Step 3 notes

[Anonymous]

I want to express my gratitude to all the members who come and work together as a team ........
I am in this form sometimes....but i feel that i should not just see this forum and leave , take print out and go..

I will try to paste as much as notes i have for step3 and recalls from this forum ....

I have not taken the exam yet.... i don't know if i going to be successful or not....but i want to give back to this forum much more than it gave me.....

Thank you again..
Bull

!!! bites notes!!! September 28 2003, 4:52 AM

a)if stray dog bites to some one give both ig and vaccine....make sure 1/2 of ig is sprinkled over the wound and half inthe buttocks if kids and in adult in deltoid muscle...and make sure igand vaccine should b on sep sites of injection...

if neighbours dog bites which has all his vaccination upto date then just reassure the victom and clean with soap and water....nothing to worry about

if human bites to another human in my exam they gave a q that a man comes with a bite wound that result in swelllingof his whole forearm...and on qustioninghe admiited that his wife bit him... what u will do....since human bites r worse tahn all other bc zof aerobic and anaerobic becteria in one s mouth need sp attention and treta mentin this man case since it was such an extensive lesion so we have to admit him and give him iv antibiotic....augumentin is goood as out pt and inpt u can give ampicilline.ivand clindamycine


if cat bites if kid is asymptomatic do nothing just clean with soap and water ... if extensive wound then give ampicillin or augumentin

if dog bites same augumentin or amp...(domestic)

scorpion bites ..... brown reclouse ...will cause stinging sensation,sloughing ,necrosis need dexamethasoneand tetanus....

if black widow bites then u will have abdominal cramps and rigidity u hav eto give calcium gluconate ...about snake bites i dont remmber much but its imp tooo..so read it.. they will also ask about botulism ......

in y exam they ask a mom is worried that babyis so lethargic not takingbotttle and she is not having any fever just dialted pupil on exam....and ans was did u give him honey lately.....other choices i dont recalll... lucine...u ask v goood q.....its v imp atleast 5-6 qs..on bites ..goodluck dear!!!blaze and gulabooo plez read it tooo...its usually on sec day


BROWN RECLUCE SPIDER September 28 2003, 11:33 PM

Add DAPSONE to the treatment ( familypractice.com)

and always remmber ppl who have allergy to sulfa or who r deficient in g6pd they dont need bactrim or dapsone if they have hiv or aids they need atovaquin...another exam q






================
Xray,Ekg and Pics in exam


pic of a kid with arm and mouth vesicular lesion i put cocksake virus a....bcz it was hand mouth fooot diease kind of pic...

kid with the xray chest with pnumo one side and bowel other..cong diaphragmatic h

man with apple core lesion..colorectal ca
a fib ...ekg

3rd degree heart block

inf mi...st elevation in typical leads

pic of scabies
pic of pudohyphe
pic of shingles with eye involvement

pic of nodular cystic acne

ct of head with lenticualr mass .....epiduarl hematomaa.

achalasia....pic

pic of pudohyphe, I have this in my EXAM yesterday

kid with the xray chest with pnumo one side and bowel other..cong diaphragmatic.

It is a newborn and left diaphrama hernia asking which is the most commen complication??

======

Most sensitive/specific clinical parameters:
1)'pinna displaced inferiorly and laterally' =mastoiditis
2)'cervical motion tenderness' = PID

3)'tenderness of sinuses' = sinusitis

4)'fixed and immobile TM' = OM

5)'tender tragus or pain on traction of pinna' = Otitis externa

6) 'temp, chills, RUQ pain' = cholangitis

7)'palpable painless abdominal mass[typically, noticed by mom while bathing the kid] with hypertension' = Wilms tumor

8)'Rash that begins at hairline+ face with retroauricular/post cervical/post occipital LN' = Rubella

9)'high fever followed by rash in infants' =roseaola infantum

10)'growth failure assoc with cough & vomiting'= fistula or reflux

11)'muffled, hot potato voice' =quincy

12)'mid-dilated, fixed pupil with headache & red eye'=glaucoma

13)''orientation of long axis of oval macules &papules along lines of skin cleavage' pityriasis rosea

14)maculopapular rash that blanches with pressure, begins in groin,neck and axilla' = scarlet fever

15)'dark wavy lines that end in a pearly bleb' =scabies

16)h/o change in mental status+ pulmonary inf = FB aspiration

17)h/0 psoriasis + sore throat/inf = guttate psoriasis

18)'tenosynovitis' = gonococcal arthritis

19)'sandpaper like rash + strawberry tongue' = scarlet fever
The following sources are the best:
alll pic come in exam from crush so pay attention:
ekg all ist degree sec degree third degree blocks,and wpw,a fib,a flutter,they ask with dif senario what u will give for treatment...

like for svt which includeafib and a flutter if thereis no conraindication then bb is best

if they giv e history of chf then digitalis

never give verapamil in kids less than i yr for arrythmia

child< 1 year with umbilical hernia_______ Do nothing. ( do you agree) ?

a child< 1 year with hydrocele_______ Do nothing. do you agree)?

a child < 1 year with indiredt inguinal hernia ????
observe or interfere?

a man with incisional reducible hernia______ Do nothing

a man with reducible direct or indirect hernia ________ what should we do?
Faram


Agree with no treatment for hydrocele in a child < 1 yr

Addition...


Empty scrotum in a child < 1 year ==> observation and follow-up. Wait till the child is 1 yr.

Empty scrotum in a child > 1 yr ==> surgical removal of the abdominal/pelvic testis with orchiopexy.

Cryptorchidism in an adult ==> surgical removal without orchiopexy


==========

Anthrax - a guide for doctors and patients

Introduction:
Anthrax is a bacterial disease. It is caused by a bacteria that belongs to the same family as E. coli. called Enterobacteraciae. It is not a virus. Unfortunately, it has become a recent threat as it can be used for biological warfare.

The bacteria:
It is a rod shaped bacteria with rounded edges. It cannot be seen by the naked eye. Labs need a microscope to see it.

When doctors check or screen for bacteria, they stain the specimens commonly with a simple technique called gram staining. There are very few bacteria that are rod shaped and test positive on this test. Fortunately - for diagnostic purposes, anthrax bacteria test positive. This immediately raises a flag.

Modes of spread:
It is spread by its spores that can survive harsh natural conditions for years.

It may be transmitted by infected or contaminated animals and animal products, insect bites, inhalation or ingestion.

Spread of anthrax usually does not take place from person to person except where the patient has skin lesions. It could however take place by handling contaminated articles.

In the Florida cases, it seemed to be transmitted by exposure from spores that were sitting on the computer keyboard (I am looking at my own keyboard as I type this).

I do not want people to panic because Florida is currently one of the most prepared states in the United States to tackle this problem. In my own office, we have at least a hundred doses of medicines that tackle anthrax. I am sure other doctors are prepared too.

Types of disease:
It is seen in three main forms.

Skin (cutaneous), intestinal (gastrointestinal), and its most dangerous form - lung infection or pneumonia (pulmonary).

Cutaneous anthrax is the most common manifestation of infection with B. anthracis. Inhalation (pulmonary) anthrax occurs in persons working in certain occupations where spores may be forced into the air from contaminated animal products, such as animal hair processing. Occupational risk groups include those coming into contact with livestock or products from livestock, e.g., veterinarians, animal handlers, abattoir workers, and laboratorians.

A patient with this form of anthrax may present with a blister with central denting and surrounding swelling that cannot be indented.

This is full of the antrax bacteria, making it highly infective as it sheds a lot of bacteria.

The intestinal form shows up as diarrhea and fever. Fortunately the commonest family of drugs used to treat this type of illness even in the non-anthrax condition treats anthrax as well.

The lung form of the disease begins abruptly with high fever and chest pain. It quickly turns into a bleeding type of illness and is frequently fatal. These cases are not highly infective.

If untreated, anthrax in all forms can lead to the bacteria entering the bloodstream and quickly - death. Early treatment of cutaneous (skin) anthrax is usually curative, and early treatment of all forms is important for recovery. 25% to 75%. of patients with gastrointestinal (intestinal) anthrax will die. Almost 90 - 100% of those with lung anthrax will die.

Preventing disease and its spread:
Anthrax in the veterinary world commonly affects herbivorous animals. Human immunity against anthrax is higher than the herbivores. This does not mean that vegetarians are any less immune to the bacteria than non-vegetarians.

We must identify what common things that come in contact with many hands in a day's time and be cautious about their safety. I am going to list a few here.

Currency notes and coins, Paper files and inter office mail envelopes, Card swiping areas, e.g. time card machines and credit card machines, Support bars into a bus, Door knobs, Water fountains, Gas station vending handles, Vending machines, Public telephones, Perfume testers in a mall, Coins and tokens for a slot machine, Buttons at traffic signals used by pedestrians to get access, Library computers, books and video tapes, Rented video tapes, etc, Objects in churches that many people touch, etc.

Please wash your hands before you touch your mouth or nose after you touch something that may be contaminated. Avoid opening letters if you have a wound on your hands.

Treatment:
Early treatment is vital. Therefore you do not need to hoard a full course of the antibiotics that are effective but just the first dose alone.

Many good antibiotics are available that are approximately equally useful but Once symptoms of the lung form appear, fatality is high inspite of treatment.

Levaquin, Cipro, Tequin, avelox are good medicines that could be used.

Penicillin too is useful as are many other antibiotics.

Most commonly, the skin form comes along and one can treat that very effectively.

What should your doctor do?
Having been a licensed practitioner for over 10 years, practice of reasonable and economical medicine has now become second nature to me. I am not trying to say that what is outlined here is perfect but these guidelines will certainly help those who have not put in a lot of thought into this. If other doctors also put in thought into this, they will come out with similar answers.

If a patient wants to keep antibiotics at home for him and his family, he should only be offered dosing for 24 hours.

This means 2 tablets of Ciprofloxacin (Cipro) or 1 tablet of Levaquin or Avelox or Tequin. He should be told that this should be given if suspicion is high and the patient should be examined by a doctor soon.

Giving out long courses are going to create a shortage and thus further panic in the community.

If the doctor has a suspicion of anthrax in the patient, he should immediately draw and keep blood from the patient and then administer the first dose of the antibiotic immediately.

If it is a skin lesion that the doctor sees, he should take a scraping from the skin lesion and send part of it for a Gram stain and another part for culture. Antibiotic of course should be given immediately.

Doctors also should try to avoid use of these antibiotics in conditions where other antibiotics are equally effective.

What does it mean that the cases are due to genetically un-altered bacterial strains?

Since the cases had the above type of strain, it is unlikely that these are from terrorists. It is more likely that someone who has animals got that strain and now has mailed the stuff to different people across the country. One should look through veterinary records and match up people who owned animals that died of anthrax in the Tampa-bay area. I could certainly be wrong but I rarely am.

How concerned should we be about the future:
Not very. I am not an astrologer nor a psychic but seeing that these cases have been from unaltered bacteria, I feel that these are not well prepared terrorists left around. Had this attack come from well prepared terrorists, we would have seen very communicable, genetically altered anthrax strains. They would have used their biowarfare material already within this one month. Regardless, almost all doctor's offices are well prepared with antibiotics.

Vaccine:
In the civilian world, the health departments are most likely going to be the first to recieve vaccine supplies. I think that many of us doctors should volunteer and offer to give out the vaccines if that is decided by the government. Our clinic has already registered with the health department for this purpose.

===============

it is easier to remember the nonreportable diseases...
this would be
Herpes[pt is already crying with pain,so u dont have to bother to report it!thats the way i remember it]
HIV +ve status
Chlamydia[but in ur list,i see that it is nonreportable?]
------------------------------------------------------------------------------------------------------------------------------
Reportable diseases:

A single case of a disease of known or unknown etiology that may be a danger to the public health.
Unusual manifestation(s) of a communicable disease.
An outbreak of a disease of known or unknown etiology is reportable immediately by telephone.


Acquired immunodeficiency
syndrome (AIDS)
Amebiasis
ƒÏAnimal bites
ƒÏAnthrax
ƒÏBotulism
Brucellosis
Chancroid
chlamydia
ƒÏCholera
ƒÏDiphtheria
Encephalitis
Gonococcal infection
ƒÏHaemophilus influenzae type b
invasive disease
Hepatitis, viral (AƒÏ, B, C, all other
types and undetermined)
Kawasaki syndrome
Legionellosis
Leprosy
Leptospirosis
Lyme disease
Malaria
ƒÏMeasles (rubeola)
Meningitis (viral, bacterial,
parasitic, and fungal)
ƒÏMeningococcal disease
Mumps (infectious parotitis)
Mycobacteriosis, other than
tuberculosis and leprosy
ƒÏPertussis
Pertussis vaccine
adverse reactions
ƒÏPlague
ƒÏPoliomyeltis
Psittacosis
ƒÏRabies
Rocky Mountain spotted fever
ƒÏRubella (German measles) and
Congenital rubella syndrome
Salmonellosis
Septicemia in newborns
Shigellosis
Syphilis
Tetanus
Trichinosis
Tuberculosis
ƒÏƒnTularemia
ƒÏƒnTyphoid fever (case or carrier)

Acquired immunodeficiency syndrome (AIDS)
Anthrax
Botulism
Brucellosis
Chancroid
Chlamydia trachomatis, genital infection
Cholera
Coccidioidomycosis
Cryptosporidiosis
Cyclosporiasis
Diphtheria
Ehrlichiosis, human granulocytic
Ehrlichiosis, human monocytic
Ehrlichiosis, human, other or unspecified agent
Encephalitis, California serogroup viral
Encephalitis, eastern equine
Encephalitis, St. Louis
Encephalitis, western equine
Escherichia coli: enterohemorrhagic (EHEC), O157:H7
Gonorrhea
Haemophilus influenzae, invasive disease
Hansen disease (leprosy)
Hantavirus pulmonary syndrome
Hemolytic uremic syndrome, postdiarrheal
Hepatitis A, acute
Hepatitis B, acute
Hepatitis B, perinatal
Hepatitis C; non-A, non-B
Human immunodeficiency virus (HIV) infection, adult
HIV infection, pediatric (<13 yrs)
Legionellosis
Listeriosis
Lyme disease
Malaria
Measles
Meningococcal disease
Mumps
Pertussis
Plague
Poliomyelitis, paralytic
Psittacosis
Q fever
Rabies, animal
Rabies, human
Rocky Mountain spotted fever
Rubella
Rubella, congenital syndrome
Salmonellosis
Shigellosis
Streptococcal disease, invasive, group A
Streptococcal toxic-shock syndrome
Streptococcus pneumoniae,invasive, drug-resistant
Streptococcus pneumoniae,invasive, <5 yrs
Syphilis
Syphilis, congenital
Tetanus
Toxic-shock syndrome
Trichinosis
Tuberculosis
Tularemia
Typhoid fever
Varicella (chickenpox)*
Varicella deaths
Yellow fever

==========


Three vaccine can induce anaphylactic reactions in egg-allergic people: INFLUENZA, YELLOW-FEVER and MMR.
The MMR and yellow fever still can be given in egg allergic people.

Varicella zoster vaccine is given at age of 1 year! (with the MMR).

Influenza vaccine ==> all people > 50 YEARLY

Penumococcal vaccine ==> for adults above 65 with chronic diseases/immunocompromised

MALE HOMOSEXUAL..What vaccines you give beside Hepatitis B? Hepatitis A !!! (becuase hepatitis A transmits through the faeces like feco-oral or feco-mucosal route...Male homosexual are thus subject to Hepatitis A).

60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows hyperplastic polyp..next step:
a-colonoscopy
b-do nothing
The answer is do nothing..Itis hyperplastic polyp..

60 year old patient ..came with positive occult blood stool..sigmoidoscopy shows tubular adenoma polyp..next step:
a-colonoscopy
b-do nothing
The answer is colonoscopy...It is tubular adenoma..It has risk of malignancy. So, you have to make sure that there are no more tubular adenoma polyps..sigmoidoscopy screens the descending colon only and doesn't reach the rest of the colon..so, colonoscopy should be the next step.

PAP shows ASCUS ==> Repeat test in 4-6 months
LGSIL/HGSIL on PAP ==> colposcopy and followed by cervical biopsy.

ITP ==> steroids are the first line. IVIG is the second line.
TTP/Gullian Barre ==> plasmapheresis

When the patient is in severe depression/suicidal tendency, he is not compotent:
30 year old man found on the floor with empty bottle of valium. A suicidal note was found saying that he wants to die peacefully and doesnot want any heroic procedures to save his life. Next step:
a-Flumazine i.v
b-Intubate and move to the ICU.
Choose B

For any drug overdose, do not choose the option of the anti-dote/the antagonist..remove the drug first by charcot/gastric lavage unless contraindicated.
Acetaminophin overdose..next step:
a-N-acetylcystiene iv
b-gastric lavage
Choose B

Don't afraid to give morphine for the pain management in patients with terminal stage of their cancers:
..but it should be under monitoring to prevent respiratory depression!!
75 patient with pacreatic cancer and severe back pain ..next step:
a-morphine intrathecal
b-morphine i.v every 3 hours
c-morphine i.v on needed basis
d-morphine i.v in a monitored bed.
Jump to D

Emancipated minor is the minor who lives alone/married/works
Pregnant minors are not emancipated but have the excetion of signing the consents!
A 16 year pregnant girl need Cesearan section for delivery ..who signs the consent?
a-In most states, she is emancipated minor.
b-In most states, she can sign the consent
Point your arrow to B

Jehovah's witness refuses blood transfuion..His Bp is 50/0..next step:
a-do nothing
b-iv fluids
Respect the autonomy but tries to do any supportive measure outside the conflict!! so jump to B

Do not respect the patient's wishes in organ donation if they parents refuse the donation even if he has the organ donation card! This is the only excetion for the patient's autonomy after hhis brain death.

The spouse is the next after the patient (not his parents or siblings). Ask the wife for any consents if there is no guardian or advance directive!!

Treat keloid by intralesional steroids. The same thing for alopecia aerata (NOT topical!!)

Emergent reversal for warafin overdose is FFP (not Vit K) while emergent reversal of heparin is protamine sulphate (not FFP!!..The FFP is c.i.)

If the Q is clueless..choose the most common
70 yo patient with weight loss...next step; CXR (to exclude lung cancer which is the most common malignancy)
70 yo patient with fatigue...CBC (to detect iron deificency anemia..followed by colonoscopy becuase lower GI bleeding is the most common cause of iron deficiency in the US..NOT NUTRITIONAL CAUSE!)

EFFECTs of OCP:
HDL LDL Glucose TG
a low high high high
b high low high normal
c high high normal normal
d normal normal normal normal
e normal normal high high

The answer is E why?
Remember that estrogen increases HDL but decreases LDL
Progetreone decreases HDL and increases LDL
Their combined effects is nill!!keeping the levels of LDL and HDL normal
TG is elevated and impaired glucose tolerance!!

Patients with adenomyosis/endometriosis/leiomyomata uteri (refused surgery)..What is the medical treat? OCP. Remember all these cases are caused by state of hyperestrogenism..but you still have to give OCP..not progestrone only.

Patient with rheumatoid arithritis...refused to take steroids..The alternative drug should be: METHOTREXATE

Patient with SLE...refused to take steroids..The alternative drug should be: CYLCOPHOSMAIDE

Patient with Crohn's disease..The first line is s-ASA with metronidazole or cirpofloxacin...Steroids are SECOND LINE..AZATHIOPRINE or ^-Mercaptopurine are THIRD line. INFLXIMAB is the last line OR for the treatment of FISTULAS!!

Treatment of IBS (Irritable bowel syndrome)?? FIBER+ ANTICHOLINERGIC DRUGS like hyoscine

GERD ==> First line is therapeutic trial of H2 blockers , followed by Proton-pump inhibitors. If fails, go to 24-hr esophageal PH monitoring. Don't forget the life style modification before any pharmacologic therapy.


A patient presents with heartburn and regurgitation..

First step..Life style modifications..

Failed..

The patient can be tried on H2 blockers/anatcids/promotility drugs..

Doesnot respond..

Trial of omeprazole..

No response..

24-hour esopaheal PH monitoring/ Esophageal acid infusion test (Bernstein test)

Proton pump inhibitors are indicated for use in severe GERD or if it is resistent to other treatments.

Fundoplication is the last resort.


Question examples::::

45 year old obese patient came to you with epigastric pain..first step:

a-EKG
b-CXR
c-Zantac

EKG first...Epigastric pain can be cardiogenic!!!

Next step:

a-Lansoprazole
b-Zantac
c-Counselling the patient about losing wieght, bed head elevation..

The answer is of course C

Came to your office 4 weeks later and the heartburn persists:

next step
Zantac or Tagamet (H2 blockers) for 8 weeks

Came back with no response..next step:

a-Omperazole
b-Increase the dose of Zantac
c-Fundoplication

Choose A

The patient's pain is improved. The patient came to you after five years..next step:

Endoscopy

To rule out Barett esophagus!!!!!!1 The most common LONG-TERM complication of GERD!!!!


well in IBS, the anticholinergics are not given routinely. Only if it is IBS-diarrheal predominant. ANd also when the urge occurs acutely after the meals( In which case loperamide is given).


=========
Immunization & Pregnancy..

The following vaccinations should not be given during pregnancy becuase they are live attenuated virus vaccines:

1-Mumps/Measles/Rubellla
2-Yellow fever
3-Varicella

REMEMBER>>>
A prgenant in her 2nd trimester exposed to a child with Varicella one day age. You checked her serum for varicella antibodies titre and it was negative..Give VZV ig (not vaccine) ..It should be given within 96 hours of exposure.
The mother ask you: Does the VZIG protect my fetus againts infection? NO. VZIG is given to prevent MATERNAL NOT CONGENITAL/FETAL infection!. The congenital varicella syndrome results from exposure during the first 16 weeks of pregnancy

These vaccines can be safely given and their indications are not aletred by pregnancy:

1-Pneumococcus (polysaccharide)
2-Meningococcus (polysaccharide)
3-Rabies (killed virus)
4-Influenza (inactivated virus)
5-Hepatitis B (purified surface antigen)
6-Hepatitis A
7-Tetanus-Diphtheria (toxoid)

LEAVE STATISTICS ALONE IF UWILL B MASTRE U WILLL NEVER GET WHAT THEY WILL GIVE U INEXAM SO FORGET ABOUT IT ITWONT B MORE THAN 6-7 QS MAX..


READ PEADS.....ALOT GYNE AND SURGERY JUST IMP STUFFF....DO ALOT OF CDS FINISH THEM ALLL 3 TIMES ...LIKE QBANK,ALERT ,ACE THE BOARD,IST PASS,CCS CDS,U WILL MAKE IT


IF UWONTCLLL CONSULT OR IF U CANT FIGUREOUT WHAT S THE DIAG THEY WILL FORGIVE U BUT IF UORDER CT DIRECT INSTEAD OF XRAY THEY WILL CHEW U....THEY SAID THAT IN THEIRORIENTATION LECTURE IN CD...SO THINK LIKE PT...HOW U WOULD FEEL IF U GET THIS MUCH BILLL ..SO COSTEFFECTIVENESS IST


Metastatic prostate cancer
Spine metastasis is urgency...Radiation first to reduce the compression.

To relieve the spine compression:

Dexamethason i.v (systemic intravenous NOT intrathecal....A real Q!!)
Followed or accompanied by spine radiation
Laminectomy is the last resort

Total orchiectomy is the Rx for metastatic prostate cancer in general.

==========

isolation from school/daycare

1)chicken pox:until all lesions have dried and crusted
2)scarlet fever: until atleast 24hrs after appropriate antibiotics
3)rubella:7days after onset of rash
4)measles:until 4 days after onset of rash
5)mumps:return to school 9 days after appearance of parotitis
6)strep pharyngitisL:until 24hrs after appropriate antibiotics
7)parvovirus B19 (5th disease): until appearance of rash [pregnant pt should be evaluated]
8)rota virus: until stool is contained by diapers or toilet use

=========
=>Alendronate(or/& other Mx) in postmenopausal
-women with low impact trauma
-T score< 2.5
-T score <1.5 with risk factors
-women with loss of bone mass despite preventive intervention

=>Bipolar disorder(rapid cycling)
-valproic acid
-thyroid supplements
-[rapid cycling: >4 discreet mood episodes within one calender yr]

=>=>CAD with depression
-DOC: paroxetine (anti-platelet action)
proven to decrease mortality

=>=>ARDS
-Treatment: PEEP(>10cmH02) with TV < 6cc/Kg & PIP<35cmH02
[lower tidal volume and limit plateau pressure]

=>=>Poorly controlled Asthma:
1)Albuterol rescue treatment> 2 x week
2)Nighttime waking >2 x month
3)Albuterol canisters >2 x month

=>=>Orbital fracture:
-Inferior rectus injury-> restriction of upward gaze


=>=>Fetal distress-> CST-> positive(50% FP)-> BPP-> <6 -> Delivery

HIV/AIDS
-Azt/zidovudine: S.E-macrocytic anemia
-all D's (DDI/didanosine, DDC/zalcitabine, D4T/Stavudine): S.E-pancreatitis, neuropathy
-3TC/lamivudine: used to treat hep B

Protease I
-Indinavir: renal stones
-ritonavir:both hyperlipedemia, hyperglycemia

=>needle stick injury prophylaxis
-2nucleoside+ 1 protease I x 1month

=>pregnant HIV+ve with CD4<350 and viral load >55k
-2nucleoside +1 protease =immediately thru preg
=>neonate born to HIV
-AZT x 6 weeks

=>HIV +ve guy
-doctor shud tell g/f(tarasoff 1)[emember:there is legal protection to BUT NOT legal requirement for partner notification]
-written/informed consent req for testing

=>NONE of antiretroviral drugs are TERATOGENIC

=>chance of transmission of HIV
-female to male= 1/3000
-male to female=1/1000(women are exposed for longer time to semen)
-needle= 1/300
-anal receptive=1/100

=>PCP
-if suspected do CXR(almost never normal), LDH, ABG(remember criteria for steroid!!)[PCP cannot be culture]
=>Routine 28 week prenatal visit
-check 2 things:1) GTT
2)Blood type

=>Breast feed
-AAP recommends breat feeding until 12 months
-After 6 months, iron-enriched foods or supplements should be added to prevent IDA

=>HBV & breast feeding
-not a CI to breast feeding, baby needs Ig and vaccine asap after birth

=>Temporary teeth
-1st tooth:L central inscissors, 6-7mon
-2nd tooth:U central inscissors, 6-7mon
-All teeth formed by 20-30mon
-All teeth lost by 10-11yr
Vs

Permanent teeth
-1st tooth:lower 1st molar, 6yrs
-All teeth by 11-12yr

=>Eczema/ Atopic dematitis:
-generalized xerosis, tend to worsen in winter
-Sites of predeliction: antecubital fossa, poplitial fossa, face & neck
-other findings: keratosis pilaris, accentuated palmar creases, lichenification, cataracts, & allergic shiners
(infraorbital discoloration)
atopic dermatitis: allergy to environmental, food, animals, sometimes maybe assoc with hay fever or asthma..Histology: Acute - spongiosis of epidermis; chronic - hyperkeratosis and acanthosis

=>Mulluscum Contagiosum
-pox virus
-pearly umbilicated papules & white, curd-like core may be easily expressed
-generally asymptomatic

=>=>Drug eruption:
-generalized morbilliform erythematous plaques begining on trunk and extend peripherally

=>=>Head Lice
-cause by pediculosis humanis capitis
-spread by direct contact with hair if infected person, hat, combs & hairbrushes
-treatment: permethrin
-NO isolation from school required; NO prophylaxis for family members, bedmates should be treated

==========

=>Unilateral vision changes without an acute history of trauma:
1)Optic neuritis:
young female, vision changes & pain with eye movement), afferent pupil
2)Retinal detachment:
ocular trauma, surgery
flashing lights or sparks, floaters, 'dark curtain', afferent pupil
3)Macular degeneration:
'Metamorphopsia'(distortion of shape of objects in view) usually slowly progressive
4)Amaurosis Fugax:
h/o intravascular procedures.
5)CRVO: prognosis variable; H/O of HTN, AS, Glaucoma
painless loss of vision, classic "blood and thunder" fundus.
6)CRAO: profound visual loss

=>CRVO......2 types 1)ischemic,which is painful
2)non-ischemic ,which is painless..more common.the second type is relatively more common than the first

7)Vitreous h'aghe:
Trauma, conditions causing neovascularization[DM,RVO], SAH
clue: if red reflex cannot be seen but the lens appears clear.
8)Ac. Glaucoma:
Increased cup:disc ratio, fixed mid-dilated pupil, hazy cornea, hard tender eye
9)Ischemic Optic neuritis:
>50yrs, painless, afferent pupil, swelling of disc, assoc with GCA

=>=>And ALWAYS get a right sided EKG in inferior infarction patterns:
-To look for posterior (RV) extension of the infarct, which occurs in 50% of inf MI and 14%-84%
of all LV infarctions
-RV infarct:clinical triad of hypotension, elevated jugular veins, and clear lung fields.

=>Mobitz type 1 rhytm: Inferior wall MI[block within AVnode due to increased vagal tone or
ischemia of AV junction]
Mobitz type 2 rhytm: Anterior wall MI[AV junc or bundle of his damage]

=>=>CDC criteria for hospital admission of pt's with PID
1)noncomplaint pts
2)pregnant pts with PID
3)pts with severe nausea & vomiting precluding outpatient management
4)pts with abscess or peritonitis
5)immunodeficient pts with PID
6)and all those who fail outpatient therapy

=>Indications for Tonsillectomy:
1)Obstructive tonsils (sleep apnea, dysphagia, speech defects, failure to cry)
2)Recurrent sore throat(relative):
->[7 episodes/yr or >5 in each of 2 yrs or >3 x 3yrs ] assoc with T>100.4 or increased Cx LN or
exudate or +ve strep c/s

=>=>Poorly controlled Asthma:
1)Albuterol rescue treatment> 2 x week
2)Nighttime waking >2 x month
3)Albuterol canisters >2x month

=>=>Orbital fracture:
-Inferior rectus injury-> restriction of upward gaze
=>=>Air travel in pregnancy:
-In healthy women:safe upto 36 wks ; C.I >36 wks
-C.I : h/o PIH
Preterm delivery
poorly controlled DM
Sickle cell anemia
=>=> Necrotizing Fascitis:
-group A streptococci account for about 60% of these cases(also staph, bacteroids, anaerobic strep &
Vibrio[shell fish & sea food exposure]
-gram stain may not show the classic textbook images of streptococci in "chains"
-Surgery is required for both diagnosis and therapy
rq 36: a ACLS case. V-tach/v fib, after failed convert, patient is now in asystoly. What to do next? give epi.

rq37: mostly likely org in 4 yo bacterial meningitis?

rq38: mostly likely org causing skin infection after surgery?

rq39: 50 man urinary retention big smooth prostate, Foley or suprapubic empty bladder.

rq40: several growth chart related quesitons.


Thallium stress test was mentioned several times in the answers. So pay attentions to the inplication of the stress test.
//
rq30: old patient second day after TURP, agitated with intermittent COMBATIVE and WITHDRAWAL. I thought delirium so ordered Lyte study. the next quesiton ask what to treat: haldol or restraint?

rq31: Bald area in man's head, ask treatment: tramcinolone injection.

rq32: About a dozen raised lesions on the back of a black teenage girl, with h/o acne. ask for the treamtnet: surgery removal of every lesion, steroid injection.

rq33: 6 y AA boy came in with malaize and some clue of leukemia. Ask what will change. I chose leukocyte number. dont remember other choice.

rq34: picture of hand xray of a man who just caught a baseball. ask what is the damage to the hand. I have no idea and picked ligment damage.

rq35: A young man got a bee sting 10 min ago, has wheezing and some sort skin reaction. He works with bee for more than 5 years and never has this before. Then the history said only in his early career that he was sting MILDLY. what you give to prvent future event? I chose Epipen.

rq26: 1 yo with flat feet, what to do: observation or correct shoe?
Spontaneous correction is usually expected within one year of walking. No treatment is indicated for painless flexible flat foot. Trauma, occult infection, a foreign body, tarsal coalition, bone tumors or osteochondrosis of the tarsal navicular bone may cause a stiff and painful flat foot. Where referral to ortho would be indicated


rq27: Your patient asks you to her wedding:

thank you, but I may not have time to go.
Thank you, but my professional standard would not permit to go.

re28: 15 yo boy malaize with a node in the left neck about 3cm. 3 wk later, symptoms improves but the node only slightly smaller. What do you do: biopsy or observe?

rq29: man runing 5 miles x3/wk, now has right leg pain. what will you find? bone scan and MRI not in the choice and stress fracture not mentioned. I chose normal xray finding.

rq30: 30 yo female now has ammenorrhea, FSH and LH increased. what is the cause? ovarian failure, PCOS etc

===========

rq21: adenovirus eye infection -conjucvitis in child.

rq22: EKG picture, AV block, I mistakenly chose A-flutter. So rest is much important before the exam day.

rq23: 60 male with atypical chest pain last 5 min usually. Did not remember has history of CAD or not. Pt now has 3 times chest during the last week and each lasts 20 min. EKG is normal. ask you
admit? (chosen this one)
thallium stress?
no choice for regular treadmill.

rq24: 50 yo GERD symptoms, related to food, sometimes NTG also help. ask work uP
upper endo
echo

rq25: skin leions ask causes among: simvasta, b-blocker, or levothyroxin


q23. atypical cp, it depends on RFs and his symp.

q24, gerd, betwn egd adn echo, I will with egd. but upper gi series is better initial test if it is on the list.

q25. skin lesion from meds: synthroid does not cause sl. other two(statin and bb) cause sl but rare, need more info to close.
rq16: Xray Picture of pt's knee pretty bad. ask treatment. I chose total knee replace over meds.

rq17: New born baby picture, one leg is significantly shorter than the other. observe, treat in one year, ortho immediately?

rq18: recalled last week or so. ICU nurse gave Tylenol to pt who allergic to tylenol. what do you do?
tell patient
wait, don't tell if no symptom.

rq19: gauze in the abdomen after surgery (old recall). you should
consult patient?
call lawyer?
hospital comitte

rq20: topic of rotavirus infection in small baby.


on that rq 10, the 13 wk preg, a following qusteioin ask what do you f/u pt with? US (chosen) or aminiocentisis.

rq11: another rq many time twisted, on my it read this: preg girl Rh-, previous baby Rh-, current husband Rh-. Do you give RhoGam?

She cried and said she did not know who the current baby's father is. what do you do?

rq12: skin lesion after wood cut. recalled before.

rq13: samll body with superficial redish skin lesion (picture) under the right armpit. ask tX? antibiotic, soap and wash. etc. Because no infor about the temp and symptoms so I chose soap wash. did not remember about steroid etc.

rq14: 70 yo male's back, a lot black dot (stuck on?) picture, not a very good picture. I chose the common one with the stuck on appearance.

rq15: 9 month old can he say mama and dada, or can he say 2-3 words?

rq6: HIV positive pt with no sign of TB but PPD 6. what do you treat? inh +B6; or 3 TB med (no PZA), others less likely for me.

rq7: Hispanic nurse newly PPD 10, cxr given which I thought is normal. and no symptoms. ask treamtent option. forgot choice. just topic. quite a few TB related questions with boardline information to confuse.

rq8: 70 yo female picture has uterocele. diagnosis.

rq9: 70 yo vaginal bleeding, SMALL uterus, ask waht to do. endo sample or hesterectomy?

rq10:13 wk preg woman exposed to varicella. pt has MILD chicken pox as child. what to do? I chose do NOTHING.
this one discussed before many times. a lot qs are repeated with a twister. i put several unrelated q together for easiness.

recalls 1: You got call from MEXICO, where the family is vacationing. The 5 yo son got bite by a stray dog. The boy has ALL vac in US (did not mention specifically, I assume all regular). Father asked you what to do after the basic treatment. choose immune ig and vac.

rq2: this q is a exact usmle sample q. the Italian man, a mechanic does his job. His friend refer him to see you for paranoid disorder. you should treat him in detail but professional manner. not over do it.

rq3: pedegree, muscle problem with mitochondrial. woman patient in first generation with a normal husband gave diseases to all their children (f and male). a man in second generation married a normal woman, ask about the chance of their daughter having the disease? not remember exactly, so read the topic. does anyone know this kind?

rq4: 14 yo girl with bluish lesion on skin. She wants to be treated for acne. THe mom said it is not acne and ask you to confirm. You said not acne. what is the girl's disorder? Conversion or dysmorphic etc. I chose the later among all the choices.

re5: fascarnet AIDS patient meds causing seizure. recalled manytimes.

1) THE main DIFFIRENCE between TTP and HUS is lack of Neurological involvement in HUS....otherwise same as both have inc BUN/CRETINE both have INC LDH both ha THROMBOCYTOPENIA both have MICROANGIOPATHIC HEMOLYTIC anemia......both have SHISTOCYTES on periphral bloood smear...v imp for exammmm REMMBER BOTH HAVE NORMAL COAG AND NORMAL OTHER CELL LINES...

2)INC PTT IN CLASSIC HEMOPHILIA AND ITS XLINKED...TREAT WITH FACTOR 8 AND IF IT DOESNT CORRECT PTT THEN IT MEANS THAT PT HAVE ANTIBODIES AGAINST FACTOR 8 WHICH CAN OCCUR IN 10% OF TH E CASES AND TEST THIS WITH MIXING STUDY MEANING WHEN U WILL MIX PTS BLOOOD WITH FFP OR NORMAL BLOOOD NOTHING WILL CORRECT PTT IT WILL STILL INC ...TRETAMENT OF THIS WILL B CYCLOPHOSPHAMDIE ALONG WITH PREDNISONE

3)MOST COMMON CONGENITAL BLEEDING PROB IS WITH VON VILLIBRAND DIASES ITS AUTOSOAML DOMINENT...AND IT WILL INC BLEEDING TIME..INMILD CASES U CAN GIVE PT DESPOPRESSIN ,,,AND IN SEVER CASES CRYO WILL HELP...DONT GIVE DESMO IN SEVER CASES IT WILL MAKE IT WORSE..

4)DESMOPRESSINIS ALSO GOOOD FOR MILD CLASSIC HEMOPHILIA A...

5)IN ITP THERE WILL B MEGAKARYOCYTES ONPERIPHRAL BLOOOD SMEAR BCZ THERE IS INC RATE OF DISTRUCTION OF PLATELETS AND DEC FORMATION OF PLATELETS DUE TO AUTOIMMUNE PHENOMENON, ANTPLATELET IgG ANTOBODIES DESTRY ALL PLATESLETS SO THESE PTS R MORE PRONE TO HAV EMUCOSAL BLEEDING LIKE THEY WILL HAV E MENORHAGIA,OR EPISTAXIS.....FORTREATMENT IST TRY WITH PREDNISONE IT HELPS ALOT BY INC THE PLATELETS itworks by dec the affinity of platelets to activated macrophagesin th e spleen and steroid also dec the binding of autoantobodies toplatelets....tretament always start with low dose of platelets it will inc th eplatelets numb but if u hav eto keep thept on prednisoneor u hav eto inc the dose then do splenectomyis the definate treatmentofitp if they ask u in step 3,,,,but make sure that u give pnumovac and h influenza vac 2 wk prior to splenectomy,other drugs that use when platelets r low and causing bleeding or if pt is going for urgent surgery is ivig..its v expensive so only reserve for life thretening bleeders and its always given slow and never in ppl who have igA defiency bc zthey will die from anaphylaxis...another imp point is that when pt cant go for splenectomy or cantbon prednisone or cant afford 5 k dollerivig give him danazol,or rh gam its helpful tooo...som e tried inflaximab group its helpful but infectionis the side efefct....so watch for that...if u c ccs in exam which most of u willl..... just treta as an out pt with prednisone and call pt in 2 wks and when platelets above 50 taper prednisone and advise for no contact sport..and pt teaching about diease ...v imp...

6)dic is dif from sub acute dic in thatpttis normal and fibrinogenis normal...and remmber in dic treat the underlying cause...
never give aminocaproic acid in dic without heparin bc zit cause severe thrombosis...
7)liver disease have both prolong pt and ptt but fibrinogen level is normal...ff will correct th ebleeding..
8)the dif bet the vitamin k deficiency and dic is noraml platelets and normal fibrinogen vit k will help....
9)if platelet r 10 k still u can perform splenectomy so never ever give platelets in itp when its in exam..bcz it will b destryed by the antibodies...
10)inmy exam they ask that baby had circumcison and lost lots of bloood on lab hisptt was 100 an his bleedint time was 12....and mom said his uncle has sam e prob he bled in suregry and after surgery...whatu will do u will check factor 8and 9...its dic,its ttp,its itpand blabla...
11)remmber factor x11 deficiney u wont have bleeding just inc ptt they canhave surgery without any prob its also callled hadgman factor deficiency..
12) ifpt is having factor 13 deficiency.u will hav e normal coag but still u will hav e bleeding....so remmebr these clues they will help u to exclude wrong choices in exam...
13)lupus anticoagulant antibodies is v imp subjects so u have to read about it.....its igG or igM antobodies taht produce aprolonged pttby binding to phospholipids,its present in 10% pt of sle and is characterized by recurrent abortion,and thrombosis .there is no bleeding unless second ry factor is presenttaht cause bleeding,the prolonged ptt will failed to correct with mixing study so that is a clue for diag....the russell viper venum isgood and senstive assey and is diag of lupus anticoagulant...antiphpjolipid and lupus anticoagulant will cause the false positive vdrl...u can suspect lupus anticoagulant when inc ptt but no bleeding and vdrl is in and anticardiolipid and natiphospholipid positive...predison is th ebest treatment and give heparin if thrombosis is suspected....
14)autologous bloood can b given to pt for surgery and it can b stored for upto 35 days...it dec the chance of infection and reaction..

15)i pack of rbc pack can raise the hct by 3-4%and prbc is used to raise hct ...not the whole blood that is reserved for sever hypovolemic pt...
16) dont transfuse awake juhuwa witness against his will but for a kid go ahead and transfuse if urgent or in nonurgent situation just tak e court oreder...ifkid belongs to juhuwa witness
17)always remmber when ever kid is in the womb mom will give consent for every thing evenif she is competent and refusing for csection and endangering her baby thats fine u just listen to her an d respect her wish..but as soon as she deliver she has no longer authority if child lif eis in danger....but for non urgent cases we stilll need her consent even if she is in jail or drug addict .....
18)febrile bloood transusion reaction pt need leukopooor bloood
19)for graft verses host reaction u need to give iiridiated bloood next time..
20)HIT need that u d/d heparin and coumadin both and start with leupridine...inc risk of thrombosis with the HIT...plez read more from wash manual ....21)...in cases of hemoglobuburia weather its due to rhabdoor bloodo transfusion reaction give vigrous hydration with n/s and mannito or lasix...so hemoglonuria will not damage kidney tubule....bcz atn will cause rf sooon..if will not go aggressive hydration v imp for exam....
21)ist day jaundance is always due to abo imcompatibility
22) if husband is onegative and wife is tooo no prob baby will b normal..(.cam e in my exam..)..case senario was that a gal is pregnantand her rh is negative and her b fd is rh positive and they tell s u in sep setting that this babyis not my b fd but my ex and he is rh negative what u will tell her....

23)delayed transfusion reaction is due to duffy,kell and c,e loci of rh system..they cause delayed reaction after 8 to10 days of transfusion..
.
24)i unit of platelet will inc 5 k of platelets usually we giv e 6 pack..

25)fever chillsl and sever backach eis due to heamolytic reaction,stop transfusion and give ns bolus and lasix..flush th ekid so no damage to tubule and no renal failure other prob is dic....

26)kid if they have dirrhea due to slmonella sheggella or due to e coli they will most like ly have hus so keep that inmind in exam they ask that akid ate hamburger while his father was stilll barb qing...an dkid has now fever and dec inc bun/cretinine .. and thrombocytopenia and in c ldh itS HUS
27)WALDSTROME MACROGLOBUNEMAI IS DUE TOMONOCLONAL IGm paraprotein and in MM ITS DUE TO IgG
THE MAIN DIFIS THAT NO LYTIC BONE LESION IN THE WALDSTROME ...the cause of death in mm is due to infection from streptp pnumoni and h infuenza...
28)hairy cell leukia is having pancytopenia,splenomegalyand hairy celll on p blood smear and bm biopsy

========
Know different problems faced by health care workers who are either carriers or get exposed to different Bacteria/viruses.

Explanation

The discussion will focus on HIV & HBV exposure, Meningococcal exposure, Needlestick injury, MRSA & VRE carrier states.

All of us should be immunized against Hepatitis B.

HIV does not preclude a doctor or nurse to discontinue their job.

A needlestick injury must be carefully evaluated. If a needle contaminated with a patient,s body fluid enters a healthcare worker, the employer is responsible for all the expenses. Anti HIV medications MUST be offered within 4 hours. SOLID needles (eg lance for accucheck) have not been shown to transmit HIV. At least 2 anti HIV drugs should be offered. If the source patient has been on Zidovudine, the victim should also be offered a 3rd anti HIV drug as well. These should be taken for 1 month & victim to be sexually protective for 6 months. The source & patient needs to be checked immediately and in 6 weeks, 12 wks & 6 mo- and the source patient has no right to refuse but we generally get a consent form signed.

There was recently a question on the risk of HIV transmission - it is 1 in 200 encounters. The risk of Hepatitis B on the other hand is 1 in 20 encounters. This is also called the transmission rate.

Meningococcal prophylaxis must be given to close contacts of the patient with meningococcal meningitis. The drug of choice is Rifampin for 2 days. A good alternative is Ciprofloxacin - single dose but this cannot be given to patients under the age of 17.

MRSA & VRE carriage states are no longer of any isolation benefit. Mupirocin cream is good for MRSA eradication from the nostril.

Recognize the manifestations of carpal tunnel syndrome.



Explanation:

Pain, tingling and numbness in the median nerve distribution (lateral 3 and a half fingers) but may go up as high as the shoulder.

Worst after sleep because of abnormal positioning as one sleeps. Tinel's(tingling on tapping over course of median nerve at the wrist) and Phalen's(tingling on keeping the wrist hyper-flexed for a minute or two) signs may be elicited.

Diagnosis is clinical but Nerve Conduction Study confirms the diagnosis.

First line therapy is wrist splints during sleep.

If not effective then try hydrocortisone injection under carpal tunnel

If Motor signs are present at any time- confirm diagnosis and operate for release of carpal tunnel.(minor surgery).

FOR AA October 2 2003, 11:27 AM

I have this real exam question. Presentation is CTS carpal tunnel syndrome + atrophy of the affected hand =
Treatment? splint, steroid, surgery.thenar muscle wasting is an indication for surgery--kaplan

Recognize the complications of Aminoglycosides

Explanation

Aminoglycoside antibiotics are extremely useful in serious infections. Unfortunately they have a very narrow therapeutic index. The most important question asked on them is the adjustment of the dose amount and dose interval based on the Trough and peak levels.

There are 2 levels measured - the peak and the trough. The peak level is measured 1 hour after the 3rd dose is given and the trough is measured just before the next dose (4th dose) is given.

Higher the amount in each dose, higher will be the peak. The efficacy is related to its peak level. If it is found to be lower than the recommended value, please increase the dose of each shot to ensure that the person gets the most benefit from the drug (It also improves the post antibiotic effect of Aminoglycosides).

The toxicities of Aminoglycosides are related to its trough level. This is related to the time interval between doses (Shorter the interval, higher the troughs & higher the chances of toxicity therefore if troughs are too high, please increase the interval between the doses to decrease the trough and its related toxicities).

The toxicities of Aminoglycosides are:

Renal failure - due to tubular necrosis that can be reduced in the presence of antipseudomonal penicillins.

Muscle weakness: Direct Neuro muscular junction blockade therefore cautioned in Myasthenia.

Deafness due to cochlear toxicity

Vertigo - vestibular toxicity
Complications can be prevented by good hydration and monitoring the trough levels.


Sensitivity/specificity
Sensitivity = I am going to explain the sensitivity of a radio. There are 10 stations in the air. If it can only pick up 7 of them, it is 70% sensitive. Therefore if there are 10 cases of a disease in a population, and only 7 can be picked up by the test, it is 70% sensitive.

Specificity = Of all that are free of the disease, how many actually test negative. Now we think of a machine which opens oysters that have pearls inside. We feed it 20 oysters. It opens 8 of them. 2 out of the 8 did not have pearls. We then went on to open all those that it did not open and found 3 pearls but 9 were without pearls. Therefore the specificity is 9/11 - i.e. of the total without the pearls (11), it correctly identified 9.

DNR ¹ DNRx

DNR holds a meaning only in the code situation. When a patient has either cardiac or respiratory ARREST, we will not start CPR. That is what it means. It does not hold you back from a treatment that addresses a different issue. For example, if a patient who is DNR goes into VT where he has a pulse, you are allowed to cardiovert. If he goes into VF or pulseless VT, on the other hand, the situation constitutes cardiac arrest and you should not enter the ACLS protocol.

When a patient is DNR (do not resuscitate), many doctors hold off on vasopressors and strong antibiotics or interventions such as pacemaker or even ventilators for respiratory distress. This is incorrect. This is the kind of situation that exams like to test on.

If you think it is not appropriate to use pressors or cardioversion or antibiotics because you deem them futile, you have to address each one separately and specify on the consent form.
GENERAL INTERNAL MEDICINE



Understand the initial treatment of acute hyperkalemia if the ECG shows features of high potassium.

Explanation:

When presented with a patient with high potassium and Electrocardiographic abnormality- Calcium chloride is the drug of choice because its specific action is cardio protection. This fact is asked so commonly that you should not mix this up with the treatments given below. Calcium chloride is more readily available than Calcium gluconate.

Thereafter or in a non emergency situation one can use Insulin/Glucose combination or Sodium Bicarbonate or Albuterol (Salbutamol). These push potassium into the cells therefore reducing serum potassium.

The Potassium binding resin (Sodium polystyrene sulfonate) should be given to everyone as this is the primary medicine to REMOVE and not just cause a trans-cellular shift of potassium.

If medical measures fail - Dialyze (hemofilter if dialysis not available)


Recognize the clinical manifestations and appropriate treatment of otitis externa and malignant external otitis



Explanation:

Otitis externa is a common problem and is usually treated topically but its rarer counterpart: malignant otitis externa needs parenteral antibiotics aimed at Pseudomonas.

Otitis externa is associated with the tragus sign where -if you push or pull the external ear gently - you elicit pain.

As the skin and cartilage of the external ear are so tightly held together - the swelling tries to rip these two apart and thus is responsible for the pain associated with the condition.

Pain relief along with swelling relief is key to treatment-commonly used preparations include combo of hydrocortisone with neomycin/polymyxin..

If the inflammation becomes obvious on the pinna and is no longer restricted to the ear canal - 2 diagnoses should come to mind

1. Malignant otitis externa(MOE) or
2. Relapsing polychondritis (RP).

MOE will be suggested by the presence of Immunosuppression/Diabetes/malignancy - all of which predispose to MOE. Findings include unbearable pain and pus discharge ( If there is pus but no pain - think otitis media with ruptured tympanic membrane).

MOE is treated IN HOSPITAL with IV antipseudomonal antibiotics (Ciprofloxacin/Ceftazidime/Antipseudomonal penicillins-Ticarcillin)and usually requires surgical debridement too (unless it is very early) .

RP on the other hand is suggested by another cartilage being affected or prior history of the problem. This could be the nasal or laryngeal cartilages and is treated with steroids. These patients can go into laryngeal stridor but need not be admitted if there is no suggestion of it.
i got these cases:

MVA with 3rd degree heart block
Down syndrome with duodenal atresia
ovarian torsion
cardiomyopathy
DUB
lead poisoning
SAH
colon carcinoma
last case was of an african american , may be of gastritis, i couls not reach the diagnosis...will write the details later...

CCS in sep 24/25
subacute thyroiditis
niddm
spouse abuse
turner syndrme
as
urosepsis
TCA overdose
meningitis 9month old baby
sigmoid diverticulitis

1- Exacerbation of asthma
2-G 6 PD deficiency with sulfa allergy
3-UTI with pregnancy
4-Ovarian cancer
5-MI with high blood sugar
6-erforated peptic ulcer
7- DKA
8-Colon cancer
9- Normal Physical exam with HTN in young male


http://cyberdev.ucsd.edu/curricular_...quiz/quiz1.htm


==========
CCS TURP
do ABC
pulse oximetery
o2
heparinized ivline
look for hypertautremia if not s/s atart ringer or ns
pt stable move to pe and look for any sing sum of sepsis, menigit, chest sin for pe, aspiration, cardiad anomaly
cbc, bmp, ecg, cxr.
abg
do another pe and check the test reslts
anything abnormal go for it and try to find the reason.
i continue with admit to ICU if BP not stable or confusion cardiac problem.
other wise to ward
npo,
o2
bed rest
int/ouput control
weight monitor
vital q 1 h
ask for results
if all neg and hypo tension gone
it could be hypovolimia and anethesia fever
if something wrong follow it
--------------------------------------------------
You asked a very important Q a bout a patient with indwelling catheter and developed UTI..next step:

a-ABS.
b-Remove the catheter.

Also this is a real CCS..A patient who had TUR of his prostate and developed a fever postoperatively..He had indwelling catheter
------------------------

on MVA accident, patient on vent, pinpoint pupil reactive to light, decerebrate posturing, no advance directive, friend says patient wants to live life the fullest.... what will you do?

pull out vent?
give steroids?
order MRI?
etc?
etc?
Ethical issue is respecting the patient's wishes in doing whatever possible to prolong his life

Understanding neurology!!

DECEREBRATE POSTURE indicates a brain ijury at the level of the brain stem (compare this with decorticate level which results from corticospinal tracts injury)

Corticosteroid will not add significant effect!

May be doing MRI will be help to identify any lesion at the level of the brain sten and manage the patient accordingly..(MRI is the diagnostic study)

I will go with MRI unless better options are there!
------------------------------------
21 yr old male dead after MVA had a organ donation card which family did not know about and they refuse to allow donation so what do you do now
go ahead donate
do not donate
ethics commitee
-Patient has advance directives saying to go all the way, has been on life support for 10 days now with neurology saying no hop, family wants the vent off, what do you do
pull the vent off
cont with the vent
ethics comitee
eeg

For the first ethics Q,
Do not donate. For organ donation, family wishes are respected. This is the only excetion to override patient's wishes!. Discussed before on this forum.

For the second ethic Q,
The advance directive say go all the way..
The family says wean the patient from the ventilator..
The neurologist says no hope...

How to solve the Q?

Since the patient has advance directives ==> immediately ignore patient's family wishes and respect the decision of the advance directives.

But if you continue the ventilatory support according to advance directive wishes, the ventilation is "futile"...This means it produces no benefit to the patient. THE PHYSICIAN RESPECTS THE AUTONOMY OF THE PATIIENT IN THE WISHES WHICH ARE CONSISTENT WITH THE PROFESSIONAL STANDARD OF CARE.
If the physycian agrees that the interventions in question would be futile, the goal should be to withdraw or withhold these interventions.

So the answer is withdraw it.

No need to refer the issue to the ethics committee as the ethic principle here is clear.

----------------------------------------
read kaplan ethics and digest every single word..
-------------------------------
ccs-Coccydynia-Diagnosis-I do not remember the choices I put rectal exam

Pain in the area of the coccyx (tailbone) is called coccydynia or coccygodynia (or sometimes a variety of other spellings). Coccydynia can be anything from discomfort to acute pain, varying between people and varying with time in any individual. The name describes a pattern of symptoms (pain brought on or aggravated by sitting), so it is really a collection of conditions which can have different causes and need different treatments.

The links on the right cover all the causes of pain on sitting that I have found in the medical literature or that people have emailed me about.

Coccydynia can follow after falls, childbirth, repetitive strain or surgery. In some cases the cause is unknown. The pain can disappear by itself or with treatment, or it can continue for years, and may get worse. It is five times more common in women than men, probably because the female pelvis leaves the coccyx more exposed. It appears that in most cases the pain is caused by an unstable coccyx, which causes chronic inflammation.

Medical trials have shown that coccydynia can be cured eventually in the great majority of cases, given the right treatment. However, finding a doctor who can do a proper diagnosis of the condition and supply effective treatments is difficult, and many people suffer years of pain.

Causes of coccydynia
The coccyx is the very bottom portion of the spine. It represents a vestigial tail (hence the common term "tailbone") and consists of four or more very small bones fused together. The coccyx articulates with the sacrum through a vestigial disc, and is also connected to the sacrum with ligaments (see Figure 1).

It is not clearly understood which portions of the anatomy can cause coccyx pain. Either the ligaments or the vestigial disc may be a cause of pain and, rarely, a primary bone tumor or soft tissue tumor can cause pain.

It is thought that the condition is more common in women because:

In women the coccyx is rotated and faces backward, which makes it more susceptible to trauma.

Women have a broader pelvis, which means that sitting places pressure not only on their ischial tuberosities ("butt bone") but also on the coccyx. (Men tend to sit only on their ischial tuberosities without a lot of pressure applied to the coccyx.)

Childbirth is a common cause of the condition

The two most common causes of coccydynia are:

Local trauma. A fall on the tailbone can inflame the ligaments or injure the coccygeal attachment to the sacrum

Childbirth. During delivery, the baby’s head rides over the top of the coccyx and can injure Causes of pain

Unstable coccyx

Spur on coccyx

Misaligned, rigid, or long coccyx

Muscle spasm or tightness

Pilonoidal cyst

Tarlov/meningeal cyst

Pudendal neuropathy

Cancer

Referred pain

Neuropathic pain

Idiopathic coccydynia

Imaginary pain



Diagnosis
A health professional diagnoses coccydynia by taking a thorough medical history and completing a physical examination. Diagnostic tests, such as x-*** or MRI, are also commonly performed in order to rule out other potential causes of the pain.

A thorough physical examination should include:

Pelvic and rectal exam to check for a mass or tumor that could be a cause of the pain

Palpation to check for local tenderness.

The most striking finding on examination is usually the local tenderness upon palpation of the coccyx. If the coccyx is not tender to palpation, then the pain in the region is referred from another structure, such as a lumbosacral disc herniation or degenerative disc disease.

Diagnostic studies that should be done include:

X-rays of the sacrum and coccyx should be done to rule out the unlikely event that either an obvious fracture or a large tumor is the cause of the discomfort.

An MRI scan is useful to rule out infection or tumor as a cause of pain

Bone scans and CT scans add very little information and are generally not done. Typically, all imaging studies will be

Conservative treatments for coccydynia
Treatments for coccydynia are usually conservative and local. The first line of treatment typically includes:

Non-steroidal anti-inflammatory drugs NSAID’s. NSAID’s (such as ibuprofen, naproxen, COX-2 inhibitors) help reduce the inflammation that can cause pain.

A donut-shaped pillow to help take pressure off the coccyx when sitting

Patience is also very important, since it often takes many weeks, or even months, for the pain to subside.

If the pain is persistent or severe, additional conservative treatments may include:

A local injection of a numbing agent (lidocaine) and steroid (to decrease inflammation in the area) can provide some relief.

Some practitioners treat the condition with manipulations.

Stretching the ligaments attached to the coccyx can be helpful.

Physical therapy with ultrasound can also be helpful.

Provided that infection and tumor has been ruled out as a cause of pain (through exam, x-***, and MRI scan), then prolonged conservative treatment is a reasonable option.

Surgical treatments for coccydynia
For people who have persistent pain that is not alleviated or well-controlled with conservative treatment, surgical removal of the coccyx (coccygectomy) is an option.

This surgery is rarely performed, and the procedure is not even included in most spine surgery textbooks. It is, however, a relatively simple operation.

Surgical approach

A one to two-inch incision is made right over the top of the coccyx, which is located directly under the skin and subcutaneous fat tissue. There are no muscles to dissect away.

The covering over the bone (the periosteum) is then dissected away from the bone starting on the back and carried around the front. Staying in this plane of tissue is very safe, and allows the coccyx to be dissected free and then separated from the sacrum.