyperKalemia is common showing tall T waves on EKG. The Best Dx test: Creatine Kinase. Best Initial Management: Osmotic diuretics and bicarbonate (to alkaline urine) to prevent renal failure.

RHESUS ISOIMMUNIZATION It happens when there is contact of Rhesus-positive fetal blood and Rhesus negative of maternal blood. This results in mother's antibodies to cross over to baby's circulation and cause hemolysis of baby blood. Severe cases cause Hydrops Fetalis. Mild cases cause jaundice within the first 24hr after birth. Any incident that causes bleeding can cause this (amniocentesis, CV Sampling, Abortion, ectopic pregnancy, labor and delivery. Best Tx: To prevent mother's immune system to be in contact with fetus blood cells, the best thing is AntiD-gammaglobin (Rho-GAM) prevents contact by decreasing availability of fetal RBC in maternal circulation. In case mother was not sensitized (antibody titers < 1:6) RhoGAM is still indicated. It should be given to ALL Rh-negative women at 28 weeks and within 72 hrs after any procedure of incident (abortion) and delivery. In case the mother is already sensitized (antibody =>1:6) administration of RhoGAM is useless and close fetal monitoring for hemolysis is required. Methods used for this is Amniotic Fluid Spectrophotometry, it measured bilirubin in amniotic fluid. U/S used in conjunction with it to detect Hydrops fetalis.

RHEUMATIC FEVER - 3 MCC Mitral stenosis is RF. Principle symptoms are dyspnea, pulmonary edema, and precipitated by exercise, fever, anemia, sex intercourse, tachycardia and pregnancy. In MS the left atrium gets very large and pushes up the left main stem bronchus. Occasionally pressing the phrenic nerve causes persistent cough. Other findings: are loud S1, opening snap and a diastolic murmur. ECG reveals atrial fibrillation. ECHO will confirm dx. All pt should receive Endocarditis prophylaxis. Tx: Mitral Valve Surgery. *Prevention of recurrent attacks of RF might slow down progression of MS, so Penicillin prophylaxis with monthly IM Benzathine Penicillin is recommended in adolescent. +/- Carditis need prophylaxis: (+) Carditis need 10 yr and (-) 5 yrs. If there is (+) hx of embolic events anticoag is indicated.

RIB FRACTURE MCC is auto accidents. Complications: Atelectasis, pneumonia and respiratory arrest. It could be deadly in elderly, this is due to the pain which causes hypoventilation & atelectasis/pneumonia. Pain management: the PRIME priority in these pts. Local nerve block is used if oral or systemic analgesics are not helpful.

RITORDRINE SE, OBGYN, 6/2 Beta 2 agonist (Ritordrine, for Tocolysis) may increase edema by decreased water clearance, tachycardia and increased myocardial work load. They also increased Gluconeogenesis (in Liver and Muscle) resulting in increase demand for insulin in DM pts.

ROCKY MOUNTAIN SPOTTED FEVER Characterized by fever, myalgias, HA, and petechial rash. The MC and fatal Tick-borne dz in USA; delayed in Dx can lead to Shock and systemic signs. If shock is there (BP reduced a lot) then IV hydration is to be done prior to anything else; then Tetracycline, oral or IV.

ROSACEA In pt of 30-60 yo, light skin and eye color, telangiectasia over the cheeks, nose and chin. Flushing of these areas is precipitated by hot drinks, heat, motion and rapid body T changes. Tx: Aims at papules, pustules and erythema by topical Metronidazole.

ROTATOR CUFF TEAR Pt presents with shoulder pain aggravated by movements like pushing, pulling, and positioning the arm above shoulder. If limitation of abduction or external rotation does not reverse with Lidocaine injection rules out Tendonitis and focuses on RCT. Dx: MRI or Arthrography. If that is the case then surgery will fix the problem.

ROTOR’S SYNDROME Presents with Conjugated bilirubin in urine (urine dipstick show it). If bilirubin is in urine it must be conjugated since uncongugated can be excreted.

RUBELLA - 5 Maculopapular rash, posterior cervical and posterior auricular lymphadenopathy and polyarthralgia. Pt can be tx with acetaminophen for symptoms. Pt can be infectious 1 wk prior to the onset of the rash and 15 days after. Best protection: Live attenuated vaccine. Rash starts on the face and then progress to trunk. Arthritis that develops in adult females is a clue for rubella. ***Most cases of postnatal acquired rubella are asymptomatic. Classic Rubella: Rash, low grade fever, lymphadenopathy. Lymphadenopathy and fever appear about 14 days after initial infection and prior to rash. Rash is in distinguishable from Measles. DDx1: Scarlet Fever: pharyngitis, fever, sandpaper-like rash DDx2: Chicken pox has vesicular rash. DDx3: Erythema Infectiosum Slapped- cheek appearing rash. Roseola Infantum Herpes virus 6, abrupt high-grade fever, and then maculopapular rash on trunk and then periphery. Pt is no longer febrile when rash appears. ***After rubella vaccination, it’s recommended that no pregnancy for 3 months. But so far there are no reported fetal transmission in this regard, so if it does happen and the is then gets pregnant, just reassure the mother nothing else needs to be done. ****Congenital Rubella Syndrome (CRS): Presents Triad: Sensorineural deafness, cardiac malformation (PDA, ASD) and Cataracts (White reflex) ery muffin spots and thrombocytopenia. Pt also has 'blub. transmission in 4th week of pregnancy. Maternal infection: Rash, arthralgias and lymphadenopathy. If it is at the beginning of pregnancy its worst, might lead to spontaneous abortion or CRS (risk is 50% if transmitted in 4 week, and 1% if in last trimester). Maternal infection is confirmed by antibody to rubella virus In infant, there is IgM antibody or persistent IgG beyond 6 mo. Prevention of Rubella is by vaccination of ALL females of child-bearing age. If immune status is unknown, titers should be obtained 1st trimester. Vaccination should not be given in pregnancy. DDx1: Sturge-Weber: Neurocutaneous dz, port wine stain in distribution of trigeminal nerve, MR, seizure and glaucoma. DDx2: Retinoblastoma: May present with unilateral or bilateral white reflex, HOWEVER No deafness or PDA as is CRS. DDx3: Congenital CMV and Toxoplasma: Both manifest with Hydrocephalus, cerebral calcification, Chorioretinitis, and microcephaly; but no deafness or cardiac anomaly.

SALICYLATE TOXICITY mixed respiratory alkalosis and metabolic acidosis.

SALMON PATCH A flat salmon-colored lesion over eyelids and neck. It’s a vascular lesion that disappears early in childhood.

SARCOIDOSIS - 4 DOC: Systemic steroids-- Indicated in pt with disabling symptoms (visual disturbances, cough, SOB) and organ dysfunction. PE: Hilar lymphadenopathy (organ derangement). Steroid MOA: Suppress activated T-induced cell process at dz site. Asymptomatic pts need no tx. ****CXR: Granular Hilar opacity in lungs bilaterally (mediastinum adenopathy). Once mediastinum adenopathy is seen on CXR, the next step: Perform mediastinal bronchoscopy & obtain tissue for biopsy. Ca++ is increased and Steroids are tx of choice for SYMPTOMATIC pts. ****Pt with no symptoms but dyspnea that has gotten worst and joint pain with CXR: Hilar adenopathy and non-caseating granuloma. ****Skin manifestation of rash is found in 30% of pts; Dx: Scintigraphy, to Confirm biopsy and NC Granulomas.

SCABIES Tx for adults is 5% Permethrin cream

SCAPHOID FRACTURE Common in adults, after a fall on a outstretched hand. Pt presents with pain at wrist movement. Tenderness in Anatomical snuffbox. It might not show on XR for 2 weeks. So if signs are there but XR is negative tx as if it is fracture. 10% go to have AVN due to tx error. Cast immobilization is recommended in the treatment of all Non-displaced scaphoid fractures (fx <2mm displacement and no angulation). Open reduction and internal fixation if initial XR shows displacement fracture. *****If fracture is suspected even if the XR doesn’t show it (cause it takes a few weeks) then the best mngmnt is long arm cast and treat it as if there is a fracture.

SCARLET FEVER Presents with fever, toxicity, pharyngitis (Grey-white exudate), sandpaper-like rash and strawberry tongue and 'circumoral pallor'. By Group A Strep, because of erythrogenic toxins. Tx: Penicillin V. If allergic, Erythromycin and Clindamycin are alternatives. DDx1: Kawasaki, due to pharyngitis, strawberry tongue, Lymphadenopathy and rash. However, it must have either change is peripheral extremity or conjunctival injection, to make dx. Difficult to DDx but response to Penicillin makes the dx.

SCHIZOAFFECTIVE DISORDER Combination of Schizophrenia and mood disorder. So pt hears voices, but not violent and just wanna be alone.

SCHIZOPHRENIA - 10 Fluphenazine & Haloperidol (both long acting and injectable) are the tx of choice in pts who suffer relapses due to tx non-compliance. Injection can be done outpatient and intervals (twice per month). ******The symptoms are 2 types, (+) & (-).

(+) Symptoms (-) Symptoms Hallucination Five "A"s: Delusion Affective Flattening (diminished emotional Disorganized behavior and responsiveness) speech Alogia (poverty of speech) Apathy (impaired grooming, unwillingness to perform activities) Asociality (social detachment) and Attention (impaired attention when interviewed) respond well to typical respond to Atypicals, Risperidone antipsychotics 1- Schizoid: Social detachment and restricted range of expressed emotions. 2-Schizotypal: Eccentric behavior and a reduced capacity for close relationship. They might believe in magical thinking and might have bizarre fantasy or believe in telepathy or 6TH sense. 3-Avoidant personality: hypersensitive to criticism. They fear ridicule. 4-Borderline personality has Splitting. 5- Schizophreniform: hallucinations, delusion, disorganized speech, catatonic or flattened affect. Symptoms must be there for at least 1 mo but < 6 mo. 6-Schizophrenia is like number 5 but symptoms last more than 6 months. ***Subtypes of Schizophrenia are: 1-Paranoid: Preoccupation with delusion, auditory hallucination w/o disorganized speech or inappropriate affect, they respond to pharmacotherapy. 2- Disorganized: disorganized behavior & speech and flat or inappropriate affect. 3-Catatonic: physical symptoms including immobility or excessive motor activity and assumption of bizarre postures. 4-Undifferentiated: mixed symptoms that don’t meet the criteria of other subtypes. ***Schizotypal is presents with odd behavior (like saying I have some powers) and no close friends. DDx is Schizoid are those have social detachment but no odd behavior (powers and things). DDx is Avoidant are those who want to be socially involved but are afraid of rejection. ****Schizophrenic pts have enlarged ventricular size, Decreased: cerebral mass, hippocampal mass, temporal mass and no change in cerebellar mass. ****The following S&S are indication for hospitalization of schizophrenic pts: Homicidal or suicidal ideation, grave disability, gross disorganization, agitated or threatened behavior. ****Catatonic (move, talk, and there is rigidity) Tx: Benzodiazepine (Lorazepam (DOC)). ****remember DDx b/w Schizophrenia and schizophreniform is duration of more then 6months.

SCLERODERMA CREST syndrome; Assoc w/ anti Scl-70 antibodies; Wegener assoc with C-ANCA. Polymyositis & Dermatomyositis are assoc w/ ANA and Anti Jo 1 antibody.

SCOLIOSIS Types are: Idiopathic 2- 3-Congenital Tx options: Neuromuscular (the MC) has 3 If MILD (<20 O) curve à types: Careful observation & follow Infantile <3yo up Juvenile <10 yo If 1ST time notice is >30O Adult >10yo give braces If initial notice is >40O Surgery is required. Dx: Bending over & Cobb's angle of scoliosis. Dx: Bending over & Cobb's angle of scoliosis. SEBORRHEIC DERMATITIS Dry scales and underlying erythema of scalp central face, interscapular area umbilicus and body folds. Assoc w/Parkinson's Dz. Suspect HIV in young pt with SD. Suspect Hepatitis C in pt with Lichen Planus.

SEBORRHEIC KERATOSIS Referred to as "barnacles of old age." Benign. Velvety or warty, greasy, with stuck- on appearance. Color from pink to black. Anywhere except palms and soles. Dx: Shave biopsy. Remove for cosmetic reasons.

SECONDARY to the SPINE Metastasis from carcinoma is the MCC malignant tumor of the skeletal system. In pts w hx of malignancy, back pain raises suspicion for bone metastasis. Progressive low back pain not relieved by rest and worst at night suggests vertebral body metastasis. Secondary METS to the BONE mainly arise from primaries carcinomas of the prostate, breast, lung, lymphoma multiple myeloma. Technetium 99 scintiscanning is the method of choice.

SEIZURES - 2 Generalized Status Absence Simple Complex Dx: Tonic Clonic Epilepticus Partial Partial (involves all multiple last a few focal focal seizure Initial: CT of brain) epileptic seconds motor followed by the head Characteristics: seizures NO sensory or transient or WITHOUT Aura (lights); one after postictal autonomic incomplete contrast when followed by the other confusion symptoms impaired a pt is presented stiffness & NOR LOC & no LOC. consciousness with impaired LOC. Next step: consciousness Tonic-clonic Tx: or seizures jerky moves, Diazepam CT w/ contrast biting the is usu. tongue, indicated if incontinence brain tumors and postictal or other confusion. masses (Toxoplasma, Lymphoma) are suspected. If the NON contrast CT excludes the hemorhage then Next step: MRI or CT WITH contrast

***Todd’s palsy is a transient hemiplasia that occurs after a seizure.

SELECTIVE IgA/IgG DEFICIENCY Pt presents with recurrent sinopulmonary infections and chronic diarrhea due to bacterial infection. Dx: Quantitative measurement of serum Ig will help determine Dx.

SEPTIC Abortion Is to be suspected in ALL abortions outside hospital who come back with pain and vaginal discharge. Management: Cervical and blood sampling, IV antibiotics and gentle suction curettage.

SEPTIC ARTHRITIS - 2 Acute inflammatory monoarticular arthritis in a previously damaged joint suggests SA. Leukocyte count of >50K or 100K in synovial fluid. ****Like Osteomyelitis in a child, SA is also hematogenous in origin and occurs after URI, MC organism in children is aureus and Strep. Characterized by: severe pain, leukocytosis, elevated ESR. Pt refuses to walk, keeps limb externally ROTATED. U/S guided aspiration should be done immediately. Dx: Fluid >100,000 Empiric antibiotics should be given immediately. **In Infants: Nafcillin + 3rd gen cephs and >5yo Nafcillin alone. It’s a true surgical emergency. Needs surgery and drainage immediately, a delay of 4-6 hrs can lead to AVN

SEPTIC SHOCK Septic Cardiogenic Neurogenic decreased systemic vascular If PCWP >18 means resistance due to significant Cardiogenic shock (Tension vasodilatation pneumothorax, CHF, Tamponade, arrhythmia).

Hyperdynamic circulation: Normal: MVo2 & Mixed Venous O2 concentration **************** To treat the induced metabolic acidosis: IV normal saline + Vasopressin + Abx. Use Sodium Bicarbonate is only recommended for pH<7.2, and then it’s only given to raise pH to 7.20 and then use other means to normalize it.

ELEVATED DECREASED ELEVATED DECREASED ELEVATED DECREASED *cardiac *systemic PCWP (too MVo2 output vascular much blood (increased O2 resistance; to pump due extraction by *RA to shock) hypoperfused pressure tissues) *PCWP

Hemorrhagic *Presents w/bleeding: happens in trauma setting, most probably from ruptured abd organs bleeding.

*Presents with 70/0 BP and CVP of 0. If pt is Unstable with suspected intra- abdominal bleeding the best dx procedure is Peritoneal Lavage. USG is actually the best option. The pt may ultimately need exploratory laparotomy but 1st step is DPL.

UNSTABLE STABLE Either ER U/S or Diagnostic CT is indicated in stable pts with suspected Peritoneal Lavage w/ IV fluids solid organ injury connected

****HYPOVOLEMIC SHOCK à 1st parameter to change is pulse rate. REMEMBER: Muffled heart sounds are common in severe hypovolemia & DOESN’T necessarily indicate Pericardial fluid, moreover Cardiac Tamponade is unlikely in the absence of JVD; so problem is most likely ruptured abdominal organ.

SEROUS OTITIS MEDIA The MC ear infection in pt w/AIDS. Characterized by: Hearing difficulty, dull tympanic membrane, air bubbles. DDX with Chronic OM is that COM has purulent aural discharge. Tympanic membrane: Thickened with calcified patches and perforation. Otosclerosis occurs in 3rd decade of life and there is absent of stapedial reflex. It’s limited to temporal bone.

SEVERE COMBINED IMMUNE DEFICIENCY (SCID) A life-threatening syndrome. Presents with recurrent sinopulmonary infection, oral candidiasis, persistent diarrhea, opportunistic and viral infections. Dx is confirmed by: Absent LN and tonsils, lymphopenia, absent thymic shadow on CXR, and abnormal T & B cells & natural killer cells DDx1: Common Variable Immune Deficiency or Acquired Hypogammaglubinemia: Is similar to Burton's, however less severe symptoms and at a later age like 15-35, Ig A/G/M/E may be decreased but no absence of B cells. DDx2: Bruton's Agammaglubulinemia, X-linked, Pt is a male infant asymptomatic until 6mo of age, then recurrent pyogenic infection (S. pneumonia, H. inf); Dx: Decreased Ig A/G/M/E along WITH decreased B cells DDx3: Wiskott Aldrich, X-linked Pt is a young boy with Eczema, thrombocytopenia and recurrent infection with capsulated germs Initial manifestation is petechiae, bruises, bleeding from circumcision or bloody stool. Low IgM/A/E levels, reduced T cells and platelets DDx4: Chronic Granulomatous Dz: Defect of phagocytic cells due to dysfunction of NADPH oxidase enzyme complex, leading to recurrent and uncontrolled infection with catalase positive organism, the MC infection are lymphadenitis, abscesses of skin and liver, Lymphocytes are normal. Dx: Nitro Blue Tetrazolium test

SHEEHAN SYNDROME Develops due to ischemic necrosis of pituitary gland. Impaired ADH secretion causes full blown Diabetes Insipidus.

SHINGLES After initial infection with VZV (chicken pox) latent infection is established in the sensory dorsal ganglia. Characterized by vesicular eruption that occurs in a dermatomal distribution. ******START EDIT SHOCK - 4 From FA: How to Dx shock?

1st question: If CO<5 If CO >5 2nd question: PCWP PCWP >18 3rd question: Is there fever? <18

HYPOVOLEMIC: CARDIOGENIC: FEVER (+) à FEVER (-) à Trauma TPX SEPTIC shock: NEUROGENIC or Blood loss Burns CHF Due to decreased ANAPHYLACTIC Tamponade systemic vascular shock: (Bee sting, Arrhythmia resistance due to meds, food (too much blood to significant allergy) . ****Hypovolemic pump due to shock) vasodilatation. Neurogenic: has shock, 1st parameter Can be caused by Hyperdynamic low MVo2 due to to change is pulse severe BB toxicity circulation leads to increased rate. elevated CO & oxygen Normal MVo2 extraction by therefore hypoperfused 4 stages depends on a) Elevated: CO tissues. Low LV degree of bld lost: b) Low: Systemic preload is also vascular resistance; characteristic. RA pressure and PCWP c) Normal: Mixed Venous O2 concentration.

. CLASS 1: 10% bld loss CLASS 2: 20% bld HEMORRHAGIC: Trauma setting, likely (about a unit) loss. Confused & from ruptured abdominal organs Alert but slight combative. bleeding. lightheaded. Normal Although mean If UNstable on IV fluids are connected: BP Unaffected: Skin & arterial BP is Either ER U/S or DPL on IV fluids are Organs. Pt responds normal, Narrowed connected. w/ tachycardia. (1st PP (systole- **Presents with 70/0 BP and CVP of 0. If response to diastole). The PP pt is Unstable with suspected intra- compensate in change is consistent abdominal bleeding the best dx hemorrhagic shock). w/ increased procedure is Peritoneal Lavage. USG is Physiologically this vasoconstriction. actually the best option. The pt may response is affected by Decreased Urine ultimately need exploratory laparotomy secretion of Output. Skin: Cool but 1st step is DPL. If pt is stable then CT catecholamines & an & moist. Mental is the best option for dx. increase in Status: fight or sympathetic tone flight. ***REMEMBER muffled heart sounds are common in severe hypovolemia & DONT necessarily indicate Pericardial fluid, moreover Cardiac Tamponade is unlikely in the absence of JVD. So problem is most likely ruptured abdominal organ CLASS 3 : 35-40% CLASS 4: blood loss & can’t if blood loss >40%. maintain BP. Maintain pt goes to coma & CO by further BP is incompatible increasing both HR w/ life & afterload. Mental status: stupor

SHOULDER DISLOCATION Tonic-Clonic seizures may cause POSTERIOR DISLOCATION of SHOULDER. It presents with internally rotated arm and pt can’t do external rotation of the arm, and there is intact sensation and reflexes. Anterior dislocation occurs with sensory loss and Pt can rotate the arm externally. Axillary nerve is the MC nerve injured in this situation.

SHY-DRAGER SYNDROME Characterized by 1-Parkinsonism, 2-Autonomic dysfunction (Postural hypotension, abnormal sweating, bowel or bladder control problems, abnormal salivation or lacrimation, Impotence or gastroparesis). 3-Widespread neurological signs. Always suspect if pt w Parkinson experiences postural hypotension, impotence or incontinence. Anti-Parkinson drugs -- ineffective, and Tx goal: Intravascular volume expansion. DDx: DM Neuropathy: can cause the symptoms but it happens in a pt not controlling blood sugar and it takes a while to develop.

SIADH - 3 Assoc w/small cell carcinoma of the lung. Severe hypoNa+ (especially w/ CNS syms like disoriented and irritable) requires aggressive moment with IV 3% saline +/- Furosemide. Rapid correction should be avoided because it can lead to Pontine Myelinosis. Hypotonic hypoNa+ with euvolumia, Low plasma osm and high urine osm, before Dx of SIADH is entertained; hypothyroidism and adrenal insufficiency should be ruled out. One of the causes of SIADH is NSAID therapy. DDx DI: polyuria, polydipsia, hyperNa+, low urine osm and high serum osm. **Tx steps:

Tx Reason for specific tx Step 1: Water Restriction (to manage hypoNa+)

Step 2: 3% Sodium Chloride solution If the pt Na+ < 120 or if he is seizing, (Emergency Tx) (hypertonic saline) to raise serum Na+ to 125

Step 3: Furosemide maybe added If the pt has evidence of fluid overload, Hx of CHF or is resistant to Tx Step 4:Chronic Tx may involve Lithium or Demeclocycline, which inhibit ADH action

SUMMARY of MANAGEMENT: HYPONa+ due to SIADH 1-Mild (Asymptomatic w/Na+ 120-130) Fluid restriction

2-Moderate (Asymptomatic & Na+ 110- Loop diuretic and Normal saline 120)

3-Severe (CNS symptoms) Hypertonic saline (3%)

SIALOLITHIASIS Sialolithiasis or calculus in the ductal system of salivary gland is MC in Submandibular gland followed by sublingual and parotid. Pt will have recurrent Sialoadenitis (infection of salivary gland). Sialolithiasis presents as postprandial pain and swelling. Stones in Wharton duct are radiopaque, XR is dx. Tx: dilation and incision of involved duct to remove the calculus.

SICK EUTHYROID SYNDROME Pts with any acute severe illness may have abnormalities of thyroid hormones and TSH in absence of any underlying thyroid abnormality. This is called SES. The MC pattern is a fall in total and free T3 and normal T4 and TSH levels.

SICK SINUS SYNDROME Test#6. Q=22. Tx: Permanent pacemaker

SICKLE CELL DZ - 6 Sickle cell trait is MC assoc w/ Painless hematuria in black male *****Supplementation of Folic acid is recommended in ALL pts to prevent occurrence of aplastic crisis. Aplastic crisis happens for 2 reasons: 1-Folate def 2-Infection with Parvovirus. ****Pts with SC encounter constant clumping of sickled cells, leading to repeated micro infarctions in the spleen. By 2-3 of age, they have functional asplenia. Since one of important functions of spleen is to remove CAPSULATED organism, like Pneumococcus, and H. Influenza, pts will be at risk of infection with these organisms. For this reason, antibiotic prophylaxis and vaccination against Pneumococcal and H. Inf & Influenza are given standard to pts with functional asplenia. If a 5-yo boy presents with high-grade fever, hypotension, altered mental status, elevated WBC and Bandemia, it's sepsis due to Pneumococcus. *****When pt present with acute severe anemia, may be Aplastic Crisis, Splenic Sequestration Crisis or Hemolytic Crisis. ****Acute Chest Syndrome: Chest pain, fever and infiltrates on CXR -- One of the MC complications of SC. SICKLE CELL DZ MEDICAL INTERVENTIONS: Acute Sickle Crisis—Tx: Exchange Transfusion Hydroxyurea Acute Vaso- Aplastic Crisis Splenic Sequestration Crisis or Occlusive Crisis Hemolytic Crisis MOA: increases HbF levels. (for prevention) May cause: MCC: B19 result In pts who have not yet had HbF fxn: retard sickling STROKE from transient Splenectomy; vasoconstriction leading to decreased PRIAPISM arrest of & pooling of bld in spleen. sickling and less Acute Painful erythropoiesis There’s marked decrease in occlusion of vessels by Crisis and mf assoc w/ [Hb] but persistent sickled cells. (decrease infections; reticulocytosis Pt develops freq-pain crisis) sudden drop of rapid splenomegaly, severe Use: painful crisis HbF hypotensive & shock. happens frequently concentration that interrupts life and absent reticulocytes. May cause acute First step Acute Pain painful crisis. Crisis: Hydration & Tx: Blood Tx: Splenectomy Adequate hydration opioid analgesics. If transfusion & O2 therapy is pt has frequent (If aplastic necessary to end the acute crisis, then crisis occurs) episode. Hydroxyurea is Folic acid helps indicated w/erythropoies is, prevents aplastic crisis.

SIDEROBLASTIC ANEMIA Results from defective heme synthesis, MCC: Pyridoxine-dependant impairment. Especially if pt is taking Isoniazid. It manifest as hypochromic microcytic anemia simulating iron def anemia. But iron studies reveal elevated iron and increased TIBS (DDx). Tx: Pyridoxine (B6). MCC: Chronic Alcoholism. Smear: BLUE Iron BLUE granules around the nucleus.

SIDS Infants should be put on their back (SUPINE) while sleeping to reduce mortality. They are the leading cause of infant mortality from 1mo-1yo SINUSITIS, ACUTE BACTERIAL MC Pediatric: Strep pneumonia, (#2) H. Influenza, (#3) Moraxella catarrhalis. Children Dx: 250/L, SAAG >1.1 (Serum to Ascites Albumin Gradient) and GNB in a cirrhotic pt is highly suggestive of SBP. Presence of WBC/L >10000, multiple organism, or failure to improve after 48 hr therapy is suggestive of 2ary Peritonitis. Suspected SBP should treat empirically with Cefotaxime or Ampicillin. Recurrence is very common.

SJOGREN’S An autoimmune chronic dysfunction of exocrine glands. Pt develops dental carries due to salivary insufficiency. Xerostomia leads to difficulty swallowing and talking. Eye show keratoconjunctivitis. Lab: anemia, leukopenia, eosinophilia and elevated ESR. Lip biopsy is the ONLY specific Dx technique. SLE - 8 MCC of death is chronic renal failure. ****DDx b/w SLE and RA: SLE RA Arthritis: NON-EROSIVE EROSIVE (Narrowing of the space and juxta articular erosions) Kidney is damaged due to immune- complex deposition (type II) ***When there is evidence of SLE Renal Involvement: Due to immune complex- kidney failure in SLE, the next step mediated glomerular injury. These complexes are is RENAL BX and therapy is directed primarily composed of Anti-DsDNA antibodies. to the pattern of the glomerular Remember: Anti-Sm antibodies remain elevated involvement. even when dz is no longer active. There are 5 patterns. Type I & II no Wrists, MCP, PIP: Symmetric swelling x 6 wks need for tx. Type II & IV tx w/ immunosuppressants; Mainstay of tx is IV methyprednisone. If no response then immunosuppressants (Cyclophosphamide) is given. In SLE pt with active Nephritis OCP should be avoided.

SLE presents wi th 5 types of renal ****Tricky SLE Q: if the vignette says no anti- involvement: SMITH antibodies that doesn’t rule out SLE because 1-Mesangial: The earliest and least 30-40 of pt don’t have it. SLE pt could have: severe. musculoskeletal, hematological, skin, lungs, kidney 2-Focal: More severe than and serious membrane problems. If a pt has 4 or Mesangial; there are proliferative more it’s Dx. DDx with Mixed CTD is Anti-RNP changes and areas of necrosis. antibodies 3-Diffuse Proliferative: MC type & severest type & worst prognosis. **************************************** S/S: Hematuria, proteinuria, ****Scarring Alopecia is the skin related problem in renal insufficiency, HTN, SLE pts. hypocomplementemia, marked elevation of anti-dsDNA. **************************************** 4-Membraneous GN: preserved Anti-RO antibodies are assoc with Neonatal Lupus. Renal fxn, thickened BM, and subepithelial deposits are present, a better Px than Diffuse. 5-Sclerosing type: Presents healing of previous inflammatory damage, urine is normal and immunosuppressive drugs are not effective since there’s no inflammation.

"Goodpasture" damage is caused by type III. "Methacillin interstitial nephritis" caused by IgE (Type I). "DM & Hypertension" are caused by non-immune reasons.

SLEEP APNEA 1 ST line of Tx : Weight loss, avoidance of sedatives (benzos) and alcohol, and avoidance of supine posture during sleep. Other Options: Positive Continuous Airway Pressure. If all fails then Tracheostomy is the option. Dx is with polysomnography.

SLEEP TERROR DISORDER Episodes of sudden fearful waking. Later they don't remember it. DDx: Nightmare disorder: pt remembers in detail the dream.

SLIPPED CAPITAL FEMORAL EPIPHYSIS - 2 SCFE is a result of failure of the growth plate b/w femoral neck and femoral head, resulting in displacement. It’s seen in adolescence with overweight problem. Pain & limp are presenting complains. Dx: XR: Must contain Hip, and both front 'AP' and Lateral 'frogs' views. SCFS can progress to AVN if untreated; XR will show bone cyst or sclerosis. If AN is in advanced stages, XR shows collapse of the bone. ****A medical emergency the prompt surgical intervention is needed to prevent the 2 complications of AVN of the femoral head and Chondrolysis. Tx of Choice: Urgent Surgical fixation of hips w/screws

SMALL CELL CARCINOMA OF LUNG Assoc with SAID. SCC has usually metastasized by the time it’s discovered.

SMOKING CESSATION Use Bupropion.

SOCIAL PHOBIA pt is isolated because he is afraid of being in public; He can speak in front of people and gets anxious even in small parties. Tx of choice is Assertiveness training (Cognitive & Behavior Therapy or CBT) plus SSRI.

SOLITARY PULMONARY NODULE T9Q8

SOMATIZATION DISORDER - 2 Pt presents with pain and symptoms in: 2 GIT, sexual or reproductive symptoms, and 1 pseudoneurological symptom (HA, blindness, deafness, weakness). It presents before age of 30 and in mostly females. *** If pt asks for CT, tell her you would like to see her on regular basis before CT scan.

SPECIFIC PHOBIA - 2 Pt is afraid of swimming pool. The best approach is Systemic Desensitization. Beta-blockers are for Performance anxiety. Benzodiazepines are for acute panic attack. Cognitive-Behavior therapy is for chronic Panic attack and GAD. **** 9 yo doesn’t go to school and he says he s afraid of Dark clouds. Tx is CBT (cognitive-behavioral therapy) that repeatedly exposure to the object.

SPHEROCYTOSIS - 2 Due to RBC membrane defect mostly from Spectrin deficiency. In PNH defect is in Decay Accelerating factor. In Thalassemia Defect: Absence Beta chain synthesis. Malabsorption results in B12 and Folate deficiency that is the cause for Macrocytic anemia. In Sickle Cell: is substitution of Glutamine for Valine in polypeptide chain. ****Autoimmune Hemolytic Anemia: Pallor, Jaundice, elevation of indirect bilirubin & reticulocyte count & LDH are all indicative of AHA. SPLENOMEGALY is assoc with EXTRAVASCULAR HEMOLYSIS, while AHA: DECREASED HAPTOGLOBIN is indicative of INTRAVASCULAR HEMOLYSIS. Hereditary Spherocytosis have Extravascular hemolysis. It’s an autosomal dominant so there MUST be family Hx in vignette. MCHC is elevated, Osmotic Fragility test is positive, but it’s ALSO positive in AHA. . Now in AHA Coomb's test is also positive. But since it’s not always positive in all cases of AHA we do Micro- Coombs test to confirm the Dx of AHA. Bottom Line: Spherocytosis may also be seen with AHA and Negative family hx and positive Coombs test; these DDx AHA from Spherocytosis.

SPIDER BITES - 2 1-Black Widow spider: causes acute abdomen (abdominal rigidity and muscle cramps), develop N&V and initial site of bite is not seen. Tx: Combination of Muscle relaxant + Calcium Gluconate. 2-Brown Recluse spider: Produces extensive localized skin necrosis resembling Pyoderma Gangrenosum. ****Brown spider bite, pt has an ulcer on the thigh; the MC complication: Deep ulcer with necrotic center and erythematous halo. Tx of choice: Local excision

SPINAL CORD COMPRESSION Or Cauda Equina Syndrome; Pt presents with absent rectal tone, urinary incontinence, motor and sensory loss in extremities. This is a surgical emergency. Do MRI to determine the site of compression. It may occur in males repeatedly due to prostate cancer that has metastasized to spinal column.

SPINAL CORD INJURIES

Anterior Cord Syndrome Central Cord Syndrome Brown Sequard Syndrome BURST fracture of the elderly due to Lateral Hemisection vertebra hyperextension of the neck injury total loss of motor Burning pain and Ipsilateral motor and function below the paralysis in upper proprioception and level of lesion with loss extremities with relative contralateral pain loss of pain and sparing of lower extremities below the level of temperature. On both *disproportionately lesion. sides below the lesion greater motor impairment preservation of sensations in upper compared to carried by the posterior lower extremities, columns (fine touch and BLADDER DYSFXN, proprioception) variable degree of sensory loss below the level of injury MRI is the best Dx method SPINAL STENOSIS, LUMBAR - 2 It can present with Neurogenic claudication: calf pain when he stands up and walks; Neurogenic claudication from spinal stenosis. It’s POSITIONAL Intermittent Claudication: NO pain at rest while standing or in certain position, it happens only pt walks. Dx: MRI. DDx1: Cauda Equina Syndrome: (tumor) causes urinary retention or overflow incontinence. DDx2: Leriche Syndrome: presents with atherosclerotic vascular dz, impotence and intermittent claudication. DDx3: Arterial Insufficiency is not positional. Dx: Arteriography and Doppler.

SPLENIC CONTUSION Assoc with fracture of the left lower ribs. Breath sounds are normal and no respiratory distress.

SPLENIC TRAUMA Immediate management caused by blunt abdominal injury depends on hemodynamic status and response to IV fluids. *****If initially, UNSTABLE, but improves with fluid, Next best step à CT. *****If initially UNSTABLE and IV FLUID don’t help à EMERGENT EXPLORATORY LAPAROTOMY indicated. If CT shows no operation is required, then admit to surgical ICU for monitoring.

SPONDYLOLISTHESIS Is a developmental disorder characterized by a forward slip of a vertebra, that usually manifest in pre-adolescent children, Back pain, neurological dysfxn (urinary incontinence) and a palpable step-off at the lumbosacral area are present if the dz is severe.

SPONTANEOUS BACTERIAL PERITONITIS Always suspect SBP in cirrhotic pt with fever and ascites. SBP is peritonitis in the absence of an apparent source of infection. SBP is almost always seen in adults 2ary to severe cirrhosis especially alcoholic cirrhosis. It almost always occurs in pt with ascites. Characterized by growing a single bacteria in ascites fluid, usually E. Coli. HIGHLY SUGGESTIVE of SBP Clinical features: unexplained fever in a pt with cirrhotic ascites and abdominal pain. Ascites fluid containing PMN>250/L (Serum to Ascites Albumin Gradient) SAAG >1.1 GNR in a cirrhotic pt is highly suggestive of SBP. Suggestive of SECONDARY PERITONITIS à10,000 WBC/L, multiple organism, or failure to improve after 48 hr therapy. Suspected SBP should be treated empirically: Cefotaxime or Ampicillin with an aminoglycoside. Recurrence is very common. SPOROTRICOSIS Gardener’s dz, pustules and painless ulcers at finger tip. Tx: Potassium Iodine

SQUAMOUS CC LUNG HyperCa and hilar mass in a smoker AGE > 45 yo is most likely SCC of lung. Even though hypercalcemia usually develops due to metastatic bone involvement, it’s also because PTHrP (r=related, p=protein). It’s like PTH and bind to same receptor and increased absorption of Ca++ in distal tubules.

SQUAMOUS CC SKIN - 5 The single most important factor is sunlight exposure. Associated with: Leukoplakia (a whitish patch in tongue that is hard to remove and is granular, an incisional biopsy or cytology should be done). Appears as NONHEALING ulcer on the LOWER lip. Characterized by: invasive cords of squamous cells with Keratin pearls. DDx: includes many types of benign and malignant lesions, including basal cell carcinoma, keratoacanthoma, actinic keratosis, verruca vulgaris (small usually painless wart), and seborrheic keratosis. ***Whenever an open ulcer fails to heal after a period, you need to biopsy to ensure that it has not degenerated into SCC. These ulcers are known as MARJOLIN's ulcer. Also remember Actinic Keratosis is a precursor to SCC. **** When ulcer doesn‘t heal, suspect SCC, next step is PUNCH biopsy. If (+) SCC, WIDE excision is the Tx of choice. ****Actinic Keratosis turns into SCC.

STATIN INTOLERANCE/TOXICITY CPK elevation > 10 times in presence of myalgias/myopathy. Rhabdomyolysis in an Acute renal failure could be a consequence. Tx: Stop drug & supportive therapy for Rhabdo.

STATUS EPILEPTICUS An emergency. Mgmnt steps: 1-Place in LATERAL POSITION with mandible pushed forward. 2-Start medication 3-if medication failed after 30 min, then general anesthesia and intubation is indicated.

STEVEN JOHNSON SYNDROME Target-shaped mucocutanous lesions and systemic signs of toxicity. Pathology involves immune complex-mediated hypersensitivity.

STILL’S DZ, ADULT Is a variant of RA. Pt presents with 20-30yo, high-spiking fevers with CHARACTERISTIC salmon-colored rash, arthralgias, arthritis, Leukocytosis. DDx1: Parvovirus (Slapped cheek dz), malar, erythematous rash, arthralgia or arthritis. DDx2: Henoch-Schonlein Purpura: in children, rash, abdominal pain, arthralgias and renal dz. Rash is pruritic and involves lower legs or buttocks. **DDX2: RF, PECCS. Erythema Marginatum is Evanescent (tending to vanish) erythematous non-pruritic mostly on the trunk.

STOMACH CANCER The only malignancy that has decreased universally. The reason is not known.

STRABISMUS The MCC of amblyopia (decreased visual acuity) is strabismus. The MC type of strabismus is esodeviation (medial deviation of the eye). Tx: Cover normal eye.

STRANGER ANXIETY When a child is left in unfamiliar places (daycare). From 6-8 months and peaks in 12-15 months. DDx: Separation Anxiety is with older child when separated from a love one.

STRESS FRACTURE Bone pain at rest, worsens with exercise, swelling and point tenderness, XR is normal at initial stage and MRI is dx. Tx: Restrictive weight-bearing with short leg cast, healing in 3-4 weeks. It occurs in young dancer’s legs.

STROKE - 6 Hemorrhagic Ischemic intercerebral or 2ND to *If presents within 3h of subarachnoid thrombosis, ischemic attack, GIVE tPA embolism or (Tx of choice) (after CT systemic scan) Don’t try to regulate hypoperfusion BP 1ST, it may impair auto- regulation & worsen; Streptokinase won’t help either.

****HTN is the highest risk factor for Stroke, more than smoking, alcohol, hypercholesterolemia. MANAGEMENT OF POSSIBLE STROKE: ****Pt presents w/HEMIPLASIA #1 Differentiate b/w Hemorrhagic and Ischemic stroke à Do CT WITHOUT contrast then #2 Give medication. if it’s ischemic (thrombi) then give ASA; then do CAROTID DOPPLER & TEE to evaluate source of embolism.

Blood supply of the brain: INTERNAL ANTERIOR MIDDLE CEREBRAL: CAROTID: CEREBRAL: Effects Upper>Lower: Anterior Effects Contralateral motor and vasculature Lower>Upper: sensory, homonymous : Contralateral motor hemianopsia and sensory deficit If DOMINANT (left): aphasia, Urinary incontinence, NONDOMINANT (right): LEFT gait ataxia neglect synd & anosognosia (can’t tell there’s an injury to the body). Posterior paired Vertebral A join to PCA: Homonymous Hemianopsia, ataxia Vasculature make Basilar A which w/o agraphia, visual hallucination : divides to make (Calcarine cortex), sensory symptoms Posterior Cerebral A (thalamus), 3CN palsy w/paresis of vertical eye movement and motor deficit (midbrain)

LACUNAR infarcts THALAMIC stroke Expressive aphasia small non-cortical infarcts Involves VPL part of Frontal Parietal caused by occlusion of a thalamus that transmits Dominant dominant branch of a cerebral artery sensory info from Contralateral part of body

Risk factors: HTN, DM or Hemianesthesia (no Presents Can’t Polycythemia. Usually feeling of sensations) with understand don’t produce both accompanied by hemiparesis what is motor and sensory hemiparesis, athetosis. and speech being said symptoms but rather Dysesthesia (numbness difficulty; to him have well recognized and tingling burning broken (Dyscalculia, syndromes, like pure feeling) of the area words Dysgraphia) motor hemiparesis, pure affected by the sensory sensory stroke, dysarthria loss is characteristic; is (clumsy hand or ataxic called thalamic pain hemiparesis) phenomenon

STURGE-WEBER SYNDROME: A neurocutanous condition. It’s autosomal dominant therefore doesn’t affect multiple generations. Pt will have a cerebral lesion on the same side as facial nevus; exophthalmos due to ICP. Dx is CT. The cerebral lesions are nevi involving the leptomeninges and are thus similar to the facial lesions. *****Cavernous unilateral hemangioma is another presentation. Skull XR: 2 yo shows gyriform intracranial calcifications that resembles the tramline. Tx: Control seizure and reduce ICP w/Laser therapy w/Argon to remove skin lesions.

SUBACROMIAL BURSITIS Inflammation of the subacromial bursa. It occurs in athletes as part of impingement syndrome: Characterized by shoulder pain, which is absent at rest but present at overhead activity. ROM: Limited by pain. (+) Neer sign (pain on passive internal rotation and forward flexion at shoulder) is present. Confirms Dx: U/S or MRI. Tx: Conservative-NSAID & physical therapy. DDx: Tear of long head of BICEPS TENDON, which will lead to bulging muscle mass in the middle of the arm.

SUBACUTE COMBINED DEGENDERATION T9Q42. Tx is B12

SUBARACHNOID HEMORRHAGE 4 6/3 MOST FREQUENT CAUSE: Rupture of aneurysm. HTN is MCC for Intracerebral Hemorrhage. They are most prone to rupture when >7mm. Pt should be evaluated with cerebral angiography and treated surgically. AVM is the MCC of SAH in children, the hx of seizure and migraine-like HA is characteristic. ****Vasospasm is the major cause of morbidity and mortality in pts with SAH. CCB (Nimodipine) are used to prevent spasm in these pts. ****SAH or "cerebral-salt wasting syndrome". Pathology involves 1-SIADH (inappropriate vasopressin secretion) which causes water retention. 2-An increased secretion of an atrial/brain natriuretic peptide. SIADH also results in hypoNa+ for which water restriction is the Tx of choice. So HypoNa+ is one of the important complications of SAH.

SUBCONJUCTIVAL HEMORRAHGE. Ophth. 6/3 Redness in the eye; due to hard rubbing or trauma. It’s benign and heals spontaneously.

SUBDURAL HEMATOMA Tear of bridging veins. Picture shows crescent-shaped, semi-lenticular hematoma. MC in Elderly & Alcoholics. Tx: Conservative if no midline shift is present on CT. Tx: Prevention of ICP by head elevation, hyperventilation (causes vasoconstriction and thus decreases cerebral BF), and if needed acetazolamide and MANNITOL. If there is a midline shift then Craniotomy is indicated but its assoc with grave prognosis. DDx1: Epidural Hematoma where Middle Meningeal A. is injured. Biconvex hematoma in NON-CONTRAST CT. Lucid interval. DDx2: Hypertensive Hemorrhage Putamen & Thalamus. DDx3: Subarachnoid Hemorrhage, rupture of aneurysm.

SUBLIMATION A mature defense mechanism that allows for unacceptable impulses to be channeled into more acceptable activities. Like a man w/fiery temper who channels his anger into athletic pursuits.

SUMATRIPTAN TOXICITY C/I: include Prinzmetal Angina, CAD, pregnancy. So if a female of child-bearing age wants it make sure she is not pregnant. SUPERFICIAL THROMBOPHLEBITIS: Dull pain in the region of the affected vein, erythema, induration and tenderness along the vein. High fever chills and rigor is suggestive of septic phlebitis. Presence of edema and deep calf tenderness is characteristic of DVT. ST is not risk factor for Pulmonary Embolism. Localized ST is treated with bed rest, heat and NSAID

SUPERIOR VENA CAVA SYNDROME Pt presents with Venous congestion of face and arms. The MCC of superior vena cava obstruction is Bronchogenic carcinoma (Small cell tumor) (smokers). Today Angioplasty with stenting is tx of choice.

SVT Narrow QRS, HR>140, regular, loss of P wave. UNSTABLEàCardioversion. STABLEà VAGAL maneuvers initially, if failed à IV Adenosine. Verapamil is 2ND DOC.

SUPRACLAVICULAR FRACTURE It compromises brachial artery resulting in brachial artery pulse loss.

SYMPTOMATIC BRADYCARDIA Pt has HR of 40, DIZZINESS, LIGHTHEADED, clammy extremities, but NO DYSPNEA or CHEST PAIN nor HYPOTENSION. He is having If severe symptomatic bradycardia à IV Atropine. If that didn't workà TRANSCUTANEOUS PACING. If bradycardia & HYPOTENSION à EPI Remember Adenosine à SUPRAVENTRICULAR TACHYCARDIA SYNCOPE - 3

Exertional Syncope of Vasovagal Syncope due Situational Syncope due (effort) cardiac etiology (vasodepressor) to PE syncope to seizures syncope syncope cardiac typically Precipitated by indicates Usual abrupt onset outflow begins & ends unpleasant massive scenario: & associated obstruction, suddenly and physical or pulmonary middle-age w/ muscular mainly due spontaneousl emotional vascular man LOC jerking or to aortic y MC d/t an stimuli (e.g. obstruction immediately convulsions, stenosis arrhythmia pain, fright, after incontinence, sight of bld) urination or tongue biting during coughing fits Usually in the often assoc Pathophys: upright posture, w/ dyspnea Autonomic & is often tachypnea Dysregulation preceded by chest explained by vagally discomfort staining or mediated cyanosis rapid warning hypotensio bladder symptoms n emptying Dx: Upright tilt table testing which includes Carotid sinus massage.

Know basic pathophys mechanism and different types of Syncope. MCC: pathophys basis for syncope is an acute decrease in cerebral blood flow (with resultant cerebral hypoxemia) 2ND to decreased cardiac output; arrhythmias, including conduction abnormalities, are the most frequent cause.

SYNOVITIS of the HIP Bed rest with the hip joint in a comfortable position is tx of choice.

SYPHILIS - 4 Once Dark field microscopy shows the spirochete and its positive, no need to do VDRL or FTA-ABS. But since the pt is at risk of HIV we need to do ELISA for HIV screening. ****PRIMARY: Presents with Painless, shallow CHANCRE ulcer WITH PUNCHED OUT BASE and ROLLED EDGES and painless bilateral lymphadenopathy. Best dx test: Dark field microscopy. **Secondary: presents with Condylomata lata, highly contagious. ****** IF allergic to Penicillin, give Oral Doxycycline. SYRINGOMYELELIA Suspect in a pt with upper extremity areflexia weakness and associated anesthesia in a "cape" distribution. When syringomyelia is associated with Arnold-Chiari malformation, there is caudal displacement of cerebral tonsils through the foramen magnum

SYSTEMIC SCLEROSIS The cause of pulmonary complication is interstitial fibrosis not lightning of the skin. Prolonged oral administration (> 1.5 yr) of penicillamine (0.5 to 1.0 g/day) can reduce skin thickening. For renal disease, ACE-I are the DOC.

TACHYCARDIA VENTRICULAR Regular (Wide Complex) Ventricular tachycardia has 2 types of tx. 1-If pt is hemodynamically stable (BP is normal, K normal, no bleeding) à IV Amiodarone or Lidocaine (alternative). If Unstabilize à cardioversion is choice. Digoxin is C/I in VT. It’s used for Atrial Tachy. For SVT Carotid massage is choice.

TAMOXIFEN - 3 An anti-estrogen drug used for breast cancer. When used as adjuvant therapy for early stage disease it reduces the risk of recurrence of original cancer and new cancer in other breast. However it increases the risk of: 1- endometrial (lining of Uterus) and Uterine Sarcoma. ***It reduces the risk of breast cancer in those who are at increased risk for developing breast cancer, IT’S PROVEN. SEE RALOXIFENE. ****It increases the risk for endometrial cancer by 1% and ONLY in postmenopausal women. It decreased risk of breast cancer, so overall it reduces mortality rate. It also decreases risk factor in the opposite breast. It protects against osteoporosis. However it causes hot flashes and vaginal dryness due to its anti-esterogenic effect. Remember its mixed agonist-antagonist on estrogen receptors.

TAY-SACHS DZ: Defic: Hexosaminidase and accumulation of GM2 gangliosidase, particularly in CNS. Pt presents with hyperacusis, MR, seizure, cherry red macula but NOT hepatomegaly or lymphadenopathy.

TB - 2 1- Induration of 5 or > is (+) in: Close contacts of TB pt, HIV pt, Organ transplant, chronic steroid therapy. 2-Induration of 12 or > is + in: Recent immigrants, IVDA, homeless person, prisoners and healthcare workers. Once PPD is positive, it does not mean pt has TB, they have to undergo CXR. If TB is diagnosed then full therapy, if TB is excluded then 9 months of Isoniazid prophylaxis. TB is the MCC of Constrictive pericarditis in immigrants. It should be considered in pt with unexplained elevation of JVP and hx of predisposure. *****Erythema induratum are nodules in the shins and calves. They are small tender erythematous nodules. TCA DRUG TOXICITY MCC of hospitalization and death due to excessive ingestion of prescription drugs. Pt with TCA overdose presents with anticholinergic, CV and neurological symptoms. CV SE: prolonged QRS and AV block. Also dry mouth, dilated pupils, decreased bowel sounds, urinary retention, constipation, tachycardia, flushed skin and hyperthermia. It’s been realized that QRS interval more reliably predicts the level of toxicity than the serum or urine drug levels.

TCA INTOXICATION - 4 T9Q15. Tx: Sodium bicarbonate prevents arrhythmia by alleviating cardio- depressant action on sodium channel. EKG: QRS widening; It also helps correct acidosis. If pt presents with seizures that need tx - give Diazepam.

TENNIS ELBOW or Lateral Epicondylitis is condylitis about the origin of extensors of forearm. Characterized by point tenderness over the lateral epicondyle of humerus and exacerbation of pain by extension of the wrist against resistance (hitting the ball) DDx: Radial Tunnel Syndrome which could coexist, pain is produces by simultaneously extending the wrist and ring finger while the long finger is passively flexed by the examiner.

TESTICULAR CANCER - 2 1-Seminoma: elevated Placenta Alkaline Phosphatase. 2-Embryonal: elevated Alpha Feto Protein (AFP). 3-Choriocarcinoma: elevated beta-hCG. Once the dx of carcinoma is made, U/S shows solid nodule, then initial mngmt is Orchiectomy. Trans-scrotal Bx and FNA is C/I because it might spread lymphatically or hematogenously. ****Leydig cell tumors are MC type of testicular sex cord stromal tumor. Testosterone and Estrogen are markedly increased with 2ary inhibition of FSH & LH. Pt presents with Bilateral Gynecomastia. DDx1: Choriocarcinoma: beta hCG is increased. DDx2: Seminomas contain Syncytiotrophoblastic giant cells.DDx3: Yolk sac tumors show increased AFP.

TESTICULAR FEMINIZATION Defect of absence of androgen receptors resulting in feminine phenotype with 46XY genotype. The MIF is produced by the gonads, so the uterus, vagina and tubes are absent. Breast develops due to peripheral production of estrogen, whereas axillary and pubic hair does not. Tx: Resect testicles and make vagina.

TETANUS GUIDELINES Hx of Tetanus Immunity Clean Wounds Dirty-looking wounds =3 dose of tetanus toxoid in past TT: Yes if last dose >10y ago, TIg: No TT: yes if last dose>5y ago, TIg: No

TETRACYCLINE TOXICITY A5- Photosensitivity. TETRALOGY OF FALLOT - 2 Most prominent feature: Cyanosis that rarely improves with oxygen. Classic presentation: Squatting that improves cyanosis. "Tet" spells are hypoxic episodes characterized by rapid breathing. Immediate Tx: Oxygen & put the child in a Knee-Chest position; followed by fluids, morphine, propranolol. TOF is a Cyanotic (early) condition. ASD & VSD aren't cyanotic (late). ****Pansystolic murmur, Hepatomegaly.

TESTICULAR FEMINIZATION Defect or absence of androgen receptor results in feminine phenotype with 46XY genotype. MIF is produced by gonads, so uterus and vagina are absent. Breast develop because peripheral production of estrogen, whereas axillary hair and pubic hair does not. Tx is testicular resection at puberty and creation of a new vagina. Presents with amenorrhea, developed breasts, absent pubic and axillary hair, absent internal reproductive organs and a 46XY karyotype.

THEOPHYLINE TOXICITY 1-CNS stimulation (HA, insomnia), 2-GI (N, V), 3-Cardiac toxicity (arrhythmia)

THIAZIDE SE Hyper GLUC= Hyper 1-Glycemia, Lipidemia, Uricemia, Calcemia. HypoK+ and HypoNa+

THIORIDAZINE TOXICITY - 2 Unlike other antipsychotics, thioridazine is assoc with cardiac arrhythmias. Symptoms of Thioridazine OD: Deep sleep, coma, abnormal involuntary movements, hypotension, tachypnea and arrhythmias. EKG: Prolonged QRS. Pt needs sodium bicarbonate. ****Antipsychotics like Thioridazine, galactorrhea 2ary to Dopamine blocking effect. Pt presents with lactation and menstruation irregularity.

THORACIC OUTLET SYNDROME Refers to compression of neuro-vascular structures supplying upper extremity. Pain wakes up the pt from sleep. There is paresthesias and weakness of fingers. Vascular involvement presents with pallor, pulselessness and coldness. Dx cause of compression: CXR, MRI and angiography. Conduction velocity studies identify the site of compression and overhead pulley exercise helps to relieve compression.

THREATENED ABORTION - 3 Hemorrhage before 20 week. Cervix is closed, NO fetal tissue passage, fetal heart if normal, 25% of women have this. When the pt comes to you 1ST step: Make sure fetus is alive. Once that is fulfilled, mngmt: Reassurance & performance of USG 1 wk later. Tx: Reassurance & outpatient follow up. DDx1: Incomplete abortion, some tissue is evacuated, cervix is dilated. DDx2: Complete abortion: whole conceptus passes though cervix. Cervix is closed. USG shows empty uterus. ****Complete abortion is when product has come out and cervix is closed with blood in vaginal vault. DDx3: Inevitable abortion: low abdominal cramp radiated to the back, dilated cervix. USG shows ruptures or collapsed gestational sac with absence of fetal cardiac motion. ****Cerclage is used to tx or prevent 1st trimester abortions when the cause is incompetent cervix.

THROMBOPHLEBITIS Characterized by palpable, indurated, cord-like, tender, subcutaneous venous segments, low fever.

THYMOMA- 2 ANTERIOR mediastinum MIDDLE mediastinum POSTERIOR mediastinum CT: Thymoma Pericardial cyst All Neurogenic tumors (Neuroblastoma) assoc with Red cell aplasia which is everything except RBC, ESR, Hct, Hb and reticulocytes are normal

THYROID CARCINOMA MC cancers PAPILLARY FOLLICULAR ANAPLASTIC MEDULLARY Carcinoma Carcinoma Carcinoma Carcinoma (solid) MC thyroid cancer accts for about 15% of accts for 10% or may occur (60 to 70% of all thyroid cancers less of thyroid sporadic (usually thyroid cancers) cancers unilateral) or as familial (frequently bilateral)

F > M MC in elderly mostly in elderly & autosomal (2-3x greater) women slightly dominant more than in men

More frequent in the DDx w/ ADENOMA is that rapid and painful young; but more cancers demonstrate enlargement malignant in elderly; invasion of capsule and MC if hx of radiation BVs

Hurtle cells exist. Encapsulated W/OUT Hurtle cells exist Psammoma bodies distinctive nuclear features. Rare LN involvemt Follicular Ca is rare, unlike papillary

FNAB: Lg cells w/ Dx: FNA, but FNA a proliferation of ground glass can’t ddx b/w parafollicular cells cytoplasm & pale Follicular cancer (C- cells) produce nuclei w/central and Follicular excessive amts bodies and central Adenoma of calcitonin, a grooving. hormone that can lower serum Ca & phosphate (PO4)

Prognosis is excellent more malignant than about 80% of Total even with metastasis papillary carcinoma; patients die within thyroidectomy is spread hematogenously 1 yr of diagnosis). indicated, even if with distant metastases bilat involvement is not obvious.

THYROID NODULES - 2 MCC: COLLOID (benign), 2nd MC is FOLLICULAR adenoma (benign). Dx: First step: Measure of TSH; the subsequent steps (T4, T3) are all dependent on TSH levels.

COLLOID FOLLICULAR Adenoma MC type 2ND MC type invasion of the capsule and blood vessels is required It’s almost impossible to ddx Follicular ADENOMA from Follicular CANCER

. THYROTOXICOSIS one of the MC causes of thyrotoxicosis with reduced thyroid uptake is Subacute Lymphocytic (painless) Thyroiditis. Leakage of thyroid hormones into the circulation due to inflammatory damage to the thyroid follicles results in Thyrotoxicosis. Most cases happen postpartum. Other causes of TT with low radioactive iodine uptake are 1-Subacute granulomatous (De Quervain) thyroiditis (Assoc with intense pain in thyroid), Tx is NSAID. 2-Levothyroxine overdose, 3-Iodine induced TT.

TIA – 4

Embolic TIA Atherothrombotic TIA Presents: focal neurologic deficits (right-sided weakness, expressive aphasia) (MS might show same way but CT shows it)

PROLONGED & SINGLE, last for HRS recurrent and shorter in duration, minute

Tx includes avoidance or correction of risk factor like smoking, HTN and Hypercholesterolemia If emboli arise from the heart consider All should get anti-platelet therapy if no Anticoagulation; Heparin is given C/I. ASA (initial agent of choice) Use followed by Warfarin Clopidogrel if intolerant of ASA. If C/I still exist then Ticlopidine. Use ASA combo w/ Dipyridamole if pt has a hx of TIA despite being on ASA.

Transesophageal ECHO is performed to MRI and CT show the site of injury. clots or vegetations

**** There are 3 pathophys for TIA: 1-BV abnormality (atherosclerosis, inflammation), 2-Embolic source (heart), 3-Inadequate cerebral BF. MCC in ELDERLY: Atherosclerosis & Emboli MCC) in YOUNG: Arrhythmia (Emboli usually from the heart, IE, valvular dz or Myxoma) Less common are: VENOUS EMBOLI that reach arterial circulation via ASD or patent foramen ovale. Transatlantic flights increases the risk for Venous Thrombosis. To identify the cause TRANSTHORACIC ECHO is performed. If ECHO is normal work up for hypercoagulable conditions should follow. ****In TIA assoc w/ focal

TICK BORNE DISEASES 1- Lyme 2-Ehrlichinosis (RMSF): Fever, malaise, HA & V. 3-Babesiosis: Endemic in Long Island. Occurs in pt >40, SPLENECTOMIZED, or immunocompromised. Parasite enters RBC and causes hemolysis. Progression is Jaundice, hemoglobinuria, renal failure and death. Unlike other tick dz RASH IS NOT a symptom. There is intravascular hemolysis, anemia, abnormal LFT, elevated ESR. Dx: Blood smear Tx: Either Quinine-Clindamycin or Atovaquone- Azithromycin parasite enters RBC and causes hemolysis. Progression is Jaundice, hemoglobinuria, renal failure and death. Unlike other tick diseases RASH IS NOT a symptom. There is intravascular hemolysis, anemia, abnormal LFT, elevated ESR. Dx: Blood smear. Tx is either Quinine-Clindamycin or Atovaquone-Azithromycin.

TINEA CORPORIS Ring shaped scaly patches with central clearing and distinct borders, topical tx with 2% antifungal lotions and creams (terbinafine) or systemic tx with Griseofulvin (for extensive disease).

TINEA VERSICOLOR Velvety pink or whitish, hypopigmented macules that don’t tan and don’t appear scaly, but scale on scraping. Agent is Malasezia furfur. KOH: shows "spaghetti and meatballs" Tx: Topical Selenium sulfide lotion or Ketoconazole shampoo is recommended.

TMJ DYSFUNCTION Always think: Referred otalgia when pt presents with ear pain and no hx. TMJD is a CC of referred otalgia, and pain aggravated by chewing, with psychogenic grinding (bruxism). TOURETTE’S SYNDROME - 2 Tx is TYPICAL antipsychotics, like Haloperidol or Pimozide. *** Pts are at risk of developing OCD (keep repeating the same gestures and obsessed about counting the same numbers).

TORSADES DE POINTES - 2 Could be caused by Quinidine. Tx: 1ST: stop the drug; then increase the heart rate by Magnesium. Torsades de pointes (see Fig. on DT), or twisting of the points, causes symptoms and death in patients with the rare congenital long QT syndromes. It’s importance in everyday practice is its provocation by drugs (especially antiarrhythmics, which are C/I in its further management) or electrolyte imbalance. Management: Stop all cardioactive drugs (e.g. antidepressants, antiarrhythmics, phenothiazines), normalize electrolytes (particularly K and Mg). ***TDP is also termed Polymorphic VT. It's a very rapid VT characterized by gradually changing QRS, prolonged QT. The MCC is Quinidine. In the acute setting Mg replacement is the tx.

TORUS PALATKNUS A benign bony mass on the palate. It’s basically an outgrowth of the hard palate. No medical or surgery is required. Cause is unknown. So in a young person who present with a fleshy immobile mass on his hard palate it's most likely Torus Palatinus

TOXIC ADENOMA - 2 Increased thyroid hormones with suppressed TSH are indicative of Thyrotoxicosis. Furthermore if radioactive Iodine uptake increased only in one lobe, that confirms Toxic Adenoma. DDx: Grave's is that in Graves iodine uptake is diffusely increased not just a specific area, also have exophthalmos. DDx: Multinodular Goiter: uptake is patchy. DDx: Painless Thyroiditis: uptake is markedly reduced. ***** Increased hyperthyroid pt like TA is at increased risk of rapid bone loss. Direct effect of thyroid hormone on the bone cells eventually leads to increased OsteoClastic bone resorption.

TOXIC EPIDERMAL NECROLYSIS A life-threatening skin disease in which the epidermis peels off in sheets, leaving widespread denuded areas. Primary manifestation: Erythematous morbilliform eruption that rapidly evolves into exfoliation of the skin. Patches of skin slides off with slightest pressure (Positive Nikolsky sign). Oral mucosa shows painful blisters. Could be caused by Sulfonamides, barbiturates, Phenytoin, NSAIDS. Tx is supportive. Sulfonamides could also cause Stevens Johnson's syndrome (Erythema Multiforme Major), but typical lesions are "target" shape. Same with Erythema multiforme minor.

TOXIC SHOCK SYNDROME symptoms include sudden onset of flu-like syndrome, high fever, hypotension, erythematous rash -- 1-2 wk after onset skin peels. Tx: Pt should be hydrated and debridement of the wound should be performed. All source of infection should be removed and anti-Staph antibiotics should be started.

TRACHOMA MCC of blindness in the world. Dx: Presence of lymphoid follicles on the conjunctiva, scarring and limbal follicles. Tx: Erythromycin or Tetracycline.

TRANSIENT SYNOVITIS of the HIP: Inflammation and swelling around the hip joint. Cause is unknown but could be due to virus. Bed rest with the affected joint in a comfortable position is the treatment of choice. Pt gets better in 3-4 days. DO NOT give ASA due to the fear of Reyes Syndrome.

TRANSPLANTATION Oral TMP-SMX (DOC) for preventing PCP in transplant pts. DAPSONEà If there is allergy.

TRANSPOSITION of GREAT VESSELS The MC cyanotic heart dz that presents with cyanosis within the first 24hr of life. TOF shows cyanosis after few years.

TRICHOMONAS VAGINALIS T. vaginalis is a flagellated protozoan found in the GU tract of both men and women. The organism is usually pear-shaped. Copious Malodorous vaginal Grayish-green color, thin and frothy. Also vaginal pruritus, dysuria and dyspareunia. Petechial patches on the cervix show "strawberry cervix". Dx: Microscopic observation of flagellated organism on wet mount preparation. Tx: Either one-dose 2000mg or 250mg t.i.d. x 7 days, for both partners. Metronidazole is teratogenic avoid using in 1st trimester.

TRICUSPID ATRESIA: A cyanotic congenital heart disease characterized by cyanosis early in life and left axis deviation. Most cases, 90%, are assoc with VSD. DDx is TOF.

TRICUSPID REGURGITATION A pansystolic murmur at the left sternal border

TRICUSPID STENOSIS A mid-diastolic rumble, best heard along the left lower sternal border

TCA DRUG TOXICITY MCC of hospitalization and death due to excessive ingestion of prescription drugs. Pt with TCA overdose presents with anticholinergic, CV and neurological symptoms. CV SE: prolonged QRS and AV block. Also dry mouth, dilated pupils, decreased bowel sounds, urinary retention, constipation, tachycardia, flushed skin and hyperthermia. Its been realized that QRS interval more reliably predicts the level of toxicity than the serum or urine drug levels.

TRIGEMINAL NEURALGIA - 2 At surgery or autopsy, intracranial arterial and, less often, venous loops compressing the trigeminal nerve root where it enters the brain stem have been found, suggesting that the tic is a compressive neuropathy. Paroxysmal lightning pain on the face, tx is carbamazepine.

TMP-SMX TOXICITY In African-Americans it can cause acute hemolysis, back pain due to G6PD deficiency. NOTE: Vignette says that "G6PD I normal", Don't fall for that because in these pts it is normal but the cause is still G6PD def. This also happens with Primaquine.

TORUS PALATINUS Is a benign bony mass on the hard palate. No medical or surgery is required. Cause is unknown. Tx is reassurance.

TROPICAL SPRUE Blunting of the villi and hx of travel is DDX with CELIAC disease. A common presentation is the TRIAD: sore tongue, diarrhea, and weight loss. All features of a malabsorption syndrome may develop. Steatorrhea is common, and D- xylose absorption is abnormal > 90% of cases. Folic acid and vitamin B12 deficiencies lead to megaloblastic anemia. Shortening of the villi and lengthening of the crypts, with changes in the surface epithelium and an inflammatory cell infiltrate of lymphocytes, plasma cells, and eosinophils. Best treatment is tetracycline

TTP presents with Pentad of 1-Severe Thrombocytopenia, 2-Microangiopathic Hemolytic Anemia (RBC fragments), 3-Neurological Signs, 4-Renal Failure, 5-Fever. LDH is elevated, PT & PTT are normal. HUS is like TTP w/o neuro signs. Both need Emergent Plasmaphoresis. DDx: ITP: Dx of Exclusion, presents with isolated decreased in platelet count. Hb and WBC are normal, PT & PTT are normal. DDx3: DIC: RBC fragments, PT, PTT and BT are elevated. Renal failure is not a feature.

TUBEROUS SCLEROSIS Initial presentation is SEIZURES. The cutaneous anomaly is called adenoma sebaceum, appears before 5-10 yo. TS occurs in 1ST year of life: Clusters of BRIEF SYMMETRICAL CONTRACTIONS of the neck, trunk and extremities known as infantile spasms, demonstrating EEG patterns. There are also hyperpigmented lesions (Ash leaf) and cortical tubers on head CT. DOC is ACTH IM.

TUBO-OVARIAN ABSCESS Is seen in 10% of pt w/ PID. Admit the pt, Broad-spectrum antibiotics started immediately AFTER taking cultures. Gentamicin+Clindamycin+Ampicillin. In absence of obvious response within 48 hours, drainage should be considered. If there is doubt of Dx: Do Laparoscopy. If there is rupture need to do exploratory Laparotomy.

TUMOR LYSIS SYNDROME - 2 Characterized by Hyperuricemia. Seen in pt undergoing chemotherapy, with high nucleic acid turnover such as Leukemia and Lymphoma. Prophylactic Allopurinol is the most effective method to prevent gout in these pts. Hydration is good but alone is not enough; it should be used with Allopurinol. ****Tumors which have high cell turnover are frequently assoc with TLS, like Burkitt's, ALL and AML. There is Hyperphosphatemia, Hypercalcemia, HyperKalemia and Hyperuricemia. The reason is both K+ and PO4 are intracellular so they increase, PO4 causes HypoCa and degradation of cellular protein causes increased Uric acid.

TURCOT'S SYNDROME It refers to an assoc w/ brain tumors (primarily medulloblastoma and gliomas) and FAP (Familial Adenomatous Polyposis) or HNPCC (Hereditary Non Polyposis Colorectal Cancer. It's Autosomal recessive and occurs mostly in teens. DDX1: Gardner: Autosomal Dominant, colonic polyps are seen with extra- intestinal lesions, like Desmoid tumors, sebaceous or epidermal cysts, lipomas, osteomas (mandible) Gastric polyps and nasopharyngeal angiomas. DDx2: Peutz-Jeghers: Autosomal dominant, intestinal hamartomatous polyps with cutaneous melanocytic macules. DDx4: Multiple Hamartoma Syndrome: assoc of GIT hamartomas and breast cancer, thyroid cancer and gingival hyperplasia.

TURNER’S SYNDROME Since all ova are lost by atresia before menarche, pts have streaked ovaries. There is no estrogen production, as there are no functional follicular cells in streak ovaries. Absence of follicular cells results in absence of estrogen and inhibin from the ovaries as a result of loss of feedback inhibition of estrogen on LH & FSH causing their elevation. Inhibin only causes feedback inhibition of FSH, so in the absence of inhibin, serum FSH are more than LH, which is pathognomonic for Primary Ovarian Failure. **** Variation is possible, as in 1 X and 1 Y Ch. In this case the pt needs a bilateral gonadectomy due to increase risk for gonadoblastoma. *****CXR: Rib notching due to coarctation of the aorta.

ULCERATIVE COLITIS - 3 Toxic Megacolon is a complication of UC. It’s an emergency and prompt admin of IV steroids, nasogastric decompression & fluid management is required. Pt presents with diarrhea and bloody stools, Dx: Clinically and Colonoscopy. As it progresses, the rectum loses its elasticity and lumen collapses. Once tx is started some pt remit but some go and manifest weight lost and fever, when this acute colitis symptoms are associated with radiologic evidence of colonic dilatation its called toxic megacolon. ****Pts with UC that have pancolitis should begin surveillance colonoscopy after 8 yrs of dz.

ULCERATIVE ESOPHAGITIS CMV is the most frequent cause in HIV pt. Triad of focal substernal burning pain with Odynophagia, shallow superficial ulceration and intracellular inclusions are dx of CMV (tx is gancyclovir). If ulcers are caused by HSV (tx is Acyclovir) they are multiple, well-circumscribed and look like volcanoes.

ULNAR NERVE ENTRAPMENT Decreased sensation to 4 & 5 digits and weak grip. MC: Site is the elbow, in medial epicondyle groove.

UMBILICAL CORD COMPRESSION Assoc with VARIABLE DECELERATION. Fetal sleep presents with decreased long-term variability. Fetal Head compression is assoc with EARLY deceleration. Uteroplacental Insufficiency presents with LATE deceleration. Intrauterine infection presents with tachycardia.

UMBILICAL HERNIA Is due to imperfect closure or weakness of the umbilical ring. Common in low weight and Black infants. It’s covered with skin and is easily reduced. > Most disappear by one year. Surgery is advised if hernia persists to the age of 3-4, diameter> 2cm in diameter, causes symptoms, becomes strangulated or progressively enlarges after 1-2 yrs.

URETHRAL INJURY, POSTERIOR - 2 Hallmark of Urethral injury is TRIAD: 1-Blood at urethral meatus 2-Inability to void 3-Distended bladder Two types of UI:

ANTERIOR POSTERIOR Urethral injury anterior to Posterior urethra consists of prostate urethra perineal membrane and membranous urethra MC due to blunt trauma to MC assoc with pelvic fracture and high riding perineum (saddle injuries) prostate An immediate surgery is tx Initial mgmnt: Retrograde urethrogram and then suprapubic catheterization. Remember Urethrogram with post void film is for Bladder injuries.

URETHRITIS A/01/03. Tx for Uncomplicated infections: Tetracycline, Azithromycin. For Pregnant women Erythromycin.

URIC ACID STONES Visualized and evaluated via CT of abdomen or IV pyelography. ***** Urine analysis: Needle-shaped crystals indicate uric acid stones. Uric acid stones, which are radiolucent. The stone can cause Ileus, possibly due to vagal reaction due to urethral colic. The result will be absent bowel sounds, constipation, signs of obstruction and no gas passing. Tx: URETEROLITHIASIS (will relieve ileus)

UTERINE RUPTURE - 2 Presents with intense abdominal pain assoc w/ vaginal bleeding, ranging from spotting to massive hemorrhage. UR is preceded by agitation, rapid breathing, tachycardia. ****Risk in transverse line is 0.5% and in Vertical its 5.0%. If pt does not want any more childrenà TOTAL HYSTERECTOMY (Tx of choice). If she wants more kids à Debridement and closure is indicated. ****Difficult to ddx from abruptio placenta.

UTI in FEMALES - 3 The MCC in order are: 1-Shorter urethra compare to men 2-Contraceptives, 3-Wt periuretral environment, 4-Close proximity to anus. *****E. Coli is the MCC but it dos not produce urease so it doesn't alter the normal acidic pH of urine. Proteus is a urease producer; and a frequent cause of UTI. Protease makes the urine Alkaline. **** Suspect C.Trochomata à In a female that there is no response to TMP-SMX and yellow/green mucopurulent endocervical discharge and edematous friable cervix. Dx: Cervical culture. Tx of choice: A single doze of Azithromycin for both partners. DDx: Chlamydia Urethritis: Suspect in sexually active pt with prolonged dysuria 7-10 days unresponsive to therapy for Chlamydial CYSTITIS. Chlamydia, Gonococcal prophylaxis in not needed, but in Gonococcal infection, empiric tx of Chlamydia is recommended. Severe PID (abdominal pain, uterine adnexal tenderness on bimanual exam, and cervical motion tenderness). Tx: Hospitalization and IV

UVEITIS MCC of red eye in pt with Ankylosing Spondylitis.

VAGINISMUS - 2 Involuntary spasm of the perineal musculature that interferes with sexual intercourse. ****Unlike dyspareunia, vaginismus is not due to any medical cause. In ALL cases, it's due to ignorant of women's anatomy, a huge apprehension about penetration, and an uncontrollable fear of pain. Tx: includes Relaxation, Kegel exercise (to relax vaginal muscle), and Graduation dilatation (penetration).

VAGINITIS, CANDIDA It's not an STD. It may appear in presence of risk factors like DM, OCP, pregnancy and immunosuppressive therapy. It can also trigger by Alkaline pH of the vagina during menses that is favorable for growth of Candida. Symptoms are vaginal and vulvar pruritus, burning and dyspareunia. Discharge has cottage cheese appearance. It’s NOT malodorous and pH is 4-4.5. Dx: KOH wet mount preparation and visualization of pseudohyphae and spores. Tx: Imidazole cream or 10 day oral Ketoconazole (especially if recurrent). Fluconazole is the new drug with fewer SE. Give 2 doses, a week apart. Most recurrences are due to non-compliance. If that is OK, then suspect another organism and culture on Sabouraud. 50% of recurrence is due to other organism like T. Glabrata and Candida tropicalis. In addition, 35% of pt with recurrent yeast infection and w/ negative cultures, have HPV on biopsy. DDx1: Trichomonas (Metro) DDx2: Gardenella Vaginitis (Metro).

VARICOSE VEINS

VARICOSE VEINS DDx1: DDx2: DDx3: DVT ARTERIAL DM ULCERS INSUFFICIENCY fatigue, tiredness in DVT-related the leg, aching Claudication Similar to ulcers take swelling. They are worsened by leg arterial, but years to worsened by elevation. Pulse is they are @ develop and prolonged sitting or weak or absent and pressure they are standing. The the ulcers are deep and points unlikely in swelling and pain at the distal parts of the active pts. rapidly goes away leg. There is NO when leg is elevated. SWELLING but hair loss The edema is assoc with and muscle atrophy is peripheral noted incompetence. Ulcers occur in medial aspect of the leg

VASA PREVIA - 2 Hemorrhage w/fetal heart rate changes, progressing from tachycardia to bradycardia to a sinusoidal pattern. "APT" test distinguishes maternal from fetal blood. Mortality risk is 75%. Dx: Transvaginal U/S in combination with Doppler. Vasa Previa necessitates emergency C-section.

VENTRICULAR TACHYCARDIA When a pt has recurrent VT 1 st step : After stabilization (Amiodarone); look for the cause, Most probably due to Diuretics (i.e. Furosemide causes HypOkalemia); so order electrolytes and correct them if needed.

VENTRICULAR FIBRILLATION Tx: Defibrillation with 200-360 joules. If it fails, Lidocaine or Amiodarone (DOC) can be loaded & shocked again. EPI can sensitize and lower the threshold for conversion.

VERAPAMIL POISONING May cause bradycardia, hypotension, AV block and cardiac arrest. Like hypotension caused by other poisons, 1 st step : IV saline; then Calcium Chloride (reverses the effect of CCB including bradycardia, AV block and hypotension). VESICOURETERAL REFLUX Retrograde flow of urine from bladder to ureter and renal pelvis. It‘s a risk for recurrent UTI and renal scarring ultimately. Renal scaring is the major cause of end stage disease in children. Reflux exists in all children with renal scars and renal scars are in 60% of children with gross reflux. Dx made with voiding cystourethrogram.

VIPoma A Pancreatic tumor. Produce Vasoactive Intestinal Peptide. It causes diarrhea, hypOkalemia resulting in leg cramp, and decrease in amount of acid in stomach. Woman > Male. Other symptoms: Weight loss, facial flushing and redness. Dx: High VIP in blood. CT or MRI find location. Tx: 1st goalà Treat dehydration; next is to slow the diarrhea with Octreotide. If tumor has not metastasized, surgery is indicated.

VITAMIN K DEFICIENCY - 2 Vit K def presenting as hemorrhagic dz of the newborn occurs in infants born at home with no prenatal care. Vit K given to all infants after birth. Newborns are susceptible due to low fat stores, low vit K breast milk and liver immaturity. Newborns present as intracranial bleeding as well as skin and GI. In adults: Chronic small bowel disease, after small bowel resection or prolonged antibiotic therapy. Dx: Elevated PT or decreased clotting factors. BT & Platelet are normal. Platelet in normal; PTT may or may not be elevated.

VITAMIN K DDx1: DDX2: DDx3: DDx4: DEFICIENCY VON HEMOPHILIA LIVER DZ ITP WILLEBRAND (XR) DZ (AD) PT elevated normal Normal elevated PTT Normal/ elevated Elevated normal elevated BT normal elevated Normal normal Platelets normal decreased clotting Decreased Decreased Decreased factors (2,7,9,10, factor 8 factor 8 protein C+S)

VITAMIN D DEFICIENCY Most commonly due to MALABSORPTION causes reduced plasma Calcium and Phosphorous. DDx: Hyperparathyroidism and Pseudoparahypothyroidism cause decreased in Ca but increase in phosphate. ****In infants: presents with bone abnormality like softness or deformity. Typical pts are low birth weight, Unsupplimented dark skinned infants, infants with inadequate exposure to the sun, and breast-fed infants. Pathology: Defective mineralization of the bone. *****Rickets is developed due to Vit D def in children who stay indoors all the time and eating is not balanced. Presents with: Enlarged costochondral junctions, thick wrists and ankles XR: shows cupping and frying of the distal end of radius and ulna, large anterior fontanel.

VITAMIN D TOXICITY, Misc. 6/2 Confusion, HA, Nausea from HyperCa++. Mental Status changes. Constipation (MC GI SE). Renal SE is nephrolithiasis, AR Insuff and CRI. Tx: Stop the vitamin, low Ca++ diet, keep urine acidic and giving corticosteriods.

VITAMIN DEFICIENCY 1- Thiamine def (B1) assoc with infantile and adult Beriberi as well as Wernicke- Korsakoff ***Dry Beriberi: Symmetrical peripheral neuropathy with sensory and motor involvement ***Wet beriberi Includes neuropathy in addition to cardiac involvement. 2- Riboflavin (B2) is unusual in industrialized nations. Symptoms: Photophobia, Dermatitis and Anemia. 3- Niacin (B3) Diarrhea, Dementia, Dermatitis, Death 4- Vit C: Ecchymosis, petechiae, bleeding gums, Hyperkeratosis, Sjogren's

VITILIGO - 2 Presents with pale patches of skin, symmetrically around the mouth and areola. Borders are well circumscribed & hyperpigmented. Pathology is destruction of melanocytes. Few experience spontaneous remission. ***Its assoc with Pernicious anemia, Grave's dz, DM-I, Alopecia Areata.

VITREOUS HEMORRHAGE -2 Sudden loss of vision with floaters in the visual field. MCC: Diabetic Retinopathy. Fundus is hard to visualize. Basically there are 3 types of Ophthalmologic Hemorrhages: Conjunctival: Vitreous Hemorhage: Retinal Hemorrhage:

Causes: Minor trauma, produces black reflex in HTN: is flame-shaped cough, sneeze or strain exam, cause is DM and DM or septic infarction: is retinal vein occlusion, dot & blot à always retinal tears, its significant. absorbed slowly, no tx needed, resolves bleeding is controlled w/ within 2 wks photocoagulation

VOLKMAN'S ISCHEMIC CONTRACTURE Displaced anterior fat pad is a radio-G sign of Supracondylar fracture that may be complicated by VIC VOLVULUS, MIDGUT Present: Child <1 month old with bilious vomit, abdominal distension and passage of blood stained stools. Child is irritable but no signs of pain. DDx1:Pyloric stenosis: Non-bilious vomit. Duodenal Atresia has no blood in stool. In Down’s infants: Hirschsprung fails to pass stool. Meconium Ileus: Fails to pass meconium, assoc with CF

VON WILLEBRAND DZ vWF is decreased; a congenital bleeding disorder characterized by a lifelong tendency toward easy bruising, frequent epistaxis, and menorrhagia vWF fxns: in both primary (involving platelet adhesion) and secondary hemostasis

VSD Harsh and holosystolic murmur heard at the left lower sternal border, MC cardiac congenital defect. If it’s small and causes no symptoms for the infant, 40% of the time it closes spontaneously by 3 yo and 70% chance of closure by 10 yo. Risk of Infective endocarditis is increased so prophylaxis for dental is indicated. If the defect is large (Soft murmur) then it might turn in to Eisenmenger syndrome and reverse of the blood flow which is irreversible. Med and surgery is then indicated prior to irreversible stage.

VULVAR HYPERTROPHIC DYSTROPHY Thick and hyperkeratotic due to long term scratching. Mostly seen in POSTMENOPAUSAL women.

VULVAR PAPILLOMATOSIS or Condylomata acuminata; caused by HPV 6,11. Present as exophytic lesions with a raised papillomatous or spiked surface may grow into a cauliflower- like formation.

WALDENSTROM MACROGLOBULINEMIA a rare chronic plasma cell neoplasm. Plasma cells multiple and invade BM, spleen and LN. They produce excess IgM that causes thickening of the blood, hyperviscosity. Major S&S: 1-Enlarged: Spleen, Liver, LN; 2-Tiredness (from anemia) 3-Bleed easily (little platelet), 4-Night sweats, 5-HA and dizzy, 6- Visual problems, 7-Pain and numbness in extremities. DDx: Multiple Myeloma: there is IgA/G not IgM. Also No hyperviscosity (Engorgement of the retinal vein) like in WM.

WARFARIN-INDUCED SKIN NECROSIS - 2 Dermo. 6/3 A serious complication of oral anticoags. Sometimes assoc with protein C deficiency. Female are more prone; a hypercoagulable state. Commonly affected sites are breast, thighs, buttocks and abdomen. Initial complain: Pain followed by bullae and skin necrosis. It occurs within wks of starting therapy. Administer Vit K in the early stage and Warfarin discontinued if lesion progresses. Heparin should be used until necrotic lesion heals. **** Note of the dz: Warfarin-treated pts should be given FFP instead of Vit K when emergency surgery is to be performed. DDx: Cholesterol Embolic Syndrome; Don’t be fooled with Bruit, see the whole picture.

WASHING CELLS Febrile reaction is a common transfusion reaction that is caused by antibodies in the pt's plasma reacting with donor’s leukocytes. Leukocyte depletion technique, like cell washing, decreases the probability of febrile, NON-hemolytic transfusion reaction.

WATERHOUSE-FRIEDRICHSEN Or Adrenal Glands Hemorrhage is a very serious complication of Meningococcal meningitis caused by Neisseria. It’s bilateral bleeding into adrenal gland due to DIC, carries 100% mortality. In an infant with Meningococcemia watch out for WFS, which is characterized by a sudden vasomotor collapse and skin rash due to adrenal hemorrhage.

WEGENER GRANULOMATOSIS - 2 Hematuria+Hemoptysis+Sinusitis. Underlying pathology involves Necrotizing vasculitis with granuloma formation. Positive C-anca. Typical XR: Nodular cavities. ****Demonstration of Anti Neutrophil Cytoplasmic Antibodies confirm dx. The Cytoplasmic pattern (C-ANCA) is highly specific. CXR: Infiltrates, nodule, cavities and masses.

WERDNIG-HOFFMAN An autosomal recessive disorder involves degeneration of anterior horn cells and CN motor nuclei. It causes floppy baby syndrome (like Botulism)

WERNICKE ENCEPHALOPATHY Characterized: Ataxia, Opthalmoplegia, nystagmus, and altered mental status. It's seen in chronic alcoholics due to B1 (THIAMINE) deficiency. DDx1: Folate Deficiency: which is common in alcoholics but won’t present with B1 def symptoms. Remember B3 (NIACIN) causes Pellagra, 3Ds, due to corn-based diet. B2 (FLAVIN) causes Cheilosis and Glossitis.

WHIPPLE’S DZ - 4 Caused by bacterium T. Whippelli, affects men 30-60yo. Presents with joint pain + abdominal pain + diarrhea + weight loss. Dx: PAS (+), foamy macrophages containing a glycoprotein in intestine. Also skin Hyperpigmentation. Untreated dz is fatal and progressive. Tx: Procaine penicillin G followed by tetracycline. *Dx is by PAS staining, it can be confirmed with upper GI endoscopy with biopsy on the small intestine. ***D-Xylose absorption is abnormal in both Whipple and bacterial overgrowth. However, the test becomes normal after antibiotic tx.

WHOOPING COUGH - 2 B. Pertussis. Tx: Erythromycin and cough suppressants. Hospitalize if serious. Pt might develop rectal prolapse, epistaxis and pulmonary pathology *****It’s highly contagious. Presents: Severe bouts of coughing spells after an URI. They are so severe that they can cause rectal prolapse, epistaxis, pneumothoraces and subconjunctival hemorrhage.

WILM’S TUMOR - 2 Between ages of 2-5. MC primary tumor of kidneys in childhood; asymptomatic abdominal mass (80%) discovered by mother. In 10% bilateral masses. ****4yo with right flank mass and both kidneys being palpable with stable vital signs is Wilms. This tumor originates from METANEPHRONS Tx: Nephrectomy. If tx at early age majority have long term survival. DDx1: Neuroblastoma: If the child <1 yo suspect it. It presents with unilateral abdominal mass w/o bilateral enlargement of kidneys, fever, weight loss, hepatomegaly and HTN. It usually crosses mid- line. Dx: Measure urinary catecholamine products. This tumor is a malignancy of neural crest cells. DDx2: Polycystic Kidney Dz: Presents with BILATERAL flank masses.

WILSON’S DZ - 2 Dx: Decreased serum ceruloplasmin, increased urinary copper and slit lamp examination of the eye. Liver Bx: Mallory's hyaline. It’s recessive dz. Decreased ceruloplasmin leads to copper deposition in liver, cornea, basal ganglia (hepatolenticular degeneration). Dz starts in infancy, but since all infants have increased level of copper for the first 3 months, best to diagnose it after the 1st yr; if not treated the dz is fatal.****Dx: Ceruloplasmin, increased urinary copper and hepatic copper deposition in liver biopsy. Tx: Penicillamine. Fulminant Hepatitis needs liver transplantation.

WISKOTT ALDRICH SYNDROME Characterized by: Recurrent Pyogenic infections, atopic eczema and thrombocytopenia. Presents: Within 1 year of age, XR. First manifestations: Hemorrhagic episodes followed by pyogenic infections. IgM is decreased but IgA & IgG are normal. Deficiency: Inability to produce immune response to capsulated polysaccharide antigens. Pt are predisposed to ALL and Hodgkin’s. Thrombocytopenia is due to splenic destruction of platelets. Tx: Continue antibiotics; splenectomy and BMT DDx1: CGD: presents age< 2 yo, defect is inability to generate oxidative burst to kill organism after being phagocytosed; lack of NADPH oxidase. In lab, it can be confirmed with Nitro Blue Tetrazolium will be NEGATIVE. DDx2:Chediak-Hegashi: is recurrent pyogenic infections. Defect: Is in neutrophils as their lysosomes fail to empty their contents. Pt will have partial Albinism and neuropathies and Nystagmus. B&T cell function is normal. NBT is normal.

WRIST FRACTURES 1-Colles: MC fracture of distal radius in outstretched hand. Characterized by dorsal displacement & dorsal angulation. 2-Smith: Reverse of Colles 3- Chauffeur's: Fracture of radial styloid process. 4-Galeaizi: isolated fracture anywhere in radius with assoc injury to radio-ulna joint. fx of RADIAL SHAFT(between middle and distal 1/3's) & DISLOCATION of DISTAL RADIOULNAR JOINT - usually the dislocation is dorsal, but in some cases can be palmar; - fx is almost always located just above proximal border of PRONATOR QUADRATUS - usually there is anterior angulation w/ transverse or short oblique config; - injury to RU joint may be purely ligamentous, or the ligament complex may remain intact and ulnar styloid may be avulsed (in children there may be separation of the distal ulnar epiphysis) - MOA: usually direct blows and falls;

ZENKER'S DIVERTICULUM - 2 Pt presents: oropharyngeal dysphasia, neck mass and are >50yo. UES dysfunction and esophageal dysmotility (motor dysfunction and motility problem) are believed to be the cause. Barium exam helps to delineate the diverticulum. Tx: Surgery includes excision and frequently cricopharyngeal myotomy. ****Zenker is defined as herniation of mucosa through the fibers of cricopharyngeal muscle. Confirmatory Test of Choice: Barium Esophagography, not Esophagoscopy.

ZINC DEFICIENCY Alopecia, mental changes, diarrhea, dysgeusia (distortion of taste), smell abnormalities, maculopapular rash around the mouth and eyes and impaired wound healing.

ZOLLINGER-ELLISON SYNDROME (Gastrinoma) -4 Characterized by multiple severe drug-resistant ulcerations in GIT. The MCC of ZE is a gastrin-producing pancreatic tumor. As a result of uncontrolled gastrin production, parietal cell hyperplasia occurs and stomach acid production is significantly increased. Multiple Duodenal ulcers are typical, and a Jejunal ulcer is almost pathognomic for this condition. Steatorrhea may develop, because increased production of stomach acid inactivates pancreatic enzymes. Tx of choice: K-H ATPase inhibitor Omeprazole, indefinitely until surgery. If meds fail; have to go to total Gasterectomy. *Is Assoc with MEN-I: Hyperparathyroidism, Pancreatic carcinoma and Pituitary tumors