CK Notes

Neerajs
USMLE Step-2CK HY Material and NOTES

HY Notes: CK(Q-bank)
Familial short stature: normal birth weight and length age of 2-3 years growth decelerate and drops to 5th
percentile The onset and progression of puberty normal : Bone age is typically consistent with the
chronologic age.
Immunizations:
Hep B vaccine- At birth, 1 month, and 6 months
DTaP- At 2, 4, and 6 months, 15-18 months, and 4-6 years Td booster- 11-12 years, and then every 10 years
Hib- At 2, 4, and 6 months, and 12-15 months
IPV- At 2 and 4 months, 6-18 months, and 4-6 years
MMR- At 12-15 months and 4-6 years
Varicella- 12 months
Chemo-prophylaxis tuberculosis: The usual agent isoniazid. Indicated in the following groups:
1) tuberculin skin test has converted from negative to positive within the previous 2 years;
2) all small children (<4 years of age)exposed by known close contact to a person with
untreated tuberculosis or who have a positive PPD; In young children, not to delay
chemoprophylaxis until the PPD test becomes positive in child,
3) all HIV patients with positive PPD;
4) elderly patients with a definite conversion of PPD;
5) PPD positive persons with apical scars;
6) PPD positive persons with significant risk of recurrence due to diabetes mellitus,
prolonged corticosteroid therapy, gastrectomy, end-stage renal disease, or gastric
stapling.
CHARGE syndrome: colobomas, heart defects, choanal atresia, retardation, genitourinary abnormalities/
cryptorchidism and ear anomalies,not genetically transmitted and is not associated with a teratogenic effect of
any substance.
Amount of Factor VIII to hemophiliac A patients: weight in pounds x 20 x desired plasma level in units.
(Not applicable in hemophiliac B patients because Factor IX tends to bind to the endothelium of the vessel
walls.Monitor the patient for cessation of bleeding or check clotting times before assuming that a calculated
dose of Factor IX had its intended effect)
Ataxia-telangiectasia: autosomal recessive disease.Ataxia,Choreoathetoid movements, slurred speech,
ophthalmoplegia, and progressive mental retardation,Telangiectasias.Recurrent sinopulmonary infections.
lack of IgA and IgE, cutaneous anergy and a progressive cellular immune defect. predisposition for certain
cancers (leukemias, brain cancer, and gastric cancer). Most of these patients die of their neurologic
deterioration by age 30.
Irreversible muscle weakness in Duchenne muscular dystrophy seen after ventilator put for respiratory
distress due to pneumonia etc hypoventilation on weaning tracheostomy will reduce the dead space and
airway resistance.
Infants usually double their birth weight by 6 months
Infants are triple their birth weight by the age of 12 months.
Infants usually quadruple their birth weight by 24 months.
Infants usually double their length by 4 years.
Most patients with ALL are significantly granulocytopenic = like aplastic anemia associated with bone pain
& fever = features like ecchymoses & infections
Orthostatic proteinuria:very common protein excretion rate is higher while the child is in an upright
position obtain a "first morning" urine before the child has had much time in an upright position. DDx
Minimal change ds = Edema, hypercholesterolemia & hypoproteinemia
Neonate with pneumonia and h/o conjunctivitis on the fourth day of life. The leukocyte count is elevated at
15,000 with 40% eosinophils = suspect Chlamydia
Corrossive ingestion: ingestion can cause severe esophageal necrosis of the liquefaction type. Full-thickness
injury is common. In severe cases, it can cause esophageal perforation and mediastinitis. Acid ingestion
causes coagulation necrosis and eschar formation. The eschar tends to protect the esophagus from fullthickness injury and corrosive perforation.
Perform an esophagoscopy within 24 hours of exposure for the following patients following alkali ingestion:
1. Small children
KaplanQbankNotes:Neeraj
2. Symptomatic older children and adults

3. Patients with abnormal mental status
Esophagoscopy should not be performed in patients with evidence of gastrointestinal perforation, significant
airway edema, or necrosis and in those who are hemodynamically unstable.
Children with sickle cell disease are at risk of serious bacterial infection and sepsis because they have
impaired splenic function. Intravenous ceftriaxone is the most commonly used antibiotic in a febrile child
with sickle cell disease. It is effective against both S. pneumoniae and H. influenzae.
Red urine = hematuria, hemoglobinuria, myoglobinuria, certain foods or medications (e.g., rifampin,
nitrofurantoin, chloroquine, azo dyes, beets, and blackberries), and the presence of urates.
+ Strip-test for blood in a urinalysis = red blood cells, hemoglobin or myoglobin = perform microscopic
analysis to DDx
Raised serum creatinine phosphokinase = rhabdomyolysis = admit for aggressive IV hydration and treatment
with sodium bicarbonate to alkalinize the urine to prevent precipitation of the myoglobin in the renal tubules.
Nightmares:frightening dreams that awaken the child from REM sleep recall details of the dream.
Nightterror: Stage 3 or 4 sleep,not recalled Rx simply let it go but prevent injury
Functional abdominal pain is pain that lasts for more than 3 months and often interferes with normal activity.
The pain is periumbilical and often hard to describe. The pain typically does not awaken patients from sleep
or interfere with pleasant activities. The pain is real and is the result of the regulation of gastrointestinal
motility in response to either psychological or physical stress.
Fragile X male = Adv Cytogenetic testing in female siblings = Heterozygous females frequently have
developmental and behavioral problems such as ADHD. They may also have borderline or mild mental
retardation.
Rx Acne vulgaris: retinoid (tretinoin, adapalene, and the new yeast-derived agent azaleic acid).S/E skin
irritation & photosensitivity. Frequent face washing with strong soap will probably cause exacerbation of
acne. Gentle face washing once or twice daily with mild soaps is recommended.
Toxicities tricyclic antidepressant ingestion:

1. A prolongation of the QRS interval is highly predictive of both cardiac and CNS toxicities
2. Right deviation of the QRS axis (greater than 120 degrees) is very predictive of cardiac toxicity
from tricyclics.
Fat embolism brain = multimodal petechiae in the white matter represent the most common pathologic
change.
Corpus callosum and cerebral peduncles small petechiae = Diffuse axonal injury = coma a few hours to days
after head trauma.
Multiple cortical infarcts, usually of the hemorrhagic type = Septic embolism / white matter is spared.
Prostatic abscess:Infecting organisms include aerobic gram-negative bacilli and Staphylococcus aureus.
Hyper IgM immunodeficiency = increased susceptibility to major gram-positive pathogens and opportunistic
infections (such as the patient's Pneumocystis infection). The biochemical basis defect in a receptor on the T
cell membrane that helps to trigger B cell switching from IgM to IgA, IgG, and IgE.
The tidal volume for a patient on respirator is generally estimated as 10 mL/kg of weight.
Screening every 5 years, a random cholesterol level should be checked = > 240 mg/dL =fasting lipid profile
Scaling skin on back and extensor surfaces of the extremities/flexor surfaces are uninvolved. Cracking of the
skin is prominent on the palms and soles. + atopy = ichthyosis vulgaris, Rx minimizing bathing with use of
soaps only in the intertriginous areas. Bathing limited to 10-minute periods (to hydrate the stratum corneum),
followed by immediate application of an emollient such as petrolatum, can help to control the scaling. In
addition, 50% propylene glycol in water under occlusion by thin plastic film or bags during the night is
helpful in adults, but is not usually used in children.
Nummular dermatitis: chronic inflammation / etiology unknown. Coin-shaped/discoid itchy patches of

vesicles and papules (ooze serum and crust over)numerous on the extensor surfaces of the extremities and on
the buttocks. Heal and then reappear at the same sites. Microscopically, localized spongiosis (corresponding
to edema) of the epidermis, which may also contain minute fluid-filled holes that correspond to the tiny
vesicles seen clinically in early lesions. Treatment of these patients is problematic, and numerous regimens
involving corticosteroids or antibiotics have been recommended, each of which appears to work with some
but not all patients.
Euthyroid sick syndrome: seriously ill patient with low T4 /T3, but below normal, normal, or minimally
elevated TSH and clinically do not have clinical hypothyroidism.DDx true hypothyroidism (significantly
raised TSH).
End-stage liver disease/Cirrhosis renal vasoconstriction occurs worsening fatigue and confusion distal
convoluted tubule responds by conserving sodium diminished urine output and low urinary sodium
Deranged BUN/creatinine hepatorenal syndrome Rx Liver transplantation reverse this
vasoconstriction and kidney function will return to normal.
HIV encephalitis (AIDS dementia complex): most common CNS complication in AIDS = cognitive
impairment, incontinence, impairment of motor skills, and confusion = sub acute inflammatory infiltration of
the brain caused by direct spread of HIV = diagnosis of exclusion = MRI studies and CSF analysis are useful
in excluding other CNS diseases.
Patient with respiratory distress due to pneumonia oxygen saturation is 80% on room air Hypoxia puts
at significant risk for delirium, cardiac arrhythmias, and cardiopulmonary arrest Oxygen should first be
administered noninvasively starting with a non-rebreather face mask Failed go for invasive methods
like endotracheal intubation.
Hospitalization in community-acquired pneumonia :Criteria for hospitalization: one of the following is

needed:
1. respiratory rate > 30 breaths/min,
2. room air PaO2< 60 mm Hg,
3. O2 saturation less than 90% on room air,
4.
or bilateral or multiple lobes involved
The normal value for the anion gap is 12 4 mEq/L
Gaucher disease: deficiency of the enzyme glucocerebrosidase (Ashkenazi Jews ) progressive

accumulation of glucocerebroside within lysosomes of histiocytes Gaucher cells, large histiocytes with
their cytoplasm engorged with glycolipid = "crumpled tissue paper" appearance most common adult
variant (type I) =most severely affected organs are the bone marrow, liver, and spleen Bone marrow
involvement =progressive pancytopenia and bone fractures Glucocerebrosidase levels in circulating
leukocytes: diagnostic. In the US, the disease is Rx glucocerebrosidase named alglucerase(safe but
expensive)
an erythematous, slightly raised, 2-cm patch of skin on sunexposed area (Face mostly) area has a rough, very adherent, yellow-brown scale Actinic keratosis
Rx application of 5-fluorouracil cream twice daily x 4 one-week cycles alternated with no treatment weeks
heal without scarring.
Ventilator delivering high concentrations of oxygen lead to irreversible pulmonary fibrosis Use
positive-end expiratory pressure (PEEP) to prevent the development of oxygen toxicity But PEEP does
increase the risk of both barotrauma and hypotension by impairing right-sided heart filling.
Secondary hyperparathyroidism developed in renal failure in an attempt to correct the hypocalcaemia

bone calcium deficits and pathologic bone lesions Rx Calcium supplementation in Renal failure
Atypical nevus(Dysplastic):size from 5 to 12 mm most

commonly on sun-exposed skin round in color, but some have subtly notched borders or are slightly
asymmetrical intermediate category between obviously benign nevi and malignant melanoma increased
rate of progression to melanoma Isolated dysplastic nevi are often excised to remove the melanoma
riskcases with large numbers careful monitoring with serial photographs can identify any changing
lesions which may be undergoing malignant transformation.
Post-MI patients: Ejection fraction near or minimally subnormal Rx Beta blockers decreasing both oxygen
demand and the incidence of ventricular arrhythmia Improved survival
But if ejection fractions less than 40% Rx Angiotensin-converting enzyme (ACE) inhibitors
Tension headache: headache often triggered or worsened by stressful situations, anxiety and fatigue Rx
NSAIDs
Eosinophilic fasciitis:Orange peel skin on the anterior aspects of the extremities= scleroderma-like disorder
involving the arms, legs, and sometimes face and trunk, but not usually the hands and feet lead to eventual
restriction of arm and leg motion related to inflammation and fibrosis of fascia Biopsy of the skin or fascia
shows cellular infiltrates with histiocytes, plasma cells, lymphocytes and (in only some cases, despite the
name) eosinophils Rx high dose prednisone followed by tapering and maintenance for 2 to 5 years on low
dose prednisone.
Pulsus paradoxus: significant fall in systolic blood pressure with inspiration = severe asthmatic attack
Look for associated accessory muscles of respiration, i.e., the internal intercostal muscles and the
sternocleidomastoid muscles.
Traumatic hemolytic anemias: repeatedly compressed tiny blood vessels, causing fragmentation of some red
cells (triangle and helmet shapes) e.g. forced march DDx rhabdomyolysis: high creatine kinase
Atrial fibrillation (in CHF) causes cardiovascular embarrassment and pulmonary edema adequate
management of atrial fibrillation is rate control Rx Digoxin with or without a nodal agent such as a beta
blocker.However,in sinus tachycardia seen with hyperthyroidism DOC is propanolol alone.
Bleeding in diverticular usually due to the disruption of an often single arteriole or small artery in a
diverticulum vessel can be sufficiently stretched by the diverticulum that it cannot undergo contraction.
Sheehan syndrome: panhypopituitarism due to intrapartum necrosis of the pituitary insulin challenge
Measuring plasma levels of growth hormone and cortisol and evaluating thyroid hormones and TSH levels
Rx hydrocortisone (IV not oral like prednisolone) and thyroid hormones.
Blood supply from 1978 to 1985 was likely to be tainted with HIV positive blood patients with a history of
blood transfusions during these years even if currently asymptomatic, should be screened.
Hyperkalemia First to give: IV calcium gluconate to counteract the effect of the high potassium on the
heart and muscle
Hypercalcemia Rx IV saline and furosemide rapid and safe way to lower serum.
hemochromatosis = total body iron load >5 g; (hemosiderosis = milder iron overload)
cirrhosis and portal hypertension Rx Propanolol (to reduce his portal pressure) and Frusemide to relieve
ascites dehydration (dry mucous membranes) related to his diuretic BUN elevated may exacerbate
hepatic encephalopathy but pulse does not demonstrate a reflex tachycardia because of the propranolol.
In portal hypertension strictly restrict or entirely avoid any medications with a sedative effect, e.g.,
benzodiazepines as they may ppt an encephalopathy.
Silent lymphocytic thyroiditis: common disorder of postpartum women,autoimmune reaction to the thyroid
gland produce transient hyperthyroidism (related to follicle destruction) followed by hypothyroidism (that
may be either permanent or resolve within 1 year).
Seborrhic Keratosis: This lesion is characterized by light brown to

black papules or plaques with an adherent waxy, greasy scale. The "stuck-on" appearance is very
characteristic. It is most often found on the face and trunk.
The findings of a coagulopathy or of an encephalopathy confer the worst prognosis in patients with acute
viral hepatitis.These findings, in fact; suggest the possibility of fulminant hepatic failure.
IgA type heavy chain diseas:centered in the Middle East ,ages of 10-30present with abdominal mass and
malabsorption (behaves like an abdominal lymphoma but not mailgnant)confined to the gut and mesenteric
lymph nodes may represent an aberrant reaction to some sort of bacterial infection Rx corticosteroids,
cytotoxic drugs and broad-spectrum antibiotics.
Pemphigus vulgaris:uncommon
autoimmune skin disorder characterized by blistering and erosions involving the mucous membranes and skin
autoimmune attack is on the junctions between epithelial cells in the epidermis blisters occur high in
the epithelium and can rupture easily(Nikolsky's sign) begin in the mouth rapid rupture of the
blisters may lead to the impression that the initial lesion is an ulcer rather than a blister IgG deposition on
epithelial cell surfaces life-threatening as a result of fluid/electrolyte imbalance, secondary infection, or
complications of the high-dose corticosteroid therapy.
Marrow fibrosis suggests myelofibrosis. The marrow in aplastic anemia is fatty, rather than fibrotic
Excess vitamin C supplementation can lead to uricosuria and the development of calcium oxalate stones.
The perfusion territory of the anterior spinal artery includes the anterior horn cells and part of the pain and
temperature pathways. Thrombosis of this artery causes flaccid paralysis, loss of bowel and bladder function
and loss of pain and temperature sensation
Infectious Mononucleosis: Ampicillin therapy leads to a maculopapular rash. An antibiotic should not be
given.
To rapidly assess for the possibility of antifreeze ingestion, the physician can evaluate the patient's urine
under a Wood's lamp for fluorescence. Manufacturers of ethylene glycol-containing antifreezes typically add
fluorescein to the mix, which will fluoresce under a Wood's lamp.
Paroxysmal nocturnal hemoglobinuria(Marchiafava-Micheli syndrome):genetic defect in glycosylphosphatidyl-inositol "anchor marked sensitivity of RBC to serum complement factor C3 Hemolysis
triggered by infection, iron use (prescribed to treat the anemia), vaccination, or menstruation predisposed
for thrombotic disease, including Budd-Chiari Syndrome Ham test:classic but non-specific:acid incubation
causes red cell lysisflow cytometric analysis using CD 55 and CD 59 (most definitive).Prognosis good
only a few require allogenic bone marrow transplant.
AMI : Thrombolytic therapy is indicated in patients up to 75 years of age .Absolute contraindications include
a bleeding diathesis, major surgery or trauma within 6 months, gastrointestinal bleeding, or the presence of
aortic dissection or a known intracranial tumor.
Whenever you see Lewys Body think of relation with Parkinsons dementia with visual hallucinations
and extrapyramidal signs dementia with Lewy bodies Like parkinsons it shows fluctuating clinical
course with alternating periods of improvement and deterioration DDx Pick dementia =Personality
changes & disinhibition,affecting younger than 65 striking atrophy of the frontal and anterior temporal
lobes.
Suspected lung carcinoma hoarsenessmetastatic disease to the recurrent laryngeal nerveincurability

by surgical means.
Charcoal is DOC within 4 hrs of toxic ingestion in any case also applicable to Acetominophen Give
charcoal + N-acetylcysteine within 4hrs of ingestion If >4 hrs but <10 hrs = N-acetylcysteine alone
continue oral treatment for 72 hours.
Tangier disease:alpha-lipoprotein deficiency very low high-density lipoprotein (HDL)recurrent

polyneuropathy, lymphadenopathy, and hepatosplenomegaly due to storage of cholesterol esters in
reticuloendothelial cells orange-yellow tonsillar hyperplasia (due to the cholesterol ester deposits) is a
distinctive clue
HIV patient with bloody diarrhea + tensmus + urgency/fecal incontinence Sigmoidoscopy showing
proctosigmoiditis with deep ulcers suspect CMV
Obese patient? in postop state developing respiratory distress think about PE
Nephritic syndrome with bland urine in drug users who "skin pop" their drugs and have recurrent infections
Enlarged kidneys ?Amyloidosis DDx Heroin Nephritis=Small kidneys
Idiopathic hypertrophic subaortic stenosis (Earlier name of Hypertrphic cardiomyopathy):frequent

cause of syncope or near syncope in young patients characteristic murmur by its increase with the
Valsalva maneuver (Any maneuver that decreases left ventricular size will increase the murmur
because the obstructive component increases as the left ventricular cavity shrinks systolic ejection
murmur is diminished when the patient lies down (This increases cardiac size by increasing venous return
and tends to diminish the intensity of the murmur.This increases the ventricular size and diminishes the
murmur).Rx Beta-blockers, such as propanolol, help relax the left ventricular smooth muscle and reduce
ventricular outflow obstruction.
Mesalamine (active ingredient 5-aminosalicylic acid) rectal suspension, suppositories, delayed release oral
tablets and controlled release oral capsules not absorbed and acts topically modulation of arachidonic
acid metabolites, including prostaglandins, leukotrienes, and hydroxyeicosatetraenoic acids well tolerated
except sulfite sensitivity.
Hypertensive emergency (Raised both systolic & diastolic BP)may lead to increased Intracranial
tension(Blurry vision/Papilledema) subarachnoid hemorrhage and end-organ failure (Like renal manifesting
as cola colored urine) Rx Control BP but the blood pressure should not be lowered too far systolic
pressure in the range of 160-170 mm Hg because some of the elevated pressure may represent a
compensatory mechanism to maintain cerebral perfusion pressure in the face of increased intracranial
pressure or cerebral arterial narrowing (May lead to watershed infarcts)IV nitroprusside is a good agent
because it can be titrated with the blood pressure. If the pressure drops too low, the IV can be turned off.
IgG subclass deficiency: minor forms of immunodeficiency disease deficiency may involve either or both
IgG2 and IgG3 with or without IgG4 deficiency (IgG1 is the major form, and its deficiency leads to a
deficiency of total IgG (by definition not considered a "subclass" deficiency)potentially clinically
important point that patients with IgG2 deficiency may also have IgA deficiency and may develop
anaphylaxis if given IgA-containing blood products.
Chronic "autoimmune" hepatitis young age & hypergammaglobulinemiabiopsy demonstrating portal

inflammation with lobular damage resulting in bridging necrosis
1. Type I(classic type: most frequent):associated with antinuclear and anti-smooth muscle
autoantibodies
2. Type II(more common in women of Western European descent):associated with autoantibodies to
circulating liver-kidney microsomes. insidious + amenorrhea.
Chronic hepatitis C positive enzyme immunoassay test for HCV-antibodies(this test may be falsely
positive in situations with hypergammaglobulinemia like seen in chronic autoimmune hepatitis)positivity
should be confirmed by a more specific RIBA.
Ganglion cyst: degenerative nontumourous/cystic swellings with gelatinous material having high hyaluronic
acid content the center over dorsal aspect of the wrists, usually near or attached to tendon sheaths and joint
capsules Common sites:65%scapholunate joint,volar aspect of the radius and the flexor tendon sheath.
regress spontaneously or after needle aspiration of the contents. Recurrent ganglia or ganglia that are
cosmetically unacceptable to the patient can be surgically excised, but may recur after excision.
Strenuous exercise like swimmingdevelopment of headache, dizziness, One sided arm clumsiness and leg
weakness + loss of pain and temperature sensation on same side face and contra lateral body areas No
prior illness ? lateral medullary syndrome investigate vertebral artery dissection.
Diagnosis of Myocardial infarction requires either characteristic ST segment elevations on the ECG OR
elevations in serum markers for cardiac injury. Myocardial ischemia may or may not always manifest as
MI(Angina). Diabetics often have silent ischemia.
Propranolol is considered to be relatively contraindicated in patients with peripheral claudication & asthma.
HIV/ lymphomas/organ transplants. Evidence of destruction of myelin at multiple sites in the CNS
PMLJC virus(papovavirus) involves Oligodendrocytes in active lesions contain characteristic
intranuclear inclusions.
In constrictive pericarditis (calcification of the anterior pericardium) a pericardial knock is heard 0. 06-0. 12
seconds after the aortic valve closes. This corresponds to the sudden cessation of ventricular filling.
Hypertrophic heart disease is the best recognized cause of diastolic dysfunction
ECG P waves preceding the QRS complex but no two P waves have the same morphology Multifocal
atrial tachycardiaVariable P wave morphology and PR and RR intervals associated with severe
pulmonary diseasecontrol of this tachycardia comes with improved ventilation and oxygenation.
HSV is thought to cause encephalitis following transport to the brain along the trigeminal nerve.
HIV with pneumocystis showing respiratory distress oxygen saturation on room air is 71% Rx intravenous
trimethoprim-sulfamethoxazole and prednisone given in any patient showing significant respiratory
distress or room air oxygen saturation of less than 75 % otherwise in HIV Steroids are only given if the
question of adrenal insufficiency, a common complication of HIV, is suspected.
HIV patient with watery diarrhea typical small bowel-type diarrhea(weakness & weight loss)most
common etiology cryptosporidiosisspores can be seen on the tips of the villi on biopsy.
Hypotension always accompanied with Tachycardia but when it is associated with Bradycardia It is vagal
response Rx Atropine.E.g: post AMI
Amyotrophic lateral sclerosis is a progressive motor neuron disease that affects both upper and lower motor
neurons. Patients present with a gradual onset of asymmetric weakness of the distal limb. Even in advanced
disease, sensory and bladder function are preserved. On exam, there is hyperactivity of muscle stretch
reflexes.
If autonomic dysfunction is suspected in a diabetic patient, a useful maneuver on physical examination is to

look for a decrease in heart rate in response to the Valsalva maneuver (forced expiratory effort against a
closed airway).
Meniere disease = tinnitus, vertigo, and progressive hearing loss thought to be related to a degeneration of
the vestibular and cochlear hair cellsRx includes bed rest, a low-salt diet, dimenhydrinate, cyclizine or
meclizine.
Heparin-induced thrombocytopenia (HIT) is the result of platelet aggregation (platelet count falls below
50,000/mm3) caused by heparin-induced antibodieslead to limb-threatening thromboses and constitutes
a medical emergency (Arterial thrombosis is a manifestation of the HIT syndrome) Rx discontinue heparin
and use lepirudin.
An atypical gastric upset, heartburn, indigestion may turn out to be a myocardial ischemia ++> Look for
objective signs of sympathetic activation including sweating, anxiety, tachypnea, and tachycardia or lightheadedness, dyspnea, orthopnea, cough, nausea and syncope. An ECG examination is imperative in any
patient presenting with this symptomatology. A normal tracing is rare with acute MI.
Cerebellar bleed
abrupt onset
lucid patient
cerebellar tonsillar herniation
should be evacuated as soon as possible before coma ensues
Cerebral bleed
develops slowly
early loss of consciousness
No herniation
No such need
The most common cause of chronic AF is valvular disease, followed by congestive heart failure (CHF).
The most common anatomic correlate seen in patients with AF (Framingham Heart Study) is an enlarged left
atrium.
Otosclerosis may progress more rapidly in pregnancyRx hearing aids; severe cases may respond to
removal of the stapes with implantation of a prosthesis
Amylodosis: echocardiogram reveals ventricular walls with a "speckled pattern restrictive

cardiomyopathy ventricular filling is impaired and the cardiac silhouette may be mildly enlargedECG
nonspecific arrhythmias Like all restrictive ds develops into diastolic dysfunction.
The pulmonary artery catheter/Swan-Ganz catheter allows direct, simultaneous measurement of pressures in
the right atrium, right ventricle, pulmonary artery, and the filling pressure ("wedge" pressure) of the left
atrium elevated right-sided pressure and low wedge pressure Rt ventricular infarct? Causing backing up
of venous blood and decreased forward flow, producing a decrease in left ventricular filling, Rx aggressive
fluid administration.
A communication between an arteriole and venule in the cecum is a description of a vascular ectasia, also
known as an arteriovenous (AV) malformation. This a common cause of painless colonic bleeding in the
elderly and may present with acute gastrointestinal bleeding,chronic gastrointestinal bleeding, or irondeficiency anemia. These lesions may be difficult to demonstrate, as the bleeding may be intermittent or the
colon may be so full of blood that the site of origin is obscured. Techniques used to demonstrate bleeding AV
malformations include colonoscopy, intraoperative endoscopy, and visceral angiography. Treatment of these
lesions is problematic because many patients will subsequently develop new or recurrent bleeding vessels.
Having difficulty holding and using a writing instrument due to hand and forearm spasms no medications,
dizziness or loss of consciousness or any history suggestive of a seizure focal dystonia of unknown cause.
CardioversionSynchronized electrical cardioversion is the process by which an abnormally fast heart rate
or cardiac arrhythmia is terminated by the delivery of therapeutic dose of electrical current to the heart at a
specific moment in the cardiac cycle as determined by a compute0r(Pharmacologic cardioversion uses
medication) Synchronized electrical cardioversion is used to treat hemodynamically significant
supraventricular (or narrow complex) tachycardias, including atrial fibrillation and atrial flutter. It is also
used in the emergent treatment of wide complex tachycardias, including ventricular tachycardia, when a
pulse is present. Pulseless ventricular tachycardia and ventricular fibrillation are treated with
unsynchronized shocks referred to as defibrillation.
So,hemodynamically unstable(loss of consciousness)vetricular tachcardia treat with asynchronous
cardioversion.
Hypertensioneye tries to protect itself from the hypertension arteriolar constrictionthickening of the
arteriolar walls (producing the broad light reflex) arterioles squeeze down too hard superficial foci of
retinal ischemia(cotton wool spots) hemorrhage and deposits occur because of vessel damage with leakage
of contents.Hypertensive retinopathy seen in chronic essential hypertension, malignant hypertension, and
toxemia of pregnancy. Rx control of the hypertension. (Practically, progression can be stopped and the
hemorrhages will resolve, but the vessel changes remain.)
Nonproliferative diabetic retinopathy= hemorrhage and exudates in the retina + microaneurysms (visible as
red dots).
Proliferative diabetic retinopathy = nonproliferative diabetic retinopathy +neovascularization with vessel

growth into the vitreous.
Brain-death no electrical activity and no clinical evidence of brain function on physical examination (no
response to pain, absent cranial nerve reflexes ,pupillary response:fixed pupils, oculocephalic reflex, corneal
reflexes), absent response to the caloric reflex test and no spontaneous respirations. But patient without such
criteria but with no purposeful activity one week after an anoxic brain injury bodes poorly for a meaningful
neurological recovery!(Not a brain death but recovery not meaningful).
Whenever you see a case with a link to water reservoir/source like cruise/hospital/air-conditioner system and
patient developed mental changes + diarrhea + Pneumonia = DDx Legionnaires pneumonia Rx Erythromycin
Yersinia enterocolitica: Right lower quadrant pain mimicking appendicitis with symptoms of an acute ileitis
and diarrhea (In appendicitis patient typically have difficulty moving their bowels). Acquired through the
fecal-oral route and diagnosis is based on clinical suspicion and the finding of the organism in stool cultures.
Campylobacter jejuni: acute onset of either watery or bloody diarrhea consistent with colitis, severe fecal
urgency, nocturnal bloody diarrhea sigmoidoscopy reveals continuous, symmetric inflammation from the
anal verge to the proximal sigmoid colon diarrhea in all age groups/peak of incidence is in young
childrenFecoral spread
Intentional inhalation of volatile hydrocarbons(model glue, correction fluid, spray paint and gasoline) in a
large quantity = "quick drunk": resembles alcoholic intoxicationvery high dose ataxia, hallucinations, and
nystagmus Encephalopathy is the major chronic morbidity (Hydrocarbons are highly lipophilic leading to
CNS damage) high level of suspicion is needed no drug screen test that can detect inhalant
hydrocarbons.
Rubella vaccine Gap of 3 months to be pregnant(theoretical risk of exposure to the rubella virus through
vaccination)But if pregnancy occurs within 3 months after vaccinationnot an indication or a reason to
terminate the pregnancy(Simply woman should be counseled about the theoretical risk).
Neonatal especially preterm steatorrhea due to smaller bile acid pool substitute medium-chain
triglycerides (MCTs) in the formula for long-chain triglycerides (LCTs)MCTs do not require bile acids for
absorption.
Milestones:
1. 4-years draw a four-sided figure (i.e., a square), count to 4, identify four colors, say a four-to
five-word sentence, and draw a picture of a person with at least four parts. (Easily remembered as
4-year-olds do things in 4's.)
2. 5 yrs Drawing a triangle,count to 10, repeat a 10-syllable sentence, and draw a picture of a
person with 8-10 parts
3. 6 yrs Building a staircase with cubes,can perform simple addition and draw a person with 12-15
parts.
4. 7- yrs ability to repeat five digits,can repeat three digits backward, draw a diamond shape, and
draw a person with 18-22 parts.
Mitral valve prolapse =An apical click followed by a late systolic murmur Rx antibiotic before Dental
procedure
Mitral and tricuspid regurgitation = produce holosystolic murmurs with relatively uniform intensity. Mitral
regurgitation is heard at the apex while tricuspid regurgitation is best heard along the lower left sternal
border.
Mitral stenosis= mid-diastolic murmur heard after an opening snap.
nasal foreign body: frequent sneezing and obstruction(Often misinterpreted as a common cold or allergy)
infection develops resulting in a purulent and malodorous dischargeunilateral involvement
A saturation of 90% corresponds to an oxygen partial pressure of around 60 mm Hg =Hypoxia needs oxygen
hepatitis A diagnosis is best made by determination of IgM levels against hepatitis A virusacute
infection(antibody peaks at 4-6 weeks and does not persist beyond 6 months)while IgG is produced in the
primary infection, but for most viral infections, including hepatitis A, it persists for a life time.
Attention deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, and

inattention lasting at least 6 months and disorder must have started before age 7.
Cardiac defects:
1. Hypoplastic Lt heart syndrome: underdevelopment of the left cardiac chambers(left atrium and
ventricle often exhibit endocardial fibroelastosis), atresia or stenosis of the aortic and/or the mitral
orifices, and hypoplasia of the aorta No murmur, precordial hyperactivity(enlarged right
ventricle is contracting against systemic pressure), loud second heart sound (because the
pulmonary artery acts as the aorta by pumping blood to the systemic circulation through the ductus
arteriosus). When the ductus closes, or when the pulmonary vasculature resistance falls, the flow to
10
2.
3.
the systemic circulation will decrease, causing greatly diminished peripheral pulses. Management
includes infusion of prostaglandin E1 and administration of room air while on a ventilator.
Prostaglandin E1 may open the ductus arteriosus and restore systemic blood flow.
Total anomalous pulmonary venous return:pulmonary veins forming a confluence behind the left
atrium, and draining into the right atrium Complete mixing takes place in the right atrium
right-to-left shunt through the foramen ovale to the left side of the heart Often, no murmur is
heard chest roentgenogram often shows a normal heart size with pulmonary edema. If there is
obstruction to pulmonary venous return, as is almost always present with veins draining inferior to
the diaphragm, cyanosis can be very prominent.
Neonate becomes cyanotic then lost consciousness following feeding or when crying vigorously
baby picked her up and held infant regained hypercyanotic spells or "Tet spells"TOF
DDx Frequent cyanosis and difficult breathing following birth but improves while
cryingChoanal atresia Rx intubation via oropharynx
Post infectious Bells palsy:Mostly EBV
CHF in infant: respiratory distress, tachycardia and/or hyperdynamic precordium, and cardiac enlargement
evidenced by echocardiogram. DDx left-to-right shunt (ASD, VSD, PDA, atrioventricular canal, or AV
fistula), left-sided obstruction leading to myocardial dysfunction (severe coarctation or AS), or intrinsic
myocardial dysfunction (myocarditis, cardiomyopathy, or infarct due to anomalous coronary artery). Rx IV
furosemide provide quick symptomatic relief and improve respiratory distress.
Rx streptococcal pharyngitis is oral penicillin V for 10 days. However, Benzathine penicillin G can be given
as a single dose intramuscularly. It is a long-acting antibiotic and can complete the treatment:Prevention of
Rheumatic heart Ds in a noncompliant patient
Patients with sickle cell disease are at risk for infection by Salmonella and other gram-negative bacteria
increased risk for acute recurrent Salmonella osteomyelitis. However, even in patients with sickle cell
disease, Staphylococcus aureus is still the most common pathogen for osteomyelitis.
Children <3 years with harsh, barking cough(sounds like a seal),runny nose but no fever or drooling +
hoarse with inspiratory stridor Acute laryngotracheobronchitis (viral croup)
DDx
1. Epiglossittis fever, drooling, muffled voice, cyanosis, and soft stridor.
2. Laryngomalacia persistent stridor that is first noted early in infancy
Tanner stages:
1. Stage I (0-15yrs): preadolescent breast development with no pubic hair.
2. Stage II(8-15 yrs)breast budding or thelarche + small pubic hair near the labia + growth spurt
3. Stage III :more pubic hair
4. Stage IV (10-17yrs) breast and nipple enlargement with some contour separation of the areola is
noted. Hairs adult quality but not distribution.
5. Stage V (12-18 yrs) complete breast enlargement with no contour separation of the areola. Pubic
hair is of adult quality and distribution.
Neonatal Group B Streptococcus (GBS): Early-onset / first week of life: involve the respiratory tract causing
pneumonia .Late-onset (weeks 2 and 4): meningitis.
Long Q-T syndrome (LQTS):50% familial: syncope and sudden death from torsades de pointes (TDP).
1. Romano-Ward syndrome has autosomal-dominant transmission;
2. Jervell-Lange-Nielsen syndrome has autosomal-recessive transmission.(High Mortality)
On ECG QT prolongation (QTc averages 0. 49 seconds).
Rx beta-blocker or implantable cardiac defibrillator in resistant cases.
Child's recurrent leg painsBilateral(Organic pain :Unilateral) occurring soon after going to
bedrelieved from rubbing his legs and knees no limp and is able to participate in sports activities
"growing" pains but unrelated to growth(affect 3-10 years).
Metabolic alkalosis in cystic fibrosis due to excess sweating (summer)infants & dehydration
hyponatremic, hypochloremic, metabolic alkalosis
11
Breast-feeding jaundicedecreased intake and increased enterohepatic circulation.
Any ingested toxic substance/overdose presented within 60 mints Gastric lavage+ Add charcoal if possible
Hypernatremic dehydration: hypotonic fluid loss (history of diarrhea or vomiting),inadequate supply of

mother's milk or high concentration of sodium in mothers milk irritable,lethargic infant and have a highpitched cry Complication like intracranial hemorrhage
Intussusception usually occurs within the 6 to 12-month-old age group
Conscious Sedation minor procedures like suturing laceration able to maintain airway patency,
protective airway reflexes and responses to physical stimuliUse short-acting or long-acting benzodiazepine
(midazolam or diazepam, respectively) by the oral or rectal route for (Intravenous midazolam or diazepam
can be used for procedures that produce more intense pain or discomfort, such as repair of complex
lacerations, bone marrow aspiration, and reduction of fractures)
"Do's" and "Don't's." during the seizure episodedon't Put any object into the patient's mouth,do Place the
patient on the side,Put a pillow or other soft object under the patient's head,Loosen tight clothing around the
neck,Remove sharp objects from the surroundings.After the seizures, caretakers or parents should remain
with the patient until he/she is fully alert and allow him/her to go back to the usual activities.
Child with ecchymosesEliminate bleeding abnormalities by coagulation studies Normal studyThink

about Abuse!
Triad of thrombocytopenia (hemorrhage may be the presenting complaint), eczema, and recurrent infections
(often respiratory) Wiskott-Aldrich syndrome(X-linked recessive) defects in both T and B cell
functionvulnerable to pyogenic bacteria, viruses, fungi and Pneumocystis cariniioften died by age 15
and survivors have increased incidence of cancer (lymphoma /ALL) Rx splenectomy, continuous
antibiotic therapy, IV immunoglobulin, and bone marrow transplantation.
Severe combined immunodeficiency (Autosomal recessive) "bubble boy" disease because its victims are
extremely vulnerable to infectious diseasesadenosine deaminase deficiency (purine salvage enzyme and
deficiency leading to turn off DNA synthesis)Low T/B cells counts.
X linked SCIDmutations in gene encoding the common gamma chain (c),shared by the receptors for
multiple interleukins affects development and differentiation of T and B cellsAll males with the
defective gene will have SCID Females are carriers.
Bruton agammaglobulinemiaCellular immunity is intact mature B-lymphocytes do not

formgerminal centers are absent in lymph nodes infections after about six months (maternal antibodies
have decreased)recurrent pyogenic infections, particularly of the lungs, sinuses, and bones.
Common variable immunodeficiency syndromeClinically same as Brutons but onset in late

adolescence/young adulthoodhypogammaglobulinemia with markedly decreased IgMfailure of Blymphocytes to differentiate into plasma cells patients have an increased risk for B-cell lymphomas, gastric
carcinoma, and skin cancer
Meconium =fetal stool(desquamated cells from the gastrointestinal tract admixed with enough bile to give the
soft stool a greenish color)distressed fetus will pass meconium into the amniotic fluid and then may
aspirate itIn maternal preeclampsia, hypertension, or postmaturityaspirated meconium is very irritating
to the lungs and causes a chemical pneumonitisRx prompt suction of the nasopharynx and mouth
Kawasaki disease:systemic vasculitis of unknown originmucocutaneous lymph node syndromeClinical

and echocardiographic features remain the basis for diagnosisAn (unidentified) infectious origin and a Tcell immune activation Fever, bilateral non-exudative conjunctivitis, mucous membrane changes (injected
pharynx, cracked lips, or strawberry tongue), extremity changes (edema, desquamation, erythema, or rash),
and cervical adenopathy myocarditis, valvular insufficiency, arrhythmias, pericardial effusion, and
congestive heart failureLeukocytosis and an elevated C-reactive protein are associated with the
development of coronary artery aneurysmsRx aspirin ,IV immune globulin &
Corticosteroids(Controversial:Reduces coronary artery aneurysm?).
12
The most commonly abused drug by pregnant mothers is cocaineInfants small for gestational age (SGA)
and sometimes,microcephaly and neurodevelopmental abnormalitiesirritable and cries in high-pitch.
increased risk of sudden infant death syndrome & Periventricular leukomalacia.
Interesting facts that pancreatitis may show normal amylase(Rely more on lipase)
Interesting facts that Gullain Barre synd may rarely have sensory involvement
Listeriosis acquired by mothers exposed to unpasteurized dairy products or raw vegetables exposed to cattle
or sheep manureamnionitisabortion, stillbirth or neonatal sepsisbrown, murky amniotic fluid or
Disseminated disease in the fetus can cause granuloma formation (with associated tissue destruction) in many
tissues, including liver, adrenal glands, lymphatic tissue, lungs, and brain(granulomatosis infantiseptica)
Prenatal toxoplasmosisRx Treatment is with combination antibiotic therapy, including pyrimethamine,

sulfadiazine, and leucovorin.
Bupropion antidepressant with both dopaminergic and noradrenergic propertiesimprove depression

and cognitive functioning (term cognition is used in several loosely related ways to refer to a faculty for the
human-like processing of information, applying knowledge and changing preferences)also used to reduce
Nicotine craving/dependence Any drug with anticholinergic properties might impair cognitive
function(even SSRI)
Propranolol known to occasionally lead to depressive symptoms
Loosening of associationsideas are disconnected and seem to jump from one topic to an unconnected topic.
Clang associationsWords that rhyme are frequently associated.
Concrete thinking poor ability to think in abstract terms despite normal intelligence.
Tangential thoughtsthoughts that go off on a tangent, interviewer is commonly left with the sense that a
question to the patient elicited a long string of thoughts that ended up having nothing to do with the original
question.
Thought blocking occurs when thoughts and speech halt, often in mid-sentence, as if forgotten. The
thought may be picked up later, after a period of apparent confusion.
Cimetidine known to cause psychiatric effects like delusions and psychosisrelated to the effects of
cimetidine on the H-2 histamine receptor in the brain.
Electroconvulsive therapy (ECT) has been safely used in pregnancy. In case of psychotic depression with
increased risk for suicide, the situation requires expeditious treatment to protect the mother and fetus, and
ECT is the treatment of choice.
Post-traumatic stress disorderRx Sertaline
Maternity blues is a normal state of sadness, dysphoria, frequent tearfulness, and dependence that about 20%
to 40% of women experience in the postpartum period. It is thought to be derived from rapid changes in
women's hormonal levels and the stress of childbirth associated with maternity
Behavioral therapy is the most frequently used treatment in children with enuresis. Dry nights are recorded
on a calendar and rewarded with a star as a gift.
Agoraphobia(fear of open spaces or of the marketplace)is a fear of panic attacks in situations from which it
would be difficult to gracefully remove oneself. Behavioral therapy is used to encourage patients to modify
their activities.
Generally conventional antipsychotic + prophylactic anticholinergic agent (benztropine, diphenhydramine, or

trihexyphenidyl).is given togethersudden ceassation of anticholinergicPpt Extrapyramidal signs like
dystonic reaction/torticollisRx IM administration of an anticholinergic agent
Although risperidone is an atypical antipsychotic, it is like conventional antipsychotics in its ability to cause
significant elevations in plasma prolactin levels.
13
Psychomotor agitation is a series of unintentional and purposeless motions that stem from mental tension of
an individual. This includes pacing around a room, wringing one's hands, pulling off clothing and putting it
back on and other similar actions. In more severe cases, the motions may become harmful to the individual,
such as ripping, tearing or chewing at the skin around one's fingernails to the point of bleeding DDx
Psychomotor agitation in major depressive disorder > bipolar depression
Catatonia include stupor, negativism(motiveless resistance to all attempts to be moved or to all instructions),
rigidity, posturing, mutism, stereotypies, mannerisms, waxy flexibility, and catatonic excitement. Catatonia
may be associated with schizophrenia (catatonic type), mood disorders (with catatonic features), or general
medical condition or Extrapyramidal side effect of drug .
Nihilistic delusions are false feelings that the self or others do not exist or are destroyed. It is typical for
depression with psychotic features. At its extreme, it is called Cotard's syndrome.
Prescribing antidepressants in bipolar depression may un-mask underlying mania Start mood stabilizer
before beginning treatment with an antidepressant
Panic disorder Rx benzodiazepine like clonazepam or use of cognitive behavior therapy, which incorporates
exposing the patient to disturbing stimuli in an attempt to develop coping mechanisms in response to the
stimuli.
Adjustment disorder is exemplified by a set of behavioral or emotional symptoms developing as a response to

an identifiable stressor within 3 months after exposure to the stressor. The symptoms are excessive compared
with what one would expect from the exposure, and they cause marked impairment in social functioning.
Any event that affects the vasculature, such as a myocardial infarction or a cerebrovascular accident (CVA),
has been shown to increase the risk of major depressive disorder in the months following such an event.
Post-stroke mania is a rare phenomenon usually seen in infarctions of right frontal lobe and sometimes
other parts of the right hemisphere.
Pemoline is a sympathomimetic agent approved for the treatment of attention deficit/hyperactivity disorder.
Given the rate of reported cases of hepatic failure. Dextroamphetamine is approved for the treatment of
attention deficit/hyperactivity disorder. Its main adverse reactions involve the cardiovascular system, the
CNS, the gastrointestinal system, and the endocrine system.
Prevalence of ADHD is estimated to decline by 50 % every 5 years until the mid-20's i.e. older the children
get without symptoms of ADHD, the less likely they have the disorder. (Generally manifest before 6-7yrs)
Mini-Mental Status Examination (MMSE) is a brief instrument designed to grossly assess cognitive
functioning. It assesses orientation, memory, calculation, reading and writing capacity, visuospatial ability,
and language. The maximum score is 30. can be re-administered periodically to follow progression of
dementia.
prochlorperazine and haloperidol administration feeling of restlessness & agitation(akathisia)Rx

lorazepam given IV during administration of the neuroleptic drug.
The most serious side effect of lamotrigine(adjunct in the treatment of refractory seizures and bipolar
disorder) is rash (skin changes that looked like burns.)Stevens-Johnson syndrome
Clozapine is an atypical agent more effective in resistant schizophrenia. It exerts an antagonistic effect on D1
and D4 receptorsS/E agranulocytosisrequires regular blood count monitoring
14
15
Thyroid nodule? Benign or malignantnodule large enough to cause airway or digestive tract
obstruction emergent thyroid surgery without further evaluation.
Step-1:TSHDecreased =hyperactive nodule=typically benignA
Step-2:TSHNormal or elevated TSH = non-functioning or normally functioning nodule.
Step-3:Imaging and/or a biopsy to obtain a tissue diagnosisultrasoundmost useful diagnostic tool
fine needle aspirate (FNA)result from an FNA
1. First, the sample can represent benign lesions= no further treatment (unless the lesion
continues to grow causing obstruction to breathing or eating, or causing unacceptable cosmetic
disfigurement in the neck).
2. Second, the specimen can be a follicular lesion = treated with a surgical removal of part or all
of the thyroid gland to determine whether it is a benign or malignant type.
3. Third, the biopsy can show a clearly malignant lesion = treated with surgical removal of the
thyroid gland.
4. Finally, the sample can be nondiagnostic = requires a repeat FNA. However, after three
nondiagnostic biopsies, a surgical removal of the affected thyroid lobe is usually
recommended.
Approach towards Breast Lump:

1.
2.
Nipple discharge: Pathologic discharges are spontaneous, bloody or associated with a mass. These
discharges are usually unilateral. The most common cause of pathologic nipple discharge is intraductal
papilloma, followed by duct ectasia.10 If a palpable mass is present in association with a discharge, the
likelihood of cancer is greatly increased.
Dominant breast mass:DDx macrocyst (clinically evident cyst), fibroadenoma, prominent areas of
fibrocystic change, fat necrosis and cancer.
16
(a)Solid Masses in Women Less Than 40 Years of Age

1.
2.
3.
4.
Physical Examination No evidence of mass reassured and instructed in breast self-examination.

Physical Examination physical finding is uncertain directed ultrasound examinationnot demonstrate
a massRepeat physical examination?mammogram (35 to 40 years not in younger)
Physical Examination dominant mass (? suspicious mass is solitary, discrete, hard and often, adherent to
adjacent tissue) mammographypathologic diagnosis.
Physical Examination dominant mass (? Not a suspicious mass or clinically benign) discus options of
surgical excision or follow-up with the patientpatient desires surgical excisionno additional testing is
donepatient opts for further work-upan ultrasound examination and fine-needle aspiration are performed
to confirm that the mass is benign. "Triple test" (clinical examination, ultrasonography [or mammography]
and fine-needle aspiration).
The size of the lesion must be measured with a ruler at presentation and on subsequent visits to allow an
accurate assessment of size over time.
patient is examined every three or four months for one year to ensure stability of the mass.
(B)Solid Masses in Women More Than 40 Years of Age.

1.
2.
3.
Abnormalities detected on physical examination in older women should be regarded as possible cancers
until they are documented to be benign.
mammography is a standard part of the evaluation of a solid breast mass.
In the presence of a dominant breast mass, a normal mammogram should never be considered proof of
the absence of breast cancer.
Premenstrual dysphoric disorder: constellation of physical and emotional symptoms occurring during the
late luteal phase of the menstrual cyclesymptoms must be present during most cycles in the past year and
during at least two subsequent cyclesat least five of the following symptoms: depressed mood, marked
anxiety, affective lability, decreased interest, decreased energy, sleep disturbance, craving food, feeling
overwhelmed, and difficulties concentratinginterfere with social or occupational functioning and are not
due to other psychiatric or medical disorders.
Exposure therapya type of behavior therapymost commonly used treatment of specific phobia
desensitizes the patient by a gradual exposure to the phobic stimulusRelaxation and breathing control are
important parts of the treatment.
Alprazolam belongs to the group of short-acting benzodiazepines. Even though it has a short half-life, it can
produce confusion, disinhibition, and amnestic problems like blackouts in the elderly population. The risk is
increased if it is combined with CYP3A inhibitors.
In pseudodementia of depression, the patient often tends to emphasize disability related to memory loss much
more than patients experiencing true dementia.
Olanzapine is an atypical antipsychotic indicated for the management of psychotic disorders. It is said to be
associated with weight gain.
HIV dementia is characterized by affective, cognitive, behavioral, and motor symptoms and signs. It presents
as a subcortical process and is most likely to occur in patients with a CD4 count below 200/mm3. It usually
has a slow onset, and, after a period of stability, there can be a precipitous decline. The diagnosis is made
when other causes of delirium are excluded; the disease may present with psychosis within HIV dementia.
The symptoms are controlled with low doses of neuroleptics.
Circumstantiality refers to speech that is delayed from reaching the point, characterized by overinclusion of
details.DDxTangentiality : patient never gets to the desired goal from the starting point of discussion.
Patients with disorganized type schizophrenia are likely to exhibit disorganized speech, disorganized
behavior, and flat or inappropriate affect. Examples of disorganized thoughts and speech include: loosening
17
of associations or derailment, flight of ideas, tangentiality, circumstantiality, word salad, neologisms, and
clang associations.
The newer atypical antipsychotics have minimal, if any effect on plasma prolactin concentrations, except for
risperidone, which is associated with elevated prolactin.
A Papanicolaou smear should ideally be a sampling of the transformation zone(adequate sample should show
endocervical cells)endocervical cells not present?whether the transformation zone was fully
sampledRepeat the sample if high risk individual or after 1 yr if with no high risk and had all earlier pap
normalEvery woman should have yearly pap smear after first intercourse or 18yrs whatever comes earlier
Rarely struma ovarii is a cause of hyperthyroidism and patients with this manifestation may have symptoms
of hyperthyroidism, as well as elevated levels of thyroid hormones and decreased levels of thyroid
stimulating hormone (TSH).
There is no evidence that breast-feeding increases HCV transmission to the baby.
Postpartum endometritis Cesarean section is the major risk factorOrganisms ascending from the vagina
and causing a polymicrobial infection of the endometrium fever and chills, lower abdominal pain, a foulsmelling vaginal discharge and malaise abdominal tenderness, and uterine tendernessRx clindamycin
and gentamicin ( prophylactic antibiotics are recommended in all cases of nonscheduled cesarean delivery
i.e. a cesarean delivery that is not anticipated like with membranes broke but non-progressing/Breech etc and
are given before or after the umbilical cord is clamped)
Discharge criteria patient should be alert, able to ambulate (if this was her preoperative level of function),
able to tolerate adequate oral intake(Patient on IV intake should not be discharged), have stable vital
signs, and have satisfactory bowel and urinary tract function.
Chorioamnionitis (can develop at any time before and during delivery)fever and uterine tendernessRx
ampicillin or penicillin with gentamicin.
Asymptomatic bacteriuria in pregnant womenassociation with preterm delivery/low birth weight Rx

trimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexinfollow-up urine culture after 10 days of
completing the medicationtest-of-cure.
Gestational diabetesusually diagnosed by means of oral glucose tolerance testingPatients with

gestational diabetes and normal fasting glucosetwo major risksfetal macrosomia & eventual
development of overt diabetes(within the next 20 years)with gestational diabetes and abnormal fasting
glucose increased risk of stillbirth.
Significant mitral stenosis during pregnancy should be monitored invasively using a Swan-Ganz catheter
second stage of labor be shortened using forceps or vacuum to prevent excess maternal Valsalva efforts and
maternal tachycardia.
HIV Positive mother combination of ZDV therapy + cesarean delivery decreases the risk of transmission
to approximately 2% Amniocentesis should be avoided, if possible, in the HIV-positive woman.
1. 2% vertical transmission with ZDV + Scheduled CS prior to the onset of labor or rupture
of membranes
2. 8% antiretroviral therapy in mother + Infant
3. 25% when none used
Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is
12 1/2 years, but it may be delayed until 16 or may begin as early as age 10.
Current recommendations are that pregnant women who will be in the second or third trimester during the flu
epidemic season should be given the influenza vaccination.
"once a cesarean, always a cesarean." This is no longer the case. Some women are allowed to
approximately 70% of all women attempt vaginal birth after a prior cesarean delivery will be successful.
18
Face presentationCauses: anencephalic fetus, pelvic contraction, and high parityvaginal delivery is
possible when the fetus is in a mentum anterior position (i.e., the fetal chin is oriented toward the maternal
pubic symphysis.)Fetus can flex its head, thereby allowing delivery Vacuum delivery /Forceps delivery
with a non-vertex presentation would be contraindicated.
The presence of a classic uterine scar (vertical incision into the uterus that extends from the lower uterine
segment up into the active myometrial portion toward the fundus of the uterus) mandates elective repeat
cesarean delivery when the fetus is mature as patients with a previous classic cesarean delivery have roughly
a 10% risk of uterine rupture.
Oxytocin or Prostaglandin (PGE2) gel is an effective agent to use for labor inductionshown to improve the
Bishop's score, to shorten the length of labor and delivery, to decrease the amount of oxytocin needed, and to
decrease the cesarean delivery ratemain complication from its use is uterine
hyperstimulationincreased frequency of contractions (greater than 5 every 10 minutes) or an increased
length of each contraction (greater than 2 minutes) or contractions of normal duration occurring within 1
minute of each other and a non-reassuring fetal heart rate tracing Rx IV or subcutaneous terbutaline or IV
magnesium sulfate(MgSo4 also most effective medication for seizure prophylaxis in women with
preeclampsia) in case of PGE2 or discontinuing the oxytocin (bradycardia to the 80s) or reducing its dosage
(where the fetal heart rate tracing is not as non-reassuring)
Home uterine activity monitoring (HUAM) women are monitored at home with a tocodynamometer (a
way to measure uterine contractions)will allow for preterm labor to be recognized and treated in its earliest
stagesto prevent preterm birthsIn practice not been proven to prevent preterm birthpossible benefit
early recognition of preterm laborwould allow for the administration of corticosteroids to bring about fetal
pulmonary maturity (Steroid administration in a Diabetic mother may lead to increased dosage of Insulin).
Fetal scalp sampling (FSS):method of fetal assessment with fetal blood pH When the fetal heart rate
tracing is not reassuring, FSS can be used to determine the acid-base status of the fetus, which will help with
management of the laborpH is > 7.25 then the patient may be managed expectantly pH is between 7.20
and 7.25:repeat in 15 to 30 minutespH is < 7.20, steps should be taken to bring about delivery(Acidemia
likely to cause damage to the fetus appears to occur at values < 7.00, by using a cutoff of 7.20, there is a
margin for error to protect the fetus)
Forceps and the vacuum extractorTo expedite the deliveryindications:

1. non-reassuring fetal heart rate tracing,
2. maternal exhaustion
3. maternal contraindications to pushing (such as maternal cardiac disease.
Choice of forceps or vacuum ? Forceps may be used in face presentation with a mentum anterior
presentation(vacuum is contraindicated) Vaccum extractor does not occupy space next to the fetal head;
this should lead to less trauma to maternal tissuesBoth the vacuum and forceps should preferably be used
only in low- or outlet- situations (i.e., with the fetal vertex at +2 station or lower.)
A major advantage of chorionic villus sampling is that it can be performed at 10-12 weeks, as opposed to
amniocentesis, which is performed in the second trimester. CVS thus allows a woman to undergo an earlier
termination than amniocentesis allows for. However, there is some evidence that one subtype of limb defect,
called transverse digital deficiency, is more common with CVS.
The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the vagina at the
5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the
posterior vagina.They undergo rapid growth during the process of puberty and they shrink after the
menopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst resultscyst
becomes infectedBartholin's abscesspolymicrobial /gonococcus implicated in 25% Rx placement of a
Word catheter.( This is a small balloon-tipped catheter)allows drainage of the cyst and the formation of an
epithelialized tract that will allow continued drainage once the catheter is removedtract should prevent the
cyst from reformingIf Bartholin's cysts continue to form in spite of the use of the Word catheter, a
marsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding
skin to prevent re-closure and re-formation of the cystinterestingly; one cannot make this assumption in a
postmenopausal patientcystic mass on the vulva in a postmenopausal woman must be biopsied(as there is
a higher likelihood that this lesion represents a Bartholin's gland carcinoma)
High-grade squamous intraepithelial lesion (HGSIL) will progress to invasive cervical

cancercolposcopically directed biopsydiagnosis of HGSIL is confirmedthe distribution of the lesion
19
is known, removal or destruction of the entire transformation zone should be performeddone with a loop
electrode excision procedure (LEEPa thin-wire loop electrode is used to excise the entire transformation
zoneLEEP can thus be used as both a diagnostic and therapeutic procedure immediate risks of LEEP are
bleeding and infection. The possible long-term risks include cervical incompetence and cervical stenosis.
The American Heart Association guidelines for the prevention of bacterial endocarditisantibiotic
prophylaxis is not necessary for cesarean delivery or normal vaginal delivery Except patient with "high
risk" cardiac conditions, which include women with a history of endocarditis, or who have prosthetic heart
valves, complex cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts
Mitral valve prolapse if associated with mitral regurgitation (demonstrated by Doppler or a murmur) is
considered a moderate risk condition and therefore antibiotic prophylaxis is not necessary.
Physiologic leukorrhea can be seen during 2 different periods of childhood. Some female neonates develop a
physiologic leukorrhea shortly after birth as maternal circulating estrogens stimulate the newborn's
endocervical glands and vaginal epithelium. Physiologic leukorrhea can also be seen during the months
preceding menarche. During this time, rising estrogen levels lead to a whitish discharge not associated with
any symptoms of irritation or infection.
With each uterine contraction, blood flow to the placenta decreases, and the fetus is exposed to transient
hypoxia. As the labor progresses and more and more contractions occur, this hypoxia can eventually lead to a
change from aerobic to anaerobic metabolisfetal academiamost fetuses tolerate the stressprotective
mechanismsincluding a blood buffering system and the diving reflex (a lowering of the heart rate in times
of hypoxic stress)Electronic fetal monitoring is used to determine whether the fetus is becoming
dangerously acidemic or "stressed"? But many fetuses with a non-reassuring fetal heart rate tracing do not
have academiaThus, the delivery of many fetuses is expedited because of the concern for fetal acidemia
when, in fact, the fetus is not acidemic at all!
Group B Streptococcus part of the normal bacterial colonization of many women which women will
receive antibiotics during labor? likelihood of infection is increased if following risk factors are present:
1. The five risk factors are: 1. History of a GBS-affected neonate. 2. Urine culture with GBS (GBS
bacteriuria) 3. Preterm labor (<37 weeks). 4. Membranes ruptured for greater than eighteen hours
in labor. 5. Temperature greater than 38.0 C (100.4 F) in labor. A woman with any one of these five
risk factors should receive antibiotics in labor.
2. also provide antibiotic if pregnant women being screened for GBS and found positive at 35 to 37
weeks with a culture of the vagina, perineum, and anus.
Rx penicillin.
Needle prick injury may transmit HBV>HIV during operative procedures etc
BRCA1 is associated with high risk for breast and ovarian cancer.
BRCA2 is associated with a high risk of female and male breast cancer.
But total number of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentage
of the total number Therefore, screening of the general population is not recommended.
RhoGAM (anti-D immune globulin) is given at 28 weeks' gestation, within 72 hours after the birth of an Rhpositive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis, threatened
abortion, antenatal bleeding, external cephalic version, or abdominal traumaThe amount is 300 g (covers
a fetal to maternal hemorrhage of 30 mL or 15 mL of fetal cells)when fetal to maternal hemorrhage in
excess of this 30 mL like with manual removal of the placenta (like this patient had) or placental abruption.
To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a
Kleihauer-Betke test This acid-dilution procedure allows fetal red blood cells to be identified and
counted.
Aspiration pneumonitis is a major cause of anesthesia-related death in obstetrics Rx treatment positivepressure ventilation with 100% oxygen administered through an endotracheal tube when an epidural is
going to be placed, the patient should be given an antacid
Two of the major risk factors for uncomplicated UTI are sexual intercourse and hypoestrogenism.
Hypoestrogenism is believed to be a risk factor for UTI because it is known that postmenopausal women not
receiving estrogen replacement therapy (ERT) are at greater risk for developing a UTI compared with those
women who do use ERT.
20
There is no effective screening test for endometrial cancer .It is not cost-effective to screen asymptomatic
women for endometrial cancer.
Cancer screening should be an essential part of an annual examination. Colorectal cancer screening should
begin at age 50 with no significant family history. Screening consists of a digital rectal examination with
fecal occult blood testing. This can be performed at the same time that pelvic examination is performed.
Sigmoidoscopy should be performed every 3-5 years.
Various studies have also shown that rates of preeclampsia, placental abruption, and heart failure may be
increased in pregnant patients with hypothyroidism. Pregnancy often leads to an increased requirement for
thyroid hormone replacement (thyroxine) as the pregnancy progresses.
Coumadin is contraindicated during the first trimester because of the risk of birth defects. Coumadin
embryopathy is a syndrome consisting of nasal hypoplasia and stippled vertebral and femoral epiphyses.
Second- and third-trimester exposure to Coumadin can lead to hydrocephaly, microcephaly, ophthalmologic
abnormalities, fetal growth retardation, and developmental delay. Low-molecular-weight heparin has been
shown to be an excellent anticoagulant because it has a longer half-life and a more predictable doseresponse relationship,also less likely to cause thrombocytopenia and hemorrhagic complications than
unfractionated heparin.
Tubal ligation failure may result from many factors including recannalization of the tube and poor surgical
technique. The most commonly quoted failure rate is about 1 in 100, although a more accurate figure may be
closer to 1 in 300.
Raloxifene is selective estrogen receptor modulators (SERMs) have pro-estrogenic effects in some tissues
and anti-estrogenic effects in other tissuesapproved for prevention of osteoporosisno effect on hot
flashes.
Patient post-hysterectomy for Endometrial CA asking for HRT? if any neoplasm is remaining in body it
will grow and recur earlier! +Standard risk of venous thrombosis
Hot flashes can respond to estrogen or progestin bothWhen both are contraindicated(like H/o pulmonary
embolus for estrogen or depression for progestin) Rx alternative treatment Clonidine in low doses.
Vitamin A supplementation during pregnancy is not needed or recommended for most women. In fact,
vitamin A supplementation has been associated with birth defects, including cranial neural crest
malformations. Most commonly used prenatal vitamins contain 5000 IU or less, and this is considered
acceptable.
Ovarian hyperstimulation syndrome (OHSS)in patients undergoing ovulation induction mild OHSS
(ovaries <5 cm) mild weight gain and pelvic discomfortmoderate OHSS, (up to 10 cm)least a 10-pound
weight gain, nausea, and vomitingsevere OHSS, (>10 cm) with ascites, hydrothorax, hemoconcentration,
and oliguria Rx mild cases: conservatively, more severe cases: paracentesis, thoracentesis, or surgery.
Pelvic or abdominal examinations can lead to rupture of the ovarian capsule hence ultrasound examination
is preferred.
During pregnancy: gastric acid secretion & motility is reduced and mucus secretion increased Reduced
peptic ulcer disease Similarly 70% of women with migraines will have improvement(Rx acetaminophen
and antiemetics or Codeine or meperidine may be given for severe headachesErgotamine preparations
should be avoided in pregnancy) safety of sumatriptan during pregnancy has not been established?
Mode of delivery with twin gestations:

1. Vertex-vertex twins are generally allowed to have a vaginal delivery.
2. presenting twin that is non-vertex are generally advised to have a cesarean delivery
3. Presenting twin vertex and the non-presenting twin non-vertex may decide which mode of
delivery they would preferOnce the presenting (vertex) twin has deliveredfirst option is an
external cephalic version, in which the head of the second twin is guided into the pelvis so that it
becomes a vertex presentationsecond option is a breech extraction of the second twin(Breech
extraction may be performed so long as there is an adequate pelvis, a fetal weight greater than
2,000g, an experienced physician, a flexed fetal head, and available general anesthesia)
21
DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed on
cultured amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliable
for the diagnosis of fragile X syndrome because of different methylation patterns in the trophoblast
compared with the fetus.
Kallmann syndrome (i.e., isolated gonadotropin deficiency or familial hypogonadotropic hypogonadism) can
present with primary amenorrhea ,anosmia or hyposmia, color blindness, and cleft lip or cleft palate(during
embryogenesis the GnRH neurons originally develop in the epithelium of the olfactory placode and normally
migrate into the hypothalamusThus exists the link between the midline defects and the amenorrhea)Rx
exogenous estrogen and progestin replacement therapyIf pregnancy is desired, ovulation induction can be
brought about with the pulsatile administration of exogenous GnRH.
In case of PID: The partner of the patient must be treated as well as the patient herself in order to prevent
reinfection. A test of cure (TOC) should be performed 4 to 6 weeks after treatment is given to ensure that the
organism has been completely eradicated from the patient and her partner or partners.
PID in preganacyRx Clindamycin + gentamycin
Meperidine can be used as a systemic analgesic during labor. It is an opioid and readily crosses the placenta;
therefore, the fetus is exposed to the medication. As an opioid, it causes respiratory depression. Neonates are
at greatest risk for respiratory depression when delivery occurs approximately 2 to 3 hours after meperidine is
administered to the mother.Rx nalaxone
Compound presentation:when an extremity prolapses alongside the fetal presenting partbrought about
when the pelvic inlet is not completely occluded by the fetal head(Most often with premature fetuses)
compound presentation can be allowed to undergo a normal labor and delivery.
Women of child-bearing age should consume 0.4 mg/day of folic acid starting preconceptionally and
continuing for the first 3 months of pregnancy.
Molar preganancy: Once there is pathologic confirmation of the diagnosis, it is essential that the patient
continued to be followed weekly until the beta-hCG value returns to 0. The patient should then be followed
monthly for an additional year to ensure that the values stay at 0 and that there is no evidence of persistent or
metastatic disease.
Syphillis in preganancy :Only Rx is penicillin as no other drug permits safe and effective treatment of the
fetus as well as the motherIn a patient who is allergic to penicillin, oral desensitization must be performed
first in a hospital setting with appropriate facilities.
Genital herpes: no "cure" for herpes genitalis. Acyclovir can be used to shorten the duration of symptoms. In
patients who have more than 6 outbreaks per year, daily oral acyclovir is recommended to prevent these
frequent outbreaks.
In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection
episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however,
antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis
are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be
sought.
Fluid replacement in a case of burns the Parkland calculations made by standard formulas are only an
educated guess. Once fluid administration begins, we judge its adequacy by the information provided by
urinary output and central venous pressure, aiming for an output of 1-2 mL/kg/hr, while not exceeding a
venous pressure of 10 or 15.
Parkland formula: 4 mL of Ringer's lactate x body weight in Kg x percentage of the body surface burned +
2000 mL of dextrose 5% in water
The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman,
except for two restrictions: no chemotherapy during the first trimester, and no radiation therapy during the
pregnancy. It is not necessary to terminate the pregnancy. The surgical option could be mastectomy or
lumpectomyas per the size.Should axillary nodes be positive, systemic therapy should be done later.
22
2nd postoperative day after an operative procedureurinary output in the past 2 hours has been zero (ARF
ruled out as some urine is still produced in ARF, although it is a small volume)Rule out catheter block?
Lumpectomy alone has an unacceptably high incidence of local recurrenceAlways add local radiation
therapyIf metastatic disease found in axillary nodesAdd systemic therapy. As a rule, chemotherapy is
preferred for premenopausal women & receptor positive.
Never operate a patient under GA if liver function marginal would be tipped into overt liver failure by an
anesthetic and an operation
Any gunshot wound below the nipples involves the abdomen, and the management of all gunshot wounds
of the abdomen requires exploratory laparotomy.
Compartment syndrometriggered by prolonged ischemia followed by reperfusion (the arm pressed against
the park bench until he woke up and changed position), and located in one of the two most common sites
(forearm and lower leg)reliable physical finding pain on passive extension and the diagnosis is not ruled
out by normal pulses. Only a fasciotomy will solve his problem.
Amputed finger under transportmust be kept from drying outmust not be injured with any direct
chemical agentsmust not be placed in direct contact with ice or allowed to freeze.
There is some evidence that high-dose corticosteroids administered as soon as possible after the injury will
result in a better ultimate outcome
A rough guideline to quantify water loss every 3 mEq/L that the serum sodium concentration is above
normal, represents about 1 L of water deficit E.g Na+ 155 = excess of 15 = water deficit of about 5 L.
While correcting hypernatremia the tonicity correction should not happen with the same speed with which the
volume is going to be corrected (Brain should adapt with osmolality changes) That delay is achieved by
choosing a fluid that is not pure water, but one that has some sodium in it to dampen the effect on
tonicityE.g Dextrose with half NS
Severe head trauma sufficient to produce coma + facial injuriesalways evaluate with CT to R/o bleed and
include Neck also
All failed regimen in anal fissure Opt for Forceful dilatation under anesthesia, lateral sphincterotomy, or
botulinum toxin injections
Abdominal compartment syndromethe life-saving massive fluid infusions produce severe edema in the
surgical fieldForced closure would compromise ventilation and venous returnA temporary plastic
coverage, or a mesh, allows the bowel to be protected without undue pressure.
Pelvic bone fracture Falling BP but no free fluid within abdomen Pelvic fractures can bleed massively,
and often the source is torn veins that are not easily controlledMinimizing the motion of the bone
fragments by external fixation can be helpful Comminuted fractures of the femurs are also known to be
one of the few places in the body where enough occult blood loss may occur to lead to hypovolemic shock.
Hyperthyroid state But the thyroid gland normalRadioactive iodine uptake should be high if her gland
is indeed hyperfunctioning but it will be near zero if it is suppressed by the exogenous hormone.
Breast mass found after trauma not regressing after week might not be a hematoma or fat necrosistrivial
trauma sometimes brings to the attention of the patient an area of the body that had not been examined
beforeA breast mass in a >40-year-old woman requires a mammogram and biopsy.
Gunshot wounds to the base of the neck may injure major vessels, the tracheobronchial tree, and the
esophagus diagnostic studies should precede surgical intervention if time allows
Several months after sustaining a crushing injury to armconstant, burning, agonizing pain in that
armNot responding to usual analgesic medications aggravated by the slightest stimulation of the area,
such as rubbing from the shirt sleevesarm not swollen and pulses normalneurologic function of major
23
nerves intactcausalgia (reflex sympathetic dystrophy)If sympathetic block relieves the symptoms,
permanent cure will be obtained with surgical sympathectomy.
Small umbilical hernias can close spontaneously up to the age of 2 years.
Enucleation of EyeOften done for two malignant tumorsretinoblastoma and melanomamelanoma may
present as metastatic tumour after even 20-some yearsA patient with a glass eye or missing toe and a liver
full of tumor is classic examples to illustrate the unpredictable behavior of melanoma.
Suspected Skin CA Always perform biopsy edge of the lesion offers the best information for the
pathologistAn excision before pathologic diagnosis risks doing too much (a basal cell cancer needs only 1
or 2 mm of margins) or too little (a melanoma should have at least 2 cm).
most important thing that can be done for caustic chemical burns is to wash away the caustic agent as soon as
possible
When coagulopathy develops during operative procedure provide fresh frozen plasma and platelet packs.
when hypothermia complicates the pictureClose the abdomen immediately bleeding surfaces have to
be packed, waiting for a more propitious time in which to attempt hemostasis, once coagulation function and
body temperature have improved
Diffuse esophageal spasm v/s Nutcracker esophagus on manometry there is a mean distal esophageal
peristaltic amplitude of more than 180 mm Hg, including an elevated baseline pressure in the lower sphincter
in Nutcracker (Normal pressure and relaxation in diffuse esophageal spasm).
De Quervain's tenosynovitis: Tenosynovitis of the abductor or extensor tendons of the thumb positive
Finkelstein sign (the pain produced by ulnar deviation to stretch the affected tendons).
Advanced breast CARad/chemo to make it operable
A high spinal anesthetic can produce vasomotor shock by inducing widespread vasodilation. Vasoconstrictors
are the appropriate therapy, but since the capacity of the vascular tree is also increased under these
circumstances, filling it up with additional volume is also helpful.
Follicular thyroid cancers can metastasize by way of the blood stream to the liver, lung, brain, or bones.
Because the tumor has rudimentary functional capability, it can be traced with and ablated by radioactive
iodine; however, the tumor cannot compete successfully with normal thyroid tissue for the capture of iodine.
After removal of the entire gland, the tumor becomes the most effective iodine trapper in the body.
Very tender spot in the third interspace foot(between the third and fourth toes)no redness, limitation of
motion, or signs of inflammationclassic for Morton's neuroma, a benign neuroma of the third plantar
interdigital nerve.
A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likely
cause would be a lytic lesion from metastatic breast cancer.
Post-traumatic hemothoraxcriteria to perform thoracotomy if the initial blood recovery exceeds 1000
mL, or if subsequent drainage adds up to 600 mL or more, over the ensuing 6 hours.
wound dehiscence after abdominal surgerydraining copious amounts of clear pink fluid from his midline
laparotomy woundcould have been handled by taping the wound securely Immediate surgical repair is
mandatoryNot allowed to strain abdomen or move aroundOnce the bowel came out, the problem
became an evisceration
Acute Senility within short periods of weeks Suspect chronic SDH.
In case of Pheochromocytoma presence of catabolites from epinephrine indicates that the tumor is in the
adrenal glands, and not at an extra-adrenal site.
24
When hitting the knees against the dashboard, the femurs can be driven backward and out of the acetabulum,
resulting in posterior dislocation of the hips. Because of the tenuous blood supply of the femoral heads, such
injury must be promptly recognized and treated.
Postoperative complications:
1. Atelectasis : seen on day 1
2. Fever day 3 is usually from the urinary tract infection.
3. Deep thrombophlebitis 5-7 days after surgery
4. Intra-abdominal abscess 7-10 days
Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is
prolonged hypotension. Furthermore, the mortality greatly surpasses that of a myocardial infarction de novo
(ie, unrelated to surgery), reaching upto 50-90%
heel pain every time foot strikes the groundworse in the mornings, preventing him from putting any weight
on the heelwhen the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation
plantar fasciitis.
central cord syndrome:mechanism of injury (hyperextension)relative sparing of the lower extremities in

the presence of upper extremity deficits are classic
Anterior cord syndrome all functions are lost, except for positional and vibratory sense. Those injuries occur
with blowout of the vertebral bodies.
Posterior cord syndrome is quite rare, and it would show loss of positional and vibratory sense.
Anorectal signs and mass with Inguinal nodes has to be anal SCCAdenoCa of rectum will never
metastasize to inguinal nodes.
Ogilvie syndrome is the acute pseudoobstruction and dilation of the colon in the absence of any mechanical
obstruction in severely ill patients
Brain tumor with increased intracranial pressuredevelopment of hypertension and bradycardia (Cushing's
reflex) signifies that the brain has run out of compensatory mechanisms to minimize the intracranial pressure
elevation generated by increased intracranial volume. When that point is reached, brain perfusion suffers and
death is imminent.
Posterior dislocation of the shoulder: Can be missed in AP view mechanism of injury (massive contraction
of all muscles in the area)Axillary view x-ray films are needed to make the diagnosis.
25

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Neerajs

USMLE Step-2CK HY Material and NOTES

2. Symptomatic older children and adults

Toxicities tricyclic antidepressant ingestion:

Nummular dermatitis: chronic inflammation / etiology unknown. Coin-shaped/discoid itchy patches of

Hospitalization in community-acquired pneumonia :Criteria for hospitalization: one of the following is

The normal value for the anion gap is 12 4 mEq/L

Gaucher disease: deficiency of the enzyme glucocerebrosidase (Ashkenazi Jews ) progressive

Secondary hyperparathyroidism developed in renal failure in an attempt to correct the hypocalcaemia

Atypical nevus(Dysplastic):size from 5 to 12 mm most

Seborrhic Keratosis: This lesion is characterized by light brown to

Suspected lung carcinoma hoarsenessmetastatic disease to the recurrent laryngeal nerveincurability

Tangier disease:alpha-lipoprotein deficiency very low high-density lipoprotein (HDL)recurrent

Obese patient? in postop state developing respiratory distress think about PE

Idiopathic hypertrophic subaortic stenosis (Earlier name of Hypertrphic cardiomyopathy):frequent

Chronic "autoimmune" hepatitis young age & hypergammaglobulinemiabiopsy demonstrating portal

Hypertrophic heart disease is the best recognized cause of diastolic dysfunction

If autonomic dysfunction is suspected in a diabetic patient, a useful maneuver on physical examination is to

Amylodosis: echocardiogram reveals ventricular walls with a "speckled pattern restrictive

Proliferative diabetic retinopathy = nonproliferative diabetic retinopathy +neovascularization with vessel

Attention deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, and

Post infectious Bells palsy:Mostly EBV

Breast-feeding jaundicedecreased intake and increased enterohepatic circulation.

Hypernatremic dehydration: hypotonic fluid loss (history of diarrhea or vomiting),inadequate supply of

Intussusception usually occurs within the 6 to 12-month-old age group

Child with ecchymosesEliminate bleeding abnormalities by coagulation studies Normal studyThink

Bruton agammaglobulinemiaCellular immunity is intact mature B-lymphocytes do not

Common variable immunodeficiency syndromeClinically same as Brutons but onset in late

Kawasaki disease:systemic vasculitis of unknown originmucocutaneous lymph node syndromeClinical

Prenatal toxoplasmosisRx Treatment is with combination antibiotic therapy, including pyrimethamine,

Bupropion antidepressant with both dopaminergic and noradrenergic propertiesimprove depression

Propranolol known to occasionally lead to depressive symptoms

Post-traumatic stress disorderRx Sertaline

Generally conventional antipsychotic + prophylactic anticholinergic agent (benztropine, diphenhydramine, or

Adjustment disorder is exemplified by a set of behavioral or emotional symptoms developing as a response to

prochlorperazine and haloperidol administration feeling of restlessness & agitation(akathisia)Rx

Approach towards Breast Lump:

(a)Solid Masses in Women Less Than 40 Years of Age

Physical Examination No evidence of mass reassured and instructed in breast self-examination.

(B)Solid Masses in Women More Than 40 Years of Age.

There is no evidence that breast-feeding increases HCV transmission to the baby.

Asymptomatic bacteriuria in pregnant womenassociation with preterm delivery/low birth weight Rx

Gestational diabetesusually diagnosed by means of oral glucose tolerance testingPatients with

Forceps and the vacuum extractorTo expedite the deliveryindications:

High-grade squamous intraepithelial lesion (HGSIL) will progress to invasive cervical

Mode of delivery with twin gestations:

PID in preganacyRx Clindamycin + gentamycin

Small umbilical hernias can close spontaneously up to the age of 2 years.

Advanced breast CARad/chemo to make it operable

Acute Senility within short periods of weeks Suspect chronic SDH.

central cord syndrome:mechanism of injury (hyperextension)relative sparing of the lower extremities in

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